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Dhs form resources upon entering a medical facility printable

Dhs form resources upon entering a medical facility printable 2026

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The document from the Iowa Department of Human Services outlines the necessary information and resources required when one spouse enters a medical facility for 30 days or more. It details how this information is used to assess Medicaid eligibility for the institutionalized spouse, while clarifying that the form is not a Medicaid application. The document includes sections for identifying information, resource listings, and instructions on appealing decisions made by the DHS regarding assistance eligibility.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Identifying Information section. Enter the name, social security number, and contact details of both spouses, including the facility name and date of first entry.
Proceed to the Resource Information section. List all resources owned by either spouse as of the first day of the month when the spouse entered the facility. Indicate 'Yes' or 'No' for each resource and provide amounts and locations where applicable.
Answer questions regarding vehicle ownership, home ownership, and any other real estate. Be sure to provide details such as estimated values and names associated with properties.
Complete the life insurance policy section by listing all relevant policies along with necessary details like policy numbers and beneficiaries.
Finally, read through the certification statement carefully before signing. Ensure that all information is accurate before submitting your form.

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