Arizona Medical Lien Agreement

Make sure your bills get paid. Have your patients sign this Arizona Patient Consent and Medical Lien Agreement at the time of treatment.

  • The patient consents to treatment and authorizes release of all medical information with respect to the patient's claim regarding the accident or injury for which the patient is being treated.
  • The patient agrees to be personally liable for paying the medical provider's fees regardless of the outcome of the patient's claim.
  • 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.
  • The patient will notify the medical provider if he/she retains new legal counsel.
  • Buy the form once, and it's yours to use as often as you require.
  • Intended for use only in the State of Arizona.
Document Type: Microsoft Word
Last Updated: 06-March-2025
SKU: 8354
$12.49
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