Forms

 
Downloadable Form

470-0040

Adjustment Request

470-0042

Case Activity Report

470-0369

Agreement for Nursing Facilities and Skilled Nursing Facilities

470-0372

Agreement for Intermediate Care Facilities for the Mentally Intellectually
Disabled/Developmentally Disabled Persons Participation in the Medicaid Program

470-0373

Voluntary Contribution Agreement

470-0374

ICF/ID Resident Care Agreement

470-0377

Nondiscrimination Compliance Review

470-0443

Application and Contract Agreement for Residential Care Facilities

470-0602

DHS Notice of Decision

470-0664

Financial and Statistical Report for Purchase of Service Contracts

470-0829

Request for Prior Authorization

470-0835

Consent for Sterilization

470-0835S

Formulario de Consentimiento Requerido (Consent for Sterilization, Spanish)

470-0836

Certification Regarding Abortion

470-1999

Amendment to Provider Agreement

470-2145

Augmentative Communication System Selection

470-2169

Provider Request for Member Disenrollment

470-2464

Report for Enhanced Services

470-2615

Agreement for Participation as a Patient Manager in the
Iowa Medicaid Patient Access to Service System (MediPASS)

470-2618

Election of Medicaid Hospice Benefit

470-2619

Revocation of Medicaid Hospice Benefit

470-2780

Certification of Need for Inpatient Psychiatric Services

470-2826

Insurance Questionnaire

  •  After this form is filled out, please FAX it to (515)725-1352

470-2917

Medicaid HCBS Waiver Provider Application

470-2942

Medicaid Prenatal Risk Assessment

470-3165

Child Mental Health Screen

470-3174

Addendum to Dental Provider Agreement for Orthodontia

470-3372

HCBS Consumer - Directed Attendant Care Agreement

470-3449

HCBS Supplemental Schedule D4

470-3494

Nurse Aide Education Program Waiver Request

470-3495

Medicaid Wraparound Payment Form

470-3744

Iowa Medicaid Program Provider Inquiry Form

470-3748

Verification of Ambulance Compliance Form

470-3816

Medicaid Billing Remittance

470-3923

Request for Medicaid Services Data Changes and Verifications

470-3931

Medically Needy Expense Deletion Request

470-3969

Claim Attachment Control

470-4202

Electronic Funds Transfer (EFT) Authorization Form

470-4210

Certification of Enteral Nutrition

470-4211

Children's Mental Health Waiver Assessment

470-4223

Dental Addendum Ortho Agreement

470-4228

Affidavit and Agreement for Issuance of Duplicate Check

470-4360

Pharmaceutical Care Management (PCM) Billing Tool

470-4361

PCM Request for Patient Eligibility

470-4362

PCM Pharmacy Eligibility Application - Instructions

470-4363

PCM Pharmacist Eligibility Application - Instructions

470-4389

Consumer Directed Attendant Care (CDAC) Daily Service Record

470-4392

Certification for Level of Care for Home and Community Based Services (HCBS)

470-4393

Level of Care Certification for Facility Care

470-4427

Employment Agreement

470-4428

Financial Management Service Agreement

470-4429

Semi-Monthly Timesheet

470-4490

PACE Program Level of Care Assessment Form

470-4492

Independent Support Broker Agreement

470-4510

Individual CDAC & AFSCME Authorization Form

470-4560

Attestation of Medical Record Loss or Destruction

470-4608

Address Change Request Form

470-4622

TCM Cover Form

470-4687

Home Health Retrospective Medical Review Fax Cover Form

470-4694

Targeted Case Management (TCM) Comprehensive Assessment Form

470-4767

Examiner Report of Need for a Hearing Aid

470-4829

Nursing Facility Enhanced Medicaid Payment Report

470-4836

Nursing Facility Quality Assurance Assessment Calculation Worksheet

470-4869

CMPQII Grant Application and Guidelines

470-4973

Private Duty Nursing/PC Program- Retrospective Medical Review

470-4987

Recoupment Request

470-5023

CDAC Adjustment

470-5047

Certificate of Medical Necessity for Waiver Assistive Devices

470-5048

Certificate of Medical Necessity for Consumer-Directed Attendant Care

470-5049

Certificate of Medical Necessity for Environmental Modification

470-5050

Certificate of Medical Necessity for Home and Vehicle Modification

470-5051

Certificate of Medical Necessity for Prevocational Services

470-5100

Iowa Medicaid Health Home Provider Agreement

470-5111

Iowa Medicaid Ordering/Referring Provider Enrollment Application

470-5156

Level of Care Certification for Swing Bed Facility

 

470-5160

Iowa Medicaid Integrated Health Home Provider Agreement General Terms

470-5170

Application for Health Coverage and Help Paying Costs

470-5177

Iowa Wellness Plan Patient Manager Agreement

470-5189

Client Participation Notices Access Request

470-5198

Medically Exempt Attestation and Referral Form

470-5200

Application for Certification to become a Qualified Entity (QE)

470-5201

Qualified Entity (QE) Medicaid Presumptive Eligibility Portal (MPEP) Access Request Form

470-5210

Dental Wellness Plan Wraparound Payment Request

470-5211

Iowa Market Place Choice Wraparound Payment Request

470-5218

Iowa Medicaid Accountable Care Organization (ACO) Agreement

470-5262

Medicare Beneficiaries (QMB) Provider Enrollment Application

470-5264

Iowa Wellness Plan ACO Readiness Application

Health Home Provider Application
470-5273
Medicaid Cost Report Forms by Provider Type
  • Home Health Agencies (HHA) - EPSDT Financial and Statistical Report 2013 - 2-14
    In submitting this cost report and supporting schedules, the provider and all signatories jointly and severally certify that the information and responses on this cost report and supporting schedules are true, accurate, complete, verifiable, and prepared from the records of the provider in accordance with applicable instructions.
    View Instructions
     
  • RSP Cost Report
    Financial and Statistical Report for Remedial Services Provider Identification Page

Cooperative Agreement

  • LEA Agreement
    The purpose of this agreement is to assure the implementation of 34 CFR 300.
     
  • I/T Contract
    The purpose of this agreement is to assure the implementation of 34 CFR 303.