New York Patient Consent and Doctor's Lien

Ensure that your fees for medical services are paid by placing a lien on damages awarded to a patient with this New York Patient Consent and Doctor's Lien.

Why should you have your injury patients sign this Doctor's Lien form?

Any hospital or medical practitioner that provides emergency medical treatment to accident victims can seek reimbursement for their costs through a medical lien against any settlement amount or personal injury claim awarded to the victim.

All patients receiving treatment for third party injuries (including on-the-job accidents) should sign this form.

Patient Consent

The patient's legal action may necessitate access to their confidential medical records. This form includes a section where the patient authorizes the hospital to release that information.

Grant of Lien and Obligation to Pay

The patient gives the doctor an irrevocable lien on any settlement or damages awarded, which will be applied to payment of 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.

Format and Scope of Use

This is a reusable legal form in MS Word format. Once you've purchased it, you can use it as often as you like. The template can be customized for your specific business needs.

This Patient Consent and Doctor's Lien form is intended for use only in the State of New York.