Get IA 470-2486 2008-2022
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. .
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