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


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



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

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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

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201201090015487

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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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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

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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


1154568400

7/9/2012 116341 CARISOPRODOL 350 MG TABLET 60 30 KREIZMAN SOAP

62756044602 1497B25434

Generic No Product Selection Indicated


1154568400

71912012 116342. DIAZEPAM 10 MG TABLET 90 30 KREIZMAN 'sop00603321521 1497825434

Swede No Product Selection Militated


1154568400

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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



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


CLAIM #:: W000024420


PHARMACY: GOOD DAY PHARMACY LL

PHARMACY ID: 1154568400

ADJUSTER: Sherri Cich

DUE UPON RECEIPT


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

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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

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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


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


GOOD DAY PHARMACY LL

1154568400

12/112011 0112009 DIAZEPAM 10 MG TABLET 90 30 KREIZMAN

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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


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



1154568400

1012512012 118620 DIAZEPAM 10 MG TABLET 90 30 ISAAC KREIZMAN

00172392760 1497825434



1154568400

1012512012 118621 OXYCODONE HCL 30 MG TABLET 120 30 ISAAC KREIZMAN

00603499221 1497825434



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Emall: [email protected]

$0.00

50.00

5060

TOTAL AMOUNT DUE:

Amounts denoted by 1r etPRE NEGOTIATED RATE

0010



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

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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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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



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'



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



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



r201109060016814

.4°. '41:94;44..n• v. • sc • .4c .. • 00.092

sUROICANE OF EN0LEW0011111r9

ANESTHESIA RECORD DATE /IV; a9

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OtIT rip' SDP el •

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00 8



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:


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 *



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



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



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



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



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



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


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



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



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



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



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



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

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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

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0030



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)

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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

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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

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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



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NAME: NCA Comp NAME: JASON GIACALONE

14 LaFayette Square CLAIM#: W000024420

Suite 700 CARDHOLDER D: 170677848

Buffalo, NY 14203 ADJUSTER: Sherrie etch


CRISP Trust

RX#

DescriptionNDC Code

Dnig TypePharmacy Name

Pharmacy 10

DUE UPON RECEIPT


Presaibing M. D.Days Physician t.D.

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9/27/2012 117956 OXYCODONE HCL 30 MG TABLET 120 30 KREIZMAN $0.00 5141.47 5136.35 55.12

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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


FOR Pai of 1,Rev/Auct: Sti/DM

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ICD-0X1: V58.69 Long-term use meds -NEC

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'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

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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

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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)



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



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


INVOICE FEDEJ

INV011

INVOR

-NAME, - -JASON GlAeAltONE

CLAIM #s W000024420 1

CARDHOLDER ID' 1706778

ADJUSTER Sherrie Clch

DUE UPON RECEIPT


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


150 30 KREIZMAN

1497825434


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 ••••

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1497825434


It• t./• •• al

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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

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Nealth Systems1 NA I

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INVOICE FEDEF

INVOK

INVOIC


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


Prescribing M O.

Qty. Supply DAW

Ph.ysiela n LO.

Billed ByPharmacy (Itpaper claim) Fer

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TOTAL AMOUNT DUE:

Amounts denoled by "0- an !

PRE NEGOTIATED RATE -


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%

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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



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

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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



Claim Number.Claimant:Provider Tax ID:Provider Ref:

Region: 04


VV000024420GIACALONE, JASON PPO ID:201270006 Vendor 201270006-0001 NPI Number:


ISSAC KREIZMAN5223 9TH AVEBROOKLYN, NY 11220

Process Date: 12232011Control Number: 4893816



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 *



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


1. Your Last Name: icre-imaa

2. WCB Authorization #: 206647-0B

Line 2:

State: NY Zlp Code: 11209 CEILDtry:

4. Federal:Tax 10#: 201270E06


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



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



ZV.L1.LUZU0UU0 I f

•

:• •

00032

•

Patlenti Jason OlsealontDOB:SSN:Date: VIVOAttending: hue J. Krakow, MI)


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.




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.

9 I)

0

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•

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•40050



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

o 00 a

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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



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


CLAIM #: W000024420



DUE UPON RECEIPT


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


1154568400

10/10/2011 0110933 DIAZEPAM 10 MG TABLET

00603321521

Generic


1154568400

•0

•

180 30

90 30

• 0 0 0

tit 0 9 0

• 0 • ••eia•• •

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KREIZMAN

1497825434


KREIZMAN

1497825434

No Product Selection indicated

•


• • • • • •Heallti Systems InternationalP.O.tx 881, Indianapolis, IN 46206-0881

. • s86q.856.2021 Toll Free • 866.701.2781 Fax• . Email: rx Mus-hsi.com

$0.00

50.00

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

O FEE SCHEDSONC

. NI TO PAY: No,g6

$7.68

told'

0053.



• •

D. Billing

1. EMPleffelit

2. Carrier

a insuranceCity: JAH;SVILLE

- '

Infom

Insurance carrier:

Code Ift

'11.201204230001644 .

' toe 3e: • .• .

ma bergaa. sr ante '1,

.

•

- 4I .n

Line

t

2: .

-carrier's address:- r 10-BCOt .231-

,,53A47 . . Country; 1 -

1

.•

• State! id . Zip Code:- '

4. Diagnosis or nature of disease or injury:i I

. 'Enter 1CD9 Code: icp9 Descriptor "

t .1 724e2 ' LUSHASO ,. . . . .

i 2 724.4 - THOR/LUMB02ACMINWIP/RADICULIT.Uki. . .. •

3 7e3.2 • AHNOLOALITY. or GAI2 - • .J. .. . .. .

4 . L.. .

. .. ..RetatelCD9 codes above to Diagnosis Code column by line. ' .

Dales °M ervin

From To

Placeof

SweatLeaveBlank

oraliakodesProsedure

Vs, &aka or Suppiles

CPTIHCPCS MAW 1 Mothler2MagmaCode 5Chirps

. . .

MP,Unib CO9

.. . .

*cob sternsea* essmoderad

9/13/2141. . .

9i13/2011 11 99213. .

-.

12 t4.07'

1 11220. .. . . . , .. . .

•. .

' .

,. . .. .. . .

.. . - . . .

...• .

.'

. . .•

• - •••..

•

0 Swims were provided by a WC139aderred pnailder organization

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.

'

(PPO);

-

the competent medical

of the InitnyAliness?

your objective tint:Onus?

too, oos

ToWthalp

Scr

Arnaud PM 'll(ceder Useatyle

000000

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•

ar Usean .

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cause of throgifty/illriselMrs!0 0

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0

MG

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COMPENSATION BOARD)

Provider's Last Name: First Name

Provider's Specialty!

Board Authorized Health Care Provider.

Last Name: scresaPan Fust Name: Yisan Mt '

Sped*: PHYSICAL MED/CINWHEHAHILITATION Mac 10/3/2011

'EC-4NARK (1240) Page 2 Of 2

MI:



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011/1118\'')• ire,k-• etez -02-.c

20 204230001644• .00138 ' •

Jam OlsonloneDOMSitDate: 08/13111attending: Isaac I. KJ-cling% bib

HISTORY ói PRESENTILLNESS:

t

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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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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General: Well nourished. Well dressed. Not in acute distress. 0 a

0FfEENT: Norinocephalic, Atrausitatio. EOM are Intel 000060

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.Chests Clear to auscultation bllaterally. No wheezing, no tales, no rhonchi. ? . .9 000 !

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CV; There is a regelar nate and rhythm. Normal SI-S2. 0000 0

Abdi 71 he abdomen is soil. Non-tender, Nap-distended Normal bowel !owls we p4serit.. co • CO

Nett Ectarnasinal tenderness noted, Frill range of modon. . 1Midllekr No Farah:pine' tenderness noted. Full range of motion. . :°. 9

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• Erx,:rEskl.4-L5pusispinatiendercfss Dowd, -Limited range Of modork...• . ' , .4. ,...V-••e,-..”4irjsne is no

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45.11ts. . f,nitlick strength.: NopinfOna4 RIS re:twee so,okon. ' t.. ' •• : -• . • ... • • • •7,1•111i..1.14 mita& st.:r:?"19.14? Totitnetnres. PUO rfmge•ofmhtinr..,. .

• ;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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ASOFSIMENTE

Lower back pain .2. LoivpFciftretnity.pahiI. /Riled back surgery, upidurtils and pain procedures

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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


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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



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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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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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



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



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: °°°°"

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. .

• The claimant moves his head, neck, body freely during unguarded a ••

a. : ..• The claimant is unable to sit. ° a

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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.

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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



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. :"."")

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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*

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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.

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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.

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0067



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

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For how long?.

• •

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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:

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tD„NO If so. whoa at was the =WY? (3DECAIIIR

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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

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/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

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n 201112020009167

MOW Jana Mac:doneDOtte •instDates 10/10/11Atlending Isaac J. Katmai', MD

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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.




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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,.::

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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; • °

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PHYSICAL EXAM: ••°o•° *

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Upright BP = 120/80mning 0 0 S 00 000

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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



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



Claim Number:Claimant:Provider Tax ID:Provider Ref:

Region:04


W000024420GIACALONE. JASON PPO ID:201270006 Vendor 201270006-0001 NPI Number:

Geo Zip: 11220 WC E3 Case Number


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 '



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.


1. Last Name' Glacalane First Name: Jason

2. Social Security #: INS 3. Home Phone 7187538959

4. WCB Case # (if known):


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


1. Employer when Injury occurred:

Company/Agency Name. Program Development

2. Employer Phone #. 7182562212

a Employer Address;

City:


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




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


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%


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:



Last Name: Kreitman First Name: issac MI:

Specialty: PHYSICAL MEDICINE/REHABILITATION Date: 7/2/2012

EC-4NARR (12-10) Page 2 of 2 0075



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


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


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


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




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:


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.


MOTORIZED SIGNATURE ON FILE WITH NEW YORE WORKERS COMPENSATION BOARD]

Provideei Last Name:


First Name:

a


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



t? Health SystemsINTERNA TIONAL

RX

INVOICE FEDE1

INVOlt

INVOK


14 LaFayette Square CLAIM 4: W000024420


Buffalo, NY 14203 ADJUSTER: Sherri Clch

Atln:Steven Gidwitz

CRISP TrustDUE UPON RECEIPT


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


00603321521 1497825434



1154568400

W13/2011 0110348 OXYCODONE HCL 30 MG TABLET 180 30 KREIZMAN

52152021502 1497825434



1154568400

OK TO FEE SCREC57.

IMOUNT TO PO

PAID: 130C11 Vta-'


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



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



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



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.


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



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


1. Your Last Name: End-man

Line 2:

0010

0

00

State: kw Zip Code: 112 09 Country:


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:


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




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


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.


[NOTnoviED SIGNATURE ON FILE WITH NEW YORH names COMPENSATION BOARD]

0.

01,090

• • •

Provider's Last Name; First Name: MI;

Providers Specialty:


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!



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


MPS;He is currently taking Vali


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



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

• •

.

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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.



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

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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 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


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


1. Your Last Name: Icri2thaan

• 0

13. Patient's Account #: 028820wa Ovaa

1 0a$5 00000 e °0

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?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




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


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



MOTORISED SIGNATURE ON FILE WITH NEW YORK WORKERS COMPENSATION BOARD]

4 • 0

00

a.

000000

0

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ProVidets Last Name: First Name: MI:



Last Name: frroizow First Name: issao MI:

Specialty: PHYSICAL MEDICINE/REHABILITATION Data: 2/6/2012

EC-4NARR 02-10) Page 2 of 2

007



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.


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:


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.


Company/Agency Name: program Development

2. Employer Phone #:21.82562212

a EmPloYer Address: 6916 Neu Utreht Avenue

City: Brooklyn State: Hy


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

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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


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



, 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



724.2 liUMBAG01

2 724.4 THORMUMBOSACRL NURIT/RADICULIT UNS

3 781.2

Line 2:


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•°"


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:



Last Name: Kreitman First Name:Issas MI:

Specialty: PHYSICAL litiltertM/RzEIABILITAinott Date: litie/zon

EC-AWARR (12-10) Page 2 of 2

0089



, O

I IW-•tit(

PA S


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.



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



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.

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CV: There is a regular rate and rhythm. Normal S1-57. .

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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



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

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CLAIM ft: W000024420

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ADJUSTER: Sherrie Cich

First Date ofPR Service RX4

PLEASE INCLUDE

DescriptionROC Code

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6/11/2017 115/91 DIAZEPAM 10 MG TABLET atl 30 KREZMAN 50.00

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8/1172012 115792 CARISOPRODOL 350 MG TABLET 60 30 KREIZMAN $0 00

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krb6 ,SeiteeiDeS6riPliSini

08/18/2011 11 99213 OFFICE OUTFT EST

TOTALS:

TOTAL RECOMMENDED ALLOWANCE;

Process Date. 11/10/2011Control Number: 4892929


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


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 •



Patient: Jason G taeatone-DOB:

SSN:Date: February 21,2012Attending: Isaae1 KreiZnion, MD


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.



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



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



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

00 0

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IBUCARSSL0001/81441021138061600

00000 0000000

0 • 00

0000

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3 or3 0098



Claim Number.Claimant:Provider Tax ID:Provider Ref:


VV000024420GIACALONE, JASON PPO/OSR ID:113630760 Vendor: 113630760-0001 NPI Number:

Geo Zip: 11214 WCB Case Number

Process Date: 12/05/2012Control Number 4898286


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.


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



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 -


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 .

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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

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4, DATE OF CURRENT: 4 ILLNESS (First symptom) ORMM : DO t YY INJURY (Accident) OR

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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


ISAAC KREIZMAN MD

V810

17b. NPI 1497825434

In. HOSPITALIZATION eRlIES 9lIELATED 12 CURIIENTgRyipate . aMM , DO YY

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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

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D. PROCEDURES. SERVICES. OR SUPPLIEStExpla.n Unusual Circumstances)

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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


1857 86TH STREET


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



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]



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

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00000 ••00.0 0 0 :•

0

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0 0 • 0 •

0000 • a00000• 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



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

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SEX

FIN

b. AUTO ACCIDENT? PLACE (Ewe)

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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

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1A, DATE 068UIRREW? AI I II

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16, DATES riVIENtONALER WORK IIINVOTT ODC0CLAO1941, ,),uu 1

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18. HOSPITAI ALMIZATION

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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

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CPTIHCPCS 1 MODIFIER

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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


1857 86TH STREETYEE ATIL 11 /1 411 OR

33. BILLING PROVIDER INFO 8 PH a C718)) 232-1515


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



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



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

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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



oh,c Health SystemsINTERNATIONAL

RX

NAME: NCA Comp

14 LaFayette Square

Suite 700

Buffalo, NY 14203

CRISP Trust

INVOICE FEVEI

INVOI

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CLAIM th W000024420


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

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816/2012 116887 OXYCODONE HCL SO MG TABLET 159 30 KREIZMAN $0.00

52162021502 1497825434


G000 DAY PHARMACY LLC

1154568400

81612012 1168138 CARISOPRODOL 350 MG TABLET 90 3P KREIZMAN $0.00

62756044602 1497825434



1154568400

8/6/2012 116889 DIAZEPAM 10 MG. TABLET 90 3b KREIZMAN

00603321521 1497825434



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

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PLEASE REMIT PAYMENT TO.

Health Systems InternationalP.O. Box 881, Indianapolis. IN 46206-0881866 895.2021 Toll Free • 866.701.2761 Fax

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INVOICE FEDI

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NAME: NCA Comp NAME: JASON G1ACALON

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First Date ofFill Service RX#

DescriptionNOG Code

Drug TypePharmacy NamePharmacy 10

DUE UPON RECEIPT


Days Prescribing M.D. Billed By

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9/27/2012 117959 OXYCONTIN 40 MG TABLET

59011044010

Single Source Brand


1154568400

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4 8 e4 4.8

8-

60 30 KREIZMAN

1497825434

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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]

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TOTAL AMOUNT DUE

Amounts denoted by "O'l a

PRE NEGOTIATED RATE

0107



Clain) Number:

Claimant

Provider Tax ID:

Provider Ref

Regen,104


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


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

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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



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LENCO DIAGNOSTIC LABORATORY1857 867H STBROOKLYN NY 11214-3108

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: •

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❑ Other:

n The employer listed did not have insurance coverage with PMA onto the appropriate insurance carrier.

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Of f <4.;

Name and address of employer:

Date of injury:

Social Security number:

Claim Number shown in your records:

•}.:: To FEE SCHED. •

'MD:

PAY:

Your help in this matter is very much appreciated.

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JJENCO DIAGNOSTIC LABORATORY

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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

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CUTOFF-200BENZODIAZEPINE

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NEGATIVE

NEGATIVE

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NEGATIVE

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POSITIVE

POSITIVE

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(AI

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END OF REPORT.

uNKOOOLilOpoiztOOPmj1126/2012 6.16 PM!

Units Reference Range

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nglmt.

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FINAL COPY ACcesstonI 939 04 Pellent ID. 076038Lab Results For: GIACALONE , JASON

Lena Agranoty, M D,0116[la ry borato Oir or(



$

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


AMPHETAMINES

cuTorr=1000BARBITURATES

CUTOFF-200BENzoDIAZEPINE

CUTOFF=2ooCANNABINOMS

CUTOFE=50COCAINE METABOLITE

CUTOFF=300METHADONE

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ptfroFF=x9

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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

ng/mL

POSITIVE ng/mL

ng.mL


END OF REPORT.

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Reference Range

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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



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


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

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ng.mL


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




Gsim Number: W000024420Claimant: GIACALONE, JASON PPO ID:Provider Tax ID: 201270006 Vendor 201270006-0001 NPI Number:Provider Ref. Geo Zip: 11220 WCB Case Number:


Region" 04

P901'7: C9g litia 101'5(4 DectiptItin'..•12/2001 11 09213 OFFICE OUTPT EST15 1.000

TOTALS:


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'



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 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,


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


3, Employer Information


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



D. Billing

1. Employees

2 Carrier

3. Insurance' cat.

Information

Insurance carder.:

Code 9:

2012052500053.32

•

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.Line2: 'carrier's address:

JANESVILLE

.

20 BOX 5231

53542 Country:State: wx Zlp Code:



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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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?



kNOTORINEG SIGNATURE ON FILE WITH NEW YORK.WORKERS

(PPO


of the Injury/Illness?

your objective findings?

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Tole Charge

60. 07

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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

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EC-4 NAFtR (12-10) Page 2 of 2

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-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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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


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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0124



-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.

•

• • CO •

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0125



-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



-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.


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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0127



-5-

Re: Jason Giacalone


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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-8-

Re: Jason Glacelone


DOWNSFATE CENTRALIZED MINGthsr New Yorkab.HINDIQTD•1 State Olfte BEd *aro

Foetal Elfeekte) Mhz MegPO Do 21101 tircaldmt IN 11202501/ 100 Eiroakey 41Howley St 295Men Shut 130 Mato St W.NYC (100)07745Thlfemp(1156) 1361. Wends DENCIHAMTON butte 400 ROCHESTER 935 Armes SLDE4045YA(85010414354,0446) ALBANY 12241 13901 Buffalo, NY 114 SYRACUSE 13203

MOST dathIT750•5157 SR 11024551 14203 f6S6)45 MOW QM 602-3730

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

E NATE ANDADDRESS OP PARWITEdasrpre INFORMATIONthator, P.C.P13. ROOOld tiltdokNI 001117

3.PITACTRTONEi8 ime Atrocamore No.tonna

4. IME EN RENSTRATTONNO.01/mpthehte) 5. DATE OFTME010133 0412511012

IL ClADVdert NAND I 1. CIAINATITICAGE NO. 5. DATE OF MAYbeen Obtain I WIMP 051192005

9, DATE OF THIS REPORT

Platerant 10 Section AT of the Wodute' O'npem5Oen taw, 0 e predawn' who ha pedtimed orw10 he platenntn0 en Independent mediaeaternhteron uf e sorbet oampensalan chdment iscelves a mensal tor Informabn re0aidin5 the debut, Indsdhs thud or etedreMcdytranarrdtbed requests. the pratebirm not subtle aamy Hem request far Inftnestlmt le the Weiland Combiner*, Beard aterhs len days of the'testi el the mquosL In addles, settles of all IthltrOnSee to midi iambs Indetthig all SAS Tehlth em podded In response to the fewest&rhallmmdareedbYthersaprerrO Predakmar th tabard mIlit tenders& the etinthelan Hike ammo Is tie Mithesten .

lithe reveal for the Informstfon Ts Undted to a formett for scheduling of an Independent merRaltamettetIon, you seed not Mir oda form.However, you mast end a copy of Form IME4 relelmentb Notthe of tedependent feedlot ExemtnsUonl is the deenabed Werkom'Compensallen Board Office.

m OciaPlelD aeMamlrying Intennalion. Earns 11 shave.b. To 'pmt a flit complete Pam 10 Ordsm aff1a date and may to appropdate Compassebn Bernd Mild

Mice vdthr ten deye ofrecethlot moist A copyel the rast rrost be elached.a, Te mpart prechezinde Mom Co a Wand tor Monne*, conmrath Urn 11 bdow, Alt data and man lo appropriate Wontort

Compornedron Board esfActotbe %been ten days ot submbslon of mthome b the requester. A copy Hem roseate end 'emoted)*sent tothe mthrester MWthe ettedted,

d. tl the pradboner region& to the requester VIER ten den al The rambler the tetteest complete, sign end dem hens 10 pit 11 end •mall to te appmprItle Waled Compemesecin Board OEM Ors with ten (bye or recebt of stout Irsab œptea 11 meat and'spend *chat Obibeas, aulamt upends forms to mood request and yar response Mika the Ome Omits phin In th end tabaft

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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Jeffrey M. Pass?* htD•

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0129



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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0130



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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0131



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


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


GOOD DAY PHARMACY 'LC

1154568400

4/17/2012 114685 DIAZEPAM JO MG TABLET 90 30 KREIZMAN 50.00

00603321521 1497825434.



1164568400

4/17/2912 114687 OXYCODOPIE14CL 30 MG TABLET

52152021502

leo, _30, KREIZMAN

1497625434

so 6*



1154568400

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4 • lb • •. .• • • • • •PLEASE REMIT PAYMENT TO:.

•. Health %alma Internationalen. BB, BEM 011411panitolis; IN 46205-0881

• 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



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0133



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



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thisinvi,f0 tt-T;04,30,44,5i

Claim Number.ClaimantProvider Tax ID:Provider Ref:

Region: 04


W000024420GIACALONE, JASON PPO ID:

201270006 Vendor 201270006-0001 NPI Number:

Geo Zip: 11220 WCB Case Number.


Process Date: 03/22/2012



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


• ali T3 PAY. IBC thitillaRrht


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



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:


CLAIM a: VV000024420


ADJUSTER: Sherri Clch

DUE UPON RECEIPT


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


1154568400

3/2012012 114131 OXYCODONE FICL 30 MG TABLET

52152021502

Generic


1154588400

3/20/2012 4455389 CARISOPRODOL 350 MG TABLET

00603258221

Generic

t4AROLDS PHARMACY

• 699160239 - • . . • • •

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90 30 KREIZMAN

1497825434

No Product SelecUon Indicated

180 30 KREIZMAN

1497825434


60 30 KREIZMAN

BK5374474



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



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


Prescribing M.D.Dayshysic

Qty. Supply P DAWian I.D.

Billed ByPharmacy (ifpaper claim) re'


00603321521 1497825434



1154568400

212342012 113617 OXYCODONE HCL 30 MG TABLET 180 30 KREIZMAN

00228287911 1497825434



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



. 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.


1. Last Giaoalone

f9)4NARR

First Name: Jason MI:

2. Social Security #: 3. Home Phone #: 1181538953

4. VVCB Case # (ff known): 09311829


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:


unknown 0 0 0

• •• •

12. Is the patient working now? Yea. 13. Patient's Account #: 028820w3


1. Employer when•Injury occurred:

Company/Agency Name: proqrai Development


• • •

3. Employer Address: 991.6 New Utreht Avenue Line 2:

City: Brooklyn

00.7,114

•0 0•0••

• 14•

ea 41.• • 0 .000••• 0 e

the 0 0 •

• •00

PO 0

• •State: , NY Zip Code: 11299 Country:


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


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:


EG4NARR 02-10) Page 1 of 2


THE WORKERS' COMPENSATION BOARDEMPLOYSAn SERVESPEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION

01 8



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:


724.2 LUMBAGO1

2

3

4

724.4 THOR/LUMBOSACRL NURIT/RADICVLIT UPS


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.


(NOTORTZED SIGNATURE ON rim WITH NEW YORKVIC/MRS COMPENSATION BOARD]

• ODO AI p

a •

• 0 0 6




Last Name: Breiznan First Name:xvsaa MI:

specialty: PHYSICAL MEDICINEAUSHABILITATION Date: 9n/203.1

ECaThIARB (12-10) Page 2of 2

0139



20120312000264200125

Pathan Jason OinenioneDOB:SSN;Date: 8/16/11Attending: ham J, Kralawn, MD


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.

a0000

0 •

o

•0 •

•0

00.0 0

Diets Patient is not on any particular diet.0009

a •• 0•9• Ce • • •

FAMILY HISTORY: 0•00 0 •

a 0 •00000Non-contributory.

•

••• 0 •0

V O•00°

MEDS: 00

•

The patient is currently taking roxycodine, Soma and Valium. •42




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



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



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

90000

a •9 •

00 lie

000000

0000000•

000000

6.0

00

000000

L. 0 0

00000

O 00 •009o 0 C.

• 000 O 6

0 0 0000000

a 0 000909000000 0

0000

00 is

31)f 3 01 2



IUUM11..‘ISU.201203120002640

of f V X .wear AUDIALOWSLL=U

Doctor's Ntheitive ReportState of New York - Workers' Compensation Board


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

:11

Oda

Oo

12. Is the patent working now7 Yes



Company/Agency Name: Program Development


000000

13. Patients Account #: 029820uu4. •

00 00

0000• o

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:


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:


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


THE WORKERS' COMPENSATION BOARD storms MD SERVESPEOPLE WITH DISABILMES WTHOUT DISCRIMINATION

01 3



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


Enter ICD9 Code: (009 Descriptor

1 724.2 LUMBAGO

Line 2:


2 724.4.

3 781.2

4

THOR/LUMBOSACRL NURIT/NADIgGLIT DNS

ABNORMALITY OF GAIT


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:


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



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.



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



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



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



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



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.


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


S. Employer Information


Company/Agency Name: program Development


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


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




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


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?


Board Authorized Head, Care Provider.I Provided the services listed above

MOTORIZED SIGNATURE ON FILE WITH NEW YORK. WORKERS

(PPO).


of the injury/illness?


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]



First Name:


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,



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.


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.


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



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



•

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



201203120019010

Submitted: 2/6/2011 Last Resubmitted: ;#1%*2

Doctor's Narrative ReportState of New York- Workers' Compensation Board


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.


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


unknown

12. Is the cadent working now? Yes



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


Line 2:

Zip Code: 11220 County:

9. Billing phone #:


EC-4NARR (12-10) Page 1 of 2 INEWORKERS' COMPENSATION BOARD EMPLOYS AND SERVESPEOPLE N6&4 lABABILITIES %Meta DLSOWALLOTION

01 3:



_ . P


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;


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).


of the injundillness?


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)]



First Name:


Last Name: freirman First Name:Isaac

Specialty Date: PHYSICAL MEDICINE/REHABILITATION2/6/2012

EC-4NARR (1240) Page 2 of 2

MI:

MI:

4



8..0fficePhorie

Submitted: 11/15(.2011 Last Resubmitted: 11/16/2011

Doctor's fiStrative ReportState of New York - Workers' Compensation Board


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



1. Last Name: Giaoalcne

2. Socks security •

4 WCB Case # (if known): 09317829


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:


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-


Company/Agency Name: Program, Development

2. Employer Phone #:

3. Employer Address:

City: Brooklyn

7182562212

6916 Hew Utreht Avenue


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


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




1. Employers insurance carrier:

2. Carrier Code #:

P kt

DMA MEDICAL BILLING

3. Insurance carrier's address:ONESVILLE

DO BOX 5231 Line 2:


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



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 ••




Last Name: iireizman Flit Name:Issao MI:

Specialty: PHYSICAL MEDICINE/REHABILITATION


Date: 11/15/2011

0156



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


DUE UPON RECEIPT


DaysQty. Supply


Billed ByPharmacy (ifpaper claim)

1/26/2012 113087 OXYCODONE HCL 30 MG TABLET 180 30 KREIZMAN

00228287911 1497825434



1154568400


00603321521 1497825434



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 •


• 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



..V,Sin,rtion' W4A

Claim Number.Claimant:Provider Tax ID:Provider Ref

Region: 04


W000024420GIACALONE, JASON PPO ID:201270006 Vendor 201270006-0001 NPI Number:


ISSAC KRSZMAN5223 9TH AVEBROOKLYN, NY 11220

Prodess Date: 01/24,2012Control Number 4894269


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:


#13:041t. 600!..eRarrliet'fff.,;H.

0.00 40.00

64.07 060 24.01 0.00 40.00

40.00


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 "



PLI1911.-Lett. .1.4f .L.D1 al.L.L.203.201090015487

Doctor's Narrative ReportState of New York- Workeits' Compensation Board


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.


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


Company/Agency Name: Programs Development


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:


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

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20120.1090915487


1. Employer's insurance carrier: ...pha WADICAL BILLING2. Carrier Code #:

3. Insurance carrier's address:

City: JANESVILLE



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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


Board Authorized Health Care Provider.I Provided the services listed above

[NOTORIZED SIGNATURE ON FILE WITH NEWYORKWORKERS COMPENSATION BOARD]

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Last Name: Kreizman

Specialty: PHYSICAL MEDICINE/REHABILITATION

First Name: MI:

First Name:tat/ea . MI:

Date: 12/19/2011


01 0



201201090015487

Patient: Jason Cacalone

ISM:Data: 12/I/IIAttending: Isaac 7. Ifselzman, MD


-- • 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


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The patient is currently taking Valium 10mg ad. androxycodine q.4h180/30mg. •••4


tivormanastortinNon-contributory

SURGICAL HISTORY:The patient has had multiple surgeries with hardware to the lumbar spine.

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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.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



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

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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. •

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BRENT: Nommeephalici Atraumatic. EOM are intact •000

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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

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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.

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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

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-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

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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


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



-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

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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



-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".


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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-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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0168



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

POIMI0111 to tiOcan 137 of Mn Waking Compsnaellon Loa If a prazhTanm eta hu penned or WE bo potomtIng en Indopoodaal medicalenntallon of a waken' compeneolloa Manua recelvas a raped far tillOMUltir aorta the dalmont Malay fond or erectrantoallytrtunratad pouts, the preckonar sulattl d tan of the request tot [Anton to the Mint' Compansegon Bond Waft len dope of seittelpt of Sao mama Maddltbn, spine ad mapensas tont* requests Indudteg oularlida MU' MI plaided ha moons° to therequeotbratone sutettlad by ltarespateg predNonar tothe Board veinier' doye al ihosubadssion °Rho response to the paquester.

tithe request bran Intomiedonle kind to o ragout tor achadullag of en independent enthral mandoellon, you need not Ille this fonn.Novaya'', you must sea a carry of Toms isles celebrant's Rake of Independent Medical Exandnallorn to the designated Workers'Compilation tfondOittoo.Instmoliona

a. Complete an ident0fing infonnalko, Num 1-0 abase.b. TO I5Pa4e Nowt for information, corrode° nom 10 beam eign, dale and man to apptoprialo Viotinoss Contoonsollon Board distant

oalcovilThln ton days of receipt olrequat A copy of the lemunt muel to attached.a.- To moon punt= ta ampapsattanassmiktignangga oaNdebbam 11 beim, alga-dela encbmia loapproprlate Market. •

Canbensallon Band datrad 'Zoo within today* of aulansfon ol retpanso to to requaner. A topper the tooponseanda0 materialssent to tho motet/ mot be allachoi

d. O Oa bream maponda to oho mossier wIlldn ten days of the nvelpl al dm moven, complete, don and data Seen t0 gal 11 andMall to to WWI* Man' Componallon Booed fa olate velMe ten days id real of request with codes II moan' andtespoino candled. Otheavate, submit impends fens to report most end your response within to Mme Ocalli Oen In b. and e.above.

NOTE no piscalortare wow el meal endfor avant! compensetIon roods ba to Board manor the mast) pally le eabyed toappOcahlo tan teganOno mnadan0alayofaua4 Moats, Wading bn notarelted to Salton 110-a of to Wokart COmponsallon Ufa Sedanblotto Pablo Health Log andother nate and brand Iowa.KORA Rogan In ardor to adludkaaawadeitmnpomalmdalm,WCLuodlone 13o and 137 puma en employer amnia to have adolman ammlned by a late& cora prodder. Punstentio4S CM 012 sheath provIdar who has been Tanned by ea amployet Of al flai toevaluate evarkpfecololuryb exempt from H1PAAb nishkeen on 'Adana of hathtnformallon.

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EGMALEXAMNATI NEI Ka UlSotRINETIRCODINOTTEMOVAMIUMNIRIUTir

10. PRXIGRONERS REPORT °FREQUENT FOR INFORMATION RE i ' ' 'I G INDEPOIDENT51801CAL DAMNATION

Oita rawest letelvadMatted b aoopy of a inquest lot [Mannikin nwohad Inflame Moll

Jaffrey At Pankt MD,

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11. PRACRTIONEWS REPORT OF RESPONSE TO RECEESTEONINFO

One mama Salta reluastor

TION REGARDING INDEPENDENT MEDICAL EXARMATION i

Attechad Isotopy pimp response to a mount for kimealon In the casa I '

Jeffrey At Pomba, M.O.

above, end all may is a Mal bo Oa reauestu. ....a.

C9- — 22-1li-h --PrectbonataNarto Signature I Date .. n.

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0169



UniMex, P.C. P.O. Box 760, Old Bridge, Ni 08857


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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Should the claimant fail to keep this appointment kindly notify us promptly.000

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UniMex Medical Exams

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0170



UniMex, P.C.P.O. Box 760, Old Bridge, NJ 08857


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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at, Health °. :'lltsuftneEa.0 0

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NAME: NCA Comp0

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Suite 7000 000 000 t, • Gee


Buffalo, NY 14203

Attn:Steven Gidwitze 0

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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



1154568400

2/2912011 0112579 OXYCODONE HCL 30 MG TABLET 180 30 KREIZMAN

52152021602 1497825434



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



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



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



exhibit - judiciary of new york

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