Medical Lien Form

Please read the Medical Lien Requisites before submitting request. Please complete the full form with information that is to best of you knowledge.

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Your Information

Full Name

Provider Full Name

Company Name

Phone

Address, City, State, Zip code

Patient Information

Patient Full Name

Address, City, State, Zip code

Date of Patients First Visit

Date of Patients Last Visit (If applicable)

Is Patient Still Treating

County Where Injuries Occurred

City, State, Zip code Where Injuries Occurred

Amount Claimed For All Treatment to Date

Insurance Information

Third Party Insurance Name

Claim Number

Address, City, State, Zip code

Phone

First Party Insurance Name

Claim Number

Address, City, State, Zip code

Phone

Attorney Information

Attorney Full Name

Name of Law Firm

Address, City, State, Zip code

Phone

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Medical Lien$75

Expedite$20

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Service Fees

Lien Release Form

Medical Lien Requesites

Medical Lien Form

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Your Information

Patient Information

Insurance Information

Attorney Information

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