Motion to Appoint Counsel in Darryl Nowak v. Sea Wolf Marine Transportation, Llc, Wittich Brothers Marine, Inc, Weeks Marine,Inc.| Trellis.Law

On May 01, 2018 a Exhibit,Appendix was filed involving a dispute between Darryl Nowak, and Sea Wolf Marine Transportation, Llc, Weeks Marine,Inc., Wittich Brothers Marine, Inc, for Torts - Other (Slip and fall) in the District Court of New York County.

Preview
FILED: NEW YORK COUNTY CLERK 09/21/2022 03:08 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 182 RECEIVED NYSCEF: 09/21/2022

EXHIBIT D
FILED: NEW YORK COUNTY CLERK 09/21/2022 03:08 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 182 RECEIVED NYSCEF: 09/21/2022

From: Ron Betancourt
To: Ivan Rodriguez
Cc: Jnapoli@napolilaw.com; gwolfson@mahoneykeane.com
Subject: RE: DARRYL NOWAK
Date: Thursday, July 14, 2022 4:07:00 PM
Attachments: Napoli 25 ltr.pdf
Napoli 26 ltr.pdf
HIPAAs 6-13-22 (2nd) - Not Signed.pdf
HIPAAs 6-13-22 - Not Signed.pdf

Dear Ivan,

Thank you for your email. The signed authorizations you provided below are
not the ones outstanding and of which we spoke. The presently outstanding
authorizations are for:

1. Plaintiff’s tax records for 2019 through 2021;
2. Dr. Mark McMann;
3. Momentum Medicine Plus;
4. Jersey City Diagnostic Center;
5. Dr. Paul Furalford;
6. Dr. Adrian Padkowsky;
7. Dr. George Padkowsky; and
8. Dr. Charlie Gonzales.

Attached are further copies of our earlier correspondence concerning same
along with blank form authorizations previously provided.

Also, at plaintiff’s deposition we demanded the production of plaintiff’s tax
records for 2019 through 2021 (trans. p. 279); plaintiff’s current passport and all prior
passports (trans. p. 314); and IRS notices/correspondence regarding disallowed
deductions and/or expenses (trans. p. 328). Plaintiff testified he had copies of all of
these documents within his possession.

Would you kindly provide us with the requested executed authorizations and
documents without further delay. Thank you.

Best regards,
Ron Betancourt
Betancourt, Van Hemmen, Greco & Kenyon LLC
FILED: NEW YORK COUNTY CLERK 09/21/2022 03:08 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 182 RECEIVED NYSCEF: 09/21/2022

Phone: 732-530-4646 (N.J.) | 914-997-1100 (N.Y.)

From: Ivan Rodriguez
Sent: Tuesday, July 12, 2022 1:01 PM
To: Ron Betancourt
Subject: DARRYL NOWAK

Ron:

Enclosed please find the signed authorizations we discussed.

Thanks.

Ivan Rodriguez
Senior Paralegal

(212) 397-1000 Ext. 1011 | IRodriguez@NapoliLaw.com
360 Lexington Avenue, Eleventh Floor, New York, NY 10017

Our Mission Statement

Notice: This communication, including attachments, may contain information that is confidential and protected by the attorney/client or other privileges. It
constitutes non-public information intended to be conveyed only to the designated recipient(s). If the reader or recipient of this communication is not the
intended recipient, an employee or agent of the intended recipient who is responsible for delivering it to the intended recipient, or you believe that you
have received this communication in error, please notify the sender immediately by return e-mail and promptly delete this e-mail, including attachments
without reading or saving them in any manner. The unauthorized use, dissemination, distribution, or reproduction of this e-mail including attachments, is
prohibited and may be unlawful. Receipt by anyone other than the intended recipient(s) is not a waiver of any attorney/client or other privilege.

This e-mail and all other electronic (including voice) communications from the sender's firm are for informational purposes only. No such communication
is intended by the sender to constitute either an electronic record or an electronic signature, or to constitute any agreement by the sender to conduct a
transaction by electronic means. Any such intention or agreement is hereby expressly disclaimed unless otherwise specifically indicated.
FILED: NEW YORK COUNTY CLERK 09/21/2022 03:08 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 182 RECEIVED NYSCEF: 09/21/2022

New Jersey 151 Bodman Place, Suite 200, Red Bank, NJ 07701
Telephone: 732.530.4646 Telefax: 732.530.9536

New York 75 South Broadway, 4th Floor, White Plains, NY 10601
Telephone: 914.997.1100 Telefax: 914.997.1101

June 13, 2022

Via Email and Fax
Joseph P. Napoli, Esq.
NAPOLI SHKOLNIK, PLLC
360 Lexington Ave, 11th Floor
New York, New York 10017

Re: Darryl Nowak v. Sea Wolf Marine Transportation, LLC et al.
Supreme Court, New York County, Index No. 154000/2018

Dear Sirs,

This serves to confirm the request made at plaintiff’s May 27, 2022 deposition for
executed authorizations allowing the release to us of plaintiff’s medical records from:

1. Dr. Adrian Padkowsky, Stat Medical Services LLC, 845 Broadway, Bayonne,
NJ 07002;

2. Dr. George Padkowsky, Stat Medical Services LLC, 845 Broadway, Bayonne,
NJ 07002; and

3. Dr. Charlie Gonzales, D.C., Gonzales Chiropractic of Bayonne, 120 Lefante
Way, Bayonne, NJ 07002.

This also serves to confirm the further request for an executed authorization for the
release to us of plaintiff’s federal tax returns for the years 2019 through 2021. Form HIPAA
and IRS authorizations for plaintiff’s execution are provided herewith.

Very truly yours,
BETANCOURT, VAN HEMMEN, GRECO & KENYON LLC

By: s/ Ronald Betancourt
RB/jc
cc: MAHONEY & KEANE, LLP
Garth Wolfson, Esq.

www.bvgklaw.com
FILED: NEW YORK COUNTY CLERK 09/21/2022 03:08 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 182 RECEIVED NYSCEF: 09/21/2022

New Jersey 151 Bodman Place, Suite 200, Red Bank, NJ 07701
Telephone: 732.530.4646 Telefax: 732.530.9536

New York 75 South Broadway, 4th Floor, White Plains, NY 10601
Telephone: 914.997.1100 Telefax: 914.997.1101

June 13, 2022

Via Email and Fax
Joseph P. Napoli, Esq.
NAPOLI SHKOLNIK , PLLC
360 Lexington Ave, 11th Floor
New York, New York 10017

Re: Darryl Nowak v. Sea Wolf Marine Transportation, LLC et al.
Supreme Court, New York County, Index No. 154000/2018

Dear Sirs,

Attached are HIPAA form authorizations for plaintiff’s execution for further medical
care providers referenced in plaintiff’s Social Security records:

C Mark S. Mc Mahon, MD;
C Momentum Medicine Plys LLC;
C Jersey City Diagnostic Center; and
C Paul F. Furlaford, Ph.D. D/B/A Psychometric Services.

Would you please return the authorizations to us duly executed by plaintiff.

Very truly yours,
BETANCOURT , VAN HEMMEN , GRECO & KENYON LLC

By: s/ Ronald Betancourt
RB/jc
cc: MAHONEY & KEANE , LLP
Garth Wolfson, Esq.

www.bvgklaw.com
FILED: NEW YORK COUNTY CLERK 09/21/2022 03:08 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 182 RECEIVED NYSCEF: 09/21/2022

Form 6 Request for Copy of Tax Return

(Novmeber2021) º Do not sign this
form unlessall applicable
lines
have been completed, OMB No. 1545-0429
º Request may be rejectedif the
form is incompleteor illegible.
Departmentof the Treasury
IntemalFlevenueService ºFor more informationabout Form 4506, visit
wwwJrs.gov/form45OS.
Tip:Get fasterservice:Onlineat www.irs.gov,
Get Your Tax Record or by calling
(Get Transcript) 1-800-908-9946 forspecialized
assistance.We
have teams available
to assist.
Note:Taxpayers may register
touse Get Transcripttoview, or
print, download the transcript
following types:Tax
Return Transcript(shows most line items Adjusted
including Gross Income (AGI) fromyouroriginal
Form 1040-seriestaxreturnas filed,
along with
any formsand schedules),
Tax Account Transcript(shows basic data such
as return type,
marital AGI, taxable
status, Incomeand all paymenttypes),
Record of Account Transcript(combines the taxretum and taxaccount transcripts
intoone complete Wage
transcript), and Income Transcript
(shows datafrom information
returnswe receivesuch as Forms W-2, 1099, 1098 and Form 5498),and of
Verification Letter
Non-filing (provides
proof that the IRS has no record
of a filed Form
1040-seriestax return
for the year you request).

1a Name shown on tax return.
If a joint
return, enter the name shown
first. 1b Firstsocialsecuritynumber on taxreturn,
individual
taxpayer identification
number, or
employer identification
number (see instructions)

Darryl Nowak
2a If a joint
retum, enter spouse's
name shown on tax retum. 2b Second socialsecuritynumber or individual
taxpayer identification
number if ]oint
taxreturn

3 Currentname, address apt.,
(including room, or suite no.), city, state,
and ZIP code(see instructions)

4 Previousaddressshown on the last retum from line 3 (see instructions)
filed if different

5 If the tax return is to be mailed to a third
party (such as a mortgage
company), enter the third
party'sname, address,and telephone
number.

Betancourt,Van Hemmen, Greco & Kenyon LLC, 151 Bodman Place,Suite200, Red Bank,NJ 07701; tel.
(732)530-4646
,Caution:If the tax retum
is being
sent to the third
party,ensure that lines 5 through
7 are completedbefore (see instructions).
signing.
6 Tax return requested. Form 1040, 1120, 941, etc.and allattachments as submitted
originally to the IRS, includingForm(s)W-2,
schedules,or amended returns.Copies ofForms 1040, 1040A, and 1040EZ are available
generally for7 yearsfrom before
filing they are
destroyed by law.Otherreturnsmay for
be available a longerperiod Enter
of time. only one returnnumber. if youneed more than one
type of retum, you must complete
anotherForm 4506. º Form 1040
Note:If the copies for court
must be certified or administrative
proceedings,checkhere . . . . . . . . . . . . . . .

7 Year or periodrequested. date of the tax year or period
Enter the ending using the mm/dd/yyyyformat(see instructions).
12 / 31 / 2019 12 / 31 / 2020 12 / 31 / 2021 / /

/ / / / / / / /

8 Fee. Thereis a $43 fee for each retum
requested.Fullpayment must be included withyour requestor it will
be rejected.Make your check or money order payableto "UnitedStates Treasury."Enter yourSSN, ITIN,
or EIN and"Form 4506 request"on your check or money order.
a Cost for each return
. . . . . . . . . . . . . . . . . . . . . . . . . . . S 43.00
b Number of retumsrequestedon line 7 .. . . . . . . . . . . . . . . . . . . . . 3
c Total cost.
Multiplyline Sa by line 8b
. . . . . . . . . . . . . . . . . . . . . . S 129.00
9 If we cannot the fee. If the refund
we will refund
find the tax return, shouldgo to the third
party on line 5, check
listed here . . . . .
Caution:Do not sign this form lines have been completed.
unless all applicable
Signatureof taxpayer(s). or 2a, or a person authorized to obtain the tax return
I declare that I am either the taxpayer whose name Is shown on Ilne la
requested. if the request applies to a joint retum, at least one spouse must sign. If signed by a corporate officer, 1 percent or more shareholder, partner,
trustee, or party other than the taxpayer, 1certify that I have the authority to
managing member, guardian, tax matters partner, executor, receiver, administrator,
execute Form 4506 on behalf of the taxpayer. Note: This form must be received by IRS within 120 days of the signature date.
Signatory attests thathe/she has read the attestation clause and upon so reading
that he/she has the to sign the Form 4506. See instructions. Phone number of taxpayer
on line
declares authority
l a or 2a

Signature (see instructions) Date
Sign
Here Print/Typename Title (if line 18 above is a corporation, partnership, estate, or trust)

Spouse's signature Date

Printffype name
For PrivacyActand Paperwork Reduction Act Notice,seepage 2. Cat. No. 41721E Form 4506 (Rev. 11-2021)
FILED: NEW YORK COUNTY CLERK 09/21/2022 03:08 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 182 RECEIVED NYSCEF: 09/21/2022
OCA OfficialForm No.:960
.. AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York State Department of Health|

Patient Name Date of Birth Social Securit Number

Darryl Nowak
Patient Address

I, ormy authorized representative,request thathealth information regarding my careand treatmentbe released as setforthon thisform:

In accordance with New York StateLaw and.the Privacy Rule of theHealth Insurance Portabilityand Accountability Act of 1996
(HIPAA), I understand that:
1. This authorizationmay include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place on
initials
TREATMENT, psychotherapy notes, only my
the appropriatelinein Item 9(a). In theevent the health information described below includesany ofthese types of information, and 1
initial
the lineon the box in Item9(a), I specifically
authorize releaseofsuch information tothe person(s) indicatedin Item 8.
2. If Iam authorizing the releaseof HIV-related, alcohol ordrug treatment, or mental health treatment information, the recipientis
prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I
understand thatI have the righttorequest 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, 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 are
responsiblefor protectingmy rights.
3. 1 have the rightto revoke thisauthorization at any time by writing tothe healthcare provider listedbelow. I understand thatI may
revoke thisauthorization except tothe extentthat actionhas already been taken based on this authorization.
4. I understand thatsigning thisauthorization is voluntary. My treatment, payment, enrollment in a health plan, or for
eligibility
benefitswill notbe conditioned upon my authorization ofthisdisclosure.
5. Information disclosed under thisauthorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosuremay no longer be protectedby federalor statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of healthprovider or entityto releasethisinformation:
Mark S. Me Mahon, M.D., 876 Park Avenue, New York, NY 10075
8. Name and address ofperson(s) or category ofperson to whom this information willbe sent:
Betancourt, Van Hemmen, Greco & Kenyon LLC, 151 Bodman Place, Suite 200, Red Bank, NJ 07701
9(a). Specificinformation to be released:
2 Medical Record from (insertdate) 01/01/2012 to (insert
date) current
Entire Medical Record, including patient office
histories, notes(except psychotherapy notes),testresults,radiology studies,films,
referrals,consults,billingrecords,insurance records,and records sent toyou by other health careproviders.
O Other: Include:(Indicate by lnitialing)

Alcohol/Drug Treatment
Mental Health Information
Authorization to Discuss Health Information HIV-Related Information

(b) O By here
initialing I authorize
Initials Name ofindividualhealthcare provider
to discussmy healthinformation with my attorney,or a governmental agency, listedhere:

(Attorney/FirmName or GovernmentalAgency Name)
10. Reason forreleaseof information: 11. Date or event on which thisauthorizationwill expire:
O At requestof individual
0 Other: Litigation Conclusion of Litigation
12. Ifnot the patient,name ofperson signingform: 13. Authority to signon behalf of patient:

All items on thisform have been completed and my questions about thisform have been answered. Inaddition, I havebeen provided a
copy of the form.

Date:
Signature of patientor representativeauthorizedby law.
* Human Virus thatcauses AIDS. The New York State PublicHealth Law protectsinformation which could
Immunodeficiency reasonably
identifysomeone as havingHIV symptoms orinfectionand information regarding a person'scontacts.
FILED: NEW YORK COUNTY CLERK 09/21/2022 03:08 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 182 RECEIVED NYSCEF: 09/21/2022
.. OCA OfficiniForm No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York State Department of Health]

Patient Name Date of Birth Social Securi Number
Darryl Nowak
Patient Address

I,or my authorized representative,request thathealth information careand treatmentbe released as setforthon thisform:
regarding my
In accordance with New York StateLaw and the Privacy Rule of theHealth Insurance and Act of 1996
Portability Accountability
(HIPAA), I understand that:
1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifIplace initialson
TREATMENT, psychotherapy notes, only my
the appropriateline inItem 9(a). In the event the healthinformation described below includes any of these typesof information, and I
initial
the lineon the box in Item 9(a),I specifically
authorize releaseof such information tothe person(s) indicatedin Item 8.
2. If Iam authorizing the releaseof HIV-related, alcohol or drug treatment, or mental health treatment information, the recipientis
prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I
understand that I havethe righttorequest a list
of people who may receive oruse my HIV-related information without authorization.If
I experience discriminationbecause ofthe releaseor disclosure ofHIV-related information, I may contact theNew 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 are
responsible forprotectingmy rights.
3. I have the rightto revoke thisauthorization at any time by writing tothe healthcare provider listedbelow. I understand thatI may
revoke thisauthorization except to theextentthat actionhas already been taken based on this authorization.
4. I understand thatsigning thisauthorization is voluntary. My treatment, payment, enrollment in a health plan, or for
eligibility
benefitswill notbe conditioned upon my authorization ofthisdisclosure.
5. Information disclosed under this authorizationmight 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 THAN THE ATTORNEY OR GOVERNMENTAL AG ENCY SPECIFIED IN ITEM 9 (b).
7. Name and address ofhealth provideror entityto releasethisinformation:
Momentum Medicine Plus LLC, 113 West White Horse Road, Suite 7, Voorhees, NJ 08043
8. Name and address of person(s)or category ofperson to whom this information willbe sent:
Betancourt, Van Hemmen, Greco & Kenyon LLC, 151 Bodman Place, Suite 200, Red Bank, NJ 07701
9(a). Specificinformation to be released:
0 Medical Record from (insertdate) 01/01/2012 to (insert
date) current
2 EntireMedical Record, includingpatient office
histories, notes (except psychotherapy notes),testresults,
radiology studies,films,
referrals,
consults, records,
billing insurance records,and records sentto you by other health careproviders.
O Other: Include:(Indicate by Initialing)

Alcohol/Drug Treatment
Mental Health Information
Authorization to Discuss Health Information HIV-Related Information

(b)O By here
initialing I authorize
Initials Name ofindividualhealthcare provider
to discussmy healthinformation with my attorney,or a governmental agency, listedhere:

(Attomey/Firm Name or Govemmental Agency Name)
10. Reason forreleaseof information: 1 l.Date or event on which thisauthorizationwill expire:
O At requestof individual
2 Other: Litigation Conclusion of Litigation
12. Ifnot the patient,name ofperson signingform: 13. Authority to signon behalf of patient:

All items on thisform have been completed and my questionsabout thisform have been answered. In addition,I have been provideda
copy of theform.

Date:
Signature of patient
or representativeauthorized by law.
* Human Virus thatcauses AIDS. The New York State PublicHealth Law protectsinformationwhich could
Immunodeficiency reasonably
identifysomeone as havingHIV symptoms orinfectionand information regarding a person'scontacts.
FILED: NEW YORK COUNTY CLERK 09/21/2022 03:08 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 182 RECEIVED NYSCEF: 09/21/2022
OCA OfficialForm No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York State Department of Health]

Patient Name Date of Birth Social Securi Number
Darryl Nowak
Patient Address

1, ormy authorized representative,request thathealth information regarding my careand treatmentbe released as setforthon thisform:
In accordance with New York StateLaw and the Privacy Rule ofthe Health Insurance Portabilityand Accountability Act of 1996
(HIPAA), I understand that:
1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION if Iplace initialson
TREATMENT, psychotherapy notes, only my
the appropriateline inItem 9(a). In the event the healthinformation described below includes any of these typesof information, and I
initial
the lineon the box in Item 9(a),I specifically
authorizerelease of such information tothe person(s) indicatedin Item 8.
2. If Iam authorizing the releaseof HIV-related, alcohol ordrug treatment, or mental health treatment information, the recipientis
prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I
understand that I havethe righttorequest 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, I may contact the New York StateDivision
of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at(212) 306-7450. These agencies are
responsiblefor protectingmy rights.
3. I have the rightto revoke thisauthorization at any time by writingto the healthcare provider listedbelow. I understand that1 may
revoke thisauthorization except to theextentthat actionhas already been taken based on this authorization.
4. I understand thatsigning thisauthorization is voluntary. My treatment, payment, enrollment in a health plan, or for
eligibility
benefitswill notbe conditioned upon my authorization ofthisdisclosure.
5. Information disclosed under this authorizationmight be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosuremay no longer be protectedby federalor statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address ofhealth provider or entitytorelease thisinformation:
Jersey City Diagnostic Center, 2300 Kennedy Boulevard, Jersey City, NJ 07304
8. Name and address ofperson(s) or category ofperson to whom this information willbe sent:
Betancourt, Van Hemmen, Greco & Kenyon LLC, 151 Bodman Place, Suite 200, Red Bank, NJ 07701
9(a). Specificinformation to be released:
6 Medical Record from (insertdate) 01/01/2012 to (insertdate) current
EntireMedical Record, including patient office
histories, notes(except psychotherapy notes),testresults,radiologystudies,films,
referrals,consults,billingrecords,insurance records,and records sent toyou by otherhealth careproviders.
O Other: Include:(Indicate by Initialing)

Alcohol/Drug Treatment
Mental Health Information
Authorization to Discuss Health Information HIV-Related Information

(b)O By here
initialing I authorize
Initials Name ofindividualhealthcare provider
todiscuss my healthinformation with my attorney,or a governmental agency, listedhere:

(Attorney/FirmName or GovernmentalAgency Name)
10. Reason forreleaseof information: 11. Date or event on which thisauthorizationwill expire:
O At requestof individual
Q Other: Litigation Conclusion of Litigation

12. Ifnot the patient,name ofperson signing form: 13. Authority to signon behalf of patient:

All items on thisform have been completed and my questions about thisform have been answered. In addition,I have been provided a
copy of theform.

Date:
Signature of patientor representative
authorized by law.
* Human Virus thatcauses AIDS. The New York State PublicHealth Law protectsinformationwhich could
Immunodeficiency reasonably
identifysomeone as havingHIV symptoms orinfectionand information regarding aperson's contacts.
FILED: NEW YORK COUNTY CLERK 09/21/2022 03:08 PM INDEX NO. 154000/2018
NYSCEF DOC. NO. 182 RECEIVED NYSCEF: 09/21/2022
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 of Birth SocialSecuri Number

Darryl Nowak
PatientAddress

I,or my authorized representative,request thathealth information regarding my careand treatment be released as setforthon this form:

In accordance with New York StateLaw and the Privacy Rule ofthe Health Insurance Portabilityand Accountability Act of 1996
(HIPAA), I understand that:
1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifIplace initialson
TREATMENT, psychotherapy notes, only my
the appropriateline inItem 9(a). In the event the healthinformation described below includes any of thesetypes of information, and I
initial
the lineon the box in Item 9(a),I specifically
authorizerelease of such information tothe person(s) indicatedin Item 8.
2. If Iam authorizing the releaseof HIV -related,alcohol or drug treatment, or mental health treatment information, the recipientis
prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I
understand that I havethe righttorequest a list
of people who may receive oruse my HIV-related information without authorization.If
I experience discriminationbecause of the releaseor disclosureof HIV-related information, I may contact the New York StateDivision
of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at(212) 306-7450. These agencies are
responsible forprotectingmy rights.
3. I have the rightto revoke thisauthorization at any time by writingto the healthcare provider listedbelow. 1 understand thatI may
revoke thisauthorization except tothe extentthat actionhas already been taken based on thisauthorization.
4. I understand thatsigning thisauthorization is voluntary. My treatment, payment, enrollment in a health plan, or for
eligibility
benefitswill notbe conditioned upon my authorization ofthisdisclosure.
5. Information disclosed under thisauthorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosuremay no longer be protectedby federalor statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of healthprovider or entitytorelease thisinformation:
Paul F. Furlaford, Ph. D. D/B/A/ Phychometric Services, 100 Hamilton Plaza, Suite 1221, Paterson, NJ 07505

8. Name and address ofperson(s) or category ofperson to whom this information willbe sent:
Betancourt, Van Hemmen

Case Info

Judge

Shlomo S. Hagler Track Judge’s New Case

Case No.

(Subscribe to View)

Document Filed Date

September 21, 2022

Case Filing Date

May 01, 2018

County

Parties

Darryl Nowak Plaintiff
EVANS, ALTON JAMES Attorney for the Defendant
NAPOLI, JOSEPH P. Attorney for the Plaintiff
NAPOLI, MARIE Attorney for the Plaintiff
SEA WOLF MARINE TRANSPORTATION, LLC Defendant
WEEKS MARINE,INC. Defendant
WITTICH BROTHERS MARINE, INC Defendant
WOLFSON, GARTH S Attorney for the Defendant
WOLFSON, GARTH S Attorney for the Defendants
KRISTINA GEORGIOU Attorneys for Plaintiffs
EDWARD KEANE Attorneys for Defendants
RONALD BETANCOURT Attorneys for Defendants
KRISTIN ROBBINS Attorneys for Defendants
PATRICK ROHAN Attorneys for Defendants
SELMA MOY Attorneys for Defendants

For full print and download access, please subscribe at https://www.trellis.law/.

Exhibit,Appendix: Darryl Nowak v. Sea Wolf Marine Transportation, Llc, Wittich Brothers Marine, Inc, Weeks Marine,Inc.

Preview

Case Info

Parties