DHS FORMS

ADMINISTRATIVE FORMS

Form Name

Send To

Authorization for Release of Information 470-0461

County Offices

Authorization to Take and Use Photographs 470-0060

Authorization to Take and Use Photographs of a Minor 470-0064

Authorizationfor the Department toRelease Information470-2115

APPEALS & EXCEPTIONS

Form Name

Send To

Appeal and Request for Hearing 470-0487

Submit On-Line

Petition for Exception to Policy 470-3888

Request for Withdrawal of Appeal 470-0492


Apelacion y Solicitud de Audiencia 470-0487(S)

BACKGROUND CHECKS

Form Name

Send To

Authorization for Release of Child Abuse Information 470-3301

Central Abuse Registry

IA DHS

P.O. Box 4826

Des Moines, IA 50305

Fax to: 515-564-4112

Email:

DHSAbuseRegistry@dhs.state.ia.us

Authorization for Release of Dependent Adult Abuse Information 470-4531

Record Check Evaluation 470-2310

Non-Redissemination Agreement 470-3767

Request for Child Abuse Information 470-0643

Request for Dependent Adult Abuse Registry Information 470-0612


Evaluacion de Cheque del Registro 470-2310(S)

CASH ASSISTANCE

Form Name

Send To

Employer's Statement of Earnings 470-2844

County Offices

Financial Support Application 470-0462
Report on Incapacity 470-0447

Request for FIP Beyond 60 Months 470-3826

Requirements of Claiming Good Cause 470-0170

Review/Recertification Eligibility Document 470-2881

Ten-Day Report of Change for FIP and Medicaid 470-0499

Informe de Cambios de Diez Dias para FIP y Medicaid 470-0499(S)

Solicitud de Apoyo deFinanciero 470-0466(S)

CHILD CARE ASSISTANCE

Form Name

Send To

Financial Support Application 470-0462 (Multi-Program*)

County Offices

Child Care Assistance Application 470-3624 (Child Care Assistance Only)


Solicitud de Apoyo deFinanciero 470-0462(S) (Varios Programas*)

Solicitud Para Child Care Assistance 470-3624(S)(Solamente Child Care Assistance)

*Multi-program application can be used to apply for Food Assistance, Child Care Assistance, Medical Assistance and Cash Assistance

CHILD SUPPORT


Please see the Child Support website


FOOD ASSISTANCE

Form Name

Send To

Financial Support Application 470-0462(Multi-Program*)

County Offices

Application for Food Assistance 470-0306(Food Assistance Only)

Change Report 470-0321

Employer's Statement of Earnings 470-2844

Review/Recertification Eligibility Document 470-2881

Solicitud de Apoyo deFinanciero 470-0466(S) (Varios Programas)

Solicitud de Asistencia Alimenticia 470-0307 (Solamente Asistencia Alimenticia)

Informe De Cambio 470-0322

*Multi-program application can be used to apply for Food Assistance, Child Care Assistance, Medical Assistance and Cash Assistance

HEALTH CARE/MEDICAL

Medical Assistance/Medicaid

Form Name

Send To

County Offices

Health Services Application 470-2927 (Medical Only)

Medical Transportation Claim 470-0386

Employer's Statement of Earnings 470-2844

Review/Recertification Eligibility Document 470-2881

Medicaid Review 470-3118(M)

Solicitud de Servicios Medicos 470-2927(S) (Solamente Medico)

*Multi-program application can be used to apply for Food Assistance, Child Care Assistance, Medical Assistance and Cash Assistance

hawk-i (Children's Health)

Form Name

Send To

hawk-i On-line Application (submit on-line)

hawk-i Solicitud

hawk-i Program

PO Box 71336

Des Moines, IA 50325-9958

Privacy In Health Care/HIPAA

Form Name

Send To

Authorization to Obtain or Release Health Care Information 470-3951

Request to End an Authorization 470-3949

Request to Amend Health Information 470-3950

Request for a List of Disclosures 470-3985

Request to Restrict Use or Disclosure of Health Information 470-3953

Request for Access to Health Information 470-3952

HIPAA Complaint 470-3981

Request to Change How Health Information is Provided 470-3947


Autorizacion para Obtener o Proporcionar Informacion Sobre el Cuidado de la Salud 470-3951(S)

HIPAA Privacy Officer

IA Dept of Human Svcs

1305 E Walnut

Des Moines, IA 50319

Home & Community Based Services (Waivers)

Form Name

Send To

Consumer Directed Attendant Care Individual Provider Enrollment - 470-3638

HCBS Consumer-Directed Attendant Care Agreement 470-3372

Your Targeted Case Manager

MANDATORY REPORTER FORMS

Form Name

Send To


Report of Suspected Child Abuse 470-0665
Suspected Dependent Adult Abuse Report 470-2441

Central Abuse Registry

IA DHS

P.O. Box 4826

Des Moines, IA 50305

PROVIDERS

Invoice (All Providers)

Form Name

Send To

Provider Invoice 470-0020

County Offices

General Accounting Expenditure GAX

Child Care Assistance Providers

Form Name

Send To

Payment Application for Nonregistered Providers 470-2890

Child Care Assistance Provider Agreement 470-3871

Non-Law Enforcement Record Check Request Form A 595-1489

Non-Law Enforcement Record Check Request Form A (Spanish) 595-1489

Central Child Care Unit

1305 E Walnut St

Des Moines, IA 50319-0114

Facilities

Form Name

IME Provider Forms Web Site

In Home Health Related Care Providers

Form Name

Send To

Provider Health Assessment 470-0672

Statement of Services Rendered 470-0648

County Offices

State Payment Plan (Providers)

Form Name

Send To

Legal Settlement Worksheet 470-3439

Central Point of Coordination Application CPC-APP

CPC in the Client's County of Residence

Images of people and children