Get Notice Of Claim Of Lien For Medical Services Form

The claimant claims a lien for the reasonable value of claimant s services which were rendered necessary by the following described injury to the patient to-wit state the character of injury if known and if unknown so state Claimant By Title OVER Form No. 5 Notice of Claim of Lien for Medical Services ES 2006 Washington Legal Blank Portland OR www. SA M PL E After recording return to Name Address Zip NOTICE OF CLAIM OF LIEN FOR MEDICAL SERVICES Grantor Claimant Grantee Patient Reference No s of Documents Assigned or Released NOTICE IS HEREBY GIVEN that the undersigned claimant whose address is and who claims as a a practitioner a physician a nurse a hospital a ambulance service indicate which has performed services for patient whose address is and whose place of domicile is which services were rendered necessary to the patient as the result of an injury which occurred at the following place on date through the fault of tort-feasor whose address is. wlbforms. com NO PART OF ANY WASHINGTON LEGAL BLANK FORM MAY BE REPRODUCED IN ANY FORM OR BY ANY ELECTRONIC OR MECHANICAL MEANS* STATE OF WASHINGTON ss. County of I certify that I know or have satisfactory evidence that is/are the individual s who appeared before me and who acknowledged that he/she/they signed this instrument and acknowledged it to be his/her/their free and voluntary act for the uses and purposes mentioned in the instrument. DATED Notary Public for Washington My appointment expires ASSIGNMENT OF CLAIM The above named claimant hereby sells assigns sets over and delivers unto of cause of action and moneys due or to become due for the performance of the services above described and as incident thereto hereby assigns to the assignee the above claim of lien therefor. wlbforms. com NO PART OF ANY WASHINGTON LEGAL BLANK FORM MAY BE REPRODUCED IN ANY FORM OR BY ANY ELECTRONIC OR MECHANICAL MEANS* STATE OF WASHINGTON ss. County of I certify that I know or have satisfactory evidence that is/are the individual s who appeared before me and who acknowledged that he/she/they signed this instrument and acknowledged it to be his/her/their free and voluntary act for the uses and purposes mentioned in the instrument. County of I certify that I know or have satisfactory evidence that is/are the individual s who appeared before me and who acknowledged that he/she/they signed this instrument and acknowledged it to be his/her/their free and voluntary act for the uses and purposes mentioned in the instrument. DATED Notary Public for Washington My appointment expires ASSIGNMENT OF CLAIM The above named claimant hereby sells assigns sets over and delivers unto of cause of action and moneys due or to become due for the performance of the services above described and as incident thereto hereby assigns to the assignee the above claim of lien therefor. wlbforms. com NO PART OF ANY WASHINGTON LEGAL BLANK FORM MAY BE REPRODUCED IN ANY FORM OR BY ANY ELECTRONIC OR MECHANICAL MEANS* STATE OF WASHINGTON ss. County of I certify that I know or have satisfactory evidence that is/are the individual s who appeared before me and who acknowledged that he/she/they signed this instrument and acknowledged it to be his/her/their free and voluntary act for the uses and purposes mentioned in the instrument. DATED Notary Public for Washington My appointment expires ASSIGNMENT OF CLAIM The above named claimant hereby sells assigns sets over and delivers unto of cause of action and moneys due or to become due for the performance of the services above described and as incident thereto hereby assigns to the assignee the above claim of lien therefor.