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Get IA 470-5168 2020-2024

Write in any new information. Name/State ID or CIN Birth Date 470-5168 Rev. 12/15 H5168A Social Security Number Relationship to You Page 1 Gender Male/Female Resident of Iowa U.S. Citizen Yes/No Eligible Immigration Status If yes list document type and ID number. Iowa Department of Human Services Medicaid/hawk-i Review USE ONLY BLUE OR BLACK INK. IOWA DEPT. OF HUMAN SERVICES Due Date Case Number County Number Email Address Phone Number Contact Preference Worker Name It s time to review your case. Please fill out this form and send it to the address above by the due date. This information will be used to decide if you will continue to get Medicaid/hawk-i. What do I do with this form You must Fill out this form* Sign and date page 6. Send the form to us at the address above by Use extra paper if needed for your answers. What if I have questions Call your worker at. We will accept collect calls. Household Members These people get benefits with you or are counted to figure your benefits. Please fill in any missing information in the table below. Cross out any information that is not correct about members of your household. Do you have a physical mental or emotional health condition that causes limitations in activities like bathing dressing daily chores etc* or live in a medical facility or nursing home Yes No Is anyone in your household pregnant If yes who Number of expected babies Is there anyone else living in your home that is not listed on page 1 If yes fill out the information below. Has anyone moved in or out of your home Social Security Name Moved In Out Applying for Benefits If you have moved give your new address. Street Address City State and Zip Code Mailing Address if different If anyone is in the military a veteran or a spouse of a veteran list who and which they are. Was anyone in the household on foster care at age 18 or older List here I can confirm that no one applying for medical assistance on this application is incarcerated detained or jailed. If not the name of the person incarcerated is American Indian or Alaskan Native Family Members AI/AN Are you or anyone in your family an American Indian or Alaska Native AI/AN Person 1 Name first middle last Member of a federally recognized tribe If yes tribe name Has this person ever gotten a service from the Indian Health Service a tribal health program or urban Indian health program or through a referral from one of these programs If no is this person eligible to get any of these services How often Certain money received may not be counted for Medicaid or Healthy and Well Kids in Iowa hawk-i. List any income amount and how often reported on your application that includes money from these sources Per capita payments from a tribe that come from natural resources usage rights leases or royalties. Payments from natural resources farming ranching fishing leases or royalties from land designated as Indian trust land by the Department of Interior including reservations and former reservations.

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