Common Contracts
1 similar Lien Agreement contracts
PATIENT – ATTORNEY MEDICAL LIEN AGREEMENTLien Agreement • March 19th, 2015
I, ______________________ do hereby authorize my attorney, ____________________ to furnish Medici Medical Arts, LLC, with prepaid copies of medical records relevant to my injury or accident for which he/she is representing me. I further authorize and direct my attorney to pay directly to furnish Medici Medical Arts, LLC, such sums of monies as may be due and owing to them, (a) for medical services rendered to me for the injury and/or, (b) for any other services, supplies, or reports, and/or (c) legal medical (i.e. impairment rating reports, attorney-physician conferences, and depositions) and to withhold such sums from any settlement or judgment as may be necessary to adequately protect and pay for my treatment. I hereby grant Medici Medical Arts, LLC a lien on my claim against any and all proceeds of any settlement or judgment which may be paid to you, my attorney, or myself as the result of the injuries for which I have been treated for/or other related services. I fully understand t
