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To inform clients of their rights and responsibilities concerning actions to deny or reduce their benefits.
When to Prepare
Certification office staff use Form H1017-A with the computer-printed Form H1017, Notice of Benefit Denial or Reduction, to inform clients of their rights and responsibilities.
Number of Copies and Transmittal
Certification office staff attach one copy of Form H1017-A to the computer-printed Form H1017 and give or mail both forms to the client. It is not necessary to attach a copy of Form H1017-A to the case record copy of Form H1017.
There is no retention requirement.
The form is self-explanatory.