Letter of Protection/Attorney Lien Template Form

This form is copyrighted by Simons & Associates Law, P.A.  You are authorized to use if if you are a member of our Practice Management Network or a client, so you may remove the copyright notice in the footnote when you customize the form for your use. 

Instructions:  Have the patient sign this Letter of Protection to obtain a lien against the proceeds the patient may be entitled to upon settlement or winning a verdict in his/her personal injury case. Items in red may be customized or require an insertion.  

Please note that this form does not allow you to disclose medical or claim information to the attorney. You must have the patient sign a separate HIPAA compliant Authorization to Disclose Protected Health Information before disclosing medical records or bills to the patient’s attorney.  

Please also note that if you billed Medicare as a conditional secondary payer, you can only bill the amount allowed by Medicare pursuant to your status with Medicare as a participating or non-participating provider.  You cannot balance-bill the patient your full fees upon settlement.  This same rule applies if you billed the patient’s commercial health plan as an in-network provider.  Therefore your lien is only for unpaid copays, coinsurance and/or deductibles plus interest if you already billed another payer. 

And remember – you do not have to agree to discount your fees if the attorney asks you to after a settlement has been reached.  If the attorney says the “Common Fund Doctrine” requires you to, you can say that only applies to health insurers, not providers.  

Send a copy of this form to the patient’s attorney after the patient signs it.  The attorney does not have to sign or agree to the terms as long as the patient has agreed and signed.  

Letter of Protection/Attorney Lien

I hereby authorize my attorney, _______________________, to pay directly to [Provider/Company] such sums as may be due and owing the facility for professional services rendered to me both by reason of this accident and by reason of any other bills that are due to [Provider/Company] and to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately protect [Provider/Company].  I hereby acknowledge that sums owed by me may include interest that may accrue beginning ____ months after the last of service with an annual percentage rate of 18 percent.  I hereby grant a lien to [Provider/Company] on any and all proceeds of any settlement or judgment made in connection with injuries for which I have been or will be treated by [Provider/Company].

I fully understand that I am directly and fully responsible to [Provider/Company] for all professional bills submitted to me for services rendered to me and that this agreement is made solely for [Provider’s/Company’s] additional protection and in consideration of [Provider/Company] deferring the collection of such bills.

I recognize that liens are either statutorily created or created by agreement and are absolutely binding upon me and my attorney. I further recognize that my attorney is not a personal guarantor of such liens and is only responsible for such liens as long as there are sufficient proceeds to pay the liens after deduction of reasonable attorney's fees, court costs, and other lawful expenses.

I further understand that the payments due to [Provider/Company] from me are not contingent on my receiving the proceeds from any settlement, judgment or verdict and that after payment of such liens, there may not be any proceeds left for personal compensation to me. 

Patient’s Signature _______________________________________________  Date: ______________  

Witness:  ______________________________________________________   Date:  ______________