Form H1204, Long Term Care Options
Effective Date: 3/2005
English PDF: H1204.pdf
Spanish PDF: H1204-S.pdf
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.