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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-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member (PDF) DMS English 02/2025 No
F-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member (Word) DMS English 02/2025 No
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program (PDF) DMS English 02/2025 No
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program (Word) DMS English 02/2025 No
F-00842 Pharmacy Services Lock-In Program - Program Summary (PDF) DMS English 07/2013 No
F-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services (PDF) DMS English 02/2025 No
F-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services (Word) DMS English 02/2025 No
F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services (PDF) DMS English 02/2025 No
F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services (Word) DMS English 02/2025 No
F-00406 Pharmacy Services Lock-In Program HMO Member Designation of Pharmacy (Word) DMS English 02/2025 No
F-00406 Pharmacy Services Lock-In Program HMO Member Designation of Pharmacy (PDF) DMS English 02/2025 No
F-11184 Pharmacy Services Lock-In Program Member Designation of Providers (Word) DMS English 02/2025 No
F-11184 Pharmacy Services Lock-In Program Member Designation of Providers (PDF) DMS English 02/2025 No
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use (Word) DMS English 02/2025 No
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use (PDF) DMS English 02/2025 No
F-13074 Pharmacy Special Handling Request (Word) DMS English 04/2014 No
F-13074 Pharmacy Special Handling Request (PDF) DMS English 04/2014 No
F-13074A Pharmacy Special Handling Request: Completion Instructions (PDF) DMS English 07/2012 No
F-00401 Preferred Drug List (PDL) Expedited Emergency Supply Request (Word) DMS English 01/2021 No
F-00401 Preferred Drug List (PDL) Expedited Emergency Supply Request (PDF) DMS English 01/2021 No
F-00401A Preferred Drug List (PDL) Expedited Emergency Supply Request, Instructions (PDF) DMS English 01/2021 No
F-03185 Prenatal Care Coordination Care Coordinator Visit Checklist (PDF) DMS English 06/2023 No
F-03185 Prenatal Care Coordination Care Coordinator Visit Checklist (Word) DMS English 06/2023 No
F-03183 Prenatal Care Coordination Care Plan (PDF) DMS English 06/2023 No
F-03183 Prenatal Care Coordination Care Plan (Word) DMS English 06/2023 No
F-03183A Prenatal Care Coordination Care Plan, Instructions (PDF) DMS English 06/2023 No
F-03186 Prenatal Care Coordination Monthly Time Log for Ongoing Care Coordination and Monitoring (PDF) DMS English 12/2023 No
F-03186 Prenatal Care Coordination Monthly Time Log for Ongoing Care Coordination and Monitoring (Word) DMS English 12/2023 No
F-03186A Prenatal Care Coordination Monthly Time Log for Ongoing Care Coordination and Monitoring, Instructions (PDF) DMS English 12/2023 No
F-03184 Prenatal Care Coordination Personnel Management and Training Plan (PDF) DMS English 06/2026 No
F-03184 Prenatal Care Coordination Personnel Management and Training Plan (Word) DMS English 06/2026 No
F-03188 Prenatal Care Coordination Plan of Operation (PDF) DMS English 06/2026 No
F-03188 Prenatal Care Coordination Plan of Operation (Word) DMS English 06/2026 No
F-01105 Prenatal Care Coordination Pregnancy Questionnaire (PDF) DMS English 07/2024 No
F-01105 Prenatal Care Coordination Pregnancy Questionnaire (Word) DMS English 07/2024 No
F-01105A Prenatal Care Coordination Pregnancy Questionnaire Instructions (PDF) DMS English 07/2024 No
F-01105AH Prenatal Care Coordination Pregnancy Questionnaire Instructions, Hmong (PDF) DMS Hmong 07/2024 No
F-01105AS Prenatal Care Coordination Pregnancy Questionnaire Instructions, Spanish (PDF) DMS Spanish 07/2024 No
F-01105H Prenatal Care Coordination Pregnancy Questionnaire, Hmong (PDF) DMS Hmong 07/2024 No
F-01105H Prenatal Care Coordination Pregnancy Questionnaire, Hmong (Word) DMS Hmong 07/2024 No
F-01105S Prenatal Care Coordination Pregnancy Questionnaire, Spanish (PDF) DMS Spanish 07/2024 No
F-01105S Prenatal Care Coordination Pregnancy Questionnaire, Spanish (Word) DMS Spanish 07/2024 No
F-03187 Prenatal Care Coordination Referral (PDF) DMS English 12/2023 No
F-03187 Prenatal Care Coordination Referral (Word) DMS English 12/2023 No
F-03187A Prenatal Care Coordination Referral, Instructions (PDF) DMS English 12/2023 No
F-00704 Prior Authorization - Committee Public Testimony Registration (PDF) DMS English 08/2016 No
F-00694 Prior Authorization - Preferred Drug List (PA/PDL) for Cytokine and Cell Adhesion Molecule (CAM) Antagonist Drugs for Ulcerative Colitis (PDF) DMS English 12/2013 No
F-11038 Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) (PDF) DMS English 07/2012 No
F-11038 Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA) (Word) DMS English 07/2012 No
F-11038A Prior Authorization / Adult Mental Health Day Treatment Attachment (PA/MHDTA): Completion Instructions (PDF) DMS English 07/2012 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