Form Name

Send To

• Authorization for Release of Information 470-0461
• Authorization to Take and Use Photographs 470-0060

• Authorization to Take and Use Photographs of a Minor 470-0064

County Offices

Form Name

Send To

• Appeal and Request for Hearing 470-0487
• Request for Withdrawal of Appeal 470-0492
• Petition for Exception to Policy 470-3888
• Apelación y Solicitud de Audiencia 470-0487(S) 

Submit On-Line

Form Name

Send To

• Request for Child Abuse Information 470-0643
• Request for Dependent Adult Abuse Registry Information 470-0612
• Authorization for Release of Child Abuse Information 470-3301
• Authorization for Release of Dependent Adult Abuse Information 470-4531
• Non-Redissemination Agreement 470-3767
• Record Check Evaluation 470-2310
• Evaluación de Cheque del Registro 470-2310(S)

Central Abuse Registry

IA Dept of Human Svcs

1305 E Walnut

Des Moines, IA 50319

Fax to: 515-242-6884

County Offices

Form Name

Send To

• Health and Financial Support Application 470-0462
• Report on Incapacity 470-0447
• Ten-Day Report of Change for FIP and Medicaid 470-0499
• Requirements of Claiming Good Cause 470-0170
• Employer's Statement of Earnings 470-2844

• Request for FIP Beyond 60 Months 470-3826 

• Solicitud de Apoyo de Salud y Financiero 470-0466(S)
• Informe de Cambios de Diez Dias para FIP y Medicaid 470-0499(S)

County Offices

Form Name

Send To

• Health and Financial Support Application 470-0462 (Multi-Program*)
• Child Care Assistance Application 470-3624 (Child Care Assistance Only)

• Solicitud de Apoyo de Salud y Financiero 470-0466(S) (Varios Programas)

• Solicitud Para Child Care Assistance 470-3624(S)(Solamente Child Care Assistance)

*Multi-program application can be used to apply for Food Assistance, Child Care Assistance, Medical Assistance and Cash Assistance

County Offices

Form Name

Send To

• Application for Non Assistance Support Services 470-0188
• Auth for Pay by Telephone or Web Withdrawal 470-2603
• Authorization for Automatic Deposit 470-2612
• Cancel or Change Authorization for Automatic Deposit 470-3995
• Cancel or Change Authorization for Pay by Phone or Web Withdrawal 470-3996
• Cancel or Change Authorization for Automatic Withdrawal 470-3997 

• Child Support Guidelines
• Child Support Guidelines Worksheet 470-2640
• Child Support Guidelines - five or More Children
• Child Support Guidelines - Four Children
• Child Support Guidelines - Three Children
• Child Support Guidelines - Two Children

Collection Services Center

PO Box 9125

Des Moines, IA  50306-9125

Information Only

Form Name

Send To

• Health and Financial Support Application 470-0462 (Multi-Program*)
• Application for Food Assistance 470-0306 (Food Assistance Only)
• Change Report 470-0321
• Employer's Statement of Earnings 470-2844 

• Solicitud de Apoyo de Salud y Financiero 470-0466(S) (Varios Programas)
• Solicitud de Asistencia Alimenticia 470-0307 (Solamente Asistencia Alimenticia)
• Informe De Cambio 470-0322

*Multi-program application can be used to apply for Food Assistance, Child Care Assistance, Medical Assistance and Cash Assistance

County Offices

Form Name

Send To

• Health and Financial Support Application 470-0462 (Multi-Program*)
• Health Services Application 470-2927 (Medical Only)
• Medical Transportation Claim 470-0386
• Employer's Statement of Earnings 470-2844 

• Solicitud de Apoyo de Salud y Financiero 470-0466(S)  (Varios Programas)
• Solicitud de Servicios Medicos 470-2927(S) (Solamente Medico)

*Multi-program application can be used to apply for Food Assistance, Child Care Assistance, Medical Assistance and Cash Assistance

County Offices

Form Name

Send To

• hawk-i On-line Application (submit on-line)

• hawk-i Solicitud

hawk-i Program

PO Box 71336

Des Moines, IA  50325-9958

Form Name

Send To

• Authorization to Obtain or Release Health Care Information 470-3951
• Request to End an Authorization 470-3949
• Request to Amend Health Information 470-3950

• Request for a List of Disclosures 470-3985

• Request to Restrict Use or Disclosure of Health Information 470-3953
• Request for Access to Health Information 470-3952
• HIPAA Complaint 470-3981
• Request to Change How Health Information is Provided 470-3947

• Autorización para Obtener o Proporcionar Información Sobre el Cuidado de la Salud 470-3951(S)

HIPAA Privacy Officer

IA Dept of Human Svcs

1305 E Walnut

Des Moines, IA 50319

Form Name

Send To

• Application for HCBS Rent Subsidy and Household Assistance 470-3302

• Consumer Directed Attendant Care Individual Provider Enrollment - 470-3638

• HCBS Consumer-Directed Attendant Care Agreement  470-3372

Your Targeted Case Manager

Form Name

Send To

• Report of Suspected Child Abuse 470-0665

• Suspected Dependent Adult Abuse Report 470-2441

County Offices

Central Abuse Registry

IA DHS

1305 E Walnut

Des Moines, IA 50319

Form Name

Send To

• Provider Invoice 470-0020

County Offices