Healthcare Medical Lien Form

Healthcare Medical Lien Form

Provider Information

Patient Information

Patient Name:

Claim and Incident Information

Date of Injury/Incident:

Insurance Information

Medical Information

Statement of Account

Provide an itemized description of services rendered, dates of service, and amounts. This will form the basis of the lien claim.

Additional Charges: The provider reserves the right to seek reasonable costs of collection, interest on unpaid balances where permitted by law, and legal fees where collection requires legal action.

Lien and Assignment of Rights

By signing below, Patient Name: acknowledges that the provider identified above has performed medical services and hereby asserts a lien against any and all causes of action, judgments, settlements, insurance proceeds, or other recoveries arising from or related to the incident described herein, up to the amount of the provider's reasonable and customary charges for such services.

Patient assigns to Provider all rights to recover medical expenses from third-party defendants or their insurers to the extent of the Provider's billed and unpaid balance. Provider's lien is intended to be a primary charge against any recovery related to the injury for which care was rendered and shall be paid from any settlement, judgment, award, or proceeds prior to distribution to the patient or patient’s counsel.

Patient agrees to promptly notify Provider and to provide Provider with copies of any demand, correspondence, settlement communications, pleadings, or other documents related to any claim or potential recovery. Patient further authorizes Provider to communicate directly with Patient's attorney or claims representative regarding the lien.

Authorization to Release Information

Patient authorizes Provider to release medical records, billing records, and any other documentation necessary to substantiate Provider's lien to third-party payors, adjusters, attorneys, and courts as required to enforce this lien. This authorization includes records necessary to negotiate, prosecute, or defend claims arising from the incident.

Patient Acknowledgment and Certification

I certify that I am the patient named in this form or the authorized guardian of the patient. I understand and agree that Provider may enforce its lien against any recovery related to the injury for which Provider rendered services. I acknowledge that I have read and understand this Medical Lien Form, that the statements made herein are true and correct to the best of my knowledge, and that I will cooperate with Provider in pursuing payment from third-party recoveries.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been provided with the Provider's Notice of Privacy Practices regarding use and disclosure of my protected health information. I consent to release the records and information as described in this form for the purposes of lien enforcement, claims handling, and reimbursement.

Acknowledgment: I acknowledge receipt of the Provider's privacy notice and consent to release records as described.

Governing Law and Miscellaneous

This Medical Lien Form shall be governed by the laws of the state in which the Provider is located to the extent permitted by law. If any provision of this form is held invalid or unenforceable, the remaining provisions shall remain in full force and effect. Provider retains all rights and remedies available under law to enforce this lien and to seek recovery for unpaid medical services.

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