Legal Hospital Lien Form

LEGAL HOSPITAL LIEN FORM

This Hospital Lien ("Lien") is entered into effective as of by and between Lienholder: with principal place of business at and Patient/Debtor: whose address is .

RECITALS

WHEREAS, Lienholder is a hospital or medical provider that rendered medical services, care and related items to Patient in connection with injuries sustained by Patient on or about (the "Incident"); and

WHEREAS, Patient has or may have claims, causes of action, judgments, settlements, policy proceeds or other recovery (collectively, "Proceeds") arising from the Incident; and

WHEREAS, Lienholder seeks to secure payment of amounts owed to Lienholder for reasonable and necessary medical services and related charges by asserting a lien on any Proceeds recovered by or on behalf of Patient.

NOW, THEREFORE

In consideration of the mutual covenants and promises contained herein, the parties agree as follows:

1. DEFINITIONS

For purposes of this Lien, the following terms shall have the meanings ascribed: "Charges" means all hospital and medically related fees, costs, expenses and other amounts billed to Patient by Lienholder for services rendered in connection with the Incident; "Proceeds" has the meaning set forth above.

2. STATEMENT OF AMOUNT AND SERVICES

Lienholder asserts a lien in the aggregate amount of $ representing Charges for services rendered to Patient during dates of service from through . A detailed itemization of services, charges and account balance is attached or described below.

3. LIEN AND SECURITY INTEREST

To secure payment of the Charges, Lienholder hereby asserts a lien on any and all Proceeds recovered by Patient from any third party, insurer, tortfeasor, settlement, judgment, arbitration award, or other source, whether by settlement, judgment or otherwise. This lien is a charge against such Proceeds, and Patient agrees not to permit disbursement of such Proceeds without satisfaction or appropriate protection of this lien.

4. NOTICE TO THIRD PARTIES AND ATTORNEYS

Patient represents that Patient has notified, or will promptly notify, any attorney, insurer, claims administrator or third party responsible for Proceeds of the existence of this lien and of the obligation to retain sufficient funds to satisfy the lien. If Patient is represented by legal counsel, counsel's name is: and counsel's address is: .

5. ENFORCEMENT AND REMEDIES

If Proceeds are paid to Patient, Patient's counsel, or any third party without providing for payment of this lien, Lienholder may recover from Patient or such third party the unpaid Charges and pursue any remedies available at law or equity, including but not limited to instituting an action to enforce this lien, recovering costs of collection and reasonable attorneys' fees. Lienholder's rights under this section are cumulative and in addition to any other rights or remedies.

6. LIMITATIONS

This Lien is limited to Charges for services rendered by Lienholder and shall not exceed the reasonable value of such services. Lienholder will provide upon request copies of records, itemized bills, and supporting documentation substantiating the Charges and the balance claimed.

7. CERTIFICATION BY LIENHOLDER

Lienholder certifies under penalty of perjury that the Charges are true and accurate to the best of Lienholder's knowledge, that the services were necessary and were provided to Patient, and that the amount claimed is reasonable for the services billed. Lienholder further certifies that, to the extent known, no prior valid lien exists that would have priority over this lien for the same charges.

8. ACKNOWLEDGMENT BY PATIENT

Patient acknowledges receipt of a copy of this Lien, acknowledges being informed of the amount claimed, and agrees that Patient will not authorize release of Proceeds to any person or entity without paying this Lien in full or making other arrangements acceptable to Lienholder.

9. NOTICES

All notices, demands or other communications required or permitted under this Lien shall be in writing and delivered by hand, certified mail, or overnight courier to the addresses set forth below (or to such other address as a party may designate in writing).

10. AMENDMENT, WAIVER AND COUNTERPARTS

This Lien may be amended or modified only by a writing signed by both parties. No waiver by either party of any breach or default shall constitute a waiver of any other right or subsequent breach. This Lien may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

11. GOVERNING LAW

This Lien shall be governed by and construed in accordance with the laws of the State specified below without regard to its conflict of laws principles. The parties submit to the exclusive jurisdiction of the courts of that State for disputes arising under this Lien.

12. ENTIRE AGREEMENT; SEVERABILITY

This Lien constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings. If any provision of this Lien is held to be invalid or unenforceable, the remaining provisions shall remain effective and enforceable to the fullest extent permitted by law.

13. EXECUTION AND ACKNOWLEDGMENT

Each signatory below represents and warrants that such person is duly authorized to execute this Lien on behalf of the party for which such person signs, and that the information contained herein is true and correct.

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