• MURRAY L. GREENFIELD & ASSOCIATES
    ATTORNEYS AT LAW
    9636 BUSTLETON AVENUE
    PHILADELPHIA, PENNSYLVANIA 19115
    (215) 677-5300 FAX (215) 677-8625
    www.murraygreenfield.com
  • MURRAY L. GREENFIELD, ESQUIRE
    murraygreenfield@verizon.net
  • MICHAEL F. MCCARTIN, ESQUIRE
    michael@murraygreenfield.com
  • ADAM J. SCHWARTZBERG, ESQUIRE
    adam@murravgreenfield.com

  • CONTINGENT FEE AGREEMENT AND POWER OF ATTORNEY

  • I hereby agree that the compensation of my attorney for services shall be determined as follows: My attorney shall receive one third – (33.3%) of the gross sum secured whether by settlement or verdict. All expenses incident to the prosecution or litigation of this case are to be borne by the client at the time of distribution unless otherwise agreed in writing. I do hereby direct and authorize my attorney to pay directly and without additional consent from any proceeds of the settlement or verdict any unpaid balance for treatment, services or other costs made necessary by the injuries sustained in this accident and/or the prosecution/litigation of this claim. Expenses include but are not limited to such things as investigation, photos, experts, filing fees, court costs and/or research costs. In the event that no money is recovered in this case, the client shall not be liable for legal fees as a result.
  • I hereby acknowledge that MURRAY L. GREENFIELD, ESQUIRE has taken this representation on a contingent fee agreement as stated in this document. He is sharing in both the risk and recovery regardless of the number of hours invested. MURRAY L. GREENFIELD, ESQUIRE may withdraw as my attorney at any time without obligation at his sole discretion.
  • In the event that the client terminates said attorney's representation, said attorney is entitled to be paid for services rendered on a quantum meruit basis.
  • MURRAY L. GREENFIELD, ESQUIRE is authorized to endorse my name to any draft, insurance drafts, or settlement drafts only for the purpose of depositing same draft into his escrow account. No representation has been made as to what amounts if any I may be entitled to recover in this case.
  • I agree to keep MURRAY L. GREENFIELD, ESQUIRE advised of my whereabouts at all times and to cooperate in the preparation and trial of the case, to appear on a reasonable notice for depositions and court appearances, and to comply with all reasonable requests made in connection with the preparation and presentation of my case.
  • I hereby state and affirm under penalty of law that the facts regarding me and my background, the accident, injuries, participates and witnesses are true and correct as presented to my attorney and I understand that he is relying upon those fact to accept my representation for this matter.
  • I hereby acknowledge that I have read the foregoing fee agreement and agree to the terms.
  • TODAY'S DATE:
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  • MURRAY L. GREENFIELD & ASSOCIATES
    ATTORNEYS AT LAW
    9636 BUSTLETON AVENUE
    PHILADELPHIA, PENNSYLVANIA 19115
    (215) 677-5300 FAX (215) 677-8625
    www.murraygreenfield.com

  • MURRAY L. GREENFIELD, ESQUIRE
    murraygreenfield@verizon.net

    MICHAEL F. MCCARTIN, ESQUIRE
    michael@murravgreenfield.com

    ADAM J. SCHWARTZBERG, ESQUIRE
    adam@murravgreenfield.com

  • HIPPA AUTHORIZATION FORM

  • I hereby authorize use or disclosure of protected health information about me as described below.
  • 2. The following person or class of persons may receive disclosure of protected health information about me:
    Murray L. Greenfield & Associates
    9636 Bustleton Avenue
    Philadelphia, PA 19115
  • 4. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.
  • 5. I may revoke this authorization by notifying Murray L. Greenfield & Associates in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed and my revocation will not affect those actions. I understand that the medical provider to whom this authorization is furnished may not condition its treatment of me on whether or not I sign the authorization.
  • 6. 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 abuse.
  • 8. A photo static copy of this Authorization shall serve in its stead.
  • DATE OF BIRTH
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  • DATE
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  • Should be Empty: