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

Instructions for Opening a Form

Some forms cannot be viewed in a web browser's PDF viewer and must be opened in the Adobe Reader application on your desktop system. Click here for instructions on opening this form.

Documents

Effective Date: 12/2023

English H1200-MBI (PDF)
Spanish H1200-MBI-S (PDF)

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)".