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121FOR INTERNAL USE ONLY Received by: Christine Fulton ~l Jessica Fulton ^ Date Received: ~ /~ ~~~' FOIL Ser. #: DEPARTMENT: ASSESSOR ^ ACCOUNTING ^ CODE ENFORCEMENT ^ PLANNING ^ ZONING ^ FIRE INSPECTOR ^ HIGHWAY ^ RECEIVER OF TAXES ^ RECREATION ^ SUPERVISOR ^ TOWN CLERK WATER/SEWER ^ DOG CONTROL OFFICER ^ TOWN ENGINEER ^ TOWN ATTORNEY ^ 2009-10-16 JCM TOWN OF WAPPINGER Application for Public Access to Records FOIL REQUEST FOR DEPARTMENT USE ONLY Date Received by Dept ~ / ~/ ~ Department Head approval: (mit) Date Applicant Contacted: ~ 1~.;~ / Date FOIL fulfilled or enied• ~ /~ /~(_~ Closed by: Date: Notes: ~~1~ y~~y ~ ~l ~ Amount Due: ~~ages for a total of $ Name: ~~t? ~ S ~~~'~. • ^ check here if you are Address: C~olci~~~ ~2~~-ll~a • requesting that the records `" be mailed to this address. .z Agency or firm: Telephone #: ( ) - FAX #: ( ) - Email address: SPECIFIC DESCRIPTION OF RECORD: ~p 1P .~-~-f,P.P_aZ_o~.~ FORMAT OF RECORD (if available) ^ I request to be notified when I can come to inspect the record(s) described above ^ I request copies of the records described above and agree to pay the cost of such records in accordance with the fee schedule on the back of this application ^ I request that the records be sent via a-mail to the address listed above ^ I request that the records be faxed to the number listed above !s GOLDBERG SEGALLALLP July 27, 2012 Town of Wappingers Falls 20 Middlebush Road Wappingers Falls, NY 12590 Re: Cecilio Vasquez Date of Birth: 2/24/61 GS File No.: 2800.0288 Dear Sir or Madam: Karen Sack ;Paralegal Direct 914.798.5472 j ksack@goldbergsegalla.com Enclosed please find a duly executed, "HIPAA" compliant authorization, permitting the release of the application for handicap driving stick, pertaining to Cecilio Vasquez. This request is made in conjunction with pending litigation and all records received will be used for this purpose only. This request is made pursuant to Public Health Law Sections 17 and 18 and the decision of the Supreme Court Appellate Division, Second Department, State of New York in Bolt,~a v. Southside Hospital et al. and Cassillo v. St. John's Episcopol Hospital and includes that: a. No "search and retrieval" fee may be charged; b. No additional fee may be charged for paper copies retrieved from storage on microfilm, microfiche or optical disc; c. Postage and sales tax may be added; d. Copies of x-ray films are not covered; and e. The reasonable charge for paper copies shall not exceed seventy-five (75) cents per page. Accordingly, we trust your invoice will specify tree number of Pages contained in the requested records, and that your charge will not exceed the maximum allowable fee as prescribed by law. Please include your Federal Tax Identification number on your invoice. 11 Mar° , A. _ _ quite _, ~ .'Jhitc: f ~.~r > Ne:w Yc . 1- 3A j 14 j i=ax 914_ ~ 98 G , ' v~~ww Gc~r~?~?~ n,~,: ,~~~! .corn ~ ~ N ~ j F ~ ~ ivw~~,.~ i,~ i;r~Nv [ vv'~i ' p ~ , + L. ~ ir:.1.Ah7~ ~... I, Page #2 July 27, 2012 In addition, also enclosed please find a "Certification of Office Records Authenticity" form, which should be executed in the presence of a notary public and returned to the undersigned. Should you have any questions or require any additional information in order to process this request, please do not hesitate to call or write the undersigned. Your anticipated time and assistance in this matter is appreciated. Very truly yours, ~~ Karen Sack /ks Enc. CERTIFICATION OF OFFICE RECORDS AUTHENTICITY I hereby certify before a notary public that the attached photocopies of records are complete, true and accurate copies of the original records kept in the usual course of this office's business and practice, as of the date of this certification for PATIENT: Certified by: Office Title: Signed: DATE: (please print) (please print) (please print) NOTARY PUBLIC SIGNATURE: uc;A Vfticial H'orm No.: 960 .l:,,t'~f~~ AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA "':~_~ / (This form has been approved by the New York State Department of Health Patient Name Date of Birth Social Security Number Cecilio Vasquez 2-24-61 xxx-xx-3797 Patient Address 76 Fieldstone Blvd., Wappingers Falls, NY 12590 I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA}, 1 understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and l initial the line on the box in Item 9(a), 1 specifically authorize release of such information to the person(s) indicated in Item 8. 2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. 1 understand that 1 have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure ofHIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that 1 may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 b 7. Name and address of health provider or entity to release this information: Town of Wa in er_s_ cells 0 Middlebush Road Wa in ers ails _NY 12590 8. Name and address ofperson((s)) or category ofperson to whom this information will be sent: G ld o ber-Segalla, LLP, 11 Martine Ave. , White Plains, NY 10606 9(a). Specific information to be released: ^ Medical Record from (insert date) to (insert date) ^ Entire Medical Record, including patient histories, office notes (except psychotherapy notes) test results radiology studies films , , , , referrals, consults, billing records, insurance records, and records sent to you by other health care providers. d~Other: medical records Include: (Indicate by Initialing) application for handicap driving sticker Alcohol/Drug Treatment Mental Health Information Authorization to Discuss Health Information HIV-Related Information (b) ^ By initialing here I authorize Initials Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: Attorne /Firm Name or Governmental A enc Name) 10. Reason for release of information: 1 1. Date or event on which this authorization will expire: ^ At request of individual W~pther: liti ation one year 12. If not the patient, name of person signing form: 13. Authority to sign on behalf of patient: All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a cop oft form. Date: Signature of patient or repr ent ve authorized by law. * Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a person's contacts. TOWN OF WAPPINGER TOWN CLERK Christine Fulton 20 MIDDLEBUSH ROAD WAPPINGERS FALLS, NY 12590 W WW.TOWNOFWAPPINGER.US (845) 297-4158 -Main (845) 297-5771 -Direct (845) 298-147R -Fax Office of the Town Clerk Goldberg Segalla LLP 11 Martine Ave, 7th Floor White Plains, New York 10606 Attn: Karen Sack July 30, 2012 Dear Karen: SUPERVISOR Barbara A. Gutzler TOWN BOARD William H. Beale Vincent Bettina Ismay Czarniecki Michael ICuzmicz Our office received your request through FOIL for the Handicap application for Cecilio Vasquez. On the advice of the New York State Committee on Open Government, it is their opinion that "Applications for handicapped parking permits are not subject to HIPAA. HIPAA applies to medical records prepared by providers of medical care (i.e., doctors, hospitals, etc.), as well as insurers. A town would not, in this context, maintain records falling within the scope of HIPAA". This record in not subject to FOIL and to provide you with this record would be an invasion of privacy. Therefore, as Records Access Officer, I have denied your request. Please do not hesitate to contact my office at 845-297-5771 should you have any further questions. Sincerely, Christine Fulton Town Clerk/Records Access Officer Via Fax