Connecticut Doctor's Lien and Patient Consent

Make sure you get paid for medical services rendered to a patient with this Connecticut Doctor's Lien and Patient Consent form.

• Patients should sign this form before you provide treatment.
• The patient authorizes the facility to release medical information about the injury and treatment, for purposes of the injury claim.
• The patient gives the medical provider an irrevocable lien on any settlement or damages awarded to the patient and directs his/her attorney to satisfy the lien from those proceeds.
• The patient will be personally liable for paying the health care provider's fees if there is no settlement or if it's insufficient to pay the medical bills.
• The patient will notify the medical provider if he/she retains new legal counsel.

Don't wait for settlement to secure repayment of your bills. Do it now with this Connecticut Doctor’s Lien and Patient Consent Form.