Fillable Digitek Plaintiff Fact Sheet

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Digitek Plaintiff Fact Sheet

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Digitek® Plaintiff Fact Sheet Page 1
THISDOCUMENTCONTAINSCONFIDENTIALINFORMATION
IN THE CIRCUIT COURT
OF KANAWHA COUNTY, WEST VIRGINIA
IN RE: DIGITEK® LITIGATION Civil Action No. 08-C-5555
Individual Case No.:
PLAINTIFF: __________________________
(name)
DIGITEK® PLAINTIFF FACT SHEET
Please provide the following information for each individual on whose behalf a claim is being made. In
completing this Fact Sheet, you are under oath and must provide information that is true and correct to the
best of your knowledge. If you cannot recall all of the details requested, please provide as much
information as you can. You must supplement your responses if you learn that they are incomplete or
incorrect in any material respect. If you are completing the Fact Sheet for someone who has died or who
cannot complete the Fact Sheet him/herself, please answer as completely as you can for that person.
The Fact Sheet shall be completed in accordance with the requirements and guidelines set forth in the
applicable Case Management Order. A completed Fact Sheet shall be considered interrogatory answers
pursuant to W.Va. R. Civ. P. 33 and as responses to requests for production pursuant to W.Va. R. Civ. P.
34 and will be governed by the standards applicable to written discovery under those Rules. The
questions and requests for production contained in the Fact Sheet are non-objectionable and shall be
answered without objection.
In filling out this form, please use the following definition: “healthcare provider” means any hospital,
clinic, center, physician’s office, infirmary, medical or diagnostic laboratory, or other facility that
provides medical care or advice, and any pharmacy, x-ray department, radiology department, laboratory,
physical therapist or physical therapy department, rehabilitation specialist, chiropractor, or other persons
or entities involved in the diagnosis, care and/or treatment of you.
In addition, to the extent that the form does not provide enough space to complete your responses or
answers, please attach additional sheets as necessary.
I. CASE INFORMATION
1. Please state the following for the civil action that you filed:
a. Case caption:______________________________________________________________
b. Civil Action Number:_______________________________________________________
c. Court in which action was originally filed:_______________________________________
d. Your attorney:
Reset Form
Digitek® Plaintiff Fact Sheet Page 2
THISDOCUMENTCONTAINSCONFIDENTIALINFORMATION
Name:___________________________________________________________________
Address:__________________________________________________________________
_________________________________________________________________________
2. Name of person completing this form: ________________________________________
3. Please list any other names you have used or by which you have been known and dates you used
those names:
4. Your current address:
5. If you are completing this Fact Sheet in a representative capacity (e.g., on behalf of the estate of a
deceased person or a minor), please complete the following:
a. Describe the capacity in which you are representing the individual or estate:
b. If you were appointed as a representative by a court, state the:
Court Which Appointed You:
Date of Appointment:
c. What is your relationship to the individual you represent:
d. If you represent a decedent’s estate, state:
Decedent’s Date of Death:
Address of Place Where Decedent Died:
e. If you are claiming the wrongful death of a family member, identify any and all family
members, beneficiaries, heirs or next of kin of that person, including their relationship to
Decedent:
Digitek® Plaintiff Fact Sheet Page 3
THISDOCUMENTCONTAINSCONFIDENTIALINFORMATION
THE REST OF THIS FACT SHEET REQUESTS INFORMATION ABOUT THE
PERSON WHO PURCHASED, OR PURCHASED AND USED DIGITEK®. WHETHER YOU
ARE COMPLETING THIS FACT SHEET FOR YOURSELF OR FOR SOMEONE ELSE,
PLEASE ASSUME THAT “YOU” MEANS THE DIGITEK® PURCHASER OR PURCHASER
AND USER.
II. CLAIM INFORMATION
1. Name of Digitek® Purchaser/User:
__________________________________________________________________
2. Have you used any other names in the last five (5) years? Yes ____ No ____
If yes, please list any such names that you have used:
3. Do you claim that you suffered bodily injuries as a result of taking Digitek®?
Yes ___ No ___ If Yes, please answer the following:
a. What bodily injuries do you claim resulted from your use of Digitek®?
b. When is the first time you saw a health care provider for any of the symptoms you link to
your alleged injury?__________________________________________________
c. Are you currently experiencing symptoms related to your alleged injury?
Yes ___ No ___ If Yes, please describe the symptoms:_____________________
__________________________________________________________________
d. Did you see a doctor, clinic or healthcare provider for the bodily injuries or illness listed
above?
Yes ___ No ___ If Yes, who:_________________________________________
__________________________________________________________________
e. Who diagnosed your injury?___________________________________________
f. Date of diagnosis:___________________________________________________
g. Were you hospitalized?
Yes ___ No ___ If Yes, please answer the following:
Digitek® Plaintiff Fact Sheet Page 4
THISDOCUMENTCONTAINSCONFIDENTIALINFORMATION
1) Date of hospital admission:______________________________________
2) Date of discharge:_____________________________________________
3) Hospital name and address:______________________________________
____________________________________________________________
h. What harm or consequence including physical limitations, do you claim you suffered as a
result of the bodily injury above, excluding any mental or emotional damages, lost wages
or out of pocket expenses listed below?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
i. Do you claim that your injury was caused by ingesting defective Digitek® medication?
Yes ___ No ___ If Yes, please answer the following:
1) Describe in detail what you claim the defect to have been in the Digitek®
medication that you ingested:_____________________________________
____________________________________________________________
____________________________________________________________
2) How much of the defective product did you ingest?___________________
3) When did you ingest the product?_________________________________
j. Have you had any discussions with any doctor or other healthcare provider about whether
Digitek® caused you to suffer any illness or injury?
Yes ___ No ___ If Yes, who:_________________________________________
__________________________________________________________________
4. Are you claiming mental and/or emotional damages as a result of taking Digitek®?
Yes___ No ____
If Yes, what mental and/or emotional damages do you claim resulted from your use of Digitek®?
Digitek® Plaintiff Fact Sheet Page 5
THISDOCUMENTCONTAINSCONFIDENTIALINFORMATION
If Yes, for each provider (including but not limited to primary care physicians, psychiatrists,
psychologists, and/or counselors) from whom you have sought treatment for psychological,
psychiatric or emotional problems, state the following:
NAME ADDRESS CONDITION
TREATED
DATES
TREATED
MEDICATIONS
PRESCRIBED
5. Are you making a claim for lost wages or lost earning capacity?
Yes___ No ____ If Yes, state the annual gross income you derived from your employment for
each of the last five (5) years:
6. Have you incurred any out-of-pocket expenses as a result of using Digitek®?
Yes___ No ____ If Yes, please identify and itemize all out-of-pocket expenses you have
incurred:
7. What other damages, if any, do you claim you suffered as a result of the purchase or
ingestion of Digitek®?
III. DIGITEK® PRESCRIPTION INFORMATION
1. Have you ever used Digitek®? Yes___ No ____
2. If you answered yes to No. 1, identify the following for each period of time during which you took
Digitek®:
DOSAGE
(.125 MG OR .250
MG)
HOW OFTEN
PER DAY
OR WEEK?
DATE STARTED DATE STOPPED NAME OF
PRESCRIBER
.250
.250
.250
Digitek® Plaintiff Fact Sheet Page 6
THISDOCUMENTCONTAINSCONFIDENTIALINFORMATION
3. Name(s) and address(es) of pharmacies where prescriptions were filled:_________________
__________________________________________________________________________
__________________________________________________________________________
4. Identify the condition for which you were prescribed Digitek®:___________________________
__________________________________________________________________________
5. Did you receive any free samples of Digitek®?
Yes __ No __ If Yes, please state the following:
a. Who provided the samples?
b. When were samples provided?
c. What was the dosage of the samples?
d. How many samples were provided?
6. Do you have in your possession or does your attorney have the packaging from the Digitek® you
allegedly purchased, or purchased and used, and/or any Digitek® tablets?
Yes ____ No____
a. If yes, who currently has custody of the Digitek® packaging and/or tablets?
b. If you or your attorney is in possession of tablets, how many do you have? _____________
c. Have you or anyone on your behalf tested the Digitek® tablets in your possession?
Yes ____ No____ If Yes,
1) Who tested the tablets?__________________________________________
2) What test(s) was performed?_____________________________________
____________________________________________________________
3) How many tablets were tested?___________________________________
Digitek® Plaintiff Fact Sheet Page 7
THISDOCUMENTCONTAINSCONFIDENTIALINFORMATION
4) When were the tests performed?__________________________________
5) What were the test results?______________________________________
____________________________________________________________
(NOTE: In lieu of answering the following Question Nos. 7a and 7b, please attach a clear
copy of the product packaging and/or the label on the vial or blister pack of Digitek® in
your or your attorney’s possession that provides the information sought below.)
7a. Do you know the lot number(s) for any of the Digitek® you received?
Yes ____ No____
If Yes, what is/are the lot number(s): _______________________________
7b. Do you know the expiration date for any of the Digitek® you received?
Yes ____ No____
If Yes, when is/was/were the expiration date(s): _______________________
8. Have you had any communication, oral or written, with any of the defendants or their
representatives?
Yes ____ No____
If Yes, set forth the date of the communication, the method of communication, the name of the
person with whom you communicated, and the substance of the communication between you and
any defendants or their representatives:
9. Have you ever used any other digoxin or digitalis product (i.e. Lanoxin)?
Yes____ No____
If Yes, please state:
DOSAGE
(.125 MG OR .250
MG)
HOW OFTEN
PER DAY
OR WEEK?
DATE STARTED DATE STOPPED NAME OF
PRESCRIBER
10. Are you aware that Digitek® was recalled?
Yes___ No ____ If Yes, please state the following:
.250
.250
.250
Digitek® Plaintiff Fact Sheet Page 8
THISDOCUMENTCONTAINSCONFIDENTIALINFORMATION
a. When you became aware of the recall:__________________________________
b. How you became aware of the recall:___________________________________
_______________________________________________________________
11. Did you discuss the recall with any healthcare provider or pharmacist?
Yes___ No ____ If Yes, please state the following:
a. When that discussion occurred:_______________________________________
b. With whom:_____________________________________________________
12. Did you return any Digitek® to Stericycle or any pharmacy?
Yes _____ No_____ If Yes, please state the following:
a. When did you return the product?_________________________________
b. Do you have your paperwork regarding the return? Yes _____ No _____
c. To whom did you return the product?______________________________
13. Have you ever visited a website, chat-room, message board or other electronic forum containing
information or discussion about Digitek®?
Yes___ No ____ If Yes, please provide the name of the website:______________________
IV. MEDICAL BACKGROUND
1. Current Height: ______
2. Current Weight: ______
3. Approximate weight at the time of your injury: ______
4.A. To the best of your knowledge, have you, or any blood-relative family member (child, parent,
brother, sister, or grandparent), ever experienced or been diagnosed with any of the following
conditions? Please select Yes or No for each condition. For each condition for which you answer
Yes, please identify who suffered the condition, you or a relative, and please provide the relative’s
name and relationship to you. If you suffered the condition, please provide the additional
information requested in the table following 4(B):
CONDITION EXPERIENCED OR DIAGNOSED YES NO
WHO SUFFERED
CONDITION
Abnormal heart rhythm, atrial fibrillation, atrial flutter,
ventricular fibrillation, or heart block
Allergic reaction to medication (e.g., skin reaction, rash,
or anaphylaxis)
Digitek® Plaintiff Fact Sheet Page 9
THISDOCUMENTCONTAINSCONFIDENTIALINFORMATION
CONDITION EXPERIENCED OR DIAGNOSED YES NO
WHO SUFFERED
CONDITION
Blocked or narrow arteries/plaque buildup/coronary
artery disease
Cardiomyopathy/enlarged heart
Chest pain/angina
Congenital heart abnormality
Congestive heart failure
Heart attack/MI/myocardial infarction
High blood pressure/hypertension
High cholesterol or triglycerides
Kidney disease or condition
Stroke/transient ischemic attack/TIA/aneurysm
4.B. To the best of your knowledge, have you ever experienced or been diagnosed with any of the
following conditions? Please select Yes or No for each condition. If you suffered the condition,
please provide the additional information requested in the table following this chart:
CONDITION EXPERIENCED OR DIAGNOSED YES NO
Alcoholism or other substance abuse
Alzheimer's, senility, confusion
Arthritis (osteoarthritis or rheumatoid arthritis)
Autoimmune diseases (e.g., rheumatoid arthritis, lupus,
Sjogren's, etc.)
Bleeding or clotting disorders
Cancer
Chronic obstructive pulmonary disease/COPD/chronic
lung disease/asthma
Deep vein thrombosis/DVT
Depression, anxiety, schizophrenia, bipolar disorder
Dermatologic diseases or conditions
Diabetes mellitus
Electrolyte imbalance
Enlarged prostate, bladder dysfunction
Gastrointestinal problems (e.g., ulcers, heartburn, acid
reflux, GERD, increased or decreased motility)
Hardening of the arteries/stenosis/aneurysms
Heart valve problems (e.g., murmur, leaky valve,
prolapse, regurgitation)
Hormonal replacement therapy
Hypothyroidism/Thyroid condition
Immune system disease or dysfunction (including HIV or
AIDS)
Liver disorder or disease (cirrhosis, hepatitis, etc.)
Multiple sclerosis, myasthenia gravis
Osteoporosis, bone fractures, calcium deficiency
Peripheral vascular disease or peripheral arterial disease
Pulmonary embolism/blood clot to the lungs
Pulmonary hypertension
Raynaud's syndrome/phenomenon
Rheumatic Fever/Scarlet Fever
Tobacco use or addiction
Vasculitis
Digitek® Plaintiff Fact Sheet Page 10
THISDOCUMENTCONTAINSCONFIDENTIALINFORMATION
For each condition for which you answered Yes in the previous two charts, please provide the
information requested below:
CONDITION YOU
EXPERIENCED
DATE OF
ONSET
MEDICATION/
TREATMENT
TREATING
PHYSICIAN
AND/OR
HOSPITAL
5. Please indicate whether you have ever been the subject of any cardiovascular surgeries
including, but not limited to, open heart/bypass surgery, CABG, pacemaker or defibrillator
implantation, stent placement, vascular surgery, angioplasty, IVC filter placement, carotid (neck)
surgery, or valve replacement.
Yes ___ No __ I don't recall __ If Yes, please specify the following:
SURGERY REASON FOR
SURGERY
DATE TREATING
PHYSICIAN
HOSPITAL
6. Please indicate whether you have ever been the subject of any of the following cardiovascular
diagnostic tests or interventions and provide the requested information about each: including, but
Digitek® Plaintiff Fact Sheet Page 11
THISDOCUMENTCONTAINSCONFIDENTIALINFORMATION
not limited to, stress test C-reactive protein (CRP); chest X-ray; angiogram/catheterization; CT
scan; MRI; EKG; echocardiogram; TEE (trans-esophageal echo); endoscopy; lung bronchoscopy;
carotid duplex/ultrasound; MRI/MRA of the head/neck; angiogram of the head/neck; CT scan of
the head; bubble/microbubble study; and Holter monitor.
Yes ___ No __ I don't recall __ If Yes, please specify the following:
DIAGNOSTIC TEST/
INTERVENTION
REASON FOR
TEST/
INTERVENTION
DATE TREATING
PHYSICIAN/
HOSPITAL
RESULT OF
DIAGNOSTIC TEST/
INTERVENTION
7. Do you now or have you ever smoked tobacco products? Yes ___ No ___ If Yes, please specify
the following:
a. How long have/did you smoke?
b. How much do/did you smoke? ______________________________
8. Did you drink alcohol (beer, wine, etc.) in the three years before your alleged injury?
Yes ___ No ___ If Yes, please specify the following:
a. How often did you drink?________________________________________
b. How much did you drink?________________________________________
9. Have you ever used any illicit drugs of any kind within the five (5) years before, or at any time
after, your alleged injury?
Yes ___ No ___ If Yes, identify the substance(s) and your first and last use:_____________
_______________________________________________________________________
V. ADDITIONAL MEDICATIONS
(INCLUDING OTHER DIGOXIN PRODUCTS, SUCH AS LANOXIN®)
1. For any medications, herbal products or supplements other than Digitek® that you took on a
regular basis in the ten (10) years prior to, and at the time of, the incidents described in your
Complaint, please provide the information requested below:
Digitek® Plaintiff Fact Sheet Page 12
THISDOCUMENTCONTAINSCONFIDENTIALINFORMATION
NAME OF
MEDICATION
USED
DOSAGE PRESCRIBING
PHYSICIAN
DATES OF USE PURPOSE OF
PRESCRIPTION
2. Have you ever experienced any side effects while you were taking any of the medications
identified in this section in the past ten (10) years?
Yes ___ No ___ If Yes, please specify the following:
a. The name of the medication:____________________________________________
b. The side effect(s):____________________________________________________
c. The date the side effect was experienced:__________________________________
Digitek® Plaintiff Fact Sheet Page 13
THISDOCUMENTCONTAINSCONFIDENTIALINFORMATION
VI. PERSONAL INFORMATION
1. Current Address and Date when you began living at this address:
2. Social Security Number:
3. Date and Place of Birth:
4. Marital Status:
If married, spouse’s name, occupation and date of marriage:
If divorced, dates of the marriage, case name/jurisdiction for the divorce:
Has your spouse filed a loss of consortium in this action? Yes ___ No ___
5. If you have children, please list each child’s name and date of birth:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
6. For any school attended after High School, please provide the following information:
a. School Name:______________________________________________________
b. Address:__________________________________________________________
c. Dates attended:_____________________________________________________
d. Diploma/Degree:____________________________________________________
7. Employment information for the last ten (10) years. Please include employer’s name, address,
dates of employment, job title, job description and duties:
8. Have you ever served in the military, including the military reserve or National Guard?
Yes ___ No ___
Digitek® Plaintiff Fact Sheet Page 14
THISDOCUMENTCONTAINSCONFIDENTIALINFORMATION
If Yes, were you ever rejected or discharged from military service for any reason relating to your
physical condition? Yes ___ No ___
If Yes, state the condition for which you were rejected or discharged:__________________
______________________________________________________________________
9. Has any insurance or other company, or Medicare or Medicaid, provided medical coverage to you
or paid medical bills on your behalf in the last ten (10) years?
Yes ___ No ___ If Yes, please specify the following:
a. The name of the company/agency:______________________________________
b. Address:_________________________________________________________
c. Dates of Service:___________________________________________________
10. Have you applied for workers’ compensation (WC) and/or social security disability (SSI or SSD)
benefits in the last ten (10) years?
Yes ___ No ___ If Yes, please specify the following:
a. Type of claim:_____________________________________________________
b. Year application filed:_______________________________________________
c. Agency where application was filed:____________________________________
d. Nature of disability:_________________________________________________
e. Time period of disability:_____________________________________________
11. Have you filed a lawsuit or made a claim in the last ten (10) years, other than in the present suit,
relating to any bodily injury?
Yes ___ No ___ If Yes, please specify the following:
a. Court in which suit/claim filed or made:__________________________________
b. Case/Claim Number:_______________________________________________
c. Nature of Claim/Injury:_____________________________________________
12. As an adult, have you been convicted of, or plead guilty to, a felony and/or crime of fraud or
dishonesty?
Yes ___ No ___ If Yes, please set forth where, when and the felony and/or crime:______
_____________________________________________________________________
Digitek® Plaintiff Fact Sheet Page 15
THISDOCUMENTCONTAINSCONFIDENTIALINFORMATION
VII. HEALTHCARE PROVIDERS AND PHARMACIES
1. Identify each doctor or other healthcare provider who you have seen for medical care and
treatment in the past ten (10) years:
NAME AND
SPECIALTY
ADDRESS REASON FOR
VISIT
APPROX
DATES/YEARS OF
VISITS
2. Identify each hospital, clinic, or healthcare facility where you were hospitalized (in-patient, out-
patient, or emergency room visit) in the past ten (10) years:
NAME ADDRESS ADMISSION
DATE(S)
REASON FOR ADMISSION
3. Identify each pharmacy that has dispensed medication to you in the past ten (10) years:
NAME OF PHARMACY ADDRESS
APPROX DATES/YEARS
YOU USED PHARMACY
Digitek® Plaintiff Fact Sheet Page 16
THISDOCUMENTCONTAINSCONFIDENTIALINFORMATION
VIII. DECEASED INDIVIDUALS AND AUTOPSY INFORMATION
1. If you are filling this out on behalf of an individual who is deceased, please state the following
from the Death Certificate of the individual:
(NOTE: In lieu of the following, please attach a copy of the death certificate.)
Date of death:
Place of death (city, state and county):
Facility or location where death occurred:
Name of physician who signed death certificate:
Cause of death:
If you are filling this out on behalf of an individual who is deceased and on whom an autopsy was
performed, please fill in the information below pertaining to the autopsy and the autopsy report:
(NOTE: In lieu of the following, please attach a copy of the autopsy report.)
Date:
Performed by:
Facility where autopsy was performed:
Place where autopsy was performed (city, state, county):
Describe any and all tissue preserved:
IX. FACT WITNESSES
1. Please identify all persons who you believe possess information concerning your injury(ies) and
current medical conditions, other than your healthcare providers, and please state their name
address and his/her/their relationship to you:
Name:
Address:
Relationship to you:
Name:
Address:
Relationship to you:
Name:
Address:
Relationship to you:
Name:
Address:
Digitek® Plaintiff Fact Sheet Page 17
THISDOCUMENTCONTAINSCONFIDENTIALINFORMATION
Relationship to you:
Name:
Address:
Relationship to you:
IX. DOCUMENT DEMANDS
1. Authorizations: please sign authorizations that are attached hereto as Exhibit A, for each of the
healthcare providers that you have identified above in your Answers to §II, Question Nos. 1-3, and
§ IV, Question No. 2.
2. Documents in your possession, including writings on paper or in electronic form: If you have any
of the following materials in your custody or possession, please attach a copy to this Fact Sheet.
a. All documents constituting, concerning or relating to product use instructions, product
warnings, package inserts, pharmacy handouts or other materials distributed with or
provided to you in connection with your use of Digitek®.
b. Copies of the entire packaging, including the box and label, for Digitek® and any
Digitek® tablets (plaintiffs or their counsel must maintain the originals of the items
requested in this subpart).
c. All documents relating to your purchase of Digitek®, including, but not limited to,
receipts, prescriptions or records of purchase.
d. All photographs, drawing, journals, slides, videos, DVDs or any other media relating to
your alleged injury.
e. Copies of letters testamentary or letters of administration relating to your status as plaintiff
(if applicable).
f. Decedent’s death certificate and autopsy report (if applicable).
g. Medical records, bills, correspondence, reports and all other documents from any health
care provider who saw, evaluated or treated Plaintiff/Decedent in the last five (5) years.
h. All emergency responder, paramedic or EMT reports regarding Plaintiff/Decedent.
i. Documents concerning any communication between Plaintiff/Decedent or
Plaintiff/Decedent’s attorneys or agents and the FDA or any Defendant regarding the
events giving rise to the lawsuit or relating to Digitek.
j. Non-privileged documents, including any diaries, calendars or notes that record
Plaintiff/Decedent’s health, use of Digitek or alleged injuries
Digitek® Plaintiff Fact Sheet Page 18
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X. VERIFICATION
I declare under penalty of perjury that all of the information provided in this Plaintiff Fact Sheet is true
and correct to the best of my knowledge. I have supplied all the documents requested in Part ___ of this
declaration, to the extent that such documents are in my possession, custody, or control, or in the
possession, custody, or control of my lawyers, and supplied the authorizations attached to this declaration.
Further, I acknowledge that I have an obligation to supplement the above responses if I learn that they are
in any material respects incomplete or incorrect.
Date:
Signature
HIPAA
COMPLIANT AUTHORIZATION FOR RELEASE OF INFORMATION PURSUANT TO 45 C.F.R. 164.508
Patient Name:
Identification: Date of Birth Date of Death Soc. Sec.
Parents Name/Previous Name(s)
Provider:
(Who is releasing
the information)
Requestor:
(to whom the information
will be provided)
Name RecordTrak
Address 651 Allendale Road
King of Prussia, PA 19406
I authorize the disclosure of all protected medical information, from the time period 1998 to present, in written or electronic form
for the purpose of review and evaluation in connection with a legal claim. I expressly request that all covered entities under
HIPAA identified above disclose full and completed protected health information, including, but not limited to, the following:
• All medical records, including, but not limited to: inpatient, outpatient & emergency room treatment; all clinical charts,
reports, documents, correspondence, test results, statements, questionnaires/histories, office and doctor’s handwritten
notes; and records received from other physicians or health care providers;
• All laboratory, histology, cystology, pathology, radiology, CT Scan, MRI, echocardiogram & cardiac catheterization reports;
• All radiology films; myelograms; CT Scans; photographs; bone scans; pathology, cytology, histology, autopsy, immuno-
histo-chemistry specimens;
• All pharmacy prescription records, including, but not limited to: NDC numbers and drug information handouts/monographs
Information Requested:
• All billing records, including, but not limited to: all statements, itemized bills, and insurance records.
• All documents related to amendment of any record requested.
Purpose of Release: For the purpose of review and evaluation in connection with a legal claim.
This authorization expires when the following event occurs: the resolution of litigation. I understand that I may revoke this authorization at any time, except to the
extent that action has already been taken in reliance upon it, by giving written notice to RecordTrak. I understand that the covered entity to whom this
authorization is directed may not condition treatment, payment, enrollment or eligibility benefits on whether or not I sign the authorization. This information, once it
is released, may be re-disclosed by the recipient, and if re-disclosed, the information would no longer be protected by the federal privacy rule. Any facsimile, copy
or photocopy of the authorization authorizes you to release the records requested herein.
Signature of Patient if 18 years of age or older
Date
Signature of Parent or Legal Representative
Date
Relationship to Patient, if not signed by Patient
SPECIFIC authorization for release of information protected by state or federal law In addition to the authorization and other provisions contained above,
hereby incorporated by reference, I authorize: (i) the release of data and information to RecordTrak; and (ii) RecordTrak’s re-disclosure of the data
and information to its consultants, experts, agents, and/or other counsel; any and all data, notes, records, reports, and/or any other documents and
information relating to:
X 1. Substance Abuse (Alcohol/Drug) X 2. Mental Health (includes psychological testing) X 3. HIV-related information (AIDS related testing)
This form does not authorize re-disclosure of medical information beyond the limits of this consent. Where information has been disclosed from records protected
by federal law for alcohol/drug abuse records or by state law for mental health records, federal requirements (42 C.F.R. Part 2) and state requirements prohibit
further disclosure without specific written consent of the patient, or as otherwise permitted by such law and/or regulations. A general authorization for the release
of medical or other information is not sufficient for these purposes. Civil and/or criminal penalties may attach for unauthorized disclosure of alcohol/drug abuse or
mental health information. Federal regulations state that any person who violates any provision of this law shall be fined not more than $500, in the case of a first
offense, and not more than $5000 in the case of each subsequent offense. Drug Abuse Office and Treatment Act of 1972 (21 U.S.C. 1175); Comprehensive
Alcohol Abuse Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (42 U.S.C. 4582).
Signature of Patient if 18 years of age or older _________
Date
Signature of Parent or Legal Representative ___________
Date
Relationship to Patient, if not signed by Patient ___________
HIPAA
COMPLIANT AUTHORIZATION FOR RELEASE OF EMPLOYMENT INFORMATION
Employee Name:
Identification: Date of Birth: Soc. Sec:
Parents Name/Previous Name(s)
Provider:
(Who is releasing
the information)
Requestor:
(to whom the information
will be provided)
Name RecordTrak
Address 651 Allendale Road
King of Prussia, PA 19406
I authorize the disclosure of all protected information in any form (including oral, written and electronic) for the purpose of review and
evaluation in connection with a legal claim. I expressly request that all entities identified above disclose full and completed protected
employment information spanning the time period of 1998 to present, including, but not limited to, the following:
• All applications for employment, resumes, records of all positions held, job descriptions of positions held, payroll records, W-2
forms and W-4 forms, performance evaluations and reports, statements and reports of fellow employees, attendance records,
worker's compensation files, disability records; records submitted in connection with any claims by all physicians,
psychologists, psychiatrists, hospital and testing facilities, radiologists, and any and all other health care providers; records of
any payments made; records of any litigation resulting from denials of coverage;
• All insurance records, claim forms, renewal records, questionnaires and records of payments made, all insurance policies,
and employee benefit records certificates and benefit schedules regarding the insured's coverage, including supplemental
coverages; health and physical examination records reviewed for underwriting purposes; questionnaires and records
submitted in connection with the applications or renewals;
• All hospital, physician, clinic, infirmary, nurse, psychiatric, psychological and dental records; x-rays, test results, physical
examination records and other medical records, medication records;
• All documents related to amendment of any record requested;
• All records pertaining to medical or disability claims, or work-related accidents including correspondence, accident reports,
injury reports and incident reports;
• All pension records, disability benefit records, and all records regarding participation in company-sponsored health, dental, life
and disability insurance plans; and
• Any other records concerning employment of the Employee named above.
Purpose of Release:
For the purpose of review and evaluation in connection with a legal claim brought by __________________.
This authorization is expires when the following event occurs: the resolution of litigation I understand that I may revoke this authorization at any time, except to the extent that action has
already been taken in reliance upon it, by giving written notice to RecordTrak. I understand that the covered entity to whom this authorization is directed may not condition treatment,
payment, enrollment or eligibility benefits on whether or not I sign the authorization. This information, once it is released, may be re-disclosed by the recipient, and if re-disclosed, the
information would no longer be protected by the federal privacy rule. Any facsimile, copy or photocopy of the authorization authorizes you to release the records requested herein.
Signature of Employee if 18 years of age or older
Date
Signature of Legal Representative
Date __________
Relationship to Employee, if not signed by Employee
I.
AUTHORIZATION FOR RELEASE OF
DISABILITY CLAIMS RECORDS
To: ___________________________________________________
Name
___________________________________________________
Address
___________________________________________________
City, State and Zip Code
This will authorize you to furnish copies of any and all records of disability claims of any sort,
including, but not limited to, statements, applications, disclosures, correspondence, notes, settlements,
agreements, contracts or other documents, for the time period of 1998 to the present, concerning:
Name:
whose date of birth is ________________ and whose social security number is
______________________.
You are authorized to release the above records to the following representatives of defendants in
the Digitek® litigation, who have agreed to pay reasonable charges made by you to supply copies of such
records:
Name RecordTrak
Address 651 Allendale Road
King of Prussia, PA 19406
This authorization does not authorize you to disclose anything other than documents and records to anyone.
This authorization shall be considered as continuing in nature and is to be given full force and effect to
release information of any of the foregoing learned or determined after the date hereof. It is expressly understood
by the undersigned and you are authorized to accept a copy or photocopy of this authorization with the same
validity as though the original had been presented to you.
Date: _________________________ ____________________________________
Claimant/Guardian/Personal Representative Signature
HIPAA COMPLIANT AUTHORIZATION FOR
RELEASE OF INSURANCE RECORDS
To:
Insured Name:
Date of Birth:
Soc. Sec. No.:
Requesting
Attorneys:
RecordTrak
651 Allendale Road
King of Prussia, PA 19406
I hereby authorize all insurers of ______________________, to disclose all insurance information, from
the time period of 1998 to present, including protected medical and mental health records, to and for the
use of RecordTrak and any of their agents, consultants or designees. By way of example, the insurance
information includes, but is not limited to, the following:
All applications for insurance coverage and renewals; insurance policies, certificates and
benefit schedules regarding the insured’s coverage, including supplemental coverage;
health and physical examination records that were reviewed for underwriting purposes, and
any statements, communications, correspondence, reports, questionnaires, and records
submitted in connection with applications or renewals for insurance coverage, or claims;
physician, hospital, psychiatric, psychological, and dental reports, prescriptions,
correspondence, test results, radiological films and any other medical records submitted for
claims review purposes; claim records; records of all litigation; and all other records of any
kind concerning or pertaining to _________________________.
The purpose of this authorization is for the review and evaluation of the information in connection with
the Digitek® litigation.
I understand that the information is confidential and is accorded specific protection by federal and/or state
laws and regulations. By signing this authorization, I consent to the disclosure to and use by the
Recipients of all protected information. I understand that, except as otherwise stated in this authorization,
information disclosed pursuant to this authorization may be subject to redisclosure by the Recipients and
may no longer be protected by privacy laws and regulations.
I understand that certain records may be protected by federal or state law, including HIV, psychiatric or
mental health treatment, alcohol/drug treatment or communicable diseases, and I am requesting that any
and all such protected records be released under this authorization. Federal and/or state confidentiality
rules prohibit the redisclosure of such protected records unless redisclosure is expressly permitted by the
written consent of the person who is the subject of the information. A general authorization for the
release of medical or other information is not sufficient for this purpose.
I understand that I may inspect or copy the protected health information sought to be used or disclosed in
this authorization. I also understand that I am not required to sign this authorization and may in fact
refuse to sign this authorization.
HIPAA COMPLIANT AUTHORIZATION FOR
RELEASE OF INSURANCE RECORDS
Page 2
You are hereby released from any and all liability in connection with disclosure of records, documents,
writings and physical evidence to the above firms.
This authorization is effective for one year from this date, or when the following event occurs: Final
resolution of the above-identified civil action. Notwithstanding the immediately preceding sentence, I
understand that I may revoke this authorization at any time prior to its expiration, except to the extent that
action already has been taken in reliance on this authorization, by sending written notice of revocation to
RecordTrak. I understand that the entity to whom this authorization is directed, may not condition
treatment, payment, enrollment or eligibility benefits on whether or not I sign the authorization.
A copy of this authorization shall have the same force and effect as the original.
____________________________________ ______________________________
Signature of Insured or Insured’s Representative Date
Name of Insured:
Former/Alias/Maiden Name of Insured
Insured’s Date of Birth
Insured’s Social Security Number
Insured’s Address
Name of Insured’s Representative (if applicable) Description of Authority
to Act for Insured
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Digitek Plaintiff Fact Sheet

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Completed 6 May 2020

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