New York Patient Consent and Doctor's Lien

This New York Patient Consent and Doctor's Lien form can ensure that your fees for medical services are paid by placing a lien on damages awarded in an injury claim.

• Patients receiving treatment for third party injuries (including on-the-job accidents) should sign this agreement before treatment begins.
• The legal action may necessitate access to the patient's medical records. The form includes a section where the patient authorizes the hospital to release that information.
• The patient gives the doctor an irrevocable lien on any settlement or damages awarded, which will then be used to pay the lien.
• The patient agrees to be legally liable for paying the full amount of the health care provider's fees, regardless of the outcome of the claim.

Download the New York Patient Consent and Doctor's Lien form today.