Estate Recovery Program Referral Form

Pursuant to Iowa Code Section 249A.53(2)

To: Estate Recovery Program
Iowa Medicaid
P.O. Box 13110
Des Moines, IA 50310
Phone: 515-246-9841 / Toll-Free: 877-463-7887
Fax: 515-246-0155

From:
Street Address:
City:
State: Zip:
Phone:
Email:

You are hereby notified of the death of:

Name:
Date of Death:
Date of Birth:
Social Security Number:

The surviving spouse, if any, is:

Name:
Street Address:
City: State: Zip:
Social Security Number:
Date of Birth:

The name and address of the contact person who is handling the affairs for the deceased is the surviving spouse listed above, or if not, as follows:

Name:
Street Address:
City: State: Zip:
Relationship to Deceased:
Phone:

Further information regarding the marital status of the deceased is as follows:


The deceased has used or will likely use the services of the following:

Funeral Home:
City:
Attorney:
City:
Bank:
Account Number:
City:

The deceased had an interest in real estate at the following address:

Street Address:
City: State:

The deceased had an interest in a trust.

The trustee is:
Street Address:
City: State: Zip:

The attorney is:
Street Address:
City: State: Zip:

The deceased had a burial fund with an approximate value of $

Other information that may be helpful:
0/500