Medically Frail Attestation & Referral Form (Page 4 of 4) in pdf

Medically Frail Attestation & Referral Form Page 4

PROVIDER or REFERRING ENTITY INFORMATION

Provider / Entity: Agency or Business Name (Please Print)

Provider / Entity Name: Individual Completing this Referral (Please Print)

Provider / Entity Signature

Provider NPI #

Telephone

Provider Email

I certify that I am the individual practitioner who is signing this document and understand that any

false statement, omission, or misrepresentation may result in prosecution under state and federal

laws.

Submit Referral

Ways to reach the Iowa Medicaid Enterprise

Use the “Submit Referral Form” button above to submit this form electronically. You may also use

the methods below to contact the Iowa Medicaid Enterprise regarding this referral form.

TELEPHONE

MAIL

Iowa Medicaid Enterprise

Toll-Free

Member Services

(800) 338-8366

(Attn: Medically Exempt)

Local # in Des Moines

PO Box 36510

(515) 256-4606

Des Moines, Iowa 50315

FAX

515-725-1351

IMEMemberServices@dhs.state.ia.us

470-XXXX (10/13)

Iowa Medicaid Enterprise

100 Army Post Road

Des Moines IA 50315

Medically Frail Attestation & Referral Form Page 4