MEDICAL PROVIDER LIEN AGREEMENT

Letter of Protection / Deferred Payment Agreement

PARTIES TO THIS AGREEMENT

Date of Agreement: [________________________________]

PATIENT:
Name: [________________________________]
Address: [________________________________]
City, State, Zip: [________________________________]
Date of Birth: [________________________________]
Phone: [________________________________]

MEDICAL PROVIDER:
Name/Facility: [________________________________]
Contact Person: [________________________________]
Address: [________________________________]
City, State, Zip: [________________________________]
Phone: [________________________________]
Fax: [________________________________]
Tax ID/NPI: [________________________________]

ATTORNEY:
Name: [________________________________]
Firm: [________________________________]
Address: [________________________________]
City, State, Zip: [________________________________]
Phone: [________________________________]
Fax: [________________________________]
Email: [________________________________]
State Bar Number: [________________________________]

RECITALS

A. Patient sustained injuries on or about [DATE OF INCIDENT] (the "Incident") and has retained Attorney to represent Patient in pursuing claims for compensation.

B. Patient requires medical treatment for injuries sustained in the Incident.

C. Patient does not have sufficient funds or insurance coverage to pay for medical treatment at this time.

D. Medical Provider is willing to provide treatment to Patient and defer payment until resolution of Patient's legal claims, subject to the terms of this Agreement.

E. Attorney agrees to protect Medical Provider's interest in any recovery obtained on Patient's behalf.

AGREEMENT

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

1. MEDICAL SERVICES

1.1 Treatment to be Provided

Medical Provider agrees to provide the following medical services to Patient:

☐ Initial evaluation and examination
☐ Diagnostic testing (X-ray, MRI, CT, etc.)
☐ Treatment and therapy
☐ Surgery and related services
☐ Follow-up care
☐ Prescription medications
☐ Durable medical equipment
☐ Other: [________________________________]

1.2 Duration of Treatment

Medical Provider agrees to provide treatment:

☐ Until maximum medical improvement (MMI)
☐ Until [SPECIFIC DATE]
☐ For an estimated [NUMBER] visits/sessions
☐ As medically necessary, subject to periodic review
☐ Other: [________________________________]

1.3 Treatment Limitations

☐ Maximum treatment value under this Agreement: $[________]
☐ Treatment exceeding this amount requires renegotiation
☐ No limitation on treatment value

2. PATIENT'S OBLIGATIONS

2.1 Payment Obligation

Patient agrees to pay Medical Provider for all medical services rendered in connection with injuries from the Incident. Payment shall be made from any settlement, judgment, or other recovery obtained in Patient's legal claim.

2.2 Assignment of Proceeds

Patient hereby assigns to Medical Provider a lien against any and all proceeds from settlement, judgment, arbitration award, or other recovery arising from the Incident, to the extent of Medical Provider's charges for services rendered under this Agreement.

2.3 Patient's Responsibilities

Patient agrees to:

(a) Attend all scheduled appointments or provide reasonable notice of cancellation.

(b) Follow Medical Provider's treatment recommendations.

(c) Provide accurate and complete medical history.

(d) Notify Attorney and Medical Provider of any change in contact information.

(e) Not settle the case without ensuring Medical Provider's charges are addressed.

(f) Cooperate with Medical Provider in documenting injuries and treatment.

3. ATTORNEY'S OBLIGATIONS

3.1 Acknowledgment of Lien

Attorney acknowledges Medical Provider's lien created by this Agreement and agrees to protect Medical Provider's interest in any recovery.

3.2 Notice of Settlement

Attorney agrees to notify Medical Provider before disbursing any settlement or judgment funds and to provide Medical Provider an opportunity to submit final billing.

3.3 Payment from Settlement

Attorney agrees to pay Medical Provider's charges directly from settlement proceeds before disbursing funds to Patient, unless:

(a) The charges are disputed by Patient or Attorney; or

(b) There are insufficient funds after payment of attorney fees, costs, and superior liens; or

(c) Medical Provider has agreed to a reduction in writing.

3.4 No Guarantee of Recovery

Attorney makes no representation or guarantee that any recovery will be obtained. Attorney's obligation is limited to protecting Medical Provider's interest in any recovery actually obtained.

3.5 Limitations

Attorney does not guarantee:

(a) That there will be any recovery in this matter.

(b) That any recovery will be sufficient to pay Medical Provider's charges.

(c) The priority of Medical Provider's lien relative to other liens.

(d) That Medical Provider's full charges will be paid.

4. MEDICAL PROVIDER'S OBLIGATIONS

4.1 Treatment Standards

Medical Provider agrees to:

(a) Provide treatment consistent with the standard of care.

(b) Maintain complete and accurate medical records.

(c) Provide copies of records to Attorney upon request.

(d) Provide narrative reports as reasonably requested.

(e) Testify at deposition or trial if required (subject to fee agreement).

4.2 Billing

Medical Provider agrees to:

(a) Submit itemized billing to Attorney upon request or at treatment completion.

(b) Charge Patient usual and customary rates (or rates agreed herein).

(c) Provide billing codes and supporting documentation.

(d) Update billing as additional charges are incurred.

4.3 No Balance Billing (Optional)

☐ Full Satisfaction Clause: Medical Provider agrees to accept payment from settlement proceeds as payment in full and will not balance bill Patient for any remaining charges, provided the settlement is reasonable and [___]% of charges are paid.

☐ This provision does not apply - Medical Provider reserves the right to pursue Patient for any unpaid balance.

5. BILLING AND CHARGES

5.1 Fee Schedule

Medical Provider's charges shall be as follows:

☐ Usual and customary charges
☐ Reduced rate of [___]% of usual charges
☐ Flat fee of $[________] for specified services
☐ As set forth in attached fee schedule (Exhibit A)

5.2 Current Charges

As of the date of this Agreement, Patient's current balance is: $[________]

5.3 Estimated Future Charges

Estimated additional charges for anticipated treatment: $[________]
(This is an estimate only and not a guarantee)

6. LIEN PRIORITY AND NEGOTIATION

6.1 Lien Priority

The parties acknowledge that Medical Provider's lien may be subordinate to:

(a) Attorney's fees and costs

(b) Medicare and Medicaid liens

(c) ERISA health plan reimbursement claims

(d) Workers' compensation liens

(e) Statutory hospital liens

(f) Other government liens

6.2 Lien Negotiation

In the event settlement proceeds are insufficient to pay all liens and provide reasonable recovery to Patient, Medical Provider agrees to negotiate in good faith regarding reduction of charges. Specifically:

☐ Medical Provider agrees to reduce charges by [___]% if settlement is limited

☐ Medical Provider agrees to accept pro-rata payment with other lienholders

☐ Medical Provider agrees to consider reductions based on case value

☐ Other: [________________________________]

6.3 Dispute Resolution

If there is a dispute regarding Medical Provider's charges:

☐ The disputed amount shall be held in Attorney's trust account pending resolution

☐ The parties shall attempt to resolve through negotiation

☐ Unresolved disputes shall be submitted to [mediation/arbitration]

7. NO RECOVERY SITUATION

7.1 If No Recovery

If Patient's legal claim results in no recovery, the parties agree as follows:

☐ Option A: Medical Provider agrees to waive all charges and Patient shall owe nothing.

☐ Option B: Patient remains personally liable for all charges, payable within [___] days after case conclusion.

☐ Option C: Medical Provider agrees to accept $[________] as payment in full if no recovery.

☐ Option D: Patient agrees to [payment plan terms]: [________________________________]

7.2 Definition of No Recovery

"No recovery" includes:

(a) Dismissal of Patient's claims

(b) Defense verdict at trial

(c) Settlement for zero dollars

(d) Other disposition resulting in no payment to Patient

8. MEDICAL RECORDS AND TESTIMONY

8.1 Medical Records

Medical Provider agrees to provide copies of Patient's medical records:

☐ At no charge
☐ At cost of copying only
☐ At statutory rates
☐ At rate of $[________]

8.2 Narrative Reports

Medical Provider agrees to provide narrative medical reports:

☐ At no additional charge (included in treatment fee)
☐ At a fee of $[________] per report

8.3 Expert Testimony

If Medical Provider is required to provide testimony:

Deposition testimony: $[________] per hour
Trial testimony: $[________] per half-day / $[________] per full day
Cancellation fee: $[________] if cancelled within [___] days

9. TERM AND TERMINATION

9.1 Term

This Agreement shall remain in effect until:

(a) All charges are paid in full; or

(b) Patient's legal claim is resolved and appropriate payments made; or

(c) This Agreement is terminated as provided below.

9.2 Termination by Medical Provider

Medical Provider may terminate this Agreement upon [30] days written notice if:

(a) Patient fails to attend scheduled appointments without reasonable cause

(b) Patient fails to follow treatment recommendations

(c) Patient's case is dismissed or abandoned

(d) Other good cause: [________________________________]

9.3 Effect of Termination

Upon termination, charges incurred prior to termination remain subject to this Agreement's lien provisions.

10. GENERAL PROVISIONS

10.1 Entire Agreement

This Agreement constitutes the entire agreement between the parties and supersedes all prior discussions and agreements.

10.2 Amendments

This Agreement may only be modified by written document signed by all parties.

10.3 Governing Law

This Agreement shall be governed by the laws of the State of [________________________________].

10.4 Severability

If any provision is found invalid, the remaining provisions remain in full force.

10.5 Notices

All notices shall be sent to the addresses listed above or such other address as a party may designate in writing.

10.6 Counterparts

This Agreement may be executed in counterparts and by electronic signature.

11. ACKNOWLEDGMENTS

Patient Acknowledges:

☐ I understand that I am personally responsible for payment of Medical Provider's charges.

☐ I understand that payment will come from any settlement or judgment I receive.

☐ I understand there is no guarantee of any recovery in my case.

☐ I have read and understand this Agreement.

☐ I was advised to consult with my Attorney before signing.

Medical Provider Acknowledges:

☐ I understand there is no guarantee of payment from this patient's case.

☐ I understand that my lien may be subject to reduction or subordination.

☐ I understand that the Attorney does not guarantee any recovery.

☐ I agree to the terms and conditions of this Agreement.

Attorney Acknowledges:

☐ I acknowledge Medical Provider's lien created by this Agreement.

☐ I agree to protect Medical Provider's interest in any recovery.

☐ I make no guarantee of any recovery or payment.

☐ I have explained this Agreement to my client.

SIGNATURES

PATIENT:

Signature: _________________________________ Date: ______________

Printed Name: _________________________________

MEDICAL PROVIDER:

Signature: _________________________________ Date: ______________

Printed Name: _________________________________

Title: _________________________________

ATTORNEY:

Signature: _________________________________ Date: ______________

Printed Name: _________________________________

State Bar Number: _________________________________

EXHIBIT A: FEE SCHEDULE (if applicable)

[Attach Medical Provider's fee schedule for services covered by this Agreement]

OFFICE USE ONLY