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Eligibility Management (Income Maintenance) Home >> IM Forms

Division of Health Care Financing (DHCF)
Medicaid Forms Sorted by Form Number

Last Revised: July 14, 2008

This list contains all Medicaid forms that are available from DHCF. Forms marked as "PDF-Fillable" indicates the PDF form can be filled in using your computer and then printed; see About PDF Forms. If this list includes Microsoft Word or Excel forms, they can be filled in, saved, and transmitted electronically. You must have access to Microsoft Office 97, or a more recent version, to use these forms.

Form Number Form Title Form Type Revised Date Language
F-10093 Medicaid / BadgerCare Plus Overpayment Notice PDF - Fillable 2/1/2008 English
F-10093S Medicaid / BadgerCare Overpayment Notice - Spanish PDF - Fillable 3/1/2005 Spanish
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse PDF - Fillable 1/1/2008 English
F-10096 Community Spouse Asset Share Notice PDF - Fillable 4/1/2008 English
F-10097 Medicaid Income Allocation Notice PDF - Fillable 2/1/2008 English
F-10098 Medicaid Member Asset Allocation Notice PDF - Fillable 1/1/2008 English
F-10099 Notice of State Authorized Placement of a Medicaid Member in an Out-of-State Treatment Facility PDF - Fillable 2/1/2008 English
F-10101 Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet PDF - Fillable 8/1/2008 English
F-10101H Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Hmong) PDF - Fillable 8/1/2007 Hmong
F-10101R Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Russian) PDF - Fillable 8/1/2007 Russian
F-10101S Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Spanish) PDF - Fillable 8/1/2007 Spanish
F-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice PDF - Fillable 1/1/2008 English
F-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice PDF - Fillable 1/1/2008 English
F-10108 Medicaid Manual Notice for Cost of Care Contribution PDF - Fillable 4/1/2008 English
F-10108A Medicaid Manual Notice for Cost of Care Contribution Instructions PDF - Print 4/1/2008 English
F-10109 Medicaid Remaining Deductible Update PDF - Print 11/1/2003 English
F-10110 Medicaid / BadgerCare Certification form Paper 1/1/1999 English
F-10111 Good Faith Medicaid / BadgerCare Plus Certification PDF - Fillable 2/1/2008 English
F-10111A Good Faith Medicaid Certification Instructions PDF - Print 8/1/2003 English
F-10112 Medicaid - Disability Application PDF - Fillable 10/1/2007 English
F-10112S Medicaid - Disability Application (Spanish) PDF - Fillable 10/1/2007 Spanish
F-10113 Information for Medicaid Disability Applicants PDF - Print 2/1/2008 English
F-10113S Information for Medicaid Disability Applicants (Spanish) PDF - Print 2/1/2008 Spanish
F-10114 Medicaid Disability Redetermination Report PDF - Fillable 1/1/2004 English
F-10115 BadgerCare Plus / Medicaid Health Insurance Information PDF - Fillable 2/1/2008 English
F-10115S BadgerCare Plus / Medicaid Health Insurance Information (Spanish) PDF - Fillable 12/1/2004 Spanish
F-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration PDF - Fillable 9/1/2008 English
F-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information PDF - Print 3/1/2008 English
F-10126 Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative PDF - Fillable 2/1/2008 English
F-10126H Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (Hmong) PDF - Fillable 2/1/2008 Hmong
F-10126S Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (Spanish) PDF - Fillable 2/1/2008 Spanish
F-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption  PDF - Fillable 3/1/2008 English
F-10129 Medicaid / BadgerCare Plus and Family Planning Services Registration Application PDF - Fillable 2/1/2008 English
F-10129H Medicaid, BadgerCare and Family Planning Waiver Registration Application - Hmong PDF - Fillable 1/1/2003 Hmong
F-10129R Medicaid, BadgerCare and Family Planning Waiver Registration Application - Russian PDF - Fillable 1/1/2003 Russian
F-10129S Medicaid, BadgerCare and Family Planning Waiver Registration Application - Spanish PDF - Fillable 1/1/2003 Spanish
F-10130 Medicaid Presumptive Disability PDF - Fillable 4/1/2008 English
F-10137 Medicaid Change Report PDF - Fillable 1/1/2008 English
F-10137H Medicaid Change Report - Hmong PDF - Fillable 2/1/2008 Hmong
F-10137R Medicaid Change Report - Russian PDF - Fillable 2/1/2008 Russian
F-10137S Medicaid Change Report - Spanish PDF - Fillable 2/1/2008 Spanish
F-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application PDF - Fillable 2/1/2008 English
F-10140S Wisconsin Medicaid Supplement to FoodShare Wisconsin Application (Spanish) PDF - Fillable 2/1/2008 Spanish
F-10141 Wisconsin Funeral and Cemetery Aids Program Reimbursement Request PDF - Fillable 3/1/2008 English
F-10141A Wisconsin Funeral and Cemetery Aids Program Reimbursement Request Instructions PDF - Print 3/1/2008 English
F-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant PDF - Fillable 10/1/2005 English
F-10143 Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice PDF - Fillable 2/1/2008 English
F-10144 Life Insurance Inquiry Word - Fillable 1/1/2005 English
F-10146 Employment Verification of Earnings Word - Fillable 12/1/2007 English
F-10150 Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin PDF - Print 8/1/2007 English
F-10150S Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin - Spanish PDF - Print 5/1/2007 Spanish
F-10154 Statement of Identity for Children Under 18 Years of Age PDF - Fillable 2/1/2008 English
F-10154H Statement of Identity for Children Under 18 Years of Age (Hmong) PDF - Fillable 2/1/2008 Hmong
F-10154R Statement of Identity for Children Under 18 Years of Age (Russian) PDF - Fillable 2/1/2008 Russian
F-10154S Statement of Identity for Children Under 18 Years of Age (Spanish) PDF - Fillable 2/1/2008 Spanish
F-10155 Employer Verification of Health Insurance Word - Fillable 4/1/2008 English
F-10161 Statement of Citizenship and / or Identity for Special Populations PDF - Fillable 2/1/2008 English
F-10162 Verification of Veterans Benefits PDF - Fillable 2/1/2008 English
F-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding PDF - Fillable 4/1/2007 English
F-10175 Statement of Identity for Persons in Institutional Care Facilities PDF - Print 2/1/2008 English
F-13023 Medicaid Purchase Plan Premium - Recipient / Employer Electronic Funds Transfer Information and Instructions  PDF - Fillable 12/1/2001 English
F-13024 Medicaid Purchase Plan Premium - Employer Wage Withholding Information and Instructions  PDF - Fillable 12/1/2001 English
F-13039 Estate Recovery Program (ERP) Disclosure PDF - Fillable 7/1/2005 English
F-13039A Estate Recovery Program (ERP) Disclosure Instructions PDF - Print 7/1/2005 English
F-14014 Authorization to Disclose Information to Disability Determination Bureau (DDB) PDF - Print 7/1/2008 English
F-14014AS Authorization to Disclose Information to Disability Determination Bureau Instructions (DDB) (Spanish) PDF - Print 7/1/2008 Spanish
F-16001 Negative Notice PDF - Fillable 1/1/2008 English
F-16001S Negative Notice - Spanish PDF - Fillable 4/1/2006 Spanish
F-16014 Notice of Program Violation PDF - Fillable 4/1/2005 English
F-16015 Positive Notice PDF - Fillable 1/1/2008 English
F-16015S Positive Notice - Spanish PDF - Fillable 4/1/2006 Spanish
F-16021 Student Financial Report PDF - Fillable 4/1/2008 English
F-16022 Social Security Number Referral PDF - Fillable 1/1/2008 English
F-16031 Student Aid and Expense Worksheet PDF - Fillable 12/1/2001 English
F-16034 Self-Employment Income Worksheet - Corporation PDF - Fillable 3/1/2008 English
F-16035 Self-Employment Income Worksheet - Subchapter S Corporation PDF - Fillable 3/1/2008 English
F-16036 Self-Employment Income Worksheet - Partnership PDF - Fillable 3/1/2008 English
F-16037 Self-Employment Income Worksheet - Sole Proprietor Farm and Other Business PDF - Fillable 3/1/2008 English
F-16038 Administrative Disqualification Hearing Notice PDF - Fillable 1/1/2008 English
F-16083 Income Maintenance Quality Assurance (IMQA) Web Request PDF - Fillable 4/1/2005 English
F-16104 Local Agency Customer Feedback PDF - Print 8/1/2007 English