Peter F Merkle MD PA Plaintiff vs. State Farm Mutual Automobile Ins Co Defendant, CONO17007949, 10-02-2018_Affidavit (Fla. Broward Cty. Ct. Oct. 2, 2018) (2024)

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`knowledge.
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`1 have personal knowledge of the facts in this affidavit.
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`testify.
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`2.
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`3.
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`I am over eighteen (18) years of age and otherwise competent to
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`At all times material hereto, 1 am a licensed physician in good
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`standing authorized and entitled to perform medical services.
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`4.
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`I have reviewed the entire file for Antoinette Besbris from
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`Peter F. Merkle, MD, PA, for date of accident August 18, 2015, and therefore have
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`personal knowledge of the file. A copy of the patient’s medical and billing documents
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`are attached hereto as Exhibit ”A" Assignment of Benefits and Exhibit "B" as chart.
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`5.
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`At all
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`times material herein,
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`1 was a treating physician for
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`Antoinette Besbris related to her injuries sustained as a result of an automobile accident
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`on August 18, 2015.
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`6.
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`1 am familiar with the diagnosis of injuries, evaluations, testing,
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`medical care and medical treatment that has been provided to the patient, Antoinette
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`Besbris.
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`Sample
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`7. The treatment was rendered at the offices located at 1101 East
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`Road,
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`Pompano Beach, FL 33064 where Antoinette Beshris was treated for the injuries she
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`sustained arising out of and related to the accident of August 18, 2015.
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`8.
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`The medical treatment prescribed and administered to Antoinette
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`Besbris by myself or at our direction and under our supervision for medical services and
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`treatment which is at issue herein was rendered on August 31, 2015, for the injuries
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`sustained in an automobile accident occurring on August 18, 2015 and were provided at
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`the Piaintiff’ s facility by myself and staff.
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`9.
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`The facility and entire staff are properly licensed to render
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`medical services pursuant to the iaws governing the practice of medicine in the State of
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`Florida, County of Broward, City of Pompano Beach and all other regulatory bodies.
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`10.
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`I initially examined Antoinette Besbris in my office on August 31,
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`2015. At this time she was seen for injuries sustained to the left ankle, low back, and
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`ribs. She also had contusions on both thighs and the left leg.
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`11. As a result of the findings during this examination, Ms. Besbris was
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`diagnosed, x-rays were taken and reviewed, a closed reduction was performed, a short leg
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`cast applied, she was prescribed a treatment regimen of physical therapy, prescriptions,
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`and a follow up Visit. Ms. Besbris was instructed to utilize a fracture sandal and
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`crutches, to be nonweightbearing on the left lower extremity. Additionally, she was
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`unable to work.
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`12.
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`During this examination,
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`the patient complained of personal
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`injuries sustained as a result of her automobile accident that occurred on August 18,
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`2015, including pain in the left ankle, low back, and ribs, contusions on both thighs and
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`the left leg.
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`13. My impression was: Antoinette Besbris was seen today due to an
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`emergency medical condition, which is the direct result of the auto accident on August
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`18, 2015. She is status post a lumbar strain. She is status post a contusions of both
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`thighs. She has developed a seroma of the left thigh. She is status post development of a
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`hematoma of the right medial leg. She is status post a fracture of the left ankle iaterai
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`malleolus.
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`14. On August 31, 2015, I evaluated, examined and treated the patient,
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`Antoinette Besbris for several different complaints. My evaluation and examination on
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`August 31, 2015 was not limited solely to the patient’s fracture of the left ankle lateral
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`malleolus.
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`15. The Evaluation and Management services provided on August 31,
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`2015 to the patient, Antoinette Besbris, for her lumbar pain, rib pain, left leg contusion
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`and contusions of both thighs are significant and separately identifiable as unrelated to
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`the closed treatment of distal fibular fracture (lateral malleolus); with manipulation.
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`16. The medical services rendered to Antoinette Besbris at Peter F. Merkle, MD,
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`PA., 1101 East Sample Road, Pompano Beach, FL 33064 were rendered for the purpose
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`of diagnosing and treating her injuries and were performed by myself and my staff in
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`accordance with generally accepted standards of medical practice.
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`17.
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`The treatment rendered consisted of examination, supplies, medications,
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`X-rays, and closed treatment of the distal fibular fracture to relieve her pain and muscle
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`spasm, reduce inflammation and increase activities of daily function and return ranges of
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`motion which were reduced due to the trama.
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`18.
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`The treatment, examination and re-examinations described in paragraph
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`17. were clinically appropriate in terms of type, frequency, extent, site, and duration and
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`clearly were not for the convenience of the patient or myself, or physician, or any other
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`health care provider but were done for the purpose of treating the patient and resolving
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`the pain and injuries she sustained as a result of the automobile accident.
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`19. The medical treatment was for treatment and services
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`rendered to a reasonable degree of medical certainty as it pertains to the medical care and
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`treatment rendered to the patient, Antoinette Besbris, resulting from the August 18, 2015
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`automobile accident.
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`20.
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`I have reviewed all of the medical records and the treatment and
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`diagnostic testing required for Antoinette Besbris and the treatment rendered was
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`medically necessary and was rendered as a result of the August 18, 2015 accident.
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`21. The charge for Antoinette Besbris’s Office Visit billed under CPT
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`Code 99204 25 for date of service August 31, 2015 in the amount of $450.00 is
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`reasonable.
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`22.
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`I am familiar with what is customarily charged in the community
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`of Broward County, Florida for the services provided to Antoinette Besbris based on my
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`experience of practicing medicine in Broward County, Florida as a Physician.
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`23.
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`The charges for the medical treatment provided to Antoinette
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`Besbris were reasonable in the community of Broward County, Florida, where Plaintiff’s
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`business is located and were billed in accordance with the applicable Florida standards.
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`The appropriate CPT Codes for the treatment and supplies provided are listed on the
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`HCFA forms and ledger attached hereto in accordance with the medical treatment or
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`service performed.
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`24.
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`All examinations, evaluations, testing, medical care, and medical
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`treatment provided by myself and my staff have been medically necessary, reasonable,
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`and are related to the injuries sustained by Antoinette Besbris in the accident that
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`I HEREBY CERTIFY that on this day, before me, an officer duly
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`authorized in the State and County aforesaid to take acknowledgements, personally
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`appeared DR. PETER MERKLE, to me known to be the person described in and who
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`executed the foregoing instrument and who acknowledged before me that he executed the
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`same fi‘eely, voluntarily and with personal knowledge.
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`WITNESS my hand and official seal
`aforesaid this d7 day (mm ,20 8.
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`in the County and State last
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`Relationahieia patient:
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`ACKNQWLEIQGEMENT @F REGEEPT m: @REVACY NQTUCE
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`By signing this form, you are agreeing fine”: you havereoeiveci a copy of PETER F.
`MERKLE MD, PA. Privacy Notice, which describes how we use and disclose your
`health information. You have the right to re‘use to Sign this Acknowledgment, in which
`case we must doeumenfi our good faith effort to obtain your acknowleggment and line
`A by it was not obtained. ,
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` rinf name
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`For Office Use Only:
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`i personally delivered the Notice of Privacy Practices to the above-named patient (or authorized
`representative of the patient). A written acknowledgement of receipt by’ the patient or
`representative was not obtained for the following reaé’oMe):
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`Signature of Office Staff Member]
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`{Date}
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`Name:
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`CLAIM N0 59-6223—348
`LOSS DATE 0848-2015
`POLICY N0 0880-023—59F
`INSURED BESBRIS, GARY LEE
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`PAYMENT NO
`1
`
`PAYMENT AMOUNT $174.16
`ISSUE DATE 01-06-20
`
`Y CATHY V
`AUTHORIZED BY
`mom: {344) 292-8'615 V
`
`
`
`PETER MERKLE
`1 101 E SAMPLE RD OFC
`POMPANO BEACH FL 33064-5172
`
`START DATE 12-09-2015
`END DATE
`12-09—2015
`
`REMARKS
`
`BILL REFERENCE NO A162620052
`
`COVERAGE DESCRIPTION
`PERSONAL INJURY PROTECTION - MEDICAL
`
`ON BEHALF OF
`
`BESBRIS, ANTOINETTE
`
`AMOUNT
`174.16
`
`RETAIN STUB FOR RECORDS
`
`

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`&StateFarm
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`m
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`Claim Number: 59
`
`43223-348
`
`EXPLANATiON OF REVlEW
`This is W W
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`A8-2015
`Office Name: State F
`Date of Loss 08
`Company
`PIPMPC A’l Office » WlN
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`arm Mutual Automobile insurance
`
`Patient: Antoinette Beabrls
`cIo Shapiro lniury Group PA.
`3000 EDGEWATER DR
`ORLANDO, FL 32804»3720
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`Clai
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`mHandler. Bruce
`Sn‘vel
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`Address: PO Box 106134
`Atlanta, GA 3034845134
`Phone: {84432928615
`Ext: 8633182961
`Date Received: 12-242015
`,
`,
`
`Jurisdiction: Florida
`Bill Reference Number: A162820652
`
`SBRlS, GARY LEE
`Named Insured; BE
`@2369?
`Policy Number: 0880
`
`nu:_
`Payment Number:_
`Zip of Service: 33064-5196
`
`Diagnosis Codes:
`
`882.65XD - Nondisplaced fracture of
`with routine healing
`V43.52XD ~ Car driver injured in collision with other type car in traffic acci
`
`lateral melleolus of left fibula, subsequent encounter for closed fracture
`dent, subsequent encounter
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`12-39-2015-12—092015
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`~ @2015 — 12—09-2015
`Total Submitted Charges:
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`Total Approved Amount:
`Amount Not Payable:
`Deductible:
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`CoPay:
`Apportionment I Pro Rata:
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`Offset:
`a are Amoueé:
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`OPT!
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`Submitted
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`Approved
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`”0205 M Unigg Am Amati!“ W
`99213
`1.00
`$180.00
`$151.12 305
`73610
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`$200.00
`$68.58 881
`$380.00
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`$217.70
`$43.54
`330,00
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`DATE 07-06-2016
`1006978
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`based upon 200% ofthe 2007 Limiting Charge of Medicare physician fee schedule for the locale in which the services were rendered
`
`Procedure Guide
`
`73610 - Radiologic examination, ankle; complete, minimum of 3 views
`99213 — Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3
`key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low
`complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are
`provided consistent with the nature of the problem(s) and the patients andlor family’s needs. Usually, the presenting problem(s) are of
`low to moderate severity. Typically, 15 minutes are spent face-to—face with the patient andlcr family,
`
`Pursuant to Florida Statute, should you have any information to substantiate payment of an additional amount
`for the services rendered, please forward for our consideration within 1 5 days.
`
`Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, files a statement of claim
`containing false, incomplete, or misleading information is guilty of a felony of the third degree. F.S. 817.234(1)(b).
`
`Information on administering benefits under the 9810A policy form: Due to ongoing iitigation in Myers v. McCarty,
`(Case No. 2013-CA—0073) (Fla. 2d Jud’l Cir.), the Emergency Medical Condition provisions of the No-Fault statute are not being
`applied. Please contact us if you have any questions.
`
`1008978
`DATE: 01054016
`
`59 6223-348
`
`Professional
`2001 14mg 281 22-89-2015
`
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`01/20/16
`
`Acct Date
`
`Dep # Name
`
`PATIENT FINANCIAL HIS
`
`TORY BY DT SERVICE
`PETER P. MERKLE, M.D.,P.A.
`Accc*nts 162620 — 162620
`All Dates
`
`Page
`
`l
`
`.
`
`Dr# Procedure
`
`
`162620 BESBRIS,ANTOINETTE
`
`08/31/15
`BESBRIS,ANTOINETTE
`08/31/15
`BESBRIS,ANTOINETTE
`BESBRIS,ANTOINETTE
`BESBRIS,ANTOINETTE
`BESBRIS‘ANTOINETTE
`BESBRIS,ANTOINETTE
`BESBRIS,ANTOINETTE
`BESBRIS,ANTOINETTE
`Check Payment
`Adjustment
`(95}
`(95}
`Adjustment
`(95}
`Adjustment
`(9S)
`Adjustment
`BESBRIS,ANTOINETTE
`BESBRIS,ANTOINETTE
`Adjustment
`(29)
`Check Payment
`Adjustment
`(95)
`Adjustment
`(29)
`Check Payment
`Adjustment
`(95)
`RESERIS,ANTOINETTE
`‘BESERIS,ANTOINETTE
`BESBRIS,ANTOINETTE
`Check Payment
`Adjustment {95)
`Adjustment
`(9S)
`
`EV
`
`MMwM
`
`82%.
`
`10/03/15
`10/03/15
`10/03/15
`10/03/15
`10/03/15
`
`10/10/15
`10/10/15
`10/10/15
`10/31/15
`10/31/15
`10/31/15
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`01/10/16
`01/18/16
`01/18/15
`
`NEW PATIENT (45 MIN}
`X—RAY,ANKLE—COMPLETE
`X'RAY, 30100 - LUMEA
`CAST, APPLICATION SH
`ANKLE,FX TREATfLAT M
`EST pATIENT {15 MIN)
`X~RAY,ANKLE-COMPLETE
`POST op 0/0 INCL IN
`Ins 05902
`PIP ADJUSTMENT
`919 ADJUSTMENT
`010 ADJUSTMENT
`PIP ADJUSTMENT
`NEW PATIENT (45 MIN)
`XmRAY,ANKLE-COMPLETE
`INCLD IN OTHER PROC
`Ins 06982
`210 ADJUSTMENT
`INCLD IN OTHER 9000
`Ins #5902
`010 ADJUSTMENT
`EST PATIENT (15 MIN)
`X~RAY,ANKLE—COMPLETE
`EST PATIENT (15 MIN)
`Ins #6982
`01? ADJUSTMENT
`212 A03081M201
`
`4
`4
`4
`4
`4
`4
`1
`4
`
`99204
`73510
`72110
`29125
`2770010
`99213
`73510
`99024
`
`8—31
`
`4
`4
`
`99204
`73510
`
`9-14
`9-14
`
`10-9
`10-9
`
`4
`4
`4
`
`99213
`73610
`99213
`
`12—9
`
`0 0 O 0
`
`CO0C3
`
`08/31/15
`00/31/15
`
`0§K§2/15
`09/14/15
`09/14/15
`09/21/15
`10/03/15
`10/03/15
`10/03/15
`10/03/15
`10/03/15
`10/09/15
`10/09/15
`10/10/15
`10/10/15
`10/10/15
`10/31/15
`10/31/15
`10/31/15
`12/09/15
`12/09/15
`01/14/16
`01/18/16
`01/18/16
`01/10/15
`
`TOTALS FOR ACCOUNT 162620
`
`PAYMENTS
`REFUNDS:
`
`1319.22
`0.00
`
`ADJUSTS
`
`3020 90
`
`CHARGES
`
`.00
`
`1319.22
`
`3020.90
`
`

`

`09/22/15
`
`PATIENT ?INANCIAL HISTORY BY DT SERVICE
`PETER F. MSRKLE, M.D,,P.A.
`Accounts 162620 - 162620 All Dates
`
`fa*ge
`
`1
`
`Acct Date
`
`Dep # Name
`
`Dr% Procedure
`
`Ref Dt
`
`Diag
`
`Units
`
`Amount
`
`162620 BESBRZS,ANTOINETTE
`
`08/31/15
`08/31/15
`08/31/15
`08/31/15
`09/02/15
`09/14/15
`09/14/15
`09/21/15
`
`0
`0
`0
`0
`0
`0
`0
`0
`
`IBESBRIS,ANTOINETTE
`BESBRIS,ANTOINETTE
`BESBRIS,ANTOINETTE
`BBSBRES,ANTOENETTE
`EESBRIS,ANTOINETTE
`BESBRIS,ANTOINETTE
`EESBRlS,ANTOINETTE
`EEéBRIS,ANTOINETTE
`
`4
`4
`§
`4
`4
`4
`4
`4
`
`99204
`73610
`72110
`29428
`27788,W
`99213
`73610
`99024‘
`
`.
`
`_
`
`Previous Balance 2
`
`NEW PATIENT {48 MIN)
`XvRAY,ANKLEvCOMPLETE
`X~RAY, SPINE » LUMBA
`
`CAbT, &?
`£2 TECE SH
`ANKLE,FX TREAT~LAT M
`EST PATEENT (15 MIN)
`X'RAY,ANKLE-COMPLETE
`POST OP F/U INCL IN
`
`824.2
`824‘2
`847,2
`82$.2
`824.2
`82é.2
`824,2
`824.2
`
`TOTALS FOR ACCOUNT 162620
`
`PAYMENTS :
`REFUNDS:
`
`0.00
`0400
`
`ADJUSTS
`
`:
`
`0.00
`
`CHARGES :
`
`§180.pO
`
`0.00
`
`450.00
`200 00
`250.00
`45“ 90
`2450 00
`180.00
`200 00
`0.00
`
`4180,00
`
`1 00
`1 00
`1 00
`‘ 0“
`1 00
`1 00
`1 00
`1 00
`
`8.00
`
`

`

`PAYMENT NO
`
`ISSUE DATE
`AUTHORIZED BY
`PHONE
`
`1 .
`2'
`
`
`
`CLAIM N0 59—6223-348
`L033 DATE 08-18-2015
`POLICY N0 0880-023-59F
`INSURED BESBRIS, GARY LEE
`.
`
`1
`
`'
`
`PETER MERKLE
`1101 E SAMPLE RD OFC
`POMPANO BEACH FL 33064-5172
`
`START DATE 01—14-2016
`END DATE 01442018
`
`BILL REFERENCE NO A16260063
`‘
`
`COVERAGE DESCRiPTmN
`PERSONAL INJURY PROTECTION - MEDICAL
`
`,
`
`ON BEHALF OF
`BESBRIS, ANTOINETTE
`
`AMOUNT
`122.05
`
`RETAIN STUB FOR RECORDS
`
`

`

`@StateI-‘armr
`
`EXPLANATION OF REVIEW
`
`This is not a bill
`
`Claim Number: 590223—348
`
`Date of Loss: 08-18-2015
`
`Office Name: State Farm Mutual Automobile lnsurance
`Company
`PIPMPC A1 Office - WlN
`
`Patient: Antoinette Besbris
`cio Shapiro injury Group PA.
`3000 EDGEWATER DR
`ORLANDO, FL 328043320
`
`{
`
`Provider: Peter Merkle
`1101 E SAMPLE RD OFC
`POMPANO BEACH, FL 33084-5172
`
`'
`
`Claim Handler: Bruce Snively
`Address: PO Box 106134
`Atlanta, GA 30348-6134
`
`Phone: (844)292-8615
`
`Ext: 8633182961
`
`Named insured: BESBRIS, GARY LEE
`Policy Number: 0880-023-59F
`
`Date Received: 01-22~2016
`Jurisdiction: Florida
`Bil! Reference Number: A16260063
`
`TlN:—
`Payment Number:—
`Zip of Service: 33064-5196
`
`Diagnosis Codes: 017.24 ~ Benign lipomatous neoplasm of skin and subcutaneous tissue of left leg
`882.65XD — Nondisplaced fracture of lateral malleolus of left fibula, subsequent encounter for closed fracture
`with routine healing
`_
`V43.52XD w Car driver injured in collision with other type car in traffic accident, subsequent encounter
`
`.
`rvic
`of
`Lice D
`9.95.
`1
`01-14-2016« 01—14-2016
`11
`Total Submitted Charges:
`Total Approved Amount:
`Amount Not Payable:
`Deductible:
`
`OPT}
`89.393, M9053.
`99213
`,
`$180.00
`$152.56
`$30.51
`$0.00
`
`CoPay:
`Apportionment 1 Pro Rate:
`Offset:
`Paid Amount:
`
`$0.00
`$0.00
`$0.00
`$122.05
`
`Date
`1.00
`
`Submitted
`esteem:
`$180.00
`
`Approved
`Amount Rmcgm
`$152.56 305
`
`'
`
`Explanations
`306 ~ Our payment for this service is based upon a reasonable amount pursuant to both the terms and conditions of the policy of
`insurance under which the subject claim is being made as well as the Florida No-Fauit Statute, which permits, when determining a
`reasonable charge for a service, an insurer to consider usual and customary charges and payments accepted by the provider,
`reimbursem*nt levels in the community and various federal and state fee schedules applicable to automobile and other insurance
`coverages, and other information relevant to the reasonableness of the reimbursem*nt for the service. The payment for this service is
`based upon 200% oi the Participating Levei of Medicare Part B fee schedule for the locale in which the services were rendered.
`
`Procedure Guide
`99213 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3
`key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of tow
`
`DATE: 02-01-2016
`1006978
`
`59-6223~348
`
`Professional
`2002 147768 202 meiosis
`
`

`

`o
`
`complexity. Counseling and coordination of care with other physicians, other qualified health care professionals. or agencies are
`provided consistent with the nature of the problem(s) and the patient‘s and/or family’s needs. Usually, the presenting probiemis) are of
`low to moderate severity. Typically, 15 minutes are spent face—to-face with the patient andlor family.
`
`Pursuant to Florida Statute, should you have any information to substantiate payment of an additional amount
`for the services rendered, please forward for our consideration within 15 days.
`
`Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, files a statement of claim
`containing false, incomplete, or misleading information is guilty of a felony of the third degree. RS. 81 7.234(1 )(b).
`
`information on administering benefits under the 9810A policy form: Due to ongoing litigation in Myers v. McCarty,
`(Case No. 2013-CA—0073) (Fla. 2d Jud‘l Cit): the Emergency Medical Condition provisions of the No—Fault statute are not being
`applied. Please contact us it you have any questions.
`
`DATE: 02-01—2016
`1006978
`‘
`
`i
`
`59-6223-348
`
`Professional
`2002 147788 202 12244015
`
`

`

`Explanations
`
`65 ~This procedure is considered to be part of the global procedural package. Services such as casting, strapping, dressing
`changes andfor evaluation and management services are included.
`305 - Our payment for this service is based upon a reasonable’amount pursuant to both the terms and conditions of the
`policy of insurance underwhich the subject claim is being made as well as the Florida No~Fault Statute, which permits,
`when determining a reasonable charge for a service, an insurer to consider usual and customary charges and payments
`accepted by the provider, reimbursem*nt levels in the community and various federal and state tee schedules applicable to
`automobile and other insurance coverages, and other information relevant to the reasonableness of the reimbursem*nt for
`the service. The payment for this service is based upon 200% of the Participating Level of Medicare Part B fee schedule for
`the locale in which the services were rendered.
`681 - Our payment for this service is based upon a reasonable'amount pursuant to both the terms and conditions of the
`policy of insurance under which the subject claim is being made as well as the Florida No-Fault Statute, which permits,
`when determining 8 reasonable charge for a service, an insurer to consider usual and customary charges and payments
`accepted by the provider, reimbursem*nt levels in the community and various federal and state fee schedules applicable to
`automobile and other insurance coverages, and other information relevant to the reasonableness of the reimbursem*nt for
`the service. The payment for this service is based upon 200% of the 2007 Limiting Charge of Medicare physician fee
`schedule for the locale in which the services were rendered.
`
`Procedure Guide
`27788 ~ Closed treatment of distal fibular fracture (lateral malieclus); with manipulation
`29425 - Application of short leg cast (below knee to toes); walking or ambulatory type
`72110 — Radiologic examination, spine, lumbosacral; minimum of 4 views
`*3610 — Radioiogic examination, ankle; complete, minimum of 3 views
`99204 - Office or other outpatient visit for the evaluation and management of a new patient. which requires these 3 key
`components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity.
`Counseling andfor coordination of care with other physicians, other qualified health care professionals, or agencies are
`provided conswith the nature of the problem(s) and the patients and/or familys needs. Usually, the presenting problem(s)
`are of low of moderate to high severity. Typically, 45 minutes are spent face~to~face with the patient and/or family.
`
`Fursuent to Ronda Statute, should you have any information to substantiate payment oi an additionai amount
`for the services rendered, please forward for our consideration within 15 days.
`
`Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, flies a statement of claim
`containing false, incomplete, or misleading information is guilty of a felony of the third degree. F8. 817.234(il(b).
`information on administering benefits under the 9810A policy form: Due to ongoing litigation in Myers v. McCarty,
`(Case No. 2013—CA~0073) (Fla. 2d Jud'l Cit), the Emergency Medical Condition provisions of the No-Fault statute are not
`being applied. Please contact us ifyou have any questions.
`
`DATE: 09-22-2015
`
`59-6223-348
`
`Professional
`
`

`

`
`
`STATE FARM
`7,),,
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`1101
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`
`
`
`

`

`@PETER F. MERKLE, IIII.D., P.A.
`110061 L?” W
`‘ §
`1101 East Sample Road Pompano Beach, FL. 33064-5196
`\
`[D 1? 65-01369
`k (954)783-7100
`BS #05995 481/ L1anK 6
`
`”1 Medicaid
`.
`1
`1 Medicare
`1 BCIBS -
`I
`I CHI
`1
`1 Other
`
`Date
`Patient Name
`P08
`‘ DOB
`1 Chart#
`Insurance1:
`
`
`09121115
`ANTOINEJIE 8135131213
`01109160
`1
`~ 152520
`595223340
`
`Aad're'ssw'wm'w'
`0111, 51315215
`A
`1 Phone 111) 1754) 353-0135
`MARGATE FL 33063
`1 PhOne (W)
`7537 PARKSIDE PLACE
`
`
`1
`— 1
`
`5311
`§
`-
`
`
`
`
`
`
`"
`H
`........8f? M
`
`43710120 DEPOSITION
`L4350
`ANKLE AIR CAST
`g
`
`DEPOSITION
`A445§14ELASTIC1ACE) BANDAGE
`73130 I HAND
`
`CONFERENCE
`L3950
`HUMERUS T-X BRACE
`73110 WRIST
`
`99455
`1.M.E.
`L1930
`ANKLE FRACT,8PL1NT!BRACE 1r
`73090flPOREARM
`
`99455
`DE.
`E0100
`CANE
`73000
`ELBOW
`
`L3260
`CAST SHOE
`730501 HUMERUS
`WL
`
`@2525
`1.3223
`POST OP SHOE—MA
`73030
`SHOULDER
`
`MINOR PROB
`L0531
`1E0MBOPLUS BACK DRACE
`73000
`CLAVICLE
`
`99202MLOWTOMOD SE)!(20 MIN)
`50500
`CERVICALOVRDOORrTRACTIO
`73010TSCAPULAR
`
`99203)“ MODERATE SEV 130 MIN)
`K0627
`TLCERVICAL TRACTION (MC)
`73050
`AC JOlNT
`.
`
`1MODAHIGH SEV145 MIN)
`L3660
`CLAVICLE STRAP
`735301713010
`7
`“:4
`
`I
`1
`SWOSWOD-WGHSEV(50MN)
`1.3900)
`co*ck~UPWRISTSPLINT
`73510
`ANKLE
`99053
`EMERGENCY SERVICE
`1.3307
`TITAN WRIST SPLINT
`73550
`HEEL
`99354
`PROLONGSERV(1STHOUR)
`L1815HL2795-GENUTRAINKNEEBRAC?
`2’3590HLOWERLEG(TII31A)
`E
`99555
`ADDL(30MIN)
`E01141 CRUTCHES
`735001
`70KNEE
`
`KNEE 1MMOB1L1ZER
`1*
`73551? PEMUR
`
`,)
`1.
`NEOPRENE KNEE
`73510
`HIP
`I
`
`
`
`
`99211
`MINIMAL PROBLE (
`N)
`LUMBAR SUPPORT
`1
`72050
`CERVICAL SPINE
`
`
`, INOR PROBLEM {10 MN)
`POST OP KNEE BRACE
`72070
`THORACIC SPINE
`
`' 0‘
`-MODERATE115 A1011
`#TENNIS ELBOW Sfigflwwvuwlw
`72110L LUMBO-SACRAL SPINE
`
`
`
`
`MOO-HIGH (25 MIN)
`1 V
`TENS UNIT
`72170HPELWS
`1"
`
`
`MODHTGH (40 MIN)
`THERMOPHORE HEATING
`72220
`SACRUM 5 COCCYX
`
`PLO. FIU INCL GLOBAL
`iNEUMATIC BOOT
`Jr
`72202
`SACROILLIAC JOiNTS
`
`71120
`STERNUM
`_‘
`.1
`I
`01f
`71100flRIBS UNILATERAL
`!
`
`
`
`
`ED (15 MINS)
`SHORT ARM CAST
`711101“ RIBS BILATERAL
`_1
`
`LOW SEVERITY (30 MIN)
`73000
`STERNOCLAVICULAR
`
`
`MODERATE SE); (40 MIN)
`+
`29055
`LONG ARM CAST
`72090
`SC'OLIOSIS STUDY
`
`
`HIGH SEVERITY (60 MIN)
`1
`71020
`CHEST XRAY
`
`HIGH SEVERITY (80 MIN)
`29405.; SHORT LEG CAST
`RE-X-RAY
`
`
`fNON FACEIFACE 11 ST 30)
`29425
`SHORT LEG WALKING CAST
`ADDL (30 MIN)
`29345 LLONG LEG CAST
`1L
`.,
`
`
`
`
`29355
`CYLINDER CAST
`{ALGAN
`
`
`
`CERVICAL EPID
`29125
`SPLINT: SHORT ARM
`1
`
`
`
`52311
`LUMBAR EPIDURAL
`29105
`SPLINT; LONG ARM
`01040
`DEPOMEDROL
`
`
`27095
`51 JOlNT 1NJEC‘HON
`FINGER SPLINT
`13301
`KENALOG
`
`
`54499
`LUMBAR PACET BLOCK
`1 CASTING SUPPLY
`200001
`SM. JOINT
`1
`
`722751
`EPIDUROGRAPHY
`L
`20505
`INTERN JOINT OR BURSA
`
`770031 ELUOROSCOPY
`29505
`SPLINT: LONGLEG
`20510
`)FMAJORJOINTORBURSA
`L
`
`
`1
`29515
`SPLINT: SHORT LEG
`E 20550
`TENOON SHEATH OR LIG
`
`
`10051
`I 0 D (ABSCESS)
`80
`SK
`r
`110001: DEBRIDEMENT
`'
`
`
`
`
`1770791 1PERIPHERAL
`10410
`I a D (HEMATOMA)
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
` CACTURES
`'1 MONTHS
`WEEKS
`1 DAYS
`RETURN:
`L
`’
`1
`1
`1 NEXTAP TL
`'3
`_
`
`1
`[OZ '3 (/5 DAY
`MONTH
`LDATE
`1 TIME AMIPM
`//:/5flm
`
`___________
`
`' A
`
`7
`
`
`
`k
`
`
`
`
`
`
`
`
`
`
`
`

`

`ID # 65-0136948
`
`Chart #
`
`I
`
`‘
`
`I
`
`I
`
`>
`
`I
`
`20605
`
`INTERN J'
`
`3 53“
`
`17
`
`PETER F. MERKLE M. D., P. A.
`1101 East Sample Road Pompano Beach, FL. 33064-5196
`,
`\' (054) 7037100
`\
`8.8. # 05996
`
`
`Medicaid
`‘U Medicare
`fl BCIBS
`I‘IGHI
`I
`I Other
`Date
`Patient Name
`POS
`DOB
`Insurance 23
`09114i15
`ANTOINETTE BESBRIS
`01!!)91‘60
`I
`162620
`I
`596223348
`
`
`
`
`ICIIy, State, Zip
`Address
`TPhone (H)
`(754) 366-0136
`MARGATE FL 33063
`#Phone