Healthcare Lien Forms

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











Patient Information

















Med Pay Information











Third Party Information











Attorney Information








Additional Comments



We have read this complete Authorization and Contract and agree to all the stipulations contained therein, and agree to pay all legal fees should there be any breach of contract, or if I/we supply any forms and or data for use by anyone else not under contract with Dar-Liens, Inc.

PRELIMINARY NOTICES & MECHANIC LIENS

In need of a Certified Legal Document Preparer? Contact us here, or call 480-607-2290. We're always happy to help.

CONTACT US TODAY
loading