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

470-0602

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

470-5177

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
  • 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.