FILED: KINGS COUNTY CLERK 04/16/2018 07:03 PM
`FILED: KINGS COUNTY CLERK 04m2018 07:03 P
`NYSC 3F DOC. NO. 24
`NYSCEF DOC. NO. 24
`
`IND
`EX NO.
`513649/2016
`INDEX NO. 513649/2016
`
` VYSC
`
` «IIV-4 .D
`
`
`3F:
`04/16/2018
`RECEIVED NYSCEF: 04/16/2018
`
`EXHIBIT “B”
`
`

`

`FILED: KINGS COUNTY CLERK 04/16/2018 07:03 PM
`NYSCEF DOC. NO. 24
`
`INDEX NO. 513649/2016
`
`RECEIVED NYSCEF: 04/16/2018
`
`SUPREME
`COUNTY
`--------
`ROY DAVE
`
`COURT
`OF KINGS
`--
`
`DAVIS,
`
`OF THE STATE
`
`OF NEW YORK
`
`-----------------------X
`ANSCHERLEY
`
`NOEL,
`
`Plaintiffs,
`
`-against-
`-agal ns't-
`
`PLAINTIFF'S
`TO
`REPLY
`COMPLIANCE
`ORDER
`
`CONFERENCE
`
`SORIN
`
`DANCU,
`
`JOSEPH
`
`S. DANCU,
`
`Index#:
`
`513649/2016
`
`Defendants,
`------------------------------------------------------------X
`
`Plaintiff,
`
`ROY
`
`DAVE
`
`DAVIS,
`
`by
`
`his
`
`attorneys,
`
`GREGORY
`
`SPEKTOR
`
`AND
`
`ASSOCIATES,
`
`P.C.,
`
`responding
`
`to Compliance
`
`Conference
`
`Order,
`
`dated
`
`June
`
`26,
`
`2017
`
`alleges,
`
`upon
`
`information
`
`and
`
`belief,
`
`as follows;
`
`As
`
`to Plaintiff
`
`ROY DAVE
`
`DAVIS:
`
`1. Respond
`
`to
`
`Post
`
`EBT
`
`Demands
`
`for
`
`Discovery
`
`along
`
`with
`
`IIIPAA
`
`Authorizations
`
`were
`
`provided
`
`to your
`
`office
`
`on July
`
`5th, 2017.
`
`2.
`
`Trial
`
`Authorizations
`
`for
`
`all providers
`
`are annexed
`
`hereto.
`
`Dated:
`
`Rosedale,
`
`NY
`
`July
`
`7'"
`7th, 2017
`
`etc.
`Yours,
`GREGORY
`SPEKTOR
`for Plaintiffs
`Attorney
`ROY DAVE
`One Cross
`
`DAVIS,
`Island
`Plaza,
`NY 11422
`Rosedale,
`528-5272
`(718)
`
`AND ASSOCIATES,
`
`P.C.
`
`ANSC11ERLEY
`Suite
`203C
`
`NOEL
`
`

`

`FILED: KINGS COUNTY CLERK 04/16/2018 07:03 PM
`NYSCEF DOC. NO. 24
`
`INDEX NO. 513649/2016
`
`RECEIVED NYSCEF: 04/16/2018
`
`To:
`
`JAMES
`Attorneys
`SORIN
`JOSEPH
`100 Duffy
`Hicksville,
`
`516-861-1830516-861-1830
`
`G. BILELLO
`for Defendant(s)
`DANCU,
`S. DANCU.
`Suite
`Avenue,
`NY 11801
`
`& ASSOCIATES
`
`500
`
`

`

`FILED: KINGS COUNTY CLERK 04/16/2018 07:03 PM
`NYSCEF DOC. NO. 24
`
`INDEX NO. 513649/2016
`
`RECEIVED NYSCEF: 04/16/2018
`
`AFFIDAVIT
`
`OF SERVICE
`
`STATE
`
`OF NEW YORK)
`
`COUNTY
`
`OF QUEENS)
`
`ss.
`
`Dow p
`
`gee
`
`/i
`
`aes
`
`being
`
`duly
`
`sworn
`
`deposes
`
`and
`
`says.'
`says:
`
`I am over
`
`18 years
`
`of
`
`age,
`
`I am not
`
`a party
`
`to the
`
`action,
`
`and
`
`I
`
`reside
`
`in Queens
`
`County
`
`in the State
`
`of New York.
`
`I served
`
`a true
`
`copy
`
`of
`
`the
`
`annexed:
`
`PLAINTIFF'S
`
`REPLY
`
`TO COMPLIANCE
`
`CONFERENCE
`
`ORDER
`
`On
`
`0
`__day
`dsy
`
`of Ótede,
`
`2017
`
`the
`
`same
`
`in a sealed
`
`by mailing
`or official
`
`to the last
`
`depository
`known
`
`of
`
`the U.S.
`
`envelope,
`Postal
`
`with
`
`postage
`
`prepaid
`
`Service
`
`within
`
`the State
`
`in a post
`thereon,
`of New York,
`
`office
`
`addressed
`
`address
`
`of
`
`the
`
`addressee
`
`as indicated
`
`below:
`
`JAMES
`Attorneys
`SORIN
`JOSEPH
`100 Duffy
`Hicksville,
`516-861-1830
`
`G. BILELLO
`for Defendant(s)
`DANCU,
`S. DANCU.
`Avenue,
`NY 11801
`
`Suite
`
`& ASSOCIATES
`
`500
`
`l
`
`Sworn
`On
`
`to before me
`J<4
`7
`
`day
`
`. 2017
`
`Notary
`
`Pubhe
`
`STETSKA
`OKSANA
`STATE OF NEW YORK
`PUBUC
`NOTARY
`COUNTY
`WESTCHESTER
`LIC. # 01ST6358193
`
`

`

`FILED: KINGS COUNTY CLERK 04/16/2018 07:03 PM
`NYSCEF DOC. NO. 24
`
`INDEX NO. 513649/2016
`
`RECEIVED NYSCEF: 04/16/2018
`
`a~ON
`
`~;„.r„ie
`
`AUTHORIZATION
`[This
`
`FOR RELEASE
`OF HEALTH
`INFORMATION
`form has been approved
`by the New York State Department
`
`PURSUANT
`of Health]
`
`OCA Official Form No,: 960
`TO HIPAA
`
`Patient Name
`Roy Dave Davis
`Patient Address
`
`)423
`
`(llpÓCStreet,
`
`Elmont,
`
`NY 11003
`
`Date of Birth
`
`WJ$6t257
`
`Social Security Number
`26,2se-spr
`
`be released as set forth on this form:
`regarding my care and treatment
`Act of 1996
`the Health Insurance Portability
`and Accountability
`
`is
`I
`If
`
`I understand that
`
`I may
`
`for
`
`by the recipient
`
`(except
`
`as noted above in Item 2), and this
`
`INFORMATION
`SPECIFIED
`
`OR MEDICAL
`IN ITEM 9 (b)..
`
`Ro'G $2 mS ½ of
`& ectu
`/W i
`p, my
`
`j'3i
`
`8~
`8
`will
`be sent:
`Re m ors
`
`SQw,
`
`I, or my authorized
`that health information
`request
`representative,
`In accordance with New York State Law and the Privacy Rule of
`I understand
`that:
`(HIPAA),
`HEALTH
`MENTAL
`to ALCOHOL
`information
`1. This
`authorization
`and DRUG
`of
`disclosure
`include
`ABUSE,
`relating
`may
`HIV* RELATED
`I place my initials on
`only if
`notes, and CONFIDENTIAL
`except psychotherapy
`INFORMATION
`TREATMENT,
`and I
`the appropriate
`these types of
`line in Item 9(a).
`In the event
`below includes any of
`the health information
`described
`information,
`initial
`in Item 8.
`the line on the box in Item 9(a),
`I specifically
`release of such information
`indicated
`authorize
`to the person(s)
`If
`the release of HIV-related,
`I am authorizing
`alcohol
`or mental
`or drug treatment,
`health treatment
`the recipient
`2.
`information,
`from redisclosing
`to do so under
`federal
`or state law.
`prohibited
`such information
`without my authorization
`unless permitted
`understand that
`I have the right
`to request a list of people who may receive or use my HIV-related
`authorization.
`information
`without
`I experience
`the New York State Division
`discrimination
`because of
`the release or disclosure
`of HIV-related
`I may contact
`information,
`of Human Rights
`the New York City Commission
`These agencies are
`at (212) 480-2493
`or
`of Human Rights
`at
`(212) 306-7450.
`responsible
`for protecting my rights.
`I have the right
`listed below.
`to the health care provider
`at any time by writing
`3.
`to revoke this authorization
`that action has already been taken based on this authorization.
`revoke this authorization
`to the extent
`except
`I understand
`4.
`in a health plan, or eligibility
`is voluntary.
`enrollment
`that signing,
`this authorization
`treatment,
`payment,
`My
`benefits will not be conditioned
`upon my authorization
`of
`this disclosure.
`be redisclosed
`5.
`Information
`disclosed
`under
`this authorization
`might
`redisclosure may no longer be protected
`by federal or state law.
`YOU TO DISCUSS MY HEALTH
`6. THIS
`DOES NOT AUTHORIZE
`AUTHORIZATION
`OR GOVERNMENTAL
`AGENCY
`CARE WITII
`OTHER
`THE ATTORNEY
`ANYONE
`THAN
`7. Name and address of health provider
`to release this information:
`or entity
`r
`0
`f
`C9eiX,X,'/6
`o.C
`7/,
`rent
`8. Name and address of person(s
`of person to whom this information
`or category
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`c-'r'
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`twh( ~e
`o n
`.
`Â(it
`cr
`5
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`. pecific
`to be released:
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`Record from (insert date) P /P
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`us Entire Medical Record,
`including
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`
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`(A
`to (insert date)
`test results,
`office notes (except psychotherapy
`patient histories,
`notes),
`radiology
`to you by other health care providers.
`insurance
`records, and records sent
`/ n
`Include:
`(Indicate
`by Initialing)
`1 /f
`,
`Treatment
`Alcohol/Drug
`Mental Health
`Information
`Information
`HIV-Related
`
`studies,
`
`films,
`
`Authorization
`
`to Discuss Health
`
`Information
`
`(b) 0 By initialing
`
`here
`
`I authorize
`
`Initials
`to discuss my health information
`
`with my attorney,
`
`or a governmental
`
`Name of individual health care provider
`listed here:
`agency,
`
`information:
`release of
`10. Reason for
`O At
`request of
`individual
`4
`< fo
`-Zr./
`>
`tbt
`4TOther:
`the patient, ndme of person signing
`If not
`
`12.
`
`(Attorney/Firm Name or Governmental Agency Name)
`11. Date or event on which this authorization
`> ¾ ['
`d
`A½d
`.~~
`.Z~/i
`c
`if
`to sign on behalf of patient:
`13. Authority
`
`form:
`
`will expire:
`
`'c
`
`items on this form have been completed
`All
`copy of
`the form.
`
`and my questions about
`
`this form have been answered.
`
`In addition,
`
`I have been provided
`
`a
`
`fg~-
`by law.
`of patient or representative
`Signatu
`* Human Immunodeficiency
`Law protects information which reasonably could
`Virus that causes AIDS. The New York State Public llealth
`regarding a person's coniacts.
`or
`someone ss
`infection
`inl'urmaiion
`sympioms
`snd
`having MIV
`iden(il'y
`
`authorized
`
`Date:
`
`

`

`FILED: KINGS COUNTY CLERK 04/16/2018 07:03 PM
`NYSCEF DOC. NO. 24
`
`INDEX NO. 513649/2016
`
`RECEIVED NYSCEF: 04/16/2018
`
`AUTHORIZATION
`[This
`
`OF HEALTH
`FOR RELEASE
`INFORMATION
`form has been approved
`by the New York State Department
`
`PURSUANT
`of Healthl
`
`OCA Ofilcial Form No.: 960
`TO HIPAA
`
`Patient Name
`Roy Dave Davis
`Patient Address
`
`340FJ‡d0t$46gW,
`
`Elmont,
`
`NY 11003
`
`Date of Birth
`5/29/1993
`
`Social Security Number
`9T
`)b$6t$
`
`be released as set forth on this form:
`Act of 1996
`and Accountability
`
`is
`l
`If
`
`I understand that
`
`I may
`
`for
`
`by the recipient
`
`(except as noted above in Item 2), and this
`
`INFORMATION
`SPECIFIED
`
`OR MEDICAL
`IN ITEM 9 (b). ~
`
`N'
`ff
`ÂÂQ.Q M~~5'
`
`/
`
`«
`it'>
`t (til
`
`I'
`
`studies,
`
`films,
`
`that health information
`I, or my authorized
`regarding my care and treatment
`request
`representative,
`In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability
`I understand
`that:
`(HIPAA),
`HEALTH
`MENTAL
`and DRUG
`to ALCOHOL
`of
`include
`1. This
`authorization
`information
`disclosure
`ABUSE,
`may
`relating
`HIV*
`I place my initials on
`only if
`INFORMATION
`RELATED
`notes, and CONFIDENTIAL
`except psychotherapy
`TREATMENT,
`and I
`these types of
`the appropriate
`below includes
`any of
`line in Item 9(a).
`the health information
`described
`In the event
`information,
`in Item 8.
`initial
`the line on the box in Item 9(a),
`I specifically
`to the person(s)
`indicated
`authorize
`release of such information
`the recipient
`If
`I am authorizing
`or mental
`2.
`the release of HIV-related,
`alcohol
`or drug treatment,
`health treatment
`information,
`to do so under
`federal
`or state law.
`prohibited
`from redisclosing
`'such
`without my authorization
`permitted
`information
`unless
`understand that
`without
`authorization.
`I have the right
`to request a list of people who may receive or use my HIV-related
`information
`the New York State Division
`I may contact
`I experience
`discrimination
`the release or disclosure
`of HIV-related
`because of
`information,
`These agencies are
`of Human Rights
`the New York City Commission
`of Human Rights
`306-7450.
`at
`(212) 480-2493
`or
`at
`(212)
`for protecting my rights.
`responsible
`to the health care provider
`I have the right
`listed below,
`at any time by writing
`to revoke this authorization
`3.
`that action has already been taken based on this authorization.
`revoke this authorization
`to the extent
`except
`in a health plan, or eligibility
`enrollment
`I understand
`4.
`that signing
`this authorization
`is voluntary.
`payment,
`My treatment,
`benefits will not be conditioned
`of
`upon my authorization
`this disclosure.
`this authorization
`5.
`Information
`disclosed
`under
`might
`be redisclosed
`redisclosure may no longer be protected
`by federal or state law.
`YOU TO DISCUSS MY HEALTH
`DOES NOT AUTHORIZE
`6, THIS AUTHORIZATION
`OR GOVERNMENTAL
`AGENCY
`OTHER
`CARE WITH
`ANYONE
`THAN
`THE ATTORNEY
`or entity to release this information:
`7. Nnme and address of health provider
`f(
`$1W /( Å
`q u d
`a
`n /4t
`.
`E<.'6
`//Ÿ.Pl/
`r (
`(p(pp
`of person to whom this information
`8 Name and address of person(s) or tafegory
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`/4'
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`A>re
`(etc(
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`informn
`b (3
`VMedical
`Record from (insert date)
`test results,
`office notes (except psychotherapy
`Entire Medical Record,
`patient histories,
`notes),
`radiology
`including
`to you by other health care providers.
`insurange records, and records sent
`records,
`referrals,
`consults,
`billing
`* Pr
`P Ji
`r~A
`7
`C
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`/(.2c'8<
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`d
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`r
`e
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`Alcohol/Drug
`Mental Health
`Information
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`
`P27
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`t 6 Or>t
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`ft &'N
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`
`- 2W to (insert date) Ê 6/4
`
`fw
`
`<>t
`
`>4l
`
`Authorization
`
`to Discuss Health
`
`Information
`
`(b) 0 By initialing
`
`here
`
`I authorize
`
`Initials
`to discuss my health information
`
`with my attorney,
`
`or a governmental
`
`Name of individual health care provider
`listed here:
`agency,
`
`information:
`release of
`10. Reason for
`individual
`At
`request of
`eOther:
`the patient, narKe of person signing form:
`If not
`
`12.
`
`(Attorney/Firm Name or Governmental Agency Name)
`11 Date or event on which this authorization
`
`will expire:
`
`~ f.
`d(r
`f
`13. Authority
`
`.-@ ~ -'( ggA.(
`(~~/
`gp
`to sign on behalf of patient
`
`items on this form have been completed
`All
`copy of
`the form.
`
`and my questions about
`
`this form have been answered.
`
`In addition,
`
`I have been provided a
`
`I
`
`SCZl
`by law.
`authorized
`Signa ure of patient or representative
`* Human Immunodeficiency
`Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could
`a peinon's cuniacis.
`and
`infurmaiiun
`having HIV
`sytnpiums or
`infectiun
`sumeune as
`regarding
`ideniii'y
`
`Date:
`
`.0
`
`

`

`FILED: KINGS COUNTY CLERK 04/16/2018 07:03 PM
`NYSCEF DOC. NO. 24
`
`INDEX NO. 513649/2016
`
`RECEIVED NYSCEF: 04/16/2018
`
`~i A~a
`
`AUTHORIZATION
`[This
`
`INFORMATION
`OF HEALTH
`FOR RELEASE
`form has been approved
`by the New York State Department
`
`PURSUANT
`of Health]
`
`OCA Official Form No.: 960
`TO HIPAA
`
`Patient Name
`Roy Dave Davis
`Patient Address
`
`)ØFMØp)lgl@pl(Elmont,
`
`NY 11003
`
`Date of Birth
`5/29/1993
`
`Social Security Number
`INN-&'
`F-p$g
`
`be released as set forth on this form:
`regarding my care and treatment
`Act of 1996
`the Health Insurance Portability
`and Accountability
`
`is
`I
`If
`
`I understand that
`
`I may
`
`for
`
`by the recipient
`
`(except
`
`as noted above in Item 2), and this
`
`INFORMATION
`SPECIFIED
`
`//
`.v//
`
`/3
`S/5
`fida
`3 60
`Scophyn>gg
`-
`
`OR MEDICAL
`2 P
`IN ITEM 9 (b)..
`g-
`// 2 37
`'/
`s unt
`rr O N 2
`
`Cr p
`
`/
`
`that health information
`I, or my authorized
`request
`representative,
`In accordance with New York State Law and the Privacy Rule of
`I understand
`that:
`(HIPAA),
`HEALTH
`MENTAL
`1. This
`authorization
`and DRUG ABUSE,
`to ALCOHOL
`of
`include
`information
`disclosure
`may
`relating
`HIV* RELATED
`I place my initials on
`INFORMATION
`only if
`notes, and CONFIDENTIAL
`except psychotherapy
`TREATMENT,
`and I
`any of
`these types of
`the appropriate
`line in Item 9(a).
`In the event
`described
`below includes
`the health information
`information,
`initial
`the line on the box in Item 9(a),
`release of such information
`indicated
`in Item 8.
`I specifically
`to the person(s)
`authorize
`If
`the recipient
`2.
`the release of HIV-related,
`I am authorizing
`or mental
`health treatment
`alcohol
`or drug treatment,
`information,
`from redisclosing
`federal
`or state law.
`such information
`unless
`permitted
`to do so under
`prohibited
`without my authorization
`I have the right
`to request a list of people who may receive or use my HIV-related
`information
`authorization.
`understand that
`without
`I experience
`the New York State Division
`discrimination
`because of
`of HIV-related
`I may contact
`the release or disclosure
`information,
`These agencies are
`of Human Rights
`(212) 480-2493
`at
`or
`the New York City Commission
`of Human Rights
`at (212) 306-7450,
`responsible
`for protecting my rights.
`to the health care provider
`I have the right
`listed below.
`3.
`to revoke this authorization
`at any time by writing
`revoke this authorization
`that action has already been taken based on this authorization.
`except
`to the extent
`4. 1 understand
`in a health plan, or eligibility
`that signing
`this authorization
`enrollment
`is voluntary.
`treatment,
`payment,
`My
`benefits will not be conditioned
`upon my authorization
`of
`this disclosure.
`5.
`Information
`under
`disclosed
`this authorization
`be redisclosed
`might
`redisclosure may no longer be protected
`by federal or state law.
`YOU TO DISCUSS MY HEALTH
`6. THIS
`AUTHORIZATION
`DOES NOT AUTHORIZE
`AGENCY
`OR GOVERNMENTAL
`CARE WITH
`OTHER
`THAN
`THE ATTORNEY
`ANYONE
`7. Name and address of health provider
`or entity to release this information:
`ed
`th'CC?a :
`ccrf'
`ct d l)rdwptudh
`¥rte
`8
`/g.'
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`.dÛ S^9
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`will be synt:
`of person to whom this information
`8. Name and address of pers'on(s) or category
`dy Rwm
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`cc5
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`ion to be released:
`pccific
`Record from (insert date)
`l'Medical
`(R'Entire Medical Record.,
`including
`consults,
`records,
`referrals,
`billing
`Other:
`
`-
`
`studies,
`
`films,
`
`2D /f
`®T
`to (insert date)
`office notes (except psychotherapy
`test results,
`patient histories,
`notes),
`radiology
`records, and records sent to you by other health care providers.
`insurance
`Include:
`(Indicate
`by Initialing)
`Treatment
`Alcohol/Drug
`Information
`Mental Health
`Information
`HIV-Related
`
`Authorization
`
`to Discuss Health
`
`Information
`
`(b) 0 By initialing
`
`here
`
`I authorize
`
`initials
`to discuss my health information
`
`with my attorney,
`
`or a governmental
`
`Name of individual health care provider
`listed here:
`agency,
`
`10. Reason for
`release of
`information:
`individual
`At
`request of
`Gn
`O
`>
`c'c f
`Orùther:
`If not
`the patient, nafne of person signing
`
`12.
`
`(Auorney/Finn Name or Governmental Agency Name)
`1l. Date or event on which this authorization
`
`form:
`
`Nts
`a
`(
`13. Authority
`
`War'j'r>cc
`ted
`0 r
`to sign on behalf of patieftf:
`
`expire.'
`will expire:
`OS
`
`items on this form have been completed
`All
`copy of
`the form.
`
`and my questions about
`
`this form have been answered.
`
`In addition,
`
`I have been provided
`
`a
`
`authorized
`by law.
`re of patient or representative
`Signa
`* Human Immunodeficiency
`that causes AIDS, The New York State Public Health Law protects information which reasonably could
`Virus
`regarding a persun's contacts,
`someone as
`infection
`and
`information
`IIIV symptoms or
`having
`identify
`
`Date:
`
`

`

`FILED: KINGS COUNTY CLERK 04/16/2018 07:03 PM
`NYSCEF DOC. NO. 24
`
`INDEX NO. 513649/2016
`
`RECEIVED NYSCEF: 04/16/2018
`
`95
`
`AUTHORIZATION
`
`OF HEALTH
`FOR RELEASE
`INFORMATION
`form has been approved
`by the New York State Department
`
`PURSUANT
`of Health]
`
`[This
`
`OCA Officini perm INo.: 960
`TO HIPAA
`
`Patient Name
`Roy Dave Davis
`Patient Address
`
`)@OpgnpOt$$@Ç
`
`Elmont,
`
`NY 11003
`
`Date of Birth
`5/29/1993
`
`Social Security Number
`R§dy$T-AOff
`
`be released as set forth on this form:
`Act of 1996
`and Accountability
`
`is
`I
`If
`
`I understand that
`
`I may
`
`for
`
`by the recipient
`
`(except
`
`as noted above in Item 2), and this
`
`t
`
`regarding my care and treatment
`that health information
`I, or my authorized
`request
`representative,
`In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability
`I understand
`that:
`(HIPAA),
`HEALTH
`ABUSE, MENTAL
`and DRUG
`to ALCOHOL
`information
`of
`disclosure
`include
`1. This authorization
`may
`relating
`HIV*
`I place my initials on
`only if
`RELATED
`notes, and CONFIDENTIAL
`INFORMATION
`except psychotherapy
`TREATMENT,
`and I
`these types of
`below includes any of
`In the event
`described
`the health information
`the appropriate
`line in Item 9(a).
`information,
`in Item 8.
`indicated
`release of such information
`initial
`the line on the box in Item 9(a),
`I specifically
`to the person(s)
`authorize
`the recipient
`or mental health treatment
`If
`the release of HIV-related,
`I am authorizing
`alcohol
`or drug treatment,
`2.
`information,
`to do so under
`or state law.
`without my authorization
`federal
`prohibited
`from redisclosing
`such information
`unless permitted
`without
`to request a list of people who may receive or use my HIV-related
`information
`authorization.
`understand that
`I have the right
`the New York State Division
`of HIV-related
`the release or disclosure
`I may contact
`1 experience discrimination
`because of
`information,
`These agencies are
`of Human Rights
`at
`of Human Rights
`480-2493
`or
`the New York City Commission
`306-7450.
`at
`(212)
`(212)
`responsible
`for protecting my rights.
`to the health care provider
`listed below.
`at any time by writing
`3.
`I have the right
`to revoke this authorization
`that action has already been taken based on this authorization.
`revoke this authorization
`to the extent
`except
`enrollment
`in a health plan, or eligibility
`I understand
`;this authorization
`is voluntary.
`4.
`that
`treatment,
`payment,
`My
`signing
`this disclosure.
`will not be conditioned
`upon my authorization
`of
`be redisclosed
`under
`this authorization
`Information
`disclosed
`might
`5.
`redisclosure may no longer be protected
`by federal or state law.
`YOU TO DISCUSS MY HEALTH
`DOES NOT AUTHORIZE
`6. THIS AUTHORIZATION
`AGENCY
`OR GOVERNMENTAL
`ANYONE
`OTHER
`THAN
`THE ATTORNEY
`CARE WITIl
`to release this information:
`7. Name and address of health provider
`or entity
`Mc~ssg
`snod
`c~
`<< MxcQcpt'Ceu/<rp
`22cot
`/Á&OL-u
`flk
`ft
`/<nt
`w 11be sent:
`1or category of person to whom this information
`8. Name and address of person
`: Jabpew
`hom
`CDmf r
`hardsr,<r et'
`thn
`ich
`~
`(pµu¾
`s
`fopteuy
`T 6 2P
`tion tobe released:
`cific inforn
`9(a).
`i'
`5 Medical Record from (insert date)
`to (insert date)
`test results,
`office notes (except psychotherapy
`patient histories,
`ÛfF.ntire Medical Record.
`notes),
`radiology
`including
`records, and records sent to you by other health care providers.
`insurance
`referrals,
`consults,
`records,
`billing
`(Indicate
`Include:
`Other:
`by Initialing)
`Treatment
`Alcohol/Drug
`Information
`Mental Health
`Information
`HIV-Related
`
`INFORMATION
`SPECIFIED
`
`f
`
`rae
`acto
`
`?
`
`36D
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`r
`
`OR MEDICAL
`IN ITEM 9 (b). .
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`Gro'
`/ #2w
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`
`n,
`
`'
`
`studies,
`
`films,
`
`Authorization
`
`to Discuss Health
`
`Information
`
`(b) 0 By initialing
`
`here
`
`I authorize
`
`Initials
`to discuss my health information
`
`with my attorney,
`
`or a governmental
`
`health care provider
`Name ofindividual
`listed here:
`agency,
`
`release of
`10. Reason for
`information:
`O At
`f individ
`tal
`request
`.'(vier/1 gu
`@ /i
`8 0(hcr;
`If not
`the patient, name of person signing
`
`12.
`
`form:
`
`(Attorney/Firm Name or Governmental Agency Name)
`11. Date or event on which this authorization
`a(
`13. Authority
`
`to sign on behalf of patient:
`
`will expire:
`
`items on this form have been completed
`All
`the form.
`copy of
`
`VJ
`
`and my questions about
`
`this form have been answered.
`
`In addition,
`
`I have been provided
`
`a
`
`Date:
`
`)
`
`authorized
`by law.
`Signature of patient or representative
`* Human Immunodeficiency
`Virus that causes AIDS. The New York State Public Heal th Law protects information which reasonably could
`jicrsun's
`contacts.
`int'urmatiun
`regarding»
`infectiun»nd
`symptums or
`having HIV
`sumcune»s
`identify
`
`

`

`FILED: KINGS COUNTY CLERK 04/16/2018 07:03 PM
`NYSCEF DOC. NO. 24
`
`INDEX NO. 513649/2016
`
`RECEIVED NYSCEF: 04/16/2018
`
`AUTHORIZATION
`
`OF HEALTH
`FOR RELEASE
`INFORMATION
`form has been approved
`by the New York State Department
`
`PURSUANT
`of Health]
`
`This
`
`OCA Official Form No,: 960
`TO HIPAA
`
`Patient Name
`Roy Dave Davis
`Patient Address
`
`Elmont,
`
`NY 11003
`
`Date of Birth
`5/29/1993
`
`Social Security Number
`69
`265-)$
`
`be released as set forth on this form:
`regarding my care and treatment
`Act of 1996
`the Health Insurance Portability
`and Accountability
`
`is
`I
`If
`
`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)..
`
`, (
`40m r
`('
`
`coltyn
`26tE//
`.
`Brod
`
`//n
`3
`//_21
`ms 3¼d
`tr
`/Mo/
`M1/
`
`studies,
`
`films,
`
`Information
`
`I, or my authorized
`that health information
`request
`representative,
`In accordance with New York State Law and the Privacy Rule of
`I understand
`that:
`(HIPAA),
`1. This
`of
`authorization
`HEALTH
`disclosure
`include
`MENTAL
`and DRUG ABUSE,
`to ALCOHOL
`information
`relating
`may
`HIV* RELATED
`except psychotherapy
`I place my initials on
`notes, and CONFIDENTIAL
`INFORMATION
`only if
`TREATMENT,
`the appropriate
`line in Item 9(a).
`these types of
`and I
`In the event
`the health information
`below includes any of
`described
`information,
`initial
`the line on the box in Item 9(a),
`I specifically
`in Item 8.
`authorize
`release of such information
`to the person(s)
`indicated
`If
`I am authorizing
`2.
`the release of HIV-related,
`alcohol
`or mental health treatment
`or drug treatment,
`the recipient
`information,
`from redisclosing
`prohibited
`such information
`federal
`unless permitted
`to do so under
`or state law.
`without my authorization
`understand
`that
`I have the right
`to request a list of people who may receive or use my HIV-related
`authorization.
`information
`without
`I experience
`the New York State Division
`because of
`the release or disclosure
`discrimination
`of HIV-related
`I may contact
`infoimation,
`of Human Rights
`at (212) 480-2493
`or
`These agencies are
`the New York City Commission
`of Human Rights at
`(212) 306-7450.
`for protecting my rights.
`responsible
`listed below.
`to the health care provider
`3.
`I have the right
`to revoke this authorization
`at any time by writing
`that action has already been taken based on this authorization.
`revoke this authorization
`to the extent
`except
`4. 1 understand
`that signing
`authorization
`enrollment
`is voluntary.
`in a health
`this
`treatment,
`payment,
`My
`benefits will not be conditioned
`of
`this disclosure.
`upon my authorization
`under
`this authorization
`5.
`Information
`disclosed
`might
`be redisclosed
`redisclosure may no longer be protected
`by federal or state law.
`YOU TO DISCUSS MY HEALTH
`6. THIS AUTHORIZATION
`DOES NOT AUTHORIZE
`OR GOVERNMENTAL
`AGENCY
`CARE WITH
`ANYONE
`THE ATTORNEY
`OTHER
`THAN
`ame and address of health provider
`or entity to release this information:
`7.
`&W feyf
`7 e-r . M b
`JS hw/
`.'
`.
`2 { 9
`cZ
`/Pricum
`„~
`Caney
`will be sent:
`8. Name and addrVss of person(s) or category of person to whom·tl(is
`information
`'I
`I
`hpreme
`.'
`~
`Sulpamo
`~
`Ceur
`4<.
`ep,ds
`ü
`('ptu,
`/:
`t&
`3
`At
`on to be fcleased:
`9(a). Specific
`informa
`cleuscd:
`to (insert date) Ó 44/
`.7-
`2
`/5
`ledical Record from (insert date)
`Entire Medical Record,
`patient histories, office notes (except psychotherapy
`test results,
`notes),
`radiology
`including
`insurance records, and records sent
`to you by other health care providers.
`referrals,
`consults, billing
`records,
`Other:
`(Indicate
`Include:
`by Initialing)
`Treatment
`Alcohol/Drug
`Mental Health
`Information
`Information
`HIV-Related
`
`Authorization
`to Discuss Health
`(b) 0 By initialing
`
`here
`
`Initials
`to discuss my health information
`
`I authorize
`
`with my attorney,
`
`or a governmental
`
`Name of individual health care provider
`listed here:
`agency,
`
`10. Reason for
`release of
`information:
`0 At
`request of
`itldividua],
`c-
`) Or
`t"- f
`her
`M>
`j
`me of person signing
`the patient,
`
`12.
`
`If not
`
`form:
`
`(Attorncy/Firm Name or Governmental Aµency Name)
`11. Date or event on which this authorization
`g c'~t g p.+
`7
`to sign on behalf of patient
`
`+4'~~
`
`ps
`13. Authority
`
`will expire:
`
`g g~
`
`j,Qp
`
`items on this form have been completed
`All
`the form.
`copy of
`
`and my questions about
`
`this form have been answered.
`
`in addition,
`
`1 have been provided a
`
`I
`M/2..,----
`by law
`Signatu e of patient or representative
`* Human Immunodeficiency
`Virus that causes AIDS. The New York State Public Health Law protects information
`n person's contacts.
`hsvlng ill V
`symptoms or infection nnd
`information
`someone as
`identify
`regarding
`
`authorized
`
`Date:
`
`which reasonably could
`
`

`

`FILED: KINGS COUNTY CLERK 04/16/2018 07:03 PM
`NYSCEF DOC. NO. 24
`
`INDEX NO. 513649/2016
`
`RECEIVED NYSCEF: 04/16/2018
`
`(
`
`AUTHORIZATION
`
`FOR RELEASE
`OF HEALTH
`INFORMATION
`form has been approved
`by the New York State Department
`
`PURSUANT
`of Health]
`
`[This
`
`OCA Official Form No.: 960
`TO HIPAA
`
`Patient Name
`Roy Dave Davis
`Patient Address
`
`WGG4640t§4dif
`
`Elmont,
`
`NY 11003
`
`Date of Birth
`5/29/1993
`
`Social Security Number
`)$Ø$¶)
`
`regarding my care and treatment
`the Health Insurance Portability
`
`be released as set forth on this form:
`Act of 1996
`and Accountability
`
`is
`1
`If
`
`I understand that
`
`I may
`
`for
`
`by the recipient
`
`(except
`
`as noted above in Item 2), and this
`
`will be sent:
`'stan'
`A>Orn
`
`~
`
`INFORMATION
`SPECIFIED
`
`OR MEDICAL
`IN ITEM 9 (b). .
`
`avWr
`#d‡
`f(õ.8
`8 eaaP~
`
`+g
`n d
`.rr
`
`/~/
`//
`5 & af
`WQ //C/r
`
`r'
`
`/
`
`studies,
`
`films,
`
`h den
`
`I, or my authorized
`that health information
`request
`representative,
`In accordance with New York State Law and the Privacy Rule of
`I understand
`that:
`(HIPAA),
`1. This authorization
`to ALCOHOL
`of
`disclosure
`include
`MENTAL
`and DRUG ABUSE,
`information
`HEALTH
`may
`relating
`HIV* RELATED
`notes, and CONFIDENTIAL
`except psychotherapy
`only if 1 place my initials on
`INFORMATION
`TREATMENT,
`the appropriate
`line in Item 9(a).
`the health information
`any of
`and I
`In the event
`described below includes
`these types of
`information,
`initial
`the line on the box in Item 9(a),
`I specifically
`release of such information
`authorize
`in Item 8.
`to the person(s)
`indicated
`If
`the release of HIV-related,
`I am authorizing
`2.
`alcohol
`or mental
`or drug treatment,
`health treatment
`the recipient
`information,
`from redisclosing
`prohibited
`such information
`without my authorization
`to do so under
`federal
`or state law.
`unless permitted
`understand that 1 have the right
`to request a list of people who may receive or use my HIV-related
`authorization.
`information
`without
`I experience
`discrimination
`because of
`the release or disclosure
`the New York State Division
`of HIV-related
`I may contact
`information,
`of Human Rights
`These agencies are
`at
`(212) 480-2493
`or
`the New York City Commission
`of Human Rights
`at
`306-7450.
`(212)
`responsible
`for protecting my rights.
`to the health care provider
`3.
`l have the right
`to revoke this authorization
`listed below.
`at any time by writing
`that action has already been taken based on this authorization.
`revoke this authorization
`except
`to the extent
`I understand
`in a health plan, or eligibility
`4.
`this authorization
`that signing
`is voluntary.
`enrollment
`treatment,
`payment,
`My
`benefits will not be conditioned
`upon my authorization
`of
`this disclosure.
`5.
`disclosed
`Information
`under
`this authorization
`be redisclosed
`might
`redisclosure may no longer be protected
`by federal or state law.
`YOU TO DISCUSS MY HEALTH
`6. THIS
`DOES NOT AUTHORIZE
`AUTHORIZATION
`CARE WITH
`AGENCY
`OR GOVERNMENTAL
`ANYONE
`OTHER
`THAN
`THE ATTORNEY
`7, Name and address of health provider
`or entity to release this information:
`y,' Mmu , &údf'r
`'
`-
`i/(Ir
`90
`/
`, P.0
`)
`{
`//
`770 f
`f
`•Á//
`8. Name a d address of person(s) or category of person to whom this information
`<rE'r<fl & rt)
`.'
`CAJccer v'I
`ra~
`Sac
`I e s.
`f rh
`i sr
`to (insert date) Ñ 4/W
`9(a).
`pecific
`infornDion
`to be released:
`· Ppn
`Gif
`edical Record from (insert date)
`test results,
`patient histories,
`office notes (except psychotherapy
`Entire Medical Record,
`notes),
`radiology
`including
`to you by other health care providers,
`insurance
`records, and records sent
`referrals,
`consults,
`records,
`billing
`Include:
`(Indicate
`Other:
`by Initiallng)
`Treatment
`Alcohol/Drug
`Information
`Mental Health
`Information
`HIV-Related
`
`Information
`
`Authorization
`to Discuss Health
`(b) 0 By initialing
`
`here
`
`Initials
`to discuss my health information
`
`I authorize
`
`with my attorney;
`
`or a governmental
`
`Name of individual health care provider
`listed here:
`agency,
`
`release of
`10, Reason for
`information:
`request
`f Jndividual
`At
`6L
`/ f o(
`GTOther:
`If not
`the patient,½ame
`
`12.
`
`/ th
`of person signing
`
`(Attorney/Firm Name or Governmental Agency Name)
`I l. Date or event on which this authorization
`Ne
`-fu d O
`to sign on behalf of patient:
`13. Authority
`
`form:
`
`will expire:
`
`items on this form have been completed
`All
`the form.
`copy of
`
`l
`
`and my questions about
`
`this form have been answered.
`
`In addition,
`
`I have been provided a
`
`r
`re of patient or representative
`Signa
`by law.
`* Human ImmunodeGciency
`Virus that causes AIDS. The New York State Public Health Law protects information
`snd information
`regarding s person's contacts.
`someone ss
`inl'ection
`symptoms or
`having IIIV
`iden(ify
`
`r
`authorized
`
`Date:
`
`which reasonably could
`
`

`

`FILED: KINGS COUNTY CLERK 04/16/2018 07:03 PM
`NYSCEF DOC. NO. 24
`
`INDEX NO. 513649/2016
`
`RECEIVED NYSCEF: 04/16/2018
`
`AUTHORIZATION
`
`OF HEALTH
`FOR RELEASE
`INFORMATION
`This form has been approved
`by the New York State Department
`
`PURSUANT
`of Health}
`
`OCA Official Form Noa 960
`TO HIPAA
`
`Patient Name
`Roy Dave Davis
`Patient Address
`)MF Jd$1O$f16
`
`RElmont,
`
`NY 11003
`
`Date of Birth
`5/29/1993
`
`Social Security Number
`Mdt%@$5
`
`regarding my care and treatment
`the Health Insurance Portability
`
`be released as set forth on this form:
`Act of 1996
`and Accountability
`
`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)..
`
`cp.C'
`
`Ju'r
`wilt be sent:
`e ygpr
`
`'
`
`'/
`
`f60
`dr
`
`/~i
`
`p
`Yc
`½ my
`~
`D~~gF
`r!
`
`4
`
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`studies,
`
`films,
`
`that health information
`I, or my authorized
`request
`representative,
`In accordance with New York State Law and the Privacy Rule of
`I understand
`that:
`(HIPAA),
`HEALTH
`MENTAL
`and DRUG
`to ALCOHOL
`information
`of
`l. This
`authorization
`disclosure
`include
`ABUSE,
`relating
`may
`HIV* RELATED
`I place my initials on
`only if
`INFORMATION
`notes, and CONFIDENTIAL
`except psychotherapy
`TREATMENT,
`and I
`these types of
`below includes any of
`line in Item 9(a).
`In the event
`the health information
`described
`the appropriate
`information,
`indicated
`in Item 8.
`initial
`I specifically
`release of such information
`to the person(s)
`the line on the box in Item 9(a),
`authorize
`is
`the recipient
`or mental
`If
`the release of HIV-related,
`I am authorizing
`or drug treatment,
`health treatment
`alcohol
`2,
`information,
`federal
`I
`or state law.
`without my authorization
`to do so under
`from redisclosing
`such information
`unless
`permitted
`prohibited
`If
`without
`authorization.
`I have the right
`to request a list of people who may receive or use my HIV-related
`information
`understand
`that
`the New York State Division
`of HIV-related
`I may contact
`I experience
`because of
`the release or disclosure
`discrimination
`information,
`These agencies are
`the New York City Commission
`of Human Rights
`at
`306-7450.
`of Human Rights
`at (212) 480-2493
`or
`(212)
`responsible
`for protecting my