FILED: SUFFOLK COUNTY CLERK 10/06/2017 03:28 PM
`FILED: SUFFOLK COUNTY CLERK 10m2017 03:28 PM
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`NYSC
`3F DOC. NO. 20
`NYSCEF DOC. NO. 20
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`INDEX NO. 606631/2017
`INDEX NO~ 606631/2017
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`RfiCfiIVfiD VYSCEF:
`10/06/2017
`RECEIVED NYSCEF: 10/06/2017
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`SUPREME COURT OF THE STATE OF NEW YORK
`
`COUNTY OF SUFFOLK
`——————————————————————————————————————————————————————————————————————X RESPONSE TO
`
`DEBRA A. DILLON,
`
`Plaintiff(s),
`
`—against—
`
`NICHOLAS L. PACINELLO,
`
`PRELIMINARY
`CONFERENCE ORDER
`
`Index N0.: 606631/2017
`
`Defendant(s).
`______________________________________________________________________X
`
`Plaintiff(s), by their attorneys, GRUENBERG KELLY DELLA, as and for a response to
`
`preliminary conference order dated October 03, 2017 alleges upon information and belief, as
`
`follows:
`
`
`INSURANCE INFORMATION
`
`Not applicable.
`
`
`BILL OF PARTICULARS
`
`The Plaintiffpreviously served the Verified Bill of Particulars on May 25, 2017. A copy of same
`
`is attached.
`
`MEDICAL RECORDS AND AUTHORIZATIONS
`
`Authorizations were previously provided on May 25, 2017. Copies of same are attached.
`
`WITNESSES
`
`Plaintiff is not aware of any witnesses at this time; however, plaintiff reserves the right to amend
`
`this response should any become available.
`
`
`EMPLOYMENT RECORDS
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`Plaintiff, Debra A. Dillon, is/was employed by Broadspire Services located at 898 Veterans
`
`Highway, Suite 410, Hauppauge, NY 11788 at the time of the accident. An authorization was
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`1 of 55
`1 of 55
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`FILED: SUFFOLK COUNTY CLERK 10/06/2017 03:28 PM
`FILED: SUFFOLK COUNTY CLERK 10m2017 03:28 PM
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`: NYSCEF DOC. NO. 20
`NYSCEF DOC. NO. 20
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`INDEX NO. 606631/2017
`INDEX NO~ “6631/2017
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`R«C«IV«D VYSCEF: 10/06/2017
`RECEIVED NYSCEF: 10/06/2017
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`
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`previously provided. A copy of same is attached.
`
`
`COLLATERAL SOURCE
`
`Plaintiff, Debra A. Dillon’s medical expenses were partially and/or fully paid for by Progressive
`
`Insurance Company located at PO. Box 22031, Albany, NY 12201. An authorization was
`
`previously provided. A copy of same is attached.
`
`PHOTOGRAPHS
`
`Plaintiff is not currently in possession of said photographs; however, Plaintiff reserves the right
`
`to provide the same should any become available.
`
`Dated: Ronkonkoma, New York
`October 4, 2017
`
`
`
`I ellyplla, ,,
`,Gmen
`Attorneys for Plain 'iff(s)
`700 Koehler Avenue
`
`Ronl<onkoma, NY 11779
`631—737—41 10
`
`TO:
`
`The Law Office of Russo & Tambasco
`
`Attorney for Defendant(s)
`Nicholas L. Pacinello
`
`115 Broadhollow Road
`Suite 300
`
`Melville, NY 1 1747
`(631) 760—0900
`
`20f 55
`2 of 55
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`INDEX NO.
`606631/2017
`INDEX NO. 606631/2017
`FILED: SUFFOLK COUNTY CLERK 10/06/2017 03:28 PM
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`T
`FILED. SUFFOLK COUNTY CLERK 10m2017 03:28 PM
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`
`
`i NchmFEn-SjC:SUFE20LK COUNTY CLERK 05— R«.c.IFFBJNYWEfiMFS/ldélbillfi
`RECEIVED NYSCEF: 10/06/2017
`NYSCEF DOC. NO. 20
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`6
`RECEIVED YSCEF:
`‘ NYSCEF DOC. NO.
`05/26/2017
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`1‘
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`SUPREME COURT OF THE STATE OF NEW YORK
`COUNTY OF SUFFOLK
`______________________________________________________________________ x
`
`DEBRA A. DILLON,
`
`P1alntlf‘f(s),
`
`against—
`
`NICHOLAS L. PACINELLO,
`
`Defendant(s)
`_____________________________».....u.._u-..".-u~~~u-uu—mausaw..m.u—.a—-.m.mu—-——- SS
`
`RESPONSE TO
`
`DEFENDANT 'S
`
`COMBINED DEMANDS
`
`Index No: 606631/2017
`
`P1aintiff(s), by her attorneys! GRUENBERG KELLY DELLA, as and for a response to
`
`Defendant NICHOLAS L. PACINELLO, Combined Demands dated May 17, 2017, allege(s)
`
`upon information and belief, as follows:
`
`RESPONSE TO DEMAND FOR MEDICARE/MEDICAID INFORMATION:
`
`Plaintiff, Debra A. Dillon is not currently a Medicare/Medicaid recipient.
`
`RESPONSE TO DEMAND FOR INDEX NUMBER:
`
`1116 index numbei obtained. for the Within action1s 606631/2017
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`RESPONSE TO DEMAND FOR ALL PARTIES APPEARING;
`
`The following parties have appeared, in the Within action:
`
`Gruenberg Kelly Della
`700 Koehler Avenue
`
`Ronkonkoma, New York 11779
`Attorneys for Plaintiff
`
`The Law Office of Russo & Ta111basoo
`For Defendant Nicholas L. Pacinello
`115 Broadhollow Road, Suite 300
`Melville, NY 11747
`
`1 of 31
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`3 of 55
`3 of 55
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`FILED: SUFFOLK COUNTY CLERK 10/06/2017 03:28 PM
`’ FILED: SUFFOLK COUNTY CLERK 10m2017 03:28 PM
`NYSCEF DOC. NO. 20
`- Nmme. sUFFeLK COUNTY CLERK 05mm 7
`2:53 PM
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`NYSCEF DOC. NO.
`6
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`INDEX NO. 606631/2017
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`INEEX NO~ 606631/2017
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`RECEIVED NYSCEF: 10/06/2017
`recurFIDLNYEQEFQOW/WPNN
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`RECEIVED \IYSCEF: 05/26/2017
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`RESPONSE TO DEMAND FOR INSURANCE COVERAGE 'I‘O‘ PLAINTIFFS ON
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`COUNTERCLAIM AND/OR 'COHDEFENDANT:
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`Not applicable.
`
`RESPONSE TO DEMAND FOR WITNESSES:
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`Plaintiff is not aware of any witnesses at this time; however, plaintiff reserves the right to
`
`amend this response should any become available.
`
`RESPONSE TO DEMAND FOR EXPERT WITNESS:
`
`Plaintiff has not yet retained the services of an Expert Witness; however, Plaintiff
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`reserves the right to do so and to supplement said response in the future pursuant to the
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`CPLR.
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`RESPONSE TO DEMAND FOR ACCIDENT REPORTS:
`
`Plaintiff did not prepare a written report in the regular course of business operation or
`
`practice concerning this accident.
`
`" RESPONSETO DEMAND’FOE STATEMENT{
`
`,,
`
`Plaintiff is» not in possession ofany adverse party statements; however, plaintiff reserves
`the right to supplement said response.-
`‘
`
`RESPONSE TO DEMAND FOR PHOTOGRAPHS:
`
`Plaintiff is not currently in possession of said photographs; however, Plaintiff reserves
`
`the right to provide the same should any become available,
`
`RESPONSE" TO DEMAND FOR INCOME TAX RETURNS:
`
`Plaintiff objects to providing authorizations for Income Tax Records in that said demand
`
`is overly broad, unduly burdensome, irrelevant and the same may contain information
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`that is private, privileged. and otherwise irrelevant herein. Additionally, “tax returns are
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`
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`20f3l
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`FILED: SUFFOLK COUNTY CLERK 10/06/2017 03:28 PM
`FILED: SUFFOLK COUNTY CLERK 10m2017 03:28 PM
`NYSCEF DOC. NO. 20
`NFFEMLSMFFGLK COUNTY CLERK 05 m 20 7 12:53 PM
`' NYSCEF DOC. NO.
`6
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`INDEX NO. 606631/2017
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`INDEX NO~ 606631/2017
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`RECEIVED NYSCEF: 10/06/2017
`R«C«IWBEPfim-Efiépmmmfi
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`RCECVLIVVLD NYSCEF: 05/26/2017
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`generally not discoverable in the absence of a strong showing that the information is
`
`indispensable to the claim and cannot be obtained from other sources" See Pugliese V.
`
`Mondello, 871 N.Y..S.2d. 174; 57 A.D.3d 637 ('2nd Dept. 2008) citing Beni’eld V Altidor V
`
`State—Wide Ins. Co, 22 AD3d 43 5, 801 N.Y.S.2d 545 (21“1 Dept. 2007); see also Tia—tangy
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`Smith, 304 AD2d 534, 536, 758’ N.Y.S..2d 135 (21‘1" Dept. 2003').
`
`RESPONSE TO DEMAND FOR SCHOOL AUTHORIZATIONS:
`
`Not applicable.
`
`RESPONSE TO DEMAND FOR EMPLOYMENT AUTHORIZATIONS:
`
`See. Bill] of Particulars for employment information. An authorization allowing your
`
`office to obtain records from Broadspire Services located at 898 Veterans Highway, Suite
`
`41 0, Hauppauge, NY 1 l 788 is attached.
`
`RESPONSE TO DEMAND FOR NO~FAULT RECORDS:
`
`Plaintiff DEBRA A. DILLON'S medical expenses were partially and/or fully paid for by
`
`
`T V
`
`V 7 ' progressive InsTJranee- Company located at FONT-376x320?)17,7A1banypN‘Y 1201(2th ,
`
`7
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`authorization is attached.
`
`RESPONSE TO DEMAND FOR WORKER’S COMPENSATION RECORDS:
`Not applicable.
`I
`
`RESPONSE TO DEMAND FOR D’ISABHLTY RECORDS:
`
`To be provided, if applicable.
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`RESPONSE TO DEMAND FOR INFORMATION ON COLLATERAL SOURCE:
`
`See paragraph above.
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`30f3l
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`FILED: SUFFOLK COUNTY CLERK 10/06/2017 03:28 PM
`' FILED: SUFFOLK COUNTY CLERK 1om2o17 03:28 PM
`NYSCEF DOC. NO. 20
`> N -- mesoFFoLK COUNTY CLERK 05m2017 12:53 P
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`NYSCEF DOC . NO .
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`INDEX NO. 606631/2017
`INDEX NO. 606631/2017
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`RECEIVED NYSCEF: 10/06/2017
`R«.C «.ItENDiENYSQEFQO @QBMQMG 1 7
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`ucurvwfin NYSCEF: 05/2 6/2 017
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`RESPONSE TO DEMAND FOR MEDICAL INFORMATION:
`
`l—4.
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`Listed below are the names and addresses of the physicians who currently and/or
`
`previously treated or examined plaintiff, DEBRA A. DILLO’Ni
`
`
`
`
`
`Carriage House Chiropractic and Acupuncture, PLLC
`9 Carlton Avenue
`
`East Setauket, NY 11733
`
`Comprehensive Neurology of Long Island/Michael Guo
`2500 Nesconset Highway
`Suite 5B
`
`Stony Brook, NY 11790
`
`Kenneth Fishberger M.D./Southwest Suffolk Medical
`200 Belle Terre Road
`Suite 110
`
`Port Jefferson, NY 11777
`
`Long Island Spine Specialists/Dr. Merinelste'in/Dr. San-elli
`763 Larkfield Road
`
`Commack, NY 11725
`
`Magdy Shady MD.
`25 00' Nesconset Highway 7
`W 7 WW 7 Building’lfSCfiw 7
`Stony Brook, NY 11790-
`
`Medih‘ealth Medical PC/Dr. Elfiky
`200 East Main Street
`
`Patchogue, NY 1 1772
`
`North Shore Orthopedic Surgery & Sports Medicine/DrJVesey
`48 Route 25A
`Suite 106
`
`Smithtown, NY 11787
`
`St Catherine of Siena Medical Center
`50 Route 25A
`'
`
`Smithtown, NY 11787
`
`St. Charles Hospital & Rehabilitation Center
`200 Belle Terre Road
`
`Port Jefferson, NY 11777
`
`403531
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`6 of 55
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`FILED: SUFFOLK COUNTY CLERK 10/06/2017 03:28 PM
`FILED: SUFFOLK COUNTY CLERK 10m2017 03:28 PM
`NYSCEF DOC. NO. 20
`NemuoemeFmLK COUNTY CLERK 05 2017 12:53 PM
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`7 NYSCE‘F DOC. NO.
`6
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`INDEX NO. 606631/2017
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`INDEX N0. 606631/2017
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`RECEIVED NYSCEF: 10/06/2017
`decilwwifimflép695mm“
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`REC ‘IVED NYSCEF: 05/26/2017
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`St. Charles Orthopedics/Dr. Harary
`6 Technology Drive
`East Setauket, NY 11733
`
`St. Charles Rehabilitation Network
`
`2100 Middle Country Road
`Centereach, NY 11720
`
`St. Charles Rehabilitation Network
`200 Belle Terre Road
`
`Port Jefferson, NY 11777
`
`Zwanger—Pesiri Radiology
`347 Middle Country Road
`Coram, NY 11727
`
`Authorizations are attached.
`Not applicable.
`Not applicable.
`Attached please find authorizations allowing your office to obtain records regarding the
`
`5-.
`6.
`7.
`
`.
`
`plaintiff’s prior accident on February 20‘, 2015 from the following facilities:
`
`’ cementEg’Kefly Della
`700- Koehler Avenue
`
`.
`
`New York, Ronkonkoma 11779
`
`City MD
`1995 Nesconset Highway
`Lake Grove, NY 11755
`
`Comprehensive Neurology of Long ISIand/Mi’chael Guo
`2500 Nesconset Highway, Suite 58
`Stony Brook, NY 11790
`
`Lighthouse Physical Therapy, PC
`60 North Country Road
`Suite 104
`
`Port Jefferson, NY 1 1777
`
`Medical Arts Radiology
`23 Technology Drive
`East Setauket, NY 11733
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`50f31
`7of55
`7 of 55
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`}
`1
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`FILED: SUFFOLK COUNTY CLERK 10/06/2017 03:28 PM
`FILED: SUFFOLK COUNTY CLERK 10m2017 03:28 PM
`NYSCEF DOC. NO. 20
`; N mesacFFcLK COUNTY CLERK 05 2017 12:53 PM
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`NYSCEF DOC. NO.
`6
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`INDEX NO. 606631/2017
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`INDEX NO~ 606631/2017
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`RECEIVED NYSCEF: 10/06/2017
`R«c«IWDEKYWEFQOQWMMG17
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`
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`RECEIVED NYSCEF: 05/26/2017
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`M. Ather Mirza
`
`290 East Main Street
`Suite 200
`
`Smithtown, NY 1 1787
`
`North Shore Orthopedic Surgery & Sports Medicine/Dr. Wertlieb
`48 Route 25A
`
`Suite 106
`
`Smithtown, NY 11787
`
`.
`
`Orthopedic. Associates of Long Island/Dr. Christoforou
`6 Technology Drive
`Suite 100
`
`East Setauket, NY 11733
`
`St. Catherine of Siena Medical Center
`50 Route 25A
`Smithtown, NY 11787
`
`St. Charles HOSpital & Rehabilitation Center
`200 Belle Terre Road
`
`‘
`
`1
`
`/
`
`'
`
`7
`
`7
`
`7
`
`7 77
`
`Port Jefferson, NY 11777
`
`7
`Shafi Wani
`2500 Nesconset Highway
`Building 715-
`‘Stonyf’B’roé’kfiY 11790
`
`8,
`
`To be provided, if applicable.
`
`Dated;
`
`Ronkonlcoma, New York
`May 24, 201 '7
`
`‘
`1
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`‘
`;
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`7
`l
`'
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`‘
`'
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`!7
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`M‘ (e Della, E . q
`C ~Uteriberg Ke
`”torneys for Plaintiffis)‘
`
`700 Koehler Avenue
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`
`
`
`Ronkonkoma, NY 11779
`631737-4110
`
`6of3l
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`80f 55
`8 of 55
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`FILED: SUFFOLK COUNTY CLERK 10/06/2017 03:28 PM
`FILED: SUFFOLK COUNTY CLERK 10m2017 03:28 PM
`NYSCEF DOC. NO. 20
`NCEEJEEDDQSMFEGLK COUNTY CLERK 05m2017 12:53 PM
`= NYSCEF DOC. NO.
`6
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`INDEX NO. 606631/2017
`INDEX NO~ “6631/2017
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`RECEIVED NYSCEF: 10/06/2017
`R*-C*IIWDENM-‘EEMWWTDN
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`RECEIVED \IYSCEF: 05/26/2017
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`TO:
`
`' The Law Office of Russo & Tambasoo
`Attorney for Defendant(s)
`Nicholas L. Pacinello
`
`115 Broadhollow Road
`Suite 300
`
`Melville, NY 11747
`(631) 760~09OO
`
`70f 31
`9of 55
`9 of 55
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`FILED: SUFFOLK COUNTY CLERK 10/06/2017 03:28 PM
`FILED: SUFFOLK COUNTY CLERK 10m2017 03:28 PM‘
`NYSCEF DOC. NO. 20
`
`
`INDEX NO.
`606631/2017
`INDEX NO. 606631/2017
`
`
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`Rae «.Irrnoanynonrao catamarans 1 7
`RECEIVED NYSCEF: 10/06/2017
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`RECEIVED VYSCEF:
`05/26/2017
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`
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`"er”
`
`AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
`
`Date of Birth: _
`Debra A. Dillon
`Patient Name;
`!
`"f:
`i
`'
`
`Patient Address: 190 Villa D'Est, Apartment D15. Coram, NY 11 27
`
`
`
`
`
`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:
`I. 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 itI place my initials on the appro
`prlate 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 per‘son(s) indicated in Item 8.
`2.
`III am authorizing the release ofHIV~reiated, alcohol or drug treatment, or mental health treatment information, the reel
`pient is prohibited from
`r'edisclosing such information without my authorization unless permitted to do so under federal or state law.
`I understand th
`atI have the right to request
`a list of people who may receive or use my HIV~related information without authorization.
`If I experience discrimination becaus
`6 of the release or
`disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) 4-80-2493 or the New York City
`Commission ot‘Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights.
`3.
`Ihave the right to revoke this authorization at any time by writing to the health care provider listed be]
`authorization except to the extent-that action has already been taken based on this authorization.
`.4.
`Iunderstand 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 recipienttexcept as noted above in Item 2),
`longer be protected by federal or state law.
`and this redrsclo‘sure may no
`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).
`'C.
`7. Name and address ofhealth provider or enti
`to release this information; _p/:\9[/'VLS.-I"7 ("Cm gal lama/2 Cg
`(’0 tear. ZZDS’J
`Kid/ramp
`Inez
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`8. Name and address ofperson(s) or category ofpersonJo whom this information will be sent: Ar, firm 7L 7&4 {an(.520
`Hr” amt/tattoo at stares Malta/Lt M a???
`
`v
`
`v
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`2
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`[
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`ow.
`
`I understand that I may revoke this
`
`
`
`,,
`7”
`9(a). Specific information to be released:
`_
`to (insert date)
`' "J
`El'Medical Record. nominees date) ”w
`
`‘
`E Entire Medical Record, including patient histories, office notes (exceptpsychotherapynotes), test results, radioi
`films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
`
`EEOtherz.
`‘F n
`‘
`’
`'
`‘
`Include: (Indicate by Jnitialing)
`
`
`flaw
`__ Alcohol/Drug Treatment
`
`Mental Health Information
`
`Authorization to Discuss Health Information-
`_ HIV-Related Information
`(b)
`By initialing here _ -
`I authorize
`
` (Initials) . (Name ofindividual health care provider)
`
`to discuss my health information with my attorney, or a governmental agency, listed here:
` (Alfal‘ney/Firm Name or Governmental/13mgName)
`IO. Reason for release ofinformation:
`ll. Date or event On which this authorization will. expire:
`D At request of individual
`Conclusion of Case
`[X] Other: Legal
`
`ogy studies,
`
`12.
`
`El
`
`It” not the patient, name ofperson signing form:
`
`13. Authority to Sign on behalf ofpatient:
`
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`Public. State of New York
`titled In Suffolk County
`Iigtgiztration #01506288749
`* I—Iuman Inrrntrnodeflci'ency Virus that causes AIDS. The New York State Public Health Law
`ngéigfimrunfitwaifldplflmgbiia
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`someone as having I—IIV symptorns or infection and information regarding a person’s contacts,
`as:
`. v
`8 of 31
`10 of 55
`10 of 55
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`FILED: SUFFOLK COUNTY CLERK 10/06/2017 03:28 PM
`FILED: SUFFOLK COUNTY CLERK 10m2017 03:28 PM
`NYSCEF DOC. NO. 20
`Nmntb,¢%,$UFFOJLK COUNTY CLERK 05m2017 12:53 PM'
`: NYSCf ‘) NO
`6
`
`{Exhaust
`‘U AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO I-IIPAA
`
`
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`RECEIVED NYSCEF: 05/26/2017
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` '3
`. 606631/2017
`INDEX NO. 606631/2017
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`IND-X NO
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`R«.c «.Ivnnisnynonreo awn/@0201 7
`RECEIVED NYSCEF: 10/06/2017
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`
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`L
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`:
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`SSN:
`
`
`
`Date of Birth: M1960
`Debra A, Dillon.
`Patient Name:
`100 Villa D’Est, Apartment D15, Coram, NY 11727
`Patient Address:
`
`Manama-m. m. m. i. may.» um ,,._...n,,i,/...»...,...._.4...~l.,.v.».,.,’...—; "a .
`,.
`.- i..
`.i.
`.
`
`I, or my authorized representative, request that health information regarding my care and treatment be released asset forth on this form; In accordance
`with New York State Law and the Privacy Rule ofthe Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:
`l.
`'l‘hisauthorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT,
`except psychotherapy notes, and CONFIDENTIAL I:IIV* 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.
`It I am authorizing the release of HIV—related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from
`redisclo‘slng such information without my authorizationunless permitted to do so under federal or state law,
`I understand thatI 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 ofHuman 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.
`I understand that I may revoke this
`authorization except to the extent that action has already been taken based on this authorization.
`4.
`Iunderstand 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 underthis 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 (b).
`7. Name and address ofhealth provider or entity to release this information:
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`10. Reason for release of information:
`11. Date or event on which this authorization will expire:
`C] At request of individual
`Conclusion of Case
`[X] Other: Legal
`
`13, Authority to sign on behalf ofpatient:
`12. D If not the patient, name ofperson signing form:
`All items on this form have been completed and my questions about this form have been answered.
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`FILED: SUFFOLK COUNTY CLERK 10/06/2017 03:28 PM
`FILED: SUFFOLK COUNTY CLERK 102017 03:28 PM
`NYSCEF DOC. NO. 20
`N EEIEEJDDC.SUFE@LK COUNTY CLERK 052017 12:53 PM *
`c
`NO
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`NYS
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`”my” AUTHORIZATION FOR RELEASE OF HEALTH INFORIVIATION PURSUANT TO HIPAA
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`INDEX NO. 606631/2017
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`RECEIVED NYSCEF: 10/06/2017
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`RECEIVED \lYSCEF: 05/26/2017
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`INj‘X NO' 06636;:‘gégigl7
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`Patient Name:
`Patient Address:
`
`
`Date of Birth:
`Debra A. Dillon
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`100 Villa D'Est. Apartment D15 ,_Coran;, NY 11727,
`
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`I, ormy 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 (I-IIPAA), I understand that:
`i. 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 it‘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 I~IIV~related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from
`redisciosing such information without my authorization unless permitted to do so under federal or state law.
`I understand thatl have the right to request
`a list of people who may receive or use my HIV~related information without authorization It‘I experience discrimination because ot'lthe release or
`ciisalosure 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 bel
`ow.
`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 underthis authorization might be redisciosed by the recipient (except as noted above in Item 2)., and this redisciosure 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 (b).
`7. Name and address ofhealth provider or entity to release this. information:
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`10. Reason for release of information:
`11. Date or event on which this authorization will expire:
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`Conclusion of Case
`[X] Other: Legal
`
`13. Authority to Sign on behalf ofpatient:
`12. D If not the patient, name of person signing form:
`All items on this, form have been completed and my questions about this form have been answered.
`In addition, I have been provided
`a opy of the form.
`
`
`Date:
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` 7
`606631/2017
`INDEX NO. 606631/2017
`FILED: SUFFOLK COUNTY CLERK 10/06/2017 03:28 PM
`mix so.
`2017 03:28 PM
`
`:3
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`ED: SUFFOLK COUNTY CLERK 10m— .
`R*.C*.I\¥lhl@ sysemoaeweman
`i E‘ELMEEJ“ SUFFOLK COUNTY CLERK 052017 12:53 PM
`
`
`
`RECEIVED NYSCEF: 10/06/2017
`NYSCEF DOC. NO. 20
`
`
`
`RECEIVED NYSCEF: 05/26/2017
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`
`
`
`Patient Name:
`Date of Birth:
`Debra A. Dillon
`Patient Address:
`100 Villa D'Est, Apartment D15. Coram. NY 11727
`
`I, or my authorized representative, request that health information regarding my care and treatment he re
`leased 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:
`I. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT,
`except psychotherapy notes, and CONFIDENTIAL I-IIV* 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 ofthese 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 treatmen
`t information, the recipient is prohibited from
`redisclosing such information without my authorization unless permitted to do sounder federal or state law,
`I understand thatI 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 ofthe release 0r
`disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) 4800493 or the New York City
`Commission ofHuman Rights at (212) 306-7450. These agencies are responsible for protecting my rights.
`3.
`lhave the right to revoke this authorization at any time by writing to the health care provider listed below.
`I understand th
`at I may revoke this
`authorization except to the extent that action has already been. taken based on this authorization,
`4.
`Iundcrstand 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 th
`is 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 (b).
`7. Name an address ofhealth provider or entity to releaSe this information:
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`10. Reason for release of information:
`,
`11. Date or event on which this authorization will expire:
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`12.
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`FILED: SUFFOLK COUNTY CLERK 10/06/2017 03:28 PM
`10m2017 03:28 PM
`ILED: SUFFOLK COUNTY CLERK
`me.,sunuoLK COUNTY CLERK 05 m 2017 12:53 P
`NYSCEF DOC. NO. 20
`
`
`
`NYSCE.’
`,
`' "
`6
`.
`arm” t No .
`
`
`
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`“3 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO I-III’AA
`
`Patient Name:
`Debra A, Dill-on
`Date of Birth'
`SSN '
`100 Villa D'Esflt, Apartment DISLCoram, NY 11727
`Patient Address:
`
`
`INDEX NO. 606631/2017
`INDEX NO. 606631/2017
`
`4
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`
`RECEIVED NYSCEF: 10/06/2017
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`with New York State Law and the Privacy Rule-of the Health Insurance Portability and Accountability Act of 1996 (I—IIPAA), 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" RE ATED INFORMATION only it‘I place my initials on the appropriate line in Item
`9(a). In the event the health information desoribcd 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 au