ERISA Lien Claim Form

ERISA LIEN CLAIM FORM

This ERISA Lien Claim Form is submitted by Claimant Name: (Claimant) to Plan Name: (Plan), administered by Plan Administrator: concerning Participant/Patient: born .

RECITALS

WHEREAS, Claimant provided medical services, treatment or paid benefits for the Participant as described herein, and Claimant asserts a right to reimbursement, subrogation or equitable lien against benefits payable under the Plan arising from such services;

WHEREAS, the Plan is an employee benefit plan governed by the Employee Retirement Income Security Act of 1974 (ERISA) and the Plan or Plan Administrator may hold or administer assets or benefits subject to equitable liens, subrogation rights, reimbursement provisions, or assignment rights as set forth in the Plan documents; and

WHEREAS, Claimant seeks formal notice to the Plan of Claimant's asserted lien, the amount claimed, supporting documentation, and a demand for reimbursement from Plan benefits or other proceeds.

NOW, THEREFORE

Claimant submits the following claim and asserts the below-described lien and demand against Plan benefits, and in support thereof provides the factual and legal information requested.

1. CLAIM INFORMATION

Date(s) of Service: | Invoice/Claim No.: | Provider Tax ID/EIN:

2. BASIS FOR LIEN / AUTHORITY

Claimant asserts this lien under the express terms of the Plan and applicable equitable doctrines recognized under ERISA, including but not limited to subrogation, reimbursement, and constructive trust remedies. Claimant represents that it has a contractual, statutory or equitable right to be reimbursed from benefits or recoveries paid to or for the Participant. Claimant further represents that any assignment, subrogation agreement, coordination-of-benefits provision, or Plan provision that grants Claimant rights to recover funds has been attached to this form or will be provided upon request.

3. SUPPORTING DOCUMENTATION

The following documents are submitted in support of this claim (check all that apply):

Itemized bills or invoices
Medical records or treatment summaries
Explanation of Benefits (EOB) or Plan payment records
Assignment, subrogation or reimbursement agreement
Other

4. DEMAND, PAYMENT INSTRUCTIONS AND DEADLINE

Claimant demands payment of the claimed amount to Claimant Payee Name: at Payment Address: . If payment is not made or an allowable offset is not applied within Response By Date: , Claimant reserves the right to seek enforcement, equitable relief, attorneys' fees and interest to the fullest extent permitted by the Plan and applicable law.

5. CALCULATION OF AMOUNT CLAIMED

Original billed charges: ; Payments and adjustments received: ; Net amount claimed: .

6. REPRESENTATIONS, WARRANTIES AND CERTIFICATION

Claimant hereby certifies under penalty of perjury that the information provided herein is true, complete and accurate to the best of Claimant's knowledge, that Claimant is the lawful holder of the claimed lien or is authorized to assert the claim on behalf of such holder, and that Claimant has not previously released or waived the asserted rights except as disclosed in writing. Claimant further represents that all charges for which reimbursement is sought were reasonable and related to the treatment of the Participant unless otherwise indicated.

7. REMEDIES, ENFORCEMENT AND LIMITATIONS

Claimant may seek enforcement of this lien by means permitted under the Plan and ERISA, including equitable relief, setoff, recoupment or recovery from benefit payments, settlement proceeds, or other recoveries attributable to the Participant's claim. Claimant also reserves the right to seek reasonable attorneys' fees and costs where provided by the Plan or applicable law. Nothing in this form shall be construed to waive Claimant's right to assert additional claims or defenses.

8. NOTICES

All notices, demands, or communications regarding this claim shall be delivered to the addresses set forth below. Notice to the Plan should be directed to Plan Administrator Contact: and Plan Address:

Notice to Claimant should be sent to Claimant Contact listed above at:

9. AMENDMENT, WAIVER, COUNTERPARTS

This claim may be amended by written notice to the Plan to provide additional documentation or modify the amount claimed. No waiver by either party of any provision of this claim form shall be effective unless in writing and signed by an authorized representative. This form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

10. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

Governing Law: This claim and any enforcement proceedings shall be governed by the laws governing the Plan and federal law as applicable to ERISA-governed plans. Entire Agreement: This form, together with attachments and the Plan documents incorporated herein by reference, constitutes the entire statement of Claimant's lien claim and supersedes all prior written or oral statements concerning the subject matter. Severability: If any provision of this claim is held invalid or unenforceable, the remaining provisions shall continue in full force and effect to the extent permitted by law.

11. AUTHORIZED REPRESENTATIONS

The undersigned represents and warrants that the signer is authorized to submit this claim on behalf of Claimant and that the information and documents submitted are true, complete and accurate to the best of the signer's knowledge.

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