Iowa Department of Human Services

• Application Checklist for Facility Medicaid
• Health Services Application form 470-2927
• Insurance Questionnaire, form 470-2826
• Resources Upon Entering a Medical Facility, form 470-2577
• Case Activity Report, form 470-0042
• Level of Care assessment to IME, form 470-4393
• Authorization for the Department to Release Information, form 470-2115
• Application for Health Coverage, form 470-5433 or form 470-5433 in Spanish
• Information for Application Assistance for Nursing Facility Medicaid Applicants and Families
• Resource Definitions
• Income Sources Definitions

To apply for Nursing Facility Medicaid benefits please complete the Health Services Application, write NURSING FACILITY MEDICAID on top of page 3, and mail, fax or email to the DHS – Centralized Facility Eligibility Unit at:

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