Healthcare Lien Form

HEALTHCARE LIEN FORM

Patient Name:   Provider Name:

Patient Information

Provider & Billing Information

Claim / Incident Information

Treatment & Charges

Lien Statement, Authorization & Release

Provider hereby asserts and records a lien upon any and all proceeds of any claim, cause of action, judgment, settlement, verdict or other recovery that the patient may obtain from any third party, insurer, uninsured or underinsured motorist coverage, or other responsible person or entity, whether by settlement, arbitration award or court judgment, to the extent necessary to secure payment for services rendered and to be rendered by the provider for the injury described above (the "Lien"). The Lien secures all reasonable and customary charges for professional services, supplies and equipment provided to the patient related to the injury, including costs of collection and reasonable attorney fees incurred in enforcing this Lien where permitted by law.

Patient authorizes and directs any attorney, insurer, claims administrator, third-party payor, or other responsible party to withhold or cause to be withheld from any settlement, judgment, award or other recovery an amount sufficient to satisfy the Provider's Lien, and to remit such funds directly to Provider upon resolution of the claim. This authorization constitutes an assignment of the patient's right to receive payment from any third party to the extent of the Provider's Lien. Patient further authorizes the release of medical records and billing information to third parties, attorneys, insurers and their representatives as necessary to investigate, evaluate, document, secure, and enforce the Lien.

Patient understands and acknowledges that the Provider may pursue collection against any proceeds of recovery, and may enforce the Lien through settlement negotiations, arbitration or court proceedings if necessary. Patient agrees not to settle or release any claim without first notifying Provider and satisfying the Provider's Lien in full or entering into a written agreement with Provider regarding payment. Patient further acknowledges the right to seek independent legal counsel regarding the effect of this Lien on any recovery.

This authorization to release information, to assert a lien and to receive payment from settlement proceeds shall remain in effect until satisfied in full or until the following expiration date, whichever occurs first.

Acknowledgment & Certification

By signing below, Patient certifies that the information provided in this form is true and accurate to the best of Patient's knowledge; that Patient has received a clear explanation of the Lien and the Provider's billing practices related to this matter; that Patient authorizes the release of medical and billing records as necessary to pursue the Lien; and that Patient consents to Provider asserting and enforcing the Lien as described above. Patient further acknowledges that Provider has not guaranteed the amount that may be recovered from any third party and that Provider's Lien is limited to the amounts charged and allowable for treatment related to the incident described herein.

Patient acknowledges the right to revoke this authorization in writing, which revocation shall not apply to disclosures or actions already taken in reliance on this authorization. Revocation does not extinguish the Provider's right to assert a Lien for services already rendered prior to such revocation.

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