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Filing # 61603873 E-Filed 09/15/2017 05:10:55 PM
IN THE CIRCUIT COURT OF THE
11TH JUDICIAL CIRCUIT IN AND FOR
MIAMEDADE COUNTY, FLORIDA
CASE NO.: 17-014926 CA 01 (31)
XIOMARA LLERENA AND
ROBERTO LLERENA ,
Plaintiff(s),
vs.
QUINTANA FAMILY DAY CARE HOME
D/B/A LEARNING AND GROWING FAMILY
CHILD CARE,
Defendant(s).
DEFENDANT’S COLLATERAL SOURCE REQUEST TO PRODUCE TO PLAINTIFF
Defendant, QUINTANA FAMILY DAY CARE HOME D/B/A LEARNING AND
GROWING FAMILY CHILD CARE, by and through undersigned counsel, and pursuant to
Florida Rule of Civil Procedure Rule 1.350, hereby propound their Collateral Source
Request for Production to Plaintiff, XKOMARA LLERENA, produce and permit Defendant to
inspect and photograph the following:
1. Copies of any and all notices and notifications of the Plaintiff's intent to claim
damages from the alleged tortfeasor which have been sent to any and all collateral source
providers pursuant to §768.76 (6) of the Florida Statutes, and any applicable hospital tien
ordinance.
2. Copies of any and all claims of lien, statements, correspondence or
documentation received from all providers of collateral sources asserting or waiving anyclaim of subrogation or reimbursement pursuant to §768.76 (7) of the Florida Statutes, and
any applicable hospital lien ordinance.
3. Copies of any and all subrogation or reimbursement notices, policy
provisions and claims of lien for all providers of collateral sources for medical treatment
received by Plaintiff as a result of the incident that is the subject of this litigation.
4. Any and all documentation establishing the amount of money and benefits
paid by any and all collateral sources for medical treatment received by the Plaintiff as a
result of the incident which is the subject of this litigation.
5. Copies of any and all releases of hospital liens and satisfactions of hospital
liens pertaining to the Plaintiff for any medical and chiropractic care rendered as an alleged
result of the incident which is the subject of this litigation.
6. Copies of any and all Complaints and Statements of Claim filed by any
medical provider against the Plaintiff for any medical and chiropractic care which is
alleged to have been rendered as a result of the incident which is the subject of this
litigation.
7. Copies of ail drafts, checks, money orders and receipts showing payment by
the Plaintiff of any hospital lien charges which are alleged to have been incurred as a result
of the incident which is the subject of this litigation.
8. Copies of any correspondence between the Plaintiff and any health care
provider, including hospitals, pertaining to collection of accounts, payment of bills and
liens and reimbursement/subrogation rights.9, Any and all Workers Compensation, TRICARE/Champus, Medicare, HRS
Medicaid, Hospital liens, HMO notices, PPO notices, ERISA plan, health insurance,
medical payment (Med Pay) and commercial PIP notices of subrogation and
reimbursement rights pertaining to any health care (both medical and chiropractic)
rendered to Plaintiff as an alleged result of the incident which is the subject of this
litigation.
10. Copies of any and all drafts and checks showing payment by any Workers
Compensation carrier, TRICARE/Champus, Medicare, HRS Medicaid, health insurance,
HMO, PPO, ERISA plan, Med Pay plan, any public program providing medical expenses
and commercial PIP to Plaintiff and any health care provider (medical and chiropractic) for
the benefit of the Plaintiff.
11. Copies of any checks, drafts, documentation and correspondence sent by the
Social Security Administration, motor vehicle accident insurer (including PIP), any federal,
state or local income disability provider, any public program providing disability payments,
and income disability insurer to the Plaintiff for any wage loss and loss, disability and loss
of earning capacity payments made as an alleged result of the incident which is the subject
of this action.
12. Copies of any contract or agreement by any group, organization, partnership,
or corporation to provide, pay for, or reimburse the costs of hospital, medical, dental, or
other health care services that pertain to the Plaintiff herein.13, Copies of any contractual or voluntary wage continuation plan and contract
provided by Plaintiffs employer(s) or by any other system intended to provide wages during
a period of disability.
14. Copies of the Complaints in any lawsuit and arbitration concerning a dispute
between any collateral source providers as defined in §768.76 and Plaintiff.
15. Produce all Medicare Summary Notices (MSN), or any other notices,
reports, statements, or other documents from any source that describe, total or reference
any Medicare benefits that plaintiff has received from the date of the accident till the
present.
16. Produce a printout showing all benefits paid by Medicare for any and all
services or supplies that your providers and suppliers billed through Medicare and are
contained on your personal account history at www.mymedicare.gov.
a7, Produce all correspondences or other documents from CMS or any
other source that describe, total or reference any liens on the claims raised in this case.
18. A signed and executed copy of Social Security Administration Consent for
Release authorization form SSA-3288, attached as Exhibit “A”.
19, A signed and executed copy of Request for Social Security Earnings
Information authorization form SSA-7050-F4, attached as Exhibit “B”,
20. A signed and executed copy of Internal Revenue Service Request for
Transcript of Tax Return authorization form 4506, attached as Exhibit “C”.
21. A signed and executed copy of Consent to Release for Medicare
authorization form, attached as Exhibit “D”.22, A signed and executed copy of Medicaid Healthcare Administration
Authorization form, attached as Exhibit “E”,
23. Praduce all Medicare Summary Notices (MSN), or any other
notices, reports, statements, or other documents from any source that describe, total or
reference any Medicare benefits that plaintiff has received from the date of the accident till
the present.
24, Produce a printout showing all benefits paid by Medicare for any and all
services or supplies that your providers and suppliers billed through Medicare and are
contained on your personal account history at www. Care. gov.
25, Produce all correspondences or other documents from CMS or any other
source that describe, total or reference any liens on the claims raised in this case.
It is hereby requested that the aforesaid production of copies be made and sent to
the offices of LUKS, SANTANIELLO, PETRILLO & JONES. If plaintiff offers to make such
documents available for inspection only, it is hereby requested that copies be provided to
undersigned counsel and we will reimburse all reasonable or actual charges associated
with said copies.CERTIFICATE OF SERVICE
WE HEREBY CERTIFY that a true and correct copy of the foregoing has been
furnished via Electronic Mail, to all counsel of record on the attached Service List, this 15th
day of September, 2017.
LUKS, SANTANIELLO,
PETRILLO & JONES
Attorneys for Defendant
150 W. Flagler Street, Suite 2750
Miami, FL 33130
Telephone: (305) 377-8900
Facsimile: (305) 377-8901
By: {6] Heather M, Calhosn
DANIEL J. SANTANIELLO,
Florida Bar No.: 860948
HEATHER M. CALHOON,
Florida Bar No.: 495573
SMIA-Pleadings@LS-LaSERVICE LIST
Michael J. Carmona, Esq.
Friedland Law Group
1430 South Dixie Highway
Suite 305
Coral Gables, FL 33146
email @friedlandiawgroup.comSocial Security Administration Form Approved
Consent for Release of Information oF
You must compiete all required fields. We will not honor your request unless ail required fields are completed. (*signifies a
required field).
TO: Social Security Administration
“Ry Full Nara “Ny Date of Birth “hy Social Security Number
{MM/DDIYYYY}
| authorize the Social Security Administration to release information or records about me to:
*NAME OF PERSON OR ORGANIZATION: “ADDRESS OF PERSON OR ORGANIZATION:
Heather M. Calhoon 28 WH
trille & Jones Suite 150
“t want this information released because: Pending Litgiation
We mey change a fee to release information fof HOa-pragram purposes.
*Please release the following information selected from the list below:
You must specify the records you are requesting by checking at least one box. We will not honor a request for "any and alf
records” or "my entire file." Also, we will not disclose records unless you include the applicable date ranges where requested.
4. [K] Social Security Number
2. Current monthly Social Security benefit amount
3. Xj Current monthly Suppiementai Security Income payment amount
4. (J My benefit or payment amounts from date ... 'o date
8.
6.
My Medicare entitlement fram date
Madical records from my claims folder(s) from date _.. to date.
if you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social
Security office.
. §] Complete medica! records from my claims folder(s)
. [7] Other record(s) from my file (you must specify the records you are requesting, e.g., doctor report, application,
determination or questionnaire)
on
| am the individual, to whom the requested information or record applies, or the parent or legal guardian of a minor, or
the legal guardian of a legally incompetent adult, | declare under penalty of perjury (28 CFR § 16.44(d}(2004)) that | have
examined all the information on this form, and any accompanying statements or forms, and it is true and correct to the
best of my knowledge. | understand that anyone who knowingly or willfully seeks or obtain access to records about
another person under false pretenses is punishable by a fine of up to $5,000. | also understand that | must pay all
applicable fees for requesting information for a non-program-related purpose.
“Signature: . . . “Date:
“Address: .
Relationship (if not the subject of the record)
“Daytime Phone:
Witnesses must sign this form ONLY if the above signature is by mark (X). If signed by mark (X), two witnesses to the signing
who know the signee must sign below and provide their full addresses. Please print the signee’s name next to the mark (X) on the
signature fine above,
4 Signature of wi ignature of witness
Address(Number and street, Clty, State, and Zin Oo:
Form S8A-3288 697-2013) EF (07-2043)Form SSA-708G-F4 (40-2018) UF Page 2 af4
REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION
he name of the individual whose
1, Provide your name aa # appears on your most recent Social Security card or
eamings you are reque: 5
First Name: Middle Initial: C]
Last Name:
Social Security Number (SSN) ~ - One SSN par request
Date of Birth: ! ‘ Date of Death: / f
Other Name(s) Used
{include Maiden Narra}
2, What kind of earings Information do you need? (Choose ONE af the following typas af earnings or SSA rnust raturn this request.)
a Hemized Statement of Earnings $415 Year(s) Requested: to
(inchides the names and addresses of employers)
Year(s) Requested: to
If you check this box, tell us why you need this information below. (3) Rea
‘Check this box if you want the eamings information
CERTIFIED for an additional $33.00 fee.
["] Certified Yearly Totals of Eamings $33 Yeax{s) Requested: to
(Qoes not include the names and addresses of employers}
Yearly earings iotels are FREE to the public if you do not Year(s) Requested: to
require certification. To obtain FREE yearly totals of sarnings,
visit our website at www.ssa.gov/myeccount,
3. If you would like this information sent to someone else, please fill in the information below.
| authorize the Social Security Administration to release the earnings information to:
Name Heather M. Calhoon / Luks Santaniello Petrillo 4 Jones
Address: 150 W. Flagler Street - Suite 2750 State BL
ZIP Cade 33420
‘son authorized to sign on behalf of that individual}, |
l ny faise representation to knowingly and willfully obtain information from Social Security records is
punishable by a fine of not more than $5,006 er one year in prison.
Signature AND Printed Name of Individual or Legal Guardian SSA mast weneive this fue withia TE days rom ihe dale agned
Date ; | ‘
Relationship (if applicable, you must attach proof) Daytime Phono:
Address | State
City ZIP Code
he above signature is by marked {x}. ff signed by mark (X}, two witnesses fo the signing who
Witnesses must sign this form ONLY if
Please print the signee’s name next te the mark (X) on the signature
Ise Must sign below and provide thelr full address
1. Signature of Witness 2. Signature of Witness
Address (Number and Street, City, State and ZIP Code) Addiess (Number and Street, City, State and ZIP Cade)rom 4906 Request for Copy of Tax Return
(Rew. January 2032} OMB No, 1545-0429
2enoat of the Teasu > Request may be rejected If the form is incomplete or illegible.
Intemal Revenue Servion
Tip. You may be able fo get your tax return or retum information from other sources, If you had your tax retum completed by a paid preparer, they
should be able to provide you a copy of the return, The IRS can provide a Tax Return Transcript for many returns free of charge. The transcript
grovides most of the line entries from the original tax return and usually contains the information that a thir party (such as a mortgage campany}
requires. See Form 4506-T, Request for Transcript of Tax Return, or you can quickly request transcripts by using our automated salf-help service
tools. Plaase visit us at IRS.gov and click on "Order a Transerigt” or call 1-800-908-9946.
the name shown first. 16 First social seourtly number on tex retum,
individual taxpayer klantification number, or
employer identification manber eee instructions}
da Name shown on tax ret
Joint return, ante
28 Second social seourhy number or individual
taxpayer Mentifioation number if joint tax return
‘code (see i
iuding apt., room, or aul
4 Previous address shown on the fast retura Hed if different from Hine 3 (exe Instructions}
igaga company), enter the third parly’s name, address, and talepl
i tax return ts to be mailed fo a third parly (euch ae ah
Gaution. if the tax return is being matied to a third party, ensure that you have filled in linas 6 and 7 before signing. Sign and date the form once you
fave Tiled in these fines. Cornpisting these stems hsies to protect your privacy. Once the JAS discloses your IRS return fo the third party fisted on line
&, the #43 has 110 control over what the third party does with the information, if you wauld like to limit the third party's authority to disclose your retum
information, you can specity this imitation in your written agreement with the third party.
6 Tax return requested. Form 1040, 1120, 941, etc. and alt attachments as originally submitted to the IRS, including Form(s) W-2,
schedules, or amended returns. Copies of Forms 1040, 1040A, and 1040EZ are generally available for 7 years from filing before they are
destroyed by law. Other returns may be available for a fonger period of time, Enter only one return number. If you need more than one
type of return, you must complete another Farm 4506. seas
Note. /f the copies must be cartiiad for court or administrative proceedings, checkhere . . 6. 6. g
7 Year or period requested. Enter the ending date of the year or period, using the mmydd/yyyy format, If you are requesting more than
eight years or periods, you must attach another Form 4506,
8 Fee. Thery is a $87 fee for each retum requested, Full payment must be included with your request or it will
be rejected. Make your check or money order payable to “United States Treasury.” Enter your SSN or EIN
and “Form 4506 request” on your cheok ar money onder.
@ Costforeachretim 2. 1, SE ee ee ee LS $87.00
b Number of returns requested on line 7
Tota’ cost. Multiply fine Ba byline 8b...
% _ it we cannot find the tax retum, we will refund the fea, 1
Caution. Do not sign this form unless ail applicable lines have been completed.
Signature of taxpayer(s}. | deciare that | am either the faxpayer whose same is shown on line 12 or 2a, or a person authorized to obtain the tax return
requested, If the request applies to a joint retum, either husband or wife must sign. If signed by a corporate afflear, partner, guardian, tax matters
partner, executor, ver, adrninistrator, trustee, or party other than the taxpayer, | certify that { have the authority to execute Form 4508 on behalf of
is @ third party, this form must be received within 120 days of the signature date.
go to the third party listed online §, check here... EJ
Prone mu
aor an
See Caparata
7 BSiais, oF trae
) omer
For Privacy Aut anc Paperwork Reduotion Act Notice, see page &, Cat. No. 847215CONSENT TO RELEASE
The language below should be used when you, a Medicare beneficiary, want to authorize someone other than
your attorney or other representative to receive information, including identifiable health information, from the
Centers for Medicare & Medicaid Services (CMS) related to your liability insurance ( including self-insurance),
no-fault insurance or workers’ compensation claim.
i, (print your name exactly as shown on your Medicare card)
hereby authorize the CMS, its agents and/or contractors to release, upon request, information related to my
injury/iliness and/or settlement for the specified date of injury/illness to the individual and/or entity Hsted
below:
CHECK ONLY ONE OF THE FOLLOWING TO INDICATE WHO MAY RECEIVE INFORMATION
AND THEN PRINT THE REQUESTED INFORMATION:
(if you intend to have your information released to more than one individual or entity, you must complete a
separate release for each one.}
[FI Insurance Company [7] Workers’ Compensation Carrier (2 Other Self Insurance
(Explain)
Name of entity: Luks Santaniello Petrillo & Jones
Contact for above entity: Heather M. Calhoon
Address: 150 West Flagler Street — Suite 2750
Miami, FL 33130
Telephone: (305) 377-8900
CHECK ONE OF THE FOLLOWING TO INDICATE HOW LONG CMS MAY RELEASE VOUR
INFORMATION (The period you check will run from when you sign and date below,):
[] One Year (Two Years [7] Other
(Provide a specific period of time)
T understand that I may revoke this “consent to release information” at any time, in writing.
MEDICARE BENEFICIARY INFORMATION AND SIGNATURE:
Beneficiary Signature Date signed:
Note: If the beneficiary is incapacitated, the submitter of this document will need to include documentation establishing the authority
of the individual signing on the beneficiary’s behalf. Please visit www.mspre.info for further instructions.
Medicare Health Insurance Claim Number (the number on your Medicare card):,
Date of Injury/IIlness:RICK SCOTT
GOVERNOR
JUSTIN M,
ENIOR,
ETARY
Authorization for the Use and Disclosure of Protected Health information
Federai law states that we cannot share an individual's health information without the individual's permission, except in certain situations.
By signing this form, you are giving us permission to share the information you indicate below. If you decide later that you do not want us to
share this Information any more, you can revoke this authorization at any time in writing or sign the REVOCATION SECTION on the back of
this form and return it to the Florida Medicaid TPL Recovery Program. This form must be completed and signed by the Medicaid recipient or |.
by an Individual who has the authority to act on the Medicaid reciptent’s behalf (parent of a minor, jegal guardian, trustee, power of attorney,
personal re tive of the esi rior arasity).
PLEASE COMPLETE THE FOLLOWING $
1. Personal information:
Medicaid Recipient's Name, RIQMARA LLERENS Date of Birth,
Medicaid (D Number Socigi Security Number
2 i glve permission to the Agency for Health Care Administration (AHCA) and Its contract representatives to share the health information
listed below with the following:
Name of the Law Firm or Law Office_Luks, Santanialio, Petrillo & Janes, 150 W, Flagler Street, Suits 2750, Mieri, Fl 33430
Name of the Insurance Cornpany,
Other
3. Indicate the purpose for which the disclosure is to be made:
x_ To substantiate Medicaid’s lien relating to a lawsuit
To substantiate Medicaid's claim against the estate or against a trust account or annuity
Other
4. indicate the information that you want te be disctosed, related to the following (check one):
‘The Medicaid lien refating to the injury or negligence charges, for the period beginning with the date of incident.
__Medicaid’s claim against the estate.
‘he amount that is due Medicaid from the trust account, [Please send a copy of the trust agreement).
———The amount that is due Medicaid from the annuity account, [Please send a copy of the annuity agreement].
Xuma tther, [Pease be soeoific) _ Hemlzed paid clairas history with total amount.
5. Enter the specific date that you want this authorization to expire: (ie., one year from date of release}, .
(if you do not enter a date, this authorization will expire in five years.)
| understand that the information described above may be redisclosed by the person or group that | hereby give AHCA and its contract representatives
permission to share my information with, and that my information would no longer be protected by the federal privacy regulations. Therefore, | release
AHCA, its workforce members, and its contract representatives from ail liability arising from the disclosure of my health information pursuant to this
agreement. | understand that | may inspect or request copies of any information disclosed by this authorization if ANCA or its contract representatives
initiated this request for disclosure. | understand that | may revoke this authorization by notifying AHCA through its contractor representatives, in writing,
knowing that previously disclosed information would not be subject to my revocation request. | understand that | may refuse to sign this authorization
and that my refusal to sign will not affect my ability to obtain treatment, payment or eligibility for benefits.
§. Recipient Signature, Print Name, aes Date,
OR
Mame of Legal Representative {Print} Relationship,
Signature of Legal Representative * Date,
* you are not the individual, but represent the individual, please attach a copy of the laga! document that varifies that you are
ofa rninor, legal guardian, trustee, power of attorney, personal representative of the estate, grantor of an a
EXHIBIT
We
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Preview
Filing # 61603873 E-Filed 09/15/2017 05:10:55 PM IN THE CIRCUIT COURT OF THE 11TH JUDICIAL CIRCUIT IN AND FOR MIAMEDADE COUNTY, FLORIDA CASE NO.: 17-014926 CA 01 (31) XIOMARA LLERENA AND ROBERTO LLERENA , Plaintiff(s), vs. QUINTANA FAMILY DAY CARE HOME D/B/A LEARNING AND GROWING FAMILY CHILD CARE, Defendant(s). DEFENDANT’S COLLATERAL SOURCE REQUEST TO PRODUCE TO PLAINTIFF Defendant, QUINTANA FAMILY DAY CARE HOME D/B/A LEARNING AND GROWING FAMILY CHILD CARE, by and through undersigned counsel, and pursuant to Florida Rule of Civil Procedure Rule 1.350, hereby propound their Collateral Source Request for Production to Plaintiff, XKOMARA LLERENA, produce and permit Defendant to inspect and photograph the following: 1. Copies of any and all notices and notifications of the Plaintiff's intent to claim damages from the alleged tortfeasor which have been sent to any and all collateral source providers pursuant to §768.76 (6) of the Florida Statutes, and any applicable hospital tien ordinance. 2. Copies of any and all claims of lien, statements, correspondence or documentation received from all providers of collateral sources asserting or waiving anyclaim of subrogation or reimbursement pursuant to §768.76 (7) of the Florida Statutes, and any applicable hospital lien ordinance. 3. Copies of any and all subrogation or reimbursement notices, policy provisions and claims of lien for all providers of collateral sources for medical treatment received by Plaintiff as a result of the incident that is the subject of this litigation. 4. Any and all documentation establishing the amount of money and benefits paid by any and all collateral sources for medical treatment received by the Plaintiff as a result of the incident which is the subject of this litigation. 5. Copies of any and all releases of hospital liens and satisfactions of hospital liens pertaining to the Plaintiff for any medical and chiropractic care rendered as an alleged result of the incident which is the subject of this litigation. 6. Copies of any and all Complaints and Statements of Claim filed by any medical provider against the Plaintiff for any medical and chiropractic care which is alleged to have been rendered as a result of the incident which is the subject of this litigation. 7. Copies of ail drafts, checks, money orders and receipts showing payment by the Plaintiff of any hospital lien charges which are alleged to have been incurred as a result of the incident which is the subject of this litigation. 8. Copies of any correspondence between the Plaintiff and any health care provider, including hospitals, pertaining to collection of accounts, payment of bills and liens and reimbursement/subrogation rights.9, Any and all Workers Compensation, TRICARE/Champus, Medicare, HRS Medicaid, Hospital liens, HMO notices, PPO notices, ERISA plan, health insurance, medical payment (Med Pay) and commercial PIP notices of subrogation and reimbursement rights pertaining to any health care (both medical and chiropractic) rendered to Plaintiff as an alleged result of the incident which is the subject of this litigation. 10. Copies of any and all drafts and checks showing payment by any Workers Compensation carrier, TRICARE/Champus, Medicare, HRS Medicaid, health insurance, HMO, PPO, ERISA plan, Med Pay plan, any public program providing medical expenses and commercial PIP to Plaintiff and any health care provider (medical and chiropractic) for the benefit of the Plaintiff. 11. Copies of any checks, drafts, documentation and correspondence sent by the Social Security Administration, motor vehicle accident insurer (including PIP), any federal, state or local income disability provider, any public program providing disability payments, and income disability insurer to the Plaintiff for any wage loss and loss, disability and loss of earning capacity payments made as an alleged result of the incident which is the subject of this action. 12. Copies of any contract or agreement by any group, organization, partnership, or corporation to provide, pay for, or reimburse the costs of hospital, medical, dental, or other health care services that pertain to the Plaintiff herein.13, Copies of any contractual or voluntary wage continuation plan and contract provided by Plaintiffs employer(s) or by any other system intended to provide wages during a period of disability. 14. Copies of the Complaints in any lawsuit and arbitration concerning a dispute between any collateral source providers as defined in §768.76 and Plaintiff. 15. Produce all Medicare Summary Notices (MSN), or any other notices, reports, statements, or other documents from any source that describe, total or reference any Medicare benefits that plaintiff has received from the date of the accident till the present. 16. Produce a printout showing all benefits paid by Medicare for any and all services or supplies that your providers and suppliers billed through Medicare and are contained on your personal account history at www.mymedicare.gov. a7, Produce all correspondences or other documents from CMS or any other source that describe, total or reference any liens on the claims raised in this case. 18. A signed and executed copy of Social Security Administration Consent for Release authorization form SSA-3288, attached as Exhibit “A”. 19, A signed and executed copy of Request for Social Security Earnings Information authorization form SSA-7050-F4, attached as Exhibit “B”, 20. A signed and executed copy of Internal Revenue Service Request for Transcript of Tax Return authorization form 4506, attached as Exhibit “C”. 21. A signed and executed copy of Consent to Release for Medicare authorization form, attached as Exhibit “D”.22, A signed and executed copy of Medicaid Healthcare Administration Authorization form, attached as Exhibit “E”, 23. Praduce all Medicare Summary Notices (MSN), or any other notices, reports, statements, or other documents from any source that describe, total or reference any Medicare benefits that plaintiff has received from the date of the accident till the present. 24, Produce a printout showing all benefits paid by Medicare for any and all services or supplies that your providers and suppliers billed through Medicare and are contained on your personal account history at www. Care. gov. 25, Produce all correspondences or other documents from CMS or any other source that describe, total or reference any liens on the claims raised in this case. It is hereby requested that the aforesaid production of copies be made and sent to the offices of LUKS, SANTANIELLO, PETRILLO & JONES. If plaintiff offers to make such documents available for inspection only, it is hereby requested that copies be provided to undersigned counsel and we will reimburse all reasonable or actual charges associated with said copies.CERTIFICATE OF SERVICE WE HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished via Electronic Mail, to all counsel of record on the attached Service List, this 15th day of September, 2017. LUKS, SANTANIELLO, PETRILLO & JONES Attorneys for Defendant 150 W. Flagler Street, Suite 2750 Miami, FL 33130 Telephone: (305) 377-8900 Facsimile: (305) 377-8901 By: {6] Heather M, Calhosn DANIEL J. SANTANIELLO, Florida Bar No.: 860948 HEATHER M. CALHOON, Florida Bar No.: 495573 SMIA-Pleadings@LS-LaSERVICE LIST Michael J. Carmona, Esq. Friedland Law Group 1430 South Dixie Highway Suite 305 Coral Gables, FL 33146 email @friedlandiawgroup.comSocial Security Administration Form Approved Consent for Release of Information oF You must compiete all required fields. We will not honor your request unless ail required fields are completed. (*signifies a required field). TO: Social Security Administration “Ry Full Nara “Ny Date of Birth “hy Social Security Number {MM/DDIYYYY} | authorize the Social Security Administration to release information or records about me to: *NAME OF PERSON OR ORGANIZATION: “ADDRESS OF PERSON OR ORGANIZATION: Heather M. Calhoon 28 WH trille & Jones Suite 150 “t want this information released because: Pending Litgiation We mey change a fee to release information fof HOa-pragram purposes. *Please release the following information selected from the list below: You must specify the records you are requesting by checking at least one box. We will not honor a request for "any and alf records” or "my entire file." Also, we will not disclose records unless you include the applicable date ranges where requested. 4. [K] Social Security Number 2. Current monthly Social Security benefit amount 3. Xj Current monthly Suppiementai Security Income payment amount 4. (J My benefit or payment amounts from date ... 'o date 8. 6. My Medicare entitlement fram date Madical records from my claims folder(s) from date _.. to date. if you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social Security office. . §] Complete medica! records from my claims folder(s) . [7] Other record(s) from my file (you must specify the records you are requesting, e.g., doctor report, application, determination or questionnaire) on | am the individual, to whom the requested information or record applies, or the parent or legal guardian of a minor, or the legal guardian of a legally incompetent adult, | declare under penalty of perjury (28 CFR § 16.44(d}(2004)) that | have examined all the information on this form, and any accompanying statements or forms, and it is true and correct to the best of my knowledge. | understand that anyone who knowingly or willfully seeks or obtain access to records about another person under false pretenses is punishable by a fine of up to $5,000. | also understand that | must pay all applicable fees for requesting information for a non-program-related purpose. “Signature: . . . “Date: “Address: . Relationship (if not the subject of the record) “Daytime Phone: Witnesses must sign this form ONLY if the above signature is by mark (X). If signed by mark (X), two witnesses to the signing who know the signee must sign below and provide their full addresses. Please print the signee’s name next to the mark (X) on the signature fine above, 4 Signature of wi ignature of witness Address(Number and street, Clty, State, and Zin Oo: Form S8A-3288 697-2013) EF (07-2043)Form SSA-708G-F4 (40-2018) UF Page 2 af4 REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION he name of the individual whose 1, Provide your name aa # appears on your most recent Social Security card or eamings you are reque: 5 First Name: Middle Initial: C] Last Name: Social Security Number (SSN) ~ - One SSN par request Date of Birth: ! ‘ Date of Death: / f Other Name(s) Used {include Maiden Narra} 2, What kind of earings Information do you need? (Choose ONE af the following typas af earnings or SSA rnust raturn this request.) a Hemized Statement of Earnings $415 Year(s) Requested: to (inchides the names and addresses of employers) Year(s) Requested: to If you check this box, tell us why you need this information below. (3) Rea ‘Check this box if you want the eamings information CERTIFIED for an additional $33.00 fee. ["] Certified Yearly Totals of Eamings $33 Yeax{s) Requested: to (Qoes not include the names and addresses of employers} Yearly earings iotels are FREE to the public if you do not Year(s) Requested: to require certification. To obtain FREE yearly totals of sarnings, visit our website at www.ssa.gov/myeccount, 3. If you would like this information sent to someone else, please fill in the information below. | authorize the Social Security Administration to release the earnings information to: Name Heather M. Calhoon / Luks Santaniello Petrillo 4 Jones Address: 150 W. Flagler Street - Suite 2750 State BL ZIP Cade 33420 ‘son authorized to sign on behalf of that individual}, | l ny faise representation to knowingly and willfully obtain information from Social Security records is punishable by a fine of not more than $5,006 er one year in prison. Signature AND Printed Name of Individual or Legal Guardian SSA mast weneive this fue withia TE days rom ihe dale agned Date ; | ‘ Relationship (if applicable, you must attach proof) Daytime Phono: Address | State City ZIP Code he above signature is by marked {x}. ff signed by mark (X}, two witnesses fo the signing who Witnesses must sign this form ONLY if Please print the signee’s name next te the mark (X) on the signature Ise Must sign below and provide thelr full address 1. Signature of Witness 2. Signature of Witness Address (Number and Street, City, State and ZIP Code) Addiess (Number and Street, City, State and ZIP Cade)rom 4906 Request for Copy of Tax Return (Rew. January 2032} OMB No, 1545-0429 2enoat of the Teasu > Request may be rejected If the form is incomplete or illegible. Intemal Revenue Servion Tip. You may be able fo get your tax return or retum information from other sources, If you had your tax retum completed by a paid preparer, they should be able to provide you a copy of the return, The IRS can provide a Tax Return Transcript for many returns free of charge. The transcript grovides most of the line entries from the original tax return and usually contains the information that a thir party (such as a mortgage campany} requires. See Form 4506-T, Request for Transcript of Tax Return, or you can quickly request transcripts by using our automated salf-help service tools. Plaase visit us at IRS.gov and click on "Order a Transerigt” or call 1-800-908-9946. the name shown first. 16 First social seourtly number on tex retum, individual taxpayer klantification number, or employer identification manber eee instructions} da Name shown on tax ret Joint return, ante 28 Second social seourhy number or individual taxpayer Mentifioation number if joint tax return ‘code (see i iuding apt., room, or aul 4 Previous address shown on the fast retura Hed if different from Hine 3 (exe Instructions} igaga company), enter the third parly’s name, address, and talepl i tax return ts to be mailed fo a third parly (euch ae ah Gaution. if the tax return is being matied to a third party, ensure that you have filled in linas 6 and 7 before signing. Sign and date the form once you fave Tiled in these fines. Cornpisting these stems hsies to protect your privacy. Once the JAS discloses your IRS return fo the third party fisted on line &, the #43 has 110 control over what the third party does with the information, if you wauld like to limit the third party's authority to disclose your retum information, you can specity this imitation in your written agreement with the third party. 6 Tax return requested. Form 1040, 1120, 941, etc. and alt attachments as originally submitted to the IRS, including Form(s) W-2, schedules, or amended returns. Copies of Forms 1040, 1040A, and 1040EZ are generally available for 7 years from filing before they are destroyed by law. Other returns may be available for a fonger period of time, Enter only one return number. If you need more than one type of return, you must complete another Farm 4506. seas Note. /f the copies must be cartiiad for court or administrative proceedings, checkhere . . 6. 6. g 7 Year or period requested. Enter the ending date of the year or period, using the mmydd/yyyy format, If you are requesting more than eight years or periods, you must attach another Form 4506, 8 Fee. Thery is a $87 fee for each retum requested, Full payment must be included with your request or it will be rejected. Make your check or money order payable to “United States Treasury.” Enter your SSN or EIN and “Form 4506 request” on your cheok ar money onder. @ Costforeachretim 2. 1, SE ee ee ee LS $87.00 b Number of returns requested on line 7 Tota’ cost. Multiply fine Ba byline 8b... % _ it we cannot find the tax retum, we will refund the fea, 1 Caution. Do not sign this form unless ail applicable lines have been completed. Signature of taxpayer(s}. | deciare that | am either the faxpayer whose same is shown on line 12 or 2a, or a person authorized to obtain the tax return requested, If the request applies to a joint retum, either husband or wife must sign. If signed by a corporate afflear, partner, guardian, tax matters partner, executor, ver, adrninistrator, trustee, or party other than the taxpayer, | certify that { have the authority to execute Form 4508 on behalf of is @ third party, this form must be received within 120 days of the signature date. go to the third party listed online §, check here... EJ Prone mu aor an See Caparata 7 BSiais, oF trae ) omer For Privacy Aut anc Paperwork Reduotion Act Notice, see page &, Cat. No. 847215CONSENT TO RELEASE The language below should be used when you, a Medicare beneficiary, want to authorize someone other than your attorney or other representative to receive information, including identifiable health information, from the Centers for Medicare & Medicaid Services (CMS) related to your liability insurance ( including self-insurance), no-fault insurance or workers’ compensation claim. i, (print your name exactly as shown on your Medicare card) hereby authorize the CMS, its agents and/or contractors to release, upon request, information related to my injury/iliness and/or settlement for the specified date of injury/illness to the individual and/or entity Hsted below: CHECK ONLY ONE OF THE FOLLOWING TO INDICATE WHO MAY RECEIVE INFORMATION AND THEN PRINT THE REQUESTED INFORMATION: (if you intend to have your information released to more than one individual or entity, you must complete a separate release for each one.} [FI Insurance Company [7] Workers’ Compensation Carrier (2 Other Self Insurance (Explain) Name of entity: Luks Santaniello Petrillo & Jones Contact for above entity: Heather M. Calhoon Address: 150 West Flagler Street — Suite 2750 Miami, FL 33130 Telephone: (305) 377-8900 CHECK ONE OF THE FOLLOWING TO INDICATE HOW LONG CMS MAY RELEASE VOUR INFORMATION (The period you check will run from when you sign and date below,): [] One Year (Two Years [7] Other (Provide a specific period of time) T understand that I may revoke this “consent to release information” at any time, in writing. MEDICARE BENEFICIARY INFORMATION AND SIGNATURE: Beneficiary Signature Date signed: Note: If the beneficiary is incapacitated, the submitter of this document will need to include documentation establishing the authority of the individual signing on the beneficiary’s behalf. Please visit www.mspre.info for further instructions. Medicare Health Insurance Claim Number (the number on your Medicare card):, Date of Injury/IIlness:RICK SCOTT GOVERNOR JUSTIN M, ENIOR, ETARY Authorization for the Use and Disclosure of Protected Health information Federai law states that we cannot share an individual's health information without the individual's permission, except in certain situations. By signing this form, you are giving us permission to share the information you indicate below. If you decide later that you do not want us to share this Information any more, you can revoke this authorization at any time in writing or sign the REVOCATION SECTION on the back of this form and return it to the Florida Medicaid TPL Recovery Program. This form must be completed and signed by the Medicaid recipient or |. by an Individual who has the authority to act on the Medicaid reciptent’s behalf (parent of a minor, jegal guardian, trustee, power of attorney, personal re tive of the esi rior arasity). PLEASE COMPLETE THE FOLLOWING $ 1. Personal information: Medicaid Recipient's Name, RIQMARA LLERENS Date of Birth, Medicaid (D Number Socigi Security Number 2 i glve permission to the Agency for Health Care Administration (AHCA) and Its contract representatives to share the health information listed below with the following: Name of the Law Firm or Law Office_Luks, Santanialio, Petrillo & Janes, 150 W, Flagler Street, Suits 2750, Mieri, Fl 33430 Name of the Insurance Cornpany, Other 3. Indicate the purpose for which the disclosure is to be made: x_ To substantiate Medicaid’s lien relating to a lawsuit To substantiate Medicaid's claim against the estate or against a trust account or annuity Other 4. indicate the information that you want te be disctosed, related to the following (check one): ‘The Medicaid lien refating to the injury or negligence charges, for the period beginning with the date of incident. __Medicaid’s claim against the estate. ‘he amount that is due Medicaid from the trust account, [Please send a copy of the trust agreement). ———The amount that is due Medicaid from the annuity account, [Please send a copy of the annuity agreement]. Xuma tther, [Pease be soeoific) _ Hemlzed paid clairas history with total amount. 5. Enter the specific date that you want this authorization to expire: (ie., one year from date of release}, . (if you do not enter a date, this authorization will expire in five years.) | understand that the information described above may be redisclosed by the person or group that | hereby give AHCA and its contract representatives permission to share my information with, and that my information would no longer be protected by the federal privacy regulations. Therefore, | release AHCA, its workforce members, and its contract representatives from ail liability arising from the disclosure of my health information pursuant to this agreement. | understand that | may inspect or request copies of any information disclosed by this authorization if ANCA or its contract representatives initiated this request for disclosure. | understand that | may revoke this authorization by notifying AHCA through its contractor representatives, in writing, knowing that previously disclosed information would not be subject to my revocation request. | understand that | may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment or eligibility for benefits. §. Recipient Signature, Print Name, aes Date, OR Mame of Legal Representative {Print} Relationship, Signature of Legal Representative * Date, * you are not the individual, but represent the individual, please attach a copy of the laga! document that varifies that you are ofa rninor, legal guardian, trustee, power of attorney, personal representative of the estate, grantor of an a EXHIBIT We af