Houston Texas Sample Letter for Irrevocable Assignment and Lien to Medical Provider

• Category: Letters - Legal - Personal Injury
• State: Multi-State
• City: Houston
• 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. Houston Texas 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 for Medical Services Dear [Medical Provider's Name], I hope this letter finds you well. I am writing to formally assign and place a lien against any present or future medical payments or proceeds that may result from any claim or legal action against a third party. This assignment and lien are in regard to the medical services provided by your esteemed healthcare facility [or include specific department name]. As an acknowledgment of my financial responsibility for the medical services received, I, [Your Name], hereby irrevocably assign and transfer any billing and reimbursement rights, including but not limited to benefits, medical payments, and proceeds, which I am or will be entitled to, to your medical practice, [Medical Provider's Name]. The purpose of this irrevocable assignment and lien is to ensure that you, as the medical provider, will receive direct payment for services rendered, directly from any liable third-party payers, without delays or interference. By placing this lien, I authorize and request all insurance companies, government entities, or other responsible parties to make direct payment for any debt or amounts due directly to your facility. It is important to note that this assignment and lien are contingent upon the successful resolution of any resulting claim or legal action and will only apply to any monetary awards, settlements, or benefits arising from such proceedings. Should you require any further information or documentation regarding this assignment and lien, please do not hesitate to contact me at the details provided above. I am more than willing to cooperate fully to facilitate the efficient resolution of any claims or legal actions. I appreciate your understanding and cooperation in this matter and trust that this agreement will ensure the prompt payment of outstanding medical bills. Thank you for your ongoing commitment to providing exceptional healthcare services to the Houston community. Sincerely, [Your Name]

Houston Texas 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 for Medical Services Dear [Medical Provider's Name], I hope this letter finds you well. I am writing to formally assign and place a lien against any present or future medical payments or proceeds that may result from any claim or legal action against a third party. This assignment and lien are in regard to the medical services provided by your esteemed healthcare facility [or include specific department name]. As an acknowledgment of my financial responsibility for the medical services received, I, [Your Name], hereby irrevocably assign and transfer any billing and reimbursement rights, including but not limited to benefits, medical payments, and proceeds, which I am or will be entitled to, to your medical practice, [Medical Provider's Name]. The purpose of this irrevocable assignment and lien is to ensure that you, as the medical provider, will receive direct payment for services rendered, directly from any liable third-party payers, without delays or interference. By placing this lien, I authorize and request all insurance companies, government entities, or other responsible parties to make direct payment for any debt or amounts due directly to your facility. It is important to note that this assignment and lien are contingent upon the successful resolution of any resulting claim or legal action and will only apply to any monetary awards, settlements, or benefits arising from such proceedings. Should you require any further information or documentation regarding this assignment and lien, please do not hesitate to contact me at the details provided above. I am more than willing to cooperate fully to facilitate the efficient resolution of any claims or legal actions. I appreciate your understanding and cooperation in this matter and trust that this agreement will ensure the prompt payment of outstanding medical bills. Thank you for your ongoing commitment to providing exceptional healthcare services to the Houston community. Sincerely, [Your Name]