Medicaid Disclosure Form

Whereas the client wishes to retain the services of Burgos & Brein Wealth Management, LLC to assist in the Medicaid application process to obtain a determination of Medicaid eligibility in the State of Florida.

The following services will be provided by Burgos & Brein Wealth Management, LLC

• Provide client with a list of needed documents/information required to complete the Medicaid application.
• Complete and review the application and all materials.
• Submit completed application and all materials.

IT IS AGREED:

• LEGAL ADVICE & LEGAL WORK: Client understands that Burgos & Brein Wealth Management, LLC is not a law firm and does not give legal advice. Any Medicaid strategies for asset protection or legal documents must be advised & drafted by a Florida licensed attorney. If you do not have an attorney, Burgos & Brein Wealth Management, LLC will provide you with a referral.
• EXPENSES: Client is responsible for payment of all expenses which may be incurred in connection with the Medicaid application. This includes and not limited to Attorney Fees. Client will be advised of any fees before they are incurred.
• CLIENT OBLIGATION: Client acknowledges that Burgos & Brein Wealth Management, LLC will be unable to provide meaningful assistance in obtaining a determination of Medicaid eligibility without the client’s full and timely cooperation. Client agrees to provide such complete and timely cooperation.
• AGREEMENT: This agreement constitutes the entire agreement between parties. This agreement may only be terminated, modified, or changed by an agreement in writing, signed by both parties. This agreement may not be assigned by either party. It is agreed and understood that no guarantees, assurances or promises have been made as to the client’s eligibility for Medicaid, or as to the success or outcome of said application. This agreement shall be governed by the laws of the State of Florida, without regard to principals of conflicts of law.
• DISPUTES: All disputes arising in connection with this agreement shall first be mediated or arbitrated, if a settlement cannot be reached, the matter will be brought forth to a court of competent jurisdiction, in Seminole County, Florida. The prevailing party in the dispute, will be entitled to all attorney fees. Client acknowledges that they have entered into this agreement voluntarily and have received a signed and dated copy hereof.

By their signatures below, the parties agree to the terms of the agreement set forth herein.