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.
Form H1272-A is the cover letter to Form H1272.
- To notify a couple who have requested a resource assessment under spousal impoverishment provisions of the purpose of the assessment.
- To explain what information must be reported on Form H1272, Declaration of Resources, and what verifications are required to complete the assessment.
- To notify the couple of the time frames for completing the assessment.
- To notify the couple that the Texas Department of Human Services (DHS) conducts tape matches with other government agencies on persons approved for Medicaid services.
- To explain that Form H1272, Declaration of Resources, is not an application for Medicaid.
- To explain how the resource assessment is used in determining eligibility after an application for Medicaid is filed.
When to Prepare
Complete Form H1272-A when a couple who have requested a resource assessment under spousal impoverishment provisions is provided with the Form H1272, Declaration of Resources.
Number of Copies
Complete only an original of Form H1272-A.
Send the original of Form H1272-A to the couple at the time that Form H1272, Declaration of Resources, is sent.
Heading— Enter the name of the institutionalized spouse (or of the couple, for example, Mr. and Mrs. Thomas Jones) and his mailing address or that of his responsible party.
Date— Enter the date that Form H1272-A and Form H1272, Declaration of Resources, are mailed in response to a request for a resource assessment.
Eligibility Specialist— Self-explanatory.
Office Address and Telephone No.— Enter the complete office address and telephone number of the eligibility specialist.
You entered a Title-XIX certified nursing facility (NF) on— Enter the date the institutionalized spouse was admitted to the nursing facility.