Products tagged with 'medical lien form'

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Picture of Georgia Patient Consent and Medical Lien Agreement

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
Picture of New York Patient Consent and Doctor's Lien

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
Picture of Illinois Doctor's Lien and Patient Consent Form

Illinois Doctor's Lien and Patient Consent Form

Do you treat patients who have been injured by accident or third parties. Have them sign this Illinois Doctor's Lien and Patient Consent Form at the time of treatment.

  • The patient gives his/her consent for the treatment and authorizes the medical practitioner to release any information required to conduct the patient's injury claim.
  • Regardless of the outcome of the claim, the patient will be personally liable for paying the medical bills.
  • The doctor has an irrevocable lien on any settlement or damages awarded to the patient. The patient's lawyer is instructed to satisfy the lien out of the settlement proceeds.
  • The patient must give notice if he/she hires a different attorney.
  • Intended for use only in the State of Illinois.
$12.49
Picture of Texas Patient Consent and Doctor's Lien

Texas Patient Consent and Doctor's Lien

Secure payment of your medical fees by getting your patients to sign this Texas Patient Consent and Doctor's Lien Agreement before treatment begins.

  • The patient authorizes the doctor / hospital to release any information about his/her injury and treatment for purposes of the personal injury claim.
  • Regardless of the outcome of the injury 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.
  • Intended for use only in the State of Texas.
$12.49
Picture of Arizona Medical Lien Agreement

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.
$12.49
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