Page 67

Effective Date:

Approval Date: 67

Iowa Department of Human Services REFERRAL TO THE hawk-i PROGRAM Denied Application/Individual (provide Medicaid application date) Canceled Case/Individual Date: Case Name: Worker Name: Worker Number: Case Number: Worker County: Worker Phone: Case Phone: County of Residence: People in Household Social Security Number Birth Date Sex Citizen (If No, explain alien status in Comments) How Related to Case Name (spouse, parent, child, etc.) Medicaid End Date (only on canceled cases or individuals) Language Preference If child, do they have health insurance coverage? 1.

M F Yes No

English Spanish Other: Yes No 2.

M F Yes No

English Spanish Other: Yes No 3.

M F Yes No

English Spanish Other: Yes No 4.

M F Yes No

English Spanish Other: Yes No 5.

M F Yes No

English Spanish Other: Yes No 6.

M F Yes No

English Spanish Other: Yes No 7.

M F Yes No

English Spanish Other: Yes No