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.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- 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.
To request information about an applicant/recipient's health insurance policies.
When to Prepare
The worker sends Form H1253 to insurance companies to get pertinent information about insurance policies.
Number of Copies
The worker completes an original and one copy. (Follow regional instructions.)
The worker sends the original to the appropriate insurance company and keeps the duplicate in the case record. Attach Form H0003, Authorization to Furnish Information, (signed by the applicant, recipient, or responsible person) to the original.
If the insurance company returns the form indicating prescription coverage or nursing home coverage, enter the client number in the "Comments" section and send a photocopy to:
Providers Claim Payment Services
State Office Y-948
Keep the returned original in the case record, according to regional instructions.
Inside Address — Enter the name and address of the insurance company.
Date — Self-explanatory.
Eligibility Specialist — Enter the eligibility specialist's signature.
Office Address and Telephone No. — Self-explanatory.
Applicant/recipient information — Enter insurance policy number(s), names of policy owner and insured person, social security number(s) if known, and any pertinent comments.
To Be Completed by Insurance Representative — Self-explanatory.