MEDICAL LIEN AGREEMENT
This Medical Lien Agreement is entered into on ______________ by and between
________________________ (hereinafter referred to as the “Patient”) and
______________________ (hereinafter referred to as the “Medical Provider”).
Together referred to as “parties.”
WHEREAS this agreement arises from injury/incident that occurred on __________;
WHEREAS the Patient herein has instituted the Personal Injury case of reference
CASE #/COURT (Later Add If Needed): _________________________________
The parties have agreed as follows; –
1. The Patient desires medical treatment by the Medical Provider, including all
entities related to Medical Provider, for injuries sustained in the above-
referenced personal injury incident and has or shall be retaining the below-
referenced Attorney to seek compensation from a potentially liable “third party.”
2. At the Patient’s request, the Medical Provider agrees to a delay in being paid by
establishing a creditor-debtor relationship through this contractual Agreement,
whereby the Medical Provider agrees to provide medical treatment to the Patient
on a “lien” basis.
3. The Medical Provider agrees to wait and be paid promptly upon resolution of the
underlying legal matter or immediately upon a breach of this Agreement should
the Patient fail to comply with the provisions of this Medical Lien.
4. The Medical Provider’s Medical Lien is against any proceeds arising from the
Incident, including, but not limited to, “med pay” or PIP insurance payment(s),
case settlement (in whole or in part), judgment, or verdict, which may be paid to
the patient directly or through their Attorney.
5. In exchange of the Medical Provider agreeing to delay being fully paid, the
Parties to this Medical Lien agree to the following:
i. The Medical Provider may release all medical information, billings, treatment
notes, etc., concerning the Patient’s condition and treatment to the Patient’s
insurance company, attorney, or insurance adjuster, as well as Provider’s
attorney or lien rep, in connection with the incident.
ii. The Patient and the Attorney will notify the Provider in writing of any objection
or issue regarding the Provider’s fees or charges within ten (10) days of
receipt of any interim or individual billing statement.
iii. No modification to this Medical Lien shall be effective unless such
modification (including any stamp, addendum, or handwritten change) is
initialed by the Medical Provider.
iv. There will be no reduction of the Medical Provider’s outstanding Medical Lien
balance without the Medical Provider’s signed written agreement to a specific
dollar amount. Any request for a bill reduction should be made to the Medical
Provider before the Patient agrees to accept any lawsuit settlement. A
v. Any transmission of partial funds by Attorney (or Patient if no Attorney) to the
Medical Provider, even if stating “full and final satisfaction of the Medical
Provider’s lien” (or similar language), without the Medical Provider’s prior
written agreement to accept that reduced sum, shall not in any way be
deemed an “accord and satisfaction” or otherwise limit the Medical Provider’s
entitlement to the total balance due and owing.
vi. Suppose the Patient’s case or lawsuit does not result in a recovery sufficient
to pay the Medical Provider’s bill in full according to this Medical Lien. In that
case, the Patient agrees to remain fully liable for any remaining balance and
promptly pay all the remaining monies due and owing personally.
vii. The Medical Provider is required to retain an attorney to recover all or part of
the Provider’s Medical Lien, the prevailing party in any action arising from this
Agreement shall be entitled to their reasonable attorney’s fees and costs,
including, but not limited to, any such fees and expenses incurred in pre-filing
collection efforts, negotiations or any Interpleader action involving the sums
due.
viii. The Medical Provider may sell or assign the rights to this lien to a third party
without restriction. The cost of any such sale or assignment shall not reduce
or be deemed to reduce the amount owed on the Medical Provider’s Medical
Lien.
ix. Any delay by the Medical Provider in the enforcement of this Agreement will
not be deemed a waiver of the Medical Provider’s rights and remedies in any
respect.
The Patient herein agrees and acknowledges that they have read all the above and
understand to honor all terms and conditions of this Medical Lien Agreement. The
Patient has consulted with Attorney (if Attorney is retained), and should the Patient
retain new counsel, the Patient agrees to provide that new counsel a copy of this
Medical Lien prior to formal retention.
Signature: ____________________________
Name: _______________________________
Guardian: ____________________________
Date: ________________________________
The attorney (if any) agrees to honor all terms and conditions of this Medical Lien
agreement as stated above. Upon the Attorney’s full and timely compliance with the
provisions of this Medical Lien as applies to the Attorney, the Attorney’s fiduciary
duties to the Medical Provider shall be deemed fully satisfied.
Signature: ____________________________
Designation: __________________________
Name: _______________________________
Date: ________________________________
The Medical Provider, relying upon the representations made and the agreement by
both the Patient and the Attorney (if any) to all the above, agrees to accept and treat
the Patient and to delay receiving payment for services related to the injuries
sustained in this Incident under the conditions stated and no others. No modification
to this Agreement, or any addendum or stamp, is valid unless approved by the
Medical Provider of those changes evidenced by their signature or initials next to
each such change or on any attachment.
Signature: ____________________________
Designation: __________________________
Names: ______________________________
Date: ________________________________
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