I irrevocably agree to list McQueen Pain Ventures, McQueen Professional Group and McQueen Anesthesia Group on any settlement draft(s)/check(s). I also agree that this lien and all the rights granted to McQueen Pain Ventures, McQueen Professional Group and McQueen Anesthesia Group will continue in full force and be binding upon me and counsel if I change attorneys in the future. Should I change attorneys, I will notify McQueen Pain Ventures, McQueen Professional Group and McQueen Anesthesia Group promptly of the same. Should I not obtain new counsel, or not provide current whereabouts within a reasonable period of time to McQueen Pain Ventures, McQueen Professional Group and McQueen Anesthesia Group, then McQueen Pain Ventures, McQueen Professional Group and McQueen Anesthesia Group may deal directly with any applicable insurance company, so as to satisfy said lien obligation.

I also provide, by signing below, durable power of attorney on behalf of McQueen Pain Ventures, McQueen Professional Group and McQueen Anesthesia Group to be able to endorse any draft/check on my behalf, so that any outstanding amount due and owing McQueen Pain Ventures, McQueen Professional Group and McQueen Anesthesia Group can be satisfied without additional signature from me.

I agree and acknowledge that this lien can and may be sold and reassigned and recognize that the purchaser of this lien will be entitled to all rights, as expressed herein

I understand that I am directly and fully responsible to McQueen Pain Ventures, McQueen Professional Group and McQueen Anesthesia Group for all amounts due and owing and that this lien is being provided solely as additional protection to McQueen Pain Ventures, McQueen Professional Group and McQueen Anesthesia Group. I provide this lien in consideration of McQueen Pain Ventures, McQueen Professional Group and McQueen Anesthesia Group waiting on payment. I further recognize that payment to McQueen Pain Ventures, McQueen Professional Group and McQueen Anesthesia Group is not contingent upon any settlement, judgment or verdict that I may or may not eventually obtain as reimbursement of said fee.

I finally agree that I shall not submit, without express permission from McQueen Pain Ventures, McQueen Professional Group and McQueen Anesthesia Group, the medical bills arising out of such lien for payment to any private health plan or state or federal government sponsored health plan, including but not limited to, Medicare and Medicaid. I also further agree that I will see McQueen Pain Ventures, McQueen Professional Group and McQueen Anesthesia Group’s medical providers on a lien basis, and allow billing to my private health insurance if I have any, and only if my health insurance allows balanced billing. Should my health insurance not allow balanced billing, I agree to forego submission to my health insurance, and allow my attorney to pay medical provider all expenses out of my settlement proceeds. If McQueen Pain Ventures, McQueen Professional Group and McQueen Anesthesia Group elects to bill an indemnification plan, neither my attorney nor I will assert a claim for a pro rata of attorney fees for collection of settlement funds or make a claim for reduction under Samaritan vs. LaBombard.

I further understand that as part of the process of recording a lien/assignment, I will receive certified mail with a copy of the lien/assignment enclosed and that this copy is for my own records and does not require any response on my part.

(Patient’s or guardian’s signature. If guardian, please indicate same)

The undersigned, being attorney of record, does hereby acknowledge receipt of the above lien, does further acknowledge good and valuable consideration to McQueen Pain Ventures, McQueen Professional Group and McQueen Anesthesia Group by acceptance of this lien, and does agree to honor the same to protect McQueen Pain Ventures, McQueen Professional Group and McQueen Anesthesia Group adequately.