The LAw offices of Miguel A. Muñoz
The LAw offices of Miguel A. Muñoz
Lien Document for Medical Treatment
Patient Name:__________________________________Date of Birth:________________.
Date of Injury:_______________________________
Attorney Name: Law Offices of Miguel A. Muñoz, P.A.C.
Address: 714 West Olympic Blvd., Suite 740
City: Los Angeles, CA 90015 State: California Zip Code: 90015
Phone: (323) 657-6565 Ext 101 Fax: (213) 279-2999
Email: Miguel@MiguelMunozLaw.Com
Auto Insurance Company:_______________________________Claim:______________________.
Adjuster Name:_______________________________________Phone:______________________.
AjusterEmail:__________________________________________Policy:_____________________.
Phone: ______________________________________Fax:_______________________________.
I authorize the release of all my protected health information in _____________________________
possession, including reports, images, and billing records, to my attorney. I hereby release ____________________________________ and your employees from any and all liability for fulfilling the authorization request to release medical information. I understand it is possible that the
the recipient may disclose the information in my medical records to other parties. This consent will expire when the case settles. I have given my consent freely, voluntarily, and without coercion. I may revoke this authorization at any time, providing that I notify _________________________________, a professional corporation, in writing to that effect. I understand that any releases made before my revocation, in compliance with this authorization, shall not constitute a breach of my rights to confidentiality.
A photocopy/facsimile of this authorization is acceptable in lieu of the original.
I, at this moment, authorize and direct you, my attorney, to: (1) withhold from any settlement, judgment, or verdict resulting from the accident in an amount equal to any and all sums I owe to ____________________________________________ for medical services provided to me by ____________________________________________; and (2) pay such sums directly to ____________________________________________. I hereby acknowledge that _____________________________________________ has provided and/or will provide medical services to me as a result of such injury. I hereby further give a lien on my case to_________________________________________against any and all proceeds of my settlement, judgment, or verdict which may be paid to you, my attorney or myself as a result of the injuries I have been treated or injuries in connection therewith.
I fully understand that I am directly and solely responsible to ____________________________ for all medical bills submitted for services provided to me, regardless of whether I receive any settlement, judgment, or verdict as a result of the accident.
By signing and returning the below, I have been advised that if my attorney does not wish to cooperate in protecting the medical provider’s interest, _________________________________will not await payment but may declare the entire balance due and payable. I understand that a photocopy/facsimile of this authorization is acceptable in lieu of the original.
Please date, sign, and return one copy to ___________________________________________and keep one for your records.
Date:________________________________
Patient Signature:__________________________________________.
Date:________________________________
Attorney Signature: Electronically signed on______________________.
Miguel A. Muñoz, A.P.C.
The undersigned, being the attorney of the above patient, does hereby agree to observe all terms of the above to pay _____________________________from any settlement, judgment, or verdict.
Please email or fax the signed lien form to the contact information below.
Personal Injury Billing Department
Phone: 323-657-6565 Extension 101
Fax: (213) 279-2999
The LAw Offices of Miguel A. Muñoz, A.P.C.
(323) 657-6565 Ext 101
All rights reserved.
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