WISCONSIN DEPARTMENT OF HEALTH SERVICES
Division of Medicaid Services
F-10101 (03/2024)
WISCONSIN MEDICAID FOR THE ELDERLY, BLIND OR DISABLED
APPLICATION PACKET
HOW TO APPLY
This is an application for health care benefits for people who are 65 years of age or older, blind or have a
disability.
To apply for health care benefits, complete this application and return it to the following address or complete an
application online at access.wi.gov. See below for more information about applying online.
Mail or Fax Applications and/or Proof/Verification to:
If you live in Milwaukee County:
MDPU
6055 N 64
th
St.
Milwaukee, WI 53218
Fax: 888-409-1979
If you do not live in Milwaukee County
CDPU
PO Box 5234
Janesville, WI 53547-5234
Fax: 855-293-1822
You can also upload any proof documents online at access.wi.gov.
You will need to provide proof of some of your answers. For more information on what you will need to
provide, see the Proof/Verification Section starting on page 5.
If you have questions about Medicaid, need help filling out this application or want to answer the questions in
person or over the phone, contact your agency to set up an appointment. If you need the address and/or phone
number of your agency, see page 7. Information is also available online at dhs.wi.gov/im-agency.
If you have a disability and need this information in an alternate format, or if you need it translated to another
language, contact your agency. These services are free of charge.
APPLY ONLINE
ACCESS is an online tool that lets you apply for benefits, check the status of your benefits, report changes or
complete your annual renewal. To visit ACCESS go to access.wi.gov. An online application is the same as a
paper application.
LETTERS AVAILABLE THROUGH THE ACCESS WEBSITE
Members can get letters and information about their benefits online instead of by regular mail. To make this
choice, the member needs to contact their agency, or log into their ACCESS account at access.wi.gov. If a
member does not have an ACCESS account, they must create one to view their letters online.
HOW TO USE THIS FORM
1. Read the Important Information section and all the instructions before completing the application.
2. Print clearly. Use blue or black ink.
3. Write dates in the mm/dd/yyyy format. (Example: April 2, 1958, would be 04/02/1958.)
4. Enter information about you and/or your spouse.
5. Completely fill out the application. There may be a delay in Medicaid benefits if the application is not
complete. (Use the checklist on page 24 to make sure your application is complete.) If your application is not
complete, the agency will contact you for more information.
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IMPORTANT INFORMATION
The following is important information regarding Medicaid for persons who are elderly, blind or have a
disability.
Legal Guardian, Conservator, or Power of Attorney
If you have a legal guardian of the estate, legal guardian of the person and the estate, conservator, or activated
durable power of attorney for finances, that person can fill out and submit this form on your behalf. That person
would also need to submit documents about his or her appointment along with this form.
When submitting this application, include the legal documentation authorizing the appointed legal guardian,
conservator, or durable power of attorney for finances for the applicant.
A legal guardian of the person can act on your behalf with your Medicaid eligibility and benefits only if this
power is granted in the court documents appointing the legal guardian of the person.
A power of attorney for health care does not have the ability to act on your behalf with your Medicaid eligibility
and benefits.
Authorized Representative
You may have an authorized representative apply for you. To appoint an authorized representative, fill out either
the Appoint, Change, or Remove an Authorized Representative: Person form, F-10126A, or the Appoint,
Change, or Remove an Authorized Representative: Organization form, F-10126B, found in this application
packet. This allows your authorized representative to complete and sign the application for you. You can also
get this form by calling 800-362-3002 or going to dhs.wi.gov/forwardhealth/representative-types.htm.
Application Date
Your application date is the date the Medicaid office gets your signed application. A decision on your Medicaid
will be mailed to you within 30 days of your application date. Unsigned forms will be returned. It is important to
apply as soon as possible since the date your benefits will begin, if you meet all program rules, is based on your
application date.
Help Paying for Medical Expenses
If insurance has not paid for your medical expenses from the last three months, you can apply for health care
coverage to pay those expenses. If you want help paying for health care for any of the past three months,
complete the “Help Paying for Medical Expenses Request” page found in this application packet.
Personally Identifiable Information/Social Security Number
Personally identifiable information and Social Security Numbers are used only for the direct administration of
the Medicaid program.
If someone in your household is not applying for Medicaid, you do not need to provide Social Security Number
(SSN) information for that person. Any person who wants Wisconsin Medicaid, but does not provide their SSN
or apply for one will not be eligible for benefits, pursuant to Wis. Stat. § 49.82(2).
If you are applying only for Emergency Services because of your immigration status, or you are a pregnant
woman applying for BadgerCare Plus Prenatal Services, you do not need to provide SSN information.
Your SSN permits a computer check of your information with government agencies such as the Internal
Revenue Service (IRS), Social Security Administration, Department of Revenue and the Department of
WISCONSIN MEDICAID FOR THE ELDERLY, BLIND, OR DISABLED APPLICATION PACKET
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Workforce Development. In addition, the Department of Health Services will match your name and SSN with
information provided by health insurance carriers to determine if you have other health insurance.
Your SSN will not be shared with the United States Citizenship and Immigration Services (USCIS).
Renewals
If you are able to get Medicaid, you will need to complete a renewal at least once every 12 months to see if you
still meet all the program rules for enrollment in Medicaid.
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Estate Recovery
If you are enrolled in Medicaid, Wisconsin State
law, with limited exceptions, requires the recovery
of certain Medicaid benefits from your estate. The
Estate Recovery Program Handbook, P-13032
provides you with information on estate recovery.
You may get a copy of the brochure online
(dhs.wi.gov/library/collection/P-13032), from your
local agency or by contacting Member Services at
800-362-3002. Certain benefits you get in the
community after age 55 and all Medicaid benefits
you get while residing in a nursing home or while
you are an inpatient in a hospital for 30 days or
more, are recoverable. Also, if you reside in a
nursing home or are institutionalized in a hospital,
and are not expected to return home to live, a lien
may be placed on your home. A lien may not be
placed on your home if you, your spouse or certain
other family members reside in the home.
Rights and Responsibilities
Rights
State and Federal laws guarantee rights for
members, which include:
• The right to be treated with respect by state and
county employees.
• The right to confidentiality of all information
given to agencies to determine eligibility. (This
does not prohibit the use of such records for
program administration.)
• The right of access to agency’s records and files
relating to your case, except information obtained
by the agency under a promise of confidentiality.
• The right to remain eligible for Medicaid benefits
even if temporarily absent from the state, if you
remain a Wisconsin resident.
• The right to a speedy determination of eligibility
status and prior notice of proposed changes in
such status.
• The right to emergency medical care.
• The right to request reasonable accommodation
to participate in the program for a disability-
related reason, or the right to request interpreters
or translators to participate in the program.
• The right to appeal any action taken concerning
your Medicaid application or ongoing benefits
that you do not agree with by requesting a fair
hearing.
Fair Hearing
You may appeal to the Division of Hearings and
Appeals or your agency if:
• Your application for Medicaid was denied in
error.
• Your application was not processed within 30
days from the date the agency received it.
• You disagree with the agency’s decision to
discontinue, terminate, suspend, or reduce your
benefit.
• Your request for prior authorization for a
medical service was denied.
You may request a fair hearing by writing to:
Wisconsin Department of Administration
Division of Hearings and Appeals
PO Box 7875
Madison, WI 53707-7875
The Request for Fair Hearing form can be found at
dhs.wi.gov/forwardhealth/resources.htm.
If you choose to write a letter instead of using the
form, you must include:
• Your name.
• Your mailing address.
• A brief description of the problem.
• The name of the agency.
• Your CARES case number.
• Your signature.
An appeal must be made no later than 45 days after
the date of the action.
You may also contact the agency where you applied
and ask for help filing a Fair Hearing request. Refer
to the ForwardHealth Enrollment and Benefits
Handbook, P-00079, to learn more about the fair
hearing process. You will get a handbook when the
agency gets your application or you can find the
handbook at dhs.wi.gov/library/collection/P-00079.
If you have questions about the fair hearing process,
you can call the Division of Hearings and Appeals at
608-266-7709.
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Responsibilities
Reporting Changes
Report to the agency within 10 days:
• Any changes in income of any member of your
household.
• Any other change in the information you have
given on your application that is required to be
reported on the Medicaid Change Report form,
F-10137, located in this application packet.
Changes can be reported online at access.wi.gov, by
calling your agency or you can use the Medicaid
Change Report form, F-10137, in this application
packet. Do not send this form with your
application; keep it for future use.
Verification/Proof
You will need to provide verification/proof of
certain information. Some of these include:
Citizenship/Identity
Federal law requires that all U.S. citizens applying
for, or getting Medicaid benefits must show proof of
their U.S. citizenship and identity unless they are
exempt. Exempt people include recipients of Social
Security Disability Insurance (SSDI), Supplemental
Security Income (SSI), Medicare, Foster Care, and
Adoption Assistance. If you are applying for
benefits, you will have at least 95 days, from the
date of your application, to provide proof to the
agency. If you have provided this information in the
past, it may already be on file; your agency will let
you know if more proof is needed.
We also verify with the U.S. Department of
Homeland Security the immigration status of all
immigrants who apply for benefits for themselves.
Immigration status will not be verified with United
States Citizenship and Immigration Services
(USCIS) for people in your household who are not
applying for assistance. If someone in your
household is not applying for Medicaid, you do not
need to answer this question for that person.
Note: Undocumented immigrants are only eligible
for coverage of emergency health care services if
they would otherwise be eligible for Medicaid.
Pregnant immigrants may be able to enroll in
BadgerCare Plus Prenatal Services.
Examples of what you can use to prove both
citizenship and identity are:
• U.S. passport
• Certificate of U.S. Citizenship
• Certification of U.S. Naturalization
• A state-issued enhanced driver’s license
• Tribal identification documents
Examples of what you can use to prove
citizenship are:
• U.S. birth certificate
• U.S. State Department Report of Birth Abroad
• U.S. citizen ID card
• Adoption papers showing U.S. birth
• Hospital record of U.S. birth
• U.S. military record of service or draft record
showing U.S. birth
• Life or health insurance record showing U.S.
birth
• Nursing home admission papers showing U.S.
birth
Examples of what you can use to prove identity
are:
• State driver’s license
• ID card issued by federal, state, or local
government
• School ID card with photo
• U.S. military dependent ID card
• U.S. military ID card
• For children under age 18, a signed Statement of
Identity form, F-10154
(dhs.wi.gov/library/collection/f-10154)
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Assets
You will be required to provide proof of all your
assets. Examples of proof documents include a copy
of your bank statement showing the value of your
bank account on the date the application is
completed, property tax bill, vehicle
title/registration, or something that shows the face
value and cash value of your life insurance policy. If
married and applying for Institutional Medicaid, an
Asset Assessment will be required for both the
applicant and spouse.
Other
Your worker may also ask for proof of the
following:
• Medical expenses to meet a deductible
• Physician’s certification (verbally or in writing)
that the person is likely to return to the home or
apartment within 6 months for institutionalized
persons maintaining a home or property and who
may be entitled to a home maintenance
allowance. If allowed, expenses will need to be
verified
• Documentation for power of attorney, legal
guardianship, or conservator
• Disability
If you have these items available on the day you
submit this application, provide a copy of them with
your application. You will be contacted by the
agency and be asked to provide proof of missing,
conflicting or vague information, if the information
would affect the decision about your Medicaid
enrollment.
Do not send original documents in the mail. You
may bring in original documents or send
photocopies of these items with your application. If
you are having trouble getting what you need to
provide proof, contact your agency and ask for help.
Income Maintenance Consortiums and Tribal Agencies
Contact Information
Income maintenance consortiums (often called agencies) and tribal agencies can help you with eligibility services for
programs like Medicaid, BadgerCare Plus, and FoodShare. The table below lists income maintenance consortiums and
tribal agencies alphabetically and includes telephone numbers as well as the counties that make up each consortium. If
you have questions about your eligibility or case, call the consortium that represents your county or your tribal agency.
Bad River Band of Lake Superior Tribe of Chippewa Indians
715-682-7127
Bay Lake
888-794-5747
• Brown
• Door
Capital
888-794-5556
• Adams
• Columbia
• Dane
• Juneau
• Sheboygan
Central
888-445-1621
• Langlade
• Marathon
East Central Income Maintenance Partnership
888-256-4563
• Calumet
• Green Lake
• Kewaunee
• Marquette
• Waushara
Forest County Potawatomi Community
715-478-4433
Great Rivers
888-283-0012
• Barron
• Burnett
• Chippewa
• Douglas
• Eau Claire
• Pierce
• St. Croix
• Washburn
Lac Courte Oreilles Band of Lake Superior Tribe of Chippewa Indians of Wisconsin
715-634-8934
Lac du Flambeau Band of Lake Superior Tribe of Chippewa Indians
715-588-4235
Menominee Indian Tribe of Wisconsin
715-799-5137
Milwaukee Enrollment Services (MilES)
888-947-6583
Milwaukee
Moraine Lakes
888-446-1239
• Fond du Lac
• Ozaukee
Northern
888-794-5722
• Ashland
• Bayfield
• Florence
• Forest
• Lincoln
• Price
• Taylor
• Vilas
Oneida Nation
800-216-3216
Red Cliff Band of Lake Superior Chippewa
715-779-3706
Sokaogon Chippewa Community
715-478-3265
Southern
888-794-5780
• Crawford
• Grant
•
Green
• Jefferson
• Rock
Stockbridge-Munsee Community
715-793-4032
Western Region for Economic Assistance
888-627-0430
• Buffalo
• Clark
• Jackson
• Monroe
• Vernon
Wisconsin’s Kenosha Racine Partnership (WKRP)
888-794-5820
• Kenosha
Division of Medicaid Services
P-02342 (02/2019)
Map of Income Maintenance Consortiums
and Tribal Agencies
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WISCONSIN MEDICAID FOR THE ELDERLY, BLIND OR DISABLED APPLICATION
Instructions: Before completing this form, read all instructions. Use black or blue ink only. Write all dates in the
mm/dd/yyyy format (for example, April 2, 1958, would be 04/02/1958). If you need more space to write your
answers, use an additional sheet of paper. Try to give us as much information as you can. If you do not give us
some information now, we may have to ask for it before we can make a decision about your application.
Keep pages 1 through 8 and the Medicaid Change Report, F-10137, of this application packet for future
use.
If you are completing this application for someone else, complete either the Appoint, Change, or Remove an
Authorized Representative: Person form, F-10126A, or the Appoint, Change, or Remove an Authorized
Representative: Organization form, F-10126B, found in this application packet, or attach legal documentation
authorizing you as the appointed legal guardian, conservator, or durable power of attorney for finances for the
applicant. Information provided on this application should be about the applicant, not the representative.
SECTION I – APPLICANT INFORMATION – In this section, we need you to tell us about yourself.
Name – Applicant (last, first, MI)
Do you have any names you have previously used such as a married or maiden name? Yes No
If yes, what are those names?
Date of Birth Social Security Number
Sex Male Female
Ethnicity* (optional)
Hispanic or Latino Not Hispanic or Latino
Race* (optional, choose one or more)
American Indian/Alaska Native Asian Black/African American
Hawaiian/Other Pacific Islander White
*You don’t have to answer the ethnicity and race questions if you don’t want to. We’re asking these questions
to help improve our programs and make sure they do not discriminate based on ethnicity or race. Your
answers will not be used to make a decision about your programs and benefits.
Are you a member, child, or grandchild of a
member of an American Indian Tribe or an Alaska
Native?
Yes No
In what language do you want your letters printed?
English Spanish
Primary language spoken in your home
Are there any children under 18 in the home?
Yes No
SECTION 2 – CONTACT INFORMATION – Please tell us how we can contact you. For phone numbers, please
include the area code.
Name of contact, if not the applicant
Phone Number – Applicant
Home Cell Work
Phone Number – Authorized Representative / Power
of Attorney
Home Cell Work
Other Number Where We Can Leave a Message If you are deaf or hard of hearing and you have asked
us to get in touch with you by phone, what method do
you use?
Relay TTY None
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Email Address – Applicant Email Address - Authorized Representative/Power of
Attorney
Are you homeless* now or have you been homeless in the last 12 months?
Yes No
*By homeless, we mean you do not have a long-term place to stay at night. You could be staying at a shelter or with a
friend or relative or may not have a place to stay.
What is the best way to contact you during weekdays?
Email Home Phone Cell Phone Other (explain)
What is the best time to call you during weekdays (for example, Monday after 3:00 p.m., Monday–Friday
before 12 p.m.)?
You can get letters about your programs and benefits online. If you choose to get letters online:
• You will get an email every time you have a new letter to view. Log in to your ACCESS account to view
your letters.
• You will not get copies of your letters in the regular mail. However, there are some letters that must
always be sent by regular mail (such as forms that you must fill out and send back to us).
Do you want to get letters about your benefits online instead of by regular mail? Yes No
You can choose to get emails about your health services from our health care partners (for example, an HMO).
Only the primary person for a case (the person who is applying for benefits) may get information about health
services for themselves and anyone in the home who is younger than age 19.
Other adults on a
case who are older than age 18 will need to create their own ACCESS account to choose to
get emails about health services from our health care partners.
Do you want to
get email from our health partners? Yes No
SECTION 3 – ADDITIONAL APPLICANT INFORMATION – In this section we need additional information about
you, the applicant.
Where are you currently living? If you live in a medical institution, use the name and address of the institution.
Street
City
State
Zip Code
Is this also your mailing address? Yes No If you answered no, what is your mailing address?
Are you currently living in a nursing home, institution for mental disease (IMD), or hospital? Yes No
If yes, what is the date you were admitted?
Did you live in a nursing home, IMD, or hospital in the past? If so when?
Are you working with an Aging & Disability Resource Center (ADRC) to get long-term care services in your
home or assisted living facility?
Yes No
If you answered yes to either of the previous two questions, complete Section 20 in this packet.
Do you plan to keep living in Wisconsin? Yes No
Do you need help paying for health care you got in the last three months? Yes No
If you answered yes, complete Section 19 in this packet.
Marital Status
Married Legally separated Annulled Divorced Widowed Never married
Are you a U.S. citizen? (See page 4)
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Yes No
If no, complete the following questions:
What is your Alien Registration or USCIS number?
When did you come to the U.S. to live?
Do you have a sponsor? Yes No
Are you on active duty in the U.S. military or an honorably discharged veteran, married to someone on active
duty or an honorably discharged veteran, the surviving spouse of a veteran, or the child of someone on active
duty or an honorably discharged veteran?
Yes No
SECTION 4 – SPOUSE INFORMATION – In this section, we will ask you general information about your
spouse, if you are married, separated, or legally separated. Answer all questions in this section with your
spouse’s information. If you are not married, go to Section 5.
Name (last, first, MI)
Social Security Number Date of Birth
Other Names Previously Used, Such as a Maiden or Married Name
Spouse’s Address (if different from applicant’s address)
Street City State Zip Code
Ethnicity* (optional)
Hispanic or Latino Not Hispanic or Latino
Race* (optional)
American Indian/Alaska Native Asian Black/African American
Hawaiian/Other Pacific Islander White
*You do not have to answer the ethnicity and race questions if you do not want to. We are asking these
questions to help improve our programs and make sure they do not discriminate based on ethnicity or race.
Your answers will not be used to make a decision about your benefits.
Is your spouse currently living in a nursing home, IMD, or hospital?
Yes No If you answered yes and your spouse is applying for Medicaid, complete Section 20.
If yes, what is the date your spouse was admitted?
Did your spouse live in a nursing home, IMD, or hospital in the past? Yes No
If yes, when?
Is your spouse applying for Medicaid? Yes No
If you answered “No”, stop here and go to Section 5.
Does your spouse plan to keep living in Wisconsin? Yes No
Does your spouse need help paying for health care they got in the last three months? Yes No
If you answered yes, complete Section 19 in this packet.
Is your spouse working with an ADRC to get long-term care services in their home or assisted living facility?
Yes No If you answered yes, complete Section 20 in this packet.
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Is your spouse a member, child, or grandchild of a member of an American Indian Tribe or an Alaska Native?
Yes No
Is your spouse a U.S. citizen? (See page 4)
Yes No
If no, complete the following questions:
What is your spouse’s Alien Registration or USCIS number?
When did your spouse come to the U.S. to live?
Does your spouse have a sponsor?
Yes No
Is your spouse on active duty in the U.S. military or an honorably discharged veteran, the surviving spouse of
a veteran, or the child of someone on active duty or an honorably discharged veteran?
Yes No
SECTION 5 – DISABILITY INFORMATION
Applicant
Have you been determined blind or disabled by the Social Security Administration?
If not, would you like us to send you a Disability Application Form?
Yes No
Yes No
Have you received Supplemental Security Income (SSI) in the past? Yes No
If you are disabled and not currently working, are you interested in participating in the
Health and Employment Counseling (HEC) program as a part of an effort to find work?
Yes No
Spouse
Has your spouse been determined blind or disabled by the Social Security Administration?
If not, would you like us to send you a Disability Application Form?
Yes No
Yes No
Has your spouse received SSI in the past? Yes No
If your spouse is disabled and not currently working, is your spouse interested in
participating in the Health and Employment Counseling (HEC) program as part of an effort
to find work?
Yes No
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SECTION 6 – ASSETS
In this section, list all assets owned by you and/or your spouse. Include assets owned jointly with any other
person. Do not include the value of personal household belongings (televisions, furniture, appliances). Do not
list motor vehicle information in this section as we will ask for that in Section 9. Assets include items such as
cash, checking or savings accounts, prepaid debit cards, certificates of deposit, trust funds, stocks, bonds,
retirement accounts, interest in annuities, U.S. savings bonds, property agreements, contracts for deeds,
timeshares, rental property, life estates, tools, livestock, farm machinery, Keogh plans or other tax shelters,
personal property being held for investment purposes, health savings accounts, etc.
NOTE: You will be asked to provide proof of your assets. See page 5 for more information. Use an additional
sheet of paper if more room is needed.
Type of Asset
(See above.)
Name of Owner(s)
Current Dollar
Amount
Bank / Financial Institution Name
and Account Number
$
$
$
$
$
$
Do any of the accounts listed include money that is set aside for burial? Yes No
If so, which account(s)?
How much?
SECTION 7 – BURIAL ASSETS
List all burial assets owned by you and/or your spouse. You will be asked to provide proof of your assets. Use
an additional sheet of paper if more room is needed.
Type of Burial Asset
Name of Owner(s)
Value
Burial insurance Yes No $
Irrevocable burial trust* Yes No
*This means it cannot be returned or
c
hanged.
$
Other Yes No
Note: O
ther examples could be a
headstone, casket, vault, marker, or
opening and closing costs.
$
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SECTION 8 – ANNUITY OWNERSHIP
Do you or your spouse own an annuity? Yes No
Did you or your spouse purchase an annuity on or after 01/01/2009? Yes No
Did you or your spouse make any substantive changes on or after 01/01/2009 to any annuity that either you or
your spouse own, regardless of when it was purchased?
Yes No
A substantive change would be an addition to principal, an elective withdrawal, a distribution change request,
a change in ownership or other similar action.
Note: If you answered yes, to any of the questions above, you will be required to provide and verify additional
information about this annuity in order to qualify for Medicaid Institutional/Long-Term Care Services.
I, the applicant and my spouse acknowledge that we are naming the State of Wisconsin as a remainder
beneficiary on my/our annuity, by virtue of the provision of Medicaid Institutional/Long-Term Care services.
This assignment provision will apply to any annuity purchased by me or my spouse, on or after 01/01/2009, or
any annuity owned by me or my spouse, regardless of the purchase date, for which a substantive change
and/or transaction has occurred on or after 01/01/2009. The State of Wisconsin will be named as the
remainder beneficiary in my/our annuity in the first position or if I am married or have a minor and/or disabled
child, the State of Wisconsin will be named as a remainder beneficiary in the next position after my spouse
and/or minor or disabled child.
SECTION 9 – VEHICLE INFORMATION
List all motor vehicles owned by you and/or your spouse, if married. Include vehicles owned jointly with another
person. Use an additional sheet of paper if more room is needed.
Vehicle 1
Type of Vehicle
Year
Make
Model
Amount Owed on Vehicle $ Fair Market Value* $
Vehicle 2
Type of Vehicle Year Make Model
Amount Owed on Vehicle $ Fair Market Value* $
*By fair market value, we mean the price you could sell the vehicle for right now. Looking up the vehicle's Blue
Book value online (www.kbb.com/whats-my-car-worth
) is a good way to find this out.
Section 10 – Real Estate Information
List all real estate owned by you and/or your spouse, if married. Include all real estate, whether the property is
located in the State of Wisconsin or not, owned solely or jointly with another person. Include any rental property
owned.
Property 1
Owner(s) of property
Address – Street City State Zip Code
Amount owed on property $ Fair Market Value* $
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Property 2
Owner(s) of Property
Address – Street City State Zip Code
Amount Owed on Property $ Fair Market Value* $
*By fair market value, we mean the price you could sell the property for right now. You may be able to find this
on your property taxes or on a recent appraisal if you have had one.
SECTION 11 — LIFE INSURANCE
Please tell us about any life insurance you and/or your spouse have.
Do you and/or your spouse have any life insurance policies? Yes No
If yes, complete the section below. If no, stop and go to Section 12.
Name of Owner(s)
Name of life insurance
company
Type: (whole life,
term, etc.)
Cash Surrender
Value*
$
Face
Value**
$
$ $
$ $
*By cash surrender value, we mean the amount you will get if you cancel the policy.
**By face value, we mean the minimum benefit paid out upon death. In most cases, this is the amount
written on the policy.
SECTION 12 – JOB INCOME AND WAGES
In this section, we need to know about any job income or wages you and/or your spouse get from employment.
List the gross income for each job. By gross, we mean the amount earned before taxes and deductions. Do not
list self-employment in this section, we will ask you about self-employment in Section 13.
Job 1
Are you and/or your spouse employed? Yes No If yes, answer the following questions. If no, stop
here and go to Section 14.
Who has a job? You Your spouse
Date Employment Began
Employer Name and Address
Gross Monthly Earnings Expected This Month
$
Gross Monthly Earnings Expected Next Month
$
Hours worked each week? How much are you paid each hour? $
How often are you paid?
Each week Every other week Twice each month Once a month
Are you paid a salary? Yes No If “yes,” how much are you paid each pay period? $
Do you get tips or compensation other than your hourly wages or salary? Yes No
If “yes,” how much do you get each pay period? $
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Job 2
Who has a job? You Your spouse
Date Employment Began
Employer Name and Address
Gross Monthly Earnings Expected This Month
$
Gross Monthly Earnings Expected Next Month
$
Hours worked each week?
How much are you paid each hour? $
How often are you paid?
Each week Every other week Twice each month Once each month
Are you paid a salary? Yes No If “yes,” how much are you paid each pay period? $
Do you get tips or compensation other than your hourly wages or salary? Yes No
If “yes,” how much do you get each pay period? $
Note: If you have any other jobs or wages from a job, you can use an additional sheet of paper and attach it to
this application.
SECTION 13 – SELF-EMPLOYMENT
Please tell us about any self-employment income you and/or your spouse receive. If more room is needed or
you have more than two self-employment businesses, use a separate sheet of paper.
Self-Employment 1
Are you and/or your spouse self-employed? Yes No
If yes, answer the questions below. If no, go to Section 14.
Who is self-employed? You Your spouse
Business Name
Business Address
Business Ownership Type
Partnership S corporation Sole proprietorship
I don’t know
Business Type (for example, a farm, home day
care)
Date Business Started
Has this business filed taxes? Yes No
If yes, for what tax year did the business last file taxes?
Has the business had a significant change in income or expenses? Yes No I don’t know
On average, how much does this business make each month? Please give us the income received before
expenses are taken out. $
On average, what are the total expenses this business has each month? $
On average, how many hours per month does this person work for this business?
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Self-Employment 2
Are you and/or your spouse self-employed? Yes No
If yes, answer the questions below. If no, go to Section 15.
Who is self-employed? You Your spouse
Business Name
Business Address
Business Ownership Type
Partnership S corporation Sole proprietorship
I don’t know
Business Type (for example, a farm, home day
care)
Date Business Started
Has this business filed taxes? Yes No
If yes, for what tax year did the business last file taxes?
Has the business had a significant change in income or expenses? Yes No I don’t know
On average, how much does this business make each month? Please give us the income received before
expenses are taken out. $
On average, what are the total expenses this business has each month? $
On average, how many hours per month does this person work for this business?
SECTION 14 – IN-KIND INCOME INFORMATION
In this section, tell us if you and/or your spouse currently receive items in-kind (such as goods, services, or food)
in return for work. Be sure to list the number of hours you work in exchange for goods, services, or food. If you
volunteer but do not get anything in exchange for your work, these hours are not considered in-kind.
In-Kind Income 1
Are you and/or your spouse working in exchange for goods, services, or food instead of money?
Yes No
You Your spouse
Date you/your spouse started getting goods, services, or food in exchange for work:
How many hours of work do you/your spouse provide in exchange for goods, services, or food, per month?
__________You __________Your Spouse
In-Kind Income 2
Are you and/or your spouse working in exchange for goods, services, or food instead of money?
Yes No
You Your spouse
Date you/your spouse started getting goods, services, or food in exchange for work:
How many hours of work do you/your spouse provide in exchange for goods, services, or food, per month?
__________You __________Your Spouse
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SECTION 15 – OTHER TYPES OF INCOME
In this section, tell us if you and/or your spouse receive any other types of income (other than a current job or
self-employment). Examples of other income may include, but are not limited to payments from an annuity or
trust, alimony/maintenance, charity, child support, disability/sick pay, interest/dividends, pension/retirement,
worker’s compensation, money from another person, interest on loan/promissory note repayments, rental
income, severance pay, Supplemental Security Income (SSI), Social Security, Veterans Benefits, unemployment
insurance, etc. List the gross amount, before taxes and deductions.
Type of Income Who Gets Income Gross Monthly Amount Company Name / Address
You Spouse $
You Spouse $
You Spouse $
You Spouse $
You Spouse $
You Spouse $
SECTION 16 – OUT-OF POCKET MEDICAL EXPENSES
List the types of out-of-pocket medical expenses you and/or your spouse have such as co-payments or the cost
of over-the-counter drugs. You must indicate if the item is an impairment related work expense. By impairment
related work expense, we mean any item you or your spouse needs due to your impairment in order to do your
job. The expense cannot be one that a similar worker without a disability would have, such as uniforms. Do not
list medical insurance premiums or items for which you are reimbursed.
Expense 1
Do you and/or your spouse have any medical expenses?
Yes No
If yes, complete the information below. If no, stop and go to Section 18.
Type of Medical Expense Amount of Expense
$
Who has the expense?
You Your spouse
How often paid?
Is this an impairment-related work expense? Yes No
Expense 2
Type of Medical Expense Amount of Expense
$
Who has the expense?
You Your spouse
How often paid?
Is this an impairment-related work expense? Yes No
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SECTION 17 – OTHER ALLOWABLE EXPENSES
In this section, tell us about any other allowable expenses you and/or your spouse have. Allowable expenses
may include court ordered family support/alimony, court ordered attorney and guardian fees, court ordered child
support, and other support obligations.
Who has an Expense What is the Expense Amount of Expense How Often Paid
$
$
$
SECTION 18 – HEALTH INSURANCE
You must report any third party that may be liable to pay for medical care for you and/or your spouse, including
private health insurance, nursing home/long-term care insurance, Medicare or Medi-GAP insurance. You must
give information as requested. This also includes any insurance that may be available through an employer
group health plan or long-term care policy.
Do you have Medicare Part A or Part B coverage?
Yes No
Medicare ID Number Part A Start Date Part A Premium Part B Start Date Part B Premium
$ $
Does your spouse have Medicare Part A or Part B coverage? Yes No
Medicare ID Number Part A Start Date Part A Premium Part B Start Date Part B Premium
$ $
Do you and/or your spouse have Medicare Part D coverage? Yes No
Who has the coverage? Name of Plan Start Date Monthly Premium
Amount
$
$
If you and/or your spouse are applying for Medicaid and are eligible for Medicare, your agency will check to
see if you and/or your spouse are eligible to have Medicaid pay for your Medicare premiums through the
Medicare Savings Program. Please contact your agency if you are not interested in or have questions about
the Medicare Savings Program.
If eligible, would you and/or your spouse like the State of Wisconsin to pay your Medicare premiums?
Yes No
Are you covered by any health insurance policies? Yes No
Name – Policy Owner Date Coverage Began Premium Amount
$
How Often Paid
Policy/Insurance Number Group Number
Name and Address of Insurance Company
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Is your spouse covered by any health insurance policies? Yes No
Name of Policy Owner Date Coverage Began Premium Amount
$
How Often Paid
Policy/Insurance Number Group Number
Name and Address of Insurance Company
Have you or your spouse received medical bills due to an accident or do you have an accident claim pending?
Yes No If yes, check all that apply. Incurred bills Claim or settlement pending
SECTION 19 – HELP PAYING FOR MEDICAL EXPENSES REQUEST
If insurance has not paid for your medical expenses from the last three months, you can apply for health care
coverage to pay those expenses. If you meet all program rules in those months, you can get health care
coverage benefits starting up to three months before your application month. The application month is the month
in which your agency gets your application.
When you apply for health care benefits in prior months, you must provide all of the needed information for
those prior months and you must meet all program rules for those months. If you want help paying for health
care for any of the three months before your application month, make sure you checked the “Yes” box in Section
3 of the application where this question is asked and complete this form.
If there are any changes in the three months before your application month, list the changes below for each
month. These changes may include: your address, who lives in the household, income, assets, vehicles,
insurance, etc.
What is the date you want your health care coverage to begin? Note: This date cannot be more than three
months before the month you apply.
Month Prior to Application
Are you asking for help paying for medical expenses from the month prior to the month you are applying?
Yes No
If yes, is
the information you provided in your application the same in that month? Yes No If no,
describe the changes.
Two Months Prior to Application
Are you asking for help paying for medical expenses from two months prior to the month you are applying?
Yes No
If yes, is
the information you provided in your application the same in that month? Yes No If no,
describe the changes.
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Three Months Prior to Application
Are you asking for help paying for medical expenses from three months prior to the month you are applying?
Yes No
If yes, is
the information you provided in your application the same in that month? Yes No If no,
describe the changes.
SECTION 20 – LONG-TERM CARE INFORMATION
Complete this section if you or your spouse are currently residing in a nursing home, Institution for Mental
Disease (IMD), or hospital, or you or your spouse are asking for long-term care services in your home.
A. Intent to Return Home
If you are currently living in a nursing home, IMD, hospital, or assisted living facility, do you plan to return to
your home sometime in the future?
Yes No
If your
spouse is currently living in a nursing home, IMD, hospital, or assisted living facility, does he/she intend
to return to the home sometime in the future?
Yes No
B. Request for Community Waivers
Are you applying for Medicaid to get services in your home or assisted living facility? Yes No
Is your spouse applying for Medicaid to get services in the home or assisted living facility? Yes No
C. Income Allocation
If you are married, you may be eligible to give some of your income to your spouse up to a maximum amount.
This is called an income allocation. If you are married and both you and your spouse are applying for long-term
care services, you must choose who will allocate the income.
Who will allocate income? You Your spouse
Do you or your spouse want to allocate the maximum allowed portion of income? Yes No
If “No”, how much do you or your spouse want to allocate $
Note: If you do not want to allocate the maximum allowed portion of your income but do not tell us how much
you want to allocate or leave the dollar amount blank, we will assume you do not want to allocate any income
to your spouse.
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D. RESOURCE/INCOME TRANSFER
Please tell us about any income or resources you and/or your spouse have given away or sold for less than fair
market value in the last five years. Examples of resources include cash and cash gifts, real estate, stocks or
bonds, etc. This includes any amounts you have gifted to minors, such as money you have put in a college fund
for your grandchild. You must report these amounts below. Use an additional sheet of paper if more room is
needed.
Check all that apply. In the last five years, did you and/or your spouse:
Yes No Sell any assets for less than fair market value*?
Yes No Trade assets or income?
Yes No Transfer or give away assets or income?
Yes No Establish or fund a trust?
Yes No Decline or refuse to accept an inheritance?
Yes No Purchase an annuity, life estate in another person’s home, promissory note, loan or
mortgage?
If you answered yes to any of the questions above, fill out the asset and income information below. If you
answered no, go to Section E.
*By fair market value, we mean the amount that you would get if you sold it on the open market.
Asset or Income 1
Type of Asset or Income
Date Given Away or Sold
Value of Asset or Income
$
What did you get in return? Who was asset given/sold to?
Asset or Income 2
Type of Asset or Income Date Given Away or Sold Value of Asset or Income
$
What did you get in return? Who was asset given/sold to?
E. SHELTER/UTILITY COST
In this section, tell us about your household expenses. Some of these may include, but are not limited to
mortgage/rent, property taxes, condominium fees, homeowner/renter insurance, water or sewer bills,
gas/electric bills, and heating cost. If it is a shared expense, be sure to list the actual amount paid per person.
Type of Expense Who Has Expense Amount of Expense How Often Paid
$
$
$
$
$
$
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F. LONG-TERM CARE INSURANCE
Do you have private long-term care insurance? Yes No
Name – Policy Holder Date Coverage Began Premium Amount
$
How Often Paid
Policy/Insurance Number Group Number
Name and Address of Insurance Company
Does your spouse have private long-term care insurance? Yes No
Name of Policy Holder
Date Coverage Began
Premium Amount
$
How Often Paid
Policy/Insurance Number Group Number
Name and Address of Insurance Company
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SECTION 21 – CHECKLIST
Please read and check each off before you mail your application. This could save time in processing your
application.
Read the Rights and Responsibilities Section.
Complete all applicable sections of the application.
Enclose with your application any current proof documents, additional documentation or sheets of paper
used to complete the application. If requesting help paying for medical expenses from the past three months,
be sure to include verification for those months.
Include a copy of your immigration status documents, if you are not a U.S. citizen.
If you have a legal guardian of the estate, legal guardian of the person and the estate, conservator, or
activated durable power of attorney for finances, attach the legal documentation authorizing the appointed
legal guardian, conservator, or power of attorney for the applicant. If you have an authorized representative,
attach the Appoint, Change, or Remove an Authorized Representative form (F-10126A for a Person or F-
10126B for an Organization).
Complete the Help Paying for Medical Expenses Request section if you want help paying for medical
expenses from the past three months.
Complete the Long-Term Care Information section if you are requesting coverage for long-term care
services.
Keep pages 1 through 8 and the Medicaid Change Report, F-10137, of this application packet for future use.
Sign and date the application form.
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SECTION 22 – SIGNATURE
By signing the application, you are authorizing the local agency and the Wisconsin Department of Health
Services to request any information that is appropriate and necessary for the proper administration of the
Medicaid program under Wisconsin law. Any person, including financial institutions, credit reporting agencies or
educational institutions may release this information, unless it is prohibited or restricted by law. Your
authorization remains in effect until one of the following:
• Your Medicaid application is denied.
• Your Medicaid eligibility ends.
• You inform the Department of Health Services in writing that you wish to end your authorization.
Also, your signature on the application means that you understand the questions and statements on this
application form and the penalties for giving false information or breaking the rules. By signing the application,
you are certifying, under penalty of perjury and false swearing, that all of your answers are correct and complete
to the best of your knowledge, including information provided about the immigration and citizenship status of
each household member applying for benefits. Also, you understand and agree to provide documents to prove
what you have said.
If you are married and are applying for Long-Term Care Medicaid because you are residing in a medical
institution or asking for long-term care services in your home, your spouse is known as a Community Spouse.
A Community Spouse must sign the application to be considered a valid application for Long-Term Care
Medicaid. Your spouse may be able to have additional assets and income without affecting your Medicaid
eligibility. Both you and your spouse must sign your application for Long-Term Care Medicaid or your application
will be denied. Your spouse has 30 days from your Medicaid application date to sign the application.
SIGNATURE – Applicant/Representative/Guardian/Power of Attorney/Conservator Date Signed
SIGNATURE – Applicant/ Community Spouse/Representative/Guardian/ Date Signed
Power of Attorney/Conservator
SIGNATURE – Witness (Needed if signed with an “X” above) Date Signed
SIGNATURE – Witness (Needed if signed with an “X” above) Date Signed
Note: The applicant’s signature must be witnessed by two people, if signed with an “X.”
Mail or Fax Applications and/or Proof/Verifications
If you live in Milwaukee County:
MDPU
6055 N 64
th
St.
Milwaukee WI 53218
Fax: 888-409-1979
If you do not live in Milwaukee County
CDPU
PO Box 5234
Janesville, WI 53547-5234
Fax: 855-293-1822
You can also scan and/or upload any proof online at access.wi.gov
.
STATE OF WISCONSIN
DEPARTMENT OF HEALTH SERVICES
Division of Medicaid Services
F-10126A (03/2024)
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APPOINT, CHANGE, OR REMOVE AN AUTHORIZED REPRESENTATIVE: PERSON
Fill out and submit the Appoint, Change, or Remove an Authorized Representative: Person form, F-10126A, to appoint,
change, or remove a person as your authorized representative.
To appoint an organization as your authorized representative, fill out and submit the Appoint, Change, or Remove and
Authorized Representative: Organization form, F-10126B, instead.
If you have a legal guardian of the estate, legal guardian of the person and the estate, or conservator, that person must
appoint an authorized representative for you if you want someone besides them to be your authorized representative. If
you have an activated durable power of attorney for finances, you or your power of attorney can appoint an authorized
representative.
A legal guardian of the person can appoint an authorized representative for you only if the court documents appointing the
legal guardian of the person grants the guardian the authority to act on your behalf with your eligibility and benefits in
public assistance programs.
A power of attorney for health care does not have the ability to act on your behalf to appoint an authorized representative.
The personally identifiable information provided on this form will only be used for the direct administration of Wisconsin
Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, and Caretaker Supplement.
Authorized Representative Information
An authorized representative is a person who is familiar with your household’s circumstances and that you trust to act on
your behalf. Anyone can serve as your authorized representative except for the following:
• People who are disqualified for an intentional FoodShare program violation cannot serve as an authorized
representative during their disqualification period unless no one else is able to serve as an authorized representative.
• Homeless meal providers cannot serve as an authorized representative for a homeless food unit. (A food unit is one or
more people who live together and buy and make food together.)
• Agency employees who help determine eligibility or benefits may not serve as an authorized representative. Special
written approval may be given for them to serve as an authorized representative in certain circumstances.
• Retailers who are authorized to accept FoodShare benefits may not serve as an authorized representative.
Once appointed, your authorized representative may do any or all of the following on your behalf:
• Apply for or renew benefits
• Report changes to your information
• Work with your agency on any matters related to your benefits
• File grievances and appeals about your eligibility for programs you are applying for or are enrolled in
You can also choose to have your authorized representative get copies of letters about your eligibility and benefits, get
your ForwardHealth card, work with ForwardHealth Member Services and your HMO (health maintenance organization)
on your behalf, and file grievances and appeals about your health care services (for example, treatment and bills).
You do not need to have an authorized representative to apply for or get benefits.
The authorized representative you appoint on this form can act on your behalf for any of the following programs:
Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, and/or Caretaker Supplement. If you
are enrolled in any of these programs and Wisconsin Works (W-2), your authorized representative may also act on your
behalf for W-2.
The authorized representative you appoint on this form cannot act on your behalf for the Wisconsin Shares Child Care
Subsidy Program. If you are applying for Wisconsin Shares, you need to apply for yourself.
Form Instructions
If required information is missing on this form, including any of the signatures, the form will be considered incomplete, and
your authorized representative cannot act on your behalf.
Section 1 — You need to complete Section 1. You will need to choose if you are appointing, changing, or removing an
authorized representative. You will also need to provide your name and date of birth so we can identify you. If you are
appointing or changing an authorized representative, choose if you want your authorized representative to get copies of
your letters. If you are also applying for or are enrolled in a health care program, choose if you want to let your authorized
F-10126A
Page 2 of 5
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representative take more actions on your behalf. Make sure you read and agree to the protected health information
authorization before you check Yes. Next, read the statements of understanding. If you agree, sign and date the form.
Section 2 — Your authorized representative needs to complete Section 2. Your authorized representative will need to
provide their name and contact information. They will also need to read the statements of understanding and sign and
date the form if they agree to the statements.
Section 3 — If you are appointing or changing an authorized representative, you will need to have someone besides your
authorized representative watch you sign this form. This person is called a witness. If you sign this form with an “X,” then
two witnesses must watch you sign the form. The witness or witnesses will need to provide their name, signature, and the
date they signed the form.
Form Submission
You can submit your completed form in one of the following ways:
Online
Scan all pages of the form to ACCESS. You can do this
through your ACCESS account, which you can log into at
access.wi.gov. (Note: If you do not have an ACCESS
account, you can go to access.wi.gov and create one.)
Note: You can only scan forms to ACCESS at certain
times. If you are unable to scan the form to ACCESS,
submit the form using one of the other ways.
Fax
• If you live in Milwaukee County, fax the form to
888-409-1979.
• If you do not live in Milwaukee County, fax the form to
855-293-1822.
Mail
• If you live in Milwaukee County, mail the form to:
MDPU
6055 N. 64
th
St.
Milwaukee, WI 53218
•
If you do not live in Milwaukee County, mail the form to:
CDPU
P.O. Box 5234
Janesville, WI 53547
In Person
Take the form to your agency. Your agency contact
information is on the Wisconsin Department of Health
Services (DHS) website at
dhs.wi.gov/im-agency.
For more information about authorized representatives, go to the DHS website at www.dhs.wisconsin.gov/forwardhealth/
representative-types.htm.
SECTION 1 To Be Filled Out by Applicant/Member
I am:
☐ Appointing an authorized representative. You must fill out all of Section 1.
☐ Changing my authorized representative. You must fill out all of Section 1. Make sure you write in the name of your new
authorized representative in Part B.
☐ Removing my authorized representative. You must fill out Part A and E of Section 1. Leave Part B and C blank.
Part A: Personal Information
Name — Applicant/Member (Last, First, Middle Initial)
Date of Birth
Case Number (if you have one)
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Part B: Authorization Information
I appoint the following person to be my authorized representative:
I want my authorized representative to get copies of letters about my eligibility and benefits.
☐ Yes ☐ No
Part C: Additional Authorization Information — Health Care Programs Only (Optional)
I am applying for or am enrolled in a health care program (for example, Wisconsin Medicaid, BadgerCare Plus, or Family
Planning Only Services) and want my authorized representative to do all of the following:
• Get my ForwardHealth card instead of me.
• Enroll me in an HMO.
• Talk to ForwardHealth Member Services or my HMO about a bill, service, or other medical information, including
protected health information. Make sure you read and agree to the protected health information authorization below
before you check Yes.
• File grievances and appeals about my health care services (for example, treatment and bills).
☐ Yes ☐ No
Authorization for Use and Disclosure of Protected Health Information
By checking Yes above, I am authorizing the Wisconsin Department of Health Services and its contractors, including
HMOs, to disclose (share) my protected health information with my authorized representative.
The information that I am authorizing to be shared may include the following types of information: claims, medical records,
substance abuse care, reproductive care, mental health, communicable diseases, pharmacy services, HIV/AIDS, dental
records, and developmental disabilities.
The information is being shared so my authorized representative can help me manage my health care benefits.
I understand that any information used or shared based on this authorization could be reshared by the person or entity
receiving the information and will no longer be protected by federal privacy regulations.
I understand that this authorization is voluntary and that I may refuse to authorize the release of my protected health
information by checking No above. Checking No will not affect the provision of treatment, payment, enrollment in a health
plan, or eligibility for benefits unless the authorization is necessary for determining eligibility for the program or enrollment
in the program.
This authorization will continue until I remove the authorized representative on this form from being my authorized
representative or let my agency know that I do not want my authorized representative to have access to my protected
health information any longer. I can let my agency know in writing about this at any time; however, removing the
authorization will not affect protected health information that has already been shared.
F-10126A
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Page 4 of 5
Part D: Statements of Understanding
I understand and agree that:
• I have the right to choose any person I want to be my authorized representative.
• I can change or remove my authorized representative at any time. I must let my agency know in writing that I want to
change or remove my authorized representative.
• I do not have to tell a person that I am removing them as my authorized representative.
• The authorized representative listed on this form will stay my authorized representative until I change or remove them.
• My authorized representative will have access to my personal information, such as my Social Security number,
financial statements, and medical information, to help me manage my eligibility. If I agreed to the protected health
information authorization above, I understand that my authorized representative will also have access to this
information to help me manage my health care services (for example, treatment and medical bills).
• I must provide my authorized representative with true and accurate information.
• I am responsible for errors and incorrect information that my authorized representative reports. I understand that if
either my authorized representative or I give false information or withhold information, I may:
o Have to pay back benefits I should not have gotten.
o Be fined.
o Be banned from a program.
o Be prosecuted for fraud.
• By signing this form, I am saying that I understand and agree to the statements above.
Part E: Signature and Date
SIGNATURE — Applicant/Member
Date Signed
SECTION 2 To Be Filled Out by Authorized Representative
Part A: Contact Information
Name — Authorized Representative (Last, First, Middle Initial)
Street Address
City
State
Zip Code
Phone Number (include area code)
Email Address (optional)
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Part B: Statements of Understanding
I understand and agree that:
• As an authorized representative, I am limited to doing any or all of the following on the applicant’s or member’s behalf:
o Applying for or renewing benefits
o Reporting changes
o Working with the applicant’s or member’s agency on any benefit-related matters
o Filing eligibility-related grievances and appeals
• I am expected to be familiar with the applicant’s or member’s circumstances.
• The applicant or member can remove me from being their authorized representative at any time.
• The applicant or member does not need to notify me that I have been removed from serving as their authorized
representative.
• I am the applicant’s or member’s authorized representative until they request a different authorized representative or
choose not to have an authorized representative.
• I must provide truthful and accurate information.
• If I provide inaccurate or false information, the applicant or member may need to repay any health care benefits
received in error.
• If I intentionally violate program rules, I must repay any FoodShare benefits that were misused or received in error.
• I must comply with applicable state and federal laws concerning conflicts of interest and confidentiality of information.
• By signing this form, I am saying that I understand and agree to the statements above.
• By signing this form, I am saying that I will serve as the authorized representative for the applicant or member listed in
Section 1.
Part C: Signature and Date
SIGNATURE — Authorized Representative
Date Signed
SECTION 3 To Be Filled Out by Witness(es)
Name — Witness (Last, First, Middle Initial)
Name — Witness (Last, First, Middle Initial) (if applicant/member signed with an X)
SIGNATURE — Witness
Date Signed
SIGNATURE — Witness
Date Signed
REP
STATE OF WISCONSIN
DEPARTMENT OF HEALTH SERVICES
Division of Medicaid Services
F-10126B (03/2024)
APPOINT, CHANGE, OR REMOVE AN AUTHORIZED REPRESENTATIVE: ORGANIZATION
Fill out and submit the Appoint, Change, or Remove an Authorized Representative: Organization form, F-10126B, to
appoint, change, or remove an organization as your authorized representative. To change the organization’s contact
person, either you or the organization must contact your agency. Your agency contact information is on the Wisconsin
Department of Health Services (DHS) website at dhs.wi.gov/im-agency
.
To appoint a person as your authorized representative, fill out and submit the Appoint, Change, or Remove an Authorized
Representative: Person form, F-10126A, instead.
If you have a legal guardian of the estate, legal guardian of the person and the estate, or conservator, that person must
appoint an authorized representative for you if you want someone besides them to be your authorized representative. If
you have an activated durable power of attorney for finances, you or your power of attorney can appoint an authorized
representative.
A legal guardian of the person can appoint an authorized representative for you only if the court documents appointing the
legal guardian of the person grants the guardian the authority to act on your behalf with your eligibility and benefits in
public assistance programs.
A power of attorney for health care does not have the ability to act on your behalf to appoint an authorized representative.
The personally identifiable information provided on this form will only be used for the direct administration of Wisconsin
Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, and Caretaker Supplement.
Authorized Representative Information
An authorized representative is an organization that is familiar with your household’s circumstances and that you trust to
act on your behalf. Anyone can serve as your authorized representative except for the following:
• People who are disqualified for an intentional FoodShare program violation cannot serve as an authorized
representative during their disqualification period unless no one else is able to serve as an authorized representative.
• Homeless meal providers cannot serve as an authorized representative for a homeless food unit. (A food unit is one or
more people who live together and buy and make food together.)
• Agency employees who help determine eligibility or benefits may not serve as an authorized representative. Special
written approval may be given for them to serve as an authorized representative in certain circumstances.
• Retailers who are authorized to accept FoodShare benefits may not serve as an authorized representative, except for
Drug and Alcohol treatment centers that are authorized retailers.
Once appointed, your authorized representative may do any or all of the following on your behalf:
• Apply for or renew benefits
• Report changes to your information
• Work with your agency on any matters related to your benefits
• File grievances and appeals about your eligibility for programs you are applying for or are enrolled in
You can also choose to have your authorized representative get copies of letters about your eligibility and benefits.
You do not need to have an authorized representative to apply for or get benefits. To apply for FoodShare while staying in
a Drug and Alcohol treatment center, an authorized organization representative must apply on your behalf.
The authorized representative you appoint on this form can act on your behalf for any of the following programs:
Wisconsin Medicaid, BadgerCare Plus, FoodShare, Family Planning Only Services, and/or Caretaker Supplement. If you
are enrolled in any of these programs and Wisconsin Works (W-2), your authorized representative may also act on your
behalf for W-2.
The authorized representative you appoint on this form cannot act on your behalf for the Wisconsin Shares Child Care
Subsidy Program. If you are applying for Wisconsin Shares, you need to apply for yourself.
REP
F-10126B
Page 2 of 6
Form Instructions
If required information is missing on this form, including any of the signatures, the form will be considered incomplete, and
your authorized representative cannot act on your behalf.
Section 1 — You need to complete Section 1. You will need to choose if you are appointing, changing, or removing an
authorized representative. You will also need to provide your name and date of birth so we can identify you. If you are
appointing or changing an authorized representative, choose if you want your authorized representative to get copies of
your letters. Next, read the statements of understanding. If you agree, sign and date the form.
Section 2 — A person who can act on behalf of the organization needs to complete Section 2. The person will need to
provide the organization’s name and contact information as well as their own. The person will also need to read the
statements of understanding and sign and date the form if the organization and contact person agree to the statements.
Section 3 — If you are appointing or changing an authorized representative, you will need to have someone besides your
authorized representative watch you sign this form. This person is called a witness. If you sign this form with an “X,” then
two witnesses must watch you sign the form. The witness or witnesses will need to provide their name, signature, and the
date they signed the form.
Form Submission
You can submit your completed form in one of the following ways:
Online
Mail
Scan all pages of the form to ACCESS. You can do this
through your ACCESS account, which you can log into at
access.wi.gov. (Note: If you do not have an ACCESS
account, you can go to access.wi.gov and create one.)
Note: You can only scan forms to ACCESS at certain
times. If you are unable to scan the form to ACCESS,
submit the form using one of the other ways.
• If you live in Milwaukee County, mail the form to:
MDPU
6055 N. 64
th
St.
Milwaukee, WI 53218
• If you do not live in Milwaukee County, mail the form to:
CDPU
P.O. Box 5234
Janesville, WI 53547
Fax
In Person
• If you live in Milwaukee County, fax the form to
888-409-1979.
• If you do not live in Milwaukee County, fax the form to
855-293-1822.
Take the form to your agency. Your agency contact
information is on the DHS website at dhs.wi.gov/im-agency.
For more information about authorized representatives, go to the DHS website at www.dhs.wisconsin.gov/forwardhealth/
representative-types.htm.
REP
F-10126B
Page 3 of 6
SECTION 1 To Be Filled Out by Applicant/Member
I am:
☐ Appointing an authorized representative. You must fill out all of Section 1.
☐ Changing my authorized representative. You must fill out all of Section 1. Make sure you write in the name of your new
authorized representative in Part B.
☐ Removing my authorized representative. You must fill out Part A and D of Section 1. Leave Part B blank.
Part A: Personal Information
Name — Applicant/Member (Last, First, Middle Initial)
Date of Birth
Case Number (if you have one)
Part B: Authorization Information
I appoint the following organization to be my authorized representative:
I want my authorized representative to get copies of letters about my eligibility and benefits. Please note that the letters
will be sent to the organization’s contact person.
☐ Yes ☐ No
Part C: Statements of Understanding
I understand and agree that:
• I have the right to choose any organization I want to be my authorized representative.
• I can change or remove my authorized representative at any time. I must let my agency know in writing that I want t
o
change or remove my authorized representative.
• I do not have to tell an organization that I am removing it as my authorized representative.
• The authorized representative listed on this form will stay my authorized representative until I change or remove them.
• Drug and Alcohol treatment center authorized representatives will be removed upon discharge. Submitting this
document to end the authorization is optional.
REP
F-10126B
Page 4 of 6
• My authorized representative will have access to my personal information, such as my Social Security number,
financial statements, and medical information to help me manage my eligibility.
• I must provide my authorized representative with true and accurate information.
• I am responsible for errors and incorrect information that my authorized representative reports. I understand that if
either my authorized representative or I give false information or withhold information, I may:
o Have to pay back benefits I should not have gotten.
o Be fined.
o Be banned from a program.
o Be prosecuted for fraud.
• By signing this form, I am saying that I understand and agree to the statements above.
Part D: Signature and Date
SIGNATURE — Applicant/Member
Date Signed
REP
F-10126B
Page 5 of 6
SECTION 2 To Be Filled Out by Authorized Representative
Part A: Contact Information
Name — Organization
Street Address
City
State
Zip Code
Phone Number (include area code)
Name — Organization Contact (Last, First, Middle Initial)
Job Title — Organization Contact
Email Address — Organization Contact (optional)
Part B: Statements of Understanding
I understand and agree that:
• I am authorized to act on behalf of the organization listed in Section 2, Part A.
• As an authorized representative, the organization is limited to doing any or all of the following on the applicant’s or
member’s behalf:
o Applying for or renewing benefits
o Reporting changes
o Working with the applicant’s or member’s agency on any benefit-related matters
o Filing eligibility-related grievances and appeals
• The organization is expected to be familiar with the applicant’s or member’s circumstances.
• The organization must report to the applicant’s or member’s agency any changes to the contact listed in Section 2,
Part A.
• The applicant or member can remove the organization from being their authorized representative at any time.
• The applicant or member does not need to notify the organization that it has been removed from serving as their
authorized representative.
• The organization is the applicant’s or member’s authorized representative until they request a different authorized
representative or choose not to have an authorized representative.
• The organization and anyone acting on its behalf must provide truthful and accurate information.
• If the organization provides inaccurate or false information, the applicant or member may need to repay any health
care benefits received in error.
• If the organization intentionally violates program rules, it must repay any FoodShare benefits that were misused or
received in error.
REP
F-10126B
Page 6 of 6
• The organization and anyone acting on its behalf must comply with applicable state and federal laws and regulations,
including 42 C.F.R. Part 431, Subpart F; 42 C.F.R. § 447.10; 45 C.F.R. § 155.260(f); and 7 CFR 273.2(n)(4),
concerning conflicts of interest and confidentiality of information.
• By signing this form, I am saying that I understand and agree to the statements above on behalf of the organization
listed in Section 2, Part A.
• By signing this form, I am saying that the organization listed in Section 2, Part A will serve as the authorized
representative for the applicant or member listed in Section 1.
Part C: Signature and Date
SIGNATURE — Organization Contact
Date Signed
SECTION 3 To Be Filled Out by Witness(es)
Name – Witness (Last, First, Middle Initial)
SIGNATURE — Witness
Date Signed
Name — Witness (Last, First, Middle Initial) (if applicant/member signed with an X)
SIGNATURE — Witness
Date Signed
WISCONSIN DEPARTMENT OF HEALTH SERVICES
Division of Medicaid Services
F-10137 (06/2023)
WISCONSIN MEDICAID CHANGE REPORT
If you are receiving Medicaid, you must report any changes in the make up of your household (if anyone moves
in or out of your household, if anyone gets married, becomes pregnant, or gives birth to a child), a change in
address, income, assets or employment status within 10 days. If this report does not provide enough room to
document a change, attach a sheet of paper with the additional information written on it to this report. You may
also report changes online at access.wi.gov, by telephone or in person.
If you fail to report any changes or provide false information, you may be fined, have to pay back any Medicaid
benefits you received that you should not have (even if you did not use your card), be prosecuted or all three.
You may be required to provide proof of any changes you report.
Personally identifiable information will be used only for the direct administration of the Medicaid program.
Your Name Case Number Worker Name
SECTION 1 - CHANGE IN ADDRESS
If you have moved, you must report your new address.
Date of Change
New Telephone Number
New Address - Street City State Zip Code
SECTION 2 - CHANGE IN HOUSEHOLD COMPOSITION
You must report if anyone moves in or out of your household, if anyone gets married, becomes pregnant or
gives birth to a baby (include information about the person who gave birth and the newborn.)
Name(s) (Last, First, MI)
Date of Change
Social Security Number (SSN)* Date of Birth Relationship to Case Head
Describe the Change
*Providing or applying for an SSN is voluntary; however, any person who wants Wisconsin Medicaid but does
not want to provide their SSN or apply for one will not be eligible for benefits, pursuant to Wisconsin Statutes
section 49.82(2).
SECTION 3 - CHANGE IN ASSETS
You must report changes in your household’s cash, bank accounts, bonds, stocks or other assets.
Name of Owner (Last, First, MI)
Date of Change
Type of Asset Describe the Change New Value or Amount
$
Administrative Rule DHS 102.01 (6)
CHG
WISCONSIN MEDICAID CHANGE REPORT
F-10137
Page 2 of 3
SECTION 4 – CHANGE IN RESOURCES/INCOME
You must report any income or resources you and/or your spouse have given away or sold for less than fair
market value. Examples of resources include cash and cash gifts, real estate, stocks or bonds, an inheritance,
etc.
Type of asset or income
Date sold or given away
Value of asset or income
$
What did you get in return?
SECTION 5
– CHANGE IN VEHICLES
You must report if you obtain, sell or give away a car, truck, motorcycle, boat, snowmobile, camper or another
type of vehicle.
Name of Owner(s) (last, first, MI)
Date of Change
Type of Vehicle
Make
Model
Year
Describe Change (bought, sold, etc.)
Amount Received
$
Fair Market Value*
$
Amount Owed
$
* By fair market value, we mean the amount that you would get if you sold it on the open market.
SECTION 6
- CHANGE IN INCOME
You must report a change in your gross income amount, a new source of income, changes in your employment
status (part-time to full-time or full-time to part-time, loss of employment), changes in salary or rate of pay,
changes in the amount of Social Security, Unemployment Insurance, Worker’s Compensation, Veterans
benefits, or any other change in the amount of money your household gets.
Name (Last, First, MI)
Date Income Changed
Source of Income
Monthly Amount
$
How Often Paid Each Week Every Other Week Twice Each Month Once Each Month
SECTION 7
- OTHER CHANGES
You must report any other changes that may affect your Medicaid eligibility. Examples of other changes include
someone getting or dropping health insurance, someone becoming disabled or recovering from a disability. A
change could also be a change in expenses such as an increase or decrease in health insurance premiums,
medical costs or shelter costs.
Describe change
Do you expect that the changes reported on this form will remain the same next
month? Yes No If no, explain.
Date of Change
CHG
CHG
WISCONSIN MEDICAID CHANGE REPORT
F-10137
Page 3 of 3
SECTIO
N 8 – SIGNATURE
Yes No I understand that there are penalties for hiding information or giving false information.
Yes No I understand that I may have to pay back any benefits I receive because I do not fully report
changes in my circumstances (even if I do not use my Medicaid card).
Yes No I agree to provide proof of any changes, if asked to do so.
Yes No My answers on this report are correct and complete to the best of my knowledge.
SIGNATURE – Applicant/Representative/Guardian/Power of Attorney/Conservator
Date Signed
Telephone Number (including area code)
If this report does not provide enough room to document a change, attach a sheet of paper with the additional
information written on it to this report.
Mail or
Fax Applications, Forms and/or Proof/Verifications
If you live in Milwaukee County:
MDPU
6055 N. 64th St.
Milwaukee, WI 53218
Fax: 1-888-409-1979
If you do not live in Milwaukee County
CDPU
PO B
ox 5234
Janesville, WI 53547-5234
Fax: 1-855-293-1822
You can also scan and/or upload any proof online at access.wi.gov.
CHG
RESET FORM
Supplemental Nutrition Assistance Program (SNAP) and Food Distribution Program on Indian Reservations (FDPIR) state
or local agencies, and their subrecipients, must post the following Nondiscrimination Statement:
In accordance with federal civil rights law and U.S. Department of Agriculture
(USDA) civil rights regulations and policies, this institution is prohibited from
discriminating on the basis of race, color, national origin, sex (including gender
identity and sexual orientation), religious creed, disability, age, political beliefs, or
reprisal or retaliation for prior civil rights activity.
Program information may be made available in languages other than
English. Persons with disabilities who require alternative means of
communication to obtain program information (e.g., Braille, large print, audiotape,
American Sign Language), should contact the agency (state or local) where they
applied for benefits. Individuals who are deaf, hard of hearing or have speech
disabilities may contact USDA through the Federal Relay Service at (800) 877-
8339.
To file a program discrimination complaint, a Complainant should complete a
Form AD-3027, USDA Program Discrimination Complaint Form which can be
obtained online at: https://www.usda.gov/sites/default/files/documents/ad-
3027.pdf, from any USDA office, by calling (833) 620-1071, or by writing a letter
addressed to USDA. The letter must contain the complainant’s name, address,
telephone number, and a written description of the alleged discriminatory action
in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about
the nature and date of an alleged civil rights violation. The completed AD-3027
form or letter must be submitted to:
1. mail:
Food and Nutrition Service, USDA
1320 Braddock Place, Room 334
Alexandria, VA 22314; or
2. fax:
(833) 256-1665 or (202) 690-7442; or
3. email:
FNSCIVILRIGHTSCOMPLAINTS@usda.gov
This institution is an equal opportunity provider.
02/15/2023
Nondiscrimination Notice: Discrimination is Against the Law – Health Care-Related Programs
The Wisconsin Department of Health Services complies with applicable Federal civil rights laws and does not discriminate on the basis
of race, color, national origin, age, disability, or sex. The Department of Health Services does not exclude people or treat them
differently because of race, color, national origin, age, disability, or sex.
The Department of Health Services:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters.
o Written information in other formats (large print, audio, accessible electronic formats, other formats).
• Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters.
o Information written in other languages.
If you need these services, contact the Department of Health Services civil rights coordinator at 844-201-6870.
If you believe that the Department of Health Services has failed to provide these services or discriminated in another way on the basis
of race, color, national origin, age, disability, or sex, you can file a grievance with: Department of Health Services, Attn: Civil Rights
Coordinator, 1 West Wilson Street, Room 651, PO Box 7850, Madison, WI 53707-7850, 844-201-6870, TTY: 711, fax: 608-267-1434,
or email to d[email protected]isconsin.gov. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance,
the Department of Health Services civil rights coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically
through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.