Doctor’s Lien
To Attorney(s): ________________________________________ |
Dr. Gregory P. Skye |
________________________________________ |
Skye Chiropractic |
________________________________________ |
1187 Old Hickory Blvd |
________________________________________ |
Brentwood, TN 37027 |
|
615.377.7770 phone |
Patient’s Name:________________________________________ |
615.377.0448 fax |
Date of Birth: ________________________________________ |
|
I do hereby authorize Gregory P. Skye, D.C. to furnish to you, my attorney, with a full report of his examination, diagnosis, treatment, prognosis, etc., of my self in regard to the accident in which I was recently involved.
I hereby authorize and direct you, my insurance company, and/or my attorney to pay directly to said doctor such sums as may be due and owing him for medical service rendered to me both by reason of settlement, judgment, or verdict as may be necessary to adequately protect said doctor. I hereby further give a LIEN on my case to said doctor against any and all proceeds of my 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 agree never to rescind this document and that a rescission will not be honored by my attorney. I hereby instruct that in the event another attorney is substituted in this matter, the new attorney honor this lien as inherent to the settlement and enforceable upon the case as if it were executed by him.
I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for service rendered me and that this agreement is made solely for said doctor’s additional protection and in consideration of his awaiting payment. I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee.
If my attorney does not wish to cooperate in protecting the doctor’s interest, the doctor will not await payment but may declare the entire balance due and payable.
Patient’s Signature: ______________________________________ Date:_____________
________________________________________________________________________
ATTORNEY(S): Please sign, date and return one copy to doctor’s office and keep one copy for your records.
The undersigned being attorney of record for the above patient do hereby agree to observe all the terms of the above and agrees to withhold such sums form any settlement, judgment or verdict as may be necessary to adequately protect said doctor named. Attorney further agrees that in the event this lien is litigated that the prevailing party will be awarded attorney fees and costs.
Attorney Signature:______________________________________ Date: _______________
