Form H1272-A is the cover letter to Form H1272.
- To notify a couple who have requested a resource assessment under spousal impoverishment provisions of the purpose of the assessment.
- To explain what information must be reported on Form H1272, Declaration of Resources, and what verifications are required to complete the assessment.
- To notify the couple of the time frames for completing the assessment.
- To notify the couple that the Texas Department of Human Services (DHS) conducts tape matches with other government agencies on persons approved for Medicaid services.
- To explain that Form H1272, Declaration of Resources, is not an application for Medicaid.
- To explain how the resource assessment is used in determining eligibility after an application for Medicaid is filed.
When to Prepare
Complete Form H1272-A when a couple who have requested a resource assessment under spousal impoverishment provisions is provided with the Form H1272, Declaration of Resources.
Number of Copies
Complete only an original of Form H1272-A.
Send the original of Form H1272-A to the couple at the time that Form H1272, Declaration of Resources, is sent.
Heading— Enter the name of the institutionalized spouse (or of the couple, for example, Mr. and Mrs. Thomas Jones) and his mailing address or that of his responsible party.
Date— Enter the date that Form H1272-A and Form H1272, Declaration of Resources, are mailed in response to a request for a resource assessment.
Eligibility Specialist— Self-explanatory.
Office Address and Telephone No.— Enter the complete office address and telephone number of the eligibility specialist.
You entered a Title-XIX certified nursing facility (NF) on— Enter the date the institutionalized spouse was admitted to the nursing facility.