Certification Of Notice To Administrator Of Medicaid Estate Recovery {7.0}

PROBATE COURT OF COUNTY, OHIO , JUDGE ESTATE OF: _______________________________________________________________ CASE NO. ___________________ CERTIFICATION OF NOTICE TO ADMINISTRATOR OF MEDICAID ESTATE RECOVERY PROGRAM [2117.061 AND 5111.11] FORM 7.0 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 5111.11 was served upon the following by a method authorized by Civ. R. 73 on the _____ day _____________________, 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) Attorney Registration No. ________________________ ___________________________________________ Telephone Number (include area code) FORM 7.0 - CERTIFICATION OF NOTICE TO ADMINISTRATOR OF MEDICAID ESTATE RECOVERY American LegalNet, Inc. www.FormsWorkFlow.com