Release & Settlement Agreement (Medical Expenses)

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This Release and Settlement Agreement (Patient Medical Expense) is between a patient and a medical provider who renders services but is paid after an insurance claim settlement. It is imperative that this type of agreement be clearly set out in writing.

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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.

Protect yourself and your family by using our attorney-prepared forms.

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
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.











Release and Settlement Agreement
(Patient Medical Expenses)







This Packet Includes:
1. General Instructions & Checklist;
2. Information; and
3. Release and Settlement Agreement
    (Patient Medical   Expenses)





 General Instructions & Checklist
Release And Settlement Agreement
(Patient Medical Expenses)



   The Provider and Patient should read the Agreement carefully.

   Both parties must sign the Agreement.  Fill in the blanks for addresses, account information, amount settled upon, and the actual amount owed.  Generally, there are at least two originals, signed by both parties so that each party can retain an Agreement with actual ink signatures.

   This form contains the language that is necessary to settle a medical bill for a lower amount than is due.  This frequently happens when a Patient for some reason needs to settle with a defendant in a lawsuit (usually because legal costs are getting too high) and it would be unjust for the Patient to pay the medical bill due based on the circumstances.  This form includes provision 5, which is specific to California law.  If this form is to be used in a state other than California, delete provision 5 and renumber the agreement.



   Laws regarding this Agreement may vary from state to state.  This form is not intended as a substitute for legal advice.  This form should only be considered a template and, unless you are an attorney, you should not use it before first consulting with an attorney to ensure that it addresses your particular situation.  An attorney should be consulted before negotiating any document with another party.

   The purchase and use of this form is subject to the “Disclaimers and Terms of Use” found at findlegalforms.com.



Information
Release and Settlement Agreement
(Patient Medical Expenses)

Personal Injury litigation can sometimes find an injured plaintiff in the position where continuing the law suit becomes a cost benefit analysis meaning a plaintiff has to consider whether the end award of a case is going to justify continuing to pay legal fees through that point.  Many times the answer is “no” and a plaintiff must then focus on maximizing settlement with the defendant and with the plaintiffs medical provider.

This is a comprehensive settlement agreement that can be used once the settlement dollars are determined so that the settlement is properly documented and can be used to straighten out any problems regarding this matter in the future (i.e., plaintiffs credit discrepancies).

No agreement can cover every situation and it is advised that if the person using this form is not an attorney, then they should consult an attorney first to tailor this agreement to fit the situation before using.






DISCLAIMER:

FindLegalForms, Inc. (“FLF”) is not a law firm and does not provide legal advice.  The use of these materials is not a substitute for legal advice. Only an attorney can provide legal advice.  An attorney should be consulted for all serious legal matters.  No Attorney-Client relationship is created by use of these materials.  



THESE MATERIALS ARE PROVIDED “AS-IS.  FLF DOES NOT GIVE ANY EXPRESS OR IMPLIED WARRANTIES OF MERCHANTABILITY, SUITABILITY OR COMPLETENESS FOR ANY OF THE MATERIALS FOR YOUR PARTICULAR NEEDS.  THE MATERIALS ARE USED AT YOUR OWN RISK.  IN NO EVENT WILL:  I) FLF, ITS AGENTS, PARTNERS, OR AFFILIATES; OR II) THE PROVIDERS, AUTHORS OR PUBLISHERS OF ITS MATERIALS, BE RESPONSIBLE OR LIABLE FOR ANY DIRECT, INDIRECT, INCIDENTAL, SPECIAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES (INCLUDING, BUT NOT LIMITED TO, PROCUREMENT OF SUBSTITUTE GOODS OR SERVICES; LOSS OF USE, DATE OR PROFITS; OR BUSINESS INTERRUPTION) HOWEVER USED AND ON ANY THEORY OF LIABILITY, WHETHER IN CONTRACT, STRICT LIABILITY, OR TORT (INCLUDING NEGLIGENCE OR OTHERWISE) ARISING IN ANY WAY OUT OF THE USE OF THESE MATERIALS. 

RELEASE AND SETTLEMENT AGREEMENT

      This RELEASE AND SETTLEMENT agreement (“Agreement”), is made on ____________________, by and between ____________________________, whose address is: __________________________________________________ (hereafter referred to as “Provider”) and _________________________________ whose address: (hereafter referred to as “Patient”).

      WHEREAS, Provider provided medical services to Patient as identified by file number ______________ (the “Services”); and

      WHEREAS, Patient signed, personally, and through Patients attorney, a Lien Form and Insurance Assignment executed ______________ that gave, in addition to other terms, Provider a lien against any and all proceeds of any settlement paid to Patient or Patients attorney as a result of the injuries for which Patient received the Services (the “Lien”);

      WHEREAS, Provider now asserts that the balance due for the Services is __________________________ ($___________) (the “Medical Bill”), which both parties acknowledge has resulted in a dispute that qualifies for settlement negotiations;

      WHEREAS, Provider warrants and represents that it has the exclusive legal right and authority to grant this Release and to enter into this Agreement, with Provider being authorized to release Patient from liability from the Lien and to settle the alleged amount due for the Services; and

      WHEREAS, Provider and Patient desire to compromise and fully and finally settle the amount due for the Services on the terms and conditions of this Agreement.

      NOW, THEREFORE, upon the mutual promises and covenants herein contained, the parties hereto agree as follows:

1.        Patient shall pay to Provider the sum of _________________ ($________) (the “Payment”) after the receipt of an executed copy of this Agreement.

2.      Provider agrees to accept the payment provided for in paragraph 1 as full satisfaction of the Medical Bill.

3.      Provider does hereby generally release and forever discharge Patient, and Patients attorney, their successors, and assigns (“Released Parties”) of and from any and all manner of claims, debts, costs, contracts, liens, accounts, demands, actions, suits, causes of actions, obligations, expenses, liabilities of every kind and nature, known or unknown, suspected or unsuspected, fixed or contingent, in law or in equity, arising out of or in any way connected with or related to the Medical Bill and the Lien, that Provider, its assigns and successors now has up to the date of this Agreement, or at anytime hereafter may have, against the Released Parties with regard to the Medical Bill and the Lien.

4.      The parties acknowledge that the disputed amount of the Medical Bill and the terms of the Lien serve as adequate consideration to support a valid accord and satisfaction, and that it is the parties intentions that this Agreement shall be effective as a full and final accord and satisfaction between parties, constituting full settlement of all claims of every nature to date in connection with the Medical Bill and the Lien.

5.      With respect to the foregoing release, Provider hereto hereby acknowledges and expressly waives and relinquishes any and all rights with respect to Section 1542 of the Civil Code of the State of California, which provides as follows:

A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH, IF KNOWN BY HIM, MUST HAVE MATERIALLY AFFECTED HIS SETTLEMENT WITH THE DEBTOR.
   
     6.   This Release and Agreement sets forth the entire understanding between the parties, and cannot be changed, modified or canceled except by an instrument signed by the party sought to be bound. Any controversy arising under this Agreement and the rights and obligations established herein shall be governed by and construed in accordance with the laws of the State of California.  Both parties agree that this Agreement is valid if executed in counterparts and that an executed facsimile version is as binding as an original. 
   
      IN WITNESS WHEREOF, the parties have executed this agreement the date and year above set forth.

“Patient


By:______________________________                                            
 

AGREED & ACCEPTED

“Provider


By: ______________________________                                              
          An Authorized Signatory
Number of Pages4
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#28202
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.











Release and Settlement Agreement
(Patient Medical Expenses)







This Packet Includes:
1. General Instructions & Checklist;
2. Information; and
3. Release and Settlement Agreement
    (Patient Medical   Expenses)





 General Instructions & Checklist
Release And Settlement Agreement
(Patient Medical Expenses)



   The Provider and Patient should read the Agreement carefully.

   Both parties must sign the Agreement.  Fill in the blanks for addresses, account information, amount settled upon, and the actual amount owed.  Generally, there are at least two originals, signed by both parties so that each party can retain an Agreement with actual ink signatures.

   This form contains the language that is necessary to settle a medical bill for a lower amount than is due.  This frequently happens when a Patient for some reason needs to settle with a defendant in a lawsuit (usually because legal costs are getting too high) and it would be unjust for the Patient to pay the medical bill due based on the circumstances.  This form includes provision 5, which is specific to California law.  If this form is to be used in a state other than California, delete provision 5 and renumber the agreement.



   Laws regarding this Agreement may vary from state to state.  This form is not intended as a substitute for legal advice.  This form should only be considered a template and, unless you are an attorney, you should not use it before first consulting with an attorney to ensure that it addresses your particular situation.  An attorney should be consulted before negotiating any document with another party.

   The purchase and use of this form is subject to the “Disclaimers and Terms of Use” found at findlegalforms.com.



Information
Release and Settlement Agreement
(Patient Medical Expenses)

Personal Injury litigation can sometimes find an injured plaintiff in the position where continuing the law suit becomes a cost benefit analysis meaning a plaintiff has to consider whether the end award of a case is going to justify continuing to pay legal fees through that point.  Many times the answer is “no” and a plaintiff must then focus on maximizing settlement with the defendant and with the plaintiffs medical provider.

This is a comprehensive settlement agreement that can be used once the settlement dollars are determined so that the settlement is properly documented and can be used to straighten out any problems regarding this matter in the future (i.e., plaintiffs credit discrepancies).

No agreement can cover every situation and it is advised that if the person using this form is not an attorney, then they should consult an attorney first to tailor this agreement to fit the situation before using.






DISCLAIMER:

FindLegalForms, Inc. (“FLF”) is not a law firm and does not provide legal advice.  The use of these materials is not a substitute for legal advice. Only an attorney can provide legal advice.  An attorney should be consulted for all serious legal matters.  No Attorney-Client relationship is created by use of these materials.  



THESE MATERIALS ARE PROVIDED “AS-IS.  FLF DOES NOT GIVE ANY EXPRESS OR IMPLIED WARRANTIES OF MERCHANTABILITY, SUITABILITY OR COMPLETENESS FOR ANY OF THE MATERIALS FOR YOUR PARTICULAR NEEDS.  THE MATERIALS ARE USED AT YOUR OWN RISK.  IN NO EVENT WILL:  I) FLF, ITS AGENTS, PARTNERS, OR AFFILIATES; OR II) THE PROVIDERS, AUTHORS OR PUBLISHERS OF ITS MATERIALS, BE RESPONSIBLE OR LIABLE FOR ANY DIRECT, INDIRECT, INCIDENTAL, SPECIAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES (INCLUDING, BUT NOT LIMITED TO, PROCUREMENT OF SUBSTITUTE GOODS OR SERVICES; LOSS OF USE, DATE OR PROFITS; OR BUSINESS INTERRUPTION) HOWEVER USED AND ON ANY THEORY OF LIABILITY, WHETHER IN CONTRACT, STRICT LIABILITY, OR TORT (INCLUDING NEGLIGENCE OR OTHERWISE) ARISING IN ANY WAY OUT OF THE USE OF THESE MATERIALS. 

RELEASE AND SETTLEMENT AGREEMENT

      This RELEASE AND SETTLEMENT agreement (“Agreement”), is made on ____________________, by and between ____________________________, whose address is: __________________________________________________ (hereafter referred to as “Provider”) and _________________________________ whose address: (hereafter referred to as “Patient”).

      WHEREAS, Provider provided medical services to Patient as identified by file number ______________ (the “Services”); and

      WHEREAS, Patient signed, personally, and through Patients attorney, a Lien Form and Insurance Assignment executed ______________ that gave, in addition to other terms, Provider a lien against any and all proceeds of any settlement paid to Patient or Patients attorney as a result of the injuries for which Patient received the Services (the “Lien”);

      WHEREAS, Provider now asserts that the balance due for the Services is __________________________ ($___________) (the “Medical Bill”), which both parties acknowledge has resulted in a dispute that qualifies for settlement negotiations;

      WHEREAS, Provider warrants and represents that it has the exclusive legal right and authority to grant this Release and to enter into this Agreement, with Provider being authorized to release Patient from liability from the Lien and to settle the alleged amount due for the Services; and

      WHEREAS, Provider and Patient desire to compromise and fully and finally settle the amount due for the Services on the terms and conditions of this Agreement.

      NOW, THEREFORE, upon the mutual promises and covenants herein contained, the parties hereto agree as follows:

1.        Patient shall pay to Provider the sum of _________________ ($________) (the “Payment”) after the receipt of an executed copy of this Agreement.

2.      Provider agrees to accept the payment provided for in paragraph 1 as full satisfaction of the Medical Bill.

3.      Provider does hereby generally release and forever discharge Patient, and Patients attorney, their successors, and assigns (“Released Parties”) of and from any and all manner of claims, debts, costs, contracts, liens, accounts, demands, actions, suits, causes of actions, obligations, expenses, liabilities of every kind and nature, known or unknown, suspected or unsuspected, fixed or contingent, in law or in equity, arising out of or in any way connected with or related to the Medical Bill and the Lien, that Provider, its assigns and successors now has up to the date of this Agreement, or at anytime hereafter may have, against the Released Parties with regard to the Medical Bill and the Lien.

4.      The parties acknowledge that the disputed amount of the Medical Bill and the terms of the Lien serve as adequate consideration to support a valid accord and satisfaction, and that it is the parties intentions that this Agreement shall be effective as a full and final accord and satisfaction between parties, constituting full settlement of all claims of every nature to date in connection with the Medical Bill and the Lien.

5.      With respect to the foregoing release, Provider hereto hereby acknowledges and expressly waives and relinquishes any and all rights with respect to Section 1542 of the Civil Code of the State of California, which provides as follows:

A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH, IF KNOWN BY HIM, MUST HAVE MATERIALLY AFFECTED HIS SETTLEMENT WITH THE DEBTOR.
   
     6.   This Release and Agreement sets forth the entire understanding between the parties, and cannot be changed, modified or canceled except by an instrument signed by the party sought to be bound. Any controversy arising under this Agreement and the rights and obligations established herein shall be governed by and construed in accordance with the laws of the State of California.  Both parties agree that this Agreement is valid if executed in counterparts and that an executed facsimile version is as binding as an original. 
   
      IN WITNESS WHEREOF, the parties have executed this agreement the date and year above set forth.

“Patient


By:______________________________                                            
 

AGREED & ACCEPTED

“Provider


By: ______________________________                                              
          An Authorized Signatory

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