Letter of Protection

Fee Guarantee Agreement

I, the above noted Patient, do hereby authorize and direct my present and any future attorney to honor this fee guarantee agreement.  This agreement is made in favor of the above named Medical Provider and shall be termed a “Letter of Protection.” The Letter of Protection shall serve to place a continuing lien on any proceeds I recover in any legal action related to the above noted accident date.

Consideration

In consideration of the medical treatment provided and time provided to pay for said medical treatment, I hereby grant a direct lien on any and all funds I may recover in any legal action related to the above accident date.