PERSONAL INJURY INTAKE SHEET PERSONAL INFORMATION:Client's Name ___________________________________________ Aliases
_________________________ Date _____________Address _____________________________________________________________ Phones (H)
__________________________________________________________________________________________________ (W)
_____________________________SSN _________________________________ Race: ___________ Sex: _________ Age: ________
DOB: ____________________Married? M[ ] S[ ] D[ ] Resides With: ____________________________________ Phone
__________________________________Education: Elem [ ] H.S. Grade ______ Diploma? [ ] _____________________ College
__________________________________Trade School_________________________________________________________________________Spouse's Name: _______________________________________ Phones (H) __________________(W)
______________________Address _________________________ Employer
____________________________________________________________________________________________ _______________________________________________Children: Name ______________________________________ DOB
______________________________ Age ________________Name ______________________________________ DOB ______________________________ Age
________________Father's Name: _________________________________________ Phones(H)______________________
(W)___________________[ ]L [ ]D Address _________________ Employer
____________________________________________________________________________________________ ____________________________________________________Mother's Name: _________________________________________
Phones(H)______________________ (W) _________________[ ]L [ ]D Address __________ Employer ____________________________________________________________________________________________ ____________________________________________________If client is acting on behalf of a deceased relative, list the names, addresses, telephone numbers and
relationships to decedent of the decedent's immediate family:Name: ____________________________ Name: ________________________________________Address: __________________________ Address: ________________________________________________________________________ _______________________________________________Telephone: ________________________ Telephone:
__________________________________________Relation: __________________________Relation:
____________________________________________
Page -2- Name: ____________________________Name:
______________________________________________Address: __________________________Address:
_________________________________________________________________________________________________________________________________Telephone: ________________________Telephone: __________________________________________Relation: __________________________Relation:
____________________________________________List the addresses where client has resided during the past 10 years and give the period of time at each
residence:Residence AddressFrom/to_______________________________________ ____________________________________________________________________________________________________________________________________________________ ___________________________________EMPLOYMENT INFORMATION:Name of employer (if unemployed, last employer): __________________________________________Address of employer:
_____________________________________________________________________ Telephone
number: _________________________Personnel Director/Supervisor: ______________________________________________________Job title/type of work:
____________________________________________________________________Present rate of pay: $ ____________________________(per week/month/year) Hours worked each week:
_______________Do you regularly work overtime? __________ If so, indicate approximate amount of time & rate of pay:
_____________Do you receive tips or other type of income? _________ If so, indicate: Type of income Amount Per week/month/year______________________________$ __________________ per________________________________________________________$ __________________ per_________________________________________________________$ __________________ per___________________________When did you first begin working for this employer? ___________________If unemployed, when did you leave this employer? ______________________Reason for leaving:
_____________________________________________________________________What was your reported income in the year before your accident?$ ____________________________Were you working for your employer at the time the injury occurred? __________________________Have you applied for worker's compensation benefits as a result of your accident?
_____________________If so, indicate the amounts paid to or received by you to date: $ ___________________________State your employment history for past ten years:Name of employer:
_______________________________________________________________________Address: _______________________________________________________________________________Period of employment:
From_____________________________To__________________________________
Page -3- Position: _____________________________________________________ Salary:
____________________Reason for leaving:
_____________________________________________________________________Name of employer: ____________________________________________________________Address: _______________________________________________________________________________Period of employment: From_____________________________ To_____________________Position: _____________________________________________________ Salary:
_____________________Reason for leaving: ______________________________________________________________Name of employer: ___________________________________________________________________Address: ______________________________________________________________________________Period of employment: From_____________________________
To_______________________________Position: _____________________________________________________ Salary:
____________________Reason for leaving:
_______________________________________________________________________Name of employer:
_______________________________________________________________________Address: ______________________________________________________________________________Period of employment: From_____________________________
To________________________________Position: _____________________________________________________ Salary:
____________________Reason for leaving: _________________________________________________________________Is your spouse employed? _____ If so, indicate:Employer's name: ______________________________________________ Telephone: ___________Address of spouse's employer: ____________________________________________________________Present rate of pay: $___________ (per week/month/year) Average yearly income of spouse: $
_________How long employed with this employer? _______________________________List spouse's employment history for past five years:Name of employer: _________________________________________________________________Address: ___________________________________________________________________________Period of employment: From_____________________________
To________________________________Position: _____________________________________________________ Salary:
__________________Reason for leaving: __________________________________________________________________
Page -4- Name of employer:
_______________________________________________________________________Address: _______________________________________________________________________________Period of employment: From_____________________________
To_________________________________Position: _____________________________________________________ Salary:
_____________________Reason for leaving:
_______________________________________________________________________Name of employer:
______________________________________________________________________Address: _____________________________________________________________________________Period of employment: From_____________________________
To________________________________Position: _____________________________________________________ Salary:
____________________Reason for leaving: ________________________________________________________Name of employer:
_______________________________________________________________________Address: _____________________________________________________________________________Period of employment: From_____________________________
To_______________________________Position: _____________________________________________________ Salary:
__________________Reason for leaving: ____________________________________________________________________POLICE RECORD:Have you ever been convicted of a felony? _________ If so, describe as follows:1. Date of conviction: _______________ Place: ________________________ Charge:
__________________ Result: _______________________________________________________________________ 2. Date of conviction: _______________ Place: ________________________ Charge: _________ Result: ___________________________________________________________________ Is there now, or has there ever been, a restriction on your driver's license?
_____________________________ If so, describe the details of such restriction:______________________________________________________________________________________ CLAIMS AND LAWSUITS:Have you ever been involved in any claim or lawsuit, excluding divorce? _________________If so, list below every claim you have made for money or lawsuits in which you have ever been involved:Date: _____________ Place: ____________________________ Against whom:
______________________ Nature of claim: ___________________________________________________________
Page -5- Result: ________________________________________________________________________________Date: _____________ Place: ____________________________ Against whom:
_______________________ Nature of claim: _________________________________________________________ __________Result: ______________________________________________________________ ________ INSURANCE INFORMATION:Name of insurance company: _________________________________________ Adjuster's name:
_________________Street address: ____________________ Telephone: _________________City, state, zip: ________________________________ Policy number:
____________________________Do you have insurance covering damage to your car? ____________ Deductible amount: $
_______________ How much does your insurance cover if you hurt someone else with your car? $ ________________ Uninsured motorist policy limits: _________________________ Med Pay Amount $ _______________ Do you have a second uninsured motorist policy? _____________________If so, fill in the following:Name of second insurance company: _________________________________________________ Address: ______________________________________________________________City, state, zip: ______________________________________________ Claim adjuster's name: _______ Telephone: __________ Policy limits: $ ______________________ Policy number: _________ Do you have health or accident insurance? _______ If so, indicate:Name of health insurance company: ______________________________________ Address: __________________________________________________________Telephone: _________________ Policy #: __________ nsurance agent's name:
_____________________ Name of accident insurance company:
_________________________________________________________ Address: ________________________________________________________________________________Telephone: ________________________ Policy #: __________________Insurance agent's name:
_________ Have you ever had insurance of any kind declined or cancelled? ______ If so, give reason:
___________________________________________________________________________________________________EDUCATION:Educational background, listing names of schools attended, addresses, years attended and any degrees
obtained:Name & address of schoolYears attended Degree___________________________________________________ _________________________________________________________________________________________________________________________________________________________________MEDICAL HISTORY BEFORE ACCIDENT
Page -6- Have you been hospitalized at any time before this accident? _______ If so, list below all
hospitalizations:Date Name of Hospital and Doctor Duration Nature of illness______ ____________________________________________________
____________________ ______ ____________________________________________________
____________________ Have you had any physical examinations before this accident? _______ If so, list below all physical
examinations for five years before this accident:Date Name of Doctor Address Purpose______ ______________________ ______________________ _________________________ ____________________________________________ _____________________ ______ ____________________________________________ _________________________ ____________________________________________ _____________________ Have you had any accidents or injuries before this accident? _______ If so, list below every such accident
or injury and whether there was a claim for damages or not:Date: _______________ Place: _____________________________________ Nature of accident/injury: _______________________________________Name of treating physician: _________________________ claim? ______Date: _______________ Place: _____________________________________ Nature of accident/injury: _______________________________________Name of treating physician: _________________________ claim? ______Date: _______________ Place: _____________________________________ Nature of accident/injury: _______________________________________Name of treating physician: _________________________ claim? ______Have you had any chronic illnesses or diseases before this accident? ________ If so, list every such
illness or disease suffered in the five years before this accident:_________________________________ ________________________________
___________________________________Have you had any other chronic health problems or disabilities? _______ If so, list them below:__________________________________________________________________________________________________________________________________Did you use any drugs or medication regularly before the accident? __________ If so, list the type of
drug and reason for use:
_______________________________________________________________________ _______________ ________________________________________________________
________________________ ________________________________________________
________________________________Have you ever had any broken bones? _______ If so, give date and circumstances:Date: __________ Circumstances: ________________________________________________ Date: __________ Circumstances: __________________________________________________MILITARY BACKGROUND:
Page -7- Were you in the military service? _____ Dates: from______ to______ Type of discharge:
______________ Branch of service: ______________ Any service-connected injuries? _______ If so,
describe details:____________________________________________________________________________________________________________________________________________________________________________________________________________________Have you received or do you receive payments from VA, social security or other source?
________________________Claim number: __________________________________ FACTS OF THE ACCIDENT:Date: ________________ Day: _________________ Time: ____________ Weather conditions: ______________________________________________ Describe what happened: __________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ________________________________________________________________________________DIAGRAM:Indicate on a diagram in the space below what happened. Write in street or highway names or numbers
and show direction of travel by arrows. Also, show north by putting an arrow in a circle:Show north: ______Were seat belts in use in your vehicle? ________ If so, who in your vehicle was using a seat belt and who
was not using a seat belt: ____________________________________________________ Were police called to the scene of the accident? ________ If so, did the police take photographs of the
accident scene? ________ If so, which police department has possession of such photographs?
____________________________________FACTS CONCERNING THE DEFENDANT:Name and address of person (defendant) responsible for accident:Full name of defendant:
Page -8- _____________________________________________________________________________________Street address: _____________________________________________________________________________________City, state, zip:____________________________________________________________________________________Name of defendant's employer:_____________________________________________________________________________Name of defendant's spouse: _________________________________________________________________________________Name of defendant's insurance company:_____________________________________________________________________Street address: ______________________________________________________________________________________City, state, zip: ______________________________________________________________________________________Adjuster's name: ______________________Phone________________________________________Do you know what the defendant's financial circumstances are without regard to any insurance he might
have? ______ If so, specify: __________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________ ________________________Give your observations about the defendant as a person:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________Name of 2nd person responsible for accident: ________________________________________________________________Street address: _________________________________________________________________________________City, state, zip: _______________________________________________________________________________Name of 2nd person's insurance company:____________________________________________________________________Address: _____________________________ Claim no: _________________________________Adjuster's name: _______________________ Policy no: ______________ Policy limits: $
_______________Name of 3rd person responsible for accident: ________________________________________________________________Street address: _______________________________________________________________________________
Page -9- City, state, zip: __________________________________________________________________________________Name of 3rd person's insurance company: ____________________________________________________________________Address: _____________________________________ Claim no:
_________________________________Adjuster's name: _______________________ Policy no: ______________ Policy limits: $
_______________OTHER INJURED PARTIES:Were other parties, other than the defendant, injured in this accident? _____ If so, indicate the following:Name of 2nd injured party: (2nd plaintiff):
_________________________________________________________________Street address: _____________________________________ Telephone number:
_____________________City, state, zip: _____________________Birthdate: _______________________________Relationship to you:
_____________________________________________________________________Name of 3rd injured party: (3rd plaintiff):
_____________________________________________________Street address: ______________________________________________________ Telephone number:
_____________________City, state, zip: _________________________________ Birthdate:
_______________________________Relationship to you: ____________________________________________________________________WITNESSES TO THE ACCIDENT:List the names, addresses, and telephone numbers of all witnesses to the accident, and any other persons
who may be of assistance in testifying about your case, your injuries or changes in your activities since
the accident:Name of 1st witness: ________________________________________________________________Address: _______________________________________ Telephone: ______________ Age: ________Employment: _______________________________________________________________________Nature of testimony:
_______________________________________________________________________Name of 2nd witness:
_____________________________________________________________________Address: ______________________________________ Telephone: ______________ Age: ________Employment: _____________________________________________________________________________Nature of testimony:
_______________________________________________________________________Name of 3rd witness:
______________________________________________________________________Address: ___________________________________ Telephone: ______________ Age: ________Employment: _____________________________________________________________________
Page -10- Nature of testimony: ________________________________________________________________STATEMENTS MADE:Have you talked with any police officer, investigator, insurance adjuster or any other person about this
incident? _______ If so, indicate to whom you have spoken, the person's address and telephone number:Name Address Telephone_________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ _________________Have you given a written or recorded statement to any person about this incident? _____ If so, answer the
following:Name of person to whom statement was given:
________________________________________________Date given: ______________ If written, do you have a copy? ________ Persons present at time:
__________________________________________________________________________________Did you sign the statement? ______________________________________Did the defendant make any statement to you or in your presence concerning this incident? _______ If so,
indicate what was said and to whom: __________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________When and where was the above statement made?
________________________________________________List the names and addresses of any persons who may have heard it:Name: _________________________ Address:
_______________________________________________Name: __________________________ Address:
_______________________________________________Were any statements about the accident made to or taken from anyone else at the scene of the accident?
__________ If so, describe the name of the person from whom the statement was taken, as follows:Name: _______________________________Telephone number: _____________________________Address: _____________________________________________________________________________Nature of statement: ___________________________________________________________________Name: __________________________________Telephone number: _____________________________Address: _______________________________________________________________________________Nature of statement:
_______________________________________________________________________DAMAGES FROM ACCIDENT:
Page -11- The amount of recovery made in this case will be affected by the injuries, damages or expenses incurred
as a result of your accident. It is important that you fully list all information regarding your injuries and
your expenses as a result of this accident.State in full detail all injuries you received as a result of this accident:_____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________State your present physical condition such as scars, deformities, headaches, etc.:_____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________Describe "loss of enjoyment of life" by listing below what normal activities, including sports, hobbies or
other activities, you enjoyed before this accident and cannot do now as a result of the accident:Number of times/week Number of times/week Activity prior to accident Since accident_____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________ ________________________________________________________________________________Have you missed time from work as a result of your injuries? ______________If so, indicate the following:From: _________ To: _________ From: _________ To: _________ From: _________ To: _________
From: _________ To: _________Did you lose wages for the periods of time missed from work due to this accident? ______ If so, state the
total wages lost to date and the dates:Wages lost: __________________________________________________ Dates:
______________________Wages lost: __________________________________________________ Dates:
______________________Have you had any increases or decreases in your pay since the accident? _____ If so, explain:_____________________________________________________________________________________ _____________________________________________________________________________________________________________________________Did you lose any promotion or merit increase or fringe benefits due to the accident? _______ If so,
describe:_____________________________________________________________________________________ _____________________________________________________________________________________________________________________________
Page -12- If self employed, have you had to hire anyone to take your place? _______ If so, indicate the costs involved:_____________________________________________________________________________________ _____________________________________________________________________________________________________________________________If you are a student, indicate time lost from school: ___________________________________________Indicate period of time you were confined to your home:
_________________________________________Indicate period of time you were confined to bedrest: _______________________________________When is it expected you can return to work?
___________________________________________________List any non-monetary compensation you have lost: ________________________________________________________________________________________________________________________________ _____________________Have you been forced to borrow any money as a result of your injuries and inability to work? ______ If
so, describe:_____________________________________________________________________________________ _____________________________________________________________________________________________________________________________Are you able to work part time? _____ If so, where or what kind of work could you do?
_____________________________________________________________________________________________________________ ____________________List all hospitals in which you were examined or treated or to which you were admitted as a patient as a
result of the injuries sustained in this accident:Name of hospital: ___________________________________________________________Address: __________________________________ From: _______________ To: __________________________________________________ Total costs: ____________________________Name of hospital:
_________________________________________________________________________Address: _________________________________________ From: _______________ To:
________________________________________________________ Total costs: ____________________________Name of hospital:
________________________________________________________________________Address: ______________________________________ From: _______________ To:
______________________________________________________ Total costs: ____________________________List the full name, address and telephone number of each physician who has examined or treated you for
your injuries:Doctor's name: _______________________________________ Telephone:
___________________________
Page -13- Address: ______________________________________________________________________________ Specialty: _______________________________________________________Type of treatment:
________________________________________________________________________Doctor's name: _______________________________________ Telephone:
___________________________ Address: ____________________________________________________________________________ Specialty: _______________________________________________________Type of treatment: __________________________________________________________________Doctor's name: ______________________________________ Telephone:
___________________________ Address: _______________________________________________________________________ Specialty: ________________________________________________________________________Type of treatment:
________________________________________________________________________Doctor's name: ______________________________________ Telephone:
___________________________ Address: _________________________________________________________________________ Specialty: _______________________________________________________Type of treatment:
________________________________________________________________________Have you used any of the following in connection with treatment?Wheelchair .................... Dates: From_________ To__________ Back or neck brace/collar ..... Dates: From_________ To__________ Crutches ...................... Dates: From_________ To__________ Traction ...................... Dates: From_________ To__________ Physical therapy .............. Dates: From_________ To__________ Other: ________________________ Dates: From_________ To_________List all medications which you have taken for injuries, the name of the doctor prescribing each
medication and length of time you took the medication:Type of medicationPrescribing doctor's name Length of time _____________________________________________________ ___________________________________________ __________________________________________________________Indicate the amount of all bills/expenses incurred to date as a result of this accident: $
___________________________(attach copies of all such bills, whether paid or unpaid.)Have you sustained any other injuries since this accident? __________________ If so, indicate date,
nature of injury and whether you received medical treatment for said injuries:
Page -14- Date of injuryNature of injury Medical treatment _________________ ____________________
____________________________________________________________________________ _______________________________________PROPERTY DAMAGE:If your vehicle was damaged and has been repaired, indicate name and address of party who made repairs:_________________________________________________________________________________Telephone number: __________________ Have you incurred car rental expenses?$
_____________________Where is your vehicle presently located? _____________________________________________If any other personal property was damaged, describe said property:
_______________________________________________________________________________________Total medical & related expenses to date: $ _________________ Date: _______________________Total of property damage amount to date: $ _________________________ Date: ___________________ IMPORTANT Please collect and attach copies of all medical and related bills incurred to date as a result of this accident,
indicating which have been paid and which are still due. Please be sure to forward copies of all future
medical bills, drug/medication bills, etc., As they are incurred, even if paid by insurance. See the
following two pages for list of items to provide to your attorney and a list of general instructions that will
require your attention. In completing this intake sheet, have you thought of any information which I have
not asked which may be of some assistance to me in representing you? If so, state it on the back of this
form no matter how silly, trivial or embarrassing it may seem. __________________________________________ Client's signature Date: _________________________
Page -15- INSTRUCTIONS TO CLIENT Please be sure to provide me with the following:1. All medical and hospital records;2. Photographs (of scene of accident, of client showing injuries, braces, casts, etc., of automobile or other
damaged property);3. All hospital, medical and related bills, either paid or unpaid (physicians, surgeons, ambulance,
hospitals, private nursing care, therapy, drugs/medication, crutches, braces, x-rays, domestic help, car
rental, clothing, etc.);4. Income tax returns for the last five years;5. Your automobile insurance policy or policies;6. Insurance policy that may require aid of attorney to notify and collect (income protection,
hospitalization, etc.); 7. Copies of any statements previously made to anyone (opposing side, your insurance carrier, etc.);8. Repair bill on any damaged property;9. Repair estimates on any damaged property;10. Purchase invoices and estimates of value of personal property damaged or lost in accident (including
clothing, jewelry, cameras, and all other property damaged in accident);11. Correspondence with insurance company, insurance adjusters;12. Business cards from insurance company agents and adjusters, opposing driver, etc.; 13. Copy of any accident reports;14. Statement from employer regarding lost wages showing time and wages lost from work;15. Copies of check stubs and/or other records showing hourly rate of pay;16. Copies of any application for other insurance benefits;17. Copy of any application for unemployment benefits;18. Copy of social security card;19. Make copy of current driver's license;Please note the following general instructions:1. Do not talk to insurance adjuster;2. Do not discuss the facts of the accident with anyone before having your first conference with the
attorney;3. Do not sign anything without your attorney's permission;4. Keep a diary of your trips to all doctors, hospitals, therapists and notes of your pain with times and
dates;5. Keep all your medicine bottles and containers (as possible evidence at trial);6. Bring or send all future medical bills to attorney's office;7. When you return to treating physicians for follow- up examinations, be sure to advise them at each
examination the nature of all of your continuing problems resulting from the accident;8. Keep a record of all out-of-pocket expenses, including travel expenses for medical treatment;9. Report to your attorney any suspicious actions, such as someone taking pictures, movies, etc.
Page -1- EMPLOYMENT CONTRACT AND POWER OF ATTORNEY IN A PERSONAL INJURY CASE THIS AGREEMENT made this date at Jackson, Mississippi, by and between MARK T. FOWLER,
Attorney at Law, hereinafter known as ATTORNEY and
__________________________________________ hereinafter known as CLIENT. WITNESSETH: 1. CLIENT retains ATTORNEY to represent him as his Attorney at Law in a cause of action against
_____________________ regarding the following facts, to-wit: ______________________________________________________________________________________________________________________________________________________________________________________________________ ________________________This contract empowers ATTORNEY to institute such legal action as may be advisable in his judgment
and to compromise and settle the matter at any time, with the consent of the CLIENT, and CLIENT
agrees to pay ATTORNEY for his services, thirty-three and one-third percent (33 1/3%) of the
amount recovered if settled without suit, or, fifty percent (50%) of the amount recovered after suit is
instituted by filing the first paper therein for litigation through Circuit, Chancery, or Federal Court. In the
event of an appeal to the State Supreme Court or the Federal Appellate Courts, ATTORNEY shall be
further entitled to all penalties assessed against the Defendant, as his fee. All costs and expenses advanced
by the ATTORNEY shall be deducted from the CLIENT'S share.2. CLIENT hereby assigns and gives ATTORNEY a lien on said claim, cause of action, and/or any sum
recovered by way of settlement or judgment thereon for the sum and share hereinabove mentioned as his
fee. CLIENT hereby agrees that said Attorney's lien shall attach in full (in the percentages set out in
paragraph one (1) to any offer of settlement extended in this matter while ATTORNEY is employed.3. CLIENT agrees that if this employment agreement is terminated by CLIENT for any reasons after
employment begins but prior to a settlement offer being extended, that ATTORNEY is entitled to be paid
for his time expended to the date of termination at a liquidated rate of one-hundred dollars ($100.00) per
hour, plus reimbursement of all advanced cost and expenses. CLIENT agrees to pay said fees, cost and
expenses prior to his file being returned to him, unless retaining said file prejudices the rights of the
CLIENT.4. CLIENT hereby agrees that if he elects to employ other counsel that said counsel shall be paid out of
CLIENT'S share. ATTORNEY agrees to pay any counsel associated by ATTORNEY out of
ATTORNEY'S share.5. CLIENT hereby gives ATTORNEY his POWER OF ATTORNEY to execute all complaints, claims,
contracts, checks, settlements, drafts, compromises, releases, verifications, dismissals, deposits and orders
as he would himself. CLIENT agrees that he will make no settlement except in the presence of his
Page -2- ATTORNEY or with his knowledge and approval, and should he do so in violation of this agreement, he
agrees to pay ATTORNEY the sum and share indicated in paragraph one (1) of this agreement.6. The ATTORNEY hereby accepts employment in the above particulars and agrees to represent the
CLIENT to the best of his ability and with all fidelity.7. It is mutually understood that the masculine shall include the feminine and the neuter, and the singular
shall include the plural, wherever used hereinabove.IN WITNESS WHEREOF, the parties have set their hands this the ________ day of ____________,_______________________________, 20_______. ATTORNEY:CLIENT(S): BY: ____________________________________________
__________________________________________________ ** _________________________________________________
Page -1- MEDICAL AUTHORIZATION TO WHOM IT MAY CONCERN:I, the undersigned __________________________________________________, hereby authorize any
physician, hospital, nurse, chiropractor, dentist, psychologist, or other medical attendant to furnish full
and complete medical reports, records, and other information herewith requested by
___________Attorney at Law, or to any representative, attorney or investigator from his firm.The purpose of this authorization is to allow the above attorney to obtain all medical records which will
aid in or are necessary for the prosecution of claims I am making.This authorization includes the right to examine all x-rays and records of any kind, and the right to
receive full and complete information pertaining thereto, including copies of all such records.This authorization is intended to and will allow the above attorney to obtain any and all medical records,
and shall include any and all records prior to or subsequent to the date of the claim referred to above.In addition, it is expected that I may need further treatment beyond the date of this authorization, and you
are therefore authorized and requested to provide to the above attorney any and all medical records
related to examinations and treatment which take place subsequent to the date of the execution of this
authorization, so long as this authorization has not been cancelled or revoked by me in writing.Your full cooperation with my attorney is requested. You are further requested to disclose no information
nor discuss my medical condition with any insurance adjuster or other person without my written
authority to do so.
This authority shall be valid until cancelled or revoked by me in writing.A photostatic copy of this authorization shall be considered as effective and as valid as the originalALL PRIOR AUTHORIZATION IS HEREBY CANCELLED________________________________________________
_______________________________________DATE PATIENT
Page -1- FORM 4506 REQUEST FOR COPY OF TAX FORM OR INDIVIDUAL
INCOME TAX ACCOUNT INFORMATION (OMB Clearance Number
1545-0429) 1. Name of taxpayer as shown on tax form: _________________________________________2. Current name and address:_______________________________________________________________________________ ___________________________________________________________________________________________________________________________________3. If information is to be mailed to someone else, show the third party's name and address:_______________________________________________________________________________ ___________________________________________________________________________________________________________________________________4. If name in third party's records differs from item 1 above,show here (see instructions for item
3):_______________________________________________________________________5. Social security or employer identification number as shown on tax form:
____________________________6. Spouse's social security number as shown on tax form:Spouse's name: ___________________________________________________________Spouse's SS no.: ___________________________________7. Tax form number (Form 1041, 941, etc.): _________________________________________8. Tax period(s) (No more than 4 per request): ______________________________________9. Amount due (Make check payable to IRS): $ ______________________________________Note: Full payment must accompany your request.10. Describe what you want (Check only one box):$5.00 each [ ] Copy of tax return and all attachments (including forms w-2) [ ] Note: if you need these copies certified for court or administrative proceedings, check
here also. $2.50 each [ ] Tax account information only (do not use for income averaging)$2.50 each[ ] Form 1040a or form 1040ez verification only. PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE We ask for this information to carry out the Internal Revenue laws of the United States. We need
the information to gain access to your return in our files and properly respond to your request. If
you do not furnish the information, we may not be able to fill your request.DATE: ______________ Signature:
_______________________________________________ Telephone: _______________________________________________ Out of Pocket Expenses Client: _________________________________________________________ DOCTOR BILLS______________________________________________________________ $
_________________________________________________________________________________$
_________________________________________________________________________________$
_________________________________________________________________________________$
_________________________________________________________________________________$
___________________
Page -2- ______________________________________________________________$
_________________________________________________________________________________$
___________________ TOTAL DOCTOR BILLS$
_________________ DRUGS______________________________________________________________$
_________________________________________________________________________________$
_________________________________________________________________________________$
_________________________________________________________________________________$
_________________________________________________________________________________$
___________________ TOTAL DRUG BILLS$
________________ HOSPITAL______________________________________________________________$
_________________________________________________________________________________$
_________________________________________________________________________________$
_________________________________________________________________________________$
___________________ TOTAL HOSPITAL BILLS$
_________________ PROPERTY DAMAGE______________________________________________________________$
_________________________________________________________________________________$
_________________________________________________________________________________$
___________________ TOTAL PROPERTY LOSS$
_________________ EARNINGS LOSS______________________________________________________________$
_________________________________________________________________________________$
_________________________________________________________________________________$
___________________ TOTAL EARNINGS LOSS$
__________________ OTHER LOSS______________________________________________________________$
___________________ TOTAL OTHER LOSS$
__________________ TOTAL OUT OF POCKET LOSS $
__________________
