Medical Lien Agreement Template: Treatment Payment Terms

Medical Lien Agreement Template

This Medical Lien Agreement (“Agreement”) is entered into as of [Date], by and among:

Patient: [Patient Full Name], of [Address]

Provider: [Medical Provider / Practice / Facility Name], of [Address]

Attorney, if applicable: [Attorney or Law Firm Name], of [Address]

1. Patient and Claim Information

Patient states that Patient received or expects to receive medical evaluation, treatment, services, supplies, or care from Provider in connection with the following injury claim or legal matter:

Type of claim: [Personal Injury / Auto Accident / Premises Liability / Other]

Date of incident: [Date]

Short description of incident:

[Describe accident, event, or injury matter]

Claim against:

[Name of insurer, defendant, or other responsible party, if known]

Attorney representing Patient, if any:

[Attorney Name / Law Firm / Contact Information]

2. Medical Services Covered

This Agreement applies to medical services, treatment, consultation, testing, therapy, supplies, procedures, or related care provided by Provider to Patient in connection with the above matter.

Covered services may include:

• office visits;

• hospital or facility charges;

• diagnostic testing;

• therapy or rehabilitation;

• specialist care;

• procedures or follow-up care; and

• other related charges: [Describe]

office visits;

hospital or facility charges;

diagnostic testing;

therapy or rehabilitation;

specialist care;

procedures or follow-up care; and

other related charges: [Describe]

3. Purpose of Agreement

The purpose of this Agreement is to allow Provider to render treatment or continue treatment with the understanding that payment for Provider’s charges may be made from any settlement, judgment, verdict, arbitration award, insurance payment, or other recovery obtained by or for Patient in connection with the claim described above.

4. Grant of Lien and Assignment of Proceeds

Patient grants Provider a lien against, and assigns to Provider to the extent of Provider’s unpaid charges, any recovery obtained by or for Patient arising from the claim described in this Agreement.

This lien and assignment apply to:

☐ Settlement proceeds

☐ Judgment proceeds

☐ Arbitration award

☐ Insurance payment

☐ Other recovery related to the claim: [Describe]

The lien applies only to unpaid amounts owed to Provider for covered services unless otherwise stated here:

[Describe any limit or write “None”]

5. Authorization to Pay Provider from Recovery

Patient authorizes and directs that Provider’s unpaid charges be paid from any recovery described above before funds are disbursed to Patient, to the extent permitted by law and subject to any valid superior liens, court orders, or other legal obligations.

If Attorney signs this Agreement, Attorney acknowledges receipt of notice of Provider’s claim to payment from recovery proceeds and agrees to handle any funds received in a manner consistent with this Agreement and applicable law.

6. Patient Responsibility

Patient understands and agrees that this Agreement does not cancel or reduce Patient’s responsibility for medical bills.

If no recovery is obtained, or if the recovery is not sufficient to pay all charges in full, Patient remains personally responsible for any unpaid balance unless Provider separately agrees otherwise in writing.

Any special billing or reduction arrangement is as follows:

[Describe or write “None”]

7. Billing and Account Information

Provider may issue bills, statements, or account summaries showing charges for services covered by this Agreement.

Current or estimated charges, if known:

[Insert amount or write “To and Account Information

be billed as services are provided”]

Provider may update charges as additional services are rendered.

Patient agrees to keep Provider informed of:

• changes in Attorney representation;

• settlement status;

• insurer or claim information;

• address changes; and

• any payment received relating to the claim.

changes in Attorney representation;

settlement status;

insurer or claim information;

address changes; and

any payment received relating to the claim.

8. No Guarantee of Recovery

Provider does not guarantee that Patient will recover money from the claim.

Attorney, if involved, does not guarantee that settlement, judgment, or payment will occur unless Attorney separately agrees in writing.

This Agreement only addresses how Provider’s charges may be paid if a recovery is obtained.

9. Notice to Attorney or Payor

Patient authorizes Provider to notify Attorney, insurer, adjuster, defendant, or other relevant party of this Agreement and Provider’s claim to payment, to the extent reasonably necessary to protect Provider’s interest and as permitted by applicable law.

10. Medical Records and Information

Patient authorizes Provider, to the extent permitted by applicable law, to release billing records, treatment dates, balances due, and other reasonably necessary information relating to the charges covered by this Agreement for purposes of claim administration, payment, lien protection, or settlement handling.

Any separate medical authorization or privacy document required shall be handled as follows:

[Describe or write “To be signed separately if needed”]

11. Reduction, Compromise, or Payment Negotiation

Provider is not required to reduce, compromise, or waive charges unless Provider agrees in writing.

Any discussion of reduction, compromise, or payment adjustment shall not be binding unless confirmed in writing by Provider.

If a reduced payment is accepted in full satisfaction, that agreement shall be stated here or in a separate signed writing:

[Describe or write “None at this time”]

12. Attorney Acknowledgment

Complete this section only if Attorney is signing.

Attorney acknowledges:

• Attorney represents Patient in connection with the claim identified above;

• Attorney has received notice of Provider’s claim to payment under this Agreement;

• Attorney will not disregard this Agreement when handling recovery funds received on Patient’s behalf; and

• if Attorney knows of a good-faith dispute about the amount or validity of the claim, Attorney may handle disputed funds as required by applicable law and professional obligations.

Attorney represents Patient in connection with the claim identified above;

Attorney has received notice of Provider’s claim to payment under this Agreement;

Attorney will not disregard this Agreement when handling recovery funds received on Patient’s behalf; and

if Attorney knows of a good-faith dispute about the amount or validity of the claim, Attorney may handle disputed funds as required by applicable law and professional obligations.

13. Discharge and Release of Lien

Provider shall release this Agreement and any lien claim arising under it when:

☐ Provider has been paid in full

☐ Provider agrees in writing to accept a lesser amount in full satisfaction

☐ The parties otherwise resolve the account in writing

☐ Other condition: [Describe]

14. Governing Law

This Agreement shall be governed by the laws of [State/Country], except to the extent mandatory lien, contract, medical billing, trust-account, or professional responsibility law applies.

15. Entire Agreement

This Agreement contains the complete understanding of the parties regarding payment of Provider’s charges from any recovery arising from the claim described above and supersedes prior oral discussions on that subject.

Any amendment to this Agreement must be in writing and signed by the parties to be bound.

16. Signatures

Patient:

Signature: __________________________

Name: [Patient Full Name]

Date: [Date]

Provider:

Signature: __________________________

Name: [Authorized Provider Representative]

Title: [Title]

Provider Name: [Provider Name]

Date: [Date]

Attorney, if acknowledging:

Signature: __________________________

Name: [Attorney Name]

Law Firm: [Law Firm Name]

Date: [Date]

17. Optional Witness or Notary

Witness / Notary, if desired:

Signature: __________________________

Name: [Name]

Title: [Witness / Nota

y / Other]

Date: [Date]