MANIFEST ANU

This agreement is made between [Provider/Clinic Name] ("Provider"), [Law Firm Name] ("Attorney"), and the above- named patient ("Patient"

The Patient authorizes Provider to furnish Attorney with full reports, billing, and/or SOAP notes, regarding the Patient's examination, diagnosis, treatment, prognosis, and any other information related to the injury at issue.

The Patient hereby grants Provider a lien against any and all proceeds of any settlement, judgment, or verdict arising from the incident. This lien secures payment for: Services rendered by Provider related to this injury, and Any other outstanding bills owed to Provider by the Patient. 3. Attorney's Direction of Payment The Patient authorizes and directs Attorney to pay Provider directly such sums as may be due and owing for professional services, and to withhold such sums from any settlement, judgment, or verdict as necessary to

protect Provider's interest. Attorney acknowledges this lien and agrees to

4. Patient Responsibility The Patient understands that they are directly and fully responsible for all bills submitted by Provider. This agreement is made solely for Provider's additional protection and in consideration of Provider awaiting payment. The Patient understands that Provider's right to payment is not contingent upon recovery by settlement, judgment, or verdict. 5. Change of Attorney The Patient agrees to promptly notify Provider of any changes or additions to their legal representation and instructs Attorney to do the same. Attorney further agrees to provide a copy of this lien to any substituted or additional attorney(s 6. Payment Conditions If Attorney declines to cooperate in protecting Provider's interest, Provider may, at its discretion, await payment but also reserves the right to declare the entire balance due and payable.

Acknowledgment and Agreement By signing below, all parties acknowledge and agree to the terms of this