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    California Patient Fee and Lien Agreement


    Don't take the risk that your bills for medical services will not be paid. Get your patients to sign this California Patient Fee and Lien Agreement form before you provide treatment.

    • 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 is a reusable legal form. Buy it, download it, and it's yours to use as often as you require.
    • Available in MS Word format and fully customizable.
    • Intended to be used only in the State of California.
    Download Type: Microsoft Word
    Last Updated: 17-May-2023
    SKU: 8353