MA Clearance Certificate for a Transfer on Death Deed (DHS-5893A)

Follow these instructions for the DHS-5893A to issue a Medical Assistance (MA) clearance certificate after receiving a Transfer on Death Deed Application for an MA Clearance Certificate (DHS-5893).

1. Enter today’s date

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

2. Choose your county from the dropdown menu

Select your county from the dropdown menu found in the first sentence on the form.

3. Indicate whether your county has a claim

Check the appropriate box for indicating whether your county has an MA claim.

a. Your county has a claim

Enter the name of the decedent for whom you have an MA claim, the decedent’s date of birth and death and the amount of the claim. If there is more than one decedent for whom you have a claim, click the “Add deceased person” button and repeat this data entry. Then enter your name, telephone number and email address.

b. Your county does not have a claim

Enter the name of the decedent you do not have an MA claim for, the decedent’s date of birth and date of death.

4. Certify the certificate

Have the certificate notarized when you enter your county’s contact information, sign and date the form and indicate whether you are a director or designee of your county agency.

5. 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.

6. Send the certificate

Send the completed certificate to the person who sent you the Transfer on Death Deed Application for a Medical Assistance Clearance Certificate (DHS-5893).