EXHIBIT(S) - X (Motion #007) WUH April 16, 2013 Admission Possible SSN Administratively Redacted - WUH April 16, 2013 Admission Possible SSN Administratively Redacted February 12, 2018 (2024)

 
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 D: NA AU OUN PK Dv INDEX NO. 606206/2015NYSCEF Doc. NO. 137 RECEIVED NYSCEF: 02/12/2018 a. ee a oe ne Exhibit X pense rene isaernantes aT. RRL HESE jt reD: NA AU OUN PK Dv INDEX NO. 606206/2015NYSCEF DOC NO-~ 137 RECEIVED NYSCEF C27T. "7 WINTHROP University Hospital . hereby certify that the attached record is in the custody of and is a true and complete record of the condition, transaction, occurrence or event of this institution concerning: q FRANTINO, DESIREE ‘Name of Patient 80171598 (Records from 2010 thru 2014) Medical Record Number / Dates of Service I further certify that this record was made in the regular course of business of this institution, and that it is in the regular course of business of this institution to make such record, and that such record was made at the time of the condition, transaction, occurrence, event or a reasonable time thereafter, APRIL 12, 2016 Date BR a4 | Hoe t-F YY ht Brent Hoggatt Information Access Manager Health Information Management 200 Old Country Rd—Suite 580 Mineola, NY 11501D: NA AU OUN PK PIV INDEX NO. 606206/2015NYSCEF DOC. NO. 137 RECEIVED NYSCEF: 02/12/2018 WINTHROP ADMISSION RECORD MRN 80171598 == I University Hospital FRANTINO, DESIREE Mineola, L. L, New York 11501 F 18 CTH WEINBLATT MARK PED TRN 04/16/2013 AD2066 ENG PATIENT NAME THLE ‘AKAIMAIDEN NAME ‘MED REC NO. ‘ADMITTING NO. FRANTINO, DESIREE 80171598 as ‘ADDRESS ADMIT TIME: “ADMIT DAY "ADMIT DATE: 41 ORCHARD ST 5:39 PM WED 04/16/2013 omy IP COUNTY [STATE] ROOM NSG STA CAPD ‘SERVICE [ETHNICITY | PREF LANG] RACE FARMINGDALE 11735] 280 NY|N55605 NPSA PED |N ENG | W TELEPHONE ‘SEX ] MS REL ‘BIRTH DATE AGE ‘ADMITTING DIAGNOSIS: (516) 420-1353| F| S| CTH ‘SOCIAL SECURITY NO. ‘OCCUPATION |: SEPTIC SHOCK/PNEUMONIA [ATTENDING MD 1D NO. STUDENT EINBLATT MARK 02856 EMPLOYER EMPLOYER TELEPHONE: REFERRING MD TONG, STUDENT EINBLATT MARK 02856 EMPLOYERS ADDRESS: PROCEDURE “TYPEOF ADMISSION, ‘SERVICE TYPE] "ADMIT SOURCE ISOLATION INDIGATOR EDNO. URGENT TRN TH NONE a ‘GUARANTOR NAME ‘GUARANTOR DOB RELATION TO PATIENT [GUARANTOR S00. SEC. NO. MODE OF ARRIVAL FRANTINO, DESIREE SELF AP ‘GUARANTOR EMPLOYER GUARANTOR EMPLOYER ADDRESS: STUDENT ‘GUARANTOR EMPLOYER TELEPHONE "ADVANCE DIRECTIVE: INFO. COPY ON FILE: BILL OF RIGHTS [PAT PRIOR HOSPITAL NAME XY N Y N WINTHROP UNIV. HOSF PRIMARY EMERGENCY CONTACT RELATION TO PATIENT TELEPHONE PRIOR HOSPITAL DATES FRANTINO PAUL FATHER 516 420-1353 041013 041613 MERGENGY CONTACT ADDRESS ‘BUSINESS TELEPHONE 41 ORCHARD ST FARMINGDALE NY 11735 718 463-7896 ‘SECONDARY EMERGENCY CONTACT RELATION TO PATIENT TELEPHONE BUSINESS TELEPHONE FRANTINO VIOLA MOTHER 516 420-1353 917 862-5617 ‘SITE OF ACCIDENT ‘ACCIDENT DATE/TIME, AL ‘DX COMMENTS: [COMMENTS PLAN CODE PLAN DESCRIPTION POLICY NO. ‘GROUP NO. PRIORITYVERIFY INDICATOR PATIENT RELA INSURANCE TELEPHONE ‘SUBSCRIBER NAME TO SUBSCRIBER PREFIX SUFFIX AUTH. NO. KO1 HIP MEDICAID 999999 1 YX FRANTINO DESTREE 1 866) 447-9717 24572893 G25 MEDICAID GME DR60601M 2 XY FRANTINO, DESEREE ‘COMMENTS COMMENTS CLERGY VISITS: Fo PT. STATUS DEL TYPE Ww IA "ANNOINTED BY [ORIGIN CODE ADMITTED BY ST_JOSEPH'S HOSPITALAD2066 KOi HIP MEDICAID EFFE 10/1/12, TRACE 4572 9 PER WEB ADI to: MA ELIG PER HDX=HIP ADIR 4 Pisrbution 625 Records Patient Accounts 75489-A 5/99 Rev. 06/07, 10/07 Social WorkD: NA AU OUN PK PIV INDEX NO. 606206/2015NYSCEF DOC. NO. 137 RECEIVED NYSCEF: 02/12/2018 WINTHROP ADMISSION RECORD MRN 80171598 ! University Hospital FRANTINO ,DESIREE Mineola, L. |., New York 11501 F 8 CTH WEINBLATT MARK PED 04/16/13 AD5773 ENG PATIENT NAME THLE ‘AKAIMAIDEN NAME MED REG NO. ‘ADMITTING NO. FRANTINO , DESIREE 80171598 as "ADDRESS: “ADMIT TIME “ADMIT DAY “ADMIT DATE 41 ORCHARD ST 05:39P TUE 04/16/13 cry ZIP COUNTY STATE) ROOM NSO STA CAPD ‘SERVICE [ETHNICITY [PREF LANG] RACE FARMINGDALE 11735]280 NY |N55605 |NP5A PED N ENG Ww TELEPHONE SEX] MS REL BIRTH DATE ‘AGE ‘ADMITTING DIAGNOSIS 516-420-1353 | F | S| CTH 18 SEPTIC SHOCK/PNEUMONIA ‘SOCIAL SECURITY NO. ‘OCCUPATION ATTENDING MD TO NO. STUDENT WEINBLATT MARK 02856 EMPLOYER EMPLOYER TELEPHONE JREFERRING MD 1D NO. STUDENT = - WEINBLATT MARK 02856 EMPLOYERS ADDRESS PROCEDURE ‘TYPE OF ADMISSION ‘SERVICE TYPE] "ADMIT SOURCE ISOLATION INDIGATOR ED NO. URGENT TRN TH es GUARANTOR NAME ‘GUARANTOR DOB | RELATIONTO PATIENT [GUARANTOR SOC. SEC. NO. ‘MODE OF ARRIVAL FRANTINO , DESIREE ‘GUARANTOR EMPLOYER | ‘GUARANTOR EMPLOYER ADDRESS SEL AP STUDENT ‘GUARANTOR EMPLOYER TELEPHONE ‘ADVANCE DIRECTIVE: INFO. COPY ON FILE, BILL OF RIGHTS [PAT PRIOR HOSPITAL NANE - - Y N Y N WINTHROP UNIV. HO PRIMARY EMERGENCY CONTACT RELATION TO PATIENT TELEPHONE PRIOR HOSPITAL DATES FRANTINO , PAUL FATHER 516-420-1353 04/10/13 04/16/13 EMERGENCY CONTACT ADDRESS ‘BUSINESS TELEPHONE 41 ORCHARD ST FARMINGDALE NY 11735 718-463-7896 ‘SECONDARY EMERGENCY CONTACT RELATION TO PATIENT TELEPHONE ‘BUSINESS TELEPHONE FRANTINO , VIOLA MOTHER 516-420-1353 917-862-5617 ‘SITE OF ACCIDENT ACCIDENT DATE/TIME ‘DX COMMENTS: ‘COMMENTS PLAN CODE PLAN DESCRIPTION POLIGY NO. “GROUP NO. PRIORITVIVERIFY INDICATOR SUBSCRIBER NAME PT REL PREFIX SUFFIX INSURANCE TELEPHONE. AUTH. NO. KO1 FRANTINO PR6O6O1M HIP MEDICAID , DESIREE am” 866-447-9717 999999 1 N - - ‘COMMENTS [COMMENTS ‘CLERGY VISITS: FC Pi. STATUS DEL TYPE Ww IA "ANNOINTED BY [ORIGIN CODE "ADMITTED BY ST JOSEPH'S HOSPITA AD5773 URGENT TRANSFER/NEEDS AUTH]T Disteibution to: Medical Records ationt Accounts. 75489-A 5/99 Rev. 06/07, 10/07D: NA AU OUN PK PIV INDEX NO. 606206/2015NYSCEF DOC. NO. 137 RECEIVED NYSCEF: 02/12/2018 MRN 80171598 1007164 VWiibs in. RE FRANTINO, DESIREE F Univers: Hospital 18 CTH WEINBLATT MARK PED TRN 04/16/2013 NU0359 ENG PATIENT CONSENT TO THE RELEASE OF RECORDS FOR NYS EXTERNAL APPEAL The patient, the patient's designee, and the patient's provider have a right fa an external appeal of certain adverse determ ns made hy health plans. In the event an external appeal is filed, a consent to the release of medical records. signed and dated by the patient, is necessary. An extemal apgeal agent assigned by the New York State Insurance Department wit! use this consent to obtain medical information from the patient's health plan and health care providers. The name and address of the external appeal! agent will be provided with the request for medical information. V authorize my health plan and providers to release all relevant medical or treatment records related to the external appeal, including any HIV-related information, mentai health treatment information, or alcohol / substance abuse treatment informaiion, to the external apyeal ageni. | understana ihe external appeal agent will use this information solely to make a decision on the appeal and the information will be kept confidential and not released to anyone else. This release is valid for one year. | may revoke my consent at any time, except lo the extent that action has been taken in reliance on it, by contacting the New York State {nsurarice Department in writing. | understand that my health plan cannot condition trectment, enrol! tenet, eligibility. er payment on whether | sign this for. | ackncwledge that the decision of the external appeal agent is binding. } agree not to commence a laga! proceeding against the external appeala to review the agent's decici iy: proviced. howover, this shail rt limit my right to bring an action against ‘he eyterr: appeal agent for damages for bad fait or grass negligence, or to bring an action against my health plan. 1) a Qe A atils Signature of Patient ‘Date) {Or the pationt’s representative wee 1 consent to the release of the patient's medical recerds. If a parent signs for a ininor child, indicate the age of the chi Ifa guardian or executor signs, include precf af the appointment.) Print Nove: Patient's Health Plan ID#: Tebrcerd AR Goto! hol SATISD: NA AU OUN PK PIV INDEX NO. 606206/2015NYSCEF DOC. NO. 137 RECEIVED NYSCEF 02/12/2018 SY MRN 80171598 100716419 WINTHROP University Hospital FRANTINO, DESIREE 18 Fe CTH WEINBLATT MARK PED TRN Mineola, L.l., New York 11501 ENG 04/46/2013 AD1841 Acknowledgement | acknowledge receipt of the booklet, Your Rights as a Hospita! Pat.ent in New York State, prepared by the New York State Department of Health. r Patient's Bill of Rights An Important Message Regarding Your Rights as a Hospital Inpatient Admission Notice to Medicare Beneficiaries Important Message from Medicare Planning in Advance for Your Medical Treatment (an explanation of Advance Directives) Deciding about CPR: Do-Not-Resuscitate (DNR) Orders - A Guide for Patients and Families Appointing Your Health Care Agent - New York Siate’s Proxy Law Health Care Proxy form Letter from the New York State Department of Health (explains the Sparcs data collection System) Organ Donor information Smoking Cessation / Educational Material lf you have any questions regarding these documents, please speak to your physician, nurse or call Patient Relations at x2058. -- a Patient's Signature nee GVA Date — U Signature of Patient's De —— ynated Representative Indi seiko te relationship to patient HIS IS'‘TO BECOME A PART OF THE PATIENTS PERMANENT MEDICAL RECORD 70027 (19/00) Rev 7/01, 8/05D: NA AU OUN PK PIV INDEX NO. 606206/2015NYSCEF DOC. NO. 137 RECEIVED NYSCEF: 02/12/2018 WINTHROPUniversity Hospital Mineola, L. L, New York 11501 ADMISSION RECORD MRN 80171598 FRANTINO ,DESIREE 1 18 FE CTH WEINBLATT MARK PED 046/13. AD5773 ENG: PATIENT NAME TITLE ‘AKAMMAIDEN NAME ‘MED REG NO. ‘ADMITTING NO. FRANTINO , DESTREE 80171598 a ‘ADDRESS: “ADMIT TIME “ADMIT DAY ‘ADMIT DATE 41 ORCHARD ST 05:39P TUE 04/16/13 cry ZF COUNTY /STATE| ROOM ‘NSG STA CAPD ‘SERVICE [ETHNICITY [PREF LANG] RACE FARMINGDALE 117351280 NY|N55605 |NP5A PED N ENG Ww TELEPHONE Sex] Ms REL ‘BIRTH DATE AGE [ADMITTING DIAGNOSIS: 516-420-1353 F[S|CTH 18 SEPTIC SHOCK/PNEUMONIA ‘SOCIAL SECURITY NO. OCCUPATION [ATTENDING MD_ 1D NO. STUDENT WEINBLATT MARK 02856 EMPLOYER EMPLOYER TELEPHONE EFERRING MD TO NO. STUDENT - - WEINBLATT MARK 02856 EMPLOYERS ADDRESS, PROCEDURE ‘TYPE OF ADMISSION. SERVICE TYPE] “ADMIT SOURCE ISOLATION INDIGATOR ED NO. URGENT TRN TH a GUARANTOR NAME ‘GUARANTOR DOB RELATION TO PATIENT ‘GUARANTOR SOC. SEC. NO. ODE OF ARRIVAL FRANTINO ,DESIREE ‘GUARANTOR EMPLOYER | ‘GUARANTOR EMPLOYER ADDRESS SF AP STUDENT ‘GUARANTOR EMPLOYER TELEPHONE "ADVANCE DIRECTIVE: INFO. COPY ON FILE BRL OF RIGHTS [PAT PRIOR HOSPITAL NAME: - - Yy N Y N WINTHROP UNIV. HO PRIMARY EMERGENCY CONTACT RELATION TO PATIENT TELEPHONE PRIOR HOSPITAL DATES FRANTINO , PAUL FATHER 516-420-1353 04/10/13 04/16/13) EMERGENCY CONTACT ADDRESS [BUSINESS TELEPHONE 41 ORCHARD ST FARMINGDALE NY 11735 718-463-7896 "SECONDARY EMERGENCY CONTACT RELATION TO PATIENT, TELEPHONE BUSINESS TELEPHONE FRANTINO , VIOLA MOTHER 516-420-1353 917-862-5617 ‘SITE OF ACCIDENT ‘ACCIDENT DATETIME DX COMMENTS ‘COMMENTS PLAN CODE PLAN DESCRIPTION POLICY NO. ‘GROUP NO. PRIORITYNERIFY INDIGATOR ‘SUBSCRIBER NAME PT REL, PREFIX SUFFIX INSURANCE TELEPHONE AUTH. NO. KOL HIP MEDICAID 999999 1 sN FRANTINO , DESIREE 1 66-447-9717 DR60601M E COMMENTS. [COMMENTS H O Jauxervars Fe PT. STATUS: DEL TYPE Ww IA s ANOINTED BY ‘ORIGIN CODE ‘ADMITTED BY ST JOSEPH'S HOSPITA ADS773 URGENT TRANSFER/NEEDS AUTHJT Distribution to: jedical Records 75489-A 5/99 Rev. 06/07, 10/07 senD: NA AU OUN PK Dv INDEX NO. 606206/2015NYSCEF DOC. NO. 137 RECEIVED NYSCEF 02/12/2018 WwUniversity Hospreal P “**PREADMIT/ASU WORKSHEET** Mineola, L. 1, New York 11801 PATIENT NUMBER: 100716419 PATIENT NAME: FRANTINO ,DESIREE ISOLATION: - MRN: 80171598 HOSP SVC: PED PATIENT INFO: ADDRESS: 41 ORCHARD ST PT #: CITY: FARMINGDALE STATE: NY ZIP: 11735 PHONE NUMBER: 516-420-1353 BIRTHDATE: a MARITAL STATUS: Ss SEX: F RELIGION: CTH RACE: Ww ALT PHONE NUMBER: ETHNICITY: N PREFERRED LANGUAGE: ENG EMPLOYER INFO: OCCUPATION: STUDENT EMPLOYER: STUDENT EMPLOYER ADDRESS: CITY: STATE: ZIP: EMPLOYER PHONE: -- GUARANTOR INFO: GUARANTOR NAME: FRANTINO ,DESIREE RELATIONSHIP TO PATIENT: ADDRESS: 41 ORCHARD ST APT: CITY: FARMINGDALE STATE: Ny ZIP: 11735 PHONE NUMBER: 516-420-1353 INSURANCE INFO: PLAN CODE; KO1 PLAN DESCRIPTION: HIP MEDICAID POLICY NUMBER: ADR60601M01 SUBSCRIBER: FRANTINO ,DESIREE PREFIX: SUBSCRIBER REL TO PT: 1 PRIORITY: 1 HOME PHONE: 516-420-1353 INSURANCE CO PHONE: 866-447-9717 AUTHORIZATION NUMBER: PLAN CODE; PLAN DESCRIPTION: POLICY NUMBER: DR60601M SUBSCRIBER: PREFIX; SUBSCRIBER REL TO PT: PRIORITY: HOME PHONE: 7 INSURANCE CO PHONE: -s AUTHORIZATION NUMBER: PLAN CODE: PLAN DESCRIPTION: POLICY NUMBER: SUBSCRIBER: PREFIX: SUBSCRIBER REL TO PT: PRIORITY: HOME PHONE: oe INSURANCE CO PHONE: s AUTHORIZATION NUMBER: PLAN CODE: PLAN DESCRIPTION: POLICY NUMBER: SUBSCRIBER: PREFIX: SUBSCRIBER REL TO PT: PRIORITY: HOME PHONE: ae INSURANCE CO PHONE: + AUTHORIZATION NUMBER; ATTENDING DOCTOR: WEINBLATT MARK ATTN DRNO: 02856 ATTN DR PH#: 516-663-9400 REFERRING DOCTOR: WEINBLATT MARK REF DR NO: 02856 PRIMARY CARE DR: PCP DR NO: CALMA MARIA F 02226 ADMIT DATE: 04/1613 SURGERY DATE: TN, DIAGNOSIS: DIFFICULTY BREATHING COMMENTS: RESP PARTY: AD3283D: NA AU OUN PK Dv INDEX NO. 606206/2015NYSCEF DOC "NOT 37 RECEIVED NYSUEF U2742/2018 Winthrop University Hospital Acct#: 100716419 PtName: FRANTINO DESIREE MR#: 80171598 Gender : Female 8 Die josition lome, Self Care (1) Admit Date : 04/16/2017 Disch Date : 04/20/2013 AP DRGs (NY) DRG Information 584 SEPTICEMIA W MAJOR CC S.l.wt 4.1633 MeanLOS 12 LowTrim 3 High Trim 38 APR (all versions) DRG and MDC Information 720 SEPTICEMIA & DISSEM INFECT APRwt 1.3272 LowTrim 2 HighTrim 20 ALOS 6,62 GLOS 5.77 Status: LOS Iniier 018 INFECTIOUS & PARASITIC DISEASES. 3 Major Severity of Iliness 3 Major Risk of Mortality Principal Diagnosis *0389 Unspecified septicemia Affects secondary DRG *SOl=P Principal diagnosis used for SO! calculation *ROME=P Principal diagnosis used for ROM calculation Present On Admission: Y Secondary Diagnoses **78552 Septic shock (manifestation) *SOl=3 Major % *ROM=4 Extreme Present On Admission: Y #28419 Pancytopenia *SOI=3 Major ROM=2 Moderate Present On Admission: ¥ #486 Pneumonia, organism unspecified SOl=2 Moderate ROM=2 Moderate Present On Admission: Y 99592 Severe sepsis SOl=X Excluded ROM=X Excluded Present On Admission: Y 68601 Pyoderma gangrenosum SOl=1 Minor ROM=1 Minor Present On Admission: Y V1251 Personal history of venous thrombosis and embolism SOl=1 Minor ROM=1 Minor Present On Admission: E Principal Procedure page 1NA AU OUN Dv INDEX NO. 606206/2015NYSCEF DOC. NO. 137 RECEIVED NYSCEF: 02/1P/2018t1 Winthrop University Hospital Acct#: 100716419 PtName: FRANTINO DESIREE MR#: 80171598 3893 Venous catheterization 04/16/2013 02856 Other Procedures 3891 Arterial catheterization 04/16/2013 02856 9804 Transfusion of packed cells 04/18/2013 02856 | certify that the narrative descriptions of the principal and secondary diagnoses and the major procedures performed (oe are accurate and complete to the best of my knowledge. S fielie % —_——_ Physician's Signature Date e page 2D: NA AU OUN PK Dv INDEX NO. 606206/2015 = YSNYSCEF DOC. NU. 137 /2018 ae wi NIGROP University Hospital MRN Mineoia, LI, New York 11504 Yorrsre: ' goo? K . SUMMARY SHEET RARTINO — YesIPee Asks AD! SERVICE (CE DAYS [ADMISSION PHYSICIAN OL wae feZ| [> DISCHARGE PATE DISCHARGE SERVICE | SERVICE DAYS: DISCHARGE PHYSICIAN a [OTHER SERV. TRANS. Fc SERVICE DAYS TRANSFER PHYSICIAN ‘ORG [OTHER SERV. TRANS, TRANSFER SERVICE SERVICE DAYS TRANSFER PHYSICIAN - = {CONSULTANT Ss: uel 2220 WS PROVISIONAL DX: working Dx, complete within 2¢ ts, of admission. BBLS nt ICD-9-CM CODE 6384 PRINCIPAL OX tho one conditiin established after the study to bo chiefly responsitle Ter cccadioring this admission. O3%4 SECONDARY Dx: yiasi Q2Bi4 4 459d 73SSa 4ak Ev6ol PRINCIPAL PROCEDURE: procedure performed for definitive treatment, and most related to the principal a 384 @ . oo « 

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