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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...

How to fill out medical lien letter template form

How to fill out Golinsky Specific Chiropractic Notice of Doctor's Lien

1. Begin by obtaining the Golinsky Specific Chiropractic Notice of Doctor's Lien form.
2. Fill in your personal information, including your name, address, and contact details, at the top of the form.
3. Provide the patient's information, including their name and address, in the designated section.
4. Specify the details of the treatment provided, including dates and types of services rendered.
5. Clearly outline the amount owed for the services, including any payment agreements if applicable.
6. Include any relevant case or claim number that may apply.
7. Sign and date the form, confirming that the information provided is accurate.
8. Deliver the completed notice to the appropriate parties, ensuring it is sent to both the patient and their attorney.

Who needs Golinsky Specific Chiropractic Notice of Doctor's Lien?

1. Chiropractors who have provided services and are seeking compensation directly from a third party, such as an insurance company or legal settlement.
2. Patients who have received chiropractic care and are involved in an accident or personal injury case where compensation is expected.

People Also Ask about medical lien template

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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What is Golinsky Specific Chiropractic Notice of Doctor's Lien?

The Golinsky Specific Chiropractic Notice of Doctor's Lien is a legal document that ensures a chiropractor's right to payment for services rendered from a patient's settlement or judgment in a personal injury case.

Who is required to file Golinsky Specific Chiropractic Notice of Doctor's Lien?

Chiropractors who provide treatment to a patient involved in a personal injury case are required to file the Golinsky Specific Chiropractic Notice of Doctor's Lien to secure their payment.

How to fill out Golinsky Specific Chiropractic Notice of Doctor's Lien?

To fill out the Golinsky Specific Chiropractic Notice of Doctor's Lien, the chiropractor must provide their name, address, patient details, description of services, and the amount owed, along with the necessary signatures.

What is the purpose of Golinsky Specific Chiropractic Notice of Doctor's Lien?

The purpose of the Golinsky Specific Chiropractic Notice of Doctor's Lien is to protect the financial interests of chiropractors by ensuring they receive payment directly from settlement funds related to the patient's injury claim.

What information must be reported on Golinsky Specific Chiropractic Notice of Doctor's Lien?

The Golinsky Specific Chiropractic Notice of Doctor's Lien must report the chiropractor's name, address, patient information, date of service, description of services provided, and the total amount due for those services.