Patient understands that the medical services, supplies and treatment Patient is receiving as a part of the ongoing personal injury claim shall be billed as a lien, as authorized by applicable state law and practice. Patient hereby irrevocably authorizes and directs Attorney, to pay directly to Texas Regional Physicians, such sums due and owing for services rendered to Patient by reason of the accident from which the claim arises, and by reason of any other bills that are due to Texas Regional Physicians, and to withhold such sums from any claim, settlement, judgement or verdict as may be necessary to adequately protect and clear Patient's account with Texas Regional Physicians prior to and before any fees are paid to Attorney out of said settlement.
By this assignment, Patient gives this Lien on Patient's claim to Texas Regional Physicians against any and all proceeds of any settlement, judgement or verdict that may be paid to Attorney, or Patient or to another individual on Patient's behalf, that results from the injuries or injuries and illnesses in connection thereto, for which Patient has been treated. If Patient assigns any or all of the Patient's rights to his or her claim or a portion thereof, Patient agrees to notify Texas Regional Physicians, in writing, at the below address within thirty (30) days from the date of assignment. If another attorney is substituted in this matter, the new attorney shall honor this Lien as inherent to Patient's claim, and notice of, and substitution of, this Lien shall be both Patient and Attorney's responsibility.
NOTICE
This Lien may be executed in one or more counterparts, ease of which shall be deemed to be an original but all of which together will constitute one and the same instrument. It is understood and agreed that a copy of this Lien shall have the same force and effect as the original. Texas Regional Physicians is authorized, but not required, to file a copy of this Lien.
PAYMENT RESPONSIBILITY
Patient understands that Patient remains personally responsible to Texas Regional Physicians for all medical bills submitted for service rendered to Patient and that this Lien is made solely for Texas Regional Physicians protection and in consideration of awaiting payment.
Patient further understands that such payment is not contingent on any claim, settlement, judgement or verdict by which Patient may eventually recover said fee. Patient shall notify Texas Regional Physicians of any payment received by Patient for medical services from an insurance company or any other source. Payments will be forwarded to Texas Regional Physicians as requested. Patient further understands and accepts financial responsibility for payment of all accounts with Texas Regional Physicians. Patient understands that the legal settlement may pay all, part, or none of Patient's account(s) and that Patient is responsible for complete payment of all account(s Patient understands that Patient is financially responsible for any amount unpaid by this assignment of proceeds and/or Lien, as may be authorized by applicable state law and practice. By signing this document Patient fully understands all provisions set forth in this.