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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-01063 HealthCheck Family History DMS English 08/2017 Word No
F-01063S HealthCheck Family History, Spanish DMS Spanish 08/2017 PDF No
F-01063S HealthCheck Family History, Spanish DMS Spanish 08/2017 Word No
F-01002 HealthCheck Individual Health History DMS English 08/2019 PDF No
F-01002 HealthCheck Individual Health History DMS English 08/2019 Word No
F-01002H HealthCheck Individual Health History, Hmong DMS Hmong 08/2019 PDF No
F-01002H HealthCheck Individual Health History, Hmong DMS Hmong 08/2019 Word No
F-01002S HealthCheck Individual Health History, Spanish DMS Spanish 08/2019 PDF No
F-01002S HealthCheck Individual Health History, Spanish DMS Spanish 08/2019 Word No
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) DMS English 07/2008 PDF No
F-01066 HealthCheck Infant's Food Record (Birth to 12 Months of Age) DMS English 07/2008 Word No
F-01066S HealthCheck Infant's Food Record (Birth to 12 Months of Age), Spanish DMS Spanish 07/2008 PDF No
F-01066S HealthCheck Infant's Food Record (Birth to 12 Months of Age), Spanish DMS Spanish 07/2008 Word No
F-00021 HealthCheck Referral DMS English 01/2017 PDF No
F-11285 HealthCheck Screener Affirmation OIG English 04/2022 Word No
F-11285 HealthCheck Screener Affirmation OIG English 04/2022 PDF No
F-01112 HealthCheck Verification Card DMS English 07/2008 Yes
F-01067 HealthCheck Your Child's Speech and Hearing DMS English 07/2008 Word No
F-01067 HealthCheck Your Child's Speech and Hearing DMS English 07/2008 PDF No
F-13148 HIPAA Privacy Access Request DMS English 07/2008 PDF No
F-13149 HIPAA Privacy Accounting Request DMS English 07/2008 PDF No
F-13151 HIPAA Privacy Amendment Request DMS English 07/2008 PDF No
F-13145 HIPAA Privacy Authorization for Use or Disclosure DMS English 07/2008 PDF No
F-13146 HIPAA Privacy Revocation of Authorization DMS English 07/2008 PDF No
F-01359 Historical Earnings Verification Request DMS English 02/2022 Word No
F-03112 HMO Quarterly Appeals Log DMS English 03/2024 Excel No
F-03112A HMO Quarterly Grievance Log DMS English 01/2024 Excel No
F-03112AI HMO Quarterly Grievance Log Instructions DMS English 01/2024 PDF No
F-02319 Home and Community-Based Waiver Medicaid Enrollment for the Children's Long-Term Support Waiver Program DMS English 06/2023 PDF No
F-22541 Incident Report - IRIS DMS English 07/2020 PDF No
F-22541 Incident Report - IRIS DMS English 07/2020 Word No
F-20445 Individual Service Plan - Children’s Long-Term Support Programs DMS English 09/2022 PDF No
F-20445 Individual Service Plan - Children’s Long-Term Support Programs DMS English 09/2022 Word No
F-20445H Individual Service Plan - Children’s Long-Term Support Programs, Hmong DMS Hmong 09/2022 PDF No
F-20445H Individual Service Plan - Children’s Long-Term Support Programs, Hmong DMS Hmong 09/2022 Word No
F-20445I Individual Service Plan - Children’s Long-Term Support Programs, Instructions DMS English 09/2022 PDF No
F-20445S Individual Service Plan - Children’s Long-Term Support Programs, Spanish DMS Spanish 09/2022 Word No
F-20445S Individual Service Plan - Children’s Long-Term Support Programs, Spanish DMS Spanish 09/2022 PDF No
F-20445A Individual Service Plan - Outcomes - Children’s Long-Term Support Programs DMS English 05/2022 Word No
F-20445A Individual Service Plan: Outcomes, Children’s Long-Term Support Programs DMS English 05/2022 PDF No
F-20445AH Individual Service Plan: Outcomes, Children’s Long-Term Support Programs, Hmong DMS Hmong 05/2022 PDF No
F-20445AH Individual Service Plan: Outcomes, Children’s Long-Term Support Programs, Hmong DMS Hmong 05/2022 Word No
F-20445AS Individual Service Plan: Outcomes, Children’s Long-Term Support Programs, Spanish DMS Spanish 05/2022 PDF No
F-20445AS Individual Service Plan: Outcomes, Children’s Long-Term Support Programs, Spanish DMS Spanish 05/2022 Word No
F-10097 Institutional Medicaid Income Allocation DMS English 04/2024 PDF No
F-10097H Institutional Medicaid Income Allocation, Hmong DMS Hmong 04/2024 PDF No
F-10097S Institutional Medicaid Income Allocation, Spanish DMS Spanish 04/2024 PDF No
F-11040A Instructions DMS English 12/2019 PDF No
F-00286 Instructions DMS English 07/2015 PDF No
F-11079 Instructions DMS English 07/2017 PDF No
Last revised January 24, 2023