THIS SECTION IS REQUIRED
AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
The type of and amount of information to be used or disclosed is as follow: Problem list, Medication List, List of Allergies, Immunization Records, Most Recent History & Physical, Laboratory Results, X-ray and Imaging Reports, Consultation Reports, Billing Records, Entire Records and Other.
2. I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug.
3. This information may be disclosed to and used by following individual or organization: The Witherspoon Law Group, PLLC, 1101 Ridge Road, Suite 224 Rockwall, Texas 75087, Fax: (972) 696-9982 For the purpose of: Litigation
4. I understand I have the right to revoke this information at any time. I understand if I revoke this authorization I must do so in writing and present my written revoke to this authorization I must understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise disposition of the lawsuit referenced in paragraph 4 above or two years form the date of this authorization. Whichever comes later.
5. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed, a provided in CFR 164.524. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentially rules. A photocopy of this authorization shall be as valid as the original.
*** PLEASE EMAIL ANY PHOTOGRAPHS OR BILLS IN YOUR POSSESSION
RELATED TO THE ACCIDENT TO email@example.com
I HAVE READ AND I AGREE TO THE
I HAVE READ AND I AGREE WITH THE
I HAVE READ AND I UNDERSTAND THE
CONTINGENCY FEE AGREEMENT
IDENTIFICATION OF PARTIES. This agreement is made between Witherspoon Law Group and any referral attorneys "Attorney" or the “Firm” and
hereafter referred to as "Client" for the incident occurring on
RESPONSIBILITIES OF ATTORNEY AND CLIENT. Attorney will perform the legal services called for under this agreement to the best of Attorney's abilities, keep Client informed of progress and developments, and respond promptly to Client's inquiries and communications. Client will be truthful and cooperative with Attorney and keep Attorney reasonably informed of developments and of Client's address, telephone number, and whereabouts.,
SETTLEMENT & DEPOSIT. Attorney will not settle Client's claim without the approval of Client. Client authorizes Attorney to sign and deposit any settlement on their behalf into Attorney trust account.
NON-SOLICITATION. I have not been solicited, coerced, or promised money or anything of value by The Witherspoon Law Group, or its agents, employees or representatives. I chose The Witherspoon Law Group, of my own free will, voluntarily, and without compensation or promise of compensation or anything else of value.
ATTORNEY'S FEES - CONTINGENCY CONTRACT. Attorney agrees to waive hourly fees of $450 and instead pursue Client’s claim on a contingency basis. The contingency upon which compensation is to be paid is the collection of monies following settlement or award on the claim or claims set forth above and the amount of such compensation which is to be paid by the Client to the Firm shall be on the gross amount recovered as follows: Our firm fee is 35 % of the amount of any offer of settlement made before a lawsuit is filed; 40% of the amount of any offer of settlement or verdict after lawsuit has been filed but before sixty (60) days of the first trial setting; 45% of any settlement or recovery made for client within sixty (60) days of the first trial setting and thereafter excluding any appeals or post-trial work. Attorney does not handle appeals. Appeals must be filed 30 days after jury trial.
DEFERRED PAYMENT. If payment of all or any part of the amount to be received will be deferred (such as in the case of an annuity, a structured settlement, or periodic payments), the "total amount received," for purposes of calculating the Attorney's fees, will be the initial lump-sum payment plus the present value, as of the time of the settlement, final arbitration award, or final judgment, of the payments to be received thereafter. If the payment is insufficient to pay the Attorney's fees in full, the balance will be paid from subsequent payments of the recovery before any distribution to Client.
ASSIGNMENT OF PAYMENT/POWER OF ATTORNEY. In consideration of services or to be rendered under this agreement, Client agrees to assign to Attorney all monies paid by insurance company on account of claims submitted for services rendered by Attorney, whether submitted by Client or Attorney. Client authorizes payment directly to Attorney for services rendered and gives Attorney power of attorney for the purpose of signing Client’s signature on settlement checks and depositing proceeds into Attorney IOLTA. These provisions shall be cancelled upon completion of services. Client grants Attorney limited power of attorney for all purposes related to this claim. Attorney may sign any and all documents on behalf of client as “attorney-in-fact.” Client expressly provides Attorney power of attorney for all purposes related to this lawsuit, including medical authorizations, releases, affidavits and other forms related to HIPAA.
CASE COSTS. Attorney will advance all "case costs" and will recoup all costs advanced. Case costs will be deducted from any settlement or award after attorney’s fees are subtracted. Client is still responsible for client’s own "personal expenses" (e.g.: medical bills, liens, other party costs, etc). Upon final disposition of case, client agrees to pay a $250.00 case cost fee, which covers the cost but not limited to copies, postage, police reports, etc.
LIENS/DISCHARGE. Client hereby grants to Attorney a lien for Attorney's fees and costs advanced on all claims and causes of action that are the subject of representation of Client under this agreement and on all proceeds of any recovery obtained by any means. Client will be obligated to pay Attorney out of the recovery Attorney's fees for all services provided and to reimburse Attorney out of the recovery for all costs advanced if attorney is discharged. Client understands and that Attorney is not financially responsible or liable for any outstanding liens, medical expenses, loans, etc.
ENTIRITY/MODIFICATION. This agreement contains the entire agreement of the parties. No other agreement, statement, or promise made on or before the effective date of this agreement will be binding on the parties. This agreement may be modified only by an instrument in writing by both parties.
EFFECTIVE DATE OF AGREEMENT. The effective date of this agreement will be the date when, having been executed by Client, one copy of the agreement is received by Attorney. The Client has read this agreement carefully and understands the terms hereof.
By completing this Intake Form online, I represent that I am the person completing the form or have the authority to complete said form and
that all information is true and correct and completed to the best of my knowledge. I acknowledge that I've been informed that The Witherspoon Law Group is headquartered licensed in Texas, Illinois, Missouri and may associate with counsel in other jurisdictions.