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Record

Draft: efta02784508

COMPOSITE EXHIBIT 6 (File Under Seal)

40 'a. %., 5)LAS • St "E. .200 • 0• I ._At,DERDA i

March 8, 2016

v n W. Olsen I.D.

Re: Virginia

Dear Dr. Olsen:

Sigrid S. McCawley, Esq. Email: smccawlevObsfilp.com

This Firm represents the above-named individual. Please provide us with all medical records, including, but limited to. progress notes. reports of tests and test results, billing information, and patient files pertaining to our client. Please make sure to include records detailing our client's current medication/prescriptions.

Please advise me if there are any fees for copying her records. In addition, it is necessary that we receive records and reports as soon as possible.

Enclosed is an authorization form executed by our client authorizing you to release this information to this Firm. Please forward all documents to my attention at Boles, Schiller & Flexner LLP, 401 East Las Olas Boulevard, Suite 1200, Fort Lauderdale, FL 33301.

We appreciate your cooperation in this matter. If you have any questions, please contact me at 954-356-001 I.

SSM/ep Enclosure Sincerely,

Sigrid S. awley

Name: IMS

Address:

Date of Birth:

Soc. Sec. /I

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:
    1. Specific person/organization (or class of persons) authorized to receive and use the information: Sigrid S. McCawley, Else. Boles. Schiller & Flexner LLP 401 E. Las Olas Blvd.. Suite 1200, Ft. Lauderdale, FL 33301
    1. Specific description of the information: Complete medical record from inception of treatment to 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 1 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.

  2. I understand that I am entitled to receive a copy of this authorization.

  3. 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.

  4. Photocopies of this authorization are to be given the same effect as the original.

![](_page_4_Figure_98.jpeg)

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401 EAST i_AS Ol AS 110.A EVARD • SUITE . 200 • FORT LAUDERDALE FL 33301 a a, l• PH 054.356 CO. ' FAX 9o4 356.0022

Sigrid S. McCawley, Esq. Email: smccawley@lisflIp.com

March 28, 2016

Dr. Mona Devancsan, M.D.

Re:

Dear Dr. Devanesan:

This Firm represents the above-named individual. Please provide us with all medical records, including, but limited to, progress notes, reports of tests and test results, billing information, and patient files to Please make sure to include records detailing our client's current medication/prescriptions.

Please advise me if there are any fees for copying her records. In addition, it is necessary that we receive records and reports as soon as possible.

Enclosed is an authorization form executed by our client authorizing you to release this information to this Firm. Please forward all documents to my attention at Boies, Schiller & Flexner LLP, 401 East Las Olas Boulevard, Suite 1200, Fort Lauderdale, FL 33301.

We appreciate your cooperation in this matter. If you have any questions, please contact me at 954-356-0011.

SSM/ep Enclosure Sincerely,

7

Sigrid S. cCawley

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) authorised to provide the information:
    1. Specific person/organization (or class of persons) authorized to receive and use thc information: Sigrid S. McClumsy, Eq. Boca. SOW & name( LLP 401 E. Las Olas Wad., Suite 1200. Ft Lauderdale FL 33301
    1. Specific description of the information: Complete medical record from inception of treatment to 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 tha 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 c\ptess revocation, one year from the date of signing, or if l 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 basal on this authorization. 1 understand that revocation will not apply to information that has already been released as speotiod 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:

  2. I understand that thc medical information released by this authorization may include information concerning treatment of physical and mental illness, alcohol/drug abuse and past medical history.

  3. I understand that after this information is disclosed, federal law might not protect it and the recipient might disclose it.

  4. I understand that I am entitled to receive a copy of this authorization.

  5. 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.

  6. Photocopies of this authorization are to be given the same effect as the original.

401 EAST LAS OLAS BOULEVARD • SUITE 1200 • FORT LAUDERDALE, FL 33301-2211 • PH. 954.356.0011 • FAX 954.356.0022

Sigrid S. McCawley, Esq.
Email: smccawley@bsfllp.com

April 5, 2016

Dr. Chris Donohue

[REDACTED]

Re: [REDACTED]

Dear Dr. Donohue:

This Firm represents the above-named individual. Please provide us with all medical records, including, but limited to, progress notes, reports of tests and test results, billing information, and patient files pertaining to our client. Please make sure to include records detailing our client's current medication/prescriptions.

Please advise me if there are any fees for copying her records. In addition, it is necessary that we receive records and reports as soon as possible.

Enclosed is an authorization form executed by our client authorizing you to release this information to this Firm. Please forward all documents to me in the enclosed FedEx return envelope provided for your convenience.

We appreciate your cooperation in this matter. If you have any questions, please contact me at 954-356-0011.

Sincerely,

SSM/dk
Enclosures

Name:

Address:

Date of Birth:

Soc. Sec. #

Ihereby 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:
    1. Specific person/organization (or class of persons) authorized to receive and use the information: Sigrid S. MoCawley, Esq. Boles, Schiller & Flexner LLP 401E. Les Olas Blvd., Suite 1200. FL Lauderdale, FL 33301
    1. Specific description of the information: Complete medical record from inception of treatment to 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 1 am aminor, on the date T 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 tinder 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, alcohoUdrug 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.

  2. I understand that I am entitled to receive a copy of this authorization.

  3. 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.

  4. Photocopies of this authorization are to be given the same effect as the original.

401 EAST LAS OAS BOULEVARD • S..JTL I200• FORT LAu::EliDALE. FL. 33301 221 • PH 9S4 2ob.00i J • FAX 954 356.0022

Sigrid S. McCawley, Esq. Email: smccawleyetedllp.com

April 5, 2016

Re:

Dear Dr. Harris:

This Firm represents the above-named individual. Please provide us with all medical records, including, but limited to, progress notes, reports of tests and test results, billing information, and patient files pertaining to our client. Please make sure to include records detailing our client's current medication/prescriptions.

Please advise me if there are any fees for copying her records. In addition, it is necessary that we receive records and reports as soon as possible.

Enclosed is an authorization form executed by our client authorizing you to release this information to this Firm. Please forward all documents to me in the enclosed FedEx return envelope provided for your convenience.

We appreciate your cooperation in this matter. If you have any questions, please contact me at 954-356-0011.

SSM/dlc Enclosures Sincerely,

igrid S. McCawley

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:

  2. Specific person/organization (or class of persons) authorized to receive and use the information:

Sigrid S. McCavAey, Esq. Boles, Schiller & Flamer LLP 401 E. Las Olga Blvd., Suds 1200, Ft. Lauderdale. FL 33301

  1. Specific description of the information: Complete medical record from inception of treatment to 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.

  2. 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.

  3. I understand this authorization will expire, without my express revocation, one year front the date of signing, or if I am a minor, on the date I become an adult according to state Iaw. 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 insurcr with the right to contest a claim under my policy or the policy itself.

  4. 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.

  5. I understand that after this information is disclosed, federal law might not protect it and the recipient might disclose it

  6. I understand that I am entitled to receive a copy of this authorization

  7. 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.

  8. Photocopies of this authorization are to be given the same effect as the original.

401 EAST LAS OLAS BOULEVARD * SUITE 1200 * FORT LAUDERDALE, FL 33301-2211 * PH. 954.356.0011 * FAX 954.356.0022

Sigrid S. McCawley, Esq.
Email: smccawley@bsfllp.com

April 5, 2016

Dr. Sellathurai

![](_page_14_Picture_112.jpeg)

Re:

![](_page_14_Picture_114.jpeg)

Dear Dr. Sellathurai:

This Firm represents the above-named individual. Please provide us with all medical records, including, but limited to, progress notes, reports of tests and test results, billing information, and patient files pertaining to our client. Please make sure to include records detailing our client's current medication/prescriptions.

Please advise me if there are any fees for copying her records. In addition, it is necessary that we receive records and reports as soon as possible.

Enclosed is an authorization form executed by our client authorizing you to release this information to this Firm. Please forward all documents to me in the enclosed FedEx return envelope provided for your convenience.

We appreciate your cooperation in this matter. If you have any questions, please contact me at 954-356-0011.

Sincerely,

Sigrid S. McCawley

SSM/dk
Enclosures

Name.

Address:

Date of Birth:

Soc. Sec. #

Ihereby authorize the use and/or disclosure of my protected health information as described in this authorization.

  • I. Specific person/organization (or class of persons) authorized to provide the information:

    1. Specific person/organization (or class of persons) authorized to receive and use the information:

Sigrid S. McCavAey, Esq.

Boles. Schiller & Flexner LLP

401E. Les Orns Blvd., Suite '200, Ft. Lauderdale FL 33301

    1. Specific description of the information: Complete medical record from inception of treatment to present, including, hut not limited to, all of my office medical records, hospital medical records, patient information sheets, questionnaires, x-ray's, 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.

5I understand this authorization will expire, without my express revocation, one year from the date of signing, or if I am aminor, on the date 1 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 aclaim 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.

  2. I understand that I am entitled to receive a copy of this authorization.

  3. 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.

  4. Photocopies of this authorization are to be given the same effect as the original.

BOIES, SCHILLER & FLEXNER LLP

401 EAST LAS OLAS BOULEVARD • SUITE 1200 • FORT LAUDERDALE, FL 33301-2211 • PH. 954.356.001 • FAX 954.356.0022

Sigrid S. McCawley, Esq.
Email: smccawley@bsfllp.com

April 5, 2016

Dr. Wah Wah

![](_page_17_Picture_100.jpeg)

Re:

![](_page_17_Picture_102.jpeg)

Dear Dr. Wah Wah:

This Firm represents the above-named individual. Please provide us with all medical records, including, but limited to, progress notes, reports of tests and test results, billing information, and patient files pertaining to our client. Please make sure to include records detailing our client's current medication/prescriptions.

Please advise me if there are any fees for copying her records. In addition, it is necessary that we receive records and reports as soon as possible.

Enclosed is an authorization form executed by our client authorizing you to release this information to this Firm. Please forward all documents to me in the enclosed FcdEx return envelope provided for your convenience.

We appreciate your cooperation in this matter. If you have any questions, please contact me at 954-356-0011.

Sincerely,

SSM/dk
Enclosures

Name.

Address:

Date of Birth:

Soc. Sec. #

Ihereby 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:
    1. Specific person/organization (or class of persons) authorized to receive and use the information:

Sigrid S. MeCawley, Esq.

Boles, Schiler & Flexner LLP

401E. Lae Oles Blvd., Suite 1200. Ft Lauderdale FL 33301

    1. Specific description of the information: Complete medical record from inception of treatment to present, including, but not limited to, all of my office medical records, hospital medical records, patient information sheets, questionnaires, x-ray's, 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. 1 understand this authorization will expire, without my express revocation, one year from the date of signing, or if I am aminor. 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 aclaim 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

  2. I understand that I am entitled to receive a copy of this authorization.

  3. 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.

  4. Photocopies of this authorization are to be given the same effect as the original.

zoo • Or LAuDERDALL F._ 3:.,JC • -)r- '.3.>4..3::b OCT . • FAX 954.356.0022

Sigrid S. McC-awley, Fsq. Email: smccawlotbsflIp.aem

April 5, 2016

Oaks Medical Center

Atm: Records Dept.

Re:

Dear Sir/Madam:

This Finn represents the above-named individual. Please provide us with all medical records, including, but limited to, progress notes, reports of tests and test results, billing information, and patient files pertaining to our client. Please make sure to include records detailing our client's current medication/prescriptions.

Please advise me if there arc any fees for copying her records. In addition, it is necessary that we receive records and reports as soon as possible.

Enclosed is an authorization form executed by our client authorizing you to release this information to this Firm. Please forward all documents to me in the enclosed FedEx return envelope provided for your convenience.

We appreciate your cooperation in this matter. If you have any questions, please contact me at 954-356-0011.

SSM/dk Enclosures Sincerely,

Sigrid S. Mc wlcy

Name:

Address:

Date of Birth:

Soc. Scc. #

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:

  2. Specific person/organization (or class of persons) authorized to receive and use the information:

Sigrid S. McCewley, Esq. Boles. Schiller & Flexors LLP 401 E las Ores Blvd., Suite 1200, Ft. Lauderdale, Fl. 33301

  1. Specific description of the information: Complete medical record from inception of treatment to 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.

  2. 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.

  3. 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. 1 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

  4. 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.

  5. I understand that after this information is disclosed, federal law might not protect it and the recipient might disclose it

  6. I understand that I am entitled to receive a copy of this authorization.

  7. 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.

  8. Photocopies of this authorization are to be given the same effect as the original.

401 EAST LAS OLAS BOULEVAait • SJ TE 1200 • rORT -ALDER L :333:Y 2211 • Pi t 354.350 00 • P AX 954 356 0022

Sigrid S. McCawley, Esq. Email: smccawlev@bsflln.com

April 28, 2016

Dr Carol I lavek. M D

Re:

Dear Dr. Hayek:

This Finn represents the above-named individual. Please provide us with all medical records, including, but limited to, progress notes. reports of tests and test results, billing information, and patient files pertaining to Please make sure to include records detailing our client's current medication/prescriptions.

Please advise me if there are any fees for copying her records. In addition, it is necessary that we receive records and reports as soon as possible.

Enclosed is an authorization form executed by our client authorizing you to release this information to this Firm. Please forward all documents to my attention at Boies, Schiller & Flexner LLP, 401 East Las Olas Boulevard, Suite 1200, Fort Lauderdale, FL 33301.

We appreciate your cooperation in this matter. If you have any questions, please contact me at 954-356-0011.

SSM/ep Enclosure Sincerely,

Sigrid S. McCawley

Name:

Address:

Date of Birth:

Soc. Sec. #

![](_page_24_Picture_6.jpeg)

I hereby authorize the use and/or disclosure of my protected health information as described in this authorization.

  • I. Specific person/organization (or class of persons) authorized to provide the information:

Dr. Carol Hayek

    1. Specific person/organization (or class of persons) authorized to receive and use the information:

Sigrid McCawley Boles, Schiller & Flexner LLP 401 East Las Olas Blvd., Suite 1200 Fort Lauderdale, FL 33301

    1. 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 1 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.

  2. I understand that after this information is disclosed, federal law might not protect it and the recipient might disclose it.

  3. I understand that I am entitled to receive a copy of this authorization.

  4. 1 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.

IQ. -Photocopies of this authorization are to be given the same effect as the original. I

I I 1. Signatu Date

401 EAST LAS OLAS BOULEVARD • SUITE 1200 • FORT LAUDERDALE, FL 33301-2211 • PH. 954.356.0011 • FAX 954.356.0022

Sigrid S. McCawley, Esq.
Email: smccawley@bsfllp.com

May 4, 2016

Via Federal Express

Judith Lightfoot

![](_page_26_Picture_105.jpeg)

Re: [REDACTED]

[REDACTED] S. Lightfoot:

This Firm represents the above-named individual. It is my understanding that you are a psychologist that has counselled my client, [REDACTED] via telephone. Please provide us with all treating records, including, but limited to, progress notes, reports of tests and test results, billing information, and patient files pertaining to [REDACTED].

Please advise me if there are any fees for copying her records. In addition, it is necessary that we receive records and reports as soon as possible.

Enclosed is an authorization form executed by our client authorizing you to release this information to this Firm. Please forward all documents to my attention at Boies, Schiller & Flexner LLP, 401 East Las Olas Boulevard, Suite 1200, Fort Lauderdale, FL 33301.

We appreciate your cooperation in this matter. If you have any questions, please contact me at 954-356-0011.

Sincerely,

Sigrid S. McCawley

SSM/ep
Enclosure

Name:

Address:

Date of Birth:

![](_page_27_Picture_6.jpeg)

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:

Judith Lightfoot

    1. Specific person/organization (or class of persons) authorized to receive and use the information:

Sigrid McCawley

Boies, Schiller & Flexner LLP

401 East Las Olas Blvd., Suite 1200

Fort Lauderdale, FL 33301

    1. 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.

  2. 1 understand that after this information is disclosed, federal law might not protect it and the recipient might disclose it.

  3. I understand that 1 am entitled to receive a copy of this authorization.

  4. 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.

10., (yttot opies of this authorization are to be given the same effect as the original. li t

54)- /lc .,

Signature Date

at** TX REPORT is.

TRANSMISSION OK

TX/RX NO 3024 RECIPIENT ADDRESS 17192852030 DESTINATION ID ST. TIME TIME USE PACES SENT RESULT 05/23 09:02 01'34 2 OK

N'c

BOIES SCHILLER & FLEXNER LLP

401East Las Olas Boulevard, Suite 1200

Fort Lauderdale, Florida 33301

Telephone: (954) 356-0011

Fax: (954) 356-0022

FACSIMILE COVER SHEET

TO: Centura Health Medical Records FAX: 719.285-2030 St. More Hospital TELEPHONE: 719-285-2000 Canon City, CO

FROM: Meredith

DATE: May 23, 2016

Total Number of Pages: (INCLUDING THIS COVER SHEET): 2

RE: Patient Authorization to Disclose Protected Health Information

MESSAGE: Please see attached Patient Authorization to Disclose Protected Health Information. Per the attached form, please fax all records to 954-356-0022 to the attention of Meredith

New York ■ Washin ton DC r Florida ■ New Ham )shire ■ California r New Jersey ■ Nevad•

401 East Las Olas Boulevard, Suite 1200

Fort Lauderdale, Florida 33301

Telephone: (954) 356-0011

Fax: (954) 356-0022

FACSIMILE COVER SHEET

TO: Centura Health Medical Records FAX: 719-285-2030 St. More Hospital TELEPHONE: 719-285-2000 Canon City, CO

FROM: Meredith

DATE: May 23, 2016

Total Number of Pages: (INCLUDING THIS COVER SHEET): 2

RE: Patient Authorization to Disclose Protected Health Information

MESSAGE: Please see attached Patient Authorization to Disclose Protected Health Information. Per the attached form, please fax all records to 954-356-0022 to the attention of Meredith

THE ATTORNEY-CLIENT AND/OR ATTORNEY WORK-PRODUCT PRIVILEGES

This facsimile transmission is intended solely for the above-named recipient and may contain confidential information which is exempt from disclosure and protected by the attorney-client and/or attorney work-product privileges. Any unauthorized use or disclosure is strictly prohibited and may result in civil and/or criminal liability. If any of the information contained in this transmission is misdirected to you, please call (954) 356-0011 collect and mail such information back to us. Thank you.

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