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Filing # 157577243 E-Filed 09/16/2022 01:26:13 PM
IN THE CIRCUIT COURT FOR THE FIFTH JUDICIAL CIRCUIT
IN AND FOR LAKE COUNTY, FLORIDA
ERLENE FEDRICK,
Plaintiff,
Case No.: 2022-CA-754
Vv.
PATRICK DONALD HENES and
ARCH INSURANCE COMPANY, a
Foreign Profit Corporation,
Defendants.
/
DEFENDANT, ARCH INSURANCE COMPANY’S MOTION TO
COMPEL DISOVERY
Defendant, ARCH INSURANCE COMPANY (“ARCH”), by and through undersigned
counsel and pursuant to Fla. R. Civ. P. 1.380, hereby files this Motion to Compel Discovery and
in support thereof states:
1 On June 9, 2022, ARCH served upon Plaintiff a Request to Produce and
Interrogatories (attached hereto as Composite Exhibit A).
2. Plaintiff failed to respond to the discovery within 30 days as required, and did not
seek an extension to respond.
3 On September 2, 2022, the undersigned sent an e-mail to Plaintiff's counsel
advising of the overdue discovery responses, and providing a September 9, 2022 deadline to
provide responses lest ARCH move to compel same (e-mail attached as Exhibit B).
4 To date, Plaintiff has failed to provide the requested discovery responses.
FILED: LAKE COUNTY, GARY J. COONEY, CLERK, 09/16/2022 03:14:15 PM.
5 ARCH cannot properly defend itself from this suit without Plaintiff's discovery
Tesponses.
6 The undersigned certifies that ARCH has made a good-faith effort to obtain the
discovery responses without court intervention (including waiting nearly two months after the
original deadline to advise Plaintiffs counsel of the discovery violation).
WHEREFORE the Defendant, ARCH INSURANCE COMPANY, respectfully requests
the Court to enter an Order compelling Plaintiff to respond to ARCH’S Interrogatories and Request
to Produce and to award ARCH fees and costs associated with preparing and hearing of this
Motion.
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of this Motion to Compel has been
served via the Florida E-Filing Portal to all counsel of records on this 16th day of September 2022.
/s/ Troy Beecher
TROY BEECHER, ESQ.
Florida Bar No.: 37348
GOLDBERG SEGALLA LLP
800 N. Magnolia Avenue, Suite 450
Orlando, Florida 32803
Phone: (407) 458-5612
Fax: (407) 458-5699
tbeecher@goldbergsegalla.com
psouza@goldbergsegalla.com
sherndon@goldbergsegalla.com
EXHIBIT A
Filing # 151174265 E-Filed 06/09/2022 12:15:30 PM
IN THE CIRCUIT COURT OF THE FIFTH JUDICIAL CIRCUIT,
IN AND FOR LAKE COUNTY, FLORIDA
ERLENE FEDRICK, CASE NO.: 2022-CA-000754
Plaintiff,
Vv.
PATRICK DONALD HENES and
ARCH INSURANCE COMPANY,
Defendants.
/
DEFENDANT ARCH INSURANCE COMPANY’S FIRST REQUEST TO PRODUCE TO
PLAINTIFF ERLENE FEDRICK
Defendant, ARCH INSURANCE COMPANY, by and through the undersigned attorneys
and pursuant to Rule 1.350, Florida Rules of Civil Procedure, hereby requests the Plaintiff,
ERLENE FEDRICK, to produce the following:
DEFINITIONS
The following definitions apply to terms as they are used in this discovery request,
regardless of tense or whether the terms are used in the singular, plural or possessive case:
a. “You” and “your” refers to the party to whom this discovery request is addressed,
including the party’s employees and agents, if any, and all other individuals acting or purporting
to act on the party’s behalf.
b “Person” and/or “Persons” includes the plural and singular versions of people and
also includes a natural person, corporation, partnership, joint venture, association, government
agency, organization, firm, commission, board, or agency.
Cc. “Entity” includes all corporations, partnerships, sole proprietorships, individuals
and “person” as that term is defined in these definitions.
d. "Document" means any electronically stored, written, typed, recorded, or graphic
matter, however produced, of any type or description, whether sent or received, including both
sides of originals, known identical copies, and drafts, and including, without limitation, e-mails,
papers, books, letters, correspondence, telegrams, bulletins, notices, announcements,
instructions, charts, manuals, brochures, schedules, cables, telex messages, memoranda, text
messages, notes, notation, accountants’ working papers, transcripts, minutes, agendas, reports,
33597856.v1
and recordings of telephone or other conversations, of interviews, of conferences, or of other
meetings, affidavits, statements, summaries, opinions, report studies, analyses, evaluations,
contracts, agreements, journals, statistical records, desk calendars, appointment books, diaries,
lists, tabulations, sound recordings, voicemail recordings, computer printouts, data processing
input and output, microfilms, and other records kept by electronic, photographic or mechanical
means, and things similar to any of the above, however denominated by, and any other
documents or electronically stored information.
€. “Communications” and “Correspondence” means any oral or written statement,
dialogue, colloquialism, discussion, conversation and/or agreement.
f. “Relate to,” “relating to” or “concerning” means to make a statement about,
discuss, describe, reflect, constitute, identify, deal with, refer to, be in connection with or akin to,
consist of, establish, comprise, list, evidence, substantiate or in any way pertain, in whole or in
part, to the subject.
8. “Plaintiff” means the Plaintiff named in the caption of this lawsuit.
h, When producing documents, documents should be identified to correspond with
the particular categories in this request.
L To “identify" a document means to state: (a) the identity of the person who
prepared the document; (b) the identity of the person who signed the document or in whose name
the document was issued; (c) the identity of each person to whom the document was addressed or
distributed; (d) the nature or substance of the document with sufficient particularity to facilitate
identification of the document. (To the extent you refuse to disclose the nature or substance of
the document, state the nature of the privilege and the circumstances on which you rely in
support of your claim); (e) the document’s date and, if the document bears no date, the date when
the document was prepared; and (f) the physical location and custodian of the document.
J To “identify" a person with reference to a natural person means to give the
person’s name, the person’s last known address, and, if employed, the name and address of that
person’s employer and job title or position. To identify a person who is not an individual means
to state the name and principal office of that person.
INSTRUCTIONS
a. Unless otherwise defined, all words and phrases used herein should be given their
usual meaning and interpreted in their common, ordinary style.
b. This request is continuing so as to require supplemental responses in the event
you, or any person acting on your behalf, obtain additional information between the time of the
original response and conclusion of the trial in this case.
C. With respect to those documents to which you may claim privilege, you are
requested to identify each such document, in writing, on or before the due date of the answers to
these document requests, together with the following information: the nature or description,
date, subject matter and author of the document, as well as the identity of all persons to whom
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the document was directed, addressed, or received, and the document request to which the
document corresponds. For each such document you are further required to state the basis for
your claim of privilege, attorneys’ work product, or trial preparation materials.
d In the event that any requested document or tangible thing is known to have
existed and cannot now be located or has been destroyed or discarded, that document or tangible
thing shall be identified by: (a) the last known custodian; (b) date of destruction or discard; (c)
the manner of destruction or discard; (d) the reason(s) for destruction or discard; (e) as to lost or
misplaced documents or tangible things, the efforts made to locate such documents or tangible
things; (f) a statement describing the document, including a summary of its contents, or the
tangible thing; (g) the identity of the author(s) or creator(s); and (h) persons to whom it was sent
or shown.
FIRST REQUEST TO PRODUCE TO PLAINTIFF ERLENE FEDRICK
1 Any and all of Plaintiff ERLENE FEDRICK’S medical bills, paid or owing, as a
result of the alleged accident involved in this lawsuit.
2 Any and all medical reports from any physician pertaining to the care and
treatment received by Plaintiff ERLENE FEDRICK asa result of the alleged accident herein.
3 Any and all hospital, physician, chiropractic, clinic, emergency room or other
health care provider records, x-rays, tomography studies, medical reports, and doctors’ reports,
related to or connected with any medical care or treatment rendered to Plaintiff ERLENE
FEDRICK related to the subject accident.
4 Any and all hospital, physician, chiropractic, clinic, emergency room records, x-
rays, tomography studies, medical reports, and doctors' reports, related to or connected with the
medical care and treatment rendered to Plaintiff ERLENE FEDRICK during the past ten (10)
years.
5 Any and all hospital, physician, chiropractic, clinic, emergency room or other
health care provider records, x-rays, tomography studies, operative reports, medical reports, and
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doctors' reports, specifically related to the pre-existing disease or physical defect that Plaintiff
ERLENE FEDRICK alleges to have been aggravated as a result of the incident.
6 Any and all hospital, physician, chiropractic, clinic, emergency room or other
health care provider records, x-rays, tomography studies, operative reports, medical reports, and
doctors' reports, specifically related to the permanent injury that Plaintiff ERLENE FEDRICK
alleges to have incurred as a result of the incident.
7
Any and all hospital, physician, chiropractic, clinic, emergency room or other
health care provider records, x-rays, tomography studies, operative reports, medical reports, and
doctors' reports, specifically related to the significant and permanent loss of an important bodily
function and/or permanent and significant scarring that Plaintiff ERLENE FEDRICK alleges to
have incurred as a result of the incident.
8. Any and all medical records, reports, and medical bills generated as a result of
any EMS, ambulance service, fire/rescue, or hospital transportation service, with regard to
transportation of Plaintiff ERLENE FEDRICK to a hospital on the date of the subject accident,
as a direct result of the subject accident.
9 Any and all medical records, reports, and medical bills generated as a result of
any EMS, ambulance service, fire/rescue, or hospital transportation service, with regard to
transportation of Plaintiff ERLENE FEDRICK to a hospital on any date after the date of the
subject accident, for which transportation was a direct result of the subject accident.
10. Signed copies of Plaintiff ERLENE FEDRICK’S Federal Income Tax returns for
the years 2015, 2016, 2017, 2018, 2019, 2020, and 2021.
11. Copies of all of Plaintiff ERLENE FEDRICK’S W-2 Withholding Tax Statements
and any and all other business records or income records and any other evidence of income for
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the years 2015, 2016, 2017, 2018, 2019, 2020, and 2021.
12. All evidence of income Plaintiff ERLENE FEDRICK earned in 2022 to date of
production.
13. For any year that a Federal Income Tax return has not been filed by Plaintiff
ERLENE FEDRICK, please produce proof of all earned income and all non-earned income for
those years.
14. Any and all photographs of the Plaintiff showing alleged injuries related to the
subject accident.
15. Any and all photographs of the accident scene and/or vehicles involved in the
subject accident.
16. Any and all police reports, and police investigation records and files of any type
regarding the subject accident from any police agency or department concerning the subject
accident.
17. Any and all repair estimates, invoices, photographs and other documentation
evidencing and depicting any repairs made to ERLENE FEDRICK’S vehicle subsequent to the
accident described in Plaintiff's Complaint allegedly as a result of the subject accident.
18. Any and all written or recorded statements taken of the Defendant.
19. Any and all written or recorded statements taken of witnesses.
20. Any and all diagrams, charts, maps or descriptions of the accident scene involved
in this accident.
21. Any and all records, papers, documents or other forms of evidence of any
agreements, covenants or promises reached between or with any party as to any settlements,
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covenants not to collect, limitations on collection or limitations on liability.
22. Any and all medical reports, records and bills from any doctor or hospital,
incurred by Plaintiff ERLENE FEDRICK for any injury sustained in subsequent accidents ot
incidents to the accident claimed herein.
23. Copies of any and all documentation, as well as any and all copies of payments or
other documentation made by collateral sources, reflecting benefits paid on behalf of Plaintiff
ERLENE FEDRICK for medical treatment, lost wages and/or property damage.
24. All documents supporting the Plaintiffs claim for economic damages in this
lawsuit and not produced in response to the preceding paragraphs.
25 A copy of Plaintiff ERLENE FEDRICK’S Driver's License, front and back.
26 Copy of Plaintiff ERLENE FEDRICK’S Social Security card.
27 Copy of Plaintiff ERLENE FEDRICK’S most recent Social Security Statement.
28 Copy of Plaintiff ERLENE FEDRICK’S Application(s) for Social Security
Disability, if applicable, and response(s) thereto.
29. Copy of any and all documents evidencing payments to Plaintiff ERLENE
FEDRICK from the Social Security Administration as a result of any application(s) for Social
Security Disability.
30. Any and all statements, explanation of benefits, notices, letters, notes, memoranda
or other documents, however titled and in whatever form, detailing, listing, explaining or
itemizing all payments made by any third party for the damages and medical, hospital or other
health care services provided to Plaintiff ERLENE FEDRICK as a result of the alleged accident.
(For purposes of this request for production, "any third party" includes but is not limited to any
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federal, state, local or other public program providing medical expenses payments; any health,
accident or sickness insurance providing insurance benefits or medical expenses payments; any
contract or agreement of any group, organization, partnership or corporation to provide, pay for
or reimburse the costs of your hospital, medical or other health care services; Medicare;
Medicaid, and Workers' Compensation Law).
31. Any and all statements, explanation, notices, letter, notes, memoranda or other
documents, however titled and in whatever form, detailing, listing, explaining and itemizing any
third party's claims of right of subrogation or reimbursement for any amounts paid or payable
and the amount of each third party's claim.
32. Any and all documents evidencing prior or current lawsuits of any kind, wherein
Plaintiff ERLENE FEDRICK is/was a Plaintiff or Defendant, Claimant or Respondent, including
small claims matters, and excluding the current matter. This request is for any lawsuit during
Plaintiff ERLENE FEDRICK’S lifetime, and requests any and all documents from any court. If
you are not in possession of the documents, please identify state and court filed, opposing party,
and any other identifiable information so as to allow this Defendant to obtain records.
33. A complete copy of all health insurance policies in effect for insuring Plaintiff
ERLENE FEDRICK during the last five (5) years.
34. A complete copy of all automobile insurance policies in effect for insuring
Plaintiff ERLENE FEDRICK during the last five (5) years, with the exception of any Arch
Insurance Company policies.
35. Copies of any letters of protection, or similar document, given by the Plaintiff or
anyone acting on behalf of the Plaintiff to any health care provider regarding the charges of the
health care provider.
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36. A complete copy of the report of each person who the Plaintiff expects to call as
an expert witness at trial.
37. A copy of any general or partial release executed by the Plaintiff as a result of the
accident which is the subject matter of this lawsuit.
38. A complete copy of any settlement agreement, or in the alternative, a complete
copy of any document acting as a tentative settlement agreement, between the Plaintiff and any
other person or entity relating to the subject accident.
39. A fully executed Florida Medicaid Authorization for use and Disclosure of
Protected Health Information attached hereto and marked as Exhibit “A”.
40. A fully executed Medicare Consent to Release attached hereto and marked as
Exhibit “B”.
Al. A fully executed Social Security Administration Consent for Release of
Information attached hereto and marked as Exhibit “C”.
42. A fully executed Request for Social Security Earning Information attached hereto
and marked as Exhibit “D.”
43. Any and all cellular telephone records for any cellular telephone owned, leased,
rented, in control of and in Plaintiff ERLENE FEDRICK’S possession on the date and time of
the subject accident evidencing voice calls, text messaging, data usage and transfer of any type.
44. Any and all writs of garnishment levied against Plaintiff ERLENE FEDRICK.
45. Any and all criminal records of Plaintiff ERLENE FEDRICK in Plaintiffs
possession.
46. Any and all photographs of any and all vacations Plaintiff ERLENE FEDRICK
has taken since the date of the subject accident.
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CERTIFICATE OF SERVICE
WE HEREBY CERTIFY that the foregoing has been electronically filed and served via
Florida ePortal to: Devry R. Kelly, Esq., Dan Newlin Injury Attorneys, 7335 W. Sand Lake
Road, Suite 300, Orlando, FL 32819 at devry.kelley@newlinlaw.com;
patricia.croc@newlinlaw.com; devry.pleadings@newlinlaw.com; on June 09, 2022.
GOLDBERG SEGALLA, LLP
800 North Magnolia Ave., Suite 450
Orlando, FL 32803
Telephone: (407)458-5600
/s/ Troy Beecher
Troy Beecher, Esquire
Florida Bar No.: 37348
Email: theecher@goldbersegalla.com
sherndon@goldbergsegalla.com;
psouza@golbergsegalla.com
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EXHIBIT “A”
Authorization for the Use and Disclosure of Protected Health
Information
Information Identifying the Individual Whose Records Are Being Requested
Name of Individual: SSN:
Disclosure of your Social Security Number is not mandatory. The Agency for Health Care Administration (AHCA or Agency) may request
your Social Security Number pursuant to Section 119.071, Florida Statutes. If provided, the Agency will use your information for purposes
of finding the requested information.
Individual’s Street Address:
City: State: Zip Code:
Medicaid 1D or Gold Card Number:
Phone Number: Date of Birth:
Provide the specific dates of service included. From: To: ———
Purpose for this disclosure:
Date | wish this authorization to expire (expires in one year if no date is provided):
Oo I direct AHCA to mail the requested hard copy records to the below person(s), group or entity:
Documents Requested: Cpaia Claims Records Cc] Denied Claims Records oO All Claims Records
O Other:
Name:
Street Address:
City: State: Zip Code:
Oo \ authorize the below person(s), group or entity to verbally discuss specific topics with AHCA:
The specific topics to be discussed are:
Name:
Lunderstand the following: | have the right to revoke this authorization at any time by writing to the Agency's Privacy Officer or
Officer. |
completing the revocation section on the second page of this form and sending it to the address listed for the Agency's Privacy
my revocation request. The information described above may
understand that any information previously disclosed would not be subject to
that ! am giving the Agency permission to disclose to and therefore my information may no longer be
be re-disclosed by the person or group
if the Agency
protected by Federal privacy regulations. 1 may inspect or request copies of any information disclosed by this authorization
initiated this request for disclosure. | may refuse to sign this authorization and my refusal to sign will not affect my ability to obtain
treatment, payment for health care services or eligibility for benefits.
drug, alcohol or
This form specifically includes authorization to provide documents related to sensitive health conditions including:
genetic diseases or tests,
substance abuse, psychological or psychiatric treatment, sickle cell anemia, birth control or family planning,
tuberculosis, and HIV/AIDS or STDs. To restrict sensitive information, see Page 2.
1 DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT.
Signature: Date:
Printed Name:
Legal Authority (If Other Than Individual):
must provide
If you are a legal representative of the person whose information you are requesting disclosure of, you
request this information (for example, power of attorney, guardianshi p papers,
documentation proving your legal authority to
Appointing Personal Representati ve, Letters of Administrati on).
health care surrogate form, Custody Order, Order
AHCA Form 1000-3003, Revised (AUG 2018) Page 1 of 2
Authorization for the Use and Disclosure of Protected Health
Information
Instructions for Completing this Form
1. ‘Complete the first page of this form and return it to: HIPAA Privacy Officer, Agency for Health Care Administration, 2727
Mahan Dr., MS #4, Tallahassee, FL 32308, Phone: 850-412-3960, Fax 850-414-6837
Email: HIPAAComplianceOffice@AHCA. MyFlorida.com.
2. Special types of health information have specific taws and rules that must be followed before that information may be
disclosed:
Hi : All information about HIV/AIDS and sexually transmitted diseases is
protected under Federal and State laws and cannot be disclosed without your written authorization unless otherwise provided in
the regulations, To release HIV/AIDS or STO information, this authorization must include a statement of the specific HIV/AIDS or
STD information you are giving the Agency permission to disclose. Re-disclosure of HIV/AIDS information is not allowed except in
compliance with law or with your written permission, To NOT INCLUDE this Information, Initial here.
Alcoh ol
or Drug Treatment: Alcohol and/or drug treatment records are protected under Federal and State Jaws and regulations
and cannot be disclosed without your written authorization, unless otherwise provided for in Federal and State laws or regulations.
To release alcohol and/or drug treatment information, this authorization must include a statement of the specific information
that you are giving the Agency permission to disclose (for example, “For the purposes of my assessment, treatment plan,
attendance, or discharge plan.”) Re-disclosure of your alcohol and/or drug treatment records is not allowed exceptincompliance
with law or with your written permission (see 45 CFRPart 2). To NOT INCLUDE this information, Initial here
Health Tre: : Mental health treatment records are protected under Federal and State laws and regulations and cannot
be disclosed without your written authorization unless otherwise allowed in Federal or State laws or regulations. To release
mental health treatment information, this authorization must include a statement of the specific information that you are giving the
Agency permission to disclose (for example, “For the purposes of my assessment, treatment plan, attendance, or discharge
plan.*) Disclosure of your psychotherapist’s notes needs separa te Re-disclosure of your mental health
written permission.
treatment records is not allowed except in compliance with law or with your writtenpermission. To NOT INCLUDE this information,
Initial here:
Revocation of Authorization
N.
DO NOT COMPLETE FOR A NEW AUTHORIZATION. THIS SECTION IS ONLY FOR REVOKING A PREVIOUS AUTHORIZATIO
your
Disclosure of your Social Security Number is not mandatory. The Agency for Health Care Administration may request
Social Security Number pursuant to Section 119.071, Florida Statutes.
Name Date of Birth
Phone Social Security|
Number
Medicaid ID Number or Gold Card Number
Street Address
City State Zip Code
to the
Thereby revoke my authorization for the Agency for Health Care Administration to disclose my protected health information
following person(s), group or entity:
Signature Date
Printed Name |Legal Relationship]
ito Individual
legal authority to revoke this
If you are the subject’s legal representative, you must provide documentation proving your
authorization. (For example, an authorization, power of attorney, guardianship papers, health care surrogate form, Order
Appointing Personal Representative , Letters of Administratio n).
AHCA Form 1000-3003, Revised (AUG 2018) Page 2 of 2
EXHIBIT “B”
Consent to Release
Liability Insurance (Including Self-Insurance), No-Fault Insurance,
or Workers’ Compensation
Where to find Information on “Consent to Release” vs. “Proof of Representation”
Please refer to the PowerPoint document on this website titled: “Rules and Model Language for ‘Proof of
Representation’ vs. ‘Consent to Release’ for Medicare Secondary Payer Liability Insurance (Including Self-
Insurance), No-Fault Insurance, or Workers’ Compensation” for detailed information on
e When to use a “consent to release” document vs. a “proof of representation” document,
e Appropriate content for both documents,
. The need for appropriate documentation when there are two layers of representatives involved (examples:
attorney | refers a case to attorney 2; the beneficiary’s guardian hires an attorney to pursue a liability
insurance claim) or when a beneficiary’s representative signs a “consent to release” document on the
beneficiary’s behalf,
What liability insurers (including self-insurers), no-fault insurers, and workers’ compensation entities must
have in order to obtain conditional payment information, and
e Use of agents by insurers’ or workers’ compensation.
General
‘A “consent to release” document is used by an individual or entity who does not represent the Medicare
beneficiary but is requesting information regarding the beneficiary’s conditional payment information. A
“consent to release” does not authorize the individual or entity to act on behalf of the beneficiary or make
decisions on behalf of the beneficiary.
Model Language
to
See attached. Use of the model language is not required, but any documentation submitted as a “Consent
Release” must include the information the model language requests.
Where to Submit a “ Consent to Release” document:
Liability Insurance, No-Fault Insurance, Workers’ Compensation:
NGHP
PO Box 138832
Oklahoma City, OK 73113
Fax: (405) 869-3309
MODEL LANGUAGE
NSE} RE! E
The language below should be used when you, a Medicare beneficiary, want to authorize someone other than
your attorney or other representative to receive information, including identifiable health information, from the
Centers for Medicare & Medicaid Services (CMS) related to your liability insurance (including self-insurance),
no-fault insurance or workers’ compensation claim.
4 (print your name exactly as shown on your Medicare card)
hereby authorize the CMS, its agents and/or contractors to release, upon request, information related to my
injury/illness and/or settlement for the specified date of injury/illness to the individual and/or entity listed
below:
HECK INLY ONE OF T! FOLLOWING TO ICATE WHO MAY RECEIVE INFORMATION
AND THEN PRINT THE REQUESTED INFORMATION:
(If you intend to have your information released to more than one individual or entity, you must complete a
separate release for each one.)
Insurance Company Workers’ Compensation Carrier Other
(Explain)
Name of entity:
Contact for above entity:
Address:
Address Line 2:
City/State/ZIP:
Telephone:
CHECK ONE OF THE FOLLOWING TO INDICATE HOW LONG CMS MAY RELEASE YOUR.
INF IRMATION
(The period you check will run from when you sign and date below.):
One Year Two Years Other
(Provide a specific period of time)
Iunderstand that I may revoke this “consent to release information” at any time, in writing.
MEDICARE BENEFICIARY INFORMATION AND SIGNATURE:
Beneficiary Signature: Date signed:
Note: If the beneficiary is incapacitated, the submitter of this document will need to include documentation
establishing the authority of the individual signing on the beneficiary’s behalf. Please visit
https://go.cms.gov/cobro for further instructions.
Medicare ID (The number on your Medicare card.):
Date of Injury/Illness:
EXHIBIT “C”
Social Security Administration Form Approved
Consent for Release of Information OMB No. 0960-0566
Instructions
for Using this Form
Com) ete this form only if you want us to give information or records about you, a minor, ora ally incompetent adult, to an
i
indivi idual or group (for example, a doctor or an insurance co! mpany). If you are the natural ag optive parent or legal guardian,
acting on behalf of a minor ild, may complete this form to release only the minor's non-medical records. We may charge a
fee for providing information unrelated to the administration of a program under the Social Security Act.
NOTE: Do not use this form to:
+ Request the release of medical records on behalf of a minor child. Instead, visit your local Social Security office or call our toll-
free number, 1-800-772-1213 (TTY-1-800-325-0778), or
+ Request detailed information about your earnings or employment history. Instead, complete and mail form SSA-7050-F4. You
can obtain form SSA-7050-F4 from your local Social Security office or online at .gOv! issa-
‘We will not honor this form unless all required fields are completed. An asteri isk (*) indicates a required field. Also, we will not
honor blanket requests for "any and all records" or the “entire file." You must specify the information you are requesting and you
must sign and date this form. We may charge a fee to release information for non-program purposes.
+ Fill in your name, date of birth, and social security number or the name, date of birth, and social security number of the person
to whom the requested information pertains.
+ Fill in the name and address of the person or organization where you want us to send the requested information.
+ Specify the reason you want us to release the information.
* Check the box next to the type(s) of information you want us to release including the date ranges, where applicable.
+ For non-medical information, you, the parent or the legal guardian acting on behalf of a minor child or legally incompetent adult,
must sign and date this form and provide a daytime phone number.
+ If you are not the individual to whom the requested information pertains, state your relationship to that person. We may require
proof of relationship.
Y AC ME!
Section 205(a) of the Social Security Act, as amended, authorizes us to collect the information requested on this form. We will
the records we maintain about you or to process your
Ise the information you provide to respond to yourrequesttt for acce:
request to release your records to a third party. You t have to prov
ide the requested information. ‘our response is
voluntary; however, we cannot honor your request to release information or records about you to another person or organization
without your consent. We rarely use the information rovided on this form for any purpose other than to respond to requests for
S
SSA records information. However, the Privacy Act (5 U.S.C. 552a(b)) permits us to disclose the information you provide on this
form in accordance with approved routine uses, which include ut are not limited to the following:
1.To
2.To
enable an agen or third pai
Fe
to assist Social Securit) y in establishing rights to Social Securit benefits and or coverage;
make determinations for eligi bility in similar health and income maintenance programs at the ede! ral, State, and local level;
3.To comply with Fede! ral laws requiring the disclosure of the information from our records;
4.To facilitate statistical research, aud it, or investigative activities necessary to assure the integrity of SSA programs.
We may also use the information you provi ide when we match records by computer. Computer matching programs compare our
records with those of other Federal, State, or local government ag encies. We use information from these matchi incorrect programs to
establish or verify a person's eligibility for Federally-funded or administered benefit programs and for repayment
ments or overpayments under these programs. Additional information regarding this form, routine uses of information, and
other Social Security programs is available on ‘our Internet website, www.socialsecurity.gov, or at your local Social Security office.
PAPERWORK REDUCTION ACT STATEMENT
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the
4 You do not need to answer these questions unless we display a val lid Office of Management and Budget edt
questions. SEND
number. We estimate that it will take about 3 minutes to read the instructions, ather the facts, and answer the
OR BRING THE COMPLETED FORM TO YOUR LOCAL SO! CIAL SECURI OFFICE. You can find your local Social
Security office through SSA's website a‘ . Offices are also listed under U.S. Government agencies
in your telephone directo! or you may call 1-801 }0-772-1213 (TYY 1-800-325-0778). You may send comments on our time
estimate above to: SSA, 6401 Securi ty Eid. Baltimore, MD 21235-6401. Send only comments relating to our time estimate
to this address, not the completed
Form SSA-3288 (11-2016) uf
Destroy Prior Editions
Social Security Administration Form Approved
Consent for Release of Information OMB No. 0960-0566
You must com lete all required fields. We will not honor your request unless all required fields are completed. (*Signifies a
required field. P "Ple ase complete these fields in case we need to contact you about the consent form).
TO: Social Security Administration
*My Full Name *My Date of Birth *My Social Security Number
(MMIDD/YYYY)
| authorize the Social Security Administration to release information or records about me to:
*NAME OF PERSON OR ORGANIZATION: *ADDRESS OF PERSON OR ORGANIZATION:
*| want this information released because:
We may charge a fee to release information for non-program purposes.
*Please release the following information selected from the list below:
Check at least one box. We will not disclose records unless you include date ranges where applicable.
4. [1] Verification of Social Security Number
2. [J Current monthly Social Security benefit amount
3. [J Current monthly Supplemental Security Income payment amount
4. [1] My benefit or payment amounts from date. to date
5. [1] My Medicare entitlement from date to date
6. [] Medical records from my claims folder(s) from date. to date.
If you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social
Security office.
7. (J Complete medical records from my claims folder(s)
8. (] Other record(s) from my file ( (We will not honor a request for “any and all records" or "the entire file." You must specify
other records; e.g., consultative exams, award/denial notices, benefit applications, appeals, questionnaires,
doctor reports, determinations.)
lam the Individual, to whom the requested in‘ formation or record applles, or the parent or legal guardian of a minor, or the
legal guardian of a legally incompetent adult. I declare under penalty of perjury (28 CFR § 16.41(d)(2004) that | have examined
all the information on this form and it is true an d correct to the best of my knowledge. | understand that anyone who knowingly
or willfully seeking or obtaining access to records about another person under false pretenses Is punishable by a fine of up to
$5,000. | also understand that | must pay al II applicable fees for requesting Information fora non-program-related purpose.
*Signature: *Date:
**Address: Daytime Phone:
Relationship (if not the subject of the record): ™Daytime Phone:
Witnesses must sign this form ONLY if the above si ni ature is by mark (X) . If signed by mark (X), two witnesses to the signing
fi
who know the signee must sign below and provide tl air full addresses. PI lease print the signee’s name next to the mark (X) on the
signature line above.
1.Signature of witness 2.Signature of witness
Address(Number and street,City,State, and Zip Code) Address(Number and street,City,State, and Zip Code)
Form SSA-3288 (11-2016) uf
EXHIBIT “D”
Form SSA-7050-F4 (02-2021)
Discontinue Prior Editions Page 1 of4
Social Security Administration OMB _No. 0960-0525
REQUEST FOR SOCIAL SECURITY EARNING INFORMATION
*Use This Form If You Need
DO NOT USE THIS FORM TO REQUEST
1 Certified/Non-Certified Detailed Earnings Information YEARLY EARNINGS TOTALS
Includes periods of employment or self-employment
and the names and addresses of employers. Yearly earnings totals are free to the public
if you do not require certification.
Certified Yearly Totals of Earnings
Includes total earnings for each year but does not To obtain FREE yearly totals of earnings,
include the names and addresses of employers. visit our website at www.ssa.gov/myaccount|
Privacy Act Statement
Collection and Use of Personal Information
Section 205 of the Social Security Act, as amended, allows us to collect this information. In addition, the Budget and
Accounting Act of 1950 and Debt Collection Act of 1982 authorize us to collect credit card information, if you choose to
pay for the earnings information you have requested with a credit card. Furnishing us this information is voluntary.
However, failing to provide all or part of the information may prevent us from processing your request.
We will use the information to identify your records, process your request, and send the earnings information you request.
We may also share the information for the following purposes, called routine uses:
4. To the Internal Revenue Service (IRS) for auditing SSA's compliance with the safeguard provisions of the Internal
Revenue Code of 1986, as amended.
2. To contractors and other Federal agencies, as necessary, for the purpose of, assisting the Social Security
Administration (SSA) in the efficient administration of its programs.
3. To banks enrolled in the Treasury credit card network to collect a payment or debt when the individual has given
his/her credit card number for this purpose.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example,
our records are
where authorized, we may use and disclose this information in computer matching programs, in which
compared with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of
incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORNs) 60-0059, entitled
Earnings Recording a! ind Self-Employment Income System, 60-0090, entitled Master Beneficiary Record, 60-0224,
Preview
Filing # 157577243 E-Filed 09/16/2022 01:26:13 PM IN THE CIRCUIT COURT FOR THE FIFTH JUDICIAL CIRCUIT IN AND FOR LAKE COUNTY, FLORIDA ERLENE FEDRICK, Plaintiff, Case No.: 2022-CA-754 Vv. PATRICK DONALD HENES and ARCH INSURANCE COMPANY, a Foreign Profit Corporation, Defendants. / DEFENDANT, ARCH INSURANCE COMPANY’S MOTION TO COMPEL DISOVERY Defendant, ARCH INSURANCE COMPANY (“ARCH”), by and through undersigned counsel and pursuant to Fla. R. Civ. P. 1.380, hereby files this Motion to Compel Discovery and in support thereof states: 1 On June 9, 2022, ARCH served upon Plaintiff a Request to Produce and Interrogatories (attached hereto as Composite Exhibit A). 2. Plaintiff failed to respond to the discovery within 30 days as required, and did not seek an extension to respond. 3 On September 2, 2022, the undersigned sent an e-mail to Plaintiff's counsel advising of the overdue discovery responses, and providing a September 9, 2022 deadline to provide responses lest ARCH move to compel same (e-mail attached as Exhibit B). 4 To date, Plaintiff has failed to provide the requested discovery responses. FILED: LAKE COUNTY, GARY J. COONEY, CLERK, 09/16/2022 03:14:15 PM. 5 ARCH cannot properly defend itself from this suit without Plaintiff's discovery Tesponses. 6 The undersigned certifies that ARCH has made a good-faith effort to obtain the discovery responses without court intervention (including waiting nearly two months after the original deadline to advise Plaintiffs counsel of the discovery violation). WHEREFORE the Defendant, ARCH INSURANCE COMPANY, respectfully requests the Court to enter an Order compelling Plaintiff to respond to ARCH’S Interrogatories and Request to Produce and to award ARCH fees and costs associated with preparing and hearing of this Motion. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Motion to Compel has been served via the Florida E-Filing Portal to all counsel of records on this 16th day of September 2022. /s/ Troy Beecher TROY BEECHER, ESQ. Florida Bar No.: 37348 GOLDBERG SEGALLA LLP 800 N. Magnolia Avenue, Suite 450 Orlando, Florida 32803 Phone: (407) 458-5612 Fax: (407) 458-5699 tbeecher@goldbergsegalla.com psouza@goldbergsegalla.com sherndon@goldbergsegalla.com EXHIBIT A Filing # 151174265 E-Filed 06/09/2022 12:15:30 PM IN THE CIRCUIT COURT OF THE FIFTH JUDICIAL CIRCUIT, IN AND FOR LAKE COUNTY, FLORIDA ERLENE FEDRICK, CASE NO.: 2022-CA-000754 Plaintiff, Vv. PATRICK DONALD HENES and ARCH INSURANCE COMPANY, Defendants. / DEFENDANT ARCH INSURANCE COMPANY’S FIRST REQUEST TO PRODUCE TO PLAINTIFF ERLENE FEDRICK Defendant, ARCH INSURANCE COMPANY, by and through the undersigned attorneys and pursuant to Rule 1.350, Florida Rules of Civil Procedure, hereby requests the Plaintiff, ERLENE FEDRICK, to produce the following: DEFINITIONS The following definitions apply to terms as they are used in this discovery request, regardless of tense or whether the terms are used in the singular, plural or possessive case: a. “You” and “your” refers to the party to whom this discovery request is addressed, including the party’s employees and agents, if any, and all other individuals acting or purporting to act on the party’s behalf. b “Person” and/or “Persons” includes the plural and singular versions of people and also includes a natural person, corporation, partnership, joint venture, association, government agency, organization, firm, commission, board, or agency. Cc. “Entity” includes all corporations, partnerships, sole proprietorships, individuals and “person” as that term is defined in these definitions. d. "Document" means any electronically stored, written, typed, recorded, or graphic matter, however produced, of any type or description, whether sent or received, including both sides of originals, known identical copies, and drafts, and including, without limitation, e-mails, papers, books, letters, correspondence, telegrams, bulletins, notices, announcements, instructions, charts, manuals, brochures, schedules, cables, telex messages, memoranda, text messages, notes, notation, accountants’ working papers, transcripts, minutes, agendas, reports, 33597856.v1 and recordings of telephone or other conversations, of interviews, of conferences, or of other meetings, affidavits, statements, summaries, opinions, report studies, analyses, evaluations, contracts, agreements, journals, statistical records, desk calendars, appointment books, diaries, lists, tabulations, sound recordings, voicemail recordings, computer printouts, data processing input and output, microfilms, and other records kept by electronic, photographic or mechanical means, and things similar to any of the above, however denominated by, and any other documents or electronically stored information. €. “Communications” and “Correspondence” means any oral or written statement, dialogue, colloquialism, discussion, conversation and/or agreement. f. “Relate to,” “relating to” or “concerning” means to make a statement about, discuss, describe, reflect, constitute, identify, deal with, refer to, be in connection with or akin to, consist of, establish, comprise, list, evidence, substantiate or in any way pertain, in whole or in part, to the subject. 8. “Plaintiff” means the Plaintiff named in the caption of this lawsuit. h, When producing documents, documents should be identified to correspond with the particular categories in this request. L To “identify" a document means to state: (a) the identity of the person who prepared the document; (b) the identity of the person who signed the document or in whose name the document was issued; (c) the identity of each person to whom the document was addressed or distributed; (d) the nature or substance of the document with sufficient particularity to facilitate identification of the document. (To the extent you refuse to disclose the nature or substance of the document, state the nature of the privilege and the circumstances on which you rely in support of your claim); (e) the document’s date and, if the document bears no date, the date when the document was prepared; and (f) the physical location and custodian of the document. J To “identify" a person with reference to a natural person means to give the person’s name, the person’s last known address, and, if employed, the name and address of that person’s employer and job title or position. To identify a person who is not an individual means to state the name and principal office of that person. INSTRUCTIONS a. Unless otherwise defined, all words and phrases used herein should be given their usual meaning and interpreted in their common, ordinary style. b. This request is continuing so as to require supplemental responses in the event you, or any person acting on your behalf, obtain additional information between the time of the original response and conclusion of the trial in this case. C. With respect to those documents to which you may claim privilege, you are requested to identify each such document, in writing, on or before the due date of the answers to these document requests, together with the following information: the nature or description, date, subject matter and author of the document, as well as the identity of all persons to whom Page 2 of 9 33597856.v1 the document was directed, addressed, or received, and the document request to which the document corresponds. For each such document you are further required to state the basis for your claim of privilege, attorneys’ work product, or trial preparation materials. d In the event that any requested document or tangible thing is known to have existed and cannot now be located or has been destroyed or discarded, that document or tangible thing shall be identified by: (a) the last known custodian; (b) date of destruction or discard; (c) the manner of destruction or discard; (d) the reason(s) for destruction or discard; (e) as to lost or misplaced documents or tangible things, the efforts made to locate such documents or tangible things; (f) a statement describing the document, including a summary of its contents, or the tangible thing; (g) the identity of the author(s) or creator(s); and (h) persons to whom it was sent or shown. FIRST REQUEST TO PRODUCE TO PLAINTIFF ERLENE FEDRICK 1 Any and all of Plaintiff ERLENE FEDRICK’S medical bills, paid or owing, as a result of the alleged accident involved in this lawsuit. 2 Any and all medical reports from any physician pertaining to the care and treatment received by Plaintiff ERLENE FEDRICK asa result of the alleged accident herein. 3 Any and all hospital, physician, chiropractic, clinic, emergency room or other health care provider records, x-rays, tomography studies, medical reports, and doctors’ reports, related to or connected with any medical care or treatment rendered to Plaintiff ERLENE FEDRICK related to the subject accident. 4 Any and all hospital, physician, chiropractic, clinic, emergency room records, x- rays, tomography studies, medical reports, and doctors' reports, related to or connected with the medical care and treatment rendered to Plaintiff ERLENE FEDRICK during the past ten (10) years. 5 Any and all hospital, physician, chiropractic, clinic, emergency room or other health care provider records, x-rays, tomography studies, operative reports, medical reports, and Page 3 of 9 33597856.v1 doctors' reports, specifically related to the pre-existing disease or physical defect that Plaintiff ERLENE FEDRICK alleges to have been aggravated as a result of the incident. 6 Any and all hospital, physician, chiropractic, clinic, emergency room or other health care provider records, x-rays, tomography studies, operative reports, medical reports, and doctors' reports, specifically related to the permanent injury that Plaintiff ERLENE FEDRICK alleges to have incurred as a result of the incident. 7 Any and all hospital, physician, chiropractic, clinic, emergency room or other health care provider records, x-rays, tomography studies, operative reports, medical reports, and doctors' reports, specifically related to the significant and permanent loss of an important bodily function and/or permanent and significant scarring that Plaintiff ERLENE FEDRICK alleges to have incurred as a result of the incident. 8. Any and all medical records, reports, and medical bills generated as a result of any EMS, ambulance service, fire/rescue, or hospital transportation service, with regard to transportation of Plaintiff ERLENE FEDRICK to a hospital on the date of the subject accident, as a direct result of the subject accident. 9 Any and all medical records, reports, and medical bills generated as a result of any EMS, ambulance service, fire/rescue, or hospital transportation service, with regard to transportation of Plaintiff ERLENE FEDRICK to a hospital on any date after the date of the subject accident, for which transportation was a direct result of the subject accident. 10. Signed copies of Plaintiff ERLENE FEDRICK’S Federal Income Tax returns for the years 2015, 2016, 2017, 2018, 2019, 2020, and 2021. 11. Copies of all of Plaintiff ERLENE FEDRICK’S W-2 Withholding Tax Statements and any and all other business records or income records and any other evidence of income for Page 4 of 9 33597856.v1 the years 2015, 2016, 2017, 2018, 2019, 2020, and 2021. 12. All evidence of income Plaintiff ERLENE FEDRICK earned in 2022 to date of production. 13. For any year that a Federal Income Tax return has not been filed by Plaintiff ERLENE FEDRICK, please produce proof of all earned income and all non-earned income for those years. 14. Any and all photographs of the Plaintiff showing alleged injuries related to the subject accident. 15. Any and all photographs of the accident scene and/or vehicles involved in the subject accident. 16. Any and all police reports, and police investigation records and files of any type regarding the subject accident from any police agency or department concerning the subject accident. 17. Any and all repair estimates, invoices, photographs and other documentation evidencing and depicting any repairs made to ERLENE FEDRICK’S vehicle subsequent to the accident described in Plaintiff's Complaint allegedly as a result of the subject accident. 18. Any and all written or recorded statements taken of the Defendant. 19. Any and all written or recorded statements taken of witnesses. 20. Any and all diagrams, charts, maps or descriptions of the accident scene involved in this accident. 21. Any and all records, papers, documents or other forms of evidence of any agreements, covenants or promises reached between or with any party as to any settlements, Page 5 of 9 33597856.v1 covenants not to collect, limitations on collection or limitations on liability. 22. Any and all medical reports, records and bills from any doctor or hospital, incurred by Plaintiff ERLENE FEDRICK for any injury sustained in subsequent accidents ot incidents to the accident claimed herein. 23. Copies of any and all documentation, as well as any and all copies of payments or other documentation made by collateral sources, reflecting benefits paid on behalf of Plaintiff ERLENE FEDRICK for medical treatment, lost wages and/or property damage. 24. All documents supporting the Plaintiffs claim for economic damages in this lawsuit and not produced in response to the preceding paragraphs. 25 A copy of Plaintiff ERLENE FEDRICK’S Driver's License, front and back. 26 Copy of Plaintiff ERLENE FEDRICK’S Social Security card. 27 Copy of Plaintiff ERLENE FEDRICK’S most recent Social Security Statement. 28 Copy of Plaintiff ERLENE FEDRICK’S Application(s) for Social Security Disability, if applicable, and response(s) thereto. 29. Copy of any and all documents evidencing payments to Plaintiff ERLENE FEDRICK from the Social Security Administration as a result of any application(s) for Social Security Disability. 30. Any and all statements, explanation of benefits, notices, letters, notes, memoranda or other documents, however titled and in whatever form, detailing, listing, explaining or itemizing all payments made by any third party for the damages and medical, hospital or other health care services provided to Plaintiff ERLENE FEDRICK as a result of the alleged accident. (For purposes of this request for production, "any third party" includes but is not limited to any Page 6 of 9 33597856.v1 federal, state, local or other public program providing medical expenses payments; any health, accident or sickness insurance providing insurance benefits or medical expenses payments; any contract or agreement of any group, organization, partnership or corporation to provide, pay for or reimburse the costs of your hospital, medical or other health care services; Medicare; Medicaid, and Workers' Compensation Law). 31. Any and all statements, explanation, notices, letter, notes, memoranda or other documents, however titled and in whatever form, detailing, listing, explaining and itemizing any third party's claims of right of subrogation or reimbursement for any amounts paid or payable and the amount of each third party's claim. 32. Any and all documents evidencing prior or current lawsuits of any kind, wherein Plaintiff ERLENE FEDRICK is/was a Plaintiff or Defendant, Claimant or Respondent, including small claims matters, and excluding the current matter. This request is for any lawsuit during Plaintiff ERLENE FEDRICK’S lifetime, and requests any and all documents from any court. If you are not in possession of the documents, please identify state and court filed, opposing party, and any other identifiable information so as to allow this Defendant to obtain records. 33. A complete copy of all health insurance policies in effect for insuring Plaintiff ERLENE FEDRICK during the last five (5) years. 34. A complete copy of all automobile insurance policies in effect for insuring Plaintiff ERLENE FEDRICK during the last five (5) years, with the exception of any Arch Insurance Company policies. 35. Copies of any letters of protection, or similar document, given by the Plaintiff or anyone acting on behalf of the Plaintiff to any health care provider regarding the charges of the health care provider. Page 7 of 9 33597856.v1 36. A complete copy of the report of each person who the Plaintiff expects to call as an expert witness at trial. 37. A copy of any general or partial release executed by the Plaintiff as a result of the accident which is the subject matter of this lawsuit. 38. A complete copy of any settlement agreement, or in the alternative, a complete copy of any document acting as a tentative settlement agreement, between the Plaintiff and any other person or entity relating to the subject accident. 39. A fully executed Florida Medicaid Authorization for use and Disclosure of Protected Health Information attached hereto and marked as Exhibit “A”. 40. A fully executed Medicare Consent to Release attached hereto and marked as Exhibit “B”. Al. A fully executed Social Security Administration Consent for Release of Information attached hereto and marked as Exhibit “C”. 42. A fully executed Request for Social Security Earning Information attached hereto and marked as Exhibit “D.” 43. Any and all cellular telephone records for any cellular telephone owned, leased, rented, in control of and in Plaintiff ERLENE FEDRICK’S possession on the date and time of the subject accident evidencing voice calls, text messaging, data usage and transfer of any type. 44. Any and all writs of garnishment levied against Plaintiff ERLENE FEDRICK. 45. Any and all criminal records of Plaintiff ERLENE FEDRICK in Plaintiffs possession. 46. Any and all photographs of any and all vacations Plaintiff ERLENE FEDRICK has taken since the date of the subject accident. Page 8 of 9 33597856.v1 CERTIFICATE OF SERVICE WE HEREBY CERTIFY that the foregoing has been electronically filed and served via Florida ePortal to: Devry R. Kelly, Esq., Dan Newlin Injury Attorneys, 7335 W. Sand Lake Road, Suite 300, Orlando, FL 32819 at devry.kelley@newlinlaw.com; patricia.croc@newlinlaw.com; devry.pleadings@newlinlaw.com; on June 09, 2022. GOLDBERG SEGALLA, LLP 800 North Magnolia Ave., Suite 450 Orlando, FL 32803 Telephone: (407)458-5600 /s/ Troy Beecher Troy Beecher, Esquire Florida Bar No.: 37348 Email: theecher@goldbersegalla.com sherndon@goldbergsegalla.com; psouza@golbergsegalla.com Page 9 of 9 33597856.v1 EXHIBIT “A” Authorization for the Use and Disclosure of Protected Health Information Information Identifying the Individual Whose Records Are Being Requested Name of Individual: SSN: Disclosure of your Social Security Number is not mandatory. The Agency for Health Care Administration (AHCA or Agency) may request your Social Security Number pursuant to Section 119.071, Florida Statutes. If provided, the Agency will use your information for purposes of finding the requested information. Individual’s Street Address: City: State: Zip Code: Medicaid 1D or Gold Card Number: Phone Number: Date of Birth: Provide the specific dates of service included. From: To: ——— Purpose for this disclosure: Date | wish this authorization to expire (expires in one year if no date is provided): Oo I direct AHCA to mail the requested hard copy records to the below person(s), group or entity: Documents Requested: Cpaia Claims Records Cc] Denied Claims Records oO All Claims Records O Other: Name: Street Address: City: State: Zip Code: Oo \ authorize the below person(s), group or entity to verbally discuss specific topics with AHCA: The specific topics to be discussed are: Name: Lunderstand the following: | have the right to revoke this authorization at any time by writing to the Agency's Privacy Officer or Officer. | completing the revocation section on the second page of this form and sending it to the address listed for the Agency's Privacy my revocation request. The information described above may understand that any information previously disclosed would not be subject to that ! am giving the Agency permission to disclose to and therefore my information may no longer be be re-disclosed by the person or group if the Agency protected by Federal privacy regulations. 1 may inspect or request copies of any information disclosed by this authorization initiated this request for disclosure. | may refuse to sign this authorization and my refusal to sign will not affect my ability to obtain treatment, payment for health care services or eligibility for benefits. drug, alcohol or This form specifically includes authorization to provide documents related to sensitive health conditions including: genetic diseases or tests, substance abuse, psychological or psychiatric treatment, sickle cell anemia, birth control or family planning, tuberculosis, and HIV/AIDS or STDs. To restrict sensitive information, see Page 2. 1 DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT. Signature: Date: Printed Name: Legal Authority (If Other Than Individual): must provide If you are a legal representative of the person whose information you are requesting disclosure of, you request this information (for example, power of attorney, guardianshi p papers, documentation proving your legal authority to Appointing Personal Representati ve, Letters of Administrati on). health care surrogate form, Custody Order, Order AHCA Form 1000-3003, Revised (AUG 2018) Page 1 of 2 Authorization for the Use and Disclosure of Protected Health Information Instructions for Completing this Form 1. ‘Complete the first page of this form and return it to: HIPAA Privacy Officer, Agency for Health Care Administration, 2727 Mahan Dr., MS #4, Tallahassee, FL 32308, Phone: 850-412-3960, Fax 850-414-6837 Email: HIPAAComplianceOffice@AHCA. MyFlorida.com. 2. Special types of health information have specific taws and rules that must be followed before that information may be disclosed: Hi : All information about HIV/AIDS and sexually transmitted diseases is protected under Federal and State laws and cannot be disclosed without your written authorization unless otherwise provided in the regulations, To release HIV/AIDS or STO information, this authorization must include a statement of the specific HIV/AIDS or STD information you are giving the Agency permission to disclose. Re-disclosure of HIV/AIDS information is not allowed except in compliance with law or with your written permission, To NOT INCLUDE this Information, Initial here. Alcoh ol or Drug Treatment: Alcohol and/or drug treatment records are protected under Federal and State Jaws and regulations and cannot be disclosed without your written authorization, unless otherwise provided for in Federal and State laws or regulations. To release alcohol and/or drug treatment information, this authorization must include a statement of the specific information that you are giving the Agency permission to disclose (for example, “For the purposes of my assessment, treatment plan, attendance, or discharge plan.”) Re-disclosure of your alcohol and/or drug treatment records is not allowed exceptincompliance with law or with your written permission (see 45 CFRPart 2). To NOT INCLUDE this information, Initial here Health Tre: : Mental health treatment records are protected under Federal and State laws and regulations and cannot be disclosed without your written authorization unless otherwise allowed in Federal or State laws or regulations. To release mental health treatment information, this authorization must include a statement of the specific information that you are giving the Agency permission to disclose (for example, “For the purposes of my assessment, treatment plan, attendance, or discharge plan.*) Disclosure of your psychotherapist’s notes needs separa te Re-disclosure of your mental health written permission. treatment records is not allowed except in compliance with law or with your writtenpermission. To NOT INCLUDE this information, Initial here: Revocation of Authorization N. DO NOT COMPLETE FOR A NEW AUTHORIZATION. THIS SECTION IS ONLY FOR REVOKING A PREVIOUS AUTHORIZATIO your Disclosure of your Social Security Number is not mandatory. The Agency for Health Care Administration may request Social Security Number pursuant to Section 119.071, Florida Statutes. Name Date of Birth Phone Social Security| Number Medicaid ID Number or Gold Card Number Street Address City State Zip Code to the Thereby revoke my authorization for the Agency for Health Care Administration to disclose my protected health information following person(s), group or entity: Signature Date Printed Name |Legal Relationship] ito Individual legal authority to revoke this If you are the subject’s legal representative, you must provide documentation proving your authorization. (For example, an authorization, power of attorney, guardianship papers, health care surrogate form, Order Appointing Personal Representative , Letters of Administratio n). AHCA Form 1000-3003, Revised (AUG 2018) Page 2 of 2 EXHIBIT “B” Consent to Release Liability Insurance (Including Self-Insurance), No-Fault Insurance, or Workers’ Compensation Where to find Information on “Consent to Release” vs. “Proof of Representation” Please refer to the PowerPoint document on this website titled: “Rules and Model Language for ‘Proof of Representation’ vs. ‘Consent to Release’ for Medicare Secondary Payer Liability Insurance (Including Self- Insurance), No-Fault Insurance, or Workers’ Compensation” for detailed information on e When to use a “consent to release” document vs. a “proof of representation” document, e Appropriate content for both documents, . The need for appropriate documentation when there are two layers of representatives involved (examples: attorney | refers a case to attorney 2; the beneficiary’s guardian hires an attorney to pursue a liability insurance claim) or when a beneficiary’s representative signs a “consent to release” document on the beneficiary’s behalf, What liability insurers (including self-insurers), no-fault insurers, and workers’ compensation entities must have in order to obtain conditional payment information, and e Use of agents by insurers’ or workers’ compensation. General ‘A “consent to release” document is used by an individual or entity who does not represent the Medicare beneficiary but is requesting information regarding the beneficiary’s conditional payment information. A “consent to release” does not authorize the individual or entity to act on behalf of the beneficiary or make decisions on behalf of the beneficiary. Model Language to See attached. Use of the model language is not required, but any documentation submitted as a “Consent Release” must include the information the model language requests. Where to Submit a “ Consent to Release” document: Liability Insurance, No-Fault Insurance, Workers’ Compensation: NGHP PO Box 138832 Oklahoma City, OK 73113 Fax: (405) 869-3309 MODEL LANGUAGE NSE} RE! E The language below should be used when you, a Medicare beneficiary, want to authorize someone other than your attorney or other representative to receive information, including identifiable health information, from the Centers for Medicare & Medicaid Services (CMS) related to your liability insurance (including self-insurance), no-fault insurance or workers’ compensation claim. 4 (print your name exactly as shown on your Medicare card) hereby authorize the CMS, its agents and/or contractors to release, upon request, information related to my injury/illness and/or settlement for the specified date of injury/illness to the individual and/or entity listed below: HECK INLY ONE OF T! FOLLOWING TO ICATE WHO MAY RECEIVE INFORMATION AND THEN PRINT THE REQUESTED INFORMATION: (If you intend to have your information released to more than one individual or entity, you must complete a separate release for each one.) Insurance Company Workers’ Compensation Carrier Other (Explain) Name of entity: Contact for above entity: Address: Address Line 2: City/State/ZIP: Telephone: CHECK ONE OF THE FOLLOWING TO INDICATE HOW LONG CMS MAY RELEASE YOUR. INF IRMATION (The period you check will run from when you sign and date below.): One Year Two Years Other (Provide a specific period of time) Iunderstand that I may revoke this “consent to release information” at any time, in writing. MEDICARE BENEFICIARY INFORMATION AND SIGNATURE: Beneficiary Signature: Date signed: Note: If the beneficiary is incapacitated, the submitter of this document will need to include documentation establishing the authority of the individual signing on the beneficiary’s behalf. Please visit https://go.cms.gov/cobro for further instructions. Medicare ID (The number on your Medicare card.): Date of Injury/Illness: EXHIBIT “C” Social Security Administration Form Approved Consent for Release of Information OMB No. 0960-0566 Instructions for Using this Form Com) ete this form only if you want us to give information or records about you, a minor, ora ally incompetent adult, to an i indivi idual or group (for example, a doctor or an insurance co! mpany). If you are the natural ag optive parent or legal guardian, acting on behalf of a minor ild, may complete this form to release only the minor's non-medical records. We may charge a fee for providing information unrelated to the administration of a program under the Social Security Act. NOTE: Do not use this form to: + Request the release of medical records on behalf of a minor child. Instead, visit your local Social Security office or call our toll- free number, 1-800-772-1213 (TTY-1-800-325-0778), or + Request detailed information about your earnings or employment history. Instead, complete and mail form SSA-7050-F4. You can obtain form SSA-7050-F4 from your local Social Security office or online at .gOv! issa- ‘We will not honor this form unless all required fields are completed. An asteri isk (*) indicates a required field. Also, we will not honor blanket requests for "any and all records" or the “entire file." You must specify the information you are requesting and you must sign and date this form. We may charge a fee to release information for non-program purposes. + Fill in your name, date of birth, and social security number or the name, date of birth, and social security number of the person to whom the requested information pertains. + Fill in the name and address of the person or organization where you want us to send the requested information. + Specify the reason you want us to release the information. * Check the box next to the type(s) of information you want us to release including the date ranges, where applicable. + For non-medical information, you, the parent or the legal guardian acting on behalf of a minor child or legally incompetent adult, must sign and date this form and provide a daytime phone number. + If you are not the individual to whom the requested information pertains, state your relationship to that person. We may require proof of relationship. Y AC ME! Section 205(a) of the Social Security Act, as amended, authorizes us to collect the information requested on this form. We will the records we maintain about you or to process your Ise the information you provide to respond to yourrequesttt for acce: request to release your records to a third party. You t have to prov ide the requested information. ‘our response is voluntary; however, we cannot honor your request to release information or records about you to another person or organization without your consent. We rarely use the information rovided on this form for any purpose other than to respond to requests for S SSA records information. However, the Privacy Act (5 U.S.C. 552a(b)) permits us to disclose the information you provide on this form in accordance with approved routine uses, which include ut are not limited to the following: 1.To 2.To enable an agen or third pai Fe to assist Social Securit) y in establishing rights to Social Securit benefits and or coverage; make determinations for eligi bility in similar health and income maintenance programs at the ede! ral, State, and local level; 3.To comply with Fede! ral laws requiring the disclosure of the information from our records; 4.To facilitate statistical research, aud it, or investigative activities necessary to assure the integrity of SSA programs. We may also use the information you provi ide when we match records by computer. Computer matching programs compare our records with those of other Federal, State, or local government ag encies. We use information from these matchi incorrect programs to establish or verify a person's eligibility for Federally-funded or administered benefit programs and for repayment ments or overpayments under these programs. Additional information regarding this form, routine uses of information, and other Social Security programs is available on ‘our Internet website, www.socialsecurity.gov, or at your local Social Security office. PAPERWORK REDUCTION ACT STATEMENT This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the 4 You do not need to answer these questions unless we display a val lid Office of Management and Budget edt questions. SEND number. We estimate that it will take about 3 minutes to read the instructions, ather the facts, and answer the OR BRING THE COMPLETED FORM TO YOUR LOCAL SO! CIAL SECURI OFFICE. You can find your local Social Security office through SSA's website a‘ . Offices are also listed under U.S. Government agencies in your telephone directo! or you may call 1-801 }0-772-1213 (TYY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Securi ty Eid. Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed Form SSA-3288 (11-2016) uf Destroy Prior Editions Social Security Administration Form Approved Consent for Release of Information OMB No. 0960-0566 You must com lete all required fields. We will not honor your request unless all required fields are completed. (*Signifies a required field. P "Ple ase complete these fields in case we need to contact you about the consent form). TO: Social Security Administration *My Full Name *My Date of Birth *My Social Security Number (MMIDD/YYYY) | authorize the Social Security Administration to release information or records about me to: *NAME OF PERSON OR ORGANIZATION: *ADDRESS OF PERSON OR ORGANIZATION: *| want this information released because: We may charge a fee to release information for non-program purposes. *Please release the following information selected from the list below: Check at least one box. We will not disclose records unless you include date ranges where applicable. 4. [1] Verification of Social Security Number 2. [J Current monthly Social Security benefit amount 3. [J Current monthly Supplemental Security Income payment amount 4. [1] My benefit or payment amounts from date. to date 5. [1] My Medicare entitlement from date to date 6. [] Medical records from my claims folder(s) from date. to date. If you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social Security office. 7. (J Complete medical records from my claims folder(s) 8. (] Other record(s) from my file ( (We will not honor a request for “any and all records" or "the entire file." You must specify other records; e.g., consultative exams, award/denial notices, benefit applications, appeals, questionnaires, doctor reports, determinations.) lam the Individual, to whom the requested in‘ formation or record applles, or the parent or legal guardian of a minor, or the legal guardian of a legally incompetent adult. I declare under penalty of perjury (28 CFR § 16.41(d)(2004) that | have examined all the information on this form and it is true an d correct to the best of my knowledge. | understand that anyone who knowingly or willfully seeking or obtaining access to records about another person under false pretenses Is punishable by a fine of up to $5,000. | also understand that | must pay al II applicable fees for requesting Information fora non-program-related purpose. *Signature: *Date: **Address: Daytime Phone: Relationship (if not the subject of the record): ™Daytime Phone: Witnesses must sign this form ONLY if the above si ni ature is by mark (X) . If signed by mark (X), two witnesses to the signing fi who know the signee must sign below and provide tl air full addresses. PI lease print the signee’s name next to the mark (X) on the signature line above. 1.Signature of witness 2.Signature of witness Address(Number and street,City,State, and Zip Code) Address(Number and street,City,State, and Zip Code) Form SSA-3288 (11-2016) uf EXHIBIT “D” Form SSA-7050-F4 (02-2021) Discontinue Prior Editions Page 1 of4 Social Security Administration OMB _No. 0960-0525 REQUEST FOR SOCIAL SECURITY EARNING INFORMATION *Use This Form If You Need DO NOT USE THIS FORM TO REQUEST 1 Certified/Non-Certified Detailed Earnings Information YEARLY EARNINGS TOTALS Includes periods of employment or self-employment and the names and addresses of employers. Yearly earnings totals are free to the public if you do not require certification. Certified Yearly Totals of Earnings Includes total earnings for each year but does not To obtain FREE yearly totals of earnings, include the names and addresses of employers. visit our website at www.ssa.gov/myaccount| Privacy Act Statement Collection and Use of Personal Information Section 205 of the Social Security Act, as amended, allows us to collect this information. In addition, the Budget and Accounting Act of 1950 and Debt Collection Act of 1982 authorize us to collect credit card information, if you choose to pay for the earnings information you have requested with a credit card. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from processing your request. We will use the information to identify your records, process your request, and send the earnings information you request. We may also share the information for the following purposes, called routine uses: 4. To the Internal Revenue Service (IRS) for auditing SSA's compliance with the safeguard provisions of the Internal Revenue Code of 1986, as amended. 2. To contractors and other Federal agencies, as necessary, for the purpose of, assisting the Social Security Administration (SSA) in the efficient administration of its programs. 3. To banks enrolled in the Treasury credit card network to collect a payment or debt when the individual has given his/her credit card number for this purpose. In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, our records are where authorized, we may use and disclose this information in computer matching programs, in which compared with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs. A list of additional routine uses is available in our Privacy Act System of Records Notices (SORNs) 60-0059, entitled Earnings Recording a! ind Self-Employment Income System, 60-0090, entitled Master Beneficiary Record, 60-0224,