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Golinsky Specific Chiropractic Notice of Doctors Lien free printable template
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Golinsky Specific Chiropractic Philip D. Golinsky D.C. 1110-D Elden Street Suite 206 Herndon VA 20170 Voice 703 904-9666 Fax 703 471-4548 E-Mail RxWellness AOL.com NOTICE OF DOCTOR S LIEN Patient s Name Date of Incident Attorney s Name and Phone I do hereby authorize Golinsky Specific Chiropractic/Philip Golinsky D.C. to furnish my attorney named above with a full report of my examination diagnosis treatment prognosis etc. with regard to the incident in which I was recently injured. I further...authorize and direct my attorney to pay directly to Golinsky Specific Chiropractic/Philip Golinsky D.C. such sums as may be due and owing for medical services rendered to me both by reason of this incident and by reason of any other bills that are due and to withhold such sums from any settlement judgment or verdict as may be necessary to adequately protect and fully compensate said doctors. I hereby further give a Lien on my case to Golinsky Specific Chiropractic/Philip Golinsky D.C. against...any and all proceeds of my settlement judgment or verdict which may be recovered or paid as the result of the injuries for which I have been treated. I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for services rendered me and that this agreement is made solely for said doctor s additional protection and in consideration of his awaiting payment. Golinsky Specific Chiropractic Philip D. Golinsky D*C* 1110-D Elden Street Suite 206...Herndon VA 20170 Voice 703 904-9666 Fax 703 471-4548 E-Mail RxWellness AOL*com NOTICE OF DOCTOR S LIEN Patient s Name Date of Incident Attorney s Name and Phone I do hereby authorize Golinsky Specific Chiropractic/Philip Golinsky D*C* to furnish my attorney named above with a full report of my examination diagnosis treatment prognosis etc* with regard to the incident in which I was recently injured* I further authorize and direct my attorney to pay directly to Golinsky Specific...Chiropractic/Philip Golinsky D*C* such sums as may be due and owing for medical services rendered to me both by reason of this incident and by reason of any other bills that are due and to withhold such sums from any settlement judgment or verdict as may be necessary to adequately protect and fully compensate said doctors. I hereby further give a Lien on my case to Golinsky Specific Chiropractic/Philip Golinsky D*C* against any and all proceeds of my settlement judgment or verdict which may be...recovered or paid as the result of the injuries for which I have been treated* I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for services rendered me and that this agreement is made solely for said doctor s additional protection and in consideration of his awaiting payment. I further understand that such payment is not contingent on any recovery made by me. I hereby agree to waive the defense of Statute of Limitations as it...pertains to any claim filed against me beyond three years or other statutory after services were rendered* I agree to promptly notify said doctor of any change or addition of attorney s used by me in connection with this accident and I instruct my attorney to do the same and to promptly deliver a copy of this lien to any such substituted or added attorney s.
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A comprehensive guide to the Golinsky Specific Chiropractic Notice Form
How does the Golinsky Specific Chiropractic Notice Form work?
The Golinsky Specific Chiropractic Notice Form is crucial for patients receiving chiropractic care while involved in legal matters, particularly personal injury cases. This form, which serves as a Notice of Doctor's Lien, declares the chiropractor's right to receive payment directly from any settlement or judgment the patient receives.
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It authorizes a lien: This allows the chiropractor to secure payment for services rendered.
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Protects patient interests: Patients are guaranteed that their medical bills will be prioritized in the settlement.
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Integration with practice: The form is commonly used in Virginia chiropractic practices, ensuring consistency.
What should be included in the Notice of Doctor's Lien?
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Accurate details about the patient, including name, contact, and insurance information, are essential to validate the lien.
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Thoroughly documenting the incident helps establish the connection between treatment received and the legal claim.
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Including this information is critical as it facilitates communication between all parties involved.
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This clause outlines the patient's consent for their attorney to pay the chiropractor directly from any settlement.
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This section reassures the patient that their treatment costs will be prioritized in any financial recovery.
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Clarifying this term helps patients understand their obligations and rights regarding payment.
How do you fill out the Golinsky Specific Chiropractic Notice Form?
Filling out the Golinsky Specific Chiropractic Notice Form can appear daunting, but it becomes easier with a systematic approach. Start by gathering all necessary information including patient data and details of the legal incident.
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Follow a structured method, filling in one section at a time, cross-referencing with your documentation.
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Ensure all required sections are complete to avoid delays in processing.
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The platform provides editing tools, allowing you to complete, sign, and even store your form securely in the cloud.
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In Virginia, electronic signatures are legally recognized, ensuring the form can be signed remotely without issues.
What happens after submitting the Notice of Doctor's Lien?
Once the Golinsky Specific Chiropractic Notice Form is submitted, it's crucial to understand the ensuing process. The submission goes to the attorney, who examines the details and initiates a claim.
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Patients should be aware that processing claims can take time, usually depending on the attorney's workload and the complexity of the case.
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Being prepared for constructive feedback or requests for additional information can help streamline the process.
How can pdfFiller help manage your chiropractic documents?
pdfFiller equips chiropractors and patients with innovative tools for managing their documents. Its cloud-based platform allows users to create, edit, and collaborate from any location.
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Easily store and retrieve patient records, helping practices stay organized.
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Teams can work together seamlessly, minimizing errors and ensuring that everyone is on the same page.
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With features designed for safe sharing, patient data remains protected.
What are the compliance and legal considerations for practitioners?
Practicing chiropractors need to be aware of Virginia laws regarding chiropractic care and the specific regulations related to liens. Compliance not only protects patients but also upholds the integrity of chiropractic practices.
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Understanding local laws ensures that chiropractors are fully compliant and able to provide optimal care.
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Employing best practices when completing forms protects both the patient’s health information and the chiropractic practice.
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Implementing secure methods and protections for sensitive patient data is essential for maintaining trust.
Frequently Asked Questions about medical lien template form
What happens if I need to change my attorney?
If you change your attorney, you must inform your new attorney about the existing Notice of Doctor's Lien. They will likely request a transfer of the lien to ensure continuity in settling medical bills.
How is the lien enforced?
The lien is typically enforced during the settlement discussions once the case is resolved. Your attorney will ensure that the chiropractor is paid before any funds are disbursed to you.
What should I do if the settlement doesn't cover medical bills?
If the settlement falls short, it’s important to consult with your attorney about covering the remaining medical expenses. There could be options like negotiating with the chiropractor or discussing alternative arrangements.
Can I fill out the form online?
Yes, you can fill out the Golinsky Specific Chiropractic Notice Form online using platforms like pdfFiller, which allows for easy editing and signing from anywhere.
What are the consequences of not submitting the notice?
Failing to submit the notice can lead to financial complications where you may end up paying out-of-pocket for chiropractic services, as the lien protects the chiropractor's right to compensation.
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People Also Ask about chiropractic lien form search
What is a lien treatment?
To be treated on a lien basis means that your doctor will not require you to have medical insurance or to pay up front or at the time of treatment. Instead, your doctor or other medical provider will treat you now and wait to be paid after your personal injury case is completed.
What is a medical lien in NC?
A doctor, nurse, hospital, or other medical service providers can claim a medical lien under North Carolina law. This lien gives them the right to compensation for medical services provided to you after your accident.
How long is a medical lien good for in California?
California's statute of limitations for contractual medical liens is generally four years after you break your promise to pay.
What is a medical lien in Washington state?
When Does A Medical Lien Apply In Washington State? Washington state law (RCW 60.44) allows for healthcare providers who have not been paid for their care to place a lien on an injured patient's insurance claim.
What is a medical lien in Illinois?
In Illinois when an injured person receives medical treatment for injuries they sustain due to the negligence of a third party, a Medical provider or a Medical Professional administering medical treatment can pursuant to Illinois Health Care Services Lien Act assert a lien on the individuals pending personal injury
What is lien in medical terms?
A medical lien, in short, is the ability of a healthcare provider (doctor, radiologist, hospital, etc.) to place request for payment on your personal injury claim to recoup any money that is owed to them for treatment as a result of that specific accident.
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