SCSR Medical Lien Acknowledgement - Patient

  • Provider: Southern California Sports Rehabilitation
    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 Southern California Sports Rehabilitation (SCSR) 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 SCSR such sums as may be due and owning SCSR for therapy services rendered to me both by reason of this accident and by the reason of any bills that are due to SCSR and to withhold such sums from any settlement, judgement or verdict as may be necessary to adequately protect SCSR. And I hereby further give a lien on my case to SCSR 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 SCSR for all medical bills submitted by SCSR for therapy services rendered to me and that this agreement is made solely for said SCSR’s additional protection and in consideration for SCSR 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.

  • Patient's signature

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