Application for COVID-19 Testing Coverage

This application is only used for the determination of COVID-19 Testing medical coverage for the uninsured. Do not use this application for people who are not seeking coverage for COVID-19 tests.

The health coverage you will get if you are found eligible using this application will only pay for medical tests for COVID-19. It will not help you pay for other medical costs, including doctor visits, hospital care, or prescriptions.

To apply for full medical benefits, please visit dhsservices.iowa.gov or go to Healthcare.gov. You may also call the Help Center at 1-855-889-7985. Hours of operation are Monday through Friday 8:00 am to 5:00 pm.

Instructions:
  • Complete the whole form. If you need more room to write, attach additional pages. If you are unable to complete the entire form now, you may print this application and send to the mailing address or fax number below with only a name, address, and signature provided. This will delay your eligibility determination.
  • Complete this application for one person only. A separate application must be completed for each person needing COVID-19 testing coverage.
  • Sign the application at the bottom of the last page. Your application is not complete until it is signed.
Mail or Fax your completed application if additional pages were needed to:
Member Services
P.O. Box 36510
Des Moines, IA 50315
Fax number: (515) 725-1351

CONTACT INFORMATION

One adult in the family should be the contact person. The contact person does not have to be applying for coverage.

TELL US ABOUT THE PERSON APPLYING

Answer the following questions about the person applying for COVID-19 testing coverage. Do not apply for more than one person on this application.

Your Current Health Coverage

Answer the following question about other health coverage.

YOU CAN CHOOSE AN AUTHORIZED REPRESENTATIVE

You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an "authorized representative."

By signing, you allow this person to sign your application, get official information about this application, and act for you on all future matters with this agency.

NOTE: Your signature here does not complete the application. You must check the box and electronically sign in the SIGNATURE section below to complete this application.

SIGN THIS APPLICATION

Estate Recovery

Federal law requires Iowa to have an estate recovery program. If you get Medicaid, you may be subject to estate recovery. This means any Medicaid funds used to pay for your healthcare, including the monthly fee paid to a Managed Care Organization (MCO), will need to pay back from your estate after your death. Estate recovery applies if you get Medicaid and are:

  • Age 55 or older, or
  • Are under age 55 and live in a medical facility and cannot reasonably be expected to return home.

For more information, call the Iowa Medicaid Estate Recovery Program at 1-877-463-7887 or go online to

http://dhs.iowa.gov/sites/default/files/Comm123.pdf (English) or
http://dhs.iowa.gov/sites/default/files/Comm123S.pdf (Spanish).

The person whose name is listed under the Contact Information section should sign this application. If you are an authorized representative, you may sign here as long as you have provided the information required or the applicant has provided limited verbal authorization for you to complete, sign, and submit an application on their behalf based on information that is being provided telephonically.

By signing this application, I acknowledge that I have read and agree to the contents of Rights and Responsibilities, Comm. 233.

I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

I have agreed to submit this application by electronic means. By signing this application, I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge, including information provided about the citizenship and alien status for each household member applying for benefits. I know I may be subject to penalties under federal law if I provide false or untrue information.

SIGNATURE:

I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES OF AMERICA THAT THE INFORMATION CONTAINED IN THIS STATEMENT OF FACTS IS TRUE, CORRECT, AND COMPLETE