▲

ZAlignment HealthPlanSR PromiseCare/HCMG

CARRIER
1545 W Florida Ave
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 Hemet, CA 92543-3814
PICA Page 01 of 01 PICA ▼
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S I.D. NUMBER (For Program in Item 1) ▲
HEALTH PLAN BLK LUNG
X (Medicare#) (Medicaid#) (ID#/DoD#) (Member ID#) (ID#) (ID#) (ID#) 00000121179
2. PATIENT'S NAME (Last Name, First Name, Middle Initial 3. PATIENT'S BIRTH DATE 4. INSURED'S NAME (Last Name, First Name, Middle Initial)
MM DD YY SEX
Jarson Beverly 06 06 1953 M F
X Jarson Beverly
5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street)

27200 Roger Street Self X Spouse Child Other 27200 Roger Street
CITY STATE 8. RESERVED FOR NUCC USE CITY STATE

PATIENT AND INSURED INFORMATION

Hemet CA Hemet CA
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)

92544 ( ) 92544 ( )
9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH
MM DD YY SEX
YES
X NO 06 06 53 M F
X
b. RESERVED FOR NUCC USE b. AUTO ACCIDENT? PLACE (State) b. OTHER CLAIM ID (Designated by NUCC)

YES X NO
c. RESERVED FOR NUCC USE c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME

YES X NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES (Designated by NUCC) d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

YES NO If yes,, complete items 9, 9a and 9d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below.
below.

SIGNED Signature On File DATE 02/29/24 SIGNED SIGNATURE ON FILE ▼

14. DATE OF CURRENT ILLNESS ,INJURY or PREGNANCY (LMP) 15. OTHER DATE 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION ▲
MM DD YY MM DD YY MM DD YY MM DD YY
QUAL.
QUAL. FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM DD YY MM DD YY
DN Spicer Mark 17b. NPI
1619905684 FROM TO
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB? $ CHARGES

RECONSIDERATION YES X NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. Relate A-L to service line below (24E) ICD Ind. 0 22. RESUBMISSION
CODE ORIGINAL REF. NO.
A. C3491 B. C7931 C. D. 7 20407119210223000052
23. PRIOR AUTHORIZATION NUMBER
E. F. G. H.
I. J. K. L.
24. A. DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J.
From To DIAGNOSIS DAYS EPSDT

PHYSICIAN OR SUPPLIER INFORM ATION

PLACE OF (Explain Unusual Circumstances) ID. RENDERING
OR Family
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS Plan QUAL. PROVIDER ID. #

1 02 29 24 02 29 24 11 99204 AB 352 00 1 NPI 1619905684

2 NPI

3 NPI

4 NPI

5 NPI

6 NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. Revd for NUCC use
(For govt. claims, see back)
852151199 X 007600011522 X YES NO $ 352 00 $ 352 00
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION ( 951 ) 652-8700
33. BILLING PROVIDER INFO & PH#
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
Seven Star Neurosurgery Seven Star Neurosurgery
apply to this bill and are made a part thereof.) 29826 Haun Rd Suite 200 41889 E Florida Ave
SPICER, MARK Menifee CA 92586-6547 Hemet CA 92544-5042
05/04/24
SIGNED DATE
a.
NPI
1063015154 b. a.
NPI
1063015154 b.
852151199 ▼
NUCC Instruction Manual available at: www.nucc.org PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12)
 Seven Star Neurosurgery
Mark Spicer MD
29826 Haun Rd Suite 200 * Menifee, CA 92586-6547
Phone: (951)595-4596 * Fax: (951)595-4597
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Patient: Beverly Jarson

Date of Birth: 06/06/1953
Visit Type: Consult
Date: 02/29/2024 10:30 AM
Historian: self

This 70 year old client presents for Brain Mass.

History of Present Illness:
1. Brain Mass
February 29, 2024.
Beverly is a very pleasant, 70-year-old, right-handed, Caucasian, female who presents with her
son Christopher, daughter-in-law Robin, and grandson Cash, for evaluation of metastatic
squamous cell carcinoma with intracranial lesions. She is referred by Dr. Hanalla. She was first
diagnosed in 2018 with a 3.7 x 3 cm lesion in the right lung for which she underwent right
middle lobe lobectomy without adjuvant treatment. She was subsequently found to have
harbor a right upper lobe perihilar mass measuring 1.1 x 0.7 x 1.2 cm during routine
surveillance every 20/6/2021. She was treated with definitive radiation therapy combined
with chemotherapy (not further characterized in the medical records). Newly were
subsequently found December 4, 2023 on her last PET CT scan which was also revealing of a
1.2 left intertrochanteric lesion for which she has undergone radiation with, "excellent" relief
of her left hip pain. She reports no pain at this time. She does continue to ambulate with a
four-point cane held in the right hand secondary to gait instability. Her major complaint at
this time is that she is continually walking into objects such as doorjambs which she strikes
with her left side. She also complains of instability and falling to her left as though she were
drunk. She does not report any headaches, seizure activity or any other new, overt, focal
neurologic deficits.

Contagion Exposure
(Detailed document)
Active Contagion Exposure
Exposure Incubation Where Exposure Arrival Departure Level of Duration Risk
Date Exposure
COVID - 19 2 - 14 days no risk

Jarson, Beverly 000000003432 06/06/1953 02/29/2024 10:30 AM Page: 1/5

Allergies:
Ingredient Reaction (Severity) Medication Comment
Name
NO KNOWN
ALLERGIES

Review of Systems:
System Neg/Pos Details
Constitutional Positive Fatigue.
Constitutional Negative Chills, Fever, Malaise, Night sweats, Weight gain and Weight loss.
ENMT Negative Ear drainage, Hearing loss, Nasal drainage, Otalgia, Sinus pressure and
Sore throat.
Eyes Negative Eye discharge, Eye pain and Vision changes.
Respiratory Negative Chronic cough, Cough, Dyspnea, Known TB exposure and Wheezing.
Cardio Positive Chest pain.
Cardio Negative Claudication, Edema and Irregular heartbeat/palpitations.
GI Positive Constipation, Diarrhea, Nausea, Vomiting.
GI Negative Abdominal pain, Blood in stool, Change in stool pattern, Decreased
appetite and Heartburn.
GU Negative Dysuria, Hematuria, Polyuria (Genitourinary), Urinary frequency, Urinary
incontinence and Urinary retention.
Endocrine Negative Cold intolerance, Heat intolerance, Polydipsia and Polyphagia.
Neuro Positive Dizziness, Extremity weakness, Headache, Memory impairment,
Numbness in extremity.
Neuro Negative Gait disturbance, Seizures and Tremors.
Psych Positive Anxiety, Depression, Insomnia.
Integumentary Positive Change in shape/size of mole(s).
Integumentary Negative Brittle hair, Brittle nails, Hair loss, Hirsutism, Hives, Pruritus, Rash and Skin
lesion.
MS Positive Muscle weakness, Neck pain.
MS Negative Back pain, Joint pain and Joint swelling.
Hema/Lymph Negative Easy bleeding, Easy bruising and Lymphadenopathy.
Allergic/Immuno Negative Contact allergy, Environmental allergies, Food allergies and Seasonal
allergies.
Reproductive Negative Breast discharge, Breast lumps, Dysmenorrhea, Dyspareunia, History of
abnormal PAP smear, Hot flashes, Irregular menses and Vaginal
discharge.

Vital Signs:

Time BP Pulse Resp Temp F Ht ft Ht in Wt lb BMI O2 Sat% Pain

mm/Hg /min /min kg/m2 Score
11:20 AM 100/70 81 18 98.2 5.0 8.00 112.00 17.03 96

Physical Exam
Alert and oriented ×4

Cranial nerves:
OU 3 mm to 2mm brisk, direct and consensual.
No complaint of diplopia. No nystagmus

Jarson, Beverly 000000003432 06/06/1953 02/29/2024 10:30 AM Page: 2/5

 Extraocular muscles are intact bilaterally. Deviation is conjugate
Face is symmetric to motor and sensation.
Audition intact to finger rub bilaterally.
Symmetrical bilateral shoulder elevation and head turning.
Tongue is midline.

Sensory:
Normal light touch
Normal pain and temperature.

Cerebellar:
Left dysmetria on finger to nose testing
No dysdiadochokinesis.

Motor
Cachectic in all groups. No fasciculations or tremors.

MOTOR STRENGTH Graded on scale of 5

Upper extremities: R L Lower extremities: R L
Deltoid 4- 4- Quadriceps 4- 4-
Biceps 4- 4- Hamstring 4- 4-
Triceps 4- 4- Gastrocnemius 4- 4-
Brachioradialis 4- 4- EHL 4- 4-
Wrist extension 4- 4- Dorsiflexion 4- 4-
PIP extension 4- 4- Plantar flexion 4- 4-
Hand grasp 4- 4- Iliopsoas 4- 4-

Beverly ambulates with a four-point cane held in the right hand. She is heavily assisted by her son, Christopher, who is very attentive
and takes great care with her.

Assessment/Plan:
# Detail Type Description
1. Assessment Squamous cell carcinoma of right lung (C34.91).

2. Assessment Malignant neoplasm metastatic to brain (C79.31).

Impression MRI with brain with and without gadolinium contrast very 20/1/2024. No priors for
comparison. The current study demonstrates multiple enhancing metastatic lesions
throughout the cerebrum and cerebellum with associated surrounding vasogenic edema
which is causing effacement of the sulci of the superior posterior right parietal lobe. No
hemorrhage, herniation or hydrocephalus. No midline shift. No visualized extra-axial fluid
collections.

PET/CT tumor imaging skull base to mid thigh January 16, 2023. Current study is
correlated with prior PET/CT August 25, 2022 and multiple prior exams. The current study
demonstrates a new tiny but hypermetabolic right pretracheal lymph node consistent with
metastatic disease. A precarinal lymph node has increased activity since the prior exam,
there is mixed response in subcarinal lymph nodes with one area having increased activity
in another area having decreased/resolved activity. No other evidence of metastatic
disease. Postsurgical changes present from prior right middle lobectomy. There is
increasing focal consolidation this region which has similar mild FDG activity, favored as
inflammatory, although residual/recurrent disease is not excluded. Stable additional
non-oncologic findings are also noted.

PET/CT tumor imaging skull base to mid thigh December 4, 2023 is compared to prior
Jarson, Beverly 000000003432 06/06/1953 02/29/2024 10:30 AM Page: 3/5
 studies of unknown modality September 6, 2023 and May 19, 2023. The current study
demonstrates progression of metastatic disease. 2 new metastatic lesions within the left
proximal femur. Subcentimeter pulmonary nodules, indeterminate for intrapulmonary
metastatic disease as above. Stable distribution of intensely hypermetabolic mediastinal
and lower cervical lymph node metastases. These studies were reviewed and have been
scanned into the patient's chart. Images and reports from the studies detailed above were
reviewed by me in the office today in the presence of the patient, all of whose questions
were answered in detail and to the patient's fullest satisfaction. Please refer to the reading
radiologist's report for further details..
Patient Plan Beverly presents with advanced metastatic squamous cell carcinoma to the brain of right
lung origin. She has undergone prior surgery, chemo and radiation treatment and
treatments at this time are palliative in nature. She remained essentially neurologically
intact with the exception of a homonymous hemianopsia and left left dysmetria on finger
to nose testing. These findings are consistent with the presence of large right posterior
parietal and large left cerebellar cystic lesions. I explained to Beverly, her son and her
daughter-in-law that while stereotactic aspiration of the cystic portions of these 2 large
lesions is entirely possible it is also likely that the cystic fluid would reaccumulate within a
matter of days. In that regard she would be subjecting herself to the risks of surgery for
no significant benefit. She is scheduled to have whole brain radiation in the near future
and I would advised her that this may result in increased swelling of her brain for which
she would require an increase in her dose of Decadron (currently 4 mg by mouth every 8
hours) and at which time aspiration of the cystic portions of these lesions may be indicated
even for temporary decompression of the brain.

Otherwise there is no immediate indication for neurosurgical operative/procedural

intervention. All of their questions were answered in detail and to their full satisfaction. I
have invited them to return at anytime to see me for further consultation should they wish
to do so. I will of course be happy to followup at anytime in the interval should the need
arise.

Thank you, Dr. Hanalla, for allowing me to take part in the care of this delightful lady and
her family.

I spent 45 minutes discussing this patient's diagnosis, prognosis and treatment

alternatives. All questions were answered in detail and to the patient's fullest satisfaction. I
hereby attest that this medical record fully and accurately reflects notations that I made in
my capacity at that time I treated/diagnosed the above patient. I do hereby attest that this
information is true, accurate and complete to the best of my knowledge.

Please do not hesitate to call me at (951) 414-4020 with any questions regarding this
patient and thank you for this referral.

This medical document was created using an electronic medical record system with Dragon
Medical voice recognition. Although this document has been carefully reviewed, there
may still be some phonetic and typographical errors. These errors are purely
typographical, due to imperfections of the software programs, and do not reflect any
compromise in the patient's medical care.

Medications (added, continued or stopped this visit):

Start Date Medication Directions Stop Date
albuterol sulfate 0.63 mg/3 mL
solution for nebulization
Jarson, Beverly 000000003432 06/06/1953 02/29/2024 10:30 AM Page: 4/5
 albuterol sulfate HFA 90 inhale 2 puff by inhalation route every 4 - 6
mcg/actuation aerosol inhaler hours as needed
dexamethasone 4 mg tablet take 1 tablet by oral route every day
olanzapine 2.5 mg tablet take 2 tablet by oral route every day
Reglan 5 mg tablet take 1 tablet by oral route 4 times every day 30
minutes before meals and at bedtime
Medication Reconciliation:
Medications reconciled today.

Active Patient Care Team Members

Name Contact Agency Support Relationship Active Date Inactive Specialty
Type Role Date
Mark Spicer Patient PCP
provider

Spicer, Mark 02/29/2024 12:35 PM

Document generated by: Mark Spicer MD 02/29/2024 12:35 PM

Electronically signed by Mark Spicer MD on 02/29/2024 12:39 PM

Jarson, Beverly 000000003432 06/06/1953 02/29/2024 10:30 AM Page: 5/5