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Agenda 12-12-12
BOYNTON BEACH POLICE OFFICERS' PENSION FUND SPECIAL BOARD MEETING Wednesday, December 12, 2012 @ 9:30 AM Renaissance Executive Suites - Conference Room #1 1500 Gateway Blvd., Suite #220 Boynton Beach, FL 33426 AGENDA I. CALL TO ORDER — Lt. Gary Chapman, Chairman II. AGENDA APPROVAL III. APPROVAL OF MINUTES — N/A IV. FINANCIAL REPORTS: N/A V. CORRESPONDENCE: N/A VI. OLD BUSINESS: 1) Pending Disability Application — Robert Epstein — a) Update - review — Termination documents b) HIPPA Authorization to Disclose Health Info VII. NEW BUSINESS: VIII. PENSION ADMINISTRATOR'S REPORT: N/A IX. COMMENTS: X. ADJOURNMENT: Next Regular Meeting Date — Tuesday, February 12, 2013 @ 9:30 a.m. — 1500 Gateway Blvd. Suite 220, Boynton Beach, FL 33426 If you cannot attend, please call Barbara @ 561- 739 -7972 NOTICE IF A PERSON DECIDES TO APPEAL ANY DECISION MADE BY THE POLICE OFFICERS' PENSION BOARD WITH RESPECT TO ANY MATTER CONSIDERED AT THIS MEETING, HE /SHE WILL NEED A RECORD OF THE PROCEEDINGS AND, FOR SUCH PURPOSE, HE/SHE MAY NEED TO ENSURE THAT A VERBATIM RECORD OF THE PROCEEDING IS MADE, WHICH RECORD INCLUDES THE TESTIMONY AND EVIDENCE UPON WHICH THE APPEAL IS TO BE BASED. (F.S. 286.0105) THE CITY SHALL FURNISH APPROPRIATE AUXILIARY AIDS AND SERVICES WHERE NECESSARY TO AFFORD AN INDIVIDUAL WITH A DISABILITY AN EQUAL OPPORTUNITY TO PARTICIPATE IN AND ENJOY THE BENEFITS OF A SERVICE, PROGRAM, OR ACTIVITY CONDUCTED BY THE CITY. PLEASE CONTACT PAM WELSH, (561) 742 -6013 AT LEAST TWENTY -FOUR HOURS PRIOR TO THE PROGRAM OR ACTIVITY IN ORDER FOR THE CITY TO REASONABLY ACCOMMODATE YOUR REQUEST. THE BOARD (COMMITTEE) MAY ONLY CONDUCT PUBLIC BUSINESS AFTER A QUORUM HAS BEEN ESTABLISHED. IF NO QUORUM IS ESTABLISHED WITHIN TWENTY MINUTES OF THE NOTICED START TIME OF THE MEETING THE CITY CLERK OR DESIGNEE WILL SO NOTE THE FAILURE TO ESTABLISH A QUORUM AND THE MEETING SHALL BE CONCULDED. BOARD MEMBERS MAY NOT PARTICIPATE FURTHER EVEN WHEN PURPORTEDLY ACTING IN AN INFORMAL CAPACITY. S: \CC \WP\JANET\POLICE PENSION FUND.doc 1 r ,-er /i4vice. fid ` . i ; '. City of Boynton Beac 1 Emp Activity Report O 1 Please type In your input g_r select from the drop down menus where applkable Employee: Robert Epstein Employee #t it#iet '-‘ 25 f, .Requfs,Date: 09/25/2012 Department: Polite Division: Account# 1 EMPLOYMENT REQUtsmoN Requestor. HR USE: AUTHORIZATION N Replacement internal Applicants Will Dept Share Background for: Only? Advertising Costs? Check Level Hourly Annual Job Title : Pay Grade : Salary : Salary : Bargaining Supervisors Job # : Unit : Name : Position Hiring Mgr.'s Type : Location : Name : Department Head Date Human Resources Director Date City Manager Date EMPLOYEE ACTIVITY , Effective 4, (Pleaseselect 'Termination te: 2 Current Job New Job Title: Police Officer mie: Current New Department Dept : Current Curt Shift/ New New Shift/ Dept. # Schedule: Dept. it Schedule: Current Current FLSA New New FLSA Job # Step: Status : New Job # Step : Status : Current New Emergency Location : Location : Designation : Current Current Barg. New New Barg. Supervisor : Unit ? Supervisor : Unit ? FROM : Current Salary ` TO: New Salary ' (Ann ually)/(Houriy)(A) I :(1-01 Gradel - (Annually) /(Hourly) (A I ; (H) - - - - ' Grade! _ . ___ New Employee Info Or Change Of Name/Address/Phone To: l Name (New): Phone # Cell # Address: City: State Zip Code E -Mail: Additi aIInformatlion: REQUIRED FOR TERMINATIONS BI Date LIM,Qu Worked HTE, End Date Comments (Justification for action or additional information): 1 110/0A/1x ; E '°i 03 /.to Per attached memorandum. For Resignation or R . Attach letter /documen . F r all others, please attach Justhkatlon for this request and forward to Human Resources 401 00 I 4 7 42„s' 1? ., ff ....cav ws a c 0,1,Alh--u4, 09 dslia Dep. - , s• ector to H Resources Director Date r f SEf$kti, I- a ag r Date ,• .•, Employee Date •y.0 Conditional Offer Approved - City Manager _ ; ; ; Request for Conditional Offer - HR Director `f` e&/kw W) . tO 00 ofi 1,9 s-Ila Barbara Ladue From: Bonni S. Jensen [bsjensen ©perryiensenlaw.com] Sent: Thursday, November 29, 2012 4:49 PM To: Gary Chapman; Athol, Toby; 'Ranzie, Frank'; Llopis Jason; Scott Caudell Cc: Barbara LaDue; Thepensionteam ©perryjensenlaw.com Subject: Boynton Beach Police Pension Fund - Epstein Attachments: Granger.PDF; Raines decision (00019901) PDF Trustees, I have received a copy of the City's termination documents for Mr. Epstein. They are dated September 25, 2012 and indicate that he was terminated on October 3, 2012 (last day worked 10/3/12). Mr. Epstein subsequently applied for his pension on October 12, 2012. Section 18- 169(c)(1)a. provides that "any member who receives a medically substantiated service connected injury, disease or disability which injury disease or disability totally and permanently disabled him or her to the extent that in the opinion of the Board of Trustees, he or she is wholly prevented from rendering useful and efficient service as a police officer ...." This section provides that a "member" is entitled to a benefit provided certain conditions are met. A "member" is a police officer (see section 18 -168) and "Police Officer" is defined as any person "who is elected, appointed or employed full time by the City of Boynton Beach . . ." At the time that Mr. Epstein applied he was not employed by the City of Boynton Beach as a police officer and therefore not a member. I am aware of two different cases where courts have upheld the denial of the benefit for disability applicants who are not members at the time of application. See attached (the Raines decision is most similar). I believe that this is a threshold matter which needs to be determined before this application is processed. Please let me know if you want to have a special meeting to discuss. If you want to respond to this email, please remember to exclude the other trustees from your response. TO SEND MAIL TO MY ENTIRE TEAM, PLEASE RESPOND TO THEPENSIONTEAM@PERRYJENSENLAW.COM Bonni S. Jensen <bsjensen@,perryjensenlaw.com> Law Offices of Perry & Jensen, LLC 400 Executive Center Drive, Suite 207 West Palm Beach, Florida 33401 Telephone: (561)686 -6550 Facsimile: (561)686 -2802 CONFIDENTIALITY NOTICE: This communication is confidential, may be privileged and is meant only for the intended recipient. If you are not the intended recipient, please notify the sender ASAP and delete this message from your system. IRS CIRCULAR 230 NOTICE: To the extent that this message or any attachment concerns tax matters, it is not intended to be used and cannot be used by a taxpayer for the purpose of avoiding penalties that may be imposed by law. 1 BOYNTON BEACH POLICE OFFICERS' PENSION FUND Scheduled 2013 Quarterly Board Meetings February 12, 2013, Tuesday, @ 9:30AM May 14, 2013, Tuesday, @ 9:30AM August 13, 2013, Tuesday, @ 9:30AM November 12, 2013, Tuesday, @ 9:30AM (Meeting dates on 2 Tuesday of the Month) Meeting Location: Renaissance Commons Executive Suites 1500 Gateway Blvd., Suite 220 Boynton Beach, FL 33426 November 13, 2012revtsed / 7,SfraL,4, -‘t4 ctid NJ R tiy\ BETHESDA MEMORIAL HOSPITAL 2815 S. Seacrest Blvd. BOYNTON BEACH. FL 33435 (561) 737 -7733 • , •• EMERGENCY DEPARTMENT FACESHEET •- **** * **********k** *************** * *,k**** *** * ********t*** ******* PT STS: ET SVC: EMG ADMIT DATE TIME DSCH DATE MR#: 105413215 PT NO: 1020011357 01/07/12 14:18 PREV DSCH DATE: ***** ***** * ***** ***** ****,t*** * * **** ****** * ********** PT NAME: EPSTEIN .ROBERT BED: AGE: 37 RELIGION: NIN ACC DT: 01/07/12 CITY: JUPITER ST: FL ZIP: 33478- ACC TIME: 01:00 PT OCCUPATION: EMPR TEL: - EXT EMPR NAME: CITY OF BOYNTON EMPR ADOR: 100 EAST BOYNTON BEACH BLVD VIP STS: ISOL IND: EMPR CITY: BOYNTON BEACH ST: FL ZIP: 33435 - EMG CONTACT: EPSTEIN .KELLY REL U EMG ADDR: TEL: EMG CITY: ST: FL ZIP: - ** **************Or*****1Hrir****** ************* ** ****** * ***** ******* ADM DX: . ADM SOURCE: EO ADM DR #: 005033 ADM DR: ED PHYSICIAN ACC INDICATOR: 0 ATN DR #: 005033 ATN DR: ED PHYSICIAN JOB REL IND: ORGAN DONOR: DONOR INFO GIVEN: ADVANCED DIRECTIVE: ********* **** *lrskir************* *** ******** GUAR NAME: EPSTEIN .ROBERT REL S GUAR ADOR: GUAR TEL: GUAR CITY: ST: FL ZIP: - GUAR EMPR NAME: CITY OF BOYNTON *** *** mik******** * *******,r*** * *** *** ***** ****** A4**,4************** ****** *** ** **** INSURANCE COMMENT: NUMBER OF INSURANCE PLANS: 1 TREATMENT AUTHORIZATION: . PLAN #1 INS CODE: 215 DESCRIPTION: WORKERS COMP POLICY NUMBER: GROUP #: PRIORITY GROUP EMPR ID: TEL: 813 - 289 -3900 # 1 ADDRESS: PO BOX 18319 CITY: TAMPA ST: FL ZIP: 33679 - SUBSCRIBER: EPSTEIN ,ROBERT ***************************, t************* * **************,k**** * * ***************** PLAN #2 INS CODE: DESCRIPTION: POLICY NUMBER: GROUP #: PRIORITY GROUP EMPR ID: TEL: - # ADDRESS. CITY: ST: ZIP: SUBSCRIBER: ********************************************* ,r**** *************** *** ******* PLAN #3 INS CODE: DESCRIPTION: POLICY NUMBER: GROUP#: PRIORITY GROUP EMPR ID: TEL: - # SUBSCRIBER: PRIOR ADMIT: REMARKS: REG BY DATE: HOLLYF PCP DR #: 062653 PCP OR: FELICIANO ANGEL Y'e Emergency Department EXAMINED TIME Adult InRIel AssessmentlFioW Sheet 0 NURSE . Bethesda Memorial Hospital 0 ERMD Boynton Beach, FL. 33436 (561) 737 -7733 0 PMD • d � SECONDARY NORMS A$SE$%MB T 0 0 WA 0 Blood 0 Freq. 0 Burning 0 0ysurie 0 Incontinence I t : :1 L:L ; III Deea,plen: Meek Louden 1 Abmion 4111 1 2 Bum • 3 Bruiae 4 Decubiti size: cm 0 Stln 5 Edema 6 Laceration 7 Rash 8 Scar 9 Ostomy 10 Other • Front (sear NURSING DIAGNOSIS 0 ttnowkOpe baeidL Reload to PLAN I IN ION 0 0 ME INIT. MEOICIITION J GtE emir( • PAIN EDUCATION ❑ See Code Bine Flowshoet 0 See Medereto Sedition Flpwsheet 1111111111=11111111111 MRN: 1054/3215 1 EPSTEIN .ROBERT Signature )tN / Print N p'`_ ID: 10200113ti7 Emergency Department Adult Initial Assessment/Flow Sheet ) . Bethesda Memorial 1400101 . Boynton Beach, Ft. 33435 (561) 737.7733 , TESTI/TIMATMENT - 11ME • wee onaw - urn - TOME COS kytt *NT 7) Accuctbck MD CALLED ME RESPONDE a l Barges - Fadklg Glu • as 000rt SPINAL Tao mesRn s OT err Pno 1 t0 1 Year 80 - mg/di TTPE 1to8 74- 127mg/di 7 to 19 Years 70 - 108 mg /dl Ni ro xr♦AY. 0 NM WIC o WI FOOT NM 20 Yams or prntsr 85 -110 mp /dl TAE 6 "` 'rl i3kn ii AT1dw s s MSORSEO wpm dY mew. . kI >►�.; i1 mom iFii: 11MIN: =7_ricAMC "T' ' _ MI • . / - NURSING SIGNATURE PRINT INITIALS 0 Suspected as possible victim 0i mistreatment /neglect / abuse 0 Report aced to 1 •x00.95 -A9USE 0 Donor Number 1400-255-GIVE Aannted:0 Tranntarnd: 0 0 DOW TN: 81911slpmplontc YabNletAklonginps: 0 Stable 0 Hospital 0 Medical Examiner 0 Persistent • Enlrm.nbl. 0 Aam 01)07/12 Pt 1020011357 IIIIIIirIiisiI tI OWN Page 3 of 3 3 Order Session Summary Report + + Computerized Physician Order Entry Patient Name : EPSTEIN. ROBERT Allergies : Diagnosis : Ordering Or :Cesar Carralero. M.D. Cardiology • Orders Order No Order As Written Order Start Occurrence Order Priority Daternme Start DateMme Status CPOE Order No Order As Written Order Start Oecun!enee Order Priority Date/Time Start Date/Time Status Imaging Services Order No Order As Written Order Start Occurrence Order Priority Laboratory Order No Order As Written Order Start Occurrence Order Priority Medication/IV Order No Order As Written Order Start Occurrence Order Priority DateMme Start Date/Time Status ElecaoMealy signed by Cesar Carmiero, M.D. 01/072012 15:16:00 Provider Date Time Bethesda Memorial Hospital Pint mew: r►s , Wing Room- Ninon ' BETHESDA MEMORIAL HOSPITAL, INC. BOYNTON BEACH, FLORIDA (561) 737.7733 • + PHYSICIAN ORDERS - EMERGENCY DEPARTMENT • • LLERGIES: ❑ NKDA Required for ail admission orders.) EIGHT/WEIGHT: Required for Pediatric, Neonate and Chemotherapy patients and all orders requesting Pharmacy to dose.) DATE TIME MEDICATION / TREATMENT Nurse Initials ❑ • • • WHITE: CHART YELLOW: ED PHYSICIAN ISIUMMININIMMIN MRN: 105413215 EPSTEIN ,ROBERT Norm / 8141 5 Bethesda Memorial Hospital '` • 2815 South Scacrest Blvd F • Boynton Beach, USA 33435 • Respiratory Care Services ,. 4 • Blood Gas Report _ • ...'s Name: EPSTEIN, ROBERT Sex: M ' Pat. ID: Parameter Results €037.0 •C Normal Ranges !' A -aD02 mmHg • s . i : Other Information: Oxygen/Ventilator Sciatica: • is tt • ; Analyzer; GEM4000 -3 Oxygen Device: Rouen Air :• Yg PEEP: Ordering Doctor: CARRALLERO MD,, RRB FIO2: 21.00 CPAP: Technician: JOSEPH, JONATHAN LPM: 0 Pressure Support: ;,,} • Operator ID: 3001 Pulse OX%: Pressure Control: Roam /Bed: WR Minute Volume; BI -Pap Settinp: ::Araf' �_ Sample Site: RRAD Tidal Volume: MODE: Allen Test: POS Respiratory Rate: AMP/HTZ: -,% Notified Time: 15:38:00 Spout. Rate: MAP: .. :. • Noti icatloa to: CARRALLERO MD„ RRB I -TIME, ,• 1,, Comment: E -TIME: - : 1 r : *Critical values delivered ,read back,Confirmed To: /Tccb initials Time: r • • ' . Y•. i r 1 . • • . • • Bethesda Memorial Hosptal • • • - • ! Bethesda Memorial Hospital • • 2815 Saaa+st Boulevard l 2815 S. Stecrest Boulevard Boynton Beach, FL 33435 i . . 1 Boynton Beach, FL 33435 581.737.7733 581.i 37 -7733 ' NAME 'DATE , ; NAME DATE M ADDRESS I°DDRESS • . / • ri 00 NOT OPENATO N NEA NAT MAONweRY orEC NEAw iMC11M�TV WNW TMOMO MEDICATKIN VOILE IMMO MOOICATION r i "1 aVIY STOMACH EMPTY STOMACN • . REFILL TIMES DEA REFILL TIMES DEA DR. I DR. • (''' "a111ttlsodaT Rsv.tut+ • - INST ROC. i 1%3N SHE .E- I (S) GIVEN !rs < r ,m1 t<.X [raw OMarl red w OeprNm kair o wound liriy tGilflas ❑ S,T,O .IPnplsne y OIIR O Asarpe RSaaeen O MOM pain 0 Noss Shed ❑ Gawe«wrles - O s.d.EOn 0 Abdeall.J Pen 0 Olabsas 0 Oak Medls/Otes Exton. 0 URYPnsuaanb O 0 Eye Ova 0 Rie injury 0 TI P,Monsp Jos 0 - 0 Yad./ Ned1 Cam O ft•Ur •d1Ed O Sole Throat/Tooth O Stood Pwmlr• 0 . IN ∎ ■R TiC N TO PATIENT r Ira ��a� n•t I ,. , r- u� . *7TTc::.lc31- • ' P %,' i02001 +357 111111111111111111 • •Arrr. "-r rIT .....t* . ,• ■ wad , [�, RE; - i- Ri E o C� (( (GPI 1 . • • MAKE APPOINTMENT IN s MAYS. If YOU HAVE ANY TNOUSLE OETT APPOINTMENT WITHIN THE PERIOD INDICATED. PLEASE CALL us FOR INSTRUCTIONS. • IF NO IMPROVEMENT IN � ( 1 / / . HOURS /DAYS. OR IF YOUR CONDITION WORSENS. OR IF ANY NEW SYMPTOMS ARISE, CALL YOUR PRIVATE PHYSICIAN OR RETURN TO THE EMERGENCY DEPARTMENT FOR A RECHECK. PATIE N1 S. . ;GNA` Li RE t 0110111T00110.F M 0.101001CY CN1i F01001111111 aRI1a • NOT IMIe1MW TO I! CO, FU1t MOOS MINI Mae e* CMS 0001111A10110.1 0000,41010 T.MT 1 NMY! NM 001111,0180 10 COMB! MASON! mimes* asesers Y 100 COIR wao NO C0101.m01 111111F,A. 0011101111. OM NO 111u1,MWr. nRas. saws Memo Q440[11 !rat 0e POVOIWO far .0100 reraWaft NO M NOWT 14110 4000110 Of aWarl 1R 01001PAkoss IIRL &as, ne 11011000V OPT Na1M0, mamma 1 mass. 1 ALM UMO0MTNO II01 Mr IO*1 1O NIn10RQI ICMIOA MIN1010LI*MR* 10 POLEMIC FILM/0T FART Q M .1 MONO II CtUOUIO. • 01‘.10011.. 41101111110011 F00/000 • 1101 NOM IW 7!!704 worm 111W rH M0010s ANO 0111* moos *00110. TlMM0I1)10 M IMAM 1.0110 011041 I IMNI -A0 ANO UNOEO$TANO 1111 NON! MOM A COPY OF 001 10141. A/O APFuC 1a1L ovarauC110• OWL MO 1 I me POILON 01 WM.. DI CI QE TIME • PAT1ENT. 0 PARENT . O 13UARDW4 0 OTHER ' . . DISCMAkQS NURSE SIGNATURE . DATE WORK SCHOOL STATEMENT } 41l.assn` Dr. ,�,! . at on 1 / i. , • . 0 MAY RETURN TO WORK /SCHOOL 1 RESTRICTIONS L7MIJST BE REEVALUATED BY FAMILY /OCCUPATIONAL PHYSICIAN BEFORE RETURNING TO WORK /SCHOOL 0 MAY RETURN TO RESTRICTED D&/TIES FOR DAIS 0 NO ATHLETICS /PHYSICAL EDUCATION: DAYS. RESTRICTIONS: 1, ID • WAS HERE WITH RELATIVE /CHLD 0 WILL REQUIRE TIME OFF WORK /SCHOOL ESTIMATED 11M €_ DAYS. M.D. • Form 1209C 10/08 , . CHART . . t S • ' 1 7 BETHESDA MEMORIAL HOSPITAIIBETHESDA HEALTHCARE SYSTEM BOYNTON BEACH, FLORIDA (561) 737.7733 CONSENT RECORD . • 1. FINANCIAL AGREEMENT • I hereby guarantee payment of at charges incurred for services rendered 61 Bethesda Memorial Haplt*VBatliesda Healthcare System (Bethesda) authorized treating physiicien(s). Further, I hereby gonna. payment of al attorney's tees. court coats and collection charges burred n to event • coYSatlon Neon is MMtated by Bethesda and autorke the meow of my consumer report it deemed necessary, I authorize to hostile or business associates d the hospital to eomam me by the use of any automatic Mang Byrom or by pre•rscorded tonne d voice/messaging systems. Further, I authorize the hoaptat or business associates of tie hospital to contact me Ma al telephone and elsctrone man owned or used by the patent or roaponsMlM party I understand to cost of a private room Is net covered by kourates and ague to pay the additional clotgs. 2. MEDICARESIEDICAID ASSIGNMENT AND AUTHORIZATION TO RELEASE INFORMATION AND PAYMENT REQUEST -1 telly that to intonation 1 provided to eppy for payment under Title XVM or The XIX of the Social Security Act N correct. I authorize the released err nooks' or other mformMlon to Social Secwity AdisYisuallon. 3. ANENT OF BENEFITS - I assign boneflls and request tut payment be made directly to Bethesda. I also understand that any credit balance resuNIng from payment of Insurance or other sorese may be applied to other s aunts owed to Bethesda or phyaldans by the Insured Of lanly.1 uderstand that 1 am resporelble for any deductibles end co-payments app Icable. 4. USES AND DISCLOSURES OF IIEAI.TH INFORMATION - Upon inquiry, Bethesda may make notable b the public MonmsIon about s patent including gist name, verification of hospitalization, and their tone re conrtlon. Tuebtned for drug abuse, alcohol abuse, mental Ikea or HNV Is exempt from 8* praotoe. If the pates or to petrel legal npnserged* DOES NOT want such Hom*bon to be released. harsh. must make a wrMlen request that such kdamaton be witdhsti l understand that Bethesda wit use end disclose my persons' heath bdormaton to provide bsMment, process payment dIn w, as necessay for hs&Nnaw operadona (e.g., Performance Nrhpovemmt, U14Uation Review, mamAadurers of srgksty placed impel*Ns) or a required by law. Thie includes Meese of blfometon to Insurance comae, 3rd pony payers or their agents. WM any right to privacy waived ktcklang any Manned for mental Ilness, alcohol abuse, dug abuse or HIV as • may be neassey. Further, ny Information and medical records may be *dosed to members of to Hospihts medical staff or outpatient lorapy department knvdved in my suMequent care and treatment For details d uses and disclosures, refer to Betltesda's Hots o1 Privacy Practices. Records shall be maintained for 7 yeas .ter the date of vlsk 6. CONSENT FOR GENERAL MEDICAL OR SURGICAL TREATMENT - I hereby authorize Bethesda and ptysidn(s) in dwge of my are to adh*Nper e y treatment, to allow a photograph to be taken for Interne medal mood documentation, receive mulls of tests and services rendered, to adrnirdstsr anesthetics and medlatone, to perking apsrcloIWIPOCedIne (nckdna blood banehrstorel, to peilorm Morrow procedures and Mali (Including blood Ws tar any disease or oonollon), and to dispose of any Issues, body parts or organs removed as deemed nsoassay or advisable In my diagnosis end see$net.1 am amore that to practice of medicine and surgery is not as exact science and f acknowledge that no guarantees haw been made to rte as to the results of treatments or aaminallon s at Bethesda. 1 understand that d the paten Alin to Fbepll, Including any oonsu4trg physicians. Physician on cot, or Ms hospiWbasd prsatbnas (to.. 4 , 4 , Emergency Deponent Physicians, Radobpisb, Pathologists, Radiation Oncologists, Neonabbgists, AnatteMolopbts, ObsIsptdane. Gynecologist. and Nuns Praciloners e.g., Nurse MdalRe, Name Anesthetist) are not employees of no actin as gents o1 to Hospital nor is the Hos lobe to their eclon. 1 understand and agree that Bethesda Monocle Hospital is a fading fatly with medical students, Meets and residents who may participate in my petters are under to supervision o1 a *skein proctor. a. VALUABLES • I em Weed Net Bethesda has a safe free of charge for patent vakubles. I accept full responsibly for any valuables or personal Irene kept by me Ws ny room or an my person. 7. ADVANCE DIRECTIVES • I have been Wormed of my runt to execute an Advance Dkecthve or peke changes to an existing ono. Further, the Hospital has given me wditen midst* contenting ny kndvidud rights wider Florida Law to make decisions afoul ny medical ceu. I understand that 1 an not required to execute an . Advance Dtreed ve as a condition to receiving care In this Hospital. t understand that M Mrs of any Advance Okective we be followed by is Hospital b Ile extent required or allowed by law. & PATIENT BILL OF RIGHTSfff iRMVANCE PROCEDURE • 1 have been given a copy d BetMsde's 811 of Nights and Grtevana Procedure. Should 1 hove a gdennce, I have been advised t0 cot Hospital extension 84402 to express my concern. 1 PRIVACY PRACTICES • I haw been node swam of Bet ssdds privacy practices as described In the Notice of Pavlov Practices. Further, In scoordencs troth the Hosplld s Privacy Practices and b protect to oortdaW*Mly of my protected health ntometon (PHI). I be aby *ad Net dadoaure of my PHI be resulted. BpecBcaNy. no documentation of any k lormebon Meted to my say or tmatmert, including but not Smiled b any documents or other materiels prepared for peer review, risk management, or quality assurance purposes, is to be disclosed under any circumstances, receded or otherwise, to anyone not alMlesd *111 the HoepitP, for any purpose other then payment or ice sretaoaedilaton requirements. v47houI my expressed written consent or 1st expressed when comsat of ny authorized representative. . 1 understand that this comas is suhrecl to revocation at any time except to the extent that aclorh has been taken In referee thereon. 1 certify That' have read to forepolrg, received a copy tenon, and I sin to patient the patent's legal representative or duly authorized by the plat as the petenrs general aged b execute to above and accept its Isms. 1 oleo My understand the consort tamable(' in this record and voluntarily execute k. Tranest d byname a anpfi)' Date: The: Date: O 1- 07. 17 Time: io PatientfRepreserdetiveTu . 7NimeaSgrhahae; -. oats:OI. din. 0 Ten.: 11111101111111111111111111 MRN. EPSTEIN ,ROBERT August Form 0: 11 MIIIIIIAlliillia 3 r .. -- =- "'"'"^ ''''''- r'r+•......-....". .1.`"'—' o'ra— - •••• -- .` •■`!^.....-"`••••- .... -... .. ••••••• . , _. .. f 'BOYNTON BEACH FIRE RESCUE EMERGENCY MEDICAL REPORT Revised 1/2008 . , Name . e hO £ ��. G7 • / / ' } Meds rt41 *j i } . location - '�' ZIP ss# Prs'Address / • • • Phone #'t 1 - Transported to:. `/ BLS Ambulance, Trauma Hawk, POV, PD, .None Mileage alt(s) FDID #'s 7 1 / < D !' /0 . i PRIMARY S RVEY WNL Abn Blood Glucose •- S Time BP Pulse R • Sa02 . ECG _ Time µ Med __m Route MID _ • ' / O/R 4/12 ' / O • 4 12 • ~,' / - O/R 4 / 12 • i t O1R 4/12 • • • • • !, . • • , • ' AIRWAY / 02 • INTRAVE CCESS • • • � • �1 Fri �1 ❑OPA•' -0NPA• ❑Combs Responding •Hospital A ❑ � ❑MMidrfp, ❑ Regubr, 0 BT First Arrival Available 1 Att ests Su Y N ID #_ (Departure to LLZZ� . • Signature and FDID# of Pararnedi ).. j ire7r ;;• 0 Ignature and FDID# of CO . . . vi i P _ .. _._. . . . .... . ... . . _ . 1 BET) IFSDA,MEMORIAL HOSPITAL ....1,-- �� MRN: N. EMERGENCY PHYSICIAN RECORD ADU EPSTEIN ,ROBERT f ED PHYSICIAN EMS 1 caretaker Ada Dstn: 0107112 Historian ( History tin p Tratulutor Pt ID: 102001135 11111111111111111111 • CHIEF COMPLAINT [ �' F �Y OF SYS ADS: A LL SYST tMS EMS VIEWED & NE GA TN EXCEPT AS /NIIIC.I TEO Ii,sT9 QF PR -� -: Q ROS avant be Moire* polka angle m mum be age: d._ r 1^ 1 N / O Len • ,� N Cherk�ox If sown A noraral: i d / Geserat: fever NMgbtloss wi , 7441:110 %1 1lt�'�J lur thole Milillialli � � ENT: sore throat nasal esngestiss visual eamplaluts '47 / / T AW%TrI ri/ 1El ' Y.172 13 Reap: SOS /DOE � ��,�//�� /; / ) j r�/�(� 0 G I : chest sin ��/r�Y� � �I S�Jt��!'I��is/"e O GI: diarrhea / constipation Palo / I / 111 /.4 % , Q GU: flank pals argeae) dyauris trc uewc) 1 beataturla decreased tine output outset: t / ' 0 )s / weeks / montbr LNa1P: G _ P _ Ab O grad Q suddea asset Skeletal: mval& arthralgia dining: persists worse better remised e.net•nt Intermittent back pain Severity of symptoms: lulled moderate severe • Skim rub Pain scale (1 -10 ): euro/Payeb: headache as vier) Associated symptoms: Q fever 1 galls Q eousea/somklag/dlarrhea confusion face) weakness wheal complaints ❑ chest pale / S00 / DOE ❑ myalg1a/ artMal& . Itsdoeriae: weight change Easearbatiog tamers: O none pehwrla / pohdypsla 0 movement ADDITIONAL HISTORY Atk■4tiag folders: 0 lase ❑rest Q old records requested / reviewed Similar symptoms prevluedy: VES I NO – PMH/'SH/FH 0 Bavlewid on nurse's es sad mIQ'ee PAST MEDICAL HISTORY Q HTN Q 13 bowel bowed seeada: asnare&Weeressd Q CVA teadernese R A. O pulsatile mess 1 bruit 1 0 111111111111111111111111111111111 ` BETHESDA MEMORIAL HOSPITAL EPSTEIN , • EMERGENCY PHYSICIAN RECORD A D 1 11IIIIIIN11Nw111a 1 RADIOGItAP lY r p wbaaRad t CXR: 0 ab J tterer tamal `• ~ Olker radiological Radice: 4 :.-7.%) CRC: • .sand BMP: 0 MO r, I uln: +x * , • % 1 APIs / beads:�x , it J,, 1}w _% . Cardiac Pretties 0 Dermal meepl: _ _ BACK O normal 0 'Maine / muscular tanderaeea ED COURSE SKIN o aoroal ❑ rash 0 sited depressed CRITICAL CARE TIME Q 30-74 Mlwres 0 75 -1114 Miasma (Melee other &Alailo premieres or mobilo, too toda loP O 1 HAVE PERFORMED A MEDICAL SCREWING EVALUATION • 0 NO EMERGENCY MEDI • CLINICAL IMPRESSION O marmotev , EDTO num ' otT 1 ' in • Ids disease teak / metabolic , Cardiac monitor r r 0 as mtopy EKG: Rate: .4 0 a • me D SITION (time: ) EMC: renoiroi /auiilkod homoissoot Rh)tbm: 0 R r tachycardia 0 bradyeardia 0 paced Chamber al 0 I.VH 0 RVH 0 RN. atrial eolar'gcmeat (ustr.etlans: Q11S: rmsl Q WVCD 0 RBBB 0 1.1111B Q PRWP Q warm Q sepal Rs: 51771 � s1 0 n.nspedlk ehagps Q ST stBmeats elevated / depressed Q T wares Rat / Wrested ATTENDING . - Isapredea: 0 normal EKG 0 abnormal EKG: 0 reddest/PI A owe rev O I have : e face bee evaluative of the km Compared geoid EKG: 0 unavailable 0 aslehaaged 0 labs 0 a-rays maimed (date. ) 0 1 sg with a is 0 1 base reviewed t , txwaual plan / meow Resident / NP / PA ....B r war' MD / DO O See A , . er/ CopjW bf dee a cirelve est of N.spid ?* okMMw s 11 Bethesda Hospital East Bethesda Hospital West 2815 5 Seacrest Blvd 9655 Boynton Beach Blvd Boynton Beath, FL 33435 Boynton Beach, FL 33472 (561)737 -7733 (561)737 -7733 Laboratory Results Report Patient Name: EPSTEIN, ROBERT DOB: Age/Sex: 37Y/M Primary Dx: Allergies: No Known Drug Allergies Hematology Normals Collected at 01/07112 15 26 WBC (Leukocyte Count) Chemistry Nonnsh Collected at 01/07/12 1526 BUN, Serum ABG NonmM Collected at 01/07/12 15:33 SampleType Arterial pH Printed On: 16-0u -12 10:08 Pat>cnt Name: EPSTEIN, ROBERT Printed By. Petlit Number: Location. Pepe 1 of 2 HRH: Physician: Attending Admit Date: 1 (9---- Laboratory Results Report Patient Name: EPSTEIN, ROBERT DOB: Age/Sex: 37Y/M Primary Dx: Allergies: No Known Drug Allergies ABG Nonmals Collected at 01107/12 15 33 p02 Printed On: *0ct• 12 10:08 Patient Name: EPSTEIN. ROBERT Printed By PetkM Bunter: Location. Page 2 o/2 I4RN: 105413215 Attending Physician: Admit Date: 3 I Bethesda Hospital East Bethesda Hospital West 2815 5 Sescrest Blvd 9655 Boynton Beach Bbd Boynton Beach, FL 33435 Boynton Beach, FL 33472 (561)737 -7733 (561)737-7733 Chest - Portable Results Patient Name EPSTEIN, ROBERT DOB: Primary Dx: Allergies: No Known Drug Allergies •'•' Stat Result •'••' Order Name: Chest- Portable Observation Dome: 01/07/2012 16:31 Result Name: Chest- Portable Result Status: Final Result Report Dictated by DARLENE P. DACOSTA, MD. on: Jan 7 2012 4:34P This document has been electronically Signed by: DR. DARLENE P. DACOSTA, MD. Jan 7 2012 4:34P Transcribed by: DPD on Jan 7 2012 4:34P Comments Result Comments: Requisition Comments: Ordering Dr: Carralero Cesar Order DateTme: 01/07/2012 15:16 Ord#/Occurrencet 5075350 / 6904745 Chet- Portable Results 8MH Patient Name: EPSTEIN, ROBERT 3701 Prkded B metro, Ruth Patient Number. 1020011357 location: Printed On: 16-Oct-12 1008 MRN: 105413215 Page 1 or 1 Attending Physician Carralero, Cesar M.D. Admit Date: 01/07/2012 14:18 ILI 4.4 N - - - - - + - -_� I, ' . O , . : ., s : - • .._. „ . . . „ . • . • • ', .: - . -:... .• : • -: .•.,- . ..,- . . - ,...: . , „-. , - . v ..-. ; --:. . S:i:';'1*:" t ' .... : . . „ .....,..« • -,.. t ... :: : ', I." :1` .,,,' .. . . , I i 1 .. r. 3, . L . .• , 1...... , :i L . • ...,, - :.■, - ..''' j - ' A A . 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' '14.• '''.• . .. • *' ; ' ,..1 • • on. . • :: ' *kw* ' • -- MEI* shi • :'''' '"' •Pdtilregitoolfiel . „ . . . • - - • ... ;13,,,,,041„ - - -01:4, ' Aid 'the lialiant.° . . - '.•., =" : -'-• - - • , • at , ; co p- : . _. '. :-• *--- - — - „i;.#7. . i _ i ie / , , . - - . - - Provide' i mom It -44t4A MAQAZZU. PAC 1 7 - . . - .. .., z -.., :. .."."-' - . - • +4111.1.. ._..L.) : SA riff .. PM/0003879 -,.. --..--, r r.; '.47' •"•: . 7.V. • • ' • • " • ' ' - _.. . . .. . '• , • - , . , .. . . . - .. • • timid; t Pr. _ . - t - . E 7 Tli _ �, . r ON PAGE 3 NOTE: can providers shall and accurately complete all sections of this form, Ikniting their responses to their area of expedite. 1. Insurer None: 2. Visit/Review Date: 6. FOR INSURER USE ONLY 01113 /2012 3. injured Employee (Patient) Name: 4. Date of Bkth: EPSTEIN. ROBERT 6. Date of Accident: 7. Employer Name 8. Initial visit with this ph Ician? 01 /07 /2012 CITY OF BOYNTON BEACH 1,1 NO • b YES <<-CTI()N I CLINIC d., /%5SE SPIE rJT 1 DETERi.]V ATION 5 9. ❑ No change kr Items 8 — 13d since last reported visit K checked, GO TO SECTION 11. 10. Injury / illness for which treatment is sou ht Is: ❑ a) NOT WORK RELATED [� bj WORK RELATED ❑ c) UNDETERMINED as of /his date 11. Has the patient been de ermined to have Objective Relevant Medical Findings? Pain or abnormal anatomical findings, in the absence of objective relevant medical f shall not an Indicator of injury and/or Illness and are not oompensable. ❑ N YES or UNDETERMINED, explain: 12. Diagnosls(es): 13. Major Contributing Cause: When there is more than one contributing cause, the reported work - rotated injury must contribute more than 60% to the present condition and be based on the llndkngs In item 11. a) is there a pre.existkng condition o the current medical disorder? ❑ al) NO [U as) YES ❑ as) UNDETERMINED as of this date b) Do the objective relevant medical findings Identified In Item 11 represent an exacerbation (temporary worsening) or aggravation (progression) of a pre-mdsting condition? ❑ bi) NO ❑ b2) exacerbaton ❑ b,) aggravation ❑ br) UNDETERMMiED as of this data e) Are there other relevant co-morbidities that will reed to be considered In evaluating or managing this patient? ❑ cr) NO ❑ c2 YES d) Given your responses to the items above, Is the injury/illness M question the major contributing cause for ❑ di) NO ❑ d2) YES the reported medical condition? ❑ ds) NO ❑ d.) YES the treatment recommended (nranageaenHbrabnent plan)? ❑ di/ NO • ds) YES the functional limitations and restrictions determined? SE H FA i iErir Q 15. LEVEL 11 - Key issue: regional or generalized decondWoning (i.e. deficits In strength, flexibility, endurance, and Motor control. Treatment: physical reconditioning and functional restoration. ❑ 16. LEVEL 111 -Key issue: poor correlation between patient's complaints and objective, relevant physical findings, indicating both somatic and non-somatic clinical factors. Treatment: interdisciplinary rehabilitation and management • 17. LEVEL r , , AS OF THIS DATE nor; ❑ 18. No clinical services indicated at this time. If checked, 00 TO SECTION iV O 19. No change In Items 20a — 20g since last report submitted. if checked, GO TO SECTION IV 20. The following proposed, subsequent clinical senAce(s) Islam deemed medicaly necessary. ❑ a) Consultation with or refensl to a specialist identify principai physician: identify specialty & provide rationale: ❑ a CONSULT ONLY ❑ a = ) REFERRAL & CO- MANAGE ❑ c PhyaicallOccupaUanal therapy, Chiropractic, Osteopathic or comparable physical rehabilitation. ❑ 0 Physical Reconditioning (Level II Patient Classification) ❑ c Interdisdplknary Rehabilitation Program (Level III Patient Classification) ❑ f) Surgical Intervention - specify procedure(s): ❑ f,) In- Office: (� ❑ f Surgical Facility: b ❑ 1 Injectable(s) (e.g. pain management): ❑ g) Attendant Caro: Form OFS- F5- DWC-25 (revised 1/31/2008) Page 1 WI li;: U..1CiJc E i !• :, �rs - ` 7�,. °,� °i4. • - _ r7:11 001: 0110712 012 [rt:"77' I Fi Assignment Bons or nosb coons must ' based upon figured employee's . - , c dysfunction or abuts rested to the work Way. However, the presence of ollscthre relevant medical findings does not neat to an automatic pmltation or resbidlon In funcliort. Lx 21. No functional limitations Identified or restrictions • crlbed as of the • ; • ' date: • • 22. The Injured workers' functional limitations and restrictions, Identified In detail below, are of such severity that he/she cannot perform activities, wen at a sedentary level (e.g. hospitalization, cognitive impairment, Infection, contagion), as of the fo1 • data: . Use addldona/ sheet ff needed. F ono! Acti 1 r'Tl•.11111 1111111.= • • ono ' on `:t•: 3I '*? 't?ry;•7;!Tt is Bend • airy • Climb • Grasp IL taovarfeed ��, • elk • ■ c" ... , . � . ; .. ; ; v V • avy q . pt :�- : a ye • r • .-r �,•. m Environmental Conditions: • • • at • ,u:. • • ' Job T ' a • etc. NOTE: Any functional lindladons or � esbtctions assigned above apply to both on end oat the job acdvidss, and are M effect until the next scheduled appointment unless othetwbe noted or modified prior to the appointment date. those and - • h - svhicb are If /Pont have been • In bun X. 24. Patient has achieved improvement? • / ❑ d) Anticipated MMI date cann be detennlned at this time. Future Medical Care Anticipated: ❑ e) YES ❑ 1) No ❑ Comments: 26. —% Permanent impairment Rating (body as a whale) Body part/system: 26. Guide used for calculation of Permanent Impairment Rating (based on date of accident - see Instructions): ❑ a) 1996 FL Uniform PIR Schedule ❑ b) Other, specify: 27. Is a residual clinical • nction or residual functional loss anticipated for the work-related Injury? • a YF-S • NO • c • st this 5 c ..: 28. Next Scheduled . • • • Dab i Tine: • ' •,,.. 'As the Physician, I hereby attest that all responses herein have been made, In accordance with the ; ' .-' • as pert of this form, to a reasonable degree of medical certainty based on objective relevant medical findings, are consistent with my medical documentation regarding this patient, and have been shared with the patient. • 'I certify to any PAM / PIR information proWded b this form.' Physician Group: MEDEXPRESS URGENT C: °° Data: r A3 / 1 Z 4620 DONALD ROES , RC- . MICHAEL MellMLLIN. Physician Signature: a.i.. if�ra�4r5 €NS's - to Physician DOH Licensed: M 0 Physician Name: PHOt4E (681) 216 Physician Specialty: mane 19221»470 4. 641 2964141 I a direct • ble services for this 'i were rendered" • .1 • • • otter than a -base _ ,below: '1 hereby attest that al responses herein relating la services I rendered have been made, in accordance with the instructions as part of this form, to a reasonable degree of medical certainty based on objective relevant medical findings, are consistent with my medical documentation regarding this patient, and have been shared with the patient' I ^ Provider Signature: Provider DOH License 6: lt ` Provider Name: Date: 1 I •.tname Form • S- F5 -DWC-25 (. '*r 1 1/2008) Page 2 of 2 Patient Name: ROBERT E EPSTEIN Visit Date: 1/8/2012 Seen At: MedExpress Palm Beach Gardens Phone: 561- 776 -3090 Rendering Physician: Diana Magazzu 4520 Donald Ross Road, 100 Fax. 561- 296 -8141 Palm Beach Gardens, FL 33418 -5105 Printed by snino on 10/12/2012 Page 5 of 8 Patient Name: ROBERT E EPSTEIN Exam This record was electronically signed by Diana Magazzu, PA-C on 01/08/12 at 8:06 PM This record was electronically co- signed by Michael McMillin, MD on 01/08/12 at 9:01 PM 0 ( Printed by snino on 10/12/2012 Page 6 of 8 Patient Name: ROBERT E EPSTEIN Visit Date: 1/13/2012 Seen At MedExpress Palm Beach Gardens Phone: 561- 776 -3090 Rendering Physician: Michael McMillin 4520 Donald Ross Road, 100 Fax: 561- 296 -8141 Palm Beach Gardens, FL 33418 -5105 Chief Complaint Printed by snino on 10/12/2012 Page 7 of 8 Patient Name: ROBERT E EPSTEIN A/P This record was electronically signed by Michael McMillin, MD on 01/13/12 at 11:50 AM C2 Printed by snino on 10/12/2012 Page 8 of 8 DAVID O. KATEB M.D. P.A. - -, 4760 W. ATLANTIC AVE DELRAY BEACH,FL 334453839 5616373933(p) 5616373935(1) Name : Robert Epstein Sex : Male DOB : Age : 32 ServiceDate : 05/10/2012 i : I Powered by Emedpractice.com 02-11 1 1 1 of 3 5/10/2012 3:47 PM DAVID 0. KATEB M.D. P.A. ti.. 4760 W. ATLANTIC AVE c. DELRAY BEACH,FL 334453839 5616373933(p) 5616373935(1) Name : Robert Epstein Sex : Male DOB : Age : 3Z ServiceDate : Q5/10/2012 No Known Drug Allergies. VITALS : Weight : 306 lb Height : 5.8 ft.& in. BMI : 46.5 BSA : 2.6 BP : 124/82 _. _.. !Powered by Emedpractice.com 2 of 3 5/10/2012 3:47 PM Ma_ . DAVID O. KATEB M.D. P.A. 4760 W. ATLANTIC AVE Cao ca., DELRAY BEACH,FL 334453839 T 5616373933(p) 5616373935(f) Name : Robert Epstein Sex : Male DOB : Age : 32 ServiceDate : 05/10/2012 Followllp : PRN. $ILLING SERVICES ; / 94010 -- Spirometry, i 99214 -- OFFICE MODERATE COMPLEXITY -- 0000 »786.05 »472.0, G8496 -- PREVENTIVE MEASURES PERFORM -- 0000 »786.05 »472.0 Provid :D i i!». KATEB, M.D., P.A. 1 Powered by Emedpractice.com . (7‘2 3 of 3 5/10/2012 3:47 PM r ..,,.,.,...,, ,,.. JWiri rLUKUUA Ilan Session Date: 10MAY2012 Puri Bennet Rena II Session Time: 62:15PM S /N: G- 20020370135 0 Last Cal Check: 24MAR2011 Version: 1.1.11 BEST FVC1fVt REPOBT ID: Height: 68" Physician: Sensor Code: 838347 Name: EPSTEIN.ROBERT Age: 37YRS Technic Temperature: 72F Gender: MALE Weight: 285LBS Barometric Press: 760mdHg Medication: Smoker: NO BTPS Carrectton': 1.104 Dosage: Ethnicity /Correction: CAUCASIAN 100 0% Normals: KNUDSON 83 Clinical Format: PREMED - 02:15PM < ndicai es ReJcw LLN Best Criteria: VAL P Report Summa re ests 9 ICccepta6Te 0 Reprod�Icibre 0 FVC VAR: 52I141. FEVI VAR: FAME PEF VAI 30 /S ATS Interpretation: Corent: . : - .+ 2 C•=1S TIMB ( Page 1 of 2 .7 aF t s .wn.:%.I ,J I...Frvt t, JVU I1I I LURLUt% UUU - 1 JCJJ IUII UULX . IUPINILU1L Puritan- Bennett Renaissance II Session Time: 02: 5PM S /N: G- 20020370135 Last Cal Check: 24M011 Version: 1.1.11 BEST MVV REPORT ID: Height: 68" Physician: Sensor Code: 838347 Name: EPSTEIN,ROBERT Age: 37YRS Technician: Temperature: 72F Gender: MALE Weight. 285L8S Barometric Press; 760mraHg Medication: Smoker: NO BTPS Correction: 1.104 Dosage: Ethnicity /Correction: CAUCASIAN 100.01 Normals: KNUDSON 83 Clinical Format: PREMED - 02:15PM Page 2 of 2 ) y5 „i.ps: sernnce.emedprac :iLe.com emr env_ Swnmary.aspx!tab_ld— DAVID O. KATEB M.D. P.A. 4760 W. ATLANTIC AVE DELRAY BEACH,FL 334453839 5616373933(p) 5616373935(f) t Name : Robert Eostein Sex : Male DOB : Age : 3z ServiceDate : 03/22/2012 CHIEF COMPLAINT : Powered by Emedpractice.com l of 3 3/22/2012 2:45 PM DAVID 0. KATEB M.D. P.A. 4760 W. ATLANTIC AVE DELRAY BEACH,FL 334453839 5616373933(p) 5616373935(f) Name : Robert Epstein Sex : Male DOB : Age :12 ServiceDate : 03/22/2012 � I 4 Refills # 30(Thirty), !Powered by Emedpractice.com 361 2 of 3 3/22/2012 2:45 PM imps. I I SC rvice.emeapracuce.com emriemr Surnmary.aspx*Itabid= DAVID 0. KATEB M.D. P.A. 4760 W. ATLANTIC AVE DELRAY BEACH,FL 334453839 5616373933(p) 5616373935(f) Name : Robert Epstein Sex : Mile DOB : Age : 3.2 ServiceDate : 03/22/2012 BILLING SERVICES : / 111 99214 -- OFFICE MODERATE COMPLEXITY -- 0000»786.05»786.2»278.00 Provider :DAV .• , TEB, M.D., P.A. Powered by Emedpractice.com • 3 ! 3 of 3 3/22/2012 2:45 PM DAVID O. KATEB M.D. P.A. 4760 W. ATLANTIC AVE DELRAY BEACH,FL 334453839 .? T 5616373933(p) 5616373935(f) Name : Robert Epstein Sex : Male DOB : Age : az ServiceDate : 02/24/201Z 32-- powered by emedpractice.com I of 3 2/24/2012 3:02 PM P : 105 F102 RR : 16 RPM Temp : 96 F 02 SAT :97% on 02 21% ROS : ; PRESCRIPTIONS : :'lowered by emedpractice.com 33 2 of 3 2/24/2012 3:02 Ph/ , IrIg�'SERVICES : • -- 9921,8- _,;,,_OFFICE MODERATE COMPLEXITY -- 278.00 »786.05 *786.2 *506.0 , G8553 -- E- PRESCRIBING -- 278.002.786.2 Provider : • A •/ 4 %TEB, M.D., P.A. / Powered by emedpractice.com �j q 3 of 3 2/24/2012 3:02 PN • "t" • v.. David O. KATEB M.D. P.A. 4760 W. ATLANTIC AVE DELRAY BEACH,FL 334453839 5616373933(p) 5616373935(f) Name : Robert Epstein Sex :big DOB : Age : 7 ServiceDate : 01/25/2012 CHIEF COMPLAINT : — ---- __ - -_ -- P : 90 F102 RR : 16 RPM Temp : 98 F 02 SAT :97% on 02 21% https://service.emedpractice.com/emr/emr_Summary.aspx?tab_id=19 1/25/2012 * wbv a.. va ✓ I1ROS : f - - - • - ASSESSMENTS : f — - - PLANS - ...- -- _ -- - - -- - - - -- ii _ PRESCRIPTIONS : , https:// service.emedpractice.com/emr /emr Summary. aspx?tab_id =19 1/25/2012 1 u .J FollowUp : 1 Months. iNI - -- 99204 -- OFFICE NEW MODERATE COMPLEXITY -- 519.11»506.0»786.2, G8553 E-PRESCRIBING -- 786.2 , 9401T-- Splrometry -- 506.0 Physidan :D. :AL , TEB, M.D., P.A. ma , _ _ TLVEretillyrernEdpr rict oi - https://service.emedpractice.com/emr/emr Summary.aspx?tab id=19 1/25/2012 IL •L—/ JV Iv.,Y IJV r Cif t.0 SEACREST MRI 2828 S. SEACREST BLVD. SUITE 202 4800 LINTON BLVD. SUITE A-203 10140 FOREST HIU. BLVD. SUITE 120 BOYNTON BEACH, FL 33435 DELRAY BEACH, FL 33445 WELLINGTON, FL 33414 PHONE: (561) 730 -9674 PHONE: (561) 7394674 PHONE (561) 7304874 FAX: (561) 739 -9668 FAX: (661) 739 -9666 FAX: (561) 7394668 PATIENT NAME: EPSTEIN, Robert DOB` - - DA OPSTUDY: =3f Z2Of2 =- ___ - _ _ _ • REFERRED BY: Dr. Timothy A nderson Thank you for referring this patient. )6 "344/J'Ale v. Joseph Kozlowski, MD Diplomats American Board of Radiology Fellowship Trained MRI Specialist Cl/20120313. 031 /JK/GANY Signed: 3/13/201211:62:28 AM by: Joseph Kozlowski MD [Electronic Signature} Page 1 LAW OFFICES OF FRANKS & KOENIG 8371 N. Military Trail, Suite 101 Palm Beach Gardens, FL 33410 PHONE: (561) 616 -3800 FAX: (561) 616 -5678 ELI A. FRANI{,S, ESQ.* Andrew Neuwelt, Esq. JUDD P. I OENIG, ESQ.* Eric S.-Lakind,•Esq. - = - *Licensed to Ge 4 - ` - — _ __ _ __ _ _ _. _ _ _ _ _ _ _ May 4, 2012 IT" ,41 David Kateb 4760 W Atlantic Ave Delray Beach, FL 33445 ( L3 9 RE: Employee Robert Epstein Employer : City of Boynton Beach Police Department D/A : 1/7/2012 Dear Dr. Kateb: Please be advised that I represent the employee/claimant, RobertEpstein, date of birth: in the above workers' compensation claim. It is my understanding that you have provided treatment for the claimant as a result of this accident or another condition. Please accept this as our request for a complete_ copy ..of y r xeco ;.:r ecting—treatment- rendered. to date. We do not need " -- statements or certification. I would also ask that you place my name on your chart to receive copies of future records as they are prepared. Enclosed you *ill find my client's signed medical records authorization. If possible, please forward any records via email to reception©franksandkoenia.com or via fax Additionally, if the cost of this request is in excess of $50.00, please call the undersigned for confirmation. 1 appreciate your cooperation and assistance in this matter. Very ly Y urs, • Andrew S Neuwelt me . Enclosures: medical release • • - • frr• • . 4 SOUTH FLORIDA PULMONARY 4760 WEST ATLANTIC AVE. DELRAY BCH, FL 33445 Nam: EPSTEIN, ROBERT ID: 5260 Physician: DAVID O. KATEB, M.D. Study Date: 2/2212012 10:26 Technician: AMADA KNIGHT Age: 37 Diagnosis: Bronchospasms/exposure to smoke Gender. Male Smoke Status: Never Height: 172.7 cm, 68.0 in Pack years: Weight: 129.5 kg, 284.9 be _ -- - - - - - _ _- Raw: VViilte -- _ _ :---:-•_ - - > Lt0 Name: EPSTEIN .RT Page 2 ( HI Name: EPSTEIN Rd .TT 3 Al* VI% 4,01.t7 ArVci, LAW OFFICES OF FRANKS & KOENIG 8371 N. Military Trail, Suite 101 Palm Beach Gardens, FL 33410 PHONE: (561) 616 -3800 FAX: (561) 616 -5678 ELI A. FRANKS, ESQ.* Andrew Neuwelt, Esq. JUDD P. KOENIG, ESQ.* __ Eric S..Lakind,..Esg. _ 'licensed i�cGeorgut = — •= — — _ _ __ - - _ - - - —_ — May 4, 2012 David Kateb 4760 W Atlantic Ave Delray Beach, FL 33445 RE: Employee : Robert Epstein Employer : City of Boynton Beach Police Department D/A : 1/7/2012 Dear Dr. Kateb: Please be advised that I represent the employee/claimant, RobertEpstein, date of birth: in the above workers' compensation claim. It is my understanding that you have provided treatment for the claimant as a result of this accident or another condition. Please accept this as our request for a complete copy of your records reflecting treatment rendered to date. We do not need patient statements or certification. I would also ask that you place my name on your chart to receive copies of future records as they are prepared. Enclosed you will find my client's signed medical records authorization. If possible. please forward anv records via email to receotiont7a ,franksandkoenig.com or via fax Additionally, if the cost of this request is in excess of $50.00, please call the undersigned for confirmation. 1 appreciate your cooperation and assistance in this matter. Very my Y urs, Andrew S. Neuwelt me Enclosures: medical release y to1� PATIENT AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION (PHI) • 1, gnho( -- (x - ke‘ n hereby authorize -) , its _-�agents,_emp�loyees and : associates,- torelease -t ie- protected- health - information -that ice.— ----_—_-- — described below to the Law Othces ot Hanks & ! ce g._ _— • The specific information that should be disclosed is: any and all medical records pertaining to my physical or mental condition, including drugs, mental health, alcohol or HIV, whether past, present or future. A photostatic copy of this authorization should be likewise honored. • This protected health information is to be used for representation in a workers' compensation action. • 1 understand that the information used or disclosed may be subject to re- disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations. • This release may be revoked by a signed and properly dated written revocation, delivered to the health care provider, provided that this release cannot be revoked as to protected health information that had been previously released in reliance on this document. • I understand that a refusal to sign this form will not result in a denial of health care by the hospital or any other health care provider and that this release has not been coerced by a health care entity or any of its business associates. • This release expires one year from date. • Dated Si 41 J Z . Patient/Clien Signature r Date of Birth: bit' ail. GV. CV IL 9: V tHm Y"WtKl,lAl K1SK MANAGEMENT No. 0566 P. 2/2 26, (�o2 mmei�uial Risk Managc iient, Inc. Affiliate Southeastern Underwriters, Inc. uary P.O. Box 18366, Tampa, FL 33679 -8366 —Phone (813) 289 -3900 — Fax (813) 289 -3771 an David Kateb, MD Fax 561 637 -3935 RE: Employee: ROBERT EPSTEIN Employer: CITY OF BOYNTON BEACH Z D /A: 01/07/2012 File: 06250376 Dear Dr. Kateb: ) 4 1.4 (si . a � ateb / date) Please fax back to me at 813 289 -3771. Sincerely, I r k/ . 4,414,. Regina Lingner Sr. Claims Adjuster Spi romeetry Report SOUTH FLORIDA PUIM Session Date: 253AN2O12 Puritan - Bennett Renaissancf Sesstnn Time: Q2:44PM SIN: G- 20020370135 Last Cal Check: 24MAR2011 Vprsinn- 1 1 11 RFST FVC7FV1 RFPCNL ID: height: 68' Physician: Sensor Code: 339772 Name: EPSTEIN.ROBERT Age: 37YRS Technician: Temperature: 72F Gender: MALE Weight: 285LBS Barometric Press: 760mmHg Medication: Smoker: NO BTPS Correction: 1.104 Dosage: Ethnicity /Correction: CAUCASIAN 100.0% Normals: KNUDSON 83 Clinical Format: PREMED - 02:45!91 < Indicates Below LLN Best Criteria: VAL MFIISIRFMFNT Refit wry: ()retied: Tests 6 Acceptable 0 Reproducible 0 FVC VAR: 127ML FEV1 VAR: 226ML PEF VAR: 56Q9ML /S ATS InLerpreLaLiar PREMED - Norval SpirtmieLry c - Pagclof2 ti(0 spirometry Report SOUTH FLORIDA PULM Session Date: 25JAN20 Puritan - Bennett Rena1ssanef Se sio 'Fie e: 02: 441 SIN: G- 20020370135 Last Cal Check: 24MAR20. version: 1.1.11 BEST° MW REPORT ID: Height: 68" Physician: Sensor Cade: Name: 1N. 3397 e: EPSTC.ROOERT Age: 37YRS. Technician: tnec_ 7 Gender: MALE llCight: 2851BS Barometric Press: 76O0m Medication: Smoker: NO BPS Correction; 1.1( Dosage: Ethnicity /Correction: CAUCASIAN 1OO.0t Normals: KNUDSON i Clinical. Conaat� _ :. - =Cl,2:45PM g7 Page 2 of 2