Contracting & Credentialing Forms

• Contract Request Form (PDF)
• Delegated Practitioner & Facility Roster Form (Excel)
• Facility/Ancillary Provider Application (PDF)
• Iowa Statewide Universal Practitioner Credentialing Application (PDF)
• HCBS Waiver Provider Application (PDF)
• Non-Delegated Practitioner & Facility Roster Form (Excel)
• Provider Change Form (PDF)
• Practitioner Data Form (PDF)
• Iowa Roster Addendum (PDF)
• W-9 Form (PDF)

Submit these forms to Iowa Total Care via email: networkmanagement@iowatotalcare.com.