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Please read these instructions carefully (you may also listen to audio above):
In order for us to represent you, we need you to fill out the following forms. You can print out these PDF forms and sign them wherever you seen an "X" on the form. Please DO NOT fill out any other parts of the forms - only where you see an "X." Then return the forms to our office so that we can proceed with your representation.
1) AGENCY AUTHORIZATION: This form allows my office to represent you. It essentially states that you have hired our office to represent you in your case. This allows insurance companies and others to speak to my office regarding your matter. Please sign ONLY WHERE you see the "X" on the form. Each client should sign one of these. If you are signing on behalf of a minor child, please follow the instructions on the form.
2) HIPAA AUTHORIZATION: This form allows my office to obtain your medical records. In some cases you will be able to obtain your own billing and records, but my office will use these forms if you are unable to obtain your own billing and records. Each client should sign one of these. If you are signing on behalf of a minor child, please follow the instructions on the form. Please ONLY fill out the bottom of this form.
3) POLICE REPORT AND EMPLOYMENT AUTHORIZATION: This allows us to obtain your police report and employment information from your employer (if necessary to prove any lost earnings). Please ONLY sign where you see an "X" on the form.
4) ATTORNEY-CLIENT AGREEMENT: This is the contract between the client and the attorney. If more than one person is hiring our office, you can all sign the same form. Our form is designed to accommodate up to three clients. If you are signing on behalf of a minor child, please follow the instructions on the form. Please ONLY sign where you see an "X" on the form.
5) THINGS TO KEEP IN MIND: Download this form and review it carefully. It contains very information about how to handle your personal injury case and other important things to keep in mind. We view our relationship as a partnership. We need your help, and this list of things to keep in mind helps us handle your case properly. Please sign the form at the bottom.
6) DAILY LIFE ACTIVITIES: How an accident affects your daily home, work, school and life activities may be considered by some insurance companies when evaluating your personal injury claim. However, you must make sure these things are documented in your medical records. Otherwise, the insurance companies probably won't consider them. Use this form to assist you in documenting such issues.
1) AGENCY AUTHORIZATION: This form allows my office to represent you. It essentially states that you have hired our office to represent you in your case. This allows insurance companies and others to speak to my office regarding your matter. Please sign ONLY WHERE you see the "X" on the form. Each client should sign one of these. If you are signing on behalf of a minor child, please follow the instructions on the form.
2) HIPAA AUTHORIZATION: This form allows my office to obtain your medical records. In some cases you will be able to obtain your own billing and records, but my office will use these forms if you are unable to obtain your own billing and records. Each client should sign one of these. If you are signing on behalf of a minor child, please follow the instructions on the form. Please ONLY fill out the bottom of this form.
3) POLICE REPORT AND EMPLOYMENT AUTHORIZATION: This allows us to obtain your police report and employment information from your employer (if necessary to prove any lost earnings). Please ONLY sign where you see an "X" on the form.
4) ATTORNEY-CLIENT AGREEMENT: This is the contract between the client and the attorney. If more than one person is hiring our office, you can all sign the same form. Our form is designed to accommodate up to three clients. If you are signing on behalf of a minor child, please follow the instructions on the form. Please ONLY sign where you see an "X" on the form.
5) THINGS TO KEEP IN MIND: Download this form and review it carefully. It contains very information about how to handle your personal injury case and other important things to keep in mind. We view our relationship as a partnership. We need your help, and this list of things to keep in mind helps us handle your case properly. Please sign the form at the bottom.
6) DAILY LIFE ACTIVITIES: How an accident affects your daily home, work, school and life activities may be considered by some insurance companies when evaluating your personal injury claim. However, you must make sure these things are documented in your medical records. Otherwise, the insurance companies probably won't consider them. Use this form to assist you in documenting such issues.
