Form 470 3118 PDF Details

The Iowa Department of Human Services' 470 3118 form is a critical document for individuals receiving Medicaid or State Supplementary Assistance, necessitating a comprehensive review to determine continued eligibility. This form requires detailed information about family composition, income, expenses, and assets, ensuring that all data relevant to the applicant's financial and living situation is accurately captured. Applicants must use blue or black ink to complete the form and attach necessary evidence of their expenses, income, and assets - all originals should be kept safe as only copies will be accepted. Any unreported or incorrectly filled sections could lead to misunderstandings or a halt in Medicaid benefits. Furthermore, the form includes a section for voluntary consent, allowing the Iowa Department of Human Services to gather additional information if required without needing a new authorization form, streamlining the process for both the applicant and the department. This measure highlights the importance of the form in maintaining transparency and ensuring that assistance is provided efficiently to those in need. With strict deadlines and the potential impact on one's healthcare coverage, understanding and accurately completing the 470 3118 form is paramount for beneficiaries of Iowa's Medicaid and supplementary assistance programs.

QuestionAnswer
Form NameForm 470 3118
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namesiowa forms medicaid, iowa dhs forms, forms medicaid iowa, iowa medicaid application online

Form Preview Example

Iowa Department of Human Services

Iowa Department of Human Services

Medicaid Review

County Number:

Worker Name:

Case Number:

Phone No.:

Instructions

It is time for your eligibility for Medicaid or State Supplementary Assistance to be reviewed. You must answer the questions on this form and sign Page 4. Use only blue or black ink. Then, return it to the imaging center address by

Be sure to send proof of your expenses, income and assets. Send copies because we cannot return originals to you.

If you leave a space blank, we will take that to mean that you have no information to give us. You may be asked to prove what you tell us. Please use an additional sheet of paper, if needed. Most of the information that we ask for is required. You do not have to answer questions that are marked as optional. Your answers are used to decide if you can continue to get Medicaid. If you do not return the form by the due date or give us information, your Medicaid may stop. Call us if you have any questions.

Information About Your Family

List yourself and the people who live in your home.

 

Name (First, Last)

Relationship to You

Age

Social Security Number

 

 

 

 

 

 

 

 

 

 

Self

Tell us if your mailing or living address changed from the address shown above.

Mailing address

Living address

City

State

Zip Code

City

State

Zip Code

Do you have a guardian, conservator, or representative? If yes, print their names here:

470-3118 (Rev. 12/11) H3118A

Page 1

Expenses

To get the most help you can, tell us about your expenses. Send proof of your expenses.

Medical expenses

If you pay for health insurance, write in how much you pay:

If you started or changed health insurance, write in the name of the new company:

If your health insurance ended, write in the date it stopped:

Amount $

 

per month

Date:

List anyone in your home who has ongoing medical bills that Medicaid does not pay:

Who:

 

Relationship to you:

Other expenses

List your share of any day care paid for a child or a disabled adult who lives with you:

Who gets care:

 

Amount $

 

per month

If anyone currently pays child support, give the following information:

Who pays:

 

Amount $

 

per month

Income

List income of the people in your home. This includes you, your spouse, and your unmarried children under the age of 18 who are living with you or who are living in a nursing home.

 

Where the Money Comes From

Who Gets the Money

 

Gross Amount

 

 

 

Per Month

 

 

 

 

 

 

Social Security, Social Security Disability, or SSI

 

 

 

 

 

 

 

 

 

Veterans, Pensions or Retirement Benefits

 

 

 

 

 

 

 

 

 

Unemployment, Worker’s Compensation or Disability

 

 

 

 

 

 

 

 

 

Child Support or Alimony

 

 

 

 

 

 

 

 

 

Cash Medical Support

 

 

 

 

 

 

 

 

 

Money from Friends or Relatives

 

 

 

 

 

 

 

 

 

Money from Interest or Dividends

 

 

 

 

 

 

 

 

 

Money You Get from Contracts

 

 

 

 

 

 

 

 

 

Money From Work Before Taxes (Gross)

 

 

 

 

 

 

 

 

 

Self-Employment or Odd Jobs

 

 

 

 

 

 

 

 

 

Tips, Bonuses and Commissions

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

470-3118 (Rev. 12/11) H3118B

 

 

Page 2

 

List the name of all employers:

Send proof of your money from work for the past 30 days.

 

 

 

 

Do you work for anyone who pays you in the form of food, clothing or

Yes

No

shelter?

 

 

 

 

Does anyone give you food, clothing or shelter?

Yes

No

Assets

List all cars, trucks, boats, campers, motorcycles or other licensed or unlicensed vehicles that anyone in your home owns or is buying:

Make

Model

Year

Value or Worth

Amount

Owed

List the total money everyone in your home has in:

Type

Who

Bank or Location

Amount

 

 

 

 

Cash

Bank/Credit Union Accounts (Checking, savings, etc.)

Stocks, bonds, savings certificates, IRAs, Keogh or other assets

Nursing home account

Other

Send your most recent bank statement with this form.

List anyone in your home who has or owns any land, buildings or houses other than the house you live in:

List anyone in your home who has or has sold a conservatorship, trust or life estates:

If you bought, changed, or disposed of life insurance, a burial contract, or a burial plot in the past year, tell us about the change:

470-3118 (Rev. 12/11) H3118C

Page 3

If you got an inheritance or turned down an inheritance, list the following:

When?

 

Amount $

 

 

 

 

If anyone gave away anything of value, transferred anything for less than its value, or added someone else’s name to a resource, tell us:

When?What?

Other Changes or Comments

Your Signature

I understand that if the may be referred to the coverage.

children on this application are not eligible for Medicaid, this application hawk-i program to see if the children could get hawk-i health care

I certify, under penalty of perjury, that:

My answers are correct and complete to the best of my knowledge.

I kept the information on page 7 and 8.

Your Signature or Mark

Phone Number

Today’s Date

 

 

 

Signature of Person, If Any, Who Helped Complete the Form

Relationship/Phone Number

Today’s Date

 

 

 

Remember to send proof of your expenses, income and assets.

470-3118 (Rev. 12/11) H3118D

Page 4

Iowa Department of Human Services

Addendum to Application and Review Forms for Release of Information

OPTIONAL Release of Information

Help Us Help You!

You do not have to sign this, but it will help us get information we need to help you,

without having to get your signature on specific requests.

You should know that:

We may need more information to decide if you can get assistance.

If more information is needed from you, you will get a letter telling you what we need and the date you must get it to us.

You are responsible to get the information or to ask us for help to get it.

If you do not give us the information or ask for help by the due date, your application may be denied or your assistance may stop.

We may be able to use the release below to get the information we need. But you still have to provide information we request or ask us for help.

We may attach a copy of this release to a form that asks other people or organizations (like your employer) for specific information needed about you or others in your household.

Print and sign your name below to give us permission to get needed information.

RELEASE OF INFORMATION

I hereby authorize any person or organization to give the Iowa Department of Human Services requested information about me or other members of my household.

A copy of this release is as valid as the original.

This release does not apply to protected health information.

This release is good for 12 months from the date signed.

________________________________

________________________________

Your Name (please print clearly)

Other Adult Name (please print clearly)

________________________________

________________________________

Signature or Mark

Signature or Mark

________________________________

 

Date

 

470-3118 (Rev. 12/11) H3118E

Page 5

470-3118 (Rev. 12/11) H3118F

Page 6

Keep this page for your records.

You Have the Right to Appeal

You, or the person helping you, may request an appeal hearing if you do not agree with any action taken on your case. To appeal in writing do one of the following:

Fill out an appeal electronically at https://dhssecure.dhs.state.ia.us/forms/, or

Write a letter telling us why you think a decision is wrong, or

Fill out an Appeal and Request for Hearing form. You can get this form at your county DHS office.

Send or take your appeal to the Department of Human Services, Appeals Section, 5th Floor, 1305 E Walnut Street, Des Moines, Iowa 50319-0114. If you need help filing an appeal, ask your county DHS office.

You can represent yourself. Or, you can have a friend, relative, lawyer or someone else act on your behalf.

You may contact your county DHS office about legal services. You may have to pay for these legal services. If you do, your payment will be based on your income. You may also call Iowa Legal Aid at (800) 532-1275. If you live in Polk County, call (515) 243-1193.

You Will Not Be Discriminated Against

It is the policy of the Iowa Department of Human Services (DHS) to provide equal treatment in employment and provision of services to applicants, employees and clients without regard to race, color, national origin, sex, sexual orientation, gender identity, religion, age, disability, political belief or veteran status.

If you feel DHS has discriminated against or harassed you, please send a letter detailing your complaint to:

Iowa Department of Human Services, Office of Human Resources, Hoover Building – 1st Floor, 1305 E. Walnut, Des Moines IA 50319-0114; fax (515) 281-4243, or via e-mail stopit@dhs.state.ia.us

Changes You Need to Tell Us About

Within 10 days of the date the change happens, you must tell the DHS county office about changes, such as:

Income, including any one-time payments you get

Resources, which includes getting an inheritance or a one-time payment of past due child support

Someone moving in or out of your home

Your health insurance coverage

You file an insurance claim or get an attorney to recover bills paid by Medicaid

Someone is no longer disabled

470-3118 (Rev. 12/11) H3118G

Page 7

Things You Need to Know

By signing this form, you give permission to release confidential information to the Quality Control unit or Investigations unit. You must cooperate with them to keep your benefits.

You will have to pay back any benefits you got or that was paid to a third party on your behalf for which you were not eligible.

Section 1128B of the Social Security Act provides federal penalties for fraudulent acts and false reporting in connection with these programs.

Anyone who gets, tries to get, or helps any other person get assistance to which they are not entitled, is guilty of violating the laws of the State of Iowa. This includes, but is not limited to, Iowa Code Chapters 249, 249A and 249F.

You must give the social security numbers for everyone who wants Medicaid. This is required by Section 1137(a)(1) of the Social Security Act and 42 CFR 435.910. We use social security numbers to:

Identify people who apply for or get Medicaid

Verify income and eligibility for Medicaid

Match records with other agencies

By signing this application, you give your permission for DHS to share:

The status of your Medically Needy case, the amount of your spenddown, and the bills used to meet your spenddown with the provider whose bills are being used.

If the Medicaid for Employed People with Disabilities (MEPD) premium has been paid by the due date with your Medical provider.

You agree to assign medical payments from a third party to the Medicaid agency for you and others who are eligible for Medicaid for whom you legally can assign benefits. You also agree to cooperate in obtaining medical payments from third parties.

470-3118 (Rev. 12/11) H3118H

Page 8

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1. The medicaid forms iowa will require specific information to be inserted. Be sure the subsequent blank fields are complete:

The way to fill in iowa dhs forms portion 1

2. After this section is filled out, go to enter the applicable information in these - Tell us if your mailing or living, Mailing address, Living address, City, State, Zip Code City, State, Zip Code, Do you have a guardian conservator, Rev HA, and Page.

Filling out segment 2 in iowa dhs forms

3. This third stage is normally straightforward - fill out all the fields in If you pay for health insurance, If you started or changed health, Amount, If your health insurance ended, Date, per month, List anyone in your home who has, Who, Relationship to you, Other expenses, List your share of any day care, Who gets care, Amount, per month, and If anyone currently pays child in order to complete this part.

Filling out section 3 in iowa dhs forms

4. This subsection arrives with the following empty form fields to complete: Where the Money Comes From, Who Gets the Money, Per Month, Social Security Social Security, Veterans Pensions or Retirement, Unemployment Workers Compensation, Child Support or Alimony, Cash Medical Support, Money from Friends or Relatives, Money from Interest or Dividends, Money You Get from Contracts, Money From Work Before Taxes Gross, SelfEmployment or Odd Jobs, Tips Bonuses and Commissions, and Other.

Tips on how to fill in iowa dhs forms part 4

5. When you reach the conclusion of the document, you'll notice several more requirements that should be satisfied. Mainly, Send proof of your money from work, Do you work for anyone who pays, Does anyone give you food clothing, Assets, Yes No, Yes No, List all cars trucks boats campers, Make, Model, Year, Value or Worth, List the total money everyone in, Amount Owed, Type, and Who should all be filled in.

iowa dhs forms completion process clarified (portion 5)

Those who use this document frequently make some errors while filling in List all cars trucks boats campers in this part. Be sure you review everything you enter right here.

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