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Medicaid Forms

Below is a list of all Medicaid 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-11268 BadgerCare Plus Express Enrollment for Pregnant Women Provider Certification (PDF) OIG English 01/2021 No
F-01726 Basic Equipment List for Nurse Aide Training Programs (Word) DQA English 01/2023 No
F-00922 Behavioral Health Integrated Care Health Home Certification Application (PDF) DMS English 12/2013 No
F-00922 Behavioral Health Integrated Care Health Home Certification Application (Word) DMS English 12/2013 No
F-12023 Birth to Three Program HMO Exemption Request (PDF) DMS English 12/2024 No
F-12023H Birth to Three Program HMO Exemption Request, Hmong (PDF) DMS Hmong 12/2024 No
F-12023S Birth to Three Program HMO Exemption Request, Spanish (PDF) DMS Spanish 12/2024 No
F-01153 Breast Pump Order (Word) DMS English 10/2024 No
F-01153 Breast Pump Order (PDF) DMS English 10/2024 No
F-00023 Case Management Agency Self-Audit Checklist (PDF) DMS English 01/2017 No
F-11318 Certification Criteria for Partners and Providers to Provide Express Enrollment of Children in BadgerCare Plus (PDF) OIG English 04/2021 No
F-11317 Certification Criteria for Providers Express Enrollment of Pregnant Women in BadgerCare Plus (PDF) OIG English 04/2021 No
F-01162 Certification of Emergency for Non-U.S. Citizens (PDF) DMS English 02/2009 No
F-01162A Certification of Emergency for Non-U.S. Citizens Completion Instructions (PDF) DMS English 02/2009 No
F-11047 Certification of Need for Elective / Urgent Psychiatric / Substance Abuse Admissions to Hospital Institutions for Mental Disease for Members Under Age 21 (PDF) DMS English 02/2009 No
F-01197 Certification of Need for Specialized Medical Vehicle Transportation (PDF) DMS English 06/2009 No
F-01197 Certification of Need for Specialized Medical Vehicle Transportation (Word) DMS English 06/2009 No
F-01197A Certification of Need for Specialized Medical Vehicle Transportation Completion Instructions (PDF) DMS English 06/2009 No
F-03391 Child Care Coordination (CCC) Care Plan (PDF) DMS English 07/2025 No
F-03391 Child Care Coordination (CCC) Care Plan (Word) DMS English 07/2025 No
F-03391A Child Care Coordination (CCC) Care Plan Instructions (PDF) DMS English 07/2025 No
F-01118 Child Care Coordination (CCC) Family Questionnaire Domains and Questions (Word) DMS English 07/2025 No
F-01118 Child Care Coordination (CCC) Family Questionnaire Domains and Questions (PDF) DMS English 07/2025 No
F-01118H Child Care Coordination (CCC) Family Questionnaire Domains and Questions, Hmong (Word) DMS Hmong 07/2025 No
F-01118H Child Care Coordination (CCC) Family Questionnaire Domains and Questions, Hmong (PDF) DMS Hmong 07/2025 No
F-01118S Child Care Coordination (CCC) Family Questionnaire Domains and Questions, Spanish (Word) DMS Spanish 07/2025 No
F-01118S Child Care Coordination (CCC) Family Questionnaire Domains and Questions, Spanish (PDF) DMS Spanish 07/2025 No
F-03390 Child Care Coordination Care Coordinator Visit Checklist (PDF) DMS English 07/2025 No
F-03390 Child Care Coordination Care Coordinator Visit Checklist (Word) DMS English 07/2025 No
F-03257 Child Care Coordination Monthly Time Log for Ongoing Care Coordination and Monitoring (PDF) DMS English 12/2023 No
F-03257 Child Care Coordination Monthly Time Log for Ongoing Care Coordination and Monitoring (Word) DMS English 12/2023 No
F-03257A Child Care Coordination Monthly Time Log for Ongoing Care Coordination and Monitoring, Instructions (PDF) DMS English 12/2023 No
F-03256 Child Care Coordination Referral (Word) DMS English 07/2025 No
F-03256 Child Care Coordination Referral (PDF) DMS English 07/2025 No
F-13470 Claim Form Attachment Cover Page (PDF) DMS English 03/2023 No
F-13470 Claim Form Attachment Cover Page (Word) DMS English 03/2023 No
F-13470A Claim Form Attachment Cover Page: Instructions (PDF) DMS English 03/2023 No
F-13066 Claim Refund (Word) DMS English 08/2012 No
F-13066 Claim Refund (PDF) DMS English 08/2012 No
F-13066A Claim Refund Completion Instructions (PDF) DMS English 08/2012 No
F-01159 Commercial Other Coverage Discrepancy Report (PDF) DMS English 04/2017 No
F-01159 Commercial Other Coverage Discrepancy Report (Word) DMS English 04/2017 No
F-01159A Commercial Other Coverage Discrepancy Report Instructions (PDF) DMS English 04/2017 No
F-10096 Community Spouse Asset Share (PDF) DMS English 07/2008 No
F-10096S Community Spouse Asset Share, Spanish (PDF) DMS Spanish 07/2008 No
F-10097A Community-Based Long-Term Care Services Medicaid Income Allocation (PDF) DMS English 06/2022 No
F-10097AH Community-Based Long-Term Care Services Medicaid Income Allocation, Hmong (PDF) DMS Hmong 06/2022 No
F-10097AS Community-Based Long-Term Care Services Medicaid Income Allocation, Spanish (PDF) DMS Spanish 06/2022 No
F-13073 Compound Drug Claim (Word) DMS English 04/2017 No
F-13073 Compound Drug Claim (PDF) DMS English 04/2017 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