`
`—_—FLED: NEWV ‘o‘RK ”COUNTY cL'ERK'09 4-31—2617osiififlp’MV' M
`1me N01 150123/2016’
`INDEX NO. 150123/2016
`FILED: NEW YORK COUNTY CLERK 09/13/2017 03:17 PM
`
`
`
`
`
`
`
`NYSCEF DOC. NO. 24
`RaCaIVaD VYSCEF: 09/13/2017
`NYSCEF DOC. NO. 24
`RECEIVED NYSCEF: 09/13/2017
`
`EXHIBIT K
`
`

`

`FILED: NEW YORK COUNTY CLERK 09/13/2017 03:17 PM
`FILED: NEW YORK COUNTY CLERK 09m2017 03:17 PM
`
`NYSCEF DOC. NO. 24
`NYSCEF DOC. NO. 24
`
`150123/2016
`INDEX NO. 150123/2016
`INDEX NO~
`
`
`
`
`
`RfiCfiIVfiD VYSCEF:
`09/13/2017
`RECEIVED NYSCEF: 09/13/2017
`
`
`
`SUPREME COURT OF THE STATE OF NEW YORK
`COUNTY OF NEW YORK
`
`MANUELAMENDOEIRA £11111 MARIA AMENDOERIA
`
`Index No.: 150123/2016
`
`Plaintiffs,
`
`-against—
`
`CITY OF NEW YORK, NEW YORK CITY TRANSIT
`AUTHORITY and the METROPOLITAN
`
`TRANSPORTATION AUTHORITY,
`
`COUNSELORS:
`
`Defendants.
`
`PLAINTIFFS’ RESPONSE
`
`TO COMPLIANCE
`CONFERENCE ORDER
`5
`5 DATED JANUARY 3, 2017
`
`In response to the Compliance Conference Order dated January 3, 2017 the following is
`
`annexed hereto:
`
`. Authorization for the release of records from MagnaCare - Headquarters:
`One Penn Plaza, 46th Floor, New York, NY 10119; Member ID #:
`276000441292, and Empire Plan BlueCross BlueShield, 15 Metro Tech
`Center, 6th Fl., Brooklyn, NY 11201; ID#: PGY89487848.
`
`Authorization for the release of records from Laborers’ International
`Union of North America, 905 16th Street, Northwest, Washington, DC
`20006; Member No.2 4730262.
`
`. Primary Care Physician: Dr. Keith Apuzzo. Authorization previously
`provided in Plaintiffs’ Response to Discovery Demands dated August 26,
`20 1 6.
`
`. Copy of Plaintiffs marriage certification.
`
`. Copy of Plaintiff’s passport.
`
`. Dr. Alex Garcia: There is no doctor by this name. Annexed hereto is a
`copy of Plaintiff” s executed 50H Transcript.
`
`. MRI Facilities: Authorizations for the release of records from New York
`Spine Institute Imaging Center, 761 Merrick Avenue, Westbury, New
`York 11590 and Stand-Up MRI of Carl Place, PC, 31 Old Country Road,
`Car Place, NY 11514.
`
`. Authorization for the release of pharmacy records from Walgreens Store
`#13961, 12 E Jericho Turnpike, Mineola, New York 11501.
`
`. Psychiatrist: Dr. Vilor Shpitalnik, MD PhD, Authorization previously
`provided in Plaintiffs’ Response to Discovery Demands dated August 26,
`20 1 6.
`
`

`

`FILED: NEW YORK COUNTY CLERK 09/13/2017 03:17 PM
`FILED: NEW YORK COUNTY CLERK 09m2017 03:17 PM
`
`NYSCEF DOC. NO. 24
`NYSCEF DOC. NO. 24
`_
`
`
`
`INDEX NO. 150123/2016
`INDEX NO~ 150123/2016
`
`
`
`
`
`RECEIVED NYSCEF: 09/13/2017
`RaCaIVaD VYSCEF: 09/13/2017
`
`10. Physical therapy records: New York Spine Institute, previously provided
`in Plaintiffs’ Response to Discovery Demands dated August 26, 2016.
`
`11. Portuguese Club member: Authorization for the release of attendance
`records from Mineola Portuguese Center, Inc., 306 Jericho Turnpike,
`Mineola, New York, 11501.
`
`RESPONSE TO NOTICE FOR DISCOVERY AND INSPECTION
`
`1. Annexed hereto is a copy of Plaintiff’ s executed 5 0H Transcript.
`
`2. Previously provided in Plaintiffs’ Response to Discovery Demands and in this Response
`to Compliance Conference Order dated January 3, 2017.
`
`3. Previously provided in Plaintiffs’ Response to Discovery Demands and in this Response
`to Compliance Conference Order dated January 3, 2017.
`4. Objection to the request for Plaintiffs’ tax records and authorizations. Annexed hereto is
`the release of employment records limited to salary and attendance: EE Cruz and Tully
`Construction, 1850 2nd Ave, New York, NY 10128.
`
`5. Please see response to number 4.
`
`6. Please see response to number 4.
`
`7. Annexed hereto is color copies of all photographs plaintiff is in plaintiffs’ possession
`related to this accident.
`
`8. Plaintiffs are not presently aware of any witnesses at this time. However, should plaintiff
`learn of any witnesses, the proper information will be exchanged pursuant to the
`provisions of the CPLR.
`9. Request for medical records 5 years prior to the date of accident is not applicable. Please
`see response to number 2 and 3.
`
`10. Previously provided in Plaintiffs’ Response to Discovery Demands and in this Response
`to Compliance Conference Order dated January 3, 2017.
`
`11. Annexed hereto is an original Workers’ Compensation authorization signed by Plaintiff,
`and an authorization for the release of records from AIG Domestic Claims, PO Box 1822,
`Alpharetta, GA 30023; WCB#: WC36789-11.
`
`12. To be provided at the time of pre-trial discovery proceedings.
`
`Dated: New York, New York
`January 19, 2017
`
`MARC J. BERN & PARTNERS, LLP
`
`Attorneys for Plaintifl
`
`
`
`.
`
`-
`By:
`
`Erica C. Stapleton,
`sq.
`60 E 42nd Street, Suite 950
`New York, New York 10165
`T: (212) 702-5000
`
`

`

`FILED: NEW YORK COUNTY CLERK 09/13/2017 03:17 PM
`FILED: NEW YORK COUNTY CLERK 09m2017 03:17 PM
`
`NYSCEF DOC. NO. 24
`NYSCEF DOC. NO. 24
`
`INDEX NO. 150123/2016
`INDEX NO~ 150123/2016
`
`
`
`
`
`RaCaIVaD VYSCEF: 09/13/2017
`RECEIVED NYSCEF: 09/13/2017
`
`
`
`TO:
`
`LANDMAN, CORSI, BALLAINE & FORD, P.C.
`Attorneysfor Defendants
`120 Broadway, 27th Floor
`New York, New York 10271-0079
`
`(212) 238-4800
`
`

`

`FILED: NEW YORK COUNTY CLERK 09/13/2017 03:17 PM
`FILED: NEW YORK COUNTY CLERK 09312017 03:17 PM
`
`NYSCEF DOC. NO. 24
`
`NYSCH‘_.OC. NO. 24
`
`
`
`INDEX NO. 150123/2016
`INDEX NO- 150123/2016
`
`
`
`
`
`RECEIVED NYSCEF: 09/13/2017
`RaCaIVaD VYSCEF: 09/13/2017
`OCA Official Form No.: 960
`
`
`
`Q
`
`
`
`AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
`
`
`
`[This form has been approved by the New York State Department of Health]
`
`
`
`Patient Name .
`Manuel Amendoeira
`Patient Address
`
`Date of Birth
`1959
`
`
`
`Social Security Number
`-4149
`
`
`
`
`
`—Mineola, New York 11501
`
`
`
`I, or my authorized representative, request that health information regarding my care and treatment be 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
`(HIPAA),
`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 if I place my initials 0n
`the appropriate line in Item 9(a).
`In the event the health information described below includes any of these types of information, and 1
`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.
`2. If I am authorizing the release of HIV—related, alcohol or drug treatment, or mental health treatment information, the recipient is
`prohibited from redisclosing 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 of people who may receive or use my HIV-related information without authorization. If
`I experience discrimination because of the release or disclosure 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 Human Rights at (212) 306-7450. These agencies are
`responsible for protecting my rights.
`3.
`I have the right to revoke this authorization at any time by writing to the health care provider listed below.
`revoke this authori7ation 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 rediselosed by the recipient (except as noted above in Item 2), and this
`redisclosure may no longer be protected by federal or state law.
`6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY IIEALTH INFORMATION OR MEDICAL
`CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 b .
`
`I understand thatl may
`
`
`
`7. Name and address of health provider or entity to release this information:
`MagnaCare - Headquarters: One Penn Plaza, 46th Floor, New York, NY 10119
`
`
`
`8. Name and address of person(s) or category of person to whom this information will be sent:
`
`
`Landman, Corsi, Ballaine & Ford, P.C., 120 Broadway, 27th FL, New York, NY 10271-0079
`
`
`
`9(a). Specific information to be released:
`
`
`to (insert date)
`Cl Medical Record from (insert date)
`
`
`
`C] 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: Collateral Source Records:
`.
`lude: (Indicate by Initialing)
`1/31/15-Present; ID#:276000441292
`Alcohol/Drug Treatment
`Mental Health Information
`HIV-Related Information Authorization to Discuss Health Information
`
` (b) C] By initialing here
`I authorize
`to discuss my health information with my attorney, or a governmental agency, listed here:
`
`
`
`
`
`
`
`Initials
`
`Name of individual health care provider
`
`Attome lFirm Name or Governmental A one Name
`
`
` 10. Reason for release of information:
`
`11. Date or event on which this authorization will expire:
`
`C] At request of individual
`
`
`
`[2 Other: Litigation
`To the end of litigation.
`
`
`
`
`13. Authority to sign on behalf of patient:
`12. If not the patient, name of person signing form:
`Erica C. Stapleton, Esq. - Marc J. Bern & Partners, LLP Power of Attorney
`
`
`
`All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a
`copy of the form.
`
`
`
`lgnature of patient or representative authorized by law.
`
`Date:
`
`l
`
`l
`
`Tl
`
`
`
`* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could
`identify someone as having HIV symptoms or infection and information regarding a person's contacts.
`
`

`

`FILED: NEW YORK COUNTY CLERK 09/13/2017 03:17 PM
`FILED: NEW YORK COUNTY CLERK 09312017 03:17 PM
`
`NYSCH .-ec. NO. 24
`NYSCEF DOC. NO. 24
`‘
`
`
`
`INDEX NO. 150123/2016
`INDEX NO- 150123/2016
`
`
`
`
`
`RnCnIVnD VYSCEF: 09/13/2017
`RECEIVED NYSCEF: 09/13/2017
`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 ofHealthl
`
`Patient Name
`Manuel Amendoeira
`
`Date of Birth
`.959
`
`Social Security Number
`-149
`
`
`Patient Address ineola, New York 11501
`
`I, or my authorized representative, request that health information regarding my care and treatment be 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
`(HIPAA),
`I understand that:
`1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL IIEALTH
`TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I 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 information, and I
`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.
`2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
`prohibited fi‘om redisclosing 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 of people who may receive or use my HIV-related information without authori7ation. If
`I experience discrimination because of the release or disclosure of I-HV-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 for protecting my rights.
`3.
`I have the right to revoke this authorization at any time by writing to the health care provider listed below.
`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 no longer be protected by federal or state law.
`6. THIS AUTHORIZATION DOES NOT AUTIIORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
`CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 b .
`
`I understand that I may
`
`7. Name and address of health provider or entity to release this information:
`Empire Plan BlueCross BIueShieId, 15 Metro Tech Center, 6th FL, Brooklyn, NY 11201
`
`8. Name and address of person(s) or category of person to whom this information will be sent:
`Landman, Corsi, Ballaine & Ford, RC, 120 Broadway, 27th FL, New York, NY 10271-0079
`
`
`
`
`
`9(a). Specific information to be released:
`to (insert date)
`CI Medical Record from (insert date)
`Cl 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.
`(2 Other: Collateral Source Records:
`Include: (Indicate by Initialing)
`1/31/15-Present;ID#:PGY89487848
`Alcohol/Drug Treatment
`Mental Health Information
`
`
`
`Authorization to Discuss Health Information
`
`(b) Cl By initialing here
`
`I authorize
`
`HIV-Related Information
`
`
`Name of individual health care provider
`Initials
`to discuss my health information with my attorney, or a governmental agency, listed here:
`
`Attorne /Firm Name or Governmental A _enc Name
`11. Date or event on which this authorization will expire:
`
`
`10. Reason for release of information:
`CI At request of individual
`
`
`To the end of litigation.
`[2] Other: Litigation
`13. Authority to sign on behalf of patient:
`12. If not the patient, name of person signing form:
`Erica C. Stapleton, Esq. - Marc J. Bern & Partners, LLP Power of Attorney
`All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a
`copy of the form.
`
`
`Signature of patient or representa ve authorize
`
`Q,
`
`
`
`
`y law.
`
`Date:
`
`I
`
`l ‘0' S S’q‘
`
`* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could
`identify someone as having HIV symptoms or infection and information regarding a person’s contacts.
`
`

`

`FILED: NEW YORK COUNTY CLERK 09/13/2017 03:17 PM
` FILED: NEW YORK COUNTY CLERK 09m2017 03:17 PM
`
`NYSCEF DOC. NO. 24
`flshc. NO. 24
`
`
`
`INDEX NO. 150123/2016
`INDEX NO- 150123/2016
`
`
`
`
`
`RECEIVED NYSCEF: 09/13/2017
`R«.C«.IV«.D \IYSCEF: 09/13/2017
`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]
`
`
`— Mineola, New York 11501
`
`Patient Name
`Manuel Amendocira
`Patient Address
`
`Date of Birth
`-1959
`
`Social Security Number
`-149
`
`I, or my authorized representative, request that health information regarding my care and treatment be 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
`(HIPAA),
`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 if I 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 information, and I
`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.
`2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
`prohibited from redisclosing 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 of people who may receive or use my HIV-related information without authorization. If
`I experience discrimination because of the release or disclosure 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 Human Rights at (212) 306-7450. These agencies are
`responsible for protecting my rights.
`3.
`I have the right to revoke this authorization at any time by writing to the health care provider listed below.
`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 no longer be protected by federal or state law.
`6. TIIIS 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 .
`
`I understand that I may
`
`
`
`7. Name and address of health provider or entity to release this information:
`New York Spine Institute Imaging Center, 761 Merrick Avenue, Westbury, New York 11590
`
`
`
`8. Name and address of person(s) or category of person to whom this information will be sent:
`
`
`Landman, Corsi, Ballaine & Ford, P.C., 120 Broadway, 27th FL, New York, NY 10271-0079
`
`9(a). Specific information to be released:
`
`
`Medical Record from (insert date) 1/31/15
`to (insert date) Present.
`
`
`Cl 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.
`Cl Other:
`elude: (Indicate by Initialing)
`
`
`
`
` (b) D By initialing here
`
`
`Authorization to Discuss Health Information
`
`I authorize
`
`Initials
`
`Alcohol/Drug Treatment
`Mental Health Information
`
`HIV-Related Information
`
`
`Name of individual health care provider
`
`to discuss my health information with my attorney, or a governmental agency, listed here:
`
`Attorne /Firm Name or Governmental Aene Name
`
`10. Reason for release of information:
`
`
`11. Date or event on which this authorization will expire:
`
`Cl At request of individual
`
`
`
`To the end of litigation.
`[21 Other: Litigation
`
`
`13. Authority to sign on behalf of patient:
`12. If not the patient, name of person signing form:
`
`
`
`Erica C. Stapleton, Esq. - Marc J. Bern & Partners, LLP Power of Attorney
`
`All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a
`co y of the form.
`
`M Date:
`
`’lllclSll
`
`
`
`Signature of patient or representative authorized by law.
`
`* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could
`identify someone as having HIV symptoms or infection and information regarding a person’s contacts.
`
`

`

`FILED: NEW YORK COUNTY CLERK 09/13/2017 03:17 PM
`FILED: NEW YORK COUNTY CLERK 09312017 03:17 PM
`
`NYSCH
`C. NO. 24
`NYSCEF DOC. NO. 24
`
`
`
`
`INDEX NO. 150123/2016
`INDEX NO- 150123/2016
`
`
`
`
`
`RaCaIVaD VYSCEF: 09/13/2017
`RECEIVED NYSCEF: 09/13/2017
`OCA Official Form No.: 960
`
`
`
`' AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
` c.—
`[This form has been approved by the New York State Department of Health]
` Patient Name
`
`Date of Birth
`Social Security Number
`
`Manuel Amendoeira
`-1959
`
`
`
`Patient Address
`
`
`
`
`— Mineola, New York 11501
`
`-4l49
`
`I, or my authorized representative, request that health information regarding my care and treatment be 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
`(HIPAA),
`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 if I 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 information, and I
`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.
`2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
`prohibited from redisclosing 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 of people who may receive or use my HIV-related information without authorization. If
`I experience discrimination because of the release or disclosure 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 Human Rights at (212) 306-7450. These agencies are
`responsible for protecting my rights.
`3.
`I have the right to revoke this authorization at any time by writing to the health care provider listed below.
`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 no longer be protected by federal or state law.
`6. TIIIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
`CARE WlTl-I ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 b .
`
`I understand that I may
`
`
`
`
`
`
`
`7. Name and address of health provider or entity to release this information:
`Stand-Up MRI of Carl Place, PC, 31 Old Country Road, Car Place, NY 11514
`
`8. Name and address of person(s) or category of person to whom this information will be sent:
`Landman, Corsi, Ballaine & Ford, P.C., 120 Broadway, 27th FL, New York, NY 10271-0079
`
`9(a). Specific information to be released:
`
`
`El Medical Record from (insert date) “31/15
`to (insert date) Present.
`
`
`
`Cl 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.
`Cl Other:
`I
`ude:
`Indicate by Initialing)
`
`
`
`
`
`Alcohol/Drug Treatment
`Mental Health Information
`
`
`
`HIV-Related Information Authorization to Discuss Health Information
`
`
` (b) CI By initialing here
`I authorize
`
`
`Name of individual health care provider
`Initials
`to discuss my health information with my attorney, or a governmental agency, listed here:
`
`
`Attome /Firm Name or Govemmental A enc Name
`
`10. Reason for release of information:
`11. Date or event on which this authorization will expire:
`
`
`
`Cl At request of individual
`
`
`
`12] Other: Litigation
`To the end of litigation.
`
`13. Authority to sign on behalf of patient:
`[2. If not the patient, name of person signing form:
`
`
`Erica C. Stapleton, Esq. - Marc J. Bern & Partners, LLP Power of Attorney
`All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a
`co y of the form.
`
`
`
`
`1g ature 0 patient or represen tive authorize by law.
`
`Date:
`
`
`
`l
`
`‘ lol II
`
`i
`
`
`
`* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could
`identify someone as having HIV symptoms or infection and information regarding a person’s contacts.
`
`

`

`FILED: NEW YORK COUNTY CLERK 09/13/2017 03:17 PM
`FILED: NEW YORK COUNTY CLERK 09m2017 03:17 PM
`
`NYSCEF DOC. NO. 24
`NYSCI
`lug-C. NO. 24
`
`7
`
`
`
`INDEX NO. 150123/2016
`INDEX NO- 150123/2016
`
`
`
`
`
`RECEIVED NYSCEF: 09/13/2017
`R«.C«.IV«.D \IYSCEF: 09/13/2017
`OCA Official Form No.: 960
`
`
`
`
`
`
`. AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
`V
`”er cm
`
`[This form has been approved by the New York State Department of Health]
`
` Patient Name
`
`Manuel Amendoeira
`Patient Address
`
`Date of Birth
`-1959
`
`—Vlineola, New York 11501
`
`
`
`Social Security Number
`-4149
`
`I understand that I may
`
`
`
`
`
`I, or my authorized representative, request that health information regarding my care and treatment be 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
`(HIPAA),
`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 IIIV* RELATED INFORMATION only if I place my initials on
`the appropriate line in Item 9(a). 1n the event the health information described below includes any of these types of information, and 1
`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.
`2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
`prohibited from redisclosing 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 of people who may receive or use my HIV-related information without authorization. If
`I experience discrimination because of the release or disclosure 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 Human Rights at (212) 306-7450. These agencies are
`responsible for protecting my rights.
`3.
`I have the right to revoke this authorization at any time by writing to the health care provider listed below.
`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 no 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 h .
`
`7. Name and address of health provider or entity to release this information:
`Walgreens Store #13961, 12 E Jericho Turnpike, Mineola, New York 11501
`8. Name and address of person(s) or category of person to whom this information will be sent:
`Landman, Corsi, Ballaine & Ford, RC, 120 Broadway, 27th FL, New York, NY 10271-0079
`
`
`
`
`
`
`
`
`9(a). Specific information to be released:
`
`
`to (insert date)
`Cl Medical Record from (insert date)
`Cl 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.
`(2] Other: Pharmacy records: 1/31/15 to
`.tscludc; (Indicate by [nitialing)
`
`
`Present.
`Alcohol/Drug Treatment
`Mental Health Information
`
`
`Authorization to Discuss Health Information
`HIV-Related Information
`
` I authorize
`
`Initials
`Name of individual health care provider
`
`to discuss my health information with my attorney, or a governmental agency, listed here:
`
`
`Attorne /Firm Name or Governmental A enc Name
`
`
`11. Date or event on which this authorization will expire:
`10. Reason for release of information:
`
`
`[3 At request of individual
`
`
`
`
`To the end of litigation.
`[21 Other: Litigation
`
`
`
`
`12. If not the patient, name of person signing form:
`
`
`Erica C. Stapleton, Esq. - Marc J. Bern & Partners, LLP Power of Attorney
`
`All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a
`copy of the form.
`'
`
`
`
`Signature 0 p tient or representati e authorized by law.
`
`
`
`-
`
`(b) Cl By initialing here
`
`13. Authority to sign on behalf of patient:
`
`* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could
`identify someone as having HIV symptoms or infection and information regarding a person’s contacts.
`'
`
`
`
`

`

`FILED: NEW YORK COUNTY CLERK 09/13/2017 03:17 PM
`FILED: NEW YORK COUNTY CLERK 09312017 03:17 PM
`
`NYSCEF DOC. NO. 24
`Nyscaflmc. NO. 24
`7
`
`
`
`INDEX NO. 150123/2016
`INDEX NO- 150123/2016
`
`
`
`
`
`RECEIVED NYSCEF: 09/13/2017
`R«.C«.IV«.D \IYSCEF: 09/13/2017
`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]
`
`
`— Mineola, New York 11501
`
`Patient Name
`Manuel Amendoeira
`Patient Address
`
`Date of Birth
`-1959
`
`Social Security Number
`-4149
`
`I, or my authorized representative, request that health information regarding my care and treatment be 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
`(HIPAA),
`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 if I 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 information, and I
`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.
`2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
`prohibited from redisclosing 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 of people who may receive or use my HIV-related information without authorization. If
`I experience discrimination because of the release or disclosure 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 Human Rights at (212) 306-7450. These agencies are
`responsible for protecting my rights.
`3.
`I have the right to revoke this authorization at any time by writing to the health care provider listed below.
`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 no longer be protected by federal or state law.
`6. THIS AUTHORIZATION DOES NOT AUTIIORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
`CARE WITH ANYONE OTHER TIIAN TIIE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 b .
`
`
`I understand that] may
`
`7. Name and address of health provider or entity to release this information:
`Mineola Portuguese Center, Inc., 306 Jericho Turnpike, Mineola, New York, 11501
`8. Name and address of person(s) or category of person to whom this information will be sent:
`Landman, Corsi, Ballalne & Ford, P.C., 120 Broadway, 27th FL, New York, NY 10271-0079
`
`9(a). Specific information to be released:
`to (insert date)
`13 Medical Record from (insert date)
`Cl Entire Medical Record, including patient histories, office notes (except p