Move Fit Physical Therapy PC
156 Dolson Ave STE 11
Middletown, NY, 10940
Date of Accident or Illness:
I do hereby authorize the above doctor any settlement to furnish you, my attorney/insurance carrier, with a full report of his case history, examination, diagnosis, treatment, and prognosis of myself in regard to the accident/illness which occurred/began on the date above.
I hereby give a lien to said doctor on any settlement, claim, judgement, or verdict as a result of said accident/illness, and authorize and direct you, my attorney/insurance carrier, to pay directly to said doctor, such sums as may be due and owing him for service rendered me and to withhold such sums from such settlement, judgement, or verdict as may be necessary to protect said doctor adequately.
I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for service rendered me and that this agreement is made solely for said doctor's additional protection and In consideration of his awaiting payment. And I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee.
The undersigned being attorney for the above patient does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment or verdict, as may be necessary to adequately protect said doctor above-named. Attorney further agrees that in the event the Lien is litigated, that the prevailing party will be awarded attorney fees and costs.
Blumenthal Chiropractic, P.C.
156 Dolson Ave STE 11
Middletown, NY, 10940
Ph: 845-360-2500
Fax: 845-345-8201
to furnish you, my attorney, with a full
report of his examination, diagnosis, treatment, prognosis, etc... of myself in regard to the accident in which I was recently involved.
I hereby authorize and direct you, my attorney, to pay directly to said doctor such sums as may be due and owing him for medical service rendered me both by reason of this accident and by reason of any other bills that are due his office and to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately protect said doctor. And I hereby further give a Lien on my case to said doctor against any and all proceeds of my settlement, judgment or verdict which may be paid to you, my attorney, or myself, as the result of the Injuries in connection therewith.
I agree never to rescind this document and that a rescission will not be honored by my attorney. I hereby instruct that in the event another attorney is substituted in this matter, the new attorney honor this Lien as inherent to the settlement and enforceable upon the case as if it were executed by him.
I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for service rendered me and that this agreement is made solely for said doctor's additional protection and In consideration of his awaiting payment. And I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee.
Please acknowledge this letter by signing below and returning to the doctor's office: I have been advised that if my attorney does not wish to cooperate In protecting the doctor’s interest, the doctor will not await payment but may declare the entire balance due and payable.
The undersigned being attorney for the above patient does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment or verdict, as may be necessary to adequately protect said doctor above-named. Attorney further agrees that in the event the Lien is litigated, that the prevailing party will be awarded attorney fees and costs.
