Preview
FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019
"F"
EXHIBIT
FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019
Shore Psychiatric Center
Ronald L Taddeo, MD
Margaret Galvin, NF
MacConneS, LCSW, BCD
Mary
Parente, LCSW
Hilary
Jane Indilla-Brown, LMSW
Û
Lata Agnikotri, LMSW
Erin Hayes, LMSW O
Christine Sadousby, LMVW
4PhyiMr Drim SuiteH
Patehogue, NY 11772
Tel (631) 447-75ó0
Certif ied in Psychiatry
Fax 447-7561
123293 a . (631)
NYS Medical License
PRESCRIPTIONN:
TEMPHONE
DATE
6 C Don:
PATIENTNAME
MFRCATILONS NEEDED:
C4
PHARMACY:
APPROVED BY:
DATE: ( Û
BY: 6
CALLED IN
FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019
Shore Psychiatric Genter
Ronald J. Teddeo, MJJ
Margaret Galvin, lvP
MacConneK, LCSW, BCD
Mary
Hilary Parente, LCSW
Jane Indilla-Brown, LMSW
Lata Agnikotri, LMSW
Erin Hayes, LMSW
Christàte Sadousky, LBlSW
4PhyRiv RM Suites
Patehogue, NY 11772
Tel (631) 447-756ti
Certif ted in Psychiatry
., Fax (631) 447-7561
S Medical License 123293
TELEPHONE PRE8CFdPTIONS:
DATE: '04
PAHENT NAM E: (A
ÎC cd [CC 3o3
ca
Praza c 20m
PHARMACY:
APPROVED BY:
DATE:
CALLED IN BY:
FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019
medco
Patient Prescription Request
RNWL INVOICE: 867153526 12
Our patient would like to receive the medication listed below through Medco
Please review, fill in any required inforrnation, sign, date, and return fax.
Questions? Call 1 888 327-9791
STEP 1 » Review and complete Information:
Prescriber: RONALD TADDEO
4 PHYLLIS DR STE H
PATCHOGUE NY 11772-2900
631 447-7560 _J
Patient: xxxxxx xxxxxxxx
1734 SPUR DR S
ISLIP NY 11751-1200
DOB:
Drug: BUPROPION HCL XL TABS
Strength: 150MG
Quantity: 180
Refili: 0
Directions: TAKE 1 TABLET TWICE A DAY
REQUIRED ate
Date:
S Perrnissible
Date:
Dispense as Written
REQUIRED NPl: NPI ON FILE
STEP 2 > sign, date and fax without cover sheet to 1 800 837-0959
² ™
L Case Item No.259681406-7 Rx No.0924721011 Location 12
J
Notice:Thiscornmunicationand any attachments
are intended
solely for the use of the addressee
named above and contains confidential
and
inforrnation.
egally privileged If you are not the intended
recipient, any d -lion,distribution
or copying is strictly prahibited.
If you receivedthis cc
by fax or phone irnmediately.
notify Medco
n error, please Medco facsimile
rnachines are secure and in compliance with HIPAA privacy standards.
of the infortnation
The provision requestedin this fortn is for your patient's
benefit. Medco does not cornpensate for c:mp!:Sq
this fortn.
FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019
medco
Patient Prescription Request
RNWL INVOICE: 867153526 12
Our patient would like to receive the medication listed below through Medco
Please review, fill in any squired information, sign, date, and return fax.
Questions? Call 1 888 327-9791
STEP 1 > Review and cornplete inforrnation:
Prescriber: RONALD TADDEO
4 PHYLLIS DR STE H
PATCHOGUE NY 11772-2900
631 447-7560
Patient: xxxxxx xxxxxxxx
1734 SPUR DR S
ISLIP NY 11751-1200
DOB:
Drug: SERTRALINE HCL TABS
Strength: 100MG
Quantity: 180
Refill: 0
Directions: TAKE 2 TABLETS DAILY
REQUIRED Date:
Dat '
Substitu Pefmissible
Date: I I
Dispense as Written
REQUIRED NPI: NPI ON FILE Ê/
(REQUIRED
if missing)
STEP 2 > Sign, date and fax without cover sheet to 1 800 837-0959
² ™
Ilil I 1111111111111lll111111111 IllilIll 11111111111
L Case Item No. 259681407-5 Rx No.0924721012 Location 12
Notice:
Jonfidentiality This ::mmunication are intended solely for the use of the addressee
and any attachments narned above and contains conMantial
and
informa½n.
egally privileged li you are not the intended or copying is strictly prohibited.
recipient, any disseeidnauun, distribution If you receivedthis coiiiiiisii|sation
Medco facsimile
n error, olease notify Medco by fax or phone irnmediately. machines are secure and in usiiipliaiice
with HIPAA privacy standards.
of the information
Tne provision requestedin this brm
is for your patient's for completing this form.
benefit. Medco does not compensate
FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019
TRANSMISSION VERIFICATION REPORT
TIME : 09/04/2009 18:22
DATE, TIME 09/04 18: 20
FAX NO. /NAME 18008370959
DURATION 00:01:51
PAGE(S) 03
RESULT OK
MODE STANDARD
ECM
FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019
medco
Patient Prescription Request
RNWL INVOICE: 867153526 12
Our patient would like to receive the medication listed below through Medco
Please review, fillin any required information, sign, date, and return fax.
Questions? Call 1 888 327-9791
STEP 1 > Review and cornplete Information:
Prescriber: RONALD TADDEO
4 PHYLLIS DR STE H
PATCHOGUE NY 11772-2900
631 447-7560
Patient: xxxxxx xxxxxxxx
1734 SPUR DR S
ISLIP NY 11751-1200
DOB:
Drug: TOPIRAMATE TABS
Strength: 200MG
Quantity: 360
Refill: 0
Directions: TAKE 1 TABLET FOUR TIMES A DAY
REQUIRED Date:
Dat
Sub-t:‡LS:= Permissible
Date:
Diwpense aw Wr inen
REQUIRED NPl: NPI ON FILE
(REQUIRED
if missing)
STEP 2 > sign, date and fax without cover sheet to 1 800 837-0959
"® ² ™
IIIII 1111111111111ll111111111111 IIII 11111111111
L Case item No.259681410-9 Rx No.0924721015 Location 12
3cr.*!dent!a!!+v
Notice:This c emüüistion ano any attachments
are intended
solely for the use of the addressee
named above and contains confidential
ano
egally privileged
inbrmefen. If you are not the intended
recipient. any dissemination, or copying is strictly prohibited.
distribution If you receivedthis communication
Medco facsimile
notify Medco by fax or phone immediately.
n error, please machines are secure and in ce.ne|iâoca with HIPAA privacy standards.
of the information
The provision reauestedin this form is for your patient's
benefit. Medco does not compensate
for completing this form.
FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019
P Pad15of2D111612009
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OFFICIAL NEW YORK STATE PRESCRIPTION
PATCHOGUE, NY iT/2
(631)447-7560 .
UC.123293
1A17T 6 2
Patient
Name Date
Address
Sex
. City - State Zip Age M F
Prescr r Sin X
THISPRESCRI N WILL8 D GENERICAI1Y WRFES'daw IN BOXBELOW
UN ESSPRESCRIBER
REFILLS O None. 0KKQDB 16
Refills: gilinn
smuggum•
PHARMACIST . ü¡¡i
TEST AREA: . ,...---
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FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019
f ] f f'( .*() Pharmacy New Prescription
=
YOUR PATIENT WOULD LIKE TO RECEIVE THEIR PRESCRIPTION WlEDICATION FROM MEDCO,
F IIIllill 11111111 III IllIll '7
Please complete ALL information below. incomplete forms cannot be pr0casséû- Picase printclearly.
STEP 1 Prescriber information Questions? Call 1.688.EASYRX1
)
Note to
Prescriber
PrescriberName . -- DEA - b 2-) Û
RwoultedRMCrtt-CVmedicat\ana
Secure faxnumber . ....... NPI . .
STEP 2 Member information
p
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STEP 3 Patient Information STEP 4 ) Prescription information
Pleasecomplete nr at1nchpresenptionbelow
---------------------------------------
sU•nt Nama O:f(\f A ho (hir
City,State, Zip
ship to addives
Tel•Phone
Patchogue, NY 11772
Ilophone (831) 447-7580
Allergies ~~---------~~""" "-"- --""---
None O Sutfe Q Penicillin
lodine PatientName 1..
O Aspirin U Codelne O
Other_ _. . ..... ... . _. DOB . lesueDate . . .
Medical conditions
HeartFellure Q Hypertension
u
U Heart Attack/AnginalG Astrima
O Glaucoma O Ulcer
other .
. _... ....
....
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STEP 5 p
NO COVER SHEET REQUIRED
FaxthispageONLYto
1 800 837-0959 .....-.np., , .e.
Medco cannot accept vie fox
Cil prescriptions
) PresenbarSignature
) Fox fomis when sent fmm a
wil only be accepted
NWnse as MtWn
ofDce
prescriber's
fax casifirmakn
The printed of receipt
is r;oof
p
Most patientscan recatvaa 90-daysupply plusrefills I (We cannot acceptSignatureStamps)
up to1 year whereappropriate.
L___-__________________________________
L 1111111 I Ilill I lill 111111
for the use of the eddmanesnamedabove and
Confidenuality Notice:This comrqunicationand any anachmentsare intenced solely
COntalnconfidentl8Iend legally privHogedInformation.If you are not tthe inlanded recipient any dissemination,distributtonor fr)pying
planta notify Marlenby inx or phoneImrantitatnty.
a aidctly prohitilted. If you tecelynd this communlantionin error,
standesds.
f } W( ( ?
Medco facstmilemactibios are accureants to compilant:awmsHIPAA privacy
FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019
Mar.31.2009 10: 26 AM PAGE. 1/ 1
// ICC ( () Pharmacy New Prescriptiori
YOUR PATIENT WOULD LlKE TO RECElVE THEIR PRESCRIPTION MEDICATION FROM MEDCO,
F ""||lilli |l|l|l I ll|ll lilill l
Please complete ALL !r.'-=a*!en below. incemplete forms cannot be processed. Please printclearly.
STEP 1 p Prescriber information Questione? Call 1.868,EASYRXi
Note to
Prescriber
PrescriberName a tVrd/ ) f/) DEA .
Reuntredfor Clu-CVenadicarfona
Secure faxnumber ._ ... NPl p.
STEP 2 Member nformation
member No. 1 4 2 9 4 6 7 6 1 5 3 9
(inchitin all charactarnianve bon blank for apacan)
Member Name ard holder):
Patient information STEP 4 Prescription inforriistiGr
STEP 3
Plaouecoroplete or anachprerenptionbelow
=•u.nin=• oaMcR hoffer
----------,-----------------------------,
City,8 at,Z
Bhip to address Telephone VG,
Alterglam
d PatientName .
piin U odeirte
.--.. -..- .__ DOB . fasueDate . .
Other ...
MedicalConditions
Heart Fallure L) Hypertension
u
U Heart Aiind/Añûlim fQ Asthma
O Giaucoma O Ulcer
Other .
....... ....
....
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STEP 5 >
Refills
.._.._____ .
NO COVER SHEET REQUIRED
Fax thispageONLYto
1 800 837-0959 ......on..... .
) Medco cannot accept vis fox
Cll prescriptions
c Ibar Stonetura
Fox formaWiionlybe wap!ed when sent from a __
)
a office
prescriber
p is p;ool of receipt
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(We cannot accept8 gnatureStamps)
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. 1
up to1 year wheresppropriate.
L ||lilll Ilill I ll I illll
and any attachmentsare!menced solely tor the use of the eddmeseenarnedabove ano
Confidentiality Notice:This coric;ñir. GTcopying
intendedrecipient.any classmination,-":1
contain--e!m!-!endtegally pavileged Information.if you are not ithe ?
in errori plunganotify Matich by fax or phone %•*at!!a!e!y.
18HDictlyproh1Nted.if you recelyndthin Wenkstlan
{
standards.
Medco facstn|ttemach‡nosara accuro and in Complluncowtth HiPAA privacy
FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019
Mar. 31. 2009 10:2 6 AM PAGE. 1/ 1
() Pharmacy New Prescription
YOUR PATIENT WOULD LlKE TO RECElVE THEIR PRESCRIPTION MEDICATION FROM MEDCO.
I-
""°ª
||ll|lil||||llill||l||ll||l||lilill "I
Please complete ALL information below. Incomplete forms cannot be procassêd. Please printclearly.
STEP 1 Prescriber information Questions? Call 1.888.EASYRX1
p
Note to
Prescriber
Peacriber Name . ..- DEA . 2 Ñ ......
Reeutredstr CR‡•CV
spadfcatiotts
secure faxnumber _... .... ... NP1 )
STEP 2 Member Information
h
emberso. [1]4 2 9 4 6 7 6 1 5
3]9]
(inchitin nu charactarninave bon blank tor apacon)
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STEP 3 Patient Information STEP 4 Prescription information
p
Plansecanoplete ar anannpresenptionbelow
City ate Zip
Bhip to address
W(A N Pathogue, NY 11772
phooe (8311447-7580
Aftergree -
None O Sulfa Q Penicillin
O lodine PattentName
O Aspirin U Codeine g
Other -..... . ...-. -... .__ DOB . issueDate . .
Medical Conditions
HeartFellure O Hypertension
U
U Heart Attack/Angina
ifJAsthma
O Glaucoma O Ulcer
Other .-.... ....
....
Retum Fax
STEP 5
NO COVER SHEET REQUIRED
FaxthispageONLYto
1 800 837-0959 ..... e.n... .
Medco cannot accept vie fox
Cl| prescriptions
PresothberSignature
) when sent from a
Fox forrns wil only be accepted ... .. ..
lePenes so ilmtten
preuctlber's
office
fax confirneanis proof of receipt 1
) The printed
patientscan recotvaa so-day plustefills (We cannot acceptSignature Stamps)
Most supply
up to 1 year where
appropriate.
L ||llillilllllillfillillllillill
end any attachmentsare intended solely forthe use of the addressesnamedabove end
Nottce:Thla ===:-t:!;n
Confidentiality -":!-'t::!:2:7
contain confidentistend Legallypavitogadinformation.if you are not tthe intendedrecipient.any dissemination,
copying
planse notify Madco by inx or phoneimrnastintaly.
la nidctly prenicited. tr you teceived this communicanonin etror, f ff ( ( (( ?
MBcNues are accuto and in complietst:ewmrHIPAA p:tvacy standards.
hfedco raCSImUR
FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019
Mar. 31. 2009 10: 2 6 AM PAGE . 1/ 1
/ f f (( {.*() Pharmacy New Prescription
YOUR PATIENT WOULD LiKE TO RECElVE THElR PRESCRIPTION MEDICATION FROM MEDCO.
F ""°ª||ll|ll|||||l|lll||l||llIl|lill 'l
Please comp!ete ALL Mformation below. incamplete forms cannot be processad. Please printclearly.
STEP 1 Prescriber information Questione? Call 1.858.EASYRX1
Note to
Prescriber
AY^'
PrescriberName DEA . (G ¥Ÿ 9 2--f O
for Clu•CVess/cations
Reewtrant
Secure faxnumber -.- NPi A ____
STEP 2 Member nfe a b
Member No. 1 4 2 9 4 6 7 6 1 5 3 9
(inclu In nHcharacternianya box hiank for apacen 1
Membat Nemelard h0lder): __.. .. . . ... . ___
STEP 3 Patient information STEP 4 Prescription information
h
Pleasecompleteor annonprencnptionbelow
-------------------------------------- -
u.n -.,n. o (ler
Patchogue NÝ tt772
(68 1) 447-7560
Allerglam
None O Sulfa Q PGñiGlitiñ
U Codelrte O lodine PatientName
O Aspirin
. . ..-.. ._ DOB issueDate . . . ...
Other
MedicalConditions
Heart Failure O Hype-tens:ùn
y
U Heart Attack/AnginalilAsthma
O Glaucoma O Ulcer
Other .-.... ....
....
STEP 5 } Retum Fax
NO COVER SHEET REQUIRED
Faxthis pageONLYto
" "
1 800 837-0959 .u..o-n..nn..e.
) Medco cannot accept vie fox
Cil prose-iptiaris
PrescribarSignature
) when sent fmm a
Fox forms wit only be accepted Wffin----
ns. as
office
prescriber's
is pmof of receipt
The printed fax c^n!kmetion 1 f
p (We cannot acceptS!gnetu-eStamps)
Most patientscan recatvoa 90-daysupply plusrefills |
up to1 year whereappropriate.
L--____________________________________
L ||lllillil||llifilll||lilliffil|lil
and any 8ttachmentsareintended solely for the useof the addreannenamed above ano
Notice:Thts co=-,;r.ison
Confidentiality E;E GEoror copying
contain conDdentialand tegally privilogadinformallon.If you are not ithe intendedrecipient.any d!-౱n,
in arror, plansn notify Manceny inx or phone imrnariininly.
is ninctly pronitated.1fyou received th!r.t--za'-"on f ff f ( (*(
Medco facsimilemactshresara accuto nm1tn compliant:owmsHIPAAprivacy standstds.
FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019
OFFICIAL NEW YORK STATE PRESCRIPTION
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FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019
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Preview
FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019 "F" EXHIBIT FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019 Shore Psychiatric Center Ronald L Taddeo, MD Margaret Galvin, NF MacConneS, LCSW, BCD Mary Parente, LCSW Hilary Jane Indilla-Brown, LMSW Û Lata Agnikotri, LMSW Erin Hayes, LMSW O Christine Sadousby, LMVW 4PhyiMr Drim SuiteH Patehogue, NY 11772 Tel (631) 447-75ó0 Certif ied in Psychiatry Fax 447-7561 123293 a . (631) NYS Medical License PRESCRIPTIONN: TEMPHONE DATE 6 C Don: PATIENTNAME MFRCATILONS NEEDED: C4 PHARMACY: APPROVED BY: DATE: ( Û BY: 6 CALLED IN FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019 Shore Psychiatric Genter Ronald J. Teddeo, MJJ Margaret Galvin, lvP MacConneK, LCSW, BCD Mary Hilary Parente, LCSW Jane Indilla-Brown, LMSW Lata Agnikotri, LMSW Erin Hayes, LMSW Christàte Sadousky, LBlSW 4PhyRiv RM Suites Patehogue, NY 11772 Tel (631) 447-756ti Certif ted in Psychiatry ., Fax (631) 447-7561 S Medical License 123293 TELEPHONE PRE8CFdPTIONS: DATE: '04 PAHENT NAM E: (A ÎC cd [CC 3o3 ca Praza c 20m PHARMACY: APPROVED BY: DATE: CALLED IN BY: FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019 medco Patient Prescription Request RNWL INVOICE: 867153526 12 Our patient would like to receive the medication listed below through Medco Please review, fill in any required inforrnation, sign, date, and return fax. Questions? Call 1 888 327-9791 STEP 1 » Review and complete Information: Prescriber: RONALD TADDEO 4 PHYLLIS DR STE H PATCHOGUE NY 11772-2900 631 447-7560 _J Patient: xxxxxx xxxxxxxx 1734 SPUR DR S ISLIP NY 11751-1200 DOB: Drug: BUPROPION HCL XL TABS Strength: 150MG Quantity: 180 Refili: 0 Directions: TAKE 1 TABLET TWICE A DAY REQUIRED ate Date: S Perrnissible Date: Dispense as Written REQUIRED NPl: NPI ON FILE STEP 2 > sign, date and fax without cover sheet to 1 800 837-0959 ² ™ L Case Item No.259681406-7 Rx No.0924721011 Location 12 J Notice:Thiscornmunicationand any attachments are intended solely for the use of the addressee named above and contains confidential and inforrnation. egally privileged If you are not the intended recipient, any d -lion,distribution or copying is strictly prahibited. If you receivedthis cc by fax or phone irnmediately. notify Medco n error, please Medco facsimile rnachines are secure and in compliance with HIPAA privacy standards. of the infortnation The provision requestedin this fortn is for your patient's benefit. Medco does not cornpensate for c:mp!:Sq this fortn. FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019 medco Patient Prescription Request RNWL INVOICE: 867153526 12 Our patient would like to receive the medication listed below through Medco Please review, fill in any squired information, sign, date, and return fax. Questions? Call 1 888 327-9791 STEP 1 > Review and cornplete inforrnation: Prescriber: RONALD TADDEO 4 PHYLLIS DR STE H PATCHOGUE NY 11772-2900 631 447-7560 Patient: xxxxxx xxxxxxxx 1734 SPUR DR S ISLIP NY 11751-1200 DOB: Drug: SERTRALINE HCL TABS Strength: 100MG Quantity: 180 Refill: 0 Directions: TAKE 2 TABLETS DAILY REQUIRED Date: Dat ' Substitu Pefmissible Date: I I Dispense as Written REQUIRED NPI: NPI ON FILE Ê/ (REQUIRED if missing) STEP 2 > Sign, date and fax without cover sheet to 1 800 837-0959 ² ™ Ilil I 1111111111111lll111111111 IllilIll 11111111111 L Case Item No. 259681407-5 Rx No.0924721012 Location 12 Notice: Jonfidentiality This ::mmunication are intended solely for the use of the addressee and any attachments narned above and contains conMantial and informa½n. egally privileged li you are not the intended or copying is strictly prohibited. recipient, any disseeidnauun, distribution If you receivedthis coiiiiiisii|sation Medco facsimile n error, olease notify Medco by fax or phone irnmediately. machines are secure and in usiiipliaiice with HIPAA privacy standards. of the information Tne provision requestedin this brm is for your patient's for completing this form. benefit. Medco does not compensate FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019 TRANSMISSION VERIFICATION REPORT TIME : 09/04/2009 18:22 DATE, TIME 09/04 18: 20 FAX NO. /NAME 18008370959 DURATION 00:01:51 PAGE(S) 03 RESULT OK MODE STANDARD ECM FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019 medco Patient Prescription Request RNWL INVOICE: 867153526 12 Our patient would like to receive the medication listed below through Medco Please review, fillin any required information, sign, date, and return fax. Questions? Call 1 888 327-9791 STEP 1 > Review and cornplete Information: Prescriber: RONALD TADDEO 4 PHYLLIS DR STE H PATCHOGUE NY 11772-2900 631 447-7560 Patient: xxxxxx xxxxxxxx 1734 SPUR DR S ISLIP NY 11751-1200 DOB: Drug: TOPIRAMATE TABS Strength: 200MG Quantity: 360 Refill: 0 Directions: TAKE 1 TABLET FOUR TIMES A DAY REQUIRED Date: Dat Sub-t:‡LS:= Permissible Date: Diwpense aw Wr inen REQUIRED NPl: NPI ON FILE (REQUIRED if missing) STEP 2 > sign, date and fax without cover sheet to 1 800 837-0959 "® ² ™ IIIII 1111111111111ll111111111111 IIII 11111111111 L Case item No.259681410-9 Rx No.0924721015 Location 12 3cr.*!dent!a!!+v Notice:This c emüüistion ano any attachments are intended solely for the use of the addressee named above and contains confidential ano egally privileged inbrmefen. If you are not the intended recipient. any dissemination, or copying is strictly prohibited. distribution If you receivedthis communication Medco facsimile notify Medco by fax or phone immediately. n error, please machines are secure and in ce.ne|iâoca with HIPAA privacy standards. of the information The provision reauestedin this form is for your patient's benefit. Medco does not compensate for completing this form. FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019 P Pad15of2D111612009 SWCNYRxPadMV338835 N OFFICIAL NEW YORK STATE PRESCRIPTION PATCHOGUE, NY iT/2 (631)447-7560 . UC.123293 1A17T 6 2 Patient Name Date Address Sex . City - State Zip Age M F Prescr r Sin X THISPRESCRI N WILL8 D GENERICAI1Y WRFES'daw IN BOXBELOW UN ESSPRESCRIBER REFILLS O None. 0KKQDB 16 Refills: gilinn smuggum• PHARMACIST . ü¡¡i TEST AREA: . ,...--- .....rnon:uw.n DispenseAsWritten FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019 f ] f f'( .*() Pharmacy New Prescription = YOUR PATIENT WOULD LIKE TO RECEIVE THEIR PRESCRIPTION WlEDICATION FROM MEDCO, F IIIllill 11111111 III IllIll '7 Please complete ALL information below. incomplete forms cannot be pr0casséû- Picase printclearly. STEP 1 Prescriber information Questions? Call 1.688.EASYRX1 ) Note to Prescriber PrescriberName . -- DEA - b 2-) Û RwoultedRMCrtt-CVmedicat\ana Secure faxnumber . ....... NPI . . STEP 2 Member information p Manberso. 1 4 2 9 4 6 7 6 1 5 3 9 (incIndn nucharactarninave bon blank for apanon) Member Name rd holder): .. . .... .. STEP 3 Patient Information STEP 4 ) Prescription information Pleasecomplete nr at1nchpresenptionbelow --------------------------------------- sU•nt Nama O:f(\f A ho (hir City,State, Zip ship to addives Tel•Phone Patchogue, NY 11772 Ilophone (831) 447-7580 Allergies ~~---------~~""" "-"- --""--- None O Sutfe Q Penicillin lodine PatientName 1.. O Aspirin U Codelne O Other_ _. . ..... ... . _. DOB . lesueDate . . . Medical conditions HeartFellure Q Hypertension u U Heart Attack/AnginalG Astrima O Glaucoma O Ulcer other . . _... .... .... Retum Fax STEP 5 p NO COVER SHEET REQUIRED FaxthispageONLYto 1 800 837-0959 .....-.np., , .e. Medco cannot accept vie fox Cil prescriptions ) PresenbarSignature ) Fox fomis when sent fmm a wil only be accepted NWnse as MtWn ofDce prescriber's fax casifirmakn The printed of receipt is r;oof p Most patientscan recatvaa 90-daysupply plusrefills I (We cannot acceptSignatureStamps) up to1 year whereappropriate. L___-__________________________________ L 1111111 I Ilill I lill 111111 for the use of the eddmanesnamedabove and Confidenuality Notice:This comrqunicationand any anachmentsare intenced solely COntalnconfidentl8Iend legally privHogedInformation.If you are not tthe inlanded recipient any dissemination,distributtonor fr)pying planta notify Marlenby inx or phoneImrantitatnty. a aidctly prohitilted. If you tecelynd this communlantionin error, standesds. f } W( ( ? Medco facstmilemactibios are accureants to compilant:awmsHIPAA privacy FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019 Mar.31.2009 10: 26 AM PAGE. 1/ 1 // ICC ( () Pharmacy New Prescriptiori YOUR PATIENT WOULD LlKE TO RECElVE THEIR PRESCRIPTION MEDICATION FROM MEDCO, F ""||lilli |l|l|l I ll|ll lilill l Please complete ALL !r.'-=a*!en below. incemplete forms cannot be processed. Please printclearly. STEP 1 p Prescriber information Questione? Call 1.868,EASYRXi Note to Prescriber PrescriberName a tVrd/ ) f/) DEA . Reuntredfor Clu-CVenadicarfona Secure faxnumber ._ ... NPl p. STEP 2 Member nformation member No. 1 4 2 9 4 6 7 6 1 5 3 9 (inchitin all charactarnianve bon blank for apacan) Member Name ard holder): Patient information STEP 4 Prescription inforriistiGr STEP 3 Plaouecoroplete or anachprerenptionbelow =•u.nin=• oaMcR hoffer ----------,-----------------------------, City,8 at,Z Bhip to address Telephone VG, Alterglam d PatientName . piin U odeirte .--.. -..- .__ DOB . fasueDate . . Other ... MedicalConditions Heart Fallure L) Hypertension u U Heart Aiind/Añûlim fQ Asthma O Giaucoma O Ulcer Other . ....... .... .... Retum Fax STEP 5 > Refills .._.._____ . NO COVER SHEET REQUIRED Fax thispageONLYto 1 800 837-0959 ......on..... . ) Medco cannot accept vis fox Cll prescriptions c Ibar Stonetura Fox formaWiionlybe wap!ed when sent from a __ ) a office prescriber p is p;ool of receipt The printed fox confirmation (We cannot accept8 gnatureStamps) Most patientscan recotvaa 90-daysupply plusrefills . 1 up to1 year wheresppropriate. L ||lilll Ilill I ll I illll and any attachmentsare!menced solely tor the use of the eddmeseenarnedabove ano Confidentiality Notice:This coric;ñir. GTcopying intendedrecipient.any classmination,-":1 contain--e!m!-!endtegally pavileged Information.if you are not ithe ? in errori plunganotify Matich by fax or phone %•*at!!a!e!y. 18HDictlyproh1Nted.if you recelyndthin Wenkstlan { standards. Medco facstn|ttemach‡nosara accuro and in Complluncowtth HiPAA privacy FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019 Mar. 31. 2009 10:2 6 AM PAGE. 1/ 1 () Pharmacy New Prescription YOUR PATIENT WOULD LlKE TO RECElVE THEIR PRESCRIPTION MEDICATION FROM MEDCO. I- ""°ª ||ll|lil||||llill||l||ll||l||lilill "I Please complete ALL information below. Incomplete forms cannot be procassêd. Please printclearly. STEP 1 Prescriber information Questions? Call 1.888.EASYRX1 p Note to Prescriber Peacriber Name . ..- DEA . 2 Ñ ...... Reeutredstr CR‡•CV spadfcatiotts secure faxnumber _... .... ... NP1 ) STEP 2 Member Information h emberso. [1]4 2 9 4 6 7 6 1 5 3]9] (inchitin nu charactarninave bon blank tor apacon) Member N:m'card holder): O , STEP 3 Patient Information STEP 4 Prescription information p Plansecanoplete ar anannpresenptionbelow City ate Zip Bhip to address W(A N Pathogue, NY 11772 phooe (8311447-7580 Aftergree - None O Sulfa Q Penicillin O lodine PattentName O Aspirin U Codeine g Other -..... . ...-. -... .__ DOB . issueDate . . Medical Conditions HeartFellure O Hypertension U U Heart Attack/Angina ifJAsthma O Glaucoma O Ulcer Other .-.... .... .... Retum Fax STEP 5 NO COVER SHEET REQUIRED FaxthispageONLYto 1 800 837-0959 ..... e.n... . Medco cannot accept vie fox Cl| prescriptions PresothberSignature ) when sent from a Fox forrns wil only be accepted ... .. .. lePenes so ilmtten preuctlber's office fax confirneanis proof of receipt 1 ) The printed patientscan recotvaa so-day plustefills (We cannot acceptSignature Stamps) Most supply up to 1 year where appropriate. L ||llillilllllillfillillllillill end any attachmentsare intended solely forthe use of the addressesnamedabove end Nottce:Thla ===:-t:!;n Confidentiality -":!-'t::!:2:7 contain confidentistend Legallypavitogadinformation.if you are not tthe intendedrecipient.any dissemination, copying planse notify Madco by inx or phoneimrnastintaly. la nidctly prenicited. tr you teceived this communicanonin etror, f ff ( ( (( ? MBcNues are accuto and in complietst:ewmrHIPAA p:tvacy standards. hfedco raCSImUR FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019 Mar. 31. 2009 10: 2 6 AM PAGE . 1/ 1 / f f (( {.*() Pharmacy New Prescription YOUR PATIENT WOULD LiKE TO RECElVE THElR PRESCRIPTION MEDICATION FROM MEDCO. F ""°ª||ll|ll|||||l|lll||l||llIl|lill 'l Please comp!ete ALL Mformation below. incamplete forms cannot be processad. Please printclearly. STEP 1 Prescriber information Questione? Call 1.858.EASYRX1 Note to Prescriber AY^' PrescriberName DEA . (G ¥Ÿ 9 2--f O for Clu•CVess/cations Reewtrant Secure faxnumber -.- NPi A ____ STEP 2 Member nfe a b Member No. 1 4 2 9 4 6 7 6 1 5 3 9 (inclu In nHcharacternianya box hiank for apacen 1 Membat Nemelard h0lder): __.. .. . . ... . ___ STEP 3 Patient information STEP 4 Prescription information h Pleasecompleteor annonprencnptionbelow -------------------------------------- - u.n -.,n. o (ler Patchogue NÝ tt772 (68 1) 447-7560 Allerglam None O Sulfa Q PGñiGlitiñ U Codelrte O lodine PatientName O Aspirin . . ..-.. ._ DOB issueDate . . . ... Other MedicalConditions Heart Failure O Hype-tens:ùn y U Heart Attack/AnginalilAsthma O Glaucoma O Ulcer Other .-.... .... .... STEP 5 } Retum Fax NO COVER SHEET REQUIRED Faxthis pageONLYto " " 1 800 837-0959 .u..o-n..nn..e. ) Medco cannot accept vie fox Cil prose-iptiaris PrescribarSignature ) when sent fmm a Fox forms wit only be accepted Wffin---- ns. as office prescriber's is pmof of receipt The printed fax c^n!kmetion 1 f p (We cannot acceptS!gnetu-eStamps) Most patientscan recatvoa 90-daysupply plusrefills | up to1 year whereappropriate. L--____________________________________ L ||lllillil||llifilll||lilliffil|lil and any 8ttachmentsareintended solely for the useof the addreannenamed above ano Notice:Thts co=-,;r.ison Confidentiality E;E GEoror copying contain conDdentialand tegally privilogadinformallon.If you are not ithe intendedrecipient.any d!-‡±±n, in arror, plansn notify Manceny inx or phone imrnariininly. is ninctly pronitated.1fyou received th!r.t--za'-"on f ff f ( (*( Medco facsimilemactshresara accuto nm1tn compliant:owmsHIPAAprivacy standstds. FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019 OFFICIAL NEW YORK STATE PRESCRIPTION EWCWRxPadR316854P Pad20of2010/22/2008 N n , n- %. :w., OFFICIAL NEW YORK STATE PRESCRIPTION I .{f Ji RONALDATAD IWD ~SUlFEC PHVLEIS í3R ÑÒ NÝ 77È (631)44A7560 (631)447t75 0 LIC 123293 . Patient Name Qate Name Patient to Address Address City State Zip Age Sex City State_ Zip Age M F axcilugDAH ' XDOSE THISPRESCRIPTION WillBE IED GENERICAliY UNLESS PRESCRIBER 'daw' WRITES INBOXB Prescriber Sig ure eï±emi RERL S O None SK7Q8D 2t THISPRE5CRIPTION WILLB ILLEDGENERICALLY WI TESdaw N BOXfiELOW UNLE55PRESCRIBER Refills: .:;; nmi RERLLS O None PHARMACIST . :..... . .... . .. DispenseAs a ' ''°*"""" a5 " PHARMACIST TEST AR °5''"° DispenseAsWritten . . FILED: SUFFOLK COUNTY CLERK 01/09/2019 02:38 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 01/09/2019 a u 0 3 5