• Date Format: MM slash DD slash YYYY
  • Procedure: EMG/NCV Testing

  • The undersigned Attorney acknowledges that he/she is legal counsel of record for the above-referenced patient (the “Patient”), and that the Patient has executed a Medical Lien in favor of Precision Occupational Medical Group, Inc. (“Provider”).

    The undersigned Attorney agrees to observe all of the terms of the Medical Lien. The undersigned Attorney hereby agrees to withhold sums from any settlement, award, judgment, insurance, or verdict as may be necessary to protect and compensate Provider for the medical care and treatment rendered to the Patient. The undersigned agrees to promptly notify Provider if he/she is discharged or withdraws from representation of Patient, or in the event the Patient’s file is closed without receiving any payments.

    The undersigned agrees that this Medical Lien – Attorney Acknowledgement may be electronically signed, and that his/her electronic signature appearing on this agreement shall be deemed the same as handwritten signatures for purposes of validity, enforceability and admissibility and is binding as an original on the undersigned.

  • Signed by Attorney