Doctors Lien

NOTICE OF DOCTOR'S LIEN

I do hereby authorize Dr. Anthony T. Rayman to furnish you, my attorney, with a full report of his examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accident in which I was recently involved.

I hereby authorize and direct you, my attorney, to pay directly to said doctor such sums as may be due and owing him for medical service rendered both by reason of this accident and by reason of any other bills that are due to his office and to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect and fully compensate said doctor. And 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 for which I have been treated or injuries in connection therewith.

I fully understand that I am directly and fully responsible 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. And I further understand that such payment is not contingent on any settlement, judgment, or verdict by which I may eventually recover said fee.

I agree to promptly notify said doctor of any change or addition of attorney(s) used by me in connection with this accident, and I instruct my attorney to do the same and to promptly deliver a copy of this lien to any such substituted or added attorney (s).

Please acknowledge this letter by signing below and returning to the doctor's office. I have been advised that 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.

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 and fully compensate said doctor above-named. Attorney further agrees that in the event this lien is litigated that the prevailing party will be awarded attorney fees and costs.

Please date, sign and return one copy to doctor's office. Also keep one copy for your records.

Keystone Chiropractic 3001 I Street, Sacramento, CA 95816 (916) 452-5055

[email protected] fax (916) 244-0606

Thank you for taking the time to fill out this form.

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OFFICE HOURS AND LOCATIONS

Our Regular Schedule

Monday

8am - 11am

3pm - 6pm

Tuesday

8am - 11am

2pm - 5pm

Wednesday

Closed

3pm - 6:30pm

Thursday

By Appointment Only

Friday

8am - 12pm

Saturday

By Appointment Only

Sunday

Closed

Closed

Monday
8am - 11am 3pm - 6pm
Tuesday
8am - 11am 2pm - 5pm
Wednesday
Closed 3pm - 6:30pm
Thursday
By Appointment Only
Friday
8am - 12pm
Saturday
By Appointment Only
Sunday
Closed Closed