FILED: KINGS COUNTY CLERK 08/10/2022 02:06 PM
`NYSCEF DOC. NO. 373
`
`INDEX NO. 504685/2015
`
`RECEIVED NYSCEF: 08/10/2022
`
`Exhibit
`
`N
`
`
`
`FILED: KINGS COUNTY CLERK 08/10/2022 02:06 PM
`NYSCEF DOC. NO. 373
`
`INDEX NO. 504685/2015
`
`RECEIVED NYSCEF: 08/10/2022
`
`OF THE STATE
`
`OF NEW YORK
`
`COURT
`SUPREME
`OF KINGS
`COUNTY
`________________________________________________________________Ç
`LEMA,
`
`JOSE
`
`Plaintiff,
`
`-against-
`
`Index
`
`No.:
`
`703769/2018
`
`WITH
`COMPLIANCE
`MAY 20,
`2022 COURT
`ORDER
`
`ERENSTEIN
`IRIS
`PROPERTIES,
`SPINKLER
`ALLSTATE
`MANAGEMENT
`CO.
`
`PROPERTIES,
`STREET
`EVAN
`
`individually,
`
`CORP.,
`R. BESEN
`and
`
`LTD.,
`231/249
`L.L.C.,
`and MALCOLM
`JAMES
`and
`of
`as owners
`
`L.L.C.,
`SCHUR
`CORP.,
`JORDAN
`WEST
`
`SCHUR
`39th
`
`M. BESEN,
`M. BESEN,
`subject-premises,
`
`________________________________________________________________Ç
`
`Defendants.
`
`Plaintiff,
`
`JOSE
`
`LEMA,
`
`by his
`
`attorneys,
`
`LAW OFFICES
`
`OF MICHAEL
`
`S.
`
`LAMONSOFF,
`
`PLLC,
`
`as and
`
`for
`
`his
`
`compliance
`
`with
`
`the Court's
`
`order
`
`dated May
`
`20,
`
`2022,
`
`sets
`
`forth
`
`as follows:
`
`Annexed
`
`hereto
`
`are the
`
`following
`
`authorizations:
`
`"
`
`"
`
`"
`
`"
`
`"
`
`"
`
`"
`
`"
`
`"
`
`"
`
`"
`
`Healthquest
`
`Bellevue
`Dr. Michael
`Steven
`Dr.
`Dr. Gary
`Dr. Gianni
`
`Lenox
`
`Hill
`
`Dr.
`
`Timur
`
`Hospital
`
`Center
`
`Gerling
`Touliopoulos
`
`Thomas
`
`Persich,
`
`Radiology
`Hanan
`
`DPM
`
`Dr. Charles
`
`DeMarco
`
`Surgicare
`
`Mount
`
`of Manhattan
`Sinai
`Queens
`
`
`
`FILED: KINGS COUNTY CLERK 08/10/2022 02:06 PM
`NYSCEF DOC. NO. 373
`
`INDEX NO. 504685/2015
`
`RECEIVED NYSCEF: 08/10/2022
`
`SUPPLEMENTAL
`DEMANDS
`DATED
`
`RESPONSE
`APRIL
`
`22,
`
`TO POST-DEPOSITION
`2022
`
`4.
`
`9.
`
`Annexed
`years
`
`hereto
`
`2018,
`
`2019,
`
`is an authorization
`and
`2021.
`
`2020,
`
`for
`
`copies
`
`of
`
`the
`
`plaintiff's
`
`tax
`
`records
`
`for
`
`the
`
`is not
`Plaintiff
`Compensation
`
`in possession
`Board
`
`reducing
`
`of
`
`the
`the
`
`correspondence
`of his
`
`frequency
`
`the
`
`from
`physical
`
`Workers'
`
`therapy.
`
`24.
`
`Annexed
`
`hereto
`
`are authorizations
`
`for
`
`the
`
`plaintiff's
`
`records
`
`from
`
`Dr.
`
`Igor
`
`Stiler.
`
`PLEASE
`
`TAKE
`
`NOTICE,
`
`that
`
`Plaintiff
`
`reserves
`
`his
`
`right
`
`to supplement
`
`and/or
`
`amend
`
`these
`
`responses
`
`up to and
`
`including
`
`at
`
`the time
`
`of
`
`the
`
`trial
`
`of
`
`this matter.
`
`Dated:
`
`New York,
`1, 2022
`June
`
`New York
`
`Yours,
`
`etc.,
`
`LAW
`
`ES OF M HAEL
`
`FI
`
`S. LAMONSOFF,
`
`PLLC
`
`By
`
`OVIC
`
`Plaintiff
`
`10005
`
`T
`OMINA
`for
`ttorneys
`OSE LEM
`Slip-
`floor
`8th
`32 Old
`New York
`New York,
`962-1020
`(212)
`File
`26141
`
`#:
`
`TO:
`
`& SMITH,
`
`LLP.
`
`BISGAARD
`LEWIS
`BRISBOIS
`for Defendants,
`Attorneys
`ERENSTEIN
`IRIS
`PROPERTIES,
`ALLSTATE
`SPINKLER
`MANAGEMENT
`SCHUR
`STREET
`EVAN
`Ste.
`77 Water
`Street,
`New York
`New York,
`232-1300
`(212)
`
`L.L.C.,
`SCHUR
`CORP.,
`JORDAN
`
`LTD.,
`
`CO.
`
`L.L.C.,
`PROPERTIES,
`and MALCOLM
`JAMES
`and
`
`CORP.,
`R. BESEN
`
`39th
`
`WEST
`231/249
`M. BESEN,
`M. BESEN,
`
`2100
`
`10005
`
`
`
`FILED: KINGS COUNTY CLERK 08/10/2022 02:06 PM
`NYSCEF DOC. NO. 373
`
`INDEX NO. 504685/2015
`
`RECEIVED NYSCEF: 08/10/2022
`
`& McMANUS
`
`CORP.
`
`DEMERS
`AHMUTY,
`for Defendant
`Attorneys
`SPRINKLER
`ALLSTATE
`Road
`I.U. Willets
`200
`NY 11507
`Albertson,
`294-5433
`
`(516)
`
`
`
`FILED: KINGS COUNTY CLERK 08/10/2022 02:06 PM
`NYSCEF DOC. NO. 373
`POWER OF ATTORNEY
`DURABLE
`FOR PATIENT
`REQUEST
`INFORMATION
`OF THE NEW YORK
`STATE
`PUBLIC
`
`RECEIVED NYSCEF: 08/10/2022
`A WRITTEN
`TO EXECUTE
`UNDER
`SECTION
`LAW
`HEALTH
`
`18
`
`INDEX NO. 504685/2015
`
`DOCUMENT
`THIS
`DECISIONS.
`
`DOES
`
`NOT
`
`AUTHORIZE
`
`ANYONE
`
`TO MAKE
`
`MEDICAL
`
`OR HEALTH
`
`CARE
`
`to
`
`intended
`constitute
`under
`Section
`Lema
`
`a DURABLE
`the New York
`18 of
`
`POWER
`State
`
`OF ATTORNEY
`Public
`Health
`Law:
`
`to execute
`
`a written
`
`request
`
`for
`
`patient
`
`is
`This
`information
`
`Jose
`
`1,
`do hereby
`
`appoint
`
`a representative
`
`at
`
`the:
`
`LAW OFFICES
`
`OF MICHAEL
`
`S. LAMONSOFF,
`
`PLLC.
`
`as my attorney-in-fact
`Public
`Health
`Law
`
`to execute
`in my name,
`
`request
`a written
`and stead
`place
`
`infonnation
`for patient
`in any way which
`I myself
`
`under
`could
`
`Section
`if
`
`do,
`
`the New York
`18 of
`present.
`I personally
`
`State
`
`OF
`POWER
`DURABLE
`THIS
`OR INCOMPETENCE.
`DISABILITY
`
`ATTORNEY
`
`SHALL
`
`NOT
`
`BE
`
`AFFECTED
`
`BY MY
`
`SUBSEQUENT
`
`ANY THIRD
`ANY THIRD
`TO INDUCE
`THAT
`AGREE
`PARTY
`I HEREBY
`TO ACT HEREUNDER,
`PARTY
`MAY
`ACT
`INSTRUMENT
`A DULY
`COPY
`OR
`EXECUTED
`THIS
`RECEIVING
`FACSIMILE
`OF
`AND THAT
`SHALL
`BE INEFFECTIVE
`AS TO
`OR TERMINATION
`HEREOF
`REVOCATION
`HEREUNDER,
`SUCH
`KNOWLEDGE
`SUCH
`OF
`OR
`THIRD
`ACTUAL
`UNLESS
`AND
`PARTY
`NOTICE
`UNTIL
`AND I FOR
`HAVE
`BEEN RECEIVED
`BY SUCH THIRD
`OR TEMINATION
`SHALL
`REVOCATION
`PARTY,
`FOR MY HEIRS,
`AND
`MYSELF
`HEREBY
`AND
`LEGAL
`REPRESENTATIVES
`EXECUTORS,
`ASSIGNS,
`FROM AND AGAINST
`AND HOLD
`AGREE
`TO INDEMNIFY
`ANY
`PARTY
`HARMLESS
`ANY
`SUCH THIRD
`AND ALL
`THAT MAY ARISE
`BY REASON
`OF SUCH
`CLIAMS
`AGIANST
`PARTY
`SUCH
`THIRD
`TIRD
`PARTY
`HAVING
`ON THE PROVISION
`OF THIS
`INTRUMENT.
`RELIED
`
`THIS
`
`DURABLE
`
`POWER OF ATTORNEY
`
`MAY BE REVOKED
`
`BY ME AT ANY TIME.
`
`In Witness
`
`Whereof
`
`I have
`
`hereunto
`
`signed my name
`
`this 6Ó
`
`of
`
`G ()0Q
`
`(cid:144)
`
`, 20
`
`State
`
`County
`
`of New York
`} ss.:
`of New York
`
`}
`
`}
`
`day
`
`X
`
`do
`
`e
`
`evp
`
`On the
`
`day
`
`of
`
`CAA U d f
`
`in the year
`
`20
`
`, before
`
`me,
`
`the undersigned,
`
`a Notary
`
`Public
`
`in and for
`
`said
`
`State,
`
`personally
`
`appeared
`
`6 58
`
`be /I
`
`cL
`
`,, personally
`
`known
`
`to me
`
`or proved
`
`to me
`
`on the
`
`basis
`
`satisfactory
`
`evidence
`
`to be the individual
`
`whose
`
`name
`
`is subscribed
`
`to the within
`
`instrument
`
`and acknowledged
`
`to
`
`me that
`
`he/ehe-executed
`
`the same
`
`in his/her
`
`capacity,
`
`and that by his/her
`
`signature
`
`on the instrument,
`
`the individual,
`
`or
`
`the person
`
`upon
`
`behalf
`
`of which
`
`the individual
`
`acted,
`
`executed
`
`the instrument.
`
`No ary P blic
`
`JACQUEUNE VASQUEZ
`Notary Public, State of New York
`No. 01VA5019763
`Qualified in Kings County
`Commission Expires November 1,20
`
`
`
`FILED: KINGS COUNTY CLERK 08/10/2022 02:06 PM
`NYSCEF DOC. NO. 373
`
`INDEX NO. 504685/2015
`
`RECEIVED NYSCEF: 08/10/2022
`
`Form
`
`(March2019)
`
`erna Re enueS
`
`e(cid:25)
`
`º Do not sign this form unless all applicable
`lines have been completed.
`ºRequest
`if the form is incomplete
`may be rejected
`or illegible.
`º For more information
`about Form 4506, visitwww.irs.gov/form4506.
`
`OMB No. 1545-0429
`
`Tip. You may be able to get your tax return or return information from other sources.
`If you had your tax return completed by a paid preparer,
`they
`should be able to provide you a copy of the return. The IRS can provide a Tax Return Transcript
`for many returns free of charge. The transcript
`tax return and usually contains the information that a third party (such as a mortgage company)
`provides most of the line entries from .the original
`for Transcript
`requires. See Form 4506-T, Request
`of Tax Return, or you can quickly request
`transcripts by using our automated self-help service
`tools. Please visit us at IRS.gov and click on "Get a Tax Transcript..." or call 1-800-908-9946.
`
`1a Name shown on tax return.
`
`If a joint return, enter the name shown first.
`
`OM
`
`f)¾
`
`_ _. .
`_ _
`2a If a joint return, enter spouse's name shown on tax return.
`
`1b First social security number on tax return,
`individual
`taxpayer
`identification
`number, or
`employer
`identification
`(see instructions)
`number
`
`M45-
`
`y© f
`
`2b Second social security number or individual
`taxpayer
`identification
`number
`if joint
`tax return
`
`3 Current name, address (including apt., room, or suite no.), city, state, and ZIP code (see instructions)
`u223
`Boo
`6oene
`Roed
`4 Previous address shown on the last return filed if different
`
`yn &Éym(
`
`from line 3 (see instructions)
`
`d7)ro
`
`5 If the tax return is to be mailed to a third party (such as a mortgage company), enter the third party's name, address, and telephone number.
`
`If the tax return is being mailed to a third party, ensure that you have filled in lines 6 and 7 before signing. Sign and date the form once you
`Caution:
`have filled in these lines. Completing these steps helps to protect your privacy. Once the IRS discloses your tax return to the third party listed on line
`If you would like to limit the third party's authority to disclose your return
`5, the IRS has no control over what
`the third party does with the information.
`information, you can specify this limitation in your written agreement with the third party.
`Form 1040, 1120, 941, etc. and all attachments
`Tax return
`requested.
`to the IRS,
`submitted
`as originally
`6
`Form(s) W-2,
`including
`schedules, or amended returns. Copies of Forms 1040, 1040A, and 1040EZ are generally available for 7 years from filing before they are
`returns may be available for a longer period of time. Enter only one return number.
`If you need more than one
`by law. Other
`destroyed
`º
`type of return, you must complete another Form 4506.
`If the copies must be certified for court or administrative proceedings, check here .
`Note:
`Year or period requested. Enter the ending date of the year or period, using the mm/dd/yyyy
`eig t year or periods, you must attach another F m 4506.
`SH 20
`(9
`20)9
`8
`
`.
`
`.
`.
`format.
`
`.
`
`.
`.
`.
`.
`.
`.
`.
`.
`.
`If you are requesting more than
`Q 3r/20Z/
`
`.
`
`¡
`
`7
`
`8
`
`a
`b
`c
`
`$
`
`50.00
`
`.
`
`.
`
`.
`
`.
`
`¡
`
`Phone number of taxpayer on line
`1a or 2a
`
`Fee. There is a $50 fee for each return requested. Full payment must be included with your
`request or it will
`be rejected. Make your check or money order payable to "United States Treasury." Enter your SSN,
`ITIN,
`or EIN and "Form 4506 request"
`on your check or money order.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`-
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`Cost for each return
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`Number of returns requested on line 7 .
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`.
`$
`.
`Total cost. Multiply line Ba by line 8b
`find the tax retum, we will refund the fee. If the refund should go to the third party listed on line 5, check here .
`If we cannot
`9
`Caution: Do not sign this form unless all applicable lines have been completed.
`I declare that I am either the taxpayer whose name is shown on line l a or 2a, or a person authorized to obtain the tax return
`Signature of taxpayer(s).
`If the request applies to a joint return, at least one spouse must sign. If signed by a corporate officer, 1 percent or more shareholder, partner,
`requested.
`trustee, or party other than the taxpayer, I certify that I have the authority to
`managing member, guardian, tax matters partner, executor, receiver, administrator,
`execute Form 4506 on behalf of the taxpayer. Note: This form must be received by IRS within 120 days of the signature date.
`and upon so reading
`clause
`has read the attestation
`¡
`that he/she
`attests
`Signatory
`to sign the Form 4506. See instructions.
`has the authority
`that he/she
`declares
`5-2tn
`Date
`
`Sign
`Here
`
`gnature (seeinstruc ions)
`
`Title (if line 1a above is a corporation, partnership, estate, or trust)
`
`Spouse's signature
`For Privacy Act and Paperwork Reduction Act Notice, see page 2.
`
`Date
`Cat. No. 41721E
`
`Form 4506
`
`(Rev.3-2019)
`
`
`
`FILED: KINGS COUNTY CLERK 08/10/2022 02:06 PM
`NYSCEF DOC. NO. 373
`
`INDEX NO. 504685/2015
`
`RECEIVED NYSCEF: 08/10/2022
`
`AUTHORIZATION
`
`INFORMATION
`OF HEALTH
`FOR RELEASE
`by the New York State Department
`This form has been approved
`
`PURSUANT
`of Health)
`
`OCA Official Form No.: 960
`TO HIPAA
`
`Patient Name
`
`n Aad
`
`en
`
`u222
`
`foy
`regarding my care and treatment be released as set forth on this form:
`the Health Insurance Portability
`and Accountability
`Act of 1996
`
`Patient Address 300)0
`that health information
`request
`I, or my authorized
`representative,
`In accordance with New York State Law and the Privacy Rule of
`that:
`I understand
`(HIPAA),
`and DRUG
`to ALCOIIOL
`MENTAL
`information
`of
`disclosure
`authorization
`rnay include
`HEALTH
`1. This
`ABUSE,
`relating
`HIV*
`INFORMATION
`only if 1 place my initials
`RELATED
`notes, and CONFIDENTIAL
`except psychotherapy
`on
`TREATMENT,
`these types of
`any of
`the health information
`described
`below includes
`line in Item 9(a).
`In the event
`the appropriate
`and I
`information,
`indicated
`in Item 8.
`the line on the box in Item 9(a),
`I specifically
`authorize
`release of such information
`to the person(s)
`initial
`or mental
`health treatment
`the release of 1UV-related,
`alcohol
`or drug treatment,
`the recipient
`I am authorizing
`2.
`If
`information,
`such information
`without my authorization
`to do so under
`federal
`from redisclosing
`unless permitted
`or state law.
`prohibited
`I have the right
`to request a list of people who may receive or use my HIV-related
`information
`that
`without
`understand
`authorization.
`I may contact
`because of
`the release or disclosure
`of HIV-related
`the New York State Division
`discrimination
`I experience
`information,
`at (212)
`at
`(212) 480-2493
`or
`the New York City Commission
`of Human Rights
`306-7450.
`These agencies
`of Human Rights
`are
`for protecting my rights.
`responsible
`listed below.
`to the health care provider
`at any time by writing
`to revoke this authorization
`I have the right
`3.
`that action has already been tak.en based on this authorization.
`except
`to the extent
`revoke this authorization
`enrollment
`in a health
`that signing
`this authorization
`is voluntary.
`I understand
`4.
`treatment,
`payment,
`My
`benefits will not be conditioned
`upon my authorization
`of
`this disclosure.
`disclosed
`under
`this authorization
`be redisclosed
`might
`Information
`5.
`redisclosure may no longer be protected by federal or state law.
`YOU TO DISCUSS MY HEALTH
`DOES NOT AUTHORIZE
`6. THIS AUTHORIZATION
`OTHER
`THE ATTORNFüOR
`GOVERNMENTAL
`THAN
`AGEd
`ANYONE
`CARE WITH
`health provid
`or e tity to el
`se this info
`tion:
`dress
`Name
`
`is
`I
`If
`
`I understand
`
`that
`
`I may
`
`plan, or cligibility
`
`for
`
`by the recipient
`
`(except
`
`as noted above in Item 2), and this
`
`INFORMATION
`-Y SP
`IFIED
`
`OR MEDICAL
`IN ITEM 9_@.
`
`erson to
`^
`
`hom
`
`is in
`
`rmation will be s a t:
`/_
`twydr
`. 2/
`
`)f
`
`Êf
`/o
`
`)d
`15TD
`
`)f¯¯
`S
`
`category o
`Name and ad res o per 'on(s
`qyd
`0
`,L
`rnd
`7
`to be re eased:
`information
`pecific
`Medical Record from (insert date)
`O Entire Medical Record,
`including
`re ords,
`consu ts, billing
`referrals,
`Other:
`/()
`/] bf
`
`9(a).
`
`|Ô
`d f
`to Discuss Health
`
`Authorization
`
`to (msert date)
`test results,
`off ce notes (except psychotherapy
`patient histories,
`notes),
`radiology
`nd records sent
`insurance
`to you by other health care providers.
`records,
`/YU b'
`/) o f
`Include:
`(Indicate
`by Initiating)
`Ñfn
`[
`fl
`Treatment
`Information
`Information
`
`studies,
`
`films,
`
`Alcohol/Drug
`Mental Health
`HIV-Related
`
`f)/
`
`Information
`
`(b) O By initialing
`
`here
`
`I authorize
`
`Inhials
`to discuss my health information
`
`with my attomey,
`
`or a governmental
`
`Name of individual health care provider
`listed here:
`agency,
`
`information:
`10. Reason for release of
`individual
`request of
`El At
`& C4| M C
`)D Other:
`C
`t, name of person signing
`the pati
`If not
`
`12.
`
`form:
`
`11. Date or event on which this authorization
`
`wiÜ expire:
`
`OF LITIGATION
`COMPLETION
`to sign on behalf of patient:
`13. Authority
`
`items on this form have been completed
`All
`the form.
`copy of
`
`and my questions about
`
`this form have been answered.
`
`In addition,
`
`I have been provided
`
`a
`
`i nature of patient or representative
`by law.
`infon 1 io which reasonably could
`Virus that causes AIDS. The New York State Public Health Law protects
`Human Immunodeficiency
`identify someone as having HIV symptoms or infection and information
`a person's contacts.
`regarding
`
`authorized
`
`No
`
`New York
`b c.
`M763
`¬.
`O m in K as Gwnty
`Commisswo Expkes November 1, 20
`
`
`
`FILED: KINGS COUNTY CLERK 08/10/2022 02:06 PM
`NYSCEF DOC. NO. 373
`
`AUTHORIZATION
`
`OF HEALTH
`INFORMATION
`FOR RELEASE
`State Department
`form has been approved
`by the New York
`
`[This
`
`Patient Name
`LEMA
`Address
`
`Patient
`
`JOSE
`
`300 Quentin
`
`Road,
`
`Apt.
`
`#2, Brooklyn,
`
`New York
`
`11223
`
`Date of Birth
`
`5-24-1979
`
`INDEX NO. 504685/2015
`
`RECEIVED NYSCEF: 08/10/2022
`OCA Official
`Form No.: 960
`TO HIPAA
`
`PURSUANT
`of Health]
`
`Social Security Number
`
`regarding
`the Health
`
`my care and treatment
`Insurance
`
`Portability
`
`be released
`as set
`and Accountability
`
`Rule of
`
`forth
`
`on this form:
`
`Act of 1996
`
`include
`
`information
`request
`that health
`I, or my authorized
`representative,
`with New York
`State Law and the Privacy
`In accordance
`that:
`I understand
`(HIPAA),
`HEALTH
`MENTAL
`and DRUG ABUSE,
`to ALCOHOL
`information
`of
`disclosure
`1. This
`authorization
`relating
`may
`HIV*
`if
`I place my initials
`RELATED
`notes, and CONFIDENTIAL
`on
`INFORMATION
`except
`TREATMENT,
`only
`psychotherapy
`and I
`described
`below includes
`any of
`these types of
`the health
`information
`In the event
`the appropriate
`line in Item 9(a).
`information,
`authorize
`release of such information
`in Item 8.
`initial
`the line on the box in Item 9(a),
`I specifically
`to the person(s)
`indicated
`or drug
`or mental
`health
`treatment
`the recipient
`the release
`of HIV-related,
`I am authorizing
`alcohol
`2.
`If
`treatment,
`information,
`such
`information
`without
`authorization
`unless
`permitted
`to do so under
`federal
`or
`state
`law.
`prohibited
`from redisclosing
`my
`a list of people who may receive
`or use my HIV-related
`understand
`that
`I have the right
`to request
`information
`without
`authorization.
`discrimination
`because
`of
`the release or disclosure
`of HIV-related
`I may contact
`the New York
`State Division
`I experience
`information,
`the New York
`City Commission
`of Human
`of Human
`Rights
`at
`480-2493
`or
`Rights
`at
`306-7450.
`These
`agencies
`are
`(212)
`(212)
`for protecting
`my rights.
`responsible
`listed
`care provider
`to the health
`at any time by writing
`to revoke
`this authorization
`3.
`I have the right
`been taken based on this authorization.
`that action
`has already
`to the extent
`revoke
`this authorization
`except
`enrollment
`in a health
`is voluntary.
`authorization
`4.
`I understand
`that
`this
`treatment,
`payment,
`My
`signing
`upon my authorization
`benefits will
`not be conditioned
`of
`this disclosure.
`Information
`disclosed
`under
`this
`authorization
`might
`be redisclosed
`5.
`may no longer
`be protected
`by federal
`or state law.
`redisclosure
`DOES NOT AUTHORIZE
`AUTHORIZATION
`6. THIS
`CARE WITH ANYONE
`OTHER THAN THE ATTORNEY
`Name
`and addr
`ss of he lth
`r vider
`to rel
`e th/s
`or enti
`
`is
`I
`If
`
`below.
`
`I understand
`
`that
`
`I may
`
`plan,
`
`or eligibility
`
`for
`
`by
`
`the recipient
`
`(except
`
`as noted
`
`above
`
`in Item 2), and this
`
`YOU TO DISCUSS MY HEALTH
`OR GOVERNMENTAL
`AGENCY
`formation:
`
`INFORMATION
`SPECIFIED
`
`OR MEDICAL
`IN ITEM
`9 (b).
`
`to whom this information
`77 Water
`LLP,
`Street,
`
`will
`be sent:
`Ste. 2100, New York,
`
`New York
`
`10005
`
`of person
`or category
`and address of person(s)
`8. Name
`BISGAARD
`& SMITH,
`LEWIS
`BRISBOIS
`information
`to be released:
`9(a).
`Specific
`/ - / L/-20
`date) p reen
`to (insert
`Record
`from (insert
`019fedical
`F&ndc#wr/I7
`date)
`O Entire Medical
`test
`notes (except
`office
`patient
`notes),
`histories,
`results,
`Record,
`radiology
`psythotherapy
`including
`sent
`insurance
`cons
`reco ds,
`reco ds, and records
`to you by other health
`care providers.
`referrals,
`Its, billing
`lÛ *
`)O
`Ir1ther:
`Include:
`(1ndicate
`d
`dmy
`
`|6
`
`repoM
`
`u t0ap
`
`studies,
`
`films,
`
`by initialing)
`T,ea,_t
`Information
`Information
`
`A,.o
`D,ug
`Health
`Mental
`HIV-Related
`
`Authorization
`to Discuss Health
`(b) O By initialing
`
`here
`
`Information
`
`I authorize
`
`to discuss my health
`
`Initials
`information
`
`with my attorney,
`
`or a governmental
`
`Name of
`agency,
`
`individual
`listed
`
`health care provider
`here:
`
`information:
`release of
`for
`10. Reason
`O At
`request
`of
`individual
`El Other:
`If not
`the patient,
`12.
`ANNA
`OLONA
`items on this form have been completed
`All
`copy of
`the form.
`
`(Attorney/Firm
`
`Name or Governmental
`Agency Name)
`11. Date or event on which
`
`this authorization
`
`will
`
`expire:
`
`name of person
`
`Litigation
`form:
`
`signing
`
`case
`
`of court
`
`upon
`conclusion
`of patient:
`to sign on behalf
`13. Authority
`See Annexed
`Power
`of Attorney
`this form have been answered.
`In addition,
`
`I have been
`
`r
`
`and my questions
`
`about
`
`natur
`* Human
`identify
`
`ati
`
`t or repres
`
`Immunodeficienc
`someone as havi
`
`y law·
`irus that causes AIDS. The New York State Public Health
`t
`Law pr
`and information
`c n
`or infection
`a person's
`g HIV symptoms
`regarding
`
`C
`Ive authorized
`
`Date:
`
`TAR
`
`t
`
`in ggy
`
`dit
`
`1
`
`P rf4
`f IEFP a
`es
`
`R
`20 4
`
`
`
`FILED: KINGS COUNTY CLERK 08/10/2022 02:06 PM
`NYSCEF DOC. NO. 373
`
`AUTHORIZATION
`
`INFORMATION
`OF HEALTH
`FOR RELEASE
`State Department
`form has been approved
`by the New York
`
`[This
`
`Patient Name
`LEMA
`Address
`
`Patient
`
`JOSE
`
`300 Quentin
`
`Road,
`
`Apt.
`
`#2, Brooklyn,
`
`New York
`
`11223
`
`Date of Birth
`
`5-24-1979
`
`INDEX NO. 504685/2015
`
`RECEIVED NYSCEF: 08/10/2022
`OCA Official
`Form No.: 960
`TO HIPAA
`
`PURSUANT
`of Health]
`
`Social Security Number
`
`regarding
`the Health
`
`my care and treatment
`Insurance
`
`Portability
`
`be released
`as set
`and Accountability
`
`Rule of
`
`forth
`
`on this form:
`
`Act of 1996
`
`include
`
`request
`that health
`information
`I, or my authorized
`representative,
`State Law and the Privacy
`with New York
`In accordance
`that:
`I understand
`(HIPAA),
`to ALCOHOL
`HEALTH
`MENTAL
`and DRUG ABUSE,
`information
`of
`disclosure
`1. This
`authorization
`relating
`may
`HIV*
`if
`I place my initials
`RELATED
`notes, and CONFIDENTIAL
`on
`INFORMATION
`except
`TREATMENT,
`only
`psychotherapy
`described
`below includes
`any of
`these types of
`and I
`the health
`information
`In the event
`the appropriate
`line in Item 9(a).
`information,
`authorize
`in Item 8.
`initial
`the line on the box in Item 9(a),
`I specifically
`release of such information
`to the person(s)
`indicated
`or drug
`or mental
`health
`treatment
`the recipient
`the release
`of HIV-related,
`I am authorizing
`alcohol
`2.
`If
`treatment,
`information,
`information
`without
`authorization
`unless
`to do so under
`federal
`or state
`prohibited
`from redisclosing
`such
`permitted
`law.
`my
`understand
`that
`I have the right
`to request
`a list of people who may receive
`or use my HIV-related
`information
`without
`authorization.
`discrimination
`the release
`or disclosure
`of HIV-related
`the New York
`State Division
`I experience
`because
`of
`I may contact
`information,
`the New York
`of Human
`of Human
`Rights
`at
`480-2493
`or
`City Commission
`Rights
`at
`306-7450.
`These
`agencies
`are
`(212)
`(212)
`for protecting
`my rights.
`responsible
`care provider
`to the health
`at any time by writing
`this authorization
`listed
`3.
`I have the right
`to revoke
`been taken based on this authorization.
`to the extent
`that action
`has already
`revoke
`this authorization
`except
`is voluntary.
`authorization
`enrollment
`in a health
`4.
`I understand
`that
`this
`treatment,
`payment,
`My
`signing
`of
`this disclosure.
`upon my authorization
`benefits will
`not be conditioned
`under
`authorization
`might
`be redisclosed
`5.
`Information
`disclosed
`this
`by federal
`or state law.
`redisclosure
`may no longer
`be protected
`YOU TO DISCUSS MY HEALTH
`DOES NOT AUTHORIZE
`6. THIS
`AUTHORIZATION
`OR GOVERNMENTAL
`AGENCY
`CARE WITH ANYONE
`OTHER THAN THE ATTORNEY
`ati
`:
`of
`ealth
`rovider
`to r
`ase this info
`or entity
`7. Name
`and address
`
`is
`I
`If
`
`below.
`
`I understand
`
`that
`
`I may
`
`plan,
`
`or eligibility
`
`for
`
`by
`
`the recipient
`
`(except
`
`as noted
`
`above
`
`in Item 2), and this
`
`INFORMATION
`SPECIFIED
`
`OR MEDICAL
`IN ITEM
`9 (b).
`
`to whom this information
`77 Water
`LLP,
`Street,
`
`be sent:
`will
`Ste. 2100, New York,
`
`New York
`
`10005
`
`)
`
`films,
`
`and address
`8. Name
`LEWIS
`BRISBOIS
`information
`9(a).
`Specific
`GF1sfedical Record
`O Entire Medical
`consul
`referrals,
`EFOther:
`
`of person
`or category
`of person(s)
`& SMITH,
`BISGAARD
`to be release
`:
`from (insert
`da
`Record,
`including
`s, billing
`cords,
`AS
`
`(
`
`tÔq
`
`Ob 5 f)
`
`(
`
`fnÌd/
`to (insert
`date)
`patient
`notes (except
`office
`notes),
`histories,
`psychotherapy
`ins
`sent
`s and records
`to you by other health
`r nee recor
`Û HÓ Ó
`Include:
`(Indicate
`D/Ó
`O
`f
`
`Authorization
`
`Information
`
`I authorize
`
`here
`
`to Discuss Health
`(b) O By initialing
`
`to discuss my health
`
`Initials
`information
`
`with my attorney,
`
`or a governmental
`
`Name of
`agency,
`
`individual
`listed
`
`health care provider
`here:
`
`test
`results,
`radiology
`care providers.
`
`studies,
`
`by Initialing)
`Treatment
`Information
`Information
`
`Alcohol/Drug
`Mental
`Health
`HIV-Related
`
`release of
`10. Reason
`information:
`for
`O At
`individual
`request
`of
`El Other:
`If not
`the patient,
`12.
`ANNA
`OLONA
`All
`items on this form have been completed
`copy of
`the form.
`
`(Attorney/Firm
`
`Name or Governmental
`Agency Name)
`11. Date or event on which
`
`this authorization
`
`will
`
`expire:
`
`name of person
`
`Litigation
`form:
`
`signing
`
`upon
`conclusion
`13. Authority
`See Annexed
`
`of court
`case
`to sign on behalf
`of patient:
`Power
`of Attorney
`this form have been answered.
`In addition,
`
`I have been provided
`
`a
`
`and my questions
`
`about
`
`nature
`* Human
`identify
`
`aÓe
`
`e rese
`
`1
`
`honz
`
`y law.
`
`NOTARY
`
`B
`
`Law
`irus that causes AIDS. The New York State Public Health
`Immunodeficiency
`a person'
`or
`and information
`infection
`someone as having HIV symptoms
`regarding
`
`rotec
`c
`
`m:lwikich GdMeNably
`Nov
`s on Expires
`
`c uld
`
`
`
`FILED: KINGS COUNTY CLERK 08/10/2022 02:06 PM
`NYSCEF DOC. NO. 373
`
`AUTHORIZATION
`
`OF HEALTH
`FOR RELEASE
`INFORMATION
`form has been approved
`State Department
`by the New York
`
`[This
`
`Patient Name
`LEMA
`Address
`
`JOSE
`Patient
`
`300 Quentin
`
`Road,
`
`Apt.
`
`#2, Brooklyn,
`
`New York
`
`11223
`
`Date of Birth
`
`5-24-1979
`
`INDEX NO. 504685/2015
`
`RECEIVED NYSCEF: 08/10/2022
`OCA Official
`Form No.: 960
`TO HIPAA
`
`PURSUANT
`of Health]
`
`Social Security Number
`
`regarding
`the Health
`
`my care and treatment
`Insurance
`
`Portability
`
`be released
`as set
`and Accountability
`
`Rule of
`
`forth
`
`on this form:
`
`Act of 1996
`
`include
`
`information
`that health
`request
`I, or my authorized
`representative,
`State Law and the Privacy
`In accordance
`with New York
`I understand
`that:
`(HIPAA),
`to ALCOHOL
`HEALTH
`MENTAL
`and DRUG ABUSE,
`information
`of
`disclosure
`1. This
`authorization
`relating
`may
`HIV*
`notes, and CONFIDENTIAL
`I place my initials
`INFORMATION
`RELATED
`except
`on
`if
`TREATMENT,
`psychotherapy
`only
`the health
`line in Item 9(a).
`In the event
`described
`below includes
`any of
`these types of
`the appropriate
`information
`and I
`information,
`initial
`the line on the box in Item 9(a),
`I specifically
`authorize
`release of such information
`to the person(s)
`in Item 8.
`indicated
`2.
`If
`the release
`of HIV-related,
`I am authorizing
`alcohol
`or mental
`or drug
`health
`treatment
`the recipient
`treatment,
`information,
`from redisclosing
`such
`information
`without
`authorization
`prohibited
`unless
`permitted
`to do so under
`federal
`or
`state
`law.
`my
`a list of people who may receive
`understand
`that
`I have the right
`to request
`or use my HIV-related
`information
`without
`authorization.
`I experience
`discrimination
`because
`of
`the release
`or disclosure
`of HIV-related
`I may contact
`the New York
`State Division
`information,
`of Human
`at
`480-2493
`or
`the New York
`City Commission
`of Human
`Rights
`Rights
`at
`306-7450.
`These
`agencies
`are
`(212)
`(212)
`for protecting
`my rights.
`responsible
`to the health
`at any time by writing
`I have the right
`to revoke
`this authorization
`listed
`care provider
`3.
`been taken based on this authorization.
`that action
`this authorization
`to the extent
`has already
`revoke
`except
`is voluntary.
`4.
`I understand
`that
`this
`authorization
`enrollment
`in a health
`My treatment,
`payment,
`signing
`upon my authorization
`of
`this disclosure.
`benefits will
`not be conditioned
`authorization
`5.
`Information
`disclosed
`under
`this
`might
`be redisclosed
`redisclosure
`may no longer
`be protected
`by federal
`or state law.
`DOES NOT AUTHORIZE
`AUTHORIZATION
`6. THIS
`OTHER THAN THE ATTORNEY
`CARE WITH ANYONE
`7. N
`to rel ase t
`e and ad
`ess of health
`provider
`or entity
`
`is
`I
`If
`
`below.
`
`I understand
`
`that
`
`I may
`
`plan,
`
`or eligibility
`
`for
`
`by
`
`the recipient
`
`(except
`
`as noted
`
`above
`
`in Item 2), and this
`
`YOU TO DISCUSS MY HEALTH
`OR GOVERNMENTAL
`AGENCY
`is informa
`n:
`
`INFORMATION
`SPECIFIED
`
`OR MEDICAL
`IN ITEM
`9 (b).
`
`to whom this information
`77 Water
`LLP,
`Street,
`
`will
`be sent:
`Ste. 2100, New York,
`
`New York
`
`10005
`
`of person
`or category
`and address of person(s)
`8. Name
`& SMITH,
`BISGAARD
`LEWIS
`BRISBOIS
`information
`to be released:
`9(a).
`Specific
`CD49Iedical Record
`from (insert
`date)
`O Entire Medical
`Record,
`including
`cons
`r cords,
`referrals,
`Its, billing
`d 5
`/ /Ì
`Other:
`O (
`
`2 O R
`
`to (insert
`date)
`office
`notes (except
`patient
`test
`histories,
`results,
`notes),
`psyclotherapy
`radiology
`care providers.
`sent
`ànd records
`insu ance records,
`to you by other health
`M4
`Include:
`(Indicate
`
`O
`
`studies,
`
`films,
`
`by Initialing)
`Treatment
`Information
`Information
`
`Alcohol/Drug
`Mental
`Health
`HIV-Related
`
`Authorization
`
`Information
`
`I authorize
`
`here
`
`to Discuss Health
`(b) O By initialing
`
`to discuss my health
`
`Initials
`information
`
`with my attorney,
`
`or a governmental
`
`Name of
`agency,
`
`individual
`listed
`
`health care provider
`here:
`
`release of
`for
`10. Reason
`information:
`O At
`request
`of
`individual
`El Other:
`If not
`the patient,
`12.
`ANNA
`OLONA
`All
`items on this form have been completed
`copy of
`the
`.
`
`(Attorney/Firm
`
`Name or Governmental
`Agency Name)
`11. Date or event on which
`
`this authorization
`
`will
`
`expire:
`
`name of person
`
`Litigation
`form:
`
`signing
`
`upon
`conclusion
`of court
`case
`13. Authority
`to sign on behalf
`of patient:
`See Annexed
`Power
`of Attorney
`this form have been answered.
`In addition,
`
`I have been provided
`
`a
`
`and my questions
`
`about
`
`6-(
`ient or representative
`
`gnature
`* Human
`identify
`
`by law.
`that causes AIDS. The New York State Public Health
`Virus
`Immunodeficiency
`someone as having HIV symptoms
`or
`infection
`a per
`and information
`regarding
`
`authorized
`
`.
`
`Date:
`
`TE O N
`stration No. OiSH
`
`O 0
`
`O
`
`aw pr
`6
`
`iqstwhi
`
`lerr a
`
`could
`
`
`
`FILED: KINGS COUNTY CLERK 08/10/2022 02:06 PM
`NYSCEF DOC. NO. 373
`
`AUTHORIZATION
`
`INFORMATION
`OF HEALTH
`FOR RELEASE
`State Department
`form has been approved
`by the New York
`
`[This
`
`Patient Name
`LEMA
`Address
`
`Patient
`
`JOSE
`
`300 Quentin
`
`Road,
`
`Apt.
`
`#2, Brooklyn,
`
`New York
`
`11223
`
`Date of Birth
`
`5-24-1979
`
`INDEX NO. 504685/2015
`
`RECEIVED NYSCEF: 08/10/2022
`OCA Official
`Form No.: 960
`TO HIPAA
`
`PURSUANT
`of Health]
`
`Social Security Number
`
`regarding
`the Health
`
`my care and treatment
`Insurance
`Portability
`
`be released
`as set
`and Accountability
`
`Rule of
`
`forth
`
`on this form:
`
`Act of 1996
`
`include
`
`request
`that health
`information
`I, or my authorized
`representative,
`with New York State Law and the Privacy
`In accordance
`I understand
`that:
`(HIPAA),
`HEALTH
`MENTAL
`and DRUG ABUSE,
`to ALCOHOL
`information
`of
`disclosure
`1. This
`authorization
`relating
`may
`HIV*
`notes, and CONFIDENTIAL
`if
`I place my initials
`INFORMATION
`RELATED
`except
`on
`TREATMENT,
`psychotherapy
`only
`In the event
`the health
`described
`below includes
`any of
`these types of
`and I
`the appropriate
`line in Item 9(a).
`information
`information,
`initial
`the line on the box in Item 9(a),
`I specifically
`authorize
`release of such information
`in Item 8.
`to the person(s)
`indicated
`or mental
`health
`If
`the release
`of HIV-related,
`I am authorizing
`alcohol
`or drug
`treatment
`the recipient
`2.
`treatment,
`information,
`from redisclosing
`such
`information
`without
`authorization
`prohibited
`unless
`permitted
`to do so under
`federal
`or
`state
`law.
`my
`a list of people who may receive
`understand
`that
`I have the right
`to request
`or use my HIV-related
`information
`without
`authorization.
`I experience
`discrimination
`because
`of
`the release
`or disclosure
`of HIV-related
`I may contact
`the New York
`State Division
`information,
`of Human
`Rights
`at
`480-2493
`or
`the New York
`City Commission
`of Human
`Rights
`at
`306-7450.
`These
`agencies
`are
`(212)
`(212)
`responsible
`for protecting
`my rights.
`at any time by writing
`to revoke
`this authorization
`listed
`care provider
`to the health
`3.
`I have the right
`to the extent
`been taken based on this authorization.
`that action
`has already
`revoke
`this authorization
`except
`authorization
`enrollment
`in a health
`is voluntary.
`4.
`I understand
`that
`this
`My treatment,
`payment,
`signing
`of
`this disclosure.
`benefits
`will
`not be conditioned
`upon my authorization
`5.
`Information
`disclosed
`under
`authorization
`might
`be redisclosed
`this
`may no longer
`by federal
`or state law.
`redisclosure
`be protected
`DOES NOT AUTHORIZE
`6. THIS
`AUTHORIZATION
`CARE WITH ANYONE
`OTHER THAN THE ATTORNEY
`to release this i
`Name
`and ad
`ss of he
`th
`o ider or enti
`
`is
`I
`If
`
`below.
`
`I understand
`
`that
`
`I may
`
`plan,
`
`or eligibility
`
`for
`
`by the recipient
`
`(except
`
`as noted
`
`above
`
`in Item 2), and this
`
`YOU TO DISCUSS MY HEALTH
`OR GOVERNMENTAL
`AGENCY
`fh
`tion:
`
`INFORMATION
`SPECIFIED
`
`OR MEDICAL
`IN ITEM
`9 (b).
`
`to whom this information
`77 Water
`LLP,
`Street,
`
`be sent:
`will
`Ste. 2100, New York,
`
`New York
`
`10005
`
`patient
`histories,
`insu ance reco
`
`studies,
`
`films,
`
`of person
`or category
`and address of person(s)
`8. Name
`& SMITH,
`BISGAARD
`LEWIS
`BRISBOIS
`9(a).
`Spe ific
`information
`to be released:
`edical Record
`from (insert
`date)
`O Entire Medical
`Record,
`including
`billin
`consults,
`records,
`referrals,
`G(*
`(Grbther:
`U
`
`2
`
`d myah
`
`d(
`
`(cid:27)(Î
`to (insert
`(.90
`/ d
`(cid:8)ff)/Ú/)
`date)
`test
`notes (except
`psyc
`office
`results,
`notes),
`radiology
`otherapy
`s, and records
`care providers.
`sent
`to you by other health
`Include:
`(Indicate
`
`by Initialing)
`Treatment
`Information
`Information
`
`AlcowDrug
`Mental
`Health
`HIV-Related
`
`repU
`
`d
`
`hw ond
`
`Information
`
`I authorize
`
`Authorization
`to Discuss Health
`(b) O By initialing
`
`here
`
`to discuss my health
`
`Initials
`information
`
`with my attorney,
`
`or a governmental
`
`Name of
`agency,
`
`individual
`listed
`
`health care provider
`here:
`
`information:
`release of
`for
`10. Reason
`O At
`request
`of
`individual
`El Other:
`If not
`the patient,
`12.
`ANNA
`OLONA
`All
`items on this form have been completed
`t
