ACUERDO DE RETENCIÓN

Nombre del Cliente:

Direccion del Cliente:

Por medio de este acuerdo, retengo / retenemos a MEIROWITZ & WASSERBERG LLP, 1040 6th Avenue, Suite 12B, New
York, New York, 10018, (en lo sucesivo denominados "Abogados") como mis / nuestros abogados, para representar,
procesar y / o ajustar para yo / nosotros, un reclamo por daños derivados de lesiones personales, sostenido por mí en la
fecha:
, 20 [FECHA DEL ACCIDENTE]. Por la presente, doy a mis abogados el
derecho exclusivo de tomar todas las medidas legales para hacer cumplir mi reclamo y además acepto no llegar a un
acuerdo de ninguna manera sin el consentimiento por escrito de mis abogados.

PAGA DEL ABODAGO: En consideración por los servicios prestados y que prestará el Abogado, el Cliente acuerda pagar
al Abogado, y el Abogado está autorizado a retener del dinero que pueda llegar a manos del Abogado, el treinta y tres y
un tercio por ciento 33.33 % de la recuperación entera. Meirowitz & Wasserberg, LLP se reserva el derecho exclusivo de
cobrar los honorarios de su abogado en efectivo al momento de la liquidación o en pagos diferidos, independientemente
de la forma en que se pague la recuperación del Cliente.

Después de tener la opción de pagar los gastos del caso, el Cliente eligió que el Abogado adelantara esos costos. Al elegir
esta opción, el cliente entiende que los honorarios del abogado se basarán en la recuperación total (suma total del
acuerdo) en lugar de la recuperación neta (suma del acuerdo después de deducir los gastos). Si no hay recuperación, el
Cliente no tendrá que pagar ningún gasto del caso. (Iniciales del cliente).

GASTOS DEL CASO: Los gastos del caso incluyen todos los costos de investigar y litigar el caso, incluidos, entre otros,
investigadores e investigaciones, honorarios de testigos, correo, transcripciones, tarifas de presentación, tarifas de
servicio de proceso, copias, investigación legal en línea, tarifas para expertos, testimonios de expertos, investigación,
viajes, teléfono, fotocopias, servicios patrimoniales asociados con el enjuiciamiento de reclamos por muerte injusta
(incluido el nombramiento de administradores y compromisos de muerte) u otros servicios razonables y / o necesarios,
con cargo al reclamo. El abogado puede optar por financiar los gastos relacionados con el caso a una tasa de interés
razonable. El interés sobre dichos gastos se deducirá como un costo del caso.

GRAVÁMEN: Todos los gravámenes de cualquier tipo deben pagarse de la parte del cliente de la recuperación (pagada
directamente por el Abogado) antes de desembolsar los fondos al cliente y de ninguna manera reducirá, o actuará como
una reducción de los honorarios del abogado, a pagar según lo mencionado anteriormente.

APELACIONES: Este acuerdo de retención no obliga al Abogado a emprender una apelación de un veredicto adverso,
orden o sentencia dictada a favor de los acusados. El enjuiciamiento de cualquier apelación de este tipo y los términos en
los que se lleva a cabo pueden ser objeto de un acuerdo de retención por separado que negociarán las partes.
SUSTITUCIÓN: La retención de otros abogados en lugar del Abogado con lleva la obligación de reembolsar
inmediatamente al Abogado, todos los desembolsos incurridos o adelantados por el Abogado y el derecho, a opción del
Abogado, de tener un porcentaje fijo de la recuperación final determinada de inmediato, o al final del caso, como y por los
honorarios de abogado.

RESPONSABILIDADES DEL CLIENTE: El cliente comprende y acepta que es su responsabilidad mantener a la empresa
informada de cualquier cambio en la dirección, número de teléfono, correo electrónico u otra información de contacto del
Cliente y el Cliente debe informar a la empresa de cualquier cambio tan pronto como sea posible. posible, pero a más
tardar 30 días después del cambio. Si el cliente no puede mantener la firma así informada, y la empresa no puede ser
contactada después de la debida diligencia, el Cliente autoriza a la firma, a su exclusivo criterio:
a) comprometer o resolver su caso sin mayor aprobación o consulta con el Cliente; y
b) participar en cualquier arbitraje vinculante, mediación, juicio o cualquier otra alternativa de resolución de disputas
para comprometer o resolver el reclamo del Cliente, y
c) para la autoridad otorgada bajo a) o b), arriba, para colocar la firma del Cliente para documentos para resolver el caso
como su Abogado de hecho y distribuir fondos a partir de entonces, ya sea manteniendo el dinero perteneciente al cliente
en la cuenta privada de la firma o transferir los dichos ingresos al Fondo de Abogados para la Protección del Cliente del
Estado de Nueva York.

FECHA:

_____________________________________
Firma de Cliente

_____________________________________ __________________________________
Nombre de Cliente Firma de Abogado
 MEIROWITZ & WASSERBERG, LLP
332 EAST 149TH STREET SUITE 201
BRONX, NEW YORK 10451

CONFIDENTIAL INTAKE FORM – PERSONAL INJURY

Name: _______________________________ DOB: _______________ SS#: ____________________

Address: _______________________________________________________________________

Length of Time at that Address: years, months

Home Tel.: Cell #: Fax No.:

Email Address: Former/Maiden Name(s):

Marital Status: Single Married Divorced

Spouse Name: DOB: SS#:

Emergency Contact: Name: Phone #:

Referred by: Name: Address:

Relationship to you:

ACCIDENT INFORMATION

Date of Injury: Time:

Client Status: (Circle All That Apply) Owner Operator Passenger Pedestrian Bicyclist Motorcyclist

Police Department, Precinct, & Case#:

Location of Accident:

City: State: County:

1. Take photographs of your injuries, if possible.

2. Give no information to anyone other than our office.
3. Forward a copy of the police report and any accident report you might have, including a description of how the
accident happened, if there were any witnesses, and the information of the drivers/owners involved.
4. Sign and return the Retainer, no-fault signature page, and HIPAA Authorizations (sign and initial only – do not
date or fill out information).
5. Forward copies of all bills or receipts for hospital, x-ray, loss of earnings and medical reports.
6. Additional instructions will be given to you based on your individual situation.
 OCA Official Form No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York State Department of Health]

Patient Name Date of Birth Social Security Number

Patient Address

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996
(HIPAA), I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on
the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I
initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I
understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If
I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division
of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are
responsible for protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may
revoke this authorization except to the extent that action has already been taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for
benefits will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protected by federal or state law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of health provider or entity to release this information:

8. Name and address of person(s) or category of person to whom this information will be sent:

9(a). Specific information to be released:

q Medical Record from (insert date) ___________________ to (insert date) ___________________
q Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films,
referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
q Other: __________________________________ Include: (Indicate by Initialing)
__________________________________ ________ Alcohol/Drug Treatment
________ Mental Health Information
Authorization to Discuss Health Information ________ HIV-Related Information
(b) q By initialing here ____________ I authorize ________________________________________________________________
✔

Initials Name of individual health care provider

to discuss my health information with my attorney, or a governmental agency, listed here:
______________________________________________________________________________________________________
(Attorney/Firm Name or Governmental Agency Name)
10. Reason for release of information: 11. Date or event on which this authorization will expire:
q At request of individual
q Other: Litigation
✔ Termination of Litigation
12. If not the patient, name of person signing form: 13. Authority to sign on behalf of patient:

All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a
copy of the form.

______________________________________________ Date: _____________________________

Signature of patient or representative authorized by law.
* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could
identify someone as having HIV symptoms or infection and information regarding a person’s contacts.
 OCA Official Form No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York State Department of Health]

Patient Name Date of Birth Social Security Number

Patient Address

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996
(HIPAA), I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on
the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I
initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I
understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If
I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division
of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are
responsible for protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may
revoke this authorization except to the extent that action has already been taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for
benefits will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protected by federal or state law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of health provider or entity to release this information:

8. Name and address of person(s) or category of person to whom this information will be sent:

9(a). Specific information to be released:

q Medical Record from (insert date) ___________________ to (insert date) ___________________
q Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films,
referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
q Other: __________________________________ Include: (Indicate by Initialing)
__________________________________ ________ Alcohol/Drug Treatment
________ Mental Health Information
Authorization to Discuss Health Information ________ HIV-Related Information
(b) q By initialing here ____________ I authorize ________________________________________________________________
✔

Initials Name of individual health care provider

to discuss my health information with my attorney, or a governmental agency, listed here:
______________________________________________________________________________________________________
(Attorney/Firm Name or Governmental Agency Name)
10. Reason for release of information: 11. Date or event on which this authorization will expire:
q At request of individual
q Other: Litigation
✔ Termination of Litigation
12. If not the patient, name of person signing form: 13. Authority to sign on behalf of patient:

All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a
copy of the form.

______________________________________________ Date: _____________________________

Signature of patient or representative authorized by law.
* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could
identify someone as having HIV symptoms or infection and information regarding a person’s contacts.
 OCA Official Form No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York State Department of Health]

Patient Name Date of Birth Social Security Number

Patient Address

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996
(HIPAA), I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on
the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I
initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I
understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If
I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division
of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are
responsible for protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may
revoke this authorization except to the extent that action has already been taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for
benefits will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protected by federal or state law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of health provider or entity to release this information:

8. Name and address of person(s) or category of person to whom this information will be sent:

9(a). Specific information to be released:

q Medical Record from (insert date) ___________________ to (insert date) ___________________
q Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films,
referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
q Other: __________________________________ Include: (Indicate by Initialing)
__________________________________ ________ Alcohol/Drug Treatment
________ Mental Health Information
Authorization to Discuss Health Information ________ HIV-Related Information
(b) q By initialing here ____________ I authorize ________________________________________________________________
✔

Initials Name of individual health care provider

to discuss my health information with my attorney, or a governmental agency, listed here:
______________________________________________________________________________________________________
(Attorney/Firm Name or Governmental Agency Name)
10. Reason for release of information: 11. Date or event on which this authorization will expire:
q At request of individual
q Other: Litigation
✔ Termination of Litigation
12. If not the patient, name of person signing form: 13. Authority to sign on behalf of patient:

All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a
copy of the form.

______________________________________________ Date: _____________________________

Signature of patient or representative authorized by law.
* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could
identify someone as having HIV symptoms or infection and information regarding a person’s contacts.