Attorneys at Law. Información del Cliente

Transcripción

1 Attorneys at Law Información del Cliente Fecha: Fecha del Accidente: Ubicación: Ciudad/Estado/Condado Nombre completo del cliente: Adulto [ ] Menor de Edad [ ] Nombre del Representante Personal: Dirección: Ciudad: Estado: Código Postal: Casa: ( ) Otro: ( ) Empleo: ( ) Fax: ( ) Celular: ( ) Correo Electrónico: Fecha de Nacimiento: Lugar de Nacimiento: Edad: Número del Seguro Social: Resides en Florida? Cuanto Tiempo? Casado: Fecha de la Boda: Hijos: Nombre de Cónyuge: Numero Social de Cónyuge: Fecha de Nacimiento de Cónyuge: Divorciado: Fecha de Divorcio: Referidos Por:, Doctor [ ], Cliente [ ], Amigo [ ], Empleado [ ], Guía Telefónica [ ], Pagina de Web [ ], INTERNET [ ], Televisión [ ], Otro [ ] TIPO DE INCIDENTE: AUTO [ ] - Conductor [ ] Pasajero [ ] Peatonal [ ] Relacionado con el Trabajo Si [ ] No [ ] Responsabilidad Premisas/ Negligencia de Seguridad [ ], Resbalones y Caídas [ ], Negligencia Médica [ ], Productos Defectuosos [ ], Aviación [ ], Otro: COMO OCURRIO EL ACCIDENTE: Estaba usando un cinturón de seguridad? [ ] Si [ ] No CONDUCTOR [ ] PASAJERO [ ], ASIENTO DELANTERO [ ], ASIENTO TRASERO [ ] TESTIGOS DEL INCIDENTE CONOCIDO AL DEMANDANTE con la información de contacto: Informe de Accidente de Tráfico [ ], Cambio de Información de Conductores [ ], Ningún Informe [ ] Reporte de Incidente [ ], Reporte de Homicidio [ ], Informe de Fuego [ ] Informe de Arresto [ ] FHP [ ], PD [ ], Oficina de Aguacil [ ], Oficina de Fiscal de Distrito [ ] Agencia:

2 Información de Cliente Página 2 Transportado? SI [ ] No [ ] por Ambulancia [ ], Vehículo Privado [ ], Bombero/Rescate [ ], EMS [ ] HERIDAS SUFRIDAS: Cuello [ ] Espalda [ ] Extremidades Superiores [ ] Extremidades Inferiores Dolores de Cabeza [ ] Otros (Sea Específico): NOMBRES DE TODO LOS MEDICOS, HOSPITALES, Y CLINICAS DE TRATAMIENTO: Hospital [ ] Clínica de Cuidados Urgente [ ] Nombre de Facilidad: Quiropráctico [ ] Nombre: Medico Personal: Medico(s) [ ] Nombre(s): Especialista(s): Ortopédico [ ], Neurólogos [ ], Dolor/Trama [ ], Cirujano [ ] Otro [ ] Nombre(s): (Lista de Todos): ATENCIÓN MÉDICA CONTINUADA PARA ESTE ACCIDENTE: ALGUN PLEITO PREVIO? [ ] Si [ ] No Si alguno, Cuanto tiempo hace? Tipo de Caso: Nombre/Dirección de Abogado que te represento: Progresivo [ ], Acepto Arreglo [ ], Rechazo Arreglo [ ] Insolvencia o Compensación de Trabajo pendiente: Si [ ], No [ ] Nombre de Abogado/Numero de Teléfono: HISTORIA DE EMPLEO: Empleado [ ], Desempleado [ ], Retirado [ ], Estudiante [ ] Empleador Presente: Teléfono: Cuantos Años: Nombre de Supervisor: Perdió tiempo de empleo: [ ] Si [ ] No Cuanto Días/Tiempo Perdido: Salario: Por Hora [ ], Semanal [ ], Asalariado [ ], Valor por hora $ SEGURO MEDICO: Medicaid [ ], Medicare [ ], Otro [ ], Nombre: Numero de Póliza.: Numero de Grupo: Numero de Identificación: Numero de Reclamaciones y Dirección: INFORMACION DE SEGURO DE AUTOMOVIL: Demandante como Propietario de Vehículo [ ], Pasajero [ ], Relacionado a el Asegurado/Residente de la Casa [ ], Inquilino [ ], Nombre de Asegurado: Seguro de Automóvil: Nombre de Ajustador: Numero Teléfono de Ajustador: Numero de Póliza: Numero de Reclamo:

3 Información de Cliente Página 3 Otros vehículos poseídos por Demandante: UM/UIM Cobertura(s): Si [ ], No [ ] Danos de Propiedad? Si [ ] No [ ] Pudieron Resolver? Si [ ], No [ ] Cantidad por los Daños: $ Marca de Vehículo/Modelo/Ano: Pasajeros: INFORMACION DE SEGURO DEL DEMANDADO: (Culpable) Seguro de Automóvil: Nombre de Ajustador: Numero Teléfono de Ajustador: Número de Póliza: Número de Reclamo: Marca de Vehículo/Modelo/Ano: Pasajeros: RESBALONES Y CAIDAS/NEGLIGENCIA MÉDICA /OTRO: (No Relacionado con accidente automovilístico) Nombre de Entidad: Tipo De Accidente: Dueño de Casa [ ], Propietario de Negocio [ ], Otro: (Sea Especifico) Si un acusado comerciales o de negocios; Medpay disponibles? Si [ ], No [ ] Cualquier Cobertura de sombrilla: Cobertura de otros posibles: Representación antes de esta afirmación? Si eso es el caso, Lista de Nombre: Caso dado de alta por el abogado? Si [ ] No [ ], o Por Cliente Si [ ] No [ ] Carta de descarga previsto? Si [ ], No [ ] Demandante Entrevistado En: Oficina [ ], Casa [ ], Hospital [ ], Otro Lugar [ ] Entrevistado Por: Notas Adicionales:

4 Attorneys at Law LA AUTORIDAD PARA REPRESENTAR Y EL ACUERDO DEL HONORARIO DE CONTINGENCIA Yo, el cliente abajofirmante, por la presente retiene y emplea el Bufete de abogados de Pineyro Law Firm, P.A., como mis abogados para representarme en mi reclamo para daños contra o contra cualquier otro partido, empresa o corporación responsables por lo tanto, resultando de un accidente que ocurrió en. Yo POR LA/EL PRESENTE CONCUERDO en pagar por los costos contraído por Pineyro Law Firm, P.A., a procesar este reclamo y los autorizo emprenda contrae tales costos como ellos pueden creer necesario de vez en cuando. Estos costos incluyen, pero no son limitados a, tales artículos como los informes de policía, el hospital y los historiales médicos, las fotografías, archivando el honorario, los costos de servir citaciones y citaciones, los honorarios de periodistas de tribunal, la lista del jurado, las exhibiciones, los registros del estado, los gastos de la investigación, los honorarios expertos de testigo, inclusive honorarios para el testimonio y honorarios médicos para conferencias médicas. Ellos harán cada esfuerzo de mantener estos costos en un absoluto mínimo coherente con los requisitos del caso. En aquel momento el caso es cerrado, una contabilidad será causada todos desembolsos hechos en mi caso. Cuando la compensación para sus servicios, yo concuerdo en pagar le a mis abogados del continúa de la recuperación el siguiente honorario: a. Antes el expediente de una respuesta o la demanda por la cita de árbitros o, si ninguna respuesta si archivado o ninguna demanda por la cita de árbitros es hecha, el vencimiento del período de tiempo previo tal acción: /3% de cualquier recuperación hasta $1 millón; más 2. 30% de cualquier porción de la recuperación entre $1millón y $2 millones; más 3. 20% de cualquier porción de la recuperación que excede $2 millones. b. Después de que el expediente de una respuesta o la demanda por la cita de árbitros o, si ninguna respuesta es archivada o ninguna demanda por la cita de árbitros es hecha, el vencimiento del período de tiempo previo tal acción, por la entrada del juicio: 1. 40% de cualquier recuperación hasta $1 millón; más 2. 30% de cualquier porción de la recuperación entre $1 millón y $2 millones; más 3. 20% de cualquier porción de la recuperación que excede $2 millones.

5 Autoridad Para Representar Página 2 c. Si todos acusados admiten ser responsable en aquel momento de la Clasificación de sus respuestas y solicitan un ensayo sólo en daños: /3% de cualquier recuperación hasta $1 millón; más 2. 20% de cualquier porción de la recuperación entre $1 millón y $2 millones; más 3. 15% de cualquier porción de la recuperación que excede $2 millones. d. Un adicional 5% de cualquier recuperación después de que nota de la atracción sea archivada o anuncia el alivio del juicio o la acción es requerida para la recuperación en el juicio. ES CONCORDADO y ES COMPRENDIDO que este empleo está sobre una base contingente del honorario, y si ninguna recuperación es hecha, yo no seré endeudado a mis abogados para ninguna suma todo lo que como honorarios de abogados. EL CLIENTE ABAJOFIRMANTE TENER, ANTES DE FIRMAR ESTE CONTRATO, RECIBIO Y LEYO LA DECLARACION DE DERECHOS de CLIENTE, Y COMPRENDE QUE CADA UNO DE LOS DERECHOS EXPONEN EN ESO. EL CLIENTE ABAJOFIRMANTE TENER FIRMO LA DECLARACION Y RECIBIO UNA COPIA FIRMADA PARA MANTENER PARA REFERIRSE A MIENTRAS SER REPRESENTADO POR EL ABAJOFIRMANTE UN. ESTE CONTRATO MAYO ES CANCELADO POR la NOTIFICACION ESCRITA AL TIEMPO DE ABOGADO EN DENTRO DE TRES (3) DIAS HABILES DE LA FECHA QUE EL CONTRATO FUE FIRMADO, COMO MOSTRADO ABAJO, Y SI CANCELO A EL CLIENTE IR NO ES OBLIGADO A PAGAR NINGUN HONORARIO AL ABOGADO (ABOGADOS) PARA EL TRABAJO REALIZADO DURANTE QUE TIEMPO. SI EL ABOGADO (ABOGADOS) LES HA AVANZADO LOS FONDOS A OTROS EN REPRESENTACION DEL CLIENTE, EL ABOGADO (ABOGADOS) TIENEN DERECHO PARA SER REEMBOLSADO PARA TALES CANTIDADES COMO ELLOS HAN AVANZADO RAZONABLEMENTE A FAVOR DEL CLIENTE. Este día de del 20. Por: CLIENTE Por: CLIENTE El empleo por la presente es aceptado sobre los términos indicados arriba. Por: ABOGADO

6 Attorneys at Law LA DECLARACION DE DERECHOS DEL CLIENTE Antes usted, el futuro cliente, arregla un acuerdo del honorario de la contingencia con un abogado, usted debe comprender esta declaración de sus derechos como un cliente. Esta declaración no es una parte del contrato verdadero entre usted y su abogado, pero, como un futuro cliente, usted debe ser consientes de estos derechos. 1. No hay requisito legal que un abogado carga a un cliente un honorario fijo o un porcentaje del dinero recuperado en un caso. Usted, el cliente, tiene el derecho de hablar con su abogado acerca del honorario propuesto y para negociar acera de la tasa o el porcentaje como en cualquier otro contracto. Si usted no llegar a un acuerdo con un abogado, usted puede hablar con otros abogados. 2. Cualquier contrato del honorario de la contingencia debe estar en la escritura y usted tiene tres (3) días hábiles para volver a considerar el contrato. Usted puede cancelar el contrato sin cualquier razón si usted notifica a su abogado por escrito de tres (3) hábiles de firmar el contrato. Si usted retira del contrato dentro de los primer tres (3) días, usted no le debe el abogado un honorario aunque usted pueda ser responsable de los costos reales del abogado durante ese tiempo. Pero si su abogado comienza a representarle, su abogado no puede retirar del casa sin darle advierte, entregando lo papeles necesarios a usted, y le permite tiempo de emplear a otro abogado. A menudo, su abogado sin la causa buena después del periodo de tres (3) días, usted puede tener que pagar un honorario para el trabajo el abogado ha hecho. 3. Antes de contratar a un abogado, usted, el cliente, tiene el derecho de saber de la educación del abogado, entrenamiento y la experiencia. Si usted pregunta, el abogado le debe decir específicamente acerca de la experiencia verdadera de abogado que trata con casos semejantes a suyo. Si usted pregunta, el abogado debe proporcionar información sobre la instrucción o el conocimiento específicos y darle esta información en la escritura si usted lo solicita. 4. Antes de firmar un contrato contingente del honorario con usted, un abogado le debe aconsejar si el abogado piensa manejar su caso solo o si otros abogados estarán ayudando con en el caso. Si su abogado piensa referirse el caso a otros abogados, el abogado le debe decir que clase del arreglo de compartir de honorario será hecha con los otros abogados. Si abogados de bufetes de abogados diferentes le representaran, por lo menos un abogado de cada bufete de abogados debe firmar el contrato contingente del honorario.

7 Derechos del Cliente Página 2 5. Si su abogado piensa referirse su caso a otro abogado o el consejo con otros abogados, su abogado le debe decir acerca de eso al principio. Si su abogado toma el caso y decide luego referírselo a otro abogado o para asociarse con otros abogados, usted debe firmar un nuevo contrato que incluye a los nuevos abogados. Usted, el cliente, también tiene el derecho de consultar con cada abogado que trabaja en su caso y cada abogado es legalmente responsable representar su interés y es legalmente responsable de los actos de otros abogados implicados en el caso. 6. Usted, el cliente, tiene el derecho de saber en avanza como usted necesitara pagar los gastos y los gastos judiciales a fines del caso. Si usted paga un deposito en el avance para costos, usted puede hacer preguntas razonables acerca de cómo el dinero será o ha sido gastado y cuanto de ellos se queda no gastado. Su abogado debe dar una estimación razonable acerca de futuros costos necesarios. Si su abogado concuerda en prestar o avanzarle dinero para preparar o investigar el caso, usted tiene el derecho de saber periódicamente cuanto que su abogado ha gastado en su beneficio. Usted también tiene el derecho de decidir, después de consultar con su abogado, cuánto dinero es de ser gastado para preparar un caso. Si usted paga lo gastos, usted tiene el derecho de decidir cuánto gastar. Su abogado también le debe informar si el honorario será basado en la cantidad bruta recuperada o la cantidad recupero menos los costos. 7. Usted, el cliente, tiene el derecho de ser dicho por su abogado acerca de consecuencias adversas posibles si usted pierde el caso. Esas consecuencias adversas quizás incluyan dinero que usted quizás tenga que pagar a su abogado para los costos y la obligación que usted quizás tenga para los honorarios de abogado al otro lado. 8. Usted, el cliente, tiene el derecho de recibir y aprobar una declaración final a fines del caso antes usted paga cualquier dinero. La declaración debe listar todos los detalles financieros del caso entero, inclusive la cantidad recuperada, todos gastos, y una declaración precisa de su gasto de abogado. Hasta que usted apruebe la declaración final, usted necesita no le paga dinero a nadie, inclusive su abogado. Usted también tiene el derecho de tener a cada abogado o el bufete de abogados que trabajan en su caso firman esta declaración final. 9. Usted, el cliente, tiene el derecho de preguntar a su abogado en intervalos razonables como el progreso de caso y para tener estas preguntas contestadas al mejor de la capacidad de su abogado. 10. Usted, el cliente, tiene el derecho de hacer la decisión final con respecto al arreglo de un caso. Su abogado le debe notificar de todas las ofertas de cualquier arreglo antes de y después del juicio. Las ofertas durante el caso deben ser comunicadas inmediatamente, y usted debería consultar con el abogado con

8 Derechos del Cliente Página 3 respecto a si aceptar cualquier arreglo. Sin embargo, usted debe hacer la decisión final para aceptar o rechazar un arreglo. 11. Si en tiempo, usted, el cliente, cree que su abogado ha cargado un honorario excesivo o ilegal, usted tiene el derecho de informar el asunto a La Barra de Florida, la agencia que supervisa la práctica y la conducta de todos abogados en Florida. Para la información en cómo alcanzar The Florida Bar, tendrás que llamar (800) , o contactar la asociación local de la Bar Asociación. Cualquier descuerdo entre usted y su abogado acerca de un honorario pueden ser tomados para cortejar y usted puede desear emplear otro abogado para ayudarlo a resolverse este desacuerdo. Generalmente, disputas de honorario deben ser manejadas en un pleito separado, a menos que su contrato del honorario prevea el arbitraje. Usted puede solicitar, pero no puede requerir, que una provisión para el arbitraje (bajo el Capitulo 682, los Estatutos de Florida, ni bajo la regla del arbitraje del honorario de las reglas que Regulan La Barra de Florida) es incluido en su contrato del honorario. Este día de del 20. Por: CLIENTE Por: CLIENTE El empleo por la presente es aceptado sobre los términos indicados arriba. Por: ABOGADO

9 Attorneys at Law PODER DE ABOGADO Por medio de este Poder designo a Johnny A. Pineyro, y el Pineyro Law Firm P.A., como Agente y Abogado de Hechos para actuar en mi favor, negociar en todas y cada una de las transacciones requeridas por este caso, incluyendo cualquier transacción bancaria; cheques bancarios que sean recibidos a mi favor y referentes a dicho reclamo. Firma De Cliente STATE OF FLORIDA COUNTY OF The foregoing instrument was acknowledged before me this day of, 20 by who is personally known to me/produced as identification. (Notary Seal) Printed Name: Notary for the State Of Florida at Large My Commission Expires: Commission No.:

10 Attorneys at Law GASTOS POR VIAJES DE LA FIRMA En Pineyro Law Firm, P.A., nuestro deseo o intención es encontrar el medio más eficiente y razonable cuando sea necesario transportarnos fuera de nuestras oficinas para cumplir obligaciones con su caso. Por la presente, el cliente(s) está de acuerdo en que dichos gastos por viajes asociados con su caso serán descontados del dinero recibido una vez que dicho caso sea finalizado. El Pineyro Law Firm, P.A., no logra resolucionar su caso; ningún gasto, incluyendo gastos de viajes, serán responsabilidad de usted, nuestro cliente(s). Por lo tanto, usted(es), nuestro cliente(s), otorga(n) consentimiento a nuestra firma para usar nuestro avión, propiedad de Pin-Aero, LLC, para el uso exclusivo de su caso cuando sea requerido el uso de transporte aéreo. Estamos consientes que transporte aéreo privado es menos costoso que el uso de transporte aéreo comercial. No todos los casos requieren el uso de transporte aéreo. Por lo tanto, se entiende que usted(s) no incurrirá(n) gastos de este tipo durante la representación legal a menos que sea necesario el uso de transporte aéreo para su caso. Firma De Cliente Fecha Firma De Cliente Fecha

11 Attorneys at Law MILEAGE CLAIM FORM Name: Date of Accident: Claim #: Date List Trips Taken Such as Home to ; or Work to Round Trip Daily Mileage I HEREBY CERTIFY that the above information furnished by me is true and correct and based upon this information, I hereby claim pay for the above mileage as indicated. Signature Date

12 Attorneys at Law PATIENT AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION (PHI) (HIPAA) I, Date of Birth:, SSN: hereby authorize: or its agents, employees and associates, to release the protected health information that is described below, to PINEYRO LAW FIRM, PA, 1170 Celebration Blvd., Suite 100, Celebration, Florida its agents and employees. The protected health information released herein is specifically as follows: I hereby acknowledge my rights as disclosed hereinafter and authorize the release of the records as outlined above: This authorization expires on:. If no date is provided, this authorization expires in three years. DATED this day of,. Patient or Legal Representative If executed by a legal representative, the representative's authority to act on the patient's behalf is: (e.g. "As a parent, or attorney, or as legal guardian"). The protected health information released herein is specified as follows: The complete medical record/chart of the above-named patient and all materials or information including, but not limited to, all medical records, hospital records, physicians records, surgeons records, consultation records, operative reports, physical therapy and other therapy records; x-rays, CT scans, MRI scans, PET scans and reports, ultrasounds, or other diagnostic studies; laboratory reports; patient information and history questionnaires; history and physical examination records; discharge summaries; progress notes, prescriptions and medication records; nurses notes; psychotherapy and/or psychiatric records and notes; correspondence; consent for treatment; statements for services rendered; labor/delivery records and fetal monitor strips (if applicable); and/or any other materials (whether written or stored, created or maintained in any other form, including or facsimile transmissions relating or pertaining to this patient), including documents and records received from or that were created by another provider. I understand that the information in the patient s 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, or treatment for alcohol or drug abuse. A photographic copy of this authorization shall be as valid as the original. The purpose of this authorization and request is to obtain ALL medical information about the patient s physical condition, which may be relevant as it pertains to certain personal injury claims or litigation. I hereby authorize my attorneys at PINEYRO LAW FIRM, to speak to my healthcare professionals privately or to take testimony at deposition or trial as may be requested.

13 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 by sending or presenting my written revocation to the Privacy Contact of the health care provider named above. I understand that the revocation of this authorization will not apply to the extent that the health care provider has taken action in reliance thereon; or if the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself. I understand that a refusal to sign this form will not result in a denial of health care by the hospital or any other health care provider and that this release has not been coerced by a health care entity or any of its business associates. I understand that once the patient s health information (PHI) is disclosed, it may be re-disclosed to individuals or organizations that are not subject to the federal privacy regulations such as expert witnesses, litigants, insurance companies, and even may become public record if filed with a court of law. I understand that authorizing the disclosure of this health care information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in 45 CFR I have the right to inspect and amend my medical records as provided in 45 CFR I have the right to an accounting of the use and disclosure of my health information to any third party as provided in CFR I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure of the patient s health information by the recipient, resulting in the health information no longer being protected by federal or state confidentiality rules. Florida Statutes provides: (1) Any licensed facility shall upon written request, and only after discharge of the patient, furnish, in a timely manner, without delays for legal review, to any person admitted therein for care and treatment of treated thereat, or to any such person s guardian, curator, or personal representative, or in the absence of one of those persons, to the next of kin of a decedent or the parent of a minor, or to anyone designated by such person in writing, a true and correct copy of all patients records including X-rays, and insurance information concerning such person, which records are in the possession of the licensed facility, provided the person requesting such records agrees to pay a charge. The exclusive charge for copies of patient records may include sales tax and actual postage, and except for nonpaper records which are subject to a charge not to exceed $2 as provided in s (9)(c), may not exceed $1 per page, as provided in s (8)(a). A fee of up to $1 may be charged for each year of records requested. These charges shall apply to all records furnished, whether directly from the facility or from a copy service providing these services on behalf of the facility. However, a patient whose records are copied or searched for the purpose of continuing to receive medical care is not require to pay a charge for copying or for the search. The licensed facility shall further allow any such person to examine the original records in its possession, or microforms or other suitable reproductions of the records, upon such reasonable terms as shall be imposed to assure that the records will not be damaged, destroyed or altered.

14 AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI) Section A: This section must be completed for all Authorizations Patient Name: Birth Date: Social Security No. (optional): Provider s Name: Recipient s Name: Provider s Address: Address 1: Address 2: City: State: Zip: This authorization will expire on the following: (Fill in the Date or the Event but not both. If no date or event is specified this authorization will expire one year from date of signature.) Date: Event: Purpose of disclosure: Description of information to be used or disclosed Is this request for psychotherapy notes? Yes, then this is the only item you may request on this authorization. You must submit another authorization for other items below. No, then you may check as many items below as you need. Description: Date(s): Description: Date(s): Description: Date(s): All PHI in medical record Admission form Operative Information Special test/therapy Other: DIGITAL IMAGES: Dictation reports Rhythm Strips ACH RBH Physician orders Clinical Test Medication Sheets Nursing Information Transfer forms Billing record Itemized bill: CENTERPOINT LRHC LSH MMC OPRMC OTHER I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results or AIDS information. (Initial) I understand that: 1. I may refuse to sign this authorization and that it is strictly voluntary. 2. If I do not sign this form, my health care and the payment for my health care will not be affected unless stated otherwise in section C. 3. I may revoke this authorization at any time in writing, but if I do, it will not have any affect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy Practices. 4. If the requester or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be redisclosed. 5. I understand that I may see and obtain a copy the information described on this form, for a reasonable copy fee, if I ask for it. 6. I get a copy of this form after I sign it. Section B: Is the Requester of this PHI another health plan or health care provider? If yes, the health plan or health care provider must complete Section B, otherwise skip to Section C. What is the purpose of this use or disclosure? Will the requester receive financial or in-kind compensation in exchange for using or disclosing this information? Yes No If yes, describe: Section C: Will the PHI be created for research and include treatment of the patient? If yes, complete Section C below otherwise skip to Section D. Describe the extent to which the PHI will be used or disclosed to carry out treatment, payment or health care operations? Describe the disclosures that will NOT be made even if they are permitted by law. Will the Requester plan to obtain the patient s consent and/or provide a notice of privacy practices? Yes, then all statements above are binding. No Section D: Signatures I have read the above and authorize the disclosure of the protected health information as stated. Signature of Patient/Guardian/Patient Representative: Print Name of Patient s Representative: Date: Relationship to Patient:

15 AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI) To the extent applicable to this Agreement, Contractor agrees to comply with the Health Information Technology for Economic and Clinical Health Act of 2009 (the "HITECH Act"), the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, as codified at 42 USC 1320d through d-8 ("HIPAA") and any current and future regulations promulgated under either the HITECH Act or HIPAA, including without limitation the federal privacy regulations contained in 45 C.F.R. Parts 160 and 164 (the "Federal Privacy Regulations"), the federal security standards contained in 45 C.F.R. Parts 160, 162 and 164 (the "Federal Security Regulations"), and the federal standards for electronic transactions contained in 45 C.F.R. Parts 160 and 162 (the "Federal Electronic Transactions Regulations"), all as may be amended from time to time, and all collectively referred to herein as "HIPAA Requirements." Contractor agrees to enter into any further agreements as necessary to facilitate compliance with HIPAA Requirements.

16 RICK SCOTT GOVERNOR Better Health Care for all Floridians ELIZABETH DUDEK SECRETARY Authorization for the Use and Disclosure of Protected Health Information Federal law states that we cannot share an individual s health information without the individual s permission, except in certain situations. By signing this form, you are giving us permission to share the information you indicate below. If you decide later that you do not want us to share this information any more, you can revoke this authorization at any time in writing or sign the REVOCATION SECTION on the back of this form and return it to ACS Recovery Services (ACS). This form must be completed and signed by the Medicaid recipient or by an individual who has the authority to act on the Medicaid recipient s behalf (parent of a minor, legal guardian, trustee, power of attorney, personal representative of the estate, grantor of an annuity). PLEASE COMPLETE THE FOLLOWING SECTIONS 1. Personal Information: Medicaid Recipient s Name Date of Birth Medicaid ID Number Social Security Number 2. I give permission to the Agency for Health Care Administration (AHCA) and its contract representatives to share the health information listed below with the following: Name of the Law Firm or Law Office Name of the Insurance Company Other 3. Indicate the purpose for which the disclosure is to be made: To substantiate Medicaid s lien relating to a lawsuit To substantiate Medicaid s claim against the estate or against a trust account or annuity Other 4. Indicate the information that you want to be disclosed, related to the following (check one): The Medicaid lien relating to the injury or negligence charges, for the period beginning with the date of incident. Medicaid s claim against the estate. The amount that is due Medicaid from the trust account, [Please send a copy of the trust agreement]. The amount that is due Medicaid from the annuity account, [Please send a copy of the annuity agreement]. Other, [Please be specific]. 5. Enter the specific date that you want this authorization to expire: (i.e., one year from date of release) (If you do not enter a date, this authorization will expire in five years.) I understand that the information described above may be redisclosed by the person or group that I hereby give AHCA and its contract representatives permission to share my information with, and that my information would no longer be protected by the federal privacy regulations. Therefore, I release AHCA, its workforce members, and its contract representatives from all liability arising from the disclosure of my health information pursuant to this agreement. I understand that I may inspect or request copies of any information disclosed by this authorization if AHCA or its contract representatives initiated this request for disclosure. I understand that I may revoke this authorization by notifying AHCA through its contractor representatives, in writing, knowing that previously disclosed information would not be subject to my revocation request. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment or eligibility for benefits. 6. Recipient Signature Print Name Date OR Name of Legal Representative (Print) Relationship Signature of Legal Representative * Date * If you are not the individual, but represent the individual, please attach a copy of the legal document that verifies that you are a representative (parent of a minor, legal guardian, trustee, power of attorney, personal representative of the estate, grantor of an annuity).

17 INSTRUCTIONS FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION 1. Complete the front of the form and return it to ACS Recovery Services, Post Office Box 12188, Tallahassee, Florida , Phone (toll-free) (877) or Fax (866) If the signer is a guardian, has a power of attorney or is an authorized representative, documentation of the representative s authority to act on the individual s behalf must be attached. If an agency has custody of a child and a representative signs the release, include a copy of the custody order. 3. Special kinds of health information have specific laws and rules that have to be followed before that information can be disclosed. HIV and Sexually Transmitted Diseases (STD): All information about HIV and sexually transmitted diseases is protected under federal and state laws and cannot be disclosed without your written authorization unless otherwise provided in the regulations. To release HIV or STD information, this authorization must include a statement in the Information You Want Disclosed section of the specific HIV or STD information that you are giving permission to release. Re-disclosure of HIV information is not allowed, except in compliance with law or with your written permission. Alcohol and Drug Treatment: Alcohol and/or drug treatment records are protected under federal and state laws and regulations and cannot be disclosed without your written authorization, unless otherwise provided for in federal and state laws or regulations. To release alcohol and drug treatment information, this authorization must include a statement in the Information You Want Disclosed section of the specific information that you are giving permission to release, such as assessment, treatment plan, attendance, discharge plan. Re-disclosure of you alcohol and/or drug treatment records is not allowed, except in compliance with law or with your written permission. Mental Health Treatment: Mental health treatment records are protected under federal and state laws and regulations and cannot be disclosed without your written authorization, unless otherwise allowed in federal and state laws or regulations. To release mental health treatment information, this authorization must include a statement in the Information You Want Disclosed section of the specific information that you are giving permission to release, such as assessment, treatment plan, attendance, discharge plan. Also, disclosure of your therapist s own notes (psychotherapy notes) needs separate permission. Re-disclosure of your mental health treatment records is prohibited, except in compliance with law or with your written permission. 4. You will be provided with a copy of this form. REVOCATION SECTION To revoke your authorization, complete the following section and return the form to ACS Recovery Services at the address given above. (Use of this form to revoke your authorization is optional; however, you must submit your revocation request in writing.) I no longer want my information shared. Name Date of Birth Street Address City State Zip If applicable, your Medicaid ID number Signature OR Signature of Authorized Representative Date Date Relationship of Authorized Representative (Revised November 2008)

18 CONSENT TO RELEASE I, hereby authorize the Centers for Medicare & Medicaid Services (CMS), its agents and/or contractors to release, upon request, information related to my injury/illness and/or settlement to the individual(s) and/or firm(s) listed below: PLEASE CHECK: Claimant s attorney (Name and/or firm) Insurance carrier (Name and/or company) Other (Explain) (Name and/or firm) How long can we give out the information? (Check one Block) Ongoing, beginning Month/Date/Year Limited time through Month/Date/Year Month/Date/Year One time only Claimant s Signature Date of Injury Date Signed Medicare Number If your Power of Attorney (POA) or legal representative signs this form for you, a copy of their POA or representation papers must be sent to us with this form. Completion and signing of this consent form: Authorizes release of information to the person named above upon their request. This means that information disclosed to the above named person may be re-disclosed by them and may no longer be protected by law. Allows release of Medicare claims and other information related to your injury/illness. Is for release of information purposes only and does not affect benefits you are entitled to under the Medicare Program. You have the right to revoke your authorization at any time in writing, except to the extent that CMS has already acted based on your permission. To revoke, send a written request to the address listed below. Medicare Secondary Payer Contractor Post Office Box 33828, Detroit, MI ML045

19 APPLICATION FOR FLORIDA NO FAULT BENEFITS NAME OF INSURANCE COMPANY DATE OUR POLICY HOLDER DATE OF ACCIDENT FILE NUMBER TO ENABLE US TO DETERMINE IF YOU ARE ENTITLED TO BENEFITS UNDER THE FLORIDA PERSONAL INJURY PROTECTION LAW, PLEASE COMPLETE THIS FORM AND RETURN IT PROMPTLY. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURANCE COMPANY MAKES A STATEMENT OF CLAIM CONTAINING ANY FALSE INCOMPLETE OR MISLEADING INFORMATION, IS GUILTY OF A FELONY OF THE THIRD DEGREE. YOUR NAME PHONE NO. YOUR ADDRESS (NO, STREET, CITY OR TOWN, STATE AND ZIP CODE) DATE OF BIRTH SOCIAL SECURITY NO. HOME BUSINESS PERMANENT ADDRESS, IF DIFFERENT HOW LONG HAVE YOU LIVED IN FLORIDA? DATE AND TIME OF ACCIDENT PLACE OF ACCIDENT (STREET, CITY OR TOWN AND STATE) BRIEF DESCRIPTION OF ACCIDENT AND VEHICLES INVOLVED: DESCRIBE MOTOR VEHICLE YOU OWN - DESCRIBE MOTOR VEHICLE OWNED BY ANY MEMBER OF YOUR FAMILY- AS A RESULT OF THIS ACCIDENT, WERE YOU INJURED? HERE AND RETURN THIS FORM TO US. SIGNATURE: DESCRIBE YOUR INJURY IF YOUR ANSWER IS YES, COMPLETE THE REST OF THIS FORM. IF NO, SIGN DATE: WERE YOU TREATED BY A DOCTOR? IF YOU WERE TREATED IN A HOSPITAL, WERE YOU AN IN PATIENT OUT PATIENT AMOUNT OF MEDICAL BILLS TO DATE DOCTOR'S NAME AND ADDRESS HOSPITAL'S NAME AND ADDRESS WILL YOU HAVE MORE MEDICAL EXPENSE? DID YOU LOSE WAGES OR SALARY AS A RESULT OF YOUR INJURY? IF YES, AMOUNT OF LOSS TO DATE AT THE TIME OF YOUR ACCIDENT, WERE YOU IN THE COURSE OF YOUR EMPLOYMENT? IF YOU LOST WAGES: DATE DISABILITY FROM WORK BEGAN DATE YOU RETURNED TO WORK WHAT IS YOUR AVERAGE WEEKLY WAGE OR SALARY? HAVE YOU RECEIVED, OR ARE YOU ELIGIBLE FOR, PAYMENTS UNDER ANY WORKMEN'S COMPENSATION OR EMPLOYMENT LAW? IF YES, AMOUNT PER WEEK PER MONTH LIST NAMES AND ADDRESSES OF YOUR PRESENT EMPLOYER(S) AND GIVE YOUR OCCUPATION AND DATES OF EMPLOYMENT FOR EACH EMPLOYER AND ADDRESS YOUR OCCUPATION FROM TO EMPLOYER AND ADDRESS YOUR OCCUPATION FROM TO EMPLOYER AND ADDRESS YOUR OCCUPATION AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES? SIGNATURE: DATE: FROM IF YES, EXPLAIN ON REVERSE SIDE TO IMPORTANT: 1. TO BE ELIGIBLE FOR BENEFITS COMPLETE AND SIGN THIS APPLICATION 2. SIGN AND ATTACH AUTHORIZATION(S) 3. RETURN PROMPTLY WITH ANY MEDICAL BILLS YOU HAVE RECEIVED TO DATE

20 DO NOT DETACH AUTHORIZATION FOR MEDICAL INFORMATION THIS AUTHORIZATION OR PHOTOCOPY HEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY CONDITION WHILE UNDER YOUR OBSERVATION OR TREATMENT, INCLUDING THE HISTORY OBTAINED, X-RAY AND PHYSICAL FINDINGS DIAGNOSIS AND PROGNOSIS. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE FLORIDA NO FAULT AUTO INSURANCE LAW (CHAPTER F.S.) SIGNATURE DATE DO NOT DETACH AUTHORIZATION FOR WAGE AND SALARY INFORMATION THIS AUTHORIZATION OR PHOTOCOPY HEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY WAGES OR SALARY WHILE EMPLOYED BY YOU. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE FLORIDA NO FAULT AUTO INSURANCE LAW (CHAPTER F.S.) SIGNATURE DATE SOCIAL SECURITY NO.