Personal Injury Intake — Law Office of Yates & Associates

1) Client Info
2) Accident Details
3) Medical Info
4) Authorization

Name

Name *

Phone Number *

Email Address *

How did you hear about us?

Date of Birth *

Sex *

Male Female

Are you presently represented? *

Yes No

Social Security Number

Address *

City *

State *

Zip Code *

Married

Yes No

Involved Children

EMPLOYMENT

Occupation

Employer

Supervisor's Name

Start Date

Wage/Salary

Telephone Number

Have you missed work as a result off the incident? *

Yes No

NON-SOLICITATION ACKNOWLEDGEMENT

I acknowledge. *

I, the undersigned hereby state that I am of sound mind, competent and have the authority to sign this Non-Solicitation Acknowledgment. I have not been solicited, coerced, or promised money or anything of value by The Law Office of Yates and Associates, or its agents, employees or representatives. I am aware that The Law Office of Yates & Associates is licensed in the State of Texas and may hire local counsel or make a referral. No independent contractor, agents, employees or representatives that are not attorneys have held themselves out as attorneys. I realize that I have the right to choose any attorney to represent me in this matter and have chosen The Law Office of Yates & Associates, to represent me as evidenced by the signed contract attached hereto. If I am completing the online intake form I understand and agree that my electronic signature is legal and enforceable as a traditional Acknowledgment signed in ink. I have read, understand, agree and accept this Acknowledgment. I chose The Law Office of Yates & Associates, of my own free will, voluntarily, and without compensation or promise of compensation or anything else of value. My signature below confirms this.

Accident Details

Date of Accident *

City Accident Occurred In *

Time of Accident *

State Accident Occurred In *

Police Report or Incident # *

Intersection

Now please tell us what happened? *

Where there passengers in the car?

Yes No

Witness(es)

List anyone who witnessed the accident that was NOT involved in the accident. Include name and phone number

Client Vehicle Information

Vehicle Color / Year / Make / Model

Was your vehicle insured?

Yes No

Defendant's Vehicle Information

Vehicle Color / Year / Make / Model

Owner of the vehicle

License Plate #

Defendant Name if Different from Owner

Was the defendant's vehicle insured?

Yes No

EMERGENCY ROOM

Injuries

Did you travel by ambulance?

Yes No

Hospital:

Hospital Phone Number

Date of First Visit

Additional Clinics/Doctors

Patient Name *

I hereby consent: *

By checking this box I authorize the disclosure of my health information as described and stated above. I authorize the use of disclosure of the above named individual’s health information as described below: The following individual or organization is authorized to make the disclosures from date of accident

The type of and amount of information to be used or disclosed is as follow: Problem list, Medication List, List of Allergies, Immunization Records, Most Recent History & Physical, Laboratory Results, X-ray and Imaging Reports, Consultation Reports, Billing Records, Entire Records and Other.
2. 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.
3. This information may be disclosed to and used by following individual or organization: The Law Office of Yates & Associates PLLC, 440 Louisiana, Suite 1575, Houston, TX 77002, Fax: (713) 236-8990 For the purpose of: Litigation
4. I understand I have the right to revoke this information at any time. I understand if I revoke this authorization I must do so in writing and present my written revoke to this authorization I must 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 disposition of the lawsuit referenced in paragraph 4 above or two years form the date of this authorization. Whichever comes later.
5. 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, a 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 confidentially rules. A photocopy of this authorization shall be as valid as the
6. 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, a 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 confidentially rules. A photocopy of this authorization shall be as valid as the original.
*** PLEASE EMAIL ANY PHOTOGRAPHS, OR BILLS IN YOUR POSSESSION
RELATED TO THE ACCIDENT TO OUR OFFICE ***

CONTINGENCY FEE AGREEMENT
IDENTIFICATION OF PARTIES. This agreement is made between The Law Office of Yates & Associates and any referral attorneys "Attorney" or the “Firm” and

Full Name

hereafter referred to as "Client" for the incident that occurred on:

Date

RESPONSIBILITIES OF ATTORNEY AND CLIENT. Attorney will perform the legal services called for under this agreement to the best of Attorney's abilities, keep Client informed of progress and developments, and respond promptly to Client's inquiries and communications. Client will be truthful and cooperative with Attorney and keep Attorney reasonably informed of developments and of Client's address, telephone number, and whereabouts.,

SETTLEMENT & DEPOSIT. Attorney will not settle Client's claim without the approval of Client. Client authorizes Attorney to sign and deposit any settlement on their behalf into Attorney trust account.

NON-SOLICITATION. I have not been solicited, coerced, or promised money or anything of value by The Witherspoon Law Group, or its agents, employees or representatives. I chose the Law Office of Yates & Associates, of my own free will, voluntarily, and without compensation or promise of compensation or anything else of value.

ATTORNEY'S FEES - CONTINGENCY CONTRACT. Attorney agrees to waive hourly fees of $450 and instead pursue Client’s claim on a contingency basis. The contingency upon which compensation is to be paid is the collection of monies following settlement or award on the claim or claims set forth above and the amount of such compensation which is to be paid by the Client to the Firm is as follows: Our firm fee is 33.3% of the amount of any offer of settlement made before a lawsuit is filed. If a lawsuit is filed our fee increases to 40%. Attorney does not handle appeals. Appeals must be filed 30 days after jury trial.

DEFERRED PAYMENT. If payment of all or any part of the amount to be received will be deferred (such as in the case of an annuity, a structured settlement, or periodic payments), the "total amount received," for purposes of calculating the Attorney's fees, will be the initial lump-sum payment plus the present value, as of the time of the settlement, final arbitration award, or final judgment, of the payments to be received thereafter. If the payment is insufficient to pay the Attorney's fees in full, the balance will be paid from subsequent payments of the recovery before any distribution to Client.

ASSIGNMENT OF PAYMENT/POWER OF ATTORNEY. In consideration of services or to be rendered under this agreement, Client agrees to assign to Attorney all monies paid by insurance company on account of claims submitted for services rendered by Attorney, whether submitted by Client or Attorney. Client authorizes payment directly to Attorney for services rendered and gives Attorney power of attorney for the purpose of signing Client’s signature on settlement checks and depositing proceeds into Attorney IOLTA. These provisions shall be canceled upon completion of services. Client grants Attorney limited power of attorney for all purposes related to this claim. Attorney may sign any and all documents on behalf of client as “attorney-in-fact.” Client expressly provides Attorney power of attorney for all purposes related to this lawsuit, including medical authorizations, releases, affidavits and other forms related to HIPAA.

CASE COSTS. Attorney will advance all "case costs" and will recoup all costs advanced. Case costs will be deducted from any settlement or award after attorney’s fees are subtracted. Client is still responsible for client’s own "personal expenses" (e.g.: medical bills, liens, other party costs, etc). Upon final disposition of case, client agrees to pay a $250.00 case cost fee, which covers the cost but not limited to copies, postage, police reports, etc.

LIENS/DISCHARGE. Client hereby grants to Attorney a lien for Attorney's fees and costs advanced on all claims and causes of action that are the subject of representation of Client under this agreement and on all proceeds of any recovery obtained by any means. The client will be obligated to pay Attorney out of the recovery Attorney's fees for all services provided and to reimburse Attorney out of the recovery for all costs advanced if the attorney is discharged. Client understands and that Attorney is not financially responsible or liable for any outstanding liens, medical expenses, loans, etc.

ENTIRETY/MODIFICATION. This agreement contains the entire agreement between the parties. No other agreement, statement, or promise made on or before the effective date of this agreement will be binding on the parties. This agreement may be modified only by an instrument in writing by both parties.

EFFECTIVE DATE OF AGREEMENT. The effective date of this agreement will be the date when, having been executed by Client, one copy of the agreement is received by Attorney. The Client has read this agreement carefully and understands the terms hereof.

I AGREE, ACKNOWLEDGE, UNDERSTAND and ACCEPT: *

By checking this box, I AGREE, ACKNOWLEDGE, UNDERSTAND and ACCEPT the full terms of the (1) Non - Solicitation Acknowledgement, (2) Authorization to Disclose Health Information and (3) Contingency Fee Agreement.

By completing this Intake Form online, I represent that I am the person completing the form or have the authority to complete said form and that all information is true and correct and completed to the best of my knowledge. I acknowledge that I've been informed that The Witherspoon Law Group is headquartered licensed in Texas, Illinois, Missouri and may associate with counsel in other jurisdictions.

SIgnature

Client Name *

Date of acceptance *

IF SIGNED BY LEGAL REPRESENTATIVE, RELATIONSHIP TO CLIENT