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