Exhibit,Appendix: Olena Kharchenko v. Ossie R. Munroe, Nissan-Infiniti Lt, Nilt, Inc.

On April 30, 2021 a Exhibit,Appendix was filed involving a dispute between Olena Kharchenko, and Nilt, Inc., Nissan-Infiniti Lt, Ossie R. Munroe, for Torts - Motor Vehicle in the District Court of Kings County.

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FILED: KINGS COUNTY CLERK 07/19/2022 04:01 PM INDEX NO. 510246/2021
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 07/19/2022

EXHIBIT C
FILED: KINGS COUNTY CLERK 07/19/2022 04:01 PM INDEX NO. 510246/2021
NYSCEF DOC. NO. 13 . RECEIVED NYSCEF: 07/19/2022

FRIEDMAN SANCHEZ, LLP
ATTORNEYS AT LAW

16 Court 26"
Street, Floor
Brooklyn,New York 11241
Tel: (718)797-2488
Fax: (718)797-4304

ANDREW M. FRIEDMAN
EMIL J. SANCHEZ

Admittedin NY & CA

May 20, 2021

Anna J. Ervolina
Atnn: Elias Falcon, Esq.
l'I'
130 Livingston Street, 1 Floor

Brooklyn, New York 11201

RE: Alexander Eykher v. New York City Transit Authority

County Index No.: 510246/2021

Dear Counselors:

Pursuant to your Demand for a Bill of Particulars and Discovery and Inspection, enclosed

please fmd the following:

1. Verified Bill of Particulars;
2. Combined response to demands for discovery & inspection;
3. HIPAA compliant authorizations for the following:

a. Medicare release;
b. NY Presbyterian Brooklyn Methodist Hospital;
c. Chima Nwanko, M.D.;
d. Duane Reade Pharmacy;
4. Form 4506 for the years 2015-2020.

5. Photographs of the scene of the incident

I trust the foregoing is fully in compliance with your demand.

Very truly yours,

._...-----

Emil J. Sanchez, Esq.

Encl.
FILED: KINGS COUNTY CLERK 07/19/2022 04:01 PM INDEX NO. 510246/2021
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 07/19/2022

SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF KINGS
______________________________________________________________________Ç

ALEXANDER EYKHER, Index No: 510246/2021

Plaintiff, COMBINED RESPONSE
TO DEFENDANT'S
-against- DEMAND FOR
DISCOVERY AND
NEW YORK CITY TRANSIT AUTHORITY, INSPECTION

Defendant.

______________________________________________________________________Ç

PLEASE TAKE NOTICE, that the following is plaintiff's Combined Response to

Defendant's Demand for Discovery and Inspection pursuant to the demand of the defendant,

THE NEW YORK CITY TRANSIT AUTHORITY:

1. APPEARING PARTIES: Parties appearing in this action are as follows:

I. Names and addresses of all litigants:

ALEXANDER EYKHER
4 Park Avenue, Apt 10V

New York, New York 10016

NEW YORK CITY TRANSIT AUTHORITY
130 Livingston Street

Brooklyn, New York 11201

II. Names and addresses of all appearing attorneys:

FRIEDMAN SANCHEZ, LLP
Attorneys for Plaintiff
Street- 26d'
16 Court Floor

Brooklyn, New York 11241
718-797-2488

ANNA J. ERVOLINA
Attorneys for Defendant
NEW YORK CITY TRANSIT AUTHORITY
FILED: KINGS COUNTY CLERK 07/19/2022 04:01 PM INDEX NO. 510246/2021
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 07/19/2022

11th
130 Livingston Street, PlOOr

Brooklyn, New York 11201

(718) 694-3965

2. COLLATERAL SOURCE: Some or all of Plaintiff's medical expenses have

been paid by Plaintiff's insurance:

Aetna Medicare
PO Box 981106
El Paso, Texas 79998

IDI MEBQWGBV
GRP: 354635

Medicare
PO Box 138832

Oklahoma City, OK 73113

Medicare Number: 8XHi-NV2-DT20

3. REIMBURSEMENTS: Not applicable.

4. MEDICARE RECORDS: Annexed hereto are HIPAA compliant authorizations

pennitting your office to obtain plaintiff's Medicare records.

5.
WORKERS' COMPENSATION RECORDS: Not applicable.

6. BIRTH CERTIFICATE: Not applicable/improper demand for a Bill of

Particulars.

7. MARRIAGE LICENSE: Not applicable/improper demand for a Bill of

Particulars.

8. METROCARD: Not applicable.

9. 50-H TRANSCRIPT: A copy of plaintiff's 50-H transcript is in the possession of

the defendant's counsel and has not been served on plaintiff.

10. SCHOOL RECORDS: Not applicable.

11. PRIOR EMPLOYERS: Plaintiff has been self-employed as a taxi driver for the
FILED: KINGS COUNTY CLERK 07/19/2022 04:01 PM INDEX NO. 510246/2021
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 07/19/2022

past five years.

12. TAX RETURNS: Annexed hereto is Form 4506 authorizing your office to obtain

plaintiff's tax returns for five years prior to the date of occurrence.

13. TREATMENT RECORDS: Annexed hereto are HIPAA complaint

authorizations permitting your office to obtain plaintiff's medical and treatment records from the

following providers:

New York Presbyterian Brooklyn Methodist Hospital
6th
506 street

Brooklyn, New York 11215

Duane Reade Pharmacy
4 Park Avenue
New York, New York 10016

14. ARONS AUTHORIZATIONS: Annexed hereto are authorizations allowing

your office to speak with the following medical provider:

Chima Nwankwo, M.D.
506 6th St,
Brooklyn, New York 11215

15. PRIOR INJURIES: Not applicable. Plaintiff did not have pre-existing injuries to

his right elbow.

16. SUBSEQUENT INJURIES: Not applicable. Plaintiff has not experienced any of

the damages or injuries alleged in the Complaint subsequent to the negligence alleged in the

Complaint, caused or related to the negligence alleged in the Complaint.

17. WITNESSES: Plaintiff is currently unaware of any witnesses to the occurrence

and/or damages, or the condition alleged in the Complaint other than the parties hereto. Plaintiff

reserves their right to supplement this response up to and including the time of trial.
FILED: KINGS COUNTY CLERK 07/19/2022 04:01 PM INDEX NO. 510246/2021
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 07/19/2022

18. STATEMENTS: Plaintiff is not in possession of any adverse-party statements at

this time, however, Plaintiff reserves their right to provide same should any become available.

19. REPORTS: Plaintiff is not in possession of any reports describing the negligence

in the complaint.

20. FOIL: Plaintiff is not in possession of any FOIL records at thistime, however,

Plaintiff reserves his rights to provide same should any become available.

21. PHOTOGRAPHS: Copies of photographs are attached herewith.

22. EXPERT WITNESSES: Other than physicians who treated the Plaintiff for

injuries she sustained as a result of the within occurrence, who will testify to their fimdings,

including diagnosis and prognosis and who are set forth herein, Plaintiff cannot state who, if any,

other expert witnesses will be called at the trial,and Plaintiff will notify the Defendants of said

witnesses prior to the trial as may be called.

Dated: Brooklyn, New York

May 20, 2021

Yours, etc.,

EMIL J. SANCHEZ, ESQ.
FRIEDMAN SANCHEZ, LLP
Attorneys for Plaintiff
16 Court Street, Suite 2600

Brooklyn, New York, 11241

(718) 797-2488

TO: ANNA J. ERVOLINA
By: Elias Falcon, Esq.
Attorneys for Defendant
NEW YORK CITY TRANSIT
AUTHORITY
d'
130 Livingston Street, 1l Floor

Brooklyn, New York 11201

(718) 694-3965
FILED: KINGS COUNTY CLERK 07/19/2022 04:01 PM INDEX NO. 510246/2021
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 07/19/2022

SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF KINGS
______________________________.._______________________________________Ç
ALEXANDER EYKHER, Index No: 510246/2021

Plaintiff, VERIFIED BILL OF
PARTICULARS
-against-

NEW YORK CITY TRANSIT AUTHORITY,

Defendant.
________________________-_____________________________________________Ç

PLEASE TAKE NOTICE, that the following is plaintiff's Verified Bill of Particulars

pursuant to the demand of the defendant, THE NEW YORK CITY TRANSIT AUTHORITY:

1. Plaintiff's address is 4 Park Avenue, Apt. 10V, New York, New York 10016.

2. Plaintiff's date of birth is December 14, 1949.

3. Plaintiff objects to the demand for a Social Security number as privileged, as an

interrogatory, as not designed to amplify the pleadings, and also to the disclosure of such

information in a filing to be publicly filed, due to the danger of identity theft. Notwithstanding

such objection, the last four digits of Plaintiff's Social Security number are 7500.

4. The accident occurred on July 4, 2020 at approximately 12:40 P.M.

5-6. The incident occurred at the entrance and/or exit steps and/or stairway of the

Atlantic Avenue subway station, located inside One Hansen Place, and more particularly the first

set of stairs from the street as one enters the said subway station, on the fourth stair down, in

Brooklyn, NY, in the County of Kings, City and State of New York.

7. Not applicable as to bus or other vehicles.

8. Not applicable as to trains.
FILED: KINGS COUNTY CLERK 07/19/2022 04:01 PM INDEX NO. 510246/2021
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 07/19/2022

9. Not applicable. No police officer appeared at the scene of the occurrence.

10. The abovementioned occurrence and the results thereof were caused by the

negligence of the Defendant and/or said Defendant's servants, agents, employees and/or licensees

in the ownership, operation, management, maintenance and control of the aforesaid stairs and in

causing, allowing and pennitting said stairs at the place abovementioned to be, become and

remain for a period of time after notice, either actual or constructive, in a broken, defective,

cracked, uneven, irregular, unleveled, dangerous and/or hazardous condition; in causing,

allowing and pennitting a trap to exist at said location; in failing to maintain the aforesaid stairs

in a reasonably safe and proper condition; in failing to fix or repave said area and/or improperly

repaving same; in causing, allowing and pennitting an obstruction to Plaintiffs safe passage at

said location; in causing, allowing and permitting the existence of a condition which constituted

a trap, nuisance, menace and danger to lawful pedestrians; in failing to take necessary steps and

measures to prevent the abovementioned location from being used while in said dangerous

condition; in failing to give Plaintiff adequate and timely signal, notice or warning of said

condition; in negligently and carelessly causing and permitting the abovementioned stairs to be

and remain in said condition for an unreasonable length of time, resulting in a hazard to the

Plaintiff and others; in failing to take suitable and proper precautions for the safety of persons on

and using said stairs; and in being negligent, reckless and careless in permitting and/or allowing,

after notice, the existence of a dangerous and hazardous obstruction to protrude from the stairs at

the above location.

11. The defendant had actual and constructive notice of said dangerous and defective

conditions. The defendant had actual notice of said dangerous and defective condition by virtue

of the fact that defendants, its agents, servants and/or employees used, managed, controlled and
FILED: KINGS COUNTY CLERK 07/19/2022 04:01 PM INDEX NO. 510246/2021
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 07/19/2022

cared for said stairs and were required to manage, control, care for, repair and supervised sarne.

Actual notice is claimed by virtue of the fact that defendants, their agents, servants and/or

employees suffered and pennitted said stairs to be and to remain in the dangerous and defective

condition, as aforesaid, the defendant, their agents, servants and/or employees caused and/or

created said condition. Actual notice is claimed in that the condition was actually seen by and

known to the agents, servants and/or employees of the defendants who traversed the said area.

The defendants had constructive notice of said dangerous and defective condition by virtue of the

fact that defendants, their agents, servants and/or employees knew or should have known of said

dangerous and defective condition in that the said condition existed for an unreasonable length of

time prior to the said accident. Infonnation regarding specific instances of actual notice are in the

exclusive possession of the defendant.

12. Plaintiff sustained the following injuries:

" Right elbow fracture

o Displaced fracture of head of right radius;

0 Displaced fracture of olecranon process;

o Displaced fracture of shaft of right ulna;

o Small posterior capitellar impaction fracture

" Cubital tunnel syndrome on right;

" Open reduction internal fixation surgeries;

" Right radial head arthroplasty;

" Ulnar Nerve In-Situ decompression.

Permanencies are claimed for all of the residuals of the trauma to the right elbow,

and further post traumatic effects and adverse personality change as appears; including
FILED: KINGS COUNTY CLERK 07/19/2022 04:01 PM INDEX NO. 510246/2021
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 07/19/2022

pain, stiffness, spasm, restriction, and limitation of motion, function and use thereof; for

all of the residuals of the shock to the nervous system and post traumatic nervousness,

insomnia, irritability;and general weakness, fatigue; all together with pain and suffering

and any and all osteoarthritic changes or deterioration and post traumatic sequelae

resulting from the foregoing.

Said injuries have caused said plaintiff severe pain, mental anguish and nervous

system together with tenderness, stiffness, weakness, disfiguration and restriction of

motion and loss of function. The foregoing injuries directly affected the bones, tendons,

tissues, muscles, ligaments, nerves, blood vessels and soft tissues in and about the

involved areas and sympathetic and radiating pains, from all of which Plaintiff suffer,

stillsuffer and will pennanently suffer as a result of the accident and the injuries therein

sustained.

13. Not applicable.

14. Not applicable. Plaintiff did not have pre-existing injuries to his right elbow.

15. Not applicable. Plaintiff has not experienced any of the damages or injuries

alleged in the Complaint subsequent to the negligence alleged in the Complaint, caused by or

related to the negligence alleged in the complaint. .

16. Not applicable. Plaintiff has not experienced any of the damages or injuries

alleged in the Complaint or any other damages or injuries subsequent to the injuries alleged in

the Complaint, caused by any reason other than the negligence alleged in the Complaint.

17. Plaintiff was treated at the following medical facilities:

New York Presbyterian Brooklyn Methodist Hospital
6th
506 street

Brooklyn, New York 11215
FILED: KINGS COUNTY CLERK 07/19/2022 04:01 PM INDEX NO. 510246/2021
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 07/19/2022

18. Not applicable. Plaintiff is not a student.

19. Plaintiff is self-employed as a Taxi Driver. Plaintiff has been incapacitated from

employment from the date of the accident, July 4, 2020, to present.

20. Special damages are as follows:

" Health Care Providers: Approx. $50,000.00

" Medical Supplies: Approx. $2,500.00

" Loss of Earnings: Authorization provided

" Worker's Compensation Reimbursement: Not applicable

" Anticipated Loss of Eamings: To be provided

" Nurse Services: Not claimed

" Expenses Incurred: Not claimed

" Transportation Costs: Approx. $500.00

" Other: Not claimed

21. Not applicable.

22. Plaintiff is a recipient of Medicare. Medicare Number: 8XH1-NV2-DT20.

Plaintiff was eligible for Medicare Benefits Part A and Part B starting 12/01/2014. Plaintiff is

eligible based on age.

23. Not applicable. Property damages is not claimed.

24. Not applicable.

25. Not applicable.

26. Not applicable.

27. Not applicable.

28. Not applicable.
FILED: KINGS COUNTY CLERK 07/19/2022 04:01 PM INDEX NO. 510246/2021
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 07/19/2022

Dated: Brooklyn, New York

May 20, 2021

Yours, etc.,

EM . SANCHEZ, ESQ.
FRIEDMAN SANCHEZ, LLP
Attorneys for Plaintiff
16 Court Street, Suite 2600

Brooklyn, New York, 11241

(718) 797-2488
TO: ANNA J. ERVOLINA
By: Elias Falcon, Esq.

Attorneys for Defendant
NEW YORK CITY TRANSIT
AUTHORITY
1ld'
130 Livingston Street, Floor

Brooklyn, New York 11201

(718) 694-3965
FILED: KINGS COUNTY CLERK 07/19/2022 04:01 PM INDEX NO. 510246/2021
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 07/19/2022

ATTORNEY'S VERIFICATION

EMIL J. SANCHEZ, an attorney duly admitted to practice before the Courts of
the State of New York, affinns the following to be true under the penalties of perjury:

I am an attorney at FRIEDMAN SANCHEZ, LLP, attorneys of record for Plaintiff(s),
ALEXANDER EYKHER, I have read the annexed

BILL OF PARTICULARS

And know the contents thereof, and the same are true to my knowledge, except those matters
therein which are stated to be alleged upon information and belief, and as to those matters I believe
them to be true. My belief, as to those matters therein not stated upon knowledge, is based upon

facts, records, and other pertinent information contained in my files.

DATED: Brooklyn, New York

May 20, 2021

EM . SANCHEZ, ESQ.
FILED: KINGS COUNTY CLERK 07/19/2022 04:01 PM INDEX NO. 510246/2021
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 07/19/2022

OCA Official Form No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[Thisform has been approved by the New York State Department of Health]

PatientName Date of Birth Social Security Number

Alexander Eykher 12-14-1949 -
Çyy
PatientAddress

4 Park Ave, Apt 10V, New York, New York 10016

I.or my authorized representative,request thathealth information regarding my careand treatment be releasedas setforth on thisform:

In accordance with New York State Law and the Privacy Rule of theHealth Insurance Portabilityand Accountability 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 ifI place
TREATMENT, psychotherapy notes, only my initials
on
the appropriate linein Item 9(a). In the event the healthinformation described below includes any of these types of information, and I
initial
the lineon the box in Item 9(a),I specifically
authorize release ofsuch information tothe person(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 redisclosing such information without my authorization unless permitted to do so under federal or statelaw. I
understand thatI have the rightto requesta listofpeople who may receive or usemy HIV-related information without authorization. If
I experience discrimination because ofthe releaseor disclosure of 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
responsible for protectingmy rights.
3. I have the rightto revoke this authorizationatany timeby writingto the healthcare provider listedbelow. 1 understand that Imay
revoke thisauthorization except to theextentthataction has already been taken based on thisauthorization.
4. I understand that signing thisauthorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibilityfor
benefitswillnot be conditioned upon my authorization ofthisdisclosure.
5. Infomiation disclosed under this authorizationmight 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 of healthprovider or entityto releasethisinformation:

DUAAF RFr¤µ PRARMMy L( PA f t AV ENut N EW ntf AW tho f fo
8. Name and address of person(s$or category ofperson to whom thisinformation will be sent:

A MAlA d. EP-UOLH A IBot tl/
m(.STom ST \\ h FUA Pgoo)U Al
, , , f //20/
9(a). Specific information tobe released:
O Medical Record from (insertdate) to (insertdate)
Q EntireMedical Record, including patient histories,officenotes(except psychotherapy notes),test results,
radiology studies,films,
efen·als,consults,billingrecords, insurance records,and recordssent to you by other healthcare providers.
El Other: prBS ptian and nleiita0 rNudd Include:(Indicate by Initialing)
- Treatment
Gr 7/È21 pmsere AE Alcohol/Drug
A Mental Health Information
Authorization to Discuss Health Information Af, HIV-Related Information

(b) O By initialinghere I authorize
initials Name ofindividualhealthcare provider
todiscuss my healthinformation with my attomey, or a governmental agency, listedhere:

(Attorney/Firm
Name or Governmental Agency Name)
10. Reason forrelease of information: 11. Date or event on which thisauthorization will expire:
O At requestof individual
Q Other: Litigation Upon conclusion of litigation

12. Ifnot the patient,,name of person signing form: 13. Authority tosign on behalf of patient:

All items n thisfo have been completed and my questionsabout thisform have been answered. In addition,I have been provided a
copy of e fo

Date: __ 5/18/ Li
isnature f patient
or representativeauthorized by law.

--
* Huma Virus thatcauses AIDS. The New York StatePublicHealth Law protectsinformation which could
mmunodeficiency reasonably
identif cameana as havi==mu -:-'---° -- -
FILED: KINGS COUNTY CLERK 07/19/2022 04:01 PM INDEX NO. 510246/2021
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 07/19/2022

OCA Official
Form 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 Social SecurityNumber

Alexander Eykher 12-14-1949
) _ _
-

Patient Address

4 Park Ave, Apt 10V, New York, New York 10016

I,or my authorized representative,request thathealth information regarding my careand treatmentbe released as setforth on thisfoma:

In accordance with New York StateLaw and thePrivacy Rule of theHealth Insurance Portabilityand 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 ifI place
TREATMENT, psychotherapy notes, only my initials
on
the appropriate line in Item 9(a). In theevent thehealth information described below includes any of these typesof information, and I
initial
the lineon the box in Item 9(a),I specifically
authorize releaseof such information to theperson(s) indicated inItem 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 to do so under federal or state law. I
understand thatI have the rightto requesta listof peoplewho may receive or usemy HIV-related information without authorization. If
I experience discriminationbecause ofthe release ordisclosure of HIV-related information, I may 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 are
responsiblefor protectingmy rights.
3. I have the rightto revoke this authorizationat any time by writing to thehealth care provider listedbelow. Iunderstand thatI may
revoke thisauthorization except to theextent thataction has alreadybeen taken based on thisauthorization.
4. I understand that signing this authorization is voluntary.My treatment, payment, enrollment ina health plan,or for
eligibility
benefitswill not 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 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 of healthprovider or entityto releasethisinformation:
&* ST'
Cl MA MAJAkiten M.p. 50to StoottvA/, A/y IffM
8. Name and address of person s) orcategory of perlon towhom thismformation willbe sent:

Å GRilhLtASA Bo Dyin&RID AI ST frth Ft”ft M/ //fo/
AAINA , R&xe¤A),
9(a). Specificinformation to be released:
E•Medical Record from (insert
date) 07 / 4/2 to (insert
date) PrasuyF
Q 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.
O Other: Include: (Indicate by Initiating)

J.1% Alcohol/Drug Treatment

45 Mental Health Information
Authorization to Discuss Health Information M HIV-Related Information

(b)Óy here
initiating AE. I authorize (MAAA NiffAA/kO M.D. __
Initials Name Ôf individual
healthcare provider
todiscuss my healthinformation with my attorney,or a governmental agency, listedhere:
AA/A/A d. EElDL\AM CtD0247E coagEL
(Attomey/Fim1 Name or Governmental Agency Name)
10. Reason forrelease ofinformation: 11. Date or event on which thisauthorization willexpire:
O At requestof individual
Q Other: Litigation Upon conclusion of litigation

12. Ifnot the patient,name of person signing form: 13. Authority to signon behalf of patient:

All item.on thisf rm have been completed and my questions about thisform have been answered. In addition,I have been provided a
copy o he fo

Date: 6 f
ignature patientor representativeauthorized by law.

* Human Virus thatcauses AIDS. The New York StatePublic Health Law protectsinformationwhich could
mmunodeficiency reasonably
FILED: KINGS COUNTY CLERK 07/19/2022 04:01 PM INDEX NO. 510246/2021
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 07/19/2022

OCA OfficialForm No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT T

Case Info

Judge

Robin Sheares Track Judge’s New Case

Case No.

(Subscribe to View)

Document Filed Date

November 04, 2021

Case Filing Date

April 30, 2021

County

Parties

DIAMOND, BETH MICHELLE Attorney for the Plaintiff
MENSCHING, PETER THOMAS Attorney for the Defendant
NILT, INC. Defendant
NISSAN-INFINITI LT Defendant
Olena Kharchenko Plaintiff
Ossie R. Munroe Defendant
SLOTNICK, MICHAEL JONATHAN Attorney for the Defendant
NICHOLAS BENEDETTO Attorney
MUSTAPHA NDANUSA Attorney
SCOTT APPELBAUM Attorneys for Plaintiffs
MICHAEL PONTONE Attorney
DOMINIC FAMULARI Attorney
MICHAEL MICHAEL Attorneys for Plaintiffs
EMIL SANCHEZ Attorneys for Plaintiffs
JOHN MERINGOLO Attorney
FABIEN ROBLEY Attorneys for Plaintiffs
ANNA ERVOLINA Attorneys for Defendants

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