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FILED: WESTCHESTER COUNTY CLERK 12/14/2023 02:47 PM INDEX NO. 65752/2023
NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 12/14/2023
SUPREME COURT OF STATE OF NEW YORK
COUNTY OF WESTCHESTER
___....________________________--________Ç
LESLIE as Executrix of the Estate of Index No,: 65752/2023
ROSENBERG,
JOSEPHINE NARDI,
Plaintiff,
NOTICE FOR
DISCOVERY
WESTCHESTER MEDICAL CENTER HEALTH NETWORK
AND INSPECTION
a/k/a WESTCHESTER MEDICAL CENTER, and
PROVIDENCE REST, INC,
Defendant(s).
______.._______---.___________--_______-..--Ç
C O U N S E L O R S:
PLEASE TAKE NOTICE that the Defendant PROVIDENCE REST, INC., pursuant to Section
3101et seq. and Rule 3120 of the CPLR, are required to produce and allow discovery, inspection
and copying by the Plaintiff and his attorneys of the following items, writings and objects
maintained, controlled or supervised by the Defendant's agents, servants and/or employees. In
lieu of strict compliance with the terms and conditions of this Notice, the undersigned will accept
clearly legible photocopies of the following items if received by the undersigned within 30 days
after Defendant's receipt here of, together with a letter from defendant's attorneys advising as
to the completeness of the items provided, at the office of Kelly & Grossman, LLP:
1, Complete copies of the Pollcies and Procedures for Bedsores Prevention and
Treatment, Assessment, Care Planning and Documentation.
Dated: West Islip, New York
December 5, 2023
Yours, etc.,
KELLY, GROSS & RIGAN, LLP
ennis Kelly, Es
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FILED: WESTCHESTER COUNTY CLERK 12/14/2023 02:47 PM INDEX NO. 65752/2023
NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 12/14/2023
Attorneys for Plaintiff
1248 Montauk Highway
West Islip, New York 11795
Telephone: (631) 314-4996
Facsimile: (516) 686-6771
TO:
Gerald D. DiEdwards, Esq.
Schiavetti, Corgan, DiEdwards, Weinberg & Nicholson, LLP
Attorney for Defendant: Providence Rest, Inc.
711 Westchester Avenue, Suite 406
White Plains, New York 10604
Claudine L Weis, Esq.
Wilson, Bave, Conboy, Cozza & Couzens, P.C.
Attorney for Defendant: Westchester Medical center Health Network a/k/a Westchester Medical
Center
707 Westchester Avenue, Suite 213
White Plains, New York 10604
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FILED: WESTCHESTER COUNTY CLERK 12/14/2023 02:47 PM INDEX NO. 65752/2023
NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 12/14/2023
OCA Offielal 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
Josephine Nardi
Patient Address
c/o KELLY, GROSSMAN & KERRIGAN, LLP, 1248 Montauk Highway, West Islip, NY 11795
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* INFORMATION
TREATMENT, except psychotherapy notes, and CONFIDENTIAL RELATED 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 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 1 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 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
Y /ITH 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:
Providence Rest, e/o Schiavetti, Corgan DiEdwards, Weinberg & Nicholson, LLP, 711 Westchester Avenue, Suite 406, White Plains, New
York I0604
8. Name and addSss of person(s) or category of person to whom this information will be sent:
Kelly, Grossman & Kerrigan, LLP, 1248 Montauk Highway, West Islip, New York 11795
9(a). Specific information to be released:
Medical Record from (insert date) to (insert date)
O Entire Medical Record, including patient histories, office notes (except psychotherapy notes), tests results, radiology studies, fthns,
Referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
O Other: Inclu e: (Indicate by hatialing)
1) Alcohol/Drug Treatment
t))( Mening Health Information
Authorization to Diseuss Health Information 0)}(, 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:
(Attomey/Fimi Name or Govemmental Agency Name)
10. Reason for release of information: 11. Date or Event on which this authorization will expire:
O At request of individual
Other: Litigation Trial of Action
12. If not the patient, name of person signing form: 13. Authority to sign on behalf of patient:
Dennis Kelly, Esq. As Power of Attorney pursuant to PHL section 18, et seq.
All items on this form have been completed and my questions about this form have been answered. In addition, 1 have been provided a copy
of the form.
Date: /;) ly
' b3
Signature o t(tient o re tet•ve authorized by law.
* Human Virus that causes AIDS. The New York State Public Health Law protects information which could
Immemodeficiency reasonably
identify someone as having HIV symptoms or infection and information mgarding a person's contacts.
A A DA ALS New York
- State of
Motary Public M6860
Quaged in suffolk county2
kes Dec. m
gy Com_m.Ex
3 of 3
Preview
FILED: WESTCHESTER COUNTY CLERK 12/14/2023 02:47 PM INDEX NO. 65752/2023 NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 12/14/2023 SUPREME COURT OF STATE OF NEW YORK COUNTY OF WESTCHESTER ___....________________________--________Ç LESLIE as Executrix of the Estate of Index No,: 65752/2023 ROSENBERG, JOSEPHINE NARDI, Plaintiff, NOTICE FOR DISCOVERY WESTCHESTER MEDICAL CENTER HEALTH NETWORK AND INSPECTION a/k/a WESTCHESTER MEDICAL CENTER, and PROVIDENCE REST, INC, Defendant(s). ______.._______---.___________--_______-..--Ç C O U N S E L O R S: PLEASE TAKE NOTICE that the Defendant PROVIDENCE REST, INC., pursuant to Section 3101et seq. and Rule 3120 of the CPLR, are required to produce and allow discovery, inspection and copying by the Plaintiff and his attorneys of the following items, writings and objects maintained, controlled or supervised by the Defendant's agents, servants and/or employees. In lieu of strict compliance with the terms and conditions of this Notice, the undersigned will accept clearly legible photocopies of the following items if received by the undersigned within 30 days after Defendant's receipt here of, together with a letter from defendant's attorneys advising as to the completeness of the items provided, at the office of Kelly & Grossman, LLP: 1, Complete copies of the Pollcies and Procedures for Bedsores Prevention and Treatment, Assessment, Care Planning and Documentation. Dated: West Islip, New York December 5, 2023 Yours, etc., KELLY, GROSS & RIGAN, LLP ennis Kelly, Es 1 of 3 FILED: WESTCHESTER COUNTY CLERK 12/14/2023 02:47 PM INDEX NO. 65752/2023 NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 12/14/2023 Attorneys for Plaintiff 1248 Montauk Highway West Islip, New York 11795 Telephone: (631) 314-4996 Facsimile: (516) 686-6771 TO: Gerald D. DiEdwards, Esq. Schiavetti, Corgan, DiEdwards, Weinberg & Nicholson, LLP Attorney for Defendant: Providence Rest, Inc. 711 Westchester Avenue, Suite 406 White Plains, New York 10604 Claudine L Weis, Esq. Wilson, Bave, Conboy, Cozza & Couzens, P.C. Attorney for Defendant: Westchester Medical center Health Network a/k/a Westchester Medical Center 707 Westchester Avenue, Suite 213 White Plains, New York 10604 2 of 3 FILED: WESTCHESTER COUNTY CLERK 12/14/2023 02:47 PM INDEX NO. 65752/2023 NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 12/14/2023 OCA Offielal 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 Josephine Nardi Patient Address c/o KELLY, GROSSMAN & KERRIGAN, LLP, 1248 Montauk Highway, West Islip, NY 11795 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* INFORMATION TREATMENT, except psychotherapy notes, and CONFIDENTIAL RELATED 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 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 1 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 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 Y /ITH 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: Providence Rest, e/o Schiavetti, Corgan DiEdwards, Weinberg & Nicholson, LLP, 711 Westchester Avenue, Suite 406, White Plains, New York I0604 8. Name and addSss of person(s) or category of person to whom this information will be sent: Kelly, Grossman & Kerrigan, LLP, 1248 Montauk Highway, West Islip, New York 11795 9(a). Specific information to be released: Medical Record from (insert date) to (insert date) O Entire Medical Record, including patient histories, office notes (except psychotherapy notes), tests results, radiology studies, fthns, Referrals, consults, billing records, insurance records, and records sent to you by other health care providers. O Other: Inclu e: (Indicate by hatialing) 1) Alcohol/Drug Treatment t))( Mening Health Information Authorization to Diseuss Health Information 0)}(, 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: (Attomey/Fimi Name or Govemmental Agency Name) 10. Reason for release of information: 11. Date or Event on which this authorization will expire: O At request of individual Other: Litigation Trial of Action 12. If not the patient, name of person signing form: 13. Authority to sign on behalf of patient: Dennis Kelly, Esq. As Power of Attorney pursuant to PHL section 18, et seq. All items on this form have been completed and my questions about this form have been answered. In addition, 1 have been provided a copy of the form. Date: /;) ly ' b3 Signature o t(tient o re tet•ve authorized by law. * Human Virus that causes AIDS. The New York State Public Health Law protects information which could Immemodeficiency reasonably identify someone as having HIV symptoms or infection and information mgarding a person's contacts. A A DA ALS New York - State of Motary Public M6860 Quaged in suffolk county2 kes Dec. m gy Com_m.Ex 3 of 3