- Application Checklist for Facility Medicaid
- Application for Health Coverage and Help Paying Costs, form 470-5170
- Appendix A, Application for Health Coverage, form 470-5433 or form 470-5433 in Spanish
- Insurance Questionnaire, form 470-2826
- Resources Upon Entering a Medical Facility, form 470-2577
- Case Activity Report, form 470-0042
- Level of Care assessment to IME, form 470-4393
- Authorization for the Department to Release Information, form 470-2115
- Information for Application Assistance for Nursing Facility Medicaid Applicants and Families
- Resource Definitions
- Income Sources Definitions
To apply for Nursing Facility Medicaid benefits please complete the Application for Health Coverage, write NURSING FACILITY MEDICAID on top of page 1, and mail, fax or email to the DHS – Centralized Facility Eligibility Unit at:
Imaging Center 1
Iowa Department of Human Services
417 E Kanesville Blvd
Council Bluffs, IA 51503
FAX: 515-564-4040
Email: facilities@dhs.state.ia.us