List the value of assets of the deceased at time of death and the allowed expenses of the deceased.
Check: if assets remain after expenses are paid, and there is no spouse, disabled child, or hardship waiver requested, enclose a check or money order payable to Iowa HHS.
Funds: if Total Assets minus Total Expenses is greater than the medical assistance debt, do not send any funds at this time.
Trusts: if the member had a Medical Assistance Income Trust (Miller Trust) or Special Needs Trust, send first bank statement after date of death.
Funeral expenses: if the services were guaranteed, include proof from the funeral home.
| Question | Answer |
|---|---|
| Form Name | 470-4339 |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 48 |
| Avg. time to fill out | 8 min |
| Edition | Rev 11/24 |
| Issuing agency | Iowa Department of Health and Human Services |
| Other names | 470-4339, 470 4339, Form 470-4339, Iowa 470-4339, Medical Assistance Debt Response, Iowa estate recovery response |
| Official source | 470-4339 (Rev 11/24), Iowa Department of Health and Human Services |
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