Oakland Michigan Sample Letter for Irrevocable Assignment and Lien to Medical Provider

• Category: Letters - Legal - Personal Injury
• State: Multi-State
• County: Oakland
• 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] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, ZIP] Subject: Irrevocable Assignment and Lien to Medical Provider Dear [Medical Provider's Name], I hope this letter finds you well. I am writing to formally establish an irrevocable assignment and lien in favor of [Medical Provider's Name] for medical services rendered to [Patient's Name]. Please find enclosed copies of all relevant medical records, itemized bills, and invoices for the medical services provided to [Patient's Name]. The purpose of this letter is to inform you that the assigned benefits, payments, and reimbursements made by the responsible party, including insurance providers and any other liable third parties, are now irrevocably assigned to [Medical Provider's Name] as payment for the services received by the patient. By executing this irrevocable assignment, [Medical Provider's Name] will have the right to receive direct payment from any responsible party. This assignment includes but is not limited to, any statutory liens, insurance claims, lawsuit settlements, worker's compensation benefits, and other monetary awards in favor of the patient or their representatives related to the medical services rendered. It is important to note that this assignment and lien is inclusive of all present and future treatment and services provided by [Medical Provider's Name] related to the incident which necessitated medical care. The assignment and lien are binding and enforceable against any responsible party or entity that may be legally obligated to pay for the medical services received. Should there be any disputes, discrepancies, or inquiries regarding the outstanding balance or payment arrangements, please contact me at the address provided above or by phone at [Your Phone Number]. I am more than willing to discuss any concerns and resolve them amicably. I appreciate your cooperation and understanding in this matter. Furthermore, I trust that [Medical Provider's Name] will diligently pursue the assigned benefits to ensure timely and appropriate reimbursement for the services rendered. If there are any additional forms, documents, or information required to facilitate this process, kindly inform me, and I will comply promptly. Thank you for your attention to this matter, and I look forward to a successful resolution. Sincerely, [Your Name]

[Your Name] [Your Address] [City, State, ZIP] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, ZIP] Subject: Irrevocable Assignment and Lien to Medical Provider Dear [Medical Provider's Name], I hope this letter finds you well. I am writing to formally establish an irrevocable assignment and lien in favor of [Medical Provider's Name] for medical services rendered to [Patient's Name]. Please find enclosed copies of all relevant medical records, itemized bills, and invoices for the medical services provided to [Patient's Name]. The purpose of this letter is to inform you that the assigned benefits, payments, and reimbursements made by the responsible party, including insurance providers and any other liable third parties, are now irrevocably assigned to [Medical Provider's Name] as payment for the services received by the patient. By executing this irrevocable assignment, [Medical Provider's Name] will have the right to receive direct payment from any responsible party. This assignment includes but is not limited to, any statutory liens, insurance claims, lawsuit settlements, worker's compensation benefits, and other monetary awards in favor of the patient or their representatives related to the medical services rendered. It is important to note that this assignment and lien is inclusive of all present and future treatment and services provided by [Medical Provider's Name] related to the incident which necessitated medical care. The assignment and lien are binding and enforceable against any responsible party or entity that may be legally obligated to pay for the medical services received. Should there be any disputes, discrepancies, or inquiries regarding the outstanding balance or payment arrangements, please contact me at the address provided above or by phone at [Your Phone Number]. I am more than willing to discuss any concerns and resolve them amicably. I appreciate your cooperation and understanding in this matter. Furthermore, I trust that [Medical Provider's Name] will diligently pursue the assigned benefits to ensure timely and appropriate reimbursement for the services rendered. If there are any additional forms, documents, or information required to facilitate this process, kindly inform me, and I will comply promptly. Thank you for your attention to this matter, and I look forward to a successful resolution. Sincerely, [Your Name]