Form H1204, Long Term Care Options

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Effective Date: 7/2019


Updated: 7/2019


To serve as an informational letter for all medical assistance only (MAO) applications. State law requires that information about all long-term services and supports be provided to applicants, responsible parties, and at least one family member so they can make an informed choice about service options.


When to Prepare

Send Form H1204 with each MAO application (Form H1200 and Form H1200-EZ), along with Form H0003 and either Form H1228 or Form H1228-A. TIERS sends out Form H1204 with every MEPD Medicaid certification regardless of application series used.

Community Care Service Eligibility (CCSE) and Program Specialist Unit (PSU) staff share Form H1204 at initial application for CAS or waiver services.