Preview
FILED: NEW YORK COUNTY CLERK 02/25/2022 12:25 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 160 RECEIVED NYSCEF: 02/25/2022
Power of Atlornev
To Execute HIPAA Medicel Record Authorization Forms Pursuant To the HEALTH
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 PUBLIC LAW
104-191, August 2\1996
I,?^ \ \.)o.,oqt.-
of u)G J- Oloez
(rnsert your name and
do hercby appoint: NapoU fjh-kolnik,P!,LC, with oftices at J60 l"qeirtgton
Awnlrq.l-l'h Floor,
NeW York-NY lS0!t my sttorneys -in-fsct to act (each agenl may act scparately) in my name,
place and stead in any wey which I myself could do, if I wore personally present to exccute
HIPAA Medicst Record Authorlzation Forms Purrusnt To th€ HDALTII INS{TRANCE
PORTABILITY AIYD ACCOUNTABILITY ACT OF 1996 PTJBLIC LAW Augurt
IO,I.I9T,
21, 1996. This power of attomey may be revoked by me at any time. This Power of Attomey
shall not be affectedby my subsequent disabilityor incompetence.
To induce any third party act hereundet, I hereby agree that any third party receiving a duly
executed copy of facsimile of this instrument may act hereunder, and that revocation or
termination hereof shall be ineffbctive as to such third party unless and until actual notice or
knowledge of such revocalion or termination shall have been received by such third parly, and I
fnr mysclf nnd for rny heirs, executon, legal ropresentatives and a.ssigns, hereby tgree to
inelcmnify and hold lumless any such third party from snd against any and all clairns that rnay
arise ngginst such thirdparfyby reason of such party
ttrird having reliedon the provisions of this
instrument.
In Witness Whereof I have hereunto signed my name this 2l day of fut+, 20 22_
ACKNOWLEDGEMENT
STATE OF l./c"'r 'io r /c
COUNTY OF Neqr 1oc l\-
2l day of 5o* tEv\ 20-$sfore me the undersigned, personally appeared
6 rNcrit- pursonaQ| known to be or proved to me on the basis of satisfactory
evidence to be the individual whose narne is subscribed to the within instrument and
acknowledged to me that he executed the same inhis capacity,and thatby his sigratureon the
the individual, or the person who acted on behalf of the individual, executed the
and ttrat such indfvidual made such appearance before the undersigned.
Notary
IVAN RODRIGUEZ
Notary Publlc, State ol NewYork
No.01PO6116071
in Rlchmond County
Qualllled
.ommission Expiros Septembet 20'204\
FILED: NEW YORK COUNTY CLERK 02/25/2022 12:25 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 160 RECEIVED NYSCEF: 02/25/2022
OCA Official
Form W.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
This form has been approved by the New York State Depa rtment ofliealth|
PatientName Date ofRirth SocialSecurityNumber
Darryl Nowak 12/23/1963
PatientAddress
927 Broadway, Bayonne, NJ 07002
L or my authorized request
representative, that health
information regarding my care andtreatmentbe releasedas set forth
on thisform:
In accordancewith New York StateLaw and the Privacy
Rule of the Ilealth
InsurancePortabilityand AccountabilityAct of I996
(HIPAA), I understandthat:
L This authorizationmay include disclosureof infonnation relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifIplace initials
on
TREATMENT, psychotherapy notes, only my
the appropriatelinein Item9(a). In theevent the health
information describedbelow includesany of thesetypes ofinfomiation,and 1
innialthe uneon the box in Item9(a), authorize
1 specifically releaseof such informationto the person(s)
mdicated in Item8.
2 If I am authorizingthe releaseof l
lIV-related,alcohol ordrug treatment. ormental health treatmentinformation. therecipientis
prohibited from redisclosingsuch informationwithout my authorizationunless peanutted todo so under federal or statelaw. I
understand thatI havethe right
to requesta list
of peoplewho may receiveoruse my HIV-relatedinformation withoutauthorization.If
I experiencediscriminationbecause of thereleaseor of
disclosure IIIV-relatedinformation.I may comact the New York Stage Division
of f lumanRights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are
responsibleforprotectingmy rights.
3. Ihave the rightto revoke thisauthorizationat anytime by writingto thehealthcare provideslistedbelow. I understandthatI may
sevoke thisauthorizationexceptto the extent
thatactionhas already been takenbased on thisauthorization.
4. I understand that signingthis authorizationisvoluntary. My treatment,payment, enrollment in a healthplan, or for
eligibility
benefitswillnot be conditionedupon my authorizationofthisdisclosure.
5. Inforrnationdisclosedunder thisauthorizationmight be redisclosedby the recipient(except as noted above in Item 2),and this
redisclosure
may no longerbe protectedby federalor state
law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address ofhealth provideror to release
entity thisinformation:
District Carpenters'
NYC Council of Benefit Funds, 395 Hudson St.,New York, NY 10014
8. Name and address ofperson(s)or categoryof personto whom thisinformationwill be sent:
Retancourt, Van Hemmen, Greco & Kenyon LLC, 151 Bodman Pl.,Suite 200,Red Bank, NJ 07701
9(a).Specificinformation to be released:
O Medical R "cord from (insert
date) to (insert
date)
Q Entir• edical patient officenotes (except test results,
Record,including histories, psychotherapy notes), radiologystudies,
films,
consults,
crrals, billingrecords,insurancerecords,and recordssent to youby otherhealthcare providers.
Other: All Pension Plan records h ude:(Indicateby Initialmg)
Alcohol/Drug Treatment
Mental ItealthInformation
Authorization to DiscussHealth Information HIV-Related Information
(b)O By here
initialing I authorize
Initials health care provider
Name of individual
to discussmy healthinformation with my attorney,or a governmentalagency, listed
here:
Name or Govemmental
(Attorney/Firm Agency Name)
10. Reason forrelease ofinformation: 11. Date or eventon which thisauthorizationwillexpire:
O At requestofindividual
O Other: litigation at conclusion of litigation
12. Ifnotthe pt tient,
name of personsi ning form: 13. Authority to signon behalfof patient:
All itemson thisform have been completed and my questionsal out
thisform have been answered. in addition,I havebeen provided
copy of the form.
Signatureof patientor representative
authorizedby law.
* IIuman I --±&iency Virus thatcauses AIDS.The New York StatePublicHealth Law protectsinformationwhich could
reasonably
someone
identify as havingHIV symptoms or infection
and information regardinga person's
contacts.
FILED: NEW YORK COUNTY CLERK 02/25/2022 12:25 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 160 RECEIVED NYSCEF: 02/25/2022
Instructions for the Use
of the HlPAA-compliant Authorizatjon Form to
Release Health Information Needed for Litigation
Tlris form is the product of a collaborative process between the New york State
Office of Court Administration, representatives of the metlical provider cornmunify in
New York, and the bench and bar, designecl to produce a stantlarcl official fonn that
complies with the privacy requirements of the federal Health Insurance portability and
Accountability Act ("HIPAA") and its implementing regulations, to be used to authorize
fhe release of health infornration needed for litigati& in wew 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 useftil.
The goal was to produce a standard HlPAA-cornpliant official form to obviate the
current disputes which often take place as to whether neatttr 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 filied out on linc 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 cxpire, the person filling out the form may designatc an event such as ..at the
conclusion of my court case" orprovide a specific date amount of time, such as,,3 years
from this date".
If a patient seeks to authorize tlte release of his or her entire medical record, but
only from a certain date, the first two boxes in scction 9(a) should both be checked, and
the relevant date inserted on the first line containing the nist uox.
FILED: NEW YORK COUNTY CLERK 02/25/2022 12:25 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 160 RECEIVED NYSCEF: 02/25/2022
OCA OfficialForm No.: 960
AUTHOR1ZATION FOR RELEASE OF HEALTII INFORMATION PURSUANT TO HIPAA
This form has been approved by the New York State Department ofHeaHh|
PatientName Date ofBirth SocialSecurityNumber
Darryl Nowak 12/23/1963
PatientAddress
927 Broadway, Bayonne, NJ 07002
1, or myauthorized request
representative, thathealth informationregardingmy careand treatmentbe releasedas set forth
on this
form:
In accordancewith New York StateLaw and the PrivacyRule ofthe HealthInsurance and Accountability
Portability Act of 1996
(HIPAA), I understandthat:
1. This authorizationmay include disclosureof information relatingto ALCOHOL and DRUC ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifIplace initials
on
TREATMENT, psychotherapy notes, only my
the appropriatelincin Item9(a). In the eventthe healthinformationdescribedbelow includesany of thesetypes ofinformation,and I
the line
initial on the box in Item9(a),I specifically
authorizereleaseof suchinformation to the person(s)
indicatedinItem 8.
2. If Iam authorizingtherelease ofHIV-related, alcohol ordrug treatment,or mental health treatmentinformation, he recipient is
prohibited from redisclosingsuch informationwithout my authorizationunless permitted todo so under federal or statelaw. I
understand thatI havethe to request
right of
a list peoplewho may receive oruse my HIV-relatedinformationwithout authorization.If
I experiencediscriminationbecause of or
the release disclosureof HIV-relatedinformation,I may 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 ate
responsibleforprotectingmy rights.
3. 1 have therightto revoke thisauthorizationat anytime by writingto thehealthcare provider listed
below. I understandthatI may
revoke thisauthorizationexcept to the extent
thatactionhas alreadybeen takenbased on thisauthorization.
4. I understand thatsigning this authorizationisvoluntary. My treatment,payment, enrollment in a healthplan, or for
eligibility
benefitswillnot be conditionedupon my authorizationof this
disclosure.
5. Information disclosedunder thisauthorizationmight be redisclosedby the recipient(except as noted above in Item 2),and this
redisclosure
may no longerbe protectedby federalor state law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and addressofhealth provider to release
or entity thisinformation.
District Council ofCarpenters' Benefit Hudson NY 10014
NYC Funds, 395 St.,New York,
8. Name and address ofperson(s)or categoryof personto whom thisinformationwillbe sent:
Betancourt, Van Hemmen, Greco & Kenyon LLC, 151 Na= Pl.,Suite 200, Red Bank, NJ 07701
9(a) Specificinformationto be released:
O Medical Record from (insert
date) to (insert
date)
Gl EntireMedical Record, includingpatient officc
histories, notes(exceptpsychotherapy notes),test results,
radiologystudies,films
r- insurance and recordssent to you other healthcareproviders.
rrals,
consults,
billingrecords, records, by
ther: All Welfare Plan records h lude:( Indicate
hv Indialing)
Alcohol/Drug Treatment
Mental IIealthInformation
Authorization to DiscussHealth Information IIIV-Related Information
(b)O By here
initialing I authorize
Initials Name of individual
health care providel
to discuss
my healthinformationwith my attorney,or a governmentalagency, listed
here:
(Anomey/Finn Name or GovernmentalAgency Namc)
10. Reason forreleaseof information: 11. Date or event on which thisauthorizationwillexpire:
O Atrequest ofindividual
21 Other: litigation at conclusion of litigation
12. Ifnot the m •nt, nameof personsignin • form: 13. Authorit nign on rh¡ f patient: o
Allitems on this
form have bee completed and my questionsabout form
this have been answered. Inaddition,I havebeen provided a
copy of the for
n.
Date: 2-
Signatureof patient
or representative
authorized by law.
* Human Virus thatcauses AIDS.The New York State Public
Health Law protectsinformationwhich could
Les:±ficiency reasonably
someone as having
identify HIV symptoms or infection
and informationregarding coulacts.
a person's
FILED: NEW YORK COUNTY CLERK 02/25/2022 12:25 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 160 RECEIVED NYSCEF: 02/25/2022
Instructions tbr the Use
of the HlPAA-compliant Authorization Form to
Release Health Information Needed for Litigation
This forrn is the product of a collaborative process between the New york State
officc of Court Administration, representatives of the medical provider. community in
New York, and the bench and bar, designed to produce a stanclard official foln that
complics with the privacy requirements of the federal Health Insurance por.tability and
Accountability Act ("HIPAA") and its implernenting regulations, to be used to authorize
tlte relcase 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 HlPAA-compliant official form to obviate the
culrent disputes which often take place as to whether health information requests madc in
the course of Iitigation nreet the rcquirements of the HIPAA privacy Rule. It shoulcl be
noted, though, that the form is optional. This form may be filled out on lile and
downloaded to be signed by hand, or downloacled and fillcd out entirely on paper.
Whcn filing out Item 11, which requests the date or event when the authorization
will expire, the person filling out the form may designate an evenl such as ..at the
conclusion of my court case" or provide a specific date amount of time, such ,,3
as years
frorn this date".
If a patient sccks to authorize the release of his or her entire mecliciil record, but
only from a ceftain date, the first two boxes in section 9(a) should both be cSecked, and
the relevant date inserted on the first line containing the first box.
FILED: NEW YORK COUNTY CLERK 02/25/2022 12:25 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 160 RECEIVED NYSCEF: 02/25/2022
OCA Official
Form No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York State Department of Health]
PatientName Date ofBirth SocialSecurityNumber
Darryl Nowak 12/23/1963
PatientAddress
927 Broadway, Bayonne, NJ 07002
1, or myauthorized request
representative, thathealthinformation regardingmy care andtreatment be releasedas set forth
on thisform:
In accordancewithNew York State Law and the PrivacyRule ofthe Health Insurance and
Portability AccountabilityAct of1996
(HIPAA), 1 understandthat:
1. This authorizationmay includedisclosure of information relatingto ALCOHOL and DRUG AHUSE, MENTAL HEALTH
except and CONFIDENTIAL IIIV* RELATED INFORMATION if
I place initials
on
TREATMENT, psychotherapynotes, only my
the appropriatelineinhem 9(a). Inthe eventthe ltealth
information describedbelow includesany ofthese typesof information,and I
initial
the line
on the box in Item9(a),I specifically
authorizereleaseof such informationto theperson(s)indicatedin Item8.
2. If I am authonzing the releaseof alcohol
lilV-related, ordrug treatment, ormental health treatment information,therecipientis
prohibited from redisclosingsuch informationwithout my authorizationunlesspermitted todo so under federal or statelaw, I
understand thatl have the right
torequest a list
ofpeople who may receiveor use my HIV-related informationwithout authorization.[f
1 experience
discriminationbecause of the release
or disclosureof HIV-relatedinformation,1 may contactthe New York StateDivision
of Human Rights at (212)480-2493 or the New York City Commission of Human Rights at(2 l2)306-7450. These agenciesare
responsibleforprotectingmy rights.
3. I have therightto revoke thisauthorizationat anytime by writingto thehealthcase providerlistedbelow. I understandthatI may
revoke thisauthorizationexceptto the extent
thatactionhas alreadybeen takenbased on thisauthorization.
4. I understand that signingthis authorizationisvoluntary. My treatment,payment, enrollment ina health plan,or for
eligibility
benefitswillnot be conditionedupon my anthorizationofthisdisclosure.
5. Information disclosed under thisauthorizationmight be redisclosed by the recipient(exceptas noted above in Item 2),and this
redisclosuremay no longerbe protectedby federalor state
law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address ofhealth provideror entity
to releasethisinformation:
Csrpcaters' NY
NYC District Council of Benefit Funds, 395 Hudson St.,New York, 10014
8. Name and address ofperson(s)or categoryofperson to whom thisinformationwillbe sent:
Betancourt, Van Hemmen, Greco & Kenyon LLC, 151 Beds Pl.,Suite 200, Red Bank, NJ 07701
9(a). Specificinfonnation to be released.
O Medical Record from (insert
date) to (insert
date)
·
121linti a ledical patient officenotes(except test results,
Itecord.including histories. psychotherapy notes), radiologystudies,films,
r errals,consults,
billingrecords,insurancerecords.and records senttoyou by other healthcarcproviders.
Other: All Union Membership records Include:(/ndicate/>yinitialmg)
Alcohol/Drug Treatment
Mental IIealthinformation
Authorization to DiscussHealth Information HIV-Related information
(b)El By here
initialing I authorize
Initials Name of individual
health care provider
to discussmy healthinformation with my attorney,or a governmentalagency, listed
here:
(Attomey/Finn
Name or GovernmentalAµcncy Nume)
10. Reason forrelease ofinformation: 1L Date or eventon which thisauthorizationwillexpirc:
O At requestofindividual
F/dOther: litigation at conclusion of litigation
12. Ifnot name
te patient. ofperson * fonu:
si •nin 13. signon behalf ofpatient:
Authority
All itemson thisform have been complete and my questionsaboutthisform have been answered. Inaddition, tavebeen provided a
copy of the form.
Date: 2-
. __ _ .
Signatureof patientor representative
authorizedby law.
* Human Virus thatcauses AIDS.The New York StatePublicHealth Law protectsinformationwhich could
?rrrrdciency reasonably
someone
identify as having
HIV symptoms or infection
and informationregarding a person's
contacts.
FILED: NEW YORK COUNTY CLERK 02/25/2022 12:25 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 160 RECEIVED NYSCEF: 02/25/2022
Instructions for the Use
of the HIPAA-compliant Authorization Fonn to
Release Health Information Neecled for Litigation
This forrn is the product of a collaborative process between the New york State
Office of Court Administration, representatives of the meclical provider cornrnunity in
New York, and the bcnch and bar, designed to produce a standarcl official fbnn that
complies with the privacy requirements of the federal Heaith lnsur.ancc portability and
Accountability Act ("HIPAA") and its implementing regulations, to be used to authorize
thc release of health infornration needed for litigation in New york Statc courts. Itcan,
however, be used morc broadly than this and be used befbre litigation has been
commenced, or whenever counsel would find it useful.
The goal was to produce a standard HlPAA-compliant official fonn to obviate the
culrent disputes which often take place as to whether health information requcsts made in
the coutse of litigation meet the requirements of the HIPAA Privacy Rule. It should be
noted, though, that the form is optional. This form may be filled 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 sucS as .,at the
cotrclusion of my court case" 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, the first two boxes in section 9(a) should both be checked, and
the relevant datc inserted on the first rine containing the first box.
FILED: NEW YORK COUNTY CLERK 02/25/2022 12:25 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 160 RECEIVED NYSCEF: 02/25/2022
OCA Omcial Form No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPA A
[This form has been approved by the New York State Department of Health|
PatientName Date ofBijth SocialSecurityNumber
Darryl Nowak 12/23/1963
PatientAddress
927 Broadway, Bayonne, N.1 07002
I, or myauthorized request
representative, thatheahh informationregardingmy careand treatmentbe releasedas set forth
on thisform:
In accordancewith New York StateLaw and the Privacy
Rule ofthe HealthInsurance and Accountability
Por1ability Act of l996
(HIPAA), I understandthat:
1. fhis authoj¡zationmay include disclosureof information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
TREATMENT. except and CONFIDENTIAL HIV* RELATED INFORMATION if I place on
initials
psychotherapy notes, only my
theappropriatelinein Item9(a). In the eventthe healthinformationdescribedbelow includesany of thesetypes ofinformation,and I
initial
the line
on the box inItem 9(a),I specifically
authorizereleaseof such informationto the person(s)
indicatedinItem 8.
2, If 1 am authorizingthe releaseof HIV-related,alcohol ordrug treatment,or mental health treatmentinformation, therecipientis
prohibited from redisclosingsuch informationwithout my authorizationunless permitted todo so under federal or statelaw. I
understand thatI havethe rightto request
a list
of peoplewho may receive oruse my HIV-relaledinformationwithout authorization.If
I experiencediscriminationbecause ofthe releaseor disclosure
of HIV-related information,I may contactthe New York StateDivision
of Human Rights at(212) 480-2493 or theNew York City Commission oflluman Rights at (212)306-7450. These agencies are
responsibleforprotectingmy rights.
3. I have the right
to revoke thisauthorizationat anytime by writingto thehealthcareprovider listed
below. I understandthatI may
revoke thisauthorization
except tothe extentthatactionhas alreadybeen taken based on thisauthorization.
4. I understand thatsigning this authorizationisvoluntary. My treatment,payment, enrollment in a healthplan, or for
eligibility
benefitswillnot be conditionedtiponmy authorizationofthisdisclosure.
5. Informationdisclosed under thisauthorizationmight be redisclosed by the recipient(exceptas noted above in Item 2),and this
redisclosure
may no longerbe protectedby federal
or statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7.Name and address ofhealthprovider or entity
to releasethis
information:
District Council Carpenters' Benefit IIndson NY 10014
NYC of Funds, 395 St.,New York,
8. Name and address ofperson(s)or categoryof personto whom thisinformationwillbe sent:
Retancourt, Van H.......on,Greco & Kenyon LLC, 151 Bodman Pl.,Suite 200, Red Bank, NJ 07701
9(a).Specificinfonnationto be released:
O Medical Record from (insert
date) to (insert
date)
W Entir- edicalRecord, includingpatient office
histories, notes (exceptpsychotherapy notes),test results,
radiologystudies,
films,
r• rrals, insurance
records, and recordssent to you otherhealthcare providers.
consults,billing records, by
)ther:All Safty & Education records Inylude:(Im/«·nre/,y /mriating)
Alcohol/Drug Treatment
Mental Ilenishinformation
Authorization to DiscussHealth Ir.fermatiGr. lilV-Related information
(b)O By here
initiating I authorize
blitials Name of individual
health care pmvider
to discuss
my healthinformationwith my attorney,or a govemmental agency, listed
here:
(Attomey/FinnName or Govemmental Agency Name)
10. Reason forreleaseof information: 11. Date or eventon which thisauthorizationwillexpile:
O At requestofindividual
3 Other:litigation at conclusion of litigation
12 Ifnot tl e name
alient, ofperson signingform: 13. Authority to signon behal ofpatient:
All itemson thisform hav been completed nd my questions about form
this have been answered. In I have
addition, been provided a
copy of the form.
. Date:
Signatureof patientor representative
Preview
FILED: NEW YORK COUNTY CLERK 02/25/2022 12:25 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 160 RECEIVED NYSCEF: 02/25/2022 Power of Atlornev To Execute HIPAA Medicel Record Authorization Forms Pursuant To the HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 PUBLIC LAW 104-191, August 2\1996 I,?^ \ \.)o.,oqt.- of u)G J- Oloez (rnsert your name and do hercby appoint: NapoU fjh-kolnik,P!,LC, with oftices at J60 l"qeirtgton Awnlrq.l-l'h Floor, NeW York-NY lS0!t my sttorneys -in-fsct to act (each agenl may act scparately) in my name, place and stead in any wey which I myself could do, if I wore personally present to exccute HIPAA Medicst Record Authorlzation Forms Purrusnt To th€ HDALTII INS{TRANCE PORTABILITY AIYD ACCOUNTABILITY ACT OF 1996 PTJBLIC LAW Augurt IO,I.I9T, 21, 1996. This power of attomey may be revoked by me at any time. This Power of Attomey shall not be affectedby my subsequent disabilityor incompetence. To induce any third party act hereundet, I hereby agree that any third party receiving a duly executed copy of facsimile of this instrument may act hereunder, and that revocation or termination hereof shall be ineffbctive as to such third party unless and until actual notice or knowledge of such revocalion or termination shall have been received by such third parly, and I fnr mysclf nnd for rny heirs, executon, legal ropresentatives and a.ssigns, hereby tgree to inelcmnify and hold lumless any such third party from snd against any and all clairns that rnay arise ngginst such thirdparfyby reason of such party ttrird having reliedon the provisions of this instrument. In Witness Whereof I have hereunto signed my name this 2l day of fut+, 20 22_ ACKNOWLEDGEMENT STATE OF l./c"'r 'io r /c COUNTY OF Neqr 1oc l\- 2l day of 5o* tEv\ 20-$sfore me the undersigned, personally appeared 6 rNcrit- pursonaQ| known to be or proved to me on the basis of satisfactory evidence to be the individual whose narne is subscribed to the within instrument and acknowledged to me that he executed the same inhis capacity,and thatby his sigratureon the the individual, or the person who acted on behalf of the individual, executed the and ttrat such indfvidual made such appearance before the undersigned. Notary IVAN RODRIGUEZ Notary Publlc, State ol NewYork No.01PO6116071 in Rlchmond County Qualllled .ommission Expiros Septembet 20'204\ FILED: NEW YORK COUNTY CLERK 02/25/2022 12:25 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 160 RECEIVED NYSCEF: 02/25/2022 OCA Official Form W.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA This form has been approved by the New York State Depa rtment ofliealth| PatientName Date ofRirth SocialSecurityNumber Darryl Nowak 12/23/1963 PatientAddress 927 Broadway, Bayonne, NJ 07002 L or my authorized request representative, that health information regarding my care andtreatmentbe releasedas set forth on thisform: In accordancewith New York StateLaw and the Privacy Rule of the Ilealth InsurancePortabilityand AccountabilityAct of I996 (HIPAA), I understandthat: L This authorizationmay include disclosureof infonnation relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifIplace initials on TREATMENT, psychotherapy notes, only my the appropriatelinein Item9(a). In theevent the health information describedbelow includesany of thesetypes ofinfomiation,and 1 innialthe uneon the box in Item9(a), authorize 1 specifically releaseof such informationto the person(s) mdicated in Item8. 2 If I am authorizingthe releaseof l lIV-related,alcohol ordrug treatment. ormental health treatmentinformation. therecipientis prohibited from redisclosingsuch informationwithout my authorizationunless peanutted todo so under federal or statelaw. I understand thatI havethe right to requesta list of peoplewho may receiveoruse my HIV-relatedinformation withoutauthorization.If I experiencediscriminationbecause of thereleaseor of disclosure IIIV-relatedinformation.I may comact the New York Stage Division of f lumanRights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsibleforprotectingmy rights. 3. Ihave the rightto revoke thisauthorizationat anytime by writingto thehealthcare provideslistedbelow. I understandthatI may sevoke thisauthorizationexceptto the extent thatactionhas already been takenbased on thisauthorization. 4. I understand that signingthis authorizationisvoluntary. My treatment,payment, enrollment in a healthplan, or for eligibility benefitswillnot be conditionedupon my authorizationofthisdisclosure. 5. Inforrnationdisclosedunder thisauthorizationmight be redisclosedby the recipient(except as noted above in Item 2),and this redisclosure may no longerbe protectedby federalor state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address ofhealth provideror to release entity thisinformation: District Carpenters' NYC Council of Benefit Funds, 395 Hudson St.,New York, NY 10014 8. Name and address ofperson(s)or categoryof personto whom thisinformationwill be sent: Retancourt, Van Hemmen, Greco & Kenyon LLC, 151 Bodman Pl.,Suite 200,Red Bank, NJ 07701 9(a).Specificinformation to be released: O Medical R "cord from (insert date) to (insert date) Q Entir• edical patient officenotes (except test results, Record,including histories, psychotherapy notes), radiologystudies, films, consults, crrals, billingrecords,insurancerecords,and recordssent to youby otherhealthcare providers. Other: All Pension Plan records h ude:(Indicateby Initialmg) Alcohol/Drug Treatment Mental ItealthInformation Authorization to DiscussHealth Information HIV-Related Information (b)O By here initialing I authorize Initials health care provider Name of individual to discussmy healthinformation with my attorney,or a governmentalagency, listed here: Name or Govemmental (Attorney/Firm Agency Name) 10. Reason forrelease ofinformation: 11. Date or eventon which thisauthorizationwillexpire: O At requestofindividual O Other: litigation at conclusion of litigation 12. Ifnotthe pt tient, name of personsi ning form: 13. Authority to signon behalfof patient: All itemson thisform have been completed and my questionsal out thisform have been answered. in addition,I havebeen provided copy of the form. Signatureof patientor representative authorizedby law. * IIuman I --±&iency Virus thatcauses AIDS.The New York StatePublicHealth Law protectsinformationwhich could reasonably someone identify as havingHIV symptoms or infection and information regardinga person's contacts. FILED: NEW YORK COUNTY CLERK 02/25/2022 12:25 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 160 RECEIVED NYSCEF: 02/25/2022 Instructions for the Use of the HlPAA-compliant Authorizatjon Form to Release Health Information Needed for Litigation Tlris form is the product of a collaborative process between the New york State Office of Court Administration, representatives of the metlical provider cornmunify in New York, and the bench and bar, designecl to produce a stantlarcl official fonn that complies with the privacy requirements of the federal Health Insurance portability and Accountability Act ("HIPAA") and its implementing regulations, to be used to authorize fhe release of health infornration needed for litigati& in wew 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 useftil. The goal was to produce a standard HlPAA-cornpliant official form to obviate the current disputes which often take place as to whether neatttr 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 filied out on linc 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 cxpire, the person filling out the form may designatc an event such as ..at the conclusion of my court case" orprovide a specific date amount of time, such as,,3 years from this date". If a patient seeks to authorize tlte release of his or her entire medical record, but only from a certain date, the first two boxes in scction 9(a) should both be checked, and the relevant date inserted on the first line containing the nist uox. FILED: NEW YORK COUNTY CLERK 02/25/2022 12:25 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 160 RECEIVED NYSCEF: 02/25/2022 OCA OfficialForm No.: 960 AUTHOR1ZATION FOR RELEASE OF HEALTII INFORMATION PURSUANT TO HIPAA This form has been approved by the New York State Department ofHeaHh| PatientName Date ofBirth SocialSecurityNumber Darryl Nowak 12/23/1963 PatientAddress 927 Broadway, Bayonne, NJ 07002 1, or myauthorized request representative, thathealth informationregardingmy careand treatmentbe releasedas set forth on this form: In accordancewith New York StateLaw and the PrivacyRule ofthe HealthInsurance and Accountability Portability Act of 1996 (HIPAA), I understandthat: 1. This authorizationmay include disclosureof information relatingto ALCOHOL and DRUC ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifIplace initials on TREATMENT, psychotherapy notes, only my the appropriatelincin Item9(a). In the eventthe healthinformationdescribedbelow includesany of thesetypes ofinformation,and I the line initial on the box in Item9(a),I specifically authorizereleaseof suchinformation to the person(s) indicatedinItem 8. 2. If Iam authorizingtherelease ofHIV-related, alcohol ordrug treatment,or mental health treatmentinformation, he recipient is prohibited from redisclosingsuch informationwithout my authorizationunless permitted todo so under federal or statelaw. I understand thatI havethe to request right of a list peoplewho may receive oruse my HIV-relatedinformationwithout authorization.If I experiencediscriminationbecause of or the release disclosureof HIV-relatedinformation,I may 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 ate responsibleforprotectingmy rights. 3. 1 have therightto revoke thisauthorizationat anytime by writingto thehealthcare provider listed below. I understandthatI may revoke thisauthorizationexcept to the extent thatactionhas alreadybeen takenbased on thisauthorization. 4. I understand thatsigning this authorizationisvoluntary. My treatment,payment, enrollment in a healthplan, or for eligibility benefitswillnot be conditionedupon my authorizationof this disclosure. 5. Information disclosedunder thisauthorizationmight be redisclosedby the recipient(except as noted above in Item 2),and this redisclosure may no longerbe protectedby federalor state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and addressofhealth provider to release or entity thisinformation. District Council ofCarpenters' Benefit Hudson NY 10014 NYC Funds, 395 St.,New York, 8. Name and address ofperson(s)or categoryof personto whom thisinformationwillbe sent: Betancourt, Van Hemmen, Greco & Kenyon LLC, 151 Na= Pl.,Suite 200, Red Bank, NJ 07701 9(a) Specificinformationto be released: O Medical Record from (insert date) to (insert date) Gl EntireMedical Record, includingpatient officc histories, notes(exceptpsychotherapy notes),test results, radiologystudies,films r- insurance and recordssent to you other healthcareproviders. rrals, consults, billingrecords, records, by ther: All Welfare Plan records h lude:( Indicate hv Indialing) Alcohol/Drug Treatment Mental IIealthInformation Authorization to DiscussHealth Information IIIV-Related Information (b)O By here initialing I authorize Initials Name of individual health care providel to discuss my healthinformationwith my attorney,or a governmentalagency, listed here: (Anomey/Finn Name or GovernmentalAgency Namc) 10. Reason forreleaseof information: 11. Date or event on which thisauthorizationwillexpire: O Atrequest ofindividual 21 Other: litigation at conclusion of litigation 12. Ifnot the m •nt, nameof personsignin • form: 13. Authorit nign on rh¡ f patient: o Allitems on this form have bee completed and my questionsabout form this have been answered. Inaddition,I havebeen provided a copy of the for n. Date: 2- Signatureof patient or representative authorized by law. * Human Virus thatcauses AIDS.The New York State Public Health Law protectsinformationwhich could Les:±ficiency reasonably someone as having identify HIV symptoms or infection and informationregarding coulacts. a person's FILED: NEW YORK COUNTY CLERK 02/25/2022 12:25 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 160 RECEIVED NYSCEF: 02/25/2022 Instructions tbr the Use of the HlPAA-compliant Authorization Form to Release Health Information Needed for Litigation This forrn is the product of a collaborative process between the New york State officc of Court Administration, representatives of the medical provider. community in New York, and the bench and bar, designed to produce a stanclard official foln that complics with the privacy requirements of the federal Health Insurance por.tability and Accountability Act ("HIPAA") and its implernenting regulations, to be used to authorize tlte relcase 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 HlPAA-compliant official form to obviate the culrent disputes which often take place as to whether health information requests madc in the course of Iitigation nreet the rcquirements of the HIPAA privacy Rule. It shoulcl be noted, though, that the form is optional. This form may be filled out on lile and downloaded to be signed by hand, or downloacled and fillcd out entirely on paper. Whcn filing out Item 11, which requests the date or event when the authorization will expire, the person filling out the form may designate an evenl such as ..at the conclusion of my court case" or provide a specific date amount of time, such ,,3 as years frorn this date". If a patient sccks to authorize the release of his or her entire mecliciil record, but only from a ceftain date, the first two boxes in section 9(a) should both be cSecked, and the relevant date inserted on the first line containing the first box. FILED: NEW YORK COUNTY CLERK 02/25/2022 12:25 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 160 RECEIVED NYSCEF: 02/25/2022 OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health] PatientName Date ofBirth SocialSecurityNumber Darryl Nowak 12/23/1963 PatientAddress 927 Broadway, Bayonne, NJ 07002 1, or myauthorized request representative, thathealthinformation regardingmy care andtreatment be releasedas set forth on thisform: In accordancewithNew York State Law and the PrivacyRule ofthe Health Insurance and Portability AccountabilityAct of1996 (HIPAA), 1 understandthat: 1. This authorizationmay includedisclosure of information relatingto ALCOHOL and DRUG AHUSE, MENTAL HEALTH except and CONFIDENTIAL IIIV* RELATED INFORMATION if I place initials on TREATMENT, psychotherapynotes, only my the appropriatelineinhem 9(a). Inthe eventthe ltealth information describedbelow includesany ofthese typesof information,and I initial the line on the box in Item9(a),I specifically authorizereleaseof such informationto theperson(s)indicatedin Item8. 2. If I am authonzing the releaseof alcohol lilV-related, ordrug treatment, ormental health treatment information,therecipientis prohibited from redisclosingsuch informationwithout my authorizationunlesspermitted todo so under federal or statelaw, I understand thatl have the right torequest a list ofpeople who may receiveor use my HIV-related informationwithout authorization.[f 1 experience discriminationbecause of the release or disclosureof HIV-relatedinformation,1 may contactthe New York StateDivision of Human Rights at (212)480-2493 or the New York City Commission of Human Rights at(2 l2)306-7450. These agenciesare responsibleforprotectingmy rights. 3. I have therightto revoke thisauthorizationat anytime by writingto thehealthcase providerlistedbelow. I understandthatI may revoke thisauthorizationexceptto the extent thatactionhas alreadybeen takenbased on thisauthorization. 4. I understand that signingthis authorizationisvoluntary. My treatment,payment, enrollment ina health plan,or for eligibility benefitswillnot be conditionedupon my anthorizationofthisdisclosure. 5. Information disclosed under thisauthorizationmight be redisclosed by the recipient(exceptas noted above in Item 2),and this redisclosuremay no longerbe protectedby federalor state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address ofhealth provideror entity to releasethisinformation: Csrpcaters' NY NYC District Council of Benefit Funds, 395 Hudson St.,New York, 10014 8. Name and address ofperson(s)or categoryofperson to whom thisinformationwillbe sent: Betancourt, Van Hemmen, Greco & Kenyon LLC, 151 Beds Pl.,Suite 200, Red Bank, NJ 07701 9(a). Specificinfonnation to be released. O Medical Record from (insert date) to (insert date) · 121linti a ledical patient officenotes(except test results, Itecord.including histories. psychotherapy notes), radiologystudies,films, r errals,consults, billingrecords,insurancerecords.and records senttoyou by other healthcarcproviders. Other: All Union Membership records Include:(/ndicate/>yinitialmg) Alcohol/Drug Treatment Mental IIealthinformation Authorization to DiscussHealth Information HIV-Related information (b)El By here initialing I authorize Initials Name of individual health care provider to discussmy healthinformation with my attorney,or a governmentalagency, listed here: (Attomey/Finn Name or GovernmentalAµcncy Nume) 10. Reason forrelease ofinformation: 1L Date or eventon which thisauthorizationwillexpirc: O At requestofindividual F/dOther: litigation at conclusion of litigation 12. Ifnot name te patient. ofperson * fonu: si •nin 13. signon behalf ofpatient: Authority All itemson thisform have been complete and my questionsaboutthisform have been answered. Inaddition, tavebeen provided a copy of the form. Date: 2- . __ _ . Signatureof patientor representative authorizedby law. * Human Virus thatcauses AIDS.The New York StatePublicHealth Law protectsinformationwhich could ?rrrrdciency reasonably someone identify as having HIV symptoms or infection and informationregarding a person's contacts. FILED: NEW YORK COUNTY CLERK 02/25/2022 12:25 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 160 RECEIVED NYSCEF: 02/25/2022 Instructions for the Use of the HIPAA-compliant Authorization Fonn to Release Health Information Neecled for Litigation This forrn is the product of a collaborative process between the New york State Office of Court Administration, representatives of the meclical provider cornrnunity in New York, and the bcnch and bar, designed to produce a standarcl official fbnn that complies with the privacy requirements of the federal Heaith lnsur.ancc portability and Accountability Act ("HIPAA") and its implementing regulations, to be used to authorize thc release of health infornration needed for litigation in New york Statc courts. Itcan, however, be used morc broadly than this and be used befbre litigation has been commenced, or whenever counsel would find it useful. The goal was to produce a standard HlPAA-compliant official fonn to obviate the culrent disputes which often take place as to whether health information requcsts made in the coutse of litigation meet the requirements of the HIPAA Privacy Rule. It should be noted, though, that the form is optional. This form may be filled 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 sucS as .,at the cotrclusion of my court case" 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, the first two boxes in section 9(a) should both be checked, and the relevant datc inserted on the first rine containing the first box. FILED: NEW YORK COUNTY CLERK 02/25/2022 12:25 PM INDEX NO. 154000/2018 NYSCEF DOC. NO. 160 RECEIVED NYSCEF: 02/25/2022 OCA Omcial Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPA A [This form has been approved by the New York State Department of Health| PatientName Date ofBijth SocialSecurityNumber Darryl Nowak 12/23/1963 PatientAddress 927 Broadway, Bayonne, N.1 07002 I, or myauthorized request representative, thatheahh informationregardingmy careand treatmentbe releasedas set forth on thisform: In accordancewith New York StateLaw and the Privacy Rule ofthe HealthInsurance and Accountability Por1ability Act of l996 (HIPAA), I understandthat: 1. fhis authoj¡zationmay include disclosureof information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT. except and CONFIDENTIAL HIV* RELATED INFORMATION if I place on initials psychotherapy notes, only my theappropriatelinein Item9(a). In the eventthe healthinformationdescribedbelow includesany of thesetypes ofinformation,and I initial the line on the box inItem 9(a),I specifically authorizereleaseof such informationto the person(s) indicatedinItem 8. 2, If 1 am authorizingthe releaseof HIV-related,alcohol ordrug treatment,or mental health treatmentinformation, therecipientis prohibited from redisclosingsuch informationwithout my authorizationunless permitted todo so under federal or statelaw. I understand thatI havethe rightto request a list of peoplewho may receive oruse my HIV-relaledinformationwithout authorization.If I experiencediscriminationbecause ofthe releaseor disclosure of HIV-related information,I may contactthe New York StateDivision of Human Rights at(212) 480-2493 or theNew York City Commission oflluman Rights at (212)306-7450. These agencies are responsibleforprotectingmy rights. 3. I have the right to revoke thisauthorizationat anytime by writingto thehealthcareprovider listed below. I understandthatI may revoke thisauthorization except tothe extentthatactionhas alreadybeen taken based on thisauthorization. 4. I understand thatsigning this authorizationisvoluntary. My treatment,payment, enrollment in a healthplan, or for eligibility benefitswillnot be conditionedtiponmy authorizationofthisdisclosure. 5. Informationdisclosed under thisauthorizationmight be redisclosed by the recipient(exceptas noted above in Item 2),and this redisclosure may no longerbe protectedby federal or statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7.Name and address ofhealthprovider or entity to releasethis information: District Council Carpenters' Benefit IIndson NY 10014 NYC of Funds, 395 St.,New York, 8. Name and address ofperson(s)or categoryof personto whom thisinformationwillbe sent: Retancourt, Van H.......on,Greco & Kenyon LLC, 151 Bodman Pl.,Suite 200, Red Bank, NJ 07701 9(a).Specificinfonnationto be released: O Medical Record from (insert date) to (insert date) W Entir- edicalRecord, includingpatient office histories, notes (exceptpsychotherapy notes),test results, radiologystudies, films, r• rrals, insurance records, and recordssent to you otherhealthcare providers. consults,billing records, by )ther:All Safty & Education records Inylude:(Im/«·nre/,y /mriating) Alcohol/Drug Treatment Mental Ilenishinformation Authorization to DiscussHealth Ir.fermatiGr. lilV-Related information (b)O By here initiating I authorize blitials Name of individual health care pmvider to discuss my healthinformationwith my attorney,or a govemmental agency, listed here: (Attomey/FinnName or Govemmental Agency Name) 10. Reason forreleaseof information: 11. Date or eventon which thisauthorizationwillexpile: O At requestofindividual 3 Other:litigation at conclusion of litigation 12 Ifnot tl e name alient, ofperson signingform: 13. Authority to signon behal ofpatient: All itemson thisform hav been completed nd my questions about form this have been answered. In I have addition, been provided a copy of the form. . Date: Signatureof patientor representative