Prior to being seen in the office for a medical lien, you will need to complete the “ Lien Information “ sheet. In order to complete this form, it is imperative that you know the name and address of the person who caused your accident. This is called the “Third Party” – this is the person responsible for the accident. You will also need to know their insurance company’s name, address, phone number, policy and claim numbers. Your attorney should have all this information. If you do not have an attorney this information will be on the police report if filed. We strongly urge you to seek legal representation. We will need a copy of the police report and the name and contact information for your attorney if you have one. You will also need to read and sign the “Patient Financial Agreement” form prior to being seen by Dr. Wall.

After this information is received and Dr. Wall sees and treats you, a medical lien will be recorded with the Official Records of Maricopa County Recorder. You, your attorney and the third party insurance will receive a copy of the lien via certification of mail.

Patient Lien Information