Form H1204, Long Term Care Options

Effective Date: 3/2005


English PDF: H1204.pdf

Spanish PDF: H1204-S.pdf


Updated: 6/2002


To serve as an information cover letter for all medical assistance only (MAO) applications, except for state supported living centers, state hospitals, and state centers. State law requires that information about all long-term care services be provided to applicants, responsible parties, and at least one family member so they can make an informed choice about service options.


When to Prepare

Send Form H1204 with each MAO application (Form H1200 and Form H1200-EZ), along with Form H0003 and either Form H1228 or Form H1228-A.

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