One of the nice features of personal injury litigation is that you will not have to pay your lawyer up front. The attorney fee is calculated on a percentage basis at the end of the case. Here is a sample fee agreement. There are almost endless varieties. Below the fee agreement is a medical authorization form that I use. It allows me to get the medical records for my clients. You will probably be asked to sign something similar. If you are considering signing a contingent fee agreement and/or medical authorization, feel free to call me to discuss. My number is 215 563 7088.
CONTINGENT FEE AGREEMENT
I, [insert name here], hereby appoint EVAN K. AIDMAN, ESQUIRE, as my attorney to prosecute a claim for Personal Injuries against [insert name here] and all other responsible parties. The injury occurred on [insert date here].
I hereby agree that the compensation for Mr. Aidman for services shall be determined as follows: That out of whatever sum is secured by Mr. Aidman from the above defendant(s) by way of settlement or verdict, Mr. Aidman shall receive 33.3% (thirty three and one third percent) thereof for professional services; the expenses, including the fees of witnesses, filing fees, investigation, photographs, postage, copying, telephone and other proper costs incurred in the preparation, trial or settlement shall be deducted after payment of Mr. Aidman’s fee, and all otherwise unpaid medical expenses shall be paid from the balance remaining after payment of Mr. Aidman’s fee and expenses.
Should either party terminate this contract before the payment of an outstanding settlement offer or verdict, Mr. Aidman is entitled to 33.3% (thirty three and one third percent) of any such settlement offer or verdict outstanding, plus advanced costs, as of that date, to be paid out of monies actually paid or collected by me or on my behalf. In order to enforce his entitlement to the said fee and costs, Mr. Aidman shall have a lien against any settlement or judgment I may obtain after termination of this contract.
In the event that there shall arise a dispute between me and Mr. Aidman over his fee and/or his costs, each such dispute shall be submitted for binding resolution to the American Arbitration Association, and the AAA rules shall apply.
I hereby acknowledge acceptance of this Contingent Fee Agreement.
_____________________ ________________________
Name Date
AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
Patient Name: [insert name here] Date of Birth: [insert dob here]
I authorize the use or disclosure of the above named individual’s medical records as described below:
THIS AUTHORIZATION IS LIMITED TO RECORDS ONLY AND DOES NOT AUTHORIZE THE DISCLOSURE OF ANY INFORMATION NOT CONTAINED IN THE RECORDS. THIS AUTHORIZATION DOES NOT AUTHORIZE ANY COMMUNICATIONS WITH THE HOLDER OF THE AUTHORIZATION OTHER THAN THE TRANSMITTAL OF RECORDS PRESENTLY IN THE PATIENT’S FILE. THIS AUTHORIZATION DOES NOT AUTHORIZE THE FURNISHING OF ANY REPORTS NOT PRESENTLY CONTAINED IN THE RECORDS.
THIS AUTHORIZATION DOES NOT AUTHORIZE THE DISCLOSURE OF RECORDS RELATING TO SEXUALLY TRANSMITTED DISEASES, ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS), OR HUMAN IMMUNODEFICIENCY VIRUS (HIV) OR RECORDS RELATING TO BEHAVIORAL OR MENTAL HEALTH SERVICES, OR TREATMENT FOR ALCOHOL AND DRUG ABUSE.
I hereby authorize
to release my health information to:
EVAN K. AIDMAN
Information to be used or disclosed:
Discharge summary X-ray reports Nurses’ notes
ER and outpatient reports Lab reports PT records
Consultation reports Progress notes Billing summary
History and physical Doctor’s orders Patient’s chart
Operative and pathology reports Ambulance records
I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing. I understand that the revocation will not apply to information that has already been released in response to this authorization. Unless otherwise revoked, this authorization will expire on the following date, event or condition: settlement of my case.
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, as 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 confidentiality rules. If I have questions about disclosure of my health information, I can contact LAW OFFICES OF EVAN K. AIDMAN, ESQUIRE at 215 563 7088. Permission is hereby granted to the LAW OFFICES OF EVAN K. AIDMAN, ESQUIRE to photocopy or scan this authorization and any photocopy thereof shall be as valid as an original.
Name: Date:
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