ORS 87.570 Form of notice

The form of the notice required by ORS 87.565 shall be substantially as follows: __________________________________________ Notice is hereby given that has rendered hospitalization services or medical treatment for , a person who was injured on the day of in the city of , county of , State of , on or about the day of , and the (name of claimant) hereby claims a lien upon any money due or owing or any claim for compensation, damages, contribution, settlement, award or judgment from any person alleged to have caused the injuries and any other person liable for the injury or obligated to compensate the injured person on account of the injuries. The lien applies to any person or insurer that provides for payment for hospitalization services or medical treatment rendered to the injured person, including an insurer that provides personal injury protection coverage or similar no-fault medical insurance. The hospitalization services or medical treatment was rendered to the injured person between the day of and the day of .

__________________________________________ Thirty days have not elapsed since that time. The claimant’s demand for hospitalization services or medical treatment is in the sum of $ and no part thereof has been paid, except $ , and there is now due and owing and remaining unpaid thereof, after deducting all credits and offsets the sum of $ , in which amount lien is hereby claimed. , Claimant. State of Oregon, ) ) ss. County of ) I, , being first duly sworn on oath say: That I am named in the foregoing claim of lien; that I have read the same and know the contents thereof and believe the same to be true. Subscribed and sworn to before me this day of , 2 . , Notary Public.

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