Preview
Filing #85416026 E-Filed 02/25/2019 10:33:59 AM
IN THE CIRCUIT COURT OF THE NINTH JUDICIAL CIRCUIT
IN AND FOR ORANGE COUNTY, FLORIDA
CIVIL DIVISION
CASE NO.: 2017-CA-007422-0
JEAN DUME
Plaintiff,
Vv.
JONATHAN BURGIEL
Defendant.
/
NOTICE OF PRODUCTION FROM NON-PARTY
YOU ARE NOTIFIED that after ten (10) days from the date of service of this Notice, if service is
by delivery, or fifteen (15) days from the date of service, if service is by mail, and if no objection
is received from any party, the undersigned will issue or apply to the Clerk of this Court for
issuance of the attached Subpoena directed to the following persons and entities who are not
parties as follows:
PART: 18
Connecticut General Life Insurance Company/Cigna Health and Life Insurance (Insurance -
Health)
900 Cottage Grove Road
B6LPA
Hartford, CT 06152
to produce the items listed at the time and place specified in said subpoena.
CERTIFICATE OF SERVICE
THEREBY CERTIFY that on Fe eS 5 atrue and correct copy of the forgoing
Defendant’s Notice of Production of Documents from Non Party was e-mailed to:
Jeremy L. Hogan, Esquire
Hogan & Hogan, P.A.
906 E Michigan St.
Orlando, FL 32806
; jhogan@hoganicgal.com
jhogan@hoganlegal.com;
scunningham@hoganlegal.com
rcho@hoganlegal.com
9940
Micha it, r, Esquire
Florida Bar Number: 0717843
The Law Office of Deborah N. Hartwell
1000 Legion Place, Suite 850
Orlando, FL 32801
TELEPHONE: 407-648-8236
orlandogeico@geico.com
9940
IN THE CIRCUIT COURT OF THE NINTH JUDICIAL CIRCUIT
IN AND FOR ORANGE COUNTY, FLORIDA
CIVIL DIVISION
‘CASE NO.: 2017-CA-007422-0
JEAN DUME
Plaintiff(s),
VS.
JONATHAN BURGIEL
Defendant(s).
/
SUBPOENA. DUCES ‘TECUM FOR RECORDS WITHOUT DEPOSITION /
THE STATE OF FLORIDA
Records Custodian of Connecticut General Life Insurance Company/Cigna Health and Life
Insurance
900 Cottage Grove Road
B6LPA
Hartford, CT 06152
YOU ARE HEREBY COMMANDED TO APPEAR at MDA Records Retrieval, Inc., 2907 W.
Bay to Bay Blvd, Ste 218, Tampa, FL 33629 within 10 days from the date of service, and have
with you at that time and place the-following:
Any and ali health insurance claim records, including but not limited to: policies, policy
applications, underwriting information, claim forms, medical reports and hospital records
including the entire hospital chart, notes, patient information sheets, bills, lab reports, nursing
reports, x-rays, MRI's, CT scans, radiographic materials and radiographic reports, work sheets,
insurance forms, and correspondence in your possession, pertaining to: JEAN DUME.
if your charges for complying with this subpoena exceed $200.00, before co) leas:
fax a detailed list of your complete inventory of films and/or for both complete and abstract
ecords on this plaintiff to the attention of MDA Records Retrieval, Inc. at 813-515-4915,
listing additionally the dates taken and the costs involved in obtaining these copies.
Health Insurance Portabili and Accountabili Act — (HIPAA
Compliance Certification
I hereby certify that written notice of the intent to obtain medical records has been provided to
the individual whose documents are being sought, that the notice included sufficient information
about the litigation or proceeding to permit the individual to raise any objection to the production
9940.018 Y
of the requested documents, and that the time to raise an objection has elapsed and that no
objection was made or filed.
These items will be inspected and may be copied at that time. You will not be required to
surrender the origina! items. YOU MAY COMPLY WITH THIS SUBPOENA BY MAILING
OR DELIVERING A COPY OF THIS SUBPOENA TOGETHER WITH LEGIBLE
COPIES OF THE ITEMS TO BE PRODUCED TO THE ADDRESS WHICH APPEARS
IN PARAGRAPH 1 OF THIS SUBPOENA AND THEREBY ELIMINATE THE
NECESSITY OF YOUR APPEARANCE AT THE TIME AND PLACE SPECIFIED
ABOVE. You may condition the preparation of the copies upon the payment in advance of the
reasonable cost of preparation: You have the right to object to the production pursuant to this
Subpoena at any time before the production by giving written notice to the attorney whose name
appears on this Subpoena. THIS WILL NOT BE A DEPOSITION. NO TESTIMONY
WILL BE TAKEN.
IF YOU FAIL TO:
1 Appear as specified;
2. Furnish the records instead of appearing as provided above; or
3. Object to this Subpoena,
you may be in contempt of Court. You are subpoenaed by the attorney whose name appears on
this Subpoena and unless excused from this Subpoena by the attorney or the Court, you shall
respond to this Subpoena as directed.
DATED ON » 2019,
Micha: it ir, Esquire
Florida Bar Number: 0717843
The Law Office of Deborah N. Hartwell
1000 Legion Place, Suite 850
Orlando, FL, 32801
Email: orlandogeico@geico.com
*PLEASE DIRECT ALL CORRESPONDENCE TO INCLUDE CERTIFICATE OF NO
RECORDS TO MDA RECORDS RETRIEVAL, INC., 2907 W. Bay to Bay Blvd. Ste 218,
‘Tampa, FL 33629. PLEASE CALL 813-209-0029 IF YOU HAVE ANY QUESTIONS.*
9940.018 Y
SCHEDULE A
ADDENDUM TO SUBPOENA UNDER RULE 2.516 FOR PRODUCTION
OF DOCUMENTS WITHOUT DEPOSITION
Due to new privacy rules, the Social Security Number and Date of Birth were not included in the
subpoena. Below is the plaintiff's name and vital information for compliance of the subpoena:
JEAN DUME
9940.018 Y
Provider’s Name: Connecticut General Life Insurance Company/Cigna Health and
Life Insurance
Provider’s. Phone Number: 1-800-997-1654
Patient’s Name: JEAN DUME
AFFIDAVIT OF CUSTODIAN OF RECORDS
1, the undersigned, being the -duly authorized Custodian of Records or other qualified witness, and having the
authority to certify the authenticity of the records declare the following:
The records:
1 were made-at or near the time of ‘the occurrence of the matters set forth by, or from information transmitted
by, a person having knowledge of those matters;
were kept on the course of the regularly conducted activity ; and
were made as a regular practice in the course of the regularly conducted activity.
A) CERTIFICATION OF RECORDS:
All records called for in the subpoena or authorizations are in my custody and have been released for
documentation.
All records maintained in accordance with our document retention policy and pursuant to state and/or
federal statutes and regulations are provided and total pages.
B) CERTIFICATION OF NO RECORDS:
All records for the time period in question have been destroyed in accordance with our document retention
policy.
A thorough search has been performed and no such records were found in response to your request.
I declare under penalty of perjury under the laws of the State of Florida that the foregoing is true and
correct,
Executed on the day of ,2019.
Connecticut General Life Insurance Company/Cigna Health and Life Insurance
Signature of Records Custodian
900 Cottage Grove Road
B6LPA
Hartford, CT 06152 Print Name
NOTARY SECTION
Subscribed and sworn to before me this day of 2019.
Seal
Notary Public:
Please Print
9940.018 Y
Preview
Filing #85416026 E-Filed 02/25/2019 10:33:59 AM IN THE CIRCUIT COURT OF THE NINTH JUDICIAL CIRCUIT IN AND FOR ORANGE COUNTY, FLORIDA CIVIL DIVISION CASE NO.: 2017-CA-007422-0 JEAN DUME Plaintiff, Vv. JONATHAN BURGIEL Defendant. / NOTICE OF PRODUCTION FROM NON-PARTY YOU ARE NOTIFIED that after ten (10) days from the date of service of this Notice, if service is by delivery, or fifteen (15) days from the date of service, if service is by mail, and if no objection is received from any party, the undersigned will issue or apply to the Clerk of this Court for issuance of the attached Subpoena directed to the following persons and entities who are not parties as follows: PART: 18 Connecticut General Life Insurance Company/Cigna Health and Life Insurance (Insurance - Health) 900 Cottage Grove Road B6LPA Hartford, CT 06152 to produce the items listed at the time and place specified in said subpoena. CERTIFICATE OF SERVICE THEREBY CERTIFY that on Fe eS 5 atrue and correct copy of the forgoing Defendant’s Notice of Production of Documents from Non Party was e-mailed to: Jeremy L. Hogan, Esquire Hogan & Hogan, P.A. 906 E Michigan St. Orlando, FL 32806 ; jhogan@hoganicgal.com jhogan@hoganlegal.com; scunningham@hoganlegal.com rcho@hoganlegal.com 9940 Micha it, r, Esquire Florida Bar Number: 0717843 The Law Office of Deborah N. Hartwell 1000 Legion Place, Suite 850 Orlando, FL 32801 TELEPHONE: 407-648-8236 orlandogeico@geico.com 9940 IN THE CIRCUIT COURT OF THE NINTH JUDICIAL CIRCUIT IN AND FOR ORANGE COUNTY, FLORIDA CIVIL DIVISION ‘CASE NO.: 2017-CA-007422-0 JEAN DUME Plaintiff(s), VS. JONATHAN BURGIEL Defendant(s). / SUBPOENA. DUCES ‘TECUM FOR RECORDS WITHOUT DEPOSITION / THE STATE OF FLORIDA Records Custodian of Connecticut General Life Insurance Company/Cigna Health and Life Insurance 900 Cottage Grove Road B6LPA Hartford, CT 06152 YOU ARE HEREBY COMMANDED TO APPEAR at MDA Records Retrieval, Inc., 2907 W. Bay to Bay Blvd, Ste 218, Tampa, FL 33629 within 10 days from the date of service, and have with you at that time and place the-following: Any and ali health insurance claim records, including but not limited to: policies, policy applications, underwriting information, claim forms, medical reports and hospital records including the entire hospital chart, notes, patient information sheets, bills, lab reports, nursing reports, x-rays, MRI's, CT scans, radiographic materials and radiographic reports, work sheets, insurance forms, and correspondence in your possession, pertaining to: JEAN DUME. if your charges for complying with this subpoena exceed $200.00, before co) leas: fax a detailed list of your complete inventory of films and/or for both complete and abstract ecords on this plaintiff to the attention of MDA Records Retrieval, Inc. at 813-515-4915, listing additionally the dates taken and the costs involved in obtaining these copies. Health Insurance Portabili and Accountabili Act — (HIPAA Compliance Certification I hereby certify that written notice of the intent to obtain medical records has been provided to the individual whose documents are being sought, that the notice included sufficient information about the litigation or proceeding to permit the individual to raise any objection to the production 9940.018 Y of the requested documents, and that the time to raise an objection has elapsed and that no objection was made or filed. These items will be inspected and may be copied at that time. You will not be required to surrender the origina! items. YOU MAY COMPLY WITH THIS SUBPOENA BY MAILING OR DELIVERING A COPY OF THIS SUBPOENA TOGETHER WITH LEGIBLE COPIES OF THE ITEMS TO BE PRODUCED TO THE ADDRESS WHICH APPEARS IN PARAGRAPH 1 OF THIS SUBPOENA AND THEREBY ELIMINATE THE NECESSITY OF YOUR APPEARANCE AT THE TIME AND PLACE SPECIFIED ABOVE. You may condition the preparation of the copies upon the payment in advance of the reasonable cost of preparation: You have the right to object to the production pursuant to this Subpoena at any time before the production by giving written notice to the attorney whose name appears on this Subpoena. THIS WILL NOT BE A DEPOSITION. NO TESTIMONY WILL BE TAKEN. IF YOU FAIL TO: 1 Appear as specified; 2. Furnish the records instead of appearing as provided above; or 3. Object to this Subpoena, you may be in contempt of Court. You are subpoenaed by the attorney whose name appears on this Subpoena and unless excused from this Subpoena by the attorney or the Court, you shall respond to this Subpoena as directed. DATED ON » 2019, Micha: it ir, Esquire Florida Bar Number: 0717843 The Law Office of Deborah N. Hartwell 1000 Legion Place, Suite 850 Orlando, FL, 32801 Email: orlandogeico@geico.com *PLEASE DIRECT ALL CORRESPONDENCE TO INCLUDE CERTIFICATE OF NO RECORDS TO MDA RECORDS RETRIEVAL, INC., 2907 W. Bay to Bay Blvd. Ste 218, ‘Tampa, FL 33629. PLEASE CALL 813-209-0029 IF YOU HAVE ANY QUESTIONS.* 9940.018 Y SCHEDULE A ADDENDUM TO SUBPOENA UNDER RULE 2.516 FOR PRODUCTION OF DOCUMENTS WITHOUT DEPOSITION Due to new privacy rules, the Social Security Number and Date of Birth were not included in the subpoena. Below is the plaintiff's name and vital information for compliance of the subpoena: JEAN DUME 9940.018 Y Provider’s Name: Connecticut General Life Insurance Company/Cigna Health and Life Insurance Provider’s. Phone Number: 1-800-997-1654 Patient’s Name: JEAN DUME AFFIDAVIT OF CUSTODIAN OF RECORDS 1, the undersigned, being the -duly authorized Custodian of Records or other qualified witness, and having the authority to certify the authenticity of the records declare the following: The records: 1 were made-at or near the time of ‘the occurrence of the matters set forth by, or from information transmitted by, a person having knowledge of those matters; were kept on the course of the regularly conducted activity ; and were made as a regular practice in the course of the regularly conducted activity. A) CERTIFICATION OF RECORDS: All records called for in the subpoena or authorizations are in my custody and have been released for documentation. All records maintained in accordance with our document retention policy and pursuant to state and/or federal statutes and regulations are provided and total pages. B) CERTIFICATION OF NO RECORDS: All records for the time period in question have been destroyed in accordance with our document retention policy. A thorough search has been performed and no such records were found in response to your request. I declare under penalty of perjury under the laws of the State of Florida that the foregoing is true and correct, Executed on the day of ,2019. Connecticut General Life Insurance Company/Cigna Health and Life Insurance Signature of Records Custodian 900 Cottage Grove Road B6LPA Hartford, CT 06152 Print Name NOTARY SECTION Subscribed and sworn to before me this day of 2019. Seal Notary Public: Please Print 9940.018 Y