Iowa Department of Human Services

Important Information Regarding Claims Forms
The claims forms provided on this website are for reference purposes only. In order to process claims, IME must have original versions of the forms. Please do not submit claims on the forms found on this website. Original versions of the CMS-1500, UB-04 and Dental Claim forms can be found at office supply stores. Originals of the Targeted Medical Care claim forms can be requested from IME by contacting Provider Services at 1-800-338-7909 or locally at 515-256-4609.

All Claim Instructions and Forms

CMS-1500 Claims

^{_{CMS-1500 Instructions}} - ^{_{[ 43kb]}}
^{_{CMS-1500 Sample Claim Form}} - ^{_{[ 350kb]}}

UB04 Claims

UB04 Instructions
^{_{UB04 Sample Claim Form}} - ^{_{[ 1,001kb]}}

ADA 2006 Claims

ADA 2006 Instruction
^{_{ADA 2006 Sample Claim Form}} - ^{_{[ 489kb]}}

Targeted Medical Care 470-2486 Claim

Crossover Claims

^{_{Institutional Crossover Instructions}} - ^{_{[ 50kb]}}
^{_{Institutional Crossover Forms}} - ^{_{[ 776kb]}}
^{_{Professional Crossover Instructions}} - ^{_{[ 50kb]}}
^{_{Professional Crossover Forms}} - ^{_{[ 757kb]}}
^{_{Crossover Tips – Avoiding returned claims}} -
^{_{[ 29 kb]}}

Fill out the waiver claim form using this easy template, print, and mail in!

Template for Targeted Medical Care, 470-2486

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