STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Heath Care Access and Accountability F-16004R (07/08)
EBT
/ FOODSHARE
Social Security Numbers FoodShare Wisconsin. , FoodShare. , QUEST , FoodShare, . , FoodShare . QUEST . QUEST. QUEST , . , QUEST: 1-877-415-5164.
Case Name
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: , / . « ». - , « Medicaid/BadgerCare Plus/FoodShare» (HCF 10126R). , -: dhfs.wisconsin.gov/forms/DHCF/HCF10126R.pdf. For Case Worker Use Only New Authorized Buyer SIGNATURE IM Worker New Alternate Payee Remove Authorized Buyer Date Signed Remove Alternate Payee
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