126FOR INTERNAL USE ONLY
Received by: Christine Fulton I,~
Jessica Fulton ^
Date Received: 0 / ~ / ~ c~
FOIL Ser. #: ~ ~ ~
DEPARTMENT:
ASSESSOR ^
ACCOUNTING ^
CODE ENFORCEMENT ^
PLANNING ^
ZONING ^
FIRE INSPECTOR ^
HIGHWAY ^
RECEIVER OF TAXES ^
RECREATION ^
SUPERVISOR ^
TOWN CLERK ~l
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 ~ / l ~'
Department Head approval:
mit)
Date Applicant Contacted: _ / - /
Date FOIL fulfilled r denied: ~ ~ /~
Closed by:
Date: 0 / (.p /~ a'
Notes: ~~ C~ ~ .~
Amount Due: ~ges for a total oT~~.
Name: C ^ check here if you are
Address: /f~ / ~ ~ requesting that the records
- f~ f ~ aa. be mailed to this address.
Agency or firm: 1 ~?- t ~'~ ~-
Telephone #: ( ~ ), - ~. .CPO FAX #: ( ) -
Email address:
SPECIFIC DESCRIPTION OF RECORD:
~~ ~~ ~/
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
I ~+~ ~
,,.w,
-`'`~.,~
f
.a M -~r
Town of Wappingers Falls
20 Middlebush Road
Wappingers Falls NY 12590
Attn: Records Department
8/2/2012
RE: Subject: Vasquez, Cecilio
SSN: 3797
Date of birth: 02/24/1961
Litigation Solutions, LLC.
Skylar Washabaugh
Brentwood Towne Centre
101 Towne Square Way, Suite 251
Pittsburgh, PA 15227
Tel: 503-327-8660
Fax: 412-253-1080, 412.882.3477
Email: Washabaugh@litsol.com
www.litigationsolutions.com
OfOce Hours:
Monday -Friday 8:OOam to 5:OOpm
Please remit the application for Handicap Driving Sticker for Cecilio Vasquez.
Dear Sir or Madam:
Attached you will find a properly executed authorization for release of the records specified above
relating to the above referenced individual.
Please complete and sign the attached RECORD CERTIFICATION STATEMENT and return it with the
records.
IF YOU DO NOT HAVE THESE RECORDS, PLEASE STATE SO ON THE RECORD CERTIFICATION AND
RETURN IMMEDIATELY VIA MAIL OR FAX.
Sections 17 and 18 of Public Health Law (PHL), Laws of 1991, Chapter 165, sections 48 and 49:
The cost can be no more than Seventy-Five cents ($.75) per page for paper copies and a
reasonable charge for diagnostic images, plus postage.
Thank you for your anticipated cooperation in this matter.
Sincerely,
a~, ,a~,
Skylar Washabaugh
•.. I.V,. JVV
.:~~,.~~IGt,I,•• AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
~'~'=='~ ~ This form has been approved by the New York State Department of Healthi
Patient Name Date of Birth Social Security Number
Cecilio Vasquez 2-21+-61 xxx-xx-3797
...
Patient Address
76 Fieldstone 81vd. , Wappingers Falls, NY 12590
i, or my autmonzeq 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 Rulc of the Health lnsurance Portability and Accountability Act off 996
(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 1
initial the line on the box in Item 9{a), 1 specifically authorize release of such information to the persons} indicated in Item 8.
2. If I am authorizing the release of H1V-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 I have the right to request a list of people who may receive or use my HfV-related information without authorization. ]f
1 experience discrimination because of the release or disclosure ofHIV-related information, 1 may contact the New York State Division
of Human Rights at (2I2) 48Q-2493 or the New York City Commission of Human Rights at (212} 30ti-745Q. 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, ]understand that I may
revoke this authorization except to the extent that action has already been taken based on this authorization.
4. 1 understand that signing this authorization is voluntary, My treatment, payment, enrollment in a health plan, or eligibility for
benefits will .not 6e conditioned upon my authorization of this disclosure.
S. Information disclosed under this authorization might be redisclosed by the recipient {except as noted above in ]tern 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 ATTnRIVFV nR rnvFVUnt~,vT., ..-~,.~,-.. C.,....,..,~.~ ._.._-__ _
----- ---°---- ...~~..~......a..•...~.~r~urwrft~t.~ J1-r.WClt'.UIIV lIL'My(b~
7. Name and address of health provider or entity to release this information: ~'-""----
Town of Wappingers Fails, 20 Middlebush Road, Wappingers Falls, NY 12590
8. Name and address of erson s or Cate o of `~""`
p {) g ry person to whom this information will be sent: ___.~~_
Law Offices of_ E stein ~ Ra hill 565 Taxter Ro Elmsfor
.
~ ~Y 10+~~,3
~a-
.
.
- .
9(a}, Specific information to be released; •-
^Medical Record from (insert date) to (insert date)
0 Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies
f:]ms
,
,
referrals, consults, billing records, insurance records, and records sent to you by other health care providers
.
i (Other: medical records Include; (Indicate by ]nriialing)
application for handicap driving sticker
Alcohol/Drug Treatment
Mental Health Information
Authorization to Discuss Health Information HIV-Related Information
(b) ^ l3y initialing here C authorize
Initials Name of indivdual health care provider
to discuss my health information with my attorney, or a governmental agency
listed here:
,
_(Attorney/Firm Name or Governmental Agency Name)
~_~.
~ ..~
10 Reason for release of information: I t. Date or event on which this authorization will expire:
l.~ At request of individual
_ __~~pthert lilt ation one year
~
12, If not the patient, name of person signing form: 13. Authority to sign on behalf of patient:
i em n ~s orm ave een comp ete and my questions about this form have been answered, In addition, t have been provided a
top oft form.
~~ . ...._. _ _ _ _ Date:
Signature of patient or rcpr en ? ve authorized by law_
Human Immunodeficiency Virus that causes AIRS. The New York State Public Health L.aw protects information which reasonably could
identify someone as having HIV symptoms or infection and information regarding a person's Contacts,
LAW OFFICES
EPSTEIN & R.AYHILL
TRACEY J. EPSTEIN Employees of Nationwide Mutual Insurance Company® PARALEGALS
CECIL E. FLOYD Not a Partnership
AYLA DAMS
DANIEL J. GENOVESE SUITE 275 JOANNE L. MANGUSI
DAVID M. HEELER
KAREN QUEENAN 565 TARTER ROAD JOSEPHINE B. WALSH
BRIAN J. RAYHILL ELMSFORD, NY 10523
JONATHAN R. WALSH -- -_
9143476360
FAX (914) 347.7017
To Whom It May Concern:
Please be advised that Litigation Solutions has been retained by the Law Offices of
Epstein &Rayhill for the purposes of record retrieval. Please let this also serve as
authorization for Litigation Solutions to request, retrieve, copy and/or scan medical
records, including medical bills and/or employment records on behalf of the Law Offices
of Epstein &Rayhill.
If there are any questions or concerns, please feel free to contact the undersigned.
Sincerely,
Epstein and Rayhill