Preview
FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014
NYSCEF DOC. NO. 84 RECEIVED NYSCEF: 11/01/2022
EXHIBIT
D
FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014
NYSCEF DOC. NO. 84 RECEIVED NYSCEF: 11/01/2022
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF SUFFOLK
--------------------------------------------------X
LOGAN RYAN, an infant by his mother and natural
Index No. 63290/14
guardian, KRISTIN RYAN, and KRISTIN RYAN,
RESPONSE TO
mdividually'
COMBINED
Plaintiffs '
DEMANDS AND
RESPONSE TO
-against-
VARIOUS DISCOVERY
DMNDS
THREE VILLAGE CENTRAL SCHOOL DISTRICT
and DON CAPPABIANCA,
Defendants.
___________-----_----------------------X
Plaintiff, by his attorneys, DELL & DEAN, PLLC, as and for his responses to
Defendants'
Combined Demands, Demand Pursuant to Medicare/Medicaid Mandatory
Reporting Law, Demand for Production as to Prior and Subsequent Related Injuries and
Conditions, upon information and belief, hereby states the following:
RESPONSE TO COMBINED DEMAND
1. Upon information and belief, the following are witnesses to the incident:
" Daniel address unknown.
Catalina,
" Tyler address unknown.
Traujed,
" Jessie address unknown.
Jane,
" Juliana 8 Nathan Hale NY.
Wilson, Drive, Setauket,
" Alan Principal
Baum,
" Another name unknown.
Principal, male,
" School names and addresses unknown.
security guards,
" Numerous names unknown.
students,
2. Plaintiff is not in possession of any signed or unsigned statements in the
possession, custody or control of any party represented in this action and/or on
FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014
NYSCEF DOC. NO. 84 RECEIVED NYSCEF: 11/01/2022
whose behalf such statements were taken from defendants, or from any agent,
servant or employee of defendants, whether such statements were oral, written or
electronically recorded, irrespective or whether such statements have been
transcribed or reduced to written or typed form. Plaintiff reserves the right to
supplement the response to this demand upon completion of discovery.
3. Annexed hereto are duly executed HIPAA authorizations to the following medical
providers:
Deborah M. Weisbrot, M.D.
Stony Brook School of Medicine
Department of Psychiatry
Putnam Hall South Campus
101 Nicolls
Stony Brook, NY 11794
David Morgan, LCSW-R
215 Hallock Road, Suite 6A
Stony Brook, NY 11790
South Oaks Psychiatric Hospital
400 West Sunrise Highway
Amityville, NY 11701
John T. Mather Hospital - Adolescent Psychiatric
75 No. Country Road
Port Jefferson, NY 11777
Dr. Rhonda Burmeister
70 N. Country Road
Port Jefferson, NY 11777
Also annexed hereto is a copy of Dr. Burmeister's medical records.
4. Annexed hereto are eleven (11) color photographs.
5. Tax Returns - not applicable.
6. The plaintiff is not in possession of any accident report.
7. The name(s) of attorneys appearing in this action are listed at the end of this
FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014
NYSCEF DOC. NO. 84 RECEIVED NYSCEF: 11/01/2022
document.
8. Annexed hereto is a duly executed authorization to the following:
Three Village Central School District
100 Suffolk Avenue
Stony Brook, NY 11790
Workers' -
9. Compensation not applicable.
10. Employment record - not applicable.
11. At this time, the plaintiff reserves the right to call as an expert each and every
physician, physical therapist, and medical practitioner seen by the plaintiff for
whom we have supplied reports and authorizations to the defendants. The content
and qualifications of each expert are stated in their respective reports and records
and the content of their testimony will be based on the contents of such reports
and records. Any other experts which may be called by the plaintiff will be duly
noticed to defendants before trial.
11. Annexed hereto are duly executed authorizations to the following providers of
collateral source:
GHI
P.O. Box 3000
New York, NY 10016
Empire Blue Cross/Blue Shield
1 Liberty Street
New York, NY 10007
12. Plaintiff, LOGAN RYAN, demands judgment against the defendants on the first,
second, third, fourth and fifth causes of action in the amount of ONE MILLION
($1,000,000.00) DOLLARS, together with costs and disbursement of this action.
Plaintiff, KRISTIN RYAN, demands judgment against the defendants on the sixth
FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014
NYSCEF DOC. NO. 84 RECEIVED NYSCEF: 11/01/2022
cause of action in the amount of FIVE HUNDRED THOUSAND ($500,000.00)
DOLLARS , together with costs and disbursement of this action.
RESPONSE TO DEMAND PURSUANT TO
MEDICARE/MEDICAID MANDATORY REPORTING LAW
The infant plaintiff is not a recipient of Medicare or Medicaid.
RESPONSE TO DEMAND FOR PRODUCTION AS TO PRIOR
AND SUBSEOUENT RELATED INJURIES AND CONDITIONS
Annexed hereto is a duly executed HIPAA authorization to the following:
David Morgan, LCSW-R
215 Hallock Road, Suite 6A
Stony Brook, NY 11790
PLEASE TAKE NOTICE that Plaintiff reserves the right to serve further, supplemental
and/or amended responses up to the time of trial.
Dated: Garden City, New York
January 8, 2015
By: JO PH Ô DELL
DELL bEAN,PLE
Attorneys for Plaintiffs
1325 Franklin Avenue, Suite 120
Garden City, New York 11530
516-880-9700
TO: DEVITT SPELLMAN BARRETT, LLP
Attorneys for Defendants
50 Route 111, Suite 314
Smithtown, NY 11787
(631) 724-8833
FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014
NYSCEF DOC. NO. 84 RECEIVED
OCA NYSCEF:
OfficialForm 11/01/2022
No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO WPAA ,
[Thisform has been approved by the New York State Department of Health]
PatientName Date of Birth SocialSecurityNumber
LOGAN RYAN 5/29/97
. ... .. . . . ..
PatientAddress 21 Bobcat Lane,East Setauket,
NY 11733
I,or my authorized representative,request thathealthinformation regarding my careand treatment be releasedas set forthon thisform:
In accordance with New York StateLaw and the PrivacyRule of theHealth Insurance Portabilityand Accountability Act of 1996 (HIPAA), I
understand that:
1. This authorizationmay include disclosureof information relatingtoALCOHOL andDRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifIplace initials
on the
TREATMENT, psychotherapy notes, only my
appropriate linein Item 9(a).In the eventthe healthinformation described below includes any ofthese typesof information, and Iinitialthe
lineon the box in Item 9(a),I specifically
authorizerelease ofsuch information to the persons(s)indicated inItem 8.
2. IfI am authorizing the releaseofHIV related,alcohol ordrug treatment, ormental healthtreatment information,the recipientis prohibited
from redisclosing such information without my authorizationunlesspermitted to do so under federalor statelaw. I understand thatI have a
rightto requesta list
of people who may receive or use my HIV relatedinformation without authorization. IfI experience discrimination
because of therelease or disclosureofHIV-related information,I may contact theNew York StateDivision of Human Rights at (212)480-
2493 or theNew York CityCommission ofhuman rightsat (212)306-7450. These agencies are responsibleforprotecting my rights.
3. I havetheright to revokethisauthorization at anytime by writing tothe healthcare provider listedbelow. I understandthat I may revoke
thisauthorization except tothe extentthat actionhas alreadybeen taken based on this authorization.
4. I understandthatsigning thisauthorization is voluntary.My treatment,payment, enrollment ina healthplan, oreligibilityforbenefitswill
not be conditionedupon my authorization ofthis disclosure.
5. Information disclosed under thisauthorizationmight be redisclosed my the recipient(except as noted above inItem 2),and this
redisclosure may no longer be protectedby federalor statelaw.
6.THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE
WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of health provideror entitytoreleasethis information:
Dr. Deborah M. Weisbrot, Stony Brook School ofMedicine, Dept. Of Psychiatry, Putnam Hall South Campus, Stony Brook, NY 11794
8. Name and address of person(s)or category ofperson to whom thisinformation willbe sent:
Devitt Spellman Barrett,LLP, 50 Route 111, Smithtown, NY 11787
9(a). Specific information tobe released:
O Medical Record from
Entire Medical Record, includingpatient office
histories, notes (exceptpsychotherapy notes),testresults,radiology studies,
films, referrals,
consults,billingrecords,insurance records, and recordssentto you by other healthcare providers.
O Other: Include:(Indicateby Initialing)
cohol/Drug Treatment
/ lentalHealth Information
C HIV-Related Information
Authorization to Discuss Health Information
(b) O By here
initialing I authorize
Initials Name of individual
healthcare provider
to discuss my healthinformation with my or
attorney, a governmental agency, listedhere:
(Attorney/Firm Name or Governmental Agency Name)
10. Reason for releaseof information: 11. Date orevent on which thisauthorization willexpire:
O At request of individual
X Other: Legal Purpose Discontinuance, Dismissal or Settlement of Litigation
12. Ifnot thepatient,name of person signingform 13. Authority tosign on behalf ofpatient:
Kristin Ryan Mother and Natural Guardian ofLogan Ryan
All items on s form hav been ted and n)y- u stions aboutthis form have been answered. In I have
addition, been provided a copy
ofthef
Signatureof patientor represe ativeauthoriz fly law
*Human Immunodeficien Virus thatcauses AIDS. The New York Sate Public Health Law protects information which reasonably
could identifysomeone as having HIV symptoms or infectionand information regarding a person's contacts.
.
FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014
NYSCEF DOC. NO. 84 RECEIVED NYSCEF: 11/01/2022
OCA OfficialForm No.: 960
AUTlIORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
.. [Thisform has beeiiapproved by the New York State Department of Health]
PatientName Date of Birth SocialSecurityNumber
LOGAN RYAN 5/29/97
PatientAddress 21 Bobcat Lane, East
Setauket,NY 11733
I,or my authorized representative,requestthat healthinformation regarding my careand treatmentbe released as set forth
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 authorizationmay include disclosureof information relatingtoALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials
on the
TREATMENT, psychotherapy notes, only my
appropriate lineinItem 9(a).In theevent the healthinformation described below includes any ofthese types ofinformation, and I initial
the
lineon the box in Item 9(a), authorize
I specifically release ofsuch information to thepersons(s) indicatedin Item 8.
2. IfI am authorizing the releaseofHIV related,alcohol ordrug treatment,or mental healthtreatment information, therecipientis prohibited
from redisclosing such information without my authorization unlesspermitted todo so underfederal orstatelaw. I understandthatI have a
rightto requesta listofpeople who may receive or use my B1V relatedinformation without authorization. IfIexperience discrimination
because of therelease or disclosureofHIV-related information,I may contact the New York StateDivision of Human Rights at (212)480-
2493 or the New York CityCommission ofhuman rightsat (212)306-7450. These agencies are responsible forprotectingmy rights.
3. I havetheright torevoke thisauthorization at anytime by writing tothe healthcareprovider listedbelow. I understandthatI may revoke
thisauthorizationexcept to theextentthat action has alreadybeen taken based on thisauthorization.
4. I understandthatsigning thisauthorization is voluntary.
My treatment,payment, enrollment in a healthplan,or for
eligibility benefits will
not be conditionedupon my authorization ofthisdisclosure.
5. Information disclosed under thisauthorizationinightbe redisclosed my the recipient(exceptas noted above in Item 2),and this
redisclosure may no longer be protectedby federalor statelaw.
6.THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY BEALTH.INFORMATION OR MEDICAL CARE
WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of healthprovider or entityto releasethisinformation:
D
b/h/ 4 404 /W u suºR,
a' 5 I¼rtlow It S
BrooK( /W /n9
8. Name and address ofperson(s) or category of person towhom thisinformation will be sent:
hevirr Sntl~n Pwetwr so 0te itt, SaMmo, e
y
nWr 7
9(a). Specificinformation tobe released:
O Medical Record from
Entire Medical Record, including patienthistories,officenotes (exceptpsychotherapy notes),testresults,
radiology studies,
films,referrals,consults,billingrecords,insurance records,and records sent to youby otherhealth care providers.
O Other: clude: (Indicateby Initialing)
cohol/Drug Treatment
ental Health Information
L/ . HIV-Related Information
Authorization to Discuss Health Information
(b) O By here
initialing I authorize
Initials Name of individual
healthcare provider
to discussmy healthinformation with my attorney,or a governmental agency, listedhere:
(Attorney/Firm Name or Governmental Agency Name)
10. Reason forrelease ofinformation: 11. Dateor event on which thisauthorization willexpire:
O At requestof individual
X Other: Legal Purpose Discontinuance, Dismissal or Settlement of Litigation
12. Ifnot the patient,
name ofperson signing form: 13. Authorityto sign on behalfof patient:
Kristin Ryan Mother and Natural Guardian of Logan Ryan
111items on 's formhave been co p ted and my es ons about thisform have been answered. In addition,I havebeen provideda copy
of thefo .
r /( e d4d f . ) Date: O
Signiture of patientbr represe 'veauthoriZed
*Human Immunodeficienc irus thatcauses S. The New York Sate Public Health Law protects information which reasonably
could identifysomeone as having HIV symptoms or infection and information regarding a person's contacts.
FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014
NYSCEF DOC. NO. 84 RECEIVED NYSCEF: 11/01/2022
OCA Official Form No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA *
[This form has been approved by the New York State Department of Health]
PatientName Date of Birth SocialSecurityNumber
LOGAN RYAN 5/29/97
PatientAddress 21 BobcatLane, East Setauket, NY11733
I,or my authorized representative,request thathealth informationregarding my careand treatment be releasedas setforth on thisform:
In accordance with New York StateLaw and thePrivacy Rule of theHealth Insurance Portabilityand Accountability Act of 1996 (HIPAA), I
understand that:
1. This authorizationmay include disclosureof information relatingtoALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials
on the
TREATMENT, psychotherapy notes, only my
appropriate lineinItem 9(a).In the eventthe healthinformation described below includes any ofthese typesof information, and Iinitialthe
lineon the box in Item 9(a),Ispecificallyauthorizerelease ofsuch information to thepersons(s) indicated inItem 8.
2. IfI am authorizing therelease ofHIV related,alcohol or drugtreatment, ormental health treatment information,the recipientisprohibited
from redisclosing such information without my authorizationunlesspermitted to do so under federalor statelaw. I understand thatI have a
rightto requesta list
of people who may receiveor use my HIV relatedinformation without authorization.IfI experience discrimination
because of therelease or disclosureof HIV-related information,I may contact theNew York State Division ofHuman Rights at (212)480-
2493 or the New York City Commission of human rightsat(212) 306-7450. These agencies areresponsible forprotecting my rights.
3. I havetheright torevoke this authorizationat any timeby writing tothe healthcare provider listedbelow. I understandthat I may revoke
thisauthorization except tothe extentthat actionhas alreadybeen taken based on thisauthorization.
4. I understand thatsigning thisauthorization is voluntary.
My treatment,payment, enrollment ina healthplan, or for
eligibility benefits will
not be conditioned upon my authorization ofthisdisclosure.
5. Information disclosed under thisauthorization might be redisclosed my the recipient(except as notedabove inItem 2),and this
redisclosure may no longer be protected by 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 health provider or to
entity releasethisinformation:
South Oaks Hospital,400 West Sunrise Highway, Amityville,NY 11701 - f°SjCIATMC SS f
8. Name and address of person(s)or category ofperson to whom this information willbe sent:
Devitt Spellman Barrett,LLP, 50 Route 111, Smithtown, NY 11787
9(a).Specific information to be released:
O Medical Record from
Entire Medical Record, including patient office
histories, notes (except psychotherapy notes),testresults,
radiology studies,
films/referrals,consults,billingrecords, insurancerecords, and records sentto you by other healthcare providers.
O Other: clude:(Indicateby Initialing)
Alcohol/Drug Treatment
E.JIental Health Information
HIV-Related Information
Authorization to Discuss Health Information
(b) O By here
initialing I authorize
Initials Name ofindividualhealthcare provider
to discuss my healthinformation with my or
attorney, a governmental agency, listedhere:
(Attorney/Firm Name or Governmental Agency Name)
10. Reason forrelease ofinformation: 11. Date orevent on which thisauthorization willexpire:
O At requestof individual
X Other: Legal Purpose Discontinuance, Dismissal or Settlement of Litigation
12. Ifnot the name
patient, of person signingform: 13. Authority tosign on behalf ofpatient:
Kristin Ryan Mother and Natural Guardian of Logan Ryan
All items on s form have been co d and my tionsabout this form have been answered. In addition,I have been provided a copy
ofthe fo .
Date:
Si'gnature
of patientor repre'se ve authorized law
*Human Immunodeficienc irus that causes AIDS. The New York Sate Public Health Law protects information which reasonably
could identifysomeone as having HIV symptoms or infection and information regarding a person's contacts.
FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014
NYSCEF DOC. NO. 84 RECEIVED
OCA NYSCEF:
OfficialForm
11/01/2022
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 SocialSecurityNumber
LOGAN RYAN 5/29/97
PatientAddress 21 Bobcat Lane, NY
East Setauket, 11733
I,or my authorized representative,request thathealthinformation regarding my careand treatment be released as set forth
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 authorizationmay include disclosureof information relatingtoALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials
on the
TREATMENT, psychotherapy notes, only my
appropriate lineinItem 9(a).In the eventthe healthinformation described below includesany of these typesof information, and I initial
the
lineon the box in Item 9(a),I specifically
authorizerelease ofsuch informationto thepersons(s) indicated inItem 8.
2. IfI am authorizing therelease ofHIV related,alcohol ordrug treatment, ormental health treatment information, therecipientis prohibited
from redisclosing such information without my authorization unless permittedto do so under federalor statelaw. I understand thatI have a
rightto requesta list
of people who may receiveor usenly HIV relatedinformation without authorization. IfI experience discrimination
because of thereleaseor disclosure ofHIV-related information,I may contact theNew York State Division of Human Rights at (212)480-
2493 orthe New York City Commission ofhuman rightsat (212)306-7450. These agencies are responsiblefor protectingmy rights.
3. I havethe righttorevoke this authorizationat anytime by writing tothe healthcare provider listedbelow. I understandthatI may revoke
thisauthorization exceptto the extentthat actionhas alreadybeen takenbased on this authorization.
4. I understand thatsigning thisauthorizationis voluntary.My treatment,payment, enrollment ina healthplan, or for
eligibility benefits will
not be conditioned upon my authorizationof thisdisclosure.
5. Information disclosed under thisauthorization might be redisclosed my the recipient(exceptas noted above inItem 2), and this
redisclosure may no longer be protected by federalor statelaw.
6.THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE
WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address ofhealth provider or entity
to releasethisinformation:
John T. Mather Hospital, 75 North Country Road, PortJefferson,NY 11777 - AboleSQr qycü w yiC
8. Name and address ofperson(s) or category ofperson to whom this informationwillbe sent:
Devitt Spellman Barrett,LLP, 50 Route 111, Smithtown, NY 11787
9(a).Specific information to be released:
O Medical Record from
EntireMedical Record, including patient office
histories, notes (except psychotherapy notes),testresults,radiologystudies,
films, eferrals,
consults,billingrecords, insurancerecords, and records sent to youby other healthcare providers.
O Other: Include: (Indicate by Initialing)
Alcohol/Drug Treatment
Mental Health Information
HIV-Related Information
Authorization to Discuss Health Information
(b) O By here
initialing I authorize
Initials Name of individual
healthcare provider
to discussmy healthinformation with my attorney,or a governmental agency, listedhere:
(Attorney/Firm Name or Governmental Agency Name)
10. Reason forrelease ofinformation: 11. Date orevent on which thisauthorization willexpire:
O At requestof individual
X Other:Legal Purpose Discontinuance, Dismissal or Settlement of Litigation
..........
12. Ifnot the name
patient, of person signingform: 13. Authority tosign on behalf ofpatient:
Kristin Ryan Mother and Natural Guardian ofLogan Ryan
Allitems o hisform ha e been eted and estions about thisform have been answered. In addition,I havebeen provideda copy
Date:
Signature of pat(entorrepre n ativeauthori d by law
*Human Immunodeficie cy Virus that causes AIDS. The New York Sate Public Health Law protects information which reasonably
could identify someone as having HIV symptoms or infectionand information regarding a person's contacts.
FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014
NYSCEF DOC. NO. 84 RECEIVED NYSCEF: 11/01/2022
OCA OfficialForm No.: 960
1 "* AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[Thisform has been approved by the New York State Department of Health]
PatientName Date of Birth SocialSecurityNumber
LOGAN RYAN 5/29/97
PatientAddress 21 Bobcat Lane, East Setauket,
NY 11733
I,or my authorized representative,requestthat healthinformation regarding my careand treatmentbe released as set forth
on thisform:
In accordance with New York StateLaw and the PrivacyRule of theHealth Insurance Portabilityand Accountability Act of 1996 (HIPAA), I
understand that:
1. This authorization may include disclosureof information relatingtoALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place
TREATMENT, psychotherapy notes, only my initials
on the
appropriate lineinItem 9(a).In theevent the healthinformation described below includes any of thesetypes ofinformation, and I initial
the
lineon the box in Item 9(a), authorize
I specifically release ofsuch information to thepersons(s) indicatedin Item 8.
2. IfI am authorizing the releaseofHIV related,alcohol ordrug treatment, ormental health treatmentinformation, the recipientis prohibited
from redisclosing such information without my authorization unlesspermitted to do sounder federal orstatelaw. Iunderstand thatI have a
rightto requesta listofpeople who may receiveor use my HIV relatedinformation without authorization.If Iexperience discrimination
because of therelease or disclosue ofB1V-related information,I may contact theNew York StateDivision of Human Rights at (212)480-
2493 orthe New York CityCommission ofhuman rightsat (212)306-7450. These agenciesare responsible forprotectingmy rights.
3. I havetherightto revoke thisauthorization at anytime by writing tothe healthcare providerlistedbelow. I understand thatI may revoke
thisauthorizationexcept tothe extentthat action has alreadybeen taken based on thisauthorization.
4. I understandthatsigning thisauthorization is voluntary.My treatment,payment, enrollment in a healthplan,or for
eligibility benefits will
not be conditionedupon my authorizationof thisdisclosure.
5. Information disclosed under thisauthorizationmight be redisclosed my the recipient(exceptas noted above inItem 2), and this
redisclosure may no longer be protectedby federalor statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE
WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name healthprovider or entity
torelease thisinformation·
and address of
8. Name and address ofperson(s) or category ofperson to w thisinformation will be sent:
9(a). Specific information to be released:
Medical Record from 5
Entire Medical Record, including patienthistories,officenotes (exceptpsychotherapy notes),testresults,
radiology studies,
films,referrals,consults,billingrecords,insurance records,and records sentto you by otherhealth careproviders.
O Other: clude: (Indicateby Initialing)
. , cohol/Drug Treatment
entalHealth Information
HIV-Related Information
Authorization to Discuss Health Information
(b) O By here
initialing I authorize
Initials Name of individual
healthcare provider
to discussmy health informationwith my attorney,or a governmental agency, listedhere:
(Attorney/Firm Name or Governmental Agency Name)
10. Reason forrelease of information: 11. Date orevent on which thisauthorization willexpire:
O At request of individual
X Other: Legal Purpose Discontinuance, Dismissal or Settlement of Litigation
. .
12. Ifnot the patient,name ofperson signing form: 13. Authorityto sign on behalfof patient:
KristinRyan Mother and Natural Guardian of
Preview
FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014 NYSCEF DOC. NO. 84 RECEIVED NYSCEF: 11/01/2022 EXHIBIT D FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014 NYSCEF DOC. NO. 84 RECEIVED NYSCEF: 11/01/2022 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF SUFFOLK --------------------------------------------------X LOGAN RYAN, an infant by his mother and natural Index No. 63290/14 guardian, KRISTIN RYAN, and KRISTIN RYAN, RESPONSE TO mdividually' COMBINED Plaintiffs ' DEMANDS AND RESPONSE TO -against- VARIOUS DISCOVERY DMNDS THREE VILLAGE CENTRAL SCHOOL DISTRICT and DON CAPPABIANCA, Defendants. ___________-----_----------------------X Plaintiff, by his attorneys, DELL & DEAN, PLLC, as and for his responses to Defendants' Combined Demands, Demand Pursuant to Medicare/Medicaid Mandatory Reporting Law, Demand for Production as to Prior and Subsequent Related Injuries and Conditions, upon information and belief, hereby states the following: RESPONSE TO COMBINED DEMAND 1. Upon information and belief, the following are witnesses to the incident: " Daniel address unknown. Catalina, " Tyler address unknown. Traujed, " Jessie address unknown. Jane, " Juliana 8 Nathan Hale NY. Wilson, Drive, Setauket, " Alan Principal Baum, " Another name unknown. Principal, male, " School names and addresses unknown. security guards, " Numerous names unknown. students, 2. Plaintiff is not in possession of any signed or unsigned statements in the possession, custody or control of any party represented in this action and/or on FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014 NYSCEF DOC. NO. 84 RECEIVED NYSCEF: 11/01/2022 whose behalf such statements were taken from defendants, or from any agent, servant or employee of defendants, whether such statements were oral, written or electronically recorded, irrespective or whether such statements have been transcribed or reduced to written or typed form. Plaintiff reserves the right to supplement the response to this demand upon completion of discovery. 3. Annexed hereto are duly executed HIPAA authorizations to the following medical providers: Deborah M. Weisbrot, M.D. Stony Brook School of Medicine Department of Psychiatry Putnam Hall South Campus 101 Nicolls Stony Brook, NY 11794 David Morgan, LCSW-R 215 Hallock Road, Suite 6A Stony Brook, NY 11790 South Oaks Psychiatric Hospital 400 West Sunrise Highway Amityville, NY 11701 John T. Mather Hospital - Adolescent Psychiatric 75 No. Country Road Port Jefferson, NY 11777 Dr. Rhonda Burmeister 70 N. Country Road Port Jefferson, NY 11777 Also annexed hereto is a copy of Dr. Burmeister's medical records. 4. Annexed hereto are eleven (11) color photographs. 5. Tax Returns - not applicable. 6. The plaintiff is not in possession of any accident report. 7. The name(s) of attorneys appearing in this action are listed at the end of this FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014 NYSCEF DOC. NO. 84 RECEIVED NYSCEF: 11/01/2022 document. 8. Annexed hereto is a duly executed authorization to the following: Three Village Central School District 100 Suffolk Avenue Stony Brook, NY 11790 Workers' - 9. Compensation not applicable. 10. Employment record - not applicable. 11. At this time, the plaintiff reserves the right to call as an expert each and every physician, physical therapist, and medical practitioner seen by the plaintiff for whom we have supplied reports and authorizations to the defendants. The content and qualifications of each expert are stated in their respective reports and records and the content of their testimony will be based on the contents of such reports and records. Any other experts which may be called by the plaintiff will be duly noticed to defendants before trial. 11. Annexed hereto are duly executed authorizations to the following providers of collateral source: GHI P.O. Box 3000 New York, NY 10016 Empire Blue Cross/Blue Shield 1 Liberty Street New York, NY 10007 12. Plaintiff, LOGAN RYAN, demands judgment against the defendants on the first, second, third, fourth and fifth causes of action in the amount of ONE MILLION ($1,000,000.00) DOLLARS, together with costs and disbursement of this action. Plaintiff, KRISTIN RYAN, demands judgment against the defendants on the sixth FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014 NYSCEF DOC. NO. 84 RECEIVED NYSCEF: 11/01/2022 cause of action in the amount of FIVE HUNDRED THOUSAND ($500,000.00) DOLLARS , together with costs and disbursement of this action. RESPONSE TO DEMAND PURSUANT TO MEDICARE/MEDICAID MANDATORY REPORTING LAW The infant plaintiff is not a recipient of Medicare or Medicaid. RESPONSE TO DEMAND FOR PRODUCTION AS TO PRIOR AND SUBSEOUENT RELATED INJURIES AND CONDITIONS Annexed hereto is a duly executed HIPAA authorization to the following: David Morgan, LCSW-R 215 Hallock Road, Suite 6A Stony Brook, NY 11790 PLEASE TAKE NOTICE that Plaintiff reserves the right to serve further, supplemental and/or amended responses up to the time of trial. Dated: Garden City, New York January 8, 2015 By: JO PH Ô DELL DELL bEAN,PLE Attorneys for Plaintiffs 1325 Franklin Avenue, Suite 120 Garden City, New York 11530 516-880-9700 TO: DEVITT SPELLMAN BARRETT, LLP Attorneys for Defendants 50 Route 111, Suite 314 Smithtown, NY 11787 (631) 724-8833 FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014 NYSCEF DOC. NO. 84 RECEIVED OCA NYSCEF: OfficialForm 11/01/2022 No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO WPAA , [Thisform has been approved by the New York State Department of Health] PatientName Date of Birth SocialSecurityNumber LOGAN RYAN 5/29/97 . ... .. . . . .. PatientAddress 21 Bobcat Lane,East Setauket, NY 11733 I,or my authorized representative,request thathealthinformation regarding my careand treatment be releasedas set forthon thisform: In accordance with New York StateLaw and the PrivacyRule of theHealth Insurance Portabilityand Accountability Act of 1996 (HIPAA), I understand that: 1. This authorizationmay include disclosureof information relatingtoALCOHOL andDRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifIplace initials on the TREATMENT, psychotherapy notes, only my appropriate linein Item 9(a).In the eventthe healthinformation described below includes any ofthese typesof information, and Iinitialthe lineon the box in Item 9(a),I specifically authorizerelease ofsuch information to the persons(s)indicated inItem 8. 2. IfI am authorizing the releaseofHIV related,alcohol ordrug treatment, ormental healthtreatment information,the recipientis prohibited from redisclosing such information without my authorizationunlesspermitted to do so under federalor statelaw. I understand thatI have a rightto requesta list of people who may receive or use my HIV relatedinformation without authorization. IfI experience discrimination because of therelease or disclosureofHIV-related information,I may contact theNew York StateDivision of Human Rights at (212)480- 2493 or theNew York CityCommission ofhuman rightsat (212)306-7450. These agencies are responsibleforprotecting my rights. 3. I havetheright to revokethisauthorization at anytime by writing tothe healthcare provider listedbelow. I understandthat I may revoke thisauthorization except tothe extentthat actionhas alreadybeen taken based on this authorization. 4. I understandthatsigning thisauthorization is voluntary.My treatment,payment, enrollment ina healthplan, oreligibilityforbenefitswill not be conditionedupon my authorization ofthis disclosure. 5. Information disclosed under thisauthorizationmight be redisclosed my the recipient(except as noted above inItem 2),and this redisclosure may no longer be protectedby federalor statelaw. 6.THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address of health provideror entitytoreleasethis information: Dr. Deborah M. Weisbrot, Stony Brook School ofMedicine, Dept. Of Psychiatry, Putnam Hall South Campus, Stony Brook, NY 11794 8. Name and address of person(s)or category ofperson to whom thisinformation willbe sent: Devitt Spellman Barrett,LLP, 50 Route 111, Smithtown, NY 11787 9(a). Specific information tobe released: O Medical Record from Entire Medical Record, includingpatient office histories, notes (exceptpsychotherapy notes),testresults,radiology studies, films, referrals, consults,billingrecords,insurance records, and recordssentto you by other healthcare providers. O Other: Include:(Indicateby Initialing) cohol/Drug Treatment / lentalHealth Information C HIV-Related Information Authorization to Discuss Health Information (b) O By here initialing I authorize Initials Name of individual healthcare provider to discuss my healthinformation with my or attorney, a governmental agency, listedhere: (Attorney/Firm Name or Governmental Agency Name) 10. Reason for releaseof information: 11. Date orevent on which thisauthorization willexpire: O At request of individual X Other: Legal Purpose Discontinuance, Dismissal or Settlement of Litigation 12. Ifnot thepatient,name of person signingform 13. Authority tosign on behalf ofpatient: Kristin Ryan Mother and Natural Guardian ofLogan Ryan All items on s form hav been ted and n)y- u stions aboutthis form have been answered. In I have addition, been provided a copy ofthef Signatureof patientor represe ativeauthoriz fly law *Human Immunodeficien Virus thatcauses AIDS. The New York Sate Public Health Law protects information which reasonably could identifysomeone as having HIV symptoms or infectionand information regarding a person's contacts. . FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014 NYSCEF DOC. NO. 84 RECEIVED NYSCEF: 11/01/2022 OCA OfficialForm No.: 960 AUTlIORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA .. [Thisform has beeiiapproved by the New York State Department of Health] PatientName Date of Birth SocialSecurityNumber LOGAN RYAN 5/29/97 PatientAddress 21 Bobcat Lane, East Setauket,NY 11733 I,or my authorized representative,requestthat healthinformation regarding my careand treatmentbe released as set forth 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 authorizationmay include disclosureof information relatingtoALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials on the TREATMENT, psychotherapy notes, only my appropriate lineinItem 9(a).In theevent the healthinformation described below includes any ofthese types ofinformation, and I initial the lineon the box in Item 9(a), authorize I specifically release ofsuch information to thepersons(s) indicatedin Item 8. 2. IfI am authorizing the releaseofHIV related,alcohol ordrug treatment,or mental healthtreatment information, therecipientis prohibited from redisclosing such information without my authorization unlesspermitted todo so underfederal orstatelaw. I understandthatI have a rightto requesta listofpeople who may receive or use my B1V relatedinformation without authorization. IfIexperience discrimination because of therelease or disclosureofHIV-related information,I may contact the New York StateDivision of Human Rights at (212)480- 2493 or the New York CityCommission ofhuman rightsat (212)306-7450. These agencies are responsible forprotectingmy rights. 3. I havetheright torevoke thisauthorization at anytime by writing tothe healthcareprovider listedbelow. I understandthatI may revoke thisauthorizationexcept to theextentthat action has alreadybeen taken based on thisauthorization. 4. I understandthatsigning thisauthorization is voluntary. My treatment,payment, enrollment in a healthplan,or for eligibility benefits will not be conditionedupon my authorization ofthisdisclosure. 5. Information disclosed under thisauthorizationinightbe redisclosed my the recipient(exceptas noted above in Item 2),and this redisclosure may no longer be protectedby federalor statelaw. 6.THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY BEALTH.INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address of healthprovider or entityto releasethisinformation: D b/h/ 4 404 /W u suºR, a' 5 I¼rtlow It S BrooK( /W /n9 8. Name and address ofperson(s) or category of person towhom thisinformation will be sent: hevirr Sntl~n Pwetwr so 0te itt, SaMmo, e y nWr 7 9(a). Specificinformation tobe released: O Medical Record from Entire Medical Record, including patienthistories,officenotes (exceptpsychotherapy notes),testresults, radiology studies, films,referrals,consults,billingrecords,insurance records,and records sent to youby otherhealth care providers. O Other: clude: (Indicateby Initialing) cohol/Drug Treatment ental Health Information L/ . HIV-Related Information Authorization to Discuss Health Information (b) O By here initialing I authorize Initials Name of individual healthcare provider to discussmy healthinformation with my attorney,or a governmental agency, listedhere: (Attorney/Firm Name or Governmental Agency Name) 10. Reason forrelease ofinformation: 11. Dateor event on which thisauthorization willexpire: O At requestof individual X Other: Legal Purpose Discontinuance, Dismissal or Settlement of Litigation 12. Ifnot the patient, name ofperson signing form: 13. Authorityto sign on behalfof patient: Kristin Ryan Mother and Natural Guardian of Logan Ryan 111items on 's formhave been co p ted and my es ons about thisform have been answered. In addition,I havebeen provideda copy of thefo . r /( e d4d f . ) Date: O Signiture of patientbr represe 'veauthoriZed *Human Immunodeficienc irus thatcauses S. The New York Sate Public Health Law protects information which reasonably could identifysomeone as having HIV symptoms or infection and information regarding a person's contacts. FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014 NYSCEF DOC. NO. 84 RECEIVED NYSCEF: 11/01/2022 OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA * [This form has been approved by the New York State Department of Health] PatientName Date of Birth SocialSecurityNumber LOGAN RYAN 5/29/97 PatientAddress 21 BobcatLane, East Setauket, NY11733 I,or my authorized representative,request thathealth informationregarding my careand treatment be releasedas setforth on thisform: In accordance with New York StateLaw and thePrivacy Rule of theHealth Insurance Portabilityand Accountability Act of 1996 (HIPAA), I understand that: 1. This authorizationmay include disclosureof information relatingtoALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials on the TREATMENT, psychotherapy notes, only my appropriate lineinItem 9(a).In the eventthe healthinformation described below includes any ofthese typesof information, and Iinitialthe lineon the box in Item 9(a),Ispecificallyauthorizerelease ofsuch information to thepersons(s) indicated inItem 8. 2. IfI am authorizing therelease ofHIV related,alcohol or drugtreatment, ormental health treatment information,the recipientisprohibited from redisclosing such information without my authorizationunlesspermitted to do so under federalor statelaw. I understand thatI have a rightto requesta list of people who may receiveor use my HIV relatedinformation without authorization.IfI experience discrimination because of therelease or disclosureof HIV-related information,I may contact theNew York State Division ofHuman Rights at (212)480- 2493 or the New York City Commission of human rightsat(212) 306-7450. These agencies areresponsible forprotecting my rights. 3. I havetheright torevoke this authorizationat any timeby writing tothe healthcare provider listedbelow. I understandthat I may revoke thisauthorization except tothe extentthat actionhas alreadybeen taken based on thisauthorization. 4. I understand thatsigning thisauthorization is voluntary. My treatment,payment, enrollment ina healthplan, or for eligibility benefits will not be conditioned upon my authorization ofthisdisclosure. 5. Information disclosed under thisauthorization might be redisclosed my the recipient(except as notedabove inItem 2),and this redisclosure may no longer be protected by 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 health provider or to entity releasethisinformation: South Oaks Hospital,400 West Sunrise Highway, Amityville,NY 11701 - f°SjCIATMC SS f 8. Name and address of person(s)or category ofperson to whom this information willbe sent: Devitt Spellman Barrett,LLP, 50 Route 111, Smithtown, NY 11787 9(a).Specific information to be released: O Medical Record from Entire Medical Record, including patient office histories, notes (except psychotherapy notes),testresults, radiology studies, films/referrals,consults,billingrecords, insurancerecords, and records sentto you by other healthcare providers. O Other: clude:(Indicateby Initialing) Alcohol/Drug Treatment E.JIental Health Information HIV-Related Information Authorization to Discuss Health Information (b) O By here initialing I authorize Initials Name ofindividualhealthcare provider to discuss my healthinformation with my or attorney, a governmental agency, listedhere: (Attorney/Firm Name or Governmental Agency Name) 10. Reason forrelease ofinformation: 11. Date orevent on which thisauthorization willexpire: O At requestof individual X Other: Legal Purpose Discontinuance, Dismissal or Settlement of Litigation 12. Ifnot the name patient, of person signingform: 13. Authority tosign on behalf ofpatient: Kristin Ryan Mother and Natural Guardian of Logan Ryan All items on s form have been co d and my tionsabout this form have been answered. In addition,I have been provided a copy ofthe fo . Date: Si'gnature of patientor repre'se ve authorized law *Human Immunodeficienc irus that causes AIDS. The New York Sate Public Health Law protects information which reasonably could identifysomeone as having HIV symptoms or infection and information regarding a person's contacts. FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014 NYSCEF DOC. NO. 84 RECEIVED OCA NYSCEF: OfficialForm 11/01/2022 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 SocialSecurityNumber LOGAN RYAN 5/29/97 PatientAddress 21 Bobcat Lane, NY East Setauket, 11733 I,or my authorized representative,request thathealthinformation regarding my careand treatment be released as set forth 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 authorizationmay include disclosureof information relatingtoALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials on the TREATMENT, psychotherapy notes, only my appropriate lineinItem 9(a).In the eventthe healthinformation described below includesany of these typesof information, and I initial the lineon the box in Item 9(a),I specifically authorizerelease ofsuch informationto thepersons(s) indicated inItem 8. 2. IfI am authorizing therelease ofHIV related,alcohol ordrug treatment, ormental health treatment information, therecipientis prohibited from redisclosing such information without my authorization unless permittedto do so under federalor statelaw. I understand thatI have a rightto requesta list of people who may receiveor usenly HIV relatedinformation without authorization. IfI experience discrimination because of thereleaseor disclosure ofHIV-related information,I may contact theNew York State Division of Human Rights at (212)480- 2493 orthe New York City Commission ofhuman rightsat (212)306-7450. These agencies are responsiblefor protectingmy rights. 3. I havethe righttorevoke this authorizationat anytime by writing tothe healthcare provider listedbelow. I understandthatI may revoke thisauthorization exceptto the extentthat actionhas alreadybeen takenbased on this authorization. 4. I understand thatsigning thisauthorizationis voluntary.My treatment,payment, enrollment ina healthplan, or for eligibility benefits will not be conditioned upon my authorizationof thisdisclosure. 5. Information disclosed under thisauthorization might be redisclosed my the recipient(exceptas noted above inItem 2), and this redisclosure may no longer be protected by federalor statelaw. 6.THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address ofhealth provider or entity to releasethisinformation: John T. Mather Hospital, 75 North Country Road, PortJefferson,NY 11777 - AboleSQr qycü w yiC 8. Name and address ofperson(s) or category ofperson to whom this informationwillbe sent: Devitt Spellman Barrett,LLP, 50 Route 111, Smithtown, NY 11787 9(a).Specific information to be released: O Medical Record from EntireMedical Record, including patient office histories, notes (except psychotherapy notes),testresults,radiologystudies, films, eferrals, consults,billingrecords, insurancerecords, and records sent to youby other healthcare providers. O Other: Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) O By here initialing I authorize Initials Name of individual healthcare provider to discussmy healthinformation with my attorney,or a governmental agency, listedhere: (Attorney/Firm Name or Governmental Agency Name) 10. Reason forrelease ofinformation: 11. Date orevent on which thisauthorization willexpire: O At requestof individual X Other:Legal Purpose Discontinuance, Dismissal or Settlement of Litigation .......... 12. Ifnot the name patient, of person signingform: 13. Authority tosign on behalf ofpatient: Kristin Ryan Mother and Natural Guardian ofLogan Ryan Allitems o hisform ha e been eted and estions about thisform have been answered. In addition,I havebeen provideda copy Date: Signature of pat(entorrepre n ativeauthori d by law *Human Immunodeficie cy Virus that causes AIDS. The New York Sate Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infectionand information regarding a person's contacts. FILED: SUFFOLK COUNTY CLERK 11/01/2022 03:27 PM INDEX NO. 063290/2014 NYSCEF DOC. NO. 84 RECEIVED NYSCEF: 11/01/2022 OCA OfficialForm No.: 960 1 "* AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [Thisform has been approved by the New York State Department of Health] PatientName Date of Birth SocialSecurityNumber LOGAN RYAN 5/29/97 PatientAddress 21 Bobcat Lane, East Setauket, NY 11733 I,or my authorized representative,requestthat healthinformation regarding my careand treatmentbe released as set forth on thisform: In accordance with New York StateLaw and the PrivacyRule of theHealth Insurance Portabilityand Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosureof information relatingtoALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place TREATMENT, psychotherapy notes, only my initials on the appropriate lineinItem 9(a).In theevent the healthinformation described below includes any of thesetypes ofinformation, and I initial the lineon the box in Item 9(a), authorize I specifically release ofsuch information to thepersons(s) indicatedin Item 8. 2. IfI am authorizing the releaseofHIV related,alcohol ordrug treatment, ormental health treatmentinformation, the recipientis prohibited from redisclosing such information without my authorization unlesspermitted to do sounder federal orstatelaw. Iunderstand thatI have a rightto requesta listofpeople who may receiveor use my HIV relatedinformation without authorization.If Iexperience discrimination because of therelease or disclosue ofB1V-related information,I may contact theNew York StateDivision of Human Rights at (212)480- 2493 orthe New York CityCommission ofhuman rightsat (212)306-7450. These agenciesare responsible forprotectingmy rights. 3. I havetherightto revoke thisauthorization at anytime by writing tothe healthcare providerlistedbelow. I understand thatI may revoke thisauthorizationexcept tothe extentthat action has alreadybeen taken based on thisauthorization. 4. I understandthatsigning thisauthorization is voluntary.My treatment,payment, enrollment in a healthplan,or for eligibility benefits will not be conditionedupon my authorizationof thisdisclosure. 5. Information disclosed under thisauthorizationmight be redisclosed my the recipient(exceptas noted above inItem 2), and this redisclosure may no longer be protectedby federalor statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name healthprovider or entity torelease thisinformation· and address of 8. Name and address ofperson(s) or category ofperson to w thisinformation will be sent: 9(a). Specific information to be released: Medical Record from 5 Entire Medical Record, including patienthistories,officenotes (exceptpsychotherapy notes),testresults, radiology studies, films,referrals,consults,billingrecords,insurance records,and records sentto you by otherhealth careproviders. O Other: clude: (Indicateby Initialing) . , cohol/Drug Treatment entalHealth Information HIV-Related Information Authorization to Discuss Health Information (b) O By here initialing I authorize Initials Name of individual healthcare provider to discussmy health informationwith my attorney,or a governmental agency, listedhere: (Attorney/Firm Name or Governmental Agency Name) 10. Reason forrelease of information: 11. Date orevent on which thisauthorization willexpire: O At request of individual X Other: Legal Purpose Discontinuance, Dismissal or Settlement of Litigation . . 12. Ifnot the patient,name ofperson signing form: 13. Authorityto sign on behalfof patient: KristinRyan Mother and Natural Guardian of