Preview
FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018
NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF QUEENS
_________________________....______________________Ç
ROSEMARY DANIELS, as Administrator of
the Estate of IVOIRE DANIELS, deceased,
RESPONSE TO
Plaintiff, PCO 2.25.2020
-against-
SOTIRIOS KASSAPIDIS, M.D., PAUL S. Index #704658/18
LAJOS, M.D., JAYANTILAL PATEL, M.D.,
GARY SCLAR, M.D. and MOUNT SINAI
HOSPITAL QUEENS,
Defendants.
_____..________________________________________x
Plaintiff, by her attorneys, BURNS & HARRIS, as and for a response to the Preliminary
Conference Order dated 2.25.2020, upon information and belief, provides the following:
(3) Medical Reports(s), Record(s) and Authorization(s):
Annexed hereto are the following:
-
Eva Waite, M.D. @ Mt. Sinai Hospital Primary Care Physician
-
Ronald Tamler, M.D. @ Mt. Sinai Hospital Endocrinologist
Northern Dutchess Hospital - wound care and physical therapy
Mt. Sinai Hospital Queens
Mt. Sinai Hospital Manhattan
VNS - Dutchess County
Social Administration - benefits
Security Disability
(7) Other Disclosure:
TT to provide Medicare conditional payment letter - upon information and belief
the plaintiff-decedent was not a Medicare recipient.
TT to provide response to defendant SACS and defendant Kassapidis outstanding
demands:
Defendant SACS letter dated 2.10.2020 - Response provided 2.20.2020 (copy
enclosed)
Defendant Kassapidis letterdated 1.16.2020 - Response provided 2.14.2020
(copy enclosed)
Death Certificate annexed hereto;
FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018
NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022
Supplemental BP's provided on 2.14.2020 and 2.20.2020;
Plaintiff reserves the right to supplement this response should additional information
become available.
Dated: New York, New York
March 18, 2020
Yours, etc.,
BURNS & HARRIS, ESQS.
Attorneys for flaintiff
Ma'rla St n, Esq.
233 Br adway, Suite 900
New/ ork, New York 10279
(212) 393-1000
TO:
Law Offices of Benvenuto & Slattery
Attys for Defts. - KASSAPIDIS & SCLAR
1800 Northern Boulevard
Roslyn, New York 11576
(516) 775-2236
File #: 20495
Shaub, Ahmuty, Citrin & Spratt, LLP
Attys for Defts. LAJOS; PATEL & and MOUNT SINAI
1983 Marcus Avenue
Lake Success, New York 11042
(516) 488-3300
SACS File #: 02-00549
FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018
NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022
FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018
NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022
OCA Official Form No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[Ihisform has been approved by the New York StateDepartment of Health]
PatientName Date of Birth Social SecurityNumber
Ivoire Daniels
Patient Address
23-38 31st Rd, Apt. 3C, Astoria, NY 11106
form·
I,or my authorized request
representative, that healthinformation regarding my care and treatment be releasedas set forthon this
In accordance withNew York StateLaw and the PrivacyRule bfthe Health Insurance Portabilityand Accountability Act of 1996(HIPAA),
I understandthat:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials
on
TREATMENT, psychotherapy notes, only my
the appropriatelinein Item 9(a). In the event the health information described below includes any of these types ofinformation, and I
initial
the lineon the box in Item 9(a),Ispecificallyauthorize release of such information to theperson(s) indicatedin I1em 8.
2. If Iam authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipientis
prohibited from redisclosing Luch information without my authorizationanless permitted to do so under federalor statelaw. I understand
thatI have the rightto request a list
of people who may receive oruse my HIV-related information without authorization.If I experience
discriminationbecause of the releaseor disclosure of HIV-related information, Imay contact the New York StateDivision of Human
Rights at (212)480-2493 or the New York City Conimission of Human Rights at (212) 306-7450. These agencies are responsible for
protecting my rights.
3. I havethe rightto revokethisauthorization at anytime by writing tothe healthcare providerlistedbelow. I understandthatI may revoke
thisauthorization except tothe extent thataction has alreadybeen takenbased on thisauthorization.
4. I understand thatsigning thisauthorization isvoluntary.My treatment, payment, enrothnent in a healthplan, oreligibilityforbenefits
will not be conditioned upón my authorizationof thisdisclosure.
5. Information disclosed under thisauthorization might be redisclosed by the recipient(except as noted above in Item 2), and this
redisclosure may no longer be protectedby federal orstatelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPEIFIED IN REM 9 (b).
7. Name and address of healthprovider or entitytorelease thisinformation:
Mt Sinai Manhattan 1468 Madison Ave, New York, NY 10029
sent.
8. Name and address of person(s)or category ofperson to whom thisinformation will be
Shaub, Ahmuty, Citrin & Spratt 1983 Marcus Avenue Suite 260 Lake Success, NY 11042
9 a).Specific information to be released:
edicalRecord
EntiraMedical Record, including patienthistories,officenotes (except psychotherapy notes),test results,
radiology studies,fihns,
referrals,
consults, billingrecords,inburance records, and records sent toyou by otherheakh careproviders.
Oh, Include: (Indicateby Initiating)
Alcohol/Drug Treatment pe
Mental Health Information
HIV-Related Information
Authorization to Discuss Health Information
By here
initiating I authorize
'
Initials
todiscuss my healthinformation with my attorney,or a governmental agency, list
here:
10. Reason forrelease of information: 11. Date orevent on which thisauthorization willexpire:
At request of individual End of Litigation
Other litigation
12. Ifnotthe patient,namp of person signing form: 13. Authority tosign on behalf ofpatient:
Prince Grant for Burns & Harris Power ofAttorney
U1 items on thisform have been completed and my questions about thisform have been answered. In addition, I havebeen a
copy the form.
Date: 3-18-2020
Signature of patientor representativeauthorized by law. K ACEVE
" Human Immunodeficiency Virus that causes AIDS. The New York StatePublic Health Law proilel!PlfMillistm$MMit%Whably
could identify someone as having HIV symptoms or infection and information regarding a person's coritect9s
AC61014t4
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in Richmond County
py Commission Emires Nov. 10, all
FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018
NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022
OCA OfficialForm No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
. [Thisform has been approved by the New York StateDepartment of Health]
PatientName Social SecurityNumber
Ivoire Daniels
PatientAddress
23-38 31st Rd, Apt. 3C, Astoria, NY 11106
I,or my authorized represeItative,request thathealth infonnation regarding my careand treatment be released as set forthon thisform:
In accordance withNew York State Law and thePrivacyRule oftheHealth InsurancePortability and Accountability Act of 1996 (HIPAA),
I understand that:
l. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initialson
TREATMENT, psychotherapy notes, only my
the appropriatelinein Item 9(a). In the event the health information described below includes any of these typesof information, and I
initialikelineon the box in Item 9(a),I authorize
specifically releaseof such information to theperson(s) indicatedinItem 8.
2. If Iam authorizing the release of HIV-related, alcoholor drug treatment, or mental health treatment information, the recipimt is
prohibited from redisclosing such information without my authorizationunless pennitted to do so under federalor statelaw. I understand
thatI have the righttorequest a listofpeople who may receive or usemy HIV-related information without authorization. IfI experience
discriminationbecause of the releaseor disclosure of HIV-related information,I may contact the New York State Division of Human
Rights at (212)480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies areresponsible for
protecting my rights.
3. I havetheright to revokethisauthorization at anytime by writing tothe healthcare provider listed
below. I understandthatI may revoke
thisauthorization except to theextent thataction hasalready been taken based on thisauthorization.
4. I understandthat signing thisauthorization is voluntary.
My treatment, payment, enrolhnent in a healthplan, or for
eligibility benefits
willnot be conditioned upon my authorizationof thisdisclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no leger be protectedby fedeml or statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPEIFIED IN ITEM 9(b).
7. Name and address of healthprovider or entityto releasethisinformation:
Mt Sinai Queens 25-10 30th Ave, Queens, NY 11102
8. Name and address of person(s)or category of person towhom thisinformation will be sent
Shaub, Ahmuty, Citrin & Spratt 1983 Marcus Avenue Suite 260 Lake Success, NY 11042
9(a).Specific information.tobe released:
Medical Record
EntireMedical Record, including patienthistories,officenotes (exceptpsychotherapy notes), testresults,radiology studies,films,
consults,
referrals, billing records,insurance records,and records sent toyou by other health careproviders.
Ober. Include: (Indicateby Initialing)
Treatment fd
OAlcohol/Drug
OMental Health Information
HIV-Related Information
Authorization to Discuss Health Information
O By here
initialing I authorize
InitialS
to discussmy healthinformation with my attorney, or a governmental agency, listhere:
10.Reasm forrelease of information: 11. Date orevent on which thisauthorization will expire:
At requestof individual End of Litigation
Other:litigation
12. Ifnot thepatient,name of person signing form: 13. Authority tosign on behalf ofpatient:
Prince Grant for Burns & He rris Power ofAttorney
111 itemson thisform have been completed and my questionsabout thisform have been answered. In additim, I have been provided
copy the form. .
. Date: 3-18-2020
Signature of patientor representativeauthorized by law.
" Human Virus thatcauses AIDS. The New York StatePublic Health Law protect41almdMllini
Immunodeficiency
could someone ashaving HIV symptoms or infectionand information regarding aperson's contac%go.:01AC6101414
identify
QualiAed in RichmondCounty
Convelselon Empires Nov.10,
aty
FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018
NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022
OCA OfficialForm No.·960
AUTHORIZATION FOR RELEASE OF HEALTII INFORMATION PURSUANT TO HIPAA
IThis form has been approved by the New York StateDepartment of Health]
Psient Name . Date of Birth
Ivoire Daniels
Patient Address
23-38 3 1st Rd, Apt. 3C, Astoria, NY 11106
I,or my authorizedrepresentttive,request thathealth information regarding my care and treatmentbe released as setforth on thisform:
In accordance with New York StateLaw and thePrivacy Rule of theHealth InsurancePortability and Accountability Act of 1996 (HIPAA),
I understand that
1. This authorization may include disclosure of infonnation relating to AI£OHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifIplace initials
on
TREATMENT, psychothempy notes, only my
the appropriate linein Item 9(a). In the event thehealth information described below includes any of thesetypes ofinformation, and I
the
initial lineon the box in Item9(a),I authorize
specifically release of such infonnation tothe person(s) indicatedin Item 8.
2. If Iam authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipientis
prohibited from redisclosing such information without my authorizationunless permitted to do so under federalor statelaw. Iunderstand
thatI have the rightto reqùest a list
of people who may receive oruse my HIV-related information without authorization.If Iexperience
discrimination because of the releaseor disclosure of HIV-related information, Imay contactthe New York State Division ofHuman
Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for
protecting my rights.
3. I havetherightto revoke thisauthorization at anytime by writing to thehealthcare provider listed
below. I understandthat I may revoke
. thisauthorization except tothe extent thataction hasalready been taken based on thisauthorization.
4. I understandthat thisauthorization is vohmtary. My treatment,payment, enrothnent ina healthplan, or for
eligibility benefits
signing
willnot be conditioned upon my authorizationof thisdisclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longerbe protected by federalor statelaw.
6. THIS AUTHOREATION DOES NOT AUTHOREE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPEIFIED IN ITEM9 (b).
information·
7. Name and address of healthprovider or entitytorelease this
Ronald Tamler @ Mount Sinai 5 E 98th St 3rd Floor, New York, NY 10029
8. Name and address of person(s)or category of person towhom thisinformation willbe sent
Shaub, Ahmuty, Citrin & Spratt 1983 Marcus Avenue Suite 260 Lake Success, NY 11042
released·
9 a).Specific information to be
edicalRecord
EntireMedical Record, including patienthistories,officenotes (exceptpsychotherapy notes),testresults,radiology studies,films,
consults,
referrals, billing·records,insurance records,and records sentto you by otherhealth careproviders.
Include:(Indicate by Initialing)
Treatment po
Alcohol/Drag
ental Health Information C
HIV-Related Information -
Authorization to Discuss Health Information
O By initiatinghere I authorize
Initials
to discussmy healthinformation with my attorney,or a governmental agency, listhere:
10. Reason for releaseof information: 11. Date orevent on which thisauthorization willexpire:
OAt request ofindividual End of Litigation
Other·
litigation
12.If notthe patient,name ofperson signingforne 13. Authorilyto sign on behalfof patient
·
Prince Grant for Burns & Harris Power ofAttorney
11items on thisform have been completed and my questions about thisform have been answered. In addition, I have been a
Date: 3-18-2020
Signature of patientor representativeauthorized law. .ACEVED
by
" Human Virus thatcauses AIDS. The New York StatePublic Health Law
Immunodeficiency p fridilnBrPNfBBiffBilsonably
could identifysomeon'e as having HIV symptoms or infection and information regarding a person's t4mpassesto34t4
Quailed in IVchmond
County
14 Commission ExpiresNov.10, 20
FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018
NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022
OCA Official Form No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[Thisform has been approved by the New York StateDepartment of Health]
PatientName Date of Birth SocialSecurity Number
Ivoire Daniels
PatientAddress
23-38 31st Rd, Apt. 3C, Astoria, NY 11106
I,or my authorized request
representative, thathealth information regarding my careand treatment be released as setforth on thisform:
In accordance with New York StateLaw and the PrivacyRule of theHealth Insurance Portabilityand Accountability Act of 1996 (HIPAA),
that·
I understand
1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and HIV* RELATED INFORMATION ifI place initials
on
TREATMENT, psychotherapy notes, CONFIDENTIAL only my
the appropriate linein Item 9(a). In the event the healthinformation describedbelow includes any ofthese types of infounation, and I
initial
the lineon the box in Item 9(a),I specificallyauthorizerelease ofsuch information to theperson(s) indicated in Item 8.
2. If Iam authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatnent information, the recipientis
prohibited from redisclosing such information without my authorizationunless permitted todo so under federalor statelaw. I understand
thatI have the rightto request a list
of people who may receive oruse my HIV-related information without authorizatiori.
If Iexperience
discrimination because of therelease or disclosure of HIV-related information, Imay contact the New York StateDivision ofHuman
Rights at (212)480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for
protecting my rights.
3. I havetheright to revoke thisauthorizationat anytime by writing to the
health careprovider listedbelow. I understandthatImay revoke
thisauthorization except tothe extent thataction hasalready been taken based on thisauthorization.
4.I understand that signingthis authorizationis voluntary.My treatment,payment, enrolhnent in a healthplan, or for
eligibility benefits
, will
not be conditioned upon my authorization ofthis disclosure.
5. Information disclosed under this authorization might be redisclosedby the recipient (except as noted above in Item 2), and this
redisclosure may no longerbe protected by federalor statelaw.
6, THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPEIFIED IN ITEM 9 (b).
7. Name and address of healthprovider or entityto releasethisinformation: .
Northern Dutchess Hospital 6511 Spring Brook Ave, Rhinebeck, NY 12572
8. Name and address of person(s)or category ofperson to whom thisinformation willbe sent:
Shaub, Ahrnuty, Citrin & Spratt 1983 Marcus Avenue Suite 260 Lake Success, NY 11042
9(a).Specific ·informationto be released:
OMedical Record
EntireMedical Record, including patient office
histories, notes (exceptpsychotherapy notes),testresults, radiology studies,films,
consults,
referrals, records,
billing insurance records, and recordssent toyou by other health carepmviders.
Other: Wound Care and Physical Include:(Indicate by Initialing)
Including
OAlcohol/Drug Treatment
Therapy
OMental Health Information
OHIV-Related Information
Authorization to Discuss Health Information
O By here
initialing I authorize
InitialS
to discussmy healthinformation withmy attorney, or a governmental agency, list
here:
10. Reason forrelease of information: 11.Date orevent on which thisauthorization will expire:
OAt requestof individual End of Litigation
Other:litigation
patient·
12. Ifnot thepatient,name of person signingform: 13. Authority tosign on behalf of
Prince Grant forBurns & Harris Power ofAttorney
11items on thisform have been completed and my questionsabout thisform have been answered. In addition I have been d a
copy of e form.
-- -- ___-. _ __-- - Date: 3-18-2020 t£ACEV
Signature of patientor representativeauthorized by law. poetje,stateof New Yorit
" Human Immunodeficiency Virus that causesAIDS. The New York StatePublic Health Law protects infgngt¡imDglhreasonably
could identifysomeone as having HIV symptoms or infection and information regarding a person's
ccfb Richmond County
My commission ExpiresNov.10,2 .
FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018
NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022
OCA Official Form No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York StateDepartment of Health]
Patient
Ivoire
Patient
Name
Daniels
Address
M
Date of Birth Social Securi Number
23-38 31st Rd, Apt. 3C, Astoria, NY 11106
I,or my authorizedrepresentative,request thathealth information regarding my care and treatment be releasedas set forthon thisform:
In accordance withNew York StateLaw and the PrivacyRule of theHealth Insurance Portabilityand Accountability Act of 1996 (HIPAA),
I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials
on
TREATMENT, psychotherapy notes, only my
the appropriate linein Item 9(a). In the event the healthinformation described below includes any of these typesof information, and I
the
initial lineon the box inItem 9(a),I specificallyauthorizerelease of such informatica tothe person(s) indicatedin Item 8.
2. If Iam authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipientis
prohibited from redisclosing such information without my authorizationunless permitted to do so under federalor statelaw. Iunderstand
thatI have the righttomquest a list
of people who may receive oruse my HIV-related information without authorization.If I experience
discriminationbecause of therelease or disclosure of HIV-related information, Imay contact the New York StateDivision of Human
Rights at (212)480-2493 or theNew York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for
protecting my rights.
3. I havetheright to myoke thisauthorizationat anytime by writing tothe healthcare provider below.
listed I understandthatI may revoke
thisauthorization except to theextent thataction has alreadybeen taken based on thisauthorization.
4. I understandthat signing thisauthorizationis voluntary.My treatment, payment, enrollment in a healthplan, or for
eligibility benefits
willnot be conditioned upon my authorizationof thisdisclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protectedby federalor statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPEIFIED IN ITEM 9 (b).
7. Name and address of healthprovider or entityto releasethisinformation:
Express Scripts 19-00 PollittDr, Fair Lawn, NJ 07410
8. Name and address of person(s)or category of person towhom thisinformation will be sent:
Shaub, Ahrnuty, Citrin & Spratt 1983 Marcus Avenue Suite 260 Lake Success, NY 11042
9(a).Specific informatiorltobe released:
OMedical Record
EntireMedical Record, including patienthistories,oilicenotes (exceptpsychotherapy notes),test results,
radiology studies,films,
refeirals,
consults,billing records,insurance records, and recordssentto you by other health careproviders.
Include:(Indicate by Initialing)
Other: Complete copy of pharmaceutical records
OAlcohol/Drug Treatment fs
OMental Health Information
HIV-Related Information
Authorization toDiscuss Health Information
O By initialinghere I authorize
Initials
to discussmy healthinfonnation with my attorney, or a governmental agency, listhere:
10. Reason forrelease of information: 11.Date orevent on which thisauthorization willexpire:
OAt request of individual End of Litigation
Other: litigation ... .
12. Ifnot thepatient,name of person signingform: 13. Authority tosign on behalf of patient
Prince Grant forBurns & Harris ...... Power of Attorney
All itemson thisform have been completed and my questions about thisform have been answered. In addition,I havebeen provid a
copy of the form.
Date: 3-18-2020
Signature of patientor representativeauthorized by law, DENISE M. ACEVE
" Human Virus that causesAIDS. The New York StatePublic Health Law
Immunodeficiency proteststigfestationtsubishmeavottably
could identifysomeone as having HIV symptoms or infection
and information regarding a person's
contgts01AC6101414
QuaNed in Richmond County
My Commissien ExpiresNov.10,20_
FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018
NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022
OCA Official Form No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[Ihisform has been approved by the New York StateDepartment of Health]
PatientName Date of Birth SocialSecuri Number
23-38 31st Rd, Apt. 3C, Astoria, NY 11106
I,or my authorizedrepresentative,request thatbealth information regarding my careand treatment be releasedas set forthon thisform:
In accordance with New York StateLaw and thePrivacy Rule of theHealth Insurance Portabilityand Accountability Act of 1996 (HIPAA),
I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFBENTIAL HIV* RELATED INFORMATION ifI place initialson
TREATMENT, psychotherapy notes, only my
the appropriatelinein Item 9(a). In the event the health information described below includesany ofthese types of information, and I
initial
the lineon the box in Item 9(a),I specifically
authorize release ofsuch information to the person(s)indicated inItem 8.
2. the'release health treatment the recipientis
If Iam authorizing of HIV-related, alcohol or drug treatment, or mental information,
prohibited from redisclosing such information without my authorizationunless permitted todo so under federalor statelaw. I understand
thatI have the rightto requesea listofpeople who may receive or usemy HIV-related information without authorization.If Iexperience
discrimination because of the releaseor disclosure of HIV-related information, Imay contactthe New York StateDivision ofHuman
Rights at (212)480-2493 or theNew York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for
protecting my rights.
3. I havetheright to revoke thisauthorizationat anytime by writing to thehealthcare provider listed
below. I understandthatI may revoke
thisauthorization except to theextent thataction has alreadybeen takenbased on thisauthorization.
4. Iunderstand thatsigning this authorizationisvoluntary.My treatment,payment, enrollment in a healthplan, or for
eligibility benefits
will not be conditioned upon my authorizationof thisdisclosure.
5. Information disclosed under thisauthorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protectedby federalor statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPEIFIED IN ITEM 9 (b).
. ... ...
7. Name and address of healthprovider or entityto releasethisinformation:
Visiting Nurse Service of NY Dutchess County Heritage Square Bldg 2 Suite 209 Hopewell Junction, NÝ 12533
8. Name and address of person(s)or category of person to whom thisinformation will be sent:
Shaub, Ahmuty, Citrin & Spratt 1983 Marcus Avenue Suite 260 Lake Success, NY 11042
9(a).Specific information to be released:
Medical Record
EntireMedical Record, including patienthistories,officenotes (exceptpsychotherapy notes),testresuks, radiology studies,fibns,
referrals,
consults,billingrecords, insurance records,and records sentto you by other health careproviders.
Other, Include:(Indicate by Initialing)
OAlcohol/Drug Treatment p6
OMental Health Information
OHIV-Related Information
Discuss'
Authorization to Health Information
O By here
initialing I authorize
Initials
to discussmy healthinformation with my attorney, or a governmental agency, list
here:
10.Reason forrelease of information: 11.Date orevent on which thisauthorization willexpire:
At request of individual End of Litigation
Other·
litigation
12. Ifnotthe patient,name of person signingform: 13. Authority tosign on behalf ofpatient:
Prince Grant for Burns & Harris Power ofAttorney
All items on thisform have been completed and my questi
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FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018 NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF QUEENS _________________________....______________________Ç ROSEMARY DANIELS, as Administrator of the Estate of IVOIRE DANIELS, deceased, RESPONSE TO Plaintiff, PCO 2.25.2020 -against- SOTIRIOS KASSAPIDIS, M.D., PAUL S. Index #704658/18 LAJOS, M.D., JAYANTILAL PATEL, M.D., GARY SCLAR, M.D. and MOUNT SINAI HOSPITAL QUEENS, Defendants. _____..________________________________________x Plaintiff, by her attorneys, BURNS & HARRIS, as and for a response to the Preliminary Conference Order dated 2.25.2020, upon information and belief, provides the following: (3) Medical Reports(s), Record(s) and Authorization(s): Annexed hereto are the following: - Eva Waite, M.D. @ Mt. Sinai Hospital Primary Care Physician - Ronald Tamler, M.D. @ Mt. Sinai Hospital Endocrinologist Northern Dutchess Hospital - wound care and physical therapy Mt. Sinai Hospital Queens Mt. Sinai Hospital Manhattan VNS - Dutchess County Social Administration - benefits Security Disability (7) Other Disclosure: TT to provide Medicare conditional payment letter - upon information and belief the plaintiff-decedent was not a Medicare recipient. TT to provide response to defendant SACS and defendant Kassapidis outstanding demands: Defendant SACS letter dated 2.10.2020 - Response provided 2.20.2020 (copy enclosed) Defendant Kassapidis letterdated 1.16.2020 - Response provided 2.14.2020 (copy enclosed) Death Certificate annexed hereto; FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018 NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022 Supplemental BP's provided on 2.14.2020 and 2.20.2020; Plaintiff reserves the right to supplement this response should additional information become available. Dated: New York, New York March 18, 2020 Yours, etc., BURNS & HARRIS, ESQS. Attorneys for flaintiff Ma'rla St n, Esq. 233 Br adway, Suite 900 New/ ork, New York 10279 (212) 393-1000 TO: Law Offices of Benvenuto & Slattery Attys for Defts. - KASSAPIDIS & SCLAR 1800 Northern Boulevard Roslyn, New York 11576 (516) 775-2236 File #: 20495 Shaub, Ahmuty, Citrin & Spratt, LLP Attys for Defts. LAJOS; PATEL & and MOUNT SINAI 1983 Marcus Avenue Lake Success, New York 11042 (516) 488-3300 SACS File #: 02-00549 FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018 NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022 FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018 NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022 OCA Official Form No.:960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [Ihisform has been approved by the New York StateDepartment of Health] PatientName Date of Birth Social SecurityNumber Ivoire Daniels Patient Address 23-38 31st Rd, Apt. 3C, Astoria, NY 11106 form· I,or my authorized request representative, that healthinformation regarding my care and treatment be releasedas set forthon this In accordance withNew York StateLaw and the PrivacyRule bfthe Health Insurance Portabilityand Accountability Act of 1996(HIPAA), I understandthat: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials on TREATMENT, psychotherapy notes, only my the appropriatelinein Item 9(a). In the event the health information described below includes any of these types ofinformation, and I initial the lineon the box in Item 9(a),Ispecificallyauthorize release of such information to theperson(s) indicatedin I1em 8. 2. If Iam authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipientis prohibited from redisclosing Luch information without my authorizationanless permitted to do so under federalor statelaw. I understand thatI have the rightto request a list of people who may receive oruse my HIV-related information without authorization.If I experience discriminationbecause of the releaseor disclosure of HIV-related information, Imay contact the New York StateDivision of Human Rights at (212)480-2493 or the New York City Conimission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights. 3. I havethe rightto revokethisauthorization at anytime by writing tothe healthcare providerlistedbelow. I understandthatI may revoke thisauthorization except tothe extent thataction has alreadybeen takenbased on thisauthorization. 4. I understand thatsigning thisauthorization isvoluntary.My treatment, payment, enrothnent in a healthplan, oreligibilityforbenefits will not be conditioned upón my authorizationof thisdisclosure. 5. Information disclosed under thisauthorization might be redisclosed by the recipient(except as noted above in Item 2), and this redisclosure may no longer be protectedby federal orstatelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPEIFIED IN REM 9 (b). 7. Name and address of healthprovider or entitytorelease thisinformation: Mt Sinai Manhattan 1468 Madison Ave, New York, NY 10029 sent. 8. Name and address of person(s)or category ofperson to whom thisinformation will be Shaub, Ahmuty, Citrin & Spratt 1983 Marcus Avenue Suite 260 Lake Success, NY 11042 9 a).Specific information to be released: edicalRecord EntiraMedical Record, including patienthistories,officenotes (except psychotherapy notes),test results, radiology studies,fihns, referrals, consults, billingrecords,inburance records, and records sent toyou by otherheakh careproviders. Oh, Include: (Indicateby Initiating) Alcohol/Drug Treatment pe Mental Health Information HIV-Related Information Authorization to Discuss Health Information By here initiating I authorize ' Initials todiscuss my healthinformation with my attorney,or a governmental agency, list here: 10. Reason forrelease of information: 11. Date orevent on which thisauthorization willexpire: At request of individual End of Litigation Other litigation 12. Ifnotthe patient,namp of person signing form: 13. Authority tosign on behalf ofpatient: Prince Grant for Burns & Harris Power ofAttorney U1 items on thisform have been completed and my questions about thisform have been answered. In addition, I havebeen a copy the form. Date: 3-18-2020 Signature of patientor representativeauthorized by law. K ACEVE " Human Immunodeficiency Virus that causes AIDS. The New York StatePublic Health Law proilel!PlfMillistm$MMit%Whably could identify someone as having HIV symptoms or infection and information regarding a person's coritect9s AC61014t4 Qualilied in Richmond County py Commission Emires Nov. 10, all FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018 NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022 OCA OfficialForm No.:960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA . [Thisform has been approved by the New York StateDepartment of Health] PatientName Social SecurityNumber Ivoire Daniels PatientAddress 23-38 31st Rd, Apt. 3C, Astoria, NY 11106 I,or my authorized represeItative,request thathealth infonnation regarding my careand treatment be released as set forthon thisform: In accordance withNew York State Law and thePrivacyRule oftheHealth InsurancePortability and Accountability Act of 1996 (HIPAA), I understand that: l. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initialson TREATMENT, psychotherapy notes, only my the appropriatelinein Item 9(a). In the event the health information described below includes any of these typesof information, and I initialikelineon the box in Item 9(a),I authorize specifically releaseof such information to theperson(s) indicatedinItem 8. 2. If Iam authorizing the release of HIV-related, alcoholor drug treatment, or mental health treatment information, the recipimt is prohibited from redisclosing such information without my authorizationunless pennitted to do so under federalor statelaw. I understand thatI have the righttorequest a listofpeople who may receive or usemy HIV-related information without authorization. IfI experience discriminationbecause of the releaseor disclosure of HIV-related information,I may contact the New York State Division of Human Rights at (212)480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies areresponsible for protecting my rights. 3. I havetheright to revokethisauthorization at anytime by writing tothe healthcare provider listed below. I understandthatI may revoke thisauthorization except to theextent thataction hasalready been taken based on thisauthorization. 4. I understandthat signing thisauthorization is voluntary. My treatment, payment, enrolhnent in a healthplan, or for eligibility benefits willnot be conditioned upon my authorizationof thisdisclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no leger be protectedby fedeml or statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPEIFIED IN ITEM 9(b). 7. Name and address of healthprovider or entityto releasethisinformation: Mt Sinai Queens 25-10 30th Ave, Queens, NY 11102 8. Name and address of person(s)or category of person towhom thisinformation will be sent Shaub, Ahmuty, Citrin & Spratt 1983 Marcus Avenue Suite 260 Lake Success, NY 11042 9(a).Specific information.tobe released: Medical Record EntireMedical Record, including patienthistories,officenotes (exceptpsychotherapy notes), testresults,radiology studies,films, consults, referrals, billing records,insurance records,and records sent toyou by other health careproviders. Ober. Include: (Indicateby Initialing) Treatment fd OAlcohol/Drug OMental Health Information HIV-Related Information Authorization to Discuss Health Information O By here initialing I authorize InitialS to discussmy healthinformation with my attorney, or a governmental agency, listhere: 10.Reasm forrelease of information: 11. Date orevent on which thisauthorization will expire: At requestof individual End of Litigation Other:litigation 12. Ifnot thepatient,name of person signing form: 13. Authority tosign on behalf ofpatient: Prince Grant for Burns & He rris Power ofAttorney 111 itemson thisform have been completed and my questionsabout thisform have been answered. In additim, I have been provided copy the form. . . Date: 3-18-2020 Signature of patientor representativeauthorized by law. " Human Virus thatcauses AIDS. The New York StatePublic Health Law protect41almdMllini Immunodeficiency could someone ashaving HIV symptoms or infectionand information regarding aperson's contac%go.:01AC6101414 identify QualiAed in RichmondCounty Convelselon Empires Nov.10, aty FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018 NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022 OCA OfficialForm No.·960 AUTHORIZATION FOR RELEASE OF HEALTII INFORMATION PURSUANT TO HIPAA IThis form has been approved by the New York StateDepartment of Health] Psient Name . Date of Birth Ivoire Daniels Patient Address 23-38 3 1st Rd, Apt. 3C, Astoria, NY 11106 I,or my authorizedrepresentttive,request thathealth information regarding my care and treatmentbe released as setforth on thisform: In accordance with New York StateLaw and thePrivacy Rule of theHealth InsurancePortability and Accountability Act of 1996 (HIPAA), I understand that 1. This authorization may include disclosure of infonnation relating to AI£OHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifIplace initials on TREATMENT, psychothempy notes, only my the appropriate linein Item 9(a). In the event thehealth information described below includes any of thesetypes ofinformation, and I the initial lineon the box in Item9(a),I authorize specifically release of such infonnation tothe person(s) indicatedin Item 8. 2. If Iam authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipientis prohibited from redisclosing such information without my authorizationunless permitted to do so under federalor statelaw. Iunderstand thatI have the rightto reqùest a list of people who may receive oruse my HIV-related information without authorization.If Iexperience discrimination because of the releaseor disclosure of HIV-related information, Imay contactthe New York State Division ofHuman Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights. 3. I havetherightto revoke thisauthorization at anytime by writing to thehealthcare provider listed below. I understandthat I may revoke . thisauthorization except tothe extent thataction hasalready been taken based on thisauthorization. 4. I understandthat thisauthorization is vohmtary. My treatment,payment, enrothnent ina healthplan, or for eligibility benefits signing willnot be conditioned upon my authorizationof thisdisclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longerbe protected by federalor statelaw. 6. THIS AUTHOREATION DOES NOT AUTHOREE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPEIFIED IN ITEM9 (b). information· 7. Name and address of healthprovider or entitytorelease this Ronald Tamler @ Mount Sinai 5 E 98th St 3rd Floor, New York, NY 10029 8. Name and address of person(s)or category of person towhom thisinformation willbe sent Shaub, Ahmuty, Citrin & Spratt 1983 Marcus Avenue Suite 260 Lake Success, NY 11042 released· 9 a).Specific information to be edicalRecord EntireMedical Record, including patienthistories,officenotes (exceptpsychotherapy notes),testresults,radiology studies,films, consults, referrals, billing·records,insurance records,and records sentto you by otherhealth careproviders. Include:(Indicate by Initialing) Treatment po Alcohol/Drag ental Health Information C HIV-Related Information - Authorization to Discuss Health Information O By initiatinghere I authorize Initials to discussmy healthinformation with my attorney,or a governmental agency, listhere: 10. Reason for releaseof information: 11. Date orevent on which thisauthorization willexpire: OAt request ofindividual End of Litigation Other· litigation 12.If notthe patient,name ofperson signingforne 13. Authorilyto sign on behalfof patient · Prince Grant for Burns & Harris Power ofAttorney 11items on thisform have been completed and my questions about thisform have been answered. In addition, I have been a Date: 3-18-2020 Signature of patientor representativeauthorized law. .ACEVED by " Human Virus thatcauses AIDS. The New York StatePublic Health Law Immunodeficiency p fridilnBrPNfBBiffBilsonably could identifysomeon'e as having HIV symptoms or infection and information regarding a person's t4mpassesto34t4 Quailed in IVchmond County 14 Commission ExpiresNov.10, 20 FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018 NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022 OCA Official Form No.:960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [Thisform has been approved by the New York StateDepartment of Health] PatientName Date of Birth SocialSecurity Number Ivoire Daniels PatientAddress 23-38 31st Rd, Apt. 3C, Astoria, NY 11106 I,or my authorized request representative, thathealth information regarding my careand treatment be released as setforth on thisform: In accordance with New York StateLaw and the PrivacyRule of theHealth Insurance Portabilityand Accountability Act of 1996 (HIPAA), that· I understand 1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and HIV* RELATED INFORMATION ifI place initials on TREATMENT, psychotherapy notes, CONFIDENTIAL only my the appropriate linein Item 9(a). In the event the healthinformation describedbelow includes any ofthese types of infounation, and I initial the lineon the box in Item 9(a),I specificallyauthorizerelease ofsuch information to theperson(s) indicated in Item 8. 2. If Iam authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatnent information, the recipientis prohibited from redisclosing such information without my authorizationunless permitted todo so under federalor statelaw. I understand thatI have the rightto request a list of people who may receive oruse my HIV-related information without authorizatiori. If Iexperience discrimination because of therelease or disclosure of HIV-related information, Imay contact the New York StateDivision ofHuman Rights at (212)480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights. 3. I havetheright to revoke thisauthorizationat anytime by writing to the health careprovider listedbelow. I understandthatImay revoke thisauthorization except tothe extent thataction hasalready been taken based on thisauthorization. 4.I understand that signingthis authorizationis voluntary.My treatment,payment, enrolhnent in a healthplan, or for eligibility benefits , will not be conditioned upon my authorization ofthis disclosure. 5. Information disclosed under this authorization might be redisclosedby the recipient (except as noted above in Item 2), and this redisclosure may no longerbe protected by federalor statelaw. 6, THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPEIFIED IN ITEM 9 (b). 7. Name and address of healthprovider or entityto releasethisinformation: . Northern Dutchess Hospital 6511 Spring Brook Ave, Rhinebeck, NY 12572 8. Name and address of person(s)or category ofperson to whom thisinformation willbe sent: Shaub, Ahrnuty, Citrin & Spratt 1983 Marcus Avenue Suite 260 Lake Success, NY 11042 9(a).Specific ·informationto be released: OMedical Record EntireMedical Record, including patient office histories, notes (exceptpsychotherapy notes),testresults, radiology studies,films, consults, referrals, records, billing insurance records, and recordssent toyou by other health carepmviders. Other: Wound Care and Physical Include:(Indicate by Initialing) Including OAlcohol/Drug Treatment Therapy OMental Health Information OHIV-Related Information Authorization to Discuss Health Information O By here initialing I authorize InitialS to discussmy healthinformation withmy attorney, or a governmental agency, list here: 10. Reason forrelease of information: 11.Date orevent on which thisauthorization will expire: OAt requestof individual End of Litigation Other:litigation patient· 12. Ifnot thepatient,name of person signingform: 13. Authority tosign on behalf of Prince Grant forBurns & Harris Power ofAttorney 11items on thisform have been completed and my questionsabout thisform have been answered. In addition I have been d a copy of e form. -- -- ___-. _ __-- - Date: 3-18-2020 t£ACEV Signature of patientor representativeauthorized by law. poetje,stateof New Yorit " Human Immunodeficiency Virus that causesAIDS. The New York StatePublic Health Law protects infgngt¡imDglhreasonably could identifysomeone as having HIV symptoms or infection and information regarding a person's ccfb Richmond County My commission ExpiresNov.10,2 . FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018 NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022 OCA Official Form No.:960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York StateDepartment of Health] Patient Ivoire Patient Name Daniels Address M Date of Birth Social Securi Number 23-38 31st Rd, Apt. 3C, Astoria, NY 11106 I,or my authorizedrepresentative,request thathealth information regarding my care and treatment be releasedas set forthon thisform: In accordance withNew York StateLaw and the PrivacyRule of theHealth Insurance Portabilityand Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials on TREATMENT, psychotherapy notes, only my the appropriate linein Item 9(a). In the event the healthinformation described below includes any of these typesof information, and I the initial lineon the box inItem 9(a),I specificallyauthorizerelease of such informatica tothe person(s) indicatedin Item 8. 2. If Iam authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipientis prohibited from redisclosing such information without my authorizationunless permitted to do so under federalor statelaw. Iunderstand thatI have the righttomquest a list of people who may receive oruse my HIV-related information without authorization.If I experience discriminationbecause of therelease or disclosure of HIV-related information, Imay contact the New York StateDivision of Human Rights at (212)480-2493 or theNew York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights. 3. I havetheright to myoke thisauthorizationat anytime by writing tothe healthcare provider below. listed I understandthatI may revoke thisauthorization except to theextent thataction has alreadybeen taken based on thisauthorization. 4. I understandthat signing thisauthorizationis voluntary.My treatment, payment, enrollment in a healthplan, or for eligibility benefits willnot be conditioned upon my authorizationof thisdisclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protectedby federalor statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPEIFIED IN ITEM 9 (b). 7. Name and address of healthprovider or entityto releasethisinformation: Express Scripts 19-00 PollittDr, Fair Lawn, NJ 07410 8. Name and address of person(s)or category of person towhom thisinformation will be sent: Shaub, Ahrnuty, Citrin & Spratt 1983 Marcus Avenue Suite 260 Lake Success, NY 11042 9(a).Specific informatiorltobe released: OMedical Record EntireMedical Record, including patienthistories,oilicenotes (exceptpsychotherapy notes),test results, radiology studies,films, refeirals, consults,billing records,insurance records, and recordssentto you by other health careproviders. Include:(Indicate by Initialing) Other: Complete copy of pharmaceutical records OAlcohol/Drug Treatment fs OMental Health Information HIV-Related Information Authorization toDiscuss Health Information O By initialinghere I authorize Initials to discussmy healthinfonnation with my attorney, or a governmental agency, listhere: 10. Reason forrelease of information: 11.Date orevent on which thisauthorization willexpire: OAt request of individual End of Litigation Other: litigation ... . 12. Ifnot thepatient,name of person signingform: 13. Authority tosign on behalf of patient Prince Grant forBurns & Harris ...... Power of Attorney All itemson thisform have been completed and my questions about thisform have been answered. In addition,I havebeen provid a copy of the form. Date: 3-18-2020 Signature of patientor representativeauthorized by law, DENISE M. ACEVE " Human Virus that causesAIDS. The New York StatePublic Health Law Immunodeficiency proteststigfestationtsubishmeavottably could identifysomeone as having HIV symptoms or infection and information regarding a person's contgts01AC6101414 QuaNed in Richmond County My Commissien ExpiresNov.10,20_ FILED: QUEENS COUNTY CLERK 07/14/2022 02:04 PM INDEX NO. 704658/2018 NYSCEF DOC. NO. 169 RECEIVED NYSCEF: 07/14/2022 OCA Official Form No.:960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [Ihisform has been approved by the New York StateDepartment of Health] PatientName Date of Birth SocialSecuri Number 23-38 31st Rd, Apt. 3C, Astoria, NY 11106 I,or my authorizedrepresentative,request thatbealth information regarding my careand treatment be releasedas set forthon thisform: In accordance with New York StateLaw and thePrivacy Rule of theHealth Insurance Portabilityand Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFBENTIAL HIV* RELATED INFORMATION ifI place initialson TREATMENT, psychotherapy notes, only my the appropriatelinein Item 9(a). In the event the health information described below includesany ofthese types of information, and I initial the lineon the box in Item 9(a),I specifically authorize release ofsuch information to the person(s)indicated inItem 8. 2. the'release health treatment the recipientis If Iam authorizing of HIV-related, alcohol or drug treatment, or mental information, prohibited from redisclosing such information without my authorizationunless permitted todo so under federalor statelaw. I understand thatI have the rightto requesea listofpeople who may receive or usemy HIV-related information without authorization.If Iexperience discrimination because of the releaseor disclosure of HIV-related information, Imay contactthe New York StateDivision ofHuman Rights at (212)480-2493 or theNew York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights. 3. I havetheright to revoke thisauthorizationat anytime by writing to thehealthcare provider listed below. I understandthatI may revoke thisauthorization except to theextent thataction has alreadybeen takenbased on thisauthorization. 4. Iunderstand thatsigning this authorizationisvoluntary.My treatment,payment, enrollment in a healthplan, or for eligibility benefits will not be conditioned upon my authorizationof thisdisclosure. 5. Information disclosed under thisauthorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protectedby federalor statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPEIFIED IN ITEM 9 (b). . ... ... 7. Name and address of healthprovider or entityto releasethisinformation: Visiting Nurse Service of NY Dutchess County Heritage Square Bldg 2 Suite 209 Hopewell Junction, NÝ 12533 8. Name and address of person(s)or category of person to whom thisinformation will be sent: Shaub, Ahmuty, Citrin & Spratt 1983 Marcus Avenue Suite 260 Lake Success, NY 11042 9(a).Specific information to be released: Medical Record EntireMedical Record, including patienthistories,officenotes (exceptpsychotherapy notes),testresuks, radiology studies,fibns, referrals, consults,billingrecords, insurance records,and records sentto you by other health careproviders. Other, Include:(Indicate by Initialing) OAlcohol/Drug Treatment p6 OMental Health Information OHIV-Related Information Discuss' Authorization to Health Information O By here initialing I authorize Initials to discussmy healthinformation with my attorney, or a governmental agency, list here: 10.Reason forrelease of information: 11.Date orevent on which thisauthorization willexpire: At request of individual End of Litigation Other· litigation 12. Ifnotthe patient,name of person signingform: 13. Authority tosign on behalf ofpatient: Prince Grant for Burns & Harris Power ofAttorney All items on thisform have been completed and my questi