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MC-350EX
ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: FOR COURT USE ONLY
name: Kyle W. Jones, Esq. 224797
riemname: Law Office of Kyle W. Jones
streetappress: 1620 Mill Rock Way, Suite 100
ory. Bakersfield state: CA zipcone: 93311
Teveponeno. 661.833.1090 raxno: 661.412.4861
emanaopress: Kyle jones@kwjoneslaw.com
ATTORNEY FOR (Name): Petitioner
SUPERIOR COURT OF CALIFORNIA, COUNTY OF Kern
‘STREET ADDRESS: 1215 Truxtun Avenue
MAILING ADDRESS: SAME AS ABOVE
CITY AND ZIP CODE: Bakersfield, CA 93301
BRANCH NAME: Metropolitan Division - Justice Bldg
CASE NAME; ‘CASE NUMBER:
KAIDEN LAU VS. MARY LOU HOUTZ BCV-24~100128-BCB
[XQ No hearing date is requested.
PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF
CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF (Co mearie nate
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY TIME:
DEPT
NOTICE TO PETITIONER
You must use this form to request expedited court approval of a qualifying (1) compromise of a minor's disputed claim, (2) compromise
lof a pending action or proceeding in which a minor or a person with a disability (including a conservatee) is a party, or (3) disposition of
the proceeds of a judgment for a minor or person with a disability. (See Code Civ. Proc., § 372; Prob. Code, §§ 3500, 3600-3613.) You
may request expedited approval only if (1) you are represented by an attorney; (2) the statements in items 3a, 3b, 3c, 3d, 3e, 3f, and
either 3g(1) or 3g(2), below, are true and accurate; and (3) the court does not otherwise order.
If your compromise or judgment qualifies and you choose to use this form, the court may consider and act on your petition without a
hearing. If your compromise or judgment qualifies for expedited consideration but you choose not to use this form or your compromise
or judgment does not qualify for expedited consideration, you must use Petition for Approval of Compromise of Claim or Action or
Disposition of Proceeds of Judgment for Minor or Person With a Disability (form MC-350), and the court will schedule a hearing.
1 Petitioner (name or pseudonym’): YVONNE LAU
is the (check all boxes that apply) [qq Parent (2) Guardian ad litem O20 Guardian (1 Conservator
(Q] Other (specify retationship): Mother
of the claimant identified i item 2. (“Petitioner may appear under a pseudonym only if appointed as guardian ad litem under that
pseudonym. (See Code Civ, Proc., § 372.5.)}
Claimant (name) Kaiden Lau
a. Address: 3810 Europa Lane, Bakersfield, CA 93312
b. Date of birth: 10/23/2008 c. Age: 15 d. [XJ Minor or [23 Person with a disability
(if the claimant is an adult with a disability who (1) has capacity to consent to the order requested and (2) does not have a
conservator of the estate, check e. and f. and ensure that the claimant personally reads and signs item 21. (Prob. Code, § 3613.))
e. (2) Has the capacity, within the meaning of Probate Code section 812, to consent to the requested order.
f. [XJ Does not have a conservator of the estate.
Qualification for Expedited Approval
The claimant's claim or action is not for damages for the death of a person caused by the wrongful act or neglect of another.
No portion of the net proceeds of the judgment or settlement in favor of the claimant is to be placed in a trust
There are no unresolved disputes concerning liens to be satisfied from the proceeds of the judgment or settlement.
Petitioner's attorney did not become involved with this matter, directly or indirectly, at the request of a party against whom the
claim is asserted or a party's insurance carrier.
Petitioner's attorney is not representing, employed by, or associated with a defendant in this matter or an insurance carrier.
All defendants that have appeared in a pending action on the claim are participating in the proposed compromise or the court
has made a final determination that all settling parties entered into the settlement in good faith.
(1) QQ The judgment described in item 4c (exclusive of interest and costs) or the total settlement described in items 11 and
12 payable to the claimant and all other persons named in item 12 is in the amount of $50,000 or less; or
(2) (] The settlement described in item 11 represents payment of the single-person policy limits of all liability insurance
policies covering the defendants named in that item. The investigation described in Attachment 3 shows that all of
those defendants are judgment-proof outside of their insurance coverage. (Describe investigation and results in
Attachment 3.) Page 1 of 7
Apter fyAeanaive Mendalny Use PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Code of Civil Procedure, § 372:
frlose st Probate Cade, 3 505i,
jig! Council of Ca CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF al. RislesofFas ut, rules 3.1384)
(Rev. January1, 2021] 7.960.
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY www courts.ca.gov
CIB Essential
ceb.com | §e/Forms LAU, KAIDEN
MC-350EX
CASE NAME: CASE NUMBER:
LAU VS. HOUTZ BCV-24-100128-BCB
Claim The claim of the minor or adult person with a disability:
a. [X) Is not the subject of a pending action or proceeding. (Complete items 5-23.)
b. [.) Is the subject of a pending action or proceeding that will be compromised without a trial. (Complete items 5-23.)
Name of court:
Case no.: Trial date:
c. [2] Is the subject of an action or proceeding in which a judgment has been or will be entered for the claimant against the
defendants named below in the amount (exclusive of interest and costs) of (specify): $
Defendants (names):
L-}Additional defendants listed on Attachment 4. (Coy the judgment was filed on (date):
(Attach a copy of the (proposed) judgment as Attachment 4c and complete items 13-23.)
Incident or accident The incident or accident occurred as follows:
a. Date 02/16/2020 Time: 2:16 p.m.
b. Place: Buena Vista Road and Ming Avenue in the City of Bakersfield,
County of Kern, California.
Persons involved (names):
Kaiden Lau
Mary Lou Houtz
David Lau
Yvonne Lau
C2} Additional persons listed on Attachment 5.
Nature of incident or accident
The facts, events, and circumstances of the incident or accident are (describe what happened):
David Lau was driving southbound in the number one designated left
turn lane. Mr. Lau came to a complete stop at the intersection of
Buena Vista Rd. and Ming Ave. when defendant, Mary Lou Houtz, drove
over the raised center median, and stuck the driver side of the Lau
vehicle.
(CJ Continued on Attachment 6.
Injuries
The following injuries were sustained by the claimant as a result of the incident or accident (describe):
Kaiden Lau sustained injuries to his head and suffered emotional
trama.
() Continued on Attachment 7.
Treatment
The claimant received the following care and treatment for the injuries described in item 7 (describe):
Brimhall Pediatrics and Artisa Moten, MS MFT.
[2] Continued on Attachment 8.
MC-350EX [Rev. January 1, 2021] PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page
2 of 7
CB Essential CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF
ceb.com fe|Forms JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
LAU, KAIDEN
MC-350EX
CASE NAME: CASE NUMBER:
LAU VS. HOUTZ BCV-24-100128-BCB
9. Extent of injuries and recovery (An original or a photocopy of any doctor's report containing a diagnosis of the claimant's injuries
or a prognosis for the claimant's recovery, and a report of the claimant's current condition, must be attached to this petition as
Attachment 9. A new report is not necessary if a previous report accurately describes the claimant's current condition.)
a. [XQ] The claimant has recovered completely from the effects of the injuries described in item 7, and there are no permanent
injuries.
b. [2] The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries
from which the claimant has not recovered are temporary (describe the remaining injuries and symptoms):
[2] Continued on Attachment 9b.
c. (2) The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries
from which the claimant has not recovered are permanent (describe the permanent injuries and symptoms):
[2] Continued on Attachment 9c.
10. Petitioner has made a careful and diligent inquiry and investigation into the facts and circumstances of the incident
or accident in which the claimant was injured; the responsibility for the incident or accident; and the nature, extent,
and seriousness of the claimant's injuries. Petitioner understands that if the compromise proposed in this petition is
approved by the court and consummated, the claimant will never be able to recover any more compensation from the
settling defendants named below even if the claimant's injuries turn out to be more serious than they now appear.
1 Amount and terms of settlement
To settle the claim in 4a or 4b, the defendants named below have offered to pay the following amounts to the claimant:
a. The total amount offered by all defendants named below is (specify): $ 25,000
b. The defendants and amounts offered by each are as follows (specify):
Defendants (names) Amounts
Mary Lou Houtz 20,000
BAA Med Pay 5,000
(J Additional defendants and amounts offered are listed on Attachment 11b.
c. The terms of settlement are described on Attachment 11c. (ifthe settlement is to be paid in installments, both the total amount
and the present value of the setflement must be included.)
12. Settlement payments to others
a. [No defendant named in item 11b has offered to pay money to any person or persons other than the claimant to settle
claims arising out of the same incident or accident that resulted in the claimant's injury.
b. [One or more of the defendants named in item 11b have also offered to pay money to a person or persons other than
claimani to settle claims arising out of the same incident or accident that resulted in the claimant's injury.
(1) The total amount offered by all defendants to others (specify): Mary Lou Houtz $ 85,488
(2) []} Petitioner would receive money under the proposed settlement.
(3) The settlement payments are to be apportioned and distributed as follows:
Other plaintiffs or claimants (names) Amounts
David Lau $ 58,737
Yvonne Lau $ 26,751
$
$
CA) Additional plaintiffs or claimants and amounts are listed on Attachment 12.
(4) Lyhe settlement payments are apportioned between the claimant and each other plaintiff or claimant named above on
a pro rata basis, based upon the special damages claimed by each. The special damages claimed by each other
plaintiff or claimant are specified on Attachment 12.
(5) [Reasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant
named above are specified on Attachment 12.
MG-350EX [Rov. January 1, 2021] PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page 3 of7
CEB’ Essential CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF
(Forms: LAU, KAIDEN
cebcom JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
MC-025
SHORT TITLE: CASE NUMBER,
> LAU VS. HOUTS BCV-24-100128~BCB
ATTACHMENT (Number): Q
(This Attachment may be used with any Judicial Council form.)
EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM FOR MINOR
MEDICAL RECORDS FROM:
ARTISA MAE MOTEN, MS, LMFT
S & T PROFESSIONAL GROUP
2201 wpe STREET
BAKERSFIELD, CA 93301
661.324.1982
(if the item that this Atachment concems is made under penalty of pedjury, all statements in this Page of
Aitachment are made under penalty of perjury.) (Add pages as required)
Form Approved for Optional Use ATTACHMENT www courtinfo.ca.gov
Judicial Couneil of California
MC-025 [Rev. July 1. 2009], to Judicial Council Form
CEB | Essential LAU, KAIDEN
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S & T Professional Group
May 19, 2023
RE: KAIDEN LAU
DOB: 10/23/2008
To Law Office of Kyle W. Jones,
The above named client last date of treatment was 11/21/22.
Thank you so much for your assistance. Parents of K. Lau has given me written consent to
discuss her case with you, and a copy of that confidentiality waiver can be obtained from my
office upon request. Should you have additional questions, please do not hesitate to contact me.
Kindly,
Artisa Mae Moten
MS, LMFT #120733
2201 F Street | Bakersfield CA 93301
Phone: 661.324.1982 | Fax: 661.324.1220 | E-mail: stproroup|@gmail.com1 of 7
S&T Professional Group
August 29, 2023
Law Office of Kyle W. Jones
1620 Mill Rock Way, Suite 100
Bakersfield, CA 93311
Subject: Treatment Summary for Kaiden Lau (DOB: 10/23/2008)
Dear Mr. Jones,
[am writing to provide a treatment summary for Kaiden Lau, who was under my care for therapy
following a car accident. Kaiden Lau's treatment began on March 12, 2020, and concluded on
July 19, 2022. During this period, Kaiden was diagnosed with Acute Stress Disorder (ASD),
which later progressed to Post-Traumatic Stress Disorder (PTSD).
Treatment Timeline and Progression:
Initial Assessment: March 12, 2020
Kaiden Lau was referred to our clinic following a car accident that occurred on [date of car
accident]. He exhibited symptoms of Acute Stress Disorder (ASD) including intense fear,
avoidance behaviors, and recurring distressing memories related to the accident. Our initial
assessment confirmed the diagnosis, and therapy was initiated promptly.
Treatment for Acute Stress Disorder: March 2020 - April 2020
Kaiden underwent a structured therapy plan focusing on managing the acute stress symptoms
triggered by the car accident. Techniques such as cognitive-behavioral therapy (CBT) and
exposure therapy were utilized to address avoidance behaviors and distressing thoughts. Kaiden
demonstrated gradual improvement over this period.
Progression to PTSD: After 4 Weeks
Despite initial progress, Kaiden's distress persisted beyond the expected recovery period, leading
to a diagnosis of Post-Traumatic Stress Disorder (PTSD). Treatment was adjusted to target the
specific symptoms associated with PTSD, including flashbacks, nightmares, hypervigilance, and
emotional numbing.
2201 F Street, Bakersfield, California 93301
Telephone (661) 324-1982 Fax (661) 324-1220
stprogroup1@gmail.com
1/2
S&T Professional Group
Treatment for PTSD: May 2020 - July 2022
Kaiden engaged in an extended therapy regimen to address the PTSD symptoms that arose from
the car accident. The therapy incorporated various techniques such as trauma-focused CBT, eye
movement desensitization and reprocessing (EMDR), and mindfulness strategies. Gradually,
Kaiden displayed significant improvement, and his PTSD symptoms began to diminish.
Successful Completion of Therapy: July 19, 2022
After consistent and dedicated effort, Kaiden successfully completed his therapy for PTSD
related to the car accident. He now demonstrates improved emotional regulation, reduced
avoidance behaviors, and decreased distressing memories associated with the incident. His
ability to operate without PTSD-related symptoms is notable, and his Viable Occupational
Capacity (VOC) is assessed at 6/7, considering logical fears during situations involving reckless
driving by others.
Should there be any inquiries or uncertainties regarding this matter, please feel free to contact us
at (661) 324-1982.
Sincerely,
Artisa Mae Moten, MS
LMFT #120733
2201 F Street, Bakersfield, California 93301
Telephone (661) 324-1982 Fax (661) 324-1220
stprogroup1@gmail.com
2/2
MC-025
SHORT TITLE: CASE NUMBER,
[ LAU VS. HOUTZ BCV-24-100128-BCB
ATTACHMENT (Number): 11c
(This Attachment may be used with any Judicial Council form.)
EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM FOR MINOR
THE TERMS OF THE SETTLEMENT ARE AS FOLLOWS:
UPON APPROVAL OF THE EXPEDITED MINORS COMPROMISE, THE FULL SETTLEMENT
AMOUNT OF $20,000.00 WILL BE ISSUED TO THE LAW OFFICES OF KYLE JONES IN
TRUST FOR KAIDEN LAU.
(if the item that this Attachment concems is made under penalty of perjury, all statements in this Page of
Attachment are made under penaity of pequry.) (Add pages as required)
Form Approved for Optional Use ATTACHMENT wirw.courtinfo.ca.gov
Judicial Council of California
MC-025 [Rev. July 1, 2008} to Judicial Council Form
CB Essential LAU, KAIDEN
ceb.com {2]Forms:
MC-350EX
CASE NAME: CASE NUMBER:
LAU VS. HOUTZ BCV-24-100128-BCB
13. Claimant's medical expenses—including expenses paid by petitioner, Medicare, Medi-Cal, and private insurers—that are to
be paid or reimbursed from the proceeds of the settlement or judgment
a Totals
(1) Total medical expenses before any reductions: $ 10,352
(2) Total medical expenses paid (include payments by private insurance, Medi-Cal, or Medicare): g
(3) Total of negotiated, contractual, or statutory reductions, if any: ($ 3,460)
(4) Total amount of medical expenses to be paid or reimbursed from proceeds: $ 6,892
(5) Total amount of statutory or contractual liens, if any: $ 3,892
(identify each medical expense payer and the amount each paid, and explain any differences between items 13a(1), (4), and (5)
in Attachment 13a.)
(1) [oJNone of the claimant's medical expenses have been paid by Medicare.
(2) (Medicare paid some or all of claimant's medical expenses. In full satisfaction of its lien rights,
Medicare will be reimbursed in the amount of:
(Attach a copy of the final Medicare demand feiter or letter agreement as Attachment 13b(2).)
(1) [None of the claimant's medical expenses have been paid by Medi-Cal.
(2) ky Medi-Cal paid some or al! of claimant's medical expenses.
(a) Notice of this claim or action has been given to the Director of Health Care Services. (Welf. & Inst. Code, § 14124.73.)
Acopy of the notice and proof of delivery [is attached [_] was filed in this matter on (date):
(b) In full satisfaction of its lien rights, Medi-Cal has agreed to accept reimbursement
in the amount of: $ 3,892
(Attach a copy of the final Medi-Cai demand letter or letter agreement as Attachment 13c(2).)
(24 The claimant's health plan is requesting reimbursement for medical expenses paid under the plan.
In full satisfaction of the plan's lien rights, it will be reimbursed in the amount of: $
{Attach statements from the plan showing expense payments and requesting reimbursement.)
(} Petitioner has paid claimant's medical expenses to be reimbursed in the amount of: $
(See instructions for item 15.)
(1) ()There are no statutory or contractual liens for payment of the claimant's medical expenses.
(2) (There are one or more liens from medical service providers for payment of the claimant's medical expenses.
In full satisfaction of their lien claims, the lienholders have agreed to accept the sum of: $ 3,000
(Select (1) or (2) below.)
(1) ]Latest statements from all medical service providers are attached as Attachment 13g.
(2) LXJAI medical expenses have been paid by private insurance, Medicare, or Medi-Cal.
14. Claimant's attorney's fees and all other expenses (except medical expenses), including fees or expenses paid by petitioner
and claimant's attorney, to be paid or reimbursed from proceeds of settlement or judgment
a, Total amount of attorney's fees for which court approval is requested: $ 5,000
(if fees are requested, attach as Attachment 14a a declaration fram the attomey explaining the basis for the request, including a
discussion of applicable factors listed in rule 7.955(b) of the Cal. Rules of Court. include a copy of any written attorney fee
agreement in Attachment 14a.)
The following additional items of expense (other than medical expenses) have been incurred or paid, are reasonable, resulted
from the incident or accident, and should be paid or reimbursed out of claimant's share of the proceeds of the settlement or
judgment:
Items Payees (names) Amounts
Filing Fee Kern County Superior Court 458
[2] Continued on Attachment 14b. Total: $B
c. (.) Costs of suit attributable to more than one settling plaintiff are not apportioned between them on a pro rata basis based
on their gross settlement amounts. The apportionment of these costs is described and explained in Attachment 14c.
MC-350EX [Rev. January 4, 2024] PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page
4 of 7
GB Essential
Forms:
CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
LAU, KAIDEN
MC-025
SHORT TITLE: (CASE NUMBER:
LAU VS. HOUTZ BCV-24-100128-BCB
ATTACHMENT (Number): 138
(This Attachment may be used with any Judicial Council form.)
EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM FOR MINOR
MEDICAL PROVIDERS:
BELINDA A. SANTOS-SENAR, MD
(1) Total medical expenses before reduction: 35 68
(2) Total medical expenses paid by Medi-Cal: 35 68
(3) Total of negotiated, contractual, or statutory reductions
if any 00
(4) Total amount of medical expenses to be paid or reimbursed
from proceeds 00
(5) Total amount of statutory or contractual liens, if any: $ 35 68
ARTISA MAE MOTEN, MS/S&T PROFESSIONAL GROUP
(1) Total medical expenses before reduction: $5,850 00
(2) Total medical expenses paid by Medi-Cal: $5,316 00
(3) Total of negotiated, contractual, or statutory reductions
if any $1,461 4l
(4) Total amount of medical expenses to be paid or reimbursed
from proceeds 8 0 00
(5) Total amount of statutory or contractual liens, if any: $3,855 59
The minor's health insurance, Medi-Cal, paid $5,351.68 for the medical
expenses above and wrote off $1,460.41. The amount owing to Medi-Cal
that will be paid from the proceeds is, $3,891.27.
(if the item that this Attachment concerns is made under penalty of perjury, all statements in this Page of
Attachment are made under penalty of perjury.) (Add pages as required)
Form Ap noved for tional Use ATTACHMENT www courtinfo.ca.gov
Judicial f Councilof California
MC-026 (Rev. July 4, 2009) to Judicial Council Form
cB Essential
cebcom jelForms
MC-025
SHORT TITLE: CASE NUMBER:
- LAU VS. HOUTZ BCV-24-100128-BCB
ATTACHMENT (Number): 13cf2_
(This Attachment may be used with any Judicial Council form.)
EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM FOR MINOR
Final Medi-Cal Lien Demand Letter
{if the item that this Attachment concems is made under penaily of peiury, ail statements in this Page of
Attachment are made under penalty of perjury.) (Add pages as required)
Form Approved for Optional Use ATTACHMENT weeu.courtinfo.ca.gov
Judicial Council of California
MC-025 [Rev. July 1, 2009] to Judicial Council Form
CLB Essential
ceb.com | f2iForms
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BIICS
ge Department of
Health Care Services Moh feel (de Cel of
2070
Thank You Gum 3/4 cmt
Your information has been submitted, thank you.
Back to Top Version: 2.0.0.26
Copyright © 2008 DHCS/CDPH, State of California
https://apps.dhes.ca.gov/AutoForm2/Page/Thank
Y ou.aspx 3/9/2020
State of California GAVIN NEWSOM, Governor
=ESensss========:=: =: ==: = =
Department of Health Care Serv ices
Recovery Section, MS 4720
P.O. Box
997425
Sacramento, CA 95899-7425
(916) 445-9891 NOTICE OF MEDI-CAL LIEN
March 16, 2020
KYLE JONES
ATTORNEY AT LAW
1620 MILL ROCK WAY STE 100
BAKERSFIELD, CA 93311
This letter serves as an acknowledgment that the Department of Health Care
Services (DHCS) received notification regarding a potential third party
settlement involving the below-named individual. This individual is a
Medi-Cal member and may have received health care services relating to this
injury. Pursuant to sections 14124.70 through 14124.795 of the Welfare and
Institutions Code (W&I Code), DHCS has the right to assert a lien against
any settlement, judgment, or award obtained from a liable third party.
DHCS Case Name KAIDEN LAU
DHCS Account Number C98813938E-001
Injury Date February 16, 2020
If not previously provided, please submit the name and contact information
of the liable third party or carrier pursuant to W&I Code section
14124.73(c).
DHCS will issue a lien after the following information has been received:
*Date of final treatment related to the injury by a Medi-Cal provider,
AND/OR
*Date of settlement - If the matter has been settled, please provide DHCS
with the settlement documentation, attorney fees, and an itemization of
litigation costs.
This information should be provided by visiting our website at
dhes.ca.gov/piforms and select Step 2, "Case Update or Additional
Documentation" Please have the DHCS Account Number and be prepared to
attach electronic copies of supporting documents.
***New feature available: Online Inquiry***
Use our new Online Inquiry page to receive a secure response within 24
hours. Visit dhes.ca.gov/ing to submit the following inquiries:
- Questions about the status of an existing case. Please have the
13-6268
KYLE JONES
Page 2
DHCS Account Number available.
- Requests for Medi-Cal member's Client Index Number (CIN).
Use when you need to submit a new case notification but do not
know your client's CIN.
If you have any questions, please contact the Medi-Cal Personal Injury
Program at (916) 445-9891 or submit a case status inquiry at
dhes.ca.gov/ing.
CAS1090A (11/19)
13-6269
Ge
State of California GAVIN NEWSOM, Governor
=====: —=.
=====: == == SSS som:
one: =: =
Department of Health Care Services
Recovery Section, MS 4720
P.O. Box 997425
Sacramento, CA 95899-7425
(916) 445-9891 February 16, 2024
KYLE JONES
ATTORNEY AT LAW
1620 MILL ROCK WAY STE 100
BAKERSFIELD, CA 93311
The Medi-Cal beneficiary listed below has received $5,351.68 in benefits
through the Medi-Cal Program related to the third party liability injury
(Injury) on February 16, 2020. The Department of Health Care Services
(DHCS) xetains reimbursement rights for the reasonable value of benefits
provided pursuant to Welfare and Institutions Code (W&I Code) sections
14124.70 et seq., and section 14024.
DHCS Case Name KAIDEN LAU
DHCS Account Number C98813938E-001
Injury Date February 16, 2020
Amount Due $3,891.27
DHCS' reimbursement is limited to the lesser of: 1) no more than the
Medi-Cal beneficiary recovers after deducting attorney's fees and
litigation costs paid for by the Medi-Cal beneficiary per W&I Code section
14124.78;or 2) the lien amount after deducting the director's reasonable
share of attorney's fees and litigation costs per W&I Code section
14124,72(d) Pursuant to W&I Code section 14124.785 and the information
received to date, DHCS has reduced the lien for reimbursement of the
reasonable value of benefits from $5,351.68 to $3,891.27.
Reimbursement in the amount of $3,891.27 will satisfy DHCS' lien, subject
to the conditions set forth below:
1) Pursuant to W&I Code sections 14124.785 and 14124.79, you are
required to notify DHCS if there are additional settlements arising
out of the same Injury. DHCS retains all statutory lien rights
arising from Medi-Cal paid services regarding any other settlement,
judgment, or award related to the same Injury as authorized by law.
2) If you are aware of additional services provided as a result of the
above-referenced Injury, please notify DHCS immediately. DHCS may
11-2952
Ee
KYLE JONES
Page 2
be entitled to additional reimbursement for the reasonable value of
Medi-Cal benefits that were not included in the above-referenced
amount.
3) Payment may become due upon the death of
KAIDEN LAU pursuant to W&I Code section
14009.5, as applicable, and/or termination of a trust, if any,
created pursuant to Title 42 U.S. Code 1396 (p) (d) (4) (a-c)
for the benefit of KAIDEN LAU.
4) If medical payment coverage (MedPay) is available, please notify
this office as this may affect the calculation of reimbursement
due.
Please remit payment in the amount of $3,891.27. A payment for less than
the amount owed will be credited to the account but will not be considered
payment in full for the DHCS lien.
To make an Electronic Funds Transfer (EFT) payment:
1 Go to dhcs.ca.gov/epay.
2 Scroll to the bottom of the page and select the option "Make an EFT
Payment."
3 On the payment page, you can choose to make a one-time payment or
to apply to become an enrolled user.
* To become an enrolled user, complete and submit an enrollment
form found at the bottom of the dhes.ca.gov/epay webpage.
Provide the Medi-Cal beneficiary's DHCS account number and all the
necessary payment, contact, and banking information.
Print or save the information on the payment confirmation page,
including the confirmation number, for your records.
EFT is a fast, easy and secure method for payment submission. It offers
many advantages, including free online payment submission, savings on
postage and printing costs, quicker delivery and processing time, and
reduced waste. You have the option to make a one-time payment or to become
an enrolled user. The enrolled user option allows you to easily make a
payment, schedule future payments, cancel a payment, and track payment
history.
Please visit dhcs.ca.gov/epay for more information and to view the EFT
Information Guide with step-by-step instructions for making an EFT payment.
Payment by check or money order may take up to 7-10 business days to
process and must include the Medi-Cal beneficiary's DHCS account number.
If you have any questions, please contact the Medi-Cal Personal Injury
Program at (916) 445-9891.
Enclosure
11-2953
Be
KYLE JONES
Page 3
CAS3050A (03/21)
woe-e enn 5 ee ee en en nnn en ee een nee nnn
PLEASE DETACH AND ENCLOSE WITH YOUR PAYMENT
OR TO MAKE AN EFT PAYMENT, GO TO: DHCS.CA.GOV/EPAY
DHCS Account Number: C98813938E-001
DHCS Case Name KAIDEN LAU
Mail your payment to:
AMOUNT DUE: $3,891.27
Department of Health Care Services
Recovery Branch - MS 4720 AMOUNT ENCLOSED: $
P.O, Box 997421
Sacramento, CA 95899-7421
11-2954
RE LAU, KAIDEN PAGE 1
INJURY DATE: FEBRUARY 16, 2020
INJURY-RELATED SERVICES PAID BY THE MEDI~CAL PROGRAM
--------------- ++ - == = == = ee
LYNDON & BELINDA SENAR
02/18/20 Headache $35 68
S & T PROFESSIONAL GRP IN
03/12/20 Post-traumatic stress disorder, uns $72 00
pecified
03/24/20 Post-traumatic stress disorder, uns $69 00
pecified
04/01/20 Post-traumatic stress disorder, uns $69 00
pecified
04/16/20 Post-traumatic stress disorder, uns $69 00
pecified
04/23/20 Post-traumatic stress disorder, uns $69 00
pecified
04/27/20 Post-traumatic stress disorder, uns $69 00
pecified
05/05/20 Post-traumatic stress disorder, uns $69 00
pecified
05/26/20 Post-traumatic stress disorder, uns $69 00
pecified
06/03/20 Post-traumatic stress disorder, uns $69 00
pecified
06/09/20 Post-traumatic stress disorder, uns $69 00
pecified
06/11/20 Post-traumatic stress disorder, uns $69 00
pecified
06/13/20 Post-traumatic stress disorder, uns $69 00
pecified
06/16/20 Post-traumatic stress disorder, uns $69 00
pecified
06/18/20 Post-traumatic stress disorder, uns $69 00
pecified
06/23/20 Post-traumatic stress disorder, uns $69 00
pecified
07/07/2
Preview
MC-350EX ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: FOR COURT USE ONLY name: Kyle W. Jones, Esq. 224797 riemname: Law Office of Kyle W. Jones streetappress: 1620 Mill Rock Way, Suite 100 ory. Bakersfield state: CA zipcone: 93311 Teveponeno. 661.833.1090 raxno: 661.412.4861 emanaopress: Kyle jones@kwjoneslaw.com ATTORNEY FOR (Name): Petitioner SUPERIOR COURT OF CALIFORNIA, COUNTY OF Kern ‘STREET ADDRESS: 1215 Truxtun Avenue MAILING ADDRESS: SAME AS ABOVE CITY AND ZIP CODE: Bakersfield, CA 93301 BRANCH NAME: Metropolitan Division - Justice Bldg CASE NAME; ‘CASE NUMBER: KAIDEN LAU VS. MARY LOU HOUTZ BCV-24~100128-BCB [XQ No hearing date is requested. PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF (Co mearie nate JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY TIME: DEPT NOTICE TO PETITIONER You must use this form to request expedited court approval of a qualifying (1) compromise of a minor's disputed claim, (2) compromise lof a pending action or proceeding in which a minor or a person with a disability (including a conservatee) is a party, or (3) disposition of the proceeds of a judgment for a minor or person with a disability. (See Code Civ. Proc., § 372; Prob. Code, §§ 3500, 3600-3613.) You may request expedited approval only if (1) you are represented by an attorney; (2) the statements in items 3a, 3b, 3c, 3d, 3e, 3f, and either 3g(1) or 3g(2), below, are true and accurate; and (3) the court does not otherwise order. If your compromise or judgment qualifies and you choose to use this form, the court may consider and act on your petition without a hearing. If your compromise or judgment qualifies for expedited consideration but you choose not to use this form or your compromise or judgment does not qualify for expedited consideration, you must use Petition for Approval of Compromise of Claim or Action or Disposition of Proceeds of Judgment for Minor or Person With a Disability (form MC-350), and the court will schedule a hearing. 1 Petitioner (name or pseudonym’): YVONNE LAU is the (check all boxes that apply) [qq Parent (2) Guardian ad litem O20 Guardian (1 Conservator (Q] Other (specify retationship): Mother of the claimant identified i item 2. (“Petitioner may appear under a pseudonym only if appointed as guardian ad litem under that pseudonym. (See Code Civ, Proc., § 372.5.)} Claimant (name) Kaiden Lau a. Address: 3810 Europa Lane, Bakersfield, CA 93312 b. Date of birth: 10/23/2008 c. Age: 15 d. [XJ Minor or [23 Person with a disability (if the claimant is an adult with a disability who (1) has capacity to consent to the order requested and (2) does not have a conservator of the estate, check e. and f. and ensure that the claimant personally reads and signs item 21. (Prob. Code, § 3613.)) e. (2) Has the capacity, within the meaning of Probate Code section 812, to consent to the requested order. f. [XJ Does not have a conservator of the estate. Qualification for Expedited Approval The claimant's claim or action is not for damages for the death of a person caused by the wrongful act or neglect of another. No portion of the net proceeds of the judgment or settlement in favor of the claimant is to be placed in a trust There are no unresolved disputes concerning liens to be satisfied from the proceeds of the judgment or settlement. Petitioner's attorney did not become involved with this matter, directly or indirectly, at the request of a party against whom the claim is asserted or a party's insurance carrier. Petitioner's attorney is not representing, employed by, or associated with a defendant in this matter or an insurance carrier. All defendants that have appeared in a pending action on the claim are participating in the proposed compromise or the court has made a final determination that all settling parties entered into the settlement in good faith. (1) QQ The judgment described in item 4c (exclusive of interest and costs) or the total settlement described in items 11 and 12 payable to the claimant and all other persons named in item 12 is in the amount of $50,000 or less; or (2) (] The settlement described in item 11 represents payment of the single-person policy limits of all liability insurance policies covering the defendants named in that item. The investigation described in Attachment 3 shows that all of those defendants are judgment-proof outside of their insurance coverage. (Describe investigation and results in Attachment 3.) Page 1 of 7 Apter fyAeanaive Mendalny Use PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Code of Civil Procedure, § 372: frlose st Probate Cade, 3 505i, jig! Council of Ca CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF al. RislesofFas ut, rules 3.1384) (Rev. January1, 2021] 7.960. JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY www courts.ca.gov CIB Essential ceb.com | §e/Forms LAU, KAIDEN MC-350EX CASE NAME: CASE NUMBER: LAU VS. HOUTZ BCV-24-100128-BCB Claim The claim of the minor or adult person with a disability: a. [X) Is not the subject of a pending action or proceeding. (Complete items 5-23.) b. [.) Is the subject of a pending action or proceeding that will be compromised without a trial. (Complete items 5-23.) Name of court: Case no.: Trial date: c. [2] Is the subject of an action or proceeding in which a judgment has been or will be entered for the claimant against the defendants named below in the amount (exclusive of interest and costs) of (specify): $ Defendants (names): L-}Additional defendants listed on Attachment 4. (Coy the judgment was filed on (date): (Attach a copy of the (proposed) judgment as Attachment 4c and complete items 13-23.) Incident or accident The incident or accident occurred as follows: a. Date 02/16/2020 Time: 2:16 p.m. b. Place: Buena Vista Road and Ming Avenue in the City of Bakersfield, County of Kern, California. Persons involved (names): Kaiden Lau Mary Lou Houtz David Lau Yvonne Lau C2} Additional persons listed on Attachment 5. Nature of incident or accident The facts, events, and circumstances of the incident or accident are (describe what happened): David Lau was driving southbound in the number one designated left turn lane. Mr. Lau came to a complete stop at the intersection of Buena Vista Rd. and Ming Ave. when defendant, Mary Lou Houtz, drove over the raised center median, and stuck the driver side of the Lau vehicle. (CJ Continued on Attachment 6. Injuries The following injuries were sustained by the claimant as a result of the incident or accident (describe): Kaiden Lau sustained injuries to his head and suffered emotional trama. () Continued on Attachment 7. Treatment The claimant received the following care and treatment for the injuries described in item 7 (describe): Brimhall Pediatrics and Artisa Moten, MS MFT. [2] Continued on Attachment 8. MC-350EX [Rev. January 1, 2021] PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page 2 of 7 CB Essential CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF ceb.com fe|Forms JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY LAU, KAIDEN MC-350EX CASE NAME: CASE NUMBER: LAU VS. HOUTZ BCV-24-100128-BCB 9. Extent of injuries and recovery (An original or a photocopy of any doctor's report containing a diagnosis of the claimant's injuries or a prognosis for the claimant's recovery, and a report of the claimant's current condition, must be attached to this petition as Attachment 9. A new report is not necessary if a previous report accurately describes the claimant's current condition.) a. [XQ] The claimant has recovered completely from the effects of the injuries described in item 7, and there are no permanent injuries. b. [2] The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries from which the claimant has not recovered are temporary (describe the remaining injuries and symptoms): [2] Continued on Attachment 9b. c. (2) The claimant has not recovered completely from the effects of the injuries described in item 7, and the following injuries from which the claimant has not recovered are permanent (describe the permanent injuries and symptoms): [2] Continued on Attachment 9c. 10. Petitioner has made a careful and diligent inquiry and investigation into the facts and circumstances of the incident or accident in which the claimant was injured; the responsibility for the incident or accident; and the nature, extent, and seriousness of the claimant's injuries. Petitioner understands that if the compromise proposed in this petition is approved by the court and consummated, the claimant will never be able to recover any more compensation from the settling defendants named below even if the claimant's injuries turn out to be more serious than they now appear. 1 Amount and terms of settlement To settle the claim in 4a or 4b, the defendants named below have offered to pay the following amounts to the claimant: a. The total amount offered by all defendants named below is (specify): $ 25,000 b. The defendants and amounts offered by each are as follows (specify): Defendants (names) Amounts Mary Lou Houtz 20,000 BAA Med Pay 5,000 (J Additional defendants and amounts offered are listed on Attachment 11b. c. The terms of settlement are described on Attachment 11c. (ifthe settlement is to be paid in installments, both the total amount and the present value of the setflement must be included.) 12. Settlement payments to others a. [No defendant named in item 11b has offered to pay money to any person or persons other than the claimant to settle claims arising out of the same incident or accident that resulted in the claimant's injury. b. [One or more of the defendants named in item 11b have also offered to pay money to a person or persons other than claimani to settle claims arising out of the same incident or accident that resulted in the claimant's injury. (1) The total amount offered by all defendants to others (specify): Mary Lou Houtz $ 85,488 (2) []} Petitioner would receive money under the proposed settlement. (3) The settlement payments are to be apportioned and distributed as follows: Other plaintiffs or claimants (names) Amounts David Lau $ 58,737 Yvonne Lau $ 26,751 $ $ CA) Additional plaintiffs or claimants and amounts are listed on Attachment 12. (4) Lyhe settlement payments are apportioned between the claimant and each other plaintiff or claimant named above on a pro rata basis, based upon the special damages claimed by each. The special damages claimed by each other plaintiff or claimant are specified on Attachment 12. (5) [Reasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant named above are specified on Attachment 12. MG-350EX [Rov. January 1, 2021] PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page 3 of7 CEB’ Essential CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF (Forms: LAU, KAIDEN cebcom JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-025 SHORT TITLE: CASE NUMBER, > LAU VS. HOUTS BCV-24-100128~BCB ATTACHMENT (Number): Q (This Attachment may be used with any Judicial Council form.) EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM FOR MINOR MEDICAL RECORDS FROM: ARTISA MAE MOTEN, MS, LMFT S & T PROFESSIONAL GROUP 2201 wpe STREET BAKERSFIELD, CA 93301 661.324.1982 (if the item that this Atachment concems is made under penalty of pedjury, all statements in this Page of Aitachment are made under penalty of perjury.) (Add pages as required) Form Approved for Optional Use ATTACHMENT www courtinfo.ca.gov Judicial Couneil of California MC-025 [Rev. July 1. 2009], to Judicial Council Form CEB | Essential LAU, KAIDEN ceb.com rms" S&T ona, ee i! NG, 5 4, Ns Gjtt eee S & T Professional Group May 19, 2023 RE: KAIDEN LAU DOB: 10/23/2008 To Law Office of Kyle W. Jones, The above named client last date of treatment was 11/21/22. Thank you so much for your assistance. Parents of K. Lau has given me written consent to discuss her case with you, and a copy of that confidentiality waiver can be obtained from my office upon request. Should you have additional questions, please do not hesitate to contact me. Kindly, Artisa Mae Moten MS, LMFT #120733 2201 F Street | Bakersfield CA 93301 Phone: 661.324.1982 | Fax: 661.324.1220 | E-mail: stproroup|@gmail.com1 of 7 S&T Professional Group August 29, 2023 Law Office of Kyle W. Jones 1620 Mill Rock Way, Suite 100 Bakersfield, CA 93311 Subject: Treatment Summary for Kaiden Lau (DOB: 10/23/2008) Dear Mr. Jones, [am writing to provide a treatment summary for Kaiden Lau, who was under my care for therapy following a car accident. Kaiden Lau's treatment began on March 12, 2020, and concluded on July 19, 2022. During this period, Kaiden was diagnosed with Acute Stress Disorder (ASD), which later progressed to Post-Traumatic Stress Disorder (PTSD). Treatment Timeline and Progression: Initial Assessment: March 12, 2020 Kaiden Lau was referred to our clinic following a car accident that occurred on [date of car accident]. He exhibited symptoms of Acute Stress Disorder (ASD) including intense fear, avoidance behaviors, and recurring distressing memories related to the accident. Our initial assessment confirmed the diagnosis, and therapy was initiated promptly. Treatment for Acute Stress Disorder: March 2020 - April 2020 Kaiden underwent a structured therapy plan focusing on managing the acute stress symptoms triggered by the car accident. Techniques such as cognitive-behavioral therapy (CBT) and exposure therapy were utilized to address avoidance behaviors and distressing thoughts. Kaiden demonstrated gradual improvement over this period. Progression to PTSD: After 4 Weeks Despite initial progress, Kaiden's distress persisted beyond the expected recovery period, leading to a diagnosis of Post-Traumatic Stress Disorder (PTSD). Treatment was adjusted to target the specific symptoms associated with PTSD, including flashbacks, nightmares, hypervigilance, and emotional numbing. 2201 F Street, Bakersfield, California 93301 Telephone (661) 324-1982 Fax (661) 324-1220 stprogroup1@gmail.com 1/2 S&T Professional Group Treatment for PTSD: May 2020 - July 2022 Kaiden engaged in an extended therapy regimen to address the PTSD symptoms that arose from the car accident. The therapy incorporated various techniques such as trauma-focused CBT, eye movement desensitization and reprocessing (EMDR), and mindfulness strategies. Gradually, Kaiden displayed significant improvement, and his PTSD symptoms began to diminish. Successful Completion of Therapy: July 19, 2022 After consistent and dedicated effort, Kaiden successfully completed his therapy for PTSD related to the car accident. He now demonstrates improved emotional regulation, reduced avoidance behaviors, and decreased distressing memories associated with the incident. His ability to operate without PTSD-related symptoms is notable, and his Viable Occupational Capacity (VOC) is assessed at 6/7, considering logical fears during situations involving reckless driving by others. Should there be any inquiries or uncertainties regarding this matter, please feel free to contact us at (661) 324-1982. Sincerely, Artisa Mae Moten, MS LMFT #120733 2201 F Street, Bakersfield, California 93301 Telephone (661) 324-1982 Fax (661) 324-1220 stprogroup1@gmail.com 2/2 MC-025 SHORT TITLE: CASE NUMBER, [ LAU VS. HOUTZ BCV-24-100128-BCB ATTACHMENT (Number): 11c (This Attachment may be used with any Judicial Council form.) EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM FOR MINOR THE TERMS OF THE SETTLEMENT ARE AS FOLLOWS: UPON APPROVAL OF THE EXPEDITED MINORS COMPROMISE, THE FULL SETTLEMENT AMOUNT OF $20,000.00 WILL BE ISSUED TO THE LAW OFFICES OF KYLE JONES IN TRUST FOR KAIDEN LAU. (if the item that this Attachment concems is made under penalty of perjury, all statements in this Page of Attachment are made under penaity of pequry.) (Add pages as required) Form Approved for Optional Use ATTACHMENT wirw.courtinfo.ca.gov Judicial Council of California MC-025 [Rev. July 1, 2008} to Judicial Council Form CB Essential LAU, KAIDEN ceb.com {2]Forms: MC-350EX CASE NAME: CASE NUMBER: LAU VS. HOUTZ BCV-24-100128-BCB 13. Claimant's medical expenses—including expenses paid by petitioner, Medicare, Medi-Cal, and private insurers—that are to be paid or reimbursed from the proceeds of the settlement or judgment a Totals (1) Total medical expenses before any reductions: $ 10,352 (2) Total medical expenses paid (include payments by private insurance, Medi-Cal, or Medicare): g (3) Total of negotiated, contractual, or statutory reductions, if any: ($ 3,460) (4) Total amount of medical expenses to be paid or reimbursed from proceeds: $ 6,892 (5) Total amount of statutory or contractual liens, if any: $ 3,892 (identify each medical expense payer and the amount each paid, and explain any differences between items 13a(1), (4), and (5) in Attachment 13a.) (1) [oJNone of the claimant's medical expenses have been paid by Medicare. (2) (Medicare paid some or all of claimant's medical expenses. In full satisfaction of its lien rights, Medicare will be reimbursed in the amount of: (Attach a copy of the final Medicare demand feiter or letter agreement as Attachment 13b(2).) (1) [None of the claimant's medical expenses have been paid by Medi-Cal. (2) ky Medi-Cal paid some or al! of claimant's medical expenses. (a) Notice of this claim or action has been given to the Director of Health Care Services. (Welf. & Inst. Code, § 14124.73.) Acopy of the notice and proof of delivery [is attached [_] was filed in this matter on (date): (b) In full satisfaction of its lien rights, Medi-Cal has agreed to accept reimbursement in the amount of: $ 3,892 (Attach a copy of the final Medi-Cai demand letter or letter agreement as Attachment 13c(2).) (24 The claimant's health plan is requesting reimbursement for medical expenses paid under the plan. In full satisfaction of the plan's lien rights, it will be reimbursed in the amount of: $ {Attach statements from the plan showing expense payments and requesting reimbursement.) (} Petitioner has paid claimant's medical expenses to be reimbursed in the amount of: $ (See instructions for item 15.) (1) ()There are no statutory or contractual liens for payment of the claimant's medical expenses. (2) (There are one or more liens from medical service providers for payment of the claimant's medical expenses. In full satisfaction of their lien claims, the lienholders have agreed to accept the sum of: $ 3,000 (Select (1) or (2) below.) (1) ]Latest statements from all medical service providers are attached as Attachment 13g. (2) LXJAI medical expenses have been paid by private insurance, Medicare, or Medi-Cal. 14. Claimant's attorney's fees and all other expenses (except medical expenses), including fees or expenses paid by petitioner and claimant's attorney, to be paid or reimbursed from proceeds of settlement or judgment a, Total amount of attorney's fees for which court approval is requested: $ 5,000 (if fees are requested, attach as Attachment 14a a declaration fram the attomey explaining the basis for the request, including a discussion of applicable factors listed in rule 7.955(b) of the Cal. Rules of Court. include a copy of any written attorney fee agreement in Attachment 14a.) The following additional items of expense (other than medical expenses) have been incurred or paid, are reasonable, resulted from the incident or accident, and should be paid or reimbursed out of claimant's share of the proceeds of the settlement or judgment: Items Payees (names) Amounts Filing Fee Kern County Superior Court 458 [2] Continued on Attachment 14b. Total: $B c. (.) Costs of suit attributable to more than one settling plaintiff are not apportioned between them on a pro rata basis based on their gross settlement amounts. The apportionment of these costs is described and explained in Attachment 14c. MC-350EX [Rev. January 4, 2024] PETITION FOR EXPEDITED APPROVAL OF COMPROMISE OF Page 4 of 7 GB Essential Forms: CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY LAU, KAIDEN MC-025 SHORT TITLE: (CASE NUMBER: LAU VS. HOUTZ BCV-24-100128-BCB ATTACHMENT (Number): 138 (This Attachment may be used with any Judicial Council form.) EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM FOR MINOR MEDICAL PROVIDERS: BELINDA A. SANTOS-SENAR, MD (1) Total medical expenses before reduction: 35 68 (2) Total medical expenses paid by Medi-Cal: 35 68 (3) Total of negotiated, contractual, or statutory reductions if any 00 (4) Total amount of medical expenses to be paid or reimbursed from proceeds 00 (5) Total amount of statutory or contractual liens, if any: $ 35 68 ARTISA MAE MOTEN, MS/S&T PROFESSIONAL GROUP (1) Total medical expenses before reduction: $5,850 00 (2) Total medical expenses paid by Medi-Cal: $5,316 00 (3) Total of negotiated, contractual, or statutory reductions if any $1,461 4l (4) Total amount of medical expenses to be paid or reimbursed from proceeds 8 0 00 (5) Total amount of statutory or contractual liens, if any: $3,855 59 The minor's health insurance, Medi-Cal, paid $5,351.68 for the medical expenses above and wrote off $1,460.41. The amount owing to Medi-Cal that will be paid from the proceeds is, $3,891.27. (if the item that this Attachment concerns is made under penalty of perjury, all statements in this Page of Attachment are made under penalty of perjury.) (Add pages as required) Form Ap noved for tional Use ATTACHMENT www courtinfo.ca.gov Judicial f Councilof California MC-026 (Rev. July 4, 2009) to Judicial Council Form cB Essential cebcom jelForms MC-025 SHORT TITLE: CASE NUMBER: - LAU VS. HOUTZ BCV-24-100128-BCB ATTACHMENT (Number): 13cf2_ (This Attachment may be used with any Judicial Council form.) EXPEDITED PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM FOR MINOR Final Medi-Cal Lien Demand Letter {if the item that this Attachment concems is made under penaily of peiury, ail statements in this Page of Attachment are made under penalty of perjury.) (Add pages as required) Form Approved for Optional Use ATTACHMENT weeu.courtinfo.ca.gov Judicial Council of California MC-025 [Rev. July 1, 2009] to Judicial Council Form CLB Essential ceb.com | f2iForms Intranet - AutoForms Page | of 1 BIICS ge Department of Health Care Services Moh feel (de Cel of 2070 Thank You Gum 3/4 cmt Your information has been submitted, thank you. Back to Top Version: 2.0.0.26 Copyright © 2008 DHCS/CDPH, State of California https://apps.dhes.ca.gov/AutoForm2/Page/Thank Y ou.aspx 3/9/2020 State of California GAVIN NEWSOM, Governor =ESensss========:=: =: ==: = = Department of Health Care Serv ices Recovery Section, MS 4720 P.O. Box 997425 Sacramento, CA 95899-7425 (916) 445-9891 NOTICE OF MEDI-CAL LIEN March 16, 2020 KYLE JONES ATTORNEY AT LAW 1620 MILL ROCK WAY STE 100 BAKERSFIELD, CA 93311 This letter serves as an acknowledgment that the Department of Health Care Services (DHCS) received notification regarding a potential third party settlement involving the below-named individual. This individual is a Medi-Cal member and may have received health care services relating to this injury. Pursuant to sections 14124.70 through 14124.795 of the Welfare and Institutions Code (W&I Code), DHCS has the right to assert a lien against any settlement, judgment, or award obtained from a liable third party. DHCS Case Name KAIDEN LAU DHCS Account Number C98813938E-001 Injury Date February 16, 2020 If not previously provided, please submit the name and contact information of the liable third party or carrier pursuant to W&I Code section 14124.73(c). DHCS will issue a lien after the following information has been received: *Date of final treatment related to the injury by a Medi-Cal provider, AND/OR *Date of settlement - If the matter has been settled, please provide DHCS with the settlement documentation, attorney fees, and an itemization of litigation costs. This information should be provided by visiting our website at dhes.ca.gov/piforms and select Step 2, "Case Update or Additional Documentation" Please have the DHCS Account Number and be prepared to attach electronic copies of supporting documents. ***New feature available: Online Inquiry*** Use our new Online Inquiry page to receive a secure response within 24 hours. Visit dhes.ca.gov/ing to submit the following inquiries: - Questions about the status of an existing case. Please have the 13-6268 KYLE JONES Page 2 DHCS Account Number available. - Requests for Medi-Cal member's Client Index Number (CIN). Use when you need to submit a new case notification but do not know your client's CIN. If you have any questions, please contact the Medi-Cal Personal Injury Program at (916) 445-9891 or submit a case status inquiry at dhes.ca.gov/ing. CAS1090A (11/19) 13-6269 Ge State of California GAVIN NEWSOM, Governor =====: —=. =====: == == SSS som: one: =: = Department of Health Care Services Recovery Section, MS 4720 P.O. Box 997425 Sacramento, CA 95899-7425 (916) 445-9891 February 16, 2024 KYLE JONES ATTORNEY AT LAW 1620 MILL ROCK WAY STE 100 BAKERSFIELD, CA 93311 The Medi-Cal beneficiary listed below has received $5,351.68 in benefits through the Medi-Cal Program related to the third party liability injury (Injury) on February 16, 2020. The Department of Health Care Services (DHCS) xetains reimbursement rights for the reasonable value of benefits provided pursuant to Welfare and Institutions Code (W&I Code) sections 14124.70 et seq., and section 14024. DHCS Case Name KAIDEN LAU DHCS Account Number C98813938E-001 Injury Date February 16, 2020 Amount Due $3,891.27 DHCS' reimbursement is limited to the lesser of: 1) no more than the Medi-Cal beneficiary recovers after deducting attorney's fees and litigation costs paid for by the Medi-Cal beneficiary per W&I Code section 14124.78;or 2) the lien amount after deducting the director's reasonable share of attorney's fees and litigation costs per W&I Code section 14124,72(d) Pursuant to W&I Code section 14124.785 and the information received to date, DHCS has reduced the lien for reimbursement of the reasonable value of benefits from $5,351.68 to $3,891.27. Reimbursement in the amount of $3,891.27 will satisfy DHCS' lien, subject to the conditions set forth below: 1) Pursuant to W&I Code sections 14124.785 and 14124.79, you are required to notify DHCS if there are additional settlements arising out of the same Injury. DHCS retains all statutory lien rights arising from Medi-Cal paid services regarding any other settlement, judgment, or award related to the same Injury as authorized by law. 2) If you are aware of additional services provided as a result of the above-referenced Injury, please notify DHCS immediately. DHCS may 11-2952 Ee KYLE JONES Page 2 be entitled to additional reimbursement for the reasonable value of Medi-Cal benefits that were not included in the above-referenced amount. 3) Payment may become due upon the death of KAIDEN LAU pursuant to W&I Code section 14009.5, as applicable, and/or termination of a trust, if any, created pursuant to Title 42 U.S. Code 1396 (p) (d) (4) (a-c) for the benefit of KAIDEN LAU. 4) If medical payment coverage (MedPay) is available, please notify this office as this may affect the calculation of reimbursement due. Please remit payment in the amount of $3,891.27. A payment for less than the amount owed will be credited to the account but will not be considered payment in full for the DHCS lien. To make an Electronic Funds Transfer (EFT) payment: 1 Go to dhcs.ca.gov/epay. 2 Scroll to the bottom of the page and select the option "Make an EFT Payment." 3 On the payment page, you can choose to make a one-time payment or to apply to become an enrolled user. * To become an enrolled user, complete and submit an enrollment form found at the bottom of the dhes.ca.gov/epay webpage. Provide the Medi-Cal beneficiary's DHCS account number and all the necessary payment, contact, and banking information. Print or save the information on the payment confirmation page, including the confirmation number, for your records. EFT is a fast, easy and secure method for payment submission. It offers many advantages, including free online payment submission, savings on postage and printing costs, quicker delivery and processing time, and reduced waste. You have the option to make a one-time payment or to become an enrolled user. The enrolled user option allows you to easily make a payment, schedule future payments, cancel a payment, and track payment history. Please visit dhcs.ca.gov/epay for more information and to view the EFT Information Guide with step-by-step instructions for making an EFT payment. Payment by check or money order may take up to 7-10 business days to process and must include the Medi-Cal beneficiary's DHCS account number. If you have any questions, please contact the Medi-Cal Personal Injury Program at (916) 445-9891. Enclosure 11-2953 Be KYLE JONES Page 3 CAS3050A (03/21) woe-e enn 5 ee ee en en nnn en ee een nee nnn PLEASE DETACH AND ENCLOSE WITH YOUR PAYMENT OR TO MAKE AN EFT PAYMENT, GO TO: DHCS.CA.GOV/EPAY DHCS Account Number: C98813938E-001 DHCS Case Name KAIDEN LAU Mail your payment to: AMOUNT DUE: $3,891.27 Department of Health Care Services Recovery Branch - MS 4720 AMOUNT ENCLOSED: $ P.O, Box 997421 Sacramento, CA 95899-7421 11-2954 RE LAU, KAIDEN PAGE 1 INJURY DATE: FEBRUARY 16, 2020 INJURY-RELATED SERVICES PAID BY THE MEDI~CAL PROGRAM --------------- ++ - == = == = ee LYNDON & BELINDA SENAR 02/18/20 Headache $35 68 S & T PROFESSIONAL GRP IN 03/12/20 Post-traumatic stress disorder, uns $72 00 pecified 03/24/20 Post-traumatic stress disorder, uns $69 00 pecified 04/01/20 Post-traumatic stress disorder, uns $69 00 pecified 04/16/20 Post-traumatic stress disorder, uns $69 00 pecified 04/23/20 Post-traumatic stress disorder, uns $69 00 pecified 04/27/20 Post-traumatic stress disorder, uns $69 00 pecified 05/05/20 Post-traumatic stress disorder, uns $69 00 pecified 05/26/20 Post-traumatic stress disorder, uns $69 00 pecified 06/03/20 Post-traumatic stress disorder, uns $69 00 pecified 06/09/20 Post-traumatic stress disorder, uns $69 00 pecified 06/11/20 Post-traumatic stress disorder, uns $69 00 pecified 06/13/20 Post-traumatic stress disorder, uns $69 00 pecified 06/16/20 Post-traumatic stress disorder, uns $69 00 pecified 06/18/20 Post-traumatic stress disorder, uns $69 00 pecified 06/23/20 Post-traumatic stress disorder, uns $69 00 pecified 07/07/2