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Filing # 181011601 E-Filed 09/01/2023 02:34:59 PM
»
AFFIDAVIT OF SERVICE
Case: Court: County: Job:
2022- IN THE CIRCUIT COURT FOR THE FIFTH JUDICIAL CIRCUIT LAKE 9157522
CA IN AND FOR LAKE COUNTY, STATE OF FLORIDA
2134
Plaintiff / Petitioner: Defendant / Respondent:
MELISSA MAGLIO, an Individual DOLGENCORP, LLC, a Foreign Limited Liability Company
Received by: For:
JB FLORIDA PROCESS SERVICE RTI-ETC.
To he served upon:
RECORDS CUSTODIAN AND/OR REPRESENTATIVE OF DR, LANGHEIER & DR. RAVIPATI INJURY HEALTHCARE
I certify that | am over the age of 18, am in good standing and have no interest in the above action, | have been properly certified as a
process server by Administrative Order A2008-21B and am currently certifled to serve process pursuant to the provisions of the order,
Under penalties of Perjury, | declare | have read this document and the facts stated in it are true, NO NOTARY REQUIRED PURSUANT TO FS,
92,525(2)
Recipient Name / Address: RECORDS CUSTODIAN AND/OR REPRESENTATIVE OF DR. LANGHEIER & DR, RAVIPATI INJURY HEALTHCARE, 402
WHIGHLAND BLVD, INVERNESS, FL 34452
Manner of Service: Authorized, Jul 11, 2023, 9:50 am EDT
Documents: SUBPOENA DUCES TECUM WITHOUT DEPOSITION, DEFENDANT'S CERTIFICATE OF NON-OBJECTION,
CERTIFICATE OF SERVICE, (Recelved
Jul 6, 2023 at 12:23pm EDT)
Additional Comments:
1) Successful Attempt: Jul 11, 2023, 9:50 am EDT at 402 W HIGHLAND BLVD, INVERNESS, FL 34452 received by RECORDS CUSTODIAN AND/OR
REPRESENTATIVE OF DR. LANGHEIER & DR, RAVIPATI INJURY HEALTHCARE. Age: 30-35; Ethnicity: Caucasian; Gender: Male; Welght: 185;
Height: 6'0"; Halr: Brown; Eyes: Green;
UPON ARRIVAL TO THE LISTED ADDRESS | SUCCESSFULLY SERVED THE DESIGNATED AUTHORIZED AGENT JASON H. ON BEHALF OF THE
LISTED RECIPIENT, ALL LISTED DOCUMENTS WITH DATE AND TIME ENDORSED BY ME.
Melissa Dunn
Mtn Oh 07/24/2023
Date
102221-2
RTI-ETC,
P.O, Box 600253
ST JOHNS, FL 32260
FILED: LAKE COUNTY, GARY J. COONEY, CLERK, 09/01/2023 02: 4PM
IN THE CIRCUIT COURT, FIFTH
JUDICIAL CIRCUIT, IN AND FOR
LAKE COUNTY, FLORIDA.
CASE NO,: 2022-CA-002134
MELISSA MAGLIO,
an individual,
Plaintiff,
VS,
DOLGENCORP, LLC,
a Foreign Limited Liability Company
Defendant,
/
SUBPOENA DUCES TECUM WITHOUT DEPOSITION
IN COMPLIANCE WITH HIPAA REQUIREMENT (e)(1)(iii)(a) PROPER NOTICE HAS
BEEN SERVED ON COUNSEL AND THERE HAS BEEN NO OBJECTION MADE TO
OBTAINING THESE RECORDS, THE MATERIAL RECEIVED PURSUANT TO THIS
SUBPOENA MAY BE USED FOR TRIAL AND FOR OTHER PURPOSES AS ARE
PERMITTED UNDER THE APPLICABLE FLORIDA STATUTES AND FLORIDA RULES
OF CIVIL PROCEDURE AND IT MAY BE DISCLOSED TO OTHER PERSONS.
THE STATE OF FLORIDA
TO: Records Custodian and/or Representative
Dr, Langheier & Dr. Ravipati
Injury Healthcare
402 W. Highland Blvd.
Inverness, FL 34452
YOU ARE COMMANDED to produce without deposition and deliver by mail no later
than’ to ST, DENIS & DAVEY, P.A., 1300 Riverplace Boulevard, Suite
401, Jacksonville, FL 32207, the following items listed on the attached “Schedule A”,
THIS SUBPOENA IS INTENDED TO BE BROAD ENOUGH TO COVER EVERY
SINGLE PIECE OF PAPER IN YOUR FILES CONCERNING THIS PERSON
You will not be required to surrender the original items. You may comply with this
subpoena by providing legible copies of the items to be produced to the attorney whose name
be
appears on this subpoena on or before the scheduled date of production. The copies must
legible as to the date of occurrence, date of execution and/or preparation, You may condition
the preparation of the copies upon the payment in advance of the reasonable cost of preparation.
You may mail or deliver the copies to the attorney whose name appears on this subpoena at the
time and place specified above. 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: (a) furnish the records as provided above; or (b) object to this
subpoena, you may be in contempt of court. You are subpoenaed by the following attorneys and,
unless excused from this subpoena by these attorneys or the Court, you shall respond to this
subpoena as directed,
Appropriate notice of this subpoena has been given to all parties to this action according to
Fla. R. Civ. P, 1.351(b).
DATED on February i , 2023,
KACIE K. HUTCHINSON, ESQUIRE
For the Court
ST. DENIS & DAVEY, P.A.
KACTE K. HUTCHINSON, ESQUIRE
Florida Bar Number 016121
kacie@sdtriallaw.com
1300 Riverplace Boulevard, Suite 401
Jacksonville, FL 32207
(904) 396-1996 — Telephone
(904) 396-1991 — Facsimile
Attorney for Defendant
IN ACCORDANCE WITH THE AMERICANS WITH DISABILITIES ACT, PERSONS WITH DISABILITIES NEEDING A SPECIAL
ACCOMMODATION TO PARTICIPATE IN THIS PROCEEDING SHOULD CONTACT ST. DENIS & DAVEY, P.A. 1300 RIVERPLACE
BOULEVARD, SUITE 401, JACKSONVILLE, FLORIDA 32207, TELEPHONE (904)396-1996, NO LATER THAN SEVEN (7) DAYS PRIOR
TO THE PROCEEDING. IF HEARING IMPAIRED (TDD) 1-800-955-8771, OR VOICE (V) 1-800-955-8770, VIA FLORIDA RELAY
SERVICE.
Schedule A - MEDICAL RECORDS/ FILMS/ BILLING
A copy of your entire file(s) on the patient to include but not limited to:
All medical records, history forms, patient intake forms, medical records, documentation, reports,
charts, notes memoranda, phone call correspondence, notes, messages, intake sheets, all reports,
records and documentation received from other medical providers, requests made to other
providers, patient’s file folder itself and any attachments made a part of the file folder, all contents
of file folder(s), and all other records pertaining to patient,
All films and diagnostic raw data (ie, x-tay, MRIs, CT scan films), diagnostic
impressions/findings, radiology reports, computer generated reports, and all other records
pertaining to patient,
All billing, invoicing, accounts receivable, accounts payable, Assignment of Benefits forms,
“Signature on File” forms, doctot’s liens, all HCFA/CMS-1500 forms and/or UB-92/UB-04 forms
(whichever applicable), statements of accounts, insurance claim forms, outstanding balance forms,
computer generated billing (to include but not limited to the HCPCS/CPT & ICD-9 codes and
charges), statements of accounts, insurance acknowledgements, and all other records pertaining to
patient.
PATIENT: Melissa Claire Maglio f/k/a Melisaa Claire Scardino
DOB:
SSN:
THIS SUBPOENA IS INTENDED TO BE BROAD ENOUGH TO COVER EVERY
SINGLE PIECE OF PAPER IN YOUR FILES CONCERNING THIS PERSON.
IN THE CIRCUIT COURT, FIFTH
JUDICIAL CIRCUIT, IN AND FOR
LAKE COUNTY, FLORIDA
CASE NO.: 2022-CA-002134
‘
MELISSA MAGLIO,
an individual,
Plaintiff,
VS,
DOLGENCORP, LLC,
a Foreign Limited Liability Company
Defendant.
/
EREND, ?S CERTIFICATE OF NON-OBJECTION
Defendant, DOLGENCORP, LLC, by and through its undersigned counsel and pursuant
to Rule 1.351 of the Florida Rules of*Civil Procedure, hereby gives notice that the Plaintiff,
MELISSA MAGLIO, was provided with the Notice of Production from Non-Party and Subpoena
Duces Tecum without Deposition for Records, dated the 14" day of February, 2023; that no
objection from Plaintiff's counsel to the aforesaid subpoena was received by Defendant’s counsel:
and that Plaintiff's counsel waived the time period in which to object to the issuance of the
aforesaid,
J, Records Custodian and/or Representative
T-Mobile
4 Sylvan Way
Parsippany, NJ 07054
Records Custodian and/or Representative
Terramia Ristorante
1150 Douglas Avenue, #1150
Altamonte Springs, FL 32174
3. Records Custodian and/or Representative
Kemper Auto Infinity Insurance
c/o Chief Financial Officer
200 E, Gaines Street
Tallahassee, F1 32399
Records Custodian and/or Representative
GEICO Indemnity Company
c/o Chief Financial Officer
200 E. Gaines Street
Tallahassee, Fl 32399
Records Custodian and/or Representative
Walgreens Co,
1901 E. Voorhees Street
MS 735
Danville, IL 61834
Records Custodian and/or Representative
CVS Privacy Office
One CVS Drive
Woonsocket, RI 02895
Records Custodian and/or Representative
Dr. Steven K, Brooks
515 W. State Road 434, Suite 302,
Longwood, FL 32750
Records Custodian and/or Representative
AdventHealth Altamonte Springs
601 E. Altamonte Drive
Altamonte Springs, FL 32701
Records Custodian and/or Representative
HCA Florida Citrus Hospital
502 W. Highland Blvd.
Inverness, FL 34452
10. Records Custodian and/or Representative
Tampa Back Institute
6536 Gunn Hwy
Tampa, FL 33625
11. Records Custodian and/or Representative
Lake Medical Imaging
Sharon L. Morse Medical Center
1400 US 441, #510
The Villages, FL 32159
12. Records Custodian and/or Representative
Citrus Open MRI Center
2687 B, Gulf Lake Hwy
Inverness, FL 34453
13, Records Custodian and/or Representative
UF Health Leesburg Hospital
600 E, Dixie Avenue
Leesburg, FL 34748
14. Records Custodian and/or Representative
Integrity Medical Group
17820 Southeast 109" Ave.
Summerfield, FL 34491
15, Records Custodian and/or Representative
Dr. Langheier & Dr. Ravipati
Injury Healthcare
402 W. Highland Bivd,
Inverness, FL 34452
16. Records Custodian and/or Representative
Dr, Nivedita Mathur
7074 Grove Road
Brooksville, FL 34609
17, Records Custodian and/or Representative
Dr. Gurnani Parmanand
3787 E, Gulfto Lake Hwy .
Tnverness, FL 34453
18. Records Custodian and/or Representative
Optical Outlets
3922 Suncoast Blvd.
Homosassa, FL 34448
19, Records Custodian and/or Representative
Dr. Kumar
405 N, Central Avenue
Inverness, FL 34453
20, Records Custodian and/or Representative
Poshmark Headquarters
203 Redwood Shores Parkway, 8" Floor
Redwood City, CA 94065
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a copy of the foregoing has been furnished via the Florida
Courts E-Filing Portal System,to Lisa.M. Nommensen, Esquire, Law Office of ‘Nooney, Roberts,
Hewett & Nowicki, 1680 Emerson Street, Jacksonville, FL 32207, lisa@nrhnlaw.com, and.
meneil@nthnlaw.com, Attorney for Plaintiff, on this afte day of February, 2023.
ST. DENIS & DAVEY, P.A.
Cc
KACIEK ‘HUTCHINSON, ESQUIRE
Florida Bar Number 016121
kacie@sdtriallaw.co
1300 Riverplace Boulevard, Suite 401
Jacksonville, Florida 32207
(904) 396-1996 — Telephone
(904) 396-1991 — Facsimile
Attorneys for Dolgencorp, LLC
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Filing # 181011601 E-Filed 09/01/2023 02:34:59 PM » AFFIDAVIT OF SERVICE Case: Court: County: Job: 2022- IN THE CIRCUIT COURT FOR THE FIFTH JUDICIAL CIRCUIT LAKE 9157522 CA IN AND FOR LAKE COUNTY, STATE OF FLORIDA 2134 Plaintiff / Petitioner: Defendant / Respondent: MELISSA MAGLIO, an Individual DOLGENCORP, LLC, a Foreign Limited Liability Company Received by: For: JB FLORIDA PROCESS SERVICE RTI-ETC. To he served upon: RECORDS CUSTODIAN AND/OR REPRESENTATIVE OF DR, LANGHEIER & DR. RAVIPATI INJURY HEALTHCARE I certify that | am over the age of 18, am in good standing and have no interest in the above action, | have been properly certified as a process server by Administrative Order A2008-21B and am currently certifled to serve process pursuant to the provisions of the order, Under penalties of Perjury, | declare | have read this document and the facts stated in it are true, NO NOTARY REQUIRED PURSUANT TO FS, 92,525(2) Recipient Name / Address: RECORDS CUSTODIAN AND/OR REPRESENTATIVE OF DR. LANGHEIER & DR, RAVIPATI INJURY HEALTHCARE, 402 WHIGHLAND BLVD, INVERNESS, FL 34452 Manner of Service: Authorized, Jul 11, 2023, 9:50 am EDT Documents: SUBPOENA DUCES TECUM WITHOUT DEPOSITION, DEFENDANT'S CERTIFICATE OF NON-OBJECTION, CERTIFICATE OF SERVICE, (Recelved Jul 6, 2023 at 12:23pm EDT) Additional Comments: 1) Successful Attempt: Jul 11, 2023, 9:50 am EDT at 402 W HIGHLAND BLVD, INVERNESS, FL 34452 received by RECORDS CUSTODIAN AND/OR REPRESENTATIVE OF DR. LANGHEIER & DR, RAVIPATI INJURY HEALTHCARE. Age: 30-35; Ethnicity: Caucasian; Gender: Male; Welght: 185; Height: 6'0"; Halr: Brown; Eyes: Green; UPON ARRIVAL TO THE LISTED ADDRESS | SUCCESSFULLY SERVED THE DESIGNATED AUTHORIZED AGENT JASON H. ON BEHALF OF THE LISTED RECIPIENT, ALL LISTED DOCUMENTS WITH DATE AND TIME ENDORSED BY ME. Melissa Dunn Mtn Oh 07/24/2023 Date 102221-2 RTI-ETC, P.O, Box 600253 ST JOHNS, FL 32260 FILED: LAKE COUNTY, GARY J. COONEY, CLERK, 09/01/2023 02: 4PM IN THE CIRCUIT COURT, FIFTH JUDICIAL CIRCUIT, IN AND FOR LAKE COUNTY, FLORIDA. CASE NO,: 2022-CA-002134 MELISSA MAGLIO, an individual, Plaintiff, VS, DOLGENCORP, LLC, a Foreign Limited Liability Company Defendant, / SUBPOENA DUCES TECUM WITHOUT DEPOSITION IN COMPLIANCE WITH HIPAA REQUIREMENT (e)(1)(iii)(a) PROPER NOTICE HAS BEEN SERVED ON COUNSEL AND THERE HAS BEEN NO OBJECTION MADE TO OBTAINING THESE RECORDS, THE MATERIAL RECEIVED PURSUANT TO THIS SUBPOENA MAY BE USED FOR TRIAL AND FOR OTHER PURPOSES AS ARE PERMITTED UNDER THE APPLICABLE FLORIDA STATUTES AND FLORIDA RULES OF CIVIL PROCEDURE AND IT MAY BE DISCLOSED TO OTHER PERSONS. THE STATE OF FLORIDA TO: Records Custodian and/or Representative Dr, Langheier & Dr. Ravipati Injury Healthcare 402 W. Highland Blvd. Inverness, FL 34452 YOU ARE COMMANDED to produce without deposition and deliver by mail no later than’ to ST, DENIS & DAVEY, P.A., 1300 Riverplace Boulevard, Suite 401, Jacksonville, FL 32207, the following items listed on the attached “Schedule A”, THIS SUBPOENA IS INTENDED TO BE BROAD ENOUGH TO COVER EVERY SINGLE PIECE OF PAPER IN YOUR FILES CONCERNING THIS PERSON You will not be required to surrender the original items. You may comply with this subpoena by providing legible copies of the items to be produced to the attorney whose name be appears on this subpoena on or before the scheduled date of production. The copies must legible as to the date of occurrence, date of execution and/or preparation, You may condition the preparation of the copies upon the payment in advance of the reasonable cost of preparation. You may mail or deliver the copies to the attorney whose name appears on this subpoena at the time and place specified above. 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: (a) furnish the records as provided above; or (b) object to this subpoena, you may be in contempt of court. You are subpoenaed by the following attorneys and, unless excused from this subpoena by these attorneys or the Court, you shall respond to this subpoena as directed, Appropriate notice of this subpoena has been given to all parties to this action according to Fla. R. Civ. P, 1.351(b). DATED on February i , 2023, KACIE K. HUTCHINSON, ESQUIRE For the Court ST. DENIS & DAVEY, P.A. KACTE K. HUTCHINSON, ESQUIRE Florida Bar Number 016121 kacie@sdtriallaw.com 1300 Riverplace Boulevard, Suite 401 Jacksonville, FL 32207 (904) 396-1996 — Telephone (904) 396-1991 — Facsimile Attorney for Defendant IN ACCORDANCE WITH THE AMERICANS WITH DISABILITIES ACT, PERSONS WITH DISABILITIES NEEDING A SPECIAL ACCOMMODATION TO PARTICIPATE IN THIS PROCEEDING SHOULD CONTACT ST. DENIS & DAVEY, P.A. 1300 RIVERPLACE BOULEVARD, SUITE 401, JACKSONVILLE, FLORIDA 32207, TELEPHONE (904)396-1996, NO LATER THAN SEVEN (7) DAYS PRIOR TO THE PROCEEDING. IF HEARING IMPAIRED (TDD) 1-800-955-8771, OR VOICE (V) 1-800-955-8770, VIA FLORIDA RELAY SERVICE. Schedule A - MEDICAL RECORDS/ FILMS/ BILLING A copy of your entire file(s) on the patient to include but not limited to: All medical records, history forms, patient intake forms, medical records, documentation, reports, charts, notes memoranda, phone call correspondence, notes, messages, intake sheets, all reports, records and documentation received from other medical providers, requests made to other providers, patient’s file folder itself and any attachments made a part of the file folder, all contents of file folder(s), and all other records pertaining to patient, All films and diagnostic raw data (ie, x-tay, MRIs, CT scan films), diagnostic impressions/findings, radiology reports, computer generated reports, and all other records pertaining to patient, All billing, invoicing, accounts receivable, accounts payable, Assignment of Benefits forms, “Signature on File” forms, doctot’s liens, all HCFA/CMS-1500 forms and/or UB-92/UB-04 forms (whichever applicable), statements of accounts, insurance claim forms, outstanding balance forms, computer generated billing (to include but not limited to the HCPCS/CPT & ICD-9 codes and charges), statements of accounts, insurance acknowledgements, and all other records pertaining to patient. PATIENT: Melissa Claire Maglio f/k/a Melisaa Claire Scardino DOB: SSN: THIS SUBPOENA IS INTENDED TO BE BROAD ENOUGH TO COVER EVERY SINGLE PIECE OF PAPER IN YOUR FILES CONCERNING THIS PERSON. IN THE CIRCUIT COURT, FIFTH JUDICIAL CIRCUIT, IN AND FOR LAKE COUNTY, FLORIDA CASE NO.: 2022-CA-002134 ‘ MELISSA MAGLIO, an individual, Plaintiff, VS, DOLGENCORP, LLC, a Foreign Limited Liability Company Defendant. / EREND, ?S CERTIFICATE OF NON-OBJECTION Defendant, DOLGENCORP, LLC, by and through its undersigned counsel and pursuant to Rule 1.351 of the Florida Rules of*Civil Procedure, hereby gives notice that the Plaintiff, MELISSA MAGLIO, was provided with the Notice of Production from Non-Party and Subpoena Duces Tecum without Deposition for Records, dated the 14" day of February, 2023; that no objection from Plaintiff's counsel to the aforesaid subpoena was received by Defendant’s counsel: and that Plaintiff's counsel waived the time period in which to object to the issuance of the aforesaid, J, Records Custodian and/or Representative T-Mobile 4 Sylvan Way Parsippany, NJ 07054 Records Custodian and/or Representative Terramia Ristorante 1150 Douglas Avenue, #1150 Altamonte Springs, FL 32174 3. Records Custodian and/or Representative Kemper Auto Infinity Insurance c/o Chief Financial Officer 200 E, Gaines Street Tallahassee, F1 32399 Records Custodian and/or Representative GEICO Indemnity Company c/o Chief Financial Officer 200 E. Gaines Street Tallahassee, Fl 32399 Records Custodian and/or Representative Walgreens Co, 1901 E. Voorhees Street MS 735 Danville, IL 61834 Records Custodian and/or Representative CVS Privacy Office One CVS Drive Woonsocket, RI 02895 Records Custodian and/or Representative Dr. Steven K, Brooks 515 W. State Road 434, Suite 302, Longwood, FL 32750 Records Custodian and/or Representative AdventHealth Altamonte Springs 601 E. Altamonte Drive Altamonte Springs, FL 32701 Records Custodian and/or Representative HCA Florida Citrus Hospital 502 W. Highland Blvd. Inverness, FL 34452 10. Records Custodian and/or Representative Tampa Back Institute 6536 Gunn Hwy Tampa, FL 33625 11. Records Custodian and/or Representative Lake Medical Imaging Sharon L. Morse Medical Center 1400 US 441, #510 The Villages, FL 32159 12. Records Custodian and/or Representative Citrus Open MRI Center 2687 B, Gulf Lake Hwy Inverness, FL 34453 13, Records Custodian and/or Representative UF Health Leesburg Hospital 600 E, Dixie Avenue Leesburg, FL 34748 14. Records Custodian and/or Representative Integrity Medical Group 17820 Southeast 109" Ave. Summerfield, FL 34491 15, Records Custodian and/or Representative Dr. Langheier & Dr. Ravipati Injury Healthcare 402 W. Highland Bivd, Inverness, FL 34452 16. Records Custodian and/or Representative Dr, Nivedita Mathur 7074 Grove Road Brooksville, FL 34609 17, Records Custodian and/or Representative Dr. Gurnani Parmanand 3787 E, Gulfto Lake Hwy . Tnverness, FL 34453 18. Records Custodian and/or Representative Optical Outlets 3922 Suncoast Blvd. Homosassa, FL 34448 19, Records Custodian and/or Representative Dr. Kumar 405 N, Central Avenue Inverness, FL 34453 20, Records Custodian and/or Representative Poshmark Headquarters 203 Redwood Shores Parkway, 8" Floor Redwood City, CA 94065 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy of the foregoing has been furnished via the Florida Courts E-Filing Portal System,to Lisa.M. Nommensen, Esquire, Law Office of ‘Nooney, Roberts, Hewett & Nowicki, 1680 Emerson Street, Jacksonville, FL 32207, lisa@nrhnlaw.com, and. meneil@nthnlaw.com, Attorney for Plaintiff, on this afte day of February, 2023. ST. DENIS & DAVEY, P.A. Cc KACIEK ‘HUTCHINSON, ESQUIRE Florida Bar Number 016121 kacie@sdtriallaw.co 1300 Riverplace Boulevard, Suite 401 Jacksonville, Florida 32207 (904) 396-1996 — Telephone (904) 396-1991 — Facsimile Attorneys for Dolgencorp, LLC