Designation of Personal Representative, Form 470-3948 - Iowa ... - dhs state ia-2026

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4 out of 5

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The document is a form from the Iowa Department of Human Services that allows a client to designate a personal representative for various programs, including Medicaid and hawk-i. It requires the client's information, the name and relationship of the designated representative, and includes spaces for signatures and dates.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the 'Name of Client' at the top of the form. This identifies who is designating a personal representative.
Fill in the 'Date of Request' to indicate when you are completing this form.
Provide your 'Mailing Address' including street or P.O. Box, city, state, and zip code for correspondence.
Enter your 'Social Security Number', 'Patient Number', or 'State ID' for identification purposes.
Indicate your phone number for any follow-up communication.
Check all applicable programs such as Medicaid or hawk-i that relate to your situation.
In the section labeled 'I designate', write the name of the person you wish to appoint as your personal representative.
Select the relationship of this person to you from options like son, spouse, friend, attorney, or specify another relationship.
Sign and date the form at the bottom to validate your designation.

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2022	4.4 Satisfied (57 Votes)
2011	4 Satisfied (46 Votes)

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What is an example of a personal representative?

A personal representative is also an individual with the authority to make certain decisions for others. For example, a personal representative may make health-care-related decisions for another person.

What is a personal representative designation form?

Use this form to identify a person who can make decisions about your healthcare, request and disclose your PHI or exercise your rights on your behalf.

What is a designation of representative form?

A Designation of Authorized Representative is a formal document (form) that allows a third party, such as a friend, family member, attorney, or healthcare provider, to act on behalf of the patient/beneficiary in handling specific aspects of an insurance claim or appeal.

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How do I change my address with Medicaid in Iowa?

By phone: Call Iowa Medicaid at 1-800-338-8366. In person: Visit your nearest HHS office.

What is a personal representative designation?

The Personal Representative Is: An Adult or. An Emancipated Minor. A person with legal authority to make health care decisions on behalf of the individual. Examples: Health care power of attorney. Court appointed legal guardian.

Is a personal representative the same as a POA?

The Key Differences between a POA and a PR: Purpose: A Power of Attorney is often used for incapacity planning or to facilitate decision making during the individuals lifetime, while a PR is appointed to handle the affairs of a deceased individuals estate after their death.

Designation of Personal Representative, Form 470-3948 - Iowa ... - dhs state ia-2026

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How to use or fill out Designation of Personal Representative, Form 470-3948 - Iowa with our platform

See more Designation of Personal Representative, Form 470-3948 - Iowa ... - dhs state ia versions

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How can I generate an eSignature on my Designation of Personal Representative, Form 470-3948 - Iowa ... - dhs state ia from Google Chrome?

How to fill out Designation of Personal Representative, Form 470-3948 - Iowa ... - dhs state ia online for free in 2024?

What is an example of a personal representative?

What is a personal representative designation form?

What is a designation of representative form?

Security and compliance

People also ask

How do I change my address with Medicaid in Iowa?

What is a personal representative designation?

Is a personal representative the same as a POA?

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Designation of Personal Representative, Form 470-3948 - Iowa ... - dhs state ia-2026

Here's how it works

How to use or fill out Designation of Personal Representative, Form 470-3948 - Iowa with our platform

See more Designation of Personal Representative, Form 470-3948 - Iowa ... - dhs state ia versions

Complete this form in 5 minutes or less

Got questions?

How can I generate an eSignature on my Designation of Personal Representative, Form 470-3948 - Iowa ... - dhs state ia from Google Chrome?

How to fill out Designation of Personal Representative, Form 470-3948 - Iowa ... - dhs state ia online for free in 2024?

What is an example of a personal representative?

What is a personal representative designation form?

What is a designation of representative form?

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Security and compliance

People also ask

How do I change my address with Medicaid in Iowa?

What is a personal representative designation?

Is a personal representative the same as a POA?

Related links

Try more PDF tools