Forms
Downloadable Forms

470-0040 Adjustment Request
  • Form 470-4987 - Recoupment Request Form
    		•

    [ 69kb]
    470-0042 Case Activity Report

    [ 72kb]
    470-0369 Agreement for Nursing Facilities and Skilled Nursing Facilities

    [ 39kb]
    470-0372 Agreement for Intermediate Care Facilities for Mentally Retarded/Developmentally Disabled Persons Participation in the Medicaid Program

    [ 90 kb]
    470-0373 Voluntary Contribution Agreement

    [ 29 kb]
    470-0377 Nondiscrimination Compliance Review

    [ 88 kb]
    470-0602 DHS Notice of Decision

    470-0664 Financial and Statistical Report for Purchase of Service Contracts

    [ 387 kb]
    470-0829 Request for Prior Authorization

    [ 17 kb]
    470-0835 Consent for Sterilization

    [ 41 kb]
    470-0835S Formulario de Consentimiento Requerido (Consent for Sterilization, Spanish)

    [ 47 kb]
    470-0836 Certification Regarding Abortion

    [ 18 kb]
    470-1999 Amendment to Provider Agreement

    [ 11 kb]
    470-2145 Augmentative Communication System Selection

    [ 18 kb]
    470-2169 Provider Request for Member Disenrollment

    [ 31 kb]
    470-2464 Report for Enhanced Services

    [ 28 kb]
    470-2579 Application For Authorization To Make Presumptive Medicaid Eligibility Determinations For Pregnant Women

    [ 59 kb]
    470-2615 Agreement for Participation as a Patient Manager in the Iowa Medicaid Patient Access to Service System (MediPASS)

    [ 93 kb]
    470-2618 Election of Medicaid Hospice Benefit

    [ 40 kb]
    470-2619 Revocation of Medicaid Hospice Benefit

    [ 25 kb]
    470-2780 Certification of Need for Inpatient Psychiatric Services

    [ 23 kb]
    470-2826 Insurance Questionnaire
    ? After this form is filled out, please FAX it to (515)725-1352

    [ 59 kb]
    470-2917 Medicaid HCBS Waiver Provider Application

    [ 174 kb]
    470-2942 Medicaid Prenatal Risk Assessment

    [ 54 kb]
    470-3165 Child Mental Health Screen

    [ 31 kb]
    470-3174 Addendum to Dental Provider Agreement for Orthodontia

    [ 35 kb]
    470-3372 HCBS Consumer - Directed Attendant Care Agreement

    [ 75 kb]
    470-3449 Supplemental Schedule

    [ 91 kb]
    470-3494 Nurse Aide Education Program Waiver Request

    [ 29 kb]
    470-3495 Medicaid Wraparound Payment Form

    [ 21 kb]
    470-3744 Iowa Medicaid Program Provider Inquiry Form

    [ 36 kb]
    470-3748 Verification of Ambulance Compliance Form

    [ 55 kb]
    470-3816 Medicaid Billing Remittance

    [ 26 kb]
    470-3864 Application for Authorization to Make Presumptive Medicaid Eligibility Determinations (BCCT)

    [ 22 kb]
    470-3923
    		 ISIS Q&A Form

    470-3931 Medically Needy Expense Deletion Request

    [ 23 kb]
    470-3969 Claim Attachment Control

    [ 28 kb]
    470-4166 Iowa Medicaid Provider Form Request

    [ 30 kb]
    470-4202 Electronic Funds Transfer (EFT) Authorization Form

    [ 28 kb]
    470-4210 Certification of Enteral Nutrition

    [ 26 kb]
    470-4211 Children's Mental Health Waiver Assessment

    [ 236 kb]
    470-4223 Dental Addendum Ortho Agreement
    ? View Orthodontia FAQ

    [ 38 kb]
    470-4228 Affidavit and Agreement for Issuance of Duplicate Check

    [ 39 kb]
    470-4360 Pharmaceutical Care Management (PCM) Billing Tool

    [ 22kb]
    470-4361 PCM Request for Patient Eligibility

    [ 27kb]
    470-4362 PCM Pharmacy Eligibility Application - Instructions

    [ 43kb]
    470-4363 PCM Pharmacist Eligibility Application - Instructions

    [ 48kb]
    470-4389 Consumer Directed Attendant Care (CDAC) Daily Service Record

    [ 49kb]
    470-4392 Certification for Level of Care for Home and Community Based Services (HCBS)

    []
    470-4393 Level of Care Certification for Facility Care

    [ 661kb]
    470-4425
    		 Habilitation Cost Report

    []
    470-4490 PACE Program Level of Care Assessment Form

    [ 79kb]
    470-4510 Individual CDAC & AFSCME Authorization Form

    [ 167kb]
    470-4560 Attestation of Medical Record Loss or Destruction

    [ 30kb]
    470-4608 Address Change Request Form

    [ 55kb]
    470-4622 TCM Cover Form

    [ 26kb]
    470-4687 Home Health Retrospective Medical Review Fax Cover Form

    [ 55kb]
    470-4767 Examiner Report of Need for a Hearing Aid

    [ 29kb]
    470-4829 Nursing Facility Enhanced Medicaid Payment Report
  • Form Instructions
    		•

    [ 58kb]
    470-4836 Nursing Facility Quality Assurance Assessment Calculation Worksheet
  • Worksheet Instructions
    		•

    [ 89kb]
    470-4869 CMPQII Grant Application and Guidelines

    [ 69kb]
    470-4973 Private Duty Nursing/PC Program- Retrospective Medical Review

    [ 80kb]
    470-4987 Recoupment Request
  • Form 470-0040
    		•

    [ 67kb]
    470-4990 Application for Authorization to Make Presumptive Medicaid Eligibility Determination for Children

    [ 77kb]
    470-5023 CDAC Adjustment

    [ 36kb]
    470-5047 Certificate of Medical Necessity for Waiver Assistive Devices

    [ 81kb]
    470-5048 Certificate of Medical Necessity for Consumer-Directed Attendant Care

    [ 81kb]
    470-5049 Certificate of Medical Necessity for Environmental Modification

    [ 90kb]
    470-5050 Certificate of Medical Necessity for Home and Vehicle Modification

    [ 91kb]
    470-5051 Certificate of Medical Necessity for Prevocational Services

    [ 81kb]
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    Medicaid Cost Report Forms by Provider Type

    RSP Cost Report Financial and Statistical Report for Remedial Services Provider Identification Page

    [ 235kb]
    RSP Parent Cost Report Financial and Statistical Report for Remedial Services Provider Identification Page (Parent)

    [ 235kb]
    CMHC Cost Report Community Mental Health Center Financial & Statistical Report
    - View Instructions[ 58kb]

    [ 52kb]
    FQHC Federally Qualified Health Center (FQHC)

    [ 33kb]
    Hab. Svcs. - FS Habilitation Services Financial and Statistical Report

    [ 153kb]
    Hab. Svcs. - Parent Habilitation Services Parent Cost Report

    [ 152kb]
    HCBS Home and Community Based Services (HCBS)

    [ 3,178kb]
    Home Health Agency Apportionment of Patient Service Costs - Home Health Agency

    [ 95kb]
    Hospital-CAH Hospital - Critical Access

    [ 41kb]
    Hospital Hospital - Not Critical Access

    [ 66kb]
    Financial & Statistical
    Report    		 Nursing Facility (NF) / Intermediate Care Facility for Mentally Retarded (ICFMR) / Residential Care Facility (RCF)
    - View Instructions[ 217kb]

    [ 1,087kb]
    PMIC Psych Medical Institution for Children (PMIC)

    [ 123kb]
    RHC Rural Health Clinic (RHC)

    [ 25kb]
    MHI State Mental Health Institute (MHI)

    [ 110kb]
    Case Management Targeted Case Management (TCM)

    [ 85kb]
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    Cooperative Agreement

    LEA Agreement The purpose of this agreement is to assure the implementation of 34 CFR 300.

    [ 30 kb]
    I/T Contract The purpose of this agreement is to assure the implementation of 34 CFR 303.

    [ 30 kb]
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    PC-ACE Pro32 Help Documents

    Downloading and Installing

    [ 23 kb]
    Installing the Updates

    [ 28 kb]
    Completing the Reference Files

    [ 38 kb]
    Creating Institutional Claims ? Nursing Facility

    [ 37 kb]
    Creating Institutional Claims ? UB92

    [ 34 kb]
    Creating Professional Claims ? CMS 1500

    [ 34 kb]
    Creating Professional Claims ? Dental

    [ 34 kb]
    Creating Professional Claims ? Waiver/Targeted Case Mgmt.

    [ 32 kb]
    Preparing Claims for Transmission

    [ 28 kb]
    Submitting Electronic Transactions

    [ 34 kb]
    Reactivating Claims

    [ 31 kb]
    Backing Up and Restoring

    [ 30 kb]
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    Images of people and children