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Click ‘Get Form’ to open it in the editor.
Begin by entering your case number, county number, email address, and phone number at the top of the form. Ensure all information is accurate.
In the 'Household Members' section, list all individuals receiving benefits with you. Fill in their names, birth dates, Social Security numbers, and relationships to you. Cross out any incorrect information.
Answer health-related questions regarding physical or mental conditions and pregnancy status. Provide details as necessary.
Complete the income section by detailing all sources of income for each household member. Include job details and self-employment information if applicable.
Review your entries for accuracy before signing and dating page 6 of the form. Use our platform's features to ensure everything is filled correctly.
Finally, submit the completed form by mailing it to the provided address or bringing it directly to your local office.
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Adults (Ages 19-64) Persons in householdIncome limit 1 $20,030 2 $27,185 3 $34,341 4 $41,4965 more rows
What is the maximum income to qualify for Medicaid in Iowa?
The Iowa Departments of Public Health (IDPH) and Human Services (DHS) are becoming one, single, department. IDPH and DHS will fully transition into the Iowa Department of Health and Human Services (HHS) by July 1, 2023.
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