Free Estate Recovery Program Heir Information, HCF 13174 - Wisconsin


File Size: 47.0 kB
Pages: 1
Date: October 26, 2005
File Format: PDF
State: Wisconsin
Category: Health Care
Author: BHCSO
Word Count: 217 Words, 1,382 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/F1/F13174.pdf

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Department of Health and Family Services Division of Health Care Financing HCF 13174 (Formerly HCF 1113) (Rev. 10/05)

State of Wisconsin

ESTATE RECOVERY PROGRAM HEIR INFORMATION
**To be used whenever money is sent to anyone or anywhere other than to the Estate Recovery Program** Personal identifiable information will be used only in the administration of the Estate Recover Program
Name of Deceased Resident Total Amount of Funds at Nursing Home (including patient account and excess patient liability) Social Security Number Date of Death

Dates Resident Resided in Nursing Home From To

Patient Account

Excess Patient Liability Yes Yes Yes
No No No

Does the deceased have a surviving spouse? Does the deceased have any surviving minor children under the age of 21? Does the deceased have any surviving disabled children?



Unknown Unknown Unknown

INFORMATION ABOUT THE PERSON OR PLACE TO WHOM THE FUNDS WERE CONVEYED
Name of Heir, Guardian or Place Address City, State and Zip Code

Relationship to deceased resident

Telephone Number

INFORMATION ABOUT THE PERSON WHO CONVEYED THE FUNDS
Name of Person Who Conveyed Funds Title Amount Conveyed

Name of Nursing Home/Facility

Address

City, State, and Zip Code

Telephone Number

Please mail this completed form to: Division of Health Care Financing. Estate Recovery Program P.O. Box 309 Madison, WI 53701-0309