Puerto Rico 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. Puerto Rico Sample Letter for Irrevocable Assignment and Lien to Medical Provider [Your Name] [Your Address] [City, State, Zip] [Email Address] [Phone Number] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, Zip] Subject: Irrevocable Assignment and Lien to Secure Medical Payments Dear [Medical Provider's Name], I hope this letter finds you well. I am reaching out to provide you with an irrevocable assignment and lien relating to medical payments for myself or my dependent, [Name of Patient], (hereinafter referred to as the "Patient") who has received or will receive medical treatment and services from your esteemed healthcare facility. I hereby assign to you, [Medical Provider's Name], all rights, title, and interest in and to any and all insurance settlements, judgments, claims, liens, causes of action, and/or other proceeds and recoveries, whether in the form of cash, checks, drafts, or any other medium, which may arise out of, relate to, or result from the medical treatment and services rendered to the Patient. This irrevocable assignment is made with the explicit purpose of securing payment for all outstanding medical bills incurred by the Patient. I understand and acknowledge that upon receipt of any insurance settlements or other forms of payment related to the Patient's treatment, you shall be authorized to retain and satisfy any outstanding balances for medical services rendered on behalf of the Patient. Furthermore, you are authorized to endorse, negotiate, or deposit any check, draft, or instrument received in payment of the assigned rights. It is essential to state that this irrevocable assignment and lien shall remain in effect until the total satisfaction of all medical bills and fees owed to your facility, including any interest, late fees, and collection costs deemed necessary to collect such outstanding amounts. I pledge to cooperate with your billing department and promptly provide any necessary information or documentation required for the completion of insurance claims or other forms of reimbursement. Additionally, I authorize and request that you communicate and cooperate with my attorney, insurance company, or any other authorized party involved in the resolution of claims or settlements concerning the medical treatment of the Patient. This will ensure a seamless claims process and facilitate accurate allocation of funds toward the outstanding medical expenses. Should there be any amendments or modifications to this irrevocable assignment and lien, it is imperative that all parties involved provide written consent and agree to any changes. This document shall be binding upon all successors, assigns, heirs, and legal representatives. Thank you for your attention to this matter. I appreciate your understanding and cooperation in securing the necessary funds to cover the outstanding medical bills. If you have any further questions or require additional information, please do not hesitate to contact me at the details provided above. Sincerely, [Your Name]

Puerto Rico Sample Letter for Irrevocable Assignment and Lien to Medical Provider [Your Name] [Your Address] [City, State, Zip] [Email Address] [Phone Number] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, Zip] Subject: Irrevocable Assignment and Lien to Secure Medical Payments Dear [Medical Provider's Name], I hope this letter finds you well. I am reaching out to provide you with an irrevocable assignment and lien relating to medical payments for myself or my dependent, [Name of Patient], (hereinafter referred to as the "Patient") who has received or will receive medical treatment and services from your esteemed healthcare facility. I hereby assign to you, [Medical Provider's Name], all rights, title, and interest in and to any and all insurance settlements, judgments, claims, liens, causes of action, and/or other proceeds and recoveries, whether in the form of cash, checks, drafts, or any other medium, which may arise out of, relate to, or result from the medical treatment and services rendered to the Patient. This irrevocable assignment is made with the explicit purpose of securing payment for all outstanding medical bills incurred by the Patient. I understand and acknowledge that upon receipt of any insurance settlements or other forms of payment related to the Patient's treatment, you shall be authorized to retain and satisfy any outstanding balances for medical services rendered on behalf of the Patient. Furthermore, you are authorized to endorse, negotiate, or deposit any check, draft, or instrument received in payment of the assigned rights. It is essential to state that this irrevocable assignment and lien shall remain in effect until the total satisfaction of all medical bills and fees owed to your facility, including any interest, late fees, and collection costs deemed necessary to collect such outstanding amounts. I pledge to cooperate with your billing department and promptly provide any necessary information or documentation required for the completion of insurance claims or other forms of reimbursement. Additionally, I authorize and request that you communicate and cooperate with my attorney, insurance company, or any other authorized party involved in the resolution of claims or settlements concerning the medical treatment of the Patient. This will ensure a seamless claims process and facilitate accurate allocation of funds toward the outstanding medical expenses. Should there be any amendments or modifications to this irrevocable assignment and lien, it is imperative that all parties involved provide written consent and agree to any changes. This document shall be binding upon all successors, assigns, heirs, and legal representatives. Thank you for your attention to this matter. I appreciate your understanding and cooperation in securing the necessary funds to cover the outstanding medical bills. If you have any further questions or require additional information, please do not hesitate to contact me at the details provided above. Sincerely, [Your Name]