Client Intake Form

The Miller Firm, LLC uses Arctrieval’s service to request and manage documents, records and evidence related to your case or claim. By signing below, I understand, agree to and authorize the following:

1. Arctrieval’s Privacy Policy and Terms of Use which may be reviewed at www.Arctrieval.com.
2. The Miller Firm, LLC and Arctrieval Inc. to use my personally identifiable information, government issued identification and a digital image of my signature to obtain any and all information related to my case or claim.
3. The Miller Firm, LLC and Arctrieval Inc. to affix a digital image of my signature to documents necessary to obtain information related to my claim or case with the same authority as if I signed the document myself.
4. Information related to my case or claim may include, but is not limited to: protected health information, medical records, billing records, medical images, accident reports, repair estimates, witness statements, insurance claim information, etc…
5. My authorization and this agreement are voluntary and I may refuse to sign this form.
6. I may revoke this agreement and my authorization at any time, in writing by submitting a written revocation to:

The Miller Firm, LLC
108 Railroad Avenue
Orange, Virginia 22960


7. My revocation will take effect upon receipt, except to the extent others have already acted in reliance upon this agreement and my authorization.
8. Unless, I revoke this agreement and my authorization earlier, it will expire 24 months from the date shown below.