Registration – Assignments of Proceeds and/or Lien For Medical Services

    • Texas Regional Clinic

      8301 Katy Freeway | Ste 101 | Houston, Texas

      Scheduling Direct Line: (713)489-1741

      Fax: (713)984-8481



      (“this Lien”)

    • Date Format: MM slash DD slash YYYY
    • Date Format: MM slash DD slash YYYY

    • II. Certification, Authorization and Release in Accordance with HIPAA.

      The above-referenced patient (“Patient”) and Attorney of Record (“Attorney”) certify that the information provided in this Lien is correct and complete and acknowledge that this is a lien for Texas Regional Center, LLC to secure payment for rendered medical-related services in connection to Patient’s personal injury claim. Patient understands that, in accordance with the Health Information Portability and Accountability Act of 1996 (“HIPAA”), Patient’s medical information relating to this personal injury claim may be shared to manage and expedite Patient’s medical diagnosis and treatment. Patient authorizes Patient’s physician, Attorney and Texas Regional Center to secure, release and disclose such medical treatment information with companies and individuals deemed necessary, and further agrees that examinations, diagnoses, medical treatments, films and reports can be shared with parties involved in patients claim by Texas Regional Center. Attorney acknowledges and represents to Texas Regional Center that Attorney has obtained a Release of Medical Information (“Release”) from Pa- tient for purposes of communications regarding Patient’s medical information and that Texas Regional Center is covered by such Release, and as a result Texas Regional Center is authorized to receive and release such information.

    • III. Assignment and/or Lien for Medical Services.

      Patient understands that the medical services, supplies and treatment Patient is receiving as a part of the ongoing personal injury claim shall be billed as a lien, as authorized by applicable state law and practice. Patient hereby irrevocably authorizes and directs Attorney, to pay directly to Texas Regional Center, such sums due and owing for services rendered to Patient by reason of the accident from which the claim arises, and by reason of any other bills that are due to Texas Regional Center, and to withhold such sums from any claim, settlement, judgement or verdict as may be necessary to adequately protect and clear Patient’s account with Texas Regional Center prior to and before any fees are paid to Attorney out of said settlement. By this assignment, Patient gives this Lien on Patient’s claim to Texas Regional Center against any and all proceeds of any settlement, judgement or verdict that may be paid to Attorney, or Patient or to another individual on Patient’s behalf, that results from the injuries or injuries and illnesses in connection thereto, for which Patient has been treated. If Patient assigns any or all of the Patient’s rights to his or her claim or a portion thereof, Patient agrees to notify Texas Regional Center, in writing, at the below address within thirty (30) days from the date of assignment. If another attorney is substituted in this matter, the new attorney shall honor this Lien as inherent to Patient’s claim, and notice of, and substitution of, this Lien shall be both Patient and Attorney’s responsibility.

    • IV. Notice

      This Lien may be executed in one or more counterparts, ease of which shall be deemed to be an original but all of which together will constitute one and the same instrument. It is understood and agreed that a copy of this Lien shall have the same force and effect as the original. Texas Regional Center is authorized, but not required, to file a copy of this Lien.

    • V. Payment Responsibility

      Patient understands that Patient remains personally responsible to Texas Regional Center for all medical bills submitted for service rendered to Patient and that this Lien is made solely for Texas Regional Center protection and in consideration of awaiting payment. Patient further understands that such payment is not contingent on any claim, settlement, judgement or verdict by which Patient may eventually recover said fee. Patient shall notify Texas Regional Center of any payment received by Patient for medical services from an insurance company or any other source. Payments will be forwarded to Texas Regional Center as requested. Patient further understands and accepts financial responsibility for payment of all accounts with Texas Regional Center. Patient understands that the legal settlement may pay all, part, or none of Patient’s account(s) and that Patient is responsible for complete payment of all account(s). Patient understands that Patient is financially responsible for any amount unpaid by this assignment of proceeds and/or Lien, as may be authorized by applicable state law and practice. By signing this document Patient fully understands all provisions set forth in this.

    • Date Format: MM slash DD slash YYYY
      (Today's Date)
    • Your Signature (Type Your Name)

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