Attorney Lien Form - Items marked with * are required.

I do hereby authorize and direct my attorney to pay directly to Imaging Healthcare Specialists Medical Group Inc. 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 Imaging Healthcare Specialists Medical Group Inc. 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 Imaging Healthcare Specialists Medical Group Inc. 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 acknowledge that I will be billed ordinary and customary rates charged by Imaging Healthcare Specialists Medical Group Inc. to other patients under its Global Fee Schedule, which Patient acknowledges having received and which may change from time to time. I will be responsible for billing any medical insurance plans for reimbursement of services. 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 Imaging Healthcare Specialists Medical Group Inc. 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 Imaging Healthcare Specialists Medical Group Inc. 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 Imaging Healthcare Specialists Medical Group Inc. decides to file a legal action against me without enforcing this lien, that this will not make the lien invalid.

By clicking the submit button, you are hereby certifying that you are the individual stated above and you authorize Imaging Healthcare Specialists to process this request. This action takes the place of your signature. Please refer to our privacy policy for our specific privacy practices.