• Procedure: EMG/NCV Testing

  • MM slash DD slash YYYY
  • I (“Patient”) desire medical treatment from Precision Occupational Medical Group, Inc., aka Precision Medical Group (“Precision”), including all physicians and specialists that provide services for, at or through Precision, (collectively “Provider”), for injuries sustained in the above-referenced personal injury incident (“Incident”). I have retained an attorney (“Attorney”) to seek compensation for my injuries arising from the Incident (“Litigation”). I understand that Provider, at my request and as an accommodation to me, has agreed to treat me on a “lien basis” pursuant to this Medical Lien Agreement.

    I hereby grant to Provider a lien upon, and direct my Attorney to pay Provider from, any sums awarded to me or my personal representative, by judgment, award, court ruling, verdict or pursuant to a settlement or compromise, in the amount and to the extent of Provider’s billed charges. I understand that a lien is considered to be a legal binding agreement and promise to pay Provider at the end of my case. I further understand that I am directly and fully responsible to pay for the care and treatment provided to me by Provider whether or not I receive a financial award from my case, and that this Medical Lien Agreement is made solely for additional protection of the Provider and in consideration of the Provider awaiting payment.

    I hereby authorize and direct Provider to release medical records and reports to my Attorney and other health care providers who are providing care and treatment to me. I also authorize Provider to release medical records, reports and billing information to any insurance carrier(s) or its/their legal representative as may be deemed necessary for the purposes settling my case or receiving reimbursement for the treatment provided to me. I further authorize and direct the insurance carrier(s) or its/their legal representative to pay Provider directly any monies owed for my care and treatment.

    I fully understand that I am directly responsible to the Provider to pay for all care and treatment provided to me. If the need to bill any private insurance arises, I understand that it will be my responsibility to submit any billings to my private health insurance for any payments or reimbursement, if applicable. I further understand that Provider will not bill any private health insurance carrier(s) as it is my sole responsibility to do so if and where applicable.

    I or my Attorney will notify Provider in writing of any objection or issue concerning Provider’s fees or charges prior to the start of treatment or no later than ten (10) days following receipt of any bill or statement. My Attorney and I will keep Provider updated on the status of the Litigation, promptly communicate the date of filing of a complaint seeking redress for my injuries, case number, the setting or moving of any scheduled trial/arbitration/mediation, any change in my Attorney or if co-counsel is brought in to try the matter (in which case co-counsel shall also be bound by this Medical Lien Agreement), and the disposition of the Litigation, including the amount of any settlement, judgment or other award. Best efforts shall be used, and time is of the essence.

    I understand and agree that, if any provision of this Medical Lien Agreement is not followed by me or my Attorney, the Provider may declare a breach and I thereupon agree to pay the full balance owed to Provider immediately. If I fail to timely pay Provider, then Provider may immediately file a lawsuit against me for all amounts I owe and I will also be obligated to pay Provider for the attorneys’ fees and costs incurred enforcing this Medical Lien Agreement.

    Any delay by Provider in the enforcement of this Agreement will not be deemed a waiver of Provider’s rights and remedies in any respect. I expressly waive any applicable time limitation defense, including any statute of limitations, statute of repose, or the equitable defense of laches regarding Provider’s right to recover payment for any of the care or treatment provided to me. This Lien Agreement may not be altered, modified, revoked, or compromised in any way without approval of Provider and shall remain in force and effect at all times until all monies due to Provider have been paid in full.

    This document may be executed in any number of counterparts, each of which so executed shall be deemed to be an original, and such counterparts shall together constitute but one and the same Agreement. The parties agree that this agreement may be electronically signed, and that any electronic signature(s) 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.

    I REPRESENT TO PROVIDER THAT I HAVE BEEN GIVEN THE OPPORTUNITY TO HAVE MY LEGAL COUNSEL REVIEW THIS MEDICAL LIEN AGREEMENT AND HAVE EITHER DONE SO OR HEREBY WAIVE MY RIGHT TO DO SO. I HAVE COMPLETELY READ EACH OF THE TERMS OF THIS MEDICAL LIEN AGREEMENT. I EXECUTE THIS MEDICAL LIEN AGREEMENT VOLUNTARILY, WITH FULL KNOWLEDGE AND UNDERSTANDING OF EACH OF ITS TERMS AND CONDITIONS, AND I HEREBY AGREE TO BE BOUND BY EACH OF THE TERMS AND CONDITIONS OF THIS LIEN AGREEMENT.

  • Signed by Patient