Free Letter - District Court of Delaware - Delaware


File Size: 66.1 kB
Pages: 3
Date: December 31, 1969
File Format: PDF
State: Delaware
Category: District Court of Delaware
Author: unknown
Word Count: 712 Words, 4,428 Characters
Page Size: 611.28 x 790.92 pts
URL

https://www.findforms.com/pdf_files/ded/9384/70-2.pdf

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Case 1:05-cv-00067-SLR Document 70-2 Filed 11/14/2007 Page 1 of 3
Christiana Care Health Services
November 1, 2007
Attn; ERIKA Y. TROSS
DEPARTMENT OF JUSTICE
820 N. FRENCH ST.
CARVEL STATE OFFICE BLDG.
WILMINGTON, DE 19801 A
Telephone: 302~577-8933 l
RE: 900023324 DAVIS, WILLIAM F
1
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!
The request for information you have submitted on the I
above patient cannot be processed at this time. After an 1
initial review of our files, the records are not available §
at this time-.
If you still desire the requested information, please
re-submit your request with this letter.
Thank you for your patience and anticipated cooperation.
E
Sincerely, [
Christiana Care Health Services J
Release of Information Y
1
P.O. Box 1668 .
Wilmington, DE 19899
I
(302}-428-6852 I
Monday — Friday 8:00 to 4:30
Page 1 W

I Case 1:05-cv-00067-SLR Document 70-2 Filed 11/14/2007 ge 2 of 3 n
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302 577-S500
DEPARTMENT or JUSTICE l
JOSEPH R. BIDEN, lll ¤2¤NNE;¥·i$iiii°=iql[iEN(;i3igIir1pl‘i;ET FAX (ana) im-saacq l
ATTORNEY GENERAL WILMINGTON, DELAWARE 1sa01 '|'|'Y<3¤2l57?—5 83 l
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August 23, 2007
[New Castle County-Civil Division]
Christiana Care Health Services
HIMS Department
Wilmington Hospital l
501 West 14th Street l
Wilmington, DE 19899 l
i Re: Request for Medical Records of
William FZ Davis, III, DOB 11/7/60
Dear Sir or Madam:
Enclosed please find a copy of an Authorization for the Release of Health
Information signed on August 12, 2007, by a patient formerly in your care — Mr. William
F. Davis, III. As the form indicates, Mr. Davis’s medical records are needed for pending l
litigation. Please send me, at your earliest convenience, all of the records requested on t
the authorization form marked by an X.
- lf you have any `questions or concernsplease contact me at (302) 577-8400.
rims you. A 1
Sincerely, E
. u
Erika Y. Tross
Deputy Attorney General l
EYT/vd ,‘
Enclosure
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_ Case 1:05-cv-00067-SLR Document 70-2 Filed 11/14/2007 Page 3 of 3
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Client Name: (print) William F. Davis, IH Date of Birth November 7, l960 1
I, William F. Davis, [Il authorize
(Client’s Name) (Name of Healthcare Provider)
to release and/or provide copies of my health information to:
Erika Y. Tross, DAG
Department of lustice p
820 N. French Street, 6m Floor ‘
Wilmington, DE 1980t AND; I
to allow any member or employee of said tirm, or any physician appointed by said firm, to examine such health infomation regarding the condition
or treatrnent of me, to confer with any member or employee of said tirrn regarding such treatment or condition, if such physician chooses to do so
provided I am notified sumciently in advance of any such discussion or conference in order to attend, and provided that a copy of everything
obtained with this authorization shall be promptly provided to me.
These records are needed for the following reason(s):
_____ Medical Care
X Legal Consultation
____ Insurance Review l
___ Other (specihz)
The following information is to be released: \
X Medical Records (including, but not limited to: Physician’s Orders, Progress Notes, Diagnostics, Treatrnents) Q
_____ Financiai Records
___ Other (specify) _
In reference to the following (where applicable);
l
__ Date(s) of Service -
__ Location(s) i
___ Department(s)
______ ”l‘ype(s) of Service:
Expiration of this authorization:
This authorization expires in one year or upon the following date or event: .
(specify date or event)
Revoking this authorization. This authorization may be revoked at any time but is not retroactive for requests that have been complied with in good
faith. To revoke this authorization, please provide a written request to the department releasing your information. 1
, Z e77" E "g 4:-; on 1
(Signature of Patient!Client) (Date) E

(Signature of Legal Representative & Relatwnsiup) (Phone) _ (Date) l
Information, once released, may no longer be protected by Federal Privacy Rules and may be subject to re-disclosure by the recipient. However,
information covered under Federal Regulation 42 CFR Part 2 may not be re-disclosed unless expressly permitted by the authorization or the
regulations. 7
*A photocopy ofthe signed authorization is as valid as the ¤riginal* _
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