Preview
FILED: QUEENS COUNTY CLERK 09/27/2022 03:49 PM INDEX NO. 703721/2018
NYSCEF DOC. NO. 113 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: Lenox Hill Hospital: Northwell Health
77th
100 East
New York, New York 10075
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
9th
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
Defendants, 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. 113 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: GEN O AK, ESQ.
McMAI N, MARTINE & GALLAGHER, LLP
Attorney for Defendants
795 FI TH AVENUE CORPORATION
and IHMS LLC
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. 113 RECEIVED NYSCEF: 09/27/2022
TO: Lenox Hill Hospital: Northwell Health
77*
100 East Street
New York, New York 10075
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. 113 OCA
RECEIVED OfficialForm
NYSCEF: No.: 960
09/27/2022
" . - * · AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
IThis form has been approved by the New York State Department of Health]
PatientName ThaliaAgathocleous Date ofBirth:04/05/1963 SocialSecurityNumber:
PatientAddress 110-29 55thAvenue, Flushing,NY I 1368
I,or my authorized representative,request thathealth information regarding my care and treatment be released as setforthon this form:
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 ifI place initialson
TREATMENT, psychotherapy notes, only my
the appropriate linein Item 9(a). In theevent thehealth information described below includes any of thesetypes of information, and I
initial
the line on thebox inItem 9(a),I specificallyauthorizerelease ofsuch information tothe persons(s) indicated in Item 8.
2. If I am authorizing therelease of HIV related,alcohol or drug treatment, ormental health treatment information, the recipient
is
prohibited from redisclosing such information without my authorization unless permitted to do so under federal orstatelaw. I understand
that I havea rightto request a listofpeople who may receive oruse my HIV related information without authorization. If I experience
discrimination because of therelease or disclosureof HIV-related information, I may contact theNew York State Division of Human
Rights at (212)480-2493 or theNew York City Commission of human rightsat (212)306-7450. These agencies are responsiblefor
protecting my rights.
3. I havethe rightto revoke thisauthorization atany time by writing tothe health careprovider listedbelow. I understand thatI may
revoke thisauthorization except to theextent that actionhas 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 ofthis disclosure.
5. Information disclosed under this authorization might be redisclosedby the recipient (except as noted above in Item 2),and this
redisclosure may no longer be protected by federalor state law.
6.THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7.Name and address of healthprovider or entityto releasethisinformation: Lenox Hill Hospital: Northwell Health, 100 East 77th
Street, New York, NY 10075
8. Name and address of person(s)or category of person to whom thisinformation will be sent:ATTN: Subpoena Records Room,
Supreme Court, Queens County 88-11 Sutphin Boulevard Jamaica, NY 11435
'
9(a). Spe mformation to be released:
M icalRecord from 1/6/2018 to Present
ntireMedical Record, including patienthistories,office notes (except psychotherapy notes),testresults,radiology studies,
films, referrals,
consults, billingrecords, insurance records, and records sent toyou by other healthcare providers.
O Other: Includ (Indicate by Initialing)
Alcohol/Drug Treatment
Mental Health Information
HIV-Related Information
Authorization to Discuss Health Information
(b) O By initialinghere I authorize
Initials Name of individualhealthcare provider
to discussmy health information with my attorney,or a governmental agency, listedhere:
(Attorney/Firm Name or Governmental Agency Name)
10. Reason forrelease of information: 1 1. Dateorevent on which thisauthorization willexpire:
O At request of individual
® Other: Legal Matter UPON CONCLUSION OF THIS MATTER
12. Ifnot the patient,name of person signing form: 13.Authority to signon behalfof patient:
SACCO & FILLAS, LLP BY: ElliotL. Lewis, Esq. ATTORNEY-IN-FACT
Allitems on thisfor v been co pleted and my questions about this form have been answered. In addition,I have been provided a
copy of theform.
Date:_Dec 24, 2019
Signature of patientor representativeauthorized 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. 113 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,
D C C O US
of (m
-
STrh A-ve.vae__ Rw//Mr, #y /af f
(insert your name and address)
do hereby appoint: SACCO & FILLAS, LLP, their attorneys, employees and agents
with offices at 31-19 NEWTOWN AVENUE, SEVENTH FLOOR3 ASTORIA, NEW
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 third party to act hereunder, I hereby agree that any third party receiving a
duly executed copy or facsimile of thisinstrument 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 , 20_
x
SIGNATURE)
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 his signature on the
instrument, theindividual, orthe person who actedon behalf ofthe individual,executed the
instrument and that such individual made such appearance before the undersigned atQueens,
w York.
Not REGINA M SZMUC
()
Natary Public - State of New York
NC. 01826342939
Oualified in Oueens County
y CommissionExpiras May 31, 2020
5 of 7
FILED: QUEENS COUNTY CLERK 09/27/2022 03:49 PM INDEX NO. 703721/2018
NYSCEF DOC. NO. 113 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
Defendant.
--___________________________________________________________________Ç
PLEASE EXECUTE THE FOLLOWING AFFIDAVIT 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.
STATE OF )
) 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 Lenox Hill Hospital: Northwell Health, 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. 113 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. 113 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: Lenox Hill Hospital: Northwell Health 77th 100 East New York, New York 10075 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 9th 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 Defendants, 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. 113 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: GEN O AK, ESQ. McMAI N, MARTINE & GALLAGHER, LLP Attorney for Defendants 795 FI TH AVENUE CORPORATION and IHMS LLC 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. 113 RECEIVED NYSCEF: 09/27/2022 TO: Lenox Hill Hospital: Northwell Health 77* 100 East Street New York, New York 10075 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. 113 OCA RECEIVED OfficialForm NYSCEF: No.: 960 09/27/2022 " . - * · AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA IThis form has been approved by the New York State Department of Health] PatientName ThaliaAgathocleous Date ofBirth:04/05/1963 SocialSecurityNumber: PatientAddress 110-29 55thAvenue, Flushing,NY I 1368 I,or my authorized representative,request thathealth information regarding my care and treatment be released as setforthon this form: 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 ifI place initialson TREATMENT, psychotherapy notes, only my the appropriate linein Item 9(a). In theevent thehealth information described below includes any of thesetypes of information, and I initial the line on thebox inItem 9(a),I specificallyauthorizerelease ofsuch information tothe persons(s) indicated in Item 8. 2. If I am authorizing therelease of HIV related,alcohol or drug treatment, ormental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal orstatelaw. I understand that I havea rightto request a listofpeople who may receive oruse my HIV related information without authorization. If I experience discrimination because of therelease or disclosureof HIV-related information, I may contact theNew York State Division of Human Rights at (212)480-2493 or theNew York City Commission of human rightsat (212)306-7450. These agencies are responsiblefor protecting my rights. 3. I havethe rightto revoke thisauthorization atany time by writing tothe health careprovider listedbelow. I understand thatI may revoke thisauthorization except to theextent that actionhas 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 ofthis disclosure. 5. Information disclosed under this authorization might be redisclosedby the recipient (except as noted above in Item 2),and this redisclosure may no longer be protected by federalor state law. 6.THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7.Name and address of healthprovider or entityto releasethisinformation: Lenox Hill Hospital: Northwell Health, 100 East 77th Street, New York, NY 10075 8. Name and address of person(s)or category of person to whom thisinformation will be sent:ATTN: Subpoena Records Room, Supreme Court, Queens County 88-11 Sutphin Boulevard Jamaica, NY 11435 ' 9(a). Spe mformation to be released: M icalRecord from 1/6/2018 to Present ntireMedical Record, including patienthistories,office notes (except psychotherapy notes),testresults,radiology studies, films, referrals, consults, billingrecords, insurance records, and records sent toyou by other healthcare providers. O Other: Includ (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) O By initialinghere I authorize Initials Name of individualhealthcare provider to discussmy health information with my attorney,or a governmental agency, listedhere: (Attorney/Firm Name or Governmental Agency Name) 10. Reason forrelease of information: 1 1. Dateorevent on which thisauthorization willexpire: O At request of individual ® Other: Legal Matter UPON CONCLUSION OF THIS MATTER 12. Ifnot the patient,name of person signing form: 13.Authority to signon behalfof patient: SACCO & FILLAS, LLP BY: ElliotL. Lewis, Esq. ATTORNEY-IN-FACT Allitems on thisfor v been co pleted and my questions about this form have been answered. In addition,I have been provided a copy of theform. Date:_Dec 24, 2019 Signature of patientor representativeauthorized 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. 113 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, D C C O US of (m - STrh A-ve.vae__ Rw//Mr, #y /af f (insert your name and address) do hereby appoint: SACCO & FILLAS, LLP, their attorneys, employees and agents with offices at 31-19 NEWTOWN AVENUE, SEVENTH FLOOR3 ASTORIA, NEW 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 third party to act hereunder, I hereby agree that any third party receiving a duly executed copy or facsimile of thisinstrument 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 , 20_ x SIGNATURE) 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 his signature on the instrument, theindividual, orthe person who actedon behalf ofthe individual,executed the instrument and that such individual made such appearance before the undersigned atQueens, w York. Not REGINA M SZMUC () Natary Public - State of New York NC. 01826342939 Oualified in Oueens County y CommissionExpiras May 31, 2020 5 of 7 FILED: QUEENS COUNTY CLERK 09/27/2022 03:49 PM INDEX NO. 703721/2018 NYSCEF DOC. NO. 113 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 Defendant. --___________________________________________________________________Ç PLEASE EXECUTE THE FOLLOWING AFFIDAVIT 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. STATE OF ) ) 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 Lenox Hill Hospital: Northwell Health, 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. 113 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