Preview
FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020
NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020
Schwartzapfel Lawyers P.C.
F IGH TING FOR YOU
December 24, 2019
VIA CERTIFIED MAIL 91 7199 9991 7039 9095 2396
GEICO
P.O. Box 9111
Macon, GA 31208
Attention: Linda Sylvan
Re: Claimant: Chetanaben A. Patel
Insured: Avantkumar Patel
Claim Number: 0193881330101098
Date of Accident: 4/30/2019
Our File Number: 1900970
Dear Ms. Sylvan:
Enclosed herewith please find the following documentation with respect to the above referenced
matter:
A. Police Accident Report dated April 30, 2019;
B. New York Presbyterian Queens Hospital's Admission Records dated April 30,
2019 through May 4, 2019;
C. Lenox Hill Hospital's Surgical Records dated August 9, 2019;
D. Ramesh Babu M.D.'s Medical Reports and Records including diagnostic records;
E. Neurological Specialties of Long Island, P.C. 'sMedical Reports and Records;
F. Bell Plaza Physical Therapy 'sRecords;
G. Central Island Physical Medicine and Rehabilitation's Records;
H. Demand for Arbitration; and
I. No Fault Authorization.
Thank you for your courtesy and cooperation in this matter.
Very truly yours,
John F. Campbell, III, Esq.
JFC:sh
Enclosures: Exhibits A-I
Main Office
600 Old Country Road, Suite 450 • Garden City, NY 11530
NEW YORK | WHITE PLAINS | BRONX fightingforyou.com
R 515.342.2200
F 516.342.2400
FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020
NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020
EXHIBIT A
FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020
NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020
Page1 of 2 Pag•a New YorkState Departmentof MotorVehicles
Pr.dnat POUCE ACCIDENT REPORT (NYC) 30
110 MV-104AN (7/11)
Accident
No. Complaint 1
MV-2019-110-001204 Number
AqI‰ntbele DayofWeek Militarfilme No of No.lojured No.1(illed NoUnveangated LellScene
PolicePliF 20
Vehicles atScene
Month Day Yaer --.-.........__.-----.--...,....
4 30 2 019 TUESDAY 16 r55 2 0 0 Reconstructed No
VEHICI.E1 VEHICLE2 BlCYCLISTO PEDESTRIAN¤ OTHERPEDESTRIAN
h Driver
VEHICLE 2- priver
StateofI.1c. VEHICLE Staeo ..Ic
2 ucenseIDNumber 3 D1554677 NY Unance
IDNumber 202 940604
- NY 21
Oriver
Narns-eractly DdverNarne-exactly
anprhtedon1Icense
PATEL, CHETANAB.EN, A aspantedenscenseGONZALEZ , SAMUEL, RONAN
Addrese
(include
Number& 8keet) Apt.No.Addreas
(include
Number
& stme4 Apt.No.
421 HERRICK S RD 504 5 NEWTOWN RD 4D ¯-
CitycrTown State ZipCode CityorTown State 21pCode 22
NEW EYDE PARK NY 11040 QUEENS NY 11377 9
3 0ataof|31rth Sex Unlicensed No.of Pubilm Da ofBhth sex UnllcensedNo.of PntMic
Month Day Year Occupants erty Men Day Year Qccupants Property
1 12 1969 F 1 amaged 9 16 1974 M 2 oamaged
asprintedonregistration
Narse-exactly SeltDate
ofBirl asprintedenregistration
Name-exacHy Sex Dal irl
onth ay Year Month ay Year
PATEL, AVANTKUMAR, M M VILLEGAS, MARITEA U
-
Addmss Number& Street}
(inclucts Naz.
Apl.No, i Ral sed Address
(/nclude
Numbar&Sheaf) Apt.No. Hat I Re-I-a-ed 23
421 HERRICKS RD po a 2244 BRONX PKE 3A
C[tyarTown State ZI Code CityarTown state2ip Cods
NBW HYDE PARK NY 11 40 BRONX NY
PlateNumber SisteofReg.VaNcleYaar&Make VehicleType Ina,CodePlateNumber lalaofReg.Vehlele
Year&Make VeNote
Type Inu.Gode
GGU3184 NY 2013 CHEVROLET SW/SUV 14 a DSV6144 NY 200 6 TOYOTA SEDAN 639
Th:kef/Arrest Ticke1/Arreal
Number(a) Number(s)
Vkilallon - VIolation
Secdon(a) . Sectlan(8)
CheckIf Involvedvehicleis: Check f Involvedvehicleis: Circlethe diagrambelowthat describesthe accident,or drawyour own
1
than95 Incheswide; '
Omore then 95 incheswide;
0 ¤more diagramInspace#9. Nurnberthevehicles.
V Omore than 34 feet Iong; V Ornore than 34 feetiong; RearEnd Le m RightAngle
-
1 RightTum HeadOn
E
H
operatedwith an overweightpermit;
E Coperated with an overweightpermit;
3+
O0Perated with arl overdlmensionpermit
operatedwith an overdimenalonpermit
H
4 3. 5. 7,
1| VEH1CLE1 DAMAGE CODES VRH1CLE2 DAMAGECODES ™•'wrm LeftTum RightTumSideswipe 26
C 1 2 C - 1 2 (sam cuon) øpposits
Box 1 - Pointof Impact Box 1Pointof Impact 1
7 -
L . Box 2
MostDamage 8 8 L 80X2- MostDamage 2 2 2. + 0. 4. a. a. ++
2 E E
Enterup to three 3 4 g Enterup1othree a 4 5 ACCIDENTDIAGRAM
moreDamageCodes moreDamageCodes 1 3
2
VehicleBy VeNcle By 1
Towed: Yowed'
To To
. VEHICLEDAMAGECODING 7
1-13, SEEDIAGRAMON RIGHT. 1 REAR END
14, UNDERCARRIAGE 17.. DEMOLISHED a
. 15. TRAILER 18, No DAMAGE 9. 28
16, OVERTURNED 19, OTHER Cost of repairs to any one veNcle w[II be rnore than $1000.
1
Unknowri/Unableto Determine Yes [--|No
ReferenceMarker } Coordinates(if available)
Place Where AcoldentOccurred: BRONX¤KINGS NEW YORK QUEENS RICHMOND
Latitude/Northing: HORACE HARDING EXPRESSWAY
RoadanwNchaccidentoccurred
orStreetName)
(liouteNumber 29
BOULEVARD
at1)intersectingstreet JUNCTION
Langitude/Easting: (RouteNurnber
orStreelNarne)
N S
or 2)- E W of --
Fest Miles NItarest
(19tilenost.
Intarsacting of$1teelNarne)-
|¾uteNumber
AccidentDescription/OfficersNotes AT
TPO DRIVER OF V1 STATES SHE WAS REAR ENDED BY DRIVER OF V2 WHILE 3D
WAITING FOR THE TRAFFIC LIGHT TO TURN GREEN. DRIVER OF V2 STATES THAT DRIVER OF V1
STOPPED BHORT CAUSING HIM TO STRIKE HER IN THE REAR, CAUSING DAMAGE , NO INJURIES
REPORTED. POLICE DID NOT WITNESS .
P
8 9 1D 11 12 13 14 15 10 17 BY TO ·f8 Namesof all hwaived Date of Death( nly
A A 1 4 1 50 F - - - PATEL, CHETANABEN, A
1
L a - - - - GONZALEZ SAMUEL ROMAN
W
2 1 4 1 44 M , ,
I 3 4 1 92 M - - - VILLEGAS , ISMAEL
N-
V
D
officers Rank Tax 10No. NCIC No. Precinct Post/Sector Reviewing Oatefl-imeRevfewed
and CST
EiOn_g|Mre 9 64664 03030 110 SGT ERIC R 05 / O2f20190E: D9
Prin1Name
In Full BRANDON M MORALES
FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020
NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020
PERSONS KILLED OR INJURED IN ACCIDENT (Letter
designation
of personskilled or injured
must correspondwithletter designation
on front).
Last Name Firel M.L LastName First MJ.
Address Address
Date of Birth Telephone(AreaCode) Dateof Birth Telephone{Aree code)
Margh Day Year Nonth Day Yest
Last Name First M.I. LastName First M.1
Address Address
Date of Birth Telephone(AreaCode) Dateof Sirth Telephone(AreaCode}
Month Day Year Month Day Yanr
Last Name First M.L
HigilwayDIst.atScene? Yes No
Name:
Address
Date of BMh Telephone(AreaCode) Shield No,
Month Day Year
ENTER INSURANCE POLICY NUMBER FROM INSURANCE iDENTiFiCATION CARD, EXPIRATION DATE (lNALL CASES), AND VIN.
VehicleNo.1 4464186511 VehicleNo.2 443 809 93 86
ExpirationDate 05/12/2019 ExpirationDate 05 /18/2019
VIN 1GNKRFED4DJ222156 VIN JTDER32576008 9664
WITNESS (Attach separate shest,ifnecessary)
-
Name Address - Phone
. ..
DUPLICATE COPY REQUIRED FOR:
Dept.of MotorVehicles MotorTransport Division ¤ NYC Taxi& Limousine Cornm. Other CityAgency
(if anyone -
is killed/injured) (P.D. vehicle (if a Ucensedtaxi or Ilmc;.is!ñê
Involved) (Specify)
Involved)
Officeof Cornptroller Personnel SafetyUnit Highway Unit
vehicle
(if a City involved) (if a P.D. vehicle
involved)
NOTlFICATIONS: of friend or relative notified. If aided person is unidentified,
(Enter name, address, and relationship list Mlssing Person Squad mernber w
was notified. In either case, give date and time of notification.)
PROPERTY DAMAGED (otherthan vehicles) OWNER OF PROPERTY (include where
city agency, applicable)
IF NYPD VEHICLE lS INVOLVED:
PoliceVehide -operatofs
FirstName LastName Rank ShleIdNo. Tex ID.No. Command
Make ofVehicle Year Typeof Vehicle PlateNo. Dept.VehicleNo. AssignedToWhat Command
EquipmentIn UseAt Ume ofAccident
Ham Turret Light High-Level Warning
Lights Traffic Cones Headlights
Siren 4-Way Flasher
.
ACTIONS OF POLICE VEHICLE
Code Signal O with Station House Directive
cornplying
Responding to
Violator O Routine Patrol
Pursuing
Other (Describe)
MV ANU/11) Page 2 of 2 Pages
FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020
NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020
Rear End : MV-2019-110-001204
Reporting Officer : POM BRAND ON M MORALES
Reviewing Officer : SGT ERIC R CHAFFER Reviewed Date : 05/02/2019 06:09
Vehicle 1 Vehink 2
FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020
NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020
EXHIBIT B
FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020
NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020
J NewYork-Presbyterian
Queens .
Disclosure Notice
"This information has been disclosed to you from confidential recortis which are
protected by state and Federal laws. The laws prohibits you from reaking any further
disclosure of this information without the specific written consent of the person to whom
itpertains, or as otherwise permitted by law. Any unauthorized further dim!osure is a
viciation of state and federal law and may result in a fine or jailsentence or both, A
general authorization for release of medical or other information is not sufficient
disclosure."
authorization for further
FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020
NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020
No'
Financial 421547052 Medical Record No 3593147
NewYork-Presbyterlan/QueenS
UNIVERSAL REGISTRATION FORM
05/03./19
Patient Type/Service MED Hx: Datemme 03: 20A
., Name PATEL, CHETANABEN Language EN interpreter NO
Race · 0 V
Address 421 Hanaxcas RD
City,State,Zip BEW HYDB PARK NY 1104 O . sthpl IN Job
Phone 516-240-6977 Last NYHMC.Q Enc Proxy N
N Name-8NF SEX AGE DOS MAR REL PAT
T
F 50 01/12/19 69
a Spouse/Parent Mtr'sNo Relation 1
. E Name AVANT Name AvamT Kuman
PATEL, KUMAR PA2n, .
Address 421 HERRICKB RD AddreSS 421 HERRICKS RD ·
A
T City,State, NEW NYDE PARE NY 11040 NEW .HYDE PARK NY 11040
Zip City,State,Zip
o Home Phone 516-580-2098 Relationship Home Phone 516-580-2098 Relationship
N Bus Phone Bus Phone
p Room/Bed ED ED 15 Vet DRG
A Accom ma Organ Donor Mean LOS
1 I Admit Type 11 $W/DP #1 . Actual LOS UNKNOWN
NE Admit Source nou #2 . FinalDisch Sve
Y Adm1t Status Last NYHMC,Q Admit Final Disch Date
8 last00 days - Date Name
Hosp .
o·
Name Loma, saWJAt INSURANCE FIn CI
Phone 718-335-4747 Phys No 203590 Prim 9099 9 F01
T Name LOMA, SAREAY NO Fat&T
Phone Phys No E03590 999 9
a DX Code M542 Sec
Å
Adm DX CERVICALGIA SnF PAY
erge
Pducil at Die CODE NCi na
Diagar con-
determined
ahm etudy, to have
a ms to t
tiospital.
Other Diagnoses- 113
Principal and U4
secondary
Procedures,
. PATEL,CHETANASEN
- 01/12/1969 MR: 3593't47
1111111111111111111111111111
421547052
CONSULTATIONS us INFECTION
O YES O NO
- DISPOSITION - "Y
Icertifythatthe :=rrat!vedescription of theprincipal and
G-
RECOVERED IMPROVED Gl. Secondary da 3 and themajor procedures performed are
EXPIRED IN MEDICAL AUT. S accurate and complete to thebo0% of my knOWledge.
O H.C. SNF 48 HOURS EXAMINER
SGNATUREOFRESIDENTORINTERN 119 SIGNATURE
OFATTEN01NG
PHYSICIAN 120 DATE • 121
280a(7ios) MEDICAL RECORD (CHART COPY)
FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020
NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020
J NewYorlePresbyterian
Queens
EMERGENCY DEPARTMENT
Hey^y¶ 3593147
CONSENT FORM
421547052
MEDIGAL SURGICAL CONSENTS: The undersigned hereby consents to the
diagnostleand Isboratoryprocedures, medical,surgical
and/or treatmentand hospitalservicesenderad to thepatientunder of the
the instructlans physic:âñor physicians
anesthesiology
attendingpatient. event
in the of surgeryor complexdiagnostic procedures
or therapeutic arerequired,thepatient'sphysicianshall
obtainthe pallent's
Informed consent,Ifneessery, to suchtreatment,procedures or services. ..
RELEASE OF INFORMATION: I herebyauthorizeand directNewYork-Presbyterian/Queens havingtreatedme, to releaseto
Govemment Agencies, Insurance or others
Garries, who are liable
fiñaric:â:|y forrnyheepite!!=tionand Medical Care, all
Information
needed to substan#atepayment forsuch hospitailzation
end medical and to permitrepresentatives
thereofto êxarsiñeand make copies
of all
records to
relating such care and treatment.
ASSIGNMENT OF INSURANCE BENEFITS: The undere!gned whether he/shesigns as agentor as patient,
Irrevocablyauthorizes
directpayment to the hospital
and physic;âñ.of any InsurancebenefitsGtharwisepayable to theundersigned for the
hospitalization
and
services
physiciai) at a rate
not to exceedthe hospital's
and physician's
regularcharges, It Is agreed
thatpayrnentto the hospital
and
phy5|Giañby an Insurance company pursuantto this
authorizationby an Insurancecornpany shalldischargesaid insurancecompany
of anyObligat?casunder to the
e policy extentof such payment. It Is understood
by the undersigned he/sheis financially
responsiblefor
oharges not covered by this
assignment.
ASSUIviP ficii OF RISK: Should thepatientleavethe Hospitalbeforebeing released or dischargedby thephysiciañattendinghim/her
or shouldpatientfail to otherwise
followinstructions
given him/herby said physician the undersigned
or physIclans, agrees to assurne
all responsibility
for any
injuryor damage sufferedthereby and furtheragreesto releaseand hold the physician
or physicians.their
agents, thehospital,Its employeesand agents,freeand harmless from and againstany and all claims,
demands of suits
fordâmages
from any complicationswhatever arisingtherefrom..
PATLENT/S CERTIFICATION, AUTHORIZATION TO RELEASE INFORMATION, AND PAYMENT REQUEST: MEDICARE, HOSPITAL
AND MEDICAL INSURANCE BENEFITS.
t certify
thattheinformationgivenby me for
in applying payment under the Title
XVll of the Social
SecurityActIs correct
I authorize
any holder ofmedical orother about
inforrnation me to releasetothe SocialSecurityAdiñinistiation
orits or
intermediaries carriers
any
infarrñat!GG
needed for this
or a related
Medicare Irequest
olairn. thatpayment of authorized
benefitsbe made on my behalf.
NOTIFICATIOlÓF A FA|VIILY MEMBER OR REPRESENTATIVE
Do you w a familymember or representative of your
notified admission?
O No Yes, if yes
request and complete theadditionalinformationbelow
O P entunwilling/unableto answer(aircle
one)
Contact Information:
Name: Relationship:
Phoned EmailAddress:
NOTIFlQATION PATIENT's PHYSICIAN
Do you want our physician of your
notified admission?
O No O a, if yes
complete, requestand cornpletethe information
additional below.
Contact oformation:
Name: . Phone#: Email Addresst
THE UNDERSIGNED CERTIFlES THAT HE/SHE HAS READ THE POREGOING, AND HAS BEEN F Y INFORMED AS TO THEIR
MEANING.
DATE: TIME: WITNESS: .
()
PATIENT/PARENT/I.EGAL
REPRESENTATION DATE TNE RELATIONSHIPIF OTHERTHANPATIENT
P800259 (10/16) EDConsent
Forrn # MRCA # 103516
FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020
NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020
-1 NeWyork esbyterian
9 Qu ens
PATEL, CHETANABEN F
. 01/t2/1969 50 Hx: MED
421547052 05/01/10 3593147
LoDHA, SANJAY
LODHA SANJAY
1111111111111I11511111111
GEISERAL CONSENT FOR TREATMENT
Patient/Proxy or Surrogate i unabl unavailable to sign
PERMIS8[ON FOR G RAL ADM!SS!ON PROCEDURES, VALUABLE RELEASE;
DistributionOF REGULATORY INFORMATION
O I hareby authorize my admission to The NewYork-Presbyterian/Queens.
D I hareby authorize the adrnission of
PATIEhrf
to The NewYork-Presbyterlan/Queens.
I aut1orize the hospital, the physicians, dentists,podlatilets, (Medical Staff) and aliled health profese[onals on
Its the
stitff, mainbers of itshouse staff,nursing staffand paramedical staff,assisted by the employees of the
hosp herefnafter
tal, referred to uollectivaiyas hospitalpersonnel, to provide such medical and/or dental care and
to administer such routine diagnostic and procedures, Including but not limited to, diagnostic x-rays: the
. admhWetion and/or injection of pharmaceutical products and rMicaticiis; the drawing of and/or adm1nistration
of bited, pooled plasma or other derivatives;the photographing and/or videotaping of my body patts In coññëtica
with ny care with the understanding that my identitywillremain confidentlal;as In jqdgment of theabove hospital
personnel and/or the medical staffdeem necessary oradvisable in providingcare.
2 4 achcvv1õdgõ that nò guarantles or assurances have been made to me conceming the resultaof findingsintended
from the treatment or examination in thehospital.
3 I understand that no valuables should be in my possession/patient's possession during my hospitalstay.I have been
advited tosend any personal items of value home. I fully
understand that the HoslWtal isnot resp0ñsible forany
pêr6öria: items in my possession during rny hospital stay.I acknowledge alsothat 1 have been advised that as a
convanlence tome, my valuables may be kept by the Hospital during my stay. I understand that my property shall
. be rtturned tome upon discharge during the normal business hours of the Hospital'scashier's departiiient.I have
beer advised that the Hospitalis not an insurerof my valuables during my stay.
State" Guide."
4 I.have received a copy of"You're Rights as a Hospital Patient inNew York and:the "Patient
TheE e booklets contain Important informationincluding: :
• Advance Directives and the importance of a proxy !
appointing
• Bill
of.Rights .
Responsibilities as a Patient
• Message from Medicare
• a complaint tothe State of New York Department of Health and the Joint Commission
L.odging
• Cessation
Smoking
Ih ve rec aivedan explanation foreach ofthese documents In my preferred language.
If section4 is addressed other than through the Patient Access Department, Indicate accordiapy
SectIon 4 -eviewed and presented by Date: Time: PM
Patient/Pray or Surrogate Date Time: PM
. Date: Time: M
PIGNTNAM DATE TIME
RELATIONSHIP(IF SIGNEDBY PER5oN OTHERTAAN PÄTlENT)
I hpvebe6n given information about HIV and I accepttesting.
O No, I d6 notwant an HIV test at thistime.
Si a Date Time: AM/PM
Date Time M
TNESSSIGNATURE . PRINTNAME
F00017 . Page 1 of 2 . MRGA 1394fi
FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020
NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020
JNewYorléPresbyterian
"7 Queens
0
42
GENERAL CONSENT FOR TREATMENT
1. This certlflesthat I am leaving(taking the above named patient from) The NewYork-PrGabyterian/Queens against
the advice of my / the patient's
physician and The NewYork-Presbyterian/Queens aüGictiGes.
2. Dr. has informed -me of
the dangers to / the patient's physical and inental which discharya form The NewYork-
my health, acc0mpany
Presbyterian/Queens at thistime. I havebeen given theopportunity to ask any questions and allmy queshe have
been answered fuKyand satisfactortly. .
3. I persGñâuy assume the riskand cansequences of thisdischarge and release The NewYork-Prasbyterian/Queens,
itsgüve niiigbody, officers,
=ppo!ñtsea, agents, erñplayees, students and medical stafffrom any and all and
liability
consequences which may resultfrom thisdischarge. . -. . .
4. I confirm thatI have read and fullyunderetend the above, and thatallthe blank spaces have been completed prior
to my signing.
Patient / Proxyor Surrogate:
SIGNATURE
PRINTNAME
Date: / Time: AM/PM
REt.ATIONSHIP(IF SIGNEDBY PERSONOTHERTHANPATIENT)
Witness:
'
SIGNATURE PRINTNAME
Date: . Time: AM/PM
. .
I herpby that
certify Ihave expisiñed theduñgers,érhich accoriipañÿ discharge at this
time have offered to answer any
questions and have fullyanswered al
Preview
FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020 NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020 Schwartzapfel Lawyers P.C. F IGH TING FOR YOU December 24, 2019 VIA CERTIFIED MAIL 91 7199 9991 7039 9095 2396 GEICO P.O. Box 9111 Macon, GA 31208 Attention: Linda Sylvan Re: Claimant: Chetanaben A. Patel Insured: Avantkumar Patel Claim Number: 0193881330101098 Date of Accident: 4/30/2019 Our File Number: 1900970 Dear Ms. Sylvan: Enclosed herewith please find the following documentation with respect to the above referenced matter: A. Police Accident Report dated April 30, 2019; B. New York Presbyterian Queens Hospital's Admission Records dated April 30, 2019 through May 4, 2019; C. Lenox Hill Hospital's Surgical Records dated August 9, 2019; D. Ramesh Babu M.D.'s Medical Reports and Records including diagnostic records; E. Neurological Specialties of Long Island, P.C. 'sMedical Reports and Records; F. Bell Plaza Physical Therapy 'sRecords; G. Central Island Physical Medicine and Rehabilitation's Records; H. Demand for Arbitration; and I. No Fault Authorization. Thank you for your courtesy and cooperation in this matter. Very truly yours, John F. Campbell, III, Esq. JFC:sh Enclosures: Exhibits A-I Main Office 600 Old Country Road, Suite 450 • Garden City, NY 11530 NEW YORK | WHITE PLAINS | BRONX fightingforyou.com R 515.342.2200 F 516.342.2400 FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020 NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020 EXHIBIT A FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020 NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020 Page1 of 2 Pag•a New YorkState Departmentof MotorVehicles Pr.dnat POUCE ACCIDENT REPORT (NYC) 30 110 MV-104AN (7/11) Accident No. Complaint 1 MV-2019-110-001204 Number AqI‰ntbele DayofWeek Militarfilme No of No.lojured No.1(illed NoUnveangated LellScene PolicePliF 20 Vehicles atScene Month Day Yaer --.-.........__.-----.--...,.... 4 30 2 019 TUESDAY 16 r55 2 0 0 Reconstructed No VEHICI.E1 VEHICLE2 BlCYCLISTO PEDESTRIAN¤ OTHERPEDESTRIAN h Driver VEHICLE 2- priver StateofI.1c. VEHICLE Staeo ..Ic 2 ucenseIDNumber 3 D1554677 NY Unance IDNumber 202 940604 - NY 21 Oriver Narns-eractly DdverNarne-exactly anprhtedon1Icense PATEL, CHETANAB.EN, A aspantedenscenseGONZALEZ , SAMUEL, RONAN Addrese (include Number& 8keet) Apt.No.Addreas (include Number & stme4 Apt.No. 421 HERRICK S RD 504 5 NEWTOWN RD 4D ¯- CitycrTown State ZipCode CityorTown State 21pCode 22 NEW EYDE PARK NY 11040 QUEENS NY 11377 9 3 0ataof|31rth Sex Unlicensed No.of Pubilm Da ofBhth sex UnllcensedNo.of PntMic Month Day Year Occupants erty Men Day Year Qccupants Property 1 12 1969 F 1 amaged 9 16 1974 M 2 oamaged asprintedonregistration Narse-exactly SeltDate ofBirl asprintedenregistration Name-exacHy Sex Dal irl onth ay Year Month ay Year PATEL, AVANTKUMAR, M M VILLEGAS, MARITEA U - Addmss Number& Street} (inclucts Naz. Apl.No, i Ral sed Address (/nclude Numbar&Sheaf) Apt.No. Hat I Re-I-a-ed 23 421 HERRICKS RD po a 2244 BRONX PKE 3A C[tyarTown State ZI Code CityarTown state2ip Cods NBW HYDE PARK NY 11 40 BRONX NY PlateNumber SisteofReg.VaNcleYaar&Make VehicleType Ina,CodePlateNumber lalaofReg.Vehlele Year&Make VeNote Type Inu.Gode GGU3184 NY 2013 CHEVROLET SW/SUV 14 a DSV6144 NY 200 6 TOYOTA SEDAN 639 Th:kef/Arrest Ticke1/Arreal Number(a) Number(s) Vkilallon - VIolation Secdon(a) . Sectlan(8) CheckIf Involvedvehicleis: Check f Involvedvehicleis: Circlethe diagrambelowthat describesthe accident,or drawyour own 1 than95 Incheswide; ' Omore then 95 incheswide; 0 ¤more diagramInspace#9. Nurnberthevehicles. V Omore than 34 feet Iong; V Ornore than 34 feetiong; RearEnd Le m RightAngle - 1 RightTum HeadOn E H operatedwith an overweightpermit; E Coperated with an overweightpermit; 3+ O0Perated with arl overdlmensionpermit operatedwith an overdimenalonpermit H 4 3. 5. 7, 1| VEH1CLE1 DAMAGE CODES VRH1CLE2 DAMAGECODES ™•'wrm LeftTum RightTumSideswipe 26 C 1 2 C - 1 2 (sam cuon) øpposits Box 1 - Pointof Impact Box 1Pointof Impact 1 7 - L . Box 2 MostDamage 8 8 L 80X2- MostDamage 2 2 2. + 0. 4. a. a. ++ 2 E E Enterup to three 3 4 g Enterup1othree a 4 5 ACCIDENTDIAGRAM moreDamageCodes moreDamageCodes 1 3 2 VehicleBy VeNcle By 1 Towed: Yowed' To To . VEHICLEDAMAGECODING 7 1-13, SEEDIAGRAMON RIGHT. 1 REAR END 14, UNDERCARRIAGE 17.. DEMOLISHED a . 15. TRAILER 18, No DAMAGE 9. 28 16, OVERTURNED 19, OTHER Cost of repairs to any one veNcle w[II be rnore than $1000. 1 Unknowri/Unableto Determine Yes [--|No ReferenceMarker } Coordinates(if available) Place Where AcoldentOccurred: BRONX¤KINGS NEW YORK QUEENS RICHMOND Latitude/Northing: HORACE HARDING EXPRESSWAY RoadanwNchaccidentoccurred orStreetName) (liouteNumber 29 BOULEVARD at1)intersectingstreet JUNCTION Langitude/Easting: (RouteNurnber orStreelNarne) N S or 2)- E W of -- Fest Miles NItarest (19tilenost. Intarsacting of$1teelNarne)- |¾uteNumber AccidentDescription/OfficersNotes AT TPO DRIVER OF V1 STATES SHE WAS REAR ENDED BY DRIVER OF V2 WHILE 3D WAITING FOR THE TRAFFIC LIGHT TO TURN GREEN. DRIVER OF V2 STATES THAT DRIVER OF V1 STOPPED BHORT CAUSING HIM TO STRIKE HER IN THE REAR, CAUSING DAMAGE , NO INJURIES REPORTED. POLICE DID NOT WITNESS . P 8 9 1D 11 12 13 14 15 10 17 BY TO ·f8 Namesof all hwaived Date of Death( nly A A 1 4 1 50 F - - - PATEL, CHETANABEN, A 1 L a - - - - GONZALEZ SAMUEL ROMAN W 2 1 4 1 44 M , , I 3 4 1 92 M - - - VILLEGAS , ISMAEL N- V D officers Rank Tax 10No. NCIC No. Precinct Post/Sector Reviewing Oatefl-imeRevfewed and CST EiOn_g|Mre 9 64664 03030 110 SGT ERIC R 05 / O2f20190E: D9 Prin1Name In Full BRANDON M MORALES FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020 NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020 PERSONS KILLED OR INJURED IN ACCIDENT (Letter designation of personskilled or injured must correspondwithletter designation on front). Last Name Firel M.L LastName First MJ. Address Address Date of Birth Telephone(AreaCode) Dateof Birth Telephone{Aree code) Margh Day Year Nonth Day Yest Last Name First M.I. LastName First M.1 Address Address Date of Birth Telephone(AreaCode) Dateof Sirth Telephone(AreaCode} Month Day Year Month Day Yanr Last Name First M.L HigilwayDIst.atScene? Yes No Name: Address Date of BMh Telephone(AreaCode) Shield No, Month Day Year ENTER INSURANCE POLICY NUMBER FROM INSURANCE iDENTiFiCATION CARD, EXPIRATION DATE (lNALL CASES), AND VIN. VehicleNo.1 4464186511 VehicleNo.2 443 809 93 86 ExpirationDate 05/12/2019 ExpirationDate 05 /18/2019 VIN 1GNKRFED4DJ222156 VIN JTDER32576008 9664 WITNESS (Attach separate shest,ifnecessary) - Name Address - Phone . .. DUPLICATE COPY REQUIRED FOR: Dept.of MotorVehicles MotorTransport Division ¤ NYC Taxi& Limousine Cornm. Other CityAgency (if anyone - is killed/injured) (P.D. vehicle (if a Ucensedtaxi or Ilmc;.is!ñê Involved) (Specify) Involved) Officeof Cornptroller Personnel SafetyUnit Highway Unit vehicle (if a City involved) (if a P.D. vehicle involved) NOTlFICATIONS: of friend or relative notified. If aided person is unidentified, (Enter name, address, and relationship list Mlssing Person Squad mernber w was notified. In either case, give date and time of notification.) PROPERTY DAMAGED (otherthan vehicles) OWNER OF PROPERTY (include where city agency, applicable) IF NYPD VEHICLE lS INVOLVED: PoliceVehide -operatofs FirstName LastName Rank ShleIdNo. Tex ID.No. Command Make ofVehicle Year Typeof Vehicle PlateNo. Dept.VehicleNo. AssignedToWhat Command EquipmentIn UseAt Ume ofAccident Ham Turret Light High-Level Warning Lights Traffic Cones Headlights Siren 4-Way Flasher . ACTIONS OF POLICE VEHICLE Code Signal O with Station House Directive cornplying Responding to Violator O Routine Patrol Pursuing Other (Describe) MV ANU/11) Page 2 of 2 Pages FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020 NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020 Rear End : MV-2019-110-001204 Reporting Officer : POM BRAND ON M MORALES Reviewing Officer : SGT ERIC R CHAFFER Reviewed Date : 05/02/2019 06:09 Vehicle 1 Vehink 2 FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020 NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020 EXHIBIT B FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020 NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020 J NewYork-Presbyterian Queens . Disclosure Notice "This information has been disclosed to you from confidential recortis which are protected by state and Federal laws. The laws prohibits you from reaking any further disclosure of this information without the specific written consent of the person to whom itpertains, or as otherwise permitted by law. Any unauthorized further dim!osure is a viciation of state and federal law and may result in a fine or jailsentence or both, A general authorization for release of medical or other information is not sufficient disclosure." authorization for further FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020 NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020 No' Financial 421547052 Medical Record No 3593147 NewYork-Presbyterlan/QueenS UNIVERSAL REGISTRATION FORM 05/03./19 Patient Type/Service MED Hx: Datemme 03: 20A ., Name PATEL, CHETANABEN Language EN interpreter NO Race · 0 V Address 421 Hanaxcas RD City,State,Zip BEW HYDB PARK NY 1104 O . sthpl IN Job Phone 516-240-6977 Last NYHMC.Q Enc Proxy N N Name-8NF SEX AGE DOS MAR REL PAT T F 50 01/12/19 69 a Spouse/Parent Mtr'sNo Relation 1 . E Name AVANT Name AvamT Kuman PATEL, KUMAR PA2n, . Address 421 HERRICKB RD AddreSS 421 HERRICKS RD · A T City,State, NEW NYDE PARE NY 11040 NEW .HYDE PARK NY 11040 Zip City,State,Zip o Home Phone 516-580-2098 Relationship Home Phone 516-580-2098 Relationship N Bus Phone Bus Phone p Room/Bed ED ED 15 Vet DRG A Accom ma Organ Donor Mean LOS 1 I Admit Type 11 $W/DP #1 . Actual LOS UNKNOWN NE Admit Source nou #2 . FinalDisch Sve Y Adm1t Status Last NYHMC,Q Admit Final Disch Date 8 last00 days - Date Name Hosp . o· Name Loma, saWJAt INSURANCE FIn CI Phone 718-335-4747 Phys No 203590 Prim 9099 9 F01 T Name LOMA, SAREAY NO Fat&T Phone Phys No E03590 999 9 a DX Code M542 Sec Å Adm DX CERVICALGIA SnF PAY erge Pducil at Die CODE NCi na Diagar con- determined ahm etudy, to have a ms to t tiospital. Other Diagnoses- 113 Principal and U4 secondary Procedures, . PATEL,CHETANASEN - 01/12/1969 MR: 3593't47 1111111111111111111111111111 421547052 CONSULTATIONS us INFECTION O YES O NO - DISPOSITION - "Y Icertifythatthe :=rrat!vedescription of theprincipal and G- RECOVERED IMPROVED Gl. Secondary da 3 and themajor procedures performed are EXPIRED IN MEDICAL AUT. S accurate and complete to thebo0% of my knOWledge. O H.C. SNF 48 HOURS EXAMINER SGNATUREOFRESIDENTORINTERN 119 SIGNATURE OFATTEN01NG PHYSICIAN 120 DATE • 121 280a(7ios) MEDICAL RECORD (CHART COPY) FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020 NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020 J NewYorlePresbyterian Queens EMERGENCY DEPARTMENT Hey^y¶ 3593147 CONSENT FORM 421547052 MEDIGAL SURGICAL CONSENTS: The undersigned hereby consents to the diagnostleand Isboratoryprocedures, medical,surgical and/or treatmentand hospitalservicesenderad to thepatientunder of the the instructlans physic:âñor physicians anesthesiology attendingpatient. event in the of surgeryor complexdiagnostic procedures or therapeutic arerequired,thepatient'sphysicianshall obtainthe pallent's Informed consent,Ifneessery, to suchtreatment,procedures or services. .. RELEASE OF INFORMATION: I herebyauthorizeand directNewYork-Presbyterian/Queens havingtreatedme, to releaseto Govemment Agencies, Insurance or others Garries, who are liable fiñaric:â:|y forrnyheepite!!=tionand Medical Care, all Information needed to substan#atepayment forsuch hospitailzation end medical and to permitrepresentatives thereofto êxarsiñeand make copies of all records to relating such care and treatment. ASSIGNMENT OF INSURANCE BENEFITS: The undere!gned whether he/shesigns as agentor as patient, Irrevocablyauthorizes directpayment to the hospital and physic;âñ.of any InsurancebenefitsGtharwisepayable to theundersigned for the hospitalization and services physiciai) at a rate not to exceedthe hospital's and physician's regularcharges, It Is agreed thatpayrnentto the hospital and phy5|Giañby an Insurance company pursuantto this authorizationby an Insurancecornpany shalldischargesaid insurancecompany of anyObligat?casunder to the e policy extentof such payment. It Is understood by the undersigned he/sheis financially responsiblefor oharges not covered by this assignment. ASSUIviP ficii OF RISK: Should thepatientleavethe Hospitalbeforebeing released or dischargedby thephysiciañattendinghim/her or shouldpatientfail to otherwise followinstructions given him/herby said physician the undersigned or physIclans, agrees to assurne all responsibility for any injuryor damage sufferedthereby and furtheragreesto releaseand hold the physician or physicians.their agents, thehospital,Its employeesand agents,freeand harmless from and againstany and all claims, demands of suits fordâmages from any complicationswhatever arisingtherefrom.. PATLENT/S CERTIFICATION, AUTHORIZATION TO RELEASE INFORMATION, AND PAYMENT REQUEST: MEDICARE, HOSPITAL AND MEDICAL INSURANCE BENEFITS. t certify thattheinformationgivenby me for in applying payment under the Title XVll of the Social SecurityActIs correct I authorize any holder ofmedical orother about inforrnation me to releasetothe SocialSecurityAdiñinistiation orits or intermediaries carriers any infarrñat!GG needed for this or a related Medicare Irequest olairn. thatpayment of authorized benefitsbe made on my behalf. NOTIFICATIOlÓF A FA|VIILY MEMBER OR REPRESENTATIVE Do you w a familymember or representative of your notified admission? O No Yes, if yes request and complete theadditionalinformationbelow O P entunwilling/unableto answer(aircle one) Contact Information: Name: Relationship: Phoned EmailAddress: NOTIFlQATION PATIENT's PHYSICIAN Do you want our physician of your notified admission? O No O a, if yes complete, requestand cornpletethe information additional below. Contact oformation: Name: . Phone#: Email Addresst THE UNDERSIGNED CERTIFlES THAT HE/SHE HAS READ THE POREGOING, AND HAS BEEN F Y INFORMED AS TO THEIR MEANING. DATE: TIME: WITNESS: . () PATIENT/PARENT/I.EGAL REPRESENTATION DATE TNE RELATIONSHIPIF OTHERTHANPATIENT P800259 (10/16) EDConsent Forrn # MRCA # 103516 FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020 NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020 -1 NeWyork esbyterian 9 Qu ens PATEL, CHETANABEN F . 01/t2/1969 50 Hx: MED 421547052 05/01/10 3593147 LoDHA, SANJAY LODHA SANJAY 1111111111111I11511111111 GEISERAL CONSENT FOR TREATMENT Patient/Proxy or Surrogate i unabl unavailable to sign PERMIS8[ON FOR G RAL ADM!SS!ON PROCEDURES, VALUABLE RELEASE; DistributionOF REGULATORY INFORMATION O I hareby authorize my admission to The NewYork-Presbyterian/Queens. D I hareby authorize the adrnission of PATIEhrf to The NewYork-Presbyterlan/Queens. I aut1orize the hospital, the physicians, dentists,podlatilets, (Medical Staff) and aliled health profese[onals on Its the stitff, mainbers of itshouse staff,nursing staffand paramedical staff,assisted by the employees of the hosp herefnafter tal, referred to uollectivaiyas hospitalpersonnel, to provide such medical and/or dental care and to administer such routine diagnostic and procedures, Including but not limited to, diagnostic x-rays: the . admhWetion and/or injection of pharmaceutical products and rMicaticiis; the drawing of and/or adm1nistration of bited, pooled plasma or other derivatives;the photographing and/or videotaping of my body patts In coññëtica with ny care with the understanding that my identitywillremain confidentlal;as In jqdgment of theabove hospital personnel and/or the medical staffdeem necessary oradvisable in providingcare. 2 4 achcvv1õdgõ that nò guarantles or assurances have been made to me conceming the resultaof findingsintended from the treatment or examination in thehospital. 3 I understand that no valuables should be in my possession/patient's possession during my hospitalstay.I have been advited tosend any personal items of value home. I fully understand that the HoslWtal isnot resp0ñsible forany pêr6öria: items in my possession during rny hospital stay.I acknowledge alsothat 1 have been advised that as a convanlence tome, my valuables may be kept by the Hospital during my stay. I understand that my property shall . be rtturned tome upon discharge during the normal business hours of the Hospital'scashier's departiiient.I have beer advised that the Hospitalis not an insurerof my valuables during my stay. State" Guide." 4 I.have received a copy of"You're Rights as a Hospital Patient inNew York and:the "Patient TheE e booklets contain Important informationincluding: : • Advance Directives and the importance of a proxy ! appointing • Bill of.Rights . Responsibilities as a Patient • Message from Medicare • a complaint tothe State of New York Department of Health and the Joint Commission L.odging • Cessation Smoking Ih ve rec aivedan explanation foreach ofthese documents In my preferred language. If section4 is addressed other than through the Patient Access Department, Indicate accordiapy SectIon 4 -eviewed and presented by Date: Time: PM Patient/Pray or Surrogate Date Time: PM . Date: Time: M PIGNTNAM DATE TIME RELATIONSHIP(IF SIGNEDBY PER5oN OTHERTAAN PÄTlENT) I hpvebe6n given information about HIV and I accepttesting. O No, I d6 notwant an HIV test at thistime. Si a Date Time: AM/PM Date Time M TNESSSIGNATURE . PRINTNAME F00017 . Page 1 of 2 . MRGA 1394fi FILED: NASSAU COUNTY CLERK 10/01/2020 04:29 PM INDEX NO. 607524/2020 NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 10/01/2020 JNewYorléPresbyterian "7 Queens 0 42 GENERAL CONSENT FOR TREATMENT 1. This certlflesthat I am leaving(taking the above named patient from) The NewYork-PrGabyterian/Queens against the advice of my / the patient's physician and The NewYork-Presbyterian/Queens aüGictiGes. 2. Dr. has informed -me of the dangers to / the patient's physical and inental which discharya form The NewYork- my health, acc0mpany Presbyterian/Queens at thistime. I havebeen given theopportunity to ask any questions and allmy queshe have been answered fuKyand satisfactortly. . 3. I persGñâuy assume the riskand cansequences of thisdischarge and release The NewYork-Prasbyterian/Queens, itsgüve niiigbody, officers, =ppo!ñtsea, agents, erñplayees, students and medical stafffrom any and all and liability consequences which may resultfrom thisdischarge. . -. . . 4. I confirm thatI have read and fullyunderetend the above, and thatallthe blank spaces have been completed prior to my signing. Patient / Proxyor Surrogate: SIGNATURE PRINTNAME Date: / Time: AM/PM REt.ATIONSHIP(IF SIGNEDBY PERSONOTHERTHANPATIENT) Witness: ' SIGNATURE PRINTNAME Date: . Time: AM/PM . . I herpby that certify Ihave expisiñed theduñgers,érhich accoriipañÿ discharge at this time have offered to answer any questions and have fullyanswered al