Preview
Filing # 22951755 E-Filed 01/26/2015 11:34:23 AM
06-3972 IN THE CIRCUIT COURT OF THE
SEVENTEENTH JUDICIAL CIRCUIT, IN AND
FOR BROWARD COUNTY, FLORIDA
CASE NO.: CACE 14-014218 (04)
KHAI NGUYEN, Individually, and as
Personal Representative of the Estate of
MAI TUYET NGUYEN, Deceased, and
on behalf of KRISTEN HUYNH, KYLIE
NGUYEN and KADEN NGUYEN, the
surviving children of MAI TUYET
NGUYEN, and as the natural parent of
KADEN NGUYEN, a minor,
Plaintiffs,
vs.
PLANTATION GENERAL HOSPITAL,
L.P. d/b/a PLANTATION GENERAL
HOSPITAL, ALEX BIRMAN, MD,
SUNLIFE OB/GYN SERVICES OF FT.
LAUDERDALE, P.A., GEORGES
EDOUARD, MD, GEORGES
EDOUARD, MD, P.A. d/b/a
PLANTATION PAVILION OB/GYN,
MELISSA MACHAN, ARNP,
ROBERTA SANTINI, MD, DORI
RATHBUN and FLORIDA UNITED
RADIOLOGY, L.C.,
Defendants.
/
DEFENDANTS’ MOTION TO COMPEL
PLAINTIFF’S EXECUTED AUTHORIZATIONS
COME NOW the Defendants, ROBERTA SANTINI, MD and FLORIDA UNITED
RADIOLOGY, L.C., by and through their undersigned counsel, and file this their Motion to
Compel Plaintiffs Executed Authorizations for the Release of Records, and as grounds in
support thereof would state:
*** FILED: BROWARD COUNTY, FL HOWARD FORMAN, CLERK 1/26/2015 11:34:22 AM.****1, This is a wrongful death claim predicated on alleged malpractice.
2. On December 1, 2014, Defendants provided Plaintiff with three (3)
Authorizations for the release of records, one directed to Joe DiMaggio Children’s’ Hospital
and two (2) directed to the Social Security Administration, (See Exhibit “A”, attached
hereto).
3. These executed authorizations are necessary in order for the Defendants to
obtain relevant medical and financial records and information needed in the defense of this
matter and Defendants are entitled to same.
4. Defendants have no other method by which to obtain these records.
5. To date, the Plaintiff has not returned the executed authorizations.
6. Defendants have attempted in good faith to obtain the executed authorizations
from Plaintiffs counsel who has not responded to date. (See Exhibit “B” attached hereto).
7. Defendants will be prejudiced if not provided with the documents sought in by
these authorizations.
WHEREFORE, Defendants, respectfully request this Honorable Court for the entry of
an Order compelling the Plaintiff to provide fully executed authorizations for the release of
records directed to Joe DiMaggio Children’s Hospital and the Social Security
Administration, and any further relief as this Court deems meet and proper.
Page -2-CERTIFICATE OF SERVICE
WE HEREBY CERTIFY that a true and correct copy of the foregoing was e-filed
with the Clerk of Court through the E-Filing Portal on _January 26, 2015 , and is to be
e-served by the Court Clerk to: ALL COUNSEL OF RECORD ON THE ATTACHED
SERVICE LIST.
CHIMPOULIS, HUNTER & LYNN, P.A.
Attorneys for Defs/ROBERTA SANTINI, MD
and FLORIDA UNITED RADIOLOGY, L.C.
150 South Pine Island Road | Suite 510
Plantation, Florida 33324
Phone: (954) 463-0033
BY: _/s) M. Katherine Hunter
M. KATHERINE HUNTER, ESQUIRE
Florida Bar No.: 981877
khunter@chl-law.com
chl-sbsI \files-04and06-27\06-3972\pleadingsim-compel.002 - pl auths.docx.
Page -3-SERVICE LIST
NGUYEN vs. SANTINI, MD, ET AL
Case No.: CACE 14-014218 (04)
Counsel for Plaintiffs:
MARIA D. TEJEDOR, ESQUIRE
Diez-Arguelles | Tejedor
505 North Mills Avenue
Orlando, FL 32803
(407) 705-2880 Phone
(888) 611-7879 FAX #
(888) 888-3773 Toll Free Phone
EMAIL: maria@theorlandolawyers.com
SERVICE OF PLEADINGS — mail@theorlandolawyers.com; robin@theorlandolawyers.com;
jack@theorlandolawyers.com; michele@theorlandolawyers.com
Counsel for Defendants/Plantation General Hospital and Dori Rathbun:
JOHN W. MAURO, ESQUIRE / CAROL J. HEALY GLASGOW, ESQUIRE
Billing, Cochran, Lyles, Mauro & Ramsey, P.A.
515 East Las Olas Boulevard
6th Floor SunTrust Center
Fort Lauderdale, FL 33301
(954) 764-7150
(954) 764-7279 FAX #
EMAIL: jwm@belmr.com; cjg@belmr.com
SERVICE OF PLEADINGS -— _ ftl-pleadings@belmr.com; aliciag@bclmr.com;
cig@belmr.com
Counsel for Defendants/Alex Birman, MD and Sunlife OB/GYN Services:
ARIEL D, WIDLANSKY, ESQUIRE
Lubell & Rosen, LLC
200 South Andrews Avenue
Suite 900 Museum Plaza
Fort Lauderdale, FL 33301
(954) 755-3425
(954) 755-2993 FAX #
EMAIL: ariel@lubellrosen.com
SERVICE OF PLEADINGS ~ ariel@lubellrosen.com; amanda@lubellrosen.com
Page -4-LAW OFFICES
CHIMPOULIS, HUNTER & LYNN, P.A.
MASSEL J. ABISROR
JAY P, CHIMPOULIS*
DANIEL T. DOYLE
ERIC D. FREEDMAN
HAILEY A. GOLDMAN
M. KATHERINE HUNTER
JONATHON P. LYNN
BARBRA G. PAIGE
MARCI L. STRAUSS.
OF COUNSEL
BRIAN C. HUNTER
WILLIAM R. LEMOS
1958 - 2006
Moo Adautte Minos
Maria D. Tejedor, Esquire
7901 SOUTHWEST 36™ STREET
SUITE 206
DAVIE, FLORIDA 33328
TEL (954) 463-0033
Fax (954) 463-9562
December 1, 2014
Diez-Arguelles & Tejedor, P.A.
505 North Mills Avenue
Orlando, Florida 32803
RE: Estate of Mai Tuyet Nguyen v. Roberta A. Santini, M.D.
Our File No.: 06-3972
Dear Ms. Tejedor:
NURSE CONSULTANT
KATY JONES, RN, BSN, MSN
PARALEGALS
ELIZABETH CHIMPOULIS, CLA
ALICE D. HONEY, A.S.
JACKIE MIZRACHI, CP
FIRM ADMINISTRATOR
DIANE 8, STEAD
Enclosed please find Authorizations for the Release of Records, directed to Joe DiMaggio
Children’s Hospital and the Social Security Administration (one for Mai Nguyen and one for Kyle
Nguyen).
Authorizations, and have the completed forms returned to us.
Thank you for your assistance in this regard.
Very truly yours,
Please provide the information that is highlighted, have your client sign the
On Kesthesine Nunl
M. KATHERINE HUNTER
Signed in my absence to avoid delay
MKH/adh
Encl.:
\ehl-sbs | \files-O4and06-27 06-3972 subpoenas tejedor.007 - encl auths.docx
DEFENDANT’S
] “A”AUTHORIZATION FOR THE RELEASE
OF MEDICAL RECORDS
TO: Records Custodian
Joe DiMaggio Children’s Hospital
c/o Memorial Healthcare System
3501 Johnson Street
Hollywood, Florida 33021
Patient: Mai Nguyen (deceased)
SSN: | eee
DOB: 11/28/1974
Patient: Kaden Nguyen
DOB: = 7/26/12
SSN: unknown
You are hereby authorized to provide the Law Firm of Chimpoulis, Hunter & Lynn,
P.A,, and Diez-Arguelles & Tejedor, P.A. (if requested by them separately) with the following:
Any and all in-patient, out-patient and emergency room records including but
not limited to reports, charts, documents, microfilmed documents, emergency
room discharge instructions, correspondence, laser copies of photographs,
psychological records, request for records, and any and all other evidence
relating to the examination, treatment care, diagnosis, physical and mental
condition of the person named below, from the inception of your records to
the present.
Thereby declare that I have read this authorization to release medical records and have
been informed of my rights under the Health Insurance Portability & Accountability Act of
1996 (HIPAA), 45 CFR Parts 160 and 164.
I hereby waive my rights, including notice and objection, under the Health Insurance
Portability & Accountability Act of 1996 (HIPAA), 45 CFR Parts 160 and 164 and hereby
authorize you to release the requested medical information (my complete medical chart)
regarding all care and treatment provided to me by your facility.
I understand that I have a right to revoke this authorization at any time. I understand
that if I revoke this authorization, I must do so in writing and present my written revocation to
the Health Information Management Department. I understand that the revocation will not
apply to my insurance company when the law provides my insurer with the right to contest a
claim under my policy. Unless otherwise revoked, this authorization will be in effect for one
(1) year.I understand that authorizing the disclosure of health information is voluntary. I can
refuse to sign this authorization. I need not sign this form in order to assure treatment. I
understand that I may inspect or copy the information to be used or disclosed, as provided in
CFR 164.524 understand that any disclosure of information carries with it the potential for an
unauthorized redisclosure and the information may not be protected by federal confidentially
rules, If I have questions about disclosure of my health information, I may contact the
Privacy officer or the Health Information/Medical Record Department.
Khai Nguyen, as Personal Representative Date
of the Estate of Mai Tuyet Nguyen
(A copy of this authorization shall be considered valid and is good for one (1) year from this
date)
AUTHORIZATION FOR THE RELEASE OF MEDICAL RECORDS
MEMORIAL HEALTHCARE (JDCH)
Page - 2 -Social Security Administration Form Approved
Consent for Release of Information OMB No. 0960-0586
You must complete all required fields. We will not honor your request unless all required fields are completed. (*signifies a
required field).
TO: Social Security Administration
Mai Tuyet Nguyen 11/28/1974 a
*My Full Name *My Date of Birth My Social Security Number
(MMI/DDIYYYY)
| authorize the Social Security Administration to release information or records about me to:
*NAME OF PERSON OR ORGANIZATION: “ADDRESS OF PERSON OR ORGANIZATION:
Chimpoulis, Hunter & Lynn 150 South Pine Island Road, Suite 510
Plantation, FL 33324
*| want this information released because: on-going litigation
We may charge a fee to release information for non-program purposes.
*Please release the following information selected from the list below:
You must specify the records you are requesting by checking at least one box. We will not honor a request for “any and all
records" or "my entire file." Also, we will not disclose records unless you include the applicable date ranges where requested.
Social Security Number
HEE ionthly Social Security benefit amount
Current monthly Supplemental Security Income payment amount
My benefit or payment amounts from date 21/28/74 to date Present
My Medicare entitlement from date 22/28/74 to date Present
Medical records from my claims folder(s) from date?3/28/74 to date__present
If you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social
Security office.
Complete medical records from my claims folder(s)
Other record(s) from my file (you must specify the records you are requesting, e.g., doctor report, application,
determination or questionnaire)
OaAare
any and all records, including applications for disability benefits, medical exams,
reports, determinations of disability, death benefits, payouts, etc.
| am the individual, to whom the requested information or record applies, or the parent or legal guardian of a minor, or
the legal guardian of a legally incompetent adult. | declare under penalty of perjury (28 CFR § 16.41(d)(2004)) that | have
examined all the information on this form, and any accompanying statements or forms, and it is true and correct to the
best of my knowledge. | understand that anyone who knowingly or willfully seeks or obtain access to records about
another person under false pretenses is punishable by a fine of up to $5,000. | also understand that | must pay all
applicable fees for requesting information for a non-program-related purpose.
*Signature: *Date:
“Address:
Relationship (if not the subject of the record): *Daytime Phone:
Witnesses must sign this form ONLY if the above signature is by mark (X). If signed by mark (X), two witnesses to the signing
who know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X) on the
signature line above.
1.Signature of witness 2.Signature of witness
Address(Number and street, City, State, and Zip Code) Address(Number and street, City State, and Zip Code)
Form SSA-3288 (07-2013) EF (07-2013)Social Security Administration Form Approved
Consent for Release of Information OMB No. 0960-0566
Instructions for Using this Form
Complete this form only if you want us to give information or records about you, a minor, or a legally incompetent adult, to an
individual or group (for example, a doctor or an insurance company). If you are the natural or adoptive parent or legal guardian,
acting on behalf of a minor child, you may complete this form to release only the minor's non-medical records. We may charge a
fee for providing information unrelated to the administration of a program under the Social Security Act.
NOTE: Do not use this form to:
+ Request the release of medical records on behalf of a minor child. Instead, visit your local Social Security office or call our toll-
free number, 1-800-772-1213 (TTY-1-800-325-0778), or
+ Request detailed information about your earnings or employment history. Instead, complete and mail form SSA-7050-F4. You
can obtain form SSA-7050-F4 from your lacal Social Security office or online at www.ssa.gov/online/ssa-7050.pdf.
How to Complete this Form
We will not honor this form unless all required fields are completed. An asterisk (*) indicates a required field. Also, we will not
honor blanket requests for "any and all records" or the “entire file." You must specify the information you are requesting and you
must sign and date this form. We may charge a fee to release information for non-program purposes.
+ Fill in your name, date of birth, and social security number or the name, date of birth, and social security number of the person
to whom the requested information pertains.
+ Fill in the name and address of the person or organization where you want us to send the requested information.
+ Specify the reason you want us to release the information.
» Check the box next to the type(s) of information you want us to release including the date ranges, where applicable.
+ You, the parent or the legal guardian acting on behalf of a minor child or legally incompetent adult, must sign and date this form
and provide a daytime phone number.
+ If you are not the individual to whom the requested information pertains, state your relationship to that person. We may require
proof of relationship.
PRIVACY ACT STATEMENT
Section 205(a) of the Social Security Act, as amended, authorizes us to collect the information requested on this form. We will
use the information you provide to respond to your request for access to the records we maintain about you or to process your
request to release your records to a third party. You do not have to provide the requested information. Your response is
voluntary; however, we cannot honor your request to release information or records about you to another person or organization
without your consent. We rarely use the information provided on this form for any purpose other than to respond to requests for
SSA records information. However, the Privacy Act (5 U.S.C. § 552a(b)) permits us to disclose the information you provide on this
form in accordance with approved routine uses, which include but are not limited to the following:
1.To enable an agency or third party to assist Social Security in establishing rights to Social Security benefits and or coverage;
2.To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level:
3.To comply with Federal laws requiring the disclosure of the information from our records; and,
4.To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of SSA programs.
We may also use the information you provide when we match records by computer. Computer matching programs compare our
records with those of other Federal, State, or local government agencies. We use information from these matching programs to
establish or verify a person's eligibility for Federally-funded or administered benefit programs and for repayment of incorrect
payments or overpayments under these programs. Additional information regarding this form, routine uses of information, and
other Social Security programs is available on our Internet website, www.socialsecurity.gov, or at your local Social Security office.
PAPERWORK REDUCTION ACT STATEMENT
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take about 3 minutes to read the instructions, gather the facts, and answer the questions. SEND
OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social
Security office through SSA's website at www.socialsecurity.gov. Offices are also listed under U.S. Government agencies
in your telephone directory or you may call 1-800-772-1213 (TYY 1-800-325-0778). You may send comments on our time
estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate
to this address, not the completed form.
Form SSA-3288 (07-2013) EF (07-2013) Destroy Prior EditionsSocial Security Administration Form Approved
Consent for Release of Information OMB No. 0960-0566
You must complete all required fields. We will not honor your request unless all required fields are completed. (*signifies a
required field).
TO: Social Security Administration
Kaden Nguyen (minor) 07/29/2012
*My Full Name *My Date of Birth *My Social Security Number
(MM/DDIYYYY)
| authorize the Social Security Administration to release information or records about me to:
*NAME OF PERSON OR ORGANIZATION: *ADDRESS OF PERSON OR ORGANIZATION:
Chimpoulis, Hunter & Lynn 150 South Pine Island Road, Suite 510
Plantation, FL 33324
“| want this information released because: On-going litigation
We may charge a fee to release information for non-program purposes.
*Please release the following information selected from the list below:
You must specify the records you are requesting by checking at least one box. We will not honor a request for "any and all
records" or "my entire file." Also, we will not disclose records unless you include the applicable date ranges where requested,
Social Security Number
Current monthly Social Security benefit amount
Current monthly Supplemental Security Income payment amount
My benefit or payment amounts from date 97/29/2012 to date Present
My Medicare entitlement from date 97/29/2012 to gate Present
Medical records from my claims folder(s) from date®7/29/2012 to date__present
If you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social
Security office.
7 Complete medical records from my claims folder(s)
Other record(s) from my file (you must specify the records you are requesting, e.g., doctor report, application,
determination or questionnaire)
OA kona
~
any and all records, including applications for benefits, medical exams, reports,
determinations of disability, death benefits, payouts, etc.
lam the individual, to whom the requested information or record applies, or the parent or legal guardian of a minor, or
the legal guardian of a legally incompetent adult. | declare under penalty of perjury (28 CFR § 16.41(d)(2004)) that | have
examined all the information on this form, and any accompanying statements or forms, and it is true and correct to the
best of my knowledge. | understand that anyone who knowingly or willfully seeks or obtain access to records about
another person under false pretenses is punishable by a fine of up to $5,000. | also understand that | must pay all
applicable fees for requesting information for a non-program-related purpose.
*Signature: *Date:
*Address:
Relationship (if not the subject of the record): *Daytime Phone:
Witnesses must sign this form ONLY if the above signature is by mark (X). If signed by mark (X), two witnesses to the signing
who know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X) on the
signature line above.
1.Signature of witness 2.Signature of witness
Address(Number and street, City, State, and Zip Code) Address(Number and street, City,State, and Zip Code)
Form SSA-3288 (07-2013) EF (07-2013)Social Security Administration Form Approved
Consent for Release of Information OMB No. 0960-0566
Instructions for Using this Form
Complete this form only if you want us to give information or records about you, a minor, or a legally incompetent adult, to an
individual or group (for example, a doctor or an insurance company). If you are the natural or adoptive parent or legal guardian,
acting on behalf of a minor child, you may complete this form to release only the minor's non-medical records. We may charge a
fee for providing information unrelated to the administration of a program under the Social Security Act.
NOTE: Do not use this form to:
+ Request the release of medical records on behalf of a minor child. Instead, visit your local Social Security office or call our toll-
free number, 1-800-772-1213 (TTY-1-800-325-0778), or
+ Request detailed information about your earnings or employment history. Instead, complete and mail form SSA-7050-F4. You
can obtain form SSA-7050-F4 from your local Social Security office or online at www.ssa.gov/online/ssa-7050.pdf.
How to Complete this Form
We will not honor this form unless all required fields are completed. An asterisk (*) indicates a required field. Also, we will not
honor blanket requests for “any and all records" or the “entire file." You must specify the information you are requesting and you
must sign and date this form. We may charge a fee to release information for non-program purposes.
+ Fill in your name, date of birth, and social security number or the name, date of birth, and social security number of the person
to whom the requested information pertains.
+ Fill in the name and address of the person or organization where you want us to send the requested information.
+ Specify the reason you want us to release the information.
+ Check the box next to the type(s) of information you want us to release including the date ranges, where applicable.
+ You, the parent or the legal guardian acting on behaif of a minor child or legally incompetent adult, must sign and date this form
and provide a daytime phone number.
+ If you are not the individual to whom the requested information pertains, state your relationship to that person. We may require
proof of relationship.
PRIVACY ACT STATEMENT
Section 205(a) of the Social Security Act, as amended, authorizes us to collect the information requested on this form. We will
use the information you provide to respond to your request for access to the records we maintain about you or to process your
request to release your records to a third party. You do not have to provide the requested information. Your response is
voluntary; however, we cannot honor your request to release information or records about you to another person or organization
without your consent. We rarely use the information provided on this form for any purpose other than to respond to requests for
SSA records information. However, the Privacy Act (5 U.S.C. § 552a(b)) permits us to disclose the information you provide on this
form in accordance with approved routine uses, which include but are not limited to the following:
1.To enable an agency or third party to assist Social Security in establishing rights to Social Security benefits and or coverage;
2.To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level;
3.To comply with Federal laws requiring the disclosure of the information from our records; and,
4.To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of SSA programs.
We may also use the information you provide when we match records by computer. Computer matching programs compare our
records with those of other Federal, State, or local government agencies. We use information from these matching programs to
establish or verify a person's eligibility for Federally-funded or administered benefit programs and for repayment of incorrect
payments or overpayments under these programs. Additional information regarding this form, routine uses of information, and
other Social Security programs is available on our Internet website, www. socialsecurity.gov, or at your local Social Security office.
PAPERWORK REDUCTION ACT STATEMENT.
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take about 3 minutes to read the instructions, gather the facts, and answer the questions. SEND
OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social
Security office through SSA's website at www.socialsecurity.gov. Offices are also listed under U.S. Government agencies
in your telephone directory or you may call 1-800-772-1213 (TYY 1-800-325-0778). You may send comments on our time
estimate above to: SSA, 6401 Security Bivd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate
to this address, not the completed form.
Form SSA-3288 (07-2013) EF (07-2013) Destroy Prior EditionsLAW OFFICES
CHIMPOULIS, HUNTER & LYNN, P.A.
150 SOUTH PINE ISLAND ROAD
MASSEL J. ABISROR NURSE CONSULTANT
JAY P. CHIMPOULIS* suITE 510 KATY JONES, RN, BSN, MSN
DANIEL T. DOYLE PLANTATION, FLORIDA 33324
ERIC D. FREEDMAN PARALEGALS
HAILEY A. GOLDMAN ELIZABETH CHIMPOULIS, CLA
M. KATHERINE HUNTER Te (954) 463-0033 ALICE D. HONEY, A.S.
JONATHON P. LYNN Fax (954) 463-9562 JACKIE MIZRACHI
BARBRA G. PAIGE
MARCI L. STRAUSS FIRM ADMINISTRATOR
a December 17, 2014 Se EEeE eee
OF COUNSEL
BRIAN C. HUNTER
WILLIAM R. LEMOS
1958 - 2006
Xoo Admited in Danis
Maria D. Tejedor, Esquire
Diez-Arguelles & Tejedor, P.A.
505 North Mills Avenue
Orlando, Florida 32803
RE: Estate of Mai Tuyet Nguyen v. Roberta A. Santini, M.D.
Our File No.:06-3972
Dear Ms. Tejedor:
Please advise as to the status of the Authorizations for the Release of Records, directed to Joe
DiMaggio Children’s Hospital and the Social Security Administration (one for Mai Nguyen and one
for Kaden Nguyen), sent to you on December 1, 2014.
Thank you for your cooperation in this regard.
Very truly yours,
An Kertheuns Tonle
M. KATHERINE HUNTER
Signed with my permission to avoid delay
MKH/adh
Encl.:
\\chl-sbs I\files-04and06-27\06-3972\subpoenas'tejedor.008 - status of auths.docx
DEFENDANT’S
i "eS"
Preview
Filing # 22951755 E-Filed 01/26/2015 11:34:23 AM 06-3972 IN THE CIRCUIT COURT OF THE SEVENTEENTH JUDICIAL CIRCUIT, IN AND FOR BROWARD COUNTY, FLORIDA CASE NO.: CACE 14-014218 (04) KHAI NGUYEN, Individually, and as Personal Representative of the Estate of MAI TUYET NGUYEN, Deceased, and on behalf of KRISTEN HUYNH, KYLIE NGUYEN and KADEN NGUYEN, the surviving children of MAI TUYET NGUYEN, and as the natural parent of KADEN NGUYEN, a minor, Plaintiffs, vs. PLANTATION GENERAL HOSPITAL, L.P. d/b/a PLANTATION GENERAL HOSPITAL, ALEX BIRMAN, MD, SUNLIFE OB/GYN SERVICES OF FT. LAUDERDALE, P.A., GEORGES EDOUARD, MD, GEORGES EDOUARD, MD, P.A. d/b/a PLANTATION PAVILION OB/GYN, MELISSA MACHAN, ARNP, ROBERTA SANTINI, MD, DORI RATHBUN and FLORIDA UNITED RADIOLOGY, L.C., Defendants. / DEFENDANTS’ MOTION TO COMPEL PLAINTIFF’S EXECUTED AUTHORIZATIONS COME NOW the Defendants, ROBERTA SANTINI, MD and FLORIDA UNITED RADIOLOGY, L.C., by and through their undersigned counsel, and file this their Motion to Compel Plaintiffs Executed Authorizations for the Release of Records, and as grounds in support thereof would state: *** FILED: BROWARD COUNTY, FL HOWARD FORMAN, CLERK 1/26/2015 11:34:22 AM.****1, This is a wrongful death claim predicated on alleged malpractice. 2. On December 1, 2014, Defendants provided Plaintiff with three (3) Authorizations for the release of records, one directed to Joe DiMaggio Children’s’ Hospital and two (2) directed to the Social Security Administration, (See Exhibit “A”, attached hereto). 3. These executed authorizations are necessary in order for the Defendants to obtain relevant medical and financial records and information needed in the defense of this matter and Defendants are entitled to same. 4. Defendants have no other method by which to obtain these records. 5. To date, the Plaintiff has not returned the executed authorizations. 6. Defendants have attempted in good faith to obtain the executed authorizations from Plaintiffs counsel who has not responded to date. (See Exhibit “B” attached hereto). 7. Defendants will be prejudiced if not provided with the documents sought in by these authorizations. WHEREFORE, Defendants, respectfully request this Honorable Court for the entry of an Order compelling the Plaintiff to provide fully executed authorizations for the release of records directed to Joe DiMaggio Children’s Hospital and the Social Security Administration, and any further relief as this Court deems meet and proper. Page -2-CERTIFICATE OF SERVICE WE HEREBY CERTIFY that a true and correct copy of the foregoing was e-filed with the Clerk of Court through the E-Filing Portal on _January 26, 2015 , and is to be e-served by the Court Clerk to: ALL COUNSEL OF RECORD ON THE ATTACHED SERVICE LIST. CHIMPOULIS, HUNTER & LYNN, P.A. Attorneys for Defs/ROBERTA SANTINI, MD and FLORIDA UNITED RADIOLOGY, L.C. 150 South Pine Island Road | Suite 510 Plantation, Florida 33324 Phone: (954) 463-0033 BY: _/s) M. Katherine Hunter M. KATHERINE HUNTER, ESQUIRE Florida Bar No.: 981877 khunter@chl-law.com chl-sbsI \files-04and06-27\06-3972\pleadingsim-compel.002 - pl auths.docx. Page -3-SERVICE LIST NGUYEN vs. SANTINI, MD, ET AL Case No.: CACE 14-014218 (04) Counsel for Plaintiffs: MARIA D. TEJEDOR, ESQUIRE Diez-Arguelles | Tejedor 505 North Mills Avenue Orlando, FL 32803 (407) 705-2880 Phone (888) 611-7879 FAX # (888) 888-3773 Toll Free Phone EMAIL: maria@theorlandolawyers.com SERVICE OF PLEADINGS — mail@theorlandolawyers.com; robin@theorlandolawyers.com; jack@theorlandolawyers.com; michele@theorlandolawyers.com Counsel for Defendants/Plantation General Hospital and Dori Rathbun: JOHN W. MAURO, ESQUIRE / CAROL J. HEALY GLASGOW, ESQUIRE Billing, Cochran, Lyles, Mauro & Ramsey, P.A. 515 East Las Olas Boulevard 6th Floor SunTrust Center Fort Lauderdale, FL 33301 (954) 764-7150 (954) 764-7279 FAX # EMAIL: jwm@belmr.com; cjg@belmr.com SERVICE OF PLEADINGS -— _ ftl-pleadings@belmr.com; aliciag@bclmr.com; cig@belmr.com Counsel for Defendants/Alex Birman, MD and Sunlife OB/GYN Services: ARIEL D, WIDLANSKY, ESQUIRE Lubell & Rosen, LLC 200 South Andrews Avenue Suite 900 Museum Plaza Fort Lauderdale, FL 33301 (954) 755-3425 (954) 755-2993 FAX # EMAIL: ariel@lubellrosen.com SERVICE OF PLEADINGS ~ ariel@lubellrosen.com; amanda@lubellrosen.com Page -4-LAW OFFICES CHIMPOULIS, HUNTER & LYNN, P.A. MASSEL J. ABISROR JAY P, CHIMPOULIS* DANIEL T. DOYLE ERIC D. FREEDMAN HAILEY A. GOLDMAN M. KATHERINE HUNTER JONATHON P. LYNN BARBRA G. PAIGE MARCI L. STRAUSS. OF COUNSEL BRIAN C. HUNTER WILLIAM R. LEMOS 1958 - 2006 Moo Adautte Minos Maria D. Tejedor, Esquire 7901 SOUTHWEST 36™ STREET SUITE 206 DAVIE, FLORIDA 33328 TEL (954) 463-0033 Fax (954) 463-9562 December 1, 2014 Diez-Arguelles & Tejedor, P.A. 505 North Mills Avenue Orlando, Florida 32803 RE: Estate of Mai Tuyet Nguyen v. Roberta A. Santini, M.D. Our File No.: 06-3972 Dear Ms. Tejedor: NURSE CONSULTANT KATY JONES, RN, BSN, MSN PARALEGALS ELIZABETH CHIMPOULIS, CLA ALICE D. HONEY, A.S. JACKIE MIZRACHI, CP FIRM ADMINISTRATOR DIANE 8, STEAD Enclosed please find Authorizations for the Release of Records, directed to Joe DiMaggio Children’s Hospital and the Social Security Administration (one for Mai Nguyen and one for Kyle Nguyen). Authorizations, and have the completed forms returned to us. Thank you for your assistance in this regard. Very truly yours, Please provide the information that is highlighted, have your client sign the On Kesthesine Nunl M. KATHERINE HUNTER Signed in my absence to avoid delay MKH/adh Encl.: \ehl-sbs | \files-O4and06-27 06-3972 subpoenas tejedor.007 - encl auths.docx DEFENDANT’S ] “A”AUTHORIZATION FOR THE RELEASE OF MEDICAL RECORDS TO: Records Custodian Joe DiMaggio Children’s Hospital c/o Memorial Healthcare System 3501 Johnson Street Hollywood, Florida 33021 Patient: Mai Nguyen (deceased) SSN: | eee DOB: 11/28/1974 Patient: Kaden Nguyen DOB: = 7/26/12 SSN: unknown You are hereby authorized to provide the Law Firm of Chimpoulis, Hunter & Lynn, P.A,, and Diez-Arguelles & Tejedor, P.A. (if requested by them separately) with the following: Any and all in-patient, out-patient and emergency room records including but not limited to reports, charts, documents, microfilmed documents, emergency room discharge instructions, correspondence, laser copies of photographs, psychological records, request for records, and any and all other evidence relating to the examination, treatment care, diagnosis, physical and mental condition of the person named below, from the inception of your records to the present. Thereby declare that I have read this authorization to release medical records and have been informed of my rights under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), 45 CFR Parts 160 and 164. I hereby waive my rights, including notice and objection, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), 45 CFR Parts 160 and 164 and hereby authorize you to release the requested medical information (my complete medical chart) regarding all care and treatment provided to me by your facility. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Health Information Management Department. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will be in effect for one (1) year.I understand that authorizing the disclosure of health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524 understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentially rules, If I have questions about disclosure of my health information, I may contact the Privacy officer or the Health Information/Medical Record Department. Khai Nguyen, as Personal Representative Date of the Estate of Mai Tuyet Nguyen (A copy of this authorization shall be considered valid and is good for one (1) year from this date) AUTHORIZATION FOR THE RELEASE OF MEDICAL RECORDS MEMORIAL HEALTHCARE (JDCH) Page - 2 -Social Security Administration Form Approved Consent for Release of Information OMB No. 0960-0586 You must complete all required fields. We will not honor your request unless all required fields are completed. (*signifies a required field). TO: Social Security Administration Mai Tuyet Nguyen 11/28/1974 a *My Full Name *My Date of Birth My Social Security Number (MMI/DDIYYYY) | authorize the Social Security Administration to release information or records about me to: *NAME OF PERSON OR ORGANIZATION: “ADDRESS OF PERSON OR ORGANIZATION: Chimpoulis, Hunter & Lynn 150 South Pine Island Road, Suite 510 Plantation, FL 33324 *| want this information released because: on-going litigation We may charge a fee to release information for non-program purposes. *Please release the following information selected from the list below: You must specify the records you are requesting by checking at least one box. We will not honor a request for “any and all records" or "my entire file." Also, we will not disclose records unless you include the applicable date ranges where requested. Social Security Number HEE ionthly Social Security benefit amount Current monthly Supplemental Security Income payment amount My benefit or payment amounts from date 21/28/74 to date Present My Medicare entitlement from date 22/28/74 to date Present Medical records from my claims folder(s) from date?3/28/74 to date__present If you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social Security office. Complete medical records from my claims folder(s) Other record(s) from my file (you must specify the records you are requesting, e.g., doctor report, application, determination or questionnaire) OaAare any and all records, including applications for disability benefits, medical exams, reports, determinations of disability, death benefits, payouts, etc. | am the individual, to whom the requested information or record applies, or the parent or legal guardian of a minor, or the legal guardian of a legally incompetent adult. | declare under penalty of perjury (28 CFR § 16.41(d)(2004)) that | have examined all the information on this form, and any accompanying statements or forms, and it is true and correct to the best of my knowledge. | understand that anyone who knowingly or willfully seeks or obtain access to records about another person under false pretenses is punishable by a fine of up to $5,000. | also understand that | must pay all applicable fees for requesting information for a non-program-related purpose. *Signature: *Date: “Address: Relationship (if not the subject of the record): *Daytime Phone: Witnesses must sign this form ONLY if the above signature is by mark (X). If signed by mark (X), two witnesses to the signing who know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X) on the signature line above. 1.Signature of witness 2.Signature of witness Address(Number and street, City, State, and Zip Code) Address(Number and street, City State, and Zip Code) Form SSA-3288 (07-2013) EF (07-2013)Social Security Administration Form Approved Consent for Release of Information OMB No. 0960-0566 Instructions for Using this Form Complete this form only if you want us to give information or records about you, a minor, or a legally incompetent adult, to an individual or group (for example, a doctor or an insurance company). If you are the natural or adoptive parent or legal guardian, acting on behalf of a minor child, you may complete this form to release only the minor's non-medical records. We may charge a fee for providing information unrelated to the administration of a program under the Social Security Act. NOTE: Do not use this form to: + Request the release of medical records on behalf of a minor child. Instead, visit your local Social Security office or call our toll- free number, 1-800-772-1213 (TTY-1-800-325-0778), or + Request detailed information about your earnings or employment history. Instead, complete and mail form SSA-7050-F4. You can obtain form SSA-7050-F4 from your lacal Social Security office or online at www.ssa.gov/online/ssa-7050.pdf. How to Complete this Form We will not honor this form unless all required fields are completed. An asterisk (*) indicates a required field. Also, we will not honor blanket requests for "any and all records" or the “entire file." You must specify the information you are requesting and you must sign and date this form. We may charge a fee to release information for non-program purposes. + Fill in your name, date of birth, and social security number or the name, date of birth, and social security number of the person to whom the requested information pertains. + Fill in the name and address of the person or organization where you want us to send the requested information. + Specify the reason you want us to release the information. » Check the box next to the type(s) of information you want us to release including the date ranges, where applicable. + You, the parent or the legal guardian acting on behalf of a minor child or legally incompetent adult, must sign and date this form and provide a daytime phone number. + If you are not the individual to whom the requested information pertains, state your relationship to that person. We may require proof of relationship. PRIVACY ACT STATEMENT Section 205(a) of the Social Security Act, as amended, authorizes us to collect the information requested on this form. We will use the information you provide to respond to your request for access to the records we maintain about you or to process your request to release your records to a third party. You do not have to provide the requested information. Your response is voluntary; however, we cannot honor your request to release information or records about you to another person or organization without your consent. We rarely use the information provided on this form for any purpose other than to respond to requests for SSA records information. However, the Privacy Act (5 U.S.C. § 552a(b)) permits us to disclose the information you provide on this form in accordance with approved routine uses, which include but are not limited to the following: 1.To enable an agency or third party to assist Social Security in establishing rights to Social Security benefits and or coverage; 2.To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level: 3.To comply with Federal laws requiring the disclosure of the information from our records; and, 4.To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of SSA programs. We may also use the information you provide when we match records by computer. Computer matching programs compare our records with those of other Federal, State, or local government agencies. We use information from these matching programs to establish or verify a person's eligibility for Federally-funded or administered benefit programs and for repayment of incorrect payments or overpayments under these programs. Additional information regarding this form, routine uses of information, and other Social Security programs is available on our Internet website, www.socialsecurity.gov, or at your local Social Security office. PAPERWORK REDUCTION ACT STATEMENT This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 3 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA's website at www.socialsecurity.gov. Offices are also listed under U.S. Government agencies in your telephone directory or you may call 1-800-772-1213 (TYY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form. Form SSA-3288 (07-2013) EF (07-2013) Destroy Prior EditionsSocial Security Administration Form Approved Consent for Release of Information OMB No. 0960-0566 You must complete all required fields. We will not honor your request unless all required fields are completed. (*signifies a required field). TO: Social Security Administration Kaden Nguyen (minor) 07/29/2012 *My Full Name *My Date of Birth *My Social Security Number (MM/DDIYYYY) | authorize the Social Security Administration to release information or records about me to: *NAME OF PERSON OR ORGANIZATION: *ADDRESS OF PERSON OR ORGANIZATION: Chimpoulis, Hunter & Lynn 150 South Pine Island Road, Suite 510 Plantation, FL 33324 “| want this information released because: On-going litigation We may charge a fee to release information for non-program purposes. *Please release the following information selected from the list below: You must specify the records you are requesting by checking at least one box. We will not honor a request for "any and all records" or "my entire file." Also, we will not disclose records unless you include the applicable date ranges where requested, Social Security Number Current monthly Social Security benefit amount Current monthly Supplemental Security Income payment amount My benefit or payment amounts from date 97/29/2012 to date Present My Medicare entitlement from date 97/29/2012 to gate Present Medical records from my claims folder(s) from date®7/29/2012 to date__present If you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social Security office. 7 Complete medical records from my claims folder(s) Other record(s) from my file (you must specify the records you are requesting, e.g., doctor report, application, determination or questionnaire) OA kona ~ any and all records, including applications for benefits, medical exams, reports, determinations of disability, death benefits, payouts, etc. lam the individual, to whom the requested information or record applies, or the parent or legal guardian of a minor, or the legal guardian of a legally incompetent adult. | declare under penalty of perjury (28 CFR § 16.41(d)(2004)) that | have examined all the information on this form, and any accompanying statements or forms, and it is true and correct to the best of my knowledge. | understand that anyone who knowingly or willfully seeks or obtain access to records about another person under false pretenses is punishable by a fine of up to $5,000. | also understand that | must pay all applicable fees for requesting information for a non-program-related purpose. *Signature: *Date: *Address: Relationship (if not the subject of the record): *Daytime Phone: Witnesses must sign this form ONLY if the above signature is by mark (X). If signed by mark (X), two witnesses to the signing who know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X) on the signature line above. 1.Signature of witness 2.Signature of witness Address(Number and street, City, State, and Zip Code) Address(Number and street, City,State, and Zip Code) Form SSA-3288 (07-2013) EF (07-2013)Social Security Administration Form Approved Consent for Release of Information OMB No. 0960-0566 Instructions for Using this Form Complete this form only if you want us to give information or records about you, a minor, or a legally incompetent adult, to an individual or group (for example, a doctor or an insurance company). If you are the natural or adoptive parent or legal guardian, acting on behalf of a minor child, you may complete this form to release only the minor's non-medical records. We may charge a fee for providing information unrelated to the administration of a program under the Social Security Act. NOTE: Do not use this form to: + Request the release of medical records on behalf of a minor child. Instead, visit your local Social Security office or call our toll- free number, 1-800-772-1213 (TTY-1-800-325-0778), or + Request detailed information about your earnings or employment history. Instead, complete and mail form SSA-7050-F4. You can obtain form SSA-7050-F4 from your local Social Security office or online at www.ssa.gov/online/ssa-7050.pdf. How to Complete this Form We will not honor this form unless all required fields are completed. An asterisk (*) indicates a required field. Also, we will not honor blanket requests for “any and all records" or the “entire file." You must specify the information you are requesting and you must sign and date this form. We may charge a fee to release information for non-program purposes. + Fill in your name, date of birth, and social security number or the name, date of birth, and social security number of the person to whom the requested information pertains. + Fill in the name and address of the person or organization where you want us to send the requested information. + Specify the reason you want us to release the information. + Check the box next to the type(s) of information you want us to release including the date ranges, where applicable. + You, the parent or the legal guardian acting on behaif of a minor child or legally incompetent adult, must sign and date this form and provide a daytime phone number. + If you are not the individual to whom the requested information pertains, state your relationship to that person. We may require proof of relationship. PRIVACY ACT STATEMENT Section 205(a) of the Social Security Act, as amended, authorizes us to collect the information requested on this form. We will use the information you provide to respond to your request for access to the records we maintain about you or to process your request to release your records to a third party. You do not have to provide the requested information. Your response is voluntary; however, we cannot honor your request to release information or records about you to another person or organization without your consent. We rarely use the information provided on this form for any purpose other than to respond to requests for SSA records information. However, the Privacy Act (5 U.S.C. § 552a(b)) permits us to disclose the information you provide on this form in accordance with approved routine uses, which include but are not limited to the following: 1.To enable an agency or third party to assist Social Security in establishing rights to Social Security benefits and or coverage; 2.To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; 3.To comply with Federal laws requiring the disclosure of the information from our records; and, 4.To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of SSA programs. We may also use the information you provide when we match records by computer. Computer matching programs compare our records with those of other Federal, State, or local government agencies. We use information from these matching programs to establish or verify a person's eligibility for Federally-funded or administered benefit programs and for repayment of incorrect payments or overpayments under these programs. Additional information regarding this form, routine uses of information, and other Social Security programs is available on our Internet website, www. socialsecurity.gov, or at your local Social Security office. PAPERWORK REDUCTION ACT STATEMENT. This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 3 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA's website at www.socialsecurity.gov. Offices are also listed under U.S. Government agencies in your telephone directory or you may call 1-800-772-1213 (TYY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Bivd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form. Form SSA-3288 (07-2013) EF (07-2013) Destroy Prior EditionsLAW OFFICES CHIMPOULIS, HUNTER & LYNN, P.A. 150 SOUTH PINE ISLAND ROAD MASSEL J. ABISROR NURSE CONSULTANT JAY P. CHIMPOULIS* suITE 510 KATY JONES, RN, BSN, MSN DANIEL T. DOYLE PLANTATION, FLORIDA 33324 ERIC D. FREEDMAN PARALEGALS HAILEY A. GOLDMAN ELIZABETH CHIMPOULIS, CLA M. KATHERINE HUNTER Te (954) 463-0033 ALICE D. HONEY, A.S. JONATHON P. LYNN Fax (954) 463-9562 JACKIE MIZRACHI BARBRA G. PAIGE MARCI L. STRAUSS FIRM ADMINISTRATOR a December 17, 2014 Se EEeE eee OF COUNSEL BRIAN C. HUNTER WILLIAM R. LEMOS 1958 - 2006 Xoo Admited in Danis Maria D. Tejedor, Esquire Diez-Arguelles & Tejedor, P.A. 505 North Mills Avenue Orlando, Florida 32803 RE: Estate of Mai Tuyet Nguyen v. Roberta A. Santini, M.D. Our File No.:06-3972 Dear Ms. Tejedor: Please advise as to the status of the Authorizations for the Release of Records, directed to Joe DiMaggio Children’s Hospital and the Social Security Administration (one for Mai Nguyen and one for Kaden Nguyen), sent to you on December 1, 2014. Thank you for your cooperation in this regard. Very truly yours, An Kertheuns Tonle M. KATHERINE HUNTER Signed with my permission to avoid delay MKH/adh Encl.: \\chl-sbs I\files-04and06-27\06-3972\subpoenas'tejedor.008 - status of auths.docx DEFENDANT’S i "eS"