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TN health care providers, make sure you get paid for your services by having patients sign this Tennessee Patient Consent and Doctor's Lien form at the time treatment is provided. - 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 Tennessee Patient Consent and Doctor's Lien template is available in MS Word format, and can be easily customized to fit your business needs.
[Name Of Medical Provider] [Address of Medical Provider] [Phone #] [Fax #] PATIENT CONSENT AND LIEN RE: Patient: __________________________________________ Date of Accident/Injury: ___________________________ Case Name: ______________________________________ Case Number: ________________ Court: ___________________________________________ County of _____________________, State of Tennessee Consent and Release The undersigned patient _____________________________________________________ [insert name of patient], (“Patient”) hereby consents to the examination, treatment, procedures and services to be performed by __________________________ [insert name of medical provider] (“Provider”), including emergency treatment. Patient authorizes Provider to release any information needed to process the claims with respect to the examination, treatment, procedures and services rendered by Provider. Patient further directs that a photocopy of this Consent, Release and Lien Agreement be considered as valid as the original. Patient further authorizes ___________________________________ [insert name of attorney], (“Attorney”) to keep Provider advised of the progress of Patient’s court case at reasonable intervals. Irrevocable Lien Patient hereby gives an irrevocable lien to Provider (as its interest may appear) against all proceeds derived from the said court case (whether by settlement, judgment or otherwise) to secure payment of all fees owed to Provider by Patient for treatment arising out of injuries sustained as of the time such proceeds are received. Patient hereby notifies Attorney that Patient is giving Provider a lien on these benefits or settlement proceeds. Patient hereby authorizes and directs Attorney to pay Provider directly any sums due for medical services rendered to Patient. Patient directs Attorney to withhold such funds from any settlement, verdict or judgment that is rendered in the said court case. In consideration for Provider waiting for payment, this lien is irrevocable and can only be satisfied by full payment of all sums due for medical services rendered. Patient understands that any settlement, verdict or judgment proceeds cannot be disbursed to Patient without first satisfying this lien. Patient understands and agrees that even though this lien has been given, Patient remains personally responsible for payment in full of Provider’s fees for all services rendered. Patient is solely responsible to make appropr
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