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....
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 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.
- Click ‘Get Form’ button to access the IA 470-2917 and open it in the editor.
- 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.
- Fill in the National Provider Identifier (NPI) if applicable; if not, leave it blank.
- Enter your Legal Business Name and Doing Business As (DBA) Name, ensuring it matches your IRS Form W-9.
- Provide your mailing address, with any different billing or street address as necessary.
- Input your contact details, including telephone numbers and email address.
- Specify your desired effective date for enrollment, noting that it cannot be retroactive.
- For individual applicants, proceed to Section II and enter your Social Security Number and select the relevant HCBS waiver types applicable to your application.
- Ensure all necessary supporting documentation is attached, including proof of age, and if applying for Brain Injury Waiver services, provide additional required documentation.
- Review the application thoroughly for completeness, sign, and date the application. Incomplete forms can cause delays in the enrollment process.
- 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.
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.