Provider Quality Management Self-Assessment

The Home- and Community-Based Services (HCBS) Provider Quality Management Self-Assessment is required of all providers enrolled for the services identified, regardless of whether those services are currently being provided. All sections of the self-assessment template must be completed as requested  and submitted as a single document with any required supporting documents by December 31, 2021. For clarification as to whether a Medicaid provider will be required to complete the self-assessment template, review the information on Section B of the Self-Assessment. If you are providing any services under the waiver programs listed in this section you are required to complete a Self-Assessment. 

View completed HCBS Provider Quality Management Self Assessments

If you are uncertain which services your agency is enrolled for,
please contact the IME Provider Services at 800-338-7909 or
515-256-4609 (option 2) if in the Des Moines metro area.


2021 Provider Quality Management Self-Assessment

As introduced in 2016, information on HCBS service setting sites will continue to be collected and analyzed. An Address Collection Tool has been sent to providers using the email provided in Section A on last year’s self-assessment. If you are a new provider or did not receive a copy of the tool, please request it directly from your HCBS specialist. The Address Collection Tool should be submitted at the same time as the completed self-assessment by emailing it to

Please note the 2021 self-assessment form functionality will not work correctly if you simply click on the link below and attempt to complete the form within your web browser. You must first save the form as a PDF file to your computer and then open and complete the PDF version in order for the form to work as intended.


2021 Provider Quality Management Self-Assessment Resources:


Archive of Self-Assessment Resources from Previous Years

Additional questions should be directed to the HCBS Specialist in the county where your parent agency is located. To locate contact information for your specialist visit the webpage HCBS Waiver Provider Contacts and click on List of HCBS Specialists for each region.