East Palestine Train Derailment Questionnaire - Welcome

Note: Your privacy is very important to us. To better serve you, the form information you enter is recorded in real time.

Thank you for your interest in us representing you in this case. Our team is made up of some of the best lawyers across the country that have represented thousands of families and communities, and non-lawyers like public advocate Erin Brockovich who has spent her life fighting for families just like yours. 


There are a few steps to this process. The first step is to answer the following questions to help us see whether we are able to represent you in this case. If you qualify, we will have you complete our contract at the end of the qualification section. Our engagement team will be reaching out to you to gather additional necessary information in regards to your claim.


If at any point you prefer to talk to someone on the phone and go through this with them, you can call (330) 584-9084. Let's get started.

East Palestine Train Derailment Questionnaire - Introduction

Does the claim pertain to you or another person?*
Are you represented by another lawyer in connection with this case yet?*

Thank you for that information, we are not legally allowed to speak with you at this time. In the future, if you decide to formally terminate your prior representation, and can provide us with a copy of the termination email/letter, we can then move forward.

Thank you for that information, we are not legally allowed to speak with you, if you currently have other representation. If you determine that you do not have representation, we can then proceed forward.

Do you have an email or letter termination that representation? *

Our team will need a copy of that email/letter sent to us. I will provide that contact information at the end of this, so please make sure you have a pen and paper handy.

Please receive a copy of the email or letter then call us back to complete going through the qualification. I’m sorry we couldn’t complete it today. Thank you for your time.

PreQual Box

East Palestine Train Derailment Questionnaire - Introduction

Were you present for at least 8 hours within 30 miles of the Ohio Train Derailment between February 3, 2023 and February 8th, 2023?*
Do you own a property within 10 miles of the Ohio Train Derailment on February 3, 2023?*
Did you lose commercial livestock with an uninsured value of at least $10,000.00 as a result of the Ohio Train Derailment on February 3, 2023?*
Pre-Qualified2

East Palestine Train Derailment Questionnaire - Contact Information

Do you have a smartphone or a flip phone?*
Do you have a suffix?*
What is your date of birth?*

East Palestine Train Derailment Questionnaire - Contact Information

Do you have a smartphone or a flip phone?*
What is the name of the person you're calling on behalf of? *
Is the person a minor or adult?*
What is their date of birth? *
Is the person you're reaching out for deceased?*
Do you have legal authority to sign on behalf of the person you are calling for?*
Do you have documentation/proof that you will be able to provide our attorneys that prove you have this authority? *
What type of documentation do you have showing you have a right to the decedent’s claim?*

Please obtain documentation showing you have the right to the decedent's claim then call us back to complete going through qualification. I’m sorry we couldn’t complete it today. Thank you for your time.

What documentation/proof do you have that we will be able to provide to our attorneys that you have this authority?*
In what state did the death occur?*
What was the date of death?*
Do you have a suffix?*
Qualified

East Palestine Train Derailment Questionnaire - Property Information

What is the business or residential addresses of the property that you own, rented, or lived in that was affected by the train derailment? *
Is your home or land in a Trust?*

If your home, business, or land is in a trust, we will need a contract for the legal entity.

Is your business or commercial property owned by an LLC, Incorporation, Corporation, Trust, etc?*
What was the approximate distance from the train derailment?*
Were you at this address at the time of the accident?*
Do you believe you have property damage?*
Would you like to add information for another property?*

Second Property Information

What is the business or residential addresses of the SECOND property that you own, rented, or lived in that was affected by the train derailment? *
Is your home or land in a Trust?*

If your home, business, or land is in a trust, we will need a contract for the legal entity.

Is your business or commercial property owned by an LLC, Incorporation, Corporation, Trust, etc?*
What was the approximate distance from the train derailment?*
Were you at this address at the time of the accident?*
Do you believe you have property damage?*
Would you like to add information for another property?*

Third Property Information

What is the business or residential addresses of the THIRD property that you own, rented, or lived in that was affected by the train derailment? *
Is your home or land in a Trust?*

If your home, business, or land is in a trust, we will need a contract for the legal entity.

Is your business or commercial property owned by an LLC, Incorporation, Corporation, Trust, etc?*
What was the approximate distance from the train derailment?*
Were you at this address at the time of the accident?*
Do you believe you have property damage?*
Would you like to add information for another property?*

Fourth Property Information

What is the business or residential addresses of the FOURTH property that you own, rented, or lived in that was affected by the train derailment? *
Is your home or land in a Trust?*

If your home, business, or land is in a trust, we will need a contract for the legal entity.

Is your business or commercial property owned by an LLC, Incorporation, Corporation, Trust, etc?*
What was the approximate distance from the train derailment?*
Were you at this address at the time of the accident?*
Do you believe you have property damage?*
Would you like to add information for another property?*

Fifth Property Information

What is the business or residential addresses of the FIFTH property that you own, rented, or lived in that was affected by the train derailment? *
Is your home or land in a Trust?*

If your home, business, or land is in a trust, we will need a contract for the legal entity.

Is your business or commercial property owned by an LLC, Incorporation, Corporation, Trust, etc?*
What was the approximate distance from the train derailment?*
Were you at this address at the time of the accident?*
Do you believe you have property damage?*
Would you like to add information for another property?*

Information for Additional Properties

This may just be where you lived, but if you had multiple properties or owned/rented business properties too, we will want to collect those as well.

East Palestine Train Derailment Questionnaire - Household Member Information [1]

Would you like to include any other household members?*
What is their date of birth?*
What is their Relationship to You?*
Would you like to include another household member?*

East Palestine Train Derailment Questionnaire - Household Member Information [2]

What is their date of birth?*
What is their Relationship to You?*
Would you like to include another household member?*

East Palestine Train Derailment Questionnaire - Household Member Information [3]

What is their date of birth?*
What is their Relationship to You?*
Would you like to include another household member?*

East Palestine Train Derailment Questionnaire - Household Member Information [4]

What is their date of birth?*
What is their Relationship to You?*
Would you like to include another household member?*

East Palestine Train Derailment Questionnaire - Household Member Information [5]

What is their date of birth?*
What is their Relationship to You?*
Would you like to include another household member?*

East Palestine Train Derailment Questionnaire - Household Member Information [6]

What is their date of birth?*
What is their Relationship to You?*
Would you like to include another household members?*

East Palestine Train Derailment Questionnaire - Household Member Information [7]

What is their date of birth?*
What is their Relationship to You?*
Would you like to include additional household members?*

East Palestine Train Derailment Questionnaire - Household Member Information

East Palestine Train Derailment Questionnaire - Emotional Distress and Personal Injury

Did anyone in your household witness the derailment?*
What time did they see the derailment?
:  
Where were they when they witnessed the derailment?
What was their proximity to the incident?*
Did you and your family evacuate?*
What day were you evacuated?*
What day did you return home?*
Has anyone in your household suffered any symptoms or injuries after the train derailment? *

Symptoms or Injuries - Member 1

Which of the following symptoms did you experience?*
Did you seek medical treatment?*

Symptoms or Injuries - Member 2

Which of the following symptoms did you experience?*
Did you seek medical treatment?*

Symptoms or Injuries - Member 3

Which of the following symptoms did you experience?*
Did you seek medical treatment?*

Symptoms or Injuries - Member 4

Which of the following symptoms did you experience?*
Did you seek medical treatment?*

Symptoms or Injuries - Member 5

Which of the following symptoms did you experience?*
Did you seek medical treatment?*

Symptoms or Injuries - Member 6

Which of the following symptoms did you experience?*
Did you seek medical treatment?*

Symptoms or Injuries - Member 7

Which of the following symptoms did you experience?*
Did you seek medical treatment?*

East Palestine Train Derailment Questionnaire - Income Loss

Did you/they suffer personal income loss because of the train derailment?*

Document Uploads

Note: If you are not able to provide a driver's license or government ID for all adults in the household, we will not be able to submit your case to our lawyers.  If you cannot upload front and back pictures now, make sure to send a copy of the driver's license or government ID via email or by bringing it to the office. 

Will you be able to provide us with a copy of a driver's license or government ID which shows your current address, or, if not reflected on your license, any other document showing your residence?*
Please upload the front picture of the driver's license or government ID.*
No File Chosen
File uploads may not work on some mobile devices.
Please upload the back picture of the driver's license or government ID.*
No File Chosen
File uploads may not work on some mobile devices.
For name, will you be able to provide us with a copy of a driver's license or government ID which shows their current address, or, if not reflected on their license, any other document showing their residence?*
Please upload the front picture of the driver's license or government ID. *
No File Chosen
File uploads may not work on some mobile devices.
Please upload the back picture of the driver's license or government ID. *
No File Chosen
File uploads may not work on some mobile devices.
For name, will you be able to provide us with a copy of a driver's license or government ID which shows their current address, or, if not reflected on their license, any other document showing their residence? *
Please upload the front picture of the driver's license or government ID. *
No File Chosen
File uploads may not work on some mobile devices.
Please upload the back picture of the driver's license or government ID. *
No File Chosen
File uploads may not work on some mobile devices.
For name, will you be able to provide us with a copy of a driver's license or government ID which shows their current address, or, if not reflected on their license, any other document showing their residence? *
Please upload the front picture of the driver's license or government ID. *
No File Chosen
File uploads may not work on some mobile devices.
Please upload the back picture of the driver's license or government ID. *
No File Chosen
File uploads may not work on some mobile devices.
For name, will you be able to provide us with a copy of a driver's license or government ID which shows their current address, or, if not reflected on their license, any other document showing their residence? *
Please upload the front picture of the driver's license or government ID. *
No File Chosen
File uploads may not work on some mobile devices.
Please upload the back picture of the driver's license or government ID. *
No File Chosen
File uploads may not work on some mobile devices.
For name, will you be able to provide us with a copy of a driver's license or government ID which shows their current address, or, if not reflected on their license, any other document showing their residence? *
Please upload the front picture of the driver's license or government ID. *
No File Chosen
File uploads may not work on some mobile devices.
Please upload the back picture of the driver's license or government ID. *
No File Chosen
File uploads may not work on some mobile devices.
For name, will you be able to provide us with a copy of a driver's license or government ID which shows their current address, or, if not reflected on their license, any other document showing their residence? *
Please upload the front picture of the driver's license or government ID. *
No File Chosen
File uploads may not work on some mobile devices.
Please upload the back picture of the driver's license or government ID. *
No File Chosen
File uploads may not work on some mobile devices.
For name, will you be able to provide us with a copy of a driver's license or government ID which shows their current address, or, if not reflected on their license, any other document showing their residence? *
Please upload the front picture of the driver's license or government ID. *
No File Chosen
File uploads may not work on some mobile devices.
Please upload the back picture of the driver's license or government ID. *
No File Chosen
File uploads may not work on some mobile devices.
For name, will you be able to provide us with a copy of a driver's license or government ID which shows their current address, or, if not reflected on their license, any other document showing their residence? *
Please upload the front picture of the driver's license or government ID. *
No File Chosen
File uploads may not work on some mobile devices.
Please upload the back picture of the driver's license or government ID. *
No File Chosen
File uploads may not work on some mobile devices.

East Palestine Train Derailment Questionnaire - Secondary Contact

This may be someone in your household.
What is their Relationship to You?

East Palestine Train Derailment Questionnaire - Qualification Status

Based on the information you provided, our team is able to represent you!


The next step in this process is to sign our Engagement Agreement, which one of our team members will be assisting you with momentarily once your packet is ready to print. Once that is complete, you will have established an attorney-client relationship with us, which allows us to begin working on your case.


Clicking the Next button will advance you to the page to Submit your information.

Thank you for providing that information. Based on your answers, we have come to the unfortunate conclusion that we will not be able to represent you in this case. 


Please do not infer from our decision that you do not have a meritorious claim or could not prevail on your claim. We make no representations in this regard. Another attorney may disagree with our criteria and accept your case. We encourage you to seek legal advice from another attorney if you desire a second opinion as to whether you should pursue a claim. We regret that we are unable to proceed with your potential case.

East Palestine Train Derailment Questionnaire - Engagement Agreement

CONTRACT OF EMPLOYMENT AND CONSENT TO FEE SHARING (EAST PALESTINE OHIO NORFOLK SOUTHERN TRAIN DERAILMENT)


The undersigned “Clients”: (client’s printed name; or if deceased, name of client and decedent as: (client) individually and as representative of the estate and/or the successor in interest of (decedent)), hereby employs the Bevan & Associates LPA, Watts Guerra, LLC, Watts Guerra, LLP, Sunridge Law Group LLC, and the Law Office of Douglas Boxer called “the Firms,” as my attorneys to represent me in all claims, suits, or other matters arising out of and resulting from damages suffered by me or decedent related to the February 3, 2023 Norfolk Southern Corp. train derailment in East Palestine, Ohio.

1. THE FIRMS’ AUTHORITY. THE FIRMS’ AUTHORITY. Client fully authorizes and directs the Firms to manage and handle my claims as they deem proper and to investigate and prosecute them, with or without filing a lawsuit, in any manner they deem advisable. Client authorizes the Firms to deliver in my name any and all notices, receipts, authorizations, releases, pleadings and any other documents proper in and to the handling of my claims. Client authorizes the Firms to use their professional judgment and any relevant documents, records, or other information that the Firms deem necessary to proper representation of Client. If, at any time, the Firms determine, for any permissible reason, that prosecution of Client’s claims should be discontinued, the Firms may withdraw from my representation. Client understands and agrees that the Firms may transmit Client’s protected health information electronically in the course of representing Client. The Firms do not provide tax advice. THIS CONTRACT WILL BE VOIDED IF A SCIENTIFIC TEST DETERMINES THAT YOU DO NOT HAVE THE REQUISITE LEVEL OF EXPOSURE TO CERTAIN CHEMICALS AS DETERMINED BY WATTS GUERRA LLC

2. CLIENT’S COOPERATION. Client agrees to cooperate fully with the Firms, disclose all relevant facts and promptly advise the Firms of any change in address or telephone number, and to promptly comply with all reasonable requests of the Firms on all matters related to this contract. Client consents to being contacted by the Firms via telephone, text message, email, and specifically through the use of robocall technology as well as any other necessary methods of communication. Client understands that failure to fully cooperate may be a basis for termination of this contract. Client agrees not to attempt on his/her part to unilaterally settle the claims made the subject of this contract. The Client will rely exclusively upon the representation of the Firms during any settlement negotiations. No settlement will be made without the Client’s consent.

3. CONTINGENT FEE ARRANGEMENT. The Firms will assume joint responsibility for Client’s representation. In consideration of such legal services, Client hereby assigns and grants to the Firms the following percentage of any monies, interest, settlement, judgement, Court awarded costs or attorney fees or property recovered FORTY PERCENT (40%) or the maximum amount below that amount allowed by Federal Law. Client consents to the Firms’ sharing these attorneys’ fees 45.125% to Watts Guerra LLC, 2.375% to Watts Guerra LLP, 43.9375% to Sunridge Law Group, LLC and 3.5625% to the Law Office of Doug Boxer and 5% to Bevan & Associates LPA, Inc. Client consents to the Firms sharing their attorneys’ fees with local counsel as necessary. Attorneys’ fees will be determined before repayment of expenses; that is, attorneys’ fees will be calculated based on the gross recovery, before expenses are deducted. Client will receive all funds paid to Client by Client’s insurance company and no portion of insurance proceeds will be included in the contingent fee arrangement. This contingency fee is not set by law but is negotiable between the Attorney and Client. In the event there is no recovery, Client owes the Firms nothing.

4. EXPENSES PAID BY THE FIRMS. The Firms agree to advance any and all reasonable expenses associated with the prosecution of client’s claim. Expenses advanced by the Firms will be repaid to them from any recoveries made. In the event no recovery is made, no repayment of expenses advanced will be required. Advanced expenses that shall be reimbursed include office expenses attributable to the representation, other than general overhead expenses. Such reimbursable office expenses shall include, but are not limited to, internal document copying and scanning at $0.25 per page, document copying and scanning performed by others, photograph, video and document imaging expenses and reproduction thereof, mileage at the rate allowed by the Internal Revenue Service, travel, and all airfare, mileage, legal research and investigation charges, long distance telephone charges, fax and electronic mail expense and postage. The reimbursable expenses will also include any and all expenses or costs paid to or for persons, entities or businesses outside the firm which are related to the representation, including but not limited to, experts and their staffs; jury consultants; specialized legal counsel for bankruptcy proceedings initiated by defendants; Medicare/Medicaid, hospital lien, and subrogation resolution services; interpreters; investigators; court reporters; videographers; and document imaging companies and personnel. Regardless of outcome, Client will be responsible for all medical bills and liens incurred as a result of medical treatment received. Client understands the Firms may be representing multiple clients and agrees that in representing multiple clients many of the expenses incurred are common case expenses, which are costs and expenses incurred for the benefit of multiple clients, including expert witness fees, depositions of defendants, experts, and non-party witnesses, settlement conferences, trial expenses, filing fees, copy costs, and other expenses that are incurred for purposes of influencing the outcome of multiple clients’ claims. Client agrees the expenses that I am required to reimburse, if there is a recovery, include not only expenses for my own claims, but also client’s pro rata share of the common case expenses.

5. MULTIPLE CLIENTS. Client understands and agrees that the Firms may be representing more than one client in this matter and that the following aspects of joint representation have been disclosed: (1) the Client might gain or lose some advantages if represented by separate counsel; (2) the Firms cannot serve as an advocate for one client against another client; (3) the Firms must deal impartially with every client; (4) information received by the Firms from or on behalf of any jointly represented client concerning the matter may not be confidential or privileged as between the jointly-represented clients; and (5) if a conflict arises between clients, the Firms might not be able to continue representing any of the clients involved. Client consents to the Firms representing more than one client in this matter.

6. LAW AND VENUE. This agreement shall be governed by and interpreted under Ohio substantive law, and exclusive venue and jurisdiction of any lawsuit or claim arising out of or relating to this agreement shall lie in Ohio State Court in Columbiana County, Ohio. If any provision of this agreement shall be held to be invalid, illegal, unenforceable or in conflict with the law of any jurisdiction, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or impaired thereby.

7. NO SOLICITATION OF CLIENT. By signing and entering into this agreement, Client hereby affirms that Client’s case was not solicited by the Firms, the agreement is not being entered into as a result of promises of money, no promises of a successful recovery have been made to Client, and Client has freely and voluntarily entered into this agreement.

READ AND ACCEPTED BY:

CLIENT NAME:
CLIENT MAIN EMAIL ADDRESS:

List the Names of Minors the Client is the custodial parent/guardian of, that Client is signing on behalf of


If Client has additional adult family members, Client’s adult family members will receive agreement to sign when Client speaks to case manager.


BY WATTS GUERRA LLC
BY WATTS GUERRA LLP
BY BEVAN & ASSOCIATES LPA, INC.
BY SUNRIDGE LAW GROUP, LLC
BY LAW OFFICE OF DOUGLAS BOXER
Use your mouse or finger to draw your signature above
Use your mouse or finger to draw your signature above

East Palestine Train Derailment Questionnaire - Power of Attorney

STATE OF

COUNTY OF


That I, , have made, constituted, and appointed, and do so by this instrument hereby make, constitute, empower, and appoint, Paige Boldt, Mikal C. Watts, and or WATTS GUERRA, Attorneys at Law (collectively, my “attorneys”), 5726 W Hausman Rd, Suite 119, San Antonio, Texas 78249, as my true and lawful attorneys for me and give my attorneys the powers listed below to act in my name, place, and stead to appear for and represent me in the claims involving the February 3, 2023 Norfolk Southern East Palestine, OH Train Derailment giving my said attorneys full power to do everything whatsoever requisite and necessary and in any way which I, myself, could do if I were personally present.


My attorneys’ powers shall include the power to: (a) take any and all steps necessary to request and collect medical and pharmacy records related to my representation; (b) take any and all steps necessary to request and collect any and all mental health records related to my representation; (c) take any and all actions necessary to resolve issues with ordering medical and or pharmaceutical records, including signing my name to medical, pharmacy, Health Insurance Portability and Accountability Act of 1996 (HIPAA), and similar authorizations, or otherwise digitally affixing a copy of my signature to said authorizations, in order to obtain medical and pharmaceutical records related to my representation; (d) take any and all actions necessary to verify, affirm, and or attest to discovery responses in my lawsuit, including plaintiff fact sheets or similar requests, including signing my name to said discovery documents, or otherwise digitally affixing a copy of my signature to said documents; and (e) take any and all actions necessary to identify and resolve liens that are or might be asserted related to my injuries, including, but not limited to Medicare, Medicaid, insurance, workers compensation, and or other health care related liens, by signing my name or otherwise digitally affixing a copy of my signature to documents retaining, and otherwise utilizing, specialized lien resolution groups to assist in said matters.


It is understood and agreed that the attorneys’ fees in my case are governed by and are subject to the attorney Employment Contract entered into between WATTS GUERRA and myself, and further, no settlement will be made without my consent. This Power of Attorney shall become effective immediately upon execution; however, I may revoke this power of attorney at any time by providing written notice to my Attorneys.


I agree that any third party who receives a copy of this document may act under it. Revocation of this power of attorney is not effective as to a third party until the third party receives actual notice of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of reliance on this power of attorney.


IN TESTIMONY WHEREOF, I have hereunto set my signature, this

STATE OF

COUNTY OF


That I, , as a representative and guardian of , have made, constituted, and appointed, and do so by this instrument hereby make, constitute, empower, and appoint, Paige Boldt, Mikal C. Watts, and or WATTS GUERRA, Attorneys at Law (collectively, my “attorneys”), 5726 W Hausman Rd, Suite 119, San Antonio, Texas 78249, as my true and lawful attorneys for me and give my attorneys the powers listed below to act in my name, place, and stead to appear for and represent me in the claims involving the February 3, 2023 Norfolk Southern East Palestine, OH Train Derailment giving my said attorneys full power to do everything whatsoever requisite and necessary and in any way which I, myself, could do if I were personally present.


My attorneys’ powers shall include the power to: (a) take any and all steps necessary to request and collect medical and pharmacy records related to my representation; (b) take any and all steps necessary to request and collect any and all mental health records related to my representation; (c) take any and all actions necessary to resolve issues with ordering medical and or pharmaceutical records, including signing my name to medical, pharmacy, Health Insurance Portability and Accountability Act of 1996 (HIPAA), and similar authorizations, or otherwise digitally affixing a copy of my signature to said authorizations, in order to obtain medical and pharmaceutical records related to my representation; (d) take any and all actions necessary to verify, affirm, and or attest to discovery responses in my lawsuit, including plaintiff fact sheets or similar requests, including signing my name to said discovery documents, or otherwise digitally affixing a copy of my signature to said documents; and (e) take any and all actions necessary to identify and resolve liens that are or might be asserted related to my injuries, including, but not limited to Medicare, Medicaid, insurance, workers compensation, and or other health care related liens, by signing my name or otherwise digitally affixing a copy of my signature to documents retaining, and otherwise utilizing, specialized lien resolution groups to assist in said matters.


It is understood and agreed that the attorneys’ fees in my case are governed by and are subject to the attorney Employment Contract entered into between WATTS GUERRA and myself, and further, no settlement will be made without my consent. This Power of Attorney shall become effective immediately upon execution; however, I may revoke this power of attorney at any time by providing written notice to my Attorneys.


I agree that any third party who receives a copy of this document may act under it. Revocation of this power of attorney is not effective as to a third party until the third party receives actual notice of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of reliance on this power of attorney.


IN TESTIMONY WHEREOF, I have hereunto set my signature, this

Current Date
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East Palestine Train Derailment Questionnaire - Spouse - Power of Attorney

STATE OF

COUNTY OF


That I, , have made, constituted, and appointed, and do so by this instrument hereby make, constitute, empower, and appoint, Paige Boldt, Mikal C. Watts, and or WATTS GUERRA, Attorneys at Law (collectively, my “attorneys”), 5726 W Hausman Rd, Suite 119, San Antonio, Texas 78249, as my true and lawful attorneys for me and give my attorneys the powers listed below to act in my name, place, and stead to appear for and represent me in the claims involving the February 3, 2023 Norfolk Southern East Palestine, OH Train Derailment giving my said attorneys full power to do everything whatsoever requisite and necessary and in any way which I, myself, could do if I were personally present.


My attorneys’ powers shall include the power to: (a) take any and all steps necessary to request and collect medical and pharmacy records related to my representation; (b) take any and all steps necessary to request and collect any and all mental health records related to my representation; (c) take any and all actions necessary to resolve issues with ordering medical and or pharmaceutical records, including signing my name to medical, pharmacy, Health Insurance Portability and Accountability Act of 1996 (HIPAA), and similar authorizations, or otherwise digitally affixing a copy of my signature to said authorizations, in order to obtain medical and pharmaceutical records related to my representation; (d) take any and all actions necessary to verify, affirm, and or attest to discovery responses in my lawsuit, including plaintiff fact sheets or similar requests, including signing my name to said discovery documents, or otherwise digitally affixing a copy of my signature to said documents; and (e) take any and all actions necessary to identify and resolve liens that are or might be asserted related to my injuries, including, but not limited to Medicare, Medicaid, insurance, workers compensation, and or other health care related liens, by signing my name or otherwise digitally affixing a copy of my signature to documents retaining, and otherwise utilizing, specialized lien resolution groups to assist in said matters.


It is understood and agreed that the attorneys’ fees in my case are governed by and are subject to the attorney Employment Contract entered into between WATTS GUERRA and myself, and further, no settlement will be made without my consent. This Power of Attorney shall become effective immediately upon execution; however, I may revoke this power of attorney at any time by providing written notice to my Attorneys.


I agree that any third party who receives a copy of this document may act under it. Revocation of this power of attorney is not effective as to a third party until the third party receives actual notice of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of reliance on this power of attorney.


IN TESTIMONY WHEREOF, I have hereunto set my signature, this

Current Date
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East Palestine Train Derailment Questionnaire - HIPAA Disclosure

AUTHORIZATION FOR USE & DISCLOSURE OF INDIVIDUALLY IDENTIFIABLE AND PROTECTED HEALTH INFORMATION (“HEALTH INFORMATION”)
1. PATIENT IDENTIFICATION
PRINTED NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:

2. PATIENT ADDRESSES
ADDRESS (Current Residence):

3. PERSONS/ORGANIZATIONS AUTHORIZED TO DISCLOSE HEALTH INFORMATION: (hereinafter referred to as “Custodian Of Records”):

4. PERIODS OF HEALTH CARE/HEALTH INFORMATION/ACADEMIC INFORMATION TO BE DISCLOSED
By signing, I authorize the Custodian of Records to release my medical or billing records containing information in reference to: Communicable and Non-Communicable Diseases, and/or Drug and/or Alcohol Abuse, and/or Psychiatric, and/or HIV/AIDS Records.

5. TO WHOM AND WHERE TO SEND DISCLOSED HEALTH INFORMATION:
I authorize the disclosure and use of the Health Information described above to the following person(s) or organization(s):

6. PURPOSE OF DISCLOSURE/USE: CIVIL LITIGATION

7. RE-DISCLOSURE:
I understand the information disclosed by this Authorization may be subject to re-disclosure by the recipients and no longer be protected by the Health Insurance Portability and Accountability Act of 1996. The facilities, their employees and officers are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

8. LIMIT & RIGHT TO REVOKE AUTHORIZATION:
Except to the extent that action has already been taken in reliance on this Authorization, I understand this Authorization is voluntary and that I may revoke it at any time by submitting a notice in writing to the Custodian of Records or organization(s) providing the Protected Health Information. Unless revoked this Authorization will expire on the following date or event: upon completion of pending civil litigation. Expiration date/event is further defined as resolution of the claim asserted or at the conclusion of any litigation instituted in connection with the subject matter of pending civil litigation and/or of the Notice of the Health Care Claim.

Treatment, payment, enrollment in a health plan, or eligibility for health insurance benefits may not be conditioned on my signing this authorization.

9. The office of WATTS GUERRA LLC, is authorized to discuss with any health care provider, therapist, individual, fiduciary, agent, or other person any evidence, testimony or fact deemed by said attorneys to be material, and said attorneys and their agents are authorized to examine, inspect, copy, and/or inquire of any person, firm, corporation, institution or agency thereof concerning or relating to any evidence, documents, reports, and/or records. All such persons are requested to freely cooperate with said attorneys or their agents.

10. The Custodian of Records is released from any legal responsibility for the disclosure of the above stated Health Information to the extent indicated and authorized herein.

11. A facsimile, photostatic, carbon or other copies of this Authorization are intended and shall be treated as an original.

12. I understand that the health information described above may be transmitted electronically and may be redisclosed electronically by WATTS GUERRA LLC.

13. RIGHTS & SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE REQUESTING DISCLOSURE:
I understand that I do not have to sign this Authorization and that my treatment or payment for services will not be denied if I do not sign this form unless specified above under Purpose of Request. I can inspect or copy the Health Information to be used or disclosed. I may see and receive a copy of this Authorization. I authorize the Custodian of Records to disclose the Health Information specified above. The information I am requesting may be sent by U.S. mail service, expedited mail services (such as Federal Express, Lone Star, etc.) and/or electronic facsimile in accordance with the provider’s facsimile policy.
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East Palestine Train Derailment Questionnaire - Spouse - HIPAA Disclosure

AUTHORIZATION FOR USE & DISCLOSURE OF INDIVIDUALLY IDENTIFIABLE AND PROTECTED HEALTH INFORMATION (“HEALTH INFORMATION”)
1. PATIENT IDENTIFICATION
PRINTED NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:

2. PATIENT ADDRESSES
ADDRESS (Current Residence):

3. PERSONS/ORGANIZATIONS AUTHORIZED TO DISCLOSE HEALTH INFORMATION: (hereinafter referred to as “Custodian Of Records”):

4. PERIODS OF HEALTH CARE/HEALTH INFORMATION/ACADEMIC INFORMATION TO BE DISCLOSED
By signing, I authorize the Custodian of Records to release my medical or billing records containing information in reference to: Communicable and Non-Communicable Diseases, and/or Drug and/or Alcohol Abuse, and/or Psychiatric, and/or HIV/AIDS Records.

5. TO WHOM AND WHERE TO SEND DISCLOSED HEALTH INFORMATION:
I authorize the disclosure and use of the Health Information described above to the following person(s) or organization(s):

6. PURPOSE OF DISCLOSURE/USE: CIVIL LITIGATION

7. RE-DISCLOSURE:
I understand the information disclosed by this Authorization may be subject to re-disclosure by the recipients and no longer be protected by the Health Insurance Portability and Accountability Act of 1996. The facilities, their employees and officers are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

8. LIMIT & RIGHT TO REVOKE AUTHORIZATION:
Except to the extent that action has already been taken in reliance on this Authorization, I understand this Authorization is voluntary and that I may revoke it at any time by submitting a notice in writing to the Custodian of Records or organization(s) providing the Protected Health Information. Unless revoked this Authorization will expire on the following date or event: upon completion of pending civil litigation. Expiration date/event is further defined as resolution of the claim asserted or at the conclusion of any litigation instituted in connection with the subject matter of pending civil litigation and/or of the Notice of the Health Care Claim.

Treatment, payment, enrollment in a health plan, or eligibility for health insurance benefits may not be conditioned on my signing this authorization.

9. The office of WATTS GUERRA LLC, is authorized to discuss with any health care provider, therapist, individual, fiduciary, agent, or other person any evidence, testimony or fact deemed by said attorneys to be material, and said attorneys and their agents are authorized to examine, inspect, copy, and/or inquire of any person, firm, corporation, institution or agency thereof concerning or relating to any evidence, documents, reports, and/or records. All such persons are requested to freely cooperate with said attorneys or their agents.

10. The Custodian of Records is released from any legal responsibility for the disclosure of the above stated Health Information to the extent indicated and authorized herein.

11. A facsimile, photostatic, carbon or other copies of this Authorization are intended and shall be treated as an original.

12. I understand that the health information described above may be transmitted electronically and may be redisclosed electronically by WATTS GUERRA LLC.

13. RIGHTS & SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE REQUESTING DISCLOSURE:
I understand that I do not have to sign this Authorization and that my treatment or payment for services will not be denied if I do not sign this form unless specified above under Purpose of Request. I can inspect or copy the Health Information to be used or disclosed. I may see and receive a copy of this Authorization. I authorize the Custodian of Records to disclose the Health Information specified above. The information I am requesting may be sent by U.S. mail service, expedited mail services (such as Federal Express, Lone Star, etc.) and/or electronic facsimile in accordance with the provider’s facsimile policy.
Use your mouse or finger to draw your signature above

East Palestine Train Derailment Questionnaire - Wrap Up

Thank you for trusting us to represent you and work on your claim. We will be here with you every step of the way. 


Thank you for your time today. We are thinking of you and your community and will be fighting for you every step of the way. 

  • Welcome

  • Intro Questions

  • Contact Information

  • Qualification Questions

  • Wrap-up

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