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State of Maryland Medical Assistance Manual Revised April 2014

ASSIGNMENT OF SUPPORT RIGHTS

I, _______________________________________________, do hereby assign, relinquish and transfer to the State of Maryland, Department of Health and Mental Hygiene, Medical Assistance Program all of my rights, privileges, and claims to any support required to be provided to me by my (husband/wife), __________________, For the period for which I am receiving Medical Assistance benefits for institutional care in a long term care facility.

This assignment is irrevocable and can terminate only upon my discontinuance of Medical Assistance benefits. However, the assignment for the period during which I received Medical Assistance benefits will remain in full force and effect until the Medical Assistance funds that were expended on my behalf during the period of my institutionalization are paid or otherwise reimbursed to the Medical Assistance Program.

I also hereby agree to cooperate with the State in bringing criminal action for nonsupport against my (husband/wife)____________________________________, under Family Law Article, §§10-201 and 202, Annotated Code of Maryland.

_______________________________ ___________________________ DATE SIGNATURE

Attachment B