I authorize Vincent DiCarlo, M.D. & Associates, P.A. d/b/a Neurology and Physical Therapy Centers of Tampa Bay (“Provider”) to furnish to my attorney(s), their employees and agents who represent/represented me regarding any claim(s) related to my accident/loss with a full report of examination, diagnosis, treatment, prognosis and any medical information or any information regarding services provided to me, including all records received for care from other sources, billing information and any other information regarding me which may be in Provider’s possession.
I authorize and direct my attorney(s) who represent(s)/represented me regarding any claim(s) related to my accident/loss to pay directly to Provider all sums that are due for all services Provider rendered to me regarding my accident/loss and to withhold such sums from any settlement, judgment or verdict. I hereby further give a lien on my claim(s) to said judgement or verdict paid to my attorney(s) or me regarding my accident/loss.
I understand that my attorney(s) will be sent a copy of this letter of protection and authorization as notice of my authorization, direction to them, and my responsibility. I agree to keep Provider updated if there is a change in status with my current attorney(s) and if there are any changes to my representation. If there is a change, I agree that this letter of protection and authorization will also apply to my new attorney(s) and they will also be notified. I understand that I am directly responsible to the Provider for all bills for Provider’s services rendered to me, regardless of payment source. I understand payment is not contingent on any settlement, judgment or verdict by which I may eventually recover payment for Provider’s services.