Certification Of Notice To Administrator Of Medicaid Estate Recovery Program {7.0} | Pdf Fpdf Doc Docx | Ohio

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Certification Of Notice To Administrator Of Medicaid Estate Recovery Program {7.0} | Pdf Fpdf Doc Docx | Ohio

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

This is a Ohio form that can be used for Estate within County (Court Of Common Pleas), Montgomery, Probate.

Alternate TextLast updated: 4/21/2015

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PROBATE 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) Attorney Registration No. _______________________________ Telephone Number (include area code) _______________ 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 American LegalNet, Inc. www.FormsWorkFlow.com

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