Illinois Doctor's Lien and Patient Consent Form

Do you treat patients who have been injured by accident or third parties. Have them sign this Illinois Doctor's Lien and Patient Consent Form at the time of treatment.

• The patient gives his/her consent for the treatment and authorizes the medical practitioner to release any information required to conduct the patient's injury claim.
• Regardless of the outcome of the claim, the patient will be personally liable for paying the medical bills.
• The doctor has an irrevocable lien on any settlement or damages awarded to the patient. The patient's lawyer is instructed to satisfy the lien out of the settlement proceeds.
• The patient must give notice if he/she hires a different attorney.
• Intended for use only in the State of Illinois.