California health care providers, make sure you get paid for your services by having patients sign this Patient Fee and Lien Agreement 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 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.

This California Patient Fee and Lien Agreement is available in MS Word format, and can be easily customized to fit your business needs. Buy the form once, and it's yours to use as often as you require.