Healthcare MRI Lien

HEALTHCARE MRI LIEN

Provider Name:    Provider Address:

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Relationship:    Phone:

Insurance Information

Policy/ID Number:    Group Number:

Service and Account Details

Date(s) of Service:

Total Charges: $    Amount Outstanding: $

Statement of Lien and Assignment

The undersigned Patient hereby acknowledges receipt of MRI services from Provider and grants Provider a lien (the "Lien") to secure payment for the reasonable and customary charges for such services. Patient assigns and transfers to Provider all rights, claims, proceeds, causes of action, recoveries, settlements, judgments and/or verdicts against any third party, insurer or benefit plan arising from the events or injuries for which the MRI services were provided, up to the amount of the outstanding balance stated above together with reasonable costs, collection fees and attorneys' fees incurred in enforcing this Lien.

Patient authorizes Provider to notify any third party payer, adjusting company, attorney, or other person or entity reasonably likely to pay proceeds of a claim, of the existence of this Lien and to request that such party withhold payment in whole or in part until the Lien is satisfied. Patient further agrees not to release, compromise, or settle any claim for proceeds without first providing Provider with written notice and an opportunity to assert and enforce this Lien.

Lien Expiration Date: . If proceeds subject to this Lien are paid to Patient, Patient agrees to remit payment to Provider within days of receipt.

Assignment of Benefits and Authorization

Patient assigns and transfers to Provider the right to be paid directly from any settlement, judgment, verdict or other recovery arising from the Event. Patient authorizes release of medical records, billing information and reports related to the MRI services to any insurer, claims administrator, attorney or third party as necessary to enforce this Lien and collect payment. This authorization includes disclosure of Protected Health Information as permitted by law.

I authorize the release of medical records and billing information to insurers, attorneys, adjusters, and other payors for the purpose of claim resolution and lien enforcement.
I authorize direct payment to Provider from any settlement, judgment, or third-party proceeds up to the outstanding balance owed to Provider.
I acknowledge I have received Provider's privacy practices and understand that my Protected Health Information may be used to process these claims and enforce this Lien.

Patient Certification and Acknowledgment

By signing below, Patient certifies under penalty of perjury that the information contained in this Lien is true and correct to the best of Patient's knowledge, that Patient has the authority to assign and otherwise grant the rights and authorizations contained herein, and that Patient understands this Lien creates a security interest in any proceeds recovered on account of the injury or event giving rise to the MRI services. Patient understands that Provider may seek recovery of the balance of charges, interest, costs and attorneys' fees from proceeds and, if necessary, through lawful collection remedies.

Patient further acknowledges that execution of this Lien is not contingent upon the negligence of any party and that Patient has not been coerced to sign. Patient agrees to notify Provider promptly if any claim, demand, suit, settlement negotiation, or payment is initiated or concludes.

Additional Information

Phone:    Claim/File Number:

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