Products tagged with 'accident injury claim form'
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Georgia Patient Consent and Medical Lien Agreement
Secure the payment of your bills for medical services by having your patients sign this Georgia Patient Consent and Medical Lien Agreement before treatment begins.
- The patient authorizes the medical practitioner to release any information about the accident or injury being treated for purposes of the patient's injury claim.
- Notwithstanding any settlement of the claim, the patient is personally responsible for paying the fees.
- The medical provider has an irrevocable lien over any amounts awarded to the patient. The patient's attorney is directed to satisfy the lien out of the settlement funds.
- This is a reusable legal form. 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 form is intended for use only in the State of Georgia.
$6.29
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.
$6.29
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