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If the Tax ID is already enrolled and active, the following form is required: Form 470-0254, Iowa Medicaid Universal Provider Enrollment Application (Section B) – Attach a photocopy of all certifications, licenses, or accreditation documents.
Download Printable Form 470-0254 In Pdf - The Latest Version Applicable For 2024. Fill Out The Iowa Medicaid Universal Provider Enrollment Application - Iowa Online And Print It Out For Free. Form 470-0254 Is Often Used In Provider Enrollment, Iowa Department Of Health And Human Services, Health Insurance Form, Iowa Legal Forms, Legal And ...
New enrollees and those with a new Tax Identification Number (ID): Form 470-0254, Iowa Medicaid Universal Provider Enrollment Application – Attach a photo copy of all certifications, licenses, or accreditation documents (See page 9 for a complete list of required supporting documentation.)
How to Enroll. If the Tax ID that you are enrolling under is not actively enrolled in the Iowa Medicaid program the following forms are required: Provider Application Form 470-0254. Provider Agreement Form 470-2965. Electronic Fund Transfer (EFT) Authorization Form 470-4202. IRS Form W-9.
Download Iowa Medicaid Universal Provider Enrollment Application (470-0254) – Human Services (Iowa) form.
Complete IA DHS 470-0254 2019-2024 online with US Legal Forms. Easily fill out PDF blank, edit, and sign them. Save or instantly send your ready documents.
Complete IA 470-0254 2015-2024 online with US Legal Forms. Easily fill out PDF blank, edit, and sign them. Save or instantly send your ready documents.
