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SAMPLE FORM:COPY, PASTE and EDIT.
Attorney Notice of
Practice Lien
I do hereby authorize ________________________________ to furnish you, my attorney, with a full report
of his/her examination, diagnosis, treatment, prognosis, etc. of myself in regard to the accident in which I was recently
involved.
I hereby authorize and direct you, my attorney, to pay directly to said NAME OF PRACTICE such sums as may be
due and owing NAME OF PRACTICE for medical service rendered to me both by reason of this accident and by reason of any other
bills that are due the providers office and to withhold such sums from any settlement, judgment, or verdict as may be necessary
to adequately protect and fully compensate PRACTICE NAME. And, I hereby further give a lien on my case to said practice against
any and all proceeds of my settlement, judgment, or verdict which may be paid to you, my attorney, or myself, as a result
of the injuries for which I have been treated or injuries in connection therewith.
I fully understand that I am directly
and fully responsible to said practice for all medical bills submitted by said practice for service rendered me and that this
agreement is made solely for said practice additional protection and in consideration of the practice awaiting payment. And
I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually
recover said fee.
I agree to promptly notify PRACTICE NAME of any change or addition of attorney(s) used by me in connection
with this accident, and I instruct my attorney to do the same and to promptly deliver a copy of this lien to any such substituted
or added attorney(s).
Please acknowledge this letter by signing below and returning to PRACTICE NAME. I have been advised
that if my attorney does not wish to cooperate in protecting the PRACTICE NAME interest, the practice will not await payment
but may declare the entire balance due and payable.
Dated: ________________ CLIENT_______________________
The undersigned
being attorney of record for the above patient does hereby agree to observe all the terms of the above and agrees to withhold
such sums from any settlement, judgment, or verdict, as may be necessary to adequately protect and fully compensate said doctor
above-named. Attorney further agrees that in the event this lien is litigated that the prevailing party will be awarded attorney’s
fees and costs.
Dated: ________________ ATTORNEY___________________________________
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