Healthcare Medical Lien

HEALTHCARE MEDICAL LIEN

Parties and Claimant Identification

Patient Name:

Date of Birth:    Gender:

Provider / Lienholder Information

Provider Entity Type: Hospital Clinic Physician Other

Insurance / Claim Information

Medical Treatment and Charges

From:    To:

Total Charges Incurred: $    Amount Claimed as Lien: $

Lien Grant, Terms, and Authorization

For and in consideration of medical services provided by to the Patient named above, Patient hereby grants and conveys a lien upon any and all proceeds, recovery, settlement, judgment, or other proceeds from any third-party claim, liability, or insurance relating to the incident that necessitated such medical services.

Patient authorizes any attorney representing Patient, and any insurer, to withhold from settlement, judgment, or other recovery such sums as are due and owing to Provider for care rendered, including principal, agreed interest, and reasonable costs and attorneys' fees incurred in enforcing this lien. Patient further authorizes Provider to enforce this lien against any settlement or recovery on Patient's behalf until full payment is received.

Interest Rate on Unpaid Balance: . Patient agrees that Provider may recover reasonable collection costs, including attorneys' fees, if enforcement becomes necessary.

This lien constitutes an express assignment of a portion of any recovery sufficient to satisfy Provider's lien. Patient certifies that Patient is the person entitled to the proceeds and has authority to grant this lien. If Patient is not the claimant, the person signing below warrants that they are authorized to sign on behalf of the claimant and that the claimant will be bound by this lien.

Patient authorizes Provider to release medical records, billing records, and pertinent facts of treatment to Patient's attorney, insurer, claims adjuster, or other responsible parties for the purpose of enforcing this lien and for resolving claims related to the incident. Patient also authorizes any insurer or attorney holding settlement proceeds to provide payment information directly to Provider upon request.

This authorization and lien shall remain in effect until the lesser of full satisfaction of the amount claimed as lien or until , unless sooner released in writing by Provider.

Acknowledgments and Representations

Patient represents and warrants that: (a) all information provided in this Medical Lien is true and correct to the best of Patient's knowledge; (b) Patient has not assigned the proceeds of any claim to another party except as disclosed herein; and (c) Patient will notify Provider in writing of any settlement, judgment, or change in counsel or insurer handling the claim.

Governing Law: This Medical Lien shall be governed by and construed in accordance with the laws of the state where Provider rendered services, without regard to conflict of law principles. If any provision of this Lien is held invalid, the remaining provisions shall continue in full force and effect.

Certification and Signatures

By signing below, Patient certifies under penalty of perjury that Patient has read and understands this Medical Lien, consents to the release of records as described above, and agrees that Provider may pursue any remedies available to enforce payment of the lien. Provider certifies that the services and amounts claimed are accurate to the best of Provider's knowledge and that Provider is authorized to file and enforce this lien.

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