To submit this form, fill out all the required fields and sign it. You can submit the form via email to merp@hhsc.state.tx.us, fax it to the appropriate number provided by your case manager, or mail it to the Texas Health and Human Services Commission at P.O. Box 13247, Austin, TX 78711-3247. For online submissions, visit the HHSC website and follow the instructions provided. It is advisable to keep a copy for your records and ensure all information is accurate before submission.

This form affects long-term care services received after the age of 55 and only if applied after March 1, 2005. These dates are essential for determining the applicability of the Medicaid Estate Recovery Program (MERP) to an individual's estate. Always check for the most current dates and guidelines with your case manager or the health plan provider.

The purpose of this form is to inform individuals applying for long-term care services paid by Medicaid about the Medicaid Estate Recovery Program (MERP). It ensures that applicants understand how the program works, when the state may request repayment from their estate, and the exceptions and hardships considered. By signing this form, individuals acknowledge receipt of this important information and confirm their understanding of the program.

• 1. Name of Applicant or Individual: Enter the full name of the applicant or individual receiving long-term care services.
• 2. Medicaid ID or Social Security No.: Provide the Medicaid ID or Social Security Number of the applicant or individual.
• 3. Printed Name - Individual: Print the name of the individual acknowledging receipt of the information.
• 4. Signature: The individual must sign the form to acknowledge receipt of the information about MERP.
• 5. Date: Enter the date when the form is signed.
• 6. Printed Name - Responsible Person: If applicable, the responsible person should print their name.
• 7. Relationship to Individual: Specify the relationship of the responsible person to the individual, if not the individual themselves.
• 8. Printed Name - Case Manager: The case manager should print their name if they provided the form.
• 9. Signature: The case manager must sign the form if they provided it.
• 10. Date: Enter the date when the case manager signs the form.

Failure to submit this form will not result in denial of Medicaid services. However, the state may still file a claim against your estate after you die, unless exemptions or hardships apply.

• State Claim: The state may file a claim against your estate after you die.
• Exemptions and Hardships: Certain exemptions and hardships can prevent the state from filing a claim, so failure to submit the form may impact these considerations.

• 1. Application for Long-term Care Services: Submit this form when applying for Medicaid-funded long-term care services to acknowledge receipt of MERP information.
• 2. Informing Heirs: Use this form to inform your estate representatives and heirs of the potential for state claims against your estate after your death.