Preview
FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018
NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022
MRO
1000 Madison Avenue
Suite 100
Norristown, PA 19403
Ph: (610) 994-7500 Opt. 1
Medical Records Transmittal
Date: 6/15/2022
Request Number: 57244441
Page Count: 59
Your requested medical records are attached.
Patient Name: DINO BONAVITA
Medical Facility: Glen Cove Hospital
Requester: Records Department
Organization: Choice Legal, Inc./PORTAL
Your reference number: 78789.067
Thank you,
MRO
MROcorp_corn
00001
FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018
NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022
lia, 19-71-53bcf 5q- , 353
Choice Legal
PO Box 1215
TAMPA, FL 33601
/0/3/1W1-7-4
813-229-1444 Phone / Fax: 813-452-6642
Email: Records@ChoiceLegal.com
VIA: [ ] MAIL [ X ] FAX: MAIL FOR MEDS
ATTN: CUSTODIAN OF RECORDS:
Glen Cove Hospital I Northwell Health
Attn: Medical Records
101 St. Andrews Lane
Glen Cove, New York 11542
Please find enclosed a request for records of:
PATIENT: Dino Bonavita
DOB:
SSN:
On behalf of Dorf & Nelson, Choice Legal is a third party records retrieval company that is
handling the retrieval of records for this matter involving the above mentioned patient. Please
direct any questions or concerns to Choice Legal. Any prepayment invoices or film breakdowns
need to be sent to Choice Legal. Attached is a signed authorization provided to us from our client,
Dorf & Nelson, in order to obtain the following requested records per the authorization attached.
***If copy costs exceed $5000.00 please contact Choice Legal, Inc.
for approval prior to sending records.***
***RUSH CASE - PLEASE EXPEDITE***
***PLEASE SEND RECORDS WITHIN TEN DAYS***
Requesting certified Medical for all dates of service indicated on authorization
We need these records and legal documents returned BEFORE: As soon as possible .
[ ] Subpoena [ ] Cross Questions
[ ] Written Questions [ ] Affidavit of No Record
[ ] Affidavit [ x ] Authorization
Contact: Records Retrieval Department '
Order No. 78789.067
00002
FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018
NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022
le),(00T7-53V-ri
DORF & NELSONLLP
The International Corporate Center, 555 Theodore Fremd Avenue, Rye, NY 10580
Telephone: 914.381.7600 • www.dorflatv.com • Facsimile: 914.967.1765
DIANE KENNEDY
PARALEGAL
E-MA: dkennedvederflaw.com
Direct Dial: 914-607-5920
May 20, 2022
To: Custodian of Records
Please be advised that for the purposes of this request, Choice Legal is an authorized
representative of DORF & NELSON LLP. All requested materials are to be released to the
custody of:
Choice Legal, 9204 King Palm Drive, Tampa, FL 33619.
Thank you for your anticipated cooperation.
Sincerely,
A -441.39__aj, 4
Diane Kennedy
Choice Order No: 78789.067
Manhattan cctitcheSter I°Oran City I Los Angeles
00003
FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018
NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022
P-Wqc5,3Wta
OCA Official Form No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York State Department of Health]
Patient Name Date of Birth Social Security Number
DINO BONAVITA
Patient Address
17 Sinclair Martin Dr., Roslyn, NY 11576
I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996
(HIPAA), I understand that:
I. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
TREATMENT, except psychotherapy notes, and CONFIDENTIAL! HIV* RELATED INFORMATION only if I place my initials on
the appropriate line in Item 9(a).
In the event the health information described belOw includes any of these types of information, and I
initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
2. If I am authorizing the release of 11W-related, alcohol or drug treatment, or mental health treatment information, the recipient is
prohibited from redisclosing such information without my
authorization unless permitted to
do so under federalor state law.I
understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization.
If
I experience, discrimination because of the release or disclosure of MV-related information, I may contact the New York State Division
of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are
responsible for protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed below.
I understand that I may
revoke this authorization except to the extent that action has already been taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for
benefits will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protected by federal or state law.
6, THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM
7. Name and address of health provider or entity to release this information:
Glen Cove Hospital, 101 St Andrews Ln, Glen Cove, NY 11542
8. Name and address of person(s) or category of person to whom this information will be sent:
Dorf & Nelson, LLP 555 Theodore Freud Ave., Rye, NY 10580
9(a).Specific information to be released:
0 Medical Record from (insert date) to (insect date)
El Entire Medical Record, including patient histories, Office notes (except psychotherapy notes), test results, radiology studies, films,
referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
0 Other: Include: (Indicate by Initialing)
at . Alcohol/Drug Treatment
e-drL Mental Health Information
Authorization to Discuss Health Information CA--- HIV-Related Information
(b) 0By initialing here I authorize
Initials Name of individual health care provider
to discuss my health information with my attorney, or a governmental agency, listed here:
(Attorney/Finn Name or Governmental Agency Name) •
10. Reason for release of information: 11.Date or event on which this authorization will expire:
Cl At request of individual
El Other: Litigation End of Litigation
12. If not the patient, name of person signing foam: 13. Authority to sign on behalf of patient
CAITLIN ROBIN POWER OF ATTORNEY
All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a
copy of the form.
Date: SI/ 71 9
Signature of patient or representative authorized by law.
* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could
identify someone as having HIV symptoms or infection and information regarding a person's contacts.
00004
FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018
NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022
•
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00005
FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018
NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022
CC Payment Receipt
Transaction Status: Approved
Transaction Date and Time: 6/15/2022 11:10:25 PM
Transaction Reference No.: 3541052
Approval Code: 0003373053
Order Number: 57244441
Charge Amount: $113.50
Credit Card Number: )00000000000(2009
Credit Card Holder: Alexa Jessee
00006
FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018
NYSCEF
Pgge 1 of DOC.
59 NO. 95 RECEIVED NYSCEF: 08/29/2022
FACE SHEET
GLEN COVE HOSPITAL MUST BE COMPLETED AT TIME OF =CHARGE BY PHYSICIAN
nnact Dramosts: PHYSICIAN DATE
OP RECORD
(PLEASE PRINT)
S
SIGN FOR DICES=
ADS COED=TONS: DISCHARGE SECTARY
4F DRS. SIGNATURE
DATE
COMPLICATIONS: OP REPORT
DRS. SIGNATURE
DRS. SIGNATURE
DATE
SEND COPIES TO
OPERATIONS: DATES:
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CERVICAL CYTOLOGY AIRWAY ••••.\.--- 1;1141..
0 TEST E 0 CONTRAINDICATED DENTITION L
• DONE <3 YRS. \'• \ \N\\., 0REFUSED LAST STRESS TEST?
LAST ECHO?
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ANESTHETIC OPTIONS DISCUSSED: cs-...a .,..,.\. , ,.%,„.
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THE PATIENT IS AN ACCEPTABLE CANDIDATE FOR THE PROPOSED PROCEDURE AN STHESIA
YES NO PENDING
SIGNATURE: 1 -e‘\s::,,..":„ ‘ ,.... , '''& ',? —c Mittetkv AciDzuglas, MD
DR ' PA
• The patient has been examined and the? istory and Physical has been reviewed. There are no significant changes in the patient's condition
unless noted below.
SIGNATURE DATE/TIMEV. //
----7 /IAA 4 01
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FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018
NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022
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;1744;; Glen Cove Hospital 10111
11;174 Northwell Health.
• 12011530
• BONAVITA ' DINO
OPERATIVE NOTE 05 1b35 3 UNIC M 49 Y
GREENBERG BURT 8 t
DATE: t\cir I TIME: FA IN
PRE OPERATIVE DIAGNO IS:
Ti--WPf
POST-OPERATIVE DIAGNOS S: -ztAe
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OPERATION:
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ANEiTHESIA: 4%-(461 -1WC1 1
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SURGEON:
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ASSISTANT:
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FINDINGS: /..
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rciPECIMENS:
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LOSS:
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BLOOD]\;, 1.v
COMPLICATIORS:
Nt)ASC---
ANESTHESIOLOGIST:
• •••thc )s......
FLUIDS GIVEN:
DRAINS/TUBES:
C a.
WOUND CLASSIFICATION: I Q III IV
SITE VERIFIED PRE-OP: (0-4\4.ve k\tze.,,,f,
PACU ARRIVAL CONDITION: 5.444
SIGNATU
r.%)
INTED NAMEPail Diamond, PA 00013_
12:573(2min12
FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018
NYSCEF DOC.
e8of59 NO. 95 RECEIVED NYSCEF: 08/29/2022
cSliCttl
Glen Cove Hospital' i.o3111
741:1 Northwell Health°
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INTERDISCIPLINARY PROGRESS NOTES
PLEASE DATE AND SIGN ALL NOTES
BONAY1TA
0051b353
GREENBERG
UNK
BURT H
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•
Physician: I Nursing, Respiratory, Dietary, ?92qWork, Physical Therapy:
Please Start Your otes Here: Please Start Your Notes Here
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INTERDISCIPLINARY PROGRESS NOTES
FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018
NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022
Pre 9 of 59
J
m
N;": Glen Cove Hospital BONAVITA ,DINO
Northwell Health.
NR#: 00576353
DOB: SEX: M
GREENBERG BURT M
PRE SURGICAL TESTING
NAME: Bonavii-a- -0 I11-6 MD: Great b c.-r-9
DATE OF SURGERY: 01 3 1 DATE OF PST: i OW °
ICD 9 CODE: 11\110 Ci . a` t'1 REGISTRATION:
HISTORY AND PHYSICAL: YES CY7 NO 0 ((Please check one)
PRE SURGICAL TESTING ORDERS
• Check off al testing to be performed - provide diagnosis and codes
TEST DIAGNOSIS CODE
(atl3C ---S—\Q,
1:14/renal/glucose —"S\„Z
0 LFT'S
0 PT/PTT
0 Pregnancy
0 Sickle prep
• 0 U/A
‘
• CXR
0 OTHER
BLOOD BANK:
TYPE AND SCREEN GREATER THAN 200 ML EBL
TYPE/CROSSMATCH UNITS
•
Signature MD
Signature 5 \\WC
1
- ' MP
000015-
FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018
NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022
Pale 10 of59
PRE ANESTHESIA EVALUATION
• r iiE01
°
•4,03.111
PA IENT LABEL
•
DIAGNOSIS: riats, ifird7 Art—
(-ft4-fi( 1260115364
• PROPOSED liROCEOURE: 4/AA_ giftirovvor
BONAVITA
OS
GREENOLRG
3,3
.0INO
on
BURT N
0 49 Y
SURGICAL/FAMILY HISTORY: (11)
MEDICAL HISTORY/PHYSICAL EXAM: VS: BP P ft BMI SPO2 BASELINE
11115. 4 )
6° / 1t) c 9l', 2 ¶07
=VASCULAR 0 NEGATIVE RESPIRATORY 211EGAN NEUROLOGICAL NEGATNE ENDIVAIETABOUC a NEGATIVE
0 VALVE DISEASE0 ASTHMA ❑ CVWIIA CI DISC DISEASECI TYPE] DM 01)NOTEROIDS
0 CAD 0 CHF NYHA O COPO 0 SEIZURES O CORD PROBLEM 0 TYPE IIDM O ITRIMATAD ARTHRITIS
0 PREVIOUS MI 0 ARRHYTHMIA O OSA 0 DEMENTIA O CHRONICPAIN 0 HYPOTHYROID O SLE
0 SW CABS 0 AAA 0 PAT CI ALLERGIC RHINOS Q PARKIFISMIS HEACHACHE 0 HYPERTHYROID O HYPERUPIDEMA
O PTCA__/ _J._ 0 METAL MOM 0 GLAUCOMA HBROMYALGIA OTHER
O SMOKING PACKATARS 0 QUIT
0 PACEMAKERAICO TYPO 0 MS
ROSETOTEREERION 0 EWA
OTHER taIf&Jr (4(444 Xt-7
CT CHEST PAIN O TERIPHERALlaRCHUNf
METS
OTHER OTHER
HEA)ONC GASTROINTESTINAL
NEGATIVE GENITMIRINAHY
0 NEGATIVE TErrATIVE
NE A ec
SOCIAL RAMIS
0 ANEMIA THERAPY0 RAUSE/WO/ARM 0 OBSTRUCTION 0 RENAL INNATICIOC!
0 RENAL FALURE .mtbH: at 0 NO
0 SICKLE CELL UGASTROPARESIS
0 EN RADATION Tx O OROHNIXOURS O SPIRANSPLANE 0 URINALYSIS ❑REC DRUGS: ❑YES 21D
COAMILOPATIff OTT D HATA.HERNIA fj(GERD -Controlled
0 PROSTATE 0 DIALYSED EDICATIDILS(CRECK THOSE TAXER TODAY)
0 PE El PIM O GERD- Umontiollal
t:1TRMSFUSION 0 LIAP 0 PREGNANT
0 HEPATITIS:CIRRHOSIS
0 BAAS
a FIXN
0 AIM EtATELETMEDS
a IAA Ct 0,f474
0 MALIGNANCY OTHER
0 MASA OTHER
0 MEWING ct-wf
PHYSICAL E(AM NITIMN ALLERGIES: 0 NONE
• 0 RS NORMAL
0 ENS NORMAL
OTHER
AIR
0 LOOSE
0 BRIDGES a
NORMAL COMM. 69611VO 4
0 DECREASEDROMOF NECKAIANDISLE
0 BEARD a
DEMITION: 0 NORMAL 0 POOR 0 DENTURE 0 UPPER 0 LOWER
a
0 SHORTNEM( PAST:MGM C EC:
0 TMO—cm
GA 0 EA am CMG 0 REGIONAL a
MOUGIO4NN6 cm
MALIAMPATI a
1ei 4
P
NONE
S WITH ANESTHESIA:
0 1IN 0 FAMILY Mx 0 AA( DIFFICULT/
CI ANTICIPATED
DIFFICULT AIRWAY OTHER a
LAB: \rita toi kit@
HB Plt K tc'it ris. B HCG Glucose EKG Af #14.
PT INR FIT ECHO ER SWMA Fixed/Reversible Aortic V Mitre' V
Other:
ASA: 1 2 3 4 5 6 E NPO After
PLAN:" General 0 Regional IVAS I MAC Post Procedure Disposition:
I have explained the administration of
general 0 spinal 0 epidural 0 WAS/MAC or 0 regional anesthesia as appropriate to the.
atient 0 parent
0 guardian.Thls dlonmslon included the risks, benefits and alternatives. He/She understands the risks explained including minor discomfort and major
complications including Injury to an organ or body part, infection, disability or death. Also discussed were the use of 0
artenal 0central venous and
CI FA catheters, the use of 0
epidural and 0 0 transesophageal echocardiography. The risks,
regional catheters for anesthesia or analgesia and
benefits and alternatives of transfusion have been discussed as appropriate. All questions have been answered. He/She consents to the planned
anesthetic and procedures stated above.
CRNA/Resident:
PRINT SIGN _roll V TIME mi
Attending Physician:
PRINT DATE TIME
/ 4N/0 "
PRINT PATE
00016
NAPA AR-7.3.1
FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018
NYSCEF DOC. NO. 95 ,r.:.; ..1s. RECEIVED NYSCEF: 08/29/2022
• ge 1 of 59 '. — .,
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ID - 103.1.11
.-e
ADDITIONAL NOTES 1260115364
All entries must have BONA VITA DOING
date, time and signature 0051b1 ) 3 UNK M 49 y
GREENBERG
Date Time '
......,_
POST ANESTHESIA EVALUATION
1. MENTAL STATUS: Patient Participation &Awake CI Arousable 0 Sedated 0 Other
Z AIRWAY PATENCY: %Satisfactory 0 Other Oxygen Saturation (Sp02%) ,
Room Air "Nasal Cannula (F102) Face Mask(FIO2) Intubated (Fi02)
3. VITAL SIGNS: Blood Pressursi 1M(nmHg) Pulse Rate bpm) Respiratory Rate Aso (bpm) Temp. 3 &'a
4. HYDRATION STATUS:c2rSatisfactory 0 Other
5. NAUSEA /VOMITING: 41None 0 Controlled 0 Other
6. PAIN: grdontrolled with current regimen 0 Other
COMMENTS:
KW° A14 1~/3rf
Wks
PRINT NAME SI DATE TIME
00017
FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018
, . . , .
NYSCEF DOC. NO.
e notiBth../ '31i 95
lIi_ Room# ai9.. cr.c.
RECEIVED ,
NYSCEF: 08/29/2022
4.01
.....
V
a h
Ln 111,
A
103111
ANESTHESIOLOGIST: tAnTrAC-1 2 Peter _.- • .„,
Pmtliame SIMS.
RESIDENT/SRNA: --- 1:1 1:2 1260'115364
„
1
0
Ratan* &game° BONA)/ ITA • DINO
CRNA:
_---
11 1:2 1.3 n4005% 353 LINK K 49 Y
Patten* Sgatin GREENBERG mit tt
PROCEDURIST(S): Peen‘we\ 1 st1-1( 00/0.3119sa
ANESTHESIA TECHNIQUE: a --G-ENERAL 0 REGIONAL 0 IVAS/MAC
PROCEDURE: flopidmittdoi f4itsnic 7JA tErvla Flak/real Res t witil-L. 009E: C)(bi °
/ 1r 500 1262645
DIAGNOSIS:
1: 014ky,
L
PATIENT STATUS:
-
sooa
ASA 1 2j4
clamvAt.c.
5 6 E
,NI4c\- LimA
yATIENT IDENTIFIED - -
CODE: H(path
--arr''ROCEDURE CONSENT SIGNED
STATUS CHANGE FROM PRE-OP 2140 0 YES "LITHE PATENT ISA SURABLE CANDIDATE FORTHE PLANNED PROCEDURE AND ANESTHETIC.
COMMENT: - --
EQUIPMENT CHECK: 02SUPPLY 02ANALYZER AIRWAYS alUCTION 124/CCHINE ARMS
MONITORS: elfre 0 STETH _04; EMP PROBE atICO2% a6CO2 El NERVE STIMULATOR 0 OTHER
al ANESTH. START: PRE-OP STOP: OR ENTER:3 PROCEDURE/INCISION PROCEDURE END: ANESTH. END:
h START: Lot; II"
>P
09 I
PRE OP IV ANTIBIOTIC:
69 C L. n
TIME GIVEN: c,, 5-3 INCI
: te lt
ION TIME: I 0, ( 1.,
474/A, a•J to* A)t-
Preview
FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018 NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022 MRO 1000 Madison Avenue Suite 100 Norristown, PA 19403 Ph: (610) 994-7500 Opt. 1 Medical Records Transmittal Date: 6/15/2022 Request Number: 57244441 Page Count: 59 Your requested medical records are attached. Patient Name: DINO BONAVITA Medical Facility: Glen Cove Hospital Requester: Records Department Organization: Choice Legal, Inc./PORTAL Your reference number: 78789.067 Thank you, MRO MROcorp_corn 00001 FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018 NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022 lia, 19-71-53bcf 5q- , 353 Choice Legal PO Box 1215 TAMPA, FL 33601 /0/3/1W1-7-4 813-229-1444 Phone / Fax: 813-452-6642 Email: Records@ChoiceLegal.com VIA: [ ] MAIL [ X ] FAX: MAIL FOR MEDS ATTN: CUSTODIAN OF RECORDS: Glen Cove Hospital I Northwell Health Attn: Medical Records 101 St. Andrews Lane Glen Cove, New York 11542 Please find enclosed a request for records of: PATIENT: Dino Bonavita DOB: SSN: On behalf of Dorf & Nelson, Choice Legal is a third party records retrieval company that is handling the retrieval of records for this matter involving the above mentioned patient. Please direct any questions or concerns to Choice Legal. Any prepayment invoices or film breakdowns need to be sent to Choice Legal. Attached is a signed authorization provided to us from our client, Dorf & Nelson, in order to obtain the following requested records per the authorization attached. ***If copy costs exceed $5000.00 please contact Choice Legal, Inc. for approval prior to sending records.*** ***RUSH CASE - PLEASE EXPEDITE*** ***PLEASE SEND RECORDS WITHIN TEN DAYS*** Requesting certified Medical for all dates of service indicated on authorization We need these records and legal documents returned BEFORE: As soon as possible . [ ] Subpoena [ ] Cross Questions [ ] Written Questions [ ] Affidavit of No Record [ ] Affidavit [ x ] Authorization Contact: Records Retrieval Department ' Order No. 78789.067 00002 FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018 NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022 le),(00T7-53V-ri DORF & NELSONLLP The International Corporate Center, 555 Theodore Fremd Avenue, Rye, NY 10580 Telephone: 914.381.7600 • www.dorflatv.com • Facsimile: 914.967.1765 DIANE KENNEDY PARALEGAL E-MA: dkennedvederflaw.com Direct Dial: 914-607-5920 May 20, 2022 To: Custodian of Records Please be advised that for the purposes of this request, Choice Legal is an authorized representative of DORF & NELSON LLP. All requested materials are to be released to the custody of: Choice Legal, 9204 King Palm Drive, Tampa, FL 33619. Thank you for your anticipated cooperation. Sincerely, A -441.39__aj, 4 Diane Kennedy Choice Order No: 78789.067 Manhattan cctitcheSter I°Oran City I Los Angeles 00003 FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018 NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022 P-Wqc5,3Wta OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health] Patient Name Date of Birth Social Security Number DINO BONAVITA Patient Address 17 Sinclair Martin Dr., Roslyn, NY 11576 I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: I. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL! HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described belOw includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8. 2. If I am authorizing the release of 11W-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federalor state law.I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience, discrimination because of the release or disclosure of MV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6, THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 7. Name and address of health provider or entity to release this information: Glen Cove Hospital, 101 St Andrews Ln, Glen Cove, NY 11542 8. Name and address of person(s) or category of person to whom this information will be sent: Dorf & Nelson, LLP 555 Theodore Freud Ave., Rye, NY 10580 9(a).Specific information to be released: 0 Medical Record from (insert date) to (insect date) El Entire Medical Record, including patient histories, Office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. 0 Other: Include: (Indicate by Initialing) at . Alcohol/Drug Treatment e-drL Mental Health Information Authorization to Discuss Health Information CA--- HIV-Related Information (b) 0By initialing here I authorize Initials Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: (Attorney/Finn Name or Governmental Agency Name) • 10. Reason for release of information: 11.Date or event on which this authorization will expire: Cl At request of individual El Other: Litigation End of Litigation 12. If not the patient, name of person signing foam: 13. Authority to sign on behalf of patient CAITLIN ROBIN POWER OF ATTORNEY All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form. Date: SI/ 71 9 Signature of patient or representative authorized by law. * Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a person's contacts. 00004 FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018 NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022 • ettlicAttet JULE NOT410ri PuHL10;414.tp'?F1ANW.N.98.10: .Np. 01 LAp.041 (R. ttuoppap in NNW Yu firc ' MY Opm r1116$ tan Itupites 12-1 e4frza 00005 FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018 NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022 CC Payment Receipt Transaction Status: Approved Transaction Date and Time: 6/15/2022 11:10:25 PM Transaction Reference No.: 3541052 Approval Code: 0003373053 Order Number: 57244441 Charge Amount: $113.50 Credit Card Number: )00000000000(2009 Credit Card Holder: Alexa Jessee 00006 FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018 NYSCEF Pgge 1 of DOC. 59 NO. 95 RECEIVED NYSCEF: 08/29/2022 FACE SHEET GLEN COVE HOSPITAL MUST BE COMPLETED AT TIME OF =CHARGE BY PHYSICIAN nnact Dramosts: PHYSICIAN DATE OP RECORD (PLEASE PRINT) S SIGN FOR DICES= ADS COED=TONS: DISCHARGE SECTARY 4F DRS. SIGNATURE DATE COMPLICATIONS: OP REPORT DRS. SIGNATURE DRS. SIGNATURE DATE SEND COPIES TO OPERATIONS: DATES: \-)•‘\4" g AfFiff• Aki ‘..„..sz>Sks‘.,A, 0 NL RECTAL ❑ NL 0 • ENDOCRINE: .c:z.}.,\\„Si.b BACK EXTREMITIES Mt \NZ:t.......,s st , V141_ ...teINL REPRODUCTIVE: 'i s:...A.,:v szlN \1 4\.,9 /..\ ez&s t \•$ NEUROLOGIC ali z , 1 LMP S"%cs.s.a‘.._-tx..._ G SKIN agt. CERVICAL CYTOLOGY AIRWAY ••••.\.--- 1;1141.. 0 TEST E 0 CONTRAINDICATED DENTITION L • DONE <3 YRS. \'• \ \N\\., 0REFUSED LAST STRESS TEST? LAST ECHO? C?..p.r\I•SI-\\^ 1 -_)•\St-S ASSESSMENT ASA • \- Class. 5\C — ANESTHETIC OPTIONS DISCUSSED: cs-...a .,..,.\. , ,.%,„. „ \,.....<1ct..,z-N. 4,14‘", 1.\ \NtyNk 0_, Q4).Z4.41,-;,,s 1 eivcs,c, trs•N t. \t•stz,w< &S.W.,\SaVet THE PATIENT IS AN ACCEPTABLE CANDIDATE FOR THE PROPOSED PROCEDURE AN STHESIA YES NO PENDING SIGNATURE: 1 -e‘\s::,,..":„ ‘ ,.... , '''& ',? —c Mittetkv AciDzuglas, MD DR ' PA • The patient has been examined and the? istory and Physical has been reviewed. There are no significant changes in the patient's condition unless noted below. SIGNATURE DATE/TIMEV. // ----7 /IAA 4 01 UV I cr FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018 NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022 e7d59 ...t.n r •rhgoo.goar•• Wm= ;1744;; Glen Cove Hospital 10111 11;174 Northwell Health. • 12011530 • BONAVITA ' DINO OPERATIVE NOTE 05 1b35 3 UNIC M 49 Y GREENBERG BURT 8 t DATE: t\cir I TIME: FA IN PRE OPERATIVE DIAGNO IS: Ti--WPf POST-OPERATIVE DIAGNOS S: -ztAe (10 1 OPERATION: 6 ; \49 4\ 41 eii di a- SY ANEiTHESIA: 4%-(461 -1WC1 1 4 / 4:3 rt ., it 14. IV P -ellr I' Ck " it .<4-01 ) 1'4 VINSta *NJ:tit eA/04 SURGEON: - 9 ep.r -1\11t) ASSISTANT: e r t nikt A \ Pk FINDINGS: /.. (157D A dr-a. rciPECIMENS: L-KeikrtiSaNg--- irc- ).(‘ el/Xi-kir"' LOSS: z.... BLOOD]\;, 1.v COMPLICATIORS: Nt)ASC--- ANESTHESIOLOGIST: • •••thc )s...... FLUIDS GIVEN: DRAINS/TUBES: C a. WOUND CLASSIFICATION: I Q III IV SITE VERIFIED PRE-OP: (0-4\4.ve k\tze.,,,f, PACU ARRIVAL CONDITION: 5.444 SIGNATU r.%) INTED NAMEPail Diamond, PA 00013_ 12:573(2min12 FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018 NYSCEF DOC. e8of59 NO. 95 RECEIVED NYSCEF: 08/29/2022 cSliCttl Glen Cove Hospital' i.o3111 741:1 Northwell Health° 12b01153b4 onto INTERDISCIPLINARY PROGRESS NOTES PLEASE DATE AND SIGN ALL NOTES BONAY1TA 0051b353 GREENBERG UNK BURT H tt 49 4, Y • Physician: I Nursing, Respiratory, Dietary, ?92qWork, Physical Therapy: Please Start Your otes Here: Please Start Your Notes Here wilawatwarrAtp , .., isna mmailmenatt. , ....„ t. a il k Al oktref.„;. a ` i ASS At" _ r i . i. , Slia iaif 1 I _ ate lin_ r ., , \n • k • 1 1\ \ I 1 A ., .1—.. , .. r._ Tait._ a o r RI niernOrrt p • S 12573 (2/3/17) 22 00014 INTERDISCIPLINARY PROGRESS NOTES FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018 NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022 Pre 9 of 59 J m N;": Glen Cove Hospital BONAVITA ,DINO Northwell Health. NR#: 00576353 DOB: SEX: M GREENBERG BURT M PRE SURGICAL TESTING NAME: Bonavii-a- -0 I11-6 MD: Great b c.-r-9 DATE OF SURGERY: 01 3 1 DATE OF PST: i OW ° ICD 9 CODE: 11\110 Ci . a` t'1 REGISTRATION: HISTORY AND PHYSICAL: YES CY7 NO 0 ((Please check one) PRE SURGICAL TESTING ORDERS • Check off al testing to be performed - provide diagnosis and codes TEST DIAGNOSIS CODE (atl3C ---S—\Q, 1:14/renal/glucose —"S\„Z 0 LFT'S 0 PT/PTT 0 Pregnancy 0 Sickle prep • 0 U/A ‘ • CXR 0 OTHER BLOOD BANK: TYPE AND SCREEN GREATER THAN 200 ML EBL TYPE/CROSSMATCH UNITS • Signature MD Signature 5 \\WC 1 - ' MP 000015- FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018 NYSCEF DOC. NO. 95 RECEIVED NYSCEF: 08/29/2022 Pale 10 of59 PRE ANESTHESIA EVALUATION • r iiE01 ° •4,03.111 PA IENT LABEL • DIAGNOSIS: riats, ifird7 Art— (-ft4-fi( 1260115364 • PROPOSED liROCEOURE: 4/AA_ giftirovvor BONAVITA OS GREENOLRG 3,3 .0INO on BURT N 0 49 Y SURGICAL/FAMILY HISTORY: (11) MEDICAL HISTORY/PHYSICAL EXAM: VS: BP P ft BMI SPO2 BASELINE 11115. 4 ) 6° / 1t) c 9l', 2 ¶07 =VASCULAR 0 NEGATIVE RESPIRATORY 211EGAN NEUROLOGICAL NEGATNE ENDIVAIETABOUC a NEGATIVE 0 VALVE DISEASE0 ASTHMA ❑ CVWIIA CI DISC DISEASECI TYPE] DM 01)NOTEROIDS 0 CAD 0 CHF NYHA O COPO 0 SEIZURES O CORD PROBLEM 0 TYPE IIDM O ITRIMATAD ARTHRITIS 0 PREVIOUS MI 0 ARRHYTHMIA O OSA 0 DEMENTIA O CHRONICPAIN 0 HYPOTHYROID O SLE 0 SW CABS 0 AAA 0 PAT CI ALLERGIC RHINOS Q PARKIFISMIS HEACHACHE 0 HYPERTHYROID O HYPERUPIDEMA O PTCA__/ _J._ 0 METAL MOM 0 GLAUCOMA HBROMYALGIA OTHER O SMOKING PACKATARS 0 QUIT 0 PACEMAKERAICO TYPO 0 MS ROSETOTEREERION 0 EWA OTHER taIf&Jr (4(444 Xt-7 CT CHEST PAIN O TERIPHERALlaRCHUNf METS OTHER OTHER HEA)ONC GASTROINTESTINAL NEGATIVE GENITMIRINAHY 0 NEGATIVE TErrATIVE NE A ec SOCIAL RAMIS 0 ANEMIA THERAPY0 RAUSE/WO/ARM 0 OBSTRUCTION 0 RENAL INNATICIOC! 0 RENAL FALURE .mtbH: at 0 NO 0 SICKLE CELL UGASTROPARESIS 0 EN RADATION Tx O OROHNIXOURS O SPIRANSPLANE 0 URINALYSIS ❑REC DRUGS: ❑YES 21D COAMILOPATIff OTT D HATA.HERNIA fj(GERD -Controlled 0 PROSTATE 0 DIALYSED EDICATIDILS(CRECK THOSE TAXER TODAY) 0 PE El PIM O GERD- Umontiollal t:1TRMSFUSION 0 LIAP 0 PREGNANT 0 HEPATITIS:CIRRHOSIS 0 BAAS a FIXN 0 AIM EtATELETMEDS a IAA Ct 0,f474 0 MALIGNANCY OTHER 0 MASA OTHER 0 MEWING ct-wf PHYSICAL E(AM NITIMN ALLERGIES: 0 NONE • 0 RS NORMAL 0 ENS NORMAL OTHER AIR 0 LOOSE 0 BRIDGES a NORMAL COMM. 69611VO 4 0 DECREASEDROMOF NECKAIANDISLE 0 BEARD a DEMITION: 0 NORMAL 0 POOR 0 DENTURE 0 UPPER 0 LOWER a 0 SHORTNEM( PAST:MGM C EC: 0 TMO—cm GA 0 EA am CMG 0 REGIONAL a MOUGIO4NN6 cm MALIAMPATI a 1ei 4 P NONE S WITH ANESTHESIA: 0 1IN 0 FAMILY Mx 0 AA( DIFFICULT/ CI ANTICIPATED DIFFICULT AIRWAY OTHER a LAB: \rita toi kit@ HB Plt K tc'it ris. B HCG Glucose EKG Af #14. PT INR FIT ECHO ER SWMA Fixed/Reversible Aortic V Mitre' V Other: ASA: 1 2 3 4 5 6 E NPO After PLAN:" General 0 Regional IVAS I MAC Post Procedure Disposition: I have explained the administration of general 0 spinal 0 epidural 0 WAS/MAC or 0 regional anesthesia as appropriate to the. atient 0 parent 0 guardian.Thls dlonmslon included the risks, benefits and alternatives. He/She understands the risks explained including minor discomfort and major complications including Injury to an organ or body part, infection, disability or death. Also discussed were the use of 0 artenal 0central venous and CI FA catheters, the use of 0 epidural and 0 0 transesophageal echocardiography. The risks, regional catheters for anesthesia or analgesia and benefits and alternatives of transfusion have been discussed as appropriate. All questions have been answered. He/She consents to the planned anesthetic and procedures stated above. CRNA/Resident: PRINT SIGN _roll V TIME mi Attending Physician: PRINT DATE TIME / 4N/0 " PRINT PATE 00016 NAPA AR-7.3.1 FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018 NYSCEF DOC. NO. 95 ,r.:.; ..1s. RECEIVED NYSCEF: 08/29/2022 • ge 1 of 59 '. — ., ._ ir I i c_.0 ID - 103.1.11 .-e ADDITIONAL NOTES 1260115364 All entries must have BONA VITA DOING date, time and signature 0051b1 ) 3 UNK M 49 y GREENBERG Date Time ' ......,_ POST ANESTHESIA EVALUATION 1. MENTAL STATUS: Patient Participation &Awake CI Arousable 0 Sedated 0 Other Z AIRWAY PATENCY: %Satisfactory 0 Other Oxygen Saturation (Sp02%) , Room Air "Nasal Cannula (F102) Face Mask(FIO2) Intubated (Fi02) 3. VITAL SIGNS: Blood Pressursi 1M(nmHg) Pulse Rate bpm) Respiratory Rate Aso (bpm) Temp. 3 &'a 4. HYDRATION STATUS:c2rSatisfactory 0 Other 5. NAUSEA /VOMITING: 41None 0 Controlled 0 Other 6. PAIN: grdontrolled with current regimen 0 Other COMMENTS: KW° A14 1~/3rf Wks PRINT NAME SI DATE TIME 00017 FILED: NASSAU COUNTY CLERK 08/29/2022 05:34 PM INDEX NO. 611506/2018 , . . , . NYSCEF DOC. NO. e notiBth../ '31i 95 lIi_ Room# ai9.. cr.c. RECEIVED , NYSCEF: 08/29/2022 4.01 ..... V a h Ln 111, A 103111 ANESTHESIOLOGIST: tAnTrAC-1 2 Peter _.- • .„, Pmtliame SIMS. RESIDENT/SRNA: --- 1:1 1:2 1260'115364 „ 1 0 Ratan* &game° BONA)/ ITA • DINO CRNA: _--- 11 1:2 1.3 n4005% 353 LINK K 49 Y Patten* Sgatin GREENBERG mit tt PROCEDURIST(S): Peen‘we\ 1 st1-1( 00/0.3119sa ANESTHESIA TECHNIQUE: a --G-ENERAL 0 REGIONAL 0 IVAS/MAC PROCEDURE: flopidmittdoi f4itsnic 7JA tErvla Flak/real Res t witil-L. 009E: C)(bi ° / 1r 500 1262645 DIAGNOSIS: 1: 014ky, L PATIENT STATUS: - sooa ASA 1 2j4 clamvAt.c. 5 6 E ,NI4c\- LimA yATIENT IDENTIFIED - - CODE: H(path --arr''ROCEDURE CONSENT SIGNED STATUS CHANGE FROM PRE-OP 2140 0 YES "LITHE PATENT ISA SURABLE CANDIDATE FORTHE PLANNED PROCEDURE AND ANESTHETIC. COMMENT: - -- EQUIPMENT CHECK: 02SUPPLY 02ANALYZER AIRWAYS alUCTION 124/CCHINE ARMS MONITORS: elfre 0 STETH _04; EMP PROBE atICO2% a6CO2 El NERVE STIMULATOR 0 OTHER al ANESTH. START: PRE-OP STOP: OR ENTER:3 PROCEDURE/INCISION PROCEDURE END: ANESTH. END: h START: Lot; II" >P 09 I PRE OP IV ANTIBIOTIC: 69 C L. n TIME GIVEN: c,, 5-3 INCI : te lt ION TIME: I 0, ( 1., 474/A, a•J to* A)t-