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.

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. 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.

If still having trouble viewing or downloading a form, click here.

Effective Date: 
7/2005

Documents


Instructions

Updated: 1/1999

Purpose

To advise the recipient or responsible relative of the need for restitution of overpayment of Medicaid benefits; the amount of overpayment; and the period in which overpayment occurred.

Procedure

When to Prepare

The Long-Term Care eligibility worker sends Form H1225 to the recipient or responsible relative when an overpayment subject to restitution is discovered. Only overpayments in the vendor rate should be sought through restitution.

Number of Copies

Complete an original and one copy of Form H1225.

Transmittal

Send the original of Form H1225 to the recipient or responsible relative. File the copy of Form H1225 in the recipient's case record under the Legal divider.

Form Retention

The case record copy is retained for three years after the case is closed or denied.

DETAILED INSTRUCTIONS

In the box at the top of the form, enter the mailing address of the recipient/responsible relative.

Date— Enter the date the form is completed.

Caseworker— Enter the caseworker's name. The signature must be legible.

Office Address and Telephone No.— Enter the office address and telephone number of the worker.

In the first paragraph, the recipient's name is entered in the space following the wording "on the behalf of."

The period in which the overpayment occurred is entered in the space following the wording "during the period."

The total overpayment is entered in the space in the first paragraph following the wording "a total overpayment of."

The worker's telephone number is entered in the blank space in the third paragraph.

Comments— The exact circumstances for the resulting overpayment must be entered to advise the recipient. This statement must clearly convey to the recipient the eligibility factor which prompted the letter.

An example of a proper entry is: "During your periodic review in April, I found you had received an increase in your teacher retirement benefit in January, which you did not report. This resulted in an underpayment of the amount you should have paid to the nursing home."