470 4339 Form PDF Details

Addressing the aftermath of a loved one's passing can be an emotionally taxing process, especially when it involves settling their affairs and financial obligations. Among the many forms and procedures to navigate during this time, the 470 4339 form issued by the Iowa Department of Human Services plays a crucial role for families of deceased Medicaid members. This form, grounded in Iowa Code Section 249A.5(2), is a vital component of the Estate Recovery Program. It serves as a formal request for information regarding the deceased's financial estate, specifically targeting Medicaid's attempt to recoup some of the benefits paid out during the individual's lifetime. The process requires executors or family members to report assets and debts of the deceased, including savings and checking accounts, real estate, vehicles, and any other valuables. Furthermore, it delves into obligations such as funeral expenses and last illness medical bills, comparing these against the estate's value to determine if reimbursement to Medicaid is warranted. Understanding and completing this form is essential, as it impacts how the estate is settled and how Medicaid recovery efforts are managed, presenting a detailed path for executors to follow to ensure compliance with state law and Medicaid rules.

QuestionAnswer
Form Name470 4339 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesiowa dhs medical debt response, form 470 debt, 470 4339 rev 12 10, iowa medical assistance debt response

Form Preview Example

Iowa Department of Human Services

Medical Assistance Debt Response

PURSUANT TO IOWA CODE SECTION 249A.5(2)

Estate Recovery Program, PO Box 36445, Des Moines, Iowa 50315

Phone: (515) 246–9841, Toll-Free: (888) 513–5186, Fax: (515) 246–0155

Instructions: Please answer the questions below about the deceased Medicaid member and fax or send the form and any other documents requested back in the enclosed envelope within 30 days.

Name of Deceased:________________________________________________ Date of Death:__________________

 

 

 

 

 

 

 

List the Value of Assets of the Deceased at Time of Death

List Allowed Expenses of the Deceased

 

 

 

 

 

 

 

Savings Account

For all accounts, send

$

Court Costs or Other Costs of Administration

$

 

the first statement after

Send an itemized list of any amounts listed as costs of

 

 

date of death, which

 

administration

 

 

Checking Account

includes the name and

$

Attorney Fees

$

 

 

address of the bank or

 

 

 

 

Annuities/IPERS

institution and the

$

Executor Fees

$

 

account number.

 

 

 

 

 

 

 

 

 

 

 

 

Home and Real Estate

$

Taxes or Debts Still Owed to the Federal or State

$

 

Governments

 

 

 

 

 

 

 

 

 

 

 

 

Household Goods

 

$

Medical Expenses of Last Illness

$

 

 

 

 

 

 

 

Vehicles

 

$

Mortgage or Lien Against any Real Estate

$

 

 

 

 

 

 

Prepaid Burial Fund Amount

$

Funeral and Burial Expenses

$

 

 

 

 

 

 

Enclose a statement of itemized expenses that include the funeral home’s name and address. If the services were guaranteed, include proof from the funeral home.

 

Did the deceased have a life estate, or

If yes, list the

Amount Paid or Still Owed to the Nursing Home

 

 

other interest in real estate, trusts, litigation,

estimated value.

After Death

 

 

or any other assets, including any jointly

 

Nursing Home Name:

 

 

held bank accounts or property, that are not

$

 

 

$

 

already listed above, at the time of death?

 

 

 

 

YES

NO

 

Nursing Home Address:

 

 

 

 

 

 

 

If Yes, list type _______________________

 

 

 

 

 

Total of all Assets

 

 

$

Total of all Expenses

$

 

 

 

 

 

 

 

 

Total Assets - Total Expenses = $

If Total Assets minus Total Expenses is less than the medical assistance debt, and there is no spouse, disabled child, or hardship waiver requested, please enclose a check or money order payable to: Iowa Department of Human Services. Send a separate check, if

there are any Medical Assistance Income Trust or Special Needs Trust funds listed below. If Total Assets minus Total Expenses

is greater than the medical assistance debt, do not send any funds at this time, as an updated amount of the debt will be provided to you.

Trusts: If the member had a Medical Assistance Income Trust (Miller

Medical Assistance Income Trust

$

Trust) or Special Needs Trust, send first bank statement after date of

 

 

death, which includes the name and address of the bank and the account

 

 

number. Additional information about trusts is enclosed.

Special Needs Trust

$

Please provide the following information regarding the deceased member’s marital status.

The deceased was:

married

never married or

divorced and not remarried.

If married, spouse’s name __________________________________

Spouse is surviving? Yes

No

Date of Birth ___/___/___ SSN __________________

If no, Date of Death: ___/___/___

I CERTIFY UNDER PENALTY OF PERJURY AND PURSUANT TO THE LAWS OF THE STATE OF IOWA THAT THIS PAGE WAS COMPLETED CORRECTLY TO THE BEST OF MY KNOWLEDGE.

Signature

Date

Your Address

Print Name

Your Phone Number

Your relationship to the deceased

470-4339 (Rev. 12/10)

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4339 medical assistance response conclusion process clarified (portion 2)

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