Get Ia 470-3948 2022-2025

The IA 470-3948 form is an important document that allows individuals to designate a personal representative for various programs. This guide will provide you with clear, step-by-step instructions on how to complete the form online efficiently.

Follow the steps to successfully complete the IA 470-3948 form.

1. Click the ‘Get Form’ button to access the IA 470-3948 form and open it in your online editor.
2. Start filling out the form by entering the name of the client, ensuring accuracy in spelling and details.
3. Provide the date of the request, formatted appropriately as month/day/year.
4. Enter the mailing address, including street or P.O. Box, city, state, and zip code to ensure proper delivery.
5. Include the social security number, patient number, or state ID as required for identification purposes.
6. Indicate the phone number where the client can be contacted for any follow-up.
7. Check all applicable programs by marking Medicaid, Hawki, or any others relevant to your situation.
8. Enter the client's birth date to verify their identity.
9. Specify the facility, if applicable, where the client is receiving services.
10. In the section titled 'To be completed by client', write the name of the designated personal representative.
11. Describe the relationship of the personal representative to the client by selecting from the provided options or specifying another relationship.
12. Add the client's signature to authenticate the designation.
13. Fill in the date for the signature to indicate when the request was made.
14. Once you have completed all fields, you can save changes, download, print, or share the completed form as needed.

Complete your IA 470-3948 form online today to ensure proper representation for your needs.