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Effective Date: 



Updated: 10/2007


To serve as an application and recertification form for Medicare cost-sharing programs and Medicaid community-based programs, except waiver programs. (Form H1200-EZ is an optional alternative to Form H1200 and Form H1200-A for these programs.)


The applicant/client or his bona fide representative completes one copy of Form H1200-EZ and returns it to the eligibility specialist. The eligibility specialist files the form in the case record.

Attach Form H1045 or H1045-S as the cover letter for this form.

Detailed Instructions

When Form H1200-EZ is used for reviews, the identification sections must be completed before the form is mailed to the client.

All sections are self-explanatory.

If the client or spouse indicates he wants to register to vote, send Form 0025, Voter Registration Application, and ask if he needs help in completing the form.

To evaluate specific responses, refer to the policies specified in the Medicaid Eligibility for the Elderly and People with Disabilities Handbook.

Signature/Dates — The applicant/client (or his bona fide representative) and the client's spouse (including a community spouse or ineligible spouse), if any, must complete and sign Form H1200-EZ. If the eligibility specialist assists the client, the eligibility specialist initials his entries. If the entire form is completed by HHSC staff, enter the name and title of the person completing the form.