FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`
`From: AAAFiling (AAAFiling@sslawny.com)
`Sent: 12/14/2020 12:00:11 PM
`To: NYICMC.FilingSubmissions (NYICMC.FilingSubmiss@adr.org)
`Subject: File # 113464 - SANJEEV SHARMA
`
`
`*** External E-Mail – Use Caution ***
`
`
`
`SAMANDAROV & ASSOCIATES, P.C.
`
`250 Jericho Turnpike, Suite 205
`Floral Park, NY 11001
`T. (516) 492-3280
`F. (516) 619-0429
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`
`SAMANDAROV
`& ASSOCIATES,
`
`P.C.
`
`Steve
`Samandarov
`-----------------------------
`
`Anthony
`Aaron
`
`Gregory
`Abraham
`Sabiné
`David
`
`Alton
`J. Perretta
`Itingen
`J. Meir
`Sciarrotto
`Gottlieb
`
`Carrier:
`Provider:
`
`Claimant:
`
`Claim
`
`Date
`
`#:
`
`of accident:
`of
`
`service:
`in dispute:
`
`Date(s)
`Amount
`File
`
`#:
`
`205
`Suite
`250 Jericho
`Turnpike,
`Park, NY 11001
`Floral
`Tel:
`492-3280
`(516)
`Fax:
`342-5543
`(516)
`www.sslawny.com
`
`12/7/2020
`
`COMPANY
`
`TRANSIT
`SADHNANI,
`SHARMA
`
`INSURANCE
`PC
`
`AMERICAN
`MANOJ
`SANJEEV
`67750402
`
`4/2/2017
`4/17/2019
`
`$5,357,25
`
`SS-113464
`
`Arbitration
`
`Table
`
`of Contents
`
`AR-1
`
`Assignment
`
`of Benefits/Bill
`
`Medical
`
`Documentation
`
`Response
`
`to Verification
`
`Request(s)
`
`Exhibit
`
`Exhibit
`
`Exhibit
`
`Exhibit
`
`A:
`
`B:
`
`C:
`
`D:
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`
`SAMANDAROV
`& ASSOCIATES,
`
`P.C.
`
`Steve Samandarov
`---------------------------
`
`Anthony
`Aaron
`
`Gregory
`Abraham
`Sabiné
`David
`
`Alton
`J. Perretta
`Itingen
`J. Meir
`Sciarrotto
`Gottlieb
`
`Dear
`
`Respondent:
`
`205
`Suite
`250 Jericho
`Turnpike,
`Park, NY 11001
`Floral
`Tel:
`492-3280
`(516)
`Fax:
`342-5543
`(516)
`www.sslawny.com
`
`Please
`
`take
`
`notice
`
`that
`
`this
`
`firm
`
`has been
`
`retained
`
`no-fault
`us at
`
`arbitration.
`
`the
`
`address
`
`Accordingly,
`above.
`
`we
`
`request
`
`that
`
`you
`
`to represent
`forward
`
`all
`
`the Applicant
`
`in this matter
`
`with
`
`further
`
`correspondence
`
`regarding
`
`respect
`this matter
`
`to a
`
`to
`
`notice
`
`that
`
`Please
`
`take
`
`possession
`
`for
`
`our
`
`[Nassau
`
`Dist
`
`further
`which
`are
`demand
`may
`Ct 2004];
`
`directly
`be
`found
`Hudson
`
`applicant
`the
`defenses
`to any
`related
`in Westbury
`Medical
`P.C.
`Med.,
`
`is hereby
`of medical
`
`P.C.
`
`Care
`
`Ins.
`
`Co.,
`
`and
`records
`all medical
`demanding
`raised
`in the
`denial(s).
`necessity
`v. Lumbermans
`183 Misc
`2d 749
`
`Mut.
`
`Ins.
`
`Co.
`
`[App
`
`Term,
`
`2d Dept
`
`reports
`legal
`The
`5 Misc
`
`in your
`
`basis
`838
`
`3d
`
`1999]
`
`v Allstate
`
`Please
`
`take
`
`the
`
`respondent
`
`to provide
`
`said
`
`the
`
`applicant
`
`of medical
`
`their
`AD2d
`Astrel
`
`inedical
`
`introduction
`84
`[2d
`Dept
`v Yarborough,
`necessity
`
`further
`as well
`
`notice
`that
`if
`as to respondent's
`v Progressive
`
`2002];
`Bajaj
`31 AD3d
`defenses
`pursuant
`
`356
`
`defense(s)
`Ins.
`2006].
`
`Dept
`[2d
`to Presbyterian
`
`fails
`lack
`
`of
`
`14 Misc
`
`Co.,
`The
`applicant
`v. Maryland
`
`3d
`will
`
`Casualty,
`
`records,
`necessity.
`
`[Civ
`
`1202(A)
`furthermore
`90 NY2d
`
`object
`will
`v Bradshaw
`
`to
`292
`
`County
`of
`
`2006],
`lack
`
`of
`
`See Wagman
`Ct, Queens
`seek
`preclusion
`
`274
`
`[1977].
`
`Moreover,
`Consultant
`(IHC).
`to include
`
`read
`
`objects
`to the
`applicant
`11 NYCRR
`§ 65-4.7
`a CPC.
`
`use
`
`of
`
`specifically
`
`a Certified
`and
`
`Professional
`
`clearly
`
`defines
`
`Coder
`an IHC-
`
`as an Independent
`(CPC)
`a definition
`which
`
`Health
`
`cannot
`
`be
`
`Please
`to the
`provided.
`
`prior
`
`been
`
`take
`
`further
`
`notice
`
`that
`
`with
`
`respect
`
`to the
`
`peer
`
`and/or
`
`filing
`
`of
`
`the
`
`AR1
`
`form
`
`herein,
`
`we
`
`reserve
`
`our
`
`right
`
`to
`
`IME
`submit
`
`reports
`
`not
`
`provided
`
`a rebuttal
`
`after
`
`the
`
`CC:
`
`American
`Arbitration
`120 Broadway
`New York,
`
`NY,
`
`10271
`
`Association
`
`applicant
`
`to the
`peer
`reports
`
`have
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`
`Exhibit
`
`A:
`
`AR-1
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`
`AMERICAN
`
`ARBITRATION
`
`ASSOCIATION
`
`New York
`
`Motor
`
`Vehicle
`
`No-Fault
`
`Insurance
`
`Law
`
`Arbitration
`
`Request
`
`Form
`
`Please clearly complete (print or type) all applicable sections of this form and submit
`it by email to nyicmc.filingsubmissions@adr.org or by mail to the American
`Arbitration Association, 32 Old slip, 33rd FL,New York, NY 10005, along with a $40.00 filing fee. If filing by email, please use Quick Pay
`https://apps=adr.org/PCIPayment/faces/NYSlHome.jsf
`to pay the filing fee. For additional
`information regarding arbitration regulations, please visit the Department of
`Financial services (DFs) website h_ttp_s;/Jwwwjfs.n_ygov.
`insurance or a statement of claim for
`Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial
`any commercial or personal
`insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact
`thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to
`material
`make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance
`insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the
`company, commits a fraudulent
`subject motor vehicle or stated claim for each violation.
`The undersigned affirms and certifies as true under the penalty of perjury that this filing is being made in good faith and that upon information, belief and reasonable
`inquiry the documents being submitted herewith are not fraudulent and that exact copies of all documents provided herewith have been mailed to the insurer against
`whom the arbitration is being requested. Unless disclosed with this submission, the disputed amounts remain unpaid to the applicant by any payor and there has been
`no other filing of an arbitration request or lawsuit to resolve the disputed matters contained in this submission.
`
`FILING PARTY DETAILS
`
`(Please place an "X" within
`
`the box to indicate
`
`your answer.)
`
`Filed by An Applicant
`
`Attorney?
`
`Yes
`
`No
`
`Applicant
`
`file number:
`
`SS-113464
`
`Name of entity:
`
`Address:
`
`City:
`
`State:
`
`Zip code:
`
`Samandarov
`
`& Associates,
`250 Jericho Turnpike,
`
`P.C.
`
`Suite 205
`
`Floral Park
`
`N.Y
`
`11001
`
`Telephone
`
`number:
`
`(516) 492-3280
`
`Email:
`
`Signature:
`
`Date:
`
`DETAILS
`
`steve@sslawny.com
`
`12/07/2020
`
`Ple s
`
`fill out date in XX/XX/XXXX
`
`format.
`
`APPLICANT
`
`Select
`
`the Applicant
`
`(Please place an "X" within
`for Benefits:
`Medical
`
`the box to indicate
`
`your answer.)
`
`Provider
`
`Injured
`
`Party
`
`Name of Applicant:
`
`MANOJ SADHNANI,
`
`PC
`
`235-20
`
`147TH AVENUE, SUITE 7
`
`ROSEDALE
`
`N.Y
`
`11422
`
`Address:
`
`City:
`
`State:
`
`Zip code:
`
`Telephone
`
`number:
`
`Email:
`
`Name
`
`of
`
`injured
`
`party:
`
`SANJEEV SHARMA
`
`*To list additional
`
`injured
`
`parties, medical providers,
`
`insurers,
`
`and/or
`
`claims
`
`in dispute, please use the supplemental
`
`form on pages 4-6.
`
`Please
`
`indicate
`
`the number
`
`of supplemental
`
`pages
`
`included
`
`in your
`
`submission:
`
`O
`
`Please
`
`indicate
`
`number,
`
`if none leave as "O"
`
`AAA Form AR1 (Effective 01/01/2020)
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`
`AMERICAN
`
`ARBITRATR)N
`
`ASSOCIATION®
`
`New York Motor
`
`Vehicle
`
`No-Fault
`
`Insurance
`
`Law Arbitration
`
`Request
`
`Form,
`
`Page
`
`2
`
`INSURER/SELF
`Name of entity:
`
`INSURER
`
`Address:
`
`City:
`
`State:
`
`Zip code:
`
`AMERICAN TRANSIT INSURANCE COMPANY
`
`ONE METROTECH CENTER
`
`BROOKLYN
`
`NY
`
`11201
`
`Telephone
`
`number:
`
`1-800-683-2842
`
`Email:
`
`Claim Number:
`
`Policy Number:
`
`67750402
`
`THIRD
`
`PARTY ADMINISTRATOR
`
`(Please place an "X" within
`
`the box to indicate
`
`your answer.)
`
`Is there a third
`
`party
`
`administrator?
`
`Yes
`
`No (lf no, proceed
`
`to ACCIDENT DETAILS.)
`
`Name of entity:
`Contact
`Information:
`
`Every attempt
`
`should
`
`be made to resolve
`
`this claim with
`
`the insurer
`
`prior
`
`to filing
`
`for arbitration.
`
`format.
`
`When was the insurer
`
`last contacted?
`
`Please
`
`fill out date in XX/XX/XXXX
`
`Name and title
`
`of
`
`the person
`
`contacted
`
`(the last date of contact must be within
`
`90 days):
`
`ACCIDENT
`Did the accident
`
`DETAILS
`
`occur
`
`(Please place an "X" within
`2
`in New York State?
`
`the box to indicate
`Yes
`
`your answer.)
`No
`
`Date of accident:
`
`0002/2017
`
`REQUESTS
`
`FOR SPECIAL HANDLING
`
`(Please
`
`fill out date in XX/XX/XXXX
`Please
`place an "X" within
`
`the box to indicate
`
`format.
`
`your answer.)
`
`to 11 NYCRR 65-4.5
`Arbitration:
`Submissions
`has the discretion
`(a), an arbitrator
`Pursuant
`Written
`basis of written
`submissions
`where
`the amount
`in dispute
`is less than $2,000. Are you interested
`arbitrator
`on the written
`submissions
`without
`an in-person
`hearing?
`entirely
`
`parties'
`
`claims on the
`to consider
`in having this case decided
`by the
`
`a telephone
`
`hearing
`
`of
`
`this case,
`
`No
`Yes
`in having
`Are you interested
`No
`Yes
`(90-day):
`to 11 NYCRR 65-4.5
`for
`the request
`where
`Arbitration
`(i) (2), a party may elect Priority
`Arbitration
`Pursuant
`Priority
`for EACH claim in dispute.
`either
`of a denial
`90 days after
`A
`receipt
`of claim or the claim became
`is made within
`arbitration
`overdue,
`file that qualifies
`is scheduled
`within
`45 days from the date of
`transmittal
`from the conciliation
`center. Are you
`Arbitration
`for Priority
`90 days after
`each claim in dispute was denied
`Arbitration?
`filing within
`or became
`overdue
`and electing
`
`instead
`
`of an in-person
`
`hearing?
`
`Priority
`
`Yes
`Special Expedited
`for cases denied
`Arbitration
`within
`
`No
`(Late Notice):
`Arbitration
`based on failure
`to submit
`30 days after
`the mailing
`
`(b), Special Expedited
`to 11 NYCRR 65-4.5
`Pursuant
`of claim within
`the accident.
`notice
`30 days after
`of
`the denial
`to qualify.
`
`available
`proceedings
`Arbitration
`are
`Special Expedited
`You must
`request
`
`Was the denial
`
`of claim based on late notice
`
`to the carrier?
`
`If yes, are you requesting
`
`Special Expedited
`
`Arbitration?
`
`¡
`¡
`
`yes
`
`Yes
`
`No
`
`No
`
`AAA Form AR1 (Effective 01/01/2020)
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`
`AMERICAN
`
`ARBITRATION
`
`ASSOCIATION
`
`New York Motor
`
`Vehicle
`
`No-Fault
`
`Insurance
`
`Law Arbitration
`
`Request
`
`Form,
`
`Page
`
`3
`
`CLAIM(S)
`
`IN DISPUTE
`
`(Please
`
`check
`
`all
`
`that
`
`apply
`
`by placing
`
`an "X" within
`
`the
`
`boxes.)
`
`Medical
`
`Total Amount
`
`in Dispute:
`
`$5,357.25
`
`AMOUNT
`
`OF BILL
`
`$5,357.25
`
`PAID
`
`$0.00
`
`CLAIMED
`
`$5,357.25
`
`DATES OF SERVICE
`
`FROM
`
`TO
`
`DATE VERIFICATION
`SUPPLIED (if
`applicable)
`
`04/17/2019
`
`04/17/2019
`
`10/13/2020
`
`TOTAL
`
`$5,357.25
`
`$0.00
`
`$5,357.25
`
`in dispute above. If any supplemental pages are included in your
`*Please indicate the total amount
`in dispute at the end of your itemized claims.
`submission, please indicate the total
`
`AAA Form AR1 (Effective 01/01/2020)
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`
`A MERICAN ARBITRATION
`
`ASSOCIATION
`
`New York Motor
`
`Vehicle
`
`No-Fault
`
`Insurance
`
`Law Arbitration
`
`Request
`
`Form,
`
`Page
`
`4
`
`CLAIM(S)
`
`IN DISPUTE
`
`(Please
`
`check
`
`all
`
`that
`
`apply
`
`by placing
`
`an "X"
`
`within
`
`the
`
`boxes.)
`
`Loss of Earnings
`
`INJURED PARTY
`
`FROM
`
`TO
`
`GROSS EARNING
`
`PER MONTH
`
`AMOUNT
`
`CLAIMED
`
`DATE CLAIM
`
`MADE
`
`TOTAL
`
`Other Necessary
`
`Expenses
`
`$0.00
`
`INJURED PARTY
`
`TYPE OF EXPENSE CLAIMED
`
`AMOUNT
`
`CWMED
`
`AMOUNT
`
`IN
`
`DISPUTE
`
`DATE
`INCURRED
`
`DATE
`
`MAILED
`
`$0.00
`
`$0.00
`
`INJURED PARTY
`
`DATE DEATH CERTIFICATE WAS MAILED TO INSURER
`
`TOTAL
`
`Death Benefit
`
`Interest
`
`INJURED PARTY
`
`BILL PAID LATE
`
`AMOUNT
`
`OF
`
`DATE MAILED
`
`BILL
`
`TO INSURER
`
`WAS VERIFICATION
`REQUESTED?
`
`DATE PAID BY
`
`YES/NO
`
`DATE
`SUPPLIED
`
`INSURER
`
`Attorney's
`
`Fee
`
`AAA Form AR1 (Effective
`
`01/01/2020)
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`
`Exhibit
`
`B:
`
`Assignment
`
`of
`
`benefits/Bill
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`
`S
`
`D
`
`R
`
`& ASSOCIATES,
`
`P.C.
`
`Anthony
`Aaron
`
`Steve Samandarov
`-----------------------------
`Alton
`J. Perretta
`Itingen
`Gregory
`Eli Shmulik
`Abraham
`
`Meir
`
`250 Jericho
`Suite
`205
`Turnpike,
`Park, NY 1 1001
`Floral
`Tel:
`492-3280
`(516)
`Fax:
`342-5543
`(516)
`www.sslawny.com
`
`AMERICAN
`TRANSIT
`INSURANCE
`ONE METROTECH
`CENTER
`NY I 1201
`
`BROOKLYN,
`
`COMPANY
`
`Provider:
`
`Claimant:
`Claim //:
`Date of accident:
`of service:
`amount:
`
`Date(s)
`Billed
`File //:
`
`SADHNANI,
`SHARMA
`
`PC
`
`MANOJ
`SANJEEV
`67750402
`4/2/2017
`
`4/17/2019
`$5,357.25
`SS-1 13464
`
`Dear No Fault Claim Adjuster:
`
`5/10/2019
`
`Please
`
`be advised
`that we represent
`the provider
`is being
`submitted
`for payment
`herewith.
`Enclosed
`please
`assignment
`of benefits,
`and medical
`documentation.
`All
`provider.
`
`in connection
`the enclosed
`with
`bill
`for services
`rendered
`which
`find
`the health
`provider's
`proof
`of claim,
`the bill,
`including
`documents
`attached
`to this
`letter were
`prepared
`by the health
`
`medical
`
`Please
`
`send all payments,
`requests
`examination
`and any other
`reports,
`
`for additional
`documents
`
`denials
`verification,
`to this matter
`
`relating
`
`of claim,
`peer
`to our office.
`
`review
`
`reports,
`
`independent
`
`All
`
`payments
`
`should
`
`be made
`
`payable
`
`to the above
`
`referenced
`
`health
`
`provider
`
`c/o Samandarov
`
`& Associates,
`
`P.C.
`
`Yours
`
`truly,
`
`Steve Samandarov,
`
`Esq.
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`
`O
`
`OJ
`
`.1
`
`Q
`
`INSURANCE
`
`CLAIM
`
`FORM
`
`L H
`
`EALTH
`
`t LDI 7E
`
`**LDIu C
`
`Pf
`
`L
`
`2 r L
`
`e--
`
`SHARMA
`
`SANJEEV
`
`81 BARBARA LN
`crr r
`LEVITTOWN
`
`r
`
`NY
`
`11756
`
`(718
`
`) 2333748
`
`1969
`
`SHARMA
`
`SANJEEV
`
`81 BARBARA LN
`
`LEVITTOWN
`
`11756
`
`NY
`
`f 718
`
`) 2233748
`
`t HL LI EJ r
`
`, Ut t tI+
`
`\
`
`09
`29
`4Wft I 1 1 F
`
`1969
`
`t
`
`READBACKOFFORMBEFORECO*1PLETIIGf SI NNGTHISFOR*1
`
`F C
`
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`1I
`
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`
`05/06/2019
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`
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`M25571
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`r
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`04
`
`17
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`19
`
`04
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`17
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`17
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`19
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`
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`
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`
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`
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`
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`
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`
`25.FEDERALTAXI.D.NUMBER
`
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`
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`
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`INCLUDINGDEGREESORCREDENTIALS
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`MTdChªNòTªªª
`"
`
`E ACCEPTASSGN
`¡No
`Es
`32 SERVICEFACR!FYLOCAuONINFORMATiON
`ALL CITY SURGlCAL HEALTHCARE
`3632 NOSTRAND AVENUE
`NY 112295305
`BROOKLYN,
`05/06/2019
`a 1215939186
`rE
`NUCC InstructiOn Manual available at www.nucc.org
`
`21 TOTALCHARGE
`29 AMOUNTPAD
`a 5357
`5 0
`25
`00
`33.BILLINGPROVIDERNFC&PH
`( H )
`CENTER Dr.Manoj Sadhnani DPM, PC
`235-20 147th avenue, Suite 7
`ny 11422-3293
`Rosedale,
`1275625378
`APPROVED OMB-0938-1197 FORM 1500 (02-12)
`
`30 Rsvdfo NUCCU
`
`EM3
`
`PLEASE PRINT OR TYPE
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`
`Exhibit
`
`C:
`
`Medical
`
`documentation
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`- Print
`The New Protocol
`Report
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`1 of 3
`Page
`
`ALLCITY
`
`HEALTHCARE
`FAMILY
`Ave.
`3632 Nostrand
`NY 1 1229
`Brooklyn,
`
`CENTER
`
`17, 2019
`
`Sharma
`Name:
`Sanjeev
`April
`of Surgery:
`Date
`Account
`No:
`3011845
`Date
`of Birth:
`Age:
`49
`Gender:
`
`Male
`
`/1969
`
`SURGEON:
`
`Manoj
`
`Sadhnani,
`
`DPM
`
`ASSISTANT
`
`SURGEON:
`
`Albert
`
`Samandarov,
`
`DPM
`
`ASSISTANT:
`ANESTHESIA:
`
`Carolina
`General
`
`and Madhuri
`Perez
`anesthesia
`
`Mehta-
`
`PGY
`
`ESTIMATED
`
`BLOOD
`
`LOSS:
`
`Minimal
`
`TOURNIQUET:
`
`350 mmHg thigh
`
`tourniquet
`
`was used over
`
`the right
`
`thigh
`
`PREOPERATIVE
`DIAGNOSES:
`1. RIGHT
`IMPINGEMENT
`ANKLE
`ANKLE
`2. RIGHT
`LATERAL
`ANKLE
`3. RIGHT
`MEDIAL
`4. RIGHT
`LONGITUDINAL
`TENDONS
`BREVIS
`5. PAIN
`AT THE RIGHT
`
`ANKLE
`
`INSTABILITY
`HARDWARE
`PAINFUL
`TEAR
`THE
`OF
`PERONEUS
`
`POSTOPERATIVE
`DIAGNOSES:
`ANKLE
`IMPINGEMENT
`1. RIGHT
`ANKLE
`2. RIGHT
`LATERAL
`ANKLE
`3. RIGHT
`MEDIAL
`4. RIGHT
`LONGITUDINAL
`TENDONS
`BREVIS
`5. PAIN
`AT THE RIGHT
`
`ANKLE
`
`INSTABILITY
`HARDWARE
`PAINFUL
`TEAR
`THE
`OF
`PERONEUS
`
`LONGUS
`
`AND
`
`PERONEUS
`
`LONGUS
`
`AND
`
`PERONEUS
`
`PROCEDURE:
`ANKLE
`AND EXCISION
`ARTHROTOMY
`1. OPEN
`RIGHT
`OF OSTEOPHYTE
`TENDONS
`LONGUS
`AND PERONEUS
`2. REPAIR
`OF PERONEUS
`BREVIS
`HARDWARE
`MALLEOLUS
`PAINFUL
`3, EXCISION
`OF MEDIAL
`ANKLE
`4. USE OF ARTHREXINTERNAL
`FOR LATERAL
`BRACE
`
`STABILIZATION.
`
`PROCEDURE
`IN DETAIL:
`table
`was brought
`The
`patient
`in the supine
`on the operating
`the operating
`into
`room and placed
`was placed
`at 350
`pneumatic
`position.
`After
`induction
`a thigh
`of general
`tourniquet
`anesthesia,
`sterile
`fashion.
`At
`this
`mmHg.
`At
`this
`the right
`in the usual
`leg was then prepped
`and draped
`time,
`the right
`ankle
`where
`attention
`directed
`to the right
`the
`lateral
`of
`was
`ankle
`at
`aspect
`
`time,
`
`a
`
`https://www.thenewprotocol.con(cid:26)MTUsers/webmt30/print.asp?Hinfo=Hl&Patno=59&Mod...
`
`5/6/2019
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`- Print
`The New Protocol
`NYSCEF DOC. NO. 5
`Report
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`Page
`2 of 3
`
`of
`
`curvilinear
`incision
`was placed
`the posterior
`at
`the lateral malleolus
`aspect
`over
`the peroneal
`At
`tendons.
`this
`incision
`was
`time,
`down
`carried
`to the retinaculum
`deep
`and at
`this
`the
`time,
`brevis
`peroneus
`and peroneus
`longus
`were
`tendons
`The
`identified.
`incision
`extended
`carefully
`to the base of
`the fifth metatarsal.
`distally
`this
`At
`longitudinal
`tears were
`time,
`identified
`in the
`peroneus
`langus
`and peroneus
`brevis
`and at
`this
`tendons
`the tendons
`were
`debrided
`and at
`time,
`this
`they were
`repaired
`time,
`#2-0
`Ethibond
`and they were
`using
`tubularized
`at
`this
`time.
`The
`peroneal
`groove
`was
`inspected
`and it was noted
`to be deep
`in a proper
`anatomical
`position
`with
`the peroneal
`At
`tendons.
`this
`upon
`completion
`of
`the repair,
`time,
`a small
`incision
`was placed
`at
`the distal
`aspect
`of
`the peroneal
`retinaculum
`to place
`the peroneal
`retinaculum
`in order
`superiorly
`to cover
`and protect
`the peroneus
`brevis
`and peroneus
`longus
`tendons.
`At
`this
`#2-0
`time,
`using
`the peroneal
`retinaculum
`Vicryl,
`was repaired
`and was sutured
`in place. At
`this
`deep tissues
`time,
`were
`reapproximated
`#3-0 Vicryl
`and superficial
`skin was reapproximated
`staples
`and
`using
`#4-0 Prolene.
`
`using
`
`Sharma
`
`of
`
`ankle
`
`where
`
`Re: Sanjeev
`Page 2
`At
`this
`attention
`was
`time,
`the
`to
`directed
`lateral
`aspect
`the
`right
`another
`curvilinear
`incision
`was made
`over
`the location
`of
`the talofibular
`ligament
`over
`extending
`distally
`the talus.
`At
`this
`dissection
`was
`carried
`time,
`over
`the joint
`At
`capsule.
`this
`the anterior
`time,
`ankle was inspected
`and using
`a rangeur,
`osteophytes
`were
`identified
`and they were
`excised
`using
`a rongeur
`at
`the aspect
`of
`the anterior
`ankle
`and the medial
`gutter
`the ankle was also debrided
`of
`where
`the osteophytes
`were
`excised
`and passed
`off
`to the field
`for pathological
`evaluation.
`At
`this
`the wound
`was
`time,
`irrigated
`with
`normal
`saline.
`copiously
`The
`ankle
`was
`placed
`in range
`of
`motion
`and
`appropriate
`range
`of motion
`was
`satisfactory.
`At
`this
`attention
`was
`time,
`directed
`where
`the
`incision
`had
`been made
`over
`the ankle
`joint
`at
`the
`level
`of
`the anterior
`talofibular
`ligament
`and the periosteum
`was
`reflected
`from the lateral malleolus.
`At
`this
`the internal
`time,
`brace was used and the lateral malleolus
`was
`identified
`as well
`as the lateral
`aspect
`of
`the talus
`where
`a lateral malleolus
`3.5 SwiveLock
`was used and the hardware
`remained
`in their
`predrilled
`fibular
`home.
`At
`this
`the ankle joint
`was
`time,
`inspected
`and the hardware
`was not visualized.
`At
`this
`it was decided
`that a 4.75 SwiveLock
`time,
`was to be used in the lateral
`aspect
`of
`the talus. At
`this
`an internal
`brace was placed while
`time,
`the foot was everted
`and it was noted
`to be in proper
`anatomical
`correction
`at
`the right
`ankle.
`At
`this
`the joint
`capsule
`time,
`was
`reapproximated
`using
`#2-0
`Vicryl
`and
`tissues
`were
`reapproximated
`deep
`#3-0
`Vicryl
`and
`subcutaneous
`tissue
`was
`reapproximated
`#4-0
`nylon.
`At
`this
`using
`attention
`was directed
`time,
`to the medial
`aspect
`of
`the
`ankle.
`A small
`incision
`was placed
`over
`the lateral
`aspect
`of
`the medial malleolus.
`the C-
`Using
`screw
`was
`arm,
`identified.
`At
`this
`incision
`was
`time,
`deepened
`down
`through
`the
`level
`of
`subcutaneous
`tissues
`down
`to the level
`of bone,
`down
`to the level
`of
`the hardware
`was
`identified.
`At
`this
`a small mallet
`time,
`and osteotome,
`the bony
`using
`overgrowth
`was
`removed
`from on top
`of
`the screw.
`At
`this
`the wound
`was
`time,
`irrigated.
`At
`this
`the head of
`the screw had been
`time,
`identified.
`There was a cruciate
`type
`of screw.
`At
`this
`the screw was
`removed
`time,
`and passed
`off
`the field
`for pathological
`evaluation.
`At
`this
`the wound
`was
`time,
`reapproximated
`#2-0
`using
`Vicryl.
`incisions
`were
`reapproximated
`Deep
`#3-0 Vicryl
`and #4-0 Prolene
`was used on top
`using
`of
`it at
`this
`time
`to reapproximate
`all
`tissues.
`Upon
`completion
`of
`the procedure,
`the
`incisions
`were
`all
`irrigated
`with
`copious
`normal
`saline.
`The
`incisions
`were
`dressed
`with
`Xeroform.
`They
`were
`covered
`with
`dry sterile
`of 4 x 4s, Kling,
`and Webril.
`dressing
`this
`consisting
`a cast
`time,
`was placed
`the right
`lower
`extremity.
`it was
`bivalved.
`The
`Next,
`pneumatic
`ankle
`tourniquet
`was deflated.
`It was noted
`that prompt
`hyperemie
`response
`to all digits
`of
`the right
`foot and at
`this
`time, when
`the cast was placed
`and bivalved,
`it was noted
`that
`the patient
`tolerated
`the procedure
`and anesthesia
`well
`and was transferred
`to the recovery
`room with
`vital
`signs
`stable
`and vascular
`status
`intact
`to the right
`lower
`extremity.
`
`at
`
`At
`
`https://www.thenewprotocol.com/MTUsers/webmt30/print.asp?Hinfo=H1&Patno=59&Mod...
`
`5/6/2019
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`The New Protocol
`- Print
`NYSCEF DOC. NO. 5
`Report
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`Page
`3 of 3
`
`Submitted
`
`by,
`
`Manoj
`
`S dhnani, DPM
`
`DD:
`DT:
`
`04/17/2019
`04/18/2019
`
`AS/MS:
`APT
`
`ak/PS
`
`https://www.thenewprotocol.com/MTUsers/webmt30/print.asp?Hinfo=H1&Patno=59&Mod...
`
`5/6/2019
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`..
`NYSCEF DOC. NO. 5
`
`From: GFI FaxMaker
`
`To: Albert Samandarov
`
`Page: 1/2
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`PM
`Date: 1/15/20195:59:26
`
`ZWANGER-PBSIR
`RADIOLOGY
`
`I
`
`Levittown
`Turnpike
`3235 Hempstead
`NY 11756
`Levittown,
`(516)-544-5001
`Phone:
`(516)-544-5002
`Fax:
`
`:: Albert
`:: 31-16
`Astoria,
`
`Samandarov,
`30th
`Avenue
`NY 11102
`
`DPM
`
`Patient:
`MRN:
`Acc#:
`DOB:
`Home
`Exam
`Exam:
`
`Phone:
`Date:
`
`Sharma
`
`Sanjeev
`2657663
`17147612
`/1969
`(718)223-3748
`11:11
`1/14/2019
`MRI-3T
`RIGHT
`CONTRAST
`
`AM
`ANKLE
`| 73721
`
`NON
`
`MRI-3T
`
`RIGHT
`
`ANKLE
`
`NON CONTRAST
`
`HISTORY:
`
`N25.571
`
`Right
`
`ankle
`
`pain
`
`the
`
`right
`
`ankle
`
`was
`
`performed
`
`without
`
`IV contrast
`
`on a 3.0 Tesla
`
`TECHNIQUE:
`high-field
`
`of
`MR imaging
`wide-bore
`magnet.
`
`COMPARISON:
`
`None
`
`FINDINGS:
`
`The medial
`TENDONS/MUSCLES:
`and
`peroneal,
`flexor,
`long
`intact.
`There
`is flexor
`tenosynovitis
`above
`hallucis
`longus
`the
`of Henry.
`knot
`The Achilles
`is intact.
`is no muscle
`tendon
`There
`There
`is no evidence
`edema.
`of an accessory
`muscle.
`
`extensor
`anterior
`tendons
`joint
`and
`ankle
`at
`the
`or
`intramuscular
`atrophy
`
`are
`
`The
`LIGAMENTS:
`evaluated
`poorly
`
`and
`syndesmotic
`due to susceptibility
`
`ligaments
`lateral
`ankie
`artifact
`from hardware.
`
`are intact.
`
`The
`
`deltoid
`
`ligament
`
`is
`
`of a medial
`post
`AND CARTILAGE:
`BONES
`fracture
`malleolar
`fixation
`is status
`patient
`The
`distal
`and
`malleolus
`the medial
`from hardware
`artifact
`with
`susceptibility
`traversing
`tibial
`is an old,
`is grossly
`healed
`fibular
`fracture.
`shaft.
`There
`distal
`The
`talar
`dome
`lesions.
`intact
`without
`evidence
`lesion.
`of osteochondral
`There
`are no marrow
`replacing
`of
`is no evidence
`tarsal
`There
`coalition.
`There
`is mild
`cartilage
`loss
`partial-thickness
`the
`lateral
`aspect
`of
`joint.
`the
`The
`posterior
`tibiotalar
`cartilage
`of
`the
`subtalar,
`along
`talonavicular
`and
`is intact.
`calcaneocuboid
`There
`is mild
`partial-thickness
`joint
`cartilage
`at
`the middle
`joint.
`subtalar
`
`loss
`
`JOINT
`
`FLUID:
`
`There
`
`is a physiologic
`
`amount
`
`of
`
`joint
`
`fluid.
`
`No loose
`
`bodies
`
`are
`
`identified.
`
`BURSAE:
`
`There
`
`is no retro-Achilles
`
`or
`
`retrocalcaneal
`
`bursitis.
`
`PLANTAR
`
`FASCIA:
`
`Intact.
`
`A small
`
`heel
`
`spur
`
`is noted.
`
`NERVES:
`
`Unremarkable.
`
`This fax was sent with GFI FaxMaker
`
`fax server For more information,
`
`visit http://www.gñ
`
`com
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`From: GFI FaxMaker
`
`To: Albert Samandarov
`
`Page: 2/2
`
`Date: 1/15/2019
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`5:59:26 PM
`
`MRN:
`2657663
`Patient: Sanjeev Sharma
`Acc#:
`17147612
`
`.
`
`Exam Date: 1/14/2019
`MRI-3T RIGHT ANKLE NON CONTRAST
`Exam:
`| 73721
`
`Continued...
`
`TARSAL
`
`TUNNEL:
`
`No masses.
`
`TARSI:
`SINUS
`edema/cystic
`
`There
`changes
`
`Is diffuse
`in the
`
`scarring
`portion
`
`of
`
`tarsl
`sinus
`the
`within
`the
`talus marginating
`
`reactive
`and
`the sinus
`
`marrow
`tars).
`
`SUBCUTANEOUS
`
`TISSUES:
`
`Unremarkable,
`
`IMPRESSION:
`
`Findings
`
`compatible
`
`with
`
`sinus
`
`tarsi
`
`syndrome.
`
`Flexor
`
`hallucts
`
`longus
`
`tenosynovitis.
`
`Status
`evaluation
`
`malleolar
`post medial
`tibia
`of
`the medial
`
`with
`fracture
`fixation
`ligament.
`deltold
`and
`
`susceptibility
`
`artifact
`
`limiting
`
`Old healed
`
`fracture
`
`of
`
`the
`
`distal
`
`fibula.
`
`Mild
`partial-thickness
`subtalar
`at
`the middle
`
`cartilage
`joint.
`
`loss
`
`along
`
`the
`
`lateral
`
`aspect
`
`of
`
`the
`
`tibiotalar
`
`joint
`
`and
`
`Signed
`Signed
`
`by: Brett
`Helfner
`Date:
`1/1S/2019
`
`MD
`4:23
`
`PM EST
`
`Brett
`
`Helfner,
`
`M.D.,
`
`Ext.
`
`4604
`
`Reports
`
`and
`
`Images
`
`are available
`
`on the Physicians
`
`Portal.
`
`This fax was sent with GFI FaxMaker
`
`fax server. For more information,
`
`visit http://www.gfi.com
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`
`Exhibit
`
`D:
`
`Response
`
`to
`
`Verification
`
`Request(s)
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`
`American
`
`Transit
`5 Broadway,
`Phone:
`800-683-ATIC
`
`Insurance
`
`CompanY
`NY 11520
`Freeport,
`Fax: 212-857-8248/8278
`
`Date:
`
`06/07/2019
`
`MANOJ
`DPM, P.C
`SADNANI,
`& ASSOC,
`C/o SAMANDAROV
`250 JERICHO
`TPKE, STE 205,
`FLORAL
`PARK ,NY 11001
`
`PC
`
`RE:
`
`Verification
`
`# : AV001153809
`
`Claim #:677504-02
`
`Claimant
`
`: SANJEEV
`
`SHARMA
`
`Date of Loss
`
`: 04/02/2017
`
`Amount
`
`: 5,357.25
`
`D.O.S.:04/17/2019
`
`-04/17/2019
`
`* Additionai
`
`Verification
`
`Needed
`
`*
`
`First Request
`
`to 11NYCRR 65.3 - The Insurer may deny the claim if the applicant does not provide
`to insurance Reg. 68 - fourth amendment
`Pursuant
`within 120 calendar days from the date of the initial request either all such verification under the applicant's control or possession or
`written proof providing reasonable justification for the failure to comply.
`
`Dear Sir/Madam
`
`:
`
`We received
`bill pursuant
`
`bill. The following
`your
`65:15(d).
`to 11NYCRR
`
`verification
`additional
`Please
`Provide
`this
`
`is required
`in writing.
`
`in order
`
`to properly
`
`respond
`
`to your
`
`/ Coverage
`Medical
`of Benefits.
`
`Verification
`
`Assignment
`is delayed
`Bill
`pending
`W9 form.
`Provide
`the completed
`the right ankle.
`Provide MRI
`films of
`of
`Provide
`the intraoperative
`color photos
`the right andke
`For surgery/procedure
`please
`provide
`and related
`services
`reviewed
`prior
`this surgery/procedure
`to determining
`that
`of
`to the accident
`record.
`the medical
`(hospital/ER
`Submit
`records
`to the right ankle
`injuries
`sustained
`at
`treatment
`thereafter.
`
`for which
`surgery was performed.
`all document
`the surgeon/physician
`was medically
`and causally
`necessary
`
`related
`
`any medical
`and/or
`the time of accident
`
`records)
`to verify
`
`from the date of accident
`and the necessity
`injuries
`
`of
`
`to show
`
`1
`2
`3
`4
`5
`
`6
`
`First Request
`AV
`Page 1 of 2
`
`: 06/07/2019
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`
`American
`
`Transit
`5 Broadway,
`Phone:
`800-683-ATIC
`
`Insurance
`
`Company
`NY 11520
`Freeport,
`Fax: 212-857-8248/8278
`
`Date:
`
`07/12/2019
`
`MANOJ
`SADNANI,
`C/o SAMANDAROV
`250 JERICHO
`TPKE,
`
`DPM, P.C
`& ASSOC,
`STE 205
`
`PC
`
`FLORAL
`
`PARK ,NY 11001
`
`RE:
`
`Verification
`
`# : AV001153809
`
`Claim # : 677504-02
`
`Claimant
`
`: SANJEEV
`
`SHARMA
`
`Date of Loss
`
`: 04/02/2017
`
`Amount
`
`: 5,357.25
`
`D.O.S.: 04/17/2019
`
`- 04/17/2019
`
`* Additional
`
`Verification
`
`Needed
`
`*
`
`Second
`
`request
`
`to insurance Reg. 68 - fourth amendment
`to 11NYCRR 65.3 - The Insurer may deny the claim if the applicant does not provide
`Pursuant
`within 120 calendar days from the date of the initial request either all such verification under the applicants control or possession or
`written proof providing reasonable justification for the failure to comply.
`
`Dear Sir/Madam
`
`:
`
`We received
`bill pursuant
`
`bill. The following
`your
`to 11NYCRR
`65:15(d).
`
`verification
`additional
`Please
`Provide
`this
`
`is required
`in writing.
`
`in order
`
`to properly
`
`respond
`
`to your
`
`Medical
`/ Coverage
`of Benefits.
`
`Verification
`
`of
`
`was performed.
`for which
`surgery
`all document
`the surgeon/physician
`and causally
`was medically
`necessary
`
`any medical
`and/or
`the time of accident
`
`records)
`to verify
`
`from the date of accident
`and the necessity
`injuries
`
`of
`
`related
`
`to show
`
`Assignment
`is delayed
`Bill
`pending
`W9 form.
`the completed
`Provide
`films of
`the right ankle.
`Provide MRI
`color
`the right andke
`Provide
`the intraoperative
`photos
`please
`For surgery/procedure
`and related
`provide
`services
`prior
`reviewed
`to determining
`this surgery/procedure
`that
`record.
`to the accident
`of
`the medical
`(hospital/ER
`Submit
`records
`injuries
`sustained
`to the right ankle
`at
`treatment
`thereafter.
`
`1
`2
`3
`4
`5
`
`6
`
`AV Second
`Page
`1 of 2
`
`request:
`
`07/12/2019
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`
`SAMANDAROV
`& ASSOCI
`A T ˆ
`
`S ,
`
`P . C.
`
`Steve Samandarov
`______________---------------
`
`250 Jericho
`
`Turnpike,
`
`Suite
`
`205
`
`Fax:
`342-5543
`(516)
`-.ssiawny.com
`
`Anthony
`Aaron
`
`Alton
`J. Perretta
`Itingen
`Gregory
`Eli Shmulik
`Abraham
`Meir
`Sabiné Nicole
`
`Sciarrotto
`
`AMERICAN
`INSURANCE
`TRANSIT
`ONE METROTECH
`CENTER
`NY I 1201
`
`BROOKLYN,
`
`COMPANY
`
`SADHNANI,
`SHARMA
`
`PC
`
`Provider:
`Claimant:
`Claim #:
`Date of accident:
`of service:
`amount:
`
`Date(s)
`Billed
`File #:
`
`MANOJ
`SANJEEV
`
`67750402
`4/2/2017
`4/17/2019
`$5,357.25
`SS-113464
`
`Dear No Fault Claim Adjuster:
`
`10/8/2019
`
`This
`
`is in response
`
`to your
`
`verification
`
`request
`
`for
`
`the above
`
`referenced
`
`matter.
`
`Per your
`records
`
`request
`in support
`
`see the attached
`please
`of
`the above-billed
`
`AOB for
`ankle
`surgery.
`
`the above
`
`medical
`
`claimant, W9 for Manoj
`
`Sadnani,
`
`DPM,
`
`P.C. and
`
`is not
`client
`Our
`be better
`directed
`
`in control
`toward
`
`or possession
`the MRI
`
`facility
`
`of MRI
`
`films
`
`and relevant
`
`or hospital
`hospital.
`
`would
`
`records
`
`from the date of
`
`loss. Your
`
`request
`
`Intra-operative
`
`photos
`
`were
`
`not
`
`taken
`
`for
`
`the above-billed
`
`procedure.
`
`Our
`
`client
`
`has fully
`
`complied
`
`with
`
`your
`
`verification
`
`request.
`
`Please
`
`remit
`
`payment.
`
`Thank
`
`you.
`
`Yours
`
`truly,
`
`Steve Samandarov,
`
`Esq.
`
`

`

`FILED: KINGS COUNTY CLERK 04/26/2022 01:33 PM
`NYSCEF DOC. NO. 5
`
`INDEX NO. 511998/2022
`
`RECEIVED NYSCEF: 04/26/2022
`
`NEW YORK MOTOR VEHl©lf
`NO-PAULT INSURANCE LAW
`ASSIGNMENT OF BENEFITS FORM
`FOR ACOlDENT$ OCCURRENG ON AND AFTER S/1/02)
`
`1,
`Assignor")
`(P
`hereby assign to
`patient's name)
`aft rights prMleges
`and remedfem to payment
`(Print hospital or health care providername)
`AssigneeS)
`for hesith care services provided
`entitled under Art1ole st
`(the No-Fabit etatute) of the insurance Law.
`by assignee to which Iam
`The Assignse
`hereby certities
`that
`they have not received any payment
`shall not pursue) payment directl
`from or on trehalf of the Assignor
`fripm the Assigner
`due to the motor vehicle accidentiWhich
`for services provided
`and
`by asid Assignee
`for injurfee sustained
`occurred on
`, not withstanding
`.
`to the contrary,
`any other agreement
`(Prfnt accident date)
`This agreement enay be revoked by the assignme when honefts
`of covemga andf or violation
`are not payable based upon the assignoPs
`of a polloy condition
`due to the sotions or conduct
`of the assigner.
`ANY PERSON WHO KNOWINGLY AND WITH INTENT TO.DEFRAUD ANY (NSURANCE COMPANY OR OTHF.R PERSON
`FILES AN APPLICATION FOR CoylMERolAL
`(NSURANCE OR A STATEMENT OF CLAIM FOR ANY cOMMERCIAL OR
`PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALt.Y FALSE INFORMATION, OR CONCEAL$ FOR THE
`PURFOSE OF Ml$LEADINO.
`IN cONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY
`coNCERNING ANY FACT
`AND ANY PERSON WHO,
`SOLICITS OR CONSPIRES WITH A4IOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR
`CONVERSION OF ANY MOTOR 1/EHI01.E TO A LAW ENFOROEMENT AGENOY, THE DBPARTMENT OF MOTOR
`ASSISTS, ARETS,
`VEMICLES OR AN INSURANCE CDMPANY, C6MMITS A PHAUDULENT INSURANCE AOT, WH10H 18 A CRIME AND
`SHALL ALSD 15EISUBJECT TO A 8191L PENAl-TY NOT TO EXcase
`THE SUBJECT MOTOR VEHICLE OR$TATED CLAIM FOR EACH VlOLATION.
`FIVE THOUSAND Dol.LANS
`-
`
`INFOttlÿ