DocuSign Envelope ID: AF357139-5EEF-4886-8A1D-09C92DA61802
FEE AGREEMENT
REPRESENTATION: I hereby employ The Law Office of Benjamin Misko, L.L.C., its Contract Attorneys, and
office assistants to represent me before the Social Security Administration (SSA) in my Social Security Disability
case, Supplemental Security Income (SSI) case, or both, subject to the terms of this agreement:
1. I will pay no fee at all unless I win my case.
2. We agree that if SSA favorably decides my claim at any point through the initial, reconsideration, hearing levels,
Social Security will pay my attorney, directly (via Social Security directly withholding) a maximum fee of the lower
of (a) 25% of past-due benefits, or (b) Six Thousand Dollars ($6,000.00), or the maximum amount set by the
Commissioner pursuant to 42 U.S.C. Section 406(a), even if it changes after signing of this agreement, but before
approval for benefits.
3. We agree that if SSA favorably decides my claim at the Appeals Council level; or at the ALJ hearing level after a
decision by the Appeals Council or Federal Court; or if a Federal Court favorably decides my case, I will pay my
attorney a fee equal to 25% of all past due benefits in my SSDI and/or SSI disability claims.
4. We understand that Social Security attorneys’ fees include, when applicable, 25% of any back due benefits owed
to my family members and other eligible dependents. Dependents are not always eligible.
5. In addition to the attorney fee, if the Law Offices of Benjamin Misko, LLC. has to incur any expenses in
conjunction with this disability claim, e.g., pay my doctors or hospitals for reports and copies of medical records, I
will repay these costs after I win my case and only if I win my case.
6. This agreement only governs the first three “stages” of the Social Security Disability process and my attorney has
not committed himself to pursue the matter in Federal Court.
7. I have not been promised I will win my case.
8. We agree that I the claimant authorize The Law Offices of Benjamin Misko, LLC to make reasonable attempts to
work with and communicate with family, friends, neighbors, medical providers, case workers, etc. should they be
unable to communicate with me or for the overall betterment of my claim. If there is anyone I wish for them not to
communicate with, I will advise them of such.
9. The attorney has the right to withdraw as representative at any level in the claim for any reason including, but
not limited to, lack of client cooperation, questionable claim merits or conflict of interest.
______________________ Date:__________ Maritza Gantes Ayala
For: The Law Offices of Benjamin Misko, LLC Client- Print Name
7/9/2021
________________________ Date:___________
Page 1 of 1
DocuSign Envelope ID: AF357139-5EEF-4886-8A1D-09C92DA61802
Social Security Administration Form Approved
Please read the instructions before completing this form. OMB No. 0960-0527
Name (Claimant) (Print or Type) Social Security Number
Maritza Gantes Ayala 664-12-6650
Wage Earner (If Different) Social Security Number
Part I APPOINTMENT OF REPRESENTATIVE
I appoint this person, Benjamin Misko, 1340 Poydras St. Suite 2030, New Orleans LA 70112
(Name and Address)
to act as my representative in connection with my claim(s) or asserted right(s) under:
Title II Title XVI Title XVIII Title VIII
(RSDI) (SSI) (Medicare Coverage) (SVB)
This person may, entirely in my place, make any request or give any notice; give or draw out evidence or
information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s).
I authorize the Social Security Administration to release information about my pending claim(s) or asserted
right(s) to designated associates who perform administrative duties (e.g. clerks), partners, and/or parties
under contractual arrangements (e.g. copying services) for or with my representative.
I appoint, or I now have, more than one representative. My main representative is
.
(Name of Principal Representative)
Signature (Claimant) Address
5110 Ames Blvd., Lot 31, Marrero, LA 70072
Telephone Number (with Area Code) Fax Number (with Area Code) Date
7/9/2021
(504) 427-6869
Part II ACCEPTANCE OF APPOINTMENT
I, Benjamin Misko , hereby accept the above appointment. I certify that I
have not been suspended or prohibited from practice before the Social Security Administration; that I am not
disqualified from representing the claimant as a current or former officer or employee of the United States;
and that I will not charge or collect any fee for the representation, even if a third party will pay the fee, unless it
has been approved in accordance with the laws and rules referred to on the reverse side of the
representative's copy of this form. If I decide not to charge or collect a fee for the representation, I will notify
the Social Security Administration. (Completion of Part III satisfies this requirement.)
Check one: I am an attorney. I am a non-attorney eligible for direct payment under SSA law.
I am a non-attorney not eligible for direct payment.
I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted
to practice as an attorney. Yes No
I am now or have previously been disqualified from participating in or appearing before a Federal program or
agency. Yes No
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge.
Signature (Representative) Address
1340 Poydras Street, Suite 2030
Telephone Number (with Area Code) Fax Number (with Area Code) Date
(504) 483-9102 (504) 482-6153
Part III FEE ARRANGEMENT
(Select an option, sign and date this section.)
Charging a fee and requesting direct payment of the fee from withheld past-due benefits.(SSA must authorize the
fee unless a regulatory exception applies.
Charging a fee but waiving direct payment of the fee from withheld past-due benefits --I do not qualify for or do not
request direct payment. (SSA must authorize the fee unless a regulatory exception applies.)
Waiving fees and expenses from the claimant and any auxiliary beneficiaries --By checking this block I certify
that my fee will be paid by a third-party, and that the claimant and any auxiliary beneficiaries are free of all liability, directly
or indirectly, in whole or in part, to pay any fee or expenses to me or anyone as a result of their claim(s) or asserted
right(s). (SSA does not need to authorize the fee if a third-party entity or a government agency will pay from its funds the
fee and any expenses for this appointment. Do not check this block if a third-party individual will pay the fee.)
Waiving fees from any source --I am waiving my right to charge and collect any fee, under sections 206 and
1631(d)(2) of the Social Security Act. I release my client and any auxiliary beneficiaries from any obligations, contractual
or otherwise, which may be owed to me for services provided in connection with their claim(s) or asserted right(s).
Signature (Representative) Date
Form SSA-1696-U4 (03-2011) ef (03-2011) TAKE OR SEND ORIGINAL TO SSA AND RETAIN A COPY FOR YOUR RECORDS
Destroy Prior Editions (4 copies: File, Claimant, Representative, ODAR)
DocuSign Envelope ID: AF357139-5EEF-4886-8A1D-09C92DA61802
***Pursuant to a Social Security Disability Request***
AUTHORIZATION TO USE OR DISCLOSE
PROTECTED HEALTH INFORMATION
I hereby authorize ________________________________use or disclose the following protected
health information (PHI) from the medical records of the patient listed below to:
Requestor Name: The Law Offices of Benjamin Misko, LLC
Requestor Address: 1340 Poydras Street, Suite 2030, New Orleans, LA 70112
Patient Name: Ms. Maritza Gantes Ayala
Patient DOB: 1/5/1966
Patient Social Security Number: 664-12-6650
Disclose the following PHI for treatment dates ______________to _________________: Any and all
medical records including the Entire Chart; Abstract/Pertinent; History & Physical; Discharge Summary;
Consult; Operative Report; Progress Notes; Physician Orders; Nurses Notes; ER Report; and Lab; X-ray,
prescriptions, psychiatric or psychological evaluations, CT scans, MRI’s, EMG, xray, MRI, CT and any
other diagnostic films as well as billing records.
This authorization shall expire upon this expiration date: December 31, 2022. If I fail to specify an
expiration date or event, this authorization will expire six (6) months from the date on which it was signed.
My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this
authorization.
I understand that I have the right to revoke this authorization at any time. I understand that I must do so in
writing and present the written revocation to my attorney, Ben Misko. I understand that the revocation will
not apply to information that has already been released to this authorization.
The information used or disclosed pursuant to the authorization may be subject to redisclosure by the
recipient and no longer protected. Permission is further granted to honor a photostatic copy of this
authorization. I may refuse to sign this authorization and it is strictly voluntary. I have the right to receive a
copy of this form after I execute it.
I have read the above and authorize the disclosure of the protected health information as stated.
7/9/2021
_____________________________ __________________
Patient Signature Date
