Healthcare Imaging Lien

HEALTHCARE IMAGING LIEN

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Insurance Information

Policy / ID #:    Group #:

Imaging Provider / Billing Entity

Billing Contact:    Phone:

Account and Service Details

List of imaging services for which lien is asserted (enter all applicable; attach additional statement if necessary):

Lien Declaration

Effective Date: — For valuable consideration and in consideration of the imaging services provided and to be provided to Patient named above, the Provider hereby asserts and Patient hereby grants to Provider a lien (the "Lien") against any and all proceeds, causes of action, settlements, judgments, awards, or claims (collectively, "Proceeds") now existing or hereafter arising from any claim related to the condition for which the above imaging services were performed.

The Lien secures payment for all sums due for imaging services described herein and for related expenses, including but not limited to diagnostic interpretation, facility fees, and radiologist professional fees, to the extent permitted by law and up to the Total Amount Claimed listed above. Patient grants Provider the right to enforce the Lien against Proceeds recovered by settlement, judgment, or otherwise.

Assignment of Rights and Authorization to Pay

Patient assigns and transfers to Provider any rights Patient may have to payment from any third party, insurer, attorney, or other payor for the imaging services described. Patient authorizes and directs any insurer, attorney, claims administrator, or other payor holding Proceeds to issue payment directly to Provider up to the amount of the Lien. This assignment does not alter Patient's obligation to pay Provider for services rendered.

Claim / File Number (if known):    Insurer / Payor Name:

Authorization to Release Information

Patient authorizes Provider to release to any insurer, claims administrator, attorney, or other payor any and all medical information, records, images, and billing information necessary to perfect and enforce the Lien and to secure payment. Patient further authorizes Provider to obtain from any treating provider or facility such records as are necessary to substantiate charges.

Expiration and Term

Unless earlier released in writing by Provider, this Lien shall remain in full force and effect until the earlier of: (a) payment in full of all amounts secured by this Lien; or (b) expiration on: . Provider may, at its option, renew or reassert the Lien consistent with applicable law.

Representations, Warranties and Acknowledgments

Patient represents that Patient has authority to grant this Lien and assignment, that the information provided herein is true and correct, and that there are no prior valid liens or encumbrances on the same Proceeds in favor of Provider except as disclosed in writing. Patient acknowledges receipt of copies of this Lien upon request.

Remedies and Enforcement

Provider shall be entitled to pursue any and all remedies available under law to enforce this Lien, including but not limited to suit against Proceeds, collection actions, and recovery of reasonable costs and attorneys' fees where permitted by law. Patient agrees to notify Provider promptly of any demand, settlement negotiation, or payment relating to claims that may give rise to Proceeds subject to this Lien.

HIPAA / Privacy Acknowledgment

Patient acknowledges that Provider has provided or made available its Notice of Privacy Practices describing how health information may be used and disclosed. By signing below Patient expressly authorizes release of protected health information as necessary to effectuate the Lien, assignment, and collection efforts related to the services described herein.

Patient acknowledges and understands that this Lien does not create an attorney-client relationship between Provider and any attorney representing Patient, and that Provider does not provide legal advice. Patient is encouraged to consult with Patient's own legal counsel regarding the implications of this Lien.

Sign Now