Preview
Filing # 58936125 E-Filed 07/12/2017 04:57:52 PM
IN THE CIRCUIT COURT OF THE 11TH JUDICIAL CIRCUIT
IN AND FOR MIAMI COUNTY, FLORIDA, CIVIL DIVISION
ISABEL LEVINE, as Personal
Representative of the Estate of
JOSE CLEMENTE, Deceased,
VS.
Plaintiff, CASE NO. 17-CA-014511-01
SENIOR HEALTH — TREASURE
ISLES, LLC, d/b/a TREASURE
ISLE CARE CENTER,
Defendant,
/
DEFENDANT SENIOR HEALTH- TREASURE ISLE, LLC d/b/a TREASURE ISLE
CARE C
R’S FIRST REQUEST FOR PRODUCTION OF DOCUMENTS
COMES NOW defendant SENIOR HEALTH-TREASURE ISLE, LLC d/b/a
TREASURE ISLE CARE CENTER, by and through its undersigned counsel and pursuant to the
Florida Rules of Civil Procedure, and requests from plaintiff, clear and legible copies of all
documents and items listed below within thirty (30) days of service hereof.
1.
2
Federal income tax returns of plaintiff for the past five (5) years.
Itemized medical bills incurred as result of the allegations described in the
Complaint
A complete copy of any and all policies of insurance of any kind or nature which
were in effect on the date of the incident which would provide benefits to plaintiff
by reason of the allegations contained in the Complaint.
Any and all written and/or recorded statements taken or obtained by plaintiff or
any of plaintiffs attorneys, agents or representatives, or any present employees of
defendant or any former employees of defendant who participated directly or
indirectly with the care and treatment of JOSE CLEMENTE.
All medical records and reports rendered by JOSE CLEMENTE ’S treating and
examining physicians and other health care providers listed in Answers to
Interrogatories. Please do not include TREASURE ISLE CARE CENTER
chart.
Any photographs, if any, of JOSE CLEMENTE while a resident at TREASURE
ISLE CARE CENTER.10.
11
12.
14
15
16.
17.
18
Copies of any and all documents, statements, receipts, bills, memoranda, etc.,
reflecting bills submitted to or payments made by any collateral source as the
term is defined in Section 768.76, Florida Statutes.
Copies of any report, bill, fee schedule, correspondence or any memoranda
relating to any expert who may testify in this cause
Any and all bills, invoices, or statements from any expert expected to testify or
referring or consulting organization which bills for that expert’s services.
Any and all documents received by plaintiff and/or any family member from
TREASURE ISLE CARE CENTER during JOSE CLEMENTP’’S residency.
Duplicate copies of any photographs taken of JOSE CLEMENTE of the five (5)
year period preceding during or after his admission to TREASURE ISLE CARE
CENTER.
Any and all records, documents, papers or other materials you have in your
possession which pertain to the care and treatment of JOSE CLEMENTE while a
resident at TREASURE ISLE CARE CENTER excluding any communication
with your attorneys or their representatives.
Any and all police/sheriff reports relating to any of the matters set forth in the
Complaint
Any and all HRS/AHCA reports relating to any of the matters set forth in the
Complaint
Copies of any and all receipts, invoices, or canceled checks which would evidence
payments made by you or others on behalf of JOSE CLEMENTE while a resident
at TREASURE ISLE CARE CENTER.
The names and addresses of all other health care providers upon whom plaintiff
served a Notice of Intent to Initiate Action for medical malpractice.
Copies of all invoices or bills for all expenses and damages plaintiff is alleging as
aresult of the incidents alleged in the Complaint.
A complete copy of all medical records and reports from all physicians and
medical health care providers, including hospitals, regarding treatment to JOSE
CLEMENTE currently in your possession or in the possession of your agents,
representatives, or attorneys. Please do not include TREASURE ISLE CARE
CENTER chart.19.
20.
21.
22.
24.
25.
26.
A copy of any and all notes, journal entries, or other documents from any family
members of JOSE CLEMENTE regarding his care and treatment at TREASURE
ISLE CARE CENTER.
Copies of Complaints filed against any other healthcare providers regarding care
and treatment of JOSE CLEMENTE
Any and all conditional payment letters from Medicare and/or Medicaid related to
any medical expenses or bills for JOSE CLEMENTE.
A properly executed authorization for the release of medical records/information
directed to Medicare in the form attached hereto as “Exhibit A.”
A properly executed authorization for the release of medical records/information
directed to Medicaid in the form attached hereto as “Exhibit B.”
Any and all documents referring or relating to conversations with any friends or
family members of JOSE CLEMENTE.
Any and all documents referring or relating to JOSE CLEMENTE’S residency at
TREASURE ISLE CARE CENTER any and all medical, hospital, or nursing
home records or medical, hospital, or nursing home bills.
Any bills, receipts, invoices referring or reflecting JOSE CLEMENTE’S nursing
home residency at TREASURE ISLE CARE CENTER or any other nursing home
and/or hospital where JOSE CLEMENTE resided.
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of the foregoing was furnished via
Electronic Mail delivery on this 12th day of July, 2017 to: William A. Dean, Esq., FORD,
DEAN & ROTUNDO, P.A., Turnberry Plaza, Suite 600, 2875 NE. 191 Street, Miami, FL
33180, at bill@forddean.com; zee@forddean.com; service@forddean.com.
/s/Amy L. Christiansen
GEORGE M. VINCI, JR., ESQ.
Florida Bar No. 817201
AMY L. CHRISTIANSEN, ESQ.
Florida Bar No. 0602841
Spector Gadon & Rosen, LLP
360 Central Ave., Suite 1550
St. Petersburg, FL 33701
727-896-4600; Facsimile 727-896-4604
Primary: achristiansen@lawsgr.com
Secondary: dpetersburg@lawsgr.com
Tertiary: pleadings@lawser.com
Attorneys for DefendantCIS, Medicare
CENTERS for MEDKCARE & MEDICAID SERVICES Beneficiary Services:1-800-MEDICARE (1-800-633-4227)
TTY/TD0:1-877-486-2048
This form is used to advise Medicare of the person or persons you have chosen to have access to your
personal health information.
Where to Return Your Completed Authorization Forms:
After you complete and sign the authorization form, return it to the address below:
Medicare BCC, Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044
For New York Medicare Beneficiaries ONLY
The New York State Public Health Law protects information that reasonably could identify someone as
. having HIV symptoms or infection, and information regarding a person's contacts. Because of New York's
laws protecting the privacy of information related to alcohol and drug abuse, mental health treatment, and
HIV, there are special instructions for how you, as a New York resident, should complete this form.
“e For question 2A, check the box for Limited Information, even if you want to authorize Medicare
to release any and all of your personal health information.
e Then proceed to question 2B.
Medicare BCC, Written Authorization Dept.
PO Box 4270
Lawrence, KS 66044Instructions for Completing Section 2B of the Authorization Form:
Please select one of the following options.
« Option 1 To include all information, in the space provided, write: "all information, including
information about alcohol and drug abuse, mental health treatment, and HIV". Proceed with the rest
of the form.
¢ Option 2 To exclude the information listed above, write "Exclude information about alcohol and*
drug abuse, mental health treatment and HIV" in the space provided. You may also check any of the
remaining boxes and include any additional limitations in the space provided. For example, you
could write "payment information". Then proceed with the rest of the form.
If you have any questions or need additional assistance, please feel free to call us at 1-800-MEDICARE
(1-800-633-4227). TTY users should call 1-877-486-2048.
Sincerely,
1-800-MEDICARE
Customer Service Representative
Enel.Information to Help You Fill Out the
“1-800-MEDICARE Authorization to Disclose Personal Health Information” Form
By law, Medicare must have your written permission (an “authorization”) to use or give out
your personal medical information for any purpose that isn't set out in the privacy notice
contained in the Medicare & You handbook. You may take back (“revoke”) your written
permission at any time, except if Medicare has already acted based on your permission.
If you want 1-800-MEDICARE to give your personal health information to someone other than
you, you need to let Medicare know in writing.
If you are requesting personal health information for a deceased beneficiary, please include a
copy of the legal documentation which indicates your authority to make a request for
information. (For example: Executor/Executrix papers, next of kin attested by court documents
with a court stamp and a judge's signature, a Letter of Testamentary or Administration with a
court stamp and judge's signature, or personal representative papers with a court stamp and
judge's signature.) Also, please explain your relationship to the beneficiary.
Please use this step by step instruction sheet when completing your “1-800-MEDICARE
Authorization to Disclose Personal Health Information” Form. Be sure to complete all sections
of the form to ensure timely processing.
A. Print the name of the person with Medicare.
Print the Medicare number exactly as it is shown on the red, white, and blue Medicare
card, including any letters (for example, 123456789A).
Print the birthday in month, day, and year (mm/dd/yyyy) of the person with Medicare.
2. This section tells Medicare what personal. health information to give out. Please check a
box in 2a to indicate how much information Medicare can disclose. If you only want
Medicare to give out limited information (for example, Medicare eligibility), also check '
the box(es) in 2b that apply to the type of information you want Medicare to give out.
3. This section tells Medicare when to start and/or when to stop giving out your personal
health information. Check the box that applies and fill in dates, if necessary.
4, Medicare will give your personal health information to the person(s) or organization(s) you
fill in here. You may fill in more than one person or organization. If you designate an
organization, you must also identify one or more individuals in that organization to whom
’ Medicare may disclose your personal health information.5. The person with Medicare or personal representative must sign their name, fill in the date,
and provide the phone number and address of the person with Medicare.
If you are a personal representative of the person with Medicare, check the box, provide
your address and phone number, and attach a copy of the paperwork that shows you can
act for that person (for example, Power of Attorney).
6. Send your completed, signed authorization to Medicare at the address shown here on your
authorization form.
7. Ifyou change your mind and don't want Medicare to give out your personal health
information, write to the address shown under number six on the authorization form and
tell Medicare. Your letter will revoke your authorization and Medicare will no longer
‘give out your personal health information (except for the personal health information
Medicare has already given out based on your permission).
You should make a copy of your signed authorization for your records before mailing it to
Medicare.1-800-MEDICARE Authorization to Disclose Personal Health Information
Use this form if you want 1-800-MEDICARE to give your personal health information to
someone other than you.
1. Print Name Medicare Number Date of Birth
(First and last name of the person with Medicare) (Exactly as shown on the Medicare Card) (mm/dd/yyyy)
2. Medicare will only disclose the personal health information you want disclosed.
2A: Check only one box below to tell Medicare the specific personal health
information you want disclosed:
0 Limited Information (go to question 2b)
C1 Any Information (go to question 3)
2B: Complete only if you selected “limited information”. Check all that apply:
(Information about your Medicare eligibility
U1 Information about your Medicare claims
C1 Information about plan enrollment (e.g. drug or MA Plan)
C1 Information about premium payments
C Other Specific Information (please write below; for example, payment information)
3. Check only one box below indicating how long Medicare can use this authorization
to disclose your personal health information (subject to applicable law—for example,
your State may limit how long Medicare may give out your personal health information):
O Disclose my personal health information indefinitely
O1 Disclose my personal health information for a specified period only
beginning: (mm/dd/yyyy) and ending: (mm/dd/yyyy)4. Fill in the name and address of the person(s) or organization(s) to whom you want
Medicare to disclose your personal health information. Please provide the specific
name of the person(s) for any organization you list below:
1.
Name:
Address:
Name:
Address:
Name:
Address:
I authorize 1-800-MEDICARE to disclose my personal health information listed
above to the person(s) or organization(s) I have named on this form. I
understand that my personal health information may be re-disclosed by the
person(s) or organization(s) and may no longer be protected by law.
Signature Telephone Number Date (mm/dd/yyyy)
. Print the address of the person with Medicare (Street Address, City, State, and ZIP)
( Check here if you are signing as a personal representative and complete below.
Please attach the appropriate documentation (for example, Power of Attorney).
This only applies if someone other than the person with Medicare signed above.
Print the Personal Representative's Address (Street Address, City, State, and ZIP)
Telephone Number of Personal Representative:
Personal Representative's Relationship to the Beneficiary:6. Send the completed, signed authorization to:
Medicare BCC, Written Authorization Dept.
PO Box 1270
Lawrence, KS 66044
7. Note:
You have the right to take back (“revoke”) your authorization at any time, in writing,
except to the extent that Medicare has already acted based on your permission. If you
would like to revoke your authorization, send a written request to the address shown
above.
Your authorization or refusal to authorize disclosure of your personal health
information will have no effect on your enrollment, eligibility for benefits, or the
amount Medicare pays for the health services you receive.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a —
collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-0930. The time required to complete
this information collection is estimated to average 15 minutes per response, including the
time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.FIORIDA AGENCY FOR HEALTH CARE ADMINISTRATION
Better Health Care for all Floridians INTERIM SECRETARY
RICK SCOTT
GOVERNOR
Authorization for the Use and Disclosure of Protected Health Information
Federal law states that we cannot share an individual's health information without the individual's permission, except in certain situations.
By signing this form, you are giving us permission to share the information you indicate below. If you decide later that you do not want us to
Share this information any more, you can revoke this authorization at any time in writing or sign the REVOCATION SECTION on the back of
this form and return it to ACS Recovery Services (ACS). This form must be completed and signed by the Medicaid recipient or by an
individual who has the authority to act on the Medicaid recipient’s behalf (parent of a minor, legal guardian, trustee, power of attorney,
personal representative of the estate, grantor of an annuity).
PLEASE COMPLETE THE FOLLOWING SECTIONS
1, Personal Information:
Medicaid Recipient's Name. Date of Birth,
Medicaid ID Number. Social Security Number.
2. I give permission to the Agency for Health Care Administration (AHCA) and its contract representatives to share the health information
listed below with the following:
Name of the Law Firm or Law Office,
Name of the Insurance Company.
Other,
3. _ Indicate the purpose for which the disclosure is to be made:
To substantiate Medicaid’s lien relating to a lawsuit
To substantiate Medicaid’s claim against the estate or against a trust account or annuity
Other
4. Indicate the information that you want to be disclosed, related to the following (check one):
___The Medicaid lien relating fo the injury or negligence charges, for the period beginning with the. date of incident.
__Medicaid’s claim against the estate.
___The amount that is due Medicaid from the frust account, [Please send a copy of the trust agreement).
____The amount that is due Medicaid from the annuity account, [Please send a copy of the annuity agreement].
____Other, [Please be specific].
5. Enter the specific date that you want this authorization to expire: (i.e., one year from date of release).
(If you do not enter a date, this authorization will expire in five years.)
| understand that the information described above may be redisclosed by the person or group that ! hereby give AHCA and its contract representatives
permission to share my information with, and that my information would no longer be protected by the federal privacy regulations. Therefore, | release
AHCA, its workforce members, and its contract representatives from all liability arising from the disclosure of my health information pursuant to this
agreement. | understand that | may inspect or request copies of any information disclosed by this authorization if AHCA or its contract representatives
initiated this request for disclosure. | understand that | may revoke this authorization by notifying AHCA through ils contractor representatives, in writing,
knowing that previously disclosed information would not be subject to my revocation request. | understand that | may refuse to sign this authorization
and that my refusal to sign will not affect my ability to obtain treatment, payment or eligibility for benefits.
6. Recipient Signature. Print Name, Date.
OR |
Name of Legal Representative (Print) Relationship,
Signature of Legal Representative § Date.
* ttyou are not the individual, bt represent the individual, please attach a copy ofthe egal document that verifies that you are representative (parent
ofa minor, legal guardian, trustee, power of attorney, personal representative of the estate, grantor of an antINSTRUCTIONS FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
1. Complete the front of the form and return it to ACS Recovery Services, Post Office Box 12188, Tallahassee, Florida 32317-2188,
Phone (toll-free) (877) 357-3268 or Fax (866) 443-5559.
2. If the signer is a guardian, has a power of attorney or is an authorized representative, documentation of the representative's
authority to act on the individual's behalf must be attached. If an agency has custody of a child and a representative signs the release,
include a copy of the custody order.
3. Special kinds of health information have specific laws and rules that have to be followed before that information can be disclosed.
HIV and Sexually Transmitted Diseases (STD): All information about HIV and sexually transmitted diseases is protected under
federal and state laws and cannot be disclosed without your written authorization unless otherwise provided in the regulations. To
release HIV or STD information, this authorization must include a statement in the Information You Want Disclosed section of the
specific HIV or STD information that you are giving permission to release. Re-disclosure of HIV information is not allowed, except in
compliance with law or with your written permission.
Alcohol and Drug Treatment: Alcohol and/or drug treatment records are protected under federal and state laws and regulations and
cannot be disclosed without your written authorization, unless otherwise provided for in federal and state laws or regulations. To
release alcohol and drug treatment information, this authorization must include a statement in the Information You Want Disclosed
section of the specific information that you are giving permission to release, such as “assessment, treatment plan, attendance,
discharge plan.” Re-disclosure of you alcohol and/or drug treatment records is not allowed, except in compliance with law or with your
written permission.
Mental Health Treatment: Mental health treatment records are protected under federal and state laws and regulations and cannot be
disclosed without your written authorization, unless otherwise allowed in federal and state laws or regulations. To release mental health
treatment information, this authorization must include a statement in the Information You Want Disclosed section of the specific
information that you are giving. permission to release, such as “assessment, treatment plan, attendance, discharge plan.” Also,
disclosure of your therapist's own notes (psychotherapy notes) needs separate permission. Re-disclosure of your mental health
treatment records is prohibited, except in compliance with law or with your written permission.
4. You will be provided with a copy Of this form.
REVOCATION SECTION
To revoke your authorization, complete the following section and return the form to ACS Recovery Services at the address given above.
(Use of this form to revoke your authorization is optional; however, you must submit your revocation request in writing.)
| no longer want my information shared.
Name, Date of Birth.
Street Address,
City. : State, Zip
If applicable, your Medicaid ID number,
Signature. - - Date.
OR
Signature of Authorized Representative. Date.
Relationship of Authorized Representative.
(Revised November 2008)
Preview
Filing # 58936125 E-Filed 07/12/2017 04:57:52 PM IN THE CIRCUIT COURT OF THE 11TH JUDICIAL CIRCUIT IN AND FOR MIAMI COUNTY, FLORIDA, CIVIL DIVISION ISABEL LEVINE, as Personal Representative of the Estate of JOSE CLEMENTE, Deceased, VS. Plaintiff, CASE NO. 17-CA-014511-01 SENIOR HEALTH — TREASURE ISLES, LLC, d/b/a TREASURE ISLE CARE CENTER, Defendant, / DEFENDANT SENIOR HEALTH- TREASURE ISLE, LLC d/b/a TREASURE ISLE CARE C R’S FIRST REQUEST FOR PRODUCTION OF DOCUMENTS COMES NOW defendant SENIOR HEALTH-TREASURE ISLE, LLC d/b/a TREASURE ISLE CARE CENTER, by and through its undersigned counsel and pursuant to the Florida Rules of Civil Procedure, and requests from plaintiff, clear and legible copies of all documents and items listed below within thirty (30) days of service hereof. 1. 2 Federal income tax returns of plaintiff for the past five (5) years. Itemized medical bills incurred as result of the allegations described in the Complaint A complete copy of any and all policies of insurance of any kind or nature which were in effect on the date of the incident which would provide benefits to plaintiff by reason of the allegations contained in the Complaint. Any and all written and/or recorded statements taken or obtained by plaintiff or any of plaintiffs attorneys, agents or representatives, or any present employees of defendant or any former employees of defendant who participated directly or indirectly with the care and treatment of JOSE CLEMENTE. All medical records and reports rendered by JOSE CLEMENTE ’S treating and examining physicians and other health care providers listed in Answers to Interrogatories. Please do not include TREASURE ISLE CARE CENTER chart. Any photographs, if any, of JOSE CLEMENTE while a resident at TREASURE ISLE CARE CENTER.10. 11 12. 14 15 16. 17. 18 Copies of any and all documents, statements, receipts, bills, memoranda, etc., reflecting bills submitted to or payments made by any collateral source as the term is defined in Section 768.76, Florida Statutes. Copies of any report, bill, fee schedule, correspondence or any memoranda relating to any expert who may testify in this cause Any and all bills, invoices, or statements from any expert expected to testify or referring or consulting organization which bills for that expert’s services. Any and all documents received by plaintiff and/or any family member from TREASURE ISLE CARE CENTER during JOSE CLEMENTP’’S residency. Duplicate copies of any photographs taken of JOSE CLEMENTE of the five (5) year period preceding during or after his admission to TREASURE ISLE CARE CENTER. Any and all records, documents, papers or other materials you have in your possession which pertain to the care and treatment of JOSE CLEMENTE while a resident at TREASURE ISLE CARE CENTER excluding any communication with your attorneys or their representatives. Any and all police/sheriff reports relating to any of the matters set forth in the Complaint Any and all HRS/AHCA reports relating to any of the matters set forth in the Complaint Copies of any and all receipts, invoices, or canceled checks which would evidence payments made by you or others on behalf of JOSE CLEMENTE while a resident at TREASURE ISLE CARE CENTER. The names and addresses of all other health care providers upon whom plaintiff served a Notice of Intent to Initiate Action for medical malpractice. Copies of all invoices or bills for all expenses and damages plaintiff is alleging as aresult of the incidents alleged in the Complaint. A complete copy of all medical records and reports from all physicians and medical health care providers, including hospitals, regarding treatment to JOSE CLEMENTE currently in your possession or in the possession of your agents, representatives, or attorneys. Please do not include TREASURE ISLE CARE CENTER chart.19. 20. 21. 22. 24. 25. 26. A copy of any and all notes, journal entries, or other documents from any family members of JOSE CLEMENTE regarding his care and treatment at TREASURE ISLE CARE CENTER. Copies of Complaints filed against any other healthcare providers regarding care and treatment of JOSE CLEMENTE Any and all conditional payment letters from Medicare and/or Medicaid related to any medical expenses or bills for JOSE CLEMENTE. A properly executed authorization for the release of medical records/information directed to Medicare in the form attached hereto as “Exhibit A.” A properly executed authorization for the release of medical records/information directed to Medicaid in the form attached hereto as “Exhibit B.” Any and all documents referring or relating to conversations with any friends or family members of JOSE CLEMENTE. Any and all documents referring or relating to JOSE CLEMENTE’S residency at TREASURE ISLE CARE CENTER any and all medical, hospital, or nursing home records or medical, hospital, or nursing home bills. Any bills, receipts, invoices referring or reflecting JOSE CLEMENTE’S nursing home residency at TREASURE ISLE CARE CENTER or any other nursing home and/or hospital where JOSE CLEMENTE resided. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing was furnished via Electronic Mail delivery on this 12th day of July, 2017 to: William A. Dean, Esq., FORD, DEAN & ROTUNDO, P.A., Turnberry Plaza, Suite 600, 2875 NE. 191 Street, Miami, FL 33180, at bill@forddean.com; zee@forddean.com; service@forddean.com. /s/Amy L. Christiansen GEORGE M. VINCI, JR., ESQ. Florida Bar No. 817201 AMY L. CHRISTIANSEN, ESQ. Florida Bar No. 0602841 Spector Gadon & Rosen, LLP 360 Central Ave., Suite 1550 St. Petersburg, FL 33701 727-896-4600; Facsimile 727-896-4604 Primary: achristiansen@lawsgr.com Secondary: dpetersburg@lawsgr.com Tertiary: pleadings@lawser.com Attorneys for DefendantCIS, Medicare CENTERS for MEDKCARE & MEDICAID SERVICES Beneficiary Services:1-800-MEDICARE (1-800-633-4227) TTY/TD0:1-877-486-2048 This form is used to advise Medicare of the person or persons you have chosen to have access to your personal health information. Where to Return Your Completed Authorization Forms: After you complete and sign the authorization form, return it to the address below: Medicare BCC, Written Authorization Dept. PO Box 1270 Lawrence, KS 66044 For New York Medicare Beneficiaries ONLY The New York State Public Health Law protects information that reasonably could identify someone as . having HIV symptoms or infection, and information regarding a person's contacts. Because of New York's laws protecting the privacy of information related to alcohol and drug abuse, mental health treatment, and HIV, there are special instructions for how you, as a New York resident, should complete this form. “e For question 2A, check the box for Limited Information, even if you want to authorize Medicare to release any and all of your personal health information. e Then proceed to question 2B. Medicare BCC, Written Authorization Dept. PO Box 4270 Lawrence, KS 66044Instructions for Completing Section 2B of the Authorization Form: Please select one of the following options. « Option 1 To include all information, in the space provided, write: "all information, including information about alcohol and drug abuse, mental health treatment, and HIV". Proceed with the rest of the form. ¢ Option 2 To exclude the information listed above, write "Exclude information about alcohol and* drug abuse, mental health treatment and HIV" in the space provided. You may also check any of the remaining boxes and include any additional limitations in the space provided. For example, you could write "payment information". Then proceed with the rest of the form. If you have any questions or need additional assistance, please feel free to call us at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. Sincerely, 1-800-MEDICARE Customer Service Representative Enel.Information to Help You Fill Out the “1-800-MEDICARE Authorization to Disclose Personal Health Information” Form By law, Medicare must have your written permission (an “authorization”) to use or give out your personal medical information for any purpose that isn't set out in the privacy notice contained in the Medicare & You handbook. You may take back (“revoke”) your written permission at any time, except if Medicare has already acted based on your permission. If you want 1-800-MEDICARE to give your personal health information to someone other than you, you need to let Medicare know in writing. If you are requesting personal health information for a deceased beneficiary, please include a copy of the legal documentation which indicates your authority to make a request for information. (For example: Executor/Executrix papers, next of kin attested by court documents with a court stamp and a judge's signature, a Letter of Testamentary or Administration with a court stamp and judge's signature, or personal representative papers with a court stamp and judge's signature.) Also, please explain your relationship to the beneficiary. Please use this step by step instruction sheet when completing your “1-800-MEDICARE Authorization to Disclose Personal Health Information” Form. Be sure to complete all sections of the form to ensure timely processing. A. Print the name of the person with Medicare. Print the Medicare number exactly as it is shown on the red, white, and blue Medicare card, including any letters (for example, 123456789A). Print the birthday in month, day, and year (mm/dd/yyyy) of the person with Medicare. 2. This section tells Medicare what personal. health information to give out. Please check a box in 2a to indicate how much information Medicare can disclose. If you only want Medicare to give out limited information (for example, Medicare eligibility), also check ' the box(es) in 2b that apply to the type of information you want Medicare to give out. 3. This section tells Medicare when to start and/or when to stop giving out your personal health information. Check the box that applies and fill in dates, if necessary. 4, Medicare will give your personal health information to the person(s) or organization(s) you fill in here. You may fill in more than one person or organization. If you designate an organization, you must also identify one or more individuals in that organization to whom ’ Medicare may disclose your personal health information.5. The person with Medicare or personal representative must sign their name, fill in the date, and provide the phone number and address of the person with Medicare. If you are a personal representative of the person with Medicare, check the box, provide your address and phone number, and attach a copy of the paperwork that shows you can act for that person (for example, Power of Attorney). 6. Send your completed, signed authorization to Medicare at the address shown here on your authorization form. 7. Ifyou change your mind and don't want Medicare to give out your personal health information, write to the address shown under number six on the authorization form and tell Medicare. Your letter will revoke your authorization and Medicare will no longer ‘give out your personal health information (except for the personal health information Medicare has already given out based on your permission). You should make a copy of your signed authorization for your records before mailing it to Medicare.1-800-MEDICARE Authorization to Disclose Personal Health Information Use this form if you want 1-800-MEDICARE to give your personal health information to someone other than you. 1. Print Name Medicare Number Date of Birth (First and last name of the person with Medicare) (Exactly as shown on the Medicare Card) (mm/dd/yyyy) 2. Medicare will only disclose the personal health information you want disclosed. 2A: Check only one box below to tell Medicare the specific personal health information you want disclosed: 0 Limited Information (go to question 2b) C1 Any Information (go to question 3) 2B: Complete only if you selected “limited information”. Check all that apply: (Information about your Medicare eligibility U1 Information about your Medicare claims C1 Information about plan enrollment (e.g. drug or MA Plan) C1 Information about premium payments C Other Specific Information (please write below; for example, payment information) 3. Check only one box below indicating how long Medicare can use this authorization to disclose your personal health information (subject to applicable law—for example, your State may limit how long Medicare may give out your personal health information): O Disclose my personal health information indefinitely O1 Disclose my personal health information for a specified period only beginning: (mm/dd/yyyy) and ending: (mm/dd/yyyy)4. Fill in the name and address of the person(s) or organization(s) to whom you want Medicare to disclose your personal health information. Please provide the specific name of the person(s) for any organization you list below: 1. Name: Address: Name: Address: Name: Address: I authorize 1-800-MEDICARE to disclose my personal health information listed above to the person(s) or organization(s) I have named on this form. I understand that my personal health information may be re-disclosed by the person(s) or organization(s) and may no longer be protected by law. Signature Telephone Number Date (mm/dd/yyyy) . Print the address of the person with Medicare (Street Address, City, State, and ZIP) ( Check here if you are signing as a personal representative and complete below. Please attach the appropriate documentation (for example, Power of Attorney). This only applies if someone other than the person with Medicare signed above. Print the Personal Representative's Address (Street Address, City, State, and ZIP) Telephone Number of Personal Representative: Personal Representative's Relationship to the Beneficiary:6. Send the completed, signed authorization to: Medicare BCC, Written Authorization Dept. PO Box 1270 Lawrence, KS 66044 7. Note: You have the right to take back (“revoke”) your authorization at any time, in writing, except to the extent that Medicare has already acted based on your permission. If you would like to revoke your authorization, send a written request to the address shown above. Your authorization or refusal to authorize disclosure of your personal health information will have no effect on your enrollment, eligibility for benefits, or the amount Medicare pays for the health services you receive. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a — collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0930. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.FIORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Better Health Care for all Floridians INTERIM SECRETARY RICK SCOTT GOVERNOR Authorization for the Use and Disclosure of Protected Health Information Federal law states that we cannot share an individual's health information without the individual's permission, except in certain situations. By signing this form, you are giving us permission to share the information you indicate below. If you decide later that you do not want us to Share this information any more, you can revoke this authorization at any time in writing or sign the REVOCATION SECTION on the back of this form and return it to ACS Recovery Services (ACS). This form must be completed and signed by the Medicaid recipient or by an individual who has the authority to act on the Medicaid recipient’s behalf (parent of a minor, legal guardian, trustee, power of attorney, personal representative of the estate, grantor of an annuity). PLEASE COMPLETE THE FOLLOWING SECTIONS 1, Personal Information: Medicaid Recipient's Name. Date of Birth, Medicaid ID Number. Social Security Number. 2. I give permission to the Agency for Health Care Administration (AHCA) and its contract representatives to share the health information listed below with the following: Name of the Law Firm or Law Office, Name of the Insurance Company. Other, 3. _ Indicate the purpose for which the disclosure is to be made: To substantiate Medicaid’s lien relating to a lawsuit To substantiate Medicaid’s claim against the estate or against a trust account or annuity Other 4. Indicate the information that you want to be disclosed, related to the following (check one): ___The Medicaid lien relating fo the injury or negligence charges, for the period beginning with the. date of incident. __Medicaid’s claim against the estate. ___The amount that is due Medicaid from the frust account, [Please send a copy of the trust agreement). ____The amount that is due Medicaid from the annuity account, [Please send a copy of the annuity agreement]. ____Other, [Please be specific]. 5. Enter the specific date that you want this authorization to expire: (i.e., one year from date of release). (If you do not enter a date, this authorization will expire in five years.) | understand that the information described above may be redisclosed by the person or group that ! hereby give AHCA and its contract representatives permission to share my information with, and that my information would no longer be protected by the federal privacy regulations. Therefore, | release AHCA, its workforce members, and its contract representatives from all liability arising from the disclosure of my health information pursuant to this agreement. | understand that | may inspect or request copies of any information disclosed by this authorization if AHCA or its contract representatives initiated this request for disclosure. | understand that | may revoke this authorization by notifying AHCA through ils contractor representatives, in writing, knowing that previously disclosed information would not be subject to my revocation request. | understand that | may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment or eligibility for benefits. 6. Recipient Signature. Print Name, Date. OR | Name of Legal Representative (Print) Relationship, Signature of Legal Representative § Date. * ttyou are not the individual, bt represent the individual, please attach a copy ofthe egal document that verifies that you are representative (parent ofa minor, legal guardian, trustee, power of attorney, personal representative of the estate, grantor of an antINSTRUCTIONS FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION 1. Complete the front of the form and return it to ACS Recovery Services, Post Office Box 12188, Tallahassee, Florida 32317-2188, Phone (toll-free) (877) 357-3268 or Fax (866) 443-5559. 2. If the signer is a guardian, has a power of attorney or is an authorized representative, documentation of the representative's authority to act on the individual's behalf must be attached. If an agency has custody of a child and a representative signs the release, include a copy of the custody order. 3. Special kinds of health information have specific laws and rules that have to be followed before that information can be disclosed. HIV and Sexually Transmitted Diseases (STD): All information about HIV and sexually transmitted diseases is protected under federal and state laws and cannot be disclosed without your written authorization unless otherwise provided in the regulations. To release HIV or STD information, this authorization must include a statement in the Information You Want Disclosed section of the specific HIV or STD information that you are giving permission to release. Re-disclosure of HIV information is not allowed, except in compliance with law or with your written permission. Alcohol and Drug Treatment: Alcohol and/or drug treatment records are protected under federal and state laws and regulations and cannot be disclosed without your written authorization, unless otherwise provided for in federal and state laws or regulations. To release alcohol and drug treatment information, this authorization must include a statement in the Information You Want Disclosed section of the specific information that you are giving permission to release, such as “assessment, treatment plan, attendance, discharge plan.” Re-disclosure of you alcohol and/or drug treatment records is not allowed, except in compliance with law or with your written permission. Mental Health Treatment: Mental health treatment records are protected under federal and state laws and regulations and cannot be disclosed without your written authorization, unless otherwise allowed in federal and state laws or regulations. To release mental health treatment information, this authorization must include a statement in the Information You Want Disclosed section of the specific information that you are giving. permission to release, such as “assessment, treatment plan, attendance, discharge plan.” Also, disclosure of your therapist's own notes (psychotherapy notes) needs separate permission. Re-disclosure of your mental health treatment records is prohibited, except in compliance with law or with your written permission. 4. You will be provided with a copy Of this form. REVOCATION SECTION To revoke your authorization, complete the following section and return the form to ACS Recovery Services at the address given above. (Use of this form to revoke your authorization is optional; however, you must submit your revocation request in writing.) | no longer want my information shared. Name, Date of Birth. Street Address, City. : State, Zip If applicable, your Medicaid ID number, Signature. - - Date. OR Signature of Authorized Representative. Date. Relationship of Authorized Representative. (Revised November 2008)