Nursing Home Referral Form

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:
Facility
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 below, or if not, as follows:

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

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


The resident has used or his or her representative will likely use the services of the following:

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

The nursing home named above was the representative payee.

The deceased had an account with our facility and $
remains in the account as of the date of death.

Our intentions with regard to these funds are as follows (Check one):


The resident owes a balance to our facility of $ as of (date)


Other information that may be helpful:

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