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Lien Referral Form

Referring party
Claim information

Separate claim numbers by comma

Only if case is already assigned to a board

Additional Information

Please include any information you would like us to know here.

Needed Documents

Medical Payment History, Billings, EOBs, C&R or STIP, Med Report settlement is based on, other documents relevant to lien defense.

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You may upload multiple documents. Maximum size 25MB. If you reach the file limit. E-mail the remaining documents to

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