LIEN CLAIM AND REQUEST FOR ALLOWANCE

(Workers' Compensation Medical/Service Provider Lien)

PART 1: CASE INFORMATION

WORKERS' COMPENSATION APPEALS BOARD/COMMISSION
STATE OF [STATE]

Case Number(s): [ADJ NUMBER(S)]

Injured Worker: [NAME]

Date of Injury: [DATE]

Employer: [EMPLOYER NAME]

Insurance Carrier/Claims Administrator: [NAME]

PART 2: LIEN CLAIMANT INFORMATION

2.1 Lien Claimant Identification

Type of Lien Claimant:
☐ Medical Provider (Doctor, Hospital, Clinic)
☐ Medical-Legal Provider
☐ Interpreter Services
☐ Copy Service
☐ Transportation Provider
☐ EDD (Unemployment/Disability)
☐ ERISA Health Plan
☐ Medicare/Medicaid
☐ Other: [SPECIFY]

Lien Claimant Name: [FULL LEGAL NAME OR ENTITY NAME]

Business Name (if different): [DBA]

Tax ID/EIN: [NUMBER]

NPI Number (if medical provider): [NUMBER]

License Number: [NUMBER]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE]

Fax: [FAX]

Email: [EMAIL]

2.2 Lien Claimant Representative (if applicable)

☐ Lien Claimant is self-represented
☐ Lien Claimant is represented by:

Representative/Attorney Name: [NAME]

Firm Name: [FIRM]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE]

Email: [EMAIL]

PART 3: INJURED WORKER INFORMATION

Injured Worker Name: [FULL NAME]

Date of Birth: [DATE]

Social Security Number (Last 4): XXX-XX-[LAST 4]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Injured Worker's Attorney (if any):
Name: [NAME]
Firm: [FIRM]
Address: [ADDRESS]
Phone: [PHONE]

PART 4: CLAIM INFORMATION

4.1 Claim Details

Date(s) of Injury: [DATE(S)]

Body Parts Injured: [LIST BODY PARTS]

Claim Status:
☐ Accepted
☐ Denied
☐ Pending
☐ Partially Accepted for: [SPECIFY]

4.2 Insurance Information

Insurance Carrier: [NAME]

Claims Administrator (if different): [NAME]

Claim Number: [NUMBER]

Claims Examiner: [NAME]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE]

Fax: [FAX]

4.3 Defense Attorney (if known)

Name: [NAME]

Firm: [FIRM]

Address: [ADDRESS]

Phone: [PHONE]

PART 5: LIEN CLAIM DETAILS

5.1 Nature of Services Provided

Type of Services:
☐ Medical Treatment
☐ Medical-Legal Evaluation (QME/AME)
☐ Diagnostic Testing
☐ Physical Therapy
☐ Chiropractic Care
☐ Pharmacy/Medications
☐ Durable Medical Equipment
☐ Surgery
☐ Hospital Services
☐ Interpreter Services
☐ Copy Services
☐ Transportation
☐ Other: [SPECIFY]

Description of Services:
[PROVIDE DETAILED DESCRIPTION OF SERVICES RENDERED]

____________________________________________________________________________

____________________________________________________________________________

5.2 Dates of Service

First Date of Service: [DATE]

Last Date of Service: [DATE]

5.3 Lien Amount

5.4 Billing Basis

Billing calculated pursuant to:
☐ Official Medical Fee Schedule (OMFS)
☐ Medicare Fee Schedule
☐ Usual and Customary Rates
☐ Contract Rate
☐ Other: [SPECIFY]

PART 6: AUTHORIZATION AND REFERRAL

6.1 Treatment Authorization

Was prior authorization obtained?
☐ Yes - Authorization Number: [NUMBER]
☐ No - Explain: [EXPLANATION]
☐ Not required (emergency, first visit, etc.)

Was treatment provided by:
☐ Primary Treating Physician
☐ Referral from PTP (Referring Physician: [NAME])
☐ MPN Provider
☐ Non-MPN Provider (Explain: [REASON])
☐ QME/AME
☐ Other: [EXPLAIN]

6.2 Medical Necessity

Was treatment medically necessary?
☐ Yes - Treatment was reasonably required to cure or relieve the effects of the industrial injury

Supporting Documentation:
☐ Medical reports attached
☐ Physician declaration attached
☐ Treatment notes attached

PART 7: PRIOR PAYMENT DEMANDS

7.1 Billing History

Original Bill Submitted:
Date: [DATE]
Submitted To: [CARRIER/ADMINISTRATOR]
Amount: $[AMOUNT]

Subsequent Billing/Demands:

7.2 Reason for Non-Payment

Defendant's Stated Reason for Non-Payment (if any):
☐ No authorization
☐ Treatment not medically necessary
☐ Not industrial
☐ No response to billing
☐ Utilization Review denial
☐ Fee schedule dispute
☐ Other: [SPECIFY]

____________________________________________________________________________

PART 8: BASIS FOR LIEN

8.1 Legal Basis

This lien is filed pursuant to:

☐ [CITE STATE STATUTE - e.g., California Labor Code Section 4903]

☐ Services were provided for treatment of an industrial injury

☐ Services were medically necessary to cure or relieve the effects of the injury

☐ Lien Claimant is entitled to payment from the workers' compensation benefits payable to or on behalf of the injured worker

8.2 Specific Grounds

[EXPLAIN THE LEGAL AND FACTUAL BASIS FOR THE LIEN]

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

PART 9: VERIFICATION AND DECLARATION

9.1 Verification

I, [NAME], declare under penalty of perjury under the laws of the State of [STATE] that:

☐ I am the Lien Claimant / authorized representative of the Lien Claimant.

☐ The services described in this lien claim were provided by Lien Claimant to the injured worker for treatment of the claimed industrial injury.

☐ The amount claimed represents the reasonable value of the services provided, calculated in accordance with applicable fee schedules.

☐ Payment for these services has not been received from any source, except as noted.

☐ The information contained in this lien claim is true and correct to the best of my knowledge.

☐ I understand that penalties may be imposed for filing a fraudulent lien.

Signature: _________________________________

Printed Name: [NAME]

Title: [TITLE]

Date: [DATE]

9.2 Medical Provider Certification (if applicable)

I, [PHYSICIAN NAME], [CREDENTIALS], certify that:

☐ The treatment provided was medically necessary to cure or relieve the effects of the industrial injury.

☐ The treatment was consistent with applicable treatment guidelines.

☐ The billing accurately reflects the services provided.

Physician Signature: _________________________________

License Number: [NUMBER]

Date: [DATE]

PART 10: FILING REQUIREMENTS

10.1 Filing Fee (State-Specific)

☐ Filing fee enclosed: $[AMOUNT]
☐ Filing fee previously paid
☐ No filing fee required
☐ Fee waiver requested

California Lien Fees:
- Initial Filing Fee: $150 (as of 2024)
- Activation Fee: $100 (required to set lien for hearing)

10.2 Required Attachments

Attach the following documents:

☐ Itemized billing statement
☐ Medical reports supporting services
☐ Authorization documentation (if obtained)
☐ Referral documentation
☐ Explanation of Benefits (EOB) or denial letters
☐ Proof of prior demands for payment
☐ Copy of treatment records
☐ Declaration of medical necessity
☐ Proof of filing fee payment
☐ Other: [SPECIFY]

PART 11: SERVICE OF LIEN

11.1 Proof of Service

This Lien Claim has been served on the following parties:

11.2 Declaration of Service

I, [NAME], declare under penalty of perjury that I am over 18 years of age and not a party to this action. On [DATE], I served a true copy of this Lien Claim on the parties listed above by the methods indicated.

Signature: _________________________________

Date: [DATE]

PART 12: FILING INSTRUCTIONS

File With:

[STATE] Workers' Compensation Appeals Board/Commission

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Electronic Filing: [SYSTEM NAME/URL]

Fax: [FAX NUMBER]

Deadline for Filing:

Your Deadline: [DATE]

PART 13: SETTLEMENT INFORMATION (IF CASE SETTLING)

13.1 Notice of Settlement

☐ Lien Claimant has been notified of pending settlement
☐ Lien Claimant has NOT been notified of any settlement

13.2 Lien Resolution Offer

☐ Lien Claimant has received a settlement offer of: $[AMOUNT]
☐ Lien Claimant has NOT received any settlement offer

Lien Claimant's Position:
☐ Lien Claimant is willing to negotiate
☐ Lien Claimant requests full payment of lien
☐ Lien Claimant is willing to accept $[AMOUNT] in full satisfaction

PART 14: REQUEST FOR HEARING

☐ Lien Claimant requests a lien conference/hearing to determine the amount due.

Preferred Hearing Location: [DISTRICT OFFICE]

Estimated Time for Hearing: [TIME]

Lien Claimant's Availability: [DATES/TIMES]

[END OF DOCUMENT]