## COMPOSITE
# EXHIBIT 7
(File Under Seal)
From: Erika Sent: Friday, April 29, 2016 6:19 PM To: Imenninger@hmflaw.com; jiiia@hmflaw.com Cc: Sigrid McCawley; Meredith Subject: v. Maxwell, Case no. 15-cv-07433-RWS Attachments: 2016-04-29 Supp. Response Letter to Counsel re April 25, 2016 Letter.pdf; Releases.pdf; GIUFFRE5350.pdf; GIUFFRE5351-5353.pdf; GIUFFRE5339-5341.pdf; GIUFFRE5342-5346.pdf, GIUFFRE5347-5349.pdt 2016-04-29 Second Amended Supplemental Responses and Objections.pdf; 2016-04-29 Revised Supplemental Privilege Log.pdf
Dear Counsel,
Please see attached Correspondence from Sigrid McCawley.
Thank you.
ERIKA LEGAL ASSISTANT IiOa ELL \\ \\ LEI 401 E. Las Olas Blvd.. Suite 12(X) Fort Lauderdale. FL 33301-2211 Telephone: 954-356-0011 Facsimile: 954.356.0022
4th EA5 Cl AS 50..LEVARD • SUITE I200. FC" T \_AL:DERDALE, FL 333012211• PH 954.356 00 I • FAX 954 356 0022
Sigrid S. McCawley, Esq. E-mail: smccawley@bsflIp.com
April 29, 2016
#### Via Electronic Mail
Laura A. Menninger, Esq. Jeffrey Paglitoi. HADDON, &a, P.C. 150 East 10 Avenue Denver, Colorado 80203
> Re: v. Maxwell, Case no. 15-ev-07433-RWS
Dear Ms. Menninger:
As a follow-up to my April 27, 2016 letter, I am providing you today with copies of the releases you requested as follows:
- Release for U.S. Tax and Australian Tax Records;
- Releases for any additional school records;
- Releases for the eight requested employers;
Kindly provide us with any copies of materials you receive in response to these Releases. All documents should be treated as Confidential until we have had an opportunity to review and any social security information should be redacted and not disclosed to anyone.
In addition, we are nroviding you with additional retainer letters from Counsel that have represented labelled Giuffit005350-Giuffre005353.
We are providing herewith additional medical records that we received, labelled Giuffre005339 - Giuffre005349.
Finally, we are providing you with Responses to Interrogatories 1, 3, 4, 9, and 12 as set forth in the Second Amended Supplemental Responses and Objections to Defendant's Fi f Discovery Requests, attached hereto. We expect to be able to provide you with verification page on Monday. We have also included a revised supplemental privilege log.
Letter to Laura Menninger, Esq. and Jeffrey Pagliuca, Esq.\
April 29, 2016\
Page 2
SSM:ep\
Enclosures
| Student Name:
Virginia Guiffre (formerly [REDACTED]) | |
| -------------------------------------------------------------- | --- |
| [REDACTED] | |
| [REDACTED] | |
| Telephone | |
The Family Educational Rights and Privacy Act of 1974, as amended, protects the privacy of educational records, establishes the rights of students to inspect and review their educational records, and provides guidelines for the correction of inaccurate or misleading data through informal and formal hearings. This release applies to the disclosure of educational records.
I hereby authorize Survivors Charter School to release the education records of Virginia Guiffre (formerly [REDACTED])
**To: Laura Menninger, HADDON, [REDACTED] & [REDACTED], PC, 150 East 10th Avenue, Denver, CO 80203. Tel: 303-831-7364; Fax: 303-832-2628**
These records are being released for the purpose of litigation in the case captioned *Virginia Guiffre v. Ghislaine Maxwell*, 15-CV-07433-RWS, in the United States District Court for the Southern District of New York.
The authorization includes all information in my educational records, including truancy records, attendance records, disciplinary records, grades, house, classes, financial information, graduation records, or any other records or information relating to my attendance at this educational facility.
\*\*\*\*\*
The above information will be released with my full consent. I understand that this authorization remains in effect unless specifically revoked. It will be necessary to send a written letter to revoke this authorization prior to the expiration date I have indicated, if I choose to end it sooner.
*[Handwritten signature and initials]*
Virginia Guiffre (file/a [REDACTED]) - Student Allowing Release of Information
**Student Name:**
Virginia Guiffre (formerly Virginia Roberts)
[Redacted Student Name]
[Redacted Student Name] Telephone
The Family Educational Rights and Privacy Act of 1974, as amended, protects the privacy of educational records, establishes the rights of students to inspect and review their educational records, and provides guidelines for the correction of inaccurate or misleading data through informal and formal hearings. This release applies to the disclosure of educational records.
I hereby authorize [Redacted] Palm Beach Community High School to release the education records of Virginia Guiffre (formerly [Redacted])
**To: Laura Menninger, HADDON, [Redacted] & [Redacted], PC, 150 East 10th Avenue, Denver, CO 80203. Tel: 303-831-7364; Fax: 303-832-2628**
These records are being released for the purpose of litigation in the case captioned *Virginia Guiffre v. Ghislaine Maxwell*, 15-CV-07433-RWS, in the United States District Court for the Southern District of New York.
The authorization includes all information in my educational records, including truancy records, attendance records, disciplinary records, grades, house, classes, financial information, graduation records, or any other records or information relating to my attendance at this educational facility.
\*\*\*\*\*
The above information will be released with my full consent. I understand that this authorization remains in effect unless specifically revoked. It will be necessary to send a written letter to revoke this authorization prior to the expiration date I have indicated, if I choose to end it sooner.
Virginia Guiffre (f/k/a [Redacted]) - Student Allowing Release of Information
| Student Name:
Virginia Guiffre (formerly [REDACTED]) | |
| -------------------------------------------------------------- | --------- |
| [REDACTED] | Telephone |
The Family Educational Rights and Privacy Act of 1974, as amended, protects the privacy of educational records, establishes the rights of students to inspect and review their educational records, and provides guidelines for the correction of inaccurate or misleading data through informal and formal hearings. This release applies to the disclosure of educational records.
I hereby authorize Forest [REDACTED] High School to release the education records of Virginia Guiffre (formerly [REDACTED])
**To: Laura Menninger, HADDON, [REDACTED] & [REDACTED], PC, 150 East 10th Avenue, Denver, CO 80203. Tel: 303-831-7364; Fax: 303-832-2628**
These records are being released for the purpose of litigation in the case captioned *Virginia Guiffre v. Ghislaine Maxwell*, 15-CV-07433-RWS, in the United States District Court for the Southern District of New York.
The authorization includes all information in my educational records, including truancy records, attendance records, disciplinary records, grades, house, classes, financial information, graduation records, or any other records or information relating to my attendance at this educational facility.
\*\*\*\*\*
The above information will be released with my full consent. I understand that this authorization remains in effect unless specifically revoked. It will be necessary to send a written letter to revoke this authorization prior to the expiration date I have indicated, if I choose to end it sooner.
\_\_\_\_\_\
Virginia Guiffre (f/k/a [REDACTED]) - Student Allowing Release of Information
| Student Name:
Virginia Guiffre (formerly [REDACTED]) | |
| -------------------------------------------------------------- | --- |
| [REDACTED] | |
| [REDACTED] | |
| Telephone | |
The Family Educational Rights and Privacy Act of 1974, as amended, protects the privacy of educational records, establishes the rights of students to inspect and review their educational records, and provides guidelines for the correction of inaccurate or misleading data through informal and formal hearings. This release applies to the disclosure of educational records.
I hereby authorize Crestwood Middle School to release the education records of Virginia Guiffre (formerly [REDACTED])
**To: Laura Menninger, HADDON, [REDACTED] & [REDACTED], PC, 150 East 10th Avenue, Denver, CO 80203. Tel: 303-831-7364; Fax: 303-832-2628**
These records are being released for the purpose of litigation in the case captioned *Virginia Guiffre v. Ghislaine Maxwell*, 15-CV-07433-RWS, in the United States District Court for the Southern District of New York.
The authorization includes all information in my educational records, including truancy records, attendance records, disciplinary records, grades, house, classes, financial information, graduation records, or any other records or information relating to my attendance at this educational facility.
\*\*\*\*\*
The above information will be released with my full consent. I understand that this authorization remains in effect unless specifically revoked. It will be necessary to send a written letter to revoke this authorization prior to the expiration date I have indicated, if I choose to end it sooner.
*[Handwritten signature]*\
Virginia Guiffre (f/k/a [REDACTED]) - Student Allowing Release of Information
| Employees Name:
Virginia Guiffre (formerly [REDACTED] ) | | [REDACTED] |
| ----------------------------------------------------------------------------------------------------------------------------- | --- | ---------------------------------------------------------------------- |
| | | Telephone |
| | | [REDACTED] |
I hereby authorize Roadhouse Grill to release information from the employment, payroll, workers compensation, and personnel records of Virginia Guiffre (formerly UM
To: Laura Menninger, HADDON,11.&fflp PC, 150 East 101° Avenue, Denver, CO 80203. Tel: 303-831-7 ; ax: 3
These records are being released for the purpose of litigation in the case captioned Virginia Guiffre v. Ghislaine Maxwell, 15-CV-07433-RWS, in the United States District Court for the Southern District of New York.
I specifically authorize the release of the following: all employment applications, payroll/salary records, letters of commendation or discipline, performance evaluation, vacation records, absenteeism records, medical records, requests for accommodations, and/or any and all records in my personnel files, however maintained.
This authorization is valid until the 180 day after it is signed, unless it is otherwise revoked.
The undersigned, have read and authorize the release of such information as herein contained. I have the right to revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon it. I understand that when this information is used to disclose pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless the above named facility and its parent company from all liability and damages resulting from the lawful release of my protected health information.
Date 01 I Itb
Employees Name:
Virginia Guiffre (former))
I hereby authorize Mar-A-Lano Resort & Spa to release information from the employment, payroll, workers compensation, and personnel records of Virginia Guiffre (formed
To: Laura Menninger, HADDON,Mill PC, 150 East 10th Avenue, Denver, CO 80203. Tel: 303-831-7364; Fax: 303-832-2628
These records are being released for the purpose of litigation in the case captioned Virginia Guiffre v. Ghislaine Maxwell, 15-CV-07433-RWS, in the United States District Court for the Southern District of New York.
I specifically authorize the release of the following: all employment applications, payroll/salary records, letters of commendation or discipline, performance evaluation, vacation records, absenteeism records, medical records, requests for accommodations, and/or any and all records in my personnel files, however maintained.
th This authorization is valid until the 180 day after it is signed, unless it is otherwise revoked.
The undersigned, have read and authorize the release of such information as herein contained. I have the right to revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon it. I understand that when this information is used to disclose pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless the above named facility and its parent company from all liability and damages resulting from the lawful release of my protected health information.
Date O )(2% ko
| Employees Name:
Virginia Guiffre (formerly [REDACTED]) | | [REDACTED] |
| ---------------------------------------------------------------- | --- | ---------- |
| | | Telephone |
| | | [REDACTED] |
I hereby authorize Manpower Logistics to release information from the employment, payroll, workers compensation, and personnel records of Virginia Guiffre (formerly 1
To: Laura Menninger, HADDON,3111 &111. PC, 150 East 10th Avenue, Denver, CO 80203. Tel: 303-831-7 ; as: 3
These records are being released for the purpose of litigation in the case captioned Virginia Guiffre v. Ghislaine Maxwell, 15-CV-07433-RWS, in the United States District Court for the Southern District of New York.
I specifically authorize the release of the following: all employment applications, payroll/salary records, letters of commendation or discipline, performance evaluation, vacation records, absenteeism records, medical records, requests for accommodations, and/or any and all records in my personnel files, however maintained.
ih This authorization is valid until the 180 day after it is signed, unless it is otherwise revoked.
The undersigned, have read and authorize the release of such information as herein contained. I have the right to revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon it. I understand that when this information is used to disclose pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless the above named facility and its parent company from all liability and damages resulting from the lawful release of my protected health information.
Date 0(4 ) a% II°
| Employees Name: Virginia Guiffre (formerly [REDACTED])
| [REDACTED] |
| -------------------------------------------------------------------- | ---------- |
| Telephone | [REDACTED] |
I hereby authorize Mannwav Logistics to release information from the employment, payroll, workers compensation, and personnel records of Virginia Guiffre (formerly
To: Laura Menninger, HADDON, Denver, CO 80203. Tel: 303-831-7364; Fax: 303-832-2628 PC, 150 East it Avenue,
These records are being released for the purpose of litigation in the case captioned Virginia Guiffre v. Ghislaine Maxwell, 15-CV-07433-RWS, in the United States District Court for the Southern District of New York.
1 specifically authorize the release of the following: all employment applications, payroll/salary records, letters of commendation or discipline, performance evaluation, vacation records, absenteeism records, medical records, requests for accommodations, and/or any and all records in my personnel files, however maintained.
th This authorization is valid until the 180 day after it is signed, unless it is otherwise revoked.
The undersigned, have read and authorize the release of such information as herein contained. I have the right to revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon it. I understand that when this information is used to disclose pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless the above named facility and its parent company from all liability and damages resulting from the lawful release of my protected health information.
Date 04 I a.8 1 ty
| Employees Name:
Virginia Guiffre (formerly [REDACTED] ) | | |
| ----------------------------------------------------------------------------------------------------------------------------- | --- | --------- |
| | | Telephone |
I hereby authorize Indigo Bar & Grill to release information from the employment, payroll, workers compensation, and personnel records of Virginia Guiffre (formerly '
To: Laura Menninger, HADDON,311 1& PC, 150 East it Avenue, Denver, CO 80203. Tel: 303-831-7 ; ax:
These records are being released for the purpose of litigation in the case captioned Virginia Guiffre v. Ghislaine Maxwell, 15-CV-07433-RWS, in the United States District Court for the Southern District of New York.
I specifically authorize the release of the following: all employment applications, payroll/salary records, letters of commendation or discipline, performance evaluation, vacation records, absenteeism records, medical records, requests for accommodations, and/or any and all records in my personnel files, however maintained.
This authorization is valid until the 180 day after it is signed, unless it is otherwise revoked.
The undersigned, have read and authorize the release of such information as herein contained. I have the right to revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon it. I understand that when this information is used to disclose pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless the above named facility and its parent company from all liability and damages resulting from the lawful release of my protected health information.
Date 61 1g g
| Employees Name: Virginia Guiffre (formerly [REDACTED]) | Telephone |
| ------------------------------------------------------------- | ---------------- |
| [REDACTED] | |
I hereby authorize Gemma Catering/Weddina Receptions to release information from the employment, payroll, workers compensation, and personnel records of Virginia Guiffrc (formerly
To: Laura Menninger, HADDON, & PC, 150 East 101" Avenue, Denver, CO 80203. Tel: 303-831-7364; Fax: 303.832-2628
These records are being released for the purpose of litigation in the case captioned Virginia Guiffre v. Ghislaine Maxwell, 15-CV-07433-RWS, in the United States District Court for the Southern District of New York.
I specifically authorize the release of the following: all employment applications, payroll/salary records, letters of commendation or discipline, performance evaluation, vacation records, absenteeism records, medical records, requests for accommodations, and/or any and all records in my personnel files, however maintained.
This authorization is valid until the 180 day after it is signed, unless it is otherwise revoked.
The undersigned, have read and authorize the release of such information as herein contained. I have the right to revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon it. I understand that when this information is used to disclose pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless the above named facility and its parent company from all liability and damages resulting from the lawful release of my protected health information.
Date 64 6%
Signature of Employee: \\Id5C)
| Employees Name: Virginia Guiffre (formerly [REDACTED]) | |
| ------------------------------------------------------------- | --- |
| | |
| | |
| Telephone | |
| | |
| | |
I hereby authorize Employment Training and Recruitment Australia to release information from the employment, payroll, workers compensation, and personnel records of Virginia Guiffre (formerly
To: Laura Menninger, HADDON, & PC, 150 East 10d' Avenue, Denver, CO 80203. Tel: 303-831-7364; Fax: 303-832-2628
These records are being released for the purpose of litigation in the case captioned Virginia Guiffre v. Ghislaine Maxwell, 15-CV-07433-RWS, in the United States District Court for the Southern District of New York.
I specifically authorize the release of the following: all employment applications, payroll/salary records, letters of commendation or discipline, performance evaluation, vacation records, absenteeism records, medical records, requests for accommodations, and/or any and all records in my personnel files, however maintained.
th This authorization is valid until the 180 day after it is signed, unless it is otherwise revoked.
The undersigned, have read and authorize the release of such information as herein contained. I have the right to revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon it. I understand that when this information is used to disclose pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless the above named facility and its parent company from all liability and damages resulting from the lawful release of my protected health information.
Date6'/Jab 1n0
Signature of l'Anployee: \\ii
| Employees Name: Virginia Guiffre (formerly [REDACTED]) | |
| ------------------------------------------------------------- | --- |
| | |
| | |
| Telephone | |
| | |
| | |
I hereby authorize Calmao Flamenco Bar & Restaurant to release information from the employment, payroll, workers compensation, and personnel records of Virginia Guiffre (formerly
To: Laura Menninger, HADDON, Denver, CO 80203. Tel: 303-831-7364; Fax: 303-832-2628 PC, 150 East 10lb Avenue,
These records are being released for the purpose of litigation in the case captioned Virginia Guiffre v. Ghislaine Maxwell, 15-CV-07433-RWS, in the United States District Court for the Southern District of New York.
I specifically authorize the release of the following: all employment applications, payroll/salary records, letters of commendation or discipline, performance evaluation, vacation records, absenteeism records, medical records, requests for accommodations, and/or any and all records in my personnel files, however maintained.
ih This authorization is valid until the 180 day after it is signed. unless it is otherwise revoked.
The undersigned, have read and authorize the release of such information as herein contained. I have the right to revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon it. I understand that when this information is used to disclose pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless the above named facility and its parent company from all liability and damages resulting from the lawful release of my protected health information.
Date 04 / 28 )4.
| Student Name:
Virginia Guiffre (formerly Virginia Roberts) | |
| -------------------------------------------------------------------- | --------- |
| | Telephone |
The Family Educational Rights and Privacy Act of 1974, as amended, protects the privacy of educational records, establishes the rights of students to inspect and review their educational records, and provides guidelines for the correction of inaccurate or misleading data through informal and formal hearings. This release applies to the disclosure of educational records.
I hereby authorize Growing Together to release the education records of Virginia Guiffre (formerly [REDACTED]). This authorization does not authorize the release of medical information, medical records, medical history, medical treatment records, prescription information, notes, or other documentation related to the treatment of any type of substance abuse or addiction of the undersigned. This authorization is for academic records only. Any release of medical information will be reported to all relevant authorities, and [REDACTED] will seek redress against Growing Together under both Florida and Federal law.
**To: Laura Menninger, HADDON, [REDACTED] & [REDACTED] PC, 150 East 10th Avenue, Denver, CO 80203. Tel: 303-831-7364; Fax: 303-832-2628**
These records are being released for the purpose of litigation in the case captioned *Virginia Guiffre v. Ghislaine Maxwell*, 15-CV-07433-RWS, in the United States District Court for the Southern District of New York.
The authorization includes all information in my educational records, including truancy records, attendance records, disciplinary records, grades, house, classes, financial information, graduation records, or any other records or information relating to my attendance at this educational facility. This authorization does not authorize the release of medical information, medical records, medical history, medical treatment records, prescription information, notes, or other documentation related to the treatment of any type of substance abuse or addiction of the undersigned. This authorization is for academic records only. Any release of medical information will be reported to all relevant authorities, and [REDACTED] will seek redress against Growing Together under both Florida and Federal law.
\*\*\*\*\*
The above information will be released with my full consent. I understand that this authorization remains in effect unless specifically revoked. It will be necessary to send a written letter to revoke this authorization prior to the expiration date I have indicated, if I choose to end it sooner.
## Authorization to Disclose Protected Health Information
Name:
Address:
Date of Birth:
Soc. Sec. #
I hereby authorize the use and/or disclosure of my protected health information as described in this authorization.
1. Specific person/organization (or class of persons) authorized to provide the information:
**Dr. Karen Kutikoff**
2. Specific person/organization (or class of persons) authorized to receive and use the information:
**Laura Menninger**
**Haddon, [REDACTED] and [REDACTED], P.C.**
**150 East 10th Avenue, Denver, Colorado 80203**
3. Specific description of the information: **Medical records from 1999 to the present**, including, but not limited to, all of my office medical records, hospital medical records, patient information sheets, questionnaires, x-rays, other diagnostic studies and laboratory tests, emergency room records, out-patient records, consultation records, therapy records, and all other in-patient or out-patient hospital notes, charts, documents, all personal notes and all billing records.
1. Specific purpose for the use and/or disclosure of the protected health information: At my request in connection with litigation pending in the County District Court.
1. I understand this authorization will expire, without my express revocation, one year from the date of signing, or if I am a minor, on the date I become an adult according to state law. I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken based on this authorization. I understand that revocation will not apply to information that has already been released as specified by this authorization or to my insurance company when the law provides my insurer with the right to contest a claim under my policy or the policy itself.
1. I understand that the medical information released by this authorization may include information concerning treatment of physical and mental illness, alcohol/drug abuse and past medical history.
1. I understand that after this information is disclosed, federal law might not protect it and the recipient might disclose it.
1. I understand that I am entitled to receive a copy of this authorization.
1. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment from the above-named medical provider.
1. hotocopies of this authorization arc to be given the same effect as the
original \\ dti IQ.% 1110 Signature %6 Date
## Authorization to Disclose Protected Health Information
Name:
[REDACTED]
Address:
[REDACTED]
Date of Birth:
Soc. Sec. #
I hereby authorize the use and/or disclosure of my protected health information as described in this authorization.
1. Specific person/organization (or class of persons) authorized to provide the information:
**Wellington Imaging Associates, P.A.**
2. Specific person/organization (or class of persons) authorized to receive and use the information:
**Laura Menninger**
**Haddon, [REDACTED] and [REDACTED], P.C.**
**150 East 10th Avenue, Denver, Colorado 80203**
3. Specific description of the information: **Medical records from 1999 to the present**, including, but not limited to, all of my office medical records, hospital medical records, patient information sheets, questionnaires, x-rays, other diagnostic studies and laboratory tests, emergency room records, out-patient records, consultation records, therapy records, and all other in-patient or out-patient hospital notes, charts, documents, all personal notes and all billing records.
1. Specific purpose for the use and/or disclosure of the protected health information: At my request in connection with litigation pending in the County District Court.
1. I understand this authorization will expire, without my express revocation, one year from the date of signing, or if I am a minor, on the date I become an adult according to state law. I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken based on this authorization. I understand that revocation will not apply to information that has already been released as specified by this authorization or to my insurance company when the law provides my insurer with the right to contest a claim under my policy or the policy itself.
1. I understand that the medical information released by this authorization may include information concerning treatment of physical and mental illness, alcohol/drug abuse and past medical history.
1. I understand that after this information is disclosed, federal law might not protect it and the recipient might disclose it.
1. I understand that I am entitled to receive a copy of this authorization.
1. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment from the above-named medical provider.
1. Photocopies of this authorization are to be given the same effect as the original.
otl la% I ho
Signatur&' Date
## Authorization to Disclose Protected Health Information
Name:
[REDACTED]
Address:
[REDACTED]
Date of Birth:
Soc. Sec. #
I hereby authorize the use and/or disclosure of my protected health information as described in this authorization.
1. Specific person/organization (or class of persons) authorized to provide the information:
**Mona Devanesan**
2. Specific person/organization (or class of persons) authorized to receive and use the information:
**Laura Menninger**
**Haddon, [REDACTED] and [REDACTED], P.C.**
**150 East 10th Avenue, Denver, Colorado 80203**
3. Specific description of the information: **Medical records from 1999 to the present**, including, but not limited to, all of my office medical records, hospital medical records, patient information sheets, questionnaires, x-rays, other diagnostic studies and laboratory tests, emergency room records, out-patient records, consultation records, therapy records, and all other in-patient or out-patient hospital notes, charts, documents, all personal notes and all billing records.
1. Specific purpose for the use and/or disclosure of the protected health information: At my request in connection with litigation pending in the County District Court.
1. I understand this authorization will expire, without my express revocation, one year from the date of signing, or if I am a minor, on the date I become an adult according to state law. I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken based on this authorization. I understand that revocation will not apply to information that has already been released as specified by this authorization or to my insurance company when the law provides my insurer with the right to contest a claim under my policy or the policy itself.
1. 1 understand that the medical information released by this authorization may include information concerning treatment of physical and mental illness, alcohol/drug abuse and past medical history.
1. I understand that after this information is disclosed, federal law might not protect it and the recipient might disclose it.
1. I understand that I am entitled to receive a copy of this authorization.
1. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment from the above-named medical provider.
1. /Photocopies of this authorization are to be iven the same effect as the original. \\
t/ 4 ---- gt' I Signatur Date