Comprehensive Spine & Sports Center PC (CSSC) Patient Lien Agreement
By submitting this form, I hereby affirm and acknowledge my understanding and agreement to all the following stipulations regarding my treatments and responsibilities with Comprehensive Spine & Sports Center PC (CSSC).
In consideration for my (past, present, future) treatments and in forbearance of collection activity:
I understand that I am personally responsible for the payment of all charges for services provided to me by Comprehensive Spine & Sports Center PC (CSSC), that are not covered by my health or other insurance.
I grant CSSC, a lien against any judgements, settlements, or other recoveries, for any and all services provided to me by CSSC.
I further extend this lien to any settlements or litigation proceeds, including proceeds from third party actions relating to any injuries or conditions for which I am receiving treatment from CSSC, even if all or part of these services may be in theory covered by a health insurance carrier. If, at a later time, CSSC receives duplicate payment for these services, CSSC will refund the excess to me.
I understand that during the litigation and/or settlement process, my attorney may from time to time request copies of my medical and billing records. Accordingly, I authorize CSSC to disclose this information to my attorney as needed, for purposes of obtaining payment for CSSC services. I understand, however, that attorneys have the right to a fee under Miller v Citizens and that if my attorney is entitled to any fee, this will need to be arranged by a separate agreement between CSSC and my attorney.
By signing this document, I am also authorizing my attorney to release information to CSSC about the progress of my legal claims so that CSSC may be kept informed about the status of my claims in order to evaluate whether and when payment will be made for the services CSSC provided to me.