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.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- 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.
INSTITUTIONAL STAFF – PART I
This form is to be used as a notification of admission, departure, readmission or death of an applicant/recipient of Supplemental Security Income and/or medical assistance only who enters or leaves approved Title XIX sections of State institutions.
Part I is to be completed in quadruplicate by the staff of the institution's claims office. Send the original and first copy to the Social Security district office or eligibility specialist, as appropriate. Send the second copy to the social services department of the institution. The third copy is to be retained by the person submitting the form. (Note: The third copy is retained in the institution's claims office in order that the medical assistance unit representative may obtain it during the next visit to the institution.)
Each Form H0090-I with Parts I and II completed must be filed in the permanent record of the institution.
1 — Enter name of the institution.
2 — Enter patient identifying data.
3 — If the person has moved into the section of the institution approved for Title XIX purposes, complete this portion. Enter only the information contained in the institution records or immediately available from other sources. If the patient moved from a non-approved section into the approved section of the institution, show the institution as prior address.
4 — If the person has moved from an approved section of the institution, complete this item.
5 — Enter date of entry, or leaving the medical or nursing section.
6 — Enter date of death of the individual.
7 — Enter name, relationship, address and telephone number of the individual's guardian or next of kin.
Eligibility Specialist – Part II
For eligibility specialist to notify the institution of the action taken on the patient's application and of the amount of income available to be applied to the vendor rate for the individual's maintenance support and treatment on those applications completed by the eligibility specialist.
As soon as initial action or a change is completed on the case, complete Part II and return the original to the claims office of the institution and retain the first copy in the applicant's/recipient's case record.
1 — Enter date referral received and applicable category.
2 — Check the appropriate box to indicate action taken. Enter effective date of action checked.
3 — If the applicant/recipient is eligible for medical assistance only and has income, enter the amount which is to be applied to the individual's needs and the amount of income available to be applied to the vendor rate for maintenance, support and treatment. Sign and date the form.