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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-01234A Instructions: Explanation of Medical Benefits (PDF) DMS English 04/2026 No
F-11010A Instructions: Prior Authorization / Dental Attachment 1 (PA/DA1) Check Box Format (PDF) DMS English 01/2018 No
F-01915 Marketplace or Indicator Gap Filling Eligibility Determinations Supplemental Letter (Word) DMS English 07/2017 No
F-10151 Medicaid / BadgerCare Plus Fair Hearing Information (PDF) DMS English 06/2018 No
F-10151H Medicaid / BadgerCare Plus Fair Hearing Information, Hmong (PDF) DMS Hmong 06/2018 No
F-10151S Medicaid / BadgerCare Plus Fair Hearing Information, Spanish (PDF) DMS Spanish 06/2018 No
F-10109 Medicaid / BadgerCare Plus Remaining Deductible Update (PDF) DMS English 02/2014 No
F-10093S Medicaid and BadgerCare Overpayment Notice, Spanish (PDF) DMS Spanish 09/2019 No
F-10093 Medicaid and BadgerCare Plus Overpayment Notice (PDF) DMS English 09/2019 No
F-10093S Medicaid and BadgerCare Plus Overpayment Notice, Spanish (Word) DMS Spanish 09/2019 No
F-00855 Medication Therapy Management Case Management Software Requirements (PDF) DMS English 01/2026 No
F-00855 Medication Therapy Management Case Management Software Requirements (Word) DMS English 01/2026 No
F-00855A Medication Therapy Management Case Management Software Vendor Steps for Software Approval Process (PDF) DMS English 01/2026 No
F-00855A Medication Therapy Management Case Management Software Vendor Steps for Software Approval Process (Word) DMS English 01/2026 No
F-13026 Member / Employer Electronic Funds Transfer for BadgerCare Plus Premiums (PDF) DMS English 05/2024 No
F-13026S Member / Employer Electronic Funds Transfer for BadgerCare Plus Premiums, Spanish (PDF) DMS Spanish 05/2024 No
F-01915A Member Request Gap Filling Eligibility Determinations Supplemental Letter (Word) DMS English 07/2017 No
F-11090 Mental Health Day Treatment Functional Assessment (Word) DMS English 08/2015 No
F-11090 Mental Health Day Treatment Functional Assessment (PDF) DMS English 08/2015 No
F-11090A Mental Health Day Treatment Functional Assessment: Completion Instructions (PDF) DMS English 08/2015 No
F-03452 Midwife Exemption Request (PDF) DMS English 08/2026 No
F-03452H Midwife Exemption Request, Hmong (PDF) DMS Hmong 08/2026 No
F-03452S Midwife Exemption Request, Spanish (PDF) DMS Spanish 08/2026 No
F-10180 New Enrollee Health Needs Assessment (NEHNA) Survey - Enrollee Version (PDF) DMS English 07/2008 No
F-01165 Newborn Report (PDF) DMS English 09/2019 No
F-01165 Newborn Report (Word) DMS English 09/2019 No
F-13072 Noncompound Drug Claim (PDF) DMS English 02/2025 No
F-13072 Noncompound Drug Claim (Word) DMS English 02/2025 No
F-13072A Noncompound Drug Claim: Completion Instructions (PDF) DMS English 02/2025 No
F-16015 Notice of Approval of Benefits/Positive Change in Benefits (Word) DMS English 07/2020 No
F-16015S Notice of Approval of Benefits/Positive Change in Benefits, Spanish (Word) DMS Spanish 07/2020 No
F-16001 Notice of Denial of Benefits/Negative Change in Benefits (Word) DMS English 05/2018 No
F-16001AR Notice of Denial of Benefits/Negative Change in Benefits, Arabic (PDF) DMS Arabic 05/2018 No
F-16001CM Notice of Denial of Benefits/Negative Change in Benefits, Chinese (Simplified) (PDF) DMS Chinese (Simplified) 05/2018 No
F-16001G Notice of Denial of Benefits/Negative Change in Benefits, German (PDF) DMS German 05/2018 No
F-16001H Notice of Denial of Benefits/Negative Change in Benefits, Hmong (PDF) DMS Hmong 05/2018 No
F-16001L Notice of Denial of Benefits/Negative Change in Benefits, Laotian (PDF) DMS Lao 05/2018 No
F-16001R Notice of Denial of Benefits/Negative Change in Benefits, Russian (PDF) DMS Russian 05/2018 No
F-16001SO Notice of Denial of Benefits/Negative Change in Benefits, Somali (PDF) DMS Somali 05/2018 No
F-16001S Notice of Denial of Benefits/Negative Change in Benefits, Spanish (Word) DMS Spanish 05/2018 No
F-16014 Notice of Program Violation (PDF) DMS English 03/2018 No
F-01013 Nurse Aide Training and Competency Test Reimbursement Request (PDF) DMS English 11/2018 No
F-01013 Nurse Aide Training and Competency Test Reimbursement Request (Word) DMS English 11/2018 No
F-01013A Nurse Aide Training and Competency Test Reimbursement Request Instructions (PDF) DMS English 03/2019 No
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan (Word) DMS English 10/2008 No
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan (PDF) DMS English 10/2008 No
F-11103A Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan: Completion Instructions (PDF) DMS English 07/2012 No
F-11133 Personal Care Screening Tool (PCST) (Word) DMS English 11/2024 No
F-11133 Personal Care Screening Tool (PCST) (PDF) DMS English 11/2024 No
F-11133A Personal Care Screening Tool (PCST) Instructions (PDF) DMS English 11/2024 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.

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Last revised September 30, 2025