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Effective Date: 



Updated: 10/1999


  • To request information to monitor vendor payments to the nursing facility.
  • To obtain information about transfers of assets by Supplemental Security Income (SSI) clients.


When to Prepare

Medicaid eligibility specialists prepare Form H1224:

  • On receipt of the admission Form H3618, Resident Transaction Notice, for an SSI client.
  • If a client has income other than SSI.
  • For periodic case reviews.

Number of Copies

Prepare an original. The form may be legibly handwritten or typed.


Send the original to the client. The form also may be sent to the responsible party. Record the date Form H1224 was mailed on Form H0007-A, Financial Services Activity Record. Enclose a self- addressed stamped envelope. The completed copy is retained for five years after the case is closed or denied.

Form Retention

The completed copy is retained for five years after the case is closed or denied.


In the space at the top of the form, enter the client's mailing address. The form may be addressed to the client in care of the responsible party.

Worker— Sign in legible handwriting.

Date— Enter the date the form is sent.

Office Address— Enter the office address and telephone number.

The client or responsible party completes Sections 1 through 5, signs, and returns the form to the caseworker.

If the response to question 5 is "yes," refer the request to CCAD staff via e-mail or Form H2067, Case Information.