Iowa Residents

IMPORTANT NOTE: Please print this page before proceeding so you have the instructions available while filling out the forms.  Forms must be filled out completely and legibly, and have signatures on all documents.

OIG/HHS Medicare/ Medicaid Excluded list:

Medicare/Medicaid excluded list is on the Federal Government web site http://exclusions.oig.hhs.gov

Directions to complete the form

• On the web page referred to below, type your name(s) in the spaces provided.
• Include any names used in the past seven years
• Click the Search button and print the results
• Turn in the printed results to your program chair

Criminal Record Check

The forms you need to complete to request the background check and send payment are found on the Iowa Criminal History Records web site at http://www.dps.state.ia.us/DCI/supportoperations/crimhistory/obtain_records.shtml

Directions for completing the forms:

• On the web page there are links to three forms; Billing Form, Request Form and Fax-Back Form.  Download and Print the Request Form and EITHER the Billing Form for mailing a check, or Fax-Back Form for paying by credit card.
• Hints for completing the Request form:
  • Ignore the account number and complete the rest of the information. 
  • The top right side is your return address information so that the DCI can return the data to your directly. 
  • The middle box, "Request," is where you write your identification information about yourself.
  • The next box is the "Results" section that the DCI will return to you stating whether or not you have a criminal history.  This is the proof that you will provide your school.  Please note you need a separate Form A for each last name you have had.  You do not need to sign the "Waiver" box because you are requesting this information of yourself.
• Hints for completing the Billing Forms:
  • Ignore the Account Number blank and complete the rest of the page until the very bottom.
  • Put your last name on the first entry and ignore the remaining seven blanks.
• Send a stamped, self-addressed envelope and 2 pages to the DCI: Form A and your selected Billing Form.  Within approximately 2-4 weeks you will receive a response from the DCI.

Abuse Registry Check

The forms you need to complete to request the child and dependent adult abuse checks are found on the Iowa Department of Human Services web site at http://www.dhs.state.ia.us/dhs2005/dhs_homepage/how_find/forms.html

Directions for completing the forms:

• Find the section named Background Checks and then download and print the first two forms (Request for Child Abuse Information and Request for Dependent Adult Abuse Registry Information)
• Complete these two forms and mail them to the address provided on the Request for Dependent Adult Abuse Registry Information form.
• Hint for the Request for Child Abuse Information form: Section I You - the student - are the requester.
• Hint for the Request for Dependent Adult Abuse Registry Information form: Under 'position and basis for authorization' write student.

On receipt of the response from the state agencies, turn the originals in to the program chair.