Form 4-226A. Civil complaint provisions; medical debt claims.

[For use with Rules 1-009(J), 2-201(E), and 3-201(E) NMRA] In addition to the requirements set forth in the New Mexico Rules of Civil Procedure, a pleading asserting a claim subject to Rules 1-009(J), 2-201(E), or 3-201(E) NMRA shall include, at a minimum, the following provisions: STATE OF NEW MEXICO COUNTY OF __________________ _________________ JUDICIAL DISTRICT/MAGISTRATE COURT/ METROPOLITAN COURT __________________________, Plaintiff, v. No.__________ __________________________, Defendant. CIVIL COMPLAINT FOR MEDICAL DEBT (a) The full name and address of the Defendant is as follows: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ (b) The last two (2) digits of the Defendant’s social security number, contained in the original creditor’s records are as follows: ______________________________________________________________________ ______________________________________________________________________ (c) If the Plaintiff does not provide the social security number above, the Plaintiff states, with specificity, that the basis on which it was determined that the named Defendant is the debtor on the debt is as follows: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ___ The Plaintiff has determined that the Defendant is not indigent as follows: [ ] The Plaintiff in this action is a Health Care Facility [ ] The Plaintiff conducted a screening, under 13.10.39.8 NMAC, during which it determined that the Defendant is not indigent. or [ ] After complying with 13.10.39.9(A)(a) and (B) NMAC, the Plaintiff determined that the Defendant is not indigent. or [ ] Upon information and belief, the Defendant is not indigent under the methodology in 13.10.39.9(B) NMAC, and the Plaintiff was unable to make a determination otherwise due to noncooperation by the Defendant, including after making at least the following three documented attempts to contact the Defendant: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ [ ] The Plaintiff in this action is a Third-party Health Care Provider. [ ] The Health Care Facility has not informed the Plaintiff that the Defendant is indigent. and [ ] After complying with 13.10.39.9(A)(a) and (B) NMAC, the Plaintiff determined that the Defendant is not indigent. or [ ] Upon information and belief, the Defendant is not indigent under the methodology in 13.10.39.9(B) NMAC, and Plaintiff was unable to make a determination otherwise due to noncooperation by the Defendant, including after making at least the following three documented attempts to contact the Defendant: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ [ ] The Plaintiff in this action is a Medical Creditor other than a Health Care Facility or a Third-party Health Care Provider. [ ] After complying with 13.10.39.9(A)(a) and (B) NMAC, the Plaintiff determined that the Defendant is not indigent. or [ ] Upon information and belief, the Defendant is not indigent under the methodology in 13.10.39.9(B) NMAC, and the Plaintiff was unable to make a determination otherwise due to noncooperation by the Defendant, including after making at least the following three documented attempts to contact the Defendant: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ [ ] The Plaintiff in this action is a Medical Debt Collector seeking to recover a medical debt initially owed to a Health Care Facility or a Third-party Health Care Provider or another Medical Creditor. (1) The name and address of the current owner of this debt is as follows: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ (2) The name and address of the Medical Debt Collector is: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ (3) The New Mexico license number for the Medical Debt Collector is as follows: _______________________________________________________________ (4) The name and address under which the original creditor did business with the Defendant is as follows: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ (5) The last four (4) digits of the Defendant’s account number, used by the original creditor as of the date of default are as follows: ______________________________________________________________________ (6) The name and address of the current owner of this debt is as follows: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ (7) The specific facts demonstrating that the Medical Debt Collector is the real party in interest are as follows: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ [ ] The original or copy of any instrument of writing on which the action is founded IS attached as Exhibit A. See Rules 1-009(J)(2), 2-201(E)(2), or 3-201(E)(2) NMRA. [ ] The original or copy of any instrument of writing on which the action is founded IS NOT attached. The reason the instrument of writing is not attached is as follows: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ [ ] The Plaintiff has attached an affidavit showing the chain of title or assignment of the debt. See Rules 1-017(E)(2), 2-401(D)(2), or 3-401(D)(2) NMRA. [ ] The Plaintiff communicated with the [ ] Health Care Facility [ ] Third-party Health Care Provider [ ] other Medical Creditor, which informed Plaintiff that it has not made a determination that the Defendant is indigent. and [ ] After complying with 13.10.39.9(A)(a) and (B) NMAC, the Plaintiff determined that the Defendant is not indigent. or [ ] Upon information and belief, the Defendant is not indigent under the methodology in 13.10.39.9(B) NMAC, and Plaintiff was unable to make a determination otherwise due to noncooperation by the Defendant, including after making at least the following three documented attempts to contact the Defendant: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ___ I am serving a copy of the current Attestation of Indigency form promulgated by the New Mexico Office of the Superintendent of Insurance on the Defendant for alleging indigency as a defense in Defendant’s Answer to this Complaint. The balance due at the time of default is as follows: ______________________________________________________________________ ______________________________________________________________________ (a) The total amount of the debt claimed is $ __________________, itemized as follows: Principal amount due: _____________________________ Interest: _____________________________ Other charges, fees, and expenses (specified individually): ___________________________________________________________ The itemization of the amount of the debt claimed set forth above does not include attorney fees and court costs. (b) The basis for each of the itemized charges, fees, or expenses is as follows: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ The date of last payment made by Defendant is as follows: ____________ The Plaintiff states, consistent with Rules 1-011, 2-301, or 3-301 NMRA, that the applicable statute of limitations on this claim has not run. The Plaintiff also seeks court costs and the following additional relief as specified: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ WHEREFORE, the Plaintiff demands judgment in the amount of $ _______, and costs [and attorney fees] and such further relief as the court deems proper. __________________ Date ________________________________ Signature ________________________________ Name (print) ________________________________ Address (print) ________________________________ City, State, and Zip Code (print) ________________________________ Telephone Number