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    New York Patient Consent and Doctor's Lien


    This New York Patient Consent and Doctor's Lien form can ensure that your fees for medical services are paid by placing a lien on damages awarded in an injury claim.

    • Patients receiving treatment for third party injuries (including on-the-job accidents) should sign this agreement before treatment begins.
    • The legal action may necessitate access to the patient's medical records. The form includes a section where the patient authorizes the hospital to release that information.
    • The patient gives the doctor an irrevocable lien on any settlement or damages awarded, which will then be used to pay the lien.
    • The patient agrees to be legally liable for paying the full amount of the health care provider's fees, regardless of the outcome of the claim.
    • This is a downloadable legal form in MS Word format.
    • Intended for use only in the State of New York.
    Download Type: Microsoft Word
    Last Updated: 11-May-2021
    SKU: 129