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Title 5: Centrally Administered Programs Page 12 Iowa Department of Human Services Employees’ Manual Chapter E: Healthy and Well Kids in Iowa (hawk-i) Application Processing Revised July 3, 2009 Application Form Application Form Legal reference: 441 IAC 86.3(2) Determine eligibility for the hawk-i program based on the filing of any of the following forms: ♦ Healthy and Well Kids in Iowa (hawk-i) Electronic Application Summary, form 470-4016, filed electronically through the hawk-i website; ♦ hawk-i Application, located in Comm. 156 or Comm. 156(S), hawk-i: Healthy and Well Kids in Iowa; ♦ A referral from Medicaid filed electronically or on the Referral to the hawk-i Program, form 470-3565; or ♦ A hawk-i renewal form. Who Must Sign the Application Legal reference: 441 IAC 86.3(4) To be considered a valid application, an application must have a legible name, address, and signature. An application or renewal is signed electronically when the person completing the form at www.hawk-i.org submits the form online. Before eligibility can be approved, all application forms must contain an original, faxed, or electronic signature and be signed by one of the following: ♦ A parent of the child in the home (when the parent is not prevented from acting on behalf of the child). ♦ The child on the child’s own behalf if the child is married or emancipated. ♦ Someone acting responsibly for an incompetent, disabled, or deceased parent. (This includes an individual or organization that has signed form 470-3356, Inability to Find a Responsible Person.) The responsible person who assisted in the completion of the application signs the application form, regardless of whether the parent also signed. ♦ A guardian or conservator of the child.