Get Ia 470-4612 2018-2026

Completing the IA 470-4612 form is essential for individuals looking to provide consumer-directed attendant care services in Iowa. This guide will provide you with a user-friendly approach to filling out the form online, ensuring that you complete each necessary section correctly.

Follow the steps to accurately fill out the form.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. In the first section, enter your provider name. This should reflect the name you are commonly known by, as it appears on legal documents.
3. Provide your Social Security Number (SSN). It is crucial to enter this accurately as it is used for identification and verification purposes.
4. List all states where you have lived after the age of 18 for more than one month. Be thorough to avoid any discrepancies in your application.
5. Next, you will need to list all names and aliases that you have used throughout your life to maintain clarity and accuracy in your application history.
6. You will come to a section regarding your application status for Medicaid as an individual provider. Answer either 'Yes' or 'No' as applicable.
7. Indicate whether you or any agent or managing employee has had any final adverse actions related to Medicare, Medicaid, or the Title XX services program. Answer truthfully, as this may affect your application.
8. If applicable, detail any criminal offenses you have faced and provide complete information on the original charges and outcomes. This information helps in evaluating your eligibility.
9. Provide any instances of being named as a responsible party in founded child or dependent adult abuse cases, if applicable. Make sure to follow the instructions for detailing each event.
10. Once you are satisfied with your input, you can save changes, download, print, or share the form as needed.

Make sure to complete your IA 470-4612 application online today to ensure a smooth processing experience.