Patient Responsibility Agreement
The following are agreed upon terms between the undersigned patient (the ''Patient") and Center for
Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC. The terms of this Patient Responsibility
Agreement, which is meant to be a lien for services agreement (the "Agreement") are to be strictly complied
with and may not be altered unless agreed to in a writing signed by an authorized agent of the Center for
Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC
Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC agrees to wait for payment from
Patient until Patient obtains monies from settlement, payment or judgment against a third party or collected
from a first party source including, but not limited to, Medpay/PIP, or uninsured or underinsured motorist
coverages. The purpose of this Agreement is to provide Center for Advanced Spine Care, LLC/Kai-Uwe
Lewandrowski, MD PLLC with additional security and guarantee for payment by Patient and Patient's attorney
beyond protections provided by applicable lien laws. The protection afforded to Center for Advanced
Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC by this Agreement is in addition to, not in lieu of, the
applicable lien laws. Patient understands and acknowledges that Center for Advanced Spine Care, LLC/Kai-
Uwe Lewandrowski, MD PLLC would not be providing the Services requested by Patient and the prescribing
physician or ordering attorney without Patient's strict adherence to the terms of this Agreement.
Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC will charge Patient for the Services
commensurate with Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC standard fee
schedule for all reasonable and necessary services provided.
BY SIGNING THIS AGREEMENT, PATIENT IS EITHER DECLARING THAT HE OR SHE
DOES NOT HAVE APPLICABLE HEALTH INSURANCE, OR THAT HE OR SHE IS OPTING
OUT OF USING IT. THIS CHOICE BY PATIENT CANNOT LATER BE CHANGED OR
REVOKED WITHOUT THE EXPRESS WRITTEN PERMISSION OF MULTUS.
• Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC may, as a courtesy to
Patient and in the sole discretion of Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski,
MD PLLC bill available Medpay/PIP. Whether or not Center for Advanced Spine Care, LLC/Kai-Uwe
Lewandrowski, MD PLLC bills available Medpay/PIP does not in any way limit Patient's obligation to
Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC for payment for the
Services. Patient acknowledges and agrees that if Med Pay/PIP is billed and it results in any amount
being paid, it does not limit Center for Advanced Spine Care, LLC/Kai Uwe Lewandrowski, MD
PLLCs right and ability to collect the total amount due and owing under this'Agreement. Center for
Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC offers the Services to Patient
expecting that Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC will receive
full payment commensurate with Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD
PLLCs standard fee schedule regardless of any partial payments made by any Medpay/PIP or similar
coverage available.
Patient authorizes Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC to furnish their
attorney and agents with MRI data/rendering and billing regarding the injury(ies) from the incident (the
"
Patient Information"). This authorization grants Center for Advanced Spine Care, LLC/Kai-Uwe
Lewandrowski, MD PLLC, its agents and employees permission to share the Patient Information in full with
Patient's attorneys and agents including, but not limited to, Patient Information which may be
protected under state and federal law including and regarding HIV, AIDS, mental health, substance abuse,
genetic information and confidential communications. Patient further agrees that Center for Advanced Spine
Care, LLC/Kai-Uwe Lewandrowski, MD PLLC shall have the full right and authority to utilize the Patient
Information, including any data involving imaging, including MRls, related medical
reports, films, and analyses, in developing advanced forms of medical imaging and data analysis. All data
related to the Patient Information shall become the exclusive property of Center for Advanced Spine Care,
LLC/Kai-Uwe Lewandrowski, MD PLLC. Patient further understands and agrees that this data may be made
available to third parties for purposes of developing advanced forms of imaging, provided that Patient's
personal identifying information will be removed or changed before the Patient Information is made available
to·any third parties. In the event Patient is not represented by an attorney, this authorization extends to any
applicable carrier responsible for the payment of Patients' claimed damages.
Patient understands, authorizes and grants Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD
PLLC the right to sell and/or assign this claim for payment to any other entity in the sole discretion of Center for
Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC. If Center for Advanced Spine Care, LLC/Kai-
Uwe Lewandrowski, MD PLLC exercises its right to sell and/or assign this claim for payment, it does not limit
Patient's obligation to pay the third party acquiring this claim in full.
Patient authorizes and directs the attorney signing below, if any, and any other attorneys retained in the future,
to directly pay such sums that may be due and owing for the Services, and to withhold such sums from any
settlement,judgment, collateral source or verdict, including, but not limited to, liability insurance, uninsured
coverage, underinsured coverage, or Medpay/PIP coverage.
The Patient further directs their attorney(s) to pay,
IN FULL, all amounts owed to Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC by
mailing payment to Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC at 4787 E.
Camp Lowell Drive, Tucson, AZ 85712.
Patient agrees that Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC 's lien is
primary to any and all other interest(s) or lien(s) in the settlement funds, second only to Patient's attorney's
charging lien for costs and fees and any lien which has priority based on an applicable statute. At no time shall
this lien be considered to have equal or lesser priority than any advance Patient may obtain against the proceeds
of the Patient's claim.
Should Patient not have attorney representation, Patient authorizes and directs any and all insurance companies,
whether adverse or first party (from any source), Medpay, PIP, UIM, UM, to make reimbursement directly to
Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC at the following address upon the
conclusion of the case: 4787 E. Camp Lowell Drive, Tucson, AZ 85712.
Patient irrevocably agrees to list Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC on
any settlement draft(s)/check(s). Patient also agrees that this lien and all the rights granted to Center for Advanced
Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC in this Agreement will continue in full force and be
binding on Patient and Patient's attorney, if any, including if there is a change in attorneys in the future.
Should
Patient change attorneys, Patient will notify Center for Advanced Spine Care, LLC/Kai Uwe Lewandrowski,
MD PLLC
of the change within 5 business days, and will notify any future attorney of all obligations under this
Agreement upon retention of a future attorney. If Patient does not obtain new counsel, or does no\ provide the
Patient's current whereabouts to Center for Advanced Spine Care, LLC/Kai Uwe Lewandrowski, MD PLLC
within 5 business days of a request for Patient to do so, then Patient authorizes and acknowledges Center for
Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC may deal directly with any applicable
insurance carrier regarding Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC's lien.
By signing below, Patient is providing Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD
PLLC with a durable power of attorney allowing Center for Advanced Spine Care, LLC/Kai-Uwe
Lewandrowski, MD PLLC to endorse any draft/check for the Services on Patient's behalf, which will allow any
outstanding amount due and owing to Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD
PLLC to be satisfied without additional signature from Patient.
Patient understands that Patient is directly and fully responsible to Center for Advanced Spine Care, LLC/Kai-
Uwe Lewandrowski, MD PLLC for all amounts due and owing for the Services and that this lien is being
provided solely as additional protection to Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski,
MD PLLC. Patient provides this lien to Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD
PLLC in consideration of Center for Advanced Spine Care, LLC/Kai-Uwe Lewandrowski, MD PLLC waiting
for payment for the Services. Patient further recognizes that payment to Center for Advanced Spine Care,
LLC/Kai-Uwe Lewandrowski, MD PLLC is not contingent upon any settlement, judgment or verdict that
Patient may or may not eventually obtain.