FILED: NEW YORK COUNTY CLERK 10/09/2024 01:04 PM
`NYSCEF DOC. NO. 7
`
`INDEX NO. 156397/2024
`
`RECEIVED NYSCEF: 10/09/2024
`
`Supreme Court of The Stote of NewYork
`County of NewYork
`BRYCECLARKE,
`
`Plaintiffs'
`
`- against
`
`-
`
`THECITY OFNEWYORK,POLICEOFFICERVINCENT
`J. FULGIERIANDPOLICEOFFICER"JOHN DOE"
`( FICTITIOUS NAME,REALNAMEUNKNOWN)
`
`Defendants.
`
`i
`
`Index No. 156397/2024
`RESPONSETO
`DEMAND
`
`S I R/MADAM:
`PLEASE TAKE NOTICE that
`ROONEY, as and for
`compliance with
`
`his
`
`the
`
`Plaintiff,
`
`by her Attorney, SEAN H.
`the Preliminary
`Conference Order,
`upon
`
`information
`
`alleges:
`
`and belief,
`DEMANDFORNAMESANDADDRESSESOFWITNESSES:
`FIRST: The Plaintiff
`in possession of witness information
`is not
`DEMANDFORSTATEMENTS:
`SECOND:Plaintiff
`in possession of any statement.
`is not
`DEMANDFORPHOTOGRAPHS:
`THIRD: None.
`DEMANDFORREPORTSIN THEUSUALCOURSEOFBUSINESS:
`FOURTH:None.
`DEMANDFORCOLLATERALSOURCEAUTHORIZATION:
`FIFTH: Attached hereto is a duly executed Collateral
`Source authorization
`obtain the Plaintiff's
`Medical
`records from the following:
`
`at this time.
`
`to
`
`1 of 8
`
`

`

`FILED: NEW YORK COUNTY CLERK 10/09/2024 01:04 PM
`NYSCEF DOC. NO. 7
`
`INDEX NO. 156397/2024
`
`RECEIVED NYSCEF: 10/09/2024
`
`providers:
`
`Plaintiff's
`
`providers:
`
`to obtain
`
`Jeffrey
`
`to obtain the
`
`EmblemHealth;
`ID # K6097073001
`DEMANDFORMEDICALRECORDS:
`SIXTH: Attached hereto are the Plaintiff's
`medical records from the following
`Jeffrey Schildhorn, MD.
`DEMANDFORMEDICALAUTHORIZATIONS:
`SEVENTH:Attached hereto are duly executed HIPAAauthorizations
`medical records from the following
`Northwell Health,
`Schildhorn, MDand Lenox Hill Radiology.
`DEMANDFORHOSPITALAUTHORIZATIONS:
`EIGHTH: Attached hereto is a duly executed Hippa Authorization
`records from the following
`provider: Northwell Health
`
`Plaintiff's
`
`hospital
`
`( Hospital)
`
`DEMANDFORINFORMATIONREGARDINGEXPERTS:
`NINTH: Plaintiff
`has not
`any expert witnesses as of this time except:
`retained
`of each person whomyou expect
`a. The identity
`as an expert
`to call
`witness at
`the persons whose reports
`are provided
`trial:
`in
`response to the demandfor medical
`reports.
`b. A disclosure
`in reasonable detail of the subject matter on which each
`As set
`expert
`is expected to testify:
`forth
`in their medical
`reports.
`
`c. The substance of
`the facts and opinions
`As set
`expected to testify:
`forth
`
`on which each expert
`in their medical
`reports.
`
`is
`
`d. The qualifications
`of
`each expert
`The
`witness:
`licensing
`requirements by the state for each person's
`area of practice,
`of experience
`each person has had in
`the
`years
`their
`and the continuing
`respective
`practices
`educational
`courses
`taken by said persons
`requirements were
`since
`licensing
`completed.
`
`-2-
`
`2 of 8
`
`

`

`FILED: NEW YORK COUNTY CLERK 10/09/2024 01:04 PM
`NYSCEF DOC. NO. 7
`
`INDEX NO. 156397/2024
`
`RECEIVED NYSCEF: 10/09/2024
`
`e. A summaryof the grounds for each experts
`The
`opinion:
`care and treatment of BRYCECLARKE
`examinations,
`
`f. Plaintiffs
`
`provide
`will
`details
`when any are retained.
`
`regarding
`
`any further
`
`experts
`
`if and
`
`Dated: Brooklyn, NewYork
`October 09, 2024
`
`Yours etc,
`
`The Law Office of
`SEANH. ROONEY
`for Plaintiff
`Attorney
`Office and P.O. Address
`26 Court Street, Suite 1816
`Brooklyn, NY11242
`(718) 243-2168
`
`10:
`MURIELGOODE-TRUFANT
`for Defendants
`Attorneys
`THECITY OFNEWYORK
`100 Church Street,
`NewYork, NY10007
`
`-3-
`
`3 of 8
`
`

`

`FILED: NEW YORK COUNTY CLERK 10/09/2024 01:04 PM
`NYSCEF DOC. NO. 7
`
`INDEX NO. 156397/2024
`
`RECEIVED NYSCEF: 10/09/2024
`OCAOfficial
`Form No.: 960
`AUTHORIZATIONFORRELEASEOFHEALTHINFORMATIONPURSUANTTOHIPAA
`[This form has been approved by the NewYork State Department of Health]
`Date of Birth
`12/08/1990
`
`Social Security Number
`
`representative,
`
`request
`
`that health
`
`relating
`
`to release this
`
`information:
`
`9(a).
`
`Specific
`
`information
`
`form:
`
`is
`I
`
`If
`
`below.
`
`I understand that
`
`I may
`
`plan,
`
`or eligibility
`
`for
`
`(except
`
`studies,
`
`films,
`
`Patient Name
`BRYCECLARKE
`Patient Address
`536 W. 111th Street, NewYork, NY10025
`I, or my authorized
`regarding my care and treatment be released as set
`information
`forth on this
`In accordance with NewYork State Law and the Privacy Rule of the Health Insurance Portability
`and Accountability
`Act of 1996
`1 understand that:
`(HIPAA),
`to ALCOHOLand DRUGABUSE, MENTALHEALTH
`1. This authorization may include disclosure
`of
`information
`TREATMENT,except psychotherapy notes, and CONFIDENTIALHIV* RELATEDINFORMATIONonly if
`I place my initials
`on
`line in Item 9(a).
`In the event the health
`the appropriate
`information
`described below includes
`any of these types of
`and I
`information,
`the line on the box in Item 9(a),
`release of such information to the person(s)
`authorize
`initial
`in Item 8.
`I specifically
`indicated
`I am authorizing
`the release of HIV-related,
`or mental health
`treatment
`alcohol
`or drug treatment,
`2.
`If
`the recipient
`information,
`such information without my authorization
`from redisclosing
`prohibited
`unless permitted to do so under
`federal
`or
`law.
`state
`to request a list of people whomayreceive or use my HIV-related
`understand that
`I have the right
`information without authorization.
`the NewYork State Division
`I experience discrimination
`because of the release or disclosure
`of HIV-related
`I maycontact
`information,
`(212) 480-2493 or the NewYork City Commission of HumanRights at
`of HumanRights at
`(212) 306-7450.
`These agencies are
`for protecting myrights.
`responsible
`I have the right
`to revoke this
`at any time by writing
`authorization
`to the health care provider
`3.
`listed
`revoke this authorization
`except
`that action has already been taken based on this authorization.
`to the extent
`is voluntary. My treatment,
`I understand that
`authorization
`in a health
`payment, enrollment
`4.
`this
`signing
`not be conditioned upon myauthorization
`benefits will
`of this disclosure.
`Information
`under
`might be redisclosed
`disclosed
`authorization
`as noted above in
`5.
`Item 2), and this
`by the recipient
`this
`redisclosure mayno longer be protected
`by federal or state
`law.
`6. THIS AUTHORIZATIONDOESNOTAUTHORIZEYOUTODISCUSSMYHEALTHINFORMATIONORMEDICAL
`CAREWITHANYONEOTHERTHANTHEATTORNEYORGOVERNMENTALAGENCYSPECIFIED IN ITEM 9 (b).
`7. Nameand address of health provider or entity
`Jeffrey Schildhorn, MD..521 Park Avenue, Suite 1, NewYork, NY10065
`8. Nameand address of person(s)
`or category of person to whomthis
`information will be sent:
`MURIELGOODE-TRUFANT.The City of NewYork. 100 Church Street, NewYork, NY10007
`to be released:
`OMedical Record from (insert
`date) Present
`date) 06/22/2023
`OEntire Medical Record,
`to (insert
`notes (except psychotherapy notes),
`patient
`office
`including
`test
`histories,
`radiology
`results,
`to you by other health care providers.
`insurance records, and records
`consults,
`sent
`billing
`records,
`referrals,
`films &records pertaining
`El Other: Medical
`Include:
`(Indicate
`by Initialing)
`to accident
`06/22/2023
`f3C
`C Mental Health Information
`Treatment
`Alcohol/Drug
`C HIV-Related
`
`Information
`
`Authorization
`to Discuss Health Information
`(b) OBy initialing
`here
`I authorize
`Nameof individual
`to discuss myhealth information with myattorney,
`or a governmental agency,
`listed
`(Attorney/Firm Nameor Govemmental Agency Name)
`9
`o
`11. Date or event on which t1
`hthoriz
`gg Wil
`coa . poo
`ome*
`At the end of litigation
`to sign on behalf or;Ïatient:
`13. Authority
`
`Initials
`
`care provider
`
`health
`here:
`
`10. Reason for
`release of information:
`OAt
`request of individual
`Legal Matter
`El Other:
`name of person signing
`If not the patient,
`
`12.
`
`form:
`
`e
`p
`
`form have been completed and myquestions
`
`about this
`
`form have been answered.
`
`In addition,
`
`I have been provided a
`
`items on this
`All
`copy of the form.
`CC
`SignaÓe of patient
`or representative
`by law.
`authorized
`* HumanImmunodeficiency Virus that causes AIDS. The NewYork State Public Health Lawprotects
`someone as having HIV symptoms or infection
`and information
`regarding a person's
`contacts.
`
`identify
`
`information
`
`which reasonably
`
`could
`
`Date:
`
`4 of 8
`
`

`

`FILED: NEW YORK COUNTY CLERK 10/09/2024 01:04 PM
`NYSCEF DOC. NO. 7
`
`INDEX NO. 156397/2024
`
`RECEIVED NYSCEF: 10/09/2024
`OCAOfficial
`Form No.: 960
`AUTHORIZATIONFORRELEASEOFHEALTHINFORMATIONPURSUANTTOHIPAA
`[This form has been approved by the NewYork State Department of Health]
`Date of Birth
`12/08/1990
`
`Social Security Number
`
`representative,
`
`form:
`
`relating
`
`information:
`
`Patient Name
`BRYCECLARKE
`Patient Address
`536 W. 111th Street, NewYork, NY10025
`I, or my authorized
`information regarding mycare and treatment be released
`request
`forth on this
`that health
`as set
`In accordance with NewYork State Law and the Privacy Rule of the Health Insurance Portability
`and Accountability
`Act of 1996
`I understand that:
`(HIPAA),
`to ALCOHOLand DRUGABUSE, MENTALHEALTH
`1. This authorization may include disclosure
`of
`information
`TREATMENT,except psychotherapy notes, and CONFIDENTIALHIV* RELATEDINFORMATIONonly if
`I place my initials
`on
`in Item 9(a).
`In the event the health
`the appropriate
`information
`below includes
`any of these types of information,
`line
`described
`and I
`the line on the box in Item 9(a),
`release of such information to the person(s)
`initial
`authorize
`in Item 8.
`I specifically
`indicated
`I am authorizing
`the release of HIV-related,
`If
`or mental health
`treatment
`2.
`alcohol
`or drug treatment,
`the recipient
`information,
`is
`from redisclosing
`such information without my authorization
`unless permitted
`to do so under
`prohi'oited
`federal
`or
`law.
`state
`I
`a list of people whomayreceive
`understand that
`I have the right
`or use my HIV-related
`to request
`information without authorization.
`If
`the NewYork State Division
`I experience discrimination
`because of the release or disclosure
`I maycontact
`of HIV-related
`information,
`(212) 480-2493 or the NewYork City Commission of HumanRights at
`of HumanRights at
`(212) 306-7450.
`These agencies are
`for protecting my rights.
`responsible
`I have the right
`to revoke this
`at any time by writing
`to the health care provider
`authorization
`3.
`listed
`revoke this authorization
`except
`to the extent
`that action has already been taken based on this authorization.
`is voluntary. My treatment,
`I understand that signing this
`payment, enrollment
`in a health
`4.
`authorization
`not be conditioned upon myauthorization
`of this disclosure.
`benefits
`will
`Information
`under
`might be redisclosed
`disclosed
`authorization
`(except as noted above in Item 2), and this
`5.
`by the recipient
`this
`redisclosure mayno longer be protected
`by federal
`or state
`law.
`6. THIS AUTHORIZATIONDOESNOTAUTHORIZEYOUTO DISCUSS_MYHEALTHINFORMATIONORMEDICAL
`CAREWITHANYONEOTHERTHANTHEATTORNEYORGOVERNMENTALAGENCYSPECIFIED IN ITEM 9 (b).
`7. Nameand address of health provider or entity
`to release this
`Northwell Health. Lenox Health Greenwich V(age. 30 7th Avenue, NewYork, NY10011
`8. Nameand address of person(s)
`or category of person to whomthis
`information will be sent:
`MURIELGOODE-TRUFANT. The City of NewYork. 100 Church Street, NewYork, NY10007
`information to be released:
`OMedical Record from (insert
`date) Present
`date) 06/22/2023
`to (insert
`OEntire Medical Record,
`including patient
`office
`notes (except psychotherapy notes),
`test
`histories,
`radiology
`results,
`insurance records, and records
`to you by other health care providers.
`sent
`records,
`QOther: Medical
`billing
`fihns &records pertaining
`Include:
`(Indicate
`by Initialing)
`/2, C Alcohol/Drug
`06/22/2023
`to accident
`Treatment
`/2 C Mental Health Information
`/3 C HIV-Related
`
`below.
`
`I understand that
`
`I may
`
`plan,
`
`or eligibility
`
`for
`
`studies,
`
`films,
`
`Information
`
`9(a).
`
`Specific
`
`referrals,
`
`consults,
`
`Authorization
`to Discuss Health Information
`(b) OBy initialing
`here
`Initials
`to discuss my health information with my attorney,
`
`I authorize
`
`Nameof individual
`or a governmental agency,
`listed
`
`health
`here:
`
`care provider
`
`10. Reason for
`release of information:
`OAt request of individual
`8 Other: Legal Matter
`name of person signing form:
`If not
`the patient,
`
`12.
`
`(Attorney/Firm Nameor Govemmental Agency Name)
`11. Date or event on which gig AG'%
`At the end of
`coa
`litigation
`to sign on behal{pfcpatf¿E
`13. Authority
`
`form have been completed and myquestions
`
`about this
`
`form have been answered.
`
`In addition,
`
`pire:
`
`O
`
`I have been provided a
`
`items on this
`All
`copy of the form.
`C
`Signa
`e of patient
`or representative
`authorized
`by law.
`* HumanImmunodeficiency Virus that causes AIDS. The NewYork State Public Health Lawprotects
`someone as having HIV symptoms o.r infection
`and information
`regarding a person's
`contacts.
`
`identify
`
`information
`
`which reasonably
`
`could
`
`/ O
`
`Date:
`
`5 of 8
`
`

`

`FILED: NEW YORK COUNTY CLERK 10/09/2024 01:04 PM
`NYSCEF DOC. NO. 7
`.
`
`INDEX NO. 156397/2024
`
`RECEIVED NYSCEF: 10/09/2024
`OCAOfficial
`Form No.: 960
`AUTHORIZATIONFORRELEASEOFHEALTHINFORMATIONPURSUANTTOHIPAA
`[This form has been approved by the NewYork State Department of Health]
`Date of Birth
`12/08/1990
`
`Social Security Number
`
`representative,
`
`request
`
`form:
`
`disclosure
`
`relating
`
`I understand that
`
`I may
`
`plan,
`
`or eligibility
`
`for
`
`(except
`
`9(a).
`
`Specific
`
`information
`
`referrals,
`
`consults,
`
`studies,
`
`films,
`
`Patient Name
`BRYCECLARKE
`Patient Address
`536 W. 111th Street, NewYork, NY10025
`I, or my authorized
`regarding mycare and treatment be released
`information
`that health
`forth on this
`as set
`In accordance with NewYork State Law and the Privacy Rule of the Health Insurance Portability
`and Accountability
`Act of 1996
`I understand that:
`(HIPAA),
`to ALCOHOLand DRUGABUSE, MENTALHEALTH
`L This authorization may include
`of
`information
`TREATMENT,except psychotherapy notes, and CONFIDENTIALHIV* RELATEDINFORMATIONonly if
`I place my initials
`on
`in Item 9(a).
`In the event
`the appropriate
`information
`described below includes
`the health
`any of these types of
`and I
`line
`information,
`the line on the box in Item 9(a),
`release of such information to the person(s)
`in Item 8.
`initial
`authorize
`I specifically
`indicated
`I am authorizing
`the release of HIV-related,
`If
`or mental health
`treatment
`alcohol
`or drug treatment,
`2.
`the recipient
`information,
`is
`such information without my authorization
`from redisclosing
`prohibited
`unless permitted
`to do so under
`federal
`or
`law.
`state
`I
`to request a list of peop.le whomayreceive
`understand that
`I have the right
`or use my‰IV-related information without authorization.
`If
`the NewYork State Division
`I experience discrimination
`because of the release or disclosure
`I maycontact
`of HIV-related
`information,
`the NewYork City Commission of HumanRights at
`of HumanRights at
`(212) 480-2493 or
`(212) 306-7450.
`These agencies are
`for protecting myrights.
`responsible
`I have the right
`to revoke this
`at any time by writing
`to the health care provider
`authorization
`below.
`3.
`listed
`revoke this authorization
`except to the extent
`that action has already been taken based on this authorization.
`is voluntary. My treatment,
`I understand that signing this
`payment, enrollment
`in a health
`authorization
`4.
`benefits will not be conditioned upon myauthorization
`of this disclosure.
`Information
`under
`might be redisclosed
`disclosed
`as noted above in Item 2), and this
`authorization
`5.
`by the recipient
`this
`redisclosure mayno longer be protected
`by federal
`or state
`law.
`6. THIS.AUTHORIZATIONDOESNOTAUTHORIZEYOUTO DISCUSSMYHEALTHINFORMATIONORMEDICAL
`CARE,WITHANYONEOTHERTHANTHEATTORNEYORGOVERNMENTALAGENCYSPECIFIED IN ITEM 9 (b).
`7. Nanwand address of health provider or entity
`to release this
`information:
`1, NewYork, NY10065
`Lenox Hill Radiology.
`Schildhorn, MD..521 Park Ave, Ste.
`Jeffrey
`8. Nameand address of person(s)
`or category of person to whomthis
`information will
`be sent:
`MURIELGOODE-TRUFANT. The City of NewYork. 100 Church Street, NewYork, NY10007
`to be released:
`OMedical Record from (insert
`date) Present
`date) 06/22/2023
`to (insert
`OEntire Medical Record,
`patient
`office
`notes (except psychotherapy notes),
`including
`test
`histories,
`radiology
`results,
`insurance records, and records
`to you by other health care providers.
`sent
`billing
`records,
`2 Other: Medical
`fihns &records pertaining
`Include:
`(Indicate
`by Initialing)
`/3C
`to accident
`06/22/2023
`Treatment
`Alcohol/Drug
`/2 C Mental Health Information
`C
`HIV-Related
`Information
`
`health
`here:
`
`care provider
`SE
`
`g00
`
`c
`
`to Discuss Health Information
`Authorization
`(b) E< By initialing
`here
`Initials
`to discuss my health information with myattorney,
`
`I authorize
`
`10. Reason for
`release of information:
`OAt
`request of individual
`3 Other:
`Legal Matter
`name of person signing form:
`If not the patient,
`
`12.
`
`Nameof
`individual
`or a governmental agency,
`listed
`90
`(Attorney/Firm Nameor Governmental Agency Name)
`11. Date or event on which this autho
`At the end of
`litigation
`to sign on behalf of patient:
`13. Authority
`
`o
`gÇiOA4vÏl
`
`ec
`eé
`
`I have been provided a
`
`form have been completed and my questions
`
`about this
`
`form have been answered.
`
`In addition,
`
`items on this
`All
`copy of the form.
`cc
`of patient or repre.sentative
`Signat.
`by law.
`authorized
`* Human.Immunodeficiency Virus that causes AIDS. The NewYork State Public Health Lawprotects
`someone as having HIV symptoms or infection
`and information
`a person's
`contacts.
`identify
`regarding
`
`Date:
`
`6 of 8
`
`information
`
`which reasonably
`
`could
`
`

`

`FILED: NEW YORK COUNTY CLERK 10/09/2024 01:04 PM
`NYSCEF DOC. NO. 7
`
`INDEX NO. 156397/2024
`
`RECEIVED NYSCEF: 10/09/2024
`
`AFFIDAVIT OFSERVICE
`
`STATEOFNEWYORK )
`COUNTYOFKINGS
`
`) s.s.:
`
`)
`
`1.
`
`2.
`
`3.
`
`being duly sworn, deposes and says:
`Eidileen Gitalan,
`I amnot a party to the action, amover 18 years of age and reside Queens, New
`York.
`OnOctober 01, 2024, I served the Response To Demand, by depositing
`copy thereof enclosed in a post-paid wrapper addressed to:
`MURIELGOODE-TRUFANT
`for Defendants
`Attorneys
`THECITY OFNEWYORK
`100 Church Street,
`NewYork, NY10007
`
`a true
`
`in an official
`
`depository
`
`under the exclusive
`care and custody of the U.S. Postal
`Service within NewYork State.
`
`Eidileen Gitalan
`
`Sworn to befgr
`Octo)RTr94
`
`u
`
`o
`
`NOTARYPUBLIC
`
`7 of 8
`
`

`

`FILED: NEW YORK COUNTY CLERK 10/09/2024 01:04 PM
`NYSCEF DOC. NO. 7
`
`INDEX NO. 156397/2024
`
`RECEIVED NYSCEF: 10/09/2024
`
`Supreme Court of The State of NewYork
`County of NewYork
`BRYCECLARKE,
`
`- against
`
`-
`
`THECITY OFNEWYORK,POLICEOFFICERVINCENT
`J. FULGIERI ANDPOLICE OFFICER" JOHNDOE"
`(FICTITIOUS NAME,REALNAMEUNKNOWN)
`
`Defendants.
`
`|n dex No. 156397/2024
`
`RESPONSE
`TO
`DEMAND
`
`LAWOFFICE OF SEANH. ROONEY
`for Plaintiff
`Attorney
`26 Court Street
`- Suite 1816
`Brooklyn, NewYork 11242
`shrooney@aol.com
`(E-mail):
`(t): +1 (718) 243-2168
`(f): +1 (718) 242-4636
`
`8 of 8
`
`