Brice 2012/08/13 09 : 35 : 56 2 /9 I
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' BENNER�TTE & ASSOCIATES, P.A.
Helping yotr...when help is rteeded most.TM
TOM BENNEROTTE August 10, 2012 r i���y� i
R�iJ� ' i.J
CONOR 7'OBiNt Shai7 Moore
City Clerlc, City of St Paul AUG 1 3 2012
Jo�sco�-�� y�A FAX ONLY 651-266-8574
JEFF MUItitAY ���a �`����
RE: My Client: Cylestine Brice
tAlso Admitted in Wisconsin YOUT IY1SUTeCI: Niklcole Peterson
Our File No.: 15408
Date of Injury: 10/3/11
Dear Ms. Moore:
Please be advised ouc office has been retained to reptesent Cylestine Brice in the above-
referenced accident. We unde�stand that you are tl�e insurer for the defendant in this
accident.
Please advise me of the adjuster's name and the claim number, or if any information as
captioned above is incorrect. Please do nofi contact my client directly.
As the legal representative of my client,I hereby exercise my client's right to withdraw atl
authorizations for release of information that you or any agent or representative of your
company may have previously obtained from my client,effective the date of this letter.
Please direct any future requests for signed authorizations for release of information to my
attention.
Please forward the following infoi-mation as iY becomes available to you:
1. A copy of all records you receive including,but not limited to,medical reports,
wage records,police reports and any other records received;
2. Any statements in your file of my client, or any parties or witnesses in this
accident;
3. A copy of the declaration page; and
4. Documentation of property damage, including estimates,photographs,valua#ions,
and payments made.
If there is a charge for obtaining copies of this information,ptease contact us for approval
of the cllarges prior to sending.
Pursuant to Minnesota Statute 72A.201, Subd. I 1,an insurer must disclose the coverage
and Iimits of an iilsurance policy within 30 days after the information is requested in
writing by a claimant.Please consider this as a written request for your policy limits.
The information x•equested above is deemed continuing,so that any information received
by yott subsequent to this letter should be forwarded to me. Thank you in advance for your
cooperation and assistance.
3340 Sherman Court, Suite 100 •Eagan,MN 55121
PH: 651-203-5990•FAX: 651-288-0860•www.bennerotte.com I
2012/08/13 09 : 35 : 56 3 /9
Cylestine Brice 15408
Current Medical Providers I�
West Valley Chiropractor Center
7670 W. Sahaxa Ave, Suite 2
Las Vegas,NV 89117
Las Vegas Radiology
7500 Smoke Ranch Drive, Ste 100
Las Ve�as,NV 89128
Suinmit Orthopedics
Gallery Medical Building
17 Exchange Street North, Suite 307
St. Paul,MN 55102
United Hospital
333 North Smith Avenue
St. Paul,MN 55102
Affinity Medical Gxoup
9446 36th Ave N
New Hope, MN 55427
Prior Medical Providers
Fairview HighIand Park Clinic
21 S S Ford Parkway �
St. Paul,MN SS 116
Sincerely,
BENNEROTTE &ASSOCIATES,P.A.
� � jG,... �..�- ---.�w
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Thomas R.Bennerotte �
Attoiney at Law �
TRB/mar
�nclosures
Cc: Cylestine Brice (via email) �
�
2012/08/13 09 : 35 : 56 4 /9
A,TJTHORIZA�YaN'FOR IZLJG���l�I'�l�D]ICAIL I1�F0?�MATx4�
�a-tient's Name: C^ylestine Brice
Data of Buth: 2/9/41
1.�authorize t0e us�or disclosure of tfie above n:amed ind'z�rxdual's heallh infonmation as dascribed
below.
2, 2ha following indi�viduai ar organization is authoxized to maka tha disclasure:
Affiniry Medical Grou
3. The type and amoun.t of information to bo used or disclosed zs as:fo�ows:
�l Entire record
� A.ecards xegaxd'zag AIDS ax�IV 4xeatment or dzagnosis
C� Records regarding behavioral or rnen�al health services
CJ Recards regarding txe�.hnent for a.lcohol ana drug abuse
CI Itemazed Billing Stateme�t�
L7 Other
4. I understaud#hat ttis informa�an in my�xeai#lz recoxd may include�in�oxma#�o�relating�o sexualt�
transmitfed dzsease,acquired iminunodefzcisz�cy syndz�ome(AIDS),or huznan immunodaficxez�cp
virus(H�. �t may atso inclnde iz�formation abouf bel�avioral or mental heaIth services,and
treatment for alcohol and drug abuse.
5. This inforination may ba disclosed to and used by tha�ollowing fu�n�for purposas o�litig�tiozz:
City of St. Paul
6. Z uxtdexstar�d�lrave tha right ta revoke thi�s autbpz'iization at an�y time. �understand i�I revoke fhis
authorization I inust do so in,writtzung and presentmy writtEn revoca.tian to'tfie 1zoalth informatio�
management department. Y cmders�an.d fitze revocatzon wxu not apply to information t&at has alxeatiy
been re�eased in response to this aufihorizat��z�. X uuderstand fha revocation:a�iii not a�ply to my
insuxantca oomp�any whan the law pxo�►ides m�insurax�ifh the right�c►contest a.cla�ina under my
policy. �'nlsss atherwzse xevol�ed,t�zs au�oriza�ion will e�pire withiu one yean�o�its data.
7. �understaud that authoxizing t�.e disclosiu•e ofthis heaifh information is voluntaty. I can refuse ta
sign this authorizatzon. X nead not sign f]z�is fox�n ui order to assuxa freafinem� I understand I maq
iizaspect or copy'tha information to ba used or disclosed,as�rovidad in CF�Z I69�.52�. Y andezs�nd
az�disclQSUCe of infarfnation cazxies with ifi tkte potautial foz�an anau�artzed re-disclosuxa a�nd.the
iz�or�natxon may not be proteeted by fedetat eaz�i'tdentialifiy rules.
8. A photocop�af this autlzoi�zation shall be considaxed as valid ss au origi.naL
' /� , — � `�_��–
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igna e f Pafiant or Y.ega1 Reprasentative Date
�f$igned i�y�.ega1 kepresen#ative,Relationship to Patient
2012/O8/13 09 : 35 : 56 5 /9
A��JTHORLZA:3'YON FO�t.REx.,E�1SJE��'I�D][CA.�II�TFURMATTOld'
.Fatient's Name: Cvlestine Brice
Data of Buth: 2/9/41
1.I authorize tf�e uso or disclosure of the above naaned indx�vxdual's health in.fozmation as described
below.
2. The fo�lowing indi�vidual or oxganization is autkoxized to make the disclosare:
Fairview Highland Park Clinic
3. The Lype and amount of informa�ion to ba used or disclosed'zs as£oi�ows:
�1 Enfiira record
❑ Recards zegard'zag.A.IDS ar�IIV trea�inent ar dzagnosis
I� R.ecords regarding behaviora!or rc�ental heal�h services
❑ Records regard�ng t.re�.finent for alcob�o�and drug abuse
❑ Ifemzzed Billing Sta�eznent•
L7 Other
4. I understan.d#hat tha infoxmation in my 3�ea[#h record may inaluda ixifoxmat3on relating#o se�taliy
transmit�ed dzsease,acquired immunode�icisztcy syndzame(AIDS),or huznau immunode�icze�uay
virus(H�.V}. Zt may afso include iz�ormation about hehaviural or menYaI health services,and
#aeatmeut for alco�►ol and drug abuse.
, 5. This information u�ay be disclosad to and used by tha�ollowing funz for parposes o£litig�rion:
City of St. Paul
6. X u�ndexstand�liave the right to revoke thzs�tttb,oriiza.tion at a.��time. X w�derstand if I re�ro[ce fhis
autharization I�nusf do so in�cvritwg and presentmy w�ittEn revocat�on to'�tie health inforoaatio�r
managemant dapa.rtYnenfi. Y nndexstan.d fi�e revoca�ion wzt�not appi�to inform.atian that has a�eatly
baen re�eased in response to tfiis authorizataoz�. �undarsta.nd f.�e revaoation�cvii[not apply to zuy
�uasuxan�ce ooba�sany wh�n the Iaw pxo�uides my insurer r�rifh tke right fi,o contesE a.cla�ina under my
poticy. �J'nless othenvise ravol�ed,tl�is autl�orizai3on wi11 expire within ane yeax of its data.
7. �uniierstaad that authorizivag the disclosure of this health infoxxnation is volun#a�y. I can refuse to
sign tb.is authorizatiazz. �need not slgn this�oxm in ord�r to assure traa#nent. I u.txderstazzd.I may
iunspect or eopy'the information to be�used or diselosed,as pro�vidad zn Cl�l�Z6�.524. I wadezstand
azzy disclosure of information carries w�th�it#lxe potentia�fox an unauthorized re-disctosuxe and.the
inforimaixon may nof be protec#ed 6y Pederat confzdenf�alitty rules.
8. A photoeopy of this a.utizot�za#ion sha�I ba considexed as valid as az�.original.
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igna a �Patiax►t or r,agal�teprasenta.tive Dafe
�Signed hy I.egal].tepresentativa,Relationship to Patient
2012/08/13 09 : 35 : 56 6 /9
A�IITHORIZA'T'Y4N FOR RLI,E�JE�l��DZCAI.IN�'ORMATT4�
.Fa�[ent's N�ame: Cylestine Brice
Date of Buth: 2/9/41
1.I authorize tlza uso or disclosure ofthe above naaned indx�xdual's health information as descxibed
below.
2. 'T'he foll�wzng individual or organ9zation is authoxazed to make tlxa disclosure:
Las Vegas Radiolog�
3. The type and amount of information tv be used or disclosed is as follows:
�I Entire record
❑ Records zegaxd'zag AIDS ax�T ireatment or diagnosis
Q R.ecords regaxding behavioral or r►�ental health services
❑ Records regard�ng tre�.iment for a�cohol and drug abusa
❑ Itemazed.Billing Statezuent�
O Other
4. I understand that tlta informatian in my heaitl�record may include in�oxm.atio�relating to sexuallx
transmit#ed dzsease,acquired innrnunodeficiezzcy sy�adzame(AIDS),or huznan immunode�cieuap
viras(H:[VV). �t z�nnay a.�so include in£oz�nation about beharrioral or mentaI health se�rices,and
treatmeut for aico�ol and dretg a6use.
5. This information vaay ba disclosad to and used bq ths�ollowing firni for purpeses o�lit�g�tion:
City of St. Paul
6. Z unda�staxzd�]rava the right to revoke this autttox;tzation at an�y time. �wndarstand i�I rewoke this
authorizatiori I�nuse do so int�vvri.tiwg and presentmy t�vrittEn revoca�ton to'tl'ie health informatIozr
management department. I undez•stan.d the revocatiozz w�z�ot appl�to information that has a�teatly
baen released in rasponsa to this authorization. I�utderstand the revoeation:wiII no�apply to zn.y
izxsuxance connpany when fhe law pxovides m�'vasuxex�rith the r��ht to contest a claizn under my
p�ticp. �7nless otherwise ravol�ed,t�iis aufhorization wili e�pire within one yeax of its data.
7. T understarid that aut3�oz�zing t�ie disclos��e ofthis health infox�nation is volun#a�y. I can.refusa to
sign this authorizafio�z. X need not sign tk�is£or.m in ordsr to assuxe fxeat�xte.n�. L understand I may
iunspect or copy'the information�o be used or disclosed,as�ro�vided itt C�t�6�.524. Y unders�d
any disclosuze of infan�natiou carries with it the potentia�fo�an unautl�orizedre-disc[osure and tha
�lz�oz�uatxon m�y not be proteeted by fedatai can$dent�aliiy rulas.
$. A photoco y of this au#hoi�zation shali ba considexed as valid as an original.
I / ' � - � -��-
igaa e f Patiez►t or Legal RepresentaHve Dafe
T�Signed by LegaI Representafave,Relationship to Patient
2012/08/13 09 : 35 : 56 7 /9
A�UTSORtZA'TION FOR REX,�A�JE O�'I�DxCA�II�'ORMAT]Ca�
.Fatient's Na�,te: Cylestine Brice
Date of Buth: 2/9/41
i.I authorize tfz�uso or disclosure of the above named indxvzdual's health infoxmation as descxitbed
below.
2. Tha following indi�vidual ax oxgan3zation is anthoxazed to maka tha disclosure:
Summit Orthopedics
3. The type and amount of information f.o bv used or disclasect xs as fo�lows:
�7 Entira record
❑ Records z-agaxdivag AIDS ax�'ST ireatment or diagnosis
Q R.ecords regaxding behaviora!or r�eutal flealth services
Cl Reco.rds regarding txe�#ment for a.�coho�azxd drug abuse
C7 Itemized.BiU.ing Sta�ement�
L7 Ot.her
4. I understand that tha infoxmation in my heal#h record may include in�orma�toz�relating to saxually
transmit#sd disease,acquired inarnunode�ZCiency syz�drama(AIDS),or huznan immunode�tczeucy
viras(F�/). I�may atso i�ncluda u�ortnation about bebarrioral or mental hea�th services,and
�reatmeut for alco�ol and drug abusa.
5. '�'kis information z�aay ba disclosed to and used bq tha followi�fu�m for purposas o�litig�tion:
City of St. Paul
6. X undexstand�have the right ta revoke this aut6oxization at an�titae. �understand if I revo[ce fhis
autharizatiori I inuse do so i�a�wri.tiwg and presentmy writtEn revocat�o�to'tfie 1�ealth infozmatIo�r
managemant deparf.men�. Y understand tb;e�evocation witLl�ot apply to information that has alxeady
bean re�eased in response to this aufihorizat�oz�. I undarstand the revoeation:will not apply to my
izxsuzanca com�rany whan tha law pxo�vides my uasuz'er v�rifh tt�e right to contest a cIaiun under my
poHcy. �(J'nless otherwzsa ravol�ed,t�is au�.oriza�ion will ex.pira withig ana year o£its data.
7. T unilerstarid that authoa�izxng t�ia disclosure of this heslth infoimation is volu�nta�y. I can refuse to
sign this authorizafiion�. Z need not sign fhis form in ordsr to assure ixeaianen�. I understand I may
iuzspect or copy'the informatian to ba used or diselosed,as pro�vided izi CN�t Z6A�.524. �underst�nd
a�qy disclosure of information cazries with ifi#Ixe potential foz�an unat�ho�ized re-discIosuxa a�nd the
inforruatzon.m�y not be protec#ed by federal ca�fi'tdent�alify rules.
8. A photoco y uf this authox�zation shall be considexed as valid as au origival.
/ ' 8 - � --��-
igna a f Paf�ent or Y.agal Reprasentative Dafa
T�Signed hy 1.ega112apresan#atave,Rela�Ionship to Patient
2012/08/13 09 : 35 : 56 8 /9
.A�fJTHORLZ.A:TION FOR REI,E�SJE O�'I�DICAIG INFORMATIOIN'
Faf.ient's N'am�e; Cvlestine Brice
Date of Butb: 2/9/41
1.�authorize t&e uso or disclosure of ttie above named indX'vidual's health information as descxitbed
below.
2. Tha foilawing individual.or oxgan�zation is authoxized to make the disclosure:
United Hospital
3. The lype and amount of information to bv used or disclosed xs as follows:
�7 Entira record
❑ Records zegaxdzag.AJ�S ax�i�V ireat�ztent or diagaosis
CJ �tecords regarding behavioral or�ental health services
Cl Records regarding�re�.finent for a.lcoho�and drug abusa
C7 Itemized Billing Sta�ement•
Cl Other
4. I understand#hat the information in my health record may inaluda in�oxmatlo�relatting#o sexualix
transmit�ed dzsease,acquired innrnunode�'iciezzcy syz�drama(AIDS),or h7.unan:immunodaficzezzcp
viit�s(��V). �t�onay also includa in�ormation about behavioral or mental healtlx services,a.nd
treatment for alcohol and drag abuse.
S. This information uaay ba disclosed to and used by tha�ollowu�firm for purposas o£lifig�tion:
City of St. Paul
6. I undexstand�lrave the right ta revoke this autttoz'lzafio�►at ara.y time. �wnderstand if I re�ro[ce�zis
authoriza.tion T�nust do so i�r�vritiug az�d present my^�vrittEn revoca.tion to'tfie health inforaaatloxr
managemant deparanenfi. Y undexstaud�ke revocatzon wiU z�ot apply�o inforination that has alxeatiq
bean releasad in response to t�Zis authorizat�n�. �uttdarstand ths revocation wiil not apply to my
ivasuranca oompany when the Iaw pxo�vides m�ittsurer with the right to contest a.cla�ina under my
poticy. Unless otherwise revol�ed,t�is authorization wili ea�pire within�ne yeax of its data.
7. T understan:d that auti�orizing the discloswre ofthis health information is voluntaty. I ca�.refuse to
sigtx this authoriza.tzor�. �need not sign t]uis form in order to assuxa irealaoaem� L understanc�I maq
iuxspect ox copy'the informatian to ba used or disclosed,as pxovided iui C�t�6�524. X wadexstand
anq disciosure of information carries w�t1x it t�xe potenfia�fox an cuiat�Choxized re-diseIosuxe and the
in�ornxation.uaa�y not be protected by fed�ral co�i'tdentialify rules.
8. A photocopy of this autliorization shal[ba considexed as valid as an.original.
J
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igna e f Patiant or T.agal�eprasentative Dafe
Tf Signad hy�.ega1 Represantatava,Retatlonslup to Patiant
2012/08/13 09 : 35 : 56 9 /9
A��r�ro�erzA�carr Fo�R�x,���o�l�x�xc�.�I�a�Tro�r
.Fa-tient's N�ame: Cylestine Brice ,
Date of Bu�th: 2/9/41
1.i authoriza the uso or disclosure of the above n.aaned indX'vidua�.'s heal#h infvrmation as dascxibed
below.
2. The following in.dividuax or organization is authoxiz�d to make tlxe disclosure:
West Valley Chiropractor Center
3, The type and amount of informa�ion tv ba used or discIasec�is as follows:
�] Entire recoxd
� Recards zegaxdivag.A.�DS ax�AV ireah�tent or dtagnosis
D Records regard'zug beha.vioral or�ental heal�h servzces
Cl Records regarding txe�iment for a.lcohol and drag abusa
❑ Itemazed Billing Stateznent�
O Othar
4. I understand that the inform.a�ion in my}�eaEth record may include�infaxmatiQZ�relating#o sexualiy
transmit�ed dzsease,acquired im�nunode�ZCisncy syndrama(AIDS),or h�un:an immunoda�icieuay
virrriss(H�V}. �t z�zay also inclnda info�nation about behavioral ox mental health services,and
�eatmeut for a1coT�o1 and drug abuse.
5. This informataon znay be disclosad to and used by tha�ollowing firn�for purposes o�Ii�iga�tion:
City of St. Paul
6. Z u�tdaxstand�lrave the right to revoke tlzis authoriza.�ion at a�r�y time. �understand i�I re�roEce thi,s
authoriza�ivn I in.ust do so i�.�vvrituzg an�d presentmy w.c.�tten revocation to'tfie hoalth infozmaflor�
management deparanen�. Y vmders�and fit�:e�evocat�on wil�z�ot appiy�o informafion that has al�eatiy
been released in response fio this authorizatio�. X uudarstand i�e revocation:wiii not apply to xny
ixasurance com�rany when tke iaw pxo�vides m�'insuxer�rith t1�.a right to contesE a claiva under my
policy. �7'nless otherwzse revol�ed,tl�is authoriza�ion wi11 expire within ona yeax o�its date.
7. �unilarstarid tl�at authorizing t�ie disclosiu�e ofthis health infoxznation is voluntaty. I can refuse to
sigix this aathorizatia�z. X need not stgn t.]z�is foxm in order to assaxe tceaf�en�. i understand.I may
ivaspect or copy'ths informatian to be used or diselosed,as�xowided�iu C�t�6�.524. T undexstand
aazy disclosure of information catxi�s w�tlx rt fi�ie poteufia�foz�an unatttb.arized re-disciosuxe and.tha
info�nat�on may not be protected by fedatai can$dent�ality rules.
8. A photoco y of this autho�t�za.tion shall ba considered as valid as au original.
/ ' � -- �- ----��-
igna a f Patient or Y,egal Represenfative Dafe
�Signed by Legal ltapresa�xtative,Relationship to Patieut