year our agency receives Iowa Department of Public Health Grant Funds to provide
in-home nursing care to the residents of Tama County. As a recipient of those
funds we are required by State of Iowa Law to review the financial status of our
clients receiving service to determine a person's ability to pay for all or part
of the services they receive.
Data Form outlines the necessary information needed for us to meet State law
requirements. Please download and print the Financial
Data Form by clicking on the underlined Financial
Data Form links.
The form is a PDF document, you will
need Adobe Acrobat to open
the file or it will open in a new browser window.
sure to list all income and resources as they will be considered and allowances
will be made for households with more than one person. List all banks/financial
institutions where you currently have accounts so the information may be verified.
Complete and sign the form, without your signature the information you provide
cannot be processed. Please return the completed and signed form to us either
by mail or by bringing it to our office at 129 West High Street, Toledo, IA
information you provide will be applied to our agency's sliding fee scale to determine
the amount, if any, you will pay for in-home service provided. Applicants will
be required to apply for all State and Federal programs in which they are eligible
for assistance and support. Tama County Public Health & Home Care and Tama
County will be payers of last resort. If you do not wish to disclose your income,
you may sign the statement provided (first paragraph at the top) agreeing to pay
full fee for services not covered by a third party payer.
at any time, your finances change and it will affect the income/resources that
you previously reported, you are required to complete a new Financial
Data Form so those adjustments can be made accordingly.
you have any questions, please feel free to call our office at 641-484-4788 or
toll free at 1-866-484-4788 and ask for Lori Johnson, our CFO/Fiscal Administrator.