Motion-Secondary: Julie Ayala v. 94th Avenue Jamaica, Llc, Artimus Construction Inc., Hp Jamaica 94th Avenue Housing Development Fund Company Inc, 94th Avenue Jamaica Li Llc
On October 30, 2018 a
Motion-Secondary
was filed
involving a dispute between
Julie Ayala,
and
94Th Avenue Jamaica Li Llc,
94Th Avenue Jamaica, Llc,
Artimus Construction Inc.,
Hp Jamaica 94Th Avenue Housing Development Fund Company Inc,
for Torts - Other Negligence (Premises - Labor Law)
in the District Court of Kings County.
Preview
FILED: KINGS COUNTY CLERK 02/27/2023 02:20 PM INDEX NO. 521818/2018
NYSCEF DOC. NO. 149 RECEIVED NYSCEF: 02/27/2023
HELEN F. DALTON & ASSOCIATES, P.C.
ATTORNEYS AT LAW
Roman Arshalumov
Sofya Janashvili
80-02 Kew Gardens Road, Suite 601, Kew Gardens, NY 11415
Helen F. Dalton, Esq. T. 718.263.9591 Managing Attorneys
| F. 718.263.9598
Foun&ng Partner
HelenDaltonPC@HelenDalton.com
February 27, 2023
Lewis Johs Avallone & Aviles, LLP
1377 Motor Parkway, Suite 400
Islandia, NY 11749
Re: Ayala, Julie A.
DOA: 03/26/2018
Our File No. 119-0256
Dear Counselor:
In response to your demand dated January 18, 2023, enclosed please find the correct
authorization you requested.
Thank you for your time and patience.
Very truly yours,
Cindy Reyes
Litigation Paralegal
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FILED: KINGS COUNTY CLERK 02/27/2023 02:20 PM INDEX NO. 521818/2018
NYSCEF DOC. NO. 149 RECEIVED NYSCEF: 02/27/2023
.. 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 Securi Number
Julie Ayala
Patient Address
1039 E 223rd Street Bronx, NY 10466
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 relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except psychotherapy HIV*
TREATMENT, notes, and CONFIDENTIAL 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 at (212) 480-2493 or the New York City Commission
Rights 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 not be conditioned
will 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:
warren stred orthofebc
or category
RebefifNtfon
of person to whom
P.C* J Rec Ave 4% New
yo4 A/y
looM
8. Name and address of person(s) this information will be sent:
LewrS gTohs AV½llooe-
AVhehM-8 1377 Motoc Parf1my,set' s
fç/Vy 4744
9(a). S cific information to be released:
Medical Record from (insert date) 3 1 b 10 to (insert date) Presen
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 IHV-Related Information
(b) O 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 authorization will expire:
O At request of individual
8 Other: LITIGATION END OF LITIGATION
12. If not the patient, name of person signing form: 13. Authority to sign on behalf of patient:
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
O s Date:
Signature of pa ent or representative authori by law.
* Human Im unodeficiency 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.
2 of 2
Preview
FILED: KINGS COUNTY CLERK 02/27/2023 02:20 PM INDEX NO. 521818/2018 NYSCEF DOC. NO. 149 RECEIVED NYSCEF: 02/27/2023 HELEN F. DALTON & ASSOCIATES, P.C. ATTORNEYS AT LAW Roman Arshalumov Sofya Janashvili 80-02 Kew Gardens Road, Suite 601, Kew Gardens, NY 11415 Helen F. Dalton, Esq. T. 718.263.9591 Managing Attorneys | F. 718.263.9598 Foun&ng Partner HelenDaltonPC@HelenDalton.com February 27, 2023 Lewis Johs Avallone & Aviles, LLP 1377 Motor Parkway, Suite 400 Islandia, NY 11749 Re: Ayala, Julie A. DOA: 03/26/2018 Our File No. 119-0256 Dear Counselor: In response to your demand dated January 18, 2023, enclosed please find the correct authorization you requested. Thank you for your time and patience. Very truly yours, Cindy Reyes Litigation Paralegal 1 of 2 FILED: KINGS COUNTY CLERK 02/27/2023 02:20 PM INDEX NO. 521818/2018 NYSCEF DOC. NO. 149 RECEIVED NYSCEF: 02/27/2023 .. 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 Securi Number Julie Ayala Patient Address 1039 E 223rd Street Bronx, NY 10466 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 relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH except psychotherapy HIV* TREATMENT, notes, and CONFIDENTIAL 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 at (212) 480-2493 or the New York City Commission Rights 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 not be conditioned will 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: warren stred orthofebc or category RebefifNtfon of person to whom P.C* J Rec Ave 4% New yo4 A/y looM 8. Name and address of person(s) this information will be sent: LewrS gTohs AV½llooe- AVhehM-8 1377 Motoc Parf1my,set' s fç/Vy 4744 9(a). S cific information to be released: Medical Record from (insert date) 3 1 b 10 to (insert date) Presen 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 IHV-Related Information (b) O 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 authorization will expire: O At request of individual 8 Other: LITIGATION END OF LITIGATION 12. If not the patient, name of person signing form: 13. Authority to sign on behalf of patient: 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 O s Date: Signature of pa ent or representative authori by law. * Human Im unodeficiency 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. 2 of 2