Menu HomeAbout Us About Us Our Coronavirus Policy Our Physicians Our Neurodiagnostic Technicians Affiliated ServicesLocationsEMG/NCS Information EMG/NCS Information Why it’s best to test EMG & NCS together Patient Resources Forms Patient Intake Form Consent Form Formularios de Consentimiento COVID-19 – Patient Screening COVID-19 Waiver COVID-19 Waiver – Español Interpreting Request Personal Injury Lien – Patients Attorney Medical Lien Acknowledgement Privacy Notice Conditions Tested LocationsFor Providers Why choose Precision Medical Group? For Providers Instructions to refer a patient Insurances We Accept Locations EMG Testing Referrals Newsletter SignupNewsContact UsFeedback Call Us Find a Location Personal Injury Lien - Attorneys Patient Name* First Last Date of Birth* Month Day Year Date of Injury MM slash DD slash YYYY Procedure: EMG/NCV TestingLaw Office of Attorney Name* First Last Attorney Phone*Attorney Email Attorney Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code The undersigned Attorney acknowledges that he/she is legal counsel of record for the above-referenced patient (the “Patient”), and that the Patient has executed a medical lien in favor of Precision Occupational Medical Group, Inc. (“Provider”)Provider”), in form and substance as set forth at this link: “Medical Lien”). The undersigned Attorney agrees to observe all of the terms of the Medical Lien. The undersigned Attorney hereby agrees to withhold sums from any settlement, award, judgment, insurance, or verdict as may be necessary to protect and compensate Provider for the medical care and treatment rendered to the Patient. The undersigned agrees to promptly notify Provider if he/she is discharged or withdraws from representation of Patient, or in the event the Patient’s file is closed without receiving any payments. The undersigned agrees that this Medical Lien – Attorney Acknowledgement may be electronically signed, and that his/her electronic signature appearing on this agreement shall be deemed the same as handwritten signatures for purposes of validity, enforceability and admissibility and is binding as an original on the undersigned. ATTENTION ATTORNEYS: all lien payment and negotiations are handled through MBC Systems. Call (949) 863-0022, or email liens@mbcsystems.org, or fax to (949) 863-0023. Signed by Attorney