2016 09:08 am

SUPREME COURT OF THE STATE OF NEW YORKCOUNTY OF BRONX

ENNIGIER RIVERA,x

Plaintiff,- against - Index No. 25912/2015E

NING LIN, M.D., JAIME NIETO, M.D., ELANGOLDWYN, M.D., LIONEL LAZARD, M.D.,BENJAMIN RICCIARDI, M.D., MARGARETCHIU, M.D., and NEW YORK HOSPITALQUEENS,

Defendants.

SIR/MADAM:

x

TABLE OF CONTENTS

1. Verified Answer on behalf of NING LIN, M.D.;

2. Demand for a Verified Bill of Particulars;

3. Notice of Deposition;

4. Demand for Expert Witness Information;

5. Notice to Produce Names and Addresses of Witnesses;

6. Demand Pursuant to CPLR § 2103(E);

7. Demand for Index Number Receipt;

8. Demand for Authorizations for Hospital & Physician's Records & Interviews forTreating Physician;

9. Notice to Take Physical Examination;

10. Demand for Tax Returns & Employment Records;

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FILED: BRONX COUNTY CLERK 01/08/2016 09:08 AM INDEX NO. 25912/2015E

NYSCEF DOC. NO. 17 RECEIVED NYSCEF: 01/08/2016

11. Notice to Produce Statements;

12. Notice Pursuant to CPLR §2103(5);

13. Demand for Disclosure of Medicare/Medicaid/Benefits/Eligibility; and

14. Demand for Social Networking Information.

Dated: New York, New YorkJanuary 7, 2016

To:

Yo

(‘°t1Lc1)) BY: Robert S. Deu schAARONSON RAPPAPORT FEINSTEIN &DEUTSCH, LLPAttorneys for DefendantNING LIN, M.D.Office & P.O. Address600 Third AvenueNew York, NY 10016212-593-6700

SANOCKI, NEWMAN & TURRET, LLPAttorneys for Plaintiffs225 BroadwayNew York, NY 10007Tel: 212 962-1190

{01752268.DOCX } -2-


ENNIGIER RIVERA,

x

DEMAND FOR A VERIFIED BILLPlaintiff, OF PARTICULARS

- against - Index No. 25912/2015E

NING LIN, M.D., JAIME NIETO, M.D., ELANGOLDWYN, M.D., LIONEL LAZARO, M.D.,BENJAMIN RICCIARDI, M.D., MARGARETCHIU, M.D., and NEW YORK HOSPITALQUEENS,

Defendants.

SIR/MADAM:

x

PLEASE TAKE NOTICE, that defendant, NING LIN, M.D. hereby demands thatplaintiff(s) serve on the undersigned within twenty (20) days from the date of service hereof, aVerified Bill of Particulars with respect to the following matters concerning the allegations in thecomplaint against the above named defendant:

1. State the (a) date and place of birth of plaintiff(s); (b) residence address of theplaintiff(s) at the time this action was commenced; (c) residence address of the plaintiff(s) at thetime of the alleged negligence; (d) date(s) and place(s) of plaintiff(s) marriage(s); (e) full namesand dates of birth of all children born to plaintiff(s); (f) social security number of plaintiff(s); and(g) Medicare Health Insurance Claim Number (HICN) of plaintiff(s).

2. Set forth a general statement of the acts or omissions of this defendant that areclaimed to constitute a departure from good and accepted medical practice.

3. Set forth the date(s) of this defendant's alleged negligence.

4. Set forth:

(a) The dates of first and last services rendered by each defendant;

(b) The place or places where the services were rendered by each defendant.

5. If plaintiff(s) charges this defendant with a misdiagnosis, identify the allegedmisdiagnosis and set forth the diagnosis claimed to be the proper one.

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6. If plaintiff(s) charges this defendant with having failed to administer a diagnostic testor procedure, state the test or diagnostic procedure claimed to have been required and when andwhere each test or diagnostic procedure should have been performed.

7. If plaintiff(s) charges this defendant with having failed to administer a particularcourse of therapy, state the medicines, treatments and surgical procedures claimed to have beenrequired and when and where each should have been administered or performed.

8. If plaintiff(s) charges this defendant with having administered contraindicatedmedicines, treatments, tests and/or surgical procedures, identify each and the conditions existingwhich, it is claimed, contraindicated the medicine, treatment, test and/or surgical procedure.

9. If plaintiff(s) charges this defendant with negligently having administered a medicine,treatment, test or surgical procedure, identify each so claimed and set forth the manner in whichthe technique employed by this defendant departed from such standards.

10. If any special damages are claimed as a result of the alleged negligence, set forth,including but not limited to, the following:

(a) The charges for the any and all hospitalizations, separately listing eachhospital bill;

(b) Physicians' charges;

(c) Charges for medicines, itemizing the medicines charged for;

(d) Nursing changes; and,

(e) Specify by category and amount any other special damages claimed.

11. Pursuant to CPLR 4545, identify the party who paid the damages claimed inparagraph 10 above, including the relationship of the plaintiff(s) to that party. If the third partypayments were made as a result of reimbursements through an insurance company, set forth thecomplete name and address of the company, the complete name of the person in whose name thepolicy was issued, the state the policy was issued, the date of the policy's inception, the name ofthe plan and the policy number.

12. If plaintiff(s) claims that the injuries alleged herein were caused, in whole or in part,

by the use of a defective, inappropriate or insufficient piece of equipment or instrument, identifyeach and every item so claimed and set forth those facts that support said allegations.

13. Set forth the full names and addresses of each and every person that plaintiff(s) willclaim, at the time of trial, observed this defendant acts of alleged malpractice.

14. If plaintiff(s) charges this defendant with lack of informed consent, set forth anddescribe:

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t

(a) That aspect of defendant's treatment which it will be claimed exposedplaintiffs to material risks sufficient to require disclosure;

(b) Identify each risk or danger of defendant's treatment which it will beclaimed should have been, but was not, disclosed by this defendant;

(c) State in what respect plaintiff(s) will claim this defendant's disclosure wasunreasonably inadequate;

(d) State what course of treatment would plaintiff have chosen if thisdefendant reasonably disclosed the material risks of the treatmentadministered;

(e) Set forth what available alternative choices of treatment could have beenadministered but were not disclosed and describe each alternative;

(f) Set forth the date on which plaintiff(s) claims this defendant should haveobtained an informed consent; and,

(g) Identify by name and corresponding position with the defendant each andevery employee or agent of said defendant whom plaintiff(s) charges withhaving failed to obtain an informed consent.

15. Set forth the full name and addresses of each and every physician from whom the

plaintiff-patient has received medical treatment for any medical, surgical or related condition in

the fifteen (15) years prior to the alleged malpractice with dates of treatment.

16. Set forth the full names and addresses of each and every hospital, institution, facilityor clinic in which the plaintiff-patient received treatment with respect to any medical, surgical orrelated condition for the fifteen (15) years prior to the alleged malpractice with dates ofconfinement or outpatient treatment.

17. Set forth the nature of the condition for which the plaintiff(s) sought and accepted themedical treatment rendered by this defendant.

18. The nature, location, extent and duration of each injury which, it will be claimed, wascaused by the negligence of this defendant. If any injuries are claimed to be permanent, specifyeach so claimed.

19. Set forth the full name and address of each and every subsequent treating physicianfrom whom medical treatment or consultation was sought by the plaintiff(s) by reason of theinjuries allegedly sustained.

20. Set forth full name and address of each and every physician seen by plaintiff(s)patient for consultation, physical examination and or medical tests at the direction or referral oflegal counsel. Set forth dates of each such examination or treatment.

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21. Set forth each and every condition which plaintiff(s) claim this defendantexacerbated.

22. If it will be claimed that the aforesaid injuries necessitated any hospitalizations ofplaintiff(s), set forth the name and address of each hospital with dates of confinement oroutpatient treatment.

23. If it will be claimed that the aforesaid injuries necessitated treatment at any otherinstitutions, set forth the name and address of each institution with dates of confinement.

24. If it will be claimed that the aforesaid injuries necessitated confinement to bed orhome, set forth the following:

(a) The dates of confinement to home;

(b) The dates of confinement to bed.

25. If loss of earnings is claimed as a result of the alleged negligence, set forth thefollowing:

(a) The name and address of claimant's employer at the time of the allegednegligence;

(b) The capacity in which claimant was employed;

(c) Claimant's earnings for the year prior to the alleged negligence;

(d) The last date claimant worked prior to the alleged negligence;

(e) The name and address of claimant's present employer; and,

(f) Loss of earnings claimed.

26. If it will be claimed that the aforesaid injuries necessitated any special educational,emotional, or vocational training or schooling, set forth the name and address of eachorganization and the dates.

27. Set forth the full caption of each and every lawsuit brought on plaintiff(s) behalf to

recover damages for any connected or aggravated injuries allegedly caused and sustained byreason of the acts of one or more preceding, joint, concurrent and/or succeeding tortfeasors,including:

(a) Court;

(b) Index Number;

(c) Calendar Number;

(d) Names and addresses of all litigants;

{01752130.DOCX } -4-

Names and addresses of all attorneys appearing for litigants;

Status of lawsuit:

(i) if noticed for trial, specify the date;

(ii) if settled, annex a copy of each releaser delivered indicating theamounts contributed by each defendant;

(iii) if discontinued without payment, annex a copy of each stipulationso delivered to each defendant;

(iv) if tried, annex a copy of the judgment with notice of entry; and,

(v) if judgment was satisfied, set forth date and amount of paymentand annex a copy of satisfaction of judgment.

28. If it is claimed that this defendant violated or departed from the terms of any statutes,laws or ordinances, set forth the specific statute, law or ordinance alleged to have been violatedor from which departure is claimed and the specific acts and/or omissions alleged to be the basisfor the claim of violation or departure, including dates, times and places of all such acts and/oromissions.

PLEASE TAKE FURTHER NOTICE, that in the event of the plaintiff's failure tocomply with the foregoing Demand for a Verified Bill of Particulars within twenty (20) days,defendant, NING LIN, M.D. will move to preclude the offering of any evidence as to the mattersherein demanded and for costs of such motion.


To: SANOCKI, NEWMAN &TURRET, LLPAttorneys for Plaintiffs225 BroadwayNew York, NY 10007Tel: 212 962-1190

Yours, etc.,

BY: Robert S. DeutschAARONSON RAPPAPORT FEINSTEIN& DEUTSCH, LLPAttorneys for DefendantNING LIN, M.D.Office & P.O. Address600 Third AvenueNew York, New York 10016Tel.: (212) 593-6700

(01752130.DOCX ) -5-

{01752130.DOCX } -6-


ENNIGIER RIVERA,

x

NOTICE OF DEPOSITIONPlaintiff,

Index No. 2591212015E- against -


Defendants.

SIR/MADAM:

PLEASE TAKE NOTICE, that we will take the deposition of the following

parties or persons, before a Notary Public not affiliated with any of the parties or their attorneys,

on all relevant and material issues, as authorized by Article 31 of the CPLR:

The Plaintiff ENNIGIER RIVERA

DATE: April llth, 2016

TIME: 10:00 A.M.

PLACE: AARONSON RAPPAPORT FEINSTEIN & DEUTSCH, LLP600 Third AvenueNew York, New York 10016

{01752137.DOCX }

PLEASE TAKE FURTHER NOTICE, that the persons to be examined are

required to produce all books, records and papers in their custody and possession that may be

relevant to the issues herein.


To:

Yours, etc.

BY: Robert S. DeutschAARONSON RAPPAPORT FEINSTEIN &DEUTSCH, LLPAttorneys for DefendantNING LIN, M.D.Office & P.O. Address600 Third AvenueNew York, NY 10016212-593-6700


{01752137.DOCX } -2-


ENNIGIER RIVERA,

x

DEMAND FOR EXPERT WITNESSPlaintiff, INFORMATION



Defendants.

x

SIR/MADAM:

PLEASE TAKE NOTICE, that demand is hereby made upon you, pursuant to CPLR

§3101(d)(1) to disclose the following information:

1. Disclose each person plaintiff(s) expect(s) to call as an expert witness at trial.

2. Disclose in reasonable detail the qualifications of each expert witness. Includethe following:

a) Where did the expert attend medical school and when did he or shegraduate?

b) Did the expert attend internship, residency and/or fellowship programs: Ifso, where and when?

c) Does the expert specialize in any areas of medicine?

d) Is the expert Board Certified in any areas of medicine?

e) Is the expert licensed to practice medicine in the United States? If so,where and when was he or she licensed?

f) What are the expert's hospital affiliations, if any?

{01752138.DOCX }

3. With respect to each and every act or omission which you will claim as the basisof the alleged malpractice of the defendant(s) herein, disclose in detail the substance of the factsand opinions upon which each expert is expected to testify and a summary of the grounds foreach expert's opinion, to include reference to the following:

a) The condition or conditions which it is claimed the defendant(s) undertookto treat and upon which plaintiff s(s') complaint(s) is/are based;

b) A statement of the accepted medical practices, customs and medicalstandards which it is claimed were violated by the defendant(s) herein ineach of the acts or omissions claimed to be the basis of the liability againstit (them);

c) The manner in which the defendant(s) herein departed from the aboveaccepted medical practices, customs and standards;

d) If the plaintiff(s) claim(s) that the defendant(s) ignored or improperlyinterpreted complaints, signs, symptoms or conditions; made an erroneousdiagnosis; failed to make a proper diagnosis; improperly treated theplaintiff(s); failed to take proper tests; improperly took or administeredtests; failed to perform a proper physical examination; set forth:

(i) The complaints, signs, symptoms or conditions that thedefendant(s) failed to interpret properly;

(ii) The proper interpretation, which plaintiff(s) claims should havebeen reached or made;

(iii) In what respect the diagnosis was erroneous and incorrect;

(iv) The claimed proper diagnosis;

(v) The improper treatment which it is alleged was rendered;

(vi) The treatment which it is claimed by plaintiff(s) should have beenrendered;

(vii) The name and/or description of each and every test defendant(s)failed to take or administer;

(viii) The name of each and every test the defendant(s) improperly tookor had administered or taken;

(ix) The manner in which it is claimed such test(s) should have beenadministered or taken;

(x) A description of the physical examination performed;

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.•. •••- - -- 7-7 .

(xi) The manner in which it is claimed such physical examinationshould have been performed.

e) If it is alleged that the defendant(s) herein improperly performed a surgicalprocedure or that it was contraindicated and/or unnecessary, set forth:

(i) The name of each surgical procedure and the date it wasperformed;

(ii) The surgical procedure which it is claimed was contraindicated,and/or unnecessary;

(iii) In which manner the aforesaid surgical procedure was contraindi-cated;

(iv) In what manner the aforesaid surgical procedure was improperlyperformed;

(v) In what manner the aforesaid surgical procedure should have beenperformed.

f) If any of the claims of medical malpractice relate to the prescribing of adrug or medication, state:

(i) The name of each drug or medication prescribed;

(ii) The dates(s) of each prescription;

(iii) The drugstore(s) where each prescription filled;

(iv) The number of times each prescription was filled;

(v) The pharmacy number of each prescription.

If the plaintiff claims that the defendant(s) herein administered improper,inappropriate and/or contraindicated drugs, administered proper drugs inincorrect dosages, set forth:

g)

(i) The generic and trade name of each and every improper and/orcontraindicated drug which was administered or prescribed;

(ii) The name of each proper drug allegedly administered incorrectlyor in incorrect dosages;

(iii) The manner in which it is claimed each such drug should havebeen administered and/or the correct dosage thereof, or the proper,appropriate and/or indicated drug.

(01752138.DOCX } -3-

{ - - -

PLEASE TAKE FURTHER NOTICE, that failure to comply with the said

demand within sixty (60) days from the last timely service of an answer herein, pursuant to 22

NYCRR 202.56(a)(1)(vi), will result in a motion for an order precluding the introduction, at the

time of trial, of any testimony concerning alleged departures from medical standards of care,

proximately caused injuries, or economic damages.


To:

Yours, etc.



{01752138.DOCX } -4-


ENNIGIER RIVERA,

- against -

x

NOTICE TO PRODUCE NAMESAND ADDRESSES OF WITNESSES

Plaintiff, Index No. 25912/2015E


Defendants.

x

SIR/MADAM:

PLEASE TAKE NOTICE, that pursuant to CPLR §3101, all counsel are required to

produce any and all names and addresses of persons:

1. Claimed to have witnessed the acts of omission or commission alleged in thecomplaint;

2. Claimed to have firsthand knowledge of the acts of omission or commission

alleged in the complaint;

3. Claimed to be witnesses to any acts, omissions or conditions which allegedly

caused the occurrence alleged in the complaint;

4. Claimed to be witnesses to any communications involving the defendant

which plaintiff may seek to introduce at trial; and

5. If plaintiffs' attorney, representative or plaintiff (him or herself as the case

may be) has or have conducted an interview with any of the physicians who

treated the injuries alleged herein or related conditions, whether preexisting

the alleged malpractice or occurring subsequent thereto, set forth:

a. The full name and address of the physician;

(01752142.DOCX }

-- - - - -t

b. The corresponding date on which each interview was conducted;

c. The full name and address of each person conducting the saidinterview;

d. The full name address of every other person — if any — in attendance;

e. Whether any mechanical device such as, but not limited to,stenographic note taking, audio and/ or videotaping, etc. was utilizedduring said interview.

At the offices of the undersigned attorneys within twenty (20) days from the date hereof.

PLEASE TAKE FURTHER NOTICE, that this is to be deemed a continuing

demand, and all responsive information that subsequently is made known or becomes available

to plaintiff shall be furnished to the undersigned in a timely fashion.

PLEASE TAKE FURTHER NOTICE, that failure to provide the aforesaid

information within twenty (20) days after receipt of this Notice, will leave you subject to the

provisions of the CPLR.


To:

Yours, etc.



{01752142.DOCX } -2-


ENNIGIER RIVERA,

Plaintiff,- against -


Defendants.

x

DEMAND PURSUANT TO CPLR§2103(E)

Index No. 2591212015E

SIR/MADAM:

PLEASE TAKE NOTICE, that pursuant to §2103(e) of the Civil Practice Law and Rules,

you are hereby required to furnish to the undersigned the names and addresses of the parties, and

their respective attorneys who have appeared in this action.


To:

Yours, etc.



{01752163.DOCX }

-


ENNIGIER RIVERA,

x

DEMAND FOR INDEX NUMBERPlaintiff, RECEIPT


NING UN, M.D., JAIME NIETO, M.D., ELANGOLDWYN, M.D., LIONEL LAZARO, M.D.,BENJAMIN RICCIARDI, M.D., MARGARETCHIU, M.D., and NEW YORK HOSPITALQUEENS,

Defendants.

SIR/MADAM:

x

PLEASE TAKE NOTICE, that demand is hereby made that you serve upon the

undersigned within fifteen (15) days hereof, a copy of the receipt of the purchase of the Index

Number assigned to the above-captioned matter pursuant to CPLR §306-a.


Yours, etc.


{01752169.DOCX )

To: SANOCKI, NEWMAN & TURRET, LLPAttorneys for Plaintiffs225 BroadwayNew York, NY 10007Tel: 212 962-1190

{01752169.DOCX } -2-


ENNIGIER RIVERA,

Plaintiff,

- against -


Defendants.

x

x

DEMAND FOR AUTHORIZATIONSFOR HOSPITAL AND PHYSICIAN'SRECORDS AND INTERVIEWS FORTREATING PHYSICIAN

Index No. 25912/2015E

S IR/MADAM:

PLEASE TAKE NOTICE, that demand is hereby made that you serve upon the undersigned

duly executed authorizations for the release of the records pertaining to the care and treatment

rendered to the plaintiff in any and all hospitals.

Demand is additionally made that you serve upon the undersigned duly executed

authorizations for the release of records of any and all treating physicians and other medical

providers.

Demand is further made that you serve upon the undersigned duly executed authorizations

in accordance with Arons v. Jutkowitz, 9 NY3rd 393 (2007), for the ex parte interview by defense

counsel of any and all treating physicians and all other medical providers in the form attached hereto

or other form complying with 45 CFR 164.508 [c][1], [2] to the extent that each such authorization

set forth:

1) This law firm's name;

2) The identity of this law firm's client;

3) The "protected" and related health information expected to be disclosed;

{01752180.DOCX

4) The non-party medical provider's right to refuse the request for the ex parte

interview;

5) That the aforesaid authorization is to remain valid for the duration of this lawsuit.

The aforementioned authorizations should include the full name and address of each

institution and/or physician and the dates of confinement or treatment and should be in the form

attached hereto or other HIPAA compliant form.

PLEASE TAKE FURTHER NOTICE, that failure to comply with this demand will serve as

a basis for a motion to preclude the plaintiff upon the trial of this action from offering proof relative

to all claimed injuries and medical damages if such authorizations are not forthcoming within

twenty (20) days after service of a copy of the within Demand.


Yours, etc.



{01752180.DOCX } -2-

OCA Official Form No.: 960AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

[This form has been approved by the New York State Department of Health]

Patient Name Date of Birth Social Security Number

Patient Address

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:

In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996

(HIPAA), I understand that:

1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTHTREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials onthe appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and Iinitial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient ispiohibited from redisclosing such -without my - authorization- uniess permitted to do so --imder federal or state -law: Iunderstand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. IfI experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Divisionof Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies areresponsible 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 mayrevoke 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 forbenefits 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 thisredisclosure may no longer be protected by federal or state law.

6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICALCARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9(b). 7. Name and address of health provider or entity to release this information:

8. Name and address ofperson(s_) or category of person to whom this information will. be sent:Aaronson Rappaport Feinstein & Deutsch, L-12. 600 I hird Avenue, New York, NY 10016 and then- record retrieval agents Record Access Corporation 206 FifthAvenue. New York. NY 10001 and/or Leval-hied Sonnort Tnc. 132 Fast 43rd Street. Suite 715. New York. NY 10017 la.

9(a). Specific information to be released:

0 Medical Record from (insert date) to (insert date)D Entire Medical Record, including patient histories, office notes

referrals, consults, billing records, insurance records, and records

D Other:

(except psychotherapy notes), test results, radiology studies, films,sent to you by other health care providers.

Include: (Indicate by Initialing)

Alcohol/Drug Treatment

Authorization to Discuss Health Information

(b) D By initialing here I authorize

Mental Health Information

HIV-Related Information

Initials Name of individual health care providerto discuss my health information with my attorney, or a governmental agency, listed here:

(Attomey/Firm Name or Governmental Agency Name)

10. Reason for release of information:D At request of individualD Other:

11. Date or event on which this authorization will expire:

12. If not the patient, name of person signing form:

. .

13. Authority to sign on behalf of patient:

copy of the form.

Date:

Signature of patient or representative authorized by law.

* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably couldidentify someone as having HIV symptoms or infection and information regarding a person's contacts.

Instructions for the Useof the HPAA-compliant Authorization Form toRelease Health Triformation Needed for Litigation

This form is the product of a collaborative process between the New York StateOffice of Court Administration, representatives of the medical provider community inNew York, and the bench and bar, designed to produce a standard official form thatcomplies with the privacy requirements of the federal Health Insurance Portability andAccountability Act ("Bill'AA") and its implementing regulations, to be used to authorizethe release of health information needed for litigation in New York State courts. It can,however, be used more broadly than this and be used before litigation has beencommenced, or whenever Damsel would find it useful.

The goal was to produce a standard HPAA-compliant official form to obviate thecurrent disputes which often take place as to whether health information requests made inthe course of litigation meet the requirements of the HIPAA Privacy Rule. It should benoted, though, that the form is optional. This form may be filled out on line anddownloaded to be signed by hand, or downloaded and filled out entirely on paper.

When filing out Item 11, which requests the date or event when the authorizationwill expire, the person filling out the form may designate an event such as "at theconclusion of my court case or provide a specific date amount of time, such as "3 yearsfrom this date"

If a patient seeks to authorize the release of his or her entire medical record, butonly from a certain date, the first two boxes in section 9(a) should both be checked, andthe relevant date inserted on the first line containing the first box.

AUTHORIZATION TO PERMIT INTERVIEW OF TREATING PHYSICIAN BY DEFENSE COUNSEL

To:

You are hereby authorized to discuss certain medical condition(s) involving:

with: who are the attorneys representing in a brought by against

The lawsuit is currently pending and is: in Litigation

YOU ARE PERM11 1ED TO DISCUSS ONLY THE FOLLOWING MEDICAL CONDITIONS WHICH ARE THE SUBJECTMATTER OF THE AFOREMENTIONED LAWSUIT:

1. NOTHING CONTAINED HEREIN AUTHORIZES YOU TO DISCUSS ANYTHING ABOUT THIS PATIENTOTHER THAN THE ABOVE-STATED MEDICAL CONDITIONS.

2. THE PURPOSE OF THIS INTERVIEW IS TO ASSIST THE DEFENDANT(S) IN THE DEFENSE OF THISLAWSUIT BROUGHT BY THIS PATIENT. THIS AUTHORIZATION IS NOT AT THE REQUEST OF YOUR PATIENT.

3. YOUR WILLINGNESS TO PARTICIPATE IN THIS INTERVIEW IS ENTIRELY VOLUNTARY. YOU ARE FREETO DECLINE THIS REQUEST FOR SAID INTERVIEW.

4. You are permitted to disclose information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTHTREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV-RELATED INFORMATION, only if specificallyinitialed below:(Indicate by Initialing): Alcohol/Drug Treatment Mental Health Information HIV-Related Information

5. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, therecipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal orstate law. I understand that I have the right to request a list of people who may receive or use my HIV-related informationwithout authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I maycontact 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.

6. I have the right to revoke this authorization at any time by writing to the health care provider listed. I understand that Imay revoke this authorization except to the extent that action has already been taken based on this authorization.

7. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan oreligibility for benefits will not be conditioned upon my authorization of this disclosure.

8. Information disclosed under this authorization might be redisclosed by the recipient (except as noted in Item 5 above),and this redisclosure may no longer be protected by federal or state law.

9. If not the patient, name of person signing form:

10. Authority to sign on behalf of the patient

11. Date this authorization will expire: one year from date of signature below

Signature Date


ENNIGIER RIVERA,



Defendants.

x

x

NOTICE TO TAKE PHYSICALEXAMINATION

Index No. 25912/2015E

SIR/MADAM:

PLEASE TAKE NOTICE, that pursuant to CPLR §3121, the defendants here provide

notice that a physical examination of the plaintiff will be conducted by a doctor(s) of the

defendant's choosing at a time and place to be designated.


To:

Yours, etc.



(01752198.DOCX )


ENNIGIER RIVERA,

x

DEMAND FOR TAX RETURNSPlaintiff, AND EMPLOYMENT RECORDS



Defendants.

SIR/MADAM:

x

PLEASE TAKE NOTICE, that pursuant to Rule 3120 of the CPLR, you are herebyrequired to furnish to the undersigned full and complete copies, or, authorizations to obtain fulland complete copies of all employment and tax records referable to the plaintiff(s).

PLEASE TAKE FURTHER NOTICE, that failure to provide the aforesaid authorizations

within twenty (20) days after receipt of this Notice will leave you subject to the provisions of theCPLR.


Yours, etc.


{01752201,DOCX }


{01752201.DOCX } -2-

Fo. 4506(Rev. September 2013)

Department of the TreasuryInternal Revenue Service

Request for Copy of Tax Return

IP- Request may be rejected if the form is incomplete or illegible.

OMB No. 1545-0429

Tip. You may be able to get your tax retum or retum information from other sources. If you had your tax retum completed by a paid preparer, theyshould be able to provide you a copy of the retum. The IRS can provide a Tax Retum Transcript for many retums free of charge. The transcriptprovides most of the line entries from the original tax retum and usually contains the information that a third party (such as a mortgage company)requires. See Form 4506-T, Request for Transcript of Tax Retum, or you can quickly request transcripts by using our automated self-help servicetools. Please visit us at IRS.gov and click on "Order a Return or Account Transcript" or call 1-800-908-9946.

la Name shown on tax retum. If a joint retum, enter the name shown first. lb First social security number on tax retum,individual taxpayer identification number, oremployer identification number (see instructions)

2a If a joint retum, enter spouse's name shown on tax retum. 2b Second social security number or individualtaxpayer identification number if joint tax retum

3 Current name, address (including apt., room, or suite no.), city, state, and ZIP code (see instructions)

4 Previous address shown on the last retum filed if different from line 3 (see instructions)

5 If the tax retum is to be mailed to a third party (such as a mortgage company), enter the third party's name, address, and telephone number.

Caution. 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 youhave 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 5,the IRS has no control over what the third party does with the information. If you would like to limit the third party's authority to disclose your retuminformation, you can specify this limitation in your written agreement with the third party.

6 Tax retum requested. Form 1040, 1120, 941, etc. and all attachments as originally submitted to the IRS, including Form(s) W-2,schedules, or amended returns. Copies of Forms 1040, 1040A, and 1040EZ are generally available for 7 years from filing before they aredestroyed by law. Other returns may be available for a longer period of time. Enter only one return number. If you need more than onetype of retum, you must complete another Form 4506. 0 -

Note. If the copies must be certified for court or administrative proceedings, check here 07 Year or period requested. Enter the ending date of the year or period, using the mm/dd/yyyy format. If you are requesting more than

eight years or periods, you must attach another Form 4506.

8 Fee. There is a $50 fee for each retum 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, MN,

or EIN and "Form 4506 request" on your check or money order.

a Cost for each retum

b Number of returns requested on line 7

c Total cost. Multiply line 8a by line 8b

50.00

9 If we cannot find the tax retum, we will refund the fee. If the refund should go to the third party listed on line 5, check here 0 Caution. Do not sign this form unless all applicable lines have been completed.

Signature of taxpayer(s). I declare that I am either the taxpayer whose name is shown on line la or 2a, or a person authorized to obtain the tax retumrequested. If the request applies to a joint retum, at least one spouse must sign. If signed by a corporate officer, partner, guardian, tax matters partner,executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to execute Form 4506 on behalf of thetaxpayer. Note. For tax returns being sent to a third party, this form must be received within 120 days of the signature date.

Phone number of taxpayer on linela or 2a

Sign Signature (see instructions)

HereDate

Title (If line 1a above is a corporation, partnership, estate, or trust)

Spouse's signature Date

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 41721E Form 4506 (Rev. 9-2013)

Form 4506 (Rev. 9-2013) Page 2

Section references are to the Internal Revenue Codeunless otherwise noted.

Future DevelopmentsFor the latest information about Form 4506 and itsinstructions, go to www.its.gov/form4506.Information about any recent developments affectingForm 4506, Form 4506T and Form 4506T-EZ will beposted on that page.

General InstructionsCaution. Do not sign this form unless all applicablelines have been completed.

Purpose of form. Use Form 4506 to request a copyof your tax retum. You can also designate (on line 5)a third party to receive the tax retum.

How long will It take? it may take up to 75calendar days for us to process your request.

Tip. Use Form 4506-T, Request for Transcript of TaxRetum, to request tax retum transcripts, tax accountinformation, W-2 information, 1099 information,verification of non-filing, and records of account.

Automated transcript request. You can quicklyrequest transcripts by using our automated self-helpservice tools. Please visit us at IRS.gov and click on"Order a Retum or Account Transcript" or call1-800-908-9946.

Where to file. Attach payment and mail Form 4506to the address below for the state you lived in, or thestate your business was in, when that retum wasfiled. There are two address charts: one forindividual retums (Form 1040 series) and one for allother retums.

If you are requesting a retum for more than oneyear and the chart below shows two differentaddresses, send your request to the address basedon the address of your most recent retum.

Chart for individual returns(Form 1040 series)If you filed anindividual retum Mail to:and lived in:

Alabama, Kentucky,Louisiana, Mississippi,Tennessee, Texas, aforeign country, AmericanSamoa, Puerto Rico,Guam, theCommonwealth of theNorthern Mariana Islands,the U.S. Virgin Islands, orA.P.O. or F.P.O. address

Internal Revenue ServiceRAIVS TeamStop 6716 AUSCAustin, TX 73301

Alaska, Arizona,Arkansas, Califomia,Colorado, Hawaii, Idaho,Illinois, Indiana, Iowa,Kansas, Michigan, •Minnesota, Montana,Nebraska, Nevada, NewMexico, North Dakota,Oldahoma, Oregon,South Dakota, Utah,Washington, Wisconsin,Wyoming

Internal Revenue ServiceRAMS TeamStop 37106Fresno, CA 93888

Connecticut,Delaware, District ofColumbia, Florida,Georgia, Maine,Maryland,Massachusetts,Missouri, NewHampshire, New Jersey,New York, NorthCarolina, Ohio,Pennsylvania, RhodeIsland, South Carolina,Vermont, Virginia, WestVirginia

Internal Revenue ServiceRAIVS TeamStop 6705 P-6Kansas City, MO64999

Chart for all other retums

If you lived inor your business Mail to:was in:

Alabama, Alaska,Arizona, Arkansas,California, Colorado,Florida, Hawaii, Idaho,Iowa, Kansas, Louisiana,Minnesota, Mississippi,Missouri, Montana,Nebraska, Nevada,New Mexico,North Dakota,Oldahoma, Oregon,South Dakota, Texas,Utah, Washington,Wyoming, a foreigncountry, or A.P.O. orF.P.O. address

Internal Revenue ServiceRAIVS TeamP.O. Box 9941Mall Stop 6734Ogden, UT 84409

Connecticut, Delaware,District of Columbia,Georgia, Illinois, Indiana,Kentucky, Maine,Maryland,Massachusetts,Michigan, NewHampshire, New Jersey,New York, NorthCarolina,Ohio, Pennsylvania,Rhode Island, SouthCarolina, Tennessee,Vermont, Virginia, WestVirginia, Wisconsin

Internal Revenue ServiceRAIVS TeamP.O. Box 145500Stop 2800 FCincinnati, OH 45250

Specific InstructionsLine lb. Enter your employer Identification number(EIN) if you are requesting a copy of a businessretum. Otherwise, enter the first social securitynumber (SSN) or your individual taxpayeridentification number (MN) shown on the retum. Forexample, if you are requesting Form 1040 thatincludes Schedule C (Form 1040), enter your SSN.

Line 3. Enter your current address. If you use a P.O.box, please include it on this line 3.

Line 4. Enter the address shown on the last retumfiled if different from the address entered on line 3.

Note. ff the address on Unes 3 and 4 are differentand you have not changed your address with theIRS, file Form 8822, Change of Address. For abusiness address, file Form 8822-B, Change ofAddress or Responsible Party — Business.

Signature and date. Form 4506 must be signed anddated by the taxpayer listed on line la or 2a. If youcompleted line 5 requesting the retum be sent to athird party, the IRS must receive Form 4506 within120 days of the date signed by the taxpayer or it willbe rejected. Ensure that all applicable lines arecompleted before signing.

Individuals. Copies of jointly filed tax retums maybe furnished to either spouse. Only one signature isrequired. Sign Form 4506 exactly as your nameappeared on the original return. If you changed yourname, also sign your current name.

Corporations. Generally, Form 4506 can besigned by: (1) an officer having legal authority to bindthe corporation, (2) any person designated by theboard of directors or other governing body, or (3)any officer or employee on written request by anyprincipal officer and attested to by the secretary orother officer.

Partnerships. Generally, Form 4506 can besigned by any person who was a member of thepartnership during any part of the tax periodrequested on line 7.

All othe►s. See section 6103(e) if the taxpayer hasdied, is insolvent, is a dissolved corporation, or if atrustee, guardian, executor, receiver, oradministrator is acting for the taxpayer.

Documentation. For entities other than individuals,you must attach the authorization document. Forexample, thls could be the letter from the principalofficer authorizing an employee of the corporation orthe letters testamentary authorizing an Individual toact for an estate.

Signature by a representative. A representativecan sign Form 4506 for a taxpayer only if thisauthority has been specifically delegated to therepresentative on Form 2848, line 5. Form 2848showing the delegation must be attached to Form4506.

Privacy Act and Paperwork Reduction ActNotice. We ask for the information on this form toestablish your right to gain access to the requestedretum(s) under the Internal Revenue Code. We needthis information to properly identify the retum(s) andrespond to your request. If you request a copy of atax return, sections 6103 and 6109 require you toprovide this information, including your SSN or EIN,to process your request. If you do not provide thisinformation, we may not be able to process yourrequest. Providing false or fraudulent informationmay subject you to penalties.

Routine uses of this information include giving it tothe Department of Justice for civil and criminallitigation, and cities, states, the District of Columbia,and U.S. commonwealths and possessions for usein administering their tax laws. We may alsodisclose this information to other countries under atax treaty, to federal and state agencies to enforcefederal nontax criminal laws, or to federal lawenforcement and intelligence agencies to combatterrorism.

You are not required to provide the informationrequested on a form that is subject to the PaperworkReduction Act unless the form displays a valid OMBcontrol number. Books or records relating to a formor its instructions must be retained as long as theircontents may become material in the administrationof any Internal Revenue law. Generally, tax returnsand retum information are confidential, as requiredby section 6103.

The time needed to complete and file Form 4506will vary depending on individual circumstances. Theestimated average time is: Leaming about the lawor the form, 10 min.; Preparing the fore, 16 min.;and Copying, assembling, and sending the foreto the IRS, 20 min.

If you have comments conceming the accuracy ofthese time estimates or suggeitions for makingForm 4506 simpler, we would be happy to hear fromyou. You can write to:

Internal Revenue ServiceTax Forms and Publications Division1111 Constitution Ave. NW, IR-6526Washington, DC 20224.

Do not send the fore to this address. Instead, seeWhere to file on this page.


ENNIGIER RIVERA,



Defendants.

x

SIR/MADAM:

NOTICE TO PRODUCESTATEMENTS

Index No. 25912/2015E

PLEASE TAKE NOTICE, that pursuant to §3101(e) of the Civil Practice Law

and Rules, you are hereby required to produce at the offices of the undersigned attorneys within

twenty (20) days from the date herein, any statements made by defendant NING LIN, M.D.

and/or the statements of any of his employees and/or the statements of his former employees

relating to the issues in this matter, including but not limited to any and all records obtained from

said defendant(s).

PLEASE TAKE FURTHER NOTICE, that upon failure to produce the aforesaid

items, a motion will be made to the Court for the appropriate relief with costs.


Yours, etc.


{01752204.DOCX }


{01752204.DOCX } -2-


ENNIGIER RIVERA,

Plaintiff, NOTICE PURSUANT TO CPLR§ 2103(5)

- against -Index No. 25912/2015E


Defendants.

SIR/MADAM:

PLEASE TAKE NOTICE, that pursuant to CPLR §2103(5), the defendant objects to

service of papers by facsimile transmission.


Yours, etc.



{01752206.DOCX }


ENNIGIER RIVERA,

Plaintiff,

- against -


Defendants.

x

Sir/Madam:

x

DEMAND FOR DISCLOSURE OFMEDICARE/MEDICAID/BENEFITS/ELIGIBILITY

Index No. 25912/2015E

PLEASE TAKE NOTICE that demand is hereby made that plaintiff(s) provide the

following information pursuant to CPLR 3120(a) and 42 U.S.C. Section 1395y(b)(8)(A):

1. The plaintiff's date of birth;2. The plaintiffs Social Security Number;3. The plaintiffs Medicare Health Insurance Claim Numbers (HICNs), Medicaid file

number, New York State Department of Social Services (DSS) file number, and/or

Medicare Secondary Payor (MSP) file number, if applicable;4. If the plaintiff has applied for or been awarded Medicare and/or Medicaid and/or DSS

and/or MSP benefits, all information/documentation related to the application applied

and/or award of said benefits including the amount paid out to plaintiff to date which is

subject to the mandatory reporting requirements of MMSEA § 111; include the full name

under which plaintiff applied for these benefits;5. If the plaintiff has applied for or been awarded Supplemental Security Income (SSI), or

Social Security Disability Insurance (SSDI), all information/documentation related to the

application and/or award of said benefits; include the full name under which plaintiff

applied for these benefits;6. State if plaintiff applied for insurance benefits with a private insurer pursuant to Medicare

part B, C, or D. If yes, provide the name and address of the insurer and set forth the

benefits provided.7. If plaintiff has been receiving Medicare benefits and is now deceased, please provide the

following:a. Relationship of the administrator of plaintiff s estate to plaintiff s decedent.

b. Name and address of Plaintiffs administrator.c. Telephone number and/or e-mail address of plaintiffs administrator.d. Social Security Number of plaintiffs administrator.

{01752207.DOCX

8. If the plaintiff has been denied Medicare, Medicaid, SSI, and/or SSDI benefits, provideall information/documentation concerning any such denial;

9. If the plaintiff has appealed or intends to appeal the denial of Medicare, Medicaid, SSI,and/or SSDI benefits, provide all information/documentation of any such appeal orintents to appeal of the denial of such benefits; and

10. State whether Medicare, Medicaid and/or the Social Security Administration has a lien onany potential award, judgment or settlement in this lawsuit and, if so, state the amount ofsuch lien(s) and provide all information /documentation relative to these liens.

Pursuant to CPLR § 3101(a), provide duly executed and acknowledged writtenauthorizations permitting defendant's attorneys and defendant's representatives to obtain andmake copies of all Medicaid records, specifying the correct address of said Medicaid office,along with the plaintiff's Social Security Number and the file number. Said defendantfurther demands that a signed original of the attached Authorization for Release of MedicaidProtected Information, and/or any other specific authorization required by Medicaid beexecuted and provided for use in conjunction with this demand as it pertains to healthinformation.

If plaintiff received or applied for Social Security benefits, including but not limited toSSI or SSDI benefits, provide a duly executed and acknowledged written authorizationsetting forth the correct Social Security file number, allowing the defendant's attorneys anddefendant's representatives to obtain and make copies of all files, records, and reports of the

Social Security Administration regarding the plaintiff. Said defendant further demands that asigned original of the attached Social Security Administration Consent for Release ofInformation and/or any other specific authorization required by the Social SecurityAdministration be executed and provided for use in conjunction with this demand as it

pertains to health information.

PLEASE TAKE FURTHER NOTICE that the provisions of CPLR 3122 govern this

demand and if the party to whom the notice is directed objects to the disclosure, inspection or

examination or withholds any documents which appear to be within the category of thedocuments required by the notice, compliance with CPLR 3122 is required.

PLEASE TAKE FURTHER NOTICE that in the event of failure or refusal to comply

with any of these demands, said defendant will apply to the Court for the appropriate relief

including, but not limited to, an Order compelling compliance pursuant to CPLR 3124 and/or

appropriate relief pursuant to CPLR § 3126 and 22 N.Y.C.R.R. Part 130.

{01752207.DOCX }

PLEASE TAKE FURTHER NOTICE, that all demands herein shall be deemed tocontinue during the pendency of this action through and including the trial thereof and plaintiff'sresponses must be amended or supplemented properly in compliance with CPLR § 3101(h).


Yours, etc.



{01752207.DOCX }

AUTHORIZATION FOR RELEASE OF MEDICAID PROTECTED INFORMATIONFROM THE NEW YORK STATE DEPARTMENT OF HEALTH, OFFICE OF HEALTH INSURANCE

PROGRAMS TO A THIRD PARTY OTHER THAN A MEDICAID ENROLLEE/PATIENT

Enrollee/Client Name:

Date of Birth:

Client Identification Number (C1N):

By signing this form, I understand that I am allowing the New York State Department of Health to use ordisclose all of my payment information as indicated below. This may include data on certain conditionssuch as HIV/AIDS, Mental Health and Alcohol and Substance Abuse.

Persons/organizations authorized to receive or use the information:

Name:

Address:

City: State: Zip:

Phone Number:

1. Purpose of the use/disclosure:

2. Will the person/program requesting the authorization receive financial or in-kind compensation in exchangefor using or disclosing the health information described above? Yes No

3. I understand that my health care and the payments for my health care will not be affected if I do not sign thisform except in some situations when information is needed for the health plan's eligibility or enrollmentdeterminations relating to the individual.

4. I understand, with few exceptions, that I may see and copy the information described on this form if I ask forit, and that I may get a copy of this form after I sign it.

5. I may revoke this authorization at any time by notifying the Depai intent of Health in writing at the addressbelow, but, if I do, it will not have any effect on actions that the Department took before they received therevocation. If not previously revoked, this authorization will expire upon completion of this request.

6. I understand that this authorization is voluntary. I understand that if the organization authorized to receive theinformation is not a health plan, health care provider or clearinghouse, the released information may no longerbe protected by federal privacy regulations, and therefore the recipient of the confidential data may redisclosethe confidential data.

7. This Authorization will expire upon use or one year from the date this form is signed, whichever comes first.

Signature of Medicaid Enrollee Date

Please return to:

NYS Department of HealthOffice of Health Insurance ProgramsDivision of Systems - Bureau of Data WarehouseData Access Unit800 N. Pearl Street3rd Floor - Room 322Albany, New York 12204

Information to Help You Fill Out the

"1-800-MEDICARE Authorization to Disclose Personal Health Information" Form

By law, Medicare must have your written permission (an "authorization") to use or give outyour personal medical information for any purpose that isn't set out in the privacy noticecontained in the Medicare & You handbook. You may take back ("revoke") your writtenpermission at any time, except if Medicare has already acted based on your permission.

If you want 1-800-MEDICARE to give your personal health information to someone other thanyou, you need to let Medicare know in writing.

If you are requesting personal health information for a deceased beneficiary, please include acopy of the legal documentation which indicates your authority to make a request for

information. (For example: Executor/Executrix papers, next of kin attested by court documentswith a court stamp and a judge's signature, a Letter of Testamentary or Administration with acourt stamp and judge's signature, or personal representative papers with a court stamp andjudge's signature.) Also, please explain your relationship to the beneficiary.

Please use this step by step instruction sheet when completing your "1-800-MEDICARE

Authorization t o Disclose Personal Health Information" Form. Be sure to complete all sections

of the form to ensure timely processing.

1. Print the name of the person with Medicare.

Print the Medicare number exactly as it is shown on the red, white, and blue Medicare

card, including any letters (for example, 123456789A).

Print the birthday in month, day, and year (mm/dd/yyyy) of the person with Medicare.

2. This section tells Medicare what personal health information to give out. Please check abox in 2a to indicate how much information Medicare can disclose. If you only wantMedicare to give out limited information (for example, Medicare eligibility), also checkthe box(es) in 2b that apply to the type of information you want Medicare to give out.

3. This section tells Medicare when to start and/or when to stop giving out your personal

health information. Check the box that applies and fill in dates, if necessary.

4. Medicare will give your personal health information to the person(s) or organization(s) youfill in here. You may fill in more than one person or organization. If you designate anorganization, you must also identify one or more individuals in that organization to whomMedicare may disclose your personal health information.

• 1

5. The person with Medicare or personal representative must sign their name, fill in the date,and provide the phone number and address of the person with Medicare.

If you are a personal representative of the person with Medicare, check the box, provideyour address and phone number, and attach a copy of the paperwork that shows you canact for that person (for example, Power of Attorney).

6. Send your completed, signed authorization to Medicare at the address shown here on yourauthorization form.

7. If you change your mind and don't want Medicare to give out your personal healthinformation, write to the address shown under number six on the authorization form andtell Medicare. Your letter will revoke your authorization and Medicare will no longergive out your personal health information (except for the personal health informationMedicare has already given out based on your permission).

You should make a copy of your signed authorization for your records before mailing it to

Medicare.

L _ -t

1-800-MEDICARE Authorization to Disclose Personal Health Information

Use this form if you want 1-800-MEDICARE to give your personal health information tosomeone other than you.

1. Print Name Medicare Number Date of Birth(First and last name of the person with Medicare) (Exactly as shown on the Medicare Card) (mm/dd/yyyy)

2. Medicare will only disclose the personal health information you want disclosed.

2A: Check only one box below to tell Medicare the specific personal healthinformation you want disclosed:

Limited Information (go to question 2b)

D Any Information (go to question 3)

2B: Complete only i f you selected "limited information". Check all that apply:

Information about your Medicare eligibility

Information about your Medicare claims

Information about plan enrollment (e.g. drug or MA Plan)

Information about premium payments

Other Specific Information (please write below; for example, payment information)

3. Check only one box below indicating how long Medicare can use this authorizationto disclose your personal health information ( subject to applicable law-for example,your State may limit how long Medicare may give out your personal health information):

Disclose my personal health information indefinitely

Disclose my personal health information for a specified period onlybeginning: (mm/dd/yyyy) and ending: (mm/dd/yyyy)

.••..-.•.• -

4. Fill in the name and address of the person(s) or organization(s) to whom you want

Medicare to disclose your personal health information. Please provide the specific

name of the person(s) for any organization you list below:

5.

1. Name:

Address:

2. Name:

Address:

3. Name:

Address:

I authorize 1-800-MEDICARE to disclose my personal health information listedabove to the person(s) or organization(s) I have named on this form. I

understand that my personal health information may be re-disclosed by the

person(s) or organization(s) and may no longer be protected by law.

Signature Telephone Number Date (mm/dd/yyyy)

Print the address of the person with Medicare (Street Address, City, State, and ZIP)

Check here if you are signing as a personal representative and complete below.

Please attach the appropriate documentation (for example, Power of Attorney).

This only applies if someone other than the person with Medicare signed above.

Print the Personal Representative's Address (Street Address, City, State, and ZIP)

Telephone Number of Personal Representative:

Personal Representative's Relationship to the Beneficiary:

6. Send the completed, signed authorization to:

Medicare BCC, Written Authorization Dept.PO Box 1270

Lawrence, KS 66044

7. Note:

You have the right to take back ("revoke") your authorization at any time, in writing,except to the extent that Medicare has already acted based on your permission. If youwould like to revoke your authorization, send a written request to the address shownabove.

Your authorization or refusal to authorize disclosure of your personal healthinformation will have no effect on your enrollment, eligibility for benefits, or theamount Medicare pays for the health services you receive.

Print Form

According to the Paperwork Reduction Act of 1995, no persons are required to respond to acollection of information unless it displays a valid OMB control number. The valid OMBcontrol number for this information collection is 0938-0930. The time required to completethis information collection is estimated to average 15 minutes per response, including thetime to review instructions, search existing data resources, gather the data needed, andcomplete and review the information collection. If you have comments concerning theaccuracy of the time estimate(s) or suggestions for improving this form, please write to:CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,Baltimore, Maryland 21244-1850.


ENNIGIER RIVERA,

- against -

x

Plaintiff, DEMAND FOR SOCIALNETWORKING INFORMATION


Defendants.

x

Index No. 25912/2015E

COUNSELORS:

PLEASE TAKE NOTICE, that pursuant to Article 31 of the CPLR, §2305 and §3120 of

the. CPLR, you are hereby required to serve upon AARONSON RAPPAPORT FEINSTEIN &

DEUTSCH, LLP, attorneys for the defendant NING LIN, M.D., within twenty (20) days after

service of a copy of this demand, setting forth in detail the following documents and materials:

(1) Original, signed, fully addressed, fully executed HIPAA-compliant

authorizations, containing complete names and addresses of each social networking

entity/provider, date of birth and social security number of Plaintiff, and any other identifying

information for the release of any and all historical records/information for Plaintiffs':

a) Facebook account;b) Myspace account;c) Twitter account;d) Foursquare account;e) Google Buzz account;f) Shutterfly.com account;g) Flickr.com account;h) Snapfish.com account;i) Linkedln account;

{01752211.DOCX }

j) Evite.com account;k) Punchbowl.com account;1) Classmates.com account;m) Active.com account;n) Bebo.com account;o) Friendster account; andp) Instagram account.

(2) Identify any other social networking site(s) which Plaintiff has been a member

of from five (5) years prior to the alleged date of negligence to present.

The above authorizations must include the email address linked to the account, along

with all other required identifying information. If Plaintiff never had such an account, then an

Affidavit to that effect must be provided. If Plaintiff does not currently have such an account, but

had such an account at some time prior, then an Affidavit to that effect must be provided,

including the time frame such an account existed.


To:

Yours, etc.



(01752211 DOCX )

2016 09:08 am

Documents