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Eligibility Management (Income Maintenance) Home >> IM Forms

Division of Health Care Access and Accountability (DHCAA)
Medicaid Forms Sorted by Form Title

Last Revised: July 14, 2008

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