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State of Maryland Medical Assistance Manual Revised July 2012 Attachment B Notice of Potential MA Payment Recovery SECTION I HEADING STATE OF MARYLAND DIVISION OF MEDICAL ASSISTANCE RECOVERIESP.O. BOX 13045 BALTIMORE, MARYLAND 21203 NOTICE OF POTENTIAL MA PAYMENT RECOVERYDATE:(USE DHMH 2583 INSURANCE REPORTING FORM TO REPORT HEALTH INSURANCE COVERAGE) RECIPIENT LAST NAMEFIRST MIDDLE REPRESENTATIVE LAST NAMEFIRST MIDDLE APT. NO. – STREETADDRESS - P.O. BOX APT. NO. – STREETADDRESS - P.O. BOX CITYSTATE ZIP CODE CITYSTATE ZIP CODE MA NUMBER SOCIALSECURITY NUMBER RELATIONSHIP TO RECIPIENT TELEPHONE NUMBER SEC. 2 REASON (INJURY)

COMPLETE THE APPLICABLE SECTIONS SECTION III - ASSETS PROPERTY OWNED (ATTACH PHOTOCOPY OF DEED, IF DECEASED) DESCRIPTION ADDRESS APPROX. VALUE

BANK ACCOUNTS OWNED TYPE OWNER (S) INSTITUTION AND LOCATION ACCT. NO. VALUE JOINT

JOINT

LIFE INSURANCE OWNED COMPANY ADDRESS POLICYNO. NAMED BENEFI CIARY? VALUE

YES NO FACE C.V.

YES NO FACE C.V. STOCKS / BONDS OWNED TYPE DESCRIPTION OWNER (S) QUAN. SERIAL NO. (S) VALUE

CASH AND OTHER ASSETS OWNED DESCRIPTION OWNER (S) VALUE

IV - INC SOURCE + EXPLANATION DATE REPORTED DATE OF INCOME MONTHLY AMOUNT TOTAL AMNOUNT