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HEALTH CARE PROVIDER LIEN AGREEMENT PATIENTS NAME I hereby authorize Connolly Physical Therapy Services to furnish my attorney of record with a full report of examination, including diagnosis, resulting

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How to fill out health care provider lien

01

Step 1: Obtain the necessary forms from your local health care provider or hospital.

02

Step 2: Fill in your personal information, including your name, address, and contact details.

03

Step 3: Provide details about your health care provider, such as their name, address, and contact information.

04

Step 4: Clearly state the purpose of the lien, which is to establish a claim against any settlement or insurance benefits related to your medical treatment.

05

Step 5: Include a detailed description of the medical services provided and the dates of the treatment.

06

Step 6: Indicate the amount of the medical bills and any outstanding balances.

07

Step 7: Sign and date the lien form in the presence of a notary public or witness, as required by local laws.

08

Step 8: Make copies of the completed lien form for your records and provide the original to your health care provider or their billing department.

Who needs health care provider lien?

01

Health care provider liens are typically needed by healthcare providers or hospitals who have provided medical services to patients involved in accidents or personal injury cases.

02

These liens allow the health care provider to claim a portion of the settlement or insurance benefits received by the patient to compensate for their medical expenses.

03

In some cases, health insurance companies may also require health care provider liens to ensure that they are reimbursed for any medical costs they have covered on behalf of the patient.

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