North Dakota Sample Letter for Irrevocable Assignment and Lien to Medical Provider

• Category: Letters - Legal - Personal Injury
• State: Multi-State
• Control #: US-0531LTR
• Format: Word; Rich Text

Description

This form is a sample letter in Word format covering the subject matter of the title of the form. Sample Letter for Irrevocable Assignment and Lien to Medical Provider in North Dakota: [Your Name] [Your Address] [City, State, Zip Code] [Email Address] [Phone Number] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, Zip Code] Subject: Irrevocable Assignment and Lien to Medical Provider — [Patient's Name— - [Date of Service] Dear [Medical Provider's Name], I am writing to inform you of an irrevocable assignment and lien pertaining to the medical services provided to [Patient's Name], on [Date of Service]. This letter serves as notice that I, [Your Name], hereby assign all present and future rights, benefits, and proceeds associated with any claims, causes of action, or litigation arising out of the medical treatment rendered to [Patient's Name]. Furthermore, I hereby grant a lien upon any settlement, judgment, or award received by [Patient's Name], including but not limited to insurance payments, compensation from third parties, or other potential sources of recovery. By executing this irrevocable assignment and lien, I acknowledge and confirm: 1. The responsibilities associated with paying for the medical services rendered by your institution. 2. The necessity for you to directly enforce this lien against any settlement, judgment, or award in order to satisfy the outstanding charges. 3. My agreement to provide you with any necessary documents, including but not limited to insurance policies, personal injury protection claims, medical records, and billing statements, to assist with the enforcement of this lien. 4. My understanding that your institution may charge reasonable fees related to the enforcement of this lien and that such fees are my responsibility. Please note that this assignment and lien shall remain valid until the outstanding charges are paid in full or until I provide written notice of its revocation. Additionally, any changes or updates concerning insurance coverage, legal representation, or potential settlements should be promptly communicated to your office. I understand the importance of diligently working together to ensure appropriate payment and resolution of this matter. Please feel free to contact me directly at [Your Phone Number] or [Your Email Address] if you have any questions or require further information. Thank you for your attention to this matter, and I appreciate your cooperation in this process. Sincerely, [Your Name] [Your Signature] Types of North Dakota Sample Letter for Irrevocable Assignment and Lien to Medical Provider: 1. Sample Letter for Irrevocable Assignment and Lien to Medical Provider in North Dakota — Automobile Accident Claim 2. Sample Letter for Irrevocable Assignment and Lien to Medical Provider in North Dakota — Workers' Compensation Claim 3. Sample Letter for Irrevocable Assignment and Lien to Medical Provider in North Dakota — Personal InjurClaiiiiiiiiiim.im

Sample Letter for Irrevocable Assignment and Lien to Medical Provider in North Dakota: [Your Name] [Your Address] [City, State, Zip Code] [Email Address] [Phone Number] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, Zip Code] Subject: Irrevocable Assignment and Lien to Medical Provider — [Patient's Name— - [Date of Service] Dear [Medical Provider's Name], I am writing to inform you of an irrevocable assignment and lien pertaining to the medical services provided to [Patient's Name], on [Date of Service]. This letter serves as notice that I, [Your Name], hereby assign all present and future rights, benefits, and proceeds associated with any claims, causes of action, or litigation arising out of the medical treatment rendered to [Patient's Name]. Furthermore, I hereby grant a lien upon any settlement, judgment, or award received by [Patient's Name], including but not limited to insurance payments, compensation from third parties, or other potential sources of recovery. By executing this irrevocable assignment and lien, I acknowledge and confirm: 1. The responsibilities associated with paying for the medical services rendered by your institution. 2. The necessity for you to directly enforce this lien against any settlement, judgment, or award in order to satisfy the outstanding charges. 3. My agreement to provide you with any necessary documents, including but not limited to insurance policies, personal injury protection claims, medical records, and billing statements, to assist with the enforcement of this lien. 4. My understanding that your institution may charge reasonable fees related to the enforcement of this lien and that such fees are my responsibility. Please note that this assignment and lien shall remain valid until the outstanding charges are paid in full or until I provide written notice of its revocation. Additionally, any changes or updates concerning insurance coverage, legal representation, or potential settlements should be promptly communicated to your office. I understand the importance of diligently working together to ensure appropriate payment and resolution of this matter. Please feel free to contact me directly at [Your Phone Number] or [Your Email Address] if you have any questions or require further information. Thank you for your attention to this matter, and I appreciate your cooperation in this process. Sincerely, [Your Name] [Your Signature] Types of North Dakota Sample Letter for Irrevocable Assignment and Lien to Medical Provider: 1. Sample Letter for Irrevocable Assignment and Lien to Medical Provider in North Dakota — Automobile Accident Claim 2. Sample Letter for Irrevocable Assignment and Lien to Medical Provider in North Dakota — Workers' Compensation Claim 3. Sample Letter for Irrevocable Assignment and Lien to Medical Provider in North Dakota — Personal InjurClaiiiiiiiiiim.im