Sample Letter to Client with Retainer and Medical Authorization

February 24, 2016

Steven C. Dulin
4601 First Street
Bowie, Maryland 20715

Dear Mr. Dulin:

It was a pleasure to speak with you today. I am thrilled that you are finally out of the hospital. 

As we discussed, I have enclosed the documents we need to get you started: the representation agreement and a medical authorization. We would like to get these documents back immediately so we can begin our investigation. For your convenience, I have attached a self-addressed stamped envelope.

If the Henderson Trucking or its insurance company contacts you, do not speak to them and refer them to our office. At this sensitive point, you also should not talk to your insurance company, State Farm, unless I am on the call with you. Also, make sure you do not discuss the accident or your injuries using any social media.

We look forward to working with you to achieve the best possible recovery for you in your case. If you have questions about your case, either now or anytime throughout this process, please do not hesitate to contact me. We are here to help.

Very truly yours, 


Ronald V. Miller, Jr.


Enclosures

Representation Agreement

I, Steven C. Dulin, retain and employ Miller & Zois, LLC (M&Z) as my Attorneys to represent me in my claim against any individual, company or entity for bodily injuries sustained arising out of an incident which occurred on January 27, 2016.

It is understood and agreed that my Attorneys will receive as their fee thirty-three and one-third percent (33-1/3%) of the gross amount received by way of settlement. If a lawsuit is filed, or my case is submitted to binding arbitration, my Attorneys shall receive as their fee forty percent (40%) of the gross amount received. This retainer does not apply to any appeal I may decide to pursue from a court ruling. M&Z is not obligated to file any appeal on my behalf. 

I further agree that in the event I choose to no longer pursue my case, or if this attorney-client relationship is terminated by either party, M&Z will retain my file until an agreement is made with respect to M&Z’s fee and M&Z is reimbursed for expenses incurred.

M&Z will advance all reasonable expenses associated with my case. Expenses include, but are not limited to, copies of medical records, police reports, depositions, investigative fees, photocopying, postage, filing fees of the court, expert witness fees, court reporter and videographer fees, travel expenses and any other expenses necessary for the proper handling of my case. These costs will be reimbursed to M&Z out of any financial recovery M&Z obtains on my behalf. 

M&Z may assist me in processing my personal injury protection claim ("PIP"), but will not take any fee for this assistance, nor does M&Z represent me for any claims I may have against any individual or insurance company for any disputes arising out of a PIP dispute. 

M&Z will be given power of attorney to complete and sign any application or paper work necessary to process my personal injury protection claim on my behalf.   M&Z does not represent me for any property damage claim.

If there is no recovery on my behalf, M&Z does not receive a fee and M&Z will be responsible for any and all costs or expenses incurred.

Steven C. Dulin
Miller & Zois, LLC

Authorization to Use or Disclose Health Information Compliant with Health Insurance Portability and Accountability Act (HIPAA) Regulations

Patient Name: Steven C. Dulin Date of Birth: 01/01/60
Social Security Number: 123-45-6789

  1. I authorize the use or disclosure of the above-named individual's health information as described below.
  2. The following individual(s) or organization(s) are authorized to make the disclosure:
  3. The type of information to be used or disclosed is as follows: COMPLETE MEDICAL RECORDS AND ITEMIZED ACCOUNT STATEMENTS.
  4. 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 abuse.
  5. The information identified above may be used by or disclosed to the following individuals or organization(s): My Attorneys: Miller & Zois, LLC (M&Z), 1 South St, #2450, Baltimore, MD 21202, 410-779-4600.
  6. The information for which I'm authorizing disclosure will be used for my personal injury litigation.
  7. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that 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.
  8. This authorization will expire one year from the date on which it was signed.
  9. I understand that once the above information is disclosed, it may be redisclosed by the recipient, and the information may not be protected by federal privacy laws or regulations.
  10. I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure healthcare treatment.

Signature of patient or legal representative:
___________________________________

  • Sample initial client intake forms and how to set up your intake process to best select cases
  • How to set up a personal injury case in Maryland from the beginning

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