A. Name
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H. Current physical address, including zip code, where plaintiff resides:
I. Physical address, including zip code, where plaintiff resided on March 17, 2019:
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II. CASE INFORMATION
Provide the following information for the civil action filed by the plaintiff:
C. If this Fact Sheet is being completed in a representative capacity (e.g., on behalf of the estate of a deceased person or a minor), please complete the following:
Address
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If you were appointed by the Court:
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III. CLAIM INFORMATION
IV. WITNESSES
Complete the information below for any person (not identified elsewhere in this questionnaire) who has knowledge or information concerning your claims in this matter, the injuries you claim herein, and/or facts or documents upon which you intend to rely in support of your claims in this matter and/or any motion for class action certification.
V. TIMELINE AND DAILY ACTIVITIES
PAST MEDICAL HISTORY:
C. Please state whether you suffer from chronic or recurring health conditions related to the following:
HEALTH CARE PROVIDER INFORMATION
DISCUSSIONS WITH HEALTHCARE PROVIDERS
AUTHORIZATION FOR RELASE OF MEDICAL INFORMATION
I hereby authorize all holders of all information relating to the medical diagnosis and treatment of (“Medical Information”) to disclose the Medical Information to and for the use of Baker Botts L.L.P. and any of their agents or designees (“Recipients”). This authorization is limited to Medical Information associated with medical diagnosis and treatment provided from March 17, 2014 through the present. By way of example, Medical Information includes, but is not limited to, the following: All medical records; physicians’ records; surgeons’ records; x-rays, CAT scans, MRI films, photographs, or other radiological, nuclear medicine or radiation therapy films; pathology materials, slides or tissues; laboratory reports; discharge summaries; progress notes; consultations; prescriptions; records of drug abuse and alcohol abuse; mental illness, psychological and/or psychiatric treatment, and counseling records/notes; HIV/AIDS diagnosis or treatment; physicals and histories; nurses’ notes; patient intake forms; correspondence; social workers’ records; insurance records; consents for treatment; statements of account; bills; invoices; and any other documents concerning any treatment, examination, periods of stays of hospitalization, confinement, diagnosis or other information concerning any physical or mental health condition. This release DOES NOT authorize any healthcare provider with Medical Information to discuss orally the Medical Information with the Recipients. The covered entity may not condition treatment, payment, enrollment or eligibility for benefits on whether this authorization is signed. The Medical Information may be disclosed to and used by the Recipients in connection with a civil lawsuit brought by myself, my relatives, or my heirs. I understand that the Medical Information is confidential and that HIV/AIDS diagnosis and treatment records, and drug and alcohol abuse treatment records, are 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 Medical Information, including HIV/AIDS diagnosis and treatment records; drug and alcohol abuse treatment records; and mental illness, psychological, and/or psychiatric diagnosis and treatment records. You are hereby released from any and all liability in connection with your disclosure of Medical Information to the Recipients. I understand that, except as otherwise stated in this authorization, information disclosed pursuant to this authorization may be subject to re-disclosure by the Recipients and may no longer be protected by privacy laws and regulations This authorization is continuing in nature and is to be given full force and effect until this authorization expires one year after it is signed. Notwithstanding the immediately preceding sentence, I understand that I may revoke this authorization at any time prior to its expiration by sending written notice of revocation to Baker Botts L.L.P., except to the extent that action already has been taken in reliance on this authorization. The Medical Information may be disclosed to and used by the Recipients in connection with a civil lawsuit brought by myself, my relatives or my heirs. A copy of this authorization may be used in place of and with the same force and effect as the original.
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AUTHORIZATION FOR RELEASE OF EMPLOYMENT RECORDS
I hereby authorize and permit any person, firm or entity to release to Baker Botts L.L.P., 910 Louisiana Street, Houston, Texas 77002, or their authorized representative, copies of any and all employment records, including, but not limited to, personnel records, benefits records, payroll records, medical records, and workers’ compensation records pertaining to:
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The release of the matters listed above is being authorized for purposes of a lawsuit styled as captioned above. A copy of this authorization is agreed by the undersigned to have the same effect and force as an original. Any person, firm or entity that releases matters pursuant to this authorization is absolved from any liability that might otherwise result from the release of those matters. I agree that this release remains valid for one full year from the date it is signed.
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