1 Attorneys at Law Client Intake Form Date: Date of Incident: Location: City/State/County Client Full Name: Adult [ ] Minor [ ] Guardian/Personal Representative Name (If Minor): Address: City: State: Zip: Home: ( ) Other: ( ) Work: ( ) Fax: ( ) Cell: ( ) Date of Birth: Place of Birth: Present Age: SSN: Do you live in FL? How Long? Married: Date of Marriage: Children: Name(s) of Spouse: Spouse SSN: Spouse Date of Birth: Divorced: Date of Divorce: Referred By:, Doctor [ ], Former Client [ ], Current Client [ ], Friend [ ], Employee [ ], Phonebook [ ], PLF Website [ ], INTERNET [ ], TV [ ], Other [ ] TYPE OF INCIDENT: AUTO [ ] - Driver [ ] Passenger [ ] Pedestrian [ ] Work Related Yes [ ] No [ ] PREMISES LIABILITY/NEGLIGENT SECURITY [ ], SLIP & FALL [ ], MEDICAL MALPRACTICE [ ], PRODUCTS LIABILITY [ ], AVIATION [ ], OTHER: HOW INCIDENT OCCURRED: WERE YOU WEARING A SEATBELT? [ ] Yes [ ] No PASSENGER [ ], Front Seat [ ], Back Seat [ ], DRIVER [ ] WITNESSES TO INCIDENT KNOWN TO PLAINTIFF with Contact Information: Official Traffic Crash Report [ ], Driver Exchange [ ], No Report [ ] Incident Report [ ], Homicide Report [ ], Fire Report [ ] Arrest Report [ ] By FHP [ ], PD [ ], SHERIFF S DEPT. [ ], DA Office [ ] Agency Name: Transported? Yes [ ] /No [ ] by Ambulance [ ], Private Vehicle [ ], Fire/Rescue [ ], EMS [ ]
2 Client Intake Cont. Page 2 INJURIES SUSTAINED: Neck [ ] Back [ ] Upper Extremity (ies) [ ] Headaches [ ] Lower Extremity (ies) [ ] Other, specific: NAMES OF ALL MEDICAL DOCTORS, HOSPITALS, CLINICS FOR TREATMENT: Hospital [ ] Walk-In Clinic [ ] Facility Name: Chiropractic [ ] Name: Personal Doctor: Medical Doctor(s) [ ] Name(s): Specialist: Orthopedic [ ], Neurologist [ ], Pain/Trauma [ ], Surgeon [ ] Other [ ] Name(s): (List ALL) TREATMENT(S) already given for this accident/incident: (exp. MRI Scans, CT Scans, X-rays, Hospital Inpatient/Outpatient, Physical Therapy, Massage Therapy, surgery, etc.): MEDICAL CARE CONTINUED FOR THIS ACCIDENT: ANY PRIOR LAWSUITS: [ ] Yes [ ] No If Yes, How long ago? Type of case: Name/Address of Attorney who represented you: Ongoing [ ], Settled [ ], No Settlement [ ] Bankruptcy or Work Comp Lien pending Yes [ ], No [ ] Atty Name/Phone: WORK HISTORY: Employed [ ], Unemployed [ ], Retired [ ], Student [ ] Present Employer: Phone: How many years: Supervisor Name: Did you Miss Work: [ ] Yes [ ] No If Yes, how many days missed: Wages: Hourly [ ], Weekly [ ], Salaried [ ], Rate per Hour $ MEDICAL INSURANCE: Medicaid [ ], Medicare [ ], Other [ ], Name: Policy No.: Group No.: ID.: Claims Dept Phone No.: Address: INSURANCE INFORMATION: Plaintiff as Vehicle Owner [ ], Passenger [ ], Related to insured/resident of household [ ], Renter [ ], Insured s Name: Auto Insurance: Adjuster Name: Phone: Policy No: Claim No.: Other vehicles owned by plaintiff: UM/UIM Coverage(s): Yes [ ], No [ ] Property Damage Yes [ ] No [ ] Resolved Yes [ ], No [ ] Damage Amount: $ Vehicle Make/Model/Year: Passengers:
3 Client Intake Cont. Page 3 DEFENDANT S INSURANCE INFORMATION: (At Fault Party) Auto Insurance: Adjuster Name: Phone: Policy No: Claim No.: Vehicle Make/Model/Year: Passengers: SLIP & FALL/MEDICAL MALPRACTICE/OTHER: (Non-Auto Related) Name of Entity: Type of Accident: Home Owner [ ], Business Owner [ ], Other: (specify) If a Business or Commercial defendant..medpay available? Yes [ ], No [ ] Any Umbrella Coverage: Other potential coverage: Prior Representation for this claim? If Yes, List Name: Case discharged by prior attorney Yes [ ] No [ ], or by Client Yes [ ] No [ ] Discharge Letter provided? Yes [ ], No [ ] Plaintiff Interviewed at Office [ ], Home [ ], Hospital [ ], Other [ ] Interviewed By: Additional Notes:
4 Attorneys at Law AUTHORITY TO REPRESENT AND CONTINGENCY FEE AGREEMENT I, the undersigned client, do hereby retain and employ the Pineyro Law Firm as my attorneys to represent me in my claim against. I HEREBY AGREE to pay for the costs incurred by the Pineyro Law Firm in prosecuting this claim and authorize them to undertake and/or incur such costs as they may deem necessary from time to time. These costs include, but are not limited to, such items as police reports, records, photographs, filing fees, costs of serving summonses and subpoenas, court reporters fees, jury list, exhibits, state records, investigation expenses, expert witness fees. They will make every effort to keep these costs at an absolute minimum consistent with the requirements of the case. At the time the case is closed, an accounting will be made for all disbursements made in my case. As compensation for their services, I agree to pay my said attorneys from the proceeds of recovery the following fee: a. Before the filing of an answer or the demand for appointment of arbitrators or, if no answer is filed or no demand for appointment of arbitrators is made, the expiration of the time period provided for such action: /3% of any recovery up to $1 million; plus 2. 30% of any portion of the recovery between $1 million and $2 million; plus 3. 20% of any portion of the recovery exceeding $2 million. b. After the filing of an answer or the demand for appointment of arbitrators or, if no answer is filed or no demand for appointment of arbitrators is made, the expiration of the time period provided for such action, through the entry of judgment: 1. 40% of any recovery up to $1 million; plus 2. 30% of any portion of the recovery between $1 million and $2 million; plus 3. 20% of any portion of the recovery exceeding $2 million. c. If all defendants admit liability at the time of filing their answers and request a trial only on damages: /3% of any recovery up to $1 million; plus 2. 20% of any portion of the recovery between $1 million and $2 million; plus 3. 15% of any portion of the recovery exceeding $2 million. d. An additional 5% of any recovery after notice of appeal is filed or post judgment relief or action is required for recovery on the judgment.
5 Retainer Agreement Page 2 IT IS AGREED and UNDERSTOOD that this employment is upon a contingent fee basis, and if no recovery is made, I will not be indebted to my attorneys for any sum whatsoever as attorneys fees. THE UNDERSIGNED CLIENT HAS, BEFORE SIGNING THIS CONTRACT, RECEIVED AND READ THE STATEMENT OF CLIENT S RIGHTS, AND UNDERSTANDS EACH OF THE RIGHTS SET FORTH THEREIN. THE UNDERSIGNED CLIENT HAS SIGNED THE STATEMENT AND RECEIVED A SIGNED COPY TO KEEP TO REFER TO WHILE BEING REPRESENTED BY THE UNDERSIGNED ATTORNEY(S). THIS CONTRACT MAY BE CANCELED BY WRITTEN NOTIFICATION TO THE ATTORNEY AT ANY TIME WITHIN 3 BUSINESS DAYS OF THE DATE THE CONTRACT WAS SIGNED, AS SHOWN BELOW, AND IF CANCELED THE CLIENT SHALL NOT BE OBLIGATED TO PAY ANY FEES TO THE ATTORNEY(S) FOR THE WORK PERFORMED DURING THAT TIME. IF THE ATTORNEY(S) HAS ADVANCED FUNDS TO OTHERS IN REPRESENTATION OF THE CLIENT, THE ATTORNEY(S) IS ENTITLED TO BE REIMBURSED FOR SUCH AMOUNTS AS THEY HAVE REASONABLY ADVANCED ON BEHALF OF THE CLIENT. DATED THIS day of, 20. By: CLIENT By: CLIENT By: CLIENT The above employment is hereby accepted upon the terms stated above. By: ATTORNEY
6 Attorneys at Law STATEMENT OF CLIENT S RIGHTS Before you, the prospective client, arrange a contingency fee agreement with a lawyer, you should understand this statement of your rights as a client. This statement is not a part of the actual contract between you and your lawyer, but, as a prospective client, you should be aware of these rights. 1. There is no legal requirement that a lawyer charge a client a set fee or a percentage of money recovered in a case. You, the client, have the right to talk with your lawyer about the proposed fee and to bargain about the rate or percentage as in any other contract. If you do not reach an agreement with one lawyer you may talk with other lawyers. 2. Any contingency fee contract must be in writing and you have three (3) business days to reconsider the contract. You may cancel the contract without any reason if you notify your lawyer in writing within three (3) business days of signing the contract. If you withdraw from the contract within the first three (3) days, you do not owe the lawyer a fee although you may be responsible for the lawyer's actual costs during that time. But if your lawyer begins to represent you, your lawyer may not withdraw from the case without giving you notice, delivering the necessary papers to you, and allowing you time to employ another lawyer. Often, your lawyer must obtain court approval before withdrawing from a case. If you discharge your lawyer without good cause after the 3-day period, you may have to pay a fee for the work the lawyer has done. 3. Before hiring a lawyer, you, the client, have the right to know about the lawyer's education, training and experience. If you ask, the lawyer should tell you specifically about the lawyer s actual experience dealing with cases similar to yours. If you ask, the lawyer should provide information about specific training or knowledge and give you this information in writing if you request it. 4. Before signing a contingent fee contract with you, a lawyer must advise you whether the lawyer intends to handle your case alone or whether other lawyers will be helping with the case. If your lawyer intends to refer the case to other lawyers, the lawyer should tell you what kind of fee sharing arrangement will be made with the other lawyers. If lawyers from different law firms will represent you, at least one lawyer from each law firm must sign the contingent fee contract. 5. If your lawyer intends to refer your case to another lawyer or counsel with other lawyers, your lawyer should tell you about that at the beginning. If your lawyer takes the
7 Statement of Client s Rights cont. Page 2 case and later decides to refer it to another lawyer or to associate with other lawyers, you should sign a new contract that includes the new lawyers. You, the client, also have the right to consult with each lawyer working on your case and each lawyer is legally responsible to represent your interest and is legally responsible for the acts of other lawyers involved in the case. 6. You, the client, have the right to know in advance how you will need to pay the expenses and the legal fees at the end of the case. If you pay a deposit in advance for costs, you may ask reasonable questions about how the money will be or has been spent and how much of it remains unspent. Your lawyer should give a reasonable estimate about future necessary costs. If your lawyer agrees to lend or advance you money to prepare or research the case, you have the right to know periodically how much money your lawyer has spent on your behalf. You also have the right to decide, after consulting with your lawyer, how much money is to be spent to prepare a case. If you pay the expenses, you have the right to decide how much to spend. Your lawyer should also inform you whether the fee will be based on the gross amount recovered or the amount recovered minus the costs. 7. You, the client, have the right to be told by your lawyer about possible adverse consequences if you lose the case. Those adverse consequences might include money which you might have to pay to your lawyer for costs and the liability you might have for attorney's fees to the other side. 8. You, the client, have the right to receive and approve a closing statement at the end of the case before you pay any money. The statement must list all of the financial details of the entire case, including the amount recovered, all expenses, and a precise statement of your lawyer's fee. Until you approve the closing statement, you need not pay any money to anyone, including your lawyer. You also have the right to have every lawyer or law firm working on your case sign this closing statement. 9. You, the client, have the right to ask your lawyer at reasonable intervals how the case is progressing and to have these questions answered to the best of your lawyer's ability. 10. You, the client, have the right to make the final decision regarding settlement of a case. Your lawyer must notify you of all offers of settlement before and after the trial. Offers during the trial must be immediately communicated and you should consult with your lawyer regarding whether to accept a settlement. However, you must make the final decision to accept or reject a settlement. 11. If at any time, you, the client, believe that your lawyer has charged an excessive or illegal fee, you have the right to report the matter to The Florida Bar, the agency that oversees the practice and behavior of all lawyers in Florida. For information on how to reach
8 Statement of Client s Rights cont. Page 3 The Florida Bar, call (800) , or contact the local bar association. Any disagreement between you and your lawyer about a fee can be taken to court and you may wish to hire another lawyer to help you resolve this disagreement. Usually fee disputes must be handled in a separate lawsuit, unless your fee contract provides for arbitration. You can request, but may not require, that a provision for arbitration (under Chapter 682, Florida Statutes, or under the fee arbitration rule of the Rules Regulating The Florida Bar) be included in your fee contract. DATED THIS day of, 20. By: CLIENT By: CLIENT By: CLIENT The above employment is hereby accepted upon the terms stated above. By: ATTORNEY
9 Attorneys at Law LIMITED POWER OF ATTORNEY The undersigned hereby makes, constitutes and appoints Johnny A. Pineyro, and the Pineyro Law Firm, P.A. as his/her agent and attorney-in-fact, to act in his/her name, place, and stead to negotiate any and all settlement checks drafts with regard to the claim in this matter. This Power of Attorney is only for the purpose of this claim and the recovery in this matter. Client s Signature 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 LAW FIRM TRAVEL COST It remains the intention of the Pineyro Law Firm to find the most efficient and reasonable means of transportation to accomplish its duties and obligations for the client under the circumstances. Client(s) agree(s) to pay all costs associated with the travel from any recovery earned by Pineyro Law Firm on client(s) behalf. If no recovery is made then no costs, including travel costs, are owed by client(s). Client(s) hereby consent(s) to the use of the law firm aircraft owned and/or used by Pin-Aero, LLC for the exclusive purpose of handling this case and any related matters which involve air travel. The Pineyro Law Firm has found that substantial costs can be saved when utilizing general aviation for air travel as compared to commercial aviation. Not all cases require air travel. It is understood that travel costs may not be incurred during the legal representation in which case travel costs would not be charged. Client s Signature Date
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.