This Release and Settlement Agreement is between a patient and a medical provider who agrees to render services to the patient and receive payment through a settlement which the patient receives from an insurance company. This settlement agreement sets forth the date of any signed Lien and Insurance Assignment and the total amount due for the rendered services. It also sets out that this is the final agreement between the parties. It is imperative that this agreement be clearly set out in writing. A written Release and Settlement Agreement for Patient Medical Services will prove invaluable in the event of future disagreements or misunderstandings surrounding the patient's bill.

This Release and Settlement Agreement (Patient Medical Expenses) contains the following:

• Parties: Names of the patient and the medical center and/or medical professional who rendered services;
• Services: Specific medical services which were provided to the patient and the amount due for those services;
• Release: Sets forth that any lien in connection with the medical services is now released;
• Signatures: This agreement must be signed by the patient and agreed to and accepted by the medical provider.

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This attorney-prepared packet contains:

1. General Instructions
2. Release and Settlement Agreement (Patient Medical Expenses)

State Law Compliance: This form complies with the laws of all states