DHS Forms

ADMINISTRATIVE FORMS

Send forms to DHS County Office [5]

APPEALS & EXCEPTIONS

Appeal and Request for Hearing 470-0487 [6]

Petition for Exception to Policy 470-3888 [7]

Request for Withdrawal of Appeal 470-0492 [8]

Apelacion y Solicitud de Audiencia 470-0487(S) [9]

Submit Online

BACKGROUND CHECKS

Authorization for Release of Child and Dependent Adult Abuse Information 470-3301 [10]

Access to Confidential Abuse Information and Non Redissemination Agreement 470-3767 [11]

Request for Child and Dependent Adult Abuse Information 470-0643 [12]

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 [13]

Record Check Evaluation 470-2310 [14]

Evaluacion de Cheque del Registro 470-2310(S) [15]

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 [16]

CASH ASSISTANCE

Employer's Statement of Earnings 470-2844 [17]

Financial Support Application 470-0462 [18]

Report on Incapacity 470-0447 [19]

Request for FIP Beyond 60 Months 470-3826 [20]

Requirements of Claiming Good Cause 470-0170 [21]

Review/Recertification Eligibility Document 470-2881 [22]

Ten-Day Report of Change for FIP and Medicaid 470-0499 [23]

Informe de Cambios de Diez Dias para FIP y Medicaid 470-0499(S) [24]

Solicitud de Ayuda Financiera 470-0462(S) [25]

Send forms to DHS County Office [5]

CHILD CARE ASSISTANCE

Financial Support Application 470-0462 (Multi-Program*) [18]

Child Care Assistance Application 470-3624 [26] (Child Care Assistance Only)

Solicitud de Ayuda Financiera 470-0462(S) [25]

Solicitud Para Child Care Assistance 470-3624(S) [27] (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 [5]

CHILD SUPPORT

Please see the Child Support website [28]

FOOD ASSISTANCE

Financial Support Application 470-0462 (Multi-Program*) [18]

Change Report 470-0321 [29]

Employer's Statement of Earnings 470-2844 [17]

Review/Recertification Eligibility Document 470-2881 [22]

Solicitud de Ayuda Financiera 470-0462(S) [25]

Solicitud de Asistencia Alimenticia 470-0307 [30] (Solamente Asistencia Alimenticia)

Informe De Cambio 470-0322 [31]

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

Send forms to DHS County Office [5]

HEALTH CARE/MEDICAL ASSISTANCE/MEDICAID

Health Care Coverage and Help Paying Cost Application 470-5170 [32]

Health Services Application 470-2927 [33] (Medical Only)

Employer's Statement of Earnings 470-2844 [17]

Review/Recertification Eligibility Document 470-2881 [22]

Medicaid Review 470-3118(M) [34]

Solicitud de cobertura médica y asistencia para abonar el costo 470-5170(S) [35]

Solicitud de Servicios Medicos 470-2927(S) [36] (Solamente Medico)

Send forms to DHS County Office [5]

Privacy In Health Care/HIPAA

Authorization to Obtain or Release Health Care Information 470-3951 [37]

Request to End an Authorization 470-3949 [38]

Request to Amend Health Information 470-3950 [39]

Request for a List of Disclosures 470-3985 [40]

Request to Restrict Use or Disclosure of Health Information 470-3953 [41]

Request for Access to Health Information 470-3952 [42]

HIPAA Complaint 470-3981 [43]

Request to Change How Health Information is Provided 470-3947 [44]

Autorizacion para Obtener o Proporcionar Informacion Sobre el Cuidado de la Salud 470-3951(S) [45]

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 [46]

HCBS Consumer-Directed Attendant Care Agreement 470-3372 [47]

Send forms to your Targeted Case Manager

MANDATORY REPORTER FORMS

Report of Suspected Child Abuse 470-0665 [48]

Suspected Dependent Adult Abuse Report 470-2441 [49]

Send forms to

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

PROVIDERS

Provider Invoice 470-0020 [50]

General Accounting Expenditure GAX [51]

Send forms to DHS County Office [5]

Child Care Assistance Providers

Payment Application for Nonregistered Providers 470-2890 [52]

Child Care Assistance Provider Agreement 470-3871 [53]

Non-Law Enforcement Record Check Request Form A 595-1489 [54]

Non-Law Enforcement Record Check Request Form A (Spanish) 595-1489 [55]

Send forms to

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

Facilities

IME Provider Forms Web Site [56]

In Home Health Related Care Providers

Provider Health Assessment 470-0672 [57]

Statement of Services Rendered 470-0648 [58]

Send forms to DHS County Office [5]

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