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Illinois Doctor's Lien and Patient Consent Form

Price $10.00

Document Id : 866

Illinois health care providers, make sure you get paid for your services by having patients sign this Doctor's Lien and Patient Consent Form before providing treatment.
  • 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 Illinois Doctor's Lien and Patient Consent Form is available as a downloadable MS Word file, which can be easily customized to fit your needs.

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