Motion-Secondary: Naquawn Mcintosh v. 322 Gates Llc, Airitan Management Corp.

On December 29, 2020 a Motion-Secondary was filed involving a dispute between Naquawn Mcintosh, and 322 Gates Llc, Airitan Management Corp., for Torts - Other Negligence (Premises) in the District Court of Kings County.

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FILED: KINGS COUNTY CLERK 09/22/2021 01:25 PM INDEX NO. 526100/2020
NYSCEF DOC. NO. 15 RECEIVED NYSCEF: 09/22/2021

SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF KINGS
X
NAQUAWN McINTOSH, Index no. 526100/2020

Plaintiff,
PLAINTIFF'S
-against- RESPONSE TO
DEFENDANTS'

322 GATES LLC and AIRITAN MANAGEMENT CORP., COMBINED DEMANDS

Defendants.
X

Plaintiff NAQUAWN McINTOSH, by his attorneys, ASHER & ASSOCIATES, P.C.,

hereby responds to Defendst 322 GATES LLC, Various Combined Discovery Demands dated,

April 30, 2021, and sets forth the followiñg upon infor-aden and belief:

1. RESPONSE TO DEMAND FOR COLLATERAL SOURCE INFORMATION TO
PLAINTIFF

a.-b. Plaintiff received medical benefits from the medical insurance provider

mentioned below. A duly executed HIPAA Comphant Authorization permitting Defeedsts to

attaded·
obtain a copy of Plaintiff's eõilateral source records from worker compensation is

Workers Compensation Bureau of CompHace - No Insurance Unit
Board,
100 - Menañds
Broadway
Albany, New York 12241

Plaintiff did not have any medical care, custodial care, rehabilitation services, loss of

earnings and/or economic loss recovered, replaced or indemniñed in whole or in part from any

cellateral source and does not know the nature and extent of the payments made on Plaintiff's

behalf.

2. RESPONSE TO DEMAND FOR MEDICAL REORTS AND AUTHORIZATIONS
TO PLAINTIFF

a.-c. Annexed hereto are duly executed HIPAA Compliant Authorizations permitting

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Defendants to obtain a copy of Plaintiff’s medical records maintained by the following medical

providers, facilities and/or entities whom consulted, treated, or treated the Plaintiff for the

conditions caused and/or exacerbated by defendants and described in Plaintiff’s Complaint are as

follows:

INTERFAITH MEDICAL CENTER
1545 Atlantic Avenue
Brooklyn, New York 11213

3. RESPONSE TO DEMAND FOR COLLATERAL SOURCE INFORMATION AND
AUTHORIZATIONS TO PLAINTIFF

a-b Plaintiff received medical benefits from the medical insurance provider mentioned

below. A duly executed HIPAA Compliant Authorization permitting Defendants to obtain a copy

of Plaintiff’s collateral source records from worker compensation is:

Workers Compensation Board, Bureau of Compliance - No Insurance Unit
100 Broadway – Menands
Albany, New York 12241

Plaintiff did not have any medical care, custodial care, rehabilitation services, loss of

earnings and/or economic loss recovered, replaced or indemnified in whole or in part from any

collateral source and does not know the nature and extent of the payments made on Plaintiff’s

behalf.

c Annexed hereto are duly executed HIPAA Compliant Authorizations permitting

Defendant to obtain a copy of plaintiff’s employment records from:

Foster Equites
633 Marlborough Road
Brooklyn, New York 11226

d Defendant's demand for authorization to obtain plaintiff's tax returns is improper

in this instance. Plaintiff was not working at the time of the incident. Where a self-employed

plaintiff seeks damages for a loss of earnings, tax returns are discoverable. Scholte v. Agway,

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NYSCEF DOC. NO. 15 RECEIVED NYSCEF: 09/22/2021

Inc., 544 NYS2d 105 (4th Dept. 1989). Otherwise not generally discoverable. Mayo, Lynch and

Associates v. Fine, 123 AD2d 607, 506 NYS2d 771 (2d Dept. 1986). Disclosure of tax returns is

generally disfavored in the absence of a strong showing of necessity and desirability for such

disclosure. Walter Karl, Inc. v. Wood, 555 NYS2d 840 (2d Dept. 1990).

e Social Security Disability: To be provided under separate cover sheet, if any.

f-g Plaintiff received medical benefits from the medical insurance provider mentioned

below. A duly executed HIPAA Compliant Authorization permitting Defendants to obtain a copy

of Plaintiff’s collateral source records from worker compensation is:

Workers Compensation Board, Bureau of Compliance - No Insurance Unit
100 Broadway – Menands
Albany, New York 12241

Plaintiff did not have any medical care, custodial care, rehabilitation services, loss of

earnings and/or economic loss recovered, replaced or indemnified in whole or in part from any

collateral source and does not know the nature and extent of the payments made on Plaintiff’s

behalf.

4. RESPONSE TO DEMAND FOR DISCLOSURE OF MEDICARE/MEDICAID
BENEFITS ELIGIBILITY TO PLAINTIFF

a-c Medicare: To be provided under separate cover sheet, if any.

d Social Security Disability: To be provided under separate cover sheet, if any.

e SSD Benefits: To be provided under separate cover sheet, if any.

f End-Stage Renal Failure: Not applicable.

g Kidney disease: Not applicable.

h Amyotrophic Lateral Sclerosis: Not applicable.

i Medicare: To be provided under separate cover sheet, if any.

j Deceased: Not applicable.

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NYSCEF DOC. NO. 15 RECEIVED NYSCEF: 09/22/2021

f Medicaid benefits: Annexed hereto are duly executed HIPAA Compliant

Authorizations permitting Defendant to obtain a copy of plaintiff’s Medicaid records from:

Affinity
1776 Eastchester Road
Bronx, New York 10461

5. RESPONSE TO DEMAND FOR DISCLOSURE AS TO MEDICARE/MEDICAID
LIEN INFORMATION TO PLAINTIFF

a-i Medicare/Medicaid Lien: To be provided under separate cover sheet, if any.

6. RESPONSE TO NOTICE OF DISCOVERY FOR CITIZENSHIP/IMMIGRATION
STATUS TO PLAINTIFF

a-g Fishing Expedition.

7. RESPONSE TO DEMAND FOR ALL PLEADINGS AND DISCOVERY
EXCHANGED TO PLAINTIFF

a. Attached hereto are copies of all the Pleadings

b. Notices for Discovery & Inspection: To be provided under separate cover sheet.

c. Interrogatories and responses: To be provided under separate cover sheet.

d. Notices to Admit and the Answers: To be provided under separate cover sheet.

e. All prior Court Orders: To be provided under separate cover sheet, if any.

f. Stipulations: To be provided under separate cover sheet, if any.

g. Plaintiff will make themselves available for an independent medical examination

with defendant's expert.

h. Annexed hereto are duly executed HIPAA Compliant Authorizations permitting

Defendant to obtain a copy of plaintiff’s employment records from:

Foster Equites
633 Marlborough Road
Brooklyn, New York 11226

Defendant's demand for authorization to obtain plaintiff's tax returns is improper

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FILED: KINGS COUNTY CLERK 09/22/2021 01:25 PM INDEX NO. 526100/2020
NYSCEF DOC. NO. 15 RECEIVED NYSCEF: 09/22/2021

in this instance. Plaintiff was not working at the time of the incident. Where a

self-employed plaintiff seeks damages for a loss of earnings, tax returns are

discoverable. Scholte v. Agway, Inc., 544 NYS2d 105 (4th Dept. 1989).

Otherwise not generally discoverable. Mayo, Lynch and Associates v. Fine, 123

AD2d 607, 506 NYS2d 771 (2d Dept. 1986). Disclosure of tax returns is

generally disfavored in the absence of a strong showing of necessity and

desirability for such disclosure. Walter Karl, Inc. v. Wood, 555 NYS2d 840 (2d

Dept. 1990).

Plaintiff received medical benefits from the medical insurance provider

mentioned below. A duly executed HIPAA Compliant Authorization permitting

Defendants to obtain a copy of Plaintiff’s collateral source records from worker

compensation is:

Workers Compensation Board, Bureau of Compliance - No Insurance Unit
100 Broadway – Menands
Albany, New York 12241

Plaintiff did not have any medical care, custodial care, rehabilitation

services, loss of earnings and/or economic loss recovered, replaced or indemnified

in whole or in part from any collateral source and does not know the nature and

extent of the payments made on Plaintiff’s behalf.

i. Copies of Note of Issue, Jury Demand, Readiness Statement: To be provided

under separate cover sheet, if any.

j. Copies of any other correspondence, document and information exchanged

between the parties: To be provided under separate cover sheet, if any.

8. RESPONSE TO DEMAND FOR LITIGATION FUNDING TO PLAINTIFF

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a.-d. Plaintiff objects to the demand for funding or loan information on the grounds

that it is overbroad, irrelevant, unrelated, privileged, a fishing expedition, lacks a factual

predicate or a good faith basis for the request, unduly burdensome, an invasion of

privacy, palpably improper, and not reasonably calculated to lead to the discovery of

admissible evidence. [See Cabrera v. 1279 Morris LLC, 306032/10, NYLJ

1202591426566, 1st Dept (Sup/Bronx, Decision/Order 2013. [Copy of decision attached

hereto].

9. RESPONSE TO DEMAND FOR PHOTOGRAPHS TO ALL PARTIES

a.-c. Attached, please find seven (7) photographs of the alleged condition on CD

attached to this response.

At this time, plaintiff is not in possession of any videotapes and photographs which

demonstrate the plaintiff’s injuries.

10. RESPONSE TO DEMAND FOR DISCOVERY AND INSPECTION OF ANY
STATEMENT OF ANY PARTY REPRESENTED BY THE UNDERSIGNEDF TO ALL
PARTIES

a.-b. Plaintiff is in not in possession of any statements, party statements, records,

memoranda, notes, tape recordings, or other recorded audio or video communications of

defendants. Plaintiff is not in possession of any party statements other than those

contained within medical records.

11. RESPONSE TO DEMAND FOR WITNESS INFORMATION TO ALL PARTIES

a.-f. At this time, witness to the accident is not known to the Plaintiff. If any witness

shall come forth, same will be provided under separate cover.

12. RESPONSE TO DEMAND FOR EXPERT WITNESS DISCLOSURE AS TO ALL
PARTIES

a.-d. Plaintiff has not retained an expert witness in connection with this matter.

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FILED: KINGS COUNTY CLERK 09/22/2021 01:25 PM INDEX NO. 526100/2020
NYSCEF DOC. NO. 15 RECEIVED NYSCEF: 09/22/2021

Plaintiff reserves the right to respond to this demand upon retention.

RESPONSE TO DEMAND FOR AD DAMNUM

Plaintiff demands $20,000,000.00, in total damages.

Dated: New York, New York
September 22, 2021

Yours, etc.

Joshua S. Bass, Esq.
By: JOSHUA S. BASS, ESQ.
ASHER & ASSOCIATES, P.C.
Attorneys for Plaintiff
111 John Street
Fourteenth Floor
New York, New York 10038
(212) 227-5000

TO: TRAUB LIEBERMAN STRAUS & SHREWSBERRY LLP
Attorneys for Defendant
322 GATES LLC
Mid-Westchester Executive Park
Seven Skyline Drive
Hawthorne, New York 10532
(914) 347-2600

AIRITAN MANAGEMENT CORP.
64-70 Maurice Avenue
Maspeth, New York 11378

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FILED: KINGS COUNTY CLERK 09/22/2021 01:25 PM INDEX NO. 526100/2020
NYSCEF DOC. NO. 15 RECEIVED NYSCEF: 09/22/2021

SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF KINGS
-------------------------------------------------------------------X
NAQUAWN McINTOSH, Index No.: 526100/2020

Plaintiff,
AFFIDAVIT OF E-MAIL
-against- SERVICE

322 GATES LLC and AIRITAN MANAGEMENT
CORP.,

Defendants.
------------------------------------------------------------------X
STATE OF NEW YORK )
) ss.
COUNTY OF NEW YORK )

Diana Madera, being duly sworn, says:

I am not a party to the action; I reside in Kings County in the State of New York, and I
am over 18 years of age.

That on September 22 2021, I served the within PLAINTIFF’S RESPONSE TO
DEFENDANTS’ COMBINED DEMANDS, via NYSCEF and E-Mail, due to COVID-19, at the
following E-Mail address(es) set forth below:

TRAUB LIEBERMAN STRAUS & SHREWSBERRY LLP
Attorneys for Defendant
322 GATES LLC
Mid-Westchester Executive Park
Seven Skyline Drive
Hawthorne, New York 10532
(914) 347-2600
lrolle@tlsslaw.com

Diana Madera
DIANA MADERA

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FILED: KINGS COUNTY CLERK 09/22/2021 01:25 PM INDEX NO. 526100/2020
NYSCEF DOC. NO. 15 RECEIVED NYSCEF: 09/22/2021
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]

Patient Name Date of Birth Social Security Number
Naquawn McIntosh
Patient Address:
112-20 Dillon Street, PH, Queens, New York 11433

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996
(HIPAA), I understand that:
1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on
the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I
initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand
that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience
discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human
Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for
protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may
revoke this authorization except to the extent that action has already been taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits
will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protected by federal or 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 health provider or entity to release this information:
Interfaith Medical Center, 1545 Atlantic Avenue, Brooklyn, New York 11213
8. Name and address of person(s) or category of person to whom this information will be sent:
Traub Lieberman Straus & Shrewsberry LLP, Mid-Westchester Executive Park, Seven Skyline Drive, Hawthorne, New York 10532
9(a). Specific information to be released:
 Medical Record from (04/03/2018) to (Present)
 Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films,
referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
 Other: Include: (Indicate by Initialing)
JSB Alcohol/Drug Treatment
JSB Mental Health Information
Authorization to Discuss Health Information JSB HIV-Related Information
(b)  By initializing here _______ I authorize .
Initials Name of individual health care provider
to discuss my health information with my attorney, or a governmental agency, listed here:

(Attorney/Firm Name or Governmental Agency Name)
10. Reason for release of information: 11. Date or event on which this authorization will expire:
 At request of individual End of litigation
 Other: Litigation
12. If not the patient, name of person signing form: 13. Authority to sign on behalf of patient:
Asher & Associates P.C., by Joshua S. Bass, Esq. Durable Power of Attorney
All items on this form have been completed and my questions about this form have been answered. In addition, I have been
provided a copy of the form.
Joshua S. Bass, Esq. Date: September 22, 2021
Signature of patient or 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.

9 of 21
FILED: KINGS COUNTY CLERK 09/22/2021 01:25 PM INDEX NO. 526100/2020
NYSCEF DOC. NO. 15 RECEIVED NYSCEF: 09/22/2021
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]

Patient Name Date of Birth Social Security Number
Naquawn McIntosh
Patient Address:
112-20 Dillon Street, PH, Queens, New York 11433

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996
(HIPAA), I understand that:
1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on
the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I
initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand
that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience
discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human
Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for
protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may
revoke this authorization except to the extent that action has already been taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits
will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protected by federal or 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 health provider or entity to release this information:
Workers Compensation Board, Bureau of Compliance - No Insurance Unit, 100 Broadway – Menands, Albany, New York 12241
8. Name and address of person(s) or category of person to whom this information will be sent:
Traub Lieberman Straus & Shrewsberry LLP, Mid-Westchester Executive Park, Seven Skyline Drive, Hawthorne, New York 10532
9(a). Specific information to be released:
 Medical Record from ( ) to ()
 Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films,
referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
 Other: Workers’ Compensation records Include: (Indicate by Initialing)
WCB: G2148724 JSB Alcohol/Drug Treatment
JSB Mental Health Information
Authorization to Discuss Health Information JSB HIV-Related Information
(b)  By initializing here _______ I authorize .
Initials Name of individual health care provider
to discuss my health information with my attorney, or a governmental agency, listed here:

10 of 21
FILED: KINGS COUNTY CLERK 09/22/2021 01:25 PM INDEX NO. 526100/2020
NYSCEF DOC. NO. 15 RECEIVED NYSCEF: 09/22/2021
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]

Patient Name Date of Birth Social Security Number
Naquawn McIntosh
Patient Address:
112-20 Dillon Street, PH, Queens, New York 11433

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996
(HIPAA), I understand that:
1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on
the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I
initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand
that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience
discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human
Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for
protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may
revoke this authorization except to the extent that action has already been taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits
will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protected by federal or 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 health provider or entity to release this information:
Foster Equites, 633 Marlborough Road, Brooklyn, New York 11226
8. Name and address of person(s) or category of person to whom this information will be sent:
Traub Lieberman Straus & Shrewsberry LLP, Mid-Westchester Executive Park, Seven Skyline Drive, Hawthorne, New York 10532
9(a). Specific information to be released:
 Medical Record from ( ) to ()
 Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films,
referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
 Other: Employment records Include: (Indicate by Initialing)
JSB Alcohol/Drug Treatment
JSB Mental Health Information
Authorization to Discuss Health Information JSB HIV-Related Information
(b)  By initializing here _______ I authorize .
Initials Name of individual health care provider
to discuss my health information with my attorney, or a governmental agency, listed here:

11 of 21
FILED: KINGS COUNTY CLERK 09/22/2021 01:25 PM INDEX NO. 526100/2020
NYSCEF DOC. NO. 15 RECEIVED NYSCEF: 09/22/2021
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]

Patient Name Date of Birth Social Security Number
Naquawn McIntosh
Patient Address:
112-20 Dillon Street, PH, Queens, New York 11433

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996
(HIPAA), I understand that:
1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on
the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I
initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand
that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience
discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human
Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for
protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may
revoke this authorization except to the extent that action has already been taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits
will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protected by federal or 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 health provider or entity to release this information:
Affinity, 1776 Eastchester Road, Bronx, New York 10461
8. Name and address of person(s) or category of person to whom this information will be sent:
Traub Lieberman Straus & Shrewsberry LLP, Mid-Westchester Executive Park, Seven Skyline Drive, Hawthorne, New York 10532
9(a). Specific information to be released:
 Medical Record from ( ) to ()
 Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films,
referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
 Other: Medicaid records Include: (Indicate by Initialing)
JSB Alcohol/Drug Treatment
JSB Mental Health Information
Authorization to Discuss Health Information JSB HIV-Related Information
(b)  By initializing here _______ I authorize .
Initials Name of individual health care provider
to discuss my health information with my attorney, or a governmental agency, listed here:

12 of 21
FILED: KINGS COUNTY CLERK 09/22/2021 01:25 PM INDEX NO. 526100/2020
NYSCEF DOC. NO. 15 RECEIVED NYSCEF: 09/22/2021

P g

Case Info

Judge

Robin Sheares Track Judge’s New Case

Case No.

(Subscribe to View)

Document Filed Date

September 22, 2021

Case Filing Date

December 29, 2020

County

Parties

322 GATES LLC Defendant
ACOSTA, CHRISTOPHER D. Attorney for the Defendant
AIRITAN MANAGEMENT CORP. Defendant
ASHER, ROBERTA D Attorney for the Plaintiff
BERKLEY, MICHAEL PHILLIP Attorney for the Defendant
BRUCIA, COLIN DENNEHY Attorney for the Defendant
CAPITANI, JOHN PERRY Attorney for the Defendant
FITZPATRICK, KEVIN THOMAS Attorney for the Defendant
Naquawn Mcintosh Plaintiff
ROLLE, LISA M Attorney for the Defendant
ROSS, SAMANTHA NICOLE Attorney for the Defendant
JOSHUA BASS Attorneys for Plaintiffs
LAURIE DALLOS Attorneys for Defendants
ANDREA WAISMAN Attorneys for Defendants
RYAN ASHER Attorneys for Plaintiffs
SHERRY LIN Attorney

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