Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement

Effective Date: 6/2011

Availability

Word: H1200-PFS.doc

PDF: H1200-PFS.pdf

Instructions

Updated: 4/2002

Purpose

To serve as an application for and periodic review form for state facility cases (state supported living centers, state hospitals, and state centers).

Procedure

When to Prepare

For applications, the applicant/recipient or their bona fide representative completes one copy of the Form H1200-PFS and returns it to the TXMHMR Reimbursement Manager (RM) at the state facility. The RM photocopies any materials needed for their records, then forwards all original documents to the eligibility worker. The caseworker files the form in the case record for each application.

For recertification, the applicant or the bona fide representative completes one copy of the Form H1200-PFS and returns it to the caseworker. The caseworker files the form in the case record for each periodic review.

Form Retention

Form H1200-PFS is kept in the case record for three years after the case is denied.

Detailed Instructions

For HHSC Use Only: Complete when form is received by the HHSC local office.

Category — Enter "01" if applicant/recipient is 65 years of age or older. Enter "04" if applicant/recipient is less than 65 years old.

App./Client Number — If this is an application, enter the number from the NOA when the case is filed. If this is a periodic review, enter the client number.

BJN — Enter the BJN of the worker assigned to the case.

MC — Enter the mail code where the assigned worker is housed.

Date Form Received — This is the date when the local office receives the Form H1200-PFS which is completed in its entirety, as well as properly signed and dated.

Sections 1-8: For applications, all items must be completed by the applicant or the bona fide agent. For recertification, all areas in bold lines, plus other sections in which there are changes since the last periodic review, must be completed by the applicant or the bona fide agent. All items are self-explanatory.

If the client or spouse indicates he wants to register to vote, send Form 0025, Voter Registration Application, and ask if he needs help in completing the form.

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