ADMINISTRATIVE FORMS
Authorization for Release of Information 470-0461
Authorization to Take and Use Photographs 470-0064
Authorization for the Department to Release Information 470-2115
Send forms to DHS County Office
APPEALS & EXCEPTIONS
Appeal and Request for Hearing 470-0487
Petition for Exception to Policy 470-3888
Request for Withdrawal of Appeal 470-0492
Apelacion y Solicitud de Audiencia 470-0487(S)
Submit forms online
BACKGROUND CHECKS
Authorization for Release of Child and Dependent Adult Abuse Information 470-3301
Access to Confidential Abuse Information and Non Redissemination Agreement 470-3767
Request for Child and Dependent Adult Abuse Information 470-0643
Send forms to:
Central Abuse Registry
Iowa DHS
P.O. Box 4826
Des Moines, IA 50305
Fax to: 515-564-4112
Email: DHSAbuseRegistry@dhs.state.ia.us
Record Check Evaluation 470-2310
Evaluacion de Cheque del Registro 470-2310(S)
Send forms to:
Record Check Evaluation
Iowa DHS
P.O. Box 4826
Des Moines, IA 50305
Fax to: 515-564-4034
Email: recordcheckevals@dhs.state.ia.us
CASH ASSISTANCE
Employer's Statement of Earnings 470-2844
Financial Support Application 470-0462
Request for FIP Beyond 60 Months 470-3826
Requirements of Claiming Good Cause 470-0170
Review/Recertification Eligibility Document 470-2881
Ten-Day Report of Change for FIP and Medicaid 470-0499
Informe de Cambios de Diez Dias para FIP y Medicaid 470-0499(S)
Solicitud de Ayuda Financiera 470-0462(S)
Send forms to DHS County Office
CHILD CARE ASSISTANCE
Financial Support Application 470-0462 (Multi-Program*)
Child Care Assistance Application 470-3624 (Child Care Assistance Only)
Solicitud de Ayuda Financiera 470-0462(S)
Solicitud Para Child Care Assistance 470-3624(S) (Solamente Child Care Assistance)
*Multi-program application can be used to apply for Food Assistance, Child Care Assistance, and Cash Assistance
Send forms to DHS County Office
CHILD SUPPORT
Please see the Child Support website
FOOD ASSISTANCE
Financial Support Application 470-0462 (Multi-Program*)
Employer's Statement of Earnings 470-2844
Review/Recertification Eligibility Document 470-2881
Solicitud de Ayuda Financiera 470-0462(S)
*Multi-program application can be used to apply for Food Assistance, Child Care Assistance, and Cash Assistance
Send forms to DHS County Office
HEALTH CARE/MEDICAL ASSISTANCE/MEDICAID
Health Care Coverage and Help Paying Cost Application 470-5170
Employer's Statement of Earnings 470-2844
Review/Recertification Eligibility Document 470-2881
Solicitud de cobertura médica y asistencia para abonar el costo 470-5170(S)
Send forms to DHS County Office
Privacy In Health Care/HIPAA
Authorization to Obtain or Release Health Care Information 470-3951
Request to End an Authorization 470-3949
Request to Amend Health Information 470-3950
Request for a List of Disclosures 470-3985
Request to Restrict Use or Disclosure of Health Information 470-3953
Request for Access to Health Information 470-3952
Request to Change How Health Information is Provided 470-3947
Autorizacion para Obtener o Proporcionar Informacion Sobre el Cuidado de la Salud 470-3951(S)
Send forms to
HIPAA Privacy Officer
IA Dept of Human Svcs
1305 E Walnut
Des Moines, IA 50319
Home & Community Based Services (Waivers)
Consumer Directed Attendant Care Individual Provider Enrollment - 470-3638
HCBS Consumer-Directed Attendant Care Agreement 470-3372
Send forms to your Targeted Case Manager
MANDATORY REPORTER FORMS
Report of Suspected Child Abuse 470-0665
Suspected Dependent Adult Abuse Report 470-2441
Send forms to
Central Abuse Registry
IA DHS
P.O. Box 4826
Des Moines, IA 50305
PROVIDERS
General Accounting Expenditure GAX
Send forms to DHS County Office
Child Care Assistance Providers
Payment Application for Nonregistered Providers 470-2890
Child Care Assistance Provider Agreement 470-3871
Non-Law Enforcement Record Check Request Form A 595-1489
Non-Law Enforcement Record Check Request Form A (Spanish) 595-1489
Send forms to:
Central Child Care Unit
1305 E Walnut St
Des Moines, IA 50319-0114
Facilities
In Home Health Related Care Providers
Provider Health Assessment 470-0672
Statement of Services Rendered 470-0648
Send forms to DHS County Office