Medical Group Lien Agreement

Medical Group Lien Agreement

This Medical Group Lien Agreement (the Agreement) is entered into by and between Medical Group Name: with principal address: (hereinafter "Provider"), and Patient Name: residing at: (hereinafter "Patient"). Patient Date of Birth: Month Day Year .

RECITALS

WHEREAS, Provider has furnished, or will furnish, medical services, treatment and supplies to Patient arising out of injuries or medical condition related to the incident or claim identified below; and

WHEREAS, Patient has requested, and Provider has agreed to accept, payment for such services from any proceeds or recovery Patient may obtain from third parties, including insurance carriers, settlements, judgments or verdicts; and

WHEREAS, the parties wish to set forth the terms under which Provider's charges will be secured by a lien against any third-party recovery obtained by Patient.

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

1. CASE AND TREATMENT INFORMATION

From: Month Day Year    To: Month Day Year

2. EXPRESS LIEN AND ASSIGNMENT

Patient hereby grants to Provider an express, first-priority lien (the Lien) on any and all proceeds of any settlement, judgment, verdict, compromise, or other recovery (collectively, Recovery) that Patient obtains as a result of the incident, claim, or case referenced above. Patient assigns and conveys to Provider the right to be paid from such Recovery the full amount of Provider's billed charges, including but not limited to reasonable charges for services, diagnostic studies, supplies, and any applicable interest, collection costs and attorneys' fees, up to the amount of Provider's outstanding charges.

3. AMOUNT, PRIORITY AND PAYMENT

Provider's lien secures payment of Provider's reasonable and customary charges for services rendered. Provider's charges shall be calculated in accordance with Provider's usual billing practices. The Lien shall be satisfied from Recovery prior to disbursement to Patient, except to the extent required otherwise by binding statutory or contractual obligations. Patient agrees not to disburse or compromise any portion of Recovery without first satisfying Provider's Lien or obtaining Provider's written release.

4. AUTHORIZATION TO RELEASE RECORDS; COOPERATION

Patient authorizes Provider to release medical records, bills, and summaries to Patient's legal counsel, insurers, or other parties as necessary to perfect, enforce, or collect the Lien. Patient further agrees to cooperate with Provider and counsel in the prosecution, settlement, or enforcement of any claim related to the Recovery, including executing additional documents reasonably required to effectuate the Lien and assignment.

5. ATTORNEY ACKNOWLEDGMENT (IF APPLICABLE)

If Patient is represented by counsel in connection with the claim or Recovery, such counsel is requested to recognize and honor the Provider's Lien and to retain from any Recovery the amounts necessary to satisfy Provider's outstanding charges. Counsel's failure to honor this request shall not affect Patient's obligation to Provider.

6. ENFORCEMENT, COSTS AND ATTORNEYS' FEES

In the event Provider must undertake legal action or collection efforts to enforce its rights under this Agreement, Patient agrees to reimburse Provider for reasonable costs of collection and attorneys' fees incurred in enforcing the Lien and collecting the outstanding balance, in addition to the principal amount owed and lawful interest.

7. NOTICES

All notices required or permitted under this Agreement shall be in writing and delivered to the addresses set forth below or to such other address as a party may designate in writing. Notice shall be effective upon personal delivery, delivery by nationally recognized overnight courier, or three (3) business days after deposit in the U.S. mail, postage prepaid.

8. INTEREST

Unless otherwise prohibited by law, Provider may charge interest on unpaid balances at the lesser of the maximum rate permitted by law or the rate of , calculated from the date services were rendered until paid in full.

9. REPRESENTATIONS AND WARRANTIES

Patient represents and warrants that (a) Patient is the party entitled to recover from the claim identified above or is authorized to assign proceeds to Provider; (b) there are no other liens, assignments or encumbrances superior to the Lien except as disclosed to Provider in writing; and (c) Patient will not execute any settlement, release, or disbursement that would prejudice Provider's rights without first notifying Provider and satisfying or resolving the Lien.

10. GOVERNING LAW; VENUE

This Agreement shall be governed by and construed in accordance with the laws of the state in which Provider maintains its principal place of business, without regard to conflict of law principles. Venue for any action to enforce this Agreement shall lie in the state or federal courts located in the county where Provider's principal place of business is located.

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 representations. If any provision of this Agreement is held unenforceable or invalid, such provision shall be severed and the remaining provisions shall remain in full force and effect.

12. AMENDMENT; WAIVER; COUNTERPARTS

Any amendment to this Agreement must be in writing and signed by both parties. The waiver by either party of a breach of any provision of this Agreement shall not operate as a waiver of any subsequent breach. This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

13. CERTIFICATION

By signing below, Patient certifies under penalty of perjury that the information provided in this Agreement is true and correct to the best of Patient's knowledge, that Patient authorizes the release of medical records as set forth above, and that Patient knowingly assigns to Provider the right to payment from any Recovery up to the amount owed for Provider's services.

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