Preview
FILED: SUFFOLK COUNTY CLERK 02/13/2023 08:38 AM INDEX NO. 606267/2021
NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 02/13/2023
Lc GRuENsERG G N AL L TA
GRLJEMERG I ELLYDELLA
ATTORNEYS AND COlJNSELORS AT LAW
. WWW.NEWYORKLAWGROUP.COM CHRISTOPHER PAGANO
SEAN P. KELLY
AVENUE" RONKONKOMA" xR=AN
700 KOEHLER NEW YORK 11779
MICHAEL L. DELLA BRAUNSER
888.LAW.GROUP " PHONE: 631.737.4110
(888.529.4768) JOSEPH N. TIMPANARO
FAX: 631.737.4155 " EMAIL: INFO@GKNYLAW.NET
EVA L. KENNEDY
JESSICAE. VERTULLO OTHER GRIFFINGAVE., RIVERHEAD"PARKAVE., HUNTINGTON
LOCATIONS: KATHERINE R, CUTRONE
(MANAGINGATTORNEYi N. BROADWAY,JERICHO"WATERSTREET,BROOKLYN STEVEN CAULO
February 10, 2023
Lewis, Johs, Avallone Aviles LLP
1377 Motor Parkway
Suite 400
Islandia, NY 11749
Re: Balsamo v. Sunoco Gas Station
Your Client: Nexus Enterprises, Inc. DBA
Southampton Sunoco
Your File No.: 0339.1011.0000
Index No.: 606267/2021
Our File No.: 210122
Dear Sir/Madam:
Enclosed please find the following fresh authorization(s) for trial subpoena purposes:
- Barth's Pharmacy
- Lewis Anreder M.D.
- Peconic Physical Therapy
- Stephen M.D.
Fealy
- Brook Southampton Hospital
Stony
- Thrive Medical of Westhampton Beach
- Empire Blue Cross & Blue Shield (NY)
- State Farm Insurance Company
This office will not provide any authorization(s) not previously requested during the discovery
phase of this matter. If you believe that your office is entitled to any additional authorizations,
kindly send a request a request in writing along with copies of the requisite authorization provided
during discovery.
Finally, this office intends to request the first immediate trial date available following the initial
trial conference date. Please be guided accordingly.
ry truly yours,
Amanda Bonkoski
Legal Assistant
GA/ab
Enclosures
1 of 9
FILED: SUFFOLK COUNTY CLERK 02/13/2023 08:38 AM INDEX NO. 606267/2021
NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 02/13/2023
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
Patient Name: Mary Louise Balsamo Date of Birt SS
Patient Address: 15 Bayerest Avenue. , Westhampton, h
. ... . ._._ _ _._...._
L 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:
l. This authorization may include disclosure of information relating to 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 a d r It rovider to r lease t is formatiot :
8. Name and address of person(s) or category of person to whom this information will be sent: Supreme Court, Suffolk
County. 1 Court Street, Riverhead, NY 11901; Attn: Subpoenaed Records Room
9(a). Specific inforrnation to be released:
O Medical Record from (insert date) to (insert date)
O Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies,
referrals, consults, billine records insuran efrecords, and records sent to you by other health care providers.
films,
Other: . / Include: (In icate by Initialing)
/J4;f Alcohol/Drug Treatment
---Mental Health Information
Authorization t Discuss Health Information HIV-Related Information
(b) By initialing 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 auÊ i tid 1 spjre:
O At request of individual Conclusion of Case f 4 ..
[X] Other: Legal to NOTS o
12. O If not the patient, name of person signing form: 13. Authority to sign on beha f of att4
All items on this form have been completed and my questions about this form have been answe ddi ve been provided
a copy of the form.
Date: Sworn to before me thi_ day of / , 20
'
Si lature o ent or representative authorized by law. Notary Public
* Human Immunode
iciency 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 contact
2 of 9
FILED: SUFFOLK COUNTY CLERK 02/13/2023 08:38 AM INDEX NO. 606267/2021
NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 02/13/2023
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
Patient Name: Marv Louise Balsamo Date of Bi1 .
Patient Address: 15 Bayerest Avenue. , Westhampton, N 11977
or my authorized representative. request that health information
regarding my care and treatment be released as set forth on this form: In
with New York State Law and the Privacy Rule of the Health Insurance accordance
Portability and Accountability Act of 1996 (HIPAA). I understand that:
1. This authorization may include disclosure of information
relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except psychotherapy notes, and CONFIDENTIAL HIV* RELATED TREATMENT.
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 {
authorization except to the extent that action has already been taken based on this authorization. may revoke this
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
longer be protected by federal or state law. may no
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 an address health rovider or nti to release t1is information
8. Name and address of person(s) or category of person to whom this information will be sent: Supreme Court Suffolk
County. 1 Court Street, Riverhead, NY 11901; Attn: Subpoenaed Records Room
9(a). Speci ic information to be released:
C AMedical Record from (insert date) CD to (insert date)
¡ Entire Medical Record, patient
including histories, office notes (except psych therapy notes), test results, radiology studies,
films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
O Other:
Include: (Indicate by Initialing)
Alcohol/Drug Treatment
Mental Health Information
Authorization to Discuss Health Information HIV-Related Information
(b) By initialing 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 authorizatiosyill explie:
O At request of individual
Conclusion of Case
[X] Other: Legal o
12. O If not the patient, name of person form: 13. Authority to sign on behalf
signing of pitiedt:
All items on this form have been completed and my questions about this form have been answered. fl tl ion I h n provided
a copy of the form.
Date: to before
Sworn me this day of , 20
' laF'
gnature o ar nt or representative authorized by
Notary Pub ic
* Human Virus that causes AIDS. The New York State Public Health Law protects
Immunodeficiency information which reasonably could identify someone as
HIV symptoms or infection and information
having regarding a person's contact
3 of 9
FILED: SUFFOLK COUNTY CLERK 02/13/2023 08:38 AM INDEX NO. 606267/2021
NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 02/13/2023
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
Patient Name: Mary Louise Balsamo Date of Birth: ...
Patient Address: 15 Bayerest Avenue. , Westhampton.NY 11
1. 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). 1 understand that:
1. This authorization may include disclosure of information relating to 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. N me a d address of health provider or entity to release thi information/ / ()& fy& )0
8. Name and address of person(s) or category of person to whom this information will be sent: Supreme Court. Suffolk
County. 1 Court Street. Riverhead. NY 11901; Attn: Subpoenaed Records Room
9(a). Specific information to be released:
edical Record from (insert date) to (insert date)
O 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.
O Other: Include: (Indicate by Initialing)
Alcohol/Drug Treatment
Mental Health Information
Authorization to Discuss Health Information HIV-Related Information
(b) By initialing here I authorize
(Initials) (Name of individual health care provider )
to discuss my health infortnation with my attorney, or a governmental agency, listed here:
(AttorneyFirm Name or Governmental Agency Name)
10. Reason for release of information: 11. Date or event on which this authorization will expire:
O At request of individual Conclusion of Case
[x] Other: Legal
12. O If not the patient, name of person signing form: 13. Authority to sign on behalf ofipa ien
All items on this form have been completed and my questions about this form have been answered. ad I ha rovided
a copy of the form.
Date: Sw n to before me thid da , 20
S nature of ent or representative authorized by law. Notary Public
* Human Immunode
ciency 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 contact
4 of 9
FILED: SUFFOLK COUNTY CLERK 02/13/2023 08:38 AM INDEX NO. 606267/2021
NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 02/13/2023
.
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
Patient Name: Mary Louise Balsamo Date of Birth:
Patient Address: 15 Bayerest Avenue, , Westhampton, NY
L 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 relating to 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.
1 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 D OES 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. and address of lth pr er or enti release this inf rmatio
8. Name and address of person(s) or category of person to whom this information will be sent: Supreme Court, Suffolk
County. 1 Court Street. Riverhead, NY 11901; Attn: Subpoenaed Records Room
9(a). Specif information to be released: - -
Iedical Record from (insert date) to (insert date)
O 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.
O Other: Include: (Indicate by Initialing)
Alcohol/Drug Treatment
Mental Health Information
Authorization to Discuss Health Information HIV-Related Information
(b) By initialing here I authorize
(1nitials) (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 authorizati ill x re
O
O At request of individual Conclusion of Case / p.
'
[x] Other: Legal
12. O If not the patient, name of person signing form: 13. Authority to sign on behalf of pa lent o p
All items on this form have been completed and my questions about this form have been answered. h provided
a copy of the form.
Date Sworn to before me this day of , 20
Ô[23 / fA, Û&
Signature of patient or representative authorized by law. Notary ublic
* Human Virus that causes AIDS. The New York State Public Health Law protects information which
Immunodeficiency reasonably could identify someone as
having HIV symptoms or infection and information regarding a person's contact
5 of 9
FILED: SUFFOLK COUNTY CLERK 02/13/2023 08:38 AM INDEX NO. 606267/2021
NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 02/13/2023
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
Patient Name: Mary Louise Balsamo Date of Birt
Patient Address: 15 Bayerest Avenue. . Westhampton, NY
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
relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except psychotherapy notes, and CONFIDENTIAL HIV* TREATMENT,
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
authorization except to the extent that action has already been taken based on this authorization. may revoke this
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
longer be protected by federal or state law. may no
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).
Nam and addres health rovider or entity to release this information:
8. Name and address of person(s) or category of person to whom this information will be sent: Supreme Court Suffol
County. I Court Street, Riverhead, NY 11901: Attn: Subpoenaed Records Room
9(a) Specific information to be released:
')ÓRedical Record from (insert date) to (insert date)
O Entire Medical Record, patient
including histories, office notes (except notes), test results, radiology
psychotherapy studies,
films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
O Other:
Include: (Indicate by Initialing)
Alcohol/Drug Treatment
Mental Health Information
Authorization to Discuss Health Information HIV-Related Information
(b) By initialing 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: 1 l. Date or event on which this authorizatioi
illPeikiy
O At request of individual Conclusion of Case c O
[x] Other: Legal
OTA R
12. O If not the patient, name of person form: 13. Authority to sign on behalf
signing of p tien :
All items on this form have been completed and my questions about this form have been answered. •h t 9n , av e provided
a copy of the form.
Date: c Û Swon o before me this day of 20
gnature of ent or represent itive authorized bylaw
Notary Publi
* Human Im
7unodeficiency Virus that causes AIDS. The New York State Public Health Law pro
Preview
FILED: SUFFOLK COUNTY CLERK 02/13/2023 08:38 AM INDEX NO. 606267/2021 NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 02/13/2023 Lc GRuENsERG G N AL L TA GRLJEMERG I ELLYDELLA ATTORNEYS AND COlJNSELORS AT LAW . WWW.NEWYORKLAWGROUP.COM CHRISTOPHER PAGANO SEAN P. KELLY AVENUE" RONKONKOMA" xR=AN 700 KOEHLER NEW YORK 11779 MICHAEL L. DELLA BRAUNSER 888.LAW.GROUP " PHONE: 631.737.4110 (888.529.4768) JOSEPH N. TIMPANARO FAX: 631.737.4155 " EMAIL: INFO@GKNYLAW.NET EVA L. KENNEDY JESSICAE. VERTULLO OTHER GRIFFINGAVE., RIVERHEAD"PARKAVE., HUNTINGTON LOCATIONS: KATHERINE R, CUTRONE (MANAGINGATTORNEYi N. BROADWAY,JERICHO"WATERSTREET,BROOKLYN STEVEN CAULO February 10, 2023 Lewis, Johs, Avallone Aviles LLP 1377 Motor Parkway Suite 400 Islandia, NY 11749 Re: Balsamo v. Sunoco Gas Station Your Client: Nexus Enterprises, Inc. DBA Southampton Sunoco Your File No.: 0339.1011.0000 Index No.: 606267/2021 Our File No.: 210122 Dear Sir/Madam: Enclosed please find the following fresh authorization(s) for trial subpoena purposes: - Barth's Pharmacy - Lewis Anreder M.D. - Peconic Physical Therapy - Stephen M.D. Fealy - Brook Southampton Hospital Stony - Thrive Medical of Westhampton Beach - Empire Blue Cross & Blue Shield (NY) - State Farm Insurance Company This office will not provide any authorization(s) not previously requested during the discovery phase of this matter. If you believe that your office is entitled to any additional authorizations, kindly send a request a request in writing along with copies of the requisite authorization provided during discovery. Finally, this office intends to request the first immediate trial date available following the initial trial conference date. Please be guided accordingly. ry truly yours, Amanda Bonkoski Legal Assistant GA/ab Enclosures 1 of 9 FILED: SUFFOLK COUNTY CLERK 02/13/2023 08:38 AM INDEX NO. 606267/2021 NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 02/13/2023 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA Patient Name: Mary Louise Balsamo Date of Birt SS Patient Address: 15 Bayerest Avenue. , Westhampton, h . ... . ._._ _ _._...._ L 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: l. This authorization may include disclosure of information relating to 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 a d r It rovider to r lease t is formatiot : 8. Name and address of person(s) or category of person to whom this information will be sent: Supreme Court, Suffolk County. 1 Court Street, Riverhead, NY 11901; Attn: Subpoenaed Records Room 9(a). Specific inforrnation to be released: O Medical Record from (insert date) to (insert date) O Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, referrals, consults, billine records insuran efrecords, and records sent to you by other health care providers. films, Other: . / Include: (In icate by Initialing) /J4;f Alcohol/Drug Treatment ---Mental Health Information Authorization t Discuss Health Information HIV-Related Information (b) By initialing 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 auÊ i tid 1 spjre: O At request of individual Conclusion of Case f 4 .. [X] Other: Legal to NOTS o 12. O If not the patient, name of person signing form: 13. Authority to sign on beha f of att4 All items on this form have been completed and my questions about this form have been answe ddi ve been provided a copy of the form. Date: Sworn to before me thi_ day of / , 20 ' Si lature o ent or representative authorized by law. Notary Public * Human Immunode iciency 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 contact 2 of 9 FILED: SUFFOLK COUNTY CLERK 02/13/2023 08:38 AM INDEX NO. 606267/2021 NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 02/13/2023 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA Patient Name: Marv Louise Balsamo Date of Bi1 . Patient Address: 15 Bayerest Avenue. , Westhampton, N 11977 or my authorized representative. request that health information regarding my care and treatment be released as set forth on this form: In with New York State Law and the Privacy Rule of the Health Insurance accordance Portability and Accountability Act of 1996 (HIPAA). I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH except psychotherapy notes, and CONFIDENTIAL HIV* RELATED TREATMENT. 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 { authorization except to the extent that action has already been taken based on this authorization. may revoke this 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 longer be protected by federal or state law. may no 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 an address health rovider or nti to release t1is information 8. Name and address of person(s) or category of person to whom this information will be sent: Supreme Court Suffolk County. 1 Court Street, Riverhead, NY 11901; Attn: Subpoenaed Records Room 9(a). Speci ic information to be released: C AMedical Record from (insert date) CD to (insert date) ¡ Entire Medical Record, patient including histories, office notes (except psych therapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. O Other: Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information Authorization to Discuss Health Information HIV-Related Information (b) By initialing 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 authorizatiosyill explie: O At request of individual Conclusion of Case [X] Other: Legal o 12. O If not the patient, name of person form: 13. Authority to sign on behalf signing of pitiedt: All items on this form have been completed and my questions about this form have been answered. fl tl ion I h n provided a copy of the form. Date: to before Sworn me this day of , 20 ' laF' gnature o ar nt or representative authorized by Notary Pub ic * Human Virus that causes AIDS. The New York State Public Health Law protects Immunodeficiency information which reasonably could identify someone as HIV symptoms or infection and information having regarding a person's contact 3 of 9 FILED: SUFFOLK COUNTY CLERK 02/13/2023 08:38 AM INDEX NO. 606267/2021 NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 02/13/2023 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA Patient Name: Mary Louise Balsamo Date of Birth: ... Patient Address: 15 Bayerest Avenue. , Westhampton.NY 11 1. 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). 1 understand that: 1. This authorization may include disclosure of information relating to 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. N me a d address of health provider or entity to release thi information/ / ()& fy& )0 8. Name and address of person(s) or category of person to whom this information will be sent: Supreme Court. Suffolk County. 1 Court Street. Riverhead. NY 11901; Attn: Subpoenaed Records Room 9(a). Specific information to be released: edical Record from (insert date) to (insert date) O 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. O Other: Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information Authorization to Discuss Health Information HIV-Related Information (b) By initialing here I authorize (Initials) (Name of individual health care provider ) to discuss my health infortnation with my attorney, or a governmental agency, listed here: (AttorneyFirm Name or Governmental Agency Name) 10. Reason for release of information: 11. Date or event on which this authorization will expire: O At request of individual Conclusion of Case [x] Other: Legal 12. O If not the patient, name of person signing form: 13. Authority to sign on behalf ofipa ien All items on this form have been completed and my questions about this form have been answered. ad I ha rovided a copy of the form. Date: Sw n to before me thid da , 20 S nature of ent or representative authorized by law. Notary Public * Human Immunode ciency 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 contact 4 of 9 FILED: SUFFOLK COUNTY CLERK 02/13/2023 08:38 AM INDEX NO. 606267/2021 NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 02/13/2023 . AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA Patient Name: Mary Louise Balsamo Date of Birth: Patient Address: 15 Bayerest Avenue, , Westhampton, NY L 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 relating to 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. 1 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 D OES 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. and address of lth pr er or enti release this inf rmatio 8. Name and address of person(s) or category of person to whom this information will be sent: Supreme Court, Suffolk County. 1 Court Street. Riverhead, NY 11901; Attn: Subpoenaed Records Room 9(a). Specif information to be released: - - Iedical Record from (insert date) to (insert date) O 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. O Other: Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information Authorization to Discuss Health Information HIV-Related Information (b) By initialing here I authorize (1nitials) (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 authorizati ill x re O O At request of individual Conclusion of Case / p. ' [x] Other: Legal 12. O If not the patient, name of person signing form: 13. Authority to sign on behalf of pa lent o p All items on this form have been completed and my questions about this form have been answered. h provided a copy of the form. Date Sworn to before me this day of , 20 Ô[23 / fA, Û& Signature of patient or representative authorized by law. Notary ublic * Human Virus that causes AIDS. The New York State Public Health Law protects information which Immunodeficiency reasonably could identify someone as having HIV symptoms or infection and information regarding a person's contact 5 of 9 FILED: SUFFOLK COUNTY CLERK 02/13/2023 08:38 AM INDEX NO. 606267/2021 NYSCEF DOC. NO. 33 RECEIVED NYSCEF: 02/13/2023 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA Patient Name: Mary Louise Balsamo Date of Birt Patient Address: 15 Bayerest Avenue. . Westhampton, NY 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 relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH except psychotherapy notes, and CONFIDENTIAL HIV* TREATMENT, 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 authorization except to the extent that action has already been taken based on this authorization. may revoke this 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 longer be protected by federal or state law. may no 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). Nam and addres health rovider or entity to release this information: 8. Name and address of person(s) or category of person to whom this information will be sent: Supreme Court Suffol County. I Court Street, Riverhead, NY 11901: Attn: Subpoenaed Records Room 9(a) Specific information to be released: ')ÓRedical Record from (insert date) to (insert date) O Entire Medical Record, patient including histories, office notes (except notes), test results, radiology psychotherapy studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. O Other: Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information Authorization to Discuss Health Information HIV-Related Information (b) By initialing 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: 1 l. Date or event on which this authorizatioi illPeikiy O At request of individual Conclusion of Case c O [x] Other: Legal OTA R 12. O If not the patient, name of person form: 13. Authority to sign on behalf signing of p tien : All items on this form have been completed and my questions about this form have been answered. •h t 9n , av e provided a copy of the form. Date: c Û Swon o before me this day of 20 gnature of ent or represent itive authorized bylaw Notary Publi * Human Im 7unodeficiency Virus that causes AIDS. The New York State Public Health Law pro