I do hereby authorize New Life Chiropractic Center, Inc., P.C. (“NLCC”) to furnish you, my attorney, with a full report of NLCC’s examination, diagnosis, treatment, prognosis, etc., of myself in regard to the personal injury/accident in which I was recently involved.
I hereby irrevocably authorize and direct you, my attorney, to and for my benefit, to pay directly to NLCC such sums as may be due and owing to NLCC for the medical services rendered to me both by reason of the personal injury/ accident and by reason of any other related care and medical bills for my treatment that are due and owing to NLCC and to withhold such sums from any settlement, judgement or verdict as may be necessary to adequately protect and fully compensate NLCC. To the extent permitted by law, I hereby further give a lien to NLCC against any and all proceeds of my settlement, judgement, 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 and remain directly and fully responsible to NLCC for all care and medical bills submitted by NLCC for care and medical services rendered to me and that this agreement is made solely for NLCC's additional protection and in consideration of NLCC awaiting payment for a period of no less than ninety (90) days. Payment for care and medical services is not contingent on any settlement, judgment, or verdict by which I may eventually be reimbursed for said bills.
I agree to promptly notify NLCC of any change or addition of attorney(s) used by me in connection with this personal injury/accident, and I instruct my attorney to do the same and to promptly deliver a copy of this Letter of Protection to any such substituted attorney(s).
Please acknowledge this Letter of Protection by signing below and returning it to NLCC. I have been advised that if my attorney does not wish to cooperate in protecting NLCC’s interests, NLCC will not await payment and may pursue collection of the outstanding sum due without further notice.