Page 105
State of Maryland Medical Assistance Manual Revised April 2014
COVER LETTER FOR ASSIGNMENT OF SUPPORT RIGHTS
_________________________County Address:
Department of Social Services
___________________
Date:
Department of Health and Mental Hygiene Office of Eligibility Services 201. West Preston Street Room SS-10 Baltimore, MD 21201
RE: ____________________________ CID#_____________________
Enclosed please find “Assignment of Support Rights” letter for the above referenced client
Notary Certificate
Copies of Screen Prints
Separated community spouse information: Name: ___________________________ Address: _________________________
Customer’s representative address and telephone number: Name: ______________________________ Relationship:____________________
Address:________________________________________________________________
Telephone number: ____________________
Notes:
_
_
Respectfully,
________________________________________________ ____________________________________ (Case Manager’s Signature) Telephone Number
_______________________________________________ (Case Manager’s Name-Print)
Attachment A