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Filing # 120891493 E-Filed 02/05/2021 11:04:33 AM
IN THE COUNTY COURT OF THE NINTH JUDICIAL CIRCUIT,
IN AND FOR ORANGE COUNTY, FLORIDA
CASE NO.:
PREZIOSI WEST EAST ORLANDO
CHIROPRACTIC CLINIC, LLC a/a/o Vivian
Rodriguez, as legal guardian of J.R., a minor,
Plaintiff,
v.
EQUITY INSURANCE COMPANY,
Defendant.
/
COMPLAINT
Plaintiff, PREZIOSI WEST EAST ORLANDO CHIROPRACTIC CLINIC, LLC a/a/o
Vivian Rodriguez, as legal guardian of J.R., a minor (hereinafter "Plaintiff), hereby sues the
Defendant, EQUITY INSURANCE COMPANY (hereinafter "Defendant), and alleges:
1. This is an action for damages that is less than $2,500.00, exclusive of interest,
postage, costs and attorney's fees.
2. At all times material here to, Defendant was and/or is a corporation duly licensed to
transact business in Orange County, Florida.
3. The Assignor, Vivian Rodriguez, as legal guardian of J.R., a minor, was involved in a
motor vehicle crash on or about December 12, 2019 in which they sustained personal injuries.
4. As a direct and proximate result of the injuries sustained in the crash, the Assignor
incurred reasonable expenses for necessary medical, rehabilitative, nursing, and remedial care.
5. The Defendant issued a policy of insurance that provided Personal Injury Protection
benefits and/or Medical Expense Benefits Coverage required by law to comply with Florida Statutes
627.730 —
627.7405. A copy of the policy is not available to Plaintiff, but is in the possession of
Defendant.
6. The above described policy was in full force and effect on the date of the crash and
provided Personal Injury Protection coverage and/or medical expense coverage for Assignor for
bodily injuries sustained in the subject crash.
7. Assignor executed an Assignment of Benefits assigning their rights, title, and interest
under said policy of insurance to Plaintiff, for treatment related to said automobile crash. A copy of
the Assignment of Benefits is attached hereto and incorporated herein by reference as Composite
Exhibit A.
8. Alternatively, Assignor equitably assigned their rights, title, and interest under said
policy of insurance to Plaintiff for treatment related to said automobile crash.
9. Plaintiff gave notice of a covered loss to Defendant and made a demand for No Fault
Benefits for reasonable, necessary, and related medical, rehabilitative, and remedial treatment for
dates of service 12/16/2019 -
02/12/2020. Copies of the relevant Patient Account Ledger and/or CMS
1500 forms are attached hereto and incorporated herein by reference as Composite Exhibit A.
10. Plaintiff has performed all conditions precedent to entitle Plaintiff to recover benefits
for said necessary medical, rehabilitative, and remedial treatment regarding the above-described
policy. Specifically, Plaintiff complied with Florida Statute 627.736(10). Copy of Plaintiff s demand
letter is attached hereto and incorporated herein by reference as Composite Exhibit A.
11. Defendant did not make payment of the full No-Fault benefits within thirty (30) days
as required by Florida Statute 627.736(4)(b).
12. Defendant failed to pay the Plaintiff s covered loss despite the fact that Defendant
had no reasonable proof to establish that it was not responsible for payment.
13. Defendant failed to timely provide benefits as required by Florida Statute
627.736(4)(b) with such frequency as to constitute a general business practice in violation of Florida
Statute 627.736(4)(b).
14. Due to the failure of Defendant to pay No-Fault benefits in accordance with the law,
Plaintiff has been required to retain the undersigned for the prosecution of this suit.
15. Defendant has failed to pay the statutory interest penalties, postage, and the statutory
attorney's fees required by law.
16. Plaintiff would derive a benefit from the Court's judgment ordering the Defendant to
pay interest, postage, and attorney's fees even if Defendant pays all or some of the disputed benefits
before judgment is entered after suit is filed.
17. Plaintiff requests an award of attorney's fees under Florida Statute 627.428, 627.736,
and an award of costs under Florida Statutes 92.231 and 57.041.
18. Plaintiff requests a trial by jury on all issues so triable.
WHEREFORE, Plaintiff demands judgment for Personal Injury Protection benefits, Medical
Payments/Expense Benefits together, and all other benefits required to be paid under the policy of
insurance with pre-judgment interest thereon, all interest on any past benefits not timely paid,
postage, costs and attorney's fees.
DATED this February 5, 2021.
JON-114/A ATANDONE, ESQ.
Fla. Bar No. 111335
Payas, Payas & Payas LLP
1018 East Robinson Street
Orlando, Florida 32801
T: 407.425.7223 / F: 407.425.1254
Primary: Payas16@payaslaw.com
Secondary: jandone@payaslaw.com
Composite Exhibit A
12/15/2020
https://payaslaw.sendproenterprise.com/Composer/XmlRequest/GetShipLabel?guid=8625cf4a-df7c-48bc-bf87-30f65d8104d3&pagenu...
USPS CERTIFIED MAIL _
Payas Payas &Payee
III I 1 1 I I 1 1 1I 1 I
Dept 16 PIP 1016
1018 E Robinson St
Orlando, FL 32801
9407 1149 0238 2570 0257 88
Equity Insurance Company
Charles Micheal Davis
4315 Lake Shore Dr, Ste J
Waco, TX 7671 0-1 970
Shipper Ref: PIP 1016
Reference 1: PIP 1016
Reference 3: PIP 1016
httos://navaslaw.serwinroanternrise.com/Comnoser/XmIRentiest/GptShinl ahpOni
PAYAS•PAYAS•PAYAS•iip
A t t o r n e ys A t L a w
Armandn
Payas
Armando R. Payas
Carlos E. Payas
Joshua A. Andone, Esq.
1018 East Robinson Street
Orlando, Florida 32801
T: 407.425.7223
F: 407.425.1254
jandone(imayaslaw.corn
December 15, 2020
SENT VIA CERTIFIED MAIL — RETURN RECEIPT REQUESTED
Equity Insurance Company
Attn: Charles Michael Davis
4315 Lake Shore Drive, Suite J
Waco, TX 76710
DEMAND FOR PAYMENT PURSUANT TO FLA. STAT. 4627.736(10)
WRITTEN NOTICE OF INTENT TO IMTIATE LITIGATION
Name of Medical Provider: Preziosi West-East Orlando Chiropractic Clinic, LLC
Insured: Vivian Rodriguez
Patient: Jermiah Rodriguez (a minor)
Claim/Policy #: D29Y0272-04-0450
DOL: 12/12/2019
Dear Sir/Madam:
This is a demand letter under §627.736 Fla. Stat.,and under any applicable policy of insurance. The
benefits (personal injury protection and MedPay, if applicable) claimed are now overdue, and for
payment of reasonable charges for related and necessary treatment, services, accommodations or
supplies to the above-referenced patient. The above-referenced medical provider has not been properly
paid.
Specifically, this demand is for payment of the amounts listed below for the listed dates of service at
the reasonable amount billed, less any payments received by the above-referenced medical provider
from said PIP insurer. Please note that if the policy contains MedPay coverage, the amount demanded
is at 100% of the reasonable billed amount, less any payments received from said PIP insurer.
The following is demanded:
-
Date(s) of Service: 12/16/2019 —
02/12/2020
-
Arnount due at 100%: $1,220.00
o Less any amounts (excluding interest) already paid by insurer
o Made payable to the Medical Provider above
-
Interest on the Amount Due, at the statutory rate, commencing thirty (30) days after the date
the bill for services (CMS 1500) was received by the carrier/insurer up to the date payment is
made
o Made payable to the Medical Provider above
-
Penalty of 10% of amount due (maximum $250.00), and certified mail/postage cost
Orlando •
Kissimrnee •
Deltona
o Made payable to "Payas, Payas & Payas LLP" (Tax ID 20-0044781)
If the insurer has information supporting a lesser amount is owed and/or this demand is not payable for
any reason, including, but not limited to, deductible, co-payment, exhaustion, §627.736 Fla. Stat.,
please provide the appropriate explanation/support pursuant to §627.736(4)(b) Fla. Stat. If the insurer
has made an unambiguous election in its insurance policy pursuant to Fla. Stat., which permits the
insurer to limit payment to 80% of 200% of the allowable amount under the Medical Part B Physician's
Fee Schedule and/or the 80% of the maximum reimbursable allowance under workerscompensation,
then the amounts demanded herein are subject to those legally permitted amounts. The policy of
insurance is in the insurer's possession, and the insured and/or its assignee is unable to determine the
specific amount owed without this documentation. If the insurer contends that it has made an election
to limit payment as stated, please provide the portion of the policy that purportedly provides for limiting
such payment.
Please provide a copy of the insurance policy, applicable declarations page, PIP payout log, and copies
of all explanation of benefits/reimbursement that have been made on behalf of the above-referenced
patient. This request is specifically being made in an attempt to avoid filing an unnecessary lawsuit if
the insurer has properly applied the bill(s) to the deductible or if benefits have properly exhausted. We
request the insurer to notify us if the policy limits have been reached within fifteen (15) days after
reaching said limits as required by §627.736(6)(0.
We have enclosed an Assignment of Benefits (AOB) executed by the patient/claimant/insured (or their
proper guardian), as well as the requisite itemized statement/CMS 1500/E0B/EOR of what was
previously submitted that specifies the exact amounts and dates of service claimed to be due. You are
required to notify us of any objection(s) to the legal validity, form, or substance of the AOB within the
statutory time limits, else said objection(s) be waived and the Medical Provider will have standing to
file and pursue this matter.
In the event the insurer/carrier does not fully and completely comply with this demand, it is demanded
that sufficient benefits be reserved or escrowed to satisfy this outstanding claim prior to any exhaustion
of benefits, pending resolution of any action filed after this demand. We seek to preserve and pursue
all rights as provided by law and to minimize or avoid litigation, if possible. Additionally, we request
that any reply further denying or otherwise not satisfying this demand to outline the exact reasons why
the insurer/carrier denies said demand.
Failure to fully and completely comply with this demand letter within the thirty (30) days of receipt by
the insurer/carrier will result in suit being filed for all amounts legally due, including applicable costs
and attorney's fees.
PLEASE GOVERN YOURSELVES ACCORDINGLY.
Sincerely,
/s/Joshua A. Andone
Joshua A. Andone, Esq.
Enclosures (as indicated)
12/08/2020 11:54Ah1 FAX
la0002/0004
PREZIOSI WEST / EAST ORLANDO
CHIROPRACTIC CLINIC, LLC
DR. VINCENT PREZIOSI
823 PAUL STREET
ORLANDO, FL 32808
IWeb)/ assign from any and alltuitomobile insurance which provide medical benefits or no-fault
and interest
toPREZIOSI WEST / EAST ORLANDOpolicies benefits,all Benefits, rights, title
by reason of accident or illness., I CHIROPRACTIC CLINIC, LIC. As assignee for services
knowingly, rendered tmto me both
Personal Injury Protection
voluntarily and intentionally assigo the rights and benefits of
(P,I,P), and Medical my insurance, alsoknown as
I understand it is the intention of the Payments policy of insurance to the above
provider tto accept this assienment of benefits in lieu of health care
provider.
rendered and that thisdocurnent demanding payment at the tirne services are
will allow the
benefits. This is to act as a limited provider to filesuit againstan insurance company for of
assignment of my rights and benefits to the extent of the payment the insurance
constructedas a
delegation of any dutiesunder Assignee's services provided and in no way be
said attiOMObileInsurance the
conditionsprecedent under the abovereferenced insurance
policyby Assignor to Assignee,or a
delegation of any
policies.
ASSIGNMENT OF CAUSE OF ACTION
In the event rny insurance fails
to pay
Assignee the full amount due and owing to
toassignee any and all causes of action in tort or contract and Assignee after notice is given, I hereby assien and transfer
my favor against such insurance proceeds from such causes of action, that I might have or that
company and authorize Assignee tu prosecute said cause of action might exist in
I further authorize either in my name or
Assignee to compromise, settle or otherwise resolve
said claim or cause of action as Assignee's name and
they see At.
DIRECTION OF PAYMENT
Ihereby authorize said insurance company or
servicesrendered to
attorney to
pay directlyto Assignee the amount of this and/or
me. I also agreeto in any futurebills for
pay a currentnianner any differencebetween
insuranceeompany directly the total chargesand the amount
toAssignee, I furtheragree to paid by the
pay any applicabledeductible or co-payment not covered by my insurance.
PIP.LOG REQUEST
I hereby authorizerny insurancecompany to release any information
requested (hat
applicable Florida Statues, Florida ease law, the subject insurance is pertinent to
my case to
Assignee. Pursuant to the
the pip-log, declaration policyand in conjunetion with this
essignment I
sheet and copy of the insurance hereby requesta
copy of
accident be provided to policy,which reflectsthe policy limits available at the
Assignee. I hereby authorize Assignee to request and receive a tirneof this
necessary. copy of my pip-log periodically as they deem to be
RESERVATION OF BENEFITS
Please be advised that I am hereby
placing you on notice that, pursuant to Florida case
law, should you deny,
portion of or an entire bill submitted on my behalf front this ieduce or fail to pay either
a
this Is resolved, Assignee, I am requesting that you reserve, or hold aside, the same amount
dispute until
RELEASE OF INFORMATION
I hereby authorize Assignee and/or his office to disclose/release
any information concerning
my injuries protected by
requesting partywith a properly executed medical records
release.
the Federal HIPAA10 a
LIEN
further agree that any
amount that I owe forservicesperformed shallconstitute lien
injuriesand that
a on any claim or lawsuit I may have as a result of
any settlement,award, juryverdict or insuranceproceeds that I receive or become entitled my
injuries. This assignment/lien shall be placed into rny to receiveas Ulresult of my
chart and shall constitute actual notice to
bills shall be paid first from the rny attorney, or any person, that my medical
proceeds of any sttch lawsuit, settlement, award, jury
verdict or insurance benefits. 1 further
PREZIOSI WEST / EAST ORLANDO CHIROPRACTIC hereby appoint
CLINIC, LLC or its designee as my auorney-in-fact to sign my narne and
financing statement under the UCC to evidence this lien. file
If anyterm of this Assignment the
or
remainder of this Assignment shall
application thereof to any person or circumstances shall
be determined invalid or unenforceable the
affected thereby, and each term and
fullest extent of the law.
nAbe provision of this Assignment shall be valid and enforced to the
PATI EN
DATE: 1/4-ka Y9
ar‘
35( rn ic6-) qai ri3u,c
DOI"- I'll 14)-14;Ol
DR.PREZIOSI/ EAST ORL CHIRO STATEMENT
7206 CURRY FORD RD Date: 12/08/2020
ORLANDO, FL 32822
Prior Balances
(407) 275-3551
Insurance .00
Patient .00
JEREMIAH Total .00
(MINOR) RODRIGUEZ
729 AVONDALE AVE #2
ORLANDO, FL 32805
Provider:VINCENT PREZIOSI
Date Description Units Charges Transfers Insurance Paid
Patient PaidAdjustments Unpaid
12/16/2019 99203 COMPLETE INITIAL EXAM 1 200.00 .00 .00 .00 .00
12/16/2019 97139 200.00
LASER/ CLUSTER 1 40.00 .00 .00 .00 .00 40.00
12/16/2019 97039 UNATTENDED ULTRASOUND 1 40.00 .00 .00 .00 .00
12/16/2019 97010 HOT PACK IN OFFICE 40.00
1 40.00 .00 .00 .00 .00 40.00
12/18/2019 97139 LASER/ CLUSTER 1 40.00 .00 .00 .00 .00
12/18/2019 97039 40.00
UNATTENDED ULTRASOUND I 40.00 .00 .00 .00 .00 40.00
12/18/2019 98941 MANIPULATION OF 3-4 BODY P 1 100.00 .00 .00 .00 .00 100.00
01/15/2020 97139 LASER/ CLUSTER 1 40.00 .00 .00 .00 .00
01/15/2020 97039 40.00
UNATTENDED ULTRASOUND 1 40.00 .00 .00 .00 .00 40.00
01/15/2020 98941 MANIPULATION OF 3-4 BODY P 1 100.00 .00 .00 .00 .00 100.00
01/31/2020 97139 LASER/ CLUSTER 1 40.00 .00 .00 .00 .00 40.00
01/31/2020 97039 UNATTENDED ULTRASOUND 1 40.00 .00 .00 .00 .00
01/31/2020 98941 40.00
MANIPULATION OF 3-4 BODY P 1 100.00 .00 .00 .00 .00 100.00
02/07/2020 98941 MANIPULATION OF 3-4 BODY P 1 100.00 .00 .00 .00 .00
02/07/2020 97039 100.00
HYDROBED THERAPY 1 40.00 .00 .00 .00 .00 40.00
02/12/2020 97039 UNATTENDED ULTRASOUND 1 40.00 .00 .00 .00 .00
02/12/2020 97139 40.00
LASER/ CLUSTER 1 40.00 .00 .00 .00 .00
02/12/2020 G0237 HOT PACK IN OFFICE
40.00
1 40.00 .00 .00 .00 .00
02/12/2020 98941 40.00
MANIPULATION OF 3-4 BODY
P 1 100.00 .00 .00 .00 .00 100.00
Totals: 1,220.00 .00 .00 .00 .00 1,220.00
Current Insurance Balance 1,220.00 Patient Balance .00 Total Balance 1,220.00
Page 1 of 2
Preview
Filing # 120891493 E-Filed 02/05/2021 11:04:33 AM IN THE COUNTY COURT OF THE NINTH JUDICIAL CIRCUIT, IN AND FOR ORANGE COUNTY, FLORIDA CASE NO.: PREZIOSI WEST EAST ORLANDO CHIROPRACTIC CLINIC, LLC a/a/o Vivian Rodriguez, as legal guardian of J.R., a minor, Plaintiff, v. EQUITY INSURANCE COMPANY, Defendant. / COMPLAINT Plaintiff, PREZIOSI WEST EAST ORLANDO CHIROPRACTIC CLINIC, LLC a/a/o Vivian Rodriguez, as legal guardian of J.R., a minor (hereinafter "Plaintiff), hereby sues the Defendant, EQUITY INSURANCE COMPANY (hereinafter "Defendant), and alleges: 1. This is an action for damages that is less than $2,500.00, exclusive of interest, postage, costs and attorney's fees. 2. At all times material here to, Defendant was and/or is a corporation duly licensed to transact business in Orange County, Florida. 3. The Assignor, Vivian Rodriguez, as legal guardian of J.R., a minor, was involved in a motor vehicle crash on or about December 12, 2019 in which they sustained personal injuries. 4. As a direct and proximate result of the injuries sustained in the crash, the Assignor incurred reasonable expenses for necessary medical, rehabilitative, nursing, and remedial care. 5. The Defendant issued a policy of insurance that provided Personal Injury Protection benefits and/or Medical Expense Benefits Coverage required by law to comply with Florida Statutes 627.730 — 627.7405. A copy of the policy is not available to Plaintiff, but is in the possession of Defendant. 6. The above described policy was in full force and effect on the date of the crash and provided Personal Injury Protection coverage and/or medical expense coverage for Assignor for bodily injuries sustained in the subject crash. 7. Assignor executed an Assignment of Benefits assigning their rights, title, and interest under said policy of insurance to Plaintiff, for treatment related to said automobile crash. A copy of the Assignment of Benefits is attached hereto and incorporated herein by reference as Composite Exhibit A. 8. Alternatively, Assignor equitably assigned their rights, title, and interest under said policy of insurance to Plaintiff for treatment related to said automobile crash. 9. Plaintiff gave notice of a covered loss to Defendant and made a demand for No Fault Benefits for reasonable, necessary, and related medical, rehabilitative, and remedial treatment for dates of service 12/16/2019 - 02/12/2020. Copies of the relevant Patient Account Ledger and/or CMS 1500 forms are attached hereto and incorporated herein by reference as Composite Exhibit A. 10. Plaintiff has performed all conditions precedent to entitle Plaintiff to recover benefits for said necessary medical, rehabilitative, and remedial treatment regarding the above-described policy. Specifically, Plaintiff complied with Florida Statute 627.736(10). Copy of Plaintiff s demand letter is attached hereto and incorporated herein by reference as Composite Exhibit A. 11. Defendant did not make payment of the full No-Fault benefits within thirty (30) days as required by Florida Statute 627.736(4)(b). 12. Defendant failed to pay the Plaintiff s covered loss despite the fact that Defendant had no reasonable proof to establish that it was not responsible for payment. 13. Defendant failed to timely provide benefits as required by Florida Statute 627.736(4)(b) with such frequency as to constitute a general business practice in violation of Florida Statute 627.736(4)(b). 14. Due to the failure of Defendant to pay No-Fault benefits in accordance with the law, Plaintiff has been required to retain the undersigned for the prosecution of this suit. 15. Defendant has failed to pay the statutory interest penalties, postage, and the statutory attorney's fees required by law. 16. Plaintiff would derive a benefit from the Court's judgment ordering the Defendant to pay interest, postage, and attorney's fees even if Defendant pays all or some of the disputed benefits before judgment is entered after suit is filed. 17. Plaintiff requests an award of attorney's fees under Florida Statute 627.428, 627.736, and an award of costs under Florida Statutes 92.231 and 57.041. 18. Plaintiff requests a trial by jury on all issues so triable. WHEREFORE, Plaintiff demands judgment for Personal Injury Protection benefits, Medical Payments/Expense Benefits together, and all other benefits required to be paid under the policy of insurance with pre-judgment interest thereon, all interest on any past benefits not timely paid, postage, costs and attorney's fees. DATED this February 5, 2021. JON-114/A ATANDONE, ESQ. Fla. Bar No. 111335 Payas, Payas & Payas LLP 1018 East Robinson Street Orlando, Florida 32801 T: 407.425.7223 / F: 407.425.1254 Primary: Payas16@payaslaw.com Secondary: jandone@payaslaw.com Composite Exhibit A 12/15/2020 https://payaslaw.sendproenterprise.com/Composer/XmlRequest/GetShipLabel?guid=8625cf4a-df7c-48bc-bf87-30f65d8104d3&pagenu... USPS CERTIFIED MAIL _ Payas Payas &Payee III I 1 1 I I 1 1 1I 1 I Dept 16 PIP 1016 1018 E Robinson St Orlando, FL 32801 9407 1149 0238 2570 0257 88 Equity Insurance Company Charles Micheal Davis 4315 Lake Shore Dr, Ste J Waco, TX 7671 0-1 970 Shipper Ref: PIP 1016 Reference 1: PIP 1016 Reference 3: PIP 1016 httos://navaslaw.serwinroanternrise.com/Comnoser/XmIRentiest/GptShinl ahpOni PAYAS•PAYAS•PAYAS•iip A t t o r n e ys A t L a w Armandn Payas Armando R. Payas Carlos E. Payas Joshua A. Andone, Esq. 1018 East Robinson Street Orlando, Florida 32801 T: 407.425.7223 F: 407.425.1254 jandone(imayaslaw.corn December 15, 2020 SENT VIA CERTIFIED MAIL — RETURN RECEIPT REQUESTED Equity Insurance Company Attn: Charles Michael Davis 4315 Lake Shore Drive, Suite J Waco, TX 76710 DEMAND FOR PAYMENT PURSUANT TO FLA. STAT. 4627.736(10) WRITTEN NOTICE OF INTENT TO IMTIATE LITIGATION Name of Medical Provider: Preziosi West-East Orlando Chiropractic Clinic, LLC Insured: Vivian Rodriguez Patient: Jermiah Rodriguez (a minor) Claim/Policy #: D29Y0272-04-0450 DOL: 12/12/2019 Dear Sir/Madam: This is a demand letter under §627.736 Fla. Stat.,and under any applicable policy of insurance. The benefits (personal injury protection and MedPay, if applicable) claimed are now overdue, and for payment of reasonable charges for related and necessary treatment, services, accommodations or supplies to the above-referenced patient. The above-referenced medical provider has not been properly paid. Specifically, this demand is for payment of the amounts listed below for the listed dates of service at the reasonable amount billed, less any payments received by the above-referenced medical provider from said PIP insurer. Please note that if the policy contains MedPay coverage, the amount demanded is at 100% of the reasonable billed amount, less any payments received from said PIP insurer. The following is demanded: - Date(s) of Service: 12/16/2019 — 02/12/2020 - Arnount due at 100%: $1,220.00 o Less any amounts (excluding interest) already paid by insurer o Made payable to the Medical Provider above - Interest on the Amount Due, at the statutory rate, commencing thirty (30) days after the date the bill for services (CMS 1500) was received by the carrier/insurer up to the date payment is made o Made payable to the Medical Provider above - Penalty of 10% of amount due (maximum $250.00), and certified mail/postage cost Orlando • Kissimrnee • Deltona o Made payable to "Payas, Payas & Payas LLP" (Tax ID 20-0044781) If the insurer has information supporting a lesser amount is owed and/or this demand is not payable for any reason, including, but not limited to, deductible, co-payment, exhaustion, §627.736 Fla. Stat., please provide the appropriate explanation/support pursuant to §627.736(4)(b) Fla. Stat. If the insurer has made an unambiguous election in its insurance policy pursuant to Fla. Stat., which permits the insurer to limit payment to 80% of 200% of the allowable amount under the Medical Part B Physician's Fee Schedule and/or the 80% of the maximum reimbursable allowance under workerscompensation, then the amounts demanded herein are subject to those legally permitted amounts. The policy of insurance is in the insurer's possession, and the insured and/or its assignee is unable to determine the specific amount owed without this documentation. If the insurer contends that it has made an election to limit payment as stated, please provide the portion of the policy that purportedly provides for limiting such payment. Please provide a copy of the insurance policy, applicable declarations page, PIP payout log, and copies of all explanation of benefits/reimbursement that have been made on behalf of the above-referenced patient. This request is specifically being made in an attempt to avoid filing an unnecessary lawsuit if the insurer has properly applied the bill(s) to the deductible or if benefits have properly exhausted. We request the insurer to notify us if the policy limits have been reached within fifteen (15) days after reaching said limits as required by §627.736(6)(0. We have enclosed an Assignment of Benefits (AOB) executed by the patient/claimant/insured (or their proper guardian), as well as the requisite itemized statement/CMS 1500/E0B/EOR of what was previously submitted that specifies the exact amounts and dates of service claimed to be due. You are required to notify us of any objection(s) to the legal validity, form, or substance of the AOB within the statutory time limits, else said objection(s) be waived and the Medical Provider will have standing to file and pursue this matter. In the event the insurer/carrier does not fully and completely comply with this demand, it is demanded that sufficient benefits be reserved or escrowed to satisfy this outstanding claim prior to any exhaustion of benefits, pending resolution of any action filed after this demand. We seek to preserve and pursue all rights as provided by law and to minimize or avoid litigation, if possible. Additionally, we request that any reply further denying or otherwise not satisfying this demand to outline the exact reasons why the insurer/carrier denies said demand. Failure to fully and completely comply with this demand letter within the thirty (30) days of receipt by the insurer/carrier will result in suit being filed for all amounts legally due, including applicable costs and attorney's fees. PLEASE GOVERN YOURSELVES ACCORDINGLY. Sincerely, /s/Joshua A. Andone Joshua A. Andone, Esq. Enclosures (as indicated) 12/08/2020 11:54Ah1 FAX la0002/0004 PREZIOSI WEST / EAST ORLANDO CHIROPRACTIC CLINIC, LLC DR. VINCENT PREZIOSI 823 PAUL STREET ORLANDO, FL 32808 IWeb)/ assign from any and alltuitomobile insurance which provide medical benefits or no-fault and interest toPREZIOSI WEST / EAST ORLANDOpolicies benefits,all Benefits, rights, title by reason of accident or illness., I CHIROPRACTIC CLINIC, LIC. As assignee for services knowingly, rendered tmto me both Personal Injury Protection voluntarily and intentionally assigo the rights and benefits of (P,I,P), and Medical my insurance, alsoknown as I understand it is the intention of the Payments policy of insurance to the above provider tto accept this assienment of benefits in lieu of health care provider. rendered and that thisdocurnent demanding payment at the tirne services are will allow the benefits. This is to act as a limited provider to filesuit againstan insurance company for of assignment of my rights and benefits to the extent of the payment the insurance constructedas a delegation of any dutiesunder Assignee's services provided and in no way be said attiOMObileInsurance the conditionsprecedent under the abovereferenced insurance policyby Assignor to Assignee,or a delegation of any policies. ASSIGNMENT OF CAUSE OF ACTION In the event rny insurance fails to pay Assignee the full amount due and owing to toassignee any and all causes of action in tort or contract and Assignee after notice is given, I hereby assien and transfer my favor against such insurance proceeds from such causes of action, that I might have or that company and authorize Assignee tu prosecute said cause of action might exist in I further authorize either in my name or Assignee to compromise, settle or otherwise resolve said claim or cause of action as Assignee's name and they see At. DIRECTION OF PAYMENT Ihereby authorize said insurance company or servicesrendered to attorney to pay directlyto Assignee the amount of this and/or me. I also agreeto in any futurebills for pay a currentnianner any differencebetween insuranceeompany directly the total chargesand the amount toAssignee, I furtheragree to paid by the pay any applicabledeductible or co-payment not covered by my insurance. PIP.LOG REQUEST I hereby authorizerny insurancecompany to release any information requested (hat applicable Florida Statues, Florida ease law, the subject insurance is pertinent to my case to Assignee. Pursuant to the the pip-log, declaration policyand in conjunetion with this essignment I sheet and copy of the insurance hereby requesta copy of accident be provided to policy,which reflectsthe policy limits available at the Assignee. I hereby authorize Assignee to request and receive a tirneof this necessary. copy of my pip-log periodically as they deem to be RESERVATION OF BENEFITS Please be advised that I am hereby placing you on notice that, pursuant to Florida case law, should you deny, portion of or an entire bill submitted on my behalf front this ieduce or fail to pay either a this Is resolved, Assignee, I am requesting that you reserve, or hold aside, the same amount dispute until RELEASE OF INFORMATION I hereby authorize Assignee and/or his office to disclose/release any information concerning my injuries protected by requesting partywith a properly executed medical records release. the Federal HIPAA10 a LIEN further agree that any amount that I owe forservicesperformed shallconstitute lien injuriesand that a on any claim or lawsuit I may have as a result of any settlement,award, juryverdict or insuranceproceeds that I receive or become entitled my injuries. This assignment/lien shall be placed into rny to receiveas Ulresult of my chart and shall constitute actual notice to bills shall be paid first from the rny attorney, or any person, that my medical proceeds of any sttch lawsuit, settlement, award, jury verdict or insurance benefits. 1 further PREZIOSI WEST / EAST ORLANDO CHIROPRACTIC hereby appoint CLINIC, LLC or its designee as my auorney-in-fact to sign my narne and financing statement under the UCC to evidence this lien. file If anyterm of this Assignment the or remainder of this Assignment shall application thereof to any person or circumstances shall be determined invalid or unenforceable the affected thereby, and each term and fullest extent of the law. nAbe provision of this Assignment shall be valid and enforced to the PATI EN DATE: 1/4-ka Y9 ar‘ 35( rn ic6-) qai ri3u,c DOI"- I'll 14)-14;Ol DR.PREZIOSI/ EAST ORL CHIRO STATEMENT 7206 CURRY FORD RD Date: 12/08/2020 ORLANDO, FL 32822 Prior Balances (407) 275-3551 Insurance .00 Patient .00 JEREMIAH Total .00 (MINOR) RODRIGUEZ 729 AVONDALE AVE #2 ORLANDO, FL 32805 Provider:VINCENT PREZIOSI Date Description Units Charges Transfers Insurance Paid Patient PaidAdjustments Unpaid 12/16/2019 99203 COMPLETE INITIAL EXAM 1 200.00 .00 .00 .00 .00 12/16/2019 97139 200.00 LASER/ CLUSTER 1 40.00 .00 .00 .00 .00 40.00 12/16/2019 97039 UNATTENDED ULTRASOUND 1 40.00 .00 .00 .00 .00 12/16/2019 97010 HOT PACK IN OFFICE 40.00 1 40.00 .00 .00 .00 .00 40.00 12/18/2019 97139 LASER/ CLUSTER 1 40.00 .00 .00 .00 .00 12/18/2019 97039 40.00 UNATTENDED ULTRASOUND I 40.00 .00 .00 .00 .00 40.00 12/18/2019 98941 MANIPULATION OF 3-4 BODY P 1 100.00 .00 .00 .00 .00 100.00 01/15/2020 97139 LASER/ CLUSTER 1 40.00 .00 .00 .00 .00 01/15/2020 97039 40.00 UNATTENDED ULTRASOUND 1 40.00 .00 .00 .00 .00 40.00 01/15/2020 98941 MANIPULATION OF 3-4 BODY P 1 100.00 .00 .00 .00 .00 100.00 01/31/2020 97139 LASER/ CLUSTER 1 40.00 .00 .00 .00 .00 40.00 01/31/2020 97039 UNATTENDED ULTRASOUND 1 40.00 .00 .00 .00 .00 01/31/2020 98941 40.00 MANIPULATION OF 3-4 BODY P 1 100.00 .00 .00 .00 .00 100.00 02/07/2020 98941 MANIPULATION OF 3-4 BODY P 1 100.00 .00 .00 .00 .00 02/07/2020 97039 100.00 HYDROBED THERAPY 1 40.00 .00 .00 .00 .00 40.00 02/12/2020 97039 UNATTENDED ULTRASOUND 1 40.00 .00 .00 .00 .00 02/12/2020 97139 40.00 LASER/ CLUSTER 1 40.00 .00 .00 .00 .00 02/12/2020 G0237 HOT PACK IN OFFICE 40.00 1 40.00 .00 .00 .00 .00 02/12/2020 98941 40.00 MANIPULATION OF 3-4 BODY P 1 100.00 .00 .00 .00 .00 100.00 Totals: 1,220.00 .00 .00 .00 .00 1,220.00 Current Insurance Balance 1,220.00 Patient Balance .00 Total Balance 1,220.00 Page 1 of 2