Downloading a Form to Your Computer
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
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To notify an applicant or individual of exempt status for the Medicaid Estate Recovery Program (MERP).
When to Prepare
Prepare this form only after confirming the applicant or individual applied for one or more of the services listed on the form prior to March 1, 2005.
Number of Copies/Transmittal
The HHSC staff member completes an original for the applicant, individual or representative and a copy for the case record.
The case record copy is retained for three years after the case is closed.
Date — The HHSC staff member enters the date the form is completed and mailed to the applicant or individual.
HHSC Staff Member — Enter the name of the HHSC staff member.
Office Address and Telephone No. — Self-explanatory. Information should be typed or printed legibly.
Name and Address — Enter the applicant's or individual's name and mailing address.
Program List — Check the appropriate program(s) only after confirming the applicant or individual applied for one or more of the services listed on the form prior to March 1, 2005.