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Effective Date: 




Updated: 7/2005




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.

Detailed Instructions

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.

Detailed Instructions

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.