Written Statement of Claim (DHS-8348E)

Follow the instructions for (DHS-8348E) (PDF) to show the probate court that you have a Medical Assistance (MA) claim.

· Fill in the header.

· Select your county name from the top left dropdown.

· Enter the decedent’s (deceased person’s) name on the left.

· Enter the court district number in the top right. If you are unsure of your district, look up the court district.

· Since you are opening a new court file, you do not need to enter a file number. If you are filing the Written Statement of Claim in an existing file, enter the court file number in this blank.

· Fill in the body. Any statements that do not have a blank are true for all Medical Assistance (MA) claims, except where otherwise noted.

· Select the name of the county where you are signing in the first blank.

· Enter your name and the county you work for at number 1.

· Enter your county’s name at number 2.

· Enter your office contact information at number 3.

· Enter your county name and the amount of the claim at number 4.

· Enter the source of the claim at number 6 (for example, MA for long-term care, waivered services, and so forth)

· Enter date range that MA services were provided at number 7.

· You will probably leave number 10 blank. Contact the Minnesota Department of Human Services Special Recovery Unit if you have questions about this.

· Enter your name and office contact information at the bottom right, beneath “Signature of Collection Agent.”

· Enter the information for the attorney representing the county in this matter in the bottom left.

· Date and sign the document.