: SUPERIOR COURT
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`J.D. OF NEW HAVEN
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`AT NEW HAVEN
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`NOVEMBER 10, 2023
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`DOCKET NO. NNH CV23-6131539 S
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`MATTHEW ADAMO
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`V.
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`EDWARD DIBENE D/B/A ROOF
`DOCKTOR AND SON, R D
`RESTORATION & SONS, LLC, DANIEL
`GEDRIM AND SUSAN GEDRIM
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`NOTICE OF SERVICE OF STANDARD INTERROGATORIES
`AND REQUEST FOR PRODUCTION
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`Pursuant to Practice Book §§13-6(c) and 13-9(b), the Defendant(s) in the above action hereby give(s)
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`notice that he/she it/they is/are directing to the Plaintiff, MATTHEW ADAMO, Practice Book
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` Forms 202 and 205 (Directed to Plaintiff)
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`Interrogatories and Requests for Production:
` Forms 201 and 204 (Directed to Defendant)
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`_________________________________ Form 217 (Medicare Enrollment, Eligibility & Payments)
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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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` Forms 203 and 206 (Directed to Defendant - Premises)
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` Forms 208 and 209 (Supplemental Directed to Plaintiff - WC)
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` Forms 210 and 211 (Directed to Intervening Plaintiff - WC)
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` Form 212 (Directed to Plaintiff – Loss of Consortium)
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` Form 214 and 216 (Directed to Plaintiff – UM/UIM)
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`THE DEFENDANTS,
`DANIEL GEDRIM
`SUSAN GEDRIM
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`By 434154
`Michael L. Romanelli Jr., Esq.
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`LAW OFFICES OF MEEHAN, DI PALMA, ROBERTS & TURRET
`P.O. BOX 6835, SCRANTON, PA 18505-6840  (203) 294-7800  JURIS NO. 408308
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`Law Offices of Meehan, Di Palma, Roberts
`& Turret
`Tel. # 203-294-7800
`Juris # 408308
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`LAW OFFICES OF MEEHAN, DI PALMA, ROBERTS & TURRET
`P.O. BOX 6835, SCRANTON, PA 18505-6840  (203) 294-7800  JURIS NO. 408308
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`This is to certify that all personal identifying information was redacted pursuant to
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`CERTIFICATION
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`Practice Book Section 4-7. This will further certify the foregoing was mailed via U.S. Mail, postage
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`pre-paid or electronically delivered pursuant to Practice Book Section 10-14 on this 10th day of
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`November, 2023.
`Pamela L. Cameron, Esq.
`Goff Law Group LLC
`433 S. Main Street, Suite 328
`West Hartford, CT 06110
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`Peter G. Barrett, Esq.
`Markey Barrett PC
`360 Bloomfield Avenue
`Suite 301
`Windsor, CT 06095
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`Edward J. McManus, Esq.
`McManus Law Firm
`1337 Dixwell Avenue
`Hamden, CT 06514
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`__434154______________________
`Michael L. Romanelli Jr., Esquire
` Commissioner of the Superior Court
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`LAW OFFICES OF MEEHAN, DI PALMA, ROBERTS & TURRET
`P.O. BOX 6835, SCRANTON, PA 18505-6840  (203) 294-7800  JURIS NO. 408308
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`PLAINTIFF’S CERTIFICATION
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`I, MATTHEW ADAMO, hereby certify that I have reviewed the above Interrogatories and
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`Requests for Production and responses thereto and that they are true and accurate to the best of my
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`knowledge and belief.
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`___________________________
`Matthew Adamo,
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`Subscribed and sworn to before me this _____ , day of _______, 20 .
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`______________________________
`Commissioner of the Superior Court/
`Notary Public
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`LAW OFFICES OF MEEHAN, DI PALMA, ROBERTS & TURRET
`P.O. BOX 6835, SCRANTON, PA 18505-6840  (203) 294-7800  JURIS NO. 408308
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`AUTHORIZATION FOR THE RELEASE AND
`TRANSFER OF EMPLOYMENT INFORMATION
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`TO:
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`I, the undersigned, hereby consent and authorize you to disclose and release to agents,
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`servants, and employees of the Law Offices of Meehan, Di Palma, Roberts & Turret, P.O. Box 6835
`, Scranton, PA 18505-6840 (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 am informed that the above information requested is needed and is to be used for pursuing
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`the disposition of my claim arising out of an alleged accident on March 27, 2021. 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
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`original.
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`Signed:________________________
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`I authorize the transfer of said information by and between the aforesaid persons.
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`Date: ________________________
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`SS#: __________________________
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`Date of Birth: _________________
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`LAW OFFICES OF MEEHAN, DI PALMA, ROBERTS & TURRET
`P.O. BOX 6835, SCRANTON, PA 18505-6840  (203) 294-7800  JURIS NO. 408308
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`AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION
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` Records to be disclosed to:
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`Meehan, Roberts, Turret & Rosenbaum
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`P.O. Box 6835
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`Scranton, PA 18505
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` Liberty Mutual Group, and its affiliates
` 175 Berkeley Street
` Boston, MA 02116
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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.
`Purpose for Disclosure:
`Civil Litigation: Personal Injury Lawsuit ________
`Workers’ Compensation Claim _________
`Name of Health Care Provider to make Disclosure:
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` ABI Document Support Services
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` 1055 Stewart Avenue
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` Suite 104
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` Bethpage, NY 11714
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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, orthopaedic 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.
`Patient Date of Birth:
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`Patient Name and Address:
`____________________
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`___________________________
` Dates of Treatment:
`___________________________
` _____________________
`___________________________
`This Authorization shall remain in Effect for one year from date below.
`I 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.
`I 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.
`I 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.
`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.
`I 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.
`I agree that a photocopy of this Authorization has the same authority as the original.
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`LAW OFFICES OF MEEHAN, DI PALMA, ROBERTS & TURRET
`P.O. BOX 6835, SCRANTON, PA 18505-6840  (203) 294-7800  JURIS NO. 408308
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`Signature of Patient or Authorized Representative
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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 ____ Administrator/Executor of Estate _____ Power of Attorney/Conservator ____ Other-specify
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` Date
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`LAW OFFICES OF MEEHAN, DI PALMA, ROBERTS & TURRET
`P.O. BOX 6835, SCRANTON, PA 18505-6840  (203) 294-7800  JURIS NO. 408308
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