San Francisco — Updated Asbestos Authorization Forms

Source: https://sf.courts.ca.gov/system/files/local-rules/sfsc-authorization-exhibits-updated-11-13-24.pdf

Sparse pages use OCR; original PDF remains authoritative.

Attorney Name(s) or Party without Attorney Firm Name Firm Address City, State, Zip Code Phone Number(s) Fax Number Email Address

Attorney for (Name) or Self-Represented

SUPERIOR COURT OF CALIFORNIA

COUNTY OF SAN FRANCISCO

PLAINTIFF'S NAME, Case Number:

Plaintiff,

ASBESTOS – EXHIBITS I vs.
ASBESTOS FORMS
DEFENDANT'S NAME,

Defendant

November 13, 2024 ASBESTOS FORMS EXHIBIT I, 1 -15

SFCIV-030 Rev: November 13, 2024

EXHIBITS I-1 to I-14

November 13, 2024 ASBESTOS FORMS – Exhibits I-1 - I-14

SFCIV-030 Rev: November 13, 2024

EXHIBIT I - 1 AUTHORIZATION FOR MEDICAL RECORDS

November 13, 2024 ASBESTOS FORMS – Exhibit I - 1

SFCIV-030 Rev: November 13, 2024

HIPAA COMPLIANT AUTHORIZATION FOR MEDICAL RECORDS PURSUANT TO 45 CFR 164.508

TO: ____________________________________ ____________________________________

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I, _____________________________, hereby authorize you to release to and/or permit inspection and copying by RECORDTRAK, 1111 Broadway, Suite 300, Oakland, CA 94607, or their representatives, any and all medical information including but not limited to charts, records, reports, histories, laboratory studies, notes, x‐rays and/or outpatient records, all chest x‐rays, CT scans, cytology, pathology (including all slides and paraffin blocks) and PFT data and printouts pertaining to: Patient Name: ____________________________________; Date of Birth _________________; Social Security Number: ____________________; for purposes of review, evaluation and evidence in connection with a lawsuit filed on ____________.

I acknowledge the right to revoke this authorization by writing to the ROA Agent at RecordTrak at 130 Webster Street, Suite

reversed, and my revocation will not affect those actions.

I acknowledge the potential for information disclosed pursuant to this authorization to be subject to re‐disclosure by the recipient and no longer be protected under 45 CFR 164.508.

I understand that the covered entity to whom this authorization is directed may not condition treatment, payment, enrollment or eligibility benefits on whether or not I sign the authorization.

Any facsimile, copy or photocopy of the authorization shall authorize you to release the records herein.

This authorization is given in compliance with the Federal Confidentiality Law (21 U.S.C. Section 1175, 42 CFR Subsection 2.1‐2.67.1 and Health & Safety Code Section 199.21(g) and California Civil Code Section 56, et seq.) and specifically allows you to release alcohol, drug, psychiatric, sickle cell anemia information and/or HIV test results which are not unequivocally negative.

This authorization is given in compliance with the Federal Privacy Act (5 U.S.C. Section 552a(b)) and the California Confidentiality of Medical Information Act (Civil Code Section 56.10, et seq.), the restrictions of which have been specifically considered and are hereby expressly waived. A photocopy of this authorization shall be valid as the original.

This authorization is effective immediately and shall remain in effect for one year. I understand that I have a right to receive a copy of this authorization upon request. Copy requested and received: [ ] Yes [ ] No Initials: _______

It is also my understanding that RECORDTRAK is required by court order to provide my attorneys with copies of my records for a 21 day first look before sending them to any defendant involved in my asbestos case. If the preliminary fact sheet indicates plaintiff will seek trial preference, or a motion for preference has been filed, the first look is 7 days.

Dated: ___________________________ ________________________________________

The language of this authorization has been authorized by San Francisco Superior Court. No alteration of or deletion to this form may be made by plaintiff or plaintiff's attorney without order of the San Francisco Superior Court on noticed Motion.

November 13, 2024 ASBESTOS FORMS – Exhibit I - 1

SFCIV-030 Rev: November 13, 2024

EXHIBIT I - 2 AUTHORIZATION FOR MEDICAL BILLS

November 13, 2024 ASBESTOS FORMS – Exhibit I - 2

SFCIV-030 Rev: November 13, 2024

HIPAA COMPLIANT AUTHORIZATION FOR BILLING RECORDS PURSUANT TO 45 CFR 164.508

TO: ____________________________________ ____________________________________ ____________________________________

I, _____________________________, hereby authorize you to release to and/or permit inspection and copying by RECORDTRAK, 1111 BROADWAY, Suite 300, Oakland, CA 94607, or their representatives, in connection with a legal claim, the following information for any time whatsoever pertaining to the following patient for purposes of review, evaluation and evidence in connection with a lawsuit filed on ____________. Patient Name: _______________________________; Date of Birth ; Social Security Number:.

As used in this Authorization, “DOCUMENTS” means a writing, as defined in evidence Code Section 250, and includes the origina l or a copy without limitation of every kind of written, printed, typed, recorded, or graphic matter, however produced or reproduced, including but not limited to notes, forms, claims, memoranda, briefs, summaries, charts, medical records, transcripts and correspondence concerning or relating to the individual referenced above.

• Any and all billing records and statements which relate or pertain to any treatment, service, payment, credit, adjustment, or
transaction of any type.
• Any and all documents reflecting payments made by Medicare, MediCal, Medicaid and/or any other medical insurance.
• Any and all documents reflecting any payments made by the patient on his/her own behalf.
• Any and all documents reflecting the medical charges to date and the current balance of the account.
• Any and all documents reflecting the total cost of each of the patient’s medical treatments at the said facility, and the
breakdown of the amount actually paid by and/or due from each payee, including but not limited to the patient, Medicare,
MediCal, Medicaid and/or any other medical insurance.
• Any and all documents showing the amount discounted/reduced by your facility or its contracting agency from the total
medical charges.
• Any and all contracts between Medicare, MediCal, Medicaid and your facility or contracting agency, physicians, employees
and/or any other agents or representatives of your facility.
• Any and all documents contained in completed UB‐92 or HFCA 1500 forms, such as ICD‐9 diagnosis and procedure codes,
including any E‐codes, CPT codes, and DRG codes. Payment documentation should include explanations of reviews and/or
explanations of benefit forms detailing the payments accepted for services provided to the patient. Any and all
documents entitled CMS or Medicare Summary Notice.

This authorization is given in compliance with the Federal Confidentiality Law (21 U.S.C. Section 1175, 42 CFR Subsection2.12.67.1 and Health and Safety Code Section 199.21(g) and California Civil Code Section 56 et seq.) and specifically allows you to release alcohol, drug, psychiatric, sickle cell anemia information and/or HIV test results which are not unequivocally negative. This authorization is given in compliance with the Federal Privacy Act (5 U.S.C. {552 a(b)) and the California Confidentiality of Medical Information Act (C.C. Subsection 56.10, et seq.), the restrictions of which have been specifically considered and are hereby expressly waived. This authorization is effective immediately and shall remain in effect for 1 year. I understand that I have a right to receive a copy of this authorization upon request. Copy requested and received: Yes No Initials: ______

It is also my understanding that RECORDTRAK is required by court order to provide my attorneys with copies of my records for a 21 day first look before sending them to any defendant involved in my asbestos case. If the preliminary fact sheet indicates plaintiff will seek trial preference, or a motion for preference has been filed, the first look is 7 days.

I acknowledge the right to revoke this authorization by notifying the record custodian in writing at the facility identified above of my desire to revoke it. However, I understand that any actions already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. I acknowledge the potential for information disclosed pursuant to this authorization to be subject to re‐disclosure by the recipient and no longer be protected under 45 CFR 164.508. I understand that the covered entity to which this authorization is directed may not condition treatment, payment, enrollment or eligibility benefits on whether or not I sign the authorization. Any facsimile, copy or photocopy of the authorization shall authorize you to release the records herein.

Signature: _____________________________________________ Date: __________________ The language of this authorization has been authorized by San Francisco Superior Court. No alteration of or deletion to this form may be made by plaintiff or plaintiff's attorney without order of the San Francisco Superior Court on noticed Motion.

November 13, 2024 ASBESTOS FORMS – Exhibit I - 2

SFCIV-030 Rev: November 13, 2024

EXHIBIT I - 3 AUTHORIZATION FOR EMPLOYMENT RECORDS

November 13, 2024 ASBESTOS FORMS – Exhibit I - 3

SFCIV-030 Rev: November 13, 2024

AUTHORIZATION FOR RELEASE OF EMPLOYMENT RECORDS

TO: ____________________________________

---

---

I, ________________________________, hereby authorize you to release to and/or permit inspection and copying by RECORDTRAK, 1111 BROADWAY, Suite 300, Oakland, CA 94607, or their representatives, any and all employment records including but not limited to employment applications, personnel files, job descriptions and assignments, performance evaluations, attendance records, correspondence, wage and salary information, medical records and medical bills, accident reports, compensation and disability claims, insurance coverage information, pension records, and any and all employee benefits pertaining to __________________________________; Date of Birth _________________; Social Security Number: __________________; for purposes of review, evaluation and evidence in connection with a lawsuit filed ____________.

This authorization is given in compliance with the Federal Privacy Act (5 U.S.C. Section 552a(b)) and to the extent applicable, the California Confidentiality of Medical Information Act (Civil Code Section 56.10, et seq.), the restrictions of which have been specifically considered and are hereby expressly waived.

A photocopy of this authorization shall be valid as the original. This authorization is effective immediately and shall remain in effect for one year.

I understand that I have a right to receive a copy of this authorization upon request. Copy requested and received: Yes No Initials: ______

It is also my understanding that RECORDTRAK is required by court order to provide my attorneys with copies of my records for a 21 day first look before sending them to any defendant involved in my asbestos case. If the preliminary fact sheet indicates plaintiff will seek trial preference, or a motion for preference has been filed, the first look is 7 days.

Date: ________________________ ___________________________________

The language of this authorization has been authorized by San Francisco Superior Court. No alteration of or deletion to this form may be made by plaintiff or plaintiff’s attorney without order of the San Francisco Superior Court on noticed motion.

November 13, 2024 ASBESTOS FORMS – Exhibit I - 3

SFCIV-030 Rev: November 13, 2024

EXHIBIT I - 4 AUTHORIZATION FOR UNION/HEALTH & WELFARE RECORDS

November 13, 2024 ASBESTOS FORMS – Exhibit I - 4

SFCIV-030 Rev: November 13, 2024

AUTHORIZATION FOR RELEASE OF UNION/HEALTH & WELFARE RECORDS

TO: ____________________________________

---

---

I, ________________________________, hereby authorize you to release to and/or permit inspection and copying by RECORDTRAK, 1111 BROADWAY, Suite 300, Oakland, CA 94607, or their representatives, any and all union records including but not limited to union dues statements, membership records, dispatch slips, employers and employment sites, beneficiary records, health and welfare trust records, pension records, accident reports, compensation and disability claims, medical records and medical bills, union literature regarding health and safety procedures and writings reflecting meetings on health and safety issues pertaining to ____________________________________; Date of Birth _________________; Social Security Number: _________________; for purposes of review, evaluation and evidence in connection with a lawsuit filed ____________.

This authorization is given in compliance with the Federal Privacy Act (5 U.S.C. Section 552a(b)) and to the extent applicable, the California Confidentiality of Medical Information Act (Civil Code Section 56.10, et seq.), the restrictions of which have been specifically considered and are hereby expressly waived. A photocopy of this authorization shall be valid as the original. This authorization is effective immediately and shall remain in effect for one year.

I understand that I have a right to receive a copy of this authorization upon request. Copy requested and received: Yes No Initials: ______ It is also my understanding that RECORDTRAK is required by court order to provide my attorneys with copies of my records for a 21 day first look before sending them to any defendant involved in my asbestos case. If the preliminary fact sheet indicates plaintiff will seek trial preference, or a motion for preference has been filed, the first look is 7 days.

Date: ________________________ ___________________________________

The language of this authorization has been authorized by San Francisco Superior Court. No alteration of or deletion to this form may be made by plaintiff or plaintiff’s attorney without order of the San Francisco Superior Court on noticed motion.

November 13, 2024 ASBESTOS FORMS – Exhibit I - 4

SFCIV-030 Rev: November 13, 2024

EXHIBIT I - 5 AUTHORIZATION FOR DEATH CERTIFICATE

November 13, 2024 ASBESTOS FORMS – Exhibit I - 5

SFCIV-030 Rev: November 13, 2024

AUTHORIZATION FOR RELEASE OF DEATH CERTIFICATE

TO: _____________________________________

---

---

I, _____________________________, hereby authorize you to release to and/or permit inspection and copying by RECORDTRAK, 1111 BROADWAY, Suite 300, Oakland, CA 94607, or their representatives, the Death Certificate pertaining to ______________________________; Date of Birth _________________; Date of Death _________________; Social Security Number: _________________; for purposes of review, evaluation and evidence in connection with a lawsuit filed ____________.

This authorization is given in compliance with the Federal Privacy Act (5 U.S.C. Section 552a(b)) and to the extent applicable, the California Confidentiality of Medical Information Act (Civil Code Section 56.10, et seq.), the restrictions of which have been specifically considered and are hereby expressly waived. A photocopy of this authorization shall be valid as the original. This authorization is effective immediately and shall remain in effect for one year.

I understand that I have a right to receive a copy of this authorization upon request. Copy requested and received: Yes No Initials:______

It is also my understanding that RECORDTRAK is required by court order to provide my attorneys with copies of my records for a 21 day first look before sending them to any defendant involved in my asbestos case. If the preliminary fact sheet indicates plaintiff will seek trial preference, or a motion for preference has been filed, the first look is 7 days.

Date: ________________________ ______________________________________

The language of this authorization has been authorized by San Francisco Superior Court. No alteration of or deletion to this form may be made by plaintiff or plaintiff’s attorney without order of the San Francisco Superior Court on noticed motion.

November 13, 2024 ASBESTOS FORMS – Exhibit I - 5

SFCIV-030 Rev: November 13, 2024

EXHIBIT I - 6 AUTHORIZATION FOR FUNERAL RECORDS

November 13, 2024 ASBESTOS FORMS – Exhibit I - 6

SFCIV-030 Rev: November 13, 2024

AUTHORIZATION FOR RELEASE OF FUNERAL RECORDS

TO: ____________________________________

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I, _________________________________, hereby authorize you to release to and/or permit inspection and copying by RECORDTRAK, 1111 BROADWAY, Suite 300, Oakland, CA 94607, or their representatives, any and all Funeral records pertaining to: __________________________________; Date of Birth _________________; Date of Death _______________; Social Security Number: _________________; for purposes of review, evaluation and evidence in connection with a lawsuit filed ____________.

This authorization is given in compliance with the Federal Privacy Act (5 U.S.C. Section 552a(b)) and to the extent applicable, the California Confidentiality of Medical Information Act (Civil Code Section 56.10, et seq.), the restrictions of which have been specifically considered and are hereby expressly waived. A photocopy of this authorization shall be valid as the original. This authorization is effective immediately and shall remain in effect for one year.

I understand that I have a right to receive a copy of this authorization upon request. Copy requested and received: Yes No Initials: ______ It is also my understanding that RECORDTRAK is required by court order to provide my attorneys with copies of my records for a 21 day first look before sending them to any defendant involved in my asbestos case. If the preliminary fact sheet indicates plaintiff will seek trial preference, or a motion for preference has been filed, the first look is 7 days.

Date: ________________________ ___________________________________

The language of this authorization has been authorized by San Francisco Superior Court. No alteration of or deletion to this form may be made by plaintiff or plaintiff’s attorney without order of the San Francisco Superior Court on noticed motion.

November 13, 2024 ASBESTOS FORMS – Exhibit I - 6

SFCIV-030 Rev: November 13, 2024

EXHIBIT I - 7 AUTHORIZATION FOR SOCIAL SECURITY EARNINGS RECORDS

November 13, 2024 ASBESTOS FORMS– Exhibit I - 7

SFCIV-030 Rev: November 13, 2024

ASBESTOS LITIGATION

Recordtrak
1111 Broadway Ste. 300 CA

Oakland 94607

EXHIBIT I - 8 AUTHORIZATION FOR SOCIAL SECURITY DISABILITY RECORDS

November 13, 2024 ASBESTOS FORMS – Exhibit I - 8

SFCIV-030 Rev: November 13, 2024

Form SSA-3288 (02-2023) UF Page 2 of 3 Consent for Release of Information You must complete all required fields. We will not honor your request unless all required fields are completed. (*Signifies a required field. **These are not mandatory fields for the consent form to be acceptable. Please complete these fields in case we need to contact you about the consent form). TO: Social Security Administration

*Date of Birth *Full Name *Full Social Security Number
(MM/DD/YYYY)

I authorize the Social Security Administration to release information or records about me to: *NAME OF PERSON OR ORGANIZATION: *ADDRESS OF PERSON OR ORGANIZATION: ** PHONE NUMBER OF PERSON OR ORGANIZATION: RECORDTRAK 1111 BROADWAY STE. 300 ** SEE BELOW OAKLAND, CA 94607

*I want this information released because: Asbestos Litigation We may charge a fee to release information for non-program purposes.

*Please release the following information selected from the list below: Check at least one box. If requesting medical records, do not check both boxes 7 and 8. We will not disclose records unless you include specific date ranges where applicable.

1. Verification of Social Security Number

2. X Current monthly Social Security benefit amount
3. X Current monthly Supplemental Security Income payment amount
4. Social Security benefit amounts from date to date
5. Supplemental Security Income payment amounts from date to date
6. X Medicare entitlement from date to date
7. X Medical records from date to date
8. X Complete medical records
9. X Other Social Security record(s) (We will not honor a request for "any and all records" or "the entire file." You must specify which records you are seeking. For example, award/denial notices, benefit applications, appeals) Medical records, applications, questionnaires, consultative examinations, reports, determinations, etc.

I am the individual, to whom the requested information or record applies, or the parent or legal guardian of a minor, or the legal guardian of a legally incompetent adult. I declare under penalty of perjury (28 CFR § 1746) that I have examined all the information on this form and it is true and correct to the best of my knowledge. I understand that anyone who knowingly or willfully seeks or obtains access to records about another person under false pretenses is punishable by a fine of up to $5,000. *Signature: *Date:

**Address: **Daytime Phone:

**Relationship (if not the subject of the record): **Daytime Phone:

Witnesses must sign this form ONLY if the above signature is by mark (X). If signed by mark (X), two witnesses to the signing who know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X) on the signature line above. 1.Signature of witness 2.Signature of witness

Address (Number and street,City,State, and ZIP Code) Address (Number and street,City,State, and ZIP Code)

EXHIBIT I - 9 AUTHORIZATION FOR MEDICARE RECORDS

November 13, 2024 ASBESTOS FORMS – Exhibit I - 9

SFCIV-030 Rev: November 13, 2024

EXHIBIT I – 10 AUTHORIZATION FOR MILITARY RECORDS

November 13, 2024 ASBESTOS FORMS – Exhibit I - 10

SFCIV-030 Rev: November 13, 2024

Authorized for local reproduction Standard Form 180 (Rev. 0 /2023) rescribed by NARA (36 CFR 1233.18 Previous edition unusable OMB No. 3095-0029 Expires 04/30/2024 REQUEST PERTAINING TO MILITARY RECORDS Requests can be submitted online using eVetRecs at https://www.archives.gov/veterans/military-service-records/ To ensure the best possible service, please thoroughly review the accompanying instructions before filling out this form. PLEASE PRINT LEGIBLY OR TYPE BELOW. SECTION I - INFORMATION NEEDED TO LOCATE RECORDS (Furnish as much information as possible.)

1. NAME USED DURING SERVICE (last, first, full middle) 2. SOCIAL SECURITY # 3. DATE OF BIRTH 4. PLACE OF BIRTH

2. SERVICE, PAST AND PRESENT (For an effective records search, it is important that ALL service be shown below.) SERVICE NUMBER DATE DATE BRANCH OF SERVICE ENTERED RELEASED OFFICER ENLISTED (If unknown, write “unknown”)

a. ACTIVE

b. RESERVE

c. NATIONAL GUARD

6. PLEASE LIST LAST FOUR DUTY STATIONS, IF KNOWN: 1.

   2. 3. 4.

7. IS THIS PERSON DECEASED? NO YES - MUST provide Date of Death if veteran is deceased:

8. DID THIS PERSON RETIRE FROM MILITARY SERVICE? NO YES SECTION II – INFORMATION AND/OR DOCUMENTS REQUESTED

9. CHECK THE ITEM(S) YOU ARE REQUESTING: X DD Form 214 or equivalent: Year(s) in which form(s) issued to veteran (Date of Separation): This form contains information used to verify military service. An UNDELETED DD Form 214 is ordinarily required to determine eligibility for benefits. If you request a DELETED copy, the following items will be blacked out: authority for separation, reason for separation, reenlistment eligibility code, separation (SPD/SPN) code, and, for separations after June 30, 1979, character of separation and dates of time lost. Please note – recent veterans may be able to request a DD Form 214 through milConnect by visiting: https://www.va.gov/records/get-military-service-records/ An UNDELETED copy will be sent UNLESS YOU SPECIFY A DELETED COPY by checking this box: I want a DELETED copy. X Official Military Personnel File (OMPF): The OMPF may include duty stations and assignments, training and qualifications, awards and decorations received, disciplinary actions, administrative remarks, enlistment and/or discharge information (including DD Form 214, Report of Separation, or equivalent), and other personnel actions. Detailed information about the veteran's participation in battles and their military engagements is NOT contained in the record. X Medical Records: Includes health (outpatient), extended ambulatory, and dental records. If inpatient/hospitalization records are requested, please specify below. I request inpatient/hospitalization records from (facility), last treated in (year). (NOTE: Fields are required) If available, you may receive copies of inpatient narrative summaries, operative reports, discharge summaries, etc. contained in the record.

   Dental Records: Please check this box if ONLY dental records are needed from the medical record. X Other (Please Specify): Disability Records

10. PURPOSE: (Providing information about the purpose of the request is voluntary; however, it may help to provide the best possible response and may result in a faster reply. Information provided will in no way be used to make a decision to deny the request.) Benefits (explain) Employment VA Loan Programs Medical Genealogy Correction Personal X Other (explain) Explain here: LEGAL SECTION III - RETURN ADDRESS AND SIGNATURE

11. REQUESTER NAME: 2. RELATIONSHIP TO VETERAN:

I am the VETERAN’S LEGAL GUARDIAN (MUST submit copy of Court 3. I am the MILITARY SERVICE MEMBER OR VETERAN identified in Appointment) or AUTHORIZED REPRESENTATIVE (MUST submit copy of Section 1, above. Authorization Letter or Power of Attorney) I am the DECEASED VETERAN’S NEXT-OF-KIN (MUST submit OTHER (Specify): Proof of Death. See item 2a on instruction sheet.) 4. SEND INFORMATION/DOCUMENTS TO: (Please print or type. See item 4 on accompanying instructions.) 5. AUTHORIZATION SIGNATURE: I declare (or certify, verify, or state) Recordtrak / Magnals Legal Services Company under penalty of perjury under the laws of the United States of America that the information in this Section 3 is true and correct and that I authorize the release Name of the requested information. (See items 2a or 3a on the accompanying instructions 1111 Broadway, Suite 300 sheet. Without the Authorization Signature of the veteran, next-of-kin of deceased Street Address Apt. # veteran, veteran’s legal guardian, authorized government agent, or other authorized Oakland CA 94607 representative,archival. No signatureonly limitedis requiredinformationif the canrequestbe releasedis for archivalunless therecords.)request is City State ZIP Code (510) 465-3200 (510) 465-3652 Daytime Phone Fax Number Signature Required – Do not print Date rcu@magnals.com * This form is available at on the National Archives and Records Administration (NARA) website. * Email Address It is also my understanding that RECORDTRAK is required by court order to provide my attorneys with copies of my records for a 21 day first look before sending them to any defendant involved in my asbestos case. If the preliminary fact sheet indicates plaintiff will seek trial preference, or a motion for preference has been filed, the first look is 7 days.

EXHIBIT I – 11 AUTHORIZATION FOR MEDICAL RECORDS FROM MILITARY FACILITIES

November 13, 2024 ASBESTOS FORMS – Exhibit I - 11

SFCIV-030 Rev: November 13, 2024

EXHIBIT I – 12 AUTHORIZATION FOR VETERAN’S MEDICAL RECORDS

November 13, 2024 ASBESTOS FORMS – Exhibit I - 12

SFCIV-030 Rev: November 13, 2024

REQUEST FOR AND AUTHORIZATION TO RELEASE HEALTH INFORMATION

PRIVACY ACT STATEMENT:

The information requested on this form is solicited under Title 38 U.S.C. The form authorizes release of information in accordance with the Health Insurance
Portability and Accountability Act, 45 CFR Parts 160 and 164; 5 U.S.C. 552a; and 38 U.S.C. 5701 and 7332 that you specify. Your disclosure of the information
requested on this form is voluntary. However, if information needed to locate records for release is not furnished completely and accurately, VA will be unable to
comply with the request. The Veterans Health Administration may not condition the provision of treatment, payment, enrollment in the VA Health Care Program, or
eligibility for benefits on the signing of an authorization, except for research-related treatment where an authorization for the use or disclosure of individually-
identifiable health information for such research is required. VA may disclose the information that you put on the form as permitted by law. VA may make a
"routine use" disclosure of the information as outlined in the Privacy Act system of records notices identified as 24VA10A7 "Patient Medical Record - VA",
08VA05 "Employee Medical File System Records (Title 38)-VA" and in accordance with the Notice of Privacy Practices. VA may also use this information to
identify Veterans and person claiming or receiving VA benefits and their records, and for other purposes authorized or required by law.

TO: DEPARTMENT OF VETERANS AFFAIRS (Name and Location of the VA Health Care Facility)

LAST NAME- FIRST NAME- MIDDLE NAME DATE OF BIRTH (mm/dd/yyyy)

PATIENT'S MAILING ADDRESS (including City, State and Zip Code)

NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL, OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED
Recordtrak / Magna Legal Services 1111 Braodway, Ste 300, Oakland CA 94607

PURPOSE(S) OR NEED: Information is to be used by the requestor for:
TREATMENT BENEFITS x LEGAL EMPLOYMENT OTHER (Please specify below):

INFORMATION REQUESTED: Check applicable box(es) and state the extent or nature of information to be provided:
X HEALTH SUMMARY (Prior 2 Years)
X PATIENT MEDICAL RECORDS (Dates): DATES NEEDED BELOW
INPATIENT DISCHARGE SUMMARY (Dates):

X PROGRESS NOTES:
SPECIFIC CLINICS (Name & Date Range):

SPECIFIC PROVIDERS (Name & Date Range):
X DATE RANGE: DATES NEEDED BELOW
X OPERATIVE/CLINICAL PROCEDURES (Name & Date):

LAB RESULTS:

SPECIFIC TESTS (Name & Date):

DATE RANGE:

X RADIOLOGY REPORTS (Name & Date): DATES NEEDED BELOW
X LIST OF ACTIVE MEDICATIONS:
X VACCINATION (Dose, Lot Number, Date & Location):

ADMINISTRATIVE RECORDS: OTHER (Describe): All medical records, film, pathology, and/or cytology materials, paraffin blocks and slides, billing and payment X VA FORM information, Medicare & Medical payments from ________ to___ ______ OCT 2023 10-5345 Page 1 of 2

SFSC

LAST NAME - FIRST NAME- MIDDLE NAME DATE OF BIRTH (mm/dd/yyyy)

SENSITIVE DIAGNOSES: REVIEW AND, IF APPROPRIATE, COMPLETE WHEN RELEASE IS FOR ANY PURPOSE
OTHER THAN TREATMENT.

I request and authorize Department of Veterans Affairs to release the information pertaining to the condition(s) below for the non-treatment purpose(s)
listed in this authorization.
x DRUG ABUSE x ALCOHOLISM OR ALCOHOL ABUSE x SICKLE CELL ANEMIA
x HUMAN IMMUNODEFICIENCY VIRUS (HIV)

I understand that information on these sensitive diagnoses may be released for treatment purposes without me checking the above boxes, and will be
released even if the boxes are unchecked unless I indicate by checking the box below that I do not want this information released for this specific
disclosure.
I do not want sensitive diagnoses released for treatment purposes under this specific authorization. I realize this does not impact
other future requests unrelated to this authorization.

AUTHORIZATION: I certify that this request has been made freely, voluntarily and without coercion and that the information given above is
accurate and complete to the best of my knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this
authorization in writing, at any time except to the extent that action has already been taken to comply with it. Written revocation is effective upon
receipt by the Release of Information Unit at the facility housing records. Any disclosure of information carries with it the potential for
unauthorized redisclosure, and the information may not be protected by federal confidentiality rules.

I understand that the VA health care provider's opinions and statements are not official VA decisions regarding whether I will receive other VA
benefits or, if I receive VA benefits, their amount. They may, however, be considered with other evidence when these decisions are made at a VA
Regional Office that specializes in benefit decisions.

EXPIRATION: Without my express revocation, the authorization will automatically expire (select one of the following):

AFTER ONE-TIME DISCLOSURE, IF ALL NEEDS ARE SATISFIED

ON (mm/dd/yyyy) (enter a future date other than date signed by patient)
x UNDER THE FOLLOWING CONDITION(S): one year after date of execution

PATIENT SIGNATURE (Sign in ink) DATE (mm/dd/yyyy)

LEGAL REPRESENTATIVE SIGNATURE (if applicable) (Sign in ink) DATE (mm/dd/yyyy)

PRINT NAME OF LEGAL REPRESENTATIVE RELATIONSHIP TO PATIENT

FOR VA USE ONLY

TYPE AND EXTENT OF MATERIAL RELEASED

DATE RELEASED (mm/dd/yyyy) RELEASED BY:

VA FORM 10-5345, OCT 2023 It is my understanding that RECORDTRAK is required by law to provide my attorneys Page 2 of 2 with copies of my records for a 21 day first look before sending it to any defendant involved in my asbestos case. If the Preliminary Fact Sheet indicates plaintiff will seek preference, First Look is 7 days. SFSC

EXHIBIT I - 13 AUTHORIZATIONS FOR VETERAN’S DISABILITY CLAIMS RECORDS

November 13, 2024 ASBESTOS FORMS – Exhibit I - 13

SFCIV-030 Rev: November 13, 2024

REQUEST FOR AND AUTHORIZATION TO RELEASE HEALTH INFORMATION

PRIVACY ACT STATEMENT:

The information requested on this form is solicited under Title 38 U.S.C. The form authorizes release of information in accordance with the Health Insurance
Portability and Accountability Act, 45 CFR Parts 160 and 164; 5 U.S.C. 552a; and 38 U.S.C. 5701 and 7332 that you specify. Your disclosure of the information
requested on this form is voluntary. However, if information needed to locate records for release is not furnished completely and accurately, VA will be unable to
comply with the request. The Veterans Health Administration may not condition the provision of treatment, payment, enrollment in the VA Health Care Program, or
eligibility for benefits on the signing of an authorization, except for research-related treatment where an authorization for the use or disclosure of individually-
identifiable health information for such research is required. VA may disclose the information that you put on the form as permitted by law. VA may make a
"routine use" disclosure of the information as outlined in the Privacy Act system of records notices identified as 24VA10A7 "Patient Medical Record - VA",
08VA05 "Employee Medical File System Records (Title 38)-VA" and in accordance with the Notice of Privacy Practices. VA may also use this information to
identify Veterans and person claiming or receiving VA benefits and their records, and for other purposes authorized or required by law.

TO: DEPARTMENT OF VETERANS AFFAIRS (Name and Location of the VA Health Care Facility)

LAST NAME- FIRST NAME- MIDDLE NAME DATE OF BIRTH (mm/dd/yyyy)

PATIENT'S MAILING ADDRESS (including City, State and Zip Code)

NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL, OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED
Recordtrak / Magna Legal Services 1111 Braodway, Ste 300, Oakland CA 94607

PURPOSE(S) OR NEED: Information is to be used by the requestor for:
TREATMENT BENEFITS x LEGAL EMPLOYMENT OTHER (Please specify below):

INFORMATION REQUESTED: Check applicable box(es) and state the extent or nature of information to be provided:
x HEALTH SUMMARY (Prior 2 Years)
x PATIENT MEDICAL RECORDS (Dates): See dates needed below, including all hospital summary and outpatient treatment notes.
INPATIENT DISCHARGE SUMMARY (Dates):

PROGRESS NOTES:

SPECIFIC CLINICS (Name & Date Range):

SPECIFIC PROVIDERS (Name & Date Range):

DATE RANGE:

OPERATIVE/CLINICAL PROCEDURES (Name & Date):

LAB RESULTS:

SPECIFIC TESTS (Name & Date):

DATE RANGE:

RADIOLOGY REPORTS (Name & Date):

LIST OF ACTIVE MEDICATIONS:

VACCINATION (Dose, Lot Number, Date & Location):

ADMINISTRATIVE RECORDS: x OTHER (Describe):Any & all records including but not limited to disability claims, medical records & bills, pension records, veterans VA FORM benefits, Medicare & Medical payments, reimbursements & inquiries from _________ to _________ OCT 2023 10-5345 Page 1 of 2

SFSC

LAST NAME - FIRST NAME- MIDDLE NAME DATE OF BIRTH (mm/dd/yyyy)

SENSITIVE DIAGNOSES: REVIEW AND, IF APPROPRIATE, COMPLETE WHEN RELEASE IS FOR ANY PURPOSE
OTHER THAN TREATMENT.

I request and authorize Department of Veterans Affairs to release the information pertaining to the condition(s) below for the non-treatment purpose(s)
listed in this authorization.
x DRUG ABUSE x ALCOHOLISM OR ALCOHOL ABUSE x SICKLE CELL ANEMIA
x HUMAN IMMUNODEFICIENCY VIRUS (HIV)

I understand that information on these sensitive diagnoses may be released for treatment purposes without me checking the above boxes, and will be
released even if the boxes are unchecked unless I indicate by checking the box below that I do not want this information released for this specific
disclosure.
I do not want sensitive diagnoses released for treatment purposes under this specific authorization. I realize this does not impact
other future requests unrelated to this authorization.

AUTHORIZATION: I certify that this request has been made freely, voluntarily and without coercion and that the information given above is
accurate and complete to the best of my knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this
authorization in writing, at any time except to the extent that action has already been taken to comply with it. Written revocation is effective upon
receipt by the Release of Information Unit at the facility housing records. Any disclosure of information carries with it the potential for
unauthorized redisclosure, and the information may not be protected by federal confidentiality rules.

I understand that the VA health care provider's opinions and statements are not official VA decisions regarding whether I will receive other VA
benefits or, if I receive VA benefits, their amount. They may, however, be considered with other evidence when these decisions are made at a VA
Regional Office that specializes in benefit decisions.

EXPIRATION: Without my express revocation, the authorization will automatically expire (select one of the following):

AFTER ONE-TIME DISCLOSURE, IF ALL NEEDS ARE SATISFIED

ON (mm/dd/yyyy) (enter a future date other than date signed by patient)
x UNDER THE FOLLOWING CONDITION(S): one year after date of execution

PATIENT SIGNATURE (Sign in ink) DATE (mm/dd/yyyy)

LEGAL REPRESENTATIVE SIGNATURE (if applicable) (Sign in ink) DATE (mm/dd/yyyy)

PRINT NAME OF LEGAL REPRESENTATIVE RELATIONSHIP TO PATIENT

FOR VA USE ONLY

TYPE AND EXTENT OF MATERIAL RELEASED

DATE RELEASED (mm/dd/yyyy) RELEASED BY: VA FORM 10-5345, OCT 2023 It is my understanding that RECORDTRAK is required by law to provide my attorneys Page 2 of 2 with copies of my records for a 21 day first look before sending it to any defendant involved in my asbestos case. If the Preliminary Fact Sheet indicates plaintiff will seek preference, First Look is 7 days. SFSC

EXHIBIT I - 14 VA AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION TO A THIRD PARTY

November 13, 2024 ASBESTOS FORMS – Exhibit I - 14

SFCIV-030 Rev: November 13, 2024

OMB Approved No. 2900-0736 Respondent Burden: 5 minutes Expiration Date: 02/28/2026 VAY Department of Veterans Affairs (D0 nor Ware THIS SPACE) AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION TO A THIRD PARTY INSTRUCTIONS: Use this form if you want to give the Department of Veterans Affairs (VA) permission to release your personal beneficiary or claim information to a third party. This form may not be executed by any beneficiary recognized as incompetent for VA purposes, nor can VA accept this form from any beneficiary recognized as incompetent for VA purposes. SECTION | - VETERAN'S IDENTIFICATION INFORMATION NOTE: You may either complete the form online or by hand. If completed by hand print the information requested in ink, neatly, and legibly to expedite processing the form.

1. VETERAN'S NAME (First, Middle Initial, Last) LITITITITTTITITITITILILITITITITITITITITTItttit ty
2. VETERAN'S SOCIAL SECURITY NUMBER 3. VA FILE NUMBER (If known) 4. VETERAN'S DATE OF BIRTH (MM/DD/YYYY)
3. VETERAN'S SERVICE NUMBER (If applicable) SECTION Il - BENEFICIARY/CLAIMANT'S IDENTIFICATION INFORMATION
4. NAME OF BENEFICIARY/CLAIMANT WHO IS NOT THE VETERAN (First, Middle Initial, Last) LITITITITTITITITITILILCITITITITITITIITITIIttttit tl
5. ADDRESS OF BENEFICIARY/CLAIMANT (Number and Street or rural route, P.O. Box, City, State, ZIP Code and Country) see LETT TTT TT TtT Titi Titi tt ttt tti tt tt aptrunt number | | [Tt | w»LitTtTtTtTtTtttt tt ttt tt | State/Province LT] Country [TL] ZIP Code/Postal Code | | | | | |-| | | | |
6. TELEPHONE NUMBER (Include Area Code) [ | | | _ [ | | | _ [ | | | | Enter International Phone Number (Jf applicable)
7. EMAIL ADDRESS (Optional) oO | agree to receive electronic correspondence from VA in regards to my claim. SECTION Ill - CONTACT INFORMATION
8. VA IS AUTHORIZED TO DISCLOSE THE INFORMATION SPECIFIED BELOW TO ONE PERSON OR ONE ORGANIZATION LISTED BELOW. PROVIDE THE NAME AND ADDRESS OF THE PERSON YOU HAVE CHOSEN TO RECEIVE INFORMATION FROM VA IN ITEMS 10A AND 10B OR PROVIDE THE NAME AND ADDRESS OF THE ORGANIZATION YOU HAVE CHOSEN AND THE NAME OF THE ORGANIZATION'S REPRESENTATIVE IN ITEMS 10C AND 10D. A. NAME OF PERSON (First, Middle Initial, Last Name) LITITITITITITITITITILILCITTTITITITIITITIIttttt tl set LET TTT TTT Tt titi tTitTitT ttt itt t itt aptrunt number | TT Tt | wLitTtTtTttTtttt tt ttt tt | State/Province LT] Country [EE] ZIP Code/Postal Code | | | | | |-| | | | | NOTE: An organization may have more than one representative. Include the first and last name of any additional representatives. C. NAME OF ORGANIZATION (Include name of representative(s)) rR JE [c Jo[ RID TIRTATKT/ [MA [GIN Al [LEGA el Ts TeETRIv i Icle[s T ] [A|L[y][s[s[a] [clo[m][p{s[ Jor] [NTE 1[L] [clals|T{[R[o} [ | [ T 4 LTTTTTTT]T/7T>TT;]T1T~T7T;T{T]TT]T7TT{T]T]1[T } D. ADDRESS OF ORGANIZATION No. & svet L1f1fi [i] [BlRlolaAlp]wlaly] [sluli{rtel [3fofol | | | 1 | | | aptrunitnumber | | [| | [ | eyL [ | tT tt tt ttt tt tt tt tf State/Province Country ZIP Code/Postal Code | 9 [4 | 6 | 0 | 7 | - | | | | | tep20s3 ©-21-0845 SUPERSEDES VA FORM 21-0845, SEP 2016. Page 2

11. 1, THE VETERAN/BENEFICIARY/CLAIMANT AUTHORIZE VA TO CONTACT THE PERSON OR ORGANIZATION LISTED IN ITEM 10A OR 10C FOR THE PURPOSE OF PROVIDING THE FOLLOWING INFORMATION PERTAINING TO MY VA RECORD (Check only one box below to tell VA the specific benefit or claim information you want disclosed) (J LIMITED INFORMATION (Go to Item 12) Xl ANY INFORMATION (Go to Item 13)
12. IF YOU SELECTED LIMITED 5 1 7 1 1 6 417 260 145 16 96.513680 INFORMATION, CHECK ALL THAT APPLY: Oo Status of pending claim or appeal Oo Amount of money owed VA o Current benefit and rate Oo Request a benefit payment letter Oo Payment history o Change of address or direct deposit (1) Other (Specify below):
13. IF YOU SELECTED ANY 5 1 10 1 1 6 381 491 144 16 95.959099 INFORMATION, THE TERMS OF SUCH RELEASE OF INFORMATION WILL BE: oO One time only &l Ongoing until written notice is given to VA to terminate (J From the date of signing below until (Specify Date (MM/DD/YYYY)): | | | - | | | - | | | | | 14, SPECIFY THE SECURITY QUESTION YOU WANT USED WHEN VERIFYING THE IDENTITY OF YOUR DESIGNATED THIRD PARTY. CHECK ONLY ONE SECURITY QUESTION BOX IN ITEM 14A AND PROVIDE THE ANSWER IN ITEM 14B. A. SECURITY QUESTION B. ANSWER iva The city and state your mother was born in [Oo [A | KIL | A|NID] 5 | | ClA] | | | | | | | | | | | oO The name of the high school you attended | | | | | | | | | | | | | | | | | | | | | | | C1 Your trst pets name LETT TTTTTTTtTttttt tt tt ft | Oo Your favorite teacher's name | | | | | | | | | | | | | | [ | | | | | | | C1 Your fathers mide name LILTTTTTTTT TTT TTT tTtt ttt | SECTION IV - DECLARATION OF INTENT I CERTIFY THAT the statements on this form are true and correct to the best of my knowledge and belief.
14. VETERAN/BENEFICIARY/CLAIMANT'S SIGNATURE (REQUIRED) 16. DATE SIGNED (MM/DD/YYYY) L]J-LL_J-LI1[ 11 PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration as identified in the VA system of records, 58VA21/22/28 Compensation, Pension, Education, and Veteran Readiness and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by Federal Statute of law in effect prior to January 1, 1975, and still in effect. RESPONDENT BURDEN: We need this information to release your private benefit and/or claim information to a designated third party(ies). The execution of this form does not authorize the release of information other than that specifically described. The information requested on this form will authorize release of the information you specify. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 5 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form VA FORM 21-0845, FEB 2023 Page 3