Section 1, Authorization to Obtain MERP Claim Information, is to be completed by Heirs/Beneficiaries or Estate Representative.
Certification: this is not a dismissal of any other claim the State may have against this estate.
Where to send: fax or mail the completed form to HMS - The Texas Medicaid Estate Recovery Contractor, 5615 High Point Drive, Suite 100, Irving, Texas 75038.
Phone and fax: phone 1-800-641-9356, fax 214-560-3918.
| Question | Answer |
|---|---|
| Form Name | MERP Certification and Authorization Form |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 27 |
| Avg. time to fill out | 5 min |
| Edition | 09-2023 |
| Where to send | HMS - The Texas Medicaid Estate Recovery Contractor, 5615 High Point Drive, Suite 100, Irving, Texas 75038 |
| Other names | MERP Certification, MERP form, MERP Certification and Authorization Form, Texas MERP form, Texas Medicaid Estate Recovery Program Authorization and MERP Certification |
| Official source | MERP Certification and Authorization Form (Rev 09-2023), Texas Medicaid Estate Recovery Program |
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