Who completes each section of the form?

Heirs, beneficiaries, or an estate representative complete Section 1. Section 2 is completed by MERP.

Do I need to attach anything?

If reporting an existing MERP claim amount, the form says to provide the attached document as evidence of that claim.

No notary required

Authorization and MERP Certification Form

Heirs, beneficiaries, or an estate representative use this form to authorize the Texas Medicaid Estate Recovery Program to provide claim information.

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: Oct 5, 2026
Machine-readable: JSON record · about the forms index

What this form is

Heirs, beneficiaries, or an estate representative complete Section 1 to authorize the Texas Medicaid Estate Recovery Program (MERP) to provide information about a claim against a deceased owner's estate. MERP completes Section 2 with its certification. The form asks for contact details, the deceased owner's identifying information, the property address, and signatures; attach evidence if reporting an existing claim amount.

Who needs it

Heirs, beneficiaries, or an estate representative who cannot certify that the deceased owner's estate is exempt or not subject to a MERP claim may use this form.

How to submit it

Fax or mail the completed form to HMS – The Texas Medicaid Estate Recovery Contractor at the address or fax number provided. Online or email submission is also listed on the form.

About notarization

This form has no notary block; heirs, beneficiaries, or the estate representative sign it, and the text does not require a notarized or sworn attachment.

How to submit this form

1
Download the Form
Download the Authorization and MERP Certification Form.
2
Complete Section 1
Provide the requested contact, deceased owner, Medicaid or Social Security, and property information, then sign.
3
Gather Claim Evidence
If reporting an existing MERP claim amount, attach the document showing the claim.
4
Submit the Form
Mail, fax, email, or submit online to HMS using the details listed on the form.

Frequently asked questions

Do I need a notary for the MERP Authorization and Certification Form?: No. The form has no notary block; heirs, beneficiaries, or the estate representative sign it, and the text does not require a notarized or sworn attachment.
How do I submit the MERP form?: The form lists mail and fax options for HMS – The Texas Medicaid Estate Recovery Contractor, as well as online and email submission.
Who completes each section of the form?: Heirs, beneficiaries, or an estate representative complete Section 1. Section 2 is completed by MERP.
Do I need to attach anything?: If reporting an existing MERP claim amount, the form says to provide the attached document as evidence of that claim.

Need something notarized?

This Authorization and MERP Certification Form doesn’t need a notary, but Texas residents can notarize other documents online with a commissioned online notary.