Irrevocable Doctor's Lien and Assignment of Right to Recovery

In consideration and exchange for not having to immediately pay a debt owed and in consideration for receiving future care at or by Daniel O. Cook, D.C. on whose letterhead this document is printed (hereafter “Clinic”), I, the undersigned, hereby assign and convey to the Clinic a legal and equitable interest in any and all causes of action or rights of recovery I may have arising out of that certain accident or injury-producing event which occurred on or about the ____ day of ___________, 20____, to the full extent to the cost and treatment provided me by the Clinic.

Date

I hereby authorize and direct my attorney(s) to hold in trust, and pay directly to the Clinic such sums as may be due and owing the Clinic for treatment and other professional services rendered me both by reason of the accident and by reason of any other bills that are due the Clinic and to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately pay and protect the Clinic. I, hereby further give, grant, and convey a lien on my case to the Clinic against any and all proceeds of any and all causes of action, settlements, judgment or verdicts which may be paid to or through my attorney, or myself, as the result of the injuries of conditions for which I have been treated by the Clinic.

I fully understand that I am directly and fully responsible to the Clinic for all bills incurred for services rendered me, and that this agreement is made solely for the Clinic’s additional protection and in consideration for the Clinic’s waiting for payment. I further understand that payment of services rendered by the Clinic is not contingent on any settlement, judgment or verdict by which I may eventually recover. I am personally responsible for my bills, regardless of the outcome of any legal claim or case.

I fully understand that if my attorney(s) does not protect the Clinic’s interest, the Clinic may require me to make payments on a current basis. The Clinic may also bring a cause of action against my attorney(s) for failing to honor this binding and irrevocable agreement between the Clinic and me.

I further understand and agree that the Clinic is not responsible for paying any of my attorney fees and the Clinic does not agree to pay my attorney(s) any attorney fees for honoring this agreement between the Clinic and me.

I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT AND I AM VOLUNTARILY SIGNING THIS DOCUMENT. I AM DIRECTING MY ATTORNEY(S) TO PROTECT THE CLINIC’S AND DOCTOR’S INTEREST AT TIME OF SETTLEMENT AND I AM ASSIGNING AND CONVEYING CERTAIN LEGAL RIGHTS OVER TO THE CLINIC. 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 ALSO KNOW I MAY NOT REVOKE THIS AGREEMENT AT ANY TIME WITHOUT PRIOR WRITTEN AUTHORIZATION FROM THE CLINIC. I UNDERSTAND THAT AMONG OTHER THINGS, THIS IS A BINDING AND ENFORCEABLE CONTRACT, ASSIGNMENT, AND LIEN.

Name*

Patient Signature*

Date *

Please do not submit any Protected Health Information (PHI).

DC Chiropractic Center

Address

1765 State St a,
Salem, OR 97301

Phone

(503) 585-2585

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Monday

9:00 am - 6:00 pm

Tuesday

9:00 am - 4:00 pm

Wednesday

9:00 am - 6:00 pm

Thursday

9:00 am - 4:00 pm

Friday

9:00 am - 6:00 pm

Saturday

Closed

Sunday

Closed

We look forward to hearing from you

Please do not submit any Protected Health Information (PHI).