470 2486-2026

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4.9 out of 5

496 votes

The document is a claim form for targeted medical care provided by the Iowa Department of Human Services. It includes sections for member and provider information, details about services rendered, and certification statements regarding the accuracy and necessity of the claims. The form emphasizes compliance with Medicaid program requirements and provides instructions for submission.

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Click ‘Get Form’ to open the 470 2486 in the editor.
Begin by entering the MEMBER INFORMATION. Fill in the STATE ID and MEMBER’S NAME (LAST, FIRST, MI) accurately.
Next, provide PROVIDER INFORMATION. Enter the NPI PROVIDER NUMBER and complete the PROVIDER ADDRESS fields including STREET, CITY, STATE, and ZIP CODE.
Indicate if there is OTHER INSURANCE by selecting YES or NO. If applicable, provide details about any OTHER INSURANCE DENIED.
In the SERVICES section, list each service provided along with its PROCEDURE CODE, PLACE OF SERVICE, FIRST DATE, LAST DATE, UNITS, and TOTAL LINE CHARGE.
Complete CLIENT PARTICIPATION AMOUNT and THIRD PARTY PAYMENT sections as necessary.
Finally, ensure that both PROVIDER SIGNATURE and MEMBER/GUARDIAN SIGNATURE are included along with their respective dates.

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Versions	Form popularity	Fillable & printable
2008	4.9 Satisfied (496 Votes)

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470 2486-2026

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