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FILED: BRONX COUNTY CLERK 1072972014 05:33 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 10/29/2014
EXHIBIT “J”
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF BRONX
resneqmeeeeneennnae neenmeree seinen aC SRST aa Index No.: 21169/11
KELLEY PHILLIPS,
Plaintiff, FURTHER DEMAND FOR
HIPAA-COMPLIANT
- against - MEDICAL
AUTHORIZATIONS
DREW SWISS and MONTEFIORE MEDICAL CENTER,
Defendants.
aes cncniea atin es cssissinaiaii Aa ann NERA RA Serena
TO: PLAINTIFF
PLEASE TAKE NOTICE, that pursuant to CPLR Article 31, plaintiff is required to
serve the following within twenty (20) days after receipt of this demand upon HAVKINS
ROSENFELD RITZERT & VARRIALE, LLP, attorneys for defendant, MONTEFIORE
MEDICAL CENTER:
1 Duly executed and acknowledged written authorizations which are in full
compliance with the Health Insurance Portability and Accountability Act (“HIPAA”) so
that defendant herein may secure full and complete copies of any and all records from the
following facilities:
a. Facility/facilities, physicians, medical providers, institutions and/or
hospitals where plaintiff received relating to her test-taking anxiety in
2007 (as described in the Florida Institute of Technology psychodiagnostic
evaluation dated April 25, 2013);
Records and films from the facility where plaintiff underwent her cervical
spine MRI on September 10, 2012;
Records and films from the facility where plaintiff underwent her cervical
spine x-rays on September 10, 2012;
Records and films from the facility where plaintiff underwent her /umbar
spine MRI on September 10, 2012;
Records and films from the facility where plaintiff underwent her /umbar
spine x-rays on September 10, 2012;
Records and films from the facility where plaintiff underwent her cervical
spine MRI in August 2011;
Records and films from NeuroSkeletal Imaging for the following:
1 CT of the lumbar spine post discogram dated December 27,
2012;
ul Cervical spine MRI dated August 13, 2013;
iit Cervical spine MRI dated December 6, 2013;
lV. Thoracic spine MRI dated December 6, 2013;
Lumbar spine MRI dated December 6, 2013;
CT of the cervical spine post discogram dated December 9,
2013;
Facility/facilities, physicians, medical providers, institutions and/or
hospitals where plaintiff received treatment relating injuries sustained in
her November 2013 fall down the stairs (as described in plaintiff's records
received from The B.A.C.K. Center and Holmes Medical Center);
Records and films from the facility where plaintiff underwent /umbar
spine MRI (as referenced in plaintiffs records received from The
B.A.C.K. Center and Holmes Medical Center);
Records and films from the facility/facilities where plaintiff underwent
MRI and CT scans of the cervical spine performed following plaintiff's fall
down stairs in November 2013 (as referenced in plaintiffs records
received from The B.A.C.K. Center;
Upon your failure to comply you will be precluded at the trial of this action from offering
any evidence of the conditions described in the reports or records demanded or offering evidence
concerning any part of the hospital records, medical records, x-ray reports or reports of other
technicians not made available, nor will the court hear the testimony of any physicians whose
medical reports have not been served pursuant to the aforesaid demand.
PLEASE TAKE FURTHER NOTICE, that authorizations are to contain full and
proper names and addresses of the providers and of plaintiff including any other names she may
also be known by, her initials in Section 9(a), together with any necessary identifying
information, such as policy and claim numbers, if applicable, to obtain the requisite records.
Dated: Mineola, New York
July 18, 2014
HAVKINS ROSENFELD RITZERT
& VARRIALE, LLP
By:
YGDI PDTC
/ Jinan Monique Arafat, Esq.
Altorneys for Defendant
MONTEFIORE MEDICAL CENTER
114 Old Country Road, Suite 300
Mineola, New York 11501
(516) 620-1700
HRRV File No.: 11190-000305
TO:
HACH & ROSE, LLP
Attorneys for Plaintiff
Kelley Phillips
185 Madison Avenue, 14" Floor
New York, New York 10016
(212) 779-0057
O’CONNOR, MCGUINESS, CONTE,
DOYLE & OLESON
Attorneys for Defendant
DREW SWISS
One Barker Avenue, Suite 675
White Plains, New York 10601
(914) 948-4500
AFFIDAVIT OF SERVICE
STATE OF NEW YORK )
)ss.
COUNTY OF NASSAU )
JACQUELINE SCIUBBA being duly sworn, deposes and says:
Iam not a party to the action, am over 18 years of age and reside in East Meadow, New York
On the 21" day of July, 2014, I served a true copy of the within FURTHER DEMAND FOR
HIPAA-COMPLIANT MEDICAL AUTHORIZATIONS, by mailing the same in a sealed envelope,
with postage prepaid thereon, in an official depository of the United States Postal Service within the State
of New York, addressed to the last known address of the addressees as indicated below:
HACH & ROSE, LLP O’CONNOR, MCGUINESS, CONTE,
185 Madison Avenue, 14" Floor DOYLE & OLESON
New York, New York 10016 One Barker Avenue, Suite 675
White Plains, New York 10601
Nki Ci
seb
“JACQUELINE SC UBBA
eeu
a I—
Sworn to before me this
21% day of July, “O)
Hf torn lfPH
Notary Public
Notery Publi lic State of New Yor
Gualitedledin Nassay
Commission t:No. O1HY6233208
solos December 27, 29 _) UY
Preview
FILED: BRONX COUNTY CLERK 1072972014 05:33 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 10/29/2014 EXHIBIT “J” SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF BRONX resneqmeeeeneennnae neenmeree seinen aC SRST aa Index No.: 21169/11 KELLEY PHILLIPS, Plaintiff, FURTHER DEMAND FOR HIPAA-COMPLIANT - against - MEDICAL AUTHORIZATIONS DREW SWISS and MONTEFIORE MEDICAL CENTER, Defendants. aes cncniea atin es cssissinaiaii Aa ann NERA RA Serena TO: PLAINTIFF PLEASE TAKE NOTICE, that pursuant to CPLR Article 31, plaintiff is required to serve the following within twenty (20) days after receipt of this demand upon HAVKINS ROSENFELD RITZERT & VARRIALE, LLP, attorneys for defendant, MONTEFIORE MEDICAL CENTER: 1 Duly executed and acknowledged written authorizations which are in full compliance with the Health Insurance Portability and Accountability Act (“HIPAA”) so that defendant herein may secure full and complete copies of any and all records from the following facilities: a. Facility/facilities, physicians, medical providers, institutions and/or hospitals where plaintiff received relating to her test-taking anxiety in 2007 (as described in the Florida Institute of Technology psychodiagnostic evaluation dated April 25, 2013); Records and films from the facility where plaintiff underwent her cervical spine MRI on September 10, 2012; Records and films from the facility where plaintiff underwent her cervical spine x-rays on September 10, 2012; Records and films from the facility where plaintiff underwent her /umbar spine MRI on September 10, 2012; Records and films from the facility where plaintiff underwent her /umbar spine x-rays on September 10, 2012; Records and films from the facility where plaintiff underwent her cervical spine MRI in August 2011; Records and films from NeuroSkeletal Imaging for the following: 1 CT of the lumbar spine post discogram dated December 27, 2012; ul Cervical spine MRI dated August 13, 2013; iit Cervical spine MRI dated December 6, 2013; lV. Thoracic spine MRI dated December 6, 2013; Lumbar spine MRI dated December 6, 2013; CT of the cervical spine post discogram dated December 9, 2013; Facility/facilities, physicians, medical providers, institutions and/or hospitals where plaintiff received treatment relating injuries sustained in her November 2013 fall down the stairs (as described in plaintiff's records received from The B.A.C.K. Center and Holmes Medical Center); Records and films from the facility where plaintiff underwent /umbar spine MRI (as referenced in plaintiffs records received from The B.A.C.K. Center and Holmes Medical Center); Records and films from the facility/facilities where plaintiff underwent MRI and CT scans of the cervical spine performed following plaintiff's fall down stairs in November 2013 (as referenced in plaintiffs records received from The B.A.C.K. Center; Upon your failure to comply you will be precluded at the trial of this action from offering any evidence of the conditions described in the reports or records demanded or offering evidence concerning any part of the hospital records, medical records, x-ray reports or reports of other technicians not made available, nor will the court hear the testimony of any physicians whose medical reports have not been served pursuant to the aforesaid demand. PLEASE TAKE FURTHER NOTICE, that authorizations are to contain full and proper names and addresses of the providers and of plaintiff including any other names she may also be known by, her initials in Section 9(a), together with any necessary identifying information, such as policy and claim numbers, if applicable, to obtain the requisite records. Dated: Mineola, New York July 18, 2014 HAVKINS ROSENFELD RITZERT & VARRIALE, LLP By: YGDI PDTC / Jinan Monique Arafat, Esq. Altorneys for Defendant MONTEFIORE MEDICAL CENTER 114 Old Country Road, Suite 300 Mineola, New York 11501 (516) 620-1700 HRRV File No.: 11190-000305 TO: HACH & ROSE, LLP Attorneys for Plaintiff Kelley Phillips 185 Madison Avenue, 14" Floor New York, New York 10016 (212) 779-0057 O’CONNOR, MCGUINESS, CONTE, DOYLE & OLESON Attorneys for Defendant DREW SWISS One Barker Avenue, Suite 675 White Plains, New York 10601 (914) 948-4500 AFFIDAVIT OF SERVICE STATE OF NEW YORK ) )ss. COUNTY OF NASSAU ) JACQUELINE SCIUBBA being duly sworn, deposes and says: Iam not a party to the action, am over 18 years of age and reside in East Meadow, New York On the 21" day of July, 2014, I served a true copy of the within FURTHER DEMAND FOR HIPAA-COMPLIANT MEDICAL AUTHORIZATIONS, by mailing the same in a sealed envelope, with postage prepaid thereon, in an official depository of the United States Postal Service within the State of New York, addressed to the last known address of the addressees as indicated below: HACH & ROSE, LLP O’CONNOR, MCGUINESS, CONTE, 185 Madison Avenue, 14" Floor DOYLE & OLESON New York, New York 10016 One Barker Avenue, Suite 675 White Plains, New York 10601 Nki Ci seb “JACQUELINE SC UBBA eeu a I— Sworn to before me this 21% day of July, “O) Hf torn lfPH Notary Public Notery Publi lic State of New Yor Gualitedledin Nassay Commission t:No. O1HY6233208 solos December 27, 29 _) UY