Form 7.0 "Certification of Notice to Administrator of Medicaid Estate Recovery Program" - Ohio

What Is Form 7.0?

This is a legal form that was released by the Ohio Courts of Common Pleas - Probate Division - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2014;
  • The latest edition provided by the Ohio Courts of Common Pleas - Probate Division;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 7.0 by clicking the link below or browse more documents and templates provided by the Ohio Courts of Common Pleas - Probate Division.

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Download Form 7.0 "Certification of Notice to Administrator of Medicaid Estate Recovery Program" - Ohio

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PROBATE COURT OF _____________ COUNTY, OHIO
________________, JUDGE
ESTATE OF:_____________________________________________________, DECEASED
CASE NO. _______________________
CERTIFICATION OF NOTICE TO ADMINISTRATOR OF
MEDICAID ESTATE RECOVERY PROGRAM
[R.C. 2117.061 AND 5162.21]
THIS FORM SHALL BE FILED IN THE PROBATE COURT UPON COMPLETION OF
NOTICE TO ADMINISTRATOR
The undersigned certifies that a Notice in compliance with Ohio Revised Code 2117.061 and 5162.21 was
served upon the following by a method authorized by Civ.R. 73 on the __________ day of ______________,
20______:
Medicaid Estate Recovery
150 E. Gay Street, 21st Floor
Columbus, Ohio 43215
_________________________________
_______________________________
Attorney for Applicant
Person Responsible for the Estate
_________________________________
_______________________________
Typed or Printed Name
Typed or Printed Name
_________________________________
_______________________________
Address
Address
_________________________________
_______________________________
City, State, Zip Code
City, State, Zip Code
_________________________________
_______________________________
Telephone Number (include area code)
Telephone Number (include area code)
_______________
Attorney Registration No.
Print Form
FORM 7.0 – CERTIFICATION OF NOTICE TO ADMINISTRATOR OF MEDICAID ESTATE RECOVERY PROGRAM
Amended: June 1, 2014
Discard all previous versions of this form
PROBATE COURT OF _____________ COUNTY, OHIO
________________, JUDGE
ESTATE OF:_____________________________________________________, DECEASED
CASE NO. _______________________
CERTIFICATION OF NOTICE TO ADMINISTRATOR OF
MEDICAID ESTATE RECOVERY PROGRAM
[R.C. 2117.061 AND 5162.21]
THIS FORM SHALL BE FILED IN THE PROBATE COURT UPON COMPLETION OF
NOTICE TO ADMINISTRATOR
The undersigned certifies that a Notice in compliance with Ohio Revised Code 2117.061 and 5162.21 was
served upon the following by a method authorized by Civ.R. 73 on the __________ day of ______________,
20______:
Medicaid Estate Recovery
150 E. Gay Street, 21st Floor
Columbus, Ohio 43215
_________________________________
_______________________________
Attorney for Applicant
Person Responsible for the Estate
_________________________________
_______________________________
Typed or Printed Name
Typed or Printed Name
_________________________________
_______________________________
Address
Address
_________________________________
_______________________________
City, State, Zip Code
City, State, Zip Code
_________________________________
_______________________________
Telephone Number (include area code)
Telephone Number (include area code)
_______________
Attorney Registration No.
Print Form
FORM 7.0 – CERTIFICATION OF NOTICE TO ADMINISTRATOR OF MEDICAID ESTATE RECOVERY PROGRAM
Amended: June 1, 2014
Discard all previous versions of this form