12 records requests, already written and signed

January 1, 1970

Health Information Management / Medical Records
[Provider name]
[Address]

Re: Patient request for access to the complete designated record set — Jacob Thomas Raab

I am the patient. Under my right of access at 45 CFR § 164.524, I request a complete copy of my designated record set for the entire period of my care with your organization, with no date limitation.

Please provide the records electronically, in the readily producible electronic format of your choice, delivered to the email address in my signature block or by secure download link. Electronic delivery keeps the permitted fee at the cost-based minimum, and I request an itemized statement of any fee before it is charged.

Specifically, I request:

1. All clinical notes, progress notes, consultation notes, history and physicals, and discharge summaries.
2. All laboratory, pathology and diagnostic results, and all imaging studies including the images themselves, not only the reports.
3. All medication and prescribing history, immunization records, and allergy documentation.
4. All emergency department records, ambulance or EMS run reports, operative and anesthesia records.
5. All billing records and itemized statements for the same period.
6. An accounting of disclosures under 45 CFR § 164.528, identifying every party to whom my information was disclosed.

If any portion is withheld, please identify what is withheld and the specific legal basis. If your organization does not hold my records, please state that in writing so my file is complete.

Please confirm receipt of this request and the date your 30-day period begins.

Signed electronically on January 1, 1970,

/s/ Jacob Thomas Raab
Jacob Thomas Raab
383 Spruce Avenue, Niagara Falls, NY 14301
JustAsk@dbatr.com

This request is signed electronically. An electronic signature has the same force and effect as a handwritten signature under the federal E-SIGN Act (15 U.S.C. § 7001) and New York’s Electronic Signatures and Records Act (State Technology Law art. 3).

January 1, 1970

Privacy Officer
[Provider name]
[Address]

Re: Request for an accounting of disclosures of my protected health information — Jacob Thomas Raab

I am the patient. Under 45 CFR § 164.528 I request an accounting of every disclosure of my protected health information for the six years preceding this request, or for the full period your organization has held my records if that period is shorter.

This is a separate right from my right of access, and it is the part I care about most: not only what is in my file, but who was given it, when, and on what authority.

Specifically, I request:

1. The date of each disclosure.
2. The name and address of each person or entity that received my information.
3. A brief description of what was disclosed.
4. The purpose of each disclosure, or a copy of the written request or authorization relied upon.
5. Every disclosure made to any court, prosecutor, probation department, child protective agency, attorney, monitoring vendor, insurer or law enforcement agency, identified by name.
6. For electronic records, the access and audit log showing each user or system that viewed or exported my record, to the extent your system produces it.

If any disclosure was made without my authorization, state the specific permission in the Privacy Rule that your organization relied upon for that disclosure.

If your organization made no disclosures in this period, please say so in writing, so my record of this request is complete either way.

This accounting is being assembled for use in pending proceedings. Please also treat this letter as notice to preserve the underlying disclosure records and audit logs.

Signed electronically on January 1, 1970,

/s/ Jacob Thomas Raab
Jacob Thomas Raab
383 Spruce Avenue, Niagara Falls, NY 14301
JustAsk@dbatr.com

This request is signed electronically. An electronic signature has the same force and effect as a handwritten signature under the federal E-SIGN Act (15 U.S.C. § 7001) and New York’s Electronic Signatures and Records Act (State Technology Law art. 3).

January 1, 1970

Records Custodian
[Program name]
[Address]

Re: Patient request for my own treatment records — 42 CFR Part 2 — Jacob Thomas Raab

I am the patient and I am requesting my own records. This request is made both under my HIPAA right of access at 45 CFR § 164.524 and, because your program may be federally assisted, as a written authorization from me under 42 CFR Part 2 for disclosure of my records to me at the address in my signature block.

This authorization is limited to disclosure to me. It authorizes no redisclosure to any third party. It remains effective for 180 days from the date signed unless I revoke it earlier in writing.

Specifically, I request:

1. Intake and assessment documents, treatment plans and updates.
2. All progress and counseling notes, and all case management notes.
3. Discharge summaries, aftercare plans and completion certificates.
4. All toxicology and screening results.
5. Every report, letter or compliance statement your program sent to any court, probation department, agency or attorney concerning me, and the date it was sent.

Please deliver electronically where possible. If a Part 2 consent on your own form is required, send it to the email in my signature block and I will return it signed electronically the same day.

Signed electronically on January 1, 1970,

/s/ Jacob Thomas Raab
Jacob Thomas Raab
383 Spruce Avenue, Niagara Falls, NY 14301
JustAsk@dbatr.com

This request is signed electronically. An electronic signature has the same force and effect as a handwritten signature under the federal E-SIGN Act (15 U.S.C. § 7001) and New York’s Electronic Signatures and Records Act (State Technology Law art. 3).

January 1, 1970

Records Access Officer
[Agency name]
[Address]

Re: Freedom of Information Law request — records concerning Jacob Thomas Raab

Under the New York Freedom of Information Law, Public Officers Law §§ 84–90, I request copies of the records described below. I am the subject of these records, so the personal privacy exemption does not apply to my own information.

Specifically, I request:

1. All incident, arrest, supplemental and investigative reports naming me, for the dates identified above.
2. All body-worn camera, in-car camera, station and holding-area video and audio.
3. All 911 call audio, dispatch (CAD) logs and radio traffic for each incident.
4. All property, evidence and vehicle records, including tow, impound and inventory documentation.
5. All booking, custody, classification and facility medical records concerning me.
6. All communications between your agency and any other agency, prosecutor, probation department or monitoring vendor concerning me.
7. All monitoring device data, alerts, vendor logs and maintenance records for any device applied to me.

Please provide records in electronic form to the email address in my signature block. If any record is withheld in whole or part, state the specific exemption claimed and the particularized reason, and provide all reasonably segregable portions.

This letter also serves as written notice to preserve all responsive records, including video subject to any retention or overwrite schedule, pending completion of this request and any appeal.

If the response exceeds five business days without an acknowledgment and a date certain, I will treat it as a constructive denial and file an administrative appeal.

Signed electronically on January 1, 1970,

/s/ Jacob Thomas Raab
Jacob Thomas Raab
383 Spruce Avenue, Niagara Falls, NY 14301
JustAsk@dbatr.com

This request is signed electronically. An electronic signature has the same force and effect as a handwritten signature under the federal E-SIGN Act (15 U.S.C. § 7001) and New York’s Electronic Signatures and Records Act (State Technology Law art. 3).

January 1, 1970

FOIA/Privacy Act Officer
[Agency name]
[Address]

Re: FOIA and Privacy Act request for records about myself — Jacob Thomas Raab

Under the Freedom of Information Act, 5 U.S.C. § 552, and the Privacy Act, 5 U.S.C. § 552a, I request all records maintained by your agency about me, in every system of records, without date limitation. I am the subject of the request and my signed certification of identity is enclosed.

Specifically, I request:

1. All records in any system of records indexed to my name, including cross-references.
2. Any identity history summary or criminal history record your agency maintains about me, with the procedure to challenge or correct an entry.
3. All travel, border-crossing, inspection and secondary-screening records concerning me.
4. All benefit, claim, earnings and determination records concerning me.
5. All correspondence between your agency and any state or local agency about me.

I request a fee waiver or, at minimum, treatment as a non-commercial requester; if fees will exceed $25, notify me first. I request electronic production.

If records are withheld, identify the exemption for each and provide all reasonably segregable material. I request a Vaughn-style index of anything withheld in full.

Signed electronically on January 1, 1970,

/s/ Jacob Thomas Raab
Jacob Thomas Raab
383 Spruce Avenue, Niagara Falls, NY 14301
JustAsk@dbatr.com

This request is signed electronically. An electronic signature has the same force and effect as a handwritten signature under the federal E-SIGN Act (15 U.S.C. § 7001) and New York’s Electronic Signatures and Records Act (State Technology Law art. 3).

January 1, 1970

Consumer Disclosure Department
[Consumer reporting agency]
[Address]

Re: Request for complete file disclosure under FCRA § 609 — Jacob Thomas Raab

Under 15 U.S.C. § 1681g I request a complete disclosure of all information in my file, and under § 1681j I invoke my right to receive it free of charge for the current twelve-month period. This request covers every file, product and database your organization maintains about me, including any specialty report.

Specifically, I request:

1. The full contents of my consumer file, including all identifying information you associate with me and any aliases or addresses attached to my record.
2. The sources of all information in the file.
3. Every inquiry and every disclosure of my file in the maximum period the statute requires, with the identity of each recipient.
4. Any criminal, eviction, tenancy, employment-verification, insurance-loss, medical-information or check-and-banking data you maintain about me.
5. Any score you sell about me, the range, and the key factors that affected it.

If any item in the file is inaccurate, incomplete or cannot be verified, I will dispute it in writing and expect reinvestigation within 30 days under 15 U.S.C. § 1681i. If any item was already deleted after a dispute, confirm it has not been reinserted.

Please state, in writing, whether your organization maintains any file about me at all, so my record of this request is complete either way.

Signed electronically on January 1, 1970,

/s/ Jacob Thomas Raab
Jacob Thomas Raab
383 Spruce Avenue, Niagara Falls, NY 14301
JustAsk@dbatr.com

This request is signed electronically. An electronic signature has the same force and effect as a handwritten signature under the federal E-SIGN Act (15 U.S.C. § 7001) and New York’s Electronic Signatures and Records Act (State Technology Law art. 3).

January 1, 1970

Registrar / Custodian of Education Records
[Institution]
[Address]

Re: Request to inspect and receive copies of my education records — Jacob Thomas Raab

Under FERPA, 20 U.S.C. § 1232g and 34 CFR part 99, I request copies of all education records your institution maintains about me, for all years of attendance.

Specifically, I request:

1. Complete cumulative file and official transcripts.
2. Any IEP, 504 plan, evaluation, referral or related-services documentation.
3. Attendance and discipline records.
4. Standardized testing and assessment results.
5. Financial aid file and any account or collection records.
6. A list of every party to whom my education records were disclosed, and the purpose.

Please deliver electronically. If you believe any item is not an education record, identify it and the basis for that position.

Signed electronically on January 1, 1970,

/s/ Jacob Thomas Raab
Jacob Thomas Raab
383 Spruce Avenue, Niagara Falls, NY 14301
JustAsk@dbatr.com

This request is signed electronically. An electronic signature has the same force and effect as a handwritten signature under the federal E-SIGN Act (15 U.S.C. § 7001) and New York’s Electronic Signatures and Records Act (State Technology Law art. 3).

January 1, 1970

Human Resources
[Employer]
[Address]

Re: Request for my complete personnel and payroll file — Jacob Thomas Raab

I was employed by your organization during the period noted above. I request a complete copy of my personnel and payroll file.

Specifically, I request:

1. Application, offer letter, job descriptions and any agreements I signed.
2. All performance reviews, commendations, warnings and disciplinary documents.
3. Complete pay history, wage statements, W-2 or 1099 records and benefit enrollment records.
4. Separation documents, final pay records and any statement your organization provides in response to employment verification.
5. Any workers’ compensation, disability, leave or accommodation documentation.
6. Any record of complaints made by me or about me, and the outcome.

Electronic delivery to the email in my signature block is preferred. If your policy limits what may be released, please provide everything releasable and identify the remainder.

Signed electronically on January 1, 1970,

/s/ Jacob Thomas Raab
Jacob Thomas Raab
383 Spruce Avenue, Niagara Falls, NY 14301
JustAsk@dbatr.com

This request is signed electronically. An electronic signature has the same force and effect as a handwritten signature under the federal E-SIGN Act (15 U.S.C. § 7001) and New York’s Electronic Signatures and Records Act (State Technology Law art. 3).

January 1, 1970

Custodian of Records / General Counsel
[Recipient]
[Address]

Re: Notice to preserve records and electronically stored information — Jacob Thomas Raab

This letter is formal notice to preserve, and to suspend any routine destruction, overwrite, purge or retention-schedule deletion of, all records and electronically stored information relating to me and to the events identified above. Proceedings are pending and further proceedings are anticipated, and these materials are relevant to them.

Specifically, I request:

1. All video and audio, including body-worn and in-car camera, facility, holding-area and interview recordings, and all 911 and radio audio.
2. All reports, notes, logs, dispatch records and internal communications, including email, text and messaging platforms.
3. All monitoring-device data, alerts, calibration and maintenance records, and vendor communications.
4. All medical, treatment and custody records, including access and audit logs showing who viewed them.
5. All metadata, audit trails, backups and archived copies of the above.

Please confirm in writing, within ten days, that a hold is in place, and identify the custodian responsible. Failure to preserve after this notice may support a claim of spoliation and the remedies that follow from it.

This notice does not request production. A separate records request follows or has already been served.

Signed electronically on January 1, 1970,

/s/ Jacob Thomas Raab
Jacob Thomas Raab
383 Spruce Avenue, Niagara Falls, NY 14301
JustAsk@dbatr.com

This request is signed electronically. An electronic signature has the same force and effect as a handwritten signature under the federal E-SIGN Act (15 U.S.C. § 7001) and New York’s Electronic Signatures and Records Act (State Technology Law art. 3).

January 1, 1970

Internal Revenue Service — RAIVS Team
[Service center address]

cc: Social Security Administration, Office of Earnings Operations

Re: Request for wage and income transcripts and certified earnings record — Jacob Thomas Raab

I request wage and income transcripts and account transcripts for each tax year listed above, together with verification of non-filing for any year in which no return was filed. A signed Form 4506-T is enclosed.

Separately, and to the Social Security Administration, I request a certified statement of my complete earnings record for all years, showing reported earnings by year and employer.

These records are needed to establish actual income for a support proceeding in which an income figure was attributed to me without evidentiary support. A year showing no reported wages is the direct answer to that figure, so completeness by year matters more than speed.

Please deliver electronically where available.

Signed electronically on January 1, 1970,

/s/ Jacob Thomas Raab
Jacob Thomas Raab
383 Spruce Avenue, Niagara Falls, NY 14301
JustAsk@dbatr.com

This request is signed electronically. An electronic signature has the same force and effect as a handwritten signature under the federal E-SIGN Act (15 U.S.C. § 7001) and New York’s Electronic Signatures and Records Act (State Technology Law art. 3).

January 1, 1970

New York State Department of Motor Vehicles
[Records / Administrative Appeals address]

Re: Request for certified driving record and complete administrative file — Jacob Thomas Raab

I request my complete driver record and administrative file, certified where certification is available.

Specifically, I request:

1. Certified lifetime driving abstract and full license and permit history.
2. All suspension, revocation and reinstatement notices, with the date each was mailed and the address used.
3. The complete file of any administrative hearing concerning me, including the transcript, the hearing officer’s findings, and any Administrative Appeals Board decision.
4. All ignition interlock records, including installation, calibration, service and reported events.
5. All Driver Responsibility Assessment records and payment history.
6. All correspondence between the Department and any court, prosecutor or program concerning me.

If any appeal window is measured from a mailing date, please state that date expressly, since the timeliness of my appeal depends on it.

Signed electronically on January 1, 1970,

/s/ Jacob Thomas Raab
Jacob Thomas Raab
383 Spruce Avenue, Niagara Falls, NY 14301
JustAsk@dbatr.com

This request is signed electronically. An electronic signature has the same force and effect as a handwritten signature under the federal E-SIGN Act (15 U.S.C. § 7001) and New York’s Electronic Signatures and Records Act (State Technology Law art. 3).

January 1, 1970

Records Custodian / Privacy Officer
[Record holder]
[Address]

Re: Request to amend an inaccurate record, and to notify everyone who received it — Jacob Thomas Raab

The record identified above contains an entry that is inaccurate or incomplete. I request that it be amended, and that the amendment be sent to every party that previously received the erroneous version.

Where this is a health record, I make this request under 45 CFR § 164.526 and request the amendment be linked to the designated record set. Where this is a consumer report, I dispute the item under 15 U.S.C. § 1681i and request reinvestigation and deletion of anything that cannot be verified. Where this is an agency record, I request correction under that agency’s Privacy Act or equivalent procedure.

Specifically, I request:

1. Amend or delete the specific entry identified above, and state in writing what was changed.
2. Identify every person and organization that received the erroneous version, and send each of them the corrected version.
3. Confirm the corrected record is what will be produced in response to any future request, and that the prior version will not be reinserted.
4. If the amendment is denied, provide the denial in writing with the basis, and include my statement of disagreement in the record going forward.

A correction that stops at one system is not a correction. The propagation step is the part I am asking you to document.

Signed electronically on January 1, 1970,

/s/ Jacob Thomas Raab
Jacob Thomas Raab
383 Spruce Avenue, Niagara Falls, NY 14301
JustAsk@dbatr.com

This request is signed electronically. An electronic signature has the same force and effect as a handwritten signature under the federal E-SIGN Act (15 U.S.C. § 7001) and New York’s Electronic Signatures and Records Act (State Technology Law art. 3).