FILED: KINGS COUNTY CLERK 09/25/2020 04:42 PM
`NYSCEF DOC. NO. 6
`
`INDEX NO. 518206/2020
`
`RECEIVED NYSCEF: 09/25/2020
`
`Exhibit "C"
`
`

`

`FILED: KINGS COUNTY CLERK 09/25/2020 04:42 PM
`NYSCEF DOC. NO. 6
`
`INDEX NO. 518206/2020
`
`RECEIVED NYSCEF: 09/25/2020
`
`Request Exception Notification
`
`From
`
`To
`
`Mount Sinai Brooklyn
`3201 Kings Hwy
`Brooklyn NY 11234-2625
`
`SULLIVAN PAPAIN BLOCK ET AL
`120 BROADWAY
`NEW YORK NY 10271-0002
`
`Re: Margarita Sidgiyayeva
`
`We are unable to comply with your request at this time for the following reason(s):
`
`Other
`
`MISSING LETTER OF ESTATE
`
`Sincerely,
`
`Mount Sinai Brooklyn
`
`

`

`FILED: KINGS COUNTY CLERK 09/25/2020 04:42 PM
`NYSCEF DOC. NO. 6
`
`INDEX NO. 518206/2020
`
`RECEIVED NYSCEF: 09/25/2020
`
`1110151111111
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`

`

`FILED: KINGS COUNTY CLERK 09/25/2020 04:42 PM
`NYSCEF DOC. NO. 6
`
`INDEX NO. 518206/2020
`
`RECEIVED NYSCEF: 09/25/2020
`
`OCA Official Farm Noe 960
`AUTHORIZATION FOR RELEASE OF arALTEi INFORMATION PURSUANT TO HJPAA.
`'This form has been approved by the NeveYork State Department of Health]
`
`Date of B'
`
`Social Security Number
`
`Si AV 1.44 IfeYel
`
`A001
`
`.7922
`
`Patient Name
`Mug a (cid:9)
`
`Patient Address
`I el (cid:9)
`kas 14,4-9Ls±cte±2.1.4.
`or my authorized representative, request that health information regarding my care and treatment bo released as set forth on this form:
`In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996
`RIPAA), L understand that:
`1. This authorization may Include disclosure of Information relating to ALCOHOL and DRUG A.I3I7'SE, MENTAL HEALTH
`TREATMENT, except psychotherapy notes, and CONFIDEN'TL4L WV* RELATED U4FORMATION only WI place my initials on
`the appropriate line in Item 9(a). In the event the health information described below includes any of these types of informatinn, and I
`initial the line on the box in Item 9(a), I specifically authorize release of sect information to the persou(s) indicated in Dern 0.
`2. if I am authorizing the release of HIV-refuted, alcohol or drug treatment, or mental health treatment information, the recipient is
`prohibited from redisobsing such Infbnuation without my authorization unless permitted to do so under federal or state law. I
`understand that I have the right to request a list of people who May receive or use my HIV-related information without authorization. If
`I experience discrimination because of the release or disclosure of ERV-related information, I may contact the New York State Division
`of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are
`responsible far protecting my rights.
`3. 1 have the rightto revoke this authorization at any time by Ya-iting to the health care provider listed below. I understand that I may
`revakethis authorization except to the extent that action has already been taken based on this authorization.
`4. 1 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 authorleaLieu of this disclosure.
`S. Inibrroation disclosed under this authorization might be redisclosed by the recipient (exopt as noted above in Ron 2), and this
`redisolosure may no longer be protected by fbderal or state law.
`G. THIS A1JTHOICLATIOlk.4 DOES NOT AUTHOR:12E YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
`CARE VITTAI ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED I/47 IT120.1 9
`7. Name and address of health provider or entity to release this information:
`If\ACeeert+ gfeeari Becieriefee 32.01 kill*-14.14ht,a-Tu
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`115eenteola404...1 t-1.1,1_ 43_
`IL Name and address of perscat(s) or category of person to Apt this inf (cid:9) Won will be sent:
`
`S)ilitd afiaiRibil eicrime6f-aRico%Nela (cid:9)
`9(a). (cid:9)
`- , e information to be released;
`1 1 1 I (cid:9) 2.C.4.2.0 (cid:9)
`to (insert date) (cid:9)
`-1 t t tc 2020
`
`" r edieal Record front (insert date) (cid:9) ,
`(excerpt psychotherapy notes), test results, radiology studies, films,
`.= Medical Record, including patient histones, office notes
`f le (cid:9)
`sent to you by other health care providers.
`referrals, consults, billing records, insurance records, and records
`pixelbo IA tokeP CAI I
`likelier: ln- It. (cid:9)
`Include: (Indicate by Initialing)
`Alcohol/Drug Treatment
`S (cid:9)
`Mental Health Information
`5. % (cid:9)
`KEV-Related Information
`g .S (cid:9)
`- ' " - (cid:9) —
`Name of individual health eare proveier
`Inirees (cid:9)
`to &sous my heal th information with my attorney, or a governmental agency, listed here:
`
`vo, (;rt, (2speroido-vslii NH' 14"-I tc ,
`
`Authorization to Discuss Henith Caen-manor] (cid:9)
`____. . .
`(h) U Ey initialing here (cid:9)
`I atithorize (cid:9)
`
`. (cid:9)
`- (cid:9)
`
`.
`- . (cid:9)
`
`.
`
`(Attorney/Ambler:re or Goveneneatal 4geney Name)
`11. Date or event on which this authorization will expire:
`TO. R k. on for release of information:
`70-40%e coviclusi tin a -4-ele CcS.FA'''
`• request of individual (cid:9)
`CI Other
`12. Ifnot the patient, name of person signing forrn:
`13. Authority to sign on behalf of patient:
`1\4044,%er 4- IA thr....11a4 Guar& a A
`e:1 (Parka St`a 0 i 06:70e‘,AQ
`All hems on this Corm have been con platedmy questions about this farm have been answered. In addition, I have been provided a
`copy of the farm.
`
`•
`
`Signatory of 'ant or representative authorized by law.
`Samna Immunodeficiency Virus that causes AIDS. The New York State Puldie Health Law protects information which reasonably amid
`identify someone as havingUIV symptoms or infection mid information regarding Si person's outride.
`
`Date: (cid:9)
`
`15 7-Ca()
`
`(cid:9)
`

`

`FILED: KINGS COUNTY CLERK 09/25/2020 04:42 PM
`NYSCEF DOC. NO. 6
`,Z.egfa:f.V..-gV.' ':..:NE7JW.429PnfP.'"Y'' •
`07. (cid:9)
`"
`
`INDEX NO. 518206/2020
`
`RECEIVED NYSCEF: 09/25/2020
`
`r••••••••• 7,10 -ekr
`
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`
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`44.411r114,_ (cid:9)
`*VI'40110 tt,11
`
`

`

`FILED: KINGS COUNTY CLERK 09/25/2020 04:42 PM
`NYSCEF DOC. NO. 6
`
`INDEX NO. 518206/2020
`
`RECEIVED NYSCEF: 09/25/2020
`
`Request Exception Notfication
`
`Mount Sinai Brooklyn
`3201 Kings Hwy
`Brooklyn NY 11234-2625
`
`From
`
`To
`
`SULLIVAN PAPAIN BLOCK ET AL
`120 BROADWAY
`NEW YORK NY 10271
`
`Re: Margarita Sidgiyayeva
`
`We are unable to comply with your request at this time for the following reason(s):
`
`1. MISSING REQUIRED OCA 960 AUTHORIZATION FORM
`2. MISSING DEATH CERTIFICATE
`3. MISSING LETTER OF ESTATE/ ADMIN
`PLEASE RESUBMIT YOUR REQUEST WITH THE REQUIRED DOCUMENTS FOR
`PROCESSING.
`
`Sincerely,
`
`Mount Sinai Brooklyn
`
`

`

`FILED: KINGS COUNTY CLERK 09/25/2020 04:42 PM
`NYSCEF DOC. NO. 6
`
`INDEX NO. 518206/2020
`
`RECEIVED NYSCEF: 09/25/2020
`
`
`SULLIVAN PAPAIN BLOCK (cid:9)
`MCGRATH COFFINAS & CANNAVO P.C.
`120 BROADWAY • NEW YORK • NEW YORK 10271
`TELEPHONE: (212) 732-9000
`FACSIMILE: (212) 266.4141
`SPBMC-NY41rj411 ms I
`TrialLaw I .com
`
`Christopher J. DelliCarpini
`Connor T. Hopkins
`Andrew W. Salomon
`Marianne C. Burke
`Johanna Carmona
`
`Beth N. Jablon
`Ina Pecani
`Mark A. Apostolos
`Eric C. Goldman
`Steve Fils-Aime
`R. Thomas Colonna
`Anthony P. Mattroianni
`Jessica P. Denninger
`Roger A. Frankel
`Elyssa Shifrcn
`
`Author's E-Mail Address:
`ri (cid:9)
`,o TrialLawl .com
`Direct Telephone Line:
`(212)266-4116
`Private Fax Line:
`(212) 266.4176
`
`Robert G. Sullivan
`Nicholas Papain
`Michael N. Block
`Christopher T. McGrath
`Vito A. Cannavo
`John F. Nash
`Frank V. Florituti
`Marie Ng
`37.1cni Cones
`David J. Dean
`
`Hugh M. Turk
`Albert B. Aquila
`Brian J. Shoot
`Mary Anne Walling
`Eric K. Schwarz
`Elizabeth Montesano
`Deanne M. Caputo
`Liza A. Milgrim
`Thomas J. McManus
`Glenn W. Nick
`
`Hon. Joseph N. Giamboi (1925-2018) John M. Tomsky
`Stephen C. Glasser (cid:9)
`Wendell Y. Tong
`James Wilkens (cid:9)
`Craig M. Silverman
`Paul F. Oliveri (cid:9)
`Mary Tierney
`Ofeoluttei (cid:9)
`Counsel to.the Firm
`
`Mount Sinai Brooklyn
`3201 Kings Highway
`Brooklyn, NY 11234
`Attn: Medical Records Dept
`
`PLEASE REPLY TO:
`
`New York City Office
`
`September 10, 2020
`
`Re: (cid:9)
`
`Patient
`DOB : (cid:9)
`: (cid:9)
`D/A (cid:9)
`
`Margarita Sidgiyayeva, deceased by her m/n/g Sayana Sidgiyayeva
`, 2002
`July 11, 2020
`
`Dear Sir/Madam:
`
`As previously advised in our correspondence dated August 13, 2020, we represent the above-named
`patient who is deceased. Our August 13th request for copies of the decedent's medical records was
`accompanied by HIPAA compliant authorization signed by the decedent's mother as well as a copy of the death
`certificate.
`
`Notwithstanding our proper request, we recently recei‘ ed a "Request Exception Notification" from you
`denying our request for copies of the decedent's medical records on the grounds that the request was, "missing
`letter of estate." The reason for your denial of our request is improper. CPLR §4504(c) provides that a medical
`provider shall be required to disclose any information as to the mental or physical condition of a deceased
`patient privileged under Subsection (a), except, . .when the privilege has been waived: (1) by the personal
`representative, or the surviving spouse, or the next-of-kin of the decedent.
`
`SUFFOLK OFFICE
`33105 Main Road. Catalogue. New Wel, 11935
`TELEPHONE: (631) 7344500 *FACSIMILE (031) 734.2502
`$PENIO•LISTrisllaw1 cam
`
`NASSAU OFF10E
`1140 Prenldia Avenue, Garden City, Now Yorl, 11530
`TELEPHONE (5101 742.:0707 • FACSIMILE 1511042-7350
`SEfildr.L18TrialLaw 1 Qui
`
`NEW JERSEY OFFICE
`2$ Maui Strew, suite 604 Natkatteak, New Jenny 07601
`TELEPHONE: (201) 342.0037 *FACSIMILE (201)342-6461
`grEMC.NnirrintLaw1
`
`(cid:9)
`(cid:9)
`

`

`FILED: KINGS COUNTY CLERK 09/25/2020 04:42 PM
`NYSCEF DOC. NO. 6
`
`INDEX NO. 518206/2020
`
`RECEIVED NYSCEF: 09/25/2020
`
`Re: Margarita Sidgiyayeva
`Page 2 of 2
`September 10, 2020
`
`The decedent's mother, as her next of kin, is legally authorized to direct you to release a copy of the
`decedent's medical records to our office. A "letter of estate" is not required under the law. Accordingly, please
`provide our office with a certified copy of the complete verbatim hospital record, including the ambulance call
`report, for the above-named patient within 10 days of the receipt of this letter. Your failure to do so will result
`in our filing a motion in court seeking judicial relief.
`
`Your prompt attention to this matter is greatly appreciated.
`
`Very truly yours,
`
`SULLIVAN PAPAIN BLOCK McGRATH
`
`COEFINAS it.CANNAVO:P C (cid:9)
`
`B :
`
`EKS
`(112795)
`
`