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Forms: Numeric List - HCF
Division of Health Care Financing
now known as
Division of Health Care Access and Accountability
Form Number Form Title Form Type Other Location Language
HCF-01002 HealthCheck Individual Health History PDF - Print None English
HCF-01002H HealthCheck Individual Health History (Hmong) PDF - Print None Hmong
HCF-01002S HealthCheck Individual Health History - Spanish PDF - Print None Spanish
HCF-01003 Certification of Public Expenditures PDF - Fillable None English
HCF-01004 Wisconsin Medicaid School-Based Services Matching Expenditures PDF - Fillable None English
HCF-01004A Wisconsin Medicaid School-Based Services Matching Expenditures Completion Instructions PDF - Print None English
HCF-01005 Wisconsin Medicaid Maximum Allowable Fee Schedules and Related Information Order PDF - Fillable None English
HCF-01005 Wisconsin Medicaid Maximum Allowable Fee Schedules and Related Information Order Form Word - Fillable None English
HCF-01008 Wisconsin Medicaid Notification of Medicaid Hospice Benefit Election PDF - Fillable None English
HCF-01008 Wisconsin Medicaid Notification of Medicaid Hospice Benefit Election Word - Fillable None English
HCF-01009 Wisconsin Medicaid Recipient Election of Medicaid Hospice Benefit PDF - Fillable None English
HCF-01009 Wisconsin Medicaid Recipient Election of Medicaid Hospice Benefit Word - Fillable None English
HCF-01010 Wisconsin Medicaid Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge PDF - Fillable None English
HCF-01010 Wisconsin Medicaid Hospice Benefit Revocation (Non-Recertification) / Voluntary Discharge Word - Fillable None English
HCF-01011 Wisconsin Medicaid Physician Certification / Recertification of Terminal Illness PDF - Fillable None English
HCF-01011 Wisconsin Medicaid Physician Certification / Recertification of Terminal Illness Word - Fillable None English
HCF-01015 Wisconsin Medicaid Automated Voice Response System Information Optional Worksheet PDF - Fillable None English
HCF-01015 Wisconsin Medicaid Automated Voice Response System Information Optional Worksheet Word - Fillable None English
HCF-01016 Wisconsin Medicaid Provider Suggestion PDF - Fillable None English
HCF-01016 Wisconsin Medicaid Provider Suggestion Word - Fillable None English
HCF-01017 Wisconsin Medicaid Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement PDF - Fillable None English
HCF-01017 Wisconsin Medicaid Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement Word - Fillable None English
HCF-01017A Wisconsin Medicaid Verbal Orders for Recertification: Home Health Agency Request for Variance of Physician Signature Requirement Completion Instructions PDF - Print None English
HCF-01018 Wisconsin Medicaid Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers PDF - Fillable None English
HCF-01018 Wisconsin Medicaid Registration to Receive Report of Medicaid-Eligible Students for School-Based Services Providers Word - Fillable None English
HCF-01020 Wisconsin Medicaid Request for Nursing Home Care Determination PDF - Fillable None English
HCF-01020 Wisconsin Medicaid Request for Nursing Home Care Determination Word - Fillable None English
HCF-01020A Wisconsin Medicaid Request for Nursing Home Care Determination Completion Instructions PDF - Print None English
HCF-01021 Relief Block Grant Claim Paper Forms Manager English
HCF-01021A Relief Block Grant Claim Instructions (Form Letter) Paper Forms Manager English
HCF-01022A-E License Application Nursing Home, Facility for Developmentally Disabled, Institute for Mental Disease Excel - Fillable None English
HCF-01023 Wisconsin Department of Health and Family Services Current Occupancy Test Worksheet for Billing Medicaid Bed hold Days Paper Forms Manager English
HCF-01050 Wisconsin Medicaid Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification PDF - Print None English
HCF-01050A Wisconsin Medicaid Specialized Medical Vehicle Transportation Trip Ticket / Medical Care Verification Completion Instructions PDF - Print None English
HCF-01062 HealthCheck Adolescent Review PDF - Print None English
HCF-01062S HealthCheck Adolescent Review - Spanish PDF - Print None Spanish
HCF-01063 HealthCheck Family History PDF - Print None English
HCF-01063S HealthCheck Family History PDF - Print None Spanish
HCF-01066 HealthCheck Infant's Food Record - Birth to 12 Months of Age PDF - Print None English
HCF-01066A HealthCheck Child's Food Record - 1-12 Years of Age PDF - Print None English
HCF-01066AS HealthCheck Child's Food Record - 1-12 Years of Age - Spanish PDF - Print None Spanish
HCF-01066B HealthCheck Adolescent's Food Record - 13 to 20 Years of Age PDF - Print None English
HCF-01066BS HealthCheck Adolescent's Food Record - 13 to 20 Years of Age - Spanish PDF - Print None Spanish
HCF-01067 HealthCheck Your Child's Speech and Hearing PDF - Print None English
HCF-01068A General Pediatric Clinic - 3 - 4 Week Visit PDF - Print None English
HCF-01068B General Pediatric Clinic - 6-8 Week Visit PDF - Print None English
HCF-01068C General Pediatric Clinic - 4 Month Visit PDF - Print None English
HCF-01068D General Pediatric Clinic - 6 Month Visit PDF - Print None English
HCF-01068E General Pediatric Clinic - 9 Month Visit PDF - Print None English
HCF-01068F General Pediatric Clinic - 12 Month Visit PDF - Print None English
HCF-01068G General Pediatric Clinic - 15 Month Visit PDF - Print None English
HCF-01068H General Pediatric Clinic - 18 Month Visit PDF - Print None English
HCF-01068I General Pediatric Clinic - 24 Month Visit PDF - Print None English
HCF-01068J General Pediatric Clinic - Pre-school Visit PDF - Print None English
HCF-01068K General Pediatric Clinic - Elementary School Visit PDF - Print None English
HCF-01068L General Pediatric Clinic - Teenager Visit PDF - Print None English
HCF-01068M Confidential Health Survey PDF - Print None English
HCF-01068MS HealthCheck Age Specific Documentation Confidential Health Survey - Spanish PDF - Print None Spanish
HCF-01094 Medicare Part D Attestation PDF - Fillable None English
HCF-01094 Medicare Part D Attestation Word - Fillable None English
HCF-01105 Wisconsin Medicaid Pre-Natal Care Coordination Program Pregnancy Questionnaire PDF - Fillable Forms Center English
HCF-01105 Wisconsin Medicaid Pre-Natal Care Coordination Program Pregnancy Questionnaire Word - Fillable Forms Center English
HCF-01105A Wisconsin Medicaid Pre-Natal Care Coordination Program Pregnancy Questionnaire Completion Instructions PDF - Print None English
HCF-01105H Wisconsin Medicaid Pre-Natal Care Coordination Program Pregnancy Questionnaire (Hmong) PDF - Print None Hmong
HCF-01105S Wisconsin Medicaid Pre-Natal Care Coordination Program Pregnancy Questionnaire (Spanish) PDF - Print None Spanish
HCF-01109 Monthly Nursing Home Licensed Bed Assessment Paper Forms Manager English
HCF-01111A Department of Health and Family Services Wisconsin Medicaid Provider Agreement PDF - Print Provider Certification English
HCF-01111D Department of Health and Family Services Wisconsin Medicaid Provider Agreement (For Case Management Agencies) PDF - Print Provider Certification English
HCF-01111F Department of Health and Family Services Wisconsin Medicaid Provider Agreement (Pharmacy Provider) PDF - Print Provider Certification English
HCF-01111H Department of Health and Family Services Wisconsin Medicaid Provider Agreement (For School Based Services) PDF - Print Provider Certification English
HCF-01112 HealthCheck Verification Card Paper Forms Center English
HCF-01118 Family Questionnaire Paper Forms Center English
HCF-01133 Wisconsin Medicaid 24 Hour Drug FAX Cover Sheet Paper Provider Services English
HCF-01134 Wisconsin Medicaid Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit PDF - Fillable None English
HCF-01134 Wisconsin Medicaid Request for a Waiver to Wisconsin Medicaid Prescription Requirements Under the School-Based Services Benefit Word - Fillable None English
HCF-01136 Wisconsin Chronic Disease Program Participant Inquiry PDF - Print None English
HCF-01140 Wisconsin Chronic Disease Program Participant Explanation of Benefits (EOB) Statement PDF - Print None English
HCF-01140A Wisconsin Chronic Disease Program Participant Explanation of Benefits (EOB) Statement - Instructions on How to Read PDF - Print None English
HCF-01141 Wisconsin Medicaid Adult Immunization Record PDF - Print None English
HCF-01142 Wisconsin Medicaid Request for Discretionary Waiver of Qualifications for a Registered Nurse Supervisor PDF - Fillable None English
HCF-01143 Wisconsin Chronic Renal Disease Program Residency and Health Care Benefits Verification Paper Forms Manager English
HCF-01146 Wisconsin Chronic Disease Program Provider Data Sheet PDF - Print None English
HCF-01149 Wisconsin Medicaid Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements PDF - Fillable None English
HCF-01149 Wisconsin Medicaid Request for Waiver of Physical Therapist Assistant and Occupational Therapy Assistant Supervision Requirements Word - Fillable None English
HCF-01151 Medicaid Personal Care Worker Weekly Record of Care (single recipient with one or more funding sources) PDF - Fillable None English
HCF-01151A Medicaid Personal Care Worker Weekly Record of Care (single recipient with one or more funding sources) Instructions PDF - Print None English
HCF-01152 Medicaid Personal Care Workers Daily Record of Care (Two or more PCWs for one recipient in a group living situation) PDF - Fillable None English
HCF-01152A Medicaid Personal Care Workers Daily Record of Care (Two or more PCWs for one recipient in a group listing situation) Instructions PDF - Print None English
HCF-01153 Wisconsin Medicaid Breast Pump Order PDF - Fillable None English
HCF-01153 Wisconsin Medicaid Breast Pump Order Word - Fillable None English
HCF-01159 Wisconsin Medicaid Other Coverage Discrepancy Report PDF - Fillable None English
HCF-01159 Wisconsin Medicaid Other Coverage Discrepancy Report Word - Fillable None English
HCF-01160 Wisconsin Medicaid Acknowledgment of Receipt of Hysterectomy Information PDF - Fillable None English
HCF-01160 Wisconsin Medicaid Acknowledgment of Receipt of Hysterectomy Information Word - Fillable None English
HCF-01161 Wisconsin Medicaid Abortion Certification Statements PDF - Fillable None English
HCF-01162 Wisconsin Medicaid Certification of Emergency for Non-U.S. Citizens PDF - Fillable None English
HCF-01162 Wisconsin Medicaid Certification of Emergency for Non-U.S. Citizens Word - Fillable None English
HCF-01162A Wisconsin Medicaid Certification of Emergency for Non-U.S. Citizens Instructions PDF - Print None English
HCF-01164 Wisconsin Medicaid Sterilization Informed Consent PDF - Fillable None English
HCF-01164 Wisconsin Medicaid Sterilization Informed Consent Word - Fillable None English
HCF-01164A Wisconsin Medicaid Sterilization Informed Consent Instructions PDF - Print None English
HCF-01164S Wisconsin Medicaid Sterilization Informed Consent - Spanish PDF - Fillable None Spanish
HCF-01164S Wisconsin Medicaid Sterilization Informed Consent - Spanish Word - Fillable None Spanish
HCF-01165 Wisconsin Medicaid Newborn Report PDF - Fillable None English
HCF-01165 Wisconsin Medicaid Newborn Report Word - Fillable None English
HCF-01168 Request for Unique Suffix Number for Acquire Immune Deficiency Syndrome, Ventilator-Dependent, or Brain Injury Cases PDF - Fillable None English
HCF-01170 Wisconsin Medicaid Written Correspondence Inquiry PDF - Fillable None English
HCF-01170 Wisconsin Medicaid Written Correspondence Inquiry Word - Fillable None English
HCF-01174 Wisconsin Medicaid Medical Professional Statement in Support of Request for Variance of 60-Day Supervisory Visit Requirement PDF - Fillable None English
HCF-01175 Wisconsin Medicaid Recipient Request for Variance of 60-Day Supervisory Visit Requirement PDF - Fillable None English
HCF-01176 Wisconsin Medicaid Prior Authorization FAX Cover Sheet PDF - Fillable None English
HCF-01176 Wisconsin Medicaid Prior Authorization FAX Cover Sheet Word - Fillable None English
HCF-01179 Wisconsin Medicaid Provider Handbook Order Form Word - Fillable None English
HCF-01181 Wisconsin Medicaid Provider Change of Address or Status PDF - Fillable None English
HCF-01181 Wisconsin Medicaid Provider Change of Address or Status Word - Fillable None English
HCF-01181A Wisconsin Medicaid Provider Change of Address or Status Instructions PDF - Print None English
HCF-01182 Wisconsin Medicaid Declaration of Supervision for Nonbilling Providers Instructions PDF - Fillable None English
HCF-01184 Wisconsin Hemophilia Home Care Program Application PDF - Print None English
HCF-01184A Wisconsin Hemophilia Home Care Program Application Instructions PDF - Print None English
HCF-01185 Wisconsin Adult Cystic Fibrosis Program Application PDF - Print None English
HCF-01185A Wisconsin Adult Cystic Fibrosis Program Application Instructions PDF - Print None English
HCF-01186 Wisconsin Chronic Renal Disease Program Application PDF - Print None English
HCF-01186A Wisconsin Chronic Renal Disease Program Application Instructions PDF - Print None English
HCF-01187 Wisconsin Hemophilia Home Care Program Financial Need Statement PDF - Print None English
HCF-01187A Wisconsin Hemophilia Home Care Program Financial Need Statement PDF - Print None English
HCF-01188 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement PDF - Print None English
HCF-01188A Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Instructions PDF - Print None English
HCF-01189 Wisconsin Chronic Renal Disease Program Financial Need Statement PDF - Print None English
HCF-01189A Wisconsin Chronic Renal Disease Program Financial Need Statement Instructions PDF - Print None English
HCF-01195 Wisconsin Hemophilia Home Care Program Financial Need Statement Cover Memo PDF - Print None English
HCF-01196 Wisconsin Adult Cystic Fibrosis Program Financial Need Statement Cover Memo PDF - Print None English
HCF-01197 Wisconsin Medicaid Certification of Need for Specialized Medical Vehicle Transportation PDF - Fillable None English
HCF-01197 Wisconsin Medicaid Certification of Need for Specialized Medical Vehicle Transportation Word - Fillable None English
HCF-01197A Wisconsin Medicaid Certification of Need for Specialized Medical Vehicle Transportation Instruction PDF - Print None English
HCF-01198 Wisconsin Medicaid Optional School-Based Services Activity Log Nursing / Therapy Medical Services PDF - Print None English
HCF-01198 Wisconsin Medicaid Optional School-Based Services Activity Log Nursing / Therapy Medical Services Word - Fillable None English
HCF-01199 Wisconsin Medicaid Optional School-Based Services Activity Medication Administration PDF - Print None English
HCF-01199 Wisconsin Medicaid Optional School-Based Services Activity Medication Administration Word - Fillable None English
HCF-01300 Wisconsin Medicaid Specialized Medical Vehicle Information Chart PDF - Fillable None English
HCF-01300 Wisconsin Medicaid Specialized Medical Vehicle Information Chart Word - Fillable None English
HCF-01301 Wisconsin Medicaid Specialized Medical Vehicle Driver Information Chart PDF - Fillable None English
HCF-01301 Wisconsin Medicaid Specialized Medical Vehicle Driver Information Chart Word - Fillable None English
HCF-01302 Wisconsin Medicaid Weekly Driver's Vehicle Inspection Report PDF - Fillable None English
HCF-01302A Wisconsin Medicaid Weekly Driver's Vehicle Inspection Report instructions PDF - Print None English
HCF-01538 Wisconsin Medicaid School-Based Services Cost Report Excel - Fillable None English
HCF-01538A Wisconsin Medicaid School-Based Services Cost Report - Completion Instructions PDF - Print None English
HCF-01538CW Wisconsin Medicaid School-Based Services Cost Report Compensation Data Worksheet Excel - Fillable None English
HCF-01538WS Wisconsin Medicaid School-Based Services Cost Report Worksheet Excel - Fillable None English
HCF-01812 Wisconsin Medicaid Program 2007 Nursing Home Cost Report PDF - Print None English
HCF-01812A Wisconsin Medicaid Program 2007 Nursing Home Cost Report Instructions PDF - Print None English
HCF-01813 Patients by Payer Source on Last Day of Quarter Excel - Fillable None English
HCF-09002 Affidavit of Return or Exchange of Food Coupons Paper Forms Center English
HCF-09003 Coupon Account and Destruction Report Paper Forms Manager English
HCF-10075 Wisconsin Well Woman Medicaid Determination PDF - Fillable Forms Center English
HCF-10076 SeniorCare Application PDF - Print Forms Center English
HCF-10076A SeniorCare Instructions for Application Form PDF - Print Forms Center English
HCF-10076AH SeniorCare Instructions for Application Form - Hmong PDF - Print None Hmong
HCF-10076AR SeniorCare Instructions for Application Form - Russian PDF - Print None Russian
HCF-10076AS SeniorCare Instructions for Application Form - Spanish PDF - Print None Spanish
HCF-10080 SeniorCare Authorization of Representative PDF - Fillable None English
HCF-10081 BadgerCare Plus - Express Enrollment for Pregnant Women Application Paper Forms Center English
HCF-10093 Medicaid / BadgerCare Plus Overpayment Notice PDF - Fillable None English
HCF-10093S Medicaid / BadgerCare Overpayment Notice - Spanish PDF - Fillable None Spanish
HCF-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse PDF - Fillable None English
HCF-10095S Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse (Spanish) PDF - Fillable None Spanish
HCF-10096 Community Spouse Asset Share Notice PDF - Fillable None English
HCF-10097 Medicaid Income Allocation Notice PDF - Fillable None English
HCF-10098 Medicaid Member Asset Allocation Notice PDF - Fillable None English
HCF-10099 Notice of State Authorized Placement of a Medicaid Member in an Out-of-State Treatment Facility PDF - Fillable None English
HCF-10101 Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet PDF - Fillable Forms Center English
HCF-10101H Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Hmong) PDF - Fillable None Hmong
HCF-10101R Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Russian) PDF - Fillable None Russian
HCF-10101S Wisconsin Medicaid for the Elderly, Blind and Disabled Application / Review Packet (Spanish) PDF - Fillable None Spanish
HCF-10106 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approval Decision Notice PDF - Fillable None English
HCF-10106S Medicaid Qualified Medicare Beneficiary (QMB) / Specified Low-Income Medicare Beneficiary (SLMB) / Specified Low-Income Medicare Beneficiary Plus (SLMB+) Approved Decision Notice (Spanish) PDF - Fillable None Spanish
HCF-10107 Medicaid Qualified Medicare Beneficiary (QMB) Specified Low-Income Medicare Beneficiary (SLMB) Specified Low-Income Medicare Beneficiary Plus (SLMB+) Negative Decision Notice PDF - Fillable None English
HCF-10108 Medicaid Manual Notice for Cost of Care Contribution PDF - Fillable None English
HCF-10108A Medicaid Manual Notice for Cost of Care Contribution Instructions PDF - Print None English
HCF-10109 Medicaid Remaining Deductible Update PDF - Print Forms Center English
HCF-10110 Medicaid / BadgerCare Certification form Paper Forms Center English
HCF-10111 Good Faith Medicaid / BadgerCare Plus Certification PDF - Fillable None English
HCF-10111A Good Faith Medicaid Certification Instructions PDF - Print None English
HCF-10112 Medicaid - Disability Application PDF - Fillable Forms Center English
HCF-10112S Medicaid - Disability Application (Spanish) PDF - Fillable None Spanish
HCF-10113 Information for Medicaid Disability Applicants PDF - Print Forms Center English
HCF-10113S Information for Medicaid Disability Applicants (Spanish) PDF - Print None Spanish
HCF-10114 Medicaid Disability Redetermination Report PDF - Fillable None English
HCF-10115 BadgerCare Plus / Medicaid Health Insurance Information PDF - Fillable None English
HCF-10115S Medicaid Health Insurance Information - Spanish PDF - Fillable None Spanish
HCF-10119 Presumptive Eligibility for the Family Planning Waiver Program (FPWP) Paper Forms Center English
HCF-10119A Presumptive Eligibility for the Family Planning Waiver Program (FPWP) Instructions PDF - Print Forms Center English
HCF-10121 Medicaid Purchase Plan (MAPP) Independence Account Registration PDF - Fillable None English
HCF-10122 Medicaid Purchase Plan (MAPP) Member / Premium Information PDF - Print None English
HCF-10126 Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative PDF - Fillable None English
HCF-10126H Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (Hmong) PDF - Fillable None Hmong
HCF-10126S Medicaid / BadgerCare Plus / FoodShare Wisconsin Authorization of Representative (Spanish) PDF - Fillable None Spanish
HCF-10127 Medicaid Purchase Plan (MAPP) - Work Requirement Exemption  PDF - Fillable None English
HCF-10129 Medicaid / BadgerCare Plus and Family Planning Services Registration Application PDF - Fillable Forms Center English
HCF-10129H Medicaid, BadgerCare and Family Planning Waiver Registration Application - Hmong PDF - Fillable None Hmong
HCF-10129R Medicaid, BadgerCare and Family Planning Waiver Registration Application - Russian PDF - Fillable None Russian
HCF-10129S Medicaid, BadgerCare and Family Planning Waiver Registration Application - Spanish PDF - Fillable None Spanish
HCF-10130 Medicaid Presumptive Disability PDF - Fillable Forms Center English
HCF-10137 Medicaid Change Report PDF - Fillable Forms Center English
HCF-10137H Medicaid Change Report - Hmong PDF - Fillable None Hmong
HCF-10137R Medicaid Change Report - Russian PDF - Fillable None Russian
HCF-10137S Medicaid Change Report - Spanish PDF - Fillable None Spanish
HCF-10138 BadgerCare Plus Supplement to FoodShare Wisconsin Application PDF - Fillable None English
HCF-10139 BadgerCare Plus Premium Information PDF - Fillable None English
HCF-10139S BadgerCare Plus Premium Information (Spanish) PDF - Fillable None Spanish
HCF-10140 Wisconsin Medicaid Supplement to FoodShare Wisconsin Application PDF - Fillable None English
HCF-10140S Wisconsin Medicaid Supplement to FoodShare Wisconsin Application (Spanish) PDF - Fillable None Spanish
HCF-10141 Wisconsin Funeral and Cemetery Aids Program Reimbursement Request PDF - Fillable None English
HCF-10141A Wisconsin Funeral and Cemetery Aids Program Reimbursement Request Instructions PDF - Print None English
HCF-10142 Interagency Notification of Termination of Medicaid Waiver Eligibility for a Community Waiver Participant PDF - Fillable None English
HCF-10143 Wisconsin Funeral and Cemetery Aids Program Reimbursement Notice PDF - Fillable None English
HCF-10144 Life Insurance Inquiry Word - Fillable None English
HCF-10145 Agency Position on the Medicaid Eligibility Quality Control (MEQC) Error Finding PDF - Print None English
HCF-10146 Employment Verification of Earnings Word - Fillable None English
HCF-10147 Wisconsin Veterans Home at King - Medicaid Review PDF - Fillable None English
HCF-10148 BadgerCare Plus Express Enrollment for Children Application to become Certified Partner/Provider PDF - Print None English
HCF-10150 Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin PDF - Print None English
HCF-10150S Your Rights and Responsibilities for Wisconsin Works (W-2) Services, Child Care Assistance, Medicaid / BadgerCare and FoodShare Wisconsin - Spanish PDF - Print None Spanish
HCF-10151 Medicaid / BadgerCare Plus Fair Hearing Information PDF - Print None English
HCF-10154 Statement of Identity for Children Under 18 Years of Age PDF - Fillable None English
HCF-10154H Statement of Identity for Children Under 18 Years of Age (Hmong) PDF - Fillable None Hmong
HCF-10154R Statement of Identity for Children Under 18 Years of Age (Russian) PDF - Fillable None Russian
HCF-10154S Statement of Identity for Children Under 18 Years of Age (Spanish) PDF - Fillable None Spanish
HCF-10155 Employer Verification of Health Insurance Word - Fillable None English
HCF-10161 Statement of Citizenship and / or Identity for Special Populations PDF - Fillable None English
HCF-10162 Verification of Veterans Benefits PDF - Fillable None English
HCF-10171 Agency Position on the Payment Error Rate Measurement (PERM) Error Finding PDF - Print None English
HCF-10172 Agency Response to the State Quality Assurance (QA) Medicaid Finding PDF - Fillable None English
HCF-10175 Statement of Identity for Persons in Institutional Care Facilities PDF - Print None English
HCF-10176 BadgerCare Plus Express Enrollment Change Request for Partners / Providers PDF - Fillable None English
HCF-10177 BadgerCare Plus Express Enrollment for Pregnant Women Application Packet for Qualified Providers PDF - Fillable None English
HCF-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version PDF - Fillable None English
HCF-10181 Wisconsin BadgerCare Plus Employer Verification of Health Insurance PDF - Fillable None English
HCF-10182 BadgerCare Plus Application Packet PDF - Fillable Forms Center English
HCF-10182H BadgerCare Plus Application Packet (Hmong) PDF - Print None Hmong
HCF-10182S BadgerCare Plus Application Packet (Spanish) PDF - Print None Spanish
HCF-10183 BadgerCare Plus Change Report PDF - Fillable Forms Center English
HCF-10183H BadgerCare Plus Change Report (Hmong) PDF - Fillable Forms Center Hmong
HCF-10183S BadgerCare Plus Change Report (Spanish) PDF - Fillable Forms Center Spanish
HCF-10184 BadgerCare Plus Youth Exiting Out-Of-Home Care (YEOHC) Word - Fillable None English
HCF-10185 BadgerCare Plus Child Welfare Parent / Caretaker Relative (CWPC) Communication Word - Fillable None English
HCF-10186 Designation of a BadgerCare Plus Essential Person PDF - Fillable None English
HCF-11001 Wisconsin Medicaid Out-of-State Provider Data Sheet PDF - Fillable None English
HCF-11001 Wisconsin Medicaid Out-of-State Provider Data Sheet Word - Fillable None English
HCF-11002 Wisconsin Medicaid In-State Emergency Provider Data Sheet PDF - Fillable None English
HCF-11002 Wisconsin Medicaid In-State Emergency Provider Data Sheet Word - Fillable None English
HCF-11003 Wisconsin Medicaid Provider Application PDF - Print Provider Certification English
HCF-11003A Wisconsin Medicaid Provider Application Information and Instructions PDF - Print Provider Certification English
HCF-11004 Wisconsin Medicaid Provider Application Mental Health / Substance Abuse Agency Services PDF - Print Provider Certification English
HCF-11004A Wisconsin Medicaid Provider Application Mental Health / Substance Abuse Agency Services Information and Instructions PDF - Print Provider Certification English
HCF-11005 Wisconsin Medicaid Provider Application Mental Health / Substance Abuse Individual Services (for NonPhysicians) PDF - Print Provider Certification English
HCF-11005A Wisconsin Medicaid Provider Application Mental Health / Substance Abuse Individual Services (for NonPhysicians) Information and Instructions PDF - Print Provider Certification English
HCF-11006 Wisconsin Medicaid Federally Qualified Health Center Application PDF - Print Provider Certification English
HCF-11006A Wisconsin Medicaid Federally Qualified Health Center Application Information and Instructions PDF - Print Provider Certification English
HCF-11007 Wisconsin Medicaid Nursing Home Provider Application PDF - Print Provider Certification English
HCF-11007A Wisconsin Medicaid Nursing Home Provider Application Information and Instructions PDF - Print Provider Certification English
HCF-11008 Wisconsin Medicaid Prior Authorization / Therapy Attachment (PA/TA) PDF - Fillable None English
HCF-11008 Wisconsin Medicaid Prior Authorization / Therapy Attachment (PA/TA) Word - Fillable None English
HCF-11008A Wisconsin Medicaid Prior Authorization / Therapy Attachment (PA/TA) Completion Instructions PDF - Print None English
HCF-11009 Therapy Prior Authorization Review Checklist Paper Provider Services English
HCF-11010 Wisconsin Medicaid Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format PDF - Fillable None English
HCF-11010 Wisconsin Medicaid Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format Word - Fillable None English
HCF-11010A Wisconsin Medicaid Prior Authorization / Dental Attachment 1 (PA/DA1) Completion Instructions PDF - Print None English
HCF-11011 Wisconsin Medicaid Prior Authorization / Birth to 3 Attachment (PA/B3) PDF - Fillable None English
HCF-11011 Wisconsin Medicaid Prior Authorization / Birth to 3 Attachment (PA/B3) Word - Fillable None English
HCF-11013 Wisconsin Medicaid Urgent Care Dental In-State Emergency Provider Data Sheet PDF - Fillable None English
HCF-11013 Wisconsin Medicaid Urgent Care Dental In-State Emergency Provider Data Sheet Word - Fillable None English
HCF-11014 Wisconsin Medicaid Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services PDF - Fillable None English
HCF-11014 Wisconsin Medicaid Prior Authorization / Dental Attachment 2 (PA/DA2) Oral Surgery, Orthodontic, and Fixed Prosthetic Services Word - Fillable None English
HCF-11015 Wisconsin Medicaid Deletion from Publications Mailing List PDF - Print Provider Certification English
HCF-11016 Wisconsin Medicaid Prior Authorization Physician Attachment (PA/PA) PDF - Fillable None English
HCF-11016 Wisconsin Medicaid Prior Authorization Physician Attachment (PA/PA) Word - Fillable None English
HCF-11016A Wisconsin Medicaid Prior Authorization Physician Attachment (PA/PA) Completion Instructions PDF - Print None English
HCF-11017 Wisconsin Medicaid Hospital Application PDF - Print Provider Certification English
HCF-11017A Wisconsin Medicaid Hospital Application Information and Instructions PDF - Print Provider Certification English
HCF-11018 Wisconsin Medicaid Prior Authorization Request Form (PA/RF) Paper Provider Services English
HCF-11019 Wisconsin Medicaid Prior Authorization / Physician Otological Report (PA/POR) PDF - Fillable None English
HCF-11019 Wisconsin Medicaid Prior Authorization / Physician Otological Report (PA/POR) Word - Fillable None English
HCF-11019A Wisconsin Medicaid Prior Authorization / Physician Otological Report (PA/POR) Completion Instructions PDF - Print None English
HCF-11020 Prior Authorization Request for Hearing Instrument Paper Provider Services English
HCF-11020A Wisconsin Medicaid Prior Authorization Request for Hearing Instrument and Audiological Services (PA/H1AS1) Completion Instructions Paper Provider Services English
HCF-11021 Prior Authorization Request for Hearing Instrument and Audio Paper Provider Services English
HCF-11021A Prior Authorization Request for Hearing Instrument and Audio Completion Instructions Paper Provider Services English
HCF-11022 Wisconsin Medicaid Rural Health Clinic Statistical Data PDF - Fillable None English
HCF-11022 Wisconsin Medicaid Rural Health Clinic Statistical Data Word - Fillable None English
HCF-11023 Wisconsin Medicaid Rural Health Clinic Reclassification and Adjustment of Trial Balance Expenses Excel - Fillable None English
HCF-11023A Wisconsin Medicaid Rural Health Clinic Reclassification and Adjustment of Trial Balance Expenses Instructions PDF - Print None English
HCF-11025 Wisconsin Medicaid Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs PDF - Fillable None English
HCF-11025A Wisconsin Medicaid Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs PDF - Print None English
HCF-11026 Wisconsin Medicaid Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs PDF - Fillable None English
HCF-11026A Wisconsin Medicaid Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs Instructions PDF - Print None English
HCF-11027 Wisconsin Medicaid Rural Health Clinic Quarterly Cost Report PDF - Fillable None English
HCF-11027A Wisconsin Medicaid Rural Health Clinic Quarterly Cost Report Instructions PDF - Print None English
HCF-11029 Wisconsin Medicaid Prior Authorization / Chiropractic Attachment (PA/CA) PDF - Fillable None English
HCF-11029 Wisconsin Medicaid Prior Authorization / Chiropractic Attachment (PA/CA) Word - Fillable None English
HCF-11029A Wisconsin Medicaid Prior Authorization / Chiropractic Attachment (PA/CA) PDF - Print None English
HCF-11030 Wisconsin Medicaid Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) PDF - Fillable None English
HCF-11030 Wisconsin Medicaid Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) Word - Fillable None English
HCF-11030A Wisconsin Medicaid Prior Authorization / Durable Medical Equipment Attachment (PA/DMEA) Instructions PDF - Print None English
HCF-11031 Wisconsin Medicaid Prior Authorization / Psychotherapy Attachment (PA/PSYA) PDF - Fillable None English
HCF-11031 Wisconsin Medicaid Prior Authorization / Psychotherapy Attachment (PA/PSYA) Word - Fillable None English
HCF-11031A Wisconsin Medicaid Prior Authorization / Psychotherapy Attachment (PA / PSYA) Completion Instructions PDF - Print None English
HCF-11032 Wisconsin Medicaid Prior Authorization / Substance Abuse Attachment (PA/SAA) PDF - Fillable None English
HCF-11032 Wisconsin Medicaid Prior Authorization / Substance Abuse Attachment (PA/SAA) Word - Fillable None English