22 ORCHARD STREET - ILLNESS COMPLAINT The Law offices of i . And Affiliates" P.C.
FOR OVER25YEARS FIGHTING
�. THE BIG INSURANCE COMPANIES
1 AFFILIATED OFFICES THROUGHOUT
June 28, 2024 RECEIVE?
Salem Board of Health
98 Washington Street, 31d Floor JUL 43 2024
Salem, MA 01970
CITY OF SALEM
Attention: Maureen Davis, Principal Clerk BOARD OF HEALTH
Re: Our Client: Charles O'Connell
22 Orchard Street
Salem, MA 01970
Date of Accident: 06/16/2024
Dear Sir or Ms.:
Please be advised that this office represents Charles O'Connell with reference to illness he
sustained from a food purchase at the Clam Shack at 200 Fort Ave, Salem, MA 01970 which
occurred on June 16, 2024.
Please note Charles was at your office to verbally report this incident on June 17, 2024 at
between 9:00 AM and 11:00 AM.
Request is hereby made for a copy of all reports made on the matter.
Enclosed, please find a self-addressed envelope for you to send the documents back in.
Also enclosed is a signed authorization from Charles O'Connell to disclose the report(s).
Thank you for your anticipated cooperation.
Very truly yours,
THE LAW OFFICES OF
BARRY FEINS EIN &AFFILIATES, P.C.
Barry Feinstein, quire
BAF/ka
THE LAW OFFICES OF BARRY FEINSTEIN&AFFILIATES,P.C. •P.O.BOX 6049, 100 LOWELL STREET,PEABODY,MA 01960
Phone: (978) 531-7450•Toll Free: (800)262-9200.FAX:(978)531-7123 .Email:barry@barryfeinstein.com•www.barryfeinstein.com
*Licensed in Massachusetts only **Affiliated Offices Throughout Massachusetts tAffiliated Partners in ME,NH,CT and RI
DocuSign Envelope ID:FC04DAlD-616E4961-ACD0492541DD5330
AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION
1.I Hereby authorize S�t1�. S��/oard G+ ��1`� to use or disclose the following protected
I Name of hospitallphysician
health information from the medical records of the patient listed below.I understand that information used or disclosed pursuant to
this authorization could be subject to redisclosure by the recipient and,if so may not be subject to federal or state law protecting its
confidentiality. /
2.Patient name: Charles O'Connell Date of Birth: r,_l���! 11 5 1u
Address: 22 Orchard Street Salem MA 01970
Street City State Zip
3.Information to be disclosed to: Barry A. Feinstein_ & Affiliates. P.C.
Name
100 Lowell Street P.O. Box 6049
Address
Peabody MA 01961-6049
City State 'Lip
4. Disclose the following information for treatment dates: (0//1 10! L d� 1 to present
❑Complete Records d Consult Q Physical Therapy
❑Discharge Summary ❑X-Ray ❑Emergency Reports
❑History&Physical Q Laboratory A Other Specified n�l eV)
❑Outpatient Reports Q Pathology
5.The above information is disclosed for the following purposes:
❑Medical Care 6 Legal ❑Insurance ❑Personal U Other
6.1 understand I may revoke this authorization at any time by requesting such of the above referenced hospital/physician practice in
writing,unless action had already been taken in reliance upon it,or during a contestability period under applicable law.
Aeation expires on(upon) resolution of my case (Insert applicable date or event).
(,6v{ S l� I t U (0 2 7 2 dZ q
8.Signature of Patient or Legal Representative 9.Date
Charles O'Connell Self
Printed name of patient or patient's representative 10.Relationship to patient or authority to act for patient
IMPORTANT: THIS AUTHORIZATION SHALL BE DEEMED INVALID UNLESS
ALL NUMBERED ENTRIES ARE COMPLETED
N.B.In certain situations,an additonal authorization to release sensitive,legally protected information may be required.
A copy of this authorization is to be accepted by you in Lieu of an original.
lffiliates, P.C.
J; The Law offices of Barry Feinstein" And
! OvER2,5YEARS FIGHTING THE
BIG
IIANCE COMPANIES
FAFFILIATED OFFICES THROUGHOUT
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