PERSONAL INJURY CASE

TREATMENT/BILLING AGREEMENT

You have requested that we treat you for personal injuries arising from an incident where a third party is allegedly liable for your injuries. We have agreed to provide treatment to you under these circumstances; without limitation, based upon the following:

All services for treatment will be billed to you based upon our customary charges. A list of the most common types of treatment, and their respective customary charges, are available for your preview at our front desk.

By signing below you agree that our charges are customary and usual for our office and this geographical community. Our agreement to treat you is contingent upon this agreement by you, and we are materially relying upon your agreeing not to later challenge the validity of our charges being customary as stated herein. You agree you have had a fair opportunity to make any inquiry you desire, including consulting with an attorney, and are fully satisfied with our charges either now or in the future, to accept our charges as being customary and specifically not to challenge our charges in any way.

Certain patients are accustomed to having their treatment billed to health insurance. You understand that because this is a Personal Injury case, IT IS THE POLICY OF THIS OFFICE NOT TO BILL HEALTH INSURANCE, and we will not bill any of your treatment to health insurance. By treating with us, you are voluntarily relinquishing your right to utilize health insurance. We are treating you solely on a lien basis against your personal injury case, and the total customary charges must be paid in full from the proceeds of your personal injury case. If anyone should bill your health insurance, doing so is done solely as a courtesy to you, and does not limit our right to bill and collect our customary charges against your personal injury in full.

By signing below you direct us not to bill your health insurance for payment of our office’s charges, and that any bill we may send to your health insurance is being done solely as a courtesy to you. You agree to, and do, hereby waive any contractual right to have your treatment billed to health insurance, and/or any right to have charges limited as stated within any health insurance agreement versus payment of our office’s total charges; and indemnify and hold us harmless in this regard against any and all claims.

You agree that nothing is to waive our right to collect our total charges billed, and you expressly waive any right that may otherwise interfere with our right to collect our total charges; including without limitation any right obtained as a third part beneficiary.

Nothing herein limits our right of recovery, and you remain personally liable to pay our office’s total charges and accept financial responsibility for these services. You have had an opportunity to discuss these agreements with independent legal counsel, and acknowledge your understanding of these agreements, and your voluntary acceptance of these agreements as a material part of our providing treatment to you, by signing below.

YOU AGREE TO PAY, IN FULL, OUR USUAL AND CUSTOMARY TOTAL CHARGES. YOU AGREE THAT THE CHARGES LISTED AT OUR FRONT DESK, FOR YOUR REVIEW UPON QUERY, ARE USUAL AND CUSTOMARY, AND FURTHER UNDERSTAND THAT WE WILL NOT BE LIMITED TO COLLECT OUR TOTAL CHARGES REGARDLESS OF ANY HEALTH INSURANCE RIGHTS TO THE CONTRARY WHICH YOU VOLUNTARILY WAIVE. YOU UNDERSTAND THAT WE ARE RELYING UPON THIS AGREEMENT IN AGREEING TO PROVIDE TREATMENT TO YOU FOR THIS ACCIDENT CASE.