Healthcare Signed Lien Form

HEALTHCARE SIGNED LIEN FORM

Patient Information

Provider Information

Insurance / Third-Party Claim

Services, Charges and Account

Lien and Assignment of Proceeds

For valuable consideration received, Patient Name: hereby grants and conveys to Provider: a lien upon and an assignment of any and all proceeds, recoveries, settlements, judgments, or other compensation obtained from any third-party claim, liability insurance, uninsured/underinsured motorist coverage, workers' compensation, or other source arising from the incident described as: .

Patient acknowledges and agrees that Provider's lien secures payment of all reasonable and customary charges for services and supplies rendered by Provider related to the above claim, including interest and collection costs where permitted by law. Patient assigns to Provider a portion of any recovery sufficient to fully satisfy Provider's billed amount and any agreed-upon collection expenses.

Patient directs and authorizes any attorney, claims administrator, insurer, third-party payer, or other responsible party to notify Provider of any settlement, judgment, or payment and to make payment directly to Provider up to the amount of the lien. This authorization survives discharge in bankruptcy to the extent permitted by law.

Release of Records and HIPAA Authorization

Patient hereby authorizes Provider and its agents to disclose protected health information necessary to evaluate and enforce this lien to insurers, attorneys, claims representatives, and courts. Such information may include medical records, bills, itemized statements, and treatment summaries. Patient expressly authorizes release of records to the attorney or insurer handling the claim named above.

This authorization is voluntary but is necessary for Provider to assert and collect its lien. Patient understands that revocation of this authorization prior to the resolution of claims may impair Provider's ability to collect and may not be effective with respect to actions already taken in reliance on this authorization.

Acknowledgments and Consent

Patient acknowledges receipt of itemized billing upon request and the right to request an accounting of all payments received on account of the lien. Patient further acknowledges that Provider has not guaranteed a particular result in any third-party recovery and that Provider may pursue collection through legal means if necessary.

Patient affirms that the information provided in this form is true and correct to the best of Patient's knowledge. Patient understands that knowingly providing false information may subject Patient to civil or criminal penalties under applicable law.

Unless an earlier date is specified above, this authorization and assignment shall remain in effect until Provider's billed amount is satisfied in full or until revoked in writing, subject to any limitations under applicable law.

Patient Medical History (for lien verification)

Certification

By signing below, Patient certifies that Patient has read and understands the terms of this lien and assignment, that Patient authorizes the disclosures and assignments described herein, and that Patient consents to Provider's assertion and enforcement of a lien against any third-party recovery related to the above-described incident.

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