Iowa Form 470 4299 – Fill Out and Use This PDF

Iowa Department of Human Services

Verification of Emergency Health Care Services

Client Name: (Print or Type)	SID #:	County & Worker #:
Parent/Guardian:	SS #:	Date of Birth:

I give permission to the medical provider or agency to share written and oral information about the emergency health care services I received to the Department of Human Services.

Signature of Patient (or parent if patient is a minor):			Date:		This release expires one year
					from the date of signature
Relationship to person signing:
Self	Legal representative	Nearest living relative		Other (specify)
Witness to signature if required:

Provider Information

Name of the agency or person providing information:	Phone:	Fax:
Address:	City/State/Zip:

To be completed by the provider:

Did this person have a medical condition of sudden onset manifesting itself by acute symptoms of such severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:

Please give the dates of service and explain in detail the emergency medical condition(s) for which treatment was provided in the box below. Note: Please specify if treatment was related to an organ transplant procedure furnished on or after August 10, 1993.

If this person is approved for Emergency Health Care Services, the payment will cover the date the emergency occurred and the following two days.

Dates of Service:

Description of the emergency medical condition (attach additional pages if necessary):

Print or Type Name:	Date:
Medical Provider’s Signature:	Phone:
	(	)

A photocopy of this signed authorization shall have the same force and effect as the original.

A copy of this authorization shall be kept in the case file and available if Iowa Medicaid Enterprise requests a copy.

Worker Name:	Phone Number:	Fax Number:

470-4299 (Rev. 6/10)