Healthcare Neuro Lien

HEALTHCARE NEURO LIEN

Document Analysis (Designer Notes)

This Healthcare Neuro Lien is a bilateral agreement in which the patient (or the patient's authorized representative) grants a lien to the treating neurological provider/clinic securing payment of reasonable and customary charges for medical services related to a specific incident or claim. The document includes: identification of parties; patient and provider contact and treatment details; account status and estimated balance; a clear lien provision attaching to proceeds from claims, settlements, judgments, or insurance recoveries; authorization to release medical records and to receive disbursements from attorneys or insurers; HIPAA acknowledgement; expiration of authorization; billing and collection remedies; and certifications by both parties. Two signing parties are required: Patient (or authorized representative) and Provider (or authorized representative of Provider).

Recitals

This Healthcare Neuro Lien Agreement (the "Lien") is entered into between the Treating Provider and the Patient identified below. The Patient has received, or may receive, neurological evaluation, diagnostic testing, treatment, and related medical services from the Provider. The parties desire to secure payment for services rendered to the Patient by creating a lien against any and all proceeds the Patient may receive from a claim, lawsuit, settlement, judgment, arbitration award, or other recovery (collectively, the "Recovery") that arise out of the incident described below.

Patient Information

Provider Information

Treatment & Account Information

Lien Terms and Authorization

For good and valuable consideration, the receipt of which is acknowledged, Patient hereby grants and assigns to Provider a first-priority lien against any Recovery to the extent of Provider's reasonable and customary charges for the neurological services identified herein. This lien secures payment of past, present, and future charges for services rendered that relate to the incident described above and any reasonable costs of collection, including attorney fees and interest where permitted by law.

Patient authorizes Provider to furnish copies of medical bills, records, and this Lien to any attorney, insurer, third-party payer, claims adjuster, medical examiner, or other party responsible for payment of a Recovery. Patient authorizes any attorney or insurer in possession of funds to disburse directly to Provider the amount necessary to satisfy Provider's lien prior to distribution of remaining proceeds to the Patient or others. This authorization is a direct assignment of a portion of Patient's right to payment from any Recovery to Provider, limited to the amount of Provider's billed charges less any applicable payments or contractual adjustments.

The lien does not extend to funds specifically designated for non-economic damages for pain and suffering, except to the extent allowed by controlling law or by express agreement in writing. Provider's right to payment is subject to any existing legal priority of Medicare, Medicaid, or other statutory liens; however, Patient agrees to cooperate in pursuing reductions, reimbursements, or coordination efforts necessary to satisfy this lien consistent with applicable law.

HIPAA Authorization & Acknowledgements

Patient expressly authorizes Provider to use and disclose the Patient's protected health information (PHI) to attorneys, insurers, claims administrators, and other parties as necessary to enforce this Lien and to obtain payment. Patient acknowledges receipt of the Provider's Notice of Privacy Practices and understands that this authorization is voluntary but necessary to permit Provider to pursue collection from any Recovery.

I acknowledge receipt of the Provider's Notice of Privacy Practices and authorize release of PHI as described above.

Medicare/Medicaid or other statutory lien may be involved in this matter (check if applicable).

Collection, Billing and Dispute Resolution

If payment of the lien is not made from available Recovery proceeds, Provider may seek enforcement through appropriate legal remedies, including collection actions. Provider may charge interest on unpaid balances at the maximum lawful rate and recover reasonable costs of collection and attorney fees permitted by law. Any dispute arising under this Lien shall be governed by the substantive laws of the state in which Provider's principal place of business is located, without regard to choice-of-law rules.

Patient Certifications

By signing below, Patient certifies that: (1) the information provided in this Lien is true and correct to the best of Patient's knowledge; (2) Patient has received and understands the terms of this Lien and the HIPAA authorization contained herein; (3) Patient authorizes Provider to pursue payment from any Recovery and to be bound by the lien provisions above; and (4) Patient will promptly notify Provider and Patient's attorney of any settlement, offer, or payment relating to the claim identified in this Lien.

Provider Certification

The undersigned Provider certifies that the charges secured by this Lien are for services reasonably necessary for the evaluation and treatment of the Patient's neurological condition and that records supporting these charges are on file and may be provided pursuant to the authorization above.

Certification: Both Patient and Provider acknowledge that this Lien constitutes a binding assignment and authorization concerning recovery proceeds. Patient acknowledges the duty to notify Provider and Patient's counsel of any offer, settlement, or judgment. Provider acknowledges that acceptance of disbursement pursuant to this Lien obligates Provider to apply payments against the stated account and to cooperate with reasonable documentation requests necessary to effectuate lien satisfaction.

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