This is Required to Have a Lawyer Represent You in the Suboxone Dental Damage Lawsuit
Name and Contact Information
Alternate mailing address such as a PO box
Other back up email
SSN (for medical records) If you do not want to provide it, tell us you will provide it later
Social Media profile / handle name (we recommend this as a back up way to notify you if there is a payment to you)
Best Contact Time / contact instructions
Secondary/Emergency Contact Name
Suboxone Film Use
Dosage that you have been taking of the Suboxone FILM 2mg4mg8mg16mg
If your dosage changed, tell us what dosage it changed to 2mg4mg8mg16mg
Have you taken any other type of Suboxone such as the pill tablet?
If you took the Suboxone pill tablet, when did you start taking it?
If you took the Suboxone pill tablet, when did you stop taking it?
If you have not stopped taking the pill tablet please say “I’m still taking the pill tablet” here
How many times each day do / did you take the SUBOXONE TABLET?
How many times each day are you taking the SUBOXONE FILM OnceTwiceThree times
When did you have the first signs of dental damage ?
(Ohio residents only) When were you first told from a medical professional that Suboxone film was affecting your dental health?
What type of dental damage have you experienced?
Did you start taking Suboxone for pain management or opioid addiction?
Number of teeth lost 1-45-89-1213-20All
Number of teeth crumbling 1-45-89-1213-20More than 20
Number of teeth with pain 1-45-89-1213-20More than 20
Did you ever fall asleep with Suboxone film under tongue / in mouth?
Did you ever brush teeth soon after Suboxone film use?
Did you ever use unprescribed Suboxone (film or tablets)?
If you used unprescribed Suboxone film or tablet, was it before or after having a prescription for Suboxone film?
Pre-Use Suboxone Dental Care
BEFORE taking Suboxone, did you have cavities, periodontal disease or lost teeth ?
If other dental damage, please describe
Dental Care Pre-Use Provider Information
Dental Office Name or Dentist Name
Start Treatment Date
End Treatment Date
Types of treatment
How many fillings ? 1-34-910-1415 or more
How many extractions / surgery ? 1-34-910-1515 or more
Next Dental Office Name or Dentist Name
Start Treatment Date
How many fillings ?
How many extractions / surgery ?
Dental Care After Starting Suboxone (Post-Use)
What is the name of the dental office or dentist who gave you dental treatment after you started Suboxone?Provider Dental Office Name or Dentist Name
Frequency of treatment
What types of treatment have you had during the time after you started Suboxone?
End Treatment Date
Frequency of treatment One time per yearTwo times per yearThree times per yearMore than 3 times per year
Types of treatment?
ATTORNEY-CLIENT CONTINGENCY FEE RETAINER AGREEMENT
PEIFFER WOLF CARR KANE CONWAY & WISE, LLP (“Peiffer Wolf”) and LAW OFFICES OF JENNIFER DUFFY, APLC (“Duffy”), (collectively, “Attorneys”), will provide legal services to you, on the terms set forth below, provided you return a signed copy of this Agreement (“Agreement”) to Attorneys and receive a counter-signed copy from Attorneys.
SCOPE OF SERVICES: Client hereby retains and employs Attorneys to investigate and, if appropriate, pursue potential claim(s) for injuries that may have been sustained as a result of using BUPRENORPHINE-CONTAINING PRODUCTS LIKE SUBOXONE. Client authorizes Attorneys or any agent, employee, and/or other representative to investigate, represent, litigate, negotiate, incur costs, defend, and/or collect, whether by compromise or by lawsuit, any claims Client may have against any person or entity Attorneys choose to sue. Client understands and acknowledges that Attorneys WILL NOT assert any claims for medical malpractice against doctors and/or healthcare providers. Client understands that this Agreement for legal services is strictly limited to claim(s) arising out of the use of BUPRENORPHINE-CONTAINING PRODUCTS LIKE SUBOXONE only.
After investigating the potential claim(s), Attorneys shall have the right to withdraw and terminate this Agreement if they are unable or unwilling to undertake the contemplated representation. This Agreement pertains to services up and through trial. Any other services, such as post-trial appeals must be covered in a separate Agreement.
DUTIES & RESPONSIBILITIES: This is NOT a class-action case. Attorneys agree to act within all legal and ethical responsibilities imposed by law. Attorneys agree to keep Client informed on the progress of the case. Client agrees to be truthful, cooperate fully, and assist Attorneys (as needed) in the prosecution of claim(s).
Client agrees to keep Attorneys informed of Client’s current/updated contact information including phone numbers, mailing addresses, and email addresses. Client also agrees to timely respond to any communications or requests for information from Attorneys.
Client understands that he or she has a legal obligation to preserve all documents and other items (such as the product that caused alleged injuries) related to this action. “Documents” may include any written or printed materials, audio and video recordings, emails, instant messages, text messages, and any other form of electronically stored or transmitted materials. To the extent that Client is in possession of any of the above-described documents or items, Client shall make sure all necessary steps are taken to preserve them.
FEES & COSTS: Client requests a contingency fee Agreement rather than an hourly fee and grants Attorneys a lien to assure payment of fees and costs associated with any form of recovery. It is agreed and stipulated that neither the Attorneys, Client, any agent, employee, or other representative may settle, compromise, release, discontinue, or otherwise dispose of this claim or suit without confirmation or consent of the other party to this Agreement.
In consideration for the services rendered by Attorneys, Client herby assigns and transfers to Attorneys, as a lien, undivided interest in the subject matter of the claim(s) or suit in the amount of 40% of the gross recovery of claim(s).
Should local counsel, appellate counsel, settlement counsel, or other affiliated counsel be needed or used for litigation purposes only, such fees will be deducted from gross attorneys’ fees prior to split of attorneys’ fees between Attorneys. Attorneys shall have sole authority to add additional counsel to further claim(s).
Client understands and agrees that there will be a sharing of attorneys’ fees between Peiffer Wolf and Duffy with Peiffer Wolf receiving seventy percent (70%) of the fee and Duffy receiving thirty percent (30%) of the fee. Although Peiffer Wolf and Duffy are jointly responsible for the representation, Peiffer Wolf will be the lead firm handling the case and will be responsible for all or most aspects of the legal representation. Client authorizes the release of this agreement, case status, and final accounting to accountants, bookkeepers, legal consultants, marketing companies, and others who assist in furthering or administrating the law-practice business of the law firms.
Attorneys agree that any information received from Client or Client’s representatives, affiliates, or designees shall be confidential and shall not be disclosed by Attorneys to any third party, except as necessary to assist in furthering or administrating Client’s claims.
Client further agrees, in addition to the attorneys’ fees set forth above, IF AND ONLY IF there is a recovery, to be responsible for and reimburse Attorneys for all litigation expenses incurred in the claim(s) or suit, including without limitation, court costs, subpoena costs, expert fees, deposition expenses, copying, common-benefit costs, travel costs, and any other costs reasonable or necessary to advance Client claim(s). All such costs and expenses shall be deducted from any settlement out of the Client’s portion of recovery.
When Attorneys represent more than one similarly situated claimant, each Client is entitled to pay ONLY his/her proportionate share of such costs that are spent for the mutual benefit of all clients. When more than one client’s case benefits from such expenditure, said common costs shall be shared by each Client and deducted from the Client’s recovery in an equitable and proportionate manner.
Attorneys may require Client medical records to investigate and/or litigate potential claims. Attorneys can obtain Client medical records from health care providers after Client executes a medical record release, or Client can obtain medical records and provide them to Attorneys. Client can either request medical records directly from health care providers or Client can retain a personal health record (PHR) service provider to obtain the medical records. All costs associated with obtaining medical records may be advanced by Attorneys as litigation expenses.
MEDICAL LIENS: Client agrees that Attorneys may take any steps necessary towards the resolution of any medical insurer (including Medicare, Medicaid, and private insurers), disability insurer, and/or workers’ compensation insurer liens, including hiring third-party entities which will be tasked with assisting with resolving such liens. The expense of any such service shall be treated as a case cost and deducted from Client’s net recovery.
TERMINATIONS OR WITHDRAWAL OF REPRESENTATION: Client may terminate representation and/or Attorneys may withdraw from representation with written notice. Should Client discharge Attorneys, Attorneys shall nevertheless be entitled to recover the amount of fees and out-of-pocket expenses in accordance with this Agreement or allowed by law.
Should Attorneys withdraw from Client representation due to irreconcilable differences with Client or any other reason for cause and a recovery is later made, Attorneys will be entitled to recover all costs and a reasonable division of the attorneys’ fees portion based upon Attorneys’ work and services at the time of withdrawal.
LIMITATIONS PERIODS: Client understands that claim must be brought within a limited period of time or Client’s claim may be barred forever. Client agrees and acknowledges that it will take Attorneys a minimum of 120 days after the receipt of all requested information to evaluate Client’s claim(s); should the statute of limitations or any other applicable deadlines expire prior to or during the 120-day period, Client agrees to not hold Attorneys (or their associate counsel) responsible for any consequence related to the deadline expirations. Client further agrees to hold Attorneys’ harmless for any failure to timely file Client’s claim if Client has failed to provide this signed Agreement and/or any documents/information requested by Attorneys. If Attorneys determine that the relevant statute of limitations to file Client’s claim has passed, then Client understands that Attorneys may terminate representation.
POWER OF ATTORNEY: Client grants Attorneys the power of attorney to execute all documents connected with the claim for the prosecution of which Attorneys are retained, including pleadings, contracts, checks or drafts, settlement agreements, compromises, releases, verifications, dismissals, and orders, as well as all other documents which Client could properly execute.
DEATH: In the event that Client dies before the claim contemplated by this Agreement is resolved, the Agreement is binding on and shall inure to the benefit of Client’s heirs, successors, or beneficiaries, and the personal representative of the Client’s estate. Should it become necessary to retain counsel to open probate proceedings, the expenses of such counsel shall be borne by Client.
CONSENT TO USE: Client expressly consents to Attorneys’ use of public filings or proceedings, or summaries of them, for its marketing or advertising purposes as Attorneys deems appropriate.
CONSENT TO CONTACT BY TEXT AND PHONE: Client provides Attorneys and their designees and agents express permission and authorization to send text messages and automated calls to the number or numbers Client provides to Attorneys or their agents during the intake process and thereafter. Client represents that he or she is the subscriber of those numbers and has the authority to give such consent. By executing this Agreement, Client authorizes Attorneys to deliver or cause to be delivered to Client telemarketing calls using an automatic telephone dialing system or an artificial or prerecorded voice. Client is not required to provide this authorization. If Client does not wish to receive text messages or automated calls, please email Attorneys at [email protected].
THE PARTIES HAVE READ AND UNDERSTAND THE TERMS AND CONDITIONS OF THIS AGREEMENT. THE PARTIES AGREE TO THESE TERMS AND CONDITIONS, AS OF THE DATE ATTORNEYS FIRST PROVIDED SERVICES. IF MORE THAN ONE CLIENT SIGNS BELOW, EACH AGREES TO BE JOINTLY AND SEVERALLY LIABLE FOR ALL OBLIGATIONS UNDER THIS AGREEMENT. THE CLIENT SHALL RECEIVE A FULLY EXECUTED DUPLICATE OF THIS AGREEMENT.
On behalf of PEIFFER WOLF CARR KANE CONWAY & WISE, LLP and LAW OFFICES OF JENNIFER DUFFY, APC.
Attorney Signature: Signature on following page
Laurin M. Jacobsen, Esq. PEIFFER WOLF
Attorney Signature: Signature on following page
Jennifer Duffy, Esq. LAW OFFICES OF JENNIFER DUFFY, APC
Client Signature: Signature on following page
Client Name (Printed):
Client Phone Number:
Client Email Address:
NOTICE TO CLIENT REGARDING PRESERVATION, ATTORNEY-CLIENT PRIVILEGE, AND COMMUNICATIONS
During our representation:
I HAVE READ AND UNDERSTAND THESE WARNINGS AND THIS ADVICE.
Printed Name Signature on following page Date
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS AND/OR POLICE RECORDS, INCLUDING CONFIDENTIAL RECORDS - HIPAA COMPLIANT
I hereby request and authorize you to release to, confer orally, and/or permit inspection and copying to:
of any and all information including but not limited to the official personnel file, police records, employment records, financial records, billing records, death certificates, medical history and records of any kind including charts, records, reports, histories, laboratory studies, notes, x-rays and/or out-patient records including psychology or psychiatric treatment records, all chest x-rays, CT scans, cytology, pathology (including all slides and paraffin blocks), PFT data and printouts pertaining to
Date of Birth
Social Security Number If you do not want to provide social security number contact our office at [email protected] to speak to the staff
for purposes of review, evaluation and evidence in connection with a personal injury lawsuit.
This authorization is given in compliance with the Federal Confidentiality Law (21 U.S.C. Section 1175, 42 CFR Subsection 2.1-2.67.1 and Health and Safety Code Section 199.21(g) and California Civil Code Section 56 et seq.) and specifically allows release of alcohol, drug, psychiatric, sickle cell anemia information and/or HIV test results which are not unequivocally negative.
This authorization is given in compliance with the Federal Privacy Act (5 U.S.C. §552a(b)) and the California Confidentiality of Medical Information Act (C.C. Subsection 56.10, et seq.), the restrictions of which have been specifically considered and are hereby expressly waived. A photocopy of this authorization shall be valid as the original. The personal medical information authorized to be released in response to this authorization may be re-disclosed to other parties and may no longer be protected by law. Refusal to authorize disclosure of personal medical information will have no effect on enrollment, eligibility for benefits, or the amount paid for the health services received.
A photocopy of this authorization shall be considered as effective and valid as the original. This authorization shall remain valid until the final termination of any action filed by the undersigned relating to the personal injury lawsuit. It is subject to revocation at any time, in writing, except to the extent it has already been acted upon.
Sec.2, Section 1158 is added to the Evidence Code to read:
Paragraph 1158: “Whenever, prior to the filing of any action an attorney at law presents a written authorization therefore signed by a patient, or in the case of a minor then by a parent or guardian of such minor, or by the personal representative or an heir of a deceased patient, a physician and surgeon, dentist, registered nurse, dispensing optician, registered physician therapist, podiatrist, licensed psychologist, osteopath, chiropractor, clinical laboratory bioanalyst, clinical laboratory technologist, or pharmacist or pharmacy, duly licensed as such under the laws of the state, or licensed hospital, shall make all of the patient’s records under his, hers or its custody or control available for inspection and copying by the attorney …
Failure to make the records available, during business hours, within five days after the presentation of the written authorization, any subject the person or entity having custody or control of the records to liability for all reasonable expenses, including attorney’s fees, incurred in any proceeding to enforce this section.
I have received a copy of this authorization.
Signature to follow below
Patient Access Reference Number:
Re: Patient Name:
I, , am hereby submitting a request for access to my Designated Record Set (DRS), or that of a DRS I am entitled to access. I am requesting electronic copies for personal use, instructing that the DRS be released directly to me using one of the options provided below.
I am specifically requesting copies of complete electronic records, and to be as clear as possible, I am requesting electronic copies of all records, the entire DRS including PHI that is sensitive in nature such as HIV, drug/alcohol or mental health, hospital records, physicians’ records, surgeons’ records, consultation records, pre/post/all operative reports, physical therapy and other therapy records, x-ray(s), CT scan, MRI, PET scan and reports or any other diagnostic studies; pathology, slides and laboratory reports; billing statements and full patient ledger, UB04 and HICFA forms, patient information and history questionnaire; physicals and history; discharge summary; progress notes; prescriptions and medication administration; nurses’ notes; product ID/Implant stickers and serial numbers, anesthesia and pain management, correspondence; consent for treatment; and any other materials whether wri9en or stored, created or maintained in any other format, including documents, records and correspondence received from or that were created by another healthcare provider (i.e. ALL secondary or outside records).Omit NOTHING from the DRS.
Please complete the attached certi cation so I know you released my entire DRS. It only takes a moment to complete, and it will avoid me having to start this process all over again. Thank you!
I request a FULL DRS between the dates: January 1, 2000 and presentJanuary 1, 2010 and presentJanuary 1, 2015 and presentJanuary 1, 2020 and present regarding
I instruct delivery of the requested DRS be made to me directly using either of the following digital and secure options. I agree to receive this delivery by email, regardless of security risk.
My Secure Upload (PREFERRED): h9ps://chartsquad.com/chartdrop/
My personal, secure PHR email:
Thank you in advance for helping me access these records and supporting patient rights! Please know that I greatly appreciate the time and energy it requires for you to provide this information.
Federal law requires you to act on this request within THIRTY (30) DAYS, regardless of any fees required for release of information or services rendered. See 45 C.F.R. § 164.524(b)(2).
This is a direct access letter to request the release of a Designated Record Set (DRS) as de ned by HIPAA. You may not require me to complete and sign any other authorization, and you are required by federal law to accept this access request in compliance with HIPAA and HITECH.
You have my full permission to discuss all aspects of this access request, including ful llment and payments, with my PHR service provider, ChartSquad.
Please, do not mail anything to my home. Deliver it to me via my secure PHR. You may also deliver your compliant invoices to my PHR if you require a fee to release records. I will pay HIPAA compliant invoices via my PHR portal, securely and promptly.
I hereby instruct all Covered Entities who receive this access request to deliver records to me directly at my PHR account in electronic format promptly and securely. Mailing any records via mail carrier is not a secure method of delivery.
I have full and private control of my PHR account, meaning delivery to my PHR is coming directly to me, the patient. This is NOT a third- party request.
PLEASE, DO NOT MAIL RECORDS
Directly from guidance provided by the HHS and OCR: “We note that a covered entity (or a business associate) may not circumvent the access fee limitations by treating individual requests for access like other HIPAA disclosures – such as by having an individual fill out a HIPAA authorization when the individual requests access to her PHI (including to direct a copy of the PHI to a third party).”
Relationship to Patient
Signature of Patient or Personal Representative
By signing this document, I agree I have received a copy of this authorization and request for Designated Record Set.
By signing this document, I agree to the NOTICE TO CLIENT REGARDING PRESERVATION, ATTORNEY-CLIENT PRIVILEGE, AND COMMUNICATIONS.
By signing this document, I agree I have read and agree to the ATTORNEY-CLIENT CONTINGENCY FEE RETAINER AGREEMENT.
By signing this document, I agree to the AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS AND/OR POLICE RECORDS, INCLUDING CONFIDENTIAL RECORDS - HIPAA COMPLIANT
Leave this empty:
Your legal name
Your email address
Signed by Law Offices of Jennifer Duffy
Signed On: December 5, 2023
If you have questions about the contents of this document, you can email the document owner.
Document Name: This is Required to Have a Lawyer Represent You in the Suboxone Dental Damage Lawsuit
Agree & Sign