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. P....
Loading
Open form follow the instructions
Easily sign the form with your finger
Send filled & signed form or save
How to fill out the IA 470-5168 online
Filling out the IA 470-5168 form is an essential step in reviewing your Medicaid or Hawki case. This guide will provide straightforward instructions to help you complete this form online efficiently and accurately.
Follow the steps to complete your IA 470-5168 form online.
- Use the ‘Get Form’ button to access the IA 470-5168 form and open it in the online editor.
- Answer all questions on the form carefully. Ensure that you include information about every person who lives in your household and is listed on your tax return.
- Review the information specific to you and your household members. If any details are missing or have changed, make the necessary updates directly on the form.
- Complete the signature section on page 8 of the form, affirming that the information you provided is accurate.
- Once you complete the form, you can save your changes. From here, you have options to download, print, or share the completed IA 470-5168 form as needed.
Begin filling out your IA 470-5168 form online today!
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Related content
470-5168 (Rev. 1/20) H5168A. Page 1. Iowa Department of Human Services. Medicaid/Hawki...
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
If you believe that this page should be taken down, please follow our DMCA take down process here.