Michael A Impaglia III et al v. Karen M Watson, 800541/2024, 4 (N.Y. Sup. Ct., Erie County Jan. 31, 2024) (2024)

`

`FILED: ERIE COUNTY CLERK 01/31/2024 09:03 AM
`NYSCEF DOC. NO. 4
`
`INDEX NO. 800541/2024
`
`RECEIVED NYSCEF: 01/31/2024
`
`6.
`
`
`7.
`
`
`8.
`
`
`9.
`
`Any notes, records, memoranda, diagrams, drawings, photographs made
`or taken by any investigator employed by the Plaintiff(s) or the Plaintiff(s)
`representatives, even if made in contemplation of litigation.
`
`The name and address of each and every person you expect to call as an
`expert witness at the trial of this action;
`
`In reasonable detail, the subject matter on which each expert is expected to
`testify;
`
`The substance of the facts and opinions on which each expert is expected
`to testify;
`
`The qualification of each expert witness, and;
`
`
`10.
`
`11.
`
`12. Maintenance and repair records for the motor vehicle of the Plaintiff(s) for
`one (1) year prior to the alleged occurrence.
`
`A summary of the grounds for each expert's opinion.
`
`
`13.
`
`
`14.
`
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`15.
`
`
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`Copies of any letters or written communications from Plaintiff(s) to
`Defendant(s) citing any alleged defective conditions.
`
`Duly executed authorization allowing the undersigned to obtain the
`employment records of the party seeking recovery for the period
`commencing one (1) year prior to the date of the subject occurrence and
`continuing to the present date. This authorization shall allow access to,
`but shall not be limited to, records regarding the Plaintiff(s)' salary and
`attendance.
`
`(a)
`
`If Plaintiff is a student: duly executed authorization(s) allowing the
`undersigned to obtain the school records of the Plaintiff for the
`period commencing one (1) year prior to the date of the occurrence
`and continuing to the present date.
`
`Copies of the Plaintiff(s)' City, State and Federal Income Tax Records for
`the period commencing two (2) years prior to the date of the subject
`occurrence and for all subsequent years up to and including the present. If
`such records, or a portion thereof are unavailable, authorizations to obtain
`such records from the Internal Revenue Service and/or New York State
`Department of Taxation. If income tax returns were not filed for such
`period or a portion thereof, so state in reply to this demand.
`
`
`
`2
`2 of 25
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`

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`FILED: ERIE COUNTY CLERK 01/31/2024 09:03 AM
`NYSCEF DOC. NO. 4
`
`INDEX NO. 800541/2024
`
`RECEIVED NYSCEF: 01/31/2024
`
`16.
`
`
`17.
`
`
`18.
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`Duly executed and acknowledged original authorizations permitting
`this/these Defendant(s) to obtain and copy No-Fault medical and wage
`records for each Plaintiff for the period from the date of occurrence to the
`present.
`
`If a claim has or will be made pursuant to the terms of ARTICLE 51 of the
`Insurance Law of the State of New York (No-Fault Law); with respect to
`each and every application:
`
`(a)
`
`(b)
`
`Set forth the name, address, policy number and claim number of
`each company to which a claim has been or will be made,
`including OBEL, Additional PIP and Medical Payments coverage.
`
`Set forth duly executed and acknowledged written authorizations
`enabling the undersigned to obtain the records relating to the
`Plaintiff from each company identified in the response to
`Paragraph "(a)".
`
`If a claim has or will be made pursuant to the terms of the Workers'
`Compensation Law, with respect to each and every application:
`
`(a)
`
`(b)
`
`Set forth the name, address, policy number and claim number to
`which a claim has been or will be made, together with the Workers'
`Compensation Board file number.
`
`Set forth duly executed and acknowledged written authorizations
`enabling the undersigned to obtain the records relating to the
`Plaintiff from each company identified in the response to
`Paragraph "(a)".
`
`19.
`
`
`If a disability claim has or will be made pursuant to the terms of the Social
`Security Laws, with respect to each and every application:
`
`(a)
`
`(b)
`
`Set forth the claim office, the address and the claim number
`assigned.
`
`Set forth duly executed and acknowledged written authorizations
`enabling the undersigned to obtain the records relating to the
`Plaintiff.
`
`20.
`
`
`Pursuant to CPLR Section 4545(a) produce and permit the undersigned
`attorneys to inspect and copy the contents of:
`
`(a)
`
`Each and every collateral source of payment, including but not
`limited to, insurance agreements, Social Security, Workers'
`Compensation or employee benefit programs, and any other
`collateral source of payment for past or future costs or expenses
`alleged to have been incurred by the Plaintiffs and for which
`recovery is sought in the instant action and
`
`
`
`3
`3 of 25
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`

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`FILED: ERIE COUNTY CLERK 01/31/2024 09:03 AM
`NYSCEF DOC. NO. 4
`
`INDEX NO. 800541/2024
`
`RECEIVED NYSCEF: 01/31/2024
`
`(b)
`
`(c)
`
`(d)
`
`A written statement setting forth any and all such collateral sources
`and their amounts.
`
`Duly executed written authorizations permitting the undersigned
`attorneys to obtain and make copies of all records relating to
`collateral source information as set forth herein.
`
`The amounts and any and all correspondence in which, the
`plaintiff(s) will claim as lawful liens against the plaintiff(s)
`recovery.
`
`
`If it is claimed that the Plaintiff husband/wife is married to Plaintiff
`husband/wife. Please set forth a copy of their Marriage Certificate.
`
`If it is claimed that the infant Plaintiff is the natural son/daughter of the
`Plaintiff mother/father or natural guardian set forth a copy of the Birth
`Certificate of infant Plaintiff.
`
`21.
`
`
`22.
`
`
`23. Withholding statements, pay envelopes, deposit slips, or any other
`evidence of income earned by Plaintiff(s) for the current calendar year.
`
`
`24.
`
`
`25.
`
`
`26.
`
`
`27.
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`Copies of any and all bills, statements or receipts relating to any non-
`medical expense claimed as damages in this lawsuit which have not been
`produced in response to any of the preceding paragraphs.
`
`Copies of bills and/or estimates for the repair of Plaintiff(s) vehicle and
`any other damaged property. If the vehicle was not repairable, in addition,
`attach estimates of the value of the vehicle on the date of the alleged
`incident and estimates and/or receipts concerning salvage value.
`
`Any releases, and any other type of settlement agreements between
`Plaintiff(s) and any other party which may have been responsible for the
`damages claimed by Plaintiff(s).
`
`Any and all photographs, blow-ups, recordings, charts, graphs, sketches
`and any other tangible items or documentary evidence which you intend to
`use during the trial of this case and which have not been produced in
`response to any of the preceding paragraphs.
`
`All documents, papers or evidence to be introduced at trial.
`
`
`28.
`
`PLEASE TAKE FURTHER NOTICE that the within demands are continuing
`
`demands. In the event any of the above items are obtained after service of this demand, they are
`
`to be furnished to this office upon receipt.
`
`
`
`4
`4 of 25
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`

`

`FILED: ERIE COUNTY CLERK 01/31/2024 09:03 AM
`NYSCEF DOC. NO. 4
`
`INDEX NO. 800541/2024
`
`RECEIVED NYSCEF: 01/31/2024
`
`DATED: Tarrytown, NY
`January 31, 2024
`
`Yours, etc.,
`Law Offices of John Trop
`
`____________________________
`Matthew T. Murray, Esq.
`Attorney for Defendant
`KAREN M. WATSON
`120 White Plains Road, Suite 200
`Tarrytown, NY 10591
`Telephone: (716) 536-9371
`
`
`
`TO:
`
`Kristopher A. Schwarzmueller, Esq.
`RICHMOND VONA, LLC
`Attorneys for Plaintiff
`192 Seneca Street, Suite 200
`Buffalo, NY 14204
`(716) 500-5678
`
`
`
`
`
`5
`5 of 25
`
`

`

`FILED: ERIE COUNTY CLERK 01/31/2024 09:03 AM
`NYSCEF DOC. NO. 4
`
`INDEX NO. 800541/2024
`
`RECEIVED NYSCEF: 01/31/2024
`
`SUPREME COURT OF THE STATE OF NEW YORK
`COUNTY OF ERIE
`----------------------------------------------------------------------------------------------------------------------X
`MICHAEL A. IMPAGLIA, III and ELIZABETH
`A. BOWDISH,
`
` Plaintiffs,
`
` v.
`
`KAREN M. WATSON,
`
` Defendant.
`
`---------------------------------------------------------------------------------------------------------------------X
`
`
`
`
`
`DEMAND FOR COPIES OF
`PLAINTIFF’S MEDICAL REPORTS
`
`Index No. 800541/2024
`
`PLEASE TAKE NOTICE that pursuant to the Uniform Rules for the New York
`
`State Trial Courts, demand is hereby made upon the Plaintiff(s) or his attorney to:
`
`1.
`
`
`2.
`
`
`3.
`
`Serve upon and deliver to the attorney for Defendant(s), copies of the
`medical reports of those physicians who have previously treated or
`examined Plaintiff(s) and who will testify on his/her behalf. These shall
`include a detailed recital of the injuries and conditions as to which
`testimony will be offered at the trial, referring to and identifying those
`x-rays and technician's reports which will be offered at the trial.
`
`Serve upon and deliver to the attorney for Defendant(s), duly executed and
`acknowledged written HIPAA Compliant Authorizations permitting all
`parties to obtain and make copies of all hospital records and such other
`records, including x-rays and technician's reports, as to be referred to and
`identified in the statement of the Plaintiff(s) physicians.
`
`Serve upon and deliver to the attorney for Defendant(s), copies of all
`graphic, numerical, symbolic, digital, film, video, computer generated,
`computer enhanced or otherwise produced electronically and/or digitally,
`photographic or pictorial representations regarding any procedures,
`treatments, admissions, office visits, injuries, scene of the accident or the
`vehicles or instrumentalities involved, disabilities, medical or diagnostic
`procedures or tests, performed by or on behalf of the Plaintiff(s) herein or
`by any facility regarding the claims of the Plaintiff(s) herein.
`
`
`PLEASE TAKE FURTHER NOTICE that upon his failure to comply with this
`
`demand, Plaintiff(s) will be precluded upon the trial of the within action from offering in
`
`evidence or testifying as to any of the reports, records or examination demanded herein.
`
`6 of 25
`
`

`

`FILED: ERIE COUNTY CLERK 01/31/2024 09:03 AM
`NYSCEF DOC. NO. 4
`
`INDEX NO. 800541/2024
`
`RECEIVED NYSCEF: 01/31/2024
`
`DATED: Tarrytown, NY
`January 31, 2024
`
`Yours, etc.,
`Law Offices of John Trop
`
`____________________________
`Matthew T. Murray, Esq.
`Attorney for Defendant
`KAREN M. WATSON
`120 White Plains Road, Suite 200
`Tarrytown, NY 10591
`Telephone: (716) 536-9371
`
`
`
`TO:
`
`Kristopher A. Schwarzmueller, Esq.
`RICHMOND VONA, LLC
`Attorneys for Plaintiff
`192 Seneca Street, Suite 200
`Buffalo, NY 14204
`(716) 500-5678
`
`
`
`
`
`2
`7 of 25
`
`

`

`FILED: ERIE COUNTY CLERK 01/31/2024 09:03 AM
`NYSCEF DOC. NO. 4
`
`INDEX NO. 800541/2024
`
`RECEIVED NYSCEF: 01/31/2024
`
`SUPREME COURT OF THE STATE OF NEW YORK
`COUNTY OF ERIE
`----------------------------------------------------------------------------------------------------------------------X
`MICHAEL A. IMPAGLIA, III and ELIZABETH
`A. BOWDISH,
`
` Plaintiffs,
`
` v.
`
`KAREN M. WATSON,
`
` Defendant.
`
`---------------------------------------------------------------------------------------------------------------------X
`
`
`
`
`
`DEMAND PURSUANT TO
`SECTION 306(a)
`
`Index No. 800541/2024
`
`IT IS HEREBY DEMANDED that you serve upon the undersigned, either a
`
`copy of the receipt for the Index Number purchased or the date the Index Number was purchased
`
`as per said receipt.
`
`DATED: Tarrytown, NY
`January 31, 2024
`
`Yours, etc.,
`Law Offices of John Trop
`
`____________________________
`Matthew T. Murray, Esq.
`Attorney for Defendant
`KAREN M. WATSON
`120 White Plains Road, Suite 200
`Tarrytown, NY 10591
`Telephone: (716) 536-9371
`
`
`
`TO:
`
`
`
`Kristopher A. Schwarzmueller, Esq.
`RICHMOND VONA, LLC
`Attorneys for Plaintiff
`192 Seneca Street, Suite 200
`Buffalo, NY 14204
`(716) 500-5678
`
`8 of 25
`
`

`

`FILED: ERIE COUNTY CLERK 01/31/2024 09:03 AM
`NYSCEF DOC. NO. 4
`
`INDEX NO. 800541/2024
`
`RECEIVED NYSCEF: 01/31/2024
`
`SUPREME COURT OF THE STATE OF NEW YORK
`COUNTY OF ERIE
`----------------------------------------------------------------------------------------------------------------------X
`MICHAEL A. IMPAGLIA, III and ELIZABETH
`A. BOWDISH,
`
` Plaintiffs,
`
` v.
`
`KAREN M. WATSON,
`
` Defendant.
`
`---------------------------------------------------------------------------------------------------------------------X
`
`
`
`
`
`DEMAND PURSUANT TO
`SECTION 306(c)
`
`Index No. 800541/2024
`
`PLEASE TAKE NOTICE that pursuant to § 306-c Notice of commencement of
`
`action for personal injuries by recipient of medical assistance, it is hereby demanded that you
`
`serve upon the office of the undersigned, within thirty (30) days proof of compliance to the
`
`following:
`
`In the case of an individual who has suffered personal injuries and has received
`
`medical assistance pursuant to Titles Eleven and Eleven-D of Article Five of the Social Services
`
`Law on or after the date of such injury, notice of the commencement of an action by or on behalf
`
`of such individual for such personal injuries shall be sent to the Social Services District in the
`
`County in which such recipient resides, or to the Department of Health, by certified mail, return
`
`receipt requested, or electronically in accord with regulations promulgated by the Commissioner
`
`of the Department of Health, within sixty (60) days of the completion of service upon all parties
`
`to such action. Proof of sending such notice shall be filed with the Court in accordance with
`
`Rule Three Hundred Six of this Article. Sending such notice shall not be a jurisdictional
`
`requirement to commencing an action.
`
`9 of 25
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`

`

`FILED: ERIE COUNTY CLERK 01/31/2024 09:03 AM
`NYSCEF DOC. NO. 4
`
`
`INDEX NO. 800541/2024
`
`RECEIVED NYSCEF: 01/31/2024
`
`PLEASE TAKE FURTHER NOTICE that the within demands are continuing
`
`demands. In the event any of the above items are obtained after service of this demand, they are
`
`to be furnished to this office upon receipt.
`
`DATED: Tarrytown, NY
`January 31, 2024
`
`Yours, etc.,
`Law Offices of John Trop
`
`____________________________
`Matthew T. Murray, Esq.
`Attorney for Defendant
`KAREN M. WATSON
`120 White Plains Road, Suite 200
`Tarrytown, NY 10591
`Telephone: (716) 536-9371
`
`
`
`TO:
`
`Kristopher A. Schwarzmueller, Esq.
`RICHMOND VONA, LLC
`Attorneys for Plaintiff
`192 Seneca Street, Suite 200
`Buffalo, NY 14204
`(716) 500-5678
`
`
`
`
`
`2
`10 of 25
`
`

`

`FILED: ERIE COUNTY CLERK 01/31/2024 09:03 AM
`NYSCEF DOC. NO. 4
`
`INDEX NO. 800541/2024
`
`RECEIVED NYSCEF: 01/31/2024
`
`SUPREME COURT OF THE STATE OF NEW YORK
`COUNTY OF ERIE
`----------------------------------------------------------------------------------------------------------------------X
`MICHAEL A. IMPAGLIA, III and ELIZABETH
`A. BOWDISH,
`
` Plaintiffs,
`
` v.
`
`KAREN M. WATSON,
`
` Defendant.
`
`---------------------------------------------------------------------------------------------------------------------X
`
`
`
`
`
`DEMAND FOR
`MEDICARE/MEDICAID
`REIMBURsem*nT INFORMATION
`
`Index No. 800541/2024
`
`PLEASE TAKE NOTICE that pursuant to 42 U.S.C. 1395y(b)(8), 42 C.F.R
`
`411.23, and CPLR 3101 et seq., it is hereby demanded that you serve upon the office of the
`
`undersigned, within thirty (30) days the following:
`
`1.
`
`2.
`
`3.
`
`
`4.
`
`
`5.
`
`
`6.
`
`Plaintiff’s Social Security Number
`
`Plaintiff’s date of birth
`
`Plaintiff’s Medicare/Medicaid and Health Insurance Claim Numbers for
`both “Traditional" Medicare and Medicare Advantage Plans, as well as
`any additional supplemental Medicare Insurance Plan.
`
`to whether Plaintiff has received benefits from
`A statement as
`Medicare/Medicaid at any time, for any reason, not limited to the injuries
`alleged in the instant action.
`
`to whether Plaintiff has received benefits from
`A statement as
`Medicare/Medicaid claimed to be related to this instant action and an
`itemization of those benefits, including any and all information pertaining
`to Medicare Advantage Plans and any Supplemental Medicare Plan.
`
`If the answer to Request “4" or “5" above is “yes", please state or provide:
`
`(a) Whether Medicare/Medicaid has asserted a Medicare/Medicaid
`Secondary Payer right of reimbursem*nt or lien, and the amount of
`any such reimbursem*nt;
`
`11 of 25
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`

`

`FILED: ERIE COUNTY CLERK 01/31/2024 09:03 AM
`NYSCEF DOC. NO. 4
`
`INDEX NO. 800541/2024
`
`RECEIVED NYSCEF: 01/31/2024
`
`
`
`
`
`(b)
`
`(c)
`
`(d)
`
`Copies of any and all documents, records, memoranda, notes,
`correspondence etc.,
`in Plaintiff’s possession pertaining
`to
`Plaintiff’s receipt of Medicare/Medicaid benefits, including, but
`not limited to, copies of all documents provided to or received
`from the Medicare Center for Medicare/Medicaid Services (CMS),
`Coordination of Benefits Contractor
`(COBC), Commercial
`Repayment Center (CRC), Benefits Coordination and Recovery
`Center (BCRC) and Medicare Secondary Payer Recovery
`Contractor (MSPRC);
`
`A duly executed and acknowledged HIPAA Compliant
`Authorization and a CMS Consent to Release Information
`permitting Defendant to obtain copies of Plaintiff’s Medicare
`records. A copy of the Medicare and Medicaid Authorization and
`Consent to Release Information required by Medicare is attached
`hereto;
`
`If any Medicare/Medicaid Secondary Payer claims exist, please
`provide a copy of such claims. If no Medicare/Medicaid
`Secondary Payer claims exist, kindly provide a letter from
`Medicare/Medicaid attesting to that fact.
`
`
`Please state whether Plaintiff is Medicare-eligible by reason of:
`
`7.
`
`(a)
`
`(b)
`
`(c)
`
`(d)
`
`(e)
`
`(f)
`
`Being age 65 or older;
`
`Being entitled to receive Social Security Disability for the previous
`twenty-four (24) months;
`
`Having received a disability pension from the Railroad Retirement
`Board,
`
`Having received benefits for amyotrophic lateral sclerosis;
`
`Having a government job where Medicare taxes were paid, and the
`claimant meets the requirements of the Social Security Disability
`program.
`
`Being the child or widow(er), age 50 or older, including divorced
`widow(ers) of someone who has been in a government job where
`Medicare
`taxes were paid, and who meets
`the eligibility
`requirements of the Social Security Disability program;
`
`(g)
`
`Has had permanent kidney failure, a kidney transplant or receives
`maintenance dialysis, or and:
`
`(1)
`
`(2)
`
`Is eligible to or receive monthly benefits under Social
`Security or the Railroad Retirement System; or
`
`Has worked in a Medicare covered government job; or is
`the child or spouse (including divorced spouse) of a worker
`who has worked long enough under Social Security, or in a
`Medicare-covered government job.
`
`12 of 25
`
`

`

`FILED: ERIE COUNTY CLERK 01/31/2024 09:03 AM
`NYSCEF DOC. NO. 4
`
`INDEX NO. 800541/2024
`
`RECEIVED NYSCEF: 01/31/2024
`
`
`
`PLEASE TAKE FURTHER NOTICE that this demand is made pursuant to the
`
`Medicare, Medicaid and State Children’s Health Insurance Program (SCHIP) Act of 2007.
`
`Federal Law mandates that the foregoing information be provided to the Centers for Medicare
`
`and Medicaid Services following resolution of the instant litigation.
`
`PLEASE TAKE FURTHER NOTICE that failure to comply with this Demand
`
`in contravention of 42 C.F.R 411.23 may result in direct recovery by the centers for Medicare
`
`and Medicaid Services against the Plaintiff herein.
`
`PLEASE TAKE FURTHER NOTICE that the within demands are continuing
`
`demands. In the event any of the above items are obtained after service of this Demand, they are
`
`to be furnished to this office upon receipt.
`
`DATED: Tarrytown, NY
`January 31, 2024
`
`Yours, etc.,
`Law Offices of John Trop
`
`____________________________
`Matthew T. Murray, Esq.
`Attorney for Defendant
`KAREN M. WATSON
`120 White Plains Road, Suite 200
`Tarrytown, NY 10591
`Telephone: (716) 536-9371
`
`
`Kristopher A. Schwarzmueller, Esq.
`RICHMOND VONA, LLC
`Attorneys for Plaintiff
`192 Seneca Street, Suite 200
`Buffalo, NY 14204
`(716) 500-5678
`
`
`TO:
`
`
`
`
`
`13 of 25
`
`

`

`FILED: ERIE COUNTY CLERK 01/31/2024 09:03 AM
`NYSCEF DOC. NO. 4
`
`INDEX NO. 800541/2024
`
`RECEIVED NYSCEF: 01/31/2024
`
`Include: (Indicate by Initialing)
`{ } Alcohol/Drug Treatment
`{ } Mental Health Information
`{ } HIV-Related Information
`
`AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
`Name
`Date of Birth
`Social Security Number
`
`
`
`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 HEALTH
`TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on
`the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I
`initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
`2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
`prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand
`that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience
`discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human
`Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for
`protecting my rights.
`3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may
`revoke this authorization except to the extent that action has already been taken based on this authorization.
`4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits
`will not be conditioned upon my authorization of this disclosure.
`5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
`redisclosure may no longer be protected by federal or state law.
`6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
`CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9(b).
`7. Name and address of health provider or entity to release this information:
`
`8. Name and address of person(s) or category of person to whom this information will be sent:
`Law Offices of John Trop, 120 White Plains Road, Suite 200, Tarrytown, NY 10591 or their third-party record retrieval vendor
`Compex Legal Services, 5481 W. Water Ave., Suite 108, Tampa, FL 33634. (Tel#: 888-531-2919)
`9(a). Specific information to be released:
`[ ] Medical Record from (insert date) { } to (insert date) { }
`[ X ] Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results
`radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other
`health care providers.
`[ ] Other:
`
`
`
`Authorization to Discuss Health Information
`[ ] (b) By initialing here { } I authorize
` initials Name of individual health care provider
` to discuss my health information with my attorney, or a government agency, listed here:
` Law Offices of John Trop
`
` (Attorney/Firm Name or Government Agency Name)
`10. Reason for release of information:
`11. Date or event on which this authorization will
` [x ] At request of individual –Legal proceeding
`expire: At conclusion of court case.
` [ ] Other:
`12. If not, name of person signing form:
`
`All items on this form have been completed and my questions about this form have been answered. In addition, I have been
`provided a copy the form.
`
`
`______________________________________
`Signature of Patient or representative authorized by law.
`
`13. Authority to sign on behalf of patient:
`
`Date:____________________
`
` *
`
` Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify
`someone as having HIV symptoms or infection and information regarding a person’s contacts.
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`14 of 25
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`FILED: ERIE COUNTY CLERK 01/31/2024 09:03 AM
`NYSCEF DOC. NO. 4
`
`INDEX NO. 800541/2024
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`RECEIVED NYSCEF: 01/31/2024
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`
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`Workers’
`Compensation
`Board
`
` CLAIMANT’S AUTHORIZATION TO DISCLOSE
` WORKERS’ COMPENSATION RECORDS
` (Pursuant to Workers’ Compensation Law Section 110-a)
`
`
` PO Box 5205, Binghamton, NY 13902-5205 · www.wcb.ny.gov
`
`
`CLAIMANTS ARE PROHIBITED FROM AUTHORIZING RELEASE OF WORKERS’ COMPENSATION INFORMATION TO
`PROSPECTIVE EMPLOYERS OR IN CONNECTION WITH ASSESSING FITNESS OR CAPABILITY OF EMPLOYMENT.
`
`PLEASE COMPLETE ALL ITEMS. AN INCOMPLETE FORM WILL DELAY THE PROCESSING OF YOUR REQUEST.
`
`Claimant’s Social Security or
`Tax Identification Number
`
`
`Claimant’s Name
`
`
`
`IF RELEASE IS AUTHORIZED FOR ADDITIONAL CASE FILE(S), IDENTIFY BELOW BY WCB/DB/DC/PFL CASE NUMBER
`AND/OR DATE OF ACCIDENT(S)
`
`
`
`
`
`
`
`Case Number WCB DB Discrimination
` PFL and/or Date of Accident
`
`
`
`INSTRUCTIONS:
`
`Submit original to the Workers’ Compensation Board and retain a copy for your records. Authorization for disclosure
`of records for certain purposes is not valid under the law. See excerpt of WCL Section 110-a on the reverse of this form.
`This authorization is effective until it is revoked by the claimant. Claimant may revoke this authorization at any time
`upon written notice to the Workers’ Compensation Board.
`
` THIS AUTHORIZATION DOES NOT PERMIT YOU TO OPEN AN INDIVIDUAL eCASE ACCOUNT
` OR TO VIEW CASES VIA eCASE OUTSIDE OF A BOARD LOCATION.
`
`
`
`Pursuant to Section 110-a of the Workers’ Compensation Law, I, _________________________________________________,
`
`
`
`
`
`
`
`
`
`(CLAIMANT’S NAME)
`represent that I am a person who is/was the subject of the workers’ compensation case(s) indicated above, and I authorize the
`Workers’ Compensation Board to discuss the above-referenced Workers’ Compensation Board records with and/or release a copy
`of the above-referenced records to Law Offices of John Trop, 120 White Plains Road, Suite 200, Tarrytown, NY 10591 AND
`Compex Legal Services, 5481 W. Water Ave., Suite 108, Tampa, FL 33634 (Tel# 888-531-2919).
` (NAME OF SPECIFIC PERSON, CORPORATION, ASSOCIATION OR PUBLIC OR PRIVATE ENTITY)
`
`I understand that the requesting party may be required to pay a statutory fee prior to being provided copies of these records by the
`Workers’ Compensation Board.
`
`
`
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`Claimant’s Signature (ink only – use blue ink if possible)
`
`
`
`
`
`Date
`
`
`
`
`
`
`
`
`Failure to provide the information requested on this form will not result in the denial of your authorization, but may
`Delay the processing of your request. The voluntary release of your social security number enables the Board to ensure
`that information is associated with, and quick action is taken on, your request.
`
`0C-110A (12-17)
`Prescribed by the Chair, Workers' Compensation Board
`
`15 of 25
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`FILED: ERIE COUNTY CLERK 01/31/2024 09:03 AM
`NYSCEF DOC. NO. 4
`
`INDEX NO. 800541/2024
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`RECEIVED NYSCEF: 01/31/2024
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`Pursuant to Workers' Compensation Law Section 110-a:
`
`3. Individual authorization. Notwithstanding the restrictions on disclosure set forth under subdivision one of this section, a person
`who is the subject of a workers' compensation record may authorize the release, re-release or publication of his or her record to a
`specific person not otherwise authorized to receive such record, by submitting written authorization for such release to the board
`on a form prescribed by the chair or by a notarized original authorization specifically directing the board to release workers'
`compensation records to such person. However, in accordance with section one-hundred twenty-five of this article, no such
`authorization directing disclosure of records to a prospective employer shall be valid; nor shall an authorization permitting
`disclosure of records in connection with assessing fitness or capability for employment be valid, and no disclosure of records shall
`be made pursuant thereto. It shall be unlawful for any person to consider for the purpose of assessing eligibility for a benefit, or as
`the basis for an employment-related action, an individual's failure to provide authorization under this subdivision.
`
`4. It shall be unlawful for any person who has obtained copies of board records or individually identifiable information from board
`records to disclose such information to any person who is not otherwise lawfully entitled to obtain these records.
`
`5. Any person who knowingly and willfully obtains workers' compensation records which contain individually identifiable
`information under false pretenses or otherwise violates this section shall be guilty of a class A misdemeanor and shall be subject
`upon conviction, to a fine of not more than one thousand dollars.
`
`6. In addition to or in lieu of any criminal proceeding available under this section, whenever there shall be a violation of this
`section, application may be made by the attorney general in the name of the people of the state of New York to a court or justice
`having jurisdiction by a special proceeding to issue an injunction, and upon notice to the defendant of not less than five days, to
`enjoin and restrain the continuance of such violations; and if it shall appear to the satisfaction of the court or justice that the
`defendant has, in fact, violated this section, an injunction may be issued by such court or justice, enjoining and restraining any
`further violation, without requiring proof that any person has, in fact, been injured or damaged thereby. In any such proceeding,
`the court may make allowances to the attorney general as provided in paragraph six of subdivision (a) of section eighty-three
`hundred three of the civil practice law and rules, and direct restitution. Whenever the court shall determine that a violation of this
`section has occurred, the court may impose a civil penalty of not more than five hundred dollars for the first vi