When individuals or entities embark on the process of becoming a provider of services to Iowa Medicaid members, they are introduced to the 470 4457 form, a critical document issued by the Iowa Department of Human Services. This Atypical Provider Declaration form serves a unique purpose. It is specifically designed for applicants who do not fit the traditional mold of a health care provider as defined by federal regulations. By signing this declaration, applicants assert that the services they intend to provide do not meet the conventional definition of a health care provider and, consequently, are not eligible for a National Provider Identifier (NPI). This designation as an "atypical" provider encompasses a range of provider categories, including those offering Consumer Directed Attendant Care under the waiver Provider Category. The form requires essential information such as the provider's name, tax identification or social security number, and the specific provider categories they are applying under. Completion and submission of this form are steps towards authorization to serve Iowa Medicaid members, showcasing the state's structured approach to incorporating diverse service providers into its healthcare framework. This process underscores the inclusive and expansive nature of healthcare provision in Iowa, acknowledging the broad spectrum of services that support Medicaid beneficiaries.
| Question | Answer |
|---|---|
| Form Name | Form 470 4457 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | 470 4457 iowa atypical provider form |
Iowa Department of Human Services
Atypical Provider Declaration
The undersigned is in the process of submitting an application to the Iowa Department of Human Services to be a provider of services to Iowa Medicaid members. By signing this Declaration Form, we/I declare and attest that the provider category or categories for which the application is being made does not meet the definition of health care provider as defined at 45 C.F.R. § 160.103 and is/are not eligible to receive an NPI (National Provider Identifier). Instead, the applicant will be an “atypical” provider in each of the categories listed below. Provider categories are listed on the Iowa Medicaid Provider Application. Note: Individuals providing Consumer Directed Attendant Care fall under the “waiver” Provider Category.
Provider Name:
____________________________________________________________________________
Tax ID/SSN:
______________________________________________________________________________
Provider Category: (list all that apply)
Provider Category
Example: Waiver
If you need more space, please make copies of this form, or write on the back of this form.
Name of person completing this form:
__________________________________________________________
Signature:
_____________________________________________________________________________
Please return this completed form to: Provider Services Unit, Iowa Medicaid Enterprise
P.O. Box 36450
Des Moines, IA 50315