Preview
FILED: KINGS COUNTY CLERK 01/27/2021 09:15 PM INDEX NO. 528159/2019
NYSCEF DOC. NO. 60 RECEIVED NYSCEF: 01/27/2021
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF KINGS
NADIA GRIFFITH,
Plaintiff, AUTORIZATION FOR
RELEASE OF
-against-
EMPLOYMENT RECORD
LAGUARDIA CORPORATE CENTER ASSOCIATES, Index #: 528159/19
LLC; BLUMENFELD DEVELOPMENT GROUP;
PROCLEAN MAINTENANCE SYSTEMS; and CAPITAL
CONTRACTORS, INC,
Defendants.
----------------- -----------------------X
TO: New York City Department of Correction
75-20 Astoria Boulevard
Queens, New York 11370
YOU ARE HEREBY AUTHORIZED to furnish to:
CORREA, KING, MCGINNIS & LIFERIEDGE
29*
One Battery Park Plaza, Floor
New York, New York 10004
Attorney forthe defendant, a copy of the Employment Record in duplicate, forthe year 2016
through 2017, of the plaintiff, NADIA GRIFFITH, who smfained injuries from an accident which
occurred on January 24, 2017, Date of Birth: 10/9/81. All resulting expenses to be paid by the
attorney for said defendants.
Dated: December 14, 2020
N DIÄ @l 1 11
G. WESLEY SIMPSON, P.C.
Attorney for plaintiff
1"
1016 Ralph Avenue, Floor
Brooklyn, New York 11236
STATE OF NEW YORK, COUNTY OF KINGS SS.:
On the day of December, 2020, before me personally came and appeared NADIA
GRIFFITH to me known to be the individual described in and who executed thef qgoing
instrument, and who duly acknowledged to me (s)he executed the same
1 of 24
FILED: KINGS COUNTY CLERK 01/27/2021 09:15 PM INDEX NO. 528159/2019
NYSCEF DOC. NO. 60 RECEIVED NYSCEF: 01/27/2021
-4506 I requestforcopyovraxretum I
fowneber2020) I P Do notsign this
form unless all spEE:sh lineshavebeen comes-+=-3. I OMB No. 1545-0429
P Request may be s,:::M if the form
is '::=;'ste or illegible.
Departmentof the Treasury
InternalRevenueService F For more information
about Form 4506, visit
w=a-2".gov/form4506.
Tip.You may be able toget your tax
returnor retum!nfe==+ienfromothersources.If you had your tax
retum completed by a paidpreparer,
they
should be abletoprovideyou a copy of theretum.The IRS canprovidea Tax Return for
Transcript many returnsfree The transcrio+
of charge.
providesmost of theline entries
fromthe original
taxretum and contains
usually the Mes.Can thata third (sucn as a mortgage
party company;
requires.
See Form 4606-T, Rs:iuss:forTranscriptof Tax Return,
or you can quickly
request by using our Edem÷d
transcripts service
self-help
tools.
Please visit us at IRS.gov and click on "Get a Tax Transcript..?
or call 1-800-908-9946.
is Name shown on tax retum.
If a joint
retum, enter the name shown first. 1b Firstsocial number
security on taxretum,
individual
taxpayer identification
number, or
employer identification
number (see instructions)
Nadia Griffith
XXX-XX-4353
2a If a joint
retum, enter spouse's
name shown on tax return. 2b Second social number or ir,dividual
security
taxpayer identification
number if Joint tax
return
3 Currentname, address(facMng apt., room, or suite no.), city, state, and 21P code
(see in=*ade*iene
723 E. 92nd Brooldyn,
Street, New York 11236
4 shown
Previous address on the fast retum filed if different
fromline 3 (see ineMeaa)
5 If the tax return is to be mailed to a third
party (such as a mait,a~ampry), enter the third
party's and telephone
name, address, number.
Correa,King,McGinnis & Ufeieép, One Battery ParkPlaza, 29th New York,
Floor, New York 10004
CMem If the tax return is being sent to the third
party, ensure that
lines
5 through7 are cGmpiated
before signing.
(see insta2ctione).
8 Tax returnr-q=-d-d. Form 1040,1120, 941, etc.and all
attachments as submitted
originally to the IRS, including
Form(s) W-2,
schedules,or smêñdõd retums. Copiesof Forms 1040, 1040A,and 1040EZ âvâ:âbia
are generally for7 yearsfrom before
filing theyare
destroyed by law.Otherretums may be ±-=E fora longer
periodof time.Enteronlyone retum number. If youneed more thanone
type of retum, you must complete
anotherForm 4506.
Note:If the copies
must be certified
for court
or =dmin!Mve check
proceedings, here . . . . . . . . . . . . . . . O
7 Year or period
rege-ed. Enter the ending date of the tax year or period
using the mm/dd/yyyyformat(see inctaactions).
12 / 31 / 2016 12 / 31 / 2017 12 / 31 / 2018 I I
I I I I I I I I
8 Fee. There is a $43 fee for each retum
requested.Full paymsatmust be lactadadwith yourrequest orit will
Treasury." your
be rejected.
Make your check ormoney orderpayable to"United States Enter SSN, ITIN,
or EIN and "Form4606 request"on yourcheck or money order.
a Cost for each retum. . . . . . . . . - . . . . - - - . . . . . . . . . . $
b Number of retumsrequestedon line 7 .. . . . . . . - . . . . . . . . . . . . .
c Total cost. line Ba by line 8b
Multiply . . . . . . . . . . . . . . . . . . . . . . $
9 go to the third
If we cannot find the tax return, we will refund the fee. If the refund should
party listed on line 5, check
here . . . . . O
Cautiom Do not sign this form lines have been completed.
unless all applicable
Signature I declare that I am either the taxpayer whose name is shown on line 1a or 2a, or a person authorized to obtain the tax retum
of teva=yer{e).
raquested ±,
If the request applies to a joint retum, at least one spouse must sign. If signed by a corporate officer, 1 percent or more ?
partner,
managing member, guardian, tax matters partner, executor,receiver,
±Whier, trustee, or party other than the taxpayer, I certify that I have the authority to
execute Form 4500 on behalf of the taxpayer. Note: This form must be received by IRS within 120 days of the signature date.
O Signatory attests thathe/she has read the attestation clause and upon so reading
Phone number of taxpayer
on line
declaree th he/che has the d:±f to
,
si n theForm 4508. See instructions.
1a or 2a
/ f
Signature (seeinstructions Date
Sign Nadia Griffith
Here Print/rype narne oraHan,partnership,estate, or trust)
Title (if line la above is a
Spouse's signature Date
Print/Typename
For PrivacyActand Paperwork Rarinc*ianActNotice,see page 2- Cat. No. 41721E Form4506 (Rev.11-2020)
2 of 24
FILED: KINGS COUNTY CLERK 01/27/2021 09:15 PM INDEX NO. 528159/2019
NYSCEF DOC. NO. 60 RECEIVED NYSCEF: 01/27/2021
OCA OfficialForm No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York State D - -- of Health]
PatientName Date of Birth Social Number
Security
Nadia Griffith 10/09/81
PatientAddress
723 E 92nd Street, Brooklyn, New York 11236
I,or my authorized request
representative, thathealthinformation regarding my careand ticatmcñt be releasedas set forthon thisform:
In accordance with New York StateLaw and the Rule of theHealth Insurance and Act of 19%
Privacy Portability Acceüñtability
(HIPAA), I understandthat:
1. This authorization may include disclosureof information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
TREATMENT, except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place
psychotherapy notes, only my initials
on
the appropriatelinein Item 9(a). In theevent the healthinformation described below includesany of these typesof information, and I
initial
the lineon thebox inItem 9(a),I specifically
authorize releaseofsuch infoññatics,
to the person(s)indicatedin Item 8.
2. If Iam authorizing the releaseof HIV-related, alcohol or drug treatment,or mental healthtreatment information, the recipientis
prohibited from redisclosingsuch information without my authorization unless permitted to do so under federal or state law. I
understand thatI have theright torequest a list
ofpeople who may receiveor use my HIV-related information withoutauthorization. If
I experiencediscriminationbecause of the releaseordisclosure of HIV-related information, I may contact theNew 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
responsiblefor protectingmy rights.
3. I have the righttorevoke thisaud10rizanón at any time by writing tothe healthcare provider listed
below. I understand thatI may
revoke thisauthorizationexcept to theextent thataction has alreadybeen taken based on thisauthorization.
4. I understand thatsigning this authorization isvoluntary. My treatment, payment, enrollment in a health plan, or for
eligibility
benefitswillnot be condi6oned upon my authorizationof thisdisclosure.
5. Information disclosed under thisauthorization might be redisclosedby the recipient (except as noted above in Item 2), and this
redisclosuremay no longerbe protectedby fedeml or statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b),
7.Name and addressof health providerorentity toreleasethisinformation:
Kingsbrook Jewish Hospital, 585 Schenectady Avenue, Brooklyn, New York 11203
8. Name and add ess ofperson(s)or categoryof personto whom thisinformadca willbe sent:
Correa, King, McGinnis & Liferiedge, One Battery Park Plaza, 29th Floor, New York, New York 10004
9(a). Specificinformation to be released:
O Medical Record from (insert
date) to(insertdate)
O EntireMedical Record, including patient office
histories, notes (except psychotherapy notes),testresults,
radiology studies,films,
referral, consultsbilli recor , insurancerecords,and records sentto you by otherhealth careproviders.
o
0 Other: Ray__ Include:(Indicateby Initialing)
AlcaM/Drug Treatment
Mental Health Information
Authorization toDiscuss Health Information HIV-Related Information
(b)O By initialinghere I authorize
Initials Name of individual
health care provider
to discussmy healthinformation with my or
attorney, a governmental agency, listedhere:
(Attomey/Firm Name or Governmental Agency Name)
10. Reason for releaseof information: 11. Date or eventon which thisauthorizationwillexpire:
O At requestof individual
a Other: LITIGATION END OF LITIGATION
12. Ifnot thepatient,name ofperson signing form: 13. Authorityto signon behalf ofpatient:
All iteµ1s on
thisform have been compistad and my questionsabout thisform have been answered. In I have
addition, been provided a
cop the fo .
p / Date:
Signature of patientor e authorizedby law.
* fr- Virus thatcauses AIDS. New York StatePublic HealthLaw protectsinferination
which
Human sicacy The reasonably could
:-:=e-s
identify as havingHIV --p*-.s or:-fM=t and informationregarding a person'sceñtacia.
3 of 24
FILED: KINGS COUNTY CLERK 01/27/2021 09:15 PM INDEX NO. 528159/2019
NYSCEF DOC. NO. 60 RECEIVED NYSCEF: 01/27/2021
OCA OfRcial Form No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved the New York State Department of
by Health]
PatientName Date of Birth SocialSecurityNumber
Nadia Griffith 10/09/81
PatientAddress
723 E 92nd Street, Brooklyn, New York 11236
I, or myauthorized representative,request thathealthinformation regarding my careand treatment be releasedas set forth
on thisform:
In accordance with New York StateLaw and the Rule of the Health!= e Portabilityand Act of 19%
Privacy Accostability
(HIPAA), I understand that:
1. This anthürizationmay include disclosure of information relatingto ALCOHOL and DRUG MENTAL HEALTH
ABUSE,
TREATMENT, except notes,and CONFIDENTIAL HIV* RELATED INFORMATION I place
psychotherapy only if my initials
on
the appropriatelinein Item 9(a). Inthe event the healthinformation described below includes ofthese types of and I
any inforreaticñ,
initial
the lineon thebox inItem 9(a),I specifically
authorize releaseof such infóñüaticñto theperson(s) indicatedin Item 8.
2. If Iam authorizing the releaseof HIV-related, alcohol or treat-* ormental healthtreatment the recipientis
drug information,
prohibited from redisclosingsuch information without my authorization unless permitted to do so under federal or state law. I
understand thatI have theright torequest a list
of people who may receive oruse my HIV-related information without authorization.If
I experience discriminationbecause of the releaseor disclosureof HIV-related information,I may contactthe 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 are
responsiblefor protectingmy rights.
3. I have the righttorevoke thisauthorizationat any time by writing tothe healthcare providerlistedbelow. I understand thatI may
revoke thisauthorizationexcept to theextent thatactionhas already been taken based on thisauthorization.
4. I understand thatsigning this authorization isvoluntary. My treatment, payment, enrollment in a health plan, or for
eligibility
benefitswillnot be conditioned upon my authorizationof thisdisclosure.
5. Information disclosedunder thisauthorization might be rediaduacd 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 THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address ofhealth provideror entityto releasethisinformation:
NJS Physical Medicine & Rehabilitation, P.C., 1178 Flathesh Avenue, Brooklyn, New York 11226
8. Name and addressof person(s)or category of personto whom thisinformation will be sent:
Correa, King, McGinnis & Liferiedge, One Battery Park Plaza, 29th Floor, New York, New York 10004
9(a). Specificinformation to be released:
O Medical Record from (insert
date) to(insertdate)
9 EntireuMical Record, patienthistories, notes
office (except notes),testresults, studies,films,
indeding psychotherapy radiology
referral consults billi records,insuance records,and records sentto you by otherhealth careproviders.
e: D/A -24-
Other.
a Include: (Indicateby initialing)
Alcohol/Drug Treatment
Mental Health Information
Authorization to Discuss Health Information HIV-Related Information
(b)O By initialinghere I authorize
Name of individual
health care provider
todiscuss my healthinformation with my or
attorney, a goverñmental agency, listedhem:
Name or Govemmental
(Attorney/Firm Agency Name)
10. Reason forreleaseof informaticn: 11. Date or event on which thisav*hnrivation willexpire:
O At requestof individual
a Other: LITIGATION END OF LITIGATION
12. Ifnot the name
patient, ofperson signing form: 13. Authority to signon behalf ofpatient:
All on thisform-have 13een completed and my questionsabout thisform have been c=swcred. In addition,I havebeen provideda
item¶ '
copy f he fo .
/Ê Date:
Signature of patient ve authorized by law.
* Human Virus thatcauses AIDS. The New York StatePublic HealthLaw protectsinformation which ra==enebly could
identify as as havingHIV G-..g:m orinfectionand informationregarding a person'scontacts.
4 of 24
FILED: KINGS COUNTY CLERK 01/27/2021 09:15 PM INDEX NO. 528159/2019
NYSCEF DOC. NO. 60 RECEIVED NYSCEF: 01/27/2021
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 Date of Birth SocialSecurity Number
Nadia Griffith 10/09/81
Patient Address
723 E 92nd Street, Brooklyn, New York 11236
I,or my authorized representative,request thathealthinferreaticñ careand treatment be releasedas set forth
on thisform:
regarding my
Inaccordance with New York StateLaw and the Privacy Rule of the HealthInsurance and
Portability Act of 1996
Acemmtability
(HIPAA), I understand that:
1. This authorizationmay include disclosureof infoññatioñ relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
TREATMENT, except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place
psychotherapy notes, only my initials
on
the appropriatelinein Item 9(a). In theevent the healthinformation described below includesany of these typesof information, and I
initial
the lineon thebox inItem 9(a),I specifically
authorize releaseofsuch information to theperson(s) indicatedin Item 8.
2. If Iam authorizing the releaseof HIV-related, alcohol or drug treatment,or mental healthtr=.. atinformation, the recipientis
prohibited from redisclosingsuch information without my authorization unless permitted to do so under federal or state law. I
understand thatI have therightto request a list
ofpeople who may receiveor use my HIV-related information without authorization.If
I experiencediscrimination because of therelease ordisclosure ofHIV-related information,I may contact theNew 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 are
responsiblefor protectingmy rights.
3. I have the righttorevoke thisauthorizationat any time by writing tothe healthcare pravider listed
below. I understand thatI may
revoke thisauthorizationexcept to theextent thatactionhas already been taken based on thisauthorization.
4. I understand thatsigning this authorization isvoluntary. My traksent, payment, enrollment in a health plan, or for
eligibility
benefitswillnot be conditioned upon my authorizationof thisdisclosure.
5. Information disclosed under thisauthorization might be redisclosed by the recipient(except as noted above in Item 2), and this
redisclosuremay no longerbe protectedby federalor statelaw.
6. THIS AUTHORiZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address ofhealth provideror entitytorelease thisinformation:
Flatlands Medical & Urgent Care, P.C., 9613 Flatlands Avenue, Brooklyn, New York 11236
8. Name and addressof person(s)or category of person towhom thisinformation willbe sent·
Correa, King, McGinnis & Liferiedge, One Dattery Park Plaza, 29th Floor, New York, New York 10004
9(a). Specificinformation tobe released:
O Medical Record from (insert
date) to(insertdate)
B EntireMedical Record, including patient office
histories, notes (except psychotherapy notes),testresults,radiologystudies,films,
referralsconsults billin records,iñsse records,and records sentto you by otherhealth cam providers.
Ite:D/A 1-24-15
0 Other: Include: (Indicateby Initialing)
Alcohol/Drug Treatment
Mental Health Information
Authorization to DiscussHealth Information HIV-Related Information
(b)O By here
initialing I authorize
Initials Name health care provider
of individual
to discussmy healthinformationwith my attorney,or a governmental agency, listedhere:
(Attorney/HrmName or Govemental Agency Name)
10. Reason for releaseof information: 11. Date or eventon which thisauthorizationwill expire:
O At requestof individual
O Other: LITIGATION END OF LITIGATION
12. Ifnot thepatient, name ofperson signingform: 13. Authority to signon behalf of patient:
All items on thisform have been c mpktcd and my questions about thisform have been answered. In ad tiGñ,I havebeen provideda
copy of the fo .
Date:
Signatureof patient ntiftive
authorizedby law.
* Human causes AIDS. New York State PublicHealth Law protectsinformationwhich r--c; could
acy Virusthat The
sciñêüñê HIV e-- ." or i=fectic: inf6ññatiGn contacts.
identify as having and reganlinga person's
5 of 24
FILED: KINGS COUNTY CLERK 01/27/2021 09:15 PM INDEX NO. 528159/2019
NYSCEF DOC. NO. 60 RECEIVED NYSCEF: 01/27/2021
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]
PatientName Date of Birth SocialSecurity Number
Nadia Griffith 10/09/81
PatientAddress
723 E 92nd Street, Brooklyn, New York 11236
I,or my authorized representanve,request thathealthinformation careand treatment be releasedas set forthon thisform:
regarding my
In accordancewith New York StateLaw and the PrivacyRule of theHealth Insurance and Act of 19%
Portability AccannMhility
(HIPAA), I understand that:
1. This authorization may include disclosureof information relatingto ALCOHOL and DRUG MENTAL HEALTH
ABUSE,
TREATMENT, except notes,and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials
on
psychotherapy only my
the appropriatelinein Item 9(a). In theevent the healthinformation described below includes any ofthese types of information,and I
initial
the lineon thebox inItem 9(a),I specifically
authorize releaseof such information tothe person(s)indicated inItem 8.
2. If Iam authorizing the releaseof HIV-related, alcohol or drug or
treatinent, mental healthtreatment inforreatlan,the recipientis
prohibited from redisclosingsuch information without my authorization unless permitted to do so under federal or state law. I
understand thatI have theright torequest of
a list people who may receiveor use my HIV-related information without authorization.If
I experiencediscñmination because of therelease ordisclosure ofHIV-related information,I may contact theNew York StateDivision
of Human Rights at (212) 480-2493 or the New York City Commimion of Human Rights at (212) 306-7450. These agencies are
responsiblefor protectingmy rights.
3. I have the righttorevoke thisauthorizationat any time by writingto the healthcare provider listed
below. I understand thatI may
revoke thisauthorizationexcept to theextent thatactionhas already been taken based on thisauthorization.
4. I understand thatsigning this authorization isvoluntary. My treatment, payment, cñiclissentin a health plan, or for
eligibility
benefitswillnot be conditioned upon my authorizationof thisdisclosure.
5. Information disclosed under thisauthorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosuremay no longer be protectedby federalor statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address ofhealth provider orentityto releasethisinformation:
Charles J. Pearlman, M.D., FRCS-C, 2470 East 16th Street, Brooklyn, New York 11235
8. Name and addressof person(s)or category of personto whom thisinformationwill be sent:
Correa, King, McGinnis & Liferiedge, One Battery Park Plaza, 29th Floor, New York, New York 10004
9(a). Specificinformation tobe released:
O Medical Record fmm (insert
date) to(insertdate)
a EntireMedical Record, including patienthistories,officenotes (except psychotherapy notes),testresults,
radiology studies,films,
referralsconsults billin records, insurancerecords, and records sentto you by otherhealth careproviders.
Ite: D/A 1-24-1
0 Other: Include: (Indicateby Initialing)
Alcohol/Drug Treatment
Mental Health Information
Authorization toDiscuss Health Information HIV-Related Information
(b)O By initialinghere I authorize
Initials Name of individual
healthcare provider
todiscuss my healthinformation with my or
attorney, a governmental agency, listedhere:
Name or Govemmental
(Attorney/Firm Agency Name)
10. Reason forreleaseof information: 11. Date or event on which thisauthorization willexpire:
Cl At requestof individual
a Other:LITIGATION END OF LITIGATION
12. Ifnot thepatient,name ofperson signing form: 13. Authority tosign on behalf ofpatient:
All items on thisform have been completed and my questionsabout thisform have been answered. In additian,I havebeen provided a
copy off the form.
Date:
ignature of patientoffe tativeauthorized by law.
* Human L- Virns thatcauses AIDS. The New York StatePublic HealthLaw protectsinfariñsticswhich could
aieñcy reasonably
-sêæ as havingHIV ==±--- or iñfedis and information a person'scontacts.
identify regarding
6 of 24
FILED: KINGS COUNTY CLERK 01/27/2021 09:15 PM INDEX NO. 528159/2019
NYSCEF DOC. NO. 60 RECEIVED NYSCEF: 01/27/2021
OCA Official
Form No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO IHPAA
[This form has been approved by the New York State Department of Health]
PatientName Date of Birth Social Number
Security
Nadia Griffith 10/09/81
PatientAddress
723 E 92nd Street, Brooklyn, New York 11236
I,or my authorized represcñtativc,request thathealthinformation regarding my careand treatment be releasedas set forth
on thisform:
In accordance with New York SlateLaw and the Rule of theHealth Insurance and Act of 1996
Privacy Portability Accountability
(HIPAA), I understand that:
1. This authorizationmay include disclosureof information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
TREATMENT, except notes,and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials
on
psychotherapy only my
the appropriatelinein Item 9(a). In theevent the healthinformation described below includes any of thesetypes of information,and I
initial
the lineon thebox inItem 9(a),I specifically
authorize releaseof such information tothe person(s)indicated inItem 8.
2. If Iam
Preview
FILED: KINGS COUNTY CLERK 01/27/2021 09:15 PM INDEX NO. 528159/2019 NYSCEF DOC. NO. 60 RECEIVED NYSCEF: 01/27/2021 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF KINGS NADIA GRIFFITH, Plaintiff, AUTORIZATION FOR RELEASE OF -against- EMPLOYMENT RECORD LAGUARDIA CORPORATE CENTER ASSOCIATES, Index #: 528159/19 LLC; BLUMENFELD DEVELOPMENT GROUP; PROCLEAN MAINTENANCE SYSTEMS; and CAPITAL CONTRACTORS, INC, Defendants. ----------------- -----------------------X TO: New York City Department of Correction 75-20 Astoria Boulevard Queens, New York 11370 YOU ARE HEREBY AUTHORIZED to furnish to: CORREA, KING, MCGINNIS & LIFERIEDGE 29* One Battery Park Plaza, Floor New York, New York 10004 Attorney forthe defendant, a copy of the Employment Record in duplicate, forthe year 2016 through 2017, of the plaintiff, NADIA GRIFFITH, who smfained injuries from an accident which occurred on January 24, 2017, Date of Birth: 10/9/81. All resulting expenses to be paid by the attorney for said defendants. Dated: December 14, 2020 N DIÄ @l 1 11 G. WESLEY SIMPSON, P.C. Attorney for plaintiff 1" 1016 Ralph Avenue, Floor Brooklyn, New York 11236 STATE OF NEW YORK, COUNTY OF KINGS SS.: On the day of December, 2020, before me personally came and appeared NADIA GRIFFITH to me known to be the individual described in and who executed thef qgoing instrument, and who duly acknowledged to me (s)he executed the same 1 of 24 FILED: KINGS COUNTY CLERK 01/27/2021 09:15 PM INDEX NO. 528159/2019 NYSCEF DOC. NO. 60 RECEIVED NYSCEF: 01/27/2021 -4506 I requestforcopyovraxretum I fowneber2020) I P Do notsign this form unless all spEE:sh lineshavebeen comes-+=-3. I OMB No. 1545-0429 P Request may be s,:::M if the form is '::=;'ste or illegible. Departmentof the Treasury InternalRevenueService F For more information about Form 4506, visit w=a-2".gov/form4506. Tip.You may be able toget your tax returnor retum!nfe==+ienfromothersources.If you had your tax retum completed by a paidpreparer, they should be abletoprovideyou a copy of theretum.The IRS canprovidea Tax Return for Transcript many returnsfree The transcrio+ of charge. providesmost of theline entries fromthe original taxretum and contains usually the Mes.Can thata third (sucn as a mortgage party company; requires. See Form 4606-T, Rs:iuss:forTranscriptof Tax Return, or you can quickly request by using our Edem÷d transcripts service self-help tools. Please visit us at IRS.gov and click on "Get a Tax Transcript..? or call 1-800-908-9946. is Name shown on tax retum. If a joint retum, enter the name shown first. 1b Firstsocial number security on taxretum, individual taxpayer identification number, or employer identification number (see instructions) Nadia Griffith XXX-XX-4353 2a If a joint retum, enter spouse's name shown on tax return. 2b Second social number or ir,dividual security taxpayer identification number if Joint tax return 3 Currentname, address(facMng apt., room, or suite no.), city, state, and 21P code (see in=*ade*iene 723 E. 92nd Brooldyn, Street, New York 11236 4 shown Previous address on the fast retum filed if different fromline 3 (see ineMeaa) 5 If the tax return is to be mailed to a third party (such as a mait,a~ampry), enter the third party's and telephone name, address, number. Correa,King,McGinnis & Ufeieép, One Battery ParkPlaza, 29th New York, Floor, New York 10004 CMem If the tax return is being sent to the third party, ensure that lines 5 through7 are cGmpiated before signing. (see insta2ctione). 8 Tax returnr-q=-d-d. Form 1040,1120, 941, etc.and all attachments as submitted originally to the IRS, including Form(s) W-2, schedules,or smêñdõd retums. Copiesof Forms 1040, 1040A,and 1040EZ âvâ:âbia are generally for7 yearsfrom before filing theyare destroyed by law.Otherretums may be ±-=E fora longer periodof time.Enteronlyone retum number. If youneed more thanone type of retum, you must complete anotherForm 4506. Note:If the copies must be certified for court or =dmin!Mve check proceedings, here . . . . . . . . . . . . . . . O 7 Year or period rege-ed. Enter the ending date of the tax year or period using the mm/dd/yyyyformat(see inctaactions). 12 / 31 / 2016 12 / 31 / 2017 12 / 31 / 2018 I I I I I I I I I I 8 Fee. There is a $43 fee for each retum requested.Full paymsatmust be lactadadwith yourrequest orit will Treasury." your be rejected. Make your check ormoney orderpayable to"United States Enter SSN, ITIN, or EIN and "Form4606 request"on yourcheck or money order. a Cost for each retum. . . . . . . . . - . . . . - - - . . . . . . . . . . $ b Number of retumsrequestedon line 7 .. . . . . . . - . . . . . . . . . . . . . c Total cost. line Ba by line 8b Multiply . . . . . . . . . . . . . . . . . . . . . . $ 9 go to the third If we cannot find the tax return, we will refund the fee. If the refund should party listed on line 5, check here . . . . . O Cautiom Do not sign this form lines have been completed. unless all applicable Signature I declare that I am either the taxpayer whose name is shown on line 1a or 2a, or a person authorized to obtain the tax retum of teva=yer{e). raquested ±, If the request applies to a joint retum, at least one spouse must sign. If signed by a corporate officer, 1 percent or more ? partner, managing member, guardian, tax matters partner, executor,receiver, ±Whier, trustee, or party other than the taxpayer, I certify that I have the authority to execute Form 4500 on behalf of the taxpayer. Note: This form must be received by IRS within 120 days of the signature date. O Signatory attests thathe/she has read the attestation clause and upon so reading Phone number of taxpayer on line declaree th he/che has the d:±f to , si n theForm 4508. See instructions. 1a or 2a / f Signature (seeinstructions Date Sign Nadia Griffith Here Print/rype narne oraHan,partnership,estate, or trust) Title (if line la above is a Spouse's signature Date Print/Typename For PrivacyActand Paperwork Rarinc*ianActNotice,see page 2- Cat. No. 41721E Form4506 (Rev.11-2020) 2 of 24 FILED: KINGS COUNTY CLERK 01/27/2021 09:15 PM INDEX NO. 528159/2019 NYSCEF DOC. NO. 60 RECEIVED NYSCEF: 01/27/2021 OCA OfficialForm No.:960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State D - -- of Health] PatientName Date of Birth Social Number Security Nadia Griffith 10/09/81 PatientAddress 723 E 92nd Street, Brooklyn, New York 11236 I,or my authorized request representative, thathealthinformation regarding my careand ticatmcñt be releasedas set forthon thisform: In accordance with New York StateLaw and the Rule of theHealth Insurance and Act of 19% Privacy Portability Acceüñtability (HIPAA), I understandthat: 1. This authorization may include disclosureof information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place psychotherapy notes, only my initials on the appropriatelinein Item 9(a). In theevent the healthinformation described below includesany of these typesof information, and I initial the lineon thebox inItem 9(a),I specifically authorize releaseofsuch infoññatics, to the person(s)indicatedin Item 8. 2. If Iam authorizing the releaseof HIV-related, alcohol or drug treatment,or mental healthtreatment information, the recipientis prohibited from redisclosingsuch information without my authorization unless permitted to do so under federal or state law. I understand thatI have theright torequest a list ofpeople who may receiveor use my HIV-related information withoutauthorization. If I experiencediscriminationbecause of the releaseordisclosure of HIV-related information, I may contact theNew 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 responsiblefor protectingmy rights. 3. I have the righttorevoke thisaud10rizanón at any time by writing tothe healthcare provider listed below. I understand thatI may revoke thisauthorizationexcept to theextent thataction has alreadybeen taken based on thisauthorization. 4. I understand thatsigning this authorization isvoluntary. My treatment, payment, enrollment in a health plan, or for eligibility benefitswillnot be condi6oned upon my authorizationof thisdisclosure. 5. Information disclosed under thisauthorization might be redisclosedby the recipient (except as noted above in Item 2), and this redisclosuremay no longerbe protectedby fedeml or statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b), 7.Name and addressof health providerorentity toreleasethisinformation: Kingsbrook Jewish Hospital, 585 Schenectady Avenue, Brooklyn, New York 11203 8. Name and add ess ofperson(s)or categoryof personto whom thisinformadca willbe sent: Correa, King, McGinnis & Liferiedge, One Battery Park Plaza, 29th Floor, New York, New York 10004 9(a). Specificinformation to be released: O Medical Record from (insert date) to(insertdate) O EntireMedical Record, including patient office histories, notes (except psychotherapy notes),testresults, radiology studies,films, referral, consultsbilli recor , insurancerecords,and records sentto you by otherhealth careproviders. o 0 Other: Ray__ Include:(Indicateby Initialing) AlcaM/Drug Treatment Mental Health Information Authorization toDiscuss Health Information HIV-Related Information (b)O By initialinghere I authorize Initials Name of individual health care provider to discussmy healthinformation with my or attorney, a governmental agency, listedhere: (Attomey/Firm Name or Governmental Agency Name) 10. Reason for releaseof information: 11. Date or eventon which thisauthorizationwillexpire: O At requestof individual a Other: LITIGATION END OF LITIGATION 12. Ifnot thepatient,name ofperson signing form: 13. Authorityto signon behalf ofpatient: All iteµ1s on thisform have been compistad and my questionsabout thisform have been answered. In I have addition, been provided a cop the fo . p / Date: Signature of patientor e authorizedby law. * fr- Virus thatcauses AIDS. New York StatePublic HealthLaw protectsinferination which Human sicacy The reasonably could :-:=e-s identify as havingHIV --p*-.s or:-fM=t and informationregarding a person'sceñtacia. 3 of 24 FILED: KINGS COUNTY CLERK 01/27/2021 09:15 PM INDEX NO. 528159/2019 NYSCEF DOC. NO. 60 RECEIVED NYSCEF: 01/27/2021 OCA OfRcial Form No.:960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved the New York State Department of by Health] PatientName Date of Birth SocialSecurityNumber Nadia Griffith 10/09/81 PatientAddress 723 E 92nd Street, Brooklyn, New York 11236 I, or myauthorized representative,request thathealthinformation regarding my careand treatment be releasedas set forth on thisform: In accordance with New York StateLaw and the Rule of the Health!= e Portabilityand Act of 19% Privacy Accostability (HIPAA), I understand that: 1. This anthürizationmay include disclosure of information relatingto ALCOHOL and DRUG MENTAL HEALTH ABUSE, TREATMENT, except notes,and CONFIDENTIAL HIV* RELATED INFORMATION I place psychotherapy only if my initials on the appropriatelinein Item 9(a). Inthe event the healthinformation described below includes ofthese types of and I any inforreaticñ, initial the lineon thebox inItem 9(a),I specifically authorize releaseof such infóñüaticñto theperson(s) indicatedin Item 8. 2. If Iam authorizing the releaseof HIV-related, alcohol or treat-* ormental healthtreatment the recipientis drug information, prohibited from redisclosingsuch information without my authorization unless permitted to do so under federal or state law. I understand thatI have theright torequest a list of people who may receive oruse my HIV-related information without authorization.If I experience discriminationbecause of the releaseor disclosureof HIV-related information,I may contactthe 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 are responsiblefor protectingmy rights. 3. I have the righttorevoke thisauthorizationat any time by writing tothe healthcare providerlistedbelow. I understand thatI may revoke thisauthorizationexcept to theextent thatactionhas already been taken based on thisauthorization. 4. I understand thatsigning this authorization isvoluntary. My treatment, payment, enrollment in a health plan, or for eligibility benefitswillnot be conditioned upon my authorizationof thisdisclosure. 5. Information disclosedunder thisauthorization might be rediaduacd 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 THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address ofhealth provideror entityto releasethisinformation: NJS Physical Medicine & Rehabilitation, P.C., 1178 Flathesh Avenue, Brooklyn, New York 11226 8. Name and addressof person(s)or category of personto whom thisinformation will be sent: Correa, King, McGinnis & Liferiedge, One Battery Park Plaza, 29th Floor, New York, New York 10004 9(a). Specificinformation to be released: O Medical Record from (insert date) to(insertdate) 9 EntireuMical Record, patienthistories, notes office (except notes),testresults, studies,films, indeding psychotherapy radiology referral consults billi records,insuance records,and records sentto you by otherhealth careproviders. e: D/A -24- Other. a Include: (Indicateby initialing) Alcohol/Drug Treatment Mental Health Information Authorization to Discuss Health Information HIV-Related Information (b)O By initialinghere I authorize Name of individual health care provider todiscuss my healthinformation with my or attorney, a goverñmental agency, listedhem: Name or Govemmental (Attorney/Firm Agency Name) 10. Reason forreleaseof informaticn: 11. Date or event on which thisav*hnrivation willexpire: O At requestof individual a Other: LITIGATION END OF LITIGATION 12. Ifnot the name patient, ofperson signing form: 13. Authority to signon behalf ofpatient: All on thisform-have 13een completed and my questionsabout thisform have been c=swcred. In addition,I havebeen provideda item¶ ' copy f he fo . /Ê Date: Signature of patient ve authorized by law. * Human Virus thatcauses AIDS. The New York StatePublic HealthLaw protectsinformation which ra==enebly could identify as as havingHIV G-..g:m orinfectionand informationregarding a person'scontacts. 4 of 24 FILED: KINGS COUNTY CLERK 01/27/2021 09:15 PM INDEX NO. 528159/2019 NYSCEF DOC. NO. 60 RECEIVED NYSCEF: 01/27/2021 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 Date of Birth SocialSecurity Number Nadia Griffith 10/09/81 Patient Address 723 E 92nd Street, Brooklyn, New York 11236 I,or my authorized representative,request thathealthinferreaticñ careand treatment be releasedas set forth on thisform: regarding my Inaccordance with New York StateLaw and the Privacy Rule of the HealthInsurance and Portability Act of 1996 Acemmtability (HIPAA), I understand that: 1. This authorizationmay include disclosureof infoññatioñ relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place psychotherapy notes, only my initials on the appropriatelinein Item 9(a). In theevent the healthinformation described below includesany of these typesof information, and I initial the lineon thebox inItem 9(a),I specifically authorize releaseofsuch information to theperson(s) indicatedin Item 8. 2. If Iam authorizing the releaseof HIV-related, alcohol or drug treatment,or mental healthtr=.. atinformation, the recipientis prohibited from redisclosingsuch information without my authorization unless permitted to do so under federal or state law. I understand thatI have therightto request a list ofpeople who may receiveor use my HIV-related information without authorization.If I experiencediscrimination because of therelease ordisclosure ofHIV-related information,I may contact theNew 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 are responsiblefor protectingmy rights. 3. I have the righttorevoke thisauthorizationat any time by writing tothe healthcare pravider listed below. I understand thatI may revoke thisauthorizationexcept to theextent thatactionhas already been taken based on thisauthorization. 4. I understand thatsigning this authorization isvoluntary. My traksent, payment, enrollment in a health plan, or for eligibility benefitswillnot be conditioned upon my authorizationof thisdisclosure. 5. Information disclosed under thisauthorization might be redisclosed by the recipient(except as noted above in Item 2), and this redisclosuremay no longerbe protectedby federalor statelaw. 6. THIS AUTHORiZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address ofhealth provideror entitytorelease thisinformation: Flatlands Medical & Urgent Care, P.C., 9613 Flatlands Avenue, Brooklyn, New York 11236 8. Name and addressof person(s)or category of person towhom thisinformation willbe sent· Correa, King, McGinnis & Liferiedge, One Dattery Park Plaza, 29th Floor, New York, New York 10004 9(a). Specificinformation tobe released: O Medical Record from (insert date) to(insertdate) B EntireMedical Record, including patient office histories, notes (except psychotherapy notes),testresults,radiologystudies,films, referralsconsults billin records,iñsse records,and records sentto you by otherhealth cam providers. Ite:D/A 1-24-15 0 Other: Include: (Indicateby Initialing) Alcohol/Drug Treatment Mental Health Information Authorization to DiscussHealth Information HIV-Related Information (b)O By here initialing I authorize Initials Name health care provider of individual to discussmy healthinformationwith my attorney,or a governmental agency, listedhere: (Attorney/HrmName or Govemental Agency Name) 10. Reason for releaseof information: 11. Date or eventon which thisauthorizationwill expire: O At requestof individual O Other: LITIGATION END OF LITIGATION 12. Ifnot thepatient, name ofperson signingform: 13. Authority to signon behalf of patient: All items on thisform have been c mpktcd and my questions about thisform have been answered. In ad tiGñ,I havebeen provideda copy of the fo . Date: Signatureof patient ntiftive authorizedby law. * Human causes AIDS. New York State PublicHealth Law protectsinformationwhich r--c; could acy Virusthat The sciñêüñê HIV e-- ." or i=fectic: inf6ññatiGn contacts. identify as having and reganlinga person's 5 of 24 FILED: KINGS COUNTY CLERK 01/27/2021 09:15 PM INDEX NO. 528159/2019 NYSCEF DOC. NO. 60 RECEIVED NYSCEF: 01/27/2021 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] PatientName Date of Birth SocialSecurity Number Nadia Griffith 10/09/81 PatientAddress 723 E 92nd Street, Brooklyn, New York 11236 I,or my authorized representanve,request thathealthinformation careand treatment be releasedas set forthon thisform: regarding my In accordancewith New York StateLaw and the PrivacyRule of theHealth Insurance and Act of 19% Portability AccannMhility (HIPAA), I understand that: 1. This authorization may include disclosureof information relatingto ALCOHOL and DRUG MENTAL HEALTH ABUSE, TREATMENT, except notes,and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials on psychotherapy only my the appropriatelinein Item 9(a). In theevent the healthinformation described below includes any ofthese types of information,and I initial the lineon thebox inItem 9(a),I specifically authorize releaseof such information tothe person(s)indicated inItem 8. 2. If Iam authorizing the releaseof HIV-related, alcohol or drug or treatinent, mental healthtreatment inforreatlan,the recipientis prohibited from redisclosingsuch information without my authorization unless permitted to do so under federal or state law. I understand thatI have theright torequest of a list people who may receiveor use my HIV-related information without authorization.If I experiencediscñmination because of therelease ordisclosure ofHIV-related information,I may contact theNew York StateDivision of Human Rights at (212) 480-2493 or the New York City Commimion of Human Rights at (212) 306-7450. These agencies are responsiblefor protectingmy rights. 3. I have the righttorevoke thisauthorizationat any time by writingto the healthcare provider listed below. I understand thatI may revoke thisauthorizationexcept to theextent thatactionhas already been taken based on thisauthorization. 4. I understand thatsigning this authorization isvoluntary. My treatment, payment, cñiclissentin a health plan, or for eligibility benefitswillnot be conditioned upon my authorizationof thisdisclosure. 5. Information disclosed under thisauthorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosuremay no longer be protectedby federalor statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address ofhealth provider orentityto releasethisinformation: Charles J. Pearlman, M.D., FRCS-C, 2470 East 16th Street, Brooklyn, New York 11235 8. Name and addressof person(s)or category of personto whom thisinformationwill be sent: Correa, King, McGinnis & Liferiedge, One Battery Park Plaza, 29th Floor, New York, New York 10004 9(a). Specificinformation tobe released: O Medical Record fmm (insert date) to(insertdate) a EntireMedical Record, including patienthistories,officenotes (except psychotherapy notes),testresults, radiology studies,films, referralsconsults billin records, insurancerecords, and records sentto you by otherhealth careproviders. Ite: D/A 1-24-1 0 Other: Include: (Indicateby Initialing) Alcohol/Drug Treatment Mental Health Information Authorization toDiscuss Health Information HIV-Related Information (b)O By initialinghere I authorize Initials Name of individual healthcare provider todiscuss my healthinformation with my or attorney, a governmental agency, listedhere: Name or Govemmental (Attorney/Firm Agency Name) 10. Reason forreleaseof information: 11. Date or event on which thisauthorization willexpire: Cl At requestof individual a Other:LITIGATION END OF LITIGATION 12. Ifnot thepatient,name ofperson signing form: 13. Authority tosign on behalf ofpatient: All items on thisform have been completed and my questionsabout thisform have been answered. In additian,I havebeen provided a copy off the form. Date: ignature of patientoffe tativeauthorized by law. * Human L- Virns thatcauses AIDS. The New York StatePublic HealthLaw protectsinfariñsticswhich could aieñcy reasonably -sêæ as havingHIV ==±--- or iñfedis and information a person'scontacts. identify regarding 6 of 24 FILED: KINGS COUNTY CLERK 01/27/2021 09:15 PM INDEX NO. 528159/2019 NYSCEF DOC. NO. 60 RECEIVED NYSCEF: 01/27/2021 OCA Official Form No.:960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO IHPAA [This form has been approved by the New York State Department of Health] PatientName Date of Birth Social Number Security Nadia Griffith 10/09/81 PatientAddress 723 E 92nd Street, Brooklyn, New York 11236 I,or my authorized represcñtativc,request thathealthinformation regarding my careand treatment be releasedas set forth on thisform: In accordance with New York SlateLaw and the Rule of theHealth Insurance and Act of 1996 Privacy Portability Accountability (HIPAA), I understand that: 1. This authorizationmay include disclosureof information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except notes,and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials on psychotherapy only my the appropriatelinein Item 9(a). In theevent the healthinformation described below includes any of thesetypes of information,and I initial the lineon thebox inItem 9(a),I specifically authorize releaseof such information tothe person(s)indicated inItem 8. 2. If Iam