Exhibit - Judiciary of New York
Transcript of Exhibit - Judiciary of New York
Exhibit
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
ICE FEDERAL TAX ID 26.1466969
INVOICE it: RX9093991
INVOICE DATE: 1/26/2012
NAME: JASON GIACALONE
CLAIM if: W000024420
CARDHOLDER ID: 170677848
ADJUSTER: Sheol Cich
I RECEIPT
IIMER WITH YOUR PAYMENT
.dibing M.D.ysIden I.D.)AW
Billed ByPharmacy (ifpaper claim) Fee Schedule Your Price Savings
ZMAN $0.00 $209.71 5202.03 $7.68
197825434
No Product Selection Indicated
ZMAN
197825434
No Product Selection Indicated
EMIT PAYMENT TO:
Sams Intemallonalanapolls, IN 46206-0881Free • 866.701.2781 Faxnc(gus-hstoom
5000 $35.32 534.18 $1.14
TOTAL AMOUNT DUE:
Amounts denoted by "(T are credits.PRE NEGOTIATED RATE - NOT SUBJECT TO REPRICE
$236.21
0001
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
aro Health SystemsINTERN A TION_AL
RX
NAME: NCA Comp
14 LaFayette Square
Suite 700
Buffalo, NY 14203
Attn:Steven GidwIts
CRISP Trust
INVO
DUE UPON
PLEASE INCLUDE INVOICE NU
DescriptionNDC Code
First Date of Drug Type Days Pram
Fill Service Pharmacy Name Q. Supply PP
Pharmacy 113
1/26/2012 113087 OXYCODONE HCL 30 MG TABLET 180 30 KREt
00228287911 14
Generic
GOOD DAY PHARMACY LLC
1154568400
1/2612012 113088 DIAZEPAM 10 MG TABLET 90 30 KREE
00603321521 14
Generic
GOOD DAY PHARMACY LLC
1154568400
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0002
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Jolson aiaaalone12171/1 t
ASSESSMENT:
I. Loweiback pain2. Lower extremity pain3. Palled back syndrome
PLAN;
' 1. Physical therapy; Continue medication3. Follow-up in one month
201201090015487
Isaac J. Kreitman, MD
Michael Garbulsky,RPA-C
LIK/CARMM130001/8144335182706290000
O
a0000
II • 00040
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
201201090015487
boon Ohmic=mitt
Cardin: Patient denies angina, edema, hypertension, palpitations, vascular problems, high bloodpressure, heart problems, Pulmonary Fibrosis, Congestive Heart Faihne, Caronaiy Artery -Eugene, high-cholesterol, and Peripheral Vascular Disease.Respiratory: Patient denies cough, shortness of breath, sputum production, wheezing, lung/breathingproblems, chronic obstruction pulmonary disesqe, resnictive lung disease, pulmonary hypertension,sarcoidosis, dyspnea, asthma, chest pain and bronchitis.GI: Patient denies abdominal pain, bleeding, bowel changes, dyspepsia, gastrointestinal problems,peptic ulcer disease, diverticulitis, hepatitis C, GERD, irritable bowel syndrome, neurogenic bladderproblem and colitis.GU: Patient denies dysuria, frequency, hematuria, incontinence and noctusia.Henze/Lymph: Patient denies anemia, easy bruising, excessive bleeding, lymphadenopathy, deep veinthrombosis and Hyperkalemia:Ithern.Paiiinfdenks neele Ow raid:brick pith, hilaterialehiP pain, bilateral kriee pain, bilateral anklepain; ilaiend foot pain; bilateral shbulder pain; bilateral elbow pain, bilateral wrist paha and bilateralhand pain. 'Endocrine; Patient dazzles hormonal abnormalities, polydipsia, polyuria, diabetes. hypothyroidism,Cellulitis and colon cancer.Nouse/Psych: Patient denies mood Omegas, paralysis, syncope, depression, cerebmvascular acciden• t,hemiplegia, dizziness, cerebral palsy, mental retardation, traumatic braininjuty, multiple sclerosis,headaches, psychiatric problemq, neurological problems, A.D.D. and sleep apnea. -Integumentary; Patient denies pruritus, rashes, skin eruptions, infection and shingles.
PIIVSICAL. EXAM:Vital Signs: .Upright BP a 120/80 mmHg _ •
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
u. I
Pulse... 80 bent. Patient is aftibrile . ' . . 000000Rasp 1.-- •15 000000 000000 Q 0
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General: Well nourlshecL Well dressed. Not in acute distress. a • 0 • 0
• •• • • MG•0 0 0 0 •
HEENT: Normocephalici Atraumatic. EOM are intact • .. • . •• O •0
Chest: Clear to auscultation bilaterally. No wheezing, no rates, no rhonchi. • • : • • • SO
CICV: There is a regular rate and rhythm. NOcmal 81-82. • :0000 00 b oos00
Abd: The abdomen is soft. Non-tender. Non-distended. Normal bowel sounds are presents . •Neck: No paraspinal tenderness noted. Full range of motion. . ..
Minch: No paraspinal tenderness noted. Full range of motion.LowEcla Bilateral 1.4-L5 and L5-S 1 paraspinal tenderness noted. Decreased range of motion.Extrem: There is no clubbing, cyanosis, edema, erythema and cellulitis.Rue: 375 tiade stringun No contracturies:Trufrazge of11616117-- ' - ' • • •LITE: 5/5 muscle strength. No contractures. Full /sage ofmotion. •RLE: 3/5 muscle strength. Decreased range &motion.LLE: 3/5 muscle strength. Decreased range of motion.Skin: No scars, rashes, lesions, ulcerations in the head, neck trunk, RUE, LUE, RLE, LLE.Lymph: Palpation of lymph nodes in neck, axillae and groin is narmal.Munn ORIENTATION: Alert & oriented x3. The patient understood remmAncl vvell. Attention spanand concentration were normaL Remote and Recent memory were normal. There is no deficits in cranialnerves I —XII. MOOD & AFFECT': No depression, no anxiety, no agitation. TESTCOORDINATION/GA1T: Normal coordination. Abnormal gait. EXAM OF DTR: Norraal 2+ BUB.Reflexes are normal to the upperextrtmlities. EXAM OF SENSATION: Normal to light touch andpinprick. Normal vibration.
2 as
0006
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
ter10-7. Health Systems
INTERNATIONAL
RX
NAME. NCA Comp
14 LaFayette Sguari
Suite 700
Buffalo, NY 14203
Attn-Steven Gidwitz
CRISP Trust
INVOICE FEDE
INVOI
INVOI
NAME, JASON GIACALONE
CLAIM 6: W0001124420
CARDHOLDER ID: 170677i
ADJUSTER. Sherrie Cich
First Date ofRI Service
DUE UPON RECEIPT
PLEASE INCLUDE INVOICE NUMBER WITH YOUR PAYMENT
DescriptionNDC Code
Drug Type Prescribing M D.Days Physician I.D.Pharmacy Name City. Supply OAWPharmacy ID
Billed ByPharmacy (ifpaper btairr) Fe
719/2918 116340 OXY6oDCINIE HCL 30 MG TABLET 180 30 KREIZMAN 50.00'
52152021502 1497825434
Genedc No Product Selection Indicated
GOOD DAY PHARMACY LLC
1154568400
7/9/2012 116341 CARISOPRODOL 350 MG TABLET 60 30 KREIZMAN SOAP
62756044602 1497B25434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LLC
1154568400
71912012 116342. DIAZEPAM 10 MG TABLET 90 30 KREIZMAN 'sop00603321521 1497825434
Swede No Product Selection Militated
GOOD DAY PHARMACY LLC
1154568400
,..:,(A• a ns* r:sewa C. e a a •
a • 4 • A •' 4 0 • • 4 *
e * t• • *IC a Is ,'J• a sin
PLEASE REMIT PAYMENT• • • 4• • •
F(6411) Skslenis•laterpejimal e:P.O. Box 881, Indianapolis, IN 46206-08818688982021 Toll Free • 866.70 1.2781 Fak
Email: ragus-lislcom
TOTAL AMOUNT DUE:
Amounts denoted by' a
PRE NEGOTIATED RATE
nIcTO c'FV
mitt:E.:WIT •
0007
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
41; HealthSystemsINTERNATIONAL
R X
NAME: NCA Comp
14 LaFayette Square
Suite 700
Buffalo, NY 14203
Attn: Steven Gidwitz
CRISP Trust
First Date ofFill Service
Description
NOG Code
FM' Drug Type
INVOICE
NAME: JASON GIACALONE
CLAIM #:: W000024420
CARDHOLDER ID: 170677848
PHARMACY: GOOD DAY PHARMACY LL
PHARMACY ID: 1154568400
ADJUSTER: Sherri Cich
DUE UPON RECEIPT
PLEASE INCLUDE INVOICE NUMBER WITH YOUR PAYMENT
DaysQty. Supply
Prescribing M. D.
Physician I.D..
DAW Fee
fl
IN
IN
Bitted by Pharmacy(if paper claim)
08/16/2011 0109836 DIAZEPAM 10 MG TABLET 90 30 KREIZMAN
00603321521 1497825434 i
Generic No Product Selection Indicated
-0 ):.• 0=
a —Iœ a
, —4-
loss..-14.- a CA2
• 0 0
D ODOO40 •• * •• • 0 0
PLEASE REOPAPIENTA: :0:
Or° o HeillttAyStgA5 tntemItierlat-9 P.B. Boxe881, Inailariapotis, IN 44206-0131
866.895.2021 Toll Free - 866.701.2781 FaxApia: vgnisliglerprn,
TOTAL AMOUNT DUE: I
Amounts denoted by "( )"are credits.
PRE NEGOTIATED RATE - NOT S
0 0 0 0 b 0 0
0 D 0 0 40
0 0 0 CO 0 0
0 0 • * 0 0 0 •
00 0 0 000 00
0008
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Health stemsINTERNATIONA_L
RX
INVOICE FE[
INV
INV
NAME: NCA Comp NAME: JASON GIACALO
14 LaFayette Square CLAIM It W000024420
Suite 700 CARDHOLDER ID: 17061
Buffalo, NY 14203 ADJUSTER: Sherd Cich
Attn:Steven Gidwitz
CRISP Trust
First Dale ofFIll Service
DescriptionNDC CodeDrug TypePharmacy NamePharmacy ID
DUE UPON RECEIPT
PLEASE INCLUDE INVOICE NUMBER WITH YOUR PAYMENT
DaysOty. Supply
Prescrtang M.D.Physician I.D.DAW
Billed ByPharmacy (ffpaper claim)
12/1/2011 0112008 OXYCODONE HCL 30 MG TABLET 180 30 KREIZMAN
52152021502 1497825434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LL
1154568400
12/112011 0112009 DIAZEPAM 10 MG TABLET 90 30 KREIZMAN
00603321521 1497825434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LL
1154568400
ct
0
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PLEASE REMIT PAYMENT TO:
Health Systems InternationalP.O. Box 881, Indianapolis, IN 48208-0881866,895.2021 Toll free - 866.701.2781 Fax
Email: rti@ius-hslcom
moo
Moo
TOTAL AMOUNT DU
Amounts denoled by V
PRE NEGOTIATED RA1
OK?
F !
0009
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
so Health SystemsINTERNirTIONAL
RX
INVOICE FEN
INVOI
INVOI
NAME: NCA Comp NAME: JASON GIACALONI
14 LaFayette Square CLAIM ft: W000024420
Suite 700 CARDHOLDER ID: 170677.
Buffalo, NY 14203 ADJUSTER: Shenie Clch
First Date ofFill Service
CRISP Trust
FtXtI
DUE UPON RECEIPT
PLEASE INCLUDE INVOICE NUMBER WMI YOUR PAYMENT
DescriptionNDC CadeOM Type Days Prescribing M.D.Pharmacy Name Oty. Supply Physician I.D.
Pharmacy ID DAW
Billed ByPharmacy OfPaper daisn) F(
1012512012 118619 CARISOPRCOOL 350 MG TABLET 90 30 ISAAC KREIZMAN
62756044602 1497825434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LLC
1154568400
1012512012 118620 DIAZEPAM 10 MG TABLET 90 30 ISAAC KREIZMAN
00172392760 1497825434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LLC
1154568400
1012512012 118621 OXYCODONE HCL 30 MG TABLET 120 30 ISAAC KREIZMAN
00603499221 1497825434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LLC
1164%8400
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PLEASE REMIT PAYMENT TO:
Health Systems InternationalP.O. BOX 881, Indianapolis, IN 46206-0881066.895.2021 Toll Free • 866.701.2781 Fax
Emall: [email protected]
$0.00
50.00
5060
TOTAL AMOUNT DUE:
Amounts denoted by 1r etPRE NEGOTIATED RATE
0010
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
NCACompiic
Claim Number:
Claimant:
Provider Tax ID:
Provider Ref:
Region: 04
DOS
cilIIaqirmtlF,4yrtrx.
Community Residence Savings Plan (CRISP) 2900 ,
W000024420
GIACALONE, JASON
222904421 Vendor: 222904421-0001
Geo Zip: 11228
SURICARE OF ENGLEWOOD
630 EAST PALISADE AVEENGLEWOOD CL, NJ 07096
11/00/2009 24
PPO ID:
NPI Number:
WCB Case Number
"Process Date: 09/22/2011
Control Number: 4891844
FOR Page 1 of 1
Rev/Aud: DM/DM
ExternalReview Procure
ICD-DX1: 724.4 Lumbosacral neuritis NOS
ICD-DX2: 722.10 Lumbar disc displacement
01935 ANESTHESIA PERO 148 1,875.00
TOTALS:
TOTAL RECOMMENDED ALLOWANCE:
Reason Code Reimbursement Description:
128 -THE ALLOWANCE IS BASED ON THE ANESTHESIA SERVICE PERSONALLY PERFORMED BYANESTHESIOLOGIST.
1,875.0
OK TO FEE SCHED:
AMOUNT TO PAY: W15
PAID:
405.15 128
0.00 0.00 405.15
405.15
Oat,
Unless otherwise stated, reimbursement Is made according to The Official New York Workers' Compensation Medical Fee Schedule. Reimbursement fortreatment rendered by out-of-state provklers is made based on the prevailing Workers' Compensation state fee schedule for the provider's geographical area.My reduction is due to the billed charges exceeding the fee schedule allowance for the service provided and/or the application of the appropriate discountsbased on the individual provider's agreement with the preferred provider organization. 0011
• Workers Compensation'
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
HEALTItiNSURANCE CLAIM FORMST NATIONAL UNIFORM CIAIMCCINIMITTEE OWO5
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22-2904421UN EIN
MIAGA PATIENT'S ACCOUNTED.
438142 00321.... •EWM.....162t240
RI-Two-noZ. TOTAL CHARGE
i 187510020. AMOUNT PAID
s 405111so0. ONJUICE CUE
14691 8521. SIGNATUREOF PhITS4CIAN OR SUPPLIER
INCLUDING DEGREESOR CREDENTIALSV catty Mal the Dahlman MOH DAWN
ZETricitentrift4h ri7".° "1')
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SURGICARE OF ENGLEWOOD CLI?NEW630 EAST PALISADE AVE
CL, NJ 07632184SSECAUCUS,
a& BILLING PROVIDER INFO if PH I ci0 i I33-1003
JERSEY ANES FIESTA GROUP, PPOB 1593
NJ 010961593• 4689726424 MER07431.8._",,. - 81669467049T ' '.. —innuattaa Manual available al: www nucamg PLEASEPRINT OR TYPE APPROVED OMB-0938.0999 FORM CMS-1500 (08-00c
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111111ewaissOwe
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
F
Jr
PMA Management Corp.
• IF YOU HAVE ANY QUESTIONS PLEASE CALL:Pxa r.Au cettrER
4T6-2669
201109060016814
00092
CHECK 110..: 200.9329278 ACCIDENT DT: 06/19/06CHECK. DATE: 02/28/11 PAYANT TYPE: WORKERS' COMP - MEDICALCHECK AIR.: $405.15 INSURED ' CRISP - COM RESIDENCE
PAY MUDD: 11/06/09-11/06/09 MAIN NO...: W-00-00-24420
1313 TO GATE: - POLICY NO..: 290500-125269-1
RATE INVOICE NO.: 438142'003
VOUCHER ND:000922690A INVOICE DT:.: 12/29/09
BILL NO : N1282E7953 INVOICE ANT: $1,65.00NEW JERSEY ANESTHESIA GR OUPP0131593SECAUCUS, NJ 07096' 1693
FRAM - Tout - PIPIT= 0111F 11FiCRTPTITIN
11/06/09 - 11/06/09 01935 i 500) AWES
TOTAL!
IRS NUMBER.: 22-2904421-PATIENT ID.: mom
INJURED SSN:INJUREDSSW1C09 DIAG;.: 724.4 722.10
PAGE 2 OF 2OTY int I Fn ANT PAYNFNT ANT RFASQU000 sims.00 cii
$1,575.00 1404,15 by,
EXPLANATION OF BENEFITS
01 RC 01 The charge for the procedure exceeds the Egmont indicated in the fee schedule.
IF YOU DISPUTE THIS PAYMENT AIIMINT, SUBMIT A CLEARLY NARKED UNLIT'S. NEWEST FORRE-REVIEW ALONG tam THIS EBB AND ALL SUPPORTING COMMENTS TO:PMA NW CORP. PO BOX 2854. CLINIC?' IA 52733-2054.
WAG
MAR 02 2011
00 4
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
tax sent by : ant 432 9762
EOB Reprint
Se/Vice Provides:
NEW JERSEY ANESTHESIA OROUPPOS 1500SECAUCUS. NJ 07096
201109060016814PHA INS CROUP
Melted*Check Sea 04/06/2011
Chedramount 90.00PIRA Voucher th konsterrt
86-57a b19111:25R Pg : 2/2
Aeddent date: 06119/00Insured: CRISP-'COMM RESIDENCE
PIRA Sham ik W00002.4420
P011050: 29 05 00 imamInvace 54381421003
Intiolee date: 1Invoice ant $1.075.00 •
Provider tax lb: 22240-4421 003
EntrW/Tenlah 500003Injured: JASON G1AOALONE
angered SPAS
10D3 nia 124.4722,10
Sandal Wee Rev/Service Codeallottlflers UMW Elated
11/06109 11/63/09 01935 0 $1,875.0011/0609 11/00/00 PMPP o $ONO
0 $11075.00
Biplisualoa at Senate Legendi
•NSFS ti No further payment diteas payment was found to be correct, waft to the state'stea schedule miss.
PMPP : AMOUNT PAIR ON A PREVIOUS OCCASION FOR THIS SILL
Allowed-
$405.15($405.15)
$0.00
Reason
NSPI3PMPP
00 5'
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
20110 90 6001 6814
NEW JERSEY ANESTHESIA GROUniPO Box 1593, Secaucus, NJ 07096-1593Phone 201435-1003 Fax 201-635-1332
Tax 111 Number: 22-2904421
March 14, 2011
PMA Managetnent Corp.Payment Dispute/Appeal DepartmentP.O. Box 2854Clinton, IA 52733-2854
RE;PATIENT CLAIM #:
DOS:BILLED AMOUNT:
Jason.GiacalorteW00002442011/06/2009$1,875.00 (INV.ACCNT. #:438142)
To Whom R May Concern:
Enclosed please find our Claim and Corresponding Explanation of Benefit on the abovereferenced patient. I am appealing the payment we have received as we feel the claim wassignificantly under paid.
We administered and:monitored this patient while under Anesthesia. The Anesthesia time of 148minutes converts to 10 Time Units, plus the Procedure Code 01935 Base Value Units of 5,equals a total of 15 Units billed. The Explanation of Benefit form indicates you utilized a feeschedule, but did not specify what fee schedule. Please let us know, exactly what fee scheduleare you referring to? Did.you have this claim processed through a network? If so, please specifywhich network,.so we may confirm our participation and contract rate.
I am enclosing the Anesthesia Report, for this date of service, to provide further Medicaldocumentation for reprocessing otirclaim for thefullreittrbursement we should receive.
Thank you, in advance, for your prompt attention. If you have any questions or requireadditional information, please contact our office at the address/phone number listed above.
Sincerely yours
Margoet ompsenBilling DepartmentEnclosures
0016
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
201109060016814
cfs, Phone 201-635-1003 EXT 28
o do 9 2
Fax 201-635-1332
• NewJersey Anesthesia Group, P.A.P.O. BOX 1.593 SECAUCUS, A 07096-1593
August 19; 2011
PMA Management Corp.Payment Dispute/Appeal DepartmentPO Box 2854Clinton, IA 52733-2854Attention: r Level Appeals
RE: Patient Name. Jason GiacaloneClaim Nunibeif W0011024"420Date of Accident June .19,2006
To Whom It May Concern:
This letter shall serve as a second level appeal of PRM Insurance decision to issuepayment at less than the usual and customary rate. Once again, we are resubmitting thepatient's progress notes and medical records and asking you to reconsider your decision.Please provide the fee schedule in which you utilized in calculating our claim payment.We feel this payment is extremely low for the services rendered.We are asking at this time that this claim be reviewed once again and also inform us of thefee schedule that was used as it states on your EOB. Once again I have enclosed ouroriginal claim tivith the anesthesia report, your EOB and our first appeal. If furtherinformation is needed, please do not hesitate to contact me at the number listed above.
Sincerity,
Jill N Perez
it>
Billing Office
0017
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
r201109060016814
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
NCACornp.VgrekLP rontOTIrciraigotlirr a,15194
Claim NumberClaimant:Provider Tax ID:Provider Ref:
Community Residence Savings Plan (CRISP) 2900
W000024420GIACALONE, JASON PPO ID:201270006 Vendor: 201270006-0001 NPI Number.
Geo Zip: 11220 WCB Case Number:
ISSAC KREZMAN5223 9TH AVEBROOKLYN, NY 11220
Process Date: 08103/2011Control Number: 4890129
FOR Page 1 of 1Rev/Aud: DM/DM
ExtemaiReview Procure
ICD-DX1: 724.2 LumbagoICD-DX2: 724A Lumbosacral neuritis NOS
Region: 04
DOB -iiSarylcaDeraddation !Unlit. :Charge 3R/WHi.,'FBPIRPC 0,1811r/Redi,:allowriner.Reasons.
04/2872011 11 99213 OFFICE OUTPT EST 1 64.07 0.00 24.07 0.00 40.00
05125/2011 11 99213 OFFICE OUTPT EST 1 64.07 0.00 24.07 0.00 40.00
TOTALS:
TOTAL RECOMMENDED ALLOWANCE:
128.14 0.00 48.14 0.00 80.00
80.00
PPO REDUCTION: Procura/MagnaCare - For questions regarding Network Discounts, please call: (877) 461-3750.
AMOUNT TO PA
'MD:
Unless otherwise stated, reimbursement is made according to The Official New York Workers' Compensation Medical Fee Schedule, Reimbursement fortreatment rendered by out-of-state providers Is made based on the prevailing Workers' Compensation state fee schedule for the provider's geographical area,Any reduction Is due to the billed charges exceeding the fee schedule allowance for the service provided and/or the application of the appropriate discounts 0019based on the individual providers agreement with the preferred provider organization.
* Workers Comnensation *
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
iiibraitted: 5/16/2011.
201107250014600
Last Itesubnitteth, 7/21/2011 00049
Doctor's Narrative Report EC-4NARFState of New York -workers' Compensation Board
THIS FQRM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL
This form may be used to report the first time you treated the patient or to report continuing services. (To report permanentImpairment, use Form C-4.3.) Use this form only if attaching a detailed narrative report. Please-answer all questionscompletely-and submit promptly to the Board, the Insurance carrier and to the patient's attorney or licensed representative,if he/she has one; if not Benda copy to the patient Failure to do sp may delay the payment of necessary treatment,prevent the finely payment of wage.ioss benefits to the injuredworker, create the necessity for tedtlmony, and jeopardizeyour Board authorization. 0-
A. Patient's Information LosooD9. S'Yoacl
1. Last Name: caatalone A First Name: Jason MI:
2 Social Security it• !Mb 3. Home Phone #: 7187538053• .
WCB Case # (if known): 00626p57
6. Mailing Address: 72 Bay 49th Street
City: Brooklyn
7. 1?ate °flow/onset of illness:6/19/20os
5. carrier Case # (If knOW4C3P000005924
State: la
Urte 2:
Zip Code: 11214 COUMW:
8. pate of trirth:1111$1978 a Gender: Male
10. On the date of Injunftiliness what was the patient's job title or discriplion:mime=
11. On the date of Injury/illness what were the patient's usual work activities:
yt injures:1 his back while at work
12. Is the patient working now? Yea 13. Patienes.Account #: 52892014o
B. Employer Information
1. Emobyer when injury occurred:
Company/Agency Name: Program ffevelopment
2. EmployerPhone #: 7192562212
3. Employer Address: 6916 Rev Iltreht Avenue
City: Brooklyn
C. Doctor's Information
1. Your Last Name: Et attgaan
State: err
2. WCB Authorization #: 206647-013
4. Federal Tax ID #: 201270006
5. Office Address: RAM Medical Pc
Une 2:
Zip Code: iszog Country:
First Name: Issa° MI:
3. WCB Rating Code: cam
a. •
The Tax ID # is the: Em
City: Brooklyn.
6. Billing Group / Practice Name
State: 97
Line 2: 5223 9th Avenue
rip Code: 11220 Country:
7. Billing Address: 5223 9th Avenue 41
City: Brooklyn
a Or= 1310M9 #: 001-819-9627State:la
Line 2:
Zip Code: 11228 Country:
9. Billing phone #:
10. Treating Provider's NPI #:1497925434 11. You are a: Physician
Prt-AttlAtIk (19-4111 Pane 1 of 7 THEWORKERVCOMWENSATION BOARD EMPLOYs AN0 SERVES
0020
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
o
D. Billing information
1. Employees insurance carrier:
2. Carrier Code #:
201107250014600
PMA 113DICAL BILLING
3. Insurance carrier's address:
City: JANESVILLE State: WI Zip Code: 53541 Country:
00044
PO BOX 6211 Line 2:
4. Diagnosis or nature of disease or injury:
Enter ICQ9 Code: ICD9 Descriptor
724.2 LUMBAGO1
2 724.4 TBOR/LMBOSACRL NVRIT/RAD/CULIT UNS
4
781.2 ABNORMALITY OOH' GAIT
Relate ICD9 codes above to Diagnosis Code column by line..
Dales of Seneca
from- , To
Rite
ofSeaga
.
LSOBlank
.Use WCB Cedes
.Poreedures, Services OfSuppliesCPT/HCPCS Mddiffer 1 Modiffor 2
DiagnosisCode $ Charges '
Days/Urals C013
ap cots meresmoke was ;Sere
4/28/2011 4/28/2011. .
li 99213 .. 12 64.07 1 11220 .
.• • C
'KTO FEE SCI1ED:
q
. jo
din MrMOUNTTOPiit( iVii.
PAID;. .
Ej Services were provided by a WCB preferred provider organization (PPO).
Total Charge
64.07
Amount Paid(Carder Use Oidy)
Balance Due(Carrier Use Only)
E. Doctor's Opinion
1. In your opinion, was the Incidentthat:the petard detcribed the competent medical cause of thls Injury/Illness? Yes
2. Are the:patients complaints consistentwith hisfher history of the Injuiyallnets? Yes
3. Is the patient's history of the injury/Illness consistent with your objective findings?
4. What Is the percentage (0-100%) of temporary Impairment? 100 • 00*
XIS
this i0/7/1 Is signed under penalty of perjury.
Board Authorized Health Care Provider:I Provided the services listed aboveMOTORIZED SIGNATURE ON FILE WITH NEW YORK WORKERS' COMPENSATION BOARD]
Providers Last Name: First Name: Mt
Providers Specialty:
Board AuthodzedHealttrCana Provider:
Last Name: Ri'ea-sses _First Name:Iosaa MI:
Date: 5/12/zou.Specialty: PETS/CAL hMDICINE/RWHABIL/TATION
•
Ec4NARR (12-10) Page 2 of 2r'l 0021
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
20110725003.4600
00044
Patlenh Jason GladaloneDOB:S514:Date: 04/28/11Attending: Isaac J. &aka MD
OFF:fiCEA SgT
HISTORY OF PRESENT ILLNESS:
The patient is status post multiple surgeries with &Aware at multiple levels in tit lumbar spine. He iscurtutlytaking roxycodine 30mg q.6h 0180, as well as Vellum 1 Omg bid. He has a severe antalgicgait 10/10 iathe bilateratlower extremities, right greater than left
CHIEF COMPLAINT.:
The patient compla1ns of severe gait pain with 10/10 pain in the bilateral lower extremities, rightgreater than let
DEGREE OF DISABILITY;
The patient 100% disabled at this point.
EXAM:
SOCIAL HISTORY:Alcohol: NoneTobacco: Patient is anon-smoker.Drugs: None.Toxins: None.Work: Patient is not cunrentlYworldng.Diet: Patient is not on any patticular diet.
FAMILY HISTORY:Noll-contributory.
MEDS:The patient is currently taking roxycodine 30mg q.6h #180, as well as Valium f0mgbid.
ALLERGIES:.No known allergies
PAST MEDICAL HISTORY:Non-contributory
SURGICAL HISTORY:No surgical history
REVIEW OF SYSTEMS:nn
06022
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
I Jason Glacatena0448/11
e-
201107250014600
00044
Censtitutionak Patient denies anyehange in weight, fevers and sweats. The patient denies any nausea,vomiting, diarrhea or diplopia.MIT: Parfait dr-01030y ear or nose problems, viand difficulties, ear abnormalities, Margin tumor.Throat: Patient denies any problems or swelling inthe mouth, neck problems or swelling and throatdisorders.Ceram Patient denies angina, edema, bypenension, palpitations, vascular problems, high bloodpreSSELM heart problems, Pulmonary Fibrosis, "valve Heart Failure, Coronary Artery Disease. high*cholesterol, and Peripheral Vascular Disease.Respiratory Patient defiles cough, dioramas of breath, sputnik production, vvheezing,luagtreathingproblems, chronic abstraction pulmonary disease, restrictive ling disease, pulnionary hypertension,samoidosis, dispnea, asthma, chest paid and bronchitis.GI: Patient denies abdominal pain, bleeding, bowel changes, dyspepsia, gastrointestinal problems,peptic ulcer disease, diverticulitis, hepatitis C, GERD, irritable bowel syndrome, neurogenie bladderproblem and colitis.GU: Patient denies dysuria, frequency, hematuria, incontinence and wawa.Heine/Lymph: Patient denies anemia, easy bruising, excessive bleeding, lyraphade;nopathy, deep veinthrombosis and Hyperkalemia).Rheu: Patient denies neck pain, mid-back pain, bilateral hip.pain, bilateral knee pain, bilateral anklepain, bilateral tor pain, bilateral shoulder pain, bilateral elbow pain, bilateral wrist pain and bilateral
Endpain.
Endocrine: Patient denies hormonal abnormalities, polydipsia, polytaia, diabetes, hypothyroidism,cellatitis and colon cancer.Neurallosyekr-Patient denies mood changes, paralysis, syncope, depression) eciehroimsenlar accident,hemiplegla, dirtiness, cerebral palsy, mental retardation, trauinatic brain injury, multiple sclerosis,headaches, psychiatdo problems, neurological problems, A.D.D, and dean apnea.Integumentary: Patient denies pruritus, rashes, skin eruptions, infection and. shingles.
PHYSICAL EXAMVital Signs:Updght BP =120/80 mmHgPulse = &O bpm, Went is afabrileResr 15GOMM: Well nourished. Well dressed. Not in acute distress.HEENT: Nonsocephidic, Alrawnatie. EOM are intact.Chest: Clear to auscultation bilaterally. No wheeling, no Tales, no rhonehi.CV: There is irregular rate and rhythm, Normal S1-82.AM: The abdomen is soft Nontender, Non-distended. Normal bowel sounds are presentNeck: No paraspinal tenderriess noted. Full range-of motion.lindScla No paraspind tenderness noted. Pull range of =gmLowEek: L4-L5 paraspind !tenderness noted. Decreased now of motion.Extreme There is no elubblifg, cyanosis, edema, erythema and collards, .KUb: 5/5 muscle strength.No contractures. Pull range of motion.LUE: 5/5 muscle strength. No contractures. Full range of motion.RLE: 3/5 muscle strength. Decreased range of motion.LIZ; 3/5 muscle strength: Decreased range ofmotion. •Skins No scars, rashes, lesions, ulcerations in the head, neck trunk, RUE, LUE, RLE, LLE.lAympli: Palpation of lymph nodes in neck, mdllae and groin is normal.Munn ORIENTATION: Alert & oriented x3. The patient understood command wen. Mention spanand concentration were normal. Remote and Recent memory were normal There is no deficits in aanial
2451)23
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
201107250014600• 00044-
Juan Ciltumlong04/2$/11
•nerves I—M. MOOD st AFFECT: No deptesSiontnn =MY, no nett TEST
• CGORDINATION/OAM Normal coordination. Antalgic gait. EXAM OF Mt Normal 2+ BUE.Reflexes are normal to the upper extremities. EXAM OF SENSATION: Degreased to light touch andPinPliVIL •
ASSESSMEEFF:
I. -Status post muldple surgeries with hardware at multiple levels in the lumbar spine2, Severe antalgie gait3. Bilateral lower exttemity pain, right greater titan left
?AA&
1. PhYskat gra'2. Flan OxyContin 30ns q.4h #1803. Valium 10mg b.i.d.4. lib Xenax
DEGREE OF DIMIIILITY:or.
'The patient 100% disabled* this point.
.t
Isaac J. Litman, MD
Michael Garbulsky, RFA-C
UK/CARMMO0001/814411909363541
it
3 tb24
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Submitted: 6/13/2011.
201107250014599
Last Resubmitted: 7/21/2011 00043
Dodoes Narrative ReportState onNew York- Workers' Compensation Board
THIS FORM MAYONLY BE.SUBMITTED ELECTRONICALLY. DO NOT MAIL.
This form may be used to report the first time you treated the patient or to report continuIngservices. (Td reportpermanentirhpaimient, use Form C-4.3.) Use this formality if attaching a detailed narrative report. Please answer a questionscompletely and submit promptly td the Board, the insurance carrier and to the patient's attorney or licensed representative,If he/she has one; if not send a copy to the patient. Failure to do so may delay the payment of necessary treatment,prevent the timely payment of wage loss benefits to the inLured worker, create the necessity for testimony, and jeopardizeyour Board authorization.
A. Patient's Information w cee02Yna
1. Last Name: Glacial-me First Name: Jason
2. Social.Sehurity #: 3. Horne Phone # 7187538953
4. WCB Case # (if known): 0°828°57 5. Carrier Case # known): CSP000005824
6. Mailing Address; 72 Bay 49th Street
City: Brooklyn
Line 2:
EC-4NARF
State: 142 Zip Code: 11214
7. Date of Injury/onset of Illness:6/re/2906 8. Date of birthe-972 9. Gehder: Kale
10. On the date cif injuryMIness what wa6the patient's job title or description:unknown
Country:
11. On the date of injury/illness what were the patient's usual work activities:pt injured his back while at work
•
12. Is the patient working now? Yes 13. Patient's Account # 028820wo
B. Employer Information
1. Employer when injury occurred:
.Company/Agency Name: program Development
2. Employer Phone #: 7182562212.
a Employer Address: 6916 New Utreht Avenue Line 2
City: Brooklyn State: try Zip Code: 11209 Country:
C. Doctor's Information •
1. Your Last Name: scr°4zzaan First Name: Issue Mt
2. WCB Authorization #: g06647-013 3. WCB Rating Code: aural
4. Federal Tax DM 201.270006 The Tax 10 # is the: arc
5. gime Address: PARS Medical PC Line 2 5223 9th Avenue
City: Brooklyn
O. Billing Group/ Practice Name
State: 112 Zip Code: 11220 Country:
7. Billing Address: 5223 9th Ave-hug Line 2:
City: Brooklyn State: Ns • Zip Code: 11220 Country:
a office phone* 201-818-8627
10. Treating Provider's NPI #:1497825434
9. Billing phone #:
11. You area: Physician 0025
mr...4MARR 1119.4111 Panes 1 nf1 THEIMORKERS COMpEasAMN BOARD EMPL0YSAND SERVES
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
D. Billing Information
1. Employer's Insurance carrier:
2. Carrier Code #:
201107250014599
PbM. MEDICAL BILLING
a Insurance carrier's addtess: PO BON 5231 Lite 2:
00043
City: JANESVILLE State: VTI Zlp Code: 53047 Country:
4 Diagnosis or nature of dsease or inay:
Enter ICD9 Code:
1 724.2
2 724.4
3 781.2
4
(CMDescriptor
LUMBAGO
THOR/LUMBOSACRL NURIT/RADICIILIT UNS
AUNOIDIALITY or GAIT
Relate ICD9 codes above to Diagnosis Code column by lint
Dates of Service
From To
' Placeof
ServiceLeaveBlank
-Use IAMB CodesWocedines Services eaupptles
CPUHCPCS Modiffer1 Motfffer?DiagnosisCode S Charges
'MaidUnits COB
21p Code Mereservice ma renders
5/25/2011 5/25/2011 11 99213 12 64.07 I 11E20- . . .
•
. •.
— .,
.
•. •
•
. . • -
• et. •
"
jj Services were provided by a WCB preferred provider organization (PPO).
Thial Charge
64.07
Amount Pald(Carrier Use Only)
Balance Due(C.Arrier Use Only)
E. Doctor's Opinion'
1. In your opinion, was the inddent that the patient described the competent medlcal cause of this injury/IllnessT Yes
2 Are the patient's complaints consistent with histher history of the injuryfillness? Yes
3. Is the patient% history of the InjuryAllness consistent with your objective findings?
4: What is the percentage (041010 of temporary impairment? lop oos
This form is signed under penalty of perjury.
Board Authorized Health Care Provider.I Provided the services listed above
(NOTORIKED SIGNATURE ON PILE WITH NEW YORK DOREN:RS COMPENSATION BOARD]
Yes
Provider's Last Name: . .
Provider's Specialty:
First Name:
Board Authorized Health Care Providgfr
Last Name: Krei-zoan First Name:Issac MI:
Specialty: PHYSICAL DEDICiNE/R63A8/LITATION 'D; 6/13/2011
Ml:
EC-4NARR (12-10) Page 2 of 2 0026
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
201107250014599
11110ssentensrmw
00043 '
Patient: keen GineateneDOM
Date; 5125111Attending: fame 1. Kamen, MD
• HETTORY OF PRESENT ILLNESS:
The patient is status injury sustained at work to the lower back with multiple surgeries to the lumbarspit* He is not currently working. He is currently takine roxycothne 30mg 2 t i.d, and Valiuml0mgbd.d. The patientfailed a course of physical therapy, surgery and consexvallve treatment The patient
. has lower back failure syndrome, The patienthas 10/10 pain with difficulty with quality oflife andreduced ADLs.
CHIEF COMPLAINT:
The patient complains of 10/10 pain tote lower back.
EXAM:
SOCIAL HISTORY:Alcohol: NoneTobacco: Patient is a non-smoker.Drugs: None,Toxins: None.Work: Patient is currently not working.Diet: Patient is not on any particular diet.-
RAWLY HISTORY:Non-contributory.
MEDS: ."He is currently taking roxycodine 30mg 2 tea and Valium IOmg
ALLERGIES:No known allergies
PAST MEDICAL HISTORY:Non-contributory
SURGICAL HISTORY:No surgical history
REVIEWER? SYSTEMS: 0Cansdtutional: Patient dente:way change in weight, fevers and Arcata. The patient denies any nausea!*vomiting, &Mina or diplopia.ENMT: Patient denies any ear or nose problems, visual difficulties, ear abnormalities, and brain tumor.
of 30027
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NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
20110725001459900043- •
Throat Patient denies any proldems or swelling ha the mouth, neck problems or swelling and throat .disorders.Cardin: Patient denies angina, edema, hypertension, palpitations, vascular problems, high bloodpressure, heart problems, Pulmonary Fibrosis, Congestive Heart Failure, Coronary Artery Disease, high-cholesterol, and Peripheral Vascular Disease'Respiratory: Patient denies cough, shortness of breads, sputum production, wheezing, hang/breathingproblems, chronic obstruction pulmonary disease, restrictive:lung disease, pulmonary hypertension,sarcoldosis, dyspnea, asthma, chest pain and bronchitis.
Patient denies abdominatpain, bleeding, bowel changes, dyspepsia, gastrointestinal problems,peptic ulcer disease, diverticulitis, hepatitis C, GBRD, htitablelowel symkome, neurogenio bladderproblem and colitis.GU: Patient denies dysznia,.equenoy, hematuria, incontinence and nocturia.Heme/Lymplu Patient deniettmenda, easy.bruising, excessive bleeding, lymphademmathy, deep veinthrombosis and Hyped:demi&Rhen: Patient denies neck pain, mid-back pain, bilateral hip.paln, bilateral knee pain, bilateral aidepain, bilateral foot pain, bilateral shoulder pain, bilateral elbow pain, bilateral wrist pain ind bilatendbut pain.Endocrine: Patient denies hormonal abnormalities, polydipsia, pnlyuria, diabetes, hypothyroidism,cellnlitis and colon cancer.Newt/Psych: Patient denies mood changes, paralysis, syncope, depression, cetebrovascular accident,headplegia, dizziness, cerebral palsy, mental retardation, traumatic hulk injury, multiple sclerosis,headaches, psychiatric problems, neurological problems, A.DD. and sleep apnea.Integnmentaryt Patient denies pruritus, rashes, akin eruption; infection and shingles.
PHYSICAL EXAM:Vital Signs:.Upright BP =120/80 mmHgPulse = 80 bpm. Patient is febrileReap =15
General: Well nourished. Well dressed. Not in acute distress.MEND Nonnocephalk, Arraumatic. EOM are intact.Chest: Clear to auscultation ifilaterally. No wheezing, no rules, no rhonchi.CV; There is a regular rate and rhythm. Normal S1-82.Abd: The abdomen is soft Non-tender. Non-distended. Normal bowel sounds are present.Neck: No parasphialtendemess noted. Full range of motion.MIdItch: No paraspinal tenderness noted. Full range emotion.Lowliclul4 and L4-L5 paraspinal tenderness noted. Decreased range ormotion with neurologicaldeficits.Extrema: There is no clubbing, cyanosis, edema, erythema and cantinas.RUE: 5/5 muscle strength. No contractures. Full range of :notion.IDE: 5/5 muscle strength. No contractures. Full range of motion.?LE: 5/5 muscle strength. Uiuited range emotion.LLEr 5/5 Muscle strength. Limited maga Ofinotion:Skin: No scars, rashes, lesions, ulcerations in the bead, neck tnmk, RUB, LUE, R1.11, LLE.Lymph: Palpation of lymph nodes in neck, aniline and groin is normal.Nam: ORIENTATION: Alert & oriented /C3. The patient understood comntand well. Attention spanand concentration were normal. Remote and Recent memory were normal. There is no deficits in cranialnerves I —301. MOOD & AFFECT: No depmssion, no anxiety, no agitation: TESTCOORDINATION/GMT: Nonaal coordination. Gait disoider. EXAM OF DTE: Normal 2+ BUB and
• 2orto28
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NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
201107250014599 .00043
•
BU3. Reflexes are normal tO the loiirer extremidei and Upper eitreniitiesi EXAM OF SENSATION:Decreased to lien touch and pinprick to thelowor extremities. .
ASSESSMENT:
I. Lower back pain2. Lumbosacratradieulopthy3. Gait disorder
1. Continue current medicatigns2. Follow-op in one month fl
DEGREE OF IRSABILITV:
The patient is not eturently. waiting. .
Isaac Dein:Gan, MTp
Michael Garbs:Sty, Rieke
DIUCARMMG0001/814414610194230
3 of30029
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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GIACALONE, JASON 12 ti'l AM ErRxe: 108135 Date Meet 412s2011ttl 80 OXYCODONE HCL TAB 30IVIGDr. ISAAC KREITMANRefills: 0 r Dec : $22.5.00Pins c
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newt Cutunallbig Far: GIACALON E., JASONRrit:101139NDrag: OXYCODONE HCL TAB 30MGWHY IS IT PRESCRIBED?For the relief of moderate to severepain.
HOW MEDICINE ISADMINISTERED?Use this medicine exectlyasdirected on the label, unlessinstructed differently by yourdoctorThis medicine can betaken with or
without food, REGARDLESS of mealtimes. 11 stomach upset occurs, take
You may report side effectsto the FDA at 1-800-FDA-1088.
0030
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
State of New YorkWORKERS' COMPENSATION BOARD
CLAIMANT'S RECORD OF MEDICAL AND TRAVEL EXPENSES
AND REQUEST FOR REIMBURSEMENT
CLAIMANTS NAME WCB CASE NO. SOCIAL SECURITY NO.
•a e? 00 C916RESIOENTIAL ADDRESS MAILING ADDRESS (IF DIFFERENT)
-u ba,y Lki-fh 6-ifee-YBstoKi3., Nk31 naiti.
In connection with lhe aboye workers compensationcase, you are entitled lo be reimbursed for (1) drugs,crutches or any apparatus properly prescribed by yourdoctor and for (2) lares, automobile mileage or (ternecessary expenses going lo and from your doctor'soffice or the hospital.
To help you keep a record of such expenses we haveprovided this form. In order lo help insure that you areproperly reimbursed, list each item of expense below—whether or not you obtained a receipt (whereverpossible obtain receipts). Submit the completed formand copies of all receipts or bilis to the workers'compensation insurance carrier (or to youremployert,51f,°Self-insured) and to lhe Workers'!S,oinpensition: Board. (See Board addresses onº.redkse.) that you retain a copy of the
for yarrratords.I'vVet
; ; •Stint.0.4.•0
• osaan• s *0•
.eg•tt
En relación con el caso de compensación paratrabajadores antes mencionado, usted tiene derecho arecibir un reembolso por (1) medicamentos, muletas ocualquier aparato indicado como corresponde por sumédico y (2) tarifas, mili* de automóvil u otros gastosnecesarios para trasladarse desde y hasta e/ consultorio
de su médico u hospital.
Le proporcionamos este formulario para ayudarlo allevar un registro de esos gastos. Con el objetivo degarantizar que usted reciba el reembolsocorrespondiente, enumere cada ítem de gasto acontinuación, tenga o no un recibo por ese gasto(siempre que sea posible, intente obtener un recibo).Envie el formulario completo y copias de todos losrecibos o facturas a la compañía de seguros decompensación para trabajadores (o a su empleador encaso de que tenga un seguro propio) y a la Junta deCompensación para Trabajadores (Workers'Compensation Board). (Consulte las direcciones de laJunta en el reverso). Le sugerimos que guarde unacopia de los recibos y facturas para sus registros.
sí"' ° NyilRF OF EXPENSE / TIPO DE GASTOS DATE / FECHA AMOUNT / CANTIDAD
meá O' ';'1/4-\ 4/9, gia0 I/ 9%?\S- Dõ
(fiad i c.41-ion) a a,51- O o
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OME SCHENifikliak,..UNT TO HAY e 1 õ (1)i: R\ I iN‘Ç.Ov-
Continue on Reverse. - Sigue al dorso.
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINA-ni:n.49031
C-257 (9-10) LA JUNTA DE COMPENSACIÓN OBRERA EMPLEA Y SIRVE A PERSONAS INCAPACITADAS SIN DISCRIMINAR. (A
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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WHY IS IT PRESCRIBED?For the relief of moderate to severepain.HOW MEDICINE ISADMINISTERED?Use this medicine exadly asdirected on the label, unlessinstructed differently by yourdoctor'This medicine can be taken with orwithout food, REGARDLESS of mealtimes. tl stomach upset occurs, take
You may report side effectsto the FDA at 1-800-FDA-1088.
0032
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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GIACALONE, JASON n: FAX 0111.1151.11121RIM 109015 Date Met e232011
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If symptoms are mild but do not goaway or are bothersome, checkwith
You may report side effectsto the FDA at 1-800-FDA-1088
0033
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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CIACALONE, JASON 73 5- L.
Fts9: 109403 Date Filled: 7/19/2011MOO OXYCODONE RCL TAO 30MGDr. ISAAC KREIZNIANRefills: 0Plien C
Due : 6225 00
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0034
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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Page: 1
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1311.00XLYN NY 11214
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Date; 11/15/2011 GOOD DAY PHARMACY LLC Page: 24908 7th Avenue
Brooklyn NY 11226Phone: (78051-8826 Fax:(718)851-8827
RX Record From 1a/011 12:00:00 AM To 8115(2011 1200:00 AM
CLIENT 1 GENDER MGIACALONE, JASON72 BAY 49TI-1 ST
BROOKLYN NY 11214
DdIB: gim(1978LD.: 170677348TEL: (718)753-8933
niad/OMwed PSI Rent Drug Nara NOM Oly/Bays Proscriber Name Amami* Pal Pabi R.Ph
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TAKE ONE TABLET EVERY 4HOURS ASNEEDED FOR PAIN
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
rleaRL loybwri15INTERNATIONAL
RX
0•101.1•0•3100.••• FEDERAL TAX IU Z6-14t6867
INVOICE #. RX9150257
INVOICE DATE: 9/2712012
NAME: NCA Comp NAME: JASON GIACALONE
14 LaFayette Square CLAIM#: W000024420
Suite 700 CARDHOLDER D: 170677848
Buffalo, NY 14203 ADJUSTER: Sherrie etch
First Date ofFill Service
CRISP Trust
RX#
DescriptionNDC Code
Dnig TypePharmacy Name
Pharmacy 10
DUE UPON RECEIPT
PLEASE INCLUDE INVOICE NUMBER WITH YOUR PAYMENT
Presaibing M. D.Days Physician t.D.
Qty. Supply DAW
Billed ByPharmacy (ifpaper claim) Fee Schedule Your Price Savings
9/27/2012 117956 OXYCODONE HCL 30 MG TABLET 120 30 KREIZMAN $0.00 5141.47 5136.35 55.12
52152021502 1497825434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LLC
1154568400
9/27/2012 117957 CARISOPRODOL 350 MG TABLET 90 30 KREIZMAN $0.00 $47.92 $46.31 $t61
62756044602 1497825434
Ganent No Product Seleceon Indicated
GOOD DAY PHARMACY LLC
1154568400
0/27/2012 117956 DIAZEPAM 10 MG TABLET 90 30 KREIZMAN $0.00 535.32 534.18 $1.14
00603321521 1497825434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LLC
1154568400
COO
e •
I
0
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•
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p•• •
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.. Health Systems InternationalP.O. Box 881, Indianapolis. IN 46206-0881866.895.2021 Toll Free • 966.701.2781 Fax
Email: nuggus-hsLcom
TOTAL AMOUNT DUE
Amounts denoted by “()' are credits.PRE NEGOTIATED RATE - NOT SLIBJEC7EPRICE
—.rte fll
$216.84
0037
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Health System s::0. . .
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NAME: NCA Comp
14 LaFayette 5ennre:State 700
Buffalo, NY 1°4203 °
Attn: Steven Gidwitz
CRISP Trust
First Date ofFIR Service
Description
NDC Code
RX# Drug Type
•00
0
•
000
INVOICE
NAME: JASON GIACALONE
CLAIM #:: W000024420
CARDHOLDER ID: 170677848
PHARMACY: RITE AID PHARMACY
PHARMACY ID: 1104936921
ADJUSTER: Christine Str-assle
DUE UPON RECEIPT
PLEASE INCLUDE INVOICE NUMBER WITH YOUR PAYMENT
DaysQty. Supply
Prescribing M. D.
Physician 1.0..
DAWBilled by Pharmacy
(if paper claim) Fee
07/200011 0567084 DIAZEPAM 10 MG TABLET 90 30 BROZMAN
00172392770 1497825434
Generic No Product Selection Indicated
TOTAL AMOUNT DUE:
Amounts denoted by "( )•are credits.
PRE NEGOTIATED RATE - NOT
OK TO FEE SUED:
AMOUNT TO PAY:
PAID
1e PLEASE REMIT PAYMENT TO:
Health Systems InternationalP.O. Box 881, Indianapolis, IN 46206.0881866.8951021 Toll Free • 866.701.2781 Fax
Emalt raus-hsi.com
0038
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Claim Number: W000024420Claimant: GIACALONE, JASON PPO/OSR ID:
Provider Tax ID: 113630760 Vendor: 113630760-0001 NPI Number:
Provider Ref: Geo Zip: 11214 \ run Case Number:
LENCO DIAGNOSTIC LAB1857 86TH STRETEBROOKLYN, NY 11214
Community Residence Savings Plan (CRISP) 2900Process Date: 10/2f12012
Control Number: 497912
FOR Pai of 1,Rev/Auct: Sti/DM
itExternalReview Procuria
ICD-0X1: V58.69 Long-term use meds -NEC
Region: 04
BR/Rert,
'DO Ccde --- Service Description Units Charge. PO/Red' , Other/Red
08106/12 81 80100 DRUG SCR QUAL MLT 10.000 600.00 277.40 165.70 0,00
08106/12 61 82145 AMPHETAMINE/METH, 1.000 150.00 113.34 27.48 0.00
08106/12 81 83789 MASS SPECT8TANDEI 1.000 250,00 217.01 18.45 0.00
TOTALS: 1,000.00 607.75 211.63 0.00
TOTAL RECOMMENDED ALLOWANCE:-
Reason Code Reimbursement Description:
309 -THE CHARGE FOR THIS PROCEDURE EXCEEDS THE FEE SCHEDULE ALLOWANCE.
Magnacare - 1600 Stewart Avenue, Ste 700 Westbury NY 11590 800-235-7267
Allowance Reapns
156.90 309
9,18 309
14.54 309 1
180.62
180:62
Unless otherwise stated, reimbursement is made according to The Official New York Workers' Compensation Medical Fee Schedule. Reimbursemen fortreatment rendered by out-of-slate providers is made based on the prevailing Workers' compensation state fee schedule for the provider's geographl el area.Any reduction is due to the billed charges exceeding the fee schedule allowance for the service provided and/or the application of the appropriate disgountsbased on the Individual providers agreement with the preferred provider organization. 0039
*Workers Compensation*
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
4
5
6
(15,00
HEALTH INSURANCE CLAIM FORMAPPROVED DV NATIONAL UNIFORM CLAIM COMMIETEL 011/415
14 LAFAYETTE SQUARE
SUITE 700
BUFFALO, NY 14203
-‘ i PICA . ' ' R 1 I T
I MEDICAID
4* 0'4 Lem-au:kaki 0)Li: c _
44. -
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(r6114UN L OD)
‘R. INSURED'S I.D. NUMBER — (For Program m lied
40 0 0 024420 . - -
.• p -
PATIENT AND INSURED INFORMATION
2 PATIENTE•RIAMERLSINthme.Pme/RT:ZI
IACALONE, JASON"'0-78
SEX
7,
4.EURL.OS NAME 46=4 Name, fits) 611R tee PRIM)
IACALONE, JASON
..I•. .... . .....,
rE. PATIENTS ADDRESD4NR.SPeRli ::' t"eirir4 "'NSW TONSURED T, INSURED'SADDRES5(ND.,SItee!) Til
2 BAY • 49TH STREET I t.-11111 chniThootorE -:72 BAY 49TH STREET •
.. . . ..CITY arooklyn L_ 0
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t ( ).• -cis, •9. OTHER INSUREDS. NAME Thal Forne. --- MON RELATED TO: I AMMO'S POLICY GROUP OR FeCA AUMRER •
040
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s, L INSURED'S DATE OF BIRTH I Cat '-'"- 4•1e•141144 . 00 I . YY 'i 1M.134144'1. • •u. O INSvaerienAle OF BIRTH Sp .
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L EMPLOYERS NAME OR SCHOOL NAMT• • 0M! panOr a a
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OYES N.0
R. INSURANCE PLAN NAME OVelOG14cAltling: , ii• de e
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ANOTHEFifaile BENEFIT PCAN1.04
YES r NO II yes'nea4#1 IL eAlelteMplme i AL•
• READ BACK OF FORM BEFORE COMPLETING 1 SIGNING THIS FORM. RR . . .
la-PATIENTS CA AUTHORIZERPERSONS'SIONATURE -1Rdtemze Mu raknom'd my Ruske] le LEW 1111441M6VORLeseepare
1 H procosaliacierni: I elie4e148 peytnant 0I9hverm4LY4 eenfeLL Lem la my/editdr to Ns pan wild atteNS neenismeolR01444y.
SIGNED SIGNATURE ON. FILE . DATE 08 06 012
13. INSUREDE OH AUTHORIZED PEP.P.Oerati[ TURE I alepaymeneof medical bonelo io the.untite V11. 0 pectleon or s6sfin400[10500bepbs,low, •• i •
..sioueo SIGNATURE ON FILE - • ....
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te CAPES frvIlfriENTorieJEW wallet:1pr .ocrPitiail:
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;
rii, NAME OFREPERRING-PROVIDEROROTPEH SOURCE
(ISAAC KREIZMAN MD tip.]r4p)1149782 St434
40. HODEITAtellst rilciNagnitTectrAENTert.1 nyraw , . im ' , , ,
I is. RESERVED Foe LOCAL USE. . - . . . . ...
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Erl. DIAGNOSIS OR NATUREIOF ILLNESS OR INJURY (14H1 Ite , 2, Zia 4- to Item 24tE ay Lime
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22, MEDICAID RESUBMISSION • Yi,:-CODE , ORIGII64444 HQ.' • . .
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23. PRIOR.AUT/ORIZATION NUMBEft • , • e• e• t• 6
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I 24' A -.. . cAlats)0? i•:Eiyil:-Ai-f l By1: Dam • • Tv - IFE1C1-701-VM ' ' DU.' .:. :M.' .1;14M . . DE. . YY ISERa
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Jr
tat abeATerie oFleeysiciANPFIW4E11 I SI EFIVICE FACILITY LOCATION INFORMATION:-1 ] INCLUDINGriti8E-4 OH CREDENTIALSi . • Peerely theHeRRIniLthentwon IS myths° I LENCO DIAGNOSTIC LABORATORYIGNATUFtEtatt:FidP,E Pau thoent) 1
11857 86TH STREET
09 19 2012 I BROOKLYN, NY 112143108 .
n BILLING Ferit , fo A PH g. ( p.8 -)232 5
ILEX° DIAGNOSTIC LABORATORY :.
A857 86TH STREET
BROOKLYN, NY 112143188. ,
-462 8 ib- ' -- 06411 DATE j 425 54 6832 8 .1.42, 331)1012663 .,.:.f ..,' o..12S50
NUCC libleiclitin Manual available at nutc.org PLEASE PRINT OR TYPE APPROVE? M18-0938-0999 FOR CS-!1500 (08-05)
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Name: GIACALONE, JASON Phone: (718)753-8933 Accession: 1080003
Patient* 076038 Birth: 10/1978 Fasting: NO
Doctor. KREIZMAN, ISAAC 9 TH AVE Age: 34 years Collection Date: 8/612012 3:00 PM
Doctor Address: 5223 9 TH AVENUE Gender. Mate Received in Lab; 8/7/2012 12:05 PM
Brooklyn. NY 11220
Test Name In Range Out of Range Flag Units Reference Range
DRUGS OF ABUSE, URINE Run By. DK on MMUS 2 4:5 PM
AMPHETAMINES
CUTOFF=1000BARBITURATES
CUTOFF0200BENZODIAZEPINE
CUTOFF=200CANNABINOIDS
- cIPPEF750.COCAINE METABOLITE
CUMFF=300METHADONE
CUTOFF=300OPIATES
CUTOFF=300PHENCYCLIDINE
CUTOFF=25OXYCODONE
CUTOFF=100ECSTASY (MDMA)
CUTOFF=300LSO
CUTOFF=0.5ETHYL ALCOHOL
CUTOFF=10
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
POSITIVE
POSITIVE
POSITIVE
POSITIVE
nglmL
nglmL
(A) ng/mt.
(A) nglmL
ng/mL
ng/ml
(A) nglmL
ng.mL
(A)
LENCO DIAGNOSTIC LABORATORY1857 86TH STREET - BROOKLYN, NY 11214
END OF REPORT.
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Originally Printed On: 8/8/2012 9:41 AMPrinted: 1015/2012 2:14 PMPage 1 of 1
FINAL COPY Accession: 1080003 Patient ID: 07638Lab Results For: GIACALONE JA6 ON
Elena Agranovsky,Laboratory Director 0041
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
or—e--Fr1/4 ON 41 HE3,althSytstems
RX
NCA Comp
t4 LeFeyette Sq
Suite 700
Buffalo, NY 14203
CRISP Trust
First Dale ofFill Service
9/2/2912 1t7393
9/2/2012 117394
912/2012 117392
912/2012 117391
DescriptionNDC CodeDrug TypePharmacy NamePharmacy ID
INVOICE FEDEJ
INV011
INVOR
-NAME, - -JASON GlAeAltONE
CLAIM #s W000024420 1
CARDHOLDER ID' 1706778
ADJUSTER Sherrie Clch
DUE UPON RECEIPT
PLEASE INCLUDE INVOICE NUMBER WITH YOUR PAYMENT
DaysOty. Shipp&
Prescribhg M.D.Physician I.D.DAW
Billed By
Pharmacy (ifpallier claim) Fe
CARISOPRODOL 350 MG TABLET 90 3Q
62755044602
Generic
GOOD-DAY PHARMACY LLC
1154568400
OXYCODONE HCL 30 MG TABLET
52152021502
Generic
GOOD DAY PHARMACY LLC,
1154568400
DIAZEPAM 10 MG 'TABLET
00503321521
Generic
GOOD .DAY PHARMACY LLC
1154568400
KREIZMAN
1497825434
No Product Selection Indicated
150 30 KREIZMAN
1497825434
No Product Selection Indicated
SO 30 KREIZMAN
1497825434
No Product Selection Inclicrad
a • -5 *
MORPHINE S ULF ER100 MG TABLEt 40' : :• • at 0.• ••
• • •A • •
00378266101
Generic
GOOD DAY PHARMACY LLC*St Set
1154568400 ••••
•
w
••
•s.
•••• •
••••••
4, • • •
•• •
KREIZMAN
1497825434
No Product Selection Indicated
It• t./• •• al
• •• •
• •
PLEASE REMIT PAYMENT Tor
• wit Health Systems International•• P.0134991, Indianapolis. IN 46206-0851••
• a :865:495•10Z1 Toll Free 4 886.701 2781 Fax• 1. • • *Erne!: rx(gus-hslenM
50.1)(1
SO 90
$0.00
0042
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Nealth Systems1 NA I
R X
INVOICE FEDEF
INVOK
INVOIC
NAME: NCA Comp NAME: JASON GIACALONE
14 Lafayette Square CLAIM #; W000024420
Suite 700 CARDHOLDER ID; 1706778
Buffalo. NY 14208 ADJUSTER: Sherrie Cich
First Dale ofFill Service
CRISP Trust
DescriptionNOG CodeDrug Type
RX# Pharmacy NamePharmacy ID
DUE UPON RECEIPT
PLEASE INCLUDE INVOICE NUMBER WITH YOUR PAYMENT
Prescribing M O.
Qty. Supply DAW
Ph.ysiela n LO.
Billed ByPharmacy (Itpaper claim) Fer
g •11 •
o •
s •* •
•*
*40* t51*_ * • • e•• 0 • . 4 * •
• • • • 'it, 4 •
.• ti :I, • VE •9t • a •
TOTAL AMOUNT DUE:
Amounts denoled by "0- an !
PRE NEGOTIATED RATE -
PLEASE REMIT PAYMENT TO:
v. •- 0 • 6 Reah Systems International• *. . :P 013plaJBMinapolls, IN-46205-0881-, -- .-7••••er-L-r..---; '''
. 0-1' . a 17,Erraf',..Tp5,0;1 Toll Free •1366.701 2781 Fa%
• • . * • • . !emote rx@us-hai corn
PAIr
0043
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
09/08/2012 Thu 09:114111vins STONERIVER-
Pharmacy SolutionsP 0 BOX11124 Memphis, TN 30181.0124
NEIMAN ADMINSTRATORS (NC A COMP)ATTN .14 L AF AYETTE S(2 STE TEMBUFFALO NY 14203-1117
°Workers Compensation Claim.
StoneRiver Pharmacy Solutions mu192112p2000,au.1.., juuw4
INVOICE
ID: #726592 Page 3 of 3
PLEASE INCLUDEINVOICE NUMBER ON PAYMENT
BENEFITS ASSIGNED
Invoice No.Invoice Date
ClaimantAddress
SSttEmployer
Address
Carrier/Clalm Fileinjury Date
NPI *
3771102409/04/12070843848GIANCOLONE JASON118 BAY 13TH STBROOKLYN. NY 11214
PROGRAM DEVELOPMENTSERVICES6918 NEW UTRECHT AVEBROOKLYN, NY 11228-1810W00002442006/19106GOOD DAY PHA NY1164588400
Date of RX # Description Quantity UnitService10/12/10 Noma NDC# 52152021502 180 EA
OXYCODONE TAB 30MG
10/12/10 0105864 NDC0 50458092560n 7 EALEVAQUIN TAB 500M0
a No Generic Available
Dr. Name• • a .
FH1503584 HOROWITZ STEV &WO30 day supply (G) New
Amster) JDue
FH1503584 HOROWITZ STEV Limit%7 day supply (B) New • ° °
•g• •
•
— 204.70
.
• •126.13
DISI; 4.00
.....0
0 0 1.
REMIT PAYMENT TOtP.O. BOX 504591
ST. LOUIS, MO 6315D-4591(901) 681-9080 600-541-5234
FULL AMOUNT DUE UPON RECEIPTPRICING CONFORMS TO STATE FEE SCHEDULE
PAYMENT ReDUCTIONtaIMITHORIZED
STONERIVER PROCESSESPRESCRIPTIONS FROM PHARMACIES
TotalAmountDue
333.83
Page 1
I.D. 62-17709240044
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
12012 Thu 09:11 StoneRiver Pharmacy Solutions 19014350000 ID: #726662 Page 1 of 3
ax Message StoneRiver Pharmacy Solutions
19014350000
Recipient: Sherrie Pages: 3
Fax Number: 17168420018 Date / Time: 09/06/2012 Thu / 09:11
Subject: Response Requested
40 0
CI &I 0 0• •000 41
• a•
••
a• 0000 0 0 a •
00
•9 900410 00
0
0 00
0045
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
09106/2012 Thu 0.01 , ......,,,,
........
September 6, 2012
NCA COMP
Attn: Workers' Compensation
14 LAFAYETTE SO STE 700
BUFFALO, NY 14203-1917
In reference to:
StoneRivet Pharmacy SoWhom 19014360000
Patient: Jason Giancolone
Date of Injury: 06.19.2006
Pharmacy Narne: GOOD DAY PHARMACY LLC
Dear Sir or Madam:
07261182 Page 2 o13
STONERIVER"P611n41.4 Solution%
Our records indicate that the above referenced patient incurred a work-related injury. As with any injoya it was „ •unplanned, required Immediate treatment, and a timely dispensing of prescription drugs. The pharmacValtsourCesethelrworkers' compensation prescription research, claim preparation, billing and collections to StoneRiver Phermact ° es ° °.Solutions. °
• • •
Enclosed Is an invoices) for which either no response regarding compensability of the claim was recelig4Indl.br °additional Information is required regarding current status. As we have been unsuccessful in contacting you by phone, waare requesting the following information:
Ej No response has been received regarding claimantand/or Invoice status. Please remit payment forinvoice(s) attached or submit an appropriate denialthat addresses the compensability of the claim andthe medication(s) dispensed
E Confirmation that you are the Insurance Carrier forthis claim
Q Payment status at attached invoice(s)E Adjuster's name and phone number
Name of authorized treating physician
El original EOB
Copy of the Peer Review
... t ......
Closed date of the claim and tImaframs for ghte clairn wasopen for continued medical, if applicable a°
Denied date nt the claim
Settled date of the claim and name, address, and phone number ofthe responsible party
Date claim went into litigation - Phone number and nails ofattorney, and next scheduled court date
If medical documentation has been received, please provideconfirmation that the attached involce(s) was processed forpayment consideration
If claim(s) was submitted to a bill review and/or third partyprocessor, please provide name, phone number and address ofthe appropriate third party
As this claim(s) was invoiced appropriately, we request your cooperation by immediately providing the informationrequested above and/or immediately processing the attached Invoice(s) for payment consideration. Your response maybe faxed to StoneRlver Pharmacy Solutkms at 901.435.0000 or mailed to the address listed below. Thank you for yourexpedited response. Please feel free to contact me If you have any questions.
Kettle V.Ouinn-VVhiteleatherPatient Accounts Speclaliat - StoneRiver Pharmacy Solutions
1.666.493.1645 ext 7541
Enclosure: Outstanding Invoice(s)
0046PO Box 504591 St. Louls, MO 63150 o 901,581.9080 f 901.435.0000 pharmacysolutIons,stoneriver.com
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Claim Number.Claimant:Provider Tax ID:Provider Ref:
Region: 04
Community Residence Savings Plan (CRISP) 2900
VV000024420GIACALONE, JASON PPO ID:201270006 Vendor 201270006-0001 NPI Number:
Geo Zip: 11220 WCB Case Number:
ISSAC KREIZMAN5223 9TH AVEBROOKLYN, NY 11220
Process Date: 12232011Control Number: 4893816
FOR Page 1 of 1Rev/Aud: DM/DM
ExternalReview Procure
ICD-DX1: 7242 LumbagoICD-0X2: 724.4 Lumbosacral neuritis NOSICD-0X3: 781.2 Abnormality of gait
DOS Service:Descnption Units -1111Redti FiFO/Redxripther/ReitlllNiiiiiiaboe'Reasorta
10/1012011 11 99213 OFFICE OUTPT EST 1
TOTALS:
TOTAL RECOMMENDED ALLOWANCE
64.07 0.00 24.07 0.00 40.00
64.07 0.00 24.07 0.00 40.00
40.00
PPO REDUCTION: ProcuralMagnaCare - For questions regarding Network Discounts, please call: (877) 461-3750.
Unless otherwise stated, reimbursement is made according to The Official New York Workers' Compensation Medical Fee Schedule. Reimbursement for
treatment rendered by out-of-state providers is made based on the prevailing Workers' Compensation state fee schedule for the providers geographical area.
Any reduction is due to the billed charges exceeding the fee schedule allowance for the service provided and/or the application of the appropriate discounts
based on the individual providers agreement with the preferred provider organization. uu47• Workers Compensation *
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
4 201112020009167Submitted; 10/21/2011 Last Resulmitted: 11/20/2011
Doctors Narrative Report •State of New York - Werkers' Compensation Boars(
THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL
This form may be used to report the first time you treated the patient or to report continuing services. (To report permanentImpairment, use Form C-43.) Use this form oolv if attaching a detailed narrative report. Please answer all questionscompletely-and submit promptly to the Board, the insurance carrier end to the patient's attorney or licensed representative,If he/she has one; If not send a copy to the-patient. Failure to do so may delay the payment of necessary treatment,prevent the timely payment of wageless benefits to the Injured worker, creak the necessity for testimony,. and jeopardize .your Beard authorization
A. Patient's Information
1. Last Name: Eleaelme
EC-4NA RF
First Name: Jason MI:
2. Sodal Security #: Waft 3. Home Phone #: 73E7538E53
4 WCB Case # (if known): .
6. Mailing Address: 72 BeY 49th Street
City; Brooklyn
5. Carrier Case # (if known): 1083661328
Line
State: ax Zlp Code: 34214 Country:
7. Date-of injury/onset of Illness:019/2086 8. Date of birth; qpr 97° 9. Gender: male
10. On the-date of Injury/Illness what was the patient's job title or description:unknown
6
•
11. On the date of Injunfillinest what were the patient's usual work activifies:D00000
• 0 0
o 60
o0600041
0 0CO 00
-injury baok.:.14
0
.0000
000004 0 0 0
.12. Is the patient working now? Yes 13. Patients Account #: 028e70116k...
D I/
0•411)0". 0
0. •
00
°COO*.0, Employer Information 0041000
1. Employer wherkinjury occurred:
Company/Agency Name: ooram Development
2. Employer Phone #: 7182562212
3. Employer Address: sns New Chteht Avenue
City: Brooklyn
C. Doctor's Information
1. Your Last Name: icre-imaa
2. WCB Authorization #: 206647-0B
Line 2:
State: NY Zlp Code: 11209 CEILDtry:
4. Federal:Tax 10#: 201270E06
First Name: Issa° MI:
3. WCB Rating Code: CWR
The Tax ID # is the: EDI
5. Office Address: PAM Medical pc Line 2: 5223 9th Avenue
City: Brooklyn State: 14Y Zlp Code: 11220
6. Billing Group! Practice Name
Country:
7. Billing Address: 5223 9th Avenue Line 2:.
City: Brooklyn 11220 State: E7 Zip Code:
8. Office phone ft: 201-818-8627 9. Billing phone #:
Country:
10. Treating Provider's NPi #:1497825434 11. You are a: Physioian
FraudAnwit9-401 Dann, of THEWORKERS COMPENSATION BOARD EMPLOYS AND SERVES00
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
D. Billing information
1. Employers insurance carrier:
2. Carrier Code #:
20111202000 9167
PAM, MEDICAL BILLING
3. Insurance carriers address:City: ominasvma
PO BOX 6231
State: wl
4. Diagnosis or nature of disease or irftury:
Enter ICD9 Code: ICD9 Descriptor1 724.2 LUMBAGO
Line 2:
Zip Code:'53547 Country:
2 724.4 THOR/LUEBOSACRLNURIT/RADICULITUNS
3 781.2
4
ABNORMALITY OF GAIT
Relate-1CD9 codes above.to Diagnosis Code column by Ihie.
Dates of Setvloa
From To
Riceof
Benda
•
LeaveOS
- •. UseINCB CartesProtethnea, Services or suppues
cro7H0PCS Modified N,(21\gnosis
fta SchoenDelaUntle COB-
.
21p Cob whereswim was iodate
10/10/2011 10/10/2011 U. 99213
‘0/14
\ If 12 64.07 1 11220 .
CAILit 11461' a
4
If 90 0
.. ••
SUSI 1 IOCkt —1b4,5
gpu112- ElJ 000000
*
0 000 00
Ain'
i _____---e--000000
e 6 0000000 0 0 e
.
.
0 0 e
000 a 00 0000
N Services were provided by a WCB preferred provide organization (PP0).
Total Chargo 0 • oa . :
64-07
&mum Paid° "I—Nader Use ORO
0 0•006000
Balaricalee 6parr* use &Ay)
00000000000
0000000
E. Doctor's Opinion
1. In your opinion, was the Incident that the patient described the competent medical cause of this injury/illness? Yes
2: Are the patient's complaints consistent with hIsTher history of the injuiyallneds? Yea
3. testha. patient's history of the Injury/illness consistent with your objective findings? Yes
4. What is the percentage (0-100%) of temporary impairment? 60.006
This Term Is signed under penalty of perjury.
Board Authorized Health Care Provider:I Provided the sere-Ices listed above
MOTORIZED SIGNATURE ON FILE WITH NEW YORK WORKERS COMPENSATION BOARD)
Provider's Last Name: First Name: M I:
Providers-Specialty:
Board Authorized Health Care Provider:
Last Name: wreizwan . First Name: Isaac MI:
Specialty: PHYSICAL MEDICINE/REHABILITATION Date: 10/ 21/ ant
EC-4NARR (1 2-10) Page 2 of 2 004
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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Patlenti Jason OlsealontDOB:SSN:Date: VIVOAttending: hue J. Krakow, MI)
HISTORY OF PRESENT ILLNESS:
The patient is status post work-related injury to the lower back, He has had multiple surgeries andhardware to the lumbar spine for pain management. He is currently taking roxycame and Soma forpain and Valium. The patienthas 10/10 lower back pain.
CHIEF COMPLAINT:
The patient has 10/10 pain to the lower back.
EXAM:
SOCIAL HISTORY:Alcohol: NoneTobacco: Patient is a non-smoker.Drugs: None.Toxins: None.Work: Patient is non-contributory.Dietz Patient is not on any Particular diet.
FAMILY HISTORY:Non-contributory,
MEDS:The patient is mourn taking rosycodine, Soma and Valium.
ALLERGIES:No known allergies
PAST MEDICAL HISTORY:Non-contributory
SURGICAL HISTORY:No surgical history
11111111111iREVIEW OF SYSTEMS:. Constitutional: Patient denies any change in weight, fevers and sweats..Thaegatlent dernes any nausea,. ... . „
yomiting, diarrhea or diplopia. • ....
• . . ,ENMT: Patient denies any ear or nose problems, visual difficulties, ear ghnoiraalitjeis, ehd beat tumor.Throat: Patient denies any problems or swelling in the mouth, neck problems or swelling and throat"disorders.
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
ZU11102000013772
hem Glacelone
00032
Caudle: Patient denies angina, edema, hypertension, palpitations, vascular problems, high bloodpressure, heart problems, Pulmonary Fibrosis, Congestive Heart Failure, Coronary Artery Disease, high-eholesteml, and Peripheral Vascular Disease.Respiratory: Patient denies cough, shortness of breath, sputum production, wheezing, lung/breathing.problems, chronic obstruction pulmonary disease, restrictive hula disease, pulmonary hypertension,sarcoidosis, dyspnea, asthma, chest pain and bronchitis.GI: Patient denies abdominal pain. bleeding, bowel changes, dyspepsia, gastrointestinal problems,peptic ulcer disease, diverticulitis, hepatitis C, GERD, irritable bowel syndrome, neurogenic bladderproblem and colitis.GU: Patient denies dysuria, frequency, hematuria, incontinence and nocturia.Heme/Lymph: Patient denies anemia, easy bruising, excessive bisecting, lympliadenopathyrdeep veinthrombosis and Byperkalemia..Rhea Patient denies neck pain, mid-back pain, bilateral hip pain, bilateral knee pair; bilateral anklepain, bilateral foot pain, bilateral shoulder pain, bilateral elbow pain, bilateral wrist pain and bilateralbandpain.Endocrine: Patient denies hormonal abnommlities, polydipsia, polyuria, diabetes, hypothyroidism,ceaditis and colon cancer.Nenro/Psych: Patient denies mood changes, paralysis, syncope, depression, cerebrovascular accident,hemiplegia, dizziness, cerebral palsy, mental retardation, traumatic brain injury, multiple sclerosis,headaches, psychiatric problems, neurological problems, A.D.D. and Sleep apnea.Integumentary: Patient denies pruritus, rashes, skin atiptions, infection and shingles.
PHYSICAL EXAM:Vital Signs:Upright BP = 120/80 mmHgPulse= 80 bpm. Patient is afebrileRasp = 15 •
General: Well nourished, Well dressed. Not in acute distress.REEDIT: Normocephalic, Atranmatio EOM ere intact.Chest: Clear to auscultation bilaterally. No wheezing, no vales, no rhonchi.CV: There is a regular rate and rhythm. Normal SI -S2.Mut The abdomen is soft. Non-tender. Non-distended. Normal bowel sounds are present,Neat No paraspinal tenderness noted. Full range of motion.Midair-1u No paraspinal tenderness noted. Full range of motion.LowBelt: L3-1.4, L4-L5 and L5-S1 paraspinal tenderness. Decreased range of motion.Extrenn There is no clubbing, cyanosis, edema, erythema and celltilids.RUE: 5/5 muscle strength. No contractures. Full range of motetLUE: 5/5 muscle strength. No contractures. Full range of motion.RLE: 3/5 muscle strength. Decreased range emotion.LLE: 3/5 muscle strength: Decreased range of motion.Skint No scars, rashes, Talons, ulceratiOns ht the head, neck trunk, R.UE, LUE,RLE, LLE.Lymph: Palpation of lymph nodes in neck, axillae and groin is normal.Nearer ORIENTATION; Alert & oriented x3. The patient understood commanciik. aitintrim spanand concentration were normal, Remote and Recent memory were normal. There is unledeft; in cranialnerves I— XII. MOOD & AFFECT: No depression, no anxiety, no agitation. TESTCOORDINATION/GAIT: Normal coordination. Abnormal gait. EXAM OP OTR:Nprand, 2+ BUR...Reflexes are normal to the upper extremities, EXAM OF SENSATION: peakandtillitikttao gradepinprick in the lower extremities with weakness. 0
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Jason Gratalone
ASSESSMENT:
Lower back pain
PLAN:
L Physical therapy2. Continue pain medication3. Home exercise program4. Follow-up in one month
/'•
aae J. Kreitman, MD
•
Miebactgarbuisky, R1PA-C
LIK/CARMM60001414423014164611
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
filo Health SystemsINTERNATIONAL
RX
NAME: NCA Comp
14 LeFayette Square
Suite 700
Buffalo, NY 14203
Ann:Steven Gidwitz
CRISP Trust
First Date ofFlo Service RX#
DescriptionMX Code
Drug TypePharmacy NamePharmacy ID
INVOICE FEDERAL TAX ID 27-0083277
INVOICE #1 F1)(9073910
INVOICE DATE: 10/1 0/2011
NAME: JASON GIACALONE
CLAIM #: W000024420
CARDHOLDER ID: 170677848
ADJUSTER: Sherri Cich
DUE UPON RECEIPT
PLEASE INCLUDE INVOICE NUMBER WITH YOUR PAYMENT
DaysQty. Supply
Prescribing M.D.Physician I.D.DAW
Billed ByPharmacy (ifpaper Claim) Fee Schedule Your MILS Savings
10/10/2011 0110932 OXYCODONE HCL 30 MG TABLET
52152021502
Generic
GOOD DAY PHARMACY LL
1154568400
10/10/2011 0110933 DIAZEPAM 10 MG TABLET
00603321521
Generic
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PLEASE REMIT PAYMENT TO:
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. • s86q.856.2021 Toll Free • 866.701.2781 Fax• . Email: rx Mus-hsi.com
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TOTAL AMOUNT DUE:
Amounts denoted by 10' are credits,
PRE NEGOTIATED RATE - NOT SUBJECT TO REPRICE
$209.70 $202.02
$35.31 $34.18
$236.261
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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E. Doctor's Opinion
1. In your opinion, was the incident that the patient described
2. Are the patients complaints consistent with his/her history
3. Is the patient's history of the Injury/Brass consistent with
4. What is the percentage (0400%) of temporary impairment?
This fans Is slatted under penalty of perjury. :
Board AuthorizertHealth Care Provider: - 'I Provided the seiyiecy listed above(HOT0RISED anaihren ON PILT WITH NEW YORK 11010000.
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Provider's Specialty!
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Last Name: scresaPan Fust Name: Yisan Mt '
Sped*: PHYSICAL MED/CINWHEHAHILITATION Mac 10/3/2011
'EC-4NARK (1240) Page 2 Of 2
MI:
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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Jam OlsonloneDOMSitDate: 08/13111attending: Isaac I. KJ-cling% bib
HISTORY ói PRESENTILLNESS:
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The patient is status post work-related lujury.to the lower ha* and lower extremities. He has ;weakness with multiple hardware in liimbar Spine. The patient has had three Fineries to the luinharspine. He has failed back surgery, lumbar epidurals injections. He is entrentlY taking Valium 10 ipgtid and roxycodinc30mg Q4 hams,
CHIEF cOlVIPLAIDIT:
The patient complains of pain the lower bankand /owe r extremities,
EXAlti:
SOCIW•
hiteout trafigni is a non-smoker,Dr,ugs: None.•:.
' *mitt Pad is non-eontributory.Wet; Ratient is notion any particular diet.
•net !WILY HISTORy:
Noti-eontlibutory.. • .
MEDS:The patient it currently taking Valittin and roxycoccinelOing.
ALLERGIES:.No Lthown allergies
•
' - ‘., ± •PAST MEDICAL JEILSTORY: ,
Non-contrlbutory , I
SHRGIAL HISTORY:NO s'aigicathistory i
:::::
REVtrAit OE SYSTEMS ,;Creistitetional: Patient 'denies any change in weight, foveps and sweat,. The patient denies any nausea,4ona,.diarthea.or diplopia. . 1ENIV:' Patient deniet any ear oc-nose-problerni, visual difficulties,. ear abnormalities, and braulturnar.1 :TM.pat: Patient denies any problems or swellingin lbe mouth, neckdisorders, - - • '
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
201204230001644' 00138,
Jason Giattrioneo913/11
Oa: Patient denies amine, edema, hypertension, palpitations, iaseulat problems, high blood •pressperkeart problems, Pulmonary Fibrosis. Congestive Heart Failure, Coronary Artery Disease, high.cholesterol, and Peripheral Vascular Disease. •Respiratory: Patient denies cough, shortness of breath, sputum production, wheezing, king/breathing-problems, chronic obstruction pulmonary disease, restrictive lung disease, pulmonary hypertension,"sarcoidostr, dyspnea, asthma, chew pain and bronchitis.GlOatient denies abdominal pain, bleeding, bowel chains, dyspepsia, gastrointestinal problems, •peptic ulcer disease, diverticulitis, hepatitis C. GERD, irritable bowel syndrome, neurogenic bladderproblem and colitis. •GU: Patientdenies dynode, frequency, hematuda, incontinence and nocturia.Remeaoimpin. Patient denies anemia, easy brulsing, excessive bleeding,Iyumbarknopathy, deep veinthrombosis and Hyperkalemia.Rheas Palient denies neck Pain, odd-beck pain, bilateral hip pain, bilateral knelt pain, bilateral atOdelpain, bilateral foot pain, bilateral shoulder pain,bilaterrd elbow pain, bilateral wrist pain and bi
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'Endocrine: Patient denies hormonal abnormalities, poiydipsia, polymis, diabetes, hypodwitlism,ceflulids =Id colon cancer. . . . ... •lifeweesych: Patios sienies mood changes, paralysis, ryncoPc, depression, cerelnovasculwacitent, ,
• hertIegia, ditlit, cerebral Petty, mental rettitdadon, traumatic brain injury, multiple sclerosis —beadeches. Psychiatrin roblems, ne:urologal mobilo, ADD D. and sleep apnea.
;ft • IntymininM2.7: Patient denies pruritus, :ashes, skim:captions, infection and shingles. • . 1• I
ilg PHYSICAL EXAM1%'•.0 Vital Signe: a 0 00
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Pulse =80 bpm. Patient b afebrile •Imp =15
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Abdi 71 he abdomen is soil. Non-tender, Nap-distended Normal bowel !owls we p4serit.. co • CO
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• ;WO; ,37: resuclextre:Lith,peeesicd Anse et inoti=iMb vigaimas. ' ' :,UZI 315 t::Wscle stipiabliecscesediraesOf motion wittryealmwth. , .. : • , •MtlittNo ken, last*, lesioni, ulemationikki the bead, neck "runic, ROB; LIJE, EL; LLB. iLyppAkFakiation of f.;, modes poles in :Wok, 'Rake and grnistifhoimal, . , •:WPSOlx•GRIWTATION: Akita (ideate: x3.113e /cadent undersiod&comniand Aril. Attention wan 'ma• oaidentra/mt•wer 'trefeial,iternoteraviRecent mono*, were norntirThere is, so sigfieUs in cranialnerves I -1)411 MOOD & ATFECT:Nedegiessicm, no anxiety, noetatio—k..TES't ' ,, • , ' • 1 I'COORDINATION/GAIT: Normal coordination: Abnormal gat EXAM OF DIRINotrael 24- BUBand BLS. Reflexes are normal to the lovfcr extremities and tipper extremities. EXAM QFSENSATION: Noir* to light touch and pinprick. Noma' vibration.
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
201204230001644aoiss
3aiosiGlablogOntr09/13/11
ASOFSIMENTE
Lower back pain .2. LoivpFciftretnity.pahiI. /Riled back surgery, upidurtils and pain procedures
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Julio V. Westerband, FACS, FAAOSDiplomate American Board of Orthopedic Surgery
1302 Kings Highway, 5th Fl.Brooklyn, NY 11229
October 3, 2011
ISG Medical at One Corporate Place55 Ferncroft Road, Suite 100Danvers, MA 01923
Claimant: Giacalone, JasonClaim #: W000024420WCB#: 00626057ISG Case #: 23310Emp. Name: Program Development ServicesDOB: , 1978DOA: June 19, 2006
To Whom It May Concern:
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As you requested, I have performed an orthopedic independents. modicalevaluation regarding the above-named claimant, Mr. Jason GiacalOrae, on10/03/2011 in the Brooklyn office. Mr. Giacalone was accompanied to this examination by his girl friend, Nicole Tekolve. Photo identification waspresented prior to this examination. Nadiege, an office employee waspresent at the time of this examination. My findings are as follows:
ACCIDENT HISTORY:
The history was obtained from Mr. Giacalone who reports that he wasinvolved in a work-related accident on 06/19/2006. At that time, Mr.Giacalone explains that while lifting an air conditioning unit at work, he hurthis back.
Mr. Giacalone denies seeking hospital/medical emergency care immediatelyfollowing the accident.
TREATMENT HISTORY:
After the alleged accident, Mr. Giacalone states that he came under the careof various physicians including Dr. Jonathan Levin and Dr. Isaac Krizman forfurther assessment. He states that he was then started on a course ofphysical therapy, chiropractic care, acupuncture, heat, and ice treatments ata frequency of two to three times per week and was issued a TENS unit totake home. He states that additional diagnostic testing consisting of X-rays,
• •
0061
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Claimant: Giacalone, JasonClaim #: W000024420WCB#: 00626057ISG Case #: 23310Emp. Name: Program Development ServicesDOB: 1111111101978DOA: 06/19/2006
THE ReportPage 2
MR1s, CT scans of his back and myelogram tests were performed. He statesthat he required the use of a back brace and a walker as assistive devices asa result of this accident. He reports undergoing back surgery on 11/06/2009and multilevel spinal fusion on 02/10/2010.
MEDICAL HISTORY:
Mr. Giacalone denies any history of prior accident or injuries. He reports hishistory to be negative for diabetes and hypertension.
SURGICAL HISTORY:
Mr. Giacalone reports undergoing prior left knee surgery In 2000.
•
MEDICATIONS: a
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Mr. Giacalone reports that currently he is taking Oxycodone 30 mg and Valium 10 mg. •0•000
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ALLERGIES:000000
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Mr. Giacalone states that he is allergic to Dilantin. •00000
ADL CAPABILITIES AS STATED BY THE CLAIMANT-
Mr. Giacalone states that he can walk for a couple of blocks. He is unable tosit at all.
Mr. Giacalone states that he is unable to do the following activities becauseof his injury: sports, driving, washing dishes, washing clothes, vacuuming,sweeping, tieing his shoes, cooking, personal hygiene, childcare needs, andshopping/running errands.
EMPLOYMENT HISTORY;
Mr. Giacalone states that he was employed full time as a maintenance workerat the time of accident. He states that currently he is not working as a resultof the accident.
PRESENT COMPLAINTS:
At the time of this examination, Mr. Giacalone states that he has a complaintof pain in the lower back. Mr. Giacalone reports that his symptoms haveworsened.
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Claimant:Claim #:WCB#:ISG Case #:?ma. Name:DOB:DOA:
Giacalone, JasonW0000244200062605723310Program Development Services
01978/2006
REVIEW OF AVAILABLE RECORDS:
IME ReportPage 3
The following medical records were available at the time of the examinationfor my review:
1. EC-4 NARR forms.2. Office visit reports dated 03/03/2011 through 07/19/2011 by Isaac
J. Kreizman, MD.3. Evaluation reports dated 12/16/2010 through 02/03/2011 by Isaac
J. kriezman, MD.4. Orthopedic re-evaluation reports
07/28/2010 by Jeffrey Passick, MD.MRI report of the lumbar spine dated 02/03/2010 by Alan Berilyz ... .MD with the impression of there are findings consistent with apredominantly left paracentral disc herniation at the L5-S1 level:II:.Also noted at this level are findings consistent with an extruded "disc fragment extending predominantly below the level cr the° disc. . .space and for the most part extending to the left side of the:spinal: ....canal. There is evidence of a broad based disc herniation ewteticling ... .to both the right and left of the midline at the L4-L5 lever. Minor L.mass effect upon the dural sac is noted. There is evideneeMdischerniation within portions of the L4-L5 and L5-51 intervertebral :0••••discs. Facet arthropathy is present. • ..
6. X-ray report of the lumbar spine dated 02/25/2010 by David °."•Rosenthal, MD with the impression of post posterior spinal fusionwith intervertebral disc spacers. No destructive lesion is seen.Other findings as noted.
7. X-ray report of the lumbar spine dated 02/25/2009 by BahramChubineh, MD with the impression of negative examination.
8. X-ray report of the lumbar spine dated 08/27/2009 by DavidRosenthal, MD with the impression of possible spinal canal stenosisat L4-5. If further evaluation is deemed warranted, MRI would berecommended.
9. MRI report of the lumbosacralBromer Medical, PC Radiology.
10.C-4 form.11.Follow-up evaluation reports dated
10/12/2010 by Steven Horowitz, MD.12.Re-evaluation reports dated 09/16/2010 and 11/18/2010 by
Sanjeev Agarwal, MD.13.Progress note dated 09/29/2009 by Matthew Clarke, MD.14.Health insurance claim forms.15.Anesthesia record dated 11/06/2009 from Surgicare of Englewood.16.C-4.2 form.17.C-4 AUTH forms.
5.
dated 10/14/2009 through
spine dated 06/29/2009 from
12/09/2009 through
0063
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Claimant: Giacalone, JasonClaim #: W000024420WCB*: 00626057ISG Case #: 23310Emp. Name: Program Development ServicesDOB: ,1978DOA: 06/19/2006
INIE ReportPage 4
18.Operative report dated 11/06/2009 for the procedure of L4-L5, L5-S1 discography, L4-L5, L5-S1 arthroscopic transforaminaldiscectomy, L4, L5 and 51 annuloplasty, L4, L5 and S1 epiduralsteroid transforaminal injection with the post operative diagnosis ofL4-15 and L5-S1 disc herniation desiccation.
19.C-4 AMR form.20.0perative report dated 02/10/2010 for the procedure of revision
decompression, L4-L5 revision decompression L5-S1, open lumbarinterbody fusion, L4-L5, L5-S1 pedicle and lateral mass fusion, 14-LS, 15-S1 with autograft, local and local allograft. Interbody fusionwas with spineology optirnesh cages with the post operativediagnosis of L4-L5 lumbar disc herniation, L5-51 lumbar discherniation with disc desiccation pattern. ° .
21.Medical records dated 02/10/2010 from North Shore-Long Island: ***Jewish health system. a °
22.CT scan report of the lumbar spine dated 03/03/2010 by Jacob C. "eaAbraham, MD with the impression of post-surgical changer, no
0
gross abscess and no malalignment.23.Intraoperative neurophysiology report dated 02/10/2010 b*ya eitie" ***ven ** ** *
B. Cagen, MD. °'°24.Soap notes dated 02/11/2010 and 02/12/2010, illegible signattice.25.X-ray report of the lumbar spine dated 02/10/2010 frorn11°orth *******
Shore University hospital with the impression of post surgicalchanges of the lumbar spine.
**26.X-ray report of the chest dated 02/10/2010 from North Shore * *University hospital with the impression of negative for acutepulmonary or pleural pathology.
27.Anatomic pathology report dated 11/08/2009 by Dr. FrankMarzocca.
28.0ffice note dated 02/08/2010 by David R. Rodriguez, MD.29.0ffice evaluation report dated 02/07/2009 by David R. Rodriguez,
MD30.Follow-up visit reports dated 02/24/2009 through 12/16/2009 by
David R. Rodriguez, MD.31.Procedure note dated 12/09/2009 for the procedure of left L4, L5
and 51 transforaminal epidural steroid injection, fluoroscopicguidance used for needle localization and contrast injection with thepost operative diagnosis of back pain with radicular component.
32.Initial evaluation report dated 08/13/2009 by Matthew Clarke, MD.33.Independent Physiatric re-examination report dated 11/16/2006 by
Harvey Goldberg, MD.34.Independent Physiatric examination report dated 09/14/2006 by
Harvey Goldberg, MD.35.Progress notes dated 06/05/2006 through 06/28/2006 by Giuseppe
R. Rando, MD.36.C-2 form.
0064
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Claimant: Giacalone, JasonClaim #: W000024420WCB#: 00626057ISG Case #: 23310Emp. Name: Program Development ServicesDOB: Illink/1078DOA: 06/19/2006
ME ReportPage 5
37.Physical medicine and rehabilitaton evaluation report dated07/12/2006 by Joseph Sciortlno, MD.
38.MRI report of the lumbar spine dated 08/01/2006 by JosephLeadon, MD with the impression of disc pathology.
39.Evaluation report dated 12/03/2009 through 06/10/2010 byJonathan Lewin, MD.
40.Letter of medical necessity dated 02/09/2010 by Jonathan Lewin,MD.
PHYSICAL EXAMINATION:
Examination reveals a 33-year-old right-handed male who ambulates with anormal gait. He is 5 feet 8 inches tall, weighs 190 pounds, and he has brown .. :hair with brown eyes. He is in no acute distress and is able to understand .and cooperate during the examination. .
a .. .• ......
.... . •.. .-OBSERVATION: °°°°"
. ......' .....:. . .
. .
• The claimant moves his head, neck, body freely during unguarded a ••
a. : ..• The claimant is unable to sit. ° a
see,
a. e. o•• e
conversation.• The claimant can turn from side to side or back to front with dfiti0:e01.1°Ity. 1 ... ..
. ... ....
. .
....• The claimant can dress and undress his outerwear with no assistance.• The claimant is not using any assistive devices.
.... 0 .
ORTHOPEDIC EXAMINATION:
Lumbar Spine: Examination reveals multiple scars. There is moderatemuscle spasm upon palpation of the paralumbar muscles bilaterally. There isa complaint of mild tenderness upon palpation over L3, L4, and L5 disc spacelevels in the midline bilaterally. The claimant is unable to sit to performrange of motion. Straight leg raise is not performed.
The following orthopedic test is performed:
• Kemp's - negative.
Neurological examination of the bilateral lower extremities shows as follows:There is decreased muscle mass in the bilateral lower extremities. Musclestrength in each range is within normal limits. Deep tendon reflexes are notdone. Heel-toe-walk is not done.
0065
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Claimant: Glacalone, JasonClaim #: W000024420WCB#: 00626057ISG Case it: 23310Emp. Name: air Development ServicesDOB: 1978DOA: 06/19/2006
IME ReportPage 6
IMPRESSION:
1. Status post lumbosacral fusion, results unknown at this time.
DISABILITY:
There is evidence of a temporary total disability. Prognosis is guarded.
Aaiun TO WORK:
Mr. Giacalone is not capable of working at this time.
TREATMENT."
Based on my physical examination, Mr. Giacalone's condition warranty'.further treatment and has not reached maximum medical improvement in my .9.0°specialty, Orthopedics. Treatment to-date has been reasonable!' and.necessary. once. :"."")
0000. e ...
It is my professional medical opinion that the claimant would benefit from a'°°3D CT scan of the lumbar spine and X-rays of the lumbar spine in Arordteral •and 2 Oblique views, and a bone scan of the lumbar spine urger*
a: It is a.
important to see if the spine has fused and if the hardware is not causingsymptoms. I recommend follow up visits once every two weeks for eight 7 *****weeks. There is no need for physical therapy.
Upon completion of the examination, Mr. Giacalone offers no complaints as aresult of this examination and left the examining area stable and unchanged.
If you have any further questions regarding Mr. Giacalone, please do nothesitate to contact me.
ATTESTATION:
I, Julio V. Westerband, M.D., FAGS, FAROS, being an orthopedist, dulylicensed to practice medicine in the State of NY, pursuant to the applicableprovisions of the Civil Practice Law and Rules section 2106, hereby affirmthat Mr. Giacalone was examined according to the restricted rules concerningan independent medical examination. It is, therefore, understood that nodoctor/patient relationships exists or is implied by this examination. Mr.Giacalone was examined with reference to the specific complaint emanatingfrom the original injury. Any other medical conditions, which were eitherunreported or felt to be unrelated to the original injury, are considered to bebeyond this examination.
°°e...
•• 00
00090
0
0000..
O.
se
******
0•00
0066
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Claimant: Glaceloner Jason
Claim #: W000024420WCB#: 00626057ISG Case #: 23310Emp. Name: earn Development Services
O08: 1978DOA: 06/19/2006
IME ReportPage 7
This report is a full and truthful representation of the examiner's professional
opinion with respect to Mr. Giacalone's condition in accordance with
subparagraph (4) (e) (i) of Section 13-a of the Worker's Compensation Law.
Sincerely,
JJulio V. Westerband, M.D., FACS, FAAOS
WCB License No: 213270-2B
JW/SP/za
AVAILABILITY TO TESTIFY:
I will be available to testify by appointment only with
notice.
......
...to
,.0p0
......
four weeks advanced•.g.000 •
•.....
... .
0067
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
PATIENT INFORMATION SHEET PLEASE FILL OUT AND BRING TO DOCTORSAPPOINTMENT/ DOCTOR-PLEASE FAX TO ISG Medical
NAME: V ‘ I eli(PAL D.O.B SW111.111111DATE In 7 I
ADDRSTATE:
Well arc: 1312OCEI,
HEIGHT: WEIGHT: IttiA6\ HAIRCOLOrt (]9DiA3f1 EYE COLOR
DATE OF INJURY: (031 ,Alint9 CIRCLE ONE:30THER
2 AUTO ACCIDENT
DM you go to the hospttai YES If so, when? / /
Did you have test performed? YES NO If so, what?
CugeneYI Who referred you to your current doctor?
Are you taking medication? NO trap. what? Chatetnla so, ecri 013WERE YOU EMPLOYED AT THE TIME OF YOUR ACCIDENT/1NJURY? NO
If SO, Where 11 1. it• IWO
What rnitecick\ limigrforrnivi an
Does this Include (CIRCLE Mg FOR EACH CATEGORY)
HEAVY UFTING Occasionally Seldom Never
LIGHT LIFTING Reptile Occasionally Seldom Never
SITTING Regularly Occasionally Seldom MOW
WALKING taillir
Occrislonaily Seldom Never
Did you tufts time from work"Are you working now? YES Date returned to work: /
If yes, are you performing your regular work?
Do you work somewhere else? YES
Have you a Injured at work before? YES
If so, when? (Ust all dates)
YES NO
.....e
For how long?.
• •
.....
If yes. where are you currently working?
Have you been Injured In a previous acddent? YES
INN) did you treat with? (Ust all providers) oalonautin tow in
DO YOU PRESENTLY PERFORM:
Mac
Walking:
• Ili 0 0 0 •
0 •0 • ••
......
• • •
.00•410
o V
tD„NO If so. whoa at was the =WY? (3DECAIIIR
Wm OTIUMcd SRN
ChildSatis: YES Toni Work: YES
1ff vyeses: howhow falear7_79. aide one) DAILY(Circle one) DAILY
Cidthl• Ib onlyuortl- a 0001,o'c &Das
Shopping: YES
442)SELDOMSELDOM
• 0 Iv •
0068
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
al•
/9[1111: YES
List all hobbles: naled
V yos. how far? (Circle one) DAILY WEEKLY SELDOM
IMPORTANT NOTICE-PLEASE READ CAREFULLY!
I understand that l am not a patient of the physician who Is to examine me. This examination le beingperformed for the purpose of evaluating my present medical condition(s) and is not intended to beunderstood to be for the purpose results of your examination will be forwarded to the person who scheduledthe exam and the results of thls exam should be available within two weeks of today's date. Thank you fortaking the time to 111 out this form.of any medical treatment or diagnosis.
SIGNED: )\ )2147E4110d DATE: 0 / / ZO) I
..... *%no •
re 0•o
00000 ern 00000 •
• •e00:0e
rr rye 0.*ran o
"Ora
ooramo 0,0
so
00000 0
:**• 00(.0.;•
000 to
0069
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
n 201112020009167
MOW Jana Mac:doneDOtte •instDates 10/10/11Atlending Isaac J. Katmai', MD
••
HISTORY OF PRESENT, itipii§s: •
The patient is status post work-related injury. He is status post lumbar multiple surgeries withhardware on lumbar spine. Patient bad failed Itunbar spine surgery. He is currently taking Valiuml 0• .mg tid, otycodone 30 rag nid.
.
CHIEF COMPLAINT:
The patient complains of 10/10 pain hi the lower back and lower extremities.
EXAM
SOCIAL HISTORY:Akohok NoneTobacco; Patient is a non-smoker.Drugs: None.Toxins: None.Work: Patient is non-contributory.Diet: Patient is not on any particular diet.
FAMILY HISTORY:Non-contributory.
MEDS:No medication.
ALLERGIES:No known allergies
PAST MEDICAL HISTORY:Non-contributory
SURGICAL HISTORY:No surgical history
O0000
• a
00000
a 0
a 0500000
O• •O a
O b• 0006000
• O• 001
5 0 meate a
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0000 0 0
00
5
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REVIEW OF SYSTEMS:• Constitutional: Patient denies any change in weight, fevers and sweats. The patient denies any nausea,
vomiting, diarrhea or diplopia.ENIVIT: Patient denies any ear or nose problems, visual difficulties ear abnormalities, and brain tumor.Throat: Patient denies any problems or swelling in the mov".. Foments ox swellittgodAroatdisorders,.::
I1 1i1 11111111101 lef3Jam Gamlen1011315511MS1M10/20111
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
ZU.I.J.-LZUZUUtiflts
hoot dIacaionetermI
Cardio: Patient denies angina, edema, hypertension, palpitations, vascular problems, high blood •pressure, heart problems, Pulmonary Fibrosis, CongestiveHeart Failure, Coronary Artery Disease, high-cholesterol, and Peripheral Vascular Disease.ftespiratory: Patient denies cough, shortnets of breath, septum production, wheezing, Itmglbreathingproblems, chronic obstruction pulmonary disease, restrictive lung disease, pulmonary hypertension,sarookloals, dyspnea, astimucohest pain and bronchitis.GI: Patient denies abdominal pin:bleeding, hOwel chimps, dyspepsia, gastrointesthnd Problems, .peptic ulcer disease, diverticulitis, hepatitis C, GERD, irritable bovielwyndrome, neurogenic bladderproblem and colitis.
. •GU; Patient denies dysutia, frequency, hew:tuna, incontinence and nocturia.HenseiLymphr Patient denies anemia, easy bruising, excessive bleeding, lymphadenopathy, deep veinthrombosis and Hyperkalemia.Rheu: Patient denies neck pain, mid-back pain, bilateral hip pain, bilateral knee pain, bilateral anklepain, %lateral foot pain, bilateral shoulder pain, bilateral elbow pain, bilateral wrist pain and bilateral .hand pain.Endocrine: Patient denies hormonal abnormalities, polydipsia, polyuria, diabetes, hypothyroidism,cellulitis and colon cancer.Neuro/Psyeln Patient denies mood changes, paralysis, syncope, depressioneccrobrovasether accident, •hemlplegia, dizziness, cerebral palsy, mental retardation, traumatic brain injury, mobil/is, ailerosis,headaches, psychiatric problems, neurological problems, A.D.D. and sleep apnea. „Integlinentaryt Patient denies pruritus, rashes, skin eruptions, int:union afictshingles; • °
o0
PHYSICAL EXAM: ••°o•° *
000060
0 0
•0 00
0000••
• •
Vital Signs: .°16°. 00 0000
Upright BP = 120/80mning 0 0 S 00 000
0 •0 •
Pulse= 80 bpin. Patient b &febrileResp = 15
Gmooe 0
000000
o
tonna0
General: Weil' nourished. Well dressed. Not in acute distress. .000
0 0
HEENT: Normocephalic, Atraumatic. EOM ere Intact •Chest: Clear to auscultation bilaterally. No wheezing, no rates, no rhcnchi.CV: There is a regular rate and rhythm. Normal 81-82.Abd: The abdomen is soft. Non-tender. Non-distended. Normal bowel sounds-are presentNeck: No paraspinal tenderness noted. Full range ofmotion.Midllek: No paraspinal tenderness noted. Full range emotion.Lowlick:L3-L4, L4-L5 and L5-S1 paraspinaltenderness noted.-Limited range of motion flexion andextension of the lumbar spine.Extreme There is no clubbing, cyanosis, edema, erythema and cellulitis.RUE: 5/5 muscle strength. No contractures. Full range of motion.LUE: 5/5 muscle strength. No contractures. Full range Of motion.RLE: 315 muscle strength. Limited range ofmotion.LLEs 3/5 muscle strength. Limited range of motion. •Skin: No scars, rashes, lesions, ulcerations in the head, neck iitmk, RUE, LUE, RLE, LLB.Lymph: Palpation of lymph nodes in neck, axillac and groin is normal.Neuro: ORIENTATION: Alert & oriented x3. The patient understood command well. Attention spanand concentration were nomad. Remote and Recent memory were normal. There is no deficits in cranialnerves I — XIL MOOD &. AFFECT: No depression, no anxiety, no agitation. TESTCOORDINATION/GAIT: Normal coordination. Abnormal gait. EXAM OF DTR: Normal 2+ SUE.Reflexes are normal to the upper extreraldes. EXAM OF.SENSATION: Decreased to light touch andpinprick in the tower extremities.
2 ofe
007
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
ZU1112U2UUU9167
Jam Girl:alone10/10/11
ASSESSMENT:
1. tower *beck pain2. Lumbosamal radicuMpathy3. Gait disorder
PLAN:
1. Continue physical therapy2. Follow-up M one month
000000
00 0
0 0 0Michael Gartmlskyl RPA-P
• 001)
000000 a 00 010
1.11V0ARMIVIG0001/814423417401989 000000
0
a00000
oOo 0 ft
0000• 0 CIO 0000
0 0 e b 0
*000 or 0
00000
n 0
00006
00
• 600000
000000
•
o0000
30f3
007
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Claim Number:Claimant:Provider Tax ID:Provider Ref:
Region:04
Community Residence Savings Plan (CRISP) 2900
W000024420GIACALONE. JASON PPO ID:201270006 Vendor 201270006-0001 NPI Number:
Geo Zip: 11220 WC E3 Case Number
ISSAC KREIZMAN5223 9TH AVEBROOKLYN, NY 11220
Procths Date. 08/23/2012Control Number 4897216
EOR Page 1 of 1Rev/Audi DM/DM
ExternalReview Procura
ICD-DX1: 724.2 LumbagoICD-DX2 724.4 Lumbosacrai neuritis NOSICD-DX3 781 2 Abnormality of oil
c-: _POS Service Descrigtik r J 43138ren prvala mesoot Moan 02123112 11 99213 OFFICE OUTPT ESTI 5 1.000 64.07 o 00 24.07 0 00 40.00
TOTALS::
TOTAL RECOMMEND SO ALLOWANCE:
PPO REDUCTION: Procura/MagnaCare
64.07 0.0D 24.07 0.00 40.00
40.00
Unless otherwise stated, reimbursement is made according to The Official New York Workers Compensation Medical Fee Schedule, Reanbursement fortreatment rendered by out-of-state providers is made based on the prevallmg Workers' Compensation state fee schedule for the providelgeograpikal area.Any reduction is due to the billed charges exceeding the tee schedule allowance for the service provided andtor the application of the app opriate docount073based on the indw dual provider's agreement with the preferred provider organization.
• Workers Compensation '
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
4Y1411-4-tU. ri-4.1c0s4 4441•4. nC> 4+rrru. L{.v4- O/•1V/<Vl<
Doctor's Narrative Report ECr4NARRState of New York - Workers' Compensation Board
THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL.
This form may be used to report the first time you treated the patient or to report continuing services. (To repot permanent
impairment, use Form C-4.3.) Use this form only if attaching a detailed narrative report. Please answer all questions
completely and submit promptly to the Board, the insurance carrier and to the patient's attorney or licensed representative,
if he/she has one; if not send a copy to the patient. Failure to do so may delay the payment of necessary tre,tment,
prevent the timely payment of wage loss benefits to the injured worker, create the necessity for testimony, aid jeopardize
your Board authorization.
A. Patient's Information
1. Last Name' Glacalane First Name: Jason
2. Social Security #: INS 3. Home Phone 7187538959
4. WCB Case # (if known):
6. Mailing Address: 72 Bay 49th Street
5, Carrier Case # (if known): CSP000005824
City. Brooklyn State
7. Date of injury/onset of illness:8/19/2006
Line 2:
Zip code 13.21.4
8 Date of birth:101978 9. Gender: Male
10. On the date of injury/illness what was the patient's job title or description'unknown
Co nt
11. On the date of injury/illness what were the patients usual work activities:
pt injured his back while at work
12, Is the patient working now? Yes
B. Employer Information
1. Employer when Injury occurred:
Company/Agency Name. Program Development
2. Employer Phone #. 7182562212
a Employer Address;
City:
C. Doctor's Information
Tr•• • e
13. Patients Account ft, 028820wc 4-if, •
::eeme 4
44 •
1. Your Last Name: Kreizman First Name: IssaP MI
2. WCB Authorization 14: 206647,0B 3. WCB Rating Code: CPMR
4. Federal Tak DM 201270006 The Tax ID # is the: Eni
5. Office Address: PAas Medical PC Line 2: 5223 9th Avenue
City: Brooklyn Stateybli Zip Code: 11220 tuntry
S.:Billing Group f Practice Name
Billing7. Address: 5223 9th Avenue Line 2.
City; Brooklyn State' NY Zip Code; 11220 Country:
8. Office phone #: 291-818-8627
10. Treating Provider's NPI #: 1497825434
9. Billing phone #.
11. You are a: Physician
rtS4NARF1 (19-ita Pane i of 2 THEWORICERSICOMPENSATIONfloARDEMPLOYSANDSERVES
0074
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NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
D. Billing Information
1. Employer% insurance carrier:
2. Carrier Code #:
NCA
3. Insurance carriers address:City: BUFFALO
14 LAFAYETTE SQUARE
4. Diagnosis or nature of disease or Injury:
Enter ICD9 Code: ICD9 Descriptor
724.2 LUMBAGO1
2 724.4 THOR/LUMHOSACRL NURIT/RADICULIT UNS
3 781.2
4
State: NY
Line 2: SUITE 700
Zip Code: 14203 Country:
ABNORMALITY OF GAIT
Relate ICD9 codes above to Diagnosis Code column by line.
Dates of Service
From To
Placeof
ServiceLeaveBlank
Use WCB CodesProcedures Services or Supplies
CPT(HCPCS liodifier 1 Waal. 2DiagnosisCode S Charges
Days/Units
•
iCOB
Bp Coda whereservice was rendered
2/23/2012 2/23/2012 11 99213 12 64.07 1 112202913
00000
ci Services were provided by a WCB preferred provider organization (FPO).
Total Charge
64.07
Amounthui ci °(Canner UseOnry)
Soot,
Selaree DueratiiierriUse Only)° °
E. Doctors Opinion0000
O 0 000 0
1, In your opinion, was the incident that the patient described the competent medical cause of this ingsyfilkess'a res.
2. We the patients complaints consistent with his/tier history of the injuryfillnees? , Yes
3. Is the patient's history of the injury/illness consistent with your objective findings? Yes
4. What is the percentage (0-100%) of temporary impairment? 100.00%
This form is signed under penalty of perjury.
Board Authorized Health Care Provider:I Provided the services listed above
MOTORIZED SIGNATURE ON FILE WITH NEW, YORK WORKERS COMPENSATION BOARD]
00 0 saea
O 00
Provider's Last Name: First Name: MI:
Provider's Specialty:
Board Authorized Health Care Provider:
Last Name: Kreitman First Name: issac MI:
Specialty: PHYSICAL MEDICINE/REHABILITATION Date: 7/2/2012
EC-4NARR (12-10) Page 2 of 2 0075
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Submitted: 9/7/2011 Lost Resubmitted: I0/17/2011 0 0 0 3 2
Doctor's Narrative Report EC-4NARState of New York- Workers' Compensation Board
THIS FORM MAY ONLY BE SUBMI I !EU ELECTRONICALLY. DO NOT MAIL
This form may be used to report the first time you treated the patient or to report continuing 80N1Ces. (To report permanentimpairment, use Form C-4.3.) Use this form only if attaching a detailed narrative report. Please answer all questionscompletely and submit promptly to the Board, the Insurance carrier and to the patient's attorney or licensed representative,if he/she-has one; if not send a copy to the patient. Failure to do so may delay the payment of necessary treatment,prevent the timely payment of wage lose benefits to the injured worker, create the. necessity for testimony, and jeopardizeyour Board authorization.
A.. Patient's Information
1. Last Name: Giaoalatcl First Name: Jason Ml:
Luccoo 2-Y7.2 0
zsociaisecurity#:S 3. Home Phone #: 7197038983
4. WCB Case # (if known): 09317829
6. Mailing Address: 72 Bay 49th Street
5. Carrier Case # (If known): 37546225620
Line 2:
City: Brooklyn State: NY Zip Code: 11214
7. Date of injury/onset of illness:6/19/2006 8. Date of birth:fek1978 9: Gender: Mate
10. On the date of InjuryThiness what was the patient's Job title or description:unknown
Country.
11. On the date of injury/Illness what were the patients usual work activities!
unlmown
12. le the patient working how? Yes
B. Employer Information
1. Ernployer when injury occurred:
Compary/Agency Name: Program Development
2. Employer Phone #: 7182562212 ,
3. Etriployer Address: 6916 pew Dbreht avenue
City: Brooklyn
C. Doctors Information
1. Your Last Name: Itreiznan
13. Patients Account #: 029820"
Line 2:
State: ny Zlp Code: 11209 Country:
First Name: Issas MI:
2.•WCB Authorization #: 206647-05 3. WCB Rating Code: °KIR
4.•Federal Tax ID #: 201270006
5. Office Address: PAM 5944.10a1. PC
City; Brooklyn
6. Billing Group / Practice Name
The Tax ID# Is the: allst
State: NY
Line 2: 5223 9th Avgnr-e • • •
. Zip Code: 1322D ; • • tdurrtry:
7. Billing Address; 5323 9th Avenue Line 2: 000 00e
•
• Oak*
City: Brooklyn State: ---NY zip Code: It-9° ;0 s .* st • MOW:
8. Office ()hone #: 201-9187-8827 9. Billing phone #:
10. Treating Providers NPI #: 1491825434 11. You are a: Physician
Pri•MARg141-ifil Rana 1 of 7
a•
THEINORKERSISOMPENSATEM BOARD EMPLOYS AND SERVES0 •
00
4 6000 0
O 0
• 00• 0 0
Or 00,
0
O 0
0 CI
O 0
O a
060076
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
D. Billing Information
1. Employer's Insurance carrier:
2. CaMer Code #:
•
PEA MEDICAL BILLING
3. Insurance carrier's address:Car. own-craw
PO BOX 5231
.4 Diagnosis or nature of disease or injury:
Enter ICD9 Code: ICD9 Descriptor
724.2 LUMBAGO1,
2
3
4
State: WI
lJne 2:
00.032
Zip Code: 53547 COUntlY:
724.4 THOWLINBOSACRI NURITMADIO3LIT UNS
Relate.ICD9 codes abovelo Diagnosis Code column by line.
Dates of Service
Frain To
'Rineof
SpiceLeaseBlank
Use WCB CodesProcedures Services or Supplies
OPTI}ICPC$ Marti 1 Madiger2DiagnosisCode $ Charges
Days!Ungs COB
Mg Code Awemelon was renders
9/16/20]19/16/201111 9921,3
I\
2 64.07 1 11220
•n
FEVEDI ..,,.is e _ et.
eic Tg44 S. .
AggicluIfki
• -----• .
-PAO. .-------------c--
(3 Services were'provided by a WCB preferred provider organization (FPO).
Talal Charge
64.07
Amount Pid(Owner Use Only)
Balance Due(darner Use Only)
E. Doctor's Opinion
1. In your opihion, was the Incident that the patient described the competent medical cause of this injury/11'ms; ? Yes
2. Are the patients complaints consistent with hls/her history of the InjuiyAllness? Ton
a is the patients history of the InjuryAllness consistent with your objective findirigs? Yes
4. What is the percentage (0-100%) of temporary impairment? 8°.009
This form Is signed under penalty of perjury.
Board Authorized Health Care Provider:I Provided the services listed above
MOTORIZED SIGNATURE ON FILE WITH NEW YORE WORKERS COMPENSATION BOARD]
Provideei Last Name:
Provider's Specialty:
First Name:
a
Board Authorized Health Care Provider:
Last Name: Kreizacn Rid NalTle:Isgaa *ay opo
Specialty: PHYSICAL MEDICINE/RERABILITATION Date: eti/zinzoJ
0 o• g g
Oa SO• o
O 000 O O 4
MI:
EC-4NARRI12-1 0) Page 2 of 2 •
0 000 •G 0 0 o• 0 00o 00 0 •
O 0 o 0 oo 0 000 Go
007t
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
t? Health SystemsINTERNA TIONAL
RX
INVOICE FEDE1
INVOlt
INVOK
NAME: NCA Comp NAME: JASON GIACALONE
14 LaFayette Square CLAIM 4: W000024420
Suite 700 CARDHOLDER ID: 1706776
Buffalo, NY 14203 ADJUSTER: Sherri Clch
Atln:Steven Gidwitz
CRISP TrustDUE UPON RECEIPT
PLEASE INCLUDE INVOICE NUMBER WITH YOUR PAYMENT
DescriptionNDC Code
First Date of Drug Type Days Prescribing M.D.
Fill Service FIX., Pharmacy Name Oly, Supply Physician I.D.
Pharmacy ID DAW
Billed ByPharmacy (11paper claim) Fe
9/13/2011 0110347 DIAZEPAM 10 MG TABLET 90 30 KREIZMAN
00603321521 1497825434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LL
1154568400
W13/2011 0110348 OXYCODONE HCL 30 MG TABLET 180 30 KREIZMAN
52152021502 1497825434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LL
1154568400
OK TO FEE SCREC57.
IMOUNT TO PO
PAID: 130C11 Vta-'
PLEASE REMIT PAYMENT TO:
Health Systems InternationalP.O. Box 881, Indianapolis, IN 46206-0881866.895.2021 Toll Free • 866.701.2781 Fax
rx Ous•hal.com
$0.00
$0,00
TOTAL AMOUNT DUE:
Amounts denoted by 'O a
PRE NEGOTIATED RATE
RE$I
0078
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
STATE OF NEW YORK - WORKERS' COMPENSATION BOARD• PRACTITIONER'S REPORT OF INDEPENDENT MEDICAL EXAMINATION
A copy of oath report of Independent Medical Bouranation shall be submitted on the same day and In the same manner to tha Workers' CompensationBoard, the Insurence canter or self-Insured employer. the claimant's attending physician er oilier ettendlna practitioner. tho elaknallee roPlestrnathaaIf any, and the claimant.
"ECK CHIE: I l PSYSCIAN l I POOSTIXIST I I L CEROPWW1OR 1 1 l paycNotwoon
MIS EICAMIUMION WAS REOUEBIE0 BY: CARRIEWEMPLO I
Wee CASENO. CARRIER CASE NO. (IF KNOWN) DATE OF INIMF4Y MIRED PERSONSSOCtAL SECURE? /01 R
DATE OF EXAPARATION
00E126057 W000014420 1090/2000 10712011
INWREOPERSON
(T241 Now) (ARR 1.030) (Lot NaomiJason Wacalaw
ADDRESS podude Apt. No.)72 14.2491‘ Weal 2nd Floorbuldw, NY 11214
EMPLOYER Room Devokomonl &Ekes
INSURANCEWRIER
Rtoccop, INC- RAWSKEW OW
14 LAKE, SwamSuns 700BOW] NY 14203
If laCAMINEFI 00E0E07E131MS WCA1014A1ION AS AN EMPLOYEE OF AN RECOMPANY, OR UNDER CON1RACT OR ARRANGEMENT WRY! AN WE 0074PANY. STATE NAMEAND WORKERS' OCIMPENSATION BOARD REGEOROWON NUMBER OF IME COLIPANY.L5G14041:31WWWwistratlon 0010200
Results of Examination (continue on revers. or attach additional sheets, If necessary}
cc: Sherrie Cich, Ncacomp, INC- BuffaloMguiti, 'Catkin & Gentile LLPNew York Workers Compensation Board-BinghamtonDr. Kreizman
009:00
0000
• 0
00099
PLEASE SEE ATTACHED REPORT
hereby teary that tits report Is a (fd/ and truthful repomontstion of my profaselonal opinion tmpaello the dramas condition.
Julio itiNtraterbend, M.D.
000099
00•0
••
009c.
099600
0 •
0911000
•000000
to it) IPractitioners Name Racial* gnetere
1302 Kings Highway Eth floor Brooklyn, NY 11220
Practitioners Mamas
Date
010200
IME Authorization No.
NO PRAGETIONER EXAMINING OR EVALUATING A CLAIMIWT WIDER THE WORKERS' Ca mpENSARON LAW NoR ANY SUFERVOWNG ARRIORRY OR PROPRIETOR 133RINStIRANCE COWER OR EmpLOya4 MAY ea DIRECT OR ENCOURAGE A REPORT TO 11E SUWATTED AS EMERGE IN WORKERS' COMPENSATOR CLAIMADWIECATION wifiCz1 DIFFERS SUBSTANTIALLY FROM THE PROFESSIONAL OPINION OF NE ICIALONING PPACTMCINER SOC.41AN ACTION SHALL BE CONSIDEREDYORIIN TOE JUSRWOICTION OF THE WORKERS COmPEKSATIONFRAED INSPECTOR GENERAL AND MAY BE REFERRED AS A FrowoULENT PRACTICE.
IME-4 (11-01)
0079
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
DOWNSTATE CENTRALIZED MAILING04914449Ploni Cry, Hempsbxed.Heopaug4 &Pmludigl 01941444
PO Box 5205 Binghamton, NY 13502520.5SYCREARTAMEAAR.9 hl•.(14364ARROORTROSSI
1CO alialbay Stale Office &Oleg SAS TOMS 190AYIn slmovtMem& 49 Heyday Waal 107 Delaware Ave. RocfrEsmi 14814
ALBANY 17141 91t4GHNATON 13901 BUFFALO 14202 ow 2110644mem 7506157 peal 501-3604 ORS 211-0645
535 SamosSYRACUSE I=WAS 1102-3730
State of New YorkWORKERS' COMPENSATION BOARD
PRACTITIONER'S REPORT OF REQUEST FOR INFORMATION/RESPONSE TO REQUESTREGARDING INDEPENDENT MEDICAL EXAMINATION
I.PRACTITIONERS WA AM ADDRESS
V404tokforoi
1302 Kings Highway 5th FloorBrooklyn, NY 11229
2, NAME ANDADDRESSOF PAWN REQUESTING RiFORUAllOM
Noacornp, INC- BuffaloSherrie Clch14 Lafayette SquareSuite 700Buffalo, NY 14203
3. PRACTITIONER'S NE AUTNORIZARON ND.
092557-8B4. WEENTTrYSESISTEUMON NO. (EARReade)
0102095. DATE OF DEXEPENCENEMEINCAL EMANATION
lei a- o6. CIAONNWS NAME
Jason GiadolonaI. CLAIMANTS WW MEMO.
006260575. SAMOS INJURY
6/19/20069.DATE OF THIS REPORT
Pursuant to Section 137 of the Workers' Compensation taw. If a practitioner who has performed or Wit be performing an Independentmedical examination of a workers' compensation dalmant receives a rogues for Information regarding Ute claimant, inducting faxed arelectronically-transmitted meta the practitioner must submit a COPY of the MP& for leffirmallon to the Workers' Compensation Beardwithin ten days of Me receipt of the request hi addition, copies of all 9115123112.85 to soda requests, Including all materials which ereprovided In response to the requester, shall be submitted by the responding practitioner to the Board within ten days of the submission ofthe response to the requester.
If the request for Information is limited to a request for scheduling of an Independent medical examination. you need AnittalthisConn. However, you must send a copy of Form IME-5 ('Claimant's Notice of Independent Medical ExernInatiotY) to thedesignated Worker' Compensation Octant office. 0 0 e•
•
ffistruddene••••
a. Complete all kientilytm information, Items 1-9 abovegme•00•
b. To report a request for information, complete Item 10 below. sign, date and mail to appropriate WorkelM41313INIsatioi Etealciledistrict office vAthIn ten days of receipt of request A copy of the request must be attached.
c. To report practitioners response to a request for Information, complete Item 11 below. sign. date and otrift& "appropriate •Workers' Compensation district office within ten days of submission of response to the requester. A copyof the responM ificralmaterials sent to the requester must be attached
d. elf the practitioner responds to the requester widen ten days of the receipt of the request, complete, stgrunti.def Items 10 and•0000
11 and mall to the appropriate Workers' Compensation Board district office within ten days of receipt of the request w10),pggills,of request and response attadted. Dthervilse, submit separate forms to report request and your response 'written the hoe limitsgiven in b, and c. above. •
s.NOTE: The pracgtionets release of medical anffior Workers' compensation records to the Board and/or to the naquesEnga party issubject to applicable laws regarding the confidentiality of Such records, MdudIng but not Welted to Section 110-a of the Workers'Compensation Law. Section 18 of the Public Health Law, and other applicable state and federal laws.
HIPAA Notice: In order to adjudicate a worker' compensation claim. WCL Sections 13-a and 137 permit an employer or canterto have a claimant examined by a health care prodder. Pursuant to 45 CFR 512 a health cam provider who has been retainedby an employer or carder ta evaluate a workplace Injury Is exempt from HIPAA's restrictions on disclosure of health Information.
PRACTITIONERS WHO FAIL TO FILE REQUIRED FORMS MAY BE SUBJECT TO DISCIPLINE, INCLUDING REMOVAL. OFAUTHORIZATION TO PERFORM INDEPENDENT MEDICAL EXAMINATIONS.
10. PRACTITIONERS REPORT OF REQUEST FOR INFORMATION REGARDING INDEPENDENT MEDICAL EXAMINATION
Date request receivedAttached is a copy of a request for Infommtion received In the case Identified above.
Pc. 4.1C5114sOnri q r9Cle I I
Practitioners Name re.afg-12-- MS
1 I. pRACTITIONER'S REPORT OF RESPONSE TO REQUEST FOR INFORMATION REGARDING INDEPENDENT MEDICALEXAMINATION
Date request receivedAttached is a copy of my response to a request for information received In the tffied above and all materialssupplied to the requester.
Dr.. Vtayiretbanci 10 -3-IIPractitioner's Name -praetor° Date
IME-3 (8-03) (0401-0378 12331023816) twitv.wcb.statany.us
u 0
00 • •
es 0
0000
0080
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
i0.11411.1.4 1.1./ 1að cuii 201203120002639
Doctor's Na relive ReportState of New York Workers! Compensation Board
THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DONOT MAIL.
Thls form may be used-to report the first time you treated the patient or to report contirsdng services. .(To report permanentimpairment, use Form c-ta) Use this form only if attaching a detailed narrative report. Please answer all questionscompletely and submit promptly to the Board, the insurance carrier and to the patient's attorney or licensed representative,if he/she has one; irnot send a copy to the patient. Failure to do so may delay the payment of necessary treatment,prevent the timely payment of wage loss benetits to the Injured worker, create the necessity for testimony, and jeopardizeyour Board authorization.
A. Patient's Information
1. Last Name: Glacial-ans. First Name: Jason MI:
C NARR
2 Social Security #: a Home Phone ft. 7187538953
4, WCB Case # (If known): 09317829 5, Carder Case # mown); CSP000005824
6. Mailing Address: 72 Bay 49th Street . Line 2:
City: Brooklyn
7. Date of injury/onset of iliness:6/19/zoos
State: 1.12 Zip Code: 11214
8. Date of birth:0111075 9. Gender: Male
10. On the date of Injury/Illness what was the patient's job title or desorlption: -unknown
Country:
11. On the date of injurytiliness what were the patients usual work activities:
unknown
12. Is the patient working now? Yes
B. Employer Information
1. Employer when injury occurred:
0 0 •
00 W4
•
00000
:
13. Patient's unt #: 05
OK TO FEE SCHED 0 •
• 00
• a •walla
, •AMOUNT TO Pat . 0
Company/Agency Name: Program nevelopment
.2. Employer Phone #:
3. Employer Address:
City: en:chive
7182562212
6916 New Utreht Avenue
C. Doctor's Information
1. Your Last Name: End-man
Line 2:
0010
0
00
State: kw Zip Code: 112 09 Country:
First Name: Issa° MI:
WCB Authorization #: 206647-013 3. WCB Rating Code: court
4 Federal Tax [Dm 201270006 The Tax ID # is the: • EDT
5. Office Address: PAas Medical pc Line 2; 5223 9th Avenue
City: Brooklyn state: NY Zip Code: 11220 Country:
6. Billing Group / Practice Name
7. eying Address: 543 9th Avenue Une 2:
ay: Brooklyn
8. Office phone #: 201-818-8627
" State n zip Code: 11220 Country:
9. Billing phone #:
10. Treating Providers NPI #:1497825434 11, You are a: Physician
EC-4NARR (12-10) Paget of 2 THEWORKERS COMPENSATION BOARD EMPLOYS AND SERVESPEOPLE IM1H DISABILITIES INRHOUT DISCRIMINATION 0
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
D. Billing Information
t. Employers Insurance carrier:
2. Carder Code #:
201203120002639
00122
PMA MEDICAL BILLING
3. Insurance carrier's address:city: JANESVILLE
PO pox 5231 Line 2:
4 Diagnosis or nature of disease or injury:
ICD9 Descriptor
LUMBAGO
Enter ICD9 Code:
1 724.2
2 724.4
3 781.2
4
State: Ifs Zip Code: 53547 COUNTY:
THOR/LUMBOSACRL.HURIT/RAD/OULIT UGS
ABNORMALITY or GAIT
Relate ICD9 codes above to Diagnosis Code column by line.
Dates of Service
From To
Placeof
ServiceLeaveBlenk.
UterWCBCodesProcedures, Services or Supplies
CPT/HCPCS Modifier! Modfier2IliagnosteCode $ Charges
Days(Unlb COB
Zip Cade Mereservice was rendamd
11/7/2011 11/7/2011 11 99213 12 64.07 1 11220
' .0.4***
. . *• • • • • • • •
.• .•°°:
° •
° --- .•••
. ahy
ID Services were provided by a WCB preferred provider organization (FPO).
Total Charge
64.07
, 11-i
Arniuld fre'd d
regfirs Only] :. . - •
I SI,
Balance Due '(Csrriej Use Chilyr .•• • • ° °
00000
E. Doctors Opinion
1. In your opinion, was the Incident that the patient described the competent medical cause of this injury/lilnessYvg;°
2. Are the patient's complaints consistent with hls/her history of the Injury/illness? Yes
3. Is the patient's history of the Injuiyfillness consistent with your objective findings? Yes
4 What Is the percentage (0-100%) of temporary impairment? eil•00%
This form Is signed under penally of perjury.
Board Authorized Health Care Provider:I Provided the services listed above
[NOTnoviED SIGNATURE ON FILE WITH NEW YORH names COMPENSATION BOARD]
0.
01,090
• • •
Provider's Last Name; First Name: MI;
Providers Specialty:
Board Authorized Health Care Provider:
Last Name: Kre"Man First Narse:Issaa
Specialty: PHYSICAL MEDICINE/REETAISILITATION Date: 11/15/2011.
MI:
EC-4NARR (12-10) Page 2 of 2
0.82!
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
20120312000263900122
401.110
,13
HISTORY OF PRESENT IL NESS:
The patient isstatus postiroxycodlne 30mg q.4h-6hHe is status post multiple
CHIEF COMPLAINT;,
ury to the lower bagr pain. He is comppries with hardwa
OBIN:
atet II/7/11'Attending' Isaac 3. Krekinifil, MD
. tient Jason otacalose .
He is currently taking Valium 10mg ad. andMing Of lower back pain, lower extremity weakness.e to lumbar spine. Patient states 10/10 pain scale.
He is complaining of lot back pain with lower extremity weakness.
EXAM:
SOCIAL HISTORY:Alcohol: NoneTobacco: Patient is a non sl-Drugs: None.Toxins: None.Work: Patient is non-contriDiet Patient is not on any
FAMILY HISTORY:Non-contributory.
MPS;He is currently taking Vali
ALLERGIES:No known allergies
PAST MEDICAL HISTORY}Non-contributory
oker.
utory.rticular diet.
..10mg t.i.d, and ro
Ivcodme30mg q.4h-6h.
SURGICAL HISTORY:He has had multiple surgerif with hardware to Itsmbarapine.
REVIEW OF SYSTEMS:Constitutional: Patient devomiting, diarrhea or diplENIVIT: patient denies any ar or nose problems; visual difficultio
• Throat: Patient denies any oblems or swellingiin the mouth, needisorders.
•••0
•O*0
•0 • ••• •
•
• ••
•
•0•0• J
•
• ••0
iika • •
•*
•
any change in weight, fevers and•Sweats. The patient denies any nausea,
III NMJason alakite •375406529141CM1166V751 11/1101111
illO 83
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Calk): Patient denies angipressure; heart problems, Pcholesterol, and Peripheralgespinitory: Patient denies•problems, chronic obstructisarcoidosjs, dyspnea, asthmGI: Patient denies abdomipeptic ulcer disease, divert!problem and colitis.GU: Patient denies dysuria,HemeilLymph; Patient denthrombosis and HyperkalRhein Patient denies neck'pain, bilateral foot pain, bilband pain.Endocrine: Patient deniescellulitis and colon cancer.Nenro/Psych: Patient dentehemiplegia, dizziness, cereheadaches, psychiatric probIntemunentaryi Patient den
PHYSICAL EXAM:Vital Signs:Upright BP =120/80 zranTriPulse 680 bpi. Padeot isRasp =15
Qeneral: Well nourished.HUNT: Nonnocephalic,Chest Clear to auscultationCV: There is a regular rateAbd: The abdomen js soft;Ncck: No paraspinal tendemMidBelc: No paraspinal tendLowBek: L4-L5 paraspinalExtract There is no dubbinRUE: 5/5 muscle strength.LIJR!, 5/5 muscle strength.RLE; Decreased Muscle sweakness. . .LLE. Decreased muscle .swee/ Mast. • ' •51e: No IgnSt ro.ohel, LIP?140.2hypelpatiorroflywit &des it neck; =ills and grain is •• .
. .
Mite; ORIENTATION; AI?' canted x3. The patient anderstociiliicarFdand Pittenticts span
2012.03120002639'6422 -
edema; hypertensipn, palpitations, vascular problems, high bloodnary Fibrosis, Cohgestive Heart Pattie, ComnarY.Artery Disease, high-
cular Disease,ugh, shortness of &oath, sputum production, wheezing, lung/breathingpulmonary disease, restrictive lung disease, pulmonary hypertension,chest pain and bron hitis.pain, bleeding, bo I changes, dyspepsia, gastrointestinal problems,Ifs, hepatitis C, 0 irritable bowel syndrome, neurogenic bladder
uency, hematuriaj incontinence and nocturia.s anemia, easy bruising, excessive bleeding, tymphadenopathy, deep vein
n, mid-back pain, bshoulder pain, b!
ateral hip pain, bilateral knee pain, bilateral ankleetersl elbow pain, bilateral wrist pain and bilateral
rmonal abnorrnaliti , polydipsia, polyuria, diabetes, hypothyroidism,. and
mood changes, patysis, syncoperdempssion, cerebrovascular accident,palsy, mental rot ation, traumade brain injury, multiple sclerosis, *.
ms, neurological problems, ADD, andsleop apnea. •es pruritis, rashes,hkin eruptions, Infection ene,thingles. .
0000
i• 0
0.90
a a
tt.oseentraticra were nonem! I - XII. MOOD &COORDINATION/GAIT: Nand BLE. Reflexes-are no.OF SENSATION:: Normal t
febrile •
11 dressed. Not in ;Ste distress.umatic. EOM are i tact,
flaterally. No whee ing, no rates, no rhonchi.d rhythm, Normal S I-S2.on-tender. Non-dist ded. Normal bowel sounds are present.ss noted. Full range of motion.ess noted. Full ratige of motion.
ndemess noted. Diereased range of motion.ythema and cellulitis.
ge.ofinotion. -.ange of motion. -. - • . . ... • .ge amodon. SLR 4,3- osgrees forward fiorion with
, cyanosis, edema,o contractures. Fullo contractures. Full
b. .Debreased ra
• •
.
0o ••
• • ,
De:; isedrartge of mOtinit; NIA 10 derreilfOrw.artgetipSwith
tr.:Cando:is iq the head, neck tram", Kb-till-4.M, TIE.
Remote end Reedit memory were normal. There is no deficits in cranialECT: No depressidn, no anidety, no agitation. TEST;anal coordination. Alinonnal gait. EXAM OF DM Normal 2+ BMto the lower extremities and deoreased to the upper extremities. EXAM
light touch and pinpOck Normal vibration.
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
PLAN,
201203120002639•
ASSRSSKENT:
1. Lower back2. Status post multip!c surgeries to lumbar spin‘
.1. • Physical therapy2. Home exercise pr3, Continue Valium and xycodine4. Follow-up in one :non*
L
'44
IsiraeJ.C-einnoms, MD
Michael eaxliulsky, RPA-C
UK/CARuM00001/814435613.483139
/. •
0••0 •
c•
•9 • 0
•• • 0
4 6
00 Oa
0000 0 0
•
0 C0
•0
• 0a
• Q
• 0•O•
*• 0 •
cb00
• 0000
• • ••••
0 0 •0
c. • •t, • •
• •
3G;3
00 5
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
201203120019010
Submitted: 2/6/2012 Last Resubmitted: 061/218 2
Doctor's Narrative Report NM:a •
State of New York- Workers' Compensation Board
THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL.
This form may be used to report the first-tiros you treated the patient or to report continuing services. (To report permanentimpairment, use FORD C-43.) Ude this form enly if attaching a detailed narrative-report Please answer all questionscompletely and submit promptly to the Board, the Insurance carrier and to the patient's attorney or licensed representative,if he/she has one; if not send a copy to the patient Failure to do so may delay the payment of necessary treatment,prevent the timely payment ot wage loss benefits to the Injured worker, create the necessity for testimony, and Jeopardizeyour Board authorization
A. Patients Information
1. Last Name: GisoaiDna First Name: Jason MI:
2 Social Security iklia
4. WCB Case # (if known):
6, mailing Address: 72 Bay 49th Street
3:Home Phone #: 7187538953
5. carrier case # known): C9130000051324
aty: Brooklyn State: SY
Line 2:
zip Code: 3.3214 Gouty:
7. Date of lnjurylonset of illness:6/19/2006 8. Date of birth:111,1978 9. Gender: Male
10. On the date of Injury/illness what was the patients job title or description:unknown
11. On the date of Injury/Mess what were the patients usual work activities.
unknown
12.1s the patient working now? Yes
B. Employer Information
i. Employer when Injury occurred:
CarnFanYIAgerloY Name: Biter= Development
2. Employer Phone #: .7182562212
3. Employer Address: , sea,s,a.re,t• Thzeht Avenue
City: Brooklyn State: Ny
C. Doctor's Information
1. Your Last Name: Icri2thaan
• 0
13. Patient's Account #: 028820wa Ovaa
1 0a$5 00000 e °0
° G4'0:
O 0
a
nic10 FEESCan•C•SI *4
a 0
. .0
e
0 ct:. • .
At/1011. litiOuP:-------472:
01.0
.0 0 00O 0 6 00".00800 0 0
De
?MD:P Code: 13.209 . Count ° 6* OOGO
2. WCB Authorization #: 206647-013
4. Federal Ttor.til 201270006
First Name: Issas
a • a
3. WCB Rating Code: C9149
The Tax ID ft Is the: EDI
5. office Address: PARS Medical BC line 5223 9th Avenue
MI:
City: Brooklyn State: NY Zip Code: 3./.22o Country:
8. Billing Group / PraCtice Name
7. Billing Address: 5223 9th Avon= Line 2
City: Brooklyn State:EY 11220Zip Code:
B. office phone 201-01B-8627 9. Billing phone #:
Country:
10. Treating Provickes NPI # 1497825434 11. You are a: Physician
EC-4NARR (12-10) Pagelof 2 niewortttette COMPENSATION BOARD EMPLOYS AND SBRWsPenne WITH DISMILdissefirROUr oisalunaknON
0 60
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
D. Billing Information
t Employer's insurance °artier:
2. Carrier Code #:
201203120019010
\
PMA MEDICAL BILLING
a Insurance carriers address:
City: JANESVILLE
PO BOX 5231 Line 2:
State: fa Zip Code: 53547
4. Diagnosis or nature of disease or Injury:
Enter ICD9 Code: 1CD9 Descriptor
1 724.2 LUMBAGO
Country:
2 724.4 THOR/LUMBOSACRL ITURIT/RADICULIT UNS
3 781.2
4
ABNORMALITY OP GAIT
Relate ICD9codes above to Diagnosis Code column by tine..
Dales of Service
From To
Placeof
SmiteLeaveBlank
.Use INCBCodes
Procedures Setviees or SuppliesCPTgiCPCS Modger i Weer 2.
DiagnosisCode SS Charges
Days/Oils COB
.
Bp Code stunsmoke was rendered
1/26/2012 1/26/2012 11 00213 1.2 64.07, 1 112202913
•
. .
. . 0000
were provided by a WCB preferred provider organization (FPO)_
Told Charge
64.07
Amount Prid(Carrier Uee Ordy)
Beltway bua(Calder Wee Only)40
. 00
. 00sa Services 004
•
000500 0 0 0
0 0 DO 000
E. Doctor's Opinion 000:00 100000 a•
•
1. In your opinion, was the Incident that the patient described the competent medical cause of tnitsquW/Illnesst • •°
2. Are the patients complaints consistent with histher history of the InjuryillIness? Yes
3, Is the patients history of the InjuryAllness consistent with your objective findings? Yes
4. What is the percentage (0-100%) of temporary Impairment? D. pp°
00000
•00000
This form is signed under penalty of perjury.
Board Authorized Health Care Provider:I Provided the services listed above
MOTORISED SIGNATURE ON FILE WITH NEW YORK WORKERS COMPENSATION BOARD]
4 • 0
00
a.
000000
0
0000
ProVidets Last Name: First Name: MI:
Provider's Specialty:
Board Authorized Health Care Provider:
Last Name: frroizow First Name: issao MI:
Specialty: PHYSICAL MEDICINE/REHABILITATION Data: 2/6/2012
EC-4NARR 02-10) Page 2 of 2
007
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Submitted: 11/15/2011 Last Resubmitted: 11/16/2011
Doctor's tilarrative Report eNARRState of New York- Workers' Compensation Board
THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. 00 NOT MAIL.
Thls form may be used to report the first time you treated the patient or to report continuing services. (To report permanentimpairment, use Form C-4.3.) Use this formsateIf attaching a detailed narrative report. Please answer all questionscompletely and submit promptly to the Board, the insurance carrier and to the patient's attorney or licensed representative,If he/she has one; if not send a copy to the patient Failure to do so may delay the payment of necessary treatment,prevent the timely payment of wage loss benefits to the injured Worker, oreate the necessity for testimony, and Jeopardizeyour Board authorization.
A. Patient's Information
1. Last Name: Glacial-one First Name: Jason MI:
2. Soolal Security-s: 10111111a 3. Horne Phone#: 7187538953
4. WCB Case # (if known): oollmo 5. Carrier Case # of known): CW000005824
a Mailing Address: 72 Day 49th Street
City: Brooklyn. State: NY
Line 2:
Zip Code: 11214 Country:
7. Date of Injury/onset of illness; a/le/zoos 8. Date of birth:1111197° 9. Gender: iriale
10. On the date of infuryillkieis what was the patients lop title °I:description:
, . . . •Whafwere the patient's usual work activitirist: '
12413? • . ;
12. Is the patient working now? YO-9 • • -•• •13: Patient's Amount #: Ohbenvo • •-•
B. Employer Information.
1. Employer when injury occurred:
Company/Agency Name: program Development
2. Employer Phone #:21.82562212
a EmPloYer Address: 6916 Neu Utreht Avenue
City: Brooklyn State: Hy
C. Doctor's Information
1. Your Last Name: Ktel2man
2. WCB Authorization #: 206647-0B
4. Federal Tax 10#: 201270006
5. Office Address: PARS Had-teal- BC
Line 2:
. • 0
• 0 • 0
Zip COde: 11209
000000
00,:00
0000
•* 0
0000••
DOO• 0
• •• 0 0
00 00 006000
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• 000000000000 • 11 el
•
• 00 0000O 0 0 0
0000 0 •
• annum.*
Country:0
0090
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First Name: issa° M1:
3. WCB Rating Code: en
The Tax ID # Is the: ETD
City: Brooklyn
SyBillingiGroup / Practice Name
7.BillinfiAddresk 'an;:bciiraegis&
Car' eroonyii
B. 'Office 'phone 201--919-i3821
State: NY
State:
Lille -2: 5223 -9th Avenue
Zip Code: 11220 Country:
Line 2: • 4'
Zip Code: lino
9 Billing phone S.
4 —44 4e4w .44.e .44 4
Country;
10. Treating Provider's NPI It 1497625434 11.).(011 are a: Physician
90-4NAftR (12-10) Page 1 of 2 THEW:WHEW COMPENSATION BOARD EMPLOYS ANDSERVESPEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION 0088
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
, D. Billing information
1. Employer's Insurance carrier
2. Carrier Code #:
IP It
PMA MEDICAL BILLING
3. Insurance carders address: PO BOX 5231
city: JANESVILLE state: wr
4. Diagnosis or nature of disease or injury:
Enter ICD9 Code: ICD9 Descriptor
724.2 liUMBAG01
2 724.4 THORMUMBOSACRL NURIT/RADICULIT UNS
3 781.2
Line 2:
Zip Code: 53547 Country:
4
ABNORMALITY OF GAIT
Relate ICD9 codes above to Diagnosis Code column by line.•
Dates of Santee
From To
Placa•ol
ServiceLeaveBlank
Us IAICEI CedesProcedures Sendass or Supplies
CPTIHCPCS Madder' Mocgfier2DlagnosisCode $ Charges
.Days/Units COB
21p Code °hereservice was rendered
1e./8/203.1 n./sizoii n 99213 12 64.07 1 _,11220
'....."
.
in Services were provided by a WCB preferred provider organization (PPO).
TolatC,harge
ad.oe
Amount Paid 4
(Canter Use Only)/Solana° DIM(Canter Use Only)0 00 0900O
•E. Doctor's Opinion • • • • • •0000
1. In your opinion, was the incident that the patient described the competent medical cause of thfs, injurS#11Inedans
••
V.0000
0
.
0100,0
0,2. Are the patients complaints consistent with his/her history of the injuryfiliness? Yes 00 0 • OD
a Is the.patients history of the Illy/illness consistentwith your objective,findlngs? Yes
4. What Is the percentage (0-100%)•of temporary impairment? 80•°"
This form is signed under penalty of perjury.
Board Authorized Health Care Provider:I Provided the services listed above[MOTORIZED SIGNATURE ON FILE WITH NEW YORK WORKERS CONDENSATION BOARD]
O 0 000000
▪ 0000
OD •
ö •O 00
Provider's Last Name: First Name: M I:
Provider's Specialty:
Board Authorized Health Care Provider:
Last Name: Kreitman First Name:Issas MI:
Specialty: PHYSICAL litiltertM/RzEIABILITAinott Date: litie/zon
EC-AWARR (12-10) Page 2 of 2
0089
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
, O
I IW-•tit(
PA S
HISTORY OF PRESENT ILLNESS:
201205250005132
,Palent:Iaton CoacaloneDOB:SSN:Date: 1212911 1Attending: Isaac d. Kceinnan, MD ,
The patient is status post injury to the lower hack with multiple surgeries and hardware who is
complaining of 10/10pain, He has failed hack Syndrome. He has had multiple surgeries. The patient
is on °plaid management with oxycodine 30trig and Valium 10mg. The patient is ambulating with astraight cane. He failed physical therapy, epidurals, anti-inflammatories, opiaids and multiple lumbarinvasive surgeries.
,C14 FRI' COMPLAINT:
The patient is complaining of 10/10 pain to the lower back,
EXAIVI: , -
• SOCIA_L HISTORY.:Alcohol: NoneTobacco: Patient is anon-smoker.Drugs: None,Toxins: None.Work Patient is non-contdbutory.Diet: Patient is not on any particular diet.
FAMILY HISTORY:Nam contributory.
WEEDS:The patient is on °plaid management with oxyco dine 3 fang and Valium f Omg.
ALLERGIES:No known allergies
PAST MEDICAL HISTORY:Non-contributory
SURGICAL HISTORY:The patient has had multiple surgeries.
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REVIEW OF SYSTEMS:Constitutional: Patient denies any change in weight, fevers and sweats. T to vaient denies an nausea,vomiting, diarrhea or diplopia.ENNIT: Patient denies any ear or nose problems, visnal difficult 1111111N
Awl cinalra•PRIA175556911 2/29poni
0090
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
201205250005132
Jason anealose •12/29/t
•Threat: Patient denies any problems or swelling inthe mouth, neckprobleins or swelling and throatdisorder's.Cardio: Patient denies angina, edema, hypertension, palpitations, vasculdt problans, high bloodpressure, heart problems, Pulmonary Fibrosis, Congestive Heart Failure, Coronary Artery Disease, high-cholesterol, and Peripheral Vascular Disease.Respiratory: Patient denies cough, shortneks of breath, sputum production, wheezing, lung/breathingproblems, chronic obstruction pulmonary disease, restrictive lung disease, pulmonary hypertension,sarcoidosis, dyspnea, asthma, chest pain and bronchitis.GI: Patient denies abdominal pain, bleeding, bowel changes, dyspepsia, gastrointestinal problems,peptic ulcer disease, diverticulitis, hepatitis C, GERD, irritable bowel syndrome, neurogenic bladderproblem and colitis.GU: Patient denies dysurial, frequency, hematuria, incontinence and noctuda.*Herne/Lymph: Patient denies anemia, easy bruising, excessive bleeding, lymphatlenopathy, deep veinthrombosis and Hyperkaleraitt.Mem Patient denies neck pain, mid-back pain, bilateral hip pain, bilateral knee pain, bilatetal anklepain, bilateral foot pain, bilateral shoulder pain, bilateral elbow pain, bilateral wrist pain and bilateralhandpain.Endocrine: Patient denies hormonal abnormalities, polydipsia, polyuria, diabetes, hypothyroidism, andcellulitis and colon cancer.N.:ire/Psych: Patient denies mood changes, paralysis, syncope, depression, cerebrovascular accident,hemiplegia, dizziness, cerebral palsy, mental retardation, traumatic brain injury, multiple sclerosis,headaches, psychiatric problems, neurologkalproblems, A.D.D. and sleep apnea.Integumentary: Patient denies imuitus, rashes, skin eruptions, infection and shingles.
0000• •0040
PHYSICAL EXAM: ono
Vital Signs: 0 •
00
Upright BP =120/80 mmHgPulse =80 bpm. Patient is afebnle
........
•Opfla 0
Resp =15 •09°9°0
General: Well nourished. Well dressed. Not in acute distress. 0 0
IIEENT: Normocephalic, Atraumatic. EOM are intact. • •Chest: Clear to auscultation bilaterally. No wheezing, no rales, no rhombi.
00001)
CV: There is a regular rate and rhythm. Normal S1-57. .
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. •0001700 0 0• 000
AM: The abdomen is soft. Non-tender. Non-distended. Normal bowel sounds are present! a D : .Neck: No paraspinal tenderness noted. Full range of motion.
. Mdnela No paresPinal tenderness noted. Full range of motion.• Lownek: L3-IA, L4-L5 and L5-S1 paraspinal tenderness noted. Decreased range of motion.Extreme There is no clubbing, cyanosis, edema, erythema and ceIlulitis.RUE: 3/5 muscle strength. Decreased range of motion.LUE: 3/5 muscle strength. Decreased range of motion.RLE: 515 muscle strength. No contractures. Full range of motion.LLE: 5/5 muscle strength. No contractures. Full range of motion.Skin: No scars, rashes, lesions, ulcerations In head, neck trunk, RUB, LUE, R1E, LLE.Lymph: Palpation of lymph nodes in neck, aniline and groin is normal.Neuro: ORIENTATION: Alert & oriented x3. The patient understood command well. Attention spanand concentration were normal. Remote and Recent memory were normal. There is no deficits incranial nerves I — xn. MOOD & AFFECT: No depression, no anxiety, no agitation. TESTCOORDINATION/GAIT: Normal coordination. Abdomen gait. The patient is ambulating with astraight cane. EXAM OF DTR: Normal 2+ BUE and BLE. Reflexes are normal to the lower
2 of 3
0091
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
201205250005132
Jason Mica=!WM?'
extremities oil upper extremities. EXAM OF SENSATION: Decreased to light touch and pinprickin
the quadriceps and calves and gash-or:mains.•
ASSESSMENT:
L Lower back pain2. Lumbar radiculopathy3. Gait disorder4. Failed back syndrome5. Multiple surgeries and hardware
PLAN;
I. continue pain medications2. Home exercise program3. Follow-up in one month
Michael Garbulsky, REA-c
IIICICARMMG0001/8144207523712 • • 0
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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Health Systems7 :F
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NAME: NCA Comp
14 LaFayette Square
Salta 700
Buffalo, NY 14203
Attn:Steyen Gidwitz
CRISP Trust
INVOICE FEDEF
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NAME: JASON GIACALDNE
CLAIM ft: W000024420
cARDHow 1706778
ADJUSTER: Sherrie Cich
First Date ofPR Service RX4
PLEASE INCLUDE
DescriptionROC Code
Drug TypePharnmey Name Qty.Pharmacy
DUE UPON RECEIPT
Baled ByPharmaCy htpaper claim)
INVOICE NUMBER WITH YOUR PAYMENT
Prescribing M.D.Days
Physician ED.Supply DAW
6/11/2017 115/91 DIAZEPAM 10 MG TABLET atl 30 KREZMAN 50.00
60603321521 1497825434
Generic No Product Selection Indicated
G000 DAY PHARMACY LLC
1154568400
8/1172012 115792 CARISOPRODOL 350 MG TABLET 60 30 KREIZMAN $0 00
62756044602 1497825434
Generic No Product Selectlfin Indicated
GOOD DAY PHARMACY LLC
1154568400
6/1112052 1415193 OXYCODONE HCL 30 MG TABLET 180 30 KIREIZMAN $0.00
52152021502 1497825434
Generic No Product Selection Indicated
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PLEASE REMIT PAYMENT TO:
Health Systems InternationalRO, Box 891, Indianapolis, IN 4620E-0881865.895.2021 Toll Free • 666701.2781 Fax
Email: otQuabsi.com
TOTAL AMOUNT DUE:
Amounts denoted by IT ar
PRE NEGOTIATED RATE
0093;
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
gir Health stemsINTERNATIONAL
RX
INVOICE FEDEI
INV011
INVOI
NAME: NCA Comp NAME JASON GIACALONE
14 LaFeyette Square CLAIM #: W000024420
Suite 700 CARDHOLDER ID: 1706Th
Buffalo, NY 14203 ADJUSTER: Sherri Cich
Attn:Stevert GidwItc
CRISP Trust
First Dale ofFill Service EOM
DescriptionNDC CodeDrug TypePharmacy NamePharmacy ID
DUE UPON RECEIPT
PLEASE INCLUDE INVOICE NUMBER WITH YOUR PAYMENT
DaysQtY supply
Prescribing M.D.Physician I.D.DAW
Billed ByPhannacy Ofpaper claim) Fe
11(72011 0111534 DIAZEPAM 10 MG TABLET 90 30 KREIZMAN
00603321521 1497825434
Generic No Product Selection indicated
GOOD DAY PHARMACY LL
1154568401)
11!7/2011 0111535 OXYCODONE HCL 30 MG TABLET 180 30 KREIZMAN
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Claim Number:ClaimantProvider Tax ID:Provider Ref:
Region: 04
Community Residence Savings Plan (CRISP) 2900
W000024420GIACALONE, JASON PPO ID:201270006 Vendor: 201270006-0001 NPI Number:
Geo Zip: 11220 WCB Case Number:
ISSAC KREIZMAN5223 9TH AVEBROOKLYN, NY 11220
krb6 ,SeiteeiDeS6riPliSini
08/18/2011 11 99213 OFFICE OUTFT EST
TOTALS:
TOTAL RECOMMENDED ALLOWANCE;
Process Date. 11/10/2011Control Number: 4892929
FOR Page 1 of 1Rev/Aud: DM/DM
ExtemalReview Procure
ICD-DX1: 724.2 LumbagoICD-DX2: 724.4 Lumbosacral neuritis NOS
eti4roi'Ll' RIROdi PfrO/Red Older/Red ;, Alhwence,Reasods :
1 64.07 0.00 2407 0.00 40.00
44.07 0.00 24.07 0.00 40.00
40.00
PPO REDUCTION: Procura/MagnaCare - For questions regarding Network Discounts, please call: (877) 461-3750.
Unless otherwise stated, reimbursement is made according to The Official New York Workers' Compensation Medical Fee Schedule. Reimbursement fortreatment rendered by out-of-slate providers is made based on the prevailing Workers' Compensation state fee schedule for the provider's geographical area.
Any reduction is due to the billed charges exceeding the fee schedule allowance for the service provided and/or the application of the appropriate discounts
based on the Individual provider's agreement with the preferred provider organization. 0095• Workers Compensation •
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Patient: Jason G taeatone-DOB:
SSN:Date: February 21,2012Attending: Isaae1 KreiZnion, MD
HISTORY OF PRESENT ILLNESS:
The patient is status post failed back syndrome currently taking Oxycodone 30 mg, Soma and Valibm. He has at
history of multiple surgeries of the lumbar spine. He has 8/10 back pain radiating to both lower 'extremities.
Patient is fully disabled from all work duty.
CHIEF COMPLAINT:
The patient is complaining of severe back pain radiating to bdth lower extremities
EXAM:
SOCIAL HISTORY:Alcohol: NoneTobacco: Patient is a non-smoket.Drugs: None.Toxins: None_Work: Patient is non-contributory,Diet: Patient is not on.any particular diet,
FAMILY IIISTORY:Non-contributory,
Ml DS:Oxycodone 30 mg, Soma and Valium.
ALLERGIES:No known allergies
PAST MEDICAL HISTORY:Non-contributory
SURGICAL HISTORY:Multiple surgeries as above.
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REVIEW OF SYSTEMS:Constitutional: Patient denies any change in weight. fevers and sweats, The patient deni s any nauseavomiting. diarrhea or diplopia_ENMT: Patient denies any ear or nose problems, visual difficuities,1Throat: Patient denies any pmblems or swelling in the mouth, neck
ilk) )111111111 I tPM 1Q73
LI INdisorders.
0096
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Jason GlaceIoneFebruary 23, 2012
Cardin: Patient denies angina, edema. hypertension, palpitations, vascular problems. high bloodpressure, heart problems. Pulmonary Fibrosis, Congestive Heart Failure, Coronary Artery Disease. high-
cholesterol, and Peripheral Vascular Disease.Respiratory: Patient denies cough, shortness of breath, sputum production, wheezing, lung/breathing
problems, chronic obstruction pulmonary disease, restrictive lung disease, pulmonary hypertension.sarcoidosis, dyspnea, asthma, chest pain and bronchitis.GI: Patient denies abdominal pain. bleeding, bowel changes, dyspepsia. gastrointestinal problems.peptic ulcer disease, diverticulitis, hepatitis C, GERD, irritable bowel syndrome, neurogenic bladderproblem and colitis.GU: Patient denies dysuria. frequency. hematuria. incontinence and nocruria.Heme/Lymph: Patient denies anemia. easy bruising. excessive bleeding, lymphadenopathy. deep veinthrombosis and Hyperkalemia.Rheu: Patient complaining of lower back pain. He denies neck pain. mid-back pain. bilateral hip pain.bilateral knee pain, bilateral ankle pain, bilateral foot pain. bilateral shoulder pain. bilateral elbow pain.bilateral wrist pain and bilateral hand pain.Endocrine: Patient denies hormonal abnormalities. polydipsia. polyuria. diabetes, hypothYroidism.cellulitis and colon cancer.Neuro/Psych: Patient denies mood changes, paralysis. syncope. depression, cerebrovascular accident.hemiplegia, dizziness. cerebral palsy, mental retardation. traumatic brain injury, multiple sclerosis.headaches, psychiatric problems, neurological problems, A.D.D. and sleep apnea.Integumentary: Patient denies pruritus. rashes. skin eruptions, infection and shingles.
PHYSICAL EXAM:Vital Signs: 00
000•00
0 0
Upright BP - 120/80 mmHg 00 0 Co bla
•Pulse = 80 bpm. Patient is afebrile . 0 9
Resp 15General: Well nourished. Well dressed. Not in acute distress.HEENT: Normocephalic. Atraumatic. EOM are intact. •Chest: Clear to auscultation bilaterally. No wheezing, no rates, nu rhonchi. 0 0
00000
CV: There is a regular rate and rhythm. Normal SI -S2.mAbd: The abdomen is soft. Non-tender. Non-distended. Normal bowel sounds are piettaatt
Neck: No paraspinal tenderness noted. Full range of motion.MidBek: No paraspinal tenderness noted. Full range of motion.LowBek: L4-L5 paraspinal tenderness and weakness noted. Decreased range of motion.Extrem: There is no clubbing, cyanosis. edema, erythema and cellulitis.RUE: 5/5 muscle strength. No contractures. Full range of motion.LUE: 5/5 muscle strength. No contractures. Full range of motion.RLE: 3/5 muscle strength. No contractures. Decreased range of motion, flexion and extensionLLE: 4/5 muscle strength. No contractures. Decreased range of motion, flexion and extensionSkin: No scars, rashes. lesions, ulcerations in the head, neck trunk. RUE, LUE. RLE. LLE.Lymph: Palpation of lymph nodes in neck, axillae and groin is normal.Neuro: ORIENTATION: Alert & oriented x3. The patient understood command well. Attention spanand concentration were normal. Remote and Recent memory were normal. There is no deficits in cranialnerves 1— XII. MOOD & AFFECT: No depression. no anxiety. no agitation. TESTCOORDINATION/GAIT: Normal coordination. Antalgic gait. EXAM OF DTR: Norma( 2+ BUE.Reflexes are normal to the and upper extremities. EXAM OF SENSATION: Decreased to light touchand pinprick. Normal vibration.
' °I bow
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Jason ClaesIoneFebruary 23, 2012
ASSESSMENT:
I. Lower back pain, status post multiple surgeries.
2. Failed back syndrome3. Bilateral lower extremity pain and weakness
PLAN:
I. Physical therapy.2. Home exercise program3. Medication4. Follow-up in one month.5. Therapy has failed at this point.6. Fully disabled from work duty.
Isaac J. ICrelzman, MD
Michael Garbulsky, RPA-C
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Claim Number.Claimant:Provider Tax ID:Provider Ref:
Community Residence Savings Plan (CRISP) 2900
VV000024420GIACALONE, JASON PPO/OSR ID:113630760 Vendor: 113630760-0001 NPI Number:
Geo Zip: 11214 WCB Case Number
Process Date: 12/05/2012Control Number 4898286
FOR Page 1 of 1Rev/Aud: DM/DM
ExtemalReview Procure
legion: 04
LENCO DIAGNOSTIC LAB185786TH STRETEBROOKLYN, NY 11214
ICD-DX1: V5889 Lang-term use meds NEC
)OS POS Code Mod Service Desaiption Unite Charge BR/Red PPO1Red Olher/Red Allowance Reasons
19/27112 81 80100 DRUG SCR QUAL I 10.000 600.00 277.40 0.00 0.00 322.60 30919/27/12 81 82145 AMPHETAMINE/MI 1.000 150.00 113.34 0.00 0.00 36.66 30919/27/12 81 83769 MASS SPECTETAt 1.000 250.00 217.01 0.00 0.00 32.99 30910/25/12 81 80100 DRUG SCR QUAL I 10.000 600.00 277.40 0.00 0.00 322.60 30910/25/12 81 82145 1.000 150.00 113.34 0.00 0.00 36.66 309AMPHETAMINE/ME10/25/12 81 83789 MASS SPECT&TAr 1.000 250.00 217.01 0.00 0.00 nee 309
TOTALS: 2,000.00 1,215.50 0,00 0.00 784.50
TOTAL RECOMMENDED ALLOWANCE: 784.50
leason Code Reimbursement Description:at-ADA& r
309 -THE CHARGE FOR THIS PROCEDURE EXCEEDS THE FEE SCHEDULE ALLOWANCE.
Unless otherwise stated, reimbursement is made according to The Official New York Workers' Compensation Medical Fee Schedule. Reimbursement for
treatment rendered by out-of-state providers is made based on the prevailing Workers: Compensation stale tee schedule for the provider's geographical area.
Any reduction 15 due to the billed charges exceeding the fee schedule allowance for the service provided andlor the application of the appropdale discounts
based on the individual providers agreement with the preferred provider organization.
• Workers Compensation •U099
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
1500 HEALTH INSURANCE CLAIM FORMAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08205
'PICA
NCA
14 LAFAYETTE SQUARE
SUITE 700
BUFFALO, NY 14203
1, MEDICARE MEDICAID IFHIlact5s CHAMPVA GROUP FECA OTHERHEALTHPIAN
Medicire a) Medicaid 0)0 (Sponsor's SSN) El Wattleno4❑ (SSN or ID) D,sskr pmla. INSURED'S 1.13, NUMBER {For Pt t in Item l)
W000024420
l -
PATIENT AND INSURED INFORMATION
j-
2, PATIENT'S NAME Ilust Name. First Nemo, Middle frilling
'IACALONE, JASON
a PATIENTS BIRTH DATE SEX
F❑silietYL4n 4_ INSUREDS NAME (Last Name. First Name. Middle lei )
GIACALONE, JASON
S, PATIENTS ADDRESS No., Sheet)
2 BAY 49TH STREET
E. PATIENT RELATIONSHIP TO
-seln Spousen Child.
INSURED
Other
7. INSUREDS ADDRESS (No.. SIrml0
72 BAY 49TH STREET
CITY
rOoklYn
STATE
NY
8. PATIENT STATUS
Single MnnindnOmen
CITY
Brooklyn
STATE
NY
ZIP CODE
1214
TELEPHONE (Include Area Code)
) CmPlOYed SFutiltidaolnir PaSlutrinml eL..71
ZIP CODE
1 214
TELEPHONE (Include Area )
( )
9 OTHER INSURED'S NAME (L st Name, Fest Namo, Middle Iniliall It IS PATIENT'S CONDITION RELATED TO: S I. INSUREDS POLICY GROUP OR FECA NUMBER
a OTHER INSUREDS POLICY OR GROUP NUMBER a EMPLOYMENT, (Current or Prei:mus)
YES 0
a. INSUREDS DATE OF BIRTH SEXNM i 00 1 YY .
IC F❑
b. OTHER INSUREDS DATE OF BIRTH SEXMU 1 DR , YY __
. 1 MO I:
b. AUTO ACCIDENT? puct ismi0)
El YES 0,0b. E LOVERS NAME OR SCHOOL NAME
-
c. EMPLOYERS NAME OR SCHOOL NAME c. OTHER ACCIDENT,
YES 1NO
c. INSURANCE PLAN NAME OR PROGRAM NAME
• •
d. INSURANCE PLAN NAME OA PROGRAM NAME 10d. RESERVED FOR LOCAL USE 0. IS THERE ANOTHER HEALTH BENEFIT3nrAW .
YES till NO If yes. retuctietydrelelo Hem 9 ail
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.12. PATIENTS OR AUTHORIZED transoms SIGNATURE I authorize the alcase of nny mathcal or other inforinalion necessary
In process Ibis claim. I also request Paymen1 or gammon, benefits either n myself or M tho patty Rim accepts assignment
below.
SIGNED _:SIGNATURE ONFILE._ J mor.09_27 2012_
13. INSUREDS OR AUTHORIZED PERSON'S SIGNATURE brolly 4• ° •
payment of medical Valli Ipjhe undersitIEUVsioan :eon ipEsenrices described below_ o a • CI 9
e :..ft:. 0•:::gg:• •••a a
*NE _ NINNANUNN_ON:t7114____! •
4, DATE OF CURRENT: 4 ILLNESS (First symptom) ORMM : DO t YY INJURY (Accident) OR
i PREGNANCYILLAM,
15. IF PATIENT HAS HAD SAME DR SIMILAR ILLNESS.GIVE FIRST DATE MM , DD ; YY
16 DATES PATIENT UNARLER WORK UN NI 00Cat•RoVe •MM : 00 ,
FROM l •
10 •• • •• o ao , • •
PHYSICIAN OR SUPPLIER INFORMATION
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
ISAAC KREIZMAN MD
V810
17b. NPI 1497825434
In. HOSPITALIZATION eRlIES 9lIELATED 12 CURIIENTgRyipate . aMM , DO YY
ILO al • , ' •
FROM , i 0 .tP( •.o-•.
_,••••
e-o-a-o
19. RESERVED FOR LOCAL USE 20. OUTSIDE I. AB? SO/LARGER •woo
l'1]Y ES NO 1 .4•13:10
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Rama Items 1, 2, 3 cy 4 lo Ilmn 24E tiy Line)
---4LIV5P62 I [
22. MEDICAID RESUBMISSIONCODE ORIGINAL REF. NO.
1— --23. Pnton AUTHORIZATION NUMBER
33D1012663
74. A DATES) OF SERVICE aRom To FACECT
MM CID YY MM DO YY MRYCE
C
EMG
D. PROCEDURES. SERVICES. OR SUPPLIEStExpla.n Unusual Circumstances)
CPI/HCPCS I MODIFIER
EDIAGNOSISPOINTER
F.
S CHARGES
JLontMm4
1.4 k m,Pan
.1 -•Dust,
RENDERINGPROVIDER ID.
9 27 12 109 27 12 el l l 80100 I 11 600 tto 10 l Nw
. i27 12 109 27 12 el I j 82145 150 00 1 NM
t191D9 27 12 109 27 32 el 83789 1 11 250 00 1
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NPI
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1114r,I I
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INPI
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2S FEDERAL TAX 1,1/ NUMBER SSN EIN . 28. PATIENTS ACCOUNT NO. i 27. AC,CiEST4t,,SSIalkliEr,
11363076t - : DC] 121120467 i OYES ONo
28. TOTAL CHARGE
S l000:po29. At.1OUNT PAID
s opa BALANCE DUE
s 1000 do31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS(I certify Mal the statements on lho reverse
n Memel.),-li(ialalt"airflit'1
10 17 2012
32. SERVICE FACILITY LOCATION INFORMATION
LENCO DIAGNOSTIC LABORATORY
H857 86TH STREET
BROOKLYN, NY 112143108
33. BILLING PROVIDER INFO A PH 0 ((718))232-1515
LENCO DIAGNOSTIC LABORATORY
1857 86TH STREET
BROOKLYN, NY 112143108
SIGNED DATE 11.255468328 °G2 33D1012663 1255468328 b.. _n_J
APPROVED MB-0938-0999 FORM CABS-1NUCC Instruction Manual available al: w ucc.erg PLEASE PRINT OR TYPE
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
FINAL COPY
Patient: GIACALONE , JASON Aec #: 1120467Patient #: 076038 Birth: 0978 Fasting: UNKNOWNDoctor. KREIZMAN, ISAAC 9 TH AVBkcge: years Collection Date: 9127/2012 10:05 AMDoctor Addr. 5223 9 TH AVENUE Gender. Male Received in Lab: 9/27/2012 10:05 PM
BROOKLYN, NY 11220
ZigitOtaing*L'iCLINICAL REPORT
Clinical Abnormalities SummaryTest Name Result Flag Test Name Result Flag
BENZODIAZEPINE POSITIVE ABNORMAL CANNABINOIDS POSITIVE ABNORMALOPIATES POSITIVE ABNORMAL OXYCODONE POSITIVE ABNORMAL
Nik4191to4 p- J n ilatariatifitillit 'II atitaitilia:-YW.F6bititta
DRUGS OF ABUSE, URINEOXYCODONECU2VFF=100
POSITIVE (A) I lo: ....: 4 817/2012 . •
OD Oa
ECSTASY (MDMA)CUTOFF=300
°
• 0
•
•a
.4 witalf%••
%.- a a
NEGATIVE
LSDCUTOFF=0 . 5
NEGATIVE .0000.• •
•
• • I 8/72012
• •D•01.•
4ETHYL ALCOHOLCUTOFF=10
NEGATIVE I °• •. .s
I 8/7/21112•.• °
AMPHETAMINESCUTOFF=1000
NEGATIVE ng/mL I I 817/2012
BARBITURATES NEGATIVE ng/mL I I 8/7/2012‘VIVFF=200
BENZODIAZEPINECUTOFF=200
POSITIVE (A) ng/mL I I 8/7/2012
CANNABINOIDSCUTOFF=50
POSITIVE (A) ng/mL I I 8f7/2012
COCAINE METABOLITECOMFF=300
NEGATIVE ng/mL I I 817/2012
METHADONECOTOFF=300
NEGATIVE ng/mL I I 8/7/2012
OPIATESCUT0Fra300
POSITIVE (A) ng/mL I 8/712012
PHENCYCLIDINECUTOFF=25
NEGATIVE ng.mL I I 8/7/2012
Originally Reported On: 9/28/2012 3:12 PM Accession: 1120467 Patient ID: 076038Printed: 11/8/2012 2:08 PM 01 01Page 1 d 2 STAT[S] Corrected [C] Added [A]
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
FINAL COPY
Patient: GIACALONE , JASON Acc #: 1120467Patient #: 076038 Birth: 1978 Find ' UNKNOWNDoctor. KREIZMAN, ISAAC 9TH AVIAge: years Codertion Date: 9/27/2012 10:05 AMDoctor Addr. 5223 9 TH AVENUE Gender. Male Received In Lab: 9/27/2012 10:05 PM
BROOKLYN, NY 11220LENCO DIAGNOSTIC LABORATORY
1857 86TH STREET - BROOKLYN, NY 11214END OF REPORT.
•
• •
• •• ea 110
O a e •
00000 ••00.0 0 0 :•
0
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0 0 • 0 •
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00
Originally Reported On: 9/28/2012 3:12 PM Accession: 1120467 Patient ID: 076038
Printed: 11/8/2012 2:08 PMPage 2 of 2 STATISI Corrected ICI Added [A] 0102
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
1500)HEALTH INSURANCE CLAIM FORMAPPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 1705
PICA
NCA
14 LAIWYETTE SQUARE
SUITE 700
BUFFALO, NY 14203
t
1. MEDICARE MEDICAID TRICARE CHAMPVACHAMPUS
D(Medicare dI❑(Medicied OT D (Sponsors SSN) 0 Nember100)GROUPHEALTH PLAN
Ill (SSN or 10) .
FECA OTHERELK LU(SSW oP
la, INSURED'S W. NUMBER (For Program in Item l)
N000024420Z. PATIENTS NAME Lust Name. Feel Nome, Middle Neal)
3IACALONE JASON
3. PATIENTS BIRTH DATE SEXMM 1 OD . YY
MI6 1978 mEl rEl4. INSURED'S NAME (Last Name. First Name, Middle Initial)
GIACALONE, JASON5. PATIENTS ADDRESS (No., Swel)
72 BAY 49TH STREET
6. PATIENT RELATIONSHIP TO INSURED
SeIC Spouse Child Oaken
T. INSURED'S ADDRESS (No.. Seem)
72 BAY 49TH STREETCRY
3rooklyn
STATE
NY
O. PATIENT STATUS
single 0 Matted 0 Other❑
CITY
Brooklyn
STATE Z0
NY 17-
ZIP CODE
11214
TELEPHONE (Include Med Coda)
( )Fulallme 1-1 Part•Timarel
EmploYee Student Li Wan! 1_1
ZIP CODE
11214
TELEPHONE (looted° Area Code) ea2
( ) CC0Li.
9. OTHER INSUREDS NAME (Las* Name. First Name, NNW Initial) 10.15 PATIENTS CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER Z
0111
a. OTHER INSUREDS POLICY OR GROUP NUMBER a EMPLOYMENT? (Cunard
0 YESor Previous)
IINO
a, INSURED'S DATE OF BIRTH SEX CCMM 1 CID, YY 7
MO F❑ W
Z
b. OTHER INSUREDS DATE OF BIRTHMM DO , YY
I MI .1
SEX
FIN
b. AUTO ACCIDENT? PLACE (Ewe)
DYES NOl__J
b. EMPLOYERS NAME OR SCHOOL NAME 0Z4
c. EMPLOYERS NAME OR SCHOOL NAME c OTHER ACCIDENT?
❑YES 1NO
C. INSURANCE PLAN NAME OR PROGRAM NAMEW
• o
d. INSURANCE PLAN NAME OR PROGRAM NAME 1Di RESERVED FOR LOCAL USE d. IS THERE ANOTHER
0 YES
aHEALTH BENEFITtPLAN? a.
i NO If yes. relut ingteimplote item 0 ad,
READ BACK OF FORM BEFORE COMPLEING li SIGNING THIS FORM.12, PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorise the !obese of any medical or othorInformation nowssary
lo prams this claim.] also MCIUOR paymanl of government beeafils eilher o myself or lo the party l'410 wasPls assignment
below.
SIGNED-PaGNATURE-(nnA DATE_1,0_25 1 all
13. INSUREDS OR AUTHORIZED PERSON'S SIGNATURE [AAP °aDaemon' 01 Moeltal/K98558 Walla undersipnectohysiciim Or worollw bar
services descnbad balm. eo • •
000000 0 if •0 • •
YSIGNED ..J_SIn- • I . •-noes
1A, DATE 068UIRREW? AI I II
Littsysiiitz,),TDIr) ORPREGNANCYKMP)
15.1 PATIENT HAS HAQ,SpME gn SIMILAR ILLNESS.GIVE FIRST DATE MM / up i W
r I
16, DATES riVIENtONALER WORK IIINVOTT ODC0CLAO1941, ,),uu 1
FROM ; TO Of
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
Tzar IMP T MAN WI 17b.NM 1497825434
18. HOSPITAI ALMIZATION
O 8ititlfAELATED TDCUS43ENTSErVir.,Ekt A a,
, D . Yre d'n •FROM : - 1 SO00
19. RE SERVED FOR LOCAL USE 20. OUTSIDE LAB? SIGHAROES• a e
ElYES Et NO 1 • • • l
21, DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Hems 1, 2.3 or 410 Item 24E by Line)
---4#1 Lus869____ a L___
22. MEDICAID RESUBMISSIONCODE ORIGINAL REF. NO.
2. 1_,_ 4-L____.
23. PRIOR AUTHORLZATION NUMBER
33D101266324. A. DATE'S) OF SERVICE
From To
MM OD YY MM DO W
B.PIACECEMINCE
C
ERG
CS PROCEDURES. SERVICES, OR SUPPLIESlExelain Unusual Claumsmnoes)
CPTIHCPCS 1 MODIFIER
EDIAGNOSISPOINTER
F.
5 CHARGES
G.facesOP
LROls
11.NIODIFa*ote
I.ID -
OVAL.
J. ZRENDERING O
PROVIDER ID. 4 1
, . 1 1 r
1n b, -6 I 1 n 1794, 141 I and nn I I1 600 00 I 10 I NPI
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1 : ; I l • ,.31') DR i7 Iln 175 'IC 61 I F17145 I I1 150 00 I 1 I
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CLI4
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inj)C Ili Iln Cc 1, k1 1 A171:19 I 11 250 00 I 1 l NM
:11- 0.
a.=
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1 1 I NP1
N a
0
Z
)I I 1 I I I I NPI
4r.,a
II ' r
, I I I I INM
› 2
25. FEDERAL TAX I.D. NUMBER SSN EIN
111A1n7A0 Eln
26. PATIENTS ACCOUNT NO, 27.4EacynmaitAINTI
121147521 i El yES LINO
28. TOTAL CHARGE1
S 1000_100
29. AMOUNT PAIDi
5 00
30_ BALANCE DUE
5 1000 OD
1.SIENATUREOF PHYSICIANOR SUPPLIERINCLUDING DEGREES OR CREDENTIALS0 MIN IND DM StillOrnOnIS on Ma mamaapply to Ns bill and aro made a pail Marva)
SIGNATURE ON FILE
32, SERVICE FACIUTY LOCATION NFORMATION
LENCO DIAGNOSTIC LABORATORY
1857 86TH STREETYEE ATIL 11 /1 411 OR
33. BILLING PROVIDER INFO 8 PH a C718)) 232-1515
LENCO DIAGNOSTIC LABORATORY
1857 86TH STREETnwilowLyN, NY
11 08 2012 r.-111301110
iSIGNED DATE AZ45468328
hG2 33012226E3
?12141108
h1255468328 0
I.
2
NUCC Instruction Manual available al: www.nuCc.Org PL3
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
FINAL COPY
Patient: GIACALONE , JASON Aec #: 1142521Patient #: 076038 Birth: a1978 Fasting: UNKNOWNDoctor KREIZMAN, ISAAC 9 TH AVIAge: years Collection Date: 10/25/2012 11:30 AP.Doctor Addr. 5223 9 TH AVENUE Gender Mate Received in Lab: 10/25/2012 9:00 PM
BROOKLYN, NY 11220
wiesawsrariumciiminiger-Th':t.ioutuittitiegtor tto oft' frittermiiiir'Priii CLINICAL REPORT
Clinical Abnormalities SummaryTest Name Result Flag Test Name Result Flag
BENZODIAZEPINE POSITIVE ABNORMAL CANNABINOIDS POSITIVE ABNORMALOPIATES POSITIVE ABNORMAL OXYCODONE POSITIVE ABNORMAL
;.igt.bi' iitof. lib° .Fá9. .iiiiiits.. -,tiRet.t.iian!oPAge,R:Millt. bate.' 1DRUGS OF ABUSE, URINE
0
OXYCODONE POSITIVE (A)000000
T E.-0;1 9/2§M2CUTOFF=100
ECSTASY (MDMA)CUTOFF=300
NEGATIVE 000:00
0400
i040:1 9/240/0411
LSD NEGATIVE ...... °°:°1 9/28120f2LaPJFF=0.5
ETHYL ALCOHOLCUTOFF=10
NEGATIVE:0 01
9/28PM12• • •• 0.
AMPHETAMINESCUTOFF=1000
NEGATIVE ng/mL l l 9/28/2012
BARBITURATESCUTOFF=200
NEGATIVE ng/mL l I 9/28/2012
BENZODIAZEPINE POSITIVE (A) ng/mL l i 9/28/2012
CUTUFF=200
CANNABINOIDSCUTOFF=50
POSITIVE (A) ng/mL 9/28/2012
COCAINE METABOLITECUTOFF=300
NEGATIVE ng/mL I i 9/28/2012
METHADONECUTOFF=300
NEGATIVE ng/mL 9/28/2012
OPIATESCUTOFF=300
POSITIVE (A) ng/mL l l 9/28/2012
PHENCYCLIDINECUTOFF=25
NEGATIVE ng.mL l l 9/28/2012
Originally Reloaded On: 10/26/2012 219 PM Accession: 1142521 Patient ID: 076038Printed: 11/8/2012 2:08 PMPage 1 of 2 STAT[S] Corrected [C] Added [A] 0104
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
FINAL COPY
Patient: GIACALONE , JASON Acc #: 1142521Patient #: 076038 Birth: 1978 Fasting: UNKNOWNDoctor KREIZMAN, ISAAC 9 TH AVERge: years Collection Date: 10/25/201211:30 AhDoctor Addr: 5223 9 TH AVENUE Gender. Male Received in Lab: 10/2512012 9:00 PM
BROOKLYN, NY 11220LENCO DIAGNOSTIC LABORATORY
1857 86TH STREET- BROOKLYN, NY 11214END OF REPORT.
a000000o
o a000000
0000004
0000000
0000
a
o a000000a
0000000 0
00 00
0000000 0 0• o
0 0 a 00 0000
• 0 0 0 0 0 0
0000 0 0
000000 0 0 00
00000000000
0000
00 •o 0 0O Oa
Originally Reported On: 10/26/2012 2:19 PM Accession: 1142521 Patient ID: 076038Printed: 11/8/2012 2:08 PMPage 2 of 2 STAT[S] Corrected [C] Added [A] 0105
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
oh,c Health SystemsINTERNATIONAL
RX
NAME: NCA Comp
14 LaFayette Square
Suite 700
Buffalo, NY 14203
CRISP Trust
INVOICE FEVEI
INVOI
INVOI.
NAME: JASON GIACALONE
CLAIM th W000024420
CARDHOLDER ID: 1706771
ADJUSTER Sherrie Cich
DUE UPON RECEIPT
PLEASE INCLUDE INVOICE NUMBER MTN YOUR PAYMENT
DescriptionNDC Code
First Date of Drug Type Days
Prescribing M D. Billed By
Fill Service RXIt Pharmacy Name Qty. Supply Physician I.D. Pharmacy (if
FePharmacy 10 OAW paper claim)
816/2012 116887 OXYCODONE HCL SO MG TABLET 159 30 KREIZMAN $0.00
52162021502 1497825434
Generic No Product Selection indicated
G000 DAY PHARMACY LLC
1154568400
81612012 1168138 CARISOPRODOL 350 MG TABLET 90 3P KREIZMAN $0.00
62756044602 1497825434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LLC
1154568400
8/6/2012 116889 DIAZEPAM 10 MG. TABLET 90 3b KREIZMAN
00603321521 1497825434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LLC
1154568400
8/6/2012 116890 MORPHINE &ULF ER 100 MG TABLET 60 30 KREIZMAN
00378266101 1497825434
ar•gr , in • GEMiE, No Product Selection Indicated4 •
✓ a DeAlflARMACY LLC
• :I* • Le M45614116
.*•
• •
• •
46
• • 41410 • *
41 • 41: ea •••• a •
t4E
PLEASE REMIT PAYMENT TO.
Health Systems InternationalP.O. Box 881, Indianapolis. IN 46206-0881866 895.2021 Toll Free • 866.701.2761 Fax
rx@us-hsLcom
MOO
$0.00
0106
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Health steAms
-Ft"-• r-c• stRX
INVOICE FEDI
INVO
NAME: NCA Comp NAME: JASON G1ACALON
14 LaFayette Square CLAIM ft W000024420
Suite 700 CARDHOLDER ID: 170677
Buffalo, NY 14203 ADJUSTER Sherrie Cfch
CRISP Trust
First Date ofFill Service RX#
DescriptionNOG Code
Drug TypePharmacy NamePharmacy 10
DUE UPON RECEIPT
PLEASE INCLUDE INVOICE NUMBER WITH YOUR PAYMENT
Days Prescribing M.D. Billed By
Physician I.D. Pharmacy (IfQty. Supply
UAW paper claim)
9/27/2012 117959 OXYCONTIN 40 MG TABLET
59011044010
Single Source Brand
GOOD DAY PHARMACY LLC
1154568400
- 8•4e •
4 8 e4 4.8
8-
60 30 KREIZMAN
1497825434
No Producl Selection Indicated
PLEASE REMIT PAYMENT TO;
Health Systems InternationalP.O. Box 881, Indianapolis, IN 46206-0881866,895.2021 Toll Free • 866.701,2781 Fax
Emait [email protected]
S0,00
TOTAL AMOUNT DUE
Amounts denoted by "O'l a
PRE NEGOTIATED RATE
0107
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Clain) Number:
Claimant
Provider Tax ID:
Provider Ref
Regen,104
Community Residence Savings Plan (CRISP) 2900
W000024420
GIACALONE. JASON PPO
113630760 Vender 113630760-0001 NP I NumberGeo Zip, 11214 WCB Case Number:
LENCO DIAGNOSTIC LAB185786TH STRETEBROOKLYN. NY 11214
Process Date: 0124/2012
Control Number 4897570
FOR Pabe 1 of 1Rey/Audi' DM/DM
ExternalReview Procure
ICD-DX1: 478.32 Vocal Patel unitat total
DEO -E06 14nermialjeScifog‘I 1. ;.,trig_ SR/Red 'PaiiRkr, tlthie/Red
01126112 11 aoioo DRUG SCR QUAL MLT 10 000 600.00 277.40 165.70 0 00
01126/12 11 62145 AMPHETAMINE/METH, 1.000 150.00 113.34 27.48 0.00
01/26/12 11 83789 MASS SPECT8TANDE 1 000 250 00 0,00 235.46 0,00
01/26112 11 60100 DRUG SCR QUAL MLT 10;000 600.00 277.40 165.70 0 00
01/26/12 11 82145 AMPHETAM1NEAAETH, 10000 150.00 D.00 58.20 0.00
01/26112 11 83789 MASS SPECT8TANDEI 10.000 250.00 DLO 104.60 0.00
03/20/12 11 60100 DRUG SCR OU N. MLT 10.000 600.00 277 40 165.70 0:00
03120/12 11 92145 AMPHETAM1NE/METH, 10.000 15000 0.00 58'20 D.00
03/20/12 11 83789 MASS SP ECT&TANDEI 10 000 250.00 0.00 104.60 0.00
03120/12 11 80100 DRUG SCR QUAL MLT 10 000 600.00 27740 165.70 0130
03120/12 11 82145 AMPHETAMINE/METH, 10.000 150,00 0.00 58.20 0.00
03120/42 11 63789 MASS SPECTATANDE1 10.000 250.00 0 00 104.60 000
04/17112 11 80100 DRUG SCR QUAL MLT 10.000 600.00 277.40 165.70 0.00
04/17/12 11 62145 AMPHETAMINE/METH. 1,000 150 00 113.34 27,48 um04/17/12 11 63789 MASS SPECT&TANDE1 1.000 250.00 0.00 235.46 0.00
04/17/12 11 80100 DRUG SCR QUAL MLT 10.000 600 00 277.40 165.70 0.00
04/17/12 11 82145 AMPHETAMINE/METH, 10 000 150,00 0,00 58.20 0.00
04/17/12 11 83789 MASS SPECTSTANO0 10.000 250.00 0.00 104,60 0.00
TOTALS: 6000.00 1.891.08 2071.28 0,00
TOTAL RECOMMENDED ALLOWANCE'
Reason Code Reimbursement DeScriPtion:
309 -THE CHARGE FOR THIS PROCEDURE EXCEEDS THE FEE SCHEDULE ALLOWANCE,
PPO REDUCTION: Procura/MagnaCare
-Allbwance-ifeagEfli
i 156,90.309
918 3091 14.54156.90 309
91.80
145,40
! 156,90 309 1
91,80 r
i 145.40
' 156.90 30
91.80
145,40
165.90 309 i
ale 309 I14.54
1156.90 309 i91,80
1 145A0
1!937.64
1b3T.64
Unless offienvise stated. reimbursement is made according to The Official New York Workers' Compensation Medical Fee Scheduie„ Rennbursement
treatment rendered by out-of-state providers is made based on the Prevailing Workers' Compensation state fee schedule for the provider's geographicallarea
My reduction is due to the billed charges exceeding the fee Schedule allowance for the service provided and/or the application of the apprbpriate diadotts
based on the individual provider's agreement with the preferred provider organization
* Workers Compensation
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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RE: Claim number: MLN
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In order to process the attached document, the information indicated below is required. Pleaseprovide the requested information and resubmit, including this letter, to:
bi0 i qi06,PMA Mail Stop 170180PO Box 5231Janesville WI 53547-5231
Federal Tax Identification Number required.
Or call 1-888-476-2869
chin% w ccootQyw200,excimparky: •
El Document Illegible. Please improve document quality and resubmit.
❑ Other:
n The employer listed did not have insurance coverage with PMA onto the appropriate insurance carrier.
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Name and address of employer:
Date of injury:
Social Security number:
Claim Number shown in your records:
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PAY:
Your help in this matter is very much appreciated.
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
1
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Name: GIACALONE , JASON Phone' (718)753-8933 Accession:
Patient it- 076038 Birth, NM 978 Fasting:
Dettor. KREIZMAN. ISAAC 9 TH AVE Age: 33 years Collection Date:
DOCtOr Address 5223 9 TH AVENUE Gender: Male Received in Lab:
Brooklyn, NY I12213
Test Name In Range Out of Range Fiag
DRUGS OF ABUSE, URINE
AMPHETAMINES
CUTOFP=1000BARBITURATES
CUTOFF-200BENZODIAZEPINE
CUTOEF=200._-4,.;AANABINOIDS
PUTOFF=50COCAINE METABOLITE
CUTOFP300METHADONE
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CUTOFF=300PHENCYCLIDINE
auTOFF=25
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NEGATIVE
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POSITIVE
POSITIVE
POSITIVE
(AI
(A)
,(A)
LENCO DIAGNOSTIC LABORATORY1857 66TH STREET - BROOKLYN, NY 11214
END OF REPORT.
uNKOOOLilOpoiztOOPmj1126/2012 6.16 PM!
Units Reference Range
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Originally Printed On. 1/27/2012 3 39 PMPrinted: 9111/2012 4:10 PMPage 1 W 1
FINAL COPY ACcesstonI 939 04 Pellent ID. 076038Lab Results For: GIACALONE , JASON
Lena Agranoty, M D,0116[la ry borato Oir or(
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
$
Name; GLACALONE , JASON Phone. (718)753-8933 Accession:
Patient P. 076038 Birth: X978 Fasting:
Doctor; KREIZMAN, ISAAC 9TH AVE Age; 34 years Collection Date:
Doctor Address: 5223 9 TN AVENUE Gender Male Received in Lab.
Brooklyn, NY 11220
Test Name In Range Out of Range Flag
DRUGS OF ABUSE, URINE
AMPHETAMINES
cuTorr=1000BARBITURATES
CUTOFF-200BENzoDIAZEPINE
CUTOFF=2ooCANNABINOMS
CUTOFE=50COCAINE METABOLITE
CUTOFF=300METHADONE
CuroFF=300OPIATES
ptfroFF=x9
CLITOFF=26
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
9/7899,UNKNOWN ,t
' 3/20/2012 10100 AM3/20/2012 12:30 P
Units
nglmL
ng/mt.
POSITIVE (A) ng/ml
POSITIVE ng/mL
ngIrriL
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POSITIVE ng/mL
ng.mL
LENCO DIAGNOSTIC LABORATORY1857 86TH STREET - BROOKLYN, NY 11214
END OF REPORT.
• • It•••
so.. it •
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Reference Range
Run Bp.IC an 321/2012 lin PM
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Originally Printed On: 121/2012 3:08 PMPrinted: 9/11/2012 4.10 PMPage 1 of 1
FINAL- COPY Accession: 9771399 Patient IQ 076038Lab Results For;; GIACALONE , JASON
Elena Agrana ky, M,D. 0117Laboratory Dir ctor
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Name:Patient ft:.Doctor:Doctor Address
Test Name
GIACALONE JASON phone: (718)753-8933 Accession:,076038 Birth: Illw1978 Fasting.
KREIZMAN, ISAAC 9 TH AVE Agei 34 years Collection Date:
5223 9 TH AVENUE Gender Male Received in Lab:
Brooklyn. NY 11220
DRUGS OF ABUSE, URINE
AMPHETAMINES
CUTOFF=000BARBITURATES
CUTOFF=820BEN2DDIAZEPINE
CUTOFF--,200'CAN NABINOIDS
CUTOFF=50COCAINE METABOLITE
CLITOFF=300METHADONE
CUTOFF=300— - _OPIATES
CUTORF=30gadiiiTYCLJDINE
CUTOFF=25ECSTASY (MDMA)
CUTOFF-300BURKENLINPINE (SUBOXEN)
PLITOFF=10
cuTorrto_sETHYL ALCOHOL
CUTOFF=iO
In Range Out of Range
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
POSITIVE
POSITIVE
POSITIVE
P9a
990390-iiiT
4/17/2012 3-13D PM411712012 4:25 Pk
Units Reference Range
Min Sy. .1Cian 4/1w2012
ngfmL
ng/mL
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ng/mL
ng/mL
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LENCO DIAGNOSTIC LABORATORY1857 86TH STREET - BROOKLYN, NY 11214
END OF REPORT,
••
Originally Printed On: 4/18/2012 218 PMPrinted: 9/11/2012 4:10 PMPagel of I
FINAL COPY Accession: 998490 Patient I i 076038Lab Results Fori GIACALON . JASON
Elena Ag rano ky, M.D. es .4.4 44,'Laboratory°Victor WI I 0
I
1
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Community Residence Savings Plan (CRISP) 2900
Gsim Number: W000024420Claimant: GIACALONE, JASON PPO ID:Provider Tax ID: 201270006 Vendor 201270006-0001 NPI Number:Provider Ref. Geo Zip: 11220 WCB Case Number:
ISSAC KREIZMAN5223 9TH AVEBROOKLYN, NY 11220
Region" 04
P901'7: C9g litia 101'5(4 DectiptItin'..•12/2001 11 09213 OFFICE OUTPT EST15 1.000
TOTALS:
TOTAL RECOMMENDED ALLOWANCE:
Process Date: 06/23/2012Control Number. 4896457
FOR Page 1 of 1Rev/Aud•. MOM
ExternalReview Procuta
ICD-DX1: 724.2 Lumbago
ICD-0X2: 724.4 Lumbosacral neuritis NOS
ICD-DX3 781.2 Abnormality of gait
.01)49e;I:7.1.3R410.- I eFIctiggi:...2(01,fikiedr PilloWatht, lReaPlikns.
64.07 0.00 24 07 0.00 40.00
64.07 0.00 24.07 0.00 40.00
40.04
PPO REDUCTION: Procura/MagnaCare - For questions regarding Network Discounts, please Call: (677) 461-3780.
Unless othenViSe staled, reimbursement is mode according to The Official New York Workers Compensation Medical Fee Schedule Reimbursement fortreatment rendered by out-of-state providers is made based on the prevailing Workers' Compensation state fee schedule for the provider's geographical area.Any reduction Is due to the billed charges exceed.ng the fee schedule allowance foible service provided andrer the application of the a pprepdate discountsbased on the Intik/idiot prat/idea agreement with the prefetred provider organization.
' Workers Compensation'
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
L4•1=1‘. no ?AU•SILL 1..1..••4 •203?0.2.5 0005132
Doctor's Narrative ReportState Of New York- Workers' Compensatleo Board
THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL.
This form may be used to report the Ilist time you treated the patient or to report continuing services. (To report permanentimpqirrnent, use Form 0.4.3.) Use this form pnly if attaching a detailed narrative report. Please answer all questionscompletely and submit promptly to the Board, the insurance carrier and to the patient's attorney or licensed representative,If he/she has one; if not send a copy to the patient Failure to do so may delay the payment of necessary treatment,prevent the timely payment of wage lass be...nelite to the injured worker, create the necessity for testimony, and jeopardizeyour Board authorization,
A. Patient's Information
1. Last Name: Giagal°ne
2. Social Security
First Name; Jason Mt:
3. Home Phone ft: 7197538953
4 WCB Case # (if known): 5. Carrier Case # (If known): esP°0000502.2
G. Mailing Address: 72
my: Brooklyn
Bay 49t1; Streak
7. Date of injury/onset of illness:ens/zoos
Line 2.
State: NY Zip Code 1123.4
8. Date of bIrth:10110.970 9. Gender: Male
105.0n the date of injuryfillness whatwas the patient's job title or description:unknown
Country:
11. On the date of injury/illness wh ere the patient's usual work activities;
Unknown
12. Is the patient working now? Yes
3, Employer Information
1. Employer when Injury occurred:
Company/Agency Name: Program nevelonment
2. Employer Phone it 7182562211
3. Employer Address; 6916 new taxa Avenue
Obi Brooklyn
Doctor's information
1. Your Last Name: ICtelaean
State: gy
13. Patient's Account #:. 02882
3KTO FEE SCHED:
- 11111Alf4liiCTTrPA.
IPS ,4?Alt)
2, WCB Authorization #: 206647-os
4. Federal Tax ID #: 20127000e
5. Office Address: PARS Mediaal PC
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First Name; Issac
3. WCB Rating Code. MIR
The Tax ID # is the: sin
City: Brooklyn Statp:
6. Billing Group / Practice. Name
MI:
Line 2, 5223 ettt Avenue
Zip Code: 11220 Countryi
7, Billing Address:, 5223 PtIt Avenue
City; Brooklyn
8. Office phone #: 251-141-5-5627
state: Iq
Line 2:
Zip Code:11225
9. Billing phone #:
Country:
10 Treating Providers NM ft: 1497625434 'h. You are a: Physician
EC-4NARR (12-10) Page 1 of 2ThelAsCiilKERSCOMPatiSATION 90/RD Se:TieASP SERVES
?MOLE:Vete DiseeenesvereouteisceeiiiemiON120
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
D. Billing
1. Employees
2 Carrier
3. Insurance' cat.
Information
Insurance carder.:
Code 9:
2012052500053.32
•
pm uspycjAL_BIzaalgs
.Line2: 'carrier's address:
JANESVILLE
.
20 BOX 5231
53542 Country:State: wx Zlp Code:
4. Diagnosis or nature of disease or Injury:
Enter ICD9 Code: ICD9 Descriptor
i 724.2 LUMBAGO. .
2 724.4 . .THOR/LUMBOSNMEL NURIT/BADICULIT UNS.
3 781.2 ABNORMALITY OF GAIT
4.
Relate ICD9 codes above to Diagnosis Code column by line.'
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urectRaCedesProtein; Seances at Supp2as
CEDHCPCS 'Modifier-1 WaalDiagnosisCoda $ Charges
DENUnits COB
.
Zp Cana otossondrawas rendered
12/29/2011 12/29/2011 11 99213 12 64.07 1 12202913
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0 Services were provided by a WCB preferred provider organization
E. Doctor's Opinion
1. In your opinion, was the Incident that the patient described
2. Are the patients complaints consistent with hislher history
3. Is the patients history of the Injury/illness consistent with
4 What Is the percentage (0-100%) of ternporary Impairment?
This form Is signed under penalty of perjury.
Board Authorized Health Care Provider:I Provided the services listed above
kNOTORINEG SIGNATURE ON FILE WITH NEW YORK.WORKERS
(PPO
the competent medical
of the Injury/Illness?
your objective findings?
100-00s
Tole Charge
60. 07
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cause of thlitritiryfiliness?
Yes
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Provider's Last Name:
Provider's Specialbi:
First Name:
Board Authorized Health Cam Provider:
Last Name: Kreszman First Name•Iosec
Specialty PHYSICAL MED/CINE/REHMILITAT/ON Date: 1/6/2012
Mt
MI:
EC-4 NAFtR (12-10) Page 2 of 2
01
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
-9.
Re: Jason GiacaloneExam: April 25, 2012
STATE OF NEW YORK—WORKERS COMPENSATION BOARD 62578PRACTITIONER'S REPORT OF INDEPENDENT MEDICAL EXAMINATION
A copy of each mead of Inff Wooden' Modlool Esandlunton shad be aubmIllad on the some day end In the eemo marmotlo the Workers' Compensation Board. the Insurance canter or self, Instead employer, the otelmant's attending physician erother attending pm:Wooer, the claimants IIIIRENNOESNA Eq. and Oto thrift
CHECK ONE: IJ PHYSICIAN 1_1 PODIATRIST I_ 1 CHIROPRACTOR 1_ PSYCHOLOGISTTHIS IDCAMiNATION WAS REQUESTED BY: 1 XI CARRIERIEMPLOYER 1_ I
Woe Caoe No, canter Cattab.11111Cnown) Date of MIUM Injured Powers SRN Date et Examination
000243637 W000024420 06/19/2005 martini
INJUREDPERSON Jean Glacefona
72 Boy 4911 Sr2nd FloorBlookhtn. NY 11214
EMPLOYER Program Pent
INSURANCECARRIER Co INCNCAmp, 14 Lafayette SO STE 100
Buffet% NY 14203
IF EXAMINER CONDUCTED THIS E<AMINATION AS AN EMPLOYEE OR UNDER CONTRACT WITH AN IMECOMPANY, STATE NAME AND WORKERS COMPENSATION BOARD REGISTRATION NUMBER OF IMECOMPANY.
UntMex, P.C. Regletrallon 0010133
Rkitilla of ereniklat Centlfille on men* or s
"SEE ATTACHED NARRATIVE REPORT"
additional sheets, If necessary)
CC: Workers Compensation Bored, PO Box 8205, Binghamton NY 130024205 L"NCAComp, INC, 14 Lafayette SO STE 700, Buffalo NY 14203 • ...-Jason Gleeelone, 72 Bay 491h SI, Ind Sam, Brooklyn NY 11214Ansa Wade & Cadge Ea • 80 Say Street Staten island NY 10301-Issue KrelomuttaILD., 5223 di Ave, BroclOyff NY 11220
I hereby certify that We report Is a full end truthful repcondition.
Jeffrey IL Pant*, M.D.11/academes Name
2269 Omen AveBrooklyn, NY 11228 166191.713
PrectIllonatio Address IME Atdhormation No.
NO armannotren Iten4e1m0 OR 'VALUATING A CLAIMANT WI tit THE WORKMEN. cotammtantioN LAW on MY stlitERWOHO ALRIKATITTOtIPROHEUTIORNOR IttOUBlitmeanaliM OR EAVILOTOR NAY UWE DIRECT oREOCOURATS A REM'S TORE eUtlitellED NIMES= toWORXERtr roar NORM clam REUUDICATIOR Yancii OEMS attartaartintto FROM THE pitliFENHONN MOGI OP THE MUNN°
ilettERALHWOPRACTIMONT,Nt NOTION SHAM OE constaratee MIEN 1HE +OMICRON OF lite WORKER' COMPEROATION fRAUD INSPECTOR
UCHWREFNT A FRAUDULENT PRoottE
profesalonal opinion with rasped to the Getman
Data
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
JEFFREY PASSICK, M.D., F.A.A.O.S.DIPLOMATE AMERICAN BOARD OF ORTHOPEDIC SURGERY
2269 Ocean Avenue Tel. # 718-287-4200Brooklyn, NY 11229 Fax # 718-287-4225
April 25, 2012
UniMex, P.C.PO Box 760Old Bridge, NJ 08857
RE: Giacalone, JasonWCB #: 00626057Carrier Case No.: W000024420UniMex No.: 62578DOI: June 19, 2006Employer: Program PevelCarrier: NCAComp, Inc.Request Type: Workers' Compensation IME
To Whom It May Concern:
As per your request, I performed an independent orthopedic re-examination onthe above-claimant on April 25, 2012 in my Brooklyn, New York office. Theclaimant presented valid photo identification, which was witnessed and copied.
My findings of the examination are as follows:
HISTORY:
Mr. Giacalone states that he was injured while lifting an air conditioning atwork on June 19, 2006. The claimant sustained reported injuries to the Jawerback with radiation to his left leg. There were no reported laceration's-Or:aclaimed loss of consciousness, Mr. Giacalone did not sderernerVicytreatment for his injuries. .
• • ••. . .Subsequently, Mr. Giacalone was prescribed medication, plityliogl therlegby,chiropractic care and acupuncture. Mr. Giacalone started retrdiVing therapyimmediately after the accident. He states that he did not improve with therapy,but rather feels "worse". He is no longer receiving treatment.
The examinee reported during prior examination appointments that he wasprovided with medical a back brace, a massager, a bone stimulator unit, aback corset and a TENS unit.
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
-2-Re: Jason GiacaloneExam: April 25, 2012
Mr. Giacalone underwent surgery to the back on 11/6/09 and 2/10/10(discectorny and fusion).
REVIEW OF MEDICAL RECORDS:
• MRI report of the lumbosacral spine from Bromer Medical, P.C. dated6/26/09. Impression: (1) The S1 vertebral body is transitional. (2) Diffuseposterior bulging disc L5-S1 is identified extending into the epidural fatdeforming the theca! sac and bilateral SI nerve roots. This as well ashypertrophic changes of the bilateral zygapophyseal joints is resulting inbilateral neuroforaminal stenosis and deformity noted upon the bilateral15 nerve roots. (3) Diffuse posterior bulging disc L4-L5 is identifieddeferring the thecal sac and bilateral L5 nerve roots, (4) Loss of normaldisc signal intensity and height is identified from the L4-L5 and L5-S1 discsspace levels.
• MRI report of the lumbar spine dated 2/3/10 by Alan Berliy, M.D.Impression: Findings consistent with a predominantly left paracentral discherniation at the L5-S1 level. Also noted at this level are findings consistentwith an extruded disc fragment extending predominantly below the levelof the disc space and for the most part extending to the left side of thespinal canal. There is evidence of a broad based disc herniationextending to both the right and left of the midline at the L4-L5 level. Minormass effect upon the dural sac is noted. There is evidence of discherniations within the portions of the L4-L5 and 15-51 intervertebral discs.Facet arthropathy is present.
• MRI report of the lumbar spine from Brooklyn Medical Imaging Centerdated 8/1/06. Impression: Disc pathology as described above.
• MRI report of the lumbosacral spine from Bromer Medical, P.C. Radiologydated 6/29/09.
• MRI report of the lumbar spine from Joseph Leadon, M.D. dated 8/.1./0.6.Impression: Disc pathology.
• CT lumbar myelogram report from Corinthian Diagnostic Radiology 4perteid6/7/10.
• CT scan report of the lumbar spine from Jacob C. Abraharouv1.D. &Mad3/3/10. Impression: Post-surgical changes, no gross aptness a ccid„malalignment. . •
• X-ray report of the lumbar spine from North Shore University.Hospital ddtpd2/10/10. Impression: Post surgical changes of the lumbar spine.
• X-ray report of the chest from North Shore University Hospital clatqd2/10/10. Impression: Negative for acute pulmonary or pleural pathology.
• X-ray report of the lumbar spine from David Rosenthal, M.D., HighwayImaging Associates dated 8/27/09. Impression: Possible spinal canalstenosis at L4-5. If further evaluation is deemed warranted, MRI would berecommended.
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
-3-
Re: Jason Giacalone
Exam: April 25, 2012
• X-ray report of the lumbar spine from David Rosenthal, M.D. dated2/25/10. Impression: Post posterior spinal fusion with intervertebral discspacers. No destructive lesion is seen. Other findings as noted.
• X-ray report of the lumbar spine from Bahram Chubineh dated 2/25/09.Impression: Negative examination.
• X-ray report of the lumbar spine from David Rosenthal, M.D. dated8/27/09. Impression: Possible spinal canal stenosis at L4-5. If furtherevaluation is deemed warranted, MRI would be recommended.
• Doctor's narrative report from Isaac Kreizman, M.D. dated 12/16/10 to12/29/11.
• Medical examination report from Isaac Kreizman, M.D., Pain andRehabilitation Services dated 12/16/10 to 12/29/11.
• Medical examination report from Steven Horowitz, M.D., Brooklyn PremierOrthopedics dated 8/18/10 to 10/12/10.
• Doctors initial report from Sanjeev Agarwal, M.D. dated 9/16/10.• Medical examination report from Sanjeev Agarwal, M.D., SUNY Downstate
Medical Center dated 9/16/10 to 11/18/10.• Doctor's progress report from Sanjeev Agarwal, M.D. dated 11/18/10.• Orthopedic IME report from Julio V. Westerbrand, M.D. dated 10/3/11.• Orthopedic IME reports from Jeffrey M. Passick, M.D. dated 7/28/10 to
2/22/12.
PAST MEDICAL HISTORY:
Past medical history, as reported by the claimant, is negative.
The claimant denied being involved in any prior motor vehicle or workers'compensation accidents or sustaining any prior injuries.
SURGICAL HISTORY:0000.
Surgical history, as reported by the claimant, is significant for surgery to ficleleftknee in 2000. 9 000
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EMPLOYMENT HISTORY:
The claimant was employed full-time as a maintenance worker when the _nine19, 2006 accident occurred. He reported during the 2/22/12 examinationappointment that he returned to work for 1 day and was let go. He is notcurrently working.
0126
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
-4-Re: Jason GiacaloneExam: April 25, 2012
CHIEF COMPLAINTS:
This individual states that he feels pain in the lower back, right ankle and leftfoot.
Mr. Giacalone rates his pain to be a 10/10 (10 being the most severe). He tookpain-relieving medication prior to today's physical examination appointment.He describes his pain to be achy, burning, sharp and nagging in quality. Hereports a radiation of pain to the left leg and right foot. He is able to walk 1 to 2blocks. Climbing stairs cause him difficulty. He cannot sit without experiencingpain. Bending, walking, sleeping and turning left worsen his pain.
PHYSICAL EXAMINATION:
The claimant is a 34-year-old male who stands 5' 8" tall and weighs 195 lbs. Hehas brown eyes and dark brown hair. The claimant stated being right-handdominant.
The claimant was examined with the examining room door left ajar. He wasasked to inform me as to any pain or tenderness during the examination.
EXAMINATION OF THE LUMBAR SPINE: Healed, post-operative scarring wasobserved over the lower back. Examination of the lumbar spine revealed noparaspinal spasms to palpation. There was moderate bilateral paraspinaltenderness to light touch. Neurological examination of the lower extremitiesdemonstrated muscle testing to be +5/5 throughout. Sensory responses wereintact throughout the lower extremities. Patellar and Achilles reflexes were +2and equal bilaterally. Atrophy of the intrinsic muscles was absent. The claimantwas unable to perform the straight leg raising test. The claimant was unable towalk on heels and toes. There was increased pain with the Valsalva maneuver.
LUMBAR SPINE
RANGE OF MOTION NORMAL CLAIMANTFLEXION 90° 10°EXTENSION 30° 10°RIGHT LATERAL BENDING 30° 10°LEFT LATERAL BENDING 30° 10°
DIAGNOSIS: The claimant presents with a diagnosis of:
1. Failed back syndrome, S/P lumbar spine fusion.
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
-5-
Re: Jason Giacalone
Exam: April 25, 2012
The diagnosis, as documented, is based upon the claimant's description of theaccident and the physical examination, taking into account both the subjectivecomplaints and the objective findings.
DISCUSSION:
Mr. Giacalone has constant pain. He has been told nothing else can be done.He is on chronic pain medications.
Maximum medical improvement has been obtained.
PERMANENCY:
The lumbar spine permanency is a Class 5, Severity Ranking J (Table 11.2). Class5 is for post-operative complications - Mr. Giacalone has failed back syndrome,which is a complication.
My assessment is in accordance with the New York State Workers'Compensation Board Guidelines effective 1211/10 Treatment Guidelines, as wellas the State of New York Workers' Compensation Board, Medical Guidelines,June 1996.
I, Jeffrey Passick, being a Diplomate of the American Board of OrthopaedicSurgery, am duly licensed to practice medicine in the State of New York. Iaffirm, under the penalties of perjury, that the information contained within thisdocument was prepared and is the work product of the undersigned, and istrue to the best of my knowledge and information.
With reasonable notice, I am available to testify, by appointment, should theneed arise.
Sincerely,
Jeffrey Passick, M.D., F.A.A.O.S.Diplomate of American Board ofOrthopedic SurgeryLicense: # 166191, NY
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
-8-
Re: Jason Glacelone
Exam: April 25, 2012
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State of New YorkWORKERS' COMPENSATION BOARD 62578
PRACTITIONER'S REPORT OF REQUEST FOR INFOSIMATIOWRESPONSE TO REQUESTREGARDING INDEPENDENT MEDICAL EXAMINATION
1.PRACTMONEESNAIdE ANDAODREESJewel Passktt EEL2200 Ocean AmBroobbr. NY TM
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NOTE The preclOwees Edam of meal enter eiflets' compensation meads to tar Board anew to modes* party b edged laappaahle tine rogerothetonlIdeallehly of swat wards. thcbileg but nalembdto Sodom 1104 al the Walked Conmenadan law. &don16 of the Mb HeatOrLek and ether ;tole and federal IanWPM Nobs: In ardor le *Ocala a waiter/ campers:91bn dabs Wen amore 134 end 137 remit en employer or canter to nave Tdelment exeratntd 12, a TSUI cal proildet Paean! le 45 CFR 512 a health Mader rad hes been robbed by so ompeoYof W corder toendues ewadmiece Webb tumid Tram IRPAOreeidaagondtsdaureofhaaat Informalton.
PRACTMONER6 MO FAIL TO HIE REQUIRED FORMS MAY SUBJECT TO OISCITTLINE. INCLUDING REMOVAL-OF AUTHORIZATIONORMOJDEPENDENT MEDICAL EXUMA IONS.
ID PRACTITIONER'S REPORT OF REQUEST FOR INFORMATI
Dem meuestrftoefred
' •i• 01143 INDEPENDENT MEDICAL EXAMINAIION
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liffrey M.Paseck, HO.
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0129
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
UniMex, P.C.P.O. Box 760, Old Bridge, NJ 08857
Phone 800-524-5585 • Fax 732-679-1676Email: [email protected]
411012012Jeffrey M. Passick, M.D.2269 Ocean AveBrooklyn. NY 11229
Claim Type: WCBCarrier: NCAComp. INCClaimant: Jason Glacalone0/0/B: 978Client Flle #: W000024420UniMex Elle #: 62578Date of Accident: 06/19/2006Employer. Program PevelAppointment #:WCB FOe 00626057
Dear Doctor:
LOCATION: In your office, at the above address.
DATE: 04/25/2012 (Wednesday) TIME: 12:15 PM
Report to be received within 7 days of exam so as to be billable.
Please address if the claimant Is at MMI. If so, does permanency apply? To what degree? Pleasereview all the medical reports and degree of disability given by the doctors.
PLEASE ADDRESS THE FOLLOWING:
> 2012 Impairment Guidelines - Please give your opinion on permanency. Please indicate theseverity ranking, class and primary impairment table that were used when determining youropinion.> Classification - Is current disability PERMANENT?> MMI - Has Maximum Medical Improvement been obtained?> Permanency -
APPOINTMENTS CAN BE RESCHEDULED ONLY BY CONTACTING UniMex PRIOR°11:1°48HOURS OF EXAMINATION DATEI
Should the claimant fail to keep this appointment kindly notify us promptly.
Sincerely,
UniMex Medical Exams
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
UniMex, P.C. P.O. Box 760, Old Bridge, NJ 08857
Phone 800-524-5585 • Fax 732-679-1676Email; [email protected]
CC: Workers Compensation Board, PO Box 5205, Binghamton NY 13902-5205NCAComp. INC, 14 Lafayette SCI STE 700, Buffalo NY 14203Jason Giacalone, 72 Bay 49th St, 2nd Floor, Brooklyn NY 11214Attorney: Anguili Katkin 8, Gentile Esq., 60 Bay Street, Staten Island NY 10301-TP: Issac Kreizman, M.D., 5223 9th Ave, Brooklyn NY 11220
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
a' Health Systemsn- tf\ NA TIoN A L RX
NAME RCA Comp
14 LaFayette Square
Suite 700
Buffalo, NY 14203
Attn:Strwen Gidwitz
CRISP Trust
INVOICE FEDER
INVOIC
INVOIC
NAME: JASON GIACALONE
CLAIM it: W000024420
CARDHOLDER la 17067784
ADJUSTER: Sherd Clch
First Date ofFill. Service R/Cfl
DUE UPON RECEIPT
ISJ-EASE INCLUDE INVOICE NUMBER WITH YOUR PAYMENT
DescriptionNIDGCOrlaDrug Type Prescribing M.D.Days
Pharmacy Name PhySicianQty. StiPPIY DAN/Pharmacy I0
Billed ByPharmacy (Ifpaper claim) Fee
4/17/2012 11468B CARISOPRODOL 350 MG TABLET SO 30 KREIZMAN 50.00
62756044602 1497825434
Generic No Product Selection indicated
GOOD DAY PHARMACY 'LC
1154568400
4/17/2012 114685 DIAZEPAM JO MG TABLET 90 30 KREIZMAN 50.00
00603321521 1497825434.
Generic No Product Selection Indicated
GOOD DAY PHARMACY LLC
1164568400
4/17/2912 114687 OXYCODOPIE14CL 30 MG TABLET
52152021502
leo, _30, KREIZMAN
1497625434
so 6*
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1154568400
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• t66.89.5.2021 7411Pree k 866 701,2787 Fax• „ tizeat cblia-h14 com
TOTAL AMOUNT DUE:
Amounts denoted by •()" are
PRE NEGOTIATED RATE -
0132
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
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0133
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
UniMex, P.C. Exam Request Form
Clienc N inAddress: Signature: SKUVW-
Exam Type: WCB dC:J1
NO FAULT 0
Claim# 1 n 0000 dt-tilaoDOA: to 10(oWCB#: no 1419/4657 Employer: 0 WA be lit 3.DOBSS
Specialists O Cardiologist
O Chiropractor
O Dentistry
O DermatologistO General Surgeon
O Internist
O Neurologist
O Ophthalmologist
O Orthopedists
O Plastic SurgeonO Psychiatrist
Date of Request ell / ay loCity State N1 Zip Tel#: I lo Ext /9 c-
LIAB 0 DISABILITY 0 OTHER 0
Claimant Jason 6- is Ca )(1(QAddress 72;tAcitha- ?no' Olin( City erring/I state WI Zip //gig Telephone #
Attorney t) ]791 i) i tat- 4in 6n4; Le Address 0 Bay S
' State PP/ Zip i 03rsTelephone # 112 - 8 ILI • 60
Treating Physician TR.5aC rreizman Address 5 2q#3 gill AV e City PwaDviqn State N i Zip 09 0Telephone # ,261 ? % - 21
O Other IF Pcds eL
O Diagnosis
O Causal Relationship
O Degree of Disability
O Need for Treatment
0 Need for Surgery
O Return to Work
Issues To Be Addressed
O Apportionment
O M8cS 15-8
O Schedule Loss
Ti ClassificationkMMI
O Restrictions on RTW
• X-Rays
Non-invasive Tests Authorized
0 Other 0 None
• .0Specific Ins ctionaI IA• 1. it IA IA Aa
iwonwifiwarroar_ inser-iriP.O. Box 760, old Bridge, NJ 08857 Phone#: 00-524-5585
Fax#: 732-679-1676Email: [email protected]
ncy
0134
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
r-
thisinvi,f0 tt-T;04,30,44,5i
Claim Number.ClaimantProvider Tax ID:Provider Ref:
Region: 04
Community Residence Savings Plan (CRISP) 2900
W000024420GIACALONE, JASON PPO ID:
201270006 Vendor 201270006-0001 NPI Number:
Geo Zip: 11220 WCB Case Number.
ISSAC KREIZMAN5223 9TH AVEBROOKLYN, NY 11220
Process Date: 03/22/2012
Control Number: 4895125
FOR Page 1 of 1Rev/Aud: DM/DM
ExternalRevlew Procure
ICD-DX1: 724.2 LumbagoICD-DX2: 724A Lumbosacral neuritis NOSICD-DX3: 781.2 Abnormality of gait
PPS.: 40S ode
1110712011 11 99213 OFFICE OUTPT EST 1 64.07 0.00 24.07 0.00 40.00
11109/2011 11 99213 OFFICE OUTPT EST 1 64.07 0.00 24.07 0.00 40.00
0112612012 11 igg9213 OFFICE OUTPT EST' 1 64.07 0.00 24.07 0.00 40.00
TOTALS: 192.21 0.00 72.21 0.00 120.00
TOTAL RECOMMENDED ALLOWANCE: 120.00
PPO REDUCTION: Procura/MagnaCare - For questions regarding Network Discounts, please call: (877) 461-3750.
• ali T3 PAY. IBC thitillaRrht
Unless otherwise stated, reimbursement is made according to The Official New York Workers' Compensation Medical Fee Schedule. Reimbursement for
treatment rendered by out-of-slate providers is made based on the prevailing Workers' Compensation Nate fee schedule for the providers geographical area.
Any reduction is due to the billed charges exceeding the fee sthedule allowance for the service provided and/or the application of the appropriate discounts
based on the individual providers agreement with the preferred provider organization. 5" Workers Compensation
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
ar Health SystemsI T F; NATiONAL
RX
NAME: NCA Comp
14 Larayette Square
Suite 700
Buffalo, NY 14203
Attn:Steven Gidwitz
CRISP Trust
First Date ofFill Service RX#
DescriptionNDC Code
Oftlg TypePharmacy Name
Pharmacy ID
INVOICE FEDERAL TAX ID 26-1466949
INVOICE #:
INVOICE DATE:
NAME: JASON GIACALONE
CLAIM a: VV000024420
CARDHOLDER ID: 170877848
ADJUSTER: Sherri Clch
DUE UPON RECEIPT
PLEASE INCLUDE INVOICE NUMBER WITH YOUR PAYMENT
DaysQty. Supply
Prescribing M.D.Physician 1.0.DAW
Billed ByPharmacy Ofpaper claim) Fee Schedule
RX9105488
3/20/2012
Your Price Savings
3/2012012 114130 DIAZEPAM 10 MG TABLET
00603321521
Genetic
GOOD DAY PHARMACY LLC
1154568400
3/2012012 114131 OXYCODONE FICL 30 MG TABLET
52152021502
Generic
GOOD DAY PHARMACY LLC
1154588400
3/20/2012 4455389 CARISOPRODOL 350 MG TABLET
00603258221
Generic
t4AROLDS PHARMACY
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180 30 KREIZMAN
1497825434
No Product Selection Indicated
60 30 KREIZMAN
BK5374474
No Product Selection Indicated
PLEASE REMIT PAYMENT TO:
Health Systems internationalP.O. Box 801, Indianapolis. IN 46206-0681666.895.2021 Toll Free • 866.701.2781 Fax
Emelt rxams-hacom
50.00
50.00
50.00
535.32 534.18
5209.71 5202,03
533.82 532.54
Amounts denoted by V are aedlts.
PRE NEGOTIATED RATE - NOT SUBJECT TO REPRICE
WO FEE :,c1::10: 9U"
AMOUNT 10 FAY: 1-1-3-5
PAID:
51.14
57.68
51.08
0136
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
IgoN. • Health Systems
I NTE FtivAtioNALRX
INVOICE FEDEF
INVOII
INVOIr
NAME: NCA Comp NAME JASON GIACALONE
14 LaFayette Square CLAIM #: W000024420
Suite 700 CARDHOLDER 10: 1706778
Buffalo, NY 14203 ADJUSTER: Sherd Cich
Attn:Steven Gidwitz
CRISP Trust
First Date ofFRI Service RYA
DescriptionNDC Code
Drug TypePharmacy NamePharmacy ID
DUE UPON RECEIPT
PLEASE INCLUDE INVOICE NUMBER WITH YOUR PAYMENT
Prescribing M.D.Dayshysic
Qty. Supply P DAWian I.D.
Billed ByPharmacy (ifpaper claim) re'
2/23/2012 113616 DIAZEPAM 10 MG TABLET 90 30 KREIZMAN
00603321521 1497825434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LLC
1154568400
212342012 113617 OXYCODONE HCL 30 MG TABLET 180 30 KREIZMAN
00228287911 1497825434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LLC
1164566400
$0.00
$0.00
TOTAL AMOUNT DUE:
Amounts denoted by "War
PRE NEGOTIATED RATE
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Health Systems iniemationalP.O. Box 881, Indianapolis, IN 46206-0881866.895.2021 Toll Free • 866.701.2781 Fax
Email: rx©us-hsi.com
0137
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
. P7 LUJ-J,
201203120002642a.aa4 POLL11/0.1.1..1:111.
Doctor's Nt9iitive ReportState of New York Workers' Compensation Board
THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY, DO NOT MAIL.
This form may be used to report the first time you treated the patient or to report continuing services. (To report permanentimpairment, use Form C-4.3.) Use thls.form only If attaching a detalled narrative report. Please answer all questionscompletely and submit promptly to the Board, the insurance carder and to the patient's attorney or licensed representative,If he/she has one; If not send a copy to the patient. Failure to do so may delay the payment of necessary treatment,prevent the timely payment of wage loss benefits to the Injured worker, create the necessity for testimony, and jeopardizeyour Board authorization.
A. Patients Information
1. Last Giaoalone
f9)4NARR
First Name: Jason MI:
2. Social Security #: 3. Home Phone #: 1181538953
4. VVCB Case # (ff known): 09311829
6. Mailing Address: 72 Bay 49th Street
City: Brooklyn
5. Carrier Case # (If known): C22000005824
Line 2:
State: Zip Code: 11214
7. bate of /rimy/onset of Illness:a/Ls/zoos B. Date of birth:
10. On the date of injury/Mness what was the patient's job title or description:unknown
9. Gender: male
Country:
11. On the date of Injury/illness what were the patient's usual work activities:
unknown 0 0 0
• •• •
12. Is the patient working now? Yea. 13. Patient's Account #: 028820w3
B. Employer Information
1. Employer when•Injury occurred:
Company/Agency Name: proqrai Development
2. Employer Phone #: 7182562212
• • •
3. Employer Address: 991.6 New Utreht Avenue Line 2:
City: Brooklyn
00.7,114
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• •State: , NY Zip Code: 11299 Country:
C. Doctor's Information
1. Your LastName: First Name: Issao MI:
2. WCB Authortzation 206647-DB 3. WCB Rating Code: CPMB
4. Federal Tax ID #: 201270006 The Tax 10 # Is the: am
5. Office Address: BMW Medical BC Line 2: 5223 9th Avenue
City: Brooklyn
6. Billing Group / Practice Name
7. Billing Address: 5223 9th Avenue
State: NY Zip Code: 11220 Country:
city: Brooklyn State: NY8. office phone #: 201-212-8627
Line 2:, Zip coop: 11220
9. Billing phone #:
Country:
10. Treating Provider's NPI #: 1497225434
EG4NARR 02-10) Page 1 of 2
11. You are a: Physician
THE WORKERS' COMPENSATION BOARDEMPLOYSAn SERVESPEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION
01 8
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
p. Billing information1. Employees Insurance carrier
2. Carrier Code #:
20120312000264200125
PMA MEDICAL BILLING
3. Insurance carrier's address: PO BOX 5231 Line?:
City: JANESVILLE State: III Zlp Code: 53547 Country:
4 Diagnosis or nature of disease or Injury:
Enter ICD9 Code: ICD9 Descriptor
724.2 LUMBAGO1
2
3
4
724.4 THOR/LUMBOSACRL NURIT/RADICVLIT UPS
Relate ICD9 codes above to Diagnosis Code column by line.
Dates of Service
From To
Pieceel
ServiceLeaveStank
lise WCB CodasProcedures Services a Supplies
OPTMCPCS Maar 1 Manor 2DiagnosisCode S Charges
Days/Undo GOB
Zip Cade whereservice WO rendered
9/16/2011. 8a6/2011 11 99213 12 64.07 1 11220
..a..
.2°• "
-
0 Services were provided by a WCB preferred provider organization (PRO).
TotalCharge
64.07
Amount Paid .(Onwiimllse OM. °
balance Due.....(Lank? Ssenigl .•
E. Doctor's Opinion
0000
•0 •
0000
•
1. In your opinion, was the incident that the patient described the competent medical cause of this:IritriyAlinesr:Ios 6
WO
2. Are the patient's complaints consistent with his/her history of the Injury/illness? Yes
3. Is the patients history of the injuryfifiness consistent with your objective findings? Yes
4. What is the percentage (0-100%) of temporary impairment? 80. one
This form is Signed under penalty of perjury.
Board Authorized Health Care Provider:I Provided the services listed above
(NOTORTZED SIGNATURE ON rim WITH NEW YORKVIC/MRS COMPENSATION BOARD]
• ODO AI p
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Provider's Last Name: First Name: MI:
Provider's Specialty:
Board Authorized Health Care Provider:
Last Name: Breiznan First Name:xvsaa MI:
specialty: PHYSICAL MEDICINEAUSHABILITATION Date: 9n/203.1
ECaThIARB (12-10) Page 2of 2
0139
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
20120312000264200125
Pathan Jason OinenioneDOB:SSN;Date: 8/16/11Attending: ham J, Kralawn, MD
HISTORY OF PRESENT ILLNESS:
The patient is status post work-related Injury to the lower back. Ha has had multiple surgeries andhardware to the lumbar spine for pain management. He is currently taking roxycodhte and Soma forpain and Valium. The patient has 10/10 lower back pain.
CHEF COMPLAINT: -
The patient has 10/10 pain to the !mister back
EXAM:
SOCIAL HISTORY:Alcohoh NoneTobacco: Patient is a non-smoker.Dray:None.Toxins: None.Work: Patient Is non-contributory. •
110.
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Diets Patient is not on any particular diet.0009
a •• 0•9• Ce • • •
FAMILY HISTORY: 0•00 0 •
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MEDS: 00
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The patient is currently taking roxycodine, Soma and Valium. •42
ALLERGIES:No known allergies
PAST MEDICAL HISTORY:Non-contributory
SURGICAL HISTORY:No surgical history
REVIEW OF SYSTEMS:Constitutional: Patient denies any change in weight, fevers and sweats. The patient demos any nausea,vomiting, diarrhea or diplopia.ENMT: Patient denies any ear or nose problems, visual difficulties, ear abnormalities, and brain tumor.Throat: Patient denies anyproblems or swelling lathe mouth, neck problems or swelling and throatdisorders.
I of301 0
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
20120312000264200125
•Jason Oiscalone
Cardin: Patient denies angina, edema, hypertension, palpitations, vascular problems, high bloodpressure, heart problems, Pulmonary Fibrosis, Congestive Heart Faiktre, Coronary Artery Disease, high.cholesterol, and Peripheral Vascular Disease.Respiratory: Patient denies cough, shortness of breath, sputum production, wheezing, lung/breathingproblems, chronic obstruction pulmonary disease, restriedve lung disease, pulmonary hypotension,sateoldosis, dyspnea, asthma, chest pain and bronchitis.GU Patient denies abdominal pain, bleeding, bowel changes, dyspepsia, gastrointestinal problems,peptic ulcer disease, diverticulitis, hepatitis C, OEM, irritable bowel syndrome, neurogenic bladderproblem and colitis.GU: Patient denies dysuria, frequency, hematuria, incontinence and noctutia.Herne/Lymph: Patient denies anemia, easy bruising, excessive bleeding, lymphadenopathy, deep veinthrombosis and Hyperkalemia.Ebert: Patient depies neck pain, mid-back pain, bilateral hip pain, bilateral knee pain, bilateral anklepain, bilateral foot pain, bilateral shoulder pain, bilateral elbow pain, bilateral wrist pain and bilateralhand pain.Endocrine: Patient denies hormonal abnormalities, polydipsia, polyuda, diabetes, hypothyroidism,cc-bilis and colon cancer.Neuro/Psyein Patient denies mood changes, paralysis, syncope, depression, cerebrovaicular accident,hentiplegia, dizziness, cerebral palsy, mental retardation, traumatic butt itlittrY, multiple sclerosis,headaches, psychiatric problems, neurological problems, AD.D. and sleep apnea.Integumentary: Patient denies pruritus, rashes, skin eruptions, infection and shingles.
PHYSICAL EXAM:••00
Vital Signs: •... ,Uptight BP = 120/80 trunHg • 0
.• O• 0 v •
Pulse = 801mm. Patient is afebrlle °
. ..Rasp = 15
00000b . Oa OS
General; Well nourished. Well dressed. Not in acute distress. .... : a 0 0 •
O
/MEND Normoeephalic, Atraumatic. EOM am intact. 0000
:
; •
0
. II.
0000
Chest: Clear to auscultation bilaterally. No wheezing, no rates, no thonchi. . ,•
, 4.004o
0 0
CV; There is a regular rate and rhythm. Normal S1 -S2. ...•.• .
Abd: The abdomen is soft. Non-tender. Non-distended. Normal bowelsounds are Present : - , . . Neck: No paraspinal tenderness noted. Full range of motion 00 •
0000
1VIldBck: No paraspinal tenderness noted. Full range of motion. • co
a 4
LowEek: L3-L4, L4-L5 and L5-51 paraspinal tenderness. Decreased range of motion.Extrem: There is no clubbing, cyanosis, edema, erythema and cellulitis.RUE: 5/5 muscle strength. No contractures. Full range of motion.LUE: 5/5 muscle strength. No contractures. Full range of motion.RIX: 3/5 muscle strength. Decreased range of motionLLE: 315 muscle strength. Decreased range of motion,Eldn: No scars, rashes, lesions, ulcerations in the head, neck trunk, RUE, UM, RLE, LLE.Lymph: Palpation of lymph nodes in neck, mini= and groltt is normal.Neuro: ORIENTATION: Alert & oriented x3. The patient understood command well. Attention spanand concentration were normal, Remote and Recent memory were normal. There is no deficits in cranialnerves I - XII, MOOD & AFFECT: No depression, no anxiety, no agitation. TESTCOORDINATION/GAIT: Normal coordination. Abnormal gait. EXAM OF DIR.:Normal 2+ BUB.Reflexes are normal to the upper extremities. EXAM OF SENSATION: Decreased to light touch andpinprick in the lower extremities with weakness.
00
2of31
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
20120312000264200125
Jason GaonIone
ASSESSMENT:
Lower back pain
KLAN:
t. Physical therapy2. Coittititte pain medication3. Home exercise prograni4. Follow-up in one month
6ne J..Kreikman, MDMichael-Giirbuisky,RPA-C
LTK/CAR*400001/814423014164611 6000
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
IUUM11..‘ISU.201203120002640
of f V X .wear AUDIALOWSLL=U
Doctor's Ntheitive ReportState of New York - Workers' Compensation Board
THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL.
This form may be used to report the first time you treated the patent or to report continuing services. fro report permanentImpairment, use•Form C-43.) Use this form only If attaching a detailed narrative report. Please answer all questionscompletely and submit promptly to the Board, the insurance carrier and to the patients attorney or licensed representative,if he/she has one: if not send a copy to the patient Failure to do so may delay the payment of necessary treatment,prevent the timely payment of wage loss benefits to the injured worker, create the necessity for testimony; and jeopardizeyour Board authorization,
C 4NARR
A. Patient's information
1. Last Name: Giaoalon; First Name: Jason
2. Social Security 3. Horne Phone #: 7187538933
4 WCB Case # (if known):
8. Mailing Address: 72 UP 49th Street
City: Brooklyn
S. Carrier Case # known): C88000005824
State: ITY
Urte 2:
MI:
Zip Code: 11214
7. Date of Injury/onset of illness:8/19/2006 8. Date of birth: igiv1978 9. Gender: Male10. On the date of Injury/illness whatwas thapatients roblitle or description:unknown
Country:
11. On the date of injury/illness what were the patient's usual work activities:O 0O000
•
injury back...000000
b 0 0
00 do
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Oda
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12. Is the patent working now7 Yes
B. Employer Information
1. Employer when injury occurred:
Company/Agency Name: Program Development
2. Employer Phone #: 7182562212
000000
13. Patients Account #: 029820uu4. •
00 00
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000 0 0Oci• 0 0
0 •
0•40 0 •
9 0
3. Employer Address: 6916 new Utreht Avenue Line 2:
0000.0
00 0
00000
City: Brooklyn State: if,/ Zip Code: mpg Country:
C. Doctor's Information
1. Your Last Warne: Ereinan First Name: isnao MI:
2. WCB Authorization #: 2 06 641-0 3. WCB Rating Code: cam
4. Federal Tax ID #: 201270006 The Tax ID # is the: BIN
5. Office Address: PARS Medical PC Line 2: 5223 9th Avenue
City: Brooklyn State: Ni Ztp Code: 11220 Country:
6. Billing Group / Practice Name
7. Billing Address: 5223 9th Avenue Line 2:
City: Brooklyn
8. Office phone #: 201-818-8627State: In Zip Code: 4220 Country:
9. Billing phone #:
10. Treating Provider's NPI #: 149/825434 .
50-4NARR (12-10) Page 1 of 2
11. You are a: Physician
THE WORKERS' COMPENSATION BOARD storms MD SERVESPEOPLE WITH DISABILMES WTHOUT DISCRIMINATION
01 3
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
b. Billing Information
1. Employer's insurance carrier:
2. Carrier Code #:
20120312000264000123
PMA MEDICAL BILLING
3. Insurance carrier's address: PO BOX 5231
City: JANESVILLE State: la
4. Diagnosis or nature of disease or injury:
Enter ICD9 Code: (009 Descriptor
1 724.2 LUMBAGO
Line 2:
Zip Code: 53547 Country:
2 724.4.
3 781.2
4
THOR/LUMBOSACRL NURIT/NADIgGLIT DNS
ABNORMALITY OF GAIT
Relate ICD9 codes above to Diagnosis Code column by line.
Dales of Service
From TO
Placeof
beltsLeaveBlank
• • •Use VOCA3CodesProcedures, &mikes or Supplies
CPT/WPCS Modifier I Modifier 2DiagnosisCode. $ Charges
•Days)Units COB
.
Zip Code wesett/Mamas rendered
10/10/201.1 10/10/2011 14 99213 t2 64.07 1 11220
0900
9000•
i R.' •
•0 nn.O.nt
• 0 0
" •• 0040
.6
.°
Pnnn n 6
90 01
6 •0. -
were provided by a WCB preferred provider organization (FPO).
Total Charge .
St 07
Awned Paid •J(earrierlige Only):
090000000
•C' •
Reliance Cue t 'f@anier Use 00...
0 0
n M Services
E. Doctorial:minion00
1. In your opinion, was the incident that the patient described the competent medical cause of this injuty/illnetsW's
2. Are the patient's complaints consistent with his/her history of the Injury/illness? Yes
3. Is the patient's history of the Injuryfillness consistent with your objective findings?
4. What Is the percentage (0-100%) of temporary Impairment? 50.000
Yes
This form !s signed under penalty of perjury.
Board Authorized Health Care ProVider:Provided the services listed above
MOTORIZED SIGNATURE ON FILE WITH NEW YORK WORKERS COMPENSATION BOARD]
900000a
0000
Provider's Last Name: • First Name: MI:
Pnivider's Specialty:
Board Authorized Health Care Provider:
Last Name: Kreizmars First Name:Issaa MI:
Specialty; PHYSICAL MEDICINE/REHABILITATION Date: 10/21/2011
'EC-4NARR (12-10) Page 2 Of 2' 01 4
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
e
Q
s.sa
. zal. • .., ,.•
." , •HISTORY 01/ PliESENTILLNESS:
The patient is status post work-related injury. He is status post lumbar multiple surgeries with
hardware on lumbar spine. Patient had failed lumbar spine surgery. He is currently taking Valium10
mg tid, oxyeodone 30 mg qid.
CHIEF COMPLAWT:
The patient complains of 10/10 pain In the lower back and lower extremities.
EXAM:
201203120002640. 0012'3• •
-Patient Jason OlecalmnnOlt: •
Date:Attending: Isaac L Krefnaan, Mt:
•
SOCIAL HISTORY:Alcohol: NoneTobacco: Patient is a non-smoker.Drugs: None.Toxins: None.
• • 000•
00o•
00000
0 ••
Oe o•
00 0
Work: Patient is non-contributory. 0,000.
Diet Patient is not on any particular diet.o000•
• o • • 00•000
0.00••
• •
0990 e• o•
FAMILY HISTORY:• •
•00•0 • a
Non-contributory. 00 DDDDD
•0OOOOOO
••• •
••
WINDS: a •
0 0 •
No medication.
ALLERGIES:No known allergies
PAST MEDICAL HISTORY:Non-contributory
SURGICAL HISTORY:No surgicaltistory
REVIEW OF SYSTEMS:Constitutional: Patientdepies any change in weight, fevers and sweats. The patient denies any nausea,vomiting, diarrhea or diplopia.ENMT: Pedant denies any ear or nose problems, visual difficulties, ear abnormalities, and brahrtumor.
Throat: Patient denies any problems or swelling in the motia, nremerns.or swept/ wand throat
disorders,.
111 OEM 11111111 I of3
_• • 015
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
20120312000264000123
•Jason disealone10/10/11
Cardio: Patient denies angina, edemarhypertension, palpitations, vascular problems, high blood " •pressure, heart problems, Pulmonary Fibrosis, Congestive Heart Failure, Coronary Artery Disease, high-cholesterol, and Peripheral Vascular Diseas4Respiratory: Pedant denies cough, shortnesi of breath, spntam production, wheezing, Isms/breathingproblems, chronic obstruction pulmonary disease, restrictive lung disease, pulmonary hypertension,sareoidosis, dyspnea, asthma, chest pain and brimehitb.GI: Patient denies abdominal pain, bleeding,.bowel changes, dyspepsia, gastrohnestinal problems,peptic ulcer disease, diverticulitis, hepatitis C, OERD, irritable bowel syndrome, neurogenic bladderproblem and colitis.GU: Patient denies dysuria, frequency, hematuria, incontinence and nocturia.Heme/Lymplu Patient denies anemia, easy bruising, excessive bleeding, Iymphadenopathy, deep veinthrombosis and Hyperkalemia.Rheu: Patient denies neck pain, mid-back pain, bilateral hip pain, bilateral knee pain, bilateral anklepain, bilateral foot pain, bilateral shoulder pain, bilateral elbow pain, bilateral wrist pain and bilateral •hand pantEndocrine: Patient denies hormonal abnormalities, polydipsia, polyurla, diabetes, hypothyroidism,callulitis and colon cancer.Neuro/Psycln Patient denies mood changes, paralysis, syncope, depression,•cerebrovascular accident,hemiplegia, dizziness. cerebral palsy, mental retardation, traumatic brain injury, multiple sclerosis,headaches, psychiatric problems, neurological problems, A.D.D. and.sleep apnea.Integumentary: Patient denies pruritus, rashes, skin eruptions, infection and shingles.
° 0
•41 .9
PHYSICAL EXAM:Vital Signs:Upright BP —120/80 mmHg G.,•..
....... - : a. a. .. ay* ::. 0000,00
0
60 cr0
0•000•
Pulse =80 bpm. Patie.nt is afebrile .•.•.. •• G.
: ... : . .. .
. • . .. .. .. .
BUNT: Nonnocephalic, Atraumatic. EOM are Intact.Generals Well nourished. Well dressed. Not in acute distress.Rasp —15
•00.0 G
•110;
e
0
Chest: Clear to auscultation bilaterally. No wheezing, no tales, no rhoncht .0 tl
CV: There is a regular rate and rhythm, Nonnal S1-S2. . ... a
Alb& The abdomen is soft. Non-tender. Non-distended. Normal bowel soundanre present.Necks No paraspinal tenderness noted. Full range ofmotion.Miditek: No paraspinal tenderness noted. Full range'of motion.LowIleks L3-IA, L4-L5 and L5-S1 paraspinal tenderness noted. Limited range of motion flexion andextension of the lumbar spine,ID:rirem: There is no clubbing, cyanosis, edema, erythema and cellelitis.RUE: 5/5 muscle strength. No contractures. Full range of motion.LIM: 5/5 muscle strength. No contractures. Pull range Of motion.RLE: 3/5 muscle strength. Limited range of motion.LLE; 3/5 muscle strength. Limited range of motion, •Skin: No scars, rashes, lesions, ulcerations in the head, neck trunk, RUE, LUE, RLE, LLE.Lymph: Palpation of lymph nodes in neck, ascillae and groin is normal.Newer, ORIENTATION: Alert & oriented x3. The patient understood command well. Attention spanand concentration were normal. Remote and Recent memory were normal. There is no deficits in cranialnerves I — XII. MOOD & AFFECT: No depression, no anxiety, no agitation. TESTCOORDINATION/GAIT:Normal coordination. Abnormal gait. EXAM OF DTR: Normal 2+ HUE.Reflexes are normal to the upper extremities. EXAM OF SENSATION: Decreased to light touch andpinprick in the lower extremities.
2 on
01 6
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
20120312000 2640awns .
Jason Glacatone10/10/11.
ASSESSMENT:
1. Lowerhack pain2. .LuMbOsacral rmliculopathy3. Gait disorder
PLAN:
1. Continue physical therapy2. Follow-up in one month
Michael Garbulskyt RPA-c
IJK/CARMMG0001/814428417401989000000
o
*Devoe
0000
e 0s
00000
006 a 0
0100
•000a
0oDO vv
•
0 •000000
0 •00 c
0600
a 0000900
000
0 00
000000
00 00
a00000
0000
o
00
000000
00000
30f3
0147
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
I ULU ...lett{ • J.& • S&P/G•• t• ZioCiaLlIalJololett•201...93120002 63 9
Doctor's !Nitiiiive ReportState of New York - Workers' Compensation Beard
THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO-NOT MAIL
This form may be usedlo report the firsttime you treated the patient or to report continuing services. .(To report permanentImpairment, use Form C-4.3.) Use this form anh( N attaching a detailed narrative report. Please answer all questionscompletely and submit promptly to the Board, the Insurance carrier and to the patient's attorney or licensed representative,
if he/she has one; if not send a copy to the patient. Failure to do so may delay the payment Of necessary treatment,
prevent the tlrnety payment of wage loss benefits to the Injured worker, create the necessity for testimony, and jeopardize
your Board authorization.
A. Patient's Information
1. Last Name: Giaealcno. First Name: 744134
2. Social Security #:11.0.11111S 3. Home Phone #: 7107538953
4. WCB Case # ((f known): 09317929
Mailing Address: 72 Bay 49th Street
oky: Brooklyn
5. Carrier Case # of known): CSP000005824
State: NY
Una 2
NARR.
Zip Code: 11214 Country:
7. Date of injury/onset of illness:fi/19/2006 6. Date of birth:J1978 9. Gender: }dale
10, On the date of Injoyfiliness what was the patient's job title or description: •unknown
0
11. On the date of Injury/illness what were the patient's usual work activates:
unknown
• • 0
12. Is the patient working now? Yes
S. Employer Information
1. Employer when injury occurred:
Company/Agency Name: program Development
2. Employer Phone #: 7182562212
3. Employer Address: seis New Utreht Avenue
13. Patient's Account #: 028820wo
Line 2:
• •• •
•
0 0
0 •
sea
e
0 0• •• • •
•
gra a•a•
ad
• •
• •
• . •0•00
0 •
••••
V •• •
• 0
0 0 0 0
CRY: Brooklyn State: ay Zip Code: 3.1zo9 Country:
C. Doctors Information
1, Your Last Name: Krsizaan FIrsti4ame: xssa° Ml:
2. WCB Authorization #: 206647-0B 3. WCB Rating Code: m
41 Federal Tax 'Gm 201270006 The Tax ID # is the: Em
6. Office Address: PARS Medical se Line 2: 5223 9th Avenue
City: Brooklyn
6. Billing Group / Practice Name
state: NY Zlp Code: 11220. Country:
7. Billing Address: sns 9th Avenue
City; Brooklyn
8, office phone 8: um-ale-am
Line 2:
Statetwz Zip Code: 1122°
9. Billing phone ft
Country:
10. Treating Provider's NPI #: 1497825434 11, You are a: Physician
EC-4NARR (12-10) Page 1 of 2 THEWORKEREP COMPENSATION BOARD EMPLOYS AND SERVESPEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION
0 8
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
D. Billing Information
1.. Employers
2. Carrier Cade
3. Insurance
Gir JANESVILLE
Insurance carder:
#:
201203120002639 . .
0 0 12 2
emps bonen, BILLING
0
•
°° .•
.4
• •
Line
.
2:carrier's address: PO pox 5231
Country;State: WI Zlp Code:53547
4 Diagnosis or nature of disease or injury:
Enter 1CD9 Code: ICD9 Descriptor
1 724 .2 LUMBAGO .
2 724.4 THOR/LUMBOSACRLITURIT/RADIOULIT ThiS. .
3 781.2 ABNORMALITY Or GAIT
4
Relate ICD9 codes above to Diagnosis Code column by line.
Dates of Service
From To
Race
ofService
Leave
Blank.
UNTWC9 CodesProcedures 'Services or Supplies
CPTMCPCS Modified limner 2
Diagnosis
Code $ Charges
Days,Units COB
ap Code vAierewoke was rendered
11/7/2011 1i/7/2011 11 99213 12 6 4 . 07 1 11220
.
.
.
4.
*.o..•
10670
0 0a LI a
•• 00 ••••••aPO
0 0
+a a
0 *gra
0 Services were provided by a WCB preferred provider organization
E. Doctor's Opinion'
1. In your opinion, was the incident that the patient described
2. Are the patient's complaints consistent with hls/her history
3. Is the patient's history of the Injury/illness consistent with
4. What is the percentage (0-100%) of temporary Impairment?
This form Is signed under penalty of perjury.
Board Authorized Head, Care Provider.I Provided the services listed above
MOTORIZED SIGNATURE ON FILE WITH NEW YORK. WORKERS
(PPO).
the competent medical
of the injury/illness?
your objective findings?
80. Dot
Total Charge
64. 01
Amount Fla(Colier114
00000
d 0Only) :
Balance Due g(cell Use Ore• • • ••
cause of this injungillnessYrgi•
YoS
0 . . ..•
Yes
COMPENSATION BOARD]
Provider's Last Name:
Provider's Specialty:
First Name:
Board Authorized Health Care Provider:
Last Name: wredulum
Specialty: PHYSICAL MEDICINE/REHAB ILITATION
First Name:Isaac
Date: 11/15/2011
MI:
MI:
EPANAAR (12-10) Page 2 of 2
0149,
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
20120312000263900122•
HISTORY OF PRESENtIL NESS:
IsIdea!: Jason MeeImoOMN:Met 1117111
'Attending; Isaac J. Ktehrean, MD
The patient is-status post ury to the lower bac . He is currently taking Valium 10mg t.i.d. androxypodine 30mg q.4h-6h r pain. He is comp ining of lower back pain, lower extremity weakness.He is *MS post multiple series with hard e to lumbar spine. Patient states 10/10 pain scale.
CiiiEF COMPLAINT:
He is complaining of 'owes
EXAM:
back pain with to
SOCIAL HISTORY:•Alcohol: None
Tobacco: Patient is a non-mhoker.Drugs: None.
•Toxins: None.Work: Patient is non-cent: utory.Diet Patient is not on any 'cular diet.
FAMILY HISTORY:Non-contributory.
extremity weakness.
• 04 0 00
• •
• CI • ••
000000 0000•0 • •
•
0000
• 4
• DO•
0000 ▪ 0 •
O0 0
O
▪ °00•
MEDS;He is oturently taking Valium 10mg and rovcodkie 30mg q,4h-611.
ALLERGIES:No known allergies
PAST MEDICAL HISTORY}Non-contributory
SURGICAL 1.11STORY:He has had multiple surged:Is with hardware to hunbarspine.
REVIEW OF SYSTEMS:Constitutional: Patient de es any change in weight, fevers and Sweats. The patient denies any nausea,vomiting, diarrhea or dIploENMT: Patient denies any ar or nose problems; visual difficultly
11111011111 111111• Throat: Patient denies any troblems or swellinOnihe mouth, neodisorders. ma Gnaw. •
nnanooniumuoara: unin
oo
0 50
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Catena: Patient denies angipressure,' heart problems,cholesterol, and PeripheralRespiratory; Patient denies.problems, chronic obstructi
201203120002639001.22 - c`.
edema; hypertension, palpitations, vascular problems, high blooslonary Fibrosis, Cohgestive Heart R&M, CorOnartArtery Dimase, high-Quiet Disease.
ough, shortness of Oreath, sputum production, wheezing, lung/breathingpulmonary &war, restrictive lung disease, pulmonary hypertension,
sarcoidosjs, dyspnea, asthm chest pain and bron Janis.GI: Patient denies abdo ' pain, bleeding, bo 1 changes, dyspepsia, gastrointestinal problems,peptic ulcer disease, diverts000 litis, hepatitis C, 0 , irritable bowel syndrome, neurogealc bladderproblem and colitis.GU: Patient denies dysurla, qUency, hematuri incontinence and nocturia.Herne/Lymph; Patient dents anemia, easy bruis 8, excessive bleeding, tymphadenopatiry, deep veinthrombosis and Hyperkalem:Rhein Patient denies neck in, mid-back pain, b lateral hip pain, bilateral knee pain, bilateral anklepain, bilateral foot pain, bit shoulder pain, b sternt elbow pain, bilateral wrist pain and bilateralband pain.Endocrine: Patient denies onal abnormalitieir, polydipsia, polyuria, diabetes, hypothyroidism,. andcellulitis and coton career.Nairn/Psych: Patient dente mood changes, p ysis, syncoperdepression, cerebrovascular accident,hemiptegia, dizziness, cere palsy, mental let ation, traumatic brain injury, multiple sclerosis, ••headaches, psychiatric prob ms, neurological pr lens, A.D.D. and sleep apnea. •
Integumentary: Patient den es pruriiis, rashes,t in eruptions, infection andt,shingles. • •• • •
PHYSICAL EXAM;Vien3 Signs:Upright BP =120180 rnmaPulse 680 bpm. Patient is febrileRasp= l5
General: Well nourished.REENT: Nonnocephalic,Chest Clear to auscultationCV: There is a regular rateAbd: The abdomen is soft.'Neck: No paraspinal tendemIVIldlIde: No paraspinal tendLowBcle L4-L5 paraspinalExtrom: There is no dubbinRUE: 5/5 muscle strength.LIJEt 5/5 muscle strength.RLE; Decreastd tn:usds
dressed. Not in Itetkite distress.matic. EOM are Watt.
ilaterally. No wheeling, no :ales, no rhonehl.d Myna Normal 51-52.on-tender. Non-distss noted. Full rangemess noted. Full rendemess noted. Dcyanosis, edema,o contractures. Fulla contractures. Fullagth. .Dei3reased
900400
00090
0000
•o o°>00
0
• 000040.
0 •
OW (60
Ci
00000 Of 0000
0 0 • 0 • •
0000 0 0
0 0 •
900060
ed. Normal bowel sounds are present.f motion.ge of motion.creased range of motion,
a and cellulltis.grit emotion. "
ange of motion. • .ge of motion. SLR IS orgrees forWard llwri.on with
weakness. . . . .Decreased muscle .3 ngth. Deaf: aged range of Mellon: SLR 45; destccifOrwarstflexiSvith
innleast •Ste: No acgal rashes, Iv.sio s, nlierations in thettied, :leek trim's, MT! ;LDE,E12, LLE.Lypiphygelpationof*.h. pdes it -.2v.elt; wallet and &cm is norn:4. •Ilie.te.ORIENTATION; Au,' to othinled x3, The patient anderstood•Orn..-4414 Well. Attenein spanand toncentraticm were no • 1: Remote end Receistmemori were normal. There is no deficits in cranialnerves, I — XII, MOOD Ita ECT: No depremion„ no °satiety, no agitation. TEST.COORDINATION/GAIT: smal coordination. Abnormal gait. EXAM OF DTR: Normal 2+ BUEand BLE. Reflexes• are no. to the lower extremities and decreased to the upper extremities. EXAMOF SENSATIOJ Normal t light touch and pinpiick. Normal vibration.
090000
2 of3
0151
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
•
0_,Mbanari
1. Lower back2. Status post multipkt
FLAN
.1. • Physical therapy- 2. Home exercise progr3, Continue Valium and4. Follow-up in one mon
201203120002 639
• i
it
i
erica to lumbar spitt
1xycodine
UK/CARlike16000U814435612483i39
660000
0000
0 •
w •••004.
0•0 •
c•
▪ • 0o 0 0•
• •• 04
• • 0 0 0
O 00• • 0
,,.o
• 0
a moo
a tv•a 0.000
OD •O 0 •• 09
3c;3
01 2
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
201203120019010
Submitted: 2/6/2011 Last Resubmitted: ;#1%*2
Doctor's Narrative ReportState of New York- Workers' Compensation Board
THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL.
Tha form may be used to report the firstdme you treated the patient or to report continuing services. (To report permanentImpairment, use Fenn C-43.) Ude this form only if attaching a detailed nerraliveTeport. Please answer all questionscompletely and submit promptly to the Board, the !neurones carrier and to the patients attorney or licensed representative,If he/she has one; If not send a copy to the patient Failure to do so may delay the payment of necessary treatment,prevent the timely payment of wage loss benefits to the Injured worker, create the necessity for testimony, and jeopardizeyour Board auttarlzsAon.
A. Patients Information
1. Last Name: Giaaaione First Name: 0.ascmi
Z Social Security #11.1.11.1MS 3.'Home Phone ft 7197338033
4. WCB Case # (if known): 5. Carrier Case # (if known): C39990993924
g. mailing Address: 72 Bay 49th Street
City: Brooklyn
7. Date of injury/onset of Illness:dile/zoos
State: HY
Line
NARR
Zip Code 11211 Country:
8. Date of birtt‘11.3-978 9. Gender. Hale
10. On the date of Injury/Mess what was the patients job title or description:unknown
11. On the date of Injury/illness what were the patient's usual work activities:
unknown
12. Is the cadent working now? Yes
B. Employer Information
1. Employer when Injury occurred:
Company/Agency Name: Program Development
2. Employer Phone #: .7182562212
3. Employer Mamas: .69i6-14ew'Dtreht Avenue
City: Brooklyn State: By
C. Doctor's information
1. Your Last Name: KratZ111821
13. Patients Account #: 028820wo
2. WCB Authorization 4: 206647-013
4. Federal tax ID ft 201270006 The Tax ID # Is the: EIS
• tine 2:'
0.00
0000
0 •
4 0 0
00 00
0
O ea Oa
O 0
ia •
0
O 0 0 00 000
O 9 0 a 0 4 a
0400 0 o
00000
a ao 0
Zlp Code: 3.12o9 .
40
Country: 000000 0
First Name: Isgac MI:
3, WCB Rating Code: cm
5. Office Address: PARS Medical PC Line 2: 5223 9th Avenue
City: Brooklyn StatEDWE Zip Code: 11220 Country:
6. Billkig Group / Practice Name
7. Biding Address: 5223 9th Avenue
City: Brooklyn
8. pate phone t 201-1318-8627State: NY
10. Treating Provider's NPI #: 1497825634
Line 2:
Zip Code: 11220 County:
9. Billing phone #:
11. You are a: Physician
EC-4NARR (12-10) Page 1 of 2 INEWORKERS' COMPENSATION BOARD EMPLOYS AND SERVESPEOPLE N6&4 lABABILITIES %Meta DLSOWALLOTION
01 3:
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
_ . P
D. Billing Information
1. Employees
2. Carrier Code
3. Insurance
city: JANESVILLE
Insuranoe carder.
#:
201203120019010
Vif ‘44-
plia. mama BILLING
0
••
00
0
a " .,tSO
° ° ° 4°0
Line 2;carriers address: PO AOX 5231
83547 Country: State: WI zip Code:
4. Diagnosis or nature of disease or injury;
Enter ICD9 Code: ICD9 Descriptor
1 724.2 MBA=
2 724.4 THOR/LUMBOSACRL NURIT/RADICULIT ON8
3 781,2 ABNORMALITY OP GAIT '-.- . ...
4
Relate ICS codes above to Diagnosis Code column by One.
Dales o Service
From Ta
Rateof
ServiceLeaveElko*
Use WMCotsProteduree, Seethes er Suppilas
CPT/HCPCS Modifier 1 Modifier2DiagnosisCode S Chafgee
Days(Units COB
Zs Cade Meeservice was rendered
1/26/2012 1/26/2012 11 99213 12 64.07, 1 112202913
. .
Only)Iiehmeal)ueWager tiss Odd, ..0 . 00 60.400© Services were provided by a
E. Doctors Opinion
1. In your opinion, was the incident
2. Are the patients complaints
WCB preferred provider organization
that the patient described
consistent with hisfier Nstory
injury/illness consistent with
of temporary impairment?
of perjury.
Provider:listed abovePILE WITH NEW YORK YORKERS
(PPO).
the competent medical
of the injundillness?
your objective findings?
cl• 00,
Total Charge
64.01
Amara Paid(Caster Use
°°•a•°
0000
cause of thiscipjuryfillnessl
Yes moo. 0
0 ••
• 0 DO
In' 0 . •. . .0
° • a •000440 w
0400
.. .0 •
• • .
Yes_,4000.
3. Is the patient's history of the
4. What Is the percentage (0-100%)
This form is signed under penally
Board Authorized Health CareI Provided the servicesMOTORISED SIGNATURE ON COMPENSATION BOAR)]
Provider's Last Name:
Provider's Specialty:
First Name:
Board Authorized Health Care Provider:
Last Name: freirman First Name:Isaac
Specialty Date: PHYSICAL MEDICINE/REHABILITATION2/6/2012
EC-4NARR (1240) Page 2 of 2
MI:
MI:
4
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
8..0fficePhorie
Submitted: 11/15(.2011 Last Resubmitted: 11/16/2011
Doctor's fiStrative ReportState of New York - Workers' Compensation Board
THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL.
This form may be used to report the first time you treated the patient or to report continuing services. (To report permanent
Impairment, use Form C-4.3.) Use this form only W attaching a detailed narrative report Please answer all questions
oonpletely and submit promptly to the Board, the Insurance carrier and to the patient's attorney or licensed representative,
If he/she has one; if not send a copy to the patient. Failure to do so may delay the payment of necessary treatment,prevent the timely payment of wage loss benefits to the injured worker, create the necessity for testimony, and jeopardize
your Board authorization.
A. Patients Information
1. Last Name: Giaoalcne
2. Socks security •
4 WCB Case # (if known): 09317829
6. Mailing Address: 72 Bay 49th Street
City: Brooklyn
7. Date of Injury/onset of illness:6/19/mm
First Name: Jason
3. Home Phone*. 7187538953
MI:
NARR
5 Carrier Case # known): ose00000saza
State: 5Y
Line 2:
Zip Code: 11214 Country:
8. Date of birth: x1978 9. Gender; Main
10. On the date of infurytilltleis what was the patient's job title cal:description:• unknown.... . . _ .
.ft Gail Ihe•deifebf InjurytilineilWhafwere the patient's usual work aotIvItieSt:
12. is the patient worldng now? no . S. Patient's Account #: 028820wo •
B. Employer Information-
1. Employer when injury occurred:
Company/Agency Name: Program, Development
2. Employer Phone #:
3. Employer Address:
City: Brooklyn
7182562212
6916 Hew Utreht Avenue
C. Doctor's Information
1. Your Last Name: Kreitman
State: la
2. WCB Authorization #: 206647-tua
0.4moo0
6600
Line 2:
Zip Code: naea
0O 0 0OD 09
000000 0 00 00
9 O4 •
•
000006 6900
0 • • 0 0 0
001.41 0 0
0000o 00
00060ntntin60
.06.6
Colintry.00
O 6 0• oa
First Name: Issac MI:
3. WCB Rating Code: ohms
4. Federal Tax ID #: 201270°08 The Tax ID # is the: BIN
5. Office Address: PARR 14c4kaa2- 80
City: Brooklyn State: NY
',Inez 5223 9th Avenue
Zip Code: 11220 Country:
ti. BIiting:Group / Practice Name
7. Biliing Addrese? •'. 'tine 2: . .
• Gay:- tfrooldyil State: NY Zip Cede:11220 country: • ,
9. Billing phone #: • • •
10. Treating Providers NP1 1497825434 11. You are a: Physician
EcsINARR (12-10 Pagel oft THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVESPEOPLE WITH DISABILBIESINITHOUT DISCRIMINATION 0155
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
D. Billing Information
1. Employers insurance carrier:
2. Carrier Code #:
P kt
DMA MEDICAL BILLING
3. Insurance carrier's address:ONESVILLE
DO BOX 5231 Line 2:
4. Diagnosis or nature of disease or Injury:
Enter ICD9 Code: 1CD9 Descriptor
724.2 LUMBAGO1
2
3
4
State: la Zip Code: 53547 Country:
724.4 TroaftAnmosacat annumArtsnoune mos
781..2 ABNORMALITY OP GAIT
Relate IC09 codes above to Diagnosis Code column by line.•
Oates of Scarce
From To
Mace•of
SearlesLeaveBlank
Use IA/CBCodasProcedures Services or Supplies
CPT/HCPCS Modified Morrifier2DiagnosisCode
.
$ Charges
..
Days/Units COB
.
Zp Code itkeresorsioe was rendered
11/8/2011 11/8/2011 11 99213 12 64.07 1 11220
•
•
•
nne
In Services were provided by a WCB preferred provider organization 02130).
Total Charge
54.07
Amount Paid `•(Cartier Use Only) a
ci• ii0*
Nance Due(Cartier Use Only)
0
• ° • t. •
E. Doctor's Opinion 000000
0000
1. In your opinion, was the incident that the patient described the competent medical cause of thkInjurVfillneWstes
2. Are the patients complaints consistent with his/her history of the InjuryAllness? Yes
3. Is the .patients history of the injulyAliness consistent with yomr objectivefindings? Yes
4. What Is the percentage (0-100%)-of temporary Impairment? 80`°091
This form is signed under penalty of perjury.
Board Authorized Health Care Provider:I Provided the services listed above
MOTORIZED SIGNATURE ON PILE WITH NEW YORK WORRERS COMPENSATION BOARD]
00000
0
10
0 0
06000
•
• 00
0 •000•0
•000ri
DO 00 0 0
0 ••
Provider's Last Name: First Name: MI:
Provider's Specialty:
Board Authorized Health Care Provider:
Last Name: iireizman Flit Name:Issao MI:
Specialty: PHYSICAL MEDICINE/REHABILITATION
EC-4NARR (12-10) Page 2 of 2
Date: 11/15/2011
0156
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Inaw ,. Health SystemsINTERNATIONAL
RX
NAME: NCA Comp
14 LaFayette Square
Suite 700
Buffalo, NY 14203
Attn:Steven Gidwitz
CRISP Trust
First Date ofEll Service RX#
DescriptionNDC CodeDrug TypePharmacy Name
Pharmacy ID
INVOICE FEt
INV
INV
NAME: JASON GIACALO
CLAIM It W000024420
CARDHOLDER ID: 1706
ADJUSTER: Sherri Cich
DUE UPON RECEIPT
PLEASE INCLUDE INVOICE NUMBER WITH YOUR PAYMENT
DaysQty. Supply
Prescribing M.D.Physician I.D.DAW
Billed ByPharmacy (ifpaper claim)
1/26/2012 113087 OXYCODONE HCL 30 MG TABLET 180 30 KREIZMAN
00228287911 1497825434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LLC
1154568400
1/26/2012 113088 DIAZEPAM 16 MG TABLET 90 30 KREIZMAN
00603321521 1497825434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LLC
1154560400
o ea
O 0 • 0
0 )0 0
a
$0.00
$0,00
TOTAL AMOUNT DU
Amounts denoted by v
PRE NEGOTIATED RA1
ease a 0 0090
• •
o
0 0 0
0 0 0
• • 0 0
0 9
00
0 °Mc0
a •
PLEASE REMIT PAYMENT TO:
• 0 000 0 Health Systems International• 0 0 0
0 0P.O. Box 881, Indianapolis, IN 46206-0881
05 866.895.2021 Toll Free • 666.701.2781 Fax..•• 0 000 0 [email protected]
0157
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
..V,Sin,rtion' W4A
Claim Number.Claimant:Provider Tax ID:Provider Ref
Region: 04
Community Residence Savings Plan (CRISP) 2900
W000024420GIACALONE, JASON PPO ID:201270006 Vendor 201270006-0001 NPI Number:
Geo Zip: 11220 WCB Case Number:
ISSAC KRSZMAN5223 9TH AVEBROOKLYN, NY 11220
Prodess Date: 01/24,2012Control Number 4894269
FOR Page 1 of 1Rev/Aud: DM/DM
ExtemalReview Procura
ICD-DX1: 724.2 LumbagoICD-DX2: 724.4 Lumbosacral neuritis NOSICD-DX3: 781.2 Abnormality of gait
,pc)8JuoTeMMifa:#11igiag ''' Ac.8803110.984.98fic"'MPICigitr,914rde RPRIL12/0112011 11 99213 OFFICE OUTPT EST 1 64.07 0.00 24.07
TOTALS:
TOTAL RECOMMENDED ALLOWANCE:
#13:041t. 600!..eRarrliet'fff.,;H.
0.00 40.00
64.07 060 24.01 0.00 40.00
40.00
PPO REDUCTION: Procura/MagnaCare - For questions regarding Network Discounts, please call: (877) 461-3750.
Unless otherwise stated, reimbursement is made according to The Official New York Workers' Compensation Medical Fee Schedule. Reimbursement fortreatment rendered by out-or-stale providers is made based on the prevailing Workers' Compensation state fee schedule for the providers geographical area.Any reduction is due to the billed charges exceeding the lee schedule allowance for the service provided and/or the application of the appropriate discountsbased on the individual providers agreement with the preferred provider organization. ni 58
" Workers Compensation "
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
PLI1911.-Lett. .1.4f .L.D1 al.L.L.203.201090015487
Doctor's Narrative ReportState of New York- Workeits' Compensation Board
THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL.
This fon may be used to report the first time you treated the patient or to report continuing services. (To report permanentImpairment, use Form C-43.) Use this form onlv if attaching a detailed narrative report Please answer all questionscompletely and submit promptlyto the Board, the insurance carder and to the Patient's attorney or licensed representative,if he/she has one; if not send a copy to the patient Failure to do so may delay the payment of necessary treatment,prevent the timely payment of wage loss benefits to the injured worker, create the necessity for testimony, and jeopardizeyour Board authorization.
A. Patient's Information
1. Last Name: Giacal®e First Name: Jason
2. Social Security #: 3. Horne Phone ik 7197538953
4 WCB Case # (lf known): 00626057
6 Mailing Address: 72 Bay 49th Street
5. Carrier Case # or known): CSP000005824
City: Brooklyn
7. Date of injury/onset of illness:3/19/2006
Line 2:
-4NA RR
M1
rip Code: 11214 Country:
8. Date of birth 9. Gender: Male
10. On the date of injury/Illness what was the patient's Job title or description:unknown
11. On the date of irliwyrdlness what were the patient's usual work activities:
pt injured his back while at work
800
00 0 0•o o
12.1s the patient woridng now? Yes
B. Employer Infommtion
1. Employer when Injury occurred:
Company/Agency Name: Programs Development
2. Employer Phone #: 7182562212
13. Patients Account #: oesseoiro
Employer Address: 6916 New Utreht Avenue Une
••
D 0 lee
•00000900000 o O O
• 0nee
a e 000 0 0000• 0 0 0 0 o
00 D •
a • •0
•nannsn 0 •
0000
00 0▪ o •O se
City: Brooklyn _ State: ay Country:ZIP Code: 11209
C. Doctors information
1. Your Last Name: Icreizman First Name: Isaac M I:
2. WCB Authorization It: 206647-0B 3. WCB Rating Code: CUBA
4. FederarTax ID #: 201270005 The Tax ID # is the: en
5. Office Address: PARS kfediezal Pc Line 2: 5223 9th Avenue.
City: Brooklyn state: Ni Zlp code: 11220 Country:
6. Billing Group / Practice Name
7. BlMng Address:, 5223 9th Avenue Line 2:
City: Brooklyn
8. office phone it .201-818-8627State:8Y Zip Code: 11220
9. Billing phone tk
Country:
10. Treating Provider's NPI #: 1497825434 11. You ate a: Physician
ge.4NARR (12-10 Page tof 2 THE WORKERS" COMPENSATION BOARD EMPLOYS AND SERVESPEOPLE NTH DISABILITIES W911010 DISCRIMINATION
0 9:
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
20120.1090915487
D. Billing Information
1. Employer's insurance carrier: ...pha WADICAL BILLING2. Carrier Code #:
3. Insurance carrier's address:
City: JANESVILLE
4. Diagnosis or nature of disease or injury:
Enter ICD9 Code: ICD9 Descriptor
724.2 • =MBA=
P-
PO 130X 5231 Line 2:
State: Tr Zip Code: 53547 COURW:
2 724.4 THOR/LUMBOSACRL NURIT/RADICULIT VNs
3 781.2
4
ABNORMALITY OP GAIT
Relate ICD9 codes above to Diagnosis Code column by line.
Nee of Sendce
From To
Place
ofSwim
LeaveBlank
Use WCS CodesProcedures, Services or Cupidles
CPT/HOPCS Modffier 1 triarMar2OlegoosisNo Sohn s
Days/Units COB
Ep Code vimsmite was pondered
11/1/2011 12/1/2011 11 99213 /2 64.07 1 112202913
44 1 leo°Lilt TO /Fr SCUFF)
*e_
1 A Lig 0000
AFVEUUIS1 IU PAY: 0000
PAID: 1/91,74 All000000
' . ..
0 Services were provided by a WCB preferred provider organization (PRO).
Thal Charge
64.07
PAniounfiVdPith° aka 01 i ),0
0 000
Balance Die° e*sitaraie r U 4 MU :0 0000
E. Doctors Opinion . 000000
0 •
1. In your opinion, was the incident that the patient described the competent medical cause of this Injury/illness? Yes00
2. Are the patient's complaints consistent with his/her history of the Injury/Illness? Yes
3. Is the patient's history of the Injuryfiliness consistent with your objective findings? Yes
4. What is the percentage (0-100%) of temporary Impairment? 100. 009
This form is signed under penalty of perjury.
Board Authorized Health Care Provider.I Provided the services listed above
[NOTORIZED SIGNATURE ON FILE WITH NEWYORKWORKERS COMPENSATION BOARD]
•00
*00009
Provider's Last Name:
Provider's Specialty:
Board Authorized Health Care Provider:
Last Name: Kreizman
Specialty: PHYSICAL MEDICINE/REHABILITATION
First Name: MI:
First Name:tat/ea . MI:
Date: 12/19/2011
EC-4NARR (12-10) Page 2 of 2
01 0
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
201201090015487
Patient: Jason Cacalone
ISM:Data: 12/I/IIAttending: Isaac 7. Ifselzman, MD
HISTORY OF PRESENT ILLNESS:
-- • The patient is status postwork-retated Ming to the lower back and lower extremities with-10/10 pain.He has. failed backayndtome. He is cuneutly takirig Valium Mink ti.d. and roxycodine q.4h180/30mg..-:The patient has had multiple surgeries with hardware to the lumbar spine.. .
CHIEF PONIPLARNIT;
The patient is complaining of 10/10 pain to the lower back.
• EXAM:
SOCIAL HISTORY:Alcohols NoneTobacco: Patient is a non-smoker.Drugs: None. •Toxins: None.
- Work: Patient is non-contributory.Diet: Patient is noton any particular diet
FAMILY HISTORY:Non-contributory.
COO
• 0 •
0000
0000000
000000
00 00
a a
0000
00 II
4 0000•0
090 0 00011
0 0 00
00 0 0
e•
'WEDS: 0 000000
0
The patient is currently taking Valium 10mg ad. androxycodine q.4h180/30mg. •••4
ALLERGIES:No known allergies
tivormanastortinNon-contributory
SURGICAL HISTORY:The patient has had multiple surgeries with hardware to the lumbar spine.
DO 0
i? 0 00 •O
REVIEW OF SYSTEMS:Constitutional: Patient denies any change in weight, fevers and sweats. The patient denies any nausea,vomiting, diarrhea or diplopia.EN M1': Patient cloning any ear or nose problems, visual difficulties, ear abnormalities, and brain tumor.Throat: Patientdenies any problems or rivalling in the mouth, neck problesns or swelling and throatdisorders.
MIUMMI I of 3
01
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
201201090015487
Jason ritacatme12/1/11
Cardin: Patient denies angina, edema, hypertension, palpitations, vascular problems, high bloodpressure, heart problems, Pulmonary Fibrosis, Congestive Heart Failure, Coronary Artery Disease, high..cholesterol, and Peripheral Vascular Disease.Respiratory: Patient denies cough, shortness of breath, sputum production, wheezing, lung/breathingproblems, chronic obstruction pulmonary disease, restdotive lung disease, pulmonary hypertension,sarcoiclosis, dyspnea, asthma, chest pain and bronchitis.GI: Patient denies abdominal pain, bleeding, bowel changes, dyspepsia, gastrointestinal problems,peptic ulcer disease, diverticulitis, hepatitis C., GEED, irritable bowel syndrome, neurogerdc bladderproblem and colitis. •GU: Patient denies dysuria, frequency, hematuria, incontinence and noeturia.Heme/Lymph: Patient denies anemia, easy bruising, excessive bleeding, lymphadenopathy, deep veinthrombosis and Hyperkalemla:ItheuiPidentrienies nedlg pain; midAreick pitikbilaterithip pain, bilateral knee pain, bilateral anklepain; bilateral foot P11111.; bilateral-shoulder Pain; bilateral elbow pain, bilateral wrist piin and bilateral
Endocrine; Patient denies hormonal abrionnalitiee, polydipsia, polyuria, diabetes, hypothyroidism,Celluthis and colon dancer.Neuro/Psych: Patient denies mood changes, paralysis, syncope, depression, cerebrovasoular accident,herniplegia, (tininess, cerebral palsy, mental retardation, traumatic thaininjusy, multiple sclerosis,headaches, psychiatric problems, neurological problems, A.D.D. and sleep apnea. •Integumentary: Patient denies pruritus, rashes, skin eruptions, infection and shingles.
PHYSICAL EXAM:VitaiSigns: 006000
0
•000
Upright BP 4120/80 mmHg -4I 0 GO
0 OD.
Pulse 80 bent. Patient is afabrile 0 GCMG
keSP6 15 0110:0
0 0
General: Well nourished. Well dressed. Not in acute distress. •
0/0•0
0.•"00 0
BRENT: Nommeephalici Atraumatic. EOM are intact •000
00 la 4
Chest: Clear to auscultation bilaterally. No wheezing, no tales, no rhonc•hi. ..; ..° °
CV: There is a regular rate and rhythm. NOrnral 31-82. 04,0000 a
000
Abd: The abdomen is soft. Non-tender. Non-distended. Normal bowel sounds are pm"'Neck: No paraspinal tenderness noted. Full range of motion.Wrack: No paraspinal tenderness noted. Full range of modem.LowBela Bilateral L4-L5 and L5-81 paraspizial tenderness noted. Decreased range of motion.Estrum There is no clubbing, cyanosis, edema, erythema and carding.
' xu1i3/ nMeseTe BrerigIENo contractrierreltrange of mot—gn7 * •LITE: 5/5 'tinkle strength. No contractures. Full range of motion. '
• RLE: 3/5 muscle strength. Decreased range emotion.LLE: 3/5 muscle strength. Decreased nurse of motion.Skin: No scars, rashes, lesions, ulcerations in the head, neck trunk, RUE, 1,13E, RLE, LLE.Lymph: Palpation of lymph nodes In neck, a:dllee and groin is normal.Nauru: ORIENTATION: Alert & oriented x3. The patient understood command welL Attention spanand concentration were normal. Remote and Recent memory were normal. There is no deficits in cranialnerves 1—MI. MOOD & AFFECT: No depression, no anxiety, no agitation. TESTCOORDINATION/GAIT: Normal coordination. Abnormal gait. EXAM OF DTR: Normal 2+ BUE.Reflexes are normal to the upper-extremities. EXAM OF SENSATION: Norma to light touch andpinprick. Normal vibration.
00
000
°0000° •
2 of3
012
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
2 012 010 90 0154 87
Jason Olsoolono12/1/11
ASSESSMENT:
1. Lower backpain2. Lower extrpmity pain3. Failed back syndrome
PLAN.
1. Physical therapycontinue medication
3. Follow-up in one month
heap S. Krelzman, MD
1Vlichael Garbrdsky, RPA-C
LTIC/CA13MM00001/8144335182706290000
0000
o 0
000000
9
0000o
0 o
00000
00 0o 000
• 000 00
0000000 0
0000•0 0
000904.1 • o 00
000009 • 0 00000
0000
00 9,0
o 00
3 of 3
01
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
-5-
Re: Jason Giacalone
Exam: February 22, 2012
STATE OF NEW YORK—WORKERS' COMPENSATION BOARD 80075
PRACTITIONER'S REPORT OF INDEPENDENT MEDICAL EXAMINATIONA copy of each wort of Independent Medical MedullaeIlan shell ba submitted on the same day and In the same mannerto the Woikent Compensenon Board, the insurance carrier or self-Insured employer, the claimant's attending physician orother attending pradItionsr, the ristmanTa representative, If any, and the dolma
CHECK ONE: I J PHYSICIAN 1_1 PODIATRIST i _I CHIROPRACTOR I I PSYCHOLOGISTTHIS EXAMINATION WAS REQUESTED BY: I a I CARRIEFUEMPLOYER 1_1 CLAIMANT
WCB Case No. Carder Case No. Of Known) Date al injury Injured Person's SRN Date of Examlnallon
00(128087 W300024420 6119/2000 22212012
INJUREDPERSON Jason Glawtone
72 Day 49111 SI2nd FloorBrooklyn, NY 11214
EMPLOYER WWI= Revel
INSURANCECARRIER NCAC.omp, INC
14 Lafayette S0 STE 700Buffalo, NY 14203
IF EXAMINER CONDUCTED THIS EXAMINATION AS AN EMPLOYEE OR UNDER CONTRACT WITH AN IMECOMPANY, STATE NAME AND WORKERS COMPENSATION BOARD REGISTRATION NUMBER OF IMECOMPANY.
UAW's, P.C. Flentstrallon 11010133
Results of Exam na on (continue on reveres or attach addIllonal s eels, If necessary)
SEE ATTACHED NARRATIVE REPORT"
. CO: Vvadmteammosilon Ppont..PQ Box WM ilingkirnkill.EY,1359?:.02.0.5_ .Jason GlacisloneArlOo0/1011210 & Goethe Esq., e Street, Staten Island NY loam-Immo Kreitman, MD., 522311th Omar NY 11220
I hereby canny that thle report la a full end truthful rapresondandltIon.
J0theY NL Pail*, M.D.Practitioner's Nome Pracffilonefe Ski
of my profsaalonel opinion irAth respect to the clainicinis
Oslo
Brooklyn, NY 11229 1138191.70Prectillonarla Address IME Authorization No.
rio PRACTITIONER DAWNING OR EVALUATING A CLAIMANT UNOWI THE WOIUNWITI COUPENEATION TAW OR ANY OPERVIBWO AUTHORITYOR PROPRIETOR NOR mountica CARRIER OR MUM KW CAUSE DIRECT OR ENCOURAGER REPORT MOE SUBMITTED AS EVIDENCE INWORWAT COMPENSATION CLAN ADJUDICATION WHICH DEFERS NOIYANISALIN MOM TEE PROFESSIONAL ormaN OF TEE PAWNINGPRACTITIONER. SUCH PM ACTION MALL FIE CONSIDERED WITHIN THE DAUSDICTION OF THE WORKERS' CONPENIATION FRAUD INSPECTORGENERALNID /WEE REFERREDAS A FRAUDULENT PRACTICE
IME-4 (3.01) .a•••
••••0
0 0
se 0,0......
•
Oil 00
00•O
0
ail, a
• 4 0 •
0 •006
0 014
•••0
0 •
9.100
• •
a 0ad 0
• •
00000. .00•
......•
ae•O••••••
0164
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
JEFFREY PASSICK, M.D., F.A.A.O.S.DIPLOMATE AMERICAN BOARD OF ORTHOPEDIC SURGERY
2269 Ocean Avenue Tel. # 718-287-4200Brooklyn, NY 11229 Fax # 718-287-4225
February 22, 2012
UniMex, P.C.PO Box 760Old Bridge, NJ 08857
RE: Giacalone, JasonWCB #: 0062 6057Carrier Case No.: W000024420UniMex No.: 60975DOI: June 19, 2006Employer: Program PevelCarrier: NCA Comp, Inc.Request Type: Workers' Compensation IME
To Whom It May Concern:
As per your request, l performed an independent orthopedic re-examination onthe above-claimant on February 22, 2012 in my Brooklyn, New York office. Theclaimant presented valid photo identification, which was witnessed and copied.
My findings of the examination are as follows:
HISTORY:
Mr. Giacalone states that he was involved in a work related accident on June19, 2006. He explains that he injured his back while lifting an air conditioner Theclaimant sustained reported injuries to the lower back with radiation to thWreftleg. There was no loss of consciousness. Mr. Giacalone did not seek emerOendytreatment for his injuries. •
The claimant was prescribed medication, physical therapy, chirotIcaciiseexeand acupuncture. Mr. Giacalone started receiving therapy,.;:rightfollowing the accident. He states that he did not improve.;&erall. withtreatment. He explains that his "pain never goes away". He is no longerreceiving therapy. Mr. Giacalone states that he was provided with mediEal•aback brace, a massager, a bone stimulator unit, a back corset and a TENS unit.
......
0165
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
-2-Re: Jason GlacatoneExam: February 22, 2012
Mr. Giacalone reports that he underwent surgery to the back on 11/6/09 and2/10/10.
REVIEW OF MEDICAL RECORDS:
• Evaluation reports from Brooklyn Premier Orthopedics. P.C. dated 8/18/10to 10/12/10.
• Doctor's initial report from Sanjeev Agarwal, M.D. dated 9/16/10.• Evaluation reports from Suny Downstate Medical Center dated 9/16/10 to
11/18/10.• Doctor's progress reports from Sanjeev Agarwal, M.D. dated 11/18/10 to8/1 6/11.
• Doctor's narrative reports from Isaac Kreizman dated 12/16/10 to 12/1/11.• Evaluation report from Pain 8, Rehabilitation Services, P.C. dated 12/16/10
to 12/1/11.• Orthopedic IME report from Julio V. Westerband, M.D. dated 10/3/11.• Orthopedic IME reports from Jeffrey Passick, M.D. dated 10/14/09 to
7/28/10.
PAST MEDICAL HISTORY:
Past medical history, as reported by the claimant, is negative.
The claimant denied being involved in any prior motor vehicle or workers'compensation accidents or sustaining any prior injuries.
SURGICAL HISTORY:
Surgical history, as reported by the claimant, is significant for surgery to the leftknee in 2000.
MEDICATION:
The claimant is taking Oxycodone, Prevacid and Valium at this time.J
00 •0
EMPLOYMENT HISTORY: a0000
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The claimant was employed full-time as a maintenance worker When the-1C/We c• •,.
19, 2006 accident occurred. He reports that he missed 1 1/2 yearrfrom work •.
following the accident. He explains that he returned to work for f 'day anct wogs, -•O00
let go from his job. He is not currently working.a 0 0a 0a
CHIEF COMPLAINTS:
This individual states that he feels pain in the lower back and left leg.
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0166
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
-3-Re: Jason GiacaloneExam: February 22, 2012
Mr. Giacalone rates his pain today to be a 10 on a scale of 0 to 10 (10 being theworst). He took Oxycodone prior to today's physical examination appointment,which helped to reduce his pain "a little". He describes his pain to be sharp,stabbing and nagging in quality. He reports a radiation of pain down the leftleg. He is able to walk 1 to 2 city blocks without experiencing too much pain.He reports having difficulty climbing stairs. He cannot sit without experiencingpain. Pain is worsened by "everything".
PHYSICAL EXAMINATION:
The claimant is a 34-year-old male who stands 5' 8" tall and weighs 190 lbs. Hehas brown eyes and dark brown hair. The claimant stated being right-handdominant.
The claimant was examined with the examining room door left ajar. He wasasked to inform me as lo any pain or tenderness during the examination.
EXAMINATION OF THE LUMBAR SPINE: Healed, post-operative scarring wasobserved over the lower back. Examination of the lumbar spine revealed noparaspinal spasms to palpation. There was moderate bilateral paraspinaltenderness to light touch. Neurological examination of the lower extremitiesdemonstrated muscle testing to be +5/5 throughout. Sensory responses wereintact throughout the lower extremities. Patellar and Achilles reflexes were +2and equal bilaterally. Atrophy of the intrinsic muscles was absent. The claimantwas unable to perform the straight leg raising test. The claimant was unable towalk on heels and toes. There was increased pain with the Valsalva maneuver.
LUMBAR SPINE
RANGE OF MOTION NORMAL CLAIMANTFLEXION 90° 10°EXTENSION 300 10°RIGHT LATERAL BENDING 30° 10°LEFT LATERAL BENDING 30° 10°
DIAGNOSIS: The claiman presents with a diagnosis of:
1. Failed back syndrome, S/P lumbar spine fusion.
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The diagnosis, as documented, is based upon the claimant's description orrlsigaccident and the physical examination, taking into account both the subjetiki.complaints and the objective findings.
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
-4-Re: Jason GiacaloneExam: February 22, 2012
DISCUSSION:
There has been no change in the claimant's condition since the last evaluationperformed by me. The claimant did not have stimulation due to theconfiguration of hardware in his back. He complains of lower back pain into theleft leg. There is no bowel or bladder dysfunction. Valsalva maneuver causedincreased pain. He is unable to perform his activities of daily livingindependently.
TREATMENT:
Maximum medical improvement from physical therapy has been obtained. Theinjury is not at MMI.
DISABILITY:
There is objective evidence upon re-examination to support total ( 1 00%)orthopedic disability. Mr. Giacalone is unable to work at this point.
My examination and report are in accordance with the New York StateGuidelines for Determining Permanent Impaimient and Loss of Wage Earning
Capacity, January 2012.
I, Jeffrey Passick, being a Diplomate of the American Board of OrthopaedicSurgery, am duly licensed to practice medicine in the State of New York. I&firm, under the penalties of perjury, that the information contained within this
document was prepared and is the work product of the undersigned, and istrue to the best of my knowledge and information.
With reasonable notice, I am available to testify, by appointment, should theneed arise.
Sincerely,
Jeffrey Passick, M.D., F.A.A.O.S.Diplomate of American Board ofOrthopedic SurgeryLicense: # 166191, NY
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
Re: Jason Giacalone
Exam: February 22, 2012
DOWNSTATE CENTRALIZED MAILING(for NowYorkCIN,Harantoadh StelaOffba EEtcon Square
Pinball MTh) Building BublingPOSoi'2007 Brooldyabill 112024017 10080a:1m mere St 205 Main Sheet 130 Main SI. W.NYC0100A77-1373111arop.(8613)01. Menands BINGHAMTON Stla400 ROCHESTER 035.0uneaSi.S354Matrp,(1161)08143541Pook(800) MANY 12241 13201 Bultdo, NY 14514 SYRACUSE 13203
740-0552 (9613)750.5167 (806) 0023504 14203 (056) 211-0444 010318024730State of New Tod(
WORKERS' COMPENSATION BOARD SOWNPRACTITIONER'S REPORT OF REQUEST FOR INFORMATIONIRESPONSE TO REQUEST
REGARDING INDEPENDENT MEDICAL EXAMINATION1.PRAOT1IONEWSRAME AND AODRESSJeffrey M. Pater* MA2269 OceanAvelbooldm. NY 1123J. PRACTIPON5111 IME MRHORIZATION N0.140101.7B O. CLAIMANTS WCJason Glacolusa
atameNNAOORESSOPPARTY REQUESTING INFORMATIONUMMAP.C.P.O.Ilm
Oft.N.1 000574. INE ENTITY REGISTRATION NO. (napkin')010133
7, MACAWS CASE NO.00020057
& MATE OF MAY(V1012000
5. DATE OF IME2/2212012
9. DATE OF THIS REPORT
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
UniMex, P.C. P.O. Box 760, Old Bridge, Ni 08857
Phone 800-524-5585 • Fax 732-679-1676Email: [email protected]
2/3/2012Jeffrey M. Passick, M.D.2269 Ocean AveBrooklyn, NY 11229
Claim Type: WCBCarrier: NCAComp, INCClaimant: Jason Giacalone0/0/6: slavaClient Elle #: W000024420UniMex File it-. 60975Dale of Accident: 6/19/2006Employer: Program PevelAppointment #:WCB File ft: 0062 6057
Dear Doctor:
LOCATION: In your office, at the above address.
DATE: 2/22/2012 (Wednesday) TIME: 02:45 PM
Report to be received within 7 days of exam so as to be billable.
PLEASE ADDRESS THE FOLLOWING:
> Degree of Disability - [None-0%, Mild-25%, Moderate-50%, Marked-75%, or Total-100%?)...BESPECIFIC.> Diagnosis - Current diagnosis?> MMI - Has Maximum Medical Improvement been obtained?> Restrictions on RTW Please list all restrictions/limitations in regards to returning to work.
> Return to Work - If the claimant has not yet returned to work, please estimate a probable return
date. If the claimant cannot to his normal job, can he perform a lesser function?
APPOINTMENTS CAN BE RESCHEDULED ONLY BY CONTACTING UniMex PRIOR TO 48
end
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HOURS OF EXAMINATION DATE! ° ° °0000
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Should the claimant fail to keep this appointment kindly notify us promptly.000
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Sincerely, 0000e
UniMex Medical Exams
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FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
UniMex, P.C.P.O. Box 760, Old Bridge, NJ 08857
Phone 800-524-5585 • Fax 732-679-1676Email: [email protected]
CC: Workers Compensation Board, PO Box 5205, Binghamton NY 13902-5205NCAComp, INC, 14 Lafayette SC) STE 700, Buffalo NY 14203Jason Ciscolone, 72 Bay 49th St, 2nd Floor, Brooklyn NY 11214Attorney: Anguili Katkin & Gentile Esq., 60 Bay Street, Staten Island NY 10301-TP: Ism Kreizman. MD., 5223 9th Ave, Brooklyn NY 11220
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0171
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
at, Health °. :'lltsuftneEa.0 0
FEDEISystemsINTEnNATIONAL a • 0 o
0 000 a INVOlt
RX INVOI(
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NAME: NCA Comp0
0 0
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e00 NAME: JASON GIACALONE
14 LaFayette Square0 0
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0 o o• • 0 0 CLAIM #: W000024420
Suite 7000 000 000 t, • Gee
CARDHOLDER ID: 1706778
Buffalo, NY 14203
Attn:Steven Gidwitze 0
,000eeoo a to
ADJUSTER: Sherri Clch
CRISP Trust 0 000due uPogi SFCEIPTPLEASE INCLUDE INVOICE NUMBER WITH YOUR PAYMENT
DescriptionNDC Cade
First Date of Dwg Type Days Prescribing M.D.
Flll Service RX# Pharmacy Name Qty, Supply Physician ID.Pharmacy ID DAW
Billed ByPharmacy (Ifpaper claim) Fe
12129/2011 0112578 DIAZEPAM 10 MG TABLET 90 30 KREIZMAN
00603321521 1497825434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LL
1154568400
2/2912011 0112579 OXYCODONE HCL 30 MG TABLET 180 30 KREIZMAN
52152021602 1497825434
Generic No Product Selection Indicated
GOOD DAY PHARMACY LL
1154588400
50.00
50.00
TOTAL. AMOUNT DUE:
Amounts denoted by Ir al
PRE NEGOTIATED RATE
AIPLEASE REMIT PAYMENT TO:
Health Systems InternationalP.O. Box 8131: Indianapolis, IN 46206-08811366.895.2021 Toll Free • 866.701.2781 Fax
Email: nceus-hsl.com
0172s
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
UniMex, Exam Request Form
client:Nen comp Date of Request0 ? / 0 97 / e Address: J,cl* sch_Sie mo Cityft 1E111/0 State AN Zip /14,203 Signature: a e r-t` fts Cir h Tel#: -I lit -84 a - W-15 Ext 145
Exam Type: WCB Rif NO FAULT 0 LIAB 0 DISABILITY 0 OTHER 0
Claim# 0000 r ii a 6 claimant Jason 6ickaii ri n..e . DOA: Address 12 Priii q q th SI- ) 2nd FL-Wat#: City Srerlii4 h State A/1 Zip nail/ Employer Telephone # 1 I 3- lr-g- 8 14 3% DOBSS#
-r)( Spec JerFr(9 aISSiCIL
ialists
3 Cardiologist
El Chiropractor
0 Dentistry
O Dermatologist
❑ General Surgeon
O Internist
Attorney n9iuiii fyin 4.6-eyi /it°Address 40City Mi. WarTelephone # 7 g
Sit! cxms_____zip 1196
O Neurologist
O Ophthalmologist Treating Physician /53Ct C rr- Pi riryj n
O Orthopedists Address 590 3 cith Fiveo Plastic Surgeon CityerangnState
O Psychiatrist Telephone # 1 D Other
Zip 0990
Diagnosis
O Causal Relationship
‘15.,Degree of Disability
O Need for Treatment
O Need for Surgery
-.134leturn to Work
❑ X-Rays
Issues To Be Addressed
O Apportionment
O M&S 15-8
❑ Schedule Loss
O Classification
Restrictions on RTW
Non-Invasive Tests Au
❑ Other 0 None
Specific Instructions
P.O. Box 760, Old Bridge, NJ 08857 Phone#: 800-524-5585Fax#: 732-679-1676Email: [email protected] 0173
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017
teeliTEIE PM&ipe
GIitOUP p E
Name of Individual
Submitting Print
Request:
Claim #:
Date Submitted:
Preferred Method of
Delivery:
Claim Image print request form
cn
Matthew Banks
W000024420
3/24/11
0 E-mail* (please enter email
address in address line 1)® CDEj Paper
Standard cover letter will be ID Document needs
utilized unless otherwise special cover letter
indicated: which is attached
All dales will be included unless otherwise indicated:
Special Instructions:
Phone Number:
Claimant Name:
Due Date:
Deliver To
(Name):
*Address l:
Address 2:
City:
State:
Zip:
Limit Date From:
1/1/09
fir
315-251-6237
Jason Giacolone
3/31/11
Matthew Banks
5789 Widewaters Pkwy
Dewitt, NY
NY
13214
To: present
Include all log notes? ❑ YES (log notes can not be limited —all will be copied)
Please check items you need to be sent.
0 ENTIRE IMAGE FILE
IS1 BILLING
MEDB I LLS
o EXPENSES
❑ PAYMS
ID CREDITS
❑ CORRESP
0 OUTGOING
❑ SVCPROV
[3 LEGAL
El ICA
❑ INJURED
0 CLAIMANT
1: BROKER
❑ INSURED
0 HOCLAIMS
El REINS
0 BUREAU
❑ CLOSING
El OTHER
❑ CORRESP
123 INCOMING
MEDRTP
❑ SVCPROV
El LEGAL
❑ ATTORNEY
0 SUMMONS
0 ICA
0 INJURED
CI CLAIMANT
0 BROKER
0 INSURED
❑ HOCLAIMS
0 REINS
0 SOCSEC
0 BUREAU
0 CLOSING
❑ OTHER
❑ FIRSTRPT
❑ INTERNAL
El INSTRUCT
0 REPORTS
ID 30 DAY❑ 6MONTH
0 SPCLSTAT
❑ INCRDCHG
0 OTHER
❑ CORRESP
❑ MEMO
0 COV ERAGR
0 INVSTGTN
0 PMAPOLICY
0 OTHCARR
❑ POLICIE
0 AGREEMN
0 CLMINVST
❑ SITEVENU
0 OTHER
Date Completed:0174
FILED: KINGS COUNTY CLERK 03/20/2017 11:55 AM INDEX NO. 502135/2012
NYSCEF DOC. NO. 74 RECEIVED NYSCEF: 03/20/2017