Alaska Sample Letter for Irrevocable Assignment and Lien to Medical Provider

• Category: Letters - Legal - Personal Injury
• State: Multi-State
• Control #: US-0531LTR
• Format: Word; Rich Text

Description

This form is a sample letter in Word format covering the subject matter of the title of the form.

[Your Name] [Your Address] [City, State, Zip Code] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, Zip Code] Subject: Alaska Sample Letter for Irrevocable Assignment and Lien to Medical Provider Dear [Medical Provider's Name], I hope this letter finds you in good health and high spirits. I am writing to address the matter of medical expenses related to my recent treatment at your esteemed facility. In order to ensure proper reimbursement of these expenses, I hereby present an "Irrevocable Assignment and Lien" in accordance with relevant laws and regulations in the state of Alaska. As per the provisions set forth by the Alaska Statutes, Title 09 — Code of Civil Procedure, Section 09.40.060, this letter serves as an expression of my intent to assign all rights, benefits, and interests in any third-party payment for my medical bills to the medical provider, [Medical Provider's Name], until such expenses are settled in full. This assignment and lien shall be considered irrevocable, meaning that it cannot be modified, terminated, or cancelled without the written consent of the medical provider. By granting this irrevocable assignment, I authorize and empower [Medical Provider's Name] to pursue any necessary legal actions against responsible third parties, including but not limited to insurance companies, governmental entities, or other liable parties, to secure full payment for the services rendered. Furthermore, I hereby authorize [Medical Provider's Name] to release any pertinent medical records or bills to any third party involved in the claims process or debt collection, as required to pursue reimbursement. Please note that this irrevocable assignment and lien takes effect as of the date of this letter and applies to all present and future medical services provided by [Medical Provider's Name] related to the incident in question. Should there be any developments or changes regarding the aforementioned medical expenses, or if there are additional procedures or treatments required, I will promptly inform your office to ensure accurate and updated records are maintained. Thank you for your attention to this matter. I trust that this letter clarifies my position and intent clearly. Please acknowledge receipt of this letter, signifying your agreement to the terms stated herein, by signing and returning the enclosed duplicate of this document at your earliest convenience. I appreciate your diligence and professionalism, and I remain grateful for the exceptional care I received at your facility. Yours sincerely, [Your Name] Copy: [Your Attorney's Name, if applicable] [Your Attorney's Address] [City, State, Zip Code] Enclosure: Duplicate copy of Irrevocable Assignment and Lien.