Form 4-301A. Answer to civil complaint for medical debt.

[For use with Rules 1-009(J)(2), 2-201(E)(2), 2-302, 3-301(E)(2), and 3-302 NMRA] STATE OF NEW MEXICO COUNTY OF _______________ ___________________ COURT No. ____________ _____________________________, Plaintiff v. _____________________________, Defendant ANSWER TO CIVIL COMPLAINT FOR MEDICAL DEBT1 1. The Plaintiff seeks recovery for medical debt as defined in NMSA 1978, Section 57-32-2(I). Collection actions, including lawsuits seeking recovery for medical debt, must be dismissed if the defendant is indigent. NMSA 1978, Section 57-32-4(A). 2. [ ] A copy of an Attestation of Indigency form was served on me with the Plaintiff’s Complaint; OR [ ] The Plaintiff did not attach a copy of the Attestation of Indigency form. 3. [ ] I am an indigent patient as defined in NMSA 1978, Section 57-32-2(G). This means I have a household income no greater than two hundred (200) percent of the federal poverty level. [ ] In support of my assertion that I am an indigent patient, I have filled out and attached to this Answer a copy of the Attestation of Indigency form; OR [ ] I have attached other proof of indigency such as copies of pay stubs or other relevant documents, while making unreadable all but the last two (2) digits of my social security number or other taxpayer numbers; OR [ ] I admit I am not an indigent patient. 4. (If applicable) In addition, the Plaintiff is not entitled to the amount claimed because: [ ] The Plaintiff did not attach a copy of the Attestation of Indigency form; [ ] The Plaintiff did not contact me to obtain information to determine whether I am an indigent patient; OR [ ] Other reasons the Plaintiff is not entitled to the amount claimed (list reasons): _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________. 5. (If applicable) Defendant asserts the following counterclaim or set-off against the Plaintiff: _____________________________________________________________________ _____________________________________________________________________. 6. Trial by jury [ ] is [ ] is not demanded. (If Plaintiff has already demanded trial by jury, as indicated in the complaint, a jury will be provided automatically and you need not fill in this item. If Plaintiff has not demanded trial by jury, you may do so here, but if you do, you must pay an additional cost upon filing this answer.) Dated: ____________________ ________________________________________ Signed ________________________________________ Name (print) ________________________________________ Address (print) ________________________________________ City, state and zip code (print) ________________________________________ Telephone number CERTIFICATE OF SERVICE2 I hereby certify that on this ____ day of ______________, ______ this ______________ (insert paper served, such as “answer” or “notice”) was [mailed by United States first class mail, postage prepaid, and addressed to: Name: __________________________________________________________ Address: ________________________________________________________ City, State _______________________________________________________ and zip code: _____________________________________________________] [faxed by ________________________ (name of person who faxed document) to ______________________ (name of recipient) at _________________ (telephone number). The transmission was reported as complete. The time and date of the transmission was ________ (a.m.) (p.m.) on _____________________ (date).] [e-mailed to ______________________ (name of party or attorney) at _________________ (electronic mail address of recipient) upon agreement of the party to accept electronic service. The transmission was reported as complete. The time and date of the transmission was _________ (a.m.) (p.m.) on _____________________ (date).] [delivered to __________________________ (Specify how service by delivery was made. See Use Note 2 for the methods service that may be made using this alternative) ________________________________________________:] ________________________________ Signature of person sending paper ________________________________ Date of signature