POLICY HISTORY FOR 6.1.8 DISCLOSURE fORM

Release 05-02

6.1.8 DISCLOSURE FORM

Complete an Estate Recovery Program Disclosure Form whenever a MA client:

  1. Enters or resides in a nursing home, or

  2. Enters or resides in an inpatient hospital and is required to pay a MA cost of care liability, or

  3. Becomes 55 years old.

Do this even if s/he has zero assets.

Complete the form with information about the client, his/her spouse, and his/her children that are blind, disabled, and under age 21.

Attach a legible copy of the latest property tax bill or a copy of the property deed for any homestead property reported if possible.  This may give ERP staff the property’s legal description needed to file a lien.

Request the client or his/her agent to sign the completed form.  If s/he will not sign the form:

  1. Sign the form at the “Client Signature” line.

  2. Note near your signature that you reviewed the data with the person or his/her agent.  Indicate:

  1. That s/he did or did not agree the data was accurate.

  1. The reason s/he did not sign.  

In a mail-in application situation, document if the form was not returned or was returned without a signature.

Send the completed form to the ERP.  File a copy in the case record.

Update this form unless there is a substantial change in circumstances (for example, an inheritance).

This page last updated in Release Number : 03-01

Release Date: 01/01/03

Effective Date: 01/01/03