Submit Hospital Lien

Amount of Gross Settlement?

Have you reached impasse in your medical lien negotiations?

Hospital Name

Amount of Medical Bill/Lien?

Amount paid by PIP, if any?

Amount of Legal Fees?

Amount of Legal Costs?

Amount of other liens against settlement?

Please describe any other important issues/details.

Please submit a copy of your Itemized Medical Bill.

Please Contact Us, but we cannot begin until your case settles.

Please Contact Us, but we cannot begin until your negotiations reach impasse.