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Effective Date: 




Updated: 4/2018



To provide a client a completed application form for prior Medicaid coverage.



When to Prepare

Complete Form H1113 when

  • unpaid medical bills are claimed; or
  • when Medicaid services are provided by the DSHS for a month before the month:
    • The advisor gives the form to the individual before or during the interview. The form may also be mailed to the individual when the interview is conducted by phone or when processing an application for a type of assistance that does not require an interview.
    • The individual or the individual's authorized representative completes and signs the form. If necessary, the advisor helps complete the form.

Number of Copies and Transmittal

The advisor gives or mails one copy of Form H1113 to the individual with a return envelope. The advisor sends Form H1113 for imaging into the state portal.

Form Retention

Keep the case record image of the Form H1113 for three years after the case is closed or denied.


Detailed Instructions

How to Prepare

  1. If the current eligibility factors for Medicaid, including income, are exactly the same as those during the prior  period and current eligibility is documented, the advisor documents this in the Case Comments.
  2. If any factor of eligibility is different and precludes eligibility for the prior period, the worker documents the r eason for ineligibility.


  • For Children's Medicaid do not
    • request more income verification for prior Medicaid coverage than what is required for ongoing eligibility (that is, at least once paycheck stub for each working family member for each prior month).
    • require Form H1113 if the family provides enough information to determine eligibility for prior months.
  • For Medicaid for Breast and Cervical Cancer (MBCC), do not require Form H1113 or verification of unpaid medical bills when processing a request for prior months.

For Agency Use Only — The advisor records the month(s) involved in the prior Medicaid application.

Items 1-4 — All questions are self-explanatory. Verification of unpaid bills is required. The worker must verify income for each month in which there are unpaid medical bills.