intake injury form

Client information

Emergency Contact

If potential Client is minor, please complete the details

Accident Information

Auto Accident Only

Your Insurance Information

Defendants Insurance Information

Your Injuries

RETAINER AGREEMENT

The Firm shall devote its full professional abilities to the Client’s case and the Client agrees to fully cooperate with the Firm. Neither the Firm nor the Client shall settle the case without the other’s consent. In consideration for the professional services of the Firm, the Client agrees to pay the Firm as attorney’s fees an amount based upon 33.3 percent of the gross receipts of any money sum by settlement obtained on behalf of the client, and 40 percent of gross receipts of any money received after the filing of a lawsuit by settlement, verdict, or judgment, said attorney’s fees shall be paid first before all other payees.

Further, the Firm shall be considered a secured creditor of the client as to the attorney’s fee due and shall hold a secured interest in all attorneys’ fees due. A decision to file a lawsuit will require the consent of the Firm and the Client. This retainer does not cover any appeals or post trial proceedings and the compensation to the Firm for any such post trial proceedings will be determined by separate agreement.
In the event that through the efforts of the Firm an offer of settlement has been made by an insurance company or anyone claimed by the Client to be responsible for any damages incurred by the Client, and the Client elects to terminate the services of the Firm after an offer of settlement or judgment, the Firm shall withdraw as counsel to the Client and the Firm shall be entitled to assert as an Attorney’s Fee Lien on amount equivalent to the time and costs incurred by the Firm on behalf of the Client, or the percentage of 33.3 or 40 percent (if the suit has been filed) of the settlement amount offered or judgment obtained at the time of termination, whichever sum is greater.

In addition to the recovery of attorney’s fees, the firm shall also recover any costs or expenses incurred by the Firm. It is understood that the Firm may associate with such other counsel as it deems appropriate to advance the interests of this matter and that the Client hereby agrees to retain such other counsel. In no event, however, shall the attorney’s fees exceed the above stated amount.

It is furthered agreed that if the Firm negotiates and recommends acceptance of a particular settlement, as offered by the defendant or his agent, and I refuse to accept the settlement, such refusal shall constitute sufficient grounds of the Firm to withdraw from representation of me and I agree to be indebted to the Firm for any amount of the attorney’s fees and costs and expenses incurred based upon said offer as recommended.

Also, it is further agreed that to assist attorney with its representation of you in connection with the matter covered by this agreement, you hereby give us full power, authority, and power of attorney to execute all pleadings, documents, claims, deposits, drafts, checks, releases, orders, and contracts relative to this matter.

CERTIFIED RECORDS REQUEST

Dear Sir or Madam:

Please provide these medical records on a CD in a .pdf format pursuant to the requirements of the HITECH Act as set forth in 42 U.S.C. § 17935(e)(2) and 45 C.F.R. § 164.524(c).

Please send these materials in an electronic format only to:

I have enclosed a signed authorization for the release of my medical records. Thank you for your help.

The information used/disclosed pursuant to the authorization will not include psychotherapy notes (meaning detailed notes kept by your psychiatrist or psychotherapist), but may include other detailed mental health information, HIV/AIDS information and/or information regarding alcohol or substance abuse.

I understand that the information used or disclosed pursuant to this Authorization may be subject to re­ disclosure by the recipient of the information and may then no longer protected by the federal regulations. I understand that unless otherwise limited by state or federal regulations, I may revoke this Authorization at any time by presenting my revocation in writing except to the extent that the entity identified has taken action in reliance on this Authorization. I further understand that this Authorization is specific to the information checked above, for the date(s) of services indicated, and for the purpose written above. I understand that the medical provider shall not condition treatment on the receipt of this Authorization, except when such conditioning is permitted for research-related treatment or in instances where the sole purpose of creating the health information is for disclosure to a third party (for example, fitness-for-duty exams).

I further understand that this Authorization is valid for a period of(90) days from today’s date and will expire at the timeunless another date is written here: January 31, 2024..