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Get TX MERP Certification & Authorization Form 2013

Ited 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.

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