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Get and Sign 470 0254 2015-2022 Form

Get and Sign 470 0254 2015-2022 Form

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Required supporting documentation. Mail the completed Provider Application and all applicable attachments to: Iowa Medicaid Enterprise Attn: Provider Enrollment PO Box 36450 Des Moines, Iowa 50315 Required Forms: Forms are found on the DHS webpage at: http://dhs.iowa.gov/ime/providers/forms. New enrollees and those with a new Tax Identification Number (ID): If you are enrolling in the Medicaid program for the first time or already enrolled, but have a new Tax ID, the following forms are...
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