`FILED: KINGS COUNTY CLERK 08m2017 04:31 PM
`
`NYSCEF DOC. NO. 39
`NYSCEF DOC. NO. 39
`
`INDEX NO. 510600/2016
`INDEX NO~ 510600/2016'
`
`
`
`
`
`RaCaIVaD VYSCEF: 08/29/2017
`RECEIVED NYSCEF: 08/29/2017
`
`
`
`
`
`EXHIBIT I
`
`
`
`FILED: KINGS COUNTY CLERK 08/29/2017 04:31 PM
`FILED: KINGS COUNTY CLERK 08m2017 04:31 PM
`NYSCI 3F DOC. NO. 39
`'
`”‘-
`NYSCEF DOC. NO. 39
`(“'---.\
`
`(—
`
`510600/2016’
`INDEX NO. 510600/2016
`
`INDEX NO.
`
`
`
`
`3F:
`08/29/ 017
`RECEIVED NYSCEF: 08/29/2017
`RnCflIVflD \IYSCI
`
`David Hannon, Esq. *
`411917—2013)
`Mark J. Linder, Esq.
`Ira Rogowsky, Esq..
`
`- Lisa M. Turpin, Esq. '
`Thomas AIGraci, Esq.
`Jennifer R. Snider, Esq.
`Michelle Jean-Jacques, Esq.
`Eric Mausolf, Esq.
`
`Harmon, Linder & Rogowsky
`Attorneys at Law
`3 Park Avenue, 23 rd Floor
`Suite 23 00
`New YOI NY 1001.6
`
`T 1 (21;; 732 3665
`e ‘
`_
`Fax. (212) 732—1462
`
`'
`
`'
`
`Maya Kogan, Esq.
`Jordan Byrd, Esq.
`Bret Myerson, Esq.
`Brett I. Bloom, Esq.
`
`KeithA. Mininson, Esq.
`Melissa Klafter, Esq.
`Gennady Voldz, Esq.
`Colin Johnson, Esq.
`Nicole M. Bynum, Esq.
`
`Friday, March 24, 2017
`
`MELCER NEWMAN PLLC
`
`JON NEWMAN
`
`111101-131 STRET STE 1500
`
`NEW YORK, NY 10038
`
`Re: Blanco, Norma vs. Ziaur Bhuiyan
`Dynamic Construction Company USA
`Index No.: 510600/2016
`
`Dear Sirs:
`
`Please accept this letter in Response to the Preliminary Conference Order and your
`Demand for Discovery and Inspection. Accordingly please be advised as follows:
`
`1. Eyewitnesses:
`
`Plaintiff is unaware of any witnesses other than the ones which are listed on the police
`report or other public documents and all persons involved in the subject accident.
`
`2. Notice Witnesses: I
`
`None
`
`3. Adverse Party Statements:
`
`.._,._,__
`
`.r.nl_...un...___.,.-...-.—.-m.__._,,_._m__fi_,
`
`
`
`
`FILED: KINGS COUNTY CLERK 08/29/2017 04:31 PM
`FILED: KINGS COUNTY CLERK 08m2017 04:31 PM
`
`NYSCEF DOC. NO. 39
`NYSCEF DOC. NO. 39
`(J
`(«K
`4. Photographs:
`
`.
`
`INDEX NO. 510600/2016
`
`INDEX NO~ 510600/2016
`
`
`
`
`
`RECEIVED NYSCEF: 08/29/2017
`R«.C«.IV«.D \IYSCEF: 08/29/ 017
`
`At the present time plaintiffIS not in possession of any photographs, should same become
`available same shall be provided under separate cover
`
`5. Authorizations for Plaintiff:
`
`No-Fault File: Not Applicable
`
`HoSpital:
`
`Booth Memorial Hospital
`New York Hospital
`56-45 Main Street
`
`Flushing, NY, 113 55
`(All Hospital Report)
`
`Medical:
`
`'
`
`Physical Medicine and Rehabilitation of New York
`95-20 Queens Boulevard
`Rage Park, New York 1 1374
`(All Medical Reports)
`
`Randall V. Ehrlich M.D., RC.
`68 Boulder Ridge Road
`Scarsdale, NY 10583
`(All Medical Report)
`
`' Employment: Not Applicable
`
`available as there is an ongoing investigation of this matter.
`
`6.
`
`-
`
`7.
`
`'
`
`Medical Reports:
`
`Randall V. Ehrlich M.D,, P.C.
`- Physical Medicine and Rehabilitation of New York
`
`Booth Memorial Hospital
`New York Hospital
`
`Expert Witnesses:
`
`All treating physicians, including the Radiologist will testify as expert witnesses on behalf
`of the plaintiff. Please take further notice pursuant to CPLR 4532 (a) that all testifying
`physicians will display the MRI, X—ray and any other diagnostic films to the jury at trial.
`
`Plaintiff reserves the right to update this notice if and when filrther infonnation becomes
`
`
`
`
`
`INDEX NO. 510600/2016'
`INDEX NO. 510600/2016
`FILED: KINGS COUNTY CLERK 08/29/2017 04:31 PM
`FILED' KINGS COUNTY CLERK 08m2017 04:31 PM
`
`
`
`
`
`RaCaIVaD VYSCEF: 08/29/2 17
`NYSCEF DOC. NO. 39
`RECEIVED NYSCEF: 08/29/2017
`NYSCEF DOC.
`'No. 39
`p .
`
`
`
`Patient Name
`
`Norma Blanco
`
`
`_
`09/26/1940
`Patient Address
`
`
`
`
`296 Logan Street Brooldyn,NY,11208
`
`
`Social Security Number
`125—44 -6301
`
`con «New No.: 950
`UANT TO HIPAA
`
`
`
`
`
`
`so.”«firm—qr1.“...answer
`
`
`
`
`
`2. If I am authorizing the release of HIV—related
`' prohibited from redisclosing such information without my authorizatio
`:1 unless permitted to do so under federal or state law.
`understand thatI have the right to request a list ofpeople who may receive or use my HIV-related information without authorization. If
`I experience discrimination becahse of the releasepndisclosure of HIV-
`related information, I may contact the New York State-Division
`of Human Rights at (212) 480-2493 or the New York City Commission of Humaanights stagnatiesese ~ Ihase '
`'
`'
`. a
`'
`reaponsible for protecting my rights.
`'
`
`I
`
`5. Information disclosed under this authorization might be rediselosed by the reei
`redisclosure may no longer be protected by federal or state law.
`
`pieot (except as noted above in 'ltem 2), and this
`
`
`
`provider or entity to release this information:
`I
`
`
`a} New York Hospital-5645 Main Street Flushing, NY, 11355
`
`
`
`
`8. Name and address ofperson(s) or category ofperson to whom this information will be sent:
`
`
`Melcer Newman PLLC—lllJohn Street ste 1500, New York, NY, 10038
`
`
`9(a). Specific information to be released:
`
`
`El Medical Record from (insert date)
`-
`to (insert date)
`
`
`[El EntireMedical Record, includingpatienthistories, officenotes (except psychotherapy notes), testresults, radiology studies, films,
`
`
`referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
`
`
`. Other: All Hospital Report
`Include: (Indicate byInitiating)
`Re: the accident of10/05/2014
`_
`' “l
`Alcohol/DrugTreatment
`
`
`——_c___,___fi
`l
`l 3
` Authorization to Discuss Health Information
`E 1. 1'3, Mental Health Information
`
`k |.. l?) HIV-Related Information
`Name ofindividual health care provider
`Initials
`
`
`to discuss my health information with my attorney, or a goverrunental agency, listed here:
` 10. Reason for release ofinforrnation:
`CI At request of individual
`[3 Other: LITIGATION
`
`
`
`'-.t, n- n e of person signing form:
`
`l3. Authority to sign on behalf of patient:
`
`”ER,
`5 Q
`
`ATTORNEY FOR PLAINTIFF
`
`
`
`
`(13) CI By initialing here
`
`
`
`I authorize
`
`_
`
`
`
`
`
`
`
`Public Health Law protects information which reasonably could
`regarding a person‘s contacts.
`
`
`
`
`
`
`INDEX NO. 510600/2016
`FILED: KINGS COUNTY CLERK 08/29/2017 04:31 PM
`INDEX NO~ “0600/2016
`FILED: KINGS COUNTY CLERK 08312017 04:31 PM
`
`
`RECEIVED NYSCEF: 08/29/2017
`NYSCEF DOC. NO. 39
`MSG-5F DOC, @WLE GENERALPOV RDFATTORNEYNEWYORKSTAFEITORYISEGRTEEORMCEFt 08/29/ 017
`3“"“EC'I‘IVE
`TEE POWERS
`l:
`' RANT BELOW CONTINUE TO I?
`SHOULD YODTBECONEE DISABLED OR lNCOh/IPE'TBNT
`
`'
`
`'
`
`Caution: This is an important document. It gives the person whom you designate (your "Agent”) broad powers to handle your property during your
`lifetime, which may Include powers to mortgage, sell, or otherwise diapose of any real or personal property Without advance notice to you or
`approval by you. Then powers will continue to exist even after you become disabled or incompetent These powers are esplained mere hilly In New
`York General Obligations Law, Article 5, Title 15, Sections 5-1502A through 5-1503, which expressly permit the use of any other or different form
`ofpower of attorney. This. document does not authorize anyone to make medical or other health care decisions. You may execute ahealth care proxy
`to do this. Ifthere is anything about this form that you do not understand you should ask alawyer to explain it to you.
`
`Tl-TES is intended to constitute a DURABLE GENERAL POWER OF ATTORNEY pursuant to Article 5, Title 15 ofthe New York
`General Obligations Law:
`'
`r,is firmfplrmw“ do hereby appoint: Mark Linder from the firm ofT-Iarmon,
`hinder & Rogewaky, Attorneys at Law, 3 Park Avenue, 23Id Floor, New York, New York, 10016 as my attomey(s)~in~fact TO ACT
`' SEPARATELY, 1N MY NAME, PLACE AND STEAD, in any way which I myself could do, if I were personally present, with
`respect to the following matters as each ofthem is defined in Title 15 ofArticle 5 of the New York General Obligations Law to the
`_.extent that I am permitted by law to not through an agent:
`.
`_
`‘
`'
`'
`
`DIRECTIONS: Initial in the blank spaceto the left ofyour choice any one or more ofthe following lettered subdivisions as to which you WANT to
`give you agent aulhorlty. Lfthe blank space to the had of any particular lettered subdivision is' NOT initialed, NO AUTHORITY WILL BE
`GRANTED for matters that are included in that subdivision.
`
`“T ALQIX] (A) all manner and aspects of claims and litigation including settlement, execution ofNon~IEIZEPAA Authorizations
`and execution of HIPAA medical record authorization forms pursuant to NY Public Health Law §18(1)(g) as
`'
`amended 10/26/04;
`7
`.
`L [ig’di IX] (B) obtain, review and utilize all manner of records, reports, files, documents, and statements including but not
`limited to: medical/non-medical, No-Fault files, police reports, employment records, worker’s compensation records
`and non-privileged legal files.
`'
`.
`.
`.
`“ [E ‘35 [X] (C) full and unqualified anthority to my attorney(s)—inwfact to delegate any or all ofthe foregoing powors to any I
`.
`.
`person or persons Whom my attorney(s)-in-fact shall select:
`(SpectralProvisions and limitations may be included in the statutory shortform durablepower ofattorney only ifthey ecly'omz, to the requirements of
`5-1503 pfflte New York General Obligations Lam)
`'
`...............................................................................................................................................................................................................
`urn-"Hun"u-u-u-uu‘m-uuunwanna-unun":uuumunnnnu'..................m....”A..nu.--....w....-..“snubs-n..................... 4. ........................
`
`
`
`'
`
`.
`
`This Durable Power of Attorney shall not be affected by my subsequent disabilityaon-iucompetsnee.
`To induce any third party to act hereunder, I hereby agree that any third party receiving a duly executed copy or facsimile of
`this instrument may act hereunder, and that revocation or termination hereof shall be ineffective as to such third party unless,
`and until actual notice or knowledge of such revocation or- termioation-shall have been received by such thirdparlyihli’flfiéfor
`myself and for my heirs, executors, legal representatives and assigns, hereby agree to indemnify and hold harmless any such
`
`third party from and against any and all claims that may arise against such third party by reason of such third party haying
`Stalled-outline provisionsof thlsinstrument.
`-
`.
`
`This Durable General Powm' of Attorney may be revoked lay-me
`anytime.
`.
`. In Witness Whereof, I have hereunto signedmynamethis ”7'3,d [lofrlzgb2iflntf......, 2015-
`'M'M’Ww
`as?
`.(
`
`(Signature ofPIjinczpaI) .
`
`ACKNOWLEDGMENT"
`
`
`
`STATE OF NEW YO . COUNTY OF
`_
`_
`.On the 3rd day of
`[g'L-ifl (“fin the year gag/oer r‘e me, the undersigned, aNotai-y Public in and for said State, personallyappeared personally known to me or
`proved to me on the basis of satisfactory evidence toib ; e individual(s) whose namc{s) is (are) subscribed to the within instrument and acknowledged to me that
`he/shcfthey executedlbe same in hisfilfif/thalf caparfi
`(ies). andthat by hJ-sfihfitfhsiigds! emrets) on the infihumenf,the individuaks), or the Emu" upon b61131foa'whinh
`i
`I
`deal-9;"
`: -'t'
`the individuailsl
`d,
`touted the instrument
`g
`{
`Notary
`‘E
`lie oi New York
`
`
`"
`;/
`
`,
`
`Notary Puhlio: see ofNew rent
`
`l
`
`
`
`
`
`€
`
`
`FILED: KINGS COUNTY CLERK 08/29/2017 04:31 PM
`FILED: KINGS COUNTY CLERK 08m2017 04:31 PM
`
`NYSCEF DOC. NO. 39
`NYSCEF DOC. NO. 39
`(“‘1 1
`‘
`
`ocn Official Form No.: 960
`'w
`.
`‘
`“V"
`' AUTHORIZATION FOR RELEASE OF HEALTH lNFORMATION PURSUANT TO HIPAA.
`[This form has been approved by the New York State Department of Health}
`
`.
`
`("W
`
`'3
`. 510600/2016'
`INDEX NO. 510600/2016
`
`IND-X NO
`
`
`
`
`
`RnCnIVnD uYSCEF: 08/29/ 017
`RECEIVED NYSCEF: 08/29/2017
`
`
`
`,,,.._,.._._._W_,__,m,.,.__,___,_.___Ffi_.fi.____
`
`Wow".
`
`
`
`
`_._____.__,n.___._.,,,_....__,.-_...,,,_.,.....“a,
`
`' 296 Logan Street Brooklyn,NY,112l}8
`
`Date of Birth .
`09/26/1940
`
`Social Security Number
`125-44-6301
`
`
`
`'
`
`Patient Name
`
`
`Norma Blanco
`
`
`
`
`Patient Address
`
`
`I, or my authorized representative, request that health information regarding my care and treatment he released as set forth on this form:
`In accordance with New York State Law and the Privacy Rule ofthe Health Insurance Portability and Accountability Act of 1996
`CHIPAA),
`I understand that:
`'
`1. This authorization may include disclosure of information relating to ALCOHOL andxvmflf} ABUSE, MENTAL HEALTH
`TREATmmept psychotherapy notes, and CONFIDENTIAL HWI'REEAIED JNFORMATION only ifI place my initials on
`the appropriate line in Item 9(a).
`In the event the health information described below includes any ofthese types of information, and I
`' initial the line on the box in Item 9(a), I specifically authorize release ofsuch information to the person(s) indicated in Item 8.
`2. HI am authorizing the release ofI-IIV~re1ated, alcohol or drug treatment, or mental health treatment information, the recipient is
`prohibited from redisclcsing such information without my authorization unless permitted to do so under federal or state law.
`I
`understand that I have the right to request a list ofpeople who may receive or use my HIV—related information without authorization. If
`I experience discritItinationbecause of the release or disclosure-ofHIVLrelated information, I may contact the New York State Division
`of Hurnan Rights at (212) 4804493 or the New York City Commission of Human Rights at (212) 306—7450. These agencies are
`responsible for protecting my rights.
`'
`3. I hastethe right to revoke this authorization at any time by writing to the health care provider listed below. Iunderstand that I may
`revoke this authorization except to the extent that action has already been taken basedbn this authorization.
`4.
`I understand that signing this authorizationcis Voluntary: My treatment, payment, enrollment in a health-.plargscgfleljgibility for
`benefits will not be conditioned upon my authorization of this disclosure.
`'
`5.
`Information disclosed Under this authorization might be redisclosed by=~the-recipient (except as noted above in Item 2), and this
`redisclosure may no longer be protected by federal or state law.
`'
`
`
`
`7. Name and address ofhealth provider or entitylto release this information:
`.
`.
`‘
`fl
`-
`'
`
`Physical Medicine and Rehabilitation WNW York -95~20 Queens Boulevard, Rago Park',N'ew York 11374
`
`
`
`8. Name and address ofperson(s) or category of person to whom this information will be sent;
`
`
`Meleer Newman PLLC-lllJohn Street ste 1500, New York, NY, 10038
`
`
`9(a). Specific information to be released:
`
`
`
`to (insert date)
`CI Medical Record fiom (insert date)
`
`
`in Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films,
`
`
`
`referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
`
`
`a Other: All Medical Report
`Include: (Indicate by Initiating)
`Re: the accident of 10/05/2014
`
`———_—I._________
`
`__~_ Alcohol/Drug Treatment
`
`
`Mental Health Information
`
`
`HIV-Related Information
`
`
`
`Name of individual health care provider
`initials
`
`to discuss my health information with my attorney, or a governmental agency, listed here:
`
`
`
`Authorization to Discuss Health Information
`
`(b) El By initialing here
`I authorize
`
`
`
`expire:
`
`
`END OF LITIGATION
`
`
`
` 12. Ifnot the patient, 11 e ofperson signing form:
`
`
`13. Authority to sign on behalf of patient:
`
`
`ATTORNEY FOR PLAINTIFF.
`
`All items on this form ha
`en completed and my questions about this form have been answered. In addition, I have been provided a
`copy of the form.
`
`
`Date:
`
`3) " 9L! " l i
`
`SQ
`
`* Human Immunodefi ency irus that causes AIDS. The New York State Public Health Law protects lnl‘ormatioa which reasonably could
`identify someone as aving ._
`symptoms or infection and information regarding a person’s contacts.
`
`
`
`
`
`'3
`.
`10600/2016'
`INDEX NO. 510600/2016
`FILED: KINGS COUNTY CLERK 08/29/2017 04:31 PM
`IND'X NO
`5
`,
`FILED: KINGS COUNTY CLERK 08212017 04:31 PM
`
`
`
`3 : 08/29/2 17
`RECEIVED NYSCEF: 08/29/2017
`NYSCEF DOC. NO. 39
`NYSCE'F DOC. nauseous GENERAL PO ER OF ATTORNEY NEW YORK sramtromihhiiidi‘%cifiiirc F
`‘ RANT BELOW CONTINUE TOII E” “ECTIVE
`TEEPOWERS
`i,
`SHOULD YOU'BECOME DISABLED 0R ENCOWETm‘lT
`
`~
`
`'
`
`Caution: This is an important document. It gives the person whom you designate (your "Agent"} broad powers to handle your property during your
`lifetime, which may Include powers to mortgage, $511, or otherudse dispose of any real or personal property without advmcenotice to you or -
`approval by you. Then powers will continue to exist even after you become disabled or '
`incompetent. These powers are explained more fully In New .
`Yorl: Genoml Obligations Law, Article 5, Title 15, Sections S-ISOZA through 5-1503, which
`'
`of power of attorney. This document does not authorize anyone to make medical or other he
`to do this. Ifthere is anything about this form that you do not understand, you should ask a lawyer to explain it to you.
`
`THIS is intended to constitute a DURABLE GENERAL POWER OF ATTORNEY pursuant to Article 5, Title 15 ofthe New York
`General Obligations Law:
`'
`I hfiermglmw do hereby appoint: Marktinderfroththe firm ofHarmon,
`Linder cit Rogowsky, Attorneys at Law, 3 ParkAvenue, 23Id Floor, New York, New York, 10015 as my attorney(s)-in-faot TO ACT
`SEPARATELY, 1N MY NAME}, PLACE AND STEAD, in an way which lmyself could do '
`
`*—
`
`-'
`
`.
`
`.
`
`i” ME] (A) all manner and aspects of claims and litigation including settlement, execution ofNonnEfiPAA Authorizations
`and execution ofHE’AA medical record authorization forms pursuant to NY Public Health Law §18(l)(g) as
`amended 10/26/04;
`1X] {8) obtain, review and utilize all manner of records, reports, files,
`limited to: medical/non—rnedical, No—Fa ult files, police
`and uon-privilegedlegalfiles.
`[X] (C). full and unqualified authority to my attoru ey(s)-in-fs ct to dole
`person or persons whom my attorne5v(s)—inhfact shall select:
`(Specialprovisions and limitations may be included in the stoma;
`31 :S‘hw't‘jbrm durablepower ofattorney only y‘t‘hey confirm to the requirements of
`5—1503 ofrhe New York General Obligations Law.)
`
`documents, and statements including but not
`reports, employment records, worker’s compensation records.
`
`gate any or all of the foregoing powers to any- ‘
`
`'
`This Durable Power ofAttorney shall not be affected by my subsequent disability or incompetence.
`To induce any third party to act hereunder, I hereby agree that any thirdgarty receiving a duly executed copy or'facsimiie of
`this instrument may act hereunder,- and that revocation or termination hereof shall be ineffective as to such third party unless
`and until actual notice or knowledge of such revocation or termination-shall haVe been received by such third party, and I for
`myself and for In}! heirs, executors, legal representatives and assigns, hereby agree to indemnify and hold harmless any such
`third party from and against any and all claims that may arise against such third party by reason ofsuch third party having
`relied on the provisions dfsfliiiii’sfrument
`
`This Durable General Power of Attorney may be revoked by me f. an time.
`i In Witness Whereof, Ihavehereunto signed mynamethis .Z'Efda fiof. gbblfiirtf’, 2015-
`k
`We,
`
`/
`
`(Signatwe ofPIjincipal) .
`
`ACIWOWiEDGMENT
`
`
`
`STATE OFNEW tore COUNTY OF
`
`,,
`,, J
`g
`.
`0n the gm dayof 69%“ {7 inThe-year2015, bet tome, the undersigned, aNotzuy Public in and forsaid State, personallysppeared personally known to meor
`provedto me on thfibasis ofsatisfactory evidenceto,'h iii: individual(s) whosename{s) is (are) subscribedtothewithin instnnnent and aeloaowledged to methat
`he/she/they executed the some in hisfherltheir capalj'i Qies), and thatbyhiisfherlfieiggfimre-{s} on the instrtunent,.fiie individuahs), or the person upon behalfofuhieh
`the individuaKs) acted, executed the instrument.
`i
`,r'
`‘
`, ,-
`V. 1’ New York
`1
`"
`'
` . _n.-..,.,,_-
`
`
`
`i
`
`Notary Public: state ofNew York
`
`a
`
`-
`
`'
`
`I;
`
`-/
`
`
`
`
`
`
`
`
`FILED: KINGS COUNTY CLERK 08/29/2017 04:31 PM
`FILED: KINGS COUNTY CLERK 08212017 04:31 PM
`
`_
`NYSCEF DOC. NO. 39
`'a
`NYSCEF DOC, NO. 39
`("X ‘l
`(H\
`A,
`,
`|
`uk-
`j
`OCA Official Form No.: 960
`-’
`,
`
`' AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
`‘
`[This form has been approved by the New York State Department of Health]
`
`'3
`.
`0600/2016‘
`INDEX NO. 510600/2016
`
`IND'X NO
`51
`
`
`
`
`
`RaCaIVaD vyscnr:
`08/29/ 017
`RECEIVED NYSCEF: 08/29/2017
`
`
`
`p
`
`
`Patient Name
`
`
`
`
`
`Norma Blanca
`Patient Address
`
`296 Logan Street Brooklyn,NY,11208' '
`
`
`
`
`'
`
`
`
`I, or my authorized representative, request that health information regarding my care and treatment he released as 'set forth on this form:
`In accordance with New York State Law and the Privacy Rule ofthe Health Insurance Portability and. Accountability Act of 1996
`(I-DI’AA),
`I understand that:
`'
`'
`1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
`TREATMENT,”Except‘psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only ifI place my initials on
`the appropriate line in Item 9(a).
`In the event the health information described below includes any ofthese types of information, and I
`initial the line on the box in Item 9(a), Isp'ecifically authorize release of such information to the person(s) indicated in Item 8.
`2. If I am authorizing the release of I-IlV—related, alcohol or drug treatment, or mental health treatment information, the recipient is
`prohibited from redisolosing such information without my authorization unless permitted to do so under federal or state law.
`I
`understand that l have the right torequest a list of people whomay receive or use my HIV-related information without authorization. If
`I experience discrimination because of the release or disclosure of HlV~related information, I may contact the New York State Division
`of Human Rights at (212) 48042493 or the NewYorkLtdiqgji
`tflumencR-ights at (212.) 306-7450. These agencies are
`
`rcsponsiblfifitr‘protecting my rights.
`-
`3. I have the right-to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may
`revoke this authorization except to the extent that action has already been taken based on this authorization.
`4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for
`benefits will not be conditioned upon my authorization of this disclosure.
`-
`5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
`redisclosure may tie-longer be protected by federal or state law.
`'
`'
`_
`_
`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 ofhealth provider or entity to release this information:
`
`
`Randal] V- Ehrlich M.D., P.‘C.— 68 Boulder Ridge Road Scarsdale, NY 10583
`
`8. Name and address ofpersOn(s) or category ofperson to whom this information will be sent:
`
`
`Meicer Newman PLLC-ll 1John Street ste 1500, New York, NY, 10038
`
`
`9(a). Specific information to be released:
`
`
`to (insert date)
`CI Medical Record from (insert date)
`
`
`E Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films,
`
`
`referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
`
`
`El Other: All Medical R9139“
`'
`Include: (Indicate by Initiating)
`
`
`Re: the accident of10/05/2014
`AlcoholIDrug Treatment
`
`
`Mental Health Information
`
`HIV-Related Information
`
`Date of Birth
`uses/1940
`
`Social Security Number
`125-44-6301
`
`'
`
`
`
`
`
`
`
`rmflcglw..V,...._.,_,._,-,,___A,._.
`,,wasA,,fi..__nmm,..ww...w.,m.fifl.famrmefih—fiflr.
`
`
`Authorization toDiscuss Health Information
`
`-
`
`(b) D By initialing here
`
`I authorize
`
`
`Name of individual health care provider
`Initials
`
`to discuss my health information with my attomey, or a governmental agency, listed here:
`
`
`Attome [Firm Name or Governmental A_en' Name)
`
`
`10. Reason for release of information:
`
`11. Date or event on which this authorization will expire:
`[I At request of individual
`
`
`END on LITIGATION
`D Other, LITIGATION -
`
`
`
`12. Ifnot the patient,
`in ofperson signing form:
`13. Authority to sign on behalf ofpatient:
`
`
`MARK J LINDE , ES I
`ATTORNEY FOR PLAINTIFF
`
`All items on this to
`
`
`] have been provided a
`copy of the form.
`'
`
`
`
`
`
`
`
`
`
`
`- entative authorized by law.
`* Human Immunodefici“; y Virus that causes AIDS. The New York State Public Health LawI protects information which reasonably could
`identify someone as he ng HIV symptoms or infection and information regarding a person's contacts.
`
`
`39H fiij
`
`
`Date:
`
`
`
`
`INDEX NO. 510600/2016
`FILED: KINGS COUNTY CLERK 08/29/2017 04:31 PM
`INDEX NO~ 510600/2016-
`FILED: KINGS COUNTY CLERK 08312017 04:31 PM
`
`NYSCI
`RECEIVED NYSCEF: 08/29/2017
`NYSCEF DOC. NO. 39
`3F Doc. Nemesis: GENERAL Pops/nu on ATTORNEY NEW YORK STrtJEQTORYFSEfiElfi'FTOWEF‘
`0 8 / 2 9/
`0 17
`THE POWERS
`l
`_RANI‘ BELOW CONTDIUE TO 1 Effi'ECTIVE
`SHOULD YOUi'BECOIlIE DISABLED OR INCOIVEPE'laerI‘
`
`‘
`
`'
`
`Caution: This is an important document It gives the person whom you designate (your "Agent“? broad powers to handle your property during- your
`lifetime, which may Include powers to mortgage, sell, or otherwise dispose of any'real or poisons] property without advance notice to You or
`approval by you. Then powers will continue to exist even after you become disabled or incompetent These powers are explained more fiilly In New
`I York General Obligations Law, Article 5, Title 15, Sections S-ISOZA through 5-1503, which eitpressly permit the use ofany other or different form
`ofpower of attomey. This. document does not authorize anyone to make medical or other health care decisions. You may execute a health care proxy
`to do this. lfthere is anything about this form that you do not understand, you should ask alawyer to explain it to you.
`
`Tl-IiS is intended to constitute aDUZRABLE GENERAL POWER OF ATTORNEY pursuant to Article 5, Title 15 of the New York
`General Obligations Law:
`-' -=~
`'
`-
`in
`b3
`”Emma.......2; 0mm; do hereby appomt Mark Lmder fiom the firm ofl—Iatmon,
`I,
`Linder 85 R0 gowslcy, Attomeys at Law, 3 Park Avenue, .23rd Floor, New York, New York, 10016 as my attorney(s)-in-fact TO ACT
`SEPARATELY, 1N MY NAME, PLACE AND STBAD, in any way which I myself could do, ifI Were personally present, with
`respect to the following matters as each-oftbern is definedin Title 15 ofArticle 5 cfthe New York General Obligations Law to die
`extent that I am permitted by law to act through an agent:
`_
`'
`‘
`
`DIRECTIONS: Initial in the blank space to the left of your choice any one or more ofthe following lettered subdivisions as to which you WANT to .
`give your agent authority. Ifthe blank space to the left of any particular lettered subdivision is NOT initialedrNO AUTHORITY Wll.L BE
`GRANTED for matters that are included in that subdivision.
`.
`
`“fl MIX] (A) all manner and aspects of claims and litigation including settlement, execution ofNon—EIPAA Authorizations
`and execution of HEPAA medical record authorization forms pursuant to NY Public Health Law §18(1)(g) as
`amended 10126104;
`.
`
`<-
`
`1"
`
`,
`
`’
`
`[X] (B) obtain, review andutilize all manner of records, reports, flies, documents, and statements including but not
`limited to: medicaUnon-medical, No-Fault files, police reports, employment records, worker’s compensation records
`.
`and non—privileged legal files.
`MEX] (C) full and unqualified authority to my attorney(s)-in-fact to delegate any or all ofthe foregoing powers to any. ‘
`person or persons whom my attorncy(s)—in—fact shall select:-
`(Specfol provisions and limitations may be imlnded in the statutory shafiform durable power q’otromey only ifrhey corg’orm to the requirements q)"
`5-1503 oftlie New York General Obligations Law.)
`'
`-
`nun-"nun“...uu....Vo‘uhu...........................................................................................................................................................................
`
`
`
`This Durable Power of Attorney shall not be affected by my subsequent disability or incompetence.
`
`To induce any third party to act hereunder, I hereby agree that any third party receiving a duly executed copy or facsimile of
`' this instrument may act hereunder, and that revocation or termination hereof shall be inefiectlve as to such third party unless
`and until actual notice airlift owledge of such revocation or termination-shall have been received by such third party, and I for
`myself and for my heirs, executors, legal representatives and assigns, hereby agree to indemnify and hold harmless any'snch
`third partyffrom and against any and all claims that may arise against such third party by reason of such third party'hsving
`relied on the provisions of this instrument.
`--
`-
`.
`-
`‘
`-
`
`
`
`
`
`._._,.m—_.._.—.—.—,.,___—.—n——..__,—.,._...s..?__.._..__._._..__“._sw.n_,w..._.,....«WWW—sq...
`
`
`
`—-----'-'-.---~m.—‘I
`
`i
`.'
`s
`
`Norm-y Public: State ofNew York
`
`5‘
`/
`
`This Durablefleneral Power of Attorney may be revoked by me.
`.
`
`flan time.
`y
`.
`,
`
`.iibiflaflfmh, 201g
`
`X
`
`(Signature ofPinncfpal) .
`
`ACKNOWLEDGMENT
`
`STATE OF W YO .3 COUNTY OF
`
`:
`
`.
`
`In Witness What-cot, I have hereuntosignedmy namethis “Zia!do {of.
`
`Eiijj’bt/L. Ea T7152
`1/
`
`
`0n the 5Y3 day of 2&4?th“finthe-year2Ul5fbéf iii-no,theundersigned, aNomry Public in and forsaid State, personallyappeared personally knowntome01'
`proved to me on thebasis ofsatisfictogr evidence redid-fileindivi‘dualts)whosename(s) is (are) subscribedto thewithin instrument and acimowledged to methat
`helshelfiiey executedthe same in hislherlthcir capag‘i
`(ins), and thatby hisflheffmpiiéiaigturem on the instrument,the individuaKs}, or the person upon behalfofwhich
`E
`i
`a
`'
`"
`iZ'A
`the bidividuaKs) acted, executed the instrument
`3
`g’
`3.49m, a.
`Q:
`r NEW York:
`‘
`'
`at .
`
`Como
`.2.
`..my 13.13048
`I
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`‘
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`J Con: '
`Qv-
`
`
`
`
`FILED: KINGS COUNTY CLERK 08/29/2017 04:31 PM
`FILED: KINGS COUNTY CLERK 08312017 04:31 PM
`
`NYSCEF DOC. NO. 39
`NYSCEF DOC. NO. 39
`,m
`
`(
`
`u.
`
`3
`.
`0 2016
`INDEX NO. 510600/2016
`IND-X NO
`51060 /"n;
`
`
`
`
`
`
`
`Ra «IVaD VYSCEF: 08/2 ’
`017
`RECEIVED NYSCEF: 08/29/2017
`C
`9%:
`
`[I (—-\r
`
`(m I
`
`(
`
`Physical Medicine and Rehabilitatinn of New York
`95-20 Queens Boulevard
`Rego Park; New Yém 11374
`713-459-1281}
`
`
`Initial Physiatric Evaluation
`
`M
`
`Rs:
`Dammf Ancident:
`Visit Date:
`
`Norma Blanca
`October 5, 2014
`October 10, 2014
`
`CHIEF COMPLAINTS
`1. Eye pain with blurry vision.
`Neck pain radiating to left shouldnr.
`Left shoulder pain.
`.
`Low' back pain radiating to left hip.
`Left knee pain.
`Left ankle: pain.
`
`99??!"
`
`‘
`
`.
`
`’
`-
`-
`-
`.
`HISTORY OF FRESENT ELNESS
`”flan patient is a 74-year-old, right-hand donfinant fiemale status post parsonal injury on October 5, 2014.
`She was walldng when she tripped over an elevated sidewalk, fell. fdrward, and hither left eye and time.
`No loss ofconsciousness. She Was my: to Booth MemofialHospital where she states she had x—rays of
`the face, lefi hand, and shoulder as well as CAT scan affine head which were negative for fiacturas and
`bleeds. She was than scan by hat primary care physician; 1m imaging was Sent. She then came here for
`evaluate.
`'
`'
`
`Since flan accidwt, she is onmplalning ofneck pain radiating to the: left shoulder and difficulty fuming her
`head as well as low back pain radiating to her Inf: leg with cramping into the leg and difiicnlty walking.
`She also has same lance and anlde pain and difficultygoing up and down stains and walking more than
`two blocks, She has pain going from a sit-tentand pusifien. She also has lacerations in both hands that
`are causing her pain. ”She has bruising overthe lefi: eye which is radiating into herhead but no assessnrily
`causing her headaches.
`"
`'
`'
`‘
`'
`
`PAST MEDICAL HISTORY: Diahebes, hyperfinsion, hypemholesterolemla, and peripheral vascular
`diaeasn.
`"
`.
`
`PAST SURGICAL HISTORY: Hamlet mpairs and C-secflon.
`
`ALLERGIES: Denies.
`
`MEBICATIONS:Metfhmnn; simvastathl; Coreg; dopidogrel; oxybulynin; mtdodipinn; p.0. gfiane;
`Janufia; aspirin; and a new medication, Ednrbyclot.
`'
`
`Seem HISTORY: Denies-tobaccoandalcohol.
`
`
`
`
`
`
`
`FILED: KINGS COUNTY CLERK 08/29/2017 04:31 PM
`FILED: KINGS COUNTY CLERK 08312017 04:31 PM
`
`NYSC'fiF DOC
`NO
`39
`NYSCEF DOC. NO. 39
`.1.
`.
`.
`
`.
`
`“I...“
`
`'
`
`r
`‘
`
`.
`
`r“
`
`,
`i
`
`INDEX NO. 510600/2016
`INDEX NO~ “0600/2016”
`
`
`
`
`
`R«.C«.IV«.D \IYSCEF: fire/2972017
`RECEIVED NYSCEF: 08/29/2017
`i
`
`
`
`}
`
`‘
`
`Ii
`
`l
`
`i
`
`Ir
`
`I
`
`i
`
`'
`Re: Norma-Bianca
`WORK HISTORYfl‘he patient is retired.
`
`I
`
`.
`
`I
`
`Combos-10,2014
`
`PRIOR INJURIES: Denies.
`
`_ PREGNANCY: Denies.
`
`REVIEW OF svsremsmmios headodzes, dizziness, nausea, vomiting, fevers, chill