I do hereby authorize Elite Sports Medicine to furnish you, my attorney, with a full report of examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accident in which I was recently involved.
I hereby authorize and direct you, my attorney, to pay directly to said doctor such sums as may be due and owing him for the medical service rendered me both by reason of this accident and by reason of any other bills that are due his office and to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect and fully compensate said doctor. And I hereby further give a Lien on my case to said doctor against any and all proceeds of my settlement, judgment, or verdict which may be paid to you, my attorney, or myself; as the result of the injuries for which I have been treated or injuries in connection therewith.
I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for service rendered me and that this agreement is made solely for said doctor’s additional protection and in consideration of his awaiting payment. And I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee.
This lien supersedes any type of pre-paid health insurance plan, which we may contract with. The balance due after payments from your insurance company must be paid from sums collected from any settlement, judgment or verdict, which may be paid to you.
A photocopy of this lien will be considered as valid as the original. This lien is irrevocable and binding to any subsequent Attorney retained by the patient.