Preview
FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E
NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020
ATTORNEYS
JACOB ORESKY
O
MAXINE S. SILVERMAN
R
JOSHUA E. GOLDBLATT
JOHN NONNENMACHER
VICTOR BOTA
YS BARRY S. WEINSTElN
& Associates, pllc
PARALEGALS
149 East 149th Street,Bronx, New York 10451 Y SMER LAPE
P 718-993-9999 - F 718-993-0142 ELAINE CASTILLO
ADACIRIS MONTESlNO
www.oreskylaw.com
July 16, 2020
Litchfield Cavo, LLP
420 Lexington Avenue, Suite 2104
New York, NY 10170
Attention: Rachel S. Trauner, Esq.
Re: Ricardo Sanchez v. WC 28 REALTY LLC, et al.
Index No.: 30668/2019E
D/A: 2/23/2019
Dear Ms. Trauner:
As you know we represent the Plaintiff in the above referenced matter. In response to your
letter dated July 16, 2020. Enclosed please find previously served Plaintiff's Verified Bill of
Particulars and Discovery Response.
PLEASE ALSO FIND ENCLOSED THE FOLLOWING AUTHORIZATIONS WHICH
WERE PREVI_OUSLY PROVIDED TO THE DEFENDANTS:
Lincoln Medical and Mental Health Center
149th
234 East Street
Bronx, NY 10451
BronxCare Health System
1276 Fulton Avenue
Bronx, N 10456
Vista Medical Rehab, PC
2488 Grand Concourse
Bronx, NY 10458
Empire State Ambulatory Surgery Center
3170 Webster Avenue
Bronx, NY 10457
1 of 113
FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E
NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020
Behavior Medicine Associates
310 East Shore Road
Great Neck, NY 11023
Comprehensive Spine & Pain Center of New York
295 Madison Avenue
New York, NY 10017
Aric Hausknecht, MD
Complete Care
2488 Grand Concourse
Bronx, NY 10458
Gabriel Dassa, DO
2488 Grand Concourse
Bronx, NY 10458
Mitchell Zeren, DC
Concourse Chiropractic
2488 Grand Concourse
Bronx, NY 10458
Lenox Hill Radiology
1184 Broadway
Hewlett, NY 11557
Queens Radiology, PC
300'
23-08 Avenue
Astoria, NY 11102
Bilaver Construction & Management, Inc.
1042 Aratina Street
Los Angeles, CA 90042-1506
New York State Insurance Fund
199 Church Street
New York, NY 10007
claim #: 71969943-365
Worker's Compensation OC-110A form, WCB #: G2471684.
Lastly, in response to your demand forBill of Particulars dated June 11, 2020. Plaintiff hereby
rejects and objects to these demands. As you know, the purpose of a Bill of Particulars is to amplify
a pleading served upon the party. A Bill of Particulars is not a discovery device. The Plaintiff did not
serve a Complaint upon the Third-Party Defendant; consequently, there is no pleading for the Plaintiff
2
2 of 113
FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E
NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020
to amplify. The Plaintiff is not a party to the Third-Party Action.
Please be advised that on June Combined Demands was served in the above-
12, 2020,
captioned matter. As of this date, we have not received responses from your office to our demands.
Courtesy copy enclosed herein.
To avoid unnecessary delay and subsequent motion practice, please respond within 10
days.
Please feel free to contact the undersigned to discuss any aspect of this action.
Thanking you in advance for your courtesy and cooperation.
V Ó T ly Y urs,
Melissa Peralta
Paralegal
Enclosures
Cc: Previously provided
HANNUN FERETIC PRENDERGAST & MERLINO, LLC
55 Broadway, Suite 202
New York, NY 10006
GORDON & REES SCULLY MANSUKHANI, LLP
One Battery Park Plaza, 28th Floor
New York, NY 10004
(212) 269-5500
3
3 of 113
FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E
NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020
OCA Official Form No.: 960
AUTHORIZATION I- OR RELEASE OF HEALTH INFORMATION PtrKSUANT TO HIPAA
[This form has been approved by the New York State I)ep rtment of Healthl
Patient Name Date of Birth Social SecurityNumber
Patient Address .
I,or my authorized representat ve, requestthathealth information regarding 1 y care and treatment be released as setforthon thisform:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portabilityand Accountability Act of 1996 (HIPAA), I
understand that:
1. This authorization may include disclosure ofinformation relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials
on the
TREATMENT, psychotherapy notes, only my
appropriate linein Item 9(a). In theevent the health informatiaradescribed below includes any ofthese types of information,and I initial
the
lineon thebox inItem 9(a),I specificallyauthorize releaseof such information to the persons(s) indicated inItem 8.
2. If Iam authorizing the releaseof HIV related,alcohol or drug treatment, or mental health treatment information,the recipientis prohibited
from redisclosing such information without my authorization unless permitted todo so unlessfederal or statelaw. I understand that I have a
rightto request a list
of people who may receive or use my HIV relatedinformation without authorization. IfI experience discrimination
because of theuse or disclosure ofHIV-related information, I may contactthe New York State Division of Human Rights at (212)480-2493
or theNew York City Commission of Human rights at(212) 306-7450. These agencies are responsible forprotecting my rights.
3. I have the rightto revoke this authorizationat any time by writing tothe health care provider below. Iunderstand thatI may revoke this
authorization except to the extentthat actionhas already been taken based upon thisauthorization.
4. I understand that signingthis authorization isvoluntary. My treatment, payment, enrollment in a healthplan, or for
eligibility benefitswill
not be conditioned upon my authorizationof thisdisclosure.
5. Information disclosed under this authorizationmight be redisclosed by the recipient (except as notedabove in Item 2),and this
redisclosuremay no longer be protectedby federal or statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMEN AL AGEN Y SP IFIED ITEM 9 ). f
. am d addres f health id r ore i t re e thi inform ion:(,( [dff9 ( fP2ge-7
an ss of rsons( tegory to t inf a ion w be sent:
9(a). Sp icinfo ion tobe rele se :
Medical Record from to
O Entire Medical Records, inctding p tient histories,ph icaltherapy records, officenotes (except psychotherapy notes),test
results,radiology studies, films,referrals,consults,billingrecords, insurance records, and records sent toyou by other healthcare
providers.
O Other: Include: (Indicate by Initialing)
Alcohol/Drug Treatment
Mental Health Information
HIV-Related Information
Authorization to Discuss Health Information
(b) O By here
initialing I authorize
Initials Name of individualhealth care provider
to discussmy health information with my attorney,or a governmental agency, listedhere:
(Attorney/Firm Name or Governmental Apncy Name)
10. Reason for releaseof information: 11.Date orev t on w ich thisauthorizationwill expire:
[X] At request of individual
O Other: O
Ifnot the patient,name of person signing form: 13. Authori to signon behalf of patient:
All items on thisform have been completed and my questions about thisform have been answered. In additinn,I have been provided a copy
of theform.
X A Date:
Signature o ati nt orre sentativeauthorized by law.
*Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law t i ch nably could
identify someone as havingHIV symptoms or infectionand information regarding a person's w York
tate of N
c
Notary Pub oiPE6150010
No.
in Queens County
Oualified
Commission Ex ires 07/24/2022
4 of 113
FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E
NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020
OCA Official Form No.: 960
AUTHORIZATION I-OR RELEASE OF HEALTH INFORMATION PtrRSUANT TO HIPAA
IThis form has been approved by the New York State D part ent of Health]
Patient Name Date of Birth Social Security Number
Patient Address
I,or my authorized representative,request thathealth information regarding my care and trea ent be released as setforthon thisform:
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 relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials
on the
TREATMENT, psychotherapy notes, only my
appropriate line inItem 9(a). Inthe event the healthinformation described below includes any of thesetypes of information, and I initial
the
lineon thebox inItem 9(a),Ispecificallyauthorize release of such information to the persons(s) indicated inItem 8.
2. IfI am authorizing therelease of HIV related,alcohol or drug treatment, ormental healthtreatment information,the recipient is prohibited
from redisclosing such information without my authorization unlesspermitted todo so unless federal orstate law. I understand thatI have a
rightto request a list
of people who may receive or use my HIV relatedinformation without authorization. IfI experience discrimination
because of the use ordisclosure of HIV-related information, I may contactthe New York State Division of Human Rights at (212)480-2493
or theNew York City Commission of Human rightsat(212) 306-7450. These agencies are responsible forprotecting my rights.
3. I have the rightto revoke this authorizationat any time by writing tothe health care provider below. I understand thatI may revoke this
authorization except to the extentthat actionhas already been taken based upon thisauthorization.
4. I understand that signingthis authorization is voluntary.My treatment, payment, enrollment ina healthplan, or for
eligibility benefitswill
not be conditioned upon my authorizationof thisdisclosure.
5. Information disclosed under thisauthorization might be redisclosed by the recipient (except as noted above in Item 2),and this
redisclosure may no longer be protected by federal or statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVE MENTAL AGENCyÂPEC F D ITyM 9 (b).
7 and s of heal pr ider or tityto leaset isi format n
e a d address of sons te ory to w t s inf a n illbe sent:(,/Ó; >g
9(a). Sp sc info tion tobe releas :
Medical Record from to
O Entire Medical Records, in ding tienthistories,phy icaltherapy records, officenotes (except psychotherapy notes), test
results,radiology studies,films,referrals,consults,billingrecords, insurance records, and records sent toyou by other healthcare
providers.
O Other: Include: (Indicate by Initialing),
Alcohol/Drug Treatm nt
Mental Health Inforniation
HIV-Related Inform tion
Authorization to Discuss Health Information
(b) O By here
initialing I authorize
Initials Name of individualhealth care provider
to discussmy health information with my attorney,or a governmental agency, listedhere:
(Attorney/Firm Name or Governmental Aency Name)
10. Reason for releaseof information: 11.Date orevent on wh h thisa thorization will expire:
[X] At request of individual
O Other:
12. Ifnot the patient,name of person signing form: 13.Authority to signon behalfof patient:
All items on thisform have been c0mpleted and my questions about thisform have been añswered. In addition,I have been provided a copy
of theform.
X A Date:
Signature o pati nt orre esentativeauthorized by law.
*Human Immunodeficiency Virus that causesAIDS. The New York State Public Health La c n as ably could
as having HIV symptoms or infectionand information regarding a perso S MEUSSA PERA -A
identify
State of New York
Notary PubHc,
No. 01PEB150010
in Oueens County
Qualified
ComrnissionExpires 07/24/2022
5 of 113
FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E
NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020
OCA Official Form No.: 960
AUTHORIZATION I-OR RELEASE OF HEALTH INFORMATION PtrKSUANT TO HIPAA
IThis form has been approved by the New York State/Depprtment of Health] __
Patient Name Date of Social Security Number
Birtly
Patient Address c7 rim. y Y be' /dWb
I,or my authorized representative,request thathealth information regarding my care and treatrdent released as setforthon thisform:
In accordance with New York StateLaw and the Privacy Rule of the Health Insurance Portabilityand Accountability Act of 1996 (HIPAA), I
understand that:
1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials
on the
TREATMENT, psychotherapy notes, only my
appropriate line inItem 9(a). Inthe event the healthinformaticñ described below includes any of thesetypes of information, and the
I initial
lineon thebox in Item 9(a),I specificallyauthorize releaseof such information to the persons(s) indicated inItem 8.
2. IfI am authorizing therelease of HIV alcohol
related, ordrug treatment, or mental health treatment information, the recipientis prohibited
from redisclosing such information without my authorization unless permitted to do so unless federalor statelaw. Iunderstand thatI have a
rightto request a list
of people who may receive oruse my HIV related information without authorization. If Iexperience discrimination
because of theuse or disclosure of HIV-related information, I may contact theNew York StateDivision ofHuman Rights at (212) 480-2493
or theNew York City Commission of Human rights at(212) 306-7450. These agencies are responsibleforprotecting my rights.
3. I have the rightto revoke this authorizationat any time by writing tothe health care provider below. I understand thatI may revoke this
authorization except to the extentthat actionhas already been taken based upon thisauthorization.
4. I understand thatsigning this authorization is voluntary.My treatment, payment, enrollment ina health plan, or for
eligibility benefits will
not be conditioned upon my authorizationof thisdisclosure.
5. Information disclosed under thisauthorization might be redisclosed by the recipient (except as noted above in Item 2),and this
redisclosuremay no longer be protectedby federalor statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNM NTAL AGENC §PECI IED,IN JTEM,9 (b .
7 a ress ofh lthpro der or entity o release s inform tion
e d ss f ersons tegory e n t o his o ilbe sent: C )
9(a). Spec c info ation to be release
edicalRecord from to
O Entire Medical Records, incluÛing p ent histories,physi therapy records, officenotes (except psychotherapy notes),test
results,radiology studies, films,referrals,consults,billingrecords, insurance records, and records sent toyou by other healthcare
providers.
O Other: Include: (Indicate by Initialing)
Alcohol/Drug Treatm nt
Mental Health Inforn ation
HIV-Related Informetion
Authorization to Discuss Health Information
(b) O By here
initialing I authorize
Initials Name of individualhealth care provider
to discuss my health information with my attorney,or a governmcatal agency, listedhere:
(Attorney/Firm Name or Governmental Agency Name)
10. Reason for releaseof information: 11.Date orevent on w h this uthorizationwill expire:
[X] At request of individual
O Other:
12. Ifnot the name
patient, of person signing form: 13.Authority to signon behalf of patient:
All items on thisform have been conipleted and my questions about thisform have been answered. In addition,I have been provided a copy
of theform.
X . 4 Date:
Signature o ati nt orre esentative authorized by law.
*Human Irn_=ür±±Jiciency Virus that causesAIDS. The New York State PublicHealth i lycould
' MEl 18 1TA
identifysomeone as having HIV symptoms or infectionand information regarding a pe
No. 01PEG150010
Ounlihodin Queens County
Commission Expires 07/24/2022
6 of 113
FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E
NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020
OCA Official Form No.: 960
AUTHORIZATION 120R RELEASE OF HEALTH INFORMATION PtrKSUANT TO HIPAA
IThis form has been approved by the New York State pepartment of Health|
Patient Name Date of Birth Social Security Number
Patient Address 7
I,or my authorized representative,request thathealth information regarding my care add treatment be released as setforthon thisform:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portabilityand Acceüñtability Act of 1996 (HIPAA), I
understand that:
1. This authorization may include disclosure of infonnation relatingto ALCOHOL and DRUG ABUSE, MENTAL [IEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place on
initials the
TREATMENT, psychotherapy notes, only my
appropriate line inItem 9(a). Inthe event the healthinformation described below includes any of thesetypes of information, and I initial
the
lineon thebox inItem 9(a),I specificallyauthorizerelease of such information to the persons(s) indicated inItem 8.
2. IfI am authorizing therelease of HIV related,alcohol ordrug treatment,or mental healthtreatment information, the recipient is prohibited
from redisclosing such information without my authorizationunless permitted todo so unless federal orstate law. I understand thatI have a
rightto request a list
of people who may receive or use my HIV relatedinformation without authorization. IfI experience discrimination
because of theuse or disclosure ofHIV-related information, I may contact the New York State Division of Human Rights at (212)480-2493
or theNew York City Commission of Human rights at(212) 306-7450. These agencies are responsible forprotecting my rights.
3. I have the rightto revoke thisauthorization at any time by writing tothe health care provider below. Iunderstand thatI may revoke this
authorization except to the extentthat actionhas already been taken based upon thisauthorization.
4. I understand that signingthis authorization isvoluntary. My treatment, payment, enrollment ina health plan, or for
eligibility benefitswill
not be conditioned upon my authorizationof thisdisclosure.
5. Information disclosed under thisauthorization might be redisclosed by the recipient (except as noted above in Item k),and this
redisclosure may no longer be pictected by federal or statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGEN Y SPECIF ED IN ITE 9 b).
8. ess of rsons tegory n tow isi on will be se t: 'f)
9( ). Sp 1c mfo ion tobe re e ed:
Medical Record from to
O Entire Medical Records, in luding atienthistories,p sicaltherapy records, officenotes (except psychotherapy notes),test
results,radiology studies,films,referrals,consults,billingrecords, insurance records, and records sent toyou by other healthcare
providers.
O Other: Include: (Indicate by Initialing)
Alcohol/Drug Treatment
Mental Health Information
HIV-Related Information
Authorization to Discuss Health Information
(b) O By here
initialing I authorize
Initials Name of individualhealth care provider
to discussmy health information with my attorney,or a governmental agency, listed
here:
(Attomey/Firm Name or Govounuoutal Agency Name)
10. Reason forrelease of information: 11.Date orevent on whic thisauthorization will expire:
[X] At request of individual
O Other:
12. Ifnot the patient,name of person signing form: 13.Authority to signo behalf of patient:
All items on thisform have been completed and my questions about thisform have been answered. In addition,I have been provided a copy
of theform.
X A Date:
Signature o pati nt orre esentative authorized by law.
*Human Im-üñodeficiency Virus thatcauses AIDS. The New York State Public Health L p gtio e ably could
identify someone as havingHIV symptoms or infectionand information regarding a pers s USSA PF9Al TA
of New York
Notary Public, S No
No. 01 PE 1150010
Oual4iedin Oueens County
Commission Expires 07/24/2022
7 of 113
FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E
NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020
OCA Official Form No.: 960
AUTHORIZATION f OR RELEASE OF HEALTH INFORMATION PCrKSUANT TO HIPAA
This form has been ap roved by the New York State Department of Health
Patient Name Date of Birth Social Security Number
Patient Address - . __
I,or my authorized representative,request thathealth information regarding my care and treadnent be released as setforthon thisform:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portabilityand Acœüñtability Act of 1996 (HIPAA), I
understand that:
1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH
and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials
on the
TREATMENT, except psychotherapy notes, only my
appropriate line inItem 9(a). Inthe event the healthinformation described below includes any of thesetypes of information, and I initial
the
lineon thebox in Item 9(a),I specificallyauthorize releaseof such information to the persons(s) indicated inItem 8.
2. IfI am authorizing the release of HIV related,alcohol or drug treatment, or mental health treatment information, therecipient is prohibited
from redisclosing such information without my authorization unless permitted to do so unless federalor statelaw. I understand that I have a
rightto request a listofpeople who may receive or use my HIV relatedinformation without authorization. IfI experience discrimination
because ofthe use or disclosure of HIV-related information, I may contactthe New York State Division of Human Rights at (212)480-2493
or theNew York City Commission of Human rights at(212) 306-7450. These agencies are responsible forprotecting my rights.
3. I have the rightto revoke this authorizationat any time by writing tothe health care provider below. Iunderstand thatI may revoke this
authorization except to the extentthat actionhas already been taken based upon thisauthorization.
4. I understand that signingthis authorization is voluntary.My treatment, payment, enrollment ina health plan, or for
eligibility benefitswill
not be conditioned upon my authorizationof thisdisclosure.
5. Information disclosed under thisauthorization might be redisclosed by the recipient (except as noted above inItem 2),and this
redisclosure may no longer be protected by federal or statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMFNTAI AGENCY SPEFIFIED IN ITEjyl 9. ).
7. e and gddr ss o e o r ent :
8. add erson r c of person thi io w b s t: 6
9(a). S c informatio be rele e
edicalRecord m to
O Entire Medical Records, incl ding p tienthistories,physical erapy records, officenotes (except psychotherapy notes),test
results,radiology studies,films,referrals,consults,billingrecords, insurance records, and records sent toyou by other healthcare
providers.
O Other: Include: (IndicatebyInitialing)
Alcohol/Drug Treatm‡nt
Mental Health Inforniation
HIV-Related Inform tion
Authorization to Discuss Health Information
(b) O By here
initialing I authorize
Initials Name of individualhealth care provider
to discussmy health infermation with my attorney,or a govern=ental agency, listedhere:
(Attorney/Firm Name or Governmental Agency Name)
10. Reason for releaseof information: 11.Date orevent on which this uthori ion willexpire:
[X] At request of individual
'7 /6 c2/
12. Ifnot the patient,name of person signing form: 13.Authority to signon beh f ofpatient:
All items on thisform have been completed and my questions about thisform have been answered. In addition,I have been provided a copy
of theform.
X Date:
Signature o pati nt orre esentative authorized by law.
at'
*Human I==!=adeficiency Virus thatcauses AIDS. The New York State Public Health La pro n r a y could
identify someone as havingHIV symptoms or infectionand information regarding a perso
State of New York
Notary Public.
No. 01PE6150010
Q ualified in Queens07/24/2022
County
8 of 113 Commission Expues
FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E
NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020
OCA Çfficial Form No.: 960
AUTHORIZATION I-OR RELEASE OF HEALTH INFORMATION FoKSUANT TO HIPAA
|This form has been approved by the New York StateyDepa ment of Health]
Patient Name Date of Birth/ Social Security Number
atientAddress 7 , /\
I,or my authorized representative,request thathealth information regarding my care and treatmeÛt be released as setforthon thisform:
In accordance with New York StateLaw and the Privacy Rule of the Health Iñsurance Portability and Acceüñtability Act of 1996 (HIPAA), I
understand that:
1. This authorizationmay include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL (IEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place on
initials the
TREATMENT, psychotherapy notes, only my
appropriate line inItem 9(a). Inthe event the healthinformation described below includes any of thesetypes of information, and I initial
the
line on thebox in Item 9(a),I specificallyauthorize releaseof such information to the persons(s) indicated inItem 8.
2. IfI am authorizing therelease of HIV alcohol
related, ordrug treatment, or mental health treatment information, the recipientis prohibited
from redisclosing such information without my authorization unless permitted to do so unless federalor statelaw. Iunderstand thatI have a
rightto request a list
of people who may receive oruse my HIV related information without authorization. If Iexperience discrimination
because of theuse or disclosure of HIV-related information, I may contact the New York StateDivision ofHuman Rights at (212) 480-2493
or theNew York City Commission of Human rightsat(212) 306-7450. These agencies are responsiblefor protecting my rights.
3. I have the rightto revoke this authorizationat any time by writing to thehealth care previder below. I understand thatI may revoke this
authorization except to the extentthat actionhas already been taken based upon thisauthorization.
4. I understand that signingthis authorization isvoluntary. My treatmcñt, payment, enrollment in a healthplan, or cliibilityfor benefitswill
not be conditioned upon my authorization ofthisdisclosure.
5. Information disclosed under thisauthorization might be redisclosed by the recipient (except as noted above in Item 2),and this
redisclosure may no longer be protectedby federal or statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL 4GENCy SPECIFIED IN ITEM 9 fb).
7 f althpr ent thisinfo (ff )
00 • / /V . . ,
8. e an o per ns(s)o ry ofp
Preview
FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020 ATTORNEYS JACOB ORESKY O MAXINE S. SILVERMAN R JOSHUA E. GOLDBLATT JOHN NONNENMACHER VICTOR BOTA YS BARRY S. WEINSTElN & Associates, pllc PARALEGALS 149 East 149th Street,Bronx, New York 10451 Y SMER LAPE P 718-993-9999 - F 718-993-0142 ELAINE CASTILLO ADACIRIS MONTESlNO www.oreskylaw.com July 16, 2020 Litchfield Cavo, LLP 420 Lexington Avenue, Suite 2104 New York, NY 10170 Attention: Rachel S. Trauner, Esq. Re: Ricardo Sanchez v. WC 28 REALTY LLC, et al. Index No.: 30668/2019E D/A: 2/23/2019 Dear Ms. Trauner: As you know we represent the Plaintiff in the above referenced matter. In response to your letter dated July 16, 2020. Enclosed please find previously served Plaintiff's Verified Bill of Particulars and Discovery Response. PLEASE ALSO FIND ENCLOSED THE FOLLOWING AUTHORIZATIONS WHICH WERE PREVI_OUSLY PROVIDED TO THE DEFENDANTS: Lincoln Medical and Mental Health Center 149th 234 East Street Bronx, NY 10451 BronxCare Health System 1276 Fulton Avenue Bronx, N 10456 Vista Medical Rehab, PC 2488 Grand Concourse Bronx, NY 10458 Empire State Ambulatory Surgery Center 3170 Webster Avenue Bronx, NY 10457 1 of 113 FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020 Behavior Medicine Associates 310 East Shore Road Great Neck, NY 11023 Comprehensive Spine & Pain Center of New York 295 Madison Avenue New York, NY 10017 Aric Hausknecht, MD Complete Care 2488 Grand Concourse Bronx, NY 10458 Gabriel Dassa, DO 2488 Grand Concourse Bronx, NY 10458 Mitchell Zeren, DC Concourse Chiropractic 2488 Grand Concourse Bronx, NY 10458 Lenox Hill Radiology 1184 Broadway Hewlett, NY 11557 Queens Radiology, PC 300' 23-08 Avenue Astoria, NY 11102 Bilaver Construction & Management, Inc. 1042 Aratina Street Los Angeles, CA 90042-1506 New York State Insurance Fund 199 Church Street New York, NY 10007 claim #: 71969943-365 Worker's Compensation OC-110A form, WCB #: G2471684. Lastly, in response to your demand forBill of Particulars dated June 11, 2020. Plaintiff hereby rejects and objects to these demands. As you know, the purpose of a Bill of Particulars is to amplify a pleading served upon the party. A Bill of Particulars is not a discovery device. The Plaintiff did not serve a Complaint upon the Third-Party Defendant; consequently, there is no pleading for the Plaintiff 2 2 of 113 FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020 to amplify. The Plaintiff is not a party to the Third-Party Action. Please be advised that on June Combined Demands was served in the above- 12, 2020, captioned matter. As of this date, we have not received responses from your office to our demands. Courtesy copy enclosed herein. To avoid unnecessary delay and subsequent motion practice, please respond within 10 days. Please feel free to contact the undersigned to discuss any aspect of this action. Thanking you in advance for your courtesy and cooperation. V Ó T ly Y urs, Melissa Peralta Paralegal Enclosures Cc: Previously provided HANNUN FERETIC PRENDERGAST & MERLINO, LLC 55 Broadway, Suite 202 New York, NY 10006 GORDON & REES SCULLY MANSUKHANI, LLP One Battery Park Plaza, 28th Floor New York, NY 10004 (212) 269-5500 3 3 of 113 FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020 OCA Official Form No.: 960 AUTHORIZATION I- OR RELEASE OF HEALTH INFORMATION PtrKSUANT TO HIPAA [This form has been approved by the New York State I)ep rtment of Healthl Patient Name Date of Birth Social SecurityNumber Patient Address . I,or my authorized representat ve, requestthathealth information regarding 1 y care and treatment be released as setforthon thisform: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portabilityand Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure ofinformation relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials on the TREATMENT, psychotherapy notes, only my appropriate linein Item 9(a). In theevent the health informatiaradescribed below includes any ofthese types of information,and I initial the lineon thebox inItem 9(a),I specificallyauthorize releaseof such information to the persons(s) indicated inItem 8. 2. If Iam authorizing the releaseof HIV related,alcohol or drug treatment, or mental health treatment information,the recipientis prohibited from redisclosing such information without my authorization unless permitted todo so unlessfederal or statelaw. I understand that I have a rightto request a list of people who may receive or use my HIV relatedinformation without authorization. IfI experience discrimination because of theuse or disclosure ofHIV-related information, I may contactthe New York State Division of Human Rights at (212)480-2493 or theNew York City Commission of Human rights at(212) 306-7450. These agencies are responsible forprotecting my rights. 3. I have the rightto revoke this authorizationat any time by writing tothe health care provider below. Iunderstand thatI may revoke this authorization except to the extentthat actionhas already been taken based upon thisauthorization. 4. I understand that signingthis authorization isvoluntary. My treatment, payment, enrollment in a healthplan, or for eligibility benefitswill not be conditioned upon my authorizationof thisdisclosure. 5. Information disclosed under this authorizationmight be redisclosed by the recipient (except as notedabove in Item 2),and this redisclosuremay no longer be protectedby federal or statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMEN AL AGEN Y SP IFIED ITEM 9 ). f . am d addres f health id r ore i t re e thi inform ion:(,( [dff9 ( fP2ge-7 an ss of rsons( tegory to t inf a ion w be sent: 9(a). Sp icinfo ion tobe rele se : Medical Record from to O Entire Medical Records, inctding p tient histories,ph icaltherapy records, officenotes (except psychotherapy notes),test results,radiology studies, films,referrals,consults,billingrecords, insurance records, and records sent toyou by other healthcare providers. O Other: Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) O By here initialing I authorize Initials Name of individualhealth care provider to discussmy health information with my attorney,or a governmental agency, listedhere: (Attorney/Firm Name or Governmental Apncy Name) 10. Reason for releaseof information: 11.Date orev t on w ich thisauthorizationwill expire: [X] At request of individual O Other: O Ifnot the patient,name of person signing form: 13. Authori to signon behalf of patient: All items on thisform have been completed and my questions about thisform have been answered. In additinn,I have been provided a copy of theform. X A Date: Signature o ati nt orre sentativeauthorized by law. *Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law t i ch nably could identify someone as havingHIV symptoms or infectionand information regarding a person's w York tate of N c Notary Pub oiPE6150010 No. in Queens County Oualified Commission Ex ires 07/24/2022 4 of 113 FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020 OCA Official Form No.: 960 AUTHORIZATION I-OR RELEASE OF HEALTH INFORMATION PtrRSUANT TO HIPAA IThis form has been approved by the New York State D part ent of Health] Patient Name Date of Birth Social Security Number Patient Address I,or my authorized representative,request thathealth information regarding my care and trea ent be released as setforthon thisform: 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 relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials on the TREATMENT, psychotherapy notes, only my appropriate line inItem 9(a). Inthe event the healthinformation described below includes any of thesetypes of information, and I initial the lineon thebox inItem 9(a),Ispecificallyauthorize release of such information to the persons(s) indicated inItem 8. 2. IfI am authorizing therelease of HIV related,alcohol or drug treatment, ormental healthtreatment information,the recipient is prohibited from redisclosing such information without my authorization unlesspermitted todo so unless federal orstate law. I understand thatI have a rightto request a list of people who may receive or use my HIV relatedinformation without authorization. IfI experience discrimination because of the use ordisclosure of HIV-related information, I may contactthe New York State Division of Human Rights at (212)480-2493 or theNew York City Commission of Human rightsat(212) 306-7450. These agencies are responsible forprotecting my rights. 3. I have the rightto revoke this authorizationat any time by writing tothe health care provider below. I understand thatI may revoke this authorization except to the extentthat actionhas already been taken based upon thisauthorization. 4. I understand that signingthis authorization is voluntary.My treatment, payment, enrollment ina healthplan, or for eligibility benefitswill not be conditioned upon my authorizationof thisdisclosure. 5. Information disclosed under thisauthorization might be redisclosed by the recipient (except as noted above in Item 2),and this redisclosure may no longer be protected by federal or statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVE MENTAL AGENCyÂPEC F D ITyM 9 (b). 7 and s of heal pr ider or tityto leaset isi format n e a d address of sons te ory to w t s inf a n illbe sent:(,/Ó; >g 9(a). Sp sc info tion tobe releas : Medical Record from to O Entire Medical Records, in ding tienthistories,phy icaltherapy records, officenotes (except psychotherapy notes), test results,radiology studies,films,referrals,consults,billingrecords, insurance records, and records sent toyou by other healthcare providers. O Other: Include: (Indicate by Initialing), Alcohol/Drug Treatm nt Mental Health Inforniation HIV-Related Inform tion Authorization to Discuss Health Information (b) O By here initialing I authorize Initials Name of individualhealth care provider to discussmy health information with my attorney,or a governmental agency, listedhere: (Attorney/Firm Name or Governmental Aency Name) 10. Reason for releaseof information: 11.Date orevent on wh h thisa thorization will expire: [X] At request of individual O Other: 12. Ifnot the patient,name of person signing form: 13.Authority to signon behalfof patient: All items on thisform have been c0mpleted and my questions about thisform have been añswered. In addition,I have been provided a copy of theform. X A Date: Signature o pati nt orre esentativeauthorized by law. *Human Immunodeficiency Virus that causesAIDS. The New York State Public Health La c n as ably could as having HIV symptoms or infectionand information regarding a perso S MEUSSA PERA -A identify State of New York Notary PubHc, No. 01PEB150010 in Oueens County Qualified ComrnissionExpires 07/24/2022 5 of 113 FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020 OCA Official Form No.: 960 AUTHORIZATION I-OR RELEASE OF HEALTH INFORMATION PtrKSUANT TO HIPAA IThis form has been approved by the New York State/Depprtment of Health] __ Patient Name Date of Social Security Number Birtly Patient Address c7 rim. y Y be' /dWb I,or my authorized representative,request thathealth information regarding my care and treatrdent released as setforthon thisform: In accordance with New York StateLaw and the Privacy Rule of the Health Insurance Portabilityand Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials on the TREATMENT, psychotherapy notes, only my appropriate line inItem 9(a). Inthe event the healthinformaticñ described below includes any of thesetypes of information, and the I initial lineon thebox in Item 9(a),I specificallyauthorize releaseof such information to the persons(s) indicated inItem 8. 2. IfI am authorizing therelease of HIV alcohol related, ordrug treatment, or mental health treatment information, the recipientis prohibited from redisclosing such information without my authorization unless permitted to do so unless federalor statelaw. Iunderstand thatI have a rightto request a list of people who may receive oruse my HIV related information without authorization. If Iexperience discrimination because of theuse or disclosure of HIV-related information, I may contact theNew York StateDivision ofHuman Rights at (212) 480-2493 or theNew York City Commission of Human rights at(212) 306-7450. These agencies are responsibleforprotecting my rights. 3. I have the rightto revoke this authorizationat any time by writing tothe health care provider below. I understand thatI may revoke this authorization except to the extentthat actionhas already been taken based upon thisauthorization. 4. I understand thatsigning this authorization is voluntary.My treatment, payment, enrollment ina health plan, or for eligibility benefits will not be conditioned upon my authorizationof thisdisclosure. 5. Information disclosed under thisauthorization might be redisclosed by the recipient (except as noted above in Item 2),and this redisclosuremay no longer be protectedby federalor statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNM NTAL AGENC §PECI IED,IN JTEM,9 (b . 7 a ress ofh lthpro der or entity o release s inform tion e d ss f ersons tegory e n t o his o ilbe sent: C ) 9(a). Spec c info ation to be release edicalRecord from to O Entire Medical Records, incluÛing p ent histories,physi therapy records, officenotes (except psychotherapy notes),test results,radiology studies, films,referrals,consults,billingrecords, insurance records, and records sent toyou by other healthcare providers. O Other: Include: (Indicate by Initialing) Alcohol/Drug Treatm nt Mental Health Inforn ation HIV-Related Informetion Authorization to Discuss Health Information (b) O By here initialing I authorize Initials Name of individualhealth care provider to discuss my health information with my attorney,or a governmcatal agency, listedhere: (Attorney/Firm Name or Governmental Agency Name) 10. Reason for releaseof information: 11.Date orevent on w h this uthorizationwill expire: [X] At request of individual O Other: 12. Ifnot the name patient, of person signing form: 13.Authority to signon behalf of patient: All items on thisform have been conipleted and my questions about thisform have been answered. In addition,I have been provided a copy of theform. X . 4 Date: Signature o ati nt orre esentative authorized by law. *Human Irn_=ür±±Jiciency Virus that causesAIDS. The New York State PublicHealth i lycould ' MEl 18 1TA identifysomeone as having HIV symptoms or infectionand information regarding a pe No. 01PEG150010 Ounlihodin Queens County Commission Expires 07/24/2022 6 of 113 FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020 OCA Official Form No.: 960 AUTHORIZATION 120R RELEASE OF HEALTH INFORMATION PtrKSUANT TO HIPAA IThis form has been approved by the New York State pepartment of Health| Patient Name Date of Birth Social Security Number Patient Address 7 I,or my authorized representative,request thathealth information regarding my care add treatment be released as setforthon thisform: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portabilityand Acceüñtability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of infonnation relatingto ALCOHOL and DRUG ABUSE, MENTAL [IEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place on initials the TREATMENT, psychotherapy notes, only my appropriate line inItem 9(a). Inthe event the healthinformation described below includes any of thesetypes of information, and I initial the lineon thebox inItem 9(a),I specificallyauthorizerelease of such information to the persons(s) indicated inItem 8. 2. IfI am authorizing therelease of HIV related,alcohol ordrug treatment,or mental healthtreatment information, the recipient is prohibited from redisclosing such information without my authorizationunless permitted todo so unless federal orstate law. I understand thatI have a rightto request a list of people who may receive or use my HIV relatedinformation without authorization. IfI experience discrimination because of theuse or disclosure ofHIV-related information, I may contact the New York State Division of Human Rights at (212)480-2493 or theNew York City Commission of Human rights at(212) 306-7450. These agencies are responsible forprotecting my rights. 3. I have the rightto revoke thisauthorization at any time by writing tothe health care provider below. Iunderstand thatI may revoke this authorization except to the extentthat actionhas already been taken based upon thisauthorization. 4. I understand that signingthis authorization isvoluntary. My treatment, payment, enrollment ina health plan, or for eligibility benefitswill not be conditioned upon my authorizationof thisdisclosure. 5. Information disclosed under thisauthorization might be redisclosed by the recipient (except as noted above in Item k),and this redisclosure may no longer be pictected by federal or statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGEN Y SPECIF ED IN ITE 9 b). 8. ess of rsons tegory n tow isi on will be se t: 'f) 9( ). Sp 1c mfo ion tobe re e ed: Medical Record from to O Entire Medical Records, in luding atienthistories,p sicaltherapy records, officenotes (except psychotherapy notes),test results,radiology studies,films,referrals,consults,billingrecords, insurance records, and records sent toyou by other healthcare providers. O Other: Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information (b) O By here initialing I authorize Initials Name of individualhealth care provider to discussmy health information with my attorney,or a governmental agency, listed here: (Attomey/Firm Name or Govounuoutal Agency Name) 10. Reason forrelease of information: 11.Date orevent on whic thisauthorization will expire: [X] At request of individual O Other: 12. Ifnot the patient,name of person signing form: 13.Authority to signo behalf of patient: All items on thisform have been completed and my questions about thisform have been answered. In addition,I have been provided a copy of theform. X A Date: Signature o pati nt orre esentative authorized by law. *Human Im-üñodeficiency Virus thatcauses AIDS. The New York State Public Health L p gtio e ably could identify someone as havingHIV symptoms or infectionand information regarding a pers s USSA PF9Al TA of New York Notary Public, S No No. 01 PE 1150010 Oual4iedin Oueens County Commission Expires 07/24/2022 7 of 113 FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020 OCA Official Form No.: 960 AUTHORIZATION f OR RELEASE OF HEALTH INFORMATION PCrKSUANT TO HIPAA This form has been ap roved by the New York State Department of Health Patient Name Date of Birth Social Security Number Patient Address - . __ I,or my authorized representative,request thathealth information regarding my care and treadnent be released as setforthon thisform: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portabilityand Acœüñtability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL HEALTH and CONFIDENTIAL HIV* RELATED INFORMATION ifI place initials on the TREATMENT, except psychotherapy notes, only my appropriate line inItem 9(a). Inthe event the healthinformation described below includes any of thesetypes of information, and I initial the lineon thebox in Item 9(a),I specificallyauthorize releaseof such information to the persons(s) indicated inItem 8. 2. IfI am authorizing the release of HIV related,alcohol or drug treatment, or mental health treatment information, therecipient is prohibited from redisclosing such information without my authorization unless permitted to do so unless federalor statelaw. I understand that I have a rightto request a listofpeople who may receive or use my HIV relatedinformation without authorization. IfI experience discrimination because ofthe use or disclosure of HIV-related information, I may contactthe New York State Division of Human Rights at (212)480-2493 or theNew York City Commission of Human rights at(212) 306-7450. These agencies are responsible forprotecting my rights. 3. I have the rightto revoke this authorizationat any time by writing tothe health care provider below. Iunderstand thatI may revoke this authorization except to the extentthat actionhas already been taken based upon thisauthorization. 4. I understand that signingthis authorization is voluntary.My treatment, payment, enrollment ina health plan, or for eligibility benefitswill not be conditioned upon my authorizationof thisdisclosure. 5. Information disclosed under thisauthorization might be redisclosed by the recipient (except as noted above inItem 2),and this redisclosure may no longer be protected by federal or statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMFNTAI AGENCY SPEFIFIED IN ITEjyl 9. ). 7. e and gddr ss o e o r ent : 8. add erson r c of person thi io w b s t: 6 9(a). S c informatio be rele e edicalRecord m to O Entire Medical Records, incl ding p tienthistories,physical erapy records, officenotes (except psychotherapy notes),test results,radiology studies,films,referrals,consults,billingrecords, insurance records, and records sent toyou by other healthcare providers. O Other: Include: (IndicatebyInitialing) Alcohol/Drug Treatm‡nt Mental Health Inforniation HIV-Related Inform tion Authorization to Discuss Health Information (b) O By here initialing I authorize Initials Name of individualhealth care provider to discussmy health infermation with my attorney,or a govern=ental agency, listedhere: (Attorney/Firm Name or Governmental Agency Name) 10. Reason for releaseof information: 11.Date orevent on which this uthori ion willexpire: [X] At request of individual '7 /6 c2/ 12. Ifnot the patient,name of person signing form: 13.Authority to signon beh f ofpatient: All items on thisform have been completed and my questions about thisform have been answered. In addition,I have been provided a copy of theform. X Date: Signature o pati nt orre esentative authorized by law. at' *Human I==!=adeficiency Virus thatcauses AIDS. The New York State Public Health La pro n r a y could identify someone as havingHIV symptoms or infectionand information regarding a perso State of New York Notary Public. No. 01PE6150010 Q ualified in Queens07/24/2022 County 8 of 113 Commission Expues FILED: BRONX COUNTY CLERK 07/16/2020 04:16 PM INDEX NO. 30668/2019E NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 07/16/2020 OCA Çfficial Form No.: 960 AUTHORIZATION I-OR RELEASE OF HEALTH INFORMATION FoKSUANT TO HIPAA |This form has been approved by the New York StateyDepa ment of Health] Patient Name Date of Birth/ Social Security Number atientAddress 7 , /\ I,or my authorized representative,request thathealth information regarding my care and treatmeÛt be released as setforthon thisform: In accordance with New York StateLaw and the Privacy Rule of the Health Iñsurance Portability and Acceüñtability Act of 1996 (HIPAA), I understand that: 1. This authorizationmay include disclosure of information relatingto ALCOHOL and DRUG ABUSE, MENTAL (IEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place on initials the TREATMENT, psychotherapy notes, only my appropriate line inItem 9(a). Inthe event the healthinformation described below includes any of thesetypes of information, and I initial the line on thebox in Item 9(a),I specificallyauthorize releaseof such information to the persons(s) indicated inItem 8. 2. IfI am authorizing therelease of HIV alcohol related, ordrug treatment, or mental health treatment information, the recipientis prohibited from redisclosing such information without my authorization unless permitted to do so unless federalor statelaw. Iunderstand thatI have a rightto request a list of people who may receive oruse my HIV related information without authorization. If Iexperience discrimination because of theuse or disclosure of HIV-related information, I may contact the New York StateDivision ofHuman Rights at (212) 480-2493 or theNew York City Commission of Human rightsat(212) 306-7450. These agencies are responsiblefor protecting my rights. 3. I have the rightto revoke this authorizationat any time by writing to thehealth care previder below. I understand thatI may revoke this authorization except to the extentthat actionhas already been taken based upon thisauthorization. 4. I understand that signingthis authorization isvoluntary. My treatmcñt, payment, enrollment in a healthplan, or cliibilityfor benefitswill not be conditioned upon my authorization ofthisdisclosure. 5. Information disclosed under thisauthorization might be redisclosed by the recipient (except as noted above in Item 2),and this redisclosure may no longer be protectedby federal or statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL 4GENCy SPECIFIED IN ITEM 9 fb). 7 f althpr ent thisinfo (ff ) 00 • / /V . . , 8. e an o per ns(s)o ry ofp