Loading
Form preview picture

Get IA 470-2486 2008-2024

PROVIDER SIGNATURE 470-2486 Rev. 7/08 FOR CONSUMER-DIRECTED ATTENDANT CARE CLAIMS ONLY DATE MEMBER/GUARDIAN SIGNATURE White Iowa Medicaid Enterprise Yellow Provider MEDICAID PAYMENTS PROVIDER CERTIFICATION I hereby agree To keep such records as are necessary to disclose fully the extent of services provided to individuals under the Iowa Medicaid Program as specified in the Provider Manual and the Iowa Administrative Code. Iowa Department of Human Services CLAIM FOR TARGETED MEDICAL CARE If handwritten use blue or black ink only. Accuracy is important. This form may be downloaded at http //www. ime. state. ia*us/Providers/index. html MEMBER INFORMATION STATE ID MEMBER S NAME LAST FIRST MI PROVIDER INFORMATION NPI PROVIDER NUMBER PROVIDER ADDRESS NAME STREET CITY STATE ZIP CODE OTHER INSURANCE IF NO LEAVE BLANK TAXONOMY CODE YES SERVICES A. B. C. D. PROCEDURE CODE PLACE OF FIRST DATE LAST DATE MM/DD/YY E* F* UNITS TOTAL LINE CHARGE TOTAL CLAIM CHARGES CLIENT PARTICIPATION AMOUNT THIRD PARTY PAYMENT PLACE OF SERVICE REFER TO CODES ON BACK AUTHORIZED SIGNATURE S I CERTIFY THAT THE STATEMENTS ON THE BACK APPLY TO THIS BILL AND ARE MADE A PART OF IT. To furnish records and other information regarding any payments claimed for providing such services as the Iowa Department of Human Services its designee or Health and Human Services may request. To accept as payment in full subject to audit the amount paid by the Medicaid program for those claims submitted for payment under that program with the exception of authorized deductibles coinsurance copayment and spenddown* To comply with the provisions of the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973. I certify that The services shown on the front of this form were rendered to the consumer and were medically indicated and necessary for the health of the patient. The charges for these services are just unpaid actually due according to law and program policy and not in excess of regular fees. The information provided on the front of this claim is true accurate and complete. I understand that any false claims statements or documents or concealment of a material fact may be prosecuted under applicable Federal or State laws. Office Home Inpatient hospital Outpatient hospital ER room hospital Ambulatory surgical center Skilled nursing facility Nursing facility Custodial care facility Hospice Inpatient psychiatric facility Community mental health center Intermediate care facility/MR Residential substance abuse treatment facility Residential psychiatric treatment facility Comp inpatient rehab facility Comp outpatient rehab facility Public health clinic Other Complete claim form instructions and a printable version of this form are available on our website http //www. Iowa Department of Human Services CLAIM FOR TARGETED MEDICAL CARE If handwritten use blue or black ink only. Accuracy is important. This form may be downloaded at http //www. ime. state. ia*us/Providers/index. Accuracy is important. This form may be downloaded at http //www. ime. state. ia*us/Providers/index. html MEMBER INFORMATION STATE ID MEMBER S NAME LAST FIRST MI PROVIDER INFORMATION NPI PROVIDER NUMBER PROVIDER ADDRESS NAME STREET CITY STATE ZIP CODE OTHER INSURANCE IF NO LEAVE BLANK TAXONOMY CODE YES SERVICES A. .

How It Works

470 2486 care rating
4.9Satisfied
496 votes

Tips on how to fill out, edit and sign 4702486 online

How to fill out and sign Providers online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Finding a authorized expert, making a scheduled visit and going to the office for a private meeting makes finishing a IA 470-2486 from start to finish exhausting. US Legal Forms enables you to quickly make legally-compliant documents according to pre-constructed browser-based blanks.

Execute your docs within a few minutes using our easy step-by-step guide:

  1. Get the IA 470-2486 you require.
  2. Open it up using the online editor and begin editing.
  3. Fill in the empty areas; engaged parties names, places of residence and numbers etc.
  4. Change the blanks with exclusive fillable areas.
  5. Add the day/time and place your electronic signature.
  6. Click Done after double-examining everything.
  7. Download the ready-made document to your system or print it as a hard copy.

Easily generate a IA 470-2486 without needing to involve professionals. There are already more than 3 million people taking advantage of our unique collection of legal forms. Join us right now and get access to the top collection of web samples. Try it out yourself!

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Video instructions and help with filling out and completing form 470 2486

Experience the fastest and most correct way to fill out your Form. View the video guide and follow our recommendations on how to prepare documents on the web and without mistakes.

470 care iowa FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to IA 470-2486

  • false
  • spenddown
  • npi
  • printable
  • taxonomy
  • 1973
  • designee
  • Deductibles
  • inpatient
  • Ambulatory
  • applicable
  • Providers
  • Handwritten
  • Certification
  • custodial
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.