Texas Patient Consent and Doctor's Lien

Texas health care providers, protect your lien rights by having patients sign this Patient Consent and Doctor's Lien form before providing treatment.

• The patient consents to treatment and authorizes release of all medical information with respect to the patient's claim regarding the accident or injury for which the patient is being treated.
• The patient agrees to be personally liable for paying the medical provider's fees regardless of the outcome of the patient's claim.
• The patient gives the medical provider an irrevocable lien on any settlement or damages awarded to the patient and directs his/her attorney to satisfy the lien out of those proceeds.
• The patient will notify the medical provider if he/she retains new legal counsel.

This Texas Patient Records Release and Doctor's Lien is available as a downloadable MS Word file, which can be easily customized to fit your needs.