Legal Doctor's Lien Agreement

LEGAL DOCTOR'S LIEN AGREEMENT

This Legal Doctor's Lien Agreement ("Agreement") is made and entered into as of by and between Provider Name: , Provider Address: (hereinafter "Provider"), and Patient Name: , Patient Address: (hereinafter "Patient").

RECITALS

WHEREAS, Patient has received or will receive medical, surgical, diagnostic, rehabilitative or related professional services from Provider in connection with personal injuries sustained in an incident that occurred on or about (the "Incident"); and

WHEREAS, Patient has asserted or may assert a claim, demand, suit, or cause of action against one or more third parties or their insurers arising from the Incident, including claim number ; and

WHEREAS, Provider seeks to secure payment for services rendered and to be rendered by means of a lien upon any proceeds, recovery, settlement, judgment or insurance payment resulting from Patient's claim (collectively, "Proceeds").

NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Agreement, "Charges" shall mean all reasonable and customary fees, costs, and expenses for medical, surgical, hospital, diagnostic, therapeutic and ancillary services provided by Provider to Patient, whether billed or unbilled, including interest, collection costs and attorney's fees as described herein. "Proceeds" means any funds recovered by Patient by settlement, judgment, arbitration award, or insurance payment arising from the Incident.

2. GRANT OF LIEN; SCOPE

Patient hereby grants Provider and Provider's assigns, an equitable and contractual lien upon and security interest in any and all Proceeds to secure payment of all Charges arising from treatment related to the Incident. The lien shall attach to Proceeds whether recovered by settlement, judgment, arbitration, or other recovery and shall include past due Charges and Charges for future services rendered for injuries related to the Incident if the following box is checked.

Include future services and treatments related to the Incident within this lien.

3. AMOUNT SECURED; CHARGES

The lien secures all Charges for services rendered by Provider to Patient related to the Incident. Current unpaid Charges as of the date of this Agreement are: $. Charges may include reasonable interest at the agreed rate of per annum, and reasonable collection and enforcement costs, including attorney's fees if Section 6 is invoked.

4. ASSIGNMENT AND DIRECTION TO THIRD PARTIES

Patient assigns to Provider an interest in Proceeds to the extent necessary to satisfy the Charges secured by this lien. Patient hereby directs any attorney, insurer, claims administrator, or other third party holding Proceeds to withhold payment of Proceeds sufficient to satisfy Provider's lien and to make payment directly to Provider upon settlement, judgment, or award.

5. PATIENT OBLIGATIONS; AUTHORIZATIONS

Patient agrees not to execute any release, compromise or settlement of Patient's claim without giving Provider at least thirty (30) days' written notice of the proposed settlement and an opportunity to enforce or protect Provider's lien. Patient authorizes the release of medical and billing records related to the Incident to Provider, Patient's counsel, insurers, and any tribunal as necessary to enforce the lien or substantiate Charges.

6. ENFORCEMENT; REMEDIES

Upon Patient's failure to arrange payment for Charges or if Proceeds are paid without providing Provider sufficient funds to satisfy the lien, Provider shall have the right to seek relief in equity or law, including injunctive relief to restrain disbursement of Proceeds, suit on the account, attachment of Proceeds, and recovery of reasonable attorney's fees and costs of collection. Patient agrees that Provider may deduct from recovered Proceeds reasonable costs of enforcement and a proportionate share of attorney's fees if allowed by applicable law.

Patient authorizes Provider to charge reasonable costs of collection and to engage counsel to enforce this Agreement.

7. PRIORITY; SURVIVAL

The parties intend that Provider's lien attach to Proceeds as a first-priority lien to the fullest extent permitted by law except for liens or encumbrances required by statute to have priority. This Agreement and the lien granted herein shall survive payment, settlement, dismissal, substitution of parties, or assignment of claim and shall remain in force until all Charges and amounts owing under this Agreement are paid in full.

8. NOTICES

All notices required or permitted under this Agreement shall be in writing and delivered to the addresses set forth below by personal delivery, certified mail, return receipt requested, or overnight courier. Notice shall be effective upon receipt.

9. ATTORNEY ACKNOWLEDGMENT (IF APPLICABLE)

If counsel is representing Patient in connection with the claim, counsel by signing below acknowledges receipt of this lien and agrees to withhold disbursement of Proceeds sufficient to satisfy Provider's lien at closing, absent an express written agreement between counsel and Provider disposing of the lien.

10. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to conflict 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, oral or written. If any provision of this Agreement is held to be invalid or unenforceable, such provision shall be severed and the remaining provisions shall remain in full force and effect.

11. AMENDMENT; WAIVER; COUNTERPARTS

This Agreement may be amended only by a written instrument signed by both parties. No failure or delay by Provider 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, and facsimile or electronic signatures shall be effective as originals.

12. REPRESENTATIONS AND WARRANTIES

Patient represents and warrants that Patient has full authority to enter into this Agreement, that the claim described herein has not been settled or released, and that no assignment of rights has been made which would impair Provider's lien except as disclosed in writing. Provider represents that Charges set forth are for services actually rendered or to be rendered by Provider and are reasonable and customary under the circumstances.

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