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.

This Wisconsin Patient Records Release and Doctor's Lien form is available as a downloadable MS Word document which can be easily edited to fit your business needs.