Enrollment Forms

Registration Forms

The Exhibit A's below are used to obtain information required to set your facility up for testing transactions - forms reflect applicable lines of business. The forms on this page, unless otherwise indicated, are in PDF format.

Iowa Medicaid Enrollment Form

EDISS Enrollment form for Iowa Medicaid - Interactive Form*

*Interactive Form Information

The interactive forms on the EDISS site require Adobe Acrobat Reader 6.0 or higher. The Get Adobe Acrobat link below provides a link to the most recent version of Adobe Acrobat Reader which is compatible with all EDISS interactive forms.

Interactive Form Tips:

Content entered within this form can only be printed; the content entered can not be saved. The interactive form allows ease in completion by the provider as well as clarity when received at EDISS.
Select the "Highlight fields" and/or "Highlight required fields" box to view editable fields and assure the form is completed in its entirety.

Once the form is completed select Print Form and it will validate fields that are required. Then sign the form and send into EDISS.

Some of the documents located on this page are in PDF format and can be opened in Adobe Acrobat Reader. If you do not already have this application, follow the Get Adobe Acrobat link to download a free copy of the software.