Preview
FILED: BRONX COUNTY CLERK 04/26/2021 05:08 PM INDEX NO. 35149/2020E
NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 04/26/2021
EXHIBIT A
FILED: BRONX COUNTY CLERK 04/26/2021 05:08 PM INDEX NO. 35149/2020E
NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 04/26/2021
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF BRONX
----------------------------------------------------------------------X
WILLIAM MARTINEZ and VIVIANA CABRAL, as Index No. 35149/2020E
Parents and Natural Guardians of S.M ., Infant, and
WILLIAM MARTINEZ and VIVIANA CABRAL, NOTICE OF EXCHANGE OF
Individually MEDICAL INFORMATION
Plaintiffs,
-against-
DENISE UMPIERREZ-MORLEY, M.D., TIFFANY SIA,
M.D., CHRISTINA SANDERS MANICE, M.D.,
THOMAS DONG YOON SHIN, M.D., AMY WANG,
M.D., MINI KALLARACKAL, N.P., SANDRA
INFANTINO, N.P., SARAH MILBURN, M.D., SUDHA
KASHYAP, M.D., COLUMBIA UNIVERSITY
DEPARTMENT OF OBSTETRICS AND
GYNECOLOGY, NEW YORK-PRESBYTERIAN THE
UNIVERSITY HOSPITAL OF COLUMBIA AND
CORNELL, COLUMBIA DOCTORS, and THE
TRUSTEES OF COLUMBIA UNIVERSITY IN THE
CITY OF NEW YORK,
Defendants.
----------------------------------------------------------------------X
COUNSELORS:
PLEASE TAKE NOTICE that pursuant to CPLR 3101(d) and the Rules governing the
exchange of medical information, annexed hereto please find the following:
- New York-Presbyterian/University Hospital of Columbia and Cornell (for both
plaintiffs);
- Elizabeth Seton Children’s Rehabilitation Center;
- Bean town;
- Lydig Pediatrics; and
- Community League Health Center (Angeline McQueen, M.D.);
FILED: BRONX COUNTY CLERK 04/26/2021 05:08 PM INDEX NO. 35149/2020E
NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 04/26/2021
With regard to authorization(s) served herewith pursuant to CPLR Section 3121(a), you are
required to provide the undersigned with duplicate copies of whatever documents you obtain
pursuant to said authorizations.
Dated: New York, New York
April 26, 2021
Yours, etc.,
SULLIVAN PAPAIN BLOCK
McGRATH COFFINAS & CANNAVO P.C.
By: Eleni Coffinas
Eleni Coffinas
Attorneys for Plaintiff(s)
120 Broadway
New York, New York 10271
(212) 732-9000
TO:
Martin Clearwater & Bell, LLP
Attorneys for Defendants
90 Merrick Avenue
East Meadow, NY 11554
(516) 222-8500
FILED: BRONX COUNTY CLERK 04/26/2021 05:08 PM INDEX NO. 35149/2020E
NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 04/26/2021
LIMITED POWER OF ATTORNEY
To Execute HIPAA Medical Record Authorization Forms Pursuant
To NY Public Health Law §18 (1(g)As Ameñded 10/26/04
I, VIVIANA CABRAL, resideat 2698 BaileyAvenue, Apt. E12,Bronx, New York 10463 hereby appoint, my attorneys
SullivanPapain Block McGrath Coffinas & Cannavo, P.C.,as my attorneys-in-fact TO ACT, (each agent may act
separately) inmy name, place and stead inany way which Imyself could do, ifIwere personally present to execute
HIPAA medical records authorization forms pursuant to NY public health Law §18 (1(g)as Amended 10/26/04. This
power of Attorney may be revoked by me atany time. This Power of Attorney shallnot be affected by my
subsequent disabilityor incompetence.
This power of attorney expressly and unconditionally waives any doctor/patient and
privileges; or any
expectation of privacywith regard to medical reports and/or records obtained inthe prosecution or defense of my
personal injury litigationwhether from my medical providersand/or reports generated from or on behalf of
physicians retained by or on behalf of defeiidaiitsorInsurance companies. Whether or not the reports and/or
records are in thepublic domain. I expresslyconsent to the use and/or disclosure of these reports and/or records
in thefurtherance ofmy litigationand/or for the benefitof other litigantsand expressly agree that Sullivan Papain
Block McGrath Coffinas& Cannavo, P.C.in itssolediscretion can decide which of my medical records to obtain or
to provide authorizations for release inconnection with any claim or litigationbrought on my behalf.
(DIRECTIONS: Initial
inthe blank space to the leftof yourchoice anyone or more of the fal|üwhig lettered
subdivisions as towhich you WANT to giveyour agent authority. If theblankspace to the leftof any particular
lettered subdivision is NOT NO
initialed, AUTHORITY WILL BE GRANTED for matters thatare included in that
subdivision.)
(Initials)
( ) (a) to obtain any and allmedical records of Viviana CABRAL
( ) (b) to execute a HIPAA compliant form of medical authorization
forthe releaseof any and allmedical records of Viviana CABRAL
( ) (c) to execute an authorization forthe releaseof any and allnon-medical records
NC
of Viviana CABRAL, not limitedto but including employment records,
collateralsource records, school records, and/or No-Fault records.
To induce any third party to acthereunder, I hereby agree that any third party receivinga duly executed
copy or facsimileof thisinstrument may act hereunder, and that revocation or termination hereof shallbe
ineffectiveas to such thirdparty unless and untilactualnotice or knowledge ofsuch revocation or termination
shallhave been received by such third party,and I for
myself and for my heirs,executors, legalrepresentatives and
assigns, hereby agree to indemnify and hold harmless any such thirdparty by reason of such thirdparty having
relied on the provisions of thisinstrument.
ITNESS WHEREOF, I have hereunto signed my name and eal this day of
VIV NA CA RAL
STATE OF·NEW YORK, COUNTY OF ss:
On this day of C , 2020,before me personallycame VIVIANA CABRAL and executed
the oregoing instrument, and duly acknowledged to me that he/she executed the same.
IVONNE E ULLAURI
NOTARY PUDWATE OF NEW YORK
NOTARY PUBLIC
WESTCHE3ÃER COUNTY
LIC. #01UL6221589
COMM. EXP 05/17/20...Ê
FILED: BRONX COUNTY CLERK 04/26/2021 05:08 PM INDEX NO. 35149/2020E
NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 04/26/2021
OCA Ofileinl
Itorm No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[Thisform has been approvedby the New York StateDepartment of Health|
Patient Name | Date of Birth Social Security
Number
, Infant
Patient Address
2698 Bailey Avenue, Apt. E12, Bronx, New York 10463
I, or my authorized request that health informatian
represeraâtive, regardingmy care and treatment
be released as set forth on this form:
In accordance with
New York State Lawand the Privacy
Rule of the Health
insurance and
Portability Act
Accountability of1996
(HIPAA), I understand
that:
1. This authorization
may includedisclosureof information to
relating ALCOHOL and DRUG ABUSE, MENTAL HEALTH
TREATMENT, except psychotherapy
notes, and CONFIDENTIAL HIV* RELATED INFORMATION if I place my initials
only on
the appropriate
linein Item 9(a).
In the event
the heahh described
information below includes
any of these types of and I
infonnation,
initial
the line on the box in item
9(a),1 specifically
authorizerelease of such htfermation
to the person(s)
indicated
in Item 8.
2. If1 am authorizing
the release of alcohol
HIV-related, or drug or
treatment, mental healthtreatment
information,the recipient
is
prohibitedfrom such
redisclosing informationwithoutmy authorization
unlesspermittedto do so under federalorstatelaw. 1
understand that I have the right
to request a list of people who may receive or use my HIV-related
information
withoutauthorization.
If
I experience discrim!neHen
because of
the release or disclosure
of HIV-related I may contact
information, the New York State Division
of Human Rightsat (212)480-2493 or the New York CityCommission of Human Rightsat(212) 306-7450. These agenciesare
responsible
for protecting
my rights.
3. I have the right
to revoke
this authorization
at any time to the health care provider
by writing listed
below. I understand
that I may
revoke this authorization
except to the extent that action
has already been taken based on this authorization.
4. I understandthatsigningthisauthorization
isvoluntary.My treatment,
payment, enrollmentin a health
plan,or for
cligibility
benefits will
not be conditioned
upon my authorization
of this disclosure.
5. informationdisclosed
under thisauthorization
might be redisclosed
by the recipient
(exceptas noted above inItem2), and this
redisclosure
may no longer be protected by federal or state law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICA L
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFlED IN ITEM 9 (b).
7. ame and address of health
rov'der to rel
r entity ase this infonpation:
8. Name and address of person(s) or ca
on of person tohom this infò ation will
be sent
9(a).Specific
informationto be re eased:
O edical Record
from(insert
date) to (insert
date)
Medical
Entire patient
Record, including histories, notes (except
office psychotherapynotes), test results, radiology tilms
studies,
referrals,
consults, insurance records, and records sent to you by other health care providers.
records,
billing
O Other: Include:( Indicate
by Initiating)
Alcohol/Drug Treatment
Mental Health information
Authorizationto Discuss
Health Information HIV-Related Information
(b) O By initialing
here I authorize
initials Name of individual health care provider
to discuss my health informeden
withmy attorney,or a governmental
agency, listed here:
Name or Governmental Agency Name)
(Attorney/Firm ____
10.Reason for release of information: 11.Date or event on which
this authorization
willexpire:
O At request of individual
O Other:Litigation Two years from date ofexecution
.__ ...
.
12. If not the patient,
name of person signing
form: to sign on behalf
13. Authority of patient:
Williarn Martinez Father and natural guardian
Allitems on this form
have been com 'd and my questions have been answered.
about this form I have been provided
In addition, a
fo'
copy of the
Date:
H(te authorized
epresentative by law.
* inn '.......... State Public Health Law protects information
which rensonably could
Hu ney Virus
that causesAIDS. The New York
identifydomeon symptoms or Infection
s having HIV and information
regüi ng a person's contacts.
FILED: BRONX COUNTY CLERK 04/26/2021 05:08 PM INDEX NO. 35149/2020E
NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 04/26/2021
.. 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 ofBirth Social Number
Security
Viviana Cabral
PatientAddress
2698 Bailey Avenue, Apt. E12, Bronx, NY 10463
I, or myauthorizedrepresentative,requestthathealth informationregardingmy careand treatment be releasedas set forth
on thisform:
In accordancewith New York State Law and the PrivacyRule ofthe Health InsurancePortabilityand Act of 1996
Accountability
(HIPAA.), I understandthat:
l. This auilierizaticii
may include disclosureof information relating toALCOHOL 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 thehealth informationdescribed below includesany of these typesof information,and I
initial
thelineon the box in Item9(a),I specifically
authorize releaseofsuch iiiferiiinticii
to the
person(s) indicatedin Item8.
2. IfI am the
autlieriziñg releaseof HIV-related,alcohol or drug treatment,or mental healthtreatment information, therecipientis
prohibited from redisclosingsuch information without my authorizationunless permitted to do so under federal or statelaw. I
understand thatI havethe righttorequesta list
of people who may receiveor use my HIV-related iiiforiiiation
without authorization.If
I experiencediscriminationbecause ofthe releaseor disclosureofHIV-related information,I may contactthe New York StateDivision
of Human Rights at(212) 480-2493 or theNew York CityCommission of Human Rights at(212) 306-7450. These agencies are
responsibleforprotectingmy rights.
3. I have therightto revoke thisauthorizationat anytime by writingto thehealth careprovider listed
below. I understandthatI may
revoke thisauthorizationexceptto theextentthataction has alreadybeen takenbased on thisauthorization.
4. I understand thatsigning this authorizationisvoluntary. My treatment, payñicñ‡,enrollment in a healthplan,or for
eligibility
benefitswillnotbe conditioned upon my authorizationof this
disclosure.
5. Information disclosed under thisauthorizationmight be redisclosedby the reciplout(except as noted above in Item 2), and this
redisclosuremay no longerbe protectedby federalor state
law.
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 entity
to releasethisinformation:
New York-Presbyterian/University Hospital of Cekmbie & Cornell, 1414 York Ave, New York, NY 10021
8. Name and address ofperson(s)or categoryof personto whom thisinformation willbe sent:
Martin Clearwater & Bell,LLP, 90 Merrick Ave, East Meadow, New York 11554
9(a). Specificinformationto be released:
El Medical Record from (insert
date) December 1, 2017 to (insert
date) January 1, 2018
O EntireMedical Record, includingpatient office
histories, notes(except psychotherapy notes),test
results,radiologystudies,films,
referrals,
consults, records,
billing insurancerecords,and records sentto you by otherhealthcare providers.
O Other: Include:(1ndicateby Initialing)
Alcohol/Drug Treatment
Mental Health Information
Autherizaticñ to DiscussHealth Information HIV Rc!nted Information
(b)O By here
initialing I authorize
Initials Name of individual
health care provider
to discussmy healthinformation with my attorney,or a goveriiñiental
agency, listed
here:
(Attorney/Firm
Name or Goveriiiiicii:ãl
Agency Name)
10. Reason forreleaseof infGriiiaticñ: I1. Date orevent on which thisauthorization
will expire:
O At requestof liidividual
ElOther: Litigation Two years from date of execution
12. Ifnot the patient,
name ofperson signing form: 13. Authority on
to sign behalf ofpatient:
Elyssa Shifren, Esq. Attorney in Fact (Power of Attorney attached to request)
All itemson thisform have been completed and my questions about thisform have been answered. In I have
addition, been provided a
copy of he form.
Date:
Signatur o patientorrepresentatve authorizedby law.
* Human Virus thatcauses AIDS.The New York StatePublicHealth Law protectsinfGrmatiGñwhich rea::cnablycould
in::::±ñeiency
someone
identify as havingHIV symptcas or infection
and liifGrmatiGñ
regarding a person's
contacts.
FILED: BRONX COUNTY CLERK 04/26/2021 05:08 PM INDEX NO. 35149/2020E
NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 04/26/2021
asu
' OCA Official
17ormNo.: 960
..t L AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
Wro [Thisform has been approvedby the New York StateDepartment of Health|
Patient Name Date of Birth Social Security
Number
I rr - - - - -
Patient Address
2698 Bailey Avenue, Apt, E12, Bronx, New York 10463
I, or my authorized request that health
representative, infen"-Us regardingmy care and treatment
be released as set forth on this form:
In accordance with
New York State Law and the Privacy
Rule of the Health
Insurance Portability
and Accountability
Act of1996
(HIPAA), I understand
that:
1. Thisauiburisi¡un may includedisclosureof information to
relating ALCOHOL and DRUG ABUSE, MENTAL HEALTH
TREATMENT, except psychotherapy
notes, and CONFIDENTIAL HIV* RELATED INFORMATION if I place my
initials
on
only
the appropriate
linein Item 9(a).
In the event the health described
information below includes
any of these types of information,
and I
the line on the box in Item
initial 9(a), I specifically
authorizerelease of such information
to the person(s) in Item 8.
indicated
2. IfI am authorizing
the release of
HIV-related,alcoholor drug or
treatment, mental healthtreatment
information,the recipient
is
prohibitedfrom such
redisclosing informationwithoutmy unless
authorization permittedto do so under federalorstatelaw. I
understand that I have the right
to request a list of people who may receive
or use my HIV-related without
information If
authorization.
I experience discrimination
because of the release or disclosure
of HIV-related 1 may contact
information, the New YorkState Division
of Human Rightsat (212)480-2493 or the New York CityCommission ofHuman Rightsat (212)306-7450. These agenciesare
responsible
for protecting
my rights.
3. I have the right
to revoke
this authorization
at any time to the health care provider
by writing listed
below. I understand
that I may
revoke this authorization
except to the extent that action
has already been taken based on this authorization.
4. Iunderstand thatsigningthisauthorization
isvoluntary.My treatment,
payment, enrollmentina healthplan,or for
cligibility
benefits will
not be conditioned
upon my authorization
of this disclosure.
5. informationdisclosed
under thisauthorization
might be redisclosed
by the recipient
(exceptas notedabove in Item2), and this
redisclosure
may no longer be protected by federal or state law.
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 addressf health provider
or entity
to releathis information:
8. Naln andsahdress of person s) or cate
ory of person¼whor this inform
tion will
be se 1:
9(a).S ificinformation
to be released:
edicalRecord from(insert
date) to (insert
date)
EntireMedicalRecord,includingpatient histories,
officenotes (except psychotherapy
notes), test results,
radiology tilms,
studies,
consults,
referrals, billing insurance records, and records sent to you by other health care providers.
records,
O Other: Include:
(Indicateby Initialing)
Alcohol/Drug Treatment
Mental Health Information
Authorizationto Discuss Health
Information HIV-Related Information
(b) O By initialing
here I authorize
InitinIs Name of individual health cure provider
to discuss my health information
withmy attorney,or a governmental here:
agency, listed
(Attorney/Firm Name or Governmental Agency Name)
10. Reason for release of information: I I.Date or event on which will
this authorization expire:
O At request of individual
LIGgüticni
El Other: Two years from date ofexecution
12. If not the patient,
name of person signing
form: 13. to sign on behalf
Authority of patient:
William Martinez Father and naturalguardian
I
All have been comp
items on this form and my questions about this form
have been answered. I have been provided
In addition, a
.--- --
copy of the foi
Date:
Signa ure patiegforr esentative
authorized
by law.
* - in which reasonably could
Human that causesAIDS. The New Yoric State Public Henlth Law protects
aiicy Virus
Identify someone as having HIV
symptoms or infection
and liifarniáHüii
regardñga person's contacts.
FILED: BRONX COUNTY CLERK 04/26/2021 05:08 PM INDEX NO. 35149/2020E
NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 04/26/2021
OCA Ofileial
Form No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[Thisform has been approvedby the New York StateDepartmciit of Health|
Patient Name
| Date of Birth Social Security
Number
Patient Address
2698 BaileyAvenue, Apt. E12, Bronx, New York 10463
I, or my authorized request that health information
representative, regardingmy care and treatment
be released as set forth on this form:
In accordance with
New York State Lawand the Privacy
Rule of the Health
Insurance Portability
and Accountability
Act of1996
(HIPAA), 1 understand
that:
1. This authorization
may includedisclosureof information t
Preview
FILED: BRONX COUNTY CLERK 04/26/2021 05:08 PM INDEX NO. 35149/2020E NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 04/26/2021 EXHIBIT A FILED: BRONX COUNTY CLERK 04/26/2021 05:08 PM INDEX NO. 35149/2020E NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 04/26/2021 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF BRONX ----------------------------------------------------------------------X WILLIAM MARTINEZ and VIVIANA CABRAL, as Index No. 35149/2020E Parents and Natural Guardians of S.M ., Infant, and WILLIAM MARTINEZ and VIVIANA CABRAL, NOTICE OF EXCHANGE OF Individually MEDICAL INFORMATION Plaintiffs, -against- DENISE UMPIERREZ-MORLEY, M.D., TIFFANY SIA, M.D., CHRISTINA SANDERS MANICE, M.D., THOMAS DONG YOON SHIN, M.D., AMY WANG, M.D., MINI KALLARACKAL, N.P., SANDRA INFANTINO, N.P., SARAH MILBURN, M.D., SUDHA KASHYAP, M.D., COLUMBIA UNIVERSITY DEPARTMENT OF OBSTETRICS AND GYNECOLOGY, NEW YORK-PRESBYTERIAN THE UNIVERSITY HOSPITAL OF COLUMBIA AND CORNELL, COLUMBIA DOCTORS, and THE TRUSTEES OF COLUMBIA UNIVERSITY IN THE CITY OF NEW YORK, Defendants. ----------------------------------------------------------------------X COUNSELORS: PLEASE TAKE NOTICE that pursuant to CPLR 3101(d) and the Rules governing the exchange of medical information, annexed hereto please find the following: - New York-Presbyterian/University Hospital of Columbia and Cornell (for both plaintiffs); - Elizabeth Seton Children’s Rehabilitation Center; - Bean town; - Lydig Pediatrics; and - Community League Health Center (Angeline McQueen, M.D.); FILED: BRONX COUNTY CLERK 04/26/2021 05:08 PM INDEX NO. 35149/2020E NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 04/26/2021 With regard to authorization(s) served herewith pursuant to CPLR Section 3121(a), you are required to provide the undersigned with duplicate copies of whatever documents you obtain pursuant to said authorizations. Dated: New York, New York April 26, 2021 Yours, etc., SULLIVAN PAPAIN BLOCK McGRATH COFFINAS & CANNAVO P.C. By: Eleni Coffinas Eleni Coffinas Attorneys for Plaintiff(s) 120 Broadway New York, New York 10271 (212) 732-9000 TO: Martin Clearwater & Bell, LLP Attorneys for Defendants 90 Merrick Avenue East Meadow, NY 11554 (516) 222-8500 FILED: BRONX COUNTY CLERK 04/26/2021 05:08 PM INDEX NO. 35149/2020E NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 04/26/2021 LIMITED POWER OF ATTORNEY To Execute HIPAA Medical Record Authorization Forms Pursuant To NY Public Health Law §18 (1(g)As Ameñded 10/26/04 I, VIVIANA CABRAL, resideat 2698 BaileyAvenue, Apt. E12,Bronx, New York 10463 hereby appoint, my attorneys SullivanPapain Block McGrath Coffinas & Cannavo, P.C.,as my attorneys-in-fact TO ACT, (each agent may act separately) inmy name, place and stead inany way which Imyself could do, ifIwere personally present to execute HIPAA medical records authorization forms pursuant to NY public health Law §18 (1(g)as Amended 10/26/04. This power of Attorney may be revoked by me atany time. This Power of Attorney shallnot be affected by my subsequent disabilityor incompetence. This power of attorney expressly and unconditionally waives any doctor/patient and privileges; or any expectation of privacywith regard to medical reports and/or records obtained inthe prosecution or defense of my personal injury litigationwhether from my medical providersand/or reports generated from or on behalf of physicians retained by or on behalf of defeiidaiitsorInsurance companies. Whether or not the reports and/or records are in thepublic domain. I expresslyconsent to the use and/or disclosure of these reports and/or records in thefurtherance ofmy litigationand/or for the benefitof other litigantsand expressly agree that Sullivan Papain Block McGrath Coffinas& Cannavo, P.C.in itssolediscretion can decide which of my medical records to obtain or to provide authorizations for release inconnection with any claim or litigationbrought on my behalf. (DIRECTIONS: Initial inthe blank space to the leftof yourchoice anyone or more of the fal|üwhig lettered subdivisions as towhich you WANT to giveyour agent authority. If theblankspace to the leftof any particular lettered subdivision is NOT NO initialed, AUTHORITY WILL BE GRANTED for matters thatare included in that subdivision.) (Initials) ( ) (a) to obtain any and allmedical records of Viviana CABRAL ( ) (b) to execute a HIPAA compliant form of medical authorization forthe releaseof any and allmedical records of Viviana CABRAL ( ) (c) to execute an authorization forthe releaseof any and allnon-medical records NC of Viviana CABRAL, not limitedto but including employment records, collateralsource records, school records, and/or No-Fault records. To induce any third party to acthereunder, I hereby agree that any third party receivinga duly executed copy or facsimileof thisinstrument may act hereunder, and that revocation or termination hereof shallbe ineffectiveas to such thirdparty unless and untilactualnotice or knowledge ofsuch revocation or termination shallhave been received by such third party,and I for myself and for my heirs,executors, legalrepresentatives and assigns, hereby agree to indemnify and hold harmless any such thirdparty by reason of such thirdparty having relied on the provisions of thisinstrument. ITNESS WHEREOF, I have hereunto signed my name and eal this day of VIV NA CA RAL STATE OF·NEW YORK, COUNTY OF ss: On this day of C , 2020,before me personallycame VIVIANA CABRAL and executed the oregoing instrument, and duly acknowledged to me that he/she executed the same. IVONNE E ULLAURI NOTARY PUDWATE OF NEW YORK NOTARY PUBLIC WESTCHE3ÃER COUNTY LIC. #01UL6221589 COMM. EXP 05/17/20...Ê FILED: BRONX COUNTY CLERK 04/26/2021 05:08 PM INDEX NO. 35149/2020E NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 04/26/2021 OCA Ofileinl Itorm No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [Thisform has been approvedby the New York StateDepartment of Health| Patient Name | Date of Birth Social Security Number , Infant Patient Address 2698 Bailey Avenue, Apt. E12, Bronx, New York 10463 I, or my authorized request that health informatian represeraâtive, regardingmy care and treatment be released as set forth on this form: In accordance with New York State Lawand the Privacy Rule of the Health insurance and Portability Act Accountability of1996 (HIPAA), I understand that: 1. This authorization may includedisclosureof information to relating ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION if I place my initials only on the appropriate linein Item 9(a). In the event the heahh described information below includes any of these types of and I infonnation, initial the line on the box in item 9(a),1 specifically authorizerelease of such htfermation to the person(s) indicated in Item 8. 2. If1 am authorizing the release of alcohol HIV-related, or drug or treatment, mental healthtreatment information,the recipient is prohibitedfrom such redisclosing informationwithoutmy authorization unlesspermittedto do so under federalorstatelaw. 1 understand that I have the right to request a list of people who may receive or use my HIV-related information withoutauthorization. If I experience discrim!neHen because of the release or disclosure of HIV-related I may contact information, the New York State Division of Human Rightsat (212)480-2493 or the New York CityCommission of Human Rightsat(212) 306-7450. These agenciesare responsible for protecting my rights. 3. I have the right to revoke this authorization at any time to the health care provider by writing listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understandthatsigningthisauthorization isvoluntary.My treatment, payment, enrollmentin a health plan,or for cligibility benefits will not be conditioned upon my authorization of this disclosure. 5. informationdisclosed under thisauthorization might be redisclosed by the recipient (exceptas noted above inItem2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICA L CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFlED IN ITEM 9 (b). 7. ame and address of health rov'der to rel r entity ase this infonpation: 8. Name and address of person(s) or ca on of person tohom this infò ation will be sent 9(a).Specific informationto be re eased: O edical Record from(insert date) to (insert date) Medical Entire patient Record, including histories, notes (except office psychotherapynotes), test results, radiology tilms studies, referrals, consults, insurance records, and records sent to you by other health care providers. records, billing O Other: Include:( Indicate by Initiating) Alcohol/Drug Treatment Mental Health information Authorizationto Discuss Health Information HIV-Related Information (b) O By initialing here I authorize initials Name of individual health care provider to discuss my health informeden withmy attorney,or a governmental agency, listed here: Name or Governmental Agency Name) (Attorney/Firm ____ 10.Reason for release of information: 11.Date or event on which this authorization willexpire: O At request of individual O Other:Litigation Two years from date ofexecution .__ ... . 12. If not the patient, name of person signing form: to sign on behalf 13. Authority of patient: Williarn Martinez Father and natural guardian Allitems on this form have been com 'd and my questions have been answered. about this form I have been provided In addition, a fo' copy of the Date: H(te authorized epresentative by law. * inn '.......... State Public Health Law protects information which rensonably could Hu ney Virus that causesAIDS. The New York identifydomeon symptoms or Infection s having HIV and information regüi ng a person's contacts. FILED: BRONX COUNTY CLERK 04/26/2021 05:08 PM INDEX NO. 35149/2020E NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 04/26/2021 .. 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 ofBirth Social Number Security Viviana Cabral PatientAddress 2698 Bailey Avenue, Apt. E12, Bronx, NY 10463 I, or myauthorizedrepresentative,requestthathealth informationregardingmy careand treatment be releasedas set forth on thisform: In accordancewith New York State Law and the PrivacyRule ofthe Health InsurancePortabilityand Act of 1996 Accountability (HIPAA.), I understandthat: l. This auilierizaticii may include disclosureof information relating toALCOHOL 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 thehealth informationdescribed below includesany of these typesof information,and I initial thelineon the box in Item9(a),I specifically authorize releaseofsuch iiiferiiinticii to the person(s) indicatedin Item8. 2. IfI am the autlieriziñg releaseof HIV-related,alcohol or drug treatment,or mental healthtreatment information, therecipientis prohibited from redisclosingsuch information without my authorizationunless permitted to do so under federal or statelaw. I understand thatI havethe righttorequesta list of people who may receiveor use my HIV-related iiiforiiiation without authorization.If I experiencediscriminationbecause ofthe releaseor disclosureofHIV-related information,I may contactthe New York StateDivision of Human Rights at(212) 480-2493 or theNew York CityCommission of Human Rights at(212) 306-7450. These agencies are responsibleforprotectingmy rights. 3. I have therightto revoke thisauthorizationat anytime by writingto thehealth careprovider listed below. I understandthatI may revoke thisauthorizationexceptto theextentthataction has alreadybeen takenbased on thisauthorization. 4. I understand thatsigning this authorizationisvoluntary. My treatment, payñicñ‡,enrollment in a healthplan,or for eligibility benefitswillnotbe conditioned upon my authorizationof this disclosure. 5. Information disclosed under thisauthorizationmight be redisclosedby the reciplout(except as noted above in Item 2), and this redisclosuremay no longerbe protectedby federalor state law. 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 entity to releasethisinformation: New York-Presbyterian/University Hospital of Cekmbie & Cornell, 1414 York Ave, New York, NY 10021 8. Name and address ofperson(s)or categoryof personto whom thisinformation willbe sent: Martin Clearwater & Bell,LLP, 90 Merrick Ave, East Meadow, New York 11554 9(a). Specificinformationto be released: El Medical Record from (insert date) December 1, 2017 to (insert date) January 1, 2018 O EntireMedical Record, includingpatient office histories, notes(except psychotherapy notes),test results,radiologystudies,films, referrals, consults, records, billing insurancerecords,and records sentto you by otherhealthcare providers. O Other: Include:(1ndicateby Initialing) Alcohol/Drug Treatment Mental Health Information Autherizaticñ to DiscussHealth Information HIV Rc!nted Information (b)O By here initialing I authorize Initials Name of individual health care provider to discussmy healthinformation with my attorney,or a goveriiñiental agency, listed here: (Attorney/Firm Name or Goveriiiiicii:ãl Agency Name) 10. Reason forreleaseof infGriiiaticñ: I1. Date orevent on which thisauthorization will expire: O At requestof liidividual ElOther: Litigation Two years from date of execution 12. Ifnot the patient, name ofperson signing form: 13. Authority on to sign behalf ofpatient: Elyssa Shifren, Esq. Attorney in Fact (Power of Attorney attached to request) All itemson thisform have been completed and my questions about thisform have been answered. In I have addition, been provided a copy of he form. Date: Signatur o patientorrepresentatve authorizedby law. * Human Virus thatcauses AIDS.The New York StatePublicHealth Law protectsinfGrmatiGñwhich rea::cnablycould in::::±ñeiency someone identify as havingHIV symptcas or infection and liifGrmatiGñ regarding a person's contacts. FILED: BRONX COUNTY CLERK 04/26/2021 05:08 PM INDEX NO. 35149/2020E NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 04/26/2021 asu ' OCA Official 17ormNo.: 960 ..t L AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA Wro [Thisform has been approvedby the New York StateDepartment of Health| Patient Name Date of Birth Social Security Number I rr - - - - - Patient Address 2698 Bailey Avenue, Apt, E12, Bronx, New York 10463 I, or my authorized request that health representative, infen"-Us regardingmy care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of1996 (HIPAA), I understand that: 1. Thisauiburisi¡un may includedisclosureof information to relating ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION if I place my initials on only the appropriate linein Item 9(a). In the event the health described information below includes any of these types of information, and I the line on the box in Item initial 9(a), I specifically authorizerelease of such information to the person(s) in Item 8. indicated 2. IfI am authorizing the release of HIV-related,alcoholor drug or treatment, mental healthtreatment information,the recipient is prohibitedfrom such redisclosing informationwithoutmy unless authorization permittedto do so under federalorstatelaw. I understand that I have the right to request a list of people who may receive or use my HIV-related without information If authorization. I experience discrimination because of the release or disclosure of HIV-related 1 may contact information, the New YorkState Division of Human Rightsat (212)480-2493 or the New York CityCommission ofHuman Rightsat (212)306-7450. These agenciesare responsible for protecting my rights. 3. I have the right to revoke this authorization at any time to the health care provider by writing listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. Iunderstand thatsigningthisauthorization isvoluntary.My treatment, payment, enrollmentina healthplan,or for cligibility benefits will not be conditioned upon my authorization of this disclosure. 5. informationdisclosed under thisauthorization might be redisclosed by the recipient (exceptas notedabove in Item2), and this redisclosure may no longer be protected by federal or state law. 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 addressf health provider or entity to releathis information: 8. Naln andsahdress of person s) or cate ory of person¼whor this inform tion will be se 1: 9(a).S ificinformation to be released: edicalRecord from(insert date) to (insert date) EntireMedicalRecord,includingpatient histories, officenotes (except psychotherapy notes), test results, radiology tilms, studies, consults, referrals, billing insurance records, and records sent to you by other health care providers. records, O Other: Include: (Indicateby Initialing) Alcohol/Drug Treatment Mental Health Information Authorizationto Discuss Health Information HIV-Related Information (b) O By initialing here I authorize InitinIs Name of individual health cure provider to discuss my health information withmy attorney,or a governmental here: agency, listed (Attorney/Firm Name or Governmental Agency Name) 10. Reason for release of information: I I.Date or event on which will this authorization expire: O At request of individual LIGgüticni El Other: Two years from date ofexecution 12. If not the patient, name of person signing form: 13. to sign on behalf Authority of patient: William Martinez Father and naturalguardian I All have been comp items on this form and my questions about this form have been answered. I have been provided In addition, a .--- -- copy of the foi Date: Signa ure patiegforr esentative authorized by law. * - in which reasonably could Human that causesAIDS. The New Yoric State Public Henlth Law protects aiicy Virus Identify someone as having HIV symptoms or infection and liifarniáHüii regardñga person's contacts. FILED: BRONX COUNTY CLERK 04/26/2021 05:08 PM INDEX NO. 35149/2020E NYSCEF DOC. NO. 24 RECEIVED NYSCEF: 04/26/2021 OCA Ofileial Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [Thisform has been approvedby the New York StateDepartmciit of Health| Patient Name | Date of Birth Social Security Number Patient Address 2698 BaileyAvenue, Apt. E12, Bronx, New York 10463 I, or my authorized request that health information representative, regardingmy care and treatment be released as set forth on this form: In accordance with New York State Lawand the Privacy Rule of the Health Insurance Portability and Accountability Act of1996 (HIPAA), 1 understand that: 1. This authorization may includedisclosureof information t