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
