AUTHORITY TO REPRESENT AND CONTINGENCY FEE AGREEMENT Authority To Represent Step 1 of 2 50% AUTHORITY TO REPRESENT AND CONTINGENCY FEE AGREEMENTI, the undersigned client, do hereby retain Anthony-Smith Law, P.A., as my attorneys to represent me in my claim against or any other person, firm or business entity liable therefore, resulting from an incident that occurred on*As compensation for their services, I agree to pay my attorneys the following fees from the total gross recovery: a. Before the filing of an answer or the demand for appointment of arbitrators or, if no answer is filed or no demand for appointment of arbitrators is made, the expiration of the time period provided for such action: 1. 33-1/3% of any recovery up to $1 million; plus 2. 30% of any portion of the recovery between $1 million and $2 million; plus 3. 20% of any portion of the recovery exceeding $2 million. b. After the filing of an answer or the demand for appointment of arbitrators or, if no answer is filed or no demand for appointment of arbitrators is made, the expiration of the time period provided for such action, through the entry of judgment: 1. 40% of any recovery up to $1 million; plus 2. 30% of any portion of the recovery between $1 million and $2 million; plus 3. 20% of any portion of the recovery exceeding $2 million. c. If all defendants admit liability at the time of filing their answers and request a trial only on damages: 1. 33-1/3% of any recovery up to $1 million; plus 2. 20% of any portion of the recovery between $1 million and $2 million; plus 3. 15% of any portion of the recovery exceeding $2 million. d. An additional 5% of any recovery after notice of appeal is filed or post judgment relief or action is required for recovery on the judgment. e. In the event that your claim, or any portion thereof, is brought against a defendant or defendants whose liability is governed pursuant to Florida Statutes §768.28, attorneys’ fees are limited to 25% of the total gross recovery as to those defendants. f. In the event that your claim, or any portion thereof, is brought against a defendant or defendants whose liability is governed pursuant to the Federal Tort Claims Act, 28 U.S.C.A. 1346, attorneys’ fees are limited to 25% if the total gross recovery as to those defendants. g. In the event that attorneys’ fees are recovered from any adverse party pursuant to any state or federal statute, the attorneys’ fees shall be the greater of the court awarded fee or contingency fee stated above. IT IS AGREED and UNDERSTOOD that this employment is upon a contingent fee basis, and if no recovery is made, I will not be indebted to my attorneys for any sum whatsoever as attorneys’ fees. I agree that upon written notice, Anthony-Smith Law, P.A. may terminate their representation under the terms of this agreement. I HEREBY AGREE to pay for the costs incurred by Anthony-Smith Law, P.A., in prosecuting this claim and authorize them to undertake and/or incur such costs as they may deem necessary from time to time. These costs include, but are not limited to, such items as police reports, hospital and medical records, photographs, filing fee, costs of serving summonses and subpoenas, court reporters fees, jury list, exhibits, state records, investigation expenses, expert witness fees, including fees for medical testimony and fees for medical conferences. They will make every effort to keep these costs at an absolute minimum consistent with the requirements of the case. At the time the case is closed, an accounting will be made for all disbursements made in my case. In cases involving a claim for wrongful death or injury to a minor child, the law may require that a probate or guardianship proceeding be instituted. Legal services for probate and guardianship proceedings are not included within the terms of this Contingency Fee Agreement. Unless expressly stated to the contrary, Anthony-Smith Law, P.A.’s responsibility is limited solely to providing legal services directly related to the civil litigation described herein and does not include advice or services with respect to other areas such as, but not limited to, worker’s compensation, taxation, probate, bankruptcy and the like. THE UNDERSIGNED CLIENT HAS, BEFORE SIGNING THIS CONTRACT, RECEIVED AND READ THE STATEMENT OF CLIENT’S RIGHTS, AND UNDERSTANDS EACH OF THE RIGHTS SET FORTH THEREIN. THE UNDERSIGNED CLIENT HAS SIGNED THE STATEMENT AND RECEIVED A SIGNED COPY TO KEEP TO REFER TO WHILE BEING REPRESENTED BY THE UNDERSIGNED ATTORNEY(S). THIS CONTRACT MAY BE CANCELLED BY WRITTEN NOTIFICATION TO THE ATTORNEY OR FIRM AT ANY TIME WITHIN 3 BUSINESS DAYS OF THE DATE THE CONTRACT WAS SIGNED, AS SHOWN BELOW, AND IF CANCELLED THE CLIENT SHALL NOT BE OBLIGATED TO PAY ANY FEES TO THE ATTORNEY(S) OR FIRM FOR THE WORK PERFORMED DURING THAT TIME. IF THE ATTORNEY(S) OR FIRM HAVE ADVANCED FUNDS TO OTHERS IN REPRESENTATION OF THE CLIENT, THE ATTORNEY(S) AND FIRM ARE ENTITLED TO BE REIMBURSED FOR SUCH AMOUNTS AS THEY HAVE REASONABLY ADVANCED ON BEHALF OF THE CLIENT AND SUCH FUNDS BECOME DUE AND PAYABLE AT THE TIME OF DISCHARGE, REGARDLESS OF RECOVERY. Date* Date Format: MM slash DD slash YYYY Name* First Last The above employment is hereby accepted upon the terms stated above. Name* First Last To:*Patient Name*Date of Birth*SS#*I authorize and direct you to release my entire medical and billing file, including but limited to all medical records, labs, billing ledger, physician orders, medications, etc. to:*RECIPIENT INFORMATION: Name: ANTHONY-SMITH LAW, P.A. Address: 5401 S. KIRKMAN RD, SUITE 610, ORLANDO, FL. 32819 Phone: 407-299-8589 Fax: 407-299-8549SPECIFIC DOCUMENTS TO BE RELEASED:SPECIFIC DOCUMENTS TO BE RELEASED:* Select All ALL Records Face Sheet Discharge Summary History/Physical Operative Reports Consultation Labs Radiology Reports Progress Notes Physician Orders Cardiology Reports Nurses Notes Medications Itemized Bills I acknowledge and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results or AIDS information. Initials*This request is authorized to include any federal and/or state protection under Florida Statutes 394.459(9) Psychiatric Information, 397.053/396.112 Drug and Alcohol Abuse Information 381,609 HIV and AIDS related conditions and/ or 397.50(3) records of minor client.PURPOSE FOR INFORMATION:* Continued Medical Care Insurance Personal Current Litigation I understand that 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 in one year. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not 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. Name* First Last Date* Date Format: MM slash DD slash YYYY Witness* First Last Date* Date Format: MM slash DD slash YYYY
