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Filing # 146080273 E-Filed 03/21/2022 12:45:19 PM
IN THE CIRCUIT COURT OF THE
NINTH JUDICIAL CIRCUIT, IN AND
FOR OSCEOLA COUNTY, FLORIDA
CASE NO.: 2021-CA-001958 MP
DIVISION:
VIVIAN CORTEZ DOMINGUEZ,
Plaintiff,
VS.
JUAN JAVIER OMANA, M.D., FLORIDA
HOSPITAL MEDICAL GROUP d/b/a
ADVENTHEALTH MEDICAL GROUP
GENERAL SURGERY AT KISSIMMEE and
ADVENTIST HEALTH SYSTEM/SUNBELT,
INC. d/b/a ADVENTHEALTH KISSIMMEE,
Defendants.
/
PROOF OF SERVICE
BEFORE ME personally appeared Catherine Fulenwider, who deposes and says
that affiant is over the age of 18 years and is not a party to the above-captioned
litigation, that affiant personally served the attached Subpoenas Duces Tecum Without
Deposition by serving a copy thereof by mail to:
Anthony Kirkpatrick, MD, PhD
International Research Foundation
1910 East Bush Boulevard
Tampa, FL 33612
_ on March 21, 2022.
Catherine mT
STATE OF FLORIDA
COUNTY OF ORANGE
Sworn to (or affirmed) and subscribed before me by means of __ X___ physical
presence or online notarization, this 21st day of March, 2022, by Catherine
Fulenwider who is personally known __X__ or produced identification . Type of
Identification Produced ;
(SEAL) Nn om
Sonam (ZY Lhamme
ay MY COMMISSION
:t-PNG ‘ss# GG 340071
EXPIRES: June 15, 2023
“TESERES Bonded Thru Notary Public Underwriters _|f :
Notary Public
2
IN THE CIRCUIT COURT OF THE
NINTH JUDICIAL CIRCUIT, IN AND
FOR OSCEOLA COUNTY, FLORIDA
CASE NO.: 2021-CA-001958 MP
VIVIAN CORTEZ DOMINGUEZ,
Plaintiff,
vs.
JUAN JAVIER OMANA, M.D., FLORIDA
HOSPITAL MEDICAL GROUP d/b/a
ADVENTHEALTH MEDICAL GROUP
GENERAL SURGERY AT KISSIMMEE and
ADVENTIST HEALTH SYSTEM/SUNBELT,
INC. d/b/a ADVENTHEALTH KISSIMMEE,
Defendants.
___________________________________/
SUBPOENA DUCES TECUM WITHOUT DEPOSITION
for records only
THE STATE OF FLORIDA:
TO: Records Custodian for
Anthony Kirkpatrick, MD, PhD
International Research Foundation
1910 East Bush Boulevard
Tampa, FL 33612
STOP!!!! PLEASE READ THE FOLLOWING INSTRUCTIONS VERY
CAREFULLY!!!! This is a one-time use subpoena, which permits only the
production of records. The subpoena CANNOT be used subsequently for
more records or for “update” records. The time limit imposed on this
subpoena are for records on this patient for the last TEN (10) years only
and for no time period beyond. This subpoena specifically excludes
without exception: in person conferences, phone conferences or any
further verbal or written communications, the creation of new reports, nor
the answer questions.
YOU ARE COMMANDED to furnish to Dinelia Concepcion, Estes, Ingram, Foels
& Gibbs, P.A., 2600 Lake Lucien Drive, Suite 330, Maitland, FL 32701, within ten (10)
days following receipt of this Subpoena, the following:
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Any and all office notes, charts, doctors' reports, x-rays or DICOM
disc of digital radiology studies, records, nurses' notes, admission
and discharge summaries, any and all other medical, psychological,
psychiatric, hospital or emergency room records of any kind or
nature whatsoever regarding examination, treatment and
evaluations, any and all materials reviewed, and any and all billing
records for the last ten (10) years including but not limited to, any
and all itemized billing statements pertaining to:
PATIENT: VIVIAN CORTEZ DOMINGUEZ
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:XXX-XX-
These items will be inspected and may be copied at that time. You will not be
required to surrender the original items.
You may comply with this subpoena by providing legible copies of the items to be
produced to the attorney whose name appears on this subpoena on or before the
scheduled date of production. You may condition the preparation of the copies upon
the payment in advance of the reasonable cost of preparation. You may mail or deliver
the copies to the attorney whose name appears on this subpoena. You have the right
to object to the production pursuant to this subpoena at any time before production by
giving written notice to the attorney whose name appears on this subpoena. THIS WILL
NOT BE A DEPOSITION. NO TESTIMONY WILL BE TAKEN.
If you fail to:
1. furnish the records as provided above; or
2. object to this subpoena,
you may be in contempt of court. You are subpoenaed by the following attorney to
produce the above-requested records, and unless excused from this subpoena by this
attorney or the court, you shall respond to this subpoena as directed.
DATED this 21st day of March, 2022.
Dinelia A. Concepcion
For the Court
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Attorney for JUAN J. OMANA, M.D., FLORIDA HOSPITAL MEDICAL GROUP, INC.
d/b/a ADVENTHEALTH MEDICAL GROUP GENERAL SURGERY AT KISSIMMEE and
ADVENTIST HEALTH SYSTEM/SUNBELT, INC. d/b/a ADVENTHEALTH KISSIMMEE
ESTES, INGRAM, FOELS & GIBBS, P.A.
2600 Lake Lucien Drive, Suite 330
Maitland, FL 32751
(407) 481-9449
Florida Bar No.:104953
**If your cost for copies of the requested documents exceeds $100.00, please
contact my office at 407-481-9449 for approval prior to incurring the charges.
5
CERTIFICATE OF HIPAA COMPLIANCE
(STATEMENT OF SATISFACTORY ASSURANCE/NOTICE)
Patient Name: Vivian Cortez Dominguez
Patient DOB:
Patient SSN: XXX-XX-
Our File No: 110-1552
Pursuant to HIPAA (Health Insurance Portability and Accountability Act of 1996)
[45 CFR §164.512(e)], Estes, Ingram, Foels & Gibbs, P.A. does hereby certify
compliance with all applicable HIPAA provisions and does certify that the attached
NOTICE OF PRODUCTION was served upon counsel of record for the above-listed
patient pursuant to Rule 1.351, Florida Rules of Civil Procedure. Pursuant to Rule
1.351, the above-listed patient has been given ten (10) days from the date of service of
the enclosed NOTICE OF PRODUCTION to serve and/or raise an objection to the
Court. This objection period has elapsed without any objection to this production
being raised, served or filed.
Please accept this CERTIFICATE OF HIPAA COMPLIANCE and its attachments to
serve as “satisfactory assurance” of HIPAA compliance as specifically defined and/or
set forth in 45 CFR §164.512(e)(1)(iii)(A)-(C).
45 CFR §164.512(e) Standard: Disclosures for Judicial and Administrative Proceedings. [HIPAA]
(1) Permitted Disclosures. A covered entity may disclose protected health information in the
course of any judicial or administrative proceeding:
(ii) in response to a subpoena, discovery request, or other lawful process, that is not
accompanied by an order of a court or administrative tribunal, if:
(A) the covered entity receives satisfactory assurance, from the party seeking the
information that reasonable efforts have been made by such party to ensure that the
individual who is the subject of the protected health information that has been
requested has been given notice of the request ….
(iii) [A] covered entity receives satisfactory assurances from a party seeking protected
health information if the covered entity receives from such party a written
statement and accompanying documentation demonstrating that: (A) the party
requesting such information has made a good faith attempt to provide written
notice to the individual; (B) the notice included sufficient information about the
litigation or proceeding in which the protected health information is requested to
permit the individual to raise an objection to the Court; and (C) the time for the
individual to raise objections to the Court has elapsed, and no objections were
filed ….
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Preview
Filing # 146080273 E-Filed 03/21/2022 12:45:19 PM IN THE CIRCUIT COURT OF THE NINTH JUDICIAL CIRCUIT, IN AND FOR OSCEOLA COUNTY, FLORIDA CASE NO.: 2021-CA-001958 MP DIVISION: VIVIAN CORTEZ DOMINGUEZ, Plaintiff, VS. JUAN JAVIER OMANA, M.D., FLORIDA HOSPITAL MEDICAL GROUP d/b/a ADVENTHEALTH MEDICAL GROUP GENERAL SURGERY AT KISSIMMEE and ADVENTIST HEALTH SYSTEM/SUNBELT, INC. d/b/a ADVENTHEALTH KISSIMMEE, Defendants. / PROOF OF SERVICE BEFORE ME personally appeared Catherine Fulenwider, who deposes and says that affiant is over the age of 18 years and is not a party to the above-captioned litigation, that affiant personally served the attached Subpoenas Duces Tecum Without Deposition by serving a copy thereof by mail to: Anthony Kirkpatrick, MD, PhD International Research Foundation 1910 East Bush Boulevard Tampa, FL 33612 _ on March 21, 2022. Catherine mT STATE OF FLORIDA COUNTY OF ORANGE Sworn to (or affirmed) and subscribed before me by means of __ X___ physical presence or online notarization, this 21st day of March, 2022, by Catherine Fulenwider who is personally known __X__ or produced identification . Type of Identification Produced ; (SEAL) Nn om Sonam (ZY Lhamme ay MY COMMISSION :t-PNG ‘ss# GG 340071 EXPIRES: June 15, 2023 “TESERES Bonded Thru Notary Public Underwriters _|f : Notary Public 2 IN THE CIRCUIT COURT OF THE NINTH JUDICIAL CIRCUIT, IN AND FOR OSCEOLA COUNTY, FLORIDA CASE NO.: 2021-CA-001958 MP VIVIAN CORTEZ DOMINGUEZ, Plaintiff, vs. JUAN JAVIER OMANA, M.D., FLORIDA HOSPITAL MEDICAL GROUP d/b/a ADVENTHEALTH MEDICAL GROUP GENERAL SURGERY AT KISSIMMEE and ADVENTIST HEALTH SYSTEM/SUNBELT, INC. d/b/a ADVENTHEALTH KISSIMMEE, Defendants. ___________________________________/ SUBPOENA DUCES TECUM WITHOUT DEPOSITION for records only THE STATE OF FLORIDA: TO: Records Custodian for Anthony Kirkpatrick, MD, PhD International Research Foundation 1910 East Bush Boulevard Tampa, FL 33612 STOP!!!! PLEASE READ THE FOLLOWING INSTRUCTIONS VERY CAREFULLY!!!! This is a one-time use subpoena, which permits only the production of records. The subpoena CANNOT be used subsequently for more records or for “update” records. The time limit imposed on this subpoena are for records on this patient for the last TEN (10) years only and for no time period beyond. This subpoena specifically excludes without exception: in person conferences, phone conferences or any further verbal or written communications, the creation of new reports, nor the answer questions. YOU ARE COMMANDED to furnish to Dinelia Concepcion, Estes, Ingram, Foels & Gibbs, P.A., 2600 Lake Lucien Drive, Suite 330, Maitland, FL 32701, within ten (10) days following receipt of this Subpoena, the following: 3 Any and all office notes, charts, doctors' reports, x-rays or DICOM disc of digital radiology studies, records, nurses' notes, admission and discharge summaries, any and all other medical, psychological, psychiatric, hospital or emergency room records of any kind or nature whatsoever regarding examination, treatment and evaluations, any and all materials reviewed, and any and all billing records for the last ten (10) years including but not limited to, any and all itemized billing statements pertaining to: PATIENT: VIVIAN CORTEZ DOMINGUEZ DATE OF BIRTH: SOCIAL SECURITY NUMBER:XXX-XX- These items will be inspected and may be copied at that time. You will not be required to surrender the original items. You may comply with this subpoena by providing legible copies of the items to be produced to the attorney whose name appears on this subpoena on or before the scheduled date of production. You may condition the preparation of the copies upon the payment in advance of the reasonable cost of preparation. You may mail or deliver the copies to the attorney whose name appears on this subpoena. You have the right to object to the production pursuant to this subpoena at any time before production by giving written notice to the attorney whose name appears on this subpoena. THIS WILL NOT BE A DEPOSITION. NO TESTIMONY WILL BE TAKEN. If you fail to: 1. furnish the records as provided above; or 2. object to this subpoena, you may be in contempt of court. You are subpoenaed by the following attorney to produce the above-requested records, and unless excused from this subpoena by this attorney or the court, you shall respond to this subpoena as directed. DATED this 21st day of March, 2022. Dinelia A. Concepcion For the Court 4 Attorney for JUAN J. OMANA, M.D., FLORIDA HOSPITAL MEDICAL GROUP, INC. d/b/a ADVENTHEALTH MEDICAL GROUP GENERAL SURGERY AT KISSIMMEE and ADVENTIST HEALTH SYSTEM/SUNBELT, INC. d/b/a ADVENTHEALTH KISSIMMEE ESTES, INGRAM, FOELS & GIBBS, P.A. 2600 Lake Lucien Drive, Suite 330 Maitland, FL 32751 (407) 481-9449 Florida Bar No.:104953 **If your cost for copies of the requested documents exceeds $100.00, please contact my office at 407-481-9449 for approval prior to incurring the charges. 5 CERTIFICATE OF HIPAA COMPLIANCE (STATEMENT OF SATISFACTORY ASSURANCE/NOTICE) Patient Name: Vivian Cortez Dominguez Patient DOB: Patient SSN: XXX-XX- Our File No: 110-1552 Pursuant to HIPAA (Health Insurance Portability and Accountability Act of 1996) [45 CFR §164.512(e)], Estes, Ingram, Foels & Gibbs, P.A. does hereby certify compliance with all applicable HIPAA provisions and does certify that the attached NOTICE OF PRODUCTION was served upon counsel of record for the above-listed patient pursuant to Rule 1.351, Florida Rules of Civil Procedure. Pursuant to Rule 1.351, the above-listed patient has been given ten (10) days from the date of service of the enclosed NOTICE OF PRODUCTION to serve and/or raise an objection to the Court. This objection period has elapsed without any objection to this production being raised, served or filed. Please accept this CERTIFICATE OF HIPAA COMPLIANCE and its attachments to serve as “satisfactory assurance” of HIPAA compliance as specifically defined and/or set forth in 45 CFR §164.512(e)(1)(iii)(A)-(C). 45 CFR §164.512(e) Standard: Disclosures for Judicial and Administrative Proceedings. [HIPAA] (1) Permitted Disclosures. A covered entity may disclose protected health information in the course of any judicial or administrative proceeding: (ii) in response to a subpoena, discovery request, or other lawful process, that is not accompanied by an order of a court or administrative tribunal, if: (A) the covered entity receives satisfactory assurance, from the party seeking the information that reasonable efforts have been made by such party to ensure that the individual who is the subject of the protected health information that has been requested has been given notice of the request …. (iii) [A] covered entity receives satisfactory assurances from a party seeking protected health information if the covered entity receives from such party a written statement and accompanying documentation demonstrating that: (A) the party requesting such information has made a good faith attempt to provide written notice to the individual; (B) the notice included sufficient information about the litigation or proceeding in which the protected health information is requested to permit the individual to raise an objection to the Court; and (C) the time for the individual to raise objections to the Court has elapsed, and no objections were filed …. 6