The Burrell Firm Intake Packet

DATE OF ACCIDENT*

DateHourMinutesAM/PM Option

INCIDENT LOCATION: *

STREET AND/OR INTERSECTION

Street Address Line 2

CITY OR PARISHState

FIRST NAME:*

LAST NAME:*

EMAIL:*

example@example.com

STREET ADDRESS:*

CITY

ZIP CODE

PHONE NUMBER:*

DATE OF BIRTH:*

Date

SS #:*

DO YOU HAVE MEDICARE?*

DO YOU HAVE MEDICAID?*

WERE YOU THE DRIVER?*

RESPONDING POLICE DEPARTMENT

POLICE REPORT NO.

DID YOU GO TO EMERGENCY ROOM?*

IF YOU ANSWERED YES ABOVE, DID YOU GO VIA AMBULANCE?

WHAT HOSPITAL

LIST ALL INJURIES SUFFERED IN THIS ACCIDENT:

Make sure you make the doctor aware of all injuries you list here and any injuries that may come up after you complete this form. This is the only way the insurance company will be able to evaluate your claim through your injuries. If you didn't sustain injury, they aren't required to compensate you. No one know what hurts but you.

ANY PRIOR ACCIDENTS?*

It's important we know of any previous accidents, it will only help us prepare/frame your case.

Other Driver's Insurance Company

Other Driver's Insurance Company Claim No

Other Driver's Insurance Company Policy No.

DOES THE CAR HAVE UNINSURED MOTORIST (MAY HAVE TO CHECK POLICY)

Full coverage doesn't necessarily equate to Uninsured Motorist. If you are not sure, check your policy

DOES THE CAR HAVE MEDICAL PAYMENTS OR PIP (MAY HAVE TO CHECK POLICY)

Full coverage doesn't necessarily equate to this coverage, please check your policy if you are not sure.

MAKEMAKE MODELMODEL YEAR YEAR
PLATE LICENSE PLATE NUMBER POLICY NO. YOUR OWN INSURANCE

SUBMIT ANY PICTURES, VIDEOS, DOCUMENTS RELATED TO THE ACCIDENT OR ANY MEDICAL TREATMENT YOU HAVE UNDERGONE

Browse Files

HOW DID YOU HEAR ABOUT OUR FIRM?

Patient Name:

Date of Birth:

Date

Social Security Number:

1. I authorize the use or disclosure of the above named individual’s health information as described below. 2. The following individual(s) or organization(s) are authorized to make disclosure:

3. The type of information to be used or disclosed is as follows: COMPLETE MEDICAL RECORDS AND ITEMIZED ACCOUNT STATEMENTS from date in which you received this request.

4. I understand that the information in my health record may include information relating to sexually transmitted diseases, 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 abuse. 5. The information identified above may be used by or disclosed to the following individual(s) or organization(s): My Attorneys:, THE BURRELL FIRM LLC at P.O. 871567 New Orleans, LA 70187, 504-475-7578

6. The information for which I’m authorizing disclosure will be used for legal purposes in pursuing my personal injury litigation (legal 7. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke, I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides that my insurer with the right to contest a claim under my policy. 8. This authorization will expire one year from the date on which it was signed. 9. I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal privacy laws or regulations. 10. 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 to ensure healthcare treatment. 11. I understand and authorize a Photostat copy of this authorization to act as an original.

Signature*

Clear

Date of Signature:

Date

I do hereby retain, THE BURRELL FIRM LLC, as my attorney(s) and authorize them to initiate suit, or compromise such claims or actions

as may be deemed advisable by said attorney(s), to recover from all or any persons, parties, firms and/or corporations which may be responsible as a result

of an incident which occurred on or about

involving

I do herby agree to pay said Attorney as follows:

33.3% PLUS EXPENSES – of any settlement made if settled at any time prior to the filing of suit;

40% PLUS EXPENSES – of any settlement, judgment or verdict after the filing of suit.

In further consideration of the services to be rendered and the obligations assumed by THE BURRELL FIRM LLC, I assign, transfer and deliver unto THE BURRELL FIRM LLC and undivided 33.3% or 40% interest in my claim as discussed above. It is agreed that neither THE BURRELL FIRM LLC, nor I may, without the consent of the other settle, compromise, release, discontinue or otherwise dispose of the suit or claim. It is my intent to vest THE BURRELL FIRM LLC with any interest in the subject matter of my claim or any suit or suits filed thereon as permitted to La. R.S. 37:218 and afford THE BURRELL FIRM LLC all the rights and protection granted by said statute for attorney’s fees owed and all expenses and advances incurred on my behalf.

In addition to furnishing legal services, the attorney agrees to advance all cost and expenses necessary to prosecute this claim. It is understood and agreed that in addition to the attorney’s fee, all costs, including copying cost, delivery cost, mock jury, and shadow jury costs, medical expenses, travel expenses cost of medical records, depositions, expert fees, long distance telephone calls, court cost, and advances made to me or guarantees on my/our behalf, and all expenses of this litigation will be reimbursed to attorney out of any funds received on this claim.

It is further understood and agreed that THE BURRELL FIRM LLC, is hereby authorized to sign my/our name to any refund, reimbursement and/or settlement draft. It is further understood and agreed that attorney may act as co-counsel or associate with any other attorney at no extra cost to me at the attorney’s sole discretion.

It is further understood and agreed that attorney, in his sole discretion, shall have the right to retain the services of any consultants , experts, or investigators and the cost thereof shall be reimbursed as costs to attorney by me out of the funds received on this claim. There shall be no charge for services rendered unless recovery is had in the above claim.

If client(s) terminate attorney’s services without cause before the case is completed, then client(s) will still owe THE BURRELL FIRM LLC 40%, as discussed above, of all sums recovered on this claim, plus all cost and advances incurred on my/our behalf no matter what agreements are later entered into with other persons. In the event the client(s) decide not to pursue this claim, then no legal fees will be owed except that the client will owe reimbursement to THE BURRELL FIRM LLC for all cost, advances and interest (if any) incurred on this file.

I hereby bind my heirs, executors, and legal representatives by this agreement. This Employment Contract shall be controlling and supersedes and revokes any other Employment Contract executed by me, which pertains to my case, and any such other Employment Contract shall be rendered null and void.

(DISCLAIMER: By your signature below, you acknowledge that we have made no representation concerning the outcome of the claim or claims relating to the matter in controversy or the favorable outcome of any legal action that is or may be filed

DATE:*

Date

Signature

Clear

DATE OF ACCIDENT*

Date

DATE OF ACCIDENT:
Date* ;
Time ;

INCIDENT LOCATION:
Roadway Name;
City or Parish* ;

Name*

First NameLast Name

CLIENT INFORMATION

Authorization to Use or Disclose Health Information Compliant with Health Insurance Portability and Accountability Act (HIPPA) Regulations

EMPLOYMENT CONTRACT

THE BURRELL FIRM LLC

BY:

THE BURRELL FIRM LLC