This Attorney-Client Agreement (“Agreement”) is between _______________ (“you”) Labaton Keller Sucharow LLP (“Labaton”), Boies Schiller Flexner LLP (“Boies Schiller”) and Milberg Coleman Bryson Phillips Grossman PLLC (“Milberg”) (the “Firms”, “we”, or “us”).  If you have any questions about this agreement, please contact us at InstagramHarmClaim@Labaton.com.

1. Scope of Representation. 

We will serve as your attorneys in connection with potential claims you may have against Instagram LLC, Meta Payments, Inc., Meta Platform Technologies, and Meta Platforms, Inc. (hereinafter referred to as “Instagram”).  We will represent you to the best of our ability and according to our ethical duties as lawyers. PLEASE READ THIS AGREEMENT AND THE ATTACHMENTS CAREFULLY.  IN ORDER FOR US TO PROCEED ON YOUR BEHALF, YOU MUST SIGN THIS AGREEMENT ON THE LAST PAGE.  BY SIGNING AND CLICKING “FINISH,” YOU WILL MAKE THIS AGREEMENT BINDING UPON BOTH YOU AND US. 

Upon your signing this Agreement, we agree to represent you in products liability related claims against Instagram or related people or companies like subsidiaries, affiliates, directors, officers, or shareholders (the “company”) relating the Instagram social media platform.  We will only investigate your claims as a result of Instagram’s addictive and psychologically harmful design under various liability theories, including state strict liability, products liability, negligence, statutory privacy, and consumer protection laws. You also authorize us to represent you in related claims against the company that we may discover and determine are ones that are feasible for us to pursue on your behalf.  We do not represent you in any other matters unless we sign a separate agreement governing those matters. 

By signing this Agreement, you authorize us to file a claim on your behalf and in your name in an individual arbitration, if we think that it is in your best interest to do so.  We may also do other things we believe are in your best interest, including preparing and signing legal documents, negotiating a settlement, or obtaining documents from the company or third parties to evaluate and prosecute your claim. You also agree that we can file a motion or other documents, including a complaint, on your behalf in court if the need arises. By signing at the end of this Agreement you also approve the annexed Attorney Document Authorization. If we determine that you do not have a valid claim, we will so advise you and this Agreement shall terminate. 

The outcome of disputed legal matters is always uncertain.  You understand that we cannot guarantee that this claim will be successful or that you will recover any money or obtain any other form of relief. 

If the arbitrator does not rule in your favor, we will consider pursuing an appeal of the decision if allowed to do so.  However, we may determine at our sole discretion not to pursue such an appeal. If that happens, we will notify you so that you may protect any appeal rights you might have. 

2. Attorneys’ Fees, Expenses & How We Disburse Funds. 

You won’t owe us any fees unless we successfully collect a financial recovery for you by payment of an award or settlement of your claim.  You will never owe us any sums out of pocket for fees or expenses.   

Under no circumstances will we collect an unreasonably large fee. 

We are a contingency fee law firm, which means that our fees are a percentage of the settlement, award, or recovery.  In the event your claim settles or results in a recovery or award, our fee will be 40% of the gross sum recovered.  However, if the law in your state limits the contingent fees we are entitled to receive to a percentage less than 40%, we will limit our fee to the maximum amount allowed.  If you have any questions about the fee amounts that apply to your state, you may contact us at InstagramHarmClaim@Labaton.com.   You acknowledge that this fee is the result of an arms-length transaction between you and us. 

After our fees are deducted, we deduct expenses from your gross recovery. Expenses can include expenses specific to your individual case or expenses that we advance on behalf of all of our clients with similar cases for the benefit of the whole group of clients. These expenses may include our usual and customary fees for copying, messenger services and similar items, as well as travel expenses. Expenses that we pay to vendors, arbitrators, experts, or others who assist in the arbitration claim process are not kept by us and are billed at cost. We also charge a small fee of up to $8 per client, per case, for software development, maintenance, and upkeep of our case management platform, both for charges by outside vendors and in-house support staff expenses that reasonably reflect the actual costs to maintain the platform for your use and benefit. Once there is a recovery, settlement, or judgment in your favor, we will inform you in writing of the amount of expenses to be deducted from your award and the nature of the expense.

In connection with this matter, the Firms have assumed joint responsibility for this representation. If successful, the Firms will share the fee. You will not be charged any additional fees because there is more than one law firm on the case. Boies Schiller Flexner LLP will share up to 41.33% and Milberg Coleman Bryson Phillips Grossman PLLC will share up to 29.33% and of the fees in this matter.

If there is recovery or settlement in this case, you grant us the right to receive any monies resulting therefrom, deduct fees and expenses, and send you the remainder.  We will do so as soon as practicable.  If we cannot locate you or an authorized representative within 90 days after attempting to distribute your funds, we may either hold such funds in escrow or deposit them with the court. In the event you do not elect how to receive your settlement award, you agree that we may disburse your funds as an electronic/debit/credit card to the email address we have on file. You understand that we may have a lien upon any amount recovered for you. 

There may be laws that apply to your claim or provisions of your agreement with the company that allow a court or arbitrator to order the company to pay your attorneys’ fees, costs, or expenses (collectively “statutory fees”) if your claim is successful.  If these laws or contract provisions apply, you agree that we can seek to collect the statutory fees from the company.  We will only seek to collect statutory fees from the company if your claim is successful, and never from you.  If we are successful, all statutory fees received from the company, will be applied to reduce the fee we are entitled to under this Agreement.  If we receive a lump sum amount from the company, we will equitably apportion it amongst all clients we represent. Even though you will pay nothing to us unless you recover, some state laws require that we disclose to you our regular hourly rates.  The hourly rates for the attorneys and other billing professional staff who may work on your case range from $365 for junior paralegal staff to $1,350 for senior partners, but you are not responsible to pay us according to these hourly rates. If we seek our attorneys’ fees directly from the company, we will seek them using these hourly rates. You are not billed on an hourly basis, you do not owe us any attorneys’ fees unless we succeed on your claim, and your fees will never exceed 40% of your settlement or award.  We reserve the right to update these rates with 60 days’ written notice which will be sent through Labaton’s secure client portal.  You acknowledge that we may associate with other counsel in connection with your claim. 

You acknowledge that we may associate with other counsel in connection with your claim.

3. Settlement Offers.  

You have the right to accept or reject any settlement offer the company makes to you.  We will never settle your claim without your express consent.  

You give us exclusive authorization to negotiate settlements with the company, including as part of a group settlement with other similar claims, and to make decisions about litigation or settlement tactics on your behalf.  You give us the right to reject any settlement offer that is not equal to your actual loss, or the maximum allowable damages, whichever is greater, unless we believe that we have achieved the likely best settlement possible under the circumstances.  You agree that any settlement we obtain on your behalf shall include a mutual release of claims against the company and its attorneys, agents, and other related parties relating to the claims described in paragraph 1, as well as claims by the company against you or your attorneys, agents, and other related parties relating to the claims described in paragraph 1. If we bring you a settlement offer from the company or about your claim, the final decision on whether to accept the offer is yours.  However, we may advise you that we feel the settlement is fair and reasonable, and if you disagree with our advice and continuing to represent you creates an unreasonable financial burden on us, we may withdraw as counsel after giving you reasonable notice or ask the arbitral panel for permission to withdraw as your attorneys consistent with the applicable ethics rules.

You can substitute another law firm for us as your attorneys at any time; however, if you don’t do so for good cause and you later obtain a settlement, recovery, or judgment, you agree that we are entitled to an amount up to and including the full fee contemplated by this Agreement for legal services rendered. Alternatively, if you substitute another law firm for us for good cause, or if we withdraw as counsel and you later obtain a settlement, recovery, or judgment, you agree to pay us reasonable fees and expenses for legal services rendered. 

4. Multiple Clients; Apportionment of Recovery; & Conflicts of Interest.  

You acknowledge that you are not the only client we are representing with respect to this claim and that conflicts of interest could arise between you and our other clients.    

You are one of multiple plaintiffs or claimants being represented by us with respect to this case.   We may reach a single aggregate settlement of multiple claims involving the same or similar factual patterns if we believe it to be fair and adequate for the group as a whole.  In the event that you do not withdraw from the settlement, you authorize us to apportion the common expenses and recovery between all of our clients in such manner as we determine to be fair and equitable and consistent with our ethical and legal obligations.

You acknowledge that representation of multiple clients may give rise to potential conflicts of interest.  If we believe that such a conflict exists, we shall discuss the matter with you.  If it is necessary for us to withdraw, then you might have to obtain new, separate counsel, which may incur additional expense and delay as the new attorneys become familiar with the matter. If we withdraw from representing you, you agree to waive any objection to our continuing to represent other clients in this matter, provided that doing so is consistent under the applicable ethical rules.  

5. When We May Withdraw as Your Attorneys.  

We may withdraw from our representation of you in some specific circumstances:  

We will provide you reasonable notice prior to withdrawing from the representation.  Subject to the requirements of any applicable law or ethics rules, such withdrawal will be effective by sending you an electronic notification to your last known email address. 

6. Your Duties as Client; Electronic Communications.  

You have certain responsibilities as a client, including the responsibility to keep us updated as to your contact information, to promptly respond to our communications, and provide information and documents we need for your claim electronically or through our secure client portal, Lantern.   

You agree to notify us of any change in address, telephone, or other contact information by sending an email to InstagramHarmClaim@Labaton.com within two weeks of a change. 

You agree to cooperate in the prosecution of your claim.  

You agree to respond promptly to our requests for information or documents necessary to move your claim forward. 

By signing this Agreement, you acknowledge that the best way to facilitate communications between the attorneys and yourself is electronically.  You agree that most of our communications will be conducted either by email or through a private, secure client portal to which you have access solely in connection with and for the purpose of our representation of you.  You agree to be subject to the terms of the End User License Agreement (set forth below) for the use of our website and client portal. You acknowledge that the client portal is proprietary to us and that we may terminate your access at any time. 

You agree that we may place autodialed or pre-recorded calls or text messages to the telephone numbers you provide for the purposes of receiving case-related information. You understand that you can revoke consent by dialing (866) 389-6343 or by any other reasonable notice, and that you do not have to consent to these calls or text messages to receive services.

If your claim results in a settlement or resolution, you agree that any sums due to you under the terms of this Agreement may be held in a client trust account or interest on lawyers’ trust account that is located in the state of New York until they are disbursed to you under the terms of any settlement or resolution. 

7. Statute of Limitations Waiver.  

Your claims must be brought within a limited time period called the Statute of Limitations.  If the claims are brought after that time, your legal rights can be lost or barred forever. Because we need time to investigate your claims, it’s important to promptly complete this Agreement and provide any follow-up information requested by us.  If you do not, your claim may be time-barred.  Even if you complete this Agreement, you agree that we do not have to take any action on your claim if the Statute of Limitations period expires within 90 days of the date this signed Agreement is received. 

8. Third-Parties Bound.  

This Agreement binds your heirs, executors, administrators, successors and assignees. In the event of your death, it will bind any duly appointed representative of your heirs or estate to the extent allowed by applicable law. In particular, any such representative will be bound by the provisions of this Agreement relating to the recovery of attorneys’ fees and costs and other expenses from any settlement entered into by you prior to your death. 

9. Dispute Resolution; Confidentiality.  

If you and the attorneys have a dispute about our legal fees, you may have the right to seek its resolution in accordance with the New York Fee Dispute Resolution Program, Part 137 of the Rules of the Chief 

Administrator of the State of New York.  These rules are available here: http://ww2.nycourts.gov/rules/chiefadmin/137.shtml.   Upon your request we will provide you with the necessary information regarding that program.  You have the absolute right to have any fee dispute governed by the Fee Dispute Resolution Program. This applies only to disputes regarding our legal fees as provided for by Part 137. 

If you and the attorneys have any other dispute about this contract or our services, or if you determine not to utilize the Fee Dispute Resolution described above, we will first try to settle it through direct discussions.  

You agree to give us notice of any dispute by sending a letter or email to InstagramHarmClaim@Labaton.com. If you and the attorneys cannot resolve the dispute through direct discussions within thirty (30) days of the date your notice is sent, both parties agree to first try to settle the dispute by mediation administered by JAMS.  If the parties cannot resolve their entire dispute through mediation, any remaining disputes arising out of or relating to this Agreement or the breach, termination, enforcement, interpretation or validity thereof, including the determination of the scope or applicability of this agreement to arbitrate, shall be determined by arbitration administered by JAMS pursuant to its Streamlined Arbitration Rules and Procedures. Judgment on the Award may be entered in any court having jurisdiction. This clause shall not preclude parties from seeking provisional remedies in aid of arbitration from a court of appropriate jurisdiction. The arbitration shall be governed by the laws of the State of New York. Unless both parties agree otherwise, the arbitration will be based on the submission of documents or, if the arbitrator so directs, by remote or other electronic communication, and there shall be no in-person or oral hearing.  An arbitration resolves a dispute before one or more arbitrators and not a jury of one’s peers. Unlike a court proceeding, an arbitration proceeding is conducted in private and the outcome will remain confidential. The arbitrators will have no authority to award punitive or other damages not measured by the prevailing party's actual damages, except as may be required by statute.  A judicial forum generally does not permit reasonable attorney fees to be imposed against a non-prevailing client in a nonfrivolous action, and arbitrators will only have the authority to allocate attorneys' fees if a particular law permits them to do so. Arbitrators will have the authority to allocate the costs of the arbitration process among the parties.  By agreeing to arbitration, you and we waive the right to seek remedies in court except provisional remedies in aid of arbitration, including the right to jury trial, the possible waiver of broad discovery, and the loss of the right to appeal.  The benefits of arbitration are that they are less costly for you and us, and they take less time that actions take in court. If you require additional information about the differences between a matter resolved through arbitration rather than through a judicial proceeding, you may contact us at InstagramHarmClaim@Labaton.com. You also have the right to seek independent counsel to advise you before agreeing to this retainer agreement.

You agree not to oppose any reasonable protective or sealing order we may seek in any arbitration or court proceeding in order to preserve the confidentiality of the proceeding including, but not limited to, our client information, litigation strategies or work product, or confidential procedures and practices. 

 

10. No Other Lawyers.  

You represent to us that you have not signed an agreement with any other lawyers to pursue claims against the company.  If you do not remember signing such an agreement, but you did, by signing this Agreement you terminate that prior agreement and permit us to contact and communicate with the other law firm about all issues related to your claims against the company.   

11. Headings. 

The headings in this Agreement are for reference purposes only and do not have any effect on the meaning or interpretation of this Agreement.   

12. Severability; Freely Entered Into; Entire Agreement; Controlling Law.  

You agree that if any provision or part of this Agreement is found to be invalid or unenforceable, only that particular provision or part, and not the entire Agreement, will be inoperative; and the invalidity of a particular provision in a particular jurisdiction shall not invalidate such provision in any other jurisdiction. 

You confirm that you have entered into this Agreement, including the dispute resolution provision, freely and willingly and have had the opportunity to consult with attorneys of your choice, other advisors, family, or friends about doing so. 

This Agreement, along with the accompanying End User License Agreement and Attorney Document Authorization, set forth our full understanding.  Neither you nor we have made any other promise or commitment. 

This Agreement shall be governed and controlled by the laws of the State of New York, except its choice of laws provisions, and the New York Rules of Professional Conduct. 

You understand that Labaton owns the Lantern website and platform.  You agree to use our website and client portal only to access your claim information and to learn about and apply for new cases from time to time.   

This End User License Agreement (“EULA”), dated as of the date accepted by the user, is by and between Labaton Keller Sucharow LLP (“Labaton” or “Firm”) and the user who accepts this EULA ("End User"). The End User is a client of the Firm who wishes to utilize the Labaton Licensed Application in connection with Labaton’s legal representation of End User. 

1. Grant of License. Labaton has developed and owns proprietary software, applications, website, and systems to facilitate Labaton’s provision of legal services to its clients, including clients who have retained the Firm to institute mass arbitration legal claims and proceedings (hereinafter “Licensed Application”). Labaton hereby grants to End User a limited, revocable, non-sublicensable, non-exclusive, nontransferable, non-assignable license to use the Licensed Application for End User’s personal use only in connection with the Firm’s legal representation of End User. End User agrees to use the Licensed Application only in compliance with the terms and conditions of this EULA. All rights not expressly granted herein are retained by Labaton. 

2. Updates to EULA. Labaton reserves the right to change the terms of this EULA at any time or for any reason, effective immediately upon posting of the changes on the Licensed Application. End User’s continued use of the Licensed Application following the posted changes will constitute acceptance of and consent to such changes. 

3. Use Is Subject to Retainer Agreement. Labaton provides End User with access to and use of the Licensed Application pursuant to the terms and conditions of Labaton’s retainer agreement between End User and the Firm. End User acknowledges and agrees that access to and use by End User of the Licensed Application is subject in all respects to the terms and conditions of Labaton’s retainer agreement. 

4. Intellectual Property Rights. End User acknowledges and agrees that Labaton owns all right, title and interest, including patent, copyright, trade secret, trademark and other proprietary rights, in and to the Licensed Application, including but not limited to any corrections, bug fixes, enhancements, derivatives, updates or other modifications, any data or information developed or provided by Labaton (including any de-identified or aggregated data), and any know-how, methodologies, equipment, technologies, formulas, databases, data analytics, algorithms, designs, benchmarks, or processes used by Labaton to provide the Licensed Application. End User acknowledges that he or she is granted only a limited right of use of the Licensed Application, which right of use is not coupled with an interest and remains revocable in accordance with the terms of this EULA. End User warrants and agrees that he or she shall not assert any ownership interest in the Licensed Application, or any components thereof. All rights in the Licensed Application, including but not limited to, rights in intellectual property therein, confidential and trade secret material, source code, object code, trademarks, service marks, patents, copyrights and logos, and technologies, formulas, databases, data analytics, algorithms, designs, content, benchmarks or processes developed or provided by Labaton shall be and will remain the sole and exclusive property of Labaton. 

5. Acceptable Use. End User agrees that he or she may use the Licensed Application solely in object code form in connection with End User being a client of the Firm, and will not permit, assist, facilitate or encourage others to: (a) modify, publish, translate, reverse engineer, reverse compile, disassemble, translate, or create derivative or collective works from the Licensed Application or any portion thereof; (b) copy the Licensed Application; (c) sell, resell, lease, sublicense, or otherwise distribute or grant access to third parties to the Licensed Property; (d) create malicious software products, tools, designs, instructions or technologies that negatively impact the Licensed Application’s performance, functionality, or interoperability with other applications; (e) circumvent any technological measure that controls access to the Licensed Application or any part thereof; (f) remove or obfuscate any proprietary notices or labels on the Licensed Application; or (g) use the Licensed Application for any unlawful or improper purpose. 

6. End-User Suggestions for Improvements or Functionality. If End User communicates any ideas for modifications, enhancements, functionality or improvements or any other suggestions relating to Licensed Application, End User hereby assigns to Labaton all rights, title and interest End User may have in and to any suggestions, concepts or improvement concerning the Licensed Application. 

7. End User Credentials. End User acknowledges that he or she shall be granted a username and password to access the Licensed Application for End User’s sole, exclusive and personal use, and agrees to safeguard his or her username and password and not share his or her username and password with third parties. 

8. Upgrades. Labaton may, at its sole option, without notice, update, enhance, revise or improve the Licensed Application during the term of this EULA. 

9. No Warranty. TO THE MAXIMUM EXTENT PERMITTED BY LAW, THE LICENSED APPLICATION IS PROVIDED ON AN "AS IS" AND “AS AVAILABLE” BASIS. LABATON SPECIFICALLY DISCLAIMS ALL WARRANTIES, EXPRESS OR IMPLIED, WITH RESPECT TO THE LICENSED APPLICATION, INCLUDING, WITHOUT LIMITATION, THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE OR THOSE WARRANTIES ARISING FROM A COURSE OF PERFORMANCE, AND A COURSE OF DEALING OR TRADE USAGE 

10. Limitations of Liability. TO THE MAXIMUM EXTENT PERMITTED BY LAW, AND EXCLUDING ANY LIABILITY FOR PROFESSIONAL MALPRACTICE, LABATON SHALL NOT BE LIABLE FOR (i) ANY PERSONAL INJURY, HARM, DEATH OR DISABILITY ARISING FROM END USER’S ACCESS TO OR USE OF THE LICENSED APPLICATION; OR (ii) ANY INDIRECT, INCIDENTAL, SPECIAL OR CONSEQUENTIAL DAMAGES (INCLUDING BUT NOT LIMITED TO LOSS OF PROFIT AND LOSS OF USE) ARISING FROM END USER’S ACCESS TO OR USE OF THE LICENSED APPLICATION, EVEN IF LABATON HAS BEEN PREVIOUSLY ADVISED OF THE POSSIBILITY OF SUCH DAMAGES AND NOTWITHSTANDING ANY FAILURE OF ESSENTIAL PURPOSE. 

SOME STATES DO NOT RECOGNIZE EXCLUSIONS OF OR LIMITATIONS ON IMPLIED WARRANTIES OR EXCLUSIONS OF OR LIMITATIONS ON PERSONAL INJURY DAMAGES OR INDIRECT, INCIDENTAL, SPECIAL OR CONSEQUENTIAL DAMAGES SO THE PROVISIONS SET FORTH IN PARAGRAPHS 9 AND 10 MAY NOT BE APPLICABLE TO YOU DEPENDING ON THE STATE. 

11. Indemnification. End User shall indemnify and hold Labaton harmless for all liabilities, damages, costs and expenses incurred in connection with the use by the End User of the Licensed Application including, without limitation, any breach of this EULA by End User. 

12. Governing Law. The EULA shall be governed by the laws of the State of New York, without giving effect to its conflict of laws provisions, and the venue and jurisdiction for any legal action to resolve disputes concerning this Agreement shall be in the State and/or Federal Courts of the State of New York. 

13. Termination. This EULA shall commence upon the initial acceptance click by End User and remain effective until the earlier of termination of legal representation by either party in accordance with the retainer agreement. Labaton may immediately terminate End User’s access to and use of the Licensed Application for failure to comply with this EULA. 

14. Effect of Termination. Upon any termination of this EULA, End User shall immediately cease accessing and using the Licensed Application. 

 

 

 

ATTORNEY DOCUMENT AUTHORIZATION 

By signing below, you have authorized Labaton Keller Sucharow LLP (“Labaton”), 140 Broadway, 34th Floor, New York, NY, 10005, Boies Schiller Flexner LLP (“Boies Schiller”) 55 Hudson Yards, New York, NY 10001, and Milberg Coleman Bryson Phillips Grossman PLLC (“Milberg”), 405 E 50th Street, New York, NY, 10022, (the “Firms”) to act as your legal counsel in connection with claims that you have against Instagram and certain additional parties in connection with Instagram’s addictive and psychologically harmful design. You authorize the Firms to obtain, in your name and on your behalf, any information or documents that may be contained in any file, private or public, pertaining to your dispute with Instagram including information or documents held by Instagram or third parties. This authorization is valid during such time as the Firms shall continue to act as your counsel in connection with such claims. 

                               OCA Official Form No.: 960

[AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

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:               LABATON KELLER SUCHAROW LLP, BOIES SCHILLER FLEXNER LLP, MILBERG BRYSON PHILLIPS GROSSMAN PLLC
9(a).  Specific information to be released: ✔ Medical Record from (insert date)                                          to (insert date)                                          ✔ 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. ✔ Other:                                                                                              Include: (Indicate by Initialing)                     Alcohol/Drug Treatment                                 Mental Health Information                             HIV-Related Information             Authorization to Discuss Health Information                                               (b) D✔     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: LABATON KELLER SUCHAROW LLP, BOIES SCHILLER FLEXNER LLP, MILBERG BRYSON PHILLIPS GROSSMAN PLLC   (Attorney/Firm Name or Governmental Agency Name)
10.  Reason for release of information: D✔     At request of individual D✔     Other:	11.  Date or event on which this authorization will  expire:
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.

        Signature:                                             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.

---