A general release of liability to be used on patients that are requesting to be paid out on a claim of some sort, wrongful act, negligence, or malpractice. This release can free your facility of liability and essentially pay off the patient and patient then waives the right to further claim any monetary or otherwise claims made of them about your facility. This form allow you to fill in the blanks where it requires your specific information to make the form completely viable and harmless to further legal review or hearings.
GENERAL RELEASE For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, including the receipt of $______, the undersigned ____________ on behalf of himself and each of his respective agents, servants, successors and assigns (“Patient”), hereby fully, finally, and forever releases and discharges (name of health care facility) , and each of their directors, officers, managers, shareholders, employees, independent contractors, agents, successors and assigns (individually and collectively, “(name of health care facility)”), from any and all past, present and future claims, suits, judgments, damages, debts, sums, amounts owed, obligations and controversies, liabilities, losses, costs, expenses, liens, charges, fees (including attorneys' fees), damages, lawsuits, actions and causes of action of every kind and nature, whether in law or equity, and whether known or unknown, foreseen or unforeseen, patent or latent, or absolute or contingent, which Patient has had, now has or could have against (name of health care facility) by reason of the provision of medical services by (name of health care facility) and/or any fact or circumstance arising out of any alleged act or omission while Patient was located or as a result directly or indirectly of any treatment while at (name of health care facility)’s facility located at (address of health care facility) Patie
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