West Virginia 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. [Your Name] [Your Address] [City, State, ZIP Code] [Date] [Medical Provider Name] [Medical Provider Address] [City, State, ZIP Code] Subject: West Virginia Sample Letter for Irrevocable Assignment and Lien to Medical Provider Dear [Medical Provider Name], I am writing to you in regard to the medical services provided to me or my patient on [date(s)] at your esteemed facility/institution. I would like to request an irrevocable assignment and lien in accordance with West Virginia regulations to ensure the proper handling of any potential settlement or judgment proceeds that may arise from a third-party claim or lawsuit. As required by West Virginia law, I hereby assign and transfer to you, as the medical provider, the right to receive payment directly from any liability or property damage settlement or judgment that may result from an accident, injury, or any medical condition related to treatment provided by you. This assignment is irrevocable and is intended to secure payment for the medical services rendered to me or my patient. This assignment will apply to any and all parties liable for the injuries or damages suffered by me or my patient. Furthermore, I authorize you to file, perfect, and pursue any lien, claim, or cause of action necessary to preserve and enforce your rights for the services rendered. This includes, but is not limited to, filing a lien with the appropriate court and/or sending notice to the involved parties or their insurance providers. I understand that by requesting this irrevocable assignment and lien, you are taking necessary steps to protect your right to reimbursement. Should a settlement or judgment be reached, I request that you provide an itemized statement of the outstanding medical charges incurred and any related costs such as testing, medication, or hospitalization. Please include any applicable interest or other fees allowed by law. I understand that this assignment and lien may affect any medical payment coverage available under insurance policies, including but not limited to personal injury protection (PIP), medical payments' coverage (Median), or other similar policies. I authorize you to cooperate with any insurance companies involved and to provide them with all the necessary documentation required to process any claim or payment. Please find enclosed any supporting documentation that may assist you in processing this assignment and lien promptly. If you require any further information or have any specific documentation requirements, please do not hesitate to contact me directly at [Your Phone Number] or [Your Email Address]. Thank you for your attention to this matter, and I appreciate your cooperation in this process. Please acknowledge receipt of this letter and confirm your understanding of the irrevocable assignment and lien by signing and returning a copy of this letter. I look forward to a favorable resolution and appreciate your professionalism. Sincerely, [Your Name]

[Your Name] [Your Address] [City, State, ZIP Code] [Date] [Medical Provider Name] [Medical Provider Address] [City, State, ZIP Code] Subject: West Virginia Sample Letter for Irrevocable Assignment and Lien to Medical Provider Dear [Medical Provider Name], I am writing to you in regard to the medical services provided to me or my patient on [date(s)] at your esteemed facility/institution. I would like to request an irrevocable assignment and lien in accordance with West Virginia regulations to ensure the proper handling of any potential settlement or judgment proceeds that may arise from a third-party claim or lawsuit. As required by West Virginia law, I hereby assign and transfer to you, as the medical provider, the right to receive payment directly from any liability or property damage settlement or judgment that may result from an accident, injury, or any medical condition related to treatment provided by you. This assignment is irrevocable and is intended to secure payment for the medical services rendered to me or my patient. This assignment will apply to any and all parties liable for the injuries or damages suffered by me or my patient. Furthermore, I authorize you to file, perfect, and pursue any lien, claim, or cause of action necessary to preserve and enforce your rights for the services rendered. This includes, but is not limited to, filing a lien with the appropriate court and/or sending notice to the involved parties or their insurance providers. I understand that by requesting this irrevocable assignment and lien, you are taking necessary steps to protect your right to reimbursement. Should a settlement or judgment be reached, I request that you provide an itemized statement of the outstanding medical charges incurred and any related costs such as testing, medication, or hospitalization. Please include any applicable interest or other fees allowed by law. I understand that this assignment and lien may affect any medical payment coverage available under insurance policies, including but not limited to personal injury protection (PIP), medical payments' coverage (Median), or other similar policies. I authorize you to cooperate with any insurance companies involved and to provide them with all the necessary documentation required to process any claim or payment. Please find enclosed any supporting documentation that may assist you in processing this assignment and lien promptly. If you require any further information or have any specific documentation requirements, please do not hesitate to contact me directly at [Your Phone Number] or [Your Email Address]. Thank you for your attention to this matter, and I appreciate your cooperation in this process. Please acknowledge receipt of this letter and confirm your understanding of the irrevocable assignment and lien by signing and returning a copy of this letter. I look forward to a favorable resolution and appreciate your professionalism. Sincerely, [Your Name]