Free Motion for Protective Order - District Court of Federal Claims - federal

MAY-14-2@04 Ø1~01 From:

Case 1:05-cv-00186-FMA

Document 33-2

To: 3059310877 Filed 02/12/2007 Page 1 of 5

P.4/5

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âlJTlJQRIZATION TO RELF~AS)~ PSYCHOTHRRAPY l~ORMATION
TO:
All Health
to
Cll.re

PATIENT:
Providers

.RI!:L.I!:ASll:

1'0:

LAVETTA ELK

NAME: LAVETTA El.K
BTRTH DATE: 12/8/83

Represenlalivt:s or the United St(ites Attorney's Office

or Dcpilrtmcnt of Justice
Herman &. M~l'lIIdslCil'. r.A. I 8205 Iji~e9yn(~ HnuJevlttù
SUÎlll22Jll Miami. Fl
33161'1

above-llaweû pt:rsun ur class of persons to release the infocmalÍon specified below to representatives ofllie U.uited Stdes Atturney'!! Otfice or the Department of Justice. Any 1100 till recurds regarding treatment of LAVRT'l 'A. I.!LK including but Dot lin1Ïted to:
1.

IN)'ORMA1'ION

.KJJ:QLJIì:STILD:

I requcl'it and allthori~ The

All

rcéord:;

t'ecol'dings,
2.

of psychological or psychiatric testing awl psychotherapy notes, and

ur-

lrcaum:nt, including complete chart, audio and visual

Hilling records,

PllRPOSF.(S) OR. NEED FOR

WIIIcn IN'FORMA TION

IS TO BE USED:

The infnrmatic," is neçessary for the ütigalion of Lavetta Elk v. United States. No. 05-186 L, now pending in the Ulùted States Court of lied era I Clalm~_

I certify ilial Utis ct:quest has been made voluntarily and that the infònnatiOIl given i1bovc: is I unûl,:TlI1and that I may revoke this Authorizatiòn at any time, pwvided I.hut revocalÎun is in wriling, CXC,:I,;pt t(1 the extent that action has already been tahn in reliance tlús Authorualion. r understand that the doctor, health c.are providel", Of belllLh plan frum whom my medical information is rC:Cluested in this Authorization, may not condition trlmtment, payment, c:urullmt:nl ur c1ibrihility for henefits on whether I sign thi:; authorization. [undc:TStánd the potential for the i.llfonn<1tion dlsclòsed pW1lul:lJ1L II,) this Authorization to be subject to rediscJosure by the: reeipient ann no longer he protected by the Standards for Privilcy of Indjvidui.lHy lUcntitiablc: Ht:allb Informatiun, sct furth at 45 CFrc. I'artfl 1 (in and 1

CERTIFICATION:

accurate to the best

of IllY knowledgc.

M.

EXI"!.R.AT10N:
Check One:

_L'l'his

Authorization will automatically expire upon COI.11pletiou oftùe Jiûgllli~Jn Lavell.. Elk v. United States, No. 05-18b L, now pending in the United States Court of Ferlflral Clalllls.
Aul.hur.i:t:lIl.iOn

__n1Ïs

willilulonmliclllly expiTc upon completion of the administrative claim of filed on

MRY-14-2@04 01~01 From: Case 1:05-cv-00186-FMA

Document 33-2

To:30S9310S77 Filed 02/12/2007 Page 2 of 5

P.3/S

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This

Antbori.7...'ltion

~hall he effective unlil

011lER CONDIl"IONS:
.

: ::

_

-L. original.
---X-

A

copy of this ^l1thQri7.ation

OT

my signature thereon

shaH be

llosed

with the same effectiveness as ~1l .- :'.::

~n1n1Uni~lltiOns between provider
are OllThollzed.

and allY representaTive

of the U.s. Attorney's

OfficefDepartmø;;~'{{: '. :'f:: :'.:'/.: :
.
.
.

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.

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SIGNA'I''ORE OF

PATIENT:

}).Q r:.~' !J!?CU,-' c_(C~...fJ"

OR PERSON AUTHORIZED TO SIGN FOR PATIENT:*

MONl'H}.DAY/YF.AR

PRlNT OR TYPE NAME

.Provit1e basis of AuthoL'izatioll:

MRY-14-2~Ø4 Øl~Øl From:

Case 1:05-cv-00186-FMA

(

Document 33-2

To: Filed 02/12/2007

3059310S77

Page 3 of 5

P.2/5

AUTHORIZATION

TO RELRASR MRDTCAT.lNFORMATION

1'0:
All Health Carc Providers to LA VETt A ELK

PATIENT:
NAME: LAVETTA ELK

IUi:U~ASIt:

TO:

IHRTl.! DATE: 12/8/83

Representatives of the Unitcd States Anol'Jl~Y's Offiee or Department ot" Justice
Ho:rnmn & Mc.rmcJstcin, I'.A. IlUO; 8i~:i1Ylll: Uuulcvurd

Suite 2218

Miami.

1'1. .1~ 1 (,0

1 (eql1est and 8ulhorue !hI! above-named perSon or class ofpcrsons to releal'le the infonllation specified below to representatives of th~ UniLt:u ~taLeli AttorncY'1I Office or the Department ot' Justice. Any lUul all record!! regarding treatment of 'LA V.I:.i'.I.TA liLK including but not Iim.ited to;
1. <;opy
dmrt., pl'ogl'l::ss notes & inlerview nolc!!, dil$chargc summaries, operative reports, xJray & all laboratory tests, pathology tissue, and all diagnostic studies whether in electronic data imagery, or othel'

INFORM ATION RRQlJF.STEI):

of complete

format.

2. Billing records

PURPOSE(S) OR NEED FOR WHTC'H TNFORMA1'lON IS TO BE USED:
The inroTnUllion ill necessary for the litigation of Lavetta Elk v. United States Court of Fedenll CJiliUl~.
lJnitec'l Sta.t.ell,

No. 05-186 L, now pending in the

CERTIFICATION:
accurate to the best

this Authorization, may not condition treatment, payment, enrollment or eligibility for benefits on whelhl;;r Illign this I understand the .potential for the information dÜ:c1nsed pnrsuant'to this Authorization to be subject to I'edisclos\ll'~ by the l'ecipieJll ClUe! no JOUKt:r be: prult:eleù by the Standards fnr Privacy or .Individually Identifiable Health Informatíon, s~t fOl'dl ill 45 CPR Pí&Cts 160 llu11164.
aUlhoT.Î?;ation.

certity maT this request has been Jundt: vuhm(llrily and that the information given above is of my lrnowledze. T lInde~stllud ilia I I may revoke lhis Authorization at any time, provided that ill in writing, excert to the extent that action has alrcady been taken in l'elillLlCI; Lb.i::i rèvOcation Authorization. I unùcrstand that the doctor, health care provirler, or hea Ith plan from whom my medical illfol'lnation is rc:qut:llled in

I

.~XI~J..RATJON
CJ1éck uue;

:

~n1Ís Aulhori~atiun pending 05-186
L, now

will auLumatically CXpiTCi:upon completion of the litigation Lavetta Elk v, United Slales, No. in the United States Court of Fedel'ul Cluims.
will illltoll)i\rica]ly expire upon compk:lion of the administrative claim of filed 011

_This

^lIthori,..1tiol1

MRY-14-2Ø0~ Øl~~l From:

Case 1:05-cv-00186-FMA

Document 33-2

Filed 02/12/2007

To:3059310877

Page 4 of 5

P.5/5

This Authorizarion shall be dltc,tive until

OTHER CONDITIONS:
copy 2- original. ofthls AulhúrÏit.aliUIl
~

A

or my Slb'Ilature thereon shall be used with the same cffectlvenes$ a$ an
iLUd

Comrnw1ications between, provider
arc authori7.cd.

any n:pre/:lt:nlal;vc;

of the U.s.

Attorney's OLlice/Department
.

of J.l1stiç:~
:

.
.

"
~

: :: : : : :

~
.
#

~

SIGNATURE

C-QÞ:),-~O_ PATIENT:Cy;.~ O,F \W'
v

:;;ji::;;ifi
..
.

..::"..,..::"

""

..

.

..

~

..

OR PERSON AU'l'HOlUZED 1'0 SIGN FOR PATIF:NT:-

MONTHIDA Y lYRA R

PRINT OR TYPE NAME

.',pruviùc basis ()f AuthoTi?ation:

ll/lO/~D
F

nnu ~D;ql rðA ~U~U~~UOII

Case 1:05-cv-00186-FMA

-.~'-1;";,

c

Document 33-2

D.n.l\.1f1l\.1'

or.

Itl.JJl.1'\lUßL.:J.LJ..:.l.1.1'

Filed 02/12/2007

********************* TX REPORT *** *** *********************

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Page 5 of 5

'i!:I

UU.L

TRANSMISSION OK

TX/RX

NO

DEPT. ACCESS CODE CONNECTION TEL
SUBADDRESS

3806 0024

12023532021

CONNECTION

ID

ST. TIME USAGE T

11/15 16:46 01'17
5

PGS. RESULT

OK

HERMAN
AïrORNEYS
AT LAW

&

MERMELSTEIN

PA
Adam D. Horowitz Tel 305-931-2200 Fax 305-931-0877
[email protected]

18205 Biscayne Boulevard Suite 2218 Miami. Florida 33160
VtlWW .hermanlaw,com

FAX TRANSMITTAL
FROM
Adam Horowitz, Esq.

DATE
November 15.2006

NUMBER OF PAGES
5

TO
Kevin Webb; Esq.
Sara Culley, Esq.

COMPANY
U.S. Department

FAX NUMBER of Justice

202.~

'3S~-~O~\

MESSAGE
Elk v. The United
States
.

Please see the following Authorizations for Release

of Medical and Psychotherapy

Information.
Thank you.

T1-IIS M1;;SSACìE IS

INTENDED ONLY FOR THE USE OF THE INDIVIDUAl. OR ENTITY TO WHICH IT IS ADDRESSED AND MAY
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