Medical History Intake Form (Page 7 of 8) in pdf

Notice of Doctor’s Lien

Patient’s Name: ________________________________________________________

Healthcare Provider:

Release Chiropractic and Wellness Center

640 East Eisenhower Blvd. Suite 100

Loveland, CO 80537

Phone: 970-667-3393

Fax: 970-203-9690

I hereby authorize the above-mentioned healthcare provider to furnish the below-mentioned attorney with a full report of

his/her examination, diagnosis, treatments records, etc., of myself in regard to the accident in which I was involved.

I hereby further authorize and direct you, my attorney to pay directly to said healthcare provider such sums as may be due

and owing the office for professional services rendered me both by reason of this accident and by reason of any other bills

that are due to the office and to withhold such sums from any settlement, judgment or verdict as may be necessary to

adequately protect said healthcare provider. I hereby further give a lien on my case to said healthcare provider against any

and all proceeds of any 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 healthcare provider for all professional bills submitted by

him/her for services rendered me and that this agreement is solely for said healthcare provider’s additional protection and

in consideration of his/her awaiting payment. Further, I understand that such payment is not contingent on any settlement,

judgment or verdict by which I may eventually recover said fee.

________________________________________

Name

________________________________________

____________________________

Signature

Date

(Patient, please do not write below this line.)

**************************************************************************************************

The undersigned being attorney of record for the above patient does hereby agree to observe all the terms of the above and

agrees to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately protect the said

healthcare provider named above.

Attorney Name: ________________________________________________________________________

Attorney Address: _______________________________________________________________________

_______________________________________________________________________

Date: _______________________ Attorney’s Signature: _________________________________________

Please return to:

Release Chiropractic and Wellness Center

640 East Eisenhower Blvd. Suite 100

Loveland, CO 80537

Phone: 970-667-3393

Fax: 970-203-9690

Please maintain a copy for your records.

Release Chiropractic and Wellness Center, 640 East Eisenhower Blvd. Suite 100, Loveland, CO 80537

Medical History Intake Form Page 7