Effective Date: 



Updated: 4/2008


  • To notify the nursing facility that an application from a resident has been received.
  • To notify the nursing facility that the applicant is potentially eligible for retroactive Medicaid benefits.
  • To notify the provider agency that an applicant is requesting retroactive payment for attendant care services provided by that agency.


When to Prepare

The Medicaid eligibility (ME) specialist completes Form H1236 when an application is received.

The CCAD caseworker completes Form H1236 when an applicant for primary home care services requests payment through retroactive reimbursement procedures.

Number of Copies

The ME specialist completes an original, typed or legibly handwritten. The ME specialist notes on Form H0007-A the information about Form H1236 or prepares a copy of the form for the case record. (Follow regional instructions.)

The CCAD caseworker completes an original and two copies.


The ME specialist sends the original to the administrator of the facility.

The CCAD caseworker

  • sends the original to the provider agency,
  • sends the first copy to the ME specialist if appropriate, and
  • files one copy in the case folder.

Form Retention

If a copy is made for the case record, keep the copy according to the retention requirements of the case record.

Detailed Instructions

Heading — Enter the name and address of the facility administrator or provider agency.

Date — Self-explanatory.

Eligibility Specialist/CCAD Caseworker — Self-explanatory.

Office Address and Telephone No. — Enter the eligibility specialist's complete office address and telephone number.

Name of Resident — Enter the name of the attendant care services applicant or applicant (resident), application number and date of application in the blanks.

Resident — Check this box if the applicant is potentially eligible for retroactive Medicaid benefits and enter each of the three months that preceded the month of application.

Attendant Care Services — Check this box if an applicant is receiving attendant care services and is requesting payment using retroactive payment procedures. Include the months of services received during the retroactive period.

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