Preview
FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024
"A"
EXHIBIT
FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024
NYSCEF DOC. NO. 4 ..' Buckner. Kasneon RECEIVED NYSCEF: 03/11/2024
.--
" DOB: 03/12/1984 3Byro M
Dr. Benjamin ¤onal
MRN 330074 / DOS. 09/25 2022
Patient Tirne Log
HCG RESUET:
DATE:
CHEDULER FRONT DESK COMMENTS:
ID
RA C E
BOOKING SHEET
ID
SURGERY CONSENT
N 5 A NAM
ME
· -OP RN:
ARRIVAL TI
Py
MA:
N NO SEDATION°) T
ENE (NA:
J:
ARRIVAL
DEPARTURE ST:
5URGEON·
SURGERY/PROCEDURE
5TART
ASSISTANT:
END
/ / /
STERIUZER/ /
LOAD
DATE
P CU RN:
ARRIVAL
DISCHARGE MA:
FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024
Rockaways ASC
MRN# : 3300747 DOB : 03/12/1984 - 38 Sex : M
Patient Name : Bucknor, Kasheen
Address : City : Brooklyn State : NY Zip : 11213
SS# : Race : Ethnic Group :
Home# : Work# : Cell# : 646-833-5157
Contact Namo : Daverria Tuckor Emergency contact # : 718-219-6721
Emergency
BEaEQNaB.L.E..P.AST.L
P.BlMaBI.lNauBAEmi
NYC TRANSIT AUTHORITY/ CORVEL CORP
PO BOX 730 CENTRAL ISLIP
MY 11722
pr
Claim No:1282wc220300225
Policy ID : 1282WC220300225
Date of Incident: 05/23/2022
$ Ege-ry Information:
Date of Service : 09/25t2022
Doctors Name : Dr. Benjarnin Portal
Visit Reason : LESl
Visit Note : PRE OP INSTRUCTION GIVEN IN VM - MF
LEASE OF INFORMATION:
In general, medical information concoming the patents procedure is treated as confidential by Rockaways ASC, its personnel and rnembersof its
medical staff. I authorize Rockaways ASC to release any information for the purpose of determining coverage to my Insurer or other entity responsible
for clakns payment without iny further written consent.
FINANCIAL AGREEMENT & ASSIGNMENT OF INSURANCE BENEFITS:
In consideration for the sen4ces rendered to the above named patient, the undersigned hereby Indivklually obligates hirn/herself to the account of
Rockaways ASC in accordance with the Surgery Center regular rates and terms regardless of whether insurance payments are available or made on
or conection agency for conochon; I hereby agree to pay reasonable
my behalf. In the event it should be necessary 10refer the account to any attorney
attomey's lees and collections expenses. An delinquent secounts. at Rockaways ASC's option, bear interest at the legal rate
In consideration for the senaces rendered to the above named paUent, the undersigned hereby authorizes direct payment of any Insurance benefits lo
Roc1umays ASC otherwise payable to me for this admission. I transfer and assign an the right title and Interest in the above onmad insurance policy and
payment due me to the above narned Surgery Center.
I understand and agree that I am responsible for provNting any Information required by my insurance company and agree to fonow those pre admission
and pro authortrahon guidelines which the insurance company may require I understand that I am financially responsible for all charges which are not
covered by Wesurance.Including. but not ilmNod to, co-pays.deduchbles, charges in excess of patcy coverage, and Innilabons or exduslons of coverage.
I CERTIFY THAT I HAVE READ THE FOREGOING AND THAT I AM THE PATIENT, PARENT, LEGAL GUARDIAN OR AM DULY AUTHORIZED BY THE
PATIENT AS THE PDTitiMTS GENERAL AGENT TO EXECUTE THE ABOVE AND ACCEPT ITS TERMS.
I UNDERST MÍD AGREE THAT, AT THE TIME THE PATIENT HAS MET ROCKAWAYS ASC'S MEDICAL CRITERIA TO LEAVE THE FACILITY, I
WILL HAVE SPONSIBLE ßDULT PRESENT TO TAKE ME/PATIFNT HOME. I RELEASE ROCKAWAYS ASCFROM ANY RESPONSIBILITY FOR
EVENTS TION IS AGREEMENT.
-
Signed. Witness: Date: / Time:
FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024
OCA Omcial Form No.: 960
AUTHORlZATION FOR RELEASE OF HEALTll INFORMA Buckror. Kasheen
[I his form has been approved by the New York State De DOB: 03/12/1984 38y/o M
-
Dr. Benjamin Portal
Patie t Name Date of Sirt!
MRN: 3300/47 DOS C9/25:2022
Parient Address
1, or my authoÎed represc7tative, request that health infonnation regarding my care and treatment be released as set forth on this fonn:
In accordance with New York State Law and the Privacy Rule of the IIealth [nsurance Portability and Accountability Act of 1996
(1UPAA). I understand that:
1. This authorization include of information
disclosure relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
may
CONFIDENTIAL IITV* RELATED INFORMATION it I place initials on
TREATMENT, except psychotherapy notes, and only my
the appropriate line in item 9(a). in the event the health information described helow includes any of these types of infonnation, 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 I:cm 8.
2. If 1 am authorizing the release of RTV-related, alcohol or drug trea:ment, or mental health treatment infom·ation, the recipient is
without permitted '.o do so under fer.cral or state law. 1
hibited from redisclesing such information my authorization unless
,derstand that I have the right to request a list of people who receive or use IIIV-related in#ormation without authorization. If
may my
experience discrimination because of the release or disclosure of HIV-related infonnation, I may contact the New York State Division
of Human at (212) 480-2493 or the New York City Comutission
Rights of Human Rights at (212) 306 7-150. These agencies are
responsible for protecting my rights.
3. [ have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I rnay
revoke this authorization except to the extent that action has aheady heen taken based on this authodzation.
for
4. 1 understand that signing this authorization is voluntary. My treatment, payment, enrollment in a healtb plan, or eligibility
bene'its will not be conditioned upon my anthohation of this disclosure.
5. Infounation disclosed under this authoriza:ion rnight be redisclosed by the recipient (except as nored above in Item 2), and this
redisclosure may no longer be protected by federal or state law.
6. THIS AUTHORIZATION DOES NOT ACTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WT“H ANYONE OTHER THAN THE ATI ORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). __
7. Natne and address of health provider or entity to release this infunnation:
8. Name and ddress of person(s) nr catego:y of person to whom this infortcation will be sent:
). Spocific info:mation to be released:
C3 Medical Record from (insert date) to (insert date)
3-!Entire Medical Record, including patient histories, office no:cs (except psychotherapy notes), test results, radiology stadics, films,
referrals, consuhs, billing records, insurance records, and records sent to you by other health care providers.
Li Other: _ Include: (Indicate py initiating)
__ Alcohol/Drug Treatment
__
Mental 11calth Information
Authorization to Discuss Health Information HIV-Related Information
(b) O By initialing here K9) I authorize
initials Name of individual hea.th care provide:
to discuss my bealth inibnnation with my attorney, or a govenunental agency, listed here:
(Attorney/finn Name or Govemmental Agency Name)
__ _
I0. Reason for release of information: 1L Date or event on which this authorization will expire:
O At request of individual
O Other:
12. If not the patient, name of person signing form: 13. Authority to sign on behalf of patient:
All items on thi. onn have been completed and my questions about this form have been answered. In addition, 1 have been provided a
copy of the .
Date:
Signature of patient or representative authorized by law.
* Iluman Immunodeficiency Virus that causes AmS. The New York State Public Health Law protects information which reasonably could
contacts.
identify someone as having lilV symptoms or infection and informatiun regarding a person's
FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024
Buckner, Kasheen
38y/o M
DOB: 03/12i1984
Portal
Dr. Benjarnin
3300747 DOS. 09/25:2022
MRN
InstrucliOnS for the IJs
of the IllPAA-compliant Authorizi
Release Health Information Needed for Litigation
This form is the product of a collaborative process between the New York State
Office of Court Administration, representatives of the medical provider community in
New York, and the bench and bar, designed to produce a standard official form that
complies with the privacy requirements of the federal IIealth Insurance Portability and
Accountability Act ("IIIPAA") and its implementing regulations, to be used to authorize
the release of health information needed for litigation in New York State courts. It can,
however, be used more broadly than this and be used before litigation has been
commenced, or whenever counsel would find it useful.
The goal was to produce a standard H1PAA-compliant official fonn to obviate the
current disputes which often take place as to whether health information requests made in
the course of litigation meet the requirements of the HIPAA Privacy Rule. It should be
noted, though, that the form is optional. This form may be filled out on line and
downloaded to be signed by hand, or downloaded and filled out entirely on paper.
When filing out Item 11, which requests the date or event when the authorization
will expire. the person filling out the form may designate an event such as "at the
case"
conclusion of my court or provide a specific date amount of time. such as "3 years
from this date".
If a patient seeks to authorize the release of his or her entire medical record, but
only from a certain date, the first two boxes in section 9(a) should both be checked, and
the relevant date inserted on the first line containing the first box.
FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024
Buckner. Kashcen
BEACH - PATIENT DOB: 03M2/1984 38y/c M
ASC OF ROCKAWAY ACKNOWLEDGEMENTj
Dr. Benjamin Portal
I request to ASC of Rockaway Beach and authorize the facility, staff and phys
admission MRN: 3300747 DOS: 09:25:2022
care received is under the direction of my attending physician, and the center is not res
physician. I authorize the center to retain or dispose of any specimen or tissue taken f rc
financial interest in this center.
Please be aware that some of the physicians performing procedures may have a direct ownership
and discuss any questions you may have with our billing representative.
We ask that you take a minute to read the following
"technical" "facility"
knowr as the cr
1. The fee that we enarge for our services covers the non-professional component of your procedure also
for their professional
fee which Includes the cost of operating th!s facility. You will also receive a separate bill frain the physician's c4ice
for services.
senhces, anesthesia services, and possibly the laboratory any pathoicgy
registration p-ocess as long as we
2. Insurance claims will ce submitted on the patlant's behalf to the insurarce company speci'lec du-ing the
address of the 'nsurance the subscribers name, soc at security number and brth date, and the group
have the cornplete narne and company,
number and any otner required pre-authorization for the procedure. The patient authorizes payments to be inade ic ASC of Rockaway Beach,
I am responsible for said
I understand and agree that if my insurance carrier does not pay ASC of Rockaway BP.achfor services renderei
I
pay-nent in full. If receive payment frorn the insurance carrier, I am required tu rurn it over to ASC of Rockaway Beach within 7-10 business
days.
the catient, the Insurer, and our
3. We expect all known cc-payments to be paid at the time of service or as required by the contract between
center. We reserve the right to collect co-cays, deductibics, and coinsurance upon notification by the inse-cr.
4. Some Insurers require pre-certification, pre authorization, or a written referral. It is the patient's responsibility to uncerstand the
service. Failure to do
insurance plan requirements and ensure that the proper author¼at.on is obtained at least 3 days prior to the date of
denial of the clairn the insurer. it your ir.surance der es the claim, or holds payment, you nay be altimately responsible
so may result in by
for the balance.
will result in
5. If you have any questions related to the batance, please contact our Billirg office to discuss your account. Non-payrnent
and collection costs ircurred to coffect
referral to an outside collection agency that could impact the patients credit record. Legal fees
outstanding accounts will be the patients responsibility.
OFFICE USE ONLY -
of the procedure, the patient received a brochure and verbal information outlining e Patient's Rights and
Prior to the initiation
Responsibilities, Privacy Practices, Facility Ownership and the facility's policy on Advance Directives. YES ¤ NO
attent has Advance Directive O YES NO if yes, provided to the center? ¡ YES
Placed in medical chart? ¤ YES
NYS Out-Of-Network Law: Health plan networks participated in, health professionals rendering services, the hospital in which the
care plan were provided to
health care professionals are affiliated, and fees that inay not be covered by the patient's specific health
the patient.
I hereby authorize ASC of Rockaway Beach, to release any and all information necessary for
Authorization to Release Information:
the billing and processing of the account for services rendered.
I understand I should not bring any valuables to ASC of Rockaway Beach and that the center is not liable for the theft or loss of
valuables.
Benefits: I hereby authorize payment to ASC of Rockaway Beach insurance benefits, otherwise payable to
Assignrnent of insurance
me, for this service. Payment to ASC of Rockaway Beach shall not exceed the balance due for services rendered.
and agree to the terms set forth in this Acknowledgement of Financial Responsibility. I
I have read the above and understand
understand that I am financially responsible to the center for charges not covered by this assignment.
Patient's Name (printed): 9 '
PATIENT SIGNATURE:
CENTER REPRESENTATIVE SIGNATURE:
FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024
Buckner. Kasheen
03/12/1984 38yio M
ASC of Rockaway Beach
coebaniin Pord
oOS
MRR 3300m
Patient Consent and Acknowledgement o1
For Use and/or Disclosure of Protected Health Informauun to carry Out Treatment,
Payment and Healthcare Operations
I hereby state that by signing this Consent, I agree and acknowledge the following:
1. The Notice of Privacy Practices ("Privacy Notice") for ASC of Rockaway Beach (the "Center") has
been provided to me prior to my signing this Consent. The Privacy Notice includes a description
of the permissible uses and/or disclosures of my protected health information ("PHI") by the
Center. I understand that a copy of the Privacy Notice wlli be available to me at my request. The
Center has encouraged me to read the Privacy Notice carefully prior to my signing this Consent.
The Center reserves the right to change its privacy practices that are described in its Privacy
Notice, in accordance with applicable law.
2. I understand that, and consent to, the following appointment rerninders that will be used by the
Center:
a. ï Telephoning my home and leaving a message on my answering machine.
Specific Instructions
b) Telephoning my cellphone or leaving a text message
Specific Instructions
c. I understand that if I do not sign this Consent evidencing my consent to the uses and
disclosures described in the Privacy Notice, then the Center will not treat me.
I have read and understand the foregoing notice, and all of my questions have been
answered to my full satisfaction in a way that I can understand.
Patient Name (printed) _. 4 Jf a c. __
Signature Patient or Legal Representative
Signature Witness_
FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024
ASC of
Rockaway Beach o
my20Enlia PM5iCALEV£1.ULTION n o
or Ben a
s 09 25,2022
a±tones Namm
oposedhonette.
yaatMedicúEistay/R08 MitoeWF elease
uxp: 2 09.2s2022
Neurology Dr. BenP
330074 D s
brachioradialls (DTR): 2. Right patellar (DTR): 2. Left patellar (DTR): 2. gys:
Assessment and Plan
ICD: Cervicalgia (M54.2)
Assessment: I reviewed the following medical records:
MRI Lumbar spine dated 07-14-2022 demonstrates:L5-S1 DISC BULGE
MRI Cervical spine dated 07-14-2022 demonstrates: C3-6 DISC BULGES
Myalgia (M60.9)
Cervicalgia (M54.2)
Cervical Intervertebral Disc Displacement (M50.20)
Cervical Radiculopathy (M54.12, M54.13)
Cervical Facet Syndrome
Low Back Pain (M54.5)
Lumbar Radiculopathy (M54.16. M54.17)
Lumbar Intervertebral Disc Displacement (M51.26)
Lumber Facet Syndrome
Plan: The
history and physical examination findings correlate with the diagnostic testing results for this injury.
Conservativo treatment to date has not resulted in a return to pro-Injury status. MMI (Maximum medical
improvement ) has not been reached.
The following Interventional pain management procedures which are expected to improve functional capacity,
activities of daily living, work related activities, physical examination findings including spine range of motion,
motor and sensory deficits, and pain complaints were discussed with the patient as possible ootIons.
Lumbar discectomy and annuloplasty. porcutaneous
Cervical discectomy and annuloplasty, percutaneous
Epidural injections
Medial branch block injection
Trigger point injections
Prognosis is guarded
Patient o be scheduled for LESI: MRI of the lumbar spine; L5-S1 disc bulge.
Causal Relationship:
Based on my history, physical examination, review of diagnostic testing and of available medical records,
patient's injuries, limitations, restrictions, to a reasonable degree of medical certainty, are causally related to the
the accident of 05-23-2022
Aimee Jean Baptiste, P.A.
ICD: Low back pain (M54.50)
ICD: Motor vehicle accident (V89.2XXA)
CPT Codes:
Office O/p New Mod 45-59 Min (99204)
Follow up: -
Page 3
FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024
Buckner, Kasheen Male 03-12-1984
Buckner, Kasheen
DOB: 03/12/1984 38yto M
Dr. Benjamin Portal
MRN: 3300747 DOS: 09/25/2022
Alexander Bowen, M.D.
(Supervising provider)
Almee Baptiste, PA
This has been electronically signed by Aimco Baptiste, PA for visit dated 07-25-2022.
Page 4
FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024
Buckner, Kasheen
.. DOB: 03/12/1984 38yto M
Dr. Benjarnin Poc.ai
*
MRN: 3300747 DOS 09/25/2022
KASHEEN BUCKNER ( 03/12/1984 ) | SURGERY TIME : 09/25/20__ . .. .. . ... , .., ..... m., vnue .u620
NOTIFICATIONS
BMI : 28.08
BASIC INFO
First Name : KASHEEN Middle Name : Last Name : BUCKNER
Date of birth : 03/12/1984 Gender : Male
ess 1 : 252 SCHENECTADY AVE APT 2B Address 2 :
p : 11213 City : BROOKLYN State : NY
SSN : Primary Ph(Cell) : 646-833-5157 Secondary ph (f lon:e)
Work : Emergency : E-mail Id :
Patient Height : 5 ft 6 in Patient Weight : 174 Patient BMI : 28.08
SURGICAL
.................
PROCEDURE
__ ..
INFORMATION
. ........ .... .....
..__....._ .. _ __ _ ... .. ............... . .. .--. ................. . ... ..
Surgeon : Benjamin Portal Co-Assistant Sur : Surgery Date : 09/25/2022
Time : 3:45 PM Duration Needed : 30
Anesthesia Type :
dure : LESI
lock :
CPT
62323 | Injection(s), of diagnostic or therapeutic
substances with imaging guidance
ICD
M54.5 | Low back pain
INSURANCE INFORMATION
Relationship (Patient) : self
Primary Insurance : WC-CORVEL CORP (2249) (WC2249) Subscriber Name : KASHEEN BUCKNER
Subscriber SSN : Subscriber DOB : 03/12/1984 Policy Number :
Address : PO BOX 2249 , , SYRACUSE , NY , 13220
Relationship (Patient) : self
Secondary Insurance : Subscriber Name :
FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024
Buckner, Kasheen
DOB: 03/12/1964 38ylo M
Dr. Benjamin Pocal
MRN: 3300747 DOS:
KASHEEN BUCKNER ( 03/12/1984 ) | SURGERY TIME : 09/25/2022 : 3:4
Subscriber SSN : Subscriber DOB : Policy Number :
Address : , , , ,
: Workman Case Claim Number : 1282-WC-22- Date of Injury : 05/23/2022
Incident Type Comp
0300225
Employer Name : Employer Address :
Is MRI Available? : yes
: Is this a lien : no Attorney name : ORIN COHAN
Employer Phone
: 718-448-2889 Comments :
mey
Preview
FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024 "A" EXHIBIT FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024 NYSCEF DOC. NO. 4 ..' Buckner. Kasneon RECEIVED NYSCEF: 03/11/2024 .-- " DOB: 03/12/1984 3Byro M Dr. Benjamin ¤onal MRN 330074 / DOS. 09/25 2022 Patient Tirne Log HCG RESUET: DATE: CHEDULER FRONT DESK COMMENTS: ID RA C E BOOKING SHEET ID SURGERY CONSENT N 5 A NAM ME · -OP RN: ARRIVAL TI Py MA: N NO SEDATION°) T ENE (NA: J: ARRIVAL DEPARTURE ST: 5URGEON· SURGERY/PROCEDURE 5TART ASSISTANT: END / / / STERIUZER/ / LOAD DATE P CU RN: ARRIVAL DISCHARGE MA: FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024 Rockaways ASC MRN# : 3300747 DOB : 03/12/1984 - 38 Sex : M Patient Name : Bucknor, Kasheen Address : City : Brooklyn State : NY Zip : 11213 SS# : Race : Ethnic Group : Home# : Work# : Cell# : 646-833-5157 Contact Namo : Daverria Tuckor Emergency contact # : 718-219-6721 Emergency BEaEQNaB.L.E..P.AST.L P.BlMaBI.lNauBAEmi NYC TRANSIT AUTHORITY/ CORVEL CORP PO BOX 730 CENTRAL ISLIP MY 11722 pr Claim No:1282wc220300225 Policy ID : 1282WC220300225 Date of Incident: 05/23/2022 $ Ege-ry Information: Date of Service : 09/25t2022 Doctors Name : Dr. Benjarnin Portal Visit Reason : LESl Visit Note : PRE OP INSTRUCTION GIVEN IN VM - MF LEASE OF INFORMATION: In general, medical information concoming the patents procedure is treated as confidential by Rockaways ASC, its personnel and rnembersof its medical staff. I authorize Rockaways ASC to release any information for the purpose of determining coverage to my Insurer or other entity responsible for clakns payment without iny further written consent. FINANCIAL AGREEMENT & ASSIGNMENT OF INSURANCE BENEFITS: In consideration for the sen4ces rendered to the above named patient, the undersigned hereby Indivklually obligates hirn/herself to the account of Rockaways ASC in accordance with the Surgery Center regular rates and terms regardless of whether insurance payments are available or made on or conection agency for conochon; I hereby agree to pay reasonable my behalf. In the event it should be necessary 10refer the account to any attorney attomey's lees and collections expenses. An delinquent secounts. at Rockaways ASC's option, bear interest at the legal rate In consideration for the senaces rendered to the above named paUent, the undersigned hereby authorizes direct payment of any Insurance benefits lo Roc1umays ASC otherwise payable to me for this admission. I transfer and assign an the right title and Interest in the above onmad insurance policy and payment due me to the above narned Surgery Center. I understand and agree that I am responsible for provNting any Information required by my insurance company and agree to fonow those pre admission and pro authortrahon guidelines which the insurance company may require I understand that I am financially responsible for all charges which are not covered by Wesurance.Including. but not ilmNod to, co-pays.deduchbles, charges in excess of patcy coverage, and Innilabons or exduslons of coverage. I CERTIFY THAT I HAVE READ THE FOREGOING AND THAT I AM THE PATIENT, PARENT, LEGAL GUARDIAN OR AM DULY AUTHORIZED BY THE PATIENT AS THE PDTitiMTS GENERAL AGENT TO EXECUTE THE ABOVE AND ACCEPT ITS TERMS. I UNDERST MÍD AGREE THAT, AT THE TIME THE PATIENT HAS MET ROCKAWAYS ASC'S MEDICAL CRITERIA TO LEAVE THE FACILITY, I WILL HAVE SPONSIBLE ßDULT PRESENT TO TAKE ME/PATIFNT HOME. I RELEASE ROCKAWAYS ASCFROM ANY RESPONSIBILITY FOR EVENTS TION IS AGREEMENT. - Signed. Witness: Date: / Time: FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024 OCA Omcial Form No.: 960 AUTHORlZATION FOR RELEASE OF HEALTll INFORMA Buckror. Kasheen [I his form has been approved by the New York State De DOB: 03/12/1984 38y/o M - Dr. Benjamin Portal Patie t Name Date of Sirt! MRN: 3300/47 DOS C9/25:2022 Parient Address 1, or my authoÎed represc7tative, request that health infonnation regarding my care and treatment be released as set forth on this fonn: In accordance with New York State Law and the Privacy Rule of the IIealth [nsurance Portability and Accountability Act of 1996 (1UPAA). I understand that: 1. This authorization include of information disclosure relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH may CONFIDENTIAL IITV* RELATED INFORMATION it I place initials on TREATMENT, except psychotherapy notes, and only my the appropriate line in item 9(a). in the event the health information described helow includes any of these types of infonnation, 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 I:cm 8. 2. If 1 am authorizing the release of RTV-related, alcohol or drug trea:ment, or mental health treatment infom·ation, the recipient is without permitted '.o do so under fer.cral or state law. 1 hibited from redisclesing such information my authorization unless ,derstand that I have the right to request a list of people who receive or use IIIV-related in#ormation without authorization. If may my experience discrimination because of the release or disclosure of HIV-related infonnation, I may contact the New York State Division of Human at (212) 480-2493 or the New York City Comutission Rights of Human Rights at (212) 306 7-150. These agencies are responsible for protecting my rights. 3. [ have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I rnay revoke this authorization except to the extent that action has aheady heen taken based on this authodzation. for 4. 1 understand that signing this authorization is voluntary. My treatment, payment, enrollment in a healtb plan, or eligibility bene'its will not be conditioned upon my anthohation of this disclosure. 5. Infounation disclosed under this authoriza:ion rnight be redisclosed by the recipient (except as nored above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT ACTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WT“H ANYONE OTHER THAN THE ATI ORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). __ 7. Natne and address of health provider or entity to release this infunnation: 8. Name and ddress of person(s) nr catego:y of person to whom this infortcation will be sent: ). Spocific info:mation to be released: C3 Medical Record from (insert date) to (insert date) 3-!Entire Medical Record, including patient histories, office no:cs (except psychotherapy notes), test results, radiology stadics, films, referrals, consuhs, billing records, insurance records, and records sent to you by other health care providers. Li Other: _ Include: (Indicate py initiating) __ Alcohol/Drug Treatment __ Mental 11calth Information Authorization to Discuss Health Information HIV-Related Information (b) O By initialing here K9) I authorize initials Name of individual hea.th care provide: to discuss my bealth inibnnation with my attorney, or a govenunental agency, listed here: (Attorney/finn Name or Govemmental Agency Name) __ _ I0. Reason for release of information: 1L Date or event on which this authorization will expire: O At request of individual O Other: 12. If not the patient, name of person signing form: 13. Authority to sign on behalf of patient: All items on thi. onn have been completed and my questions about this form have been answered. In addition, 1 have been provided a copy of the . Date: Signature of patient or representative authorized by law. * Iluman Immunodeficiency Virus that causes AmS. The New York State Public Health Law protects information which reasonably could contacts. identify someone as having lilV symptoms or infection and informatiun regarding a person's FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024 Buckner, Kasheen 38y/o M DOB: 03/12i1984 Portal Dr. Benjarnin 3300747 DOS. 09/25:2022 MRN InstrucliOnS for the IJs of the IllPAA-compliant Authorizi Release Health Information Needed for Litigation This form is the product of a collaborative process between the New York State Office of Court Administration, representatives of the medical provider community in New York, and the bench and bar, designed to produce a standard official form that complies with the privacy requirements of the federal IIealth Insurance Portability and Accountability Act ("IIIPAA") and its implementing regulations, to be used to authorize the release of health information needed for litigation in New York State courts. It can, however, be used more broadly than this and be used before litigation has been commenced, or whenever counsel would find it useful. The goal was to produce a standard H1PAA-compliant official fonn to obviate the current disputes which often take place as to whether health information requests made in the course of litigation meet the requirements of the HIPAA Privacy Rule. It should be noted, though, that the form is optional. This form may be filled out on line and downloaded to be signed by hand, or downloaded and filled out entirely on paper. When filing out Item 11, which requests the date or event when the authorization will expire. the person filling out the form may designate an event such as "at the case" conclusion of my court or provide a specific date amount of time. such as "3 years from this date". If a patient seeks to authorize the release of his or her entire medical record, but only from a certain date, the first two boxes in section 9(a) should both be checked, and the relevant date inserted on the first line containing the first box. FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024 Buckner. Kashcen BEACH - PATIENT DOB: 03M2/1984 38y/c M ASC OF ROCKAWAY ACKNOWLEDGEMENTj Dr. Benjamin Portal I request to ASC of Rockaway Beach and authorize the facility, staff and phys admission MRN: 3300747 DOS: 09:25:2022 care received is under the direction of my attending physician, and the center is not res physician. I authorize the center to retain or dispose of any specimen or tissue taken f rc financial interest in this center. Please be aware that some of the physicians performing procedures may have a direct ownership and discuss any questions you may have with our billing representative. We ask that you take a minute to read the following "technical" "facility" knowr as the cr 1. The fee that we enarge for our services covers the non-professional component of your procedure also for their professional fee which Includes the cost of operating th!s facility. You will also receive a separate bill frain the physician's c4ice for services. senhces, anesthesia services, and possibly the laboratory any pathoicgy registration p-ocess as long as we 2. Insurance claims will ce submitted on the patlant's behalf to the insurarce company speci'lec du-ing the address of the 'nsurance the subscribers name, soc at security number and brth date, and the group have the cornplete narne and company, number and any otner required pre-authorization for the procedure. The patient authorizes payments to be inade ic ASC of Rockaway Beach, I am responsible for said I understand and agree that if my insurance carrier does not pay ASC of Rockaway BP.achfor services renderei I pay-nent in full. If receive payment frorn the insurance carrier, I am required tu rurn it over to ASC of Rockaway Beach within 7-10 business days. the catient, the Insurer, and our 3. We expect all known cc-payments to be paid at the time of service or as required by the contract between center. We reserve the right to collect co-cays, deductibics, and coinsurance upon notification by the inse-cr. 4. Some Insurers require pre-certification, pre authorization, or a written referral. It is the patient's responsibility to uncerstand the service. Failure to do insurance plan requirements and ensure that the proper author¼at.on is obtained at least 3 days prior to the date of denial of the clairn the insurer. it your ir.surance der es the claim, or holds payment, you nay be altimately responsible so may result in by for the balance. will result in 5. If you have any questions related to the batance, please contact our Billirg office to discuss your account. Non-payrnent and collection costs ircurred to coffect referral to an outside collection agency that could impact the patients credit record. Legal fees outstanding accounts will be the patients responsibility. OFFICE USE ONLY - of the procedure, the patient received a brochure and verbal information outlining e Patient's Rights and Prior to the initiation Responsibilities, Privacy Practices, Facility Ownership and the facility's policy on Advance Directives. YES ¤ NO attent has Advance Directive O YES NO if yes, provided to the center? ¡ YES Placed in medical chart? ¤ YES NYS Out-Of-Network Law: Health plan networks participated in, health professionals rendering services, the hospital in which the care plan were provided to health care professionals are affiliated, and fees that inay not be covered by the patient's specific health the patient. I hereby authorize ASC of Rockaway Beach, to release any and all information necessary for Authorization to Release Information: the billing and processing of the account for services rendered. I understand I should not bring any valuables to ASC of Rockaway Beach and that the center is not liable for the theft or loss of valuables. Benefits: I hereby authorize payment to ASC of Rockaway Beach insurance benefits, otherwise payable to Assignrnent of insurance me, for this service. Payment to ASC of Rockaway Beach shall not exceed the balance due for services rendered. and agree to the terms set forth in this Acknowledgement of Financial Responsibility. I I have read the above and understand understand that I am financially responsible to the center for charges not covered by this assignment. Patient's Name (printed): 9 ' PATIENT SIGNATURE: CENTER REPRESENTATIVE SIGNATURE: FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024 Buckner. Kasheen 03/12/1984 38yio M ASC of Rockaway Beach coebaniin Pord oOS MRR 3300m Patient Consent and Acknowledgement o1 For Use and/or Disclosure of Protected Health Informauun to carry Out Treatment, Payment and Healthcare Operations I hereby state that by signing this Consent, I agree and acknowledge the following: 1. The Notice of Privacy Practices ("Privacy Notice") for ASC of Rockaway Beach (the "Center") has been provided to me prior to my signing this Consent. The Privacy Notice includes a description of the permissible uses and/or disclosures of my protected health information ("PHI") by the Center. I understand that a copy of the Privacy Notice wlli be available to me at my request. The Center has encouraged me to read the Privacy Notice carefully prior to my signing this Consent. The Center reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law. 2. I understand that, and consent to, the following appointment rerninders that will be used by the Center: a. ï Telephoning my home and leaving a message on my answering machine. Specific Instructions b) Telephoning my cellphone or leaving a text message Specific Instructions c. I understand that if I do not sign this Consent evidencing my consent to the uses and disclosures described in the Privacy Notice, then the Center will not treat me. I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that I can understand. Patient Name (printed) _. 4 Jf a c. __ Signature Patient or Legal Representative Signature Witness_ FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024 ASC of Rockaway Beach o my20Enlia PM5iCALEV£1.ULTION n o or Ben a s 09 25,2022 a±tones Namm oposedhonette. yaatMedicúEistay/R08 MitoeWF elease uxp: 2 09.2s2022 Neurology Dr. BenP 330074 D s brachioradialls (DTR): 2. Right patellar (DTR): 2. Left patellar (DTR): 2. gys: Assessment and Plan ICD: Cervicalgia (M54.2) Assessment: I reviewed the following medical records: MRI Lumbar spine dated 07-14-2022 demonstrates:L5-S1 DISC BULGE MRI Cervical spine dated 07-14-2022 demonstrates: C3-6 DISC BULGES Myalgia (M60.9) Cervicalgia (M54.2) Cervical Intervertebral Disc Displacement (M50.20) Cervical Radiculopathy (M54.12, M54.13) Cervical Facet Syndrome Low Back Pain (M54.5) Lumbar Radiculopathy (M54.16. M54.17) Lumbar Intervertebral Disc Displacement (M51.26) Lumber Facet Syndrome Plan: The history and physical examination findings correlate with the diagnostic testing results for this injury. Conservativo treatment to date has not resulted in a return to pro-Injury status. MMI (Maximum medical improvement ) has not been reached. The following Interventional pain management procedures which are expected to improve functional capacity, activities of daily living, work related activities, physical examination findings including spine range of motion, motor and sensory deficits, and pain complaints were discussed with the patient as possible ootIons. Lumbar discectomy and annuloplasty. porcutaneous Cervical discectomy and annuloplasty, percutaneous Epidural injections Medial branch block injection Trigger point injections Prognosis is guarded Patient o be scheduled for LESI: MRI of the lumbar spine; L5-S1 disc bulge. Causal Relationship: Based on my history, physical examination, review of diagnostic testing and of available medical records, patient's injuries, limitations, restrictions, to a reasonable degree of medical certainty, are causally related to the the accident of 05-23-2022 Aimee Jean Baptiste, P.A. ICD: Low back pain (M54.50) ICD: Motor vehicle accident (V89.2XXA) CPT Codes: Office O/p New Mod 45-59 Min (99204) Follow up: - Page 3 FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024 Buckner, Kasheen Male 03-12-1984 Buckner, Kasheen DOB: 03/12/1984 38yto M Dr. Benjamin Portal MRN: 3300747 DOS: 09/25/2022 Alexander Bowen, M.D. (Supervising provider) Almee Baptiste, PA This has been electronically signed by Aimco Baptiste, PA for visit dated 07-25-2022. Page 4 FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024 Buckner, Kasheen .. DOB: 03/12/1984 38yto M Dr. Benjarnin Poc.ai * MRN: 3300747 DOS 09/25/2022 KASHEEN BUCKNER ( 03/12/1984 ) | SURGERY TIME : 09/25/20__ . .. .. . ... , .., ..... m., vnue .u620 NOTIFICATIONS BMI : 28.08 BASIC INFO First Name : KASHEEN Middle Name : Last Name : BUCKNER Date of birth : 03/12/1984 Gender : Male ess 1 : 252 SCHENECTADY AVE APT 2B Address 2 : p : 11213 City : BROOKLYN State : NY SSN : Primary Ph(Cell) : 646-833-5157 Secondary ph (f lon:e) Work : Emergency : E-mail Id : Patient Height : 5 ft 6 in Patient Weight : 174 Patient BMI : 28.08 SURGICAL ................. PROCEDURE __ .. INFORMATION . ........ .... ..... ..__....._ .. _ __ _ ... .. ............... . .. .--. ................. . ... .. Surgeon : Benjamin Portal Co-Assistant Sur : Surgery Date : 09/25/2022 Time : 3:45 PM Duration Needed : 30 Anesthesia Type : dure : LESI lock : CPT 62323 | Injection(s), of diagnostic or therapeutic substances with imaging guidance ICD M54.5 | Low back pain INSURANCE INFORMATION Relationship (Patient) : self Primary Insurance : WC-CORVEL CORP (2249) (WC2249) Subscriber Name : KASHEEN BUCKNER Subscriber SSN : Subscriber DOB : 03/12/1984 Policy Number : Address : PO BOX 2249 , , SYRACUSE , NY , 13220 Relationship (Patient) : self Secondary Insurance : Subscriber Name : FILED: RICHMOND COUNTY CLERK 03/11/2024 01:29 PM INDEX NO. 150506/2024 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/11/2024 Buckner, Kasheen DOB: 03/12/1964 38ylo M Dr. Benjamin Pocal MRN: 3300747 DOS: KASHEEN BUCKNER ( 03/12/1984 ) | SURGERY TIME : 09/25/2022 : 3:4 Subscriber SSN : Subscriber DOB : Policy Number : Address : , , , , : Workman Case Claim Number : 1282-WC-22- Date of Injury : 05/23/2022 Incident Type Comp 0300225 Employer Name : Employer Address : Is MRI Available? : yes : Is this a lien : no Attorney name : ORIN COHAN Employer Phone : 718-448-2889 Comments : mey