Contingency Fee Attorney-Workers Compensation

WORKERS’ COMPENSATION

CONTINGENT FEE CONTRACT

I hereby retain Ricci Law Firm, P.A. as my attorney to represent me in my claim for damages as a consequence of injuries and damages sustained the of, 20 . 1. I agree to pay the attorney’s fee as follows:

25% of whatever may be recovered from the claim if payment is made on a rating, the claim is settled with a Clincher Agreement, or at or after a hearing or a mediation has been held.

2. It is agreed that my attorney shall from time to time incur expenses for court costs, subpoena costs, photos, depositions, court reporter costs, expert witnesses, artificial intelligence (AI) and any other out-of-pocket expenses in the investigation or litigation of this claim. If such costs are not reimbursed at the time they are incurred, then I agree that such costs shall be deducted from any settlement or recovery I may receive. If there is no recovery, I will not be responsible for any costs.

3. The firm employs or engages nonlawyer assistants who are located outside of the U.S., and information about your matter may be shared with these persons as necessary to represent your interests.

4. In order to expedite the processing of any settlement, I authorize the Ricci Law Firm, P.A. to endorse my name on any settlement check so that any such check can be deposited immediately in the Ricci Law Firm, P.A. IOLTA Trust Account.

5. I have received a copy of this contract and agree that no promises or guarantees regarding the outcome of my claim have been made by my attorney. DATE CLIENT

The above employment is hereby accepted on the terms stated and, if on a percentage contingent fee basis, we agree to make no charge for services unless recovery is had in this matter. In addition, we agree to make no settlement without the consent of the claimant. ATTORNEY

Ricci Law Firm, P.A.

Electronically Signed 2025-10-22 13:17:30 UTC - 172.58.252.225 Nintex AssureSign® d8d9fbe3-a11b-4234-a88c-b37e00d9c992 2025-10-22 09:17:30

(UTC-04:00)

Electronically Signed 2025-10-22 13:16:45 UTC - 172.58.252.225 Nintex AssureSign® b9ba4514-328b-4ca2-848e-b37e00d9c99b AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

You are hereby authorized and directed, pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPPA”), to disclose certain protected health information (“PHI”) about me to or for the party or parties listed below.

This authorization permits to use or disclose

to:

Ricci Law Firm, P.A.,

P. O. Box 483

Greenville, NC 27835-0483

The following individually identifiable health information: a. Hospital records, x-rays, x-rays reading and reports, laboratory records and reports, all tests of any type, character and reports thereof, statements of charges, and any and all of my records pertaining to hospitalization, history, condition, treatment, diagnosis, prognosis, etiology or expense; and/or

b. Medical records, including patient's record cards, x-rays, x-ray readings and reports, laboratory records and reports, all tests of any type and character and reports thereof, statements of charges, and any and all of my records pertaining to medical care, history, condition, treatment, diagnosis, prognosis, etiology or expense.

c. Sensitive information including, but not limited to, HIV/AIDS, drug and/or alcohol abuse, and psychiatric evaluation and treatment.

For the period beginning through and including .

You are further authorized and directed to furnish oral and written reports to my attorney, or his or her delegate, as requested by him or her on any of the foregoing matters. I also authorize my attorneys or their delegate to photograph my person while I am present in any hospital. I further authorize the sending of my medical and hospital bills and statements to my attorney for the same dates of treatment as set out above.

I understand that pursuant to HIPPA I may have certain rights with respect to the confidentiality and privacy of my medical records. I hereby authorize the above-named health care provider to receive, read and review, and to provide to my attorneys named herein my medical records (including records from other health care providers which may be in my file), or any portion thereof, for the purpose of any claim or litigation in which I may be involved. By signing this authorization I acknowledge and agree that any information used or disclosed pursuant to this authorization could be at risk for re-disclosure by the recipient and no longer protected under HIPPA. I may revoke this authorization by notifying in

writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. I understand that the medical provider to whom this authorization is furnished may not condition its treatment of me on whether or not I sign the authorization. This authorization expires on the day of, 20, OR upon occurrence of the following event that relates to me or to the purpose of the intended use or disclosure of information about me Acknowledged and agreed to by:

Signature of Patient or Legal Guardian Relationship to Patient Witness Date

Name of Patient or Legal Guardian Date of Birth or Social Security Number of Patient Electronically Signed 2025-10-22 13:17:30 UTC - 172.58.252-***-****-Nintex AssureSign® 10-22 09:17:30 (UTC-c17167f6-7232-464e-04:ac20-b37e00d9c9a0 00) Electronically Signed 2025-10-22 13:16:52 UTC - 172.58.252.225 Nintex AssureSign® b7779894-42b2-41fa-8abf-b37e00d9c9a4 Desman Griffin

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