Children's Hospital Los Angeles — Children's Center for Cancer and Blood Diseases (Document 1217-2)
Summary
Document 1217-2, filed December 22, 2021, in Case 2:20-cr-00579-SVW: visit information from the Children's Center for Cancer and Blood Diseases at Children's Hospital Los Angeles for a minor patient's new-patient visit dated December 2, 2021. It lists the reason for visit as new patient, the diagnosis RBC microcytosis with the date 12/02/21, and an order for an alpha-globin mutation analysis due within 3 months. It also gives appointment instructions for Hematology-Oncology patients and notices about insurance authorization of care.
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“Children's Hospital Los Angeles — Children's Center for Cancer and Blood Diseases (Document 1217-2).”
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Case 2:20-cr-00579-SVW Document 1217-2 Filed 12/22/21 Page 1 of 8 Page ID #:19453
Children's Hospital Los Angeles
Children's Center for Cancer and Blood Diseases
4650 Sunset Blvd. MS 54
Los Angeles, CA 90027
Phone: 323 .361.4624
Thank you for allowing us to assist you with your health care needs.
The following includes information regarding your visit.
For questions related to this visit, please contact the clinic at the number above.
Visit With: Denton (Attending) MD,Christopher
Name: AYVAZYAN, ANGELINA
Clement
DOB: 9/11/2006
Visit Date: 12/2/2021
Most Recent Information
Weight: 105.1 kg/ 231.7 lb (99 percentile)
Height: 157.8 cm/ 62.1 in (26 percentile)
BMI: 42.21 kg/m2 (99 percentile)
Blood Pressure: 127/72
Heart Rate: 107
Pulse Oximetry:
Temperature: 37.0 ·c I 98.6 °F
Reason for Visit
new patient
Allergies
No known allergies
Medications
Medications Given During Visit
Orders
Description Requested Date Comments
Estimated
Alpha-Globin Common Mutation Analysis
12/02/2021
SO 11175 - Quest
Due within 3
Diagnosis: RBC microcytosis
Month
Diagnoses
Nam:!: AYVAZYAN, ANGRINA 1 of 4 12/02/2021 11 :51 :59
MRN: 4435749
Case 2:20-cr-00579-SVW Document 1217-2 Filed 12/22/21 Page 2 of 8 Page ID #:19454
Diagnosis Date Comments
RBC microcytosis 12/02/21
Upcoming Appointments
For Hematology-Oncology appointments,
-Patients with lab tests should arrive 90 minutes prior to the scheduled appointment.
-Patients with an implanted port should apply numbing cream 30 minutes before they arrive at the lab or as
instructed in your prior visit.
-If no labs are to be dra'Ml on day of appointment, arrive to the clinic at least 15 minutes prior to scheduled
appointment.
Not all future appointments may be displaying in the section below
Clinic Location Provider Date
Hem ato logy I Oncology Virtual Visit Carson NP, Susan 3/3/2022 9:00 am
Summary of Topics Discussed
Patient Instructions O
You will get labs done for alpha globin gene mapping, then we will see you in a few months to review results.
Please eat a diet with proteins, meats, vegetables, and healthy, complex grains.
follow up with your pediatrician.
It was a pleasure meeting you. We will send a letter to your PMD.
Current Addendums
This document may not be a complete record.
Please bring this Discharge Information to all doctors· appointments.
It is important to carry your updated medication information with you at all times.
Sign up for the MyChildren'sLA Patient Portal today! Our secure portal is a place where patients and
families can:
• Securely communicate with their care team
Name: AYVAZYAN, ANGB.INA 2 of 4 12/02/2021 11 :51 :59
MRN: 44357 49
Case 2:20-cr-00579-SVW Document 1217-2 Filed 12/22/21 Page 3 of 8 Page ID #:19455
• View, cancel, reschedule and request appointments
• Request prescription refills/renewals
• View most lab results, immunizations, discharge instructions, clinic visit summaries, and other
documentation
Enroll by downloading ChildrensLA from the Apple or Android App Store, or by navigating to
CHLA.org/Connected-Care. To enroll, you will need your MRN (Medical Record Number) listed above, as well as a
valid email address.
Name: AYVAZYAN, ANGB.INA 3 of 4 12/02/2021 11 :51 :59
MRN: 4435749
Case 2:20-cr-00579-SVW Document 1217-2 Filed 12/22/21 Page 4 of 8 Page ID #:19456
Name: A YVAZYAN, ANGB.INA 4 of 4 12/02/2021 11 :51 :59
MRN: 4435749
Case 2:20-cr-00579-SVW Document 1217-2 Filed 12/22/21 Page 5 of 8 Page ID #:1945
Order Requisition
Children 's Hospital of Los Angeles
HEMATOLOGY /ONCOLOGY
(323) 361-4624
Order Requisition-Laboratory
Patient: AYVAZ.YAN, ANGELINA CHLA MRN#: 4435749
DOB: 09/11/2006 Sex: Female
Order MD: Carson (NP) ,Susan
NPINo: 1386810810
Procedure Requested Exam Date Order Detail Comments
Alpha-Gklbin Common Mutations Estimated 12/02/2021 Specimen : Blood
Analysis S Due within 3 Month Diagnosis: R71.8 RBC microcytosis
Entered & electronically signed by Carson (NP) ,Susan on 12/02/2021 at 11 :47
Fax Results To: (323) 361-7128 Attn: HEMA TO LOGY /ONCOLOGY
Narre: AYVAZYAN, ANGB.INA 1 of 1 12/02/2021 11:52:11
MRN: 4435749
Case 2:20-cr-00579-SVW Document 1217-2 Filed 12/22/21 Page 6 of 8 Page ID #:19458
Page 1
Person Appointment Itinerary
Childrens Hospital Los Angeles
4650 Sunset Blvd
Los Angeles, CA 90027
(323)660-2450
AYV AZY AN, ANGELINA Medical Record Number: 4435749
17450 WEDDINGTON ST Gender: Female
ENCINO ,CA 91316 DOB: 09/11/2006
Date Time Appointment Type Resource
03/03/2022 09:00 HEM TH Follow-Up Carson NP, Susan
If you require any scheduling changes, please notify the Scheduling Department at (323)660-2450.
Thank you for choosing Cbildrens Hospital for your healthcare needs.
*** End ofltinerary ***
Case 2:20-cr-00579-SVW Document 1217-2 Filed 12/22/21 Page 7 of 8 Page ID #:19459
INFORMATIONAL LETTER TO BENEFICIARY AND/OR PROVIDER/PHYSICIAN
May 22, 2020
F02PRF205K834900 PCP: GUIRAGOS MINASSIAN MD (PCP)
AYV AZY AN, ANGELINA R PCP PHONE#: (8 I 8) 708-8044
I 7450 WEDDINGTON ST; PCP FAX#: (818) 708-8049
ENCINO, CA 91316 REQUESTED BY: GUIRAGOS MINASSIAN MD
FAX#: (818) 708-8049
MEMBER ID: BCMC9459901 IF-01
MEMBER DOB: September I l, 2006 TRACKING# PK5K8349
MEMBER PHONE: (818) 644-7103 BLUE CROSS MEDI-CAL
RE: Requested Treatment OFFICE/OUTPATIENT VISIT NEW
GUIRAGOS MINASSIAN MD has asked PREFERRED IPA to approve:
OFFICE/OUTPATIENT VISIT NEW
This is NOT a denial of service. This notice is to inform you that the requested service does require an
authorization.
The request does not have to be re-submitted for you to receive Nutritional Counseling. It can be arranged
by you directly without prior authorization by contacting LA Care Family Resource Center, Nutrition and
Exercise Classes at (213) 43 8-5497.
LA Care Family Resource Center, Nutrition and Exercise Classes - I 0807 San Fernando Rd., Pacoima,
CA9133I.
If you have any questions, please contact your health plan, BLUE CROSS MEDI-CAL at 1-888-285-
7801, for further assistance regarding the requested service( s).
Sincerely,
UM Department
Preferred IP A
cc: GUIRAGOS MINASSIAN MD
GUIRAGOS MINASSIAN MD (PCP)
Member
CONFIDENTIALITY NOTICE
The documents accompanying this telecopy transmission contain CONFIDENTIAL PROTECTED HEALTH
INFORMATIO_N, belonging to the sender, which is_ legally priv_il~ged. The information is intended only for the use of the
individual or entity names above. If you are not the intended rec1p1ent, you are hereby notified that any disclosure c •
· · ·
distribution, or the tak'mg of any action
. 111
. re 1·1ance on the contents of this
· telecop,ed
· information
, is strictly proh'b't dopying,
If u
. I . d' I 'f I I e . yo
have received this telecopy in error, p ease 1mme iate y not1 y us by telephone at I-800-874-2091 for return of the original
documents to us.
Case 2:20-cr-00579-SVW Document 1217-2 Filed 12/22/21 Page 8 of 8 Page ID #:19460
Post Office Box 4449
Chatsworih, CA 913 13
ISSUE DA TE: August 26, 2021 MEMBER ID: BCMC94599011F-Ol
MEMBER DOB: September 11, 2006
MEMBER PHONE: (818) 644-7103
PCP: GUIRAGOS S MINASSIAN
A YV AZYAN, ANGELINA R PCP PHONE: (818) 708-8044
17450 WEDDINGTON ST; REQUESTED BY: GUIRAGOS MINASSIAN MD
ENCINO, CA 91316 AUTH # PL897047
BLUE CROSS MEDI-CAL
Dear A YV AZY AN, ANGELINA R:
This is an AUTHORIZA TI0N for the following service:
99204 OFFICE 0/P NEW MOD 45-59 MIN Number= 1
and you are referred to:
CHILDRENS HOSPITAL LOS ANGELES MEDICAL GRP-HEMATOLOGY/ONCOLOGY/ BLOOD & BONE
MARROW TRANSPLANTATION
4650 SUNSET BL VD
LOS ANGELES, CA 90027
Ph# (323) 361-4100
This AUTHORIZATION is based on your being eligible at the time of service and it expires on January 23, 2022.
Please call CHILDRENS HOSPITAL LOS ANGELES MEDICAL GRP -HEMATOLOGY/ONCOLOGY/
BLOOD & BONE MARROW TRANSPLANTATION immediately to schedule an appointment. Please take any
x-rays, laboratory reports, list of medications and this authorization letter with you at the time of your
appointment.
Please note that for selected diagnostic and specialist consults you do not have to wait for prior authorization and
your physician may directly refer you to the service.
All decisions for authorization approvals are based on re~ iew of medical information provided. Materials used by
Preferred IPA to authorize care are for individual patients with similar illnesses or conditions. Specific care and treatment
may vary depending on individual need and the benefits covered under your insurance contract. All decisions are based on
medical necessity and appropriateness of care and reviewers are not incentivized in any manner.
You, your doctor or the public may request criteria used in making this decision by writing to Preferred IPA , Medical
Management Department, P.O. Box 4449, Chatsworth, CA 91313.
PIPA last revision 09/02109
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