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: 8/1994


  • To obtain a client's signed statement of intent to return to his home within six months of facility admission and his need for an allowance to maintain the home during his temporary absence.
  • To obtain a signed statement from the client's practitioner certifying that the client is likely to return home within six months of facility admission.


When to Prepare

The eligibility specialist provides Form H1280 to the client when a limited nursing facility stay is indicated and the client needs an allowance to maintain his home until the client returns.

Number of Copies/Transmittal

The eligibility specialist sends the original to the client for completion and signature.

Form Retention

Keep the signed original according to the retention requirements of the case record.

Detailed Instructions

Form H1280 is completed by the client and his practitioner.