DHS Forms

ADMINISTRATIVE FORMS

Authorization for Release of Information 470-0461

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

Send forms to DHS County Office

 

APPEALS & EXCEPTIONS

Appeal and Request for Hearing 470-0487

Petition for Exception to Policy 470-3888

Request for Withdrawal of Appeal 470-0492

Apelacion y Solicitud de Audiencia 470-0487(S)

Submit Online

 

BACKGROUND CHECKS

Authorization for Release of Child Abuse Information 470-3301

Authorization for Release of Dependent Adult Abuse Information 470-4531

Non-Redissemination Agreement 470-3767

Request for Child Abuse Information 470-0643

Request for Dependent Adult Abuse Registry Information 470-0612

Send forms to:
Central Abuse Registry
Iowa DHS
P.O. Box 4826
Des Moines, IA 50305
Fax to: 515-564-4112
Email: DHSAbuseRegistry@dhs.state.ia.us

 
Send forms to:
Record Check Evaluation 
Iowa DHS
P.O. Box 4826
Des Moines, IA 50305
Fax to: 515-564-4034
Email: recordcheckevals@dhs.state.ia.us
 

CASH ASSISTANCE

Employer's Statement of Earnings 470-2844

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 Ayuda Financiera 470-0462(S)

Send forms to DHS County Office

 

CHILD CARE ASSISTANCE

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

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

Solicitud de Ayuda Financiera 470-0462(S)

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, and Cash Assistance

Send forms to DHS County Office

 

CHILD SUPPORT

 

Please see the Child Support website

 

FOOD ASSISTANCE

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

Change Report 470-0321

Employer's Statement of Earnings 470-2844

Review/Recertification Eligibility Document 470-2881

Solicitud de Ayuda Financiera 470-0462(S)

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, and Cash Assistance

Send forms to DHS County Office

 

HEALTH CARE/MEDICAL ASSISTANCE/MEDICAID

Health Care Coverage and Help Paying Cost Application 470-5170

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 cobertura médica y asistencia para abonar el costo 470-5170(S)

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

Send forms to DHS County Office

 

Privacy In Health Care/HIPAA

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)

Send forms to

HIPAA Privacy Officer
IA Dept of Human Svcs
1305 E Walnut
Des Moines, IA 50319

 

Home & Community Based Services (Waivers)

Consumer Directed Attendant Care Individual Provider Enrollment - 470-3638

HCBS Consumer-Directed Attendant Care Agreement 470-3372

Send forms to your Targeted Case Manager

 

MANDATORY REPORTER FORMS

Report of Suspected Child Abuse 470-0665

Suspected Dependent Adult Abuse Report 470-2441

Send forms to 

Central Abuse Registry
IA DHS
P.O. Box 4826
Des Moines, IA 50305

 

PROVIDERS

Provider Invoice 470-0020

General Accounting Expenditure GAX

Send forms to DHS County Office

 

Child Care Assistance Providers

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

Send forms to

Central Child Care Unit
1305 E Walnut St
Des Moines, IA 50319-0114

 

Facilities

IME Provider Forms Web Site

 

In Home Health Related Care Providers

Provider Health Assessment 470-0672

Statement of Services Rendered 470-0648

Send forms to DHS County Office