Congratulations, you've completed Step 1!

Now you have a few additional items to submit to complete your lien referral. Please review the checklist below to ensure you submit the proper documentation so that we can immediately start working on your request.

Additional Lien Resolution Submission Forms

If you have not filled out an online lien referral form, you may download one from below to submit with the other documentation.

For Medicare Liens

  1. Proof of Representation Form - please have Beneficiary (or representative or attorney with specific POA documentation) sign and date. (Download below.)
  2. Most Recent Correspondence from Medicare, if any
  3. Settlement Information (if applicable) - a copy of your fee agreement, a list of your costs, and evidence of settlement (such as a letter from the insurance company or opposing counsel). If you don't have a settlement yet, you can still submit your lien now. However, in order for us to finalize the lien negotiation, we will need this information.

For Non-Medicare Liens (including Medicaid or other government programs)

  1. Authorization to Disclose Health Information (HIPAA Form) - please have your client sign and date. Click below to download.
  2. Most Recent Correspondence from government agencies, Healthplan or Subrogation Firm
  3. Settlement Information (if applicable) - a copy of your fee agreement, a list of your costs, and evidence of settlement (such as a letter from the insurance company or opposing counsel). If you don't have a settlement yet, you can still submit your lien now. However, in order for us to finalize the lien negotiation, we will need this information.

We cannot begin working on your lien referral until you provide all the requested information and documents. Please ensure that your submission is complete to avoid delays.

If you have questions relating to your lien request, please call Providio at 877.253.3120.

Microsoft® Word Version

Lien Referral Intake Form
Providio Lien Counsel HIPAA Release
Proof of Representation (only for Medicare liens)

PDF Version

Lien Referral Intake Form
Providio Lien Counsel HIPAA Release
Proof of Representation (only for Medicare liens)

Once you've downloaded and completed the applicable forms, return to the Referrals & Forms page to finish your referral at "Step 3: Secure File Upload".