Preview
MER-L-001657-22 04/12/2023 10:53:07 AM Pg 1 of 6 Trans ID: LCV20231247065
LAW OFFICE OF
CHARLES A. LITTLE, JR.
EMPLOYEES OF NATIONWIDE® MUTUAL INSURANCE COMPANY
NOT A LEGAL PARTNERSHIP OR PROFESSIONAL CORPORATION
CHARLES A. LITTLE, JR. 304 HARPER DRIVE, SUITE 202
MANAGING TRIAL ATTORNEY MOORESTOWN, NEW JERSEY 08057
DONALD J. BIGLEY TELEPHONE: (856) 291-7500
TIMOTHY P. SEARCH FACSIMILE: (855) 202-0107
JILL L. TEAGUE Direct Dial No.: (856) 291-7505
THOMAS L. WILKINSON EMAIL: jteague@nationwide.com
April 12, 2023
Mercer County Superior Court
Law Division – Civil Motions Clerk
175 South Broad Street
Trenton, NJ 08650
RE: Banzragch v. Husseini, et al.
Docket No.: MER-L-1657-22
Claim No.: 493627-GL
DOL: 1/22/2021
LF: 22-012388
Dear Sir/Madam:
Enclosed please find the following:
(x) Notice of Motion to Compel Plaintiff to Execute Authorizations
Please charge account #146155 for the filing fee.
Thank you for your attention to this matter.
Very truly yours,
Jill L. Teague
JILL L. TEAGUE
JLT/sts
Enclosures
cc: Gabriel R. Lependorf, Esquire
Edward Orrison, Jr./Harleysville Insurance Company
MER-L-001657-22 04/12/2023 10:53:07 AM Pg 2 of 6 Trans ID: LCV20231247065
LAW OFFICE OF
CHARLES A. LITTLE, JR.
Jill Teague, Esquire NJ ID: 028991995
304 Harper Drive, Suite 202
Moorestown, NJ 08057
T: 856-291-7512 / Fax No: 855-202-0107
Attorneys for Defendants, Mohammad K. Husseini and Rasha Darah-Tahhan
LILLY L. BANZRAGCH : SUPERIOR COURT OF NEW JERSEY
Plaintiff : LAW DIVISION – MERCER COUNTY
: DOCKET NO.: MER-L-1657-22
-vs- :
: CIVIL ACTION
MOHAMMAD K. HUSSEINI and RASHA :
DARAH-TAHHAN :
Defendants : NOTICE OF MOTION TO COMPEL
: PLAINTIFF TO EXECUTE
: AUTHORIZATIONS
:
:
:
TO: Gabriel R. Lependorf, Esquire
Attorney for Plaintiff, Lilly L. Banzragch
PLEASE TAKE NOTICE that on Friday, April 28, 2023, the undersigned counsel will
apply to the Superior Court of New Jersey, Law Division, Mercer County Court House, in Trenton,
New Jersey, for an Order to Compel Plaintiff to Execute Authorizations for the release of records
from Capital Health Regional Medical Center, Mercer Diagnostic Imaging and Precision Pain &
Spine Institute.
PLEASE TAKE FURTHER NOTICE that Defendants will rely upon counsel’s
Certification, attached hereto, in support of this Motion; and
PLEASE TAKE FURTHER NOTICE that pursuant to R. 1:6-2, Defendants:
(x) waive oral argument and consent to the disposition on the papers unless opposition
is received.
MER-L-001657-22 04/12/2023 10:53:07 AM Pg 3 of 6 Trans ID: LCV20231247065
() request oral argument.
A proposed form of Order is attached.
Discovery End Date: September 24, 2023
Arbitration Date: None
Calendar Call: None
Pre-Trial Conference: None
Trial Date: None
Dated: April 12, 2023 BY: Jill L. Teague__________________
Jill L. Teague, Esquire
Attorney for Defendants
MOHAMMAD K. HUSSEINI and
RASHA DARAH-TAHHAN
I hereby certify on the date set forth below, I caused an original and one (1) copy of a
Notice of Motion, Certification of Counsel, proposed Order, and the within Certification of
Service to be sent via e-Courts to:
Superior Court of New Jersey
Mercer County Courthouse
175 South Broad Street
Trenton, NJ 08650
Gabriel R. Lependorf, Esquire
Lependorf & Silverstein, P.C.
4365 Route One South
Princeton, NJ 08540
Dated: April 12, 2023 BY: Jill L. Teague_________________
Jill L. Teague, Esquire
Attorney for Defendants
MOHAMMAD K. HUSSEINI and
RASHA DARAH-TAHHAN
MER-L-001657-22 04/12/2023 10:53:07 AM Pg 4 of 6 Trans ID: LCV20231247065
LAW OFFICE OF
CHARLES A. LITTLE, JR.
Jill Teague, Esquire NJ ID: 028991995
304 Harper Drive, Suite 202
Moorestown, NJ 08057
T: 856-291-7512 / Fax No: 855-202-0107
Attorneys for Defendants, Mohammad K. Husseini and Rasha Darah-Tahhan
LILLY L. BANZRAGCH : SUPERIOR COURT OF NEW JERSEY
Plaintiff : LAW DIVISION – MERCER COUNTY
: DOCKET NO.: MER-L-1657-22
-vs- :
: CIVIL ACTION
MOHAMMAD K. HUSSEINI and RASHA :
DARAH-TAHHAN :
Defendants : ATTORNEY CERTIFICAITON
:
:
:
:
:
I, Jill L. Teague, Esquire hereby certify and say:
1. I am an attorney at law licensed to practice in the State of New Jersey and an
Associate of the Law Office of Charles A. Little, Jr.
2. I am an attorney entrusted with the facts and circumstances of this matter and am
fully familiar with the facts and circumstances regarding this matter.
3. On February 6, 2023, authorizations for the release of records from Capital Health
Regional Medical Center, Mercer Diagnostic Imaging and Precision Pain & Spine Institute were
forwarded to Plaintiff’s Counsel (See attached hereto Exhibit “A”).
4. Several telephone calls were placed to Plaintiff’s Counsel’s office requesting
these authorizations.
5. On March 22, 2023, an email was sent to Plaintiff’s Counsel’s office requesting
the outstanding overdue authorizations (See attached hereto Exhibit “B”).
MER-L-001657-22 04/12/2023 10:53:07 AM Pg 5 of 6 Trans ID: LCV20231247065
6. To date, the executed authorizations have not been returned.
7. Accordingly, Defendants request that the Court enter an Order Compelling
Plaintiff to Execute the authorizations for the release of records from Capital Health Regional
Medical Center, Mercer Diagnostic Imaging and Precision Pain & Spine Institute.
8. I certify the foregoing statements made by me are true. I am aware that if any of
the statements are willfully false I am subject to punishment.
Dated: April 12, 2023 BY: Jill L. Teague___________________
Jill L. Teague, Esquire
Attorney for Defendants
MOHAMMAD K, HUSSEINI and
RASHA DARAH-TAHHAN
MER-L-001657-22 04/12/2023 10:53:07 AM Pg 6 of 6 Trans ID: LCV20231247065
LAW OFFICE OF
CHARLES A. LITTLE, JR.
Jill Teague, Esquire NJ ID: 028991995
304 Harper Drive, Suite 202
Moorestown, NJ 08057
T: 856-291-7512 / Fax No: 855-202-0107
Attorneys for Defendants, Mohammad K. Husseini and Rasha Darah-Tahhan
LILLY L. BANZRAGCH : SUPERIOR COURT OF NEW JERSEY
Plaintiff : LAW DIVISION – MERCER COUNTY
: DOCKET NO.: MER-L-1657-22
-vs- :
: CIVIL ACTION
MOHAMMAD K. HUSSEINI and RASHA :
DARAH-TAHHAN :
Defendants : ORDER TO COMPEL PLAINTIFF TO
: EXECUTE AUTHORIZATIONS
:
:
:
:
THIS MATTER having been opened before the Court by Jill L. Teague, Esquire, of the
Law Office of Charles A. Little, Jr., attorneys for the Defendants, MOHAMMAD K. HUSSEINI
and RASHA DARAH-TAHHAN, for an Order to Compel Plaintiff to Execute Authorizations for
the release of records from Capital Health Regional Medical Center, Mercer Diagnostic Imaging
and Precision Pain & Spine Institute; and for good cause shown;
IT IS on this ____ day of April, 2023, ORDERED that Plaintiff execute the authorizations
for the release of records from Capital Health Regional Medical Center, Mercer Diagnostic
Imaging and Precision Pain & Spine Institute within _____________ days of the date of this Order;
IT IS FURTHER ORDERED that a copy of this Order shall be deemed served upon all
counsel via electronic upload to e-Courts.
__________________________________________
J.S.C.
MER-L-001657-22 04/12/2023 10:53:07 AM Pg 1 of 1 Trans ID: LCV20231247065
LAW OFFICE OF
CHARLES A. LITTLE, JR.
Jill Teague, Esquire NJ ID: 028991995
304 Harper Drive, Suite 202
Moorestown, NJ 08057
T: 856-291-7512 / Fax No: 855-202-0107
Attorneys for Defendants, Mohammad K. Husseini and Rasha Darah-Tahhan
LILLY L. BANZRAGCH : SUPERIOR COURT OF NEW JERSEY
Plaintiff : LAW DIVISION – MERCER COUNTY
: DOCKET NO.: MER-L-1657-22
-vs- :
: CIVIL ACTION
MOHAMMAD K. HUSSEINI and RASHA :
DARAH-TAHHAN :
Defendants : ORDER TO COMPEL PLAINTIFF TO
: EXECUTE AUTHORIZATIONS
:
:
:
:
THIS MATTER having been opened before the Court by Jill L. Teague, Esquire, of the
Law Office of Charles A. Little, Jr., attorneys for the Defendants, MOHAMMAD K. HUSSEINI
and RASHA DARAH-TAHHAN, for an Order to Compel Plaintiff to Execute Authorizations for
the release of records from Capital Health Regional Medical Center, Mercer Diagnostic Imaging
and Precision Pain & Spine Institute; and for good cause shown;
IT IS on this ____ day of April, 2023, ORDERED that Plaintiff execute the authorizations
for the release of records from Capital Health Regional Medical Center, Mercer Diagnostic
Imaging and Precision Pain & Spine Institute within _____________ days of the date of this Order;
IT IS FURTHER ORDERED that a copy of this Order shall be deemed served upon all
counsel via electronic upload to e-Courts.
__________________________________________
J.S.C.
MER-L-001657-22 04/12/2023 10:53:07 AM Pg 1 of 4 Trans ID: LCV20231247065
ISG
Lisa Belden
275 Curry Hollow Road
Building 1 Suite 150
Pittsburgh, PA 15236
Phone: (412) 240-4443
Fax: 1(412)785-3880
Email: lbelden@isgvalue.com
File Upload: www.litsol.com/filemail
Gabriel Lependorf, Esquire
Lependorf & Silverstein
4365 Route One South
Suite #104
Princeton, NJ 08540
February 06, 2023
RE: Subject: Lilly Banzragch
Case: Banzragch vs. Husseini
Case #: MER-L-1657-22
Claim #: 493627-GL
Dear Gabriel Lependorf, Esquire
ISG, is a legal services firm located in Pittsburgh, PA and we have been retained by Jill Teague,
Esquire of Law Office of Charles A. Little, Jr., to secure authorizations for the release of records
regarding your client Lilly Banzragch.
Please forward the requested signed authorizations to my attention within fifteen (15) days so
we can efficiently handle these requests. If you are unwilling to forward the executed
authorizations, please advise and we will notify our client accordingly.
If you have any questions regarding this request, please feel free to call me at (412) 240-4443.
Sincerely,
Lisa Belden
ISG
Jill Teague, Esquire
Law Office of Charles A. Little, Jr.
304 Harper Drive
Suite 202
Moorestown, NJ 08057
856-291-7500
MER-L-001657-22 04/12/2023 10:53:07 AM Pg 2 of 4 Trans ID: LCV20231247065
HIPAA Authorization for Disclosure of Health Information
I hereby authorize Capital Health Regional Medical Center to release medical information for the records of:
(Name of Facility)
Patient Name: Lilly Banzragch D.O.B.: 01/31/1968 SSN: 594-17-0634
Patient Street Address: 4404 Sayre Drive
City: Princeton State: NJ Zip Code: 08540
Date(s) of Treatment Requested: DOB to PRESENT
Information to be disclosed (check all applicable items to be released):
X Discharge Summary X ER Record X Progress Notes
X Discharge Instructions X X-Rays, MRIs, CTs & Reports X Medication Records
X History and Physical X Lab Reports X Doctor's Orders
X Consultations X EKG/ECG Tests X Nurse's Notes
X Operative Report X Therapy Notes X Treatment Plans
X Commitment Papers
X HIV Testing
X Alcohol/Drug Treatment
X Mental Health Information
X Billing
Other (please specify):
Purpose Or Need For The Disclosure Is:
Continued Medical Care Insurance X Legal Patient's Own Use Other
The Information May Be Disclosed To:
Recipient's Name: ISG
Street Address: 275 Curry Hollow Road, Building 1 Suite 150
City: Pittsburgh State: PA Zip Code: 15236
Phone #: (412) 240-4443 Fax #: 1(412)785-3880
My refusal to sign this form will not adversely affect my ability to receive health care services, reimbursement for services, enrollment in a health plan or
my eligibility for health benefits. However, information will not be released to the above-indicated recipient without my signature.
I acknowledge that the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by
Federal Law.
I have the right to revoke this authorization by written notice to the Healthcare Provider listed above. I understand that actions taken in reliance on this
authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires on: or upon the following event: one year from date of signature.
(Date)
(If no date or event is specified, this authorization will expire in six months from the date of signature.)
I understand that the information in my medical record may include information relating to treatment of drug or alcohol abuse, mental health, sexually
transmitted disease, acquired immunodeficiency syndrome (AIDS), AIDS related complex (ARC) and/or human immunodeficiency virus (HIV).
Fees: I understand and agree what there may be costs associated with this request in compliance with State copying laws.
(Signature of Patient or Personal Representative*) (Date of Signature)
*If signed by a personal representative, a description of the representative's authority to act is as follows:
Parent Legal Guardian Health Care Power of Attorney
Administrator Executor of Estate Next of Kin Beneficiary
Date:
Signature of Witness
MER-L-001657-22 04/12/2023 10:53:07 AM Pg 3 of 4 Trans ID: LCV20231247065
HIPAA Authorization for Disclosure of Health Information
I hereby authorize Mercer Diagnostic Imaging to release medical information for the records of:
(Name of Facility)
Patient Name: Lilly Banzragch D.O.B.: 01/31/1968 SSN: 594-17-0634
Patient Street Address: 4404 Sayre Drive
City: Princeton State: NJ Zip Code: 08540
Date(s) of Treatment Requested: DOB to PRESENT
Information to be disclosed (check all applicable items to be released):
X Discharge Summary X ER Record X Progress Notes
X Discharge Instructions X X-Rays, MRIs, CTs & Reports X Medication Records
X History and Physical X Lab Reports X Doctor's Orders
X Consultations X EKG/ECG Tests X Nurse's Notes
X Operative Report X Therapy Notes X Treatment Plans
X Commitment Papers
X HIV Testing
X Alcohol/Drug Treatment
X Mental Health Information
X Billing
Other (please specify):
Purpose Or Need For The Disclosure Is:
Continued Medical Care Insurance X Legal Patient's Own Use Other
The Information May Be Disclosed To:
Recipient's Name: ISG
Street Address: 275 Curry Hollow Road, Building 1 Suite 150
City: Pittsburgh State: PA Zip Code: 15236
Phone #: (412) 240-4443 Fax #: 1(412)785-3880
My refusal to sign this form will not adversely affect my ability to receive health care services, reimbursement for services, enrollment in a health plan or
my eligibility for health benefits. However, information will not be released to the above-indicated recipient without my signature.
I acknowledge that the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by
Federal Law.
I have the right to revoke this authorization by written notice to the Healthcare Provider listed above. I understand that actions taken in reliance on this
authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires on: or upon the following event: one year from date of signature.
(Date)
(If no date or event is specified, this authorization will expire in six months from the date of signature.)
I understand that the information in my medical record may include information relating to treatment of drug or alcohol abuse, mental health, sexually
transmitted disease, acquired immunodeficiency syndrome (AIDS), AIDS related complex (ARC) and/or human immunodeficiency virus (HIV).
Fees: I understand and agree what there may be costs associated with this request in compliance with State copying laws.
(Signature of Patient or Personal Representative*) (Date of Signature)
*If signed by a personal representative, a description of the representative's authority to act is as follows:
Parent Legal Guardian Health Care Power of Attorney
Administrator Executor of Estate Next of Kin Beneficiary
Date:
Signature of Witness
MER-L-001657-22 04/12/2023 10:53:07 AM Pg 4 of 4 Trans ID: LCV20231247065
HIPAA Authorization for Disclosure of Health Information
I hereby authorize Precision Pain & Spine Institute to release medical information for the records of:
(Name of Facility)
Patient Name: Lilly Banzragch D.O.B.: 01/31/1968 SSN: 594-17-0634
Patient Street Address: 4404 Sayre Drive
City: Princeton State: NJ Zip Code: 08540
Date(s) of Treatment Requested: DOB to PRESENT
Information to be disclosed (check all applicable items to be released):
X Discharge Summary X ER Record X Progress Notes
X Discharge Instructions X X-Rays, MRIs, CTs & Reports X Medication Records
X History and Physical X Lab Reports X Doctor's Orders
X Consultations X EKG/ECG Tests X Nurse's Notes
X Operative Report X Therapy Notes X Treatment Plans
X Commitment Papers
X HIV Testing
X Alcohol/Drug Treatment
X Mental Health Information
X Billing
Other (please specify):
Purpose Or Need For The Disclosure Is:
Continued Medical Care Insurance X Legal Patient's Own Use Other
The Information May Be Disclosed To:
Recipient's Name: ISG
Street Address: 275 Curry Hollow Road, Building 1 Suite 150
City: Pittsburgh State: PA Zip Code: 15236
Phone #: (412) 240-4443 Fax #: 1(412)785-3880
My refusal to sign this form will not adversely affect my ability to receive health care services, reimbursement for services, enrollment in a health plan or
my eligibility for health benefits. However, information will not be released to the above-indicated recipient without my signature.
I acknowledge that the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by
Federal Law.
I have the right to revoke this authorization by written notice to the Healthcare Provider listed above. I understand that actions taken in reliance on this
authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires on: or upon the following event: one year from date of signature.
(Date)
(If no date or event is specified, this authorization will expire in six months from the date of signature.)
I understand that the information in my medical record may include information relating to treatment of drug or alcohol abuse, mental health, sexually
transmitted disease, acquired immunodeficiency syndrome (AIDS), AIDS related complex (ARC) and/or human immunodeficiency virus (HIV).
Fees: I understand and agree what there may be costs associated with this request in compliance with State copying laws.
(Signature of Patient or Personal Representative*) (Date of Signature)
*If signed by a personal representative, a description of the representative's authority to act is as follows:
Parent Legal Guardian Health Care Power of Attorney
Administrator Executor of Estate Next of Kin Beneficiary
Date:
Signature of Witness
MER-L-001657-22 04/12/2023 10:53:07 AM Pg 1 of 2 Trans ID: LCV20231247065
Turella-Smith, Susan L
From: Lisa Belden
Sent: Wednesday, April 12, 2023 9:17 AM
To: Turella-Smith, Susan L
Subject: [EXTERNAL] Fw: Lilly Banzragch
Attachments: Auth to PC_Capital Health Regional_Banzragch.pdf; Auth to PC_Mercer Diagnostic
Imaging.pdf; Auth to PC_ Precision Pain and Spine.pdf
Nationwide Information Security Warning: This is an EXTERNAL email. Use CAUTION before clicking on links, opening
attachments, or responding. (Sender: lbelden@isgvalue.com)
Due to delivery delays via the US Postal Service, it is being asked that any information or request responses be
sent to me electronically via email at LBelden@isgvalue.com, via fax at 412-785-3880, or via our secure portal at
www.litsol.com/filemail. Thank you for your anticipated cooperation.
Lisa Belden | ISG | Record Retrieval Specialist
T 412-240-4443 | F 412-785-3880 | LBelden@isgvalue.com
Connect with ISG: website | LinkedIn | Facebook | Twitter | Instagram
Please note that I am currently in training. My Team Lead is Danielle Caruso and can be reached by
email dcaruso@isgvalue.com if you need further assistance.
From: Lisa Belden
Sent: Wednesday, March 22, 2023 3:25 PM
To: doreen@lependorf.com
Subject: Lilly Banzragch
Good afternoon,
I tried mailing some procured authorizations to your office for signatures, but they were returned as Not
Deliverable. I have attached them to this email, please return them to me as soon as possible so I can continue
with retrieving records.
Thank you.
Due to delivery delays via the US Postal Service, it is being asked that any information or request responses be
sent to me electronically via email at LBelden@isgvalue.com, via fax at 412-785-3880, or via our secure portal at
www.litsol.com/filemail. Thank you for your anticipated cooperation.
Lisa Belden | ISG | Record Retrieval Specialist
T 412-240-4443 | F 412-785-3880 | LBelden@isgvalue.com
Connect with ISG: website | LinkedIn | Facebook | Twitter | Instagram
1
MER-L-001657-22 04/12/2023 10:53:07 AM Pg 2 of 2 Trans ID: LCV20231247065
Please note that I am currently in training. My Team Lead is Danielle Caruso and can be reached by
email dcaruso@isgvalue.com if you need further assistance.
Disclaimer
The information contained in this communication from the sender is confidential. It is intended solely for use by the
recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure,
copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be
unlawful.
2
Preview
MER-L-001657-22 04/12/2023 10:53:07 AM Pg 1 of 6 Trans ID: LCV20231247065 LAW OFFICE OF CHARLES A. LITTLE, JR. EMPLOYEES OF NATIONWIDE® MUTUAL INSURANCE COMPANY NOT A LEGAL PARTNERSHIP OR PROFESSIONAL CORPORATION CHARLES A. LITTLE, JR. 304 HARPER DRIVE, SUITE 202 MANAGING TRIAL ATTORNEY MOORESTOWN, NEW JERSEY 08057 DONALD J. BIGLEY TELEPHONE: (856) 291-7500 TIMOTHY P. SEARCH FACSIMILE: (855) 202-0107 JILL L. TEAGUE Direct Dial No.: (856) 291-7505 THOMAS L. WILKINSON EMAIL: jteague@nationwide.com April 12, 2023 Mercer County Superior Court Law Division – Civil Motions Clerk 175 South Broad Street Trenton, NJ 08650 RE: Banzragch v. Husseini, et al. Docket No.: MER-L-1657-22 Claim No.: 493627-GL DOL: 1/22/2021 LF: 22-012388 Dear Sir/Madam: Enclosed please find the following: (x) Notice of Motion to Compel Plaintiff to Execute Authorizations Please charge account #146155 for the filing fee. Thank you for your attention to this matter. Very truly yours, Jill L. Teague JILL L. TEAGUE JLT/sts Enclosures cc: Gabriel R. Lependorf, Esquire Edward Orrison, Jr./Harleysville Insurance Company MER-L-001657-22 04/12/2023 10:53:07 AM Pg 2 of 6 Trans ID: LCV20231247065 LAW OFFICE OF CHARLES A. LITTLE, JR. Jill Teague, Esquire NJ ID: 028991995 304 Harper Drive, Suite 202 Moorestown, NJ 08057 T: 856-291-7512 / Fax No: 855-202-0107 Attorneys for Defendants, Mohammad K. Husseini and Rasha Darah-Tahhan LILLY L. BANZRAGCH : SUPERIOR COURT OF NEW JERSEY Plaintiff : LAW DIVISION – MERCER COUNTY : DOCKET NO.: MER-L-1657-22 -vs- : : CIVIL ACTION MOHAMMAD K. HUSSEINI and RASHA : DARAH-TAHHAN : Defendants : NOTICE OF MOTION TO COMPEL : PLAINTIFF TO EXECUTE : AUTHORIZATIONS : : : TO: Gabriel R. Lependorf, Esquire Attorney for Plaintiff, Lilly L. Banzragch PLEASE TAKE NOTICE that on Friday, April 28, 2023, the undersigned counsel will apply to the Superior Court of New Jersey, Law Division, Mercer County Court House, in Trenton, New Jersey, for an Order to Compel Plaintiff to Execute Authorizations for the release of records from Capital Health Regional Medical Center, Mercer Diagnostic Imaging and Precision Pain & Spine Institute. PLEASE TAKE FURTHER NOTICE that Defendants will rely upon counsel’s Certification, attached hereto, in support of this Motion; and PLEASE TAKE FURTHER NOTICE that pursuant to R. 1:6-2, Defendants: (x) waive oral argument and consent to the disposition on the papers unless opposition is received. MER-L-001657-22 04/12/2023 10:53:07 AM Pg 3 of 6 Trans ID: LCV20231247065 () request oral argument. A proposed form of Order is attached. Discovery End Date: September 24, 2023 Arbitration Date: None Calendar Call: None Pre-Trial Conference: None Trial Date: None Dated: April 12, 2023 BY: Jill L. Teague__________________ Jill L. Teague, Esquire Attorney for Defendants MOHAMMAD K. HUSSEINI and RASHA DARAH-TAHHAN I hereby certify on the date set forth below, I caused an original and one (1) copy of a Notice of Motion, Certification of Counsel, proposed Order, and the within Certification of Service to be sent via e-Courts to: Superior Court of New Jersey Mercer County Courthouse 175 South Broad Street Trenton, NJ 08650 Gabriel R. Lependorf, Esquire Lependorf & Silverstein, P.C. 4365 Route One South Princeton, NJ 08540 Dated: April 12, 2023 BY: Jill L. Teague_________________ Jill L. Teague, Esquire Attorney for Defendants MOHAMMAD K. HUSSEINI and RASHA DARAH-TAHHAN MER-L-001657-22 04/12/2023 10:53:07 AM Pg 4 of 6 Trans ID: LCV20231247065 LAW OFFICE OF CHARLES A. LITTLE, JR. Jill Teague, Esquire NJ ID: 028991995 304 Harper Drive, Suite 202 Moorestown, NJ 08057 T: 856-291-7512 / Fax No: 855-202-0107 Attorneys for Defendants, Mohammad K. Husseini and Rasha Darah-Tahhan LILLY L. BANZRAGCH : SUPERIOR COURT OF NEW JERSEY Plaintiff : LAW DIVISION – MERCER COUNTY : DOCKET NO.: MER-L-1657-22 -vs- : : CIVIL ACTION MOHAMMAD K. HUSSEINI and RASHA : DARAH-TAHHAN : Defendants : ATTORNEY CERTIFICAITON : : : : : I, Jill L. Teague, Esquire hereby certify and say: 1. I am an attorney at law licensed to practice in the State of New Jersey and an Associate of the Law Office of Charles A. Little, Jr. 2. I am an attorney entrusted with the facts and circumstances of this matter and am fully familiar with the facts and circumstances regarding this matter. 3. On February 6, 2023, authorizations for the release of records from Capital Health Regional Medical Center, Mercer Diagnostic Imaging and Precision Pain & Spine Institute were forwarded to Plaintiff’s Counsel (See attached hereto Exhibit “A”). 4. Several telephone calls were placed to Plaintiff’s Counsel’s office requesting these authorizations. 5. On March 22, 2023, an email was sent to Plaintiff’s Counsel’s office requesting the outstanding overdue authorizations (See attached hereto Exhibit “B”). MER-L-001657-22 04/12/2023 10:53:07 AM Pg 5 of 6 Trans ID: LCV20231247065 6. To date, the executed authorizations have not been returned. 7. Accordingly, Defendants request that the Court enter an Order Compelling Plaintiff to Execute the authorizations for the release of records from Capital Health Regional Medical Center, Mercer Diagnostic Imaging and Precision Pain & Spine Institute. 8. I certify the foregoing statements made by me are true. I am aware that if any of the statements are willfully false I am subject to punishment. Dated: April 12, 2023 BY: Jill L. Teague___________________ Jill L. Teague, Esquire Attorney for Defendants MOHAMMAD K, HUSSEINI and RASHA DARAH-TAHHAN MER-L-001657-22 04/12/2023 10:53:07 AM Pg 6 of 6 Trans ID: LCV20231247065 LAW OFFICE OF CHARLES A. LITTLE, JR. Jill Teague, Esquire NJ ID: 028991995 304 Harper Drive, Suite 202 Moorestown, NJ 08057 T: 856-291-7512 / Fax No: 855-202-0107 Attorneys for Defendants, Mohammad K. Husseini and Rasha Darah-Tahhan LILLY L. BANZRAGCH : SUPERIOR COURT OF NEW JERSEY Plaintiff : LAW DIVISION – MERCER COUNTY : DOCKET NO.: MER-L-1657-22 -vs- : : CIVIL ACTION MOHAMMAD K. HUSSEINI and RASHA : DARAH-TAHHAN : Defendants : ORDER TO COMPEL PLAINTIFF TO : EXECUTE AUTHORIZATIONS : : : : THIS MATTER having been opened before the Court by Jill L. Teague, Esquire, of the Law Office of Charles A. Little, Jr., attorneys for the Defendants, MOHAMMAD K. HUSSEINI and RASHA DARAH-TAHHAN, for an Order to Compel Plaintiff to Execute Authorizations for the release of records from Capital Health Regional Medical Center, Mercer Diagnostic Imaging and Precision Pain & Spine Institute; and for good cause shown; IT IS on this ____ day of April, 2023, ORDERED that Plaintiff execute the authorizations for the release of records from Capital Health Regional Medical Center, Mercer Diagnostic Imaging and Precision Pain & Spine Institute within _____________ days of the date of this Order; IT IS FURTHER ORDERED that a copy of this Order shall be deemed served upon all counsel via electronic upload to e-Courts. __________________________________________ J.S.C. MER-L-001657-22 04/12/2023 10:53:07 AM Pg 1 of 1 Trans ID: LCV20231247065 LAW OFFICE OF CHARLES A. LITTLE, JR. Jill Teague, Esquire NJ ID: 028991995 304 Harper Drive, Suite 202 Moorestown, NJ 08057 T: 856-291-7512 / Fax No: 855-202-0107 Attorneys for Defendants, Mohammad K. Husseini and Rasha Darah-Tahhan LILLY L. BANZRAGCH : SUPERIOR COURT OF NEW JERSEY Plaintiff : LAW DIVISION – MERCER COUNTY : DOCKET NO.: MER-L-1657-22 -vs- : : CIVIL ACTION MOHAMMAD K. HUSSEINI and RASHA : DARAH-TAHHAN : Defendants : ORDER TO COMPEL PLAINTIFF TO : EXECUTE AUTHORIZATIONS : : : : THIS MATTER having been opened before the Court by Jill L. Teague, Esquire, of the Law Office of Charles A. Little, Jr., attorneys for the Defendants, MOHAMMAD K. HUSSEINI and RASHA DARAH-TAHHAN, for an Order to Compel Plaintiff to Execute Authorizations for the release of records from Capital Health Regional Medical Center, Mercer Diagnostic Imaging and Precision Pain & Spine Institute; and for good cause shown; IT IS on this ____ day of April, 2023, ORDERED that Plaintiff execute the authorizations for the release of records from Capital Health Regional Medical Center, Mercer Diagnostic Imaging and Precision Pain & Spine Institute within _____________ days of the date of this Order; IT IS FURTHER ORDERED that a copy of this Order shall be deemed served upon all counsel via electronic upload to e-Courts. __________________________________________ J.S.C. MER-L-001657-22 04/12/2023 10:53:07 AM Pg 1 of 4 Trans ID: LCV20231247065 ISG Lisa Belden 275 Curry Hollow Road Building 1 Suite 150 Pittsburgh, PA 15236 Phone: (412) 240-4443 Fax: 1(412)785-3880 Email: lbelden@isgvalue.com File Upload: www.litsol.com/filemail Gabriel Lependorf, Esquire Lependorf & Silverstein 4365 Route One South Suite #104 Princeton, NJ 08540 February 06, 2023 RE: Subject: Lilly Banzragch Case: Banzragch vs. Husseini Case #: MER-L-1657-22 Claim #: 493627-GL Dear Gabriel Lependorf, Esquire ISG, is a legal services firm located in Pittsburgh, PA and we have been retained by Jill Teague, Esquire of Law Office of Charles A. Little, Jr., to secure authorizations for the release of records regarding your client Lilly Banzragch. Please forward the requested signed authorizations to my attention within fifteen (15) days so we can efficiently handle these requests. If you are unwilling to forward the executed authorizations, please advise and we will notify our client accordingly. If you have any questions regarding this request, please feel free to call me at (412) 240-4443. Sincerely, Lisa Belden ISG Jill Teague, Esquire Law Office of Charles A. Little, Jr. 304 Harper Drive Suite 202 Moorestown, NJ 08057 856-291-7500 MER-L-001657-22 04/12/2023 10:53:07 AM Pg 2 of 4 Trans ID: LCV20231247065 HIPAA Authorization for Disclosure of Health Information I hereby authorize Capital Health Regional Medical Center to release medical information for the records of: (Name of Facility) Patient Name: Lilly Banzragch D.O.B.: 01/31/1968 SSN: 594-17-0634 Patient Street Address: 4404 Sayre Drive City: Princeton State: NJ Zip Code: 08540 Date(s) of Treatment Requested: DOB to PRESENT Information to be disclosed (check all applicable items to be released): X Discharge Summary X ER Record X Progress Notes X Discharge Instructions X X-Rays, MRIs, CTs & Reports X Medication Records X History and Physical X Lab Reports X Doctor's Orders X Consultations X EKG/ECG Tests X Nurse's Notes X Operative Report X Therapy Notes X Treatment Plans X Commitment Papers X HIV Testing X Alcohol/Drug Treatment X Mental Health Information X Billing Other (please specify): Purpose Or Need For The Disclosure Is: Continued Medical Care Insurance X Legal Patient's Own Use Other The Information May Be Disclosed To: Recipient's Name: ISG Street Address: 275 Curry Hollow Road, Building 1 Suite 150 City: Pittsburgh State: PA Zip Code: 15236 Phone #: (412) 240-4443 Fax #: 1(412)785-3880 My refusal to sign this form will not adversely affect my ability to receive health care services, reimbursement for services, enrollment in a health plan or my eligibility for health benefits. However, information will not be released to the above-indicated recipient without my signature. I acknowledge that the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by Federal Law. I have the right to revoke this authorization by written notice to the Healthcare Provider listed above. I understand that actions taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. This authorization expires on: or upon the following event: one year from date of signature. (Date) (If no date or event is specified, this authorization will expire in six months from the date of signature.) I understand that the information in my medical record may include information relating to treatment of drug or alcohol abuse, mental health, sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), AIDS related complex (ARC) and/or human immunodeficiency virus (HIV). Fees: I understand and agree what there may be costs associated with this request in compliance with State copying laws. (Signature of Patient or Personal Representative*) (Date of Signature) *If signed by a personal representative, a description of the representative's authority to act is as follows: Parent Legal Guardian Health Care Power of Attorney Administrator Executor of Estate Next of Kin Beneficiary Date: Signature of Witness MER-L-001657-22 04/12/2023 10:53:07 AM Pg 3 of 4 Trans ID: LCV20231247065 HIPAA Authorization for Disclosure of Health Information I hereby authorize Mercer Diagnostic Imaging to release medical information for the records of: (Name of Facility) Patient Name: Lilly Banzragch D.O.B.: 01/31/1968 SSN: 594-17-0634 Patient Street Address: 4404 Sayre Drive City: Princeton State: NJ Zip Code: 08540 Date(s) of Treatment Requested: DOB to PRESENT Information to be disclosed (check all applicable items to be released): X Discharge Summary X ER Record X Progress Notes X Discharge Instructions X X-Rays, MRIs, CTs & Reports X Medication Records X History and Physical X Lab Reports X Doctor's Orders X Consultations X EKG/ECG Tests X Nurse's Notes X Operative Report X Therapy Notes X Treatment Plans X Commitment Papers X HIV Testing X Alcohol/Drug Treatment X Mental Health Information X Billing Other (please specify): Purpose Or Need For The Disclosure Is: Continued Medical Care Insurance X Legal Patient's Own Use Other The Information May Be Disclosed To: Recipient's Name: ISG Street Address: 275 Curry Hollow Road, Building 1 Suite 150 City: Pittsburgh State: PA Zip Code: 15236 Phone #: (412) 240-4443 Fax #: 1(412)785-3880 My refusal to sign this form will not adversely affect my ability to receive health care services, reimbursement for services, enrollment in a health plan or my eligibility for health benefits. However, information will not be released to the above-indicated recipient without my signature. I acknowledge that the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by Federal Law. I have the right to revoke this authorization by written notice to the Healthcare Provider listed above. I understand that actions taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. This authorization expires on: or upon the following event: one year from date of signature. (Date) (If no date or event is specified, this authorization will expire in six months from the date of signature.) I understand that the information in my medical record may include information relating to treatment of drug or alcohol abuse, mental health, sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), AIDS related complex (ARC) and/or human immunodeficiency virus (HIV). Fees: I understand and agree what there may be costs associated with this request in compliance with State copying laws. (Signature of Patient or Personal Representative*) (Date of Signature) *If signed by a personal representative, a description of the representative's authority to act is as follows: Parent Legal Guardian Health Care Power of Attorney Administrator Executor of Estate Next of Kin Beneficiary Date: Signature of Witness MER-L-001657-22 04/12/2023 10:53:07 AM Pg 4 of 4 Trans ID: LCV20231247065 HIPAA Authorization for Disclosure of Health Information I hereby authorize Precision Pain & Spine Institute to release medical information for the records of: (Name of Facility) Patient Name: Lilly Banzragch D.O.B.: 01/31/1968 SSN: 594-17-0634 Patient Street Address: 4404 Sayre Drive City: Princeton State: NJ Zip Code: 08540 Date(s) of Treatment Requested: DOB to PRESENT Information to be disclosed (check all applicable items to be released): X Discharge Summary X ER Record X Progress Notes X Discharge Instructions X X-Rays, MRIs, CTs & Reports X Medication Records X History and Physical X Lab Reports X Doctor's Orders X Consultations X EKG/ECG Tests X Nurse's Notes X Operative Report X Therapy Notes X Treatment Plans X Commitment Papers X HIV Testing X Alcohol/Drug Treatment X Mental Health Information X Billing Other (please specify): Purpose Or Need For The Disclosure Is: Continued Medical Care Insurance X Legal Patient's Own Use Other The Information May Be Disclosed To: Recipient's Name: ISG Street Address: 275 Curry Hollow Road, Building 1 Suite 150 City: Pittsburgh State: PA Zip Code: 15236 Phone #: (412) 240-4443 Fax #: 1(412)785-3880 My refusal to sign this form will not adversely affect my ability to receive health care services, reimbursement for services, enrollment in a health plan or my eligibility for health benefits. However, information will not be released to the above-indicated recipient without my signature. I acknowledge that the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by Federal Law. I have the right to revoke this authorization by written notice to the Healthcare Provider listed above. I understand that actions taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. This authorization expires on: or upon the following event: one year from date of signature. (Date) (If no date or event is specified, this authorization will expire in six months from the date of signature.) I understand that the information in my medical record may include information relating to treatment of drug or alcohol abuse, mental health, sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), AIDS related complex (ARC) and/or human immunodeficiency virus (HIV). Fees: I understand and agree what there may be costs associated with this request in compliance with State copying laws. (Signature of Patient or Personal Representative*) (Date of Signature) *If signed by a personal representative, a description of the representative's authority to act is as follows: Parent Legal Guardian Health Care Power of Attorney Administrator Executor of Estate Next of Kin Beneficiary Date: Signature of Witness MER-L-001657-22 04/12/2023 10:53:07 AM Pg 1 of 2 Trans ID: LCV20231247065 Turella-Smith, Susan L From: Lisa Belden Sent: Wednesday, April 12, 2023 9:17 AM To: Turella-Smith, Susan L Subject: [EXTERNAL] Fw: Lilly Banzragch Attachments: Auth to PC_Capital Health Regional_Banzragch.pdf; Auth to PC_Mercer Diagnostic Imaging.pdf; Auth to PC_ Precision Pain and Spine.pdf Nationwide Information Security Warning: This is an EXTERNAL email. Use CAUTION before clicking on links, opening attachments, or responding. (Sender: lbelden@isgvalue.com) Due to delivery delays via the US Postal Service, it is being asked that any information or request responses be sent to me electronically via email at LBelden@isgvalue.com, via fax at 412-785-3880, or via our secure portal at www.litsol.com/filemail. Thank you for your anticipated cooperation. Lisa Belden | ISG | Record Retrieval Specialist T 412-240-4443 | F 412-785-3880 | LBelden@isgvalue.com Connect with ISG: website | LinkedIn | Facebook | Twitter | Instagram Please note that I am currently in training. My Team Lead is Danielle Caruso and can be reached by email dcaruso@isgvalue.com if you need further assistance. From: Lisa Belden Sent: Wednesday, March 22, 2023 3:25 PM To: doreen@lependorf.com Subject: Lilly Banzragch Good afternoon, I tried mailing some procured authorizations to your office for signatures, but they were returned as Not Deliverable. I have attached them to this email, please return them to me as soon as possible so I can continue with retrieving records. Thank you. Due to delivery delays via the US Postal Service, it is being asked that any information or request responses be sent to me electronically via email at LBelden@isgvalue.com, via fax at 412-785-3880, or via our secure portal at www.litsol.com/filemail. Thank you for your anticipated cooperation. Lisa Belden | ISG | Record Retrieval Specialist T 412-240-4443 | F 412-785-3880 | LBelden@isgvalue.com Connect with ISG: website | LinkedIn | Facebook | Twitter | Instagram 1 MER-L-001657-22 04/12/2023 10:53:07 AM Pg 2 of 2 Trans ID: LCV20231247065 Please note that I am currently in training. My Team Lead is Danielle Caruso and can be reached by email dcaruso@isgvalue.com if you need further assistance. Disclaimer The information contained in this communication from the sender is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. 2