Legal Release and Medicare Form

LEGAL RELEASE AND MEDICARE FORM

This Legal Release and Medicare Form (the "Release") is made and entered into as of by and between Releasor (Claimant): and Releasee (Defendant/Insurer): .

RECITALS

WHEREAS, Releasor asserts claims arising from an incident occurring on or about (the "Incident"), related to Claim Number: ; and

WHEREAS, the parties wish to fully and finally settle, release, and resolve all claims, demands, causes of action and liability arising from or related to the Incident, including any claims for past or future medical expenses, and to address Medicare's interests, conditional payments and potential liens; and

WHEREAS, Medicare (including Medicare Parts A and B) and its contractors may have paid for medical items or services relating to the Incident and may assert a right to reimbursement from any settlement proceeds; and the parties desire to allocate responsibilities and provide necessary authorizations to address Medicare's interests.

NOW, THEREFORE

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

1. DEFINITIONS

For purposes of this Release, the following definitions apply: "Settlement Amount" means the total sum to be paid to resolve the Incident, as specified in Section 3; "Conditional Payments" means any medical payments made by Medicare that may be subject to future recovery; "Medicare Set-Aside" or "MSA" means funds set aside from the Settlement Amount for future medical care related to the Incident, if required.

2. SETTLEMENT AND RELEASE

Upon receipt of the Settlement Amount described below, Releasor, on behalf of Releasor and Releasor's agents, heirs, executors, administrators, successors and assigns, hereby fully, finally and forever releases and discharges Releasee and its insurers, attorneys, agents, employees, predecessors and successors from any and all claims, demands, causes of action, liabilities and damages of any nature arising out of or in any way connected with the Incident through the effective date of this Release.

3. MEDICARE CERTIFICATION AND OBLIGATIONS

Releasor certifies under penalty of perjury that the following information is true and accurate to the best of Releasor's knowledge:

I am currently enrolled in Medicare. I am not enrolled in Medicare.

Releasor agrees to cooperate with Releasee and any insurer or claims administrator in identifying and resolving any Conditional Payments and as necessary to allocate funds for an MSA. Releasor further agrees that any Settlement Amount may be subject to reduction, withholding or allocation to satisfy Medicare's interests and that Releasor shall remain responsible for any Conditional Payments not satisfied from settlement proceeds if required by law.

4. AUTHORIZATION TO RELEASE MEDICAL AND MEDICARE RECORDS

Releasor authorizes any physician, hospital, health care provider, and any third party who has records relating to treatment, billing or payment for services in connection with the Incident to release such records and information to Releasee, Releasee's insurer, claims administrators, Medicare or their representatives. This authorization includes the release of Medicare claims history, conditional payment records, and other data necessary to determine Medicare's potential recovery.

5. REPRESENTATIONS AND WARRANTIES

Releasor represents and warrants that Releasor has the authority to execute this Release, that Releasor has not assigned any claim released herein to any third party other than as disclosed in writing, and that Releasor will not seek recovery from Releasee for any matter released by this Release. Releasor further represents that the information provided regarding Medicare status and prior payments is complete and accurate to the best of Releasor's knowledge.

6. INDEMNIFICATION

To the extent permitted by law, Releasor agrees to indemnify, defend and hold harmless Releasee from and against any claims, demands, losses, liabilities or expenses (including reasonable attorneys' fees) arising from any untrue statement made by Releasor herein or any failure to disclose material information regarding Medicare payments, conditional payments, or other payer interests related to the Incident.

7. ALLOCATION OF SETTLEMENT

The parties agree that the Settlement Amount will be allocated among categories including pain and suffering, lost wages, and past and future medical expenses. Any allocation or set-aside for future medical care related to the Incident shall be used for Medicare's determination of its interests. The parties acknowledge that allocation is an important part of resolving Medicare's interests but does not guarantee any particular determination by Medicare or any other payor.

8. COOPERATION

Each party agrees to cooperate, execute and deliver such further documents and to take such actions as may be reasonably necessary to effectuate the purposes of this Release, including, without limitation, providing affidavits, executing subrogation assignments, or participating in discussions with Medicare or its contractors regarding conditional payments or recovery.

9. NOTICES

All notices required or permitted under this Release shall be in writing and delivered to the addresses set forth below or to such other address as a party may subsequently designate by written notice in accordance with this Section.

10. GOVERNING LAW

This Release shall be governed by and construed in accordance with the laws of the state of without regard to conflict of law principles.

11. ENTIRE AGREEMENT; SEVERABILITY

This Release constitutes the entire agreement between the parties concerning the subject matter hereof and supersedes all prior and contemporaneous agreements, representations, and understandings. If any provision of this Release is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

12. AMENDMENTS; WAIVER; COUNTERPARTS

No amendment, modification or waiver of any provision of this Release shall be effective unless in writing and signed by both parties. A waiver of any breach shall not constitute a waiver of any subsequent breach. This Release may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

13. CERTIFICATION

Releasor certifies under penalty of perjury that the information provided in this Release (including Medicare status and prior payments) is true and correct to the best of Releasor's knowledge, information and belief, and that Releasor will promptly notify Releasee in writing of any change in Medicare status or of any claims by third parties affecting the matters released herein.

14. ATTORNEY INFORMATION (IF APPLICABLE)

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