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Effective Date: 



Updated: 4/2001


To give clients information about Medicaid and to inform them of their rights and responsibilities. To provide information about the Women, Infants, and Children (WIC) Program.


When to Prepare

Certification office staff use Form H1122-A with the computer-printed Form H1122, Medicaid Action Notice, to inform clients of their rights and responsibilities and to give them information about Medicaid.

Number of Copies and Transmittal

Certification office staff attach one copy of Form H1122-A to the computer-printed Form H1122 and give or mail both forms to the client. It is not necessary to attach a copy of Form H1122-A to the case record copy of Form H1122.

Form Retention

There is no retention requirement.


This form is self-explanatory.