and Robert E. Karsch, M.D. PC ("Provider")
WHEREAS, Patient was injured in an accident or incident and is seeking medical/diagnostic care from Provider for his/her injuries; and
WHEREAS, Attorney represents Patient in a claim or lawsuit (the "Legal Action") to recover damages arising from the accident or incident, including medical/diagnostic expenses; and
WHEREAS, Provider has agreed to render treatment to Patient without requiring payment at the time of rendering services;
NOW THEREFORE, in consideration of the premises, the mutual covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:
- Patient acknowledges that, in accordance with the Health Information Portability and Accountability Act of 1996 ("HIPAA",) Patient's medical information relating to the Legal Action may be shared to manage and expedite Patient's medical treatment. Patient authorizes Provider to release any information needed by Attorney to pursue the Legal Action, including without limitation information (including billing information) regarding the examination, treatment, procedures and services rendered by Provider.
- I hereby authorize and direct you, as my attorney, to pay directly to said Provider of medical services such as sums as may be due and owing for professional services rendered to me by reason of this accident and to hold such sums from any net settlement, judgment or verdict as may be necessary to adequately protect said Provider of such medical services. I hereby agree in the event another attorney is substituted in this matter, I will instruct said attorney to comply with the terms of this agreement and to execute an agreement.
- I hereby further give assignment in contract and lien to said Provider for payment from my settlement, judgment or verdict, of medical services against any and all proceeds of any net settlement, judgment or verdict which may be paid to you, my attorney, or myself as the result of the injuries for which I have been treated or injuries in connection therewith.
- I fully understand that I am directly and fully responsible to said Provider of medical services for all professional bills submitted by them for services rendered to me and that this agreement is made solely to give said Provider of medical services additional protection and in consideration of his awaiting payment. And I further understand that such payment is not contingent on any settlement, judgment or verdict which I may eventually recover such fee. In the event that the lien is not honored at the time of settlement, any balance due is subject to all collections actions, and all fees associated with this will be Patient responsibility.
- I agree that the above assignment is irrevocable and in the event that I contradict such assignment, I authorize my Attorney to hold in trust said amounts until a court of equity or damages may resolve the validity of this assignment.
- I acknowledge that this Agreement must be signed by myself and by my attorney before any medical services will be provided to me by this Provider. I have been advised that if my attorney does not wish to cooperate in protecting my Provider's interest, Provider may declare the entire balance due and payable from Patient.
Patient's Printed Name: ______________________________
Patient's Signature: ___________________________
Date: _____________
- The undersigned being attorney of record for the above client does hereby acknowledge notice of the assignment of contract and lien entered into by the above parties. As attorney of record, I acknowledge receipt of said assignment under contract law and acknowledge the obligation imposed by the Georgia Professional Rules of Conduct 1.15(I) as to assignment and liens. The undersigned attorney of record agrees to hold any and all disputed settlement funds in trust to satisfy any and all valid liens at the time of settlement disbursement.