HomeMy WebLinkAbout969798RECEIVED 3/6/2013 at 9:55 AM
RECEIVING 969798
BOOK: 806 PAGE: 235
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
Note to Clerk: Please Do Not put recording Information Above this Line.
When Recorded, return to:
Office of the Attorney General
123 State Capitol
Cheyenne, WY 82002
VERIFIED LIEN STATEMENT FOR LIEN FOR MEDICAL ASSISTANCE
NAME OF CLAIMANT: State of Wyoming,
Department of Health
Division 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: (HEREINAFTER "DECEDENT):
NAME: Fred Celebrin
ADDRESS: 510 Opal
Kemmerer WY 83101
LEGAL DESCRIPTION OF REAL PROPERTY:
The Lot Numbered Three (3) of Block Numbered Fifty -four (54) in the Scond
Addition to the Town of Kemmerer, Lincoln County and State of Wyoming, as
surveyed, platted and recorded together with all improvements situate thereon
and all easements and appurtenances belonging thereto.
NAME AND ADDRESS OF VENDOR(S) FURNISHING MEDICAL CARE:
0023:i
The vendors providing medical care are on file with the Department of Health and
available to the decedent's personal representative upon signing a HIPAA-
compliant authorization to release medical information.
DATE OF SERVICE: 11/01/2011 to present
AMOUNT DUE FOR CARE: $40,210.85
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING,
DEPARTMENT OF HEALTH, FOR ALL CARE: $40,210.85.
THE NAME OF THE PERSON RESPONSIBLE TO PAY THE DEBT SECURED BY
THE LIEN:
the estate of the decedent as the term "estate" is defined in Wyo. Stat. Ann. §42
4 -206 (g)(ii).
IN WITNESS WHEREOF, I do hereunder set my hand this cry of February, 2013
State of Wyoming,
Department of Health
By: Sheila McInerney
Its: TPL /Recovery Coordinator
STATE OF WYOMING
ss.
COUNTY OF LARAMIE
This Verified Lien Statement for Lien for Medical Assistance consisting of
pages was subscribed, sworn to and acknowledged before me on this 4 day of
February, 2013 by Sheila McInerney as TPL /Recovery Coordinator of the Wyoming
Department of Health, Division of Healthcare Financing.
WITNESS my hand and official seal.
My Commission expires: \S"
00236