Motor Vehicle Medical Records

ATTORNEY-CLIENT CONTINGENCY FEE CONTRACT

*. It is hereby agreed by and between SLOCUMB LAW FIRM, LLC, [Attorney] [Client], that Attorney will represent Client(s) in his/her/their claim for damages against and others arising from personal injuries received in a motor vehicle accident which occurred on . 2. ATTORNEY’S FEES. . Client hereby agrees to pay Attorney Attorney’s fees equal to forty percent (40%) of the gross proceeds. NO RECOVERY—NO ATTORNEY’S FEES. It is agreed and understood that this employment is upon a contingent fee basis, and if no recovery is made, Client will not owe Attorney and Attorney’s fees. Attorney’s fees are deemed earned upon receipt of settlement funds by attorney.

3. CASE EXPENSES. Attorney shall be reimbursed for any and all expenses incurred on Client’s case assuming there is a recovery. Said expenses shall include but not be limited to long distance telephone calls, filing costs, investigative expenses, photo copy costs, travel expenses, including use of automobiles and private or commercial aircraft, court reporting expenses, and any other expenses incurred in representing Client regarding the claim referenced herein. Such costs and expenses shall be deducted from Client’s percentage of any recover effected in this cause, after Attorney’s fees have been deducted from the gross proceeds. 4. RIGHT TO WITHDRAW FROM REPRESENTATION. If after investigating this matter, or at any stage in the litigation, Attorney determines that it wishes to withdraw from representation, Attorney may withdraw as counsel for Client after giving written notice to Client. If, in Attorney's discretion, Client becomes uncooperative in the furtherance of Client's matter, in that event Attorney may withdraw with cause and recover under paragraph 5 of this agreement. 5. QUANTUM MERUIT AND SUBSTANTIAL PERFORMANCE. If Attorney has obtained a settlement offer for Client prior to Client terminating this Agreement, Attorney shall be entitled to the contingency fee of the last highest offered received prior to termination. If Attorney has not received a settlement offer prior to termination by Client, Attorney shall be entitled to compensation on a Quantum Meruit basis unless it is otherwise shown that Attorney has substantially performed in which case the Attorney shall be entitled to the contingency fee of any monies recovered by Client or on Client’s behalf. Should a settlement demand or other demand be issued on Client’s behalf, by Attorney, in that case substantial performance has been met and Attorney shall be entitled to the contingency fee set forth herein of any monies recovered by Client or on the Client’s behalf. 6. AUTHORITY TO COMPROMISE/SETTLE CLAIM. Attorney and Client both agree that the case may not be settled without the consent of Client and Attorney. Client hereby authorizes Attorney to negotiate Client’s claim/case. 7. ASSOCIATION OF COUNSEL. Attorney may associate other counsel to assist in the prosecution of Client’s claim so long as such association is disclosed to Client. 8. STRUCTURED SETTLEMENT. Should Client’s case be resolved through a structured settlement Attorney's fee is to be paid from the first monies recovered.

9. RIGHT TO PRIVACY. I hereby authorize my Attorney to disclose any and all medical information they obtain pursuant to the authorization for release of medical records and information that I have executed. 11. LIMITED POWER OF ATTORNEY. Client hereby grants Attorney a limited power of Attorney to endorse the Client’s name to any checks or drafts received by Attorney in settlement of any and all claims pursued by Attorney on behalf of Client for placement of said funds into trust for Client’s benefit. 12. CHANGES TO AGREEMENT MUST BE IN WRITING. This Agreement and its terms set forth herein may not be changed except by written amendment.

X

Client: Date:

Accepted by:

SLOCUMB LAW FIRM, LLC

BY:

2025-06-03 10:25:54

HITECH MEDICAL RECORDS REQUEST

PATIENT:

DATE OF BIRTH:

DATE(s) OF SERVICE:

Dear, Sir or Madam:

I am your patient. I am requesting:

1. A full copy of my medical records for the date(s) of service referenced above, including but not limited to MRIs, CT scans or other imaging, and any other outside medical records; and

2. Itemized billing records.

Within 30 days as required by Federal Law.

I specifically request that you certify the records and provide them in PDF format on CD, DVD or via secure email or portal.

Please send my records to:

Slocumb Law Firm, LLC

145 E. Magnolia Ave., Ste. 201

Auburn, AL 36830

Tel. 334-***-****

Fax. 888-***-****

I have designated Slocumb Law Firm as my personal representative under 45 CFR 160.103 for the purposes of disclosure of my personal health information. Because the Slocumb Law Firm

“stands in my shoes” for this request, it will pay the HITECH charges for these records. Slocumb Law firm will pre-authorize any amount below $30.00, but wants a pre-bill for any amount over that.

Thank you,

SIGNED:

PRINTED NAME:

HIPAA AUTHORIZATION TO DISCLOSE HEALTH INFORMATION Patient Name: SSN#: Date of Birth: 1. I authorize the use or disclosure of the above named individual's heath information as described below 2. The following individual or organization is authorized to make the disclosure 3. The type and amount of information to be used or disclosed is my ENTIRE RECORD AND BILLING STATEMENTS from the date of to present for treatment as a result of MVA . 4. I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus

(HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

5. I understand that my health plan will not condition its payment activities in connection with my claims, or my enrollment in my health plan, or my eligibility for benefits upon my giving this authorization. Please call me if you have any further questions.

6. This information maybe disclosed to and used by the following individual or organization: Slocumb Law Firm, LLC

145 E. Magnolia Ave., Ste. 201

Auburn, AL 36830

Tel. 334-***-****

Fax. 888-***-****

for the purpose of protecting my legal rights.

I understand I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will Expire 365 days (1 YEAR) from the dated signature below. If I fail to specify an expiration date, event or condition, this authorization will expire in six months. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the above stated medical care provider.

Signature of Patient Date If signed by a legal Representative, Relationship to Patient Signature of Witness

Contact this candidate