Directs the attorney to pay the doctor out of proceeds of settlement and, if necessary, place a lien against any proceeds. Form states patient is fully responsible for all bills and that payment is not contingent on any settlement, judgment or verdict. Complete the top section in your office, have patient sign, then send to patient's attorney. Attorney returns it to you after signing, dating and retaining a duplicate copy. Name, address and phone number imprinted in black ink on carbonless duplicate sets(white, yellow). 250 duplicate sets per package. Size: 8-1/2" x 11".