Lien Agreement

I   *   , here by grant a lien to Mizuta & Associates Physical Therapy upon any settlement claim, or judgment claim as a result of an accident, illness, or injury occurring on    Date . I authorize and direct my attorney to pay directly to Mizuta & Associates Physical Therapy any and all sums due to it for services rendered to me and withhold such sums owed Mizuta & Associates Physical Therapy from any settlement or verdict as may be necessary to adequately protect Mizuta & Associates Physical Therapy. Furthermore, I agree that Mizuta & Associates Physical therapy shall not be responsible and shall not pay any attorney’s fees, expenses, or costs for any claim or action I may have for the collection of any funds due me from any third parties. I agree to have my attorneys, whether currently retained or retained in the future execute this document and agree to be bound by the terms contained herein until Mizuta & Associates Physical Therapy has received payment in full.

I fully understand that I am directly responsible for any and all charges submitted by Mizuta & Associates Physical Therapy and that this agreement is for the protection of Mizuta & Associates Physical Therapy and in consideration of its awaiting payment. I also agree that all sums due will accrue interest at 1 ½ % per month until all sums are paid in full. Cancelations with less than 24-hour notice and No-Shows will be billed at $100 per visit. I agree to pay the reasonable costs and attorneys’ fees of Mizuta & Associates Physical Therapy in order for them to collect all sums due them on my account including any actions against me to collect such sums. If settlement is not reached six (6) months from date of first treatment, payment in full is to be made by the patient, parent, or guardian. Insurance will not be filed at that time. If settlement is reached and payment is made on all claims excluding the claim Mizuta & Associates Physical Therapy has on this settlement, any option for negotiation will be void and payment will be expected in full at the rate billed.

I further understand that such payment is not contingent on any settlement, judgment, or verdict by which I may eventually recover said fee.