• Procedure: EMG/NCV Testing

  • Date Format: MM slash DD slash YYYY
  • I do hereby authorize Precision Medical Group to furnish my attorney with a full report of the examination, diagnoses, treatment, prognosis, etc., I receive regarding the accident in which I was involved.

    I hereby grant Precision Medical Group with a lien upon my case, and hereby direct my attorney to pay Precision Medical Group in full for the bills it issues for medical service rendered to me from the proceeds of any settlement, award or judgment in my case before releasing any monies to me as compensation for pain and suffering.

    I agree that I am directly responsible to pay Precision Medical Group for the medical bills it issues to me. I agree that if my health insurance company does not pay Precision Medical Group for treatment, or if the payment is partial, the settlement or award from my case shall be utilized to pay Precision Medical Group before any funds are released to me.

    I give this lien on my case to Precision Medical Group against the proceeds of my settlement, judgment or award. I am directly responsible, however, for my bill if my attorney does not protect my doctor’s interest with this lien. I understand that when my doctor tells me that I have reached a point of maximal medical improvement, it is likely that future treatment will result in medical bills, which may be viewed as excessive by an insurance company thereby reducing monies distributed to me (the patient).

    I agree that my attorney will sign a counterpart or electronic version of the lien acknowledging the obligation to comply with this lien. I further agree that this lien is being electronically signed by me, and that my electronic signature appearing on this lien agreement shall be deemed the same as a handwritten signature for purposes of validity, enforceability and admissibility and is binding on me as an original.

  • Signed by Patient