Lien Form

Lien Inception Date*

Date of Accident*

Patient First Name*

Patient Last Name*

Patient Date of Birth*

Attorney First Name*

Attorney Last Name*

Attorney Firm*

Firm Address*

Street Address

City

State

Postal / Zip Code

Attorney Phone

Attorney Email

Attorney Fax*

Description of Service*

I do hereby authorize and direct my attorney to pay directly to Sun Radiology. such sums as may be due and owing for medical services rendered to me by reason of plaintiff’s claim for personal injury, which occurred, on or about. I do further assign and irrevocably grant a lien to Sun Radiology. for any sums now due or to become due to me as a result of any settlement, judgment, or verdict arising from said accident in order to satisfy my obligations hereunder and to pay the sums due to Sun Radiology. for services rendered to me. I understand that I am fully responsible for the services rendered to me arising out of this accident, that my obligation shall not be extinguished by the lien or assignment, and that my payment of the obligation is not contingent or in any way dependent upon any settlement or judgment, which may be awarded to me. I waive and relinquish any right, which I may have to rescind, or seek the rescission of this agreement and further agree that this agreement shall be binding upon all of my successors, assigns, agents, and attorneys. I have been advised that Sun Radiology will not discount or reduce its fee for medical services rendered as a result of my signing this agreement, and I agree to pay for these services in full.

I also agree that this lien will not affect Sun Radiology. right to use any other legal remedies, which it has to collect the amounts owed for the medical services it has provided to me. I understand that this includes the right to file a legal action against me directly to recover the amounts owed, either with or without enforcing this lien. I agree that if Sun Radiology. to file a legal action against me without enforcing this lien, that this will not make the lien invalid.

By signing below, you certify that you agree with the above statements in this agreement.

Patient's First Name

Patient's Last Name

Patient’s Signature

Date*

By signing this below, you are hereby certifying that you are the individual (patient) stated above and you authorize Sun Radiology to process this request.

Attorney's First Name

Attorney's Last Name

Attorney’s Signature

Date*

The undersigned being the attorney of record for the above patient does hereby agree to observe all terms of the above and agrees to withhold such sums from any settlement, judgment, and/or verdict as may be necessary to adequately protect Sun Radiology.