Preview
FILED: NEW YORK COUNTY CLERK 09/24/2019 04:58 PM INDEX NO. 155973/2017
NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
---------------------------------------- ¬---------------X
RESPONSE TO SECOND
IAN MACDONALD, JAMES ROBERTS and
THIRD-PARTY
BETH ANN CASSIDY-ROBERTS,
DEFENDANT'S NOTICE
FOR DISCOVERY AND
Plaintiffs '
INSPECTION AND
-against-
COMBINED DEMANDS
Index No.: 155973/2017
TURNER CONSTRUCTION COMPANY and
THE NEW YORK AND PRESBYTERIAN HOSPITAL
a.k.a. THE SOCIETY OF THE NEW YORK HOSPITAL
Defendants.
-------------------------- -- ¬---------------------------------X
TURNER CONSTRUCTION COMPANY and
THE NEW YORK AND PRESBYTERIAN HOSPITAL,
Third-Party Plaintiffs,
-against-
PORT MORRIS TILE & MARBLE CORP.
Third-Party Defendant.
-X
PORT MORRIS TILE & MARBLE CORP.
Second Third-Party Plaintiff,
-against-
TEXRON COMMERCIAL AUTO BODY WORKS, INC.,
Second Third-Party Defendant.
-------------------------------------------------- ¬------------X
Plaintiffs, by their attorneys, MORGAN LEVINE DOLAN, P.C., as and for a response
to Second Third-Party Defendant's Notice for Discovery and Inspection and Combined
Demands, dated August 6, 2019, allege(s) upon information and belief, as follows:
1. Annexed hereto are 13 color copies of photographs depicting the subject platform,
Roberts'
location/construction site and four color copies of photographs depicting plaintiff James
1 of 29
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NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019
injuries.
2-3. Plaintiff is aware of the following witnesses: Brian Lenerman, Adam Hudzik and
Eric Bauman. Their addresses will be provided under separate cover pursuant to CPLR.
4. Plaintiff is not in possession of any adverse party statements.
5. The following attorneys have appeared in this action:
41" 6th
MORGAN LEVINE DOLAN, P.C., Attorneys for Plaintiffs, 18 East Street,
Floor, New York, NY 10017, (212) 785-5115;
CULLEN and DYKMAN LLP, Attorneys for Defendants/Third-Party Plaintiffs, 44
15th
Wall Street, FlOOr, New York, NY 10005, (212) 732-2000;
CASCONE & KLUEPFEL, LLP, Attorneys for Third-Party Defendant, 1399
Franklin Avenue, Suite 302, Garden City, NY 11530, (516) 747-1990; and
LAW OFFICES OF TOBIAS & KUHN, Attorneys for Second Third-Party
Defendant, 100 William Street, Suite 920, New York, NY 10038, (212) 553-8700.
6. That information would best known and available to the defendants.
7. That information would best known and available to the defendants.
8. Plaintiffs object to defendant's demand for prior exchanged pleadings to the
extent that the information is readily obtainable from the source other than the plaintiffs in a
more convenient, less burdensome and less expensive manner. All prior pleadings in this matter
have been electronically filed on the New York State Unified Court System and are readily
obtainable therein.
9. Annexed hereto is a duly executed authorization to obtain the Ambulance Call
Report from FDNY, ACR Section, 9 MetroTech Center, Brooklyn, NY 11201-3857, for both
plaintiffs.
10-14. Annexed hereto are duly executed authorizations to obtain medical records from
the following healthcare providers for plaintiff Ian MacDonald:
2 of 29
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NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019
'
a) New York Presbyterian Hospital, 525 East 68 Street, New York, NY 10021;
b) WESTMED Medical Group, 73 Market Street, Ridge Hill, Yonkers, NY 10710;
c) Elevate Physical Therapy PLLC, 334 Underhill Avenue, Suite 1A, Yorktown
Heights, NY 10598; and
43'd
d) Douglas Schwartz, M.D., Eastside Medical Group, 211 East Street, Suite 500,
New York, NY 10017.
Annexed hereto are duly executed authorizations to obtain medical records from the
following healthcare providers for plaintiff James Roberts:
68th
e) New York Presbyterian Hospital, 525 East Street, New York, NY 10021;
f) Horizon Family Medical Group, 2570 Route 9W, Suite 4, Cornwall, NY 12518;
43rd
g) Douglas Schwartz, M.D., Eastside Medical Group, 211 East Street, Suite 500,
New York, NY 10017;
2nd
h) Dr. Sawaran Bambrah, 890 East Street, Jamestown, NY 14701;
i) Joena R. Chan, M.D., 1200 NY-208 #13, Monroe, NY 10950;
j) Arup K. Bhadra, M.D., Northeast Orthopedics and Sports Medicine, 785 Route 17M,
ShopRite Plaza, Monroe, NY 10950;
k) Dr. Craig Amnott, 1200 NY-208, Suite 13, Monroe, NY 10950;
l) Dr. Francis Imbarrato, 1200 NY-208, Suite 13, Monroe, NY 10950;
m) 3T Open Imaging of Westchester, 1915-25 Central Park Avenue, Yonkers, NY 10710;
n) Hudson Valley Imaging, 745 Route 17, Monroe, NY 10950.
15. Not applicable. This is not a No-Fault claim.
16. Not applicable.
plaintiffs'
17. Please refer to response in paragraph numbers 10-14.
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NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019
18. No prior claims or lawsuits have been filed.
19. Not applicable.
20. Annexed hereto is a duly executed authorization to obtain records from the
Workers'
Compensation Board, for each plaintiff. Annexed hereto is a duly executed
authorization to obtain records from American Zurich Insurance Company, P.O. Box 66944,
Chicago, IL 60666-0944, for each plaintiff.
21. That information would best known and available to the defendants.
22. Annexed hereto are the First Report of Injury reports for plaintiffs.
23. That information would best known and available to the defendants.
24. Plaintiffs are not self-employed. An authorization is annexed hereto to obtain W-
plaintiffs'
2s from employer.
25. Annexed hereto please find a duly executed authorization to obtain attendance
records and W-2s from Port Morris Tile & Marble, 1285 Oakpoint Avenue, Bronx, NY 10474,
from 2014 to the present, for each plaintiff.
26. Not applicable. Plaintiffs are not students.
27. That information would best known and available to the defendants.
28. Plaintiff is not in possession of audio tapes.
plaintiffs'
29. Please refer to response in paragraph number 20.
30. Annexed hereto is a duly executed authorization to obtain union and pension
35th
records from Marble Industry Trust Fund, C/o Daniel H. Cook Associates, Inc., 253 West
12th
Street, Floor, New York, NY 10001-1907, for each plaintiff.
31. Plaintiff is not in possession of transcripts from a motor vehicle hearing,
proceedings for code violations, 50-h or trial proceedings.
4 of 29
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NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019
32. Not applicable. A Notice of Claim was not filed in this action.
DEMAND FOR EXPERT WITNESS INFORMATION
Plaintiff has not designated any expert witnesses at this time. If and when any expert
witness is retained, expert disclosure will be provided pursuant to CPLR.
DEMAND PURSUANT TO CPLR §4545
plaintiffs'
Please refer to response in paragraph number 20.
DEMAND PURSUANT TO CPLR 3017
To be provided.
DEMAND FOR DISCLOSURE AS TO MEDICARE/MEDICAID LIEN
Plaintiffs have not received Medicare or Medicaid benefits.
Plaintiffs reserve the right to amend and/or supplement the above responses through and
including the time of trial.
Dated: New York, New York
September 24, 2019
M EVINE DOLAN, P.C.
Dµ'
By e . Morgan
Att neys for Plaintiff
41" 6th
18 East Street, PlOOr
New York, New York 10017
(212) 785-5115
TO: CULLEN and DYKMAN LLP
Attorneys for Defendants
15th
44 Wall Street, FlOOr
New York, NY 10005
(212) 732-2000
File No.: 5451.26
5 of 29
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CASCONE & KLUEPFEL, LLP
Attorneys for Third-Party Defendant
1399 Franklin Avenue, Suite 302
Garden City, NY 11530
(516) 747-1990
File No.: 04499DCSC
LAW OFFICES OF TOBIAS. & KUHN
Attorneys for Second Third-Party Defendant
100 William Street, Suite 920
New York, NY 10038
(212) 553-8700
File No.: Y43L83081-001
6 of 29
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OCA Official Form No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been appreved by the New York State Department of Health|
PatientName Date of Birth Social Security Number
James Roberts 01/06/1965
Patient Address: 99 Barnes Road, Washingtonville, NY 10992
1, ormy authorized representative,request thathealth information regarding my care and treatmentbe released as setforth on this form:
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 relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials
on
TREATMENT, psychotherapy notes, only my
the appropriate linein Item 9(a). In theevent the health information described below includes any of thesetypes of information, and I
initialtheline on thebox inItem 9(a), authorize
I specifically release of such information to thepersons(s) indicated in Item 8.
2. If I am authorizing therelease of HIV related,alcohol ordrug treatment,or mental health treatment information, the recipientis
prohibited from redisclosing such information without my authorization unless permitted todo sounder federalor statelaw. Iunderstand
that I havea rightto request a list
of people who may receiveor use my HIV relatedinformation without authorization. IfI experience
discrimination because of therelease or disclosure ofHIV-related information, I may contact the New York State Division of Human
Rights at(212) 480-2493 or theNew York City Commission of human rights at(212) 306-7450. These agencies areresponsible for
protecting my rights.
3. Ihave the rightto revoke thisauthorization at anytime by writing tothe healthcare provider listedbelow. I understand that1 may
revoke thisauthorization except to theextentthataction has already been taken based on thisauthorization.
4. I understand that signing thisauthorizationis voluntary.My treatment, payment, enrollment in a healthplan, oreligibilityforbenefits
willnot be conditioned upon my authorization of thisdisclosure.
5. Information disclosed under this authorizationmight be redisclosedto therecipient (except as noted above in Item 2),and this
redisclosure may no longer be protected by federalor statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of health provider or entity to release this information:
Port Morris Tile & Marble, 1285 Oakpoint Avenue, Bronx, NY 10474
8. Name and address of person(s) or category of person to whom this information will be sent:
LAW OFFICES OF TOBIAS & KUHN, 100 William Street,Suite 920, New York, NY 10038
9(a). Specific information to be released:
Medical Record from to
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.
[X] Other: W-2s and ATTENDANCE RECORDS from 2012-PRESENT Include: (IndicatebyInitiating)
Alcohol/Drug Treatment
Mental Health Information
HIV-Related Information
Authorization to Discuss Health Information
(b) []By here
initialing _ I authorize
Initials Name of individual
healthcare provider
to discussmy health information with my attorney,or a govemmental agency, listed
here:
(Attorney/Firm Name or Governmental Agency Namef
10. Reason forrelease of information: 11. Date or event on which thisauthorization will expire:
At request of individual OF CASE
CONCLUSION
[X] Other LEGAL MATTER
12. Ifnot the patient,name of person signing form: 13.Authority tosign on behalf of patient:
DUANE R. ESQ. POWER OF ATTORNEY
MORGAN,
All items on thisform have been ompleted and my questions about thisform have been answered. In addition,I have been provided a
copy of theform.
Date:
Signature of patientVrep entative authorized by law
*IIurman!r=:::½iüwy Virus thatcauses AIDS.
The New York flealth
State Public Law information
protects which rcäsGñäNy someone as
could identify
havingIIlV symptoms and information
or infection a person's
regarding contacts.
7 of 29
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NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019
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|
PatientName Date of Birth Social SecurityNumber
.Iames Roberts 01/06/1965
PatientAddress: 99 Barnes Road, Washingtonville, NY 10992
1, ormy authorized representative,request thathealth information regarding my care and treatment be released as setforthon this form:
In accordance with New York State Law and thePrivacy Rule of the Health insurance Peitabilityand 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 if I place initials
on
TREATMENT, psychotherapy notes, only my
the appropriate linein Item 9(a). In theevent the health information described below includes any of thesetypes of information, and I
initialtheline on the box in Item 9(a),I specifically
authorize release of such information to thepersons(s) indicated in Item 8.
2. If I am authorizing therelease of HIV related,alcohol ordrug treatment,or mental healthtreatment information, the recipient is
prohibited from redisclosingsuch information without my authorization unless permitted todo sounder federalor statelaw. I understand
that I have a right
to request a list
of people who may receiveor use my HIV related information without authorization. If Iexperience
discrimination because of therelease or disclosureofHIV-related information, I may contact the New York State Division of Human
Rights at (212) 480-2493 or theNew York City Commission of human rights at(212) 306-7450. These agencies areresponsible for
protecting my rights.
3. Ihave the rightto revoke thisauthorization at anytime by writingto the healthcare provider listedbelow. I understand thatI may
revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization.
4. I understand that signing thisauthorization is voluntary.My treatment, payment, enrollment in a healthplan, oreligibilityfor benefits
will not be conditioned upon my authorization of thisdisclosure.
5. Information disclosed under thisauthorization might be redisclosedto therecipient (except as noted above in Item 2),and this
redisclosure may no longer be protected by federalor statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH A_NYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of health provider or entityto release this information:
American Zurich Insurance Company, P.O. Box 66944, Chicago, IL 60666-0944
8. Name and address of person(s) or category of person to whom thisinformation will be sent:
LAW OFFICES OF TOBIAS & KUHN, 100 William Street, Suite 920, New York, NY 10038
9(a). Specificinformation to be released:
Medical Record from to
i EntireMedical Record, including patient office
histories, notes (except psychotherapy notes),testresults,radiology studies,films,
referrals,consults,billing records, insurance records, and records sentto you by otherhealth care providers.
[X] Other: WORKER'S COMPENSATION RECORDS Include: (Indicate by Initiating)
Alcohol/Drug Treatment
Mental Health Information
HIV-Related Information
Authorization to Discuss Health Information
(b) []By initialinghere I authorize
initials Name ofindividual healthcare provider
to discussmy health information with my attorney,or a governmental agency, listedhere:
(Attorney/Firm Name or Governmental Agency Name)
10. Reason for releaseof information: 11. Date or event on which thisauthorization willexpire:
At request of individual OF CASE
CONCLUSION
[X] Other: LEGAL MATTER
12. Ifnot the patient,name of person signing form: 13. Authority tosign on behalf of patient:
DUANE R. ESQ. POWER OF ATTORNEY
MORGAN,
Allitems on this en completed and my questions about thisform have been answered. In addition,1 have been provided a
copy of theform.
Date:
Signature of patientor res nta e authorized by law
*Human !===:-ilkicacy Virus that causes AIDS.
The New York State Public
HealthLaw protects
iüfür which
;âtion reasonably someone as
could identiry
havingHIV r;=pt=:= or inrection
and information a person's
regarding contacts.
8 of 29
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NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019
OCA Official Form No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been apprõved by the New York State Department of Health|
PatientName Date of Birth SocialSecurity Number
James Roberts 01/06/1965
PatientAddress: 99 Barnes Road, Washingtonville, NY 10992
I,or my authorized representative,request thathealth information regarding my care and treatmentbe released as setforth on this form:
in accordance with New York State Law and the Privacy Rule of theHealth Insurance Portabilityand Accountability Act of 1996
(HIPAA), I understand that:
l. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place on
TREATMENT, psychotherapy notes, only my initials
the appropriate linein Item 9(a). In theevent the health information described below includes any of thesetypes of information, and 1
initialtheline on thebox inItem 9(a),I specifically
authorize release of such information to thepersons(s) indicated in Item 8.
2. If I am authorizing therelease of HIV related,alcohol ordrug treatment,or mental health treatment information, the recipient is
prohibited from redisclosing such information without my authorization unlesspermitted todo so under federalor statelaw. I understand
that I havea rightto request a list
of people who may receiveor use my HIV relatedinformation without authorization. if I experience
discrimination because of therelease or disclosureofHIV-related information, I may contact the New York State Division of Human
Rights at (212) 480-2493 or theNew York City Commission of human rights at (212)306-7450. These agencies areresponsible for
protecting my rights.
3. I havethe rightto revoke thisauthorization atany time by writingto the healthcare provider listedbelow. I understand thatI may
revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization.
4. I understand thatsigning thisauthorization isvoluntary. My treatment, payment, enrollment in a healthplan, oreligibilityfor benefits
will not be conditioned upon my authorization of thisdisclosure.
5. Information disclosed under thisauthorization might be redisclosedto therecipient (except as noted above in Item 2),and this
redisclosure may no longer be protected by federalor statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of health provider or entityto releasethisinformation:
68*
New York Presbyterian Hospital, 525 East Street, New York, NY 10021
8. Name and address of person(s) or categoryof person to whom thisinformation willbe sent:
LAW OFFICES OF TOBIAS & KUHN, 100 William Street,Suite 920, New York, NY 10038
9(a). Specificinformation to be released:
[X] Medical Record from 06/13/2017 to PRESENT
[X] Entire Medical Record, including patienthistories,officenotes (except psychotherapy notes),test results,radiology studies,films,
referrals,consults, billingrecords, insurancerecords, and records sent toyou by otherhealth care providers.
[] Other: Include: (Indicate by Initiating)
Alcohol/Drug Treatment
Mental Health Information
HIV-Related Information
Authorization to Discuss Health Information
(b) []By here
initialing I authorize
Initials Name ofindividualhealthcare provider
to discussmy health information with my attorney,or a govmu.mutal agency, listedhere:
(Attorney/Firm Name or Governmenta! Agency Name)
10. Reason for releaseof information: I1. Date orevent on which thisauthorization will expire:
At request of individual CONCLUSION OF CASE
[X] Other: LEGAL MATTER
12. Ifnot the patient,name of person signing form: 13. Authority tosign on behalf of patient:
DUANE R. ESQ. POWER OF ATTORNEY
MORGAN,
Allitems on thisf ompleted and my questions about thisform have been answered. In addition, I have been provided a
copy of theform.
Date:
Signature of patientor e se tiv uthorized by law
*Iluman !==rrr±ficienc #irus that
causes AIDS.
The New York State Publie
IIealth
Law protectsinformation
which could
reasonably someone as
iden tify
havingIIIV symptoms or infection
and information
regardinga person'scontacts.
9 of 29
FILED: NEW YORK COUNTY CLERK 09/24/2019 04:58 PM INDEX NO. 155973/2017
NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019
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 Security Number
,lames Roberts 01/06/1965
Patient Address: 99 Barnes Road, Washingtonville, NY 10992
1, ormy authorized representative,request thathealth information regarding my care and treatment be released as setforthon this form:
In accordance with New York State Law and thePrivacy Rule of theHealth Insurance Portabilityand Accountability Act of 1996
(HIPAA), I understand that:
1. This authorization may include disclosure ofinformation relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION if1 place initialson
TREATMENT, psychotherapy notes, only my
the appropriate linein Item 9(a). In theevent the healthinformation described below includes any of thesetypes of information, and I
initialtheline on thebox inItem 9(a),I specifically
authorize release ofsuch information to thepersons(s) indicated in Item 8.
2. If I am authorizing therelease of HIV related,alcohol ordrug treatment, or mental health treatment information, the recipientis
prohibited from redisclosingsuch information without my authorization unlesspermitted to do so under federalor statelaw. I understand
that I havea rightto requesta list
of people who may receiveor use my HIV relatedinformation without authorization. IfI experience
discrimination because of therelease or disclosure of HIV-related information, I may contact the New York State Division of Human
Rights at (212) 480-2493 or theNew York City Commission of human rights at (212)306-7450. These agencies areresponsible for
protecting my rights.
3. Ihave the rightto revoke this authorizationatany time by writingto the healthcare provider listedbelow. I understand thatI may
revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization.
4. I understand thatsigning thisauthorization isvoluntary. My treatment, payment, enrollment in a healthplan, oreligibilityforbenefits
willnot be conditioned upon my authorization of thisdisclosure.
5. Information disclosed under thisauthorization might be redisclosed to therecipient(except as noted above in Item 2),and this
redisclosure may no longer be protected by federalor statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of healthprovider or entityto releasethisinformation:
Horizon Family Medical Group, 2570 Route 9W, Suite 4, Cornwall, NY 12518
8. Name and address of person(s)or category of person to whom thisinformation will be sent:
LAW OFFICES OF TOBIAS & KUHN, 100 William Street, Suite 920, New York, NY 10038
9(a). Specific information to be released:
[X] Medical Record from 06/13/2017 to PRESENT
[X] EntireMedical Record, including patient office
histories, notes (except psychotherapy notes),testresults,radiology studies, films,
referrals,consults,billingrecords, insurance records,and recordssent to you by other health carepreviders.
[] Other: Include: (Indicateby Initialing)
Alcohol/Drug Treatment
Mental Health Information
HIV-Related Information
Authorization to Discuss Health Information
(b) []By here
initialing I authorize
Initials Name ofindividualhealthcare provider
to discussmy health information with my attorney,or a governmental agency, listedhere:
(Attorney/Firm Name or Governmental Name)
Agency
10. Reason forrelease of information: 11. Date or eventon which thisauthorization willexpire:
At request of individual CONCLUSION OF CASE
[X] Other: LEGAL MATTER
12. Ifnot the name
patient, of person signing form: 13. Authority tosign on behalf of patient:
DUANE R. ESQ. POWER OF ATTORNEY
MORGAN,
All items on thisfo ompleted and my questions about thisform have been answered. In addition,I have been provided a
copy of the form.
N., .. Date:
Signature of patientorpse ta ve a orized byTaw
*Human !==:::±:iciency Virus that The New York
causes AIDS. State Public
HealthLaw protects
informationwhich reasona bly could someone as
identify
havingHW e;=p::== or infection
and information a person's
regarding contacts.
10 of 29
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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)
._
PatientName Date of Birth Social Security Number
James Roberts 01/06/1965
Patient Address: 99 Bames Road, Washingtonville, NY 10992
1, ormy authorized representative,request thathealth information regarding my care and treatmentbe released as setforth on this form
In accordance with New York StateLaw and thePrivacy Rule of theHealth Insurance Portabilityand Accountability Act of 1996
(HIPAA), I understand that:
I. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL
Preview
FILED: NEW YORK COUNTY CLERK 09/24/2019 04:58 PM INDEX NO. 155973/2017 NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK ---------------------------------------- ¬---------------X RESPONSE TO SECOND IAN MACDONALD, JAMES ROBERTS and THIRD-PARTY BETH ANN CASSIDY-ROBERTS, DEFENDANT'S NOTICE FOR DISCOVERY AND Plaintiffs ' INSPECTION AND -against- COMBINED DEMANDS Index No.: 155973/2017 TURNER CONSTRUCTION COMPANY and THE NEW YORK AND PRESBYTERIAN HOSPITAL a.k.a. THE SOCIETY OF THE NEW YORK HOSPITAL Defendants. -------------------------- -- ¬---------------------------------X TURNER CONSTRUCTION COMPANY and THE NEW YORK AND PRESBYTERIAN HOSPITAL, Third-Party Plaintiffs, -against- PORT MORRIS TILE & MARBLE CORP. Third-Party Defendant. -X PORT MORRIS TILE & MARBLE CORP. Second Third-Party Plaintiff, -against- TEXRON COMMERCIAL AUTO BODY WORKS, INC., Second Third-Party Defendant. -------------------------------------------------- ¬------------X Plaintiffs, by their attorneys, MORGAN LEVINE DOLAN, P.C., as and for a response to Second Third-Party Defendant's Notice for Discovery and Inspection and Combined Demands, dated August 6, 2019, allege(s) upon information and belief, as follows: 1. Annexed hereto are 13 color copies of photographs depicting the subject platform, Roberts' location/construction site and four color copies of photographs depicting plaintiff James 1 of 29 FILED: NEW YORK COUNTY CLERK 09/24/2019 04:58 PM INDEX NO. 155973/2017 NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019 injuries. 2-3. Plaintiff is aware of the following witnesses: Brian Lenerman, Adam Hudzik and Eric Bauman. Their addresses will be provided under separate cover pursuant to CPLR. 4. Plaintiff is not in possession of any adverse party statements. 5. The following attorneys have appeared in this action: 41" 6th MORGAN LEVINE DOLAN, P.C., Attorneys for Plaintiffs, 18 East Street, Floor, New York, NY 10017, (212) 785-5115; CULLEN and DYKMAN LLP, Attorneys for Defendants/Third-Party Plaintiffs, 44 15th Wall Street, FlOOr, New York, NY 10005, (212) 732-2000; CASCONE & KLUEPFEL, LLP, Attorneys for Third-Party Defendant, 1399 Franklin Avenue, Suite 302, Garden City, NY 11530, (516) 747-1990; and LAW OFFICES OF TOBIAS & KUHN, Attorneys for Second Third-Party Defendant, 100 William Street, Suite 920, New York, NY 10038, (212) 553-8700. 6. That information would best known and available to the defendants. 7. That information would best known and available to the defendants. 8. Plaintiffs object to defendant's demand for prior exchanged pleadings to the extent that the information is readily obtainable from the source other than the plaintiffs in a more convenient, less burdensome and less expensive manner. All prior pleadings in this matter have been electronically filed on the New York State Unified Court System and are readily obtainable therein. 9. Annexed hereto is a duly executed authorization to obtain the Ambulance Call Report from FDNY, ACR Section, 9 MetroTech Center, Brooklyn, NY 11201-3857, for both plaintiffs. 10-14. Annexed hereto are duly executed authorizations to obtain medical records from the following healthcare providers for plaintiff Ian MacDonald: 2 of 29 FILED: NEW YORK COUNTY CLERK 09/24/2019 04:58 PM INDEX NO. 155973/2017 NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019 ' a) New York Presbyterian Hospital, 525 East 68 Street, New York, NY 10021; b) WESTMED Medical Group, 73 Market Street, Ridge Hill, Yonkers, NY 10710; c) Elevate Physical Therapy PLLC, 334 Underhill Avenue, Suite 1A, Yorktown Heights, NY 10598; and 43'd d) Douglas Schwartz, M.D., Eastside Medical Group, 211 East Street, Suite 500, New York, NY 10017. Annexed hereto are duly executed authorizations to obtain medical records from the following healthcare providers for plaintiff James Roberts: 68th e) New York Presbyterian Hospital, 525 East Street, New York, NY 10021; f) Horizon Family Medical Group, 2570 Route 9W, Suite 4, Cornwall, NY 12518; 43rd g) Douglas Schwartz, M.D., Eastside Medical Group, 211 East Street, Suite 500, New York, NY 10017; 2nd h) Dr. Sawaran Bambrah, 890 East Street, Jamestown, NY 14701; i) Joena R. Chan, M.D., 1200 NY-208 #13, Monroe, NY 10950; j) Arup K. Bhadra, M.D., Northeast Orthopedics and Sports Medicine, 785 Route 17M, ShopRite Plaza, Monroe, NY 10950; k) Dr. Craig Amnott, 1200 NY-208, Suite 13, Monroe, NY 10950; l) Dr. Francis Imbarrato, 1200 NY-208, Suite 13, Monroe, NY 10950; m) 3T Open Imaging of Westchester, 1915-25 Central Park Avenue, Yonkers, NY 10710; n) Hudson Valley Imaging, 745 Route 17, Monroe, NY 10950. 15. Not applicable. This is not a No-Fault claim. 16. Not applicable. plaintiffs' 17. Please refer to response in paragraph numbers 10-14. 3 of 29 FILED: NEW YORK COUNTY CLERK 09/24/2019 04:58 PM INDEX NO. 155973/2017 NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019 18. No prior claims or lawsuits have been filed. 19. Not applicable. 20. Annexed hereto is a duly executed authorization to obtain records from the Workers' Compensation Board, for each plaintiff. Annexed hereto is a duly executed authorization to obtain records from American Zurich Insurance Company, P.O. Box 66944, Chicago, IL 60666-0944, for each plaintiff. 21. That information would best known and available to the defendants. 22. Annexed hereto are the First Report of Injury reports for plaintiffs. 23. That information would best known and available to the defendants. 24. Plaintiffs are not self-employed. An authorization is annexed hereto to obtain W- plaintiffs' 2s from employer. 25. Annexed hereto please find a duly executed authorization to obtain attendance records and W-2s from Port Morris Tile & Marble, 1285 Oakpoint Avenue, Bronx, NY 10474, from 2014 to the present, for each plaintiff. 26. Not applicable. Plaintiffs are not students. 27. That information would best known and available to the defendants. 28. Plaintiff is not in possession of audio tapes. plaintiffs' 29. Please refer to response in paragraph number 20. 30. Annexed hereto is a duly executed authorization to obtain union and pension 35th records from Marble Industry Trust Fund, C/o Daniel H. Cook Associates, Inc., 253 West 12th Street, Floor, New York, NY 10001-1907, for each plaintiff. 31. Plaintiff is not in possession of transcripts from a motor vehicle hearing, proceedings for code violations, 50-h or trial proceedings. 4 of 29 FILED: NEW YORK COUNTY CLERK 09/24/2019 04:58 PM INDEX NO. 155973/2017 NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019 32. Not applicable. A Notice of Claim was not filed in this action. DEMAND FOR EXPERT WITNESS INFORMATION Plaintiff has not designated any expert witnesses at this time. If and when any expert witness is retained, expert disclosure will be provided pursuant to CPLR. DEMAND PURSUANT TO CPLR §4545 plaintiffs' Please refer to response in paragraph number 20. DEMAND PURSUANT TO CPLR 3017 To be provided. DEMAND FOR DISCLOSURE AS TO MEDICARE/MEDICAID LIEN Plaintiffs have not received Medicare or Medicaid benefits. Plaintiffs reserve the right to amend and/or supplement the above responses through and including the time of trial. Dated: New York, New York September 24, 2019 M EVINE DOLAN, P.C. Dµ' By e . Morgan Att neys for Plaintiff 41" 6th 18 East Street, PlOOr New York, New York 10017 (212) 785-5115 TO: CULLEN and DYKMAN LLP Attorneys for Defendants 15th 44 Wall Street, FlOOr New York, NY 10005 (212) 732-2000 File No.: 5451.26 5 of 29 FILED: NEW YORK COUNTY CLERK 09/24/2019 04:58 PM INDEX NO. 155973/2017 NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019 CASCONE & KLUEPFEL, LLP Attorneys for Third-Party Defendant 1399 Franklin Avenue, Suite 302 Garden City, NY 11530 (516) 747-1990 File No.: 04499DCSC LAW OFFICES OF TOBIAS. & KUHN Attorneys for Second Third-Party Defendant 100 William Street, Suite 920 New York, NY 10038 (212) 553-8700 File No.: Y43L83081-001 6 of 29 FILED: NEW YORK COUNTY CLERK 09/24/2019 04:58 PM INDEX NO. 155973/2017 NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019 OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been appreved by the New York State Department of Health| PatientName Date of Birth Social Security Number James Roberts 01/06/1965 Patient Address: 99 Barnes Road, Washingtonville, NY 10992 1, ormy authorized representative,request thathealth information regarding my care and treatmentbe released as setforth on this form: 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 relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials on TREATMENT, psychotherapy notes, only my the appropriate linein Item 9(a). In theevent the health information described below includes any of thesetypes of information, and I initialtheline on thebox inItem 9(a), authorize I specifically release of such information to thepersons(s) indicated in Item 8. 2. If I am authorizing therelease of HIV related,alcohol ordrug treatment,or mental health treatment information, the recipientis prohibited from redisclosing such information without my authorization unless permitted todo sounder federalor statelaw. Iunderstand that I havea rightto request a list of people who may receiveor use my HIV relatedinformation without authorization. IfI experience discrimination because of therelease or disclosure ofHIV-related information, I may contact the New York State Division of Human Rights at(212) 480-2493 or theNew York City Commission of human rights at(212) 306-7450. These agencies areresponsible for protecting my rights. 3. Ihave the rightto revoke thisauthorization at anytime by writing tothe healthcare provider listedbelow. I understand that1 may revoke thisauthorization except to theextentthataction has already been taken based on thisauthorization. 4. I understand that signing thisauthorizationis voluntary.My treatment, payment, enrollment in a healthplan, oreligibilityforbenefits willnot be conditioned upon my authorization of thisdisclosure. 5. Information disclosed under this authorizationmight be redisclosedto therecipient (except as noted above in Item 2),and this redisclosure may no longer be protected by federalor statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address of health provider or entity to release this information: Port Morris Tile & Marble, 1285 Oakpoint Avenue, Bronx, NY 10474 8. Name and address of person(s) or category of person to whom this information will be sent: LAW OFFICES OF TOBIAS & KUHN, 100 William Street,Suite 920, New York, NY 10038 9(a). Specific information to be released: Medical Record from to 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. [X] Other: W-2s and ATTENDANCE RECORDS from 2012-PRESENT Include: (IndicatebyInitiating) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) []By here initialing _ I authorize Initials Name of individual healthcare provider to discussmy health information with my attorney,or a govemmental agency, listed here: (Attorney/Firm Name or Governmental Agency Namef 10. Reason forrelease of information: 11. Date or event on which thisauthorization will expire: At request of individual OF CASE CONCLUSION [X] Other LEGAL MATTER 12. Ifnot the patient,name of person signing form: 13.Authority tosign on behalf of patient: DUANE R. ESQ. POWER OF ATTORNEY MORGAN, All items on thisform have been ompleted and my questions about thisform have been answered. In addition,I have been provided a copy of theform. Date: Signature of patientVrep entative authorized by law *IIurman!r=:::½iüwy Virus thatcauses AIDS. The New York flealth State Public Law information protects which rcäsGñäNy someone as could identify havingIIlV symptoms and information or infection a person's regarding contacts. 7 of 29 FILED: NEW YORK COUNTY CLERK 09/24/2019 04:58 PM INDEX NO. 155973/2017 NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019 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| PatientName Date of Birth Social SecurityNumber .Iames Roberts 01/06/1965 PatientAddress: 99 Barnes Road, Washingtonville, NY 10992 1, ormy authorized representative,request thathealth information regarding my care and treatment be released as setforthon this form: In accordance with New York State Law and thePrivacy Rule of the Health insurance Peitabilityand 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 if I place initials on TREATMENT, psychotherapy notes, only my the appropriate linein Item 9(a). In theevent the health information described below includes any of thesetypes of information, and I initialtheline on the box in Item 9(a),I specifically authorize release of such information to thepersons(s) indicated in Item 8. 2. If I am authorizing therelease of HIV related,alcohol ordrug treatment,or mental healthtreatment information, the recipient is prohibited from redisclosingsuch information without my authorization unless permitted todo sounder federalor statelaw. I understand that I have a right to request a list of people who may receiveor use my HIV related information without authorization. If Iexperience discrimination because of therelease or disclosureofHIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or theNew York City Commission of human rights at(212) 306-7450. These agencies areresponsible for protecting my rights. 3. Ihave the rightto revoke thisauthorization at anytime by writingto the healthcare provider listedbelow. I understand thatI may revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization. 4. I understand that signing thisauthorization is voluntary.My treatment, payment, enrollment in a healthplan, oreligibilityfor benefits will not be conditioned upon my authorization of thisdisclosure. 5. Information disclosed under thisauthorization might be redisclosedto therecipient (except as noted above in Item 2),and this redisclosure may no longer be protected by federalor statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH A_NYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address of health provider or entityto release this information: American Zurich Insurance Company, P.O. Box 66944, Chicago, IL 60666-0944 8. Name and address of person(s) or category of person to whom thisinformation will be sent: LAW OFFICES OF TOBIAS & KUHN, 100 William Street, Suite 920, New York, NY 10038 9(a). Specificinformation to be released: Medical Record from to i EntireMedical Record, including patient office histories, notes (except psychotherapy notes),testresults,radiology studies,films, referrals,consults,billing records, insurance records, and records sentto you by otherhealth care providers. [X] Other: WORKER'S COMPENSATION RECORDS Include: (Indicate by Initiating) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) []By initialinghere I authorize initials Name ofindividual healthcare provider to discussmy health information with my attorney,or a governmental agency, listedhere: (Attorney/Firm Name or Governmental Agency Name) 10. Reason for releaseof information: 11. Date or event on which thisauthorization willexpire: At request of individual OF CASE CONCLUSION [X] Other: LEGAL MATTER 12. Ifnot the patient,name of person signing form: 13. Authority tosign on behalf of patient: DUANE R. ESQ. POWER OF ATTORNEY MORGAN, Allitems on this en completed and my questions about thisform have been answered. In addition,1 have been provided a copy of theform. Date: Signature of patientor res nta e authorized by law *Human !===:-ilkicacy Virus that causes AIDS. The New York State Public HealthLaw protects iüfür which ;âtion reasonably someone as could identiry havingHIV r;=pt=:= or inrection and information a person's regarding contacts. 8 of 29 FILED: NEW YORK COUNTY CLERK 09/24/2019 04:58 PM INDEX NO. 155973/2017 NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019 OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been apprõved by the New York State Department of Health| PatientName Date of Birth SocialSecurity Number James Roberts 01/06/1965 PatientAddress: 99 Barnes Road, Washingtonville, NY 10992 I,or my authorized representative,request thathealth information regarding my care and treatmentbe released as setforth on this form: in accordance with New York State Law and the Privacy Rule of theHealth Insurance Portabilityand Accountability Act of 1996 (HIPAA), I understand that: l. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place on TREATMENT, psychotherapy notes, only my initials the appropriate linein Item 9(a). In theevent the health information described below includes any of thesetypes of information, and 1 initialtheline on thebox inItem 9(a),I specifically authorize release of such information to thepersons(s) indicated in Item 8. 2. If I am authorizing therelease of HIV related,alcohol ordrug treatment,or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unlesspermitted todo so under federalor statelaw. I understand that I havea rightto request a list of people who may receiveor use my HIV relatedinformation without authorization. if I experience discrimination because of therelease or disclosureofHIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or theNew York City Commission of human rights at (212)306-7450. These agencies areresponsible for protecting my rights. 3. I havethe rightto revoke thisauthorization atany time by writingto the healthcare provider listedbelow. I understand thatI may revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization. 4. I understand thatsigning thisauthorization isvoluntary. My treatment, payment, enrollment in a healthplan, oreligibilityfor benefits will not be conditioned upon my authorization of thisdisclosure. 5. Information disclosed under thisauthorization might be redisclosedto therecipient (except as noted above in Item 2),and this redisclosure may no longer be protected by federalor statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address of health provider or entityto releasethisinformation: 68* New York Presbyterian Hospital, 525 East Street, New York, NY 10021 8. Name and address of person(s) or categoryof person to whom thisinformation willbe sent: LAW OFFICES OF TOBIAS & KUHN, 100 William Street,Suite 920, New York, NY 10038 9(a). Specificinformation to be released: [X] Medical Record from 06/13/2017 to PRESENT [X] Entire Medical Record, including patienthistories,officenotes (except psychotherapy notes),test results,radiology studies,films, referrals,consults, billingrecords, insurancerecords, and records sent toyou by otherhealth care providers. [] Other: Include: (Indicate by Initiating) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) []By here initialing I authorize Initials Name ofindividualhealthcare provider to discussmy health information with my attorney,or a govmu.mutal agency, listedhere: (Attorney/Firm Name or Governmenta! Agency Name) 10. Reason for releaseof information: I1. Date orevent on which thisauthorization will expire: At request of individual CONCLUSION OF CASE [X] Other: LEGAL MATTER 12. Ifnot the patient,name of person signing form: 13. Authority tosign on behalf of patient: DUANE R. ESQ. POWER OF ATTORNEY MORGAN, Allitems on thisf ompleted and my questions about thisform have been answered. In addition, I have been provided a copy of theform. Date: Signature of patientor e se tiv uthorized by law *Iluman !==rrr±ficienc #irus that causes AIDS. The New York State Publie IIealth Law protectsinformation which could reasonably someone as iden tify havingIIIV symptoms or infection and information regardinga person'scontacts. 9 of 29 FILED: NEW YORK COUNTY CLERK 09/24/2019 04:58 PM INDEX NO. 155973/2017 NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019 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 Security Number ,lames Roberts 01/06/1965 Patient Address: 99 Barnes Road, Washingtonville, NY 10992 1, ormy authorized representative,request thathealth information regarding my care and treatment be released as setforthon this form: In accordance with New York State Law and thePrivacy Rule of theHealth Insurance Portabilityand Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure ofinformation relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION if1 place initialson TREATMENT, psychotherapy notes, only my the appropriate linein Item 9(a). In theevent the healthinformation described below includes any of thesetypes of information, and I initialtheline on thebox inItem 9(a),I specifically authorize release ofsuch information to thepersons(s) indicated in Item 8. 2. If I am authorizing therelease of HIV related,alcohol ordrug treatment, or mental health treatment information, the recipientis prohibited from redisclosingsuch information without my authorization unlesspermitted to do so under federalor statelaw. I understand that I havea rightto requesta list of people who may receiveor use my HIV relatedinformation without authorization. IfI experience discrimination because of therelease or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or theNew York City Commission of human rights at (212)306-7450. These agencies areresponsible for protecting my rights. 3. Ihave the rightto revoke this authorizationatany time by writingto the healthcare provider listedbelow. I understand thatI may revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization. 4. I understand thatsigning thisauthorization isvoluntary. My treatment, payment, enrollment in a healthplan, oreligibilityforbenefits willnot be conditioned upon my authorization of thisdisclosure. 5. Information disclosed under thisauthorization might be redisclosed to therecipient(except as noted above in Item 2),and this redisclosure may no longer be protected by federalor statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address of healthprovider or entityto releasethisinformation: Horizon Family Medical Group, 2570 Route 9W, Suite 4, Cornwall, NY 12518 8. Name and address of person(s)or category of person to whom thisinformation will be sent: LAW OFFICES OF TOBIAS & KUHN, 100 William Street, Suite 920, New York, NY 10038 9(a). Specific information to be released: [X] Medical Record from 06/13/2017 to PRESENT [X] EntireMedical Record, including patient office histories, notes (except psychotherapy notes),testresults,radiology studies, films, referrals,consults,billingrecords, insurance records,and recordssent to you by other health carepreviders. [] Other: Include: (Indicateby Initialing) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) []By here initialing I authorize Initials Name ofindividualhealthcare provider to discussmy health information with my attorney,or a governmental agency, listedhere: (Attorney/Firm Name or Governmental Name) Agency 10. Reason forrelease of information: 11. Date or eventon which thisauthorization willexpire: At request of individual CONCLUSION OF CASE [X] Other: LEGAL MATTER 12. Ifnot the name patient, of person signing form: 13. Authority tosign on behalf of patient: DUANE R. ESQ. POWER OF ATTORNEY MORGAN, All items on thisfo ompleted and my questions about thisform have been answered. In addition,I have been provided a copy of the form. N., .. Date: Signature of patientorpse ta ve a orized byTaw *Human !==:::±:iciency Virus that The New York causes AIDS. State Public HealthLaw protects informationwhich reasona bly could someone as identify havingHW e;=p::== or infection and information a person's regarding contacts. 10 of 29 FILED: NEW YORK COUNTY CLERK 09/24/2019 04:58 PM INDEX NO. 155973/2017 NYSCEF DOC. NO. 34 RECEIVED NYSCEF: 09/24/2019 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) ._ PatientName Date of Birth Social Security Number James Roberts 01/06/1965 Patient Address: 99 Bames Road, Washingtonville, NY 10992 1, ormy authorized representative,request thathealth information regarding my care and treatmentbe released as setforth on this form In accordance with New York StateLaw and thePrivacy Rule of theHealth Insurance Portabilityand Accountability Act of 1996 (HIPAA), I understand that: I. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL