Notice of Estate Claim for Medical Assistance (DHS-4934)

Follow these instructions for the DHS-4934 to notify heirs, devisees and people with an ownership interest in the decedent’s real property about a Medical Assistance (MA) claim in a probate proceeding. The DHS-4934 also provides the recipient with an application for a waiver of the MA claim.

1. Enter today’s date, the notice recipient’s address and your contact information

At the top of the form, enter today’s date, the notice recipient’s name and address, and all the fields in the box found in the upper right corner. Be sure to complete all fields, as many of your entries will autofill other fields throughout the rest of the document. The “case file number” field is for the number the court assigned for the probate proceeding.

2. Enter the claim date

Under the “notice of claim” heading, enter the date on which you filed a claim against the estate.

3. Enter the name of the deceased person

Under the “notice of claim” heading, enter the name of the deceased person whose estate is being probated.

4. Enter the amount of the MA claim

Under the “notice of claim” heading, there is a blank field for entering the dollar amount of your MA claim. Enter the claim amount you have determined from the MA claims payment history.

5. Enter the name of the county court

Under the “notice of claim” heading, enter the name of the county whose district court is the venue of the probate.

6. Add your telephone number to the language block

Add your telephone number to the blank field at the top of the language block that appears at the end of the form.

7. Send both the notice and the application together

If you have completed the first six steps of these instructions, both the notice of estate claim and application for an undue hardship waiver should be ready to send to the heir, devisee or person with an ownership interest in the decedent’s real property. Send both the notice and application together, as described in notifying others about MA claims.