FULL AND FINAL RELEASE OF ALL CLAIMS
Claim Number: XXXXXXXXXX
For and in consideration of the sum of One Million DOLLARS ($1,000,000.00) hereby paid to me by NEGLIGENT COMPANY, (hereinafter called either the “Company” or “BAD COMPANY”), receipt of which is hereby acknowledged, I, PLAINTIFF [hereinafter “PLAINTIFF”], do hereby release and forever discharge the Company, and any predecessors in interest, its respective officers, employees, agents, successors and assigns from any and all claims, demands and liabilities of every kind and nature, including claims for injuries and property damage, if any, which are unknown to me, unanticipated, or unexpected at the present time, or which might become progressively worse and result in further damages arising out of the accident that occurred on or about 01/01 at or near XXXXXX,Texas, resulting in injuries to Neck, Back, and Head.
Pursuant to 42 USC §1395(y), 42 CFR §411.1 et al, the Medicare Intermediary Manual, and the Medicare Carriers Manual, the parties to this settlement warrant and represent that any rights or interests any entity may have in this settlement under the Medicare Secondary Payor Statute have been adequately considered and protected by PLAINTIFF and confirming that no lien exists that creates rights of recovery under the Medicare Secondary Payor Statute for PLAINTIFF medical care related to the injuries set forth in this Release. However, if it is determined that a lien for conditional payments does exist for medical care received by PLAINTIFF up to and including the date of this Release related to the injuries set forth in this Release, PLAINTIFF will assume the complete and total responsibility and liability to satisfy any lien that is recoverable under the Medicare Secondary Payor Statute for such conditional payments.
In addition, PLAINTIFF warrants and represents that PLAINTIFF is aware of and has had the opportunity to discuss with an attorney the Medicare Secondary Payor Statute and its associated regulations, including but not limited to 42 U.S.C. §1395y(b), 42 C.F.R. §411-24, 42 C.F.R. §411.46 and 42 C.F.R. §411.47, and that PLAINTIFF has fully complied with all obligations and duties imposed by the Medicare Secondary Payor Statute and its associated regulations and in the future will fully comply with all obligations and duties imposed by the Medicare Secondary Payor Statute and its associated regulations. PLAINTIFF agrees to assume the complete and total responsibility and liability to pay any liens that are recoverable under the Medicare Secondary Payor Statute that may be asserted for medical care received by PLAINTIFF after the date of this Release for the injuries set forth in this Release. PLAINTIFF agrees that COMPANY has no responsibility or liability to pay for any medical care received by PLAINTIFF after the date of this Release.
Should Medicare amend the published Medicare criteria triggering the need for formal Medicare approval of a Medicare Set-Aside in this case, PLAINTIFF agrees to satisfy the Medicare Set-Aside submission and approval requirements set forth by the Centers for Medicare and Medicaid Services. PLAINTIFF agrees that if PLAINTIFF is required to set aside or repay any portion or all of this settlement, PLAINTIFF will be solely responsible for setting aside or repaying such monies from his/her own funds. PLAINTIFF also agrees to defend, indemnify and hold harmless Company.
In addition, PLAINTIFF waives and releases any right to bring any action against COMPANY AND COMPANY attorneys under §1395(y) of the Medicare Secondary Payor Statute. Nothing in this release is intended as a waiver of the rights of PLAINTIFF or the Company to make a good faith challenge to any claim made by Medicare against PLAINTIFF or the Company.
INDEMNITY: PLAINTIFF AGREES TO INDEMNIFY AND HOLD HARMLESS Company AND ALL CLAIMS BROUGHT BY ANY PERSON OR
PARTY CLAIMING A RIGHT TO THE PROCEEDS FROM THIS SETTLEMENT.
It is understood and agreed that this settlement is the compromise of a disputed claim, and that the payment made is not to be construed as an admission of liability on the part of the Company or the other parties hereby released, and that said releasees deny liability therefor and intend merely to avoid litigation and buy their peace.
PLAINTIFF hereby declares and represents that the injuries sustained by me are or may be permanent and progressive and that recovery therefrom is uncertain and indefinite and in making this Release, it is understood and agreed that PLAINTIFF relies wholly upon my judgment, belief and knowledge of the nature, extent, effect and duration of said injuries and liability therefor and that this Release is entered into without reliance upon any statement or representation made by the parties hereby released.
PLAINTIFF further declares and represents that no promise, inducement or agreement not herein expressed has been made to me, and that this Release contains the entire agreement between the parties hereto, and that the terms of this Release are contractual and not a mere recital.
For and in consideration of the sum of ONE DOLLAR ($1.00) which is hereby paid to me by COMPANY as part of the larger payment to me identified above, PLAINTIFF agrees that the terms of this Release shall be confidential and further agrees not to disclose any information concerning the terms of this Release to anyone, including but not limited to past, present or future employees of COMPANY, except where required by law, without the prior written consent of COMPANY. Breach of this condition will be considered a breach of the entire Release agreement.
PLAINTIFF further declares that I have read this Release and understand that neither I, nor anyone on my behalf, can make any further claims against the Company, the other released parties and their respective officers, employees, agents, successors and/or assigns for any and all injuries sustained by me as a result of the accident referenced herein, and understands that I cannot do so even though my injuries or damages prove to be more serious or different from what I now know or understand them to be.
CLAIMANT
3
NOTARY
I HAVE FULLY READ THE FOREGOING RELEASE AND DECLARE THAT I VOLUNTARILY ENTER INTO THIS RELEASE AND FULLY UNDERSTAND IT. I HEREBY ACKNOWLEDGE RECEIPT OF A COPY OF THIS RELEASE AND SETTLEMENT AGREEMENT.
EXECUTED this ___ day of ________________, 20___.
___________________________________ Roman Duran
STATE OF ) COUNTY OF )
On this _____ day of ________________, 20__, before me personally appeared PLAINTIFF, to me known to be the person named and who executed the Release and acknowledged that the same was executed of his own free act and deed.
Witness my hand and notary seal the date aforesaid.
___________________________________ Notary Public
My Commission Expires: ___________________________________
CLAIMANT