FILED: KINGS COUNTY CLERK 10/30/2018 11:18 AM
`
`3F DOC. NO.
`49
`NYSCEF DOC. NO. 49
`
`INDEX NO. 513298/2017
`
`
`
`
`
`
`10/30/201
`RECEIVED NYSCEF: 10/30/2018
`
`
`
`2
`
`EXHIBIT
`
`
`
`

`

`FILED: KINGS COUNTY CLERK 10/30/2018 11:18 AM
`NYSCEF DOC. NO. 49
`
`INDEX NO. 513298/2017
`
`RECEIVED NYSCEF: 10/30/2018
`
`KRENTSEL
`A T
`T
`R N li
`0
`
`& GUZMAN
`
`Y S
`
`A T
`
`L A w
`
`September
`
`24,
`
`2018
`
`The
`
`Law
`
`Offices
`
`1 Executive
`
`Yonkers,
`
`Blvd,
`NY 10701
`
`of Karen
`280
`
`Suite
`
`L.
`
`Lawrence
`
`a°t"
`
`giace
`
`6th Floor
`New York, NY 10004
`
`LONGISLAND
`175 East Shore Road,
`Great Neck, NY 11023
`
`T: 212.227.2900
`
`F: 212.227.3881
`
`wwwkglawteam.com
`
`Re:
`
`Christian
`
`Index
`
`No.:
`
`Nielsen
`
`v.
`
`Shadina
`
`J. Graham
`
`513298/2017
`
`Dear
`
`Sir/Madam:
`
`Please
`
`find
`
`enclosed
`
`the
`
`following
`
`duly
`
`executed
`
`HIPAA
`
`authorizations
`
`and
`
`information:
`
`annexed
`
`1.
`
`2.
`
`3.
`
`Clinic;
`
`DSNY
`Department
`John
`
`Dr.
`
`hereto.
`
`of
`
`Sanitation
`
`(Employment
`
`Records);
`
`annexed
`
`hereto.
`
`C.
`
`L'Insalata;
`
`annexed
`
`hereto.
`
`Please
`
`be
`you
`
`advised
`have
`
`If
`
`responses.
`
`office.
`
`that
`
`the
`
`plaintiff
`
`reserves
`
`the
`
`right
`
`to
`
`supplement
`
`these
`
`any
`
`questions
`
`or
`
`concerns,
`
`please
`
`do
`
`not
`
`hesitate
`
`to
`
`contact
`
`our
`
`truly
`
`Very
`Krentsel
`
`yours,
`& Guzman
`
`LLP
`
`Michael
`
`Melendez,
`
`Paralegal
`
`

`

`FILED: KINGS COUNTY CLERK 10/30/2018 11:18 AM
`NYSCEF DOC. NO. 49
`
`INDEX NO. 513298/2017
`
`RECEIVED NYSCEF: 10/30/2018
`
`AUTHORIZATION
`
`INFORMATION
`OF HEALTH
`FOR RELEASE
`State Departiiiênt
`form has been approved
`by the New York
`
`PURSUANT
`of Healthj
`
`[This
`
`OCA Official Form No.: 960
`TO HIPAA
`
`Patient Name
`
`Nielsen
`Christian
`Patient Address
`
`45 Lincoln
`
`Road,
`
`Patcliagias,
`
`NY 11772
`
`Date of Birth
`
`Social Security Number
`
`regardiiig my care and treatment
`the Health
`Insurance Portability
`
`be released as set forth on this form:
`Act of 1996
`and Accountability
`
`is
`I
`If
`
`I understand
`
`that
`
`I may
`
`plan, or eligibility
`
`for
`
`by the recipient
`
`(except
`
`as noted
`
`above in Item 2), and this
`
`INFORMATION
`SPECIFIED
`
`OR MEDICAL
`IN ITEM 9 (b).
`
`that health information
`I, or my authorized
`request
`representative,
`In accordance with New York State Law and the Privacy Rule of
`I understand
`that:
`(HIPAA),
`and DRUG ABUSE,
`to ALCOHOL
`authorization
`HEALTH
`MENTAL
`information
`of
`disclosure
`include
`1. This
`relating
`may
`HIV*
`on
`if
`I place my initials
`INFORMATION
`RELATED
`notes, and CONFIDENTIAL
`except psychotherapy
`TREATMENT,
`only
`described
`below includes
`any of
`these types of
`and I
`information
`the appropriate
`line in Item 9(a).
`In the event
`the health
`information,
`initial
`the line on the box in Item 9(a),
`I specifically
`authorize
`release of such information
`to the person(s)
`indicated
`in Item 8.
`If
`the release of HIV-related,
`I am authorizing
`alcohol
`or mental
`or drug treatment,
`health
`treatment
`the recipient
`2.
`information,
`from redisclosing
`information
`my authorization
`permitted
`to do so under
`federal
`or state law.
`prohibited
`such
`without
`unless
`information
`understand
`that
`I have the right
`to request a list of people who may receive or use my HIV-related
`without
`authorization.
`I experience
`discrimination
`because of
`the release or disclosure
`of HIV-related
`I may contact
`the New York State Division
`information,
`of Human Rights
`at
`480-2493
`or
`the New York City Commission
`of Human Rights
`at
`306-7450.
`are
`These agencies
`(212)
`(212)
`for protecting my rights.
`responsible
`listed below.
`to the health care provider
`I have the right
`this authorization
`at any time by writing
`3.
`to revoke
`been taken based on this authorization.
`that action has already
`revoke
`this authorization
`except
`to the extent
`in a health
`enrollment
`is voluntary.
`4.
`I understand
`that
`this
`authorization
`treatment,
`payment,
`My
`signing
`of
`this disclosure.
`benefits will
`not be conditioned
`upon my authorization
`Information
`under
`might
`this authorization
`be redisclosed
`5.
`disclosed
`redisclosure may no longer be protected
`by federal
`or state law.
`YOU TO DISCUSS MY HEALTH
`AUTHORIZATION
`DOES NOT AUTHORIZE
`6. THIS
`OR GOVERNMENTAL
`ANYONE
`AGENCY
`CARE WITH
`OTHER
`THAN
`THE ATTORNEY
`7. Name and address of health provider
`or entity
`to release this information:
`NY 10013
`125 Worth
`New York,
`DSNY;
`Street,
`be sent:
`will
`8. Name and address of person(s)
`or category
`of person to whom this information
`Success, NY 11042
`of Jennifer
`3 Dakota
`Drive
`Lake
`Law Offices
`S.Adams;
`#201,
`information
`9(a). Specific
`to be released:
`O Medical
`date) 4/27/17
`date) Present
`from (insert
`to (insert
`Record
`O Entire Medical
`test
`notes (except psychotherapy
`office
`patient
`results,
`notes),
`histories,
`Record,
`radiology
`including
`and records
`insurance
`sent
`to you by other health care providers.
`referrals,
`consults,
`records,
`records,
`billing
`_Employment
`Records
`O Other:
`Include:
`(Indicate
`by initialing)
`Treatment
`Infariiiation
`Inf6riiiaticii
`
`Information
`
`Alcohol/Drug
`Mental
`Health
`HIV-Related
`
`studies,
`
`films,
`
`Aütlict
`ization
`to Discuss Health
`(b) O By initialing
`
`here
`
`to discuss my health
`
`Initials
`information
`
`I authorize
`
`with my attorney,
`
`or a governmental
`
`Name of
`agency,
`
`health care provider
`individual
`listed here:
`
`information:
`release of
`10. Reason for
`O At
`individual
`request of
`Litigation
`O Other:
`form:
`name of person signing
`If not
`the patient,
`12.
`& Guzman
`Esq.
`Dwayne
`T. Williams,
`Krentsel
`LLP;
`items on this form have been completed
`and my questions
`of
`the form.
`
`All
`co
`
`(Attorney/Firm Name or Governmental Agency Name)
`1l. Date or event on which
`
`this authorization
`
`will expire:
`
`of case
`End
`to sign on behalf of patient:
`13. Authority
`Power
`of Attorney
`this form have been answered.
`
`In addition,
`
`about
`
`I have been provided
`
`a
`
`Date:
`
`at
`* Human
`identify
`
`re of patient
`
`or representative
`
`by law.
`that causes AIDS. The New York State Public Health Law protects
`Virus
`Innsn±ficieiicy
`and information
`or infection
`a person's
`contacts.
`as having HIV symptoms
`saincon:
`regarding
`
`authorized
`
`information
`
`which rcãssiiably
`
`could
`
`

`

`that health information
`I, or my authorized
`request
`representative,
`In accordance
`with New York State Law and the Privacy Rule of
`I understand
`that:
`(HIPAA),
`to ALCOHOL
`HEALTH
`MENTAL
`and DRUG
`information
`of
`disclosure
`include
`1. This
`authorization
`ABUSE,
`relating
`may
`HIV*
`if
`I place my initials
`INFORMATION
`RELATED
`notes, and CONFIDENTIAL
`except psychotherapy
`on
`TREATMENT,
`only
`any of
`the appropriate
`line in Item 9(a).
`the health
`these types of
`and I
`described
`below includes
`In the event
`information
`iiifermation,
`indicated
`in Item 8.
`initial
`the line on the box in Item 9(a),
`I specifically
`authorize
`release of such information
`to the person(s)
`or mental
`health
`If
`the release of HIV-related,
`I am authorizing
`alcohol
`or drug treatment,
`treatment
`the recipient
`2.
`information,
`such
`information
`my authorization
`permitted
`to do so under
`prohibited
`from redisclosing
`without
`unless
`federal
`or state law.
`to request a list of people who may receive
`information
`understand
`that
`I have the right
`or use my HIV-related
`without
`authorization.
`the release or disclosure
`I may contact
`I expe1ionue
`discrimination
`because of
`of HIV-related
`the New York State Division
`informaticii,
`of Human
`at
`480-2493
`or
`the New York City Commission
`of Human Rights
`at
`306-7450.
`These agencies
`Rights
`are
`(212)
`(212)
`responsible
`for protecting my rights.
`listed below.
`to the health care provider
`at any time by writing
`I have the right
`to revoke
`this authorization
`3.
`been taken based on this authorization.
`that action has already
`this authorization
`to the extent
`revoke
`except
`in a health
`authorization
`is voluntary.
`enrollment
`4.
`I understand
`that
`this
`treatment,
`payment,
`My
`signing
`of
`this disclosure.
`benefits will
`not be conditioned
`upon my authorization
`Information
`disclosed
`under
`this authorization
`be redisclosed
`5.
`might
`redisclosure may no longer be protected
`by federal
`or state law.
`YOU TO DISCUSS MY HEALTH
`DOES NOT AUTHORIZE
`6. THIS
`AUTHORIZATION
`OR GOVERNMENTAL
`AGENCY
`CARE WITH
`ANYONE
`OTHER
`THAN
`THE ATTORNEY
`7. Name and address of health provider
`or entity
`to release this information:
`DSNY Clinic;
`NY 10004
`44 Beaver
`New York,
`Street,
`be sent:
`will
`8. Name and address of person(s)
`or category
`of person to whom this information
`Success, NY 11042
`of Jennifer
`Law Offices
`3 Dakota
`Drive
`Lake
`S.Adams;
`#201,
`information
`to be released:
`a). Specific
`8 Medical
`Record from (insert date) 4/27/17
`date) Present
`to (insert
`O Entire Medical
`test
`notes (except psychotherapy
`office
`patient
`results,
`notes),
`histories,
`Record,
`radiology
`includiiig
`insurance
`to you by other health care previders.
`and records
`sent
`consults,
`records,
`records,
`referrals,
`billing
`Employment
`Records
`Q Other:
`Include:
`(Indicate
`by Initialing)
`Treatment
`Information
`Information
`
`is
`I
`If
`
`I understand
`
`that
`
`I may
`
`plan, or eligibility
`
`for
`
`by the recipient
`
`(except
`
`as noted
`
`above in Item 2), and this
`
`INFORMATION
`SPECIFIED
`
`OR MEDICAL
`IN ITEM 9 (b).
`
`Inforniaticñ
`
`Alcohol/Drug
`Mental
`Health
`HIV-Related
`
`studies,
`
`films,
`
`FILED: KINGS COUNTY CLERK 10/30/2018 11:18 AM
`NYSCEF DOC. NO. 49
`
`INDEX NO. 513298/2017
`
`RECEIVED NYSCEF: 10/30/2018
`
`.
`
`AUTHORIZATION
`
`INFORMATION
`OF HEALTH
`FOR RELEASE
`form has been approved
`State Department
`by the New York
`
`PURSUANT
`of Health
`
`[This
`
`OCA Official Form No.: 960
`TO HIPAA
`
`J
`
`Patient Name
`
`Nielsen
`Christian
`Patient Address
`
`45 Lincoln
`
`Road,
`
`Patchogue,
`
`NY 11772
`
`Date of Birth
`
`Social Security Number
`
`regarding my care and treatment
`the Health
`Insurance Portability
`
`be released as set forth on this form:
`Act of 1996
`and Accountability
`
`I
`
`to Discuss Health
`Authorization
`(b) O By initialing
`
`here
`
`Initials
`to discuss my health information
`
`I authorize
`
`with my attorney,
`
`or a governmental
`
`Name of
`agency,
`
`health care provider
`individual
`listed here:
`
`information:
`release of
`10. Reason for
`O At
`individual
`request of
`Litigation
`O Other:
`form:
`name of person signing
`If not
`the patient,
`12.
`& Guzman
`Esq.
`T. Williams,
`Krentsel
`Dwayne
`LLP;
`items on this form have been .
`p!eted and my questions
`of
`the form.
`
`All
`co
`
`(Attorney/Firm Name or Governmental Agency Name)
`11. Date or event on which
`
`this authorization
`
`will expire:
`
`End
`of case
`to sign on behalf of patient:
`13. Authority
`Power
`of Attorney
`this form have been answered.
`
`In addition,
`
`about
`
`I have been provided
`
`a
`
`.
`by law.
`of patient
`Signature
`* Human Inns:±ñcicacy
`that causes AIDS. The New York State Public Health Law protects
`Virus
`or infection
`and information
`someone as having HIV symptoms
`a person's
`contacts.
`regarding
`identify
`
`or representative
`
`authorized
`
`Date:
`
`infüi undion which reas6nâbly
`
`could
`
`

`

`FILED: KINGS COUNTY CLERK 10/30/2018 11:18 AM
`NYSCEF DOC. NO. 49
`
`INDEX NO. 513298/2017
`
`RECEIVED NYSCEF: 10/30/2018
`
`AUTHORIZATION
`
`OF HEALTH
`FOR RELEASE
`INFORMATION
`State Department
`form has been approved
`by the New York
`
`PURSUANT
`of Health]
`
`[This
`
`OCA Official Form No.: 960
`TO HIPAA
`
`ent Name
`
`Christian
`Nielsen
`Patient Address
`
`45 Lincoln
`
`Road,
`
`Patchogue,
`
`NY 11772
`
`Date of Birth
`
`Social Security Number
`
`be released as set forth on this form:
`regarding my care and treatisicist
`Act of 1996
`the Health
`Insurance Pcitability
`and Accountability
`
`is
`I
`If
`
`I understand
`
`that
`
`I may
`
`plan, or cligibility
`
`for
`
`by the recipient
`
`(except
`
`as noted
`
`above in Item 2), and this
`
`INFORMATION
`SPECIFIED
`
`OR MEDICAL
`IN ITEM 9 (b).
`
`InfGriiiaticii
`
`Alcohol/Drug
`Mental
`Health
`HIV-Related
`
`studies,
`
`films,
`
`request
`that health information
`I, or my authorized
`representative,
`In acceidaiice
`with New York State Law and the Privacy Rule of
`I understand
`that:
`(HIPAA),
`to ALCOHOL
`HEALTH
`MENTAL
`and DRUG
`information
`of
`disclosure
`I. This
`authorization
`include
`ABUSE,
`may
`relating
`HIV*
`if
`I place my initials
`INFORMATION
`RELATED
`notes, and CONFIDENTIAL
`on
`except psychotherapy
`TREATMENT,
`only
`these types of
`and I
`described
`below includes
`any of
`the appropriate
`line in Item 9(a).
`In the event
`the health
`information
`information,
`in Item 8.
`initial
`the line on the box in Item 9(a),
`I specifically
`release of such information
`to the person(s)
`indicated
`authorize
`If
`the release of HIV-related,
`I am authorizing
`or mental
`health treatment
`the recipient
`2.
`alcohol
`or drug treatment,
`information,
`such
`information
`to do so under
`prohibited
`from redisclosing
`without
`my authorization
`unless
`permitted
`federal
`or state law.
`to request a list of people who may receive or use my HIV-related
`understand
`that
`I have the right
`information
`without
`authorization.
`I experience
`discrimination
`because of
`the release or disclosure
`of HIV-related
`I may contact
`the New York State Division
`information,
`of Human
`or
`the New York City Commission
`of Human Rights
`at
`306-7450.
`are
`These agencies
`Rights
`at
`480-2493
`(212)
`(212)
`for protecting my rights.
`responsible
`this authorization
`listed below.
`to the health care provider
`at any time by writing
`3.
`I have the right
`to revoke
`been taken based on this authorization.
`that action has already
`revoke
`this authorization
`except
`to the extent
`in a health
`authorization
`eiiiciliilent
`is voluntary.
`4.
`I understand
`that
`this
`treatment,
`payment,
`My
`signing
`of
`this disclosure.
`benefits will
`not be conditioned
`upon my authorization
`this authorization
`5.
`Information
`disclosed
`under
`might
`be redisclosed
`redisclosure may no longer be protected
`by federal
`or state law.
`YOU TO DISCUSS MY HEALTH
`6. THIS
`AUTHORIZATION
`DOES NOT AUTHORIZE
`OR GOVERNMENTAL
`ANYONE
`AGENCY
`THAN
`THE ATTORNEY
`_CARE WITH
`OTHER
`7. Name and address of health provider
`or entity
`to release this information:
`NY 11209
`Dr.
`John
`9921
`C. L'Insalata;
`4th Avenue,
`Brooklyn,
`be sent:
`will
`8. Name and address of person(s)
`or category
`of person to whom this information
`Success, NY 11042
`of Jennifer
`3 Dakota
`Drive
`Lake
`Law Offices
`S.Adams;
`#201,
`to be released:
`information
`9(a). Specific
`2 Medical
`from (insert date) 4/27/17
`date) Present
`to (insert
`Record
`O Entire Medical
`test
`notes (except psychotherapy
`office
`patient
`results,
`notes),
`histories,
`Record,
`radiology
`including
`and records
`insurance
`sent
`to you by other health care providers.
`referrals,
`consults,
`records,
`records,
`billing
`O Other: _
`(Indicate
`Include:
`by Initialing)
`Treatment
`Information
`Information
`
`to Discuss Health
`Authorization
`(b) O By initialing
`
`here
`
`Initials
`to discuss my health information
`
`I authorize
`
`with my attorney,
`
`or a governmental
`
`Name of
`agency,
`
`health care provider
`individual
`listed here:
`
`release of
`information:
`10. Reason for
`O At
`request of
`individual
`Litigation
`2 Other:
`name of person signing
`If not
`12.
`form:
`the patient,
`& Guzman
`Esq.
`Dwayne
`T. Williams,
`Krentsel
`LLP;
`items on this form have been ceiiipleted
`and my questions
`of
`the form.
`
`All
`c
`
`(Attorney/Firm Name or Governmental Agency Name)
`11. Date or event on which
`
`this authorization
`
`will expire:
`
`End
`of case
`to sign on behalf of patient:
`13. Authority
`Power
`of Attorney
`this form have been answered.
`
`In addition,
`
`about
`
`I have been provided
`
`a
`
`Date:
`
`Signature
`* Human
`identify
`
`of patient
`
`or representative
`
`by law.
`that causes AIDS. The New York State Public Health Law protects
`Virus
`I
`±ficiciicy
`and liif6riiistion
`a person's
`contacts.
`or infection
`someone as having HIV symptoms
`regarding
`
`authorized
`
`iiifGriiiatiüii
`
`which reasonaMy could
`
`