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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-00239 Completion Instructions DMS English 07/2015 PDF No
F-00694 Completion Instructions DMS English 07/2015 PDF No
F-00212 Completion Instructions DMS English 12/2019 PDF No
F-11032A Completion Instructions DMS English 10/2008 PDF No
F-11019A Completion Instructions DMS English 07/2012 PDF No
F-01197A Completion Instructions DMS English 06/2009 PDF No
F-11020A Completion Instructions DMS English 02/2016 PDF No
F-00281 Completion Instructions DMS English 07/2015 PDF No
F-11027 Completion Instructions DMS English 10/2016 PDF No
F-11031A Completion Instructions DMS English 10/2008 PDF No
F-01674A Completion Instructions DMS English 01/2017 PDF No
F-01629A Completion Instructions DMS English 12/2019 PDF No
F-01164A Completion Instructions DMS English 10/2015 PDF No
F-11035A Completion Instructions DMS English 07/2012 PDF No
F-13073 Compound Drug Claim DMS English 04/2017 Word No
F-13073 Compound Drug Claim DMS English 04/2017 PDF No
F-13073A Compound Drug Claim: Completion Instructions DMS English 04/2017 PDF No
F-01270 Comprehensive Community Services Non-Traditional Approval DMS English 07/2014 PDF No
F-01270 Comprehensive Community Services Non-Traditional Approval DMS English 07/2014 Word No
F-01068M Confidential Health Survey DMS English 08/2019 PDF No
F-01068M Confidential Health Survey DMS English 08/2019 Word No
F-01068MS Confidential Health Survey, Spanish DMS Spanish 08/2019 PDF No
F-01068MS Confidential Health Survey, Spanish DMS Spanish 08/2019 Word No
F-01164 Consent for Sterilization DMS English 10/2008 Word No
F-01164 Consent for Sterilization DMS English 10/2008 PDF No
F-01164S Consent for Sterilization, Spanish DMS Spanish 10/2008 PDF No
F-01164S Consent for Sterilization, Spanish DMS Spanish 10/2008 Word 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-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-00079 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 and F-11023A: Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) DMS English 10/2016 Excel No
F-11023 F-11023 and F-11023B: Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds - 30% Overhead Applicable for RHC Services) DMS English 10/2016 Excel No
F-11023AI F-11023AI: Completion Instructions - Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds) DMS English 07/2017 PDF No
F-11023BI F-11023BI: Completion Instructions - Cost Report for Provider-Based Rural Health Clinics (Affiliated Hospital Having 50 or Fewer Beds - 30% Overhead) DMS English 07/2017 PDF No
F-11023I F-11023I: Completion Instructions - Rural Health Clinic Reclassification and Adjustment of Trial Balance Expenses DMS English 10/2016 PDF No
Last revised January 24, 2023