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Click ‘Get Form’ to open it in the editor.
Begin by entering your Due Date, Case Number, County Number, and Worker Name at the top of the form.
Carefully answer all questions regarding your household members. Ensure you provide accurate information about each member's age, relationship to you, and residency status.
Fill in your contact information accurately. This includes your name, home address, phone number, and email address if available.
Document your income details by listing all sources of income for each household member. Attach any proof of income to expedite processing.
Review all sections thoroughly before signing on page 5. Your signature is essential for the form's completion.
Submit the completed form via mail or in-person at your local DHS office by the specified deadline to maintain your Medicaid coverage.
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If you need further assistance, please contact the helpdesk by email at AMSHelp@hhs.gov or by phone at 1-888-ONE-DHHS (1-888-663-3447).
What is the phone number for Iowa HHS?
Requesting Public Records Please email your request to hhsopenrecords@hhs.iowa.gov. When submitting a request, please provide as many specific details as possible so that we may locate the record(s) quickly and efficiently. HHS will respond to your request within 10 business days.
How do I contact the HHS in Iowa?
Give us a call toll-free at 1-800-972-2017. Send Us a Message. Visit an HHS Office in Your Area. Work with Us.
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