I understand this may include a report of my prior medical history, examination, diagnosis, treatment, prognosis, and/or recommendations for future treatment. I agree that Dr. Supraja Thota, MD may disclose my protected health information to the above-listed attorney/insurance carrier and I hereby waive any associated privilege.
I agree to provide this priority lien to Dr. Supraja Thota, MD on any settlement, claim, judgment or verdict as a result of my accident/illness. I accordingly direct you, my attorney/insurance carrier, to pay directly to Dr. Supraja Thota, MD such sums as may be due and owing them for all services rendered to me by reason of this accident/illness. I request you pay Dr. Supraja Thota, MD within sixty (60) days of receipt of any proceeds and satisfy this lien in full before disbursing any funds to me or any other claimant against said funds. I authorize and instruct you to satisfy this lien from my client trust account and/or to withhold sums from any settlement, judgment, or verdict as may be necessary to pay said Dr. Supraja Thota, MD’s billings in full.
I acknowledge and agree that I, as the patient, am directly and fully financially responsible to Dr. Supraja Thota, MD for all services rendered to me. I understand that payment is not contingent on any settlement, claim, judgment, or verdict. I understand this lien is made solely for Dr. Supraja Thota, MD’s protections and in consideration for awaiting payment. I understand that by accepting this lien Dr. Supraja Thota, MD is not providing a guarantee of a diagnosis, treatment, prognosis or recommended future treatment.
I agree that it is my responsibility to apprise Dr. Supraja Thota, MD of all information regarding my claim and agree to respond to any such requests for information within thirty (30) days. I understand that if I do not respond to a request for information within thirty (30) days, or if Dr. Supraja Thota, MD is not paid for services rendered pursuant to this lien within sixty (60) days from my receipt of any proceeds and/or final billing, my account will accrue interest at a rate of twelve percent (12%) per annum from the date services were first rendered. Further, I agree to be responsible for all fees and costs incurred by Dr. Supraja Thota, MD to enforce this agreement. I wave any applicable statute of limitations to the enforcement and collection of this lien.
I understand that in the event I discharge my attorney prior to payment in full of all medical billings due to Dr. Supraja Thota, MD, my account will become immediately due and owing unless a new attorney is engaged and endorses this lien with thirty (30) days.
By signing below, I am agreeing to the above medical lien. I understand and agree all of the provisions of this Agreement shall remain in full force and effect until revoked by me in writing. I understand this lien is enforceable against me whether or not signed by my attorney/insurance carrier.
