When dealing with the aftermath of an incident that leads to a settlement, navigating the financial and legal obligations can be overwhelming. One critical step in this process, especially in the context of lawsuits and settlements in New York, involves the Final Lien Request form. This document, issued by the Human Resources Administration's Investigation, Revenue and Enforcement Administration Division of Liens and Recovery, serves a vital purpose in ensuring that all financial claims associated with a settlement are properly addressed. With sections that require detailed information about the plaintiff, the incident, settlement amount, and legal representation, this fax form is a comprehensive tool for communicating crucial data to the responsible New York City agency. It distinguishes between updated and final lien requests, specifying the injury and including necessary contact details for all involved parties—ranging from attorneys representing both sides to insurance companies covering the defendants. Ensuring the form is accurately completed and submitted by the deadline is a key step toward concluding the financial aspects of a settlement, making it indispensable for both legal counsel and plaintiffs navigating the settlement process.
| Question | Answer |
|---|---|
| Form Name | Final Lien Request Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | final lien request form, new york state medicaid lien request, medicaid lien request form, lien request |
HUMAN RESOURCES ADMINISTRATION
INVESTIGATION, REVENUE AND ENFORCEMENT ADMINISTRATION
DIVISION OF LIENS AND RECOVERY
P.O. BOX 3786 - CHURCH STREET STATION
NEW YORK, NY
Telephone: (212)
UPDATED / FINAL LIEN REQUEST
FAX FORM
FAX #: (212)
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Date: |
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(I.) |
Plaintiff Name: |
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SSN: |
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Date of Birth: |
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Settlement Amount: |
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Date of Incident: |
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NYC File Number (if action against NYC): |
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Settlement Date: |
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Index Number: |
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Case Number or CIN: |
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Specify Injury: (E.G. Ankle Fracture), or Fax Bill of Particulars: |
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Type of Lien (circle one): |
Updated |
Final |
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(II.) Attorney requesting lien represents (circle one): |
Plaintiff |
Defendant |
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Firm Name: |
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Firm Address: |
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Telephone: |
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Fax: |
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Attorney Name: |
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Conference Date: |
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(III.) If the requesting attorney represents the plaintiff, please provide the Defendant’s name, Defendant’s attorney’s name, address and phone number. If representing the Defendant, please provide the Plaintiff’s name, Plaintiff’s attorney’s name, address and phone number.
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(IV.) Provide the Name and Address of each Insurance Company insuring each Defendant named above. Include Insurance Company Claim/File for each.
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(V.) Completed by: |
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Date: |