Fillable NOTICE TO MEDICAID ESTATE RECOVERY OF PENDING TRANSFER (Stark County Government)

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NOTICE TO MEDICAID ESTATE RECOVERY OF PENDING TRANSFER (Stark County Government)

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ODM 07408 (Rev 1/2018) Page 1 of 2
Ohio Department of Medicaid
NOTICE TO MEDICAID ESTATE RECOVERY OF PENDING TRANSFER OF
PROPERTY BY TRANSFER ON DEATH DEED
This notice is to be completed by the decedent's beneficiary, or the authorized representative of the beneficiary, and provided to the
County Recorder along with the affidavit and certified copy of the death certificate required under the Ohio Revised Code for transfer
of the deceased owner's interest. The decedent's beneficiary, or the authorized representative of the beneficiary, shall
attach a copy
of the deed
and mail it with a copy of the signed notice to:
Administrator, Medicaid Estate Recovery Program
c/o: Attorney General, Collections Enforcement
150 East Gay Street, 21
st
Floor
Columbus, Ohio 43215
The County Recorder shall ensure that this notice is
not
recorded or publicly shared. The Medicaid individual’s information and
personal data provided herein is confidential under federal and state law, including 5 USC 552a, 42 CFR 431.300 through 42 CFR
431.307, 45 CFR Parts 160 and 164, ORC Sections 5160.45 and 1347.12. Therefore, county personnel must take precautions to keep
the information secure and to keep access to the minimum necessary to accomplish Medicaid estate recovery.
Section 1 – Deceased Property Owner Name and Property Address
Name of Decedent
Property Address of Decedent
City State Zip Code
Section 2 – Information Regarding Deceased Property Owner
The deceased property owner was not a Medicaid eligible individual
The deceased property owner may have been a Medicaid eligible
individual
Social Security Number *
The deceased property owner was a Medicaid eligible individual
Social Security Number or
Medicaid Billing Number
Was the Medicaid eligible individual the deceased property owner age 55 or older at the time they received Medicaid benefits?
Yes No
Section 3 – Information Regarding Deceased Property Owner's Pre-Deceased Spouse
The deceased owner's pre-deceased spouse was not a Medicaid eligible individual
The deceased owner's pre-deceased spouse may have been a Medicaid
eligible individual
Social Security Number *
The deceased owner's pre-deceased spouse was a Medicaid eligible
individual
Social Security Number or
Medicaid Billing Number
Was the Medicaid eligible individual the deceased owner's pre-deceased spouse age 55 or older at the time they received Medicaid
benefits? Yes No
Section 4 – Information Regarding Beneficiary
If the beneficiary is a son or daughter of the decedent:
1) Is the beneficiary a child
under the age of twenty-one
(21)?
Yes No
2) Is the beneficiary age twenty-one (21) or over, AND blind or
disabled under the definition contained in 42 USC 1382c?
Y
es No
ODM 07408 (Rev 8/2017) Page 2 of 2
Section 5 – Certification of Beneficiary or Beneficiary's Representative
By my status selection and signature below, I certify that I am the beneficiary, or the beneficiary's authorized representative, of the
property listed in Section 1 of this notice and as described in the attached transfer-on-death deed. I further certify that the information
provided in this notice is complete and accurate to the best of my knowledge.
Information about Beneficiary
Name
Street Address
City, State, Zip Code
Telephone Number
Status Selection
(check one)
Beneficiary
Authorized Representative of the Beneficiary
Signature of Beneficiary OR Authorized Representative of Beneficiary
Date Signed
* Social Security Numbers:
• Are only required to be provided when the decedent or the decedent's pre-deceased spouse is believed to have received
Medicaid.
• Are required for purposes of identifying former Medicaid eligible individuals and to determine if estate recovery is warranted.
The Ohio Department of Medicaid is authorized to collect the social security numbers of Medicaid applicants and eligible
individuals, and to pursue recovery of any sums owed to Ohio Medicaid, pursuant to 42 CFR 431.302, 42 CFR 431.305, Ohio
Revised Code (ORC) Section 5162.21, and Ohio Administrative Code (OAC) Rule 5160:1-2-07.
• Will be treated as confidential and will only be used for purposes directly connected with the administration of the Medicaid
program which includes overpayment recovery and collections.
• Must be provided for any decedent or decedent's pre-deceased spouse believed to have received Medicaid ; and, if not provided,
could result in incorrect matches, as well as the potential for setting aside of the real estate transfer, upon subsequent discovery
of the Medicaid eligible individual's ownership interest in the estate.
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NOTICE TO MEDICAID ESTATE RECOVERY OF PENDING TRANSFER (Stark County Government)

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Completed 18 July 2020

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