You can open the Letter Of Protection For Doctor Template in multiple formats, including PDF, Word, and Google Docs.
Letter Of Protection For Doctor Template Printable | Editable FormSample
Examples
[Name of the Doctor]
[Doctor’s ID]
[Doctor’s Address]
[Doctor’s Phone]
[Doctor’s Email]
[Name of the Patient]
[Patient’s ID]
[Patient’s Address]
This Letter of Protection is executed to ensure the patient receives necessary medical treatment without immediate payment, acknowledging that the fees will be settled upon the resolution of the patient’s claim.
The purpose of this letter is to secure payment for medical services rendered by the Doctor to the Patient related to [Specify incident or claim].
The Doctor agrees to render medical services including but not limited to: [List specific services provided].
The Patient agrees to cooperate with medical recommendations and to pursue their claim diligently. Any delays in the claim process may affect the payment for medical services.
Payment for services will be rendered directly from any settlement or verdict obtained by the Patient. The Doctor reserves the right to seek payment directly if the Patient fails to settle the account within [Specify number of days].
The Patient authorizes the Doctor to provide necessary medical records to the Patient’s legal representative for the purposes of supporting the claims.
This Letter of Protection shall be governed by the laws of [Jurisdiction].
[Signature of the Doctor]
[Name of the Doctor]
[Signature of the Patient]
[Name of the Patient]
[Name of the Doctor]
[Doctor’s ID]
[Doctor’s Address]
[Doctor’s Phone]
[Doctor’s Email]
[Name of the Patient]
[Patient’s ID]
[Patient’s Address]
This Letter of Protection is intended for the protection of the medical provider, allowing the patient access to necessary medical care while ensuring that payment will be sought from any recovery obtained.
The Doctor shall provide medical care including: [Specify detailed services].
The Doctor understands that payment is contingent upon the successful outcome of the Patient’s claim and agrees not to demand upfront payment.
The Patient commits to actively pursue all avenues for recovery related to their claims, and keep the Doctor informed on any relevant updates.
It is agreed that payment shall be made from any settlement, judgment, or insurance payout, and the Doctor will be notified of any such resolution.
The Patient provides consent for the Doctor to share medical history and treatment records with legal representation as necessary for the claim process.
This letter will be construed under the laws of [Jurisdiction] and is binding upon both parties.
[Signature of the Doctor]
[Name of the Doctor]
[Signature of the Patient]
[Name of the Patient]
Format
Please complete the form below to create the Letter of Protection for Doctor Template. All fields must be filled out to ensure a clear and complete agreement. We provide examples to guide you through each step. Letter of Protection for Doctor Template 1. Patient Information 2. Doctor Information 3. Treatment Information 4. Payment Arrangement 5. Insurance Information 6. Acknowledgment of Liability 7. Confidentiality Agreement 8. Termination of Letter 9. Signatures and Acceptance 10. Declaration and Signatures
PDF
WORD
Google Docs
Letter Of Protection For Doctor Template Printable | Editable FormPrintable
