HomeMy WebLinkAboutFY23 Health Home Application Eff June 15 2022 1
Iowa City
Healthy Homes Application
Through Iowa City Healthy Homes, households with a member diagnosed with asthma
or COPD can receive up to $7,500 in rehabilitation assistance to address those repairs
that improve indoor air quality. For households with a child with asthma, an in-home
visit to provide tailored health education to self-manage asthma will be provided.
Healthy Homes is a partnership between the University of Iowa College of Nursing, the
City’s Housing Rehabilitation staff, and the Iowa City Free Medical Clinic.
You may be eligible for this program if a member of your household has been
diagnosed with asthma or COPD by a medical professional and your household income
does not exceed 80% of area median income by household size.
Household
Size
80% of
Median
Income
1 $61,050
2 $69,800
3 $78,500
4 $87,200
5 $94,200
6 $101,200 Effective 06/15/2022
Repairs to the home will be completed based on the in-home assessment and limited to
those improvements that improve indoor air quality. Before improvements are made to
a rental home, the property owner (landlord) must consent to the improvements and
enter an agreement with the City that requires that the rent may not increase for up to
two years and the landlord must continue to rent to the household in good faith. No
repayment is necessary if the landlord complies with the agreement. In manufactured
housing (mobile homes), the owner must have title of the home. If you own your
home, you must live in the unit for two years after rehabilitation. No repayment is
necessary if the owner complies with the agreement.
2
Iowa City Healthy Homes Application
Applicant (household member with asthma/COPD): ____________________________
Applicant birthdate: ________________________________
Address of the home: ____________________________________________________
Best contact number: ___________________________________________________
Applicant (if under 18, the parent/guardian’s) email address:
______________________________________________________________________
Interpreter needed: (Please circle) Yes No If yes, what language: ______________
If Applicant is a child (under 18), parent/primary guardian’s name:
______________________________________________________________________
Number of people in household: _______________
Annual Household Income: $_________________
General Information
Please circle:
Do you rent your home? Yes No If yes, who is your landlord: __________________
Landlord’s Address: _________________________________________________
_________________________________________________
If you live in manufactured housing (mobile home), do you have the title?
Yes No Not Applicable
Supporting Documents: The following three (3) items must be submitted with the application:
• 3 most current paystubs or fill out Employment Verification form; or fill out
Unemployment form
• Copy of most current bank statement
• If assets under $5,000, fill out & sign the Asset Certification form
(Before any rehabilitation work is completed, household must submit documentation of
household income. You don’t need to income qualify for the in-home health visit.)
3
Do you have an action plan or an understanding of how to manage your asthma/COPD?
Yes No
Have you been tested for allergies? Yes No
Do you have smokers in your home? Yes No
Do you have pets in your home? Yes No
Do you have carpet in your home? Yes No
Do you have a primary care doctor? Yes No
If yes, who is your primary care doctor? ____________________________________
Do you give permission for the University of Iowa College of Nursing to contact your
primary care doctor or the Healthy Kids School-Based Clinic? Yes No
If yes: I authorize medical information to be obtained from:
_______________________________________
Name of Doctor and/or Clinic
______________________________________________________________________
Street Address
______________________________________________________________________
City, State, Zip Code
*Records for the last five years*
Information to be released. Check all applicable.
All Information All Progress Notes Lab Reports X-ray Reports
Electrocardiogram (ECG) Allergy Records Immunization Records
Other: ______________
I understand that this authorization shall be valid for one year. I understand that I may
revoke this consent at any time, except to the extent that action has already been
taken.
Applicant’s signature: _____________________________________________________
If Applicant is under 18, parent/legal guardian’s signature:
______________________________________________________________________
Return applications to:
Neighborhood Services, 410 E. Washington St., Iowa City, IA 52240
For questions, call 319.356.5230 or email neighborhoods@iowa-city.org.