ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A.

Transcription

1 ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A. MAIN OFFICE: 4403 West Tradewinds Avenue Phone: (954) Lauderdale-By-The-Sea, Florida Fax: (954) AUTHORIZATION TO RELEASE MEDICAL INFORMATION (H.I.P.A.A.) I hereby authorize the named health care provider to release the information or records specified to ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A., at the address listed above. PROVIDER: (name and address) PATIENT: SSN: DOB: RECORDS AUTHORIZED TO BE RELEASED: All PHI in medical record Special tests Admission form Itemized bill Dictation/reports ER Information Physician orders Office notes Intake/outtake Operative information Consultation notes or reports Transfer forms Nursing information UB -92 Medication sheets Clinical tests Complete hospital chart Outpatient records Lab reports Radiological images Therapy notes Other (specify): THIS INFORMATION WILL BE USED FOR THE PURPOSE OF : Providing advocacy services Legal representation relating to an accidental injury which occurred on. Other activities at the request of the individual THIS AUTHORIZATION WILL EXPIRE ONE YEAR FROM THE DATE OF THE SINATURE BELOW. I understand that I can revoke this authorization at any time by writing to the health care provider or Attorneys Jo Ann Hoffman & Vance B. Moore, P.A., but that revoking this authorization will not affect disclosures made or actions taken before the revocation is received. I also understand that: I am not required to sign this authorization. Federal privacy regulations will no longer apply to the information disclosed, and that my attorneys may redisclose the information. I am entitled to receive a copy of this authorization. A copy of this authorization may be utilized with the same effectiveness as an original. Signature of Patient or Representative Name of Patient or Representative (print) Relationship to Patient

2 ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A. MAIN OFFICE: 4403 West Tradewinds Avenue Phone: (954) Lauderdale-By-The-Sea, Florida Fax: (954) AUTHORIZATION TO RELEASE MEDICAL INFORMATION (H.I.P.A.A.) I hereby authorize the named health care provider to release the information or records specified to ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A., at the address listed above. PROVIDER: (name and address) PATIENT: SSN: DOB: RECORDS AUTHORIZED TO BE RELEASED: All PHI in medical record Special tests Admission form Itemized bill Dictation/reports ER Information Physician orders Office notes Intake/outtake Operative information Consultation notes or reports Transfer forms Nursing information UB -92 Medication sheets Clinical tests Complete hospital chart Outpatient records Lab reports Radiological images Therapy notes Other (specify): THIS INFORMATION WILL BE USED FOR THE PURPOSE OF : Providing advocacy services Legal representation relating to an accidental injury which occurred on. Other activities at the request of the individual THIS AUTHORIZATION WILL EXPIRE ONE YEAR FROM THE DATE OF THE SINATURE BELOW. I understand that I can revoke this authorization at any time by writing to the health care provider or Attorneys Jo Ann Hoffman & Vance B. Moore, P.A., but that revoking this authorization will not affect disclosures made or actions taken before the revocation is received. I also understand that: I am not required to sign this authorization. Federal privacy regulations will no longer apply to the information disclosed, and that my attorneys may redisclose the information. I am entitled to receive a copy of this authorization. A copy of this authorization may be utilized with the same effectiveness as an original. Signature of Patient or Representative Name of Patient or Representative (print) Relationship to Patient

3 ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A. MAIN OFFICE: 4403 West Tradewinds Avenue Phone: (954) Lauderdale-By-The-Sea, Florida Fax: (954) AUTHORIZATION TO RELEASE MEDICAL INFORMATION (H.I.P.A.A.) I hereby authorize the named health care provider to release the information or records specified to ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A., at the address listed above. PROVIDER: (name and address) PATIENT: SSN: DOB: RECORDS AUTHORIZED TO BE RELEASED: All PHI in medical record Special tests Admission form Itemized bill Dictation/reports ER Information Physician orders Office notes Intake/outtake Operative information Consultation notes or reports Transfer forms Nursing information UB -92 Medication sheets Clinical tests Complete hospital chart Outpatient records Lab reports Radiological images Therapy notes Other (specify): THIS INFORMATION WILL BE USED FOR THE PURPOSE OF : Providing advocacy services Legal representation relating to an accidental injury which occurred on. Other activities at the request of the individual THIS AUTHORIZATION WILL EXPIRE ONE YEAR FROM THE DATE OF THE SINATURE BELOW. I understand that I can revoke this authorization at any time by writing to the health care provider or Attorneys Jo Ann Hoffman & Vance B. Moore, P.A., but that revoking this authorization will not affect disclosures made or actions taken before the revocation is received. I also understand that: I am not required to sign this authorization. Federal privacy regulations will no longer apply to the information disclosed, and that my attorneys may redisclose the information. I am entitled to receive a copy of this authorization. A copy of this authorization may be utilized with the same effectiveness as an original. Signature of Patient or Representative Name of Patient or Representative (print) Relationship to Patient

4 ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A. MAIN OFFICE: 4403 West Tradewinds Avenue Phone: (954) Lauderdale-By-The-Sea, Florida Fax: (954) STATEMENT OF CLIENT RIHTS It is the responsibility of this firm to see that you as our client are fully informed and knowledgeable of all of your rights. As such, we provide you with this STATEMENT OF CLIENT RIHTS: Before you, the prospective client, arrange a Contingency Fee Agreement with a lawyer, you should understand this Statement of your rights as a client. This Statement is not a part of the actual contract between you and your lawyer, but as a prospective client, you should be aware of these rights: 1. There is no legal requirement that a lawyer charge a client a set fee or a percentage of money recovered in a case. You, the client, have the right to talk with your lawyer about the proposed fee and to bargain about the rate or percentage as in any other contract. If you do not reach an agreement with one lawyer you may talk with other lawyers. 2. Any Contingency Fee Contract must be in writing and you have 3 business days to reconsider the contract. You may cancel the contract without any reason if you notify your lawyer in writing within 3 business days of signing the contract. If you withdraw from the contract within the first 3 business days, you do not owe the lawyer a fee although you may be responsible for the lawyer's actual costs during that time. If your lawyer begins to represent you, your lawyer may not withdraw from the case without giving you notice, delivering necessary papers to you, and allowing you time to employ another lawyer. Often, your lawyer must obtain court approval before withdrawing from a case. If you discharge your lawyer without good cause after the three-day period, you may have to pay a fee for work the lawyer has done. 3. Before hiring a lawyer, you, the client, have the right to know about the lawyer's education, training and experience. If you ask, the lawyer should tell you specifically about his or her actual experience dealing with cases similar to yours, If you ask, the lawyer should provide information about special training or knowledge and give you this information in writing if you request it. 4. Before signing a Contingency Fee Contract with you, a lawyer must advise you whether he or she intends to handle your case alone or whether other lawyers will be helping with the case. If your lawyer intends to refer the case to other lawyers he or she should tell you what kind of fee sharing arrangement will be made with the other lawyers. If lawyers from different law firms will represent you, at least one lawyer from each law firm must sign the Contingency Fee Contract. 5. If your lawyer intends to refer your case to another lawyer or counsel with other lawyers, your lawyer should tell you about that at the beginning. If your lawyer takes the case and later decides to refer it to another lawyer or to associate with other lawyers, you should sign a new contract which includes the new lawyers. You, the client, also have the right to consult with each lawyer working on your case and each lawyer is legally responsible to represent your interests and is legally responsible for the acts of the other lawyers involved in this case. 6. You, the client, have the right to know in advance how you will need to pay the expenses and the legal fees at the end of the case. If you pay a deposit in advance for costs, you may ask reasonable questions about how the money will be or has been spent and how much of it remains unspent. Your lawyer should give a reasonable estimate about future necessary costs. If your lawyer agrees to lend or

5 advance you money to prepare or research the case, you have the right to know periodically how much money your lawyer has spent on your behalf. You also have the right to decide, after consulting with your lawyer, how much money is to be spent to prepare a case. If you pay the expenses, you have the right to decide how much to spend. Your lawyer should also inform you whether the fee will be based on the gross amount recovered or on the amount recovered minus the costs. 7. You, the client, have the right to be told by your lawyer about possible adverse consequences if you lose the case. Those adverse consequences might include money which you might have to pay to your lawyer for costs, and liability you might have for attorney's fees and costs to the other side. 8. You, the client, have the right to receive and approve a Closing Statement at the end of the case before you pay any money or money is deducted from your proceeds. The statement must list all of the financial details of the entire case, including the amount recovered, all expenses, and a precise statement of your lawyer's fee. Until you approve the Closing Statement you need not pay any money to anyone, including your lawyer. You also have the right to have every lawyer or law firm working your case sign this Closing Statement. 9. You, the client, have the right to ask your lawyer at reasonable intervals how the case is progressing and to have these questions answered to the best of your lawyer's ability. 10. You, the client, have the right to make the final decision regarding settlement of a case. Your lawyer must notify you of all offers of settlement before and after the trial. Offers during the trial must be immediately communicated and you should consult with your lawyer regarding whether to accept a settlement. However, you must make the final decision to accept or reject a settlement. 11. If at any time you, the client, believe that your lawyer has charged any excessive or illegal fee, you, the client, have the right to report the matter to The Florida Bar, the Agency that oversees the practice and behavior of all lawyers in Florida. For information on how to reach The Florida Bar, call (850) or contact the local Bar Association. Any disagreement between you and your lawyer about a fee can be taken to court and you may wish to hire another lawyer to help you resolve this disagreement. Usually fee disputes must be handled in a separate lawsuit, unless your fee contract provides for arbitration. You can request, but may not require, that a provision for arbitration (Under Chapter 682, Florida Statutes, or under the fee arbitration rule of the Rules Regulating The Florida Bar) be included in your fee contract. READ, APPROVED AND AREED TO THIS DAY OF, 20. ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A. _ Signature of Client Jo Ann Hoffman, Esquire Vance B. Moore, Esquire Print Name ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A W. Tradewinds Avenue, Lauderdale-By-The-Sea, FL Telephone: (954) Fax: (954)

6 ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A. PERSONAL INJURY! WORKERS' COMPENSATION REPLY TO: 4403 West Tradewinds Avenue 500 Australian Avenue South, Suite 600 Lauderdale-By-The-Sea, Florida West Palm Beach, Florida (954) (561) JO ANN HOFFMAN Boca Raton: (561) VANCE B. MOORE Miami: (305) Fax: (954) LONSHORE & HARBOR WORKERS' COMPENSATION ACT AND DEFENSE BASE ACT CONTRACT OF REPRESENTATION AND POWER OF ATTORNEY I, the undersigned Employee, do hereby retain and employ the law firm of Attorneys Jo Ann Hoffman & Vance B. Moore, P.A., as my attorneys to prosecute my claim for Longshore Benefits and Defense Base Act benefits against my Employer and/or their Insurance Carrier as a result of the injuries sustained by me while in the employ of said Employer on or about. It is understood and agreed that I employ said attorneys, and they accept employment as my attorneys upon the following conditions: 1. That I agree to pay a fee to my attorneys for the professional services rendered by them in the prosecution of my case. That said fee must be approved by the District Director, Judge, or his or her designee based on the time and labor required, the novelty and difficulty of the questions involved, the skill required to properly prosecute my case, whether the acceptance of employment will preclude my lawyer from appearing at other cases likely to arise out of the transaction, the customary charges for lawyers in my community for similar services, the amount of money in controversy and the benefits resulting to me from the services of my lawyer and consideration of the contingency or certainty of the earning of a fee by my lawyer. I further understand that with regard to the value of the time and labor required of my lawyer in handling this case for me, a reasonable fee for my attorney in this community is $ per hour for the attorney's professional time spent on my behalf. If a lump sum settlement is achieved, or impairment benefits are paid, the fee will not exceed 25% of the lump sum settlement or the impairment benefit. The fee is based on the benefits secured in the past as well as the lump sum settlement along with the hours expended and the criteria listed herein. 2. I further understand that any fee to be paid by me under the Longshore and Harbor Workers' Compensation Act, the Defense Base Act or any amendments to the Acts must be approved by the Office of Workers' Compensation Programs, the Benefits Review Board or any Court before whom my lawyer may have to present this case, and that the amount of the fee may be increased or decreased within the judgment of said Office of Longshore & Harbor Workers' Compensation Programs, Benefits Review Board or Court approving same if the circumstances of the case warrant. I further understand that if my case is handled before the Office of Workers' Compensation Programs the Benefits Review Board on appeal, or a Court on further appeal, separate fees if warranted will be awarded by each of the separate bodies. Portions of the client's compensation money may be placed in escrow for the eventual payment of attorney's fees.

7 3. I hereby authorize my attorneys to investigate this claim, file a claim on my behalf, and take any and all other steps they deem necessary to prosecute the claim including an appeal (if in their opinion an appeal should be filed) to secure all benefits to which I may have become entitled under the Longshore & Harbor Workers' Compensation Acts and Defense Base Act. 4. I hereby authorize my attorneys to expend reasonable costs and expenses on my behalf in the prosecution of my claim, and I agree to reimburse them for any and all costs and expenses incurred by them in the prosecution of my claim. If my attorneys recover any of these costs from the Employer or its Insurance Company, I will be credited with the amounts recovered. Certain costs such as postage, photocopies and the like are not taxable, and as such, I agree to reimburse my attorney for costs not recovered against the Employer and /or their Insurance Company. 5. Fees owed to this law firm are separate and apart from fees I may owe other attorneys who have been previously or may later represent me. I shall be responsible for this law firm's fees for their work done, and said fee shall constitute a lien on any recovery that I may make. 6. I further agree that I will fully cooperate with my attorneys in the prosecution of my claim, and I will sign all necessary papers to properly prosecute this claim. I will appear at the request of my attorneys for all depositions, medical examinations, hearings or other appearances required in the proper presentation of my claim, and I will keep in contact with my attorneys and advise them of my whereabouts at all times so that they will be able to contact me when necessary. 7. In order to expedite my claim, this law firm may associate with an attorney to aid in litigation such as to take a deposition in ermany, conference with a doctor in Colorado, or appear for a routine motion calendar in a San Francisco court, but that appearance is covered by this firm under this retainer just as though this firm attended that legal meeting. 8. I understand that where my injury is an extremity injury (which is a body part other than the spine and shoulders), and where the carrier has accepted my extremity injury, I will be responsible to pay to my attorney from my impairment checks a portion of my checks to cover the fee. I understand that the fees will not exceed 25% of the total benefits I receive, as explained in Item 1 of this Retainer. 9. I understand that under some circumstances, my Employer, or their Insurance Carrier, may be found liable to pay all or part of my fees and court costs, such as where they denied that I had an accident, or where they denied that my needed medical care is due to the injury I suffered on the job. I will receive a credit for all fees and costs paid by the Employer or their Insurance Carrier. However, on benefits I am timely provided, such as where treatment for the knee is given but treatment for the back is denied, I may be responsible for a fee on the body part accepted. As an example, where I receive impairment payments for my knee of $8, with my attorneys' help, the attorney can charge a fee not to exceed 25% of the impairment (or $2,000.00). 10. The undersigned attorney agrees to diligently pursue the employee's workers' compensation claim and to keep the employee informed as to his claim. The attorney accepts the trust provisions of this agreement and will account to the employee as to any monies received, expended, or held on the employee's behalf at the employee's request.

8 11. The client expressly grants a Power of Attorney to the firm, to endorse and deposit into their trust account any checks in the client's name, to act in the client's place by affixing their signature to said checks and to deduct fees and costs, pursuant to this Contract, and then paying to the client their net check. No binding contract is entered into until this form is signed by the attorney. The attorney agrees to keep the client fully informed and the client will provide a viable address or telephone number for communication. READ, APPROVED AND AREED TO THIS DAY OF, 20. ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A. Signature of Client Jo Ann Hoffman, Esquire Vance B. Moore, Esquire Print Name Cell Number ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A W. Tradewinds Avenue, Lauderdale-By-The-Sea, FL Telephone: (954) Fax: (954)

9 Longshore Defense Base Act and Harbor Workers' Compensation U.S. DEPARTMENT OF LABOR USA/OWCP/DLHWC NOTICE OF RETAINER (Please read carefully.) OWCP Case No. Social Security Number: Date of Accident, Illness or Injury: Part or Parts of Body Injured: Name Address Telephone Claimant Employer Carrier Attorney or Representative for Claimant Jo Ann Hoffman, Esq. Attorneys Jo Ann Hoffman & Vance B. Moore, P.A W. Tradewinds Ave. Lauderdale-By-The-Sea, Florida (954) I have retained the above-named attorney, Jo Ann Hoffman, Esq., to represent and appear for me in all proceedings concerning my claim under the Longshore and Harbor Workers' Compensation Act, as amended and extended. I authorize the named persons to review the Office of Workers' Compensation Programs ("OWCP") file on this injury and to receive copies from it. 2. I fully understand that my representative or attorney is in no way connected with the Office of Workers' Compensation Programs. 3. I fully understand that no one other than the herein named persons is authorized to represent me at a conference or informal hearing held at the OWCP without my written consent. 4. I fully understand that I may be responsible for paying the fee approved in favor of my attorney or representative and that such fee may be deducted from my compensation. 5. I fully understand that I am not to pay any money out of this case to anyone unless it is approved by the Deputy Commissioner, the Department of Labor or its designees.

10 6. I fully understand that my attorney or representative will furnish me with a copy of this retainer and written fee application prior to submission of same to the Department of Labor/OWCP. READ, APPROVED AND AREED TO THIS DAY OF, 20. Signature of Client Print Name I agree to represent the above-named Claimant in compliance with the Longshore and Harbor Workers' Compensation Act as amended and extended and the Regulations promulgated thereunder, and I hereby give notice of my appearance in this case. All notices, decisions and other pertinent documents are to be sent to the undersigned. It is fully understood that the only fees to be paid in this case are those fixed by the District Director or his designees. It is further understood that I shall furnish a copy of this retainer and my written fee application to my client before submission to the Office of the Workers' Compensation programs. _ JO ANN HOFFMAN, ESQUIRE DATE Copies furnished: ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A W. Tradewinds Avenue, Lauderdale-By-The-Sea, FL Telephone: (954) Fax: (954)

11 IMPORTANT NOTICE 1. All retainers are to be submitted in duplicate to the Office of the Deputy Commissioner. 2. The exact part or parts of the body injured should be specified. 3. Any person who receives any fees, other consideration, or any gratuity on account of services rendered as a representative of a claimant, unless such consideration or gratuity is approved by the Deputy Commissioner, Board, or court, or who makes a business to solicit employment for a lawyer or for himself in respect of any claim or award for compensation, shall upon conviction thereof, for each offense be punished by a fine of not more than $1,000 or by imprisonment for not more than one year, or by both such fine and imprisonment. (Section 28 (e) (33 U.S.C. 928(e)). 4. Any person who willfully makes any false or misleading statement or representation for the purpose of obtaining any benefit or payment under this Act shall be guilty of a felony and on conviction thereof shall be punished by a fine of not to exceed $10,000 or by imprisonment not to exceed five years, or by both such fine and imprisonment. (Section 31) (33 U.S.C. 931). 5. Office of Workers' Compensation Programs shall, upon request, provide those making claim under the Longshoremen's and Harbor Workers' Compensation Act with information and assistance relating to the Act's coverage and compensation and the procedures for obtaining such compensation including assistance in processing claim. Office of Workers' Compensation Programs shall also provide employees receiving compensation information on medical, manpower and vocational rehabilitation services and assist such employees in obtaining the best such services available. (Section 39 (c) (1)) (33 U.S.C. 939 (c) (1)).

12 Longshore Defense Base Act and Harbor Workers' Compensation U.S. DEPARTMENT OF LABOR USA/OWCP/DLHWC NOTICE OF RETAINER (Please read carefully.) OWCP Case No. Social Security Number: Date of Accident, Illness or Injury: Part or Parts of Body Injured: Name Address Telephone Claimant Employer Carrier Attorney or Representative for Claimant Jo Ann Hoffman, Esq. Attorneys Jo Ann Hoffman & Vance B. Moore, P.A W. Tradewinds Ave. Lauderdale-By-The-Sea, Florida (954) I have retained the above-named attorney, Jo Ann Hoffman, Esq., to represent and appear for me in all proceedings concerning my claim under the Longshore and Harbor Workers' Compensation Act, as amended and extended. I authorize the named persons to review the Office of Workers' Compensation Programs ("OWCP") file on this injury and to receive copies from it. 2. I fully understand that my representative or attorney is in no way connected with the Office of Workers' Compensation Programs. 3. I fully understand that no one other than the herein named persons is authorized to represent me at a conference or informal hearing held at the OWCP without my written consent. 4. I fully understand that I may be responsible for paying the fee approved in favor of my attorney or representative and that such fee may be deducted from my compensation. 5. I fully understand that I am not to pay any money out of this case to anyone unless it is approved by the Deputy Commissioner, the Department of Labor or its designees.

13 6. I fully understand that my attorney or representative will furnish me with a copy of this retainer and written fee application prior to submission of same to the Department of Labor/OWCP. READ, APPROVED AND AREED TO THIS DAY OF, 20. Signature of Client Print Name I agree to represent the above-named Claimant in compliance with the Longshore and Harbor Workers' Compensation Act as amended and extended and the Regulations promulgated thereunder, and I hereby give notice of my appearance in this case. All notices, decisions and other pertinent documents are to be sent to the undersigned. It is fully understood that the only fees to be paid in this case are those fixed by the District Director or his designees. It is further understood that I shall furnish a copy of this retainer and my written fee application to my client before submission to the Office of the Workers' Compensation programs. _ JO ANN HOFFMAN, ESQUIRE DATE Copies furnished: ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A W. Tradewinds Avenue, Lauderdale-By-The-Sea, FL Telephone: (954) Fax: (954)

14 IMPORTANT NOTICE 1. All retainers are to be submitted in duplicate to the Office of the Deputy Commissioner. 2. The exact part or parts of the body injured should be specified. 3. Any person who receives any fees, other consideration, or any gratuity on account of services rendered as a representative of a claimant, unless such consideration or gratuity is approved by the Deputy Commissioner, Board, or court, or who makes a business to solicit employment for a lawyer or for himself in respect of any claim or award for compensation, shall upon conviction thereof, for each offense be punished by a fine of not more than $1,000 or by imprisonment for not more than one year, or by both such fine and imprisonment. (Section 28 (e) (33 U.S.C. 928(e)). 4. Any person who willfully makes any false or misleading statement or representation for the purpose of obtaining any benefit or payment under this Act shall be guilty of a felony and on conviction thereof shall be punished by a fine of not to exceed $10,000 or by imprisonment not to exceed five years, or by both such fine and imprisonment. (Section 31) (33 U.S.C. 931). 5. Office of Workers' Compensation Programs shall, upon request, provide those making claim under the Longshoremen's and Harbor Workers' Compensation Act with information and assistance relating to the Act's coverage and compensation and the procedures for obtaining such compensation including assistance in processing claim. Office of Workers' Compensation Programs shall also provide employees receiving compensation information on medical, manpower and vocational rehabilitation services and assist such employees in obtaining the best such services available. (Section 39 (c) (1)) (33 U.S.C. 939 (c) (1)).