Iowa Department of Human Services
Iowa Medicaid Provider Form Request
To order forms, please enter the quantity of each form needed. Complete your name and address in the label section, and mail to: IME, Form Requests, P.O. Box 36450, Des Moines, Iowa, 50315. Please allow 30 days for delivery.
Quantity / Description______/ Certification Regarding Abortion (4700836)
______/ Claim for Targeted Medical Care (4702486)
______/ Consent for Sterilization (470-0835)
______/ Consent for Sterilization (Spanish) (470-0835S)
______/ Hearing Aid Evaluation/Selection Report (4700828)
______/ Medicaid Prenatal Risk Assessment (4702942)
______/ Medically Needy Expense Deletion Request (4703931)
______/ Provider Inquiry (470-3744)
______/ Report for Enhanced Services (4702464)
______/ Report of Examination for a Hearing Aid (4700361)
______/ Request for Prior Authorization (4700829)
From: Provider Number______
Name______
Address______
City______State______ZIP______