10 i FLU tnt 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 1 of 55 PageID: 870
Vdf)4 : 

¶5Th’fley Cthe 

z’ floor, Site 3 

East Greerbusti, New York 12051 

March 10. 2009 

a 

Ralph R. Van Deventer Jr. 

Case #: 74518 

WWID#: 10900 

Dear Ralph R. Van Deventer Jr: 

We are writing to you concerning your Long Term Disability (LTD) application which was 

previously approved from 3/9/2009 through 4/5/2009. It has now been determined that you can 

work on a trial basis, which is known as "rehabilitation employment". When you are considered 

in a rehabilitative status, the first $250 of your monthly rehabilitative income will not affect your 

LTD Plan benefit. For any monthly rehabilitative income over $250, 600 of every $1.00 will be 

used-to- reduce- your-LTD- en-t;--Your-tetak-disabiflty-4ncome-*orraThsources--cannot-be------- 

more than you earned before you were disabled. If it is, your LTD Plan payments will be 

-ceducad_accordin-ead--Gioup 

rehabilitative period. Please notify Reed Group immediately in the event this rehabilitative 

employment status changes and you are unable to work. 

We also request that during the time period in which you are considered in "rehabilitation 

employment" that you submit copies of your pay stubs to Reed Group in the enclosed selfaddressed envelope to ensure an accurate calculation of your LTD benefits. 

LTD benefits are calculated as follows: 

Monthly Pre-Disability Earnings $2,923.22 

Scheduled LTD Benefit 

Less Social Security Benefits $ N/A 

Less LTD Rehab Income $1,268.68 

LTD Benefit $1,654.54 

You have a right to appeal this decision. A request for an appeal must be submitted in writing 

and signed by you or a duly authorized representative. It must state specifically the reason why 

you are requesting a review and must be filed with Reed Group no later than one hundred 

eighty (180) days from your receipt of this notice. You must include any new facts or new 

medical information you consider important for the appeal. Upon request, you will be provided 

with copies of all documents relevant to your claim. 

- Confidential 

Reed Group 1 15 Tech Valley Drive I 2d floor, Suite 31 East Greenbush, NY 120611 866-529-5661 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 2 of 55 PageID: 871
Reed Group’s Appeal Administrator will provide you with a full and fair review of your claim and 

this denial decision. The review on appeal will take into account all comments, documents, 

records and other information submitted that relates to the claim, even if not previously 

submitted or not considered in the initial decision. The review on appeal will be without 

deference to the initial decision and it will be conducted by the Appeals Administrator, who was 

not involved in this initial decision. 

The decision of the Appeals Administrator will be made within forty-five (45) days after the 

request for review is received, unless special circumstances require an extension of time for 

processing the review. Should an extension be required, you will be notified in writing prior to 

the expiration of the forty-five (45) day period. Where Reed Group seeks additional information 

from you; you will have forty-five (45) days to provide it. Reed Group will notify you of its 

decision within forty-five (45) days of the date you provide that information or if you fail to 

provide it, within forty-five (45) days of the date your period for furnishing the information 

expires. 

A request for appeal should be submitted to: 

Reed Group 

ATTN: Appeals Department 

10155 Westmoor Drive 

Suite 210 

Westminster, CO 80021 

All the factsandoircumstanoes of your case will be thoroughly --reviewed rshould you exerciseyour right to appeal the denial of your claim. If you follow the above procedures and your appeal 

sdanieynui.a1eJbeuighLtoa_senondJeMeisppaaLndLhe_acMaeioftftose_inatructioiJs 

at that time. 

If you have any questions or concerns regarding your claim, please call us at (866) 829-8861. 

Thank You, 

Alexandria Falk 

Reed Group 

co: Corporate Benefits 

Human Resources 

Confidential 

Admin Rec. 00430 

Reed Group 115 Tech Valley Drive I 2fld Floor, Suite 31 East Greenbush, NY 120611866-829-886 1 1 Fax: 516-680-8810 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 3 of 55 PageID: 872
RccdGroup .J 

15 Tech Valley Drive 

Suite 3, Second floor 

East Greenbush, NY 12061 

March 4, 2009 

Aiiii; Jr, 

AMENDED 

Case #:74518 

WWID#: 10900 

Dear Ralph R. Van Deventer Jr.: 

Johnson & Johnson has contracted with Reed Group to review and monitor Short Term Disability (STD) 

cases. Your disability case, beginning on 09/08/2008, was referred to us for case management on 

09/09/2008. 

Based upon your diagnosis and/or additional medical documentation provided by your treating health care 

provider, the status of your case is as follows: - 

09/08/2008 03/08/2009 Acoroved ------Disability Duration 

09/08/2008 11/30/2008 Approved ------FMLA 

03/02/2009 03/08/2009 Approved ------Modified Work 

Reed Group will continue to review your claim on an ongoing basis to determine the potential for an earlier 

release to return to work, with or without temporary restrictions. Therefore, if it is determined by Reed 

Group that you can return to work, in any capacity, prior to the last authorized date of your disability as 

indicated in this letter you are expected to comply in order to continue receiving STD benefits. 

Fitness for Duty Requirements to return to work: You are required to provide a release to return to work 

from your provider. Failure in providing this notice may delay restoration to your job. 

Please be advised that Family Medical Leave (FMLA) and/or State Family Medical Leave (SFML) does run 

concurrent with this medical leave. Your FMLA is tracked on a 12 month rolling forward calendar year. 

The requested leave will be applied toward your FMLA and/or SFML entitlement and is subject to review 

and/or recertification at a minimum of every thirty (30) days. 

Should you require an extension or will not return to work on or before the end of the authorization period 

noted above, it is your responsibility to ensure that you and/or your health care provider submits supporting 

objective medical documentation to Reed Group five (5) days prior to the last authorized date of disability. 

This information will be reviewed for an extension of STD benefits. A few examples of this documentation 

are: 

Reed Group 115 Tech Valley Drive 1 2nd Floor, Suite 3 I East Greenbush, NY 120611 

JJ1 16- STD-FMLA Approval Ltr.doc Page 1 of 2 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 4 of 55 PageID: 873
j* ReedGrüup 

Physician office/progress notes 

Diagnostic Test Results (X-rays, MRI, etc.) 

Laboratory Results 

Physical Therapy notes 

Medical clearance from disability 

If you are returning to work on or before the end of the authorization period noted above, you will need to 

provide Reed Group with written documentation of your Release to Work from your health care provider 

prior to the last authorized date of disability. As a reminder, Reed Group must receive your return to work 

release and coordinate your return with the Company prior to your actual return to the worksite; 

In addition, it is also important to note that per the Company policy, if an employee does not return to work 

within three (3) business days of the end of the approved time off, the Company may determine that the 

employee has voluntarily resigned and consider the employee’s employment to be terminated. 

Please call Reed Group toll free at 886-829-8861 if you have any questions or concerns. 

Thank you, 

Cristina Teta 

Reed Group 

cc: J&JOHN 

J&J Suoervisor 

Confidential 

Reed Group 115 Tech Valley Drive 12 Poor, Suite 3 I East Greenbush, NY 120511 865-529-8364fl3i3 

Omfl 111t A A 9 ff7 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 5 of 55 PageID: 874
92/24/2909 09:23 7325711937 STROUSE/LOFANO FACE 01 

2/23/2009 1:511 PM PAGE 3/003 Fax Server 

Individuals who operate a lomParTy vehicle (Sales Representative, lorkfltt operators, etc.’ are considered to be in a 

Safety Sensitive posiflon. If the above named Individual is required to operate acompwiy vehicle as part of their 

responsibilities, please cc nplete this section, 

Please aback one 

The above named indMdual’s medical condWorstotus does not Intarrerewith his/her thiflly to operate 

company ve>icle - 

The ebovt named individu&’t medical condftlon/status does not inierferawith his/her ablihy to 

operate a comoany I ehicie with the a mmodtlpns/ restrictions desertbed beipw 

The abow named lndMduars medical conthhion/status does Interfere with his/f er ability to drive and cannot 

operate a company vehicle at this time. 

Aoeommodations/R estriotiena Including duration: 

Use of the Fitness Gamer Johnson & Johnson sponsors a health promotion program for employees, One 

component of this prograr Is an exercise program that includes aerobic, strength and/or flexibility training 

This employee may ps rticipate in aerobic, strength and flexibility training without restrictions: 

YES J NO, then please complete next statement 

2. This employee may ps niolpate in aerobic, strength and flexibility training with the following restlotlons: 

no: trrvase vrrni) JRWHG D. STROUSE 

pease fax to 518-880 -6610 when complete 

Reed Oraup I tsTec Valley Drive 12"’Floor, Suite 2 East Groenbush, NY i2051 1ase-ese-osBi I Fax: 516-880-6610 

to Welt Porn - P1 5 2 :d C 

received on 2/2412009 9:22:11 AM [Eastern Standard Time] 

Confidential 

Adrnin Rec. 00433 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 6 of 55 PageID: 875
32/24/2939 39:23 7325711937 STROUSE/LDFANO FAGE 32 

2123fl009 1i54:11 PM PAGE 2/003 Fax Saner 

ThadGrnup r1 

Release to Work Form 

Inslwotions: Prior to rE turning to work from a Short Term Disability (STD) Leave with temporary 

restrictions you MUS Efax this form to Reed Group at 513-880-8610 for approval. 

If you have any quastic is, please call 866-329-5861. 

I oertifr that this ample fee is medically fit trturn to work on (date): 

The employees medic al condition (Please complete Part Ill) OR D will not skip to Pen V) continue 

to impact his/her abilit’ to perform all of the regular functions of his/her position. 

If temporary acoomnic fation(s) are necessary, the projected full duty rslease is (datel: 

Identify appropriate w4 Tavel’ for k 

rMndMalk 

p 

LNONE 

th3hCtrs) 

____ OONTft1UOUSLY 

bngmos1Et1he 

D °j -------- I 

drive 0 D D 

0 .- Slgnific iii dagrg or 

walkth/stanng; nme silt ig; lit up to 20 Bond I 0 0 0 

b.oconally F 

Twist F 0 El U 

11 MEN QaLNt to 50 s. I 

oewioSly; it lbs. bsqur rty;1 0 lbs scum F o U 0 

sorMantly 

Ol]rpb F 

r 

0 0 I 0 NEAVYWQ3_ UN i oto1OObs. 

ostaslonally; 50 lbs tnqU lIly; 20 lbs Grasp F 0 0 0 

ontdly 

F 0 Ell 

DyBiHEAVYWOR- Lfliine in excess 

tOO I bc. 00 acnIy; St Ibs, trequenIly;20 Raoh F 0 0 

lbs. eenstaney 

This employee may r ltum to work with the following temporary restrictions: 

RESTRICTION DATE RESTRIOTI N BINS DATE R f 7L4th 15 

3eed Group 115 T oh Vajisy 0-Ne I 2’ Floor, Suite a I East Greenbush, NY ISOCtI 59-529fl61 i FaE 519-aso-eeo 

WL14 Porir - I ant I 2 

received on 2120009 9:22:11 AM fEastern Standard Thel 

Confidential 

Admin Rec. 00434 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 7 of 55 PageID: 876
02/24/2989 @9:23 7325711937 STROUSE/LOPAND PAGE 03 

2/2312009 1:54:11 PM PAGE 1/003 Fax Sarver 

La! 

To: Dr. Irving Strouse 

Company 

Fax 117325711937 

Phone: 

From: Cristina Teta, RN 

Fax: 

Phone: 866-329-6861, ext. 8692 

E-mail: oteta@rgl.net 

NOTES: 

ear Dr. Strauss: 

,ttaehed is a return to work torn, for Ralph Vandeventar, His workaite 

’viii accommodate him working 4 hours a day in a sedentary position. 

--tleaso-fiII’tthaatteched-fomnl - ItyouAeeI_tfflspatiantJsabltp.._., 

york 4 hours a day, sedentary position at the workaits. Please 

_-___c1ude..a.s–aa.thata.taL2/Qsj_ePd an end date to the restrictions, 

’hank you for your assistance. 

;inceraly. 

ristina Tate, RN 

ate and time of transmission: Monday, February 23, 200) 1:53:26 PM 

dumber of pagas Including this cover sheet 03 

received on 2/2412009 9:22:11 Thi iEs!ern Standard TLrnej 

Confidential 

Admin Rec. 00435 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 8 of 55 PageID: 877
Feb 16 2009 10:47AM ACCESS MEDICAL 7344251042 p.1 

P.O. Box 510837 

Livorda, Michigan 481.51 

PhDne: 800-375-0270 

Fac 734425-11042 

Email: AccessEvalualiofl@aoL corn 

Facsimile Transmittal 

TO: MARIA WALLACE / 

MEGAN MCCRAE 

Company: Reed Group 

Telephone: 

Fax:#1 518-88O-6ôlOfJNJOnly) 

02 518-283-8517 

Date: February 16, 2009 

Number of pages including Fax cover: 10 

FROM 

Access Medical Evaluations 

Phone: B0O-375-0270 

Fax: 734-425-1042 

Urgent:_____ For lteviewL.._x_ Please Comment 

MESSAGE: 

X_ NARRATIVE REPORT ON _RALPH VAN DEVENTER 

(SIGNATURE PAGE OF PHYSICAN ATTACHED IF NECESSARY) 

X INVOICE 

OTHER 

SINCERELY, 

ACCESS MEDICAL EVALUATIONS, INC 

The mfcrmatian oonbzea uS 4ertile is nllthoxtivJ. The inbroaafloo is ioteodaooly lbr tie osc of tEe fiaSVIdS or wh-a it La addreS- 3f100 re usottia 

iotnadaed recipisuat, or the gent or empLoyee r ucooethEe a4i Itto the h*eed recipient, yea. mrc hcehy ooltfled t3rMy uee mile Sontor istrbuutim or repytng of 

this tommut5oo I; etrktly F’1° fl you, have received deja ireisofla is etror. plev.ee isrneAvtcly not ci by tdeohone, erA retan the ortgcnsl memeage to a.! she 

.ddreea ebove via the U. S. ?oebi Scmi,. Thexakyove. 

Confidential 

received on 2)1512009 9:51:43 AM laaatem Standard Time] - - Admin Rec. 00436 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 9 of 55 PageID: 878
Feb 19 2009 10:47AM ACCESS MEDICAL 73442E 1042 p.2 

ACCESS MEDICAL EVALUATIONS, INC. 

P.O. Box 510837 

Livonia, Michigan 48151 

Tel: (800) 375-0270 

Fax: (734)425-1042 

Customer: 

Account: 

Address: 

City/State/Zip: 

Attn: 

Reed Group, Ltd 

Johnson & Johnson 

P.O. Box 909 

Broomfield, CO 80038-0909 

Maria Wallace 

INVOICE: 8066 

Date: 02116109 

-n Unit TOTAL 

Date of Description 

02112109 Case 9- 10900 . S2550.00 

Claimant. 1aIp1rVaxrDeventerJr. ............... ...... 

Physician: Kenneth Kutner, PhD 

speCiAty --Neurop sychalogy- 

**DUEUPON RECE** – TOT S2550.00 

A late charge of535.00 will be charged on any balance not paid 

within _45_days_qforigjpgl_invoice. 

Confidential 

AdminRec. 00437 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 10 of 55 PageID: 879
Feb 15 2003 10:47AM ACCESS MEDICAL 7344251042 P. 3 

02/14/2aa 15:e4 FAXSERVER PAGE 02/59 

Kenneth C. Kutner, PhD, ABPP-CN 

FcJ1CW of National Acsdcniy c!Ncur,psychcic 

Dipinrnaicir Clinicti Noropr;chc’Iot 

011WOffice: - Lkcivc "W1,15 - conc,pondene in 5nr(c wood Office 

339 FrIncsen-sflghtatawn Road wr’. Ynrk1,iccnscKl343 Bcr cn Norcpychoogy Orcnp 

Cranbury, 4cw Jcrscy 05512 440 Cttny Avcrtuc Suitt B 

0 0 0 Engleweod, NJ 0763 I 

3000 Atthnn Way, Suitt 1,00 P\on4 20149-4--n050 

Mount Lmircl. Now jersc’ 08054 FR 701-569-9326 

NEUROPSYCHOLOGICAL EVALUATION 

NAME: Ramp,h Van venter 

DATE OF BIRTH: 

DATE OF EVALUATION: VZi12IU 

Ralph Van fleveirter is a 0 year-old, right-handed, male who was evaluated in 

wbeditt he is able tmrumt his "position as a Senior Compliance 

AnalysL Specific referral questions were alsa provided. 

HISTORY: 

Mr. Van Deventer has been out of work, on short-term disability since September 

of 2008. He indicated that he is unable to work due to worsening back pain and chronic 

left Achilles tenosynovitis. Back pain has been occurring since he sustained an injury in 

the Army 25 years ago. Mr. Van Deventer reported that his back pain ranges from 7-8 cr1, 

the classic 1-10 pain scale. Achilles area pain was noted to be constant and at a level 6. 

Mr. Van Deventer reported that he does not experience cognitive problems at this time. 

Mr. Van Deventer has received physical therapy for his back pain. He has been 

utilizing a plastic foot brace on his left foot in order to support his ankle and Achilles 

tendon. Mr. Van Deventer reported that he developed anxiety, worrying about whether he 

will be able to recover and return to his normal work and home activities. He was seen by 

psyohitrist, Dr. Rajput who placed him on Clanazepam and. Lexepro. Dr. Rajput 

discontinued Lexapro and placed hire on Etifexor, Mn Van Deventer receives monthly 

medication checks but has not received psychotherapy. 

Background educational, vocational, and medical history will follow. Mr Van 

Deventer was born in New Jersey. Educational history is negative ior learning 

weaknesses and special education, After graduating high school in 1977, he catered the 

US Army, Following basic training, he was assigned to finance (army payroll.). Mr. Van 

Deventer volunteered to for ski patrol duty at an Army recreational facility. During 

training, he fell and injured his back. He elected against receiving any evaluation, or 

treatment, as he was concerned he would be re-astigned. Following service in the Army, 

Confidential 

Admin Rec. 00438 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 11 of 55 PageID: 880
Feb 18 2009 10:47AM ACCESS MEDICAL 7344251042 p.4 

PAGE 53/SB 

Ralph Van Deventer Page 2 

he was discharged home. Mr Van Deventer attended college on a pa-ft time basis for 

approximately 2 years. He has been working for a pharmaceutical company for the past 

20 years. lie was working as a Seninr.Compliance Analyst before going out on disability. 

Mr. Van Deventer related that hk position fbbuscs on quality assurance. He indicated that 

he has desk job in which ho reviews preproduction records for compliance. Medical 

history is negative for head trraxmo, seizures, and prior anxiety and depression. 

REVIEW OF MEDICAL RECORDS: 

A September 25, 2008 Attending Physician’s Statement by orthopedic surgeon, 

Irving Strouse, MD was reviewed. Primary diagnosis was noted to he Tenosynovitis of 

the left ankle. Secondary diago,ok was Lumbar Sprain. Treatment was noted to be Cam. 

Waiker for left ankle and physical therapy for his back. It was noted that the patient was 

unable to work. 

An October 17, 2008 note by Irving Strouse, MD was reviewed. It was noted, that 

the patient was still having difficulty with both his lumbar spine and Achilles tendon. 

Plan was tu continue physical therapy and continue patient out of work. 

........................A.,Noyni-bar---l2QOçtc by Irving Strouse, MD was reviewed. it was noted 

that the left Achilles tendon was improved. However, there was still significant bcreeed 

A November 13, 2008 note by Irving Strouse, MD was reviewed. Diagnosis was 

left Achilles tendon and lumbar strain. It was noted that the patient should remain out of 

work until 12/1/08. 

A November 24, 2008 note by Irving Strouse, MD was reviewed. It was noted 

that the MRI revealed disc bulge at L4-3 and j,3-4 with superimposed disc hemiation 

along the right neural foramina at 1,4-L3. Diagnosis was: Achilles tenosynovitis and 

Lumbar Sprain L4 and L5. Dr. Strome noted there should be no work until 12/29/08, 

A December 22, 2008 note by Irving Strouse, ML) was reviewed. It was noted that 

there should be no work for one month. The patient was to continue with physical therapy 

and. was being referred to a pain management specialist to determine if eidtra1 blocks 

are iadi.cated,. 

A January 13, 2009 note by psychiatrist, iuifiqar .Raput, MD was reviewed. It 

was noted that the patient had been seen since 09/17/08, Dr. Rajput related that the 

patient was suffering with depression and anxiety. Dr. Raiput noted that the patient is 

under his care and is taking medication, 

A January 14, 2009 orthopedic evaluation by Norman Heyman, MD was 

reviewed. Presenting complaints included back pain and left foot and ankle pain. 

Diagnosis wes )urtbosatra1 sprain and strain; lumbar syndrome, mechanical in nature; 

and d-egenerative Achiilcs tendinitis on the left side, 

Confidential 

Admin Rec. 00439 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 12 of 55 PageID: 881
Feb 15 2003 10:47AM ACCESS MEDICAL 7344251042 P. 

02/14/2609 15:04 FAXSEVD PAGE @4/59 

Ralph Van Deventer Page 3 

PROCEDURES; 

bTest 

Writing Sample 

Trail Maldug Test 

Geometric Shapes 

Dot Counting Teat 

Digit Vigilance Test 

Boston Naming Test 

Review of Medical Records 

Symbol Digit Modality Test 

Neurobehavioral Status Exam 

California Verbal Learning Test 

Lateral Dominance Examthation 

Key Complex Figure with. Recall 

Multilingual Aphasia Examination 

Wechsler Adult intelligence Scale,- ITT 

Wechsler Memory Scale-Ill: Logical Memory 

Minnesota Multiphasic Personality In ventoiy-2 RF 

NEUROPSVCHO.LOGTCAL FINUTNGS: 

Neurobehavioral Status Examination 

Mr, Van Deventer was driven to the evaluation by his brother-in-law. He was 

ambulatory and wore a rigid plastic cast on his left foot Mr. Van Deventer was alert and 

maintained satisfactory arousal throughout the evaluation. Speech was clear, fluid, and 

goal directed. Responses to questions were sequitor and well organized, Orientation, to 

time, plane, and person was intact 

Mr. Van Deventer quickly developed rapport and maintained it throughout the 

assessment We was not guarded or rigid in responding to questions. The purpose of the 

current evaluation was explained to him. Specifically, that the evaluations was scheduled 

to assess his current psychological and cognitive status in regards to work capacity. 

Mr. Van Deventer indicated that he does not have cognitive problems, but that 

does experience signi–ican.t back and ankle pain during periods of extended sitting- He 

indicated that he feels he could likely work. part-time from, home, Mr. ’Van Deventer 

related that his back and ankle pain limit his ability to make One hour commutes to and 

from the work place. 

Mr. Van Deventer indicated that he is anxious about the whether or not he will 

experience recovery in his back and Achilles tendon. Specifically, he related bate; 

worried that he might not he able to play with his children (ages 5,6,9,15), pick them up. 

or return to helping Mends and family members with home repairs. Mr. Van Deventer 

Confidential 

Admin Rec. 00440 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 13 of 55 PageID: 882
-’ 

Feb 19 2009 10 47AM ACCESS MEDICAL 7244251042 P. 9 

92114/2D99 15:94 + F<SEVER P4GE OS/es 

Ralph Van Deventer Page 4 

indicated that he does not have hobbies but enjoys doing painting, plumbing, and 

completing home projects for friends and family. 

Mood was cscntiiIy normothyrnic. Clinics] interview did act reveal evidence of 

markS anxiety, panic, or phobias. There was no evidence of marked sadness, arkhedoni.a, 

psychomotor retardation, or other features of a major depression. There was evidence of 

dysthymia and what appeared to be features of apparently long standing features towards 

social isolatiom Affect was not found to be constricted in regards to range or amplitude. 

W. Van Deventer indicated that he sleeps much better on a recliner due to his 

hack and ankle conditions. He reported that that he has no specific problems either falling 

or rtmahaing asleep. He does not experience nightmares, phobias, or panic attacks. 

However, he was found to have anticipatory anxiety regarding his physical condition. 

Mr. Van Deventer maintained satidactcry composure during the evaluation. 

There was no evidence of irritability or decreased frustration tolerance. This was evident 

during discussion of his physical edition as well as during administration of more 

arduous cognitive tasks, There was also no evidence of formal thought disorder, ideas of 

reference, or any other psychotic manifestations, Reality contact was fully intact, 

MMPI-2 RF 

W. Van Deventer was administered the Minnesota Muitiphasic Personality 

in v.score format VRIN 63; TRJN-r SO; F-r 70; Fp-r 42; Es 42; FBS-r 70; L-f 66; and K-r 

48, Elevations on several of the validity scales indicate that his profile needs to he 

interpreted with caution. Clinical scale results follow, also in. t-score format: RID 72; 

TEl]) 48; BXD 43; RCd 64; RC) 59; RC2 SO; PC] 47; RC4 43; RC6 61; P.07 48; RCS 

47; and RC9 36, His pattern revealed significant malaise as well as feelings of stress and 

worry, Ruminations over his health were apparent. Mr. Van Deventer’s pattern was 

consistent with social avoidance and low positive emotion. 

Executive Skills 

The Trail Making Test (PT) was administered. Part A. of the task directed Mr. 

Van Deventer to sequence a series of numbers, which were dispersed about a page. This 

basic task was completed in 29 seconds converting to a t-score of 46. This is a nonimpaired time for basic visual scanning, Part B of the task increased in complexity. Here, 

Mr. Van. Deventer was directed to sequence both numbers and letters while alternating 

between them. This more complex series was completed in 60 seconds, converting to a 

t-score of 53. Mr. Van Deventer’s time is,. quickly alternating between two sets of stimuli 

also fell wiilin the non-impaired range. 

The Wechsler Adult Intolligence Scale-UI (WAIS-I11) was administered in order 

to provide a measure of general intellectual functioning. Full Scale IQ of 100 convened 

to a t-scorc of 45 and placed Mr. Van Deventers overall intellectual capacity within the 

Confidential 

rec&ved on 211612009 5:51:43 AM aastem afandard Tlmej 

. Admin Rec. 00441 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 14 of 55 PageID: 883
Feb 15 2009 10:47RM ACCESS MEDICAL 7344251042 p.7 

52/14/2559 15:94 + FAXSERVER PAGE 56/59 

Ralph Van Deventer Page 5 

average range. Verbal IQ of 99 converted to a t-score of 44 and fell within the average 

range, Performance IQ of 104 converted to a t-score of 49 arid fell within the average 

range. The resulting VTQ-P1Q differential of 2 points was noncontributory. Verbal 

Comprehension Index scoreof I 00 converted to a t-score of 47. The Perceptual 

Organizational Index score of 101 converted to a t-score of 47. Working Memory Index 

of 95 converted to a non-impaired t-.score of 42, Processing Speed Index of 102 

converted to a non-impaired t-score of St. Vocabulary subtest score of 11 converted to a 

ts;ore of 52. Similarities stibtest score of 9 converted, to a t-score of 43 and indicated 

satisfactory verbal abstract reasoning. Arithmetic subtest score of 10 converted to a 

t-scorc of 45, demonstrating satisfattory verbal arithmetic reasoning. Digit Span subtest 

score of 9 converted to a t-score of 44 and indicated adequate capacity for immediate rote 

recall of forward and backward numerical spans. Information subtest score of 30 

converted to at-scott of 45, demonstrating satisfactory general fund of knowledge. Letter 

Number subtest score of 9 converted to a t-score of 43. Picture Completion subtest score 

of 8 converted to a t-score of 39. Coding suhtest score of Ii converted to a t-score of 54 

and revealed psychomotor speed to be within the imzct range, Block Design subtest score 

of 13 converted to a t-score of 57, demonstrating satisfactory capacity on this task of 

visco-spatial processing. Matrix Reasoning subtest score of 10 converted to a i-score of 

47 and indicated non-impaired nonverbal reasoning. Symbol Search. subtest score of 1.0 

converted to at-score of 48. 

Response pattern analysis was obtained through administration of the b Test and 

tht Dot-Counting --Test -(DC-T)-The’b-Test-isa-letter.reccgni-t{cn- and .d.iscrimninatiorLtask 

On the b Test, his E-score of 33.2 was below the Cutoff score of > 90. The DCT 

DCT, his Mean UG Time was 63 seconds with the Mean 0 Time being 2.9 seconds. His 

DOT F-Score of 9.1 was below the Cutoff Score of > 20. Mr. Van Deventer s pattern on 

these measures of response bias reflected satisfactory task effort. 

t9Itt!Ja4 

The California Verbal Learning Test was administered in order to assess memory 

For recall of rote verbal information. On the first trial, 7 of 16 items were recalled. This 

converted to a t-score of 48, reflecting non-impaired initial encoding of verbal stimuli. A 

maximum of 10 items were learned throughout the five presentations of the list. Learning, 

curve was 7/8/8/3/1 0. Overall recall during the five trials yielded a t-score of 39, which is 

within the mild range of impairment The interference trial contained 6 of the newly 

presented 16 items and converted to a z score &0. Short Delay Free Recall (SDFR) of 

the first list contained 7 items, converting to a t-score of 36. Long Delay Free Recall 

(LDFR) contained 9 items, converting to at-score of 44. The Recognition trial contained 

10 of the 16 items. The pattern of LDFR being superior to SDFR and the Recognition 

trial store of 10 reflected psychogenic factors. 

Verbal Memory for more complex stimuli was measured, with adrrjnistration of 

the Logical Memory subiest of the Wechsler Memory Scale-Ell (WMS-III) This 

psychometric procedure encompasses oral presentation of two narrative stories for 

I eceived on 21i8i2009 9;51:3 AM [Eastern Standard lime] 

. Confidential 

Adniin Rec. 00442 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 15 of 55 PageID: 884
- 

Feb 18 2008 10:48AM ACCESS MEDICAL 7344251042 P.S 

52/14/2388 1504 + F<SERVER PASS 57/e9 

Ralph Van Deventer Page 6 

irni-nediate and subsequent recall. Mr. Van Deventer obtained a scale score of 1.3 on the 

Short Term trial, converted to a t-scors 0160, indicating above average capacity. On the 

Long ’term trial, Nit. Van Deventer, obtained a scaled score of 15, which converted to a 

t-score of 7. demonstrating above average consolidation, capacity, 

Visual triemory was measured with graphic reproductions of the Complex Roy 

Figure. On this task, Mr. Van Deventer was initially directed to reproduce the design with 

the model being present Mr. Van Deventer’s Short Term (22.3136) trial t-score of 57 

demonstrated intact capacity. The Long Tern. trial, (19.5(3(5) t-sccre of 54 revealed intact 

consolidation capacity. 

La nail age 

There was no evidence of dysarthila, dysprosody, or dysuhorsia. Capacity to 

generate semantic labels to pictures was intact on the Boston Naming Test (t-score: 61). 

Verbal fluency was also intact on FAS (I-score of 41). Comprehension of multistep 

commands as well, as task directions was found to be intact. Wriring Sample revealed. no 

evidence of dysgeaphia or any impairment within the node ofwrinenexprossiort. 

£ttentjon/Conceutrafion 

10 was evident on Arithmetic. Mr. Van Deventer was administered the Digit Vigilance 

Test (DVT) 

converted to a tscor of 58. Trail Making Test Part A was intact. Mt. Van Deventer 

completed the entire assessment without a rest break. 

Visuo-p9tia1 

Block Design subtest score of 13 demonstrated above average capacity. 

Reprpduction of the Complex Rey Figure (36/36) did not reveal evidence of 

constructions] dyspraxia. On the WAIS-13J, Mr. Van Deventer’s Perceptual Organization 

Index score was intact at 101. 

CONCLUSIONS: 

Ncuropsychological Evaluation revealed that Mr. Van DcvenAer’s ncur000gnitfve 

skills are intact. His speed of information processing and psychomotor speed fell within 

the non-impaired range. Verbal and non-verbal reasoning was intact. Language 

assessment revealed expressive and receptive skills to be intact Attenttoa/Con.centration 

was found to be non-impaired. Visuo-spatial skills were also intact, Current examination 

rcvcaitd non4rn.paired memory for complex verbal information as well as visual stitnuli. 

Isolated wealmess was evident with verbal encoding, short-torm recall for basic 

i.rormation and on DVT time. Fownvtr, analysis of his in= as well as inter task pattern, 

revealed these findings were secondary to psychogenic etiology. 

-- Confidential 

received on 2)16(2009 9:51:43 441 teastern Standard time] - Admin Rec. 00443 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 16 of 55 PageID: 885
Feb 13 2003 10:43AM ACCESS MEDICAL 7344251042 P.S 

82/14/2ee9 15:54 + FAXEERVER PAGE 52159 

Ralph Van Deventer Page 7 

Neurobehavioral Status Examination and test results from the Minnesota 

Multiphasie Personality Inventory-2 RF revealed that Mr. Van Deventer has a Dysthymic 

Disorder. Tie pattern indicates an apparent long-term propensity towards social, isolation 

and social avoidmoc. Ongoing pain and physical limitations from his baik and Achilles 

tendon conditions resulted than exacerbation of his dysthynia as well asdeveloprnent of 

anticipatory anxiety regarding his potential for recovery. 

DIAGNOSIS: 

DYSTHYMIC DISORDER 

REFERRAL QUESflONS: 

1. Neuropsychological Evaluation revealed that Mr. Van Deventer has a long standing 

Dysthymic Disorder, which was exacerbated by ongoing pain and physical limitations 

from his back and Achilles tendon corditi on ,,, 

2. Mc. Van Deventer did not demonstrate emotional decontrol. His demonstrated 

appropriate affect throughout the evaluation, and did not lose composure at any time. 

.3 . Current exaniiranot reveal evidence of neurocognitive impairment in 

attention/concentration, reasoning, intellect, speed of irfdrmntiæ i6einiàlittge ................ ... 

memory or visuo.spatial functioning. Isolated impaired scores were evident and deemed 

secondary 

tests. 

4. Mr. Van Deventer did not dcmonsLrate any reality testing impairments. There was no 

evidence for fomna] thought disorder, ideas of referette; or any other psychotic 

manifestations on neurohehavioral status exam, Similarly, there was no evidence of 

reality testing impairment on the MMPI-2 RF, 

5, Evaluation revealed no clinically significant behavioral impairment Ms Van Devenier 

was friendly, pleasant, and maintained satisfactory rapport throughout the evalua -tion. He 

was not verbally or physically agitated. Rather, he maintained a positive composure 

during his history taking as well as during administration of more arduous neurocognitive 

tasks. 

6. Mr. Van Deventer is psychologically and cognitively capable of performing an 8-hourper day job. 

7. Current evaluation revealed intact cognitive skills and a Dysthymic Disorder. Mr. Van. 

Deventer’s dysthyrnia and anticipatory arodery do not reach the level of functional 

impairment, which woild prevent him_(r.ctrrt working full time in his position as a Senior 

Compliance Analyst. Regarding treatment, it is this examiner’s opinion that Mr. Van 

Deventer is not receiving optimal treatment for his Dystbymic Disorder and anxiety. 

Treatment appears to consist solely of monthly medication checks and phanmacotherapy. 

Confidential 

rec&ved on 211612009 9:51:43 AM LEastem Standard rime3 - Admin Rec. 00444 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 17 of 55 PageID: 886
Feb 19 2009 10:49AM ACCESS MEDICAL 7344251042 p.10 

@2/14/2993 15:94 + FAX5VE 09/99 

Ralph Van Deventer Page 3 

Clearly, Mr. Van Deventer requires individual psychotherapy on a weekly basis. it is 

recommended that be receive psychotherapy utilizing cognitive behavioral teehuiques, 

which would focus on a) assisthg him in coping with his physical condition b) reducing 

is ds’sthymnia end c) reducing anticipatory anxiety through developniert or more 

effective coping strategies. 

8. Mr. Van Deventer is seen to be capable of returning to work without limitations or 

restrictions for cognitive and/or psychological factors. 

9. No applicable, 

Kenneth C. Kutner, PhD, ABPP-CN 

Board Certified Neuropsycbo!ogist 

Assistant Prossor orNeuropsychotogy 

Weill Cornell Medical School 

Confidential 

Admin Rec. 00445 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 18 of 55 PageID: 887
- - flrç.. c; 

ReedLIruu.p  tSTht y flt 

2!d Floor, Site 3 

East Oreethuth, New York 121 

February 12, 2009 

Ralph R Van Deventer Jr 

905 Forge Lane 

Toms River, NJ 08753 

Case #: 74518 

’vWIID#: 10900 

Dear Ralph Van Deventer Jr 

We have received your completed application on 02/06/2009 for Long Term Disability (LTD) benefits 

under the Johnson & Johnson Choices LTD Disability Plan. 

We will begin our review of your records in an effort to make a case .................. determination. tion. In the event we have h

Upon co onoo u r 

determination. 

Please call (866) 829-8861 if you have any questions or concerns, 

Thank You, 

Reed Group 

Cc: Corporate Benefits 

Human Resources 

Confidential 

Reed Group j 15 Tech Valley Drive 12 nd Floor, Suite 31 East Greenbush, NY 120611866-829-8861 1 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 19 of 55 PageID: 888
FEB-10-2009 03:13 P11 Pain InsLitute NJ Brick 7324774388 P. 1 

Pain Institute of New Jersey 

254 Brick Blvd., Suite 2 

Bdck4New krsey 08724 

Office: 732-477-4242 Fax: 732-4774368 

Fax Cover Sheet 

TO CJ’P# Is I hJ 1...4 FROM:

FAX 0: 

( ) Urgent ( ) Please Comment ( ) Reply ABA? ( ) Please Review ( ) FYI 

Total Page Including Cover Sheet: - 

r 4CZ’ 1 a 

S’Af 

Comment 

The document accompanying this facsimile transmission contains information for the We use of the abon-intmndsd recipient and 

contains pzivileged and confidential medical information. Any other distribution or copying of this communication is strictly 

prohibited. 

Please notify us by telephone, 732-477-4242, if you are not intendth recipient and return this original message via 7rax to Vain 

Institute of Now Jersey, 732-477-4368. 

Confidential 

received on 2/1012009 2:11:18 PM [Eastern Standard lime] Ad min Rec. 00447 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 20 of 55 PageID: 889
FE3-10-2009 0313 PM Pain lnsLilute NJ Brick 7324774368 P 2 

THE PAIN INSTITUTE OF NEW JERSEY 

254 Brick Boulevard Suite 2 

Brick, NJ 08724 

TEL: (732) 477-4242 FAX: (732) 477-4365 

PATIENT NAME: Ralph Vandeventer 

DATE OV OPERATION: February 9, 2009 

SURGEON: Carmen M. Quinones, MD 

PREOPERATIVE DIAGNOSIS: Lumbar disc herniation, lumbar radiculopathy 

POSTOPERATIVE DIAGNOSIS: Same 

OPERATION: Transforaminal epidural steroid injection, Right L5 

£NESTBISIA: local anesthetic 

BLOOD LOSS: None 

Clinical: MT. Vandeventer returns to the office for LEST L5-S l#2. Me reported minimal pain 

-- j efefwjthths-heetia--in edditiontieat-had-eXaGerbatitn-0f-the--ba2k-aa44C&fOOtrfàain-fter--- 

falling last Wednesday February 4 at home He stated he twisted his ankle. Today physical 

examination showed some swelling in the left ankle, there is echymossis inferior to the lateral 

malleoli. There is tenderness at palpation of the lateral ligaments. RaM within functional limit, 

Patiend advised to do ice, rest, elevation, compression and follow up with Dr. Strouse. Regarding 

his back pain liruly believe he will benefit of a second epidural injection but thh time I will be 

specific to the right L5 transforaminal instead of interlantinar approach. If he doesn’t obtain any 

pain relief then will consider diagnostic facet joint nerve block. Risk, benefit and alternative 

treatment were discussed with the patient, patient agreed with recommendation and signed 

informed consent. 

Method of Surgery: The patient signed an informed consent form in the pre-op area 

after all risks and complications were explained and all questions were answered, The 

patient was prepped and draped in a sterile fashion in the prone position. The patient’s 

spine was surveyed under fluoroscopic visualization and anatomical landmarks were 

identified, 

Right L5 Tnnsforarninal Epidural Steroid Injection 

The region overlying the right L5 transverse process of the right L5 nerve root to be 

blocked was localized under fluoroscopic visualization. The soft tissues overlying this 

structure were copiously infiltrated with 1 1/o Lidocaine without epinephrine. A 25gauge 

3.5 inch spinal needle was inserted down into the posterior aspect of the base of the 

transverse process; and then., it was "walked off" the inferior aspect of this transverse 

process and advanced approximately 1cm further anteriorly. A ice volume of Omnipaque 

was injected to confirm the needle location. Then, the injection was performed using 

Confidential 

received on 24!2009 2h1:18 PM rEastern Standard Thel Admin Rae. 00448 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 21 of 55 PageID: 890
FEB10-2009 03M4 FM Fain insHtue NJ Brick 7324774368 F. 3 

THE PAIN INSTITUTE OF NEW JERSEY 

254 Brick Boulevard Suite 2 

Brick, NJ 08724 

TEL: (732) 4774242 FAX: (732) 477-4365 

PATIENT NAME: Ralph Yandeventer 

DATE OF OPERAUON: February 9, 2009 

40mg K.enalog, ice of 1% Lidocaine without epinephrine and 1= of NSS preservative 

free, 

The patient tolerated the procedures well and was in good condition at the conclusion of 

the procedures. 

Complications: None 

Disposition: 1. The patient was discharged to the recovery area in good condition. 

- 2; Patie it sdvised -tocall- the office withtay questions - or concerns, 

see discharge instructions. 

_____- 3Pmienttnpplyirtointectiu& iLrpr 

4. Patient to follow up with Dr. Strouse for eval ankle sprain 

5. Schedule patient in two weeks for follow up 

Surgeon: Carmen M. Quinones, MD, FAAPMR 

received on 2flOI2UU 2:11:18 PM [Eastern Standard liniel Confidential 

Admin Rec. 00449 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 22 of 55 PageID: 891
FEB-13-2009 03:14 P11 Pak Institute NJ Brick 7324774368 P. 4 

ME PAIN INSTITUTE OF NEW JERSEY 

254 Brick Boulevard Suite 2 

Brick NJ 08724 

TEL: (732) 477-4242 FAX: (732) 477-4368 

0,-PSR4 TrVHLNfRT 

PATIENT NAME: Ralph Vanxleventer 

DATE OF OPERATION: January Z6,2009 

SURGEON: Carmen M Quinones, MD 

PREOPERATIVE DIAGNOSIS: Lumbar disc herniation 

POSTOPERATIVE DIAGNOSIS Same 

OPERATION: Lumbar epidural steroid l injection under fluoroscopicaily guidance, L4-5 

ANESTHESIA: local anesthetic 

BLOOD LOSS: None 

Method of Surgery; The patient signed an informed consent form in the pre-op area after all 

risks and complications w nedj tions were answere– Vital sign remain stable 

throughout procedur& The patient was prepped and draped in a sterile fashion in the Prone 

position. The patient’s spine was surveyed under fluoroscopic visualization and anatomical 

landmarks were identified, 

Lumbar Epidural Steroid Injection; The region overlying the right L45 interlaminar space 

was localized and the soft tissues overlying this structure were infiltrated copiously with I 

Lidocaine without epinephrine using a 270 1.5 inch skin needle. A 17 gauge 3.5 inch Tuohy 

needle was inserted through the anesthetized tract of tissue to the right LA-S epidural space. The 

epidural space was localized using a loss of resistance technique and after a negative aspiration 

for cerebrospinal fluid or blood, an AP and lateral views were obtained. 2cc of Omnipaque 240 

was injected in the epidural space and an epidurograrn was obtained. Following this, an 8 cc 

volume of fluid was injected containing 12mg Celestone, 4 c of normal saline and 2 c of 1% 

Lidocaine without epinephrine, preservative free. The patient tolerated procedum well and was in 

good condition at the end of procedure. 

Disposition 

1. The patient was discharged to the recovery area in good condition 

1 Discharge instructions provided and explained. 

3. Call with any questions or problems 

4. Apply ice to the injection sites and keep clean and dry for 24 hour 

S. Return in 2 weeks for follow up 

Carmen M Quinones, MD 

Diplomate of Physical Medicine and Rehabilitation 

Interventional Pain Management 

Confidential received on NON 2:11h8 PM tEastern Standard Time] Admin Rec. 00450 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 23 of 55 PageID: 892
FEB-10-2009 0314 PM Pain Institute NJ Brick 7324774368 P. 5 

Pain institute oI Now Jene 

254 Brick Blvd. Suite 2, Brick, NJ 08274 

Phone: 732-4774242 Fax: 732-477-4358 

January 19, 2009 

RE: Ralph Vandeventer 

ITCTL&L EVALUATION 

Dr. Inring Stro-use 

279 Third Avenue 

Long Branch 143 07740 

CHIEF COMPLAINT: Low beck and knec pain 

HISTORY OF PRESENT ILLNESS: Mr. Vandeventer Is a 50-year-old pleasant male who comes to the Pain 

Institute of NJ at Brick for initial evaluation. Mr. Vandeventer today is complaining of along history of low 

back and knee pain, which started approximately 20 years ago following a ski accident. He reports his pain has 

been on going since then but during the past 2 years, it progressively worsened. He states that the pain "comes 

out of the blue’ and is breathtaking. He has been taking over-the-counter medications with little relief of has 

pain. Mr. Vandeventer also reports right knee surgery in 2005 and due to him favoring his knee, he exacerbated 

his low back pain. Patient describes his low back pain as constant sharp and stabbing radiating down his right 

leg. He also reports radiating pain into his left buttocks. Patient underwent physical therapy November 24, 

2008. Any type of weight bearing exacerbates his pain. Sitting, lying down relieve his pain, VAS: 8/10, 

PAST MEDICAL HISTORY: Denies 

PAST SURGICAL HISTORY: Right knee menicus tear in 2005 

CURRENT MEDICATIONS: None 

ALLERGIES: None 

SOCIAL HISTORY: Patient is married with eirown children, He is presently unemployed due to his pain. 

Ptjcnt did work for Johnson and Johnson Insurance. He denies any type of tobacco, alcohol or illicit drug 

usage. 

REVIEW OF SYSTEMS: Review of systems is negative. Specifically, there were no constitutional symptoms 

or changes referable to vision, ENT, CV or respiratory systems, 01 or C}U tracts. Patient reports depression and 

memory loss, he denies any suicidal thoughts. 

PHYSICAL EXAMINATION 

Blood Pressure: 114/75 Heart Rate: 52 SP02: 94% Weight: 215 lbs Height: 02t 

Generah The patient appears their stated age and is in no acute distress. 

Neurological exam reveals that Cranial Nerves II -XII are intact The patient is alert and oriented to person, 

place, and time. The patient concentrates well and is not easily distracted, Speech is smooth and clear. Deep 

tendon reflexes at the biceps, triceps, knee, and ankle are –2 and symmetrical. Sensation is intact to light touch 

in the lower extremities. Manual muscle testing reveals 515 strength throughout both upper and lower 

extremities. Patient could heel/toe walk. 

Confidential 

14fl!16fl( ’ 44 ’ 40 bM Carn ,nr{,rd mi Admin Rec. 00451 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 24 of 55 PageID: 893
FEB-10-2009 03:15 P11 Pain Inst itue NJ Brick 7324774363 P 6 

cNewJezei 

732-4 

January 19, 2009 

RE: Ralph Vandeventer 

DIAGNOSTIC snmms MRI of the lumbar spine completed on November 13, 2008 revealed: transitional 

type vertebral body referred to as L5. Disc bulge L4-5 and 1.2-4 with a superimposed disc herniation in the 

right neural foramen at L4-5. Diffuse facet degenerative changes. 

IMPRESSION: 

Lumbar disc herniation 

Lumbar radiculopathy 

Right knee pain 

PLAN OF TREATMENT: 

Since patient just completed series of physical therapy last session November 24, 2008,1 would like to schedule 

patient for series of LESI x 3 under fluoroscopic guidance. Risks and benefits of the above procedure were 

discussed in detail. Education material was handed out. Patient understood the plan and signed the informed 

consent. Patient to continue over the counter Motrin PRIL Schedule the patient accordingly. 

Carmen M. Quinones, MD 

Pain Management Specialist 

CMQIvP (dictated but not read) 

received on 211312009 211;18 PM (Eastern Standard Time] Confidential 

Admin Rec. 00452 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 25 of 55 PageID: 894
NORMAN M. HflMAN, M.D., P.A 

ORTHOPAEDIC SURGERY 

245 UNION AVENUE 

i%RIDGEWATER, NEW JERSEY 08807-3092 

TELEPHONE (908) 526-2389 

FAX (908) 526-6753 

.FELLOW OF THE AMERICAN ACADEMY FELLOW OF THE AMERICAN ACADEMY 

OF ORTI-TOPABDIC SURGEONS - OF SURGEONS 

Exam Coordinators Network 

123 Northwest 13th Street, 9207 

Boca Raton, FL 33432 

February 11,2009 

RE: 

DOB: 

0Th 

FTLE#: 

CLAIM: 

EXAMINATION: 

DIE: 

EX&MINING 

ORTHOPAEDIC SURGEON: 

 

RALPH N OEVENTER 

27755 

Ui/I 3/2009 

NORMAN ’vt FTEYMAN, M.D. 

To Whom Tt May Concern: 

Over andihave prod I- d the information as best l could based upon 

hiS critgue of my reportand was not discussed during the exam as 

treatment was not discussed at all, nor did I discuss the examinatiojn. Whatever corrections need to be made shall 

be made and as I have noted I expressed rny opinion based upon my 40 years of orthopaedic experience as bestT 

could. 

I state that Tarn a physician, authorized by law to practice in the state of New York and the state of New Jersey: 

am not party to this proceeding; am the physician who subscribed the above (or attached) report; have read and 

personally, by my hand, signed the same and know the contents thereof; that the same is true to my knowledge, 

except in the matters stated to be on information and belief, and as to the matters, I believe, it to be true. 

The undersigned hereby affirms that the foregoing statements are true under the penalties of perjury. 

I am available for testimony via telephone on Tuesday afternoons at 2p.m. and Wednesday afternoons at 4p.m. 

weekly. 

Thank you very kindly. I remain, 

Very truly yours, 

Norman M l-levman, M.D. 

F.A,A.O.S, RA.C.S 

Tax LD.22-2093 588 

WCB Rating Code: COS 

NMI-1/ad 

Confidential 

Admin Rec. 00453 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 26 of 55 PageID: 895
2/6/2O99 B:54 7325711937 STROUSE/LOFAND PAGE 01 

FRZXI A-Z VIDEO FPX .JO. 73227042B7 Jan. 35 259 52: 4Fhi P2 

S 

ATTE ND I NG PHYSIC I AN STATEMENT 

Pease Fax to 518-880-6610 or Mall to the Address listed Below 

NOTE TO JOHYS)CIAN OR C THER HEALTH CARE PRO WDEk Your full corn pletiori of this form is neeesswy so that 

me ernployen appIketIon -benefit may bØocMd and pmcsseed Sp009 IN available on the MVerSR side If you wish 

fo amplify your eflwera 

PLEASE ANSWER ALL QUESDC N& RETURN FORM 70 REED GROUP PROMPTLY. - 

Named olftnt eae j~ V Data ofbirth 

iQiLM a;flCAA 

1. HISTORY (I 

to) When did symptoms first as tar or awd*nt happen? M _________________ Day U - Year I 

çb Date Want ceased wohc be auea of disathity Mo. Day Ye;; / 7 

(o) Has patient mar had earns a &milar condition? 0 Yes 0 No If ’Yea’ tte when end 

(cS) Is condlifan due to inlumy or a dcneso arising out of patient’s employment? C] in O NO 0 UPt:nc’wn 

(e Names and dresses of Ott sr bsatIn physicians: 

11S!: rtkr 

(d) Oeava findings: ’few pats nt may be covered under the previsions of the Johnwn & John;on Loon Term DlssbflIti (LW) Plait To eaSt seed 

- -_ n04p-a’Jlai 4sthSL4ef4SflstioLit&rSQetyoum c*apaiticn in forwarding: the yid of objeottve tes already taken (for esrnIt 

ale ae ard;rens, an ogmart2 eta, for a bask condition: 

results found through the use of other dinloal inuea. 

Do you wish his hitttnadon ret ned? U Yea 0 No 

2, DATES OF TREATMENT ’l a) Qate etllrstvisml Mo. _I_r J oay 

(b) Date or last v!sft Mo, Day 19_ 

(o5 Frequy -El Weeldy 0 MontHy 0 Other (Speedy) 

4, NATURE OF T ATMNT (hi juding surgery and medications prescribed, if ens’ 

PRO4 

t) Hat pahent 

tLI Reesuared? fr’mpteved? 0 Unchanged? 0 eb’cgraased? 

) Is patient tuletery? Q House confined? U 8ed oonfined? 0 liositat confined? 

(o) Has patient bOOn heapit 1 C inflned? 0 Yes 0 Na 

If ’Yes? give Name and Ajodm a of Hospital 

Cotittsivadfroni t zouh 

8, CARDLAC (If applicable) !\J/ 

(a) Pursatonal oap;clty J Clan 1 WIT oh) 0 Class 2 (SlIght llniitatiOn0 çsmarlcan Heart Ps’n.) I] Class S (Msrfd hrnitstk , n) Class 4 (Complete limnflssion) 

Is) Stood Pressure osat vIsit) F 

SYSTDLIC DIASTOLIC 

- 

Reed Group 15 ted Valley DrIve I 2’ Floor, SuIte 21 East Creenbtnh, NY taoelj s-e28-ae811 FEc 515-580-8610 

JJO4S 

received on 32009 8:52:29 AM [Eastern Standard Ti me] Confidential 

Adrnin Rec. 00454 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 27 of 55 PageID: 896
38:54 7325711937 STROUSE/LOFANO FA 82 

FROM z cio FX NC, Z 732278428? Jan. 30 203 ?24 1 P1’l P3 

, ReadBrpup 

ATTENDING PHYSICIAN STATME4T 

L PHYSI CAL I MPAIRMENT 

C Otees I No limitation offend snal a*e&:kT opat4e of heavy physloat soUviLy, No restdellons. (0-13%) 

o Clnsq 1 Slight Il mtaviomoffutcllonal oopaolt’; ospeble of tlhtmtflUal aotMty, (15-30%). 

Alaom S  Moderath limitation (furtotlonalcapacity! opabIe S cancel admirittrativa (a dentar) au$rRy, 

CI Close 4Marked itnEtio,t ( 5.70%) 

o Class 5 - Sevore llniftoIon cit unctionas oaSV; ti ncapalole of ItInimal (Oedtntazy) actIvity. (75-100%) 

o 

 . 

.. 

t MENTAUNSFWOUS IMPAIRMS IT (f appncaIe 11) 1 t7 

C 013,1* 1 Patient is bie to ft ct1on unr stroM arla’eM4 iKfrn&oersono[ reletloris l"IlmItationE). 

o Class 2 .- Patient Is athia to ft intion In most east altuatiois and enaa to most intetpecsonal relations (slight Ii. tatioqis). 

o Gloss S - Pthentis able too tg age in only lkrrthsd strose situation, aM engage in only Untitad interpersonal reletiors (moderate Umitelicits). 

o Class 4. Pnt I, unable Ix engage in sttss aSuetions er engage Interriersonal relations (terked limitations). 

O Class a Patient hsa ainittc ant jorig of pobalogiced, phiolgglcal. pemeonal and social ad)ustmnent (severe llnttatloM). 

U en,artcs: 

Co you believe patient Is corniF ajent to ethaolc$ aM direct the use of the proceeda thereof? U Yes U No 

8. PRONOtIS 

PAT15NVSJO 

ANY OTHER WQR< 

(a)IspW bratty tabi? Yes No 

(b)Do you a undgrnentH 

of merited change in the tutur Uw&tic--------.--_-___ - 

wbenwlflpietdr5cover...J L LI Mo. 0 a-._j_j__.. Lii Mo. U 3.CMna 

*ufldenttyth perlorro 6.5 s Mo. Day Yr. 01 4 Moo, U Never Mo. Day Yr. 0 1-3 Meg. LI Never 

(g) It No please explain: 

PKr(NTTS JOB ANY OThER WORK 

(8) It patients stable candor to 

for trial employment? ’Yes 0 f40 U Yes U No 

(I) rY3.’ when rsu(d trial I Mo. 3 Moo. ______l_f 0 1 Mo, U s 

Mo. Day ’fr 1.3 Mos U Neva Mo. Day Yr, 0 1-3 Moe. U Never 

;: ~hw type of trZTOU sugt? - J e

WQDSUSEMUPA 

ame fl/ g 

Add City or Tcwn Slate of Province Zip coee 

Err a uII Name 

Reed Group 115 Tei hVoIley Drive I 2nd ploor, Sutn I I East Creeribush, NY 120611 3S5-E284l I Fac 5I8-ZSC8I0 

received on 2/66098:52:29 AM (Eastern Standard lime] 

Confidential 

Admit, Rec. 00455 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 28 of 55 PageID: 897
VA aRecdGroup 

www.rgt.eet . 

APPLICATION FOR DISABILITY BENEFITS 

TO BE COMPLETED BY.EMPLOYEE , PLEASE TYPE OR .:f., ANSWER:ALL QUESTIONS: 

1. EMP0E FULL NAME (Last, First, Middle Initial) 2, Scold; Security Number - 

’Vcr 

3. Address (City, State, Zip Code) 4. Phone Number Area Cod) 

5. Date of Birth 6. Height 7. Weight 8. Gender 9. Merfta! Status 1O.Wpouse’3 Date of Blith ii. is bpOuse Employed? 

II 45I 

Me Day Yr I single aed Mo Day 

Yr 11 Yes 

Li F U widowed U divorced FirstName 7\rAht.f 

12. Number of 13. List names with dates of birth for unmarried children who have not finished high school: 

Children EJ& S. "J e-..ja o4 -e3--3 b- Dav-4c,- 

. Vc, Deve-4* 1212 11 :V- Vc,O even -kr tz-- q- oz 

14. What is your disabling condition? (Briefly describe the injury or illness that prevents, or has prevented, you from working,) 

C 

cQ -t:ct bc,cAc 

(i,) L er c’tc.4-J\tt 

15. Is your injury or illness related to or caused by your work in anyway? 2.. Y Lb Yes U No 

1 On what cafedid your cbffd:ticnlrrst bothefllbLf - MoT’t’ S/t?.) Day Year-1 ¶ 7-’ -- - 

2A.DJ–you work after the date shown in item I? (lr’’No, go to items 3A and Rl~yes U No 

28:’ If YOU did work since the date in item 1, did your condition cause YOU to. 

Yourjob orjob duties? .

, U Yes 

Your hours of wpr U Yes I"No 

I Your adendance? EYYes . UNc 

Anything else about your work? . , 

as U No 

(If you ans4red No to all items under 28, go to items $A and 38.) 

2G. If you answered ’Yes " to any item in 26, explain below What the changes in your work circumstances were, the dates they occurred, and how 

your oonditicn made these changes necessary. , 

5 , -1- 4~r l d3 o4 k 

94L 

j 

)c,fl- \so p,ud C’c.-d - o scftW-. 

3A. On what date did your condition finally make you stop working? Month 9 Day Year 

33, Explain how your condition now keeps you from working. 

$- t4 4o fl s4- J , on &o’ r’t,, b&dc /seocd- L e,c hU,L, J , 

baco-s,.t sHPr ?-J4. 4 bcrnc S-.- cal4 hz n s4’cj /-ik.-Rc o ’ /’t_ 

c’c.-A i. jret. m3 hAS 

j 1La, 

I 

" - MCAfl 

15 Tech Valley Drive 2 " Floor, Suite 3 jEastoreenbush, NY 12051j 555-529-3861 1 Fax 

.JJ046 - ’ - . 

. \ AdmirF&O 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 29 of 55 PageID: 898
Describe the kind and amount of physical activity this job involved during atypical day in terms of: 

 Walking (circle the number of hours a day spent walking) 0 1 0 3 4 5 5 7 5 

 Standing (oircie the number of hours a day spent standing) 0 2 3 4 5 5 7 5 

 Sitting (circle the number of hours a day spent sifting) 0 1 2 3 4 5 0 7 S 

 Bending (circle how often a day you had to bend) Never Occasionally-requentl Constantly 

 Reaching (circle how often a day you had to reach) Never Occasionally requently . Constantly 

 

Lifting and Carrying (describe belowv?hatwas lifted, and far it was carried; check heaviest weight lifted, and weight frequently lifted 

andlor carried): 

HEAVIEST WEIGHT LIED WEIGHT FREQUENTLY LIFED/CARRIED 

E 10 lbs. U 101b5. 

- Uzo . D2Olb. 

-50 tbs. 50 tbs. 

Cl too lbs. U 100 lbs. 

U Over 100 lbs. C3 Over 100 tbs. 

Have you been hospitalized or treated at a clinic for your disabling condition? U Yes 

It ’Yes, show the following and give dates of confinement 

Name of Hospital or Clinic: Address: Dates of Confinement: 

Names and addresses of any physicians consulted: Dates Consulted: 

...................... .......

---------.- ---------------------------------. .......- ---------- 

re you receeiving any income benefits? 

If Yes,’ check applicable box or boxes below and provide detail. 

U Disability Benefit U Federal Social Security, Railroad Retirement Act, Veterans Administration, any Federal, 

U Pension Plan State, or other GovemmentAgency BenefitO or Employer’s Liability Law Benefits 

O Workers Compensation , 0 Other 

D Sick Leave 

Source of Benefits Monthly Amount . Commencement Date of Payments -. ’ . Terrninabon of Payments 

PART fl --INFORMATION ABOUT YOUR EDUCATION - 

1. What is te highest grade of school that you compieted and when? 

I’ &S 

2. Have you gone to trade or vocational school or had any type of special training? U Yes PiNo 

If "Yes,’ show: O GR7. 

N 

 The type of trade or vocational school or training: 

 Approximate dates you attended: / ppfl;n/rn 

/ 

 How this schooling or training was used in any work you did: 

FEBO2ZoO9 

Empio ee Full Name VNID # k 

Reed Group 115 Tech Valley Drive 2t,d Floor, Suite 3]EastGreenbush, NY ’20611886-829-68611 Fax: 516-650-6510 

JJ045 

Confidential 

Admin Rec. 00457 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 30 of 55 PageID: 899
h - i",. ra ft . W; 

 raii 

PART IV - INFORMATION ABOUT THE WORK YOU DID 

1, List all jobs you have had in the last 15 years before you stopped working, beginning With your current job. Normally, this-will be the kind of work you 

did the longest (If you have a 6h grade education or less, AND did .only heavy unskilled labor for 35 years or more, list all of the jobs you have had 

since you began to work. Use a separate sheet as necessary and attach it to this form.) 

Jab Title Type of Date Worked Days per Week Rate of Pay 

(Be sure to begin with your ourrent Business (Month and Year) (Per hour, 

job) 

- 

day, week, 

month or From To 

year) 

SThi- RnsL . MJci&J bavct-Li frese-ii- I_.s .i&w 

2. Provide the following intomiaticnforyour usual job shown in item 1, line I: - -. 

In your job, did you: 

 use machines, tools, or equipment of any kind? ’Yes Cl No 

 use technical knowledge or skills? Yes U No 

 do any writing, complete reports, or perform similar duties? es U No 

 have supervisory responsibilities? U Yes B’ io 

Describe your daily activities in the following areas, and state what and how mush you do of each and how often you do it:: 

o Household maintenance (intlding booking, cleaning, shopping, and odd jobs around the house, as wait as any other similar activities): 

_($ r_af) K Vtn\rc. Pco ___octs .-c crrJ 1- 

o Recreational activities and hobbies (hunting, ishing, bowling, hiking, musical instruments, etc.): 

 Social contacts (visits with friends, relatives, neighbor): 

 °rc4s j_re____ivs4-’* 

o other (drive car, motorcycle ! ride bus; etc.): 

Pcc ow4A14 _ iA -i-aIre C lip 

I hereby authorize all physicians and health care professionals, hospitals and other healthcare institutions, insurers, employers, and group policy 

holderE You are authorized to provide Reed Group, 15 Tech Valley Drive East Greenbush, NY 12061 ! acting on my employers behalf 1with information 

concerning my health care, history, examination! treatment (including but not limited to copies of my medical record), advice, and supplies provided to 

me, and any employment-reibted infontation regarding my primary and/or secondary diagnoses as they relate to my disability benefits. This 

information will be used to evaluate and administer my application for disability benefits and may be reviewed by authorized medical and/or human 

resources professionals affiliated with my employer. I understand that this authorization is valid until I submit written revocation to my employer or Reed 

Group. I hereby release any person or entity providing information from any and all liability for furnishing such Information. I agree that a photographic 

or facsimile copy of this authorization is as valid as the original. 

IF 

=M21cyee’s sigAature Date 

Employee Full Nam6 WWID # 

roou 

( 

PEBO27;g 

Reed Group 115 Tech Valley Drivel 2nd Fioor, Suite 3 East Greenbush, NY 120511 B6S-B29-8S61"Fac 515-380-6610 

JJ046 ConfidentaI 

Admin Rec. 00458 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 31 of 55 PageID: 900
I 1 . I 

WAM 

Direct Deposit Enrollment Form 

To enroll or stop in Full Service Direct Deposit, simply fill out this form and mail or fax it to Reed Group at 518-880-

6610, Also, when enrolling, please also attach a voided check - not a deposit slip. If depositing to a savings 

account, ask your bank to give you the Routing/Transit Number for your account It isn’t always the same as the 

number on a savings deposit slip. This will help ensure that you are paid correctly. 

Below is a sample check MICR line, detailing where the information necessary to complete this form can be found. 

IAS-digit number always L cheddng Aacourit1 , J (this number matches thenumberin 

between these two nie rks) the upper right corner sf the checknot used sdtor sign-upi 

Important! Please read and sign before completing and submitting. 

I hereby authorize RGL to deposit any amounts owed me, by initiating credit entries to my account at the financial 

institution (hereinafter "Bank") indicated on this form. Further, I authorize Bank to accept and to credit and credit 

entries indicated by RGL to my account In the event that ROL deposits funds Erroneously into my account, I 

authorize RGL to debit my account for an amount not to exceed the original amount of the erroneous credit 

of .its .termination. insuch.ti.meand .such-manner as to afford .R to act on it, 

Name: beuc r Social security #: 

Signature: Date: 0 ( /2 rIo I 

1. Election (Must Select One): start Direct Deposit o Stop Direct Deposit o Change Account 

2. Account infbrmation 

1, Bank Name/CiJState:. / s / 

2. Account#: 

3. Type of Account: Qhecking o Savings o Other 

4. Routing/Transit#: O\ 

02 200g 

\ Lt7 

Reed Group 115 Tech Valley Drive 12 Floor, Suites ] East Sreenbush, NY 1208118e6 -529-8851 iFax: 51B-850-61 

JJ045 

Confidential 

Admin Rec. 00459 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 32 of 55 PageID: 901
8055 

I 55-SJzia 

WACIIOVIA - 

-WAOHO\flA BANK, NA - - 

NEW JERSEY 

EDRi . 

2L 200 25’; 0 

>0 a 

o a 

-n Ct! 

CD 

pCo 

0 

0 

a 

0) 

0 

DOLLARS G 

-- Jesus Knows Me This I Love 

)usL5DL5i’D55 H, 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 33 of 55 PageID: 902
REIMBURSEMENT AGREEMENT 

Johnson & Johnson Long Term Disability Plan 

EMPLOYEE STATEMENT 

Name: -. Social Security Number. I Date of Birth: 

Addrss - Street CiWfl State: Zip Code: 

"Vo’nis 9ve-r g753 

Home Ieiepnone Number: Employees Home E-mail Address (if available): 

I am familiar with and understand the provisions of the Long Term Disability Income Plan for Choices 

Eligible Employees of Johnson & Johnson and Affiliated Companies (the "Plan") that require that monthly 

payments to me will be reduced by certain amounts, such as Social Security and Workers’ Compensation 

benefits, I understand that these reductions may sometimes be based on a reasonable estimate of the 

amount of other benefits that will be paid to me. I agree to these reductions. 

further understand and agree that F am required to repay the Plan for any overpayments that have been 

made to me, including, without limitation, payments that have not been offset (or offset fully) for retroactive 

------- - awards of -Social security Workers’ - empersaiontrtther-relevant benefits- under th& -terms --of-the -- Plan------ -

and that I am required to pay the Plan any amounts that I recover from a third party in connection with my - 

accordance with the terms of the Plan, I understand and agree to the terms ofthe Plan regarding other 

rights of the Plan to recover amounts through subrogation and third party reimbursement 

I further agree to notify the Reed Group immediately upon my receiving notice that I have or will receive any 

amounts that offset my benefits under the Plan dnyamounts that oblige me to payor repay any amount 

to the Plan. - - - - 

gnature: 

Ot 

Signature: Date: 

Please Fax to 518-880-6610 or Mail to the Address Listed Below 

Vt0 

FEB 022999 

EA,7 GSE?US 

Reed Group 115 Tech Valley Drive I Floor, Suite 31 East Greenbush, NY 120611 866-620-5551 

JJ046 - - - - - 

Adrnin Rec. 00461 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 34 of 55 PageID: 903
S Reedçyp MI 

Social Security Administration 

Consent for Release of Information OMB No 0960-0566 

TO: Social Security Administration 

Name (Please Print): 

Date of Birth: 1\ I Social Security Number: 

authorize the Social Security Administration to release information or records about me to: 

NAME ADDRESS 

Alisup, Inc. (Alisup) 

P1., Belleville, IL 62223 

300 AlIsup 

want this information released because: 

provide in the future. 

Please release the following jnforrnation: 

NA Social Security Number 

NA Identifying information (includes date and place of birth, parents’ names) 

McnthlLS.uppiementLSecurity Income payment amount 

NA Information about benefit/payments I received from  to - 

NA Information about my Medicare claim/coverage from - to_ 

(specify)__________ 

NA Medical records 

NA Record(s) from my file (specify)______ 

X Other (specify): FACT Query for Primary and/or dependent(s) 

I am the individual to whom the information/record applies or that person’s parent (if a minor) or legal 

guardian. I know that if I make any representation which I know is false to obtain information from Social 

Security records, lcould be pun shed lby fine of impnsonment or both 

si iatu re: j9L 19L 

Date: 0 Relationship:_______ 

Please Fax to 518-880-6610 or Mail to the Address Listed Below 

SSA-3255 Internet (12/9) 

RECE,I,, 0 

FEB o 

22059 

Reed Group 115 Tech Valley Othe I 2td Floor, SuiteS 1 East Greenbush, NY 120511 566-529-8561 I Fax: 515-8ac-6ep 

JJ046 

Confidential 

Admin Rec. 00462 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 35 of 55 PageID: 904
:T 

BUSINESS REPLY 

FIRST-CLASS MAIL PERr1iT NO .B5 WESTMI 

- POSTAGE NILL B PAID BY ADDRESSEE 

REED GROUP 

15 TECH VALLEY DR STE 3 

EAST GREEiBUSH NY 12061 

im WE 

ac 

3:3 

a 

CD 

(p 

P a 

0 

0 

a 

0) 

0) 

111111 1011111 liii! I III 1111111 1111 III 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 36 of 55 PageID: 905
FROM AZ VIDEO FRX NO. : 7322794297 jar.. 29 2909 05:OSFM Ft 

To: Christina Teta 01/29/09 

Reed Group 

518-880-6610 Fax 

al,net 

Prom; Ralph Van Deventr 

Re: Independent Medical Evaluation for Case #74518 

Ms Christina, 

I have received the fax copy of the IMF- report dated 01/14/09 that you sent me. 

Thank you for doing this. The purpose of this letter is to clarify points in the report that 

are either transcription errors or misunderstandings during the interview. Much 

information was relayed and I think some of it was left out or confused with other points 

of discussion during note taking. Of course, this is so that you will have a comprehensive 

understanding of my condition and can be added to my case file for evaluation. I have 

referenced these points by their page # and category for easy/quick referral. 

Page 1 History of Present Illness 

 Dr. Heyman recorded the wrong dates about .rnyJifanktelAehiflsakerpexienced 

pain in my Achilles in May 2008 but held off seeking treatment thinking it would 

go away. It was in September 2008 that 1 went to Dr. Strouse for treatment of nay 

Achilles as well as my back. 

 It was December 2008 that Physical Therapy started for my left ankle, but it was 

not with heat and stimulation. They had me exercise and stretch my Achilles. The 

heat and stimulation was for treating my back injury. 

 I did not say "my back is starting to improve". This note may lead one to believe 

that my back injury is improving, but this is not the case. I merely said that due to 

the Physical Therapy program, they have taught me how to improve my back’s 

posture. 

 As regarding to sleeping, I expressed that I can only sleep in a recliner chair, with 

a lumbar support, to take the pressure off my lower back. I cannot shift from side 

to side "if’ I was laying flat on my back in bed. In the past I had to roll out of bed 

to get up, but since my injury has worsened, I have reverted to sleeping in the 

recliner. 

 Since we were talking about two areas of injury, I believe things got mixed up in 

the transcription. I definitely did not "indicate" that my back was somewhat 

better. I stated that the swelling in my left Achilles is somewhat better. 

Page 2 Medical Records Reviewed 

 Orthopedic notes are not included. Were they not part of the chart given to Dr. 

Heyman? Mostly excuse slips and prescriptions for physical therapy were noted, 

received on 1/2912109 4:22:32 PM [Eastern Standard Time] 

Confidential 

Admin Rec. 00464 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 37 of 55 PageID: 906
FROM R-Z VIDEO FAX NO. 7322754207 Jan. 29 2009 0E:OEPM P2 

 No Physical Therapy notes included. Were none supplied? In both cases, the 

absence of additional data does not help form an accurate conclusion. 

Page 2 Physical Examination - 

 Behavior indicated in the rep6rt is t)pical of my character. I was in pain, but 

because I have "managed" it for so long, I know what to do so it does not affect 

my outward appearance and how I conduct myself. This, along with taking excess 

Thuprofen, helps me get through the day. 

 I was driven to the IME appointment by my brother-in-law. 

Page 3 Sec ond Ranizeof Motion (about left ankle) 

 Left Achilles reported as "not tender". If he had squeezed it like my orthopedic, 

he would know that it is tender. He basically ran his fingers over it and measured 

it, but not squeezing it. 

Page 3 Special Tests in the Lower Extremity 

 "No shm of sciatic nerve root irritation,,.." Was in part due to the antiinflammatory taken that day along with the fact we stopped every 15-20 minutes 

for rue to pop my spine back in place and to walk around some. I was in 

discomfort with my sciatic that really never leaves me. Again, because of who I 

am and have managed my pain for so long an6he not knowfbg me fhôk that as no 

pain. Although, he did asked me if my sciatic was bothering me in which I told 

him yes, that is not in his report. The PhyFTherapist, who has been treating 

me for 5 months, knows about my sciatic pain, but since Dr. Heyman does not 

have her reports, he made ajudgment call with limited information. 

Page 4 Question 2 

I explained to Dr. Heyman that I already use lumbar support devices when I sit at 

home, in the car and even at work (when I was there). I also use a swivel disk in 

the car to sit on so I don’t have to shift my weight getting in or out of the car, it is 

like a Lazy Susan so you can spin on. Even with all these in place, I still cannot sit 

for long periods of time -20 minutes 30 on a good day. He is stating that with the 

proper coaching I could sit longer with a lumbar support. I explained to him that 

my work has us take training yearly on ergonomically work station sitting. I have 

been ergonomically trained on a yearly basis about proper sitting at the work 

station and I use a lumbar support. He did not include this information in his notes 

that I had given him. In his report he states that he does not think that the physical 

therapy exercises, that I explained to him, help. Yet at our consult he did not 

mention that to me or offer any advice to the contrary, I believe the P.T. program 

is stretching/exercises my back muscles, but do not stabilize my lumbar section, 

which I had stated to Dr. Heyman, which is not in his report either. My P.T. is 

working with me to help strengthen the muscle in my back in hopes it will 

stabilize my vertebra. Again, I told this to Dr. Heyman which is also is not in his 

report, 

received on 112912009 4:22:32 PM [Eastern Standard Time]

Confidential 

Admin Rec. 00465 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 38 of 55 PageID: 907
FROM A-Z VIDEO FAX NO. 7322704287 Jan. 29 209 216:57PM F] 

Page 4 Question 3 

A lift inside or outside the shoe will deflexed my Achilles tendon. which will hurt 

and it in turn, aggravate my back. The cam boot had this effect, which was stated 

to Dr. Heyman. I already favor my right sidçand to have this lift in place would 

only make matters worse. He never talked to me about this at the time or I could 

have explained this to him concerning my foot. 

Page 4 Qjgjon4 

I already had in place, at work, the lumbar support Dr. Heyman refers to along 

with frequent walking and stretching. I explained to him I did sit for long periods 

of time using a lumbar support. I would get up a few times daily due to my back 

and leg to walk and stretch, yet I just pushed through taking Ibuprofen and 

Tylenol during the course of the day. It came to a point that the Ibuprofen I would 

take during the day was not helping my pain. I had to stand and stretch much 

more frequently which I did for most of the summer and I still had back problems. 

The same is true at home. My daily regimen consists of frequent switches 

between sitting, walking and stretching. Those comments are not in his report. 

Page 4 Question5 

o Dr. Heyman failed to realize that djngphysiaL tS.py, I do..not.wear. the. cam............ 

boot, wiuich Itold him was the case, this did not make it into the report either. 

Puttirigjp a heel pad would caasnzpaintoinAchillescansing.il-to-4lex4s---------- 

the wrong direction (toes down), which .1 expressed to him causes great pain. 

Flexing in the opposite direction (toes up) does not cause pain. How do you drive 

if you cannot flex down for any extended length of time before it becomes a 

safety hazard? I explained to Dr. Heyman, in detail, the exercises for my Achilles, 

but he stated in his report that they "are not indicated." That was left out of the 

report also. I also explained the exercises for my back, which are difficult, but he 

does not believe they strengthen my back. 

Page 5 Question 5Cgt’d 

Again, Dr. Heyman forgot that I told him of the lumbar pillow/support used at 

home, work and in the car and yet I still experience back pain. Yet it is on his 

report as a recommendation, but I had told him I already do this. 

Experiences dining the [MB that were not recorded: 

 During the physical examination, Dr. Heyman asked me to bend and touch my 

toes. I was apprehensive knowing that I can’t and in trying to do so put me in 

jeopardy of more bank pain. With his hand on my lumbar section, 1 bent forward 

and stopped and stated at the point when. I could not go any further due to the 

pain. At the same time I stopped, Dr. Heyman said that that s enough, 

realizing/feeling the change in my back. 

 I stated that all the muscle strengthening so far still has not stabilized my spine. I 

feel my back problems to be nerve related due to structural damage. 

receivid on 112912609 4:22:32 PM fEastern Standard Time] Confidential 

Admin Rec. 00466 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 39 of 55 PageID: 908
FROM A-Z UIDEO FAX NO. 7322724297 Jan. 29 2209 OS: 07PM P4 

conveyed to Dr. Heyman the toll this has taken on rue physically and 

emotionally. I stated that this has caused me to realize that ray back and probably 

my Achilles will not get better and that this is the best it will be. Accepting this is 

hard, because I was such an active person with a large family, relying on others to 

do tasks for me--caused me ; to be depressed and anxious for the future of my wife 

and children. As a result, I have sought the help of a psychiatrist. Time is of the 

essence, as my short term disability runs out in a month. My future is in question. 

Will lever work at the job I love? Will I be terminated? How will I provide for 

my wife and children? Will I be approved for long term disability? These and 

many other unanswered questions have me more than worried - a behavior that is 

not me, Friends, neighbors and family see me as a different person than a year 

ago. 

* During the first few minutes of the IMP, Dr. Heyman quoted a renowned 

orthopedic about back pain/injury. He said and I paraphrase "America spends too 

much time, resources and money on back injuries and that people should not do 

what causes them to have back pain, and that the money spent on curing it was 

wasteful," To that I said I agree people should not get themselves into position 

that would cause them back pain, but as for the rest I could not agree, It had set an 

eerie atmosphere for the rest of the examination. I thought maybe he would not 

take to heart this philosophy and include me in this generalization, but treat me on 

- an individual basis as no two patients.areJha same-Does .his-stat.ement-torne--.......................... 

about the back injuries and the waste of time and money mean he already had a 

nteovceived notation of 

with the masses? 

,’ As an update since the IMP, I have received my first epidural block injection on 

01/26/09. They said it could take up to 72 hours to take effect. That has not 

happened and they will prescribe pain medication until my next appointment on 

02/09/09 

Lastly, my experience with those in charge of my care has been exceptional. This 

includes the orthopedic surgeon, the physical therapist and the Reed Group. I am 

grateful for the support, help and encouragement all these people have expressed 

to me. 

If you have any questions, please call me and I will be glad to answer any questions. 

Sincerely, 

Ralph Van Deventer 

cc: Dr. Stoner 

Heartland Rehabilitation 

received on 1/2912009 4:22:32 PM ]!astern Standard Time] Confidential 

Admin Rec. 00467 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 40 of 55 PageID: 909
FROM Li’ 060 FAX NO. 7322724287 Jan. 29 2009 06: OGFM P 

To: Christina Teta 01129109 

Reed Group 

51 8-880-6610 Fax 

cteta(cral.net 

From: Ralph Van DeveatexRe: Independent Medical Evaluation for Case #74518 

M& Christina, 

I have received the fax copy of the IME report dated 01/14/09 that you sent me. 

Thank you for doing this. The purpose of this letter is to clarify points in the report that 

are either transcription errors or misunderstandings during the interview. Much 

information was relayed and I think some of it was left out or conThsed with other points 

of discussion during note taking. Of course, this is so that you will have a comprehensive 

understanding of my condition and can be added to my case file for evaluation. I have 

referenced these points by their page ;4 and category for easy/quick referral. 

Page 1 History of Present Illness 

pain in my Achilles in May 2008 but held off seeking treatment thinking it would 

go away. It was in September 2008 that I went to Dr. Strouse for treatment of my 

Achilles as well as my back. 

 It was December 2008 that Physical Therapy started for my left ankle, but it was 

not with heat and stimulation. They had me exercise and stretch my Achilles. The 

heat and stimulation was for treating my hack injury. 

 I did not say "my back is starting to improve". This note may lead one to believe 

that my back injury is improving, but this is not the case. I merely said that due to 

the Physical Therapy program, they have taught me how to improve my back’s 

posture. 

 As regarding to sleeping, I expressed that I can only sleep in a recliner chair, with 

a lumbar support, to take the pressure off my lower back. I cannot shift from side 

to side "if’ I was laying flat on my back in bed. In the past I had to roll out of bed 

to get up, but since my injury has worsened, I have reverted to sleeping in the 

recliner. 

 Since we were talking about two areas of injury, I believe things got mixed up in 

the transcription. I definitely did not "indicate’ that m y back was somewhat 

better. I stated that the swelling in my left Achilles i5 somewhat better. 

Page 2 Medical Records Reviewed 

 Orthopedic notes are not included. Were they not part of the chart given to Dr. 

Heyman? Mostly excuse slips and prescriptions for physical therapy were noted. 

received on 112912689 4:22:32 PM [Eastern Standard Time] 

Confidential 

Admin Rec. 00468 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 41 of 55 PageID: 910
FROM A-Z L’WEO FRX NO, 7322794287 Jan. 29 2009 ZEOSPM F2 

No Physical Therapy notes included. Were none supplied? In both cases, the 

absence of additional data does not help form an accurate conclusion. 

Page 2 Physical Examination 

* Behayior indicated in the report is typical of my character. I was in pain, but 

because I have "managed" it for so long, I know what to do so it does not affect 

my outward appearance and how I conduct myself, This, along with taking excess 

Thuprofen, helps me get through the day. 

 I was driven to the [ME appointment by my brother-in-law. 

Page 3 Second R ange of Motion (about left ankle) 

 Left Achilles reported as "not tender". If he had squeezed it like my orthopedic, 

he would know that it is tender. He basically ran his fingers over it and measured 

it, but not squeezing it. 

Page 3 Special Tests in the Lower Extremity 

 "No sign of sciatic nerve root irritation.," Was in part due to the antiinflammatory taken that day along with the fact we stopped every 15-20 minutes 

for inc to pop my spine back in place and to walk around some. I was in 

discomfort with my sciatic that really never leaves me. Again, because of who I 

am and have managed my pain for so long and he not knowing me took that as no 

pain. Although, he did asked me if my sciatic was bothering me in which I told 

me for S months, knows about my sciatic pain, but since Dr. Heyman does not 

have her reports, he made a judgment call with limited information. 

Page 4 Question 2 

I explained to Dr. Heyman that 1 already use lumbar support devices when I sit at 

home, in the car and even at work (when I was there). I also use a swivel disk in 

the car to sit on so I don’t have to shift my weight getting in or out of the car, It is 

like a Lazy Susan so you can spin on. Even with all these in place, I still cannot sit 

for long periods of time 20 minutes 30 on a good day. He is stating that with the 

proper coaching I could sit longer with, a lumbar support. I explained to him that 

my work has us take training yearly on ergonomically work station sitting. I have 

been ergonomically trained on a yearly basis about proper sitting at the work 

station and I use a lumbar support. He did not include this information in his notes 

that I had Qven him. In his report he states that he does not think that the physical 

therapy exercises, that I explained to him, help. Yet at our consult he did not 

mention that to roe or offer any advice to the contrary. I believe the P.T. program 

is stretching/exercises my back muscles, but do not stabilize my lumbar section, 

which [had stated to Dr. Heyman, which is not in his report either. My P.T. is 

working with me to help strengthen the muscle in my back in hopes it will 

stabilize my vertebra. Again, I told this to Dr. Heyman which is also is not in his 

report. 

receivid on 112939 4:22:32 PM [Eastern Standard Time 

Confidential 

Admn Rec. 00469 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 42 of 55 PageID: 911
FROM -Z VIDEO FSX NC. 7322704287 Jan. 29 2009 05:0?PM P3 

Page 4 Question 3 

A lift inside or outside the shoe will deflexed my Achilles tendon, which will hurt 

and it in turn, aggravate my back. The cam boot had this effect, which was stated 

to Dr. Heyman. I already favor my right side and to have this 1111 in place would 

only znalce matters worse. He never talked to me about this at the time or I could 

have explained this to him concerning my foot. - 

Page 4 Qgn4 

 I already had in place, at work, the lumbar support Dr. Heyman refers to along 

with frequent walking and stretching. I explained to him I did sit for long periods 

of time using a lumbar support. I would get up a few times daily due to my back 

and leg to walk and stretch, yet I just pushed through taking Ibuprofen and 

Tylenol during the course of the day. It came to a point that the Ibuprofen I would 

take during the day was not helping my pain. I had to stand and stretch much 

more frequently which I did for most of the summer and I still had back problems. 

The same is true at borne. My daily regimen consists of frequent switches 

between sitting, walking and stretching. These comments are not in his report. 

Page 4 QpgjQn5 

* Dr. Heyman failed to realize that during physical therapy, I do riot -wear the cam 

boot, Much I told him was the case, this did not make it into the report either. 

Puffing in a heel pad would cause more pain to my Achilles causing it to flex in 

the-wTong4ireetiotoes-dos)ichxpressed- toltinreaurpiüiI, - 

Flexing in the opposite direction (toes up) does not cause pain. How do you drive 

-lr7oure1Krm0t-lrrextuwrzoraruy extencea Jeagm or tune D 1-are it becomes a 

safety hazard? I explained to Dr. Heyman, in detail, the exercises for my Achilles, 

but he stated in his report that they "are not indicated," That was left out of the 

report also. 1 also explained the exercises for my back, which are difficult, but he 

does not believe they strengthen my back 

Page 5 Question 5Cont’d 

 Again, Dr. Heyman forgot that! told him of the lumbar pillow/support used at 

home, work and in the car and yet I still experience back pain. Yet it is on his 

report as a recommendation, but I had Lold him I already do this. 

Experiences am-lug the IMP that were not recorded: 

 During the physical examination, Dr. Heyman asked me to bend and touch my 

toes. I was apprehensive knowing that I can’t and in trying to do so put me in 

jeopardy of more back pain. With his hand on my lumbar section, 1 bent forward 

and stopped and stated at the point when I could not go any further duo to the 

pain. At the same time I stopped, Dr. Heyman said that that was enough, 

realizing/feeling the change in my back. 

 I stated that all the muscle strengthening so fax still has not stabilized my spine. I 

feel my back problems to be nerve related due to structural damage. 

received on 1129I2009 4:22:32 PM tEastern Standard Time] 

Confidential 

Admin Rec. 00470 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 43 of 55 PageID: 912
FROM A-Z VIDEO FPX NO. 7322704207 Jan. 29 2009 05:07FM P4 

 I conveyed to Dr. Beyman the toll this has taken on me physically and - 

emotionally. I stated that this has caused me to realize that my back and probably 

my Achilles will not get better and that this is the best it will be. Accepting this is 

hard, because I was such an active person with a large family, relying on others to 

do tasks for me caused me to be depressed and anxious for the future of my wife 

and children. As a result, I have sought the help of a psychiatrist. Time is of the 

essence, as my short term disability runs out in a month. My future is in question. 

Will lever work at the job I love? Will I he terminated? Bow will I provide for 

my wife and children? Will I be approved for long term disability? These and 

many other unanswered questions have me more than worried - a behavior that is 

not me. Friends, neighbors and family sec me as a different person than a year 

ago. - 

During the first few minutes of the 1MB, Dr. Heyman quoted a renowned 

orthopedic about backpain/injury. Lie said and I paraphrase "America spends too 

much time, resources and money on back injuries and that people should not do 

what causes them to have back pain, and that the money spent on curing it was 

wasteful." To that I said I agree people should not get themselves into position 

that would cause them back pain, but as for the rest I could not agree. It had set an 

eerie atmosphere for the rest of the examination. I thought maybe he would not 

take to heart this philosophy and include me in this generalization, but treat md on 

an individual basis as no two patients are the same. Does his statement to me 

about the backinjunes and the waste of time and money mean he already had a 

preconceived notation of me? Not based on me personally, but grouping me in 

 As an update since the IMP, I have received ray first epidur’al block injection on 

01/26/09. They said it could take up to 72 hours to take effect. That has not 

happened and they will prescribe pain medication until ray next appointment on 

02/09/09. 

 Lastly, my experience with those in charge of my care has been exceptional. This 

includes the orthopedic surgeon, the physical therapist and the Reed Group. I am 

grateful for the support, help and encouragement all these people have expressed 

to me, 

If you have any questions, please call me and I will be glad to answer any questions. 

-Sincerely, 

Ralph Van Deventer 

cc: DL Stouse 

Heartland Rehabilitation 

received on 112912009 4:22:32 PM jEastem Standard flnlel 

Confidential 

Admin Rec. 00471 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 44 of 55 PageID: 913
ZLt’OO QG1 LJ{LUPV 

I;uepjuo 

FROM RZ JIDEO FAX NO. 72704287 Jan. 30 2009 0237PM Ri 

I’S bO55OOOO I.E200Dd1dU. I I

Asar MN 

VN’NNVe YMOH’VM tt4j 

.--. 

$ 

kaNA? crOh 

received on 1130)2009 12:53:58 PM [Eastern Standard lime] 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 45 of 55 PageID: 914
FROM PrO VIDEO FAX NO. 7322704297 jan. 30 2009 02: 3TFM P2 

rRee ds ruu p 

REIMBURSEMENT AGREEMENT 

Johnson & Johnson Long Tern, Disability Plan 

EMPLOYEE STATEMENT 

Manic: Social Seuritw Mpmb;c Date of Birth: 

Address - Street: Ci. state: L1Code: 

OS Forc L--c 

Home Telephone Number I Employees Home E-mail Address (if available): 

am familiar with and understand the provisions of the Long Term Disability Income Plan for Choices 

Eligible Employees of Johnson & Johnson and Affiliated Companies (the "Plan " ) that require that monthly 

payments to me will be reduced by certain amounts such as Social Security and Workers Compensation 

benefits, I understand that these reductions may sometimes be based on a reasonable estimate of the 

amount of other benefits that will be paid to me. I agree to these reductions. 

I further understand and agree that I am required to repay the Plan for any overpayments that have been 

ma-deiome,induthng:witlioot limitatioriypayrrrenta that have -notbeen-offset (or offset fully)-for retroactive-- 

awards of Social Security, Workers Compensation or other relevant benefits under the terms of the Plan 

in earnctia~y_ 

disability to the extent provided under the terms of the Plan. I agree to make these payments promptly, in 

accordance with the terms of the Plan. I understand and agree to the terms of the Plan regarding other 

rights of the Plan to recover amounts through subrogation and third party reimbursement 

I further agree to notify the Reed Group immediately upon my receiving notice that I have or will receive any 

amounts that offset my benefits under the Pen or any amounts that oblige me to pay or repay any amount 

to the Plan, 

Employe ’ ignature: Date: 

4ti 9 U Ct 

Witness Signature: Date: 

OaMA. .LoAJb (21/ &( n 

Please Fax to 518-880-6610 or Mail to the Address Listed Below 

M flmiin I IS Thr.h Vellp.v Drhe 1 2nd Floor, Suite 3 1 East Greenbush, NY 120511 866-629-8861 Fa>c 818-880-6610 

.4, .4 rAi1tfl/ 44,:8,O ni lr,

LeI IISta, 

r4 

ime QJ uai U T ] 

t: 

VII INVlLVV ]L.Q0 na 1Sb i Confidential 

Admin Rec. 00473 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 46 of 55 PageID: 915
FROM : A-Z uIDEO FAX NO. 7322704257 Jan. 32 2209 22:33FM P3 

Rncdpp 

Social Security Administration 

Consent for Release of information OMB No 0960-0555 

TO: Social Security Administration 

Name (Please Print): 22y Vc,r cc 

Date of Birth: t I Social Security Number: 

[authorize the Social Security Administration to release information or records about me to: 

NAME ADDRESS 

Ailsup, Inc, (Alisup) 

FL, Belleville, IL 62223 

300 Allsup 

want this information released because: 

Please release the following Information: 

NA Social Security Number 

NA Identifying information (inc 

VThflrr,+h}, Ln,--J or 

NA Monthly Supplemental Security Income payment amount 

NA Information about benefit/payments I received from - to - 

NA Information about my Medicare claim/coverage from to 

(specify) 

NA Medical records 

NA Record(s) from my file (specify)_______ 

X Other (specify): FACT Query for Primary and/or dependent(s) 

I am the individual to whom the information/record applies or that persons parent (ft a minor) or legal 

guardian. I know that if I make any representation which I know is false to obtain information from Social 

Security records, I could be punished by fine or imprisonment or both. 

Signature: -  

Date: 0) ) . Relationship: 5Q4-A 

Please Fax to 518-880-6610 or Mail to the Address Listed Below 

SSA-32$5 Inienet (12/99) 

In Mc Tarh ¶Jzflt, nrh; 2M Floor, Sure 3 East Greenbush 1 NY 1201311866-829-8851 I Fax: 51 8-550-5510 received on 1!3O!2009 2:53:5S PM [Eastern Standard lime] 

Confidential 

Admin Rec. 00474 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 47 of 55 PageID: 916
- .- - 

FROM A-Z UIOEO FAX NO. 7322784287 Jan. 30 2809 02:33FM Fl 

kcsn Ta O)/Z41" 

\]. Uer 

Ce- /Tb c cec q$’ 

-- 

netd yr 

O 41/ 

c 

 / 

Ca!) ni 

r 

recivd on V301200912:0:55 PM [Eastern Standard Time] Confidential 

Admin Rec. 00475 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 48 of 55 PageID: 917
FROM : A-Z VIDEO FAX NO. : 7322704287 Jan. 32 2209 22: 33PM F2 

#RcndGrou1 p IJ 

APPLICATION FOR DISABILITY BENEFITS 

BE COMPLETED BY EMPLOYEE PLEASE TYPE OR PRINT CLEARLY ANSWER ALL QUESTIONS  

1 EMPLOYEE FULL NAME (Last, First, Middle Initial)  2. social Security Number 

L PhoneNubsUde) 

Date otBtfth .Weight t, 2ender 19 MarItal Status 1c.tm’c DateBlith o’f 

11 7

Is Spouse Employed? H6,91 1, 1 

t Day Yr 1B’ti sing l eimarried Me D Yr 

&r LJYes 

U F widowed 0 divorced FirsiName ______ 

12. Number of 13, List names ’i 

’J

th dates of birth for unmarried children who have not finished high school; 

Chitdren a ’le’’- . n &’je p,, 7 ct fl V ar-s- to2, 

Von Oeye_-c4*’ t2"I)- L/.1 V. Vcs... Q e ve...,-4-c-r 12-/J’b3 

PART I INFORMATION ABOUT YOUR CONDITION 

14, What is ~yourddst~lirg; condition? "Briesy describe the injury or illness that prevents. or has p revented, you from working.) 

C c ccpc ,tD H 

s’t pzt Lcc.c 

I, P-eLd 

 )’O / 

ts.Js. your injury rib related t u4b’y9urwort< in anyway? 2, ci WTh’es C No 

what date did your condition first bother you: Mt Yea r 

a Did you work after the date shown in item 1? (If -No,’ go to items 3A and 33) 

20. If you did work since the date In item 1, did your condition cause you to change; 

Your job or job duties? U Yes 

Your hours ofrk? C Yes 

Your aftendance? esONo 

Anything else aided your wo rk? es C No 

(If you an red ’No’ to all items under 0, go to items 3A and 33.) 

_ 

________________________________________ ______________ 

20. It you answered Yes’ to any item in 20, explain below whet the changes in your work circumstances were, the dates they occurred, and how 

your pondition made these changes necessary. 

U ’ 

l .44o 

N? ’t 

W tc a1 aa. e 4s , V\.,’, rr rcntdY twr{ 4’L. 7t&.rs t ".’’ 

I’ 

. jc c 

3A, On what date did your condition finally make you stop working? Month Day 25 Year 

.. 

$0. Exolein how your condition now Keeps you from working. &,J 

-R +ev 

received on 113012909 12:49:55 PM [Eastern Standardlknefr 2M Floor. Suite 3 East Greenbush, NY 12061} 00S29-E561 IFar. 518-860-6610 

Confidential 

Admin Rec. 00476 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 49 of 55 PageID: 918
FROM : AZ U 7 OEO ’FRX NO. 7322704287 Jan. 30 2009 02: 34FM P3 

Describe the Rind and amount of physical activity this job involved during a typical day In terms oft. 

 Walking (circle the number of hours a day spent walking) 0 1 g 3 4 5 5 7 8 

 Standing (circle the number of hours a day spent standtng) 0 1 2 3 4 5 6 7 8 

 Sitting (circle the number of hours a day spent sitting) 0 1 2 3 4 57 

 Bending (circle how often a day you had to bend) Never Occasionally’ rrequentl Constantly 

 Reaching (circle how often a day you had to teach) Never’ Occasionally re uently Constantly 

 

Lifting and Carrying (describe below whet was lifted, and far it was carried; check heaviest weight lifted, and weight frequently lifted 

and/Or carded): - - - 

HEAVIEST WEIGHT LiPI’ED WEIGHT FREQUENTLY LIFTED/CARRIED 

1 Li 10 Ids. 10 IdaEl 20 lbs. 20 lbs. - 

-50 lbs. 50 lbs. 

loo Its. 100 Its. 

OOverloo Ida. .-, 

Dover lOQIbs 

Have you been hospitalized or treated 51 a clinic for your disabling condition? U Yes 

lf’Yes. show the following and give dates of confinement! 

Name of Hospital or Clinic: Address; Cates of Confinement. 

- Names And addresses of any physicians consulted: Dates Consulted; 

PART II - INFORMATION ABOUT OTHER INCOME 

Are you reca Wing any in come be nefris? U yes F No 

if Yes,’ check applicable box or boxes below and provide detail. 

C3 DisabIlity Benefit 0 Federal Social Security, Railroad Retirement Act, Veterans Administration, any Federal. 

o Pension Plan State, or other Government Agency Beneflts or Employas Liability Law Benefits 

El Worke?s Compensation U other 

D Sick Leave 

Source of Benefits Moi,t1iy Amount CornmenmantD8ieoLEamei’fts , lerr7rnatlon 01 tiavuiscas 

PART III - INFORMATION ABOUT YOUR EDUCATION . 

1, What is e highest grade of school that you completed and when? 

Have you gone to trade or vocational school or had any type of special training? 

If ’Yes,’ show. 

 The type of trade or vocational school or tr aining! 

 Approximate dates you attended: 

o Mow this schooling or training was used In any work you did! 

0 Yes R4o 

Emplo cc Full Name D P 

tt - \ OOO 

received on 113012030 12:49:55 PM [Eastern Standard Timefr 2’ Floor, Suite? East Greenbush, NY 120611 556-829-8861 I Fax; 515-550-5610 

Confidential 

Admir Rec. 00477 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 50 of 55 PageID: 919
FROM AZ VIDEO FflX NO. 7322794297 Jan. 30 2009 02:35FM P4 

&RnndG1p 

PART IV INFORM kTION ABOUT THE WORK YOU DID 

1. List all jobs you have had i IS years before you stopped working. beginning with your currentjob. Normally, this will be the kind of work you 

did the Longest (If you havgrade education or less, AND did only heavy unskilled labor icr 35 years or more, List all of the jobs you have had 

since you began to work. eparate sheet as necessary and attach it to this form.) 

Jpb Title Type of f. Date Worked Days per Week Sate of Pay 

(6 aura to begin with your ’current" 8u*Lnest 

HFrom 

and Year) 

I - 

2. Provide the following information for your usual job shown in Item 1, line t 

In your job, did you: 

 use machines, tools, or equipment of any kind? ’Yes U No 

 use technical knowledge or skills? f"Yes U 110 

 do any writing, complete reports, or perform similar duties? B’cee U No 

 have supervisory responsibilities? U Yes IBNo 

Describe your daily ;otMtles in thefollowtog areas, and state what and how much you do of each and how often you 

o llOtISeflQtc mainLBrmFice i ’’V"’’ ..,-.. .. -.. .. 

ao 

t 

o Recreational actIvities and hobbies (hunting, fishing, bowling, hiking, musical instruments, etc.): 

i.:.. -:. 

o Social contacts (visits with friends, relatives, neighbors): 

- Fr. J ra vtih- A* 

o Other (drive oar, motorcycle, ride bus, etc.): 

y-.tc - tW 

I hereby authorize all physicians and health care professionals, hospitals and other heelthcare institutions, insurers, employers, and group policy 

holders: You are authorized to provide Reed Group, 15 Tech Valley Drive East Greenbush, NY 12061, acting on my employer’s behalf, with information 

conciaming my health ogre, history, examination, treatment (including but not limited to copies of my medical record), edvios, and supplies provided to 

me, and any employment-related information regarding my primary and/or secondary diagnoses as they relate to my disability benefits. This 

Information will be used to evaluate and administer my application for disability benefits and may be reviewed by authorized medical and/or human 

rezouross professionals affiliated with my employer. I understand that this authorization Is valid until I submit written revocation to my employer or Reed 

Group. I hereby release any person or entity providing information from any and all liability for furnishing such information. I agree that a photographic 

or facsimile copy of this authorization is as valid as the original. 

Data 

WVV1D # 

Oi I 1K tM, \1.tis, flrk ,e 2 Floor, Suite 1 East Greenbush, NY 12061 866-829-8561 Fac 516-880-6610 

received on 1/30/2009 12:49:55 PM [Eastern Standard Tim e] Confidential 

Admin Rec. 00478 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 51 of 55 PageID: 920
FROM : P-Z VIDEO FRX NO. 7322704297 Jan. 30 2009 Ei2:35FN1 PB 

If _ 

Direct Deposit Enrollment Form 

to enroll or stop in Full Service DirGct Deposit, simply fill out this form and mail or Mx it to Reed Group at 518-880-f 

6510. Also, when enrolling, pje alsoattach a voided cçlç - not a deposit slip. If depositing to a savings 

account, ask your bank to give you the RoutinglTransit Number for your account. It isn’t always the same as the 

number on a savings deposit slip. This will help ensure that you are paid correctly. 

Below is a sample check MICR line, detailing where the information necessary to complete this form can be found. 

Rotrtingltransit# 

IA 9-4i5it number aIwsys Checking Account t (this number mtchea the number in 

between thee two _____________________ 

the upper right corner of the thecknot needed for sign.up} 

IniportRntl Please read and sign before completing and submitting. 

I hereby at thorize-RG1to-deposit-anyamoufltS-cWedmerbYlfMtlattnc-credlt er rtdes-to.m- account -at.the_financial--- 

insbtution (hereinafter "BanIC) indicated on this form. Further, I authorize Bank to accept and to credit and credit 

entries indicated by RGL to my account. In the event that RGL deposits funds erroneously into my account, I 

frnn,n,in+ nn+ +n Pmn(mf ot the krrcneOus cret 

This authorization is to remain in full force and effect until RGL and Bank have received written notice from me 

of its termination in such time and such manner as to afford RGL and Bank reasonable opportunity to act on 

Name: 2AiØoJtA4 Or.-. b en4tnc- ’T r , Social Security . 

Signature: D I/2t105 

i. Election (Must Select One): *tart Direct Deposit o Stop Direct Deposit o Change Account 

2. Account Information 

1, Bank Name/City/State: 

2. Account #: \ CC Doc ).c o 

1 Type of Account hecking o Savings m Other 

4. Routing/ Transit #: Oc\ ’ZtCS 

Please Mail to the Address Listed Below or Fax to 518-880-66I0 

Pp-an rzm,ni Is tap-i, \/IIov ndua I 2cc Floor, Suite 3 1 East Greenbush, NY 12051 865-$22-8861 I Wac 518-480-6610 

received on 1!3012009 12:49:55 PM [Eastern Standard Time} 

Confidential 

Admin Rec. 00479 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 52 of 55 PageID: 921
e1/28/2sas 14:24 7325711937 ETROUSE/LopQ PAGE 91 

ReedGrçi 

Release to Work Form 

intalctio 11 s: Prior to returr ing to work from a Short Term Disability (STD) Leave with temporary restrictions, 

you MUST fax this form to seed Group at 518-880-6810 for approval. 

If you have any r,iiestions, oaasa call 86-829-6881  

me: (Plea e 

00 

I certify that this employ e is medically fit to return to work on (date): 

The employees mediae condion wifl (Please complete Part [11) OR C wJLLn (skip to Part continue 

to Impact his/her ability .o perth all f the regular functions of his/her pos1tlon. 

If temporary accommoc ation(s) are necessary, the projected full duty release is (date): 

Identify appropriate woi k level for ACTIViTY 

WrD tiling Most of the 

r periods welk/stan Urt up to 10 Ibis. sit 

occasionally 

walE roJstandlr: some cctir : Ift - up to 20 send 

lbs. ocoasionolly 

Twist 

C] MEQjQM.wQR.-Lift .t to 50 lbs. 

occasionally; 20 lbs, frequen y 10 lbs. Squat 

ooMthrty 

Climb 

0 H&CLWOP- Un u; to 100 lot. 

acoasisnally; Sobs, frequer :ly; 20 lbS. Grasp 

constantly 

Push/Pull 

0 WORK - .11tlng in etess 

of 100 lEa. oceaslonaty; 50 , fraquently; 20 Reach 

Its. Constantly 

NONE I OCCASIONALLY I FREQUENTLY F CONTINUOUSLY 

0 , 

I. 

U 

a 

This employee may re turn to work with the following temporary restrictions: 

RESTRICTION DATE RESTRICTION BEGINS DATE RESTRICTION ENDS 

rfl 

RTWForm  Pagel of 2 

Reed Group 115 Tech alley Drive 2d Floor Suits S F East Greenbush, New York 1 2051 I 556-929-5361 I Fsc: 515-550-6510 

received on 1/2212009 2:22:33 PM [Eastern Standard Time] 

Confidential 

Admin Rec. 00480 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 53 of 55 PageID: 922
01/28/2009 14:24 7325711937 STROUSE/LOPAND FACE 02 

Individuals who operate a c Dmicany vehicle (Sales Representative, fortlift operators, etc.) are considered to be In a 

Safety Sensitive position, the above named indMdual is required to operate a company vehicle as part of their 

responsibilities, please con plate this section. 

Please check one 

_____ The above t amed indMdul’s medical condition/status does not Interfere with hlsTher ability to operate a 

company vehicle. 

The above amed indMduol’s medic nCdon/status does not interfei2 with, hisTher sinill g - 

operate a company v hiole with the accommigidationsf restriction, deccribàd below 

The above named indiulduaPs medical condition/status does interfere with his/her ability to drive and cannot 

operate a company ehiole at this time. , 

AccommodationViRi sklictiofls including duration: 

-. 

-a a 

Use of the Fitness Center Johnson & Johnson sponsors a health prcmctionproclram for employees. One 

- component of-this pregra.t.ls . an-exeroi program that n drpc L tencth arid/or flexibility training. 

1. This employee may participate in aerobic, strength and flexibility training without restiictions: 

E] YES then please complete next statement 

2. This employee may p rtidpate(in aerobic, strength and xlbility training with the following restrtdion: 

 MM 

Attending Ph ysi - a ne: s*Pd) Attending Physician’s Phone 

_______ Numbe r. 

Attending Phy clan’s c t : Date: d 

o _ 

C)\ V\4f 

(_ ’J r.- ( 

F leasefax to 518-880 7661 0 when cornIte 

R7N Fern - Page 2 of 

Reed Group 115 Tech ’v iIey Drive 1 2M Floor, Suite 3 I East Greenbush, New York 1208’, 1 S9S-829-BSSI j Fax: 913-5$g-8610 

received on 1!2812909 2:22:33 PM jEastern Standard Tine] 

Confidential 

Admin Rec. 00481 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 54 of 55 PageID: 923
21/28/2223 14:24 725711937 STROUSE/LOFANO PAGE 23 

ItaLHSVSn tang 

L!LOJJ 

HISTORY: Patie a is much improved as far as the Achilles tendon is concerned. The 

lump is markedly ri duced in size. He seems to have less tenderness and better strength. 

He can wean himse lout of the walking boot. As far as his back is concerned, he has seen 

the pain manageme it specialist and has had one epidural block. Another is scheduled for 

two weeks. There 11 no change in his neurologic sta–us He does appear to be able to work 

limited duty for apl toximately four hours per day. 

RETURN: I moi lb 

m&ph 

received an 1/2812009 2:22:33 PM IEastem Standard Time] 

Confidential 

Adrnin Rec. 00482 

Case 3:10-cv-06344-PGS-DEA Document 14-14 Filed 05/13/11 Page 55 of 55 PageID: 924