El Paso County, TX · El Paso County
Authorization and MERP Certification
This form lets an estate representative or heir authorize the Medicaid Estate Recovery Program to provide claim information for an estate pending in El Paso County Probate Court.
At a glance
- Issued by
- City of El Paso County · El Paso County, El Paso County, Texas
- Notarization
- Not required: file this form without a notary.
- Official source
- epcountytx.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
An estate representative or heir completes Section 1 to request a statement from the Medicaid Estate Recovery Program (MERP) about a claim against the deceased person’s estate. The form asks for estate and probate case details, a Social Security number, and the sender’s contact information. MERP completes Section 2 with its certification; the document says the completed form is to be presented to the Court.
Who needs it
An heir, beneficiary, or estate representative assisting with probate in the El Paso County Statutory Probate Court can complete Section 1.
How to submit it
Send the form to Texas Medicaid Recovery Program, c/o Health Management Systems, Attention: Mr. Jason W. Malmberg, Attorney, at the address or fax number printed on the form.
About notarization
This document is signed without a notary; the signer completes and signs the authorization, and the form gives no notarized or sworn attachment requirement.
How to submit this form
- 1
Download the Form
Download the Authorization and MERP Certification PDF.
- 2
Complete Section 1
Enter the estate, probate case, Social Security number, sender contact details, and printed name requested in Section 1.
- 3
Send the Form to MERP
Send the completed form to the Texas Medicaid Recovery Program address or fax number printed on the form.
- 4
Present the Returned Form
The form says MERP should return the completed certification to the sender to be presented to the Court.
Frequently asked questions
- Do I need a notary for the Authorization and MERP Certification?
- No. This form is signed without a notary, and it does not state that a related attachment must be notarized or sworn.
- Who completes the Authorization and MERP Certification?
- An heir, beneficiary, or estate representative completes Section 1. The Texas Medicaid Estate Recovery Program completes Section 2 with its certification.
- How do I submit the Authorization and MERP Certification?
- Send it to Texas Medicaid Recovery Program, c/o Health Management Systems, Attention: Mr. Jason W. Malmberg, Attorney, using the address or fax number printed on the form.