On April 08, 2021 a
Motion-Secondary
was filed
involving a dispute between
Jose N. Delcid Ramos,
and
Jose D. Chicas,
for Torts - Motor Vehicle
in the District Court of Suffolk County.
Preview
FILED: SUFFOLK COUNTY CLERK 11/14/2022 11:02 AM INDEX NO. 606262/2021
NYSCEF DOC. NO. 14 RECEIVED NYSCEF: 11/14/2022
606262/2021
SUFFOLK
JOSE N. DELCID RAMOS,
State Farm
PO Box 8000
JOSE D. CHICAS, Ballston Spa, NY 12020
(9 Pages)
State Farm
PO Box 8000
Ballston Spa, NY 12020
(9 pages)
11/14/2022
Law Offices of Karen L. Lawrence
878 Veterans Memorial Highway Suite
100
Hauppauge, NY 11788-3089
1 of 10
FILED: SUFFOLK COUNTY CLERK 11/14/2022 11:02 AM INDEX NO. 606262/2021
NYSCEF DOC. NO. 14 RECEIVED NYSCEF: 11/14/2022
Payment Log
11-10-2022
Mail to: JOSEPH C ANDRUZZI
326 BROADWAY STE 200
BETHPAGE, NY 11714-3021
Claim No: 20-06R2-66B
Injured Party: JOSE DELCID RAMOS Named Insured: FREDDY A ROJAS DUBON
Address: 28 JOHNSON ST Date of Accident: 05-07-2020
AMITYVILLE, NY 11701-1515
Claim Handler: Tara Barnette
Phone: 844-292-8615
Payment Summary - New York
Coverage - Personal Injury Protection Amount
Personal Injury Protection Applied to Limit $42,877.04
Personal Injury Protection - Medical $42,877.04
Deductible $0.00
Offset to Date $0.00
Personal Injury Protection Not Applied to Limit $0.00
Co-Pay $0.00
Interest Paid to Date - Not Applied to Limit(s) Amount
Interest $104.43
RBZ000FJ State Farm®
1007048 Page 1 of 9 2005 148026 205 08-10-2022
2 of 10
NYSCEF
FILED:
Payment Log
11-10-2022
DOC.
Claim No: 20-06R2-66B
NO.
Injured Party: JOSE DELCID RAMOS
14
SUFFOLK
Payment/ Payment/
Recovery Recovery Date Bill Deductible Co-Pay
Date Number Payee Billed Amount Received Date From Date To Coverage Description Amount Amount Paid Amount
10-09-2022 121292495J ISLAND PT & CHIROPRACTIC $369.85 09-16-2022 08-15-2022 08-30-2022 Personal Injury Protection - Medical $364.31
COUNTY
10-06-2022 121288671J MOTION MEDICAL DIAGNOSTICS Personal Injury Protection - Medical $12.43
10-06-2022 121288671J MOTION MEDICAL DIAGNOSTICS Interest $3.29
08-23-2022 121229367J ISLAND PT & CHIROPRACTIC $263.38 07-28-2022 06-23-2022 07-07-2022 Personal Injury Protection - Medical $252.20
CLERK
06-19-2022 121139360J ISLAND PT & CHIROPRACTIC $116.22 06-13-2022 06-07-2022 06-07-2022 Personal Injury Protection - Medical $114.59
06-12-2022 121130396J ISLAND PT & CHIROPRACTIC $348.66 06-07-2022 05-16-2022 05-31-2022 Personal Injury Protection - Medical $343.77
05-20-2022 121103501J ISLAND PT & CHIROPRACTIC $154.42 05-16-2022 05-09-2022 05-09-2022 Personal Injury Protection - Medical $143.24
3
05-10-2022 121089527J ISLAND PT & CHIROPRACTIC $106.47 05-04-2022 05-02-2022 05-02-2022 Personal Injury Protection - Medical $106.47
of
05-03-2022 121080678J ISLAND PT & CHIROPRACTIC $222.69 04-29-2022 04-19-2022 04-25-2022 Personal Injury Protection - Medical $221.06
10
11/14/2022
04-28-2022 121074514J RCK MEDICAL SERVICES $585.00 04-12-2022 03-21-2022 03-21-2022 Personal Injury Protection - Medical $127.41
04-27-2022 121073243K INDEPENDENT PHYSICAL EXAM $1,225.00 04-27-2022 04-14-2022 04-14-2022 Personal Injury Protection - Medical $1,225.00
REFERRALS
04-18-2022 121059918J ISLAND PT & CHIROPRACTIC $106.47 04-14-2022 04-11-2022 04-11-2022 Personal Injury Protection - Medical $106.47
11:02
04-12-2022 121052758J ISLAND PT & CHIROPRACTIC $154.42 04-07-2022 04-04-2022 04-04-2022 Personal Injury Protection - Medical $143.24
04-01-2022 121040112J ISLAND PT & CHIROPRACTIC $106.47 03-28-2022 03-21-2022 03-21-2022 Personal Injury Protection - Medical $57.30
AM
04-01-2022 121040115J ISLAND PT & CHIROPRACTIC $112.97 03-31-2022 03-28-2022 03-28-2022 Personal Injury Protection - Medical $112.97
03-22-2022 121025541J ISLAND PT & CHIROPRACTIC $106.47 03-20-2022 03-14-2022 03-14-2022 Personal Injury Protection - Medical $106.47
03-09-2022 121009230J ISLAND PT & CHIROPRACTIC $43.64 03-04-2022 02-14-2022 02-14-2022 Personal Injury Protection - Medical $8.12
03-09-2022 121009233J ISLAND PT & CHIROPRACTIC $154.42 03-05-2022 02-28-2022 02-28-2022 Personal Injury Protection - Medical $99.60
RECEIVED
02-28-2022 121995874J ISLAND PT & CHIROPRACTIC $106.47 02-24-2022 02-21-2022 02-21-2022 Personal Injury Protection - Medical $106.47
INDEX
02-24-2022 121992203J ISLAND PT & CHIROPRACTIC $106.47 02-21-2022 02-14-2022 02-14-2022 Personal Injury Protection - Medical $106.47
02-11-2022 121975162J ISLAND PT & CHIROPRACTIC $106.47 02-10-2022 02-07-2022 02-07-2022 Personal Injury Protection - Medical $106.47
NO.
NYSCEF:
RBZ000FJ State Farm®
1007048 Page 2 of 9 2005 148026 205 08-10-2022
11/14/2022
606262/2021
NYSCEF
FILED:
Payment Log
11-10-2022
DOC.
Claim No: 20-06R2-66B
NO.
Injured Party: JOSE DELCID RAMOS
14
SUFFOLK
Payment/ Payment/
Recovery Recovery Date Bill Deductible Co-Pay
Date Number Payee Billed Amount Received Date From Date To Coverage Description Amount Amount Paid Amount
02-07-2022 121968232J ISLAND PT & CHIROPRACTIC $263.38 02-02-2022 01-24-2022 01-31-2022 Personal Injury Protection - Medical $252.21
COUNTY
01-20-2022 121947213J ISLAND PT & CHIROPRACTIC $108.96 01-19-2022 01-17-2022 01-17-2022 Personal Injury Protection - Medical $108.96
01-20-2022 121947214J ISLAND PT & CHIROPRACTIC $116.22 01-11-2022 01-10-2022 01-10-2022 Personal Injury Protection - Medical $114.60
01-12-2022 121937317J ISLAND PT & CHIROPRACTIC $116.22 01-03-2022 12-27-2021 12-27-2021 Personal Injury Protection - Medical $114.60
CLERK
01-12-2022 121937318J ISLAND PT & CHIROPRACTIC $116.22 01-05-2022 01-03-2022 01-03-2022 Personal Injury Protection - Medical $114.60
12-30-2021 121924621J ISLAND PT & CHIROPRACTIC $116.22 12-20-2021 12-13-2021 12-13-2021 Personal Injury Protection - Medical $114.60
12-30-2021 121924623J ISLAND PT & CHIROPRACTIC $147.16 12-28-2021 12-20-2021 12-20-2021 Personal Injury Protection - Medical $99.60
4
12-14-2021 121905907J ISLAND PT & CHIROPRACTIC $108.96 12-12-2021 12-06-2021 12-06-2021 Personal Injury Protection - Medical $108.96
of
12-08-2021 121897627J ISLAND PT & CHIROPRACTIC 12-08-2021 12-08-2021 Personal Injury Protection - Medical $222.56
10
11/14/2022
12-08-2021 121897627J ISLAND PT & CHIROPRACTIC 12-08-2021 12-08-2021 Interest $6.98
12-07-2021 121895908J ISLAND PT & CHIROPRACTIC $43.64 07-24-2021 07-19-2021 07-19-2021 Personal Injury Protection - Medical $8.12
12-07-2021 121895909J ISLAND PT & CHIROPRACTIC $43.64 08-23-2021 08-17-2021 08-17-2021 Personal Injury Protection - Medical $29.22
11:02
12-07-2021 121895910J ISLAND PT & CHIROPRACTIC $43.64 05-05-2021 04-26-2021 04-26-2021 Personal Injury Protection - Medical $8.12
12-07-2021 121895911J ISLAND PT & CHIROPRACTIC $43.64 07-16-2021 07-12-2021 07-12-2021 Personal Injury Protection - Medical $43.64
AM
12-07-2021 121895915J ISLAND PT & CHIROPRACTIC $130.92 10-29-2021 10-19-2021 10-28-2021 Personal Injury Protection - Medical $78.21
12-06-2021 121894410J MOTION MEDICAL DIAGNOSTICS PC $585.00 11-15-2021 10-13-2021 10-13-2021 Personal Injury Protection - Medical $585.00
12-02-2021 121889944J ISLAND PT & CHIROPRACTIC $43.64 04-03-2021 03-29-2021 03-29-2021 Personal Injury Protection - Medical $5.63
11-22-2021 121879018J DURAMED LLC $1,230.00 10-29-2021 09-27-2021 09-27-2021 Personal Injury Protection - Medical $1,230.00
RECEIVED
11-22-2021 121879022J DAVID WEISSBERG $10,383.91 10-11-2021 09-27-2021 09-27-2021 Personal Injury Protection - Medical $4,571.46
INDEX
11-22-2021 121879022J DAVID WEISSBERG $10,383.91 10-11-2021 09-27-2021 09-27-2021 Interest $45.72
11-22-2021 121879024J CENTER FOR ADVANCED SPINE & $29,553.52 10-25-2021 09-27-2021 09-27-2021 Personal Injury Protection - Medical $3,368.20
NO.
JOINT SURGERY LB
NYSCEF:
RBZ000FJ State Farm®
1007048 Page 3 of 9 2005 148026 205 08-10-2022
11/14/2022
606262/2021
NYSCEF
FILED:
Payment Log
11-10-2022
DOC.
Claim No: 20-06R2-66B
NO.
Injured Party: JOSE DELCID RAMOS
14
SUFFOLK
Payment/ Payment/
Recovery Recovery Date Bill Deductible Co-Pay
Date Number Payee Billed Amount Received Date From Date To Coverage Description Amount Amount Paid Amount
11-22-2021 121879025J LONG ISLAND ANESTHESIA $415.94 11-10-2021 09-27-2021 09-27-2021 Personal Injury Protection - Medical $415.94
PHYSICIANS L
COUNTY
11-22-2021 121879025J LONG ISLAND ANESTHESIA $301.46 11-10-2021 09-27-2021 09-27-2021 Personal Injury Protection - Medical $301.46
PHYSICIANS L
11-22-2021 121879026J HEIDI FRYBERG $704.13 10-11-2021 09-27-2021 09-27-2021 Interest $3.85
11-22-2021 121879026J HEIDI FRYBERG $704.13 10-11-2021 09-27-2021 09-27-2021 Personal Injury Protection - Medical $384.42
CLERK
11-22-2021 121879027J S & M PHARMACY $1,454.36 11-02-2021 09-27-2021 09-27-2021 Personal Injury Protection - Medical $809.76
11-21-2021 121878107J ISLAND PT & CHIROPRACTIC $174.56 11-20-2021 11-01-2021 11-15-2021 Personal Injury Protection - Medical $44.40
11-21-2021 121878108J ISLAND PT & CHIROPRACTIC $179.82 11-20-2021 11-15-2021 11-15-2021 Personal Injury Protection - Medical $143.25
5
11-18-2021 121874277J ISLAND PT & CHIROPRACTIC $184.78 11-06-2021 11-01-2021 11-04-2021 Personal Injury Protection - Medical $184.78
of
11-18-2021 121874278J ISLAND PT & CHIROPRACTIC $179.82 10-15-2021 10-11-2021 10-11-2021 Personal Injury Protection - Medical $143.24
10
11/14/2022
11-18-2021 121874278J ISLAND PT & CHIROPRACTIC $179.82 10-15-2021 10-11-2021 10-11-2021 Interest $0.67
11-18-2021 121874280J ISLAND PT & CHIROPRACTIC $108.96 10-29-2021 10-25-2021 10-25-2021 Personal Injury Protection - Medical $70.95
11-18-2021 121874281J ISLAND PT & CHIROPRACTIC $250.58 10-25-2021 10-18-2021 10-19-2021 Personal Injury Protection - Medical $223.55
11:02
11-18-2021 121874283J ISLAND PT & CHIROPRACTIC $116.22 11-10-2021 11-08-2021 11-08-2021 Personal Injury Protection - Medical $114.60
11-18-2021 121874285J ISLAND PT & CHIROPRACTIC $141.62 10-19-2021 10-13-2021 10-13-2021 Personal Injury Protection - Medical $114.59
AM
11-18-2021 121874287J ISLAND PT & CHIROPRACTIC $108.96 11-02-2021 10-28-2021 10-28-2021 Personal Injury Protection - Medical $70.95
11-18-2021 121874914J DAVID WEISSBERG $60.00 10-11-2021 09-23-2021 09-23-2021 Interest $0.38
11-18-2021 121874914J DAVID WEISSBERG $60.00 10-11-2021 09-23-2021 09-23-2021 Personal Injury Protection - Medical $51.33
10-19-2021 121837002J DAVID WEISSBERG $87.80 10-08-2021 09-20-2021 09-20-2021 Personal Injury Protection - Medical $70.24
RECEIVED
10-12-2021 121828296J ISLAND PT & CHIROPRACTIC $141.62 10-09-2021 10-04-2021 10-04-2021 Personal Injury Protection - Medical $114.59
INDEX
09-27-2021 121809187J ISLAND PT & CHIROPRACTIC $141.62 09-19-2021 09-13-2021 09-13-2021 Personal Injury Protection - Medical $114.59
09-27-2021 121809187J ISLAND PT & CHIROPRACTIC $179.82 09-24-2021 09-20-2021 09-20-2021 Personal Injury Protection - Medical $143.24
NO.
NYSCEF:
RBZ000FJ State Farm®
1007048 Page 4 of 9 2005 148026 205 08-10-2022
11/14/2022
606262/2021
NYSCEF
FILED:
Payment Log
11-10-2022
DOC.
Claim No: 20-06R2-66B
NO.
Injured Party: JOSE DELCID RAMOS
14
SUFFOLK
Payment/ Payment/
Recovery Recovery Date Bill Deductible Co-Pay
Date Number Payee Billed Amount Received Date From Date To Coverage Description Amount Amount Paid Amount
09-23-2021 121805606J DAVID WEISSBERG $87.80 09-15-2021 08-31-2021 08-31-2021 Personal Injury Protection - Medical $87.80
COUNTY
09-17-2021 121798674J DAVID WEISSBERG $87.80 09-10-2021 08-23-2021 08-23-2021 Personal Injury Protection - Medical $70.24
09-13-2021 121792447J ISLAND PT & CHIROPRACTIC $141.62 09-04-2021 08-30-2021 08-30-2021 Personal Injury Protection - Medical $70.95
09-01-2021 121779889J DAVID WEISSBERG $102.99 08-04-2021 07-19-2021 07-19-2021 Personal Injury Protection - Medical $55.79
CLERK
09-01-2021 121779893J MULTI-SPECIALTY PAIN MANAGEMENT $867.40 08-09-2021 06-28-2021 06-28-2021 Personal Injury Protection - Medical $867.40
PC
09-01-2021 121779907J ISLAND PT & CHIROPRACTIC $154.42 08-23-2021 08-17-2021 08-17-2021 Personal Injury Protection - Medical $99.60
09-01-2021 121779915J ISLAND PT & CHIROPRACTIC $141.62 08-31-2021 08-23-2021 08-23-2021 Personal Injury Protection - Medical $114.59
6
08-13-2021 121758460J MULTI-SPECIALTY PAIN MANAGEMENT $87.80 08-09-2021 06-28-2021 06-28-2021 Personal Injury Protection - Medical $87.80
PC
of
08-12-2021 121756875J MOTION MEDICAL DIAGNOSTICS PC $585.00 07-06-2021 06-24-2021 06-24-2021 Personal Injury Protection - Medical $23.76
10
11/14/2022
08-12-2021 121756875J MOTION MEDICAL DIAGNOSTICS PC $585.00 07-06-2021 06-24-2021 06-24-2021 Interest $0.16
08-04-2021 121746216J ISLAND PT & CHIROPRACTIC 06-01-2020 07-06-2020 Personal Injury Protection - Medical $537.43
08-04-2021 121746216J ISLAND PT & CHIROPRACTIC 06-01-2020 07-06-2020 Interest $12.90
11:02
08-04-2021 121746928J MOTION MEDICAL DIAGNOSTICS PC $685.00 01-22-2021 01-04-2021 01-04-2021 Interest $27.65
08-04-2021 121746928J MOTION MEDICAL DIAGNOSTICS PC $685.00 01-22-2021 01-04-2021 01-04-2021 Personal Injury Protection - Medical $248.34
AM
07-29-2021 121739865J MULTI-SPECIALTY PAIN MANAGEMENT $867.40 07-06-2021 05-17-2021 05-17-2021 Personal Injury Protection - Medical $867.40
PC
07-29-2021 121739868J ISLAND PT & CHIROPRACTIC $212.94 07-24-2021 07-19-2021 07-21-2021 Personal Injury Protection - Medical $177.42
07-27-2021 121736466J ISLAND PT & CHIROPRACTIC $116.22 07-16-2021 07-14-2021 07-14-2021 Personal Injury Protection - Medical $114.59
07-26-2021 121734514J MOTION MEDICAL DIAGNOSTICS $985.00 06-11-2020 06-01-2020 06-01-2020 Personal Injury Protection - Medical $230.00
RECEIVED
07-09-2021 121716597J ISLAND PT & CHIROPRACTIC $260.89 07-01-2021 06-24-2021 06-28-2021 Personal Injury Protection - Medical $249.71
INDEX
06-23-2021 121697379J MOTION MEDICAL DIAGNOSTICS PC $585.00 02-22-2021 02-03-2021 02-03-2021 Personal Injury Protection - Medical $23.76
06-22-2021 121695969J ISLAND PT & CHIROPRACTIC $43.64 06-16-2021 06-14-2021 06-14-2021 Personal Injury Protection - Medical $43.64
NO.
NYSCEF:
RBZ000FJ State Farm®
1007048 Page 5 of 9 2005 148026 205 08-10-2022
11/14/2022
606262/2021
NYSCEF
FILED:
Payment Log
11-10-2022
DOC.
Claim No: 20-06R2-66B
NO.
Injured Party: JOSE DELCID RAMOS
14
SUFFOLK
Payment/ Payment/
Recovery Recovery Date Bill Deductible Co-Pay
Date Number Payee Billed Amount Received Date From Date To Coverage Description Amount Amount Paid Amount
06-22-2021 121695972J ISLAND PT & CHIROPRACTIC $106.47 06-16-2021 06-14-2021 06-14-2021 Personal Injury Protection - Medical $70.95
COUNTY
06-18-2021 121692376J MULTI-SPECIALTY PAIN MANAGEMENT $727.32 06-07-2021 04-19-2021 04-19-2021 Personal Injury Protection - Medical $687.40
PC
06-10-2021 121683557J ISLAND PT & CHIROPRACTIC $108.96 06-09-2021 06-07-2021 06-07-2021 Personal Injury Protection - Medical $108.96
05-30-2021 121672040J ISLAND PT & CHIROPRACTIC $121.47 05-21-2021 05-17-2021 05-17-2021 Personal Injury Protection - Medical $70.95
CLERK
05-30-2021 121672041J ISLAND PT & CHIROPRACTIC $43.64 05-21-2021 05-17-2021 05-17-2021 Personal Injury Protection - Medical $43.64
05-30-2021 121672042J ISLAND PT & CHIROPRACTIC $154.42 05-27-2021 05-24-2021 05-24-2021 Personal Injury Protection - Medical $143.24
05-21-2021 121662000J ISLAND PT & CHIROPRACTIC $227.94 05-14-2021 05-03-2021 05-10-2021 Personal Injury Protection - Medical $221.06
7
05-20-2021 121660958J DAVID WEISSBERG $102.99 03-29-2021 03-10-2021 03-10-2021 Personal Injury Protection - Medical $69.20
of
05-07-2021 121646332J ISLAND PT & CHIROPRACTIC $106.47 04-30-2021 04-26-2021 04-26-2021 Personal Injury Protection - Medical $106.47
10
11/14/2022
04-28-2021 121634967J ISLAND PT & CHIROPRACTIC $106.47 04-19-2021 04-12-2021 04-12-2021 Personal Injury Protection - Medical $70.95
04-28-2021 121634968J ISLAND PT & CHIROPRACTIC $106.47 04-24-2021 04-19-2021 04-19-2021 Personal Injury Protection - Medical $70.95
04-28-2021 121635455J MULTI-SPECIALTY PAIN MANAGEMENT $527.17 04-13-2021 03-09-2021 03-09-2021 Personal Injury Protection - Medical $469.33
PC
11:02
04-19-2021 121624331J MULTI-SPECIALTY PAIN MANAGEMENT $727.32 03-31-2021 02-22-2021 02-22-2021 Personal Injury Protection - Medical $560.31
PC
04-16-2021 121622487J ISLAND PT & CHIROPRACTIC $141.91 04-10-2021 04-05-2021 04-05-2021 Personal Injury Protection - Medical $99.60
AM
04-05-2021 121608417J ISLAND PT & CHIROPRACTIC $215.43 04-03-2021 03-24-2021 03-29-2021 Personal Injury Protection - Medical $177.43
03-24-2021 121595782J ISLAND PT & CHIROPRACTIC $106.47 03-24-2021 03-22-2021 03-22-2021 Personal Injury Protection - Medical $106.47
03-24-2021 121595785J ISLAND PT & CHIROPRACTIC $43.64 03-24-2021 03-22-2021 03-22-2021 Personal Injury Protection - Medical $8.13
03-21-2021 121592765J ISLAND PT & CHIROPRACTIC $43.64 03-21-2021 03-15-2021 03-15-2021 Personal Injury Protection - Medical $43.64
RECEIVED
03-21-2021 121592767J ISLAND PT & CHIROPRACTIC $321.90 03-21-2021 03-15-2021 03-17-2021 Personal Injury Protection - Medical $286.39
INDEX
03-13-2021 121584789J ISLAND PT & CHIROPRACTIC $319.41 03-12-2021 03-04-2021 03-09-2021 Personal Injury Protection - Medical $197.89
03-13-2021 121584790J ISLAND PT & CHIROPRACTIC $87.28 03-12-2021 03-08-2021 03-09-2021 Personal Injury Protection - Medical $87.28
NO.
NYSCEF:
RBZ000FJ State Farm®
1007048 Page 6 of 9 2005 148026 205 08-10-2022
11/14/2022
606262/2021
NYSCEF
FILED:
Payment Log
11-10-2022
DOC.
Claim No: 20-06R2-66B
Document Filed Date
November 14, 2022
Case Filing Date
April 08, 2021
Category
Torts - Motor Vehicle
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Preview
FILED: SUFFOLK COUNTY CLERK 11/14/2022 11:02 AM INDEX NO. 606262/2021 NYSCEF DOC. NO. 14 RECEIVED NYSCEF: 11/14/2022 606262/2021 SUFFOLK JOSE N. DELCID RAMOS, State Farm PO Box 8000 JOSE D. CHICAS, Ballston Spa, NY 12020 (9 Pages) State Farm PO Box 8000 Ballston Spa, NY 12020 (9 pages) 11/14/2022 Law Offices of Karen L. Lawrence 878 Veterans Memorial Highway Suite 100 Hauppauge, NY 11788-3089 1 of 10 FILED: SUFFOLK COUNTY CLERK 11/14/2022 11:02 AM INDEX NO. 606262/2021 NYSCEF DOC. NO. 14 RECEIVED NYSCEF: 11/14/2022 Payment Log 11-10-2022 Mail to: JOSEPH C ANDRUZZI 326 BROADWAY STE 200 BETHPAGE, NY 11714-3021 Claim No: 20-06R2-66B Injured Party: JOSE DELCID RAMOS Named Insured: FREDDY A ROJAS DUBON Address: 28 JOHNSON ST Date of Accident: 05-07-2020 AMITYVILLE, NY 11701-1515 Claim Handler: Tara Barnette Phone: 844-292-8615 Payment Summary - New York Coverage - Personal Injury Protection Amount Personal Injury Protection Applied to Limit $42,877.04 Personal Injury Protection - Medical $42,877.04 Deductible $0.00 Offset to Date $0.00 Personal Injury Protection Not Applied to Limit $0.00 Co-Pay $0.00 Interest Paid to Date - Not Applied to Limit(s) Amount Interest $104.43 RBZ000FJ State Farm® 1007048 Page 1 of 9 2005 148026 205 08-10-2022 2 of 10 NYSCEF FILED: Payment Log 11-10-2022 DOC. Claim No: 20-06R2-66B NO. Injured Party: JOSE DELCID RAMOS 14 SUFFOLK Payment/ Payment/ Recovery Recovery Date Bill Deductible Co-Pay Date Number Payee Billed Amount Received Date From Date To Coverage Description Amount Amount Paid Amount 10-09-2022 121292495J ISLAND PT & CHIROPRACTIC $369.85 09-16-2022 08-15-2022 08-30-2022 Personal Injury Protection - Medical $364.31 COUNTY 10-06-2022 121288671J MOTION MEDICAL DIAGNOSTICS Personal Injury Protection - Medical $12.43 10-06-2022 121288671J MOTION MEDICAL DIAGNOSTICS Interest $3.29 08-23-2022 121229367J ISLAND PT & CHIROPRACTIC $263.38 07-28-2022 06-23-2022 07-07-2022 Personal Injury Protection - Medical $252.20 CLERK 06-19-2022 121139360J ISLAND PT & CHIROPRACTIC $116.22 06-13-2022 06-07-2022 06-07-2022 Personal Injury Protection - Medical $114.59 06-12-2022 121130396J ISLAND PT & CHIROPRACTIC $348.66 06-07-2022 05-16-2022 05-31-2022 Personal Injury Protection - Medical $343.77 05-20-2022 121103501J ISLAND PT & CHIROPRACTIC $154.42 05-16-2022 05-09-2022 05-09-2022 Personal Injury Protection - Medical $143.24 3 05-10-2022 121089527J ISLAND PT & CHIROPRACTIC $106.47 05-04-2022 05-02-2022 05-02-2022 Personal Injury Protection - Medical $106.47 of 05-03-2022 121080678J ISLAND PT & CHIROPRACTIC $222.69 04-29-2022 04-19-2022 04-25-2022 Personal Injury Protection - Medical $221.06 10 11/14/2022 04-28-2022 121074514J RCK MEDICAL SERVICES $585.00 04-12-2022 03-21-2022 03-21-2022 Personal Injury Protection - Medical $127.41 04-27-2022 121073243K INDEPENDENT PHYSICAL EXAM $1,225.00 04-27-2022 04-14-2022 04-14-2022 Personal Injury Protection - Medical $1,225.00 REFERRALS 04-18-2022 121059918J ISLAND PT & CHIROPRACTIC $106.47 04-14-2022 04-11-2022 04-11-2022 Personal Injury Protection - Medical $106.47 11:02 04-12-2022 121052758J ISLAND PT & CHIROPRACTIC $154.42 04-07-2022 04-04-2022 04-04-2022 Personal Injury Protection - Medical $143.24 04-01-2022 121040112J ISLAND PT & CHIROPRACTIC $106.47 03-28-2022 03-21-2022 03-21-2022 Personal Injury Protection - Medical $57.30 AM 04-01-2022 121040115J ISLAND PT & CHIROPRACTIC $112.97 03-31-2022 03-28-2022 03-28-2022 Personal Injury Protection - Medical $112.97 03-22-2022 121025541J ISLAND PT & CHIROPRACTIC $106.47 03-20-2022 03-14-2022 03-14-2022 Personal Injury Protection - Medical $106.47 03-09-2022 121009230J ISLAND PT & CHIROPRACTIC $43.64 03-04-2022 02-14-2022 02-14-2022 Personal Injury Protection - Medical $8.12 03-09-2022 121009233J ISLAND PT & CHIROPRACTIC $154.42 03-05-2022 02-28-2022 02-28-2022 Personal Injury Protection - Medical $99.60 RECEIVED 02-28-2022 121995874J ISLAND PT & CHIROPRACTIC $106.47 02-24-2022 02-21-2022 02-21-2022 Personal Injury Protection - Medical $106.47 INDEX 02-24-2022 121992203J ISLAND PT & CHIROPRACTIC $106.47 02-21-2022 02-14-2022 02-14-2022 Personal Injury Protection - Medical $106.47 02-11-2022 121975162J ISLAND PT & CHIROPRACTIC $106.47 02-10-2022 02-07-2022 02-07-2022 Personal Injury Protection - Medical $106.47 NO. NYSCEF: RBZ000FJ State Farm® 1007048 Page 2 of 9 2005 148026 205 08-10-2022 11/14/2022 606262/2021 NYSCEF FILED: Payment Log 11-10-2022 DOC. Claim No: 20-06R2-66B NO. Injured Party: JOSE DELCID RAMOS 14 SUFFOLK Payment/ Payment/ Recovery Recovery Date Bill Deductible Co-Pay Date Number Payee Billed Amount Received Date From Date To Coverage Description Amount Amount Paid Amount 02-07-2022 121968232J ISLAND PT & CHIROPRACTIC $263.38 02-02-2022 01-24-2022 01-31-2022 Personal Injury Protection - Medical $252.21 COUNTY 01-20-2022 121947213J ISLAND PT & CHIROPRACTIC $108.96 01-19-2022 01-17-2022 01-17-2022 Personal Injury Protection - Medical $108.96 01-20-2022 121947214J ISLAND PT & CHIROPRACTIC $116.22 01-11-2022 01-10-2022 01-10-2022 Personal Injury Protection - Medical $114.60 01-12-2022 121937317J ISLAND PT & CHIROPRACTIC $116.22 01-03-2022 12-27-2021 12-27-2021 Personal Injury Protection - Medical $114.60 CLERK 01-12-2022 121937318J ISLAND PT & CHIROPRACTIC $116.22 01-05-2022 01-03-2022 01-03-2022 Personal Injury Protection - Medical $114.60 12-30-2021 121924621J ISLAND PT & CHIROPRACTIC $116.22 12-20-2021 12-13-2021 12-13-2021 Personal Injury Protection - Medical $114.60 12-30-2021 121924623J ISLAND PT & CHIROPRACTIC $147.16 12-28-2021 12-20-2021 12-20-2021 Personal Injury Protection - Medical $99.60 4 12-14-2021 121905907J ISLAND PT & CHIROPRACTIC $108.96 12-12-2021 12-06-2021 12-06-2021 Personal Injury Protection - Medical $108.96 of 12-08-2021 121897627J ISLAND PT & CHIROPRACTIC 12-08-2021 12-08-2021 Personal Injury Protection - Medical $222.56 10 11/14/2022 12-08-2021 121897627J ISLAND PT & CHIROPRACTIC 12-08-2021 12-08-2021 Interest $6.98 12-07-2021 121895908J ISLAND PT & CHIROPRACTIC $43.64 07-24-2021 07-19-2021 07-19-2021 Personal Injury Protection - Medical $8.12 12-07-2021 121895909J ISLAND PT & CHIROPRACTIC $43.64 08-23-2021 08-17-2021 08-17-2021 Personal Injury Protection - Medical $29.22 11:02 12-07-2021 121895910J ISLAND PT & CHIROPRACTIC $43.64 05-05-2021 04-26-2021 04-26-2021 Personal Injury Protection - Medical $8.12 12-07-2021 121895911J ISLAND PT & CHIROPRACTIC $43.64 07-16-2021 07-12-2021 07-12-2021 Personal Injury Protection - Medical $43.64 AM 12-07-2021 121895915J ISLAND PT & CHIROPRACTIC $130.92 10-29-2021 10-19-2021 10-28-2021 Personal Injury Protection - Medical $78.21 12-06-2021 121894410J MOTION MEDICAL DIAGNOSTICS PC $585.00 11-15-2021 10-13-2021 10-13-2021 Personal Injury Protection - Medical $585.00 12-02-2021 121889944J ISLAND PT & CHIROPRACTIC $43.64 04-03-2021 03-29-2021 03-29-2021 Personal Injury Protection - Medical $5.63 11-22-2021 121879018J DURAMED LLC $1,230.00 10-29-2021 09-27-2021 09-27-2021 Personal Injury Protection - Medical $1,230.00 RECEIVED 11-22-2021 121879022J DAVID WEISSBERG $10,383.91 10-11-2021 09-27-2021 09-27-2021 Personal Injury Protection - Medical $4,571.46 INDEX 11-22-2021 121879022J DAVID WEISSBERG $10,383.91 10-11-2021 09-27-2021 09-27-2021 Interest $45.72 11-22-2021 121879024J CENTER FOR ADVANCED SPINE & $29,553.52 10-25-2021 09-27-2021 09-27-2021 Personal Injury Protection - Medical $3,368.20 NO. JOINT SURGERY LB NYSCEF: RBZ000FJ State Farm® 1007048 Page 3 of 9 2005 148026 205 08-10-2022 11/14/2022 606262/2021 NYSCEF FILED: Payment Log 11-10-2022 DOC. Claim No: 20-06R2-66B NO. Injured Party: JOSE DELCID RAMOS 14 SUFFOLK Payment/ Payment/ Recovery Recovery Date Bill Deductible Co-Pay Date Number Payee Billed Amount Received Date From Date To Coverage Description Amount Amount Paid Amount 11-22-2021 121879025J LONG ISLAND ANESTHESIA $415.94 11-10-2021 09-27-2021 09-27-2021 Personal Injury Protection - Medical $415.94 PHYSICIANS L COUNTY 11-22-2021 121879025J LONG ISLAND ANESTHESIA $301.46 11-10-2021 09-27-2021 09-27-2021 Personal Injury Protection - Medical $301.46 PHYSICIANS L 11-22-2021 121879026J HEIDI FRYBERG $704.13 10-11-2021 09-27-2021 09-27-2021 Interest $3.85 11-22-2021 121879026J HEIDI FRYBERG $704.13 10-11-2021 09-27-2021 09-27-2021 Personal Injury Protection - Medical $384.42 CLERK 11-22-2021 121879027J S & M PHARMACY $1,454.36 11-02-2021 09-27-2021 09-27-2021 Personal Injury Protection - Medical $809.76 11-21-2021 121878107J ISLAND PT & CHIROPRACTIC $174.56 11-20-2021 11-01-2021 11-15-2021 Personal Injury Protection - Medical $44.40 11-21-2021 121878108J ISLAND PT & CHIROPRACTIC $179.82 11-20-2021 11-15-2021 11-15-2021 Personal Injury Protection - Medical $143.25 5 11-18-2021 121874277J ISLAND PT & CHIROPRACTIC $184.78 11-06-2021 11-01-2021 11-04-2021 Personal Injury Protection - Medical $184.78 of 11-18-2021 121874278J ISLAND PT & CHIROPRACTIC $179.82 10-15-2021 10-11-2021 10-11-2021 Personal Injury Protection - Medical $143.24 10 11/14/2022 11-18-2021 121874278J ISLAND PT & CHIROPRACTIC $179.82 10-15-2021 10-11-2021 10-11-2021 Interest $0.67 11-18-2021 121874280J ISLAND PT & CHIROPRACTIC $108.96 10-29-2021 10-25-2021 10-25-2021 Personal Injury Protection - Medical $70.95 11-18-2021 121874281J ISLAND PT & CHIROPRACTIC $250.58 10-25-2021 10-18-2021 10-19-2021 Personal Injury Protection - Medical $223.55 11:02 11-18-2021 121874283J ISLAND PT & CHIROPRACTIC $116.22 11-10-2021 11-08-2021 11-08-2021 Personal Injury Protection - Medical $114.60 11-18-2021 121874285J ISLAND PT & CHIROPRACTIC $141.62 10-19-2021 10-13-2021 10-13-2021 Personal Injury Protection - Medical $114.59 AM 11-18-2021 121874287J ISLAND PT & CHIROPRACTIC $108.96 11-02-2021 10-28-2021 10-28-2021 Personal Injury Protection - Medical $70.95 11-18-2021 121874914J DAVID WEISSBERG $60.00 10-11-2021 09-23-2021 09-23-2021 Interest $0.38 11-18-2021 121874914J DAVID WEISSBERG $60.00 10-11-2021 09-23-2021 09-23-2021 Personal Injury Protection - Medical $51.33 10-19-2021 121837002J DAVID WEISSBERG $87.80 10-08-2021 09-20-2021 09-20-2021 Personal Injury Protection - Medical $70.24 RECEIVED 10-12-2021 121828296J ISLAND PT & CHIROPRACTIC $141.62 10-09-2021 10-04-2021 10-04-2021 Personal Injury Protection - Medical $114.59 INDEX 09-27-2021 121809187J ISLAND PT & CHIROPRACTIC $141.62 09-19-2021 09-13-2021 09-13-2021 Personal Injury Protection - Medical $114.59 09-27-2021 121809187J ISLAND PT & CHIROPRACTIC $179.82 09-24-2021 09-20-2021 09-20-2021 Personal Injury Protection - Medical $143.24 NO. NYSCEF: RBZ000FJ State Farm® 1007048 Page 4 of 9 2005 148026 205 08-10-2022 11/14/2022 606262/2021 NYSCEF FILED: Payment Log 11-10-2022 DOC. Claim No: 20-06R2-66B NO. Injured Party: JOSE DELCID RAMOS 14 SUFFOLK Payment/ Payment/ Recovery Recovery Date Bill Deductible Co-Pay Date Number Payee Billed Amount Received Date From Date To Coverage Description Amount Amount Paid Amount 09-23-2021 121805606J DAVID WEISSBERG $87.80 09-15-2021 08-31-2021 08-31-2021 Personal Injury Protection - Medical $87.80 COUNTY 09-17-2021 121798674J DAVID WEISSBERG $87.80 09-10-2021 08-23-2021 08-23-2021 Personal Injury Protection - Medical $70.24 09-13-2021 121792447J ISLAND PT & CHIROPRACTIC $141.62 09-04-2021 08-30-2021 08-30-2021 Personal Injury Protection - Medical $70.95 09-01-2021 121779889J DAVID WEISSBERG $102.99 08-04-2021 07-19-2021 07-19-2021 Personal Injury Protection - Medical $55.79 CLERK 09-01-2021 121779893J MULTI-SPECIALTY PAIN MANAGEMENT $867.40 08-09-2021 06-28-2021 06-28-2021 Personal Injury Protection - Medical $867.40 PC 09-01-2021 121779907J ISLAND PT & CHIROPRACTIC $154.42 08-23-2021 08-17-2021 08-17-2021 Personal Injury Protection - Medical $99.60 09-01-2021 121779915J ISLAND PT & CHIROPRACTIC $141.62 08-31-2021 08-23-2021 08-23-2021 Personal Injury Protection - Medical $114.59 6 08-13-2021 121758460J MULTI-SPECIALTY PAIN MANAGEMENT $87.80 08-09-2021 06-28-2021 06-28-2021 Personal Injury Protection - Medical $87.80 PC of 08-12-2021 121756875J MOTION MEDICAL DIAGNOSTICS PC $585.00 07-06-2021 06-24-2021 06-24-2021 Personal Injury Protection - Medical $23.76 10 11/14/2022 08-12-2021 121756875J MOTION MEDICAL DIAGNOSTICS PC $585.00 07-06-2021 06-24-2021 06-24-2021 Interest $0.16 08-04-2021 121746216J ISLAND PT & CHIROPRACTIC 06-01-2020 07-06-2020 Personal Injury Protection - Medical $537.43 08-04-2021 121746216J ISLAND PT & CHIROPRACTIC 06-01-2020 07-06-2020 Interest $12.90 11:02 08-04-2021 121746928J MOTION MEDICAL DIAGNOSTICS PC $685.00 01-22-2021 01-04-2021 01-04-2021 Interest $27.65 08-04-2021 121746928J MOTION MEDICAL DIAGNOSTICS PC $685.00 01-22-2021 01-04-2021 01-04-2021 Personal Injury Protection - Medical $248.34 AM 07-29-2021 121739865J MULTI-SPECIALTY PAIN MANAGEMENT $867.40 07-06-2021 05-17-2021 05-17-2021 Personal Injury Protection - Medical $867.40 PC 07-29-2021 121739868J ISLAND PT & CHIROPRACTIC $212.94 07-24-2021 07-19-2021 07-21-2021 Personal Injury Protection - Medical $177.42 07-27-2021 121736466J ISLAND PT & CHIROPRACTIC $116.22 07-16-2021 07-14-2021 07-14-2021 Personal Injury Protection - Medical $114.59 07-26-2021 121734514J MOTION MEDICAL DIAGNOSTICS $985.00 06-11-2020 06-01-2020 06-01-2020 Personal Injury Protection - Medical $230.00 RECEIVED 07-09-2021 121716597J ISLAND PT & CHIROPRACTIC $260.89 07-01-2021 06-24-2021 06-28-2021 Personal Injury Protection - Medical $249.71 INDEX 06-23-2021 121697379J MOTION MEDICAL DIAGNOSTICS PC $585.00 02-22-2021 02-03-2021 02-03-2021 Personal Injury Protection - Medical $23.76 06-22-2021 121695969J ISLAND PT & CHIROPRACTIC $43.64 06-16-2021 06-14-2021 06-14-2021 Personal Injury Protection - Medical $43.64 NO. NYSCEF: RBZ000FJ State Farm® 1007048 Page 5 of 9 2005 148026 205 08-10-2022 11/14/2022 606262/2021 NYSCEF FILED: Payment Log 11-10-2022 DOC. Claim No: 20-06R2-66B NO. Injured Party: JOSE DELCID RAMOS 14 SUFFOLK Payment/ Payment/ Recovery Recovery Date Bill Deductible Co-Pay Date Number Payee Billed Amount Received Date From Date To Coverage Description Amount Amount Paid Amount 06-22-2021 121695972J ISLAND PT & CHIROPRACTIC $106.47 06-16-2021 06-14-2021 06-14-2021 Personal Injury Protection - Medical $70.95 COUNTY 06-18-2021 121692376J MULTI-SPECIALTY PAIN MANAGEMENT $727.32 06-07-2021 04-19-2021 04-19-2021 Personal Injury Protection - Medical $687.40 PC 06-10-2021 121683557J ISLAND PT & CHIROPRACTIC $108.96 06-09-2021 06-07-2021 06-07-2021 Personal Injury Protection - Medical $108.96 05-30-2021 121672040J ISLAND PT & CHIROPRACTIC $121.47 05-21-2021 05-17-2021 05-17-2021 Personal Injury Protection - Medical $70.95 CLERK 05-30-2021 121672041J ISLAND PT & CHIROPRACTIC $43.64 05-21-2021 05-17-2021 05-17-2021 Personal Injury Protection - Medical $43.64 05-30-2021 121672042J ISLAND PT & CHIROPRACTIC $154.42 05-27-2021 05-24-2021 05-24-2021 Personal Injury Protection - Medical $143.24 05-21-2021 121662000J ISLAND PT & CHIROPRACTIC $227.94 05-14-2021 05-03-2021 05-10-2021 Personal Injury Protection - Medical $221.06 7 05-20-2021 121660958J DAVID WEISSBERG $102.99 03-29-2021 03-10-2021 03-10-2021 Personal Injury Protection - Medical $69.20 of 05-07-2021 121646332J ISLAND PT & CHIROPRACTIC $106.47 04-30-2021 04-26-2021 04-26-2021 Personal Injury Protection - Medical $106.47 10 11/14/2022 04-28-2021 121634967J ISLAND PT & CHIROPRACTIC $106.47 04-19-2021 04-12-2021 04-12-2021 Personal Injury Protection - Medical $70.95 04-28-2021 121634968J ISLAND PT & CHIROPRACTIC $106.47 04-24-2021 04-19-2021 04-19-2021 Personal Injury Protection - Medical $70.95 04-28-2021 121635455J MULTI-SPECIALTY PAIN MANAGEMENT $527.17 04-13-2021 03-09-2021 03-09-2021 Personal Injury Protection - Medical $469.33 PC 11:02 04-19-2021 121624331J MULTI-SPECIALTY PAIN MANAGEMENT $727.32 03-31-2021 02-22-2021 02-22-2021 Personal Injury Protection - Medical $560.31 PC 04-16-2021 121622487J ISLAND PT & CHIROPRACTIC $141.91 04-10-2021 04-05-2021 04-05-2021 Personal Injury Protection - Medical $99.60 AM 04-05-2021 121608417J ISLAND PT & CHIROPRACTIC $215.43 04-03-2021 03-24-2021 03-29-2021 Personal Injury Protection - Medical $177.43 03-24-2021 121595782J ISLAND PT & CHIROPRACTIC $106.47 03-24-2021 03-22-2021 03-22-2021 Personal Injury Protection - Medical $106.47 03-24-2021 121595785J ISLAND PT & CHIROPRACTIC $43.64 03-24-2021 03-22-2021 03-22-2021 Personal Injury Protection - Medical $8.13 03-21-2021 121592765J ISLAND PT & CHIROPRACTIC $43.64 03-21-2021 03-15-2021 03-15-2021 Personal Injury Protection - Medical $43.64 RECEIVED 03-21-2021 121592767J ISLAND PT & CHIROPRACTIC $321.90 03-21-2021 03-15-2021 03-17-2021 Personal Injury Protection - Medical $286.39 INDEX 03-13-2021 121584789J ISLAND PT & CHIROPRACTIC $319.41 03-12-2021 03-04-2021 03-09-2021 Personal Injury Protection - Medical $197.89 03-13-2021 121584790J ISLAND PT & CHIROPRACTIC $87.28 03-12-2021 03-08-2021 03-09-2021 Personal Injury Protection - Medical $87.28 NO. NYSCEF: RBZ000FJ State Farm® 1007048 Page 6 of 9 2005 148026 205 08-10-2022 11/14/2022 606262/2021 NYSCEF FILED: Payment Log 11-10-2022 DOC. Claim No: 20-06R2-66B