Get Ia 470-2917 2021-2025

The IA 470-2917 is an essential form for individuals and agencies applying to provide Home and Community-Based Services (HCBS) under the Medicaid program in Iowa. This guide will provide step-by-step instructions on how to complete this form online, ensuring that your application is accurate and complete.

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

1. Click ‘Get Form’ button to access the IA 470-2917 and open it in the editor.
2. Complete the Reason for Application section by checking the appropriate box that applies to your situation—whether you are a new enrollee, reactivating, changing, or adding services.
3. Fill in the National Provider Identifier (NPI) if applicable; if not, leave it blank.
4. Enter your Legal Business Name and Doing Business As (DBA) Name, ensuring it matches your IRS Form W-9.
5. Provide your mailing address, with any different billing or street address as necessary.
6. Input your contact details, including telephone numbers and email address.
7. Specify your desired effective date for enrollment, noting that it cannot be retroactive.
8. For individual applicants, proceed to Section II and enter your Social Security Number and select the relevant HCBS waiver types applicable to your application.
9. Ensure all necessary supporting documentation is attached, including proof of age, and if applying for Brain Injury Waiver services, provide additional required documentation.
10. Review the application thoroughly for completeness, sign, and date the application. Incomplete forms can cause delays in the enrollment process.
11. Once everything is filled out and correct, you can save changes, download, print, or share the form as needed.

Complete your IA 470-2917 application online today to streamline your enrollment process.