Preview
FILED: NEW YORK COUNTY CLERK 10/02/2023 12:43 PM INDEX NO. 162516/2019
NYSCEF DOC. NO. 20 RECEIVED NYSCEF: 10/02/2023
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
-------------------------------------------------x
ERNEST WATSON and ABBY WATSON, Law Dep't No. 2020 002205
Plainti ITs, Indcx No. 16251612019
against SUBPOENA DUCES TECUM
THE CITY OF NEW YORK;
Det. "JOHN" BRADY Shield No. 646
and P.O. RENE SOTO,
Defendants.
-------------------------------------------------------x
TO: JASA - Geriatric Mental Health Services
1 Fordham Plaza - Sutte 908
Bronx, NY 10458
WE COMMAND YOU, Thai all btl.'i;ness and excuses being laid aside. you and each ofyou appear and
aI/end be/ore a notary public, 01 the office o/the undersigned allorney Robert Dembia. P.e. 160 Broadway,
Room 610, New York. NY 10038 on October ~ 2023 al /0:00 ;tM and at any recessed or
adjourned date /0 give testimony, and /0 prodllce books, papers and other records including notes a/weekly
psychotherapy sessions and oflrer medical records, statements, re/errals, correspondence) as required by
CPLR Article 23. on behalf of the plaintiffand that )'011 produce at the lime and place aforesaid. the follOWing:
Re: Ernest Watson, DOB
See attached copy of .... .. .. tv ... . .: hart, for easy reference
now in your custody. and all other deeds. evidences and writings, which you have in your custody or power.
concerning the premises.
AND all billing records, with itemization of services, goods or the item for whicb tbe charge was
made, including payments, credits and source of payments.
PLEASE PROVIDE CUSTODIAN CERTIFICATION SIGNED AND NOTARIZED.
RECORDS SHALL NOT BE PROVIDED UNLESS THE SUBPOENA IS ACCOMPANIED BY A
WRITTEN AUTHORIZATION BY THE PATIENT
A copy of this subpoena sball be annexed to the records pro~ided
ROBERT DEMBIA, P.C.
Attorney for Plaintifits)
Dated: October X,2023 ~u-fJkJ
By: Robert Dembia
160 Broadway, 6'" Floor
'~(l'v·; l-. . . . . ;f-, New York, NY 10038
(2 12) 226-5905
rdembia@aol.com
V-
FILED: NEW YORK COUNTY CLERK 10/02/2023 12:43 PM INDEX NO. 162516/2019
NYSCEF DOC. NO. 20 RECEIVED NYSCEF: 10/02/2023
0<:'\ nffidall:orm Su.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
IThis form has been lIppro\'ed ~Y t' ...• ~"'Healthl
Patient Name Social S\.'Curity Numb"...
Ernest Watson
Patient Address
2414 Creston A,'c., Bronx, NY 10468 Apt. 28
I, or my authorized representative, request that health informati. Ie released as set I(mlt on this foml:
In accordance with New York State Law and the Privacy Rule c I Accountability Act of 1996
(~III)AA). I understand that:
I. This authori711tion may include disclosure of information relating to ,\LCOIiOI. and DRUG ABUSE, MENTAl. ilEALTH
TREATME!'I.T. e.xcept psychotherapy not\.'S. and CONFIDENTIAL IIIV* 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 ty~'S of infomtation. and I
initial the line on the box in Item 9(a). I specilically authorize release of such infomtation to the person(s) indicated in Item 8.
2. If I am authorizing the release of I-IIV~related. alcohol or drug treatment. or m\.'ntal health treatment information. the recipient is
prlJhibited from redisclosing such information without my authorization unless pcnnitted to do so under federal or state law. I
understand that I have the right to request a li!>1 ofpcople who may receive or usc my HlV~related infomlation wilhoutauthori7.ation. If
I experience discrimination because of the release or disclosure of "IIV·related infornmtion, I mny contact the New York State Division
of HUlUan Rights at (212) 480·2493 or the New York City Commission of Human Rights at (212) 306·7450. These agencies arc
responsible for protecting my rights.
3. I have the right to revoke this authorizutioll at any time by writing to the health care provider listed below. I understand that I may
revoke this authorization except to the el(tent that aclion has already been taken based on this authorization.
4. I understand that signing this authoriz.1tiun is voluntary. My treatment. payment. enrollment in a hcalth plan. or eligibility for
benefits will not be conditioned upon my authoril..1tion of this disclosure.
5. Information disclosed under this authoril.ation might be redisclosed by the no'Cipient (except as noted abo\'e in Item 2). and this
redisclosuR: may no longer be protected by federal or state law.
6. TillS AUTHORIZATION DOES NOT AllTHORIZE YOU TO DlSClISS MY HEALTH I~FORMATIO~ OR MEDICAL
CARE WITH ANYONE OTHER UlAN TilE ATTORNEY OR GOVERNMENTAL AGE~CY SPECIFIED IN IT ' j 19 b.
D
9(a). Specific infonnation to be released:
a Medical Record from (insen date) to (insert date) _ _ _ _ _ _ __
Ia Entire Medical Record. including patient histories, office notes S;PSYChOlhernpy notes), test results. radiology studies. films.
referrals, consults. billing records. insurance records, and re~ords se t to you by other health care providers.
a Other: , 1\ d ~ Include: (lIIdicQte by /IIUi(lUIIS:)
J? t.<..J AlcohollDrug T~"lment
AuChorizntion to Discuss Health Inforntlllion
ffl;;
° .•
Mcntailleallh Infom'''tion
HIV-Related InformaCion
(b) Ia By initialing here _ _ _ _ _ I authorize above provider
Inili;lIs Nllmc nf indi\'idmd helllth care provider
to discuss my health information with my attorney, or a government.,1 agency. listed here:
Robert Dcmbia, P.C.
(AltOnl\! °11:inn Name or Govemml.'I1tal A 'cn . Name)
10. Reason for release of information: II. Date or event on which this authorization will expire:
Ia At request of individual
Ia Other: LeeBa matter Conclusion of Iceal maUer
12. If not the patient. name of person signing form: 13. Authority to sign on behalfofpatient:
All
__
hc~
copy of the rm.
/V]U/
'~'~; g~
• 0
_........-:. Datc:..
.
have been ""01,,0:<1 .nd nly q"",d.., aboullhi, Ii,"" haw h....n&w...... In addhl... I have been ...v;do:
Preview
FILED: NEW YORK COUNTY CLERK 10/02/2023 12:43 PM INDEX NO. 162516/2019 NYSCEF DOC. NO. 20 RECEIVED NYSCEF: 10/02/2023 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK -------------------------------------------------x ERNEST WATSON and ABBY WATSON, Law Dep't No. 2020 002205 Plainti ITs, Indcx No. 16251612019 against SUBPOENA DUCES TECUM THE CITY OF NEW YORK; Det. "JOHN" BRADY Shield No. 646 and P.O. RENE SOTO, Defendants. -------------------------------------------------------x TO: JASA - Geriatric Mental Health Services 1 Fordham Plaza - Sutte 908 Bronx, NY 10458 WE COMMAND YOU, Thai all btl.'i;ness and excuses being laid aside. you and each ofyou appear and aI/end be/ore a notary public, 01 the office o/the undersigned allorney Robert Dembia. P.e. 160 Broadway, Room 610, New York. NY 10038 on October ~ 2023 al /0:00 ;tM and at any recessed or adjourned date /0 give testimony, and /0 prodllce books, papers and other records including notes a/weekly psychotherapy sessions and oflrer medical records, statements, re/errals, correspondence) as required by CPLR Article 23. on behalf of the plaintiffand that )'011 produce at the lime and place aforesaid. the follOWing: Re: Ernest Watson, DOB See attached copy of .... .. .. tv ... . .: hart, for easy reference now in your custody. and all other deeds. evidences and writings, which you have in your custody or power. concerning the premises. AND all billing records, with itemization of services, goods or the item for whicb tbe charge was made, including payments, credits and source of payments. PLEASE PROVIDE CUSTODIAN CERTIFICATION SIGNED AND NOTARIZED. RECORDS SHALL NOT BE PROVIDED UNLESS THE SUBPOENA IS ACCOMPANIED BY A WRITTEN AUTHORIZATION BY THE PATIENT A copy of this subpoena sball be annexed to the records pro~ided ROBERT DEMBIA, P.C. Attorney for Plaintifits) Dated: October X,2023 ~u-fJkJ By: Robert Dembia 160 Broadway, 6'" Floor '~(l'v·; l-. . . . . ;f-, New York, NY 10038 (2 12) 226-5905 rdembia@aol.com V- FILED: NEW YORK COUNTY CLERK 10/02/2023 12:43 PM INDEX NO. 162516/2019 NYSCEF DOC. NO. 20 RECEIVED NYSCEF: 10/02/2023 0<:'\ nffidall:orm Su.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA IThis form has been lIppro\'ed ~Y t' ...• ~"'Healthl Patient Name Social S\.'Curity Numb"... Ernest Watson Patient Address 2414 Creston A,'c., Bronx, NY 10468 Apt. 28 I, or my authorized representative, request that health informati. Ie released as set I(mlt on this foml: In accordance with New York State Law and the Privacy Rule c I Accountability Act of 1996 (~III)AA). I understand that: I. This authori711tion may include disclosure of information relating to ,\LCOIiOI. and DRUG ABUSE, MENTAl. ilEALTH TREATME!'I.T. e.xcept psychotherapy not\.'S. and CONFIDENTIAL IIIV* 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 ty~'S of infomtation. and I initial the line on the box in Item 9(a). I specilically authorize release of such infomtation to the person(s) indicated in Item 8. 2. If I am authorizing the release of I-IIV~related. alcohol or drug treatment. or m\.'ntal health treatment information. the recipient is prlJhibited from redisclosing such information without my authorization unless pcnnitted to do so under federal or state law. I understand that I have the right to request a li!>1 ofpcople who may receive or usc my HlV~related infomlation wilhoutauthori7.ation. If I experience discrimination because of the release or disclosure of "IIV·related infornmtion, I mny contact the New York State Division of HUlUan Rights at (212) 480·2493 or the New York City Commission of Human Rights at (212) 306·7450. These agencies arc responsible for protecting my rights. 3. I have the right to revoke this authorizutioll at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the el(tent that aclion has already been taken based on this authorization. 4. I understand that signing this authoriz.1tiun is voluntary. My treatment. payment. enrollment in a hcalth plan. or eligibility for benefits will not be conditioned upon my authoril..1tion of this disclosure. 5. Information disclosed under this authoril.ation might be redisclosed by the no'Cipient (except as noted abo\'e in Item 2). and this redisclosuR: may no longer be protected by federal or state law. 6. TillS AUTHORIZATION DOES NOT AllTHORIZE YOU TO DlSClISS MY HEALTH I~FORMATIO~ OR MEDICAL CARE WITH ANYONE OTHER UlAN TilE ATTORNEY OR GOVERNMENTAL AGE~CY SPECIFIED IN IT ' j 19 b. D 9(a). Specific infonnation to be released: a Medical Record from (insen date) to (insert date) _ _ _ _ _ _ __ Ia Entire Medical Record. including patient histories, office notes S;PSYChOlhernpy notes), test results. radiology studies. films. referrals, consults. billing records. insurance records, and re~ords se t to you by other health care providers. a Other: , 1\ d ~ Include: (lIIdicQte by /IIUi(lUIIS:) J? t.<..J AlcohollDrug T~"lment AuChorizntion to Discuss Health Inforntlllion ffl;; ° .• Mcntailleallh Infom'''tion HIV-Related InformaCion (b) Ia By initialing here _ _ _ _ _ I authorize above provider Inili;lIs Nllmc nf indi\'idmd helllth care provider to discuss my health information with my attorney, or a government.,1 agency. listed here: Robert Dcmbia, P.C. (AltOnl\! °11:inn Name or Govemml.'I1tal A 'cn . Name) 10. Reason for release of information: II. Date or event on which this authorization will expire: Ia At request of individual Ia Other: LeeBa matter Conclusion of Iceal maUer 12. If not the patient. name of person signing form: 13. Authority to sign on behalfofpatient: All __ hc~ copy of the rm. /V]U/ '~'~; g~ • 0 _........-:. Datc:.. . have been ""01,,0:<1 .nd nly q"",d.., aboullhi, Ii,"" haw h....n&w...... In addhl... I have been ...v;do: