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`DOCKET NO. FBT-CV22-6119473-S
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`BIANCA DAVILA, ET AL, ,
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`V.
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`SUPERIOR COURT
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`J.D. OF FAIRFIELD
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`: AT BRIDGEPORT
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`MICHAEL GONZALEZ, ET AL.,
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`: DECEMBER 15, 2022
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`NOTICE OF SERVICE OF STANDARD INTERROGATORIES
`AND REQUEST FOR PRODUCTION
`Pursuant to Practice Book §§13-6(c) and 13-9(b), the undersigned Defendant in the above
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`action hereby gives notice that they are directing to the Plaintiff, MARCUS ANDERSON, Practice
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`Book Interrogatories and Requests for Production:
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` Forms 202 and 205 (Directed to Plaintiff)
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` XXXXX
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`To be answered under oath within sixty (60) days hereof.
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`PLEASE NOTE: The included authorization must be completed in full including the treating
`doctor/providers full name, business address and treating office address.
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`THE DEFENDANT,
`MICHAEL GONZALEZ
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`By: /S/ 420606
`Sean Carew
`Law Offices of Meehan, Di Palma, Roberts &
`Turret
`108 Leigus Road, 1st Floor
`Wallingford, CT 06492
`Tel. # 203-294-7800
`Juris # 408308
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`LAW OFFICES OF MEEHAN, DI PALMA, ROBERTS & TURRET
`108 LEIGUS ROAD, 1ST FLOOR, WALLINGFORD, CT 06492  (203) 294-7800  Juris No. 408308
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`CERTIFICATION
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`This is to certify that all personal identifying information was redacted pursuant to Practice
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`Book Section 4-7. This will further certify the foregoing was mailed via U.S. Mail, postage pre-paid or
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`electronically delivered pursuant to Practice Book Section 10-14 on this 15th day of December, 2022.
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`Attorney for Plaintiff
`Gregory E. O'Brien, Esq.
`Moore, O'Brien & Foti
`891 Straits Turnpike
`Middlebury, CT 06762
`GMOORE@MOJYLAW.COM
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`/S/_420606________________
`Sean Carew
`Commissioner of the Superior Court
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`LAW OFFICES OF MEEHAN, DI PALMA, ROBERTS & TURRET
`108 LEIGUS ROAD, 1ST FLOOR, WALLINGFORD, CT 06492  (203) 294-7800  Juris No. 408308
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`PLAINTIFF’S CERTIFICATION
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`I, MARCUS ANDERSON, hereby certify that I have reviewed the above Interrogatories
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`and Requests for Production and responses thereto and that they are true and accurate to the best of
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`my knowledge and belief.
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`Subscribed and sworn to before me this
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`MARCUS ANDERSON
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`, day of
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`, 2022.
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`Commissioner of the Superior Court/
`Notary Public
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`LAW OFFICES OF MEEHAN, DI PALMA, ROBERTS & TURRET
`108 LEIGUS ROAD, 1ST FLOOR, WALLINGFORD, CT 06492  (203) 294-7800  Juris No. 408308
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`TO:
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`AUTHORIZATION FOR THE RELEASE AND
`TRANSFER OF EMPLOYMENT INFORMATION
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`I, the undersigned, hereby consent and authorize you to disclose and release to agents,
`servants, and employees of the Law Offices of Meehan, Di Palma, Roberts & Turret, 108 Leigus
`Road, 1st Floor, Wallingford, CT 06492 (including any physician(s), nurse(s), and expert witness(es)
`retained or consulted by the Law Offices of Meehan, Di Palma, Roberts & Turret, and the liability
`insurer of the Law Offices of Meehan, Di Palma, Roberts & Turret client in connection with my
`claim), and any arbitrator(s), appointed to hear my claim, the following confidential information, to
`order, inspect, copy and/or reproduce any and all records arising from my hire/enlistment with you,
`including but not limited to wage information, pre-employment/pre-enlistment physicals, physicals
`thereafter, attendance, personnel, clinic and/or hospital records.
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`I authorize the transfer of said information by and between the aforesaid persons.
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`I am informed that the above information requested is needed and is to be used for pursuing
`the disposition of my claim arising out of an alleged accident on _________. This consent for the
`release and transfer of said information may be withdrawn at any future time and is subject to
`revocation by me when transmitted in writing, except when signed in connection with a claim for
`benefits under any insurance policy in which case it shall be valid during the pendency of that claim.
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`I agree that a photocopy of this Authorization be accepted with the same authority as the
`original.
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`Signed:
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`SS#:
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`Date:
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`Date of Birth:
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`LAW OFFICES OF MEEHAN, DI PALMA, ROBERTS & TURRET
`108 LEIGUS ROAD, 1ST FLOOR, WALLINGFORD, CT 06492  (203) 294-7800  Juris No. 408308
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`AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION
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`I, hereby voluntarily consent and authorize you, in accordance with 45 C.F.R. Sec. 164.508, to use or disclose health information including, if
`applicable, information relating to the diagnosis or treatment of mental illness, drug and/or alcohol abuse and confidential HIV/AIDS related
`information, only for the purposes and parties described below. This authorization permits you to disclose all medical, psychiatric, drug and/or
`alcohol abuse, HIV information, records, x-rays, films, bills, reports, or copies thereof relating to my examination, consultation, confinement, or
`treatment by you. This release also authorizes the disclosure of any and all payment records, billing records and insurance related information.
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`Purpose for Disclosure:
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`Civil Litigation: Personal Injury Lawsuit
`Workers’ Compensation Claim
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`Name of Health Care Provider to make Disclosure:
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`_____________________________________
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`_____________________________________
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`Records to be disclosed to:
`Law Offices of Meehan, Di Palma, Roberts &
`Turret
`108 Leigus Road, 1st Floor
`Wallingford, CT 06492
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`Liberty Mutual Group, and its affiliates
`175 Berkeley Street
`Boston, MA 02116
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`ABI Document Support Services
`1122 Franklin Avenue, Suite 300
`Garden City, NY 11530
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`Patient Date of Birth:
`_____________________
`Dates of Treatment:
`_____________________
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`Description of Records to be Disclosed: My full and complete medical file and billing records including but not limited to: office notes,
`doctor’s notes, nurse’s notes, billing records, treatment plans, laboratory results, diagnostic test results, records of other physicians in your chart,
`radiological results, history, physical exam, discharge summaries, operative records, consultations, same day surgery records, emergency room records,
`ambulatory care records, rehabilitation records, therapeutic records, psychiatric records, psychological records, counseling records, pathology records,
`cytology records, cardiology records, neurology records, orthopedic records, physiology records, hematology records, oncology records, chiropractic
`records, CT scan reports and films, MRI reports and films, X-ray reports and films, imaging reports and films, ultrasound records, immunization
`records, medication records, etc.
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`Patient Name and Address:
`_______________________________
`_______________________________
`_______________________________
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`This Authorization shall remain in Effect for one year from date below.
` understand that I may cancel this authorization at any time by notifying you in writing, but if I do it will not have any affect on actions that the
`provider took before it received the cancellation. Furthermore, the information disclosed under this authorization may be subject to further disclosure
`by the recipient and thus, no longer protected by state or federal privacy regulations.
` understand that my treatment or continued treatment by you is in no way conditioned on whether or not I sign this authorization and that I may
`refuse to sign it.
` am entitled to a copy of this authorization, and acknowledge receipt of a copy. I understand that I may inspect or copy the information disclosed
`under federal regulations.
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`The patient’s parent or legal guardian must sign this authorization if the patient is a minor (under age 18) or has a legal guardian. Minors may sign their
`own authorizations for records relating to drug/alcohol abuse treatment, sexually transmitted diseases or HIV/AIDS related diagnosis, and in certain
`circumstances, Mental Health treatment records.
` understand that you may receive compensation as set by law for copying and processing fees related to the use/disclosure of my health information
`under this authorization.
` agree that a photocopy of this Authorization has the same authority as the original.
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`________________________________________________________________
`Signature of Patient or Authorized Representative
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` ____________________________
`Date
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`If patient has not signed this form, please indicate the relationship of the signatory to the patient.
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` Parent/Guardian
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`Administrator/Executor of Estate
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`Power of Attorney/Conservator
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`Other-specify
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`LAW OFFICES OF MEEHAN, DI PALMA, ROBERTS & TURRET
`108 LEIGUS ROAD, 1ST FLOOR, WALLINGFORD, CT 06492  (203) 294-7800  Juris No. 408308
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