Legal Injury Lien Form

LEGAL INJURY LIEN FORM

This Legal Injury Lien Form (the lien) is made effective as of by and between Lienholder Name: with principal address and Claimant Name: with address .

RECITALS

WHEREAS, on or about the date of loss occurring on , the Claimant suffered injuries arising out of events related to Claim Number: ; and

WHEREAS, the Lienholder has provided medical and related services, supplies, and/or legal services to or on behalf of the Claimant and has incurred charges for such services which remain unpaid; and

WHEREAS, the parties desire to set forth their agreement concerning the security interest, assertion of lien against proceeds of any recovery, and the procedures for satisfaction or release of the lien.

NOW, THEREFORE

In consideration of the mutual promises and covenants contained herein, and other good and valuable consideration, the sufficiency of which is hereby acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Lien, the following definitions apply: "Recovery" means any settlement, judgment, award, compromise, or other distribution obtained by or on behalf of the Claimant arising from the incidents described above; "Proceeds" means funds from any Recovery from which payment is or may become due to the Claimant.

2. STATEMENT OF LIEN

The Lienholder hereby asserts and records a lien against any present or future Recovery of the Claimant to secure payment of all sums due for services rendered, including medical expenses, treatment, supplies, related charges, and reasonable collection expenses. The principal amount claimed under this lien as of the effective date is plus any accruing charges, costs, interest, and allowed fees.

3. DESCRIPTION OF SERVICES AND CHARGES

The amounts set forth in the itemization are reasonable and were incurred for services necessary to the treatment of the Claimant's injuries. The Lienholder affirms that the charges are for treatment related to the incident identified above unless otherwise specified in writing.

4. PRIORITY AND PAYMENT FROM RECOVERY

The parties agree that this lien attaches to any Recovery and that payment of the lien shall be made from Proceeds prior to disbursement to the Claimant except as otherwise required by operation of law. The Claimant and any attorney, insurer, or other payor holding Proceeds shall be authorized and directed to withhold from any Recovery sufficient funds to satisfy the lien amount plus any agreed fees and costs.

Lienholder may agree in writing to accept a lesser sum or a structured payment plan. Any such agreement must be memorialized in a written release or settlement agreement signed by both parties and shall specify the method and timing for release of the lien upon receipt of agreed consideration.

5. AUTHORIZATION TO RELEASE RECORDS

The Claimant authorizes the Lienholder to release and exchange medical records, billing information, treatment summaries, and other documents pertaining to the Claimant's care as necessary to enforce or settle this lien with insurers, attorneys, or other third parties. The Claimant further authorizes the Lienholder to communicate with insurers, claims adjusters, and counsel concerning the outstanding balance.

6. NOTICE

All notices required or permitted under this Lien must be in writing and delivered to the following addresses by personal delivery, certified mail, or overnight courier:

7. DURATION; RELEASE

This lien remains effective until paid in full, released in writing by the Lienholder, or otherwise extinguished by operation of law. Upon receipt of payment in full, the Lienholder shall promptly execute and deliver a written release of lien and any requested documentation necessary to evidence satisfaction of the lien.

8. ENFORCEMENT; REMEDIES

The Lienholder shall have the right to pursue all remedies at law or in equity to enforce this lien, including but not limited to actions to compel payment from Proceeds, to obtain a judgment, or to seek injunctive relief. The prevailing party in any enforcement action shall be entitled to recover reasonable attorneys' fees, costs, and interest as allowed by law.

9. AMENDMENT; WAIVER

This Lien may be amended only by a written instrument signed by both parties. No waiver of any provision or breach shall constitute a waiver of any other provision or subsequent breach unless made in writing and signed by the party granting the waiver.

10. GOVERNING LAW

This Lien shall be governed by and construed in accordance with the laws of the state identified below without regard to its conflict of laws principles. The parties consent to the exclusive jurisdiction of the state and federal courts located within that state for any dispute arising out of or relating to this Lien.

11. ENTIRE AGREEMENT

This Lien constitutes the entire agreement between the parties with respect to its subject matter and supersedes all prior and contemporaneous agreements, understandings, and negotiations, whether written or oral.

12. SEVERABILITY

If any provision of this Lien is held to be invalid, illegal, or unenforceable in any respect, such invalidity, illegality, or unenforceability shall not affect any other provision, and this Lien shall be construed as if such invalid, illegal, or unenforceable provision had never been contained herein.

MISCELLANEOUS

By signing below, the Claimant acknowledges receipt of a copy of this Lien, acknowledges the amounts set forth in the itemization to the extent known, and authorizes the Lienholder to assert and enforce this Lien against any Recovery. The Claimant further acknowledges the Claimant has had the opportunity to seek independent advice regarding this Lien.

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