Provider Quality Management Self-Assessment

The Home and Community Based Services (HCBS) Provider Quality Management Self-Assessment will be 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 (Sections A, B, C, D, E, and F) and submitted as a single document with any required supporting documents by December 1 of each year. 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. 

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.

News and Announcements
  • 2017 Provider Quality Management Address Collection Tool: 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
  • 2017 Provider Quality Management Self-Assessment Form: Access the 2017 Provider Quality Management Self-Assessment Form

2017 Provider Quality Management Self-Assessment Training Webinar
The 2017 Provider Quality Management Self-Assessment Training webinar is now available for viewing at your convenience. You may submit questions regarding the training and forms directly to your HCBS specialist or via email to

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.