Preview
Filing # 98933820 E-Filed 11/15/2019 10:14:19 AM
IN THE CIRCUIT COURT OF THE NINTH JUDICIAL
CIRCUIT IN AND FOR ORANGE COUNTY, FLORIDA
CASE NO. 2017-CA-004395-0
DIV: 35
BRENTLEY M. HUXTABLE,
PLAINTIFF,
V.
CARLOS E. RESUMIL,
DEFENDANT.
/
DEFENDANT'S FIRST REQUEST TO PRODUCE TO PLAINTIFF
Defendant, CARLOS E. RESUMIL, pursuant to Florida Rule of Civil Procedure 1.350,
hereby requests Plaintiff, BRENTLEY M. HUXTABLE, to produce all of the following items
within the Plaintiff s custody or control, within thirty (30) days after the service of this Request,
to the undersigned attorneys:
1. Copies of any and all medical records, hospital records, emergency room records, and
records from any health care provider pertaining to the treatment of Plaintiff(s) for any
injuries sustained in the within incident.
2. Copies of any and all medical records, hospital records, emergency room records and
records from any health care provider pertaining to the treatment of Plaintiff(s) for any
reason in the five (5) years prior to the within incident.
3. Copies of any and all medical records, hospital records, emergency room records and
records from any health care provider pertaining to the treatment of Plaintiff(s) for any
reason since the within incident.
4. Copies of any and all Radiology films, X-rays, MRI scans, CT scans, from any health
care provider pertaining to the treatment of Plaintiff, within seven (7) years prior to the
alleged incident and to present date, that pertains to any body part for which the plaintiff
is alleging was injured in the incident described in the Complaint.
5. Copies of any and all medical bills and/or statements for services rendered, paid or
unpaid, as a result of the within incident, including any bills for drugs or other related
expenses.
6. Copies of any and all bills, statements or receipts relating to any non-medical expenses
claimed as damages in this lawsuit that have not been produced in response to any of the
preceding paragraphs.
7. Copies of any and all medical reports, hospital reports, emergency room reports,
consultations, and reports from any health care provider pertaining to the treatment of
Plaintiff(s) for any injuries sustained in the within incident.
8. Copies of any and allbilling statements and/or detailed call logs from the date of the
accident, limited to one hour before the accident and one hour after the subject
accident., that is the subject of this lawsuit for all cellular phone/two way radios, that the
Plaintiff owned and/or had possession of and/or otherwise used on the date of the subject
accident.
9. Any and all incident/accident reports regarding the subject accident.
10. Signed authorization, the original of which is attached hereto, requesting
medical/psychological/psychiatric information of Plaintiff.
11. Signed authorization, the original of which is attached hereto, requesting
Disability Benefit information of Plaintiff if Plaintiff has ever applied for and/or received
Disability Benefits.
12. Signed authorization, the original of which is attached hereto, requesting
Earnings Information of Plaintiff.
13. Signed authorization, the original of which is attached hereto, requesting Medicare
Benefit information of Plaintiff, if Plaintiff has ever applied for and/or received Medicare
Benefits.
14. Signed authorization, the original of which is attached hereto, requesting Medicaid
Benefit information of Plaintiff, if Plaintiff has ever applied for and/or received Medicaid
Benefits.
15. Copies of all tax returns, W-2 Forms, or any other evidence of income for all years to
date, beginning with the three (3) years preceding the within incident.
16. Signed authorization, the original of which is attached hereto, requesting copies of
income tax returns.
17. Withholding statements, pay envelopes, deposit slips, or any other evidence of income
earned by Plaintiff(s) for the current calendar year.
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18. Copies of bills and/or estimates for the repair of Plaintiffs vehicle and any other damaged
property. If the vehicle was not repairable, in addition, attach estimates of the value of
the vehicle on the date of the alleged incident and estimates and/or receipts concerning
salvage value.
19. Any and all statements, including, but not limited to, recorded telephone interviews,
tapes, written statements, whether signed or unsigned, of all witnesses to the incident
relative to the subject matter of this action and/or any witnesses having knowledge
regarding any and all facts and issues in the instant litigation.
20. All photographs, digital images, drawings, maps, sketches, movies, videotape, survey,
plat or other reproduction of the vehicles and/or the scene of the subject incident and/or
any injuries or damages alleged,
21. Any and all photographs of Plaintiff(s) depicting injuries to Plaintiff(s) sustained as a
result of the within incident.
22. Any releases, "Mary Carter Agreements", and any other type of settlement agreements
between Plaintiff(s) and any other party which may have been responsible for the
damages claimed by Plaintiff(s).
23. Any and all photographs, blow-ups, recordings, charts, graphs, sketches and any other
tangible items or documentary evidence which you intend to use during the trial of this
cause and which have not been produced in response to any of the preceding paragraphs.
24. All policies of insurance providing collateral source payments to Plaintiff(s), including,
but not limited to, PIP insurance, medical payment insurance, disability insurance, and/or
employment related insurance.
25. All claim forms submitted by Plaintiff(s) pursuant to the policies of insurance referred to
in Paragraph 24 above.
26. All statements, including, but not limited to, recorded telephone interviews, tapes, written
statements, signed or unsigned, of Defendant(s) or any of their agents, servants or
employees relative to the within incident and any other issue which involves the instant
litigation.
27. All incident reports filed by Plaintiff(s) for any purpose, including, but not limited to,
reports to employer and/or insurance company regarding the incident, if applicable,
and/or any other reports filled out by Plaintiff(s).
28. All documents, papers or evidence to be introduced at trial.
29. All expert reports from any experts who will testify at trial.
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30. Copy of marriage certificate if a derivative claim is being made for loss of consortium,
loss of service, or any other claim by your spouse as a result of personal injury to yourself
alleged to be as a result of the within incident.
31. Any and all correspondence sent in compliance with Florida Statute 768.76(6) whereby
the provider of any collateral sources were sent by certified registered mail notifying of
the Plaintiff s intent to claim damages from a tortfeasor.
32. Any and all documents received from the provider of collateral sources, pursuant to
Florida Statute 768.76(7), specifically copies of statements asserting the collateral source
provider's right to payment of collateral source benefits and right of subrogation or
reimbursement, notification by the provider of collateral sources that no right of
subrogation or reimbursement exists for the collateral sources paid and/or notification by
the collateral source provider of itsintent to waive right of subrogation or reimbursement.
33. Any and all documentation issued by the Plaintiff or Plaintiff s counsel to any healthcare
provider whereby the Plaintiff agrees to protect the interest of the healthcare provider
(letters of protection) and pay medical bills from any settlement or judgment in favor of
the Plaintiff.
34. Any and all documentation sent to Medicare and/or Medicaid advising Medicare and/or
Medicaid that the Plaintiff has made a claim for personal injury and/or has filed suit with
regard to the injury(ies) sustained in the subject accident.
35. Any and all documentation received by the Plaintiff or on behalf of the Plaintiff from
Medicare and/or Medicaid advising of an intent to assert a lien, the amount of the lien or
an intent to waive right of its lien.
36. If the Plaintiff received benefits from a plan administered by ERISA, a copy of the
summary plan description, reimbursement agreement executed by the Plaintiff and copy
of the policy.
37. Any and all documentation to include copies of the pleadings, responses to
interrogatories, responses to request for production, deposition transcripts, releases or
judgments entered in the Plaintiff s favor and any other legal proceeding in which the
Plaintiff claimed personal injuries.
38. If the Plaintiff was covered under a group health policy at the time of the accident alleged
in the Complaint, a copy of the health insurance card.
39. If the Plaintiff was covered by a disability income policy at the time of the accident
alleged in the Complaint, a copy of the disability income policy and declarations page.
40. If the Plaintiff has ever applied for Disability benefits, a copy of any
application or documents submitted to upon which the Plaintiff based
his/her claim for disability benefits.
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41. If the Plaintiff has ever applied for workerscompensation benefits, a copy of any
application or documents submitted to workers' compensation upon which the Plaintiff
based his/her claim for workers' compensation.
42. If the Plaintiff has ever applied for unemployment benefits, a copy of any application or
documents submitted to unemployment upon which the Plaintiff based his/her claim for
benefits.
43. If the Plaintiff has ever applied for long term disability benefits, a copy of any application
or documents submitted upon which the Plaintiff based his/her claim for benefits.
44. A copy of the Plaintiff s passport (from cover to cover).
45. A copy of the Plaintiff s driver's license (front and back).
46. A copy of the Plaintiff s Green Card and/or Alien Residency card and/or proof of U.S.
citizenship.
47. A copy of the Plaintiff s card.
48. A copy of the Plaintiff s resume or curriculum vitae.
49. Any licenses or certificates of completion issued to the Plaintiff.
50. If any document is withheld on any claim of privilege or otherwise, pursuant to current
law, set forth the following:
(a) the basis of the privilege claim;
(b) the author of the document;
(c) the date of the document; the recipient or intended recipient of the document;
(d) a brief description of the substance of the document; and,
(e) all persons who received copies of the document or were shown copies of the
document, along with an identification of each such person.
CERTIFICATE OF SERVICE
The document contains no confidential or sensitive information or that any such
confidential or sensitive language has been properly protected by complying with the provisions
of Rule 2.420 and 2.425. I HEREBY CERTIFY that a true and correct copy of the foregoing has
been furnished by electronic filing to John Allan Watson, Esquire/ Travis J. McMillen, Esquire,
jwatson@boginmunns.com, storres@boginmunns.com, bmmservice@boginmunns.com, Bogin,
Munns & Munns, P.A., Gateway Center, 1000 Legion Place, Suite 1000, Orlando, FL 32801 on
this 15th day of November, 2019.
/S/ Brad Higginbotham
BRAD HIGGINBOTHAM, ESQUIRE
Fla. Bar No.: 658642
Law Office of Sonya S. Wesner
200 East Robinson Street, Suite 510
Orlando, FL 32801
Direct Dial: (407) 393-9087
Paralegal: (407) 393-9096
Secretary: (407) 393-9094
Primary E-Mail: ORLMAIL@Nationwide.com
Attorneys for Defendant
6
41114MSPRC Medicare Secondary Payer
CMS
Contract CENIERS for MUNCARE & MEDICAIO SERVICES
Recovery
CONSENT TO RELEASE FORM
I, hereby authorize the Centers for Medicare & Medicaid Services (CMS), its agents and/or contractors
to release, upon request, information related to
my injury/illness and/or settlement to the individual(s) and/or firm(s) listed below:
PLEASE CHECK:
El Claimant's attorney
(Name and/or firm)
El Insurance carrier
(Name and/or company)
El Other (Allocation Company) Medivest Allocation Services, Inc.
(Name and/or firm)
How long can we give out the information? (Check one block)
El Ongoing, beginning:
(Month/Day/Year)
E Limited time: through
(use one year period) (Month/Day/Year) (Month/Day/Year)
El One time only
Claimant's Signature Date Signed
Date of Injury Number / HICN Number
If your Power of Attorney (POA) or legal representative signs this form for you, a copy of their POA or representation papers
must be sent to us with this form.
Completion and signing of this consent form:
• Authorizes release of information to the person named above upon their request. This means that information disclosed to the
above named person may be re-disclosed by them and may no longer be protected by law.
• Allows release of Medicare claims and other information related to your injury/illness.
• Is for release of information purposes only and does not affect benefits you are entitled to under the Program.
You have the right to revoke your authorization at any time in writing, except to the extent that CMS has already acted based on your
permission. To revoke, send a written request to the address below.
Medicare Secondary Payer Contractor
PO Box 33828
Detroit MI 48232-5828
Authorization for the Use and Disclosure of Protected Health
Information
‘14010r
Information Identifying the Individual Whose Records Are Being Requested
Name of Individual:
of your Number is notmandatory. The Agency for Health Care Administration (AHCA or Agency) may request
your pursuantto Section119.071, Florida Statutes. If provided, the Agency will use your information for purposes
offinding the requested information.
Individual's Street Address:
City: State: Zip Code:
IDor Gold
Phone Number: Date of Birth:
Provide the specific dates of serviceincluded. From: To:
Purpose for this disclosure:
Date I wish this authorization to expire (expiresin one year ifno date is provided):
I direct AHCA to mail the requested hard copy records to the below person(s),group or entity:
Documents Requested: Paid Claims Records Denied Claims Records All Claims Records
Other:
Name:
Street Address:
City: State: Zip Code:
I authorize the below person(s), group orentity to verbally discuss specific topics withAHCA:
The specific topics tobe discussed are:
Name:
l understand the
following: l have theright to revoke this authorization at any time by writing to the Agency's Privacy Officer or
completing the revocation
sectionon the second page of this form and sending it to the address listed for the Agency's Privacy Officer.
I
understand that any information previously disclosed would not be subject to my revocation request.
The information described above may
be re-disclosed by the person or group that I am giving the Agency permission to disclose to and therefore my information may no longer be
protected by Federal privacy regulations.
I may inspect or request copies of any information disclosed by this authorization if the Agency
initiated this request for disclosure.
I may refuse to sign this authorization and my refusal to sign will not affect my ability to obtain
treatment, payment for health care services or eligibility for benefits.
This formspecifically includes authorization to provide documents related to sensitive health conditions including: drug, alcohol or
substance abuse,psychological or psychiatric treatment, sickle cell anemia, birth control or family planning, genetic diseases or tests,
tuberculosis, and HIV/AIDS or STDs.
To restrict sensitive information, see Page 2.
I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT.
Signature: Date:
Printed Name:
Legal Authority (If Other Than Individual):
If you are a legal representative of the person whose information you are requesting disclosure of, you must provide
documentation proving your legal authority to request this information (for example, power of attorney, guardianship papers,
health care surrogate form, Custody Order, Order Appointing Personal Representative, Letters of Administration).
AHCA Form 1000-3003, Revised (AUG 2018) Page 1 of 2
÷001+cAp.E.40,,,
9 Authorization for the Use and Disclosure of Protected Health
RO‘V
Information
Instructions for Completing this Form
1. Complete the first page of this form and return it to: HIPAA Privacy Officer, Agency for Health Care
Administration, 2727
Mahan Dr., MS #4, Tallahassee, FL 32308, Phone:850-412-3960, Fax 850-414-6837
Email: HIPAAComplianceOffice@AHCA.MyFlorida.com.
2. Special types of health
information have
specific laws and rules that
must be followed before that information may be
disclosed:
HIV/AIDSand Sexually Transmitted
Diseases All
(STD): informationabout HIV/AIDSand sexually transmitted diseases is
protected under Federal and State laws and cannot be disclosed without your written authorization unless otherwise provided in
the regulations.
To release HIV/AIDS or STD information, this authorization
must include a statement of the specific HIV/AIDS or
STD information you are giving the Agency permission to disclose. Re-disclosure of HIV/AIDS information is not allowed except in
compliance with law or with your written permission.
To NOT INCLUDE this information, initial here
Alcohol
or Drug Treatment: Alcohol and/or drug
treatment records are protected under Federal and State laws and regulations
and cannot be disclosed without your written
authorization, unless otherwise provided for in Federal and State laws or regulations.
To release alcohol and/or drug treatment information, this authorization must include a statement of the specific information
that you are giving the Agency permission to disclose (for example, "For the purposes of my assessment, treatment plan,
Re-disclosure of your alcohol and/or drug treatment records is not allowed except in compliance
attendance, or discharge plan.")
with law or with your written permission (see 45 CFR Part 2). To NOT INCLUDE this information, initial here
Mental Health Treatment: Mental health treatment records
areprotected under Federal and
State laws and
regulations and cannot
be disclosed without your written authorization unless otherwise allowed in Federal
orState laws or
regulations. To release
mental health treatment information, this authorization must include
a statement of the specific information that you are giving the
to disclose
Agency permission (for example, "For the purposes of my assessment, treatment
plan,attendance,or discharge
plan.") Disclosure of your psychotherapists
notesneeds separate written permission. Re-disclosure of your mental health
treatment records is not allowed except in compliance with law or with your written permission. To NOT INCLUDE this information,
initial here
Revocation of Authorization
DO NOT COMPLETE FOR A NEW AUTHORIZATION. THIS SECTION IS ONLY FOR REVOKING A PREVIOUS AUTHORIZATION.
Disclosure of your Number is not mandatory. The Agency for Health Care Administration may request your
pursuant to Section119.071, Florida Statutes.
Name Date of Birth
Phone
ID Number orGold
Street Address
City State Zip Code
Ihereby revokemy authorization for the Agency for Health
Care Administration to disclose
my protectedhealth information
tothe
following person(s), group or entity:
Signature Date
Printed Name Legal Relationship
to Individual
If you are the provide documentation
subjeces legal representative, you must proving your legal authorityto revoke this
authorization.(Forexample, an authorization,power of attorney,guardianship papers, health care surrogateform, Order
Appointing Personal Representative,Lettersof Administration).
AHCA Form 1000-3003, Revised (AUG 2018) Page 2 of 2
....oh-1 CARE40
d, RON DESANTIS
4c
.1..
u
't-ra GOVERNOR
Z 5:It
tu7 5
a z
MARY C. MAYHEW
SECRETARY
ST4,c oe'
'
oF Fa-
Authorization for the Use and Disclosure of Protected Health Information
Federal law states that we cannot share
an permission, except in certain situations.
individual's health information without the individual's By
signing this form, you
are giving us permissionto share the information you indicate below.
If you decide later that you do not want
us to share
this information any more, youcan writing
revoke this authorization at any time in or sign the REVOCATION SECTION on the back of this form
and return it to the Florida 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 recipient's behalf (parent of a minor, legal guardian, trustee, power of attorney, personal
representative of the estate, grantor of an annuity).
PLEASE COMPLETE THE FOLLOWING SECTIONS
1. Personal Information:
Medicaid RecipienfsName Date of
Medicaid ID Number
2. Igive permissionto the Agency for Health Care Administration(AHCA) and its contractrepresentatives to share the health information
following:
listed below with the
Name of the Law Firm orLaw Office
Name of the InsuranceCompany
Other
3. Indicate the purpose for which the disclosure is to be made:
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. following (check one):
Indicate the information that you want to be disclosed, related to the
The Medicaid lienrelating to
theinjury or negligence charges, for the period beginning
with the date of incident.
Medicaid's claim
against the
estate.
The amount that is due from the trust account, [Please send
acopy of the trust agreement].
The amount that is due from the send
annuity account, [Please a copy of the annuity agreement].
Other, (Please be specific].
5. Enter thespecific date that you
want this authorization to
expire: (i.e.,
one year from date of release)
you do not enter
(If a date, this authorization will
expirein five
years.)
I understand that the information described above may be redisclosed
by the person or group that I
hereby give AHCA and its contract representatives
permissionto share my information
with, and that my information would
no longerbe the
protected by federal privacy regulations.
Therefore, I
release
AHCA, itsworkforcemembers, and itscontract from
representatives all from
liability arising the disclosureofmy healthinformationpursuant to this
agreement. IunderstandthatI may inspectorrequest copiesofany informationdisclosedby this
authorizationif
AHCA or itscontract
representatives
initiated this request for disclosure.
I understand that I 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.
I understand that I 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.
6. Recipient Signature Print Name Date
OR
Name of Legal Representative (Print) Relationship
"
Signatureof Legal Representative Date
*
If youarenot the individual, but represent the individual, please attach a copy of the legal document that verifies that you are a representative (parent
of a minor, legal guardian, trustee, power of attorney, personal representative of the estate, grantor of an annuity).
INSTRUCTIONS FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
1. Complete the front of the form and return it to Florida TPL Recovery Program, Post Office Box 12188, Tallahassee, Florida
32317-2188, Phone (toll-free) (877) 357-3268 or Fax (844) 845-8352.
2. If the a guardian, has a power of attorney or is an authorized representative, documentation of the representative's authority
signer is
to acton the individual's behalf must be attached. If an agency has custody of a child and a representative signs the release, include a
copy of the custody order.
3. Special kinds of health information havespecific laws and rules that have to be followed before that information
can be disclosed.
HIV and Sexually Transmitted Diseases (STD): All information about HIV and sexually transmitteddiseases is protected under federal
and state laws and cannot be disclosed without your written authorization unless otherwise provided in the regulations. To release HIV
or STD information, this authorization must include a statement in the Information You Want Disclosed section of the specific HIV or STD
information that you are giving permissionto release. Re-disclosure of HIV information is not allowed, except in compliance with law or
with your writtenpermission.
Alcohol and Drug Treatment: Alcohol and/or drug treatment records are protected under federal and state laws and regulationsand
cannot be disclosed without your written authorization, unless otherwise provided for in federal and state laws or regulations.
To release
alcohol and drug treatment information, this authorization must include a statement in the Information You Want Disclosed section of the
specific informationthat you are giving permission to release, such as "assessment, treatment plan, attendance, discharge plan." Re-
disclosure of you alcohol and/or drug treatment records is not allowed, except in compliance with law or with your written permission.
Mental Health Treatment: Mental health treatment records are protected under federal and state laws and regulations and cannot be
disclosed without your written authorization, unless otherwise allowed in federal and state laws or regulations.
To release mental health
treatment information, thisauthorization must include a statement in the Information You Want Disclosed section of the specific
information that you are giving permission to release, such as "assessment, treatment plan, attendance, discharge plan."
Also, disclosure
of your therapisfs own notes (psychotherapy notes) needs separate permission. Re-disclosure of your mental health treatment records
is prohibited, except in compliance with law or with your written permission.
4. You will be provided with acopy of this form.
REVOCATION SECTION
To revoke your authorization, complete the following section and return the form to the Florida TPL Recovery Program at the
address given above. (Use ofthis form to revoke your authorization isoptional; however, you must submit your revocation request in
writing.)
Ino longer want my information shared.
of
Street
City
If applicable, your ID number
OR
Signature of Authorized Representative
of Authorized
Form SSA-7050-F4 (03-2019)
Discontinue Prior Editions Page 1 of 4
Administration OMB No. 0960-0525
REQUEST FOR EARNING INFORMATION
*Use This Form If You Need
DO NOT USE THIS FORM TO REQUEST
1. Certified/Non-Certified Detailed Earnings Information YEARLY EARNINGS TOTALS
Includes periods of employment or self-employment
and the names and addresses of employers. Yearly earnings totals are free to the public
if you do not require certification.
2. Certified Yearly Totals of Earnings
Includes total earnings for each year but does not To obtain FREE yearly totals of earnings,
include the names and addresses of employers. visit our website at www.ssa.gov/myaccount.
Privacy Act Statement
Collection and Use of Personal Information
Section 205 of the Act, as amended, authorizes us to collect the information on this form. We will use the
information you provide to identify your records and send the earnings information you request. Completion of this form is
voluntary; however, failure to do so may prevent your request from being processed.
We rarely use the information in your earnings record for any purpose other than for determining your entitlement to
benefits. However, we may use it for the administration and integrity of programs. We may
also disclose information to another person or to another agency in accordance with approved routine uses, which
include but are not limited to the following:
1. To enable a third party or an agency to assist in establishing rights to benefits
and/or coverage;
2. To comply with Federal laws requiring the release of information from records (e.g., to the
Government Accountability Office and Department of VeteransAffairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal,
State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and
improvement of programs.
A complete list of routine uses for earnings information is available in our Systems of Records Notices entitled, the
Earnings Recording and Self-Employment Income System (60-0059), the Master Beneficiary Record (60-0090), and the
SSA-Initiated Personal Earnings and Benefit Estimate Statement (60-0224). In addition,you may choose to pay for the
earnings information you requested with a credit card. 31 C.F.R. Part 206 specifically authorizes us to collect credit card
information. The information you provide about your credit card is voluntary. Providing payment information is only
necessary if you are making payment by credit card. You do not need to fill out the credit card information if you choose
another means of payment (for example, by check or money order). If you choose th
Preview
Filing # 98933820 E-Filed 11/15/2019 10:14:19 AM IN THE CIRCUIT COURT OF THE NINTH JUDICIAL CIRCUIT IN AND FOR ORANGE COUNTY, FLORIDA CASE NO. 2017-CA-004395-0 DIV: 35 BRENTLEY M. HUXTABLE, PLAINTIFF, V. CARLOS E. RESUMIL, DEFENDANT. / DEFENDANT'S FIRST REQUEST TO PRODUCE TO PLAINTIFF Defendant, CARLOS E. RESUMIL, pursuant to Florida Rule of Civil Procedure 1.350, hereby requests Plaintiff, BRENTLEY M. HUXTABLE, to produce all of the following items within the Plaintiff s custody or control, within thirty (30) days after the service of this Request, to the undersigned attorneys: 1. Copies of any and all medical records, hospital records, emergency room records, and records from any health care provider pertaining to the treatment of Plaintiff(s) for any injuries sustained in the within incident. 2. Copies of any and all medical records, hospital records, emergency room records and records from any health care provider pertaining to the treatment of Plaintiff(s) for any reason in the five (5) years prior to the within incident. 3. Copies of any and all medical records, hospital records, emergency room records and records from any health care provider pertaining to the treatment of Plaintiff(s) for any reason since the within incident. 4. Copies of any and all Radiology films, X-rays, MRI scans, CT scans, from any health care provider pertaining to the treatment of Plaintiff, within seven (7) years prior to the alleged incident and to present date, that pertains to any body part for which the plaintiff is alleging was injured in the incident described in the Complaint. 5. Copies of any and all medical bills and/or statements for services rendered, paid or unpaid, as a result of the within incident, including any bills for drugs or other related expenses. 6. Copies of any and all bills, statements or receipts relating to any non-medical expenses claimed as damages in this lawsuit that have not been produced in response to any of the preceding paragraphs. 7. Copies of any and all medical reports, hospital reports, emergency room reports, consultations, and reports from any health care provider pertaining to the treatment of Plaintiff(s) for any injuries sustained in the within incident. 8. Copies of any and allbilling statements and/or detailed call logs from the date of the accident, limited to one hour before the accident and one hour after the subject accident., that is the subject of this lawsuit for all cellular phone/two way radios, that the Plaintiff owned and/or had possession of and/or otherwise used on the date of the subject accident. 9. Any and all incident/accident reports regarding the subject accident. 10. Signed authorization, the original of which is attached hereto, requesting medical/psychological/psychiatric information of Plaintiff. 11. Signed authorization, the original of which is attached hereto, requesting Disability Benefit information of Plaintiff if Plaintiff has ever applied for and/or received Disability Benefits. 12. Signed authorization, the original of which is attached hereto, requesting Earnings Information of Plaintiff. 13. Signed authorization, the original of which is attached hereto, requesting Medicare Benefit information of Plaintiff, if Plaintiff has ever applied for and/or received Medicare Benefits. 14. Signed authorization, the original of which is attached hereto, requesting Medicaid Benefit information of Plaintiff, if Plaintiff has ever applied for and/or received Medicaid Benefits. 15. Copies of all tax returns, W-2 Forms, or any other evidence of income for all years to date, beginning with the three (3) years preceding the within incident. 16. Signed authorization, the original of which is attached hereto, requesting copies of income tax returns. 17. Withholding statements, pay envelopes, deposit slips, or any other evidence of income earned by Plaintiff(s) for the current calendar year. 2 18. Copies of bills and/or estimates for the repair of Plaintiffs vehicle and any other damaged property. If the vehicle was not repairable, in addition, attach estimates of the value of the vehicle on the date of the alleged incident and estimates and/or receipts concerning salvage value. 19. Any and all statements, including, but not limited to, recorded telephone interviews, tapes, written statements, whether signed or unsigned, of all witnesses to the incident relative to the subject matter of this action and/or any witnesses having knowledge regarding any and all facts and issues in the instant litigation. 20. All photographs, digital images, drawings, maps, sketches, movies, videotape, survey, plat or other reproduction of the vehicles and/or the scene of the subject incident and/or any injuries or damages alleged, 21. Any and all photographs of Plaintiff(s) depicting injuries to Plaintiff(s) sustained as a result of the within incident. 22. Any releases, "Mary Carter Agreements", and any other type of settlement agreements between Plaintiff(s) and any other party which may have been responsible for the damages claimed by Plaintiff(s). 23. Any and all photographs, blow-ups, recordings, charts, graphs, sketches and any other tangible items or documentary evidence which you intend to use during the trial of this cause and which have not been produced in response to any of the preceding paragraphs. 24. All policies of insurance providing collateral source payments to Plaintiff(s), including, but not limited to, PIP insurance, medical payment insurance, disability insurance, and/or employment related insurance. 25. All claim forms submitted by Plaintiff(s) pursuant to the policies of insurance referred to in Paragraph 24 above. 26. All statements, including, but not limited to, recorded telephone interviews, tapes, written statements, signed or unsigned, of Defendant(s) or any of their agents, servants or employees relative to the within incident and any other issue which involves the instant litigation. 27. All incident reports filed by Plaintiff(s) for any purpose, including, but not limited to, reports to employer and/or insurance company regarding the incident, if applicable, and/or any other reports filled out by Plaintiff(s). 28. All documents, papers or evidence to be introduced at trial. 29. All expert reports from any experts who will testify at trial. 3 30. Copy of marriage certificate if a derivative claim is being made for loss of consortium, loss of service, or any other claim by your spouse as a result of personal injury to yourself alleged to be as a result of the within incident. 31. Any and all correspondence sent in compliance with Florida Statute 768.76(6) whereby the provider of any collateral sources were sent by certified registered mail notifying of the Plaintiff s intent to claim damages from a tortfeasor. 32. Any and all documents received from the provider of collateral sources, pursuant to Florida Statute 768.76(7), specifically copies of statements asserting the collateral source provider's right to payment of collateral source benefits and right of subrogation or reimbursement, notification by the provider of collateral sources that no right of subrogation or reimbursement exists for the collateral sources paid and/or notification by the collateral source provider of itsintent to waive right of subrogation or reimbursement. 33. Any and all documentation issued by the Plaintiff or Plaintiff s counsel to any healthcare provider whereby the Plaintiff agrees to protect the interest of the healthcare provider (letters of protection) and pay medical bills from any settlement or judgment in favor of the Plaintiff. 34. Any and all documentation sent to Medicare and/or Medicaid advising Medicare and/or Medicaid that the Plaintiff has made a claim for personal injury and/or has filed suit with regard to the injury(ies) sustained in the subject accident. 35. Any and all documentation received by the Plaintiff or on behalf of the Plaintiff from Medicare and/or Medicaid advising of an intent to assert a lien, the amount of the lien or an intent to waive right of its lien. 36. If the Plaintiff received benefits from a plan administered by ERISA, a copy of the summary plan description, reimbursement agreement executed by the Plaintiff and copy of the policy. 37. Any and all documentation to include copies of the pleadings, responses to interrogatories, responses to request for production, deposition transcripts, releases or judgments entered in the Plaintiff s favor and any other legal proceeding in which the Plaintiff claimed personal injuries. 38. If the Plaintiff was covered under a group health policy at the time of the accident alleged in the Complaint, a copy of the health insurance card. 39. If the Plaintiff was covered by a disability income policy at the time of the accident alleged in the Complaint, a copy of the disability income policy and declarations page. 40. If the Plaintiff has ever applied for Disability benefits, a copy of any application or documents submitted to upon which the Plaintiff based his/her claim for disability benefits. 4 41. If the Plaintiff has ever applied for workerscompensation benefits, a copy of any application or documents submitted to workers' compensation upon which the Plaintiff based his/her claim for workers' compensation. 42. If the Plaintiff has ever applied for unemployment benefits, a copy of any application or documents submitted to unemployment upon which the Plaintiff based his/her claim for benefits. 43. If the Plaintiff has ever applied for long term disability benefits, a copy of any application or documents submitted upon which the Plaintiff based his/her claim for benefits. 44. A copy of the Plaintiff s passport (from cover to cover). 45. A copy of the Plaintiff s driver's license (front and back). 46. A copy of the Plaintiff s Green Card and/or Alien Residency card and/or proof of U.S. citizenship. 47. A copy of the Plaintiff s card. 48. A copy of the Plaintiff s resume or curriculum vitae. 49. Any licenses or certificates of completion issued to the Plaintiff. 50. If any document is withheld on any claim of privilege or otherwise, pursuant to current law, set forth the following: (a) the basis of the privilege claim; (b) the author of the document; (c) the date of the document; the recipient or intended recipient of the document; (d) a brief description of the substance of the document; and, (e) all persons who received copies of the document or were shown copies of the document, along with an identification of each such person. CERTIFICATE OF SERVICE The document contains no confidential or sensitive information or that any such confidential or sensitive language has been properly protected by complying with the provisions of Rule 2.420 and 2.425. I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by electronic filing to John Allan Watson, Esquire/ Travis J. McMillen, Esquire, jwatson@boginmunns.com, storres@boginmunns.com, bmmservice@boginmunns.com, Bogin, Munns & Munns, P.A., Gateway Center, 1000 Legion Place, Suite 1000, Orlando, FL 32801 on this 15th day of November, 2019. /S/ Brad Higginbotham BRAD HIGGINBOTHAM, ESQUIRE Fla. Bar No.: 658642 Law Office of Sonya S. Wesner 200 East Robinson Street, Suite 510 Orlando, FL 32801 Direct Dial: (407) 393-9087 Paralegal: (407) 393-9096 Secretary: (407) 393-9094 Primary E-Mail: ORLMAIL@Nationwide.com Attorneys for Defendant 6 41114MSPRC Medicare Secondary Payer CMS Contract CENIERS for MUNCARE & MEDICAIO SERVICES Recovery CONSENT TO RELEASE FORM I, hereby authorize the Centers for Medicare & Medicaid Services (CMS), its agents and/or contractors to release, upon request, information related to my injury/illness and/or settlement to the individual(s) and/or firm(s) listed below: PLEASE CHECK: El Claimant's attorney (Name and/or firm) El Insurance carrier (Name and/or company) El Other (Allocation Company) Medivest Allocation Services, Inc. (Name and/or firm) How long can we give out the information? (Check one block) El Ongoing, beginning: (Month/Day/Year) E Limited time: through (use one year period) (Month/Day/Year) (Month/Day/Year) El One time only Claimant's Signature Date Signed Date of Injury Number / HICN Number If your Power of Attorney (POA) or legal representative signs this form for you, a copy of their POA or representation papers must be sent to us with this form. Completion and signing of this consent form: • Authorizes release of information to the person named above upon their request. This means that information disclosed to the above named person may be re-disclosed by them and may no longer be protected by law. • Allows release of Medicare claims and other information related to your injury/illness. • Is for release of information purposes only and does not affect benefits you are entitled to under the Program. You have the right to revoke your authorization at any time in writing, except to the extent that CMS has already acted based on your permission. To revoke, send a written request to the address below. Medicare Secondary Payer Contractor PO Box 33828 Detroit MI 48232-5828 Authorization for the Use and Disclosure of Protected Health Information ‘14010r Information Identifying the Individual Whose Records Are Being Requested Name of Individual: of your Number is notmandatory. The Agency for Health Care Administration (AHCA or Agency) may request your pursuantto Section119.071, Florida Statutes. If provided, the Agency will use your information for purposes offinding the requested information. Individual's Street Address: City: State: Zip Code: IDor Gold Phone Number: Date of Birth: Provide the specific dates of serviceincluded. From: To: Purpose for this disclosure: Date I wish this authorization to expire (expiresin one year ifno date is provided): I direct AHCA to mail the requested hard copy records to the below person(s),group or entity: Documents Requested: Paid Claims Records Denied Claims Records All Claims Records Other: Name: Street Address: City: State: Zip Code: I authorize the below person(s), group orentity to verbally discuss specific topics withAHCA: The specific topics tobe discussed are: Name: l understand the following: l have theright to revoke this authorization at any time by writing to the Agency's Privacy Officer or completing the revocation sectionon the second page of this form and sending it to the address listed for the Agency's Privacy Officer. I understand that any information previously disclosed would not be subject to my revocation request. The information described above may be re-disclosed by the person or group that I am giving the Agency permission to disclose to and therefore my information may no longer be protected by Federal privacy regulations. I may inspect or request copies of any information disclosed by this authorization if the Agency initiated this request for disclosure. I may refuse to sign this authorization and my refusal to sign will not affect my ability to obtain treatment, payment for health care services or eligibility for benefits. This formspecifically includes authorization to provide documents related to sensitive health conditions including: drug, alcohol or substance abuse,psychological or psychiatric treatment, sickle cell anemia, birth control or family planning, genetic diseases or tests, tuberculosis, and HIV/AIDS or STDs. To restrict sensitive information, see Page 2. I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT. Signature: Date: Printed Name: Legal Authority (If Other Than Individual): If you are a legal representative of the person whose information you are requesting disclosure of, you must provide documentation proving your legal authority to request this information (for example, power of attorney, guardianship papers, health care surrogate form, Custody Order, Order Appointing Personal Representative, Letters of Administration). AHCA Form 1000-3003, Revised (AUG 2018) Page 1 of 2 ÷001+cAp.E.40,,, 9 Authorization for the Use and Disclosure of Protected Health RO‘V Information Instructions for Completing this Form 1. Complete the first page of this form and return it to: HIPAA Privacy Officer, Agency for Health Care Administration, 2727 Mahan Dr., MS #4, Tallahassee, FL 32308, Phone:850-412-3960, Fax 850-414-6837 Email: HIPAAComplianceOffice@AHCA.MyFlorida.com. 2. Special types of health information have specific laws and rules that must be followed before that information may be disclosed: HIV/AIDSand Sexually Transmitted Diseases All (STD): informationabout HIV/AIDSand sexually transmitted diseases is protected under Federal and State laws and cannot be disclosed without your written authorization unless otherwise provided in the regulations. To release HIV/AIDS or STD information, this authorization must include a statement of the specific HIV/AIDS or STD information you are giving the Agency permission to disclose. Re-disclosure of HIV/AIDS information is not allowed except in compliance with law or with your written permission. To NOT INCLUDE this information, initial here Alcohol or Drug Treatment: Alcohol and/or drug treatment records are protected under Federal and State laws and regulations and cannot be disclosed without your written authorization, unless otherwise provided for in Federal and State laws or regulations. To release alcohol and/or drug treatment information, this authorization must include a statement of the specific information that you are giving the Agency permission to disclose (for example, "For the purposes of my assessment, treatment plan, Re-disclosure of your alcohol and/or drug treatment records is not allowed except in compliance attendance, or discharge plan.") with law or with your written permission (see 45 CFR Part 2). To NOT INCLUDE this information, initial here Mental Health Treatment: Mental health treatment records areprotected under Federal and State laws and regulations and cannot be disclosed without your written authorization unless otherwise allowed in Federal orState laws or regulations. To release mental health treatment information, this authorization must include a statement of the specific information that you are giving the to disclose Agency permission (for example, "For the purposes of my assessment, treatment plan,attendance,or discharge plan.") Disclosure of your psychotherapists notesneeds separate written permission. Re-disclosure of your mental health treatment records is not allowed except in compliance with law or with your written permission. To NOT INCLUDE this information, initial here Revocation of Authorization DO NOT COMPLETE FOR A NEW AUTHORIZATION. THIS SECTION IS ONLY FOR REVOKING A PREVIOUS AUTHORIZATION. Disclosure of your Number is not mandatory. The Agency for Health Care Administration may request your pursuant to Section119.071, Florida Statutes. Name Date of Birth Phone ID Number orGold Street Address City State Zip Code Ihereby revokemy authorization for the Agency for Health Care Administration to disclose my protectedhealth information tothe following person(s), group or entity: Signature Date Printed Name Legal Relationship to Individual If you are the provide documentation subjeces legal representative, you must proving your legal authorityto revoke this authorization.(Forexample, an authorization,power of attorney,guardianship papers, health care surrogateform, Order Appointing Personal Representative,Lettersof Administration). AHCA Form 1000-3003, Revised (AUG 2018) Page 2 of 2 ....oh-1 CARE40 d, RON DESANTIS 4c .1.. u 't-ra GOVERNOR Z 5:It tu7 5 a z MARY C. MAYHEW SECRETARY ST4,c oe' ' oF Fa- Authorization for the Use and Disclosure of Protected Health Information Federal law states that we cannot share an permission, except in certain situations. individual's health information without the individual's By signing this form, you are giving us permissionto share the information you indicate below. If you decide later that you do not want us to share this information any more, youcan writing revoke this authorization at any time in or sign the REVOCATION SECTION on the back of this form and return it to the Florida 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 recipient's behalf (parent of a minor, legal guardian, trustee, power of attorney, personal representative of the estate, grantor of an annuity). PLEASE COMPLETE THE FOLLOWING SECTIONS 1. Personal Information: Medicaid RecipienfsName Date of Medicaid ID Number 2. Igive permissionto the Agency for Health Care Administration(AHCA) and its contractrepresentatives to share the health information following: listed below with the Name of the Law Firm orLaw Office Name of the InsuranceCompany Other 3. Indicate the purpose for which the disclosure is to be made: 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. following (check one): Indicate the information that you want to be disclosed, related to the The Medicaid lienrelating to theinjury or negligence charges, for the period beginning with the date of incident. Medicaid's claim against the estate. The amount that is due from the trust account, [Please send acopy of the trust agreement]. The amount that is due from the send annuity account, [Please a copy of the annuity agreement]. Other, (Please be specific]. 5. Enter thespecific date that you want this authorization to expire: (i.e., one year from date of release) you do not enter (If a date, this authorization will expirein five years.) I understand that the information described above may be redisclosed by the person or group that I hereby give AHCA and its contract representatives permissionto share my information with, and that my information would no longerbe the protected by federal privacy regulations. Therefore, I release AHCA, itsworkforcemembers, and itscontract from representatives all from liability arising the disclosureofmy healthinformationpursuant to this agreement. IunderstandthatI may inspectorrequest copiesofany informationdisclosedby this authorizationif AHCA or itscontract representatives initiated this request for disclosure. I understand that I 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. I understand that I 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. 6. Recipient Signature Print Name Date OR Name of Legal Representative (Print) Relationship " Signatureof Legal Representative Date * If youarenot the individual, but represent the individual, please attach a copy of the legal document that verifies that you are a representative (parent of a minor, legal guardian, trustee, power of attorney, personal representative of the estate, grantor of an annuity). INSTRUCTIONS FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION 1. Complete the front of the form and return it to Florida TPL Recovery Program, Post Office Box 12188, Tallahassee, Florida 32317-2188, Phone (toll-free) (877) 357-3268 or Fax (844) 845-8352. 2. If the a guardian, has a power of attorney or is an authorized representative, documentation of the representative's authority signer is to acton the individual's behalf must be attached. If an agency has custody of a child and a representative signs the release, include a copy of the custody order. 3. Special kinds of health information havespecific laws and rules that have to be followed before that information can be disclosed. HIV and Sexually Transmitted Diseases (STD): All information about HIV and sexually transmitteddiseases is protected under federal and state laws and cannot be disclosed without your written authorization unless otherwise provided in the regulations. To release HIV or STD information, this authorization must include a statement in the Information You Want Disclosed section of the specific HIV or STD information that you are giving permissionto release. Re-disclosure of HIV information is not allowed, except in compliance with law or with your writtenpermission. Alcohol and Drug Treatment: Alcohol and/or drug treatment records are protected under federal and state laws and regulationsand cannot be disclosed without your written authorization, unless otherwise provided for in federal and state laws or regulations. To release alcohol and drug treatment information, this authorization must include a statement in the Information You Want Disclosed section of the specific informationthat you are giving permission to release, such as "assessment, treatment plan, attendance, discharge plan." Re- disclosure of you alcohol and/or drug treatment records is not allowed, except in compliance with law or with your written permission. Mental Health Treatment: Mental health treatment records are protected under federal and state laws and regulations and cannot be disclosed without your written authorization, unless otherwise allowed in federal and state laws or regulations. To release mental health treatment information, thisauthorization must include a statement in the Information You Want Disclosed section of the specific information that you are giving permission to release, such as "assessment, treatment plan, attendance, discharge plan." Also, disclosure of your therapisfs own notes (psychotherapy notes) needs separate permission. Re-disclosure of your mental health treatment records is prohibited, except in compliance with law or with your written permission. 4. You will be provided with acopy of this form. REVOCATION SECTION To revoke your authorization, complete the following section and return the form to the Florida TPL Recovery Program at the address given above. (Use ofthis form to revoke your authorization isoptional; however, you must submit your revocation request in writing.) Ino longer want my information shared. of Street City If applicable, your ID number OR Signature of Authorized Representative of Authorized Form SSA-7050-F4 (03-2019) Discontinue Prior Editions Page 1 of 4 Administration OMB No. 0960-0525 REQUEST FOR EARNING INFORMATION *Use This Form If You Need DO NOT USE THIS FORM TO REQUEST 1. Certified/Non-Certified Detailed Earnings Information YEARLY EARNINGS TOTALS Includes periods of employment or self-employment and the names and addresses of employers. Yearly earnings totals are free to the public if you do not require certification. 2. Certified Yearly Totals of Earnings Includes total earnings for each year but does not To obtain FREE yearly totals of earnings, include the names and addresses of employers. visit our website at www.ssa.gov/myaccount. Privacy Act Statement Collection and Use of Personal Information Section 205 of the Act, as amended, authorizes us to collect the information on this form. We will use the information you provide to identify your records and send the earnings information you request. Completion of this form is voluntary; however, failure to do so may prevent your request from being processed. We rarely use the information in your earnings record for any purpose other than for determining your entitlement to benefits. However, we may use it for the administration and integrity of programs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include but are not limited to the following: 1. To enable a third party or an agency to assist in establishing rights to benefits and/or coverage; 2. To comply with Federal laws requiring the release of information from records (e.g., to the Government Accountability Office and Department of VeteransAffairs); 3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and, 4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement of programs. A complete list of routine uses for earnings information is available in our Systems of Records Notices entitled, the Earnings Recording and Self-Employment Income System (60-0059), the Master Beneficiary Record (60-0090), and the SSA-Initiated Personal Earnings and Benefit Estimate Statement (60-0224). In addition,you may choose to pay for the earnings information you requested with a credit card. 31 C.F.R. Part 206 specifically authorizes us to collect credit card information. The information you provide about your credit card is voluntary. Providing payment information is only necessary if you are making payment by credit card. You do not need to fill out the credit card information if you choose another means of payment (for example, by check or money order). If you choose th