Legal Chiro Lien Form

Legal Chiro Lien Form

This Chiropractic Lien Agreement (the Agreement) is entered into on Date: by and between Provider Name: with principal address and Patient Name: , Patient Address: .

RECITALS

WHEREAS, Patient received chiropractic evaluation, treatment and related health care services from Provider for injuries sustained arising out of an incident occurring on Date of Incident: (the Incident); and

WHEREAS, Provider has rendered medical services and will render further reasonable and medically necessary services related to the Incident and has billed or will bill for such services; and

WHEREAS, Patient seeks to secure payment of Provider’s charges from any recovery that Patient may obtain from any third party, insurer, claims administrator, settlement, judgment, or other source (collectively, Recovery).

NOW, THEREFORE

In consideration of the mutual covenants set forth herein and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows:

1. ESTABLISHMENT OF LIEN

Provider hereby asserts and retains a lien against any and all recoveries, settlements, judgments, insurance proceeds, claims, or other amounts that Patient now has or may hereafter obtain from any third party, insurer, or claims administrator that are related to the Incident, to secure payment of Provider’s charges for services rendered and materials provided to Patient through the date of settlement or judgment (the Lien). The Lien shall attach to proceeds of any Recovery to the extent of Provider’s unpaid charges, reasonable costs of collection, and interest as provided herein.

2. SERVICES, CHARGES AND ITEMIZATION

Provider represents that the charges for services rendered to Patient related to the Incident are set forth below. Patient acknowledges the services described and agrees that amounts listed constitute Provider’s reasonable billed charges for those services.

3. AUTHORIZATION AND ASSIGNMENT

Patient authorizes Provider to obtain and disclose medical records, billing records, and other information reasonably necessary to establish or enforce the Lien. Patient hereby assigns to Provider any right to reimbursement or recovery from third parties, insurers, or claimants, to the extent necessary to satisfy Provider’s billed charges for services related to the Incident. This assignment is limited to amounts necessary to satisfy the unpaid balance set forth above plus reasonable costs of collection and interest.

4. OBLIGATION TO WITHHOLD AND PAYMENT

Patient agrees not to instruct counsel, insurer, or any third party to disburse any Recovery without first satisfying Provider’s Lien. Patient authorizes Patient’s counsel, if any, to withhold from any settlement, judgment, or other Recovery an amount sufficient to satisfy Provider’s lien claim and to remit such funds directly to Provider upon settlement or judgment. Patient further agrees to notify Provider promptly of any settlement negotiations or demands.

5. ATTORNEY / THIRD-PARTY INFORMATION

6. COLLECTION COSTS, INTEREST, AND ATTORNEY FEES

Patient agrees that in the event it becomes necessary for Provider to enforce this Lien by suit or other collection measures, Patient shall be responsible for reasonable costs of collection, including court costs and reasonable attorney fees. Interest shall accrue on any unpaid balance at the lesser of the maximum rate permitted by law or at a rate of % per annum, calculated from the date services were rendered.

7. REPRESENTATIONS, WARRANTIES AND COVENANTS

Patient represents that Patient is the person entitled to seek Recovery for the Incident and has full authority to assign rights to Provider as provided in this Agreement. Patient covenants not to settle, compromise, or otherwise dispose of any claim or Recovery without first satisfying Provider’s Lien or obtaining Provider’s written release.

8. NOTICES

All notices required or permitted under this Agreement shall be in writing and shall be delivered to the addresses shown below for each party or to such other address as a party may designate in writing. Notice shall be effective upon personal delivery, email transmission with confirmation of receipt, or three days after deposit in the United States mail, postage prepaid.

9. AMENDMENT; WAIVER; COUNTERPARTS

This Agreement may be amended only by a written instrument signed by both parties. No failure or delay by either party in exercising any right shall operate as a waiver of that right. This Agreement may be executed in counterparts, each of which shall be deemed an original but all of which together shall constitute one agreement.

10. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Agreement shall be governed by and construed in accordance with the laws of the jurisdiction where Provider maintains its principal place of business, without regard to choice of law principles. This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings, whether written or oral. If any provision of this Agreement is found to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

11. MISCELLANEOUS

If any sum is recovered by Provider from Patient’s Recovery in excess of Provider’s valid, outstanding charges after application of costs and reasonable attorney fees, such excess shall be promptly refunded to Patient or as otherwise ordered by a court of competent jurisdiction.

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