Form H1200-MBI, Application for Benefits – Medicaid Buy-In

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Effective Date
01/2022

Availability

English PDF: Form H1200-MBI

Spanish PDF: Form H1200-MBI-S

 

Instructions

English and Spanish forms can be found under the title "Form to apply for Medicaid for People with Disabilities who Work -- Medicaid Buy-In (H1200-MBI)".