Iowa Department of Health & Human Services Forms

This Form is used for requesting to end an authorization in the state of Iowa.

This form is used for obtaining authorization to take and use photographs in the state of Iowa.

This form is used for the Iowa Medicaid Point of Sale Agreement in Iowa. It is a document that outlines the agreement between a provider and the Iowa Medicaid program regarding payment and reimbursement for services rendered at the point of sale.

This form is used for requesting a change of address for Iowa Medicaid providers in Iowa.

This form is used for disenrolling from the Program of All-inclusive Care for the Elderly (PACE) in Iowa.

This type of document is used for requesting access to client participation notices in the state of Iowa.

This form is used for requesting wraparound payments for dental wellness plans in Iowa.

This Form is used for applying for initial or recertification to be a presumptive provider (PP) in Iowa.

This form is used for conducting a survey among medically exempt members in Iowa.

This form is used for healthcare providers in Iowa to apply for enrollment in the Medicaid Qualified Medicare Beneficiaries (QMB) or Health Insurance Premium Payment (HIPP) Program.

This form is used for recertification of the Medicaid Presumptive Eligibility Portal (MPEP) for Qualified Entities (QEs) in Iowa.

This Form is used for updating insurance information for Fee-For-Service Members in Iowa.

This form is used by Iowa to assess members in home- and community-based services (HCBS) residential settings.

This document is for providers participating in the Family Planning Program in Iowa to complete an attestation form. It is used to verify eligibility and compliance with program requirements.

This document is for requesting access to the Iowa Medicaid Portal Access (IMPA) system for wraparound payment requests. It is used in Iowa.

This form is used for requesting a CAP (Caregiver Affected Participant) increase in health and disability waiver in Iowa. It requires a certificate of medical necessity to support the request.

This form is used for providers of Community-Based Neurobehavioral Rehabilitation Services (CNRS) in Iowa to conduct a self-assessment of their quality management practices. It helps ensure that the providers meet the necessary standards and provide optimal care for individuals with neurobehavioral rehabilitation needs.

This document provides instructions for completing a financial and statistical report for psychiatric medical institutions for children in Iowa. It includes guidelines for reporting financial information and statistical data related to child psychiatric medical services.

This document provides instructions for preparing a financial and statistical report for the state of Iowa. It outlines what information to include and how to format the report.

This form is used for requesting access to the Iowa Medicaid Presumptive Eligibility Portal (MPEP) for Qualified Entities (QEs).

This document is for enrolling in a managed care organization through Iowa Health Link.

This form is used for requesting additional information for the Level of Care determination for children's mental health services in Iowa.

This form is used for attesting and electing the Nominal Price option for covered outpatient drugs under the Federal Supply Schedule (FSS) and the 340B program in the state of Iowa.

This form is used for assessing emergency needs for the Home- and Community-Based Services (HCBS) Brain Injury Waiver in Iowa. It helps identify individuals who require immediate assistance due to a brain injury.

This document is used for uploading Medicaid member documentation through the Impa system in Iowa.

This document provides instructions for Home Health Agencies in Iowa on how to complete the Early and Periodic Screening, Diagnostic and Treatment Private Duty Nursing/Personal Care Services Financial and Statistical Report.

This Form is used for requesting changes for Iowans in the state of Iowa.

This form is used to request access to the Iowa Medicaid Portal Access (IMPA) System for case mix purposes in Iowa.

This Form is used for verifying compliance with Iowa Medicaid requirements for ambulance services in the state of Iowa.