HomeMy WebLinkAbout974448Note 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:
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: Lena Borino
ADDRESS: 34 Elkol Street
Diamondville WY 83116
RECEIVED 12/9/2013 at 3:12 PM
RECEIVING 974448
BOOK: 825 PAGE: 91
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
State of Wyoming,
Department of Health
Division of Healthcare Financing /EqualityCare
LEGAL DESCRIPTION OF REAL PROPERTY:
A 1 /2 interest in Parcel No. 119 of the Town of Diamondville, Lincoln County,
Wyoming, as shown on the plat thereof dated August 31, 1942, together with all
improvements situate thereon and all easements and appurtenances belonging
thereto.
NAME AND ADDRESS OF VENDOR(S) FURNISHING MEDICAL CARE:
0` r
ii �f 1
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: 08/01/2002 to present
AMOUNT DUE FOR CARE: 598,419.72
TOTAL AMOUNT DUE AND OWING CLAIMANT, STATE OF WYOMING,
DEPARTMENT OF HEALTH, FOR ALL CARE: 598,419.72.
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).
STATE OF WYOMING
COUNTY OF LARAMIE
ss.
WITNESS my hand and official seal.
State of Wyoming,
Department of Health
By: Sheila McInerney
Its: TPL /Recovery Coordinator
otary Public
9 a
IN WITNESS WHEREOF, I do hereunder set my hand this 3 day of December,
2013
This Verified Lien Statement for Lien for Medical Assistance consisting of
pages was subscribed, sworn to and acknowledged before me on this ck day of
December, 2013 by Sheila McInerney as TPL /Recovery Coordinator of the Wyoming
Department of Health, Division of Healthcare Financing.
My Commission expires: u ven.v} 2.o aC