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]


You are hereby notified of the death of:


Date of Death:

Date of Birth: 

Social Security Number:

The surviving spouse, if any, is:


[street address]

[city, state, zip code]

[social security number]

[date of birth]

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


            [street address]

            [city, state, zip code]

            [relationship to deceased]


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 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 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):

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

Other (please describe)

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

Other information that may be helpful:


Use the button below to submit the form. The following page will allow you to print a copy for your records.