Preview
Filing # 149304115 E-Filed 05/10/2022 02:32:36 PM
IN THE CIRCUIT COURT OF THE
FIFTH JUDICIAL CIRCUIT IN AND
FOR LAKE COUNTY, FLORIDA
CASE NO: 35-2021-CA-001632-AXXX-XX
xxxxxxx xxxxxxx
Plaintiff(s),
vs.
KAYLA MCCURDY, MARK MCCURDY,
INDIVIDUALS AND GEICO GENERAL
INSURANCE COMPANY, A FOREGIN
CORPORATION
Defendant(s).
/
NOTICE OF PRODUCTION FROM NON-PARTY FOR DOCUMENTS
YOU ARE HEREBY notified that after (10) days from the date of service of this notice via email, if
no objection is received from any party, the undersigned will issue or apply to the Clerk of the Court for
issuance of the attached subpoenas directed to the records custodians from:
1. Nizam Razack, MD, 7460 Docs Grove Circle, Orlando, FL 32819 (All Available (FL))
who are non-parties to this suit, to produce the items listed at the time and place specified in the subpoena,
under the provisions of Florida Rules of Civil Procedure 1.351.
FILED: LAKE COUNTY, GARY J. COONEY, CLERK, 05/10/2022 02:35:34 PM.
CERTIFICATE OF SERVICE
The document contains no confidential or sensitive information or that any such confidential or
sensitive language has been properly protected by complying with the provisions of Rule 2.420 and 2.425.
THEREBY CERTIFY that a true copy of the foregoing has been furnished via email on the following
date: May 10, 2022, to the below listed recipients:
Eben C. Self, Esquire, Law Offices of Eben C. Self, 207 E Livingston St, Orlando, FL 32801,
ebenself@yahoo.com, Opposing Counsel
On Behalf Of:
Law Office of Sarah E. Blazak
111 North Orange Avenue
Suite 1600
Orlando, FL 32801
Telephone: 407-648-8236
By!”
Tan Walters, Esquire
Florida Bar No. 0106782
IN THE CIRCUIT COURT OF THE
FIFTH JUDICIAL CIRCUIT IN AND
FOR LAKE COUNTY, FLORIDA
CASE NO: 35-2021-CA-001632-AXXX-XX
xxxxxxx xxxxxxx
Plaintiff(s),
vs.
KAYLA MCCURDY, MARK MCCURDY,
INDIVIDUALS AND GEICO GENERAL
INSURANCE COMPANY, A FOREGIN
CORPORATION
Defendant(s).
SUBPOENA DUCES TECUM WITHOUT DEPOSITION
TO: Nizam Razack, MD
7460 Does Grove Circle
Orlando, FL 32819
Attn: Records Department
You are commanded to provide by mail to ISG, Brentwood Towne Centre, 101 Towne Square Way,
Suite 251, Pittsburgh, PA, 15227, or electronically to www.litsol.com/filemail on or before 06/12/2022, the
following for:
Plaintiff / Claimant: xxxxxxx Allen xxxxxxx
Date Of Birth: Information provided in Addendum A to protect privacy
Social Security No.: Information provided in Addendum A to protect privacy
Please remit: a complete copy of any and all documents (listed below) in your possession:
¢ MEDICAL records (office records, doctors and nurses notes, insurance records, claim forms,
medical records with respect to any injury or illness, medical history, consultations, treatment,
patient questionnaires, progress notes, laboratory reports, hospital and/or emergency room records
(Emergency Room Physician Notes, Emergency Room Nurses Notes, Emergency Room Discharge
Summaries/Orders, Emergency Room Prescriptions, etc.), reports of diagnostic and surgical
procedures and any other data pertaining to the diagnosis, treatment and care of the patient)
* BILLING RECORDS (statements reflecting charges, payments, and balance owing) and any
corresponding audit trail documents.
¢ ALIST PRIOR TO PRODUCTION of any and all DUPLICATES OF ALL X-RAYS, MRI, CT
SCAN FILMS of the cervical, thoracic, lumbar spine, TMJ, hips, pelvis, and/or extremities.
All records requested should be all-inclusive and should be in no way limited to one date of incident
The records should include any notations on the file jacket as well and any and all reports or
correspondence of other physicians or hospitals included in your file and all correspondence or any
other record of any kind or nature that you have in your possession regarding the treatment of
Plaintiff including, but not limited all records from the first date of treatment to the present. Please
also include a copy of the treating physicians CV. PLEASE SEND ALL FILM CDS IN DICOM
FORMAT AND BE SURE TO INCLUDE A LIST OF ALL STUDIES CONTAINED ON ANY
RESPONSIVE CD.
These items will be inspected and may be copied at that time. You will not be required to surrender the
original items. You may comply with this subpoena by providing legible one-sided copies of the items to
be produced to ISG or the attorney whose name appears on this subpoena on or before the date of
production. Please provide a copy of this Subpoena with your records. You may condition the
preparation of the copies upon the payment in advance of the reasonable cost of preparation. You may mail
the copies to ISG or to the attorney whose name appears on this subpoena and thereby eliminate the need to
appear at a deposition. You have the right to object to the production pursuant to this subpoena at any time
before production by giving written notice to the attorney whose name appears on this subpoena. THIS
WILL NOT BE A DEPOSITION. NO TESTIMONY WILL BE TAKEN. If you fail to: (1) furnish the
records as described above; or (2) fail to object to this subpoena, you may be in contempt of Court. You are
subpoenaed by the attorney whose name appears on this subpoena and unless excused from this subpoena
by the attorney or the Court, you shall respond to this subpoena as directed. If prepayment of service
charges is necessary, please fax a copy of the invoice to the following individual handling this matter
at ISG: Lauren Surdyk at phone number 412-253-1108 and fax number 412-785-3758.
Dated On:
For the Court: CERTIFICATION OF COMPLIANCE WITH HIPAA.
REQUIREMENTS FOR SUBPOENA OF MEDICAL RECORDS
Law Office of Sarah E. Blazak
111 North Orange Avenue Thereby certify that written notice has been provided to the
Suite 1600 individual, or the attorney for the individual, whose documents
are sought, that the notice included sufficient information
Orlando, FL 32801 about the litigation or proceeding to permit the individual to
raise an objection to the production of the requested
documents, and that the time to raise an objection has elapsed
and no objections were filed. These records will be used for this
litigation only and will be destroyed after litigation is
completed. This certificate is provided in the absence of an
executed authorization or Court Order pursuant to 45CFR.
164.512.
—
Signed By:~
Tan Walters, Esquire
Florida Bar No. 0106782
In accordance with the Americans with Disabilities Act, persons with disabilities needing a special
accommodation to participate in this proceeding should contact ISG (866-574-7378) on behalf of
Jan Walters, Esquire, no later than seven (7) days prior to the due date of the records.
xxxxxxx xxxxxxx
IN THE CIRCUIT COURT OF THE
FIFTH JUDICIAL CIRCUIT IN AND FOR
Plaintiff(s),
LAKE COUNTY, FLORIDA
vs.
CASE NO: 35-2021-CA-001632-AXXX-XX
Kayla McCurdy, Mark McCurdy, individuals and Geico General
Insurance Company, a foregin corporation
Defendant(s).
CERTIFICATE OF COMPLIANCE WITH SUBPOENA
DUCES TECUM WITHOUT DEPOSITION
| hereby certify by signing below that | have (___)/ have not ) provided a true and complete copy of the documents requested
in the subpoena served on this facility regarding xxxxxxx Allen xxxxxxx.
Please remit: a complete copy of any and all documents (listed below) in your possession:
MEDICAL records (office records, doctors and nurses notes, insurance records, claim forms, medical records with respect to any
injury or illness, medical history, consultations, treatment, patient questionnaires, progress notes, laboratory reports, hospital and/or
emergency room records (Emergency Room Physician Notes, Emergency Room Nurses Notes, Emergency Room Discharge
Summaries/Orders, Emergency Room Prescriptions, etc.), reports of diagnostic and surgical procedures and any other data
pertaining to the diagnosis, treatment and care of the patient)
BILLING RECORDS (statements reflecting charges, payments, and balance owing) and any corresponding audit trail documents.
ALIST PRIOR TO PRODUCTION of any and all DUPLICATES OF ALL X-RAYS, MRI, CT SCAN FILMS of the cervical, thoracic,
lumbar spine, TMu, hips, pelvis, and/or extremities.
All records requested should be all-inclusive and should be in no way limited to one date of incident. The records should include any
notations on the file jacket as well and any and all reports or correspondence of other physicians or hospitals included in your file
and all correspondence or any other record of any kind or nature that you have in your possession regarding the treatment of
Plaintiff including, but not limited all records from the first date of treatment to the present. Please also include a copy of the treating
physicians CV. PLEASE SEND ALL FILM CDS IN DICOM FORMAT AND BE SURE TO INCLUDE A LIST OF ALL STUDIES
CONTAINED ON ANY RESPONSIVE CD.
If documents have not been provided, it is due to: (check one)
We have no documents regarding this person
We do not have the specific documents / dates in our files
Our documents are destroyed after years
The documents are in the possession of:
Other (please specify):
Printed Name Signature
Name of Facility or Provider of Records
Date
Nizam Razack, MD
7460 Docs Grove Circle
Orlando, FL 32819
ADDENDUM A
Complete Legal Name: xxxxxxx Allen xxxxxxx
Date of Birth:
Social Security Number:
Other relevant information needed to locate
information requested:
Preview
Filing # 149304115 E-Filed 05/10/2022 02:32:36 PM IN THE CIRCUIT COURT OF THE FIFTH JUDICIAL CIRCUIT IN AND FOR LAKE COUNTY, FLORIDA CASE NO: 35-2021-CA-001632-AXXX-XX xxxxxxx xxxxxxx Plaintiff(s), vs. KAYLA MCCURDY, MARK MCCURDY, INDIVIDUALS AND GEICO GENERAL INSURANCE COMPANY, A FOREGIN CORPORATION Defendant(s). / NOTICE OF PRODUCTION FROM NON-PARTY FOR DOCUMENTS YOU ARE HEREBY notified that after (10) days from the date of service of this notice via email, if no objection is received from any party, the undersigned will issue or apply to the Clerk of the Court for issuance of the attached subpoenas directed to the records custodians from: 1. Nizam Razack, MD, 7460 Docs Grove Circle, Orlando, FL 32819 (All Available (FL)) who are non-parties to this suit, to produce the items listed at the time and place specified in the subpoena, under the provisions of Florida Rules of Civil Procedure 1.351. FILED: LAKE COUNTY, GARY J. COONEY, CLERK, 05/10/2022 02:35:34 PM. CERTIFICATE OF SERVICE The document contains no confidential or sensitive information or that any such confidential or sensitive language has been properly protected by complying with the provisions of Rule 2.420 and 2.425. THEREBY CERTIFY that a true copy of the foregoing has been furnished via email on the following date: May 10, 2022, to the below listed recipients: Eben C. Self, Esquire, Law Offices of Eben C. Self, 207 E Livingston St, Orlando, FL 32801, ebenself@yahoo.com, Opposing Counsel On Behalf Of: Law Office of Sarah E. Blazak 111 North Orange Avenue Suite 1600 Orlando, FL 32801 Telephone: 407-648-8236 By!” Tan Walters, Esquire Florida Bar No. 0106782 IN THE CIRCUIT COURT OF THE FIFTH JUDICIAL CIRCUIT IN AND FOR LAKE COUNTY, FLORIDA CASE NO: 35-2021-CA-001632-AXXX-XX xxxxxxx xxxxxxx Plaintiff(s), vs. KAYLA MCCURDY, MARK MCCURDY, INDIVIDUALS AND GEICO GENERAL INSURANCE COMPANY, A FOREGIN CORPORATION Defendant(s). SUBPOENA DUCES TECUM WITHOUT DEPOSITION TO: Nizam Razack, MD 7460 Does Grove Circle Orlando, FL 32819 Attn: Records Department You are commanded to provide by mail to ISG, Brentwood Towne Centre, 101 Towne Square Way, Suite 251, Pittsburgh, PA, 15227, or electronically to www.litsol.com/filemail on or before 06/12/2022, the following for: Plaintiff / Claimant: xxxxxxx Allen xxxxxxx Date Of Birth: Information provided in Addendum A to protect privacy Social Security No.: Information provided in Addendum A to protect privacy Please remit: a complete copy of any and all documents (listed below) in your possession: ¢ MEDICAL records (office records, doctors and nurses notes, insurance records, claim forms, medical records with respect to any injury or illness, medical history, consultations, treatment, patient questionnaires, progress notes, laboratory reports, hospital and/or emergency room records (Emergency Room Physician Notes, Emergency Room Nurses Notes, Emergency Room Discharge Summaries/Orders, Emergency Room Prescriptions, etc.), reports of diagnostic and surgical procedures and any other data pertaining to the diagnosis, treatment and care of the patient) * BILLING RECORDS (statements reflecting charges, payments, and balance owing) and any corresponding audit trail documents. ¢ ALIST PRIOR TO PRODUCTION of any and all DUPLICATES OF ALL X-RAYS, MRI, CT SCAN FILMS of the cervical, thoracic, lumbar spine, TMJ, hips, pelvis, and/or extremities. All records requested should be all-inclusive and should be in no way limited to one date of incident The records should include any notations on the file jacket as well and any and all reports or correspondence of other physicians or hospitals included in your file and all correspondence or any other record of any kind or nature that you have in your possession regarding the treatment of Plaintiff including, but not limited all records from the first date of treatment to the present. Please also include a copy of the treating physicians CV. PLEASE SEND ALL FILM CDS IN DICOM FORMAT AND BE SURE TO INCLUDE A LIST OF ALL STUDIES CONTAINED ON ANY RESPONSIVE CD. These items will be inspected and may be copied at that time. You will not be required to surrender the original items. You may comply with this subpoena by providing legible one-sided copies of the items to be produced to ISG or the attorney whose name appears on this subpoena on or before the date of production. Please provide a copy of this Subpoena with your records. You may condition the preparation of the copies upon the payment in advance of the reasonable cost of preparation. You may mail the copies to ISG or to the attorney whose name appears on this subpoena and thereby eliminate the need to appear at a deposition. You have the right to object to the production pursuant to this subpoena at any time before production by giving written notice to the attorney whose name appears on this subpoena. THIS WILL NOT BE A DEPOSITION. NO TESTIMONY WILL BE TAKEN. If you fail to: (1) furnish the records as described above; or (2) fail to object to this subpoena, you may be in contempt of Court. You are subpoenaed by the attorney whose name appears on this subpoena and unless excused from this subpoena by the attorney or the Court, you shall respond to this subpoena as directed. If prepayment of service charges is necessary, please fax a copy of the invoice to the following individual handling this matter at ISG: Lauren Surdyk at phone number 412-253-1108 and fax number 412-785-3758. Dated On: For the Court: CERTIFICATION OF COMPLIANCE WITH HIPAA. REQUIREMENTS FOR SUBPOENA OF MEDICAL RECORDS Law Office of Sarah E. Blazak 111 North Orange Avenue Thereby certify that written notice has been provided to the Suite 1600 individual, or the attorney for the individual, whose documents are sought, that the notice included sufficient information Orlando, FL 32801 about the litigation or proceeding to permit the individual to raise an objection to the production of the requested documents, and that the time to raise an objection has elapsed and no objections were filed. These records will be used for this litigation only and will be destroyed after litigation is completed. This certificate is provided in the absence of an executed authorization or Court Order pursuant to 45CFR. 164.512. — Signed By:~ Tan Walters, Esquire Florida Bar No. 0106782 In accordance with the Americans with Disabilities Act, persons with disabilities needing a special accommodation to participate in this proceeding should contact ISG (866-574-7378) on behalf of Jan Walters, Esquire, no later than seven (7) days prior to the due date of the records. xxxxxxx xxxxxxx IN THE CIRCUIT COURT OF THE FIFTH JUDICIAL CIRCUIT IN AND FOR Plaintiff(s), LAKE COUNTY, FLORIDA vs. CASE NO: 35-2021-CA-001632-AXXX-XX Kayla McCurdy, Mark McCurdy, individuals and Geico General Insurance Company, a foregin corporation Defendant(s). CERTIFICATE OF COMPLIANCE WITH SUBPOENA DUCES TECUM WITHOUT DEPOSITION | hereby certify by signing below that | have (___)/ have not ) provided a true and complete copy of the documents requested in the subpoena served on this facility regarding xxxxxxx Allen xxxxxxx. Please remit: a complete copy of any and all documents (listed below) in your possession: MEDICAL records (office records, doctors and nurses notes, insurance records, claim forms, medical records with respect to any injury or illness, medical history, consultations, treatment, patient questionnaires, progress notes, laboratory reports, hospital and/or emergency room records (Emergency Room Physician Notes, Emergency Room Nurses Notes, Emergency Room Discharge Summaries/Orders, Emergency Room Prescriptions, etc.), reports of diagnostic and surgical procedures and any other data pertaining to the diagnosis, treatment and care of the patient) BILLING RECORDS (statements reflecting charges, payments, and balance owing) and any corresponding audit trail documents. ALIST PRIOR TO PRODUCTION of any and all DUPLICATES OF ALL X-RAYS, MRI, CT SCAN FILMS of the cervical, thoracic, lumbar spine, TMu, hips, pelvis, and/or extremities. All records requested should be all-inclusive and should be in no way limited to one date of incident. The records should include any notations on the file jacket as well and any and all reports or correspondence of other physicians or hospitals included in your file and all correspondence or any other record of any kind or nature that you have in your possession regarding the treatment of Plaintiff including, but not limited all records from the first date of treatment to the present. Please also include a copy of the treating physicians CV. PLEASE SEND ALL FILM CDS IN DICOM FORMAT AND BE SURE TO INCLUDE A LIST OF ALL STUDIES CONTAINED ON ANY RESPONSIVE CD. If documents have not been provided, it is due to: (check one) We have no documents regarding this person We do not have the specific documents / dates in our files Our documents are destroyed after years The documents are in the possession of: Other (please specify): Printed Name Signature Name of Facility or Provider of Records Date Nizam Razack, MD 7460 Docs Grove Circle Orlando, FL 32819 ADDENDUM A Complete Legal Name: xxxxxxx Allen xxxxxxx Date of Birth: Social Security Number: Other relevant information needed to locate information requested: