Medically exempt iowa medicaid 2026

1. Click ‘Get Form’ to open the Medically Exempt Attestation and Referral Form in the editor.
2. Begin by filling out the Member Information section. Enter the member's name, date, address, city, state/zip, telephone, cell phone, state ID, date of birth, and county of residence.
3. Proceed to the questions regarding disabling mental disorders. If applicable, check the relevant boxes indicating the member's diagnosis. If not applicable, mark 'Not Applicable' at the top.
4. Continue through each category: chronic substance use disorder, serious and complex medical conditions, physical disabilities, intellectual or developmental disabilities. Ensure you check all applicable criteria for each condition.
5. In Box 7, describe any activities of daily living (ADLs) that require assistance and specify how often help is needed.
6. Complete the Provider/Worker or Referring Entity Information section with your agency name, individual completing the referral’s name, NPI/license number, contact details, and signature.
7. Finally, click on the ‘Submit Referral Form’ button to submit electronically or choose an alternative submission method listed in the form.

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