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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-01068H General Pediatric Clinic - 18 Month Visit (Word) DMS English 08/2019 No
F-01068I General Pediatric Clinic - 24 Month Visit (PDF) DMS English 08/2019 No
F-01068I General Pediatric Clinic - 24 Month Visit (Word) DMS English 08/2019 No
F-01068A General Pediatric Clinic - 3 to 4 Week Visit (PDF) DMS English 08/2019 No
F-01068A General Pediatric Clinic - 3 to 4 Week Visit (Word) DMS English 08/2019 No
F-01068C General Pediatric Clinic - 4 Month Visit (Word) DMS English 08/2019 No
F-01068C General Pediatric Clinic - 4 Month Visit (PDF) DMS English 08/2019 No
F-01068D General Pediatric Clinic - 6 Month Visit (PDF) DMS English 08/2019 No
F-01068D General Pediatric Clinic - 6 Month Visit (Word) DMS English 08/2019 No
F-01068B General Pediatric Clinic - 6 to 8 Week Visit (Word) DMS English 08/2019 No
F-01068B General Pediatric Clinic - 6 to 8 Week Visit (PDF) DMS English 08/2019 No
F-01068E General Pediatric Clinic - 9 Month Visit (PDF) DMS English 08/2019 No
F-01068E General Pediatric Clinic - 9 Month Visit (Word) DMS English 08/2019 No
F-01068K General Pediatric Clinic - Elementary School Visit (Word) DMS English 08/2019 No
F-01068K General Pediatric Clinic - Elementary School Visit (PDF) DMS English 08/2019 No
F-01068J General Pediatric Clinic - Preschool Visit (PDF) DMS English 08/2019 No
F-01068J General Pediatric Clinic - Preschool Visit (Word) DMS English 08/2019 No
F-01068L General Pediatric Clinic - Teenager Visit (Word) DMS English 08/2019 No
F-01068L General Pediatric Clinic - Teenager Visit (PDF) 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 (PDF) DMS English 08/2019 No
F-01062 HealthCheck Adolescent Review (Word) 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 (PDF) DMS Spanish 07/2008 No
F-01066BS HealthCheck Adolescent's Food Record (13 to 20 Years of Age), Spanish (Word) DMS Spanish 07/2008 No
F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age (PDF) DMS English 07/2008 No
F-01066A HealthCheck Child's Food Record / 1 to 12 Years of Age (Word) DMS English 07/2008 No
F-01066AS HealthCheck Child's Food Record / 1 to 12 Years of Age, Spanish (Word) DMS Spanish 07/2008 No
F-01066AS HealthCheck Child's Food Record / 1 to 12 Years of Age, Spanish (PDF) DMS Spanish 07/2008 No
F-11289 HealthCheck County Outreach Case Management Plan for County (PDF) DMS English 09/2019 No
F-11289 HealthCheck County Outreach Case Management Plan for County (Word) DMS English 09/2019 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 (PDF) DMS Spanish 08/2017 No
F-01063S HealthCheck Family History, Spanish (Word) 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 (PDF) DMS Hmong 08/2019 No
F-01002H HealthCheck Individual Health History, Hmong (Word) DMS Hmong 08/2019 No
F-01002S HealthCheck Individual Health History, Spanish (PDF) DMS Spanish 08/2019 No
F-01002S HealthCheck Individual Health History, Spanish (Word) DMS Spanish 08/2019 No
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) (PDF) DMS English 07/2008 No
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) (Word) 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

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