application Checklist For Facility Medicaid · 1 Application Checklist for Facility Medicaid The...

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Application Checklist for Facility Medicaid

The following items are needed for application processing.

☐Health Services Application Form #470-2927 or Application for Health Coverage

and Help Paying Costs, Form #470-5170

☐Facility Assistance Questionnaire Worksheet

☐Insurance Questionnaire, Form #470-282 (if applicable)

☐Copy of Medicare Card (if applicable)

☐POA Documentation (if applicable)

☐Resources Upon Entering a Medical Facility, Form #470-2577 (if married and no

prior attribution)

☐Case Activity Report, Form #470-0042 (send at time of application)

☐Level of Care assessment to IME, Form #470-4393 (send to IME as soon as

completed)

☐Authorization for the Department to Release Information (indicate the facility name

or facility staff that DHS can discuss information with)

☐Any available resource and income verifications that are currently available (these

will be requested by a DHS worker if not provided with the application)

☐VA release of information (if currently receiving benefits from the VA) **Please

note, the Veteran’s Administration will not accept this release if it is signed by the

POA or another party. The release can only be signed by the client receiving the

Veteran’s benefits. If the spouse was the vet their name, Social Security number,

and Veteran’s number will need to be on page 2. The rest of page 2 will be

completed by the VA.

☐UME agreement, if applicable

☐Discuss with client and their representative the importance of due dates and

providing requested information. If any assistance or additional time is needed they

should contact the DHS worker before any due date.

Note: All forms can be obtained on the DHS website at http://www.dhs.state.ia.us

470-2927 (Rev. 12/12) Page 1

INSTRUCTIONS FOR HEALTH SERVICES APPLICATION Complete this form if you live in Iowa and want to get: ♦ Medical Assistance (Title 19 or Medicaid) – provides health care coverage

Other programs within Medical Assistance Program are: • Facility Care – helps pay your nursing home cost • Medicaid for children in foster care or subsidized adoption • Waiver – helps keep people at home and not in a nursing home • Medicare Savings Program – pays all or part of your Medicare premium • State Supplementary Assistance (State Supp) – help for people who are at least 65 or

disabled. ♦ WIC (Special Supplemental Nutrition Program for Women, Infants and Children) – helps with

checks that can be used at Iowa grocery stores and pharmacies to buy healthy foods for pregnant and postpartum women, and children under the age of 5. If you would like to apply for WIC, call 1-800-532-1579 or 515-281-6650 or visit the WIC website http://www.idph.state.ia.us/wic/families.asp for more information about making an appointment with your local WIC agency.

♦ Maternal and Child Health – provides health care services for children under the age of 21 and women of childbearing age.

If you want to get Food Assistance or cash assistance through the Family Investment Program (FIP), please complete the Health and Financial Support Application, form 470-0462, or in Spanish 470-0462(S). Please do not let fear of the Immigration and Naturalization Service (INS) keep you from getting help for your family. Getting help will not keep you from gaining lawful, permanent residence, U.S. citizenship, or from sponsoring relatives. To apply for help, follow these four easy steps: 1. Complete the Application

Fill out and sign the application. Use blue or black ink. Please be truthful. If you are helping someone else, answer the questions for that person.

2. File the Application To find out where to mail the application, call 877-347-5678. The date your help starts is based on the date the DHS office gets your application.

3. Provide Any Needed Proof See the table below for what is needed. Including copies of the proof will help speed up the processing of your application.

4. An Interview May Be Needed An interview may not be needed if you are applying only for a child. Adults applying for help may be asked to have an interview.

Proof You Need to Send

In addition to your application, please provide any proof needed for the program(s) you are applying for.

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Proof of who you are (ID): driver’s license, birth certificate, etc. Proof you are a U.S. citizen or national (birth certificate with ID, U.S. passport, etc.)

Proof you have applied for a Social Security Number (if you don’t already have one)

Proof of any health insurance premium paid: bill, pay stub showing deduction, etc.

Proof of income* or any other money coming into your household Proof of child care, dependent adult care costs, child support or alimony paid Most recent statements for any bank accounts: checking, credit union, savings, etc.**

Proof of current value of stocks/bonds, life insurance, certificates of deposit, trusts**

Proof of current living address * Pay stubs from the last 30 days if you are employed or federal income tax records if you are

self-employed. Award letters for Social Security Benefits, Veterans Benefits, etc. ** May not be needed if just applying for a child.

http://www.idph.state.ia.us/wic/families.asp

470-2927 (Rev. 12/12) Page 2

RIGHTS AND RESPONSIBILITIES – READ AND KEEP THIS SHEET INFORMATION FOR ADULTS AND CHILDREN APPLYING FOR MEDICAL ASSISTANCE • I understand I assume full responsibility for the accuracy of the statements on this form. I understand the Department of

Human Services (DHS) will use this statement to determine my eligibility for Medical Assistance. • I understand my eligibility will not be affected by my race, creed, color, national origin, age, disability, or sex, except where

this is restricted by law. • I understand that I have the right to a hearing if this application is denied or not acted upon promptly or if services granted

are terminated, reduced, or suspended. I understand that I can get a hearing by making a request in writing to my local DHS office and that I may represent myself or use a lawyer, relative, friend, or other spokesperson.

• I am aware that my case may be picked by the Department for a complete Quality Control or other review of my eligibility for assistance. If my case is selected for verification, I will cooperate fully in the verification. I hereby authorize all persons to release confidential information concerning my eligibility to a DHS reviewer. I understand that failure to cooperate with such a review can result in denial or cancellation of benefits.

• I will notify DHS within ten days of any changes in medical benefits or health insurance coverage. In addition, I understand that I am to notify my medical providers (doctors, pharmacist, etc.) if another party may be liable to pay my medical expenses. I will notify DHS within ten days if I file an insurance claim or retain an attorney to seek payment for injuries and medical expenses resulting from those injuries that otherwise would be paid by Medicaid. Failure to comply with my responsibilities can give the Department cause to deny or terminate Medicaid eligibility.

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

• I understand that I am to reimburse the Department for any money paid to me or paid to a provider on my behalf to which I was not entitled.

• I further understand that the Department will provide documents or claim forms describing the services paid by Medicaid upon my request or the request of an attorney acting on my behalf. Such documents may also be provided to a third party when necessary to establish the extent of the Department's claim for reimbursement.

• I understand that federal and state law and rules permit access by authorized federal and state officials to Medicaid providers' records. I also fully understand that my acceptance of Medicaid is my consent for these authorized persons to have access to my medical and health care records during the time I am eligible for Medicaid, as necessary to verify appropriate Medicaid payment.

• I give my permission to tell my medical providers the status for my Medically Needy case, including the amount of my spenddown and their bills used to meet spenddown, or when a premium is due for Medicaid for Employed People with Disabilities.

• If I become enrolled in a managed health care plan, I consent to disclosure of medical information, including any clinical mental health or substance abuse information, by my medical providers to the HMO, PHP, other managed care providers or to the authorized administrative body contracted by the managed care provider to determine appropriateness, quality, or utilization of services I received while enrolled in managed health care.

• I understand that if Medical Assistance is approved, support payments intended for medical costs must be assigned and paid to the Department of Human Services to the extent of the benefits I receive. I understand that the Department may intervene, according but not limited to, Iowa Code Chapters 252A, 252B, 252C, 252D, 598, and 600B, to make claim and secure support from any person or party who may be responsible for my support or that of my children. I understand that if I receive Medicaid, the Department will pursue non-medical support for myself and my children upon my request. Medical support services include the establishment of paternity and the establishment and enforcement of medical support.

• I am aware that Section 1128B of the Social Security Act provides federal penalties for fraudulent acts and false reporting. Anyone who obtains, or tries to obtain, or helps any other person to obtain public assistance to which the person is not entitled is guilty of violating the laws of the state of Iowa. These laws include, but are not limited to, Iowa Code Chapters 243, 239B, 249A, and 249A.

• I understand and agree that I will need to provide the Department with either documentation from the Citizenship and Immigration Service (CIS) or other documents the Department considers to be proof of the immigration status of each person in my household who is not a United States citizen or national. I understand that alien status may be subject to verification with CIS, which will require submission of certain information from this application form to CIS. I further understand that information received from CIS may affect my household's eligibility and level of benefits.

• If I filled out a separate application for food assistance and that application was referred to the Food Stamp Investigation Unit, I will cooperate with the investigation in order to receive Medicaid when the investigation involves income, resources and household composition that affect my Medicaid eligibility.

• I understand that the facts I give determine financial eligibility. A medical certification is also needed prior to approval for certain Medical Assistance programs. To determine medical certification, the Iowa Medicaid Enterprise (IME) Medical Services may need to contact my physician. I authorize my physician or health care provider to release information to IME Medical Services for this purpose. I agree to allow DHS to disclose the filing of this application to my nursing facility in order to obtain the level of care determination necessary for eligibility. A copy of this form received by fax will be given the same effect as the original.

MORE INFORMATION FOR ADULTS APPLYING FOR MEDICAL ASSISTANCE • I will notify the LOCAL DHS office of any change in my information on this application, including but not limited to,

anticipated income or property such as an inheritance, lump-sum payments on delinquent child support, or any change in income or living arrangements of myself or any other member of my family. If I have any doubt whether a particular change in circumstances is information that must be reported, I shall report this to my LOCAL office no later than ten days from the date the change occurs. I also understand that I am to pay back to the Department any money received by me or paid to a vendor on my behalf to which I was not entitled.

• I understand payments under the Medical Insurance Program (Part B of Medicare) will be made directly to the physicians and medical suppliers on any future unpaid bills for medical and other health services furnished me while eligible for Medicaid.

• I authorize the DHS to share information from this application, and information about my condition from the designated Assessment Tool with IME Medical Services for all home and community based service (HCBS) waivers and the Area Agency on Aging Case Management Team for my HCBS elderly waiver services

• If you made the State of Iowa a remainder beneficiary on an annuity, in order to qualify for Medicaid payment of long-term care, the State of Iowa will get any benefits remaining in the annuity, up to the amount of Medicaid benefits paid.

INFORMATION FOR THOSE APPLYING FOR WIC OR MATERNAL AND CHILD HEALTH SERVICES • I understand that a declaration of income and persons in my family and living in my household is necessary to ensure that

federal and state funds are directed to those persons least able to secure services from other sources. • I understand that the Maternal and Child Health Director of the Iowa Department of Public Health, the WIC Director, or their

designees shall have access to all information available from records maintained by the agency providing maternal health, child health, or WIC services.

470-2927 (Rev. 12/12) Page 3

Iowa Department of Human Services HEALTH SERVICES APPLICATION

HOUSEHOLD INFORMATION – Complete for all programs First Name

Middle Name

Last Name

Home Address

City State County Zip Code

Mailing Address (if different from above) OR Payee or Representative’s Name & Address Home Phone Number ( )

Message Number ( )

Name of Message Contact Person

Check the program(s) you would like to receive: Medical Assistance (Title 19 or Medicaid) Maternal and Children Health Services

Breast and Cervical Cancer Treatment Facility Medicare Savings Program Waiver WIC Foster Care/Subsidized Adoption State Supplementary Assistance Iowa Family Planning Network (IFPN)

IF YOU NEED MORE ROOM TO ANSWER ANY OF THE FOLLOWING QUESTIONS, ATTACH EXTRA PAGES.

Starting with yourself, list all the people who live in your home and mark the box yes or no if you are applying for that person. If you choose no, you only need to list their name, relationship to you and their date of birth.

NAME (First, Middle, Last)

Are you applying for this

person?

How is this

person related?

Disabled Gender Birth Date Social Security Number

Medicaid State ID Number (if known)

Birth State

U.S. Citizen?

If Alien, Status Ethnicity* Race**

If a child, is a parent NOT living with them?

Currently on

Medicaid?

Other health

insurance available?

Yes No SELF Yes

No Male Female

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Male Female

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Male Female

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Male Female

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Male Female

Yes No

Yes No

Yes No

Yes No

We have to ask your ethnicity and race, but you don’t have to answer. Your answer won’t affect how much you get or how soon. If you answer, use the following coding: * Ethnicity: H = Hispanic or Latino; N = Not Hispanic or Latino ** Race (Choose all that apply): W = White; B = Black or African American; A = Asian; I = American Indian or Alaskan Native; N = Native Hawaiian or other Pacific Islander. Did anyone receive medical care in the past three months?

List anyone who is in the military, a veteran, or a spouse of a veteran: Yes No Who? __________________________________________ What months? ________________________________ ____________________________________________________________

Is anyone fleeing to avoid prosecution, custody, or jail for a felony crime? Yes No Is anyone violating a condition of probation or parole? Yes No Is anyone in or expecting to go to jail or prison? Yes No List pregnant persons who live in your home Due Date (MMDDYY) List the name of your health insurance provider

470-2927 (Rev. 12/12) Page 4

INCOME: List all income the people living in your home get. Include income from work, self-employment, Social Security, Veteran’s Benefits, unemployment insurance, child support, worker’s compensation, railroad retirement, IPERS, pensions, civil service, cash from friends or relatives, and any other income you get.

Person who received money Employer or income source Amount before taxes or deductions How often is this amount paid?

Is this income expected to continue? If ‘NO,’ explain:

Weekly Every other week Yes No Monthly Twice a month Other _____________________




RESOURCES: A resource is cash or anything that can be changed to cash. List all resources and the amount or value. Include cash on hand, checking accounts, vehicles, life insurance, stocks, bonds, certificates of deposits (CDs), trust funds, retirement accounts, burial contracts, burial spaces, annuities, etc. If only applying for medical coverage for a child, resources may not be counted.

Person with Resource Type of Resource Amount or Value Location (bank’s name and address, home, etc.)

Did anyone in your home sell or give away anything of value for less than its value within the last five years? Yes No Does anyone in your home pay child support or alimony for a person who does not live with you? Yes No

If yes, who pays? _________________________ Amount? __________________ Does anyone in your home pay for someone to care for a child or disabled adult? Yes No

If yes, how much is paid? ___________________ How often? ________________ To whom? _________________________

470-2927 (Rev. 12/12) Page 5

Is the Child Support Recovery Unit already helping you get or enforce a child support or a medical support? Yes No If no, the Child Support Recovery Unit can help you get child support or health insurance from an absent parent. They can also help locate absent parents and their employer, establish paternity, or establish paternity or modify support orders. Do you want help from Child Support Recovery with any of these items? Yes No Are you willing to cooperate with us to get medical insurance or medical support from any parent not in the home? (You are not required to cooperate if you only want Medicaid for a child.) Yes No

Name & address of parent not in the home:

Date of birth of this parent:

Social Security number of this parent: Name of the parent’s children: County where court

order is filed, if any:

Is the parent court ordered to pay cash medical support?

SOCIAL SECURITY NUMBER (SSN) You must fill in the SSN of all persons listed on this application to get Medical Assistance. Section 1137(a) (1) of the Social Security Act and 42 CFR 435.910 requires this. If you do not want Medicaid, you do not have to give us your SSN. The SSN will be used:

• To check income, eligibility and amount of Medical Assistance payments to be made on your behalf. • To determine another person's right to Medical Assistance. • To comply with Federal law which requires release of information from Medicaid records. • To match with records in other agencies such as: Social Security Administration, Internal Revenue Services, and Iowa Workforce Development. These matches may be

done by computer or on an individual basis.

My rights and responsibilities were provided to me on the back of the instructions for this Health Services Application. I have read and removed the Rights and Responsibilities sheet from this Health Services Application for my future use. I understand that if the children on this application are not eligible for Medicaid, this application may be referred to the hawk-i program to see if the children could get hawk-i health care coverage. I CERTIFY, UNDER PENALTY OF PERJURY, THAT THESE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

Signature or mark of applicant Date Signature or mark of other

parent or stepparent in the home Date Signature of person, if any,

who helped complete this form Date

470-2927 (Rev. 12/12) Page 6

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

Facility Assistance Questionnaire Worksheet Answering each question will assist and expedite the processing of your application.

Client Name (please print)

Name of Facility or Hospital and date you entered?

Do you own your home or rent? If you own, is

there anyone other than you residing in the home?

Marital Status:

Spouses Name, Social Security # and DOB:

Income

Unearned Income:

Source You Your Spouse Yes No Gross Frequency Yes No Gross Frequency

Social Security SSI (Sup Security Inc) Black Lung Veteran Pension Veterans Aid & Attendance Veterans Compensation Veterans Dependent Benefit Civil Service Railroad Retirement Pensions – Private Workman’s Compensation IPERS Child Support/Alimony Unemployment Benefits Insurance (Nursing Home) Gifts Inheritances Paying Income Interest/Dividends Rental Property Income Miller Trust Property Sold on Contract Lump Sum Farm Income Other

Provide proof of gross income from each source marked yes above

Earned Income: (Self or Spouse)

Employer:

Frequency Paid/ Next pay date Last 30 Days Wages

Comments:

Provide proof of gross earned income for the past 30 days

Misc: Were you or your spouse a veteran or did you previously work for federal, state or local

government or railroad? No Yes Who and Where:

Resources

Bank Accounts: Whose Location Balance Interest Checking

Savings

Credit Union

Provide copies of bank statement for past 3 months (all pages ) Resources You Your Spouse

Yes No Amount Location Yes No Amount Location Cash on Hand Stock/Bonds Time Cert/Cert of Dep ‘CD’ Annuities Mutual Funds/Money Market Interest/Dividends Safe Deposit Box Mortgages/Contracts Trusts Promissory Notes IRA/Keogh/401 K accounts Life Estates

Facility Assistance Questionnaire (Answer each question) Resources You Your Spouse

Yes No Amount Location Yes No Amount Location Homestead (where you live) Non-homestead property Other List: Vehicles – Make/Model/value

Provide proof of value of each resource marked yes as of the first day of the month that you entered the facility or hospital.

Burial Plots/Contracts Burial plots? Yes No Where ____________________ How many/for whom __________________ Burial funds? Yes No Where ____________________ How much? ________________________ Contract (prepaid) Yes No Where __________________ How Much $ _________________ Irrevocable Yes No

Provide copy of burial plots and/or contract/funds

Life Insurance

Policy Owner Company Name and Address Policy # Face/Cash Value

Do you intend to use your life insurance for burial? Yes No

Provide copy of each life insurance policy and face and cash value as of the first day of the month that you entered the facility or hospital.

Inheritances: Was an inheritance disclaimed or anything of value sold or given away? No Yes What and When? Trusts: Was a trust created within 60 months prior to application?

No Yes If yes, send copy of complete trust. Transfer of Assets Are there resources that belong to you that are administered by a conservator, guardian or representative? No Yes Did you or your spouse (transfer, sell or give away) resources within the 60 months prior to this application? Transfers include real or personal property & real estate) No Yes Date resources were sold, transferred or given away or date trust was established. Month _________ Year _______

Health Insurance

Medicare Coverage:

Who Part A Part B Part D Premium Claim Number Yes No Yes No Yes No Yes No Yes No Yes No

Provide copy of Medicare Card

Other Health Insurance Coverage (Including Nursing Home Policies):

Who Ins Company Type of Policy Premium (Yearly) Frequency Paid

Provide copy of insurance card (front & back) with copy of premium statement. If Nursing Home Insurance, provide verification of amount paid daily and duration.

If you own your home, do you intend to return home? Yes No If yes, please provide

a signed written statement that those are your intentions.

470-2826 (Rev. 2/09) Copy 1: IME Revenue Collections Unit Copy 2: Case File


Insurance Questionnaire

To ensure that your bills are paid as quickly as possible, please fill out this form and return to your local Department of Human Services (DHS) office.

Your Name: Your State ID number, if any:

Do you, your children or others in your home have health insurance coverage? Yes No, then stop here.

If yes, who carries this health insurance?

You A parent who does not live with you

Someone else in your home Someone else not in your home

Please fill out the information below. The boxes with this mark * must be filled in. Use the next page if you have another policy to tell us about.

Information About First Policy

Choose all that apply to this policy:

Major Medical Drug Medicare Supplement

Dental Vision

*Policyholder (Last Name, First Name, Middle Initial)

Phone number

( ) Mailing address (House #, Street, Apt, OR PO Box, City, State, Zip)

*Social Security number

*Date of birth

*State ID #

*Insurance company name

Phone number

( ) Insurance claims office mailing address (#, Street, OR PO Box, City, State, Zip)

If the insurance is through an employer, employer’s name

*Policy number

Group number

Date policy is effective

People covered by the policy above:

Fill out the information below and tell us if each person is currently covered or if they are being added or dropped from the insurance.

Currently Covered

Choose One: Effective Date

Last Name, First Name, Middle Initial

Date of Birth

State ID Relationship to Policyholder Add Drop

470-2826 (Rev. 2/09) Copy 1: IME Revenue Collections Unit Copy 2: Case File

Information About Second Policy

Choose all that apply to this policy:

Major Medical Drug Medicare Supplement

Dental Vision

*Policyholder (Last Name, First Name, Middle Initial)

Phone number

( ) Mailing address (House #, Street, Apt, OR PO Box, City, State, Zip)

*Social Security number

*Date of birth

*State ID #

*Insurance company name

Phone number

( ) Insurance claims office mailing address (#, Street, OR PO Box, City, State, Zip)

If the insurance is through an employer, employer’s name

*Policy number

Group number

Date policy is effective

People covered by the policy above:

Fill out the information below and tell us if each person is currently covered or if they are being added or dropped from the insurance.

Currently Covered

Choose One: Effective Date

Last Name, First Name, Middle Initial

Date of Birth

State ID Relationship to Policyholder Add Drop

Is there anything else about the insurance information you gave that you want to tell about? If yes, please use this space.

For office use only: County #

Worker #

Date Rec’d

470-2577 (Rev. 1/07)


Resources Upon Entering a Medical Facility

This information is needed to determine the protection of resources for the spouse at home when the other spouse enters a medical facility and the stay is expected to last 30 days or more. This resource information is then used to determine if the spouse in the facility can qualify for Medicaid. HOWEVER, THIS FORM IS NOT AN APPLICATION FOR MEDICAID.

Identifying Information: Name of spouse in medical facility Social security number Birthdate

Facility name Telephone ( )

Street City State Zip code

Date of first entry into the facility (including entry into a hospital immediately before entering the facility named above)

Name of spouse at home Social security number Telephone ( )

Street City State Zip code Birthdate

Name of guardian or conservator of either spouse Telephone ( )

Street City State Zip code

Resource Information: List all the resources owned in whole or jointly by either spouse as of the first day of the month in which the spouse first entered a medical facility. (If the institutionalized spouse had other occurrences of being in a medical facility for 30 days or more, record the resources as of the first day of the month of the first occurrence). Please check yes or no for each spouse’s response. If you check yes, complete the whole section. (You will be asked to provide proof of your resources.)

SPOUSE IN FACILITY SPOUSE AT HOME RESOURCE Yes No Amount Location Yes No Amount Location Cash on hand

Checking account

Savings account

Stocks or bonds

Certificate of deposit

Funeral contract or funeral funds

Trust fund

Safe deposit box (list contents)

Contract for sale of real estate

Other (list)

470-2577 (Rev. 1/07) 2

1. Do you, your spouse, or your dependent relatives own any automobiles, recreational vehicles, or other vehicles?

Yes No

Owner Make/model Year Est. value



2. Do you or your spouse own a home? Yes No

If yes, in whose name is the property listed? _________________________________________________________

Who lives in the home? Name:____________________________________ Relationship:____________________

3. Do you or your spouse own real estate other than the homestead you live in? Yes No

In whose name is the property listed? _____________________________________________________________

Please describe (building, lot or acreage, and location): _______________________________________________

____________________________________________________________________________________________

__________________________________________________________ Market Value: $_____________________

Is there a mortgage against the property? Yes No Amount $_____________________________

Does anyone live in the property? Yes No Is it rented? Yes No

4. Do you, your spouse, or your dependents own or have an interest in burial space or crypts? Yes No

If so, how many? _____________________________

Who are they for? ______________________________________________________________________________

Location: _____________________________________________________________________________________

5. Do you or your spouse have a life estate? Yes No Please describe:_____________________

________________________________________________________________________________________

6. Please list all life insurance policies owned by you or your spouse (complete all information):

Person covered

Name of company

Policy number

Face value

Year purchased

Name of beneficiary

470-2577 (Rev. 1/07) 3

PLEASE READ CAREFULLY BEFORE SIGNING

I understand that I assume full responsibility for the accuracy of the information on this form, and I understand that the Department of Human Services will use this information to determine if I qualify for assistance when I actually apply for Medicaid.

I understand the social security number of each spouse is used for a computer match with the Social Security Administration and the Internal Revenue Service to check income, resources and the identity of each spouse.

I understand that Iowa laws provide that anyone who obtains or attempts to obtain or who helps any person to obtain public assistance to which that person is not entitled is guilty of violating the laws of the State of Iowa, including, but not limited to Iowa Code Chapters 234, 239, 249, 249A and 712.

I am aware that Section 1128 of the Social Security Act provides federal penalties for fraudulent acts and false reporting.

I CERTIFY THAT THE INFORMATION I HAVE PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

Signature or mark of the applicant, legal guardian or payee Date

Signature of the person, if any, who helped complete this form with the permission of the applicant

Date

Witness to mark of applicant, if applicant is unable to sign Date

PLEASE RETURN THIS FORM TO YOUR COUNTY DHS OFFICE. You will be given a copy of this form at your request.

You Have the Right to Appeal

What is an appeal?

An appeal is asking for a hearing because you do not like a decision the Department of Human Services (DHS) makes. You have the right to file an appeal if you disagree with a decision. You do not have to pay to file an appeal. [441 Iowa Administrative Code Chapter 7].

How do I appeal?

Filing an appeal is easy. You must appeal in writing by doing one of the following:

• Complete 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.

https://dhssecure.dhs.state.ia.us/forms/

470-2577 (Rev. 1/07) 4

How long do I have to appeal?

You must file an appeal:

• Within 30 calendar days of the date of a decision or • Before the date a decision goes into effect

If you file an appeal more than 30 but less than 90 calendar days from the date of a decision, you must tell us why your appeal is late. If you have a good reason for filing your appeal late, we will decide if you can get a hearing.

If you file an appeal 90 days after the date of a decision, we cannot give you a hearing.

Can I continue to get benefits when my appeal is pending?

You may keep your benefits until an appeal is final or through the end of your certification period if you file an appeal:

• Within 10 calendar days of the date of a decision or • Before the date a decision goes into effect

Any benefits you get while your appeal is being decided may have to be paid back if the Department’s action is correct.

How will I know if I get a hearing?

You will get a hearing notice that tells you the date and time a telephone hearing is scheduled. You will get a letter telling you if you do not get a hearing. This letter will tell you why you did not get a hearing. It will also explain what you can do if you disagree with the decision to not give you a hearing.

Can I have someone else help me in the hearing?

You or someone else, such as a friend or relative can tell why you disagree with the Department’s decision. You may also have a lawyer help you, but the Department will not pay for one. Your county DHS office can give you information about legal services. The cost of legal services will be based on your income. You may also call Iowa Legal Aid at 1-800-532-1275. If you live in Polk County, call 243-1193.

Policy Regarding Discrimination, Harassment, Affirmative Action and Equal Employment Opportunity

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, religion, age, disability, political belief or veteran status.

If you feel DHS has discriminated against or harassed you, you can send a letter of complaint to:

Iowa Department of Human Services, Administrator, Diversity Program Unit, 1305 E. Walnut, Des Moines IA 50319-0114; phone (800) 972-2017; fax (515) 281-4243.


Authorization for Release of Information

Date: County:Worker Number:

Information due date: Worker Name:Phone:

Email:

This form gives you permission to share information with the Department of Human Services(DHS).

Please fill out this form and send it back to us at:

If you have any questions, please call me at the phone number above.

Information Requested

Please share this information with the Department of Human Services. I give my permissionto the person or agency named above to share information about my family or me. I will nothold this person liable for giving information, even if it’s confidential. This permission stops_________________________________________.

Name (please print) Signature Date

Please use the next page to provide a response to this request.

470-0461 (Rev. 4/12) W0461A

Dear Veteran's Administration:

Veteran's AdministrationAttn: PCP/Advocacy

Veteran's benefits information - Please see the questions on the next page.

78

877-344-9628

[email protected]

Dept Human ServicesImaging Center 1417 E Kanesville BlvdCouncil Bluffs, IA 51503FAX: 515-564-4040

April 30, 2014

2012-04AOHMAJGKFMGOGJCKACMGMLPOBLNHNIKKANEDBHKKAHNDNMCKAKCGIACMGEAMIKMK

Page 1 of 2

Response to Request

Please verify:

Member Name:SSN:

Veterans #:

1.

2. What would the benefit be with UME?

3. What would the benefit be without UME?

4. Type of benefit received?

5. Is this pension subject to the $90 reduction?

______ Yes ______ No (skip to question 6)

If so, what is the effective date of the reduction?

6. What portion of the pension is attributable to UME?

7. What amount is for aid and attendance?

8. What amount is for housebound allowance?

9. What amount is for dependent allowance?

10. Please list any deductions the VA makes to this benefit, including the amount of the deduction.

Signature of Person Sharing Information Title

Phone Number Date

470-0461 (Rev. 4/12) W0461B4

Gross monthly Veteran's Benefit amount (if possible please include a copy of the award letter)

Page 2 of 2


Authorization for the Department to Release Information

I give the Department of Human Services permission to share with

confidential information about me or my household. The information that can be shared is:

This permission stops _____________________.

Signature Date

470-2115 (Rev. 4/12) W2115A Copy 1 – File Copy 2 – Client

AOHMAJGKFKCPEJEKACMGMLPOCIPCIAKKAJCCCHNAGMOLEACKAKAAOICEGACOKKMK


Annuity Release of Information

I, ____________________________________, give _______________________________________permission to share information about my annuities with the Department of Human Services. I releaseyou from all liability for disclosing this information even if it is considered confidential. This permissionstops 90 days after the date of signature.

Client Signature Social Security Number Date

To: From:

Phone:Date sent: FAX:

Email:RE: Policy Number

Annuity Owner

1. Please indicate the date the annuity was established.

2. Please indicate the type of funds used to establish the annuity

An account or trust described in subsection (a), (b), (c), (p) or (q) of section 408 of the UnitedStates Internal Revenue Code of 1986.

A simplified employee pension (within the meaning of section 408(k) of the United StatesInternal Revenue Code of 1986).

A Roth IRA described in section 408A of the United States Internal Revenue Code.

Funds owned by the above named individual.Other:

3. Please indicate the GROSS amount and frequency of annuity payments as of

4. Please indicate the portion of the gross payment attributed attributable to:

Principal $____________________ _______________Interest $

5. Please indicate any amount withheld from the gross amount and the reason for the withholding.

6. Can this annuity be cashed in for a lump sum?_______________Yes If yes, list the cash value of the annuity: $

No If no, can it be assigned or transferred? NoYes

7. Describe the payment terms of the annuity, including guaranteed amounts, deferral or balloonpayments.

8. Does this annuity have remainder beneficiaries? NoYesIf yes, list the remainder beneficiaries in the first and second positions:

Signature of Person Providing Information Title

Telephone Number Date

470-4699 (Rev. 4/12) W4699B

Department Of Human Service417 E Kanesville BLVDCouncil Bluffs, IA 51503

[email protected]

AOHMAJGKFMHPFMEKAAOKILHODIHIKAKKAOBCAEICDMKLJHBKAMOKMIKIKEAAIKMK

4/30/14

The following information can be shared with Medicaid applicants and their

families to assist in submitting a complete application. Income and resource

verification is required, please send in proof.

• The income limit for 2014 is $2,163.00. If client’s gross income is over this

amount refer to the information sheet on Medical Assistance Income Trusts.

• CFEU can obtain verification of Social Security and SSI income; if the client

has additional income from other sources CFEU will need verification of the

gross amount of the income.

• The resource limits for 2014 are $2,000.00 per individual and $3,000.00 per

couple. The applicant must be at or below this amount as of the first moment

on the first day of a month to be eligible for that month.

• To allow a deduction from client participation for health insurance premiums,

CFEU must receive verification of all health premiums paid for the client.

• If client is a Veteran and not receiving benefits they will be advised to apply

for Veteran’s benefits.

• If client is receiving Veteran’s benefits, provide a copy of their most recent

benefit letter, all pages and/or have the client receiving the benefits sign a

release so that CFEU can obtain information from the Veteran’s

Administration.

• If the client is not 65 or older, blind, or they have not been determined

disabled by the SSA. They will need to apply for SSI and SSD benefits and

provide verification to CFEU that this has been done.

• CFEU will request bank statements for all months that eligibility is requested.

This will need to include all pages of the statements and will need to show a

balance summary or daily balance so that the worker can determine balances

as of the first of every month. (For example, the worker will look at the

10/31/13 balance for resources owned as of 11/1/13).

• For all married couples, if an attribution needs to be completed the worker

will need proof of all resources as of the first of the month that the client

entered the facility. (For example, if the client entered the facility on 9/15/13

CFEU will need proof of all resources owned as of 9/1/13).

• Provide face value and cash value of all life insurance policies owned. If there

is any intent to use life polices for burial a signed statement of intent will need

to be submitted.

• Provide cash value of all other types of resources to include; CD’s, money

market accounts, savings accounts, IRA’s, vehicles, 401k’s, property, etc.

• If client owns farmland CFEU will need verification of the fair market value of

price per acre.

4/30/14

• If client owns a home and intends to return, they will need to submit a signed

statement of that intent.

• If client has any burial contracts and/or burial funds, CFEU will need copies of

contracts and proof of any funds the client has.


Ten-Day Report of Change for FIP and Medicaid

Tell Us About Your Changes

You will need to tell us within ten days of the change. If you have applied for FIP or Medicaid, but wehave not made a decision on your application yet, you must tell us about your changes within five days ofthe change.

If you don’t tell us when changes happen, we may give you too much or not enough FIP or Medicaid. Or,give you benefits that you should not have gotten. If so, you will have to pay back what you got in error.

Instructions

Check the box next to your change. If you have more than one change to tell us about, check all theboxes that apply. Tell us about the change on the backside of this form and return it to the Departmentof Human Services (DHS) office listed above.

Where You Live or Who You Live With

I have:

A new mailing or living address.

Someone moving into my home. This includes the birth of a child or the return of a parent orspouse to the home.

Someone moving out of my home or going into a nursing home.

Money Your Household Gets

Someone in my home:

Will start or stop a job. Note: People who are age 65 and over or disabled must also report achange in income from work. This includes a change in the rate of pay or number of hoursworked.

Will start or stop getting unemployment benefits, social security income, pensions, child supportor alimony, gifts, loans, school loans or grants, etc. Note: People who are age 65 and older ordisabled must also report a change in the amount of money they receive from these sources.

Will get a one-time payment such as back child support, an inheritance or an insurancesettlement.

470-0499 (Rev. 10/11) W0499A

You must tell us when something changes. You can report your change by mail, fax, or e-mail to:

Dept Human ServicesImaging Center 1417 E Kanesville BlvdCouncil Bluffs, IA 51503FAX: 515-564-4014e-mail: [email protected]

Changes in address, work or your ability to work must be reported to your DHS worker. You will also need to send proof of the change you reported.

AOHMAJGKFJAIDJAKACMGMLPODIFNGACKAMGBDGIDANEFEJDKAMIECAKACAAIMKMK

Household Expenses

Someone in my home:

Pays for child or adult care costs.

Is being billed for school expenses, conservator fees, or medical fees.

Pays court-ordered child support.

Assets or Resources

Someone in my home:

Got another car, truck, boat, or motorcycle or got rid of one.

Bought or sold a house or land.

Opened or closed a bank account or a retirement account.

Got an insurance policy or got rid of one.

Medical Coverage

Someone in my home:

Had a change in their health insurance premium amount.

Started or stopped paying premiums, including Medicare premiums.

Started getting other medical insurance or current medical insurance was dropped.

Other Changes

Someone in my home:

Got a Social Security Number.

Who is a child, has enrolled in school or dropped out of school.

Explain Your Change

Use this space to explain the changes that you checked.

Name Phone Number( )

Address

Social Security Number Date Completed

470-0499 (Rev. 10/11) W0499B

4/30/14

Income Sources (Manual Reference) 8-E-13-; Legal reference:

20 CFR 416.1102, 416.1103, 416.1123, and 416.1167

Under SSI, “income” is anything a person receives either in cash or in kind that can be used to

meet the person’s basic needs of food, clothing, or shelter.

Annuities – All clients with an annuity will be asked to sign form 470-4699 Annuity Release of

Information. Once the IM worker receives the signed release back they will send to the annuity

company to obtain the necessary information.

Social Security – IM workers can typically obtain this information from our internal system,

however, if this information is not available a Social Security Award Letter is acceptable proof

for Income verification. IM Worker also is able to contact Social Security via a phone call.

SSI (Supplemental Security Income) - IM workers can typically obtain this information from our

internal system, however, if this information is not available a Social Security Award Letter is

acceptable proof for Income verification. IM Worker also is able to contact Social Security via a

phone call.

Black Lung - Client would need to submit a benefit letter or tax form received for the current

year from the Black Lung.

Veteran Pension - Acceptable verification is the VA Award Letter as proof of income, however,

IM worker may need to send an additional release to the VA Authorization to Release Info to

DHS (470-0461), to have specific questions answered detailing gross benefit amount,

breakdown and type of benefit such as: Veteran Aid and Attendance, Veterans Dependent

Benefit, Unusual Medical Expenses, Compensation or a benefit.

Civil Service Railroad Retirement/Private Pension - A statement from the Civil

Service/Railroad/ Private Pension that details the gross amount of income is an acceptable form

of verification that can be submitted to the Department. A 1099 is also acceptable verification

as long it is in line with the current benefit received.

IPERS – A statement from IPERS showing a breakdown of the gross monthly IPERS benefit along

with amount of IPERS dividend and month it will be paid. A 1099 is NOT acceptable as it shows

the benefit and dividend together and does not show the breakdown of the benefit.

Child Support/Alimony – This information can be accessed via internal systems, only if with the

State of Iowa. If the worker is unable to obtain the information through our internal system,

the client will need to provide documentation showing the Child Support/Alimony they are

receiving.

Unemployment Benefits – This information can be accessed via internal systems, only if with

the State of Iowa. If the worker is unable to obtain the information through our internal

4/30/14

system, the client will need to provide documentation showing the Unemployment benefit(s)

they are receiving.

Interest/Dividend – Acceptable verification would be the client’s bank statements or a

statement for the company in which the client is receiving the interest/dividends from.

Rental Property Income – Complete tax returns are an acceptable form of verification showing

all rental income received. If taxes have not been filed, the client would need to submit

verification of all rental income received and an itemized list of expenses.

Property Sold on Contract – Acceptable verification is the Amortization Table showing the

payment breakdown of principal and interest. Only the interest is countable income.

Farm Income – Complete tax returns are an acceptable form of verification showing all Farm

income received. If taxes have not been filed, the client would need to submit verification of all

farm income received and an itemized list of expenses.

4/30/14

Resources (Manual Reference) 8-D- 79-129; Legal

reference: 20 CFR 416.1205, 441 IAC 50.2(1), 75.1(249A), 75.1(39)“a”(5), 76.5(2)

“Resources” are liquid and nonliquid assets owned by a person that the person is not legally

restricted from using for support and maintenance, and that could be converted to cash to use

for support and maintenance. Unless specifically exempt, all resources are considered countable

Checking/Savings/Credit Union Accounts – Acceptable verification is a bank statement

showing the balance of account(s) as the 1st moment of the 1st day of the month. If client is

unable to obtain a bank statement, IM Worker can obtain the information if a Bank or Credit

Union Information form, (470-1631 or 470-1631(s)), is filled out by the client. Form 470-1631 is

designed to secure the client’s permission for the Department to investigate information that

can be provided by a bank or credit union. The bank or credit union also uses the form to

furnish the requested information.

Burial - If you have a burial contract you will be asked to provide verification of the contract to

your Department of Human Services IM worker. If you have a life insurance policy funding a

burial contract you will need to provide verification of the face value and cash value of the life

insurance policy as well as verification of the owner and beneficiary of the policy. If you have

burial trusts, CDs, or other funds set aside for your burial, you will need to provide verification

of the value. You must also provide a complete copy of your burial contract that indicates

whether the contract is revocable or irrevocable. If any burial funds are not specifically titled

“burial funds” then we would need a separate signed statement that the funds are intended for

burial in order to exclude $1500.

Life Insurance – The client would need to obtain from the Life Insurance Company proof of

face and cash value of the policy as of the date requested.

Annuities – All clients with an annuity will be asked to sign form 470-4699 Annuity Release of

Information. Once the IM worker receives the signed release back they will send to the annuity

company to obtain the necessary information.

Property Sold on Contract - Client will need to provide a complete copy of the contract itself

and the amortization table. The Fair Market Value of the contract will need to be submitted. If

the client is unable to provide proof of FMV of the contract, then the amount currently owed

on the contract would be considered the Fair Market Value.

Promissory Notes and Loans- The client will need to provide a copy of the note/loan. This will

need to include the amortization table showing breakdown of principal and interest. The client

can also provide proof of fair market value from three dis-interested third parties as to the

value of the loan or note if sold. If they are unable to or do not provide fair market value then

the amount owed will be the resource value.

4/30/14

Retirement Funds- The client will need to provide verification from the company showing the

cash surrender value of any retirement funds. If the client has to quit their job to withdraw the

funds then they will not be counted as a resource.

Vehicles- If the client owns more than one vehicle then they will need to provide proof of fair

market value of all vehicles. If they cannot obtain verification of the value then they can provide

year, make, model, mileage and condition of vehicle and the IM worker will refer to NADA or

KBB for the values. Unless otherwise requested the department will exclude the vehicle with

the highest value.

Burial Space – The client will need to provide a statement as to how many burial spaces they

own and who they are for. If the spaces are not for immediate family then the client will need

to provide proof of fair market value of the spaces that are not intended for family.

Life Estates- The client will need to provide proof of fair market value of the entire property

and proof of the fair market value of the life estate or remainderman interest. If they cannot

obtain fair market value of the life estate/remainderman interest then the department will use

the life estate chart provided in policy manual 8-D. (Please note: if the property is farm land the

fair market value provided will need to be in price per acre)

Updated 4/30/14

What is a burial contract?

A burial contract is an agreement with

a funeral home in which a person pre-

pays for funeral expenses.

How is a burial contract counted

in determining eligibility for

Medicaid?

There are some circumstances in

which a burial contract is not counted

as a resource for Medicaid. In order

to be excluded as a resource a prepaid

burial contract must be an irrevocable

contract and the applicant or member

must be unable to access the funds.

In addition there must be a contract

with a funeral home. In other words,

you must purchase something for

your money. You may not simply put

money in an irrevocable account. This

would be considered a transfer of

assets for less than fair market value

which results in a period of

ineligibility for Medicaid.

How can a burial contract be

funded?

A burial contract can be funded by a

number of ways. The most common

ways include assigning ownership of a

life insurance policy to a funeral

home, setting up a trust at a bank

which can be funded by a certificate of

deposit of another form.

If I have a burial contract what

information do I need to

provide?

If you have a burial contract you will

be asked to provide verification of the

contract to your Department of

Human Services IM worker.

If you have a life insurance policy

funding a burial contract you will

need to provide verification of the face

value and cash value of the life

insurance policy as well as verification

of the owner and beneficiary of the

policy.

If you have burial trusts, CDs, or other

funds set aside for your burial, you

will need to provide verification of the

value.

You must also provide a complete

copy of your burial contract that

indicates whether the contract is

revocable or irrevocable.

What amount can be funded for

burial?

The average cost of a funeral in Iowa

is $11,566. If the amount funding

your burial contract exceeds $11,566

you will need to provide a statement

of goods and services verifying what

was purchased. The Department will

also need to review the contract for

any possible transfer of assets.

What if I have questions?

If you have questions about what to

provide you can call the DHS facility

unit at 877-344-9628.

Updated 4/30/14

Burial

Contract

Information

Iowa Department of Human Services - Centralized Facility eligibility Unit

After you are approved for Nursing Facility Medicaid

here are some things to remember:

• You will be assigned a new case worker to

maintain the ongoing eligibility of your case.

• You should report any changes that occur within

10 days. Some examples are:

o Income Change

o Resource Change

o Inheritance

o Marital Status (ie. If your spouse enters a

facility or you become widowed, or

divorced)

• Client Participation should be paid to the facility

that you reside in at the beginning of each

month.

• If you receive VA benefits or pension payments,

call the Veterans Administration to report you

have been approved for Medicaid.

• A Review of your eligibility will be done on an

annual basis. This form will come via US Mail.

• You may receive requests from DHS throughout

the year, please make sure to open and read

your mail from DHS.

• Resources should remain under $2,000 for

individuals and $3,000 for couples in facilities.

Keep this form so that you know when and how to

report.

IOWA DEPARTMENT OF HUMAN SERVICES - CENTRALIZED FACILITY ELIGIBILITY UNIT

I’M APPROVED; NOW WHAT?

CONTACT

INFORMATION:

Information can be

submitted via fax, email,

or US Mail.

Fax: 1-515-564-4040

Email:

[email protected]

Address:

Iowa Department of

Human Services

Centralized Facility

Eligibility Unit

Imaging Center 1

417 E Kanesville BLVD

Council Bluffs, IA 51503

For additional questions:

DHS Customer Service

1-877-344-9628

Facility Name

Facility Address

Facility Address

Facility Phone Number

Date Todays Date

This is an unmet medical request for Resident Name at Facility Location to include

the months prior to Medicaid approval. Please send a copy of the approved unmet

medical agreement to the facility. Please let us know if there are any questions! Resident Resident Name

Thank you! -Facility Name Medicaid ID # ??????A

Facility Signature Resident or Representative Signature Amount Due -$

From Through Days Description Rate Amount

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

Total Unmet Medical Requested -$

Unmet Medical Expense Directions:

1. Fill in facility information at top of form.

2. Fill in resident and facility name in paragraph below facility information.

3. Complete the date, resident name, and state ID to the right of the paragraph.

4. Itemize room and board and medically necessary ancillary charges.

5. Cable, hair care, personal items, phone, guest meals, or any other charges that are not considered medically necessary

cannot be included on this request.

6. Have facility representative and resident or resident representative sign and submit to DHS via one of the options below:

Mail:

Fax: 515-564-4040 Email: [email protected] Centralized Facility Eligibility Unit

Imaging Center 1


417 E Kanesville Blvd.

Council Bluffs, IA 51503-4470

Unmet Medical Request

Revised 4/30/14

Revised 7/7/14

CFEU Team Member

Area of Responsibility

First Name Last Name Direct Extension

(Area Code 712,

Unless Noted)

Manager JaiLi Cunningham 328-7788

Asst.Manager Elaine Walker 326-2435

Supervisor Marci Ludington 328-7789

Supervisor Dawn Helm 326-2388

Mentor/Liaison Kristen Stormer 326-2436

Applications Karen Foley 326-2371

Applications Stephen Moore 326-2373

Applications Leslie Hector 326-2348

Applications Anne McLeod 326-2361

Applications Maria Ortiz 326-2377

Applications Kayonna Copeland 326-2368

Applications Julie Moon 326-2401

Applications Athena Walker 326-2369

App Floater Vacant Vacant 326-2354

Rederts A-K Wendy Severn 326-2366

Rederts L-Z Terran Farr 326-2347

Ongoing Floater Lori Brandenburg 326-2356

A-BRO Gary Gruis 326-2407

BRP-DO Shante Chism 326-2384

DP-HAI Courtney Furmanski 326-2387

HAJ-JOL Laura Ekstrand 326-2430

JOM-MAL Amy Meyers 326-2386

MAM-ORC Claire Nelson 326-2389

ORD-SCA Shawna Morgan 326-2372

SCB-THI Corrine Schram 326-2355

THJ-Z Mandie Lytle 328-7786

Customer Service Toll Free Number (877) 344-9628

Customer Service Matt Fjare 326-2370

Customer Service Erica Fitch 326-2381

Support Trisha Babbel 326-2393

Support Teresa Voss 326-2415

Fax (515) 564-4040

IME Provider Services (800) 338-7909

IME Member Services (800) 338-8366

Email: [email protected] Fax: 515-564-4040

Do Not Distribute, for internal facility use only

Revised 7/7/14

Centralized Facility Eligibility Unit (CFEU)

Contact Information

Department of Human Services

Centralized Facility Eligibility Unit

Imaging Center 1

417 E Kanesville BLVD

Council Bluffs, IA 51503-9945

Toll Free: 877-344-9628

Fax: 515-564-4040

Email: [email protected]

Dawn Helm, Income Maintenance Supervisor – Application/Redetermination Team and Facility

Liaison

[email protected]

712-326-2388

Marci Ludington, Income Maintenance Supervisor – Ongoing Team

[email protected]

712-328-7789

Kristen Stormer, Mentor

[email protected]

712-326-2436

Elaine Walker, Income Maintenance Customer Service Center and Centralized Facility Eligibility

Unit Assistant Manager

[email protected]

712-326-2435

Jai Li Cunningham, Income Maintenance Customer Service Center and Centralized Facility

Eligibility Unit Manager

[email protected]

515-242-5994 office

641-757-9324 cell

Lori Lipscomb, Service Area Manager

Centralized Service Area

[email protected]

515-281-5741

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