Schoolcraft v. The City Of New York et al

Filing 312

FILING ERROR - DUPLICATE DOCKET ENTRY - DECLARATION of NATHANIEL B. SMITH in Support re: 305 MOTION for Summary Judgment .. Document filed by Adrian Schoolcraft. (Attachments: # 1 Exhibit Part 1)(Smith, Nathaniel) Modified on 12/24/2014 (db).

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PLAINTIFF'S MOTION EXHIBIT 27 Part 1 THE_ JAMAICA HOSPITAL INFORMATION IN THIS RECORD IS CONFIDENTIAL DO NOT REMOVE FROM HOSPITAL IMPORTANT 1. lnformaUon in this record may not be released without approval of Medical Record Depar1ment 2. Medical Records must be available at all times. Do not leave In Drawers, Cabinets, etc. 3. Return Medical Records prompUy to Medical Record Department ~ m z --i ~ m ALLERGIC TO "' ~ "'"' "' "'"' "'"' "' ~ "' ~~ ~ ..,. c.> "' .... 0 QQ 0 00 0 CD CD 0 0 """' 0 0 r.n rb JHMC 1 -- --- ---------------- Patient Fact Sheet Name and Address Employer SCHOOLCRAFT, ADRIAN UNKNOWN 82 60 88 PL NY RIDGEWOOD Phone: 11385 M (718)570-6224 Sex: 469-97-6997 Marital Status w Religion: NO BirthDate: 6/21/1975 Occupation: SSNo: Race: Phone: (999)999-9999 s Patlenfs Maiden Name: Nearest Relative Admission Data I Account Number I SCHOOLCRAFT. SELF NY RIDGEWOOD Home Phone: LUnit Number I II 130381874 82 6088 PL I Admit Date I 11385 Rei: 09 (718)570-6224 ; 1298984 IAdmit Time I IER MD I I 11/1/2009 ITriage Time I Business Phone: 8:54 I-BERNIE~ !Prim Care MDI -1 l NA J -Emergency Contact Guarantor SCHOOLCRAFT SCHOOLCRAFT, ADRIAN 82 60 88 PL I NY RIDGEWOOD Home Phone 11385 Home Phone: (718)570-6224 Business Phone Rei: (71 8)570-6224 Rei: 01 Business Phone: 01 SS: 999-99-9999 Occ: UNKNOWN Employer Insurance lnfonnation Ins: AETNA US HEALTHCARE i Policy Number: BBM6PBBA Insured: Group Number: SCHOOLCRAFT, ADRIAN US008041 009001 Rei: SELF/ PO BOX 981109 EL PASO Phone Number Auth Number TX ( 800)451-8843 799981109 FIN 19 PENDING ' !· I. JHMC2 Patient Name SCHOOLCRAFT, ADRIAN Account Number 129 8984 Medical Record No. 130381874 Dale 11/1/2009 Jamaica Hospital Medical Center ID 130381874 Emergency Department Record KTA History of Present Illness 34 Year Old Male Patient Presents wilh Paranoid. see psychiatric assessment.. Review of Systems (Symploms and Signs not co..ered in the HPI) GU Neuro ENT Resp Musculoskeletal HematologiciLymphatiC Skin Psych Heart Gl Endocrine Allerglcllmmun ologic Constitutional Sxs Eyes 0 0 QAII other ROS negative 0 Vital SignsfTriage/Nursing Notes Reviewed and Agree -- 0 Past Medical History O Hx unobtainable due lo Tx urgency or poor hislorian(s) No .Relevant PMHx Additionallnfonmalion from Police, Ambulance, Nursing Home or Relatives 0 Asthma QCOPD 0CAD 0 Other PMHx Diabetes 0HTN 0 0 0 Social History 1;21 No Relevant SoHx OETOH Family History 1;21 No Relevant FmHx INo SignifiCant FMHx Physical Exam Exam Time l Drugs Smoking 0 Cancer Psychiatric Additional Sx 0 I 0 Renal CHF 0 Old Medical Records Re'Jiewed QCVA Seizures -- I I I General Appearance HEENT Chest Abdomen I GU Extremities Neuro Skin Back INeck . Lymphatics --- JHMC3 Patient Name SCHOOLCRAFT, ADRIAN Account Number Medical Record No. 130381874 Date 1298984 111112009 Diagnostics Sped men Cdlecled I ECG _Rad OrderBd MD Initials Time Diagnostic Ordered Result Reviewed Result Interpretation Bv KTA 11/1/2009 12:59 Urinalysis Status-Cancelled- Patient Discharged KTA 111112009 12:59 Urine Tox Status-Cancelled- Autocancel by LIS-not coli/rev KTA 11/1/2009 12:59 esc Status-Interim RN Initials Time - KTA .. KTA 11/1/2009 12:59 THC (MARIJUANA) Status-Cancelled- Autocancel by LIS-not colt/rev KTA 11/1/2009 12:59 Head CT s contrast CTH-- DEPARTMENT DF RADIOLOGY Patient Name: SCHOOLCRAFT. ADRIAN MRN #: 001298984 Patient Loc: Requested by: Staff. Physician Exam: MENTAL HEALTH ER CT head wlo Result DatefTime: 11/0212009 10:45AM Radiologists: Janczuk, Peter MD -------------------------------- Clinical indication: FIRST PSYCHOTIC EPISODE: RULE OUT LESION/MASS. NONCONTRAST HEAD CT. • NO ACUTE INTRACRANIAL ! HEMORRHAGE, SPU no discrete lesions, no mass effect or abnormal intrOH:>r extra-axial fluid collections. VENTRICLES and CISTERNS have NORMAL size and position_ OSSEOUS STRUCTURES are UNREMARKABLE without definite acute or displaced fractures or discrete lesions. PARANASAL SINUSES and MASTOID CELLS are CLEAR without fiuid or significant I ! mucosal1hickeninQ. KTA 1111/2009 12:59 TSH Status-ln1erim KTA KTA 1111/2009 13:00 RPR Status-Interim KTA [BWO 1111/2009 13:50 Pulse Ox BW 13:50 Recommended LOSICPTIICD-9 Code Physician's LOS = Nurse's LOS = Diagnoses Paranoid 297.91CD-9 MD RN MD Time RN Date/ Time Admit to Disposition Condition Physician (Print) Physician Signature Tariq, Khwaja (MD) Other Physicians Tariq. Khwaja (MD)-Peteru, Sachidanand (Psychosomatic Fellow) JHMC4 ----------------- Patient Name SCHOOLCRAFT, ADRIAN Account Number Medical Record No. 13038187 4 Primary RN {Print) Calise, Michael {RN CM) Dale 1298984 11/1/2009 Other Nurses Chen, Karen (RN)-Woodruff, Brian (RN)-Okuwobi, Bukunola {LPN)-Brady, Odette (RN)-Moonsammy, Victor {RN)-Galderone. Virnalyn (RN)-Harper, Wendell (LPN)-Mero, Monica (Amb Care Rep)-Basi, Susheela (RN)-Calise, Michael (RN CM)-Arias, Carielys (Reg)-Boswell. Gwendolyn (RN)-Stancu, George (Clerk) This chart has been electronically signed via the EmpowER software. JHMC5 Patient Name Account Number SCHOOLCRAFT, ADRIAN Medical Record No. 130381874 Date 1298984 11/1/2009 Jamaica Hospital Medical Center Emergency Department Nursing Notes and Vital Sign TimeEntered: 11/1/2009 Temperature Pulse 0 99.2 T Right 16:39 Vitals Taken By: BOK Blood Pressure 81 Respirations R 18 L Left 112 60 Pulse Ox Pain Scale No Pain R TimeEntered: 11/1/2009 17:00 Vitals Taken By: BOK ---------Temperature 0 99.2 T Pulse Right- Blood Pressure 81 Respirations R 18 L Left 112 60 Pulse Ox Pain Scale No Pain R TimeEntered: 11/2/2009 Temperature Pulse 0 98.4 T Right 6:26 Vitals Taken By: Blood Pressure 90 R L Left WHA Respirations 123 73 Pulse Ox 20 Pain Scale No Pain R TimeEntered: 11/2/2009 Temperature Pulse 0 98.6 T Right 10:51 Vitals Taken By: Blood Pressure 88 R KCH Respirations Pulse Ox 18 127/63 100% Pain Scale No Pain L Left R TimeEntered: ITemperature 0 99.2 iT 11/2/2009 21:24 Vitals Taken By: Pulse Blood Pressure Right R L Vitals Respirations 124 76 6:29 93 Left BOK Pulse Ox 18 Pain Scale No Pain R Time Entered: 11/3/2009 Ta~en By: VMO I ' Temperature 0 T R 9T4 Pulse Right Left Blood Pressure 86 Respirations R 18 L 124\60 Pulse Ox Pain Scale No Pain J JHMC6 Patient Name Account Number SCHOOLCRAFT, ADRIAN Medical Record No. 130381874 Date 1298984 11/1/2009 Jamaica Hospital Medical Center Emergency Department N.ursing Notes and Vital Sign Time Entered: [mpm"'' 99.2 T 10:52 1113/2009 Vitals Taken By: GBO Pulse Blood Pressure Respirations Right R 18 Left 90 123/68 Pulse Ox Pain Scale No Pain L ---l R --~---- JHMC7 SCHOOLCRAFT, ADRIAN Patient Name Account Number Medical Record No. 130381874 Date 1298984 11/1/2009 Jamaica Hospital Medical Center Emergency Department Nursing Notes and Vital Sign Nursing Notes RN Initials Time Note Entered Note 1111/2009 13:51 1111/2009 15:38 BOK pi received on bed, awake and relaxing,pl spoke to his father on phone. PI denies suicidal or homicidal ideation safety enllironment maintained will continue to monitor pi 11/1/2009 20:11 pi ate 100% of dinner w~h no sign of distress noted 1111/2009 22:56 BOK 11/2/2009 0:03 VMO Received pt in bed asleep side\ rails up no sign\ symptoms of distress for hold\ stabilize 5:52 VMO remains asleep in bed no sign\ symptoms of distress continue to monitor 11/2/2009 6:25 VMO PI awake in bed slept well VIs stable denies suicidal\ homicidal ideation calm in control little interaction for hold\ stabilize : '1/2/2009 8:23 KCH Received pi in lounge, sitting, calm and cooperative. No sign of acute physical distress noted. No respiratory distress noted. Emotional support maintained. Encouraged pt to verbalize feelings and thoughts. Safely maintained. Will continue to monitor pi's behallior. 11112/2009 10:47 KCH PI is in bed, awake. Calm and cooperative.No sign of acute physical dis tress noted. No complaint offered. Ale meal wtth good appetite. Able to approach staff with needs. PI is for hold in Er. Safely maintained. 11112/2009 13:15 KCH Pt is in bed, awake. Calm and cooperative. No sign of acute physical distress noted. No respiratory distress noted. Ate meal with good appeilite. PI is for hold in Er. Safety maintained. 11/2/2009 16:06 BOK pt received on bed, awake and relaxing, pi denies suicidal or homicidal ideation safety environment maintained wm continue to monitor 1112/2009 18:10 BOK pi calm and quiet, pl1 00% of dinner w~h no sign of physical distress noted 11/2/2009 22:43 BOK pi in the lounge area watching tv and pi denies hallucination or delusion safety environment maintained will continue to monitor pt 11/2/2009 BWO BOK Client is a 34 year old White male police officer who was BIBINYPD in handcuffs after he was apprehended at his home. Client had an argument with his supervisor and then left the job, went home and barricaded himself in his apartment refusing to come out. Client failed his psychological exam at work one year ago and his gun was taken away. Client is reported to be paranoid believing that he has documentation to prove that his superiors are falsifying crime statistics inorder to gamer promotions. Client also believes that his superiors are out to gel him. Denies medical/ psych Hx. In control at this lime. Will continue to monitor. pt awake on bed and relaxing, pi denies suicidal or homicdal ideation .safety enllironment maintained will continue to monitor ---- ----------------------------------------·----11 .. 3/2009 0:02 SBA Received the pi asleep in bed,easily arousable. Not in distress. PI was seen by family practice MD, and has been medically cleared for inpl admission. Needs financial clearance. Observation continued. 11/3/2009 3:00 SBA Pt is seen sleeping in bed;easily arousable. No distress noted. Observation continued PI slept well during night. He is awake now,seen him writing something. Denies any physical complaints. Denies any suicidal/homicidal ideation. Has been calm and pleasant. Pt is for inpt admlssion,pending financial clearance. --------------------·----------·----------·--·------· 1113/2009 6:10 SBA 11/312009 8:27 MC6 Pis. Report received from nile shift there is no behallioral changes noted at this time. He is found awake and seated in dayroom alert,responce and verballorward staff. He has refused assistance fronn NYPD at this time. Requesting admission here at jamaica . He denies h/s ideations at this time. His appearence : good ADLs good, behallior even mannered verbal rate normal and volume nomal, contant approiated.Cognilive:preoccupied w~h curerent situation and slight paranoid reguarding NYPD. He is treated and provided with support as required. JHMC8 Patient Name Account Number SCHOOLCRAFT, ADRIAN Medical Record No. 130381874 Date 1298984 11/1/2009 Jamaica Hospital Medical Center Emergency Department Nursing Notes and Vital Sign --- 11/3/2009 12:55 MC6 Pt. remains on unit resting on streatcher this time. He is quite interactive and even mannered.He refused AM medications and ADLS and appearance are good. Verbal : rate normal, volume normal, cognitive. He still displays concern about NYPD actions towards him and paranoid at times. Menory inatact. He is treated and provided with care and support as required. Pts report give to psyh Ill pending 2 P.C. 11/3/2009 14:06 MC6 Pt. 2 P.C. Completed and pi and documents provided to patient. Report endorsed to Psych Ill. He departed unit in wheelchair with cothing and escorted by security. Primary Nurse Diagnosis Primary R:-1 (Print) Primary Nurse Outcome Achieved Calise, Michael (RN) JHMC9 Jamaica Hospital Medical Center Triage Arrival Date/Time I Triage Time 85711 1111120091 Waiting Rm Time Exam RmTime I 13441 I 10:341 Mode Medical Record Number Police Walked 1298984 NA [Police Dept - Custody No Notification Yes Chief Com~laint IPSYCH EVAL Associated Sxs Patient Name SCHOOLCRAFT ,ADRIAN 13:441 Transported by PCP Staff Status Family Physician Historian Police 14 ESI-4 (less uri Category Onset Time Asthma Age - 0 OM 0 0 HTN Psych Ocancer 0 0Renal 0CHF [J Seizures ~ Oral Rectal 0CVA Substance Abuse I Tympanic - Pulse Riqht Left Unknown 0 NoMeds Male Vitals Tern Medications 0 .... 34 Years Gender Additional: QCAO QCOPD 06121/1975 DOB No significant PMHx 0 130381874 LQcatipn Pertinent History Past Medical Histor 0 Account Number Day(s) 2 I I --] Beat# Immunizations UTD? Unknown Allergi~~ - ···-· No Known Drug Allergies J Mental Status I Psychological Eva I Eye Motor Obeys DO DO DO DO DO Total hs Blood Pressure Right :li_3~~~~u•••• Oriented 0~ Respirations Left Spontaneous Verbal *If yes to TB or Infectious question take precautions Glascow Coma Scale Alert Oriented TB Hx, PPD Pas or No Infectious Exposures? 1~15 j ~~ Ey~~ I I Equal Lung Sounds R L IClear Diminished Wheezes Rales Rhonchi Retractions i,Nuirltion ~ Norm~l ~~ Reactive DO DO DC DO DO Fixed Constricted Dilated Cataract R L Pulse Ox 1~-------- 15 Color Normal Moist Pulses Pulses Intact NoiTllal Temp Normal ! ROM Full ROM _N_o_F_a_II_R_is_k_s_ld_e_nt_if_ied _ _ _~___j _ ~e you being hurt by someone you live j ::-----==---====--1-0J -Plan Head Height Circumferenc ··-··-··-··· 1~'3" - .•l Pain Scale l No Pain English Assessed Disability No Disability I Time Communication Barrier Language Translator Motivation Level Daily Living Alone Going Home with Low _j Unknown L __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ LW Completed Txt Eloped LOIN Knowledge Level Independent Comprehension Ability Med L_____________ - BWO BWO D 0 Functional OIC Planning Woodruff, Bnan (RN) O - . Primary Language NA Living Conditions LWBS Weight (Kg ~1(_)9 ~~ es/No Mandatory completion of Domestic Violence ReferraL Suicide Risk Assessment I No risk identified 0 0 th or who takes care of you? Ll Triage Ill: Miscarriages Assessing Patient's, Child's or Parent's readiness to team Domestic VIolence Assessment Fall Risk Assessment Triage II: Ab Extremiiies ... Skin ----------.11 Triage Nurse: p 0 00 G -- --- MHU WR OBIGyn 0 AMA O AMA Refused -=~ ~ Patient Rights and Responsibilities and Guide to Pain Management given to Patient, Family, and/or Caretaker JHMC 10 ~--~------·-- -- - - - - ---------"'"------·--·- ------· ---------,---~ Patient Name SCHOOLCRAFT, ADRIAN Account Number Medical Record No. 1298984 130381874 11/1/2009 Emergency Department Pharmacy and Supply Charges Diagnostics Diag nostlc Ordered Charge Code CBC 0 Pulse Ox 0 Nurse LOS Charge Code JHMC 11 Jamaica Hospital Medical Center Medication Reconciliation Patient Name AccountNumber SCHOOLCRAFT, ADRIAN 130381874 · Medical Record No. Date of ED Visit 1298984 11/1/2009 Allergies I No Known Drug Allergies Home Medications Medications Administered in the Emergency Department Medication Prescription provided on Discharge JHMC 12 SCHOOLCRAFT, ADRIAN 1298984 M DOS: 06/2111975 ADM: 11/01/2009 08:54 1629 ALDANA-BERNIER. LILIAN R PSYC 34Y FJC: 99 130381874 ASSIGNMENT AND RELEASE OF INFORMATION STATEMENTS Assignment to Jamaica Hospllal care lo cover the I I Dale Sale Medical Oevlca Act Date Patient Entitled to Medicare Bcne11ts I certify lh<1t the information given by me in applying lor the p:•ymanl under Tille XVIII ol lhe Social Security Act is correct. I authorize the holder of medical or other infom1ation aboul. me to release to the Social Security Administralion and Heallh Care Financing Administration or its intermediaries or carries any information needed for lhis or a related MadiC<lre claim. t reque5t thai paymen.t of the .aulhorized banertts be m~de on my behalf. t assign the llenefils payable for the physician services to the physici~n or org<:~niZation furnishing tho services or authorize such physician or organi<ation to submit a claim to Medicare for paym8nl on my beh8lf. Signature of Insured or AuU10riz.ed Ropresenlalive Date Financial Agreement For and in consideration of sorvtces .. endered or to be rendered by the Jamaica Hospital, lo the patient whOse name appears below, the undersigned (jointly and severally. if more than once) hereby agree(s) to be fully and totally responsible to \he hospital for paymenl or all Glmrges ~& submitted by tho Hospital on the account ol said patient and make payment in accordance with the (>Oiicy of payrnenl of bills at said HospitaL It is further agreed that ihe charges as incurred represent lha fair and reasonable value of services rendered and are In accordance with the posted charges Ko~pllal which ·are available upon request. Paymen\ may be demanded ~I any time. and failure to demand payment of the patient shalt not tie a prerequisite to my (our) immediate responsibihty for payment. of ·uw The undersigned has read the above. been informed of its nature and signirtcance and acknowledges the cornents of s~m" ;md has received a copy or this agrecmenl, Dat~l-------------------------------------- Guarantor SCHOOLCRAFT, ADRIAN Addres..q - Guamntor Name of PalrP.nl 1110112009 08:54 Hospital No. Dale of Discharge Dale or Admission Telephone - Guarantor Witnoss Date FORM NO. JD0123 JHMC 13 ------·------------ SCHOOLCRAFT, ADRIAN 1298984 M DOS: 06/2111975 ADM: 11/01/2009 1628 ALDANA-BERNIER, LILIAN R PSYC 34Y 99 130381074 [,:CONSENTS __ PERMISSION FOR TREATMENT I HEREBI' lllJTHORIZE THE JAMAICA HOSPITAL THROUGH ITS MEDICI-L STAFF. TO PERFORM OR HAVE PERPORMED. UPON THE PATIENT WliOSIO Nll~%:fEARS HEREIN, SUCH MEDICAL AND SURGICAL SERVICES, SURGICAL OPERATION AND/OR OTHER PROCEDURES OR THER.APY ur·ER(NESTHESIA OR OTHERWISE. AS MAl' BE DEEMED NECESSARY IN RELATION TO EMERGENCY TREATMENT ON THIS DATE : , : : : u : , R t t OR 1"1!\rlT NA r G~~~~IAN •. · · - - - - - -- • --- .. ·------------- r: ----~- ~~LAr;aL~JF'_ :F s,nt:.E.QBY~£r.!;oN ClHF.R-:-r;v.:,.--,r-,.-"-r- - .• ;,~:r::-.<:~:---~yf/;£(Z~:v~--NiiiiTN,\iJF,-- -- ----7z:o--1-=-:~----=--c:·-:? DATE - - - - - - - - ' I '··' - • I J.}'' !Jl--(____:::,. ( r i I {~· AR~NTEE OF PAYMENT v FOR ~0 IN CONSIDERATION OF SERVICES RENDERED OR TO ElE RENDERED TO HIE HEREIN NAMED PATIENT, I 00 HEREElY GUA.RANTEE TO PAY TH JAMAICA HOSPITAL, THE FUI.L AND ENTIRE AMOUNT OF ANY AND ALL BillS RENOEI~!olJ FOR SAID TREATMENT. I HEREB A THORIZE THE HOSPITAL TO RELEASE ALL MEDICAL INFOfUAATION NEEDED TO SUBSTANTIATE PAYMENT FOR SUCH CARE AND TRCA/ NT WITNESS TIVE OR GUARDIAN 51GI-IATIJ'RE PF::I!-ll NAME DATE ---------1-11P. IF SIGt-;EO DY PER)ON OYnER THAN P;.Tii:HT AUTHOR\zE OF PAYMENT ._ ;EREB~SSIGN. . TflANSFER AND SET OVER TO THE JAMAICA HOSPITAL SUFFICIENT MONIES AND:OR BENEFITS TO WHICH I MAY BE ENTITLED ~FROM T~GOvERNMENT AGENCIES, INSURANCE CARRiffiS. AND OTHERS WHO A-RE FINANCIALLY LIABLE cOR MY HOSPITALIZATION AND MEDICAL <;;ARE TO ··,0 ER THE COSTS OF THE CARE AND TREATMENT RENDERED TO MYSEI.F OR MY DEPENDENT. l \ PATIENTi E(JI IVE OR GU/\t<DIAN · · · ·. __ j_ --- --- .............------ 51GNI\ UR!: WITNESS ------ -------- ----- SIGNATURE ffiiNl' NAME DATE FORM NO. J00018-2C JHMC 14 IIIRHilllll SCHOOLCRAFT, ADRIAN 1298984 M DOB: 06/2111975 34Y ADM: 11/0\/2009 1626 130331874 ALDANA-BERNIER. LILIAN R PSYGI9 ~- ACKNOWLEDGEMENT AND CONSENT By signing below, I acknowledge that I have been provided a copy of rhis Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by the Hospital and the facilities listed on the back of this f(Jmi, and how 1 may obtain access to and control this information. I also acknowledge and understand that I may request copies of separate notices explaining special p1ivacy protections that apply to THY -related information, alcohol and substance abuse treatment information, mental health intormation, and genetic information. Finally, by signing below, 1 consent to the use and disclosure of my health inf'om1ation to treat me and arrange for my medical care, to seek and receive payment for services given to me, and for the business operations of the hospital, its staff, and the facilities listed at \ the bae: o7: fonn. 1'-'7 ~~~ Sigh"' Atni'of patient or autl1orized representative .-,v RelatiQnship to patient \_ Date AFFIRMATION OF PRIOR RECEIPT By signing below, I acknmvledge that I have already received a copy of the Notice of Privacy Practices, and have given my consent for the use of my health information for the purposes noted above. I do not wish to receiv~ another copy of the Notice Privacy Practices at this time. Signature of patient or authorized represent.alivc Rclatior1Ship to patient Dote TillS FORM IS PART OF THE MEDICAL RECORD M00011 9106 JHMC 15 Jamaica Hospital Medical Center 8900 VanWyck Expressway, Jamaica, New York 11418 Telephone# 718 206-6000 LIMITED .POWER OJ.' ATTORi'IEY TO PURSU~~ PAYMENT AND APPEALS AND AUTHORIZATION TO RELEASE M.EDJ.CAL INFORMATION ("LIMITED POWER OF ATTORNEY") By signlnif. this o:locunwul, I give the Health Care Pro\·ider, ld~ntified below, a Limited l'uwer of Attorney to pursue pnymcllt from my hcaltlt insurer, ·heath maiutenanc~ Qrg~nlzalion, ~If-insurance plan, ;!overnmental ·pro~ram, or other payer ("Heath Plnn") for medical seniccs pro\·id~ In me by the Health Care Providu, and I authorize the release ur medical inflirmation. I, the undersigned Patient/Principal, appoint JAMAICA IIOSPITAL 1\H:OICAL Ct:NT~:R ("Health Care l'ro\·i<.ll.'r"), locnted at .8900 VAN \\')'CK EXPR~:SSWAY, JAMAICA. N.Y. 1141S my ;\ttl>rney-ln-fac.t and authorized repre~~nlative to net in amy way which I myself could do, if I was personikll)' pl'l>S~.nt, and lo tak~ ~~~ I'C:ISOU:tbfc action, ~s determined by the Health Care Pro1·ider, to· pursue payment from my Hcaltb Plan and/ur pursue any nppeals avail:lblc to me un<.l~r my Heallh Pl'iaa's polir.ics or pi·o~edures :and nll applicable law, including but not limited to .External ApJieals under nil Stllte and Federal laws, relating 10 bcnlth care services prol·i<.le<.l by the lleulth Care Provider. The Hcalil.t Cure Providr.r, as my agent, may pursue ·paytnent ami/or nppeal, only when my Uealth ·Plan has denied pliymrnt bas•'il on medical necessity. The Health Care l'rovidcr will not ch~rg~ n1e for its services in pursuing paynwnt an<.l/ur un app.-al on my heb:alf. I agree that my llcnlth Plan will pay any Bmuunt ow~d dir.,ctly to the H.cnltb Care Provider for th~.>se scr"!ces. In pursuing ~ucb paymenr imd/or 1111 a]lp~al: I authorize the Helilth Car(> provider and· my Health J>lnn lo release :all relevnut medical informatii>n, including (if any illY-related. information, mentul health treatm~nt inform11tion, or alcubol/suhshwcc ftbuse trelltment informlltion, relating to my treatment which is IICces~al')' to pursue payment from my Healih l'lun. I umlerstnnd that lhi~ iuformailoumay be released, bui only as ·ne~ssory, ro nay Hc11lth ·Plala, an external nppcal ngeut, ·:u·biirator, cnurt of lliW, and!or utl•cr third party reviewer ("ludcpendenl Reviewer") responsible for deciding if the Heulth Care Pnn·i<.ler's claim fur s~niccs should be paid. lnnderstaml thut my Health J'lan and/or the ln<.lcpeudent Revi~wcr nill usc th.ls lnforlun.tion to make :1 decision about pll)'ment to the Health Care Provider. I also und~rstan<.l th:al the decision by t·lte lndepcndcnr.l~eview~r will be flnnl and bindiug on me. the llcallh C11re rroYider, aud the Uealth Plan, and: Hppli~able) '... ._.J) I autlmri1.e.thc Health C>1rt! Providrr to complete, e.~ccurc, acknowledge, seal, and to deliver any consent, demand, rctfUCst, applkatlon, >tgreement, authorization or other documents necessary, to request, on my behalf, payment and/Qr appeal to my Health 1'l<1n and, if applicable, tu the lntlcpcndellt Reviewer, the New York State DepnrOnent of llenlth, the State Insurance Department, the U.S. Depal·tmcnt uf Health and Human Sen-icc~, the U.S. Depa•·tment of L•bua·, audlor "".Y IJihu 11ppllcable a~:ency or body. This Lltnlted P11wer of Attorney shall not be affected hy my ~ubscqucnt di&>hility or lncontpetencc nnd 1\l:\Y HE REVOKED HY i\-fE AT ANY TJ:HE upon prior notice to the llcallh Care Provider. Tbi• l.irnilecl Power of ..\ttom~y. including a·ullwri:wtion for release or medical lnfo·rmation, will torminate one {1) yeur from todny's dau· unless l ~grce to c~teud rt beyond that datt'. cx~cutcd uri~inal. Any persnnur entity recching this document may rely on a cupy us if ir were and IN IVJTN~~WI!EREOf',l hm ,,..,•• my "' m./\, l. ' l ,,?.,y ,, YOU SIGN 111::' o\~ PRlNTtB Ni\l\IE: ~~ AD.DRF.SS: A2 60 88 PL SCHOOLCRAFT \vlTNESS: PR1NT NAMEfl'ITLE: ADRIAN RIDGEWOOD l\U:DICAL BI;CORD # ··~.__..i ADDRESS: AJxJ .'""';J' 1298984 Lf >«C· ~~k}~~. 2 ---- '-- 8900 VanWyck Expressway, Jamaica, )/I ! .·- NY 11385 /J 7Jf\- ?j? Ne":_'~:...'':...>_1_1_4_t:..~<J..:___________ Form No. J00023 JHMC 16 . ·------·-·-·· -------·------------------ - - - - --------------------------·----- SCHOOLCRAFT, ADRIAN 1298984 M DOB: 06121/197~ 34Y F/C: 99 1628 130381874 ADM: 11101/2009 08:54 ALDANA-BERNIER. LILIAN R PSYC ACKNOWLEDGEMENT OF THE REQUEST FOR EXTERNAL APP!:AL AND RtlEASE OF MEDICAL RECORDS TO BE SIGNED BY THE PATIENT. In order for a provider to appe<\1 a health plan's payment denial for a patient's treatment, the patient must sign and date the following consent to the release of medical records. A certified external appeal agent assigned by the New York State Insurance Department will use this consent to obtain the patient's medical informati.on relating to the external appeal request from the patient's health plan and health care providers. The name and address of the external appeal agent will be provided with the request for medical information. I SCHOOLCRAFT ADRIAN _, acknowledge that my health care provider may request or is requesting an external appeal because of a retrospective adverse determination of my health plan. I authorize my HMO, insurer, or provider to release all relevant medical or treatment records, including my name and other personal identifying information, date of admission. assessment results and history, summary of treatment plan, progress and compliance. treatment recommendations, any HIV-related infonnation. mental health treatment information. or alcohol/substance abuse treatment information. related to my provider's external appeal, to the external appeal agent. I authorize the external appeal agent to use this informa!lon solely to make a determination on my provider's appeal. I understand that my records are protected under federal and/or state law and cannot be disclosed without my written consent unless oiherwise provided for in regulations. I understand that informaiion disclosed pursuant to this authorization may no longer be protected by federal privacy regulations, however, state privacy protections may still apply. I understand that my health plan cannot condition treatment. enrollment, eligibility, or payment on whether I sign_ this \ form I understand that I may revoke this consent at any lime, exceptio the extent that aclion has already been taken in reliance on it, by contacting the New York Slate Insurance \y V ' Departmen tn writing. \ f2 ".--.- ,R-~~ )/;{» 0'? (Date) f legal representative's authoriiy to act on behalf of the patient. Patient's Health Plan 10#; - - - - - - - - - - - - - - - - - - - - - If you have any questions contact the New York State Insurance Department at: 1-800-400-8882 or visit our Web site at www.lns.state.ny.us. Form No. J00027 JHMC 17 · · · - - - - -~. -·-······ ------------- IIIIWIJUIIIlmB SCHOOLCRAFT, ADRIAN 1298984 M DOB: 0612111975 34Y FIG: 99 ADM: 1110112009 08:54 1628 ALDANA-BERNIER. LILIAN R PSYC 130381874 Please provide the following infom1ation and sign tho; pati.:m certilication so we m~y accumlety bill Mcd1care. -------·-··-·- ---------- ·---------------------- . --,ALL PATIENTS----·-----------·---.. ------·- -·-· --- -· ·· 1. How old nrc you?_ _ _ _ _ Birth Date__ _ __ 2. Arc yo" ol.igiblc for any pro!)rams (inclu<ling gllwmm<-nt prog:rnm.:;) \Vhid~ \.:uuld pily fur this SLTVice'~ e.g.: Black Lung Medica) Bcncfils ur Veu.."fnn's i\dministrdrion C Yes o·:-.:<1 4. b this service for the trc-~uncnt of an illn<lii<'ncddt'JH for which onoihcr pany could h<: hcltlresponsible'! D Yes 0 Nu lfyc.<, pl=c provide thefollowin~ inlbnnation: Name and Address of no lauhlliahility insurer: _ _ _ _ _ _ __ lfYe<;, NnmeufProgram:. _ _ _ _ _ _ _ _ _ _ _ __ Polic)~ #.~------~ O:th: uf Accident:__ __ _ _ ls thi~ s~rviL:~ tOr trt!'a[nl~n[ ofwlirk r.:lmcd injury/ac~.;it.h:m:? 0 \' cs 0 N11 I I' yes, date of ll•jllry .-\.;ci<ltnt __ ! __ ! _ TYJlcoi'Accidcm: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Empluycr Nnmc m1d Ad<ln:S<.:_- - - - - - - - - - - - 3. Name or Insured:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ S. Arc ynu currclllly l11roll~ inn ho~picc 0 Y.::s Nome and Addrc,.; ufWorkds (.'(IJJip<:n•ation plall lfy"~~ t-.!aml: aotl,\ddrL""SS.tlfl~.,,iJ.il}'_- - - - - - - - - - Do you hnve a revocation kncr? DYes C PATIENTS UNDER AGE 65 I. Me you cumutly ;:rnployed (including self-empla)'ment)'l [J Yc,, 0 No If no. Disahililv Date i If ye~, does your en;ployer ha~c: (ple;;;;incltlde P.m and Fu/11ime employel's) D Le~~ than 20 employees Cl 100 employees or more Cl 20-99 employee..,; 0 Nn N1) PATIENTS OVER AG~: 65 I. ru·e you currently. employed (including sdf~~mploymem)" DYes O.No Ifno, RetirememDnle __ / __ 1 __ If yes, docs your employer hnvc: (please ind11de f'arr and Full time employees) [J Less 1han 20 employee$ [J 20-99 employees Cl!OO employees or more All ·pATIENTS I. Are you marri~d'! 0 Yes Cl No 0 Widower or Widow. Ifye;;, is your spouse \\'OTkin~'l DYes .D No If yc:;, du~~ your ;pousc's employer have: (p/en.<e iuc/ucJe Part and Full time t>mp/o)•ecsl D Less than 20 employees 0 20-99 employees D t00 employees or more Spouse's R~tircmenl Date: __ i __ l __ 3. Do you bav~ in~urance c.overagc 1luough employee.- J:f<'UP he;dth plan bnsed on your cun·erll employment or a family merubds current cmploymcnl't 0 Yes [J No If yes, Name of'Policy J·!nlder:. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Relationship tO patient. (Self, Spouse)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Name and Address o f E m p l o y c r : = - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Namc and i\drlre"-' oflnsurance Comp~ny: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ GroupiPoli.:y N u m b e r = - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 4. Arc Y•'" ~member of an 11~...10'1 (P/eas·e note if HMO authoriwrio/1 guidelines urc notJnllnwHd. ,\<{edicare willnur pay. rh1• hmw.ficitiry . , ...,JJ be )·esponsib/c.fi.n·paymiml). D Yc$ lJ No If Yc,, i.s thi' covcrag" thmugh nn Employer Group 1-TCOllth Ph·on? 0 Y<:s 0 No 5. Hnvc you rcc.,ivetl a kidney trunsplant or dialysis ITcalmems? [J Yes [J No If Y"', Dme of Tr.msplant __ ' __ Date maintcnonce dialysis beg.ins __ f __ ! _ _ Have you received self-dialy~is training? 0 Yc~ 0 No P•tiont or Guarantor C~rtific~tion I have an~wered the nbove que;;rinns completely and accurately to the bc;;t of my knowledge. I understand that i~taccuratc infonuntion con affect the amount of paymenl ullimnlt:ly made by !v.!Gdican:- and llthcr insurance carrier$ for co>•ered service.$. PatictWGuaranlllr Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dale: _ _ _ _ _ _ _ _ __ Hospitnl Rcprcscuwtiw"Witness: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Oale: _ _ _ _ _ _ _ _ _ _ __ FORM NO. M00003 JHMC 18 ------- ---------~-- - - - - - - - - - - - - - -----·--·----- IIMIIIIUUIMBR SCHOOLCRAFT, ADRIAN .1298984 M DOB: 06/21/1975 ADM: 11/01/2009 08:54 FIC: 99 34Y 130381874 1628 AlDANA-BERNIER, LILIAN R PSYC COORDINATION OF BENEFITS QUESTIONNAIRE lnstrut;tions: Please fill out all applicable saclione completely by filling In Ultl applicable clrcle(s) within eact> sBctlon ancl print clearly ln black or blue Ink In order ror us to quickly and accurately process your request. Section 1 - Member Insurance Information Are any family members that are covered under the policy above covered under any other group health insurance policy (currently or during the past 2-years)? 0 0Yes 0Medicaid Medicare Only Section TRICARE Complete ~actions 3 5and7 Complete sections 2 - 7 0No 0CHAMPUS/ 0ESRD Skip to section 7 Skip to section 7 2 - Other Insurance Information Indicate name of other insurance carrier (fill in only one) (NOTE: ff more than one other coverage, please provide the other carrier information from this section on additional page). 0 Aetna I Us Health Care 0 HIP 0 0 Blue Shield 0 Horizon BC of NJ Oother (Name or Caffier) of NENY 0 CDPHP 0CIGNA 0 OXford MVP 0 0 GHI United Health Care IIIIIIIIIIIIIIIIIIIIIII IIIl I I I 1-1 I I I-Ll I I I Customer Service Telephone Nurnoor. Type of enrollment (fill in QDl£ one): O Parent & Child( ton) 0Family Q Employee & Spouse 0Medic:al 0Prescription Drug O Dental Type of coverage (fill in;!!! that apply): 0 Individual O Hospital OVision QMenlal Henlth I Substance Abuse Effective date of the other coverage: Termina~on Effective Date (mmddyyyy) Section 3 - Primary Contact liolder Information Primary Contract Holder on the Polley indicated In Section 2: j of Other Insurance First Name Last Name Identification Number or Medicare ID number. (Include allfetrers and prefix) Group Number: (if available): I I I Data (lllmddyyyy) {II applicablei I I I I I I I I I I II I I I [] I I I I I I Relatlonship of this contract holder to the contract holder listed at the top or this form: Q Selr Qspouse lt relationship Is ·sELF~ 0 Q Oepend13nl Separated Spouse or -sPOUSE•. Indicate t!mployment st~tus Q /\cllvely vrofi...ing wiU1 employer otfcfing olher coverage. 0 Not actively wo<l<ing I Long Term Disability Q Services Ex-Spouse or Legally Retired from employer providing oU,er covarag~. If ror!red, dole \ ofratirsrmmr; IT j -'--'----'----J_-'--._..___.._____, L. provide~;~, by Emp1re He 31th Choice l-IMO. Inc:. and101 Empi1tl H.Mallh Cholc.e Assurance, tnc .. licenees of Blue Croo:; a1ld Blu~ Sh1eicJ Associatiorl. <:~n assOCi<thon a/ Form No. MOC\Qi 7j tndepElnrlenl BliJc Croo.G omd Bh~ ShJekb olans. JHMC 19 1 AOKIMI FACE SHEET AOYIT flJ.."f[ f. nMC 11/0 1!2009 08:54 ClSC!l.A.RGt CrA TC A· H~ E PlACE. OF 9\R iH LANGUAGE NY ENG STAlE NY RIDGEWOOD S0Ct.\L SEGURTTY NUMBER OCCUPADOrJ JU:LArrmiSHif' 09 R~lATIONSJ.\IP 01 3099 01 CllY STAll: AODness Te't F.F'HON.€ N\J).lBfR ZIP NY RIDGEWOOD 11385 orv STAT( (71 8)570-6224 ZIP (999)999-9999 POLICY NUMBER US HEALTHCARE St:O. • GROUP 11 US0080410090 BBM6PBBA CITY ZIP ,gTATE EL PAS<) 799981109 DATE Of 81RTH 06/2111975 ~1:0 /GROUP~ ].IF'" , U!I,J·..If OAT't:OF BiRTH SOCIAL SECUHfl Y NUMBER AUT\ IQR~7.A T:CN NlJMru::P l)f,TE ·or PJ\(-V!OU!.i 110SPfT,'\l A0MI9SfON 0~ BIRTt-t AOr..nrn:D[3'i calntonle FORM NO MOOD01 JHMC 20 LOCATION 167.8 EMERGENCY MEDICINE RECORD ----·--------- - - - - - - - - ------------RN SIGNATURE ! TIME I ---·---t·· ·- ··-·+··1 I DATE : l INON·M~:'~~:~:~~<?_RDERS IEKG, LABS. c~L~~s. Ercj_ ___ I -~~SIGNATURE. ------+---;.--- -------~-!--DATE liME I s1GNATUR~--l--~'ME ---------· ·-- - - - - - - -f------- - · · _· - _ RN :. MEDICATI N RDERS - MD SIGNATURE RN SIGNATURE ! TIME . ··-···-··_···~t--~-------~i-_--~----------==--·-··_··_-''_Q:'"-":l:"':N~===------.~---_-_--'_~----"o_u_r_•_ ___,,--------~t-------~r! I ______·I~~-J. _____________ [ ---- - -_-_-- __________[_____ , ACCOUNTING DEPT COPY --- ---- ----- . !~_- _ FORM NO. J00018 JHMC 21 --·- ..J--- ___.... IH£ .,&o\JlAip\ HOOPfTAL.IfB2tCAL CENlER MENTAL HEN, TH CLEARANCE FORM TOOAY'S DATe REASON F06 REFERfW.: Sigibility TO: Authorizalioo Mall_ Fax Phoned In Broughtln - !NSUfiANCE I!'!FORIIAJ]O~ .s~ .\:q.-:C cg Pt-f:\ , NAME OF INSURED: AEIN t\ INSURANCE COMPANY NAME: I CONTACT PERSON: INSI.JAANCE CO. TElEPHONE NO: 1.:<'~~J00!0'Ll....:Y:J...::c.)L.\!_-_~!!...BQ.L{~b~-----------'--------- INSURA.Na:; COMPNN ADDRESS: ·-----------------~------- _f'a_'·_Q_~-+.~+-~-·- --t(_1Q._. AlJ'THORIZATION NO .. _,_: PRE CERT. COOROINATOA NAME: - - - . , . . . - - - - - - - QI!3POSITTON OF INSU!1fHcE INOUIRY; APPROVED 'Cll ._f DENIED D PENDING PHYSICIAN CONTACT 0 PHY~OANNO~S. -~~H;~·~---·--------------------------------- PHYSICIAN NAME: • Financial Investigation {Whle Copy) • Mental Health Oinician (Pink Copy) • SOcial Work (Yetlo.Y COpy) :l/12/96 (~HAVTHZ. WK:J) FIN. INV.INS. lrnTT JHMC 22 Uail_ Phened In _ __ Broughtln_ !NSUBA.NCJi lNFOftUAllQ!i NAME OF INSUAED: INSURANCE COLIPANY NAME: CONTACT PERsoN: 4?2--V-· Q ) Jb INSUIWICECO.TE.E>HONENO: J@ INSUIWICECOJ.IPANY ADDRESS: -------------------~-------- ,· / EX?LANAllON OF MENTAl HEALTH BBIEFTTS( #at days autholi2ed, ate.): (fi, Yp; C:. . <. ~ - - ~/}? .. PRE CERT. COORDINA.TOR NAUE: - - - - ; - - - - - - - Dl$f'OSlnQN OF INSUf¥NCE INOUTFlY: PHY~c:.= vJ f r- DENEl 0 PENDING PHYSlaAN CONTACT 0 I PHYSIOAN NAME: l '-- • Financiallmoestigatlon {White Copy) • Mlffital Hsalth Clinit;lan (Pink C<>py) ~ Social Work (YeiiC..V Copy) 3112/l>f. (MHAIJTHZ. WK3J FIN. INV.INS. UNIT JHMC 23 ~- ! j Emdeon, Inc. Ratcb: Assistant Page 1 - 5 11/03/09 13:49:35 Slat us: Cf..OSED 11/03/2009 - ll/03/3009 Lim.i tat ions T000188 -CJ\JUAS Id:176.1 Record: l INO Covg Level ·.,_.· Aetna Subscriber Eligibility lndivJ.dual Service Type Code 30 Health Bene£it Pla11 Coverage V2.2 Period Lifetime Yes ------Input I Response Information------ In-Network 111631788 Mes~age UNLIMITED LIPE'l'IME BENB~TrS Pr.ovider 10 ----------------Benefit----------------Subscriber lD Eligibilit.y (On File) BBM6PBP11. Date Of Se.rvice ll/03/2009 469976997 Service SSN 06/21/1975 SCHOOLCRAFT ADRIAN Covg Level Date O.f Bi rt.h T..u~.St Name 11/03/2009 - 1.1/03/2009 L"imitaUons B'AM 30 Fan1ily Svc/P.t·oc Code 30 --------- --Aet.na Information------------ Service Type Code 091249298WEB Health Benefit Plan Coverage 1'rans Ref ll Firat Name 111631788 Message NO NON-!lMERGP.NC'Y COVG OON GNO 1 - -- - - - - - - ~ - - - - - -Benefit- - - - - - - - - - - - ·· -- - - Requester ID Plan Ntwk ID G,..oup/Policy . Eligibility US0080410090011 PACES - CITY OF N Y up/Policy flran w 5691654 SeLvice SCHOOLCRAFT Sub Last Name ll/03/2009 - 11/03/2009 Limitations ADRlAN Suh First Name P Covq Level Sub M.td.dle Na.me Sub Birth Date !.'AM 06/21/1975 MALE Sub Gender Family Ser-vice Type Code 55 92ND ST 1\I?T F.2 Address BROOKLYN NY 30 Heal.lh E!en"fit Plan Cove·rage Plan req n•ferral and precert Message ---------Benefit----------------- 11<09 Eligibility Eligibility 11/01/2007 Service Service ll./03/2009 - 11/03/:.!009 Co5t: Containment 11/03/2009 - 11/03/2009 1151820050231103091219298 covg Level PAM 9MBDIFAXXX Family ····--------------Bene:fit------------------ Service T-;pe <:ode 30 El igibill.Ly Health Benet± t Plan Cover<J.ge Trace l • In-Network Yes Service Message NO PENALTY l'JI.ILUH£ TO PRECERT 11/03/2009 - 11/03/2009 ----------------Benefit----------------000000149 Eligibility Facility l'acil ity Identifie1· Other source of Data ---------------·Benefit----------------Eligibility Covg Level Identification Code Service 11/03/2009 - 11/03/2009 Active Coverage F.AM Family :tl/14/:.!005 Active coverage Service Type Code FAM Family Covg ·Level 33 Chiropractic HMO ser·vice Type Code JO ----------------Benefit----------------Health Benefit Plan Coverage Eligibility Insurance Typ"' Code. HM Bervice Health l~aintennnce Organiz<>tion (HMO) HMO Commercial ;sage .___ ------------- Benef i r.------------- ---- Covg t-eve1 Eligibility - SO!rvice Type Code Se.rv.tce 11/03/2009 Co-Insurance ll/03/2000 - IND Individual 33 Chiropractic I JHMC 24 1-- ~ I Emdeon, Inc. Batch: Assistant Page 2 - 5 f>er·ccnt 100 Message Facility Inpatient Hospital Yes ---·------------Benefit----------------- ln··Netwo.rk Message Chiro Eligibility ,.---'. ___________ ·--Benefit----------------- Eligibility Service 11/03/2009 - 11/0J/2009 Co-PaymenL Service J.l/03/200.9 - ll/03/200j Covg "Level Co-Payment Covg Level IND Individual Service 'l'ype Code 3J Chiropractic t.mount $20.00 In-Network '{es Message Chiro - -- ··- -- - - ·· - -- - - - -Benefit- - - - - - -- - - -- ·--- -Eligibility r~vg I . T"evel ~~vice Type Code INl) Individual Service 'l)'pe Code •19 Hospital Inpatient Amount $300.00 In-Network Yes Message Facility Inpatient Hospital --·-------------Benefit--··---------------El.igibi.lity SeJ:vice 11/03/2009 - ll/03/2009 Co-l'a.ymenr Service l.l/03/2009 - 11/0J/2009 Cov-g Level Co-Payment lND Service Type Code Individual HID 1ndividual 48 Hospital Inpatient 33 Period Admisson Chiropractic Amount $300.00 Day In-Network $20.00 Message Period Amount In-Network Yes i:'ACILlTY lP HOSP-NEDICAL Yes ---------- ·· ··--- -Bent:'.t it----··-·· ··------ ·· ··eligibill.ty Messa<Je Specialist Chiro Office Visits -·-- ----- · -------Benefit-------··-----·--·81 igibil i t.y Se.rvice 11/03/2009 11/03/200 9 Covg Level Limitations Service 11/03/2009 covg Level [..imitations FAH Service 'T)'"Pe Code FAM filmily 48 Hospital - Inpatient Family 33 'Message Service Type Code 11/03/2009 1 COPAY/SVC based on PROV type Chiropractic -- - ---- -- -- - --- -Benefit---- ----- ·· - -----Eligibility \----- - ·· ·· -- -- -Benefit- - ------- - ------- ~l.e~sage 1 COl'AY/SVC based on PROV type ·- .. _ .. - service Eligibility 11/03/2009 Service Covg Level 11/03/2009 ·- 11/0J/2009 Covg Level Active Coverage FAM Service 1ype Code Family Sec--vice Type Code Inpatient Limitations Hospital -· lnpatient ·· -------------··-Benefit------··--··------Hospit.al 48 Message Eligibility HMO · - - -- - - ·- - -Bene I it- - ·- - - - - - - - - -- -- - - Eligibf.l ity Service ll/03/2009 - :U/03/2009 COV'J LeV<!l COIJ"9 Lt:!vel _,-···-=.vice Type Code Per·cent Tn-Net.work 11/03/7.009 Limjtatlons FN1 Family 48 ll/03/2009 Sel.-vicc 11/0J/2009 Limtt.a.tlons FAM Family Co-Insurance •18 IND Se1·vice Type Code Individual Hospital - Inpatient 48 ----------------Benefit----------------Hospital - lnpat.ient P:l i.gibi li.t.y 100 Yes Ser-vice JHMC 25 Emdeon, lnc. Batch: P.ssistant Covg Level Po.ge 3 ll/01/2009 - 11/03/2009 Covg Level Activ>i'. Coverage FAM service 'rype Code Filmily ·.......)vice Type <:ode 50 ~1essage - 5 FAJ.l Family 50 Hospit.al - Out.patient 1 COINS/SVC based on PROV type Hospital -Outpatient ----------------Benefit:---··--------------HMO Eligibility -------·-----·--Benefit----------------Eligibility Service 11/0J/200, - 11/03/2009 service Active Coverage ll/03/2009 - ll/03/2009 covg Level FAl~ Co-Insurance IND Service Type Code Individual Covg Level service Type Code Family 86 Emergency Services 50 HMO Hospital -Outpatient ----------------Benefit----------------100 Eligibility Yes Service Hospital - 0/P Surgery Per.ceJ!l in-Network N<>ssage Message HOSPITAL OUTPA'l'II:.'N'I' ---------···-----Benefit----------------Eligibility Covg ll/03/2009 - 11/03/2009 Co-Ins;urance IND Iudividual L~vel 86 Service Service Type Code 11/03/2009 - 11/03/2009 co-Payment IND Covg Level Individual so Service Type Code Hosp.i tal - Outpatient $75~00 fomC(unt Emergency Services Percent 100 In-Network Yes Messag~ Errtergeucy Room Copay Message lJrgent Care Copay ----------------Benefit----------------f.ligibility Yes - 0/ P surgery -- --- -- -- -- - - - - -Benefit- - -- - - -- --------J::ligibili ty - Covg Level .. _,:Network ~le'"iwage Hm<pi tal Service .1.1/03/2009 .. ll/03/2009 Co-Payment Service SP~g Level U./OJ/2009 - 11/03/2009 Se~·vice 'l'ype Code Co- Payment IND Period \ ~'vice 'l'ype Code Amount In-·Network ~1essage Individual Amount. 50 In-Net>~m:-k Hospi.tal - outpatient Message B6 <~mcr.gency Service.s Aclmis,wn $75. oo Y.es Emergency Room $20.00 ----------------Ben.,flt----------------Yes El igibil i.ty HOSPITAL ODTPl\.TlENT ----------------Benefit----------------Eligibility Service Covg Level 11/03/2009 - 11/03/2009 Limit:ations service Type Code Covq Level IND Individual F'AM Family Amount 50 In-Network Service ]1/03/2009 - 11/03/7.009 Co-Payment IN[.) Individual 86 gmergency Services $75.00 Yes Hospital Outpatient Message Emergency Room Copay ~lessage 1 COPAY/.SVC based on PROV type -----------------Benefit--- · -----------·· ·-----------·Benefit----------------Eligibility Eligibility Service 11/03/2009 · ll/OJ/2009 ·...__..· service C:o-Pu.y.ncnt 11/03/2009 11/03/2009 IND Limitations covg Level Ser·vice 'l'ype Code JHMC 26 -----------------Emdeon, Inc. Batch: Assistant Page 1 - 5 Individual Service Type Code Service 86 Emergency Services 11/03/7.009 - ll/03/2009 r·,unt $35.00 Co -lnzur.-J.nce <,._)Network Yes Covg Level IND Message Urgent. Care Copay Individual ·-------·-------Benefit----------------- Service Type code 90 Eligibility Professional (Physician) Visit o.fttce Service Percent 100 ll/OJ/2009 - ll/03/2009 In-Network Yes Limitatiom;; Message PCP After Hours covg Level PAM Message PCP During Hours Family ------·------Benefit----------------SeL·vice Type Code 06 Eligibility Emergency Se.rvices Service Message 1 COPAY/svc based on PROV type -- .. - - - - - - · ·· -Benefit - - - - -- - - -- · » - - - - 11/03/2009 - 11/0j/2009 Co-Payment Eligibility IND - Covg Level Individual Service { ................ 11/03/2009 - 11/03/2009 Service Typ~' Code 98 Profess.ional {Physician) Vi.sit Limitations Ofiic:e FA!~ '.._}3 Level family Amount 86 In-Netwt:n-k. Service Type Code $20.00 Yes PCP Aftel· Hours Services Message 1 COINS/SVC based on PROV t.ype - - - - - - - - · - - - -- - ·Benefit - -- - - - -- · - · - - - - - Message Eligibility -----------·-··-Benetit----------------Hligibility Em~rgency .Service Service 11/03/2009 - ll/03/2009 11/03/2009 co--Paymentc Limitations Covg· Level IND PAM Individual Family Service Type Code 98 86 Professional (Physician) Visit Emergency Services Office 11/03/7.009 Covg Level Service Type Code Limitations Amount: $15.00 ·---------Benefit.-···---------- .. ---- In-Network Yes Eligibility Message PCP During Hours - - - - - ------ - - · -- -Be.nef it.-- -- - · - · -- --- - --Service Eligibility 11/03/2009 11/03/2009 Service Limitations 11/03/2009 - 11/03/2009 FIIN Covg Level Co-Payment Family IND 86 Covg Level S'-!rvice Type Code Individual EmeJ:-gency Services 91'1 He~,sage call 1/800-621-0756 Service Type Code ----------------Benefit----------------Professional (Physician) Visit Of.f ice Eligibility Day - l?edod $20.1)0 Service A.luount Yes 11/03/2009 - 11/03/2009 In-Network :OpeciaJist Off Visit Consult Active Cl)verage Me!3sage PAM - - - -- - - - - - - -- -- - -13ene [ i L - - - - - - • • - -- • · · ·· - -- Eligibility family Message !'.ervice Type Code Professional (Phy,;ician) 98 Visit Office HHO - ·- - - ---- ---- - ·--Benefit-- - - - - ------ -- --- Covg Leve 1 Eligibility 11/03/2009 Service 11/03/2009 Limitations FJ\M fa1nily JHMC 27 · - - - - - - - - - - - - - - - - - - - - · - - - - - - ·---Emdeon, Inc. n~tcho Assistant Page 5 - 5 Se1·vice Type Code 98 Professional (Physician) Visit Office r-;.sage 1 COPAY / SVC based on l'ROV type -.,__)- ·--- - -- --- -- -Bene f i. t- - - -- - ----- -- ---Eligi.bi.lity Service 11/03/2009 - 11/03/2009 I1imitations Covg ·Level FAM Family Service Type C"de 98 l?rofeo;~s.iona.l (Physician) Visit Office Message 1 COINS/SVC based on PROV type ·-----------------PCl'------------------Period start 07/09/2008 IIERTZEL SURE 718-760-0797 Name Phone FAM Family i, )vice Type Code 30 HP.alth Benefit Plan Coverage Insurance Type Code HM Health Maintenance Organization (HMO) '~· --- -·-- --·-··--Gateway Provider---------·--Eligibility Service .ll/OJ/2009 - 11/03/2009 ·.\ntification Code 1083727762 SORE, HERTZBL , MD ~l<rfue 9425 60TH AVE illliT 84 ELMHURST NY 11373 FAM Covg Level Family Sft.rvice Type cocte 30 r '1 Health Benefit Plan coverage ':r:rrl!iurance Type Code HM Health Mainten<~nce organization (HMO) - -- - - ----- --- --Disclaimer--- --- -·-- --- --Receipt of t.hi.s information does not guaranty payment lUlder state law. Should Providel· wish to obtain ve.rification that payment will be made, or. if rnembe.r info-rmation returned differs from T'rovide·r 's patient :records, call Aetna Member Services . .~'1:':-====:-:::;::.::;;.:o.===- Tr.ansact.ion Stats :;:::=::::=:-:::::=::::=:=... Que-ry: - PASS .-· .... JHMC 28 C~ARTll.~ 'fJ;IOP.. 11/03/09 13.49:35 ID: TOOOlSS 1 nf 1, Statue: CLOSED Aetna - Subscriber Eligibility ,_" !!:~i!e·!N·~~~ri9i!.:i2': v2.2 :'?'frf~~{~~:ep:{;)~;;:J· ,. ': Subscriber IDr Date Of Service> ll/03/2009 SSNr 469976997 Date Of Birth: Last Name: 06/21/1975 SCHOOLCRAFT ADRIAN 30 DBMGPBPA Pi:i::st Nwne: Svc/Proc Code: Gioup/Poli~y: PACES - Pl,an rri; s·ub Name: ,,.. , 5691654 Sub Birth oatei Sub Gender• Ad(l:re~s: CT~Y . ·-:·· A~T~~ '±itif!?i4·itliJ:~?~:;I::: ,;;:, Plan 'Ntwk l:D 1 GNOl Gr~up/Po1i.;y,, US00004~00!l00ll OF N Y SCHOOt.CF.AFT, ADRIAN 06/21/1975 p MJI.LE 55 92ND ST APT E2. BROOKLYN, .NY 11J09 Eligibility - ll/01/2007 Servico;, - 11/03/2009 - 1~/0J/2009 ··- Dates: ·:~~~~~rr_::JtJ~~i.~~ti~~~1Jr~li~·r}~f¥0::'t!i!;i!:·;r:.}-~·-:. ;: '1':~:,·· ~~i~:~~!~~~~~~~;;(~~l~;r·· In Individual Family Co- Insurance co-Payment Co-Payment 100 .$20.00 $20.00 Day Active Coverage Limitations Message: Chiro Message: Chiro Message: Specialist Chl.ro Office Visits fiMO l·lessage: 1 COPAY /SVC bas en on Pll.OV t.ype !.~-~k~~i~~~~~~~f;~;\\l;F-. In Individual Co-Insurance :-~~;~~-·~:~~{~;~fik,Yo:.;;;~:!!!~~~ii~!f!~~~C~b~m Co-Payment $"/5.00 co-Payment $75.00 Co-Payment Admisson $35. GO Message: Message: Message: Message: Urgent: Care Copay Emergency Room F.mergency Room C:opay Urgent Care Capay Active HMO Coverage Litnitations Hessa9e: 1 COPAY/SVC based on PROV Limitations F;;uni ly t'{flC Meseage: COINS/SVC based on PROV type Message: Limitat.ions Message: L.ioti tat 'ions :~t~~~~-~~~~l.;~:;,t~k:'~~-··. In Family Limitations Family Active Coverage ·&~~&U~:;;·~~r.~~J8:':L'·. ·::ii~0ff~~t\:#~~·Me~~~g~: cost Containment Individual Limital·iorlS call l/800-624-0756 NO :.:· ···: . · ·· PENAI:TY FAILURE TO PRECERT Lifetime Message: UNLHHTED LIFETIME BENEFI'l'S Insurance ~ype Code: HM Healt.h Maint.e:nance Organizat:ion (HMO) HMO Mcbs~ge: Limit.at:..:i.ona Con~ercial Mes5age: NO NON-EMERGENCY COVG OON JHMC 29 P~OP Limitations /. nf l Message: Plan rcq referraJ a.nd pre.cert \~~~~f~)J).\':L-:: -·~ . ·:,· · Message: Facility InpaticnL Hospital Co-Payment Co-Payment $300.00 Message: FaciliLy Inpalient $300.00 Hospital E"amily Admisson Message: FACll.ITY IP HOSP-MEDIG\L ll.ctive HMO coverage Limitations Me~:;.::tg!?: l Limitations Lype Message: LintitatiotlY COPAY I SVC bas eO or1 PROV Limitations ~~~~8;~~,%~~Mi~ In 'Individual -·]~~;~[~~~:Fti;~t3r:~ssa~~~~~r~I~~l;~;)/t~t; ~~urgery Co-Insurance Co-Payment Co-Payment A<.:ti ve. Farn.i.ly ··· Message: HOSP'I'rAL OUTPATIENT Message: Hospital - O/P Surgery $75.00 $20.UO Message: HOSPITAL OUTPATIENT H~IO Cove .rage Nessage: 1 COPAY/SVC based on PROV type Message: 1 COINS/SVC based on I?ROV type Limitat-ions .Limitat.ions 1 ·:; ·: . ~~4~~1,~ ~i.,' -~ $20.00 $15.00 $20.00 co-Payment Co-Payment Co-Payment Family Message: PCP Afte:r· Hours Message: PCP During Hours Message: PCP After Hours Message: PCP During Hours Messag~: specialist Off Visit Consul.t HMO Day Active Coverage Limitations Limitat.ions type Message: COPAY/SVC ba,;ed on PROV Mes-?agc: 1 COrN.S/SVC based on PROV type Service ll/03/2009 -· 11/03/2009 0000001-19 Facility Faci 1 ity Identifier Identification Code: Othc~ Source of nata -P;;L;~d St-~-~t:~Et,~;x~-;20;;;; !fame: Pb9ne; Covg Level• Bervioe Type: cinsura.nce 'Type: ··--·· . .; ~- HF.RTZEL SURE 718-760-0797 PAM _. Family Jo - Hedlth Benefit Plan coverage HM - Health Maintenance Organization {HMO) ......... _ _.._ ;·· .. .,, .. • . ;~ .:·:·~·:· j;;;·: ~··,/,;:~:_,,L ,;.'-~7.r:.'!:::.~:~~-(;~ ·_. Eliglbil i ty JHMC 30 ------------ -~--- I'J\PT~l-s Identification Code: Service ll/03/2009 - ll/03/2009 10R3727762 Nrune 1 SURE, Covg Level: service Type: Insurance Type: HERTZEL , ~ID 9425 GOTH AVE UNIT B4 E:LMHURS'l', NY llYn FAM - Family 30 - HEalth Benefit Plan Coverage llM - Health Maintenance Organization (HMO) .. PI.~~~-!;~~.::--: . ·..· ...... ~:s::If-~:;F.'';!~~:::.:~;~·-'-~~.,~~---'·::{.:;:· ·:· r.-:~- ..~-~~ ~->~- :_~ ;/.%:):;;/~~~:~·, \;~\\~·~:ii~~!~~~:._;_~-~:~·-:·.~i--:·~ i;·~--~- ::_ ..-:. :-- . -·-:·_-. ~,-·--~-I: Receipt ot this information does not guaranr.y payment under state law. ~~;;;,id ·-pL:c;v:id;.r wish to obtain verification t.hat payment: will be made:, qr. if men\ber· in·tormat:ion t·ecurned d.i f fers from Provider Is patient t;"8COrd5, call Tll1l,N.s~(\!f()N. s'r.AT.s · Query: - PASS Aet.n~') Membe-r Service6. .!-·.: JHMC 31 (_) () ' Pr--: l o("l ' JAMAICA HOSPITAL MEO CTR- 1225176175 Change Provider: JAMAICA HOSPITAL MEO CTR-1225176175 Cl~\im.~ .. t~ - .· .. r;! · .,., -: :. i~i,·• · · ~t:li: :-•-~••rn·~ Eligib!lity Response Details Eligibility Information: Suhscrib~r/Insured Nol Found f•1.E.VS ·-· J:h;l•~·~•·~J· .- · f.l•ni!•.i~····L l~!=:-;l;•:·u·,•••. flnwt'"!:t Client Information: -· •.::..:, ;:J.·\t:.~r.-:.-.: ..• -;,".,. -.- -··r.~l ~:·_· ;":_.(':' Did<~ of Rirttt: G£:ndE'.r: ·· ."f>il...·:ll.:·:·' · :·.•,_"3 Counly: n-,:~,,,,,,s_r:~ Olfk~: • -~·-·~·-__ ::. 1;1: :o r:.,:,:::··r• Pril•f /\!:0/'l'(lVid Medicaid Coverage Information; · r.~,.ro,c_r~-·-==~' ·'t':.l'.-:c;;:.:·::'<.: Sup{.lcrt fil~s l'~nnrvcr.sa.ry: Rcc~~:-1 ilir:.ation· Medicaid Managed Care Med;cald Restricted Recipient Piilr. N.:fl1le: lmps:!:\•:w\\'.t:lll'-'dny.un!:"cPACES/MEVSiElip.ihili•yDelaii~PSO.aspx?FR0\·1=~& l II D=743CA RIAS2UU 1) I I 03135B~730(!127&... I J/V20P9 JHMC 32 rr-·12 of~ ~/ Co-Payment Information Co-Pny J.temainingc Medicaid Messages l. lndi\·OC:n~l! E,_ccption Cod~~: ... CJtCrjr···~· ol Assi!=-l~nc"!: .. Additional Payer Information JHMC 33 Unpin;: J:acilitv Online Services .... Page I of2 . ~- ( li~;.~i( M.;;t;~er~·'l(E";~~i~;;;;:·v -r;;:o"k;;~'y·;;i~~;~i.r;~]lmllffflilt On\ 1n,·· .::!:~·-..~;u;·~ 0 \''iL:r}\inq VV\~h f::rnr)ir.._. ! i F:iC:iHv Ubt.)ry ! Logout ~--)!" f;;·r~!•.1 ::(. ·:.-:.:_.:;=:- :.:1/":~:(.: ;·:Jc;.!~-::· :" :-:i-:' ...•. iii!: \, ''·!·..: : ;-"_. · ,;_;r;;!;• .; L:~t·:~i · ·1; •• ~ .- i: .. •>: -~' k~f;<·:i!!':: ~~-~·~n~d~·><ti-:_;r ';:.rd . . r. -_ .;;_;_J..:~:-~·~:r=:::-~~~!:~;~; _ l ! )-. ;.-. ,.. p • ·-=~~~~ ... J, ... ~~-l::(t-- ~~\ 1_~.\:!! I).DL~-~~~y!~_f; I ·::_t.t~r.~:.~:_:f _f:j_;_!0il'.:.~1 Enter y~ur patient's Information in the fields-below and then click search. If you a atte~pling to search lor a member in our national systoms you must include tho prehx. r.~;~-:~-~~~_j·:~-:-;gkr:.a_cJFii.t~.~-:. :-· :;_ ..~,.::~.~- ~- ~~-;.:i'.!~·!_:? $ ::_.lr:.:< ;_X:-.~~~~ f?.~. ~p-~:;~1.~~[;~~f,~:~%{~~;;;,,,,;y r:r ~~: _(: ~:~~-i~!-~_:.~~ ir~:: _i __ :i_') ::;_f:-;:l(_~:h ~- ::~-:-.-~:}=•~--(~·~r.~~--; f:. ~:,-}_1_: ~;: ti~;T:_;:rr.l•. :::_~;~_1m~-.::~:-~~=:: No!e: To view a sampln 10 card,,-;,_,;\: hr~'.":' ~~.~:;_,:;_!_!~-! ~i F.~:i.:~-J. :~ ~·.;.: ::·~ T.~.1 :f,_:~~~t g ..~fl;;iJ ;_:~:.~.:.!J?. t\ h.":~ ;_;1 if, ~-~ 1::-=.·.~:::.ft~: :~:; ;:~~-~~ ;:~:~·· !~;_;~:.: ,-_~:},_;~1·.'( ~-~-~-:?..t: !.> ~-::::c: 1 .;:_•.~-~:J.tt:)' ~ -:-" --~-~;~~~ ~~~~.: ;'•. \(::;~:-~-<~ 1-~: L'.::;.~_;;:.;_:JfJ~/ ?~.1 ~-!" ;;·-:_-_..:~ _ (::';i_!~ ::> ~-!.~l·n.,!.'!:~~t ~ :_;_•. l.~ •.:~: !: (. (.J·--~ ;·::'>: ---~-~ ~-t~t_= :l_l_;~·~:" ~~~;:~!~ . .,. ~:;_:.y~<~ ;. ;_: https:!/www.empirehcalthcare.comlhospitalservicesihospitalPonal!9ll76096gS085575462... 11/2/2009 JHMC 34 ---------------E~pirc facility Online Services Page 2 of2 ·· ...-· { ·~-·. , ... - ...\ https:!/www .empirehcalthcare.comlhnspitalscrvicesl110spitaiPorta\!l) 11 7(,(196850855 75462.. II 12/2009 JHMC 35 Puge I of2 Empire facilitv Online Services oJ Oj _, . (H~;,:,!'\(M~;;,;~r"'j(i:~~~io~~~; -)( i ·, ~k~;; '!( ;,~;~;~-;~~-,. ')jfi!ijjiij"jtj ~.:.~~,l;~"'.c";" :,v··:!r.•. :··. ! iNn!·:·.i·li'\J Wi-Hi f.lil,_.:~!.· Member f:.: r .1~:.ii!l'.' li:.;,ro:;;"',; ; { S~arcl• I? fur1!'"'r(·T ;: -:.-:i~) :n·:;.::: (.'i:' -:!;. · '·' · ·\,:Jc'· :;·;r. !~~:l::·i .~·:f.-~i·; ;·r:!ll",l ;,:_; ):~::::~:~ ·~:. ~=- ,., [~,--;._ !·. v:·:~-:.~==r~~ :..-~_,;:::_~;,.·:Y.-!'.:n :~~w·. Enter your palient's lnfonnation in the fields bolow and thon click se<orch. If you a attemptmg to se~rch for a mcmbP-r in our n<Jiional syslems you must inciude the prefix. '469976997____ ,. __,_!•.,, ·....--- ... ~;~:.r_(:,i ·.f._Q!j:~ ,'"-~';_;~;{- ~~~.:.~:{~r~:-~;_:"; :.:!;,(.t- ;.: :; ~~;~ ~~~~~~:~t·: :~;~:~--~~~ ~ ;~ ·:_1:~ .;~i -J ·~ .:'. p~ ::_ ~~::·.:::/~ti_::'~::-1_:!... ::_~; _,_: !-:1 : i..:..~: l 1·. 06 . I 21 ,lA.', .... ;_... 1~~~"-~~-~'t~' J~·. :!:'::;; --~ _kl~~~;;;_;,,_: j,_,_,'/-!l'i!i:~~-~ f ~'\!.'i~ !.= 7:' r_~~-:-:!;~:~~: f-~~).j.~~ ~-~Qr:G-\ .~J.f.!_; r:·=-~- '-\!:~:.€: f'.(~;,:Jt•:J .P; 1_'-f_t~·..~~-~ ('::J1t:.\ ~:..:.•b~;-~ i\f.;!~·-~~- '·!::=•.. "•F· ;.\P.C:~~-~~-~ ~:~-~=~-"=-~::; q.~~-:u__ ;_"i: :~·:.:_:I!.t !~ ·-' ·:!..:~~.::-:·~_;-:, _!·;!·:.: -:.'i_--;~·~-·.::L. ':-'r\_1:'.:~~:·.' c.···:.!. ~·~:}.:~t!=;:Il __·.. ;' i1·:·.~~~ :;;!.;~ ~::~<;,'.~ <::-:~~ .. ~'?:.:~ :·::.!;;;?~':'. j'J;'!y<:f -~ ·-~-~i·•.' :·:·_ .:._! ~~(JY:.i~: •':r !'ll':' > ;: https:/iwww.cmpirehealthcarc.com/hospitalserviccstllO~pita!Portal/946031 0583 794747361... 11/212009 JHMC 36 - .----· --·-----------·------ -- ---·--,----·--.--·--- -------- -~-------------- [-r~lpirc rag<: 2 or 2 facility Online Services https:/\vww .cmpirehealthcare.comthospitalserviccsihospital Porta1194o03 \ 65!:\3 794 74 736 I ---· ------- -----··· ·-------- ---·-- I 112/2009 ·--------· ---. JHMC 37 --------------------------·-···--·--·-·- . ------~--- t'mdeon, Inc . Batch: Ass.i.stanL Page 1 - 1 11/02/09 17:48:51 Stilt\J8: RETRY '!'000188- MMEROJ I d : u 5o . 1 Reco:ed : 1 Medicare Eligibility v2.J ------Input I Response Information-----r•r.nvider ID ~1edicare HlC ff neg in DOS End DOS Date Of Birth Last Name First Nawe Gendsr Sero~ice 1245:!70717 169976997A 11/02/2009 11/02/2009 06/21/1975 SCHCOLCRAF'r ADRIAN M 'lype 42 Service 1'ype 2 ~7 S~cvice 15 Type 3 Service Type 4 service Typ"' 5 14 AG servJ.ce Type 6 '30 r-.. {_ )=~===== Tran;;action Stat~ ===-=====~== QGery: - FAIL >RH0217 - Pat~ent Not Ponnd JHMC 38 . ----------~----------------- SCHOOLCRAFT. ADRIAN !~::-=~ _ -] 1298984 M DOB: OG/2'1/1975 34Y ADM: 11/01/200£1 1628 99 130381874 ALDANA-BERNIER, LILIAN R PSYC ~ISTOR:_~-~HYSI~_f~ll ---=------=--==-===-~ DI~~:~:T ~ ~-~~T~:: NOT CURRENT~ ·--- ----- -------·-----· ··--·---· . .- . . . -.. -.. . .- ......-r----- _____. ____________ 1 DPr CURREioiT 0 YES 0 NO .. ---------- : ------ --------·····---~--- . ; i----·~--------- ------ ·-·------- ------·1.. ~-~-~CUR~~~ ~-YE.S ~--~~-----. -----·-·····i··-;--r--- ,. . _, ____....:.._ ______________ ._,_ ..... --·-- . .. ····---.--·;·-···'-·:- ---------. -----"--- --.--- -----.------_ _ _..c: , - - ... ·------. ····-r··---- -.. - - - - - : - - . ;.··-~----·--.-.- - - - - - . · - · · · · · - - · - - .···::------·--··4.:......_ . ;··--+--···········-~---·.~-- ------~-L_-----~ ·-- ··- ----·:----~_______;__- - - - - - - - : . ·---------·-. -- ... ....:.....------- -·· ·-----:~=-~~~--~------~~---~-----~~~----·:·--!~-~-~:~--·._ _.-· __:~;;... -_ ···-------· --------- .. ----··· -- ···---~~--. ··------;~:- -----.--------_i·~-----··--·-.-·!-~·-·-·__ . .~--·--·.·· ····--·-·-··-····-··---·-~··:--" ···---··-····· ---·········-~ ~. ~ j•. : .- ' . - ..· ----··---~ ·····---::··~.-.-:-··· .. i. . ; "; . ; : : ·-·------ -~~-··----'--:-··· ··-----~··-.· ·-----.-----i-~· ·----·----.-·-::· ·--··-~·-----· _ ··-----·-···-----~-~-~-:- ~:~··· .... .... __ :.____________ :·, .... ~.:,__ . ______ ______ ------. , , __ - ----- _;::-...i,_.. -----:\--~'~ ; ---·- -----:; .:. ·---- -~--- .:-.~---······· ___ ._··_._,. _·_· ;._)_ ---------" _________ .. -h---____;__'-·---~:·------······---":. -~--__;'--- ------. - . ·---~~:--"-'_'·---·--------- ...--··""···-------········. ····---- .... :.~~~.:.·:______ ··- ....'=--~~2-:-----~-;--~··.-:-.-.--. ... ······:--::-:.---···~-·:·-;:--.----~·c,··----····-···---·:~.;:·_:·:. •. ·-·~ · - - - - · :::-: ~~ ;i _':__.;-, --------·-- _.....:.__-:-·· -~ -·----:·-·~:.·: ..\__;_' __). ..........-----· .. -----'-----·· -··----'--·-·· : . ·. . ; :.;:~:"?,.::.-· .. )iMPRESSIONS ; L- -~~~-- .....~-=]~ . - - - - -· RESl),\JS ___ l LA~-~~~;,~~ - i U/A .::•:.-;·:-- ·-----,-.,_-,-_. . - - - - - - ------ RBC-- WBC-- --L-+-~~·-·- I ij" ·-----·-· -----··-····--·...:.". ·····----·· PHYSlCIAN NAME (PRINT), HYSICIAN (SIGN) I NAME.. RAD\..O_g>9\1 Prol - - ID # -- - - - - - - - - - - - - - - - - - - - ------ - - - - - .. - .......... _ -~ ~~r==t=- =:1~=:~~~~-- ~~~~~- .-~jJ~~-%i~~~:~~- _ :_----~~r~- EP_~--- ,--.._; --o.:Y.Yac _ __::.=-----~-~-:- __ , :~, _::_ 6----~ -\--- 1 ___________ -__g__<;:_~-- - --'---~--- ~- --l ~-~~: -+-~~ gt--·:f--= __ g~1~~:-:=....J--=·- .. _ HBO·;-~--Jla.lhlElBU~~ I ____g B!JNtS::~ - ·-----------i------·- 1-------:o -clcLUC !__ 1 ---- --. 0 R CQ_.____ ~---- ___ ,--HGB ..- - , - .... - •,0 FEMUR .....\,._~_1'3 I 0 ,· L_ WRIST L R ----Jj§~p -----;DANKLE_L__R_ _ _ ----..- - [ EKG RESULTS , ~-- -----. ----......Q...AMtl.SE _____ ---,- _ _. 0 HIP =-~--='3-------0 PTIPTT I 1 ---· - - 0 CT SCAN ' ot:icG"- :---,-- -----.·------ . - - - - - - - - 1 0 ---- .. -0-CPK - . -:----· 1---"------- ; SERVICE CONSULTANT NAME -----. TIME CAllED 7. - - - - - · -====-- - - - - - - - __ _______ _ --+,--- ______________ .. ADDITIONAL MD NOTE;______ --------.---- . -- - ----~.QQE .. __________ .. ROOM t: "" . ________ i ---~ 0 F-AMILY MEMBER NOTIFIED--- 0 YES 0 NO ·j;~-.n"L..~.T:C..!"-:::--~~----- 0 PVr MD NOTifiiOD Of' LJISPOSITION TIME:-----· TIME:------ SIGHATURE-·----.. ·----EMERGENCY DEPT COPY n .. CASE t ..... - - - - - - .. 0 INS rHUCTIONS GIVEN (WPE) ····--------- ....... ···------ .. :;..MA ...,·;:v:-cu,J• •~u.. sFI':R~ CONDITION ON DISCHARGE DISCHARGING PHYSICIAN NAME (PRINT)_ .. . .... 0 M.E. CALLED. TIME: - - - - ACCEPTED 0 DISCHARGED. TIME: .................... -- 0 OTHER ..... SERVICE ----·--·-·- --- - - - - · ..... ---·----- WA.\...QJ.8yNQ~LS 0 EXPIRED. TIME.___ --·----··· -------- ===~-'--· 0 AOr-..HTTEO. TIME:---··--·. === ·---------· .~,ITWS I D #. DATE FORM ~JO. JOOOW JHMC 39 (p~~- q;s 1 ~ ) Z'-f <2(;, ( FArlta'l\) LOCAi"i9~:>; ?f11 X DATf. AND TIME OF ARRIVAL \ . ___ 10/31/2009 REGISTRATION ) EMERGENCY MEDICINE RECORD 23:03 MEDICAL RECORD NO. 1298984 PATIENT TYPE AGE PATIENT'S NAME SCHOOLCRAFT ADRIAN 34Y CITY STREET ADDRESS STATE ZIP CODE PATIENT COMPLAINT MODE OF ARRIVA~J- ACCOMPANIED BY DATE AND TIME OF ACCID':-cE:::-N-:::T:-----r-:P::-:O::-L,-;;IC-::E--:O-::F=:FI7 C=:ER::-N:--Ac-:M-:::E:-:&:-:B::-:A-::D-::Gc::-E-:-:N-::-O-.--'-----::c=:--:-:-::-~==::=-c=c-:--------'----------'------- 0 0 CLINIC 0 FP OTHER RELATIONSHIP TO PATIENT TELEPHONE NO. NEXT OF KIN FINANGIAL - INS,URANCE GUARANTOR'S NAME ) STATE CITY ADDRESS GUARANl OR"S SOC. SEC. NO. ZIP CODE TELEPHONE NO. ZIP CODE STATE CITY NAME GROUP NO. POLICY NO. NAME GROUP NO. POLICY NO. HOSPITAliZED PAST 60 DAYS. IF YES, WHERE AND WHEN? PLACE OF ACCIDENT INSURANCE #1: INSURANCE #2: CRIME VICTIM PCT. NO. CRIME VICTIM COMPLAINT NO. 'NURSING YITAL SIGN§ TIME B.P. PULSE RESP TEMP TIME B.P. PULSE RESP TEMP -· IF ORDERED, CHECK WHEN COMPLETED: 0 EKG 0 OXYGEN GIVEN 0 CARDIAC MONITOB._ 0 IV ANGlO#_ F L U I D • - - - - - - - - INITlALS INITIALS IHITIA\.S INITIALS METHOD INITIALS INURSES NOTE~_QVANCED D:c_IR""E""C-"TI:..:_V.o:_ES;,:__:::D_.,IS'-"C"'U-"'-S""SE""D"----'-'H'-=E'-'A""-LT'-'-H-'-"-CA:_:R:_:_E=-.:...P'-CR.:::O.:._:X_:_Y::=O:..;_Y.=;E_;;;:S_____,O,_N:_:_O::::_______:A~G::;E=-:.N.:..:T-''S:_N:..::Ac.::M..:.;_E=-:=-------- RN SIGNATURE DATE INON-MEDICATION ORDERS (EKG, LABS, CULTURES, ETC.~ TIME MD SIGNATURE RN SIGNATURE TIME -- -- DATE I TIME MEDICATION ---- ' ·....__./' MEDICATION ORDERS ROUTE DOSE MD SIGNATURE RN SIGNATURE TIME -1-------- - --~------ ACCOUNTING DEPT COPY •·.1~1-iil~l//IIIIIIIIUI/111111 · 17lBi'i I3V 1 v.> b-J · 1 lJ1f[J7] , ...... f. ' •· ••• . . ,. I ffiT~aiOd/TIO!Irttport&<l 0TrenledfTt2nslerredCafa QTreal.ad I No Tn:uuport dTI'IIInapor1ed I RetuMd C3ro QCancelled l ! . _I [_J 0 ODD C CJ CJ Cr C • = G l.l S ~ C"J 0 r=: 1-:10 c 0 C.JCl::::J r-=::i C! r:::-1 ,:-:J C Chlol Complaint I I r.. .I ~-: LJ CJ DC: Ci 0 G C C:• ::=1 0 C .:-:.:.J D C CJ C_] i_-:-.1 CJ r_ LJ W C.:~ c.: D =· I I I Tl I I [I I I I ITLI1IIII[[UJ_l1 • SH6001 (1 of 2). Rev 10. 02106 Copyrighl 2001- 2006 ScanHeallh, Inc. (Page 1) JHMC 41 Umt McoGuro Routo ~ Modil;orRy N~sary 0 R9qi.Jirod Strotz:hEr 0 SevMe Pain D \lld;IJe Bleeding c ~n nt!c 0 U('I(X)nsdoua 0 Needed Roslr.:llnlng 0 Non-AmbulaiOIY \'.\udbl! su:~trt~d I~ C::t~rr.cr':l"~•·l 0 Bed Confnod mliiiJOAsttvna 0ChroolcR&MiFall~.n~ OCanc:Etr OCVAJS!roko OOialyals OHIV/AJOS O~ychlab1eProblem!I0Sub&tmcoAbu:ie0Tuben;vknis : 0Ampuloe 0ChronleRespiralory Failuro 0Cardlaoe 0 Olabeloo 0 Emphysema 01-iyPOOenslon 0 Sei:o.w Disorder 0 Tradleoslcmy OO!her ·-:. ,-- Rolaa~e of PaUont Information 1 Assumption of Financial Ro~pon~ibilily: I roqu()stlhal payment or authori.zod Medlcare.'MOdiC<Iid i!ndlor 1or lslsuranca bentifots be mace tO lhil ~tal ~e provider rPro-..lde~) rtr nny IICir\'k:e.-1 t\lrnl~od to mv. I 11uthoriz& any hokle< o;~llto:ll)il&l or mod"ICoill inform811on about me to bel o~od ro tho PfOVIdnr, Cvnle~ for Medica~ and MeOicaid Sorvice~. and/or my huurafJSO Cilfl'i11D an:d lhoir agan~. induding ulhM.i"r\1:orTnaUon IKIOOed to ll'etennine lh6'!1o banofib or 101 bonefits payablo for rulollsd sCI"'Iccs. I p&tlllit a c::opy or !~li-s authoctl:iltJoi'lto be 1.1sod in placa d Lhe 011ginol. r undetnand ltlb Uil.horlzatlon may be used by the Provider f01 aLl rviccs 1\imlshecl in the Ml.ro unbl s1.1ch time a~ 1 revoke this authorimtion in writing. I agreo to a~ full finencial responsibiLity iol paymonl or aJI thilfli&S not COYered by rny insura11Ut n101 3S. welt i!l3 any c:oLiedion cosiS andlo• al1Dine-i"J ll'-es os allovood by 1~. Patient: Ouoobl-e to Slliln 0Rofu...-d to Sign 0 PCS Collected 0 Od'lor l=un>nca Colloe"lod \Jihorizallon lor BlllinQ I an, Dare· \ulhollzaUOn Signoluro. •liVOJcy Natke: I haruby a-c.l'IIWJ'o'o'ludgo he ProvidDf"s nformation 1.$ tn .. tl.have be-en provKIOO with o copy of NoL~ or Privacy Pr.u:llcas e,plaining llow my per.IOfl<tl health us«< and und~Wr.<l my ifXI'ovidual nghLa rolatOO tD ltlis lnfOrmaUon: CPriV<X}INotice SignatUre: ] ~r:::~•ru•• Oole ~ JHMC42 SCHOOLCRAFT, ADRIAN 1298984 M 008: 06/21/1975 JAMAICA HOSPITAL MEDICAL CENTER fi7\ CONSULTATION REPORT 34Y 081X STAFF, PHYSICIAN ADM: 10/31/2009 \jv 130381015 01 THIS SECTION TO BE FULLY COMPLETED BY THE REQUESTING PHYSICIAN REQUESTFROM: J), ' N (,.J 0, I .. S' hI' Q "i ,-,' DEPT/DIVISION: Med t'CSJI £.A REASON FOR CONSULTATION: DCONSULTATION ONLY OCONSULTATION WITH ORDERS OCONSULTATION WITH FOLLOW-UP DATE: Ll/1 SIGNATURE: I ~~ TIME: 8 .' s0 c.. joy) OPINION OF CONSULTANT: Ny~uiJ.. '- ,l J 0-t'.t r ~ J.u '.J·. v/fc:x- ~t b-J .Lr\::~ ~ I~ o ·rof ~ L J0~ C.t' v/J Ofl7 Vvt.r( /u' de" t-el r~ bJ.u--'1 p,v-J Cl-1'/' c:,_c,, ( t C_CJ.j-e_j to ~ L t k /,J 0r hC-0 h, r j (I OJ'• ''f-;' c'VI .. J'l ~Y) ~ "OVJ ,f1 c/ ~ do cc~ W>J vr fd! c-v1 o.-bo~,f •t/-.t'J {Tr'm" '-... ~ Mforh'ry J'i,~"U!... .fc.c-f yc"r. d'-o• 11 t? n·'li' 1 Consultant Print Name: Signature: ORIGINAL - MEDICAL ltECORD Date: Time: CARBON COPY- CONSULTANT FORM: 110 ITEM: 849 REV. 1/07 JHMC 43 SCHOOLCRAFT. ADRIAN JAMAICA HOSPIT. MEDICAL CEN . 1298984 M DOB: 06/21/1975 34Y ADM:10/31/2009 061X 130381015 01 STAFF, PHYSICIAN CONSULTAllON REPORT CONTINUATION ~ hot a_ .::,r! OJZP-ll"'J fw o. 6o [[ 0 ~ ~ If ' 1}.g_ JooY ftr' bcJW\ e._ WI "'-[\ cQ o "'/~-(-.f'wcAf cbtVrf11!.1VYl- cv-d l-}aJI o..c / C./l ~ fo k p/{h. t f.,f~ a.v--ol /v_ k._~ broh..o.v. '/~ hI 'W\ ~ ~ ~ lf~ r'nt'fr·b_//y to ht'WI Q\i'c...[£.._1/C>v>.. be;.,'t c..Y M1 t'/Jl-t- WNh e.v \1."1 'J c¥ . e. f,-.yJ'/1'\. lo O.Y' rt'' ( &>...~ io /.S>6f hr~' t1VlCe o~,-,i-"'/c-& 1 .1'"' fL ~l'(<l-l E P, k k Cc... vvu< Cfjt''/'a.1'-"-ol 1 iAYICo O,f'l4cv/f~ve o,.r--J v.e v- h.-...il7 e-J:/1--J/ve.. o\.Cey f'e {-e.piAdn-L.. tA..r>-t. c,~ fold A,J. f-t e...c..h',.....J M JJ fur t 'tL '1 CA.M.. cJ l :fJ "", 'v. ..t t h-1-.tL ~ ~ t c.. t.. 1 pf1 C. (Nl C-Y h t" ...-.,.'fl' / J f ly C1. ()/r r--.,( ~ n_ V1 t) t- ( 0.. Y' f ::1 cu:ert-1!. meclr'ca.l (l.r~l)~m /j'91-~"" }<-,;.fc.y ).cy ~r-d. ~ r-'fo..tkJ G'f'..C'>i-YI1 1 ~tr r~.r~ er---e).. Ne cltn/.tLJ' Consu!t.:;at Print Name: . <:6VY!plc-.t'nCJ.ct b~ 4 6 fL. oY L, ·r~'rJ· 3 rc-omcd 1 c (J'? J:~.--t'c·r'clo{ c-bdoo/YI/t--ol oloP) t->~1' t-~ fo kt'Jl ..l!..(yVJ J'fc. f'r'.-ole f-~ !:hCH·f h.t 1 .j1 ~tt'Wit'c:t'kf ;'ch.vff'C-v~ c-1' '/}t:;.'T"-fl\tJi'c/ ,'d.J2..a1i'e;Y'I - 1 . oc::---~ZGv~-e, Signature: ORIGINAL- MEDICAL RECORD FORM: 112 ITEM: 1875 REV. 1/07 ~ ..f'/r.v-1'/fr'..P. ~ ht+litr-t..f'('.(J,1tl41 .. ffe JIAfC."'r'V!'Jw 1 0. .J Co/ (jA t/t y. M Men~e.l ,;-. ._ (j VI V\ Date: Time: CARBON COPY - CONSULTANT JHMC 44 JAMAICA HOSPITAL r;;:t\ MEDICAL CENTER 0y SCHOOLCRA FT, ADRIAN 1298984 t?M:10/31/2 6'6 9 ~9~: 06/21/1975 34 y AFF, PHYSICIAN 130381015 01 0 CONSULTATION REPORT CONTINUATION At o tI CD'fl61t'c:._t o-t- .!l , wor-lc~/te 0 Consultant Print Name: Signature: ORIGINAL - MEDICAL RECORD FORM: 112 ITEM: 1875 REV. 1/07 Date: lime: CARBON COPY - CONSULTANT JHMC45 ,. JAMAICA HOSPITAL MEDICAL CENTER / PATIENT CLOTHINGNALUABLES INVENTORY 1. ALL PATIENTS CLOTHINGNALUABLESISEPIT HOME 0 YES ~NO 2. DEPITURES TAKEN HOME BY FAMILY MEMBER D YES SCHOOLCRAFT. ADRIAN 1298984 M DOS: 06/2111975 34Y ADM:10/31/2009 OB1X 130381015 01 STAFF. PHYSICIAN 0 NO ·. j i .. _J RELATIONSHIP: 22731-FORM 554 White Copy : Medical Record YeUow Copy: Nursing PI JHMC 46 SCHOOLCRAFT, ADRIAN 1298984 M DOB: 06/21/1975 ADM: 10/31/2009 23:03 STAFF, PHYSICIAN 081X 34Y F/C: 01 130381015 ASSIGNMENT AND RELEASE OF INFORMATION STATEMENTS Authorization to Jamaica Hospital for release of information: I hereby authorize and direct Jamaica Hospital having treated me, to release to governmental agencies, insurance carriers, or others who are financially liable for my hospitalization and medical care, all information needed to substantiate payment for such hospitalization and medical care and to permit representatives thereof to examine and make copies of all records relating to such care K-----::-:-----:-=---------,---------- and treatment. Date '-. Signature of Patient or Authorized Representative Assignment to Jamaica Hospital I hereby assign, transfer, and set over to Jamaica Hospital su 1cient monies and/or benefits to which I may be entitled from governmental agencies, insurance carriers, or others who are fin dally liable for my hospitalization and medical care to cover the aid hospital. costs of the care and treatment rendered to myself or my dependen \ Signature of Insured or Authorized Representative Date Safe Medical Device Act I consent to the provision of my social security number to the manufacturer of any device that must betracked pursuant to the mandates of the Safe Medical Device Act t understand that the manufacturer will be given my social security number only for the purpose of finding me in the event that a medical device, which is implanted in my body, or used in my home is defective. Date Signature of Insured or Authorized Representative Patient Entitled to Medicare Benefits I certify that the information given by me in applying for the payment under Title XVIII of the Social Security Act is correct I authorize the holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carries any information needed for this or a related Medicare claim. I request that payment of the authorized benefits be made on my behalf. I assign the benefits payable for the physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment on my behalf. Date Signature of Insured or Authorized Representative Financial Agreement For and in consideration of services rendered or to be rendered by the Jamaica Hospital, to the patient whose name appears below, the undersigned (jointly and severally, if more than once) hereby agree(s) to be fully and totally responsible to the hospital for payment of all charges as submitted by the Hospital on the account of said patient and make payment in accordance with the policy of payment of bills at said Hospital. It is further agreed that the charges as incurred represent the fair and reasonable value of services rendered and are in accordance with the posted charges of the Hospital which ilr.e available UP.on reguest. Paym.ent may be demanded at any time, and failure to demand payment of the patient shall not oe a prereqUISite to my (our) 1mmed1ate responsibility for payment. The undersigned has read the above, been informed of its nature and significance and acknowledges the contents of same and has received a copy of this agreement. Dated ___________________________________ ~-nt_o_r__________________________ SCHOOLCRAFT, ADRIAN Address - Guarantor Name of Patient 10/3112009 23:03 Hospital No. Date of Discharge Date of Admission Telephone- Guarantor Witness Date SCHOOLCRAFT, ADRIAN DOB: 06/21/1975 1298984 M ADM: 10/31/2009 081X STAFF, PHYSICIAN 01 34Y 130381015 ICONSENTS PERMISSION FOR TREATMENT I HEREBY AUTHORIZE THE JAMAICA HOSPITAL, THROUGH ITS MEDICAL STAFF, TO PERFORM OR HAVE PERFORMED, UPON THE PATIENT WHOSE NAME APPEARS HEREIN. SUCH MEDICAL AND SURGICAL SERVICES, SURGICAL OPERATION AND/OR OTHER PROCEDURES OR THERAPY UNDER ANESTHESIA OR OTHERWISE, AS MAY BE DEEMED NECESSARY IN RELATION TO EMERGENCY TREATMENT ON THIS DATE. /RELATIVE OR GUARDIAN WITNESS SIGNATURE PRINT NAME PRINT NAME DATE __________________________________ RElATIONSHIP, IF SIGNED BY PERSON OTHER THAN PATIENT ,ARANTEE OF PAYMENT FOR AND IN CONSIDERATION OF SERVICES RENDERED OR TO BE RENDERED TO THE HEREIN NAMED PATIENT, I DO HEREBY GUARANTEE TO PAY THE JAMAICA HOSPITAL, THE FULL AND ENTIRE AMOUNT OF ANY AND ALL BILLS RENDERED FOR SAID TREATMENT. I HEREBY AUTHORIZE THE HOSPITAL TO RELEASE ALL MEDICAL INFORMATION NEEDED TO SUBSTANTIATE PAYMENT FOR SUCH CARE AND TREATMENT. WITNESS SIGNATURE PRINT NAME PRINT NAME DATE _____________________________________ RELATIONSHIP. IF SIGNED BY PERSON OTHER THAN PATIENT AUTHORIZE OF PAYMENT ;EREBY ASSIGN, TRANSFER AND SET OVER TO THE JAMAICA HOSPITAL SUFFICIENT MONIES AND/OR BENEFITS TO WHICH I MAY BE ENTITLED FROM THE GOVERNMENT AGENCIES, INSURANCE CARRIERS, AND OTHERS WHO ARE FINANCIALLY LIABLE FOR MY HOSPITALIZATION AND MEDICAL CARE TO COVER THE COSTS OF THE CARE AND TREATMENT RENDERED TO MYSELF OR MY DEPENDENT. PATIENT/RiTIVE OR GUARDIAN SIGNATURE -------------------------------- PRINT NAME RELATIONSHIP, IF SIGNED BY PERSON OTHER THAN PATIENT WITNESS -:-SI-::G:c-NA:-::T-:-U-:-RE::-----------------------. - - - - - - - - - - - - - - - - ·--· PRINT NAME DATE-------------------------------------------- FORM NO. J00018-2C JHMC48 1111~11m111 ~~~~~ 1111111~ ~IIIIII SCHOOLCRAFT, ADRIAN 1298984 M DOB: 06/21/1975 34Y ADM: 10/31/2009 081X STAFF, PHYSICIAN 01 130381015 ACKNOWLEDGEMENT AND CONSENT By signing below, I acknowledge that I have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by the Hospital and the facilities listed on the back of this form, and how -I may obtain access to and control this infonnation. I also acknowledge and understand that I may request copies of separate notices explaining special privacy protections that apply to HIV -related information, alcohol and substance abuse treatment information, mental health information, and genetic information. Finally, by signing below, I consent to the use and disclosure of my health information to treat me and arrange for my medical care, to seek and receive payment for services given to me, and for the business operations of the hospital, its staff, and the facilities listed at the back of this form. Si(!Pal:t!of patient or authorized representative Relationship to patient Date AFFIRMATION OF PRIOR RECEIPT By signing below, I acknowledge that I have already received a copy of the Notice of Privacy Practices, and have given my consent for the use of my health information for the purposes noted above. I do not wish to receive another copy of the Notice Privacy Practices at this time. Signature of patient or authorized representative Relationship to patient Date THIS FORM IS PART OF THE MEDICAL RECORD M00011 9/06 1111111111111111111111111111111111111111 JHMC 49 Jaritaka Hospital Medical Center 8900 VanWyck Expressway, Jamaica, New.York 11418 Telephone# 718 206-6000 LIMITED POWER OF ATTOR~EY TO PURSUE PAYMENT AND APPEALS AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION ("LIMITED POWER OF ATTORNEY") By signing this document, I give the Health Care Provider, identified below, a Limited Power of Attorney to pursue payment from my health insurer, heath maintenance organization, self-insurance plan, governmental program, or other payer ("Heath Plan") for medical services provided to me by the Health Care Provider, and I authorize the release cf medical information. I, the undersigned Patient/Principal, appoint JAMAICA HOSPITAL MEDICAL CENTER ("Health Care Provider"), located at 8900 VAN WYCK EXPRESSWAY, JAMAICA, N.Y. 11418 my Attorney-In-Fact and authorized representative to act in any way which I myself could do, if I was personally present, and to take all reasonable action, as determined by the Health Care Provider, to pursue payment from my Health Plan and/or pursue any appeal's available to me under my He~lth Plan's policies or procedures and all applicable law, including but not limited to Exterual Appeals under all State and Federal laws, relating to health care services provided by the Health Care Provider. The Health Care Provider, as my agent, may pursue payment and/or appeal, only when my Health Plan has denied payment based on medical necessity. The Health Care Provider will not charge me for its services in pursuing p_ayment and/or an appeal on my behalf. I agree that my Health Plan will pay any amount owed directly to the Health Care Provider for these services. In pursuing such payment and/or an appeal: I authorize the Health Care provider and my Health Plan to release all relevant medical information, including (if applicable) any HIV-related information,· mental health treatment information, or alcohol/substance abuse treatment information, relating to my treatment whiCh is necessary to pursue payment from my Health Plan. I understand that this information may be released, but only as necessary, to my Health Plan, an external appeal agent, arbitrator, court of law, and/or other third party reviewer ("Independent Reviewer") responsible for deciding if the Health Care Provider's claim for services should be paid. I understand that my Health Plan and/or the Independent Reviewer will use this information to make a decision about payment to the Health Care Provider. I also understand that the decision by the Independent Reviewer will be final and binding on me, the Health Care Provider, and the Health Plan, and: 0 , I \,j I authorize the Health Care Provider to complete, execute, acknowledge, seal, and to deliver any consent, demand, request, application, agreement, authorization or other documents nece.ssary, to request, on iny behalf, payment and/or appeal to my Health Plan and, if applicable, to the Independent Reviewer, the New York State Department of Health, the State Insurance Department, the U.S. Department of Health and Human Services, the U.S. Department of Labor, and/or any other applicable agency or body. This Limited Power of Attorney shall not be affected by my subsequent disability or incompetence and MAY BE REVOKED BY ME AT ANY TIME upon prior notice to the Health Care Provider. This Limited Power of Attorney, including authorization for release of medical information, will terminate one (1) year from today's date unless I agree to extend it beyond that date. Any person or entity receiving this document may rely on a copy as if it were and executed original. IN WITNESS WHEREOF, I have signed my name lh~ day of _____________;} 200 YOUSIGNHERE:_~--~~-------------------------- PRINTED NAME: SCHOOLCRAFT ADRIAN ~~~~~------------------------------ ADDRESS: _______________________________________ ------._, I \ i .i ~TNESS: MEDICAL RECORD # __1.:. :2:. : .9-=-89:. :8:_4______________~--------__________________________________ PRINT NAMErfiTLE: - - - - - - - - - - - - - - - - - - - - - ADDRESS: ____~89~0~0~V~an~VV~y~c_k_E_x~p_re_s_sw_a~y~,_Ja_m_a_i_ca~,_N_e_w_Y_o_r_k_l_l_4_18 ____________________ IIIIIU ~11111111~111~ ~II M 1m ___________ _, __ ,.. .. Form No. J00023 JHMC 50 . · - _. __ .. _ ........ _. ___....... _.. ......_,_, ·-.- - ·---. -- -··-·--·-· .. SCHOOLCRAFT, ADRIAN DOB: 06/21/1975 1298984 M ADM: 10/31/2009 23:03 081X STAFF, PHYSICIAN 34Y F/C: 01 130381015 ACKNOWLEDGEMENT OF THE REQUEST FOR EXTERNAL APPEAL AND RELEASE OF MEDICAL RECORDS TO BE SIGNED BY THE PATIENT. In order for a provider to appeal a health plan's payment denial for a patient's treatment, the patient must sign and date the fo!lowing consent to the release of medical records. A certified external appeal agent assigned by the New York State Insurance Department will use this consent to obtain the patient's medical information relating to the external appeal request from the patient's health plan and health care providers. The name and address of the external appeal agent will be provided with the request for medical information. I SCHOOLCRAFT ADRIAN , acknowledge that my health care provider may request or is requesting an external appeal because of a retrospective adverse determination of my health plan. I authorize my HMO, insurer, or provider to release all relevant medical or treatment records, including my name and other personal identifying information, date of admission, assessment results and history, summary of treatment plan, progress and compliance, treatment recommendations, any HIV-related information, mental health treatment information, or alcohol/substance abuse treatment information, related to my provider's external appeal, to the external appeal agent. I authorize the external appeal agent to use this information solely to make a determination on my provider's appeal. I understand that my records are protected under federal and/or state law and cannot be disclosed without my written consent unless otherwise provided for in regulations. I understand that information disclosed pursuant to this authorization may no longer be protected by federal privacy regulations, however, state privacy protections may still apply. I understand that my health plan cannot condition treatment, enrollment, eligibility, or payment on whether I sign this form. I understand that I may revoke this consent at any time, except to the extent that action has already been taken in reliance on it, by contacting the New York State Insurance Department in writing. This release is valid for one year from ___________ (today's date). Sig~~nt (or legal representative) (Date) Description of legal representative's authority to act on behalf of the patient. Patient's Health Plan ID#: - - - - - - - - - - - - - - - - - - - - If you have any questions contact the New York State Insurance Department at: 1-800-400-8882 or visit our Web site at www.ins.state.ny.us. 111~11111111111111111111111111111111111 Form No. J00027 JHMC 51 ------.-----,.-- llll~lml~l~l~lllllllll~~~~~~~ SCHOOLCRAFT, ADRIAN 1298984 M DOB: 06/21/1975 34Y 01 130381015 ADM: 10/31/2009 081X STAFF, PHYSICIAN I HISTORY & PHYSICAL! I joATEj \TIME I I ACTION IF NOT CURRENT: DTCURRENT 0 YES 0 NO DPT CURRENT 0 YES 0 NO ....,_ MMR CURRENT 0 YES 0 NO _. j{ // :} . :-·· {\ =-·- ,. ·, :·-., :; ·-... _:; . . 1-.); :: ;.· ~ : .. ··: _j·.· ~ \ '! '! \ ·I' •, ·,' l '.· . .. r - _, ... -. ~ IIMPR~SSIONS TIME RESULTS UiA -- RBC-- WBCKET BLD TIME BLOOD GASES PH P02 PC02 HCO, HB02 HGB HGCO . EKG RESULTS 0 WBC 0 NA 0 CL 0 C02 ; I I l -~!L_~.L 0 GLUC. _fuM.'!:lAS L i___ ,,-' PHYSI¢iAN NAME (SIGN) Prot-·GLU X-RAY# 0 CHEST 0 ABDOMEN 0 C-SPINE. 0 L~SPINE 0 PELVIS L 0 TIBIA/FIBULA 0 FEMUR L R 0 WRIST L R 0 ANKLE~ R 0 HIP L R 0 CT SCAN 0 / TIME I 1-------- 0 PT/PTI 0 UCG 0 CPK CONSULT ANT NAME ID# T FVJ,i>ioLoGYI ·TIME 0 HGB 0 HCT -· , _.,." ··, \._ : PHYSICIAN NAM.E (PRII:IT)j LAB TESTS OK r~- -- , '-;._ I \ i --\ t_:_· . . . -:-: i _,.--· ~: ;-. i ED READING R --- ADDITIONAL MD NOTESTIME CALLED SERVICE 1 2 . - - - - - .. I DISPOSITION 0 ADMITIED, TIME:--- CODE FINAL DIAGNOSIS 3. .. I . ROOM#--- SERVICE 0 FAMILY MEMBER NOTIFIEDu.-------c---,..--NAME. RELATIONA.SHI~ 0 NO CASE# ,byv__ 0 EXPIRED. TIME: ____ 0 M.E. CALLED, TIME: _ _ _ ACCEPTED 0 YES 0 DISCHARGED, TIME: 0 INSTRUCTIONS GIVEN (TYPE) 0 PVT MD NOTIFIE~~I~POSITION OOTHER _ _ _ _ _ _ _ _ _ _~~~-=~--------- TIME:---- TIME:---,:IN-:::IT:c:-IALc::S- {AMA. WALK-OUT. TRANSFER} CONDITION ON D I S C H A R G E - - - - - - - - - - - - - - - - - - - - - - - . DISCHARGING PHYSI.CIAN NAME ( P R I N T ! - - - - - - - - - - - - - - - SIGNATURE--------- I D # - - - DATE---"'7 ' EMERGENCY DEPT COPY I FORM NO. J0001 Ei JHMC 52 Patient Fact Sheet -Name and Address Employer SCHOOLCRAFT, ADRIAN UNEMPLOYED 82 60 88 PL RIDGEWOOD Phone: (718)570-6224 SSNo: 469-97-6997 Race: NY 11385 Sex: M Phone: s Marital Status w Religion: BirthDate: 612111975 (999)999-9999 NO Occupation: UNEMPLOYED Patienfs Malden Name: ~d~ission Data Nearest Relative SCHOOLCRAFT, SELF RIDGEWOOD Home Phone: NY :r-11385 Rei: 01 (718)570-6224 IUnit Number I I Accounl Number I 1 - 82 60 88 PL 130381015 Admit Date 10131/2009 Triage Time I I I I I _I II Admit Time 23:03 /Prim Care MDI I I Business Phone: 1298984 I lER MDj_ tF, PHYSil NA I I Emergency Contact Guarantor SCHOOLCRAFT, ADRIAN SCHOOLCRAFT 82 60 88 PL NY RIDGEWOOD I 11385 (718)570-6224 Home Phone Home Phone: Business Phone Rei: Rei: 01 I Business Phone: 01 Occ: (71 8)570-6224 SS: 999-99-9999 J UNEMPLOYED Employer UNEMPLOYED Insurance Information Ins: NO COVERAGE/CHARITY CA Insured: SCHOOLCRAFT, ADRIAN Group Number: Policy Number: Rei: SELF/ 82 60 88 PL RIDGEWOOD . Phone Number I NY (718)570-6224 11385 FIN 99 Auth Number I L--------J JHMC 53 SCHOOLCRAFT, ADRIAN Patient Name Account Number 1298984 Medical Record No. 130381015 Date 10/31/2009 Jamaica Hospital Medical Center ID 130381015 Emergency Department Record SNW History of Present Illness 34 Year Old Male Patient Presents wfth Abdominal Pain Epigastric for 15 Hour(s). The Onset is Sudden. The symptoms are Mild. sharp, Intermittent, unknown duration. Symptoms improve with without treatment. Addttional Symptoms or Pertinent History also involve None. Furthermore. the PatienVFamily Denies Anorexia; Fever; Genital Pain; Back Pain;. Patient states exacerbating Factors that occur are unknown Radiating Symptoms include No Radiations. Patient is a Police Officer brought in handcuff by his colleagues.As per Patient he wasn't feeling well about 15hrs ago and at about 2 pm he told his superiors that he was le<Mng for home. His colleagues from his Prescinct went to his home and hand cuff because the EMS said Patient was behalling irrationally. Review of Systems (Symptoms and Signs not cowred in the HPI) Neuro Neg GU Neg ENT Neg Resp Neg Musculosketelal Neg Hematologicllymphatic Neg Heart Neg Psych Neg Skin Neg Gl Neg Endocrine Neg Allergidlmmunologic Neg Constitutional Sxs 0AII other ROS negative Eyes Neg Neg .. 0 Vital Signs!Triage/Nursing Notes Reviewed and Agree 0 0 0 Hx unobtainable due to Tx urgency or poor historian(s) Other PMHx 0 Asthma [ ] COPD DeAD D Past Medical History No Relevant PMHx Additional Information from Police, Ambulance. Nursing Home or Relatives Diabetes [ ] HTN 0 0 0 Social History ~ No Relevant SoHx 0ETOH Famlly History ~ No Relevant FmHx 0 Cancer 0 Psychiatric 0 Renal CHF 0 0 Old Medical Records Relliewed 0CVA Seizures I I jNo Significant FMHx Physical Exam Exam Time I Drugs Smoking Additional Sx I SNW q;Qj] General Appearance AwakeA&Ox3 HEENT PERRL EOMI Moist Mucous Membranes No Icterus Chest RRR NoM Lungs CTA No Ret Chest Wall NT Abdomen No Pulsating Masses BS-NUNo Bruits Tenderness-None GU !Extremities Throughout all extremities erythematous impressions on the wrist bilaterally at the site of handcuffs application CBR < 2 sec Active ROM-Full mild tenderness on the wrist where the hancuffs were applied ~ S:i:o No pallor/ rashes wann & moist Back NT no CVAT, Back Flexion 90 Neck NT Full ROM No JVO J ~~------N&OtbA~YD-------------------- Repeat or Additional Clinical Notes MD Notes Time SNW The following Life or Limb Threatening Differential Diagnosis were considered: Appendicitis; AAA Leaking or Rupture; Incarcerated Hernia; Mesenteric Ischemia or Thrombosis; Myocardial Infarction or CAD; Testicular Ovarian or Salping Torsion; Large or Small Bowel Volvulus; Liver Failure Pancreatitis; Rupture Viscous (Liver Spleen Bowel); lntraabdominal Abscess; Ectopic Pregnancy; Intussusception; Hemolytic Uremic Syndrome; 1111/2009 0:03 Looks Comfortable; Not Ill Appearing; No Peritoneal Signs; Genitals Non Tender; No Hernias; No Pulsating Masses; Murphy's Sign Negative; McBurneys & Rovsing Sign Neg; Femoral Pulses 2+ Bilaterally; Psoas Sign Negative; Obturator Sign Negative; 11/1/2009 0:03 PI Sx(s) improving. No Sx(s) or Objective findings that are life or limb threatening. Medically Screened and Stable for disposition(Trans_fer) from_the ED. 11/1/2009 0:14 ---SNW ------SNW JHMC 54 SCHOOLCRAFT, ADRIAN Patient Name AccountNumber 130381015 Medical Record No. Date 1298984 10/31/2009 P_s_y_c_ht-·a_t~_c_o_n_s_ul_t_c_al-le_d____________________________________________ ___1~ 11-/1/-2o_o_9 _s_Nw ·___ __ SNW Patient seen by Psychiatry team led by Dr Patel who recommended transfering Patient to Psychiatry ER after medical clearance 11/1/2009 6 50 ' JHMC 55 Patient Name SCHOOLCRAFT, ADRIAN Account Number Medical Record No. 130381015 Date 1298984 10/31/2009 Sped men Cdlected 1 ECG .Rad Ordered Diagnostics MD Initials Time Diagnostic Ordered Result Reviewed Result lnterp relation 8 RN Initials Time GLE 10/31/200 23:10 Pulse Ox 97% SN GLE 23:10 SNW 1111/2009 0:12 Amylase Amyl as e-44 ,Status-FINAL SN VCA 0:14 SNW 111112009 0:12 Troponin Cancel SN VCA 0:14 SNW 111112009 0:12 CBC WBC-12.3,Hgb-14.8,Hct-44.0,Piatelets-251,Neut-82.4,Lymph11.0,Eos-0.2,Baso-0. 7,Mono- 5. 7. MCH-29.4 .MCHC-33. G,MCV87.6,MPV-8.5,RBC-5.02,RDW-13.7,Abs Baso-0.1,Abs EosO.O,Abs Lymph-1.3,Abs Mono-D. 7,Abs Segs-10.1,Smear ReviewCompleted, Nucleated RBC-O,NRBC lnst.-O.OD,Status-FINAL SN VCA 0:14 SNW 11/112009 0:12 Chern 20/CMP AGPK-14.10.Na-138,K-4.1,CI-104,C02-24,BUN-14,CR1. O.Giucose--94, Ca-9.4,AST -46,ALT-51,Aik Phos-57.Aibumin4. 7,T -bili-0.6,Prolein-8.2,Anion Gap-10.00, Status-FINAL SN VCA 0:14 1111/2009 0:22 Lipase Lipase-55,Stalus-FINAL SN NRI 0:33 NRI --- Medical Orders MD Initials Time SNW RN Initials Time Order 111112009 0:14 VCA Heplock Location-Response-Quantity RN Remarks 0:14 - --- MD Procedures 1-Pr_o_c_e_d_ur_e_oa_s_c_ri.;.pt_lo_n _ _ _ _ _ _ _ _c_o_m_m_e_n_ts_________ _ lime ~l Recommended LOS/CPT /IC D-9 Code MD GLE 6:57 :_:P::uls::;e_::Ox~------------------------..:::.:.:.:;;D-: . 2:~. : c: . .PT 947 6 6 Physician's LOS= Nurse's LOS= 4 5 99284-26 612 APC Diagnoses Abdominal Pain 789.00 ICD-9 Psychosis NOS 298.91CD-9 MD Disposition SNW 6:56 Condition SNW 6:56 RN RN Date/ Time Transfer Psychiatric ED VCA 1111/2009 Stable VCA Physician (Print) Physician Signature Nwaishienyi, Silas (MD) (1_/l .:~-·)-fr/ ·. r. Admit to 6:58 MD Time 6:58 Other Physicians Nwaishienyi, Silas (MD)-Lwin, Khin Mar (RES) JHMC 56 Patient Name SCHOOLCRAFT, ADRIAN Account Number Medical Record No. 130381015 Primary.RN (Print} Calderone, Virnalyn (RN} Date 1298984 10/31/2009 Other Nurses Ledbetter, Glenda (RN)-Calderone, Virnalyn (RN)-Shankar, Koesmawatie (PIR)-Rinehart, Nedie (RN)-Ward, Germaine (Reg)-West. Juanita (RN)-Charran, Donna (PIR}-Paris-Taytor, Elyane (WC)-Bido-Rosa, Ana (Reg)-Stancu, George (Clerk) This chart has been electronically signed via the EmpowER software. JHMC 57 Patient Name SCHOOLCRAFT, ADRIAN Account Number Medical Record No. 1298984 Date 10/31/2009 130381015 Jamaica Hospital Medical Center Emergency Department Nursing Notes and Vital Sign TimeEntered: 11/1/2009 Temperature Pulse 0 98.0 T 4:52 Vitals Taken By: Blood Pressure Right 81 R 125/77 NRI Respirations Pulse Ox Pain Scale 21 100% Discomfort 1 - 2 L Left R Nursing Notes RN Initials Time Note Entered Note 11/1/2009 0:00 VCA Brought in per stretcher by EMT on Police custody.A & 0 x3. Unlabored resp.(+)Left Lower quadrant abd. P"ain 3-4/10 x 15 hrs ago.Denies nausea & vomitingAbd, soft, non-tender. BS(+)normoactive. Skin warm, moist, intact w/ good capillary refill. 11/112009 2:00 NRI Noted w/ redness on the Rt wrist with lhe hand cutf.Polce officer made aware.& requested to loosen a lttle bit yet refused.Will closely monitor for poor circulation. 111112009 4:39 NRI pt. Resting;A & 0 x 3. no distress.waiting for evaluation and disposition.under police custody. 11/1/2009 5:54 VCA Psyche consult in progress w/ recommendation to transfer to Psyche ED until medically cleared.Pt. Verbalized, "My wrist is numb, I doni feel anything right now."Encouraged to stay still on bed.Avoid unneccessary movements.Conversant to his lathe< by phone. 11/1/2009 6:58 VCA Psyche ED made aware of pt. For transfe<.ML pulled out.Awa~ing transfe<. Primary Nurse Diagnosis Primary Nurse Outcome Comfort, Altered Demonstrate DecreaseS & S Primary RN (Print) Achieved Calderone, Virnalyn (RN) JHMC 58 Jamaica Hospital Medical Center Triage Arrival Date/Time 1 1013112oo91 • Triage Tillle 23:0311 Category j3 ESI-3 (Urgent) I Waiting Rm lime Exam Rmlime P;:~tient I 23:031 I SCHOOLCRAFT ,ADRIAN I 23:031 Narrie PCP Staff Status _F!Jmlly Physician Transported by Mode Medical Record Number None JHMC Ambulance Stretcher 1298984 NA .Historian rPolice Dept 1 Custody Yes Notification Beat # PCT~~~~~---------------c~-------- Self ()ns~~Ti~e Chief Complaint · J !Abdominal Pain (Lower) Account Number 81, #27009 130381015 Lo~ati9n DOS Hour(s) 14 -· P< ~ No Sigrl.ificant 0 Asthma 0 0 OM Hi~tor 0 0 CAD 0 0 Renal Psych AIJ~rgi~s D Cancer 0 0 CHF CVA !Immunizabons UTD? UTD l Me~trlistrlt~~ 1P~ychol~!llc~l E~~i -•. j Alert Oriented Equal Clear ~~ Reactive Diminished DO DO I Constricted I Fixed ' Dilated Cataract p 0 Color Normal Temp Normal Moist Fall Risk Assessment ~ \ No Fall Risks Identified _ _j ~~~~~~--~----. 1 I No risk identified Time A3-09 Triage Nurse: Normal Triage Ill: LWBS Head Height Circumferenc I ROM ~--------------------JI~M_il_d_~_--__3 -_4__~--~ __ ~-~ y~u I Yes/No 23:03 Assessing Patient's, Child's or Parent's readiness to learn Primary Language I* Mandatory completion of Domestic Violence Referral. English Assessed Disability No No Disability j Communication Barrier 1 rJ Language Translator 1 0 Motivation Level Alone Going Home with Self LW Completed Txl Eloped 0 AMA 0 AMA Refused Med I Comprehension Ability GLE 0 Med Knowledge Level lndependenl Daily Living Ledbetter, Glenda (RN) GLE _l Pain Scale Are .being hurt by someone you live with or who takes care of you' Living Conditions 0 0 Functional 0/C Planning Plan Triage II: Miscarriages 0 Pulses Domestic VIolence Assessment J Ab 0 Extremities l";" c==o_ Left~ 08/Gyn 0 ------ Suicide Risk Assessment Right ---' G Motor Total Blood Pressure *If yes to TB or Infectious question take precautions I ~ji~Qx I I Weight(Kg I I \=---~~~-=~~==="--1 Jiog Kg-- _ _j I Eye Verbal DO DO DO DO DO DO jts TB Hx, PPD Pos or No Infectious Exposures? :Giascow Coma Scale R L Retractions Respirations -------------------------------------.-.- ~EJO II II I Pulse Riqht Left Unknown J Rales Rhonchi I" Tympanic _0_.--_s_u b_s_ta_n_c_e_A_bu_s_e__________________ __ . 1 199.0 Rectal ----il Seizures No Known Drug Allergies Wheezes -- Tern Additional: I Oral COPD 0 No Meds Male Vitals Medications ~ 34 Years Gender __ __t-he--sc_e_n_e______ B_P_@ PMH~ O KTN ·-···· J 1=======~=====9 '='!':~:,(.,::~~::, ~=~-- '~~ '"'"_u_s_w~it-h-in-c-re-as_ed Past Medical 06/21/1975 Age I 6ZJ - Med ----------------_J Patient Rights and Responsibilities and Guide to Pain Management given to Patient. Family, and/or Caretaker JHMC 59 Patient Name SCHOOLCRAFT, ADRIAN Accounl Number Medical Record No. 1298984 130381 015 10/31/2009 Emergency Department Pharmacy and Supply Charges Interventions Intervention Name Comments Charge Code Heplock J I Diagnostics ~_Di_ag_n_o_su_·c_o_rd_e_re_d_____________________________________________ C_ha_r_ge_C_o_d_e__________________ ~ I Pulse Ox 0 esc o Nurse LOS 5 612 APC Charge Code _ 0 JHMC 60 Jamaica Hospital Medical Center Medication Reconciliation Patient Name SCHOOLCRAFT, ADRIAN Medical Record No. 1298984 Account Number 130381015 Date of ED Visit 10/31/2009 Allergies INo Known Drug Allergies Home Medications Medications Administered in the Emergency Department Medication Prescription provided on Discharge JHMC 61 • r ~-~!!..rD 1• c~~sss1s45 11\ll\liiiiiiiii\IIU~IIIIII n131, v 1 ''' Ros_p. Agoney [_[ _l L. {Pupils) R r'C""ole..;l#,_._,--, I I ,_ J Tlms 1 -·T·····r······-, _! J J Glasgow limo 2 i .·\b•li,:'I'""·'J'f:;,.• , 0(;:.5'-:;r.:!J 0 u; l;r.~~"':.':!'-'" . D G~ .Q;;s;1hO:~ O•i~'zln;Tr:\:"1 O··icrr.!lali1Lll.-,....,, o, . . 0 ,,~,. r~y,:r;lir··~ ~ s., ..... Q\,.:rff•,ll?~l~l:•.!•l:~.: oL~I)o,_,/.<:llr"•rJ(r')>or• n-;.~\Jo~\:~J- - - - - - ~.l.·::._ --···-·-··· JHMC 62 JHMC 63 ~Cii.i!!!I'..Qt<r,tr.H.>.\~9 0Sinl.!tJ.l 0CI"'OJ.:.ir11J Olh•!n;l,rr! OC•tm:ill'il 0 o,rr;,.-uny Swei:c..~-.'!'g 0 l'b~! s: l:;t~!'\~ OIIJ/t·,n=r-:-~Jal Rmr.v::1'7Jt"' .(l!] ,,,,.,,,.,,.oi.P:tn~ [J G:tfllt.'lC,,Vt,;;i. • 01'-'iU·t~.\a Svn::;t;.!rt< o~~ 1;..~.--•v•:l'll•fl'l,.,f! []n't'~-;:,:Ql-~r;o Cl~a·•H:I Oc:''l'Jn:·-;~t:k•:= o,\:t·.;.,,, :\1';~:~1:\:::-;:n Q.:.,,,,,,-p~;1 rtf.:c:-·-m.r 0 0 0 ·':"l':,·,r:rr.,~.,;;~ ~p::r::<...'''~- C C >=:•!q!•"-'!1-:ll:: I'~ :u~ 0 -~t-: .:r'~'·i!~ .. ·~""-'""·~ , .. _. 0 ~;;. .. ~--!·,.~:~. i=:::••,!t•;:u·.~r;,,:,..:trl:!\1 o•.l:tr-.,,·t::-·, '''m!''"''-~''.1 t-1-·r;•.•r:•:•l Qlb::l ('1::··-~·;b,:!\1!1' _5,•,\.:·:r..-. f.",::po:J.~; Qr,;'.:/'1-~1 ·-;...,,if)' ~-'-'•:·.!1 Oqt.:-~Phllt'll' ~ .. ! ..•..;,! 0 ;:-,:;...-;:....-;"- - - - - - . 0 ~_,v,.. o~.t·.·,\ ~j; ==-1::~-r,,_ · ::: ;•. ~:.:~..:..:\·;·". l""=co_c="-1 Q£,n(,;.,,hor:.'\l.\l"·~"' o,,.,c .,. On:- JHMC 64 JHMC 65 ,-v<v cr =.' ~~- ! .·? L[:. il)10/31/2009 PATtENTsHAMe -- SCHOOLCRAFT ~EETAOO!iESS c..·- .r--o ·J_ AD.RIAN < -,"J- --[;,w l, ----- rL F~1Clr~1~9f"~~iON r~:-srATIJS·rc•tHEJ<~-~---"'PF:IVATE M"'5 IrA:r~~n 'Wj.a'i"On.CLINiGNMa~-- iJonE o• ARl<IVAl OAlE·-~Nr.} TIUF. r'c"coo.<PANI[Q o;-- or AC.Cit::a:r-11" _ -_] [_· .. .'FIHANljA~ ··INSURANCE l -~- cuARANTOR's 1111\)Jc (A.i,,c,J.Jr;, • ·,,;_;~:;.;;;;.""" "~ ,, lEUPHONE NO -- --- J DA.TEOI==at.n:n-t~ i 34Y lQS/21/1975 4 -~ ol..AcEu(aiRTH-- r.~n~;,t~~~N-NAMt.FI~STNAMF. . r:~;,o~ i'~-~~~~...0 - 130381015 1'"'7-Riia~------- !lr<JiiR<O ATWORK71 AUTO ACCIDENT? PCT NO HEJI:KBED FRO~. f'OUC.C OFfiCE'R NM.!E & l!AOGENO. ------r-''irni~N· ·I ·---------- R~LA TI:~~SHIP sociAL.sc~UAtiYNO n;LE~N_{>iO____ A'~'% -J.) f .. - /__)Q_d___ COJ.tPi..AlNT____ ~~~=-- \ l , ~_c \ /l PAIIENTACCOUNTNO. __1 STAte-. llecoo~ ----? / EMERGENCY MEDICINE RECORD 23:03 IMmi~U!l"~Q~R.!>'O 1298984 __ _PN.!S'!I!'P€ E DATE ~No TII.E O< AAANAl. [BEGISTRA1JON 081X LOCATION: 0 ;;o·--r PMD 0 0 TRUMP 0 CLINIC FP 0 OTHfR-•• ------------ NEXT OF KIN JI,OORESS --,---.,-,--'--------------~---,---~-----~ STA'TE ZIPCIJOC CfiY Sr~Eer ADOA~;s.-; r C.iiAAANTMs-~.;wtovER:-------- fs1~Eir Aoo.ru:ss ---- --c~ STATE ZIP CODE I ----·------N-A... -E-··--·---L .......,_.._--- .. _, ____ ,A .. - ........... _ - - - - .. -···-------··---GR.,-, -OU,-1'-..0-,---- POLICY NO. FQLICYNO. GR()UPNO. VIT Al·SIGNij TIME B.P. PULSE RESP TEMP TIME B.P. PULSE RESP TEMP . 'IF.:oRDERED, CHECK wHEN COMPLETED: 0 OXYGEN GIVEN RN SIGNATURE DATE J~oN-M~CATION~~~R~~:"~~~~~Li:uRE~. ETC~---- _J_TI~~---r·----------·-· DATE 'i MD SIGNATURE RN SIGNATURE 1 TIME ---1·----l---,- .............................. ----- -------------------·--·----..------ __, _______ -----1---- I i ...........----------------------------·-----+-----1-------''-- I TIME _L -_--r~t ~-~ i [ __ ..................--- . - .................... _ ..... +----· I MEDICACION ~ -MEDICATION :JRDERS .,<>O_S~ =_ t_·____ H_QUJ.•. ! I I ---!---f\.10 SIGNATURE RN SIGNATURE TIME --= ==- r- =-t--- _L[_ _ ACCOUNTING DEPT COPY FORM NO. J00018 JHMC 66 ~ ....... SCHOOLCRAFT, ADRIAN .HOSPITAL 1298984 NTER(I/\ \}v CONSULTATION REPORT M OOB; 06121/1975 34Y OB1X STAFF, PHYSICIAN ADM: 10/3112009 130381015 01 . THIS SECTION TO. BE FUUY COMPLETED BYTHE REQUESTING PHYSICIAN REASON FOR CONSULTATION: LJCONSULTATI()N ONLY OCONSULTAllON WtTH ORDERS b-~~~--~~------------ siG&A~ OGONSULTATION WITH FOLLOW-UP DATE: t•/' 1 ~ "{ TIME: 1): 3 o ,;... m oPiNION OF CpNSuLTANT; F=<>Y":"-"--''"'---"'-'~I""'of~~~~'""r=-·-·r-v:_.=/=(._==~J..._·_,·_t"'::..· 0 -';3..w::At=J-·-¥4=· <\l_~_,,,__J_fl'--o_f,_·_c_~__r:b~;.f _r"f'\. __ 1 j ,'__.,.,.,_1 'v ,,..,h/- t'" by___,'f!,___,\f--!.p-=J)=--_,??b [ I Jf fr.ec.1 ';...t, ;',-, -'J,..._~·c..-"..:.J._._._,c."-'i"b'lii'----'~-·o_-'-'t.V~t...-=-,J.-·';_.--'-co_l__.cc::£_'fZ --"-'t,v::...:r'__:.th.:..___c.=c.....c-r~. ~ / "-' '~ J., d_ cn-r / f'.n I .. __ h,'M /l...t l.b . t;,;3 c. -ji.o/,., , J h fr...O(.V..:~ c. """''-"( t?-.J c.afl ~ Ny~c.<iJ.. f ~'tJ c./-. Ct-r>N> If- t-J ~( d'znc'NI.fll 1<-L ~~~ ~ r:~·'t:.;.c _ _,[-y..l (.,.- '<'t'Jo·o <2r"=l I Cv!..{ J..,•,J ,~r-'J t-"tre.,t,..~t .. K,..,J r·e.(loYt"~ cv> (',c;f/,"" 'f- c..~f,·"':J ' y-~ blu'] ___ !':_v-d hi':!/.._...,. h-c..IAh.r/ {IUJ><'ti"C'VJ. J•c:-r 1'-P f-...cv> o.-b 0 •.f 1L I I (' n. n~ ll ··r<->l vV.,fl 0' h Y'.,'J Jt',-, L;_ gLt <OJ/' (1cj1C-r t c ;r o.c- f f CoMultant Print Name; ORIGINAL Signature: ~ MEDICAL RECORD t .:.~-:__b_ cJon,Vf-Vuf'•fli....-. ¥~ --------'3> ·...._. fooh /A,. -- -_. C c-n11 · ,.. lo-u! Dale: CARBON COPY· CO.NSULTANT FORM: ItO llCM: 1\49 REY. 1107 JHMC 67 ~~~LCRAMFT. =%'612111975 ADM:l0/3112009 OS1X 34Y 130381015 01 STAFF. PHYSICIAN CONSULTATION REPORT CONTINUATION -----'---·------ .),P-I'jll'f.o(laJt'py.,C~ tr~ct,.,._. .... ~ r""") ..i'v>J'I:t';,.\,,.1 r Q.<>.r:b Fr" th''J '(f,'('.,f'i...l c..v-.oL c.r..r-h'r-..J ../'(.,-tpervr'.Jw. 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(':!· ;'n.'f·~Me 1-Vc'H-. o-.f1nra".,..l'o.f':;o.,.,f <>o6b-D..c.t. t ,_ I lf.,._ r'.t ~T ...H~.J.~ni'~s ,J"'/lt"r\n'J(Y'(' 1 ·....._.- , h~lL~r-t.t'r-~ft'c'Yl 1-fl' cUn/A...t Cons tilt<! at Print Name: .. _f. H.z t'J•? '-''dj"'{ ,'d~aft·," Signature: ORIGINAL • MEDICAL RECORD pe-.Y"a.0~J_'ol 1 obo~-1- b.,'.; }.!!!:"'r'r::t'Jo.f ;"cf_.t,".fi'&Vl ,;}' ?G.,~.q. Date: Time: CARBON COPY- CONSULTANT FOKM: 112 ITEM: 1875 Rf.V. 1/07 JHMC 68 --~---------·---- ~~~l~FT. ADRIAN ~~M:10/Jl/2QQg 09{?~: D6121M75 AFF, PliYSICIAN J.IY 1J0391 015 01 CONSULTATION REPORT CONTINUATION _ ft '?. r G) IV\ Q ' 1.t r- ..,~v-d c.-y~ tl Y\ v- 6-r-o-l. "-· o.t~rr drt.,~t?f.....,t or.cl . Ht'J' - IL L! f · o JU cetnQ.. b .t-e r- v r:. tr' o_vt'---+f,:,<""'_c__ n'.J·h (il5rtf'-.l'~-"-.- fC> pJ~I :£. P. c..bf'4· (V w--a..dr"col £'(e_o,y-c:-.,..'-< V>l;'th JJr. NWoq'-J.•h/o. Y>y,'t' c.r--.ol.. J"c.,-r)"-"""'1ch'r Crl'i?.ed p;'/_:_},~JJ_,·c··_ _.!..,P_::a::_:~_::_'"_:_/_,_,_·_ _-,--,_ _ _ _ _ _ _ _ _ _ __ ";)i.t<r.tNd - Cc.p ¢P7 KhinMarlwin M!}.---- Ps;·ch/airic Residenl ' I -------~------------------- ···\..,_. GonsuHantPrintN~ Signature: ORIGlNAL ·MEDICAL RECORD Date: TU11e: CARBON COPY· CONSULTANT FORM; .112 !Th"M: 1875 REV. 1107 JHMC 69 ~ SCHOOLCRAFT. ADRIAN JAJAAlCA HOSPfTALIIEOJCAl CENTER PATIENT ClOTHlNGNAI..UABLES INVENTOIW 1. ALL PAtiEHlS GLOlliiHIJIVAI..UABLESISENT HOME 2. DENTURES TAKEH HOfiiE BY FAJIILY MEMBER I 0 YES El NO C vt:S 1198984 M DOB: 061211197~ 3-IY 0" 130381015 AOM:10/3112009 081X STAFF. PHYSIC\/;N 0 NO ·==='-'.!=="-'":=~====----- --~=------------------------·----"·------"--·--·-----·-·""'""". isTAFF MEMBER RELEASING PROPERTY: .... --·----------··" .... ... ----;;;;;;-;...--~-· !~ATIENTIFAMil Y MEMBER RECf:IV\NO PROPER fY: _ ______ · - - - - - - --- - RELATIONSHIP: 127J 1-4'0RM 554 JHMC 70 SCHOOLCR!IFI, ADRIAN 1298984 M DOB: 06/21/1975 ADM: 10/31/2009 23:03 081 X SlAFF, PHYSICIAN ~--· 34Y F/C: 01 130381015 ASSIGNMENT AND RELEASE OF INFORMATION STATEMENTS Authorizallo·n to Jamaica Hospital for rolaase of Information: I hereby authorize ancl direct Jamaica Hospital having treated me. to releasa to govcmmental ag'ltlcies. insuranct> carriers, or others who are financially liable lor my hospitalization and medical caro, all Information needed to substantiate payment for such hospitalization and medical care and to penni! rapresentetivet; thereof to examine and mako copies of all rflCOrds relating to such care and tra.almenr. -----~" d:_'---=-:-~~- y~_ ·oate Signature of Patient or Authorized Representative Assignment to J""'atca Hospital I hereby assign. transfer. and set over to Jamaica Hospital su 1cient monies ;mOlor benefits to whiCh I may be enUUed from governmental agencies, lnsumt>ec carriers, or othDrs who 3fC fin dally liable for my hospitalization and medical care to cover the ;aid hospllaL costs of the c<1re and treatment rendered to rnyself or my dependen Signalure .of Insured or AU1horized Data Representative Sale Medical Device Act I r:onsonl to the provision of my social security number to the manufacturer of any device that must betr~cked pursuant to tho mandates of Ute S3fe Medical Device Acl. I understand Umt the manufacturer will be given my socia·l serurlty number only for the pmpose or finding me In the eyent that a medical device, whir.h is implanted in my body, or uscr:l io my home is defective. Signature of Insured or Authorized Representative Patton! Entitled to Medicare Benefits I certify that the information given by me in applying for the payment under Title XVIII of the Social Security Act is correct t authome !he holder of medtc.11 or other inlormDtion about me to release to the Social Secunty Administration and Health Cere Financing Administra~on or its Intermediaries or carries any. information nt>eded lor this or a related Medic~ra claim. t request thal payment of the authorized benefits be made on my behalf. I assign the oonefllS payable lor the physician services to !he physician or Ofganizatlon furnishing the services or aiJihrlrize such physician or org~nization io subm~ a claim to Medicare for payment on my behalf. ·"-~· Date Signature oltns·ured or Aulhmized Represenlatjve Financial Agreement For "nd in c<msideration of se•vices rendered or lo be rendered by lhe Jamaica Hospital. to the patient whoso name appears below, tim u.. dorsigned (jointly end severally. if mora than once) hereby agree{s) to be tully and totally responsible lo the hospital for payment of all charges as submitted by the Hospital on the account of said patient and make payment in accordance wilh the policy of payment of bills at said Hospital. It is further agroed that lhc charges as incurred represenl th~ f~ir and reasonable value of services rendeled and are In accordance witn the posted charges of the Hospital which are available ut:)Qn lequost. Payment rnay be demantkld at any time. and lailurulo dem~nd payment of lha patient shall not oo a prerequisite to my (our) immediate r""ponsibility lor payment The undersigned has read the above. been informoo of ils natum and received a copy of lhis agreement. signific;~nce arid acknowledges llle contents or samo and has ~-~-n-to-r----------------------------------------- Dated SCHOOLCRAFT, ADRIAN -Na_m_e_o--:1-P-alient Address - Guarantqr 10/31/2009 23:03 Hoopitol No. Date ol Discharge Date or Admission 1 elephone - Guaran\or Wilnest> Date FORM NO. J00123 JHMC 71 SCHOOLCRAFT, ADRIAN 1298984 M DOB: 06121/1975 ADM: 10/31/2000 081X 01 34Y 130381015 STAFF, PHYSICIAN PERMISSION FOR TREATMENT I HEREEIY AUTHORIZE THC JAMAICA HOSPITAL. THHOUG~IITS MEDICAL STAF~, ·ro PERFORM OR HAVE PER~ORMED. UPON THE PATIENT WHOSE NAME APPEARS HEREIN. StiCH MEDICAL AND SURGICAL SERVICES, SURGICAl. OPERIIIIONANDIOR OTHER PROCEDURES OR THERAPY UNDER ANESTHESIA OR OTHERWISE. AS MAY BE DEEMED NECESSARY IN RELATION TO EMERGENCY THI'ATMI:NT ON THIS DATE. ll'tELATIVE OR GUP.ROIIIN WITNESS DATE . · · - - - - - - - · · ·"'- .ARANTEE OF PAYMENT FOR AND IN CONSIDERATION OF SERVICES RENDERED OR TO BE RENDERED TO THE HEREIN NAMED PATIENT. I DO HEREBY GUARANTEE 1'0 PAY THE JAMAICA HOSPITAL. HIE FULL AND ENTIRE AMOUNT OF ANY AND ALL BILLS RENDERED mR SAID TREAl'MENT. I HEREilY AUTHORIZE l'HE HOSPITAL TO RELEASE ALL MEDICAL INFORM/ITION NEEDED TO SUBST r,NTIATE PAYMENT FOR SUCH CARE liND TREA'IMENT. WITNESS PATift'RELATIVE OR GlJARDIAJII •... --- _, "''":.NAlU~l: _____ .................... , _______ ... . ·~;;INf.kAI'.te::-,-------·· ·····---------·-··· ··------------· DATE--.... --·-·- AUTHORIZE OF PAYMENT ·-.~·ERE~Y ASSIGN, TRANSFER AND SEl' OVER TO THE JAMAICA HOSPITAL SUFFICIENT MONIES AND/OR BENEFITS TO WHICH I MAY BE ENTITLED FROM THE GOVERNMENT AGENCIES. INSURANCE CARRIERS, AND OTHERS WHO ARE FINANCIALLY LIABLE FOR MY HOSPITALIZATION AND MEDICAL CARE TO COVER THE COSTS OF THE C!IRE AND TREATMENT RENDERED TO MYSELF OR MY DEPENDENT. WITNESS PRINT NAME DATE---· FORM NO. J0001B-2C JHMC72 IIIJWIHI:DUII SCHOOLCRAFT. ADRIAN 1296984 M ADM; 10/3112.009 DOB; 06/2111975 081X STAFF, PHYSICIAN 01 34Y 130381015 ACKNOWLEDGEMENT AND CONSENT By signing below, I acknowledge that I have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by the Hospital and the facilities Iis ted on the back of this tl.mn, and howl may obtain access to and control this information. I also acknowledge and understand that I may request copies of separate notices explaining special privacy protections that apply to HlV-rclated information, alcohol and substance abuse treatment information, mental health information, and genetic information. F1nally, by signing below, [consent to the use and disclosure of my health information to treat me and tmange for my medical care, to seek and receive payment for services given to me. and for the business operations of the hospital, its staff, and the facilities listed at the back ofthis fom1. · R.::lalionship to patient Date AFFIRMATION OF PRIOR RECEIPT By signing below, I acknowledge that I have already received a copy of the Notice of Privacy Practices, and have given my consent for the usc of my health information for the purposes noted above. I do notwish to re~eive another copy of the Notice Privacy Practices at this time. Signature of patient or authorized representative Rela1ionship 111 patient Date THIS fORM IS PART OF THE MEDICAL RECORD M00011 9106 JHMC 73 Jamaica Hospital Medical Center H900 Van Wyck Expressway, Jamaica, New York 11418 Telephone# 718 206-6000 LiMITED POWER OF ATTORNJ.:Y TO PURSUE PAYMENT AND APPEALS AND AUTIIORJZ,\ TION TO RELEASE Mf:IHCAL INI-,ORI\IATION ("J,JMITEO POWER OF ATTORNEY") 8)' siguing Ihis document, I gh·c the lleallb Care Provid••r, identifkd below, a Limited !'ower of Attorn~y to pursue J»•)·mcnt from .IllY health in~urer, hcatb nlaintcnuncc orgnniulion, s~lf-insurancc plun, governrnenlnl program, or other payn ("Jicath Plan") for medical ser.·kcs pro•ld~d to me by the Health Care Pnwitlcr, on<l I >lulhorlze the r"Jcas.- of mcdicnl lnformntlon. u,., I, undersigned Patient/Principal, appoint JJ}J\J,\ICA HOSPITM.. MEDICAL CENTF.R ("Health Care Prc>Vidcr"), located at !1900 V,\N WYCK EXPRESSWAY•. JAMAICA. N.Y. 11418 my Attorney-In-Fact and nuthori1.cd representillive It> ud in uny way which [ myself could do, if I wa$ personaBy present, nntl to takr all rt'ilson~ble adlon, as Llclerrnined by the Health Care Provider, to pursue payinent from my Health Pl:m aml/or pursue nn)· appeals :n'ail:~hle lo me under my Health l'l:m's policies or procedures and all :~pplicnblc law, including but uot limited !n Extcrnul ,\ppcnls Ullder all State nnd Federal law:., relating in health cure ~en·!ccs provided by lhe Hculth Care Pro,·itler. 'l'Jw llealth Care Provider, as my a~:ent, mll)' pursue payment a·ndior ~ppcal, only when my H.. alth J>Jati has denier! payment based on medical necessity. Th<' Heallh Care l'rovider wi.il 110t ehHrge me for its servicCJO in pursuing paym<>nl ~nd/or an app<."al on my heh:>lf. I agree thai my Heolih Plan will pny '"'Y amount owed d.ired.l~· to th~ llcallh Care .Provider fnr IJJcse services. Ju pursuing 5llch puymeul und/or nn appeal; I aulhnrlz<> tlw H~allh Cur~ pruvidcr and my H~allh l'ian to rdcasc all rclc\'11111 medical infnrmatlon, including (if applicuble) nny HIV-relnlcd information, mental hc:ilth trcntment information, or nlcobol/snbslancc abuse treatment information, relating lo my treatment whkh is uec~ssur~· lo pursue paymeill from my Health Pllln, I understand that this information may he rckast'rl, but 01ily as !lece"~ury, to my Health Piau, llll external Rppeal agent, arbitrator, court of law, and/or other lhird p"rty rt"vlewer (''Independent RcYlewer") r~sponsiblc for deciding if the Health Care Pro1··ioer's claim for scrvic~'li should be paid. I understand that my llcalth Plan and/or tbc Independent .Reviewer will use this information to make a decision allout payment to the U•·•llh C:tre Provider. l also undcr.tnnd that the de.cision by !h~ lnd~pcndenl Rcvicw.-r •••ill b~ final ;end binding on me, ll1e llcalth Cnrc l'ny,·idcr, untl the lle~lth ·rlan, ·nnd~ I anfhorize the Health Care Provider to complerP, .xecut~. acknowledge, sc:1l. und to dcli1·er nny consent, dcm~ud, rectncst, applic.atiotl, ngnement, nurhorizntion or other documents necessary, tu re<1uest, on my behulf, pn·ymeul and/or nppcul to my Health l'la.n mad, if applicable, 10 the Indcpeud~nt n~\·lewer, the !'icw York State Department or llcnllh, the Slate Insurance Department, !11e U.S. ()eparlmcnt of lleallh :uur llumnn Services, lhe U.S. Depnrtmcnt of Lnbor, and/or nny other npplicablc ~gency or body. This Limited l'uwer or Attorney sb:lll not he nffectcd by IllY •ubse'!uent disability or in<ulllpctcncc aud M,.\ Y BE REVOK}~l) BY ME AT ANY TIME upon priur notice to the Health Care Provider. 1'hfs Lhuiied Power of Attorney, indudin~ authorization for release or mcdicul inrom.lUtion, will Wrmin:~tc one (l) yenr (rom lodny's date uu.less I :~grcc to extend it beyun<l thar rlnlc. Any pc•·snn or ~ntity r~cdving thls dt)cuuuml may rely on n copy ns if it ,..,.ere and ex:ecutetl IN WITNESS WHEREOF, I have ~i~ned m)~ orip;in:~l. name \hi)<-- day of ________., 200 _ YOlJ SIGN .IU.RF.: JL__ _________ l'RJNTED NA[\Jt;; SCHOOLCRAFT ADRIAN :\DDRESS: MJ:DICAL RECORD# 1298984 WITNESS:-------------- PRINT NAJ\-IEHITLE: - - - - - - - - - - - - - - AIJDRESS: --~8~9:_0:_0::_V....:':::u:._•. .:.W:._);__'<.;: . :-k::. ·.:E...:.x:.:p...:.r_cs:...·s_"_'<-=ty:...·,_J_a_m_a_i_c_a,:..N_'_<!_w_Y_o_r_k_l_J_4_1_8_ _ _ _ _ _ _ _ _ _ __ IIYIIIIIII!BR Form No. J00023 JHMC 74 ' .. SCHOOLCRAFT, ADRIAN 1298984 M DOB: Oui21/HJ75 ADM: 10/31/200923:03 081X STAFF. PHYSICIAN 34Y F/C: 01 130381015 ACKNOWLEDGEMENT OF THE REQUEST FOR EXTERNAL APPEAL AND RELEASE OF MEDICAL RECORDS TO BE SIGNED BY THE PATIENT. In order tor a provider to appeal a health plan's payment denial for a patient's treatment, the patient must sign and date the following consent to the release of medical records. A certified external appeal agent assigned by the New York State Insurance Department will use this consent to obtain the patient's medical information relating to the external appeal request from the palif;!nt's health plan and health care providers. The name and address of the external appeal agent will be provided with the request for medical information. ·--- ··.;,.._· , acknowledge lh(!t my health care provider may I SCHOOLCRAFT ADRIAN request or is requesting an external appeal because of a retrospective adverse determination of my health pian. I authorize my HMO, insurer, or provider to release all relevant medical or treatment records, including my name and other personal Identifying information, date of admission, assessment results and history, summary of treatment plan, progress and · compliance, treatment recommendations. any HIV-related information, mental health treatment information, or alcohol/substance abuse treatment information, related to my provider's exte.rnal appeal, to the external appeal agent. I authorize the external appeal agent to use this information solely lo make a determination on my provider's appeal. I understand that my records are protected under federal and/or state taw and cannot be disclosed without my written consent unless otheJWise provided for in regulations. I understand that information disclosed pursuant to this authorization may no longer be protected by federal privacy regulations, however, state privacy protections may still apply. I understand that my health plan cannot condition treatment, enrollment, eligibility, or payment on·whe.ther 1 sign this form. I understand that I may revoke this consent at any time, except to the extent that action has already been taken In reliance on it. by contacting the New York State Insurance Department in writing. This release ts valid for one year from Sig,~ent (or legal representallve) (today's date). (Date) Description of legal representative's authority to act on behalf of the patient. Patient's Health Plan ID"it. - - - - ---------- If you have any questions contact the New York State Insurance Department at; 1-800-40G-8882 or visit our Web site at www.ins.state_ny.us_ Form No. J00027 JHMC 75 PATIENT HISTORY REPORT ,Jainaica Hospital Medical Ctr PATIENT: SCHOOLCRAFT Department of Clinical Laboratories MRN#: J1298984 8900 VanWyck Expressway, Jamaica, NY 11418 ADMIT: 10/31/09 Pathologist Name, Medical Director Loc/Rm/Bed: J081X-DOB: 06/21/1975 I ADRIAN AGE: 34 SEX: M ADM: ACCT#: J130381015 H E MA T 0 L 0 G Y -----------------------+- ----01010449-Ml------+---------------COLLECTED PRIORITY, c B jll/01/09 00,12 PHYSICIAN jREFERENCE RANGE jSTAT NWAISHIENYI, SILAj c 'N9C *12.3 RBC *5.02 14.50-5.90 M/uL HGB *14.6 114.0-18.0 g/dL HCT "~-4-t.O MCV 11 j4.8-10.8 K/uL H j42.0-52.0 87.6 180.0-94.0 fL MCH '*29.1 127.0-31.0 !'9 v. *33.6 j32.0-36.0 -~/dL MPV • 8-5 j7.2-10.4 fL Rmr lrrl3.7 Jll.S-14.5% Platelet Count 1•251 Smear Review: J•Completed Ml: Jl30-400 K/uL Troponir. was cancelled on 1:/0l/2009 at 00:12 by HIS; KEANS HISH 2 ORDERED KEANE I· 82- 4 '•!eutrophils Auto ~ymphocytes Auto. H 1~4.0-80.0 o L 113.0-43.0% 1 •11. Monocytes Auto 1 • 5 _7 ;2 .0-15.0 Eosinophils Auto. 1*0.2 1•0.7 ~ lo.G-3.0 3asophils Aut(J. % I o. o- 3. o Segs, "'lC.l Absolut~ ~lr c;, Absolute Absolute Bases, P.bsolute J2.1-8.6 K/uL I •1. 3 Lymphs, Absolute . 10.6-4.6 K/uL *o. 7 JC.l-1.6 K/UL I • o .a [0.0-C.9 KtuL 1 J*0.1 jo.0-0.4 K/uL Absolute NRBC Instrumenl•c.oo Smear Review a n u a l jNone %/100 WBC w/Au~o !*Agree ::>-iucleated RBC D i I •o NRBC Absolute e r e n t I • o .00 M RESUL.T REPOR'!'ED :'IRST TIHE f f 04/20/2010 11):39 a l JNone K/uL KEY FOR ABNORMAL COLJMI'J, Att Phy: NWAISHIENYI, SILAS Loc/Rm/Bed: J081X-PRINTED: i JNone /100 Y!BC L-L0\·1, H-HlGH, AB-i\BNORMAL, ?-PANIC MRN#: J1298984 PATIENT: SCHOOLCRAFT, ADRIAN PA:.JS: 1 of 2 JHMC 76 PATIENT HISTORY REPORT ,Jamaica Hospital Medical Ctr PATIENT: SCHOOLCRAFT, ADRIAN Department of Clinical Laboratories MRN#: J1298984 8900 VanWyck Expressway, Jamaica, NY 11418 ADMIT: 10/31/09 Pathologist Name, Medical Director Loc/Rm/Bed: J081X-DOB: 06/21/1975 AGE: 34 SEX: M ADM: , ACCT#: J130381015 C H E M I S T R Y ----------------- -----+-----D1010449-Ml------+--------------COLLECTED 111/01/09 00,22 PRIORITY, PHYSICIAN !STAT NWAISHIENY!, S!LAJ !REFERENCE RANGE -----------------------+----------------------+--------------- Glucose 1*94 17<1-106 ong/d:. BUN 1*14 19-20 mg/dL Creatinine 1'1. 0 lo-7-1-3 mgldL Sodium 1 •us 1137-145 mEq/L JJ.s-s.l mEq/L POtassium 1*4.1 Chloride 1•104 J98-107 mEqlL ( 1*24 122-30 mEq/L Calcii..:.IT: 1• 9. • IB-4-10.2 mg/dL Protein !•8.2 16 3-8.2 g/dL Albumin I •• . 7 J3.5-S.O g/<lL Bilirubin (Total) 1*0.6 10.2-1.3 mg/dL 121-72 U/L ALT (SGPT) 1-· 51 AST (SGOT) 1*46 J17-S9 U/L P.lkal ine E'hosphatase 1*57 1 H-126 Lipase 1*55 J23-JOO 1•14- 10 I ffiOlOL/L mEq/L Jl.nion Gap With K Anion Gap 1*10.00 Amylase 1• 44 Ml: 'J30-ll0 u(:. ut:. U/L Troponin was cancelled on 11/01/2009 at 00:12 by HIS; KEANE HIS~ 2 ORDERED KEANE • - RESCLT REPORTSD FIRST TIME KEY FOR ABNORMAL CO:.UMN, L-LOW, H-HIGE, AS-ABNORMAL, Att Phy: NWAISHIENYI, SILAS Loc/Rm/Bed: J081X-- P-?-~<IC MRN#: J1298984 PATIENT: SCHOOLCRAFT, ADRIAN PRINTED, 04/20/2010 1G,J9 JHMC 77 I r- ACCOUNT NUMBER MEDICAL RECORD 130381874 LOCATION I FIN CLASS 03MH NUMBE~ ADMIT DATE & TIME 1298984 9HAL 01 I SOURCE 19 7114GJbTf I TYPE p 7 , f LAST NAI'<IE I- z ~ ll. 1111111111111111111111111111111 BAR CODE-ACCOUNT NUMBER TIME 1111111111111111111111111111111111111 I FIRST NAME SCHOOLCRAFT M.l. ADRIAN AGE DATE OF BIRTH w 06/21/1975 I- BAR CODE-MEDICAL RECORD NUMBER 11/03/2009 15:00 I SEX 34Y M I I~~ I MA~ST I W ADDRESS IINTERPRET~R NEEDED LANGUAGE RACE I PLACE OF BIRTH ! NY ENG CITY TELEPHONE NUMBER STATE ZIP RIDGEWOOD 82 60 88 PL NY 11385 I OCCUPATION (718)570-6224 EMPLOYER NAME Is~~:~~~~:~RnY STATE CITY ADDRESS NUMBER i RELATIONSHIP NEXT OF KIN SCHOOLCRAFT, SELF 09 RELATIONSHIP EMERGENCY CONTACT NAME I ADDRESS - 0 w ::E a:: I- z ~ 0::: ~ ~ I p I PYT/~ERV.I ~THER PHYSICIAN I CODE MEDI~~~ERVICE ADMilTING DIAGNOSIS ICD-9-CM CODE PSYCHOSIS NOS ADMilTING PHYSICIAN' CODE I NEWBORN WEIG.HT I RESERVATION DATE & TIME ! 5904 11/03/2009 RELATIONSHIP GUARANTOR NAME SCHOOLCRAFT, ADRIAN ITEAM COLOR 15:00 SOCIAL SECURITY NUMBER OCCUPATION 999-99-9999 CITY 82 60 88 PL STATE RIDGEWOOD ADDRESS ZIP NY TELEPHONE NUMBER (718)570-6224 11385 CITY STATE ZIP TELEPHONE NUMBER UNKNOWN PLAN CODE I PRIMARY INSURANCE AETN AETNA US HEAL THCARE ADDRESS PO BOX 981109 298.9 01 ADDRESS EMPLOYER (718)570-6224 TELEPHONE NUMBER (718)570-6224 5904 HOVANESIAN, SHUSHAN HOVANESIAN, SHUSHAN 0 TELEPHONE NUMBER ZIP 11385 NY ADDRESS ATTENDING PHYSICIAN I CODE ~ (.) STATE RIDGEWOOD (999)999-9999 09 SCHOOLCRAFT, ...J CITY 82 60 88 Pl TELEPHONE NUMBER ZIP UNKNOWN (999)999-9999 POLICY NUMBER SEQ. I GROUP# AUTHORIZATION NUMBER BBM6PBBA US008041 0090 PENDING I I CITY STATE ZIP EL PASO TX 799981109 TELEPHONE NUMBER (800)451-8843 ~---------------------------------------.---------.---------------------r---~--~-------------- IRELAT~O;SHIP SUBSCRIBERS NAME SCHOOLCRAFT, ADRIAN W SECONDARY c,>.RRIER col DATE OF BIRTH SOCIAL SECURITY NUMBER 06/21/1975 I POLICY NUMBER I SEQ. I GROUP~ AUTHORIZATION NUMBER (.) z ADDRESS STATE CITY TELEPHONE NUMBER ZIP ~ I ~ :S:U~B~SC~R~IB~E~R~S~N~A~M~E~~~~---~~~~~~~~~~~~~~~~~~:~~~~~~~_j'I_,R-E~LA~-T-1-0~N-S~H~IP~C~O__J)~ t----~---.---D~A~T-E--0--F--B~IR~T-H~~~~~~~~:~S~O-C-_I_A_L~S--E-C~U~R~ITY~~N~U-M--B~E-R~~~~~~~~:--t =~T-E-R-TI-AR_Y_C_A_R_R-IE-R------------------------~~P-OL-IC_Y_N_U_M_B-ER _______________ ADDRESS STATE CITY SUBSCRIBERS NAME DATE OF PREVIOUS HOSPITAL ADMISSION i_IS_E_Q_.I_G_RO_U_P_~ IRE LA TIONSHIP CD l _________l_A_U_T_HO_R_I_ZA_T_IO_N_N_U_M_B-ER---------TELEPHONE NUMBER ZIP DATE OF BIRTH SOCIAL SECURITY NUMBER I ADMITTED BY FACILITY NAME J UNSPECIFIED I n09ad FORM NO. M00001 JHMC 78 1 UIS Data System ./13/2009 .amaica Hospital Me_dical CeiJ...ter !:'at1ent Ctr 1 Num Page 1 of 1 Coder:vdorch Attestation Statement Age DOB Patient Name Medical Rec Num SCHOOLCRAFT, ADRIAN Admit Dt/Hr Exempt IPC Gend Discharge Dt/Hr 11/03/2009 15 06/21/75 11/06/2009 130381874 1298984 -- -- 14 34 M Admit Source Disposition ~~=-=-=:=-==-=-- 7 - ER 01 - DC Home Payers Primary: ALC Days: ALC Type: ALC Date: HMO INSURANCE ATTENDING PHYSICIAN: 003819 Admit DX: 2989 Prin DX: 30924 ISAKOV, ISAK 0 Acute Days: Leave Days: LOS: 3 0 3 LIC#: 00220352 PSYCHOSIS NOS (Y)ADJUSTMENT DIS W ANXIETY Cause DX: Place DX: Secondary DXs (PoA) DRG Information----·----DRG: 427 NEUROSES EXCEPT DEPRESSIVE MDC: 19 MENTAL DISEASES & DISORDERS NYS Version: 026 Short Trim: 2 0.73860 Weight: (Base) (ALC) + $3,693.00 Long Trim: 11 Avg LOS: 5.0 $0.00 Total $3,693.00 ·-·-------- DATE PROCEDURE 1 - 9438 2 - 9425 SUPPOR VERBAL PSYCHOTHER PSYCHIAT DRUG THERAP NEC SURGEON 11/03/2009 11/03/2009 003819 003819 ISAKOV, ISAK ISAKOV, ISAK LIC #: 00220352 LIC #: 00220352 JHMC 79

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