Fill and Sign the Regarding Irrevocable Form

- 1 - RE: Patient/Client: Date of Accident: Our File No: Dear Dr. _________________: I, ___________________, do hereby authorize ______________________________ and its doctors to furnish the above-named attorney with a full report of its examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accident in which I was involved on the _____ day of _____________, 20___. In conjunction therewith, I do hereby hold _______________________________ and its employees, associates, and agents free and harmless from any and all liability whatsoever that may arise from the release of such information to the said attorney or any person designated by the said attorney. I agree and understand that upon my initial visit to for treatment or examination, I a m obligated to pay an initial partial payment to and that the balance thereof shall be paid in monthly installments to I fully understand that I am primarily and personally liable for al l treatment, examinations, and other medical services performed by anyone in the employ of _____________________________________. I further understand that my liability for payment is not conditioned upon any settlement, judgment, or recovery of monies by me for any such injuries sustained and that my liability to the said for such services rendered is a bsolute irrespective of whether I am successful in recovering any monies from those responsible for my injuries. I hereby authorize and irrevocably direct the above-named attorney to pay dire ctly to ______________________________________ any and all sums as may be due and owing it for medical and medico-legal services (including reports, conferences, appearances, etc.), interest, - 2 - service charges, and indexing charges rendered to me both by reason of this accident and by reason of any other bills that are due the said _________________________________________ for which I am responsible and to withhold such sums from any settlement or judgment effected or entered into on my behalf and to pay the same as heretofore directed. I do hereby assign, transfer, and set over to the extent I am indebted to ____________________________________ any and all proceeds of any settlement or judgment effected or entered into on my behalf resulting from any litigation arising out of the aforementioned injuries. By this assignment , I do hereby give said _____________________________________ a lien on the proceeds thereof. Patient /Client ____________________________ Signature ________________________________ Date ____________________________________ - 1 - ACKNOWLEDGMENT OF ASSIGNMENT AND LIEN BY ATTORNEY The undersigned, being the attorney of record involving litigation on behalf of the patient/client mentioned heretofore, does hereby acknowledge receipt of this assignment a nd lien and agrees to be bound by all the terms and conditions of same and to pay over to _____________________________ any monies due it for services rendered to and on behalf of the said patient/client as described hereinabove after recovery from any settl ement or judgment procured on behalf of the patient/client. In the event I am replaced as the attorne y in this matter, I agree to notify _______________________________ of the name and address of the new attorney, and I agree also to put the new attorney on notice of this lien. I agree furt her to provide ____________________________________ with the court or arbitrator case number soon after it has become known to me. Name __________________________ Attorney for _____________________ Date ___________________________