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.

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Effective Date: 



Updated: 9/2010


  • To serve as a reminder of items to be cleared during an interview with a client and/or his responsible party.
  • To record information provided by the client and/or his responsible party.


When to Prepare

The Medicaid Eligibility for the Elderly and People with Disabilities (MEPD) eligibility specialist completes Form H1246 for each application during the interview with the client and/or his responsible party.

Number of Copies

The MEPD eligibility specialist completes an original Form H1246.


File Form H1246 in the case record behind the corresponding Form H1201, MAO Worksheet.

Form Retention

Form H1246 is kept in the case record for three years after the case is denied.

Detailed Instructions


Note: When asking the client or his responsible party for information, the MEPD eligibility specialist should ask open-ended questions, if possible, and avoid using leading questions.