Preview
FILED: NEW YORK COUNTY CLERK 04/24/2018 04:09 PM INDEX NO. 154804/2017
NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 04/24/2018
FILED: NEW YORK COUNTY CLERK 04/24/2018 04:09 PM INDEX NO. 154804/2017
NYSCEF DOC. NO. 45 00026 RECEIVED NYSCEF: 04/24/2018
I
INVOICE NUMBER 0027718
NEW YORK MOTOR VEHICLE NO-FAULT INSUR/ NCE LAW
'
VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHE PROVIDER OF HEALTH SERVICE
(This form is not verification of hospital treatment
- NAME AND ADDRESS OF INSURER: - NAME )F INSURER'S CLAIM REPRESENTATIVFA
-.,N_AME
Kemper Insurance Company Jennife Burg
P.O. Box 2845
Clinton, IA 52733-2845.
DATE POLICY HOLDER POLICY NUMBER DATE 0 ACCIDENT CLAIM NUMBER
12/27/201 Corwise,Dwayne 16090301475 5/! 2016 CO29968NY16
I
PROVIDER'S NAME AND ADDRESS.
Corona Medical Plaza P.C.
104-08 Roosevelt Ave.
COrOna, NY 11368 Tel: 718 426-6500
KINDLY COMPLETE AND SUBMIT THIS FORM S SOON AS POSSIBLE. PLEASE NO"E, THIS COMPLETED
FORM MUST BE SUBMITTEDTO THE INSURERAS SOON AS REASONABLY POSSIBLE BUT FOT LATER THAN 45 DAYS AFTER
THE TREATMENT DATE, DEPENDINGUPON THE POLICY ENDORSEMENTIN EFFECTAT THE ?lME OF THE ACCIDENT.IP YOU
ARE UNSUREOF THE4PPLICABLE TIME REQUIREMENT,KINDLY CONTACTTHE CLAIMS RE?RESENTATNE TO DETERMINE
WHICH DEADLINE IS A'PPLICABLE TO THIS CLAlM.
IFYOU HAVEPREVIOUSLYSUBMITTEDAN EARUERREPORTON THE ACCIDENT,YOU NEED ONLYNOTEANY CHANGESFROMTHE INFORMATION
PREVIOUSLYFURNISHEDAND ADDITIONALCHARGES.
1. PATIENT'S NAME AND ADDRESS: Salguedo Angela
102-23 Horace Harding Exp. . Apt2A, Corona, NY 1368
2. DATE OF BIRTH 3. SEX FEMALE 4, OCCUPATION f known) .
5. DIAGNOSIS AND CONCURRENT CONDITIONS: .
724.5 - Back painO
723.1 - Neck pain (Cervicajgia)
722.0 - Displacement of Cé,rvical Disc w/o Elopathy
722.1 - Displacement of Lumbar Disc w/o Elopathy . . - .
844.9 - Sprains/strains of knee L
R/0 Meniscal
836.2 -R/O tear L
840.4 - Rule out rotator edfEinjury L
840.9 - Shoulder Sprain/Strain L I
726.10 - Shoulder tendinitis L
923.0 - Shoulder ContusionL
6. WHEN DID SYMPTOMS FIRST APPEAR? 7. WHEN DID PATIENT IRST CONSULT YOU FOR THIS CONDITION?
DATE: 5/ 9/2016 DATE: 5/17/2016
YES
~
8. HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION?
NO | X |
9. IS CONDITION SOLELY A RESULT OF THIS AUTOMOBILE ACCIDENT?
If 'YES', state when and · ascribe:
.scribe:
YES I X Ñ0 If 'NO', explain:
YES
~
10. IS CONDITION DUE TO INJ0RY ARISING OUT OF PATIENT'S EMPLOYMENT?
NO X
11. WILL INJURY RESULT INSlÖNIFICANT DISFlGUREMENT OR PERMANENT DISABILITY?
.
YES NO If 'YES', describe: NOT DEFRMINABLE AT THIS TIME| X
12. PATlENT WAS DISABLE (Unable to work) 13. IF STILL DISABLED 'HE PATIENT SHOULD BE ABLE TO
FROM: THROUGH: RETURN TO WORF ON:
. .
Continue on next page
(00968) . Page- 1 NYS FORM N-F 3 (Rev. 1/2004)
01/09/2017 KPDCN201701090000781
FILED: NEW YORK COUNTY CLERK 04/24/2018 04:09 PM INDEX NO. 154804/2017
NYSCEF DOC. NO. 45 00026 RECEIVED NYSCEF: 04/24/2018
o
PATIENT'S NAME : Salguedo Angela INVOICE NUMBER 0027718
I
14. WILL THE PATIENT REQUIRË REHABILITATION AND/OR OCCUPATIONAL THERAPY AS A Fe !SULT OF THE INJURIES SUSTAINED IN
--
THIS ACCIDENT'
ACCIDENT? C
„'"
X YES NO IFYES', descdbeyour below:
recornrnendation See doctor S report
15. REPORT OF SERVICES RENDERED - A-lTACH ADDITIONAL SHEETS IF NECESSARY
o
DATE OF PLACEOF SERVICE DESCRIPTIONOF TREATMENTOR FEESCHEDULE TOTALCHARGE
SERVICE INCLUDINGZIP C6ÒE HEALTHSERVICESRENDERED TREA'TMENTCODES
12/ 1/2016 tooosRoosevelt
Ave,Coroa,NY 11368 Follow Up 99214 $92.97
TOT·1 CHARGES TO DATE: $92.97
16. IF TREATING PROVIDER IS DIFFERENT THAN BILLING PROVIDER CÔMPLETE THE FOLLO VING:
Treating Providcts Narne Title Licence or Certificate No. ._ E ssinessRelation ( check applicable box)
Employee IndependentContractor Other (specify)
*James Avellini M.D. 148049 Owner
17. IF THE PROVIDER OF SERVICE IS A PROFESSIONAL SERVICE CORPORATION OR DOING BUSINESS UNDER AN ASSUMED
NAME (DBA), LIST THE OWNER AND PROFESSIONAL LICENSING CREDENTIALS OF ALL OWNERS (Provide an additional attachment
if necessary).
AveHini .M.D. 148049
18. IS PATIENT STILL UNDER OUR CARE FOR THIS CONDITION ? YES ~X
.X . NO
[
.
19. ESTlMATE DURATION OF FUTURE TREATMENT: Not determined at this time
ti'
as
PATIENT: Your health provider may agree to accept for health services performed directly fro.n your insur r(Authorization to
Pay Benefits) so that you are not required to make payment to the health provider at the time of service. Such agreement is optional on
the part of the health provider and must be signed by both patient and healyh provider. You may use the optional authorization language provided
below, by checking off the designated spot in item 20 of this form,
20._(IF YOU HAVE CHOSEN TO AUTHORIZE THE DIRECT PAYMENT OF BENEFITS BY CHECKING THIS OP'HON, YOU MAY
NOT ALSO ENTER INTO AN ASSIGNMENT OF BENEFITS CONTAINED IN #21)
I authorize payment of health benefits to the undersigned health care provider or supplier of serv:ces described.below. I retain all rights, privileges
and remedies to which I am entitled under Article 51 (The No-Fault provision) of the insurance law.
PRINTNAME SIGNED
Patient Patient Date
PATIENT: Your health provider may agree to have you assign your right to No-Fault benefits from·your insurer directly to your health
provider (Assignment of Benefits). If you and your health provider agree to an assignmer t of benefits, you must both sign the
agreement contained in #21 or the prescribed NF-AOB form or its equivalent. The language cont ded -sled in the assignment of benefits is mandatory
-Jied
and may not be altered or avoided by any other language added to this agreement or other writteragreement.
21. X (IF YOU HAVE CUOSEN TO ASSIGN YOUR BENEFITS TO THE HEALTH PROVIh $R BY CHECKING THIS OPTION, YOU MAY
NOT ALSO ENTER INTO AN AUTHORIZATION TO PAY BENEFITS CONTAINED IN ITEM#2 , ABOVE) .
I hereby assign to the health carte provider indicated below all right, privileges and remedies to pa. ent for health care services provided by the
assignee to which I am entitled under article 51 (the No-Fault statute) of the insurance law. The a signee hereby-certifies that they have not received
any payment from or on behalf of the assignor and shall not pursue payment directly from the assignor for services provided by said assignee for
injuries sustained due to the motor vehicle accident, notwithstanding any other agreement to the emtrary. This agreement may be revoked by the
assignee when benefits are not payable based upon the assignor's lack of coverage and/or violatics ' of a policy.condition due to the actions or conduct
of the assignor.
PRINT NAME Salguedo Angela SIGNED Signature on File
Patient (Assignor) Patient Date
PRINT NAME *James Avellini SIGNED_ Signature on File
Provider ofHealth Care Service (Assignee) Provider of Health Care Service Date
Has an Original authorization or assigmnent previously been executed? I X Yes
' '
~ No
IS the original sig nature of the parties on file? X
ANY PERSONWHO KNOWINGLYÅND WITHINTENTTO DEFRAUDANY INSURANCECOMPANYOR OTHER ·EitSON FILESAN APPLICATIONFOR
Yes
~ No
COMMERCIALINSURANCEOR A STATEMENTOF CLAIMFOR ANY COMMERCIALOR PERSONALINSURA!QE BENEFITS CONTAININGMATERIALLYFALSE
INFORMATIONOR CONCEALSFOR·THEPURPOSEOF MISLEADING.INFORMATIONCONCERNINGANY FA .TT MATERIALTHERETO,AND ANY PERSONWHO,
IN CONNECTIONWITHSUCHA[PliLICATIONOR CLAIM,KNOWINGLYMAKESOR KNOWINGLYASSISTS,AE TS, SOLICITSrORCONSPlRESWITHANOTHERTO
-'LE TO A LAW ENFORCEMENTAGENCY.THE
MAKEA FALSE REPORTOFTHE THEFT, DESTRUCTION,DAMAGEOR CONVERSIONOFANY MOTORVEHICLE
DEPARTMENTOF MOTORVEHICLEOR AN INSURANCECOMPANYCOMMITSA FRAUDULENTINSURANCETCT, WH1CHfS.A CRIME.AND SHALLALSO BE
(00968) Page - 2 . NYS FORM N-F 3 (Rev. 'I/2004)
01/09/2017 KPDCN201701090000781
FILED: NEW YORK COUNTY CLERK 04/24/2018 04:09 PM INDEX NO. 154804/2017
NYSCEF DOC. NO. 45 00026 RECEIVED NYSCEF: 04/24/2018
. PATIENT'S NAME: Salguedo.Angela INVOICENUMBER0027718
SUBJECTTO A CML PENALTYNÓTTO EXEEDFIVETHOUSANDDOLLARSAND THE VALUE OF-0-lE SUBJE T MOTORVEHICLEORSTATEDCLAIMFOR EACH
VIOLATION.
DATE ' PROVIDER SlC9NATURE IRS/TIN lDENT I:-I,,'
IFlC - TlON NO. WCB RATING CODE ..
IF NONE, SPECIALTY
TIN: 46-3655051
)/1/ ' ' —
12/27/2016 l *James Avellirii / / Lic# 148049 M.D.
r
\
I
Page- 3 NYS FORM N-F 3 (Rev. 1/2004)
(00968)
01/09/2017 KPDCN201701090000781
FILED: NEW YORK COUNTY CLERK 04/24/2018 04:09 PM INDEX NO. 154804/2017
NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 04/24/2018
00014
T
DWAYNE CORWISE-8834-DQ14701
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE
(This form is not for verification of hospital treatment )
NAME AND ADDRESS OF INSURER OR SELF- NAME, ADDRESS, AND PHONE NUMBER OF
INSURER* INSURER'S CLAIMS REPRESENTATIVE*
KEMPER INSURANCE COMPANY
P.O.BOX 2845, CLINTON, 10WA, 52733
DATE POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
38/24/2016 09 May 2016 CO29968NY16
PROVIDER'S NAME AND ADDRESS*
CitiMedical I PLLC
6555 Woodhaven Blvd, Rego Park, NEW YORK, 11374
KINDLY COMPLETE AND SUBMIT THIS FORM AS SOON AS POSSIBLE. PLEASE NOTE, THIS COMPLETED
FORM MUST BE SUBMITTED TO THE INSURER AS SOON AS REASONABLY POSSlBLE BUT No LATER
THAN 45 DAYS AFTER THE TREATMENT DATE, DEPENDING UPON THE POLICY
ENDORSEMENT IN EFFECT AT THE TIME OF THE ACCIDENT. IFiOU ARE UNSURE OF THE APPLICABLE
TIME REQUIREMENT, KINDLY CONTACT THE CLAIMS REPRESENTATIVE TO DETERMINE WHICH
DEADLINE IS APPLICABLE TO THIS CLAIM.
IF YOU HAVE PREVIOUSLY SUBMITTED AN EARLIER REPORT ON THIS ACCIDENT, YOU NEED ONLY NOTE ANY
CHANGES FROM THE INFORMATION PREVIOUSLY FURNISHED AND ADDITIONAL CHARGES.
1. PATIENT'S NAME AND ADDRESS DWAYNE CORWISE
8 LONE OAK CIRCLE, RENFIELD, NEW YORK, 11368
o nATF OF BIRTH 3. SEX 4. OCCUPATION (IF KNOWN)
Male
5. DIAGNOSIS AND CONCURRENT CONDITIONS I
M53.0 Cervicocranial syndrome, M54.12 Radiculopathy, cervical region, M54.2 Cervicaigia,
6. WHEN DID SYMPTOMS FIRST APPEAR? 7. WHEN DID PATIENT FIRST CONSULT YOU FOR THIS
DATE: 09 May 2016 CONDITION7 DATE: 03 Aua 2016
8. HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION?
YES I — II NO I X I IF'YES, state when and describe:
9. IS CONDITION SOLELY A RESULT OF THIS AUTOMOBILE ACCiDENT?
YES I X | NO | | IF "NO", explain:
10. IS CONDITION DUE TO )NJURY ARISING OUT OF PATIENT'S EMPLOYMENT7
YES I I NO I X
11. WILL INJURY RESULT IN SIGNIFICANT DISFlGUREMENT OR PERMANENT DISABILITY?
YES I NO | NOT DETERMINABLE AT THIS TIME X
IF "YES", describe:
12. PATIENT WAS DISABLED (UNABLE TO WORK) 13. IF STILL DISABLED THE PATIENT SHOULD BE
ABLE TO RETURN TO WORK ON:
FROM: THROUGH:
(DATE)
CONTINUE ON PAGE 2
NYS FORM NF-3 (Rev 1/2004)
Page 1 of 3
09/13/2016 KPDCN201609130000823
FILED: NEW YORK COUNTY CLERK 04/24/2018 04:09 PM INDEX NO. 154804/2017
NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 04/24/2018
00014
DWAYNE CORWISE-8834-DQ14701
14. WILL THE PATIENT REQUIRE REHABILITATION AND/OR OCCUPATIONAL THERAPY AS A RESULT
OF THE INJURIES SUSTAINED IN THIS ACCIDENT?
YES X NO IF YES, describe your recommendation below: See Doctor's Repolt
15.REPORT OF SERVICESRENDERED - ATTACH ADDITIONAL SHEETS IF NECESSARY
Date of Pláce of Service Description of Treatment or Health Service Fee Schedule Treitment Charges
Service Including Zip Code Rendered Code
08/03/2016 6555WoodhavenBlvd.,LL,RegoMRTCervical-Spine
w/ocontrast 72141 S879.73
Park,NY11374
TOTAL CHARGES TO DATE S 879.73
NYS FORM NF-3 (Rev 1/2004)
Page2 of3
. __ . _. . ... . . . _. - .- . .. . ..
09/13/2016 KPDCN201609130000823
FILED: NEW YORK COUNTY CLERK 04/24/2018 04:09 PM INDEX NO. 154804/2017
NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 04/24/2018
00014
DWAYNE CORWISE-8834-DQ14701
VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE PAGE 3
16. IF TREATING PROVIDER IS DIFFERENT THAN BILLING PROVIDER COMPLETE THE FOLLOWING:
TREATING PROVIDER'S LICENSEOR BUSINESSRELATIONSHIP
NAME CERTIFICATIONNO. CHECKAPPLICABLEBOX
EMPLOYEE INDEPENDENT OTHER(SPEClFY)
Michael Green, MD Lic # 120848
YES CONTRACTOR
17. IF THE PROVIDER OF SERVICE IS A PROFESSIONAL SERVICE CORPORATION OR DOING BUSINESS
UNDER AN ASSUMED NAME (DBA), LIST THE OWNER AND PROFESSIONAL LICENSING CREDENTIALS OF
ALL OWNERS (Provide an additional attachment if necessary).
CiUMedical 1,PLLC
18. IS PATIENT STILL UNDER YOUR CARE FOR THIS CONDITION? YES X NO
19. ESTIMATED DURATION OF FUTURE TREATMENT Not Determined at this time
PATIENT: Your health provider may agree to accept payment for health services performed directly from your insurer (Authorization to
Pay Benefits) so that you are not required to make payment to the health provider at the time of service. Such agreement is optional on
the part of the health provider and must be signed by both patient and health provider. You may use the optional authorization language
provided below, by checking off the designated spot in item 20 of this form.
20, (lF YOU HAVE CHOSENTO AUTHORIZETHE DIRECTPAYMENT OF BENEFITS BY CHECKINGTHIS OPTION.YOU MAY NOT
ALSD ENTER |NTO AN ASSIGNMENT OF BENEFITSCONTAINEDIN #21)
AUTHORIZATIONTO PAY BENEFITS:
I AUTHORIZE PAYMENT OF HEALTH BENEFlTS To THE UNDERSIGNED HEALTH CARE PROVIDER OR SUPPLIER OF SERVICES
DESCRIBED BELOW. I RETAIN ALL RIGHTS, PRIVILEGES AND REMED1ES TO WHICH I AM ENTITLED UNDER ARTICLE 51 (THE
NO-FAULT PROVISION) OF THE INSURANCE LAW.
PRINT NAME SIGNED
PATIENT PATIENT DATE
PATIENT: Your health provider may agree to have you assign your right to No-Fault benefits from your Insurer directly to your health
provider (Assignment of Benefits). If you and your health provider agree to an assignment of benefits, you must both sign the
agreement contained In # 21 or the prescribed NF-AOB form or its equivalent. The language contained in the assignment of benefits is
mandatory and may not be altered or avoided by any other language added to this agreement or other written agreement.
21. X (IFYOU HAVE CHOSENTO ASSIGN YOUR BENEFITSTO THE HEALTH PROVIDERBY CHECKINGTHIS OPTION,YOUMAY NOT
ALSO ENTER INTO AN AUTHOR7ZATIONTO PAY BENEFlTS CONTAINEDIN ITEM #20 ABOVE)
ASSIGNMENT OF NO-FAULT BENEFITS:
I HEREBY ASSIGN TO THE HEALTH CARE PROVIDER INDICATED BELOW ALL R3GHTS, PR1V3LEGES AND REMEDIES TO
PAYMENT FOR HEALTH CARE SERVICES PROVIDED BY THE ASStGNEE TO WHICH I AM ENTITLED UNDER ARTICLE 51 (THE
NO-FAULT STATUTE) OF THE 3NSURANCE LAW. THE ASSIGNEE HEREBY CERTIFIES THAT THEY HAVE NOT RECEIVED ANY
PAYMENT FROM OR ON BEHALF OF THE ASS3GNOR AND SHALL NOT PURSUE PAYMENT DIRECTLY FROM THE ASSIGNOR
FOR SERVICES PROV3DED BY SAID ASSIGNEE FOR INJURIES SUSTA1NED DUE TO THE MOTOR VEHICLE£ ACC3DENT,
NOTWITHSTANDING ANY OTHER AGREEMENT TO THE CONTRARY. THIS AGREEMENT MAY BE REVOKED BY THE ASS1GNEE
WHEN BENEFITs ARE NOT PAVABLE BASED UPON THE ASSIGNOR*S LACK OF COVERAGE AND/OR V3OLATION OF 4 POLICY
CONDITION DUE TO THE ACTIONS OR CONDUCT OF THE ASSIGNOR
PRINT NAME DWAYNE CORWISE SIGNED Signature on file
PATIENT (Assignor) DATE
-. ......
PRINT NAME CitiMedical I PLLC SIGNED lSIGNED
PROVIDER
OFHEALTHCARESERVICE(Assignee) PROVIDER OF HEALTH CARE SERVICE DATE
HAS AN ORIGINAL AUTHORIZATION OR ASSIGNMENT PREVlOUSLY
BEEN EXECUTED? YES x NO
IS THE ORIGINAL SIGNATURE OF THE PARTIES ON FILE7 YES ~S NO
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY
COMMERCIAL OR PERSONAL INSURANCE BENEFlTS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR
CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO,
AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR
KNOWINGLY ASSISTS, ABETS, SOLTCITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE
THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT
AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT
INSURANCE ACT, WHICH IS A CRtME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED
F1VE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEH1CLE Ok STATED CLAIM FOR EACH
VIOLATION.
DATE PROVIDER'S SIGNATURE IRSMN IDENTIFICATION NO. WCB RATING CODE
CitiMedical 1,PLLC IF NONE, SPECIALTY
08/24/2016 TIN: 46-1514006
CR-DRA
'LANGUAGE TO BE FILLED IN BY INSUREROR SELF-INSURER.
NYS FORM NF-3 (Rev 1/2004)
Page 3 of 3
_ _ . . . - .. .. - . . . . . .
09/13/2016 KPDCN201609130000823
FILED: NEW YORK COUNTY CLERK 04/24/2018 04:09 PM INDEX NO. 154804/2017
NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 04/24/2018
00001
'3
Date: 8/1/201 6 Farmacia Central Page: I
39-11 104th Street
Coron a NY 11368
Phone: (718)478-3908 Fax:(718)478-9761
oAoQ C
CLTENT : Gender M
CORWISE, DWAYNE DOB: 05/30/1968
98-15 HORACE HARDING EXP I.D.: CO29968NY 16
TEL: (929)329-9623
CORONA NY 11368
A LLERGIES No Known Allergies
Date
Filled/Ord
ered Rx#
08/01/2016 419795
Ref#
0/ 0
Drug Name
DICLOFENAC
NDC#
00115-1483.61
Qty/Dayg Prescdber Name Address
00.00 97-85 Qnssns
Amount
2363.92
1
NF2
~®0
2,363.92
per Pd R.Ph
0.00 AM
IUM 3%
05/17/2016 30 USHYAROV,
GEL o Pa NY
Mani
APPLY 3 GRAMS TO AFFECTED AREAS TWO TO THREE TIMES A DAY AS NEEDED FOR PAIN
Total Rx Count: 1 Total Amount : $2363.92
Total Patient Paid (Including Copay): $0.00
I
I
SATYA DRUG CORP
DBA
FARMACIA CENTRAL
TAX@ : 46-4782201
J
l
l
09/06/2016 KPDCN201609060000966
Preview
FILED: NEW YORK COUNTY CLERK 04/24/2018 04:09 PM INDEX NO. 154804/2017 NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 04/24/2018 FILED: NEW YORK COUNTY CLERK 04/24/2018 04:09 PM INDEX NO. 154804/2017 NYSCEF DOC. NO. 45 00026 RECEIVED NYSCEF: 04/24/2018 I INVOICE NUMBER 0027718 NEW YORK MOTOR VEHICLE NO-FAULT INSUR/ NCE LAW ' VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHE PROVIDER OF HEALTH SERVICE (This form is not verification of hospital treatment - NAME AND ADDRESS OF INSURER: - NAME )F INSURER'S CLAIM REPRESENTATIVFA -.,N_AME Kemper Insurance Company Jennife Burg P.O. Box 2845 Clinton, IA 52733-2845. DATE POLICY HOLDER POLICY NUMBER DATE 0 ACCIDENT CLAIM NUMBER 12/27/201 Corwise,Dwayne 16090301475 5/! 2016 CO29968NY16 I PROVIDER'S NAME AND ADDRESS. Corona Medical Plaza P.C. 104-08 Roosevelt Ave. COrOna, NY 11368 Tel: 718 426-6500 KINDLY COMPLETE AND SUBMIT THIS FORM S SOON AS POSSIBLE. PLEASE NO"E, THIS COMPLETED FORM MUST BE SUBMITTEDTO THE INSURERAS SOON AS REASONABLY POSSIBLE BUT FOT LATER THAN 45 DAYS AFTER THE TREATMENT DATE, DEPENDINGUPON THE POLICY ENDORSEMENTIN EFFECTAT THE ?lME OF THE ACCIDENT.IP YOU ARE UNSUREOF THE4PPLICABLE TIME REQUIREMENT,KINDLY CONTACTTHE CLAIMS RE?RESENTATNE TO DETERMINE WHICH DEADLINE IS A'PPLICABLE TO THIS CLAlM. IFYOU HAVEPREVIOUSLYSUBMITTEDAN EARUERREPORTON THE ACCIDENT,YOU NEED ONLYNOTEANY CHANGESFROMTHE INFORMATION PREVIOUSLYFURNISHEDAND ADDITIONALCHARGES. 1. PATIENT'S NAME AND ADDRESS: Salguedo Angela 102-23 Horace Harding Exp. . Apt2A, Corona, NY 1368 2. DATE OF BIRTH 3. SEX FEMALE 4, OCCUPATION f known) . 5. DIAGNOSIS AND CONCURRENT CONDITIONS: . 724.5 - Back painO 723.1 - Neck pain (Cervicajgia) 722.0 - Displacement of Cé,rvical Disc w/o Elopathy 722.1 - Displacement of Lumbar Disc w/o Elopathy . . - . 844.9 - Sprains/strains of knee L R/0 Meniscal 836.2 -R/O tear L 840.4 - Rule out rotator edfEinjury L 840.9 - Shoulder Sprain/Strain L I 726.10 - Shoulder tendinitis L 923.0 - Shoulder ContusionL 6. WHEN DID SYMPTOMS FIRST APPEAR? 7. WHEN DID PATIENT IRST CONSULT YOU FOR THIS CONDITION? DATE: 5/ 9/2016 DATE: 5/17/2016 YES ~ 8. HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION? NO | X | 9. IS CONDITION SOLELY A RESULT OF THIS AUTOMOBILE ACCIDENT? If 'YES', state when and · ascribe: .scribe: YES I X Ñ0 If 'NO', explain: YES ~ 10. IS CONDITION DUE TO INJ0RY ARISING OUT OF PATIENT'S EMPLOYMENT? NO X 11. WILL INJURY RESULT INSlÖNIFICANT DISFlGUREMENT OR PERMANENT DISABILITY? . YES NO If 'YES', describe: NOT DEFRMINABLE AT THIS TIME| X 12. PATlENT WAS DISABLE (Unable to work) 13. IF STILL DISABLED 'HE PATIENT SHOULD BE ABLE TO FROM: THROUGH: RETURN TO WORF ON: . . Continue on next page (00968) . Page- 1 NYS FORM N-F 3 (Rev. 1/2004) 01/09/2017 KPDCN201701090000781 FILED: NEW YORK COUNTY CLERK 04/24/2018 04:09 PM INDEX NO. 154804/2017 NYSCEF DOC. NO. 45 00026 RECEIVED NYSCEF: 04/24/2018 o PATIENT'S NAME : Salguedo Angela INVOICE NUMBER 0027718 I 14. WILL THE PATIENT REQUIRË REHABILITATION AND/OR OCCUPATIONAL THERAPY AS A Fe !SULT OF THE INJURIES SUSTAINED IN -- THIS ACCIDENT' ACCIDENT? C „'" X YES NO IFYES', descdbeyour below: recornrnendation See doctor S report 15. REPORT OF SERVICES RENDERED - A-lTACH ADDITIONAL SHEETS IF NECESSARY o DATE OF PLACEOF SERVICE DESCRIPTIONOF TREATMENTOR FEESCHEDULE TOTALCHARGE SERVICE INCLUDINGZIP C6ÒE HEALTHSERVICESRENDERED TREA'TMENTCODES 12/ 1/2016 tooosRoosevelt Ave,Coroa,NY 11368 Follow Up 99214 $92.97 TOT·1 CHARGES TO DATE: $92.97 16. IF TREATING PROVIDER IS DIFFERENT THAN BILLING PROVIDER CÔMPLETE THE FOLLO VING: Treating Providcts Narne Title Licence or Certificate No. ._ E ssinessRelation ( check applicable box) Employee IndependentContractor Other (specify) *James Avellini M.D. 148049 Owner 17. IF THE PROVIDER OF SERVICE IS A PROFESSIONAL SERVICE CORPORATION OR DOING BUSINESS UNDER AN ASSUMED NAME (DBA), LIST THE OWNER AND PROFESSIONAL LICENSING CREDENTIALS OF ALL OWNERS (Provide an additional attachment if necessary). AveHini .M.D. 148049 18. IS PATIENT STILL UNDER OUR CARE FOR THIS CONDITION ? YES ~X .X . NO [ . 19. ESTlMATE DURATION OF FUTURE TREATMENT: Not determined at this time ti' as PATIENT: Your health provider may agree to accept for health services performed directly fro.n your insur r(Authorization to Pay Benefits) so that you are not required to make payment to the health provider at the time of service. Such agreement is optional on the part of the health provider and must be signed by both patient and healyh provider. You may use the optional authorization language provided below, by checking off the designated spot in item 20 of this form, 20._(IF YOU HAVE CHOSEN TO AUTHORIZE THE DIRECT PAYMENT OF BENEFITS BY CHECKING THIS OP'HON, YOU MAY NOT ALSO ENTER INTO AN ASSIGNMENT OF BENEFITS CONTAINED IN #21) I authorize payment of health benefits to the undersigned health care provider or supplier of serv:ces described.below. I retain all rights, privileges and remedies to which I am entitled under Article 51 (The No-Fault provision) of the insurance law. PRINTNAME SIGNED Patient Patient Date PATIENT: Your health provider may agree to have you assign your right to No-Fault benefits from·your insurer directly to your health provider (Assignment of Benefits). If you and your health provider agree to an assignmer t of benefits, you must both sign the agreement contained in #21 or the prescribed NF-AOB form or its equivalent. The language cont ded -sled in the assignment of benefits is mandatory -Jied and may not be altered or avoided by any other language added to this agreement or other writteragreement. 21. X (IF YOU HAVE CUOSEN TO ASSIGN YOUR BENEFITS TO THE HEALTH PROVIh $R BY CHECKING THIS OPTION, YOU MAY NOT ALSO ENTER INTO AN AUTHORIZATION TO PAY BENEFITS CONTAINED IN ITEM#2 , ABOVE) . I hereby assign to the health carte provider indicated below all right, privileges and remedies to pa. ent for health care services provided by the assignee to which I am entitled under article 51 (the No-Fault statute) of the insurance law. The a signee hereby-certifies that they have not received any payment from or on behalf of the assignor and shall not pursue payment directly from the assignor for services provided by said assignee for injuries sustained due to the motor vehicle accident, notwithstanding any other agreement to the emtrary. This agreement may be revoked by the assignee when benefits are not payable based upon the assignor's lack of coverage and/or violatics ' of a policy.condition due to the actions or conduct of the assignor. PRINT NAME Salguedo Angela SIGNED Signature on File Patient (Assignor) Patient Date PRINT NAME *James Avellini SIGNED_ Signature on File Provider ofHealth Care Service (Assignee) Provider of Health Care Service Date Has an Original authorization or assigmnent previously been executed? I X Yes ' ' ~ No IS the original sig nature of the parties on file? X ANY PERSONWHO KNOWINGLYÅND WITHINTENTTO DEFRAUDANY INSURANCECOMPANYOR OTHER ·EitSON FILESAN APPLICATIONFOR Yes ~ No COMMERCIALINSURANCEOR A STATEMENTOF CLAIMFOR ANY COMMERCIALOR PERSONALINSURA!QE BENEFITS CONTAININGMATERIALLYFALSE INFORMATIONOR CONCEALSFOR·THEPURPOSEOF MISLEADING.INFORMATIONCONCERNINGANY FA .TT MATERIALTHERETO,AND ANY PERSONWHO, IN CONNECTIONWITHSUCHA[PliLICATIONOR CLAIM,KNOWINGLYMAKESOR KNOWINGLYASSISTS,AE TS, SOLICITSrORCONSPlRESWITHANOTHERTO -'LE TO A LAW ENFORCEMENTAGENCY.THE MAKEA FALSE REPORTOFTHE THEFT, DESTRUCTION,DAMAGEOR CONVERSIONOFANY MOTORVEHICLE DEPARTMENTOF MOTORVEHICLEOR AN INSURANCECOMPANYCOMMITSA FRAUDULENTINSURANCETCT, WH1CHfS.A CRIME.AND SHALLALSO BE (00968) Page - 2 . NYS FORM N-F 3 (Rev. 'I/2004) 01/09/2017 KPDCN201701090000781 FILED: NEW YORK COUNTY CLERK 04/24/2018 04:09 PM INDEX NO. 154804/2017 NYSCEF DOC. NO. 45 00026 RECEIVED NYSCEF: 04/24/2018 . PATIENT'S NAME: Salguedo.Angela INVOICENUMBER0027718 SUBJECTTO A CML PENALTYNÓTTO EXEEDFIVETHOUSANDDOLLARSAND THE VALUE OF-0-lE SUBJE T MOTORVEHICLEORSTATEDCLAIMFOR EACH VIOLATION. DATE ' PROVIDER SlC9NATURE IRS/TIN lDENT I:-I,,' IFlC - TlON NO. WCB RATING CODE .. IF NONE, SPECIALTY TIN: 46-3655051 )/1/ ' ' — 12/27/2016 l *James Avellirii / / Lic# 148049 M.D. r \ I Page- 3 NYS FORM N-F 3 (Rev. 1/2004) (00968) 01/09/2017 KPDCN201701090000781 FILED: NEW YORK COUNTY CLERK 04/24/2018 04:09 PM INDEX NO. 154804/2017 NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 04/24/2018 00014 T DWAYNE CORWISE-8834-DQ14701 NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE (This form is not for verification of hospital treatment ) NAME AND ADDRESS OF INSURER OR SELF- NAME, ADDRESS, AND PHONE NUMBER OF INSURER* INSURER'S CLAIMS REPRESENTATIVE* KEMPER INSURANCE COMPANY P.O.BOX 2845, CLINTON, 10WA, 52733 DATE POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER 38/24/2016 09 May 2016 CO29968NY16 PROVIDER'S NAME AND ADDRESS* CitiMedical I PLLC 6555 Woodhaven Blvd, Rego Park, NEW YORK, 11374 KINDLY COMPLETE AND SUBMIT THIS FORM AS SOON AS POSSIBLE. PLEASE NOTE, THIS COMPLETED FORM MUST BE SUBMITTED TO THE INSURER AS SOON AS REASONABLY POSSlBLE BUT No LATER THAN 45 DAYS AFTER THE TREATMENT DATE, DEPENDING UPON THE POLICY ENDORSEMENT IN EFFECT AT THE TIME OF THE ACCIDENT. IFiOU ARE UNSURE OF THE APPLICABLE TIME REQUIREMENT, KINDLY CONTACT THE CLAIMS REPRESENTATIVE TO DETERMINE WHICH DEADLINE IS APPLICABLE TO THIS CLAIM. IF YOU HAVE PREVIOUSLY SUBMITTED AN EARLIER REPORT ON THIS ACCIDENT, YOU NEED ONLY NOTE ANY CHANGES FROM THE INFORMATION PREVIOUSLY FURNISHED AND ADDITIONAL CHARGES. 1. PATIENT'S NAME AND ADDRESS DWAYNE CORWISE 8 LONE OAK CIRCLE, RENFIELD, NEW YORK, 11368 o nATF OF BIRTH 3. SEX 4. OCCUPATION (IF KNOWN) Male 5. DIAGNOSIS AND CONCURRENT CONDITIONS I M53.0 Cervicocranial syndrome, M54.12 Radiculopathy, cervical region, M54.2 Cervicaigia, 6. WHEN DID SYMPTOMS FIRST APPEAR? 7. WHEN DID PATIENT FIRST CONSULT YOU FOR THIS DATE: 09 May 2016 CONDITION7 DATE: 03 Aua 2016 8. HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION? YES I — II NO I X I IF'YES, state when and describe: 9. IS CONDITION SOLELY A RESULT OF THIS AUTOMOBILE ACCiDENT? YES I X | NO | | IF "NO", explain: 10. IS CONDITION DUE TO )NJURY ARISING OUT OF PATIENT'S EMPLOYMENT7 YES I I NO I X 11. WILL INJURY RESULT IN SIGNIFICANT DISFlGUREMENT OR PERMANENT DISABILITY? YES I NO | NOT DETERMINABLE AT THIS TIME X IF "YES", describe: 12. PATIENT WAS DISABLED (UNABLE TO WORK) 13. IF STILL DISABLED THE PATIENT SHOULD BE ABLE TO RETURN TO WORK ON: FROM: THROUGH: (DATE) CONTINUE ON PAGE 2 NYS FORM NF-3 (Rev 1/2004) Page 1 of 3 09/13/2016 KPDCN201609130000823 FILED: NEW YORK COUNTY CLERK 04/24/2018 04:09 PM INDEX NO. 154804/2017 NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 04/24/2018 00014 DWAYNE CORWISE-8834-DQ14701 14. WILL THE PATIENT REQUIRE REHABILITATION AND/OR OCCUPATIONAL THERAPY AS A RESULT OF THE INJURIES SUSTAINED IN THIS ACCIDENT? YES X NO IF YES, describe your recommendation below: See Doctor's Repolt 15.REPORT OF SERVICESRENDERED - ATTACH ADDITIONAL SHEETS IF NECESSARY Date of Pláce of Service Description of Treatment or Health Service Fee Schedule Treitment Charges Service Including Zip Code Rendered Code 08/03/2016 6555WoodhavenBlvd.,LL,RegoMRTCervical-Spine w/ocontrast 72141 S879.73 Park,NY11374 TOTAL CHARGES TO DATE S 879.73 NYS FORM NF-3 (Rev 1/2004) Page2 of3 . __ . _. . ... . . . _. - .- . .. . .. 09/13/2016 KPDCN201609130000823 FILED: NEW YORK COUNTY CLERK 04/24/2018 04:09 PM INDEX NO. 154804/2017 NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 04/24/2018 00014 DWAYNE CORWISE-8834-DQ14701 VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE PAGE 3 16. IF TREATING PROVIDER IS DIFFERENT THAN BILLING PROVIDER COMPLETE THE FOLLOWING: TREATING PROVIDER'S LICENSEOR BUSINESSRELATIONSHIP NAME CERTIFICATIONNO. CHECKAPPLICABLEBOX EMPLOYEE INDEPENDENT OTHER(SPEClFY) Michael Green, MD Lic # 120848 YES CONTRACTOR 17. IF THE PROVIDER OF SERVICE IS A PROFESSIONAL SERVICE CORPORATION OR DOING BUSINESS UNDER AN ASSUMED NAME (DBA), LIST THE OWNER AND PROFESSIONAL LICENSING CREDENTIALS OF ALL OWNERS (Provide an additional attachment if necessary). CiUMedical 1,PLLC 18. IS PATIENT STILL UNDER YOUR CARE FOR THIS CONDITION? YES X NO 19. ESTIMATED DURATION OF FUTURE TREATMENT Not Determined at this time PATIENT: Your health provider may agree to accept payment for health services performed directly from your insurer (Authorization to Pay Benefits) so that you are not required to make payment to the health provider at the time of service. Such agreement is optional on the part of the health provider and must be signed by both patient and health provider. You may use the optional authorization language provided below, by checking off the designated spot in item 20 of this form. 20, (lF YOU HAVE CHOSENTO AUTHORIZETHE DIRECTPAYMENT OF BENEFITS BY CHECKINGTHIS OPTION.YOU MAY NOT ALSD ENTER |NTO AN ASSIGNMENT OF BENEFITSCONTAINEDIN #21) AUTHORIZATIONTO PAY BENEFITS: I AUTHORIZE PAYMENT OF HEALTH BENEFlTS To THE UNDERSIGNED HEALTH CARE PROVIDER OR SUPPLIER OF SERVICES DESCRIBED BELOW. I RETAIN ALL RIGHTS, PRIVILEGES AND REMED1ES TO WHICH I AM ENTITLED UNDER ARTICLE 51 (THE NO-FAULT PROVISION) OF THE INSURANCE LAW. PRINT NAME SIGNED PATIENT PATIENT DATE PATIENT: Your health provider may agree to have you assign your right to No-Fault benefits from your Insurer directly to your health provider (Assignment of Benefits). If you and your health provider agree to an assignment of benefits, you must both sign the agreement contained In # 21 or the prescribed NF-AOB form or its equivalent. The language contained in the assignment of benefits is mandatory and may not be altered or avoided by any other language added to this agreement or other written agreement. 21. X (IFYOU HAVE CHOSENTO ASSIGN YOUR BENEFITSTO THE HEALTH PROVIDERBY CHECKINGTHIS OPTION,YOUMAY NOT ALSO ENTER INTO AN AUTHOR7ZATIONTO PAY BENEFlTS CONTAINEDIN ITEM #20 ABOVE) ASSIGNMENT OF NO-FAULT BENEFITS: I HEREBY ASSIGN TO THE HEALTH CARE PROVIDER INDICATED BELOW ALL R3GHTS, PR1V3LEGES AND REMEDIES TO PAYMENT FOR HEALTH CARE SERVICES PROVIDED BY THE ASStGNEE TO WHICH I AM ENTITLED UNDER ARTICLE 51 (THE NO-FAULT STATUTE) OF THE 3NSURANCE LAW. THE ASSIGNEE HEREBY CERTIFIES THAT THEY HAVE NOT RECEIVED ANY PAYMENT FROM OR ON BEHALF OF THE ASS3GNOR AND SHALL NOT PURSUE PAYMENT DIRECTLY FROM THE ASSIGNOR FOR SERVICES PROV3DED BY SAID ASSIGNEE FOR INJURIES SUSTA1NED DUE TO THE MOTOR VEHICLE£ ACC3DENT, NOTWITHSTANDING ANY OTHER AGREEMENT TO THE CONTRARY. THIS AGREEMENT MAY BE REVOKED BY THE ASS1GNEE WHEN BENEFITs ARE NOT PAVABLE BASED UPON THE ASSIGNOR*S LACK OF COVERAGE AND/OR V3OLATION OF 4 POLICY CONDITION DUE TO THE ACTIONS OR CONDUCT OF THE ASSIGNOR PRINT NAME DWAYNE CORWISE SIGNED Signature on file PATIENT (Assignor) DATE -. ...... PRINT NAME CitiMedical I PLLC SIGNED lSIGNED PROVIDER OFHEALTHCARESERVICE(Assignee) PROVIDER OF HEALTH CARE SERVICE DATE HAS AN ORIGINAL AUTHORIZATION OR ASSIGNMENT PREVlOUSLY BEEN EXECUTED? YES x NO IS THE ORIGINAL SIGNATURE OF THE PARTIES ON FILE7 YES ~S NO ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFlTS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLTCITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRtME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED F1VE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEH1CLE Ok STATED CLAIM FOR EACH VIOLATION. DATE PROVIDER'S SIGNATURE IRSMN IDENTIFICATION NO. WCB RATING CODE CitiMedical 1,PLLC IF NONE, SPECIALTY 08/24/2016 TIN: 46-1514006 CR-DRA 'LANGUAGE TO BE FILLED IN BY INSUREROR SELF-INSURER. NYS FORM NF-3 (Rev 1/2004) Page 3 of 3 _ _ . . . - .. .. - . . . . . . 09/13/2016 KPDCN201609130000823 FILED: NEW YORK COUNTY CLERK 04/24/2018 04:09 PM INDEX NO. 154804/2017 NYSCEF DOC. NO. 45 RECEIVED NYSCEF: 04/24/2018 00001 '3 Date: 8/1/201 6 Farmacia Central Page: I 39-11 104th Street Coron a NY 11368 Phone: (718)478-3908 Fax:(718)478-9761 oAoQ C CLTENT : Gender M CORWISE, DWAYNE DOB: 05/30/1968 98-15 HORACE HARDING EXP I.D.: CO29968NY 16 TEL: (929)329-9623 CORONA NY 11368 A LLERGIES No Known Allergies Date Filled/Ord ered Rx# 08/01/2016 419795 Ref# 0/ 0 Drug Name DICLOFENAC NDC# 00115-1483.61 Qty/Dayg Prescdber Name Address 00.00 97-85 Qnssns Amount 2363.92 1 NF2 ~®0 2,363.92 per Pd R.Ph 0.00 AM IUM 3% 05/17/2016 30 USHYAROV, GEL o Pa NY Mani APPLY 3 GRAMS TO AFFECTED AREAS TWO TO THREE TIMES A DAY AS NEEDED FOR PAIN Total Rx Count: 1 Total Amount : $2363.92 Total Patient Paid (Including Copay): $0.00 I I SATYA DRUG CORP DBA FARMACIA CENTRAL TAX@ : 46-4782201 J l l 09/06/2016 KPDCN201609060000966