HANDLING THE SMALL PLAINTIFF S AUTOMOBILE ACCIDENT DAMAGES CLAIM

HANDLING THE SMALL PLAINTIFF'S AUTOMOBILE ACCIDENT DAMAGES CLAIM TO A SUCCESSFUL CONCLUSION CHESTER A. BRADLEY, 111, ATTORNEY AT LAW 1888 HUDSON CIRCLE, SUITE 4 MONROE, LOUISIANA 7 1201 (3 18) 388-3401 HANDLING THE SMALL PLAINTIFF'S AUTOMOBILE ACCIDENT DAMAGES CLAIM TO A SUCCESSFUL CONCLUSION I. DEFINING THE SMALL DAMAGES CLAIM: A. DEFENDANT'S INSURANCE COMPANY'S DEFINITION- (they are small) PLAINTIFF, INJURED PARTY'S DEFINITION- There's nothing small about it. PLAINTIFF'S ATTORNEYS DEFINITION1. <$10,000.00- Personal Injury Damages a) ~eneral b) Medical c) Lost Wages <$10,000.00- Property DamageIAuto Liability Insurance Policy Limits are $10,000.00/$20,0001$10,000.00 (Minimum required by law) B. * C. 2. 3. * 11. These are the definitions we will concentrate on during this hour discussion. WHY OR WHY NOT TO HANDLE THE SMALL CLAIM A. WHY? 1. 2. Fee, (but small) a) b) Referrals from former clients (if you get the good ones); Referrals from Attorneys 3. Provide a needed service (to folks who don't use the T.V. lawyers) B. WHY NOT? 1. 2. Fee (small or often reduced) Deferrals (?) or complaints to the Office of Disciplinary Counsel. Provides needed service (to the folks the T.V. lawyers or others don't want or have time for, i.e.): a) Comparative negligence b) Multiple Claimants c) Medical liens e) Largelexcessive medical bills Property Damage exceeds policy limits f) Total loss of property damage leaves client upsideldown with mortgage holder g) 3. 111. HANDLING THE INITIAL CALL (FROM THE POTENTIAL CLIENT) OR OTHERS: A. Receptionist/Secretary/LegalAssistant 1. Using the "Telephone Client Intake Sheet" establishes who, what, when, where and saves valuable time. a. b. c. d. e. f. Date of Accident Name, address and telephone number(s) of client, or caller Client insured or not? If passenger, is driver or owner of car insured? Social Security number, date of birth (for preparing documents prior to initial interview) If attorney is not available, tell when attorney will call (or) have an appointment scheduled. B. Attorney should take the initial call, if available, or call back immediately: 1. 2. Conduct the telephone interview sheet Establishes Attorney/Client relationship Client wants to talk to "an attorney" Increases your chances of the Potential Client showing up for the initial in-office interview Warn the Potential Client of speaking to any insurance adjuster, until after the in-office consultation Obtain a verbal commitment of representation, by telling the client that you will begin working on the case (see limitations below) Schedule the in-office meetinglinterview that day, andlor ASAP Tell client to bring the following information to the office interview: a) Insurance Declaration Page/or Card b) Accident Report c) Any photographs Any witnesses (if easily available) or addresses and telephone numbers of witnesses d) Any hospital discharge papers/bills, etc. e) 3. 4. 5. 6. 7. 8. IV. PRELIMINARY WORK, PRIOR TO THE INITIAL IN-OFFICE INTERVIEW: A. Use the intake sheet to prepare: 1. Contract of Employment Medical Release Authorizations (HIPAA forms) Authorization to Release Employment Records (for lost wages) MedicaidMedicare Special Releases (HIPAA forms) Open File Enter the Prescription Date in the file system. 2. 3. 4. 5. 6. B. Obtain Uniform Motor Vehicle Traffic Crash Report (if client is not in possession of it) Prepare Letter(s) of Representation C. V. IN-DEPTH IN OFFICE INTERVIEW BETWEEN ATTORNEY AND CLIENT: A. DON'T GET IN A HURRY! 1. 2. B. Initial quality time, is a savings of unnecessary time, money and misunderstandings with clients; If you don't have time to spend with the client during the initial in-office interview, you are not going to ever have enough time to handle their case. USING THE "ATTORNEY INTERVIEW SHEET": 1. 2. Takes time, but saves time in the future from making multiple calls to the client for additional information; Provides an outline of the damage(s) claim(s) Gives you an idea of whether the damages claim fits into the small claims category Provides a history of the potential client Answers most problem questions, and most common questions found in most interrogatories Helps decide whether to accept or decline representation Review of the "Attorney Interview Sheet: a) client social history b) medical treatment/costs c) insurance coverage d) prior claims e) prior criminal record f) physical injuries g) prior medical history 1) plus or 2) minus h) prior employment history 1) plus or 2) minus 9 Automobile/Property Damage DISCUSSING WITH THE CLIENT, THE CLAIM PROCESS: 1. 2. FAULTICOMPARATIVE FAULT DAMAGES: 3. 4. 5. 6. a) b) Personal Injury 1. General 2. Medical 3. Lost Wages Property Damage 3. INSURANCE COVERAGE (what it is, and when and how it pays) a) b) c) d) e) f) Liability Med-Pay UninsuredlUnderinsured Motorist Collision Auto Rental Subrogation- (whatever applies) 4. HOW THE CLAIM EVALUATION PROCESS WORKS: a) PROPERTY DAMAGE EVALUATION 1. Adjuster's estimate of repair 2. Right to substitute vehicle (rental) 3. Total Loss-circumstances PERSONAL INJURY EVALUATION Medical treatment, type and duration Physician's diagnosis of injuries Temporary, total or permanent disability Loss of enjoyment of life (inconvenience) Physical pain & suffering Medical ExpenseIFuture Expense Lost Wages Attorneys personal experience with particular insurance adjuster Attorney's trial experience in court of jurisdiction Case evaluation of reported cases, similar Low judgment value vs. high judgment value evaluation of the claim b) c) SPECIAL CIRCUMSTANCES 1) 2) 3) Multiple Plaintiffs, not enough insurance Excessive medical billsldamages Tell the client what to expect, don't let them learn later d) SETTLEMENT DEMAND LETTER 1) 2) The give and take process of negotiation Estimate of time to settle a claim e) LITIGATION PROCESS-OPTION 1) 2) 3) 4) 5) Filing suit Answer Discovery Estimate of Trial DateIJudgment Additional costs associated D. DISCUSSING WITH THE CLIENT THE IMPORTANCE OF MEDICAL TREATMENT AND COMMUNICATION WITH THE HEALTH CARE PROVJDERS: 1. Client conversation with the doctor is important (teaching client how to talk): a) b) c> d) e) f) history-accurate what hurts and what doesn't (truthful) "head to toe" (no matter how small) how injury effects work, play, hobbies tell the doctor job duties, not just job title be descriptive, but don't give the doctor a diagnosis complimenting the doctor on improvements, while asking for help or further treatment g) 2. Importance of keeping appointments: a) Physical injury improvement medical documentation of duration of injury b) securing doctors advocacy for his patient c) Keeping up with medical bills: a) b) c) "Self-addressed, pre-stamped envelope" method (saves time, avoids problems) Notifying attorney of changes in treatment or referrals Notifying attorney of collection notices 3. E. DISCUSSING WITH THE CLIENT YOUR COMMUNICATIONS POLICY: 1. 2. Office appointments Drop-In policy Telephone callslreturn calls E-Mail Letters Copies of letters, medical recordslbills, etc. Copies of pleadings Providing updated addressltelephone numbers Signing and returning documents Advanced Cost Policy Self-addressed, pre-stamped envelope Review the Attorney client privilege and how it can be breached 3. 4. 5. 6. 7. 8. 9. 10. 1 1. 12. F. EVALUATING THE CLIENT FOR LEGAL REPRESENTATION OF THE SMALL CLAIM. 1. IT'S NOT TOO LATE TO DECLINE (even after the in-depth interview): If the client's a winker If the client asks for an advance before he's received medical treatment If the client's in too big of a hurry to sit through the interview If the client keeps telling you about a friend who wasn't hurt but got millions Client insists on going "to your doctor" but doesn't want to visit his Client asks if it "will hurt my case?" if he works Client asks you "do you take money under the table"? or states that their "last lawyer did" Client asks "how long should I go to the doctor"? Client asks "how long it will take to settle my case"? If your gut tells you no! 2. ACCEPTANCE OF REPRESENTATION a) If you believe that you can provide a legal service to the client and that the client understands your fee, the claims, process and the unique circumstance of his individual claims. No "Magic Wand" b). DISCUSSING AND REVIEWING WITH CLIENT, ATTORNEY FEE CONTRACT AND FEES AND COSTS: 1. Review the Attorney's Fee Contract with client, before the client signs. a) Provide examples of a hypothetical settlement Explain advanced costs and reimbursement Explain your advanced cost policy Make sure you feel certain that the client understands the policy b) c) d) H. DISCUSSING AND REVIEWING WITH CLIENT THE EFFECT OF SIGNING VARIOUS AUTHORIZATIONS: 1. 2. HIPAA (General, Medicaid, Medicare & Private Health Insurance) Employment VI. TIPS FOR IMPROVING COMMUNICATION WITH CLIENTS A. Don't blind copy everything to a client, unless they request it. 1) 2) This can create unnecessary telephone calls from clients, or drop-ins (visits); May create confusion of issues or unnecessary concerns; Reduces the chance of clients contacting a defendant, insurance adjuster, defense attorney, Clerk of Court or Judge, directly; Keeps the file costs down (i.e., save time for staff and lowers the overhead). 3) 4) B. C. Take clients' telephone calls, when they do call, if at all possible. If not, return them that day, if at all possible (*, refer to Communication policy discussed earlier). If client drops by the office, greet them in person, if at all possible. D. Send short letters to clients regarding status, or inquiring about their status (i.e., How they feel? Remind them to keep doctor's appointments. Hope they're doing better, etc), and/or ask them to call you. Call clients at odd times, especially if you are actually working on their case (lunch, before office hours, after office hours, Saturdays and Sunday afternoons)- lets them know you do work on their case. If telephone is disconnected, or no answer when calling, send a note, "I've been unsuccessful trying to reach you by phone"; When discussing the damages evaluation with client, always discuss net recovery to client, then confirm with a letter; When discussing settlement offers with client, always include net recovery to them, and if possible, follow-up with a letter; Copy client with settlement check (with endorsements), signed Release, signed Disbursement Sheets at time of disbursement of settlement; then, follow-up with letter enclosing copy of transmittal letters of payment and copy of Trust Account checks to healthcare providers, Lien Holders and Subrogators, etc. E. F. G. H. I. VII. RESOLVING THE PROPERTY DAMAGE CLAIM: A. WHERE IS THE CAR? LIENS, TOWING & STORAGE (First things first) B. RENTAL AGREEMENT (THE SUBSTITUTE VEHICLE): 1. 2. The advance deposit vs. insurance direct billing No collision insurance (the deposit anyway) The deposit, regardless of everything else The clients' car rental coverage (the deposit regardless) No car rental, but loss of use $ anyway Loss of use/substitute vehicle has its limits a) is the vehicle drivable? What is reasonable repair time? b) 3. 4. 5. 6. C. ADJUSTER'S ESTIMATE OF REPAIR: 1. Getting an estimate of repair set-up- ASAP The time factor: Client's collision coverage vs. defendant's liability Getting your own estimateindependent adjuster vs. body shop a. Settling the property damage claim: a. Negotiating the settlement after reviewing the estimate of damages with client 2. 3. 4. D. THE TOTAL LOSS CLAIM: 1. Estimate of repair vs. total loss Know how much the vehicle is worth: a. Bill of Sale b. NADA c. Prior damagelappearancelmileage d. liens Settling for total loss vs. retaining salvage e. The upside down total loss situation: f. Work out the best deal possible a. Don't forget other insurance coverage (mortgage insurance) b. E. PROPERTY DAMAGE-ATTORNEY FEE 1. Fee vs no fee A. Determining which small claim category the case fits: * 1. 2. Using the Attorney Interview Sheet Using the accident report- multiple claims Keeping up with the client bills Making use of all insurance available Keeping open communication with your client a) referrals to specialists b) period of treatment Keeping open communication with the Claims Adjuster (if possible, obtain liability limits from adjuster ASAP) 3. * 4. 5. 6. B. Getting started with claim process: 1. Fadmail letter of representation to all insurers ,a) Layout ground rules in your letter to adjuster(s) regarding providing documentation of your client's claims Liability adjuster(s)- when you will document claim 1. U.M. Adjuster(s)- when you will document claim 2. Med-Pay Adjuster(s)- how much and to whom the checks are to be written, 3. and where they are to be mailed. 2. Assisting/scheduling client's medical treatment: a) Client's primary care physician- use if at all possible: 1. knows historylhas records May not accept liability claims/or will not accept financial arrangements 2. b) Referring client to other physicians: 1. * c) Making financial arrangements: a) Deferring payment to settlement b) Med-Pay c) Attorney or client- deposit Tell them how, when and where to send reports and bills. d) Making arrangements for referrals to allied health care providers (Physical therapy, MRI's, etc.: 1. Tell them how, when and where to send the bills. a) b) c) d) Deferring payment to settlement Med-Pay Attorney or client- deposit Tell them how, when and where to send reports and bills. 3. Referringlor helping clients chose Health Care Providers (Cafeteria Plan vs. Specialty Shops): a) Cafeteria Plan: 1. Chiropractors and Medical Clinics a) x-ray machines MFU's b) c) Physical Therapy d) Pharmacy e) etc. Advantages: a) b) c) d) e) All in one treatment-convenience All in one billing-convenience Al I in one records-convenience More receptive to negotiated reductions Higher percentage of kept appointments 2. 3. Disadvantages: a) b) c) All in one treatment/necessary(?) All in one billingltoo high(?) All in one records/lowers impact(?) b) . Specialty Shops: 1. Individual Providers: a) Primary Care Physician b) Hospital c) Radiologist MRI's d) e) Physical Therapy f) Pharmacy ' ' 2. Advantages a) Possibly more conservative treatment b) Possibly less expensive billing Perception of more extensive treatmendgreater impact c) d) Individual records/opinionsldocumentation Disadvantages a) Less convenient for client Higher percentage of missed appointments b) C) Delay in receiving recordshills Delay in scheduling referrals or appointments/(i.e.) working out d) Financial arrangements Harder to work out reductions in bills el Increase in possibility of inaccurate history recorded in medical records f) 3. 4. Attorney Referral to a Specialist (Orthopedist, Neurosurgeon, Plastic Surgeon, etc.: a) Advantages: 1. 2. 3. 4. 5. 6. 7. 8. 9. b) Assure cliendattorney of diagnosis and prognosislbrings closure Confirms injury with another opinion Provides opinion of future medical expenses Increases client's pro-rata share of policy limits in multiple claimant case Helps to enhance general damages claim in soft tissue cases Provides an additional expert witness if case goes to trial Helps provide proof of duration of injury in gap-in-treatment claims Often locks in a diagnosis early of a physical injury claim that exceeds the policy limits, without incurring medical expenses that must be deducted from settlement Provides a well documented expert medical report Disadvantages: 1. 2. 3. 4. Usually requires sizable medical fee deposit Medical report can be expensive Medical opinion could be contrary to original diagnosis (disadvantage to settlement negotiations) May require additional expensive tests (i.e., MRI) before appointment can be scheduled or opinion rendered PERSONAL INJURY DAMAGES EVALUATION: a) COMPONENTS: Medical treatment, type and duration Physician's diagnosis of injuries Temporary, total or permanent disability Loss of enjoyment of life (inconvenience) Physical pain & suffering Medical ExpenseEuture Expense Lost Wages Review client's logldiary/calendar of pain & suffering, lost wages, loss of eventslactivities, etc. Attorneys personal experience with particular insurance adjuster Attorney's trial experience in court ofjurisdiction 1 1) 12) 6. Case evaluation of reported cases, similar Low judgment value vs. high judgment value evaluation of the claim OBTAINING SETTLEMENT AUTHORITY FROM THE CLIENT: a) b) c) 7. Meet with the client and review evaluation (or if client is not available, discuss on the telephone): Obtain settlement authority from the client, both gross demand and client's net recovery Confirm in writing with client SETTLEMENT DEMAND T O ADJUSTER: a) Settlement demand letter vs. settlement brochure: 1. Settlement Demand Letter (Contents) a) Includes General Damages demand Medical Expenses/Specials (List of itemized medical bills) b) c) Lost Wages amount d) Enclosures: 1. Medical records 2. Medical Bills 3. Lost Wages Documentation e) Advantages: 1. Meets basic obligation to attempt to negotiate settlement prior to suit 2. Probably best used when insurance company has a track record unreasonable settlement offers 3. Best used when medical bills and medical records on their face, clearly depict damages claim that exceed policy limits. Disadvantages: 1. Does not provide a professional evaluation of the client's claim 2. Does not separate your client's claim from the thousands the adjuster reads 3. May indicate to the adjuster your lack of interest or belief in your damages demand 0 2. Settlement Demand Brochure: Contents (more than a letter): a) b) c) d) e) Facts- details of the accidentlinjuries Injuries/Medical Treatment- review of systems, medical providers' treatment, diagnosis, prognosis, attendant disability: quotes of providers, if applicable, duration of treatment List of Medical Records List of Medical Bills Lost Wages- Job description, details of howlwhy injuries caused inability to work, amount of lost wages and how calculated General Damages Evaluation- provides unique examples of how the physical injuries effected the client, eluding to possible testimony from friends, family, co-workers, who can support the claims. Provide names of cases with similar facts, awarding damages. 0 Provide your evaluation of what you think a Judge would award in the jurisdiction where the suit would be filed, if the claim cannot be settled. g) Itemized list of damages: 1) General Damages.. ...... $Adequate Amount 2) Medical Expenses....... $Adequate Amount 3) Lost Wages ................ $Adequate Amount Enclosures (well organized) 1) Medical Records 2) Medical Bills Lost Wages- Lost Wages Letter(s) 3) a) employer b) other if self-employed Include a deadline to reply Advantages: 1) 2) 3) 4) h) i) j) 5) 6) 7) Makes the adjuster identify with your client's damages Provides a professional evaluation of the client's damages claim Provides details as to why your client's claim for damages is r reasonable Provides the adjuster with ammunition to ask histher supervisor for additional settlement authority Gives the adjuster your evaluation ofjudgment value (the next step if it doesn't settle Provides you with a good reference outline while discussing settlement with the adjuster on the telephone If litigation is necessary, it gives the defense attorney a summary of the uniqueness of your client's claim, for hisfher damages evaluation k) Disadvantages: If anything, time consuming 8. FOLLOW-UP NEGOTIATIONS WITH ADJUSTER: a) b) c) d) e) Reiterate your strong points in the brochure Don't be afraid to share additional examples of the uniqueness of your client's experiences (that you didn't include in the brochure) Reiterate what you can expect in Court Give the adjuster a bottom line- and don't move off of it If no settlement, make sure to withdraw your last settlement offer (bottom line) before you file suit. 9. SETTLEMENT DISBURSEMENT SHEET a) Disbursement Sheet: 1. Itemize Everything Attorney Fee (with %) or reduction a) medical bills with account numbers b) c) d) e) b) advanced costs (with attorney check numbers) Signature line with dates approved witness line with date Make copies and distribute at time of disbursement: * c) 1. 2. 3. Disbursement Sheet Front and back of endorsed settlement check Release & Receipt Mail client letter following disbursement: 1. 2. Confirming receipt of copies of above materials at time of settlement disbursement Enclosures- copies of all transmittal letters and Trust Account checks payable to third parties (i.e.) medical providers, record fees, loan pay-offs, expert witnesses, Court cost (if applicable) LITIGATION A. Choosing your forum (City Court vs. District Court) 1. City Court: a) Advantages 1. 2. 3. 4. 5. b) Court cost- low Trial dates 30-90 days (quick) Less pre-trial procedure Possibly less expert costs Judgments may be quicker Disadvantages 1. 2. 2. District Court: Less formal in some circumstances Not always quicker- trial dates a) Advantages 1. 2. Uniform Court Rules Status Conference Settlements b) Disadvantages 1. 2. 3. Court cost higher Trial dates often further out 2nd-3rd settings, etc. 3. Obtain authority from client: a) Discuss advantages and disadvantages: 1. Court cost 2. Deposition Fees 3. 4. 5. 6. -7. Time delay Anything can happen Judgments are not always higher than the settlement offer Attorney fees may change under contract If you have an unreasonable client, discuss appeal of the case B. Settlement: Sometimes it just takes a bump. C. Discovery: 1. Interrogatories a) b) c) Use prior preparation (intake sheets, etc.) for answering Prepare answers Have client review under oath, and sign Affidavit 2. Depositions a) b) c) Use prior preparation (intake sheets, medical records, etc.) to prepare client Use deposition time to prepare client for trial . Spend as much time in deposition prep as you do in initial interview D. File Motion to Fix Trial or Status Conference ASAP 1. Use this as a way to present your trial theme Use this as a way to settle the case mini-mediation (but with a Mediator who has a gavel) Get defendant to stipulate to liability or tell Judge why histher client won't shorten the trial Stipulate to submission of deposition in lieu of live testimony (experts) 2. 3. 4. E. Trial Preparation: Use settlement brochure as theme of your client's case. F. Trial Tips: 1. Keep a theme going with your client testimony Have a good non-partisan moan and groan witness Put every deposition you can into the record (to tax as Court cost) 2. 3. GOOD LUCK! DATE CALLED: DIA: CLIENT: ADDRESS: SS#: DOB: ARE YOU ALREADY REPRESENTED BY A LAWYER? (YES)(NO), IF SO, WHO? PHONEICONTACTS: CIRCLE: DRIVER PASSENGER CLIENT'SIDRIVER'S INS. POLICY #: VEHICLE: YEAR bfAKE U.M. (YES)(NO) MEDPAY (YES)(NO) CLAIM : MODEL TOWED (YES) (NO) IF.SO, WHERE TAKEN? LOCATION: DESCRIPTION. W E S T I G A T M G AGENCY: (POLICE DEPT.ISHERIFF'S DEPT., STATE TROOPER?) PARTS OF BODY INJURED: ACCIDENT REPORT (YES)(NO) DO YOU HAVE A COPY? (YES)(NO) . MEDICAL TREATMENT (YES)(NO) WHERE TREATED?: LOST WAGES (YES)(NO) EMPLOYER NAMEIADDRESS: ADDITIONAL CLIENTS: DOB: MJURIESITREATMENT?: DOB: DOB: DOB: LOST WAGES (YES)(NO) EMPLOYER NAMWADDRESS: OTHER DRIVER: VEHICLE: YEAR INSURANCE: U.M. (YES)(NO) MED-PAY (YES)(NO) TOWED (YES) (NO) IF SO, WHERE TAKEN? CLAIM #: MAKE: MODEL: POLICY #: PRESCRIPTION DATE FILE: ATTORNEY INTERVIEW S H E E T CLIENT NAME: ADDRESS: PHONES: (H) SS#: FORMER ADDRESS: SPOUSE'S NAME: ADDRESS: + . FILE: (c) DOB: BIRTHPLACE: (w) PHONES: (H) SS#: DATE OF MARRIAGE: WAS DIVORCE EVER FILED? DOB: (c) ' (w) BIRTHPLACE: PLACE: IF SO, WHEN & WHERE? SPOUSE'S EMPLOYER'S NAME, ADDRESS tk PHONE #: FORMER SPOUSE'S NAME (If Applicable): PHONES: DIVORCE OR DEATH? SS#: DATE OF DIVORCE OR DEATH? WHERE DOB: DATE OF DEATH OR TERMINATION OF MARRIAGE: LIST ALL NATURAL CHILDREN O F CLIENT: (Attach Extra Pages if ~ e c e s s a q ) : (A) NAME: ADDRESS: PHONES: (H) SS#: (B) NAME: ADDRESS: PHONES: (H) SS#: (C) NAME: ADDRESS: PHONES: (H.) SS#: (D) NAME: ADDRESS: , , - (c) DOB: BIRTHPLACE: (w) (c) DOB: BIRTHPLACE: (w) (c) DOB: BIRTHPLACE: (w) / 1 PHONES: (H) SS#: DOB: (c) BIRTHPLACE: (w) A T T O R N E Y INTERVIEW S H E E T CLIENT NAME: AUTOMOBILE DAMAGE: (YES)(NO) PHOTOS MADE (YES)(NO) FILE: DRlVEABLE (YES)(NO) WHERE LOCATED: PRIOR DAMAGE TO AUTO: MILEAGE: SPECIAL EQUIPMENT: CLEAR TITLE (YES)(NO) LIEN HOLDER: HOW MUCH DID YOU PAY FOR VEHICLE? LOAN INSURANCE (YES)(NO) COLLISION COVERAGE (YES)(NO) DATE OF PURCHASE: AUTO RENTAL COVERAGE (YES)(NO) YEAR: MAKE: MODEL: MEDICAL TREATMENT INFORMATION (Attach Extm Pages, If Necessary) CLIENT'S NAME: (A) Doctors, Hospitals, CIinics, ete., providing treatment for injuries: (1) Name & Address: Appx. Dates of Treatment: (2) Name & Address: Appx. Dates of Treatment: (3) Name & ~ddress: Nature of Treatment: -. Nature of Treatment: Appx. Dates of Treatment: (4) Name & Address: Nature of Treatment: Appx. Dates of Treatment: (5) Name & Address: Nature.of Treatment: Appx. Dates of Treatment: (6) Name & Address: Nature of Treatment: Appx. Dates of Treatment: (7) Name & Address: Appx. Dates of Treatment: (8) Name & Address: Nahlre of Treatment: Nature of Treatment: Appx. Dates of Treatment: (9) Name & Address: Nature of Treatment: ..: Appx. Dates of Treatment: (10) Name & Address: Nature of ~reatment: Appx. Dates of Treatment: Nature of Treatment: (B) MedicalInsurance at Time of Injury: Who is paying your bills? Auto Workeh Comp. Your Medical Insurer Self Other (1) HEALTH INSURANCE: Name & Address: PoIicy Number: (2) WORKER'S COW.: Name & Address: Phone #: CASE #: Policy Number: (3) AUTO INSURANCE: Name & Address: Phone #: . CLAIM #: Policy Number: U.M. (YES)(NO) MED-PAY (YES)(NO) Phone #: ATTORNEY INTERVIEW SHEET CLIENT NAME: (4) DISABILITY INSURER: Name & Address: FILE: Policy Number: Phone #: (5) HOSPITAL & ACCIDENT POLICY: Name & Address: Policy Number: (6) MEDICAID MID #: PARlSH NONAME: * Phone #: - (7) MEDICARE: Name & Address: I.D. NUMBER: (C) FACT WITNESS NAMES, ADDRESSES, PHONES: Phone #: POTENTIAL DAMAGES WITNESSES: (1) (2) (3) (4) MEDICAL TREATMENT 10 YEARS PRIOR TO ACCIDENT (Attach Extra Pages, If Necessary) (A) Doctors, Hospitals, Clinics, etc., providing treatment for injuries: (1) v: Approxrmate Dates of Treatment: Nature of Treatment: (2) Name & Address: Approximate Dates of Treatment: Nature of Treatment: (3) Name & Address: Approximate Dates of Treatment: Nature of Treatment: (4) Name & Address: Approximate Dates of Treatment: Nature of Treatment: (5) Name & Address: Approximate Dates of Treatment: Nature of Treatment: (6) Name & Address: Approximate Dates of Treatment: Nature of Treatment: ~ ATTORNEY INTERVIEW SHEET CLIENT NAME: MEDICAL TREA'IMENT 10 YEARS-PRlOR TO ACCIDENT: (7) Name & Address: FILE: Approximate Dates of Treatment: Nature of Treatment: (8) Name & Address: Approximate Dates of Treatment: Nature of Treatment: (9) Name & Address: Approximate Dates of Treatment: Nature of Treatment: (10) Name & Address: Approximnte Dates of Treatment: Nature of Treatment: EMPLOYMENT FOR LAST TEN YEARS (Anach Extra Pages, If Necessary): (A) DATES EMPLOYED (FROM-TO): : - -. TITLE & DUTIES: RATE OF PAY. (START) AVERAGE WORK SCHEDULE REASON FOR LEAVING PER (HR) (m) (MO) (YR) (END) I(HR)(WK)(MO)(YR) (B) DATES EMPLOYED (FROM-TO): NAME, ADDRESS &PHONE: TITLE & DUTIES: RATE OF PAY: (START) AVERAGE WORK SCHEDULE REASON FOR LEAVING (C) DATES EMPLOYED (FROM-TO) NAME, ADDRESS & PHONE. TITLE & DUTIES PER (HR) (WK) (MO) (Y R) (END) /(W(WK)(MO)(YR) RATE OF PAY (START) AVERAGE WORK SCHEDULE REASON FOR LEAVING (D) DATES EMPLOYED (FROM-TO). NAME, ADDRESS & PHONE TITLE & DUTIES. RATE OF PAY (START) PER (HR) (WK) (MO) (YR) (END) /(HR)(WK)(MO)(YR) PER (HR) (WK) (MO) (YR) (END) /(HR)(WK)(MO)(YR) AVERAGE WORK SCHEDULE REASON FOR LEAVING ATTORNEY INTERVIEW SHEET CLIENT NAME: EMPLOYMENT FOR LAST TEN YEARS ' (E) DATES EMPLOYED (FROM-TO): NAME, ADDRESS & PHONE: ... , FILE: . TITLE & DUTIES: RATE OF PAY: (START) AVERAGE WORK SCHEDULE REASON FOR LEAVING PER (HR) (WK) (MO) (YR) (EM') /(HR)(WK)(MO)(YR) (F) DATES EMPLOYED (FROM-TO): NAME, ADDRESS &PHONE: TITLE & DUTIES: . , RATE OF PAY: (START) AVERAGE WORK SCHEDULE REASON FOR LEAVING (G) DATES EMPLOYED (FROM-TO): NAME, ADDRESS & PHONE: TITLE & DUTIES: RATE OF PAY: (START) AVERAGE WORK SCHEDULE REASON FOR LEAVING (H) DATES EMPLOYED (FROM-TO): NAME, ADDRESS &PHONE: TITLE & DUTIES: RATE OF PAY: (START) AVERAGE WORK SCHEDULE REASON FOR LEAVING PER (HR) (WK) (MO) (YR) ' (END) I(HR)(WK)(MO)(YR) PER (HR) (WK) (MO) (YR) (END) /(HR)(WK)(MO)(YR) PER (HR) (MO) (YR) (END) /(W(WK)(MO)(YR) (I) DATES EMPLOYED (FROM-TO): NAME, ADDRESS &PHONE: TITLE &DUTIES: RATE OF PAY: (START) AVERAGE WORK SCHEDULE REASON FOR LEAVING PER (HR) (WK) (MO) (YR) (END) I(HR)(WK)(MO)(YR) ADDITIONAL INFORMATION: MINOR CHILD INFORMATION SHEET CLAIM: CHILD'S NAME: ADDRESS, IF DIFFERENT FROM PARENT(S): DOB: HOW MJLJREDIINJURIES: SS#: D/A: MEDICAL PROVIDERS: NAME OF SCHOOL CHILD ATTENDS: LOSS OF SCHOOL OR ACTIVITIES? FATHER: RESIDENTMAILING ADDRESS OF FATHER: DOB: SS#: PHONE: IS FATHER'S NAME ON BLRTH CERTIFICATE? - IF NOT, WHOSE NAME IS ON CERTIFICATE? Does (FATHER'S NAME) Court, or other document giving permission to have custody of child? MOTHER: RESIDENTMAILING ADDRESS OF MOTHER: have a custody order from Please provide copy of document. SS#: . . -DOB: NAME OF GUARDIAN (IF DIFFERENT FROM FATHER OR MOTHER): DOB: RESIDENTIMAILING ADDRESS: SS#: Does (GUARDIAN'S NAME) from Court, or other document giving permission to have custody of child? have a custody order Please provide copy of document. PRESCRIPTION DATE FILE: STATE O F LOUlSlANA PARISH ASSIGNMENT O F INTEREST AND CONTRACT O F EMPLOYMENT UNDER THE PROVISION OF R.S. 37:218 AND RS. 9:5001 / C+STER I I BY AND BETWEEN AND A. BRADLEY, 111 -ATTORNEY AT LAW CHESTER A. BRADLEY, m AND ASSOCIATES AND COUNSELORS AT LAW JAT~ORNEYS I The undersigned CHESTER A. BRADLEY, employment. Client employs Attorney to represent (clienw Ib AITORNEY AT LAW (herein called attorney), and (herein, whethe(rone or more, called Client), hereby enter into the following assignment of interest and mnmact of I ! ,200in .whose for personal injury as a result of a motor vehicle accident o Parish, Louisiana. As a attorneys fee shall reman the same as referenced above. Clientassims. and Altorney(s) acceDts and requbres ar attorney fee, a proportionate interest in the subject m&er ofany claim, action, or suit instimed or In the event thar the Client dismissis the undcrsi ed Attorney(s) from representation in the above referenced malter, the Client shall pay or the Client's new legal counsel shall pay, within thirty (30) days from the dat of the letter of dismissal from the Client to the Anorney(s), all expenses incurred and advanced by the Attorney(s) on behalf of the Client for: long distance teleph ne cost, long distanoe fax cost, photocopy cost at $. 10 per page, postage, client advances, interest on client loans, client loan payof&, medical expenses advanced, tran portation expenses, lodging expenses, expenses of investigation, medical record fees, expert witness report fees, court exhibits, court costs, filing of this employment c ntracf, Clerk ofcourt fees, deposition fees, court reporter fees, expert witness deposition fees, expert wimess trial preparation fees, expert wimess trail testimony fees, if any. settle, msact, compromise, or discontinue any demand, claim, su~t, action commenced or I I Executed on this WITNESSES: day of _ afier a due reading of the whole. Chester A. Bradley. 111. Attorney at Law Chester A. Bradley, III and Associates Attorneys and Counselors at Law 1888 Hubon Circle, Suite 4, Monroe, Louisiana 71201 or PO Box 2689 Monroe, Louisiana 71207-2689 318-388-3401 By: CHESTER A. BRADLEY, 111 STATE OF LOUISIANA~~OUACHITA PARISH I hereby authorize: (Medical Provider) 1 to use or disclose the following protected health in ormation (PHI) from the medical records of the patient listed below to: CHESTER A. BRADLEY, 111, Attorney at Law P.O. Box 2689, Monroe, Louisiana 71207-2689 Telephone: 318-388-3401, FAX: 318-388-3311 , Patient Name: Patient Social Security Number: Patient DOB: Patient Address: 1 I DA TE O F INJURY: Disclose the following PHI for treatment dates: AbstractPertinent History & Physical Operative Report ~ r o g r i s~ o t e s s ER Report Lab Other Specified: 1 1 ' I Discharge Summary physicit& Orders X-ray Consult Nurses Notes Entire Chart The above information is disclosed for the following purposes: Medical Care Legal Insurance Per' onal 1 Other 7 * * . - I acknowledge, and hereby consent to suc that the released information may contain alcohol and drug abuse, psychiatric, HIV This authorization shall expire upon this ex jiration date: **If I fail to specify an expiration date or eve .t, this authorization will expire six (6) months from the date on which it was signed. I understand that I have the right to revoke t is authorization at any time by sending a letter to the health care provider to whom the authorizati n is directed, and to CHESTER A. BRADLEY, 111. If I did, it would not affect any actions alrea y taken by the health care provider based upon this authorization. I may not be able to revoke t is authorization if its purpose was to obtain insurance (45 CFR 5 164.508 (b) (5) and 14.508 O (2)). I understand that I do not have to sign this authorization in order to get health care benetits (treatments, payment, enrollment, or eligibilip). (45 CFR 5 164.508 (b) (5) and 164.508 O (2)). The information used or disclosed pursuant the authorization may be subject to re-disclosure by 5 164.508 O (2)). the recipient and no longer I agree that a photostatic copy i may be used with the same authority as the original. I have read the above and authorize the disclosure of the protected health information as stated. Date If signed by legal representative, relationship to patient: Signature of Witness Date LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS AUTHORIZATION TO RELEASE OR OBTAIN HEALTH INFORMATION (Including paper, oral and electronic information) Name: Mailing Address: CityIStatelZip: Request Date: Date of Birth: Medicaid # or Social Security #: 1 authorize: Name: Mailing Address: City, State, Zip Code: Relat~onship: Attorney CHESTER A. BRADLEY, 111, CHESTER A. BRADLEY, I11 AND ASSOCIATES P.O. Box 2689 Monroe, Louisiana 71207-2689 Telephone: (3 18) 388-3401 Toll Free: (800) 399-0801 F a : (318) 388-331 1 TO RELEASE Information TO: OR W TO OBTAIN Information FROM: Name: Mailing Address: Relationship: Program Specialist Third PartyIMedicaid Recovery La. Dept. of Health and Hospitals/BHSF P.O. Box 91030, Baton Rouge, Louisiana 70821-9030 Telephone #: (225) 342-9041 FAX: (225) 3764674 The Purpose of this Authorization is indicated in the box(s) below: (Place an "Xu in the box(s) that apply.) Further Medical Care Personal El Legal Investigation or Action Changing Physician 0 Research related treatment Other: (Specify) Creating health information for disclosure to a third party. I authorize the release of the following protected health information. (Place an "X" in the box(s) that apply to the information you want released or you want to obtain.) Medical History, Examination, Reports Surgical Reports Treatment or Tests Immunizations Hospital Records including Reports Laboratory Reports MRIDD Records W Other: All billinp information reparding charaes submitted lo or pavmenls made bv Medicaid In compliance with state and/or federal laws which require special permission to release otherwise privileged information, please release the following records: Alcoholism Drug Abuse Sexually Transmitted Diseases Other: Mental Health Genetics Vocational Rehabilitation Psychotherapy Notes HIV (AIDS) Entire Record Prescriptions X-ray Reports This authorization shall expire on needed for the period beginning (date or event) and is and ending 1 understand that if I do not specify an expiration date, this authorization will expire six (6) months from the date on which it was signed. I acknowledge that p . Signature of Individual or Personal Representative Authorized by Law Date Signature of Witness (If signed with an "X"or mark) FOR DHH Use When Requesting Records Date l a m authorized to receive this disclosure. Documentation on the above Personal Representative has been obtained. Signature and Title of Agency Representative Date HIPAA 402P pg I STATE OF LOUISIANA PARISH OF EAST BATON ROUGE AFFIDAVIT 1, , PROGRAM SPECIALIST, Department of Health & Hospitals, Medicaid Management Information Systems, 1201 Capitol Access Road, Baton Rouge, Louisiana do hereby swear and affirm that I am familiar with the Medicaid payment accounts of # , MID Parish #-- ,whose date of birth is and whose Social Security number is ; and that all Medicaid liens in connection with medical bills paid for medical treatment as result of her motor vehicle accident on satisfied. This day of , have been fully ,200- in Baton Rouge, Louisiana. ,PROGRAM SPECIALIST This sworn to and signed before me, the undersigned authority, this ,200- in Baton Rouge, East Baton Rouge Parish, Louisiana. NOTARY PUBLIC PRINT NAME ADDRESS CITY, STATE & ZIP CODE NOTARY # EXPIRATION DATE day of I I hereby assign to the Department df Vebrans Affairs any claim I ruay havc againsl any person or entity who is or may 1.; legally responsible for the payment of the cost of medical services providcd to me by the Department of Vcterans Affairs. f. unr?crsLand*at h i s assignment slldl not limit or prejudice my right to recover for my own bcncfit any amount in excess of the cosr of rnedicnl. scnriccs provided lo tne by h Department of Veterans Anrairs or any other amount to which I may be entitled e ' I hereby appoint the Atton~cyGeneral of tho United States and the Secretary of Veterans' A f i s ahd their designees as my far Attorneys-in-fact lo toke all necessary and appropriate aclio~ls order to recover and receive all or part of the arnouulhereinassigned. in I I I~crcbyauthorize the Dcparbnent of Veterans Affairs to disclose, to my attorney a ~ to any third part nr ~.~hkii~Giiiv~ who d ilgalcy may be responsible for paynlent OF the cost oFmedica1 services n,.st.ideb iv ale, infom~dtion from my medical records as nekessary to verify m y claim. Further, 1be~eby authorize any such third party or admiuiskativc agcncy to disclose to the Department ofi~cterans NTairs any blfonnation regarding my claim. GIQNAT~RE PATIENT OF OATE SIGNATURE OF 'f'b'lVITNES$ YAFORM r JuL isas 69.6763 SLIPERSWESVA FORM 24763. NOV 1969,AND VA FORM 10.2381, MAY 1083. WHICHW~LLNOT BE USED. CHESTER A. BRADLEY, 111 AND ASSOCIATES ATTORNEYS & COUNSELORS AT LAW PHYSICAL ADDRESS: 1888 HUDSON CIRCLE, SUITE 4 MONROE, LOUISIANA 7 1201 TELEPHONE: (3 18) 388-3401 TOLL FREE: (800) 399-0801 MAILING ADDRESS: POST OFFICE BOX 2689 MONROE, LOUISIANA 7 1207-2689 FAX: (318) 388-331 1 RE: D/A: CLIENT: CLAIMS: FILE#: Dear SirIMadam: I represent the above referenced clients in regard to personal injury claims from their motor vehicle accident on ,2003 in ,Louisiana. I have enclosed a copy of the Uniform Motor Vehicle traffic Crash Report. Please advise me, by fax 3 18-388-3311 or mail, P.O. Box 2689, Monroe, Louisiana 71207-2689 of the name, address, phone number and claim representative o f , as well as the claim number assigned. With kindest regards, I remain. Sincerely yours, CABIIII dIg Enclosure