Arkansas health care providers, make sure you get paid for your services by having patients sign this Medical Consent, Release and Irrevocable Lien form.

• The patient consents to treatment and authorizes release of all medical information.


• The patient agrees to be personally liable for paying the medical provider’s fees and is responsible for making all financial arrangements for payment of the account.


• The patient assigns any Medicare or Medicaid benefits to the medical provider.


• The patient gives the medical provider an irrevocable lien on any settlement or judgment proceeds awarded to the patient and authorizes his/her attorney to satisfy the lien out of those proceeds.

This Arkansas Medical Consent, Release and Irrevocable Lien form is provided in MS Word format, and is easy to download, fill in and print. Buy the form once, and it's yours to use as often as you require.