On August 11, 2020 a
Exhibit,Appendix
was filed
involving a dispute between
Barbara Sackaroff,
and
Advanced Spine On Park Avenue Mso, Llc,
Fifth Avenue Surgery Center, Llc,
Igor Amigud M.D.,
Igor Amigud Physician P.C.,
Jande Weeks Crna,
Manhattan Spine And Pain Management, Pllc,
Sudhir Diwan M.D.,
Sudhir Diwan, Md Llc,
for Torts - Medical, Dental, or Podiatrist Malpractice
in the District Court of Kings County.
Preview
FILED: KINGS COUNTY CLERK 01/16/2023 09:29 AM INDEX NO. 514577/2020
NYSCEF DOC. NO. 99 RECEIVED NYSCEF: 01/16/2023
EXHIBIT E
FILED: KINGS COUNTY CLERK 12/16/2022
01/16/2023 03:56
09:29 PM
AM INDEX NO. 514577/2020
NYSCEF DOC. NO. 87
99 RECEIVED NYSCEF: 12/16/2022
01/16/2023
FIFTH AVE SURGERY CENTER
1049 5TH AVE NEW YORK NY 10028 PH: 212-772-6667
Date: 01/07/2020 Patient Name: Sackaroff. Barbara BirthDate: -67 DOS: 01/07/2020
Addr: 9322 3rd Avenue
SS#: Home: 917-750-8270
Brooklyn. NY 11209
Provider: %
Work:
Patient #: 3087736
Cell: 917-750-8270
Emergency Contact:
Daniel Sackaroff, Barbara
Sackaroff DOB: 67y/o F
516 382-5221 Dr. Sudhir Diwan
Procedure: MRN; 3087736 01/07/20
Visit Reason : CornerLoc Joint Stabilization
Doctors Name : Dr. Sudhir Diwan
Visit Note : *** NUMBER UPDATED 1/6/2020 16:42PM AA *** ** Number not in service. AA notified ** *** Anesthesia Type: MAC ***
Procedure - Corner Loc Joint Stabilization Procedure Right Sacroiliac CPT Right | 27279 | "ARTHRODESIS, SACROILIAC JNT,
PERC" ICD Right | M46.1 | Sacroiliitis, not elsewhere classified
* WC * NYNF * lien * Medicare * MM
Primary Insurance: Claim# Date of Injury:
MEDICARE -
Medicare
* WC * NYNF * lien * Medicare * MM
Secondary Insurance: Claim# Date of Injury:
AARP -
COMM
Primary Insurer: MEDICARE
MEDICARE
PO BOX 6178
INDIANAPOLIS
IN 46206
â–¡ate of Incident:
Claim No:
Secondary Insurer: AARP
iRP
Po Box 740819
Atlanta
GA 30374
Date of Incident:
Claim No:
Attorney Name:
Attorney Phone:
.djuster First Name :
djuster Last Name :
000001
FILED: KINGS COUNTY CLERK 12/16/2022
01/16/2023 03:56
09:29 PM
AM INDEX NO. 514577/2020
NYSCEF DOC. NO. 87
99 RECEIVED NYSCEF: 12/16/2022
01/16/2023
â– ^^^IftlTAv
eSumeryXenter Tol.:(212) 772-6667
1049 6th Ave New York, NY 10028 OfflceFax:(212) 988-8018
Patient Bookina Form
â–¡ Medicare/Medlcald â–¡Prlvate/Commerclal DNJPIP DNYNF â–¡ WC â–¡ Legal Funding â–¡ Self-Pay MTldle
Today's Dale:
12/31/2019 Yee 0 NoO l
Previous Admission: Sackaroff, Barbara
Patient's Name:
Sackroff.Barbara Patient's Social Security# DOB: 67y/o F
Dr. Sudhir Diwan
Patient's Gender:M O F«X Patlenfa Date of Birth: MRN: 3087736 01/07/20
Patient’s
Home Address;9322 3rd avenue
city: Brooklyn State: NY Zip Code: 11209
Home Phone# 917-750-8270 Work Phone# Cell Phone# 918-750-8270
Notify In Case of Emergency: Phone#, Relationship:
Primary Insurance: Medicare Claims Address:
Insurance Co. Phone Adjuster:
Policy ID# Claim# DOA/DOL:
Secondary AARP Claims Address:
InsuranceCo, Phone Adjuster:
Policy ID# Claim# DOA/DOL:
Attorneys Name: Attorne/s Phone #:
Admitting Diagnosis:Sacroiliitls (M46.1)
Proposed Procedure: Comer Loc Joint Stabilization Procedure Right Sacroiliac (27279)
Referring Physician:
Dr. Diwan Referring Clinic:
ASPA phone#: (212)535-3505
Admitting Surgeon:
Dr. Diwan Contact Person at Clinic:
Jennifer
Proposed Surgery Date:
01/07/2020 Proposed Time of Surgery:
02110
Anesthesia Type:MAC Estimated Surgery Duration:
45min
Surgeon Requires Assistant: Specific Supplies and/or
Equipment: Cornsiloc Rep 972-658-2636 ONF)
YesJSXX
Patient Needs Transportation: No O
Note Pick Up Address If Different from Home (Above):
Affirmation By Medical Staff that He/She has Explained Proposed Procedure lo the Patient to the Fullest Extent Possible By State Law
Medical Staffs Signature: Patient's Signature: yp
000002
FILED: KINGS COUNTY CLERK 12/16/2022
01/16/2023 03:56
09:29 PM
AM INDEX NO. 514577/2020
NYSCEF DOC. NO. 87
99 RECEIVED NYSCEF: 12/16/2022
01/16/2023
*
Primary Provider: Sudhir Diwan, MD
Patient Demographics
First Name Barbara Country UNITED STATES
Nick Name Street Address 9322 3RD AVE #407
Middle Name Zip Code 11209
Last Name Sackaroff City Brooklyn
Suffix State NY
Home # Emerg Cont Name
Cell # (917) 750-8270 Emerg Cont Phone
Work # (918) 750-8270 Emerg Cont Relation
Work # Extension Resp Party Name
Email Resp Party DOB
Social Security # Resp Party Relation
Date of birth Resp Party Phone
Sex Female Resp Party Email Sackaroff, Barbara
Race DOB: 67y/o F
Ethnicity Dr. Sudhir Diwan
MRN: 3087736 01/07/20
Marital Status
Preferred Language
Student Status
Referred By SUDHIR DIWAN
Primary Insurance Secondary Insurance
First First *name of insured
Middle Middle
Last Last
Suffix Suffix
Date of Date of Birth
Birth Social
SSN Security #
Relation Relation
Medicare of New York - AARP Medicare Supplement/Fixed Indemnity
Insurer Insurer
Downstate - J13 by UHC
Payer ID 13202 Payer ID 36273
ID # ID #
Group # Group #
Plan Name Plan Name
Claim Claim Office
Office
000003
FILED: KINGS COUNTY CLERK 12/16/2022
01/16/2023 03:56
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AM INDEX NO. 514577/2020
NYSCEF DOC. NO. 87
99 RECEIVED NYSCEF: 12/16/2022
01/16/2023
Tertiary Insurance Auto Accident Insurance
First First
Middle Middle
Last Last
Suffix Suffix
Date of Birth Date of Birth
SSN Social Security #
Relation Auto Accident Insurance Company
Insurer Case #
Payer ID Mailing Address
ID # Zip Code
Group # City
Plan Name State
Claim Office Date of Accident
State of Accident Occurrence
Worker's Compensation Durable Medical Equipment
Worker Comp. Provider Dme insurance company
Mailing Address Dme insurance payer id
Zip Code Dme insurance plan name
City Dme insurance plan type
State Dme insurance id number
Date of Accident Dme insurance group number
Worker Comp. W.C.B. Dme insurance notes
Worker Comp. Case #
State of Accident Occurrence
doTwioa/TStv/oF
0
000004
FILED: KINGS COUNTY CLERK 12/16/2022
01/16/2023 03:56
09:29 PM
AM INDEX NO. 514577/2020
NYSCEF DOC.
12/27^2019 NO. 87
99 __8a7f6ff5-edce-4842-8a5a-c286bc3e883d.jpf '1x470) RECEIVED NYSCEF: 12/16/2022
01/16/2023
7,"OF
3087736 01/07/20
‘1,
^ MEDICARE HEALTH IIMSURAIMCE
â– *
e
•j
7
•5
Mame/N ombre
Barbara z sackaroff
Medicare Number/Numero de Medicare
Entitled to/Con derecho a
^SPITAL (PART A) ^03^0 StartS/Cabertura emP^za
MEDICAL -----
(PART B)' 0Mll2017
i
https://storage101.lad3.clouddrive.com/v1/MossoCloudFS_929697/uploaded_media-000363/clinlcal/2019/06/_3a7f6ff5-edce-4842-8a5a-c286bc3e88...
1/1
000005
514577/2020
12/16/2022
01/16/2023
000006
NYSCEF:
INDEX NO.
O
RECEIVED
OJ
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CO ^
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cd
co : co
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Medicare Supplement Plans
-AARPI insured by UnitedHealthcare CO ^
PM
AM
Insurance Company W ^
03:56
09:29
MEMBERSHIP ID:
BARBARA SACKAR
EFFECTIVE DATE:.03-01-2017
PLAN F
12/16/2022
01/16/2023
AARP MEDICARE SUPPLEMENT
a;
^r1
Insured by UnitedHealthcare Insurance Company (for NY residents, Uniiec- fs:-;:2
gg
Insurance Company of NY).
CLERK
â– -'ffiiaieagias
5^
m
COUNTY
87
99
KINGS
DOC. NO.
FILED:
NYSCEF
FILED: KINGS COUNTY CLERK 12/16/2022
01/16/2023 03:56
09:29 PM
AM INDEX NO. 514577/2020
Eligibility & Benefits Verification Form
NYSCEF DOC. NO. 87
99 RECEIVED NYSCEF: 12/16/2022
01/16/2023
Patient Name (Last, First): _ Cu~‘
V. [ilMlil; ^ fifl/tMI Date of Birth:
Insurance Company Name: i Tiff li^O/'iL Phone # (Ani60)Dl0
COMMERCIAL INSURANCE
FACILITY IS ONLY PAR WITH GHL OXFORD, EMBLEM HEALTH. AND MCARE.
STi'SUfl-fiW ALL OTHER CARRIERS OUT OF NETWORK BENEFITS MUST BE AVAILABLE
Policy # Group# Ikt: £> Effective Date:
Coverage/YesY No Covered @ %, Procedure Being Authorized Precert Needed: YeffNo)
Authorization#:___________ __________ Deductible: $_____ j Remaining Amount: $
Out of Pocket: $_____ j Remaining Amount: $.
L$T)Q~pj
Co- Ins. %
Representative Name: Ffiftr§u£fiT^ , Ref# wIr Date: 11 LeiAWi)
fcKlO ~ft' DLt>' XZ 4 LMiirm ls {
mt -fif son' NO-FAULT
Sackaroff, Barbara
Policy # Claim# DOB: 67y/o F
Dr. Sudhir Diwan
State Policy Written: NY / NJ / OTHER
MRN: 3087736 01/07/20
Case Open: Yes / No, Benefits Exhausted: Yes / No, Amount Left on Policy: $. , Pending nvitmuu: res IIMU
Type of IME: Date IME/EUO Scheduled:
NEW YORK:
Adjuster Name Ph: , Ext:
WORKERS COMPENSATION
WCB # cc# DOA:
Case Still Open: Yes / No Established Body Parts:
Adjuster Name, Ph: j Ext:
Claim Submission Address:
000007
FILED: KINGS COUNTY CLERK 12/16/2022
01/16/2023
& Benefits09:29
03:56 PM
AM
Verification Form INDEX NO. 514577/2020
Eligibility
NYSCEF DOC. NO. 87
99 RECEIVED NYSCEF: 12/16/2022
01/16/2023
Patient Name (Last, First): _ I Yhirflu Date of Birth:
Insurance Company Name: u Phone # QTTWBTO
COMMERCIAL INSURANCE
ONLY PAR WITH GHI. OXFORD. EMBLEM HEALTH. AND MCARE.
ARRIERS OUT OF NETWORK BENEFITS MUST BE AVAILABLE
P Group# Effective Date:
Coverage: Yes / No Covered @ .%, Procedure Being Authorized Precert Needed: Yes / No
Authorization #:___________ _________Deductible: $______ Remaining Amount: $_
' cPTF#
Out of Pocket: $____________j Remaining Amount: $. j Co- Ins. %
Representative Name: Ref# Dat- Sackaroff, Barbara
DOB: 67y/o F
Dr. SudhirDiwan
MRN: 3087736 01/07/20
NO-FAULT
Policy # Claim# DOA:
State Policy Written: NY / NJ / OTHER
Case Open: Yes / No, Benefits Exhausted: Yes / No, Amount Left on Policy: $. Pending IME/EUO: Yes / No
Type of IME: , Date IME/EUO Scheduled:
NEW YORK:
Adjuster Name Ph: , Ext:
WORKERS COMPENSATION
WCB# cc# DOA:
Case Still Open: Yes / No Established Body Parts:
Adjuster Name_ Ph: , Ext:
Claim Submission Address:
000008
FILED: KINGS COUNTY CLERK 12/16/2022
01/16/2023 03:56
09:29 PM
AM INDEX NO. 514577/2020
NYSCEF DOC. NO. 87
99 RECEIVED NYSCEF: 12/16/2022
01/16/2023
%
f NEW YORK STATE
;
** j TDJKTVER LICENSES ^
J
>Wjj
» ‘.I
■»T *“ *-‘J
%
Sackaroff, Barbara
DOB: 67y/o F
Dr. Sudhir Diwan
MRN: 3087736 01/07/20
I
*- "<
'A -
i.
\ ♦ i
000009
FILED: KINGS COUNTY CLERK 12/16/2022
01/16/2023 03:56
09:29 PM
AM INDEX NO. 514577/2020
NYSCEF DOC. NO. 87
99 RECEIVED NYSCEF: 12/16/2022
01/16/2023
FIFTH aVENTTF STOGERY CENTER
AUTHORIZATION AND CONSENT
ASSIGNMENT OF BENEFITS AND RELEASE OF ^FORMATION TO
INSURANCE COMPANY
I hereby assign payment to FIFTH AVENUE SURGERY CENTER (FASC) insurance
benefits otherwise payable to me bet not to exceed the balance FASC regularly charges
for the episode of treatment. I understand that I am financially responsible to the FASC
for charges not covered by the authorization. Authorization is hereby granted to release
to the above mentioned INSURANCE COMPANY(S) information as the company may
request complete Centers insurance claim where applicable.
CERTIFICATION FOR MEDICARE PATIENTS ('ONLY)
Patient’s Certification. Authorization to release Information and payment Request
I certify that the information given by me in applying for payment under title XYHI of
the Social Security Act to be correct. I authorize any holder of medical and other
Information about me to release to the Social Security Administration or its
intermediaries claim. I request payment of authorized benefits to be made in my behalf,
where applicable.
I hereby release FASC from any responsibility for valuables, money or personal
possessions which may be brought to the Center by me and which may be taken from me to
properly carry out any procedure for my care, or for any article left in the Center which
are not claimed by me or in behalf within (30) days after my discharge.
CONSENT TO TREATMENT
I request admission to the Fifth Avenue Surgery Center and authorize the facility, staff
and physicians to provide care. I request and consent to medical care and diagnostic
procedures that my attending physician(s), or his/her designees, determine are
necessary. I acknowledge that the medical care I receive while in the Fifth Avenue
Surgery Center is under the direction of my attending physician(s) and that the Fifth
Avenue Surgery Center is not responsible for acts of omission of my attending
physician(s). / authorize the Fifth Avenue Surgery Center to retain or dispose of any
specimen or tissue taken from the above named patient.
A
/ i’a&ient’s Signature Signature of Person
Authorized to consent
For Patient
F 7-
i ate Sackaroff,
DOB:
Barbara
67y/o F
mt
ationship to Patient
Dr. Sudhir Diwan
MRN: 3087736 01/07/20
000010
FILED: KINGS COUNTY CLERK 12/16/2022
01/16/2023 03:56
09:29 PM
AM INDEX NO. 514577/2020
NYSCEF DOC. NO. 87
99 RECEIVED NYSCEF: 12/16/2022
01/16/2023
. l UmORIZAnON.-ij VD CONSENT FOR ASSIGNMENT OF ANESTHESIA BENEFITS
AND RELEASE OFINFORALiTION
TO INAUEANCZ COADPAJNY OR HEALTH MAINTENANCE ORGADAZATION.
I hereby assign payment to FIFTH AVENUE ANESTHESIA ASSOCIATES, P,C
(FAAAPC) of insurance benefits otherwise payable to me, but not to exceed the balance
FAAAPC regularly charges for the episode of anesthesia care. I understand that I am
financially responsible to FAAAPC for charges not covered by the authorization, which may
include care delivered to me by an anesthesia provider who does not participate with my
insnrance company or health maintenance organization. Authorization is herby granted to
release to FAAAPC’S INSURANCE COMPANY(S) information as the company (s) may
request to complete the insurance claim, where applicable.
CERTIFICATION FOR MEDICARE PATIENTS (ONLY)
Patient’s certification. Authorization to release Information and Payment Request
I certify that the information given by me in applying for payment under title XV111 of the
Social Security Act to be correct. I authorize any holder of medical and other information
about me to release to the Social Security Administration or its intermediaries claim. I request
payment or authorized benefits to be made in my behalf, where applicable.
POST OPERATIVE PHONE CALL
A nurse will be calling you after your surgery. If you are not available or not at home, we may
leave a message on your answering machine or with the person who might answer your phone
to request that you call the Center at your earliest convenience. If that is not what you wish,
please inform the nurse when you are admitted.
J
i Patient’s Signature V Signature of Person authorized to consent for Patient
Date Relationship to Patient
Sackaroff, Barbara
DOB: 67y/o F
Dr. Sudhir Diwan
KD/ 2008 MRN: 3087736 01/07/20
000011
FILED: KINGS COUNTY CLERK 12/16/2022
01/16/2023 03:56
09:29 PM
AM INDEX NO. 514577/2020
NYSCEF DOC. NO. 87
99 RECEIVED NYSCEF: 12/16/2022
01/16/2023
â– .
VENUE' 'ANE'STWESIAiA.l^r-P^C
IGOR AMIGUD PHYSICIAN, P.C.
1049 FIFTH AVENUE
Sackaroff, Barbara
DOB: 67y/o F
NEW YORK, NY 10028 Dr. SudhirDiwan
MRN: 3087736 01/07/20
ADVANCE BENEFICIARY NOTICE (ABN)
It is possible that your private insurance and / or iVledicare may not pay for the procedure^) that are
described below, if this happens, it does not mean that you should not have received this procedure
from us. There may be a good reason that your pain management doctor recommends that you have
this procedure.
Procedure:
MONITORED ANESTHESIA CARE FOR PAIN MANAGEMENT PROCEDURES
PLEASE CIRCLE BELOW, SIGN AND DATE:
Yes. 1 want to have the above procedure provided to me.
Please submit the claim for your services-to my private insurance and / or Medicare.
K 'Dec ‘SfLcJg: r_p A ^
PRINTED NAME
SIGNATURE
/7- Xjt_
DATE
NOTE: Any information that we collect dbout you on this form will be kept confidential in our offices.
When the claim is submitted to your private insurance and/or Medicare, your health information on this
form may be shared.
000012
FILED: KINGS COUNTY CLERK 12/16/2022
01/16/2023 03:56
09:29 PM
AM INDEX NO. 514577/2020
NYSCEF DOC. NO. 87
99 RECEIVED NYSCEF: 12/16/2022
01/16/2023
iintt tf ^tit; r^-RT?^ rTT'NrrP'g
RACE^THNI^iXY FORiVI
Facilities are required, by law to provide the New York State Department of Health (NYSDOS) with
informatioil regarding the race and ethnicity of" the parient pr/pnlation»
We want to make sure that all our patients get the best care possible. "We would like you to tell us your
tecial/etrrnfc background so that rve can review the treatment that ail patients receive and make sure that
everyone gets the highest quality of care» Sackaroff, Barbara
DOB: 67y/o F
/k ETHINICXXY (Select One) Dr. Sudhir Diwan
MRN: 3087736 01/07/20
NOT HISPANIC OR-"LATINO
SFANTSH/HISPANIC ORIGIN: klease cLeck all that apply
Spaniard Andaiusian AstErran . CastilhaTT. Belearic Islander
Gallego Valencian Canaiian Mexican _ __ Mexican American
Mexicano CMcano LaRnzs Gnatemalan __Hondrirah
Nicaraguan__ Panamanian Saivad-crari Catalonian __ South American
Boliviau Chilean Colambian Peruvian __Ecuadorian
Ufugxxaymn Crioilo Puerto Rican Cnban. _ Spanish Basque
__ Dominican -___ Venezuelan South American Indian __ Paraguayan
Central America Indian Centra.! American Mexican Arner Indian
_ Canal Zone __ Argentinean Latin American
(A RACE (Select One)
AMERICAN INDIAN OR- ALASKA NATIVE
ASIAN: Please clieck all that apply
Asian Indian __ Japanese MaMIvian _ Two Jiraan Korean
Bangladeshi
Preview
FILED: KINGS COUNTY CLERK 01/16/2023 09:29 AM INDEX NO. 514577/2020 NYSCEF DOC. NO. 99 RECEIVED NYSCEF: 01/16/2023 EXHIBIT E FILED: KINGS COUNTY CLERK 12/16/2022 01/16/2023 03:56 09:29 PM AM INDEX NO. 514577/2020 NYSCEF DOC. NO. 87 99 RECEIVED NYSCEF: 12/16/2022 01/16/2023 FIFTH AVE SURGERY CENTER 1049 5TH AVE NEW YORK NY 10028 PH: 212-772-6667 Date: 01/07/2020 Patient Name: Sackaroff. Barbara BirthDate: -67 DOS: 01/07/2020 Addr: 9322 3rd Avenue SS#: Home: 917-750-8270 Brooklyn. NY 11209 Provider: % Work: Patient #: 3087736 Cell: 917-750-8270 Emergency Contact: Daniel Sackaroff, Barbara Sackaroff DOB: 67y/o F 516 382-5221 Dr. Sudhir Diwan Procedure: MRN; 3087736 01/07/20 Visit Reason : CornerLoc Joint Stabilization Doctors Name : Dr. Sudhir Diwan Visit Note : *** NUMBER UPDATED 1/6/2020 16:42PM AA *** ** Number not in service. AA notified ** *** Anesthesia Type: MAC *** Procedure - Corner Loc Joint Stabilization Procedure Right Sacroiliac CPT Right | 27279 | "ARTHRODESIS, SACROILIAC JNT, PERC" ICD Right | M46.1 | Sacroiliitis, not elsewhere classified * WC * NYNF * lien * Medicare * MM Primary Insurance: Claim# Date of Injury: MEDICARE - Medicare * WC * NYNF * lien * Medicare * MM Secondary Insurance: Claim# Date of Injury: AARP - COMM Primary Insurer: MEDICARE MEDICARE PO BOX 6178 INDIANAPOLIS IN 46206 □ate of Incident: Claim No: Secondary Insurer: AARP iRP Po Box 740819 Atlanta GA 30374 Date of Incident: Claim No: Attorney Name: Attorney Phone: .djuster First Name : djuster Last Name : 000001 FILED: KINGS COUNTY CLERK 12/16/2022 01/16/2023 03:56 09:29 PM AM INDEX NO. 514577/2020 NYSCEF DOC. NO. 87 99 RECEIVED NYSCEF: 12/16/2022 01/16/2023 ■^^^IftlTAv eSumeryXenter Tol.:(212) 772-6667 1049 6th Ave New York, NY 10028 OfflceFax:(212) 988-8018 Patient Bookina Form □ Medicare/Medlcald □Prlvate/Commerclal DNJPIP DNYNF □ WC □ Legal Funding □ Self-Pay MTldle Today's Dale: 12/31/2019 Yee 0 NoO l Previous Admission: Sackaroff, Barbara Patient's Name: Sackroff.Barbara Patient's Social Security# DOB: 67y/o F Dr. Sudhir Diwan Patient's Gender:M O F«X Patlenfa Date of Birth: MRN: 3087736 01/07/20 Patient’s Home Address;9322 3rd avenue city: Brooklyn State: NY Zip Code: 11209 Home Phone# 917-750-8270 Work Phone# Cell Phone# 918-750-8270 Notify In Case of Emergency: Phone#, Relationship: Primary Insurance: Medicare Claims Address: Insurance Co. Phone Adjuster: Policy ID# Claim# DOA/DOL: Secondary AARP Claims Address: InsuranceCo, Phone Adjuster: Policy ID# Claim# DOA/DOL: Attorneys Name: Attorne/s Phone #: Admitting Diagnosis:Sacroiliitls (M46.1) Proposed Procedure: Comer Loc Joint Stabilization Procedure Right Sacroiliac (27279) Referring Physician: Dr. Diwan Referring Clinic: ASPA phone#: (212)535-3505 Admitting Surgeon: Dr. Diwan Contact Person at Clinic: Jennifer Proposed Surgery Date: 01/07/2020 Proposed Time of Surgery: 02110 Anesthesia Type:MAC Estimated Surgery Duration: 45min Surgeon Requires Assistant: Specific Supplies and/or Equipment: Cornsiloc Rep 972-658-2636 ONF) YesJSXX Patient Needs Transportation: No O Note Pick Up Address If Different from Home (Above): Affirmation By Medical Staff that He/She has Explained Proposed Procedure lo the Patient to the Fullest Extent Possible By State Law Medical Staffs Signature: Patient's Signature: yp 000002 FILED: KINGS COUNTY CLERK 12/16/2022 01/16/2023 03:56 09:29 PM AM INDEX NO. 514577/2020 NYSCEF DOC. NO. 87 99 RECEIVED NYSCEF: 12/16/2022 01/16/2023 * Primary Provider: Sudhir Diwan, MD Patient Demographics First Name Barbara Country UNITED STATES Nick Name Street Address 9322 3RD AVE #407 Middle Name Zip Code 11209 Last Name Sackaroff City Brooklyn Suffix State NY Home # Emerg Cont Name Cell # (917) 750-8270 Emerg Cont Phone Work # (918) 750-8270 Emerg Cont Relation Work # Extension Resp Party Name Email Resp Party DOB Social Security # Resp Party Relation Date of birth Resp Party Phone Sex Female Resp Party Email Sackaroff, Barbara Race DOB: 67y/o F Ethnicity Dr. Sudhir Diwan MRN: 3087736 01/07/20 Marital Status Preferred Language Student Status Referred By SUDHIR DIWAN Primary Insurance Secondary Insurance First First *name of insured Middle Middle Last Last Suffix Suffix Date of Date of Birth Birth Social SSN Security # Relation Relation Medicare of New York - AARP Medicare Supplement/Fixed Indemnity Insurer Insurer Downstate - J13 by UHC Payer ID 13202 Payer ID 36273 ID # ID # Group # Group # Plan Name Plan Name Claim Claim Office Office 000003 FILED: KINGS COUNTY CLERK 12/16/2022 01/16/2023 03:56 09:29 PM AM INDEX NO. 514577/2020 NYSCEF DOC. NO. 87 99 RECEIVED NYSCEF: 12/16/2022 01/16/2023 Tertiary Insurance Auto Accident Insurance First First Middle Middle Last Last Suffix Suffix Date of Birth Date of Birth SSN Social Security # Relation Auto Accident Insurance Company Insurer Case # Payer ID Mailing Address ID # Zip Code Group # City Plan Name State Claim Office Date of Accident State of Accident Occurrence Worker's Compensation Durable Medical Equipment Worker Comp. Provider Dme insurance company Mailing Address Dme insurance payer id Zip Code Dme insurance plan name City Dme insurance plan type State Dme insurance id number Date of Accident Dme insurance group number Worker Comp. W.C.B. Dme insurance notes Worker Comp. Case # State of Accident Occurrence doTwioa/TStv/oF 0 000004 FILED: KINGS COUNTY CLERK 12/16/2022 01/16/2023 03:56 09:29 PM AM INDEX NO. 514577/2020 NYSCEF DOC. 12/27^2019 NO. 87 99 __8a7f6ff5-edce-4842-8a5a-c286bc3e883d.jpf '1x470) RECEIVED NYSCEF: 12/16/2022 01/16/2023 7,"OF 3087736 01/07/20 ‘1, ^ MEDICARE HEALTH IIMSURAIMCE ■* e •j 7 •5 Mame/N ombre Barbara z sackaroff Medicare Number/Numero de Medicare Entitled to/Con derecho a ^SPITAL (PART A) ^03^0 StartS/Cabertura emP^za MEDICAL ----- (PART B)' 0Mll2017 i https://storage101.lad3.clouddrive.com/v1/MossoCloudFS_929697/uploaded_media-000363/clinlcal/2019/06/_3a7f6ff5-edce-4842-8a5a-c286bc3e88... 1/1 000005 514577/2020 12/16/2022 01/16/2023 000006 NYSCEF: INDEX NO. O RECEIVED OJ N- o CO ^ s -e ° cd co : co “ ^ ^t- § co Medicare Supplement Plans -AARPI insured by UnitedHealthcare CO ^ PM AM Insurance Company W ^ 03:56 09:29 MEMBERSHIP ID: BARBARA SACKAR EFFECTIVE DATE:.03-01-2017 PLAN F 12/16/2022 01/16/2023 AARP MEDICARE SUPPLEMENT a; ^r1 Insured by UnitedHealthcare Insurance Company (for NY residents, Uniiec- fs:-;:2 gg Insurance Company of NY). CLERK ■-'ffiiaieagias 5^ m COUNTY 87 99 KINGS DOC. NO. FILED: NYSCEF FILED: KINGS COUNTY CLERK 12/16/2022 01/16/2023 03:56 09:29 PM AM INDEX NO. 514577/2020 Eligibility & Benefits Verification Form NYSCEF DOC. NO. 87 99 RECEIVED NYSCEF: 12/16/2022 01/16/2023 Patient Name (Last, First): _ Cu~‘ V. [ilMlil; ^ fifl/tMI Date of Birth: Insurance Company Name: i Tiff li^O/'iL Phone # (Ani60)Dl0 COMMERCIAL INSURANCE FACILITY IS ONLY PAR WITH GHL OXFORD, EMBLEM HEALTH. AND MCARE. STi'SUfl-fiW ALL OTHER CARRIERS OUT OF NETWORK BENEFITS MUST BE AVAILABLE Policy # Group# Ikt: £> Effective Date: Coverage/YesY No Covered @ %, Procedure Being Authorized Precert Needed: YeffNo) Authorization#:___________ __________ Deductible: $_____ j Remaining Amount: $ Out of Pocket: $_____ j Remaining Amount: $. L$T)Q~pj Co- Ins. % Representative Name: Ffiftr§u£fiT^ , Ref# wIr Date: 11 LeiAWi) fcKlO ~ft' DLt>' XZ 4 LMiirm ls { mt -fif son' NO-FAULT Sackaroff, Barbara Policy # Claim# DOB: 67y/o F Dr. Sudhir Diwan State Policy Written: NY / NJ / OTHER MRN: 3087736 01/07/20 Case Open: Yes / No, Benefits Exhausted: Yes / No, Amount Left on Policy: $. , Pending nvitmuu: res IIMU Type of IME: Date IME/EUO Scheduled: NEW YORK: Adjuster Name Ph: , Ext: WORKERS COMPENSATION WCB # cc# DOA: Case Still Open: Yes / No Established Body Parts: Adjuster Name, Ph: j Ext: Claim Submission Address: 000007 FILED: KINGS COUNTY CLERK 12/16/2022 01/16/2023 & Benefits09:29 03:56 PM AM Verification Form INDEX NO. 514577/2020 Eligibility NYSCEF DOC. NO. 87 99 RECEIVED NYSCEF: 12/16/2022 01/16/2023 Patient Name (Last, First): _ I Yhirflu Date of Birth: Insurance Company Name: u Phone # QTTWBTO COMMERCIAL INSURANCE ONLY PAR WITH GHI. OXFORD. EMBLEM HEALTH. AND MCARE. ARRIERS OUT OF NETWORK BENEFITS MUST BE AVAILABLE P Group# Effective Date: Coverage: Yes / No Covered @ .%, Procedure Being Authorized Precert Needed: Yes / No Authorization #:___________ _________Deductible: $______ Remaining Amount: $_ ' cPTF# Out of Pocket: $____________j Remaining Amount: $. j Co- Ins. % Representative Name: Ref# Dat- Sackaroff, Barbara DOB: 67y/o F Dr. SudhirDiwan MRN: 3087736 01/07/20 NO-FAULT Policy # Claim# DOA: State Policy Written: NY / NJ / OTHER Case Open: Yes / No, Benefits Exhausted: Yes / No, Amount Left on Policy: $. Pending IME/EUO: Yes / No Type of IME: , Date IME/EUO Scheduled: NEW YORK: Adjuster Name Ph: , Ext: WORKERS COMPENSATION WCB# cc# DOA: Case Still Open: Yes / No Established Body Parts: Adjuster Name_ Ph: , Ext: Claim Submission Address: 000008 FILED: KINGS COUNTY CLERK 12/16/2022 01/16/2023 03:56 09:29 PM AM INDEX NO. 514577/2020 NYSCEF DOC. NO. 87 99 RECEIVED NYSCEF: 12/16/2022 01/16/2023 % f NEW YORK STATE ; ** j TDJKTVER LICENSES ^ J >Wjj » ‘.I ■»T *“ *-‘J % Sackaroff, Barbara DOB: 67y/o F Dr. Sudhir Diwan MRN: 3087736 01/07/20 I *- "< 'A - i. \ ♦ i 000009 FILED: KINGS COUNTY CLERK 12/16/2022 01/16/2023 03:56 09:29 PM AM INDEX NO. 514577/2020 NYSCEF DOC. NO. 87 99 RECEIVED NYSCEF: 12/16/2022 01/16/2023 FIFTH aVENTTF STOGERY CENTER AUTHORIZATION AND CONSENT ASSIGNMENT OF BENEFITS AND RELEASE OF ^FORMATION TO INSURANCE COMPANY I hereby assign payment to FIFTH AVENUE SURGERY CENTER (FASC) insurance benefits otherwise payable to me bet not to exceed the balance FASC regularly charges for the episode of treatment. I understand that I am financially responsible to the FASC for charges not covered by the authorization. Authorization is hereby granted to release to the above mentioned INSURANCE COMPANY(S) information as the company may request complete Centers insurance claim where applicable. CERTIFICATION FOR MEDICARE PATIENTS ('ONLY) Patient’s Certification. Authorization to release Information and payment Request I certify that the information given by me in applying for payment under title XYHI of the Social Security Act to be correct. I authorize any holder of medical and other Information about me to release to the Social Security Administration or its intermediaries claim. I request payment of authorized benefits to be made in my behalf, where applicable. I hereby release FASC from any responsibility for valuables, money or personal possessions which may be brought to the Center by me and which may be taken from me to properly carry out any procedure for my care, or for any article left in the Center which are not claimed by me or in behalf within (30) days after my discharge. CONSENT TO TREATMENT I request admission to the Fifth Avenue Surgery Center and authorize the facility, staff and physicians to provide care. I request and consent to medical care and diagnostic procedures that my attending physician(s), or his/her designees, determine are necessary. I acknowledge that the medical care I receive while in the Fifth Avenue Surgery Center is under the direction of my attending physician(s) and that the Fifth Avenue Surgery Center is not responsible for acts of omission of my attending physician(s). / authorize the Fifth Avenue Surgery Center to retain or dispose of any specimen or tissue taken from the above named patient. A / i’a&ient’s Signature Signature of Person Authorized to consent For Patient F 7- i ate Sackaroff, DOB: Barbara 67y/o F mt ationship to Patient Dr. Sudhir Diwan MRN: 3087736 01/07/20 000010 FILED: KINGS COUNTY CLERK 12/16/2022 01/16/2023 03:56 09:29 PM AM INDEX NO. 514577/2020 NYSCEF DOC. NO. 87 99 RECEIVED NYSCEF: 12/16/2022 01/16/2023 . l UmORIZAnON.-ij VD CONSENT FOR ASSIGNMENT OF ANESTHESIA BENEFITS AND RELEASE OFINFORALiTION TO INAUEANCZ COADPAJNY OR HEALTH MAINTENANCE ORGADAZATION. I hereby assign payment to FIFTH AVENUE ANESTHESIA ASSOCIATES, P,C (FAAAPC) of insurance benefits otherwise payable to me, but not to exceed the balance FAAAPC regularly charges for the episode of anesthesia care. I understand that I am financially responsible to FAAAPC for charges not covered by the authorization, which may include care delivered to me by an anesthesia provider who does not participate with my insnrance company or health maintenance organization. Authorization is herby granted to release to FAAAPC’S INSURANCE COMPANY(S) information as the company (s) may request to complete the insurance claim, where applicable. CERTIFICATION FOR MEDICARE PATIENTS (ONLY) Patient’s certification. Authorization to release Information and Payment Request I certify that the information given by me in applying for payment under title XV111 of the Social Security Act to be correct. I authorize any holder of medical and other information about me to release to the Social Security Administration or its intermediaries claim. I request payment or authorized benefits to be made in my behalf, where applicable. POST OPERATIVE PHONE CALL A nurse will be calling you after your surgery. If you are not available or not at home, we may leave a message on your answering machine or with the person who might answer your phone to request that you call the Center at your earliest convenience. If that is not what you wish, please inform the nurse when you are admitted. J i Patient’s Signature V Signature of Person authorized to consent for Patient Date Relationship to Patient Sackaroff, Barbara DOB: 67y/o F Dr. Sudhir Diwan KD/ 2008 MRN: 3087736 01/07/20 000011 FILED: KINGS COUNTY CLERK 12/16/2022 01/16/2023 03:56 09:29 PM AM INDEX NO. 514577/2020 NYSCEF DOC. NO. 87 99 RECEIVED NYSCEF: 12/16/2022 01/16/2023 ■. VENUE' 'ANE'STWESIAiA.l^r-P^C IGOR AMIGUD PHYSICIAN, P.C. 1049 FIFTH AVENUE Sackaroff, Barbara DOB: 67y/o F NEW YORK, NY 10028 Dr. SudhirDiwan MRN: 3087736 01/07/20 ADVANCE BENEFICIARY NOTICE (ABN) It is possible that your private insurance and / or iVledicare may not pay for the procedure^) that are described below, if this happens, it does not mean that you should not have received this procedure from us. There may be a good reason that your pain management doctor recommends that you have this procedure. Procedure: MONITORED ANESTHESIA CARE FOR PAIN MANAGEMENT PROCEDURES PLEASE CIRCLE BELOW, SIGN AND DATE: Yes. 1 want to have the above procedure provided to me. Please submit the claim for your services-to my private insurance and / or Medicare. K 'Dec ‘SfLcJg: r_p A ^ PRINTED NAME SIGNATURE /7- Xjt_ DATE NOTE: Any information that we collect dbout you on this form will be kept confidential in our offices. When the claim is submitted to your private insurance and/or Medicare, your health information on this form may be shared. 000012 FILED: KINGS COUNTY CLERK 12/16/2022 01/16/2023 03:56 09:29 PM AM INDEX NO. 514577/2020 NYSCEF DOC. NO. 87 99 RECEIVED NYSCEF: 12/16/2022 01/16/2023 iintt tf ^tit; r^-RT?^ rTT'NrrP'g RACE^THNI^iXY FORiVI Facilities are required, by law to provide the New York State Department of Health (NYSDOS) with informatioil regarding the race and ethnicity of" the parient pr/pnlation» We want to make sure that all our patients get the best care possible. "We would like you to tell us your tecial/etrrnfc background so that rve can review the treatment that ail patients receive and make sure that everyone gets the highest quality of care» Sackaroff, Barbara DOB: 67y/o F /k ETHINICXXY (Select One) Dr. Sudhir Diwan MRN: 3087736 01/07/20 NOT HISPANIC OR-"LATINO SFANTSH/HISPANIC ORIGIN: klease cLeck all that apply Spaniard Andaiusian AstErran . CastilhaTT. Belearic Islander Gallego Valencian Canaiian Mexican _ __ Mexican American Mexicano CMcano LaRnzs Gnatemalan __Hondrirah Nicaraguan__ Panamanian Saivad-crari Catalonian __ South American Boliviau Chilean Colambian Peruvian __Ecuadorian Ufugxxaymn Crioilo Puerto Rican Cnban. _ Spanish Basque __ Dominican -___ Venezuelan South American Indian __ Paraguayan Central America Indian Centra.! American Mexican Arner Indian _ Canal Zone __ Argentinean Latin American (A RACE (Select One) AMERICAN INDIAN OR- ALASKA NATIVE ASIAN: Please clieck all that apply Asian Indian __ Japanese MaMIvian _ Two Jiraan Korean Bangladeshi