Downloading a Form to Your Computer

Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.

    Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.

    If still having trouble viewing or downloading a form, click here.

Effective Date: 
3/2005

Documents


Instructions

Updated: 7/2019

Purpose

To serve as an informational letter for all medical assistance only (MAO) applications. State law requires that information about all long-term services and supports 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. TIERS sends out Form H1204 with every MEPD Medicaid certification regardless of application series used.

Community Care Service Eligibility (CCSE) and Program Specialist Unit (PSU) staff share Form H1204 at initial application for CAS or waiver services.