Preview
FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021
EXHIBIT G
FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021
7 New.3érsey 15fBodh.1an Red Bank, NJ 07701
Place, Suite.200,
BRIANCOUK1*
Telephone:732.530A646Telefax:732.530.9536.
VAN HÈMM N
GRECO & NewYork 75 South Broadway, 4* Floor, White Plains, NY 10601
KENYON LLC Telephone:914.997.n00Telefax;914.997..1101
13, 2021
May
NAPOLI SHKOLNIK, PlLC
11*
360 Lexington Ave, Floor
New York, New York 10017
Attn: Jdseph P. Napoli, Esq.
Re: Darryl Nowak v. Sea Wolf Marine et al.
Index No. 154000/2018
Dear Sirs,
We refer to.our numerous prior requests fòr plaintiff s duly executed authorizations
directed to plaintiff's union and to his union plans for the release of their records to us.
Would you please provide them without further delay, as well as the other outstanding
discovery ordered by the Court onApril 20, 2021. Form authorizations are once again
provided herewith.. Please be advised that we willnot move forward with depositions
until this lòng-outstanding discovery is.provided and we obtain the records, and any delay
caused will be at the hands of plaintiff. Thânk yòu for your anticipated
thereby solely
cooperation.
Very truly yours,
BÈTANCOUllT, VAN HEMMEN, GRECO & KENYON LLC
s/ Ronald Isetancourt
By
RB/jc
Encls.
Ce:. MAHONEY & Ï(EANE, LLP
Gartl1Wolfson, Esq.
www.bvgklaw.com
FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021
Ron Betancourt
From: Ro.n Betancourt
Sent: Thursday, May 13, 2021 2:02 PM
To; Jps.eph Napoli
Cc: gwolfson@mahoneykeane.com Diane Paric
Subject; Nowak v.Sea With et.al.
Attach±ents: Ñapo.li 10.ltr.pdf;Local 1456 auth.pdf; U.nion Annuity Plan autho.pdf;.Union S&E
auth.pdf; Union Health and Welfa e auth pdf; Union pensieri auth.pdf;.Union
membership auth.pdf
Please see attached.
B.est regards,
Ron Betancourt
Betancourt, Van Hemmen, Greco & Kenyon LLC
Phone: 732-530-4646 (N. .) I 914-997-1100 (.N.Y.).
1
FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021
AUTHORIZATION
TO; Dockbuilders Local 1456
395 Ffudson St. #8
New York, NY 10014-7451
Re: Darryl Nowak
D/O/B: 12/23/1963
Dear Sirs:
Please furnish Betaricourt, Van Hemmen, Greco & Kenyon LLC 151 Bodman
Place, Suite 200, Red Bank, .New Jersey 67701, with. certified copies of a_1L records
pertaining to nty Safety and Education file. Å photöcopy
of this authorizationinay
be used in lieu of an original
Darryl Nowak
STATE OF . . )
) as.:
COUNTY OF . . )
On the day of ________ 2020s.before me personally came _
. to me known and known to me to be the individual
describedin and who executeci the forngoing instrument and acknow.1edgedthathe
executed the same.
Public
Notary
FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021
AUTHORIZATION
To; Dockbuilders Local 1456
395 Hudsòn St. #8
New York, NY 10014-7451
Re: Darryl Nowak
D/O/B; 12/23/1963
Dear Sits:
Please furnish Betancourt, Van Hemmen, Greco & Kênyon LLC, 151 Bodman
Place, Suite:200, ited Bank, New Jersey 07701, with certified copies of all records
pertaining to rny Health and Welfare Plan. A photòcopy
òf this authorization ntay
be used in lieu of an original.
Darryl Nowak
STÁTE OF _____________ )
) ss,:
COUNTY OF ___ _________ )
On the ____ day of . . 2020, before me personally came _
to me known and known to.rne to be the individual
described in and who executed.theforegaing instrument and acknòwledgedthat he
executed the saine..
__
Notary Public
FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021
. .
AUTHORIZATION
TO: Dockbuilders Loca11456
395 Hudson St..#8
New York,.NY 10014-7451
Re:. Darryl Nowak
D/O/B: 12/23/1963
Dear Sirs:
Please furnish Betancourt, Van Hemmen Greco & KenyonLLC, 151 Bodman
Place, Suite 200, Red Bank, New Jersey 07701 with certified copies of all records.
pertaining to my Annuity Plan. A photocopy of this authorization máy be used in
lieu.of an original
Darryl Nowak
STATE OF . . .
)
) ssz:
COUNTY OF .. . . . )
On the ___ day of ____________, 2020, befbre me personally came
.,to me known and known to m.e to be the
individuAl describ.ed. in and who executed the
foregoing
instrument and
acknowledged that he executed the same.
Notary Public
FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 124 RECEIVED OCANYSCEF:
Official 07/13/2021
Ferm No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[Thi$ form has been approved by.the New York State Department of Health]
Patient Name Date..of Birth Social Securi Number
Darryl Nowak 12/23/1963
Patient.Address
927 Broadway, Bayonne,.New Jersey 07702
1, ormy authorized represcütative,.request.thathealth.information regarding my care and tr¼atment be released as setforth on this form:
In.accordance with New York State Law and the Privacy Rule of the Ñealin Insurance Portabilityand 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 if I place initials
on
TREATMENT, psÿehotherapy notes, only my
the appreptiate line in Iterh9(a). In the event the healthrinformation described below includes any of these types of information, .and I
initial
the line on the boxin Itent9(a), Ispecifically authorize release of:such information tothe person(s) indicated in Item 8.
2. IfI am authorizing the release of HIVirelated, alcohol or drug treatment, or mental health treatment infom1ation, the recipient is
penhihi †d from such information without authorization unless permitted to do so under federal oristate law I
redisclosing. my
.understand that Ihave the right torequest a listof people who may receive ór use my HIVirelated information. without authorization. If
I experience discrimination because of the releaseor disclosure:of HIV-related information, 1 may contact theNew York State Division
of.Human Rights at (215) 480-2493 or the New York: City Commission of 14uman Rights at(212) 3d644511 These agencies are
responsible forprotecting my rights.
3. I hava.the right to revoke this authorization at any time.by writing to the health care provider listedbelow. I understand thatI may
revoke thisauthorizatioñ except to theextent that actionhas already been taken based on thisauthorization.
4. I understand. thatsigning this.authorization isvoluntary. My treatment, payment, enrollment in a health plan, or eligibilityfor
beliéfith
will net be conditioned upon my authorization of thisdisclosure.
5. lñfermation disclosed under thisauthorization might he redisclosed by theorecipient (excelt as noted above in Item 2), and this
redisclosure may no lorïgerbe protected by federal orstate law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR-MEDICAL
CARE WITH ANYONE OTHER TilAN THE ATTORNEY OR GO_VERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and addmss of healthprovider or entityto releasethis infonnation:
Dockbuilders Local 1456, 395 Hudsoft St. #8 New York, NY 10014-7451
8 Name and address of person(s) orcategory of5person to.whom infomiation
titis wilibe sent
Betancourt, Van Hc==ëneGreco & Kenyon LLC, 151 Bodman Place, Suite 200, Red Bank, NJ 07701
9(a). Specific information to be released:
O Medical.Record frbm (insert date) to (insertdate)
Q Entire Medical Record,.including patient históriesyofficeriotes(except psÿchotherapy notes),testresults,radiology studies, films,
referrals,consults, irsürance
billi1ïg.records, records; and recòrds sentdo you by other health care pröviders.
Q Other. All Union records Health
incladúng Include: (Indicate by.hritialing)
& Welfare Plan records
Alcohol/Drug Treatment
Mental HealtIfInformation
Autherizgtisñ toDiscuss.Health Inicrmatiañ HIV-Relate d Information
(b) O By initialinghere I áuthorize
Initials Name of health
individual care provider
to discussmy health information with my.attömey,.or á governinental agency, listed:here:
(Attoiwey/FinaNaine6r Govemmental Agency Name)
10. Réasortfor release of information: 1 1. Dáte oreveritbrt which thisäüthóriläticiiwill expire:
O At request ofindividual
GI Other: Litigation Conclusion of Litigation
.12. Ifnot the patient,name of person signing form; 13. Authority to sign on behalf of patient:
All items on this.foun have been ce--piptedand my questions about thisform have been answered. In addition,I have been provided a
copy of theform.
Date:
Signature of patientor representative authdrized by law.
* Human Izumd Yirus thatcauses AIDS The New York StatePuÜicHealth Law protects informatiòn coidd.
elssey which:resssimhly
identifysomeone as having.HIV sympts.q or infectlenamid ir.fermaticaregarding a perso s contacts.
FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021
Instructions for the Use
ofthe HIPAA-compliant Authorization Form to
Release Health Information Needed for Litigation
This fortn is the product of a collaborative process between the New York State
Office of Court Administration, representatives of the medical provider community in
New York, and the bench and bar, designed to produce a standard ofncial form that
complies with the privacy reqmrements of the federal Health Insurance Portability and
Accountability Act ("HIPAA") and its implementing regulations, to be used to authorize
the release of health information needed for litigation-in New York State courts. It can,
however, be used more broadly than this and be used before litigation has been
commenced, or whenever counsel would find it useful
The goal was to produce a standard HIPAA-compliant official fonn to obviate the
current disputes which often take place as to whether health information requests made in
the course of litigation meet the requirements of the HIPAA Privacy Rule. It should be
noted, though, that the form is optional. This fonn may be niled out on line and
downloaded to be signed by hand, or downloaded and filled out entirely on paper.
When filing out Item 11, which requests the date or event when the authorization
will expire, the person filling out the form may designate an event such as "at the
case"
conclusion of my court or provide a specific date amount of.time, such as "3 years
from this date".
If a patient seeks to authorize the release of his or her entire medical record, but
only from a certain date, tlie first two boxes hosection 9(a) should both be checked, and
the relevant date inserted on the first line containing the first box,
FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021
AUTHOR1ZATION.
TO: Dockbuilders Local 1456
395 Hudson St..#8
New Y ork, NY 10014-7451
Re: Darryl Nowak
D/O/B: 12/23/1965
SSN:M
Dear Sirs:
Please furnish Betancourt, Van Hemmen, Greco &KenyonLLC,151BodmanPlace,
Suite 200, Red Bank,.New 07701, with certified copies of all records to my
Jersey pertaining
ofthisauthorization beusedinlieuof anoriginal.
UnionMembership.Aphotocopy may
Darryl Nowak
STATE OF ______ )
) ss.;
COUNTY OF ____ _____ )
On the .
day of __________, 2â20, before me personally cain e _
to me known and known to me to be the individual
described in and who executed the foregoing instruinent and acknowledged that he
executed the same..
Notary Public
FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021
ACTHORIZATION
TO: Dockbuilders Local 1456
395 Huds.on St. (8
New Ytirk, NY 10014-7451
Re: Darryl Nowak
D/O/B: 12/23/1963
Dear Sirs.:
Please furnish Betancourt, Van Hemnten, Greco & Kenyon LLC, 151Bodman
FlacefSuite 2003 Red Bank,- New Jersey 07701, with certified copies of al records
to Pension Planc.A of this authorization be used in
pertaining my photocopy may
.lieu of an original.
Darryl Nowak
STATE OF ______ )
) sa.:
COUNTY OF__ _____ )
On the___ day of _____ 2020,.before ine personally came _
to me knowi-1 and.known to ine to be the individual
described in and who executed the foregoing instrument and acknowledged i:hathe
executed the same.
Notary Public
Preview
FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021 EXHIBIT G FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021 7 New.3érsey 15fBodh.1an Red Bank, NJ 07701 Place, Suite.200, BRIANCOUK1* Telephone:732.530A646Telefax:732.530.9536. VAN HÈMM N GRECO & NewYork 75 South Broadway, 4* Floor, White Plains, NY 10601 KENYON LLC Telephone:914.997.n00Telefax;914.997..1101 13, 2021 May NAPOLI SHKOLNIK, PlLC 11* 360 Lexington Ave, Floor New York, New York 10017 Attn: Jdseph P. Napoli, Esq. Re: Darryl Nowak v. Sea Wolf Marine et al. Index No. 154000/2018 Dear Sirs, We refer to.our numerous prior requests fòr plaintiff s duly executed authorizations directed to plaintiff's union and to his union plans for the release of their records to us. Would you please provide them without further delay, as well as the other outstanding discovery ordered by the Court onApril 20, 2021. Form authorizations are once again provided herewith.. Please be advised that we willnot move forward with depositions until this lòng-outstanding discovery is.provided and we obtain the records, and any delay caused will be at the hands of plaintiff. Thânk yòu for your anticipated thereby solely cooperation. Very truly yours, BÈTANCOUllT, VAN HEMMEN, GRECO & KENYON LLC s/ Ronald Isetancourt By RB/jc Encls. Ce:. MAHONEY & Ï(EANE, LLP Gartl1Wolfson, Esq. www.bvgklaw.com FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021 Ron Betancourt From: Ro.n Betancourt Sent: Thursday, May 13, 2021 2:02 PM To; Jps.eph Napoli Cc: gwolfson@mahoneykeane.com Diane Paric Subject; Nowak v.Sea With et.al. Attach±ents: Ñapo.li 10.ltr.pdf;Local 1456 auth.pdf; U.nion Annuity Plan autho.pdf;.Union S&E auth.pdf; Union Health and Welfa e auth pdf; Union pensieri auth.pdf;.Union membership auth.pdf Please see attached. B.est regards, Ron Betancourt Betancourt, Van Hemmen, Greco & Kenyon LLC Phone: 732-530-4646 (N. .) I 914-997-1100 (.N.Y.). 1 FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021 AUTHORIZATION TO; Dockbuilders Local 1456 395 Ffudson St. #8 New York, NY 10014-7451 Re: Darryl Nowak D/O/B: 12/23/1963 Dear Sirs: Please furnish Betaricourt, Van Hemmen, Greco & Kenyon LLC 151 Bodman Place, Suite 200, Red Bank, .New Jersey 67701, with. certified copies of a_1L records pertaining to nty Safety and Education file. Å photöcopy of this authorizationinay be used in lieu of an original Darryl Nowak STATE OF . . ) ) as.: COUNTY OF . . ) On the day of ________ 2020s.before me personally came _ . to me known and known to me to be the individual describedin and who executeci the forngoing instrument and acknow.1edgedthathe executed the same. Public Notary FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021 AUTHORIZATION To; Dockbuilders Local 1456 395 Hudsòn St. #8 New York, NY 10014-7451 Re: Darryl Nowak D/O/B; 12/23/1963 Dear Sits: Please furnish Betancourt, Van Hemmen, Greco & Kênyon LLC, 151 Bodman Place, Suite:200, ited Bank, New Jersey 07701, with certified copies of all records pertaining to rny Health and Welfare Plan. A photòcopy òf this authorization ntay be used in lieu of an original. Darryl Nowak STÁTE OF _____________ ) ) ss,: COUNTY OF ___ _________ ) On the ____ day of . . 2020, before me personally came _ to me known and known to.rne to be the individual described in and who executed.theforegaing instrument and acknòwledgedthat he executed the saine.. __ Notary Public FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021 . . AUTHORIZATION TO: Dockbuilders Loca11456 395 Hudson St..#8 New York,.NY 10014-7451 Re:. Darryl Nowak D/O/B: 12/23/1963 Dear Sirs: Please furnish Betancourt, Van Hemmen Greco & KenyonLLC, 151 Bodman Place, Suite 200, Red Bank, New Jersey 07701 with certified copies of all records. pertaining to my Annuity Plan. A photocopy of this authorization máy be used in lieu.of an original Darryl Nowak STATE OF . . . ) ) ssz: COUNTY OF .. . . . ) On the ___ day of ____________, 2020, befbre me personally came .,to me known and known to m.e to be the individuAl describ.ed. in and who executed the foregoing instrument and acknowledged that he executed the same. Notary Public FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 124 RECEIVED OCANYSCEF: Official 07/13/2021 Ferm No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [Thi$ form has been approved by.the New York State Department of Health] Patient Name Date..of Birth Social Securi Number Darryl Nowak 12/23/1963 Patient.Address 927 Broadway, Bayonne,.New Jersey 07702 1, ormy authorized represcütative,.request.thathealth.information regarding my care and tr¼atment be released as setforth on this form: In.accordance with New York State Law and the Privacy Rule of the Ñealin Insurance Portabilityand 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 if I place initials on TREATMENT, psÿehotherapy notes, only my the appreptiate line in Iterh9(a). In the event the healthrinformation described below includes any of these types of information, .and I initial the line on the boxin Itent9(a), Ispecifically authorize release of:such information tothe person(s) indicated in Item 8. 2. IfI am authorizing the release of HIVirelated, alcohol or drug treatment, or mental health treatment infom1ation, the recipient is penhihi †d from such information without authorization unless permitted to do so under federal oristate law I redisclosing. my .understand that Ihave the right torequest a listof people who may receive ór use my HIVirelated information. without authorization. If I experience discrimination because of the releaseor disclosure:of HIV-related information, 1 may contact theNew York State Division of.Human Rights at (215) 480-2493 or the New York: City Commission of 14uman Rights at(212) 3d644511 These agencies are responsible forprotecting my rights. 3. I hava.the right to revoke this authorization at any time.by writing to the health care provider listedbelow. I understand thatI may revoke thisauthorizatioñ except to theextent that actionhas already been taken based on thisauthorization. 4. I understand. thatsigning this.authorization isvoluntary. My treatment, payment, enrollment in a health plan, or eligibilityfor beliéfith will net be conditioned upon my authorization of thisdisclosure. 5. lñfermation disclosed under thisauthorization might he redisclosed by theorecipient (excelt as noted above in Item 2), and this redisclosure may no lorïgerbe protected by federal orstate law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR-MEDICAL CARE WITH ANYONE OTHER TilAN THE ATTORNEY OR GO_VERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and addmss of healthprovider or entityto releasethis infonnation: Dockbuilders Local 1456, 395 Hudsoft St. #8 New York, NY 10014-7451 8 Name and address of person(s) orcategory of5person to.whom infomiation titis wilibe sent Betancourt, Van Hc==ëneGreco & Kenyon LLC, 151 Bodman Place, Suite 200, Red Bank, NJ 07701 9(a). Specific information to be released: O Medical.Record frbm (insert date) to (insertdate) Q Entire Medical Record,.including patient históriesyofficeriotes(except psÿchotherapy notes),testresults,radiology studies, films, referrals,consults, irsürance billi1ïg.records, records; and recòrds sentdo you by other health care pröviders. Q Other. All Union records Health incladúng Include: (Indicate by.hritialing) & Welfare Plan records Alcohol/Drug Treatment Mental HealtIfInformation Autherizgtisñ toDiscuss.Health Inicrmatiañ HIV-Relate d Information (b) O By initialinghere I áuthorize Initials Name of health individual care provider to discussmy health information with my.attömey,.or á governinental agency, listed:here: (Attoiwey/FinaNaine6r Govemmental Agency Name) 10. Réasortfor release of information: 1 1. Dáte oreveritbrt which thisäüthóriläticiiwill expire: O At request ofindividual GI Other: Litigation Conclusion of Litigation .12. Ifnot the patient,name of person signing form; 13. Authority to sign on behalf of patient: All items on this.foun have been ce--piptedand my questions about thisform have been answered. In addition,I have been provided a copy of theform. Date: Signature of patientor representative authdrized by law. * Human Izumd Yirus thatcauses AIDS The New York StatePuÜicHealth Law protects informatiòn coidd. elssey which:resssimhly identifysomeone as having.HIV sympts.q or infectlenamid ir.fermaticaregarding a perso s contacts. FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021 Instructions for the Use ofthe HIPAA-compliant Authorization Form to Release Health Information Needed for Litigation This fortn is the product of a collaborative process between the New York State Office of Court Administration, representatives of the medical provider community in New York, and the bench and bar, designed to produce a standard ofncial form that complies with the privacy reqmrements of the federal Health Insurance Portability and Accountability Act ("HIPAA") and its implementing regulations, to be used to authorize the release of health information needed for litigation-in New York State courts. It can, however, be used more broadly than this and be used before litigation has been commenced, or whenever counsel would find it useful The goal was to produce a standard HIPAA-compliant official fonn to obviate the current disputes which often take place as to whether health information requests made in the course of litigation meet the requirements of the HIPAA Privacy Rule. It should be noted, though, that the form is optional. This fonn may be niled out on line and downloaded to be signed by hand, or downloaded and filled out entirely on paper. When filing out Item 11, which requests the date or event when the authorization will expire, the person filling out the form may designate an event such as "at the case" conclusion of my court or provide a specific date amount of.time, such as "3 years from this date". If a patient seeks to authorize the release of his or her entire medical record, but only from a certain date, tlie first two boxes hosection 9(a) should both be checked, and the relevant date inserted on the first line containing the first box, FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021 AUTHOR1ZATION. TO: Dockbuilders Local 1456 395 Hudson St..#8 New Y ork, NY 10014-7451 Re: Darryl Nowak D/O/B: 12/23/1965 SSN:M Dear Sirs: Please furnish Betancourt, Van Hemmen, Greco &KenyonLLC,151BodmanPlace, Suite 200, Red Bank,.New 07701, with certified copies of all records to my Jersey pertaining ofthisauthorization beusedinlieuof anoriginal. UnionMembership.Aphotocopy may Darryl Nowak STATE OF ______ ) ) ss.; COUNTY OF ____ _____ ) On the . day of __________, 2â20, before me personally cain e _ to me known and known to me to be the individual described in and who executed the foregoing instruinent and acknowledged that he executed the same.. Notary Public FILED: NEW YORK COUNTY CLERK 07/13/2021 05:17 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 124 RECEIVED NYSCEF: 07/13/2021 ACTHORIZATION TO: Dockbuilders Local 1456 395 Huds.on St. (8 New Ytirk, NY 10014-7451 Re: Darryl Nowak D/O/B: 12/23/1963 Dear Sirs.: Please furnish Betancourt, Van Hemnten, Greco & Kenyon LLC, 151Bodman FlacefSuite 2003 Red Bank,- New Jersey 07701, with certified copies of al records to Pension Planc.A of this authorization be used in pertaining my photocopy may .lieu of an original. Darryl Nowak STATE OF ______ ) ) sa.: COUNTY OF__ _____ ) On the___ day of _____ 2020,.before ine personally came _ to me knowi-1 and.known to ine to be the individual described in and who executed the foregoing instrument and acknowledged i:hathe executed the same. Notary Public