I First Name Last Name hereby authorize and direct you, my attorney First Name Last Name , to pay directly to my health care provider, Stress Knot Mobile Massage, the total dollar amount owing for health care services, including applicable interest charges, provided for injuries arising from the motor vehicle accident on Date . I First Name Last Name hereby authorize my attorney and the involved insurance a rising from the motor vehicle accident on companies to withhold sums from any settlement, judgment, or verdict as may be necessary to adequately protect my health care provider and their office. Thereby further consent to a lien being filed on my case by said health care provider and their office against any and all proceeds of my settlement, judgment, or verdict which may be paid to you, my attorney, or me as the result of the injuries for which I have been treated.
I First Name Last Name agree never to rescind this document and that any attempt at recession will not be honored by my attorney. I hereby instruct that in the event another attorney is substituted in this matter, the new attorney shall honor this Contractual Guarantee of Payment for Health Care Services as inherent in the settlement and enforceable upon the case as if it were executed by him/her.
I First Name Last Name fully understand that I am directly and fully responsible to said health care provider or their office for all health care bills submitted by them for services rendered to me. Further, this agreement is made solely for said health care providers' additional protection and in consideration of their forbearance on payment. I also understand that such payment is not contingent on any settlement, judgment, or verdict by which I may eventually recover damages.
I First Name Last Name specifically request my attorney to acknowledge this letter by signing below and returning it to the office of ClinicalMassage Therapy. I have been advised that if my attorney does not wish to cooperate in protecting the health care providers' interest, the health care provider will not await payment, but will require me to make payments on a current basis.
Date Date . Client Signature Signature Client First and Last Name First Name Last Name
Date Date . Attorney Signature Signature Attorney First and Last NameFirst Name Last Name