Merp Certification Form PDF Details

In navigating the complexities surrounding the legacy of a loved one who benefited from Medicaid, the Texas Medicaid Estate Recovery Program (MERP) Certification Form emerges as an essential document. This form serves as a conduit between heirs or beneficiaries and MERP, setting the stage for clear communication regarding potential claims against a deceased Medicaid recipient's estate. Initially, Section 1 of the form grants MERP the authorization to delve into the deceased's estate, assessing it for any claims that may need to be settled. It becomes the responsibility of the heirs, beneficiaries, or the estate representative to initiate this process, unable to ascertain themselves the estate's exemption or liability towards a MERP claim. Following this, MERP takes the reins in Section 2, providing a meticulous certification that addresses the presence or absence of pending claims based on the deceased's social security number and other pertinent details. It's noteworthy that the form also cautions estate representatives to consider other potential claims beyond MERP, advising consultation with the Department of Aging and Disability Services. This form, significantly revised in July 2013, crystallizes into a pivotal tool for ensuring that the estate's administration complies with Texas state requirements, smoothing the path for those navigating the aftermath of a loved one's passing.

QuestionAnswer
Form NameMerp Certification Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmerp certification, merp certificate, texas merp certification form, by merp

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TEXAS MEDICAID ESTATE RECOVERY PROGRAM (MERP)

AUTHORIZATION AND MERP CERTIFICATION

FROM: Name:

 

 

 

 

 

 

 

Company/Firm:

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

Phone Number:

 

Fax Number:

 

RE:

Deceased Owner’s Name:

 

 

 

 

Date of Death:

 

 

Deceased Owner’s Medicaid ID and/or Social Security Number:

 

Complete Property Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 1:

Authorization to Obtain MERP Claim Information

(To be Completed by Heirs/Beneficiaries or Estate Representative)

The undersigned heir/beneficiaries or Estate Representative of the Deceased Owner are unable to certify that the estate of the

Deceased Owner is exempt or is not subject to a MERP claim, and hereby authorizes MERP to complete Section 2 of this form

below and provide same or any other information related to a MERP claim against Deceased Owner to the requestor above.

By: _____________________________________________

By: ______________________________________________

(Signature)

(Signature)

Printed Name: ____________________________________

Printed Name: _____________________________________

 

 

 

 

 

 

 

SECTION 2

 

 

 

 

 

 

 

 

CERTIFICATION BY MERP

 

 

 

 

 

 

 

 

(To be Completed by MERP)

 

 

 

 

□

_____

 

Based on the Social Security Number provided, there is no pending MERP Claim against the Deceased Owner’s

 

 

initial

 

estate and the State of Texas does not intend to file a MERP Claim against the Deceased Owner’s estate.

 

 

 

 

 

 

 

 

 

 

 

 

□

_____

 

There is a MERP Claim filed against the Deceased Owner’s estate in amount of $ _____________________, as

 

 

initial

 

evidenced by the attached document.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

□

_____

 

MERP intends to file a MERP claim against the Deceased Owner’s estate in the amount of $

_________.

 

 

 

initial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This is not a dismissal of any other claim the State may have against this estate. Estate representatives of deceased Medicaid

 

recipients whose estates may include assets such as, but not limited to, qualified income trusts, other trusts, annuities, torts, or

 

private insurance policies, should also check with the DADS’ Third Party Recovery unit by calling: (512) 438-2200, #4 to determine

 

if the Department of Aging and Disability Services may have other claims on this estate.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TEXAS MERP REPRESENTATIVE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

Printed Name

 

 

 

Title

 

 

 

 

 

 

 

 

 

 

 

FAX OR MAIL COMPLETED FORM TO:

HMS – The Texas Medicaid Estate Recovery Contractor

 

 

 

 

 

 

 

 

5615 High Point Drive, Suite 100

 

 

 

Irving, Texas 75038

Phone: 1-800-641-9356 Fax: 214-560-3918

MERP Certification and Authorization Form – Revised July 2013

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