Provider Forms

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Provider Forms

Form NumberForm Description
470-0228 (131.35 KB) .pdf Certificate of Medical Necessity for Adult Day Care (ADC) in the Family Home
470-0232 (46.83 KB) .docx Certificate of Medical Necessity for Medical Daycare for Children (MDC)
470-0239 (44.23 KB) .docx Universal Residential Referral
470-0241 (260.89 KB) .pdf Authorization to Disclose Personal Health Information Release Form (Medicaid Use)
470-0254Iowa Medicaid Universal Provider Enrollment Application
470-2917Iowa Medicaid Home- and Community-Based (HCBS) Waiver Provider Application
470-2965 (183.72 KB) .pdf Iowa Medicaid Provider Agreement General Terms
470-3174Iowa Medicaid Addendum to Dental Provider Agreement for Orthodontia
470-3372Home- and Community-Based Services (HCBS) Consumer-Directed Attendant Care (CDAC) Agreement (Fillable)
470-3495Iowa Medicaid Managed Care Wraparound Payment Request Form
470-3748Iowa Medicaid Enterprise Ambulance Verification of Compliance
470-3923Request for Medicaid Services Data Changes and Verifications
470-3924Request for IoWANS Changes
470-3969Pharmacy Fee-for-Service Claim Attachment Control Form
470-3970Pharmacy Fee-for-Service Prior Authorization Attachment Control Form
470-4202Electronic Fund Transfer (EFT) Authorization
470-4227Request and Acknowledgement to Conduct Registry and Record Check
470-4389Consumer-Directed Attendant Care (CDAC) Daily Service Record
470-4393Level of Care Certification for Facilities
470-4457Atypical Provider Declaration
470-4564Money Follows the Person Guardian Consent to Participate in Transition Planning
470-4566Money Follows the Person Consent to Begin Transition Planning
470-4582Money Follows the Person Consent to Proposed Transition
470-4608Iowa Medicaid Provider Address Change Request Form
470-4612Individual CDAC Disclosure
470-4815Early Periodic Screening Diagnosis and Treatment (EPSDT) Medical Needs Acuity Scoring Tool (MNAST) 
470-4816Early Periodic Screening Diagnosis and Treatment (EPSDT) Functional Needs Acuity Scoring Tool (FNAST)
470-4817Early Periodic Screening Diagnosis and Treatment (EPSDT) Social Needs Acuity Scoring Tool (SNAST) 
470-4829

Iowa Medicaid Nursing Facility Enhanced Medicaid Payment Report

470-4829 Instructions

470-4836Iowa Medicaid Nursing Facility Quality Assurance Assessment
470-4991Iowa Medicaid Meals and Lodging Claim
470-4996Iowa Medicaid Notice of Decision - Access2Care
470-5023CDAC Adjustment Cover Sheet
470-5030PACE Disenrollment Form
470-5047Certificate of Medical Necessity for Waiver Assistive Devices
470-5048Certificate of Medical Necessity for Consumer-Directed Attendant Care
470-5049Certificate of Medical Necessity for Environmental Modification
470-5050Certificate of Medical Necessity for Home and Vehicle Modification
470-5051Certificate of Medical Necessity for Prevocational Services
470-5100Iowa Medicaid Health Home Provider Agreement
470-5111Iowa Medicaid Ordering/Referring Provider Enrollment Application
470-5112Iowa Medicaid Designated Contact Person
470-5151Money Follows the Person Referral Information
470-5156Level of Care Certification for Swing Bed Facility
470-5160Iowa Medicaid Integrated Health Home Provider Agreement General Terms
470-5168Medicaid/Hawki Review
470-5170

Application for Health Coverage and Help Paying Costs

470-5177Agreement for Participation as a Patient Manager in the Iowa Health and Wellness Plan (Wellness Plan)
470-5189Client Participation Notices Access Request
470-5194Medically Exempt Member Survey
470-5198Medically Exempt Attestation and Referral Form
470-5200Application for Certification to become a Qualified Entity (QE)
470-5201Qualified Entity (QE) Medicaid Presumptive Eligibility Portal (MPEP) Access Request Form
470-5210Dental Wellness Plan Wraparound Payment Request
470-5218Iowa Medicaid Accountable Care Organization (ACO) Agreement
470-5262Iowa Medicaid Qualified Medicare Beneficiaries (QMB) or Health Insurance Premium Payment (HIPP) Program Provider Enrollment Application
470-5267Chronic Health Home Program Patient Tier Assignment Tool (PTAT) Version 3.0
470-5268Chronic Condition Health Home Program Patient Tier Assignment Tool (PTAT) Guide
470-5273Iowa Medicaid Health Home Provider Application
470-5276Off Year Assessment 
470-5297Qualified Entity (QE) Medicaid Presumptive Eligibility Portal (MPEP) Recertification
470-5298Iowa Medicaid Provider Enrollment Application Fee Hardship Exemption Request
470-5324Core Standardized Assessment (CSA) Document Access Request for the Iowa Medicaid Portal Access (IMPA) System
470-5362Iowa Medicaid Memorandum of Understanding (MOU) for Value Based Purchasing Support Activities
470-5403Medicaid Member Documentation Upload Cover Sheet through the Iowa Medicaid Portal Access (IMPA) System
470-5417Long Term Care (LTC) File Upload for the Iowa Medicaid Portal Access (IMPA) System
470-5419Wraparound Supporting Claims Detail
470-5422Intermediate Care Facilities for Individuals with an Intellectual Disability Calculation Worksheet
470-5445Insurance Update Fee-for-Service (FFS) Members
470-5465Provider Request to Terminate Enrollment
470-5473Iowa Medicaid Inpatient Psychiatric Prior Authorization
470-5475Health Insurance Premium Payment (HIPP) Provider Invoice
470-5480Iowa Medicaid Mileage Reimbursement Trip Log and Claim Form
470-5482Medicaid/State Supplementary Assistance Review
470-5484 (40.58 KB) .pdf Family Planning Program Provider Attestation
470-5486 (277.43 KB) .pdf Emergency Needs Assessment
470-5506 (90.37 KB) .pdf Attestation of Compliance with Section 6032 of The Federal Deficit Reduction Act
470-5512 (113.46 KB) .pdf 340B, Federal Supply Schedule, and Nominal Price Attestation and Election
470-5526 (124.97 KB) .pdf Authorized Representative for Managed Care Appeals
470-5528 (142.4 KB) .pdf Certificate of Medical Necessity for Health and Disability Waiver Cap Increase
470-5594 (1.78 MB) .pdf Inpatient Medicaid Prior Authorization
470-5595 (1.98 MB) .pdf Outpatient Medicaid Prior Authorization
470-5635 (453.29 KB) .pdf Children's Mental Health Waiver Level of Care Determination Request for Additional Information
470-5642Case Mix Request Access for Iowa Medicaid Portal Access (IMPA) System
470-5667 (236.01 KB) .pdf Case Mix Payer Change Form
470-5710 (109.9 KB) .pdf Chronic Condition Health Home Managed Care Organizations (MCOs) Notification
470-5795 (167.26 KB) .pdf Home- and Community-Based Services (HCBS) Waiver Priority Need Assessment (WPNA)
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Medicaid Cost Report Forms by Provider Type

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Cooperative Agreement

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PC-ACE User Documentation

PC-ACE Pro32 Help Documents

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