Preview
FILED: KINGS COUNTY CLERK 06/17/2022 04:30 PM INDEX NO. 521669/2020
NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 06/17/2022
EXHIBIT 1
FILED: KINGS COUNTY CLERK 06/17/2022 04:30 PM INDEX NO. 521669/2020
NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 06/17/2022
SCan on 2/29/2020 0951 by Nikycia D. Boston (below)
!/29/2020 8:04 AM FROM: Physio-Control TO: +17182452439 P. 1
Prehospital Care Report Summary
SeniorCare EMS
Date:02/29/2020 Call #:1008 Booklet:99361039 Branch: 911 - KingsbrookJewish MedicalCenter Time Zone:America/New__York
Call Information: # Patients Transported
In My Unit: 2
Disposition: Treated0Transported(10-82 A/B)
.Patients at Scene: 3
Initial Patient Aculty: Lower Aculty (Green)
Unit #: 48A3 - 48A3, Ground-Ambulance- BLS Trip Type: Initial Trip
Run Type to Scene: PatientResponse Emergent(Immediate Response) Call Received: 07:00:42
Incident Facillty: DIspatched: 07:00:54
Incident Location: MYRTLEAVE/THROOPAVE - Brooklyn, NY 11206(Kings County) En Route: 07:01:05
Incident Location Type: Street/Hwy On Scene: 07:07:52
Patient Contact: 07:09:53
Receiving Facility: 48 - Kings County HospitalCenter (Hospital) - 451 CLARKSONAVE - BROOKLYN,Left scene: 07:49:25
NY 11203 At Destination: 08:07:31
Facility Address: 451 CLARKSONAVE - BROOKLYN,NY 11203 Transfer of Care: 08:18:13
Destination Type: Hospital EmergencyDept in Service: 08:18:52
Dest. Reason: Nearest/MostAccessibleFacility
Registration # Unable Time On Scene: 42 Min
Time to Destination: 67 Min
Loaded Mileage: 3.0 (Total Mileage:3.0) Total Time of Run: 78 Min
Crew Members: DominiqueAmira Crandell, EMT(DS)(DH);Ashley Fields,EMT(DOC)
Moved to Amb By: Stretcher Transport Position: Semi/FullFowlers From Amb By: Stretcher
Call Origin: N/A Lights/Siren: Scene - Lightsand Sirens, Destination- No Lights and Sirens
Pre-Arrival ActIvation: No Time:
Patient Information:
DOB: 963
Name: Rickey Randell
Address: 11411
56
County: Queens
Weight: 300 Ibs, 136.08 kg (Approx.)
Broselow:
Email:
SSN: --
Driver License:
Other Contact Info
Name: Phone: Cell Phone:
Relationship:
Current Meds: " NO KNOWNMEDICATIONS Comments:
Env Allergles: NKA Comments:
Med Allergles: " NO KNOWNDRUGALLERGlES (NKDA) Comments:
Patient Physician:
Advanced Directives:
PMH: Hypertension
Comment:
Patient Physical Limitations:
Comment:
Payer Information:
Priority: Name:1199NATIONAL
BENEFlTFUND Type: Policy#: 9014860348 Group#:
Policy Holder: , , Apt , Phone: DOB:
Relationshipof Patientto Insured:
AdvanceBenetialaryNotice
Nota MedicalNecessity:No NonCoveredService: No
MileageBeyondClosestAppropriateFacility: No PreferredPhysician: No
RequestedService:
Relation:
Representative
GirosGMa×i½en:n;ser
0W25229 hiscwnisi PF::-MonaM:20si:yw::--!m:i·:::ims 9:FEme Ca:M!c098:-:.9939:0M- 1e:3 FCit: ci l
Printed on 7/15/20 10:03 AM Page 105
FILED: KINGS COUNTY CLERK 06/17/2022 04:30 PM INDEX NO. 521669/2020
NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 06/17/2022
/29/2020 8:04 AM FROM: Physio-Control TO: +17182452439 P. 2
Onset Datefl-Ime: 02/29/20 07:00:00
Dispatch Reason (EMD): MVAINJ Auto Acc W/Injuries
Medical Need:
Chief Complaint (Primary): Mya Duration: 20 Minutes
Organ System: Global/General
Anatomic Location: General/Global
Provider Impression: Pain, Unspecified
Mechanism of Injury:
Protocol 1: 200 - StandardApproachto the Patient (BLS) Protocol 2:
Aillii.ssamgats;
Time Employee Type Summary
07:23:29 Fields, Ashley ABC PattmentAtggilynn
Airway: General: Patent
Breathing: Rate: Normal Quality: Unlabored Lung Sounds: Left: Clear Lung
Sounds: Right: Clear
Circulatlan: General: Normal Skin Color: NoriT1alSkin Temperature: Normal Skin
Condition: Normal
Skin Capillary Refill: Normal
07:23:34 Fields,Ashley Neurological Mental Status: Normal
Neurological: AIINeuro Normal
AVPU: Alert
Vitals:
Time Employee Summary
07:24:19 Fields,Ashley BP: 152/98 Ausculate Type: Sys: Cuff - ManualAuscultated- Dia: Guff - Manual
Auscultated
Pulse: 108Pulse Type: RegularPulse Measurement Method: Palpated
Resp: 20 Effort: Rapid
PaIn: 10 Pain Scale: Numeric (0-10)
Glasgow Coma Score: E (4) + V (5) + M (6) = 15 RTS: 12 - Adult
07:54:45 Fields,Ashley BP: 148/ 96 Ausculate Type: Sys: Cuff - ManualAuscultated- Dia: Guff - Manual
Auscullaled
Pulse: 92 Pulse Type: RegularPulse Measurement Method: Palpated
Resp: 20 Effort: Normal
Paln: 10 Pain Scale: Numeric (0-10)
Glasgow Coma Score: E.(4) + V (5) + M (6) = 15 - Adult
Treatments/Medications:
Time Employee Summary
07:26:52 Fields,Ashley Treatment- BLS Assessment
Success: Yes
Response: Unchanged Complication: None Authorizatlan Type: Protocol
Level: BLS
Supply
Qty Suoolv
ECGDevice IncidentNumber:
NarrativeHistorvText:
48Adispatchedto MVAINJon Atlantic and MyrtleAve.
o:uawsonsro4se:vniumow c«gioetis PE::4to:msto 9: a - F:w:incow 9:½9/2i320
cs:isicoaEW.wmeM- 2ss n:9 : cH
Printed on 7/15/20 10:03 AM Page 106
FILED: KINGS COUNTY CLERK 06/17/2022 04:30 PM INDEX NO. 521669/2020
NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 06/17/2022
U29/2020 8:04 AM FROM: Physio-Control TO: +17182452439 P. 3
Upon arrival, an Amazontruck and Toyota were on scene involvedin collision.Fire on scene prior to arrival. Driverof Toyotawas found
lying supirieon ground, collar Inplace by fire prior to arrival, pt was alert and oriented.Pt was place on long board and transferredto
stretcher.Assessmentrevealed,first aided is 56 YOM who was driving down Atlanticwhen amazonvehicle collidedwith his Toyota.
PossibleLOC,complainingof neck pain radiating down to his lower back. Pt denies dizziness,denies nausea, denies headache.State
pain is a 10/10.No visiblesigns of iraurna. Negative DCAP BTLS upon headto toe assessment.PMSx4 intact, lungs soundsclear
bilaterally,+ABC, Breathingadequately, norrnalCTC. Pt vitals were laken and recorded.Pt denies SOB, denies Chest pain. Pt admits to
wearing seat belt. Driverair bag deployed. Pt was given Oxygenvia nasal at 6LPM, due to sp02 Of 90%. Long board removedonce in
ambulance.Pt has hx of HTN with an allergy to Morphine.
Note: Bystandersstate, male ended up on ground due to him getting out of vehicle immediatelyafter accidentand suddenlyfell to ground
Seconddriverof amazonvehicle, was a 25 YOM was alert and orientedwith a chief complaintof deep laGerationto left handbetween
thumb and pointerfinger. Lacerationis approximately6in. Pt admits to wearing seat belt. Driver states he was driving down myrtleAvenue
through a stop lightthat he believeswas green. Denies LOC. Pt state pain is 8/10. Pt denies LOC. Amazonvehicle Tboned Toyotadriver
side on vehicle.Pt handwas cleaned and bandaged.Pt denies any rnedicalhx and state he has an allergy to Nuts. Pt vitals weretaken
and recorded.
Both occupantsof collisionwere transportedto H48 without incident. During 82, mentalstatuses remainedthe same.
At 81, pt careand reportwere transferredoverto receiving nurse.
Unable to Stan:
Unable to Sign Reason: Severe Pain
Authorized Representative: No authorizedrepresentativeis availableor willing
Authorized Representative Signature: No
Secondary Documentation: PatientCare Report (signedby representativeof facility)
Secondary Documentation Signature: No
Comment:
AuthSignature: No PrivacyS1g:No llnableto Sigrt: Yes Refusedto Sign:No
Slanature knacets):
for BIIllng/ Releaseof PatientInformation
Authoriza1ion / AssumptionofFinancialResponsibility:
I requestthatpaymentof authorized.Medicare/Medicald
and/orotherInsurance benefitsbemadeto thepre-hospital careprovider("Provider")
foranyservicesfumishedto me.I authorizeany holderof hospitalor
medicalInformation aboutmeto bereleased10the Provider,Centersfor MedicareandMedicaldServices,and/ormy Insurancecarriersandtheiragents,
includinganyatherinformation neededto determine thesebenefitsorotherbenefitspayablefor relatedservices.I permita copyofthisauthorization
to be
usedInplaceoftheoriginal.I understand thisauthorization
maybeusedby theProviderforallservicesfurnishedInthefutureuntilsuchtimeas I revoke
inwriting.I agreeto assumefullfinancialresponsibility
thisauthorization forpaymentofall chargesnotcoveredby myinsurance
PrivacyNotice:I herebyacknowledge
thatI havebeenprovidedwitha copyof theProvider's Noticeof PrivacyPracticesexplaininghowmypersonal
healthInformationis usedandunderstand
my Individualrightsrelatedto thisInformation:
Authorization
Signature PrivacyNoticeSignature
Receiving RN/ MDSignature - RNTrentacosta- 02/29/2020 08:18 Signature- Relds,Ashley- 02/29/2020
Technician 07:27
I certify
thattheabovepatient
wasreceived byourlacilityonthedateandlimeselioith
above. Intheeventyouageunable toobtainIhesignatureofthepatientoranother
authorized I hereby
representative, signonthepallent's
behalf inordertopeimit ..
Seniorcare EMSInc.losubmitaclaimtomedicare and/ oranythird-paity
payers.
My
signature isnolanacceptanceoftinancial lorthepatient
responsibility -- --
Recommended Serv ce Level: BLS / Dispatch Service Level: BLS
esnisro4 tingaxiwee:ww owim.afe;P :: amueo fieyw - bue:c.eis 9:MHi;:e cs:issmmfirEswr -3 e'·5 ce : w s
Printed on 7/15/20 10:03 AM Page 107
FILED: KINGS COUNTY CLERK 06/17/2022 04:30 PM INDEX NO. 521669/2020
NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 06/17/2022
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 Security Number
Rickey W. Randall 1963
Patient Address
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
HIV*
TREATMENT, except psychotherapy 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)
Rights 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 that action has already been taken based on this authorization.
to the extent
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 and address of health provider or entity to release this information:
Kings County Medical Center Bid., 451 Clarkson Avenue, Brooklyn, NY 11203
8. Name and address of person(s) or category of person to whom this information will be sent:
WILSON, ELSER, MOSKOWITZ, EDELM, & DICKER, LLP, 1133 Westchester Avenue, White Plains, NY 10604
9(a). Specific information to be released:
8 Medical Record from (insert date) 02/29/2020 to (insert date) present
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) 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: 1l. 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:
Sol Z. Sokel, ESQ Power of Attorney
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.
Date:
Signature of patient or represefftative authorized by law.
* Human Virus that causes AIDS. The New York State Public Health Law protects information which could
Immunodeficiency reasonably
identify someone as having HIV symptoms or infection and information regarding a person's contacts.
FILED: KINGS COUNTY CLERK 06/17/2022 04:30 PM INDEX NO. 521669/2020
NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 06/17/2022
1 RABLE POWER OF ATTORNEY - J
EXECUTE A WRITTEN REQUEST FOR PATIENT INFORMATION UNDER
SECTION 18 OF THE NEWYORK STATE PUBLIC HEALTH LAW
THIS DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL OR OTHER
HEALTH CARE DECISIONS.
This inte ded to constitute BLE POWER OF ATTORNEY to execute a written request for
pati nt rmation under S 18 of . e New York State Public Health Law:
I, /g/e/
p , do hereby appoint my attorney:
SOL Z. SO L, ESQ.
as my attorney-in-fact to execute a written request for patient information under section 18 of the New
York State Public Health Law in my name, place and stead in any way which I myself could do, if I were
personally present.
THIS DURABLE POWER OF ATTORNEY SHALL NOT BE AFFECTED BY MY SUBSEQUENT
DISABILITY OR INCOMPETENCE.
TO INDUCE ANY THIRD PARTY TO ACT HEREUNDER, I HEREBY AGREE THAT ANY THIRD
PARTY RECEIVING A DULY EXECUTED COPY OR FACSIMILE OF THIS INSTRUMENT MAY ACT
HEREUNDER, AND THAT REVOCATION OR TERMINATION HEREOF SHALL BE INEFFECTIVE
AS TO SUCH THIRD PARTY UNLESS AND UNTIL ACTUAL NOTICE OR KNOWLEDGE OF SUCH
REVOCATÍON OR TERMINATION SHALL HAVE BEEN RECEIVED BY SUCH THIRD PARTY, AND I
FOR MYSELF AND FOR MY HEIRS., EXECUTORS, LEGAL REPRESENTATIVES AND ASSIGNS,
HEREBY AGREE TO INDEMNIFY AND HOLD HARMLESS ANY SUCH THIRD PARTY FROM AND
AGAINST ANY AND ALL CLAIMS THAT MAY ARISE AGAINST SUCH THIRD PARTY BY REASON
OF SUCH THIRD PARTY HAVING RELIED ON THE PROVISIONS OF THIS INSTRUMENT.
THIS DURABLE POWER OF ATTORNEY MAY BE REVOKED BY ME AT ANY TIME.
In Witness Wher hav he unto signed my name on this,// - day of , 20 1C
C ENT SIGNATURE
State of New York )
) ss.:
County of )
On this day of /H¶ , 20Mbefore e, the under sne ,/Notary Public
in and for said State, personally appeared --1 pt -7
known to me or proved to me on the basis of factory evidence to be the individual whose
personally
name is subscribed to the within instrument and acknowledged to me that he/she executed the same in
his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf
of which the individual acted, executed the instr nt.
Denis isakov
-n
X Commissioner of Deeds, City of New york
0--
NO. 2-14281
NOTARY PUBLI
Certificate Filed In Brooklyn, County
Commission Expires March 01, 2021
Preview
FILED: KINGS COUNTY CLERK 06/17/2022 04:30 PM INDEX NO. 521669/2020 NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 06/17/2022 EXHIBIT 1 FILED: KINGS COUNTY CLERK 06/17/2022 04:30 PM INDEX NO. 521669/2020 NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 06/17/2022 SCan on 2/29/2020 0951 by Nikycia D. Boston (below) !/29/2020 8:04 AM FROM: Physio-Control TO: +17182452439 P. 1 Prehospital Care Report Summary SeniorCare EMS Date:02/29/2020 Call #:1008 Booklet:99361039 Branch: 911 - KingsbrookJewish MedicalCenter Time Zone:America/New__York Call Information: # Patients Transported In My Unit: 2 Disposition: Treated0Transported(10-82 A/B) .Patients at Scene: 3 Initial Patient Aculty: Lower Aculty (Green) Unit #: 48A3 - 48A3, Ground-Ambulance- BLS Trip Type: Initial Trip Run Type to Scene: PatientResponse Emergent(Immediate Response) Call Received: 07:00:42 Incident Facillty: DIspatched: 07:00:54 Incident Location: MYRTLEAVE/THROOPAVE - Brooklyn, NY 11206(Kings County) En Route: 07:01:05 Incident Location Type: Street/Hwy On Scene: 07:07:52 Patient Contact: 07:09:53 Receiving Facility: 48 - Kings County HospitalCenter (Hospital) - 451 CLARKSONAVE - BROOKLYN,Left scene: 07:49:25 NY 11203 At Destination: 08:07:31 Facility Address: 451 CLARKSONAVE - BROOKLYN,NY 11203 Transfer of Care: 08:18:13 Destination Type: Hospital EmergencyDept in Service: 08:18:52 Dest. Reason: Nearest/MostAccessibleFacility Registration # Unable Time On Scene: 42 Min Time to Destination: 67 Min Loaded Mileage: 3.0 (Total Mileage:3.0) Total Time of Run: 78 Min Crew Members: DominiqueAmira Crandell, EMT(DS)(DH);Ashley Fields,EMT(DOC) Moved to Amb By: Stretcher Transport Position: Semi/FullFowlers From Amb By: Stretcher Call Origin: N/A Lights/Siren: Scene - Lightsand Sirens, Destination- No Lights and Sirens Pre-Arrival ActIvation: No Time: Patient Information: DOB: 963 Name: Rickey Randell Address: 11411 56 County: Queens Weight: 300 Ibs, 136.08 kg (Approx.) Broselow: Email: SSN: -- Driver License: Other Contact Info Name: Phone: Cell Phone: Relationship: Current Meds: " NO KNOWNMEDICATIONS Comments: Env Allergles: NKA Comments: Med Allergles: " NO KNOWNDRUGALLERGlES (NKDA) Comments: Patient Physician: Advanced Directives: PMH: Hypertension Comment: Patient Physical Limitations: Comment: Payer Information: Priority: Name:1199NATIONAL BENEFlTFUND Type: Policy#: 9014860348 Group#: Policy Holder: , , Apt , Phone: DOB: Relationshipof Patientto Insured: AdvanceBenetialaryNotice Nota MedicalNecessity:No NonCoveredService: No MileageBeyondClosestAppropriateFacility: No PreferredPhysician: No RequestedService: Relation: Representative GirosGMa×i½en:n;ser 0W25229 hiscwnisi PF::-MonaM:20si:yw::--!m:i·:::ims 9:FEme Ca:M!c098:-:.9939:0M- 1e:3 FCit: ci l Printed on 7/15/20 10:03 AM Page 105 FILED: KINGS COUNTY CLERK 06/17/2022 04:30 PM INDEX NO. 521669/2020 NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 06/17/2022 /29/2020 8:04 AM FROM: Physio-Control TO: +17182452439 P. 2 Onset Datefl-Ime: 02/29/20 07:00:00 Dispatch Reason (EMD): MVAINJ Auto Acc W/Injuries Medical Need: Chief Complaint (Primary): Mya Duration: 20 Minutes Organ System: Global/General Anatomic Location: General/Global Provider Impression: Pain, Unspecified Mechanism of Injury: Protocol 1: 200 - StandardApproachto the Patient (BLS) Protocol 2: Aillii.ssamgats; Time Employee Type Summary 07:23:29 Fields, Ashley ABC PattmentAtggilynn Airway: General: Patent Breathing: Rate: Normal Quality: Unlabored Lung Sounds: Left: Clear Lung Sounds: Right: Clear Circulatlan: General: Normal Skin Color: NoriT1alSkin Temperature: Normal Skin Condition: Normal Skin Capillary Refill: Normal 07:23:34 Fields,Ashley Neurological Mental Status: Normal Neurological: AIINeuro Normal AVPU: Alert Vitals: Time Employee Summary 07:24:19 Fields,Ashley BP: 152/98 Ausculate Type: Sys: Cuff - ManualAuscultated- Dia: Guff - Manual Auscultated Pulse: 108Pulse Type: RegularPulse Measurement Method: Palpated Resp: 20 Effort: Rapid PaIn: 10 Pain Scale: Numeric (0-10) Glasgow Coma Score: E (4) + V (5) + M (6) = 15 RTS: 12 - Adult 07:54:45 Fields,Ashley BP: 148/ 96 Ausculate Type: Sys: Cuff - ManualAuscultated- Dia: Guff - Manual Auscullaled Pulse: 92 Pulse Type: RegularPulse Measurement Method: Palpated Resp: 20 Effort: Normal Paln: 10 Pain Scale: Numeric (0-10) Glasgow Coma Score: E.(4) + V (5) + M (6) = 15 - Adult Treatments/Medications: Time Employee Summary 07:26:52 Fields,Ashley Treatment- BLS Assessment Success: Yes Response: Unchanged Complication: None Authorizatlan Type: Protocol Level: BLS Supply Qty Suoolv ECGDevice IncidentNumber: NarrativeHistorvText: 48Adispatchedto MVAINJon Atlantic and MyrtleAve. o:uawsonsro4se:vniumow c«gioetis PE::4to:msto 9: a - F:w:incow 9:½9/2i320 cs:isicoaEW.wmeM- 2ss n:9 : cH Printed on 7/15/20 10:03 AM Page 106 FILED: KINGS COUNTY CLERK 06/17/2022 04:30 PM INDEX NO. 521669/2020 NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 06/17/2022 U29/2020 8:04 AM FROM: Physio-Control TO: +17182452439 P. 3 Upon arrival, an Amazontruck and Toyota were on scene involvedin collision.Fire on scene prior to arrival. Driverof Toyotawas found lying supirieon ground, collar Inplace by fire prior to arrival, pt was alert and oriented.Pt was place on long board and transferredto stretcher.Assessmentrevealed,first aided is 56 YOM who was driving down Atlanticwhen amazonvehicle collidedwith his Toyota. PossibleLOC,complainingof neck pain radiating down to his lower back. Pt denies dizziness,denies nausea, denies headache.State pain is a 10/10.No visiblesigns of iraurna. Negative DCAP BTLS upon headto toe assessment.PMSx4 intact, lungs soundsclear bilaterally,+ABC, Breathingadequately, norrnalCTC. Pt vitals were laken and recorded.Pt denies SOB, denies Chest pain. Pt admits to wearing seat belt. Driverair bag deployed. Pt was given Oxygenvia nasal at 6LPM, due to sp02 Of 90%. Long board removedonce in ambulance.Pt has hx of HTN with an allergy to Morphine. Note: Bystandersstate, male ended up on ground due to him getting out of vehicle immediatelyafter accidentand suddenlyfell to ground Seconddriverof amazonvehicle, was a 25 YOM was alert and orientedwith a chief complaintof deep laGerationto left handbetween thumb and pointerfinger. Lacerationis approximately6in. Pt admits to wearing seat belt. Driver states he was driving down myrtleAvenue through a stop lightthat he believeswas green. Denies LOC. Pt state pain is 8/10. Pt denies LOC. Amazonvehicle Tboned Toyotadriver side on vehicle.Pt handwas cleaned and bandaged.Pt denies any rnedicalhx and state he has an allergy to Nuts. Pt vitals weretaken and recorded. Both occupantsof collisionwere transportedto H48 without incident. During 82, mentalstatuses remainedthe same. At 81, pt careand reportwere transferredoverto receiving nurse. Unable to Stan: Unable to Sign Reason: Severe Pain Authorized Representative: No authorizedrepresentativeis availableor willing Authorized Representative Signature: No Secondary Documentation: PatientCare Report (signedby representativeof facility) Secondary Documentation Signature: No Comment: AuthSignature: No PrivacyS1g:No llnableto Sigrt: Yes Refusedto Sign:No Slanature knacets): for BIIllng/ Releaseof PatientInformation Authoriza1ion / AssumptionofFinancialResponsibility: I requestthatpaymentof authorized.Medicare/Medicald and/orotherInsurance benefitsbemadeto thepre-hospital careprovider("Provider") foranyservicesfumishedto me.I authorizeany holderof hospitalor medicalInformation aboutmeto bereleased10the Provider,Centersfor MedicareandMedicaldServices,and/ormy Insurancecarriersandtheiragents, includinganyatherinformation neededto determine thesebenefitsorotherbenefitspayablefor relatedservices.I permita copyofthisauthorization to be usedInplaceoftheoriginal.I understand thisauthorization maybeusedby theProviderforallservicesfurnishedInthefutureuntilsuchtimeas I revoke inwriting.I agreeto assumefullfinancialresponsibility thisauthorization forpaymentofall chargesnotcoveredby myinsurance PrivacyNotice:I herebyacknowledge thatI havebeenprovidedwitha copyof theProvider's Noticeof PrivacyPracticesexplaininghowmypersonal healthInformationis usedandunderstand my Individualrightsrelatedto thisInformation: Authorization Signature PrivacyNoticeSignature Receiving RN/ MDSignature - RNTrentacosta- 02/29/2020 08:18 Signature- Relds,Ashley- 02/29/2020 Technician 07:27 I certify thattheabovepatient wasreceived byourlacilityonthedateandlimeselioith above. Intheeventyouageunable toobtainIhesignatureofthepatientoranother authorized I hereby representative, signonthepallent's behalf inordertopeimit .. Seniorcare EMSInc.losubmitaclaimtomedicare and/ oranythird-paity payers. My signature isnolanacceptanceoftinancial lorthepatient responsibility -- -- Recommended Serv ce Level: BLS / Dispatch Service Level: BLS esnisro4 tingaxiwee:ww owim.afe;P :: amueo fieyw - bue:c.eis 9:MHi;:e cs:issmmfirEswr -3 e'·5 ce : w s Printed on 7/15/20 10:03 AM Page 107 FILED: KINGS COUNTY CLERK 06/17/2022 04:30 PM INDEX NO. 521669/2020 NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 06/17/2022 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 Security Number Rickey W. Randall 1963 Patient Address 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 HIV* TREATMENT, except psychotherapy 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) Rights 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 that action has already been taken based on this authorization. to the extent 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 and address of health provider or entity to release this information: Kings County Medical Center Bid., 451 Clarkson Avenue, Brooklyn, NY 11203 8. Name and address of person(s) or category of person to whom this information will be sent: WILSON, ELSER, MOSKOWITZ, EDELM, & DICKER, LLP, 1133 Westchester Avenue, White Plains, NY 10604 9(a). Specific information to be released: 8 Medical Record from (insert date) 02/29/2020 to (insert date) present 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) 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: 1l. 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: Sol Z. Sokel, ESQ Power of Attorney 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. Date: Signature of patient or represefftative authorized by law. * Human Virus that causes AIDS. The New York State Public Health Law protects information which could Immunodeficiency reasonably identify someone as having HIV symptoms or infection and information regarding a person's contacts. FILED: KINGS COUNTY CLERK 06/17/2022 04:30 PM INDEX NO. 521669/2020 NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 06/17/2022 1 RABLE POWER OF ATTORNEY - J EXECUTE A WRITTEN REQUEST FOR PATIENT INFORMATION UNDER SECTION 18 OF THE NEWYORK STATE PUBLIC HEALTH LAW THIS DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL OR OTHER HEALTH CARE DECISIONS. This inte ded to constitute BLE POWER OF ATTORNEY to execute a written request for pati nt rmation under S 18 of . e New York State Public Health Law: I, /g/e/ p , do hereby appoint my attorney: SOL Z. SO L, ESQ. as my attorney-in-fact to execute a written request for patient information under section 18 of the New York State Public Health Law in my name, place and stead in any way which I myself could do, if I were personally present. THIS DURABLE POWER OF ATTORNEY SHALL NOT BE AFFECTED BY MY SUBSEQUENT DISABILITY OR INCOMPETENCE. TO INDUCE ANY THIRD PARTY TO ACT HEREUNDER, I HEREBY AGREE THAT ANY THIRD PARTY RECEIVING A DULY EXECUTED COPY OR FACSIMILE OF THIS INSTRUMENT MAY ACT HEREUNDER, AND THAT REVOCATION OR TERMINATION HEREOF SHALL BE INEFFECTIVE AS TO SUCH THIRD PARTY UNLESS AND UNTIL ACTUAL NOTICE OR KNOWLEDGE OF SUCH REVOCATÍON OR TERMINATION SHALL HAVE BEEN RECEIVED BY SUCH THIRD PARTY, AND I FOR MYSELF AND FOR MY HEIRS., EXECUTORS, LEGAL REPRESENTATIVES AND ASSIGNS, HEREBY AGREE TO INDEMNIFY AND HOLD HARMLESS ANY SUCH THIRD PARTY FROM AND AGAINST ANY AND ALL CLAIMS THAT MAY ARISE AGAINST SUCH THIRD PARTY BY REASON OF SUCH THIRD PARTY HAVING RELIED ON THE PROVISIONS OF THIS INSTRUMENT. THIS DURABLE POWER OF ATTORNEY MAY BE REVOKED BY ME AT ANY TIME. In Witness Wher hav he unto signed my name on this,// - day of , 20 1C C ENT SIGNATURE State of New York ) ) ss.: County of ) On this day of /H¶ , 20Mbefore e, the under sne ,/Notary Public in and for said State, personally appeared --1 pt -7 known to me or proved to me on the basis of factory evidence to be the individual whose personally name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instr nt. Denis isakov -n X Commissioner of Deeds, City of New york 0-- NO. 2-14281 NOTARY PUBLI Certificate Filed In Brooklyn, County Commission Expires March 01, 2021