Party Notice: DUME, JEAN vs. BURGIEL, JONATHAN, SRet al.

On August 11, 2017 a Party Notice was filed involving a dispute between Jean Dume, and Jonathan Burgiel Jr, Jonathan Burgiel Sr, in the District Court of Orange County.

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Filing #64806727 E-Filed 11/30/2017 03:55:31 PM

IN THE CIRCUIT COURT OF THE NINTH JUDICIAL CIRCUIT
IN AND FOR ORANGE COUNTY, FLORIDA
CIVIL DIVISION
CASE NO.: 2017-CA-007422-O0

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: 1
Bigley and Associates (Medical/Billing/Radiology)
1512 W. Colonial Dr.
Orlando, FL 32804

PART: 2
Ability Health Services Millenia / Vineland Clinic (Medical/Billing/Radiology)
4501 Vineland Road, Suite 103
Orlando, FL 32811

PART: 3
Family Practice & Rehab, Inc. (Medical/Billing)
2338 W. Oak Ridge Road
Orlando, FL 32809

PART: 4
Ability Sports Medicine and Rehabilitation (Medical/Billing/Radiology)
11543 Lake Underhill Road
Orlando, FL 32825

9940
PART: 5
Pan Am Diagnostic of Orlando (Medical/Billing/Radiology)
6421 Milner Blvd. #1
Orlando, FL 32809

PART: 6
Underwood Surgery Center (Medical/Billing)
110 W Underwood St, Suite B
Orlando, FL. 32806

PART: 7
Premier Orthopedics of Orlando (Medical/Billing)
1512 W. Colonial Drive
Orlando, FL 32804

PART: 8
Mid Florida Imaging (Medical/Billing/Radiology)
1150 S. Semoran Bivd., Suite F
Orlando, FL 32807

PART: 9
Sacowi Medical Clinic (Medical/Billing/Radiology)
365 Wekiva Springs Rd., Ste. 231
Longwood, FL 32779

PART: 10
Florida Department of Financial Services (Workers Compensation)
Division of Workers' Compensation
200 E. Gaines Street
Tallahassee, FL 32314-6100

PART: 11
Geico General Insurance Company (Insurance - PIP)
3535 W. Pipkin Road
Lakeland, FL 33811

to produce the items listed at the time and place specified in said subpoena.

9940
CERTIED (CATE OF SERVICE
fit fp
I HEREBY CERTIFY that on ! | if a true 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.
jhogan@hoganlegal.com
scunningham@hoganlegal.com
rcho@hoganlegal.com

NY
Angel
Pe
arre, Esquire
Florida Bar Number: 11591
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 Bigley and Associates
1512 W. Colonial Dr.
Orlando, FL 32804

YOU ARE HEREBY COMMANDED TO APPEAR at MDA Records Retrieval, Inc., 2907 W.
Bay to Bay Blvd, Ste 218, Tampa, FL 33629 within 15 days from the date of service, and have
with you at that time and place the following:

Any and all medical records, including patient information and insurance forms, prescription logs
or cards, office records, written memoranda, correspondence, copies of MRI films, x-rays, x-ray
reports, and any other records pertaining to the care and treatment at any time of JEAN DUME.
Any and all, billing ledgers which includes whether the bill has been paid and, if so, by whom, to
include individual invoices/bills and letters of protection. **Please contact attorney's office
regarding reproduction costs for x-rays.

Do not staple the records.

If your charges for complying with this subpoena exceed $200.00, before copying, pleas:
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 Portability and Accountability 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

9940.001 N
about the litigation or proceeding to permit the individual to raise any objection to the production
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 original 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 » 2017.

/s/ Angel Lamarre
Angel J, Lamarre, Esquire
Florida Bar Number: 11591
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.*

9940,001 N
ATTENTION BILLING DEPARTMENT:

PLEASE COMPLETE THIS QUESTIONAIRE AND RETURN
SAME ALONG WITH YOUR RESPONSE TO THIS SUBPOENA

Bigley and Associates
PATIENT NAME; JEAN DUME

Total Charges

Less Write-Offs / Reductions $
Less PIP Payments $
Less MedPay Payments $
Less Health Insurance Payments $
Less Medicare and/or Medicaid $
Payments
Less Patient Payments $
Less Any Other Payments

BALANCE DUE

° Is there a Letter of Protection "LOP" for this account? Yes No

. Has this account been sent to collections? Yes No

9940.001 N
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 Ability Health Services Millenia / Vineland Clinic
4501 Vineland Road, Suite 103
Orlando, FL 32811

YOU ARE HEREBY COMMANDED TO APPEAR at MDA Records Retrieval, Inc,, 2907 W.
Bay to Bay Blvd, Ste 218, Tampa, FL 33629 within 15 days from the date of service, and have
with you at that time and place the following:

Any and all medical records, including patient information and insurance forms, prescription logs
or cards, office records, written memoranda, correspondence, copies of MRI films, x-rays, x-ray
yeports, and any other records pertaining to the care and treatment at any time of JEAN DUME.
Any and all, billing ledgers which includes whether the bill has been paid and, if so, by whom, to
include individual invoices/bills and letters of protection. **Please contact attorney's office
regarding reproduction costs for x-rays.

Do not staple the records.

if your charges for complying with this subpoena exceed $200.00, before copying, pleas
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 Portabilit and Accountabilit Act — (HIPAA
Compliance Certification

| 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

9940,002 N
about the litigation or proceeding to permit the individual to raise any objection to the production
of the requested documents, and that the time to raise an objection has elapsed and that no
objection was made or filed.

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 » 2017.

fs/ Angel Lamarre
Angel J. Lamarre, Esquire
Florida Bar Number: 11591
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.*

9940.002 N
ATTENTION BILLING DEPARTMENT:

PLEASE COMPLETE THIS QUESTIONAIRE AND RETURN
SAME ALONG WITH YOUR RESPONSE TO THIS SUBPOENA

Ability Health Services Millenia / Vineland Clini
PATIENT NAME: JEAN DUME

Total Charges

Less Write-Offs / Reductions $
Less PIP Payments $
Less MedPay Payments $
Less Health Insurance Payments $
Less Medicare and/or Medicaid $
Payments
Less Patient Payments

Less Any Other Payments $
BALANCE DUE

. 1s there a Letter of Protection "LOP" for this account? Yes No

° Has this account been sent to collections? Yes No

9940.002 N
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 Family Practice & Rehab, Inc.
2338 W. Oak Ridge Road
Orlando, FL 32809

Any and all medical records, including patient information and insurance forms, letters of
protection, prescription logs or cards, office records, written memoranda, correspondence, copies
of MRI reports, x-ray reports, and any other records pertaining to the care and treatment at any
time of JEAN DUME. Please include a billing ledger which includes whether the bill has been
paid and, if so, by whom, but do not include individual invoices and/or bills.

Do not staple the records.

If your charges for complying with this subpoena exceed $200.00, before copying, pleas
fax a detailed list of your complete inventory of films and/or for both complete and abstract
records 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 Accountability Act — PAA
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

9940,003 N
of the requested documents, and that the time to raise an objection has elapsed and that no
objection was made or filed.

DATED ON » 2017.

/s/ Angel Lamarve
Angel J. Lamarre, Esquire
Florida Bar Number; 11591
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 IPF YOU HAVE ANY QUESTIONS.*

9940,003 N
ATTENTION BILLING DEPARTMENT:

PLEASE COMPLETE THIS QUESTIONAIRE AND RETURN
SAME ALONG WITH YOUR RESPONSE TO THIS SUBPOENA

Family Practice & Rehab, Inc.
PATIENT NAME: JEAN DUME

Total Charges

Less Write-Offs / Reductions $
Less PIP Payments $
Less MedPay Payments $
Less Health Insurance Payments $
Less Medicare and/or Medicaid $
Payments
Less Patient Payments $
Less Any Other Payments $
BALANCE DUE

. Is there a Letter of Protection "LOP" for this account? Yes No

e Has this account been sent to collections? Yes No

9940.003 N
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 Ability Sports Medicine and Rehabilitation
11543 Lake Underhill Road
Orlando, FL 32825

Any and all medical records, including patient information and insurance forms, prescription logs
or cards, office records, written memoranda, correspondence, copies of MRI films, x-rays, x-ray
reports, and any other records pertaining to the care and treatment at any time of JEAN DUME.
Any and all, billing ledgers which includes whether the bill has been paid and, if'so, by whom, to
include individual invoices/bills and letters of protection. **Please contact attorney's office
regarding reproduction costs for x-rays.

Do not staple the records,

If your charges for complying with this subpoena exceed $200.00, before copyii 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

9940.004 N
about the litigation or proceeding to permit the individual to raise any objection to the production
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 original 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.

DATED ON , 2017.

/s/ Angel Lamarri
Angel J. Lamarre, Esquire
Florida Bar Number: 11591
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.*

9940.004 N
ATTENTION BILLING DEPARTMENT:

PLEASE COMPLETE THIS QUESTIONAIRE AND RETURN
SAME ALONG WITH YOUR RESPONSE TO THIS SUBPOENA

Ability Sports Medicine and Rehabilitation
PATIENT NAME: JEAN DUME

Total Charges

Less Write-Offs / Reductions $
Less PIP Payments

Less MedPay Payments $
Less Health Insurance Payments $
Less Medicare and/or Medicaid $
Payments
Less Patient Payments $
Less Any Other Payments $
BALANCE DUE

e Is there a Letter of Protection "LOP" for this account? Yes No

. Has this account been sent to collections? Yes No

9940.004 N
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
Plaintiffs),

Vs.

JONATHAN BURGIEL
Defendant(s).
/

SUBPOENA DUCES TECUM FOR RECORDS WITHOUT DEPOSITION

THE STATE OF FLORIDA

Records Custodian of Pan Am Diagnostic of Orlando
6421 Milner Blvd. #1
Orlando, FL 32809

Do not staple the records.

If your charges for complying with this subpoena exceed $200.00, before copying, pleas:
fax a detailed list of your complete inventory of films and/or for both complete and abstract
records 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 Portabilit and Accountabili Act— TPAA’
Compliance Certification

T 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

9940.005 N
about the litigation or proceeding to permit the individual to raise any objection to the production
of the requested documents, and that the time to raise an objection has elapsed and that no
objection was made or filed.

DATED ON. >» 2017.

/s/ Angel Lamarre
Angel J. Lamarre, Esquire
Florida Bar Number: 11591
The Law Office of Deborah N. Hartwell
1000 Legion Place, Suite 850
Orlando, FL, 32801
Email: orlandogeico@geico.com

9940.005 N
ATTENTION BILLING DEPARTMENT:

PLEASE COMPLETE THIS QUESTIONAIRE AND RETURN
SAME ALONG WITH YOUR RESPONSE TO THIS SUBPOENA

Pan Am Diagnostic of Orlando
PATIENT NAME: JEAN DUME

Total Charges

e Is there a Letter of Protection "LOP" for this account? Yes No

. Has this account been sent to collections? Yes No

9940.005 N
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 Underwood Surgery Center
110 W Underwood St, Suite B
Orlando, FL 32806

Do not staple the records.

If your charges for complying with this subpoena exceed $200.00, before copying, pleas:
fax a detailed list of your complete inventory of films and/or for both complete and abstract
records on this plaintiff to the attention of MDA Records Retrieval, Inc, at 813-515-4915,
listing additionally the dates taken and the costs involyed in obtaining these copies.

Health Insurance Portabili and Accountabilit Act — IPAA)
Compliance Certification

IT 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

9940.006 N
of the requested documents, and that the time to raise an objection has elapsed and that no
objection was made or filed.

DATED ON 2017.

/s/ Angel Lamarr
Angel J. Lamarre, Esquire
Florida Bar Number: 11591
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.*

9940.006 N
ATTENTION BILLING DEPARTMENT:

PLEASE COMPLETE THIS QUESTIONAIRE AND RETURN
SAME ALONG WITH YOUR RESPONSE TO THIS SUBPOENA

Underwood Surgery Cente
PATIENT NAME: JEAN DUME

Total Charges

Less Write-Offs / Reductions $
Less PIP Payments $
Less MedPay Payments $
Less Health Insurance Payments
Less Medicare and/or Medicaid $
Payments
Less Patient Payments $
Less Any Other Payments $
BALANCE DUE

. Is there a Letter of Protection "LOP" for this account? Yes No

° Has this account been sent to collections? Yes No

9940.006 N
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 Premier Orthopedics of Orlando
1512 W. Colonial Drive
Orlando, FL 32804

Any and all medical records, including patient information and insurance forms, letters of
protection, prescription logs or cards, office records, written memoranda, correspondence, copies
of MRI reports, x-ray reports, and any other records pertaining to the care and treatment at any
time of JEAN DUME. Please include a billing ledger which includes whether the bill has been
paid and, ifso, by whom, but do not include individual invoices and/or biils.

Do not staple the records.

It your charges for complying with this subpoena exceed $200.00, before copying, pleas
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

9940,007 N
of the requested documents, and that the time to raise an objection has elapsed and that no
objection was made or filed.

IF YOU FAIL TO:
1 Appeat 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 appeats 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 52017.

/s/ Angel Lamarre
Angel J. Lamarre, Esquire
Florida Bar Number: 11591
The Law Office of Deborah N. Hartwell
1000 Legion Place, Suite 850
Orlando, FL, 32801
Email: orlandogeico@geico.com

9940,007 N
ATTENTION BILLING DEPARTMENT:

PLEASE COMPLETE THIS QUESTIONAIRE AND RETURN
SAME ALONG WITH YOUR RESPONSE TO THIS SUBPOENA

Premier Orthopedics of Orlando
PATIENT NAME: JEAN DUME

Total Charges

Less Write-Offs / Reductions $
Less PIP Payments $
Less MedPay Payments $
Less Health Insurance Payments “$
Less Medicare and/or Medicaid $
Payments
Less Patient Payments $
Less Any Other Payments $
BALANCE DUE

. Is there a Letter of Protection "LOP" for this account? Yes No

. Has this account been sent to collections? Yes No

9940,007 N
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 Mid Florida Imaging
1156 S. Semoran Blvd., Suite F
Orlando, FL 32807

Do not staple the records.

If your charges for complying with this subpoena exceed $200.00, before copying, pleas
fax a detailed list of your complete inventory of films and/or for both complete and abstract
records 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 Portability and Accountability Act — (HIPAA)
Compliance Certification

T 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

9940.008 N
about the litigation or proceeding to permit the individual to raise any objection to the production
of the requested documents, and that the time to raise an objection has elapsed and that no
objection was made or filed.

DATED ON, » 2017.

/s/ Angel Lamarre
Angel J. Lamarre, Esquire
Florida Bar Number: 11591
The Law Office of Deborah N. Hartwell
1000 Legion Place, Suite 850
Orlando, FL, 32801
Email: orlandogeico@geico.com

9940.008 N
ATTENTION BILLING DEPARTMENT:

PLEASE COMPLETE THIS QUESTIONAIRE AND RETURN
SAME ALONG WITH YOUR RESPONSE TO THIS SUBPOENA

Mid Florida Imaging
PATIENT NAME: JEAN DUME

Total Charges

Less Write-Offs / Reductions $
Less PIP Payments $
Less MedPay Payments $
Less Health Insurance Payments $
Less Medicare and/or Medicaid $
Payments
Less Patient Payments

Less Any Other Payments $
BALANCE DUE

e Is there a Letter of Protection "LOP" for this account? Yes No

. Has this account been sent to collections? Yes No

9940.008 N
IN THE CIRCUIT COURT OF THE NINTH JUDICIAL CIRCUIT
IN AND FOR ORANGE COUNTY, FLORIDA
CIVIL DIVISION
CASE NO.: 2017-CA-007422-O

JEAN DUME
Plaintiff(s),

vs.

JONATHAN BURGIEL
Defendant(s).
/

SUBPOENA DUCES TECUM FOR RECORDS WITHOUT DEPOSITION

THE STATE OF FLORIDA

Records Custodian of Sacowi Medical Clinic
365 Wekiva Springs Rd., Ste. 231
Longwood, FL 32779

Any and all medical records, including patient information and insurance forms, prescription logs
or cards, office records, written memoranda, correspondence, copies of MRI films, x-rays, x-ray
reports, and any other records pertaining to the care and treatment at any time of JEAN DUME.
Any and all, billing ledgers which includes whether the bill has been paid and, ifso, by whom, to
include individual invoices/bills and letters of protection, **Please contact attorney's office
regarding reproduction costs for x-rays.

Do not staple the records.

If your charges for complying with this subpoena exceed $200.00, before copying, please
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 Portability and Accountability 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

9940.009 N
about the litigation or proceeding to permit the individual to raise any objection to the production
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 original 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.

DATED ON » 2017.

/si Angel Lamar:
Angel J. Lamarre, Esquire
Florida Bar Number: 11591
The Law Office of Deborah N. Hartwell
1000 Legion Place, Suite 850
Orlando, FL, 32801
Email: orlandogeico@geico.com

9940.009 N
ATTENTION BILLING DEPARTMENT:

PLEASE COMPLETE THIS QUESTIONAIRE AND RETURN
SAME ALONG WITH YOUR RESPONSE TO THIS SUBPOENA

Sacowi Medical Clinic
PATIENT NAME: JEAN DUME

Total Charges

e Is there a Letter of Protection "LOP" for this account? Yes No

e Has this account been sent to collections? Yes No

9940.009 N
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 Florida Department of Financial Services
Division of Workers' Compensation
200 E. Gaines Street
Tallahassee, FL 32314-6100

The worker's compensation file including, but not limited to, all medical records, payment of
medical expenses, any independent medical examinations, all notices of injury by the Plaintiff in
the past five (5) years, worker's compensation payout records or summaries, x-rays, or any other
radiological studies, copies of any depositions or statements in the worker's compensation case
and any other records relating to the claim made by the Plaintiff for injuries or lost wages
concerning JEAN DUME.

If your charges for complying with this subpoena exceed $200.00, before copying, pleas
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 Portability and Accountability Act — (HIPAA)
Compliance Certification

9940.010 N
of the requested documents, and that the time to raise an objection has elapsed and that no
objection was made or filed.

Case Info

Judge

Kevin B. Weiss Track Judge’s New Case

Case No.

(Subscribe to View)

Document Filed Date

November 30, 2017

Case Filing Date

August 11, 2017

County

Status

Closed

Parties

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