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Pharmacy Card Program

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Patient Information
Patient First *
First Name
Patient Last *
Last Name
Date of birth *

Month Day Year
ex. 01/05/1976
Sex *

Male Female Unspecified
Patient Phone *
This will be the account number and must be unique per patient
Patient Email *
A copy of the card will be sent here

Attorney Information
Law Firm *
Attorney name *
Attorney Phone *
Attorney Email *
Lien and User Agreement will be sent here
Case type
Injury date *

Month Day Year
01/05/2018

Pharmacy Lien
***IMPORTANT UPDATE***

The Pharmacy Card Program now only covers prescription generic pain and inflammation medications.

If you or your client is trying to fill: Over the counter, Name Brand, Non-pain, or Non-inflammation medications, please enter the Drug Name and Strength (e.g., Valium 5mg) to the 'Comments' section below.

You can also upload a copy of the prescription below or call ahead (844) 796-3322 include non-approved medications to the Pharmacy Card.
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ASSIGNMENT OF BENEFITS/ MEDICAL LIEN AND SECURITY AGREEMENT

1. Provider’s Lien. I hereby grant to Infinity Capital Management/Infinity Health Connections, both Nevada corporations (hereinafter INFINITY) all rights to payment from my claim for personal injury which occurred on or about the above DOI, in an amount equal to the total amount owed for prescription services rendered to me by reasons of the accident above or by reason of any other bill that is due to Infinity and I instruct the ATTORNEY to withhold such sums from any settlement, judgement, or verdict.

I understand that I am directly responsible to INFINITY for bills submitted by them for prescription services and this Agreement is made solely for their additional protection in consideration of the delayed payment. I authorize my ATTORNEY to provide INFINITY a complete copy of my legal records including but not limited to copies of settlement disbursements, fee and cost accounting documents and settlement checks, at any time that INFINITY so demands. This authorization is irrevocable during the period that any balances are due and owing to INFINITY.

I understand that the Pharmacy Card issued to me is to be only used to pay for medications that are directly or indirectly related to the accident referenced on the above date, and by using my Pharmacy Card to fill prescriptions I am certifying that the medications are accident related. I acknowledge and understand that I have multiple options to fund my prescriptions, including the use of health insurance, self-pay, government programs and health maintenance organizations and acknowledge that INFINITY’s partners in this PHARMACY card program charge administrative fees and there may be medical providers or pharmacies who would provide the same services for a lower cost under an insurance policy or self-pay.

2. Assignments. I understand that all of INFINITY’S rights under this contract, including the lien are freely alienable, and INFINITY may assign these rights in full to a third party, of its choosing. PATIENT expressly authorizes INFINITY to furnish ASSIGNEE with all medical bills, medical records and other documents which are the subject of this lien. I understand that in the event of such an assignment, all of my duties and obligations associated with this contract, including but not limited to the duty to pay, as well as the duty to inform, will be enforceable by ASSIGNEE.

3. Substitution of Attorney. In the event of a change of ATTORNEY or if my Attorney rescinds his legal representation, my Attorney is instructed to make known to INFINITY the name of any ATTORNEY who represents me in the above referenced injury. This Agreement remains binding on the award or any recovery notwithstanding substitution of ATTORNEY.

4. Restriction to Disburse. PATIENT and PATIENT’S ATTORNEY specifically agree not to disburse any funds from PATIENT’S settlement (including to PATIENT or ATTORNEY) until this lien has been satisfied.

Parties agree that both original and facsimile signatures of each party shall be binding on the Parties. Photocopy and/or facsimile copies of the executed lien shall have the same force and effect as the original.

Acknowledgement of Attorney

The undersigned being attorney of record for the above patient does hereby agree to observe all the terms of the above and agrees to withhold sums from the settlement, judgement, or verdict as may be necessary to adequately protect INFINITY, I have reviewed the above terms with the above referenced patient whether or not their signature is present.

This office holds an Assignment/lien on this case for services rendered. Any settlement of this claim without honoring this

assignment/lien will cause you to be responsible for this payment. Attorney agrees that Attorney will be personally responsible to pay the full lien balance if Attorney does not pay provider/assignee directly for client’s charges upon settlement, judgement and/or award, or releases/forwards client’s settlement, judgement or award funds directly to client without paying provider/assignee requiring provider assignee to seek payment from client rather than attorney.

1700 W. Horizon Ridge Parkway, Suite 206 • Henderson, NV 89012 • USA

Phone: (877) 746-3497 • Fax: (800) 921-4811 • Email: pharmacy@infinityhealth.com • URL: http://www.infinityhealth.com
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Pharmacy Card Program

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Pharmacy Lien