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 namesphysicians lien form illinois, medical lien form for providers, medical lien form, doctor lien form

Form Preview Example

Doctor’s Lien

To Attorney(s): ________________________________________

Dr. Gregory P. Skye


Skye Chiropractic


1187 Old Hickory Blvd


Brentwood, TN 37027


615.377.7770 phone

Patient’s Name:________________________________________

615.377.0448 fax

Date of Birth: ________________________________________


I do hereby authorize Gregory P. Skye, D.C. to furnish to you, my attorney, with a full report of his examination, diagnosis, treatment, prognosis, etc., of my self in regard to the accident in which I was recently involved.

I hereby authorize and direct you, my insurance company, and/or my attorney to pay directly to said doctor such sums as may be due and owing him for medical service rendered to me both by reason of settlement, judgment, or verdict as may be necessary to adequately protect said doctor. I hereby further give a LIEN on my case to said doctor against any and all proceeds of my settlement, judgment or verdict which may be paid to you, my attorney, or myself as the result of the injuries for which I have been treated or injuries in connection therewith.

I agree never to rescind this document and that a rescission will not be honored by my attorney. I hereby instruct that in the event another attorney is substituted in this matter, the new attorney honor this lien as inherent to the settlement and enforceable upon the case as if it were executed by him.

I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for service 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 settlement, judgment or verdict by which I may eventually recover said fee.

If my attorney does not wish to cooperate in protecting the doctor’s interest, the doctor will not await payment but may declare the entire balance due and payable.

Patient’s Signature: ______________________________________ Date:_____________






ATTORNEY(S): Please sign, date and return one copy to doctor’s office and keep one copy for your records.

The undersigned being attorney of record for the above patient do hereby agree to observe all the terms of the above and agrees to withhold such sums form any settlement, judgment or verdict as may be necessary to adequately protect said doctor named. Attorney further agrees that in the event this lien is litigated that the prevailing party will be awarded attorney fees and costs.

Attorney Signature:______________________________________ Date: _______________

How to Edit Sample Doctors Lien Online for Free

The procedure of filling out the medical lien release form is quite easy. Our experts made sure our tool is not hard to work with and can help fill out almost any document in no time. The following are a few steps you will need to follow:

Step 1: Choose the orange "Get Form Now" button on this website page.

Step 2: So you're on the file editing page. You can modify and add content to the file, highlight specified content, cross or check certain words, add images, insert a signature on it, get rid of needless fields, or eliminate them altogether.

These areas are within the PDF form you will be filling out.

stage 1 to filling out doctor lien form

Put the asked particulars in the If my attorney does not wish to, Patients Signature Date, Address, City, Zip, ATTORNEYS Please sign date and, The undersigned being attorney of, and Attorney Signature Date part.

step 2 to finishing doctor lien form

Step 3: Click the Done button to assure that your finalized form is available to be exported to every gadget you select or mailed to an email you indicate.

Step 4: Make sure you avoid future troubles by producing no less than a pair of copies of your file.

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