Healthcare Settlement Form

HEALTHCARE SETTLEMENT FORM

This Healthcare Settlement Form documents the settlement terms between Patient Name: and Healthcare Provider Name: . Date of incident/service: .

Patient Information

Male Female Other / Prefer not to say

Insurance Information

Medical History (Relevant to Claim)

Settlement Terms

Settlement Amount (gross): $ . Date funds to be paid: .

Payment Method: Lump sum Installments

Allocation of gross proceeds for known obligations: Attorney Fees: $ ; Known Medical Liens: $ ; Net to Patient: $ .

By signing this form the Patient acknowledges receipt of the settlement consideration as specified above and releases the Provider, its employees, agents, successors and assigns from all claims, demands, causes of action, obligations and liabilities arising out of the incident or services referenced above through the date of execution of this Form. This release is intended to be a full and final release of all known and unknown claims related to the incident or services, except as provided herein.

No Admission of Liability: The Provider denies liability, and nothing in this agreement shall be construed as an admission of liability or wrongdoing by any released party. The Patient acknowledges that consideration is provided in compromise of disputed claims.

HIPAA Authorization and Privacy

Patient authorizes the disclosure of protected health information reasonably necessary to evaluate, negotiate and effectuate this settlement, including but not limited to medical records, billing records, and correspondence between providers and payors. This authorization is limited to information pertinent to the incident or services described in this Form.

Authorization Expiration Date: . Patient understands that this authorization may be revoked in writing, but revocation will not affect disclosures already made in reliance upon this authorization.

Liens, Third-Party Claims and Subrogation

Patient represents that all known liens, subrogation claims, and third-party obligations arising from the incident or services have been disclosed in writing to Provider. Patient agrees to cooperate in the identification and resolution of liens and assigns to Provider or its payor the right to pay lien holders directly from settlement proceeds where required.

Patient authorizes payment directly to lien holders as necessary and agrees to assist in resolution of any outstanding claims to the extent reasonably requested by the Provider or its payor.

Representations, Warranties and Miscellaneous

Patient represents and warrants that the information provided in this Form is true and complete to the best of Patient's knowledge and that Patient has read and understands this Settlement Form. Patient further represents whether or not counsel has been retained: .

Governing Law: This Form shall be governed by and construed in accordance with the laws of the state in which the Provider maintains its principal place of business. Any dispute arising under this Form shall be resolved by the procedures agreed by the parties.

Severability: If any provision of this Form is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.

Acknowledgment

Patient acknowledges receipt of the terms set forth in this Healthcare Settlement Form, and understands that by signing below Patient accepts the settlement as full and final resolution of the referenced claims against the Provider as described herein.

Sign Now