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Financial Data Form

Each 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.

The Financial 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.

Be 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

The 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.

If, 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.

If 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.

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