MERP Authorization and MERP Certification at a glance
What it is: The MERP AUTHORIZATION AND MERP CERTIFICATION authorizes MERP to complete Section 2 when the heir/beneficiaries are unable to certify that the estate is exempt or is not subject to a MERP claim.
Who signs: Heirs/Beneficiaries or Estate Representative sign after By (Signature) and enter Printed Name.
A filled-in MERP Authorization and MERP Certification example: two heirs request MERP's certification
How to fill out MERP Authorization and MERP Certification, box by box
FROM: Name, Company/Firm, Address and Phone Number
Under FROM, enter Name, Company/Firm, Address, Phone Number and Fax #/Email.
RE: Deceased Owner's Name, Date of Death and Complete Property Address
Under RE, enter the Deceased Owner's Name, Date of Death, Deceased Owner's Medicaid ID and/or Social Security Number and Complete Property Address.
SECTION 1: Authorization to Obtain MERP Claim Information
SECTION 1: Authorization to Obtain MERP Claim Information (To be Completed by Heirs/Beneficiaries or Estate Representative).
Heirs/Beneficiaries or Estate Representative sign after By (Signature) and enter Printed Name.
SECTION 2 CERTIFICATION BY MERP
SECTION 2 CERTIFICATION BY MERP is to be completed by MERP.
Initial: Based on the Social Security Number provided, there is no pending MERP Claim against the Deceased Owner's estate and the State of Texas does not intend to file a MERP Claim against the Deceased Owner's estate.
Initial: There is a MERP Claim filed against the Deceased Owner's estate in amount of $, as evidenced by the attached document.
Initial: MERP intends to file a MERP claim against the Deceased Owner's estate in the amount of $, with a MERP Case ID.
The TEXAS MERP REPRESENTATIVE enters Signature, Date, Printed Name and Title.
Common questions about MERP Authorization and MERP Certification
Where do I file it?
Fax or mail the 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; online/email submission: submissions.hms.com/submissions/estate/MERP, merpcerts@gainwelltechnologies.com.
Sources
[1] Texas Medicaid Estate Recovery Program (MERP) Authorization and MERP Certification, Rev. 09-2023, Texas Health and Human Services (the Official source link on this page).