Form 470 4457 PDF Details

The Form 470 4457 is a form that is used to request certain tax exemptions. This form can be used to request a number of different exemptions, including the exemption for providing health insurance, the exemption for providing child care, and the exemption for paying interest on student loans. The Form 470 4457 can be used by individuals or businesses. If you are requesting an exemption on behalf of your business, you will need to provide information about your business and its employees. You can either download the form from the IRS website or order it from the IRS by calling 1-800-829-3676.

QuestionAnswer
Form NameForm 470 4457
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names470 4457 iowa atypical provider form

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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

470-4457 (03/07)