LOP

Date _________________

To: Medical Provider (Name)

Address

Address

Attn.: XXX

VIA FACSIMILE: NO.

RE: Patient’s Name

D.O.A. XXX

Acct. No.:

Treatment Date:

 LETTER OF PROTECTION AND AUTHORIZATION 

You are hereby authorized, upon receipt of this Protection and Authorization Letter or a copy thereof, to furnish the undersigned law firm with a full report of patient’s examination, diagnosis, treatment, prognosis, copies of medical bills, etc., as they accrue in regard to the injuries sustained by he/she on the above-referenced date of accident. (D.O.A.)

  We are authorized to provide you this Protection and Authorization Letter, wherein, it is agreed that we will pay your office all outstanding medical expenses for our client’s injury-related treatment directly out of any settlement proceeds or payment resulting from a jury verdict.

I hereby direct and authorize the said law firm to pay directly to you, such sums received from any settlement, judgment, or verdict which may be due and owing you for professional services rendered to me by reason of this accident. 

I fully understand that I am directly and fully responsible to you for all professional bills submitted by you for services rendered and that this agreement is made solely for additional protection, services and treatment in consideration of your awaiting payment. 

This authorization or a copy thereof will enable you to furnish us with a copy of the medical records and an itemized statement of the costs of treatment for out-patient and/or in-patient care. If copies of bills are obtained through another office in your organization, kindly have our request for itemized statement routed to the appropriate office. 

  On behalf of my client, I thank you for working with my client’s payment plan. Victims of negligence are almost always put in a financial bind and if it were not for health care providers like you, who are willing to wait for payment until a settlement can be reached, many injured individuals like my client would not be able to receive proper medical attention. 

As consideration for this protection letter, it is understood that you will refrain from taking any action to collect outstanding medical bills while our client’s case is pending.

  In the event that I close this file for any reason without settlement of the case, I will notify you, so that you may take whatever action necessary. If we are unable to recover for the damages our client has sustained, it is understood that this firm is not liable for the payment of your bill. 

Your earliest attention to this request will be greatly appreciated. 

DATED: ______________________ 

Law Firm: ____________________ 

XYZ