Fill and Sign the Notice of Lien for Medial Services by Hospital Form

NOTICE OF LIEN FOR MEDICAL SERVICES BY HOSPITAL NOTICE is hereby given that ___________________________ has rendered services for hospitalization, physician services, or special nurses' services for ____________________, a person who was injured on the _________ day of ___________ at ____________ in the state, and the _____________________ (claimant) hereby claims a lien upon any money due or owing or any claim for compensation, damages, contribution, settlement, or judgment from _________ ____________________________ alleged to have caused the injuries and any other person liable for the injury or obligated to compensate the injured person on account of the injuries; the hospitalization, physician services, or special nurses' services were rendered to the injured person between the ___________ day of _________ and ________________________________________ and that 90 days have not elapsed since that time; that the claimant's demands for care and service is in the sum of $____________ and that no part of the demands has been paid, except $_______________, and that there is now due and owing and remaining unpaid thereof, after deducting all credits and offsets, the sum of $__________, in which amount lien is hereby claimed. General Description of Services Rendered and Statement of Amount Due: _________________________________ BY: _____________________________ ITS: _____________________ State of Alaska________________________ Judicial District I, _________________________________, being first duly sworn on oath say: That I am _________________________________ named in the foregoing claim of lien; that I have read the same and know the contents thereof and believe the same to be true. ____________________________________ SignatureSubscribed and sworn to before me this ________ day of ______________, 19_______ __________________________________Notary Public for Alaska AK-02014