Get Ia 470-2917 2019

The IA 470-2917, also known as the Iowa Medicaid Universal HCBS Waiver Provider Application, is an essential document for individuals or agencies wishing to provide home and community-based services in Iowa. This guide offers step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to fill out the IA 470-2917 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by reading all instructions carefully to understand the requirements for submission.
3. Fill in the ‘Reason for Application’ section by checking the appropriate box that describes your situation, whether you are a new enrollee, reactivating your number, changing your Tax Identification Number, or adding services.
4. Provide your National Provider Identifier (NPI) if you have one; if not, leave the field blank.
5. Complete the 'Legal Business Name' and 'DBA Name' fields ensuring they match your IRS W-9 form.
6. Enter your contact information, including your mailing address, email address, and telephone number.
7. Set the desired effective date for enrollment, noting that it cannot be retroactive.
8. If you are applying as an individual, complete section II, including your Social Security Number and check the applicable waiver types.
9. For agencies, proceed to section III to enter your Tax ID Number and indicate the services you are applying for.
10. Review all information you've entered to ensure it's legible, complete, and accurate; any missing fields may delay processing.
11. Once all sections are completed, save the form, then download, print, or share it as needed before submitting it to the Iowa Medicaid Enterprise.

Complete your application online by following these steps carefully.