How did you hear about our office? MEDICAL MALPRACTICE INTERVIEW Sign-Up Date: Date of Surgery: Medical Clinic Name: Telephone # Area of the Body: CLIENT S INDEX INFORMATION Were you the patient? Yes ( ) No ( ) * if you are not, state your relation: Your FULL Name: - Address: Age: City, State, zip Sex: Telephone #: ( ) Cell/alternative #( ) Marital Status: Birth date: Social Sec. #: Place of Birth: Driver s License CLIENT S EMPLOYMENT INFORMATION Occupation/Position: Employer/Company Name: Address: Telephone #: ( ) Years in this job? CLIENT S MEDICAL INFORMATION Insurance Carrier: Policy #: Telephone # Health History: Area/City of: Please explain your health history. Have you had prior surgeries (major or minor?) Please explain & date. Sickness/Surgery? Please explain why you went through surgery? What physical/mental problems did you have? Family Physician: Is this the same doctor who performed surgery? If no, please go on to next page. MEDICAL MALPRACTICE INTERVIEW 1
Date of Surgery: Where did the surgery take place: SURGERY INFORMATION Facility Name: Address: Patient #: Name of Doctor who performed surgery? Doctor worked for? Why did you need surgery? Were you prescribed any prescription medicine? Please name the medicine & the purpose of the medicine. If so, please state: Name of Drug: Name of Drug: Indication of Drug/ What was it for? Indication of Drug/ What was it for? Name of Drug: Indication of Drug/ What was it for? DESCRIBE YOUR INJURIES Was this an emergency surgery? Yes: ( ) No: ( ) How did you discover something was wrong? What did you discover? - Date: Date you discovered something was wrong? What kind of pains, sickness or experiences did/do you feel or experienced? (that are/were not normal) -- Yes: ( ) No: ( ) Do you have pictures? **If you have any pictures, please provide us with any visuals, this will help our case & for us to understand and evaluate your case. ** (examples: before or after pictures, pictures of bruises, pictures of mistakes) MEDICAL MALPRACTICE INTERVIEW 2
YOUR 2 nd OPINION/SURGERY FROM ANOTHER DOCTOR If you were able to see another doctor/physician, please tell us the information you obtained. If you have not, please let us know. Did you get a second opinion? Yes: ( ) No: ( ) Where? ** This is extremely important for us to have this information** The Doctor s Name: Date you saw this doctor? Areas of Specialty Facility Name: Address: *** Please provide us your story as to WHY you decided to seek a second opinion & what the doctor said: Client s Ultimate Desired Remedy: You do not have to answer this, however, it would be helpful for us to know what you would ultimately want us to do/get for you. Please check the desired remedy and if you have a special desire, please state in the space below: Monetary Damages ($$) Corrective Surgery by another doctor Attempt to correct his/her mistake Letter of Apology Other: Plastic Surgery Referral Referral to a different doctor Medical costs Future Medical Costs The information contained in this communication is confidential, may be attorney-client privileged, may constitute inside information, and is intended only for the use of the addressee (our client & our office). It is the property of The Bonar Law Group. Any unauthorized use, disclosure, or copying of this communication or any part thereof is strictly prohibited and may be unlawful. MEDICAL MALPRACTICE INTERVIEW 3
Client s Time Line Events This is our client s chance to give us a time line of events. Please take your time to set in the dates, to give us a clearer picture as to what happened and when and the dates. Please follow these steps to guide you: (1) Date of discovery of the problem, how did you find out and why? (2) Date you were told you needed surgery with whom? a. What happened? (3) Date you discovered something was wrong or something happened? (4) What did you do? Did you see a second opinion? With whom? What was said? (5) Anything else you find important. # Date Events 1 2 3 4 5 6 7 MEDICAL MALPRACTICE INTERVIEW 4
AUTHORIZATION FOR RELEASE OF PATIENT MEDICAL AND/OR BILLING RECORDS HIPAA COMPLIANT AUTHORIZATION FORM I authorize (name of person or facility which has information) to release health information to: Name of person or facility to receive health information Specify name/title of person to receive health information, if known / Telephone # Street Address, City, State, Zip Code Please specify the health information you authorize to be released: MEDICAL RECORDS MEDICAL BILLS Type(s) of health information: Date(s) of treatment: The following information will not be released unless you specifically authorize it by marking the relevant box(es) below: I specifically authorize the release of information pertaining to drug and alcohol abuse, diagnosis or treatment (42 C.F.R. 2.34 and 2.35). I specifically authorize the release of HIV/AIDS test results (Health and Safety Code 120980(g)). I specifically authorize the release of genetic testing information (Health and Safety Code 124980(j)). The purpose of this release is for (check one or more): At the request of the patient/patient representative Other (state reason) MEDICAL MALPRACTICE INTERVIEW 5
NOTICE Hospitals, medical facilities and many other organizations and individuals such as physicians, hospitals and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws. YOUR RIGHTS This Authorization to release health information is voluntary. Treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this Authorization except in the following cases: (1) to conduct research-related treatment, (2) to obtain information in connection with eligibility or enrollment in a health plan, (3) to determine an entity s obligation to pay a claim, or (4) to create health information to provide to a third party. This Authorization may be revoked at any time. The revocation must be in writing, signed by you or your patient representative, and delivered to THE BONAR LAW GROUP 1 Centerpointe Dr. Suite #100 La Palma, CA 90623 Telephone: (714) 452-1428 Fax Line: (714) 452-1418. The revocation will take effect when THE BONAR LAW GROUP receives it, except to the extent THE BONAR LAW GROUP or others have already relied on it. You are entitled to receive a copy of this Authorization. EXPIRATION OF AUTHORIZATION Unless otherwise revoked, this Authorization expires (insert applicable date or event). If no date is indicated, the Authorization will expire 12 months after the date of my signing this form. Print Name Signature (Patient, Parent, Guardian) Date Time Relationship to Patient (Parent, Guardian, Conservator, Patient Representative) Witness (only if patient unable to sign) MEDICAL MALPRACTICE INTERVIEW 6
RETAINER AGREEMENT The client (your name)/client and BONAR LAW GROUP, and hereinfter, client, enter the following retainer fee agreement concerning an incident which occurred on or about (date of your surgery/doctor visit/experience). Said client and attorney agree that: 1. Said attorney agrees to prosecute said claim or lawsuit on behalf of the client and to perform all of the legal services necessary or appropriate, including instituting legal action, conduction discovery, and trial of the matter in the event that the case does not settle; it is further agreed that said attorney is authorized to settle such lawsuit or claim on behalf of the client with the client's consent or when it is deemed for the best interest of the client when the client cannot be found; said attorney is authorized to employ investigators and other personnel to properly prepare the case and fees incurred therein will be added to the cost bill. 2. Effective January 1, 1988, in the event the claim or lawsuit involves a health care provider as defined in California Business and Professions Code 6146, the following fee schedule will apply to that portion of the settlement limited to the health care provider as follows: If case settles Attorney Gets Client Gets $50,000 & below 40% $50,000 - $100,000 33.33% $100,000 -$600,000 25% 60% (minus any medical fees that remain unpaid with proper lien) 66.67% (minus any medical fees that remain unpaid with proper lien) 75% (minus any medical fees that remain unpaid with proper lien) 85% $600,000 above 15% (minus any medical fees that remain unpaid with proper lien) ** The above fee schedule shall apply to each tort feasor who is a health care provider, separately. These fees are negotiable. 3. In the event that the California Business and Professions Code 6146 is altered or amended by the Legislature or any other governmental body, the client agrees to pay as and for fees in this litigation the amended fee schedule if it has become law at the time of the settlement or judgment in this matter. MEDICAL MALPRACTICE INTERVIEW 7
4. SPECIAL POWER OF ATTORNEY: Client hereby grants to The Bonar Law Group a special power of attorney to affix or sign for the client, the Client s name on any legal document or any document she deems beneficial to Client. However, if client is no where to be found/contacted after due diligence, the attorney will have the power to settle the claim and affix the client s name on any legal document for the best interest of the client and on the behalf of client as she deems fit and proper for the best interest of the client. This includes any settlement offers, which is beneficial to the client, and any documents that can protect the client. It is further understood and agreed that if, after the settlement, client is unavailable for any reason, BONAR LAW GROUP is authorized to endorse Client s name on any check, draft, or other instrument or document representing the recovery and to deposit Client s net recovery in the Law Offices of Bonar Law Group - Client s Trust Account be turned over to Client when Client becomes available. 5. As compensation for services rendered by said attorney in recovering damages from a nonhealth care provider or from a health care provider or from a health care provider for intentional torts, the client will pay 40 % of all sums so recovered by settlement or judgment. 6. In addition, said attorneys' fees are to be paid on any amount of outstanding medical bills legally discharged through attorneys' efforts. 7. In the event that any portion of plaintiff's award shall be made in the nature of an annuity or periodic payments, the attorneys' fees therefrom shall be due and payable from the proceeds of the initial cash payment, if any. 8. It is agreed that attorney fees recovered in the case may be divided with other associated attorneys in proportion to the work done and the responsibility assumed by said attorneys. 9. It is agreed that the attorney shall have a lien for his costs and fee on any sum recovered by way of settlement or judgment and this contract shall operate to enforce said claim on behalf of said attorney insofar as this is legally permitted on any amount recovered by a settlement or judgment. 10. Costs and necessary disbursements are to be advanced by client. Should attorney advance any costs, client is to reimburse attorney for said costs. Client understands that trial costs include, but are not limited to jury fees and costs of medical testimony and other expert witnesses arranged for by attorney for presentment at trial. Client promises to deposit estimated trial costs at least thirty (30) days before the date set for trial. Attorney is hereby given a lien on any sum ultimately recovered by way of settlement or judgment for the attorneys' fees and costs advanced. 11. ATTORNEY S LIEN : Client hereby grants to Attorney a lien on any causes of action or claims of Client arising hereunder and any sums received therefore, to the extent of Attorney s professional fees and any costs advanced by Attorney on behalf of Client. If Client discharges Attorney prior to any written settlement of Client s claim or causes of action being obtained by Attorney, Attorney s lien shall be based upon the number of hours expended by Attorney to the date of discharge times Attorney s hourly rate of Two Hundred Fifty Dollars ($250.00) and the costs advanced to that date. If Client discharges Attorney subsequent to Attorney obtaining on behalf of Client a written offer to settle the claim or causes of action arising hereunder, Attorney shall be entitled to a lien against Client s causes of action or claims and on any sums received therefore by Clients to the extent of Attorney s fee based upon the written settlement offer and costs advanced by Attorney on Client s MEDICAL MALPRACTICE INTERVIEW 8
behalf. If Client discharges Attorney at any time, Attorney shall retain a copy of the file and the costs of duplicating the file shall be paid by the Client together with any cost incurred by Attorney on behalf of Client to the date of discharge. 12. If during the handling of the case it becomes the attorney's opinion that there is no provable negligence, or that further prosecution would not be on the best legal interest of the client, the attorney shall make known to the client forthwith. Upon being informed of such opinion, client will release the attorney from any obligation to proceed further and the attorney will, without delay, return the file and records to the client or any other counsel retained by client. If the client wishes the attorney to keep the case active by substituting the client in as the client's own attorney ("In Pro Per"), the attorney will file appropriate papers with the court effecting this transfer. If, on the other hand, the client wishes the attorney to dismiss the case, the attorney will do so upon authorization from the client. In the event that the attorney is discharged by the client, the attorney shall be entitled to compensation for the reasonable value of his services, including all costs advanced as of the date of discharge. 13. This fee agreement shall not be applicable in the event the case is appealed or retried, at which time said attorney and client shall enter into another fee agreement if said attorney decides to continue handling the case. 14. ADMINISTRATION FEE(s) : The Bonar Law Group will charge a $2,500 - $5,000 for each and every Client. Fee will depend on the complexity of the case and the time and matters served. Our firm s administration fees reflect the most reasonable fees for postage, mail service, including FEDEX of heavy documents and professional copy services, subpoena of documents and photocopying, certification of any mail and costs that our incurs to expedite your case. 15. COSTS : Although Attorney, in her sole and unfettered discretion will try to advance all costs, Client agrees to reimburse Attorney for all cost expended by her, including but not limited to the following costs : expert fees, expert reviews, expert fees for affidavits and declaration, professional copy services, postage, photography, medical record/billing fees from medical facilities & hospitals, filing service, investigation, interpreters, experts, records securement fees, photocopying, filing fees, any misc. office fees associated with client s file, deposition fees/charges, skip trace searches and cost for any trial or arbitration, arbitration fees, including party arbitrators. It is further understood and agreed that the cost of all medical care received by Client is the responsibility of Client and that the same does not constitute costs under this agreement, nor charges against Attorney subject to any liens therefore being agreed upon between Client and Attorney. 16. ADMINISTRATION FEE(s) : The Bonar Law Group will charge a $2,500 - $5,000 for each and every Client. Fee will depend on the complexity of the case and the time and matters served. Our firm s administration fees reflect the most reasonable fees for postage, mail service, including FEDEX of heavy documents and professional copy services, subpoena of documents and photocopying, certification of any mail and costs that our incurs to expedite your case. However, this does not include investigation fees by our office. This administration fee will be collected at the end of the representation, wherein a settlement was procured for the client. 17. I / WE, hereby declare penalty of perjury that I / WE was / were in fact driving or riding a motor vehicle at the time of the accident of, and I / WE in fact sustained injuries as a result of the aforementioned accident. MEDICAL MALPRACTICE INTERVIEW 9
18. It is understood that the attorney has made no guarantee or representation of any kind regarding the successful outcome of the client's case, but has agreed to expend his best professional efforts on the client's behalf. Client acknowledges receipt of a copy of this contract. 19. I declare under penalty of perjury that the foregoing is true and correct. 20. I hereby declare under penalty of perjury that my / our decision to retain the LAW OFFICES OF BONAR LAW GROUP was not the result of any promises, offer, monetary or otherwise, and was not the result of any solicitation made by THE BONAR LAW GROUP or any of her employees, representatives or assignees. 21. CLIENT DUTIES: ACCEPTED AND APPROVED. a. I promise to cooperate with The Bonar Law Group and update my attorney in charge of any changes to my health, address or ways of living. b. I promise to update my attorneys of any health changes and any new doctor information or any doctor s comments or expert comments. c. I also promise to continually document and keep a diary of my health and updates. d. I promise to appear when Iam told to appear in person. e. I promise to cooperate with the litigation of my case and answer any questions asked. f. I also promise to be truthful in my facts. Executed : (Date) City, State Signatures: Roxanne Chung Bonar Attorney ** requires attorney s signature to take full effect. Print Name: Client s Signature MEDICAL MALPRACTICE INTERVIEW 10
NOTICE OF ARBITRATION FOR DISPUTES BETWEEN CLIENT & ATTORNEY ARISING FROM REPRESENTATION In the event of any dispute, claim, question, or disagreement (such as, for example, any claim brought by your of legal malpractice and/or legal fees and costs disagreements) arising from or relating to this agreement, the services of THE BONAR LAW GROUP or the breach thereof, the parties hereto shall use their best efforts to settle their dispute, claim, question, or disagreement. To this effect, they shall consult and negotiate with each other in good faith and recognizing their mutual interests, attempt to reach a just and equitable solution satisfactory to both parties. If they do not reach such solution within a period of 60 days, then, upon notice by either party to the other, all disputes, claims, questions, or differences from the aforementioned agreement shall be finally settled by arbitration administered by the American Arbitration Association in accordance with the provisions of its Arbitration Rules. The initial costs of the arbitration shall be borne equally by the parties, but the prevailing party shall be entitled to recover the cost of the arbitration, as well as all other costs and attorney s fees. Alternatively, the dispute may be resolved by submitting the matter to arbitration conducted by the Los Angeles County Bar Associated, in accordance with all applicable rules and statutes. The initial cost of the arbitration shall be borne by the party seeking arbitration before the Los Angeles County Bar Association or Orange County Bar Association; the prevailing party shall be entitled to recover the cots of the arbitration, as well as all other costs and attorney s fees. Disputes over fees may also be subject to voluntary mediation under California Bus. & Prof. Code 6200. Participation in mediation is a voluntary, consensual process, based on direct negotiations between the attorney and the client, and is an extension of the negotiated settlement process. NOTICE: BY SIGNING THIS CONTRACT YOU UNDERSTAND AND ARE AGREEING TO HAVE ANY AND ALL DISPUTES BETWEEN YOU AND THE BONAR LAW GROUP DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL FOR WHICH YOU WOULD OTHERWISE HAVE A RIGHT TO DEMAND AND OBTAIN. READ, ACCEPTED AND APPROVED. Client Signature(s) & Printed Name SIGNATURE PRINTED NAME BELOW MEDICAL MALPRACTICE INTERVIEW 11