2017 ORS 416.560¹
Form of notice of lien

The form of the notice required by ORS 416.550 (Procedure to perfect lien) (1) shall be substantially as follows:

______________________________________________________________________________

Notice is hereby given that the ________ has rendered assistance to____________, a person who was injured on or about the ___ day of ______ in the city of ______ and State of______, and the ________ hereby asserts a lien to the extent provided in ORS 416.510 (Definitions for ORS 416.510 to 416.610) to 416.610 (Action against recipient who fails to provide notice of claim), for the amount of such assistance upon any amount due and owing ________ (name of injured person) under a judgment, settlement or compromise from ______ alleged to have caused such injuries and from any other person or public body, agency or commission liable for the injury or obligated to compensate the injured person on account of such injuries.

Department of Human Services/Oregon Health Authority

by____________,

Director of ________ or designee.

State of Oregon, )

) ss.

County of______ )

I, ____________, being first duly sworn on oath say: That I am the Director of ________ or designee; that I have read the foregoing notice of lien and know the contents thereof and believe the same to be true.

____________

Subscribed and sworn to before me this ___ day of ______, ______.

____________, Notary Public.

______________________________________________________________________________ [Formerly 411.562; 1969 c.597 §251; 2001 c.600 §6; 2009 c.595 §350]

Atty. Gen. Opinions

Prior right of Motor Vehicles Accident Fund or Adult and Family Services Division to reimburse­ment for costs of medical services provided indigent, (1980) Vol 41, p 257

1 Legislative Counsel Committee, CHAPTER 416—Recovery of Aid and Child Support, https://­www.­oregonlegislature.­gov/­bills_laws/­ors/­ors416.­html (2017) (last ac­cessed Mar. 30, 2018).
 
2 Legislative Counsel Committee, Annotations to the Oregon Revised Stat­utes, Cumulative Supplement - 2017, Chapter 416, https://­www.­oregonlegislature.­gov/­bills_laws/­ors/­ano416.­html (2017) (last ac­cessed Mar. 30, 2018).
 
3 OregonLaws.org assembles these lists by analyzing references between Sections. Each listed item refers back to the current Section in its own text. The result reveals relationships in the code that may not have otherwise been apparent.