Get Medically Exempt Attestation And Referral Form - Iowa Department ... - Dhs State Ia

Filling out the Medically Exempt Attestation and Referral Form is an important step for individuals seeking Medicaid coverage under the Iowa Health and Wellness Plan. This guide will walk you through each section of the form and provide clear instructions to ensure a complete and accurate submission.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to acquire the form and open it in an editing tool.
2. Begin by entering the member's information in the designated fields, including their name, date of birth, address, and contact information.
3. Ensure that you have the individual’s (or legal guardian’s) written consent before proceeding to the next sections.
4. Complete the questions related to the categories of medically exempt conditions. For each condition, check the 'Not Applicable' box if it does not apply to the individual.
5. For individuals with disabling mental disorders, record the diagnosis where required and ensure the Global Assessment Functioning (GAF) score is noted.
6. If the individual has a chronic substance use disorder, confirm their diagnosis meets the required criteria before checking the appropriate boxes.
7. Provide detailed information regarding serious and complex medical conditions, ensuring to communicate any related impairments in the activities of daily living.
8. After filling in all relevant sections including physical, intellectual, or developmental disabilities, ensure that the description of the individual’s need for assistance with activities of daily living (ADLs) is clear.
9. In the section for provider, worker, or referring entity information, input the necessary details including the agency name, provider's National Provider Identifier (NPI), and contact information.
10. Review the completed form for accuracy and completeness before placing your signature and the date at the end of the form.
11. Utilize the ‘Submit Referral Form’ button to electronically submit your completed form, or choose alternative methods to reach the Iowa Medicaid Enterprise.

Complete the Medically Exempt Attestation and Referral Form online today to access vital Medicaid services.