WHEREAS, Patient was injured in an accident or incident and is seeking medical/diagnostic care from Provider forhis/her injuries; and

WHEREAS, Attorney represents Patient in a claim or lawsuit (the “Legal Action”) to recover damages arising from the accident or incident, including medical/diagnostic expenses; and

WHEREAS, Provider has agreed to render treatment to Patient without requiring payment at the time of rendering services; NOW THEREFORE, in consideration of the premises, the mutual covenants contained herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. Patient acknowledges that, in accordance with the Health Information Portability and Accountability Act of 1996 ("HIPAA"), Patient's medical information relating to the Legal Action may be shared to manage and expedite Patient's medical treatment. Patient authorizes Provider to release any information needed by Attorney to pursue the Legal Action, including without limitation information (including billing information) regarding the examination, treatment, procedures and services rendered by Provider. Patient authorizes Attorney to secure, release, and disclose such medical treatment information with individuals and entities as deemed necessary to pursue the Legal Action, and Patient further agrees that examinations, diagnoses, medical treatments, films and reports can be shared with necessary parties involved in the Legal Attorney acknowledges that Attorney has obtained a Release of Medical Information from Patient for purposes of communications regarding Patient's medical information. Patient expressly authorizes Attorney to keep Provider advised of the progress of the Legal Action at reasonable intervals.
2. Patient hereby grants to Provider a lien on the proceeds of any settlement, judgment or verdict in the Legal Action which may be paid to Patient or to Attorney by a third party as compensation for the injuries for which the health care services is subject to a lien pursuant to N.C.G.S. 44-49 et. seq. Patient hereby notifies Attorneythat Patient is giving Provider a lien on these benefits or settlement proceeds, and Patient hereby authorizes anddirects Attorney to withhold such funds from any settlement, verdict or judgment that is rendered in the Legal Action and pay Provider directly from any such proceeds any sums due for medical services rendered to This lien is irrevocable and can only be satisfied by full payment of all sums due for medical services rendered, unless Provider expressly agrees otherwise in writing. Patient understands that any settlement, verdict or judgment proceeds cannot be disbursed to Patient without first satisfying this lien.
3. Should a dispute arise regarding payment of Provider’s charges, Patient authorizes and directs Attorney to hold in escrow all monies sufficient to satisfy this lien until the dispute can be resolved. Patient and Attorneyacknowledge that it would be a

of Attorney’s ethical duties to disburse the disputed funds prior to resolution of the lien dispute.

4. Patient understands and agrees that even though this lien has been given, Patient remains personally responsible for payment in full of Provider’s fees for all services rendered, including without limitation fees for services provided at Provider’s office locations (e.g., exams and office visits, x-rays, CT, MRIs, injections, DME, PT, supplies, medicine through Comprehensive Rx or Meds Management Group) and fees for Provider’s services (e.g., surgical services) provided at any other facility. Patient is solely responsible for making appropriate arrangements for payment of such fees, including but not limited to insurance benefits. Patient acknowledges thatthis obligation to pay Provider’s fees is not dependent on the outcome of Patient’s court case. Provider and Patientagree that in the event it is necessary to enforce this Agreement in a court of law, then in addition to all damages and costs, the prevailing party shall be entitled to reasonable attorney's fees in the amount of 25% of the amount at issue.
5. Provider hereby agrees to await Patient’s payment of Provider’s fees until the Legal Action is resolved bysettlement, judgment or verdict, except to the extent that payment is available from Patient’s medical insurance.

Patient and Attorney hereby expressly acknowledge the validity and enforceability of Provider’s lien as of the date Provider’s treatment of Patient commences and expressly agree to be bound by the terms of this Agreement. Patient and Attorney expressly acknowledge that this Agreement constitutes actual notice of Provider’s medical records and bills, and Patient waives the right to assert any defense to the validity and enforceability of Provider’s lien based on Provider’s failure to perfect the lien in accordance with N.C.G.S. 44-49  et. seq. Legal Action in accordance with the requirements of N.C.G.S. 44-49 et. seq. The parties agree that a photocopy of this Agreement shall be considered valid notice of the lien. 

6. If Patient should retain new legal counsel, Attorney and Patient agree to notify Provider immediately uponsuch Patient shall direct such new legal counsel to execute another copy of this Agreement and deliver same to Provider.
7. This Agreement cannot be modified, amended or revoked by any party without the express written consent of all

Acknowledgement by Patient

PATIENT acknowledge that this Agreement must be signed by myself before any medical services will be provided to Patient by Provider.

TO PATIENT’S ATTORNEY: Please sign, date and return one copy of this Agreement to Provider. Keep one copy for your record.