Ambitious, Hard-Working Paraprofessional Seeks Legal Role
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Milberg, LLC
www.milberg.com
ATTORNEY REPRESENTATION AGREEMENT
This agreement is made between Milberg LLC, referred to in this agreement as “Attorney” and, referred to in this agreement as “Client” to set out the terms and conditions under which attorney will represent client.
1. ATTORNEY FEE: We charge on a contingency fee retainer meaning that there is no financial risk to you for signing with us. Client understands that there is no guarantee that money will be recovered. We do not charge an attorney fee unless we recover monies for you. If your case settles prior to filing or tolling, the legal fee is 40% of the gross settlement award. If the case settles after filing or tolling, the firm has the discretion to charge 45% of the gross settlement award. The “GROSS settlement” means all money or other things of value including any attorney’s fees awarded by the court. Any Court ordered fees or expenses are charged and deducted from your recovery. 2. CO-COUNSEL: You agree we can work with other law firms affiliated with your case. This association of other attorneys or legal professionals shall not increase the amount of attorney fees paid by you. An agreement has been made to share the contingency fees for the firm(s) representation of you as follows: Milberg, LLC (48%), and Douglas Sanders & Associates (52%). 3. ATTORNEY COSTS AND EXPENSES: We shall advance the court costs and other expenses for this claim, including case specific expenses and a pro rata share of general case expenses. You agree to reimburse us for case specific and general case expenses out of your share of the gross amount recovered. Case specific expenses are those incurred for the sole benefit of your individual claim, including third party case development and administration services. General case expenses are those incurred in the prosecution of your cause of action and others similarly situated. You agree to pay a pro rata share of such general case expenses in exchange for the benefit of sharing these expenses with others similarly situated. These expenses will be disclosed at the time of settlement. If we do not recover an award, you will not owe costs or expenses.
4. THIRD-PARTY EXPENSES: Expenses will be advanced by us through a third-party. Please initial consent here . You agree to reimburse the full sum of all related market rate interest charges for case specific expense costs as well as a pro rata share of related interest charges for general case expenses out of your percentage of the gross amount recovered. You grant us a lien on any proceeds or judgments recovered for your claim as security for the payment of the attorneys’ fees and expenses to be incurred. If there are no proceeds recovered on your claim, then you will not owe any money to our firm for expenses or for our time. 5. DECEASED CLAIMS: If you bring a claim relating to or arising from a deceased person’s damages or injuries, you agree to proceed both individually and as representative of the estate of the deceased person to the extent, you are legally able to do so. This agreement is intended to bind your heirs, death beneficiaries, and your estate representatives if you die. 6. SCOPE OF SERVICES: This Agreement only covers personal injury claims. 7. POWER OF ATTORNEY: We have power of attorney for obtaining medical records, determining litigation strategy, and endorsing checks on recoveries. You authorize us to execute documents necessary to conclude this representation. We can act as your negotiator in all negotiations concerning the subject of this agreement. As part of this power of attorney, you authorize us to require that any settlement Nicholas Glodziak
Document Ref: UT6RI-OMJEE-J4W4Z-ONRX9 Page 1 of 7
www.milberg.com
checks be made payable jointly to you and us and we may reimburse ourselves for expenses and fees prior to disbursing money to you. However, we cannot unreasonably withhold money from you for any recovery. 8. MEDICAL AND SUBROGATION PAYMENTS: You understand and acknowledge that prior to the disbursement of any settlement proceeds, we may be required to investigate and satisfy any third- party interest healthcare liens such as Medicare, Medicaid, and other private, government or other medical provider liens.
9. TERMINATION AND WITHDRAWAL: We can withdraw as your counsel without cause. We can withdraw or close your claim if we determine your claim is/are without merit and/or economically unviable.
10. ATTORNEY’S AUTHORITY: In connection with the claims covered by this Agreement, you hereby grant The Firm(s) the power and authority to file and withdraw loss of consortium claims for spouses at discretion of The Firm(s). The terms of this retainer shall bind spouses as well unless explicitly objected to at the time of signing this agreement. Additionally, you hereby grant The Firm(s) the power of attorney and authority to execute any HIPAA related authorizations including facility specific authorizations needing signature to retrieve medical records or other medical proof needed for your case. In connection with the claims covered by this Agreement, you hereby grant The Firm(s) the power and authority to execute and endorse any and all orders and other papers which you could properly execute or endorse, to receive on your behalf any monies or other things of value to which you may be entitled because of any judgment recovered or any settlement received, and to endorse and /or execute on your behalf any checks or drafts issued or made in connection with your matter. With respect to settling, The Firm(s) will only endorse/execute your signature after you have opted into a coordinated or individual settlement process. 11. SUBSTITUTION OF COUNSEL: The retention of other Firms/Attorneys in place of The Firm(s) carries with it the obligation to immediately repay The Firm(s) and the right at the option of The Firm(s) to have a fixed percentage of the ultimate recovery immediately determined as the fee of The Firm(s). 12. STATUTE OF LIMITATIONS: When we accept your matter, it does not mean that your case is not time-barred based on the statute of limitations grounds. There are legal time limits to prosecute your claim, generally Statutes of Limitation or Repose, and if the Claim is not timely prosecuted then the legal right to pursue the claim may be lost forever. We require reasonable time to thoroughly investigate your legal claims to uphold our ethical responsibility, and we will not act on your behalf without adequate time for investigation. You assume the risk and agree that we shall not be required to pursue your claims, to file a lawsuit, or to take any action to comply with any Statute of Limitations or Repose, if such limitations period expires within 120 days of the date this signed Agreement is received by us. 13. FEDERAL MDL COORDINATION/STATE COORDINATION: In the event there is a court ordered assessment or agreement for fees and costs to be paid to any current or future Federal Multi-district Litigation (MDL) or Federal coordinated proceedings or any State Court coordinated proceedings, this fee and/or cost agreement/assessment, which typically ranges from 6% to 12% of the gross proceeds, will be deducted pursuant to the order of the Court, from your share of the recovery and will not affect the fees and costs to be paid or reimbursed to The Firm(s). At this time, it cannot be determined what fees and costs, if any, will be paid to any of the coordinated litigations 14. SETTLEMENT DISCUSSIONS/ GROUP SETTLEMENT: Client will have authority to accept or reject any final settlement amount after receiving the advice of our attorneys. You understand that your case may be handled as a part of a larger number of cases for negotiating settlement, conducting discovery and/or trial. You authorize us to settle your case for an amount deemed Document Ref: UT6RI-OMJEE-J4W4Z-ONRX9 Page 2 of 7
www.milberg.com
appropriate by us, and acceptable to Client, from the total proceeds paid by a defendant to settle a group of cases. Client authorizes us to disclose the amount of Client's proposed settlement, the nature of Client's damages, and other factors relevant to evaluation of settlement values to other clients whose cases are included in the larger group of settled cases. Client also understands that certain expenses may be incurred in a joint effort to handle groups of cases in a cost effective manner. Client authorizes us to prorate expenses among the cases in the group so that each case, including Client's, pays its fair and appropriate share of such expenses.
15. RECOVERY/SETTLEMENT/FILING SUIT: The Firm(s) is hereby authorized to bring suit when and in any matter The Firm(s) deem advisable. you expressly grant power to the attorneys to endorse and deposit into the attorneys' Trust Account any checks in your/estates’/injured client’s name and authorizes The Firm(s) to deduct fees and to pay all liens and expenses from your share of the recovery. Any unpaid bills for medical care shall remain your obligation. 16. REFUSAL TO ACCEPT A RECOMMENDED SETTLEMENT: If a settlement offer is made, and Attorney recommends to the Client that the offer be accepted, but the Client refuses to accept it, Attorney is permitted to withdraw from representing the Client, unless this cannot be done without prejudicing the claim. The inconvenience of finding replacement counsel and the possibility replacement counsel cannot be found do not, in and of themselves, constitute prejudicing the claim. Withdrawal by the Attorney from a case in which a suit has been filed will be in accordance with the applicable court rules. If the Attorney withdraws under these circumstances, and the claim covered by this Agreement ultimately results in recovery, the Attorney will be entitled to fair compensation for the work done by them and to reimbursement of expenses advanced by them before withdrawing. Fair compensation in this instance is defined as is above.
17. SETTLEMENT PREFERRED TO TRIAL: Attorney is required to make a reasonable effort to resolve the Client’s claim by a settlement reached without going to trial. The ultimate decision to settle the case, or not, will be made by the Client with the lawyer providing legal advice and opinion. 18. STRUCTURED SETTLEMENT: We retain discretion to try and obtain an aggregate settlement for all claimants with the same matter type, with recoveries allocated by a third-party administrator to ensure fairness.
19. SOCIAL MEDIA: You understand, acknowledge and agree that you need to protect your social media site, blog, picture media site, similar or otherwise account(s) with the highest possible privacy settings. You further understand, acknowledge and agree that you will not post anything regarding your case, your injuries, your personal thoughts, photographs or conversations on any social media site, blog or otherwise. Additionally, you understand and acknowledge that ethical rules concerning your lawsuit prohibit your and your attorneys from removing, deleting, editing, concealing or withholding any information which you may have posted to any social media site, blog, picture media site or similar or otherwise and you will not remove, delete, edit, conceal or withhold that information if asked to produce it. 20. COOPERATION: You agree to ensure we have proper contact information for you and an emergency contact. If you fail to provide same, and we are unable to contact you in any six-month period, we have the right to take any actions necessary to be relieved as your counsel, including rejecting your case or moving to withdraw from any filed actions.
21. NO GUARANTEE: You hereby acknowledge that we made no guarantees regarding the successful outcome of this matter and all expressions about the outcome are only opinions. This is the entire agreement. You represent that no one has promised you anything to induce you to retain us. You understand Document Ref: UT6RI-OMJEE-J4W4Z-ONRX9 Page 3 of 7
www.milberg.com
and acknowledge that the decision to hire us was made willfully and independently without outside influence and no person has solicited you on our behalf. 22. JURISDICTION: You agree that this Attorney Representation Agreement shall be governed by Tennessee law and that the appropriate forum for resolving any disputes shall be before the United States District Court, Western District of Tennessee.
Client represents that client has carefully read and fully understood every word in this agreement and agrees to its terms and conditions, and to faithfully comply with them.
Your Signature
Your Name - Printed
Date
Injured Party Name - Printed
Milberg LLC
Firm Signature
Date
6976
Nicholas Glodziak
2026-02-28
Document Ref: UT6RI-OMJEE-J4W4Z-ONRX9 Page 4 of 7
www.milberg.com
RELEASE
I,, hereby understand and have been fully explained that the deadline for filing my claim may be determined to have passed. In light of the fact that I waited to contact an attorney until this date, I do not expect that my suit will be filed prior to this potential deadline. I hold Milberg, LLC; Douglas Sanders & Associates, and their assigns harmless, and release them from any liability for any claim by me for not filing suit prior to this deadline. I am aware of the fact that they may not be able to bring a claim on my behalf after this deadline, and that the lawyers may require further information from me in order to proceed at all. Dated: Signature: 6976
Nicholas Glodziak
2026-02-28
Document Ref: UT6RI-OMJEE-J4W4Z-ONRX9 Page 5 of 7
OCA Official Form No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York State Department of Health] Patient Name Date of Birth Social Security Number
Patient Address
I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996
(HIPAA), I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the persons(s) indicated in Item 8. 2. If I am authorizing the release of HIV related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so unless federal or state law. I understand that I have a right to request a list of people who may receive or use my HIV related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at 212-***-**** or the New York City Commission of Human rights at 212-***-****. These agencies are responsible for protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based upon this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address of health provider or entity to release this information: 8. Name and address of persons(s) or category of person to whom this information will be sent: Milberg LLC; ReleasePoint, PO Box 1390 St. Peters, MO 63376
9(a). Specific information to be released:
[x] Medical Record from to
Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
Other: Include: (Indicate by Initialing)
Alcohol/Drug Treatment
Mental Health Information
HIV-Related Information
Authorization to Discuss Health Information
(b) [X] By initialing here I authorize
Initials Name of individual health care provider
to discuss my health information with my attorney, or a governmental agency, listed here: Milberg LLC ReleasePoint, PO Box 1390 St. Peters, MO 63376
(Attorney/Firm Name or Governmental Agency Name)
10. Reason for release of information:
[X] At request of individual
Other:
11. Date or event on which this authorization will expire: upon conclusion of claim
12. If not the patient, name of person signing form: 13. Authority to sign on behalf of patient: All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form.
Date:
Signature of patient or representative authorized by law.
*Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a person’s contacts. Nicholas Glodziak 02/02/199*-*********
2026-02-28
Document Ref: UT6RI-OMJEE-J4W4Z-ONRX9 Page 6 of 7
Request Letter under HITECH Act of 2009 for Electronic Copy of my Medical Records To: Medical Care Provider:
From: Patient Name:
Patient DOB: Patient SSN: XXX-XX-
Pursuant to 45 CFR § 164.524, I am requesting that you send an electronic copy, in PDF form at, of all of my protected health information ("PHI") from to to my third-party designee(s), ReleasePoint or any subsequent or additional third party designee. I do not want a PHI summary but the full set of records.
Please scan paper records and/or convert electronic records to PDF format and email them to ******@************.***. If you are unable to email my PHI, you may save in PDF format to a thumb drive and mail the same to:
Phone
Fax
should receive any and all correspondence, including invoices for the reasonable cost-based fee for the labor cost of copying my protected health information, paper or electronic media supply costs, and postage costs. The applicable regulations provide the following rules for compliance with this request:
1. There is a 30-day deadline to supply the requested PHI. 2. There is no requirement under the HITECH Act for a HIPAA authorization. This letter is sufficient. 3. There is no expiration event or date relating to this patient or the purpose of the use or disclosure of this information.
4. Prohibited charges include access charges, inventory charges, labor for reviewing the request, searching for or retrieving the PHI.
5. Medical records contractors are covered by HIPAA regulations. 6. Noncompliance includes charging more for sending the records to my third-party designee, ReleasePoint, or any subsequent or additional third-party designee. 7. Noncompliance includes claiming the inability to provide the PHI via email or mail. 8. I have the right to revoke this authorization in writing. 9. You may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization when the prohibition on conditioning of authorizations in (b)(4) of 45 CFR § 164.508 applies. 10. There is a potential for information disclosed pursuant to this authorization to be subject to re-disclosure by and will no longer be protected by this 45 CFR §164.508. This copy is as valid as the original. Thank you for your prompt response. Signature of Patient or Legal Representative Date (Signature is valid for as long as case is pending) If Signed by Legal Representative, Relationship to Patient For more information on the Federal HITECH Act and its regulations: https://www.hhs.gov/hipaa/for- professionals/privacy/guidance/access/
Nicholas Glodziak
02/02/1998 4005
2026-02-28
Document Ref: UT6RI-OMJEE-J4W4Z-ONRX9 Page 7 of 7
REF. NUMBER
UT6RI-OMJEE-J4W4Z-ONRX9
DOCUMENT COMPLETED BY ALL PARTIES ON
01 MAR 2026 01:01:53
UTC
SIGNER TIMESTAMP SIGNATURE
NICHOLAS GLODZIAK
*********@*****.***
SENT
01 MAR 2026 00:59:45
VIEWED
01 MAR 2026 01:00:28
SIGNED
01 MAR 2026 01:01:53
IP ADDRESS
107.123.49.62
LOCATION
COLUMBUS, UNITED STATES
RECIPIENT VERIFICATION
EMAIL VERIFIED
01 MAR 2026 01:00:28
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