Personal Injury Lien - Team Physical Therapy

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P
I
L
ERSONAL
NJURY
IEN
Patient Name:
Last
First
Middle Initial
Date of Accident:
Prescribing Physician:
I hereby authorize TEAM Physical Therapy, Inc. to furnish the above listed prescribing physician with a complete
physical therapy evaluation, treatment plan and progress reports in regard to my treatment for injuries sustained in
the accident on the above listed date.
I hereby authorize and direct:
Name of Attorney:
Attorney's Address:
Attorney's Phone:
Attorney's Signature: _________________________________________________
to pay directly to TEAM Physical Therapy such sums as may be due and owing for physical therapy treatment
rendered to me, both by reason of this accident and by reason of any other bills that are due TEAM Physical Therapy
and to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately give a lien
on my case any and all proceeds of any settlement, 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 TEAM Physical Therapy for all physical therapy bills
submitted for services rendered to me and that this agreement is made solely for TEAM Physical Therapy for
additional protection and in consideration of awaiting payment. I further understand that such payment is to
eventually recover said fee.
________________________________________
Patient's Signature
Date

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