Skip to main content

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-03243 Long-Term Care (LTC) Waiver Daily Living Skills Attestation (Word) DMS English 01/2026 No
F-03243 Long-Term Care (LTC) Waiver Daily Living Skills Attestation (PDF) DMS English 01/2026 No
F-03245 Long-Term Care (LTC) Waiver Environmental Accessibility Adaptations (Home Modification) Attestation (Word) DMS English 04/2026 No
F-03245 Long-Term Care (LTC) Waiver Environmental Accessibility Adaptations (Home Modification) Attestation (PDF) DMS English 04/2026 No
F-03244 Long-Term Care (LTC) Waiver Financial Management Attestation (PDF) DMS English 09/2024 No
F-03244 Long-Term Care (LTC) Waiver Financial Management Attestation (Word) DMS English 09/2024 No
F-03234 Long-Term Care (LTC) Waiver Housing Counseling Attestation (PDF) DMS English 04/2026 No
F-03234 Long-Term Care (LTC) Waiver Housing Counseling Attestation (Word) DMS English 04/2026 No
F-03235 Long-Term Care (LTC) Waiver Incidental Personal Care Attestation (PDF) DMS English 04/2026 No
F-03235 Long-Term Care (LTC) Waiver Incidental Personal Care Attestation (Word) DMS English 04/2026 No
F-03236 Long-Term Care (LTC) Waiver Prevocational Attestation (Word) DMS English 04/2026 No
F-03236 Long-Term Care (LTC) Waiver Prevocational Attestation (PDF) DMS English 04/2026 No
F-03237 Long-Term Care (LTC) Waiver Support Broker Attestation (PDF) DMS English 04/2026 No
F-03237 Long-Term Care (LTC) Waiver Support Broker Attestation (Word) DMS English 04/2026 No
F-03238 Long-Term Care (LTC) Waiver Supported Employment and Competitive Integrated Employment Attestation (PDF) DMS English 04/2026 No
F-03238 Long-Term Care (LTC) Waiver Supported Employment and Competitive Integrated Employment Attestation (Word) DMS English 04/2026 No
F-03239 Long-Term Care (LTC) Waiver Supportive Home Care and Respite Attestation (PDF) DMS English 09/2024 No
F-03241 Long-Term Care (LTC) Waiver Vehicle Modification Attestation (PDF) DMS English 09/2024 No
F-03241 Long-Term Care (LTC) Waiver Vehicle Modification Attestation (Word) DMS English 09/2024 No
F-03242 Long-Term Care (LTC) Waiver Vocational Futures Attestation (PDF) DMS English 04/2026 No
F-03242 Long-Term Care (LTC) Waiver Vocational Futures Attestation (Word) DMS English 04/2026 No
F-01567 Long-Term Care Insurance Policy - Assignment of Benefits (PDF) DMS English 12/2018 No
F-01567 Long-Term Care Insurance Policy - Assignment of Benefits (Word) DMS English 12/2018 No
F-01567S Long-Term Care Insurance Policy - Assignment of Benefits, Spanish (PDF) DMS Spanish 12/2018 No
F-01915 Marketplace or Indicator Gap Filling Eligibility Determinations Supplemental Letter (Word) DMS English 07/2017 No
F-10112A Medicaid - Disability Application Addendum (PDF) DMS English 11/2020 No
F-10112AH Medicaid - Disability Application Addendum, Hmong (PDF) DMS Hmong 11/2020 No
F-10112AS Medicaid - Disability Application Addendum, Spanish (PDF) DMS Spanish 11/2020 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-10191 Medicaid Annuity Beneficiary Designation (PDF) DMS English 01/2009 No
F-10192 Medicaid Annuity Information - Disclosure (PDF) DMS English 01/2009 No
F-10095 Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse (PDF) DMS English 07/2015 No
F-10095S Medicaid Asset Assessment Medical Institution / Community Waiver Resident and Community Spouse, Spanish (PDF) DMS Spanish 07/2008 No
F-10137 Medicaid Change Report (PDF) DMS English 06/2023 No
F-10137DA Medicaid Change Report, Dari (PDF) DMS Dari (Afghan Persian) 06/2023 No
F-10137H Medicaid Change Report, Hmong (PDF) DMS Hmong 06/2023 No
F-10137PA Medicaid Change Report, Pashto (PDF) DMS Pashto 06/2023 No
F-10137S Medicaid Change Report, Spanish (PDF) DMS Spanish 06/2023 No
F-01298 Medicaid Deductible Worksheet (PDF) DMS English 07/2014 No
F-10112 Medicaid Disability Application (PDF) DMS English 02/2026 Yes
F-10112H Medicaid Disability Application, Hmong (PDF) DMS Hmong 02/2026 No
F-10112S Medicaid Disability Application, Spanish (PDF) DMS Spanish 02/2026 No
F-10114 Medicaid Disability Redetermination Report (PDF) DMS English 10/2023 No
F-01297 Medicaid Institution Determination Worksheet (PDF) DMS English 07/2014 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