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BadgerCare Plus Forms

Below is a list of all BadgerCare Plus forms. 

When you are searching for a document, enter the number or a portion of the title in the search box below.

Assigned number Title Division Language Release date Available to order
F-01068K General Pediatric Clinic - Elementary School Visit (Word) DMS English 08/2019 No
F-01068J General Pediatric Clinic - Preschool Visit (Word) DMS English 08/2019 No
F-01068J General Pediatric Clinic - Preschool Visit (PDF) DMS English 08/2019 No
F-01068L General Pediatric Clinic - Teenager Visit (PDF) DMS English 08/2019 No
F-01068L General Pediatric Clinic - Teenager Visit (Word) DMS English 08/2019 No
F-10111 Good Faith Medicaid / BadgerCare Plus Certification (PDF) DMS English 09/2013 No
F-10111A Good Faith Medicaid / BadgerCare Plus Certification Instructions (PDF) DMS English 09/2013 No
F-01062 HealthCheck Adolescent Review (Word) DMS English 08/2019 No
F-01062 HealthCheck Adolescent Review (PDF) DMS English 08/2019 No
F-01062S HealthCheck Adolescent Review, Spanish (PDF) DMS Spanish 08/2019 No
F-01062S HealthCheck Adolescent Review, Spanish (Word) DMS Spanish 08/2019 No
F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age) (PDF) DMS English 07/2008 No
F-01066B HealthCheck Adolescent's Food Record (13 to 20 Years of Age) (Word) DMS English 07/2008 No
F-01066BS HealthCheck Adolescent's Food Record (13 to 20 Years of Age), Spanish (Word) DMS Spanish 07/2008 No
F-01066BS HealthCheck Adolescent's Food Record (13 to 20 Years of Age), Spanish (PDF) DMS Spanish 07/2008 No
F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age (Word) DMS English 07/2008 No
F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age (PDF) DMS English 07/2008 No
F-01066AS HealthCheck Child's Food Record / 1 to 12 Years of Age, Spanish (PDF) DMS Spanish 07/2008 No
F-01066AS HealthCheck Child's Food Record / 1 to 12 Years of Age, Spanish (Word) DMS Spanish 07/2008 No
F-01063 HealthCheck Family History (PDF) DMS English 08/2017 No
F-01063 HealthCheck Family History (Word) DMS English 08/2017 No
F-01063S HealthCheck Family History, Spanish (Word) DMS Spanish 08/2017 No
F-01063S HealthCheck Family History, Spanish (PDF) DMS Spanish 08/2017 No
F-01002 HealthCheck Individual Health History (PDF) DMS English 08/2019 No
F-01002 HealthCheck Individual Health History (Word) DMS English 08/2019 No
F-01002H HealthCheck Individual Health History, Hmong (Word) DMS Hmong 08/2019 No
F-01002H HealthCheck Individual Health History, Hmong (PDF) DMS Hmong 08/2019 No
F-01002S HealthCheck Individual Health History, Spanish (Word) DMS Spanish 08/2019 No
F-01002S HealthCheck Individual Health History, Spanish (PDF) DMS Spanish 08/2019 No
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) (Word) DMS English 07/2008 No
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) (PDF) DMS English 07/2008 No
F-01066S HealthCheck Infant's Food Record (Birth to 12 Months of Age), Spanish (PDF) DMS Spanish 07/2008 No
F-01066S HealthCheck Infant's Food Record (Birth to 12 Months of Age), Spanish (Word) DMS Spanish 07/2008 No
F-00021 HealthCheck Referral (PDF) DMS English 01/2017 No
F-01067 HealthCheck Your Child's Speech and Hearing (Word) DMS English 07/2008 No
F-01067 HealthCheck Your Child's Speech and Hearing (PDF) DMS English 07/2008 No
F-01359 Historical Earnings Verification Request (Word) DMS English 02/2022 No
F-03112 HMO Quarterly Appeals Log (Excel) DMS English 02/2025 No
F-03112A HMO Quarterly Grievance Log (Excel) DMS English 02/2025 No
F-03112AI HMO Quarterly Grievance Log Instructions (PDF) DMS English 01/2024 No
F-10183 Information Change Report (PDF) DMS English 05/2017 No
F-10183DA Information Change Report, Dari (PDF) DMS Dari (Afghan Persian) 05/2017 No
F-10183H Information Change Report, Hmong (PDF) DMS Hmong 05/2017 No
F-10183PA Information Change Report, Pashto (PDF) DMS Pashto 05/2017 No
F-10183S Information Change Report, Spanish (PDF) DMS Spanish 05/2017 No
F-03112I Instructions for Logging HMO Appeals (PDF) DMS English 02/2025 No
F-00107A Instructions, Self-Employment Income Report (PDF) DMS English 04/2026 No
F-00107ACM Instructions, Self-Employment Income Report, Chinese (Simplified) (PDF) DMS Chinese (Simplified) 04/2026 No
F-00107AH Instructions, Self-Employment Income Report, Hmong (PDF) DMS Hmong 04/2026 No
F-00107AS Instructions, Self-Employment Income Report, Spanish (PDF) DMS Spanish 04/2026 No

DHS is required under Wis. Stat. § 15.04(1) to establish and maintain a forms management program, appoint a forms officer, and establish and maintain a numbering and filing system for official forms.

Glossary

 
Last revised September 30, 2025