ABSOLUTE PT LIEN STATEMENT

AUTHORIZATION TO SET UP A LIEN AND CONSTRUCTIVE TRUST FOR HEALTHCARE SERVICES AUTHORIZATION TO PAY HEALTHCARE SERVICES FEES

To: Attorney at Law:

I, _____________, (patient) do hereby authorize ABSOLUTE PHYSICAL THERAPY & REHAB CENTER, INC., (Healthcare Provider) to furnish you, my attorney, with a full report of healthcare provider evaluations, progress reports, daily treatment notes, diagnosis, etc.,

of myself in regard to the accident or incident on ___________________ (date) in which I was involved.

Date

I hereby authorize and order you, my attorney, to pay directly to ABSOLUTE PHYSICAL THERAPY & REHAB CENTER, INC. such sums as may be due and owing him/her for medical services rendered to me in connection with the injuries suffered by me in the accident, and to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect the doctor. Such medical services shall be meant to include, but not limited to, treatments heretofore or hereafter rendered up to the time of the settlement or recovery, as well as those medical reports, consultations over the telephone, depositions and court appearances on my behalf. I hereby further give a lien on my case to ABSOLUTE PHYSICAL THERAPY & REHAB CENTER, INC. 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 hereby acknowledge that I have discussed the fees that have been or will be charged to me for the services rendered by ABSOLUTE PHYSICAL THERAPY & REHAB CENTER, INC. and I agree that such charges are reasonable and fair.

I fully understand that I am directly, personally and fully responsible to ABSOLUTE PHYSICAL THERAPY & REHAB CENTER, INC. for all medical bills submitted for services rendered to me regardless of the outcome of the case, and that this agreement is made solely for additional protection of ABSOLUTE PHYSICAL THERAPY & REHAB CENTER, INC. and in consideration of his or her awaiting payment. I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee. In the event that any action is instituted to enforce any of the terms and provisions contained herein, the prevailing party in such action shall be entitled to recover reasonable attorney's fees and costs of suit.

This lien and trust is for a valid consideration and is irrevocable.

Date:

Date

Patient's Signature:

Parent or Guardian if patient is minor:

The following information is required prior to your receipt of a narrative report and itemized billing.

Defendants Insurance Company

Address and Telephone

Adjuster

File or Claim Number

Defendant Insured

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 IN TRUST from any settlement, judgment or verdict as may be necessary to adequately protect ABSOLUTE PHYSICAL THERAPY & REHAB CENTER, INC. named above. Attorney further agrees that in the event this lien is litigated, the prevailing party will be awarded attorney fees and costs. In the event of any substitution or association of attorneys in the representation of the above patient, the undersigned agrees to notify any subsequent or additional attorney of the terms and conditions of this agreement and to obtain such substituted or associated attorney's signature to this agreement.

Date:

Date

Attorney's Signature

Mr. or Ms. Attorney: Please date, sign and return one copy to ABSOLUTE PHYSICAL THERAPY & REHAB CENTER, INC. at once. Keep one copy for your records.