Conn. Practice Book Form 219

The Defendant(s) hereby request(s) that the Plaintiff provide counsel for the Defendant(s) with

copies of the documents described in the following requests for production, or afford counsel for said

Defendant(s) the opportunity or, where requested, sufficient written authorization, to inspect, copy,

photograph or otherwise reproduce said documents. The production of such documents, copies or

written authorizations shall take place at the offices of __________________________ not later than

sixty (60) days after the service of the Requests for Production.

In answering these production requests, the Plaintiff(s) are required to provide all information within

their possession, custody or control. If any production request cannot be answered in full, answer to

the extent possible.

(1) All hospital records relating to treatment received as a result of the negligence alleged in the

Complaint, and to injuries, diseases or defects to which reference is made in the answers to Interrogatories #6 and #24 (exclusive of any records relating to mental health injuries or conditions), or written

authorization, sufficient to comply with the provisions of the Health Insurance Portability and Accountability Act (HIPAA), to inspect and make copies of the hospital records. Information obtained pursuant to

the provisions of HIPAA shall not be used or disclosed by the parties for any purpose other than the

above captioned action.

(2) All reports and records of all physicians and other health care providers relating to treatment

allegedly received by the Plaintiff(s) as a result of the negligence alleged in the Complaint and to the

injuries, diseases or defects to which reference is made in the answers to Interrogatories #7, #22,

and #24 (exclusive of any records relating to mental health injuries or conditions) or written authorization, sufficient to comply with the provisions of the Health Insurance Portability and Accountability Act

(HIPAA) to inspect and make copies of said reports. Information obtained pursuant to the provisions

of HIPAA shall not be used or disclosed by the parties for any purpose other than the above captioned action.

(3) If a claim of impaired earning capacity or lost wages is being alleged, copies of, or sufficient

written authorization to obtain copies of, that part of all income tax returns relating to lost income filed

by the Plaintiff(s) for a period of three (3) years prior to the date of the negligence alleged in the

Complaint and for all years subsequent to the date of the negligence alleged in the Complaint through

the time of trial.

(4) If a claim for lost wages or lost earning capacity is being made, copies of, or sufficient written

authorization to inspect and make copies of, the wage and employment records of all employers of

the Plaintiff(s) for three (3) years prior to the negligence alleged in the Complaint and for all years

subsequent to the date of the negligence alleged in the Complaint.

(5) A copy of any nonprivileged statement, as defined in Practice Book Section 13-1, of any party

to this lawsuit concerning this action or its subject matter.

(6) All medical bills that are claimed to have been incurred as a result of the negligence alleged in

the Complaint or written authorization, sufficient to comply with the provisions of the Health Insurance

No. CV- : SUPERIOR COURT

(Plaintiff): JUDICIAL DISTRICT OF

VS. : AT

(Defendant): (Date)

Portability and Accountability Act (HIPAA) to inspect and make copies of said medical bills. Information

obtained pursuant to the provisions of HIPAA shall not be used or disclosed by the parties for any

purpose other than the above captioned action.

(7) All bills for each item of expense that are claimed to have been incurred in the answer to

Interrogatories #20 and #30, and not already provided in response to Production Request #6.

(8) Copies of all documents pertaining to claims of right to reimbursement provided to the Plaintiff

by third-party payers, and copies of, or written authorization, sufficient to comply with the provisions

of the Health Insurance Portability and Accountability Act (HIPAA) to obtain any and all documentation

of payments made by a third party for medical services received or premiums paid to obtain such

payment. Information obtained pursuant to the provisions of HIPAA shall not be used or disclosed by

the parties for any purpose other than the above captioned action.

(9) All documents identified or referred to in the answers to Interrogatory #34 unless a claim of

confidentiality has been stated.

(10) Nonprivileged copies, whether in hard copies or electronic media, of any and all documentation

referenced in Interrogatory #40.

(11) A copy of each and every recording of surveillance material discoverable under Practice Book

Section 13-3 (c), by film, photograph, video, audio or any other digital or electronic means, of any

party to this lawsuit concerning this lawsuit or the subject matter thereof, including any transcript of

such recording.

(12) Copies of any and all documents and communications concerning any and all of your disability

claim(s) with the issuing governmental office as set forth in Interrogatory #43, excluding any material

which is claimed to be protected by attorney-client privilege or other applicable privilege. In addition,

written authorization, in the form attached, permitting the undersigned to obtain a full and complete

copy of the Plaintiff’s social security disability file.

(13) Any and all photographs or recordings identified in response to Interrogatory #41.

Requests for Production #14 through #19 apply in wrongful death cases:

(14) A copy of the probate appointment, identifying the Plaintiff as Administrator of the subject estate.

(15) A copy of the death certificate.

(16) A copy of any autopsy report and/or postmortem toxicology testing report.

(17) Copies of declarations of the Plaintiff that your attorney intends to use at time of trial pursuant

to General Statutes § 52-172.

(18) Any documents, written or digital recordings, entries, memoranda, and/or transcripts of digital

recordings offered pursuant to General Statutes § 52-174.

(19) Copies of or an authorization to obtain the records referenced in Interrogatory #45.

Request for Production #20 applies to cases involving a minor Plaintiff:

(20) Copies of all education records, attendance records, nurses’ records, and materials from each

day care, preschool, school, or other educational institution the minor Plaintiff has attended (exclusive

of any records relating to mental health injuries or conditions) for the last five years to the present or

written authorization in the form attached permitting the undersigned to inspect and to make copies

of said educational records.

DEFENDANT,

BY_____________________________

CERTIFICATION

I certify that a copy of this document was or will immediately be mailed or delivered electronically

or non-electronically on (date) _______ to all attorneys and self-represented parties of record and that

written consent for electronic delivery was received from all attorneys exempt from e-filing and self-represented parties of record who received or will immediately be receiving electronic delivery.

Name and address of each party and attorney that copy was or will immediately be mailed or

delivered to*

*If necessary, attach additional sheet or sheets with the name and address which the copy was or

will immediately be mailed or delivered to.

_________________________________________________________________________________

Signed (Signature of filer ) Print or type name of person signing Date Signed

________________________________________________________________________________

Mailing address (Number, street, town, state and zip code) or Email address, if applicable Telephone number

HISTORY—2026: In the first sentence of the certification, “exempt from e-filing” was added after “from all attorneys.”

COMMENTARY—2026: The changes to this form are consistent with the changes to the proof of service language in Section

10-14 (a).

EDUCATION / SCHOOL RECORDS AUTHORIZATION

TO:

(Any educational institution, including any school, special education program, remedial education

program, developmental program, including special treatment, teacher aides and assistance that has

provided educational services to):

___________________________________________________

(insert name above)

I hereby authorize you to release copies of the records of _______________________________,

including educational records to (**defense firm name**), or its authorized representative. ‘‘Educational

records’’ for purposes of this authorization shall include, but not be limited to, attendance records,

medical records, occupational therapy records, nurses’ notes, progress reports, teacher notes, report

cards, achievement scores, evaluations, teacher progress notes, transcripts, social worker’s records,

and correspondence.

This authorization does not expire until expressly withdrawn by the undersigned.

A copy of this authorization is deemed as valid as the original.

_______________________________________________________________________________

Signature of patient or patient’s representative Date

If a patient’s representative signs this authorization, please complete the following:

________________________________________________________________________________

Printed name of patient’s representative: Relationship to patient

DAY CARE / CHILDCARE / HOME CARE RECORDS AUTHORIZATION

TO:

(Any day care, childcare, home care provider that has provided services to)

___________________________________________________

(insert name above)

I hereby authorize you to release copies of the records of _______________________________,

including educational records to (**defense firm name**), or its authorized representative. ‘‘Records’’

for purposes of this authorization shall include, but not be limited to, attendance records, medical

records, occupational therapy records, nurses’ notes, progress reports, teacher notes, report cards,

achievement scores, evaluations, teacher progress notes, transcripts, social worker’s records, and

correspondence.

This authorization does not expire until expressly withdrawn by the undersigned.

A copy of this authorization is deemed as valid as the original.

_______________________________________________________________________________

Signature of patient or patient’s representative Date

If a patient’s representative signs this authorization, please complete the following:

_______________________________________________________________________________

Printed name of patient’s representative: Relationship to patient