Preview
FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014
NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
———-
——————————————X
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DORIS KAUFMAN, : INDEX NO.: 150893/2014
Plaintiff, :
-against- : DEMAND FOR MEDICARE
INFORMATION
2451 BROADWAY MARKET, INC., YUCCA HOLDING:
CORP. and NEW HORIZON MANAGEMENT CORP.,
Defendants.
X
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PLEASE TAKE NOTICE that the defendant(s), by its attorneys, Weiner, Millo,
Morgan 4 Bonanno, LLC, hereby demands that, pursuant to Section 111 of the Medicare,
Medicaid and SCHIP Extension Act of 2007, the Plaintiff produce for discovery and inspection
the following documents and information within twenty (20) days of receipt of this demand at
the offices of the undersigned attorneys:
1. If Plaintiff has received or applied for benefits from Medicare at any time, for any
reason, not limited to the injuries alleged in the instant action, state and provide the following:
a. Plaintiff's name as it appears on plaintiffs social security card or Medicare
Benefit Card;
b. Other names by which Plaintiff is known (i.e.nick names used in place of legal
names);
c. Plaintiff's gender;
d. Plaintiff's date of birth;
e. Plaintiff's date of death (if applicable);
f. Plaintiffs Social Security number;
g. Plaintiff s residence telephone number;
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NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017
h. Plaintiff's last known address;
i. Plaintiff's Medicare Health Insurance Claim Number ("HICN");
j. Date of Plaintiff's eligibility for Medicare benefits;
k. Amounts of Medicare made payments for health care services that are related to
Plaintiff's injuries;
1. Identify amount of Medicare lien for paid benefits;
m. Contact information for Medicare office and/or individual that has contacted
Plaintiff or Plaintiff's attorney regarding receipt of Medicare benefits and this
lawsuit;
n. Date such Medicare office or individual contacted the Plaintiff or Plaintiff's
attorney regarding receipt of Medicare benefits and this lawsuit;
0. Address of the Medicare and/or Medicaid office handling the plaintiff's
claim(s);
p. True and accurate copies of all documents, records, memoranda, notes,
etc., in plaintiff's possession pertaining to plaintiff's receipt of Medicare
and/or Medicaid benefits;
q. A duly executed and acknowledged, HIPAA compliant, authorization (see
attached) permitting this office to obtain a copy of plaintiffs records from
Medicare.
2. A statement as to whether the plaintiff has received or has applied for Social
Security Disability benefits, or appealed or anticipates an appeal of a denial of benefits from
Social Security Disability at any time, for any reason, not limited to the injuries alleged in the
instant action. Ifso, please state the following:
a. Social Security File Number and/or Case Number;
b. Address of the Social Security office handling the Plaintiff's claim(s);
2
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FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014
NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017
c. True and accurate copies of all documents, records, memoranda, notes, etc., in
possession pertaining to plaintiff's receipt of Social Security
benefits;
d. A duly executed and acknowledged, HIPAA compliant, authorization (see
attached) permitting this office to obtain a copy of plaintiff's records from
Social Security;
e. Date of application for Social Security Disability benefits;
f. Date Social Security Disability benefits awarded;
g. List the period for which Social Security Disability benefits were paid (i.e.
1/1/10 to present);
h. Date of injury or diagnosis of injury of condition for which Social Security
Disability benefits were awarded;
i. If application for Social Security Disability was denied. Please provide the
following:
- Date of denial;
- Reason for denial as provided the Social
by Security
Administration (SSA);
- State date of appeal of denial;
- State date of reversal or affirmation of SSA decision.
3. Does the Plaintiff suffer from any of the following diseases or conditions:
a. Any form of kidney disease (e.g. permanent kidney failure);
- Date diagnosed
- Describe treatment;
- Medical prognosis given
- Date Medicare benefits applied for this disease
disease"
b. Amyotrophic Lateral Sclerosis a/k/a "Lou Gehrig's or "ALS";
- Date diagnosed
- Date Plaintiff applied for Social Benefits
Security
4. If the Plaintiff is deceased and Medicare paid benefits for treatment of the
3
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NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017
Plaintiff's alleged injuries, state the following:
a. amount of benefits paid;
b. provide copies of medical bills supplied to Medicare for payment;
PLEASE TAKE FURTHER NOTICE that the foregoing demand is a continuing
demand and in the event that the materials become available after the designated date, they
should be forwarded to our office within thirty (30) days of receipt. In the event that said
material is not produced for inspection and/or photocopying as required herein, the undersigned
will move this Court to invoke the penalties applicable under Article 31 of the CPLR.
Dated: New York, New York
December 15, 2017
Yours etc.,
/
John P. Bo , Esq.
WEINE , LO, R AN & BONANNO, LLC
Attorneys for Defend
YUCCA HOLDING CORP. and NEW HORIZON
MANAGEMENT CORP.
220 Fifth Avenue, 10th Floor
New York, New York 10001
(212) 213-1220
WMMB File No.: 428-234
TO: Christopher Joslin, Esq.
David Horowitz, P.C.
Attorneys for Plaintiff
171 Madison Avenue - Suite 1300
New York, New York 10016
(212) 684-3630
4
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NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017
Weisberg & Weisberg
Attorneys for Defendant
2451 BROADWAY MARKET, INC.
2463 Broadway
New York, New York 10025
(212) 787-7760
Michael J. Sweeney, Esq.
Trial Counsel for Defendant
2451 BROADWAY MARKET, INC.
25 Greenwood Road
Yonkers, New York 10701
(914) 968-7033
5
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NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017
Social Security Admin istration
Consent for Release of Information
TO: Social Security Administration
Name Date of Birth SocialSecurity Number
Address
I authorize the Social Security Administration to release information or records about me to:
NAME ADDRESS
10th
Weiner, Millo, Morgan & Bonanno, LLC 220 Fifth Avenue, Floor
(212) 213-1220 New York, New York 10001
I want this,information released because:
To establish my Social Security Disabilitystatus,date of entitlement to Medicare, and the basis for
Medicare entitlement or of Workers'
(disability age) forthe purpose my Compensation or Liability claim
to be obtained from eitherSocial Security Administration or from MyMedicare.gov website.
(There may be a charge for releasing information)
Please release the following information:
Z Social Security Number
parents'
IZ Identifying information (includes date and place of birth, names)
IZ Monthly Social Security benefit amount
IZ Monthly Supplemental Security Income payment amount
IZ Information about benefits/payments I received from to .
(E Information about my Medicare claim/coverage from to .
IE Medical Records
E Record(s) from my file(specify)
IZ Other - Medicare Health Insurance Claim # (HICN #) SSDI entitlement date.
(specify)
Medicare Part A. B & D entitlement dates, Date applied fordisability Benefits.Date SSDI
payment started,current SSDI payment status,and current SSDI payment amount.
This information be faxed to Morgan & Bonanno, LLC - Fax # 212-889-5228
may Weiner, Millo,
* Morgan & LLC will be responsible for charges that for
Weiner, Millo, Bonanno, any may apply
release of information.*
I am the individual to whom the information/record applies or thatperson's parent (ifa minor) or legal
guardian. I declare under penalty ofperjury thatI have examined allthe information on thisform and it
istrue and correct tothe best of my knowledge. I understand that anyone who knowingly gives afalse
or misleading statement about a material factin thisinformation, orcauses someone elseto do so,
commits a crime and may be sent to prison, or may face other penalties,or both.
Signature:
(Show signatures, names, and addresses of two people ifsigned by mark.)
Date: Relationship:
Form SSA-3288 (3-2005) EF (3-2005)
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FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014
NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017
WEINER, MILLO, MORGAN & BONANNO, LLC
AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED
HEALTH INFORMATION PURSUANT TO HIPAA
AND APPOINTMENT OF REPRESENTATIVE
(Health InsurancePortabilityand AccountabilityAct of 1996)
I hereby authorize the use or disclosureof my Protected Health Information and other information as described below. I
understand thatthis authorization is voluntary.
Individual/ Claimant: Individual/Claimant SSN:
Individual/Claimant Address:
DOI: Date of Birth: Medicare/HJCN #:
Persons/ Entities authorized to provide the information:
Any physicians
treating or health
care providers,
my Employer,any HealthInsurance for
Payers, the Centers Medicare & Medicaid Services,
MyMedicare.gov, Social Security and the MSPRC.
Administration,
Persons/ Entitiesauthorized to receive,use, and disclosethe information:
1. Weiner,Millo,Morgan & Bonanno, LLC
220 Fifth 10* Floor
Avenue,
New York,New York 10001
2. Centers for Medicare
& MedicaidServices (CMS)
Description ofinformation:
1. Allmedicalrecords, but not limited
including, to, documents,
reports, test results or x-rays.
notes, bills,
2. Any informationas may be requestedby Weiner, Millo,Morgan & Bonanno, LLC from any person/ authorized
entity to providethe
information,
which, inWeiner,Millo,Morgan & Bonanno's sole discretion, or necessary
is required toaccomplish the purposeofthis
Authorization.
Purpose ofAuthorization:
1. ThisAuthorizationfor use or disclosure
of information
is at the request of the individual/
claimant.
2. To providea full
disclosure
of any information
to Weiner,
Millo,Morgan & Bonanno, LLC, to enable it to evaluate,
determine,and prepare
a recommended Medicare Set-AsideArrangement, and tocomplete any otherapplicable
and requestedservices,
includingConditional
Payments (MedicareLien)Research, Final
LienAmount Demand and LienNegotiation.
3. To designateWeiner, Millo,Morgan & Bonanno, LLC as its representative
to havethe to
authority communicate with CMS and the
MSPRC to obtain Medicare
conditional
payment information on my behalf, any request for Conditional
and to dispute or negotiate, Payment
Reimbursement Medicare
related to the undersigned beneficiary,
I acknowledge and understand the following:
1. That if the person or entity
authorized the information
to receive plan or health
is not a health the released information
care provider, may
no longerbe protected
by federal
privacyregulations;
2. Thatmy health care, payment
ofhealthcare, treatment,
enrollment, for
eligibility or the amount
benefits, Medicare pays for the health
will
services not be affected
if I do not sign this authorization
form;
3. ThatI may see and copy
any information in this form;
described
4. ThatI may after I sign it, and if I am unable to make a copy,
copy this Authorization I may request a copy from
Weiner, Morgan
Millo, &
Bonanno, LLC;
5. That this authorization approval
expires upon of the Medicare
Set-AsideArrangement by CMS and completionof any other applicable
and
requested Conditional
services, including Payments (MedicareLien)Research, Final
Lien Amount Demand and LienNegotiation;
6. That I may revoke this Authorization
at any time by written
notice to Weiner,
Millo,Morgan & Bonanno, LLC, but that any revocation
shall
have no effect on actions
whichhave been taken by Weiner,
Millo,Morgan & Bonanno, LLC priorto receiving
my revocation;
7. That any personal medical that I authorize Medicare
information and no longer protected by law;
to disclose may be subject to re-disclosure
8. That I have the right
to refuse to sign this authorization.
I have read and understandthe contentsof thisAuthorization and have had theopportunity todiscuss same with counsel ofmy choice.
The contents of thisAuthorizationconfirm, and are consistentwith,my instructions,
authority, ordirectionsto Weiner,Millo,Morgan &
Bonanno, LLC, and Iunderstand that by executing thisAuthorization, Iam authorizingWeiner, Millo,Morgan & Bonanno, LLC, touse
and disclose,as permittedand outlined herein,certainnonpublic information.
Date:
Signature of Claimantor Legal Representative
Relationshipto Claimant ifLegal Representative
(Except forLegal Representativesacting incapacityas a parentto theclaimant,a copy ofthe document giving theLegal
Representativethe authorityto signthisAuthorization must be attached.)
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NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017
AFFIDAVIT OF SERVICE BY MAIL
STATE OF NEW YORK )
) ss.:
COUNTY OF NEW YORK )
Dena M. Schultz, being duly sworn, deposes and says:
I am not a party to the within action, I am over 18 years of age, and I reside in Brooklyn,
New York.
On the 19th day of December, 2017, I mailed the within DEMAND FOR MEDICARE
INFORMATION by depositing a true copy thereof, enclosed in a post-paid wrapper, in an official
depository under the exclusive care and custody of the United States Postal Service within New
York State, addressed to each of the following persons at the last known address set forth after each
name:
TO: David Horowitz, P.C.
171 Madison Avenue - Suite 1300
New York, New York 10016
Weisberg & Weisberg
2463 Broadway
New York, New York 10025
Michael J. Sweeney, Esq.
Trial Counsel for Defendant
25 Greenwood Road
Yonkers, New York 10701
DeÓM. Schultz
Sworn to before me this
19*
19 day of December, 2017
PUBI' JOHN PERRY BONANNO
N t R Notary Public State of New York
02B06184166
Qualified inNew York County +~
Commission Expires March 24, 20
6
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NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017
INDEX NO.: 150893/2014
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
DORIS KAUFMAN,
Plaintiff
- against -
2451 BROADWAY MARKET, INC., YUCCA HOLDING CORP. and NEW HORIZON
MANAGEMENT CORP.,
Defendants
DEMAND FOR MEDICARE INFORMATION
WEINER, MILLO, MORGAN as BONANNO, LLC
ATTORNEYS AT LAW
Attorneys for YUCCA HOLDING CORP. and NEW HORIZON MANAGEMENT CORP.
220 FIFTH AVENUE •1OTH FLOOR
NEW YORK, NEW YORK 10001-7708
TELEPHONE (212) 213-1220
FACSIMILE(212) 889-5228
Pursuant to 22 NYCRR 130-1.1.a, the undersigned, an attorney admitted to practicein thecourts of New York State,
certifiesthat, upon information and beliefand reasonable injury, (1) the contentions contained in the annexed
document are not frivolous and that (2) ifthe annexed document is an initiatingpleading, (i) the matter was not
obtained through illegalconduct, or that ifit
was, theattorney or otherpersons responsible for theillegalconduct are
not participating in the matter or sharing in anyfee earned therefrom and that(ii)ifthe matter involvespotential
claimsfor personal injuryor wrongful death, thematter was not obtained inviolationof22 NYCRR 1200.4-a.
Dated: December 15, 2017
JO . BO O, ESQ.
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NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
X
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DORIS KAUFMAN, : INDEX NO.: 150893/2014
Plaintiff, :
-against- : NOTICE OF EXAMINATION
BEFORE TRIAL
2451 BROADWAY MARKET, INC., YUCCA HOLDING:
CORP. and NEW HORIZON MANAGEMENT CORP.,
:
Defendants.
X
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COUNSELORS:
PLEASE TAKE NOTICE, that pursuant to Article 31 of the CPLR, upon oral
examination, the testimony of the plaintiff, DORIS KAUFMAN, will be taken before a Notary
Public who is not an attorney or employee of an attorney for any party or prospective party
herein, and is not a person who would be disqualified to act as a juror because of interest or
because of co-sanguinity or affinity to any party herein, at the offices of WEINER, MILLO,
10th
MORGAN & BONANNO, LLC, located at 220 Fifth Avenue, Floor, New York, New York,
o'
on March 15, 2018 at 10:00 clock in the forenoon of that day with respect to evidence material
and necessary for the litigation of this action.
That said persons to be examined are required to produce at such examination any and all
documents relative to the claims in the Plaintiff's Complaint and/or Bill of Particulars.
Dated: New York, New York Yours etc.,
December 15, 2017
John P o ann , s .
WEI E , MIL , ORGAN & BONANNO, LLC
Atto ys for Defendants
YUCCA HOLDING CORP. and NEW HORIZON
MANAGEMENT CORP.
220 Fifth Avenue, 10th Floor
New York, New York 10001
(212) 213-1220
WMMB File No.: 428-234
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FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014
NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017
TO: Christopher Joslin, Esq.
David Horowitz, P.C.
Attorneys for Plaintiff
171 Madison Avenue - Suite 1300
New York, New York 10016
(212) 684-3630
Weisberg & Weisberg
Attorneys for Defendant
2451 BROADWAY MARKET, INC.
2463 Broadway
New York, New York 10025
(212) 787-7760
Michael J. Sweeney, Esq.
Trial Counsel for Defendant
2451 BROADWAY MARKET, INC.
25 Greenwood Road
Yonkers, New York 10701
(914) 968-7033
2
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NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
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DORIS KAUFMAN, : INDEX NO.: 150893/2014
Plaintiff, :
-against- : DEMAND FOR DAMAGES
2451 BROADWAY MARKET, INC., YUCCA HOLDING:
CORP. and NEW HORIZON MANAGEMENT CORP.,
:
Defendants.
X
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C 0 U N S E L O R S :
PLEASE TAKE NOTICE, that pursuant to CPLR § 3017, the defendants hereby demands,
within fifteen (15) days of the date hereof, the total damages to which the plaintiff deems herself
entitled.
Dated: New York, New York
December 15, 2017
Yours etc.,
John P. an , F q.
WEIN , LL , RGAN & BONANNO, LLC
Attorne for Def ants
YUCCA HOLDING CORP. and NEW HORIZON
MANAGEMENT CORP.
220 Fifth Avenue, 10th Floor
New York, New York 10001
(212) 213-1220
WMMB File No.: 428-234
TO: Christopher Joslin, Esq.
David Horowitz, P.C.
Attorneys for Plaintiff
171 Madison Avenue - Suite 1300
New York, New York 10016
(212) 684-3630
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FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014
NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017
Weisberg & Weisberg
Attorneys for Defendant
2451 BROADWAY MARKET, INC.
2463 Broadway
New York, New York 10025
(212) 787-7760
Michael J. Sweeney, Esq.
Trial Counsel for Defendant
2451 BROADWAY MARKET, INC.
25 Greenwood Road
Yonkers, New York 10701
(914) 968-7033
2
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FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014
NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
X
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DORIS KAUFMAN, : INDEX NO.: 150893/2014
Plaintiff, :
-against- : NOTICE OF REJECTION OF
FACSIMILE
2451 BROADWAY MARKET, INC., YUCCA HOLDING: TRANSMITTALS
CORP. and NEW HORIZON MANAGEMENT CORP.,
:
Defendants.
X
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PLEASE TAKE NOTICE: that inclusion upon our letterhead of a number for
transmission of documents by electronic facsimile process ("fax") is not to be deemed consent to
service of litigation papers by such method, notwithstanding any provision of law or statute to
the contrary; and
PLEASE TAKE FURTHER NOTICE, that service of litigation papers in this or any
"fax"
other action upon the undersigned by will not be accepted and is not authorized.
Dated: New York, New York
December 15, 2017 Yours etc.,
John P. Bon no, q.
'
WEINER, IL , , l½OR & BONANNO, LLC
Attorneys f efendants
YUCCA HOLDING CORP. and NEW HORIZON
MANAGEMENT CORP.
220 Fifth Avenue, 10th Floor
New York, New York 10001
(212) 213-1220
WMMB File No.: 428-234
TO: Christopher Joslin, Esq.
David Horowitz, P.C.
Attorneys for Plaintiff
171 Madison Avenue - Suite 1300
New York, New York 10016
(212) 684-3630
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Weisberg & Weisberg
Attorneys for Defendant
Preview
FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK ———- ——————————————X ------------------------------------------------------------------------X DORIS KAUFMAN, : INDEX NO.: 150893/2014 Plaintiff, : -against- : DEMAND FOR MEDICARE INFORMATION 2451 BROADWAY MARKET, INC., YUCCA HOLDING: CORP. and NEW HORIZON MANAGEMENT CORP., Defendants. X ------------------------------------------------------------------------X PLEASE TAKE NOTICE that the defendant(s), by its attorneys, Weiner, Millo, Morgan 4 Bonanno, LLC, hereby demands that, pursuant to Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007, the Plaintiff produce for discovery and inspection the following documents and information within twenty (20) days of receipt of this demand at the offices of the undersigned attorneys: 1. If Plaintiff has received or applied for benefits from Medicare at any time, for any reason, not limited to the injuries alleged in the instant action, state and provide the following: a. Plaintiff's name as it appears on plaintiffs social security card or Medicare Benefit Card; b. Other names by which Plaintiff is known (i.e.nick names used in place of legal names); c. Plaintiff's gender; d. Plaintiff's date of birth; e. Plaintiff's date of death (if applicable); f. Plaintiffs Social Security number; g. Plaintiff s residence telephone number; 1 of 34 FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017 h. Plaintiff's last known address; i. Plaintiff's Medicare Health Insurance Claim Number ("HICN"); j. Date of Plaintiff's eligibility for Medicare benefits; k. Amounts of Medicare made payments for health care services that are related to Plaintiff's injuries; 1. Identify amount of Medicare lien for paid benefits; m. Contact information for Medicare office and/or individual that has contacted Plaintiff or Plaintiff's attorney regarding receipt of Medicare benefits and this lawsuit; n. Date such Medicare office or individual contacted the Plaintiff or Plaintiff's attorney regarding receipt of Medicare benefits and this lawsuit; 0. Address of the Medicare and/or Medicaid office handling the plaintiff's claim(s); p. True and accurate copies of all documents, records, memoranda, notes, etc., in plaintiff's possession pertaining to plaintiff's receipt of Medicare and/or Medicaid benefits; q. A duly executed and acknowledged, HIPAA compliant, authorization (see attached) permitting this office to obtain a copy of plaintiffs records from Medicare. 2. A statement as to whether the plaintiff has received or has applied for Social Security Disability benefits, or appealed or anticipates an appeal of a denial of benefits from Social Security Disability at any time, for any reason, not limited to the injuries alleged in the instant action. Ifso, please state the following: a. Social Security File Number and/or Case Number; b. Address of the Social Security office handling the Plaintiff's claim(s); 2 2 of 34 FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017 c. True and accurate copies of all documents, records, memoranda, notes, etc., in possession pertaining to plaintiff's receipt of Social Security benefits; d. A duly executed and acknowledged, HIPAA compliant, authorization (see attached) permitting this office to obtain a copy of plaintiff's records from Social Security; e. Date of application for Social Security Disability benefits; f. Date Social Security Disability benefits awarded; g. List the period for which Social Security Disability benefits were paid (i.e. 1/1/10 to present); h. Date of injury or diagnosis of injury of condition for which Social Security Disability benefits were awarded; i. If application for Social Security Disability was denied. Please provide the following: - Date of denial; - Reason for denial as provided the Social by Security Administration (SSA); - State date of appeal of denial; - State date of reversal or affirmation of SSA decision. 3. Does the Plaintiff suffer from any of the following diseases or conditions: a. Any form of kidney disease (e.g. permanent kidney failure); - Date diagnosed - Describe treatment; - Medical prognosis given - Date Medicare benefits applied for this disease disease" b. Amyotrophic Lateral Sclerosis a/k/a "Lou Gehrig's or "ALS"; - Date diagnosed - Date Plaintiff applied for Social Benefits Security 4. If the Plaintiff is deceased and Medicare paid benefits for treatment of the 3 3 of 34 FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017 Plaintiff's alleged injuries, state the following: a. amount of benefits paid; b. provide copies of medical bills supplied to Medicare for payment; PLEASE TAKE FURTHER NOTICE that the foregoing demand is a continuing demand and in the event that the materials become available after the designated date, they should be forwarded to our office within thirty (30) days of receipt. In the event that said material is not produced for inspection and/or photocopying as required herein, the undersigned will move this Court to invoke the penalties applicable under Article 31 of the CPLR. Dated: New York, New York December 15, 2017 Yours etc., / John P. Bo , Esq. WEINE , LO, R AN & BONANNO, LLC Attorneys for Defend YUCCA HOLDING CORP. and NEW HORIZON MANAGEMENT CORP. 220 Fifth Avenue, 10th Floor New York, New York 10001 (212) 213-1220 WMMB File No.: 428-234 TO: Christopher Joslin, Esq. David Horowitz, P.C. Attorneys for Plaintiff 171 Madison Avenue - Suite 1300 New York, New York 10016 (212) 684-3630 4 4 of 34 FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017 Weisberg & Weisberg Attorneys for Defendant 2451 BROADWAY MARKET, INC. 2463 Broadway New York, New York 10025 (212) 787-7760 Michael J. Sweeney, Esq. Trial Counsel for Defendant 2451 BROADWAY MARKET, INC. 25 Greenwood Road Yonkers, New York 10701 (914) 968-7033 5 5 of 34 FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017 Social Security Admin istration Consent for Release of Information TO: Social Security Administration Name Date of Birth SocialSecurity Number Address I authorize the Social Security Administration to release information or records about me to: NAME ADDRESS 10th Weiner, Millo, Morgan & Bonanno, LLC 220 Fifth Avenue, Floor (212) 213-1220 New York, New York 10001 I want this,information released because: To establish my Social Security Disabilitystatus,date of entitlement to Medicare, and the basis for Medicare entitlement or of Workers' (disability age) forthe purpose my Compensation or Liability claim to be obtained from eitherSocial Security Administration or from MyMedicare.gov website. (There may be a charge for releasing information) Please release the following information: Z Social Security Number parents' IZ Identifying information (includes date and place of birth, names) IZ Monthly Social Security benefit amount IZ Monthly Supplemental Security Income payment amount IZ Information about benefits/payments I received from to . (E Information about my Medicare claim/coverage from to . IE Medical Records E Record(s) from my file(specify) IZ Other - Medicare Health Insurance Claim # (HICN #) SSDI entitlement date. (specify) Medicare Part A. B & D entitlement dates, Date applied fordisability Benefits.Date SSDI payment started,current SSDI payment status,and current SSDI payment amount. This information be faxed to Morgan & Bonanno, LLC - Fax # 212-889-5228 may Weiner, Millo, * Morgan & LLC will be responsible for charges that for Weiner, Millo, Bonanno, any may apply release of information.* I am the individual to whom the information/record applies or thatperson's parent (ifa minor) or legal guardian. I declare under penalty ofperjury thatI have examined allthe information on thisform and it istrue and correct tothe best of my knowledge. I understand that anyone who knowingly gives afalse or misleading statement about a material factin thisinformation, orcauses someone elseto do so, commits a crime and may be sent to prison, or may face other penalties,or both. Signature: (Show signatures, names, and addresses of two people ifsigned by mark.) Date: Relationship: Form SSA-3288 (3-2005) EF (3-2005) 6 of 34 FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017 WEINER, MILLO, MORGAN & BONANNO, LLC AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION PURSUANT TO HIPAA AND APPOINTMENT OF REPRESENTATIVE (Health InsurancePortabilityand AccountabilityAct of 1996) I hereby authorize the use or disclosureof my Protected Health Information and other information as described below. I understand thatthis authorization is voluntary. Individual/ Claimant: Individual/Claimant SSN: Individual/Claimant Address: DOI: Date of Birth: Medicare/HJCN #: Persons/ Entities authorized to provide the information: Any physicians treating or health care providers, my Employer,any HealthInsurance for Payers, the Centers Medicare & Medicaid Services, MyMedicare.gov, Social Security and the MSPRC. Administration, Persons/ Entitiesauthorized to receive,use, and disclosethe information: 1. Weiner,Millo,Morgan & Bonanno, LLC 220 Fifth 10* Floor Avenue, New York,New York 10001 2. Centers for Medicare & MedicaidServices (CMS) Description ofinformation: 1. Allmedicalrecords, but not limited including, to, documents, reports, test results or x-rays. notes, bills, 2. Any informationas may be requestedby Weiner, Millo,Morgan & Bonanno, LLC from any person/ authorized entity to providethe information, which, inWeiner,Millo,Morgan & Bonanno's sole discretion, or necessary is required toaccomplish the purposeofthis Authorization. Purpose ofAuthorization: 1. ThisAuthorizationfor use or disclosure of information is at the request of the individual/ claimant. 2. To providea full disclosure of any information to Weiner, Millo,Morgan & Bonanno, LLC, to enable it to evaluate, determine,and prepare a recommended Medicare Set-AsideArrangement, and tocomplete any otherapplicable and requestedservices, includingConditional Payments (MedicareLien)Research, Final LienAmount Demand and LienNegotiation. 3. To designateWeiner, Millo,Morgan & Bonanno, LLC as its representative to havethe to authority communicate with CMS and the MSPRC to obtain Medicare conditional payment information on my behalf, any request for Conditional and to dispute or negotiate, Payment Reimbursement Medicare related to the undersigned beneficiary, I acknowledge and understand the following: 1. That if the person or entity authorized the information to receive plan or health is not a health the released information care provider, may no longerbe protected by federal privacyregulations; 2. Thatmy health care, payment ofhealthcare, treatment, enrollment, for eligibility or the amount benefits, Medicare pays for the health will services not be affected if I do not sign this authorization form; 3. ThatI may see and copy any information in this form; described 4. ThatI may after I sign it, and if I am unable to make a copy, copy this Authorization I may request a copy from Weiner, Morgan Millo, & Bonanno, LLC; 5. That this authorization approval expires upon of the Medicare Set-AsideArrangement by CMS and completionof any other applicable and requested Conditional services, including Payments (MedicareLien)Research, Final Lien Amount Demand and LienNegotiation; 6. That I may revoke this Authorization at any time by written notice to Weiner, Millo,Morgan & Bonanno, LLC, but that any revocation shall have no effect on actions whichhave been taken by Weiner, Millo,Morgan & Bonanno, LLC priorto receiving my revocation; 7. That any personal medical that I authorize Medicare information and no longer protected by law; to disclose may be subject to re-disclosure 8. That I have the right to refuse to sign this authorization. I have read and understandthe contentsof thisAuthorization and have had theopportunity todiscuss same with counsel ofmy choice. The contents of thisAuthorizationconfirm, and are consistentwith,my instructions, authority, ordirectionsto Weiner,Millo,Morgan & Bonanno, LLC, and Iunderstand that by executing thisAuthorization, Iam authorizingWeiner, Millo,Morgan & Bonanno, LLC, touse and disclose,as permittedand outlined herein,certainnonpublic information. Date: Signature of Claimantor Legal Representative Relationshipto Claimant ifLegal Representative (Except forLegal Representativesacting incapacityas a parentto theclaimant,a copy ofthe document giving theLegal Representativethe authorityto signthisAuthorization must be attached.) 7 of 34 FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017 AFFIDAVIT OF SERVICE BY MAIL STATE OF NEW YORK ) ) ss.: COUNTY OF NEW YORK ) Dena M. Schultz, being duly sworn, deposes and says: I am not a party to the within action, I am over 18 years of age, and I reside in Brooklyn, New York. On the 19th day of December, 2017, I mailed the within DEMAND FOR MEDICARE INFORMATION by depositing a true copy thereof, enclosed in a post-paid wrapper, in an official depository under the exclusive care and custody of the United States Postal Service within New York State, addressed to each of the following persons at the last known address set forth after each name: TO: David Horowitz, P.C. 171 Madison Avenue - Suite 1300 New York, New York 10016 Weisberg & Weisberg 2463 Broadway New York, New York 10025 Michael J. Sweeney, Esq. Trial Counsel for Defendant 25 Greenwood Road Yonkers, New York 10701 DeÓM. Schultz Sworn to before me this 19* 19 day of December, 2017 PUBI' JOHN PERRY BONANNO N t R Notary Public State of New York 02B06184166 Qualified inNew York County +~ Commission Expires March 24, 20 6 8 of 34 FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017 INDEX NO.: 150893/2014 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK DORIS KAUFMAN, Plaintiff - against - 2451 BROADWAY MARKET, INC., YUCCA HOLDING CORP. and NEW HORIZON MANAGEMENT CORP., Defendants DEMAND FOR MEDICARE INFORMATION WEINER, MILLO, MORGAN as BONANNO, LLC ATTORNEYS AT LAW Attorneys for YUCCA HOLDING CORP. and NEW HORIZON MANAGEMENT CORP. 220 FIFTH AVENUE •1OTH FLOOR NEW YORK, NEW YORK 10001-7708 TELEPHONE (212) 213-1220 FACSIMILE(212) 889-5228 Pursuant to 22 NYCRR 130-1.1.a, the undersigned, an attorney admitted to practicein thecourts of New York State, certifiesthat, upon information and beliefand reasonable injury, (1) the contentions contained in the annexed document are not frivolous and that (2) ifthe annexed document is an initiatingpleading, (i) the matter was not obtained through illegalconduct, or that ifit was, theattorney or otherpersons responsible for theillegalconduct are not participating in the matter or sharing in anyfee earned therefrom and that(ii)ifthe matter involvespotential claimsfor personal injuryor wrongful death, thematter was not obtained inviolationof22 NYCRR 1200.4-a. Dated: December 15, 2017 JO . BO O, ESQ. 9 of 34 FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK X ------------------------------------------------------------------------X DORIS KAUFMAN, : INDEX NO.: 150893/2014 Plaintiff, : -against- : NOTICE OF EXAMINATION BEFORE TRIAL 2451 BROADWAY MARKET, INC., YUCCA HOLDING: CORP. and NEW HORIZON MANAGEMENT CORP., : Defendants. X ------------------------------------------------------------------------X COUNSELORS: PLEASE TAKE NOTICE, that pursuant to Article 31 of the CPLR, upon oral examination, the testimony of the plaintiff, DORIS KAUFMAN, will be taken before a Notary Public who is not an attorney or employee of an attorney for any party or prospective party herein, and is not a person who would be disqualified to act as a juror because of interest or because of co-sanguinity or affinity to any party herein, at the offices of WEINER, MILLO, 10th MORGAN & BONANNO, LLC, located at 220 Fifth Avenue, Floor, New York, New York, o' on March 15, 2018 at 10:00 clock in the forenoon of that day with respect to evidence material and necessary for the litigation of this action. That said persons to be examined are required to produce at such examination any and all documents relative to the claims in the Plaintiff's Complaint and/or Bill of Particulars. Dated: New York, New York Yours etc., December 15, 2017 John P o ann , s . WEI E , MIL , ORGAN & BONANNO, LLC Atto ys for Defendants YUCCA HOLDING CORP. and NEW HORIZON MANAGEMENT CORP. 220 Fifth Avenue, 10th Floor New York, New York 10001 (212) 213-1220 WMMB File No.: 428-234 10 of 34 FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017 TO: Christopher Joslin, Esq. David Horowitz, P.C. Attorneys for Plaintiff 171 Madison Avenue - Suite 1300 New York, New York 10016 (212) 684-3630 Weisberg & Weisberg Attorneys for Defendant 2451 BROADWAY MARKET, INC. 2463 Broadway New York, New York 10025 (212) 787-7760 Michael J. Sweeney, Esq. Trial Counsel for Defendant 2451 BROADWAY MARKET, INC. 25 Greenwood Road Yonkers, New York 10701 (914) 968-7033 2 11 of 34 FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK ------------------------------------------------------------------------X DORIS KAUFMAN, : INDEX NO.: 150893/2014 Plaintiff, : -against- : DEMAND FOR DAMAGES 2451 BROADWAY MARKET, INC., YUCCA HOLDING: CORP. and NEW HORIZON MANAGEMENT CORP., : Defendants. X ------------------------------------------------------------------------X C 0 U N S E L O R S : PLEASE TAKE NOTICE, that pursuant to CPLR § 3017, the defendants hereby demands, within fifteen (15) days of the date hereof, the total damages to which the plaintiff deems herself entitled. Dated: New York, New York December 15, 2017 Yours etc., John P. an , F q. WEIN , LL , RGAN & BONANNO, LLC Attorne for Def ants YUCCA HOLDING CORP. and NEW HORIZON MANAGEMENT CORP. 220 Fifth Avenue, 10th Floor New York, New York 10001 (212) 213-1220 WMMB File No.: 428-234 TO: Christopher Joslin, Esq. David Horowitz, P.C. Attorneys for Plaintiff 171 Madison Avenue - Suite 1300 New York, New York 10016 (212) 684-3630 12 of 34 FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017 Weisberg & Weisberg Attorneys for Defendant 2451 BROADWAY MARKET, INC. 2463 Broadway New York, New York 10025 (212) 787-7760 Michael J. Sweeney, Esq. Trial Counsel for Defendant 2451 BROADWAY MARKET, INC. 25 Greenwood Road Yonkers, New York 10701 (914) 968-7033 2 13 of 34 FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK X ------------------------------------------------------------------------X DORIS KAUFMAN, : INDEX NO.: 150893/2014 Plaintiff, : -against- : NOTICE OF REJECTION OF FACSIMILE 2451 BROADWAY MARKET, INC., YUCCA HOLDING: TRANSMITTALS CORP. and NEW HORIZON MANAGEMENT CORP., : Defendants. X ------------------------------------------------------------------------X PLEASE TAKE NOTICE: that inclusion upon our letterhead of a number for transmission of documents by electronic facsimile process ("fax") is not to be deemed consent to service of litigation papers by such method, notwithstanding any provision of law or statute to the contrary; and PLEASE TAKE FURTHER NOTICE, that service of litigation papers in this or any "fax" other action upon the undersigned by will not be accepted and is not authorized. Dated: New York, New York December 15, 2017 Yours etc., John P. Bon no, q. ' WEINER, IL , , l½OR & BONANNO, LLC Attorneys f efendants YUCCA HOLDING CORP. and NEW HORIZON MANAGEMENT CORP. 220 Fifth Avenue, 10th Floor New York, New York 10001 (212) 213-1220 WMMB File No.: 428-234 TO: Christopher Joslin, Esq. David Horowitz, P.C. Attorneys for Plaintiff 171 Madison Avenue - Suite 1300 New York, New York 10016 (212) 684-3630 14 of 34 FILED: NEW YORK COUNTY CLERK 12/19/2017 03:25 PM INDEX NO. 150893/2014 NYSCEF DOC. NO. 78 RECEIVED NYSCEF: 12/19/2017 Weisberg & Weisberg Attorneys for Defendant