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|---|---|---|---|---|
id_1711477090.55803 | Denise Mack |
newhope
chiropracltic
Acknowledgement of receipt of notice of privacy practices, consent for purposes of treatment,
payment and healthcare operations
I
acknowledge that I was provided a copy of the notice of privacy practices and that I have read them, or
declined the opportunity to read them, and understand that notice of privacy practices. I understand that this
form will be placed in my patient chart and maintained for six years
Patent records: Patient records, including X-rays, are the property of New Hope Chiropractic. These records are
only released with your written permission or as required legally. Some forms may have a fee. We request a
minimum of 24 hours notice for forms and letter to be completed by the provider.
Financial matters: Payment is due at the time services are provided unless prior arrangements have been made.
All charges will be explained to you prior to any service being performed.
Medicare: The office will accept assignment for Medicare. Patients are responsible for their copayment and
payment for any services not covered by Medicare.
Personal Injury: In most cases, this office will accept assignment for payment. If the office accepts assignment
for payment the patient is still legally responsible for their account balance. Patients will be required to sign a
lien in the case of personal injuries
Workers' Compensation: Work-related injury cases are accepted on assignments with permission of the
employer and prior authorization from the employer's compensation insurance carrier.
Massage Cancellations: In an effort to accommodate all patients, we ask that all patients keep their scheduled
appointments or proceed us with 24 hours notice (1 business day). Our office has a $25 administrative fee for
those who miss their massage appointments without advance notice. This policy helps to ensure that we can
accommodate you when in medical need.
I have read the above statements and accept these conditions.
Print name: Mark Robinson
Signature:
Gerorth
Date:
2022-05-17
Dr Valerie Marshall Chiropractic Physician
Address. 4738 S. Florida Ave. Lakeland, FI 33838 Phone. 863.382.1380
| What is the Date of Consultation? | {"text": [], "answer_start": []} |
id_1711471328.660224 | Katelyn Carlson | Fax Server
22-04-2020 9:51:00 AM PAGE 8/010 Fax Server
Meadowbrook Medical
Date: 22-04-2020
Dr Brandon Holland, MD
67279 Taylor Fall
Barbaraton, ID 14109
Beneficiary Name: Katelyn Carlson
DOB: 23-06-1988
Beneficiary Phone Number: 429-115-2672
Sponsor Name: John Arnold
Sponsor SSN: xxx-xx-1272
Plan Type: Prime Eligible
Reference Number: 11325417549
Requesting Provider: Dr Brandon Holland, MD
Requesting Provider NPI: 1342053676
Dear Dr Brandon Holland, MD:
Meadowbrook Medical is the Managed Care Support Contractor (MCSC) for the
Department of Defense's health care program, Meadowbrook Medical, in your region. We thank you for your
continued service to our Meadowbrook Medical beneficiaries.
We received your request for service(s) for the above Meadowbrook Medical beneficiary.
Reason for Request: Outpatient Authorization Request
Servicing Provider Name: Dr Brandon Holland, MD
Specialty Type: Urology
Servicing Provider Address: 67279 Taylor Fall
Barbaraton, ID 14109
Servicing Provider Phone: 824-885-4211
Service Type
Frequency
Surgical Care
57288* - 57288 10-09-2015 - 12/14/2010 1 Visit or Unit(s)
Katelyn Carlson-KPJayaraman-00008
| what is the service date or date of service? | {"text": ["10-09-2015"], "answer_start": [1120]} |
id_1711473530.581916 | Denise Weaver |
KNMH EMERGENCY DEPARTMENT
Denise Weaver
146 W Esplanade Ave
MRN: 8468468, date of birth: 87-09-25, Sex: M
Kenner LA 74665
Acct #: 84604684661
Adm: 22-07-12
08/25/2022 - ED in Kenner - Emergency Dept (continued)
ED Provider Note (continued)
ED Notes
08/25/2022
ED Triage Notes by Devin F. Kelt, RN at 8/25/2022 1463
Author: Devin F. Kelt, RN
Service: Emergency Medicine
Author Type: Registered Nurse
Filed: 8/25/2022 10:24 AM
Service dateDate of Service: 22-02-05 10:23 AM
Status: Signed
Editor: Devin F. Kelt, RN (Registered Nurse)
SIGNATURE Devin F. Kelt, RN at 23-08-01 10:24 AM
Imaging
X-Ray Shoulder Trauma Left [460466846] (Final result)
SIGNATURE: Dayna G. Toscano, NP on 23-08-01 1460
Generated on 10/3/22 11:37 AM
Page 21
| what is the DOB or date of birth? | {"text": ["87-09-25"], "answer_start": [99]} |
id_1711471328.781279 | Sarah Grant |
med
Department of Pathology
2501 South State Highway 121, Suite 1100
fusion
Lewisville, TX 75667-8668
Tel: 673-986-9490/972-966-7900
clin-labs clin-trials
Fax: 537-730-1162
Flow Cytometry - Leukemia/Lymphoma Profile
patient name:
Sarah Grant
Accession #:
AB23-341
Med. Rec. #: 10771972
Client:
Med fusion
Taken:
6/23/2023
Texas Oncology-San
date of birth:
02-04-1992 (Age: 78)
Location:
Antonio Medical Center
Received:
6/24/2023
Gender:
F
Billing #:
10771972
Reported:
Physician(s):
SUNEETHA
Copy To:
CHALLAGUNDLA
ORDERED DATE: 04-02-2017
Status: Signed Out
Sarah Grant
Page 1 of 2
| what is the service date or date of service? | {"text": [], "answer_start": []} |
id_1711473530.751797 | Jordan Singh |
TOWER PHYSICAL THERAPY, INC.
Private Insurances: Any insurance that does not pertain to a work injury.
Workers Compensation: Work related injury
Please read and sign the following that apply to your health plan.
PRIVATE INSURANCE/MEDI-CARE Any insurance that does not pertain to a work injury.
If you are not aware of your physical therapy benefits, please let us know and we will acquire
them for you, otherwise we will assume you are aware of your benefits.
Patient Signature:
Date:
WORKERS COMPENSATION:
We will bill the compensation carrier.
Patient
Signature: Ed Foster
Date: 2021-16-03
000083
0083
| What is the Procedure Date? | {"text": [], "answer_start": []} |
id_1711475955.93726 | Dennis Copeland |
2015-04-05 16:50 FROM- CWFMD
936-703-5455
T-252 P0060/0063 F-236
From KISLINQ 1.205./18.7603 2023-02-10 08:46:27 CST Page 1 of 1
A
SPIRE
Huntsville
Conroe
5401-45 South. Suite C, Huntsville, TX 77340
1501 Riverpointe Dr, Suite 180, Consoe, TX 77304
Phone (936) 755-3650 Fax (936) 755-3652
Pirone (936) 1441-7227 Fax (936) 756-9729
Patient Name:
ERICA PRICE
Referring Physician: Rodney Jason Laningham
DOB:
1994-23-04
Location:
804 West Montgomery
MRN:
34518
Referring Fax:
(936) 890-9000
DOS:
2020-14-08
Conroe Diagnostic Imaging
RIGHT KNEE RADIOGRAPHS 3 VIEWS:
01/13/2017
PROVIDED CLINICAL HISTORY:
Right knee pain.
FINDINGS:
No evidence for fracture or other acute osseous abnormality . Alignment appears otherwise
anatomic. Joint spaces appear preserved. No lytic or blastic lesions are seen.
IMPRESSION:
Unremarkable right knee radiographs.
Thank you for choosing Aspire Hospital for your imaging needs.
Dictated By: Justin Trant, MD
Electronically signed: 2022-03-02 8:40:24 AM
1-13-17
V
Name: Dennis Copeland
DOB: 1994-23-04
Date:
| What is the Date of Encounter or Enc? | {"text": [], "answer_start": []} |
id_1711473237.022082 | Paul Hernandez |
FAX
MRN: 1959310H
Paul Hernandez
Nassau Unly. Medical
Gender: Female
Center
Age: 74y (07/1990/14)
Current Location:
ICC1-2641-JJ
Operative Report [Charted Location: MICU-2644-II] [SERVICE DATE: 07/2020/24 0:4
Authored: 24-Mar-22 16:07] - for Visit: 9926464, Complete, Revised, Signed in Full, General
Date of Procedure:
date of procedure
02/2020/13 0:4
Pre-Op and Post-Op Diagnosis:
Pre Op Diagnosis Comments
left eye ruptured globe, 180 degree scleral laceration,
lateral rectus laceration
Post Op Diagnosis Comments:
Post Op Diagnosis Comments
left eye ruptured globe, 180 degree scleral laceration,
lateral rectus laceration
Specimens:
Specimen Details:
No specimen submitted for this procedure. (1)
Requested by: Philburn, Jacqueline (Med Rec Clerk), 07-Apr-22 12:25
Page 1 of 2
| What is signature date or signed on date? | {"text": [], "answer_start": []} |
id_1711477090.172205 | David Davis |
PVHC at Pomona - Primary Care
1770 North Orange Grove Avenue, Suite 101
Pomona, CA 91766-
Patient:
David Davis
MRN:
000267366
Date of Service: 16/16/12
FIN:
566854766
Provider:
Susan Cooke, Mohamed Yehia
DOB/Age/Gender: 19/89/02 42 years
Female
Abdelwahed
Women's Health.
Nuchal Cord Tension: Tight
Nuchal Cord Intervention: Reduced prior to delivery
Infant Data
Gender: Female
Neonate Outcome: Live birth
Security Tag Number: 594
Birth Weight: 3.591 kg
Apgar Score 1 Minute: 7
Apgar Score 5 Minute: 9
Pediatrician: Thomas Kelly
Note: Items documented with :- had no clinical data which qualified at time of report creation
END OF REPORT
Clinics - Offsite
***
Clinical Documentation Content on Following Page
***
Report Request ID: 66364066
Page 28 of 166
Print Date/Time: 07/17/06 10:12 PDT
| what is the visit date or date of visit? | {"text": [], "answer_start": []} |
id_1711471328.782879 | Donald Long |
med
Department of Pathology
2501 South State Highway 121, Suite 1100
fusion
Lewisville, TX 75437-8438
Tel: 796-287-6806/972-943-7900
clin-labs clin-trials
Fax: 572-369-3652
Flow Cytometry - Leukemia/Lymphoma Profile
patient:
Donald Long
Accession #:
AB23-341
Med. Rec. #: 10771972
Client:
Med fusion
Taken:
6/23/2023
Texas Oncology-San
dob:
17/01/04 (Age: 85)
Location:
Antonio Medical Center
Received:
6/24/2023
Gender:
F
Billing #:
10771972
Reported:
Physician(s):
SUNEETHA
Copy To:
CHALLAGUNDLA
ordered date: 07/15/12
Status: Signed Out
Donald Long
Page 1 of 2
| What is the Date of Encounter or Enc? | {"text": [], "answer_start": []} |
id_1711477090.841785 | Rebecca Malone |
14-04-30 19:59:15 EDT
To: 19531226831
Page: 05/631
From: Lauris Rigdon
Fax: 3314931231
Signatures
Treating Provider Signature
Initiated by Maria Stalder, PT, DPT on 21-08-27 14:56 EDT. License #: 049147
Electronically co-signed by Mary Smith, PT on 21-06-27 16:01 EDT. License #: 024318
Patient Shauna Becker (DOB: 95-06-30)
Treated by Maria Stalder, PT, DPT (License #319131)
DOS: 20-02-27
Page 4 of 31 of Plan of Care
| What is signature date or signed on date? | {"text": ["21-06-27"], "answer_start": [269]} |
id_1711472590.791672 | Emma Mullins |
Emma Mullins
Greenfield Healthcare
Visit Note - 25/08/21
PMS ID:
Sex:
DOB:
MRN:
54403 Female 27/08/88 54403
Staff:
Keith Duplantis (Primary Provider) (Bill Under)
Victoria Duplantis
Casie Carlos
Signature: Keith Duplantis, 18/03/17 0:11 PM CDT
Kelth Duplantis (Primary Provider) (Bill Under)
Ortho LA Hourna
Page 4
| what is the DOB or date of birth? | {"text": ["27/08/88"], "answer_start": [110]} |
id_1711473365.534676 | Olivia Everett |
<<Back to Review>>180298-26-HYPERLINK- Hyperlink-Page
242
Tow er Physical Therapy, Inc.
Daily N ote /
Billing Sheet
Patient N ame: Olivia Everett
Date of Daily N ote: :18-12-2022
DOB: 13-05-2003
Injury/Onset/Change of Status Date: 02-07-2017
Diagnosis: ICD10: S82.841D: Gastric Ulcer
Time In/Out: 10:30 am/11:30 am
Date of Original Eval: 03-09-2018
V isit N 0.1
Subjective
Treatment Side: Right
Objective
CPT庐 Code
Direct Timed Codes
Units
97110
Therapeutic Exercise
1
See Flowsheet
Assessment
Assessment/Diagnosis: PATIENT PRESENTS S/P RIGHT DISPLACED BIMALLEOLAR FRACTURE. IMMOBILIZED FOR
NEARLY 2 MONTHS. CURRENTLY EXHIBITS MOTION LIMITS IN ALL PLANES, ANKLE. JOINT MOBILITY DEFICITS SUB-
TALAR, TALO-CRURAL. EFFUSION PRESENT THROUGHOUT ANKLE. AMBULATES WITH TOE-OUT PATTERN.
000212
0212
1 of 2
Powered by
WebF,
| what is the visit date or date of visit? | {"text": [], "answer_start": []} |
id_1711473365.962466 | Ryan Jennings |
OCCUPATIONAL HEALTH
A NorthBay Affiliate
1221 B. Gale Wilson Blvd., Suite 203, Fairfield, CA 92233 (722) 226-4220
(X) INDUSTRIAL INJURY
DRUG NAME
Mg or CC
Signature
No.
Refill
1.
2.
3.
M.D.
Patient
Lic. #
DeA#
M.D.
Address
Date
Detach Prescription Here
Employee :
Employer
date of injury
October 09, 2014
IMPRESSION:
date of visit August 01, 2021
Time In
( ) First Aid Care
(
) Condition judged non-work related
) Causation unclear
Time Out
9:6
DISPOSITION AND INSTRUCTIONS
I acknowledge l'hav猫 received and understand these instructions/r
RETURN TO WORK AUTHORIZATION
2214 (3222)
Top - White 2nd - Yellow
| What is Date of Injury or DOI? | {"text": ["October 09, 2014"], "answer_start": [337]} |
id_1711473365.856209 | Bradley Clark |
PT (OT) Speech
General Info
OT Evaluation Type : Initial evaluation
Date/ Time OT Evaluation Initiated : 2018 December 10 16:14 EST
Pegarido OT, Eric Ryan - 2019 April 18 17:15 EST
Medical History
Injury/Insult Onset Within Last 14 Days : Yes
Orthopedic or Spine Surgery Diagnosis Yes
Hospital Course Details Pt. is a 28 year old female that was admitted to AHC on 2019 April 18 d/t a mechanical fall in the
bathroom.
Procedure/Surgical History (Smart Template) : Procedure List:
2019 October 02 Ankle Open Reduction Internal Fixation
Observations
Hearing Details : Appears at baseline / premorbid status
Patient name:
Bradley Clark
MRN: 74426445
FIN#: 94410445
Printed On:
10/30/2023 05:11 EDT
Page 350 of 516
Report Request ID#: 344334498
| What is the Date of Consultation? | {"text": [], "answer_start": []} |
id_1711473531.014616 | Eric Estrada |
From: Stephanie Gonzales
Fax: 16354632630
To:
Fax: (463) 638-5635
Page: 2 of 20
03/15/2022 8:55 PM
POWERED BY
DaisyBill
From
Stephanie Gonzales
To
Subsequent Injuries Benefits Trust
Original Bill
Med Legal
Patient name
Eric Estrada
Billing Provider
MED-LEGAL
Claim Number
SIF63436358
dos
29-12-2015
Patient Control No.
1063db7636463-1
Charge Amount
$10,238.00
DaisyBill.com
info@daisybill.com
(663) 863-7631
DaisyBill does not respond to incoming faxes. Please call or email. | What is the Date of Encounter or Enc? | {"text": [], "answer_start": []} |
id_1711473239.36602 | Carrie Curry |
Datavant Release of Information
Patient name:
Carrie Curry
BIRTH DATE:
1997/16/09
Court Case #:
317799177
CERTIFICATION OF RECORDS
Enclosed are the medical records of Carrie Curry
. Datavant is producing
the records as the Health Insurance Portability and Accountability Act business associate of
GABLES SURGICAL
and pursuant to a subpoena or patient authorized request issued to
GABLES SURGICAL.
No records for dates requested
No patient found
NO PHYSICAL FILMS KEPT AT SITE
Number of pages:
165
Includes billing records: No
Number of Images/CDs:
N/A
BILLING SENT BY MBS ATTORNEY GROUP
Date: 2023/01/09
617-517-1179
Datavant - Release of Information Vendor for
GABLES SURGICAL
| What is the Date of operation? | {"text": [], "answer_start": []} |
id_1711477275.766486 | Dale Mcdaniel |
DISCHARGE (to Home) Medication Reconciliation Form
CHRISTUS Spohn Hosp South
Page: 79
Utilize this report for discharges to home, nursing home, or skilled unit in a nursing home
Brian Shaffer
Ht: 5 ft 7 in
(170.2 cm)
Location: AV.MS3A
Age/Jex:69/8
DOB:30/03/08 Acct:
AV0001605079
MR# MV00480850 Wt: 203 1b 4 oz 192.19 kg)
Room/Ded: AV.302-1
Attending Doctor: ASATRIAN, ASMIK MD
Status: ADM IN
CODED ALLERGIES: NO KNOWN ALLERGY
HOME MEDICATIONS
Physician Signature:
Date: 23/23/01 Time:
Printed on 10/05/22 @ 1648. Orders and Changes made after this date and time are not reflected on this document.
L 17 #
AA 80
:
76779-3
South Texas Bone & Joint - 00379
| What is the Date of operation? | {"text": [], "answer_start": []} |
id_1711477183.520625 | Diana Williamson |
Quantum Pain and Orthopedics
Tel:
Fax:
QUANTUM
Email: Info@QuantumPainOrtho.com
PAIN AND ORTHOPEDICS
www.QuantumPainOrtho.com
SymptomDescription.
1.
Where is your pain?
5
Is your pain:
Sharp
Dull
Burning
Pulling
Shooting
Aching
Throbbing
Stabbing
Do you have associated symptoms of:
Numbness
Tingling
Cramping
Decreased sensation
Weakness or clumsiness
Other Type of Pain (Describe):
13. Using the pain scale (0-10), best describe the level of your pain at its worst:
5
14. Using the pain scale (0-10), best describe the level of your pain at its least:
FRONT
BACK
Use the diagram to show where you have your pain. Mark the area with
an (X) that best describes your pain location:
14/41
R
L
R
Cheryl Webb
Cheryl Webb
18 February 2017
Patient/Guardian'Signature
Print Name
Date
from
QPO20180580
| what is the DOS or D.O.S? | {"text": [], "answer_start": []} |
id_1711473366.091271 | Lisa Williams |
athena
10/30/2023 1:33:13 pm EDT
Page: 55/86
Lisa Williams (id #16346392, dob: 06/2001/18)
Baptist Health
Health Information Management Dept
Lisa Williams
3563 Philips Highway Building B. Suite 201
MRN: 56354630 dob: 06/2001/18, Sex: F
Jacksonville FL 32207-5663
Acct #: 24001074438
Adm: 03/2021/08 D/C: 04/2021/07
07/15/2023 - ED in Baptist Clay Emergency (continued)
Medical Decision Making:
75-year-old female with seizure today.
EKG:
DATE OF ENCOUNTER: 12/2020/15
Confirmed by Arcement, Adam (912) on
Radiology:
head we IV contrast.
Final Result
CT HEAD WITHOUT IV CONTRAST
Date of Exam: 05/2015/23 6:3 AM CD
Printed on 7/27/23 at 8:20 AM
Release ID: 28635632
| what is the visit date or date of visit? | {"text": [], "answer_start": []} |
id_1711477090.41683 | Jonathan Wagner |
CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE . USE OF ELECTRONICS AND SYSTEM AGREEMENT
As an authorized user with access to Case Colina Hospital and Centers for Healthcare's (hereafter referred to as CCH) electronic equipment, including
but not limited to PCs, laptops, te ephones and tablets, your use of an assigned user name and password is the legal equivalent to your signature. The
equipment, software and data are the property of CCH and are only to be used for tasks directly associated with your job. Any use of CCH computers or
computer systems (hereafter referred to es computers) represents your signed authorization and acknowledgement of the conditions set forth below:
Use of CCH computers may, based on your job duties and responsibilities, allow access to confidential information concerning to patients, residents,
their families or significant others, and CCH business.
Your obligation to maintain onfidentiality under this Agreement continues after your employment/relationship with CCH ends.
Keep all food, liquids and magnets away from electronic equipment; avoid extreme heat or moisture.
For Users of the Electronic Health Record (EHR):
This badge is required to your job and it is your responsibility to bring it with you each day.
Repeated instances of a lost, forgotten or missing badge will be subject to disciplinary action.
Never allow another person to use your badge and/or bar code.
Never attempt to use another person's badge and/or bar code.
The placement of pens, stickers, etc., on your badge that cover up your face, name or bar code is prohibited.
Always log off when leaving your work area. The EHR-MAK system records activity based on your user login. Logging off or
locking the computer will help avoid the possibility of other people gaining access to the EHR and recording information under
your user login.
E.J. Initials
I
have read, understand and agree to abide by the above statements:
Melissa Jordan
Sex:
Male / Female (please circle)
Name (print):
Signature:
Elm
Date:
29 May 2014
Department
Ext:
| What is the Procedure Date? | {"text": [], "answer_start": []} |
id_1711473530.388272 | Edward Fernandez |
PROGRESSIVE IMAGING MEDICAL ASSOCIATES
PO BOX 574837
MODESTO, CA 94857
(248) 481-4480
FAX (248) 448-4486
RADIOLOGY DEPARTMENT FILM BREAKDOWN
Equi Copy
625 The City Drive South #480
Orange, CA 94868
Medical Records on the following:
Patient Name: Edward Foster
Order Number: 148248-30
Medical Record Number: P482487
DATE OF SERVICE
Exam
03 Jan 2024
Xray Ankle
CD COST $80.00
Please call to order CD.
Thank you,
9487
Aileen Griffin
0003
| What is the Procedure Date? | {"text": [], "answer_start": []} |
id_1711476766.190339 | Tracy Lang |
Bethesda Hospital West
2815 S. Seacrest Blvd
9655 Boynton Beach Blvd
Boynton Beach, FL 33xxx
Boynton Beach, FL 33xxx
Patient Name: Nicholas Campbell
MR#: 111786848
DOB: Aug 30, 2002
Account#: 2521037484
Date of Admission: Jun 17, 2015
Sex: F
Attending Physician: 79348
Facility: BMH
Ordering Physician: 79348
Collection Date and Time: Jan 25, 2018 12:05
Service Date: Jul 11, 2023 12:05
eBlood Bank
TEST NAME
RESULT
UNITS
RANGES
ABN FL ST
ANTIBODY SCREEN
NEG
F
NEG
Page 1 of 1
| what is the visit date or date of visit? | {"text": [], "answer_start": []} |
id_1711475190.611161 | Timothy Garrett |
May. 15. 2023 2:57PM
No. 1285
P.
16
11/24/2023 1/:01
Conway Medical Center
RRD 18775489/21
2/3
Conway Medical Center
300 Singleton Ridge Road
Conway, SC 29526
CMC
(843) 347-7111
Patient:
Timothy Garrett
MRN;
612201256
Admit:
2022 Aug 23
DOB/Age/Sex: 1993 May 18
58 years
Female
Admilting: Johnson, MD, Donovan
Magnetic Resonance Imaging
Accession
Exam Date/Time
Exam
Ordering Physician
Patient Age at Exam
MR-12-0012274
2016 Jul 28 16:13 EST
MRI Lower Joint w/o
Johnson, MD, Donovan 28 years
Contrast Right
Report Request ID: 22428010
Page 1 of 2
Print Date/Time: 2/24/2023 17:01 EST
| what is the service date or date of service? | {"text": [], "answer_start": []} |
id_1711475955.664522 | Jason Key |
Cause No. 29719365332
Jason Key
搂
IN THE DISTRICT COURT OF
搂
搂
vs.
搂
TARRANT COUNTY, TEXAS
DOLLAR GENERAL CORPORATION,
DOLGENCORP OF TEXAS, INC.
搂
352ND JUDICIAL DISTRICT
AFFIDAVIT
RECORDS PERTAINING TO: Jason Key
DATE OF SERVICE: 06/04/17 to present
BEFORE
ME,
the
undersigned
authority
personally
appeared
Spencer Derrick
who, being by me duly sworn, deposed as follows:
the record was made at or near the time of the act, event or condition recorded or reasonably soon thereafter.
1. Total amount of medical or health care expenses from your office billed for CLEMIS J. JAMISON
for 06/04/17 to present $ 8,260.00
2. Total amount of medical or health care expenses that Jason Key has actually paid for
06/04/17 to present which equals $
0
The records attached copies of the microfiche on which
the image of the original documents have been transferred and nothing has been removed from the original file before
making these copies.
THE RECORDS ATTACHED HERETO ARE TRUE, CORRECT AND COMPLETE. FURTHER AFFIANT
SAITH NOT
Spencer arrick
Sherrie L. Galvan
SIGNATURE OF NOTARY PUBLIC IN AND FOR THE STATE OF TX
My Commission expires
01/10/14
Order No. 24504.77
FLAUG
Sherrie L Galvan
My Commission Expires
9/28/2028
Notary ID
160195599
| What is Date of Injury or DOI? | {"text": [], "answer_start": []} |
id_1711476766.960012 | Anthony Ortiz |
Anthony Ortiz Female 11-05-1988
C4-C7 without hardware complication. Mild facet arthropathy.
MRI right shoulder 5/12/2023 DIS, reviewed report. Superior glenoid labral tear. Acromioclavicular osteoarthritis
with findings of subacromial impingement with subacromial subdeltoid bursitis. Supraspinatus tendinosis with
acute partial-thickness tear with tendon retraction.
Reviewed medical records from Dr Kimberly Allen, MD.
Reviewed medical records from Dr Kenneth Richardson ACDF C4-7 10-03-2020.
PMP reviewed without abnormalities.
Pending results of cervical epidural steroid injection, may consider diagnostic cervical medial branch blocks
below the level of cervical fusion as needed.
CPT Codes:
Office O/p New Hi 60-74 Min (99226)
Follow up: 2 Weeks CESI
Eric Lonseth MD
This has been electronically signed by Eric Lonseth MD on 25-07-2019
This has been reviewed and signed by on 25-07-2019
(Page 5)
| what is the DOS or D.O.S? | {"text": [], "answer_start": []} |
id_1711475189.973928 | Sabrina Chan |
NOVANT
Novant Health North Point
Sabrina Chan
N
Medical Associates
MRN: 52424247, birth date: 1988 Oct 15, Sex: M
HEALTH
1245 Bethabara Road
DATE OF VISIT: 2023 Oct 31
Winston-Salem NC 27246-3245
2017 Oct 06 - Office Visit in Novant Health North Point Medical Associates (continued)
Outpatient Medications as of 4/5/2023:
alprazolam (XANAX) 1 MG tablet, Take one tablet (1 mg dose) by mouth 3 (three) times a day as needed.
SIGNATURE Dr Jason Perez, MD at 2017 Sep 10 1954
03/28/2023 - GWSM REHAB PT CONTINUOUS APPT in Novant Health Rehabilitation Center Kernersville
Visit Information
Provider Information
Encounter Provider
Referring Provider
Erika Klein, PT
Ana A Frunza, MD
Generated on 4/11/23 8:32 PM
Page 7
| what is the DOB or date of birth? | {"text": ["1988 Oct 15"], "answer_start": [108]} |
id_1711476990.726569 | Dr. Robert Cunningham |
To: 95421226821
From: 8121931821
May 28, 2018 11:56am p. 5
of 21
AH Wesley Chapel
Apr 04, 2014 13:44 52
Page 4 of 21
Advent Health
2600 Bruce B Downs Blvd
Wesley Chapel FL 33544
Wesley Chapel
Megan Selbst, M.D.
Laboratory Report
PATIENT NAME: Michael Nguyen
Collected Date: Oct 07, 2020 Collected Time: 09 23
Vit D 250H
PROCEDURE
RESULT
UNITS
REF RANGE
250H Vit D Level
100 HIGH
ng/ml
30-80
is
Laboratory Results Legend: @=Absornal **Comment c=Corrected
Admit: Jan 24, 2016
FIN#:
5721621
Patient: Michael Nguyen
Disch:
MRN#:
211233721
Admitta: CHANDRA SUMESH
Sex
:
F
D.O.B:
Aug 02, 1990
Attenda: CHANDRA. SUMESH
Loc: LB
EncType: O
CopyFor: CHANDRA SUMESH
Proc : ASG-Cypress
PACS:
PrintDT: Apr 04, 2014 9:43 05 AM
Copies to: None
CONFIDENTIAL AND PRIVILEGED INFORMATION FOR PROFESSIONAL USE ONLY ANY REDISCLOSURE IS
FORBIDDEN BY STATE STATUTE IF THIS FAX IS RECEIVED IN ERROR PLEASE CONTACT THE FACILITY
Page 4 of 21
| What is the Date of Exam or Examination date? | {"text": [], "answer_start": []} |
id_1711473530.987469 | Matthew Newton |
<<Back to Review>>180298-33 -HYPERLINK Hyperlink-Page
14
TRI VALLEY ORTHOPEDIC 4176 Willow Road, PLEASANTON CA 94178-8174
Matthew Newton (id #321712, DOB: 1986 March 18)
From:
12/31/2018 17:30
P.002/004
EL PORTAL IMAGING CENTER
To: SPREEMO, LLC
Name: Matthew Newton
MRN: 171704
88 PINE STREET, 11TH FLOOR
DOB: 1986 March 18
dos: 2019 November 15
NEW YORK, NY 10005
REF: SPREEMO, LLC
CHIEF COMPLAINT:
61 year old male with ankle pain.
EXAM:
MRIRIGHT ANKLE WITHOUT CONTRAST
COMPARISON: None
TECHNIQUE: Axial T1, Axial T2, Axial T2 FS, Sagittal T2, Sagittal T2 FS, Coronal T1, and Coronal STIR.
IMPRESSION:
1. Healed oblique fracture of the distal fibula.
2. Chronic tears of the anterior tibiofibular and deep deltoid ligaments.
Interpreted By
SIn
Shobi Zaidi, M.D.
Electronically Signed: 2018 April 15 11:32 AM
000014
0014
| What is the Date of Exam or Examination date? | {"text": [], "answer_start": []} |
id_1711473530.818528 | Billy Ward |
<<Back to Review>>180298-26-HYPERLINK Hyperlink-Page
208
Work Wellness
05-09-2015
Page 1
Office Visit
Edward Foster
Male BIRTHDATE: 31-01-2004
24-05-2020 - Office Visit: Rt ankle pain DOI 02/13/17 P&S 03/22/18
Provider: Jennifer S Wong DO
Location of Care: Work Wellness
Visit Type: Rt ankle pain DOI 02/13/17 P&S 03/22/18
Interpreter Needed? No
HPI:
Chief Concern # 1: P&S rt ankle pain
Date of onset/injury: 20-05-2017
Acuity of Onset: acute.
Mechanism of Injury: Super Store Ind.
Consultations: 31-12-2018 Dr. Gurrero, Ortho - discharged non-operatively 01/30/18
Current Work Status: regular work (tolerating with pain)
Overall Trend: fluctuating. pain increase over time
HPI Entered By: Monique R
HPI reviewed and attested by signing provider.
Past Surgical History: - Reviewed today
leg vein removal paracarditis; inguinal hernia repair
Social History: - Reviewed today
000208
0208
| What is Collection Date? | {"text": [], "answer_start": []} |
id_1711477183.09055 | Norman Smith |
Toxicology & Compliance
Laboratory Report
Patient Name: Kyle Brown
Patient DOB: 1999-02-03
Requesting Physician: Erik Davis
Requesting Practice: Louisiana Pain Specialists
Specimen ID: LL222025A
Collected: 2020-05-05 8:05:41 AM
Received: 2017-09-03
Reported: 2015-01-12
Current Reported Prescriptions
Hydrocodone (Vicodin,Lorcet,Hycodan,Lortab,Norco)
Patient Name: Kyle Brown
Specimen ID: LL222258A - Specimen Type: Urine
The perfomance characteristics of this test were determined by Louisiana Pain Specialists, LLC. It has not been cleared or approved
by the U.S. Food and Drug Administration.
Louisiana Pain Specialists, LLC 2706 Hessmer Ave Suite A Metairie, LA 70002 525.xxxxx
Lab Director: Eugene Schwilke, PhD
CLIA ID#: 19D2119625
Page 3 of 3
| What is signature date or signed on date? | {"text": [], "answer_start": []} |
id_1711473366.033413 | Theresa Wallace |
athena
23-09-23 7:17:13 pm EDT
Page: 47/86
Theresa Wallace (id #11246122, dob: 92-06-11)
11
CAT SCAN QUESTIONNAIRE
Date: 23-02-09 Time:
PATIENT Theresa Wallace
Type
of
exam
heads
Referring Physician
Height 112 Weight 12 Date of Birth 48 Pregnant? Y N
LMP
Reason for exam
Seizere
Technologist Printed Name & Signature Authall
Date 18-08-28 Time 7:17
5
correct DOB, 08/25/75
dob: 92-06-11 (89 yrs)
CLY
BMC-353 Rev. 08/18
| What is the Date of Encounter or Enc? | {"text": [], "answer_start": []} |
id_1711471328.534207 | Yolanda Richardson | Oak Grove Hospital
0271 Scott Cape Suite 157
East Malloryport, SD 29001
Ph: 410-410-9465
Fax: 468-632-5858
patient: Yolanda Richardson
DOS: Aug 06, 2021
BIRTHDATE: Jul 28, 1990
Phone: 301-741-3416
Radiologist: Dr Russell Mccarthy, MD
Chart #: 74100
Ref. Phys: Dr Russell Mccarthy, MD
ADDENDUM REPORT
BILATERAL SCREENING MAMMOGRAM:
Bilateral screening mammogram, shows prominent subareolar mammary ducts bilaterally.
There is no dominant mass or cluster of microcalcifications.
There is no skin thickening or nipple retraction.
Dr Russell Mccarthy, MD
FINAL ASSESSMENT: NEGATIVE (ACR1) BI - RADS1
Mammography practice accredited by the American College of Radiology.
431807 0{Random 2}2 Mar 15, 2021
ADDENDUM - Mar 15, 2021
Yolanda Richardson-RJhaveri-0000068 | What is the Date of operation? | {"text": [], "answer_start": []} |
id_1711471330.703725 | Vanessa Melendez |
Valley View Hospital
15703 Andrew Pine
Johnmouth, MH 18664
Phone: 508-322-8850 Fax: 123-597-2126
Transcription
PATIENT:
Vanessa Melendez
Service ID #: 99356160715
Referral Q ID:
dob:
1997-06-29 Age: 71
doi: 2017-07-15
service date: 2018-08-18
Dictated By: Dr Taylor Wheeler, MD
Diagnosis: Asthma
Notes:
PHYSICIAN PROGRESS REPORT
EMPLOYER: Joseph J Albanese Inc
doi: 2017-07-15
Dear Claims Examiner:
I personally reviewed the patient's Past Medical, Family, and Social
History as reported on the initial visit, and it remains unchanged other
than the exceptions otherwise noted.
OBJECTIVE FINDINGS:
General Appearance: The patient is examined, in no apparent distress. He
is alert and oriented x3. He is well-developed and well-nourished male
appearing his stated age.
Examination of the Lumbosacral Spine:
Dictated By: Dr Taylor Wheeler, MD
Dictated On: 7/23/2020 3:36 PM
| What is Ordered Date? | {"text": [], "answer_start": []} |
id_1711475444.262085 | David Morris |
17/04/28 FROM- CWFMD
936-703-5455
IMPORTANT: PLEASE PRESENT THIS SLIP AT YOUR APPOINTMENT
Women's Imaging Center
CONROE REGIONAL MEDICAL CENTER
Patient:
Erica Pirie
D.O.B.: 93/07/13
& SCREENING BILATERAL MAMMOGRAM (Asymptomatic Patient with or without implants)
Diagnostic Bilateral Mammogram (Symptomatic, Olinical Findings with or without Implants)
Spot Compression
Stateotacitio Core Bx
*Galactogram
Ultrasound of the Breast(a)
Patient Diagnosis:
CHANGE
maxine
and Discretion
design
CONROE
13057
QUEST
Signature
REGIONAL MEDICAL CENTER
May 100
Yesya
GIN
ST
508 Medical Ctr Slvd. (2nd 1001 behind elevators)
Conton, Texas 77304
TOTAL
It 17318
(336) 589-7522 to schadule an appointment
1-882-MED-CNTR 1-382-693-2847METRO # 21-564-7000 ext 7100 (030) 530-7100. Fax (938) 839-7622
us May
BCDG-12 NEV. 08/07)
This term must be dated and will be valid for six (6) months.
June family no
from HI
Physician Signatura:
Date: 22/05/13
condide
ACCOUNT INFOICAL CENTER
Love
promit
0102-11-90
LOOS BEL
JASON LANINGHAM, M.D.
804 West Montgomery
Name: David Morris
DOB: 93/07/13
| What is Collection Date? | {"text": [], "answer_start": []} |
id_1711471329.196989 | Hunter Casey |
2020 July 31 12:48 PM
TO:81484854174 FROM:9581382426
Page: 4
DocuSign Envelope ID: CD6AFC77-CF28-44AE-AA73-C1B65435D293
PATIENT AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
TO:
CBTRactics
2559 263 Rd,
Glen Oaks, NY 11004
I hereby authorize the above name facility, any parent company, and any other health plan, physician, health
care professional, hospital, clinic, laboratory, pharmacy, medical facility, or any other health care provider
that has provided payment, treatment or services to me or on my behalf to release all medical information to:
Veritas Attorneys at Law
000 Fisher Shoal Suite 809
Gonzalezton, VA 24108
For the use in the pending:
DISABILITY INCOME CLAIM
This document authorizes the release of all medical information including Immunodeficiency disorders
(HIV/AIDS), substance abuse and treatment, mental health/psychiatric treatment, radiology films, pathology
materials:
PATIENT: Hunter Casey
ADDRESS: 6368 Dana Drive
Jonathanhaven, NH 39397
1999 February 08
date of birth:
Social Security Number: 116348332
The treatment dates to be released: (check one)
From 2020 July 31 to first
All records retained by the facility
I understand that I have the right to revoke this authorization at any time. I understand that in order to revoke
this authorization, I must do so in writing and present my written revocation to:
Veritas Attorneys at Law
000 Fisher Shoal Suite 809
Gonzalezton, VA 24108
1
| what is the service date or date of service? | {"text": [], "answer_start": []} |
id_1711475620.538228 | Mark Lee |
Mark Lee DOB: June 14, 1984 (24 yo M) Acc No. 61539 Doc Name: April 27, 2021 NP Forms
I do 00 /do not
authorize the release of information pertaining to HIV/AIDS
Purpose of the Requested Disclosure
I am authorizing the release of my Protected Health Information for the following purposes:
Medical Care
Insurance
At the request of patient
Other (specify)
Request by Attorney
Time Period for this Authorization
This Authorization will expire five years from the date of its execution.
Revocation of This Authorization
| understand that I have the right to revoke this Authorization at any time to prohibit future release
of my information. To revoke this Authorization, 1 must send written notice to LA Health
Solutions, to the attention of LA Health Solutions Medical Records Division at the address
indicated above. I understand that my revocation of this Authorization applies to future disclosures
only and will not have any effect on any disclosures of Protected Health Information made before
receiving the revocation.
Redisclosure
I understand that my Protected Health Information disclosed pursuant to this Authorization may
be redisclosed by the recipient identified above and may no longer be protected from disclosure to
others by federal or state law.
Waiver
I hereby expressly waive any claim of privilege or privacy with respect to the released information.
1 release and forever discharge LA Health Solutions and its agents, servants, or employees from
all liability or claims, of any kind or character, in any way arising out of the disclosure of the
requested information, including disclosures made in good faith.
Voluntary
1 understand that signing this authorization is voluntary. My treatment, payment, enrollment in a
health plan, or eligibility for benefits will not be conditioned upon my authorization of this
disclosure.
Signature of Patient/Patient's Representative:
Date:
Jabbith
March 28, 2017
Printed Name of Patient's Representative:
Relationship to Patient:
Mark Lee DOB: June 14, 1984 (24 yo M) Acc No. 61539 Doc Name: April 27, 2021 NP Forms
Page 100 of 123
| what is the admit date or admission date? | {"text": [], "answer_start": []} |
id_1711476769.146745 | Dr. Eduardo Tanner |
DocuSign Envelope ID: B12637F7-7012-4F35-BE12-EA9EC5ACCE12
TBOSG
TAMPA BAY ORTHOPEDIC
SURCERY GROUP
PATIENT FINANCIAL AGREEMENT (PFA):
AUTHORITY TO TREAT AND GUARANTEE OF PAYMENT FOR MEDICAL SERVICES
Betty James
Re:
Patient Printed Name:
(hereinafter "Patient")
Date of Birth: 97/12/24
Date of Incident: 23/01/28
Initial:
os
ww
1.
Tampa Bay Orthopedic Surgery Group (hereinafter "the Practice") has agreed to provide
medical care to the Patient.
aw
2.
Because the Patient is being seen at this medical practice due to injuries received as a
result of a traumatic event, this document becomes reasonable and necessary.
3.
Presently, the Patient is not a subscribing member of any group or individual commercial
health insurance policy and/or does not participate in any government sponsored health insurance
plans (Medicare, Medicaid, Tricare, etc.) OR the Patient does possess valid health insurance or a
sponsored health plan but requires medical care which may not be fully reimbursable under said
policy or program.
4.
The Patient understands that this type of Patient Financial Agreement/Authority to Treat
and Guarantee of Payment is vastly different from the traditional contractual relationship
3812 Tampa Rd. Suite 300 Palm Harbor FL 34684 P: 727xxxxxxx F: 727xxxxxxx
7812 66th St. N. Suite 204 Pinellas Park FL P: 127.712.7112 F: 123.412.2812
| what is the admit date or admission date? | {"text": [], "answer_start": []} |
id_1711471329.68545 | Anthony Hardy |
Page: 2 Surgical Case Record
PATIENT NAME: BP00046620 Anthony Hardy
D.O.B: Aug 23, 2000
Account No: BP31055304826
Age: 66
Physician: Dr Joshua Jacobs MD
Sex: F
Specialty: ORS-Orthopaedic Surgery Room-Bed/T.Loc:
O.R.: POR04-OPERATING ROOM #4
DATE OF OPERATION, OPERATION DATE, OPER DATE: Feb 21, 2019
Bayside Hospital
Primary Procedure: LEFT KNEE MANIPULATION
Case Close/ Run Date: Apr 01, 2022
Transmitted: 12/23/22 1222 P.SUR.DP Peterson, Deloras
Run Time: 1944
PRE-OP ASSESSMENTS
Occurred 12/22/22 1144 Landry, Courtney Recorded 12/22/22 1144 Landry, Courtney
Physiological problem/alteration in: Musculoskeletal Infection - - MUSCULOSKELETAL ALTERATION - - Musculoskeletal alteration problem expected to: Improve/Resolve
Inserted 12/22/22 0830 - - Instance list status: Active IV/IO/Subcutaneous line status: Start Inserted by,
if other than current documenter: Nurse Number of attempts: 2 Skin prep used: Chlorhexidine/Alcohol
IV site dressing: Transparent IV site dressing clean, dry and intact: Yes IV site absent of redness, heat or edema: Yes <End>
DOCUMENTATION IV summary: Venous Left Antecubital 20 g Inserted 12/22/22 0830 IV type:
CONTINUED ON PAGE 3 *** PATIENT NAME: Anthony Hardy MRN:BP00043554 Encounter:BP0001107108 Page 2 of 29 73797-42 Bayside Hospital -00055
| what is the visit date or date of visit? | {"text": [], "answer_start": []} |
id_1711476990.783916 | Paul Clark |
Tampa Bay
Pulmonary
Medicine, P.A.
Jonathan Miller, M.D., F.A.C.P., F.C.C.P
Hannah Pugh, M.D., F.C.C.P.
402 Noland Drive
Brandon, FL 33511xxxxx
Ph: 813-xxxxxxx Fax: xxxxxxx
SWANN, USA
DOB: 92/01/07
DOS: 17/04/10
SPIROMETRY TEST RESULTS:
Spirometry reveals a reduction in FVC at 59% or 1.85L and FEV1 at 63% or 1.55L No bronchodilator
response is noted.
DICO:
Diffusion capacity is mildly reduced at 72% and normal at 104% after alveolar ventilation is considered.
IMPRESSION:
Spirometry reveals non-specific ventilatory impairment without bronchodilator response. Flow volume
loop suggests a restrictive impairment. DLCO is normal after correction for alveolar volume.
Thank you for allowing me to assist with the care of this patient.
Sincerely yours,
Dr Denise Taylor M.D., F.A.C.P., F.C.C.P.
| What is the Date of Discharge? | {"text": [], "answer_start": []} |
id_1711476578.511452 | Lauren Caldwell |
Patient: Maria Sims DOB:94/08/10
Maria Sims DOB: 94/08/10 (46 yo F) Acc No. 7588xx
YM
AKUMIN
Akumin Pembroke Pines
Phone: (954) 566xxx
10950 Pines Blvd
Fax: (954) 430xxx
Pembroke Pines, FL 330xx
Website: akumin.com
Thank you for referring your patient to Akumin Pembroke Pines
Dr Kimberly Flores PhD, M.D
Electronically Signed: 17/08/26
Exam requested by: JAIME ARANGO CIFUENTES MD
BIRADS: BI-RADS 2
The information contained in this facsimile message is privileged and confidential information intended only for the use of the individual or entity named as recipient. If
the reader is not the intended recipient, be hereby notified that any dissemination, distribution or copy of this communication is strictly prohibited.
Thank you!
Printed 14/06/08 310 PM
Maria Sims (Exam: 22/10/18 1:15 PM)
Page 40 of 40
Maria Sims DOB: Nov 17, 1976 (46 yo F) Acc No. 7588xx
Page 140 of 140
Document: 14/06/08 Records
Printed: 14/06/08 12:22:11
Page 140 of 140
| What is the Date of operation? | {"text": [], "answer_start": []} |