Preview
FILED: NEW YORK COUNTY CLERK 01/02/2019 04:08 PM INDEX NO. 154374/2018
NYSCEF DOC. NO. 77 RECEIVED NYSCEF: 01/02/2019
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
----------------------------------------- -----
-----x
YVETTE MCCLAMB, Index No. 154374/2018
(ECF)
Plaintiff,
v.
HOUSING PARTNERSHIP DEVELOPMENT
CORPORATION, KALAHARI CONDOMINIUM,
THE BOARD OF MANAGERS OF KALAHARI Assigned Judge: Lynn R. Kotler
CONDOMINIUM, WALLACK MANAGEMENT
CO., INC., RNC INDUSTRIES, LLC and WEST
NEW YORK RESTORATION OF CT, INC.,
Defendants.
----------------------------------------------------------------x
NOTICE OF AUTHORIZATION FOR DISCLOSURE OF INFORMATION
PLEASE TAKE NOTICE that pursuant to the Health Insurance Portability and
Accountability Act ("HIPAA"), all authorizations, requested herein for records, including
but not
limited to ambulance records, medical records, no-fault records, collateral source records,
workers'
disability records and compensation records, must be in the form and substance as
annexed hereto. All required information must be provided on the authorization.
Dated: January 2, 2019
New York, New York
Yours, etc.,
Scott H. Bernstein, Esq.
STRADLEY RONON STEVENS & YOUNG, LLP
ATTORNEYS FOR CROSS-CLAIMANT-DEFENDANT,
WEST NEW YORK RESTORATION OF CT, INC.
100 Park Avenue, Suite 2000
New York, New York 10017
Telephone: (212) 812-4132
Facsimile: (646) 682-7180
Sbernstein@stradley.com
# 3766749 v. 2
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FILED: NEW YORK COUNTY CLERK 01/02/2019 04:08 PM INDEX NO. 154374/2018
NYSCEF DOC. NO. 77 RECEIVED NYSCEF: 01/02/2019
TO:
RHEINGOLD GIUFFRA RUFFO & PLOTKIN LLP
ATTORNEYS FOR PLAINTIFF YVETTE MCCLAMB
Jeremy A. Hellman, Esq.
551 Fifth Avenue, 29th Floor
New York, New York 10176
PERRY, VAN ETTEN, ROZANSKI & PRIMAVERA, LLP
ATTORNEYS FOR DEFENDANT/CROSS-CLAIMANT
RNC INDUSTRIES, LLC
Kenneth J. Kutner, Esq.
60 Broad Street, Suite 3600A
New York, New York 10004
MARGARET G. KLEIN & ASSOCIATES
ATTORNEYS FOR DEFENDANTS/CROSS-CLAIMANTS
KALAHARI CONDOMINIUM, THE BOARD OF MANAGERS OF KALAHARI
CONDOMINIUM, AND WALLACK MANAGEMENT CO., INC.
Carol Morell, Esq.
200 Madison Avenue, 2nd Floor
New York, New York 10016
DEVITT SPELLMAN BARRETT, LLP
ATTORNEYS FOR DEFENDANT/CROSS-CLAIMANT
HOUSING PARTNERSHIP DEVELOPMENT CORPORATION
Kelly E. Wright, Esq.
50 Route 11, Suite 314
Smithtown, New York 11787
2
# 3766749 v. 2
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FILED: NEW YORK COUNTY CLERK 01/02/2019 04:08 PM INDEX NO. 154374/2018
NYSCEF DOC. NO. 77 RECEIVED NYSCEF: 01/02/2019
OCA Form
Official No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York State Depaitiiiciitof Health]
Patient Name Date of Birth Social Security Number
Patient Address
I,or my authorized request
representative, that health informationregarding my careand treatment be releasedas setforth on this
form:
In accordance with New York State Law and thePrivacy Rule of theHealth Insumnce Portabilityand Acc0üntability Act of 1996
(HIPAA), Iunderstand that:
1. This authorizationmay include disclosureof information to
relating ALCOHOL and DRUG ABUSE, MENTAL HEALTH
except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place
TREATMENT, psychotherapy notes, only my
on
initials the appropriatelinein Item 9(a).In theevent thehealth information described below includes any ofthese types of
information,and Iinitial
the lineon thebox inItem 9(a),I specificallyauthorizereleaseof such information tothe person(s)
indicatedin Item 8.
2. IfI am authorizing therelease ofHIV-related, alcohol ordrug treatment, ormental health treatmentinformation, therecipientis
prohibited from redisclosingsuch information without my authorizationunlesspermitted to do so under federalorstate law.I
understand thatI have theright torequest a list
of people who may receive oruse my HIV-related information without authorization.
IfI experience discriminationbecause of therelease ordisclosureof HIV-related information, Imay 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 responsibleforprotecting my rights.
3. I have therightto revoke thisauthorizationat any timeby writingto thehealth careprovider listedbelow. I understand thatI may
revoke thisauthorizationexcept tothe extentthat actionhas already been takenbased on thisauthorization.
4. I understand thatsigning thisauthorizationis voluntary.My treatment,payment, enrollment in a healthplan,or for
eligibility
benefitswill notbe conditioned upon my authorizationof thisdisclosure.
5. Information disclosed under thisauthorizationmight be redisclosedby therecipient(except as noted above inItem 2), and this
redisclosure may no longerbe protected by federalor statelaw.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of health provider
or entity
to release this information:
8. Name or category
and address of person(s) of person to whoÄn this information
willbe sent:
9(a).Specificinformation
to be released:
Medical Recordfrom (insert
date) to (insert
date)
EntireMedicalRecord, patient
including office
histories, notes (except
psychotherapynotes),test result, radiology
studies, films,
referrals,
consults, records,
billing insurance
records,and recordssent to you care providers.
by other health
Other: Include:(Indicate by initialing)
Alcohol/Drug Treatrnent
Mental Health Inforrnation
Authorization to Discuss Health Information HIV-Related Information
(b)O By here
initialing I authorize
Initials Name of individual health care provider
to discuss
my health with
information my attorney,or a governmental
agency,listed
here:
(Attorney/Film
Name or Govermnental Agency Name)
10. Reason for release of information: 11. Date or event on which
this authorization
willexpire:
O At request of individual
O Other:
12. If not the patient,
name of personsigningform: to sign on behalf
13. Authority of patient:
All items on thisform have been completed and my questionsabout thisform have been answered. In addition,I have been provided a
copy of the fonn.
Date:
Signatureof patient
or representative
authorizedby law.
*Human Inner Virusthat causes AIDS. The New York StatePublic Health Law protectsinformation which could
±ficiency reasonably
someone
identify as havingHIV symptGms or infection
and information regardir,ga person'scontacts.
NYHIPAA 8/09
3 of 5
FILED: NEW YORK COUNTY CLERK 01/02/2019 04:08 PM INDEX NO. 154374/2018
NYSCEF DOC. NO. 77 RECEIVED NYSCEF: 01/02/2019
Instructions for the Use
of the HIPAA compliant Authorization Form to
Release Health Information Needed for Litigation
This form is the product of a collaborative process between the New York State
Office of Court Administration, representatives of the medical provider community
in New York, and the bench and bar, designed to produce a standard official form
that complies with the privacy requirements of the federal Health Insurance
Portability and Accountability Act ("HIPAA") and its implementing regulations, to
be used to authorize the release of health information needed for litigation in New
York State courts. It can, however, be used more broadly than this and be used
before litigation has been commenced, or whenever counsel would find it useful.
The goal was to produce a standard HIPAA-compliant official form to obviate
the current disputes which often take place as to whether health information
requests made in the course of litigation meet the requirements of the HIPAA
Privacy Rule. It should be noted, though, that the form is optional. This fonn
may be filled out on line and downloaded to be signed by hand, or downloaded
and filled out entirely on paper.
When filing out Item 11, which requests the date or event when the
authorization will expire, the person filling out the form may designate an event
case"
such as "at the conclusion of my court or provide a specific date amount of
time, such as "3 years from this date".
If a patient seeks to authorize the release of his or her entire medical record, but
only from a certain date, the first two boxes in section 9(a) should both be
checked, and the relevant date inserted on the first line containing the first box.
NYHIPAAB 8/09
4 of 5
FILED: NEW YORK COUNTY CLERK 01/02/2019 04:08 PM INDEX NO. 154374/2018
NYSCEF DOC. NO. 77 RECEIVED NYSCEF: 01/02/2019
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
Index No. 154374/2018
YVETTE MCCLAMB,
Plaintiff,
-against-
HOUSING PARTNERSHIP DEVELOPMENT
CORPORATION, KALAHARI CONDOMINIUM,
THEBOARDOF MANAGERSOF KALAHARI
CONDOMINIUM, WALLACK MANAGEMENT
CO., INC., RNC INDUSTRIES, LLC and WEST NEW
YORK RESTORATION OF CT, INC.,
Defendants.
NOTICE OF AUTHORIZATION FOR DISCLOSURE OF INFORMATION
STRADLEYRONON STEVENS & YOUNG,LLP
Attorneys for Defendant
100 Park Avenue, Suite 2000
New York, New York 10017
(212) 812-4124 (teleph0ñe)
Pursuant to 22 NYCRR 130-1.1, the undersigned, an attorney admitted to practice in the courts of New
York State, certifies that, upon information and belief and reasonable iiiquit y, the contentions contained
in the annexed document are not frivolous.
Dated: January __12019 Signature:
Scott H. Bernstein
5 of 5
Preview
FILED: NEW YORK COUNTY CLERK 01/02/2019 04:08 PM INDEX NO. 154374/2018 NYSCEF DOC. NO. 77 RECEIVED NYSCEF: 01/02/2019 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK ----------------------------------------- ----- -----x YVETTE MCCLAMB, Index No. 154374/2018 (ECF) Plaintiff, v. HOUSING PARTNERSHIP DEVELOPMENT CORPORATION, KALAHARI CONDOMINIUM, THE BOARD OF MANAGERS OF KALAHARI Assigned Judge: Lynn R. Kotler CONDOMINIUM, WALLACK MANAGEMENT CO., INC., RNC INDUSTRIES, LLC and WEST NEW YORK RESTORATION OF CT, INC., Defendants. ----------------------------------------------------------------x NOTICE OF AUTHORIZATION FOR DISCLOSURE OF INFORMATION PLEASE TAKE NOTICE that pursuant to the Health Insurance Portability and Accountability Act ("HIPAA"), all authorizations, requested herein for records, including but not limited to ambulance records, medical records, no-fault records, collateral source records, workers' disability records and compensation records, must be in the form and substance as annexed hereto. All required information must be provided on the authorization. Dated: January 2, 2019 New York, New York Yours, etc., Scott H. Bernstein, Esq. STRADLEY RONON STEVENS & YOUNG, LLP ATTORNEYS FOR CROSS-CLAIMANT-DEFENDANT, WEST NEW YORK RESTORATION OF CT, INC. 100 Park Avenue, Suite 2000 New York, New York 10017 Telephone: (212) 812-4132 Facsimile: (646) 682-7180 Sbernstein@stradley.com # 3766749 v. 2 1 of 5 FILED: NEW YORK COUNTY CLERK 01/02/2019 04:08 PM INDEX NO. 154374/2018 NYSCEF DOC. NO. 77 RECEIVED NYSCEF: 01/02/2019 TO: RHEINGOLD GIUFFRA RUFFO & PLOTKIN LLP ATTORNEYS FOR PLAINTIFF YVETTE MCCLAMB Jeremy A. Hellman, Esq. 551 Fifth Avenue, 29th Floor New York, New York 10176 PERRY, VAN ETTEN, ROZANSKI & PRIMAVERA, LLP ATTORNEYS FOR DEFENDANT/CROSS-CLAIMANT RNC INDUSTRIES, LLC Kenneth J. Kutner, Esq. 60 Broad Street, Suite 3600A New York, New York 10004 MARGARET G. KLEIN & ASSOCIATES ATTORNEYS FOR DEFENDANTS/CROSS-CLAIMANTS KALAHARI CONDOMINIUM, THE BOARD OF MANAGERS OF KALAHARI CONDOMINIUM, AND WALLACK MANAGEMENT CO., INC. Carol Morell, Esq. 200 Madison Avenue, 2nd Floor New York, New York 10016 DEVITT SPELLMAN BARRETT, LLP ATTORNEYS FOR DEFENDANT/CROSS-CLAIMANT HOUSING PARTNERSHIP DEVELOPMENT CORPORATION Kelly E. Wright, Esq. 50 Route 11, Suite 314 Smithtown, New York 11787 2 # 3766749 v. 2 2 of 5 FILED: NEW YORK COUNTY CLERK 01/02/2019 04:08 PM INDEX NO. 154374/2018 NYSCEF DOC. NO. 77 RECEIVED NYSCEF: 01/02/2019 OCA Form Official No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Depaitiiiciitof Health] Patient Name Date of Birth Social Security Number Patient Address I,or my authorized request representative, that health informationregarding my careand treatment be releasedas setforth on this form: In accordance with New York State Law and thePrivacy Rule of theHealth Insumnce Portabilityand Acc0üntability Act of 1996 (HIPAA), Iunderstand that: 1. This authorizationmay include disclosureof information to relating ALCOHOL and DRUG ABUSE, MENTAL HEALTH except and CONFIDENTIAL HIV* RELATED INFORMATION ifI place TREATMENT, psychotherapy notes, only my on initials the appropriatelinein Item 9(a).In theevent thehealth information described below includes any ofthese types of information,and Iinitial the lineon thebox inItem 9(a),I specificallyauthorizereleaseof such information tothe person(s) indicatedin Item 8. 2. IfI am authorizing therelease ofHIV-related, alcohol ordrug treatment, ormental health treatmentinformation, therecipientis prohibited from redisclosingsuch information without my authorizationunlesspermitted to do so under federalorstate law.I understand thatI have theright torequest a list of people who may receive oruse my HIV-related information without authorization. IfI experience discriminationbecause of therelease ordisclosureof HIV-related information, Imay 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 responsibleforprotecting my rights. 3. I have therightto revoke thisauthorizationat any timeby writingto thehealth careprovider listedbelow. I understand thatI may revoke thisauthorizationexcept tothe extentthat actionhas already been takenbased on thisauthorization. 4. I understand thatsigning thisauthorizationis voluntary.My treatment,payment, enrollment in a healthplan,or for eligibility benefitswill notbe conditioned upon my authorizationof thisdisclosure. 5. Information disclosed under thisauthorizationmight be redisclosedby therecipient(except as noted above inItem 2), and this redisclosure may no longerbe protected by federalor statelaw. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7. Name and address of health provider or entity to release this information: 8. Name or category and address of person(s) of person to whoÄn this information willbe sent: 9(a).Specificinformation to be released: Medical Recordfrom (insert date) to (insert date) EntireMedicalRecord, patient including office histories, notes (except psychotherapynotes),test result, radiology studies, films, referrals, consults, records, billing insurance records,and recordssent to you care providers. by other health Other: Include:(Indicate by initialing) Alcohol/Drug Treatrnent Mental Health Inforrnation Authorization to Discuss Health Information HIV-Related Information (b)O By here initialing I authorize Initials Name of individual health care provider to discuss my health with information my attorney,or a governmental agency,listed here: (Attorney/Film Name or Govermnental Agency Name) 10. Reason for release of information: 11. Date or event on which this authorization willexpire: O At request of individual O Other: 12. If not the patient, name of personsigningform: to sign on behalf 13. Authority of patient: All items on thisform have been completed and my questionsabout thisform have been answered. In addition,I have been provided a copy of the fonn. Date: Signatureof patient or representative authorizedby law. *Human Inner Virusthat causes AIDS. The New York StatePublic Health Law protectsinformation which could ±ficiency reasonably someone identify as havingHIV symptGms or infection and information regardir,ga person'scontacts. NYHIPAA 8/09 3 of 5 FILED: NEW YORK COUNTY CLERK 01/02/2019 04:08 PM INDEX NO. 154374/2018 NYSCEF DOC. NO. 77 RECEIVED NYSCEF: 01/02/2019 Instructions for the Use of the HIPAA compliant Authorization Form to Release Health Information Needed for Litigation This form is the product of a collaborative process between the New York State Office of Court Administration, representatives of the medical provider community in New York, and the bench and bar, designed to produce a standard official form that complies with the privacy requirements of the federal Health Insurance Portability and Accountability Act ("HIPAA") and its implementing regulations, to be used to authorize the release of health information needed for litigation in New York State courts. It can, however, be used more broadly than this and be used before litigation has been commenced, or whenever counsel would find it useful. The goal was to produce a standard HIPAA-compliant official form to obviate the current disputes which often take place as to whether health information requests made in the course of litigation meet the requirements of the HIPAA Privacy Rule. It should be noted, though, that the form is optional. This fonn may be filled out on line and downloaded to be signed by hand, or downloaded and filled out entirely on paper. When filing out Item 11, which requests the date or event when the authorization will expire, the person filling out the form may designate an event case" such as "at the conclusion of my court or provide a specific date amount of time, such as "3 years from this date". If a patient seeks to authorize the release of his or her entire medical record, but only from a certain date, the first two boxes in section 9(a) should both be checked, and the relevant date inserted on the first line containing the first box. NYHIPAAB 8/09 4 of 5 FILED: NEW YORK COUNTY CLERK 01/02/2019 04:08 PM INDEX NO. 154374/2018 NYSCEF DOC. NO. 77 RECEIVED NYSCEF: 01/02/2019 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK Index No. 154374/2018 YVETTE MCCLAMB, Plaintiff, -against- HOUSING PARTNERSHIP DEVELOPMENT CORPORATION, KALAHARI CONDOMINIUM, THEBOARDOF MANAGERSOF KALAHARI CONDOMINIUM, WALLACK MANAGEMENT CO., INC., RNC INDUSTRIES, LLC and WEST NEW YORK RESTORATION OF CT, INC., Defendants. NOTICE OF AUTHORIZATION FOR DISCLOSURE OF INFORMATION STRADLEYRONON STEVENS & YOUNG,LLP Attorneys for Defendant 100 Park Avenue, Suite 2000 New York, New York 10017 (212) 812-4124 (teleph0ñe) Pursuant to 22 NYCRR 130-1.1, the undersigned, an attorney admitted to practice in the courts of New York State, certifies that, upon information and belief and reasonable iiiquit y, the contentions contained in the annexed document are not frivolous. Dated: January __12019 Signature: Scott H. Bernstein 5 of 5