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122FOR INTERNAL USE ONLY Received by: Christine Fulton y~' Jessica Fulton 0 Date Received: ~_ / ~ /~]~.~(~- FOIL Ser. #: CJ~ ~-~` DEPARTMENT: ASSESSOR ^ ACCOUNTING ^ CODE ENFORCEMENT ^ PLANNING .^ ZONING ^ FIRE INSPECTOR ^ HIGHWAY 0 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 ~ / 3/ / ~ ~- Department Head approval: (init) Date Applicant Contacted: ~ / ~ / ~/ ~ Date FOIL fulfilled deme ~ /~J/ / o~C)/ ~- Closed by: ~ __ Date: I / Notes: /~)')GC-~~ t ~..~z ~~ ~~ ~' _ Amount Due: Pages for a total of $ Name: 0 check here if you are Address: requesting that the records be mailed to this address. Agency or firm: Telephone #: ( ) - FAX #: ( ) - Email address: SPECIFIC ESCRIPTION OF RECORD: ~ ~~./ v FORMAT OF RECORD (if available) ~J 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 2009-10-16 JCM The Town of Wappinger has designated the Town Clerk, by the adoption of Resolution No. 43 of 2002, as the Records Management Officer (RMO). It is the responsibility of the RMO to ensure compliance with the Freedom of Information Law. The Town Clerk's Office houses many of the Town's records and maintains a subject file index of those records. However, each individual Department within the Town of Wappinger government maintains records specific to their office and is designated custodian of such records. Active records are located at the Town Hall, 20 Middlebush Road, Wappingers Falls, NY, 12590. Hours of operation for the Town Hall are 8:30 AM to 4:00 PM, Monday through Friday, excluding holidays named at each Reorganization Meeting and other times during which the Town Supervisor, or other authorized official, directs the Town Hall to be closed, such as for inclement weather or other emergency. FOIL requesta~forms are-avaiiable at the Town Clerk's Office. To make a request for access to records; #ll out~the application to include the following: • Name • Agency or Firm (write "self" if making the request for yourself) • Address of applicant . Telephone number of applicant . Fax number of applicant • Notate if you would like copies of the records or would only like to inspect the records • A SPECIFIC description of the records being requested FOIL requests can be faxed, emailed, mailed or dropped off at the Town Clerk's Office. If records are being requested from multiple offices, submit separate requests for each. The cost for copies of records is $0.25 per page for paper copies up to 9" X 14". Copies for most other records will be the cost of reproduction. Other costs will be calculated in accordance with 587 of the Freedom of Information Law. Upon receipt of a FOIL request, the RMO will assign the request a serial number. The request will then be entered into a database and forwarded to the appropriate department. Within 5 days after the receipt of the request, the responsible department will make such record available to the person requesting it, deny such request in writing or furnish a written acknowledgment of the receipt of such request and a statement of the approximate date, which shall be reasonable under the circumstances of the request, when such request will be granted or denied. The approximate date will be within,20 days of the date of receipt... If the request cannot be fulfilled within 20 days, the department will, provide the requestor with an exact date that the record. will, wholly or in -part, be provided or made available. The RMO may require the requestor of certain FOIL requests to sign an affidavit that information. being provided' will`not be used for solicitation or fund-raising purposes-and that the requestor will not sell, give or otherwise make such information avaiiable to another person for the purpose of allowing that person to use-the information for solicitation orfund-raising purposes. . A requestor may ask that the Town Clerk certify records being requested. Such requests will require that the. requestor pay the appropriate fee for certified copies asset forth in Chapter 122. of the Town Code of the Town of Wappinger. If a request is denied by the RM0 or appropriate custodian, the requestor may appeal such denial within seven business days of receipt of denial. Appeals must be submitted in writing and sent to the RMO. --- The information provided here is posted to assist you with your FOIL request. It will be updated as needed, but is always to be considered subordinate to the Freedom of Information Law and the Town Code of the Town of Wappinger. If at any time, the information posted here contradicts the Freedom of Information Law or the Town Code of the Town of Wappinger, the information posted here is to be deemed invalid. Record of Attempts to Contact Applicant Staff Member I Pbone Number Called I E-mail Address fif aonlicablel I Dste I Message Lett fY/Nl Notes & Comments AHMUTY, DEMERS c~ MCMANUS (340 JOHNSON AVFNL?F: SUI7`F. 103 1loxxnlln, NEw i"oRI: u~la (({811 23-1-0`210 1531 ROUTE 82 HOPEWELL JUNCTION NY 12533 (845) 223-3470 FAX 845-223-3287 A'P'I'012NN:YS A'i` LAW 200 L U. WILI,E7`S ROAD ALBI!;R'1`SON, NF.V1' YORK 11507 ~51c) 2s~-S~ss FACSIMILE (516> 294-5387 July 27, 2012 Town of Wappingers Falls 20 Middlebush Road `Jappingers Falls, New York 12590 Re: Cecilio Vasquez SSN DOB Our File No. Dear Sir/Madam: XXX-XX-3797 2/24/61 USLW 052011 CJC 123 WILLIAM S'L'REET NF.\\' 1'OI2 [i, NE\\' 1"ORIi 10038 (2121 513-7788 OS MADISON AVF.NI~E MORRISTOWN, NEW .1 F.RSEF U700U (07:31 084_g300 Enclosed please find a duly executed HIPAA compliant authorization allowing this office to obtain plaintiff's medical record in connection for the application for handicap driving sticker. Public Health Law Sections 17 and 18 require you to deliver copies of all medical records including x-rays and test records for a copying charge not to exceed seventy-five cents per page. Please advise us of the cost of reproducing these documents, along with your Federal Tax I.D. Number and we will forward our draft for such cost. Thank you for your attention to this matter. Very truly yours, ~erar~ ~66irde GERARD A. GILBRIDE (845) 223-3470, Ext. 6504 CJC:pm Enclosure OC:A Official Form No.: 960 ;1,~~1~~ 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 1, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: fn accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I 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 1 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 I initial the line on the box in Item 9(a), I speciftcally 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. I understand that 1 have the right to request a list of people who may receive or use my HIV-related information without authorization. If 1 experience discrimination because of the release or disclosure of H[V-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. 1 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 SPF,CIFIFn IN rTF.M o rho 7. Name and address of health provider or entity to release this information: Town of Wappingers_Falls, 20 Middlebush Road, Wappingers Falls, NY 12590 8. Name and address of person(s) or category of person to whom this information will be sent: Ahmut Demers 6 McManus Es s. 1531 Rt. 82 Ho ewell i n N 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. ' f~Other: med ICaI 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 Gd~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 CLERK Christine Fulton 20 MIDDLEBUSH ROAD WAPPINGERS FALLS, NY 12590 W W W.TOWNOFWAPPINGER.US (845) 297-4158 -Main (845) 297-5771 -Direct (845) 298-1478 -Fax TOWN OF WAPPINGER Office of the Town Clerk Ahmuty, Demers & McManus Attorneys at Law 200 I.U. Willets Rd Albertson, New York-11507 - Attn: Gerard A. Gilbride July 31, 2012 Dear Gerard: SUPERVISOR Barbara A. Gutzler TOWN BOARD William H. Beale Vincent Bettina lsmay Czarniecki Michael Kuzmicz Our office received your request through FOIL for the Handicap application-for Cecilio ` :. - ,. ,.._. Vasquez. On the advice of the New fork State Committee on Open Government, it is ` their opinion that "Applications for:handicapped parking permits are not subject to - _. HIPAA. HIPAA applies ~o-medieal reeordsprepared 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