Preview
Electronically Filed 10/03/2013 04:15:14 PM ET
IN THE CIRCUIT COURT OF THE
NINTH JUDICIAL CIRCUIT IN AND
FOR ORANGE COUNTY, FLORIDA
CASE NO. 2008-CA-011228-O
DIVISION: 39
MARCELO DIAZ, as Personal
Representative of the Estate of HERMINIA
DIAZ,
Plaintiff
vs.
HARINATH SHEELA, MD; DIGESTIVE
AND LIVER CENER OF FLORIDA, P.A.,
ADVENTIST HEALTH SYSTEM/
SUNBELT, INC., d/b/a FLORIDA
HOSPITAL ORLANDO, and d/b/a
FLORIDA HOSPITAL APOPKA, JUNIAS
DESAMOUR, MD, and MID-FLORIDA
HOSPITAL SPECIALISTS, P.A.
Defendants
/
REQUEST TO PRODUCE TO PLAINTIFF
TO: MARCELO DIAZ
c/o Diez-Arguelles & Tejador, P.A.
505 North Mills Avenue
Orlando, FL 32803
COMES NOW the Defendant, ADVENTIST HEALTH SYSTEM/SUNBELT, INC. d/b/a
FLORIDA HOSPITAL ORLANDO, by and through its undersigned counsel, and hereby requests,
pursuant to Florida Rules of Civil Procedure, that the plaintiff produces within thirty (30) days the
following document:
1. A signed, executed, and notarized Authorization for Release of Protected
Health Information directed to the Plaintiff, MARCELO DIAZ, Personal
Representative of the Estate of Herminia Diaz, to obtain the complete chart of
MATTHEW M. APTER, M.D. A copy of the Authorization for your signature
is attached hereto.
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that on the 3rd day of October, 2013, I electronically filed the
foregoing with the Clerk of the Courts by using the ECF system and by electronic mail to: Carlos R.
Diez-Arguelles, Esquire, Diez-Arguelles & Tejedor, P.A., 520 N Semoran Blvd, Suite 200, Orlando,
FL 32807; and Rogelio J. Fontela, Esquire, Dennis, Jackson, Martin & Fontela, P.A. 1591 Summit
Lake Dr., Suite 200, Tallahassee, FL 32317-7943.
s/ Patrick H. Telan, Esquire___________________
PATRICK H. TELAN, ESQUIRE
Florida Bar No. 973874
JOHN J. TRESS, III, ESQUIRE
Florida Bar No. 183751
Grower, Ketcham, Rutherford,
Bronson, Eide & Telan, P.A.
PO Box 538065
Orlando, FL 32853-8065
Telephone: (407) 423-9545
Facsimile: (407) 425-7104
Primary Email: phtelan@growerketcham.com
1st Secondary: enotice@growerketcham.com
2nd Secondary: cboals@growerketcham.com
Attorney for Defendants, ADVENTIST HEALTH
SYSTEM/SUNBELT, INC., d/b/a FLORIDA
HOSPITAL ORLANDO
/EC
AUTHORIZATION FOR RELEASE OF
PROTECTED HEALTH INFORMATION
I, MARCELO DIAZ, Personal Representative of the Estate of HERMINIA DIAZ, authorizes
and requests the recipient, MATTHEW M. APTER, M.D., to furnish to: John J. Tress, III, Esquire
of the law firm Grower, Ketcham, Rutherford, Bronson, Eide & Telan, P.A., Post Office Box
538065, Orlando, FL, 32853-8065, a full and complete copy of the Protected Health Information
(“PHI”) of Herminia Diaz, deceased, pursuant to the HIPAA Privacy Rule, 45 C.F.R. 164.508 and
Florida Statutes, including, but not limited to:
all medical records, billing statements, medical notes, correspondence, alcohol and drug
abuse, HIV and AIDS information, dental, and chiropractic records and reports, ambulance
trip reports, trauma reports, diagnostic test results, doctors’ notes, nurses’ notes, progress
notes, physicians’ orders, nursing care plans, medication information, graphic charts,
histories, physicals, admission and discharge summaries, operative notes and reports,
Psychiatric, psychotherapy, and mental health records, psychiatric evaluations,
psychological history, pathology reports, pathology slides, specimens, tissue samples and
paraffin blocks, recovery room records, physical therapy, occupational therapy, speech
therapy, aquatic therapy, and equestrian therapy notes of attendance and treatment,
emergency department records, outpatient records, clinic records, consultations, lists of
authorized abbreviations used in medical charting, patient information forms and
questionnaires, x-ray reports, CT scan reports, MRI reports, ultrasound reports, laboratory
reports, correspondence, memoranda, billing records, reimbursement records, recorded
statements, consent, transfer and refusal of treatment forms, photographs, videotapes,
compact discs, notes and records reflecting verbal communications, if applicable, autopsy
reports, preliminary, supplemental, and amended autopsy reports, notes and data dictated or
written by the pathologist or medical examiner performing the autopsy, all reports and
correspondence prepared for attorneys, insurance companies, or any other person or entity of
whatever nature by the covered entity recipient and all correspondence received by the
covered entity recipient from such persons or entities, and all other medical records of any
kind or nature whatsoever regarding the examination, treatment, and evaluations of me, my
date of birth: ; Social Security Number: .
A photocopy hereof has the same force and effect as the original Authorization.
This Authorization is executed to permit the use and disclosure of my PHI to the named attorney for
all uses permitted by federal and Florida law in civil litigation.
This Authorization will remain in full force and effect until the conclusion of the civil litigation
inquiry, discovery, trial, and all related appeals of any civil, criminal, or administrative action.
This Authorization for the release of PHI may be revoked at any time, provided that the revocation is
in writing and is delivered to the recipient covered entity, except to the extent that the recipient covered
entity has taken action in reliance thereon prior to receiving the written executed revocation.
I understand that my records may be subject to re-disclosure by recipient(s) and unprotected by
federal or state law.
I also understand that Grower, Ketcham, Rutherford, Bronson, Eide & Telan, P.A. is not a covered
entity and does not condition the treatment, payment, enrollment, or eligibility for benefits on this
authorization.
A copy of records and billing statements and your invoice for copies are to be provided to the
attorney at the address listed herein.
Date: _______________________ _______________________________________
MARCELO DIAZ, Personal Representative
of the Estate of Herminia Diaz
STATE OF FLORIDA
COUNTY OF ORANGE
The foregoing document was acknowledged before me this ______ day of _____________,
2013, by MARCELO DIAZ, as Personal Representative of the Estate of Herminia Diaz.
____________________________________
Notary Public
____________________________________
Printed Name
______Personally known to me OR ______ Produced Identification
Type of Identification Produced:
__________________________________________
Preview
Electronically Filed 10/03/2013 04:15:14 PM ET IN THE CIRCUIT COURT OF THE NINTH JUDICIAL CIRCUIT IN AND FOR ORANGE COUNTY, FLORIDA CASE NO. 2008-CA-011228-O DIVISION: 39 MARCELO DIAZ, as Personal Representative of the Estate of HERMINIA DIAZ, Plaintiff vs. HARINATH SHEELA, MD; DIGESTIVE AND LIVER CENER OF FLORIDA, P.A., ADVENTIST HEALTH SYSTEM/ SUNBELT, INC., d/b/a FLORIDA HOSPITAL ORLANDO, and d/b/a FLORIDA HOSPITAL APOPKA, JUNIAS DESAMOUR, MD, and MID-FLORIDA HOSPITAL SPECIALISTS, P.A. Defendants / REQUEST TO PRODUCE TO PLAINTIFF TO: MARCELO DIAZ c/o Diez-Arguelles & Tejador, P.A. 505 North Mills Avenue Orlando, FL 32803 COMES NOW the Defendant, ADVENTIST HEALTH SYSTEM/SUNBELT, INC. d/b/a FLORIDA HOSPITAL ORLANDO, by and through its undersigned counsel, and hereby requests, pursuant to Florida Rules of Civil Procedure, that the plaintiff produces within thirty (30) days the following document: 1. A signed, executed, and notarized Authorization for Release of Protected Health Information directed to the Plaintiff, MARCELO DIAZ, Personal Representative of the Estate of Herminia Diaz, to obtain the complete chart of MATTHEW M. APTER, M.D. A copy of the Authorization for your signature is attached hereto. CERTIFICATE OF SERVICE I HEREBY CERTIFY that on the 3rd day of October, 2013, I electronically filed the foregoing with the Clerk of the Courts by using the ECF system and by electronic mail to: Carlos R. Diez-Arguelles, Esquire, Diez-Arguelles & Tejedor, P.A., 520 N Semoran Blvd, Suite 200, Orlando, FL 32807; and Rogelio J. Fontela, Esquire, Dennis, Jackson, Martin & Fontela, P.A. 1591 Summit Lake Dr., Suite 200, Tallahassee, FL 32317-7943. s/ Patrick H. Telan, Esquire___________________ PATRICK H. TELAN, ESQUIRE Florida Bar No. 973874 JOHN J. TRESS, III, ESQUIRE Florida Bar No. 183751 Grower, Ketcham, Rutherford, Bronson, Eide & Telan, P.A. PO Box 538065 Orlando, FL 32853-8065 Telephone: (407) 423-9545 Facsimile: (407) 425-7104 Primary Email: phtelan@growerketcham.com 1st Secondary: enotice@growerketcham.com 2nd Secondary: cboals@growerketcham.com Attorney for Defendants, ADVENTIST HEALTH SYSTEM/SUNBELT, INC., d/b/a FLORIDA HOSPITAL ORLANDO /EC AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION I, MARCELO DIAZ, Personal Representative of the Estate of HERMINIA DIAZ, authorizes and requests the recipient, MATTHEW M. APTER, M.D., to furnish to: John J. Tress, III, Esquire of the law firm Grower, Ketcham, Rutherford, Bronson, Eide & Telan, P.A., Post Office Box 538065, Orlando, FL, 32853-8065, a full and complete copy of the Protected Health Information (“PHI”) of Herminia Diaz, deceased, pursuant to the HIPAA Privacy Rule, 45 C.F.R. 164.508 and Florida Statutes, including, but not limited to: all medical records, billing statements, medical notes, correspondence, alcohol and drug abuse, HIV and AIDS information, dental, and chiropractic records and reports, ambulance trip reports, trauma reports, diagnostic test results, doctors’ notes, nurses’ notes, progress notes, physicians’ orders, nursing care plans, medication information, graphic charts, histories, physicals, admission and discharge summaries, operative notes and reports, Psychiatric, psychotherapy, and mental health records, psychiatric evaluations, psychological history, pathology reports, pathology slides, specimens, tissue samples and paraffin blocks, recovery room records, physical therapy, occupational therapy, speech therapy, aquatic therapy, and equestrian therapy notes of attendance and treatment, emergency department records, outpatient records, clinic records, consultations, lists of authorized abbreviations used in medical charting, patient information forms and questionnaires, x-ray reports, CT scan reports, MRI reports, ultrasound reports, laboratory reports, correspondence, memoranda, billing records, reimbursement records, recorded statements, consent, transfer and refusal of treatment forms, photographs, videotapes, compact discs, notes and records reflecting verbal communications, if applicable, autopsy reports, preliminary, supplemental, and amended autopsy reports, notes and data dictated or written by the pathologist or medical examiner performing the autopsy, all reports and correspondence prepared for attorneys, insurance companies, or any other person or entity of whatever nature by the covered entity recipient and all correspondence received by the covered entity recipient from such persons or entities, and all other medical records of any kind or nature whatsoever regarding the examination, treatment, and evaluations of me, my date of birth: ; Social Security Number: . A photocopy hereof has the same force and effect as the original Authorization. This Authorization is executed to permit the use and disclosure of my PHI to the named attorney for all uses permitted by federal and Florida law in civil litigation. This Authorization will remain in full force and effect until the conclusion of the civil litigation inquiry, discovery, trial, and all related appeals of any civil, criminal, or administrative action. This Authorization for the release of PHI may be revoked at any time, provided that the revocation is in writing and is delivered to the recipient covered entity, except to the extent that the recipient covered entity has taken action in reliance thereon prior to receiving the written executed revocation. I understand that my records may be subject to re-disclosure by recipient(s) and unprotected by federal or state law. I also understand that Grower, Ketcham, Rutherford, Bronson, Eide & Telan, P.A. is not a covered entity and does not condition the treatment, payment, enrollment, or eligibility for benefits on this authorization. A copy of records and billing statements and your invoice for copies are to be provided to the attorney at the address listed herein. Date: _______________________ _______________________________________ MARCELO DIAZ, Personal Representative of the Estate of Herminia Diaz STATE OF FLORIDA COUNTY OF ORANGE The foregoing document was acknowledged before me this ______ day of _____________, 2013, by MARCELO DIAZ, as Personal Representative of the Estate of Herminia Diaz. ____________________________________ Notary Public ____________________________________ Printed Name ______Personally known to me OR ______ Produced Identification Type of Identification Produced: __________________________________________