How To Write A Medical Lien Letter . In exchange, the provider agrees to wait until your case is over to get paid and to stop debt collection efforts. The medical collection letter example should be used as a first reminder notice to gently remind your patients to pay, or get in touch with your office to work out payment arrangements. Chiropractic Lien Form (Sample) printable pdf download from www.formsbank.com You also should identify who they should release your medical records to. If a patient is suffering from a traumatic injury that someone else is found liable for, you, the medical provider, are entitled to file a medical lien against the future personal injury settlement. A medical leave letter is not different.