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FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019
NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020
EXHIBIT B
FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019
eeplaw.com
NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020
80 Pine Street, 38
Floor
New York, New York 10005
T. 212.532.1116F.212.532.1176
New Jersey Office
576 Main Street, Suite C
Chatham,New Jersey 07928
ELEFTERAKIS JOHN ELEFTERAKIS'
ELEFTERAKIS NICHOLASELEFTERAKIS
RAYMONDPANEK
OLIVERR.TOBIAS
JEFFREYB. BROMFELD
FAlZANGHAZNAVI
GABRIELP. HARVIS
BAREEN. FETT
STEPHENKAHN
EVANM. LA PENNA
KRISTENPERRY- CONIGLIARO
AIKA DANAYEVA
ARIANAELEFTERAKlS
MICHAELINDELICATO
MICHAELMARRON
DOMINICKMINGIONE
MARKNEWMAN
AGGELIKIE. NlKOLAIDIS
JOSEPHPERRY
MARiELOUISEPRIOLO *
GOLDBERG SEGALLA
KEYONTESUTHERLAND
P.O.Box 780 WAYNEWATTLEY
Buffalo, New York 14201
*AlsoAdmitted In New Jersey
May O , 2020
Re: CORDERO v. HP MARCUS GARVEY PRESERVATION
HOUSING COMPANY, INC. et al.
Index No.: 514351/2019
Dear Counselors:
Our office is in receipt of your letter dated March 6, 2020. Enclosed herein, please find
authorizations for the following providers:
1. Big Apple Pain Management;
2. Brooklyn Medical Practice, P.C.;
3. Community Medical Imaging;
4. Island Ambulatory Surgical Center;
5. Kings County Hospital;
6. North Shore Family Chiropractic, P.C.;
7. Premier Home Health Care Services;
8. South Nassau Conununities Hospital;
9. Stand Up MRI of Brooklyn, P.C.;
10. The Charter Oak Fire Insurance Company; and
11. Bella Donna Medical.
If you have any further questions, please contact the undersigned.
Best,
{ia6rielle Cilea | Paralegal
FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019
NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020
OCA OfficialForm No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York StateDepartment of Health]
PatientName umber
Ariadni Cordero
PatientAddress
2505 Bedford Avenue 2E Brooklyn, New York 11226
I,or my authorized representative,request thathealth information regarding my careand treatment be released as set forthon thisform:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portabilityand AccountabiEty Act of 1996
that·
(HIPAA), T understand
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except CONFIDENTIAL HIV* RELATED INFORMATION
TREATMENT, psychotherapy notes, and only ifI place my initials
on
the appropriate line in Item 9(a). Inthe event the health information described below includes any of these types of information, and I
initialthe lineon the box in Item 9(a),Ispecifically authorizerelease of such information to theperson(s) indicated in Item 8.
2. If Iam authorizing the release of HIV-related, alcohol or drug trcescr , or mental health treatment infcimation, the recipientis
prohibited from redisclosingsuch information without my authorization unless permitted todo so under federal orstate law.I understand
thatI have the right to requesta listofpeople who may receive or use my HIV-related information without authorization. IfI experience
discrimination because of the releaseor disclosure of HIV-related information, Imay contact the New York State Division of Human
Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies areresponsible for
protecting my rights.
3. Ihave the rightto revoke thisauthorization atany time by writing to the health care provider listedbelow. I understand that Imay
revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization.
4. I understand thatsigning this authorization isvoluntary. My treatment, payment, enrollment ina health plan,or aligibilityfor benefits
willnot be conditioned upon my authorization of thisdisclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protected by federal orstate law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address ofhealth provider or entityto releasethis information:
Big Apple Pain Management/ Dr. Richard Apple, M.D., 410 Ditmas Ave., Brooklyn, NY 11218
8. Name and address ofperson(s) or category of person to whom thisinformation will be sent:
Goldberg Segalla, P.O. Box 780, Buffalo, New York 14201
9(a).Specific information to be released:
Medical Record from (2/7/2019) to(Present)
EntireMedical Record, including patienthisteries,officenotes (except psychotherapy notes),testresults,radiology studies,films,
consults,
referrals, billingrecords, in=rance records,and records sent toyou by otherhealth care providers.
Include: (Indicateby Initialing)
Other: also includeany diagnostic film(s) and report(s),any OAlcohol/Drug Treatment
billingrecords from DOA present
till O atal Health Information
-R_,elatedinformation
Authorization to Discuss Health Information
By here
initialing I authorize
Initials
to discussmy health information with my attorney, or a governmental agency, listhere:
10.Reason for releaseof infonnation: 11.Date or event on which thisauthorization will expire:
OAt request of individual End of Litigation
Other· Litigation
12. Ifnot thepatient,name of person signing form: 13.Authority tosign on behalf of patient:
Michael Marron, Esq. forElefterakis, Elefterakis & Panek Power ofAttorney
All items on thisform have been cc=p'c:cd and my questions about thisform have been answered. In addition, I have been provided a
copy of theform.
Date: - \f 10%
Signature of patientor representativeauthorized by law.
* Human Virus thatcauses AIDS. The New York State Public Health Law protects information which
Immunodeficiency reasonably
could identifysomeone as having HIV symptoms or infectionand infonnation regarding a person's contacts.
FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019
NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020
OCA OfficialForm No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York StateDepartment of Health]
Patient Name Social Securi Number
Ariadni Cordero
Patient Address
2505 Bedford Avenue 2E Brooklyn, New York 11226
I,or my authorized representative,request thathealth information regarding my care and treatment be released as set forthon this form:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portabilityand AccountabiHty Act of 1996
(HIPAA), I understand that:
1. This authorization may include disclosure of informativü relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION
TREATMENT, psychotherapy notes, only ifI place my initials
on
the appropriate linein Item 9(a). Inthe event the health information described below includes any of these types of information, and I
initial
the lineon thebox inItem 9(a), I specifically
authorize release of such information tothe person(s) indicated in Item 8.
2. If Iam authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
prohibited from redisclosing such information without my authorization unless permitted todo so under federalor statelaw. I understand
thatI have the rightto request a list
of people who may receive or use my HIV-related information without authorization. IfI experience
discrimination because of the release or disclosure ofHIV-related information, Imay contact the New Yodc State Division of Human
Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for
protecting my rights.
3. I have the rightto revoke this authorization atany time by writing to the health care provider listedbelow. I understand that Imay
revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization.
4. Iunderstand thatsigning thisauthorization isvoluntary. My treatment, payment, enrolhnent in a health plan,or eligibilityfor benefits
willnot be conditioned upon my authorizationof thisdisclosure.
5. Information disclosed under this authorizationmight be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosuremay no longer be protected by federal orstatelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of healthprovider orentity to releasethisinformation:
Brooklyn Medical Practice PC, 410 Ditmas Avenue, Brooklyn, New York 11218
8. Name and address of person(s) orcategory ofperson towhom thisinformation will be sent:
Goldberg Segalla, P.O. Box 780, Buffalo, New York 14201
9(a).Specific information to be released:
Medical Record from (2/7/2019) to(Present)
EntireMedical Record, including patienthistories,office notes (except psychotherapy notes),testresults,radiology studies,films,
referrals,
consults, billingrecords, insurance records, and records sent toyou by otherhealth care providers.
Include: (Indicateby Initialing)
Other: also includeany diagnostic film(s)and report(s),any ¤Alcohol/Drug Treatment
billingrecords from DOA till
present Mental nTormation
- elated Information
Authorization to Discuss Health Information
By here
initialing I authorize
Initials
to discussmy health information with my attorney, or a govemmcñtal agency, listhere:
10.Reason forrelease of information: 11.Date orevent on which thisauthorization willexpire:
At request of individual End of Litigation
Other·
Litigation
12. Ifnot thepatient,name of person signing form: 13.Authority to sign on behalf of patient:
Michael Marron,Esq. for Elefterakis, Elefterakis & Panek Power of Attorney
All items on this form have been completed and my questions about thisform have been answered. In addition, I have been provided a
copy of theform.
Date:
Signature of patient or representativeauthorized by law.
* Human Virus that causes AIDS. The New York State
Immunodeficiency Public Health Law protects information which rea-ahly
could identifysomeone as having HIV symptoms or infectionand information regarding a person's contacts.
FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019
NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020
OCA OfficialForm No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York State Department of Health]
Patient Name Number
Ariadni Cordero
Patient Address
2505 Bedford Avenue 2E Brooklyn, New York 11226
I,or my authorized representative,request thathealth infe-a*ion regarding my careand treatment be released as setforthon thisform:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accoüñtability Act of 1996
(HIPAA), I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION if I place
TREATMENT, psychotherapy notes, only my initials
on
the âpprepriate linein Item 9(a). In theevent the health infonnation described below includes any of these types of information, and I
initial
theline on thebox in Item 9(a),Ispecifically authorizerelease of such information tothe person(s) indicated in Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipientis
prohibited from redisclosing such iñformation without my authorization unless permitted to do so under federal orstate law.I understand
thatI have the rightto request a list
of people who may receive or use my HIV-related information without authorization. IfI experience
discrimination because of the releaseor disclosure of HIV-related information, Imay contact the New York State Division of Human
Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies areresponsible for
protecting my rights.
3. Ihave the rightto revoke thisauthorization atany time by writing to the health care provider listedbelow. I understand that Imay
revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization.
4. I understand thatsigning this authorizationisvoluntary. My treatment, payment, enrollment in a health plan, or for
cligibility benefits
willnot be conditioned upon my authorizationof thisdisclosure.
5. Information disclosed under this authorizationmight be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protected by federal orstatelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of health provider or entityto release thisinformation:
Community Medical Imaging, 234-28A Merrick Blvd, Rosedale, NY 11422
8. Name and address of person(s) orcategory of person to whom thisinformation will be sent:
Goldberg Segalla, P.O. Box 780, Buffalo, New York 14201
9(a).Specific information to be released:
Medical Record from (2/7/2019) to (Present)
OEntire Medical Record, including patienthistories,office notes (except psychotherapy notes),testresults,radiology studies, films,
referrals,consults,billingrecords, insurance records, and records sent toyou by other healthcare provides.
Include: (Indicateby Initialing)
Other: also include any diagnostic film(s)and report(s),any Alcohol/Drug Treatment
billingrecords from DOA till
present Mental Health Informajion
flIV-Related Inferrñ'a'tion
Authorization to Discuss Health Information
O By here
initialing I authorize
Initials
to discussmy health information with my attorney,or a governmental agency, listhere:
information- event on
10.Reason for releaseof 11. Date or which thisauthorization willexpire:
OAt request of individual End of Litigation
Other: Litigation
12.Ifnot the patient,name of person signing forrn: 13.Authority to sign on behalf ofpatient
Michael Marron, Esq. for Elefterakis, Elefterakis & Panek Power of Attorney
All items on thisform have been completed and my questions about thisform have been answered. In addition,I have been provided a
copy of theform.
Date: Û
Signature of patientor representativeauthorized by law.
* Human Virus thatcauses AIDS. The New York State PublicHealth Law protectsinformation which
Immunodeficiency reasonably
could identifysomeone as having HIV symptoms or infectionand information regarding a person's contacts.
FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019
NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020
OCA OfficialForm No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York StateDepartment of Health]
2505 Bedford Avenue 2E Brooklyn, New York 11226
I,or my authorized representative,request thathealth information regarding my careand treatment be releasedas set forthon this form:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portabilityand Accountability Act of 1996
that·
(HIPAA), I understand
1. This authorization may include disclosure of inforñistion relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION if Iplace initials
on
TREATMENT, psychotherapy notes, only my
the appmpriate line inItem 9(a). In the event the health information described below includes any of thesetypes of information, and I
initial
theline on thebox inItem 9(a),Ispecificallyauthorize release of such information to theperson(s) indicatedin Item 8.
2. If Iam authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
prohibited from redisclosingsuch information without my authorization unless permitted todo sounder federalor statelaw. I understand
that I havethe right torequest of
a list people who may receive or use my HIV-related information without authorization. IfI experience
discriw=d= because of the release or disclosure ofHIV-related information, I contact theNew York State Division of Human
may
Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for
protecting my rights.
3. Ihave the rightto revoke thisauthorization atany time by writing to the health care provider listedbelow. I understand that Imay
revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization.
4. I understandthat signing thisauthorization isvoluntary. My treatment, payment, enrollment ina health plan,or sligibilityfor benefits
willnot be co=lidoned upon my authorization of thisdisclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient(except as noted above in Item 2), and this
redisclosure may no longer be protected by federalor statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
information·
7. Name and address of health provider or entityto releasethis
18
Island Ambulatory Surgical Center/ Dr. Vitaly Zhivotenko, M.D., 2279-83 Coney Island Avenue, Floor, Brooklyn NY 11223
8. Name and address of person(s) or category of person to whom this information will be sent:
Goldberg Segalla, P.O. Box 780, Buffalo, New York 14201
9(a).Specific information to be released:
Medical Record for DOS 6/28/2019 and DOS 6/7/2019 ONLY
Entire Medical Record, including patienthistories,officenotes (except psychotherapy notes),testresults,radiology studies,films,
referrals,consults,billingrecords, insurance records, and records sent toyou by other healthcare providers.
Include: (Indicateby Initialing)
Other: also includeany diagnostic film(s)and report(s),any ¤Alcohol/Drug Treatment
billingrecords for DOS 6/28/2019 and DOS 6/7/2019 ONLY M
Authorization to Discuss Health Information
By here
initialing I authorize
Initials
to discussmy health information with my attomey, or a govemmental agency, listhere:
10.Reason for releaseof infonnation: 11.Date or event on which thisauthorization will expire:
At request of individual End of Litigation
Other. Litigation
12. If
not the patient,name of person signing form: 13.Authority tosign on behalf of patient:
Michael Marron, Esq. forElefterakis, Elefterakis & Panek Power of Attorney
All items on thisfonn have been completed and my questions aboutthisform have been answered. In addition, I have been provided a
copy of theform.
Date:
Signature of patientor representativeauthorized by law.
* Human Virus thatcauses AIDS. The New York State Public Health Law protects information which
Immunodeficiency reasonably
could identifysomeone as having HIV symptoms or infectionand information regarding a person's contacts.
FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019
NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020
OCA OfficialForm No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York StateDepartment of Health}
2505 Bedford Avenue 2E, Brooklyn, New York 11226
I,or my authorized repesentative, request thathealth infonnation regarding my care and treatment be released as setforth on thisform:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accoüatabilliy Act of 1996
(HIPAA), I understand that
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED
TREATMENT, psychotherapy notes, INFORMATION only ifI place my initials
on
the appropriate linein Item 9(a). Inthe event the bealth information described below includes any of these types of information, and I
initial
the lineon the box in Item 9(a),Ispecifically authorizerelease of such information tothe person(s) indicated in Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, ormental health treatment information, the recipient is
prohibited from redisclosingsuch information without my authorization unless permitted todo so under federalor statelaw. I understand
that I havethe right torequest a list
of people who may receive or use my HIV-related information without authorization.IfI experience
discrimination because of the release or disclosure of HIV-related information, Imay contact theNew York State Division ofHuman
Rights at (212) 480-2493 or the New York City Commi=ion of Human Rights at (212) 306-7450. These agencies are responsible for
protecting my rights.
3. I have the rightto revoke thisauthorization atany time by writing to the health care provider listedbelow. I understand that Imay
revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization.
4. Iunderstand thatsigning thisauthorization isvoluntmy. My treatment, payment, enrollment in a healthplan, or eligibilityforbenefits
willnot be conditioned upon my authorization of thisdisclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protected by federal orstatelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of health provider or entityto releasethisinformation:
Kings County Hospital, 451 Clarkson Avenue, Brooklyn, New York 11203
8. Name and address of person(s) or category of person to whom thisinformation willbe sent:
Goldberg Segalla, P.O. Box 780, Buffalo, New York 14201
9(a).Specific information to be released:
Medical Record for DOS (2/07/2019) Only
EntireMedical Record, including patienthistories,officenotes (except psychotherapy notes),testresults,radiology studies,films,
referrals,
consults, billingrecords, insurance records, and records sent toyou by otherhealth care providers.
Include: (Indicateby Initialing)
Other. also includeany diagnostic film(s) and report(s),any OAlcohol/Drug Treatment
billingrecords for DOS 2/17/2019 Only OMeatal Heal mation
¤HI ed Information
Authorization to Discuss Health Information
By here
initialing I authorize
Initials
to discussmy health information with my attorney, or a govemmental agency, listhere:
10. Reason forrelease of information: 11.Date or event on which thisauthorization will expire:
At request of individual End of Litigation
Other: Litigation
12.Ifnot the patient,name of person signing form: 13.Authority tosign on behalf ofpatient
Michael Marron, Esq. for Elefterakis,Elefterakis & Panek Power of Attorney
All items on thisform have been completed and my questions about thisform have been answered. In addition,I bave been provided a
copy of theform.
Date:
Signature of patientor representativeauthorized by law.
* Human Virus that causes AIDS. The New York State Public Health Law
Emmunedeficiency protects information which reasonably
could identifysomeone as having HIV symptoms or infectionand information regarding a person's contacts.
FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019
NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020
OCA OfficialForm No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York StateDepartment of Health]
Patient Name Social Security Number
Ariadni Cordero
Patient Address
2505 Bedford Avenue 2E Brooklyn, New York 11226
I,or my authorized representative,request thathealth infoññâtics regardiñg my careand treatment be released as set forth
on thisform:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Acco==*aMity Act of 1996
(HIPAA), Iunderstand that:
1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED
TREATMENT, psychotherapy notes, INFORMATION only ifI placemy on
initials
the appropriate linein Item 9(a). In the event the health informationdescribed below includes any of these types of information, and I
initialtheline on thebox inItem 9(a),I authorizerelease of such information to the adbatad inItem 8.
specifically person(s)
2. If Iam authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatmcat information, the recipientis
prohibited from redisclosingsuch information without my authorization unless permitted to do so under federal orstate law.I understand
that Ihave theright torequest a listofpeople who may receive oruse my HIV-related information without authorization.If Iexperience
discrimination because of the releaseor disclosure of HIV-related information, I may contact the New York StateDivision of Human
Rights at (212) 480-2493 or the New York City Commiccian ofHuman Rights at(212) 306-7450. These agencies are responsible for
protecting my rights.
3. Ihave the rightto revoke thisauthorization atany time by writing to the health care provider listedbelow. I understand that Imay
revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization.
4. I understand thatsigning this authorization isvoluntary. My treatment, payment, enrollrnentin a health plan,or eligibilityfor benefits
will notbe conditioned upon my authorization of thisdisclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient(except as noted above in Item 2), and this
redisclosure may no longer be protected by federal orstatelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of health provider orentity torelease thisinformation:
North Shore Family Chiropractic P.C., 410 Ditmas Ave. Brooklyn, NY 11218
8. Name and address of person(s) orcategory ofperson towhom thisinformation willbe sent:
Goldberg Segalla,P.O. Box 780, Buffalo, New York 14201
9(a).Specific information tobe released:
Medical Record from (2/7/2019) to (Present)
EntireMedical Record, including patient office
histories, notes (except psychotherapy notes),testresults,radiology studies,films,
referrals,
consults, billingrecords, insurance records, and records sent toyou by otherhealth care providers.
Include: (Indicateby Initialing)__ __
Other·
also includeany diagnostic film(s) and report(s),any OAlcohol/Drug Treatment
billingrecords from DOA till
present ental Sealth Information
- elated Information
Authorization to Discuss Health Information
O By here
initialing I authorize
Initials
to discussmy health information with my attorney, or a governmental agency, listhere:
10. Reason for releaseof information: 11. Date or event on which thisauthorization willexpire:
OAt request of individual End of Litigation
Other.
Litigation
12.If not thepatient,name of person signing form: 13. Authority tosign on behalf of patient:
Michael Marron,Esq. for Elefterakis,Elefterakis & Panek Power of Attorney
All items on this form have been corspleted and my questions about thisform have been answered. In addition,I have been provided a
copy of theform.
Date:5/le 12ozo
Signature of patientor representativeauthorized by law.
* Human Virus thatcauses AIDS. The New York State
Irerüüñodeficiency Public Health Law protects information which reasonably
could identifysomeone as having HIV symptoms or infectionand infoññatioñ regarding a person's contacts.
FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019
NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020
OCA OfficialForm No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York StateDepartment of Health]
Patient Name l Social
Securi Number
Ariadni Cordero
Patient Address
2505 Bedford Avenue 2E Brooklyn, New York 11226
I,or my authorized representative,request thathealth information regarding my careand treatment be released as set forth
on thisform:
In accordance with New York State Law and the Privacy Rule of the Health insurance Portability and Accountability Act of 1996
(HIPAA), I understand that:
1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION
TREATMENT, psychotherapy notes, only ifI place my initials
on
the appropriate linein Item 9(a). Inthe event the health information described below includes any ofthese types of information, and I
initial
the lineon the box in Item 9(a),Ispecificallyauthorize release of such information tothe person(s) indicated in Item 8.
2. If Iam authorizing the release of HIV-related, alcohol or drug treatmcñt, ormental health treatment information, therecipient is
prohibited from redisclosingsuch information without my authorization unless permitted todo so under federal orstate law.I understand
that I havethe right toequest of
a list people who may receive or use my HIV-related information without authorization.If I experience
discrimination because of the releaseor disclosure of HIV-related information, I may contact the New York StateDivision of Human
Rights at (212) 480-2493 or the New York City Commission of Human Rights at(212) 306-7450. These agencies are responsible for
protecting my rights.
3. Ihave the rightto revoke thisauthorization atany time by writing to the health care provider listedbelow. I understand that Imay
revoke thisauthorization except to theextent that actionhas already been taken based on thisauthorization.
4. Iunderstand thatsigning this authorization is voluntary.My treatment
Preview
FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019 NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020 EXHIBIT B FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019 eeplaw.com NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020 80 Pine Street, 38 Floor New York, New York 10005 T. 212.532.1116F.212.532.1176 New Jersey Office 576 Main Street, Suite C Chatham,New Jersey 07928 ELEFTERAKIS JOHN ELEFTERAKIS' ELEFTERAKIS NICHOLASELEFTERAKIS RAYMONDPANEK OLIVERR.TOBIAS JEFFREYB. BROMFELD FAlZANGHAZNAVI GABRIELP. HARVIS BAREEN. FETT STEPHENKAHN EVANM. LA PENNA KRISTENPERRY- CONIGLIARO AIKA DANAYEVA ARIANAELEFTERAKlS MICHAELINDELICATO MICHAELMARRON DOMINICKMINGIONE MARKNEWMAN AGGELIKIE. NlKOLAIDIS JOSEPHPERRY MARiELOUISEPRIOLO * GOLDBERG SEGALLA KEYONTESUTHERLAND P.O.Box 780 WAYNEWATTLEY Buffalo, New York 14201 *AlsoAdmitted In New Jersey May O , 2020 Re: CORDERO v. HP MARCUS GARVEY PRESERVATION HOUSING COMPANY, INC. et al. Index No.: 514351/2019 Dear Counselors: Our office is in receipt of your letter dated March 6, 2020. Enclosed herein, please find authorizations for the following providers: 1. Big Apple Pain Management; 2. Brooklyn Medical Practice, P.C.; 3. Community Medical Imaging; 4. Island Ambulatory Surgical Center; 5. Kings County Hospital; 6. North Shore Family Chiropractic, P.C.; 7. Premier Home Health Care Services; 8. South Nassau Conununities Hospital; 9. Stand Up MRI of Brooklyn, P.C.; 10. The Charter Oak Fire Insurance Company; and 11. Bella Donna Medical. If you have any further questions, please contact the undersigned. Best, {ia6rielle Cilea | Paralegal FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019 NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020 OCA OfficialForm No.:960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York StateDepartment of Health] PatientName umber Ariadni Cordero PatientAddress 2505 Bedford Avenue 2E Brooklyn, New York 11226 I,or my authorized representative,request thathealth information regarding my careand treatment be released as set forthon thisform: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portabilityand AccountabiEty Act of 1996 that· (HIPAA), T understand 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH except CONFIDENTIAL HIV* RELATED INFORMATION TREATMENT, psychotherapy notes, and only ifI place my initials on the appropriate line in Item 9(a). Inthe event the health information described below includes any of these types of information, and I initialthe lineon the box in Item 9(a),Ispecifically authorizerelease of such information to theperson(s) indicated in Item 8. 2. If Iam authorizing the release of HIV-related, alcohol or drug trcescr , or mental health treatment infcimation, the recipientis prohibited from redisclosingsuch information without my authorization unless permitted todo so under federal orstate law.I understand thatI have the right to requesta listofpeople who may receive or use my HIV-related information without authorization. IfI experience discrimination because of the releaseor disclosure of HIV-related information, Imay contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies areresponsible for protecting my rights. 3. Ihave the rightto revoke thisauthorization atany time by writing to the health care provider listedbelow. I understand that Imay revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization. 4. I understand thatsigning this authorization isvoluntary. My treatment, payment, enrollment ina health plan,or aligibilityfor benefits willnot be conditioned upon my authorization of thisdisclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal orstate law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address ofhealth provider or entityto releasethis information: Big Apple Pain Management/ Dr. Richard Apple, M.D., 410 Ditmas Ave., Brooklyn, NY 11218 8. Name and address ofperson(s) or category of person to whom thisinformation will be sent: Goldberg Segalla, P.O. Box 780, Buffalo, New York 14201 9(a).Specific information to be released: Medical Record from (2/7/2019) to(Present) EntireMedical Record, including patienthisteries,officenotes (except psychotherapy notes),testresults,radiology studies,films, consults, referrals, billingrecords, in=rance records,and records sent toyou by otherhealth care providers. Include: (Indicateby Initialing) Other: also includeany diagnostic film(s) and report(s),any OAlcohol/Drug Treatment billingrecords from DOA present till O atal Health Information -R_,elatedinformation Authorization to Discuss Health Information By here initialing I authorize Initials to discussmy health information with my attorney, or a governmental agency, listhere: 10.Reason for releaseof infonnation: 11.Date or event on which thisauthorization will expire: OAt request of individual End of Litigation Other· Litigation 12. Ifnot thepatient,name of person signing form: 13.Authority tosign on behalf of patient: Michael Marron, Esq. forElefterakis, Elefterakis & Panek Power ofAttorney All items on thisform have been cc=p'c:cd and my questions about thisform have been answered. In addition, I have been provided a copy of theform. Date: - \f 10% Signature of patientor representativeauthorized by law. * Human Virus thatcauses AIDS. The New York State Public Health Law protects information which Immunodeficiency reasonably could identifysomeone as having HIV symptoms or infectionand infonnation regarding a person's contacts. FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019 NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020 OCA OfficialForm No.:960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York StateDepartment of Health] Patient Name Social Securi Number Ariadni Cordero Patient Address 2505 Bedford Avenue 2E Brooklyn, New York 11226 I,or my authorized representative,request thathealth information regarding my care and treatment be released as set forthon this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portabilityand AccountabiHty Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of informativü relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION TREATMENT, psychotherapy notes, only ifI place my initials on the appropriate linein Item 9(a). Inthe event the health information described below includes any of these types of information, and I initial the lineon thebox inItem 9(a), I specifically authorize release of such information tothe person(s) indicated in Item 8. 2. If Iam authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted todo so under federalor statelaw. I understand thatI have the rightto request a list of people who may receive or use my HIV-related information without authorization. IfI experience discrimination because of the release or disclosure ofHIV-related information, Imay contact the New Yodc State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights. 3. I have the rightto revoke this authorization atany time by writing to the health care provider listedbelow. I understand that Imay revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization. 4. Iunderstand thatsigning thisauthorization isvoluntary. My treatment, payment, enrolhnent in a health plan,or eligibilityfor benefits willnot be conditioned upon my authorizationof thisdisclosure. 5. Information disclosed under this authorizationmight be redisclosed by the recipient (except as noted above in Item 2), and this redisclosuremay no longer be protected by federal orstatelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address of healthprovider orentity to releasethisinformation: Brooklyn Medical Practice PC, 410 Ditmas Avenue, Brooklyn, New York 11218 8. Name and address of person(s) orcategory ofperson towhom thisinformation will be sent: Goldberg Segalla, P.O. Box 780, Buffalo, New York 14201 9(a).Specific information to be released: Medical Record from (2/7/2019) to(Present) EntireMedical Record, including patienthistories,office notes (except psychotherapy notes),testresults,radiology studies,films, referrals, consults, billingrecords, insurance records, and records sent toyou by otherhealth care providers. Include: (Indicateby Initialing) Other: also includeany diagnostic film(s)and report(s),any ¤Alcohol/Drug Treatment billingrecords from DOA till present Mental nTormation - elated Information Authorization to Discuss Health Information By here initialing I authorize Initials to discussmy health information with my attorney, or a govemmcñtal agency, listhere: 10.Reason forrelease of information: 11.Date orevent on which thisauthorization willexpire: At request of individual End of Litigation Other· Litigation 12. Ifnot thepatient,name of person signing form: 13.Authority to sign on behalf of patient: Michael Marron,Esq. for Elefterakis, Elefterakis & Panek Power of Attorney All items on this form have been completed and my questions about thisform have been answered. In addition, I have been provided a copy of theform. Date: Signature of patient or representativeauthorized by law. * Human Virus that causes AIDS. The New York State Immunodeficiency Public Health Law protects information which rea-ahly could identifysomeone as having HIV symptoms or infectionand information regarding a person's contacts. FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019 NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020 OCA OfficialForm No.:960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health] Patient Name Number Ariadni Cordero Patient Address 2505 Bedford Avenue 2E Brooklyn, New York 11226 I,or my authorized representative,request thathealth infe-a*ion regarding my careand treatment be released as setforthon thisform: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accoüñtability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION if I place TREATMENT, psychotherapy notes, only my initials on the âpprepriate linein Item 9(a). In theevent the health infonnation described below includes any of these types of information, and I initial theline on thebox in Item 9(a),Ispecifically authorizerelease of such information tothe person(s) indicated in Item 8. 2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipientis prohibited from redisclosing such iñformation without my authorization unless permitted to do so under federal orstate law.I understand thatI have the rightto request a list of people who may receive or use my HIV-related information without authorization. IfI experience discrimination because of the releaseor disclosure of HIV-related information, Imay contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies areresponsible for protecting my rights. 3. Ihave the rightto revoke thisauthorization atany time by writing to the health care provider listedbelow. I understand that Imay revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization. 4. I understand thatsigning this authorizationisvoluntary. My treatment, payment, enrollment in a health plan, or for cligibility benefits willnot be conditioned upon my authorizationof thisdisclosure. 5. Information disclosed under this authorizationmight be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal orstatelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address of health provider or entityto release thisinformation: Community Medical Imaging, 234-28A Merrick Blvd, Rosedale, NY 11422 8. Name and address of person(s) orcategory of person to whom thisinformation will be sent: Goldberg Segalla, P.O. Box 780, Buffalo, New York 14201 9(a).Specific information to be released: Medical Record from (2/7/2019) to (Present) OEntire Medical Record, including patienthistories,office notes (except psychotherapy notes),testresults,radiology studies, films, referrals,consults,billingrecords, insurance records, and records sent toyou by other healthcare provides. Include: (Indicateby Initialing) Other: also include any diagnostic film(s)and report(s),any Alcohol/Drug Treatment billingrecords from DOA till present Mental Health Informajion flIV-Related Inferrñ'a'tion Authorization to Discuss Health Information O By here initialing I authorize Initials to discussmy health information with my attorney,or a governmental agency, listhere: information- event on 10.Reason for releaseof 11. Date or which thisauthorization willexpire: OAt request of individual End of Litigation Other: Litigation 12.Ifnot the patient,name of person signing forrn: 13.Authority to sign on behalf ofpatient Michael Marron, Esq. for Elefterakis, Elefterakis & Panek Power of Attorney All items on thisform have been completed and my questions about thisform have been answered. In addition,I have been provided a copy of theform. Date: Û Signature of patientor representativeauthorized by law. * Human Virus thatcauses AIDS. The New York State PublicHealth Law protectsinformation which Immunodeficiency reasonably could identifysomeone as having HIV symptoms or infectionand information regarding a person's contacts. FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019 NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020 OCA OfficialForm No.:960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York StateDepartment of Health] 2505 Bedford Avenue 2E Brooklyn, New York 11226 I,or my authorized representative,request thathealth information regarding my careand treatment be releasedas set forthon this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portabilityand Accountability Act of 1996 that· (HIPAA), I understand 1. This authorization may include disclosure of inforñistion relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION if Iplace initials on TREATMENT, psychotherapy notes, only my the appmpriate line inItem 9(a). In the event the health information described below includes any of thesetypes of information, and I initial theline on thebox inItem 9(a),Ispecificallyauthorize release of such information to theperson(s) indicatedin Item 8. 2. If Iam authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosingsuch information without my authorization unless permitted todo sounder federalor statelaw. I understand that I havethe right torequest of a list people who may receive or use my HIV-related information without authorization. IfI experience discriw=d= because of the release or disclosure ofHIV-related information, I contact theNew York State Division of Human may Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights. 3. Ihave the rightto revoke thisauthorization atany time by writing to the health care provider listedbelow. I understand that Imay revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization. 4. I understandthat signing thisauthorization isvoluntary. My treatment, payment, enrollment ina health plan,or sligibilityfor benefits willnot be co=lidoned upon my authorization of thisdisclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient(except as noted above in Item 2), and this redisclosure may no longer be protected by federalor statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). information· 7. Name and address of health provider or entityto releasethis 18 Island Ambulatory Surgical Center/ Dr. Vitaly Zhivotenko, M.D., 2279-83 Coney Island Avenue, Floor, Brooklyn NY 11223 8. Name and address of person(s) or category of person to whom this information will be sent: Goldberg Segalla, P.O. Box 780, Buffalo, New York 14201 9(a).Specific information to be released: Medical Record for DOS 6/28/2019 and DOS 6/7/2019 ONLY Entire Medical Record, including patienthistories,officenotes (except psychotherapy notes),testresults,radiology studies,films, referrals,consults,billingrecords, insurance records, and records sent toyou by other healthcare providers. Include: (Indicateby Initialing) Other: also includeany diagnostic film(s)and report(s),any ¤Alcohol/Drug Treatment billingrecords for DOS 6/28/2019 and DOS 6/7/2019 ONLY M Authorization to Discuss Health Information By here initialing I authorize Initials to discussmy health information with my attomey, or a govemmental agency, listhere: 10.Reason for releaseof infonnation: 11.Date or event on which thisauthorization will expire: At request of individual End of Litigation Other. Litigation 12. If not the patient,name of person signing form: 13.Authority tosign on behalf of patient: Michael Marron, Esq. forElefterakis, Elefterakis & Panek Power of Attorney All items on thisfonn have been completed and my questions aboutthisform have been answered. In addition, I have been provided a copy of theform. Date: Signature of patientor representativeauthorized by law. * Human Virus thatcauses AIDS. The New York State Public Health Law protects information which Immunodeficiency reasonably could identifysomeone as having HIV symptoms or infectionand information regarding a person's contacts. FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019 NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020 OCA OfficialForm No.:960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York StateDepartment of Health} 2505 Bedford Avenue 2E, Brooklyn, New York 11226 I,or my authorized repesentative, request thathealth infonnation regarding my care and treatment be released as setforth on thisform: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accoüatabilliy Act of 1996 (HIPAA), I understand that 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED TREATMENT, psychotherapy notes, INFORMATION only ifI place my initials on the appropriate linein Item 9(a). Inthe event the bealth information described below includes any of these types of information, and I initial the lineon the box in Item 9(a),Ispecifically authorizerelease of such information tothe person(s) indicated in Item 8. 2. If I am authorizing the release of HIV-related, alcohol or drug treatment, ormental health treatment information, the recipient is prohibited from redisclosingsuch information without my authorization unless permitted todo so under federalor statelaw. I understand that I havethe right torequest a list of people who may receive or use my HIV-related information without authorization.IfI experience discrimination because of the release or disclosure of HIV-related information, Imay contact theNew York State Division ofHuman Rights at (212) 480-2493 or the New York City Commi=ion of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights. 3. I have the rightto revoke thisauthorization atany time by writing to the health care provider listedbelow. I understand that Imay revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization. 4. Iunderstand thatsigning thisauthorization isvoluntmy. My treatment, payment, enrollment in a healthplan, or eligibilityforbenefits willnot be conditioned upon my authorization of thisdisclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal orstatelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address of health provider or entityto releasethisinformation: Kings County Hospital, 451 Clarkson Avenue, Brooklyn, New York 11203 8. Name and address of person(s) or category of person to whom thisinformation willbe sent: Goldberg Segalla, P.O. Box 780, Buffalo, New York 14201 9(a).Specific information to be released: Medical Record for DOS (2/07/2019) Only EntireMedical Record, including patienthistories,officenotes (except psychotherapy notes),testresults,radiology studies,films, referrals, consults, billingrecords, insurance records, and records sent toyou by otherhealth care providers. Include: (Indicateby Initialing) Other. also includeany diagnostic film(s) and report(s),any OAlcohol/Drug Treatment billingrecords for DOS 2/17/2019 Only OMeatal Heal mation ¤HI ed Information Authorization to Discuss Health Information By here initialing I authorize Initials to discussmy health information with my attorney, or a govemmental agency, listhere: 10. Reason forrelease of information: 11.Date or event on which thisauthorization will expire: At request of individual End of Litigation Other: Litigation 12.Ifnot the patient,name of person signing form: 13.Authority tosign on behalf ofpatient Michael Marron, Esq. for Elefterakis,Elefterakis & Panek Power of Attorney All items on thisform have been completed and my questions about thisform have been answered. In addition,I bave been provided a copy of theform. Date: Signature of patientor representativeauthorized by law. * Human Virus that causes AIDS. The New York State Public Health Law Emmunedeficiency protects information which reasonably could identifysomeone as having HIV symptoms or infectionand information regarding a person's contacts. FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019 NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020 OCA OfficialForm No.:960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York StateDepartment of Health] Patient Name Social Security Number Ariadni Cordero Patient Address 2505 Bedford Avenue 2E Brooklyn, New York 11226 I,or my authorized representative,request thathealth infoññâtics regardiñg my careand treatment be released as set forth on thisform: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Acco==*aMity Act of 1996 (HIPAA), Iunderstand that: 1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED TREATMENT, psychotherapy notes, INFORMATION only ifI placemy on initials the appropriate linein Item 9(a). In the event the health informationdescribed below includes any of these types of information, and I initialtheline on thebox inItem 9(a),I authorizerelease of such information to the adbatad inItem 8. specifically person(s) 2. If Iam authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatmcat information, the recipientis prohibited from redisclosingsuch information without my authorization unless permitted to do so under federal orstate law.I understand that Ihave theright torequest a listofpeople who may receive oruse my HIV-related information without authorization.If Iexperience discrimination because of the releaseor disclosure of HIV-related information, I may contact the New York StateDivision of Human Rights at (212) 480-2493 or the New York City Commiccian ofHuman Rights at(212) 306-7450. These agencies are responsible for protecting my rights. 3. Ihave the rightto revoke thisauthorization atany time by writing to the health care provider listedbelow. I understand that Imay revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization. 4. I understand thatsigning this authorization isvoluntary. My treatment, payment, enrollrnentin a health plan,or eligibilityfor benefits will notbe conditioned upon my authorization of thisdisclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient(except as noted above in Item 2), and this redisclosure may no longer be protected by federal orstatelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address of health provider orentity torelease thisinformation: North Shore Family Chiropractic P.C., 410 Ditmas Ave. Brooklyn, NY 11218 8. Name and address of person(s) orcategory ofperson towhom thisinformation willbe sent: Goldberg Segalla,P.O. Box 780, Buffalo, New York 14201 9(a).Specific information tobe released: Medical Record from (2/7/2019) to (Present) EntireMedical Record, including patient office histories, notes (except psychotherapy notes),testresults,radiology studies,films, referrals, consults, billingrecords, insurance records, and records sent toyou by otherhealth care providers. Include: (Indicateby Initialing)__ __ Other· also includeany diagnostic film(s) and report(s),any OAlcohol/Drug Treatment billingrecords from DOA till present ental Sealth Information - elated Information Authorization to Discuss Health Information O By here initialing I authorize Initials to discussmy health information with my attorney, or a governmental agency, listhere: 10. Reason for releaseof information: 11. Date or event on which thisauthorization willexpire: OAt request of individual End of Litigation Other. Litigation 12.If not thepatient,name of person signing form: 13. Authority tosign on behalf of patient: Michael Marron,Esq. for Elefterakis,Elefterakis & Panek Power of Attorney All items on this form have been corspleted and my questions about thisform have been answered. In addition,I have been provided a copy of theform. Date:5/le 12ozo Signature of patientor representativeauthorized by law. * Human Virus thatcauses AIDS. The New York State Irerüüñodeficiency Public Health Law protects information which reasonably could identifysomeone as having HIV symptoms or infectionand infoññatioñ regarding a person's contacts. FILED: KINGS COUNTY CLERK 10/08/2020 04:07 PM INDEX NO. 514351/2019 NYSCEF DOC. NO. 48 RECEIVED NYSCEF: 10/08/2020 OCA OfficialForm No.:960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York StateDepartment of Health] Patient Name l Social Securi Number Ariadni Cordero Patient Address 2505 Bedford Avenue 2E Brooklyn, New York 11226 I,or my authorized representative,request thathealth information regarding my careand treatment be released as set forth on thisform: In accordance with New York State Law and the Privacy Rule of the Health insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION TREATMENT, psychotherapy notes, only ifI place my initials on the appropriate linein Item 9(a). Inthe event the health information described below includes any ofthese types of information, and I initial the lineon the box in Item 9(a),Ispecificallyauthorize release of such information tothe person(s) indicated in Item 8. 2. If Iam authorizing the release of HIV-related, alcohol or drug treatmcñt, ormental health treatment information, therecipient is prohibited from redisclosingsuch information without my authorization unless permitted todo so under federal orstate law.I understand that I havethe right toequest of a list people who may receive or use my HIV-related information without authorization.If I experience discrimination because of the releaseor disclosure of HIV-related information, I may contact the New York StateDivision of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at(212) 306-7450. These agencies are responsible for protecting my rights. 3. Ihave the rightto revoke thisauthorization atany time by writing to the health care provider listedbelow. I understand that Imay revoke thisauthorization except to theextent that actionhas already been taken based on thisauthorization. 4. Iunderstand thatsigning this authorization is voluntary.My treatment