Preview
FILED: RICHMOND COUNTY CLERK 11/24/2021 08:31 AM INDEX NO. 150273/2021
NYSCEF DOC. NO. 32 RECEIVED NYSCEF: 11/24/2021
Supreme Court of the State of New York
County of Richmond
----- ----------------------------x
Albert Aciemo,
Plaintiff.
RESPONSE TO DISCOVERY &
-against- INSPECTION
Index #: 150273/2021
Steven Lavy Cherny and Julia Cherny,
Defendants.
x
PLEASE TAKE NOTICE that the following ccñstitutes, Plaintiff'sResponse, through his
attomey, LAW OFFICES OF JAMES MALEADY, PC, to Defendant's Response for Discovery
dated October 13, 2021:
A) See prior response dated July 2021 and served on July 7, 2021. The Plaintiff
provided appropriate authorizations in that response with regard to healthcare
providers and are annexed heretofore. The request for an IRS authorization
(Form 4506) is objected to as Plaintiffdoes not have any other source of income
other than his employment by NYPD. (See Lattimer v. Liu,2021 N.Y. Slip Op
31905, (S Ct NY County 2021)) Further itis no longer appropriate to request an
Authorization by Form 4506.
1) Upon information and belief Plaintiff may have had an MRI of the afFeded
region at Radiology Services of NY and an authorization is provided.
2) There were no prior cervical MRIs.
3) Plaintiff had a prior CT scan of his chest at NYU Langone Health Center.
An authorization is provided.
4) Plaintiff aññexes an authorization for NYPD to provide his records with
respect to weapon's certification.
5) Plaintiff willprovide Plaintiff'sout-of-pocket expenses under separate
cover within forty five (45) days.
6) An authorization is annexed for Plaintiff's pharmacy records from CVS
related to the occurrence.
1 of 33
FILED: RICHMOND COUNTY CLERK 11/24/2021 08:31 AM INDEX NO. 150273/2021
NYSCEF DOC. NO. 32 RECEIVED NYSCEF: 11/24/2021
PLEASE TAKE NOTICE that reserves the right to augment the rssponse heretofore.
Dated: November 23, 2021
Staten Island, NY
Yours, etc.,
J ES A. M ALEADY, ESQ.
OFFICE OF JAMES MALEADY, PC
292 Nelson Avenue
Staten Island, NY 10308
Tel # (347) 452-3703
Fax# (718) 317-5903
Email: maleady@nyaccident.com
2 of 33
FILED: RICHMOND COUNTY CLERK 11/24/2021 08:31 AM INDEX NO. 150273/2021
NYSCEF DOC. NO. 32 RECEIVED NYSCEF: 11/24/2021
OCA Omc1al Form No.: 960
AUTHORIZATION FOR RELEASE OF IIEALTll IN FORMATION PURSUANT TO H1PAA
.
[Thisform has heen approvedby the New YorkStateDepartment or Health|
°atientName: Date of Birth Social SecurityNumber
Albert Acierno 18Idit/1972
PatientAddress
188 Fremont Avenue Staten Island,NY 10306
reques information
that health my carc and treatment on this
be released as set forth fomr
I, or my authorized
represenÅtive. regarding
In accordance
with New York State Law:ndthe Privacy Insurance
Rule of the licahh Portability Act
and Accountability of 1996
(HIPAA), I understandthat:
1. This authorization includedisclosureof information to
relating A1.CO1101. and DRUG AHUSE, MENTAL HEALTH
may
except and CONFIDENTIAL HIV* REI.ATED INFORMATION ifIplacemy initials
on
TREATMENT, psychotherapynotes, only
the appropriate
line 9(a).
in Item information
the health
In the event below
described includesany ofthese types of and I
infom1ation.
the line on the box
initial in Item9(a), authorize
I si ecifically in Item
indicated
to the person(s)
release of such information 8.
2. IfI am authorizingtherelease of
HIU-related,alcoholor d rug
treatment.or mentalhealthtreatment the recipient
information. is
prohibitedfrom such informationwithoutmy unless
authorization permittedto do so under federal
or statelaw. 1
redisclosing
understand to request
that I have the right a list who
of people IllV-related
may reecive or use my informationwithoutauthorization.
If
discrimination
I experience because of ofHIV-related
the release or disclosure I may contact
information. the New YorkState Division
of Human Rightsat (212) 480-2493 or the New York City Commission of Iluman Rights at(212)306-7450. These agenciesare
for protecting
responsible my rights.
3. I have the right
to revokethis at any time
authori::ation by writing below.
listed
to the health care provider I understandthat I may
revokethis authorization
exceptto the extent has already been taken based on this authorization.
that action
4. I understandthatsigning thisauthorzationis voluntary.
My treatment.payment.enrollment ina healthplan,or for
eligibility
heneGts will
not be conditioned
upon of this disclosure.
my authorization
5. Informationdisclosedunder thisautharization
might be redisclosed
by (except
the recipient as notedabove in Item2), and this
may no longer
redisclosure be protected
by federal or state law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY IlEALTil INFORMATION OR MEDICAL
N' GOVERNMENTAL SPECIFIED IN ITEM 9 (bt
CARE WITH ANYONE OTHER THA THE ATTORNEY OR AGENCY
7. Name and address of healthpro id r or itytorel as info ati
. Name and ad r ss oÔp rson(s) or cate ory ofpe son towhom thisinformation willbe sent:
9(a).Specific information
to be released:
Ï Medical
Record from (insert date) to (insert date)
E.1Entire Mccal Record, including
icut histories, office notes (except psychotherapy notes), test results, radiology studies, fdms,
referrals, records.
ults, billing s nee records, and records sent to you by other health care providers.
B Other: (.D S 0 Include: ( indicate
by initiating)
b ESC Alcohol/DrugTreatment
Mental HealthInformation
to Discuss Health
Authorization isferisatics HIV-RelatedInformation
(b) 3 here
By initiating I authorize __
initials Nameof individual healthcareprovider
rny attomey, or a governmental agency, listed here:
to discuss my health in formation with
(Attorney/Fum Narneor GovemmentalAgencyName)
10. Reason forrelease of information:
I 1.Date or event on which thisauthorization willexpire:
At request of individual
O Other fŠ l 20 r atthe conclusion of my case, whichever is
earlier
12. Ifnot the patient name of person signing form: 13. Authority lo sign on behalf of patient:
All items on thisf h 've be campica d and my questions about thisform have been answered. In addition,I have been provided a
copy of theform.
Date:
Signature of pa nt orrepresentative authorized by law.
* r •
Human ½»y Virus thatcauses AIDS. The New York State Public11calthLaw protectsinfaraiâusswhich reasonablycould
identify..---- as havingHIV symptates or 'arecusa and information regarding a person'scontacts,
3 of 33
FILED: RICHMOND COUNTY CLERK 11/24/2021 08:31 AM INDEX NO. 150273/2021
NYSCEF DOC. NO. 32 RECEIVED NYSCEF: 11/24/2021
OCA Ofilclal
Form No.: 960
AUTHORIZATION FOR RELEASE OF IIEALTII IN FORMATION PURSUANT TO H1PAA
This formhas heen upproved by the New YorkStateDepartment of IIcatth[
'atientName: Date of Birth SocialSecurity Number
Albert Acierno 1M/1972
PatientAddress
188 Fremont Avenue Staten island, NY 10306
l. or my authorized reques
representative, that health
informationregarding be released as set forth
my care and treatment on thisfomr
In accordancewithNew York State Lawindthe PrivacyRule of the f lealth
Insurance and
Portability Act
Accountability of 1996
(liIPAA), I understandthat:
I. This authorization
may includedisclosureof information to
relating ALCOIIOL and DRUG ABUSE, MENTAL HEALTH
except lilV*RELATED INFORMATION if on
I place my initials
TREATMENT, psychotherapynotes, and CONFIDENTIAl. only
the appropriate
lineinItem 9(a).In the event
the heahhinformation below
described includesany ofthese types of and I
infom1ation.
initial
the line on the box
in Item9(a),I specifically
authorizerelease of such information
to the person(s)
indicated
in Item8.
2. IfI am authorizingthe release
ofHIV-related,alcoholor drug or
treatment, mental healthtreatment the recipient
information. is
prohibitedfrom redisclosingsuch informationwithoutmy authorization
unless permittedto do so under or
federal statelaw. I
understand to request
that I have the right who
a list of people may receive or use my
lilV-related
informationwithoutauthorization.
If
I experienec
discrimination
because ofthe release or disclosure
of IIIV-related I may contact
information, the NewYork State Division
of Human Rightsat (212) 480-2493 or :he New York City Commission of liuman Rightsat (212)306-7450. These agenciesare
responsible
for protecting
my rights.
3. I have the right
to revokethisauthori::ation
at any time
by writingto the health
care provider below.
listed ! understandthat I may
revokethis authorization
exceptto the extent has already been taken based on this authorization.
that action
4. I understandthatsigning thisauthorzationisvoluntary.My treatment.
payment. enrollment ina healthplan,or for
eligibility
henefits
willnot be conditioned
upon my authorization
of this disclosure.
5. informationdisclosedunder thisauthorization
might be redisclosed
by (except
the recipient as notedabove inItem 2),and this
may no longer
redisclosure be protected
by federal or state law.
6. TlilS AUT}IORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY IIEAl.Til INFORMATION OR MEDICAL
CARE WITH ANVONE OTHER THAN THE ATTORNEY OR COVERNMENTAI. AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and addre s of e Ithpr ide or entityt r lease formatio :
. Name and addr ss ofp rson(s)or cate ryof pers n towhom thi ir f stionwillbe sent:
9(a). information
Specific to be released:
Medical Record from (insert date) to (insert date)
L patient hi
Entire Medical Record, includin ,o e notes (except psychotherapy notes), test results, radiology
studies, films,
refcnals au s. billi s, inrance , records sent to you by other health care providers.
B Other: \( ÏOVT (.0 S Include: (Indicate
by Initialing)
td Alcohol/DrugTreatment
Mental HealthInformation
Authorizationto Discuss Health
Information HIV-Relatedlafa-.astica
here
(b) Cl By initialing I authorize ___
Initials Nameof individual healthcareprovider
with rny attomey, or a governmental agency, listed here:
to discuss my health inforrnation
(Anorney/Fum Nameor GowrnrnentalAgencyName)
10. Reason for releaseof information: thisauthorization willexpire:
11. Date or event on which
At request of individual
Q
Other· I 1 20Ûor at the conclusion of whichever is
¤ rny case,
earlier
12. Ifnot the patie , name of person signing form: 13. Authority to sign on behalf of patient:
All items on this rm h ve be complete d and questionsabout thisform have been answered. In addition,I have been provided a
my
-opy of thefo .
Date:
Signature of nt orrepresentativeauthorized by law.
* Virus thatcauses AIDS. The New York State PubliclicalthLaw protectsinformationwhich reasonablycould
Human L____2 .cicacy
:::ñwñê as having HIV sympto:ns orInfectionand information regardir,gaperson's contacts,
identify
4 of 33
FILED: RICHMOND COUNTY CLERK 11/24/2021 08:31 AM INDEX NO. 150273/2021
NYSCEF DOC. NO. 32 RECEIVED NYSCEF: 11/24/2021
OCA Official
Form No.: 960
AUTHORIZATION FOR RELEASE OF IIEALTH IN FORMATION PURSUANT TO HIPAA
This formhas been approved by the New YorkStateDepartment of IIealth|
0atientName: Date of Birth SocialSecurity Number
Albert Acierno 1@/1972
Patient Address
188 Fremont Avenue Staten Island, NY 10306
l. or my authorized reque.c that health
representative, informationreganling be released as set forth
my care and treatment on this fomr
In accordancewithNew York State Lawindthe Privacy Insurance
Rule of the Health and
Portability Act
Accountability of1996
(HIPAA), I understandthat:
I.This authorization
may includedisclosureof informationrelatingtoALCO}IO1. and DRUG ABUSE, MENTAL HEALTH
IIIV* INFORMATION ifI place my initials
on
TREATMENT, exceptpsychotherapynotes, and CONFIDENTIAL REl.ATED only
the appropriate
lineinItem 9(a).In the event the health
infonnation below
described includesany ofthese types of and I
information,
the line on the box
initial in Item 9(a),
I specifically to the person(s)
release of such infonnation
authorize indicated
in Item8.
2. IfI am authorizingtherelease of alcohol
HIV-related, or drug or mental
treatment, healthtreatmentinformation,the recipient
is
prohibitedfrom redisclosingsuch informationwithout my unless
authorization permittedto do so under federal
or statelaw. I
understandthat I have
the right
to request
a list of people
who or use my
may receive IllV-related
information
withoutauthorization.
If
I experience
discrimination
because ofthe release or disclosure
oflilV-related
information,I may contact
the New York State Division
of Iluman Rightsat (212) 480-2493 or the New York City Commission of Iluman Rights at(212) 306-7450. These agenciesare
responsible
for protecting
my rights.
3. 1 have the right
to revokethisauthorisation
at any time
by writing listed
to the health care provider below. I understandthatI may
revokethis authorization
exceptto the extent
that action
has alreadybeen taken based on this authorization.
4. 1 understandthatsigning thisauthorzationis voluntary.
My treatment,payment,enrollment ina healthplan,or for
eligibility
will
benefits not be canditioned of this disclosure.
upon my nuthorization
5. Informationdisclosedunder thisautharization
might be redisclosed
by (except
the recipient as notedabove in Item2), and this
redisclosure
may no longerbe protected
by federal
orstatelaw.
6. TIHS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTil INFORMATION OR MEDICAl.
CARE WITH ANYONE OTHER THA N TIrE ATTORNEY OR COVERNMENTAI. AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of healthprovider or to
tity r lease infor tion:
. Name and addre s ofperson(s) or catego y ofperso to whom thisinformation willbe sent:
9(a). information
Specific be released:
fiiMedicalRecord from (insert date) to (insert date)
O Entire Medical Record, including
patient histories, office notes (except psychotherapy notes), test results, radiology
studies, films,
referrals, ·ut ., billing i r ne ords, and records sent to you by other health carc providers.
- Other: s L( HS Include: (Indicate
by Initiating)
L MS Alcohol/DrugTreatment
Mental HealthInformation
Authorizationto Discuss Health
:=fanñatism HIV-Related Information
here
(b) Q By initiating I authorize
Initials Narneof individual healthcareprovider
a governmental agency, listed here:
with my attorney,or
to discuss my health information
(Anorney/Fim1Narneor GovemrnentalA,eencyNanw)
____
10. Reason for releaseof information: event on which thisauthorization willexpire:
1 1.Date or
At request of individual 7
er· /) I202/or at the conclusion of my case whichever is
Ot
earlier
12. Ifnot the pat , name of person signing form: 13. Authority to sign on behalf of patient:
hav been complete d and questionsabout thislbrm have been answered. In eddition,I have been provided a
All items on thÏf rm my
opy of thefo .
Date:
Signature of patientor representativeau±orized by law.
* that The New York StatePublic Health information
1.aw protects which reasonablycould
Human !=s:::d::iciency Virus causes AIDS.
::m;ss; as having HIV symptotos or infectionand informationregarding a person'scontacts.
identify
5 of 33
FILED: RICHMOND COUNTY CLERK 11/24/2021 08:31 AM INDEX NO. 150273/2021
NYSCEF DOC. NO. 32 RECEIVED NYSCEF: 11/24/2021
OCA Omcial Farm No.: MG
AUTHOR1ZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO H1PAA
IThisform has been approvedby the New YorkStateDwartment of IIcalth)
''atientName: Date of Birth Social Security Number
Albert Acierno 13d8d/1972 XXX-XX-3262
__
Patient Address
188 Fremont Avenue Staten island,NY 10306
representati, reques information
that health be released as set forth
my care and treatment form
on this
l. or my authorized regarding
In accordancewithNew York State Lawand the Privacy Insurance
Rule of the Ilealth and
Portability Act
Accountability of 1996
(IIIPAA). I understandthat:
I. This authorization includediscl3sureof information to ALCOlIOL and DRUG ABUSE, MENTAL HEALTH
may relating
and CONFIDENTIAL IIlV*RELATED INFORMATION i
f Iplacemy on
initials
TREATMENT. exceptpsychotherapynotes, only
the appropriate
lineinItem 9(a).In the event
the health
information below
described includesany of these types of and I
infom1ation.
I si ecifically
in Item 9(a),
the line on the box
initial authorizerelease of such information indicated
to the person(s) in Item8.
2. If1 am authorizingtherelease of
HIRrelated, alcoholor drugtreatment,ormental healthtreatment the recipient
information. is
prohibitedfrom such infonaationwithoutmy authorization
unless permittedto do so under or
federal statelaw. 1
redisclosing
understand to request
that I have the right a list of
peoplewho HIV-related
may receive or use my without
information authorization.
If
I experience because of
discrimination HIV-related
the release or disclosure
of I may contact
information. the NewYork State Division
of Human Rightsat (212) 480-2493 or dicNew York City Commission of liuman Rights at(212)306-7450. These agenciesare
responsible
for protecting
my rights.
3. 1 havethe right
to revokethis at any time
authori::ation by writing listed
care provider
to the health below. I understandthat 1 may
revokethis authorization
exceptto the extent has already been taken based on this authorization.
that action
4. Iunderstand thatsigning thisauthorzationisvoluntary.My treatment.
payment, enrollment ina healthplan,or for
cligibility
will
benefits not be esñditicñed
upon my of this disclosure.
authorization
5. Informationdisclosedunder thisauthorization
might be redisclosed
by therecipient(exceptas notedabove inItem 2),and this
redisclosure
may no longerbe protected
by federal or state law.
6. THIS AUTlIORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY IIEALTil INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THF. ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (bt
7. Name and dress of healthprovider o n release infor tin:
s. Name and a ress of rson(s)or cate ory ofpe on to w om t is infomati willbe sent:
9(a).Specific
informa n to be released:
li$MedicalRecord from (insert date) to (insert date)
patient histories, office notes (except psychotherapy notes), test results, radiology studies, films,
O Entire Medical Record, including
referrals, ult. ig reco dsnsur. nee r •corfs, and records sent to you by other health care providers.
B Other: Wl Include: ( indicate
by Initialing)
b in s t L h )h ( Alcohol/DrugTreatment
Mental HealthInformation
Authorizationto Discuss Health
!nfe-she HIV-Related Inforrnation
here
(b) CI By initialing I authorize
Initials Nameof individual trahh careprovider
with my attorney, or a governmental agency, listed here:
to discuss my health information
(Anorney/Finn Nameor GovemmentatAgencyName)
10. Reason for releaseof information:
l 1.Date or event on which thisauthorization willexpire:
At request of individual
Other b /Û / 20Âr at the conclusion of my case, whichever is
earlier
12. Ifnot the patient, e ofperson signing form: 13. to sign on behalf of patient:
Authority
Allitems on thisf rm ave been complett d and my
Preview
FILED: RICHMOND COUNTY CLERK 11/24/2021 08:31 AM INDEX NO. 150273/2021 NYSCEF DOC. NO. 32 RECEIVED NYSCEF: 11/24/2021 Supreme Court of the State of New York County of Richmond ----- ----------------------------x Albert Aciemo, Plaintiff. RESPONSE TO DISCOVERY & -against- INSPECTION Index #: 150273/2021 Steven Lavy Cherny and Julia Cherny, Defendants. x PLEASE TAKE NOTICE that the following ccñstitutes, Plaintiff'sResponse, through his attomey, LAW OFFICES OF JAMES MALEADY, PC, to Defendant's Response for Discovery dated October 13, 2021: A) See prior response dated July 2021 and served on July 7, 2021. The Plaintiff provided appropriate authorizations in that response with regard to healthcare providers and are annexed heretofore. The request for an IRS authorization (Form 4506) is objected to as Plaintiffdoes not have any other source of income other than his employment by NYPD. (See Lattimer v. Liu,2021 N.Y. Slip Op 31905, (S Ct NY County 2021)) Further itis no longer appropriate to request an Authorization by Form 4506. 1) Upon information and belief Plaintiff may have had an MRI of the afFeded region at Radiology Services of NY and an authorization is provided. 2) There were no prior cervical MRIs. 3) Plaintiff had a prior CT scan of his chest at NYU Langone Health Center. An authorization is provided. 4) Plaintiff aññexes an authorization for NYPD to provide his records with respect to weapon's certification. 5) Plaintiff willprovide Plaintiff'sout-of-pocket expenses under separate cover within forty five (45) days. 6) An authorization is annexed for Plaintiff's pharmacy records from CVS related to the occurrence. 1 of 33 FILED: RICHMOND COUNTY CLERK 11/24/2021 08:31 AM INDEX NO. 150273/2021 NYSCEF DOC. NO. 32 RECEIVED NYSCEF: 11/24/2021 PLEASE TAKE NOTICE that reserves the right to augment the rssponse heretofore. Dated: November 23, 2021 Staten Island, NY Yours, etc., J ES A. M ALEADY, ESQ. OFFICE OF JAMES MALEADY, PC 292 Nelson Avenue Staten Island, NY 10308 Tel # (347) 452-3703 Fax# (718) 317-5903 Email: maleady@nyaccident.com 2 of 33 FILED: RICHMOND COUNTY CLERK 11/24/2021 08:31 AM INDEX NO. 150273/2021 NYSCEF DOC. NO. 32 RECEIVED NYSCEF: 11/24/2021 OCA Omc1al Form No.: 960 AUTHORIZATION FOR RELEASE OF IIEALTll IN FORMATION PURSUANT TO H1PAA . [Thisform has heen approvedby the New YorkStateDepartment or Health| °atientName: Date of Birth Social SecurityNumber Albert Acierno 18Idit/1972 PatientAddress 188 Fremont Avenue Staten Island,NY 10306 reques information that health my carc and treatment on this be released as set forth fomr I, or my authorized represenÅtive. regarding In accordance with New York State Law:ndthe Privacy Insurance Rule of the licahh Portability Act and Accountability of 1996 (HIPAA), I understandthat: 1. This authorization includedisclosureof information to relating A1.CO1101. and DRUG AHUSE, MENTAL HEALTH may except and CONFIDENTIAL HIV* REI.ATED INFORMATION ifIplacemy initials on TREATMENT, psychotherapynotes, only the appropriate line 9(a). in Item information the health In the event below described includesany ofthese types of and I infom1ation. the line on the box initial in Item9(a), authorize I si ecifically in Item indicated to the person(s) release of such information 8. 2. IfI am authorizingtherelease of HIU-related,alcoholor d rug treatment.or mentalhealthtreatment the recipient information. is prohibitedfrom such informationwithoutmy unless authorization permittedto do so under federal or statelaw. 1 redisclosing understand to request that I have the right a list who of people IllV-related may reecive or use my informationwithoutauthorization. If discrimination I experience because of ofHIV-related the release or disclosure I may contact information. the New YorkState Division of Human Rightsat (212) 480-2493 or the New York City Commission of Iluman Rights at(212)306-7450. These agenciesare for protecting responsible my rights. 3. I have the right to revokethis at any time authori::ation by writing below. listed to the health care provider I understandthat I may revokethis authorization exceptto the extent has already been taken based on this authorization. that action 4. I understandthatsigning thisauthorzationis voluntary. My treatment.payment.enrollment ina healthplan,or for eligibility heneGts will not be conditioned upon of this disclosure. my authorization 5. Informationdisclosedunder thisautharization might be redisclosed by (except the recipient as notedabove in Item2), and this may no longer redisclosure be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY IlEALTil INFORMATION OR MEDICAL N' GOVERNMENTAL SPECIFIED IN ITEM 9 (bt CARE WITH ANYONE OTHER THA THE ATTORNEY OR AGENCY 7. Name and address of healthpro id r or itytorel as info ati . Name and ad r ss oÔp rson(s) or cate ory ofpe son towhom thisinformation willbe sent: 9(a).Specific information to be released: Ï Medical Record from (insert date) to (insert date) E.1Entire Mccal Record, including icut histories, office notes (except psychotherapy notes), test results, radiology studies, fdms, referrals, records. ults, billing s nee records, and records sent to you by other health care providers. B Other: (.D S 0 Include: ( indicate by initiating) b ESC Alcohol/DrugTreatment Mental HealthInformation to Discuss Health Authorization isferisatics HIV-RelatedInformation (b) 3 here By initiating I authorize __ initials Nameof individual healthcareprovider rny attomey, or a governmental agency, listed here: to discuss my health in formation with (Attorney/Fum Narneor GovemmentalAgencyName) 10. Reason forrelease of information: I 1.Date or event on which thisauthorization willexpire: At request of individual O Other fŠ l 20 r atthe conclusion of my case, whichever is earlier 12. Ifnot the patient name of person signing form: 13. Authority lo sign on behalf of patient: All items on thisf h 've be campica d and my questions about thisform have been answered. In addition,I have been provided a copy of theform. Date: Signature of pa nt orrepresentative authorized by law. * r • Human ½»y Virus thatcauses AIDS. The New York State Public11calthLaw protectsinfaraiâusswhich reasonablycould identify..---- as havingHIV symptates or 'arecusa and information regarding a person'scontacts, 3 of 33 FILED: RICHMOND COUNTY CLERK 11/24/2021 08:31 AM INDEX NO. 150273/2021 NYSCEF DOC. NO. 32 RECEIVED NYSCEF: 11/24/2021 OCA Ofilclal Form No.: 960 AUTHORIZATION FOR RELEASE OF IIEALTII IN FORMATION PURSUANT TO H1PAA This formhas heen upproved by the New YorkStateDepartment of IIcatth[ 'atientName: Date of Birth SocialSecurity Number Albert Acierno 1M/1972 PatientAddress 188 Fremont Avenue Staten island, NY 10306 l. or my authorized reques representative, that health informationregarding be released as set forth my care and treatment on thisfomr In accordancewithNew York State Lawindthe PrivacyRule of the f lealth Insurance and Portability Act Accountability of 1996 (liIPAA), I understandthat: I. This authorization may includedisclosureof information to relating ALCOIIOL and DRUG ABUSE, MENTAL HEALTH except lilV*RELATED INFORMATION if on I place my initials TREATMENT, psychotherapynotes, and CONFIDENTIAl. only the appropriate lineinItem 9(a).In the event the heahhinformation below described includesany ofthese types of and I infom1ation. initial the line on the box in Item9(a),I specifically authorizerelease of such information to the person(s) indicated in Item8. 2. IfI am authorizingthe release ofHIV-related,alcoholor drug or treatment, mental healthtreatment the recipient information. is prohibitedfrom redisclosingsuch informationwithoutmy authorization unless permittedto do so under or federal statelaw. I understand to request that I have the right who a list of people may receive or use my lilV-related informationwithoutauthorization. If I experienec discrimination because ofthe release or disclosure of IIIV-related I may contact information, the NewYork State Division of Human Rightsat (212) 480-2493 or :he New York City Commission of liuman Rightsat (212)306-7450. These agenciesare responsible for protecting my rights. 3. I have the right to revokethisauthori::ation at any time by writingto the health care provider below. listed ! understandthat I may revokethis authorization exceptto the extent has already been taken based on this authorization. that action 4. I understandthatsigning thisauthorzationisvoluntary.My treatment. payment. enrollment ina healthplan,or for eligibility henefits willnot be conditioned upon my authorization of this disclosure. 5. informationdisclosedunder thisauthorization might be redisclosed by (except the recipient as notedabove inItem 2),and this may no longer redisclosure be protected by federal or state law. 6. TlilS AUT}IORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY IIEAl.Til INFORMATION OR MEDICAL CARE WITH ANVONE OTHER THAN THE ATTORNEY OR COVERNMENTAI. AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and addre s of e Ithpr ide or entityt r lease formatio : . Name and addr ss ofp rson(s)or cate ryof pers n towhom thi ir f stionwillbe sent: 9(a). information Specific to be released: Medical Record from (insert date) to (insert date) L patient hi Entire Medical Record, includin ,o e notes (except psychotherapy notes), test results, radiology studies, films, refcnals au s. billi s, inrance , records sent to you by other health care providers. B Other: \( ÏOVT (.0 S Include: (Indicate by Initialing) td Alcohol/DrugTreatment Mental HealthInformation Authorizationto Discuss Health Information HIV-Relatedlafa-.astica here (b) Cl By initialing I authorize ___ Initials Nameof individual healthcareprovider with rny attomey, or a governmental agency, listed here: to discuss my health inforrnation (Anorney/Fum Nameor GowrnrnentalAgencyName) 10. Reason for releaseof information: thisauthorization willexpire: 11. Date or event on which At request of individual Q Other· I 1 20Ûor at the conclusion of whichever is ¤ rny case, earlier 12. Ifnot the patie , name of person signing form: 13. Authority to sign on behalf of patient: All items on this rm h ve be complete d and questionsabout thisform have been answered. In addition,I have been provided a my -opy of thefo . Date: Signature of nt orrepresentativeauthorized by law. * Virus thatcauses AIDS. The New York State PubliclicalthLaw protectsinformationwhich reasonablycould Human L____2 .cicacy :::ñwñê as having HIV sympto:ns orInfectionand information regardir,gaperson's contacts, identify 4 of 33 FILED: RICHMOND COUNTY CLERK 11/24/2021 08:31 AM INDEX NO. 150273/2021 NYSCEF DOC. NO. 32 RECEIVED NYSCEF: 11/24/2021 OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF IIEALTH IN FORMATION PURSUANT TO HIPAA This formhas been approved by the New YorkStateDepartment of IIealth| 0atientName: Date of Birth SocialSecurity Number Albert Acierno 1@/1972 Patient Address 188 Fremont Avenue Staten Island, NY 10306 l. or my authorized reque.c that health representative, informationreganling be released as set forth my care and treatment on this fomr In accordancewithNew York State Lawindthe Privacy Insurance Rule of the Health and Portability Act Accountability of1996 (HIPAA), I understandthat: I.This authorization may includedisclosureof informationrelatingtoALCO}IO1. and DRUG ABUSE, MENTAL HEALTH IIIV* INFORMATION ifI place my initials on TREATMENT, exceptpsychotherapynotes, and CONFIDENTIAL REl.ATED only the appropriate lineinItem 9(a).In the event the health infonnation below described includesany ofthese types of and I information, the line on the box initial in Item 9(a), I specifically to the person(s) release of such infonnation authorize indicated in Item8. 2. IfI am authorizingtherelease of alcohol HIV-related, or drug or mental treatment, healthtreatmentinformation,the recipient is prohibitedfrom redisclosingsuch informationwithout my unless authorization permittedto do so under federal or statelaw. I understandthat I have the right to request a list of people who or use my may receive IllV-related information withoutauthorization. If I experience discrimination because ofthe release or disclosure oflilV-related information,I may contact the New York State Division of Iluman Rightsat (212) 480-2493 or the New York City Commission of Iluman Rights at(212) 306-7450. These agenciesare responsible for protecting my rights. 3. 1 have the right to revokethisauthorisation at any time by writing listed to the health care provider below. I understandthatI may revokethis authorization exceptto the extent that action has alreadybeen taken based on this authorization. 4. 1 understandthatsigning thisauthorzationis voluntary. My treatment,payment,enrollment ina healthplan,or for eligibility will benefits not be canditioned of this disclosure. upon my nuthorization 5. Informationdisclosedunder thisautharization might be redisclosed by (except the recipient as notedabove in Item2), and this redisclosure may no longerbe protected by federal orstatelaw. 6. TIHS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTil INFORMATION OR MEDICAl. CARE WITH ANYONE OTHER THA N TIrE ATTORNEY OR COVERNMENTAI. AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address of healthprovider or to tity r lease infor tion: . Name and addre s ofperson(s) or catego y ofperso to whom thisinformation willbe sent: 9(a). information Specific be released: fiiMedicalRecord from (insert date) to (insert date) O Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, ·ut ., billing i r ne ords, and records sent to you by other health carc providers. - Other: s L( HS Include: (Indicate by Initiating) L MS Alcohol/DrugTreatment Mental HealthInformation Authorizationto Discuss Health :=fanñatism HIV-Related Information here (b) Q By initiating I authorize Initials Narneof individual healthcareprovider a governmental agency, listed here: with my attorney,or to discuss my health information (Anorney/Fim1Narneor GovemrnentalA,eencyNanw) ____ 10. Reason for releaseof information: event on which thisauthorization willexpire: 1 1.Date or At request of individual 7 er· /) I202/or at the conclusion of my case whichever is Ot earlier 12. Ifnot the pat , name of person signing form: 13. Authority to sign on behalf of patient: hav been complete d and questionsabout thislbrm have been answered. In eddition,I have been provided a All items on thÏf rm my opy of thefo . Date: Signature of patientor representativeau±orized by law. * that The New York StatePublic Health information 1.aw protects which reasonablycould Human !=s:::d::iciency Virus causes AIDS. ::m;ss; as having HIV symptotos or infectionand informationregarding a person'scontacts. identify 5 of 33 FILED: RICHMOND COUNTY CLERK 11/24/2021 08:31 AM INDEX NO. 150273/2021 NYSCEF DOC. NO. 32 RECEIVED NYSCEF: 11/24/2021 OCA Omcial Farm No.: MG AUTHOR1ZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO H1PAA IThisform has been approvedby the New YorkStateDwartment of IIcalth) ''atientName: Date of Birth Social Security Number Albert Acierno 13d8d/1972 XXX-XX-3262 __ Patient Address 188 Fremont Avenue Staten island,NY 10306 representati, reques information that health be released as set forth my care and treatment form on this l. or my authorized regarding In accordancewithNew York State Lawand the Privacy Insurance Rule of the Ilealth and Portability Act Accountability of 1996 (IIIPAA). I understandthat: I. This authorization includediscl3sureof information to ALCOlIOL and DRUG ABUSE, MENTAL HEALTH may relating and CONFIDENTIAL IIlV*RELATED INFORMATION i f Iplacemy on initials TREATMENT. exceptpsychotherapynotes, only the appropriate lineinItem 9(a).In the event the health information below described includesany of these types of and I infom1ation. I si ecifically in Item 9(a), the line on the box initial authorizerelease of such information indicated to the person(s) in Item8. 2. If1 am authorizingtherelease of HIRrelated, alcoholor drugtreatment,ormental healthtreatment the recipient information. is prohibitedfrom such infonaationwithoutmy authorization unless permittedto do so under or federal statelaw. 1 redisclosing understand to request that I have the right a list of peoplewho HIV-related may receive or use my without information authorization. If I experience because of discrimination HIV-related the release or disclosure of I may contact information. the NewYork State Division of Human Rightsat (212) 480-2493 or dicNew York City Commission of liuman Rights at(212)306-7450. These agenciesare responsible for protecting my rights. 3. 1 havethe right to revokethis at any time authori::ation by writing listed care provider to the health below. I understandthat 1 may revokethis authorization exceptto the extent has already been taken based on this authorization. that action 4. Iunderstand thatsigning thisauthorzationisvoluntary.My treatment. payment, enrollment ina healthplan,or for cligibility will benefits not be esñditicñed upon my of this disclosure. authorization 5. Informationdisclosedunder thisauthorization might be redisclosed by therecipient(exceptas notedabove inItem 2),and this redisclosure may no longerbe protected by federal or state law. 6. THIS AUTlIORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY IIEALTil INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THF. ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (bt 7. Name and dress of healthprovider o n release infor tin: s. Name and a ress of rson(s)or cate ory ofpe on to w om t is infomati willbe sent: 9(a).Specific informa n to be released: li$MedicalRecord from (insert date) to (insert date) patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, O Entire Medical Record, including referrals, ult. ig reco dsnsur. nee r •corfs, and records sent to you by other health care providers. B Other: Wl Include: ( indicate by Initialing) b in s t L h )h ( Alcohol/DrugTreatment Mental HealthInformation Authorizationto Discuss Health !nfe-she HIV-Related Inforrnation here (b) CI By initialing I authorize Initials Nameof individual trahh careprovider with my attorney, or a governmental agency, listed here: to discuss my health information (Anorney/Finn Nameor GovemmentatAgencyName) 10. Reason for releaseof information: l 1.Date or event on which thisauthorization willexpire: At request of individual Other b /Û / 20Âr at the conclusion of my case, whichever is earlier 12. Ifnot the patient, e ofperson signing form: 13. to sign on behalf of patient: Authority Allitems on thisf rm ave been complett d and my