Legal Chiropractic Lien Document

LEGAL CHIROPRACTIC LIEN DOCUMENT

This Chiropractic Lien Agreement (the "Agreement") is entered into as of Effective Date: by and between Provider Name: with principal address ("Provider"), and Patient Name: with address ("Patient"). Patient date of birth: .

RECITALS

WHEREAS, Patient has received chiropractic and related medical services from Provider for injuries allegedly arising from an incident identified as: Claim/Case Number: on or about Date of Injury: .

WHEREAS, Patient has legal claims, causes of action, or potential recoveries arising from the foregoing incident, including claims against third parties and claims under insurance policies; and

WHEREAS, Provider has rendered services and will render additional services related to the treatment of Patient, and Provider seeks assurance of payment by securing a lien and limited assignment against any recovery Patient obtains from third parties or insurers.

NOW, THEREFORE, in consideration of the mutual covenants and promises herein contained, the parties agree as follows:

1. DEFINITIONS

For purposes of this Agreement, the following terms shall have the following meanings: "Lien" means Provider's claim against any recovery, judgment, settlement, or proceeds obtained by Patient from any third party or insurer for injuries addressed by Provider; "Outstanding Balance" means charges for services rendered by Provider through the date of this Agreement as set forth in section 2 below; "Claims" means any claim, demand, cause of action, or right to recovery against third parties or insurers arising from the incident described above.

2. SERVICES RENDERED; CHARGES

3. LIEN; ASSIGNMENT OF CLAIMS

Patient hereby grants Provider a lien upon and against any and all proceeds of any settlement, judgment, award, or other recovery (including but not limited to underinsured/uninsured motorist benefits) obtained on account of the injuries for which Provider rendered treatment. Patient assigns to Provider the right to be paid from such recovery an amount equal to the Outstanding Balance plus reasonable costs of collection and attorney fees as set forth in this Agreement. Provider's lien shall be prior to distribution to Patient, subject only to liens or obligations of record with superior legal priority.

Provider's lien covers charges for services already rendered and those services rendered in the future related to the same injury to the extent Patient has authorized such future services in writing below: Authorize lien to include future chiropractic services for the injury described above.

4. PATIENT REPRESENTATIONS AND AUTHORIZATIONS

Patient represents that: (a) Patient has the right to assign Patient's claims and interests in any recovery; (b) Patient will not enter into any settlement, compromise, or release of any claim related to the injuries without first providing Provider written notice and the opportunity to protect Provider's lien; and (c) Patient authorizes Carrier(s), counsel, and third parties to disclose to Provider information regarding claims, settlements and payments related to the injuries.

Patient expressly authorizes Provider to furnish copies of medical records, bills, treatment summaries, and this Agreement to Patient's attorney(s), insurer(s), and other persons or entities reasonably necessary to protect and enforce Provider's lien.

5. PROVIDER RIGHTS; ENFORCEMENT

In the event Patient or Patient's insurer or other third party fails to honor Provider's lien, Provider shall have the right to enforce this Agreement by appropriate legal proceedings. Provider is entitled to seek immediate injunctive or equitable relief, to pursue collection in court, and to recover reasonable attorney fees, court costs, and collection expenses incurred in enforcing this Agreement. Provider may withhold medical records or lien enforcement until reasonable cooperation and documentation requested by Provider is provided by Patient.

6. INSURANCE; THIRD-PARTY RECOVERIES

Patient authorizes Provider to communicate directly with Patient's insurer(s) and claim representatives regarding Provider's lien and billing. Any recovery payable to Patient by insurer(s) or third parties shall be subject to Provider's lien and Provider shall be paid from such recovery prior to distribution to Patient, unless otherwise ordered by a court with competent jurisdiction or agreed in writing by Provider.

7. PAYMENTS; SETOFFS

Provider shall submit bills to insurers and will cooperate with Patient and Patient's counsel in pursuing recovery. Patient remains personally liable for the Outstanding Balance and agrees that payment from any recovery shall first be applied to satisfy Provider's lien. Provider may offset amounts otherwise payable to Patient or apply any settlement proceeds deposited with Provider to the Outstanding Balance.

8. ATTORNEY FEES AND COSTS

If any party initiates litigation to enforce this Agreement, the prevailing party shall be entitled to recover reasonable attorney fees, court costs, and expenses incurred in connection with such enforcement, including appellate proceedings.

9. NOTICES

All notices required or permitted under this Agreement shall be in writing and shall be delivered to the addresses provided below (or such other address as the receiving party designates in writing). Notice is effective upon personal delivery, upon receipt by certified mail, or upon confirmed electronic delivery if agreed in writing.

10. GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the state in which Provider maintains its primary place of business, without regard to principles of conflicts of law.

11. ENTIRE AGREEMENT; SEVERABILITY

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements, understandings, and negotiations. If any provision of this Agreement is held to be invalid or unenforceable, the remaining provisions shall continue in full force and effect.

12. AMENDMENT; WAIVER; COUNTERPARTS

No amendment or waiver of any provision of this Agreement shall be effective unless in writing and signed by both parties. Failure to exercise any right shall not constitute a waiver. This Agreement may be executed in counterparts, each of which shall be deemed an original, and electronic or facsimile signatures shall have the same effect as originals.

13. MISCELLANEOUS

Patient acknowledges that signing this Agreement does not relieve Patient of any obligation to pay co-pays, deductibles, or any portion of the Provider's fees not paid by third parties. Provider's acceptance of payment from any source shall not be deemed a waiver of Provider's lien rights unless expressly agreed in writing.

Acknowledgment

Patient acknowledges receipt of a copy of this Agreement, understands its terms, and signs voluntarily. Patient understands that this Lien may reduce the net recovery available to Patient from any settlement or judgment.

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