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Filing # 98588586 E-Filed 11/08/2019 09:36:21 AM
IN THE CIRCUIT COURT OF THE 15TH
JUDICIAL CIRCUIT IN AND FOR PALM
BEACH COUNTY, FLORIDA
CASE NO.: 50-2018-CA-15763-XXXX-
MB
ELIZABETH L. BALZARANO, Individually,
and as Personal Representative of the
ESTATE OF MICHEELE k: BALZARANO;~
Plaintiffs,
Vv.
LIFELINE RECOVERY, LLC d/b/a LIFELINE
RECOVERY SUPPORT SERVICES, a
Foreign Corporation; JOHN BROGAN; LIFE
CHANGES ADDICTION TREATMENT
CENTER OF THE PALM BEACHES; and
CAMERON VILLA, LLC, a Florida
Corporation, :
Defendants.
/
DEFENDANT’S FOURTH REQUEST FOR PRODUCTION TO PLAINTIFF
Defendant, LIFE CHANGES ADDICTION TREATMENT CENTER OF THE PALM
BEACHES, by and through undersigned counsel, pursuant to Rule 1.350, Florida Rules
of Civil Procedure, requests that the Plaintiff, ELIZABETH L. BALZARANO,
INDIVIDUALLY, AND AS PERSONAL REPRESENTATIVE OF THE ESTATE OF
MICHELLE L. BALZARANO, produce and permit the inspection and copying, within thirty
(30) days of service hereof, the following documents, writings, and other data, at the office
of the undersigned:
COLE, SCOTT & KISSANE, P.A.
‘COLE, SCOTT & KISSANE BUILDING - 9150SOUTH DADELAND BOULEVARD - SUITE 1400 - P.O, BOX 369015 - MIAMI, FLORIDA 33256 - (305) 350-5300 ~ (308) 373-2294 FAX
*** FILED: PALM BEACH COUNTY, FL SHARON R BOCK, CLERK. 11/08/2019 09:36:21 AM ***CASE NO.: 50-2018-CA-15763-XXXX-MB
1. An executed Authorization for Disclosure of Protected Health Information to
obtain the records from Jersey Shore Medical Center. (Authorization is
attached)
CERTIFICATE OF SERVICE
| HEREBY CERTIFY that on this “Hh, of November, 2019, a true and correct
a of the foregoing was filed with the Clerk of Palm Beach County by using the Florida
Courts e-Filing Portal, which will send an automatic e-mail message to the following
parties registered with the e-Filing Portal system: Thomas Scolaro, Esq., and Thomas
Graham, Esq., Leesfield, Scolaro, P.A., 2350 S. Dixie Highway, Miami, FL 33133,
Attorneys for Plaintiffs.
COLE, SCOTT & KISSANE, P.A.
Counsel for Defendant Life Changes Addiction
Treatment Center of the Palm Beaches
Cole, Scott & Kissane Building
9150 South Dadeland Boulevard, Suite 1400
P.O. Box 569015
Miami, Florida 33256
Telephone (954) 703-3770
Facsimile (305) 373-2294
Primary e-mail: alyssa.tornberg@csklegal.com
Secondary e-mail: jonathan.midwall@csklegal.com
Alternate e-mail: omaira.garcia@csklegal.com
By: _s/ Alyssa M. Tornber:
JONATHAN M. MIDWALL
Florida Bar No.; 182011
ALYSSA M. TORNBERG
Florida Bar No.: 127409
1943,0485-00/13894993
-2-
COLE, SCOTT & KISSANE, P.A.
(COLE, SCOTT & KISSANE BUILDING - 9150 SOUTH DADELAND BOULEVARD - SUITE 400 - P.O. BOX 565015 MIAMI, FLORIDA 23256 - (205) 350-5200 - (45) 373-2194 FAX({43u0- {6
Authorization To Release Medical Records:
PATIENT INFORMATION:
Nag it -
men Hichele (Balzarano “3 hol #3
FO! OBE EASED i
Mnvsnemrerreie Terses) “Shore Medical Contr Mosc Py kun
ren _Ihys New “Jerse 33 Neots City VF. 01153
< INFORMATION To BE SENT TO; ;
: eI oe eI
Nan of designated erent V Onathon HH. Miduatl Esqclo The Mes crop Tun.
mates 1475 NW \2™ Steet ike. 318 Miami SH Rezieg
INFORMATION TO BE RELEASED: {oheok one}
[ha most recent 2 years of nent information (chart notes, jabs, x-rays and special tests) .
All-medioa! records: \/ _ Billing records. __\"_ any and ail radiolgical studies (MRI's, CT Scans, X-rays et al)
Specific information {please specify)
x Attomey ——_. Insurance Doctor Personal
PATIENT AUTHORIZATION :
{understand that my records may contain information regarding the diagnosis or treatment of HIMIAIDS, sexually
transmitted diseases, drug and/or alcoho! abuse, mental tliness, or psychiatric treatment. | give my specific authorization
for these records to be released.
* EXCLUDE the following information from the records released (please Initial)
Drug / Alcohol abuse/treatment & diagnosis Sexually transmitted disease
HIVIAIDS diagnosis/treatmentiesting Mental iliness or psychiatric diagnosisitreatment
MY RIGHTS:
| understand | do not have to sign this authorization in order to obtain health care benefits (treatment, payment or
enrafiment). | may revoke this authorization In writing. To view the process for ravaking this authorization, Please read the
Privacy Notice to patients posted at the facility where your information is being released, | understand that once the
health information | have authorized to be disclosed reaches the noted recipient, that person or organization may re~
disclose tt, at which time it may no longer be protected under Privacy laws.
Signature: Date:
(Patient, guardian’, or Authorized representative*)
This authorization will expire 1 year from the date signed
Possible copying fee required
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Filing # 98588586 E-Filed 11/08/2019 09:36:21 AM IN THE CIRCUIT COURT OF THE 15TH JUDICIAL CIRCUIT IN AND FOR PALM BEACH COUNTY, FLORIDA CASE NO.: 50-2018-CA-15763-XXXX- MB ELIZABETH L. BALZARANO, Individually, and as Personal Representative of the ESTATE OF MICHEELE k: BALZARANO;~ Plaintiffs, Vv. LIFELINE RECOVERY, LLC d/b/a LIFELINE RECOVERY SUPPORT SERVICES, a Foreign Corporation; JOHN BROGAN; LIFE CHANGES ADDICTION TREATMENT CENTER OF THE PALM BEACHES; and CAMERON VILLA, LLC, a Florida Corporation, : Defendants. / DEFENDANT’S FOURTH REQUEST FOR PRODUCTION TO PLAINTIFF Defendant, LIFE CHANGES ADDICTION TREATMENT CENTER OF THE PALM BEACHES, by and through undersigned counsel, pursuant to Rule 1.350, Florida Rules of Civil Procedure, requests that the Plaintiff, ELIZABETH L. BALZARANO, INDIVIDUALLY, AND AS PERSONAL REPRESENTATIVE OF THE ESTATE OF MICHELLE L. BALZARANO, produce and permit the inspection and copying, within thirty (30) days of service hereof, the following documents, writings, and other data, at the office of the undersigned: COLE, SCOTT & KISSANE, P.A. ‘COLE, SCOTT & KISSANE BUILDING - 9150SOUTH DADELAND BOULEVARD - SUITE 1400 - P.O, BOX 369015 - MIAMI, FLORIDA 33256 - (305) 350-5300 ~ (308) 373-2294 FAX *** FILED: PALM BEACH COUNTY, FL SHARON R BOCK, CLERK. 11/08/2019 09:36:21 AM ***CASE NO.: 50-2018-CA-15763-XXXX-MB 1. An executed Authorization for Disclosure of Protected Health Information to obtain the records from Jersey Shore Medical Center. (Authorization is attached) CERTIFICATE OF SERVICE | HEREBY CERTIFY that on this “Hh, of November, 2019, a true and correct a of the foregoing was filed with the Clerk of Palm Beach County by using the Florida Courts e-Filing Portal, which will send an automatic e-mail message to the following parties registered with the e-Filing Portal system: Thomas Scolaro, Esq., and Thomas Graham, Esq., Leesfield, Scolaro, P.A., 2350 S. Dixie Highway, Miami, FL 33133, Attorneys for Plaintiffs. COLE, SCOTT & KISSANE, P.A. Counsel for Defendant Life Changes Addiction Treatment Center of the Palm Beaches Cole, Scott & Kissane Building 9150 South Dadeland Boulevard, Suite 1400 P.O. Box 569015 Miami, Florida 33256 Telephone (954) 703-3770 Facsimile (305) 373-2294 Primary e-mail: alyssa.tornberg@csklegal.com Secondary e-mail: jonathan.midwall@csklegal.com Alternate e-mail: omaira.garcia@csklegal.com By: _s/ Alyssa M. Tornber: JONATHAN M. MIDWALL Florida Bar No.; 182011 ALYSSA M. TORNBERG Florida Bar No.: 127409 1943,0485-00/13894993 -2- COLE, SCOTT & KISSANE, P.A. (COLE, SCOTT & KISSANE BUILDING - 9150 SOUTH DADELAND BOULEVARD - SUITE 400 - P.O. BOX 565015 MIAMI, FLORIDA 23256 - (205) 350-5200 - (45) 373-2194 FAX({43u0- {6 Authorization To Release Medical Records: PATIENT INFORMATION: Nag it - men Hichele (Balzarano “3 hol #3 FO! OBE EASED i Mnvsnemrerreie Terses) “Shore Medical Contr Mosc Py kun ren _Ihys New “Jerse 33 Neots City VF. 01153 < INFORMATION To BE SENT TO; ; : eI oe eI Nan of designated erent V Onathon HH. Miduatl Esqclo The Mes crop Tun. mates 1475 NW \2™ Steet ike. 318 Miami SH Rezieg INFORMATION TO BE RELEASED: {oheok one} [ha most recent 2 years of nent information (chart notes, jabs, x-rays and special tests) . All-medioa! records: \/ _ Billing records. __\"_ any and ail radiolgical studies (MRI's, CT Scans, X-rays et al) Specific information {please specify) x Attomey ——_. Insurance Doctor Personal PATIENT AUTHORIZATION : {understand that my records may contain information regarding the diagnosis or treatment of HIMIAIDS, sexually transmitted diseases, drug and/or alcoho! abuse, mental tliness, or psychiatric treatment. | give my specific authorization for these records to be released. * EXCLUDE the following information from the records released (please Initial) Drug / Alcohol abuse/treatment & diagnosis Sexually transmitted disease HIVIAIDS diagnosis/treatmentiesting Mental iliness or psychiatric diagnosisitreatment MY RIGHTS: | understand | do not have to sign this authorization in order to obtain health care benefits (treatment, payment or enrafiment). | may revoke this authorization In writing. To view the process for ravaking this authorization, Please read the Privacy Notice to patients posted at the facility where your information is being released, | understand that once the health information | have authorized to be disclosed reaches the noted recipient, that person or organization may re~ disclose tt, at which time it may no longer be protected under Privacy laws. Signature: Date: (Patient, guardian’, or Authorized representative*) This authorization will expire 1 year from the date signed Possible copying fee required