Iowa Department of Human Services
Appeal and Request for Hearing
Who is Appeal For?
Date of Birth
Case or Account Number, if known
What are You Appealing?
Check the programs you want to appeal
Attribution of Resources
Child Care Assistance
Medicaid including waivers
State Supplementary Assistance
Tell us why you are appealing:
Do you want your benefits to continue during your appeal?
(You may have to pay them back, if you lose your appeal.)
Do you want an informal conference with your worker?
Do you need help with your appeal because you are blind or hard of hearing?
Do you want a language interpreter for your hearing?
If yes, what language?
If someone will be helping you with your appeal, write that person's name and address below.
You do not have to list someone here. (If you are appealing child abuse or adult abuse, then only an attorney can help with your appeal.)
Signature of Requester
Submit Appeal Request
Submitting your request ...
Your request submitted successfully