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Medicaid Forms

Below is a list of all Medicaid forms. 

When you are searching for a document, enter the number or a portion of the title in the search box below.

Assigned Number Title Division Language Release Date File Type Available to Order
F-01164 Consent for Sterilization DMS English 10/2008 PDF No
F-01164A Consent for Sterilization Completion Instructions DMS English 10/2015 PDF No
F-01164S Consent for Sterilization, Spanish DMS Spanish 10/2008 Word No
F-01164S Consent for Sterilization, Spanish DMS Spanish 10/2008 PDF No
F-01182 Declaration of Supervision for Nonbilling Providers DMS English 07/2012 PDF No
F-01182 Declaration of Supervision for Nonbilling Providers DMS English 07/2012 Word No
F-03203 Disenrollment of Adult Long-Term Care (LTC) Waiver Program and Services DMS English 09/2024 Word No
F-10193 Divestment Penalty and Undue Hardship Notice Plus Waiver Request DMS English 08/2021 PDF No
F-10193S Divestment Penalty and Undue Hardship Notice Plus Waiver Request, Spanish DMS Spanish 08/2021 PDF No
F-00020 Drug Addition Review Request DMS English 04/2014 PDF No
F-00020 Drug Addition Review Request DMS English 04/2014 Word No
F-00079 Effective for use before 07/01/2019: Prior Authorization/Preferred Drug List (PA/PDL) for Armodafinil and Modafinil DMS English 01/2019 PDF No
F-00079A Effective for use before 07/01/2019: Prior Authorization/Preferred Drug List (PA/PDL) for Armodafinil and Modafinil Instructions DMS English 01/2019 PDF No
F-10146 Employer Verification of Earnings DMS English 02/2022 Word No
F-10146A Employer Verification of Earnings: Proof of Employment DMS English 06/2020 Word No
F-11079 Excel DMS English 10/2016 Excel No
F-01234 Explanation of Medical Benefits DMS English 04/2018 PDF No
F-01234 Explanation of Medical Benefits DMS English 04/2018 Word No
F-02296 F-02296, Medicaid Fraud Control Elder Abuse Unit Referral: Used in Partnership with HMOs, MCOs, and IRIS OIG English 10/2019 Word No
F-02296B F-02296B, Medicaid Fraud Control Elder Abuse Unit Referral Feedback: Used in Partnership with HMOs, MCOs, and IRIS OIG English 10/2019 Word No
F-02296C F-02296C, Medicaid Fraud Control Elder Abuse Unit Referral: Overpayment Recovery OIG English 02/2020 Word No
F-02296I F-02296i,Instructions: Medicaid Fraud Control Elder Abuse Unit Referral: Used in Partnership with HMOs and MCOs OIG English 10/2019 PDF No
F-02296II F-02296ii,Instructions: Medicaid Fraud Control Elder Abuse Unit Referral: Used in Partnership with IRIS OIG English 10/2019 PDF No
F-11023 F-11023, F-11023B, and F-11023C: Cost Report for Provider-Based Rural Health Clinics DMS English 06/2024 Excel No
F-11023BI F-11023BI: Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) Instructions DMS English 06/2024 PDF No
F-11023I F-11023I: Cost Report for Provider-Based Rural Health Clinics Instructions DMS English 06/2024 PDF No
F-02656 Federally Qualified Health Center Cost Report DMS English 01/2021 Excel No
F-00407 Financial Records Request DMS English 06/2023 PDF No
F-02493 ForwardHealth Prior Authorization Speech-Generating Device Purchase Recommendation Attachment DMS English 07/2019 PDF No
F-02493 ForwardHealth Prior Authorization Speech-Generating Device Purchase Recommendation Attachment DMS English 07/2019 Word No
F-02493A ForwardHealth Prior Authorization Speech-Generating Device Purchase Recommendation Attachment Instructions DMS English 07/2019 PDF No
F-02494 ForwardHealth Prior Authorization Speech-Generating Device Skills and Needs Profile Attachment DMS English 07/2019 PDF No
F-02494 ForwardHealth Prior Authorization Speech-Generating Device Skills and Needs Profile Attachment DMS English 07/2019 Word No
F-02494A ForwardHealth Prior Authorization Speech-Generating Device Skills and Needs Profile Attachment Instructions DMS English 07/2019 PDF No
F-01361 ForwardHealth Provider Express Enrollment Change of Address DMS English 09/2014 HTML No
F-01068F General Pediatric Clinic - 12 Month Visit DMS English 08/2019 PDF No
F-01068F General Pediatric Clinic - 12 Month Visit DMS English 08/2019 Word No
F-01068G General Pediatric Clinic - 15 Month Visit DMS English 08/2019 Word No
F-01068G General Pediatric Clinic - 15 Month Visit DMS English 08/2019 PDF No
F-01068H General Pediatric Clinic - 18 Month Visit DMS English 08/2019 Word No
F-01068H General Pediatric Clinic - 18 Month Visit DMS English 08/2019 PDF No
F-01068I General Pediatric Clinic - 24 Month Visit DMS English 08/2019 Word No
F-01068I General Pediatric Clinic - 24 Month Visit DMS English 08/2019 PDF No
F-01068A General Pediatric Clinic - 3 to 4 Week Visit DMS English 08/2019 PDF No
F-01068A General Pediatric Clinic - 3 to 4 Week Visit DMS English 08/2019 Word No
F-01068C General Pediatric Clinic - 4 Month Visit DMS English 08/2019 Word No
F-01068C General Pediatric Clinic - 4 Month Visit DMS English 08/2019 PDF No
F-01068D General Pediatric Clinic - 6 Month Visit DMS English 08/2019 PDF No
F-01068D General Pediatric Clinic - 6 Month Visit DMS English 08/2019 Word No
F-01068B General Pediatric Clinic - 6 to 8 Week Visit DMS English 08/2019 Word No

Glossary

 
Last revised January 24, 2023