Preview
FILED: WESTCHESTER COUNTY CLERK 03/24/2021 06:02 PM INDEX NO. 64205/2020
NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 03/24/2021
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF WESTCHESTER
-----------------------------------------------------------------------X
KEVIN LYNCH as Administrator of the Estate of ROSE Index No. 64205/2020
BOUKNIGHT,
Plaintiffs, DEMAND FOR MEDICARE /
MEDICAID INFORMATION
-against-
MONTEFIORE MEDICAL CENTER, GLEN ISLAND
CENTER FOR NURSING AND REHABILITATION and
JOPAL BRONX LLC d/b/a WORKMEN’S CIRCLE
MULTICARE CENTER,
Defendants.
-----------------------------------------------------------------------X
PLEASE TAKE NOTICE, that defendant JOPAL BRONX LLC d/b/a WORKMEN’S
CIRCLE MULTICARE CENTER, demands that plaintiff provide the following:
1. Pursuant to CPLR 3120(a) and the requirements of Section IIIof the
Medicare, Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 1395(y)(b)(7) and
(b)(8), provide:
a. The plaintiff’s date of birth;
b. The plaintiff’s Social Security Number;
c. The plaintiff’s Medicare Health Insurance Claim Numbers (HICNs),
Medicaid file number, New York State Department of Social
Services (DSS) file number, and/or Medicare Secondary Payer
(MSP) file number, if applicable;
d. If the plaintiff applied for or was awarded Medicare and/or
Medicaid and/or DSS and/or MSP benefits, all
information/documentation related to the application and/or award
of said benefits;
e. If the plaintiffapplied for or was awarded Supplemental Security
Income (SSI) or Social Security Disability Insurance (SSDI), all
information/documentation related to the application and/or award
of said benefits;
f. If the plaintiff was denied Medicare, Medicaid, SSI, and/or SSDI
benefits, provide all information/documentation concerning any
such denial; and
g. If the plaintiff appealed the denial of Medicare, Medicaid, SSI,
and/or, SSDI benefits, provide all information/documentation of
7145083
1 of 4
FILED: WESTCHESTER COUNTY CLERK 03/24/2021 06:02 PM INDEX NO. 64205/2020
NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 03/24/2021
any such appeal of the denial of such benefits.
2. State whether Medicare, Medicaid, and/or Social Security Administration
has a lien on any potential award, judgment or settlement in this lawsuit and, if so, state
the amount of liens and provide all information and documentation relative to these liens.
3. Pursuant to CPLR § 3101(a), provide executed and acknowledged written
authorizations permitting defendant’s attorneys and defendant’s representatives to
obtain and make of all Medicare records, Parts A and B, specifying the correct address
of said Medicare office, along with plaintiff’s Social Security Number and file number.
Defendant further demands that a signed original of the attached Authorization of Use
and Disclosure of Health Information and/or a specific authorization required by
Medicare be executed and provided to the undersigned for use in conjunction with this
demand.
4. Pursuant to CPLR §3101(a), provide duly executed and acknowledged
written authorizations permitting defendant’s attorneys and defendant’s representatives
to obtain and make of all Medicaid records, specifying the correct address of said
Medicaid office, along with plaintiff’s Social Security Number and file number. Defendant
further demands that a signed original of the attached Authorization for Release of
Medicaid Protected Information, and/or any other specific authorization required by
Medicaid be executed and provided for use in conjunction with this demand as it pertains
to health information.
5. If the plaintiff received or applied Social Security benefits, including but
not limited to SSI or SSDI benefits, provide a duly executed and acknowledged written
authorization setting forth the correct Social Security file number, allowing the
defendant’s attorneys and defendant’s representatives to obtain and make copies of all
files, records, and reports of the Social Security Administration regarding the plaintiff.
Said defendant further demands that a signed original of the attached Social Security
Administration Consent for Release of Information and/or any other specific
authorization required by the Social Security Administration be executed and provided
for use in conjunction with this demand as it pertains to health information.
PLEASE TAKE FURTHER NOTICE, that the provisions of CPLR §3122 govern this
demand and if the party to whom the notice is directed objects to the disclosure, inspection or
examination or withholds any documents which appear to be within the category of the
documents required by the notice, compliance with CPLR §3122 is required.
PLEASE TAKE FURTHER NOTICE, that in the event of failure or refusal to comply with
any of these demands, said defendant will apply to the Court for the appropriate relief including,
but not limited to, an Order compelling compliance pursuant to CPLR §3124 and/or appropriate
relief pursuant to CPLR § 3126 and 22 N.Y.C.R.R. Part 130.
2
7145083
2 of 4
FILED: WESTCHESTER COUNTY CLERK 03/24/2021 06:02 PM INDEX NO. 64205/2020
NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 03/24/2021
To the best of my knowledge, information and belief, formed after an inquiry reasonable under the
circumstances, the presentation of this paper or the contentions herein are not frivolous, as that
term is defined in Part 130 of the Court Rules.
Dated: Garden City, New York
March 24, 2021
Yours, etc.,
KAUFMAN BORGEEST & RYAN LLP
_________________________________
By: Gonzalo G. Suarez, Esq.
Attorneys for Defendants
JOPAL BRONX LLC d/b/a WORKMEN’S CIRCLE
MULTICARE CENTER
1205 Franklin Avenue, Suite 200
Garden City, New York 11530
(516) 248-6000
KBR File No: 470.040
TO: SINEL & OLESEN, PLLC
Attorneys for Plaintiff
7 Penn Plaza, 8th Floor
New York, New York 10001
sinelecf@sinellaw.com
(212) 465-1000
Jason D. Turken, Esq.
TURKEN, HEATH & McCAULEY, LLP
Attorneys for Defendant
MONTEFIORE MEDICAL CENTER
84 Business Pak Drive, Suite 307
Armonk, New York 10504
jturken@thmllp.com
(914) 357-8600
Nicole Atlas, Esq.
SHEELEY LLP
Attorneys for Defendant
GLEN ISLAND CENTER FOR NURSING AND REHABILITATION
100 Wall Street, 19th Floor
New York, New York 10005
atlas@sheeleyllp.com
(646) 650-5952
3
7145083
3 of 4
FILED: WESTCHESTER COUNTY CLERK 03/24/2021 06:02 PM INDEX NO. 64205/2020
NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 03/24/2021
AFFIDAVIT OF SERVICE VIA ECF & E-MAIL
STATE OF NEW YORK )
) ss.:
COUNTY OF NASSAU )
Ilana German, being duly sworn, deposes and says:
That deponent is nota party to thisaction, isover 18 years of age and resides in Suffolk County,
New York.
24th
That on day of March, 2021, deponent served the within DEMAND FOR
MEDICARE/MEDICAID INFORMATION, upon:
VIA ECF & E-MAIL
SINEL & OLESEN, PLLC
Attorneys for Plaintiff
8th
7 Penn Plaza, Floor
New York, New York 10001
sinelecf@sinellaw.com
(212) 465-1000
Jason D. Turken, Esq.
TURKEN, HEATH & McCAULEY, LLP
Attorneys for Defendant
MONTEFIORE MEDICAL CENTER
84 Business Pak Drive, Suite 307
Armonk, New York 10504
iturken@thmilp.com
(914) 357-8600
Nicole Atlas, Esq.
SHEELEY LLP
Attorneys for Defendant
GLEN ISLAND CENTER FOR NURSING AND REHABILITATION
19th
100 Wall Street, FlOOr
New York, New York 10005
atlas@sheeleyllp.com
(646) 650-5952
allattorneys in thisaction via ECF (electronic court and
filing) by transmitting the same to allattorneys via
E-Mail.
Ilana German
Sworn to before me this
24th
day Of March,
2021.,
Notary ublic
NANCY BARBATQ
NOTARY PUBLIC, State of New Yoth
No. OtBA0024216
Quafflied toWestcheater County
Commission expires s/3/
6872066
4 of 4
Preview
FILED: WESTCHESTER COUNTY CLERK 03/24/2021 06:02 PM INDEX NO. 64205/2020 NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 03/24/2021 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF WESTCHESTER -----------------------------------------------------------------------X KEVIN LYNCH as Administrator of the Estate of ROSE Index No. 64205/2020 BOUKNIGHT, Plaintiffs, DEMAND FOR MEDICARE / MEDICAID INFORMATION -against- MONTEFIORE MEDICAL CENTER, GLEN ISLAND CENTER FOR NURSING AND REHABILITATION and JOPAL BRONX LLC d/b/a WORKMEN’S CIRCLE MULTICARE CENTER, Defendants. -----------------------------------------------------------------------X PLEASE TAKE NOTICE, that defendant JOPAL BRONX LLC d/b/a WORKMEN’S CIRCLE MULTICARE CENTER, demands that plaintiff provide the following: 1. Pursuant to CPLR 3120(a) and the requirements of Section IIIof the Medicare, Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 1395(y)(b)(7) and (b)(8), provide: a. The plaintiff’s date of birth; b. The plaintiff’s Social Security Number; c. The plaintiff’s Medicare Health Insurance Claim Numbers (HICNs), Medicaid file number, New York State Department of Social Services (DSS) file number, and/or Medicare Secondary Payer (MSP) file number, if applicable; d. If the plaintiff applied for or was awarded Medicare and/or Medicaid and/or DSS and/or MSP benefits, all information/documentation related to the application and/or award of said benefits; e. If the plaintiffapplied for or was awarded Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI), all information/documentation related to the application and/or award of said benefits; f. If the plaintiff was denied Medicare, Medicaid, SSI, and/or SSDI benefits, provide all information/documentation concerning any such denial; and g. If the plaintiff appealed the denial of Medicare, Medicaid, SSI, and/or, SSDI benefits, provide all information/documentation of 7145083 1 of 4 FILED: WESTCHESTER COUNTY CLERK 03/24/2021 06:02 PM INDEX NO. 64205/2020 NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 03/24/2021 any such appeal of the denial of such benefits. 2. State whether Medicare, Medicaid, and/or Social Security Administration has a lien on any potential award, judgment or settlement in this lawsuit and, if so, state the amount of liens and provide all information and documentation relative to these liens. 3. Pursuant to CPLR § 3101(a), provide executed and acknowledged written authorizations permitting defendant’s attorneys and defendant’s representatives to obtain and make of all Medicare records, Parts A and B, specifying the correct address of said Medicare office, along with plaintiff’s Social Security Number and file number. Defendant further demands that a signed original of the attached Authorization of Use and Disclosure of Health Information and/or a specific authorization required by Medicare be executed and provided to the undersigned for use in conjunction with this demand. 4. Pursuant to CPLR §3101(a), provide duly executed and acknowledged written authorizations permitting defendant’s attorneys and defendant’s representatives to obtain and make of all Medicaid records, specifying the correct address of said Medicaid office, along with plaintiff’s Social Security Number and file number. Defendant further demands that a signed original of the attached Authorization for Release of Medicaid Protected Information, and/or any other specific authorization required by Medicaid be executed and provided for use in conjunction with this demand as it pertains to health information. 5. If the plaintiff received or applied Social Security benefits, including but not limited to SSI or SSDI benefits, provide a duly executed and acknowledged written authorization setting forth the correct Social Security file number, allowing the defendant’s attorneys and defendant’s representatives to obtain and make copies of all files, records, and reports of the Social Security Administration regarding the plaintiff. Said defendant further demands that a signed original of the attached Social Security Administration Consent for Release of Information and/or any other specific authorization required by the Social Security Administration be executed and provided for use in conjunction with this demand as it pertains to health information. PLEASE TAKE FURTHER NOTICE, that the provisions of CPLR §3122 govern this demand and if the party to whom the notice is directed objects to the disclosure, inspection or examination or withholds any documents which appear to be within the category of the documents required by the notice, compliance with CPLR §3122 is required. PLEASE TAKE FURTHER NOTICE, that in the event of failure or refusal to comply with any of these demands, said defendant will apply to the Court for the appropriate relief including, but not limited to, an Order compelling compliance pursuant to CPLR §3124 and/or appropriate relief pursuant to CPLR § 3126 and 22 N.Y.C.R.R. Part 130. 2 7145083 2 of 4 FILED: WESTCHESTER COUNTY CLERK 03/24/2021 06:02 PM INDEX NO. 64205/2020 NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 03/24/2021 To the best of my knowledge, information and belief, formed after an inquiry reasonable under the circumstances, the presentation of this paper or the contentions herein are not frivolous, as that term is defined in Part 130 of the Court Rules. Dated: Garden City, New York March 24, 2021 Yours, etc., KAUFMAN BORGEEST & RYAN LLP _________________________________ By: Gonzalo G. Suarez, Esq. Attorneys for Defendants JOPAL BRONX LLC d/b/a WORKMEN’S CIRCLE MULTICARE CENTER 1205 Franklin Avenue, Suite 200 Garden City, New York 11530 (516) 248-6000 KBR File No: 470.040 TO: SINEL & OLESEN, PLLC Attorneys for Plaintiff 7 Penn Plaza, 8th Floor New York, New York 10001 sinelecf@sinellaw.com (212) 465-1000 Jason D. Turken, Esq. TURKEN, HEATH & McCAULEY, LLP Attorneys for Defendant MONTEFIORE MEDICAL CENTER 84 Business Pak Drive, Suite 307 Armonk, New York 10504 jturken@thmllp.com (914) 357-8600 Nicole Atlas, Esq. SHEELEY LLP Attorneys for Defendant GLEN ISLAND CENTER FOR NURSING AND REHABILITATION 100 Wall Street, 19th Floor New York, New York 10005 atlas@sheeleyllp.com (646) 650-5952 3 7145083 3 of 4 FILED: WESTCHESTER COUNTY CLERK 03/24/2021 06:02 PM INDEX NO. 64205/2020 NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 03/24/2021 AFFIDAVIT OF SERVICE VIA ECF & E-MAIL STATE OF NEW YORK ) ) ss.: COUNTY OF NASSAU ) Ilana German, being duly sworn, deposes and says: That deponent is nota party to thisaction, isover 18 years of age and resides in Suffolk County, New York. 24th That on day of March, 2021, deponent served the within DEMAND FOR MEDICARE/MEDICAID INFORMATION, upon: VIA ECF & E-MAIL SINEL & OLESEN, PLLC Attorneys for Plaintiff 8th 7 Penn Plaza, Floor New York, New York 10001 sinelecf@sinellaw.com (212) 465-1000 Jason D. Turken, Esq. TURKEN, HEATH & McCAULEY, LLP Attorneys for Defendant MONTEFIORE MEDICAL CENTER 84 Business Pak Drive, Suite 307 Armonk, New York 10504 iturken@thmilp.com (914) 357-8600 Nicole Atlas, Esq. SHEELEY LLP Attorneys for Defendant GLEN ISLAND CENTER FOR NURSING AND REHABILITATION 19th 100 Wall Street, FlOOr New York, New York 10005 atlas@sheeleyllp.com (646) 650-5952 allattorneys in thisaction via ECF (electronic court and filing) by transmitting the same to allattorneys via E-Mail. Ilana German Sworn to before me this 24th day Of March, 2021., Notary ublic NANCY BARBATQ NOTARY PUBLIC, State of New Yoth No. OtBA0024216 Quafflied toWestcheater County Commission expires s/3/ 6872066 4 of 4