SUBMIT A HOSPITAL LIEN Attorney's Information * First Name Last Name Attorney's Email * Has your underlying case settled? * Yes No If yes, what is the settlement amount? If no, what is the settlement status? In Settlement Negotiations In Litigation Settlement Agreed, Not Signed Settlement Signed, Not Received Settlement Received, Not Deposited Settlement in Trust Lien Type Hospital/Provider Private Health Insurance FEHBA Military/VA Medicare Lienholder Name Has Lienholder made a written offer to reduce? Yes No If yes, how much? Any other information you'd like to share: How did you hear about Walrath Law? * Referral from an Injury Attorney Referral from Friend/Family Radio or TV Social Media Direct Email or Mail Advertisement Thank you!
