Learn about the Medicaid 1115 Transformation Waiver Renewal.
For information about COVID-19, call 2-1-1 and select Option 6.
Find a COVID-19 testing site | COVID-19 vaccine | More COVID-19 information
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 provide a record for the client of the date the
- application (TANF, SNAP or medical programs);
- Medicaid report;
- information/verification; or
- change report
is received in the local eligibility determination office.
When to Prepare
Staff complete Form H1800 when requested by the client or the client's representative when the client files the application in person or brings the Medicaid report, information/verification, or change to the local eligibility determination office.
Number of Copies
Staff complete an original and one copy.
Give the original to the client or client's authorized representative. File the copy under miscellaneous in the client's case folder.
Staff keep Form H1800 for three years from the month the form is dated for SNAP cases and three years from denial for TANF cases.
Case name — Enter the client's name.
Case number — Enter the client's case number, if applicable.
Worker — Enter the name of the caseworker assigned to the case, if applicable.
Unit — Enter the unit number the case is assigned to, if applicable.
Check the appropriate box to indicate if the client submitted an application, Medicaid report, information/verification, or change. If "other" is checked, specify.
Comments — Enter any comments.
Received by — The staff member who accepted the application, Medicaid report, information/verification, or change signs here.
Date — Enter the date the application, Medicaid report, information/verification, or change is received in the office.
Office — Enter the location of the office where the application, Medicaid report, information/ verification, or change was received.
Telephone — Enter the office telephone number.