Application for Health Coverage

and Help Paying Costs

Use this application to see what coverage choices you qualify for

 Affordable private health insurance plans that offer comprehensive coverage to help you stay
well
 A new tax credit that can immediately help pay your premiums for health coverage
 Free or low-cost insurance from Medicaid or the Children’s Health Insurance Program
(CHIP)

You may qualify for a free or low-cost program even if you earn as much as $94,000 a
year (for a family of 4).

Who can use this application?

 Use this application to apply for anyone in your family.

 Apply even if you or your child already has health coverage. You could be eligible for lower-
cost or free coverage.
 Families that include immigrants can apply. You can apply for your child even if you aren’t
eligible for coverage. Applying won’t affect your immigration status or chances of becoming a
permanent resident or citizen.
 If someone is helping you fill out this application, you may need to complete Step 6.

Apply faster online

Apply faster online at dhsservices.iowa.gov.

What you may need to apply

 Social Security Numbers (or document numbers for any legal immigrants who need
insurance)
 Employer and income information for everyone in your family (for example, from paystubs,
W-2 forms, or wage and tax statements)
 Policy numbers for any current health insurance
 Information about any job-related health insurance available to your family

470-5170 (Rev. 3/20) Cover Page

Why do we ask for this information?

We ask about income and other information to let you know what coverage you qualify for and if
you can get any help paying for it. We’ll keep all the information you provide private and
secure, as required by law.

What happens next?

Send your complete, signed application to the address on page 16. If you don’t have all the
information we ask for, sign and submit your application anyway. We’ll follow-up with you
within 30 days. You’ll get instructions on the next steps to complete your health coverage. If you
don’t hear from us within 30 days, call the DHS Contact Center at 1-855-889-7985. Filling out
this application doesn’t mean you have to buy health coverage.

Get help with this application

 Online: dhsservices.iowa.gov
 Phone: Call our Help Center at 1-855-889-7985.
 In person: There may be counselors in your area who can help. Visit our website or call
1-855-889-7985 for more information.
 En Español: Llame a nuestro centro de ayuda gratis al 1-855-889-7985.
 If you need help in a language other than English, call 1-855-889-7985 and tell the customer
service representative the language you need. We’ll get you help at no cost to you.
 TTY users should call 1-800-735-2942.

470-5170 (Rev. 3/20) Cover Page

Step 1. Tell us about yourself.

We need one adult in the family to be the contact person for your application.
First name, middle name, last name, and suffix

Home address (If you leave blank because you don’t have one, you must give us a Apartment or suite number
mailing address below.)

City State ZIP code County

Mailing address (if different from home address) Apartment or suite number

City State ZIP code County

Phone number Other phone number

Do you want to get information about this application by email? Yes No

Email address:
Preferred spoken or written language (if not English)

Step 2. Tell us about your family.

Who do you need to include on this application?

Tell us about all the family members who live with you. If you file taxes, we need to know about everyone on your
tax return. (You don’t need to file taxes to get health coverage.)

DO include: You DON’T have to include:

 Yourself  Your unmarried partner who lives with you and
doesn’t need health insurance unless you have a
 Your spouse
child or children together
 Your children under 21 who live with you
 Your unmarried partner’s children
 Your unmarried partner who needs health coverage
 Your parents who live with you, but file their own
 Your unmarried partner who lives with you when tax return (if you’re over 21)
you have a child or children together
 Other adult relatives who file their own tax return
 Anyone you include on your tax return, even if they
don’t live with you
 Anyone else under 21 who you take care of and
lives with you
The amount of assistance or type of program you qualify for depends on the number of people in your family and
their incomes. This information helps us make sure everyone gets the best coverage they can.

Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. If you
have more than five people in your family, you’ll need to make a copy of the pages and attach them. You don’t need
to provide immigration status or a Social Security Number (SSN) for family members who don’t need health
coverage. We’ll keep all the information you provide private and secure as required by law. We’ll use personal
information only to check if you’re eligible for health coverage.

470-5170 (Rev. 3/20) Page 1 of 27

Step 2. Person 1 (start with yourself)

Complete Step 2 for yourself, your spouse or partner and children who live with you and anyone on your same
federal income tax return if you file one. See page 1 for more information about who to include. If you don’t file a tax
return, remember to still add family members who live with you.
First name, middle name, last name, and suffix Relationship to you?
SELF
Date of birth (mm/dd/yyyy) Social Security Number (SSN)
Sex: Male Female

We need your SSN if you want health coverage and have a SSN. Providing your SSN can be helpful if you don’t
want health coverage too since it can speed up the application process. We use SSNs to check income and other
information to see who’s eligible for help with health coverage costs. If someone wants help getting an SSN, call
1-800-772-1213 or visit www.socialsecurity.gov/. TTY users should call 1-800-325-0778.

Do you plan to file a federal income tax return THIS YEAR?

(You can still apply for health insurance even if you don’t file a federal income tax return.)
Yes. If yes, please answer questions 1-3. No. If no, skip to question 3.
Yes No 1. Will you file jointly with a spouse?
If yes, name of spouse:
Yes No 2. Will you claim any dependents on your tax return?
If yes, list names of dependents:
Yes No 3. Will you be claimed as a dependent on someone’s
tax return? If yes, list the name of the tax filer:
How are you related to the tax filer?
Yes No Are you pregnant? If yes, how many babies are expected
during this pregnancy? What is the due date?
Yes No Are you currently incarcerated?
Yes No Are you currently assigned to a work release program?
If yes, what is the start date?

Do you need health coverage?

(Even if you have insurance, there might be a program with better coverage or lower costs.)
Yes. If yes, answer all the questions below. No. If no, skip to the income questions on page 3.
Leave the rest of this page blank.
Yes No Do you have a physical, mental, or emotional health condition that causes limitations in
activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?
Yes No Are you a U.S. citizen or U.S. national?
Yes No If you aren’t a U.S. citizen or U.S. national, do you have eligible immigration status?
If yes, fill in your document type and ID number below.
Document type: Document ID number:
Yes No Have you lived in the U.S. since before August 22, 1996?
Yes No Are you or your spouse or parent an honorably discharged veteran or an active-duty member
of the U.S. military?
Yes No Are you a resident of Iowa?
Yes No Do you need help paying for medical bills from the last three calendar months? If you answer
yes and you fall into a category that allows for retroactive approval, we will determine if you
are eligible for coverage during those months.
Yes No Are you an adult who is a main person taking care of a child under the age of 19 living in the
home?
Yes No Are you a full-time student?
Yes No Were you in foster care at age 18 or older?
Yes No If you are under age 19, do you want help with child support?

470-5170 (Rev. 3/20) Page 2 of 27

The following ethnicity and race questions are optional. Check all that apply.
If Hispanic or Latino, ethnicity: Race:
Mexican White Chinese Native Hawaiian
Mexican American Black or African Filipino Guamanian or Chamorro
Chicano/a American Japanese Samoan
Puerto Rican American Indian Korean Other Pacific Islander
Cuban or Alaska Native Vietnamese Other:
Other: Asian Indian Other Asian
Current Job and Income Information: You must tell us about the income of the people in your household. If
someone has more than one job, tell us about all jobs. If you leave a space blank, we will assume that you have no
income of this kind.
Employed. If you’re currently employed, tell us about your income. Start with Current Job 1.
Not employed. Skip to the Other Income This Month section.
Self-employed. Skip to the Self-Employment section.
Current Job 1:
Employer name and address Employer phone number

Wages and tips (before taxes) Hourly Weekly Every 2 weeks Average hours worked each
$ Twice a month Monthly Yearly month:
Current Job 2: If you have more jobs and need more space, attach another sheet of paper.
Employer name and address Employer phone number

Wages and tips (before taxes) Hourly Weekly Every 2 weeks Average hours worked each
$ Twice a month Monthly Yearly month:
Will the amount of money from jobs stay about the same? Yes No
If no, explain:
In the past three months, did you:
Change jobs Stop working Start working fewer hours None of these
Self-Employment: If self-employed, answer the following questions.
Type of work
How much net income (profits once business expenses are paid) will you get from this self-
employment this month? $
Will the amount of monthly income from self-employment stay about the same? Yes No
If no, how much do you expect to average over a 12 month period? $
Other Income This Month: Check all that apply, and give the amount and how often you get it. NOTE: You don’t
need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).
None How often? How often?
Unemployment $ Alimony received $
Pensions $ Net farming/fishing $
Social Security $ Net rental/royalty $
Retirement $ Other income $
accounts Type
Will the amount of money from other income stay about the same? Yes No
If no, explain:
Deductions: If you pay for certain things that can be deducted on a federal income tax return, check all that apply
and give the amount and how often you pay. This information can be found on the Adjusted Gross Income section of
your Federal 1040 form. NOTE: You shouldn’t include a cost that you already considered in your answer to net self-
employment.
How often? How often?
Alimony paid $ Other deductions $
Student loan $ Type
interest
470-5170 (Rev. 3/20) Page 3 of 27
Step 2. Person 2
Complete Step 2 for your spouse or partner and children who live with you and anyone on your same federal income tax
return if you file one. See Page 1 for more information about who to include. If you don’t file a tax return, remember to still
add family members who live with you.
First name, middle name, last name, and suffix Relationship to you?

Date of birth (mm/dd/yyyy) Social Security Number (SSN)

Sex: Male Female
We need your SSN if you want health coverage and have a SSN. Providing your SSN can be helpful if you don’t
want health coverage too since it can speed up the application process.
Yes No Does Person 2 live at the same address as you? If no, list address:

Does Person 2 plan to file a federal income tax return THIS YEAR?
(You can still apply for health insurance even if you don’t file a federal income tax return.)
Yes. If yes, please answer questions 1-3. No. If no, skip to question 3.
Yes No 1. Will Person 2 file jointly with a spouse?
If yes, name of spouse:
Yes No 2. Will Person 2 claim any dependents on Person 2’s tax
return? If yes, list names of dependents:
Yes No 3. Will Person 2 be claimed as a dependent on someone’s
tax return? If yes, list the name of the tax filer:
How is Person 2 related to the tax filer?
Yes No Is Person 2 pregnant? If yes, how many babies are expected
during this pregnancy? What is the due date?
Yes No Is Person 2 currently incarcerated?
Yes No Is Person 2 currently assigned to a work release program?
If yes, what is the start date?

Does Person 2 need health coverage?

(Even if they have insurance, there might be a program with better coverage or lower costs.)
Yes. If yes, answer all the questions below. No. If no, skip to the income questions on page 5. Leave
the rest of this page blank.
Yes No Does Person 2 have a physical, mental, or emotional health condition that causes limitations in
activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?
Yes No Is Person 2 a U.S. citizen or U.S. national?
Yes No If Person 2 isn’t a U.S. citizen or U.S. national, does Person 2 have eligible immigration status?
If yes, fill in their document type and ID number below.
Document type: Document ID number:
Yes No Has Person 2 lived in the U.S. since before August 22, 1996?
Yes No Is Person 2 or their spouse or parent an honorably discharged veteran or an active-duty member in
the U.S. military?
Yes No Is Person 2 a resident of Iowa?
Yes No Does Person 2 need help paying for medical bills from the last three calendar months? If you
answer yes and this person falls into a category that allows for retroactive approval, we will
determine if this person is eligible for coverage during those months.
Yes No Is Person 2 an adult who is a main person taking care of a child under the age of 19 living in the
home?
Yes No Was Person 2 in foster care at age 18 or older?
Yes No If Person 2 is under age 19, do you want help with child support?
Please answer the following questions if Person 2 is 22 or younger:
Yes No Did Person 2 have insurance through a job and lose it within the past three months?
If yes, end date: Reason insurance ended:
Yes No Is Person 2 a full-time student?
470-5170 (Rev. 3/20) Page 4 of 27
The following ethnicity and race questions are optional. Check all that apply.
If Hispanic or Latino, ethnicity: Race:
Mexican White Chinese Native Hawaiian
Mexican American Black or African Filipino Guamanian or Chamorro
Chicano/a American Japanese Samoan
Puerto Rican American Indian or Korean Other Pacific Islander
Cuban Alaska Native Vietnamese Other:
Other: Asian Indian Other Asian

Current Job and Income Information: You must tell us about the income of the people in your household. If
someone has more than one job, tell us about all jobs. If you leave a space blank, we will assume that you have no
income of this kind.
Employed. If you’re currently employed, tell us about your income. Start with Current Job 1.
Not employed. Skip to the Other Income This Month section.
Self-employed. Skip to the Self-Employment section.
Current Job 1:
Employer name and address Employer phone number

Wages and tips (before taxes) Hourly Weekly Every 2 weeks Average hours worked each
$ Twice a month Monthly Yearly month:
Current Job 2: If you have more jobs and need more space, attach another sheet of paper.
Employer name and address Employer phone number

Wages and tips (before taxes) Hourly Weekly Every 2 weeks Average hours worked each
$ Twice a month Monthly Yearly month:
Will the amount of money from jobs stay about the same? Yes No
If no, explain:
In the past three months, did Person 2:
Change jobs Stop working Start working fewer hours None of these
Self-Employment: If self-employed, answer the following questions.
Type of work
How much net income (profits once business expenses are paid) will you get from this self-employment
this month? $
Will the amount of monthly income from self-employment stay about the same? Yes No
If no, how much do you expect to average over a 12 month period? $
Other Income This Month: Check all that apply, and give the amount and how often you get it. NOTE: You don’t
need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).
None How often? How often?
Unemployment $ Alimony received $
Pensions $ Net farming/fishing $
Social Security $ Net rental/royalty $
Retirement $ Other income $
accounts Type
Will the amount of money from other income stay about the same? Yes No
If no, explain:
Deductions: If Person 2 pays for certain things that can be deducted on a federal income tax return, check all that
apply and give the amount and how often Person 2 pays. This information can be found on the Adjusted Gross Income
section of Person 2’s Federal 1040 form. NOTE: You shouldn’t include a cost that you already considered in your answer
to net self-employment.
How often? How often?
Alimony paid $ Other deductions $
Student loan $ Type
interest
470-5170 (Rev. 3/20) Page 5 of 27
Step 2. Person 3
Complete Step 2 for your spouse or partner and children who live with you and anyone on your same federal income tax
return if you file one. See Page 1 for more information about who to include. If you don’t file a tax return, remember to still
add family members who live with you.
First name, middle name, last name, and suffix Relationship to you?

Date of birth (mm/dd/yyyy) Social Security Number (SSN)

Sex: Male Female
We need your SSN if you want health coverage and have a SSN. Providing your SSN can be helpful if you don’t
want health coverage too since it can speed up the application process.
Yes No Does Person 3 live at the same address as you? If no, list address:

Does Person 3 plan to file a federal income tax return THIS YEAR?
(You can still apply for health insurance even if you don’t file a federal income tax return.)
Yes. If yes, please answer questions 1-3. No. If no, skip to question 3.
Yes No 1. Will Person 3 file jointly with a spouse?
If yes, name of spouse:
Yes No 2. Will Person 3 claim any dependents on Person 3’s tax
return? If yes, list names of dependents:
Yes No 3. Will Person 3 be claimed as a dependent on someone’s
tax return? If yes, list the name of the tax filer:
How is Person 3 related to the tax filer?
Yes No Is Person 3 pregnant? If yes, how many babies are expected
during this pregnancy? What is the due date?
Yes No Is Person 3 currently incarcerated?
Yes No Is Person 3 currently assigned to a work release program?
If yes, what is the start date?

Does Person 3 need health coverage?

(Even if they have insurance, there might be a program with better coverage or lower costs.)
Yes. If yes, answer all the questions below. No. If no, skip to the income questions on page 7. Leave
the rest of this page blank.
Yes No Does Person 3 have a physical, mental, or emotional health condition that causes limitations in
activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?
Yes No Is Person 3 a U.S. citizen or U.S. national?
Yes No If Person 3 isn’t a U.S. citizen or U.S. national, does Person 3 have eligible immigration status?
If yes, fill in their document type and ID number below.
Document type: Document ID number:
Yes No Has Person 3 lived in the U.S. since before August 22, 1996?
Yes No Is Person 3 or their spouse or parent an honorably discharged veteran or an active-duty member in
the U.S. military?
Yes No Is Person 3 a resident of Iowa?
Yes No Does Person 3 need help paying for medical bills from the last three calendar months? If you
answer yes and this person falls into a category that allows for retroactive approval, we will
determine if this person is eligible for coverage during those months.
Yes No Is Person 3 an adult who is a main person taking care of a child under the age of 19 living in the
home?
Yes No Was Person 3 in foster care at age 18 or older?
Yes No If Person 3 is under age 19, do you want help with child support?
Please answer the following questions if Person 3 is 22 or younger:
Yes No Did Person 3 have insurance through a job and lose it within the past three months?
If yes, end date: Reason insurance ended:
Yes No Is Person 3 a full-time student?
470-5170 (Rev. 3/20) Page 6 of 27
The following ethnicity and race questions are optional. Check all that apply.
If Hispanic or Latino, ethnicity: Race:
Mexican White Chinese Native Hawaiian
Mexican American Black or African Filipino Guamanian or Chamorro
Chicano/a American Japanese Samoan
Puerto Rican American Indian or Korean Other Pacific Islander
Cuban Alaska Native Vietnamese Other:
Other: Asian Indian Other Asian

Current Job and Income Information: You must tell us about the income of the people in your household. If
someone has more than one job, tell us about all jobs. If you leave a space blank, we will assume that you have no
income of this kind.
Employed. If you’re currently employed, tell us about your income. Start with Current Job 1.
Not employed. Skip to the Other Income This Month section.
Self-employed. Skip to the Self-Employment section.
Current Job 1:
Employer name and address Employer phone number

Wages and tips (before taxes) Hourly Weekly Every 2 weeks Average hours worked each
$ Twice a month Monthly Yearly month:
Current Job 2: If you have more jobs and need more space, attach another sheet of paper.
Employer name and address Employer phone number

Wages and tips (before taxes) Hourly Weekly Every 2 weeks Average hours worked each
$ Twice a month Monthly Yearly month:
Will the amount of money from jobs stay about the same? Yes No
If no, explain:
In the past three months, did Person 3:
Change jobs Stop working Start working fewer hours None of these
Self-Employment: If self-employed, answer the following questions.
Type of work
How much net income (profits once business expenses are paid) will you get from this self-employment
this month? $
Will the amount of monthly income from self-employment stay about the same? Yes No
If no, how much do you expect to average over a 12 month period? $
Other Income This Month: Check all that apply, and give the amount and how often you get it. NOTE: You don’t
need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).
None How often? How often?
Unemployment $ Alimony received $
Pensions $ Net farming/fishing $
Social Security $ Net rental/royalty $
Retirement $ Other income $
accounts Type
Will the amount of money from other income stay about the same? Yes No
If no, explain:

Deductions: If Person 3 pays for certain things that can be deducted on a federal income tax return, check all that
apply and give the amount and how often Person 3 pays. This information can be found on the Adjusted Gross Income
section of Person 3’s Federal 1040 form. NOTE: You shouldn’t include a cost that you already considered in your answer
to net self-employment.
How often? How often?
Alimony paid $ Other deductions $
Student loan $ Type
interest
470-5170 (Rev. 3/20) Page 7 of 27
Step 2. Person 4
Complete Step 2 for your spouse or partner and children who live with you and anyone on your same federal income tax
return if you file one. See Page 1 for more information about who to include. If you don’t file a tax return, remember to still
add family members who live with you.
First name, middle name, last name, and suffix Relationship to you?

Date of birth (mm/dd/yyyy) Social Security Number (SSN)

Sex: Male Female
We need your SSN if you want health coverage and have a SSN. Providing your SSN can be helpful if you don’t
want health coverage too since it can speed up the application process.
Yes No Does Person 4 live at the same address as you? If no, list address:

Does Person 4 plan to file a federal income tax return THIS YEAR?
(You can still apply for health insurance even if you don’t file a federal income tax return.)
Yes. If yes, please answer questions 1-3. No. If no, skip to question 3.
Yes No 1. Will Person 4 file jointly with a spouse?
If yes, name of spouse:
Yes No 2. Will Person 4 claim any dependents on Person 4’s tax
return? If yes, list names of dependents:
Yes No 3. Will Person 4 be claimed as a dependent on someone’s
tax return? If yes, list the name of the tax filer:
How is Person 4 related to the tax filer?
Yes No Is Person 4 pregnant? If yes, how many babies are expected
during this pregnancy? What is the due date?
Yes No Is Person 4 currently incarcerated?
Yes No Is Person 4 currently assigned to a work release program?
If yes, what is the start date?

Does Person 4 need health coverage?

(Even if they have insurance, there might be a program with better coverage or lower costs.)
Yes. If yes, answer all the questions below. No. If no, skip to the income questions on page 9. Leave
the rest of this page blank.
Yes No Does Person 4 have a physical, mental, or emotional health condition that causes limitations in
activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?
Yes No Is Person 4 a U.S. citizen or U.S. national?
Yes No If Person 4 isn’t a U.S. citizen or U.S. national, does Person 4 have eligible immigration status?
If yes, fill in their document type and ID number below.
Document type: Document ID number:
Yes No Has Person 4 lived in the U.S. since before August 22, 1996?
Yes No Is Person 4 or their spouse or parent an honorably discharged veteran or an active-duty member in
the U.S. military?
Yes No Is Person 4 a resident of Iowa?
Yes No Does Person 4 need help paying for medical bills from the last three calendar months? If you
answer yes and this person falls into a category that allows for retroactive approval, we will
determine if this person is eligible for coverage during those months.
Yes No Is Person 4 an adult who is a main person taking care of a child under the age of 19 living in the
home?
Yes No Was Person 4 in foster care at age 18 or older?
Yes No If Person 4 is under age 19, do you want help with child support?
Please answer the following questions if Person 4 is 22 or younger:
Yes No Did Person 4 have insurance through a job and lose it within the past three months?
If yes, end date: Reason insurance ended:
Yes No Is Person 4 a full-time student?
470-5170 (Rev. 3/20) Page 8 of 27
The following ethnicity and race questions are optional. Check all that apply.
If Hispanic or Latino, ethnicity: Race:
Mexican White Chinese Native Hawaiian
Mexican American Black or African Filipino Guamanian or Chamorro
Chicano/a American Japanese Samoan
Puerto Rican American Indian or Korean Other Pacific Islander
Cuban Alaska Native Vietnamese Other:
Other: Asian Indian Other Asian

Current Job and Income Information: You must tell us about the income of the people in your household. If
someone has more than one job, tell us about all jobs. If you leave a space blank, we will assume that you have no
income of this kind.
Employed. If you’re currently employed, tell us about your income. Start with Current Job 1.
Not employed. Skip to the Other Income This Month section.
Self-employed. Skip to the Self-Employment section.
Current Job 1:
Employer name and address Employer phone number

Wages and tips (before taxes) Hourly Weekly Every 2 weeks Average hours worked each
$ Twice a month Monthly Yearly month:
Current Job 2: If you have more jobs and need more space, attach another sheet of paper.
Employer name and address Employer phone number

Wages and tips (before taxes) Hourly Weekly Every 2 weeks Average hours worked each
$ Twice a month Monthly Yearly month:
Will the amount of money from jobs stay about the same? Yes No
If no, explain:
In the past three months, did Person 4:
Change jobs Stop working Start working fewer hours None of these
Self-Employment: If self-employed, answer the following questions.
Type of work
How much net income (profits once business expenses are paid) will you get from this self-employment
this month? $
Will the amount of monthly income from self-employment stay about the same? Yes No
If no, how much do you expect to average over a 12 month period? $
Other Income This Month: Check all that apply, and give the amount and how often you get it. NOTE: You don’t
need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).
None How often? How often?
Unemployment $ Alimony received $
Pensions $ Net farming/fishing $
Social Security $ Net rental/royalty $
Retirement $ Other income $
accounts Type
Will the amount of money from other income stay about the same? Yes No
If no, explain:
Deductions: If Person 4 pays for certain things that can be deducted on a federal income tax return, check all that
apply and give the amount and how often Person 4 pays. This information can be found on the Adjusted Gross Income
section of Person 4’s Federal 1040 form. NOTE: You shouldn’t include a cost that you already considered in your answer
to net self-employment.
How often? How often?
Alimony paid $ Other deductions $
Student loan $ Type
interest
470-5170 (Rev. 3/20) Page 9 of 27
Step 2. Person 5
Complete Step 2 for your spouse or partner and children who live with you and anyone on your same federal income tax
return if you file one. See Page 1 for more information about who to include. If you don’t file a tax return, remember to still
add family members who live with you.
First name, middle name, last name, and suffix Relationship to you?

Date of birth (mm/dd/yyyy) Social Security Number (SSN)

Sex: Male Female
We need your SSN if you want health coverage and have a SSN. Providing your SSN can be helpful if you don’t
want health coverage too since it can speed up the application process.
Yes No Does Person 5 live at the same address as you? If no, list address:

Does Person 5 plan to file a federal income tax return THIS YEAR?
(You can still apply for health insurance even if you don’t file a federal income tax return.)
Yes. If yes, please answer questions 1-3. No. If no, skip to question 3.
Yes No 1. Will Person 5 file jointly with a spouse?
If yes, name of spouse:
Yes No 2. Will Person 5 claim any dependents on Person 5’s tax
return? If yes, list names of dependents:
Yes No 3. Will Person 5 be claimed as a dependent on someone’s
tax return? If yes, list the name of the tax filer:
How is Person 5 related to the tax filer?
Yes No Is Person 5 pregnant? If yes, how many babies are expected
during this pregnancy? What is the due date?
Yes No Is Person 5 currently incarcerated?
Yes No Is Person 5 currently assigned to a work release program?
If yes, what is the start date?

Does Person 5 need health coverage?

(Even if they have insurance, there might be a program with better coverage or lower costs.)
Yes. If yes, answer all the questions below. No. If no, skip to the income questions on page 11. Leave
the rest of this page blank.
Yes No Does Person 5 have a physical, mental, or emotional health condition that causes limitations in
activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?
Yes No Is Person 5 a U.S. citizen or U.S. national?
Yes No If Person 5 isn’t a U.S. citizen or U.S. national, does Person 5 have eligible immigration status?
If yes, fill in their document type and ID number below.
Document type: Document ID number:
Yes No Has Person 5 lived in the U.S. since before August 22, 1996?
Yes No Is Person 5 or their spouse or parent an honorably discharged veteran or an active-duty member in
the U.S. military?
Yes No Is Person 5 a resident of Iowa?
Yes No Does Person 5 need help paying for medical bills from the last three calendar months? If you
answer yes and this person falls into a category that allows for retroactive approval, we will
determine if this person is eligible for coverage during those months.
Yes No Is Person 5 an adult who is a main person taking care of a child under the age of 19 living in the
home?
Yes No Was Person 5 in foster care at age 18 or older?
Yes No If Person 5 is under age 19, do you want help with child support?
Please answer the following questions if Person 5 is 22 or younger:
Yes No Did Person 5 have insurance through a job and lose it within the past three months?
If yes, end date: Reason insurance ended:
Yes No Is Person 5 a full-time student?
470-5170 (Rev. 3/20) Page 10 of 27
The following ethnicity and race questions are optional. Check all that apply.
If Hispanic or Latino, ethnicity: Race:
Mexican White Chinese Native Hawaiian
Mexican American Black or African Filipino Guamanian or Chamorro
Chicano/a American Japanese Samoan
Puerto Rican American Indian or Korean Other Pacific Islander
Cuban Alaska Native Vietnamese Other:
Other: Asian Indian Other Asian

Current Job and Income Information: You must tell us about the income of the people in your household. If
someone has more than one job, tell us about all jobs. If you leave a space blank, we will assume that you have no
income of this kind.
Employed. If you’re currently employed, tell us about your income. Start with Current Job 1.
Not employed. Skip to the Other Income This Month section.
Self-employed. Skip to the Self-Employment section.
Current Job 1:
Employer name and address Employer phone number

Wages and tips (before taxes) Hourly Weekly Every 2 weeks Average hours worked each
$ Twice a month Monthly Yearly month:
Current Job 2: If you have more jobs and need more space, attach another sheet of paper.
Employer name and address Employer phone number

Wages and tips (before taxes) Hourly Weekly Every 2 weeks Average hours worked each
$ Twice a month Monthly Yearly month:
Will the amount of money from jobs stay about the same? Yes No
If no, explain:
In the past three months, did Person 5:
Change jobs Stop working Start working fewer hours None of these
Self-Employment: If self-employed, answer the following questions.
Type of work
How much net income (profits once business expenses are paid) will you get from this self-employment
this month? $
Will the amount of monthly income from self-employment stay about the same? Yes No
If no, how much do you expect to average over a 12 month period? $
Other Income This Month: Check all that apply, and give the amount and how often you get it. NOTE: You don’t
need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).
None How often? How often?
Unemployment $ Alimony received $
Pensions $ Net farming/fishing $
Social Security $ Net rental/royalty $
Retirement $ Other income $
accounts Type
Will the amount of money from other income stay about the same? Yes No
If no, explain:
Deductions: If Person 5 pays for certain things that can be deducted on a federal income tax return, check all that
apply and give the amount and how often Person 5 pays. This information can be found on the Adjusted Gross Income
section of Person 5’s Federal 1040 form. NOTE: You shouldn’t include a cost that you already considered in your answer
to net self-employment.
How often? How often?
Alimony paid $ Other deductions $
Student loan $ Type
interest
470-5170 (Rev. 3/20) Page 11 of 27
Step 3. American Indian or Alaska Native (AI/AN) Family Members

American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or
urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment
periods. Answer the following questions to make sure your family gets the most help possible.
NOTE: If you have more people to include, make a copy of this page and attach.
Yes No Are you or is anyone in your family an American Indian or Alaska Native?
If yes, fill in the information below. If no, skip to Step 4.
AI/AN Person 1: AI/AN Person 2:
Name (first, middle, last) Name (first, middle, last)

AI/AN Person 1: AI/AN Person 2:

Yes No Member of a federally recognized tribe? If yes, tribe name: Yes No

Yes No Has this person ever gotten a service from the Indian Health Service, a Yes No
tribal health program, or urban Indian health program or through a
referral from one of these programs?
Yes No If no, is this person eligible to get any of these services? Yes No

$ Certain money received may not be counted for Medicaid or the $

Children’s Health Insurance Program (CHIP). List any income (amount
How often? How often?
and how often) reported on your application that includes money from
these sources:
• Per capita payments from a tribe that come from natural resources,
usage rights, leases, or royalties.
• Payments from natural resources, farming, ranching, fishing, leases,
or royalties from land designated as Indian trust land by the
Department of Interior (including reservations and former
reservations).
• Money from selling things that have cultural significance.

470-5170 (Rev. 3/20) Page 12 of 27

Step 4. Your Family’s Health Coverage

Answer these questions for anyone who needs health coverage.

Yes No Is anyone enrolled in health coverage now from the following? If yes, check the type of
coverage and write the persons’ names next to the coverage they have.
Medicaid
CHIP
Medicare
TRICARE (Don’t check if you
have direct care or Line of Duty)
VA health care programs
Peace Corps
Employer Insurance
Name of health insurance
Policy number
Is this COBRA coverage? Yes No
Is this a retiree health plan? Yes No
Other
Name of health insurance
Policy number
Is this a limited-benefit plan (like a school accident policy?) Yes No
Yes No Has anyone moved in or out of your home in the past three months?
If yes, answer the following questions.
Name
Date of birth (mm/dd/yyyy)
Social Security Number (SSN)
Relationship to you?
Date moved in?
Date moved out?
Yes No Is anyone listed on this application offered health coverage from a job? Check yes even if the
coverage is from someone else’s job, such as a parent or spouse.
If yes, answer the following question and the questions in Step 5.
If no, skip to Step 6.
Yes No Is this a state employee benefit plan?

470-5170 (Rev. 3/20) Page 13 of 27

Step 5. Health Coverage from Jobs

You don’t need to answer these questions unless someone in the household is eligible for health coverage from a
job. Attach a copy of this page for each job that offers coverage. Tell us about the job that offers coverage.
Employee Information. The employee needs to fill out this section.
Employee name (first, middle, last) Social security number

Employer Information. Ask the employer for this information.

Employer name Employer identification number (EIN)

Employer address (the Marketplace will send notices to this address) Employer phone number

City State ZIP code

Who can we contact about employee health coverage at this job?

Phone number (if difference from above) Email address

Yes No Are you currently eligible for coverage offered by this employer, or will you become eligible in
the next three months? If yes, fill out the information below. If no, skip to Step 6.
If you’re in a waiting or probationary period, when can you enroll in coverage?

List the names of anyone else who is eligible for coverage from this job.

Health Plan. Tell us about the health plan offered by this employer.
Yes No Does the employer offer a health plan that covers an employee’s spouse or dependent?
If yes, which people? Spouse Dependents
Yes No Does the employer offer a health plan that meets the minimum value standard*?
For the lowest-cost plan that meets the minimum value standard* offered only to the
employee (don’t include family plans):
If the employer has wellness programs, provide the premium that the employee would pay if
the employee received the maximum discount for any tobacco cessation programs, and did
not receive any other discounts based on wellness programs.
How much would the employee have to pay in premiums for this plan? $
How often? Weekly Every two weeks Twice a month
Once a month Quarterly Yearly
* An employer-sponsored health plan meets the “minimum value standard” if the plan’s share
of the total allowed benefit costs covered by the plan is no less than 60 percent of such
costs. (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
Employer Changes. What change will the employer make for the new plan year (if known)?
Employer won’t offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan
available only to the employee that meets the minimum value standard. (Premium should reflect discount for
wellness programs.)
How much will the employee have to pay in premiums for that plan? $
How often? Weekly Every two weeks Twice a month Quarterly Yearly
Date of change:

470-5170 (Rev. 3/20) Page 14 of 27

Step 6. Assistance with Completing this Application

You can choose an authorized representative.

You can give a trusted person permission to talk about this application with us, see your information, and act
for you on matters related to this application, including getting information about your application and signing
your application on your behalf. This person is called an “authorized representative.” If you ever need to
change your authorized representative, let us know. If you’re a legally appointed representative for someone
on this application, submit proof with the application.
Name of authorized representative (first name, middle name, last name)

Address Apartment or suite number

City State ZIP code

Phone number

Organization name ID number (if applicable)

By signing, you allow this person to sign your application, get official information about this application, and act
for you on all future matters with this agency.
NOTE: Your signature here does not complete the application. You must sign and date on page 16 to complete
this application.

Your signature Date (mm/dd/yyyy)

For certified application counselors, navigators, agents, and brokers only.

Complete this section if you’re a certified application counselor, navigator, agent, or broker filing out this
application for somebody else.
Application start date (mm/dd/yyyy)

First name, middle name, last name, and suffix

Organization name ID number (if applicable)

Step 7. Read and Sign this Application

Renewal of coverage in future years

To make it easier to determine eligibility for health coverage in future years, your income data, including
information from tax returns, can be verified electronically. You can also change your mind and not allow the
Department of Human Services to check this information.
Do you want this information to be verified in the future and used to automatically renew your eligibility?
Yes, renew my eligibility automatically.
How long? 5 years 4 years 3 years 2 years 1 year
No, don’t use my information from tax returns to renew my coverage.

470-5170 (Rev. 3/20) Page 15 of 27

Estate Recovery
Federal law requires Iowa to have an estate recovery program. If you get Medicaid, you may be subject to
estate recovery. This means any Medicaid funds used to pay for your healthcare, including the monthly fee
paid to a Managed Care Organization (MCO), will need to be paid back from your estate after your death.
Estate recovery applies if you get Medicaid and are:
• Age 55 or older, or
• Are under age 55 and live in a medical facility and cannot reasonably be expected to return home.
For more information, call the Iowa Medicaid Estate Recovery Program at 1-877-463-7887 or go online to
http://dhs.iowa.gov/sites/default/files/Comm123.pdf (English) or
http://dhs.iowa.gov/sites/default/files/Comm123S.pdf (Spanish).

Sign this application

The person who filled out Step 1 should sign this application. If you’re an authorized representative, you may
sign here as long as you have provided the information required in Step 6.
If I leave a question on this application blank, I am reporting that the question does not apply to me and all
persons listed on this application.
I agree to allow my information to be used and retrieved from data sources, including an asset verification
system database, for this application. I have consent for all people I will list on the application that allows their
information to be retrieved and used from data sources for this application.
I acknowledge that I have read and agree to the contents of Rights and Responsibilities, Comm. 233. Rights
and Responsibilities, Comm. 233 is pages 23 to 27 of this application.
By signing this application, I certify under penalty of perjury and false swearing that my answers are correct
and complete to the best of my knowledge, including information provided about the citizenship or alien status
for each household member applying for benefits. I know I may be subject to penalties under federal law if I
provide false or untrue information.
I declare under penalty of perjury under the laws of the United States of America that the information
contained in this statement of facts is true, correct, and complete.

Signature Date (mm/dd/yyyy)

Step 8. Mail the Completed Application

Mail your signed application to:

Imaging Center 4
PO Box 2027
Cedar Rapids, Iowa 52406
If you want to register to vote, you can complete a voter registration form at:
http://sos.iowa.gov/elections/pdf/voteapp.pdf

470-5170 (Rev. 3/20) Page 16 of 27

 Case Number:

Appendix A for Health Coverage

Complete this section if you or someone in the household is aged (65 and older), blind, or disabled.
Name of Person Requesting Services Marital Status Date of Birth Social Security Number

Please indicate if you or someone in the household is in need of any of the following coverage:
Help paying your facility costs (nursing facility, PMIC, skilled facility)
Services to remain in your home (HCBS waivers, PACE)
Assistance paying Medicare premiums
State Supplementary Assistance (residential care facility, in-home health-related care, dependent person)
Help paying for a hospital stay of 30 days or more.
Other

PLEASE PROVIDE VERIFICATION OF ALL ITEMS YOU MARK BELOW (copies, not originals)

1. Income – Tell us about any additional sources of income for each individual in your household, such as child
support, veteran’s payments, Black Lung, Railroad, Supplemental Security Income (SSI), worker’s compensation,
interest, alimony, and dividends, etc.
Name of Person with Income Income Type Amount How often received?

2. Resources – Tell us about all resources for each individual in your household, including cash on-hand, checking
and savings accounts, social security debit card, stocks, bonds, mutual funds, annuities, safe deposit box, 401ks,
IRAs, CDs, etc.
Name of Owner of Resource Resource Type Name/Location of Financial Institution Account Current Value

470-5170 (Rev. 3/20) Page 17 of 27

 3. Motor Vehicles – Tell us about all the vehicles owned for each individual in your household, even if the vehicle is
not in working condition.
Owner Year/Make/Model Fair Market Value Amount Owed

4. Unmet Medical Expenses – Tell us about all medical expenses for each individual in your household not being
reimbursed by a third party.
Name of Person with Unmet
Type of Medical Expense Amount How often incurred?
Medical Expenses

5. Burial/Funeral – Tell us about all burial plots, burial or funeral funds, or burial contracts for each individual in your
household.
How Many/
Type Location Current Value
For Whom

6. Life Insurance – Tell us about all life insurance policies owned by each individual in your household.

Policy Owner Company Name and Address Policy #

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

470-5170 (Rev. 3/20) Page 18 of 27

 7. Property – Tell us about all property for each individual in your household including homestead (the home you live
in) and non-homestead (other property such as vacation home, rental home, vacant lots, buildings, etc.).

Property Owner Property Address Property Value

8. Do you or anyone in your household have a life estate? Yes No

If yes, who:

9. Do you or anyone in your household have a trust? Yes No

If yes, who:

10. Have you or anyone in your household not accepted an inheritance in the past five Yes No
years?

If yes, who:

11. Have you or anyone in your household transferred, sold or given away resources for Yes No
less than their value in the past five years?

If yes, who/what:

Date this occurred:

12. Does anyone applying for benefits live in a medical institution (nursing facility, hospital, Yes No
PMIC, etc.)?

If yes, who: Date of entry:

Name of facility: Phone:

13. Do you or anyone in your household receive Long-Term Care insurance? Yes No

Name of company:

14. If you are currently living in a medical institution and own your home, do you intend to Yes No
return home?

15. Does anyone who is applying have a pending application for Social Security Disability? Yes No

If yes, who:

470-5170 (Rev. 3/20) Page 19 of 27

To speed up the processing of your application, you may provide verification of the following with your
application. If verification is not submitted with the application, you may receive a letter indicating what we
need before we can process your application.

For anyone who is applying and is not a U.S. citizen:

• Immigration status
Proof can be an alien identification card (green card, I-551, I-94), visa, passport, or documents from
Immigration Services

Send verification for those individuals who are:

• Working
Pay stubs from the last 30 days or a written statement of earnings from your employer if you do not
have pay stubs.
• Self-employed
Most recent income tax returns and all related schedules or business records if taxes are not filed.
• Getting other income
(This includes child support, veteran’s payments, Black Lung, Railroad, worker’s compensation, interest
and dividends, cash received from friends or relatives, pension, etc.) A statement from the person or
company that issues the income, copy of checks (showing gross income amount), award letter, tax
forms, court order, or other documents from the last 30 days or most current received.

Send verification for anyone who is 19 or older for the last 90 days from the date you are completing the
application:
• Bank accounts
Recent bank statements or written statement from bank showing current balance or value of accounts.
• Property
Property tax statement. Include documents showing amount owed against the property.
• Burial/funeral contracts
Burial contract and statement of goods and services from the company or funeral home that holds the
contract.
• Other resources
Includes stocks, bonds, mutual funds, annuities, safe deposit box, 401ks, IRAs, CDs, vehicles, etc.
• Life insurance policies
Face and cash value, bonds, annuities, trusts, stock ownership statements, or other documents
showing value of asset. Include documents showing current loan balance owed against the asset.
• Unmet medical expenses
Billing statements, pharmacy statements, medical transportation.

Send copies of proofs. Do not send original documents.

470-5170 (Rev. 3/20) Page 20 of 27

 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

470-5170 (Rev. 3/20) Page 21 of 27

 This page intentionally left blank

470-5170 (Rev. 3/20) Page 22 of 27

 Please keep this page for your information.

Rights and Responsibilities

When you get Medicaid from the Department of Human Services (DHS), you have the following rights and
responsibilities.

Note: “Medicaid” on this form means any DHS medical assistance program including Medicaid, Healthy and
Well Kids in Iowa (Hawki), Iowa Health and Wellness Program (IHAWP), State Supplementary Assistance
(SSA), and Refugee Medical Assistance (RMA).

What Are My Rights?

You have the right to:

♦ Apply for any program.
♦ File an application online, by phone, by mail, by fax, or in person at your county DHS office.
♦ Have someone help you apply.
♦ Have all of your questions answered.
♦ Get information about the programs you applied for and any other DHS program that you may be
able to get.
♦ Be sent a notice within 45 days of the day we get your application telling you if your application was
approved.
♦ Have information about you and your family kept private as required by law.
♦ Have your expenses used to figure your eligibility or the amount of assistance you get by reporting
your expenses, and giving proof if we ask you to. If you do not report or give proof of your expenses
when asked, you choose not to claim the expense. You can report and give proof later to have an
expense used for future months.
♦ Be treated equally without regard to race, color, national origin, sex, sexual orientation, gender
identity, religion, age, disability, political belief, or veteran status. If you feel we have discriminated
against or harassed you, send a letter detailing your complaint to: DHS, Office of Human Resources,
Hoover Building – 1st Floor, 1305 E. Walnut, Des Moines IA 50319-0114 or via email at
[email protected].
♦ Appeal any decision you do not agree with by following the directions on the last page of this form.

What Are My Responsibilities?

♦ You must tell us the truth.

• Section 1128B of the Social Security Act provides federal penalties for fraudulent acts and false
reporting in connection with Medicaid programs.
• Anyone who gets, tries to get, or helps any other person get assistance to which they are not
entitled, is guilty of violating the laws of the State of Iowa. This includes, but is not limited to,
Iowa Code Chapters 249, 249A, 249N, and 514I.
• Giving wrong information on purpose may result in us taking criminal or civil legal action against
you.
• You will have to pay back any benefits paid in error for you or anyone you apply for. You may be
liable for the full amount of any payments made, including payments made to the health and
dental plan in which the person was enrolled.
470-5170 (Rev. 3/20) Page 23 of 27
 Please keep this page for your information.
♦ You must tell us within 10 days about any changes that may affect your eligibility. This includes
changes such as:
• Mailing or living address.
• Starting or stopping a job or any other income (including lump sum payments, past due child
support, inheritances, settlements, or cash medical support).
• Someone moving in or out of your home.
• Resources or assets, including getting an inheritance.
• Changes in any other health insurance coverage (including employer-sponsored insurance,
Medicare, etc.).
• Filing an insurance claim or getting an attorney to recover bills paid by Medicaid.
To report a change:
 Call 1-877-347-5678, or
 Email [email protected], or
 Fax information to 1-877-238-0015.
♦ You must apply for and accept any other benefits and medical assistance coverage that you may be
able to get.
♦ You must give us information and give us proof when we ask for it.
♦ You must fill out review forms when you are asked to.
♦ You must cooperate with Quality Control (QC) and the Department of Inspections and Appeals
(DIA). They may contact other people or organizations to get proof of your information. By signing
the application, you give permission to release confidential information to QC or DIA.
♦ If any child applying for or receiving Medicaid has a parent living outside the home, you must
cooperate with the agency that collects medical support from an absent parent. If you think that
cooperating to get medical support will harm you or your children, you can tell us and you may not
have to cooperate.
♦ You must cooperate with the Health Insurance Premium Payment (HIPP) Program and enroll in a
health plan through your employer, if we ask you to. Visit
https://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp for explanation.
♦ You must agree to assign medical payments from a third party to the Medicaid agency for yourself
and others who are eligible for Medicaid for whom you can legally assign benefits, cooperate in
getting medical payments from third parties, give the Medicaid agency rights to pursue and get
medical support from a spouse, and give the Medicaid agency rights to pursue and get money from
other health insurance, legal settlements, or other third parties.
♦ If you get money from another person or an insurance company to pay your medical bills, you must
give that money to DHS if Medicaid paid the bill. This will be used to repay bills that Medicaid paid
for you.

This permission ends when your Medicaid stops.

470-5170 (Rev. 3/20) Page 24 of 27

 Please keep this page for your information.

Other Things You Need to Know

♦ DHS will provide documents or claim forms describing the services paid by Medicaid upon your
request or the request of an attorney acting on your behalf. Such documents may also be provided
to a third party, when necessary, to establish the extent of the DHS’s claim for reimbursement.
♦ If the State of Iowa was made the remainder beneficiary on an annuity in order for you 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 the Medicaid benefits paid.
♦ If you become enrolled in a managed health care plan, you consent to disclosure of medical
information, including any clinical mental health or substance abuse information, by your medical
providers to the PCP, other managed care providers, or to the authorized administrative body
contracted by the managed care provider to determine appropriateness, quality, or utilization of
services you received while enrolled in managed health care. A medical certification from the Iowa
Medicaid Enterprise (IME) is needed for certain medical programs. Payments on any future unpaid
medical services will be paid directly to the doctors and medical suppliers under the Medicare
Insurance Program (Medicare Part B).

We Check What You Tell Us

The information you give us may be checked by federal, state, and local officials to make sure it is true.
Things we might check include any listed person’s: social security number, job and pay, bank account
amount, immigration or alien status, and amounts received from other sources like Social Security or
unemployment. If any information you give us is not correct, we may ask you to send us proof or we may
deny or cancel your benefits.
We may check records from other states to see if any person in your household can get benefits in Iowa.
This may be because a person was disqualified from a program in another state.
As part of the eligibility determination process, we may need to retrieve your information from sources like
the Internal Revenue Service (IRS), Social Security Administration (SSA), the Department of Homeland
Security, Asset Verification System (AVS), and the state Income and Eligibility Verification System. If
something you told us is different from what the computer systems tells us, we will check to find out what is
correct. We might check your information by contacting your employer, your bank, or other people. To do
this kind of checking with your employer, bank, or other people, we will ask you first. Such information may
affect your household’s eligibility and level of benefits.
The authorization to use AVS database is in effect for as long as the Department is determining eligibility,
the individual is a Medicaid recipient, or the applicant or recipient revokes the authorization. If refusal or
revocation of the authorization is submitted, the Department may, on that basis, determine the applicant or
recipient ineligible for medical assistance.

Information About Requiring a Social Security Number

We can give help only to people who give us their social security number (SSN) or proof of application from
the Social Security office, and we will deny assistance to the people for whom you do not give us a SSN.
There are some exceptions to this. Please ask us if you have questions.
You don’t have to give us the SSN for people in your household who you do not want help for, but you can
choose to give us their SSN to speed up processing your case. We will use any SSN given to us in the
same way we use the SSN of people getting assistance. As required by Section 1137(a)(1) of the Social
Security Act and 42 CFR 435.910, we use SSNs to check income/eligibility/payments, determine a person’s
right to Medicaid, comply with federal law, and match records with other agencies.

470-5170 (Rev. 3/20) Page 25 of 27

 Please keep this page for your information.
Information About Immigration Status
You can apply for part of your household even if some members do not have lawful immigration status. For
example, parents who do not have lawful immigration status may apply for their children who are U.S.
citizens or qualified aliens. You may need to give proof of immigration status or U.S. citizenship for each
person in your household for whom you apply.
When you tell us a person applying has eligible immigration status, that person’s immigration status is
checked with the Department of Homeland Security, and this will require submission of certain information
from your application or review form. Any information we get from the Department of Homeland Security
may affect your household’s eligibility and level of benefits. We will not contact the Department of Homeland
Security about people you do not apply for. However, we may use their income and assets to see if the rest
of the household can get help.

Information About Estate Recovery

Federal law requires Iowa to have an estate recovery program. If you get Medicaid, you may be subject to
estate recovery. This means any Medicaid funds used to pay for your healthcare, including the monthly fee
paid to a Managed Care Organization (MCO), will need to be paid back from your estate after your death.
Estate recovery applies if you get Medicaid and are:
♦ Age 55 or older, or
♦ Are under age 55 and live in a medical facility and cannot reasonably be expected to return home.

For more information, call the Iowa Medicaid Estate Recovery Program at 1-877-463-7887 or go online to:
http://dhs.iowa.gov/sites/default/files/Comm123.pdf (English) or
http://dhs.iowa.gov/sites/default/files/Comm123S.pdf (Spanish).

By signing an application/review form, you give your permission for DHS to share:
♦ Your medical and other health care records with federal and state officials.
♦ The status of your Medically Needy case, the amount of your spend down, and the bills used to
meet your spend down with the provider whose bills are being used.
♦ The premium due date for Medicaid for Employed People with Disabilities (MEPD), IHAWP, DWP,
and Hawki with your medical provider.
♦ The information on your application for Home- and Community-Based Services (HCBS) waivers with
the chosen case management agency or with the Iowa Department of Public Health (IDPH) Brain
Injury Services Program manager (for HCBS brain injury waiver applications).
♦ The filing date of your application with your nursing facility.

By signing an application/review form you:

♦ Give permission for your medical provider to share your medical history with a PCP, other managed
care providers, or the authorized administrative body contracted by the managed care provider to
determine appropriateness, quality, or utilization of services you received while enrolled in managed
health care.
♦ Give permission for your medical provider to share information with IME Medical Services Unit to
certify a medical need for certain medical assistance programs or services.

470-5170 (Rev. 3/20) Page 26 of 27

 Please keep this page for your information.

Information for those Applying for WIC or Maternal and Child Health Services
♦ A declaration of income and persons in your family and living in your household is necessary to
ensure that federal and state funds are directed to those persons least able to secure services from
other sources.
♦ 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.

Information for those Applying for Presumptive Medicaid Services

♦ Your answers to some questions will not impact the presumptive Medicaid eligibility decision. These
answers are needed for DHS to make a decision for ongoing Medicaid only.
♦ If you are only applying for presumptive Medicaid, not all of your information will be checked against
data in computer systems.
♦ If you choose to have your application forwarded to DHS for an ongoing Medicaid determination,
DHS will verify income, citizenship, immigration status, identity, and other information as necessary.
♦ All presumptive Medicaid is granted on a daily basis and may be terminated on any given day,
without notice, once it is determined that the individual is no longer presumptively eligible.
♦ Appeal hearings are not granted for presumptive Medicaid.

How to Appeal

You, or the person helping you, may request an appeal hearing if you do not agree with any action taken on
your case. You can appeal in person, by phone, or in writing. To appeal in writing do one of the following:
♦ Fill out an appeal electronically at
https://secureapp.dhs.state.ia.us/dhs_titan_public/appeals/appealrequest, 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 DHS, Appeals Section, 5th Floor, 1305 E Walnut Street, Des Moines, IA
50319-0114. If you need help filing an appeal, ask your county DHS office. You can represent yourself. Or,
you can have a friend, relative, lawyer, or someone else act on your behalf.
You may contact your county DHS office about legal services. You may have to pay for these legal
services. If you do, your payment 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 (515) 243-1193.

470-5170 (Rev. 3/20) Page 27 of 27