Forms

Medicaid Forms  
470-0040 Adjustment Request
470-0042 Case Activity Report  
470-0254 Iowa Medicaid Universal Provider Enrollment Application
470-0369 Agreement for Nursing Facilities and Skilled Nursing Facilities
470-0372 Agreement for Intermediate Care Facilities for the 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
470-2310 Record Check Evaluation 
Spanish Version
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 Iowa Medicaid HCBS Waiver Provider Application

Downloadable Form

470-2942

Medicaid Prenatal Risk Assessment

470-2965

Iowa Medicaid Provider Agreement 

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

470-3747

Pharmacy Point of Sale (POS) Agreement

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

Level of Care Certification for HCBS Waiver Program

470-4393

Level of Care Certification for Facility Care

470-4427

Employment Agreement

470-4428

Financial Management Service Agreement

470-4429

Semi-Monthly Timesheet

470-4457

Atypical Provider Declaration

470-4490

PACE Program Level of Care Assessment Form

470-4492

Independent Support Broker Agreement

470-4560

Attestation of Medical Record Loss or Destruction

470-4608

Address Change Request Form

470-4612

Individual Consumer Directed Attendant Care (CDAC) Disclosure

470-4622

TCM Cover Form

470-4687

Home Health Retrospective Medical Review Fax Cover Form

470-4694

Case Management Comprehensive Assessment 

470-4698

Iowa Medicaid Critical Incident Report

470-4767

Examiner Report of Need for a Hearing Aid

470-4815

Early Periodic Screening Diagnosis and Treatment (EPSDT) Medical Needs Acuity Scoring Tool (MNAST)

470-4816

Early Periodic Screening Diagnosis and Treatment (EPSDT) Functional Needs Acuity Scoring Tool (FNAST)

470-4829

Nursing Facility Enhanced Medicaid Payment Report

470-4836

Nursing Facility Quality Assurance Assessment Calculation Worksheet

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

470-5110

Home- and Community-Based Services (HCBS) Intellectual Disability Waiver Priority Need Assessment – Statewide Waiting List

470-5111

Iowa Medicaid Ordering/Referring Provider Enrollment Application

470-5112

Designated Contact Person

470-5131

Health Home Provider Location and Practitioner Lists

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

470-5186

Iowa Medicaid Ownership and Control Disclosure

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

470-5273

Iowa Medicaid Health Home Provider Application

470-5276

Off Year Assessment 

470-5297

Qualified Entity (QE) Medicaid Presumptive Eligibility Portal (MPEP) Recertification

470-5298

Iowa Medicaid Enterprise (IME) Provider Enrollment Application Fee Hardship Exemption Request

470-5312

ICD-10 External Testing Registration

470-5324

Core Standardized Assessment (CSA) Document Access Request for the Iowa Medicaid Portal Access (IMPA) System

470-5362

Iowa Medicaid Memorandum of Understanding (MOU) for Value Based Purchasing Support Activities

470-5417

Long Term Care (LTC) File Upload for the Iowa Medicaid Portal Access (IMPA) System

470-5419 Wraparound Supporting Claims Detail
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

FAQ for HCBS Cost Report 
Frequently Asked Questions (FAQ) regarding the Home- and Community-Based Services (HCBS) Cost Report

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.

PC-ACE Pro32 Billing Guides ICD-9

PC-ACE Pro32 Billing Guides ICD-10