I authorize Coastal Medical Group to furnish my attorney with a full report of my examination, diagnosis, treatment, prognosis, and billing statement of myself regarding the injury sustained as a result of the incident. I authorize my attorney to furnish Coastal Medical Group and individual physicians with documents pertaining to my case, including, but not limited to, attorney's fee agreement, settlement agreement, and judgement or verdict. All prior authorizations are revoked. This authorization shall remain in effect until the sooner of the completion of my case or until revoked by me.
I further give a lien on my case to Coastal Medical Group and individual physicians against all proceeds of the settlement, judgment or verdict which may be paid to me or to my attorney as a result of the injuries sustained as a result of the incident and treated by Coastal Medical Group and individual physicians. I hereby authorize and direct my attorney to pay directly to Coastal Medical Group such sums as may be due and owed to them for medical services rendered. I understand and agree that payment is not contingent on any insurance company's determination as to appropriateness of services rendered and/or fees charged. I understand that if I miss a scheduled neuropsych test without prior notice, I will be responsible to pay for the full amount of the charges. I understand and accept that Coastal Medical Group and individual physicians do not accept any medical insurance.
This lien does not replace/supersede my own responsibility for outstanding medical bills, but is given as protection for the physician and in consideration for the physician's willingness to wait for delayed payment. I understand that payment of all outstanding fees to Coastal Medical Group and individual physicians are payable upon demand and are not contingent on the receipt of an award through settlement, judgment or verdict.
I agree to promptly notify Coastal Medical Group and individual physicians of any change or addition of attorney(s) used by me in connection with this incident and I instruct my attorney to do the same and to promptly deliver a copy of this lien to any such substituted or added attorney(s).
In the event legal action is required to enforce any provision of this Lien Agreement, the prevailing party in such action shall be entitled to reasonable attorney's fees and costs, including but not limited to collection costs, enforcement of judgment, wage garnishment, etc.