Preview
FILED: KINGS COUNTY CLERK 09/19/2022 02:19 PM INDEX NO. 512150/2020
NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022
File No. 31457
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF KINGS
_____.-----------------------------------------X
RAY JACKSON, PLAINTIFF'S RESPONSE
Plaintiff(s), TO DEFENDANT'S
-against-
DEMAND FOR
AUTHORIZATIONS DATED
VAN BLARCOM CLOSURES, INC., JUNE 29, 2022
Defendant(s).
-----------------------------------------------------------------X Index No.: 512150/2020
Plaintiff,RAY JACKSON, by his attorneys, SUBIN ASSOCIATES, LLC, as and for a
defendants' Authorizations"
response to "Demand for dated June 29, 2022, alleges upon information and
belief, as follows:
1. An original, unrestricted, and duly executed HIPAA-compliant authorization to obtain
Plaintiff's medical records from Dr. Gbolahan Okubadejo;
Annexed hereto is a HIPAA-compliant authorization forthe release of medical records
from Dr. Gbolahan Okubadejo located at 713 Teaneck Road, New Jersey 07666.
2. An original, unrestricted, and duly executed HIPAA-compliant authorization to obtain
Plaintiff's medical records from Duane Reade located at 756 Myrtle Avenue, Brooklyn, NY
11206;
Annexed hereto is a HIPAA-compliant authorization for the release of medical records
from Duane Reade located at 756 Myrtle Avenue, Brooklyn, NY 11206;
3. An original, unrestricted, and duly executed HIPAA-compliant authorization to obtain
Plaintiff s medical records from Sullivan Correctional Facility;
Objection. Plaintiffisnot claiming an injury treated at this facility.Please see plaintiff's
deposition transcript dated June 14, 2022; page 136: 16-25 and page 137: 1-9.
4. An original, unrestricted, and duly executed HIPAA-compliant authorization to obtain
Plaintiff'smedical records from Attica Correctional Facility;
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NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022
Objection. Plaintiff did not get injured at thisfacility.Please see plaintiff's deposition
transcript dated June 14, 2022; page 138:10-16.
5. An original, unrestricted, and duly executed MPAA-compliant authorization to obtain
Plaintiff'semployment records from any and allhealthcare records from the United States
Document Security;
Objection. Plaintiff was not employed when the accident occurred. Please see plaintiff's
deposition transcript dated June 14, 2022; page 16:12-25 and page 17:1-17.
6. An original, unrestricted, and duly executed MPAA-compliant authorization to obtain
Ambulance service that transported plaintiffon the date of the accident from the site of the
incident to Kings County Hospital;
Annexed hereto is a MPAA-compliant authorization for the Ambulance Call Report from
FDNY located at Fire Department / City of New York, Public Records Unit / ACR Section, 9
MetroTech Center, Brooklyn, New York 11201-3857.
7. An original, unrestricted, and duly executed MPAA-compliant authorization to obtain
Plaintiff's medical records from Dr. Wu, plaintiff's primary care provider;
Objection. Plaintiffdid not have medical treatment with thisprovider after the accident.
Please see plaintiff'sdeposition transcript dated June 14, 2022; page 15:15-23.
8. An original, unrestricted, and duly executed MPAA-compliant authorization to obtain
Plaintiff'smedical records from the Daytop program in Liberty, New York;
Objection. Plaintiff participated in Daytop Program before the accident occurred. Please
see plaintiff'sdeposition transcript dated June 14, 2022; page 137:10-25.
9. An original, unrestricted, and duly executed MPAA-compliant authorization to obtain
Plaintiff'smedical records from any and allophthalmologists or providers seen for treatment
rendered to plaintiff'seyes/vision;
Objection. Plaintiff is not claiming eyes/vision injuries.
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10. An original,unrestricted, and duly executed HIPAA-compliant authorization to obtain
Plaintiffs medical records from any and allcollateral source providers that plaintiff received
medical/health insurance benefits from five (5) years before the underlying incident to
present;
Annexed hereto is a HIPAA-compliant authorization for the release of plaintiff's
3rd
collateral source information from MetroPlus HealthPlan located at 160 Water Street,
Floor, New York, New York 10038.
11. An original, unrestricted, and duly executed HIPAA-compliant authorization to obtain
Plaintiff's medical records from any and allmedical providers seen five(5) years before the
underlying incident to present;
Objection. Improper demand.
12. An original, unrestricted, and duly executed HIPAA-compliant authorization to obtain
Plaintiff's medical records from any and allMedicare and Medicaid records;
Plaintiff received Medicaid coverage through MetroPlus Health Plan. See response to
#11.
Medicare: To be provided, ifapplicable.
PLEASE TAKE NOTICE that plaintiffreserves the right to amend and supplement this response
up until the time of trial.
Dated: New York, New York
September 19, 2022
Yours, etc.
JEAN MARIE GRAZIANO, ESQ.
SUBIN ASSOCIATES, LLP
Attorneys for Plaintiff
RAFAEL DOMINGUEZ
23rd
150 Broadway, Floor
New York, New York 10038
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(212) 285-3800
TO: Jerry L. Lynch, Esq.
WEBER GALLAGHER SIMPSON
STAPLETON FIRES & NEWBY, LLP
Attorneys for Defendant(s)
1500 Broadway, Suite 2401
New York, New York 10036
(646) 585-7155
File No.: 0115410
ji ynch@wglaw.com
4 of 11
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NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022
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 SocialSecurity Number
Ray Jackson
, my aumvis u 1 m uv ,1 t health information regarding my care and treatment be released as setforth on 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 authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials
on
TREATMENT, psychotherapy notes, only my
the appropriate linein Item 9(a). In the event the health information described below includes any of these types of information, and I
initialthe lineon the box in Item 9(a),I specificallyauthorizerelease of such information to theperson(s) indicatedin Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
prohibited from redisclosing such information without my authorization unless permitted todo sounder federalor statelaw. Iunderstand
that I havethe right to requesta list
of people who may receive or use my HIV-related information without authorization. IfIexperience
discrimination because 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 ofHuman Rights at (212) 306-7450. These agencies are responsible for
protecting my rights.
3. I havethe righttorevoke thisauthorization at any time by writingto thehealth care provider listed
below. I understandthatI may revoke
thisauthorization except to theextentthataction has already been taken based on thisauthorization.
4. Iunderstand thatsigning this authorizationis voluntary. My treatment, payment, enrollment in a healthplan, or for
eligibility benefits
willnot be conditioned upon my authorization of thisdisclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protected by federal orstatelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANY ONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7.Name and address of health provider or entityto releasethisinformation:
Duane Reade, 756 Myrtle Avenue, Brooklyn, NY 11206
8. Name and address of person(s) or category of person to whom thisinformation will be sent:
Weber Gallagher Simpson Stapleton Fires & Newby, LLP, 1500 Broadway, Suite 2401, New York, New York 10036
9(a).Specific information to be released:
Medical Record from 07/30/2019 to PRESENT
OEntire Medical Record, including patient histories,office notes (except psychotherapy/alcohol/drug/HIV information), test
results,radiology studies, films,referrals, consults,billing records, insurance records, and records sent to you by other health
care providers.
Include:(Indicateby Initialing)
¡Other: OAlcohol/Drug Treatment
OMental Health Information
HIV-Related Information
Authorization to Discuss Health Information
O By here
initialing I authorize
Initials
to discussmy health information with my attorney,or a governmental agency, listhere:
10. Reason forrelease of information: 11. Date or eventon which thisauthorization will expire:
OAt request of individual Upon conclusion of litigation
Other: Litigation
12. Ifnot the patient,name of person signing form: 13. Authority to sign on behalf ofpatient:
Jaime Castillo,Esq. Power of Attorney
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: 09/19/2022
Signature of at nt orrepresentative authorized by law.
* Human Im Virus that causes AIDS. The New York State Public Health Law protects information which
odeficiency reasonably
could identifysomeone as having HIV symptoms or infectionand information regarding a person's contacts
5 of 11
FILED: KINGS COUNTY CLERK 09/19/2022 02:19 PM INDEX NO. 512150/2020
NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022
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]
PatientName LDate of Birth ISocial Security N mber
Ray Jackson
DoMara A Advoce-
1, ormy aumorrzetr represemauve, requesrtniathealth information regarding my care and treatment be releasedas setforth on 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 authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initialson
TREATMENT, psychotherapy notes, only my
the appropriate linein Item 9(a). In the event the health information described below includes any of these types of information, and I
initial
the lineon the box in Item 9(a),I specificallyauthorize releaseof such information to the person(s) indicated inItem 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipientis
prohibited from redisclosingsuch information without my authorization unless permitted to do so under federal orstate law.I understand
that I havethe right to request a list
of people who may receive or use my HIV-related information without authorization. IfI experience
discrimination because 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 responsible for
protecting my rights.
3. I havethe rightto revoke thisauthorization at anytime by writing to thehealth care provider listedbelow. I understand thatI may revoke
thisauthorization except to theextent thataction has already been taken based on this authorization.
4. Iunderstand thatsigning this authorization isvoluntary. My treatment, payment, enrollment in a healthplan, or for
eligibility benefits
willnot be conditioned upon my authorization of thisdisclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient(except as noted above in Item 2), and this
redisclosure may no longer be protected by federal orstatelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7.Name and address of healthprovider or entityto releasethisinformation:
Dr. Gbolahan Okubadejo, 713 Teaneck Road, New Jersey 07666
8. Name and address ofperson(s) or category of person to whom this information will be sent:
Weber Gallagher Simpson Stapleton Fires & Newby, LLP, 1500 Broadway, Suite 2401, New York, New York 10036
9(a).Specific information to be released:
Medical Record from 07/30/2019 to PRESENT
¡Entire Medical Record, including patient histories, officenotes (except psychotherapy/alcohol/drug/HIV information), test
results,radiology studies, films,referrals, consults, billingrecords, insurance records, and records sent to you by other health
care providers.
Include: (Indicateby Initialing)
¡Other: ¡Alcohol/Drug Treatment
OMental Health Information
QHIV-Related Information
Authorization to Discuss Health Information
O By initialinghere I authorize
Initials
to discussmy health information with my attorney, or a governmental agency, listhere:
10. Reason forrelease of information: 11. Date or event on which thisauthorization willexpire:
OAt request of individual Upon conclusion of litigation
Other: Litigation
12. Ifnot the name
patient, of person signing form: 13. Authority to sign on behalf ofpatient:
Jaime Castillo, Esq. Power of Attorney
All items on thisform have been completed and my questions about this form have been answered. Inaddition,I have been provided a
copy of theform.
Date: 09/19/2022
Signature tientor representative authorizedby law.
* Human I Virus thatcauses AIDS. The New York State PublicHealth Law protectsinformation which
munodeficiency reasonably
could identifysomeone as having HIV symptoms or infectionand information regarding a person's contacts
6 of 11
FILED: KINGS COUNTY CLERK 09/19/2022 02:19 PM INDEX NO. 512150/2020
NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022
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]
PatientName lDate of Rirth social Recurity umber
Ray Jackson
1, us 111yauu1untou sopicacinauv o, 1oquom u1at healthinformation regarding my care and treatment be released as set forthon thisform:
In accordance with New York StateLaw and the Privacy Rule of theHealth Insurance Portabilityand Accountability Act of1996 (HIPAA),
I understand that:
1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL MV* RELATED INFORMATION ifI place initialson
TREATMENT, psychotherapy notes, only my
the appropriate linein Item 9(a). In the event the health information described below includes any of these types of information, and I
the
initial lineon the box in Item 9(a),I specificallyauthorize releaseof such information to the person(s) indicated inItem 8.
2. If Iam authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
prohibited from redisclosing such information without my authorization unless permitted to do so under federal orstatelaw. I understand
that I havethe rightto request a list
of people who may receive or use my HIV-related information without authorization.IfI experience
discrimination because of the releaseor disclosure of HIV-related information, Imay 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 areresponsible for
protecting my rights.
3. I havethe righttorevoke thisauthorization at anytime by writingto thehealth care provider listedbelow. I understand thatI may revoke
thisauthorization except to theextent thataction has already been taken based on thisauthorization.
4. Iunderstand thatsigning this authorizationis voluntary. My treatment, payment, enrollment in a healthplan, or for
eligibility benefits
will notbe conditioned upon my authorization of thisdisclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protected by federal orstate law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7.Name and address of healthprovider or entityto releasethisinformation:
FDNY, Fire Department/City of New York, Public Records Unit/ACR Section, 9 MetroTech Center, Brooklyn, NY 11201
8. Name and address of person(s) or category of person to whom thisinformation will be sent:
Weber Gallagher Simpson Stapleton Fires & Newby, LLP, 1500 Broadway, Suite 2401, New York, New York 10036
9(a). Specificinformation to be released:
Medical Record from 07/30/2019 to PRESENT
OEntire Medical Record, including patient histories, officenotes (except psychotherapy/alcohol/drug/HIV information), test
results,radiology studies, films,referrals, consults, billingrecords, insurance records, and records sent to you by other health
care providers.
Include: (Indicateby Initialing)
¡Other:, OAlcohol/Drug Treatment
¡Mental Health Information
OHIV-Related Information
Authorization to Discuss Health Information
¡ By initialinghere I authorize
Initials
to discussmy health information with my attorney, or a governinental agency, listhere:
10. Reason forrelease of information: 11.Date or event on which thisauthorization willexpire:
¡At request of individual Upon conclusion of litigation
Other: Litigation
12. Ifnot thepatient,name of person signingform: 13. Authority to sign on behalf ofpatient:
Jaime Esq.
Castillo, Power of Attorney
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: 09/19/2022
Signature of p(e t orrepresentative authorizedby law.
* Human I Virus that causes AIDS. The New York State PublicHealth Law protects information which
odeficiency reasonably
could identifysomeone as having HIV symptoms or infection and information regarding a person'scontacts
7 of 11
FILED: KINGS COUNTY CLERK 09/19/2022 02:19 PM INDEX NO. 512150/2020
NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022
OCA OfficialForm No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[Thisform has been approved by the New York StateDepartment of Health]
PatientName In* af hth Racial Recurity Number
Ray Jackson
I,or my authorized representative,request thathealth information regarding my care and treatment be releasedas set forthon 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 ifI place initials
on
TREATMENT, psychotherapy notes, only my
the appropriate linein Item 9(a). In the event the health information described below includes any of these types of information, and I
initial
the lineon the box inItem 9(a),I specificallyauthorize releaseof such information to the person(s) indicatedin Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
prohibited from redisclosingsuch information without my authorization unless permitted to do so under federal orstatelaw. I understand
that I havethe right to request a listofpeople who may receive or use my HIV-related information without authorization. IfIexperience
discrimination because 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 responsible for
protecting my rights.
3. I havethe rightto revoke thisauthorization at anytime by writing to thehealth careprovider listedbelow. I understand thatI may revoke
thisauthorization except to theextent that actionhas already been taken based on this authorization.
4. Iunderstand thatsigning this authorization isvoluntary. My treatment, payment, enrollment in a healthplan, or for
eligibility benefits
will notbe conditioned upon my authorizationof thisdisclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient(except as noted above in Item 2), and this
redisclosure may no longer be protected by federal orstatelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7.Name and address of healthprovider or entitytorelease thisinformation:
MetroPlus HealthPlan, 160 Water Street, 3rd Floor, New York, New York 10038
8. Name and address of person(s) or category of person to whom thisinformation will be sent:
Weber Gallagher Simpson Stapleton Fires & Newby, LLP, 1500 Broadway, Suite 2401, New York, New York 10036
9(a). Specificinformation tobe released:
EMedical Record from 07/30/2019 to PRESENT
OEntire Medical Record, including patient histories,officenotes (except psychotherapy/alcohol/drug/HIV information), test
results, radiology studies, films, referrals,consults, billingrecords, insurance records, and records sent to you by other health
care providers.
Include: (Indicateby Initialing)
¡Other: ¡Alcohol/Drug Treatment
¡Mental Health Information
OHIV-Related Information
Authorization to Discuss Health Information
¡ By initialinghere I authorize
Initials
to discussmy health information with my attorney, or a governmental agency, listhere:
10. Reason for release of information: 11.Date or event on which thisauthorization willexpire:
OAt request of individual Upon conclusion of litigation
Other: Litigation
12. Ifnot the name
patient, of person signing form: 13. Authority to signon behalf of patient:
Jaime Castillo,Esq. Power of Attorney
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: 09/19/2022
Signature of p t orrepresentative authorized by law.
* Human hn Virus that causes AIDS. The New York State PublicHealth Law protects information which
nodeficiency reasonably
could identi someone as having HIV symptoms or infection and information regarding a person's contacts
8 of 11
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NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022
POWER OF ATTORNEY
To Execute HIP AA Medical Record Authorization Forms Pursuant
To NY Public Health Law §18(I(g) As Amended 1 0/26/04.
1, ,a
do hereby appoint my attorney:
LLP (EDWIN LOPEZ,.IAIME CASTILLC. JORGE COLLADO, ANA
SUBIN ASSOCIATES,
L1LLIAN ANZALOTA. ELI SERRAN, LISA BENIGNO, ELSIE REAL, ARNIE BAUM AND
GONZALEZ,
23rd New New York 10038, my attorneys-in-fset
PETER MAY) with onices at 150 Broadway, Floor, York,
in place and stead in which I mysel fcould do, ifl
to act (each agent may act separately) my name; any way
were present to execute HIPAA rnedical record authorization fbrms pursuant to NY Public
personally
amended 10/26/04. This Power be revoked me atany time. This
Health Law §18(1)g) as ofAttorney may by
shall not be affected subsequent disability or incompetence.
Power ofAttorney by my
This power and waives any doctor/patient privilege; and/or any
ofattorney expressly unconditionally
with regard to medical reports and/or records obtained in theprosecution or defense of
expectation ofprivacy
from medical providers and/or reports generated from or on behalfof
personal injury litigation,whether my
my
or on behalfofdefendants or insurance companies, whether or not the reports and/or
physicians retained by
domain. I consent to the use and/or disclosure ofthese reports and/or records
records are in the public expressly
litigants."
in the furtherance litigationand/or for the benefit ofother
ofmy
I agree that third a duly executed copy or
To induce any third party to act hereunder, hereby any party receiving
act and thatrevocation or termination hereofshall be ineffective as
facsimile ofthis instrument may hereunder,
actual notice or knowledge ofsuch revocation or termination shall have been
to such third party unless and until
such third and Ifor myselfand for heirs, executors, legal representatives and assigns,
received by party, my
hold harmless such third reason ofsuch third party having relied on
hereby agree to indemnify and any party by
the provisions ofthis instrument.
In Witness Whereof 1 have hereunto signed my name this _ day of_ 20f
.
STATE OF NEW YORK
COUNTY OF
of 20 befbre me personally appeared
On this day
basis evidence to be the individual whose name is
known to be or proved to me on the ofsatisfactory
personally
acknowledged to me that he executed the same in his capacity. and that
subscribed to the within instrument and
or the person who acted on behalfofthe individual executed
his signature on the instrument. the individual
by
appearance before the undersigned at I 50 Broadway. 23rd
the instrument and thatsuch individual made such
Floor, New York. New York.
t.UIS F. DELEON
State of New M
Pubho,
Notary 01DE6291884
No.
County
QualmedIn Nngs 10/21/2
commission Emires
9 of 11
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NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022
STATE OF NEW YORK )
COUNTY OF NEW YORK ) SS.:
I, Paulina Lebron, am not a party to the action is over 18 years of age and I maintain an
office at 150 Broadway, New York, New York.
On September 19, 2022, I served the within PLAINTIFF'S RESPONSE TO
DEFENDANT'S DEMAND FOR AUTHORIZATIONS DATED JUNE 29, 2022, upon the
attorneys/parties in the case who are registered NYSCEF users and whose names and addresses
are set for below, by the New York State Electronic Case Filing System as well as electronic mail:
VIA EMAIL, REGULAR MAIL AND NYSCEF TO:
Jerry L. Lynch, Esq.
WEBER GALLAGHER SIMPSON
STAPLETON FIRES & NEWBY, LLP
Attorneys for Defendant(s)
1500 Broadway, Suite 2401
New York, New York 10036
(646) 585-7155
File No.: 0115410
ilynch@walaw.com
P U A L R
Sworn before me this
day of%9. nkof 2022.
Notary u ic Paola M. Ayala
Public,State ofNew York
Notary
Reg. No. 01AY6424406
Qualifiedin Queens County
Commission Expires November 1, 2025
10 of 11
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NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022
FILE #: 31457
Index No. 512150/2020
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF KINGS
RAY JACKSON,
Plaintiff(s),
-against-
VAN BLARCOM CLOSURES, INC.,
Defendant(s).
PLAINTIFF'S RESPONSE TO DEFENDANT'S DEMAND FOR AUTHORIZATIONS
DATED JUNE 29, 2022
Subin Associates LLP
Attorneys for Plaintiff
Office and Post Office Address, Telephone
23rd
150 Broadway, FlOOr
New York, New York 10038
TELEPHONE (212) 285-3800
(FAX)"
"WE DO NOT ACCEPT SERVICE BY ELECTRONIC TRANSMISSION
Service of a copy of the within ishereby admitted
Dated:, ........................................................
Preview
FILED: KINGS COUNTY CLERK 09/19/2022 02:19 PM INDEX NO. 512150/2020 NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022 File No. 31457 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF KINGS _____.-----------------------------------------X RAY JACKSON, PLAINTIFF'S RESPONSE Plaintiff(s), TO DEFENDANT'S -against- DEMAND FOR AUTHORIZATIONS DATED VAN BLARCOM CLOSURES, INC., JUNE 29, 2022 Defendant(s). -----------------------------------------------------------------X Index No.: 512150/2020 Plaintiff,RAY JACKSON, by his attorneys, SUBIN ASSOCIATES, LLC, as and for a defendants' Authorizations" response to "Demand for dated June 29, 2022, alleges upon information and belief, as follows: 1. An original, unrestricted, and duly executed HIPAA-compliant authorization to obtain Plaintiff's medical records from Dr. Gbolahan Okubadejo; Annexed hereto is a HIPAA-compliant authorization forthe release of medical records from Dr. Gbolahan Okubadejo located at 713 Teaneck Road, New Jersey 07666. 2. An original, unrestricted, and duly executed HIPAA-compliant authorization to obtain Plaintiff's medical records from Duane Reade located at 756 Myrtle Avenue, Brooklyn, NY 11206; Annexed hereto is a HIPAA-compliant authorization for the release of medical records from Duane Reade located at 756 Myrtle Avenue, Brooklyn, NY 11206; 3. An original, unrestricted, and duly executed HIPAA-compliant authorization to obtain Plaintiff s medical records from Sullivan Correctional Facility; Objection. Plaintiffisnot claiming an injury treated at this facility.Please see plaintiff's deposition transcript dated June 14, 2022; page 136: 16-25 and page 137: 1-9. 4. An original, unrestricted, and duly executed HIPAA-compliant authorization to obtain Plaintiff'smedical records from Attica Correctional Facility; 1 of 11 FILED: KINGS COUNTY CLERK 09/19/2022 02:19 PM INDEX NO. 512150/2020 NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022 Objection. Plaintiff did not get injured at thisfacility.Please see plaintiff's deposition transcript dated June 14, 2022; page 138:10-16. 5. An original, unrestricted, and duly executed MPAA-compliant authorization to obtain Plaintiff'semployment records from any and allhealthcare records from the United States Document Security; Objection. Plaintiff was not employed when the accident occurred. Please see plaintiff's deposition transcript dated June 14, 2022; page 16:12-25 and page 17:1-17. 6. An original, unrestricted, and duly executed MPAA-compliant authorization to obtain Ambulance service that transported plaintiffon the date of the accident from the site of the incident to Kings County Hospital; Annexed hereto is a MPAA-compliant authorization for the Ambulance Call Report from FDNY located at Fire Department / City of New York, Public Records Unit / ACR Section, 9 MetroTech Center, Brooklyn, New York 11201-3857. 7. An original, unrestricted, and duly executed MPAA-compliant authorization to obtain Plaintiff's medical records from Dr. Wu, plaintiff's primary care provider; Objection. Plaintiffdid not have medical treatment with thisprovider after the accident. Please see plaintiff'sdeposition transcript dated June 14, 2022; page 15:15-23. 8. An original, unrestricted, and duly executed MPAA-compliant authorization to obtain Plaintiff'smedical records from the Daytop program in Liberty, New York; Objection. Plaintiff participated in Daytop Program before the accident occurred. Please see plaintiff'sdeposition transcript dated June 14, 2022; page 137:10-25. 9. An original, unrestricted, and duly executed MPAA-compliant authorization to obtain Plaintiff'smedical records from any and allophthalmologists or providers seen for treatment rendered to plaintiff'seyes/vision; Objection. Plaintiff is not claiming eyes/vision injuries. 2 of 11 FILED: KINGS COUNTY CLERK 09/19/2022 02:19 PM INDEX NO. 512150/2020 NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022 10. An original,unrestricted, and duly executed HIPAA-compliant authorization to obtain Plaintiffs medical records from any and allcollateral source providers that plaintiff received medical/health insurance benefits from five (5) years before the underlying incident to present; Annexed hereto is a HIPAA-compliant authorization for the release of plaintiff's 3rd collateral source information from MetroPlus HealthPlan located at 160 Water Street, Floor, New York, New York 10038. 11. An original, unrestricted, and duly executed HIPAA-compliant authorization to obtain Plaintiff's medical records from any and allmedical providers seen five(5) years before the underlying incident to present; Objection. Improper demand. 12. An original, unrestricted, and duly executed HIPAA-compliant authorization to obtain Plaintiff's medical records from any and allMedicare and Medicaid records; Plaintiff received Medicaid coverage through MetroPlus Health Plan. See response to #11. Medicare: To be provided, ifapplicable. PLEASE TAKE NOTICE that plaintiffreserves the right to amend and supplement this response up until the time of trial. Dated: New York, New York September 19, 2022 Yours, etc. JEAN MARIE GRAZIANO, ESQ. SUBIN ASSOCIATES, LLP Attorneys for Plaintiff RAFAEL DOMINGUEZ 23rd 150 Broadway, Floor New York, New York 10038 3 of 11 FILED: KINGS COUNTY CLERK 09/19/2022 02:19 PM INDEX NO. 512150/2020 NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022 (212) 285-3800 TO: Jerry L. Lynch, Esq. WEBER GALLAGHER SIMPSON STAPLETON FIRES & NEWBY, LLP Attorneys for Defendant(s) 1500 Broadway, Suite 2401 New York, New York 10036 (646) 585-7155 File No.: 0115410 ji ynch@wglaw.com 4 of 11 FILED: KINGS COUNTY CLERK 09/19/2022 02:19 PM INDEX NO. 512150/2020 NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022 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 SocialSecurity Number Ray Jackson , my aumvis u 1 m uv ,1 t health information regarding my care and treatment be released as setforth on 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 authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials on TREATMENT, psychotherapy notes, only my the appropriate linein Item 9(a). In the event the health information described below includes any of these types of information, and I initialthe lineon the box in Item 9(a),I specificallyauthorizerelease of such information to theperson(s) indicatedin Item 8. 2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted todo sounder federalor statelaw. Iunderstand that I havethe right to requesta list of people who may receive or use my HIV-related information without authorization. IfIexperience discrimination because 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 ofHuman Rights at (212) 306-7450. These agencies are responsible for protecting my rights. 3. I havethe righttorevoke thisauthorization at any time by writingto thehealth care provider listed below. I understandthatI may revoke thisauthorization except to theextentthataction has already been taken based on thisauthorization. 4. Iunderstand thatsigning this authorizationis voluntary. My treatment, payment, enrollment in a healthplan, or for eligibility benefits willnot be conditioned upon my authorization of thisdisclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal orstatelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANY ONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7.Name and address of health provider or entityto releasethisinformation: Duane Reade, 756 Myrtle Avenue, Brooklyn, NY 11206 8. Name and address of person(s) or category of person to whom thisinformation will be sent: Weber Gallagher Simpson Stapleton Fires & Newby, LLP, 1500 Broadway, Suite 2401, New York, New York 10036 9(a).Specific information to be released: Medical Record from 07/30/2019 to PRESENT OEntire Medical Record, including patient histories,office notes (except psychotherapy/alcohol/drug/HIV information), test results,radiology studies, films,referrals, consults,billing records, insurance records, and records sent to you by other health care providers. Include:(Indicateby Initialing) ¡Other: OAlcohol/Drug Treatment OMental Health Information HIV-Related Information Authorization to Discuss Health Information O By here initialing I authorize Initials to discussmy health information with my attorney,or a governmental agency, listhere: 10. Reason forrelease of information: 11. Date or eventon which thisauthorization will expire: OAt request of individual Upon conclusion of litigation Other: Litigation 12. Ifnot the patient,name of person signing form: 13. Authority to sign on behalf ofpatient: Jaime Castillo,Esq. Power of Attorney 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: 09/19/2022 Signature of at nt orrepresentative authorized by law. * Human Im Virus that causes AIDS. The New York State Public Health Law protects information which odeficiency reasonably could identifysomeone as having HIV symptoms or infectionand information regarding a person's contacts 5 of 11 FILED: KINGS COUNTY CLERK 09/19/2022 02:19 PM INDEX NO. 512150/2020 NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022 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] PatientName LDate of Birth ISocial Security N mber Ray Jackson DoMara A Advoce- 1, ormy aumorrzetr represemauve, requesrtniathealth information regarding my care and treatment be releasedas setforth on 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 authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initialson TREATMENT, psychotherapy notes, only my the appropriate linein Item 9(a). In the event the health information described below includes any of these types of information, and I initial the lineon the box in Item 9(a),I specificallyauthorize releaseof such information to the person(s) indicated inItem 8. 2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipientis prohibited from redisclosingsuch information without my authorization unless permitted to do so under federal orstate law.I understand that I havethe right to request a list of people who may receive or use my HIV-related information without authorization. IfI experience discrimination because 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 responsible for protecting my rights. 3. I havethe rightto revoke thisauthorization at anytime by writing to thehealth care provider listedbelow. I understand thatI may revoke thisauthorization except to theextent thataction has already been taken based on this authorization. 4. Iunderstand thatsigning this authorization isvoluntary. My treatment, payment, enrollment in a healthplan, or for eligibility benefits willnot be conditioned upon my authorization of thisdisclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient(except as noted above in Item 2), and this redisclosure may no longer be protected by federal orstatelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7.Name and address of healthprovider or entityto releasethisinformation: Dr. Gbolahan Okubadejo, 713 Teaneck Road, New Jersey 07666 8. Name and address ofperson(s) or category of person to whom this information will be sent: Weber Gallagher Simpson Stapleton Fires & Newby, LLP, 1500 Broadway, Suite 2401, New York, New York 10036 9(a).Specific information to be released: Medical Record from 07/30/2019 to PRESENT ¡Entire Medical Record, including patient histories, officenotes (except psychotherapy/alcohol/drug/HIV information), test results,radiology studies, films,referrals, consults, billingrecords, insurance records, and records sent to you by other health care providers. Include: (Indicateby Initialing) ¡Other: ¡Alcohol/Drug Treatment OMental Health Information QHIV-Related Information Authorization to Discuss Health Information O By initialinghere I authorize Initials to discussmy health information with my attorney, or a governmental agency, listhere: 10. Reason forrelease of information: 11. Date or event on which thisauthorization willexpire: OAt request of individual Upon conclusion of litigation Other: Litigation 12. Ifnot the name patient, of person signing form: 13. Authority to sign on behalf ofpatient: Jaime Castillo, Esq. Power of Attorney All items on thisform have been completed and my questions about this form have been answered. Inaddition,I have been provided a copy of theform. Date: 09/19/2022 Signature tientor representative authorizedby law. * Human I Virus thatcauses AIDS. The New York State PublicHealth Law protectsinformation which munodeficiency reasonably could identifysomeone as having HIV symptoms or infectionand information regarding a person's contacts 6 of 11 FILED: KINGS COUNTY CLERK 09/19/2022 02:19 PM INDEX NO. 512150/2020 NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022 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] PatientName lDate of Rirth social Recurity umber Ray Jackson 1, us 111yauu1untou sopicacinauv o, 1oquom u1at healthinformation regarding my care and treatment be released as set forthon thisform: In accordance with New York StateLaw and the Privacy Rule of theHealth Insurance Portabilityand Accountability Act of1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL MV* RELATED INFORMATION ifI place initialson TREATMENT, psychotherapy notes, only my the appropriate linein Item 9(a). In the event the health information described below includes any of these types of information, and I the initial lineon the box in Item 9(a),I specificallyauthorize releaseof such information to the person(s) indicated inItem 8. 2. If Iam authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal orstatelaw. I understand that I havethe rightto request a list of people who may receive or use my HIV-related information without authorization.IfI experience discrimination because of the releaseor disclosure of HIV-related information, Imay 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 areresponsible for protecting my rights. 3. I havethe righttorevoke thisauthorization at anytime by writingto thehealth care provider listedbelow. I understand thatI may revoke thisauthorization except to theextent thataction has already been taken based on thisauthorization. 4. Iunderstand thatsigning this authorizationis voluntary. My treatment, payment, enrollment in a healthplan, or for eligibility benefits will notbe conditioned upon my authorization of thisdisclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal orstate law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7.Name and address of healthprovider or entityto releasethisinformation: FDNY, Fire Department/City of New York, Public Records Unit/ACR Section, 9 MetroTech Center, Brooklyn, NY 11201 8. Name and address of person(s) or category of person to whom thisinformation will be sent: Weber Gallagher Simpson Stapleton Fires & Newby, LLP, 1500 Broadway, Suite 2401, New York, New York 10036 9(a). Specificinformation to be released: Medical Record from 07/30/2019 to PRESENT OEntire Medical Record, including patient histories, officenotes (except psychotherapy/alcohol/drug/HIV information), test results,radiology studies, films,referrals, consults, billingrecords, insurance records, and records sent to you by other health care providers. Include: (Indicateby Initialing) ¡Other:, OAlcohol/Drug Treatment ¡Mental Health Information OHIV-Related Information Authorization to Discuss Health Information ¡ By initialinghere I authorize Initials to discussmy health information with my attorney, or a governinental agency, listhere: 10. Reason forrelease of information: 11.Date or event on which thisauthorization willexpire: ¡At request of individual Upon conclusion of litigation Other: Litigation 12. Ifnot thepatient,name of person signingform: 13. Authority to sign on behalf ofpatient: Jaime Esq. Castillo, Power of Attorney 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: 09/19/2022 Signature of p(e t orrepresentative authorizedby law. * Human I Virus that causes AIDS. The New York State PublicHealth Law protects information which odeficiency reasonably could identifysomeone as having HIV symptoms or infection and information regarding a person'scontacts 7 of 11 FILED: KINGS COUNTY CLERK 09/19/2022 02:19 PM INDEX NO. 512150/2020 NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022 OCA OfficialForm No.:960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [Thisform has been approved by the New York StateDepartment of Health] PatientName In* af hth Racial Recurity Number Ray Jackson I,or my authorized representative,request thathealth information regarding my care and treatment be releasedas set forthon 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 ifI place initials on TREATMENT, psychotherapy notes, only my the appropriate linein Item 9(a). In the event the health information described below includes any of these types of information, and I initial the lineon the box inItem 9(a),I specificallyauthorize releaseof such information to the person(s) indicatedin Item 8. 2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosingsuch information without my authorization unless permitted to do so under federal orstatelaw. I understand that I havethe right to request a listofpeople who may receive or use my HIV-related information without authorization. IfIexperience discrimination because 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 responsible for protecting my rights. 3. I havethe rightto revoke thisauthorization at anytime by writing to thehealth careprovider listedbelow. I understand thatI may revoke thisauthorization except to theextent that actionhas already been taken based on this authorization. 4. Iunderstand thatsigning this authorization isvoluntary. My treatment, payment, enrollment in a healthplan, or for eligibility benefits will notbe conditioned upon my authorizationof thisdisclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient(except as noted above in Item 2), and this redisclosure may no longer be protected by federal orstatelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THEN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7.Name and address of healthprovider or entitytorelease thisinformation: MetroPlus HealthPlan, 160 Water Street, 3rd Floor, New York, New York 10038 8. Name and address of person(s) or category of person to whom thisinformation will be sent: Weber Gallagher Simpson Stapleton Fires & Newby, LLP, 1500 Broadway, Suite 2401, New York, New York 10036 9(a). Specificinformation tobe released: EMedical Record from 07/30/2019 to PRESENT OEntire Medical Record, including patient histories,officenotes (except psychotherapy/alcohol/drug/HIV information), test results, radiology studies, films, referrals,consults, billingrecords, insurance records, and records sent to you by other health care providers. Include: (Indicateby Initialing) ¡Other: ¡Alcohol/Drug Treatment ¡Mental Health Information OHIV-Related Information Authorization to Discuss Health Information ¡ By initialinghere I authorize Initials to discussmy health information with my attorney, or a governmental agency, listhere: 10. Reason for release of information: 11.Date or event on which thisauthorization willexpire: OAt request of individual Upon conclusion of litigation Other: Litigation 12. Ifnot the name patient, of person signing form: 13. Authority to signon behalf of patient: Jaime Castillo,Esq. Power of Attorney 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: 09/19/2022 Signature of p t orrepresentative authorized by law. * Human hn Virus that causes AIDS. The New York State PublicHealth Law protects information which nodeficiency reasonably could identi someone as having HIV symptoms or infection and information regarding a person's contacts 8 of 11 FILED: KINGS COUNTY CLERK 09/19/2022 02:19 PM INDEX NO. 512150/2020 NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022 POWER OF ATTORNEY To Execute HIP AA Medical Record Authorization Forms Pursuant To NY Public Health Law §18(I(g) As Amended 1 0/26/04. 1, ,a do hereby appoint my attorney: LLP (EDWIN LOPEZ,.IAIME CASTILLC. JORGE COLLADO, ANA SUBIN ASSOCIATES, L1LLIAN ANZALOTA. ELI SERRAN, LISA BENIGNO, ELSIE REAL, ARNIE BAUM AND GONZALEZ, 23rd New New York 10038, my attorneys-in-fset PETER MAY) with onices at 150 Broadway, Floor, York, in place and stead in which I mysel fcould do, ifl to act (each agent may act separately) my name; any way were present to execute HIPAA rnedical record authorization fbrms pursuant to NY Public personally amended 10/26/04. This Power be revoked me atany time. This Health Law §18(1)g) as ofAttorney may by shall not be affected subsequent disability or incompetence. Power ofAttorney by my This power and waives any doctor/patient privilege; and/or any ofattorney expressly unconditionally with regard to medical reports and/or records obtained in theprosecution or defense of expectation ofprivacy from medical providers and/or reports generated from or on behalfof personal injury litigation,whether my my or on behalfofdefendants or insurance companies, whether or not the reports and/or physicians retained by domain. I consent to the use and/or disclosure ofthese reports and/or records records are in the public expressly litigants." in the furtherance litigationand/or for the benefit ofother ofmy I agree that third a duly executed copy or To induce any third party to act hereunder, hereby any party receiving act and thatrevocation or termination hereofshall be ineffective as facsimile ofthis instrument may hereunder, actual notice or knowledge ofsuch revocation or termination shall have been to such third party unless and until such third and Ifor myselfand for heirs, executors, legal representatives and assigns, received by party, my hold harmless such third reason ofsuch third party having relied on hereby agree to indemnify and any party by the provisions ofthis instrument. In Witness Whereof 1 have hereunto signed my name this _ day of_ 20f . STATE OF NEW YORK COUNTY OF of 20 befbre me personally appeared On this day basis evidence to be the individual whose name is known to be or proved to me on the ofsatisfactory personally acknowledged to me that he executed the same in his capacity. and that subscribed to the within instrument and or the person who acted on behalfofthe individual executed his signature on the instrument. the individual by appearance before the undersigned at I 50 Broadway. 23rd the instrument and thatsuch individual made such Floor, New York. New York. t.UIS F. DELEON State of New M Pubho, Notary 01DE6291884 No. County QualmedIn Nngs 10/21/2 commission Emires 9 of 11 FILED: KINGS COUNTY CLERK 09/19/2022 02:19 PM INDEX NO. 512150/2020 NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022 STATE OF NEW YORK ) COUNTY OF NEW YORK ) SS.: I, Paulina Lebron, am not a party to the action is over 18 years of age and I maintain an office at 150 Broadway, New York, New York. On September 19, 2022, I served the within PLAINTIFF'S RESPONSE TO DEFENDANT'S DEMAND FOR AUTHORIZATIONS DATED JUNE 29, 2022, upon the attorneys/parties in the case who are registered NYSCEF users and whose names and addresses are set for below, by the New York State Electronic Case Filing System as well as electronic mail: VIA EMAIL, REGULAR MAIL AND NYSCEF TO: Jerry L. Lynch, Esq. WEBER GALLAGHER SIMPSON STAPLETON FIRES & NEWBY, LLP Attorneys for Defendant(s) 1500 Broadway, Suite 2401 New York, New York 10036 (646) 585-7155 File No.: 0115410 ilynch@walaw.com P U A L R Sworn before me this day of%9. nkof 2022. Notary u ic Paola M. Ayala Public,State ofNew York Notary Reg. No. 01AY6424406 Qualifiedin Queens County Commission Expires November 1, 2025 10 of 11 FILED: KINGS COUNTY CLERK 09/19/2022 02:19 PM INDEX NO. 512150/2020 NYSCEF DOC. NO. 35 RECEIVED NYSCEF: 09/19/2022 FILE #: 31457 Index No. 512150/2020 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF KINGS RAY JACKSON, Plaintiff(s), -against- VAN BLARCOM CLOSURES, INC., Defendant(s). PLAINTIFF'S RESPONSE TO DEFENDANT'S DEMAND FOR AUTHORIZATIONS DATED JUNE 29, 2022 Subin Associates LLP Attorneys for Plaintiff Office and Post Office Address, Telephone 23rd 150 Broadway, FlOOr New York, New York 10038 TELEPHONE (212) 285-3800 (FAX)" "WE DO NOT ACCEPT SERVICE BY ELECTRONIC TRANSMISSION Service of a copy of the within ishereby admitted Dated:, ........................................................