TX HHS Form H1280. Statement of Residence Maintenance Needs

Form H1280, titled "Statement of Residence Maintenance Needs," is a key document used in nursing facility admissions in Texas. It allows applicants to declare their intention to return to their residence after temporary placement in a nursing facility and to specify the expenses required to maintain that residence during their absence. This form ensures both transparency and proper financial planning for the applicant’s continued residence.

Purpose of the Form

The primary purpose of Form H1280 is to document the applicant’s intent to return to their home within six months of admission to a nursing facility and to itemize the costs necessary to maintain that home. This form helps nursing facilities and state agencies verify financial responsibilities and supports planning for continuity of residence.

Who Must Complete This Form

This form must be completed by individuals entering a nursing facility who intend to return to their home within six months. It is essential for applicants seeking continued residence maintenance support or for regulatory purposes.

Section-by-Section Explanation

Applicant Information

This section collects personal details, including name, application number, and home address. Accuracy is crucial, as errors here can delay processing or affect verification of residence.

Statement of Residence Maintenance Needs

The applicant must declare the expenses necessary to maintain their residence. This includes:

• Monthly mortgage or rent
• Average monthly utilities (excluding telephone)

Applicants often make mistakes by underestimating utility costs or forgetting recurring charges. Ensure all figures are realistic and verifiable.

Attending Practitioner Certification

The attending practitioner certifies that the applicant is likely to return home within six months. This section requires the practitioner's name, address, and phone number. Omitting or providing incomplete practitioner details is a common error that can delay approval.

Typical Mistakes to Avoid

• Providing inaccurate or outdated residence or expense information
• Failing to include practitioner details
• Leaving the date fields blank
• Misstating the anticipated return timeframe

Required Attachments

Applicants may need to attach supporting documents such as:

• Mortgage or rent statements
• Utility bills
• Proof of residency

Legal and Regulatory Context

Form H1280 is governed by state regulations related to nursing facility admissions and residence maintenance support. Completion of this form is required to comply with administrative rules ensuring continuity of residence and proper financial reporting. The attending practitioner’s certification is a critical element for compliance verification.

Practical Tips for Completing the Form

• Double-check all numeric entries for accuracy
• Ensure the home address matches official records
• Obtain practitioner certification promptly
• Keep copies of all submitted documents for your records

Real-Life Examples

• An elderly applicant enters a nursing facility temporarily for recovery and lists monthly mortgage and utility expenses to ensure their home remains maintained during absence.
• An applicant applying for state-funded support uses the form to document expenses, allowing financial assistance for home maintenance.
• A family caregiver completes the form on behalf of a patient, ensuring proper certification by the attending physician.

Frequently Asked Questions (Extended FAQ)

When should I submit Form H1280?

Submit this form upon admission to a nursing facility if you intend to return home within six months.

Who is authorized to complete the form?

The applicant or a legally authorized representative may complete it, with certification by the attending practitioner.

What supporting documents are needed?

Mortgage/rent statements, utility bills, and proof of residence are commonly required.

What happens if I submit incorrect information?

Incorrect entries can delay processing or affect eligibility for residence maintenance support.

Can I update this form if circumstances change?

Yes, provide updated information and obtain new certification from your attending practitioner.

Micro-FAQ (Snippet-Friendly)

• Purpose: To document residence maintenance needs during temporary nursing facility admission.
• Who files: Applicant or authorized representative.
• Deadline: Submit upon nursing facility admission.
• Attachments: Mortgage/rent statements, utility bills, proof of residence.
• Submitted to: Nursing facility and relevant state agency.

Related Forms

• Form H1275 – Nursing Facility Admission Record
• Form H1300 – Applicant Financial Declaration
• Form H1290 – Home Care Support Request

Document Details

Form Name: Statement of Residence Maintenance Needs

Form Number: H1280

Region: Texas

Date of Revision: August 1994