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Effective Date: 
8/2012

Documents

 

Instructions

Updated: 8/2012

 

Purpose

To notify an applicant or individual of exempt status for the Medicaid Estate Recovery Program (MERP).

 

Procedure

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.

Form Retention

The case record copy is retained for three years after the case is closed.

 

Detailed Instructions

Demographic Information

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.