Preview
POS-040
ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NO: FOR COURT USE ONLY
nave: Mariah Faby
“ferret Hess w feral FIA erlor Court of California
sem: & F Brave: (A apcoel | 2 Supe ‘af San Francisco
al TELEPHONE NO{ CASES -Ly DL FAX NO. : - |
E-MAIL ee s 4 FEB 18 2022
JATTORNEY FOR (name):
[SUPERIOR COURT OF CALIFORNIA, COUNTY OF S.F, CLE! F THE CQURT
STREET ADDRESS: San Francisco Superior Court ;
MAILING ADDRESS: Civic Center Courthouse Doputy Clerk
CITY AND ZIP CODE: 400 McAllister Street, Room 103
BRANCH NAME: San Francisco, CA 94109-4514
— — Vowan Plan YT CASE NUMBER:
Plaintitf/Petitioner: o_
Defendant/Respondent: LUAcag Yeh Ca CA4 “5 4453
JUDICIAL OFFICER:
PROOF OF SERVICE—CIVIL
Check method of service (only one):
[_] By Personal Service i By Mail [1 By Overnight Delivery DEPARTMENT:
[-) By Messenger Service [__] By Fax
Do not use this form to show service of a summons and complaint or for electronic service.
See USE OF THIS FORM on page 3.
1. Atthe time of service | was over 18 years of age and not a party to this action.
2. My residence or business address is:
BN W. yet RTA SE AP aM +
3. [__] The fax number from which | served the documents is (complete if service was by fax):
4. On (date): ; | served the following documents (specify):
2) 22, Past a medica) Pecrrs
[) The documents are listed in the Attachment to Proof of Service—Civil (Documents Served) (form POS-040(D)).
5. | served the documents on the person or persons below, as follows:
ea. Name of person served: | Uicen§ Yeh repreentizt ve
b. [__] (Complete if service was by personal service, mail, overnight delivery, or messenger service.)
Business or residential address where person was served:
c. [__] (Complete if service was by fax.)
Fax number where person was served:
[J The names, addresses, and other applicable information about persons served is on the Attachment to Proof of Service—
Civil (Persons Served) (form POS-040(P)).
6. The documents were served by the following means (specify):
a. [__] By personal service. | personally delivered the documents to the persons at the addresses listed in item 5. (1) Fora
party represented by an attorney, delivery was made (a) to the attorney personally; or (b) by leaving the documents at the
attorney's office, in an envelope or package clearly labeled to identify the attorney being served, with a receptionist or an
individual in charge of the office; or (c) if there was no person in the office with whom the notice or papers could be left, by
leaving them in a conspicuous place in the office between the hours of nine in the morning and five in the evening. (2) For
a party, delivery was made to the party or by leaving the documents at the party's residence with some person not
younger than 18 years of age between the hours of eight in the morning and eight in the evening.
Page 1 of 3
Form Approved for Optional Use _—| Code of Civil Procedure, §§ 1011, 1013, 1013a,
Judicial Council of Califormia PROOF OF SERVICE CIVIL 2015.5; Cal. Rules of Court, rule 2.306
POS-040 (Rev. January 1, 2020] (Proof of Service) wwnw.courts.ca.govPOS-040
CASE NAME: CASE NUMBER:
Pebrinen_vs. Yen CGC -14-S714452
7
6. b. By United States mail. | enclosed the documents in a sealed envelope or package addressed to the persons at the
addresses in item 5 and (specify one):
(1) [_] deposited the sealed envelope with the United States Postal Service, with the postage fully prepaid.
(2) [_] placed the envelope for collection and mailing, following our ordinary business practices. | am readily familiar with this
business's practice for collecting and processing correspondence for mailing. On the same day that correspondence
is placed for collection and mailing, it is deposited in the ordinary course of business with the United States Postal
Service, in a sealed envelope with postage fully prepaid.
lam a resident or employed in the county where the mailing occurred. The envelope or package was placed in the mail at
(city and state):
c. [__] By overnight delivery. | enclosed the documents in an envelope or package provided by an overnight delivery carrier
and addressed to the persons at the addresses in item 5. | placed the envelope or package for collection and overnight
delivery at an office or a regularly utilized drop box of the overnight delivery carrier.
d. [_] By messenger service. | served the documents by placing them in an envelope or package addressed to the persons at
the addresses listed in item 5 and providing them to a professional messenger service for service. (A declaration by the
messenger must accompany this Proof of Service or be contained in the Declaration of Messenger below.)
e. [__] By fax transmission. Based on an agreement of the parties to accept service by fax transmission, | faxed the documents
to the persons at the fax numbers listed in item 5. No error was reported by the fax machine that | used. A copy of the
record of the fax transmission, which | printed out, is attached.
| declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
2422
Tergin >
(TYPE OR PRINT NAME OF DECLARANT)
Date:
NATURE OF DECLARANT)
(If item 6d above is checked, the declaration below must be completed or a separate declaration from a messenger must be attached.)
DECLARATION OF MESSENGER
[) By personal service. | personally delivered the envelope or package received from the declarant above to the persons at the
addresses listed in item 5. (1) For a party represented by an attorney, delivery was made (a) to the attorney personally; or (b) by
leaving the documents at the attorney's office, in an envelope or package clearly labeled to identify the attorney being served,
with a receptionist or an individual in charge of the office; or (c) if there was no person in the office with whom the notice or
papers could be left, by leaving them in a conspicuous place in the office between the hours of nine in the morning and five in the
evening. (2) For a party, delivery was made to the party or by leaving the documents at the party's residence with some person
not younger than 18 years of age between the hours of eight in the morning and eight in the evening.
At the time of service, | was over 18 years of age. | am not a party to the above-referenced legal proceeding.
| served the envelope or package, as stated above, on (date):
| declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
»
(NAME OF DECLARANT) (SIGNATURE OF DECLARANT)
POS-040 (Rev. January 1, 2020] PROOF OF SERVICE—CIVIL Pago 2 of 9
(Proof of Service)Patient Medical Record
Robinson, Mariah
34 yo F, DOB: Jun 7, 1987
Account Number:
317 West Portal Ave
SAN FRANCISCO, CA 94127
Patient Medical Record Page(s)
Encounters 2 to 20
Totai Pages 20
Bayview Medical.
6301 Third Street , San Francisco, CA 941243501
Medical record generated by eClinicalWorks EMR/PM Software (www. eclinicalworks.com). * SimonMed Northern CA SFMRC
~ SimonMed 1180 Post Street
See Tomorrow Today: San Francisco, CA 94109
Phone: 415-248-3700
DIAGNOSTIC IMAGING REPORT
Patient: Robinson, Mariah Sex -F DOB: 06/07/1987 Age: 33
Diag. Imaging#: 6584910
Status:
Referring Physician: MARIBEL MARIN
CC Physician:
EXAM #17036628 - 10/01/2020 9:15 AM -CR THORACIC SPINE 3 VIEWS W/SWIMMERS
CLINICAL INDICATION: Pain status post MVA 2 years ago
COMPARISON: None.
TECHNIQUE: AP, lateral and swimmers views of the thoracic spine were performed.
FINDINGS: No fracture, malalignment, or dislocation is identified. No paraspinal soft tissue abnormality is seen.
IMPRESSION:
Normal thoracic spine series.
dd: 10/03/2020 12:37 PM
Reported by: Lin, Jennifer C M.D.
Electronically signed by: LIN, JENNIFER
Thank you for your kind referral. If you require further assistance, please contact our Radiologist Hotline at
855-RAD-TALK(855-723-8255).- . : SimonMed Northern CA SFMRC
4 SimonMed 1180 Post Street
| See Tomorrow Today’ San Francisco, CA 94109
Phone: 415-248-3700
DIAGNOSTIC IMAGING REPORT
Patient: Robinson, Mariah Sex F DOB: 06/07/1987 Age: 33
Diag. Imaging}: 6584910
Status:
Referring Physician: MARIBEL MARIN
CC Physician:
EXAM #17024701 - 10/01/2020 9:15 AM -CR LUMBOSACRAL SPINE 2-3 VIEWS
CLINICAL INDICATION: Pain
COMPARISON: None.
TECHNIQUE: AP, lateral views of the lumbar spine were performed.
FINDINGS:
There is mild dextroscoliosis with the apex at L3. There is no fracture. No paraspinal soft tissue abnormality is
seen.
IMPRESSION:
Mild dextroscoliosis with the apex at L3.
dd: 10/03/2020 12:44 PM
Reported by: Lin, Jennifer C M.D.
Electronically signed by: LIN, JENNIFER
Thank you for your kind referral. If you require further assistance, please contact our Radiologist Hotline at
855-RAD-TALK(855-723-8255).2/9/22, 11:31 AM
ROBINSON, Mariah DOB: 96/87/1987 (33 yo F) Acc No. 21978 DOS: 99/23/2020
Plan:
RENE
treat.
2. Whiplash injury to neck, subsequent encounter
Clinical Notes: Patient will schedule x-ray appointment.
Referral To: Orthopedic Surgery
Reason:33 y/o female c/o chronic neck and back pain. She received chiropractic sessions, but pain
never resolved. Please evaluate and treat.
So . ster
ue ol PRN.
Follow Up: prn
Electronically signed by Maribel Marin on 09/23/2020 at 11:53 AM PDT
Sign off status: Completed
Provider: Maribel Marin, NP Date: 09/23/2020
ROBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 6 of 33SimonMed
Imaging
‘See Tomorrow Today
warw.simonmed. com
PATIENT NAME:
i Poowe: 44 KS> oBS™ (6 ZI
CLINICAL HX/DX: Whip an linjuny.
HEALTHCARE PROVIDER SIGNATURE: JY)
‘hareby authorize Health Diagnostics to act on my behalf to obtain any and
INSURANCE: |
Appointment Scheduling
Date:
fo neik, Siz. Yx1p
HEALTHCARE PROVIDER NAME: (Print) » awl ee} ALOAA :
provider PHONE: U(S-Z239- S13
DA ce Pe
WIS-329- gaTy
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INS. AUTH:
nt: (99.234 lor.
if noeded or the Abe named pallet hereby cert thatthe tes ordered are medically necessary forthe agnosis and weatment ots pai
C. Enterography
(3 routine Fax C1 STAT FAX: CO STAT CALL: i PATIENT TO CARRY CO/FILMS
co CO rims to: Ci ccreport to:
. \-RAY $5) CT Cwhwocontrastperrad Cinoiv contrast | SE% gqR_ Clwhwo contrast perrad Cino IV contrast
(Jabdomen: o2View OKUB (3D recon if indicated) (Stat if Indicated) (rbital X-ray as needed) || — (AD recon tf indicated) (Stat if indicated) (Orbital X-ray as needed)
FTohest: O1View O2View Ci Abdornen (w/ petit indcates Cerin = Clwstna
Olacs Crituitary Clorsits
Clotner:
rib OR OL OBil inc. Chest as indicated
Foot: OR OL OBI © Abdomen with Peivis CO soft Tissue Neck
(knee: OR OL oBil B Kidney Stone (a-Pwfo) C1 CTAVP (wrogram) ) F) sinus Cm
(anid: OR OL oBil a meet Oliigh Res. OLung Cancer Screening | (] maa intracrantal
Sn Sr $ ai QO Pelvis (w/ abdomen if indicated) a Cervical Carotids/Neck MRA
tar 2 Coton-Virtual 30 1 Lung screen Spine: OC oT ol
OR of oBit 2 Sinus (maxillofacial) Osacrum
shoulder Of of OB CO sinus o Fusion 0 Stryker Cishoutder OR OL oBil
ltl (wipetvis): on of Cipetvis ap © Instatrak © Landmark/Medtronic Coprachial Plexus OR OL oBil
ine Ltd. 3 Views: HE wed RM OAdd FlewExt 1] ct colon o Screening © Diagnostic Olebow OR OL oBil
Cspine Comp. 5Views:C OT OL OAdd Flev/Ext | [7] Neck (soft tissue) Cwrist OR OL oBil
Cl scoliosis C1 Temporal Bones OD orbits Oana . OR OL oOBf
OC sinus: OWaters 0 Series Cl spine: 0G oT OL CFinger OR OL
Olothen a soanoaram (leg length) Onip OR OL oBll
Extremity: Oknee OR OL oBil
* YULTRASGUND (Doppler itincicated, 30 as indicated) | CJ CTA Brain (onty) ctaNecwBrain |S aniie OR OL oBil
(J Abdomen 5 CTA Goronary Cicardacscore | root OR OL oBil
(Jaod.tro/rua = Abd. w/ Duplex CTA (other) Cin arthrograms =9OR OL
(Renal 4 A Joint
((Stat it indicated)
C)Renal w/ Bladder ~~ C1 Ren. w/ Duplex e eer thigh 70818 Cienest
Cleewie ta withtv C1 serotat with Duplex © pone oan w Mart ' Obreast (Los Gatos only) na/diagnast
te impl reening/Diagnostic
Qos S ee S Blophyslel pre BPP) C2 amyvid (ementia) C1 brain 78608 Cithoracic Outlet Syndrome (w/ contrast)
COthyroit C1 whole Body (Melanoma) 78816 Cimaa Thoracic (Aorta)
4 ror Cotter: Cl abdomen, ____ L}Eovist
I Carotid ; © Liver OKidriey — (Liver imaging)
(J Venous OUE OLE OR OL oBil 23 (MAMMOGRAPHY © Adrenal Glands © Enterography
{arterial ue OR ot . ob CTroutine Digital Screening = OR OL OB | — Pancreas OMRCP
(a Arterial LE with ABI OR OL oOBil Coiagnostic Digital Screening OR OL oBil Cpeivis OBony 0 SoftTissue
(i cervical Lymph Node Mapping Clareast uitrasound OR OL Bil | LIMRAAbdomen (Renal, Aorta)
[Aad Screening Cot . OiRenal MRA
(7) duptex Graft/Stent Imaging er Doother:
© DEKA
OC standard Exam: L-Spine, Dual Hip.
Civea (Wertebral Fracture Assessment)
(C1 Forearm (radius) BMD
C)Fotlow-up/Comparison
ROBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978|Doc Name:2020-12-01 Simon Med Xray Spine C,T,L Ord
Page 32 of 332/15/22, 2:46 PM Robinson, Mariah | Acc No:21978 | DOB:06/07/198 9$:02/14/2020
Patient: Robinson, Mariah . ; 7
Account Number: 21978 Provider: Daniel Smith, DC
DOB: 06/07/1987 Age: 32 Y Sex: Female Date: 02/14/2020
Phone: 415-685-6214
Address: 317 West Portal Ave , Apt 27444, SAN FRANCISCO, CA-94127
Pcp: Carianne zzzBlomauist .
Subjective: ’
Chief Complaints:
1. The pt was in an MVA in October 2017. She continues to experience neck and low back pain. I have RX that she
come in twice a week for 2-3 weeks and then once a week for 3 months and then re-examination...
Medical History:
Medications: Taking Loratadine 10 MG Capsule 1 capsule Orally Once a day, Taking Triamcinolone Acetonide 0.1 %
Cream 1 application to affected area Externally Twice a day, Not-Taking Stool Softener , Not-Taking Iron (Ferrous
Sulfate)
Objective:
Examination:
General Examination:
BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, cervical
tenderness.
Spinal manipulation to C6,7 performed today.
Assessment:
Assessment:
1. Whiplash injury to neck, subsequent encounter - $13.4XXD (Primary)
2. Subluxation of cervical vertebra, subsequent encounter - S13.100D
3. Muscle spasm of left shoulder - M62.838
4. Sprain of ligament of cervical spine region - S13.4XXA
Plan:
i. Whiplash injury to neck, subsequent encounter
Notes: See in 1 week.
Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS
Follow Up: 1 Week
Provider: Daniel Smith, DC
Patient: Robinson, Mariah DOB: 06/07/1987 Date: 02/14/2020
(
Electronically signed by Daniel Smith , DC on 02/14/2020 at 04:41 PM PST
Sign off status: Completed
ROBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 2 of 202/15/22, 2:46 PM Robinson, Mariah | Acc No:21978 | DOB:06/07/1¢. , 30S:01/29/2020
Patient: Robinson, Mariah a leans . r
Account Number: 21978 Provider: Daniel Smith, DC
DOB: 06/07/1987 Age: 32 Y Sex: Female Date: 01/29/2020
Phone: 415-685-6214
Address: 317 West Portal Ave , Apt 27444, SAN FRANCISCO, CA-94127
Pcp: Carianne zzzBlomquist
Subjective:
Chief Complaints:
1. 1/12--The pt was in an MVA in October 2017. She continues to experience neck and low back pain. I have RX
that she come in twice a week for 2-3 weeks and then once a week for 3 months and then re-examination.
Medical History:
Medications: Taking Loratadine 10 MG Capsule 1 capsule Orally Once a day, Taking Triamcinolone Acetonide 0.1 %
Cream 1 application to affected area Externally Twice a day, Not-Taking Stool Softener , Not-Taking Iron (Ferrous
Sulfate)
Objective:
Examination:
General Examination:
BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, lumbar
tenderness, cervical tenderness.
Spinal manipulation to L4,5 and 6,7 performed today.
Assessment:
Assessment:
1. Sprain of ligament of cervical spine region - S13.4XXA (Primary)
2. Sprain of ligaments of lumbar spine, subsequent encounter ~ $33.5XXD
3. Whiplash injury to neck, subsequent encounter - $13.4XXD
Plan:
1. Sprain of ligament of cervical spine region
Notes: See in 1 week,
Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS
Foiiow Up: 1 Week
Provider: Daniel Smith, DC
Patient: Robinson, Mariah DOB: 06/07/1987 Date: 01/29/2020
Electronically signed by Daniel Smith » DC on 01/29/2020 at 11:26 AM PST
Sign off status: Completed
2BINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 3 of 20aitoi2d, 2:40 PM . Summary View for Robinson, Mariah | Accour nber:21978
Patient: Robinson, Mariah Shears A
Account Number: 21978 Provider: Daniel Smith, DC
DOB: 06/07/1987 Age: 31Y Sex: Female Date: 03/19/2019
Phone: 415-685-6214
Address: ° 773-1937
Pcp: Carianne Blomquist
Subjective:
Chief Complaints:
1. The pt was in an MVA in October 2017. She is experiencing neck and low back pain..
Medical History:
Medications ~
Objective:
Examination:
General Examination:
BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, straight leg
raising test positive bilaterally, lumbar tenderness, cervical tenderness.
Spinal manipulation to L4,5 and C6,7 performed today.
Assessment:
Assessment:
1. Subluxation of cervical vertebra, subsequent encounter - S13.100D (Primary)
2. Subluxation of lumbar vertebra, subsequent encounter - $33.100D
3. Lumbago due to displacement of intervertebral disc - M51.26
4. Muscle spasm of left shoulder - M62.838
Pian:
1. Subluxation of cervical vertebra, subsequent encounter
Notes: See in 1 week.
Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS
Follow Up: 1 Week
Provider: Daniel Smith, DC
Patient: Robinson, Mariah DOB: 06/07/1987 Date: 03/19/2019
fu ‘
Electronically signed by Daniel Smith , DC on 03/19/2019 at 04:27 PM PDT
Sign off status: Completed
DBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 14 of 202115/22, 2:47 PM Summary View for Robinson, Mariah | Accoun’ —_iber:21978
Patient: Robinson, Mariah 6 tears . -
Account Number: 21978 Provider: Daniel Smith, DC
DOB: 06/07/1987 Age: 31 Y Sex: Female Date: 04/30/2019
Phone: 415-685-6214
Address ~ 7
Pep: Ca:anne Blomquist
Subjective:
Chief Complaints:
1, 5/12--The pt was in an MVA in October 2017. She is experiencing neck and low back pain..
Medical History:
Medication:
Objective:
Examinatio
General Examinati
BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, straight leg
raising test positive on the RIGHT, lumbar tenderness, cervical tenderness.
Spina! manipulation to L4,5 and C6,7 performed today.
Assessment:
Assessment:
1. Subluxation of cervical vertebra, subsequent encounter - S13.100D (Primary)
2. Subluxation of lumbar vertebra, subsequent encounter - $33.100D
3. Lumbago due to displacement of intervertebral disc - M51.26
4. Muscle spasm of left shoulder - M62.838
Plan:
1. Subluxation of cervical vertebra, subsequent encounter
Notes: See in 1 week,
Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS
Follow Up: 1 Week
Provider: Daniel Smith, DC
Patient: Robinson, Mariah DOB: 06/07/1987 Date: 04/30/2019
al
Electronically signed by Daniel Smith , DC on 04/30/2019 at 04:13 PM PDT.
Sign off status: Completed
ROBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 11 of 202/15/22, 2:46 PM Robinson, Mariah | Acc No:21978 | DOB:06/07/1! — DOS:11/15/2019
: ‘
Patient: Robinson, Mariah .
Account Number: 21978 Provider: Daniel Smith, DC
DOB: 06/07/1987 Age: 32 Y Sex: Female Date: 11/15/2019
Phone: 415-685-6214
Address: PO BOX 27444, SAN FRANCISCO, CA-94127-0421
Pep: Carianne Blomquist
Subjective:
Chief Complaints: i
1. 3/12--The pt was in an MVA in October 2017. She continues to experience neck and low back pain. I have RX
that she come in twice a week for 2-3 weeks and then once a week for 3 months and then re-examination..
Medical History:
Medications: Taking Loratadine 10 MG Capsule 1 capsule Orally Once a day, Taking Triamcinolone Acetonide 0.4 %
Cream 1 application to affected area Externally Twice a day, Not-Taking Stool Softener , Not-Taking Iron (Ferrous
Sulfate)
Objective:
Examination: _
General Examinatio:
BACK: paraspinal muscle spasm on the LEFT, Paraspinal muscle spasm on the RIGHT, lumbar
tenderness.
Spinal manipulation to L4,5 performed today.
Assessment:
Assessment:
1. Sprain of ligaments of lumbar spine, subsequent encounter - $33.5XXD (Primary)
2, Lumbago due to displacement of intervertebral disc - M51.26
3. Subluxation of lumbar vertebra, subsequent encounter - $33.100D
Plan:
1. Sprain of ligaments of lumbar spine, subsequent encounter
Notes: See 2 times next week.
Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS
Follow Up: 2 - 3 Days
Provider: Daniel Smith, DC
Patient: Robinson, Mariah DOB: 06/07/1987 Date: 11/15/2019
Electronically signed by Daniel Smith , DC on 11/15/2019 at 04:49 PM PST '
Sign off status: Completed
OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 4 of 202115/22, 2:46 PM. “ Rabinson, Mariah | Acc No:21978 | DOB:06/07/198 $:11/01/2019
Patient: Robinson ae Provider: Daniel Smith, DC
DOB: 06/07/1987 Age: 32Y Sex: Female Date: 11/01/2019
Phone: 415-685-6214
Address: PO BOX 27444, SAN FRANCISCO, CA-94127-0421
Pep: Carianne Blomquist
Subjective:
Chief Complaints:
1. The pt was in an MVA in October 2017. She continues to experience neck and low back pain. I have RX that she
come in twice a week for 2-3 weeks and then once a week for 3 months and then re-examination..
Medical History:
Medications: Taking Loratadine 10 MG Capsule 1 capsule Orally Once a day, Taking Triamcinolone Acetonide 0.1 %
Cream 1 application to affected area Externally Twice a day, Not-Taking Stool Softener , Not-Taking Iron (Ferrous
Sulfate)
Objective:
Examination:
General Examination:
BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, cervical
tenderness, lumbar tenderness, palpatory spinal misalignment at L4,5 and C6,7..
Spinal manipulation to L4,5 and C6,7 performed today.
Assessment:
Assessment:
1. Lumbago due to displacement of intervertebral disc - M51.26 (Primary)
2. Whiplash injury to neck, subsequent encounter - S13.4XXD
3. Subluxation of cervical vertebra, subsequent encounter - S13.100D
4. Subluxation of lumbar vertebra, subsequent encounter - S33.100D
Plan:
1. Lumbago due to displacement of intervertebral disc
Notes: See in 1 week.
Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS
Follow Up: 1 Week
Provider: Daniel Smith, DC
Patient: Robinson, Mariah DOB: 06/07/1987 Date: 11/01/2019
Electronically signed by Daniel Smith , DC on 11/01/2019 at 04:34 PM PDT
Sign off status: Completed
ROBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 5 of 202/18/22, 2:46 PM Summary View for Robinson, Mariah | Accoun \ber:21978
Patient: Robinson, Mariah .
Account Number: 21978 . Provider: Daniel Smith, DC
DOB: 06/07/1987 Age: 32 Y Sex: Female Date: 08/06/2019
Phone: 415-685-6714
Address: 3.
Pep: Carianne Blomquist
Subjective:
Chief Complaints:
1. The pt was in an MVA in October 2017. She continues to experience neck and low back pain, I have RX that she
come in twice a week for 2-3 weeks and then once a week for 3 months and then re-examination..
Medical History:
Medications:
Objective:
Examination:
General. i
BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, straight leg
raising test positive on the RIGHT, lumbar tenderness, cervical tenderness.
Spinal manipulation to L4,5 and C6,7 performed today.
Assessment:
Assessment:
1, Subluxation of cervical vertebra, subsequent encounter - S13.100D (Primary)
2. Subluxation of lumbar vertebra, subsequent encounter - S33.100D
3. Whiplash injury to neck, subsequent encounter - S$13.4XXD
4. Sprain of ligament of cervical spine region - S13.4XXA
Plan:
1. Subluxation of cervical vertebra, subsequent encounter
Notes: See in 2-3 days.
Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS
Follow Up: 2 - 3 Days
Provider: Daniel Smith, DC
Patient: Robinson, Mariah DOB: 06/07/1987 Date: 08/06/2019
i
Electronically signed by Daniel Smith , DC on 08/06/2019 at 10:49 AM PDT
Sign off status: Completed
2OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 6 of 202118/22, 2:46 PM Summary View for Robinson, Mariah| Accoun —_—rber:21978
Patient: Robinson, Mariah . . . .
Account Number: 21978 Provider: Daniel Smith, DC
DOB: 06/07/1987 Age: 31Y Sex: Female Date: 05/21/2019
Phone: 415-685-6214
Address: 25
Pcp: Carianne Blomquist
Subjective:
Chief Complaints:
1. The pt experiences neck and mid back pain and tension. The symptoms began after she was in a MVA in May
2017. The pt describes her symptoms are moderate and intermittant. If she sits for more than 30 minutes the
symptoms return. Activities of daily living seem to cause her neck and mid back pain..
Medical History:
Medications: Taking Stool Softener , Taking Iron (Ferrous Sulfate)
Objective:
Examination:
General Examination:
BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, thoracic
tenderness,cervical tenderness, palpatory grade 2+ edema at Th 6,7,8 and C6,7. Palpatory spinal
misalignment at Th 6,7,8 and C6,7. + cervical compression at the left and right side, pain and decreased
ROM at the thoracic and cervical spine.. .
Spinal manipulation to Th 6,7,8 and C6,7 performed today.
Assessment:
Assessment:
1. Sprain of ligament of cervical spine region - S13.4XXA (Primary)
2. Cervical facet joint syndrome - M47.812
3. Subluxation of cervical vertebra, subsequent encounter - $13.100D
4. Subluxation of thoracic vertebra, subsequent encounter - $23.100D
Plan:
1. Sprain of ligament of cervical spine region
Notes: Recommending 12 office visits/ 98940
Spinal manipulation to Th 6,7,8 and C6,7.
Treatment goals: Decrease inflammation at Th 6,7,8 and C6,7. Increase the ROM at the thoracic and cervical
spine. Improve spinal alignment at Th 6,7,8 and C6,7.
Re-examination date: 12-15-2019.
Referral To:Chiropractor, licensed (effective July 1973)
Reason:Pain and decreased ROM at the thoracic and cervical spine. (See examinaion findings).
2. Others
Notes: See in 1 week,
Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS
Follow Up: 1 Week
Provider: Daniel Smith, DC
Patient: Robinson, Mariah DOB: 06/07/1987 Date: 05/21/2019
\OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 7 of 202/18/22, 2:47 PM Summary View for Robinson, Mariah | Accoun iber:21978
Patient: Robinson, Mariah Rlere ‘
Account Number: 21978 Provider: Daniel Smith, DC
DOB: 06/07/1987 Age: 31Y Sex: Female Date: 05/17/2019
Phone: 415-685-6214
Addres: o . rn
Pcp: Carianne Blomquist
Subjective:
Chief Complaints:
1. 7/12--The pt was in an MVA in October 2017. She is experiencing neck and low back pain..
Medical History:
Medications
1
Objective:
BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, straight leg
raising test positive on the RIGHT, lumbar tenderness, cervical tenderness.
Spinal manipulation to L4,5 and C6,7 performed today.
Assessment:
Assessment:
1. Subluxation of cervical vertebra, subsequent encounter - S13.100D (Primary)
2. Subluxation of lumbar vertebra, subsequent encounter - $33.100D
3. Muscle spasm of left shoulder - M62.838
4, Whiplash injury to neck, subsequent encounter - S13.4XXD
Plan:
1. Subluxation of cervical vertebra, subsequent encounter
Notes: See in 1 week.
Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS
Follow Up: 1 Week
Provider: Daniel Smith, DC
Patient: Robinson, Mariah DOB: 06/07/1987 Date: 05/17/2019
Electronically signed by Daniel Smith , DC on 05/17/2019 at 04:39 PM PDT
Sign off status: Completed
\OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 9 of 202115/22, 2:47 PM Summary View for Robinson, Mariah | Accou mber:21978
Patient: Robinson, Mariah * . . 7
Account Number: 21978 Provider: Daniel Smith, DC
DOB: 06/07/1987 Age: 31Y Sex: Female Date: 05/10/2019
Phone: 415-685-6214
Address: ~~
Pep: Cariuime Blomquist
Subjective:
Chief Complaints:
1. 6/12--The pt was in an MVA in October 2017. She is experiencing neck and low back pain..
Medical History:
Medications: © !
Objective:
Examination:
General Examination:
+ palpatroy grade 2+ edema at the lower cervical spine. + cervical compression test on the left and right sides of
the cervical spine. Pain and decreased ROM at the thoracic and cervical spine. Palpatory spinal misalignment at Th
6,7,8 and C6,7, + myofascial trigger point at the left and right rhomboid muscles.
Spinal manipulation to Th 6,7,8 and C6,7 performed today. Myofascial trigger point release at the left and right
rhomboid muscles.
Assessment:
Assessment:
1. Whiplash injury to neck, subsequent encounter - $13.4XXD (Primary)
2, Subluxation of cervical vertebra, subsequent encounter - $13.100D
3. Muscle spasm of left shoulder - M62.838
4. Subluxation of thoracic vertebra, subsequent encounter - $23.100D
Plan:
1. Whipiash injury to neck, subsequent encounter
Notes: See 1 time weekly for the next 6 weeks and then re-evaluate ofr this cervical whiplash injury.
Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS
Follow Up: 1 Week
Provider: Daniel Smith, DC
Patient: Robinson, Mariah DOB: 06/07/1987 Date: 05/10/2019
Electronically signed by Daniel Smith , DC on 05/10/2019 at 04:40 PM PDT
Sign off status: Completed
-OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 10 of 202118/22, 2:47 PM Summary View for Robinson, Mariah | Accoun wber:21978
Patient: Robinson, Mariah a teas oy .
Account Number: 21978 Provider: Daniel Smith, DC
DOB: 06/07/1987 Age: 31Y Sex: Female Date: 04/23/2019
Phone: 415-685-6214
Address:
Pep: Carianne Blomquist
Subjective:
Chief Complaints:
1. 4/12--The pt was in an MVA in October 2017. She is experiencing neck and Jow back pain..
Medical History: .
Medicatior= ~ )
Objective:
Examina’
Gen io
BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, straight leg
raising test positive on the RIGHT, lumbar tenderness, cervical tenderness.
Spinal manipulation to L4,5 and C6,7 performed today.
Assessment:
Assessment:
1. Subluxation of lumbar vertebra, subsequent encounter - $33.100D (Primary)
2. Subluxation of cervical vertebra, subsequent encounter - $13.100D
3. Lumbago due to displacement of intervertebral disc - M51.26
4. Muscle spasm of left shoulder - M62.838
Plan:
1. Subluxation of lumbar vertebra, subsequent encounter
Notes: See in 1 week.
Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS
Follow Up: 1 Week
Provider: Daniel Smith, DC
Patient: Robinson, Mariah DOB: 06/07/1987 Date: 04/23/2019
Electronically signed by Daniel Smith , DC on 04/23/2019 at 04:08 PM PDT
Sign off status: Completed
OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 12 of 202/15/22, 2:47 PM : Summary View for Robinson, Mariah | Accour nber:21978
Patient: Robinson, Mariah . . a
Account Number: 21978 Provider: Daniel Smith, DC
DOB: 06/07/1987 Age: 31 Y Sex: Female Date: 04/12/2019
Phone: 415-685-6214 :
Address:
Pcp: Carianne Blomquist
Subjective:
Chief Complaints:
1. 3/12--The pt was in an MVA in October 2017, She is experiencing neck and low back pain..
Medical History:
Medications: *-'~
Objective:
Examinatior
General Examination:
Pain and decreased ROM at the lumbar and cervical spine. Palpatory spinal misalignment at L4,5 and 6,7.
Assessment:
Assessment:
1. Subluxation of lumbar vertebra, subsequent encounter - $33.100D (Primary)
2. Lumbago due to displacement of intervertebral disc - M51.26
3. Subluxation of cervical vertebra, subsequent encounter - $13.100D
4. Muscle spasm of left shoulder - M62.838
Spinal manipulation to L4,5 and C6,7 performed today.
Pian:
1. Subluxation of lumbar vertebra, subsequent encounter
Notes: See in 2-3 days.
2. Others
Notes: See in 2-3 days,
Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS
Follow Up: 1 Week
Provider: Daniel Smith, DC
Patient: Robinson, Mariah DOB: 06/07/1987 Date: 04/12/2019
Electronically signed by Daniel Smith , DC on 04/12/2019 at 04:41 PM PDT
Sign off status: Completed
XOBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 13 of 202/15/22, 2:47 PM ‘Summary View for Robinson, Mariah | Account per:21978
Patient: Robinson, Mariah
Account Number: 21978 Provider: Daniel Smith, DC
DOB: 06/07/1987 Age: 31 Y Sex: Female Date: 12/22/2018
Phone: 415-685-6214
Addres: - .
Pep: Cariarinie siomquist
Subjective:
Chief Complaints:
1. The pt was in an MVA in October 2017. She is experiencing neck and low back pain for the last 8 months. The
pt is 7 months pregnant..
Medical History:
Medications: T.
Objective:
Examination:
General Examination:
BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, straight leg
raising test positive bilaterally, lumbar tenderness, cervical tenderness.
Spinal manipulation to L4,5 and C6,7 performed today.
Assessment:
Assessment:
1. Subluxation of lumbar vertebra, subsequent encounter - S33.100D (Primary)
2, Subluxation of cervical vertebra, subsequent encounter - S13.100D
3. Lumbago due to displacement of intervertebral disc - M51.26
Plan:
1. Subluxation of lumbar vertebra, subsequent encounter
Notes: See in 1 week.
Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS
Follow Up: 1 Week
Provider: Daniel Smith, DC
Patient: Robinson, Mariah DOB: 06/07/1987 Date: 12/22/2018
Electronically signed by Daniel Smith , DC on 12/22/2018 at 10:26 AM PST
Sign off status: Completed
2OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 15 of 202115/22, 2:47 PM . Summary View for Robinson, Mariah | Accot)... _mber:21978
Decoone Nene: Mariah Provider: Daniel Smith, DC
DOB: 06/07/1987 Age: 31Y Sex: Female Date: 12/15/2018
Phone: 415-A85-A714 .
Address: .. ao
Pep: Car 2 Blomquist
Subjective:
Chief Complaints:
1. The pt was in an MVA in October 2017. She is experiencing neck and low back pain for the last 8 months. The
pt is 7 months pregnant..
Medical History:
Objective:
Examination: ©
General Examinatior
BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, lumbar
tenderness, cervical tenderness.
Spinal manipulation to L4,5 and C6,7 performed today.
Assessment:
Assessment:
1. Subluxation of cervical vertebra, subsequent encounter - $13.100D (Primary)
2. Subluxation of lumbar vertebra, subsequent encounter - S33.100D
3. Lumbago due to displacement of intervertebral disc - MS1.26
Plan:
1. Subluxation of cervical vertebra, subsequent encounter
Notes: See in 1 week.
Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS
Follow Up: 1 Week
Provider: Daniel Smith, DC
Patient: Robinson, Mariah DOB: 06/07/1987 Date: 12/15/2018
al
Electronically signed by Daniel Smith , DC on 12/15/2018 at 10:31 AM PST
Sign off status: Completed
OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 16 of 202115122, 2:47 PM ‘Summary View for Robinson, Mz
patient: Nomeon apy Provider: Daniel Smith, DC
DOB: 06/07/1987 Age: 31 Y Sex: Female Date: 10/12/2018
Phone: 415-685-6214
Address:
Pep: Khailylah Jordan
Subjective:
Chief Complaints:
1. The pt was in an MVA in October 2017. She is experiencing neck and low back pain for the last 8 months. The pt
is 7 months pregnant..
Medicai History:
Medications:
Objective:
Examination:
General Examination:
BACK; paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, straight leg
raising test positive bilaterally, lumbar tenderness, cervical tenderness.
Spinal manipulation to L4,5 and C6,7 performed today.
Assessment:
Assessment:
1, Subluxation of lumbar vertebra, subsequent encounter - $33.100D (Primary)
2, Lumbago due to displacement of intervertebral disc - M51.26
3. Subluxation of cervical vertebra, subsequent encounter - $13.100D
4. Muscle spasm of left shoulder - M62.838
Plan:
i. Subluxation of lumbar vertebra, subsequent encounter
Notes: See in 2 weeks.
Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS
Follow Up: 2 Weeks
Provider: Daniel Smith, DC
Patient: Robinson, Mariah DOB: 06/07/1987 Date: 10/12/2018
Electronically signed by Daniel Smith , DC on 10/12/2018 at 10:58 AM PDT
Sign off status: Completed
SOBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 17 of 202115/22, 2:47 PM Summary View for Robinson, Mar
oc Ropineom: Marian Provider: Daniel Smith, DC
DOB: 06/07/1987 Age: 31 Y Sex: Female Date: 09/08/2018
Phone: 415-685-6714
Address: wpe me oe ’
Pep: Khailyiah Jordan
Subjective:
Chief Complaints:
1. The pt was in an MVA in October 2017. She is experiencing neck and low back pain for the last 8 months. The pt
is 7 months pregnant..
Medical History:
Medications: Taking Prenatal 28-0.8 MG Tablet 1 tablet Orally Once a day
Objective:
Examinati
General Examin
BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, lumbar
tenderness, cervical tenderness.
Spinal manipulation to L4,5 and C6,7 performed today.
Assessment:
Assessment:
1. Subluxation of lumbar vertebra, subsequent encounter - $33.100D (Primary)
2. Subluxation of cervical vertebra, subsequent encounter - S$13.100D
3. Muscle spasm of left shoulder - M62.838
Plan:
1. Subluxation of lumbar vertebra, subsequent encounter
Notes: See in 1 week,
Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS, 97140 MANUAL THERAPY
Follow Up: 1 Week
Provider: Daniel Smith, DC
Patient: Robinson, Mariah DOB: 06/07/1987 Date: 09/08/2018
Electronically signed by Daniel Smith , DC on 09/08/2018 at 11:35 AM PDT
Sign off status: Completed
OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 18 of 202118122, 2:47 PM ‘Summary View for Robinson, Manan
ecoae Nowe pena Provider: Daniel Smith, DC
DOB: 06/07/1987 Age: 31 Y Sex: Female Date: 08/11/2018
Phone: 415-685-6214
Address:
Pep: Khailylah Jordan
Subjective:
Chief Complaints:
1. The pt was in an MVA in October 2017. She is experiencing neck and low back pain for the last 8 months. The pt
is 7 months pregnant..
Medical History:
Objective:
Examination:
General Examination:
BACK: paraspinal muscle spasm on the LEFT, Paraspinal muscle spasm on the RIGHT, lumbar
tenderness, cervical tenderness , pain and decreased ROM at the lumbar and cervical spine. + myofascial trigger
Point at the left rhomboid muscle. + cervical compression at the left cervical spine..
Spinal manipulation to L4,5 and C6,7 performed today.
Assessment:
Assessment:
1. 24 weeks gestation of Pregnancy - Z3A.24 (Primary)
2. Subluxation of lumbar vertebra, subsequent encounter - $33.100D
3. Subluxation of cervical vertebra, subsequent encounter - $13.100D
4. Muscle spasm of left shoulder - M62.838
Plan:
1. 24 weeks gestation of pregnancy
Notes: Recommending 12 office visits/98940
Spinal manipulation to L4,5 and C6,7.
Treatment goals: Improve spinal alignment at the lumbar and cervical spine. Increase the ROM at the lumbar and
cervical spine. Decrease inflammation at the lumbar and cervical spine.
Re-examination date 11-1-18,
Referral To:Chiropractor, licensed (effective July 1973)
Reason:Pain and decreased ROM at the lumbar and cervical spine. (See examination findings).
Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS, 97140 MANUAL THERAPY
Follow Up: 1 Week
Provider: Daniel Smith, DC
Patient: Robinson, Mariah DOB: 06/07/1987 Date: 08/11/2018
Electronically signed by Daniel Smith , DC on 08/11/2018 at 11:26 AM PDT
Sign off status: Completed
BINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978
Page 19 of 20
Preview
POS-040 ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NO: FOR COURT USE ONLY nave: Mariah Faby “ferret Hess w feral FIA erlor Court of California sem: & F Brave: (A apcoel | 2 Supe ‘af San Francisco al TELEPHONE NO{ CASES -Ly DL FAX NO. : - | E-MAIL ee s 4 FEB 18 2022 JATTORNEY FOR (name): [SUPERIOR COURT OF CALIFORNIA, COUNTY OF S.F, CLE! F THE CQURT STREET ADDRESS: San Francisco Superior Court ; MAILING ADDRESS: Civic Center Courthouse Doputy Clerk CITY AND ZIP CODE: 400 McAllister Street, Room 103 BRANCH NAME: San Francisco, CA 94109-4514 — — Vowan Plan YT CASE NUMBER: Plaintitf/Petitioner: o_ Defendant/Respondent: LUAcag Yeh Ca CA4 “5 4453 JUDICIAL OFFICER: PROOF OF SERVICE—CIVIL Check method of service (only one): [_] By Personal Service i By Mail [1 By Overnight Delivery DEPARTMENT: [-) By Messenger Service [__] By Fax Do not use this form to show service of a summons and complaint or for electronic service. See USE OF THIS FORM on page 3. 1. Atthe time of service | was over 18 years of age and not a party to this action. 2. My residence or business address is: BN W. yet RTA SE AP aM + 3. [__] The fax number from which | served the documents is (complete if service was by fax): 4. On (date): ; | served the following documents (specify): 2) 22, Past a medica) Pecrrs [) The documents are listed in the Attachment to Proof of Service—Civil (Documents Served) (form POS-040(D)). 5. | served the documents on the person or persons below, as follows: ea. Name of person served: | Uicen§ Yeh repreentizt ve b. [__] (Complete if service was by personal service, mail, overnight delivery, or messenger service.) Business or residential address where person was served: c. [__] (Complete if service was by fax.) Fax number where person was served: [J The names, addresses, and other applicable information about persons served is on the Attachment to Proof of Service— Civil (Persons Served) (form POS-040(P)). 6. The documents were served by the following means (specify): a. [__] By personal service. | personally delivered the documents to the persons at the addresses listed in item 5. (1) Fora party represented by an attorney, delivery was made (a) to the attorney personally; or (b) by leaving the documents at the attorney's office, in an envelope or package clearly labeled to identify the attorney being served, with a receptionist or an individual in charge of the office; or (c) if there was no person in the office with whom the notice or papers could be left, by leaving them in a conspicuous place in the office between the hours of nine in the morning and five in the evening. (2) For a party, delivery was made to the party or by leaving the documents at the party's residence with some person not younger than 18 years of age between the hours of eight in the morning and eight in the evening. Page 1 of 3 Form Approved for Optional Use _—| Code of Civil Procedure, §§ 1011, 1013, 1013a, Judicial Council of Califormia PROOF OF SERVICE CIVIL 2015.5; Cal. Rules of Court, rule 2.306 POS-040 (Rev. January 1, 2020] (Proof of Service) wwnw.courts.ca.govPOS-040 CASE NAME: CASE NUMBER: Pebrinen_vs. Yen CGC -14-S714452 7 6. b. By United States mail. | enclosed the documents in a sealed envelope or package addressed to the persons at the addresses in item 5 and (specify one): (1) [_] deposited the sealed envelope with the United States Postal Service, with the postage fully prepaid. (2) [_] placed the envelope for collection and mailing, following our ordinary business practices. | am readily familiar with this business's practice for collecting and processing correspondence for mailing. On the same day that correspondence is placed for collection and mailing, it is deposited in the ordinary course of business with the United States Postal Service, in a sealed envelope with postage fully prepaid. lam a resident or employed in the county where the mailing occurred. The envelope or package was placed in the mail at (city and state): c. [__] By overnight delivery. | enclosed the documents in an envelope or package provided by an overnight delivery carrier and addressed to the persons at the addresses in item 5. | placed the envelope or package for collection and overnight delivery at an office or a regularly utilized drop box of the overnight delivery carrier. d. [_] By messenger service. | served the documents by placing them in an envelope or package addressed to the persons at the addresses listed in item 5 and providing them to a professional messenger service for service. (A declaration by the messenger must accompany this Proof of Service or be contained in the Declaration of Messenger below.) e. [__] By fax transmission. Based on an agreement of the parties to accept service by fax transmission, | faxed the documents to the persons at the fax numbers listed in item 5. No error was reported by the fax machine that | used. A copy of the record of the fax transmission, which | printed out, is attached. | declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. 2422 Tergin > (TYPE OR PRINT NAME OF DECLARANT) Date: NATURE OF DECLARANT) (If item 6d above is checked, the declaration below must be completed or a separate declaration from a messenger must be attached.) DECLARATION OF MESSENGER [) By personal service. | personally delivered the envelope or package received from the declarant above to the persons at the addresses listed in item 5. (1) For a party represented by an attorney, delivery was made (a) to the attorney personally; or (b) by leaving the documents at the attorney's office, in an envelope or package clearly labeled to identify the attorney being served, with a receptionist or an individual in charge of the office; or (c) if there was no person in the office with whom the notice or papers could be left, by leaving them in a conspicuous place in the office between the hours of nine in the morning and five in the evening. (2) For a party, delivery was made to the party or by leaving the documents at the party's residence with some person not younger than 18 years of age between the hours of eight in the morning and eight in the evening. At the time of service, | was over 18 years of age. | am not a party to the above-referenced legal proceeding. | served the envelope or package, as stated above, on (date): | declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: » (NAME OF DECLARANT) (SIGNATURE OF DECLARANT) POS-040 (Rev. January 1, 2020] PROOF OF SERVICE—CIVIL Pago 2 of 9 (Proof of Service)Patient Medical Record Robinson, Mariah 34 yo F, DOB: Jun 7, 1987 Account Number: 317 West Portal Ave SAN FRANCISCO, CA 94127 Patient Medical Record Page(s) Encounters 2 to 20 Totai Pages 20 Bayview Medical. 6301 Third Street , San Francisco, CA 941243501 Medical record generated by eClinicalWorks EMR/PM Software (www. eclinicalworks.com). * SimonMed Northern CA SFMRC ~ SimonMed 1180 Post Street See Tomorrow Today: San Francisco, CA 94109 Phone: 415-248-3700 DIAGNOSTIC IMAGING REPORT Patient: Robinson, Mariah Sex -F DOB: 06/07/1987 Age: 33 Diag. Imaging#: 6584910 Status: Referring Physician: MARIBEL MARIN CC Physician: EXAM #17036628 - 10/01/2020 9:15 AM -CR THORACIC SPINE 3 VIEWS W/SWIMMERS CLINICAL INDICATION: Pain status post MVA 2 years ago COMPARISON: None. TECHNIQUE: AP, lateral and swimmers views of the thoracic spine were performed. FINDINGS: No fracture, malalignment, or dislocation is identified. No paraspinal soft tissue abnormality is seen. IMPRESSION: Normal thoracic spine series. dd: 10/03/2020 12:37 PM Reported by: Lin, Jennifer C M.D. Electronically signed by: LIN, JENNIFER Thank you for your kind referral. If you require further assistance, please contact our Radiologist Hotline at 855-RAD-TALK(855-723-8255).- . : SimonMed Northern CA SFMRC 4 SimonMed 1180 Post Street | See Tomorrow Today’ San Francisco, CA 94109 Phone: 415-248-3700 DIAGNOSTIC IMAGING REPORT Patient: Robinson, Mariah Sex F DOB: 06/07/1987 Age: 33 Diag. Imaging}: 6584910 Status: Referring Physician: MARIBEL MARIN CC Physician: EXAM #17024701 - 10/01/2020 9:15 AM -CR LUMBOSACRAL SPINE 2-3 VIEWS CLINICAL INDICATION: Pain COMPARISON: None. TECHNIQUE: AP, lateral views of the lumbar spine were performed. FINDINGS: There is mild dextroscoliosis with the apex at L3. There is no fracture. No paraspinal soft tissue abnormality is seen. IMPRESSION: Mild dextroscoliosis with the apex at L3. dd: 10/03/2020 12:44 PM Reported by: Lin, Jennifer C M.D. Electronically signed by: LIN, JENNIFER Thank you for your kind referral. If you require further assistance, please contact our Radiologist Hotline at 855-RAD-TALK(855-723-8255).2/9/22, 11:31 AM ROBINSON, Mariah DOB: 96/87/1987 (33 yo F) Acc No. 21978 DOS: 99/23/2020 Plan: RENE treat. 2. Whiplash injury to neck, subsequent encounter Clinical Notes: Patient will schedule x-ray appointment. Referral To: Orthopedic Surgery Reason:33 y/o female c/o chronic neck and back pain. She received chiropractic sessions, but pain never resolved. Please evaluate and treat. So . ster ue ol PRN. Follow Up: prn Electronically signed by Maribel Marin on 09/23/2020 at 11:53 AM PDT Sign off status: Completed Provider: Maribel Marin, NP Date: 09/23/2020 ROBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 6 of 33SimonMed Imaging ‘See Tomorrow Today warw.simonmed. com PATIENT NAME: i Poowe: 44 KS> oBS™ (6 ZI CLINICAL HX/DX: Whip an linjuny. HEALTHCARE PROVIDER SIGNATURE: JY) ‘hareby authorize Health Diagnostics to act on my behalf to obtain any and INSURANCE: | Appointment Scheduling Date: fo neik, Siz. Yx1p HEALTHCARE PROVIDER NAME: (Print) » awl ee} ALOAA : provider PHONE: U(S-Z239- S13 DA ce Pe WIS-329- gaTy ae Toot INS. AUTH: nt: (99.234 lor. if noeded or the Abe named pallet hereby cert thatthe tes ordered are medically necessary forthe agnosis and weatment ots pai C. Enterography (3 routine Fax C1 STAT FAX: CO STAT CALL: i PATIENT TO CARRY CO/FILMS co CO rims to: Ci ccreport to: . \-RAY $5) CT Cwhwocontrastperrad Cinoiv contrast | SE% gqR_ Clwhwo contrast perrad Cino IV contrast (Jabdomen: o2View OKUB (3D recon if indicated) (Stat if Indicated) (rbital X-ray as needed) || — (AD recon tf indicated) (Stat if indicated) (Orbital X-ray as needed) FTohest: O1View O2View Ci Abdornen (w/ petit indcates Cerin = Clwstna Olacs Crituitary Clorsits Clotner: rib OR OL OBil inc. Chest as indicated Foot: OR OL OBI © Abdomen with Peivis CO soft Tissue Neck (knee: OR OL oBil B Kidney Stone (a-Pwfo) C1 CTAVP (wrogram) ) F) sinus Cm (anid: OR OL oBil a meet Oliigh Res. 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OiRenal MRA (7) duptex Graft/Stent Imaging er Doother: © DEKA OC standard Exam: L-Spine, Dual Hip. Civea (Wertebral Fracture Assessment) (C1 Forearm (radius) BMD C)Fotlow-up/Comparison ROBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978|Doc Name:2020-12-01 Simon Med Xray Spine C,T,L Ord Page 32 of 332/15/22, 2:46 PM Robinson, Mariah | Acc No:21978 | DOB:06/07/198 9$:02/14/2020 Patient: Robinson, Mariah . ; 7 Account Number: 21978 Provider: Daniel Smith, DC DOB: 06/07/1987 Age: 32 Y Sex: Female Date: 02/14/2020 Phone: 415-685-6214 Address: 317 West Portal Ave , Apt 27444, SAN FRANCISCO, CA-94127 Pcp: Carianne zzzBlomauist . Subjective: ’ Chief Complaints: 1. The pt was in an MVA in October 2017. She continues to experience neck and low back pain. I have RX that she come in twice a week for 2-3 weeks and then once a week for 3 months and then re-examination... Medical History: Medications: Taking Loratadine 10 MG Capsule 1 capsule Orally Once a day, Taking Triamcinolone Acetonide 0.1 % Cream 1 application to affected area Externally Twice a day, Not-Taking Stool Softener , Not-Taking Iron (Ferrous Sulfate) Objective: Examination: General Examination: BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, cervical tenderness. Spinal manipulation to C6,7 performed today. Assessment: Assessment: 1. Whiplash injury to neck, subsequent encounter - $13.4XXD (Primary) 2. Subluxation of cervical vertebra, subsequent encounter - S13.100D 3. Muscle spasm of left shoulder - M62.838 4. Sprain of ligament of cervical spine region - S13.4XXA Plan: i. Whiplash injury to neck, subsequent encounter Notes: See in 1 week. Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS Follow Up: 1 Week Provider: Daniel Smith, DC Patient: Robinson, Mariah DOB: 06/07/1987 Date: 02/14/2020 ( Electronically signed by Daniel Smith , DC on 02/14/2020 at 04:41 PM PST Sign off status: Completed ROBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 2 of 202/15/22, 2:46 PM Robinson, Mariah | Acc No:21978 | DOB:06/07/1¢. , 30S:01/29/2020 Patient: Robinson, Mariah a leans . r Account Number: 21978 Provider: Daniel Smith, DC DOB: 06/07/1987 Age: 32 Y Sex: Female Date: 01/29/2020 Phone: 415-685-6214 Address: 317 West Portal Ave , Apt 27444, SAN FRANCISCO, CA-94127 Pcp: Carianne zzzBlomquist Subjective: Chief Complaints: 1. 1/12--The pt was in an MVA in October 2017. She continues to experience neck and low back pain. I have RX that she come in twice a week for 2-3 weeks and then once a week for 3 months and then re-examination. Medical History: Medications: Taking Loratadine 10 MG Capsule 1 capsule Orally Once a day, Taking Triamcinolone Acetonide 0.1 % Cream 1 application to affected area Externally Twice a day, Not-Taking Stool Softener , Not-Taking Iron (Ferrous Sulfate) Objective: Examination: General Examination: BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, lumbar tenderness, cervical tenderness. Spinal manipulation to L4,5 and 6,7 performed today. Assessment: Assessment: 1. Sprain of ligament of cervical spine region - S13.4XXA (Primary) 2. Sprain of ligaments of lumbar spine, subsequent encounter ~ $33.5XXD 3. Whiplash injury to neck, subsequent encounter - $13.4XXD Plan: 1. Sprain of ligament of cervical spine region Notes: See in 1 week, Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS Foiiow Up: 1 Week Provider: Daniel Smith, DC Patient: Robinson, Mariah DOB: 06/07/1987 Date: 01/29/2020 Electronically signed by Daniel Smith » DC on 01/29/2020 at 11:26 AM PST Sign off status: Completed 2BINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 3 of 20aitoi2d, 2:40 PM . Summary View for Robinson, Mariah | Accour nber:21978 Patient: Robinson, Mariah Shears A Account Number: 21978 Provider: Daniel Smith, DC DOB: 06/07/1987 Age: 31Y Sex: Female Date: 03/19/2019 Phone: 415-685-6214 Address: ° 773-1937 Pcp: Carianne Blomquist Subjective: Chief Complaints: 1. The pt was in an MVA in October 2017. She is experiencing neck and low back pain.. Medical History: Medications ~ Objective: Examination: General Examination: BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, straight leg raising test positive bilaterally, lumbar tenderness, cervical tenderness. Spinal manipulation to L4,5 and C6,7 performed today. Assessment: Assessment: 1. Subluxation of cervical vertebra, subsequent encounter - S13.100D (Primary) 2. Subluxation of lumbar vertebra, subsequent encounter - $33.100D 3. Lumbago due to displacement of intervertebral disc - M51.26 4. Muscle spasm of left shoulder - M62.838 Pian: 1. Subluxation of cervical vertebra, subsequent encounter Notes: See in 1 week. Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS Follow Up: 1 Week Provider: Daniel Smith, DC Patient: Robinson, Mariah DOB: 06/07/1987 Date: 03/19/2019 fu ‘ Electronically signed by Daniel Smith , DC on 03/19/2019 at 04:27 PM PDT Sign off status: Completed DBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 14 of 202115/22, 2:47 PM Summary View for Robinson, Mariah | Accoun’ —_iber:21978 Patient: Robinson, Mariah 6 tears . - Account Number: 21978 Provider: Daniel Smith, DC DOB: 06/07/1987 Age: 31 Y Sex: Female Date: 04/30/2019 Phone: 415-685-6214 Address ~ 7 Pep: Ca:anne Blomquist Subjective: Chief Complaints: 1, 5/12--The pt was in an MVA in October 2017. She is experiencing neck and low back pain.. Medical History: Medication: Objective: Examinatio General Examinati BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, straight leg raising test positive on the RIGHT, lumbar tenderness, cervical tenderness. Spina! manipulation to L4,5 and C6,7 performed today. Assessment: Assessment: 1. Subluxation of cervical vertebra, subsequent encounter - S13.100D (Primary) 2. Subluxation of lumbar vertebra, subsequent encounter - $33.100D 3. Lumbago due to displacement of intervertebral disc - M51.26 4. Muscle spasm of left shoulder - M62.838 Plan: 1. Subluxation of cervical vertebra, subsequent encounter Notes: See in 1 week, Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS Follow Up: 1 Week Provider: Daniel Smith, DC Patient: Robinson, Mariah DOB: 06/07/1987 Date: 04/30/2019 al Electronically signed by Daniel Smith , DC on 04/30/2019 at 04:13 PM PDT. Sign off status: Completed ROBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 11 of 202/15/22, 2:46 PM Robinson, Mariah | Acc No:21978 | DOB:06/07/1! — DOS:11/15/2019 : ‘ Patient: Robinson, Mariah . Account Number: 21978 Provider: Daniel Smith, DC DOB: 06/07/1987 Age: 32 Y Sex: Female Date: 11/15/2019 Phone: 415-685-6214 Address: PO BOX 27444, SAN FRANCISCO, CA-94127-0421 Pep: Carianne Blomquist Subjective: Chief Complaints: i 1. 3/12--The pt was in an MVA in October 2017. She continues to experience neck and low back pain. I have RX that she come in twice a week for 2-3 weeks and then once a week for 3 months and then re-examination.. Medical History: Medications: Taking Loratadine 10 MG Capsule 1 capsule Orally Once a day, Taking Triamcinolone Acetonide 0.4 % Cream 1 application to affected area Externally Twice a day, Not-Taking Stool Softener , Not-Taking Iron (Ferrous Sulfate) Objective: Examination: _ General Examinatio: BACK: paraspinal muscle spasm on the LEFT, Paraspinal muscle spasm on the RIGHT, lumbar tenderness. Spinal manipulation to L4,5 performed today. Assessment: Assessment: 1. Sprain of ligaments of lumbar spine, subsequent encounter - $33.5XXD (Primary) 2, Lumbago due to displacement of intervertebral disc - M51.26 3. Subluxation of lumbar vertebra, subsequent encounter - $33.100D Plan: 1. Sprain of ligaments of lumbar spine, subsequent encounter Notes: See 2 times next week. Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS Follow Up: 2 - 3 Days Provider: Daniel Smith, DC Patient: Robinson, Mariah DOB: 06/07/1987 Date: 11/15/2019 Electronically signed by Daniel Smith , DC on 11/15/2019 at 04:49 PM PST ' Sign off status: Completed OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 4 of 202115/22, 2:46 PM. “ Rabinson, Mariah | Acc No:21978 | DOB:06/07/198 $:11/01/2019 Patient: Robinson ae Provider: Daniel Smith, DC DOB: 06/07/1987 Age: 32Y Sex: Female Date: 11/01/2019 Phone: 415-685-6214 Address: PO BOX 27444, SAN FRANCISCO, CA-94127-0421 Pep: Carianne Blomquist Subjective: Chief Complaints: 1. The pt was in an MVA in October 2017. She continues to experience neck and low back pain. I have RX that she come in twice a week for 2-3 weeks and then once a week for 3 months and then re-examination.. Medical History: Medications: Taking Loratadine 10 MG Capsule 1 capsule Orally Once a day, Taking Triamcinolone Acetonide 0.1 % Cream 1 application to affected area Externally Twice a day, Not-Taking Stool Softener , Not-Taking Iron (Ferrous Sulfate) Objective: Examination: General Examination: BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, cervical tenderness, lumbar tenderness, palpatory spinal misalignment at L4,5 and C6,7.. Spinal manipulation to L4,5 and C6,7 performed today. Assessment: Assessment: 1. Lumbago due to displacement of intervertebral disc - M51.26 (Primary) 2. Whiplash injury to neck, subsequent encounter - S13.4XXD 3. Subluxation of cervical vertebra, subsequent encounter - S13.100D 4. Subluxation of lumbar vertebra, subsequent encounter - S33.100D Plan: 1. Lumbago due to displacement of intervertebral disc Notes: See in 1 week. Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS Follow Up: 1 Week Provider: Daniel Smith, DC Patient: Robinson, Mariah DOB: 06/07/1987 Date: 11/01/2019 Electronically signed by Daniel Smith , DC on 11/01/2019 at 04:34 PM PDT Sign off status: Completed ROBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 5 of 202/18/22, 2:46 PM Summary View for Robinson, Mariah | Accoun \ber:21978 Patient: Robinson, Mariah . Account Number: 21978 . Provider: Daniel Smith, DC DOB: 06/07/1987 Age: 32 Y Sex: Female Date: 08/06/2019 Phone: 415-685-6714 Address: 3. Pep: Carianne Blomquist Subjective: Chief Complaints: 1. The pt was in an MVA in October 2017. She continues to experience neck and low back pain, I have RX that she come in twice a week for 2-3 weeks and then once a week for 3 months and then re-examination.. Medical History: Medications: Objective: Examination: General. i BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, straight leg raising test positive on the RIGHT, lumbar tenderness, cervical tenderness. Spinal manipulation to L4,5 and C6,7 performed today. Assessment: Assessment: 1, Subluxation of cervical vertebra, subsequent encounter - S13.100D (Primary) 2. Subluxation of lumbar vertebra, subsequent encounter - S33.100D 3. Whiplash injury to neck, subsequent encounter - S$13.4XXD 4. Sprain of ligament of cervical spine region - S13.4XXA Plan: 1. Subluxation of cervical vertebra, subsequent encounter Notes: See in 2-3 days. Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS Follow Up: 2 - 3 Days Provider: Daniel Smith, DC Patient: Robinson, Mariah DOB: 06/07/1987 Date: 08/06/2019 i Electronically signed by Daniel Smith , DC on 08/06/2019 at 10:49 AM PDT Sign off status: Completed 2OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 6 of 202118/22, 2:46 PM Summary View for Robinson, Mariah| Accoun —_—rber:21978 Patient: Robinson, Mariah . . . . Account Number: 21978 Provider: Daniel Smith, DC DOB: 06/07/1987 Age: 31Y Sex: Female Date: 05/21/2019 Phone: 415-685-6214 Address: 25 Pcp: Carianne Blomquist Subjective: Chief Complaints: 1. The pt experiences neck and mid back pain and tension. The symptoms began after she was in a MVA in May 2017. The pt describes her symptoms are moderate and intermittant. If she sits for more than 30 minutes the symptoms return. Activities of daily living seem to cause her neck and mid back pain.. Medical History: Medications: Taking Stool Softener , Taking Iron (Ferrous Sulfate) Objective: Examination: General Examination: BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, thoracic tenderness,cervical tenderness, palpatory grade 2+ edema at Th 6,7,8 and C6,7. Palpatory spinal misalignment at Th 6,7,8 and C6,7. + cervical compression at the left and right side, pain and decreased ROM at the thoracic and cervical spine.. . Spinal manipulation to Th 6,7,8 and C6,7 performed today. Assessment: Assessment: 1. Sprain of ligament of cervical spine region - S13.4XXA (Primary) 2. Cervical facet joint syndrome - M47.812 3. Subluxation of cervical vertebra, subsequent encounter - $13.100D 4. Subluxation of thoracic vertebra, subsequent encounter - $23.100D Plan: 1. Sprain of ligament of cervical spine region Notes: Recommending 12 office visits/ 98940 Spinal manipulation to Th 6,7,8 and C6,7. Treatment goals: Decrease inflammation at Th 6,7,8 and C6,7. Increase the ROM at the thoracic and cervical spine. Improve spinal alignment at Th 6,7,8 and C6,7. Re-examination date: 12-15-2019. Referral To:Chiropractor, licensed (effective July 1973) Reason:Pain and decreased ROM at the thoracic and cervical spine. (See examinaion findings). 2. Others Notes: See in 1 week, Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS Follow Up: 1 Week Provider: Daniel Smith, DC Patient: Robinson, Mariah DOB: 06/07/1987 Date: 05/21/2019 \OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 7 of 202/18/22, 2:47 PM Summary View for Robinson, Mariah | Accoun iber:21978 Patient: Robinson, Mariah Rlere ‘ Account Number: 21978 Provider: Daniel Smith, DC DOB: 06/07/1987 Age: 31Y Sex: Female Date: 05/17/2019 Phone: 415-685-6214 Addres: o . rn Pcp: Carianne Blomquist Subjective: Chief Complaints: 1. 7/12--The pt was in an MVA in October 2017. She is experiencing neck and low back pain.. Medical History: Medications 1 Objective: BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, straight leg raising test positive on the RIGHT, lumbar tenderness, cervical tenderness. Spinal manipulation to L4,5 and C6,7 performed today. Assessment: Assessment: 1. Subluxation of cervical vertebra, subsequent encounter - S13.100D (Primary) 2. Subluxation of lumbar vertebra, subsequent encounter - $33.100D 3. Muscle spasm of left shoulder - M62.838 4, Whiplash injury to neck, subsequent encounter - S13.4XXD Plan: 1. Subluxation of cervical vertebra, subsequent encounter Notes: See in 1 week. Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS Follow Up: 1 Week Provider: Daniel Smith, DC Patient: Robinson, Mariah DOB: 06/07/1987 Date: 05/17/2019 Electronically signed by Daniel Smith , DC on 05/17/2019 at 04:39 PM PDT Sign off status: Completed \OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 9 of 202115/22, 2:47 PM Summary View for Robinson, Mariah | Accou mber:21978 Patient: Robinson, Mariah * . . 7 Account Number: 21978 Provider: Daniel Smith, DC DOB: 06/07/1987 Age: 31Y Sex: Female Date: 05/10/2019 Phone: 415-685-6214 Address: ~~ Pep: Cariuime Blomquist Subjective: Chief Complaints: 1. 6/12--The pt was in an MVA in October 2017. She is experiencing neck and low back pain.. Medical History: Medications: © ! Objective: Examination: General Examination: + palpatroy grade 2+ edema at the lower cervical spine. + cervical compression test on the left and right sides of the cervical spine. Pain and decreased ROM at the thoracic and cervical spine. Palpatory spinal misalignment at Th 6,7,8 and C6,7, + myofascial trigger point at the left and right rhomboid muscles. Spinal manipulation to Th 6,7,8 and C6,7 performed today. Myofascial trigger point release at the left and right rhomboid muscles. Assessment: Assessment: 1. Whiplash injury to neck, subsequent encounter - $13.4XXD (Primary) 2, Subluxation of cervical vertebra, subsequent encounter - $13.100D 3. Muscle spasm of left shoulder - M62.838 4. Subluxation of thoracic vertebra, subsequent encounter - $23.100D Plan: 1. Whipiash injury to neck, subsequent encounter Notes: See 1 time weekly for the next 6 weeks and then re-evaluate ofr this cervical whiplash injury. Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS Follow Up: 1 Week Provider: Daniel Smith, DC Patient: Robinson, Mariah DOB: 06/07/1987 Date: 05/10/2019 Electronically signed by Daniel Smith , DC on 05/10/2019 at 04:40 PM PDT Sign off status: Completed -OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 10 of 202118/22, 2:47 PM Summary View for Robinson, Mariah | Accoun wber:21978 Patient: Robinson, Mariah a teas oy . Account Number: 21978 Provider: Daniel Smith, DC DOB: 06/07/1987 Age: 31Y Sex: Female Date: 04/23/2019 Phone: 415-685-6214 Address: Pep: Carianne Blomquist Subjective: Chief Complaints: 1. 4/12--The pt was in an MVA in October 2017. She is experiencing neck and Jow back pain.. Medical History: . Medicatior= ~ ) Objective: Examina’ Gen io BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, straight leg raising test positive on the RIGHT, lumbar tenderness, cervical tenderness. Spinal manipulation to L4,5 and C6,7 performed today. Assessment: Assessment: 1. Subluxation of lumbar vertebra, subsequent encounter - $33.100D (Primary) 2. Subluxation of cervical vertebra, subsequent encounter - $13.100D 3. Lumbago due to displacement of intervertebral disc - M51.26 4. Muscle spasm of left shoulder - M62.838 Plan: 1. Subluxation of lumbar vertebra, subsequent encounter Notes: See in 1 week. Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS Follow Up: 1 Week Provider: Daniel Smith, DC Patient: Robinson, Mariah DOB: 06/07/1987 Date: 04/23/2019 Electronically signed by Daniel Smith , DC on 04/23/2019 at 04:08 PM PDT Sign off status: Completed OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 12 of 202/15/22, 2:47 PM : Summary View for Robinson, Mariah | Accour nber:21978 Patient: Robinson, Mariah . . a Account Number: 21978 Provider: Daniel Smith, DC DOB: 06/07/1987 Age: 31 Y Sex: Female Date: 04/12/2019 Phone: 415-685-6214 : Address: Pcp: Carianne Blomquist Subjective: Chief Complaints: 1. 3/12--The pt was in an MVA in October 2017, She is experiencing neck and low back pain.. Medical History: Medications: *-'~ Objective: Examinatior General Examination: Pain and decreased ROM at the lumbar and cervical spine. Palpatory spinal misalignment at L4,5 and 6,7. Assessment: Assessment: 1. Subluxation of lumbar vertebra, subsequent encounter - $33.100D (Primary) 2. Lumbago due to displacement of intervertebral disc - M51.26 3. Subluxation of cervical vertebra, subsequent encounter - $13.100D 4. Muscle spasm of left shoulder - M62.838 Spinal manipulation to L4,5 and C6,7 performed today. Pian: 1. Subluxation of lumbar vertebra, subsequent encounter Notes: See in 2-3 days. 2. Others Notes: See in 2-3 days, Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS Follow Up: 1 Week Provider: Daniel Smith, DC Patient: Robinson, Mariah DOB: 06/07/1987 Date: 04/12/2019 Electronically signed by Daniel Smith , DC on 04/12/2019 at 04:41 PM PDT Sign off status: Completed XOBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 13 of 202/15/22, 2:47 PM ‘Summary View for Robinson, Mariah | Account per:21978 Patient: Robinson, Mariah Account Number: 21978 Provider: Daniel Smith, DC DOB: 06/07/1987 Age: 31 Y Sex: Female Date: 12/22/2018 Phone: 415-685-6214 Addres: - . Pep: Cariarinie siomquist Subjective: Chief Complaints: 1. The pt was in an MVA in October 2017. She is experiencing neck and low back pain for the last 8 months. The pt is 7 months pregnant.. Medical History: Medications: T. Objective: Examination: General Examination: BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, straight leg raising test positive bilaterally, lumbar tenderness, cervical tenderness. Spinal manipulation to L4,5 and C6,7 performed today. Assessment: Assessment: 1. Subluxation of lumbar vertebra, subsequent encounter - S33.100D (Primary) 2, Subluxation of cervical vertebra, subsequent encounter - S13.100D 3. Lumbago due to displacement of intervertebral disc - M51.26 Plan: 1. Subluxation of lumbar vertebra, subsequent encounter Notes: See in 1 week. Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS Follow Up: 1 Week Provider: Daniel Smith, DC Patient: Robinson, Mariah DOB: 06/07/1987 Date: 12/22/2018 Electronically signed by Daniel Smith , DC on 12/22/2018 at 10:26 AM PST Sign off status: Completed 2OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 15 of 202115/22, 2:47 PM . Summary View for Robinson, Mariah | Accot)... _mber:21978 Decoone Nene: Mariah Provider: Daniel Smith, DC DOB: 06/07/1987 Age: 31Y Sex: Female Date: 12/15/2018 Phone: 415-A85-A714 . Address: .. ao Pep: Car 2 Blomquist Subjective: Chief Complaints: 1. The pt was in an MVA in October 2017. She is experiencing neck and low back pain for the last 8 months. The pt is 7 months pregnant.. Medical History: Objective: Examination: © General Examinatior BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, lumbar tenderness, cervical tenderness. Spinal manipulation to L4,5 and C6,7 performed today. Assessment: Assessment: 1. Subluxation of cervical vertebra, subsequent encounter - $13.100D (Primary) 2. Subluxation of lumbar vertebra, subsequent encounter - S33.100D 3. Lumbago due to displacement of intervertebral disc - MS1.26 Plan: 1. Subluxation of cervical vertebra, subsequent encounter Notes: See in 1 week. Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS Follow Up: 1 Week Provider: Daniel Smith, DC Patient: Robinson, Mariah DOB: 06/07/1987 Date: 12/15/2018 al Electronically signed by Daniel Smith , DC on 12/15/2018 at 10:31 AM PST Sign off status: Completed OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 16 of 202115122, 2:47 PM ‘Summary View for Robinson, Mz patient: Nomeon apy Provider: Daniel Smith, DC DOB: 06/07/1987 Age: 31 Y Sex: Female Date: 10/12/2018 Phone: 415-685-6214 Address: Pep: Khailylah Jordan Subjective: Chief Complaints: 1. The pt was in an MVA in October 2017. She is experiencing neck and low back pain for the last 8 months. The pt is 7 months pregnant.. Medicai History: Medications: Objective: Examination: General Examination: BACK; paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, straight leg raising test positive bilaterally, lumbar tenderness, cervical tenderness. Spinal manipulation to L4,5 and C6,7 performed today. Assessment: Assessment: 1, Subluxation of lumbar vertebra, subsequent encounter - $33.100D (Primary) 2, Lumbago due to displacement of intervertebral disc - M51.26 3. Subluxation of cervical vertebra, subsequent encounter - $13.100D 4. Muscle spasm of left shoulder - M62.838 Plan: i. Subluxation of lumbar vertebra, subsequent encounter Notes: See in 2 weeks. Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS Follow Up: 2 Weeks Provider: Daniel Smith, DC Patient: Robinson, Mariah DOB: 06/07/1987 Date: 10/12/2018 Electronically signed by Daniel Smith , DC on 10/12/2018 at 10:58 AM PDT Sign off status: Completed SOBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 17 of 202115/22, 2:47 PM Summary View for Robinson, Mar oc Ropineom: Marian Provider: Daniel Smith, DC DOB: 06/07/1987 Age: 31 Y Sex: Female Date: 09/08/2018 Phone: 415-685-6714 Address: wpe me oe ’ Pep: Khailyiah Jordan Subjective: Chief Complaints: 1. The pt was in an MVA in October 2017. She is experiencing neck and low back pain for the last 8 months. The pt is 7 months pregnant.. Medical History: Medications: Taking Prenatal 28-0.8 MG Tablet 1 tablet Orally Once a day Objective: Examinati General Examin BACK: paraspinal muscle spasm on the LEFT, paraspinal muscle spasm on the RIGHT, lumbar tenderness, cervical tenderness. Spinal manipulation to L4,5 and C6,7 performed today. Assessment: Assessment: 1. Subluxation of lumbar vertebra, subsequent encounter - $33.100D (Primary) 2. Subluxation of cervical vertebra, subsequent encounter - S$13.100D 3. Muscle spasm of left shoulder - M62.838 Plan: 1. Subluxation of lumbar vertebra, subsequent encounter Notes: See in 1 week, Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS, 97140 MANUAL THERAPY Follow Up: 1 Week Provider: Daniel Smith, DC Patient: Robinson, Mariah DOB: 06/07/1987 Date: 09/08/2018 Electronically signed by Daniel Smith , DC on 09/08/2018 at 11:35 AM PDT Sign off status: Completed OBINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 18 of 202118122, 2:47 PM ‘Summary View for Robinson, Manan ecoae Nowe pena Provider: Daniel Smith, DC DOB: 06/07/1987 Age: 31 Y Sex: Female Date: 08/11/2018 Phone: 415-685-6214 Address: Pep: Khailylah Jordan Subjective: Chief Complaints: 1. The pt was in an MVA in October 2017. She is experiencing neck and low back pain for the last 8 months. The pt is 7 months pregnant.. Medical History: Objective: Examination: General Examination: BACK: paraspinal muscle spasm on the LEFT, Paraspinal muscle spasm on the RIGHT, lumbar tenderness, cervical tenderness , pain and decreased ROM at the lumbar and cervical spine. + myofascial trigger Point at the left rhomboid muscle. + cervical compression at the left cervical spine.. Spinal manipulation to L4,5 and C6,7 performed today. Assessment: Assessment: 1. 24 weeks gestation of Pregnancy - Z3A.24 (Primary) 2. Subluxation of lumbar vertebra, subsequent encounter - $33.100D 3. Subluxation of cervical vertebra, subsequent encounter - $13.100D 4. Muscle spasm of left shoulder - M62.838 Plan: 1. 24 weeks gestation of pregnancy Notes: Recommending 12 office visits/98940 Spinal manipulation to L4,5 and C6,7. Treatment goals: Improve spinal alignment at the lumbar and cervical spine. Increase the ROM at the lumbar and cervical spine. Decrease inflammation at the lumbar and cervical spine. Re-examination date 11-1-18, Referral To:Chiropractor, licensed (effective July 1973) Reason:Pain and decreased ROM at the lumbar and cervical spine. (See examination findings). Procedure Codes: 98940 CHIRO MANIPULATION 1-2 REGIONS, 97140 MANUAL THERAPY Follow Up: 1 Week Provider: Daniel Smith, DC Patient: Robinson, Mariah DOB: 06/07/1987 Date: 08/11/2018 Electronically signed by Daniel Smith , DC on 08/11/2018 at 11:26 AM PDT Sign off status: Completed BINSON, Mariah DOB: Jun 7, 1987 (34 yo F) Acc No. 21978 Page 19 of 20