FILED: QUEENS COUNTY CLERK 09/20/2019 01:08 PM
`NYSCEF DOC. NO. 67
`
`INDEX NO. 708474/2019
`
`RECEIVED NYSCEF: 09/20/2019
`
`Exhibit
`
`27
`
`

`

`FILED: QUEENS COUNTY CLERK 09/20/2019 01:08 PM
`Make
`a one-time
`NYSCEF DOC. NO. 67
`FOX2
`BROOKLYN NY 11202-5108
`
`·.
`
`INDEX NO. 708474/2019
`QUICK
`PAY
`payment
`RECEIVED NYSCEF: 09/20/2019
`|
`
`EMERGENCY
`
`MEDICAL
`
`SERVICES
`
`.
`a
`
`.,.e...
`-!
`
`i
`
`For help with billing questions,
`please
`To pay online or update
`888-980-9325.
`your
`iiiaiticci, go to
`insurance
`b
`www.intermedix.com/billpay
`
`call:
`
`Fast
`
`Simple
`
`Secure
`
`Pay Online:
`
`www.intermedix.Com/bilipay
`
`Account Number
`
`Due Date
`Upon Receipt
`
`Amount Due Amount Paid
`$200.00
`
`Page 1 of 1
`
`Please
`
`make
`
`checks
`
`payable
`
`and
`
`remit
`
`to:
`
`IIIppilhIpplil;|p
`Sidia Castro
`4708 59th PI
`NY 11377-5653
`Flushing
`
`i 11EHi
`
`|HilPlIPlil•
`
`gl••HI H•l
`IliglP••lbl:pF|
`NYC Fire Department
`EMS
`PO BOX 27137
`NEW YORK, NY 10087
`
`IIE HPllP
`
`h• HªlH
`
`Check
`
`if address/insurance
`
`changes
`
`are on back
`
`Account
`
`Number
`
`Account
`
`Name
`
`Sidia Castro
`
`Date
`
`Service
`
`Description
`
`05/22/2019
`
`SIDIA CASTRO
`PATIENT:
`#: 1165
`INCIDENT
`Services
`Medical
`Emergency
`to EMS - Primary
`Payment
`insurance
`- Primary
`Insurance
`Adjustment/Assignment
`
`TOTAL
`
`BALANCE
`
`Please
`
`detach
`
`and return top portion with payment.
`
`Statement
`
`Date
`
`Due Date
`
`08/23/2019
`
`Upon
`
`Receipt
`
`Charges
`
`ay
`
`n
`
`sts
`
`e
`
`$818.50
`
`-$244.65
`-$373.85
`
`$200.00
`
`invoice
`This
`EMS on
`by New York Fire Department
`previded
`service
`is regarding
`ambulance
`to 71 - Mt.Sinai
`this
`portion
`of
`Meare HMO has paid their
`of Queens. Wellcare
`05/22/2019
`Hospital
`the
`deductible.
`If you believe
`that
`claim.
`You are responsible
`and/or
`for any
`copay,
`coinsunance,
`please
`from your
`provide
`proper
`documentation
`do not apply,
`de-Actit's
`and/or
`copay,
`coinsurance,
`this
`form
`insurer.
`please
`complete
`and sign
`the back
`If you have supplemental
`insurance,
`primary
`and return
`as it appears
`on your
`card.
`If
`it
`to us. Please make
`name
`is exactly
`insurance
`sure
`your
`you do not have additional
`deductible
`is your
`the copay,
`and/or
`insurance,
`coinsurance,
`payable
`andsis
`due within
`the next 30 days. Please make
`checks
`and money
`orders
`responsibility
`to NYC Fire Department
`on the check
`order. Credit
`EMS and include
`your
`account
`number
`or money
`cards
`are also eccephd.
`Please
`insurance
`do NOT send
`cash.
`To pay online
`or update
`your
`go to www.intermedix.com/b|i|pay.
`free to provide
`insurance
`Please
`contact
`us toll
`information,
`For a
`to make
`for any additional
`you may need at 888-980-9325.
`or
`a payment,
`aseishnee
`information,
`for
`less
`the full amount.
`To access
`limited
`some
`accounts
`of your
`may be settled
`than
`a copy
`time,
`web browser·
`online
`into your
`patient
`care report
`please
`type
`the following
`web address
`internet
`https://fdny.mypatientencounters.com/myrecord
`
`of
`
`MESSAGES
`In order
`to process
`your
`please
`your
`insurance
`provide
`claim,
`on the back
`of
`the form to PO Box 25108
`bill and mail
`this
`11202-5108
`or
`to 614-987-2074.
`To pay
`fax
`it
`go to
`online,
`If you
`are uninsured,
`or Have
`your
`exhausted
`www.intermedix.com/billpay.
`insurance
`benefits
`under
`and
`Federal
`for aid,
`you may
`Guidelines
`ualify
`be eligible
`for Financial
`of your
`ssistance
`regardless
`immigration
`status.
`Please
`use the above
`number
`to inquire
`our Charity
`Care
`Toll Free
`about
`guidelines.
`
`information
`NY
`Brooklyn,
`
`INSURANCE
`
`INFORMATION
`
`Primary:.....................
`Sidia Castro
`....................
`
`...
`
`..--.. -.Welicare Mcare HMO
`..
`amananman
`.............-..
`...............
`
`AMOUNT
`
`DUE:
`
`,
`
`

`

`FILED: QUEENS COUNTY CLERK 09/20/2019 01:08 PM
`Change
`of Address
`Name(Last,First,MiddleInitlel)
`NYSCEF DOC. NO. 67
`
`INDEX NO. 708474/2019
`
`RECEIVED NYSCEF: 09/20/2019
`
`Address
`
`City
`
`Telephone
`
`state
`
`ZIP
`
`For office use only - Patient Account Number 52775215
`Gliesmaania
`3 No
`ON LY the Patient
`
`J Yes
`
`complete
`
`Do You
`(if you
`
`Insurance?
`
`Have
`do not have insurance,
`
`Information
`
`section.)
`
`Patient
`Information
`Patient's First Name
`
`(Required
`
`Information)
`
`MI
`
`Patient's
`
`Last Name
`
`Patient's Date of Birth (MM-DD-YYYY)
`
`Patient's Social Security Number
`
`E-mail Address
`
`Patient's Sex
`J Female
`J Male
`Telephõñe Number
`(include Area Code)
`(
`)
`
`for payment
`responsible
`or any other payer
`to Medicare, Medicaid
`about me to release
`or other
`I authorize
`iniurmation
`any holder of medical
`to be
`this authorization
`in the future
`or in the past
`I permit a copy of
`for this related Medicare
`and any information
`of other
`needed
`claim, now.
`used in place of the original and request
`of medical
`benefits
`to the service
`payment
`insurance
`provider
`
`Signature
`
`to patient:
`Signer's
`relationship
`3 Self
`3 Other
`J Parent
`Signer's Street Address
`
`If other,
`
`please
`
`explain:
`
`Date
`
`City
`
`State
`
`Zip Code
`
`Medicare
`Medices
`
`Information
`ID (Include letter and numbers)
`
`Railroad
`J Yes
`
`J No
`
`Medicaid
`Medicaid
`
`Information
`ID (Include
`letter and ñümbers)
`
`State
`
`Patient
`Patient's
`
`Insurance
`First Name
`
`Information
`
`M1
`
`Patient's
`
`Last Name
`
`Insurance Company Name Q Primary J Secondary
`
`Insurance
`
`Policy Number
`
`Patient's Relationship
`J Spouse
`J Self
`Insurance Group Numbe r
`
`to insured
`J Other
`
`Insurance Company Address
`
`City
`
`State
`
`Zip Code
`
`Insurance
`Compensation
`Auto
`Accideiittharker's
`If services were related to an accident
`or injury, please
`worker's
`or liability.
`compensation,
`First Name
`Policy Holder's
`
`M1
`
`Insurance Company Name
`
`Insurance Company Address
`
`.
`
`provide
`
`any additional
`
`insurance
`
`information,
`
`such as homeowners.
`
`automobile,
`
`Policy Holder's
`
`Last Name
`
`h="=='a
`
`(
`
`)
`
`Contact Phone Number
`
`Insurance
`
`to Insured
`Patient's Relationship
`J Other
`3 Spouse
`3 Self
`Claim Number
`Policy Number
`
`City
`
`State
`
`Zip Code
`
`At-fault
`Information
`Insurance
`Party's
`Accident/Injury
`If services were related to an accident or injury, please provide any additional
`automobile, worker's compensation, or liability.
`er's First Name
`
`MI
`
`Policy Holder's
`
`Last Name
`
`!nsumnce Company Name
`
`Insurance Company Address
`
`Insurance Contact Phone Number
`)
`(
`
`Insurance
`
`City
`
`to Insured
`Patient's Relationship
`J Other
`J Spouse
`J Self
`Policy Number
`Claim Number
`
`State
`
`Zip Code
`
`insurance information
`
`for the respeeck
`
`party, such as homeowners,
`
`