You are on page 1of 4

POWER OF ATTORNEY AND EMPLOYMENT AGREEMENT: VAGINAL MESH

julie ann reilly


This agreement between ________________________ (Client) and JOHNSON LAW GROUP (Attorneys"), is for legal representation in
prosecuting the Clients Causes of Action for damages and personal injuries as a result of the TRANSVAGINAL MESH implant. Client authorizes
Attorneys to prosecute Clients Causes of Action against all potentially responsible parties.

Client requests a contingency fee contract rather than an hourly fee, and Client conveys to the Attorneys the present undivided interest in
the above claim the amount of forty percent (40%) of the gross amount of the total sum collected, made either before or after suit is filed,
regardless of whether the Defendants appeal Clients case. If the Attorneys are not successful, Client will not owe any attorney fees or case
expenses to the Attorneys. Client understands this fee is not set by law.

Attorneys will advance all of the court costs and expenses, including common costs that are reasonably necessary for the investigation,
preparation, trial, and/or settlement of this matter. All such costs and expenses, advanced or incurred by the Attorneys shall be deducted from any
settlement out of the Clients portion of recovery. The Attorneys contingent fee shall be computed on the total recovery without deduction for court
costs, expenses, common costs, or disbursements.

The terms costs and other expenses include, without limitation: filing fees, court costs, expert witness fees for evaluation, reports, and/or
testimony time, consultant fees, postage, long distance telephone calls, fax transmissions or receptions, messengers, court reporter fees, record
service fees, photocopying, preparation of exhibits and photographs, private and commercial transportation and/or lodging expenses and parking,
service of citations, investigative fees and expenses, courtmandated expenditures, specialized outside counsel and service fees and expenses (i.e.,
probate, taxation, bankruptcy), specialized nurse and medical expert fees, costs associated with collecting judgments, any expenses of a structured
settlement, witness fees and mileage, medical records, subpoenas, and all other reasonable and necessary costs and expenses which the
Attorneys in their professional judgment, determine to be reasonably needed to the prosecution and/or settlement of the Claims of the Client.

Further, the parties expressly understand that, in the event that no recovery is obtained on the Clients claim, Attorneys will
make no charges for his or her time, services, fees, court costs, or other expense that has been advanced.

Client hereby agrees that Attorneys may employ associate counsel and does not object to the participation of any lawyers the Attorneys
may choose to involve in this action. Prior to the association becoming effective, Client shall consent in writing to the terms of the arrangement after
being advised of (1) the identity of the law firm involved, (2) that the lawyers agree to assume joint responsibility for the representation, and (3) the
share of the fee that each law firm will receive. The association of additional attorneys will not increase the total fee owed by the Client. Payment of
attorneys fees to associate counsel is the responsibility of Attorneys.

If the Client terminates this agreement without cause, as that term is understood under Texas law, Client agrees to compensate Attorneys
their full contingent share of any settlement of or judgment on the claim for prosecution of which the attorney is hereby retained. The Attorneys may
move to withdraw from the Client's representation in the claim at any time upon notice of ten (10) days to the Client by mailing notice via certified
mail, return receipt requested, to the Clients last known address.

The Client understands that the Attorneys have made no representation, guarantee or warranty concerning the outcome of the claim or
recovery of any funds so desired. Further, the Client understands that the attorney has not guaranteed that he or she will obtain reimbursement to
the Client of any of the costs or expenses resulting from the occurrence out of which the claim arises.

No settlement shall be made without Clients approval and permission. Client grants Attorneys the power of attorney to execute all
documents connected with the claim for the prosecution of which the attorney is retained, including pleadings, contracts, checks or drafts, settlement
agreements, compromises, releases, verifications, dismissals, and orders, as well as all other documents which the Client could properly execute.

The Client shall keep the attorney advised of his or her whereabouts at all times, shall appear on reasonable notice at any and all
depositions and court appearances, and shall comply with all reasonable requests of the attorney in connection with the preparation and
presentation of the Client's claim and cause of action. Client acknowledges and agrees that Attorneys may provide limited Client case information to
a third party lender for the purposes of obtaining financing for the benefit of Clients case. Client agrees to provide the Attorneys with any changes of
address, telephone numbers or business affiliation. Client may rescind this agreement within 24 hours of signing this agreement by providing written
notice to attorney.

1|Page
ENTIRE AGREEMENT. This Agreement contains the entire Agreement of the parties. No other agreement, statement, or promise made
on or before the effective date of this Agreement will be binding on the parties.

SEVERABILITY IN EVENT OF PARTIAL INVALIDITY. If any provision of this Agreement is held in whole or in part to be unenforceable
for any reason, the remainder of that provision and of the entire Agreement will be severable and remain in effect.

MODIFICATION BY SUBSEQUENT AGREEMENT. This Agreement may be modified by subsequent Agreement of the parties only by an
instrument in writing signed by both of them or an oral agreement only to the extent that the parties carry it out.

The Client acknowledges that he or she has read this Attorney Fee Contract in its entirety, which is two (2) letter size pages in length, that
he or she fully understands the terms and conditions of same, and that he or she agrees to abide by its terms.

POWER OF ATTORNEY AND EMPLOYMENT AGREEMENT


julie ann reilly Jun 2, 2016
Client Signature: ___________________________________________
julie ann reilly (Jun 2, 2016) Date: ______________________________________ MM/DD/YYYY
julie ann reilly
Client Printed Name: ___________________________________________________________________________________
07/13/1958
Clients DOB: ___________________________ MM/DD/YYYY

Attorney Signature: __________________________________________

2|Page
MEDICAL AUTHORIZATION FOR RELEASE AND DISCLOSURE OF HEALTH INFORMATION
Healthcare Provider/Facility and Requested Information
Healthcare Provider/Facility: Dates of Service:
Any and All Providers All Relevant Date Ranges
Specific Request

Patient Information
First Name: Middle Initial: Last Name:

Street Address: City, State, Zip Code:

Home Phone: Date of Birth: SSN:

I authorize the above-named entity to disclose the above-named patient's health information, as described
below, to the following recipient: Johnson Law Group, 55 Waugh Drive, Suite 800, Houston, Texas 77007,
Telephone (713) 626-9336, Facsimile (800) 731-6018, Steelgate, Inc., 2307 58th Avenue East, Bradenton,
FL 32403, Telephone (941) 758-1122, Facsimile (941) 758-1164, Stratos Legal, 4229 San Felipe Suite 350,
Houston TX 77027, or any of its representatives. This authorization shall also serve to permit a representative
from Johnson Law Group to conduct a personal review of any health information in your possession that
pertains to the patient named above, and to verbally discuss this information with the health care provider listed
above.

The purpose for this disclosure of protected health information is: Legal Representation.

The only information being requested at this time is that which is identified in the Specific Request
section above; however, the type and amount of information authorized to be used or disclosed is as follows:
The complete medical record/chart of the above-named patient and all materials or information including, but
not limited to, all billing records, hospital records; physicians records; surgeons records, consultation records,
operative records, physical therapy and other therapy records; X-Ray, CT Scan, MRI, Pet Scan and reports or
other diagnostic studies; laboratory reports; patient information and history questionnaire; physicals and other
correspondence; consent for treatment; statements for services rendered; explanted mesh or any explanted
tissue; explanted medical devices or materials; and other materials (whether written or stored, created or
maintained in any other form) relating or pertaining to this patient, including documents and records received
from or that were created by another provider.

I understand that the information in the patient's health record may include information relating to sexually
transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV),
as well as psychiatric care. It may also include information about behavioral or mental health services, or
treatment for alcohol or drug abuse.

This authorization shall remain in full force and effect until it expires ONE YEAR from the date set forth
below unless I revoke the authorization prior to that time or unless otherwise specified by date, event or
condition.

I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this
authorization I must do so in writing by sending or presenting my written revocation to the Privacy Contact of
the health care provider named above. I understand that the revocation of this authorization will not apply to
jab
jab
Please Initial

the extent that the health care provider has taken action in reliance thereon; or if the authorization was obtained
as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim
under the policy or the policy itself.

I understand that treatment or payment cannot be conditioned on my signing this authorization, except in
certain circumstances such as participating in research programs, or authorization of the release of testing
results for pre-employment purposes. By signing below, I confirm that the above recipient(s) have not
conditioned treatment, payment, enrollment, or eligibility for benefits on my signing this authorization and that
I am affirmatively authorizing the above recipient(s) to use this authorization for the purpose indicated above.

I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure of
the patient's health information by the recipient, resulting in the health information no longer being protected
by federal or state confidentiality rules.

I authorize a free copy of my records to be released to Johnson Law Group on my behalf pursuant to any
governing law providing that medical records shall be released to patient free of charge.

I understand that authorizing the disclosure of this health care information is voluntary. I understand that I can
refuse to sign this authorization. I understand that I am entitled to both inspect my records as well as receive
copies of the information to be used or disclosed, as provided in 45 CFR 164.524. I also understand that I have
a right to receive a copy of this authorization.

ELECTRONIC SIGNATURES ON AND PHOTO-COPIES OF THIS RELEASE ARE VALID. My


signature below, either by hand or electronically, is affirmative proof of my intent to sign this authorization and
obtain records through the above listed recipient(s).

By signing below, I authorize my Johnson Law Group attorney to sign any other HIPAA authorization on my
behalf in order to obtain records pursuant to: Purposes Relating to Legal Representation.

julie ann reilly


julie ann reilly (Jun 2, 2016)

Signature of Patient or Legal Representative

julie ann reilly


Printed Name

patient
Relationship to Patient

Jun 2, 2016
Date