Pharmacy Lien Agreement

PHARMACY LIEN AGREEMENT

This Pharmacy Lien Agreement is entered into on this day: , by and between Pharmacy Name: , located at ("Pharmacy"), and Patient Name: , located at ("Patient").

RECITALS

WHEREAS, Pharmacy has provided and may continue to provide prescription medications, pharmaceutical supplies, and related professional services to Patient in connection with injuries or illnesses for which Patient may have a claim or entitlement to recovery from a third party, insurer, or benefits program; and

WHEREAS, Patient has requested that Pharmacy furnish such medications and services under the understanding that Pharmacy will defer collection and seek payment from any recovery, settlement, judgment, or proceeds obtained by or on behalf of Patient relating to the underlying claim (the "Recovery"); and

WHEREAS, Pharmacy and Patient desire to set forth their respective rights and obligations with respect to the pharmacy's claim for payment and to establish and perfect a lien against any Recovery.

NOW, THEREFORE

In consideration of the mutual covenants contained 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 Agreement, the following terms shall have the meanings set forth below:

"Pharmacy Charges" means all amounts invoiced by Pharmacy for medications, supplies, professional dispensing fees, and related services, including any unpaid balances, interest, and costs of collection.

"Recovery" means any proceeds, settlement, judgment, award, or payment obtained by or on behalf of Patient from any third party, insurer, benefits program, tortfeasor, or other source that relate in whole or in part to the condition or injury for which Pharmacy provided services.

2. GRANT OF LIEN

Patient hereby grants to Pharmacy a lien and security interest in any and all Recoveries to secure payment of Pharmacy Charges. The lien shall attach to and be enforceable against any Recovery, whether by settlement, judgment, compromise, arbitration, or assignment, and shall be effective as of the date Pharmacy first provided goods or services to Patient for the condition at issue.

The maximum principal lien amount claimed by Pharmacy at this time is: $ (exclusive of interest and costs).

3. PHARMACY CHARGES; DOCUMENTATION

Pharmacy shall provide Patient and, upon written request, Patient's counsel or insurer with a true and correct itemized statement of Pharmacy Charges, including dates of service, description of medications or supplies, units, and the amount owing. Itemized statement attached or described below:

Outstanding balance for Pharmacy Charges as of the date of this Agreement: $.

4. NOTICE TO THIRD PARTIES; ACKNOWLEDGMENT

Patient authorizes Pharmacy to provide notice of this lien to any insurer, third-party payer, claims adjuster, attorney, or other entity responsible for making payment of a Recovery. Patient further authorizes and directs any insurer, claims administrator, third-party payor, or attorney to withhold payment of any Recovery due to Patient until such time as Pharmacy has been paid in accordance with this Agreement.

Patient agrees to provide Pharmacy with written notice of any demand, settlement, mediation, arbitration, hearing, lawsuit, or other proceeding that may give rise to a Recovery within days of Patient's knowledge thereof.

5. PRIORITY; ENFORCEMENT

The lien granted hereunder shall have priority against Patient's Recovery to the extent permitted by applicable law. Pharmacy retains the right to file or record any documents necessary to perfect its lien or security interest and to take such actions as reasonably necessary to enforce this Agreement, including initiating legal proceedings to collect unpaid Pharmacy Charges and to recover attorneys' fees and costs.

6. PAYMENT FROM RECOVERY

Upon receipt by Patient or Patient's counsel of any Recovery, Patient agrees that funds shall be disbursed first to satisfy Pharmacy Charges in full, including reasonable costs of collection and attorneys' fees as provided in this Agreement, and then to Patient. Unless otherwise agreed in writing, Pharmacy shall receive payment within days after receipt of Recovery by Patient or counsel.

Interest on unpaid Pharmacy Charges shall accrue at the rate of per annum from the date of billing to the extent permitted by law.

7. COOPERATION

Patient agrees to cooperate with Pharmacy, its agents, and counsel in the prosecution, preservation, and collection of Pharmacy's lien, including executing any reasonable documents, providing authorization to discuss Patient's account with insurers or attorneys, and providing timely notice of any proposed settlement or recovery.

8. TERM; TERMINATION

This Agreement shall remain in effect until Pharmacy's lien is satisfied in full or until terminated by written agreement executed by both parties. Termination shall not affect Pharmacy's right to recover amounts accrued prior to termination.

9. REMEDIES; ATTORNEYS' FEES

In the event of default by Patient, Pharmacy shall be entitled to pursue all available legal and equitable remedies, including foreclosure of its lien, and to recover reasonable attorneys' fees, court costs, and collection expenses incurred in enforcing this Agreement to the extent permitted by law.

10. REPRESENTATIONS AND WARRANTIES

Each party represents and warrants that it has full power and authority to enter into this Agreement, that this Agreement constitutes a valid and binding obligation enforceable in accordance with its terms, and that the execution and performance of this Agreement do not violate any other agreement to which such party is bound.

11. NOTICES

Pharmacy Notice Address

Patient Notice Address

All notices required or permitted under this Agreement shall be in writing and shall be deemed given when delivered personally, sent by certified mail, return receipt requested, or delivered by a nationally recognized overnight courier to the addresses provided above or to such other address as a party may designate in writing.

12. GOVERNING LAW; SEVERABILITY; ENTIRE AGREEMENT

This Agreement shall be governed by and construed in accordance with the laws of the state where Pharmacy is located, without regard to its conflicts of law principles. If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall continue in full force and effect. This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior oral or written agreements, representations, and understandings.

13. 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 under this Agreement shall operate as a waiver of that right. This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

14. FURTHER ASSURANCES

Each party agrees to execute and deliver such further documents and take such additional actions as may be reasonably required to effectuate the purposes of this Agreement, including but not limited to providing authorizations, executing releases, and cooperating with the perfection and enforcement of the lien.

CERTIFICATION: Patient certifies that the information provided to Pharmacy concerning any claim, insurer, or third-party payer is true and complete to the best of Patient's knowledge. Patient acknowledges that any false or misleading information may subject Patient to legal liability and may void this Agreement.

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