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The Iowa 470 3361 form serves as a crucial tool for the Iowa Department of Human Services (DHS) in identifying children with severe disabilities who may qualify for Supplemental Security Income (SSI) benefits. This form is part of the SSI Advocacy Project, which has enlisted MAXIMUS to streamline the process of securing these benefits for eligible children in DHS custody. Foster parents or facilities are responsible for completing the form, which requires essential information such as the child's name, date of birth, and Social Security number, as well as details about the child's placement and any diagnosed impairments. It also includes a series of questions that help determine eligibility, such as whether the child has received psychiatric services or special education. If a child meets specific criteria, the form facilitates the referral process to MAXIMUS, which will take on the task of filing the benefits application. For any inquiries regarding the referral process, MAXIMUS can be reached directly at their dedicated phone number. This form not only aids in ensuring that children receive necessary financial support but also emphasizes the importance of timely reporting of any placement changes to MAXIMUS.
Iowa 470 3361 Preview
Iowa Department of Human Services
SSI ADVOCACY PROJECT REFERRAL
The Iowa Department of Human Services has selected MAXIMUS to assist in the identification of children in DHS custody who have severe disabilities and may be eligible for Supplemental Security Income benefits. MAXIMUS will file the application for benefits for children who appear to be eligible. If you have questions about referrals, please contact MAXIMUS at
Child’s Name |
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Date of Birth |
Social Security Number |
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Foster Care Parents/Facility |
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Telephone |
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Street |
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City |
State |
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Zip Code |
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Date of Placement
Is there a court order placing the child in DHS or JCS custody?
Does child have a diagnosed mental/physical impairment?
Yes
Yes
No
No
If “no” for either of these questions, do not proceed with referral.
Following are some indicators that a child may qualify for the SSI program (check all that apply):
Child has received (within last six months) or is receiving psychiatric hospital services due to diagnosed mental impairment other than substance abuse
Child was recently discharged from or is currently in a residential facility due to diagnosed mental impairment other than substance abuse
Child receives special education services to address severe learning problems
Child receives intensive outpatient counseling and/or therapy (must check one other indicator in addition to this one)
Child has moderate to severe mental retardation (IQ 70 or less)
Child has severe developmental delays (functioning
Child receives intensive medical services and/or treatment for a physical illness
Infant (less than six months old) was born at a very low birth weight (1200 grams or less)
Is the child receiving any benefits based on a deceased, disabled or retired parent’s account?
Yes
No
Referred By
County
Telephone
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Date
DHS |
JCS |
Send referral to: MAXIMUS
Fax:
PLEASE REPORT PLACEMENT CHANGES TO MAXIMUS
Document Attributes
| Fact Name | Description |
|---|---|
| Purpose | The Iowa 470-3361 form is used to refer children in DHS custody with severe disabilities for Supplemental Security Income (SSI) benefits assistance. |
| Governing Law | This form is governed by Iowa Code § 239B, which outlines the eligibility criteria and processes for SSI benefits for children with disabilities. |
| Eligibility Assessment | MAXIMUS evaluates children based on specific indicators, such as psychiatric hospital services and special education needs. |
| Contact Information | For questions regarding referrals, individuals can contact MAXIMUS at 1-800-778-1406. |
| Referral Submission | Referrals must be sent to MAXIMUS via fax at 515-284-8854 or email at iowassi@maximus.com. |
| Placement Changes | It is essential to report any changes in placement to MAXIMUS to ensure accurate processing of referrals. |
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