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Things You Should Know About This Form

What is the Iowa 470 4299 form?

The Iowa 470 4299 form is used to verify emergency health care services received by a client. It allows medical providers to share important information about the emergency treatment with the Iowa Department of Human Services. This ensures that individuals who need assistance can receive the necessary support for their medical needs.

Who needs to fill out this form?

This form must be completed by both the patient and the medical provider. The patient or their parent/guardian provides consent for the sharing of medical information. The medical provider then fills out details about the emergency treatment provided.

What information is required on the form?

Several key pieces of information are needed, including:

  • Client's name and SID number
  • County and worker information
  • Parent or guardian's name and Social Security number, if applicable
  • Date of birth
  • Details about the emergency medical condition
  • Provider's name, contact information, and signature

How long is the authorization valid?

The authorization for sharing medical information expires one year from the date of the patient's signature. After that, a new form will need to be completed to continue sharing information.

What happens if the emergency services are approved?

If the emergency health care services are approved, the payment will cover the date of the emergency and the following two days. This helps ensure that patients receive the necessary financial support for their urgent medical needs.

Yes, a legal representative can sign the form on behalf of the patient. The relationship to the person signing must be indicated on the form, ensuring that proper authorization is in place.

Is a witness required for the signature?

A witness to the signature is only required if specified. If a witness is needed, their information should be included on the form. Otherwise, the signature of the patient or their representative is sufficient.

Form Features

Fact Name Description
Form Purpose This form verifies emergency health care services provided to clients in Iowa.
Governing Law The form is governed by Iowa Code § 249A, which outlines the provisions for emergency medical assistance.
Client Information Clients must provide their name, SID number, county, and worker details on the form.
Consent Requirement Patients or their guardians must sign to allow medical providers to share information with the Department of Human Services.
Emergency Definition The form includes a definition of emergency conditions that warrant immediate medical attention.
Expiration of Authorization The authorization for sharing information expires one year from the date of the patient's signature.

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Key takeaways

Filling out the Iowa 470-4299 form is an important step for individuals seeking verification of emergency health care services. Below are key takeaways to consider when completing and using this form.

  • Client Information: Ensure that all personal details, including the client’s name, SID number, and date of birth, are accurately filled in.
  • Permission for Information Sharing: The form requires the client or their guardian to authorize the sharing of medical information with the Department of Human Services.
  • Signature Requirement: The patient or the parent/guardian of a minor must sign the form. This signature is essential for the release of information.
  • Expiration of Release: The authorization for information sharing expires one year from the date of signature. Keep this in mind for future needs.
  • Provider Information: Complete the section for the medical provider, including their name, phone number, and address. This information is crucial for verification purposes.
  • Medical Condition Assessment: The provider must indicate if the patient experienced a medical condition that required immediate attention. This assessment is vital for determining eligibility for services.
  • Dates of Service: Clearly specify the dates when the emergency services were provided. This helps establish the timeline of care.
  • Description of Condition: Provide a detailed explanation of the emergency medical condition. Additional pages may be attached if necessary.
  • Organ Transplant Note: If applicable, specify if the treatment was related to an organ transplant procedure that occurred on or after August 10, 1993.
  • Copy Retention: A photocopy of the signed authorization holds the same validity as the original. It is important to keep a copy in the case file for reference.

Understanding these takeaways can facilitate a smoother process in obtaining necessary emergency health care services through the Iowa Department of Human Services.

Sample - Iowa 470 4299 Form

Iowa Department of Human Services

Verification of Emergency Health Care Services

Client Name: (Print or Type)

SID #:

County & Worker #:

 

 

 

Parent/Guardian:

SS #:

Date of Birth:

 

 

 

I give permission to the medical provider or agency to share written and oral information about the emergency health care services I received to the Department of Human Services.

Signature of Patient (or parent if patient is a minor):

 

Date:

 

This release expires one year

 

 

 

 

 

from the date of signature

 

 

 

 

 

Relationship to person signing:

 

 

 

 

Self

Legal representative

Nearest living relative

Other (specify)

 

 

 

 

 

Witness to signature if required:

 

 

 

 

 

 

 

 

 

 

Provider Information

Name of the agency or person providing information:

Phone:

Fax:

 

 

 

Address:

City/State/Zip:

 

 

 

 

To be completed by the provider:

Did this person have a medical condition of sudden onset manifesting itself by acute symptoms of such severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:

•Placing the patient’s health in serious jeopardy, or

•Serious impairment of bodily function, or

•Serious dysfunction of any bodily part or organ? Were services for labor and delivery of a child?

Was this person previously treated for a condition related to this emergency?

Yes

Yes

Yes

No

No

No

Please give the dates of service and explain in detail the emergency medical condition(s) for which treatment was provided in the box below. Note: Please specify if treatment was related to an organ transplant procedure furnished on or after August 10, 1993.

If this person is approved for Emergency Health Care Services, the payment will cover the date the emergency occurred and the following two days.

Dates of Service:

Description of the emergency medical condition (attach additional pages if necessary):

Print or Type Name:

Date:

 

 

 

 

Medical Provider’s Signature:

Phone:

 

 

(

)

A photocopy of this signed authorization shall have the same force and effect as the original.

A copy of this authorization shall be kept in the case file and available if Iowa Medicaid Enterprise requests a copy.

Worker Name:

Phone Number:

Fax Number:

 

 

 

470-4299 (Rev. 6/10)

Similar forms

The Iowa 470-4299 form shares similarities with the HIPAA Authorization Form. Both documents require patient consent to disclose sensitive health information. The HIPAA Authorization Form is specifically designed to comply with federal regulations, ensuring that individuals have control over who can access their medical records. Like the Iowa form, it includes fields for patient identification, the type of information being shared, and the duration of the authorization. This emphasis on patient consent and privacy underscores the importance of safeguarding personal health information.

Another document akin to the Iowa 470-4299 is the Medical Release Form. This form also facilitates the sharing of medical information between healthcare providers and third parties. It typically requires the patient’s name, date of birth, and the specific records to be released. Similar to the Iowa form, it includes a section for the patient’s signature, indicating their permission for the release. Both forms aim to streamline communication in healthcare while protecting patient rights.

The Patient Information Release Form is another comparable document. This form allows patients to authorize the release of their medical information to designated individuals or entities. Like the Iowa 470-4299, it emphasizes the need for informed consent and includes sections for patient identification and the scope of information being shared. Both documents prioritize patient autonomy and ensure that sensitive information is only disclosed with explicit permission.

The Authorization for Release of Health Information is also similar in purpose and function. This document is used to obtain consent from patients before their health information can be shared with other parties. It requires details about the patient, the information to be disclosed, and the recipients of that information. Like the Iowa form, it highlights the importance of patient consent and serves to protect individuals' health information from unauthorized access.

The Emergency Medical Services (EMS) Patient Care Report shares some characteristics with the Iowa 470-4299 form. This report documents the care provided to a patient during an emergency situation and often requires patient consent for the sharing of information. Both documents focus on the immediate medical conditions and the urgency of care, underscoring the critical nature of health information during emergencies.

The Consent to Treat Form is another document that parallels the Iowa 470-4299. This form is used to obtain a patient’s consent before providing medical treatment. It typically includes information about the nature of the treatment and potential risks. Similar to the Iowa form, it emphasizes the importance of patient consent and understanding before any medical intervention occurs, ensuring that individuals are informed participants in their healthcare decisions.

For those looking to simplify the process of creating necessary rental documents, a Lease Agreement is essential, as it outlines terms and conditions between a landlord and a tenant. Having access to resources like PDF Templates can greatly aid in ensuring that all relevant details are comprehensively covered, helping to avoid misunderstandings and ensuring a smooth relationship between parties involved.

The Release of Information for Insurance Claims is also comparable. This document allows patients to authorize the release of their medical records to insurance companies for claims processing. Like the Iowa 470-4299, it requires patient identification and consent for the disclosure of health information. Both forms serve to facilitate communication between patients, providers, and insurers while ensuring that patient rights are respected.

Lastly, the Authorization for Use and Disclosure of Protected Health Information is similar to the Iowa 470-4299 form. This document allows healthcare providers to use and disclose a patient's health information for specific purposes, such as treatment or billing. It includes patient identification, the information to be shared, and the purpose of the disclosure. Both forms emphasize the necessity of obtaining patient consent, ensuring that individuals have control over their health information.