Hawaii 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.

Sample Letter for Irrevocable Assignment and Lien to Medical Provider in Hawaii [Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, ZIP Code] Subject: Irrevocable Assignment and Lien for Medical Services Rendered Dear [Medical Provider's Name], I am writing to provide you with an irrevocable assignment and lien for medical services rendered to me or my dependent under my care. This letter serves as an agreement between myself, as the assignor, and [Medical Provider's Name], as the assignee and lien holder. As per the terms of this agreement, I hereby authorize and direct any third-party payers, insurers, or settlement funds to make payments directly to [Medical Provider's Name] in accordance with any medical expenses related to the treatment provided. I fully understand that this assignment of benefits and lien is irrevocable, meaning I cannot modify or revoke it without the express written consent of [Medical Provider's Name]. This assignment is made to ensure that you will be compensated for your services promptly, while allowing me to benefit from any available insurance coverage. By signing this agreement, I acknowledge and agree to the following terms and conditions: 1. I assign and transfer to [Medical Provider's Name] the right to pursue, compromise, settle, and receive payment from any responsible party, including but not limited to, insurers, third-party payers, and any party liable for my medical expenses. 2. I authorize [Medical Provider's Name] to release any necessary medical records or other information related to the services provided, solely for the purpose of pursuing reimbursement. 3. Furthermore, I agree that [Medical Provider's Name] has the right to be reimbursed from the proceeds of any settlement, recovery, or judgment in any personal injury claim or legal action that may arise concerning the medical services provided. 4. Furthermore, I understand that payment from any third-party payer, insurer, or settlement fund will be made directly to [Medical Provider's Name] and will be applied towards the outstanding balance of my account. 5. Furthermore, I agree to cooperate fully with [Medical Provider's Name] by promptly providing any necessary information or documentation required to facilitate the collection process. Furthermore, I further acknowledge that I am responsible for any remaining balance not covered by insurance or third-party payers. In the event of any overpayment made to [Medical Provider's Name], I trust that you will promptly refund the excess amount to the responsible party. Please sign and return the enclosed copy of this letter to acknowledge your agreement and acceptance of these terms. Should you require any additional documentation, please do not hesitate to contact me at the provided phone number or email address. Thank you for your attention to this matter, and I appreciate your cooperation in ensuring that my medical expenses are handled efficiently. Sincerely, [Your Name] Enclosure: Signed copy of Irrevocable Assignment and Lien for Medical Services Rendered Additional Types of Hawaii Sample Letters for Irrevocable Assignment and Lien to Medical Provider: 1. Sample Letter for Irrevocable Assignment and Lien to Medical Provider for Dependent: This letter specifically addresses the assignment and lien for medical services rendered to a dependent under the sender's care, ensuring that the medical provider receives payment directly. 2. Sample Letter for Irrevocable Assignment and Lien to Medical Provider for Personal Injury Claim: This type of letter emphasizes the assignment and lien in the context of a personal injury claim, where the medical provider seeks reimbursement from any settlement, recovery, or judgment related to the injury. 3. Sample Letter for Irrevocable Assignment and Lien to Medical Provider for Workers' Compensation Claim: This variation of the letter focuses on the assignment and lien in the context of a workers' compensation claim, allowing the medical provider to pursue payment directly from the responsible party or insurer.