Release & Settlement Agreement (Medical Expenses)

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This Release and Settlement Agreement (Patient Medical Expense) is between a patient and a medical provider who renders services but is paid after an insurance claim settlement. It is imperative that this type of agreement be clearly set out in writing.

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This Release and Settlement Agreement is between a patient and a medical provider who agrees to render services to the patient and receive payment through a settlement which the patient receives from an insurance company. This settlement agreement sets forth the date of any signed Lien and Insurance Assignment and the total amount due for the rendered services. It also sets out that this is the final agreement between the parties. It is imperative that this agreement be clearly set out in writing. A written Release and Settlement Agreement for Patient Medical Services will prove invaluable in the event of future disagreements or misunderstandings surrounding the patient's bill.

This Release and Settlement Agreement (Patient Medical Expenses) contains the following:
  • Parties: Names of the patient and the medical center and/or medical professional who rendered services;
  • Services: Specific medical services which were provided to the patient and the amount due for those services;
  • Release: Sets forth that any lien in connection with the medical services is now released;
  • Signatures: This agreement must be signed by the patient and agreed to and accepted by the medical provider.

Protect yourself and your family by using our attorney-prepared forms.

This attorney-prepared packet contains:
  1. General Instructions
  2. Release and Settlement Agreement (Patient Medical Expenses)
State Law Compliance: This form complies with the laws of all states
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.
Number of Pages4
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#28202
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.

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Reviews: 1


Palm Desert,

CA

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Excellent letter setup and very easy to read . This site has it all . Thanks you.


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