Fill out this form as best as you can. An example is located on page 13.Understand Pennsylvania estate recovery and Medicaid payback with expert attorney guidance. Discover how you can protect your family's assets. The Pennsylvania department of human services has mailed me a letter from the Estate Recovery Program, asking her next of kin complete the questionnaire. When a MA LTC recipient (as defined in 495.1) dies, DHS will attempt to recover the costs of previously provided MA LTC services from the decedent's estate. The stakes are high, so we recommend that you not write this letter, but instead work with a law firm to draft the letter and provide supporting documentation. Retain all related records for 3 years after receipt of grant close out letter. (i) Waiver requests shall be submitted to the following address: Estate Recovery Program, Post Office Box 8486, Harrisburg, Pennsylvania 17105-8486. Were both letters from HMS or PCG?