Arkansas Medical Release and Irrevocable Lien

AR health care providers, make sure you get paid for your services by having patients sign this Arkansas Medical Consent, Release and Irrevocable Lien form at the time that treatment is provided.

• 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.
• Available in MS Word format.
• Intended to be used only in the State of Arkansas.