Forms
Downloadable Forms

470-0040
Adjustment Request

470-0042
Case Activity Report

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]

470-0374
ICF/ID Resident Care Agreement

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


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

470-2464 Report for Enhanced Services

[ 28 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

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
HCBS Supplemental Schedule D4

[ ]

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]

470-3923
ISIS Q&A Form

470-3931 Medically Needy Expense Deletion Request

[ 23 kb]

470-3969
Claim Attachment Control

470-4166 Iowa Medicaid Provider Form Request

[ 30 kb]

470-4202
Electronic Funds Transfer (EFT) Authorization Form
  • Form Instructions
  • [ 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

    []

    470-4425
    Habilitation Cost Report

    []

    470-4490 PACE Program Level of Care Assessment Form

    [ 79kb]

    470-4510
    Individual CDAC & AFSCME Authorization Form

    []

    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

    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]

    470-5156 Level of Care Certification for Swing Bed Facility
    -Attachment A


    470-5160 Iowa Medicaid Integrated Health Home Provider Agreement General Terms

    470-5177
    Iowa Wellness Plan Patient Manager Agreement

    470-5189
    Facility Client Participation Notices Access 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

    470-5211
    Iowa Market Place Choice Wraparound Payment Request

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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)

    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)

    Back to Top


    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]

    Back to Top


    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