470 4339 Form PDF Details

What Is the 470 4339 Form?

The 470 4339 form is a core component of Iowa's Estate Recovery Program, authorized under Iowa Code Section 249A.5(2). It requests detailed financial information from the estates of deceased Iowa Medicaid members so the Iowa Department of Human Services can determine how much Medicaid paid during the person's lifetime and whether any funds are recoverable from the estate.

Who Must Complete This Form

Executors, estate administrators, and family members responsible for a deceased Iowa Medicaid recipient's estate must complete this form. You will need to report savings and checking account balances, real estate holdings, vehicle values, and other assets. The form also asks about obligations such as funeral expenses and final illness medical bills.

How the Estate Recovery Process Works

The Iowa HHS compares total estate assets against reported expenses to determine if Medicaid reimbursement is warranted. If assets exceed allowable deductions, the state may file a claim against the estate. Completing this form accurately protects the executor and ensures compliance with Iowa state law and Medicaid rules.

Related Iowa Estate Forms

Families settling an Iowa estate may also need the Iowa Small Estate Affidavit for smaller estates that qualify for simplified administration. If the deceased left a cremation request, the Iowa Cremation Authorization Form is also required. For other Iowa HHS documents, see Iowa Form 470-4202.

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)

How to Edit 470 4339 Form Online for Free

To fill out the 470 4339 form online, you do not need to download any application. Use our free PDF editor directly in your browser. Our tool is designed to make the process as straightforward as possible for executors and family members handling Iowa estate recovery paperwork.

Step 1: Click the orange "Get Form" button above. This opens our PDF tool so you can begin completing the form right away.

Step 2: Use our PDF editor to fill in all required fields. You will need to provide information about the deceased's assets and any debts or expenses. The main fields include:

Stage 1 in filling out the 470 4339 Iowa medical assistance estate recovery form

Step 3: Fill in all the required sections, including asset types, total assets, total expenses, and information about the deceased's marital status. Key fields to complete are: type of assets, total of all assets, total of all expenses, net estate value, medical assistance income trust details, and the deceased's personal information.

Step 2 in completing the 470 4339 Iowa estate recovery response form

Step 4: Review all entries carefully before finalizing. Once done, click "Done" to save. With a FormsPal account, you can download the completed 470 4339 form as a PDF or send it via email. Your data is protected with secure encryption and is never shared or stored without your consent.

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