LYG AUTHORIZATION OF DIRECT PAYMENT AND DOCTOR’S LIEN

  • PERSONAL INJURY ONLY/SOLO LESIONES PERSONALES

    Provider/Proveedor: LYG/Dragon Eye 1809 E. Dyer Road. Suite 313, Santa Ana, CA 92705 Phone (949) 975-1900 * Fax (949) 975-0070 * Referrals@scsrtherapy.net
  • I do hereby authorize LYG, A Medical Corporation to furnish you a full report of the Initial Evaluation, Re-Evaluation, Progress Notes and Treatment Documentation of myself in regard to the accident in which I was involved.

    I hereby authorize and direct you, my attorney, to pay directly to LYG, A Medical Corporation such sums as may be due and owning LYG, A Medical Corporation for therapy services rendered to me both by reason of this accident and by the reason of any bills that are due to LYG, A Medical Corporation and to withhold such sums from any settlement, judgement or verdict as may be necessary to adequately protect LYG, A Medical Corporation. And I hereby further give a lien on my case to LYG, A Medical Corporation against any and all proceeds of any settlement, judgment or verdict which may be paid to you, my attorney or myself as the result of the injuries for which I have been treated or injuries in connection therewith.

    I fully understand that I am direct and fully responsible for LYG, A Medical Corporation for all medical bills submitted by LYG, A Medical Corporation for therapy services rendered to me and that this agreement is made solely for said LYG, A Medical Corporation’s additional protection and in consideration for LYG, A Medical Corporation awaiting payment. And I further understand that such payment is not contingent on any settlement, judgement or verdict by which I may eventually recover said fee.


    Por la presente autorizo ​​a LYG, A Medical Corporation a proporcionarle un informe completo de la Inicial Evaluación, reevaluación, notas de progreso y documentación de tratamiento de mí mismo con respecto al accidente en el que estuve involucrado.

    Por la presente, autorizo ​​y le ordeno a usted, mi abogado, que pague directamente a LYG, A Medical Corporation las sumas adeudadas y propias. LYG, A Medical Corporation para los servicios de terapia que me prestaron tanto por este accidente como por cualquier factura que se deben a LYG, A Medical Corporation y a retener tales sumas de cualquier acuerdo, sentencia o veredicto que sea necesario para proteger adecuadamente LYG, A Medical Corporation. Y por la presente doy un derecho de retención sobre mi caso a LYG, A Medical Corporation contra todos y cada uno producto de cualquier acuerdo, sentencia o veredicto que se le pueda pagar a usted, a mi abogado oa mí mismo como resultado de las lesiones por las cuales me han tratado o lesiones relacionadas con ellas.

    Entiendo completamente que soy directo y totalmente responsable de LYG, A Medical Corporation por todas las facturas médicas enviadas por LYG, A Medical Corporation para servicios de terapia prestados a mí y que este acuerdo se realiza únicamente para la protección adicional de dicho LYG, A Medical Corporation y en consideración para LYG, A Medical Corporation en espera de pago. Y entiendo además que dicho pago no es dependiendo de cualquier acuerdo, sentencia o veredicto por el cual eventualmente pueda recuperar dicha tarifa.

MAIN OFFICE

1809 E. Dyer Rd. #313
Santa Ana CA 92705

Fax (949) 975-0070

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No Referral Needed

MAIN OFFICE

1809 E. Dyer Rd. #313
Santa Ana CA 92705