Healthcare Lien of Protection

HEALTHCARE LIEN OF PROTECTION

PARTIES AND IDENTIFICATION

Patient Name:

Date of Birth:    Gender:

Phone:    Email:

INSURANCE AND THIRD-PARTY CLAIM

Claim/File Number (if any):    Date Claim Filed:

MEDICAL HISTORY (RELEVANT)

SERVICES, CHARGES AND ACCOUNT

Total Charges: $    Amount Outstanding / Unpaid Balance: $

LIEN AND ASSIGNMENT

For value received, the undersigned patient hereby grants and assigns to the Provider a lien and security interest upon any and all proceeds, claims, causes of action, settlements, judgments, or other recovery (collectively, "Proceeds") that may be owed to the patient arising from the incident, claim, or case described above. This Lien secures the payment of the Provider's charges described in this document in the amount of $ and any additional amounts for authorized services, costs of collection, reasonable attorney fees, and interest as set forth below.

The patient directs and authorizes any third party, including but not limited to insurers, attorneys, and personal injury defendants, to hold and withhold Proceeds sufficient to satisfy the Provider's lien pending resolution of the Provider's claim for payment. Patient further authorizes the Provider to notify any insurance carrier, claims administrator, or attorney representing the patient or an adverse party of the existence of this Lien.

The patient assigns to the Provider the rights to pursue direct payment from settlement proceeds, judgment, or other recovery, and agrees that the Provider may, at its election, perfect this Lien by filing notices or recordable instruments as permitted by applicable law. Patient consents that payment of Proceeds to third parties other than the Provider prior to satisfaction of this Lien shall not discharge the patient’s obligation to the Provider.

AUTHORIZATION TO RELEASE INFORMATION

Patient authorizes the release of medical records and billing information reasonably necessary to enforce this Lien to any insurer, claims administrator, attorney, or tribunal involved in the claim or case. This authorization includes records needed to substantiate charges, dates of service, and treatment rendered.

TERMS OF COLLECTION, INTEREST, AND EXPIRATION

If Proceeds are recovered on the patient’s behalf, the Provider shall be entitled to be paid from those Proceeds the amounts due for medical services, reasonable costs of collection, and attorney fees incurred in the enforcement of this Lien. Interest on unpaid balances shall accrue at the rate of from the date of billing unless otherwise prohibited by law.

This Authorization and Lien shall remain in effect until the Provider's claim is satisfied in full or until , whichever occurs first. Notwithstanding the foregoing, the Provider may take reasonable measures to perfect and enforce this Lien during the effective period.

ACKNOWLEDGMENTS AND REPRESENTATIONS

The patient certifies that the information provided in this document is true and correct to the best of the patient's knowledge. The patient acknowledges and understands that signing this Lien does not relieve the patient of responsibility for payment of medical services rendered and that the Provider retains the right to seek payment directly from the patient if Proceeds are insufficient to satisfy the Provider's claim.

Patient understands the right to revoke this Authorization by submitting written notice to the Provider; however, revocation will not affect disclosures already made in reliance upon this Authorization or the Provider's rights to payment for services provided prior to revocation.

Governing Law: This Lien shall be governed by and construed in accordance with the laws of the state where the Provider is located. If any provision of this Lien is held invalid, the remaining provisions shall remain in full force and effect.

CONSENT TO COLLECTION ACTIONS

Patient authorizes the Provider to take collection actions, including but not limited to: notifying involved insurers and attorneys, filing notices of lien or similar instruments, and commencing legal action to collect the unpaid balance and costs incident to collection. Patient agrees to cooperate reasonably with the Provider, including executing documents and providing information necessary to enforce the lien or pursue recovery.

SIGNATURE AND CERTIFICATION

By signing below, the undersigned certifies under penalty of perjury that the information contained herein is true, that the undersigned has the authority to execute this Lien on behalf of the patient if signing in a representative capacity, and that the undersigned knowingly and voluntarily authorizes the Provider to record and enforce this Lien as stated above.

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