Preview
FILED: QUEENS COUNTY CLERK 09/27/2022 03:49 PM INDEX NO. 703721/2018
NYSCEF DOC. NO. 115 RECEIVED NYSCEF: 09/27/2022
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF QUEENS
___________________________________________________________________Ç
THALIA AGATHOCLEOUS, Index No.: 703721/2018
Plaintiff, JUDICIAL SUBPOENA
DUCES TECUM
-against- AD TESTIFICANDUM
795 FIFTH AVENUE CORPORATION d/b/a
THE PIERRE,and IHMS LLC, Deliver or Mail records to:
Queens County Supreme Court
Civil Term - Subpoenaed Records
Defendants. 88-11 Sutphin Blvd, Room 140A
Jamaica, New York 11435
___________--______________________________________________________Ç
To: Yu-Fan Zhang M.D.
281 Broadway
New York, New York 10007
GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of
you appear and attend before the Justice presiding at the Queens County Supreme Court, at
90'
88-11 Sutphin Blvd, Jamaica, New York on the day of February, 2023 at 9:30 o'clock in the
forenoon, and at any recessed or adjourned date to give testimony in this action on the part of the
Defendant, 795 FIFTH AVENUE CORPORATION and IHMS LLC, and that you bring with
you, forward, send, or produce before the time or at the time and place aforesaid,
1. CERTIFIED copy of all hospital records, medical records and
notes pertaining to the above-named patient/plaintiff, THALIA
AGATHOCLEOUS, but not limited to charts, x-rays and reports,
doctors'
temperature sheets, physical examinations, histories, progress notes,
nurses'
and notes, medication charts, memoranda, interdepartmental
memoranda, consultation requests and reports anesthesia records,
post-operative check lists, patient problem and care plan, operating room
records, out-patient referral for admission, and any other records you may
have. Please include all out-patient records and ambulance call records. Also,
including but not limited to any and all alcohol, drug, HIV and/or psychiatric
records you may have in your possession.
2. CERTIFIED copy of all x-rays, diagnostic tests, radiological
tests and reports and/or other original documents referable to any laboratory
tests or procedures and/or other diagnostic tests be maintained in their
1 of 7
FILED: QUEENS COUNTY CLERK 09/27/2022 03:49 PM INDEX NO. 703721/2018
NYSCEF DOC. NO. 115 RECEIVED NYSCEF: 09/27/2022
original form and not be reduced to microfilm, regarding the above-named
patient/plaintiff, THALIA AGATHOCLEOUS.
3. CERTIFIED copies of all billing records.
SSN: DOB: April 5, 1963 DOA: January 6, 2018
PLEASE TAKE NOTICE, THAT NO APPEARANCE IS NECESSARY SHOULD
A PROPER CERTIFICATION OF BUSINESS RECORDS, PURSUANT TO CPLR
§3122-a(c), BE PROVIDED ALONG WITH THE REQUESTED RECORDS.
PLEASE TAKE FURTHER NOTICE, that your failure to comply with this Subpoena
is punishable as a contempt of Court and shall make you liable to the person on whose behalf this
Subpoena was issued for a penalty not to exceed fifty dollars and all damages sustained by
reason of your failure to comply.
PLEASE TAKE FURTHER NOTICE, that pursuant to CPLR §3122(a), a medical
provider shall not provide a patient's medical records pursuant to a subpoena duces tecum & ad
testificandum unless the subpoena is accompanied by a written authorization by the patient.
ATTACHED HERETO PLEASE FIND DULLY EXECUTED HIPAA AUTHORIZATION
FORM.
PLEASE TAKE FURTHER NOTICE, that pursuant to CPLR §2301, all papers or
other items delivered to the court pursuant to such subpoena shall be accompanied by copy of
such subpoena.
Dated: Brooklyn, New York
September 27, 2022 Yours, etc.,
BY: GE ,O AK, ESQ.
McMAH ', MARTINE & GALLAGHER, LLP
Attorne s for Defendant
795 FI TH AVENUE CORPORATION
d/b/a THE PIERRE
55 Washington Street, 7th Floor
Brooklyn, New York 11201
(212) 747-1230
File No.: 553.0215
2 of 7
FILED: QUEENS COUNTY CLERK 09/27/2022 03:49 PM INDEX NO. 703721/2018
NYSCEF DOC. NO. 115 RECEIVED NYSCEF: 09/27/2022
.
TO: Yu-Fan Zhang M.D.
281 Broadway
New York, New York 10007
SACCO & FILLAS, LLP
Attorneys for Plaintiff
THALIA AGATHOCLEOUS
7*
31-19 Newtown Avenue, Floor
Astoria, New York 11102
(718) 746-3440
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FILED: QUEENS COUNTY CLERK 09/27/2022 03:49 PM INDEX NO. 703721/2018
NYSCEF DOC. NO. 115 OCA
RECEIVED OfficialForm
NYSCEF: No.: 960
09/27/2022
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York State Department of Health]
PatientName ThaliaAgathocleous Date ofBirth:04/05/1963 SocialSecurityNumber:
PatientAddress 110-29 55thAvenue NY
, Flushing, 1 1368
1, ormy authorized representative,request thathealth information regarding my care and treatment be released as setforthon thisform:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portabilityand Accountability Act of 1996
(HIPAA), I understand that:
1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION
TREATMENT, psychotherapy notes, only ifI placemy initials
on
the appropriate linein Item 9(a). in theevent the health information described below includes any of thesetypes of information, and I
initial
the line on thebox inItem 9(a),1 specificallyauthorizerelease ofsuch information tothe persons(s) indicated in Item 8.
2. If I am authorizing therelease of HIV related,alcohol or drug treatment,or mental healthtreatment information, therecipientis
prohibited from redisclosingsuch information without my authorization unless permitted to do so under federal orstatelaw. 1 understand
that Ihave a rightto requesta listofpeople who may receive oruse my HIV related information without authorization. If I experience
discrimination because of therelease or disclosure of HIV-related information, I may contact theNew York StateDivision of Human
Rights at (212) 480-2493 or theNew York CityCommission of human rights at(212)306-7450. These agencies are responsiblefor
protecting my rights.
3. I havethe rightto revoke thisauthorization atany time by writingto the healthcare provider listed below. I understand thatI may
revoke thisauthorization except tothe extent thataction has already been taken based on thisauthorization.
4. I understand that signing thisauthorization is voluntary.My treatment, payment, enrollment in a healthplan, or for
eligibility benefits
willnot be conditioned upon my authorization of thisdisclosure.
5. Information disclosed under thisauthorization might be redisclosedmy the recipient(except as noted above in Item2), and this
redisclosure may no longerbe protected by federalor state law.
6. THIS AUTHORIZATION DOES NOT AUTHOR1ZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7.Name and address of healthprovider or entityto releasethisinformation: Yu-Fan Zhang, M.D., 281 Broadway, New York, NY
10007
8. Name and address of person(s)or category of person to whom this information will be sent:ATTN: Subpoena Records Room,
Supreme Court, Queens County 88-11 Sutphin Boulevard Jamaica, NY 11435
9(a). S icinformation to be released:
edicalRecord from 1/6/2018 to PRESENT
O Entire Medical Record, including patienthistories,officenotes (except psychotherapy notes),test results,
radiology studies,
films,referrals,consults, billingrecords, insurance records,and records sent toyou by other healthcare providers.
Other: Inclu Indicate by Initiating)
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 discuss my healthinformation with my attorney,or a governmental agency, listed
here:
(Attorney/Firm Name or Governmental Agency Name)
10.Reason forrelease of information: 11. Date or event on which thisauthorization willexpire:
O At request of individual
E Other: Legal Matter UPON CONCLUSION OF THIS MATTER
12. Ifnot the name
patient, of person signing form: 13.Authority to sign on behalfof patient:
SACCO & F1 AS, LLP BY: Elliot L. Lewis, Esq. ATTORNEY-IN-FACT
Allitems on thi ave bee mpleted and my questions about thisform have been answered. In addition, I have been provided a
copy of thefo
Date:_Jan 21, 2020
Signature of patientor representative authorized by law
*Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which
reasonably could identify someone as having HIV symptoms or infection and information regarding a person's contacts.
4 of 7
FILED: QUEENS COUNTY CLERK 09/27/2022 03:49 PM INDEX NO. 703721/2018
NYSCEF DOC. NO. 115 RECEIVED NYSCEF: 09/27/2022
Power of Attorney
To Execute HIPAA Medical Record Authorization Forms Pursuant to NY Public
Health Law § 18(1)(G) As Amended 10/26/04.
I, H A-f A &&A Å O C... e OUS
or / /0
-
5\ 7
ST 4 A-u e , a ê_ Fiahinr, A/
y /G( 7
(insert your name and address)
do /sereby appoint: SACCO & FILLAS, LLP, their attorneys, employees and agents
with offices at 31-19 NEWTOWN AVENUE3 SEVENTH FLOOR, ASTORIArNEW
YORK 11102, my attorneys-in-fact to act (each agent may act separately) in my name,
place, and stead in any way which I myself could do, if Iwere personally present to
execute HIPAA medical records authorization forms pursuant to NY Public Health
Law § 18(1)(G) as amended 10/26/04. This power of attorney may be revoked by me at
any time. This Power of Attorney shallnot be affected by my subsequent disability or
incompetence.
To induce any thirdparty to act hereunder, I hereby agree that any third party receiving a
duly executed copy or facsimile of this instrument may act hereunder, and thatrevocation
or termination hereof shall be ineffective as to such third party unless and until actual
notice or knowledge of such revocation or termination shall have been received by such
third party, and I for myself and for my heirs, executors, legal representatives and
assigns, hereby agree to indemnify and hold harmless any such third party from and
against any and all claims that may arise against such third party by reason of such third
party having relied on the provisions of this instrument.
In Witness Whereof I have hereunto signed my name this day of , 20Ó
(NIGNATURE)
Acknowledgement
STATE OF NEW YORK
COUNTY OF QUEENS
On this day of , 20 efore me the undersigned, personally appeared
, personallyknown tobe or proved tome on the basis of
satisfactoryevidence to be theindividual whose name is subscribed to thewithin instrument and
acknowledged to me that he executed the same inhis capacity,.and thatby hissignature on the
instrument, theindividual, orthe person who acted on behalf of theindividual, executed the
instrument and that such individual made such appearance before the undersigned at Queens,
w York.
No REGINA M sZMUC
Natary Public - State of New York
.3 NO. 01 SZ6342939
Qualified in Oueens County
.ty Commission
Expiras May 31. 2020
5 of 7
FILED: QUEENS COUNTY CLERK 09/27/2022 03:49 PM INDEX NO. 703721/2018
NYSCEF DOC. NO. 115 RECEIVED NYSCEF: 09/27/2022
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF QUEENS
____________________________________________________________________Ç
THALIA AGATHOCLEOUS, Index No.: 703721/2018
Plaintiff,
-against-
AFFIDAVIT OF BUSINESS
795 FIFTH AVENUE CORPORATION d/b/a RECORDS CERTIFICATION
THE PIERRE, and IHMS LLC
Defendants.
________________________________________________..____________________Ç
PLEASE EXECUTE THE FOLLOWING AFFDAVIT IN FRONT OF A NOTARY PUBLIC
AND FORWARD BACK TO OUR OFFICE LOCATED AT 55 WASHINGTON STREET,
SUITE 720, BROOKLYN, NY 11201. SHOULD YOU HAVE ANY QUESTION PLEASE
CONTACT US AT (212) 747-1230.
STATEOF )
) ss.:
COUNTY OF )
I, , having been duly sworn, state that the following
matters are true upon my knowledge.
1. I have received the Subpoena Duces Tecum & Ad Testificandum of the
Defendant dated September 27, 2022, directed to Yu-Fan Zhang M.D., I make this affidavit
pursuant to CPLR §3122 a-(c) to accompany the business records produced in response to said
Subpoena. I am the duly authorized custodian or other qualified witness and have the authority to
make this certification.
2. To the best of my knowledge, after reasonable inquiry, the records or
copies thereof are accurate versions of the documents described in the Subpoena that are in my
possession, custody, or control.
3. To the best of my knowledge, after reasonable inquiry, the records or
copies produced represent all the documents described in the Subpoena, or if they do not
6 of 7
FILED: QUEENS COUNTY CLERK 09/27/2022 03:49 PM INDEX NO. 703721/2018
NYSCEF DOC. NO. 115 RECEIVED NYSCEF: 09/27/2022
represent a complete set of the documents subpoenaed, an explanation of which documents are
missing and a reason for their absence is provided.
4. The records or copies produced were made by the personnel or staff of the
business, or persons acting under my control, in regular course of business, at the time of the act,
transaction, occurrence, or event recorded therein, or within a reasonable time thereafter, and that
itwas the regular course of business to make such records.
PRINT NAME:
PRINT TITLE:
Sworn to me on this
day of , 2022
NOTARY PUBLIC
7 of 7
Preview
FILED: QUEENS COUNTY CLERK 09/27/2022 03:49 PM INDEX NO. 703721/2018 NYSCEF DOC. NO. 115 RECEIVED NYSCEF: 09/27/2022 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF QUEENS ___________________________________________________________________Ç THALIA AGATHOCLEOUS, Index No.: 703721/2018 Plaintiff, JUDICIAL SUBPOENA DUCES TECUM -against- AD TESTIFICANDUM 795 FIFTH AVENUE CORPORATION d/b/a THE PIERRE,and IHMS LLC, Deliver or Mail records to: Queens County Supreme Court Civil Term - Subpoenaed Records Defendants. 88-11 Sutphin Blvd, Room 140A Jamaica, New York 11435 ___________--______________________________________________________Ç To: Yu-Fan Zhang M.D. 281 Broadway New York, New York 10007 GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you appear and attend before the Justice presiding at the Queens County Supreme Court, at 90' 88-11 Sutphin Blvd, Jamaica, New York on the day of February, 2023 at 9:30 o'clock in the forenoon, and at any recessed or adjourned date to give testimony in this action on the part of the Defendant, 795 FIFTH AVENUE CORPORATION and IHMS LLC, and that you bring with you, forward, send, or produce before the time or at the time and place aforesaid, 1. CERTIFIED copy of all hospital records, medical records and notes pertaining to the above-named patient/plaintiff, THALIA AGATHOCLEOUS, but not limited to charts, x-rays and reports, doctors' temperature sheets, physical examinations, histories, progress notes, nurses' and notes, medication charts, memoranda, interdepartmental memoranda, consultation requests and reports anesthesia records, post-operative check lists, patient problem and care plan, operating room records, out-patient referral for admission, and any other records you may have. Please include all out-patient records and ambulance call records. Also, including but not limited to any and all alcohol, drug, HIV and/or psychiatric records you may have in your possession. 2. CERTIFIED copy of all x-rays, diagnostic tests, radiological tests and reports and/or other original documents referable to any laboratory tests or procedures and/or other diagnostic tests be maintained in their 1 of 7 FILED: QUEENS COUNTY CLERK 09/27/2022 03:49 PM INDEX NO. 703721/2018 NYSCEF DOC. NO. 115 RECEIVED NYSCEF: 09/27/2022 original form and not be reduced to microfilm, regarding the above-named patient/plaintiff, THALIA AGATHOCLEOUS. 3. CERTIFIED copies of all billing records. SSN: DOB: April 5, 1963 DOA: January 6, 2018 PLEASE TAKE NOTICE, THAT NO APPEARANCE IS NECESSARY SHOULD A PROPER CERTIFICATION OF BUSINESS RECORDS, PURSUANT TO CPLR §3122-a(c), BE PROVIDED ALONG WITH THE REQUESTED RECORDS. PLEASE TAKE FURTHER NOTICE, that your failure to comply with this Subpoena is punishable as a contempt of Court and shall make you liable to the person on whose behalf this Subpoena was issued for a penalty not to exceed fifty dollars and all damages sustained by reason of your failure to comply. PLEASE TAKE FURTHER NOTICE, that pursuant to CPLR §3122(a), a medical provider shall not provide a patient's medical records pursuant to a subpoena duces tecum & ad testificandum unless the subpoena is accompanied by a written authorization by the patient. ATTACHED HERETO PLEASE FIND DULLY EXECUTED HIPAA AUTHORIZATION FORM. PLEASE TAKE FURTHER NOTICE, that pursuant to CPLR §2301, all papers or other items delivered to the court pursuant to such subpoena shall be accompanied by copy of such subpoena. Dated: Brooklyn, New York September 27, 2022 Yours, etc., BY: GE ,O AK, ESQ. McMAH ', MARTINE & GALLAGHER, LLP Attorne s for Defendant 795 FI TH AVENUE CORPORATION d/b/a THE PIERRE 55 Washington Street, 7th Floor Brooklyn, New York 11201 (212) 747-1230 File No.: 553.0215 2 of 7 FILED: QUEENS COUNTY CLERK 09/27/2022 03:49 PM INDEX NO. 703721/2018 NYSCEF DOC. NO. 115 RECEIVED NYSCEF: 09/27/2022 . TO: Yu-Fan Zhang M.D. 281 Broadway New York, New York 10007 SACCO & FILLAS, LLP Attorneys for Plaintiff THALIA AGATHOCLEOUS 7* 31-19 Newtown Avenue, Floor Astoria, New York 11102 (718) 746-3440 3 of 7 FILED: QUEENS COUNTY CLERK 09/27/2022 03:49 PM INDEX NO. 703721/2018 NYSCEF DOC. NO. 115 OCA RECEIVED OfficialForm NYSCEF: No.: 960 09/27/2022 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health] PatientName ThaliaAgathocleous Date ofBirth:04/05/1963 SocialSecurityNumber: PatientAddress 110-29 55thAvenue NY , Flushing, 1 1368 1, ormy authorized representative,request thathealth information regarding my care and treatment be released as setforthon thisform: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portabilityand Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION TREATMENT, psychotherapy notes, only ifI placemy initials on the appropriate linein Item 9(a). in theevent the health information described below includes any of thesetypes of information, and I initial the line on thebox inItem 9(a),1 specificallyauthorizerelease ofsuch information tothe persons(s) indicated in Item 8. 2. If I am authorizing therelease of HIV related,alcohol or drug treatment,or mental healthtreatment information, therecipientis prohibited from redisclosingsuch information without my authorization unless permitted to do so under federal orstatelaw. 1 understand that Ihave a rightto requesta listofpeople who may receive oruse my HIV related information without authorization. If I experience discrimination because of therelease or disclosure of HIV-related information, I may contact theNew York StateDivision of Human Rights at (212) 480-2493 or theNew York CityCommission of human rights at(212)306-7450. These agencies are responsiblefor protecting my rights. 3. I havethe rightto revoke thisauthorization atany time by writingto the healthcare provider listed below. I understand thatI may revoke thisauthorization except tothe extent thataction has already been taken based on thisauthorization. 4. I understand that signing thisauthorization is voluntary.My treatment, payment, enrollment in a healthplan, or for eligibility benefits willnot be conditioned upon my authorization of thisdisclosure. 5. Information disclosed under thisauthorization might be redisclosedmy the recipient(except as noted above in Item2), and this redisclosure may no longerbe protected by federalor state law. 6. THIS AUTHORIZATION DOES NOT AUTHOR1ZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7.Name and address of healthprovider or entityto releasethisinformation: Yu-Fan Zhang, M.D., 281 Broadway, New York, NY 10007 8. Name and address of person(s)or category of person to whom this information will be sent:ATTN: Subpoena Records Room, Supreme Court, Queens County 88-11 Sutphin Boulevard Jamaica, NY 11435 9(a). S icinformation to be released: edicalRecord from 1/6/2018 to PRESENT O Entire Medical Record, including patienthistories,officenotes (except psychotherapy notes),test results, radiology studies, films,referrals,consults, billingrecords, insurance records,and records sent toyou by other healthcare providers. Other: Inclu Indicate by Initiating) 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 discuss my healthinformation with my attorney,or a governmental agency, listed here: (Attorney/Firm Name or Governmental Agency Name) 10.Reason forrelease of information: 11. Date or event on which thisauthorization willexpire: O At request of individual E Other: Legal Matter UPON CONCLUSION OF THIS MATTER 12. Ifnot the name patient, of person signing form: 13.Authority to sign on behalfof patient: SACCO & F1 AS, LLP BY: Elliot L. Lewis, Esq. ATTORNEY-IN-FACT Allitems on thi ave bee mpleted and my questions about thisform have been answered. In addition, I have been provided a copy of thefo Date:_Jan 21, 2020 Signature of patientor representative authorized by law *Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a person's contacts. 4 of 7 FILED: QUEENS COUNTY CLERK 09/27/2022 03:49 PM INDEX NO. 703721/2018 NYSCEF DOC. NO. 115 RECEIVED NYSCEF: 09/27/2022 Power of Attorney To Execute HIPAA Medical Record Authorization Forms Pursuant to NY Public Health Law § 18(1)(G) As Amended 10/26/04. I, H A-f A &&A Å O C... e OUS or / /0 - 5\ 7 ST 4 A-u e , a ê_ Fiahinr, A/ y /G( 7 (insert your name and address) do /sereby appoint: SACCO & FILLAS, LLP, their attorneys, employees and agents with offices at 31-19 NEWTOWN AVENUE3 SEVENTH FLOOR, ASTORIArNEW YORK 11102, my attorneys-in-fact to act (each agent may act separately) in my name, place, and stead in any way which I myself could do, if Iwere personally present to execute HIPAA medical records authorization forms pursuant to NY Public Health Law § 18(1)(G) as amended 10/26/04. This power of attorney may be revoked by me at any time. This Power of Attorney shallnot be affected by my subsequent disability or incompetence. To induce any thirdparty to act hereunder, I hereby agree that any third party receiving a duly executed copy or facsimile of this instrument may act hereunder, and thatrevocation or termination hereof shall be ineffective as to such third party unless and until actual notice or knowledge of such revocation or termination shall have been received by such third party, and I for myself and for my heirs, executors, legal representatives and assigns, hereby agree to indemnify and hold harmless any such third party from and against any and all claims that may arise against such third party by reason of such third party having relied on the provisions of this instrument. In Witness Whereof I have hereunto signed my name this day of , 20Ó (NIGNATURE) Acknowledgement STATE OF NEW YORK COUNTY OF QUEENS On this day of , 20 efore me the undersigned, personally appeared , personallyknown tobe or proved tome on the basis of satisfactoryevidence to be theindividual whose name is subscribed to thewithin instrument and acknowledged to me that he executed the same inhis capacity,.and thatby hissignature on the instrument, theindividual, orthe person who acted on behalf of theindividual, executed the instrument and that such individual made such appearance before the undersigned at Queens, w York. No REGINA M sZMUC Natary Public - State of New York .3 NO. 01 SZ6342939 Qualified in Oueens County .ty Commission Expiras May 31. 2020 5 of 7 FILED: QUEENS COUNTY CLERK 09/27/2022 03:49 PM INDEX NO. 703721/2018 NYSCEF DOC. NO. 115 RECEIVED NYSCEF: 09/27/2022 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF QUEENS ____________________________________________________________________Ç THALIA AGATHOCLEOUS, Index No.: 703721/2018 Plaintiff, -against- AFFIDAVIT OF BUSINESS 795 FIFTH AVENUE CORPORATION d/b/a RECORDS CERTIFICATION THE PIERRE, and IHMS LLC Defendants. ________________________________________________..____________________Ç PLEASE EXECUTE THE FOLLOWING AFFDAVIT IN FRONT OF A NOTARY PUBLIC AND FORWARD BACK TO OUR OFFICE LOCATED AT 55 WASHINGTON STREET, SUITE 720, BROOKLYN, NY 11201. SHOULD YOU HAVE ANY QUESTION PLEASE CONTACT US AT (212) 747-1230. STATEOF ) ) ss.: COUNTY OF ) I, , having been duly sworn, state that the following matters are true upon my knowledge. 1. I have received the Subpoena Duces Tecum & Ad Testificandum of the Defendant dated September 27, 2022, directed to Yu-Fan Zhang M.D., I make this affidavit pursuant to CPLR §3122 a-(c) to accompany the business records produced in response to said Subpoena. I am the duly authorized custodian or other qualified witness and have the authority to make this certification. 2. To the best of my knowledge, after reasonable inquiry, the records or copies thereof are accurate versions of the documents described in the Subpoena that are in my possession, custody, or control. 3. To the best of my knowledge, after reasonable inquiry, the records or copies produced represent all the documents described in the Subpoena, or if they do not 6 of 7 FILED: QUEENS COUNTY CLERK 09/27/2022 03:49 PM INDEX NO. 703721/2018 NYSCEF DOC. NO. 115 RECEIVED NYSCEF: 09/27/2022 represent a complete set of the documents subpoenaed, an explanation of which documents are missing and a reason for their absence is provided. 4. The records or copies produced were made by the personnel or staff of the business, or persons acting under my control, in regular course of business, at the time of the act, transaction, occurrence, or event recorded therein, or within a reasonable time thereafter, and that itwas the regular course of business to make such records. PRINT NAME: PRINT TITLE: Sworn to me on this day of , 2022 NOTARY PUBLIC 7 of 7