Preview
FILED: KINGS COUNTY CLERK 04/17/2019 11:01 AM INDEX NO. 521833/2018
NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF KINGS
------------------------------------------------------ X
JULISSA ESCANO,
Index No.: 521833/18
Plaintiff,
-against- SUPPLEMENTAL
VERIFIED BILL OF
PARTICULARS
5223 3 AVENUE LLC, BEST WORK INC., and
MENDIETA CONSTRUCTION INC.,
Defendants.
------------------------ -------- ---------------------X
Plaintiff, JULISSA ESCANO, by her attorneys, PONTISAKOS & BRANDMAN,
P.C., set forth the following as and for her Supplemental Bill of Particulars in response to the
demands of the defendants, 5223 3 AVENUE LLC, BEST WORK INC., and MENDIETA
CONSTRUCTION INC., alleges as follows:
MEDICAL INJURIES:
As a result of defendant's negligence, plaintiff, JULISSA ESCANO,
sustained the following supplemental personal injuries:
- Tears of the rotator cuff infraspinatus and supraspinatus junction and
subscapularis tendon, left shoulder;
- SLAP tear of the superior left
labrum, shoulder;
- Extensive hypertrophic left
synovitis, shoulder;
- Multiple left
adhesions, shoulder;
- Significant hyperemic left
bursitis, shoulder;
- Thickened CA left
ligament, shoulder;
- The above injuries to plaintiff's leftshoulder required surgical intervention
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NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019
including: arthroscopy, synovectomy, bursectomy, lysis of thickened
coracoacromial ligament, intra articular debridement rotator cuff and
SLAP tears, lysis of multiple adhesions subacromial compartment.
- The was performed Dov on March 2019
surgery by Berktowiz, M.D., 27,
at the Surgicore Surgical Center of Jersey City.
The above injuries involved the surrounding nerves, tendons, muscles, blood
vessels, muscles, ligaments and connective tissue in and around the above set forth area.
The above injuries are degenerative in nature and, within reasonable medical
certainty, will worsen with the onset of inflammation and then arthritis and decreasing range of
motion.
Surgery and continued medical care and monitoring is needed.
Upon information and belief, all of the above described injuries are permanent
and progressive, except those of a superficial nature.
A power of attorney along with HIPAA Compliant Authorizations to obtain the
medical records of Dr. Dov Berkowtiz of Advanced Orthopedics, PC and Surgicore Surgical
Center of Jersey City is annexed hereto along with a copy of the operative report dated March 27,
2019.
Dated: Garden City, New York
April 15, 2019 Yours etc.,
PONTISAKO BRANDMAN, P.C.
By: J . Pontisakos
Atto eys for Plaintiff
600 ld Country Road, Ste. 323
Garden City, NY 11530
(516) 683-8888
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NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019
To:
HOFFMAN ROTH & MATLIN, LLP
Attorneys For Defendant
MENDIETA CONSTRUCTION INC.
8th
505 Avenue
Suite 1704
New York, New York 10018
(212) 964-1890
File No.: 8179
LANDMAN CORSI BALLAINE & FORD P.C.
Attorneys For Defendant
BEST WORK INC.
One Gateway Center
4th
FlOOr
Newark, New Jersey 07102
(973) 623-2700
LAW OFFICES OF YANG & PARTNERS
Attorneys For Defendant
5223 3AVE LLC
9 East Broadway
Suite 302
New York, New York 10038
(212) 608-3888
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NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019
VERIFICATION
John D. Pontisakos, an attorney duly admitted to practice law before the courts of the
State of New York, hereby affirms the truth of the following under the penalties of perjury:
Affirmant is counsel to the plaintiff in the within action.
Affirmant has read the foregoing SUPPLEMENTAL BILL OF PARTICULARS and
knows the contents thereof.
The same is true of Affirmant's own knowledge, except as to matters therein stated to be
alleged upon information and belief, and as to those matters, Affirmant believes them to be true.
This verification is made by Affirmant and not by the plaintiff as plaintiff does not reside
within Nassau County, the county where Affirmant's office is located.
The grounds of Affirmant's belief as to all matters not stated upon Affirmant's knowledge
are as follows: records, reports, documents, papers, conversations with client(s) concerning the
within matter, etc.
Dated: Garden City, New York
April 15, 2019
John . P ntYsakos
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NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019
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 SocialSecurity Number
JULISSA ESCANO September 25, 1998
PatientAddress
5005 8th Avenue, Apt 3F, Brooklyn, New York 11220
I,or my authorized representative,request thathealthinformation regarding my careand treatmcat be releasedas set forth
on thisform:
In accordancewith New York StateLaw and the Privacy Rule of theHealth Insurance Pcitabilityand Accc tyAct of 1996
(HIPAA), I understandthat:
1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION if
I place initials
on
TREATMENT, psychotherapy notes, only my
the appropriateline inItem 9(a). In the event thehealth information described below includes any of thesetypes of information,and I
initial
the lineon the box in Item 9(a),I specifically
authorizerelease ofsuch information to theperson(s) indicatedinItem 8.
2. If Iam authorizing the releaseof HIV-related, alcohol or drug treatment, or mental health treatment infarmatics, the recipientis
prohibited from redisclosing such information without my authorization unless permitted to do so under federal or statelaw. I
understand thatI have the righttorequest a list
of people who may receiveor use my HIV-related informationwithout authorization. If
I experience discriminaticñ because of the releaseor disclosureof HIV-relatedinf.x=don, I may contact theNew 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 protectingmy rights.
3. I have theright torevoke thisauthorizationat any time by writingto thehealth care providerlistedbelow. I understand thatI may
revoke thisauthorizationexcept 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
cligibility
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 of healthprovider or entitytorelease thisinformation:
Surgiccre Surgical Center of Jersey City, 550 Newark Avenue, 5th Floor, Jersey City, New Jersey 07306
8. Name and address ofperson(s) orcategory of person towhom thisinformation willbe sent:
LAW FIRM OF YANG & PARTNERS, 9 East Breadway, Suite 302, New York, New York 10038
9(a). Specificinformation to be released:
2 Medical Record from (insertdate) March 27, 2019 to(insertdate) Present
O EntireMedical Record, inc!eding patient office
histories, notes (except psychotherapy notes),testresults,radiologystudies,films,
referrals,consults,billingrecords, insurancerecords,and records sentto you by other healthcare providers.
0 Other: Include bills,records, receipts, Include: (Indicateby initialing)
diagnostic tests,MRI films, etc
Alcohol/Drug Treatment
Mental Health Information
Authorization to Discuss Health Information HIV-Related Information
(b) O By here
initialing I authorize
Initials Name ofindividual
healthcare provider
todiscuss my healthinformation with my attorney,or a governmental agency, listedhere:
(Attorney/FirmName or GovernmentalAgency Name)
10. Reason forreleaseof infermaticñ: 11. Date or event on which thisauthorizationwill expire:
O At requestof individual
0 Other: Litigation Upon co-pktie of litigation
12. Ifnot the patient,name of personsigning form: 13. Authority to signon behalf of patient:
John D. Pontisakos Power of Attorney
All items on thisf have been cc pletedand my questions about thisform have been answered. In addition,I havebeen pr0vided a
copy of e
Date: /f /Ÿ
Signatureof ati nt orrepresentativeauthorized by law.
* Human Virus thatcauses AIDS. The New York StatePublic Health Law protectsinfôrmatic= which could
!str:±feiency reseenab!y
identify•ameone as havingHIV symptoms orinfectianand infGrmatica a person'scontacts
regarding
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NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019
OCA OfficialForm No.:960
. AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
* - [This form has been approved the New York State Department of
by Health]
PatientName Date of Birth SocialSecurity Number
JULISSA ESCANO September 25, 1998
PatientAddress
5005 8th Avenue, Apt 3F, Brooklyn, New York 11220 ____
I,or my authorized request
representative, thathealth information regarding my careand treatmcat be released on
as set forth thisform:
In accordance with New York StateLaw and the PrivacyRule ofthe Health Insurance and
Portability Accountabi!ity 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 initials
on
TREATMENT, psychotherapy notes, only my
the apprapriateline inItem 9(a). In the event thehealth information described below includes any of thesetypes of information, and I
initial
the lineon the box in Item 9(a),I specifically release
autliórize ofsuch information to theperson(s) indicatedin Item 8.
2. If 1 am 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 statelaw. I
understand thatI have the righttorequest a list
of people who may receiveor use my HIV-related informationwithout authorization. If
I experiencediscrimination because of the releaseor disclosureof HIV-related infarmatics, I may contact theNew 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 anytime by writingto thehealth care providerlistedbelow. I understand thatImay
revoke thisauthorization except tothe extentthat actionhas already been taken based on thisauthorization.
4. I understand thatsigning thisauthorization is voluntary. My treatment, payment, in
earciliiiciit a health plan, or for
eligibility
benefitswill not be conditionedupon my authorizationof thisdisclosure.
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 ofhealth provider orentity toreleasethisinformation:
Dr. Dov Berkowtiz, Advanced Orktepedics, PLLC, 89-02 Kew Gardens Road, 5th Floor, Kew Gardens, NY 11415
8. Name and addressof person(s) orcategory of person towhom thisinformation willbe sent:
LAW FIRM OF YANG & PARTNERS, 9 East Broadway, Suite 302, New York, New York 10038
9(a). Specificinformation to be released:
0 Medical Record from (insertdate) February 25, 2018 to(insertdate) Present
O EntireMedical Record, including patient office
histories, notes (except notes),
psyclictlierapy testresults,radialógystudies,films,
referrals,
consults,billingrecords, insurance records,and records sentto you by other healthcare praviders.
0 Other: Include bills,records, receipts, Include:(Indicate by Initialing)
diagnostic tests,MRI films,etc
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 health infürñiatianwith my or
attorney, a governmental agency, listedhere:
(Aiiunicy/Firm
Name or Geycmmcatal Agency Name)
10. Reason forreleaseof information: 11. Date or event on which thisauthorizationwill expire:
O At requestof individual
0 Other: Litigation Upon completion of litigatión
____
12. Ifnot the name
patient, of person signing form: 13. Authority to signon behalf of patient:
John D. Pontisakos Power of Attorney
Allitems on thisform e been completed and my questionsabout thisform have been answered. In eddition,I have been prevideda
copy of the fo . •
...---- Date:
Signature of patien presentativeauthorized by law.
* Human York could
!rr=‡ficiency Virus thatcauses AIDS. The New StatePublic Health Law protectsinfürmâ‡isa which reewy
identify as having
.......... HIV symptoms orEfecth and information regardinga person'scontacts.
6 of 21
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NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019
Power of Attorney
Fd Execute HIPAA Medical Record Authorization Forms Pursuant to NY Public
. IIealth Law §13(1)(g) As A mended October 26, 2004.
h appoint: PONTISAKOS & BRANDMAN, P.C, with offices at 600 Old Country Road,
reby
Silite 323, Garden City, New York I1530, my attomeys-in-fact to act (each agent may act
se arately) in my name, place and stead in any way which I myself could do, ifI were personally
pi ent to execute HIPAA medical authorization forms pursuant to NY Public Health Law
§l 8(1)(g) as amended October 26, 2004. This power of attomey may be revoked by me at any
tine. This Power of Attomey shall not be affected by my subsequent disability or incompetence.
To induce any third place to act hereunder, I hereby agree that any third party receiving a duly
e. ecuted copy or facsimile of this instrument may act hereunder, and that revocation or termination
he reof shall be ineffective as to such third party unless and untilactual notice or knowledge of such
róocation or termination shall have been received by such third party, and I formyself and for my
he its,executors, legal representatives agrees to and hold harmless
andassigns, hereby indemnify any
st ch third party frorn and against any and allclaims that may arise against such third pmty by reason
o such third party having relied on the provisions of this instrument.
G Witness Whereof I have hereunto signed name this 9-7 of PbrcF 20 )1
my day
o Ram
ACKNOWLEDGMENT
S FATE OF NEW YORK
C OUNTY OF NASSAU
n this 17 of R 20 13before me the appeared
day bCeÇ , undersigned, personally
4 L9 , personally known to be or proved to me on the basis of satisfactory evidence
A Et>coe
be the individual whose name issubscribed to the within instrument and acknowledged to me that
t,
she/he executed the same in her/his capacity, and that by her/his signature on the instrurnent, the
ipdividual, or the person who acted on behalfof the individual, executed the instrument and that such
individual made such ap arance before the undersigned at Garden City, New York.
iOT. RY PUBL[C
Notary ublicta e o
No. 01DR 6219440
co E pi
w2- .
7 of 21
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NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019
Surgit.ore
Surgicore Surgical Center of Jersey City
550 Newark Avenue 5th Floor
Jersey City, NJ 07306 Tel 201-795-0205
OPERATIVE REPORT
Patient Name: Cardozo, Belkis
MRN #: 3021866
Date of Birth: August 07, 1976
Date of Operation: March 27, 2019
Surgeon: Dov Berkowitz, M.D.
Assistant: Sadyk Fayzulayev, P.A.
Preoperative Diagnosis: Tearing of the rotator cuff of the left shoulder.
Postoperative Diagnosis: Left Shoulder; tearing of the rotator cuff infraspinatus and
supraspinatus junction and subscapularis tendon, SLAP
tearing of the superior labrum, extensive hypertrophic
synovitis, multiple adhesions, significant hyperemic
bursitis, thickened CA ligament.
Operations: 1. Arthroscopy of the leftshoulder.
2. Extensive Synovectomy.
3. Extensive Bursectomy.
4. Lysis of thickened coracoacromial ligament.
5. Intra articular debridement rotator cuff and
SLAP tears.
6. Lysis of multiple adhesions subacromial compartment.
Anesthesia: MAC with sedation plus post op pain management with
interscalene block.
Anesthesiologist:
DESCRIPTION OF PROCEDURE:
The patisñt was placed under MAC sedation in a beach chair position. The leftshoulder was
preppêd and draped in normal sterile manner. A posterior portal was made for access of the
scope and cannula. Upon entering the joint, examination was begun. There was extensive
hypsitrophic syñovitis throughout the joint. There were no loose bodies seen. The articular
suifaces were smooth. The biceps was intact. There was a superior SLAP tear, partial
thickness. The rotator cuff subscapularis tendon had a partial thickness tearing superiorly and
the supraspiñatus and infraspinatus junction had a partial thickness tearing as well. At this point,
an anterior rotator interval portal was developed through which we placed a shaver to perform
an extensive synovectomy to address the extensive, thickened hypsitrophic synovitis
March 27,2019 Page
N 0327-036 9401 2019 00
8 of 21
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NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019
Surgi(.ore
Surgicore Surgical Center of Jersey City
550 Newark Avenue 5th Floor
Jersey City, NJ 07306 Tel 201-795-0205
encountered both anteriorly and posteriorly within the gisachumeral compartment. Once this
was accomplished, a thorough intra articular debridement of the superior SLAP tearing was
performed, down to a smooth and stable rim. This was fclicwed by a thorough debridement of
the ictatci cuff subscapularis tendon tearing, down to a smooth and stable surface; followed by
a thorough debridsmsat of the rotator cuff supraspinatus and infraspinatus junction tearing,
down to a smooth and stable surface. Hemostasis was then achieved. We then advañced the
scope into the subacromial compartment, where significant hyperemic bursitis was seen and
multip!e adhesions were restricting the mobility of the rotator cuff. Through an antericr portal, we
placed the shaver to perform an extensive bursectomy removing the significant hyperemic
bursitis encountered within the subacromial space. Once this was accomplished, a lysis of
multiple adhesions was performed, extending from anterior to posterior a!|0wing greater mobility
of the rotator cuff. This was followed by a lysis of a thickened coraccacr0mial ligament
attachmênt to the undersurface of the acromion preserving itsmedial attachment. Hemostasis
was then achieved, no significant bleeding was seen, Marcaine was injected and 3-0 nylon was
used to close the eritrance portals. Dry sterile dressing was applied.
Dov Berkowitz, M.D.
Patient Name: Cardozo, BelkIs
Page #2
March 27,2019
N 0327-035 9401 2019 00
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FILED: KINGS COUNTY CLERK 04/17/2019 11:01 AM INDEX NO. 521833/2018
NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019
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 Date of Birth SocialSecurity Number
JULISSA ESCANO September 25, 1998
PatientAddress
5005 8th Avenue, Apt 3F, Brooklyn, New York 11220
I,or my authorized representative,requestthathealth information regarding my careand treatment be releasedas set forth
on thisform:
In accordance with New York StateLaw and the Privacy Rule ofthe Health Insurance and
Peitability 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, psychothempy notes, only my
the appropriateline inItem 9(a). In the event thehealth information described below includes any of thesetypes of infemation, and I
initial
the lineon the box in Item 9(a),I specifically
authorizereleaseof such information to theperson(s) indicatedinItem 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 statelaw. I
understand thatI have the rightto requesta list
of people who may receive or usemy HIV-related informaticñ without authorization. If
I experience discrimination because of the releaseor disclosureof HIV-related information, I may contactthe 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 theright torevoke thisauthorization at anytime by writing to thehealth careprovider listedbelow. I understand thatI may
revoke thisauthorization except tothe extentthataction has alreadybeen takenbased on thisauthorization.
4. I understand thatsigning thisauthorization is voluntary. My treatment, payment, enrollment in a health plan,or eligibilityfor
benefitswillnot be conditioned upon my authorizationof thisdisclosure.
5. Infemation 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 ofhealth provider orentityto releasethisinformation:
Surgicore Surgical Center of Jersey City, 550 Newark Avenue, 5th Floor, Jersey City, New Jersey 07306
8. Name and address ofperson(s) orcategory of person towhom thisinformation willbe sent:
HOFFMAN ROTH & MATLIN, LLP, 505 Eighth Avenue, Suite 1704, New York, New York 10018
9(a). Specificinformation to be released:
O Medical Record from (insertdate) March 27, 2019 to (insertdate) Present
O EntireMedical Record, includingpatient office
histories, notes (exceptpsych0therapy notes),testresults,
radiologystudies,films,
referrals,
consults,billingrecords, insuance records,and records sent to youby other healthcare providers.
9 Other: Include bills,records, receipts, Include:(Indicateby initialing)
diagnostic tests,MRI films, etc
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 or
attorney, a gvmmuoutal agency, listedhere:
(Attorney/Firm
Name or Govem= al AgencyName)
10. Reason forreleaseof information: 11. Date or event on which thisauthorizationwillexpire:
O At requestof individual
9 Other: Litigation Upon completion of litigation
12. Ifnot the patient,name ofperson signing form: 13. Authorityto signon behalf of patient:
John D. Pontisakos Power of Attorney
Allitems on thisf -p!ctcd and my ÿüesticasabout thisform have been answered In addition,I havebeen pravideda
copy of the form
Date:
Signatureof p tentYr r resentativeauthorized by law.
* "
Human Scacy Virus thatcauses AIDS. The New York StatePublic Health Law protectsinformation which rea•e==My could
someone
identify as havingHIV syr-·±er: orinfectionand 2nformatio=regarding a person'seantae*9
10 of 21
FILED: KINGS COUNTY CLERK 04/17/2019 11:01 AM INDEX NO. 521833/2018
NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019
OCA OfficialForm No.:960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[Thisform has been sppr0ved by the New York State Department of Health]
PatientName Date of Birth Social SecurityNumber
JULISSA
Patient
ESCANO
Address
_ Sep‡ed,cr 25, 1998
5005 8th Avenue, Apt 3F, Brooklyn, New York 11220
I, ormy authorized represêñtative,requestthathealth information regarding my careand treatmcñt be releasedas set forth
on thisform:
In accordancewith New York StateLaw and the Privacy Rule of theHealth Insurance and
Portability Acceentability Act of 1996
(HIPAA), I understand that:
1. This authorizationmay include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifIplace initials
on
TREATMENT, psych0therapy notes, only my
the appropriate linein Item 9(a). In theevent the health information describedbelow includes any ofthese types ofinformation, and I
initial
the lineon the box inItem 9(a), I specifically
authorizereleaseof such infarmation tothe person(s) indicatedinItem 8.
2. If Iam authorizing the releaseof HIV-related, alcohol or drug treatmcñ:, or mental health treatment infermatics, the recipientis
prohibited from redisclosing such information without my authorization unless permitted to do so under federal or statelaw. I
understand thatI have the righttorequest a list
of people who may receive or use my HIV-related informatien without authorization. If
I experience discrimination because of the releaseor of
disclosure HIV-related infestics, I may contact theNew York StateDivision
of Human Rights at (212) 480-2493 or the New York City Commi=ion of Human Rights at (212) 306-7450. These agencies are
responsible for protectingmy rights.
3. I have the righttorevoke thisauthorizationatany time by writing to thehealth careprõvider listedbelow. I understandthat Imay
revoke thisauthorization except tothe extentthataction has alreadybeen takenbased on thisauthorization.
4. I understand thatsigning thisauthorization is voluntary. My treatment, payment, carollmcñt in a health plan,or eligi
Preview
FILED: KINGS COUNTY CLERK 04/17/2019 11:01 AM INDEX NO. 521833/2018 NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF KINGS ------------------------------------------------------ X JULISSA ESCANO, Index No.: 521833/18 Plaintiff, -against- SUPPLEMENTAL VERIFIED BILL OF PARTICULARS 5223 3 AVENUE LLC, BEST WORK INC., and MENDIETA CONSTRUCTION INC., Defendants. ------------------------ -------- ---------------------X Plaintiff, JULISSA ESCANO, by her attorneys, PONTISAKOS & BRANDMAN, P.C., set forth the following as and for her Supplemental Bill of Particulars in response to the demands of the defendants, 5223 3 AVENUE LLC, BEST WORK INC., and MENDIETA CONSTRUCTION INC., alleges as follows: MEDICAL INJURIES: As a result of defendant's negligence, plaintiff, JULISSA ESCANO, sustained the following supplemental personal injuries: - Tears of the rotator cuff infraspinatus and supraspinatus junction and subscapularis tendon, left shoulder; - SLAP tear of the superior left labrum, shoulder; - Extensive hypertrophic left synovitis, shoulder; - Multiple left adhesions, shoulder; - Significant hyperemic left bursitis, shoulder; - Thickened CA left ligament, shoulder; - The above injuries to plaintiff's leftshoulder required surgical intervention 1 of 21 FILED: KINGS COUNTY CLERK 04/17/2019 11:01 AM INDEX NO. 521833/2018 NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019 including: arthroscopy, synovectomy, bursectomy, lysis of thickened coracoacromial ligament, intra articular debridement rotator cuff and SLAP tears, lysis of multiple adhesions subacromial compartment. - The was performed Dov on March 2019 surgery by Berktowiz, M.D., 27, at the Surgicore Surgical Center of Jersey City. The above injuries involved the surrounding nerves, tendons, muscles, blood vessels, muscles, ligaments and connective tissue in and around the above set forth area. The above injuries are degenerative in nature and, within reasonable medical certainty, will worsen with the onset of inflammation and then arthritis and decreasing range of motion. Surgery and continued medical care and monitoring is needed. Upon information and belief, all of the above described injuries are permanent and progressive, except those of a superficial nature. A power of attorney along with HIPAA Compliant Authorizations to obtain the medical records of Dr. Dov Berkowtiz of Advanced Orthopedics, PC and Surgicore Surgical Center of Jersey City is annexed hereto along with a copy of the operative report dated March 27, 2019. Dated: Garden City, New York April 15, 2019 Yours etc., PONTISAKO BRANDMAN, P.C. By: J . Pontisakos Atto eys for Plaintiff 600 ld Country Road, Ste. 323 Garden City, NY 11530 (516) 683-8888 2 of 21 FILED: KINGS COUNTY CLERK 04/17/2019 11:01 AM INDEX NO. 521833/2018 NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019 To: HOFFMAN ROTH & MATLIN, LLP Attorneys For Defendant MENDIETA CONSTRUCTION INC. 8th 505 Avenue Suite 1704 New York, New York 10018 (212) 964-1890 File No.: 8179 LANDMAN CORSI BALLAINE & FORD P.C. Attorneys For Defendant BEST WORK INC. One Gateway Center 4th FlOOr Newark, New Jersey 07102 (973) 623-2700 LAW OFFICES OF YANG & PARTNERS Attorneys For Defendant 5223 3AVE LLC 9 East Broadway Suite 302 New York, New York 10038 (212) 608-3888 3 of 21 FILED: KINGS COUNTY CLERK 04/17/2019 11:01 AM INDEX NO. 521833/2018 NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019 VERIFICATION John D. Pontisakos, an attorney duly admitted to practice law before the courts of the State of New York, hereby affirms the truth of the following under the penalties of perjury: Affirmant is counsel to the plaintiff in the within action. Affirmant has read the foregoing SUPPLEMENTAL BILL OF PARTICULARS and knows the contents thereof. The same is true of Affirmant's own knowledge, except as to matters therein stated to be alleged upon information and belief, and as to those matters, Affirmant believes them to be true. This verification is made by Affirmant and not by the plaintiff as plaintiff does not reside within Nassau County, the county where Affirmant's office is located. The grounds of Affirmant's belief as to all matters not stated upon Affirmant's knowledge are as follows: records, reports, documents, papers, conversations with client(s) concerning the within matter, etc. Dated: Garden City, New York April 15, 2019 John . P ntYsakos 4 of 21 FILED: KINGS COUNTY CLERK 04/17/2019 11:01 AM INDEX NO. 521833/2018 NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019 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 SocialSecurity Number JULISSA ESCANO September 25, 1998 PatientAddress 5005 8th Avenue, Apt 3F, Brooklyn, New York 11220 I,or my authorized representative,request thathealthinformation regarding my careand treatmcat be releasedas set forth on thisform: In accordancewith New York StateLaw and the Privacy Rule of theHealth Insurance Pcitabilityand Accc tyAct of 1996 (HIPAA), I understandthat: 1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION if I place initials on TREATMENT, psychotherapy notes, only my the appropriateline inItem 9(a). In the event thehealth information described below includes any of thesetypes of information,and I initial the lineon the box in Item 9(a),I specifically authorizerelease ofsuch information to theperson(s) indicatedinItem 8. 2. If Iam authorizing the releaseof HIV-related, alcohol or drug treatment, or mental health treatment infarmatics, the recipientis prohibited from redisclosing such information without my authorization unless permitted to do so under federal or statelaw. I understand thatI have the righttorequest a list of people who may receiveor use my HIV-related informationwithout authorization. If I experience discriminaticñ because of the releaseor disclosureof HIV-relatedinf.x=don, I may contact theNew 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 protectingmy rights. 3. I have theright torevoke thisauthorizationat any time by writingto thehealth care providerlistedbelow. I understand thatI may revoke thisauthorizationexcept 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 cligibility 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 of healthprovider or entitytorelease thisinformation: Surgiccre Surgical Center of Jersey City, 550 Newark Avenue, 5th Floor, Jersey City, New Jersey 07306 8. Name and address ofperson(s) orcategory of person towhom thisinformation willbe sent: LAW FIRM OF YANG & PARTNERS, 9 East Breadway, Suite 302, New York, New York 10038 9(a). Specificinformation to be released: 2 Medical Record from (insertdate) March 27, 2019 to(insertdate) Present O EntireMedical Record, inc!eding patient office histories, notes (except psychotherapy notes),testresults,radiologystudies,films, referrals,consults,billingrecords, insurancerecords,and records sentto you by other healthcare providers. 0 Other: Include bills,records, receipts, Include: (Indicateby initialing) diagnostic tests,MRI films, etc Alcohol/Drug Treatment Mental Health Information Authorization to Discuss Health Information HIV-Related Information (b) O By here initialing I authorize Initials Name ofindividual healthcare provider todiscuss my healthinformation with my attorney,or a governmental agency, listedhere: (Attorney/FirmName or GovernmentalAgency Name) 10. Reason forreleaseof infermaticñ: 11. Date or event on which thisauthorizationwill expire: O At requestof individual 0 Other: Litigation Upon co-pktie of litigation 12. Ifnot the patient,name of personsigning form: 13. Authority to signon behalf of patient: John D. Pontisakos Power of Attorney All items on thisf have been cc pletedand my questions about thisform have been answered. In addition,I havebeen pr0vided a copy of e Date: /f /Ÿ Signatureof ati nt orrepresentativeauthorized by law. * Human Virus thatcauses AIDS. The New York StatePublic Health Law protectsinfôrmatic= which could !str:±feiency reseenab!y identify•ameone as havingHIV symptoms orinfectianand infGrmatica a person'scontacts regarding 5 of 21 FILED: KINGS COUNTY CLERK 04/17/2019 11:01 AM INDEX NO. 521833/2018 NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019 OCA OfficialForm No.:960 . AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA * - [This form has been approved the New York State Department of by Health] PatientName Date of Birth SocialSecurity Number JULISSA ESCANO September 25, 1998 PatientAddress 5005 8th Avenue, Apt 3F, Brooklyn, New York 11220 ____ I,or my authorized request representative, thathealth information regarding my careand treatmcat be released on as set forth thisform: In accordance with New York StateLaw and the PrivacyRule ofthe Health Insurance and Portability Accountabi!ity 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 initials on TREATMENT, psychotherapy notes, only my the apprapriateline inItem 9(a). In the event thehealth information described below includes any of thesetypes of information, and I initial the lineon the box in Item 9(a),I specifically release autliórize ofsuch information to theperson(s) indicatedin Item 8. 2. If 1 am 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 statelaw. I understand thatI have the righttorequest a list of people who may receiveor use my HIV-related informationwithout authorization. If I experiencediscrimination because of the releaseor disclosureof HIV-related infarmatics, I may contact theNew 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 anytime by writingto thehealth care providerlistedbelow. I understand thatImay revoke thisauthorization except tothe extentthat actionhas already been taken based on thisauthorization. 4. I understand thatsigning thisauthorization is voluntary. My treatment, payment, in earciliiiciit a health plan, or for eligibility benefitswill not be conditionedupon my authorizationof thisdisclosure. 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 ofhealth provider orentity toreleasethisinformation: Dr. Dov Berkowtiz, Advanced Orktepedics, PLLC, 89-02 Kew Gardens Road, 5th Floor, Kew Gardens, NY 11415 8. Name and addressof person(s) orcategory of person towhom thisinformation willbe sent: LAW FIRM OF YANG & PARTNERS, 9 East Broadway, Suite 302, New York, New York 10038 9(a). Specificinformation to be released: 0 Medical Record from (insertdate) February 25, 2018 to(insertdate) Present O EntireMedical Record, including patient office histories, notes (except notes), psyclictlierapy testresults,radialógystudies,films, referrals, consults,billingrecords, insurance records,and records sentto you by other healthcare praviders. 0 Other: Include bills,records, receipts, Include:(Indicate by Initialing) diagnostic tests,MRI films,etc 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 health infürñiatianwith my or attorney, a governmental agency, listedhere: (Aiiunicy/Firm Name or Geycmmcatal Agency Name) 10. Reason forreleaseof information: 11. Date or event on which thisauthorizationwill expire: O At requestof individual 0 Other: Litigation Upon completion of litigatión ____ 12. Ifnot the name patient, of person signing form: 13. Authority to signon behalf of patient: John D. Pontisakos Power of Attorney Allitems on thisform e been completed and my questionsabout thisform have been answered. In eddition,I have been prevideda copy of the fo . • ...---- Date: Signature of patien presentativeauthorized by law. * Human York could !rr=‡ficiency Virus thatcauses AIDS. The New StatePublic Health Law protectsinfürmâ‡isa which reewy identify as having .......... HIV symptoms orEfecth and information regardinga person'scontacts. 6 of 21 FILED: KINGS COUNTY CLERK 04/17/2019 11:01 AM INDEX NO. 521833/2018 NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019 Power of Attorney Fd Execute HIPAA Medical Record Authorization Forms Pursuant to NY Public . IIealth Law §13(1)(g) As A mended October 26, 2004. h appoint: PONTISAKOS & BRANDMAN, P.C, with offices at 600 Old Country Road, reby Silite 323, Garden City, New York I1530, my attomeys-in-fact to act (each agent may act se arately) in my name, place and stead in any way which I myself could do, ifI were personally pi ent to execute HIPAA medical authorization forms pursuant to NY Public Health Law §l 8(1)(g) as amended October 26, 2004. This power of attomey may be revoked by me at any tine. This Power of Attomey shall not be affected by my subsequent disability or incompetence. To induce any third place to act hereunder, I hereby agree that any third party receiving a duly e. ecuted copy or facsimile of this instrument may act hereunder, and that revocation or termination he reof shall be ineffective as to such third party unless and untilactual notice or knowledge of such róocation or termination shall have been received by such third party, and I formyself and for my he its,executors, legal representatives agrees to and hold harmless andassigns, hereby indemnify any st ch third party frorn and against any and allclaims that may arise against such third pmty by reason o such third party having relied on the provisions of this instrument. G Witness Whereof I have hereunto signed name this 9-7 of PbrcF 20 )1 my day o Ram ACKNOWLEDGMENT S FATE OF NEW YORK C OUNTY OF NASSAU n this 17 of R 20 13before me the appeared day bCeÇ , undersigned, personally 4 L9 , personally known to be or proved to me on the basis of satisfactory evidence A Et>coe be the individual whose name issubscribed to the within instrument and acknowledged to me that t, she/he executed the same in her/his capacity, and that by her/his signature on the instrurnent, the ipdividual, or the person who acted on behalfof the individual, executed the instrument and that such individual made such ap arance before the undersigned at Garden City, New York. iOT. RY PUBL[C Notary ublicta e o No. 01DR 6219440 co E pi w2- . 7 of 21 FILED: KINGS COUNTY CLERK 04/17/2019 11:01 AM INDEX NO. 521833/2018 NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019 Surgit.ore Surgicore Surgical Center of Jersey City 550 Newark Avenue 5th Floor Jersey City, NJ 07306 Tel 201-795-0205 OPERATIVE REPORT Patient Name: Cardozo, Belkis MRN #: 3021866 Date of Birth: August 07, 1976 Date of Operation: March 27, 2019 Surgeon: Dov Berkowitz, M.D. Assistant: Sadyk Fayzulayev, P.A. Preoperative Diagnosis: Tearing of the rotator cuff of the left shoulder. Postoperative Diagnosis: Left Shoulder; tearing of the rotator cuff infraspinatus and supraspinatus junction and subscapularis tendon, SLAP tearing of the superior labrum, extensive hypertrophic synovitis, multiple adhesions, significant hyperemic bursitis, thickened CA ligament. Operations: 1. Arthroscopy of the leftshoulder. 2. Extensive Synovectomy. 3. Extensive Bursectomy. 4. Lysis of thickened coracoacromial ligament. 5. Intra articular debridement rotator cuff and SLAP tears. 6. Lysis of multiple adhesions subacromial compartment. Anesthesia: MAC with sedation plus post op pain management with interscalene block. Anesthesiologist: DESCRIPTION OF PROCEDURE: The patisñt was placed under MAC sedation in a beach chair position. The leftshoulder was preppêd and draped in normal sterile manner. A posterior portal was made for access of the scope and cannula. Upon entering the joint, examination was begun. There was extensive hypsitrophic syñovitis throughout the joint. There were no loose bodies seen. The articular suifaces were smooth. The biceps was intact. There was a superior SLAP tear, partial thickness. The rotator cuff subscapularis tendon had a partial thickness tearing superiorly and the supraspiñatus and infraspinatus junction had a partial thickness tearing as well. At this point, an anterior rotator interval portal was developed through which we placed a shaver to perform an extensive synovectomy to address the extensive, thickened hypsitrophic synovitis March 27,2019 Page N 0327-036 9401 2019 00 8 of 21 FILED: KINGS COUNTY CLERK 04/17/2019 11:01 AM INDEX NO. 521833/2018 NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019 Surgi(.ore Surgicore Surgical Center of Jersey City 550 Newark Avenue 5th Floor Jersey City, NJ 07306 Tel 201-795-0205 encountered both anteriorly and posteriorly within the gisachumeral compartment. Once this was accomplished, a thorough intra articular debridement of the superior SLAP tearing was performed, down to a smooth and stable rim. This was fclicwed by a thorough debridement of the ictatci cuff subscapularis tendon tearing, down to a smooth and stable surface; followed by a thorough debridsmsat of the rotator cuff supraspinatus and infraspinatus junction tearing, down to a smooth and stable surface. Hemostasis was then achieved. We then advañced the scope into the subacromial compartment, where significant hyperemic bursitis was seen and multip!e adhesions were restricting the mobility of the rotator cuff. Through an antericr portal, we placed the shaver to perform an extensive bursectomy removing the significant hyperemic bursitis encountered within the subacromial space. Once this was accomplished, a lysis of multiple adhesions was performed, extending from anterior to posterior a!|0wing greater mobility of the rotator cuff. This was followed by a lysis of a thickened coraccacr0mial ligament attachmênt to the undersurface of the acromion preserving itsmedial attachment. Hemostasis was then achieved, no significant bleeding was seen, Marcaine was injected and 3-0 nylon was used to close the eritrance portals. Dry sterile dressing was applied. Dov Berkowitz, M.D. Patient Name: Cardozo, BelkIs Page #2 March 27,2019 N 0327-035 9401 2019 00 9 of 21 FILED: KINGS COUNTY CLERK 04/17/2019 11:01 AM INDEX NO. 521833/2018 NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019 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 Date of Birth SocialSecurity Number JULISSA ESCANO September 25, 1998 PatientAddress 5005 8th Avenue, Apt 3F, Brooklyn, New York 11220 I,or my authorized representative,requestthathealth information regarding my careand treatment be releasedas set forth on thisform: In accordance with New York StateLaw and the Privacy Rule ofthe Health Insurance and Peitability 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, psychothempy notes, only my the appropriateline inItem 9(a). In the event thehealth information described below includes any of thesetypes of infemation, and I initial the lineon the box in Item 9(a),I specifically authorizereleaseof such information to theperson(s) indicatedinItem 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 statelaw. I understand thatI have the rightto requesta list of people who may receive or usemy HIV-related informaticñ without authorization. If I experience discrimination because of the releaseor disclosureof HIV-related information, I may contactthe 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 theright torevoke thisauthorization at anytime by writing to thehealth careprovider listedbelow. I understand thatI may revoke thisauthorization except tothe extentthataction has alreadybeen takenbased on thisauthorization. 4. I understand thatsigning thisauthorization is voluntary. My treatment, payment, enrollment in a health plan,or eligibilityfor benefitswillnot be conditioned upon my authorizationof thisdisclosure. 5. Infemation 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 ofhealth provider orentityto releasethisinformation: Surgicore Surgical Center of Jersey City, 550 Newark Avenue, 5th Floor, Jersey City, New Jersey 07306 8. Name and address ofperson(s) orcategory of person towhom thisinformation willbe sent: HOFFMAN ROTH & MATLIN, LLP, 505 Eighth Avenue, Suite 1704, New York, New York 10018 9(a). Specificinformation to be released: O Medical Record from (insertdate) March 27, 2019 to (insertdate) Present O EntireMedical Record, includingpatient office histories, notes (exceptpsych0therapy notes),testresults, radiologystudies,films, referrals, consults,billingrecords, insuance records,and records sent to youby other healthcare providers. 9 Other: Include bills,records, receipts, Include:(Indicateby initialing) diagnostic tests,MRI films, etc 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 or attorney, a gvmmuoutal agency, listedhere: (Attorney/Firm Name or Govem= al AgencyName) 10. Reason forreleaseof information: 11. Date or event on which thisauthorizationwillexpire: O At requestof individual 9 Other: Litigation Upon completion of litigation 12. Ifnot the patient,name ofperson signing form: 13. Authorityto signon behalf of patient: John D. Pontisakos Power of Attorney Allitems on thisf -p!ctcd and my ÿüesticasabout thisform have been answered In addition,I havebeen pravideda copy of the form Date: Signatureof p tentYr r resentativeauthorized by law. * " Human Scacy Virus thatcauses AIDS. The New York StatePublic Health Law protectsinformation which rea•e==My could someone identify as havingHIV syr-·±er: orinfectionand 2nformatio=regarding a person'seantae*9 10 of 21 FILED: KINGS COUNTY CLERK 04/17/2019 11:01 AM INDEX NO. 521833/2018 NYSCEF DOC. NO. 26 RECEIVED NYSCEF: 04/17/2019 OCA OfficialForm No.:960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [Thisform has been sppr0ved by the New York State Department of Health] PatientName Date of Birth Social SecurityNumber JULISSA Patient ESCANO Address _ Sep‡ed,cr 25, 1998 5005 8th Avenue, Apt 3F, Brooklyn, New York 11220 I, ormy authorized represêñtative,requestthathealth information regarding my careand treatmcñt be releasedas set forth on thisform: In accordancewith New York StateLaw and the Privacy Rule of theHealth Insurance and Portability Acceentability Act of 1996 (HIPAA), I understand that: 1. This authorizationmay include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifIplace initials on TREATMENT, psych0therapy notes, only my the appropriate linein Item 9(a). In theevent the health information describedbelow includes any ofthese types ofinformation, and I initial the lineon the box inItem 9(a), I specifically authorizereleaseof such infarmation tothe person(s) indicatedinItem 8. 2. If Iam authorizing the releaseof HIV-related, alcohol or drug treatmcñ:, or mental health treatment infermatics, the recipientis prohibited from redisclosing such information without my authorization unless permitted to do so under federal or statelaw. I understand thatI have the righttorequest a list of people who may receive or use my HIV-related informatien without authorization. If I experience discrimination because of the releaseor of disclosure HIV-related infestics, I may contact theNew York StateDivision of Human Rights at (212) 480-2493 or the New York City Commi=ion of Human Rights at (212) 306-7450. These agencies are responsible for protectingmy rights. 3. I have the righttorevoke thisauthorizationatany time by writing to thehealth careprõvider listedbelow. I understandthat Imay revoke thisauthorization except tothe extentthataction has alreadybeen takenbased on thisauthorization. 4. I understand thatsigning thisauthorization is voluntary. My treatment, payment, carollmcñt in a health plan,or eligi