RELEASE AND SETTLEMENT AGREEMENT

IN CONSIDERATION of Dollars $_______paid on behalf of [Dr. Name] to [Claimant],

[Claimant] hereby completely and fully releases, agrees to settle with, acquits and forever

discharges [Dr. Name] from any and all claims, actions, causes of action, suits, controversies,

demands, rights, claims for loss of society, loss of services, damages, debts, sums of money,

expenses and liability of any kind, character or description which, [Claimant] may have or may

have had against [Dr. Name] and actual or apparent agents, arising out of, on account of, or in

any way related to the allegations of negligence for treatment that occurred on or about the [Date

1] through [Date 2] at or near [Dr. Office Location].

It is expressly understood that this is a full release of all injuries, disabilities, losses and

damages which [Claimant] sustained as a result of or in any way relating to the alleged

negligence of [Dr. Name] whether such injuries, disabilities, losses and damages are now known

or anticipated or become known hereafter.

It is further understood that [Claimant] acting on her own behalf and on behalf on her

heirs, executors, administrators, legal representatives, successors, and assigns, whether known or

unknown, hereby agree to DEFEND, INDEMNIFY AND HOLD HARMLESS [Dr. Name] from

any and all obligations, liabilities, claims, cross-actions, third party actions, indemnification or

other liability of any kind, if any, which may ever be asserted by anyone, arising out of or

relating to any and all claims, causes of action, conduct, conditions, events, injuries, and

damages, specifically or generally listed or referenced in this agreement.

[Claimant] is authorized to execute this Release and fully understands the effect and

consequences of doing so.

 IT IS FURTHER UNDERSTOOD AND AGREED [Dr. Name] has denied any and all

liability on his behalf regarding the incident giving cause to this release.

IT IS FURTHER UNDERSTOOD AND AGREED that the payment is made in the

compromise of a doubtful and disputed claim, and that payment made pursuant to this

Agreement is not to be construed as an admission or as evidence of any fact or as any admission

of liability or fault on the part of [Dr. Name].

IT IS FURTHER UNDERSTOOD AND AGREED that [Claimant] has assumed

responsibility for any Medicare and medical provider liens arising out of the incident giving

cause to this release. In the event that any lien holders attempt to pursue any contractual right or

other right to reimbursement of medical costs paid for [Claimant], [Claimant] hereby agrees to

pay any and all such liens out of the total settlement proceeds and agrees to indemnify and hold

harmless [Dr. Name]for any such claims.

IT IS FURTHER UNDERSTOOD AND AGREED that this document contains the

entire agreement and understanding of the parties with regard to the subject matter hereto and

that its contents shall remain confidential between the parties to the extent allowed by law.

[Claimant] agrees not to initiate, participate in, or have any contact with the media (electronic

and print) concerning the underlying facts or allegations of the case or its settlement, nor to

release, divulge or discuss with any other person, at any time, the terms and conditions of this

settlement, and the allegations and disputes arising out of the professional relationship with [Dr.

Name].

In entering into this agreement, [Claimant], represents [he/she] has carefully read this

agreement, fully understands it, and signed this as [his/her] free and voluntary act. This

agreement is not legal advice. [Claimant] acknowledges that [he/she] has had the opportunity to

secure legal counsel for reviewing the issues raised herein.

EXECUTED THIS DAY OF , 2024.

(Doctor Print Name)

(Signature of Doctor)

(Date)