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MC-350
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and addmss) FOR COURT USE ONLY
David
Rankin
96 N
J.
3rd
Stock
Landsness
St.,
(85655)
Ste
Lahde
500,
I Suiata
San Jose,
T.
Serverian
Reuter
CA 95112
(232148)
& Stock FILE9
SAN llaTEO COuXM
TELEPHONE NO 408-293-0463 FAX NO (Optronaf):
E-MAILADDRESS (Optronal) N1,
"TTD"E" "'( '"') Petitioner Sandra Ramos O s a oun
r)
sUPERIoR coURT oF GALIFoRNIA, coUNTY oF San Mateo
sTREET ADDREss400 County Center +~gpgp ahlIIIN
MAILINGADDRESS.
Redwood
cITY AND zIP coDE City 94063
sRANOHNAME'outhern Branch Hall of Justice
CASE NAME:
Ramos v. Gallegos OV 5 I. Ital'l
HEARING DATE
PETITION TO APPROVE: ~~ COMPROMISE OF DISPUTED CLAIM
COMPROMISE OF PENDING ACTION
DISPOSITION OF
Minor ~ PROCEEDS
Person
OF JUDGMENT
With a Disability
NOTICE TO PETITIONERS:
DEPT TIME
Except as noted below, you must use this form to request
court approval of (1) the compromiseof a disputedclaim of aminor,
(2) the compromise of a pending action or proceedingin which aminor or'aperson with a disability (including a conservatee)
is a
party, or (3) the disposition
of theproceeds of a judgmentfor aminor or person with a disability. (See
Code Civ. Proc.,
g 372; Prob.
Code, g 3600 et seq.)You and the minor or disabledperson must attend the hearing the court for good
on this petition unless cause
dispenses with a personal appearance. The court may require the presence and testimony of witnesses, or
including the attending
examining physician,and other evidence relating to the merits of the claim and
the nature and extent of the treatment,
injury, care,
and The court may consider
hospitalization. on an expedited basis without ahearing requests for approvalof the compromises of
certainclaims and actionsor the disposition
of theproceeds of certain judgments.If your daim,
action,or judgment qualifies for
expedited considerationand you want to requestit, you mustuse form MC-350EX for your request. See Cal. Rulesof Court,rule
7.950.5.
1. Petitioner (name): Sandra RamOS
2. Claimant (name): CaSSandra RamOS
a. Address: 1504 S. Claremont St., Apt B, San Mateo, CA 94402
b. Date ofbirth:8/3" /" 994 c. Age:"7 d. Sex: F e. K Minor H Person with a disability
3. Relationship
a.
~
CH
Petitioner's
Parent g. ~to the claimant
relationship (check all applicable
Other relationship
(specify:)
boxes):
b.
c. ~ Guardian
Guardian
ad litem
d.
e.
f,
~
C3
~
Conservator
Disabled
Disabled
adult claimantis a
adult claimant's
express
(See instructions
petitioner.
consent
foritems 3e and 3fbelow)
to the relief requested
in this petition is provided
on Attachment 3f.
(lfyou checked item 3e or 3f, state
facts on Attachment 3e or 3f showingthat the claimant hascapacityunder Probate
Code section 812 to petition or consent Only an adult claimant who has
to a petition. sufficient capacity and who does
not
have a conservator of the estate
may petition or consentto a petition.
See Probate Code section3613.)
4. Nature of claim The claim of theminor or adult personwith a disability:
~v'as
a.
b. ~ not been filed in an action or proceeding.
of a
Is the subject
Name of court:
pending action
(Completeitems
or proceeding
5-23.)
that will be compromised without a trial on the
merits of the claim.
Case no.: Trial date: (Complete items 5-23.)
Page1of 10
Form Adopted for
Altemalwe Mandatory Use PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Code of CMI Procedure,
g 372 et seq,
Probate Code, Ii 3500 et'seq,
Judhaal Counal of Califomta
MC-350 IRev January 1, 2011I
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF Cal Rules of Court. rules 3 1384,
7.101, 7 950, 7.951
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY www courts. ca.gov
(Miscellaneous)
MC-350
CASE NAME: CASE NUMBER
samos v. Gallegos
4.
c. ~
Nature of claim
Is the subject
the defendants
The claim of the minor or adult person
of apending
named
action or proceeding
below in the total amount
with a disability:
that hasbeen
(exdusive
or will be reduced
of interest
and costs)
to a judgment for the claimant against
of (specify below):
Defendants (names)
Additional defendantslisted on Attachment4. ~ The judgment was filed on (date):
(Attach a copy of the (proposed) judgment as Attachment 4c and complete items
5. ~ Incident or accident
a. Date and time:
The incident or accident
6/28/08, approximately
occurred
noon
as follows:
13-23.)
b. Place: Highway 101, near Ralston, in the City of Belmont
c. Persons involved(names): Mrs. Gallegos, Cassandra Ramos
6.
~
~y'ature
Continued on Attachment
of incident or accident
5.
The facts,events, and circumstances of theincident or accident
are (describe):
Minor Cassandra Ramos was a rear passenger in a vehicle driven by Mrs Gallegos, who lost
control of the vehicle after a tire blow-out. The vehicle hit the center divider.
Continued on Attachment 6.
7. ~d Injuries
The following injuries were sustained
by the claimant asa result of the incident or accident
(describe):
Non-displaced pelvic fracture, abrasions on hip and buttocks.
Continued on Attachment 7.
8.~u'reatment
The claimant received the following care
and treatment for the injuries described
in item 7 (describe):
Emergency room treatment; admitted to Lucille Packard for observation for 2 days (no surgery or
other intervention was necessary); sutures and removal of same; physical therapy; follow up visits
with doctor.
Continued on Attachment 8.
MC-350 [Rev January
2011I Page 2 of 10
1,
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME: CASE NUMBER
-Ramos v. Gallegos
9. ~i Extent of injuries and recovery of all doctors'reports
(An original or a photocopy containing a diagnosisof and prognosis
and a report of the claimant's
for the claimant's injuries, present condition,must be attached to this petition as Attachment
9.
A new report is not necessaryso long as a previousreport accuratelydescribes cunent
the claimant's condition.)
a. ~v'he claimant has recovered completely from the effectsof theinjuries described there
in item 7, and are no
b. ~ permanent injuries.
The claimant has not recovered
from which the claimanthas not recovered are temporary
of the
completely from the effects injuries described
(describe
in item 7,
the remaining injuries):
and the following injuries
~ Continued on Attachment 9b.
C. ~ The claimant has not recovered
from which the claimanthas not recovered are permanent
of the
completely from the effects injuries described
(describe
the following injuries
in item 7, and
the permanentinjuries):
10. ~I
~ Continued
Petitioner has made
on Attachment
a careful and
9c.
diligent inquiry and investigationto ascertain the facts relating to theincident or
accident in which the claimant was injured; theresponsibility for theincident or accident;and the nature,extent,
and seriousness of the claimant'sinjuries. Petitioner fully understands that if the compromise proposed in this
petition is approved by the court and is consummated, the claimant will be forever barredfrom seeking any further
recovery of compensation from the settling defendants named below even though the claimant's inJuriesmay in
the future appear to be more serious than they are now thought to be.
11. ~~ Amount and terms of settlement
By way of settlement,the defendants named below have offered to pay the following sums
to the claimant:
a. The total amount offeredby all defendantsnamed below is (specify): $ 130,867.00
b. The defendants and amounts offeredby each are as follows (specify):
Defendants (names) Amounts
Ricardo Galleaos $ 30,867.00
$
$
$
~c.
Defendants
The terms
and amounts
of settlementare
offered
as
continued on Attachment
follows (ifthe settlementis
11.
to be paidininstallments,
$
both the total amount and the
present value of the settlement
must be included):
1. $ 5,000.00 to be immediately placed into a blocked account for claimant; and
2. $ 10,000 payable directly to minor on 8/31/2015; and
3. $ 15,867 payable directly to minor on 8/31/2019
Present value of structured settlement payments = $ 23,309.95
~ Continued
MC-350 [Rav January
on Attachment 11.
2011l
1, PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 3 of 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
CASE NAME: CASE
NUMBER'CD50
—Ramos v. Gallegos
~d Settlement payments to others
~
12.
a. No defendant named in item 11b hasoffered to pay money to any personor persons other than the claimant to
b. ~ settle
Byway of settlement,
persons other than
one
incident or accident
claims arising out of the same
or more defendants
claimant to settle
named
claims arisingout of the same
in the claimant's
that resulted
in item 11b havealso offered
injury.
to pay money to a
incident or accident
person
in the
that resulted
or
claimant'sinjury.
6,190.05
(1)
(2) Petitioner ~
The total amount
reimbursement
offered
is not~
by all defendants
for expenses
is
paid
to others(specify):
a claimant against
by petitioner and
the recovery
under
listed item 15).
$
for
of the claimant (other than
(Ifyou answered "is, "explain in Attachment
12 the circumstancesand the effect your claim hason the
proposed co~mromise of the claim described in this petition.)
(3) Petitioner ~y's not M is a
"is," explain in Attachment
action with the claimant.
plaintiff in the same
the effect your claim and its disposition
(Ifyou answered 12 the circumstancesand
has on the proposed compromise of the claim or action described
in this petition.)
(4) M~ Petitioner would receive
money under the proposed settlement.
(5) The settlement payments are to be apportionedand distributedas follows:
Other olaintiffs or claimants
(names) Amounts
Petitioner Sandra Ramos $ 1 ,500.00
Lienholder Health Plan of San Mateo County $ 4,690.05
$
~
(6)
Additional plaintiffs or claimants
Reasons for the apportionment
and amounts are
of the settlement payments
$
listed on Attachment
between
12.
the claimant and each other
plaintiff or claimant
named above are specifiedon Attachment 12.
13. The claimant's medical expenses, including medical expenses paid by petitioner andinsurers, to be reimbursed from
proceeds of settlement or judgment
a. Totals
(1) Total medical expenses: $ 33,449.37
(2) Total outstandingmedical expenses to be paid from the proceeds: $ l0.00
(3) Total out-of-pocket,
co-payments, or deductiblepayments to bereimbursed from proceeds: $ l0.00
b.
(1) ~
Medical expenses
~~
Paid
Paid
were paid and
by privatehealth
are to be
insurance
reimbursed
by petitioner in the amount
of:
from proceeds
or a self-funded
as
under:
follows:
$ 1
(2)
(a)
(b)
~
~ An Employee Retirement
An ERISA self-funded
Income
plan.
plan
Security Act (ERISA) insured plan.
H/
(c)
(d)
(e)
~ A Non-ERISA insured
Amount paidby plan:
plan.
A Non-ERISA self-funded plan.
$ 4690.00
Amount of reimbursement plan from proceeds of settlement
(f)
(i)
(ii)
~
Mv'eimbursement
to the
No reimbursement is requested
is to be
made
by the plan.
to theplan and:
or judgment:
(A) C3 There is a contractual
reduction of $( )
(B) M There is anegotiated reductionof $ ( )
(C) EH No reduction has been agreed to,
for a total reimbursementto the plan in the amount
of: $ l4690.00
MC-350 (Rev January
2011]
1, PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 4 of 10
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME: CASE NUMBER
samos v. Gallegos
13. The claimant's medical expenses, including medical expenses paid by petitioner and insurers, to be reimbursed from
proceeds of settlement or judgment
reimbursed as follows:
b.
(3) ~
Medical expenses
Paid
less
were paid and
by Medicare
the statutory
are to be
in the amountof:
reductionin the amount
from proceeds
$
of: $( )
for a total reimbursementto Medicarein the amount of: $ 1
(Attach a copy of the final Medicare
demand letter or letter agreement
as Attachment 13b(3).)
Cj Paid by Medi-Gal in theamountof
(4)
(a) ~ $
Notice of this claim or action
has been given to theState Director of Health
Care
~
Services under Welfare
(b) M
~and
was
section
Institutions Code 14124.73.
Notice of this claim or action
has
A copy of the
filed in this matter on (date):
not been
notice and
given to theState
proof of its delivery
Director of HealthCare
is attached.
Services.
(c) ~ (Explain why notice has
in the amount of:
not been given in Attachment
of its lien rights,
In full satisfaction Medi-Cal has agreed
13b(4).)
to accept reimbursement
$ 1
(Attach a copy of the final Medi-Cal demand
letter or letter agreement
as Attachment
(d) ~ Petitioneris entitled
to a reductionof theMedi-Cal lien under Welfare and
13b(4).)
Institutions Code
(i)
(ii)
~
section
~
14124.76 and:
Is filing a motion seeking
Requests
a reductionof the lien concurrently
with this petition.
jurisdiction over this issue.
that the court reserve
The amount of thelien in dispute
is:$
(5) ~ (a) There are
expenses.
one or more
The total amount
or contractual
statutory
claimed
liens of medical
under these liens is:
$
service providersfor payment
.
of medical
In full satisfaction
of their lien claims,
the lienholders
have agreed to acceptthe total sum of: $
(Provide requested information on eachlienholder and certainother medical service
providers below)
(b) The name of each medical serviceprovider that furnished
care and treatment to claimant and(1) hasa lien for all
or any part of the charges
or (2) waspaid paid from the
(or will be proceeds) by petitioner for which petitioner
requests reimbursement; the amounts charged and paid; the amount of negotiatedreductionof charges, if any;
and the amount to be paid from theproceeds of the settlementor judgment to each provider areas follows:
(i) (A) Provider (name):
(B) Address:
(C) Amount charged: $
(D) Amount paid (whether or not by insurance): $ (
(E) Negotiated reduction,if any: $ (
(F) Amount to be paid from proceedsof settlementor judgment: $ (
(ii) (A)Provider (name):
(B) Address:
(C) Amount charged: $
(D) Amount paid (whether or not by insurance): $( )
(E) Negotiated reduction,if any: $ ( )
~ (F) Amount to be
Continued
paid from proceeds
on Attachment 13b(5).
of settlement
or judgment:
(Provide information about
$ (
additional providers in the above
including providers paid or to be paid by petitioner for which reimbursementis
requestedinitem
format,
13b(1)
above. You may use form MC-350(A-13b(5)) for this purpose.)
MC-350 [Rev January
2011l
1, Page a of 10
PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM
OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF
JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY
(Miscellaneous)
MC-350
CASE NAME: CASE NUMSER
samos v. Gallegos
14. The claimant's attorney'sfees and all other expenses (except medical expenses), including expenses advanced by
claimant's attorney or paid or incurred by petitioner to be reimbursed from proceeds of settlement or judgment
a. Total amount of attorney's
fees for which court approval
is requested: $ I0.00
(lffeesare requested,attach as Attachment 14a, a declarationfrom the attorney for the request,
explaining the basis including
a discussionof applicable of the
factors listed in rule 7.955(b) Cal.Rules of Court.Respond to item 18a(2)on page 7 and
attacha copy of any written attorney fee agreement
as Attachment 18a.)
b. The following additional
itemsof expense (other thanmedical expenses) have been incurredor paid,are reasonable, resulted
from theincident or accident,
and should be paid out of claimant's
share of theproceeds of the settlementor judgment:
Items Pavees (names) Amounts
Continued on Attachment 14b. Total: $ I
15. Reimbursement of expenses paid by petitioner
a.
b. ~
M~ Petitioner
Petitioner
has
has
paid
paid
none of the claimant's
(or become obligated
expenses listedin items13 and 14 for which reimbursement
of the
to pay) the following total amounts daimant's expenses
Preview
MC-350 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and addmss) FOR COURT USE ONLY David Rankin 96 N J. 3rd Stock Landsness St., (85655) Ste Lahde 500, I Suiata San Jose, T. Serverian Reuter CA 95112 (232148) & Stock FILE9 SAN llaTEO COuXM TELEPHONE NO 408-293-0463 FAX NO (Optronaf): E-MAILADDRESS (Optronal) N1, "TTD"E" "'( '"') Petitioner Sandra Ramos O s a oun r) sUPERIoR coURT oF GALIFoRNIA, coUNTY oF San Mateo sTREET ADDREss400 County Center +~gpgp ahlIIIN MAILINGADDRESS. Redwood cITY AND zIP coDE City 94063 sRANOHNAME'outhern Branch Hall of Justice CASE NAME: Ramos v. Gallegos OV 5 I. Ital'l HEARING DATE PETITION TO APPROVE: ~~ COMPROMISE OF DISPUTED CLAIM COMPROMISE OF PENDING ACTION DISPOSITION OF Minor ~ PROCEEDS Person OF JUDGMENT With a Disability NOTICE TO PETITIONERS: DEPT TIME Except as noted below, you must use this form to request court approval of (1) the compromiseof a disputedclaim of aminor, (2) the compromise of a pending action or proceedingin which aminor or'aperson with a disability (including a conservatee) is a party, or (3) the disposition of theproceeds of a judgmentfor aminor or person with a disability. (See Code Civ. Proc., g 372; Prob. Code, g 3600 et seq.)You and the minor or disabledperson must attend the hearing the court for good on this petition unless cause dispenses with a personal appearance. The court may require the presence and testimony of witnesses, or including the attending examining physician,and other evidence relating to the merits of the claim and the nature and extent of the treatment, injury, care, and The court may consider hospitalization. on an expedited basis without ahearing requests for approvalof the compromises of certainclaims and actionsor the disposition of theproceeds of certain judgments.If your daim, action,or judgment qualifies for expedited considerationand you want to requestit, you mustuse form MC-350EX for your request. See Cal. Rulesof Court,rule 7.950.5. 1. Petitioner (name): Sandra RamOS 2. Claimant (name): CaSSandra RamOS a. Address: 1504 S. Claremont St., Apt B, San Mateo, CA 94402 b. Date ofbirth:8/3" /" 994 c. Age:"7 d. Sex: F e. K Minor H Person with a disability 3. Relationship a. ~ CH Petitioner's Parent g. ~to the claimant relationship (check all applicable Other relationship (specify:) boxes): b. c. ~ Guardian Guardian ad litem d. e. f, ~ C3 ~ Conservator Disabled Disabled adult claimantis a adult claimant's express (See instructions petitioner. consent foritems 3e and 3fbelow) to the relief requested in this petition is provided on Attachment 3f. (lfyou checked item 3e or 3f, state facts on Attachment 3e or 3f showingthat the claimant hascapacityunder Probate Code section 812 to petition or consent Only an adult claimant who has to a petition. sufficient capacity and who does not have a conservator of the estate may petition or consentto a petition. See Probate Code section3613.) 4. Nature of claim The claim of theminor or adult personwith a disability: ~v'as a. b. ~ not been filed in an action or proceeding. of a Is the subject Name of court: pending action (Completeitems or proceeding 5-23.) that will be compromised without a trial on the merits of the claim. Case no.: Trial date: (Complete items 5-23.) Page1of 10 Form Adopted for Altemalwe Mandatory Use PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Code of CMI Procedure, g 372 et seq, Probate Code, Ii 3500 et'seq, Judhaal Counal of Califomta MC-350 IRev January 1, 2011I OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF Cal Rules of Court. rules 3 1384, 7.101, 7 950, 7.951 JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY www courts. ca.gov (Miscellaneous) MC-350 CASE NAME: CASE NUMBER samos v. Gallegos 4. c. ~ Nature of claim Is the subject the defendants The claim of the minor or adult person of apending named action or proceeding below in the total amount with a disability: that hasbeen (exdusive or will be reduced of interest and costs) to a judgment for the claimant against of (specify below): Defendants (names) Additional defendantslisted on Attachment4. ~ The judgment was filed on (date): (Attach a copy of the (proposed) judgment as Attachment 4c and complete items 5. ~ Incident or accident a. Date and time: The incident or accident 6/28/08, approximately occurred noon as follows: 13-23.) b. Place: Highway 101, near Ralston, in the City of Belmont c. Persons involved(names): Mrs. Gallegos, Cassandra Ramos 6. ~ ~y'ature Continued on Attachment of incident or accident 5. The facts,events, and circumstances of theincident or accident are (describe): Minor Cassandra Ramos was a rear passenger in a vehicle driven by Mrs Gallegos, who lost control of the vehicle after a tire blow-out. The vehicle hit the center divider. Continued on Attachment 6. 7. ~d Injuries The following injuries were sustained by the claimant asa result of the incident or accident (describe): Non-displaced pelvic fracture, abrasions on hip and buttocks. Continued on Attachment 7. 8.~u'reatment The claimant received the following care and treatment for the injuries described in item 7 (describe): Emergency room treatment; admitted to Lucille Packard for observation for 2 days (no surgery or other intervention was necessary); sutures and removal of same; physical therapy; follow up visits with doctor. Continued on Attachment 8. MC-350 [Rev January 2011I Page 2 of 10 1, PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME: CASE NUMBER -Ramos v. Gallegos 9. ~i Extent of injuries and recovery of all doctors'reports (An original or a photocopy containing a diagnosisof and prognosis and a report of the claimant's for the claimant's injuries, present condition,must be attached to this petition as Attachment 9. A new report is not necessaryso long as a previousreport accuratelydescribes cunent the claimant's condition.) a. ~v'he claimant has recovered completely from the effectsof theinjuries described there in item 7, and are no b. ~ permanent injuries. The claimant has not recovered from which the claimanthas not recovered are temporary of the completely from the effects injuries described (describe in item 7, the remaining injuries): and the following injuries ~ Continued on Attachment 9b. C. ~ The claimant has not recovered from which the claimanthas not recovered are permanent of the completely from the effects injuries described (describe the following injuries in item 7, and the permanentinjuries): 10. ~I ~ Continued Petitioner has made on Attachment a careful and 9c. diligent inquiry and investigationto ascertain the facts relating to theincident or accident in which the claimant was injured; theresponsibility for theincident or accident;and the nature,extent, and seriousness of the claimant'sinjuries. Petitioner fully understands that if the compromise proposed in this petition is approved by the court and is consummated, the claimant will be forever barredfrom seeking any further recovery of compensation from the settling defendants named below even though the claimant's inJuriesmay in the future appear to be more serious than they are now thought to be. 11. ~~ Amount and terms of settlement By way of settlement,the defendants named below have offered to pay the following sums to the claimant: a. The total amount offeredby all defendantsnamed below is (specify): $ 130,867.00 b. The defendants and amounts offeredby each are as follows (specify): Defendants (names) Amounts Ricardo Galleaos $ 30,867.00 $ $ $ ~c. Defendants The terms and amounts of settlementare offered as continued on Attachment follows (ifthe settlementis 11. to be paidininstallments, $ both the total amount and the present value of the settlement must be included): 1. $ 5,000.00 to be immediately placed into a blocked account for claimant; and 2. $ 10,000 payable directly to minor on 8/31/2015; and 3. $ 15,867 payable directly to minor on 8/31/2019 Present value of structured settlement payments = $ 23,309.95 ~ Continued MC-350 [Rav January on Attachment 11. 2011l 1, PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 3 of 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) CASE NAME: CASE NUMBER'CD50 —Ramos v. Gallegos ~d Settlement payments to others ~ 12. a. No defendant named in item 11b hasoffered to pay money to any personor persons other than the claimant to b. ~ settle Byway of settlement, persons other than one incident or accident claims arising out of the same or more defendants claimant to settle named claims arisingout of the same in the claimant's that resulted in item 11b havealso offered injury. to pay money to a incident or accident person in the that resulted or claimant'sinjury. 6,190.05 (1) (2) Petitioner ~ The total amount reimbursement offered is not~ by all defendants for expenses is paid to others(specify): a claimant against by petitioner and the recovery under listed item 15). $ for of the claimant (other than (Ifyou answered "is, "explain in Attachment 12 the circumstancesand the effect your claim hason the proposed co~mromise of the claim described in this petition.) (3) Petitioner ~y's not M is a "is," explain in Attachment action with the claimant. plaintiff in the same the effect your claim and its disposition (Ifyou answered 12 the circumstancesand has on the proposed compromise of the claim or action described in this petition.) (4) M~ Petitioner would receive money under the proposed settlement. (5) The settlement payments are to be apportionedand distributedas follows: Other olaintiffs or claimants (names) Amounts Petitioner Sandra Ramos $ 1 ,500.00 Lienholder Health Plan of San Mateo County $ 4,690.05 $ ~ (6) Additional plaintiffs or claimants Reasons for the apportionment and amounts are of the settlement payments $ listed on Attachment between 12. the claimant and each other plaintiff or claimant named above are specifiedon Attachment 12. 13. The claimant's medical expenses, including medical expenses paid by petitioner andinsurers, to be reimbursed from proceeds of settlement or judgment a. Totals (1) Total medical expenses: $ 33,449.37 (2) Total outstandingmedical expenses to be paid from the proceeds: $ l0.00 (3) Total out-of-pocket, co-payments, or deductiblepayments to bereimbursed from proceeds: $ l0.00 b. (1) ~ Medical expenses ~~ Paid Paid were paid and by privatehealth are to be insurance reimbursed by petitioner in the amount of: from proceeds or a self-funded as under: follows: $ 1 (2) (a) (b) ~ ~ An Employee Retirement An ERISA self-funded Income plan. plan Security Act (ERISA) insured plan. H/ (c) (d) (e) ~ A Non-ERISA insured Amount paidby plan: plan. A Non-ERISA self-funded plan. $ 4690.00 Amount of reimbursement plan from proceeds of settlement (f) (i) (ii) ~ Mv'eimbursement to the No reimbursement is requested is to be made by the plan. to theplan and: or judgment: (A) C3 There is a contractual reduction of $( ) (B) M There is anegotiated reductionof $ ( ) (C) EH No reduction has been agreed to, for a total reimbursementto the plan in the amount of: $ l4690.00 MC-350 (Rev January 2011] 1, PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM Page 4 of 10 OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME: CASE NUMBER samos v. Gallegos 13. The claimant's medical expenses, including medical expenses paid by petitioner and insurers, to be reimbursed from proceeds of settlement or judgment reimbursed as follows: b. (3) ~ Medical expenses Paid less were paid and by Medicare the statutory are to be in the amountof: reductionin the amount from proceeds $ of: $( ) for a total reimbursementto Medicarein the amount of: $ 1 (Attach a copy of the final Medicare demand letter or letter agreement as Attachment 13b(3).) Cj Paid by Medi-Gal in theamountof (4) (a) ~ $ Notice of this claim or action has been given to theState Director of Health Care ~ Services under Welfare (b) M ~and was section Institutions Code 14124.73. Notice of this claim or action has A copy of the filed in this matter on (date): not been notice and given to theState proof of its delivery Director of HealthCare is attached. Services. (c) ~ (Explain why notice has in the amount of: not been given in Attachment of its lien rights, In full satisfaction Medi-Cal has agreed 13b(4).) to accept reimbursement $ 1 (Attach a copy of the final Medi-Cal demand letter or letter agreement as Attachment (d) ~ Petitioneris entitled to a reductionof theMedi-Cal lien under Welfare and 13b(4).) Institutions Code (i) (ii) ~ section ~ 14124.76 and: Is filing a motion seeking Requests a reductionof the lien concurrently with this petition. jurisdiction over this issue. that the court reserve The amount of thelien in dispute is:$ (5) ~ (a) There are expenses. one or more The total amount or contractual statutory claimed liens of medical under these liens is: $ service providersfor payment . of medical In full satisfaction of their lien claims, the lienholders have agreed to acceptthe total sum of: $ (Provide requested information on eachlienholder and certainother medical service providers below) (b) The name of each medical serviceprovider that furnished care and treatment to claimant and(1) hasa lien for all or any part of the charges or (2) waspaid paid from the (or will be proceeds) by petitioner for which petitioner requests reimbursement; the amounts charged and paid; the amount of negotiatedreductionof charges, if any; and the amount to be paid from theproceeds of the settlementor judgment to each provider areas follows: (i) (A) Provider (name): (B) Address: (C) Amount charged: $ (D) Amount paid (whether or not by insurance): $ ( (E) Negotiated reduction,if any: $ ( (F) Amount to be paid from proceedsof settlementor judgment: $ ( (ii) (A)Provider (name): (B) Address: (C) Amount charged: $ (D) Amount paid (whether or not by insurance): $( ) (E) Negotiated reduction,if any: $ ( ) ~ (F) Amount to be Continued paid from proceeds on Attachment 13b(5). of settlement or judgment: (Provide information about $ ( additional providers in the above including providers paid or to be paid by petitioner for which reimbursementis requestedinitem format, 13b(1) above. You may use form MC-350(A-13b(5)) for this purpose.) MC-350 [Rev January 2011l 1, Page a of 10 PETITION TO APPROVE COMPROMISE OF DISPUTED CLAIM OR PENDING ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY (Miscellaneous) MC-350 CASE NAME: CASE NUMSER samos v. Gallegos 14. The claimant's attorney'sfees and all other expenses (except medical expenses), including expenses advanced by claimant's attorney or paid or incurred by petitioner to be reimbursed from proceeds of settlement or judgment a. Total amount of attorney's fees for which court approval is requested: $ I0.00 (lffeesare requested,attach as Attachment 14a, a declarationfrom the attorney for the request, explaining the basis including a discussionof applicable of the factors listed in rule 7.955(b) Cal.Rules of Court.Respond to item 18a(2)on page 7 and attacha copy of any written attorney fee agreement as Attachment 18a.) b. The following additional itemsof expense (other thanmedical expenses) have been incurredor paid,are reasonable, resulted from theincident or accident, and should be paid out of claimant's share of theproceeds of the settlementor judgment: Items Pavees (names) Amounts Continued on Attachment 14b. Total: $ I 15. Reimbursement of expenses paid by petitioner a. b. ~ M~ Petitioner Petitioner has has paid paid none of the claimant's (or become obligated expenses listedin items13 and 14 for which reimbursement of the to pay) the following total amounts daimant's expenses