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Click ‘Get Form’ to open the 470 2917 form in the editor.
Begin with Section I, where you will provide your National Provider Identifier (NPI) if applicable. If not, enter your Iowa Medicaid Provider number.
Fill in the provider's location information, including county name and number, telephone number, and email address. Ensure all entries are legible.
In Section II, if applying as an individual for Consumer-Directed Attendant Care (CDAC), enter your Social Security Number and check the relevant waiver types.
Sign and date the application at the end of Section II. Make sure to attach any required documentation such as proof of age.
For agencies applying under Section III, complete the Tax ID Number and indicate ownership type. Check applicable services and attach supporting documents.
Review all sections for completeness before submitting. An incomplete form may delay processing.
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Medicaid waivers help pay for standard medical and non-medical care, including personal care services, respite care, and adult day care.
What is the brain injury waiver program?
The Traumatic Brain Injury (TBI) Waiver Program offers a lifeline for individuals seeking to lead independent lives outside of institutional settings. Designed primarily for Medicaid recipients, this program provides crucial support for those with traumatic brain injuries, enabling access to community-based services.
What is the brain injury waiver in Iowa?
Brain Injury (BI) Waiver This waiver offers services for those who have been diagnosed with a brain injury due to an accident or illness. You must be at least one month of age for this waiver. These are the services you may receive if there is a need for this waiver: Adult Day Care.
How do I register as a provider for Medicaid in Iowa?
If you need help enrolling as a provider with Iowa Medicaid, visit our Frequently Asked Questions or contact Provider Enrollment team directly: Phone: 1-800-338-7909 (option 2). Or if in Des Moines, call 515-256-4609 (option 2). You can also email our team directly at imeproviderenrollment@hhs.iowa.gov.
What are the income guidelines for the elderly waiver program in Iowa?
Iowa has seven different HCBS waivers. For individuals to qualify for the waivers, they may first be eligible for Medicaid and then meet the requirements of the waiver.
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Form 470-2917 Medicaid HCBS Waiver Provider Application (Sections: I and III. If intending to contract and credential with the MCOs, complete section IV.) ▫
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