The 28 Iowa forms clinicians complete, from school immunization, dental and vision certificates to Medicaid prior authorization, the IPOST and commitment reports.
This page lists the Iowa forms clinicians complete, grouped by program, and each group links to its program hub. School entry brings the most paperwork: the Certificate of Immunization, the Certificate of Dental Screening for kindergarten and ninth grade, and the Certificate of Vision Screening (470-0021). Iowa Medicaid uses 470-5595 for outpatient prior authorization, 470-4108 for non-preferred drugs and 470-4393 to certify nursing facility level of care. The DOT uses form 430032 for a driver's visual acuity and 411055 for disability parking permits.
Some Iowa requests are not form fields. For a parking permit, the practitioner writes a signed statement on letterhead saying whether the disability is permanent or temporary. Commercial drug prior authorization uses the form each PBM files with the Insurance Division. Commitment reports under Rule 12.36 are filed with the district court, and the medical cannabis certification (470-0189) must be uploaded by the patient within 60 days of signing. Of these forms, 2 have a Spanish version. Vero Documents fills PDF forms from the visit note and the chart.
Vision specialist's report of visual acuity and conditions when a driver fails vision screening or a vision report is required at renewal.
Applies for a removable windshield placard, sticker or standard plates; must be accompanied by a medical statement certifying a permanent or temporary disability.
General request for prior authorization of a non-preferred drug on the Iowa Medicaid Preferred Drug List.
Medical professional's certification that a member needs nursing facility or ICF/ID level of care before admission.
Common outpatient prior authorization request used for Iowa Medicaid fee-for-service and all Iowa Medicaid MCOs (Iowa Total Care, Wellpoint, Molina).
Provider attestation that an Iowa Health and Wellness Plan (expansion) member is 'medically exempt' (serious mental illness, SUD, complex medical condition, disability) so they can get full State Plan benefits.
Proof of the dental screening required for children newly enrolling in kindergarten and ninth grade in Iowa (Iowa Code 135.17).
470-0021Proof of the child vision screening required for kindergarten and third grade enrollment (Iowa Code 135.39D / 641.52), with an eye-exam section for referrals.
Child Care Provider Physical Examination Report (Spanish, 470-5152(S))
Physical examination, immunization consultation and TB screening required for child care center personnel and child development home providers.
Annual physical exam and clearance (valid one calendar year) required for Iowa interscholastic athletics.
Licensed health care provider's evaluation and written clearance for a student removed for a suspected concussion (Iowa Code 280.13C).
Certifies that a child has age-appropriate immunizations meeting Iowa requirements for licensed child care or school enrollment.
Allows provisional school/child care enrollment for up to 60 days for a child who has started but not completed required vaccines, or a transfer student.
Medical exemption from Iowa school/child care immunization requirements when vaccines would be injurious to the applicant or a household member, or would violate live-vaccine spacing.
Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
Double-sided medical order sheet communicating resuscitation, scope of treatment and artificial nutrition preferences for frail elderly or seriously ill Iowans (Iowa Code 144D).
Rule 12.36—Form 4Court-designated examiner's report on whether a respondent is seriously mentally impaired (Iowa Code §229.10) after an application for involuntary hospitalization.
Rule 12.36—Form 8Hospital chief medical officer's report after psychiatric evaluation of a committed respondent, with diagnosis and recommended placement/treatment (Iowa Code §229.14).
Rule 12.36—Form 9Periodic report to the court on the condition and continued need for inpatient treatment of a committed respondent (Iowa Code §229.15(1)).
Rule 12.36—Form 10Periodic report on a respondent under court-ordered outpatient treatment (Iowa's assisted outpatient commitment), stating compliance and continued need (Iowa Code §229.15(2)).
Health care practitioner certifies the patient's qualifying debilitating medical condition(s) for an Iowa medical cannabis registration card.
Certifying practitioner requests a waiver allowing the patient to exceed the 4.5 g THC limit per 90 days.
470-0665Reporte de sospecha de abuso de menores
Written report of suspected child abuse by a mandatory reporter following the oral report to the Centralized Services Intake Unit.
Clinic case report of chlamydia, gonorrhea or syphilis diagnosis and treatment (including expedited partner therapy) to the Iowa STI Program.
Written report of suspected dependent adult abuse (exploitation, assault, denial of critical care, sexual offense, etc.) to Iowa HHS intake.
DNR Form 542-0417Physician certification that the applicant is a person with a disability under Iowa Code 321L.1(8) (temporary or permanent) for a severely disabled deer hunting license.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
It depends on the grade. For kindergarten, a dentist, dental hygienist, physician, nurse, ARNP or PA can sign. For ninth grade, only a dentist or dental hygienist can. The screener records treatment needs and signs with their credentials, and the certificate is not valid unless every field is complete. It goes back to the child's school for children newly enrolling in those grades.
A physician (MD or DO), physician associate, nurse or certified medical assistant signs the certification at the bottom of page 1, below the vaccine dates. Iowa also accepts certificates printed from IRIS and approved EHR printouts. A child who has started but not finished the series can enroll on the Provisional Certificate for up to 60 days, and a physician, NP or PA signs the medical exemption certificate.
Form 411055 has no medical section. The practitioner writes a separate signed statement on letterhead stating whether the disability is permanent or temporary. Physicians (including podiatrists), chiropractors, PAs, nurse practitioners and occupational or physical therapists licensed in any state can sign. A temporary placard lasts 6 months unless the statement gives an earlier date, and a permanent one lasts 5 years.
Form 470-5595, the Outpatient Medicaid Prior Authorization Form, is used for fee-for-service and every Iowa Medicaid MCO: Iowa Total Care, Wellpoint and Molina. Check the member's plan on the form, and use page 3 for each plan's fax numbers and portals. Standard decisions come within 7 days and urgent ones within 72 hours. Non-preferred drugs go on form 470-4108 instead.