ContractMedical Lien Agreement • March 22nd, 2018
The named Patient (“Patient”) desires medical treatment by the below-named Provider, including all entities related to Provider (collectively, “Provider”) for injuries sustained in the above-referenced personal injury incident (“Incident”), and has or shall be retaining the below-referenced Attorney (“Attorney”) to seek compensation from a potentially liable “third party”. At the request of Patient and/or Attorney, Provider agrees to a delay in being paid, by establishing a creditor-debtor relationship through this contractual Agreement, whereby Provider agrees to provide medical treatment to Patient on a “lien” basis (“Medical Lien”). Provider agrees to wait and be paid promptly upon resolution of the underlying legal matter, or, immediately upon a breach of this Agreement should Patient and/or Attorney fail to comply with the provisions of this Medical Lien.
LIEN CREATING AN IRREVOCABLE ASSIGNMENT OF PROCEEDSMedical Lien Agreement • March 23rd, 2017
Patient hereby grants Provider a Medical Lien, as defined herein and below and pursuant to Nevada law, inclusive, upon any sums awarded to Patient by judgment, or pursuant to a settlement or compromise, concerning the Accident, in the amount and to the extent of Provider’s billed and invoiced charges, and Patient acknowledges that, as defined above, when a Patient assigns rights to the proceeds of a tort to this Medical Lien holder, those proceeds no longer belong to the Patient and are the sole property of the Provider. Therefore, Patient, by signing this agreement, agrees to the following:
MEDICAL LIEN AGREEMENTMedical Lien Agreement • September 1st, 2021 • Michigan
I, ___________________________________________ (“Patient”) do hereby authorize and direct my attorney to pay directly to _______________________ (“Provider”) such sums of monies as may be due and owing to them arising out of the __________ motor vehicle accident for:
MEDICAL LIEN AGREEMENTMedical Lien Agreement • January 30th, 2019
The named Patient (“Patient”) desires medical treatment by the named Provider, including all entities and specialists that provide services for, at or through Provider (collectively, “Provider”) for injuries sustained in the above-referenced personal injury incident (“Incident”). Patient has or shall retain the below-referenced Attorney (“Attorney”) to seek compensation (“Litigation”) for the injuries arising from the Incident. At Patient’s request, Provider agrees to treat Patient on a “lien” basis (“Medical Lien”), establishing a debtor-creditor contractual relationship, whereby Patient remains responsible to pay Provider’s bill (“Bill”), but Provider agrees wait to be paid until the conclusion of the Litigation. However, if any provision of this Medical Lien is not strictly complied with by Patient or Attorney, Provider may declare a breach of this Medical Lien agreement, and Patient agrees to then pay the full balance owed Provider immediately; and, if Patient fails to timely pay,
Attorney Medical Lien AgreementMedical Lien Agreement • January 16th, 2020 • Arizona
I, do hereby authorize SAMUEL E. CARR, D.C., P.C. to furnish you, , my attorney, with prepaid copies of medical records relevant to my injury or accident for which he/she is representing me.
LIEN CREATING AN IRREVOCABLE ASSIGNMENT OF PROCEEDSMedical Lien Agreement • September 19th, 2016
Patient hereby grants Provider a Medical Lien, as defined herein and below and pursuant to Nevada law, inclusive, upon any sums awarded to Patient by judgment, or pursuant to a settlement or compromise, concerning the Accident, in the amount and to the extent of Provider’s billed and invoiced charges, and Patient acknowledges that, as defined above, when a Patient assigns rights to the proceeds of a tort to this Medical Lien holder, those proceeds no longer belong to the Patient and are the sole property of the Provider. Therefore, Patient, by signing this agreement, agrees to the following:
