Resources
Caregiver Agreement
Blank agreement between the person needing care and the person giving the care
DownloadCaregiver Log
Blank form used to keep track of the dates and times the caregiver is providing care
DownloadClient Participation Example
Blank form used to calculate the Applicant’s income and allowed expenses
DownloadCreditor Letter
Sample letter used to let creditors know the Applicant will not be able to pay their debt
DownloadDHS Medicaid Application
Blank form used for filing an Elderly Waiver or Title 19 Medicaid Application
DownloadDHS 10-Day Report of Change
Blank form used when there is a change with the Applicant, such as receiving an inheritance
DownloadDHS Estate Recovery Worksheet
Blank form for you to view and become familiar with what information DHS asks for
DownloadDHS Married Document List
List of documents required by DHS for the Attribution and/or Application
DownloadDHS Married Medicaid Application Example
Example of a filled-out Medicaid application form for a Married Applicant
DownloadDHS Miller Trust Document
Blank form required if the Applicant’s income is over the DHS income limit
DownloadDHS Single Person Medicaid Application Example
Example of a filled-out Medicaid application form for a Single Applicant
DownloadIntent to Return Home Letter
Example of the letter required by DHS telling them the Applicant is returning home (even though this isn’t the case)
DownloadIowa DOT Bill of Sale
Blank form for Iowa Department of Transportation bill of sale (required by DHS if anything with a registration is sold)
DownloadIowa Small Estate Affidavit
Blank form most often used with the bank of the Applicant if no one else’s name is on the bank account or other assets
DownloadReal Estate Fair Market Value Letter
Blank form for a realtor to fill out regarding the fair market value (not a market analysis) of a property, required by DHS
DownloadSocial Security Request for Changes & Information Form
Blank form to fill out before calling Social Security with the Applicant to make changes to their information
DownloadTenancy Agreement
Blank agreement for the person housing their loved one and receiving payment for the rent, utilities, and/or groceries from them
Download