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IA DHS 470-5186 2015-2025 free printable template

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Iowa Department of Human Services Iowa Medicaid Ownership and Control Disclosure Provider Name Federal Tax ID or SSN Pursuant to 42 C. F*R* sections 455. 104 through 455. 106 providers applying for Medicaid must disclose certain information about those who have a sufficient ownership interest in the provider as well as those who act as managers or agents of the provider. The following series of questions seeks the necessary information to comply with these regulations. It is the provider s...
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How to fill out IA DHS 470-5186

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How to fill out IA DHS 470-5186

01
Start by downloading the IA DHS 470-5186 form from the official Iowa Department of Human Services website.
02
Fill in your personal information, including your name, address, and contact details at the top of the form.
03
Provide details about your household members, including their names, relationships to you, and birthdates.
04
Complete the income section by listing all sources of income for you and your household members, including wages, benefits, and any other income.
05
Fill out the expenses section by detailing any relevant financial obligations, such as housing costs, utilities, and medical expenses.
06
Review the form for accuracy and make sure all required sections are completed.
07
Sign and date the form at the designated area to affirm that the information provided is true and complete.
08
Submit the form according to the instructions provided, which may include mailing it to your local DHS office or submitting it online.

Who needs IA DHS 470-5186?

01
Individuals or families applying for assistance programs offered by the Iowa Department of Human Services may need IA DHS 470-5186.
02
This form is typically required for those seeking financial aid, food assistance, or any related benefits through DHS.
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People Also Ask about

Medicaid is a state-federal funded program that is administered by the Department of Human Services of the State of 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.
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.
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.
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.

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IA DHS 470-5186 is a form used by the Iowa Department of Human Services for the assessment of eligibility for financial assistance programs.
Individuals who are applying for financial assistance or benefits from the Iowa Department of Human Services are required to file IA DHS 470-5186.
To fill out IA DHS 470-5186, applicants should provide personal information, financial details, and any necessary documentation regarding their household situation as instructed on the form.
The purpose of IA DHS 470-5186 is to gather essential information to determine an applicant's eligibility for various assistance programs offered by the Iowa Department of Human Services.
The form requires reporting personal details, income, expenses, household composition, and any other relevant information needed to assess eligibility for assistance.
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Related Links

https://www.legis.iowa.gov/docs/iac/rule/10-30-201...
Providers enrolling as ordering or referring providers shall submit Form 470-5111, Iowa Medicaid Ordering/Referring Provider Enrollment Application.
Disclosure of Company Ownership, Control, & Management
DISCLOSURE OF COMPANY OWNERSHIP, CONTROL AND MANAGEMENT ... I certify that the business identified on this form is not owned or controled by any person who:.

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Relevant keywords

iowa ownership and disclosure form iowa ssn uncollected revocations xviii npi debarment reportable revocation exclusions subcontractor falsification certifies subcontractors

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