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.
• This is a downloadable legal form in MS Word format.
• Intended for use only in the State of New York.