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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______.

STATEMENT OF AMOUNT DUE

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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.

______________________________________________________________________________ [Amended by 1989 c.727 §4; 1995 c.100 §2; 1999 c.146 §4; 2001 c.104 §27; 2007 c.71 §20]