Form Instructions
DHS hosts a number of forms used by local agencies to recover Medical Assistance (MA) funds. The following pages provide instructions on how to fill out these forms.
Request for an MHCP Member’s Claims Payment History (DHS-2133)
Referral for an MA Lien or Notice of Potential Claim (DHS-3203)
Special Needs or Pooled Trust Referral (DHS-4759)
Notice of Estate Claim for Medical Assistance (DHS-4934)
Determination of Your Request for an Undue Hardship Waiver (DHS-4935)
Annuity Designation for MA-LTC Applicants (DHS-5036)
Notice of Obligation to Issuer of an Annuity (DHS-5037)
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