Professional Service Lien

Please correct the errors described below.

do hereby authorize Enrique Umpierre, MD PLLC to furnish you (upon request), my attorney and/or my insurance company, with a full report of the examination, diagnosis, treatment, prognosis, etc. of myself in regards to the accident on

I authorize and direct you, my attorney, to pay directly to Enrique Umpierre, MD PLLC such sums as may be due and owing them for medical services rendered to me both by reason of accident and by reason of any other bills that are due to them and to withhold such sums from any settlement, judgment of verdict which may be necessary to adequately protect their bills. I hereby give lien on my case to Enrique Umpierre, MD PLLC against any and all proceeds of any settlement, judgment of verdict which may be paid to my attorney or to myself as the result of the injuries for which I have been treated or injuries connected therewith. I authorize my attorney or any third party liability carrier to disclose the settlement status, settlement statement and/or a copy of the settlement check if requested for our purposes. At the time of the settlement, the attorney is instructed that this office shall be furnished separate checks for the medical services which they have rendered for full balance due at that time. Upon settlement of the underlying, the attorney’s office will disburse funds directly to Enrique Umpierre, MD PLLC. I also fully understand that I am directly and fully responsible for all medical bills submitted by them for services rendered to me and that this agreement is made solely for Enrique Umpierre, MD PLLC. I further understand that such payment is not contingent of any settlement, judgment of verdict by which I may eventually recover said fee. I also fully understand that in the event that I should decide to secure a different attorney, other than the one representing me at the time of this agreement, he or she will honor this disbursement. Any photocopy will be valid as the original and any legal expenses, which occur as a result of this lien, will be paid to the prevailing party. I understand that I am being treated for injuries sustained in a motor vehicle accident and that failure to keep my appointments may jeopardize the insurance carrier’s responsibility for medical costs and/or compensation for pain and suffering. . I understand that this office is extending me credit for treatment and that if I miss three (3) office visits without a reasonable excuse all bills may be due immediately

I further understand that if my case does not settle in three (3) years, I will be obligated to make monthly payments of 15% of the balance or $100.00 whichever is greater to Enrique Umpierre, MD PA until my balance is paid in full or my case is settled. I understand that I will be assessed a fee of 35% of my current balance should my account be forwarded to a collection agency.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

ATTORNEY ACKNOWLEDGEMENT

The undersigned, being attorney of record for the above patient, does hereby acknowledge receipt of this document.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

ATTENTION ATTORNEY: Please return signed copy to central florida pain & rehab clinic.

Spanish Version: Por motivos legales el consentimiento del paciente debe estar consignado en este documento en inglés, pero si usted no tiene claridad con respecto a algo aquí relacionado, favor solicite la versión en español del mismo a nuestro personal.

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