Form DCO-237 "Assignment of Rights for Tea and Medicaid Applicants" - Arkansas

What Is Form DCO-237?

This is a legal form that was released by the Arkansas Department of Human Services - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2003;
  • The latest edition provided by the Arkansas Department of Human Services;
  • 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 printable version of Form DCO-237 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Human Services.

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Download Form DCO-237 "Assignment of Rights for Tea and Medicaid Applicants" - Arkansas

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ASSIGNMENT OF RIGHTS
FOR TEA AND MEDICAID APPLICANTS
ASSIGNMENT OF MEDICAL SUPPORT (MEDICAID ONLY)
I authorize any holder of medical or other information about me to release information needed
for a Medicaid claim to DHS. I further authorize release of any information to other parties
who may be liable for my medical expenses. As an eligibility condition, I automatically
assign my right to any settlement, judgment, or award which may be obtained against any
third party to DHS to the full extent of any amount which is paid by DHS for my behalf. I
authorize and request that funds, settlement or other payments made by or on behalf of third
parties, including tortfeasors or insurers arising out of a Medicaid claim, be paid directly to
DHS. My application for Medicaid benefits shall in itself constitute an assignment by
operation of law and shall be considered a statutory lien of any settlement, judgment, or award
received by me from a third party. A third party is any person, entity, institution, organization
or other source who may be liable for injury, disease, disability or death sustained by me or
others named herein, including estates of said individuals. I also assign all rights in any
settlement made by me or on my behalf arising out of any claim to the extent medical
expenses paid by DHS, whether or not a portion of such settlement is designated for medical
expenses. Any such funds received by me shall be paid to DHS. A copy of this authorization
may be used in place of the original.
CHILD SUPPORT ENFORCEMENT REQUIREMENTS
TRANSITIONAL EMPLOYMENT ASSISTANCE (TEA) - I understand that if I accept TEA
cash assistance, by state law, I will have assigned all rights, title, and interest in any
support that I have in my own behalf or in behalf of any other person for whom I am
receiving TEA. I understand that all support payments including those received by me
directly from the absent parent, are to be paid to the Office of Child Support Enforcement. I
understand that this assignment ends when I no longer receive TEA except as to any unpaid
support obligation that has accrued at the time my TEA case is closed. I also understand that
as a condition of eligibility for TEA, I must cooperate with the Office of Child Support
Enforcement in establishing paternity and obtaining child support.
MEDICAID - As a condition of eligibility for Medicaid, adult caretaker relatives receiving
Medicaid for themselves as well as for children, must cooperate with the Office of Child
Support Enforcement (OCSE) in establishing paternity and obtaining medical support for each
child who has a parent absent from the home. All other OCSE services, including collection
of child support payments from the absent parent, will be provided unless OCSE receives a
written notice from the caretaker relative declining those services. If the adult caretaker
relative is not receiving Medicaid, cooperation with OCSE is strictly voluntary.
___________________________________________
_____________________________
Signature
Date
DCO-237 (01/03)
Page 1 of 2
ASSIGNMENT OF RIGHTS
FOR TEA AND MEDICAID APPLICANTS
ASSIGNMENT OF MEDICAL SUPPORT (MEDICAID ONLY)
I authorize any holder of medical or other information about me to release information needed
for a Medicaid claim to DHS. I further authorize release of any information to other parties
who may be liable for my medical expenses. As an eligibility condition, I automatically
assign my right to any settlement, judgment, or award which may be obtained against any
third party to DHS to the full extent of any amount which is paid by DHS for my behalf. I
authorize and request that funds, settlement or other payments made by or on behalf of third
parties, including tortfeasors or insurers arising out of a Medicaid claim, be paid directly to
DHS. My application for Medicaid benefits shall in itself constitute an assignment by
operation of law and shall be considered a statutory lien of any settlement, judgment, or award
received by me from a third party. A third party is any person, entity, institution, organization
or other source who may be liable for injury, disease, disability or death sustained by me or
others named herein, including estates of said individuals. I also assign all rights in any
settlement made by me or on my behalf arising out of any claim to the extent medical
expenses paid by DHS, whether or not a portion of such settlement is designated for medical
expenses. Any such funds received by me shall be paid to DHS. A copy of this authorization
may be used in place of the original.
CHILD SUPPORT ENFORCEMENT REQUIREMENTS
TRANSITIONAL EMPLOYMENT ASSISTANCE (TEA) - I understand that if I accept TEA
cash assistance, by state law, I will have assigned all rights, title, and interest in any
support that I have in my own behalf or in behalf of any other person for whom I am
receiving TEA. I understand that all support payments including those received by me
directly from the absent parent, are to be paid to the Office of Child Support Enforcement. I
understand that this assignment ends when I no longer receive TEA except as to any unpaid
support obligation that has accrued at the time my TEA case is closed. I also understand that
as a condition of eligibility for TEA, I must cooperate with the Office of Child Support
Enforcement in establishing paternity and obtaining child support.
MEDICAID - As a condition of eligibility for Medicaid, adult caretaker relatives receiving
Medicaid for themselves as well as for children, must cooperate with the Office of Child
Support Enforcement (OCSE) in establishing paternity and obtaining medical support for each
child who has a parent absent from the home. All other OCSE services, including collection
of child support payments from the absent parent, will be provided unless OCSE receives a
written notice from the caretaker relative declining those services. If the adult caretaker
relative is not receiving Medicaid, cooperation with OCSE is strictly voluntary.
___________________________________________
_____________________________
Signature
Date
DCO-237 (01/03)
Page 1 of 2
IMPORTANT ESTATE RECOVERY NOTICE:
If you receive Medicaid in a nursing facility, ICF/MR facility, or under a home and
community based waiver program, the total amount of the Medicaid benefits paid on your
behalf will be a debt to DHS and may be recovered from your estate after your death. Your
estate is the property you own at the time of your death. DHS will not make a claim against
your estate while you are living. DHS will not make a claim against your estate after your
death if your spouse is still living, or if you have dependent children under age 21 or blind or
disabled children. DHS will collect the debt, if any, by filing a claim in your estate.
Collection may not be made if it is not cost effective to DHS or if your heirs apply for a
hardship waiver after your death. A hardship may exist if the estate property is the only
source of income for your heirs, if that income is limited, or if there are other compelling
circumstances.
I have read the Assignment of Medical Support on page 1 and the above notice on Estate
Recovery.
___________________________________________
_____________________________
Signature
Date
DCO-237 (01/03)
Page 2 of 2
Page of 2