Custom Carbonless 2-Part Doctor Lien Forms, 8-1/2" x 11", 250 Sets per Pack
$85.99
1 pack
Save 40%
$50.99
20+ pack
Custom Carbonless 2-Part Doctor Lien Forms, 8-1/2" x 11", 250 Sets per Pack
Item #:
901-QFN105411R
Model #:
7QGFM105411R
Brand:
Quill Custom Print
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$85.99
1 pack
Save 40%
$50.99
20+ pack
1 PACK = 250 EACH
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$85.99
1 pack
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Custom Carbonless 2-Part Doctor Lien Forms, 8-1/2" x 11", 250 Sets per Pack
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Description
Directs the attorney to pay the doctor out of proceeds of settlement and, if necessary, place a lien against any proceeds.
- Use to collect fees from insurance
- 8-1/2" W x 11" L
- 2-part, white/canary, carbonless; printed in black ink
- 250 sets per pack
- Complete the top section in your office, have patient sign, then send to patient's attorney
Specifications
# Up Per Sheet/Page
1
Binding Type
Glued/Gummed
Brand
Quill Custom Print
Carbonless
Yes
Color
White
Customizable
Yes
Form Size
8 1/2" x 11"
Form Type
Agreements
Format
Medical Chart
Holes Punched
No
Lines
7
Media Quantity
250
NCR Paper
Yes
Number of Parts
2
Numbered
No
Package Quantity
250
Personalization
Yes
Security Features
No
Sheet Size
8 1/2" x 11"