Michigan Estate Recovery Questionnaire

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M
D
C
H
ICHIGAN
EPARTMENT OF
OMMUNITY
EALTH
M
E
R
Q
ICHIGAN
STATE
ECOVERY
UESTIONNAIRE
Estate Recovery General Information:
Anyone who received Medicaid long-term care services after turning 55 is subject to estate recovery.
The state will only seek recovery for the total amount of services provided after the decedent turned 55 years old.
Exemptions are temporary. When an exemption no longer exists, the state will resume recovery efforts.
Instructions:
Provide all requested information and sign at the end of this form.
Provide a copy of the deceased member's death certificate. (No exceptions; a copy must accompany this
questionnaire.)
Provide copies of all additional documentation identified.
Provide an address where information may be sent regarding this form.
In order for an exemption to be granted, you must provide all requested documentation. If you have any questions about
how to complete this form, please call toll-free (877) 791-0435.
Person completing this form:
(Check one)
Name:
Address:
Personal Representative
Attorney for Estate
Telephone:
Other
Yes
No
Has there been (or do you anticipate) any third party lawsuits filed on behalf of the estate?
If YES, provide:
Case or File Number:
Date Filed:
County Court:
Yes
No
Has a petition for probate of the estate been filed?
If YES, provide:
Probate Case Number:
Date Filed:
County Probate Court:
Yes
No
If No, do you anticipate a petition for probate being filed?
Decedent's Information:
Last Name:
Date of Birth:
First Name:
Date of Death:
Middle Name:
Social Security Number:
Maiden Name:
Marital Status:
Married
Divorced
Single
Never Married
Check appropriate status
If checked married, provide a copy of the marriage license.
Yes
No
Is the Decedent's Spouse pre-deceased?
Last Name:
Date of Birth:
First Name:
Date of Death:
Middle Name:
Social Security Number:
Maiden Name:
Date of Marriage:
AUTHORITY:
MCL 400.112g
The Department of Community Health is an equal
COMPLETION: Completion is voluntary, but is required
opportunity employer, services and programs provider.
for an Estate Recovery exemption.
Page 1 of 2
MSA-0006 (06/2011)

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