Preview
FILED: BRONX COUNTY CLERK 01/08/2021 02:09 PM INDEX NO. 35123/2019E
NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 01/08/2021
Exhibit A
FILED: BRONX COUNTY CLERK 01/08/2021 02:09 PM INDEX NO. 35123/2019E
NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 01/08/2021
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF BRONX
--------------- ---------------------------------------------X
TYKIMA THOMPSON, Index No.: 35123/2019E
Plaintiff,
RESPONSE TO NOTICE
FOR DISCOVERY AND
-against- INSPECTION DATED
JUNE 30, 2020
EVEREST SCAFFOLDING INC. and JADERLYN A.
GALAN SANTAMARIA,
Defendants.
----------------------------------------------------------- ---X
Plaintiff TYKIMA THOMPSON by her attorneys, LEAV & STEINBERG, LLP,
responding to defendant's EVEREST SCAFFOLDING INC. demand for discovery and
inspection dated June 30, 2020, submits, upon information and belief, as follows:
1. Enclosed please fmd a duly executed HIPAA compliant authorization to obtain
plaintiff's No-Fault file from GEICO Insurance Company under claim no.: 0492051890101023
for prior October 11, 2017 accident.
2. Enclosed please find the following authorizations with regards to plaintiff's prior
June 18, 2013 accident:
a) Travelers Indemnity Company under claim no.: HQY8540003;
b) Infinity Insurance Company under claim no.: 20011984738;
PLEASE TAKE NOTICE that plaintiff reserves the right to serve supplemented and/or
amended responses up to the time of trial.
Dated: New York, New York
January 7, 2021
/s/ &
By: Alexander Kran III
LEAV & STEINBERG, LLP
Attorneys for Plaintiff
FILED: BRONX COUNTY CLERK 01/08/2021 02:09 PM INDEX NO. 35123/2019E
NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 01/08/2021
75 Broad Street, Suite 1601
New York, New York 10004
Tel. No.: (212) 766-5222
Fax No.: (212) 693-2377
L&S File No.: 186992
To.:
PICCIANO & SCAHILL, P.C.
Attorneys for Defendants
EVEREST SCAFFOLDING INC. and
JADERLYN A. GALAN SANTAMARIA
1065 Stewart Avenue, Suite 210
Bethpage, NY 11714
Tel. No.: (516)294-5200
FILED: BRONX COUNTY CLERK 01/08/2021 02:09 PM INDEX NO. 35123/2019E
NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 01/08/2021
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)
. .. .......... --
atient Name ""- "= Social Security Number
Tykinia Thom pson
Patien t Addrece
Î, or myluthorized representative, request that health f±mation regarding my care and treatment be released as set forth on this form:
In accordance with the 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
BIV* RELATED INFORMATION
TREATMENT, except psychotherapy notes, and CONFIDENTIAL only if I place my initials on
the epprepeate 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 penuitted 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 hi-s"lon without adedmion. If I
experience discrimination because of the release or disclosure of HIV-related iüfcargdios, 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 anderstand that signing this aütharization 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 and state law.
6. THIS AVIRORIZATION DOES NOT ACTHORIZE 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 d s of he rovider entity to release this informationi ,.-,
A d . O o $OK T/. ñM &pl110. V A
Narge and ad41ressof persqn(s) or cate y ry of person to whom this information bid be sent
Q
PICCIANO & SCAHILL, P.C., 1065 Stewart Avenue, Suite 210, Bethpage, NY 11714 .
9(a). Sp fic information to b eleasuf:
dical Record from (insert date) to (insert date) Present
tire Medical Records, including p1nt listo office notes (exceptisydthcrapy notes), test results, radiology studies, film:
referrals, onsults illi resprds, insurance records, and records sent to you by other health care providers.
MÙ\
W
Other: 1 A Include: (Indicate by Initialing)
OfWW (bY Wh0103S k Alcohol/Drug Treatment
DŸT4 W)/O Ghi~f N YF Mental/llealth Information
ft HIV-related Information
Authorization to Discuss Health Infonnation
(b) O By initialing liere I authorize
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 released of information: 11. Date or event on which this authorization will expire:
a t 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 patienti
All items on this form have been completed and my questions about this form have been answ6red. In addition I have been provided s
copy of the ibrm.
JONATHAN D. KANTOR
Notary Public, State of New York
No. 01KA6213789
Date: Qualified In Kings County
Signature o pattent5sentative authorized by law. Commission Expires Nov. 16,2
* Human '- rs:
2-acy Virus that causesAIDS. The New York State Public Health Law protects information whi r . o
identify someone as having HIV symptoms or infection and information regarding a person's contacts.
FILED: BRONX COUNTY CLERK 01/08/2021 02:09 PM INDEX NO. 35123/2019E
NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 01/08/2021
OCA Official Form No.: 960
AUTHORIZATION FOR RELEASE OF HEAIXH INFORMATION PURSUANT TO HIPAA
(This form has been approved by the New York Stite Department of Health)
.. ......-
Patient Name na6 ^™ Sodal kncl*v N"mhar
Tykima Thompson
f, or my uthorized representative, request that health ik-maion re ar ing my care and treatment be released as set forth on this form:
In •~·~d- with the 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 IMe-tion relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
HIV* RELATED INFORMATION
TREATMENT, except psychotherapy notes, and CONFIDENTIAL only if I place my initials on
the eppMpete 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 w^won 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 i den 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 infonnation without reC-- Lh 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 Coromission of Human Rights at (212) 306-7450. These agencies are responsible for
protecting my rights.
3. I have the right to revoke this entenden at any time by writing to the health care pmvider 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, enrolhnent in a health plan, or eligibility for benefits
will not be conditidned 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
radiscles"ñ may no longer be protected by federal and state law.
6. THIS AUTHORIZATION D OES NOT AUTHORIZE YOU TO DISCUSS MY REALTH 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 y entity to release this information:
R Narge and ad(Iress of perp n(s) or c tegory of person t bhorn this information will be sent:
PICCIANO & SCAHIL , P.C., 1065 Stewart Avenue, Suite 210, Bethpage,'NY 11714
9(a). fic information to be releas=f:
dical Record from (insert date) to (insert date) Present
ntire Medical Records, including patient historiestoffice notes (excep sytli'otherapy notes), test results, radiclegy studies, filme
referrals, consults, billi cords insurance records, and records sent to you by other health care providers.
Other: TX)At á, 20b Include: (Indicate by Initialing)
( if NC W Alcohol/Drug Treatment
N() ". Gt ýdh T Mental/Health Information
ff HIV-related Information
Authorization to Discuss Health Infonnation
(b) O By initialing liere I authorize
Name of individual health care provider
to discuss my health tr,fermãtiGr. with my attorney, or a governmental agency, listed here:
(Attorney/Firm Name or Govemmental Agency Name)
10.Re on for released of ide len: 1L Date or event on which this authorization will expire:
a t request of individual End of Litigation
q Other: Litigation
12.1f not the patient, name of person signing form: 13. Authority to sign on behalf of patient
All items on this form have been complete3and my questions about this form have been answered. In addition, I have been provided a
copy ofthe form.
JONATHAN D. KANTOR
Notary Public, State of New York
No. 01KA6213789
Date: Qualified In Kings County
Signature o pattent or repmentative authorized by law. Cownission Expires Nov. 16, 2
* Human I= reas
ñay Virus that causesAIDS. TheNew York State Public Health Law protects information whi o
identify someone as having HIV symptoms or infection and information regardi a person's contacts.
FILED: BRONX COUNTY CLERK 01/08/2021 02:09 PM INDEX NO. 35123/2019E
NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 01/08/2021
OCA Official Form No-: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
(This form has been approved by the New York Sta'te Department of Health)
Patient Name ¾ or Wh Roem smrHv Number
Tykima Thompson
pena AAt-
f, or mylictize r esentative, request that health En:t:n reg6rding my care and treatment be released as set forth on this form:
In accordance with the New York State Law and the Privacy rule of the Health Insurance Portability and Acceedi!ibs Act of 1996
(HIPAA), I understand that:
1, This authorization may include disclosure of irfe==etica relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
HIV* RELATED INFORMATION
TREATMENT, except psychotherapy notes, and CONFIDENTIAL only if Iplace my initials on
the spprepdate line in item 9(a). In the event the health Meetion 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 infounation 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 infe:md.cn, 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 infonnation without authorization. If I
experience didaiwton because of the release or disclosure of HIV-related infe-W.en, I may contact the New York State Division of
Human Rights at (212) 480-2493 or the New York City Commission of Human kights 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 authodzation except to the extent that action has already been taken based on this authorization.
4. I understand that signing this authcrization is voluntary- My treatment, payment, emeMment in a health plan, or eligibility for benefits
will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this ananMan might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protected by federal and state law.
6. THIS ACTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITHANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of health provider or entity to ele e this information:
Natpe and a lress of persqn(s) or category of person to whom this if eti^a will be sent: C
PICCIANO & SCAHILL, P.C., 1065 Stewart Avenue, Suite 210, Bethpage, NY 11714
9(a). Spycific infortnation to be releasÔd:
V edical Record from (insert date) to (insert date) Present
ntire Medical Records, including patient historiestoffice notes (excep sycli'otherapy notes), test results, radiology studies, fibn
referrals consults, bil)ing r cords, insurance records, and records sent to you by other health care providers.
Other: Ù)At L / Ff> 90 6 Include: (Indicate by Initialing)
f Ú Î (1 Alcohol/Drug Treatment
d0 C O Mental/1lealth Information
WT HIV-related Information
Authorization to Discuss Health Information
(b) O By initiating here Iauthorize
Name of individual health care provider
to discuss my health information with my attorney, or a governmental agency, listed here:
(Attomey/FirmName or Governmental Agency Name
10.Reason for released of information: 11. Date or event on which this authorization will expire:
a t request of individual End ofLitigation
Other: Litigation
12. Itnot the patient, name of person signing form: 13. Authority to sign on behalf of patienti
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.
JONATHAN D. KANTOR
Notary Public, State of New York
No. 01KA6213789
Date: Quanfied in Kings County
Signaté~e of aEnt offepresentative authorized by law. Cornission Expires Nov. 16, 2
* Human r •as
Immunedeficiency Virus that causesAIDS. The New York State Public Health Law protects information whi o
identify someone as having HIV symptoms or infection and information regarding a person's contacts.
Preview
FILED: BRONX COUNTY CLERK 01/08/2021 02:09 PM INDEX NO. 35123/2019E NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 01/08/2021 Exhibit A FILED: BRONX COUNTY CLERK 01/08/2021 02:09 PM INDEX NO. 35123/2019E NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 01/08/2021 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF BRONX --------------- ---------------------------------------------X TYKIMA THOMPSON, Index No.: 35123/2019E Plaintiff, RESPONSE TO NOTICE FOR DISCOVERY AND -against- INSPECTION DATED JUNE 30, 2020 EVEREST SCAFFOLDING INC. and JADERLYN A. GALAN SANTAMARIA, Defendants. ----------------------------------------------------------- ---X Plaintiff TYKIMA THOMPSON by her attorneys, LEAV & STEINBERG, LLP, responding to defendant's EVEREST SCAFFOLDING INC. demand for discovery and inspection dated June 30, 2020, submits, upon information and belief, as follows: 1. Enclosed please fmd a duly executed HIPAA compliant authorization to obtain plaintiff's No-Fault file from GEICO Insurance Company under claim no.: 0492051890101023 for prior October 11, 2017 accident. 2. Enclosed please find the following authorizations with regards to plaintiff's prior June 18, 2013 accident: a) Travelers Indemnity Company under claim no.: HQY8540003; b) Infinity Insurance Company under claim no.: 20011984738; PLEASE TAKE NOTICE that plaintiff reserves the right to serve supplemented and/or amended responses up to the time of trial. Dated: New York, New York January 7, 2021 /s/ & By: Alexander Kran III LEAV & STEINBERG, LLP Attorneys for Plaintiff FILED: BRONX COUNTY CLERK 01/08/2021 02:09 PM INDEX NO. 35123/2019E NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 01/08/2021 75 Broad Street, Suite 1601 New York, New York 10004 Tel. No.: (212) 766-5222 Fax No.: (212) 693-2377 L&S File No.: 186992 To.: PICCIANO & SCAHILL, P.C. Attorneys for Defendants EVEREST SCAFFOLDING INC. and JADERLYN A. GALAN SANTAMARIA 1065 Stewart Avenue, Suite 210 Bethpage, NY 11714 Tel. No.: (516)294-5200 FILED: BRONX COUNTY CLERK 01/08/2021 02:09 PM INDEX NO. 35123/2019E NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 01/08/2021 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) . .. .......... -- atient Name ""- "= Social Security Number Tykinia Thom pson Patien t Addrece Î, or myluthorized representative, request that health f±mation regarding my care and treatment be released as set forth on this form: In accordance with the 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 BIV* RELATED INFORMATION TREATMENT, except psychotherapy notes, and CONFIDENTIAL only if I place my initials on the epprepeate 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 penuitted 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 hi-s"lon without adedmion. If I experience discrimination because of the release or disclosure of HIV-related iüfcargdios, 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 anderstand that signing this aütharization 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 and state law. 6. THIS AVIRORIZATION DOES NOT ACTHORIZE 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 d s of he rovider entity to release this informationi ,.-, A d . O o $OK T/. ñM &pl110. V A Narge and ad41ressof persqn(s) or cate y ry of person to whom this information bid be sent Q PICCIANO & SCAHILL, P.C., 1065 Stewart Avenue, Suite 210, Bethpage, NY 11714 . 9(a). Sp fic information to b eleasuf: dical Record from (insert date) to (insert date) Present tire Medical Records, including p1nt listo office notes (exceptisydthcrapy notes), test results, radiology studies, film: referrals, onsults illi resprds, insurance records, and records sent to you by other health care providers. MÙ\ W Other: 1 A Include: (Indicate by Initialing) OfWW (bY Wh0103S k Alcohol/Drug Treatment DŸT4 W)/O Ghi~f N YF Mental/llealth Information ft HIV-related Information Authorization to Discuss Health Infonnation (b) O By initialing liere I authorize 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 released of information: 11. Date or event on which this authorization will expire: a t 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 patienti All items on this form have been completed and my questions about this form have been answ6red. In addition I have been provided s copy of the ibrm. JONATHAN D. KANTOR Notary Public, State of New York No. 01KA6213789 Date: Qualified In Kings County Signature o pattent5sentative authorized by law. Commission Expires Nov. 16,2 * Human '- rs: 2-acy Virus that causesAIDS. The New York State Public Health Law protects information whi r . o identify someone as having HIV symptoms or infection and information regarding a person's contacts. FILED: BRONX COUNTY CLERK 01/08/2021 02:09 PM INDEX NO. 35123/2019E NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 01/08/2021 OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEAIXH INFORMATION PURSUANT TO HIPAA (This form has been approved by the New York Stite Department of Health) .. ......- Patient Name na6 ^™ Sodal kncl*v N"mhar Tykima Thompson f, or my uthorized representative, request that health ik-maion re ar ing my care and treatment be released as set forth on this form: In •~·~d- with the 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 IMe-tion relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH HIV* RELATED INFORMATION TREATMENT, except psychotherapy notes, and CONFIDENTIAL only if I place my initials on the eppMpete 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 w^won 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 i den 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 infonnation without reC-- Lh 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 Coromission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights. 3. I have the right to revoke this entenden at any time by writing to the health care pmvider 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, enrolhnent in a health plan, or eligibility for benefits will not be conditidned 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 radiscles"ñ may no longer be protected by federal and state law. 6. THIS AUTHORIZATION D OES NOT AUTHORIZE YOU TO DISCUSS MY REALTH 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 y entity to release this information: R Narge and ad(Iress of perp n(s) or c tegory of person t bhorn this information will be sent: PICCIANO & SCAHIL , P.C., 1065 Stewart Avenue, Suite 210, Bethpage,'NY 11714 9(a). fic information to be releas=f: dical Record from (insert date) to (insert date) Present ntire Medical Records, including patient historiestoffice notes (excep sytli'otherapy notes), test results, radiclegy studies, filme referrals, consults, billi cords insurance records, and records sent to you by other health care providers. Other: TX)At á, 20b Include: (Indicate by Initialing) ( if NC W Alcohol/Drug Treatment N() ". Gt ýdh T Mental/Health Information ff HIV-related Information Authorization to Discuss Health Infonnation (b) O By initialing liere I authorize Name of individual health care provider to discuss my health tr,fermãtiGr. with my attorney, or a governmental agency, listed here: (Attorney/Firm Name or Govemmental Agency Name) 10.Re on for released of ide len: 1L Date or event on which this authorization will expire: a t request of individual End of Litigation q Other: Litigation 12.1f not the patient, name of person signing form: 13. Authority to sign on behalf of patient All items on this form have been complete3and my questions about this form have been answered. In addition, I have been provided a copy ofthe form. JONATHAN D. KANTOR Notary Public, State of New York No. 01KA6213789 Date: Qualified In Kings County Signature o pattent or repmentative authorized by law. Cownission Expires Nov. 16, 2 * Human I= reas ñay Virus that causesAIDS. TheNew York State Public Health Law protects information whi o identify someone as having HIV symptoms or infection and information regardi a person's contacts. FILED: BRONX COUNTY CLERK 01/08/2021 02:09 PM INDEX NO. 35123/2019E NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 01/08/2021 OCA Official Form No-: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA (This form has been approved by the New York Sta'te Department of Health) Patient Name ¾ or Wh Roem smrHv Number Tykima Thompson pena AAt- f, or mylictize r esentative, request that health En:t:n reg6rding my care and treatment be released as set forth on this form: In accordance with the New York State Law and the Privacy rule of the Health Insurance Portability and Acceedi!ibs Act of 1996 (HIPAA), I understand that: 1, This authorization may include disclosure of irfe==etica relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH HIV* RELATED INFORMATION TREATMENT, except psychotherapy notes, and CONFIDENTIAL only if Iplace my initials on the spprepdate line in item 9(a). In the event the health Meetion 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 infounation 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 infe:md.cn, 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 infonnation without authorization. If I experience didaiwton because of the release or disclosure of HIV-related infe-W.en, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human kights 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 authodzation except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authcrization is voluntary- My treatment, payment, emeMment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this ananMan might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal and state law. 6. THIS ACTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITHANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address of health provider or entity to ele e this information: Natpe and a lress of persqn(s) or category of person to whom this if eti^a will be sent: C PICCIANO & SCAHILL, P.C., 1065 Stewart Avenue, Suite 210, Bethpage, NY 11714 9(a). Spycific infortnation to be releasÔd: V edical Record from (insert date) to (insert date) Present ntire Medical Records, including patient historiestoffice notes (excep sycli'otherapy notes), test results, radiology studies, fibn referrals consults, bil)ing r cords, insurance records, and records sent to you by other health care providers. Other: Ù)At L / Ff> 90 6 Include: (Indicate by Initialing) f Ú Î (1 Alcohol/Drug Treatment d0 C O Mental/1lealth Information WT HIV-related Information Authorization to Discuss Health Information (b) O By initiating here Iauthorize Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: (Attomey/FirmName or Governmental Agency Name 10.Reason for released of information: 11. Date or event on which this authorization will expire: a t request of individual End ofLitigation Other: Litigation 12. Itnot the patient, name of person signing form: 13. Authority to sign on behalf of patienti 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. JONATHAN D. KANTOR Notary Public, State of New York No. 01KA6213789 Date: Quanfied in Kings County Signaté~e of aEnt offepresentative authorized by law. Cornission Expires Nov. 16, 2 * Human r •as Immunedeficiency Virus that causesAIDS. The New York State Public Health Law protects information whi o identify someone as having HIV symptoms or infection and information regarding a person's contacts.