Your Lien Amount
Settlement Amount
Health Care
Professional or
Lien
Other Healthcare Lienholders
Provider
Amount
Healthcare Lienholder 1
Health care professional
Healthcare Lienholder 2
Licensed physician, licensed dentist, licensed optometrist, licensed naprapath, licensed clinical psychologist, or licensed physical therapist.
Healthcare Lienholder 3
Healthcare Lienholder 4
Healthcare Lienholder 5
Healthcare Lienholder 6
Healthcare Lienholder 7
Health care provider
Healthcare Lienholder 8
Licensed hospital, licensed home health agency, licensed ambulatory surgical treatment center, licensed long-term care facilities, or licensed emergency medical services personnel.
Healthcare Lienholder 9
Healthcare Lienholder 10
Healthcare Lienholder 11
Healthcare Lienholder 12
Healthcare Lienholder 13
Healthcare Lienholder 14
Healthcare Lienholder 15
Healthcare Lienholder 16
Healthcare Lienholder 17
Healthcare Lienholder 18
Healthcare Lienholder 19
Healthcare Lienholder 20
Disclaimer: The lien available amount and the text below are based on the information provided in this form. If ANY information is innacurate, this amount and text will not be valid. If you added a lien amount and did not choose Provider or Professional for that lien amount, then the amounts below will be incorrect. All information must be complete and accurate or the information below will not be accurate.
Total amount of your lien available under settlement:
Text that could be used to respond to an attorney request:
Total Lien Amounts (inc. your lien)
Does the 40% rule apply?
1 = True, 0 = False
Max Under 40% Rule
Either 20% or
Limit Under 40% Rule
40% less Provider amounts utilized
Max Under 1/3 Rule
Never greater than 1/3
Never greater than your lien amount
Maximum amount available to each Category
Remaining
Provider or Professional
Professional
Lien Amounts