Form H1107, Request for Forced Change of Medical Coverage

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Effective Date
H1107.pdf (41.87 KB)
H1107.doc (126.5 KB)


Updated: 4/2005


  • To provide advisors a method to request State Office Data Integrity to change medical coverage when the worker is unable to make the change to SAVERR via Form 1000-A/B.
  • To provide State Office Data Integrity a method to respond to advisors' requests for forced changes.


When to Prepare

Complete Form H1107 requesting a forced change to medical coverage for a client(s) when Form H1000-A or Form H1000-B cannot be submitted to provide the additional coverage. Use a Form H1000-A or Form H1000-B instead of Form H1107 in the following situations:

  • Form H1000-A — the current date is within two years of the original file date and open/close code 090 can be used. For Form H1000-A entry information, see C-610 for TANF cases and MPC-700, Page 9, for Medical Program cases.
  • Form H1000-B — the requested MED is within six months of the current process month.

Prepare one form for each case. Include information about each client in the case whose coverage must be changed.

Do not use this form to request the following changes, which Data Integrity cannot process:

  1. a file date change,
  2. a TANF grant amount change, or
  3. removal of erroneous medical coverage, unless the erroneous coverage is prior to a client's date of birth or after a client's date of death.

Number of Copies

Prepare one self-carboning form for each case with clients requiring a change in medical coverage.


Send the original and first copy of the self-carboning form to Data Integrity. The second copy serves as a suspense document for reference while awaiting Data Integrity's response. Data Integrity will complete the bottom of the form and return to the worker.

Form Retention

File under Medical the original verifying coverage. Keep it for three years after the case is denied.

Detailed Instructions

From, Address, Mail Code — Enter name,address, and mail code to whom Data Integrity needs to respond.

Case No., Case Name, Cat., Type Program — Enter the case number, case name, category, and type program.

Client No., Client Name — Enter the number and name of each client with a medical coverage change. Do not include other clients in the case who do not require a change.

Requested Medical Coverage — Enter on the line corresponding to each client the dates to begin and end new medical coverage.

File Date for Requested Med. — Enter the file date applicable to the requested coverage.

Reason(s) for Request — Indicate the reason(s) for the request.

Worker Signature, Date — The requesting advisor must sign and date the form.

Worker Name, BJN, Phone # — Print the requesting advisor's name and BJN.

Data Integrity Response — Data Integrity personnel complete this section indicating the date they processed the forced coverage, and return the top page of the form to the requesting advisor.