Healthcare Doctor's Lien

HEALTHCARE DOCTOR'S LIEN

This Doctor's Lien ("Lien") is made by and between the healthcare provider identified below and the undersigned patient to secure payment for medical services, supplies, treatment, and related charges rendered on account of injuries sustained by the patient.

Provider Information

Patient Information

Date of Birth:    Gender:

Claim, Insurance, and Attorney Information

Dates of Service and Charges

Dates of Treatment: From to

Lien Terms and Authorization

For value received, Provider asserts and claims a lien upon any and all causes of action, claims, demands, actions, rights of recovery, insurance proceeds, settlement proceeds, judgment proceeds, and other sums payable to Patient or on Patient's behalf arising out of or related to the injuries for which Provider furnished medical services. This Lien secures payment of all charges for services, supplies, and treatment rendered by Provider to Patient.

Patient hereby assigns and transfers to Provider an undivided interest in any recovery arising from the incident described above and authorizes any insurer, claims representative, or third party to pay Provider directly from any settlement or judgment. Patient also authorizes release of medical records, bills, and any other documentation reasonably necessary to substantiate Provider's claim and to enforce this Lien.

Provider may enforce this Lien against settlement proceeds, arbitration awards, judgments, or other sums recovered by Patient. In the event of collection or enforcement proceedings, Patient agrees to pay reasonable collection costs, court costs, and attorney fees incurred by Provider to protect and enforce the Lien, to the extent permitted by law.

Interest shall accrue on any unpaid balance at a rate not to exceed the maximum lawful rate permitted by applicable law, commencing thirty (30) days after written demand for payment is delivered to Patient or Patient's counsel. Patient acknowledges that payments received by Patient or by counsel representing Patient shall be applied first to costs of collection and interest, then to Provider's outstanding balance.

This Lien shall remain in effect until the charges secured hereby are paid in full or until otherwise released in writing by Provider. Provider's rights under this Lien are cumulative of any other rights and remedies available at law or in equity.

Privacy and Release of Information

I authorize Provider to disclose my medical records, billing records, and related information to insurers, counsel, claims representatives, and other persons or entities as necessary to pursue payment of the Lien and to substantiate charges. This authorization includes release of otherwise protected health information for the limited purpose of claims administration, settlement, and enforcement of this Lien.

Acknowledgment and Certification

I certify that I am the patient (or legal guardian or authorized representative of the patient) and have read and fully understand the terms of this Lien. I acknowledge that I have been informed of my obligation to pay Provider for services rendered, that Provider has the right to record a lien or take other collection steps if payment is not made, and that I have been provided the opportunity to ask questions about this Lien.

I further certify under penalty of perjury under the laws applicable that the foregoing is true and correct and that I have authority to execute this Lien (or am the parent/guardian of the patient).

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