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SOCIAL SECURITY CLAIMANT REPRESENTATION
FEE FOR SERVICES RETAINER AGREEMENT

 

   This is a contract for services agreement between Roger N. Meyer, D.B.A. "…of a different mind" and the party named below (hereinafter referred to as claimant) wherein Roger N. Meyer agrees to fully represent the claimant's interests in all Social Security matters before administrators and adjudicators of the Oregon/Washington State Disability Determination Services and the Portland regional SSA Office of Hearings and Appeals. For purposes of this agreement, "representation" means individual advocacy for the purpose of securing medical, mental health, and other evaluations, authorized solicitation of records and documents from providers, the claimant, member of his/her family, and third party individuals or agencies knowledgeable about the claimant and/or maintaining records identifying the claimant. Representation also includes the submission of briefs and memoranda, and appearance before administrative law judges. As a condition of this agreement to represent, claimant will execute authorizations and releases for information and records provided by Mr. Meyer to be directed to third party sources, including medical and mental health providers. Medical and mental health records as well as other records containing health or mental health information require the execution of a separate Health Insurance Privacy and Portability Act HIPAA-compliant release as governed by requisite provisions of federal and state law and regulations. Claimant agrees to keep appointments with any evaluators secured through Mr. Meyer's assistance.

     Both parties to this agreement are of the understanding that:

• Mr. Meyer will hold all information about the claimant and his/her family in strictest confidence. Claimant Initials________.

• Mr. Meyer will regularly inform the claimant of contacts with claimant's case managers, counselors, therapists, and/or other providers. Claimant will also keep Mr. Meyer informed of any contacts with such persons or agencies. Claimant Initials________.

• Mr. Meyer is bound by the ethics and scope of practice requirements of federal law and regulations applicable to Social Security representatives. Claimant Initials_________.

• Under Oregon and Washington law, Mr. Meyer is obligated to report child, elder and mentally ill/dependent adult abuse information to appropriate authorities. Claimant Initials_________.

• Upon written and dated notification of the other, either party may terminate this agreement. Within five business days of termination, Mr. Meyer shall notify the appropriate office of the Social Security Administration of the termination. At time of termination, Mr. Meyer may advise claimant to secure a successor representative. Claimant's initials._________.

• In signing this agreement, claimant authorizes Mr. Meyer to secure medical and mental health records under provisions of HIPAA as claimant's authorized Social Security Claimant Representative. Claimant Initials_________.

• In signing this agreement, claimant authorizes Mr. Meyer to redisclose information initially disclosed by others and released to him to the Social Security Administration. Claimant Initials___________.

     By engaging Mr. Meyer as a Social Security Claimant Representative, claimant further agrees to sign and date a separate Social Security Appeals Fee Agreement. Mr. Meyer's terms of compensation and provisions relating to claimant's agreement to pay Mr. Meyer's direct out-of-pocket costs are described in that agreement. Direct costs are described in a copy of Fee Structure and Billing Practices for Private Clients, a copy of which will be provided to the claimant at the time of signing of this agreement and the Appeals Fee Agreement.




____________________________Date___/____/______ ______________________________
Claimant's Signature Roger N. Meyer

 

"…of a different mind" 18162 East Burnside, Portland, OR 97233
Phone and FAX: 503-6662776 Email: rogernmeyer@earthlink.com

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