Form H1017-B, Transitional Medicaid

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Reader on your desktop system. Click here for instructions on accessing your form.

Effective Date
H1017-B.pdf (34.71 KB)
H1017-B.doc (121 KB)


Updated: 4-1990


To inform clients of their rights and responsibilities concerning transitional Medicaid benefits.


When to Prepare

Certification office staff provide Form H1017-B in conjunction with Form H1017 or Form H1017-A when denying the household's TANF benefits and transferring them to TP 07 or TP 37 transitional Medicaid.

Number of Copies and Transmittal

Certification office staff attach one copy of Form H1017-B to Form H1017 or Form H1017-A and give or mail both forms to the household. It is not necessary to attach a copy of Form H1017-B to the case record copy of Form H1017.

Form Retention

There is no retention requirement.


When providing Form H1017-B to the client in person, certification office staff should verbally explain the transitional Medicaid reporting requirements.