Form H1204, Long Term Care Options

Effective Date: 3/2005

Availability

Word: H1204.doc

PDF: H1204.pdf

Instructions

Updated: 6/2002

Purpose

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.

Procedure

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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