Effective Date: 
1/1995

Documents

Instructions

Updated: 8/1984

PURPOSE

To inform clients of their rights and responsibilities concerning actions to deny or reduce their benefits.

PROCEDURE

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.

Form Retention

There is no retention requirement.

DETAILED INSTRUCTIONS

The form is self-explanatory.

Having trouble viewing or downloading a form?

Get Help