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Patient Name:



RE: Medical Reports and Physical Therapy Lien

For:



I do hereby authorize the above Physical Therapy Practice to furnish you,

with a full report of examination, diagnosis,


treatment, prognosis, etc., of myself in regard to the physical therapy which I am receiving as it

pertains to a diagnosis of:


 

I hereby authorize and direct you,

to pay

directly to said Physical Therapy Practice such sums as may be due and owing Western Massachusetts Physical Therapy. P.C. for medical service rendered by me both by reason of accident and/or by reason of any other bills that are due Western Massachusetts Physical Therapy's office and to withhold such sums from any sums, settlement, judgment or verdict as may be necessary to adequately protect said Physical Therapy Practice. And I hereby further give a lien on my case to said Physical Therapy Practice any and all proceeds of any sums, settlement, judgment or verdict which may be paid to myself as a result of the injuries for which I have been treated or injuries in connection therewith, and/or as it relates to the above diagnosis.

 

I fully understand that I am directly responsible to said Physical Therapy Practice for all medical bills submitted by them for the services rendered and that this agreement is made solely for said therapists additional protection and in consideration of them 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 fees, and that a payment on the account is due and payable on demand.

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