Estate Recovery Program Referral Form

Pursuant to Iowa Code Section 249A.5(2)

To:       Director, Estate Recovery Program                                               From:   [Name]

Iowa Medicaid Enterprise                                
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]

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 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 surviving spouse listed above, or if not, as follows:

            [name]

            [street address]

            [city, state, zip code]

            [relationship to deceased]

[phone]

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

The deceased was never married.

The deceased was married, and further:

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

Funeral Home City

Attorney City Executor

Bank Account # City

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.