Legal Fee Contract and Medical Release

LEGAL FEE CONTRACT AND MEDICAL RELEASE

This Legal Fee Contract and Medical Release (the Agreement) is made effective as of by and between Client Name: , Date of Birth: , Address: (Client), and Attorney/Firm Name: , Bar Number: , Firm Address: (Counsel).

RECITALS

WHEREAS, Client seeks legal representation by Counsel in connection with the matter described as: (the Matter); and

WHEREAS, Counsel is willing to represent Client in the Matter subject to the terms and conditions set forth in this Agreement; and

WHEREAS, the parties desire that Client authorize release of medical and related records to Counsel to assist in investigation, prosecution, settlement or defense of the Matter.

NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, the parties agree as follows.

1. ENGAGEMENT; SCOPE OF REPRESENTATION

1.1 Engagement. Client retains Counsel to provide legal services reasonably necessary for the representation of the Client in the Matter described above. Counsel will provide legal advice, prepare pleadings, negotiate settlements, and perform litigation tasks as reasonably necessary under the circumstances.

1.2 Limitations. Counsel does not guarantee any particular result. Services outside the scope of representation will require separate written agreement.

2. FEES, RETAINER, AND COSTS

2.1 Fee Structure. The parties elect the following fee arrangement (select one): Contingency fee Hourly fee

2.2 Contingency Fee Terms. If contingency fee is selected, Client agrees Counsel shall receive % of the gross recovery (whether by settlement, judgment, or other collection). Gross recovery shall include damages, settlements, court-awarded fees, and cost recoveries.

2.3 Hourly Fee Terms. If hourly fee is selected, Counsel's hourly rates are as follows: Lead Attorney per hour; Associates/Paralegals at prevailing rates. Time is billed in increments of .

2.4 Costs and Expenses. Client agrees to pay or reimburse costs advanced by Counsel for filing fees, court reporters, expert fees, medical record retrieval, courier, investigative expenses, and other disbursements (Costs). Client shall deposit an initial retainer for Costs in the amount of $ to be held and applied against Costs. Unused retainer amounts, if any, will be returned at the conclusion of representation after final accounting.

2.5 Billing and Accounting. Counsel will furnish periodic statements reflecting fees, Costs advanced, and disbursements. Client must pay any invoiced non-contingent fees or Cost balances within 30 days of invoice unless otherwise agreed in writing.

3. CLIENT RESPONSIBILITIES

Client shall cooperate fully with Counsel, provide truthful and complete information, attend scheduled meetings and hearings, and promptly respond to communications. Client is responsible for identifying known medical providers and authorizing release of records as set forth below.

4. MEDICAL RELEASE AND AUTHORIZATION

4.1 Authorization. Client hereby authorizes any physician, hospital, clinic, medical provider, insurer, pharmacy, laboratory, medical facility, and any other person or entity having records or knowledge of Client's health care, treatment, or condition to release to Counsel and Counsel's agents and representatives any and all medical records, billing records, charts, radiological images, diagnostic studies, therapy notes, mental health records, substance abuse records, and other protected health information (PHI) relevant to the Matter, including PHI relating to HIV/AIDS, mental health, and substance abuse where applicable.

4.2 Recipients and Purpose. The PHI may be disclosed to Counsel, its investigators, retained experts, insurers, adversaries, mediators, and the court as necessary to investigate, litigate, settle, or obtain benefits in the Matter. The primary recipient of PHI is Counsel: .

4.4 Time Period. This authorization applies to records for the period from through and to any earlier or later records if relevant to the Matter.

4.5 Revocation. Client may revoke this authorization in writing at any time, except to the extent Counsel has already relied upon it. Revocation will not affect disclosures already made in reliance upon this authorization.

4.6 Acknowledgment. Client acknowledges that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by privacy laws. Client authorizes Counsel as Client's agent to execute records requests and to accept copies of records on Client's behalf.

5. CONFIDENTIALITY; PRIVILEGE

Counsel shall maintain the confidentiality of information provided by Client to the extent required by law and applicable rules of professional conduct. Client understands that certain disclosures (including those made pursuant to the medical release above) may be necessary for prosecution or defense of the Matter and may be subject to discovery.

6. TERMINATION; WITHDRAWAL; UNPAID FEES

Either party may terminate this Agreement upon written notice. If Counsel withdraws for good cause or Client terminates, Counsel is entitled to reasonable fees and reimbursement for Costs incurred to the date of termination, calculated on a quantum meruit basis if necessary. Client agrees to execute any documents necessary to transfer files and records on reasonable terms.

7. NOTICES

Any notice under this Agreement shall be in writing and delivered to the addresses below by personal delivery, overnight courier, or first-class mail, postage prepaid, and will be effective upon receipt.

8. DISPUTE RESOLUTION; ATTORNEY'S FEES

Any dispute arising from or related to this Agreement shall be resolved by the state or federal courts located in the governing law jurisdiction set forth below unless the parties agree in writing to mediation or arbitration. The prevailing party in any action to enforce this Agreement shall be entitled to recover reasonable attorney's fees, costs, and expenses.

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

9.1 Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of law principles.

9.2 Entire Agreement. This Agreement constitutes the entire understanding between the parties regarding its subject matter and supersedes all prior agreements and understandings, whether written or oral.

9.3 Severability. If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

10. AMENDMENTS; WAIVER; COUNTERPARTS

10.1 Amendments. This Agreement may be amended only by a writing signed by both parties.

10.2 Waiver. Failure or delay to exercise any right shall not constitute a waiver. A waiver must be in writing.

10.3 Counterparts. This Agreement may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one instrument.

CLIENT ACKNOWLEDGMENTS

Client acknowledges receipt of a copy of this Agreement, has read and understands the terms, has had the opportunity to ask questions, and agrees to be bound by its terms.

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