Get Medical Lien Packet Pdf - Graham Lundberg Amp Peschel

Filling out the Medical Lien Packet PDF is an important step for health care providers seeking reimbursement for services rendered to injured individuals. This guide will help you understand each section of the form and provide step-by-step instructions to ensure your lien is completed correctly.

Follow the steps to fill out the Medical Lien Packet PDF successfully.

1. Press the ‘Get Form’ button to obtain the Medical Lien Packet PDF and open it in your preferred editor.
2. In the Return Address box at the top of the form, complete the section labeled ‘Claimant’ with the name and address of the health care provider claiming the lien.
3. Provide the name and address of the injured individual in the section labeled ‘Patient’.
4. Fill in the section labeled ‘Tortfeasor’ with the name and address of the person or entity responsible for the patient's injuries.
5. In the ‘Insurer’ section, enter the name of the Tortfeasor’s insurance company.
6. Specify the ‘Date and Time of Accident’ with the most accurate information available.
7. For the ‘Location of Accident,’ provide the best description possible; if not exact, listing the county is often sufficient.
8. In the ‘Claim Number’ field, you may enter the number if known, or you can put ‘unknown’ if not available.
9. Describe the ‘Nature of Injuries’ in general terms without including detailed diagnoses or medical codes.
10. Have the health care provider sign the lien, ensuring that the signature is completed in the presence of a Notary Public for validation.
11. Once all sections are completed, save your changes, download a copy for your records, and print the form as needed.
12. Send the original and one copy of the lien to your county Auditor, making sure to send a copy to the tortfeasor’s insurance company via Certified Mail, Return Receipt Requested.

Begin filling out your Medical Lien Packet PDF online today to secure the services rendered.