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How do I fill this out?
To fill out this form, start by providing your personal details and the accident information. Ensure all required fields are accurately filled. Your attorney and you will need to sign and date the form.
How to fill out the Doctor's Lien Authorization?
1
Provide your personal details including name and date of birth.
2
Enter the details of the accident you were involved in.
3
Authorize Dr. Gregory P. Skye by signing the form.
4
Ensure your attorney signs and dates the form.
5
Submit the form to the relevant parties.
Who needs the Doctor's Lien Authorization?
1
Patients who have been treated by Dr. Gregory P. Skye and need to authorize report sharing with their attorney.
2
Patients who require their attorney to pay medical services directly from settlements or judgments.
3
Attorneys who need to ensure payment settlements include due sums to the medical provider.
4
Insurance companies needing authorization to directly pay the healthcare provider.
5
Patients requiring documentation to protect their medical provider's interests in legal settlements.
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What are the instructions for submitting this form?
To submit this form, ensure all required fields are filled out accurately and signed by both the patient and their attorney. The completed form can be sent to Skye Chiropractic via fax at 615.377.0448 or mailed to 1187 Old Hickory Blvd, Brentwood, TN 37027. For further information, contact Skye Chiropractic by phone at 615.377.7770. Ensure to retain a copy for your records and provide one to your attorney.
What is the purpose of this form?
The purpose of the Doctor’s Lien form is to provide authorization for a medical provider to furnish medical reports to a patient’s attorney and to ensure the provider is paid directly from any settlement, judgment, or verdict related to the patient's case. By signing this form, the patient directs their attorney and insurance company to pay the medical provider directly for services rendered. It further protects the provider by creating a lien on the patient’s case, ensuring payment from any settlement, judgment, or verdict received.
Tell me about this form and its components and fields line-by-line.
- 1. Patient's Name: The full name of the patient involved in the accident.
- 2. Date of Birth: The birth date of the patient.
- 3. Patient's Signature: The signature of the patient authorizing the release of medical information and payment directives.
- 4. Date: The date on which the patient signed the form.
- 5. Address, City, St, Zip: The contact address of the patient including city, state, and zip code.
- 6. Attorney Signature: The attorney’s signature agreeing to withhold necessary sums from settlements for the medical provider.
- 7. Date: The date on which the attorney signed the form.
What happens if I fail to submit this form?
Failing to submit this form can result in immediate payment requirements by the medical provider and potential legal complications.
- Immediate Payment: The medical provider may not await settlement or judgment and require immediate payment for services rendered.
- Legal Action: The provider may take legal action to recover fees due for medical services if the lien is not provided.
How do I know when to use this form?
- 1. After an Accident: When you need to authorize your doctor to share medical information with your attorney following an accident.
- 2. Settlement Proceedings: To direct that payments from settlements or judgments be made directly to the medical provider.
- 3. Changing Attorneys: When substituting attorneys to ensure the new attorney honors the executed lien.
- 4. Protecting Medical Provider: To ensure your medical provider's interests are protected in any legal proceedings.
Frequently Asked Question
How do I fill out the Doctor's Lien form?
Provide your personal and accident details, sign the form, and ensure your attorney also signs it.
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Is it possible to share the completed Doctor's Lien form through PrintFriendly?
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Who needs to sign the Doctor's Lien form?
Both the patient and the attorney need to sign the form.
What should I do if I need to make corrections on the Doctor's Lien form?
Use PrintFriendly’s PDF editor to make necessary corrections and save the updated form.
Can I download the Doctor's Lien form after editing?
Yes, you can download the edited form from PrintFriendly.
How do I authorize the sharing of my medical report with my attorney?
Sign the Doctor's Lien form to authorize Dr. Gregory P. Skye to share your medical report with your attorney.
What happens if my attorney does not sign the Doctor's Lien form?
If your attorney does not sign, the doctor may require immediate payment and may not await the settlement or judgment.
How can I ensure my medical provider is protected in case of a lawsuit?
Complete and sign the Doctor's Lien form to give a lien on your case to your medical provider against any proceeds from settlements or judgments.
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