Health Care Provider’s Lien

Health Care Provider: Mile High Ambulance, LLC

Address: P.O. Box 22440
Denver, CO 80222

Patient's Name: (required)

Date of Injury: (required)

Upon receiving proceeds on my behalf, I hereby authorize and direct my attorney(s), (required)
to pay directly to the above referenced health care provider such sums from
the net proceeds of any settlement, judgment, or verdict from my personal injury claim based on the
accident referenced above, as may be necessary to pay in full said health care provider for services
rendered on my behalf.
This lien shall be irrevocable and shall be valid and enforceable out of the proceeds of my
settlement, judgment, or verdict. Net proceeds means the gross amount recovered, less any attorney fees
and costs. This lien applies to sums currently owed, and to sums which may be incurred in the future. I
intend for receipt of the document by my attorney to constitute notice to the attorney of this lien and I
intend for this lien to be valid and enforceable regardless of whether or not my attorney signs the lien
below.
I fully understand that I am directly and fully responsible to the above referenced provider for all
professional bills submitted by the provider for services rendered to me, regardless of the outcome of my
personal injury claim. This agreement is made in consideration of my health care provider awaiting
payment for services rendered to me and to grant to the provider security for the payment of the
provider’s bills. I understand that such payment is not contingent on the outcome of any action against an
insurer or any person or entity that may be responsible for the payment of such bills.

Patient Signature:


The above referenced health care provider agrees that in exchange for execution of this lien by
the patient, the provider will refrain from referring any bills for professional services
rendered to the patient, to any third party for collection, or take any legal action to collect these bills, until
the personal injury claim is resolved.

Provider's Signature


The undersigned attorney for the above patient hereby agrees to withhold sums such sums from
the net proceeds of any settlement, judgment, or verdict and to pay such sums directly to the health care
provider as required by the terms of the lien.

Attorney's Signature

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