Form H1800, Receipt for Application/Medicaid Report/Verification/Report of Change

Instructions

Updated: 4/2019

Purpose

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.

PROCEDURE

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.

Transmittal

Give the original to the client or client's authorized representative. File the copy under miscellaneous in the client's case folder.

Form Retention

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.

DETAILED INSTRUCTIONS

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.