Re: Pharmacy Charges
I do hereby authorize BUENA VISTA MEDICAL SERVICES to furnish to my attorney all type of medical and non-medical information that might be required by them in relation to the accident on the above date in which I was involved. I hereby authorize and direct you, my attorney, to pay directly to BUENA VISTA MEDICAL SERVICES all sums that maybe due for prescription services rendered to me by reasons of the accident dated above or by reason of any other bill that is due to BUENA VISTA MEDICAL SERVICES and to withhold such sums from any settlement, judgment, or verdict.
I understand that I am directly responsible to BUENA VISTA MEDICAL SERVICES for bills submitted by them for prescription services and this agreement is made solely for their additional protection in consideration of the delayed payment. I authorize my attorney to provide BUENA VISTA MEDICAL SERVICES a complete copy of my legal records, including but not limited to copies of settlement disbursements, fee and cost accounting documents, and settlement checks, at any time that BUENA VISTA MEDICAL SERVICES so demands. This authorization is irrevocable during the period of time that any balances due and owing to BUENA VISTA MEDICAL SERVICES. Further, I understand that the obligation to BUENA VISTA MEDICAL SERVICES is assignable to any third party.
I agree to follow the Terms of Service outlined at www.buenavistarx.com/terms and that failure to comply with these terms may result in termination of services and/or possible legal action. I understand that the Pharmacy Card issued to me is to be only used to pay for medications that are directly or indirectly related to the accident referenced on the above date, and by using my Pharmacy Card to fill prescriptions I am certifying that the medications are accident-related. I acknowledge and understand that I has multiple options to fund my prescriptions, including the use of health insurance, self-pay, government programs and health maintenance organizations and acknowledge that BUENA VISTA MEDICAL SERVICES charges administrative fees and that there may be medical providers or pharmacies who would provide the same services for a lower cost under any insurance policy or self-pay.
In the event of a change of attorney, or if my attorney rescinds his legal representation, my attorney is instructed to make known to BUENA
VISTA MEDICAL SERVICES the name of any attorney who represents me in the above-referenced injury. This lien remains binding on the award or any recovery notwithstanding substitution of counsel.
Further, the parties agree that facsimile signatures of each party shall be deemed, and original signatures shall be binding on the party whose signature is by facsimile as if it were their original signature. Photocopy and/or fax copy of the executed lien shall have the same force and effect as the original.
Acknowledgement of Attorney
The undersigned being attorney of record for the above patient does hereby agree to observe all the terms to the above and agrees to withhold such sums from and settlement, judgment, or verdict as may be necessary to adequately protect BUENA VISTA MEDICAL SERVICES. I have reviewed the above terms with the above referenced patient, whether or not their signature is present.
This office holds an assignment/lien on this case for services rendered. Any settlement of this claim without honoring this assignment/lien will cause you to be responsible for this payment. Attorney agrees that Attorney will be personally responsible to pay the full lien balance if attorney does not pay provider/assignee directly for client's charges upon settlement, judgment and/or award or releases/forwards client’s settlement, judgment and/or award funds directly to client without paying provider/assignee, requiring provider/assignee to seek payment from client rather than attorney
Please date; sign and return to BUENA VISTA MEDICAL SERVICES keep one copy for your records.