Chicago Illinois Sample Letter for Irrevocable Assignment and Lien to Medical Provider

• Category: Letters - Legal - Personal Injury
• State: Multi-State
• City: Chicago
• 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] [Email Address] [Phone Number] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, ZIP] Subject: Irrevocable Assignment and Lien to Medical Provider — [Patient's Name] Dear [Medical Provider's Name], I am writing to provide you with an irrevocable assignment and lien on behalf of [Patient's Name], who has received medical treatment from your esteemed facility. As [Patient's Name]'s legal representative [or "spouse" or "parent"], I hereby assign and authorize you to make claims directly with all applicable insurance companies, government programs, and settlements, for reimbursement of all outstanding medical expenses incurred by the aforementioned patient. [If applicable, explain the circumstances under which the irrevocable assignment and lien are being established, such as a personal injury incident or workers' compensation claim.] I understand that, as the medical provider, you may rely on the irrevocable assignment and lien for the determination of payment of all services rendered to the patient. Furthermore, this assignment and lien will remain in effect until the full payment of all outstanding medical bills related to the treatment of [Patient's Name] has been received. To facilitate this process, I have enclosed all relevant medical records, bills, and insurance information pertaining to [Patient's Name]'s treatment. Kindly keep us informed of any additional documentation or information required to pursue reimbursement from the responsible parties. Please note that any payments received directly from insurance carriers or other responsible parties should be forwarded immediately to [Patient's Name]'s legal representative [or "spouse" or "parent"]. Reimbursements should be made payable to both [Medical Provider's Name] and [Patient's Name's Legal Representative/Spouse/Parent] and promptly mailed to: [Your Name] [Your Address] [City, State, ZIP] Should you have any questions or require further documentation, please do not hesitate to contact me at [Your Phone Number] or via email at [Your Email Address]. Your prompt attention to this matter is greatly appreciated, as it ensures the timely settlement of our outstanding medical bills. Thank you for your cooperation and assistance in this matter. We look forward to working together to resolve the outstanding financial obligations. Sincerely, [Your Name]

[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 Medical Provider — [Patient's Name] Dear [Medical Provider's Name], I am writing to provide you with an irrevocable assignment and lien on behalf of [Patient's Name], who has received medical treatment from your esteemed facility. As [Patient's Name]'s legal representative [or "spouse" or "parent"], I hereby assign and authorize you to make claims directly with all applicable insurance companies, government programs, and settlements, for reimbursement of all outstanding medical expenses incurred by the aforementioned patient. [If applicable, explain the circumstances under which the irrevocable assignment and lien are being established, such as a personal injury incident or workers' compensation claim.] I understand that, as the medical provider, you may rely on the irrevocable assignment and lien for the determination of payment of all services rendered to the patient. Furthermore, this assignment and lien will remain in effect until the full payment of all outstanding medical bills related to the treatment of [Patient's Name] has been received. To facilitate this process, I have enclosed all relevant medical records, bills, and insurance information pertaining to [Patient's Name]'s treatment. Kindly keep us informed of any additional documentation or information required to pursue reimbursement from the responsible parties. Please note that any payments received directly from insurance carriers or other responsible parties should be forwarded immediately to [Patient's Name]'s legal representative [or "spouse" or "parent"]. Reimbursements should be made payable to both [Medical Provider's Name] and [Patient's Name's Legal Representative/Spouse/Parent] and promptly mailed to: [Your Name] [Your Address] [City, State, ZIP] Should you have any questions or require further documentation, please do not hesitate to contact me at [Your Phone Number] or via email at [Your Email Address]. Your prompt attention to this matter is greatly appreciated, as it ensures the timely settlement of our outstanding medical bills. Thank you for your cooperation and assistance in this matter. We look forward to working together to resolve the outstanding financial obligations. Sincerely, [Your Name]