Preview
EF supation Court of California
‘s
County ~ ~
Khadijah Jacob, in pro per FEB 2070
125 Mason Street, #404 CLERK OF THE COURT
San Francisco, California 94102 BY ha : A ak
(415) 409-1177
IN THE SUPERIOR COURT OF THE STATE OF CALIFORNIA
IN AND FOR THE COUNTY OF SAN FRANCISCO
KHADIJAH JACOB, Case No.: CGC-19-577484
Plaintiff,
PLAINTIFF RESPONSE TO WELLS
VS. FARGO BANK, N.A. AND BRANCH
WELLS FARGO BANK N.A., BRANCH MANAGER VLADYHCHKIN SERGIY’S
MANAGER VLADYCHKIN, SERGIY OPPOSITION TO PLAINTIFF’S MOTION
> TO QUASH SUBPOENAS OF PLAINTIFF’S
Defendant MEDICAL RECORDS
Hearing Date: February 19, 2020
Hearing Time: 9:30 a.m.
Department: 302
Location 400 McAllister Street, S.F.
Reservation: 01150219-12
Action Filed: July 9, 2020
Trial Date: — July 6, 2020
1. INTRODUCTION
Plaintiff Khadijah Jacob must reply to the Defendants’ Opposition to Plaintiff's Motion
to Quash Subpoenas of Plaintiff's Medical Records because it contains some inaccuracies. 1. Thd
Plaintiff object to Subpoenas for medical records on her back because it doesn’t pertain to this
lawsuit. She wasn’t visiting her doctor or being treated for any injury or pain to her back at the
time, she tripped and felled extremely hard at Wells Fargo Bank on November 3, 2017. She gave
no one Authorization to her Medical records nor did any Medical Providers call me which
violates HIPAA and State Laws and Patient Privacy and Confidentiality.
PLAINTIFF RESPONSE TO WELLS FARGO BANK, N.A. AND BRANCH MANAGER VLADYHCHKIN
SERGIY’S OPPOSITION TO PLAINTIFF’S MOTION TO QUASH SUBPOENAS OF PLAINTIFF’S MEDICAL
RECORDS - 12. The Plaintiff object to Subpoenas ATTACHMENTS 3 first line states the scope of my
medical record, and the descriptions are extremely broad and confusing. I hate the word “ALL;”
it means everything and is used throughout the Subpoenas. Some examples: “All documents and
records stored in any format, form or method, including, but not limited to, all office, emergency
room, inpatient and outpatient charts and records, lien files, SOAP notes, pathology records and
reports, lab reports, pharmacy and prescription records, physical therapy records, including sign-
in sheets, all descriptions of exercises prescribed and documentation which indicate date and tim
of patient’s appointments, and insurance documents; and All itemized statements of the billing
charges and/or consolidated statement of benefits, with diagnostic and procedure codes including|
all CPT and ICD-9 coding and all HCFA, UB04 and UB92 bills, to include the total charges
private or governmental; any amounts written off by the provider, and any amounts that are the
patient’s responsibility and explanation of benefits, payment history, records of any liens, any
insurance billing or payments information, emergency room physicians bills and radiology billing
from all sources, to include any computer generated billing or billing stored in any format and
payment software that contains said information; and
COPIES of all original x-rays films, CT scans, MRIs and any other scans or images taken and/or
maintained, including a comprehensive list of all dates and body parts of all firms, CT scans,
MRIs and all other images or scans provided.
MRN # 01247036, ACCT # 200018791752
Including treatment records by Catherine James, MD”
These complicated formats may give them Medical records they aren’t entitled too. The
last sentence about Doctor James violates Medical ethics rules, state laws, and federal law
known as Health Insurance Portability and Accountability Act (HIPAA) prevent doctors from
sharing patient information without their permission.
PLAINTIFF RESPONSE TO WELLS FARGO BANK, N.A. AND BRANCH MANAGER VLADYHCHKIN
SERGIY’S OPPOSITION TO PLAINTIFFS MOTION TO QUASH SUBPOENAS OF PLAINTIFFS MEDICAL
RECORDS -23. Medical record in California and Guide to Consumer Rights under HIPAA states,
providers must retain them for seven years. Most Personal Injury Attorneys ask for five years
of records unless the injured person suffered Brain damage or is paralyzed then there may be
additional years. After reading this information, I felt eight years were excessive. I feel these
Subpoenas will be an abuse on my Medical records for these reasons: First, Julia Grant, Claim
Representative for Wells Fargo & company called Monday, November 6, 2017, and we were in
communication until about May of 2019. She provided me with two medical providers requests.
The dates were November 15, 2017 and May 3, 2018, which I refused to sign and there
are some pages missing. J explained to Julia I don’t want anyone to have my Medical records.
T’ll do it based only on the injuries from when I tripped and felled in the bank, and the records
will be sent to you. February 21st and 22"4, 2019, I went to Medical record Offices and
completed Authorization Disclose Health Information Forms for three Medical Providers. I
specified what to be released; I wrote only related to Left leg, Right neck and shoulder. I was
told any other information released would violate HIPAA Laws.
Second, I believe Julia Grant has provided Attorney Debra with my Medical records soon]
after she took the case since, they both work on behalf of Wells Fargo Bank, N.A. During
discovery the Defendants Attorney Debra requested Medical records, Product Work, pictures, all
Medical records, all forms, documents, tapes, all electronic devices and all notes related to my
injuries, case, and medications. I visited my Primary Doctors and provide her notes of the pain
in my Right shoulder and arm, and pain in my Left leg continue to be inconsistent. I usually use
Deep Soothing Therma-therapy Hot Wrap or take a pain pill. I do the same to my Right shoulder
and arm when the pain is worse, and I have provided her with pictures of my injuries.
PLAINTIFF RESPONSE TO WELLS FARGO BANK, N.A. AND BRANCH MANAGER VLADYHCHKIN
SERGTY’S OPPOSITION TO PLAINTIFF’S MOTION TO QUASH SUBPOENAS OF PLAINTIFF’S MEDICAL
RECORDS -327
28
4. I’ve provided Attorney Debra with more than enough information related to my injuries.
While I have made similar requests, and I have received nothing worth having. I was shocked to
receive these Subpoenas for my Medical records, and I feel this is a serious abused of my Medica
records because most of it will be repeated information. She wrote, “However, medical records
that were provided, pursuant to your written authorization, to Sedgwick Claims
Management Services (Wells Fargo’s third party administrator for liability claims) date back
several years before the 2017 incident and include information about treatment to many areas of
your body, including your back. In fact, there is a specific report to your back, along with your
leg and shoulder, contained in a December 2018 record from your primary care physician at
Maxine Hall Health Center. We have sought medical records going back 8 years to cover the
period of time in which you sustained injuries in other slips and falls and a motor vehicle
accident.
Based on the records we have reviewed, you were diagnosed with a pretexting torn
rotator cuff several years before this incident and received treatment for that condition years
before this incident and received treatment for that condition years before. A key issue in this
case is what damage was caused by this fall as opposed to your pre-existing conditions involving
arthritis and your rotator cuff problem.” When it comes to a previous tore, rotator cuff and
treatment, I disagree with whatever document (s) you are reviewing. It’s not possible to have this|
type of injury and don’t remember. It’s a type of pain I wouldn’t have forgotten, and I been
experiencing it for the last three years; I have never been in pain for this length of time. Most
importantly, J had no pain; I was active and had great movement of my Right shoulder and arm
before I tripped and felled. Since this incident, I have been in a horrible nightmare!!
PLAINTIFF RESPONSE TO WELLS FARGO BANK, N.A. AND BRANCH MANAGER VLADYHCHKIN
SERGIY’S OPPOSITION TO PLAINTIFF’S MOTION TO QUASH SUBPOENAS OF PLAINTIFF’S MEDICAL
RECORDS -427
28
Attorney Debra’s Opposition to Plaintiff Motion to Quash Subpoenas of Plaintiff Medical
Records are filled with LIES!!! Yes, I understand what I am saying. Her page 2, lines 12 to 21
are not true. My November 3, 2017, trip and fall incident consists of different areas of my body.
Her lines 22 to 28 are not true. Any Medical records Julia Grant, has of me came from the three
Medical Providers to whom I specified what information I wanted released from my Medical
records. Any additional information they made have sent was without my permission
A | N/z9
PLAINTIFF RESPONSE TO WELLS FARGO BANK, N.A. AND BRANCH MANAGER VLADYHCHKIN
SERGIY’S OPPOSITION TO PLAINTIFF’S MOTION TO QUASH SUBPOENAS OF PLAINTIFF’S MEDICAL
RECORDS - 5CITY & COUNTY OF SAN FRANCISCO NAME* 34% cob, -ENnADIT ay
DEPARTMENT OF PUBLIC HEALTH pops ahs | 1a4e
MRN = 240 Ble
SS#
“Yrertooo2
AUTHORIZATION TO
DISCLOSE HEALTH INFORMATION PCP DA. xem FD pevent w /abe
Completion of this document authorizes the disclosure and/or use of individually identifiable health
=== information, as set forth below, consistent with California and federal law concerning the privacy of such
== information. Failure to provide ALL information marked with an asterisk (*) may invalidate this
== authorization.
hr, Takub, -AADI wat (AKA)
authorize “Maxine Yoel) Hepes CEKTK to disclose health information
(NAME OF HOSPITAL OR FACILITY) .
obtained in the course of my diagnosis and treatment for the purpose of tate clam :
Disclosure requested by DPH facility and/or agent? (KNo O Yes Purpose?__-
By checking in the spaces below, | specifically authorize the release of the following medical
records, if such records exist. Such disclosure shall be limited to the following types of information or
dates of treatment. | recognize that if | am disclosing my health information to someone who is not legally
required to keep it confidential, it may be redisclosed and may no longer be protected. California law
Tequires that recipients refrain from redisclosing such information except with my written authorization
Or as specifically required by law.
Dates of Treatment AND/OR Specific Medical Condition:
—— Complete medical record(s) ___ Outpatient Clinic Notes ~___ immunizations 1] 144
- mena
‘ —— Discharge Summary _—— Emergency Report —— Consultation ~ plectat
——History & Physical _— lab tests _—. Pathology .
—% Progress Notes — X-ray report X Otheronly (clave Tec
INITIAL below for protected classes of information: Le4,© CRN @.
EJ Mental Health Treatment [_] Substance Abuse Treatment [_] HIV/AIDS Test/Treatment
3-
z (1 Sewally Transmitted Disease (City Circ) a Developmental DeyeH N23 “W290
Gow) 2 3:
= SEND Tos Juli cree SEPAICK, P.O Bix a2 235
MY DPH RIGHTS: | understand that authorizing the disclosure of this health information is voluntary |
may refuse to sign this authorization. | may revoke this authorization at any time. Revocation must be in
writing, signed by me or on my behalf by someone with the legal authority to do so and delivered to the
DPH or other facility. My revocation will, be effective upon receipt, but will not be effective to the extent
that the DPH may have acted in reliance upon this authorization prior to revocation. | have a right to obtain
a copy of this authorization. | may not be denied treatment, payment, enroliment in a health plan, or
eligibility for benefits if | refuse to sign.
EXPIRATION: Unless otherwise revoked, this authorization will expire in 90 days, on the following
event/condition OR immediately upon fulfillment for protected classes. EVENT/CONDITION:
+ 22-1}\4 . 4 _ SELLE
‘a . Date Signature (P: lient/Pat /Guardian/Conservator) Relationship if not Patient/Client
Q Interpreter used
Witness (Required if Patient/Client unable to sign)
5799935 (Rev. 03/04) White - Releasing Facility Yellow - Medical Records Pink - Patient/Client Front of two sidesAUTHORIZATION FOR USE AND
‘DISCLOSURE OF HEALTH INFORMATION Page 1 of2
There may be fees incurred for this service.
| Patient Information (Tell us about the patient)
Patient Name: KA adi tel Tarel ee. DOBG
Address: ff 5° Hib Sani “Sheer yoy City: Se Fi a
Phone(47 & ) HO Gi tt TF Email (optional):
[Type of Access Requested (Please check ONLY one)
Paper Copy Ocp (My Health Online (1 Inspection Only 7) Email (encrypted)
C) Email (not encrypted) (Note: If you would like us to send information over email not encrypted, this
Increases the risk thet information could be read by en unauthorized third party. } EB @ NEck tup
~ B4 Other (must be agreed upon by ihe patient and provider) xsi je es feces ol fn Les Cloutd ee
| Delivery Method (Please check ONLY one) |
(Mail OH Email &] Fax (1 Pick-Up (if applicable} (1 My Health Online Portal
| Purpose of Requested Use or Disclosure (Tell us how you will use the records) |
©) Continuity of Care — Appointment Date with Physician: / I
Patient Cl Insurance OH Other: ee & COL pm
| Authorization ~ | hereby authorize: ]
CALIFORNIA PACIFIC MEDICAL CENTER
(Name of hospital, physician, healthcare provider)
|
|
|
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Alpelu? WRNGZLCT SGg
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IN.
3700 California Street, Suite 1570 San Francisco CA 94118
Address Cit State Zi
(415) 600-6246 _ Yas) 600-2113 - p
Phone Fax
| To release my health information fo: [| Check this box ifsame as patient listed above. OR |
Fiali £0 CRaN Tt, Shdgefck Chai ons Ronme coptt? ve
(Naine of hospital, physician, hedlthcare provider, other)
B.0.4ex [Geen Lov tagton Ky Yass a
Address ue a City State Zip
(a4) ¥a2-Gdoa : Fags (HO) 92 Gara
Phone Fax
[Information Disclosure (Tell us. what information you need) _ |
information to be disclosed for the following date Bn Figst DATE to Pyne SQ int
C] Hospital Records (Inpatient and Outpatient)
C1 Clinic/Foundation Records (Specify Provider Name):
‘LD Radiology Report(s ) Only ae REED Repotreep
£4 Radiology Images nea Pat Kap OS Utresouts? Dor scan MRI (J Mammography
C1 Laboratory Test(s) Onl x
. aboratory Test(s) Only 1
(ailing eoprds Other felt we Croton tently Rebeka |AIM
1000 HIM ROP
sHome eens 4 ® Mec few Stok. LDER AUTHORIZATION
ERST ete Oy sional TAERROY +0 PP Sant
Fi8St Rete ABTLA ke Oberon caeYe SUTLEY MGavtn.
AUTHORIZATION FOR USE AND
DISCLOSURE OF HEALTH INFORMATION Page 2oi2
[ Special Authorization (Tell us if we have permission fo release the following sensitive information) |
I specifically euthorize release of the following information: AO .
COHN test resulis (initial) 1 Subsiance abuse (initial)
(1 Menial Health (initial) C1 Geneiic testing (initial)
{ Expiration : |
This authorization shall become effective immediately and shall remain in effect for one (1) year from ihe date
signed unless a different daie is specified here:
[ Restrictions
California law prohibits the recipient from making further disclosure of your health information unless the
recipient obtains another authorization irom you or uhless the disclosure is required or permitted by law.
This protection does not éxtend to recipients outside the state of California.
[Your Rights : |
‘e | may refuse to sign this authorization and my refusal will not affect my ability to obtain treatment or payment
6 {may revoke this authorization at any time. My revocation must be in writing, signed by me or on my behalf,
and delivered io this address:
|
|
|
|
For Sutter Hospitals: Palo Alto Sutter East Bay Sutter Gould Sutter Pacific Sutter Nisdical
Sutter Shared Services Medicat Foundation _Wiedical Foundation Tiedical Foundation _filedical Foundation Foundation
Attn: HIM Director Attn: Hil Director Attn: HIM Director Atin: Hilv Director Autin: HIM Director ‘Adin: Hil Director .
P.O, Box 619094 795 EtCamino Real 3887 Mt Diablo Bivd. 2200 600 Road 3883 Ainvay Or. Suite320 1014 N. Market Blvd, 210
* Roseville, CA 95581 Palo Alto, CA94301 Lafayette, CA 94549 Modes 4, 95350 Sania Rosa, CA 95403 Sacramento, CA 85834
e My revocation will be effective upon receipt, but will have no impact on uses or disclosure made while my
authorization wes valid.
© [have a right io receipt a copy of this authorization (required if authorization is requesied for the provider's
use or disclosure of health information).
e | may inspect and obtain a copy of the health information of which | am authorizing the use or disclosure of
my health information.
lfthis box (2 is checked, the facility listed above will receive compensation for the use or disclosure of my
health information.
[Signature (As required by law) |
"SIGNATURE ALyactialk, Bacal Sane Dateog/evV) ‘Time:
: “Patieni/Legal/Representative) / f
if signed by other than the patient, print name and relationship:
Name: AZ Relationship:
Office Use Only Identification verified by (name):
Verified by (method): [J Photo ID [Matching Signature 1 Other:
‘SH-0908 (05.05.2017): ~ Completion of this docu nt authorizes the disclosure. d/or use of health
information about you. Failure to provide all information requested may invalidate this
authorization. Zo
“ss USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION: y
Name of Patient: K head : \ ah é aco Sr. Date of Birth: 2 | A 4 ie 4
Other Names Used: N/A Telephone Numberl4is, 499-1) 77
Medical Record or Account#: O22 71 74 2
(Hospital use only)
ci = : - “\
| AUTHORIZE: Sk Woncis Memorial thos eval
(Facility or other provider)
TO DISCLOSE TO: fi
CLAIM AQ0179F} OF
~~ at the following address: +
(Street, City, State
the following information contained in the records specified below (initial tines
below);
O_ Mental health or developmental disability treatment records (excludes
“psychotherapy notes”) Wade Orne, ©) beg & Meck g
{VO Substance abuse treatment records ShouLWeR sripormepon
{JO_ HIV test results (This authorizes disclosure of laboratory test results only.
Note that your records may include information concerning your
HIV status even if you do not initial this line.)
THE FOLLOWING RECORDS, specific types of health information, or records for
the date(s) of treatment as specified [check applicable box(es)]:
0) Billing Records ¥0§§ Emergency Room 1 Procedure Reports
1 Consultation Reports Progress Notes
- Reports O1: History and Gq X-ray Reporis¢?p
Oo Discharge o Physical 26 15/2 WRI nee cD
_ Summary Laboratory Tests «avy, O ,
A Date(s): Fam FrRst DAY +o Onesorct: Bios Eh CHARS T
Hl Other: OVLIC Wo lotod foe Qheq QNeckseSnuldor.
C1 ALL RECORDS regarding my treatment, hospitalization, and outpatient care.
A separate authorization is required for the use or discl ue of psychotherapy
i i ~ GO) SID
ngtes o arch health information. Neds krey OG} a gt Priors
. QS Patient Identification: .
SG Dignity Health Sport Medes Ye
900 Hyde Street » San Francisco, CA 94109 + (415) 353-6000
: AUTHORIZATION FOR USE OR DISCLOSURE
~ OF PROTECTED HEALTH INFORMATION
RO!
“"""g700-899 (1272107) Paget of2 :
ys we"8700-899 (12/2107) Page 20f2
. PURPOSE: The purpo: and limitations (if any) of the r | 1ested use or disclosure is:
¢ At the request of the patient or personal representative; OR
* Othe: —Enwuey @rarm
EXPIRATION: This authorization will automatically expire one (1) year from the date
of execution unless a different end date is specified: . My revocation
will take effect upon receipt, except to the extent that others have acted.
MY RIGHTS:
* I may refuse to sign this authorization. My refusal will not affect my ability to
obtain treatment or payment or eligibility for benefits.
* [may revoke this authorization at any time, but | must do so in writing and submit
it to the following address: Saint Francis Memorial. 900 Hyde St., San Francisco,
CA 94109 in reliance upon this authorization.
¢ Ihave a right to receive a copy of this authorization.
Information disclosed pursuant to this authorization could be re-disclosed by the
recipient. Such re-disclosure is in some cases not protected by California law and
may no longer be protected by federal confidentiality law (HIPAA). If this authorization
is for the disclosure of substance abuse information, the recipient may be prohibited
from disclosing the information under 42 C.FR. part 2.
SIGNATURE: AMrrdilabL rao Sas Date: O8/aa// g
" (Patient-er-persehal represbittative)
Print name of personal representative Relationship to patient
Patient/Representative Identification Verified. Initials: Dept:
Note: If the substance abuse treatment information is protected by federal
confidentiality rules (42 C.F.R. part 2) the following prohibition of re-disclosure
statements must be provided to the recipient of the information:
The federal rules prohibit the recipient from making any further disclosure of
the information unless further disclosure is expressly permitted by the written
consent of the person to whom it pertains, or as otherwise permitted by 42 C.F.R.
part 2. A general authorization for the release of medical or other information is
NOT sufficient for this purpose. The federal rules restrict any use of the
information to criminally investigate or prosecute any alcohol or drug abuse
patient. :
Patient Identification:
Sf Dignity Health.
‘Saint Francis Memorial Hospital
900 Hyde Street » San Francisco, CA 94109 « (415) 353-6000
AUTHORIZATION FOR USE OR DISCLOSURE
OF PROTECTED HEALTH INFORMATION
ROLSedgwick Claims Management Services, Inc. @
PO Box 14436
Lexington, KY 40512-4436
e sedgwick.
Phone: (704)423-6200
Fax: (704)}423-6210
November 15, 2017
Khadijah Jacob
125 Mason Street Apt 404
San Francisco, CA 94102
i
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2 490"
Cha
ATCA A 1415/2017 301789107400001 §62017111503019. California General Rules Governing Insurance — Unfair Practices Notice
We have received notice of a claim, and as required by California Insurance Code, we are providing you with
this notice concerning fair claims settlement practices.
In addition to Section 790.03 of the Insurance Code, Fair Claims Settlement Practices Regulations govern how
insurance claims must be processed in this state. These regulations are available at the Department of
Insurance Internet Web site, www.insurance.ca.gov, or by calling the department's consumer information line
at 1-800-927-HELP (4357). You may also obtain a copy of this law and these regulations free of charge from
this insurer.
We are required to notify you that Section 790.03 Subdivisions (h) and (i) define the following as unfair
methods of competition and unfair and deceptive acts or practices in the business of insurance.
h) Knowingly committing or performing with such frequency as to indicate a general busin
the following unfair claims settlement practices:
$ practice any of
(1) Misrepresenting to claimants pertinent facts or insurance policy provisions relating to any
coverages at issue.
(2) Failing to acknowledge and act reasonably promptly upon communications with respect to claims
arising under insurance policies.
(3) Failing to adopt and implement reasonable standards for the prompt investigation and processing
of claims arising under insurance policies.
(A) Failing to affirm or deny coverage of claims within a reasonable time after proof of loss
requirements have been completed and submitted by the insured.
(3) Not attempting in good faith to effectuate prompt. fair, and equitable settlements of claims in
which liability has become reasonably clear.
(6) Compelling insureds to institute litigation to recover amounts due under an insurance policy by
offering substantially fess than the nts ultimately recovered in actions brought by the insureds,
“when the insureds have made claiins for amounts reasonably similar to the amounts ultim: ely ~
recovered.
(7) Attempting to settle a claim by an insured for less than the amount to which a reasonable person
would have believed he or she was entitled by reference to written or printed advertising material
accompanying or made part of an application.
(8) Attempting to settle claims on the basis of an application that was altered without notice to, or
knowledge or consent of, the insured, his or her representative. agent. or broker.
(9) Failing, after payment of a claim, to inform insureds or beneficiaries. upon request by them. of the
coverage under which payment has been made.
(10) Making known to insureds or claimants a practice of the insurer of appealing from arbitration
awards in favor of insureds or claimants for the purpose of compelling them to accept settlements or
compromises less than the amount awarded in arbitration.
(11) Delaying the investigation or payment of claims by requiring an insured, claimant, or the
physician of either. to submit a preliminary claim report, and then requiring the subsequent
submission of formal proof of loss farms, both of which submissions contain substantially the same
information.
(12) Failing to settle claims promptly, where liability has become apparent, under one portion of the
insurance policy coverage in order to influence settlements under other portions of the insurance
policy coverage.
(13) Failing to provide promptly a reasonable explanation of the basis relied on in the insurance
policy. in relation to the facts or applicable law. for the denial of a claim or for the offer ofa
compromise settlement.
24 3
ALONG 1415/2017 301789107400001 562017111503019(14) Directly advising a claimant not to obtain the services of an attorney.
(15) Misleading a claimant as to the applicable statute of limitations.
(16) Delaying the payment or provision of hospital, medical, or surgical benefits for services provided
with respect to acquired immune deficiency syndrome or AIDS-related complex for more than 60
days alter the insurer has received a claim for those benefits, where the delay in claim payment is for
the purpose of investigating whether the condition preexisted the coverage. However, this 60-day
period shall not include any time during which the insurer is awaiting a response for relevant medical
information from a health care provider.
(i) Canceling, ar refusing to renew a policy in violation of Section 676.10.
You also have the right to be provided with a copy of. specified regulations according to CA Insurance Code.
When requested orally or in writing, a legible reproduction of Section 790.03 of the Insurance Code and copies
of Sections 2695.5, 2695.7, 2695.8, and 2695.9 of Subchapter 7.5 of Chapter 5 of Title 10 of the California
Code of Regulations will be provided to you within 15 calendar days of your request.
Sedgwick manages claims for Wells Fargo & Company on behalf of OLD REPUBLIC
INSURANCE COMPANY.
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11/15/2017 301789107400001 562017111503019Providers:
Name:
Address:
Phone
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Address:
Phone
Name:
Address:
Phone
Name:
Address:
Phone
Name:
Address:
Phone
Name:
Address:
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AACA 1115/2018 301789107400001 5620181 10501427 ieSedgwick Claims Management Services, Inc.
PO Box 14436
Lexington, KY 40512-4436
sedgwicke
Phone: (704)423-6200 Fax: (704)423-6210
May 03, 2018
Khadijah Jacob
125 Mason Street Apt 404
San Francisco, CA 94102
RE: Account: Wells Fargo & Company
Claimant: Khadijah Jacob
Date of Loss: 11/03/2017
Claim Number: 30178910740-0001
Writing Company Name: OLD REPUBLIC INSURANCE COMPANY
Dear Ms. Jacob,
in order for us to properly evaluate and administer your claim, we need to request medical information
from your medical providers (doctors, hospitals, radiologist, clinics, etc.). We need your permission to
obtain this information.
Please sign and return the enclosed Medical Authorization. Also, please provide us with the name and
address of each medical provider in the section below.
tf you have any questions, please feel free to contact me at the phone numbers listed below.
Sedgwick manages claims for Wells Fargo & Company on behalf of OLD REPUBLIC INSURANCE
COMPANY.
Sincerely,
Julia Grant
Claims Representative
Direct Dial: (704)423-6254 ©
Toll Free: (704)423-6200
Facsimile: (704)423-6210
Enclosure
Sedgwick manages claims for Wells Fargo & Company on behalf of OLD REPUBLIC INSURANCE
COMPANY.
COEUR 5/3/2018 301789107400001 562018050313436{EE
Effective 07/09/2015
Sedgwick
Authorization for Release of Personal Health Information
To: (Khadijah Jacob)
Name of Individual/Entity Authorized to Release Personal Health Information
| hereby request and authorize you to disclose to Sedgwick, a claims administration organization whose
customers are insurers and employers, and to Sedgwick’ affiliates and/or authorized representatives, any and all
personal health information you currently have or may in the future acquire related to my insurance claim
(identified below) administered by Sedgwick. Personal health information (or “PHI*) means any information or
data except age or gender, whether oral or recorded in any form or medium, created by or derived from a health
care provider or the consumer that relates to: (1) the past, present or future physical, mental or behavioral health
or condition of an individual; (2) the provision of health care to an individual; or (3) payment for the provision of
health care to an individual.
| understand that Sedgwick will utilize the personal health information obtained by use of this authorization for the
purposes of administration of the claim identified below (including evaluation, adjustment and other claims
management activities) and/or for other authorized claim administration and/or insurance functions. | understand
that Sedgwick may disclose this information to other parties in connection with performing claim administration
and/or insurance functions, including persons or organizations performing business, audit, expert evaluation or
legal services on Sedgwick's behalf, insurance companies having potential liability for my claim, government
agencies, third-party administrators, damages experts, and structured settlement brokers, or as may be otherwise
lawfully required, or as | may further authorize.
| understand that | may revoke this authorization at any time except to the extent that persona! health information
has already been obtained or released, by providing Sedgwick with written notice of my intention to revoke. 1
understand that by revoking this authorization | am not affecting any right or obligation that you or Sedgwick may
otherwise have to use and disclose my personal health information for treatment, payment, or "healthcare
~Opérations Gr as Otherwisé permitted or tequited by law: ~~ ~ en oe
| understand that information is being released pursuant to this authorization at my request. | understand that
Sedgwick rather than the health care provider is responsible for the PHI that comes into Sedgwick’s possession,
and Sedgwick will only use and may only re-disclose this PHI to the extent permitted by law.
This authorization is valid for the duration of this claim, for a maximum period of twenty-four (24) months. |
understand that | have the right to receive a copy of this authorization upon request. A copy or facsimile of this
authorization shall be considered as effective and valid as the original. This authorization is not a release of any
claim | may have.
This authorization relates to Claim Number: 30178910740-0001
Print Claimant Name:
Date of Birth: SS#
Signature Of Claimant (or by Claimant's personal representative if Date:
source of authority is specified):
Note: This Authorization is made in administering a property/casualty insurance claim and conforms to all applicable
‘state and federal privacy laws. The HIPAA Privacy Rule does not regulate property and casualty insurers’ collection,
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TURLUOCEV A UVT 5/3/2018 301789107400001 562018050313436
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EF supation Court of California ‘s County ~ ~ Khadijah Jacob, in pro per FEB 2070 125 Mason Street, #404 CLERK OF THE COURT San Francisco, California 94102 BY ha : A ak (415) 409-1177 IN THE SUPERIOR COURT OF THE STATE OF CALIFORNIA IN AND FOR THE COUNTY OF SAN FRANCISCO KHADIJAH JACOB, Case No.: CGC-19-577484 Plaintiff, PLAINTIFF RESPONSE TO WELLS VS. FARGO BANK, N.A. AND BRANCH WELLS FARGO BANK N.A., BRANCH MANAGER VLADYHCHKIN SERGIY’S MANAGER VLADYCHKIN, SERGIY OPPOSITION TO PLAINTIFF’S MOTION > TO QUASH SUBPOENAS OF PLAINTIFF’S Defendant MEDICAL RECORDS Hearing Date: February 19, 2020 Hearing Time: 9:30 a.m. Department: 302 Location 400 McAllister Street, S.F. Reservation: 01150219-12 Action Filed: July 9, 2020 Trial Date: — July 6, 2020 1. INTRODUCTION Plaintiff Khadijah Jacob must reply to the Defendants’ Opposition to Plaintiff's Motion to Quash Subpoenas of Plaintiff's Medical Records because it contains some inaccuracies. 1. Thd Plaintiff object to Subpoenas for medical records on her back because it doesn’t pertain to this lawsuit. She wasn’t visiting her doctor or being treated for any injury or pain to her back at the time, she tripped and felled extremely hard at Wells Fargo Bank on November 3, 2017. She gave no one Authorization to her Medical records nor did any Medical Providers call me which violates HIPAA and State Laws and Patient Privacy and Confidentiality. PLAINTIFF RESPONSE TO WELLS FARGO BANK, N.A. AND BRANCH MANAGER VLADYHCHKIN SERGIY’S OPPOSITION TO PLAINTIFF’S MOTION TO QUASH SUBPOENAS OF PLAINTIFF’S MEDICAL RECORDS - 12. The Plaintiff object to Subpoenas ATTACHMENTS 3 first line states the scope of my medical record, and the descriptions are extremely broad and confusing. I hate the word “ALL;” it means everything and is used throughout the Subpoenas. Some examples: “All documents and records stored in any format, form or method, including, but not limited to, all office, emergency room, inpatient and outpatient charts and records, lien files, SOAP notes, pathology records and reports, lab reports, pharmacy and prescription records, physical therapy records, including sign- in sheets, all descriptions of exercises prescribed and documentation which indicate date and tim of patient’s appointments, and insurance documents; and All itemized statements of the billing charges and/or consolidated statement of benefits, with diagnostic and procedure codes including| all CPT and ICD-9 coding and all HCFA, UB04 and UB92 bills, to include the total charges private or governmental; any amounts written off by the provider, and any amounts that are the patient’s responsibility and explanation of benefits, payment history, records of any liens, any insurance billing or payments information, emergency room physicians bills and radiology billing from all sources, to include any computer generated billing or billing stored in any format and payment software that contains said information; and COPIES of all original x-rays films, CT scans, MRIs and any other scans or images taken and/or maintained, including a comprehensive list of all dates and body parts of all firms, CT scans, MRIs and all other images or scans provided. MRN # 01247036, ACCT # 200018791752 Including treatment records by Catherine James, MD” These complicated formats may give them Medical records they aren’t entitled too. The last sentence about Doctor James violates Medical ethics rules, state laws, and federal law known as Health Insurance Portability and Accountability Act (HIPAA) prevent doctors from sharing patient information without their permission. PLAINTIFF RESPONSE TO WELLS FARGO BANK, N.A. AND BRANCH MANAGER VLADYHCHKIN SERGIY’S OPPOSITION TO PLAINTIFFS MOTION TO QUASH SUBPOENAS OF PLAINTIFFS MEDICAL RECORDS -23. Medical record in California and Guide to Consumer Rights under HIPAA states, providers must retain them for seven years. Most Personal Injury Attorneys ask for five years of records unless the injured person suffered Brain damage or is paralyzed then there may be additional years. After reading this information, I felt eight years were excessive. I feel these Subpoenas will be an abuse on my Medical records for these reasons: First, Julia Grant, Claim Representative for Wells Fargo & company called Monday, November 6, 2017, and we were in communication until about May of 2019. She provided me with two medical providers requests. The dates were November 15, 2017 and May 3, 2018, which I refused to sign and there are some pages missing. J explained to Julia I don’t want anyone to have my Medical records. T’ll do it based only on the injuries from when I tripped and felled in the bank, and the records will be sent to you. February 21st and 22"4, 2019, I went to Medical record Offices and completed Authorization Disclose Health Information Forms for three Medical Providers. I specified what to be released; I wrote only related to Left leg, Right neck and shoulder. I was told any other information released would violate HIPAA Laws. Second, I believe Julia Grant has provided Attorney Debra with my Medical records soon] after she took the case since, they both work on behalf of Wells Fargo Bank, N.A. During discovery the Defendants Attorney Debra requested Medical records, Product Work, pictures, all Medical records, all forms, documents, tapes, all electronic devices and all notes related to my injuries, case, and medications. I visited my Primary Doctors and provide her notes of the pain in my Right shoulder and arm, and pain in my Left leg continue to be inconsistent. I usually use Deep Soothing Therma-therapy Hot Wrap or take a pain pill. I do the same to my Right shoulder and arm when the pain is worse, and I have provided her with pictures of my injuries. PLAINTIFF RESPONSE TO WELLS FARGO BANK, N.A. AND BRANCH MANAGER VLADYHCHKIN SERGTY’S OPPOSITION TO PLAINTIFF’S MOTION TO QUASH SUBPOENAS OF PLAINTIFF’S MEDICAL RECORDS -327 28 4. I’ve provided Attorney Debra with more than enough information related to my injuries. While I have made similar requests, and I have received nothing worth having. I was shocked to receive these Subpoenas for my Medical records, and I feel this is a serious abused of my Medica records because most of it will be repeated information. She wrote, “However, medical records that were provided, pursuant to your written authorization, to Sedgwick Claims Management Services (Wells Fargo’s third party administrator for liability claims) date back several years before the 2017 incident and include information about treatment to many areas of your body, including your back. In fact, there is a specific report to your back, along with your leg and shoulder, contained in a December 2018 record from your primary care physician at Maxine Hall Health Center. We have sought medical records going back 8 years to cover the period of time in which you sustained injuries in other slips and falls and a motor vehicle accident. Based on the records we have reviewed, you were diagnosed with a pretexting torn rotator cuff several years before this incident and received treatment for that condition years before this incident and received treatment for that condition years before. A key issue in this case is what damage was caused by this fall as opposed to your pre-existing conditions involving arthritis and your rotator cuff problem.” When it comes to a previous tore, rotator cuff and treatment, I disagree with whatever document (s) you are reviewing. It’s not possible to have this| type of injury and don’t remember. It’s a type of pain I wouldn’t have forgotten, and I been experiencing it for the last three years; I have never been in pain for this length of time. Most importantly, J had no pain; I was active and had great movement of my Right shoulder and arm before I tripped and felled. Since this incident, I have been in a horrible nightmare!! PLAINTIFF RESPONSE TO WELLS FARGO BANK, N.A. AND BRANCH MANAGER VLADYHCHKIN SERGIY’S OPPOSITION TO PLAINTIFF’S MOTION TO QUASH SUBPOENAS OF PLAINTIFF’S MEDICAL RECORDS -427 28 Attorney Debra’s Opposition to Plaintiff Motion to Quash Subpoenas of Plaintiff Medical Records are filled with LIES!!! Yes, I understand what I am saying. Her page 2, lines 12 to 21 are not true. My November 3, 2017, trip and fall incident consists of different areas of my body. Her lines 22 to 28 are not true. Any Medical records Julia Grant, has of me came from the three Medical Providers to whom I specified what information I wanted released from my Medical records. Any additional information they made have sent was without my permission A | N/z9 PLAINTIFF RESPONSE TO WELLS FARGO BANK, N.A. AND BRANCH MANAGER VLADYHCHKIN SERGIY’S OPPOSITION TO PLAINTIFF’S MOTION TO QUASH SUBPOENAS OF PLAINTIFF’S MEDICAL RECORDS - 5CITY & COUNTY OF SAN FRANCISCO NAME* 34% cob, -ENnADIT ay DEPARTMENT OF PUBLIC HEALTH pops ahs | 1a4e MRN = 240 Ble SS# “Yrertooo2 AUTHORIZATION TO DISCLOSE HEALTH INFORMATION PCP DA. xem FD pevent w /abe Completion of this document authorizes the disclosure and/or use of individually identifiable health === information, as set forth below, consistent with California and federal law concerning the privacy of such == information. Failure to provide ALL information marked with an asterisk (*) may invalidate this == authorization. hr, Takub, -AADI wat (AKA) authorize “Maxine Yoel) Hepes CEKTK to disclose health information (NAME OF HOSPITAL OR FACILITY) . obtained in the course of my diagnosis and treatment for the purpose of tate clam : Disclosure requested by DPH facility and/or agent? (KNo O Yes Purpose?__- By checking in the spaces below, | specifically authorize the release of the following medical records, if such records exist. Such disclosure shall be limited to the following types of information or dates of treatment. | recognize that if | am disclosing my health information to someone who is not legally required to keep it confidential, it may be redisclosed and may no longer be protected. California law Tequires that recipients refrain from redisclosing such information except with my written authorization Or as specifically required by law. Dates of Treatment AND/OR Specific Medical Condition: —— Complete medical record(s) ___ Outpatient Clinic Notes ~___ immunizations 1] 144 - mena ‘ —— Discharge Summary _—— Emergency Report —— Consultation ~ plectat ——History & Physical _— lab tests _—. Pathology . —% Progress Notes — X-ray report X Otheronly (clave Tec INITIAL below for protected classes of information: Le4,© CRN @. EJ Mental Health Treatment [_] Substance Abuse Treatment [_] HIV/AIDS Test/Treatment 3- z (1 Sewally Transmitted Disease (City Circ) a Developmental DeyeH N23 “W290 Gow) 2 3: = SEND Tos Juli cree SEPAICK, P.O Bix a2 235 MY DPH RIGHTS: | understand that authorizing the disclosure of this health information is voluntary | may refuse to sign this authorization. | may revoke this authorization at any time. Revocation must be in writing, signed by me or on my behalf by someone with the legal authority to do so and delivered to the DPH or other facility. My revocation will, be effective upon receipt, but will not be effective to the extent that the DPH may have acted in reliance upon this authorization prior to revocation. | have a right to obtain a copy of this authorization. | may not be denied treatment, payment, enroliment in a health plan, or eligibility for benefits if | refuse to sign. EXPIRATION: Unless otherwise revoked, this authorization will expire in 90 days, on the following event/condition OR immediately upon fulfillment for protected classes. EVENT/CONDITION: + 22-1}\4 . 4 _ SELLE ‘a . Date Signature (P: lient/Pat /Guardian/Conservator) Relationship if not Patient/Client Q Interpreter used Witness (Required if Patient/Client unable to sign) 5799935 (Rev. 03/04) White - Releasing Facility Yellow - Medical Records Pink - Patient/Client Front of two sidesAUTHORIZATION FOR USE AND ‘DISCLOSURE OF HEALTH INFORMATION Page 1 of2 There may be fees incurred for this service. | Patient Information (Tell us about the patient) Patient Name: KA adi tel Tarel ee. DOBG Address: ff 5° Hib Sani “Sheer yoy City: Se Fi a Phone(47 & ) HO Gi tt TF Email (optional): [Type of Access Requested (Please check ONLY one) Paper Copy Ocp (My Health Online (1 Inspection Only 7) Email (encrypted) C) Email (not encrypted) (Note: If you would like us to send information over email not encrypted, this Increases the risk thet information could be read by en unauthorized third party. } EB @ NEck tup ~ B4 Other (must be agreed upon by ihe patient and provider) xsi je es feces ol fn Les Cloutd ee | Delivery Method (Please check ONLY one) | (Mail OH Email &] Fax (1 Pick-Up (if applicable} (1 My Health Online Portal | Purpose of Requested Use or Disclosure (Tell us how you will use the records) | ©) Continuity of Care — Appointment Date with Physician: / I Patient Cl Insurance OH Other: ee & COL pm | Authorization ~ | hereby authorize: ] CALIFORNIA PACIFIC MEDICAL CENTER (Name of hospital, physician, healthcare provider) | | | | J Alpelu? WRNGZLCT SGg vdeo Siate eA Zin Glas Le IN. 3700 California Street, Suite 1570 San Francisco CA 94118 Address Cit State Zi (415) 600-6246 _ Yas) 600-2113 - p Phone Fax | To release my health information fo: [| Check this box ifsame as patient listed above. OR | Fiali £0 CRaN Tt, Shdgefck Chai ons Ronme coptt? ve (Naine of hospital, physician, hedlthcare provider, other) B.0.4ex [Geen Lov tagton Ky Yass a Address ue a City State Zip (a4) ¥a2-Gdoa : Fags (HO) 92 Gara Phone Fax [Information Disclosure (Tell us. what information you need) _ | information to be disclosed for the following date Bn Figst DATE to Pyne SQ int C] Hospital Records (Inpatient and Outpatient) C1 Clinic/Foundation Records (Specify Provider Name): ‘LD Radiology Report(s ) Only ae REED Repotreep £4 Radiology Images nea Pat Kap OS Utresouts? Dor scan MRI (J Mammography C1 Laboratory Test(s) Onl x . aboratory Test(s) Only 1 (ailing eoprds Other felt we Croton tently Rebeka |AIM 1000 HIM ROP sHome eens 4 ® Mec few Stok. LDER AUTHORIZATION ERST ete Oy sional TAERROY +0 PP Sant Fi8St Rete ABTLA ke Oberon caeYe SUTLEY MGavtn. AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION Page 2oi2 [ Special Authorization (Tell us if we have permission fo release the following sensitive information) | I specifically euthorize release of the following information: AO . COHN test resulis (initial) 1 Subsiance abuse (initial) (1 Menial Health (initial) C1 Geneiic testing (initial) { Expiration : | This authorization shall become effective immediately and shall remain in effect for one (1) year from ihe date signed unless a different daie is specified here: [ Restrictions California law prohibits the recipient from making further disclosure of your health information unless the recipient obtains another authorization irom you or uhless the disclosure is required or permitted by law. This protection does not éxtend to recipients outside the state of California. [Your Rights : | ‘e | may refuse to sign this authorization and my refusal will not affect my ability to obtain treatment or payment 6 {may revoke this authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered io this address: | | | | For Sutter Hospitals: Palo Alto Sutter East Bay Sutter Gould Sutter Pacific Sutter Nisdical Sutter Shared Services Medicat Foundation _Wiedical Foundation Tiedical Foundation _filedical Foundation Foundation Attn: HIM Director Attn: Hil Director Attn: HIM Director Atin: Hilv Director Autin: HIM Director ‘Adin: Hil Director . P.O, Box 619094 795 EtCamino Real 3887 Mt Diablo Bivd. 2200 600 Road 3883 Ainvay Or. Suite320 1014 N. Market Blvd, 210 * Roseville, CA 95581 Palo Alto, CA94301 Lafayette, CA 94549 Modes 4, 95350 Sania Rosa, CA 95403 Sacramento, CA 85834 e My revocation will be effective upon receipt, but will have no impact on uses or disclosure made while my authorization wes valid. © [have a right io receipt a copy of this authorization (required if authorization is requesied for the provider's use or disclosure of health information). e | may inspect and obtain a copy of the health information of which | am authorizing the use or disclosure of my health information. lfthis box (2 is checked, the facility listed above will receive compensation for the use or disclosure of my health information. [Signature (As required by law) | "SIGNATURE ALyactialk, Bacal Sane Dateog/evV) ‘Time: : “Patieni/Legal/Representative) / f if signed by other than the patient, print name and relationship: Name: AZ Relationship: Office Use Only Identification verified by (name): Verified by (method): [J Photo ID [Matching Signature 1 Other: ‘SH-0908 (05.05.2017): ~ Completion of this docu nt authorizes the disclosure. d/or use of health information about you. Failure to provide all information requested may invalidate this authorization. Zo “ss USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION: y Name of Patient: K head : \ ah é aco Sr. Date of Birth: 2 | A 4 ie 4 Other Names Used: N/A Telephone Numberl4is, 499-1) 77 Medical Record or Account#: O22 71 74 2 (Hospital use only) ci = : - “\ | AUTHORIZE: Sk Woncis Memorial thos eval (Facility or other provider) TO DISCLOSE TO: fi CLAIM AQ0179F} OF ~~ at the following address: + (Street, City, State the following information contained in the records specified below (initial tines below); O_ Mental health or developmental disability treatment records (excludes “psychotherapy notes”) Wade Orne, ©) beg & Meck g {VO Substance abuse treatment records ShouLWeR sripormepon {JO_ HIV test results (This authorizes disclosure of laboratory test results only. Note that your records may include information concerning your HIV status even if you do not initial this line.) THE FOLLOWING RECORDS, specific types of health information, or records for the date(s) of treatment as specified [check applicable box(es)]: 0) Billing Records ¥0§§ Emergency Room 1 Procedure Reports 1 Consultation Reports Progress Notes - Reports O1: History and Gq X-ray Reporis¢?p Oo Discharge o Physical 26 15/2 WRI nee cD _ Summary Laboratory Tests «avy, O , A Date(s): Fam FrRst DAY +o Onesorct: Bios Eh CHARS T Hl Other: OVLIC Wo lotod foe Qheq QNeckseSnuldor. C1 ALL RECORDS regarding my treatment, hospitalization, and outpatient care. A separate authorization is required for the use or discl ue of psychotherapy i i ~ GO) SID ngtes o arch health information. Neds krey OG} a gt Priors . QS Patient Identification: . SG Dignity Health Sport Medes Ye 900 Hyde Street » San Francisco, CA 94109 + (415) 353-6000 : AUTHORIZATION FOR USE OR DISCLOSURE ~ OF PROTECTED HEALTH INFORMATION RO! “"""g700-899 (1272107) Paget of2 : ys we"8700-899 (12/2107) Page 20f2 . PURPOSE: The purpo: and limitations (if any) of the r | 1ested use or disclosure is: ¢ At the request of the patient or personal representative; OR * Othe: —Enwuey @rarm EXPIRATION: This authorization will automatically expire one (1) year from the date of execution unless a different end date is specified: . My revocation will take effect upon receipt, except to the extent that others have acted. MY RIGHTS: * I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment or payment or eligibility for benefits. * [may revoke this authorization at any time, but | must do so in writing and submit it to the following address: Saint Francis Memorial. 900 Hyde St., San Francisco, CA 94109 in reliance upon this authorization. ¢ Ihave a right to receive a copy of this authorization. Information disclosed pursuant to this authorization could be re-disclosed by the recipient. Such re-disclosure is in some cases not protected by California law and may no longer be protected by federal confidentiality law (HIPAA). If this authorization is for the disclosure of substance abuse information, the recipient may be prohibited from disclosing the information under 42 C.FR. part 2. SIGNATURE: AMrrdilabL rao Sas Date: O8/aa// g " (Patient-er-persehal represbittative) Print name of personal representative Relationship to patient Patient/Representative Identification Verified. Initials: Dept: Note: If the substance abuse treatment information is protected by federal confidentiality rules (42 C.F.R. part 2) the following prohibition of re-disclosure statements must be provided to the recipient of the information: The federal rules prohibit the recipient from making any further disclosure of the information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains, or as otherwise permitted by 42 C.F.R. part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. : Patient Identification: Sf Dignity Health. ‘Saint Francis Memorial Hospital 900 Hyde Street » San Francisco, CA 94109 « (415) 353-6000 AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION ROLSedgwick Claims Management Services, Inc. @ PO Box 14436 Lexington, KY 40512-4436 e sedgwick. Phone: (704)423-6200 Fax: (704)}423-6210 November 15, 2017 Khadijah Jacob 125 Mason Street Apt 404 San Francisco, CA 94102 i Oe 2 490" Cha ATCA A 1415/2017 301789107400001 §62017111503019. California General Rules Governing Insurance — Unfair Practices Notice We have received notice of a claim, and as required by California Insurance Code, we are providing you with this notice concerning fair claims settlement practices. In addition to Section 790.03 of the Insurance Code, Fair Claims Settlement Practices Regulations govern how insurance claims must be processed in this state. These regulations are available at the Department of Insurance Internet Web site, www.insurance.ca.gov, or by calling the department's consumer information line at 1-800-927-HELP (4357). You may also obtain a copy of this law and these regulations free of charge from this insurer. We are required to notify you that Section 790.03 Subdivisions (h) and (i) define the following as unfair methods of competition and unfair and deceptive acts or practices in the business of insurance. h) Knowingly committing or performing with such frequency as to indicate a general busin the following unfair claims settlement practices: $ practice any of (1) Misrepresenting to claimants pertinent facts or insurance policy provisions relating to any coverages at issue. (2) Failing to acknowledge and act reasonably promptly upon communications with respect to claims arising under insurance policies. (3) Failing to adopt and implement reasonable standards for the prompt investigation and processing of claims arising under insurance policies. (A) Failing to affirm or deny coverage of claims within a reasonable time after proof of loss requirements have been completed and submitted by the insured. (3) Not attempting in good faith to effectuate prompt. fair, and equitable settlements of claims in which liability has become reasonably clear. (6) Compelling insureds to institute litigation to recover amounts due under an insurance policy by offering substantially fess than the nts ultimately recovered in actions brought by the insureds, “when the insureds have made claiins for amounts reasonably similar to the amounts ultim: ely ~ recovered. (7) Attempting to settle a claim by an insured for less than the amount to which a reasonable person would have believed he or she was entitled by reference to written or printed advertising material accompanying or made part of an application. (8) Attempting to settle claims on the basis of an application that was altered without notice to, or knowledge or consent of, the insured, his or her representative. agent. or broker. (9) Failing, after payment of a claim, to inform insureds or beneficiaries. upon request by them. of the coverage under which payment has been made. (10) Making known to insureds or claimants a practice of the insurer of appealing from arbitration awards in favor of insureds or claimants for the purpose of compelling them to accept settlements or compromises less than the amount awarded in arbitration. (11) Delaying the investigation or payment of claims by requiring an insured, claimant, or the physician of either. to submit a preliminary claim report, and then requiring the subsequent submission of formal proof of loss farms, both of which submissions contain substantially the same information. (12) Failing to settle claims promptly, where liability has become apparent, under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage. (13) Failing to provide promptly a reasonable explanation of the basis relied on in the insurance policy. in relation to the facts or applicable law. for the denial of a claim or for the offer ofa compromise settlement. 24 3 ALONG 1415/2017 301789107400001 562017111503019(14) Directly advising a claimant not to obtain the services of an attorney. (15) Misleading a claimant as to the applicable statute of limitations. (16) Delaying the payment or provision of hospital, medical, or surgical benefits for services provided with respect to acquired immune deficiency syndrome or AIDS-related complex for more than 60 days alter the insurer has received a claim for those benefits, where the delay in claim payment is for the purpose of investigating whether the condition preexisted the coverage. However, this 60-day period shall not include any time during which the insurer is awaiting a response for relevant medical information from a health care provider. (i) Canceling, ar refusing to renew a policy in violation of Section 676.10. You also have the right to be provided with a copy of. specified regulations according to CA Insurance Code. When requested orally or in writing, a legible reproduction of Section 790.03 of the Insurance Code and copies of Sections 2695.5, 2695.7, 2695.8, and 2695.9 of Subchapter 7.5 of Chapter 5 of Title 10 of the California Code of Regulations will be provided to you within 15 calendar days of your request. Sedgwick manages claims for Wells Fargo & Company on behalf of OLD REPUBLIC INSURANCE COMPANY. oT 24 WW ll I) 7a. sso a S49 UOTE 11/15/2017 301789107400001 562017111503019Providers: Name: Address: Phone Name: Address: Phone Name: Address: Phone Name: Address: Phone Name: Address: Phone Name: Address: Phone ™ i 6 A 9 Ma C2359 oS aD pee AACA 1115/2018 301789107400001 5620181 10501427 ieSedgwick Claims Management Services, Inc. PO Box 14436 Lexington, KY 40512-4436 sedgwicke Phone: (704)423-6200 Fax: (704)423-6210 May 03, 2018 Khadijah Jacob 125 Mason Street Apt 404 San Francisco, CA 94102 RE: Account: Wells Fargo & Company Claimant: Khadijah Jacob Date of Loss: 11/03/2017 Claim Number: 30178910740-0001 Writing Company Name: OLD REPUBLIC INSURANCE COMPANY Dear Ms. Jacob, in order for us to properly evaluate and administer your claim, we need to request medical information from your medical providers (doctors, hospitals, radiologist, clinics, etc.). We need your permission to obtain this information. Please sign and return the enclosed Medical Authorization. Also, please provide us with the name and address of each medical provider in the section below. tf you have any questions, please feel free to contact me at the phone numbers listed below. Sedgwick manages claims for Wells Fargo & Company on behalf of OLD REPUBLIC INSURANCE COMPANY. Sincerely, Julia Grant Claims Representative Direct Dial: (704)423-6254 © Toll Free: (704)423-6200 Facsimile: (704)423-6210 Enclosure Sedgwick manages claims for Wells Fargo & Company on behalf of OLD REPUBLIC INSURANCE COMPANY. COEUR 5/3/2018 301789107400001 562018050313436{EE Effective 07/09/2015 Sedgwick Authorization for Release of Personal Health Information To: (Khadijah Jacob) Name of Individual/Entity Authorized to Release Personal Health Information | hereby request and authorize you to disclose to Sedgwick, a claims administration organization whose customers are insurers and employers, and to Sedgwick’ affiliates and/or authorized representatives, any and all personal health information you currently have or may in the future acquire related to my insurance claim (identified below) administered by Sedgwick. Personal health information (or “PHI*) means any information or data except age or gender, whether oral or recorded in any form or medium, created by or derived from a health care provider or the consumer that relates to: (1) the past, present or future physical, mental or behavioral health or condition of an individual; (2) the provision of health care to an individual; or (3) payment for the provision of health care to an individual. | understand that Sedgwick will utilize the personal health information obtained by use of this authorization for the purposes of administration of the claim identified below (including evaluation, adjustment and other claims management activities) and/or for other authorized claim administration and/or insurance functions. | understand that Sedgwick may disclose this information to other parties in connection with performing claim administration and/or insurance functions, including persons or organizations performing business, audit, expert evaluation or legal services on Sedgwick's behalf, insurance companies having potential liability for my claim, government agencies, third-party administrators, damages experts, and structured settlement brokers, or as may be otherwise lawfully required, or as | may further authorize. | understand that | may revoke this authorization at any time except to the extent that persona! health information has already been obtained or released, by providing Sedgwick with written notice of my intention to revoke. 1 understand that by revoking this authorization | am not affecting any right or obligation that you or Sedgwick may otherwise have to use and disclose my personal health information for treatment, payment, or "healthcare ~Opérations Gr as Otherwisé permitted or tequited by law: ~~ ~ en oe | understand that information is being released pursuant to this authorization at my request. | understand that Sedgwick rather than the health care provider is responsible for the PHI that comes into Sedgwick’s possession, and Sedgwick will only use and may only re-disclose this PHI to the extent permitted by law. This authorization is valid for the duration of this claim, for a maximum period of twenty-four (24) months. | understand that | have the right to receive a copy of this authorization upon request. A copy or facsimile of this authorization shall be considered as effective and valid as the original. This authorization is not a release of any claim | may have. This authorization relates to Claim Number: 30178910740-0001 Print Claimant Name: Date of Birth: SS# Signature Of Claimant (or by Claimant's personal representative if Date: source of authority is specified): Note: This Authorization is made in administering a property/casualty insurance claim and conforms to all applicable ‘state and federal privacy laws. The HIPAA Privacy Rule does not regulate property and casualty insurers’ collection, AOA & BA 5/3/2018 301789107400001 562018050313436Providers: Name: Address: Phone Name: Address: Phone Name: Address: Phone Name: Address: Phone Name: Address?” ~~ ons ween cee me eee Phone Name: Address: Phone Name: Address: Phone Name: Address: Phone A TURLUOCEV A UVT 5/3/2018 301789107400001 562018050313436