Notice Of Doctor's Lien----Attorney Signature

VORTEX PSYCHIATRY TMS THERAPY & KETMAINE INFUSION CENTER

EMAIL: LEGAL@VORTEXPSYCHIATRY.COM

Telephone 925-648-2650

In preparation for your first visit with Said A. Ibrahimi, M.D., Vortex Psychiatry, we will need some information.

Once we have verified your insurance benefits, a member of our staff will contact you as soon as possible to schedule your appointment. Please complete the information below.

Patient First and Last Name

Patient Date Of Birth

Patient Contact Phone Number

Patient Social Security Number

Patient Email Address

Date of Injury/Accident

Attorney Name

Law Firm Name

Law Firm Name Phone Number

Law Firm Email Address

Attorney's Signature

** note patient will sign separately**

Date

I do hereby authorize Vortex Psychiatry (Said A Ibrahimi MD) 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 me both by reason of this accident and by reason of any other bills that are due 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 of the injuries for which I have been treated or injuries in connection therewith. I fully understand that I am directly and fully responsible to said doctor 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 promptly deliver a copy of this lien to any 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. I further direct my attorney to pay said doctor one hundred percent of all medical costs associated with my treatment. I understand all costs associated with my care and believe them to be necessary, reasonable, and customary.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. The attorney further agrees that in the event this lien is litigated the prevailing party will be awarded attorney fees and costs.

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