Exhibit A - Advent hospital release — USA v. Edwards et al. (Dkt. 229-1, M.D. Fla.)

Summary

Exhibit A (Document 229-1), filed 10/18/24 in Case 6:22-cr-00201-AGM-LHP, is an Authorization for Release of Medical Information with a Federal Bureau of Prison Certification of Identity and Privacy Act Statement. The form names EDWARDS, EVAN as the currently or previously incarcerated individual and authorizes the U.S. Department of Justice to release information to, or obtain information from, a facility in New Smyrna Beach, Florida. The stated reason is continuation of care. It asks for a copy of the medical file on evaluation and treatment received from 07/01/2022 to 08/31/2022. A fax line reads Health Info Dept. FMC Devens.

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Case 6:22-cr-00201-AGM-LHP Document 229-1 Filed 10/18/24 Page 1of1PagelD
1364

eae! AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Ov

U.S. Department of Justice Federal Bureau of Prison
Certification of Identity
Privacy Act Statement. In accordance with 28 CFR Section 166. 41(d) personal data sufficient to identify the individuals submitting
requests by mail under the Privacy Act of 1974, 5 U.S.C. Section 552a, is required. The purpose of this solicitation is to ensure that the
record of individuals who are the subject of US Department of Justice systems of records are not wrongfully disclosed by the
Department. Failure to furnish this information will result in no action being taken on the request. False information on this form may

subject the requester to criminal penalties under 18 U.S.C. Section 1001 and/or 5 U.S.C. Section 552a(i)(3).

Public reporting burden for this collection of information is estimated to average 0.50 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Suggestions for reducing this burden may be sumitted to Director. Facilities and Administrative Services Staff,
Justice Management Division, US Department of Justice, Washington, DC 20530 and the Office of Information and Regulatory Affairs,
Office of Management and Budget, Public Use Reports Project (110370016), Washington, DC 20503.

Full Name Of Currently or Register Number Current Address
Previously Incarcerated Individual 73845-018

EDWARDS, EVAN

Date of Birth Place of Birth Social Security Number

| declare under penalty of perjury under the laws of the United States of America thal the foregoing is true and correct, and that | am
the person named above, and | understand that any falsification of this statement is punishable under the provisions of 18 U.S.C.
Section 1001 by a fine of not more than $10,000 or by imprisonment of not more than five years or both, and that requesting or
obtaining any recoid(s) under false pretenses is punishable under the provisions of 5 U.S.C. 552a(i)(3) by a fine of not more than
$5000,

Further, pursuant to 5 U.S.C. Section 552a(b), | authorize the U.S. Department of Justice to
[] release information to, OR obtain information from

Name/Facility: AdanceHealth New Smyrna Beach, Florida
Address: 401 Palmetto Street
City, State, Zip: New Smyrna Beach, Florida, 32168

| understand the information is to be used for (specific reason for release of information):

Continuation of care, or [__] Other

Information to be Released/Obtained: Copy of and/or information from my medical file pertaining to

my evaluation and treatment received from (dates): 07/01/2022 to 08/31/2022
This is to include: :
Complete Record [_] Discharge Summary |__| History & Physical Operative Reports
[| Consultations [| Progress Notes [ X-ray Reports C_] Pathology Reports
[__] Laboratory Reports [_] Actual Films Actual Slides
[__] Will be returned OR [_] Will be returned OR
C] Duplicates accepted Cc] Duplicates accepted

Signature

Signature of current or formerly
incarcerated Individual requesting the
release of his/her records.

Health Info Dept.
FMC Devens

42 Patton Rd,

Aver, MA 01432
Fax# 978-796-1537

DEV-—DEVENS FMC "Prescribed by P6031


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gov.uscourts.flmd.408844.229.1.pdf

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