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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-16001H Notice of Denial of Benefits/Negative Change in Benefits, Hmong DMS Hmong 05/2018 PDF No
F-16001L Notice of Denial of Benefits/Negative Change in Benefits, Laotian DMS Laotian 05/2018 PDF No
F-16001R Notice of Denial of Benefits/Negative Change in Benefits, Russian DMS Russian 05/2018 PDF No
F-16001SO Notice of Denial of Benefits/Negative Change in Benefits, Somali DMS Somali 05/2018 PDF No
F-16001S Notice of Denial of Benefits/Negative Change in Benefits, Spanish DMS Spanish 05/2018 Word No
F-13038 Notice of Intent to File a Lien (Paper Only. Follow link to order paper copy.) DMS English 06/2010 Yes
F-16014 Notice of Program Violation DMS English 03/2018 PDF No
F-10099 Notice of State Authorized Placement of a Medicaid Recipient in an Out-of-State Treatment Facility DMS English 07/2008 PDF No
F-01013 Nurse Aide Training and Competency Test Reimbursement Request DMS English 11/2018 Word No
F-01013 Nurse Aide Training and Competency Test Reimbursement Request DMS English 11/2018 PDF No
F-01013A Nurse Aide Training and Competency Test Reimbursement Request Instructions DMS English 03/2019 PDF No
F-01020 Nursing Home Care Determination Request DMS English 07/2018 PDF No
F-01020 Nursing Home Care Determination Request DMS English 07/2018 Word No
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan DMS English 10/2008 Word No
F-11103 Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan DMS English 10/2008 PDF No
F-11103A Optional Outpatient Mental Health Assessment and Treatment / Recovery Plan: Completion Instructions DMS English 07/2012 PDF No
F-01198 Optional School-Based Services Activity Log Nursing / Therapy Medical Services DMS English 07/2008 PDF No
F-01198 Optional School-Based Services Activity Log Nursing / Therapy Medical Services DMS English 07/2008 Word No
F-01199 Optional School-Based Services Activity Medication Administration DMS English 07/2008 Word No
F-01199 Optional School-Based Services Activity Medication Administration DMS English 07/2008 PDF No
F-11271 Personal Care Provider Addendum DMS English 09/2019 PDF No
F-11271 Personal Care Provider Addendum DMS English 09/2019 Word No
F-11133 Personal Care Screening Tool (PCST) DMS English 08/2017 PDF No
F-11133 Personal Care Screening Tool (PCST) DMS English 08/2017 Word No
F-02061 Pharmacy Benefit Manager (PBM) Insurance Disclosure Onboarding DMS English 03/2017 PDF No
F-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member DMS English 03/2023 PDF No
F-00841 Pharmacy Services Lock-In Program - HMO Referral for Pharmacy Services Lock-In of HMO Member DMS English 03/2023 Word No
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program DMS English 03/2023 PDF No
F-00840 Pharmacy Services Lock-In Program - HMO Responsibilities for Member Referral to Pharmacy Services Lock-In Program DMS English 03/2023 Word No
F-00842 Pharmacy Services Lock-In Program - Program Summary DMS English 07/2013 PDF No
F-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services DMS English 03/2023 PDF No
F-11183 Pharmacy Services Lock-In Program / Designation of Alternate Prescriber for Restricted Medications Services DMS English 03/2023 Word No
F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services DMS English 03/2023 PDF No
F-00345 Pharmacy Services Lock-In Program HMO Designation of Prescriber for Restricted Medication Services DMS English 03/2023 Word No
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use DMS English 03/2023 Word No
F-00250 Pharmacy Services Lock-In Program Request for Review of Member Prescription Drug Use DMS English 03/2023 PDF No
F-13074 Pharmacy Special Handling Request DMS English 04/2014 Word No
F-13074 Pharmacy Special Handling Request DMS English 04/2014 PDF No
F-13074A Pharmacy Special Handling Request: Completion Instructions DMS English 07/2012 PDF No
F-00401 Preferred Drug List (PDL) Expedited Emergency Supply Request DMS English 01/2021 Word No
F-00401 Preferred Drug List (PDL) Expedited Emergency Supply Request DMS English 01/2021 PDF No
F-00401 Preferred Drug List (PDL) Expedited Emergency Supply Request, Instructions DMS English 01/2021 PDF No
F-03185 Prenatal Care Coordination Care Coordinator Visit Checklist DMS English 06/2023 PDF No
F-03185 Prenatal Care Coordination Care Coordinator Visit Checklist DMS English 06/2023 Word No
F-03183 Prenatal Care Coordination Care Plan DMS English 06/2023 PDF No
F-03183 Prenatal Care Coordination Care Plan DMS English 06/2023 Word No
F-03183A Prenatal Care Coordination Care Plan, Instructions DMS English 06/2023 PDF No
F-03188 Prenatal Care Coordination Plan of Operation DMS English 06/2023 PDF No
F-03188 Prenatal Care Coordination Plan of Operation DMS English 06/2023 Word No
F-01105 Prenatal Care Coordination Pregnancy Questionnaire DMS English 02/2009 PDF No
Last revised January 24, 2023