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
193-F Packet Educational Packet for women
193-M Packet Educational Packet for men