Determination of Your Request for an Undue Hardship Waiver (DHS-4935)

Follow these instructions for the DHS-4935 to inform an undue hardship waiver applicant whether you have granted the applicant’s waiver request.

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

At the top of the form, enter today’s date, the 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.

2. Enter the decedent’s name, the probate county’s name and the case file number

There are three blank fields following the first sentence of the form. In the “estate of” field, enter the name of the deceased person whose estate is subject to your MA claim. This will populate the person’s name throughout the rest of the form. Then enter the name of the probate county in the second field and the probate case file number in the third field.

3. Enter the date you received the undue hardship waiver application

In the “enter the receipt date” field, add the date you received the application for an undue hardship waiver of a Medical Assistance claim.

4. Select your determination

Click the corresponding button to indicate whether you have granted the waiver, denied the waiver or granted the waiver in part and denied the waiver in part. If you chose to grant in part and deny in part, describe the extent of your grant and denial in the textbox that follows the selection.

5. Select which waiver criteria the applicant chose

Select the checkbox for the criteria under which the applicant requested an undue hardship waiver.

6. Explain the reason(s) for your determination

In the final textbox on the form, explain why you reached your determination.

7. 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.

8. Send the form to the waiver applicant