Family Planning Forms

A variety of online and paper forms are available to applicants, recipients and sponsors.  For help in applying for Medicaid, contact 1-800-362-1504.


Plan First
Provider Agreement Plan First Provider Enrollment Form
Form 357 Plan First Application for people without children - 7/15
Required Forms
Form 189 STD/HIV Risk Screening and Intervention Tool
Optional Forms
Form 137 Family Planning Periodic Assessment
Form 138 Medicaid Family Planning Consent Form - Providers may use their own form as long as all required information is contained in the provider's form 
Form 140 Family Planning Assessment Record
Form 175 Family Planning Home Visit Record and Consent  
Form 328 Extended Family Planning Counseling Form - Provided only at time of post-partum visit
Form 340 HIV Counseling - Pre and Post Test - 9/23/15
Other Forms
Complaint/Grievance Form Plan First/Family Planning Recipient Complaint/Grievance Form
Form 354 Request for Newborn Assignment - Fax or Mail
Form 393  Grievance Form to tell Medicaid if you have a complaint about a Patient 1st provider
Form  349 Fillable form used to change your Patient 1st primary medical provider (PMP) by Mail
Form 349 - Fax Fillable form used to change your Patient 1st primary medical provider (PMP) by Fax
Form 193 Sterilization Consent (providers only) - Fillable - Updated 9/26/16   Note: On 10/26/16 changes were implemented to enable providers to upload or fax Sterilization Consent Forms and supporting documentation via the Forms menu of the Web Portal.. Effective November 28, 2016, Sterilization Forms and supporting documentation received on paper will be returned to the provider. See the October 2016 Provider Insider for details.
193-F Packet Educational Packet for women
193-M Packet Educational Packet for men