Preview
FILED: BRONX CIVIL COURT - CIVIL 03/21/2022 02:07 PM INDEX NO. CV-707932-22/BX
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/21/2022
CIVIL COURT OF THE CITY OF NEW YORK Index Number:
COUNTY OF BRONX
___________________________________Ç
CLIFFSIDE PARK IMAGING & DIAGNOSTIC Plaintiffs Residence Address:
CENTER A/A/O HAOUA ILBOUDO, 596 ANDERSON AVENUE
CLIFFSIDE PARK, NEW JERSEY 07010
Plaintiff(s),
-against- The basis of venue designated:
Defendant transacts business in
MVAIC, COUNTY OF BRONX
Defendant.
_______________________________Ç
SUMMONS
TO THE ABOVE NAMED DEFENDANT (S):
YOU ARE HEREBY SUMMONED to appear in the CIVIL COURT OF THE CITY OF NEW YORK,
COUNTY OF BRONX, at the office of the Clerk of the said Court at 851 GRAND CONCOURSE, BRONX, NY
10451, COUNTY OF BRONX City of New York, within the time provided by law as noted below and to file
your answer to the annexed complaint with the Clerk; upon your failure to answer, judgment will be taken against
you for the sum of $2,250.00 with statutory interest thereon from 1/16/2022 and statutory attorney fees, together
with the costs of this action.
Dated: 3/16/2022
Defendant's Address:
MVAIC
100 WILLIAM STREET
NEW YORK, NY 10038
LAW OFFICE OF COHEN & JAFFE, LLP
Attorneys for Plaintiff(s)
2001 Marcus Avenue, Suite W295
Lake Success, NY 11042
NOTE: The law provides that:
a. If the Summons is served by its delivery to you personally within the City of New York, you must appear and
answer within TWENTY days after such a service; or
b. If this Summons is served by delivery to any person other than you personally, or is served outside the City of
New York, or by publication, or by any means other than personal delivery to you within the City of New York,
you are allowed THIRTY days after the proof of service thereof is filed with the Clerk within which to appear
and answer.
c. Where a defendant appears by an attorney a copy of his answer shall be served upon the plaintiffs attorney, or
upon the plaintiff if the plaintiff appears in person, at or before the time of filing the original answer with the
proof of service thereof.
Our Case No. 1056529
1 of 7
FILED: BRONX CIVIL COURT - CIVIL 03/21/2022 02:07 PM INDEX NO. CV-707932-22/BX
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/21/2022
CIVIL COURT OF THE CITY OF NEW YORK Index Number:
COUNTY OF BRONX
_____________________________________________________________________Ç
CLIFFSIDE PARK IMAGING & DIAGNOSTIC
CENTER A/A/O HAOUA ILBOUDO, COMPLAINT
Plaintiff(s),
-against-
MVAIC,
Defendant.
____________________________________________________________________Ç
Plaintiff(s), by its/their attorneys, LAW OFFICE OF COHEN & JAFFE, LLP,
complaining of the defendant, MVAIC alleges the
following:
1. Defendant is an insurance company licensed to do business in the State of New York.
2. Defendant transacts business in the COUNTY OF BRONX, City and State of New York.
3. The provider in question is a duly licensed Health Service Provider.
4. CLIFFSIDE PARK IMAGING & DIAGNOSTIC CENTER is the assignee of HAOUA ILBOUDO, Assignor.
5. Assignor HAOUA ILBOUDO was injured in a Motor Vehicle accident on 10/26/2021. Claim#:523658 .
6. At the time of the motor vehicle accident there was an existing insurance policy in effect issued by the
Benefits"
Defendant, containing "No Fault under the New York State No Fault Law.
7. One of the No Fault Benefits was payment of health service expenses.
8. The Plaintiff(s) Assignee rendered health services to the Assignor in connection with the injuries sustained by
Assignor as a result of the aforesaid motor vehicle accident.
9. As a result of the aforesaid accident, the Assignor was entitled to receive No Fault Benefits.
2 of 7
FILED: BRONX CIVIL COURT - CIVIL 03/21/2022 02:07 PM INDEX NO. CV-707932-22/BX
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/21/2022
AS AND FOR A FIRST CAUSE OF ACTION
10. Plaintiff repeats and reiterates the allegations contained in paragraph 1 through 9 as though set forth at length
herein.
11. Plaintiff rendered reasonable and medical services on 1/16/2022 - 1/16/2022
necessary
12. Billing for said medical services was mailed out registered mail to Defendant in timely manner.
13. Billing for said medical services was mailed out together with the provider's verification forms.
14. Billing for said medical services total $2,250.00.
15. There has been no payment of the subject Bill and same is overdue.
AS AND FOR A SECOND CAUSE OF ACTION
16. Plaintiff Assignee hired attorneys Law Offices Of Cohen & Jaffe, LLP to collect the above overdue No Fault
benefits and is entitled to recover attorney's fees pursuant to Insurance Law 5106(a) subject to the applicable
limitations referenced in 11NYCRR 65.3.10 or 11NYCRR 65.4, at the plaintiff's election.
3 of 7
FILED: BRONX CIVIL COURT - CIVIL 03/21/2022 02:07 PM INDEX NO. CV-707932-22/BX
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/21/2022
WHEREFORE, Plaintiff demands judgment against the Defendant in the principal amount totaling $2,250.00; as well
as the statutory interest of 2% per month, as well as statutory attorney fees, together with the costs and disbursements
of this action, with respect to each and every separate cause of action herein, and any other relief that the Court finds in
the interest of justice.
Dated: 3/16/2022
Lake Success, New York
Yours, etc.,
LAW OFFICE OF COHEN & JAFFE, LLP
Attorneys for Plaintiff(s)
2001 Marcus Avenue, Suite W295
Lake Success, NY 11042
Telephone: (516) 358-6900
Fax: (516) 775-7399
4 of 7
FILED: BRONX CIVIL COURT - CIVIL 03/21/2022 02:07 PM INDEX NO. CV-707932-22/BX
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/21/2022
MVAIC
HEALTH INSURANCE CLAIM FORM 14TH FLOOR
NEW YORK NY 10038
APPROVED
BYNATIONAL
UNIFORM
CLAIMCOMMITTEE
(NUCC)02/12
PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER ta. INSURED'S
1.D.NUMBER (ForProgramin item1)
HEALTHPLAN BLKLUNG
(Medicate#} (Medicaid#) (SponsorsSSN) (Member
ID (SSNor ID) (SSN) 523658
CD)
2.PATIENTSNAME(LastName,FirstName,Middleinitial) 3. PATIENT's
BIRTHDA11 SEX 4. INSURED'S
NAME(LastName,FirstName,MiddleInitial)
ILBOUDO, HAOUA ILBOUDO, HAGUA
5. PATlENTSADDRESS
(No.,Street) 6. PATIENT
RELATIONSHIP
TOINSURED 7. INSURED'S
ADDRESS
(No.,Street)
1674 TOWNSEND AVE Seit 1674 TOWNSEND
Spouse¡ Child Other AVE
CITY STATE 8. RESERVEDFORNUCCUSE CITY STATE
BRONX NY BRONX NY
ZIPCODE TELEPHONE AreaCode)
(include. ZIPCODE TELEPHONE
(IncludeAreaCode)
10453 10453
9.OTHERINSURED'S
NAME(LastNamo,FirstName,MiddleInitial 10.ISPATIEN'rSCONDITION
RELATED
TO: 11.INSURED'S
POLICY
GROUPORFECANUMBER
ILBOUDO HAOUA
a.OTHERINSUREO'S
POLICY
ORGROUPNUMBER a. EMPLOYMENT'
(Currentor Previous) DAiE OFBIRhi
a.TNSUREDg
MM DD YY SEX
b.RESERVED
FORNUCCUSE b.AUTOACCIDENT? PLACE(State) b. OTHERCLA1M
ID(Designated
byNUCC)
YES NO NJ
c. RESERVED
FORNUCCUSE c.OTHERACCIDENT? c. INSURANCE
PLANNAMEORPROGRAM
NAME
YES NO MVAIC
d. INSURANCE
Pt.ANNAMEORPROGRAM
NAME 10d.CLAIMCODES(Designated
byNUCC) d. ISTHEREANOTHER
HEALTH
BENEFIT
PLAN
NOT AVAILABLE YES
¡ NO 11yes,completoitems9, 9a,and9d.
READBACKOFFORMBEFORECOMPLETING & SIGNING THISFORM 13.INSURED'S ORAUTHORIZED PERSON'S SIGNATURE I authorize
12.PATIENTS ORAUTHORIZED PERSON'S SIGNATURE necessary paymentof medicalbenalitstothoundersigned
I authorizethereleaseof anymedicalorotherinformation physicianorsupplierfor
toprocessthisclaim.I alsorequestpaymentofgovemmontbenefitseithertomyselfortothepartywhoacceptsassignment servicesdescribedbelow.
below.
SIGNED DATE SIGNED
14.DATEOFCURRENTILLNESS, (LMP) 15.OTHERDATE
INJURY,orPREGNANCY 16.DATESPATIENT
UNABLETOWORKINCURRENTOCCUPATION
MM DD YY MM DD YY MM DD YY MM DD YY
10 26 2021 QUAL. 431 QUAL. 439 10 26 2021 FROM TO
17.NAMEOFREi:ÈXRING
PHYSICIAN
OROTHERSOURCE 17a. 18.HOSPITALIZATION
DATESRELATED SERVICES
TOCURRENT
MM OD YY MM DD YY
DN KOPACH ALEKSANDR 17L NPi 1508241456 FROM TO
19.ADDITIONAL
CLAIMINFORMATION
(Designated
byNÚCC) 20.OUTSIDE
LAB? $ CHARGES
YES NO
ORNATURE
21.DIAGNOSIS OFILLNESSORINJURY.(RelateA-L,toservicelinebelow(24E) ICD Ind. I 0 I 22.RESUBMISSION
CODE ORIGINAL
REF.NO.
A.1 M5020 B. I C.I D.L__
E.L G,l 23 PRORAUTHORIZATION
NUMBER
F. I H.I
l.| J. L K.J L. L
24. A. DATE(S)OFSERVICE B. C. D. PROCEDURES, SERVICES, ORSUPPLIEE E. F. G. H. I. J.
D S P ID.
From To PLACEOF (ExplainUriusualCircumstances) DIAGNOSIS RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCi5CS | MODIFIER POINTER $ CHARGES UNITS Plan QUAL- ID.#
PROVIDER
01 | 16 | 22 01 16 22 11 72141 A 2250 | 00 1 NPI 1285634576
| N |
NPI
NPI
NPI
NPI
NPI
TAXLD.NUMBER
25.FEDERAL SSN EIN ACCOUNT
26.PATIENTS NO. 27.ACCEPTASSIGNMENT? 28.TOTALCHARGE 29.AMOUNT PAID 30.RsvdforNUCCUse
(Forgovt.claims,seeback)
044116 YeS ¡ NO s 2250 00 s 0 00
31.SIGNATURE OFPHYSICIAN ORSUPPLIER 32.SERVICE FACILITY INFORMATION
LOCATION 33.BILLINGPROVIDER INFO& PH# 201 945 6747
INC1 sLS CliffSide Park imaging DiagnostiC Cen Cliffside Park Irnaging DiagnOStic Cen
DitNh s e
applytothisbill andaremadea partthereof.) 596 AnderSon Avenue Suite 120 P O Box 1912
CHARLES J DEMARCO M D
CliffSide Park NJ 07010 CliffSide Park NJ 07010
a.1104843689 a.1104843689
SIGNED a
NUCC Instruction Manualavailable at: www.nucc.org PLEASEPRINT OR TYPE APPROVEDOMB-0938-1197FORM150D(02-12)
5 of 7
FILED: BRONX CIVIL COURT - CIVIL 03/21/2022 02:07 PM INDEX NO. CV-707932-22/BX
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/21/2022
CIVIL COURT OF THE CITY OF NEW YORK Index Nurnber:
COUNTY OF BRONX
______________________________________________________________________Ç
CLIFFSIDE PARK IMAGING & DIAGNOSTIC CENTER A/A/O
HAOUA ILBOUDO,
Plaintiff(s),
-against-
MVAIC,
Defendant.
______________________________________________________________________Ç
SUMMONS AND COMPLAINT
LAW OFFICE OF COHEN & JAFFE, LLP
Attorneys for PLAINTIFF(s)
2001 Marcus Avenue
Lake Success, New York 11042
Telephone: (516) 358-6900
Fax: (516) 775-7399
To:
Attorney(s) for
Service of a copy of the within is hereby admitted.
Dated, ........................
Attorney(s) for
Please take notice
NOTICE OF ENTRY
that the within is a (certified) true copy of an
NOTICE OF SETTLEMENT
that an order of which the within is a true copy will be presented for settlement to
the HON. , one of the judges of the within named court, at
on , 200 at
Dated,
Yours, etc.
LAW OFFICE OF COHEN & JAFFE, LLP
Attorneys for Plaintiff(s)
2001 Marcus Avenue, Suite W295
Lake Success, NY 11042
6 of 7
FILED: BRONX CIVIL COURT - CIVIL 03/21/2022 02:07 PM INDEX NO. CV-707932-22/BX
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/21/2022
CIVIL COURT OF THE CITY OF NEW YORK Index Number:
COUNTY OF BRONX
____________________________________________________________________Ç
CLIFFS1DE PARK IMAGING & DIAGNOSTIC CERTIFICATION
CENTER A/A/O HAOUA ILBOUDO, PURSUANT TO
SECTION
Plaintiff(s)
130-1.1-A
-against-
MVAIC,
Defendant.
___________________________________________________________________Ç
The accompanying papers are being served pursuant to section 130-1.1-a:
[X] SUMMONS
[X] COMPLAINT
Dated: 3/16/2022
Yours, etc
LAW OFFICE OF COHEN & JAFFE, LLP
[ ] STEPHEN M. COHEN, ESQ
[ ] RICHARD S. JAFFE, ESQ
[ ] TRICIA C. SMITH, ESQ
LAW OFFICE OF COHEN & JAFFE, LLP
Attorneys for Plaintiff(s)
2001 Marcus Avenue, Suite W295
Lake Success, NY 11042
(516) 358-6900
CASE ID: 1056529
7 of 7
Preview
FILED: BRONX CIVIL COURT - CIVIL 03/21/2022 02:07 PM INDEX NO. CV-707932-22/BX NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/21/2022 CIVIL COURT OF THE CITY OF NEW YORK Index Number: COUNTY OF BRONX ___________________________________Ç CLIFFSIDE PARK IMAGING & DIAGNOSTIC Plaintiffs Residence Address: CENTER A/A/O HAOUA ILBOUDO, 596 ANDERSON AVENUE CLIFFSIDE PARK, NEW JERSEY 07010 Plaintiff(s), -against- The basis of venue designated: Defendant transacts business in MVAIC, COUNTY OF BRONX Defendant. _______________________________Ç SUMMONS TO THE ABOVE NAMED DEFENDANT (S): YOU ARE HEREBY SUMMONED to appear in the CIVIL COURT OF THE CITY OF NEW YORK, COUNTY OF BRONX, at the office of the Clerk of the said Court at 851 GRAND CONCOURSE, BRONX, NY 10451, COUNTY OF BRONX City of New York, within the time provided by law as noted below and to file your answer to the annexed complaint with the Clerk; upon your failure to answer, judgment will be taken against you for the sum of $2,250.00 with statutory interest thereon from 1/16/2022 and statutory attorney fees, together with the costs of this action. Dated: 3/16/2022 Defendant's Address: MVAIC 100 WILLIAM STREET NEW YORK, NY 10038 LAW OFFICE OF COHEN & JAFFE, LLP Attorneys for Plaintiff(s) 2001 Marcus Avenue, Suite W295 Lake Success, NY 11042 NOTE: The law provides that: a. If the Summons is served by its delivery to you personally within the City of New York, you must appear and answer within TWENTY days after such a service; or b. If this Summons is served by delivery to any person other than you personally, or is served outside the City of New York, or by publication, or by any means other than personal delivery to you within the City of New York, you are allowed THIRTY days after the proof of service thereof is filed with the Clerk within which to appear and answer. c. Where a defendant appears by an attorney a copy of his answer shall be served upon the plaintiffs attorney, or upon the plaintiff if the plaintiff appears in person, at or before the time of filing the original answer with the proof of service thereof. Our Case No. 1056529 1 of 7 FILED: BRONX CIVIL COURT - CIVIL 03/21/2022 02:07 PM INDEX NO. CV-707932-22/BX NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/21/2022 CIVIL COURT OF THE CITY OF NEW YORK Index Number: COUNTY OF BRONX _____________________________________________________________________Ç CLIFFSIDE PARK IMAGING & DIAGNOSTIC CENTER A/A/O HAOUA ILBOUDO, COMPLAINT Plaintiff(s), -against- MVAIC, Defendant. ____________________________________________________________________Ç Plaintiff(s), by its/their attorneys, LAW OFFICE OF COHEN & JAFFE, LLP, complaining of the defendant, MVAIC alleges the following: 1. Defendant is an insurance company licensed to do business in the State of New York. 2. Defendant transacts business in the COUNTY OF BRONX, City and State of New York. 3. The provider in question is a duly licensed Health Service Provider. 4. CLIFFSIDE PARK IMAGING & DIAGNOSTIC CENTER is the assignee of HAOUA ILBOUDO, Assignor. 5. Assignor HAOUA ILBOUDO was injured in a Motor Vehicle accident on 10/26/2021. Claim#:523658 . 6. At the time of the motor vehicle accident there was an existing insurance policy in effect issued by the Benefits" Defendant, containing "No Fault under the New York State No Fault Law. 7. One of the No Fault Benefits was payment of health service expenses. 8. The Plaintiff(s) Assignee rendered health services to the Assignor in connection with the injuries sustained by Assignor as a result of the aforesaid motor vehicle accident. 9. As a result of the aforesaid accident, the Assignor was entitled to receive No Fault Benefits. 2 of 7 FILED: BRONX CIVIL COURT - CIVIL 03/21/2022 02:07 PM INDEX NO. CV-707932-22/BX NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/21/2022 AS AND FOR A FIRST CAUSE OF ACTION 10. Plaintiff repeats and reiterates the allegations contained in paragraph 1 through 9 as though set forth at length herein. 11. Plaintiff rendered reasonable and medical services on 1/16/2022 - 1/16/2022 necessary 12. Billing for said medical services was mailed out registered mail to Defendant in timely manner. 13. Billing for said medical services was mailed out together with the provider's verification forms. 14. Billing for said medical services total $2,250.00. 15. There has been no payment of the subject Bill and same is overdue. AS AND FOR A SECOND CAUSE OF ACTION 16. Plaintiff Assignee hired attorneys Law Offices Of Cohen & Jaffe, LLP to collect the above overdue No Fault benefits and is entitled to recover attorney's fees pursuant to Insurance Law 5106(a) subject to the applicable limitations referenced in 11NYCRR 65.3.10 or 11NYCRR 65.4, at the plaintiff's election. 3 of 7 FILED: BRONX CIVIL COURT - CIVIL 03/21/2022 02:07 PM INDEX NO. CV-707932-22/BX NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/21/2022 WHEREFORE, Plaintiff demands judgment against the Defendant in the principal amount totaling $2,250.00; as well as the statutory interest of 2% per month, as well as statutory attorney fees, together with the costs and disbursements of this action, with respect to each and every separate cause of action herein, and any other relief that the Court finds in the interest of justice. Dated: 3/16/2022 Lake Success, New York Yours, etc., LAW OFFICE OF COHEN & JAFFE, LLP Attorneys for Plaintiff(s) 2001 Marcus Avenue, Suite W295 Lake Success, NY 11042 Telephone: (516) 358-6900 Fax: (516) 775-7399 4 of 7 FILED: BRONX CIVIL COURT - CIVIL 03/21/2022 02:07 PM INDEX NO. CV-707932-22/BX NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/21/2022 MVAIC HEALTH INSURANCE CLAIM FORM 14TH FLOOR NEW YORK NY 10038 APPROVED BYNATIONAL UNIFORM CLAIMCOMMITTEE (NUCC)02/12 PICA PICA 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER ta. INSURED'S 1.D.NUMBER (ForProgramin item1) HEALTHPLAN BLKLUNG (Medicate#} (Medicaid#) (SponsorsSSN) (Member ID (SSNor ID) (SSN) 523658 CD) 2.PATIENTSNAME(LastName,FirstName,Middleinitial) 3. PATIENT's BIRTHDA11 SEX 4. INSURED'S NAME(LastName,FirstName,MiddleInitial) ILBOUDO, HAOUA ILBOUDO, HAGUA 5. PATlENTSADDRESS (No.,Street) 6. PATIENT RELATIONSHIP TOINSURED 7. INSURED'S ADDRESS (No.,Street) 1674 TOWNSEND AVE Seit 1674 TOWNSEND Spouse¡ Child Other AVE CITY STATE 8. RESERVEDFORNUCCUSE CITY STATE BRONX NY BRONX NY ZIPCODE TELEPHONE AreaCode) (include. ZIPCODE TELEPHONE (IncludeAreaCode) 10453 10453 9.OTHERINSURED'S NAME(LastNamo,FirstName,MiddleInitial 10.ISPATIEN'rSCONDITION RELATED TO: 11.INSURED'S POLICY GROUPORFECANUMBER ILBOUDO HAOUA a.OTHERINSUREO'S POLICY ORGROUPNUMBER a. EMPLOYMENT' (Currentor Previous) DAiE OFBIRhi a.TNSUREDg MM DD YY SEX b.RESERVED FORNUCCUSE b.AUTOACCIDENT? PLACE(State) b. OTHERCLA1M ID(Designated byNUCC) YES NO NJ c. RESERVED FORNUCCUSE c.OTHERACCIDENT? c. INSURANCE PLANNAMEORPROGRAM NAME YES NO MVAIC d. INSURANCE Pt.ANNAMEORPROGRAM NAME 10d.CLAIMCODES(Designated byNUCC) d. ISTHEREANOTHER HEALTH BENEFIT PLAN NOT AVAILABLE YES ¡ NO 11yes,completoitems9, 9a,and9d. READBACKOFFORMBEFORECOMPLETING & SIGNING THISFORM 13.INSURED'S ORAUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENTS ORAUTHORIZED PERSON'S SIGNATURE necessary paymentof medicalbenalitstothoundersigned I authorizethereleaseof anymedicalorotherinformation physicianorsupplierfor toprocessthisclaim.I alsorequestpaymentofgovemmontbenefitseithertomyselfortothepartywhoacceptsassignment servicesdescribedbelow. below. SIGNED DATE SIGNED 14.DATEOFCURRENTILLNESS, (LMP) 15.OTHERDATE INJURY,orPREGNANCY 16.DATESPATIENT UNABLETOWORKINCURRENTOCCUPATION MM DD YY MM DD YY MM DD YY MM DD YY 10 26 2021 QUAL. 431 QUAL. 439 10 26 2021 FROM TO 17.NAMEOFREi:ÈXRING PHYSICIAN OROTHERSOURCE 17a. 18.HOSPITALIZATION DATESRELATED SERVICES TOCURRENT MM OD YY MM DD YY DN KOPACH ALEKSANDR 17L NPi 1508241456 FROM TO 19.ADDITIONAL CLAIMINFORMATION (Designated byNÚCC) 20.OUTSIDE LAB? $ CHARGES YES NO ORNATURE 21.DIAGNOSIS OFILLNESSORINJURY.(RelateA-L,toservicelinebelow(24E) ICD Ind. I 0 I 22.RESUBMISSION CODE ORIGINAL REF.NO. A.1 M5020 B. I C.I D.L__ E.L G,l 23 PRORAUTHORIZATION NUMBER F. I H.I l.| J. L K.J L. L 24. A. DATE(S)OFSERVICE B. C. D. PROCEDURES, SERVICES, ORSUPPLIEE E. F. G. H. I. J. D S P ID. From To PLACEOF (ExplainUriusualCircumstances) DIAGNOSIS RENDERING MM DD YY MM DD YY SERVICE EMG CPT/HCi5CS | MODIFIER POINTER $ CHARGES UNITS Plan QUAL- ID.# PROVIDER 01 | 16 | 22 01 16 22 11 72141 A 2250 | 00 1 NPI 1285634576 | N | NPI NPI NPI NPI NPI TAXLD.NUMBER 25.FEDERAL SSN EIN ACCOUNT 26.PATIENTS NO. 27.ACCEPTASSIGNMENT? 28.TOTALCHARGE 29.AMOUNT PAID 30.RsvdforNUCCUse (Forgovt.claims,seeback) 044116 YeS ¡ NO s 2250 00 s 0 00 31.SIGNATURE OFPHYSICIAN ORSUPPLIER 32.SERVICE FACILITY INFORMATION LOCATION 33.BILLINGPROVIDER INFO& PH# 201 945 6747 INC1 sLS CliffSide Park imaging DiagnostiC Cen Cliffside Park Irnaging DiagnOStic Cen DitNh s e applytothisbill andaremadea partthereof.) 596 AnderSon Avenue Suite 120 P O Box 1912 CHARLES J DEMARCO M D CliffSide Park NJ 07010 CliffSide Park NJ 07010 a.1104843689 a.1104843689 SIGNED a NUCC Instruction Manualavailable at: www.nucc.org PLEASEPRINT OR TYPE APPROVEDOMB-0938-1197FORM150D(02-12) 5 of 7 FILED: BRONX CIVIL COURT - CIVIL 03/21/2022 02:07 PM INDEX NO. CV-707932-22/BX NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/21/2022 CIVIL COURT OF THE CITY OF NEW YORK Index Nurnber: COUNTY OF BRONX ______________________________________________________________________Ç CLIFFSIDE PARK IMAGING & DIAGNOSTIC CENTER A/A/O HAOUA ILBOUDO, Plaintiff(s), -against- MVAIC, Defendant. ______________________________________________________________________Ç SUMMONS AND COMPLAINT LAW OFFICE OF COHEN & JAFFE, LLP Attorneys for PLAINTIFF(s) 2001 Marcus Avenue Lake Success, New York 11042 Telephone: (516) 358-6900 Fax: (516) 775-7399 To: Attorney(s) for Service of a copy of the within is hereby admitted. Dated, ........................ Attorney(s) for Please take notice NOTICE OF ENTRY that the within is a (certified) true copy of an NOTICE OF SETTLEMENT that an order of which the within is a true copy will be presented for settlement to the HON. , one of the judges of the within named court, at on , 200 at Dated, Yours, etc. LAW OFFICE OF COHEN & JAFFE, LLP Attorneys for Plaintiff(s) 2001 Marcus Avenue, Suite W295 Lake Success, NY 11042 6 of 7 FILED: BRONX CIVIL COURT - CIVIL 03/21/2022 02:07 PM INDEX NO. CV-707932-22/BX NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 03/21/2022 CIVIL COURT OF THE CITY OF NEW YORK Index Number: COUNTY OF BRONX ____________________________________________________________________Ç CLIFFS1DE PARK IMAGING & DIAGNOSTIC CERTIFICATION CENTER A/A/O HAOUA ILBOUDO, PURSUANT TO SECTION Plaintiff(s) 130-1.1-A -against- MVAIC, Defendant. ___________________________________________________________________Ç The accompanying papers are being served pursuant to section 130-1.1-a: [X] SUMMONS [X] COMPLAINT Dated: 3/16/2022 Yours, etc LAW OFFICE OF COHEN & JAFFE, LLP [ ] STEPHEN M. COHEN, ESQ [ ] RICHARD S. JAFFE, ESQ [ ] TRICIA C. SMITH, ESQ LAW OFFICE OF COHEN & JAFFE, LLP Attorneys for Plaintiff(s) 2001 Marcus Avenue, Suite W295 Lake Success, NY 11042 (516) 358-6900 CASE ID: 1056529 7 of 7