O. Box 36450 Des Moines IA 50315 For questions contact Tel. 800 338-7909 option 2 or 515 256-4609 option 2 local Individual applicants applying to provide Consumer-Directed Attendant Care CDAC must complete and submit the following forms Form 470-2917 - Medicaid HCBS Waiver Provider Application Sections I and II Form 470-2965 - Provider Agreement Form 470-4202 - EFT IRS Form W9 Form 470-4612 - Individual CDAC Disclosure Form 470-4457 - Atypical Provider Declaration Form 470-4227 - Record Check Consent Proof of age copy of driver s license birth certificate state issued ID passport Agencies and businesses applying for waiver services must complete the following forms If you are enrolling in the Medicaid program for the first time or already enrolled but you have a new Tax Identification Number the following forms are required Form 470-5112 - Designated Contract Person Agencies adding on waiver services If you are already enrolled and active to add services to your existing enrollment th....
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 470-2917 online
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.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by reading all instructions carefully to understand the requirements for submission.
- 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.
- Provide your National Provider Identifier (NPI) if you have one; if not, leave the field blank.
- Complete the 'Legal Business Name' and 'DBA Name' fields ensuring they match your IRS W-9 form.
- Enter your contact information, including your mailing address, email address, and telephone number.
- Set the desired effective date for enrollment, noting that it cannot be retroactive.
- If you are applying as an individual, complete section II, including your Social Security Number and check the applicable waiver types.
- For agencies, proceed to section III to enter your Tax ID Number and indicate the services you are applying for.
- Review all information you've entered to ensure it's legible, complete, and accurate; any missing fields may delay processing.
- 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.
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Related content
470-2917 (Rev. 10/19). Page 1. Iowa Medicaid Universal HCBS Waiver Provider Application...
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.
This form is available in several versions. Select the version you need from the drop-down list below.