Nursing Home Referral Form

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

To:       Estate Recovery Program                                               From:   [Name]

Iowa Medicaid                                 [Facility]
P.O. Box 36445                                                [Street Address]

            Des Moines IA 50315                            [City, State, Zip]

            Phone: 515-246-9841 / Toll-Free: 888-513-5186           [Phone]

            Fax: 515-246-0155                                           [Fax]

                                                                                   [E-mail]

            [name]

            [street address]

            [city, state, zip code]

            [relationship to deceased]

[phone]

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

The deceased was never married.

The deceased was married, and further:

The deceased was divorced at the time of death.
The deceased was preceded in death by a spouse:

Name:
Social security number:
Date of birth:
Date of death:

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 # City

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):

Remit to contact person named above

Remit to funeral home

Remit to the attorney if an estate will be opened

Hold the funds until further notice from the Estate Recovery Program