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Division of budget and analysis 2001 mail service center raleigh nc 27699 2001 919 855 4850. The client his responsible party or his physician completes form h1245 whenever the client plans to return home once form h1245 is completed it should not be necessary to complete it again since a question about intent to return is included on form h1200 a medical assistance only mao recertification. Microsoft word form214 intent to return home clean author ms157754 created date 4 23 2013 45706 pm . Letter of intent for certification detailed instructions sample letters of intent please specify who the applicants for certification as a health care home will be as part of this letter of intent choose only one individual clinicians 1 or more clinicians or a department not an entire primary care practice . Social services personal care homes manual request to receive services chapter 34000 i intake a definitions abuse means infliction of or intent to inflict physical pain or injury on or the imprisonment of any incapacitated adult or resident of a nursing home or other residential facility