Pennsylvania Doctor's Lien and Patient Consent

PA health care providers, preserve your lien rights for medical services rendered with this Pennsylvania Doctor's Lien and Patient Consent to Release Records.

• The patient consents to treatment and authorizes release of all medical information with respect to the patient's claim regarding the accident or injury for which the patient is being treated.
• The patient agrees to be personally liable for paying the medical provider's fees regardless of the outcome of the patient's claim.
• The patient gives the medical provider an irrevocable lien on any settlement or damages awarded to the patient and directs his/her attorney to satisfy the lien out of those proceeds.
• The patient will notify the medical provider if he/she retains new legal counsel.

This Pennsylvania Doctor's Lien and Patient Consent form is available in MS Word format, and can be easily customized to fit your business needs.