An authorized doctor or an occupational or physical therapist treating a workers' compensation claimant may require the claimant to sign an agreement, on a prescribed form, requiring such claimant to pay said doctor or therapist his or her usual and customary fees for services rendered to such claimant, in the event said claimant fails to prosecute a claim for workers' compensation for such illness or condition, or in the event it is determined by the Workers' Compensation Board that the illness or condition for which such services were rendered was not the result of a compensable workers' compensation claim.