Form H1280, Statement of Residence Maintenance Needs

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Effective Date: 8/1994


Updated: 8/1994


  • To obtain a client's signed statement of intent to return to his home within six months of facility admission and his need for an allowance to maintain the home during his temporary absence.
  • To obtain a signed statement from the client's practitioner certifying that the client is likely to return home within six months of facility admission.


When to Prepare

The eligibility specialist provides Form H1280 to the client when a limited nursing facility stay is indicated and the client needs an allowance to maintain his home until the client returns.

Number of Copies/Transmittal

The eligibility specialist sends the original to the client for completion and signature.

Form Retention

Keep the signed original according to the retention requirements of the case record.

Detailed Instructions

Form H1280 is completed by the client and his practitioner.