Form H1201-A, Client Declaration or Streamline Review Worksheet

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Effective Date: 7/2005


Updated: 8/2002


To document eligibility and applied income for reviews worked under the streamline procedures in MEHB 4220, 4221 and 4222.


When to Prepare

Must have completed a minimum of one annual redetermination using Form H1200/Form H1200-A before this form can be used. See MEHM 4221/4222.

The worker completes Form H1201-A with reviews completed under the streamline or client declaration reviews.

Note: Form H1201-EZ can also be used for client declaration or streamline reviews.

Number of Copies

The worker completes an original Form H1201-A and files it in the case record behind the corresponding streamline review form on the right side of the case record. If no review form was completed because the review is done under Option 2 of streamlining methods in MEH 4222, form is filed on the right hand side of the case record.

Form Retention

Form H1201-A is kept in the case record for three years after the case is denied.

Detailed Instructions

Note: Space is provided to record any necessary clearances or verifications.

Identifying Information — Self-explanatory.

Resources — Always enter the first day of the month that resources are verified. Under total resources enter the total of the countable resources and compare to the appropriate limits. Circle the appropriate resource limit.

Income — Self-explanatory.

Eligibility Test - All Type Programs — Use this section to determine eligibility for all type programs. Circle the appropriate individual or couple income limits.

Applied Income — Enter the total monthly countable income (excluding any mandatory payroll deductions from earned income and income taxes withheld from pension or benefit checks). Do not include any VA, A&A, HB or Out of Pocket Medical exclusions. Include income of eligible spouse if a couple case.

  • Enter any exclusion if any.
  • Enter the $60 personal needs allowance ($60 for each spouse in couple cases). In ICF/MR cases (including state supported living center), include the protected earned income allowance.
  • Enter amount of Medicare Premium if not MQMB or MSLMB eligible.
  • Enter the monthly amount of any allowable incurred medical expenses including the monthly amount of premiums assignable general health insurance policies being paid by client and eligible spouse.
  • Enter amount of applied income.

Action Taken — Self-explanatory.

Code — Click on the gray vertical line and a drop down arrow will appear. Click on this arrow and codes for the action taken (sustaining and denials) will appear.

Signature and Date — Self-explanatory.