HomeMy WebLinkAbout971451RECEIVED 6/ at 't to- 444 RECEIVING3# 971451
BOOK: 813 PAGE: 587
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 VENDOR(S) FURNISHING MEDICAL CARE:
DATE OF SERVICE: 10/06/2007 to present
AMOUNT DUE FOR CARE: $179,826.24
00587
NAME AND ADDRESS OF PERSON TO WHOM MEDICAL CARE WAS FURNISHED
AND AGAINST WHOSE PROPERTY LIEN IS FILED: (HEREINAFTER "DECEDENT):
NAME: Toni Braegger
ADDRESS: 506 Opal
Kemmerer WY 83101
LEGAL DESCRIPTION OF REAL PROPERTY:
Lot Numbered Two (2) of Block Numbered Fifty -Four (54) in the Second Addition
to the Town of Kemmerer, as surveyed, platted and recorded, together with all
improvements situate thereon and all easements and appurtenances belonging
thereto.
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.
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING,
DEPARTMENT OF HEALTH, FOR ALL CARE: $179,826.24.
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 f 6 day of June, 2013
STATE OF WYOMING
COUNTY OF LARAMIE
ss.
State of Wyoming,
Department of Health
By: Sheila Mc ne ey
Its: TPL /Recovery Coordinator
This Verified Lien Statement for Lien for Medical Assistance consisting of a"
pages was subscribed, sworn to and acknowledged before me on this 1o of
June, 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: la vAnPc ■5
BARBARA A. ROLLI
COUNTY OF
LARAMIE
My