Keep Your Nurses and Health Care Professionals for Life

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.

Offer a candidate a house staff position at a hospital in the United States with this Letter of Intent / Employment Offer template.

• The employee must obtain a State medical license or intern and residency license before beginning work.
• The employee must successfully undergo drug and criminal background screening.
• The Medical Center will provide malpractice insurance.
• Health care insurance, life insurance and disability insurance are available through the Center's insurers.
• House staff will be reimbursed for parking fees by means of an annual cash benefit.
• Moonlighting is discouraged but not prohibited. The employee's malpractice insurance does not extend to any outside employment.
• This is a fully editable MS Word document.
• Drafted to be used only in the United States.

THIS FORM IS NO LONGER AVAILABLE.

Make sure your fees for medical services get paid. Have your patients sign this Wisconsin Doctor's Lien and Patient Release.

• You can claim a lien for the fees for medical services provided to a patient with respect to accidents or injuries caused by third parties (including injuries sustained on the job).
• The patient must give his/her consent for the release of any medical information required for purposes of the patient's injury claim.
• The medical practitioner has an irrevocable lien on any settlement or damages awarded. The amount of the lien will be paid from any damages or settlement amounts paid to the patient.
• Regardless of whether or not the patient's injury claim is successful, the patient remains legally liable for paying the full amount of the fees.

Don't risk not getting paid. Download this Wisconsin Doctor's Lien and Patient Release Form for your facility.