Document Purpose

The purpose of this Notice is to protect a home from consideration by a Medicaid agency as a countable asset in determining eligibility for Medicaid benefits. This Notice is pursuant to federal rules 20 C.F.R. § 416.1212(c) and state regulations.

Who Should Use this Document

  • Medicaid long term care applicants who reside outside of their primary home or intend to reside outside their primary home in the foreseeable future.
  • Medicaid long term care beneficiaries who reside outside of their primary home who have had a change of residents who do reside in the primary home (such as a spouse or other relative).


  • Certain states require a physician’s statement to accompany this Form.  Read about them here.
  • The following states (AL, AK, DE, HI, KS, MD,NC, OK, SC, SD, TX, WY) have their own forms for Intent to Return.  Read about them here.

For health reasons, I, ____________________________________________ (Full Name) am currently residing or intend to reside outside my primary home located at ____________________________ (Street Address) in ___________________ (City) ________ (State) ________ (Zip) .
My temporary residence is at ____________________________ (Street Address)   in ___________________ (City)   ________ (State)   ________ (Zip) . However, my primary residence is still my home. When my health permits, I intend to return to reside in my home.
Accordingly, the undersigned declares she/he swears or affirms that she/he intends to return to her home.
Name:          _________________________
Date:            _________________________
Signature:    _________________________
  • Agent under Power of Attorney
  • Declarant (Applicant / Beneficiary)
  • Spouse of Declarant (Spouse of Applicant / Beneficiary)    

Should you need additional information regarding the validity, interpretation, or the administration of this Notice, you should contact the following person at:

Name:         _________________________
Phone:        _________________________
Address:     _________________________             (Insert name, address and telephone number of contact person)
This organization is not responsible for any errors or omissions, or for the results obtained from the use of this information. All information in this document is provided "as is", with no guarantee of completeness, accuracy, timeliness or of the results obtained from the use of this information.