IA 470-2917 2019 free printable template

O. Box 36450 Des Moines IA 50315 For questions contact Tel. 800 338-7909 option 2 or 515 256-4609 option 2 local Individual applicants applying to provide Consumer-Directed Attendant Care CDAC must complete and submit the following forms Form 470-2917 - Medicaid HCBS Waiver Provider Application Sections I and II Form 470-2965 - Provider Agreement Form 470-4202 - EFT IRS Form W9 Form 470-4612 - Individual CDAC Disclosure Form 470-4457 - Atypical Provider Declaration Form 470-4227 - Record...

Basic Information Required Documentation For the Basic Information and Application, you must attach the following materials; two printed, separate pages. Please have these two pages ready so that the form can be completed quickly. 1) Patient's Name 2) Date of Birth You need the patient's date of birth. If you are filing electronically, you must attach copies of medical records. You can print documents online or through your local county office. What Do I Need to Provide? Please complete the form and attach the following materials to it. Do not mail or fax the form. 1) Patient's Date of Birth: To enter the correct date, please enter the month, day, and year in the format shown on the medical record. 2) Name and Mailing Address: If different from the patient's name, please provide both the patient's name and mailing address as well as a valid California Driver's License or State Identification Card number. 3) Telephone Number: If you are a private practice physician, please include your fax number. If you are not a private practice physician, please complete this section. Please call to discuss how to complete this form online. What Are the Steps to Enroll in the HUBS Waiver? Go to the California Health Benefits Exchange's website:. Select Health Insurance (Select “Select a type” in upper right box) Select “Select a State” Select “View Your State” Select “Download and Fill Out Enrollment Application” Please click through all the application steps in order for your application to be processed automatically. Once your application is processed, and you are ready to sign, click “Submit my application”. You will receive a confirmation e-mail stating your application is complete and the HUBS Waiver application fee has been remitted to you. Be sure to forward that confirmation to your patients; otherwise, the health insurance company will not pay our claims. Is There a Fee to Have My Patient's HUBS Waiver Account Approved? No. The Health Insurance Company will not accept your Medicaid waiver application for payment. Will My HUBS Waiver Application Be Approved? In most cases, HUBS waiver applications are approved because they are complete; we do not process HUBS waiver applications that include incomplete information or incomplete supporting documentation.

People Also Ask about 470 2917 form

How do I report changes to Medicaid in Iowa?

For problems or concerns regarding your local DHS office contact the Central Office at 1-800-972-2017 or by email at contactdhs@dhs.state.ia.us.

What is the authorized representative form for Medicaid in Iowa?

Clients may use Form 470-3948 when there is a need to designate a personal representative. A "personal representative" is someone designated by another as standing in the other's place or representing the other's interest for one or more purposes. Record of Disclosure of Health Information, Form 470-4015.

What are the Medicaid guidelines for 2023 in Iowa?

In 2023, the Medically Needy Income Limit (MNIL) for individuals is the same as for married couples and is $483 / month. The amount one must “spend down” can be thought of as a deductible. It is the difference between one's monthly income and the MNIL. In IA, the spend down is calculated for a 2-month period.

What is the form for Medicaid reconsideration in Iowa?

Form 470-5526 shall be completed by the Medicaid member or their parent, if the member is a minor. The member and the authorized representative must both sign the form. Once completed, the form should be submitted to the Medicaid member's MCO, if for a managed care appeal, or to HHS, if for a state fair hearing.

How do I become a Medicaid provider in Iowa?

Providers wanting to enroll as an Iowa Medicaid provider must submit an enrollment application to the Iowa Medicaid Enterprise (IME) Provider Enrollment Unit. No payment will be made to a provider for services prior to the effective date of the department's approval of an application.

How do I appeal Medicaid denial in Iowa?

You also may call the Appeals Section at (515) 281-3094 or send us an email at appeals@dhs.state.ia.us if you have questions. We accept collect phone calls.

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