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Wisconsin Patient Records Release and Doctor's Lien
Wisconsin health care providers, make sure you get paid for your services by having patients sign this Patient Records Release 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.
Download: Wisconsin Patient Records Release and Doctor's Lien
Related Forms:
- Wisconsin Full Satisfaction of Claim for Lien
- Wisconsin Lien Waiver and Release Forms Package
- Wisconsin Notice of Intent to File Claim for Lien by Prime Contractor
- Wisconsin Prime Contractor Claim for Lien
- Wisconsin Prime Contractor Notice of Right to File Lien
Related Categories:
- Downloadable Business Forms > Health Care Industry Forms
- Downloadable Legal Forms > Lien Forms > United States > Wisconsin
More: FormsHound.com
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