Sample Doctors Lien PDF Details

Doctors often have to go through a great deal of paperwork in order to get paid for the services they provide. This includes filing a claim with insurance companies and, more recently, filling out a Doctors Lien Form. This form allows doctors to be paid directly by the patient, even if that patient has filed for bankruptcy or is currently in litigation. The form is relatively simple to fill out, and can be helpful in ensuring that you are fairly compensated for your services. In this blog post, we will provide a basic overview of what a Doctors Lien Form is and how it can help you get paid for your services.

You can find info about the type of form you want to complete in the table. It will show you the length of time you will need to finish sample doctors lien, exactly what fields you will have to fill in and a few further specific facts.

Form NameSample Doctors Lien
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesdoctor lien form, doctor's lien form, chiropractic lien form, medical lien form

Form Preview Example

Golinsky Specific Chiropractic

Philip D. Golinsky, D.C.

1110-D Elden Street, Suite 206

Herndon, VA 20170

Voice: (703) 904-9666 Fax: (703)471-4548



Patient’s Name:_____________________________________________________Date of Incident: _________________

Attorney’s Name and Phone #: ____________________________________________________________

I do hereby authorize Golinsky Specific Chiropractic/Philip Golinsky,D.C. to furnish my attorney named above

with a full report of my examination, diagnosis, treatment, prognosis, etc., with regard to the incident in which I was recently injured.

I further authorize and direct my attorney to pay directly to Golinsky Specific Chiropractic/Philip Golinsky,D.C., such sums as may be due and owing for medical services rendered to me both by reason of this incident and by reason of any other bills that are due and to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately protect and fully compensate said doctors.

I hereby further give a Lien on my case to Golinsky Specific Chiropractic/Philip Golinsky,D.C., against any and

all proceeds of my settlement, judgment or verdict which may be recovered or paid as the result of the injuries for which I have been treated.

I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for services rendered me and that this agreement is made solely for said doctor’s additional protection and in consideration of his awaiting payment. I further understand that such payment is not contingent on any recovery made by me. I hereby agree to waive the defense of Statute of Limitations as it pertains to any claim filed against me beyond three years (or other statutory) after services were rendered. I agree to promptly notify said doctor 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).

I have been advised that if my attorney does not wish to cooperate in protecting the doctor’s interest by signing this document, the doctor will not await payment but may declare the entire balance due and payable at the time of service.




Patient’s Signature




Patient’s Printed Name

The undersigned attorney or insurance company agrees:

1.To comply with the above “authorization and assignment”;

2.To withhold and pay from my proceeds from settlement, collection of judgment, PIP, med-pay or other insurance proceeds, the amount of the doctor’s charges, after contacting the doctor’s office for a current balance;

3.Advise within ten days of the doctor’s requests, the status of the above referenced claim;

4.To notify the doctor of any changes in the status of the claim which may preclude payment of the doctor’s charges;

5.To notify any attorney who may assume the representation of the patient of assignment.




Attorney’s Signature




Attorney’s Printed Name

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