Form H1298-A, SSI Prior Medical Coverage Notice (Denied Applicants)

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Acrobat Reader on your desktop system. Click here for instructions on opening this form.

Documents

Effective Date: 5/2009

Note: This form is computer generated. A sample is provided.

 

Instructions

Updated: 8/2001

Purpose

To notify certified Supplemental Security Income (SSI) clients of their potential eligibility for prior medical coverage.

Procedure

When to Prepare

Management Information Systems (MIS) produces Form H1298 on newly certified SSI clients who have indicated they have unpaid medical bills. Form H1298 is a computer-generated form. It contains the individual's name, address, Social Security number, HHSC client number, and the two months preceding the Medicaid Start Date.

Number of Copies

MIS produces one copy of Form H1298.

Transmittal

MIS sends Form H1298 to the SSI client. The SSI client is advised via Form H1298 to contact the local department office if he wishes to apply for prior medical coverage.

Form Retention

HHSC does not keep a copy of this form.

Detailed Instructions

Not applicable.