470 5170-2026

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The document is an application form from the Iowa Department of Human Services for health coverage and financial assistance with medical costs. It outlines eligibility criteria for various health insurance options, including private plans, Medicaid, and CHIP, and provides instructions on how to apply. The application can be completed online or in person, and it requires personal information about family members, income details, and existing health coverage. The document emphasizes that applying does not obligate individuals to purchase insurance and includes resources for assistance throughout the application process.

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Click ‘Get Form’ to open the 470 5170 application in the editor.
Begin by filling out your personal information in Step 1. Include your first name, last name, address, and contact details. Ensure accuracy as this will be used for communication regarding your application.
In Step 2, provide details about all family members living with you. This includes their names, relationships to you, and whether they need health coverage. Be thorough to ensure everyone who qualifies is included.
Proceed to report income information for each household member in the designated sections. Include employer details and income amounts accurately to determine eligibility for assistance.
Complete any additional sections relevant to your situation, such as health coverage from jobs or assistance needs. Review all entries for completeness before submission.
Once finished, sign the application electronically within the editor and follow the prompts to submit it directly through our platform.

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