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Iowa 470-5198: Medically Exempt Attestation Form

Iowa Medicaid uses this attestation to identify Iowa Health and Wellness Plan members with enhanced medical needs, who are considered medically exempt and may get more benefits through the Medicaid State Plan. A provider checks which of six categories apply, from serious mental illness to a Social Security disability determination, and describes any daily living impairments. Iowa Medicaid Member Services reviews the referral.

Who completes it

A provider with a current NPI, such as a physician, nurse practitioner, physician assistant or licensed mental health professional, completes questions 1 to 7 and signs page 4. Department of Human Services staff and designees of a mental health region or the Department of Corrections may also submit it.

Submitting and payment

How to submit it
Submit electronically with the form's Submit Referral Form button, or send it to Iowa Medicaid Member Services, attention Medically Exempt, by mail, fax or email.
Who pays
The form sets no fee for the provider; an approved referral can give the member coverage under the Medicaid State Plan with more benefits.

Good to know

  • Every category must be marked, either with the applicable criteria or Not Applicable. Incomplete forms are not accepted.
  • Get the individual's or legal guardian's written consent before sending the information to Iowa Medicaid; the signer certifies that consent was obtained.
  • The substance use category requires a diagnosis plus either 6 or more DSM-5 criteria or ASAM medically monitored or managed intensive inpatient criteria.
  • Do not check the disability determination box if the person has only applied for, and not yet received, a Social Security disability decision.

Get the official form

Download the current version from the source each time; forms change without notice.

Medically Exempt Attestation and Referral Form

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who is medically exempt under Iowa Medicaid?

Iowa Health and Wellness Plan members with a disabling mental disorder, a chronic substance use disorder, a serious and complex medical condition, a physical disability or an intellectual or developmental disability that impairs daily living activities, or a current Social Security disability determination. Form 470-5198 documents which category applies.

Does the patient need to consent to Iowa form 470-5198?

Yes. The form states that the submitter must obtain the individual's, or legal guardian's, written consent before conveying the information to the Medicaid program, and the signature block certifies that consent was obtained along with an acknowledgment that false statements can lead to prosecution.

How do you describe daily living impairments on form 470-5198?

Box 7 asks for the activities of daily living the member needs help with and how often. Examples include bathing, bowel and bladder management, dressing, eating, functional mobility, personal hygiene and toileting. Categories 3, 4 and 5 require this description.