Estate Recovery Program Notification of Death

ESTATE RECOVERY PROGRAM
NOTIFICATION OF DEATH

THE FOLLOWING INFORMATION MUST BE COMPLETED BY THE NURSING FACILITY OR OTHER FACILITY RETURNED TO THE DEPARTMENT OF SOCIAL SERVICES WITHIN 15 DAYS OF THE DATE OF DEATH.

Name of Deceased Resident:
Medicaid Number:
Date of Death:
Facility of Residence:

PLEASE ANSWER ALL THE FOLLOWING:
DOES THE DECEASED HAVE A:

	(1) Surviving Spouse
	(2) Surviving Minor Children
	(3) Surviving Disabled Children

PLEASE LIST BELOW THE NAME, MAILING ADDRESS, AND RELATIONSHIP OF CONTACT PERSON:

(4) WILL

EXECUTOR:
EXECUTOR ADDRESS:

(5) PRE PAID BURIAL FUND - REVOCABLE OR
IRREVOCABLE BURIAL TRUST

NAME OF PLAN:
AMOUNT OF PLAN $:
DATE FUNDS WERE REQUESTED FOR BURIAL EXPENSES:

FINAL TRUST FUND RECONCILIATION

	AMOUNT IN PERSONAL TRUST ACCOUNT ON DATE OF DEATH
	ADD DEPOSITS AND/OR CREDIT BALANCES
	SUB TOTAL OF TRUST FUND

LESS FINAL EXPENSES PAID FROM PERSONAL TRUST FUND (ATTACH COPY OF CHARGES AND PROOF OF PAYMENT)

	FUNERAL COSTS
	HEADSTONE COST
	CREMATORIUM COST
	OTHER - PLEASE LIST:




	TOTAL FINAL EXPENSES PAID

	BALANCE FOR DSS:

(IN ACCORDANCE WITH SDCL 29A-3-817 AND SDCL34-12-38 )

IF THERE IS A SURVIVING SPOUSE THERE IS NO RECOVERY BY DSS IF FUNERAL EXPENSES HAVE BEEN PAID THE BALANCE MAY BE SENT IN.

COMPLETED BY: I verify that this is my electronic signature and I am the individual filling out this form.	SIGNATURE
	NAME (PRINT)/TITLE/POSITION
	NURSING FACILITY NAME
	NURSING FACILITY MAILING ADDRESS
	NURSING FACILITY PHONE NUMBER
	DATE COMPLETED

RETURN THIS FORM TO:	DEPARTMENT OF SOCIAL SERVICES OFFICE OF RECOVERIES AND FRAUD INVESTIGATIONS ESTATE RECOVERY PROGRAM 700 GOVERNORS DRIVE PIERRE SOUTH DAKOTA 57501-2291

FOR INFORMATION CONTACT:	ESTATE RECOVERY PROGRAM AT 605-773-3653

The Facility must also notify the local eligibility caseworker of the death of a Medicaid recipient.

ESTATE RECOVERY PROGRAM NOTIFICATION OF DEATH

ESTATE RECOVERY PROGRAM
NOTIFICATION OF DEATH