Online Health Care Lien Form | Phoenix, Arizona

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Please enter all of the information you know, we do the rest!

Customer agrees that the liability of Dar-Liens, Inc., its agents and employees, in connection with services hereunder to the Customer and to all persons having contractual relationships with them, resulting from any acts, errors and/ or omissions, whether negligent or otherwise, of Dar-Liens, Inc., its agents and/or employees is limited to the total fees actually paid by the Customer to Dar-Liens, Inc., for those services.

Your Contact Information
Your Name
Your E-mail
Your Phone
Doctor's Name
Name of Clinic
Address
City
State	Zip

Patient Information
Patient Name
Address
City
State	Zip
Date of Loss
Place Where Accident Occurred
City
County Where Accident Occurred
Time of Day
Date of Patient's 1st Treatment
Date You Last Saw Patient for Treatment
Is Patient Continuing Treatment?	Yes No
Patient Treatment is Complete (Released)?	Yes No
Amount Claimed For All Treatments To Date	$

Med Pay Information
Insurance Company Name
Address
City
State	Zip
Phone
Claim Number
Policy Number
Insured
Adjuster

Third Party Information
Insurance Company Name
Address
City
State	Zip
Phone
Claim Number
Policy Number
Insured
Adjuster

Attorney Information
Attorney Name
Name of Firm
Address
City
State	Zip
Phone