Letter Of Protection Template printable pdf download

1111 Paulison Ave • Clifton, New Jersey 07015 • (973) 253-2900

Date: _________________

To: Attorney/Insurance Company:

____________________________

LETTER OF PROTECTION

I do hereby authorize the above facility to furnish you, my attorney/insurance carrier, with a full report of my

examination and diagnosis of myself in regard to my accident/illness which occurred/began on the day of

____________ (date).

I hereby give a lien to this facility on any settlement, claim, judgment or verdict as a result of my accident /illness.

I authorize and direct you, my attorney/insurance carrier, to pay directly to said facility such sums as may be due

and owing them for services rendered to me, and withhold such sums from such

settlement/claim/judgment/verdict as may be necessary to protect said facility adequately. I direct that full

payment of the facilities bill shall be paid.

I fully understand that I am directly and full responsible to this facility for all medical bills submitted by them for

service rendered to me and that this agreement is made solely for this facility’s additional protection and in

consideration of their awaiting payment. I further understand that such payment is not contingent on any

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

I agree to promptly notify said diagnostic facility of any change or addition of attorney(s) used by me in connection

with this accident. I instruct my attorney and all superseding attorneys to do the same and to promptly deliver a

copy of this lien to any such substituted or added attorney(s).

______ (initials) I understand that I need to provide my healthcare insurance card as a primary

or secondary means of payment. I may be liable for all co-pays/deductibles/penalties or

possibly the entire amount due.

I hereby authorize my attorney to forward this LOP to this facility for any unpaid bills that I

incur.

Please acknowledge this letter by signing below and returning to the diagnostic facility. I have been advised that

if my attorney does not wish to cooperate in protecting the diagnostic facility’s interest, the diagnostic facility will

not await payment but may declare the entire balance due and payable and/or may refuse to perform services.

Patient’s Name: ________________________________________________

Date:_

Patient’s Signature: ______________________________________________

_____________________

The undersigned, being the attorney of record or authorized representative for the above named patient, hereby

agrees to observe all the terms above and agrees to withhold such sums from any settlement, judgment or verdict

as may be necessary to adequately protect and fully compensate the facility named above. Attorney further

agrees that in the event this lien is litigation that the prevailing part will be awarded attorney fees and costs.

Attorney is required to advise if there are any changes in insurance or case status. We are also to be notified if

your firm discontinues to represent the above named client for any reason. Attorney shall provide a fully executed

settlement statement/copy of release/copy of settlement check at time of disbursement. Attorney further agrees to

provide status updates every three months and upon receipt of settlement, make payment to this facility within 10

business days.

Attorney/Representative’s Name: _________________________________________

Letter Of Protection Template