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E S Legal Services, LLC
PO Box 3029
Cheyenne, WY 82003
VERIFIED LIEN STATEMENT FOR LIEN FOR MEDICAL ASSISTANCE
NAME OF CLAIMANT:
NAME: Neoma Mills
ADDRESS: 509 Sapphire
Kemmerer, WY 83101
State of Wyoming
Department of Health
Office of Healthcare Financing /EqualityCare
ADDRESS: 6101 Yellowstone Road, Suite 210
Cheyenne, Wyoming 82002
NAME AND ADDRESS OF PERSON TO WHOM MEDICAL CARE WAS FURNISHED
AND AGAINST WHOSE PROPERTY LIEN IS FILED:
LEGAL DESCRIPTION OF REAL PROPERTY:
County of Lincoln, State of Wyoming
Lot 10 of Block 39 of the First Addition to the Town of Kemmerer, Lincoln County,
Wyoming as described on the offical plat thereof together with all improvements situate
thereon and all easements and appurtenances belonging thereto.
NAME AND ADDRESS OF VENDOR (S) FURNISHING MEDICAL CARE:
The primary vendors providing medical care were:
South Lincoln Nursing Center
South Lincoln Hospital
Located in Kemmerer, Wyoming, and various other providers on file with the
Department of Health.
DATE OF SERVICE: 10/01/2005 to present
AMOUNT DUE FOR CARE: 262,912.11
RECEIVED 11/22/2010 at 10:46 AM
RECEIVING 956848
BOOK: 757 PAGE: 606
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY