DocuSign Envelope ID: BEE33FE7-A8E5-42C8-80C8-DD61670192FC

Medical Records Authorizations

The following two forms require just your initials and

signature. These are medical records releases that we
may use to retrieve medical records on your behalf from
anywhere you received or receive treatment related to
JUUL addiction or injury.

Any records that we retrieve or that you send us will be

protected, confidential, and only used for your potential
compensation claim.
 DocuSign Envelope ID: BEE33FE7-A8E5-42C8-80C8-DD61670192FC

AUTHORIZATION FOR RELEASE OF INFORMATION

I, The Undersigned, Authorize:

Name of Facility:
Address:
City, State, Zip:
To Release Information From The Records Of:
Patient Name: Tarek Wegner
Patient Date of Birth: 1986-05-01
Patient Social Security Number: 531-04-4009
Information Authorized to Be Released:
Any and All Medical Records and Films Any and All Records From Other Providers

Any and All Billing Information U

X Other:
U See Streamlined Record Retrieval cover sheet for
U
dates of service and types of records needed.

Information May Be Released To:

Name: U Streamlined Record Retrieval on behalf of Beasley, Allen, Crow, Methvin, Portis & Miles, P.C.
Address: 9460 S. 700 E., Suite 203 (Union Square)
U 218 Commerce Street
City, State, Zip:Sandy Utah 84070
U Montgomery, AL 36104 U

Telephone: U (866) 983-0163 (334) 269-2343 or (800) 898-2034

Purpose of Disclosure: Product Liability Litigation

U

Understandings:
1. I understand that this consent may be revoked in writing at any time. With the exception and to the extent that disclosure of
information has already occurred prior to the receipt of revocation by the above-named provider. If written revocation
is not received, authorization will be considered valid for a period of time not to exceed three (3) years from the date of
signing. To initiate revocation of this authorization, direct all correspondence to the “Specific Requestor” above.

2. I understand that this consent is to include disclosure of: (PLEASE INITIAL EACH)

Alcohol and/or Drug Abuse Records Psychiatric Records

Sexually Transmitted Disease Information HIV/AIDS Information

3. I understand that a photocopy of this authorization is to be considered valid as the original.

4. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I
need not sign this form in order to assure treatment. I understand I may inspect or copy the information to be used or
disclosed, as provided in CFR 164.524. I understand any disclosure of information carries with it the potential for an
unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have
questions about disclosure of my health information, I can contact Beasley, Allen, Crow, Methvin, Portis & Miles, P.C.

SIGNATURE:
Patient or Personal/Legal Representative (Next-of-Kin or Legal Guardian to Sign Only If Patient is a Minor, Legally
Incompetent or Deceased)

PRINT NAME:
Tarek Wegner DATE: 1/14/2020

Relationship To Patient Of Personal/Legal Representative Signing:

JUUL Medical JUUL Medical

Authorization Authorization 2 2

a1p3Z00000D1iEG
DocuSign Envelope ID: BEE33FE7-A8E5-42C8-80C8-DD61670192FC

Patient Name: Tarek Wegner

Address: 3941 blossom dr ne Tacoma, Washington 98422 Attention: HITECH Request
DOB: 1986-05-01
SSN: 531-04-4009
for Medical, Billing Records
and Radiology Images. (42
Covered Entity Name: U.S.C. § 17935 (e))
Address:

Re: HITECH Right of Access Request for Medical Records and Your Compliance with Federal Law

Dear Records Custodian,

This is a HITECH Right of Access Request and asks that you provide a copy of
records dated from to to the representative identified below. Whether the
records are maintained in electronic or paper form, I specifically request that you provide the records in electronic PDF
format on a CD, DVD, or USB flash drive, per the requirements of 42 U.S.C. § 17935(e)(1) and 45 C.F.R. 164.524(c)(2)(ii), as
amended. These federal laws preempt applicable state laws, and provide in pertinent part:

" . . . if the individual requests an electronic copy of such information, the covered entity must provide the individual
with access to the protected health information in the electronic form and format requested . . ."

If any of the above records are available only in paper form, you are required to provide the records in the electronic form
and format requested. Furthermore, 42 U.S.C. § 17935(e) and 45 C.F.R. 164.524(c)(4) limit the cost of obtaining the records
to the actual labor costs for reproducing them in the requested electronic format, the actual cost of the portable media (in
this case, on CD, DVD, or USB flash drive), and postage. Labor costs cannot include time incurred reviewing the request,
searching for and retrieving the records requested, or preparing the records responsive to the request. The flat fee for
producing the records in electronic format may not exceed $6.50.

Pursuant to 45 C.F.R. 164.524(c)(3)(ii), I am directing you to send the requested records in electronic format directly to the
following representative:

Beasley, Allen, Crow, Methvin, Portis & Miles, P.C.

Post Office Box 4160
Montgomery, Alabama 36103-4160
Ph: 800-898-2034, Fax: 334-954-7555
Email: [email protected]

Beasley Allen Law Firm is my record retrieval representative.

Initials
I am initiating this request for my own purposes.
Initials

This is a HITECH Right of Access request and you cannot require me to complete a HIPAA Authorization form to send my
records to the designated representative. Please provide the records as soon as possible, and no later than 30 days from
your receipt of this letter, as required by 45 CFR 164.524(b)(2)(i). I acknowledge and consent to such, that the release of
information may contain alcohol and drug abuse, psychiatric, HIV or genetic information. Thank you for your prompt
attention to this request. If you are unable to comply with this request, please contact my attorney immediately.

Sincerely,

Patient or Representative Signature: (HITECH Act permits an electronic signature)

Printed Name: Tarek Wegner Phone Number: 2532023436
Relationship to Patient:
Date Signed: 1/14/2020
3 4
sms1
DocuSign Envelope ID: BEE33FE7-A8E5-42C8-80C8-DD61670192FC

Tarek Wegner
Patient Name:
Address: 3941 blossom dr ne Tacoma, Washington 98422 Attention: HITECH Request
DOB: 1986-05-01
SSN: 531-04-4009
for Medical, Billing Records
and Radiology Images. (42
Covered Entity Name: U.S.C. § 17935 (e))
Address:

Re: HITECH Right of Access Request for Medical Records and Your Compliance with Federal Law

Dear Records Custodian,

This is a HITECH Right of Access Request and asks that you provide a copy of
records dated from to to the representative identified below. Whether the
records are maintained in electronic or paper form, I specifically request that you provide the records in electronic PDF
format on a CD, DVD, or USB flash drive, per the requirements of 42 U.S.C. § 17935(e)(1) and 45 C.F.R. 164.524(c)(2)(ii), as
amended. These federal laws preempt applicable state laws, and provide in pertinent part:

" . . . if the individual requests an electronic copy of such information, the covered entity must provide the individual
with access to the protected health information in the electronic form and format requested . . ."

If any of the above records are available only in paper form, you are required to provide the records in the electronic form
and format requested. Furthermore, 42 U.S.C. § 17935(e) and 45 C.F.R. 164.524(c)(4) limit the cost of obtaining the records
to the actual labor costs for reproducing them in the requested electronic format, the actual cost of the portable media (in
this case, on CD, DVD, or USB flash drive), and postage. Labor costs cannot include time incurred reviewing the request,
searching for and retrieving the records requested, or preparing the records responsive to the request. The flat fee for
producing the records in electronic format may not exceed $6.50.

Pursuant to 45 C.F.R. 164.524(c)(3)(ii), I am directing you to send the requested records in electronic format directly to the
following representative:

Streamlined Record Retrieval

9460 S. 700 E., Suite 203 (Union Square)
Sandy, UT 84070
Ph: 866-782-1310, Fax: 877-290-2646
Email: [email protected]

Streamlined Record Retrieval is my record retrieval representative.

Initials
I am initiating this request for my own purposes.
Initials

This is a HITECH Right of Access request and you cannot require me to complete a HIPAA Authorization form to send my
records to the designated representative. Please provide the records as soon as possible, and no later than 30 days from
your receipt of this letter, as required by 45 CFR 164.524(b)(2)(i). I acknowledge and consent to such, that the release of
information may contain alcohol and drug abuse, psychiatric, HIV or genetic information. Thank you for your prompt
attention to this request. If you are unable to comply with this request, please contact my attorney immediately.

Sincerely,

Patient or Representative Signature: (HITECH Act permits an electronic signature)

Printed Name: Tarek Wegner Phone Number: 2532023436
Relationship to Patient:
Date Signed: 1/14/2020