Merp Certification Form PDF Details

Are you looking to add additional references to your resume and demonstrate a higher level of professional competency? Professional certifications are an excellent way to do just that, such as the Merp Certification. This certification is available for individuals from many different industries, with qualifications that can be invaluable when it comes to showing potential employers your wide-range of knowledge in your respective field. In this blog post, we’ll cover what exactly the Merp Certificate entails and how one can achieve certification - including details about the necessary forms required for application.

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

Form Preview Example

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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by merp texas conclusion process shown (part 1)

2. Once your current task is complete, take the next step – fill out all of these fields - CERTIFICATION BY MERP To be, Based on the Social Security, There is a MERP Claim filed, MERP intends to file a MERP claim, initial initial, initial, This is not a dismissal of any, TEXAS MERP REPRESENTATIVE, FAX OR MAIL COMPLETED FORM TO, and HMS The Texas Medicaid Estate with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

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