Structure
The Wisconsin F 10138 form, known as the BadgerCare Plus Supplement to FoodShare Wisconsin Application, plays a crucial role for individuals and families seeking assistance through these vital programs. Designed specifically for those applying for both FoodShare and BadgerCare Plus, this form streamlines the application process by gathering essential information about the applicant and their household. It includes sections that address applicant details, pregnancy status, and existing health insurance coverage. For instance, applicants are required to provide their name, address, and information about any pregnant household members, including due dates and the number of expected babies. Additionally, the form prompts applicants to disclose any medical insurance they may have had in the past three months, along with details about policyholders and coverage specifics. Acknowledging the importance of accurate information, the form emphasizes the applicant's responsibility to report any changes promptly and understand their rights and obligations regarding enrollment and benefits. By completing this form, applicants take an important step toward accessing necessary health care services and nutritional support, fostering a healthier community in Wisconsin.
Form Example
WISCONSIN DEPARTMENT OF HEALTH SERVICES
Division of Health Care Access and Accountability
APP
BADGERCARE PLUS SUPPLEMENT TO FOODSHARE WISCONSIN APPLICATION
This form is used as a supplement to the FoodShare Wisconsin Application. Complete this form only if you are applying for FoodShare Wisconsin and BadgerCare Plus.
SECTION I – APPLICANT INFORMATION
Applicant Name (First, MI, Last)
Applicant Address (Street, City, State, Zip Code)
SECTION II – PREGNANCY (Add a second sheet of paper, if more room is needed.)
Is any member of your household pregnant? 
Yes 
No
Name of pregnant woman
Due date
If multiple births are expected, list number of babies.
SECTION III – INSURANCE
Does anyone have medical or health insurance now, or in the previous three months?
Yes
No
Policyholder’s name
Policy number
Begin date
Name and address of insurance company
Who is or was covered under this policy?
Family Member’s Name(s):
Has this coverage ended in the last three months?
If yes, what is the date the coverage ended?
Why did the coverage end?
Yes
No
Is/was this insurance provided by an employer?
If yes, what is the employer’s name?
Yes
No
Does this insurance cover services from a doctor?
Yes
No
SECTION V – SIGNATURE
I understand that as a condition of enrollment in BadgerCare Plus, I must report to the local county or tribal agency any other person(s) that may be liable to pay for medical care for my family and me. I must also cooperate by giving information to assist the local county or tribal agency in pursuing payment from any other person(s). I understand that any benefits for the cost of medical care which are available under a policy will be assigned to the State by law (s. 49.45 (19), WI Statutes.) during any period of BadgerCare Plus enrollment. I understand that within 10 days I must report any changes in all of the above information. The information given above is true and complete to the best of my knowledge.
SIGNATURE – Applicant or Authorized Representative
Date Signed
BADGERCARE PLUS SUPPLEMENT TO FOODSHARE WISCONSIN APPLICATION
RIGHTS AND RESPONSIBILITIES
Your signature on the application means that you understand and acknowledge that the local county or tribal agency and the state Department of Health Services is authorized to request any information that is appropriate and necessary for the proper administration of BadgerCare Plus as authorized under Wisconsin law.
Any person, including any financial institution, credit reporting agency, employer, or educational institution, is authorized to release this information, according to Wisconsin Statute s. 49.22(2m)(a): “The Department may request from any person in this state information it determines appropriate and necessary for the administration of this section, ss.49.141 to 49.161, 49.19, 49.46, 49.468 and 49.47 and programs carrying out the purposes of 7 USC 2011 to 2029. Unless access to the information is prohibited or restricted by law, or unless the person has good cause, as determined by the Department in accordance with federal law and regulations, for refusing to cooperate, the person shall make a good faith effort to provide this information within 7 days after receiving a request under this paragraph. Except as provided in subs. (2p) and (2r) and subject to sub.(12), the Department or the county child support agency under s.59.53(5) may disclose information obtained under this paragraph only in the administration of this section, ss.49.141 to 49.161, 49.19, 49.46 and 49.47 and programs carrying out the purposes of 7 USC 2011 to 2029. Employees of the department or a county child support agency under s.59.53(5) are subject to s.49.83.”
You have the right to appeal any action taken concerning your BadgerCare Plus, or Family Planning services application or on going benefits that you do not agree with by requesting a Fair Hearing. You may request a Fair Hearing by calling or writing to:
Wisconsin Department of Administration
Division of Hearings and Appeals
P.O. Box 7875
Madison, WI
Telephone: (608)
You can download the “Request For a Fair Hearing” form from the Division of Hearing and Appeals Web site at http://dha.state.wi.us/home/.
You may also contact your local agency and ask for a Fair Hearing verbally or in writing.
The Department of Health Services (DHFS) is an equal opportunity employer and service provider. For civil rights questions, CALL (608)
To file a complaint of discrimination by contacting either the:
•Wisconsin Department of Health Services (DHFS)
Affirmative Action and Civil Rights Compliance Office
1 W. Wilson, Room 555
Madison, WI
Telephone: (608)
Fax: (608)
•U.S. Department of Health and Human Services Office for Civil Rights – Region V 233 N. Michigan Avenue
Suite 240 Chicago, IL 60601
Telephone: (312)
Document Specs
| Fact Name | Description |
|---|---|
| Form Purpose | The Wisconsin F-10138 form serves as a supplement to the FoodShare Wisconsin Application for those applying for both FoodShare and BadgerCare Plus. |
| Applicant Information | Section I of the form requires the applicant to provide their name and address, ensuring accurate identification and contact information. |
| Pregnancy Information | Section II inquires if any household member is pregnant, including details such as the due date and number of expected babies. |
| Insurance Details | Section III collects information about any medical or health insurance coverage, including policyholder details and coverage status. |
| Legal Authority | The form operates under Wisconsin Statutes, particularly s. 49.45 (19), which mandates the assignment of medical care benefits to the state during BadgerCare Plus enrollment. |
| Reporting Changes | Applicants must report any changes in their information within 10 days, ensuring the accuracy of their application and benefits. |
| Right to Appeal | Individuals have the right to appeal decisions regarding their BadgerCare Plus application by requesting a Fair Hearing through the Wisconsin Department of Administration. |
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