Index Application 2019

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 the following form is required 470-2917 Rev. 01/19 Page 1 Instructions for Completing the Iowa Department of Human Services Iowa Medicaid HCBS Waiver Provider Enrollment Application Reason for Application Check one box. Iowa Medicaid HCBS Waiver Provider Application Basic Information To avoid delays in the enrollment process you should Complete all required forms listed below. If extra space is needed to answer any questions please attach any additional pages. Type or print all information so that it is legible. Do not use a pencil* If any field is not applicable please enter N/A. An incomplete form will delay the approval process. Attach all required supporting documentation* Make sure you read the instructions before completing the application* Mail completed application and all applicable attachments to Iowa Medicaid Enterprise Provider Services P. Managed Care Organization MCO Check the box next to each MCO plan that you want your enrollment application submitted to. I. General Section National Provider Identifier NPI Complete this section only if you are a current Iowa Medicaid Provider. Enter the NPI for the provider. If you do not have an NPI enter your ten-digit Iowa Medicaid Provider number beginning with X00. 2-7 Enter the location information for the provider. 8-9 County Name and Number Enter the name and number of the county of residence if out of state enter the name and number of the county served. Telephone Number Enter area code and phone number. Cellular Telephone Number Enter area code and phone number if available. Fax Enter area code and fax number if available. Email Address Enter email address if available. By providing your email address you agree that we may communicate with you by electronic mail* Desired Effective Date for Enrollment This date cannot be retroactive before the first of the month in which the application is approved* Providers cannot bill or be paid for service provided prior to the Department of Human Services DHS approval of the service enrollment.