Lien Agreement

Client / Patient – Terms & Conditions

I hereby authorize Nationwide Lien Pharmacy Services, Inc., dba: Nationwide Rx Lien Services (the Company), to furnish my attorney with billing statements for any/all services rendered as a result of my injuries or conditions from the incident noted above.

I hereby authorize and my attorney to pay to the Company such sums that may be owed for services it has provided to me. In addition, I hereby irrevocably grant the Company a lien on my claims and any/all proceeds of my settlement, arbitration award, judgement, or verdict that relates in any way to the injuries or conditions for which I have received services from the Company.

I understand and agree that I am fully responsible for all bills submitted by the Company for services provided to me. I also understand that such responsibility is not contingent on my obtaining any verdict, settlement, award, or judgement for my claims on the above referenced incident. I hereby waive and agree to toll the statute of limitations for the Company to bring an action against me or my estate to collect what is due.

I agree to promptly notify the Company of any change or addition of attorney(s) used by me in connection with this incident or injury, and I instruct my attorney to do the same and to promptly deliver a copy of this Lien Agreement to any such substituted or added attorney(s).

I further instruct my attorney to promptly notify the Company in writing within ten (10) days after any settlement, arbitration award, judgment, verdict and/or receipt of payment, with respect to any of my claims relating to the above referenced incident. I further instruct my attorney to honor the lien by paying the Company’s bills for my services promptly upon receipt of any settlement funds, collections, or other payments upon a judgement, arbitration award or verdict.

Law Firm / Attorney – Terms & Conditions

The undersigned, being an attorney of record for the above client, hereby agrees to observe all the terms of the above and agrees to withhold or arrange for payment to the Company of such sums from any settlement, judgement, arbitration award, verdict, other payment, or fund for payment by a defendant, insurer, indemnitor, or other party, for services rendered.

If the undersigned should withdraw, be discharged, or substituted out as attorney for the client, the undersigned shall remain accountable to the Company under this Lien Agreement unless and until the undersigned attorney and the new counsel gives the Company specific written notice of the change. The undersigned attorney further agrees that in the event this lien is litigated, the prevailing party will be awarded attorney’s fees and costs.