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20130109245 Arizona Health Care Cost Containment System (AHCCCS) or Arizona Long Term Care System (ALTCS) Notice and Claim of AHCCCS Lien Case Number: 243552 Claimant: Health Management Systems (HMS), P.O. Box 10530, Phoenix, AZ 85064 Authorized Representative on behalf of AHCCCS: Gloria Delgado, Caseworker Name of Recipient: Adrian Hall AHCCCS ID: A42604731 Address of Recipient: 4768 E LAUREL COURT APT 5 GILBERT, AZ 85234 Date(s) of Other Non-Hospitalization Care: 2001-08-27 Amount Due for Care of Patient: $157,678.79 Amount for Hospital, Medical and/or Long-Term Care Services Provided to this Recipient due to this Injury for which AHCCCS is responsible. County in which Injuries were Sustained: Maricopa To the best of the director's knowledge, the names and addresses of all persons, firms or corporations claimed by the above-named recipient, or the recipient's representative, to be liable for damages are as follows: Additional copies have been sent to the following: Recipient's Attorney: Scott Palumbo Unofficial Document Palumbo Wolfe & Palumbo 2800 N Cental Ave Suite 1400 Phoenix, AZ, 85004 The recording official is directed to record and return this instrument to: Eealth Management Systems (HMS) P.O. Box 10530 Phoenix, AZ 85064 Phone; 602 954 8380 Toll free: 888 378 2836 Pax: 602 257 4180 20130109245 Arizona Health Care Cost Containment System (A HCCCS) or Arizona Long Term Care System (ALTCS) Notice and Claim of AHCCCS Lien Pursuant to the laws of the state of Arizona, specifically, A.R.S. § 36-2915 and 36-2956, AHCCCS does hereby claim a lien upon any and all causes of actions, suits, claims, counter-claims, or demands for damages accruing to the recipient Adrian Hall, or to the legal representative of such recipient, on account of injuries giving rise to such causes of action and which necessitated the recipient's hospitalization and/or medical care and treatment and the charges for hospital care and/or medical care and treatment of the above-named injured recipient for which AHCCCS is responsible in the sum herein above claimed to be due. The name and address of the recipient as set forth are the same as appear on the records of AHCCCS. STATE OF ARIZONA COUNTY OF Maricopa ) SS. VERIFICATION OF AUTHORIZED REPRESENTATIVE AND AFFIDAVIT OF MAILING Gloria Delgado, Caseworker, being first duly sworn upon oath, deposes and says: 1. That Health Management Systems (HMS) is an authorized representative acting on behalf of the director of the Arizona Health Care Cost Containment System (AHCCCS) named in the foregoing notice and claim of the AHCCCS lien; 2. That AHCCCS within five (5) days after the recording of said lien, mailed a copy thereof, postage prepaid to each person, firm, or corporation and the insurance carrier of each listed above as persons believed to be flab 1. That the matters stated are true and correct to the best of their knowledge. 'Gloria Delgado, Caseworker • Authorized Representative Acting on Behalf of the Director of AHCCCS Subscribed and Sworn to Before mc this Notary Public State of Arizona Ma rieopa County Celia G Flores ConVossion Otplres 05/24/2018 Recordation of Filing Recordation of Filing County Recorder: County Recorder: Date of Recording: Date of Recording: Hour of Recording: Hour of Recording: Docket Number: Docket Number: Page Number: Page Number: Recordation of Filing Documentation Recordation of Filing Documentation County Recorder: County Recorder: Date of Recording: Date of Recording: Hour of Recording: Hour of Recording: Docket Number: Docket Number: Page Number: Page Number: Unofficial 20Document dw MC, When Recorded, MAIL TO: $8 Arizona Casualty, Estate and TEFRA Recovery $5 P.O. Box 10530 $1 Phoenix, AZ 85064 CTSCASAZ NOTICE OF LIEN LETTER 243552 Hall, Adrian