Certification Of Notice To Administrator Of Medicaid Estate Recovery Program
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1PROBATE COURT OF _____________ COUNTY, OHIO
________________, JUDGE
ESTATE OF:_____________________________________________________, DECEASED
CASE NO. _______________________
CERTIFICATION OF NOTICE TO ADMINISTRATOR OF
MEDICAID ESTATE RECOVERY PROGRAM
[R.C. 2117.061 AND 5162.21]
THIS FORM SHALL BE FILED IN THE PROBATE COURT UPON COMPLETION OF
NOTICE TO ADMINISTRATOR
The undersigned certifies that a Notice in compliance with Ohio Revised Code 2117.061 and 5162.21
was served upon the following by a method authorized by Civ.R. 73 on the __________ day of ______________,
20______:
Medicaid Estate Recovery
150 E. Gay Street, 21st Floor
Columbus, Ohio 43215
_________________________________
_______________________________
Attorney for Applicant
Person Responsible for the Estate
_________________________________
_______________________________
Typed or Printed Name
Typed or Printed Name
_________________________________
_______________________________
Address
Address
_________________________________
_______________________________
City, State, Zip Code
City, State, Zip Code
_________________________________
_______________________________
Telephone Number (include area code)
Telephone Number (include area code)
_______________
Attorney Registration No.
Print Form
FORM 7.0 – CERTIFICATION OF NOTICE TO ADMINISTRATOR OF MEDICAID ESTATE RECOVERY PROGRAM
Amended: June 1, 2014
Discard all previous versions of this form
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