Preview
FILED: NEW YORK COUNTY CLERK 11/05/2019 03:36 PM INDEX NO. 150436/2019
NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 11/05/2019
NADINE RIVELLESE
ATTORNEY FOR
CONSOLIDATED EDISON COMPANY OF NEW YORK, INC.
4 IRVING PLACE
NEW YORK, N.Y. 10003
TEL. NO. (212) 460-3355
Counselors:
Enclosed herein is Consolidated Edison Company of New York, Inc.'s:
Demand for a Verified Bill of Particulars
Demand for Medical Records and Employment Records
and Authorizations
Notice of Discovery and Inspection for Medicaid/Medicare Liens
Consent to Release
O Notice for Discovery and Inspection
Combined Demand
Notice for Discovery and Inspection of Plaintiff
Notice for Discovery and Inspection of The City of New York
O Third Party Notice for Discovery and Inspection
O Notice of Discovery and Inspection for Collateral Source
Reimbursement
Demand for Expert Witness Information
Notice of Refusal to Accept Service by Facsimile
Notice to Take Deposition Upon Oral Questions
O Notice for Discovery and Inspection for Reimbursement for
Property Damage
O First Notice to Produce Documents
O Demand Pursuant to CPLR 2103(e)
O
O
The undersigned certifies that to the best of my knowledge, information and belief that,
as presented, served and/or filed, they are not frivolous as defined in Section 130-1.1(a)
and (c) of the Rules of the Chief Administrator of the Courts (22 N.Y.C.R.R.)
Very truly yours,
N ine Rivellese
By:
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JMC:gy
11/01/19
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
CARMEN ROMERO,
INDEX NO.
Plaintiff, 150436/19
- against -
THE CITY OF NEW YORK, THE NEW YORK CITY
DEPARTMENT OF TRANSPORTATION, THE NEW ! DEMAND FOR A
YORK CITY DEPARTMENT OF EDUCATION, j VERIFIED BILL
CONSOLIDATED EDISON COMPANY OF NEW YORK, OF PARTICULARS
INC. and CONSOLIDATED EDISON, INC.,
Defendants.
_____________________________________________________________________________________
COUNSELORS:
PLEASE TAKE NOTICE, that pursuant to CPLR §§3041, 3042, 3043, and
3044, you are required to serve the for defendants, Consolidated Edison
attorney
Company of New York, Inc. and Consolidated Edison, Inc., at 4 Irving Place, New York,
NY 10003, within thirty (30) days after service of this demand, a Verified Bill of
Particulars, setting forth the following:
1. Plaintiff's date of birth, Social Security Number, and residence.
2. Is the plaintiff Medicare eligible?
3. Has the plaintiff applied for or received any Medicare payments in
connection with the injury alleged in this lawsuit?
4. The date and approximate time of the occurrence.
5. The approximate location of the occurrence.
6. A general description of the occurrence.
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7. A statement of the acts or omissions constituting each defendant's
negligence.
8. A detailed description of the defect that caused the occurrence.
9. Whether actual or constructive notice is claimed.
10. The facts supporting any claim of actual notice of a defect,
including:
(a) The date or dates of each notice;
(b) The names of the agents or employees of the defendant
receiving notice;
(c) The name of the individual giving notice;
(d) The precise language of the notice; and
(e) The form of the notice (oral or written).
11. The facts supporting any claim of constructive notice, including the
length of time the condition existed prior to the occurrence.
12. Any statute, ordinance, or regulation violated by the defendant.
13. The names and addresses of all witnesses.
14. The nature and duration of each injury.
15. The length of time plaintiff was confined to (a) hospital; (b) bed;
and (c) home.
16. The cost of: (a) hospital; (b) medical; (c) X-rays; (d) nurses; (e)
medicines; (f) medical supplies; and (g) any other medical
expenses.
17. The dollar value of other damages, item by item.
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18. Plaintiff's occupation, name and address of employer, dates absent
from employment, and amount of lost earnings. If a student, name
and address of school, grade and dates absent:
(a) The method of calculation used to derive and all lost
any
earnings claimed; and
(b) The name and address of any entity, carrier, or organization
providing plaintiff with compensation for lost earnings
any
claimed, including, but not limited to No Fault compensation
and Workers Compensation.
19. State whether or not plaintiff has been reimbursed for claims of
economic loss from any collateral source and, ifso, set forth:
(a) The amount of reimbursement received and the name and
addresses of the person, firm or organization from whom
such reimbursement was received; and,
(b) If such reimbursement was made by an insurance company,
state the number of the under which it was paid.
policy
20. State whether or not plaintiff has made a claim for reimbursement
for economic loss to any collateral source and said claim has not as
yet been paid and, if so, set forth:
(a) The name and address of the person, corporation or
organization to whom such claim was presented, the date of
presentation and the amount claimed; and
(b) If such reimbursement was presented to an insurance
company, state the number under which it was made.
policy
Dated:New York, New York
November 1, 2019.
Yours, etc.,
NADINE RIVELLESE
Attorney for Defendants
Consolidated Edison Company
of New York, Inc. and
Consolidated Edison, Inc.
4 Irving Place, Room 1800
New York, NY 10003-3598
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TO:
STEVEN ADAM RUBIN &
ASSOCIATES, PLLC
Attorneys for Plaintiff
71 WEST 23RD STREET
SUITE 1623
NEW YORK, NY 10010
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JMC:gy
11/01/19
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
CARMEN ROMERO,
! INDEX NO.
Plaintiff, | 150436/19
- against -
THE CITY OF NEW YORK, THE NEW YORK CITY ! NOTICE FOR DISCOVERY
DEPARTMENT OF TRANSPORTATION, THE NEW j AND INSPECTION FOR
YORK CITY DEPARTMENT OF EDUCATION, j MEDICARE OR
CONSOLIDATED EDISON COMPANY OF NEW YORK, MEDICAID LIENS
INC. and CONSOLIDATED EDISON, INC.,
Defendants.
_________..___________________________________________________......_
_______________
PLEASE TAKE NOTICE, that pursuant to Article 31 of the CPLR, you are
hereby required to produce at the offices of Nadine Rivellese, the attorney for the
defendants, CONSOLIDATED EDISON COMPANY OF NEW YORK, INC. and
CONSOLIDATED EDISON, INC., within thirty (30) days, the following documents,
items and information for discovery, inspection and/or copying:
1. A statement as to whether the plaintiff has received benefits from
Medicaid, Medicare or any Medicare insurance program at any time, for any reason, not
limited to the injuries alleged in the instant action. Please state and/or provide:
(a) Plaintiff's full name;
(b) Plaintiff's gender;
(c) Plaintiff's date of birth;
(d) Plaintiff's Social Security number;
(e) Is plaintiff enrolled in Medicare Part D?
Our File
#2019-007375/
FN2030986
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(f) Is plaintiff enrolled in Medicare Part B?
(g) Plaintiff's residence telephone number;
(h) The Health Insurance Claim Number, Medicare/Medicaid
file number, New York State Department of Social Services
("DSS") file number, and/or Medicare Secondary Payor
("MSP") file number, if applicable;
(i) A copy of the plaintiff's health insurance (Medicare) card;
(j) The address of the office handling the plaintiff's
Medicare/Medicaid claims and/or benefits;
(k) A duly executed and notarized written authorization
fully
compliant with the Health Insurance Portability and
Accountability Act of 1996 ("HIPAA") and regulations
applicable thereto and expiring no less than six (6) months
after the date of signature, and plaintiff's date of birth
bearing
and Social Security number permitting this firm and/or the
representatives of defendant to obtain copies of plaintiff's
Medicaid records;
(1) A duly executed consent to release (see attached CMS form
Release"
"Consent to
http:/ /www.cms.gov/Medicare/Coordination-of-Benefits-
And-Recovery-Overview/Non-Group-Health-Plan-
Recovery/Downloads/Consent to Release.p_çl_f), valid for at
least three (3) years, which permits this firm to obtain
plaintiff's Medicare records and to communicate with
Medicare and its contractors (MSPRC or COBC); and
(m) Identify any ICD-9 codes reported to Medicare and/or its
contractors as alleged to be related to injuries sustained in the
incident which is the subject of this litigation.
2. State whether Medicare and/or Medicaid has a lien and the amount
of any such lien.
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3. Provide copies of all documents, records, memoranda, notes, etc., in
plaintiff's possession pertaining to plaintiff's receipt of Medicare and/or Medicaid
benefits, including copies of all documents provided to or received from the Medicare
and/or Medicaid administrators and/or contractors, but not limited to:
including
(a) Case
reporting correspondence to Medicare COBC
(Coordination of Benefits Contractor);
(b) Rights and responsibilities letter;
(c) Conditional payment letters;
(d) Payment summary forms;
(e) Demand/Recovery letters; and
(f) Final demand letters.
4. Provide a copy of claims summaries from Medicaid, Medicare
any
or any Medicare insurance program.
5. If plaintiff has not received Medicare and/or Medicaid benefits in
the past or is not receiving Medicare and/or Medicaid benefits now, state whether
plaintiff is eligible to receive Medicare and/or Medicaid benefits.
6. Has the plaintiff applied for Social Benefits?
Security Disability
(a) If so, when?
(b) Was the application denied?
(c) Is plaintiff appealing or re-filing for Social Security Disability
benefits?
7. Has plaintiff received dialysis treatment for disease?
kidney
8. Has plaintiff received treatment for End-Stage Renal Disease?
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9. If plaintiff has been receiving Medicare and/or Medicaid benefits
and is now deceased, please provide the following:
(a) Relationship of the administrator of plaintiff's estate to
plaintiff's decedent;
(b) Name and address of plaintiff's administrator;
(c) Telephone number and/or e-mail address of plaintiff's
administrator;
(d) Social Security number of plaintiff's administrator; and
(e) An authorization to examine and copy deceased's Medicare
and/or Medicaid records.
PLEASE TAKE FURTHER NOTICE, that pursuant to CPLR, this is a
continuing demand and that you are required to serve the demanded information within
thirty (30) days of the date of this demand.
PLEASE TAKE FURTHER NOTICE, that failure to comply with this
Demand for Medicare/Medicaid information may result in the necessity of a motion to
compel discovery accompanied a request for the appropriate costs.
by
Dated:New York, NY
November 1, 2019
Yours, etc.,
NADINE RIVELLESE
Attorney for Defendants
Consolidated Edison Company
of New York, Inc. and
Consolidated Edison, Inc.
Address:
4 Irving Place, Room 1800
New York, NY 10003-3598
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TO:
STEVEN ADAM RUBIN &
ASSOCIATES, PLLC
Attorneys for Plaintiff
71 WEST 23RD STREET
SUITE 1623
NEW YORK, NY 10010
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CONSENT TO RELEASE
The language below should be used when you, a Medicare beneficiary, want to authorize someone
other than your or other representative to receive information, identifiable health
attorney including
information, from the Centers for Medicare & Medicaid Services (CMS) related to your liability
workers'
insurance (including self-insurance), no-fault insurance or compensation claim.
I, (print your name exactly as shown on your Medicare card)
hereby authorize the CMS, its agents and/or contractors to release, upon request, information related
to my injury/illness and/or settlement for the specified date of injury/illness to the individual
and/or listed below:
entity
CHECK ONLY ONE OF THE FOLLOWING TO INDICATE WHO MAY RECEIVE
INFORMATION AND THEN PRINT THE REQUESTED INFORMATION;
(Ifyou intend to have your information released to more than one individual or entity, you must
complete a separate release for each one.)
Workers'
( )Insurance Company ( ) Compensation Carrier ( ) Other
(Explain)
Name of entity:
Contact for above entity:
Address:
Telephone: _
CHECK ONE OF THE FOLLOWING TO INDICATE HOW LONG CMS MAY RELEASE YOUR
INFORMATIO__N
(The period you check will run from when you sign and date below.):
( ) One Year ( ) Two Years ( ) Other
(Provide a specific period of time)
information"
I understand that I may revoke this "consent to release at time, in writing.
any
MEDICARE BENEFICIARY INFORMATION AND SIGNATURE:
Beneficiary Signature: Date signed
Note: Ifthe beneficiaryis incapacitated,
thesub:ni crof thisdocument will need toinclude documentation establishingthe authorityof the
individual signingon the beneficiary's
behalf.Please visit
http://go.cms.gov/cobro for furtherinstructions.
Medicare Health Insurance Claim Number (The number on your Medicare card.):
Date of Injury/Illness:
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FILED: NEW YORK COUNTY CLERK 11/05/2019 03:36 PM INDEX NO. 150436/2019
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JMC:gy
11/01/19
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
___...................._____________________________............__________________...
CARMEN ROMERO,
| INDEX NO.
Plaintiff, 150436/19
- against -
THE CITY OF NEW YORK, THE NEW YORK CITY
DEPARTMENT OF TRANSPORTATION, THE NEW ! DEMAND FOR
YORK CITY DEPARTMENT OF EDUCATION, MEDICAL AND
CONSOLIDATED EDISON COMPANY OF NEW YORK, EMPLOYMENT
INC. and CONSOLIDATED EDISON, INC., RECORDS AND
AUTHORIZATIONS
Defendants.
................._________________________...................____________________
COUNSELORS:
PLEASE TAKE NOTICE, that pursuant to CPLR Rule 3120, the
undersigned defendant herewith demands that you produce the authorizations specified
and for the discovery and inspection of the records demanded, with leave to photocopy,
at the office of the undersigned within twenty (20) days from the date hereof the
following:
a. Names and addresses and copies of any and all reports of those
physicians and health care providers who have treated and/or
examined plaintiff, CARMEN ROMERO, and the names of all
prescriptions by those physicians and health care providers issued
to the examined plaintiff and the names and addresses of pharmacies
at which said prescriptions issued by the aforementioned physicians
and health care providers were filled, as a result of any injury
(including prior injury) to the part or parts of the body allegedly
injured as a result of the occurrence giving rise to this litigation,
including any and all diagnostic reports, and ambulance call reports,
and;
Our File
#2019-007375/
FN2030986
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b. executed and acknowledged written authorizations,
Duly fully
compliant with the Health Insurance Portability and Accountability
Act of 1996 (HIPAA) and the regulations applicable thereto and
expiring no less than six (6) months after the date of signature,
permitting the undersigned or their representative to inspect and
nurses'
obtain photostatic copies of the records, office charts, notes,
diagnostic studies, x-rays and any other records maintained by
plaintiff insurer(s) and those physicians and health care facilities
by
"a"
referred to in paragraph above, and permitting the undersigned
or their representative to inspect and obtain photostatic copies of all
records of filled pharmacy prescriptions identified and referred to in
"a"
paragraph above.
c. Duly executed and notarized written authorizations, fully compliant
with the Health Insurance Portability and Accountability Act of 1996
(HIPAA) and the regulations applicable thereto and expiring no less
than six (6) months after the date of signature, permitting the
undersigned or their representative to inspect and obtain photostatic
copies of the records of any and all hospitals wherein Plaintiff was
treated and/or confined, including all x-ray reports.
d. Names and addresses of all insurance carriers, including disability,
no-fault, or workers compensation carriers who have received
claims and/or provided benefits to the plaintiff as a result of any
injury resulting from the occurrence giving rise to this litigation.
e. Duly executed and acknowledged written authorizations, fully
compliant with the Health Insurance Portability and Accountability
Act of 1996 (HIPAA) and the regulations applicable thereto and
no less than six (6) months after the date of signature,
expiring
permitting the undersigned or their representative to inspect and
obtain photostatic copies of all insurance records and files
"d"
maintained by those carriers referred to in paragraph above.
f. executed and acknowledged written authorizations, fully
Duly
compliant with the Health Insurance Portability and Accountability
Act of 1996 (HIPAA) and the regulations applicable thereto and
expiring no less than six (6) months after the date of signature,
permitting the undersigned or their representative to inspect and
obtain photostatic copies of all workers compensation records and
files maintained either by those workers compensation carriers
"d"
referred to in paragraph above or maintained by The Workers
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.
NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 11/05/2019
Compensation Board.
g. executed and acknowledged written authorizations,
Duly fully
compliant with the Health Insurance Portability and Accountability
Act of 1996 (HIPAA) and the regulations applicable thereto and
no less than six (6) months after the date of signature,
expiring
the undersigned or his representative to inspect and
permitting
obtain photostatic copies of all employment records and files
maintained plaintiff's employer. If plaintiff is self-employed,
by
then written authorizations, compliant with the Health
fully
Insurance Portability and Accountability Act of 1996 (HIPAA) and
the regulations applicable thereto and expiring no less than six (6)
months after the date of signature, permitting the undersigned or
their representative to inspect and obtain photostatic copies of
plaintiff's IRS tax returns for the year of accident and two years prior
to the date of accident, two forms of identification
including
required the IRS to obtain such records.
customarily by
In lieu of at the stated time and place, you may send by the time
appearing
required copies of the documents and a statement that you are furnishing them pursuant
to this notice.
PLEASE TAKE FURTHER NOTICE, that this demand shall be deemed to
continue the of this action, the trial thereof. In the event of
during pendency including
refusal to with this demand, the defendant shall seek to preclude the testimony
comply
of parties in relation to the information and documentation sought herein.
any
Dated:New York, New York
November 1, 2019.
Yours, etc.,
NADINE RIVELLESE
Attorney for Defendants
Consolidated Edison Company
of New York, Inc. and
Consolidated Edison, Inc.
4 Irving Place, Room 1800
New York, NY 10003-3598
Preview
FILED: NEW YORK COUNTY CLERK 11/05/2019 03:36 PM INDEX NO. 150436/2019 NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 11/05/2019 NADINE RIVELLESE ATTORNEY FOR CONSOLIDATED EDISON COMPANY OF NEW YORK, INC. 4 IRVING PLACE NEW YORK, N.Y. 10003 TEL. NO. (212) 460-3355 Counselors: Enclosed herein is Consolidated Edison Company of New York, Inc.'s: Demand for a Verified Bill of Particulars Demand for Medical Records and Employment Records and Authorizations Notice of Discovery and Inspection for Medicaid/Medicare Liens Consent to Release O Notice for Discovery and Inspection Combined Demand Notice for Discovery and Inspection of Plaintiff Notice for Discovery and Inspection of The City of New York O Third Party Notice for Discovery and Inspection O Notice of Discovery and Inspection for Collateral Source Reimbursement Demand for Expert Witness Information Notice of Refusal to Accept Service by Facsimile Notice to Take Deposition Upon Oral Questions O Notice for Discovery and Inspection for Reimbursement for Property Damage O First Notice to Produce Documents O Demand Pursuant to CPLR 2103(e) O O The undersigned certifies that to the best of my knowledge, information and belief that, as presented, served and/or filed, they are not frivolous as defined in Section 130-1.1(a) and (c) of the Rules of the Chief Administrator of the Courts (22 N.Y.C.R.R.) Very truly yours, N ine Rivellese By: 1 of 33 FILED: NEW YORK COUNTY CLERK 11/05/2019 03:36 PM INDEX NO. 150436/2019 NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 11/05/2019 JMC:gy 11/01/19 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK CARMEN ROMERO, INDEX NO. Plaintiff, 150436/19 - against - THE CITY OF NEW YORK, THE NEW YORK CITY DEPARTMENT OF TRANSPORTATION, THE NEW ! DEMAND FOR A YORK CITY DEPARTMENT OF EDUCATION, j VERIFIED BILL CONSOLIDATED EDISON COMPANY OF NEW YORK, OF PARTICULARS INC. and CONSOLIDATED EDISON, INC., Defendants. _____________________________________________________________________________________ COUNSELORS: PLEASE TAKE NOTICE, that pursuant to CPLR §§3041, 3042, 3043, and 3044, you are required to serve the for defendants, Consolidated Edison attorney Company of New York, Inc. and Consolidated Edison, Inc., at 4 Irving Place, New York, NY 10003, within thirty (30) days after service of this demand, a Verified Bill of Particulars, setting forth the following: 1. Plaintiff's date of birth, Social Security Number, and residence. 2. Is the plaintiff Medicare eligible? 3. Has the plaintiff applied for or received any Medicare payments in connection with the injury alleged in this lawsuit? 4. The date and approximate time of the occurrence. 5. The approximate location of the occurrence. 6. A general description of the occurrence. Our File #2019-007375/ FN2030986 2 of 33 FILED: NEW YORK COUNTY CLERK 11/05/2019 03:36 PM INDEX NO. 150436/2019 NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 11/05/2019 7. A statement of the acts or omissions constituting each defendant's negligence. 8. A detailed description of the defect that caused the occurrence. 9. Whether actual or constructive notice is claimed. 10. The facts supporting any claim of actual notice of a defect, including: (a) The date or dates of each notice; (b) The names of the agents or employees of the defendant receiving notice; (c) The name of the individual giving notice; (d) The precise language of the notice; and (e) The form of the notice (oral or written). 11. The facts supporting any claim of constructive notice, including the length of time the condition existed prior to the occurrence. 12. Any statute, ordinance, or regulation violated by the defendant. 13. The names and addresses of all witnesses. 14. The nature and duration of each injury. 15. The length of time plaintiff was confined to (a) hospital; (b) bed; and (c) home. 16. The cost of: (a) hospital; (b) medical; (c) X-rays; (d) nurses; (e) medicines; (f) medical supplies; and (g) any other medical expenses. 17. The dollar value of other damages, item by item. 3 of 33 FILED: NEW YORK COUNTY CLERK 11/05/2019 03:36 PM INDEX NO. 150436/2019 NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 11/05/2019 18. Plaintiff's occupation, name and address of employer, dates absent from employment, and amount of lost earnings. If a student, name and address of school, grade and dates absent: (a) The method of calculation used to derive and all lost any earnings claimed; and (b) The name and address of any entity, carrier, or organization providing plaintiff with compensation for lost earnings any claimed, including, but not limited to No Fault compensation and Workers Compensation. 19. State whether or not plaintiff has been reimbursed for claims of economic loss from any collateral source and, ifso, set forth: (a) The amount of reimbursement received and the name and addresses of the person, firm or organization from whom such reimbursement was received; and, (b) If such reimbursement was made by an insurance company, state the number of the under which it was paid. policy 20. State whether or not plaintiff has made a claim for reimbursement for economic loss to any collateral source and said claim has not as yet been paid and, if so, set forth: (a) The name and address of the person, corporation or organization to whom such claim was presented, the date of presentation and the amount claimed; and (b) If such reimbursement was presented to an insurance company, state the number under which it was made. policy Dated:New York, New York November 1, 2019. Yours, etc., NADINE RIVELLESE Attorney for Defendants Consolidated Edison Company of New York, Inc. and Consolidated Edison, Inc. 4 Irving Place, Room 1800 New York, NY 10003-3598 4 of 33 FILED: NEW YORK COUNTY CLERK 11/05/2019 03:36 PM INDEX NO. 150436/2019 NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 11/05/2019 TO: STEVEN ADAM RUBIN & ASSOCIATES, PLLC Attorneys for Plaintiff 71 WEST 23RD STREET SUITE 1623 NEW YORK, NY 10010 5 of 33 FILED: NEW YORK COUNTY CLERK 11/05/2019 03:36 PM INDEX NO. 150436/2019 NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 11/05/2019 JMC:gy 11/01/19 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK CARMEN ROMERO, ! INDEX NO. Plaintiff, | 150436/19 - against - THE CITY OF NEW YORK, THE NEW YORK CITY ! NOTICE FOR DISCOVERY DEPARTMENT OF TRANSPORTATION, THE NEW j AND INSPECTION FOR YORK CITY DEPARTMENT OF EDUCATION, j MEDICARE OR CONSOLIDATED EDISON COMPANY OF NEW YORK, MEDICAID LIENS INC. and CONSOLIDATED EDISON, INC., Defendants. _________..___________________________________________________......_ _______________ PLEASE TAKE NOTICE, that pursuant to Article 31 of the CPLR, you are hereby required to produce at the offices of Nadine Rivellese, the attorney for the defendants, CONSOLIDATED EDISON COMPANY OF NEW YORK, INC. and CONSOLIDATED EDISON, INC., within thirty (30) days, the following documents, items and information for discovery, inspection and/or copying: 1. A statement as to whether the plaintiff has received benefits from Medicaid, Medicare or any Medicare insurance program at any time, for any reason, not limited to the injuries alleged in the instant action. Please state and/or provide: (a) Plaintiff's full name; (b) Plaintiff's gender; (c) Plaintiff's date of birth; (d) Plaintiff's Social Security number; (e) Is plaintiff enrolled in Medicare Part D? Our File #2019-007375/ FN2030986 6 of 33 FILED: NEW YORK COUNTY CLERK 11/05/2019 03:36 PM INDEX NO. 150436/2019 NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 11/05/2019 (f) Is plaintiff enrolled in Medicare Part B? (g) Plaintiff's residence telephone number; (h) The Health Insurance Claim Number, Medicare/Medicaid file number, New York State Department of Social Services ("DSS") file number, and/or Medicare Secondary Payor ("MSP") file number, if applicable; (i) A copy of the plaintiff's health insurance (Medicare) card; (j) The address of the office handling the plaintiff's Medicare/Medicaid claims and/or benefits; (k) A duly executed and notarized written authorization fully compliant with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and regulations applicable thereto and expiring no less than six (6) months after the date of signature, and plaintiff's date of birth bearing and Social Security number permitting this firm and/or the representatives of defendant to obtain copies of plaintiff's Medicaid records; (1) A duly executed consent to release (see attached CMS form Release" "Consent to http:/ /www.cms.gov/Medicare/Coordination-of-Benefits- And-Recovery-Overview/Non-Group-Health-Plan- Recovery/Downloads/Consent to Release.p_çl_f), valid for at least three (3) years, which permits this firm to obtain plaintiff's Medicare records and to communicate with Medicare and its contractors (MSPRC or COBC); and (m) Identify any ICD-9 codes reported to Medicare and/or its contractors as alleged to be related to injuries sustained in the incident which is the subject of this litigation. 2. State whether Medicare and/or Medicaid has a lien and the amount of any such lien. 7 of 33 FILED: NEW YORK COUNTY CLERK 11/05/2019 03:36 PM INDEX NO. 150436/2019 NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 11/05/2019 3. Provide copies of all documents, records, memoranda, notes, etc., in plaintiff's possession pertaining to plaintiff's receipt of Medicare and/or Medicaid benefits, including copies of all documents provided to or received from the Medicare and/or Medicaid administrators and/or contractors, but not limited to: including (a) Case reporting correspondence to Medicare COBC (Coordination of Benefits Contractor); (b) Rights and responsibilities letter; (c) Conditional payment letters; (d) Payment summary forms; (e) Demand/Recovery letters; and (f) Final demand letters. 4. Provide a copy of claims summaries from Medicaid, Medicare any or any Medicare insurance program. 5. If plaintiff has not received Medicare and/or Medicaid benefits in the past or is not receiving Medicare and/or Medicaid benefits now, state whether plaintiff is eligible to receive Medicare and/or Medicaid benefits. 6. Has the plaintiff applied for Social Benefits? Security Disability (a) If so, when? (b) Was the application denied? (c) Is plaintiff appealing or re-filing for Social Security Disability benefits? 7. Has plaintiff received dialysis treatment for disease? kidney 8. Has plaintiff received treatment for End-Stage Renal Disease? 8 of 33 FILED: NEW YORK COUNTY CLERK 11/05/2019 03:36 PM INDEX NO. 150436/2019 NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 11/05/2019 9. If plaintiff has been receiving Medicare and/or Medicaid benefits and is now deceased, please provide the following: (a) Relationship of the administrator of plaintiff's estate to plaintiff's decedent; (b) Name and address of plaintiff's administrator; (c) Telephone number and/or e-mail address of plaintiff's administrator; (d) Social Security number of plaintiff's administrator; and (e) An authorization to examine and copy deceased's Medicare and/or Medicaid records. PLEASE TAKE FURTHER NOTICE, that pursuant to CPLR, this is a continuing demand and that you are required to serve the demanded information within thirty (30) days of the date of this demand. PLEASE TAKE FURTHER NOTICE, that failure to comply with this Demand for Medicare/Medicaid information may result in the necessity of a motion to compel discovery accompanied a request for the appropriate costs. by Dated:New York, NY November 1, 2019 Yours, etc., NADINE RIVELLESE Attorney for Defendants Consolidated Edison Company of New York, Inc. and Consolidated Edison, Inc. Address: 4 Irving Place, Room 1800 New York, NY 10003-3598 9 of 33 FILED: NEW YORK COUNTY CLERK 11/05/2019 03:36 PM INDEX NO. 150436/2019 NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 11/05/2019 TO: STEVEN ADAM RUBIN & ASSOCIATES, PLLC Attorneys for Plaintiff 71 WEST 23RD STREET SUITE 1623 NEW YORK, NY 10010 10 of 33 FILED: NEW YORK COUNTY CLERK 11/05/2019 03:36 PM INDEX NO. 150436/2019 NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 11/05/2019 CONSENT TO RELEASE The language below should be used when you, a Medicare beneficiary, want to authorize someone other than your or other representative to receive information, identifiable health attorney including information, from the Centers for Medicare & Medicaid Services (CMS) related to your liability workers' insurance (including self-insurance), no-fault insurance or compensation claim. I, (print your name exactly as shown on your Medicare card) hereby authorize the CMS, its agents and/or contractors to release, upon request, information related to my injury/illness and/or settlement for the specified date of injury/illness to the individual and/or listed below: entity CHECK ONLY ONE OF THE FOLLOWING TO INDICATE WHO MAY RECEIVE INFORMATION AND THEN PRINT THE REQUESTED INFORMATION; (Ifyou intend to have your information released to more than one individual or entity, you must complete a separate release for each one.) Workers' ( )Insurance Company ( ) Compensation Carrier ( ) Other (Explain) Name of entity: Contact for above entity: Address: Telephone: _ CHECK ONE OF THE FOLLOWING TO INDICATE HOW LONG CMS MAY RELEASE YOUR INFORMATIO__N (The period you check will run from when you sign and date below.): ( ) One Year ( ) Two Years ( ) Other (Provide a specific period of time) information" I understand that I may revoke this "consent to release at time, in writing. any MEDICARE BENEFICIARY INFORMATION AND SIGNATURE: Beneficiary Signature: Date signed Note: Ifthe beneficiaryis incapacitated, thesub:ni crof thisdocument will need toinclude documentation establishingthe authorityof the individual signingon the beneficiary's behalf.Please visit http://go.cms.gov/cobro for furtherinstructions. Medicare Health Insurance Claim Number (The number on your Medicare card.): Date of Injury/Illness: 11 of 33 FILED: NEW YORK COUNTY CLERK 11/05/2019 03:36 PM INDEX NO. 150436/2019 NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 11/05/2019 JMC:gy 11/01/19 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK ___...................._____________________________............__________________... CARMEN ROMERO, | INDEX NO. Plaintiff, 150436/19 - against - THE CITY OF NEW YORK, THE NEW YORK CITY DEPARTMENT OF TRANSPORTATION, THE NEW ! DEMAND FOR YORK CITY DEPARTMENT OF EDUCATION, MEDICAL AND CONSOLIDATED EDISON COMPANY OF NEW YORK, EMPLOYMENT INC. and CONSOLIDATED EDISON, INC., RECORDS AND AUTHORIZATIONS Defendants. ................._________________________...................____________________ COUNSELORS: PLEASE TAKE NOTICE, that pursuant to CPLR Rule 3120, the undersigned defendant herewith demands that you produce the authorizations specified and for the discovery and inspection of the records demanded, with leave to photocopy, at the office of the undersigned within twenty (20) days from the date hereof the following: a. Names and addresses and copies of any and all reports of those physicians and health care providers who have treated and/or examined plaintiff, CARMEN ROMERO, and the names of all prescriptions by those physicians and health care providers issued to the examined plaintiff and the names and addresses of pharmacies at which said prescriptions issued by the aforementioned physicians and health care providers were filled, as a result of any injury (including prior injury) to the part or parts of the body allegedly injured as a result of the occurrence giving rise to this litigation, including any and all diagnostic reports, and ambulance call reports, and; Our File #2019-007375/ FN2030986 12 of 33 FILED: NEW YORK COUNTY CLERK 11/05/2019 03:36 PM INDEX NO. 150436/2019 NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 11/05/2019 b. executed and acknowledged written authorizations, Duly fully compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the regulations applicable thereto and expiring no less than six (6) months after the date of signature, permitting the undersigned or their representative to inspect and nurses' obtain photostatic copies of the records, office charts, notes, diagnostic studies, x-rays and any other records maintained by plaintiff insurer(s) and those physicians and health care facilities by "a" referred to in paragraph above, and permitting the undersigned or their representative to inspect and obtain photostatic copies of all records of filled pharmacy prescriptions identified and referred to in "a" paragraph above. c. Duly executed and notarized written authorizations, fully compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the regulations applicable thereto and expiring no less than six (6) months after the date of signature, permitting the undersigned or their representative to inspect and obtain photostatic copies of the records of any and all hospitals wherein Plaintiff was treated and/or confined, including all x-ray reports. d. Names and addresses of all insurance carriers, including disability, no-fault, or workers compensation carriers who have received claims and/or provided benefits to the plaintiff as a result of any injury resulting from the occurrence giving rise to this litigation. e. Duly executed and acknowledged written authorizations, fully compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the regulations applicable thereto and no less than six (6) months after the date of signature, expiring permitting the undersigned or their representative to inspect and obtain photostatic copies of all insurance records and files "d" maintained by those carriers referred to in paragraph above. f. executed and acknowledged written authorizations, fully Duly compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the regulations applicable thereto and expiring no less than six (6) months after the date of signature, permitting the undersigned or their representative to inspect and obtain photostatic copies of all workers compensation records and files maintained either by those workers compensation carriers "d" referred to in paragraph above or maintained by The Workers 13 of 33 FILED: NEW YORK COUNTY CLERK 11/05/2019 03:36 PM INDEX NO. 150436/2019 . NYSCEF DOC. NO. 16 RECEIVED NYSCEF: 11/05/2019 Compensation Board. g. executed and acknowledged written authorizations, Duly fully compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the regulations applicable thereto and no less than six (6) months after the date of signature, expiring the undersigned or his representative to inspect and permitting obtain photostatic copies of all employment records and files maintained plaintiff's employer. If plaintiff is self-employed, by then written authorizations, compliant with the Health fully Insurance Portability and Accountability Act of 1996 (HIPAA) and the regulations applicable thereto and expiring no less than six (6) months after the date of signature, permitting the undersigned or their representative to inspect and obtain photostatic copies of plaintiff's IRS tax returns for the year of accident and two years prior to the date of accident, two forms of identification including required the IRS to obtain such records. customarily by In lieu of at the stated time and place, you may send by the time appearing required copies of the documents and a statement that you are furnishing them pursuant to this notice. PLEASE TAKE FURTHER NOTICE, that this demand shall be deemed to continue the of this action, the trial thereof. In the event of during pendency including refusal to with this demand, the defendant shall seek to preclude the testimony comply of parties in relation to the information and documentation sought herein. any Dated:New York, New York November 1, 2019. Yours, etc., NADINE RIVELLESE Attorney for Defendants Consolidated Edison Company of New York, Inc. and Consolidated Edison, Inc. 4 Irving Place, Room 1800 New York, NY 10003-3598