Effective Date: 
4/2007

Documents

Instructions

Updated: 4/2007

Purpose

To advise the couple requesting a resource assessment of their spousal protected resource amount.

Procedure

When to Prepare

Complete Form H1274 when a resource assessment has been completed.

Number of Copies

Complete an original and two copies if form is computer-entered. Complete an original and three copies if completed by hand.

Transmittal

Send the original to the client. Send one copy to the spouse.

Form Retention

Keep a copy of Form H1274 in the case record for three years after the case is denied.

Detailed Instructions

Client Name — Enter the last name, comma, first name, space and middle initial. Do not exceed 22 characters. Shorten if necessary.

Date of Birth — Enter (in MMDDYY format) the individual's date of birth.

Name of Medical Care Facility or Applicable Waiver — Enter the name of the facility in which the client lives or name of waiver program.

Address of Medical Care Facility or Waiver Client —

  • Street or Box Number — Enter the street or box number of the facility.
  • City — Enter city in which facility is located.
  • State — Enter the two-letter postal service abbreviation; for example, TX.
  • ZIP code — Enter the facility's ZIP code, up to nine digits.

Date of Admission to Medical Care Facility or Waiver Application Date — Enter the date of medical care facility entry or date of waiver application in MMDDYY format.

Date Assessment is Completed — Enter (in MMDDYY format) the date the assessment is completed.

Social Security Number — Enter the individual's nine-digit Social Security account number.

Social Security Claim Number — Enter the individual's Medicare claim number.

Assessment Number — Make no entry; reserved for future use.

BJN — Enter the eight-digit budgeted job number of the person completing the assessment. If BJN is not known, enter employee number.

Mail Code — Enter four-digit mail code of the person completing the assessment.

County Code — Enter the three-digit code of the county in which the individual resides.

Invoice Number — Make no entry; reserved for future use.

Resources — Enter the appropriate resources with dollar value as of 12:01 a.m. on the first day of the month of institutionalization.

Total Countable Resources — Enter the total dollar value of all resources listed above.

Spouse Share — Enter one-half of the amount given above.

Spouse Protected Resource Amount — Enter the spousal protected resource amount.

Spouse Allowance — Enter the current maximum spousal allowance.

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