Case 3:O7-cv-O1172- Document16 Filed lim of 35 PageID 61 IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF TEXAS DALLAS DIVISION UNITED STATES OF AMERICA, ex rel., LARRY M. GENTILELLO, M.D., FILE UNDER SEAL an Individual A Plaintiff, l. vs. CIVIL ACTION NO. THE UNIVERSITY OF TEXAS SOUTHWESTERN HEALTH SYSTEMS, 3/k/3 UT SOUTHWESTERN HEALTH SYSTEMS, THE UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS, MEDICAL 3 SERVICE, RESEARCH AND -ll I DEVELOPMENT PLAN, AND DALLAS COUNTY HOSPITAL DISTRICT CLERK DIS d/b/a PARKLAND HEALTH AND BY A "1 HOSPITAL SYSTEM A it Defendants. FIRST AMENDED QUI TAM COMPLAINT TO THE HONORABLE JUDGE OF SAID COURT: NOW COMES Qui Tam Larry M. Gentilello, M.D., by and through the undersigned attorneys, and sues Delendants, The University of Texas Southwestern Health Systems, a/k/a UT Southwestern Health Systems, University ol' Texas Southwestern Medical Center at Dallas, Medical Service, Research and Development Plan, and Dallas County Hospital District d/b/a Parkland Health and Hospital System, and respectfully alleges as follows: FIRST AMENDED QUI TAIVI COMPLAINT Page I D/7l 2959. I4 Case 3:O7-cv-O1172- Document 16 Filed lie 2 ot 35 PageID 62 I. THE PARTIES 1. Qui Tam Plaintiff/Relator in this action is Larry M. Gentilello, M.D., an individual. In accordance with 31 U.S.C. 3730 a private person may bring a civil action for a violation of 31 U.S.C. 3729 for the person and for the United States Govemment. This action is properly brought in the name of the United States Government. 2. Plaintiff/Relator, Larry M. Gentilello, M.D. Gentilello"), an individual, is a resident of Dallas County, Texas. Dr. Gentilello has personal knowledge of violations of Medicare and Medicaid billing requirements by Defendants named herein, 3. At all times material hereto, Defendant The University of Texas Southwestern Health Systems a/k/a UT Southwestern Health Systems is a Texas corporation located at 6263 Harry Hines Boulevard, Dallas, Texas, 75235, whose registered office is S303 Elmbrook Drive, Dallas, Texas, 75247-4011 and may be served with process by serving its registered agent for service ofprocess, Willis C. Maddrey, M.D. 4. At all times material hereto, Defendant The University of Texas Southwestern Medical Center at Dallas is a Texas corporation located at 5253 Harry Hines Boulevard, Dallas, Texas, 75235, whose registered office is 8303 Drive, Dallas, Texas, 75247-4011 and may be served With process by serving its registered agent for service ol` process, Willis C. Maddrey, M.D. 5. At all times material hereto, Defendant Medical Service, Research, and Development Plan is a Texas institutional trust fund whose bylaws provide that its sources of income are derived from the teaching faculty members' assigned professional income, as well as any voluntarily assigned professional income of part-tirne faculty who are not members. At all times material hereto, Medical Service, Research, and Development Plan is located in the FIRST AMENDED QUI TAM COMPLAINT Page - Case 3:O7-cv-O1172- Document 16 Filed |ie3of 35 Page|D 63 facilities of University of Texas Southwestem Medical Center at Dallas at 5323 Harry Hines Boulevard, Dallas, Texas 75325, whose registered office is 8303 Elmbrook Drive, Dallas, Texas, 75247-4011 and may be served with process by serving its registered agent for service of process, Willis C. Maddrey. 6. At all times material hereto, Defendant Dallas County Hospital District d/b/a Parkland Health and Hospital System is a Texas corporation located at 5201 Harry Hines Blvd., Dallas, Texas 75235, and may be served with process by serving its registered agent for service of process, Michael L. Silhol. II. URISDICTION AND VENUE 7. This action arises under the Federal Civil False Claims Act, 31 U.S.C. 3729, ef seq., as amended, related to false or fraudulent claims made against the United States Govemment and 31 U.S.C. 3730(h) related to retaliatory action taken in furtherance of an action related to false or fraudulent claims made against the United States Government. Pursuant to 3| U.S.C. 3730, a private person may bring a civil action for a violation of? 3729 for the person and forthe United States Government, jurisdiction is founded on 28 U.S.C. 133| and 1345. 8. Venue is proper in the Northern District of the United States District Court for the Dallas Division ofTexas, pursuant to 28 U.S.C. 1391 because the claim arose there. FIRST AMENDED TAM COMPLAINT Page 3 - Case 3:O7-cv-O1172- Document 16 Filed Pilot 35 PageID 64 COMPLIANCE WITH 31 U.S.C. AND FEDERAL RULE OF CIVIL PROCEDURE 4?1[ 9. Pursuant to 31 U.S.C. 373O(b)(2) and Federal Rulc of Civil Procedure this complaint is being filed in camera and shall remain under seal for at least 60 days and shall not be served on the Defendants until the coLu't so orders. IV. STATEMENT OF FACTS BACKGROUND 10. The University of Texas Southwestern Health Systems, a/k/a UT Southwestern Health Systems a Texas corporation, The University of Texas Southwestern Medical Center at Dallas a Texas corporation, Medical Service, Research, and Development Plan a Texas institutional trust fund, and Dallas County Hospital District d/b/a Parkland Health and Hospital System ("Parkland"), a Texas corporation, [hereinafter collectively referred to as "Defendants"], by and through their directors, officers, and management, have been involved in activities that violate the Federal False Claims Act, 3| U.S.C. 3729, et seq., as amended, relative to Medicare and Medicaid claims. As used hereinafter, "DeI`endants" includes each Defendant, as well as each Defendant's agents, employees, officers, directors, and management, 11. At all times material hereto, all acts of all Defendants' officers, directors, and management were done while acting in their respective actual and/or apparent authority and within the course and scope of their employment with and under the direction ol" Defendants. 12. Parkland has been the primary teaching hospital for UTSW since UTSW's inception. Parkland has looked to UTSW as the source of its medical staff for over sixty years, FIRST AMENDED TAM COMPLAINT Page 4 Case 3:O7-cv-01172- Document 16 Filed Pi 5 ot 35 PageID 65 Parkland has designed many of its operations to facilitate UT SW's training needs. UTSW provides all of the indigent care at Parkland and is reimbursed by Parkland and Medicare and Medicaid for any care provided to the uninsured. Parkland and UTSW receive a substantial amount of income through Medicare and Medicaid. I3. Due to the relationship between Parkland and UTSW, Parkland's administration was involved in discussions regarding the decision to hire Dr. Gentilello. Dr. Gentilello was employed by UTSW in 2003 as the Chair of the Division of Burn, Trauma and Critical Care. Dr. Gentilello is a tenured Professor of Surgery at UTSW, and occupied the Distinguished C. James Carrico M.D. Chair in Trauma. Dr. Gentilello has been nationally recognized tor his work in trauma, critical care and the treatment of drug addiction, and has published numerous articles in his field and devised procedures used by trauma surgeons around the country. 14. During his tenure with UTSW, Dr. Gentilello became aware of certain practices occurring there regarding inadequate patient care, improper surgical resident supervision and failure to follow proper operating room and patient treatment protocol, all contrary to proper Medicare and Medicaid requirements and procedures. Dr. Gentilello became aware that UTSW residents were treating patients and surgical procedures without the supervision ol` any teaching attending physician. Dr. Gentilello observed that patients at Parkland were being treated by residents with no teaching attending physician present, were undergoing surgical procedures with no teaching attending physicians present, and were undergoing surgical procedures with no teaching attending physicians in the operating room during key or critical phases ofsurgery. 15. If a resident physician participates in a service furnished in a teaching setting, Medicare payments tor that care and treatment are only made "il` a teaching physician is present FIRST AMENDED QUI TAM COMPLAINT Page 5 295914 - Case 3:O7-cv-O1172- Document 16 Filed Pi6ot 35 PageID 66 during the key portion of any service or procedure for which payment is sought." See 42 C.F.R. 415.172, see also 42 U.S.C. 1395y(a)(l)(A). 16. Dr. Gentilello became aware that (1) UTSW billed Medicare and Medicaid for the teaching attending physicians' participation in the procedures even though the teaching attending physician spent little or no time in the surgical suite, or actually did not participate in the care in any respect, or did not participate during the key or critical portions of the surgical, pre-operative and/or post-operative care; (2) that Defendants were billing global surgical fees, fees for pre- and postoperative care, and transferred care without the use of the correct billing modifiers for surgery, pre-operative, and/or post-operative care; and (3) that Defendants billed for pre- and postoperative care, surgical care, and evaluation and management services without appropriate documentation by the teaching attending physician of the participation ofthe teaching attending physician during the key or critical portions of the health care service or management ofthe patient. 17. Dr. Gentilello reasonably believed that these practices violated Medicare and Medicaid rules, regulations, statutes, and ordinances. Dr, Gentilello further believed that the practices were having an adverse effect and were resulting in poor patient outcomes, necessary additional subsequent medical care, upon the indigent patients medical care and treatment at Parkland, and resulted in billings to Medicare and Medicaid tor worthless services. Dr. Gentilello raised his concerns with Robert V. Rege, M.D, Rege"), the person responsible for setting policies lor UTSW regarding the presence of teaching attending physicians during surgery and with the power to investigate these illegal activities and to correct such illegal practices. At numerous times, Dr. Gentilello was advised that UTSW's and FIRST AMENDED QUI TAM COMPLAINT Page 6 - Case 3:O7-cv-O1172- Document 16 Filed Pi7of 35 PagelD 67 Parl> Proc. 2 - Proc. 3 - Proc. 4 - Proc. 5 - Complications: Condition: Doc.otlnc. Ct: Needle Count: 1) 2) Shift Chg: ID X-RayTaken2 Sponge Count: 1) 2) insz. Count: 1) 2) sum Chg: X-Rav HSS'-'ltr PGS N99 Other Counts: 1) 2) Oellsaver Processed: Blood: TP: CRYO: ALB: Cellsaver Retumed: Cultures: Frozen Spec: Foreign Body: Perm, Spec: Pathology Tissue/Bone Bank Disposed of None lnfection:Y IDP: Precautions: Standard Airborne Droplet Contact Strict Totallrrigationr X-Ray: Type: Qty; image: 'l1me: Drains: Type: Qty: Implants: Type: i Wound Class: Cl. CI. Cont. Cont. Dirty Location: Exceptions: Except. Time: Serial: Lot Sterilization/Expiration Date: 0028 WHITE COPY - OR QM YELLOW COPY - Med. School PINK COPY - OR Case 3:07-cv-01172-liocument 16 Filed 31 of 35 Page|D 91 Exhibit Case 3:07-cv-O1172- ocument 16 Filed 32 of 35 PageID 92 PARKLAND HEALTH HOSPUAL SYSTEM Danes Texas ro cm owen PROCEDURE TO THE PATIENT Yau have the to be Informed about your medvcal aondmun andthe sm-gfcal medrcal or ovagnosrvc proreaz/re recommended Par you dlsmosura IS not msanrmo scare Ol alarm you .rs effort to make you berier informed so yoa "say awe or your consent to the procedure understand that Pmdand Memorial Hosp?t2v1{Hospl?af) is a teaching hospmzi and that physacians In approved traumng programs ffksudemsy may >>par?ofm :mponant ea-sks #aimed recommended umn?durs lmporxant tasks molude but are nm Ivmwed ru opemng and closung me surgical SIM ramovmg and hafvesimg grams medacal dwnce-a and piacang lines Hesndems perform surgmauasks under me supefvzeson of faculty mumtaers of the L?nwersely oi Texas Southwestern Maaical Comer (UTSW) Ii ns anucopaied that Dr wull serve as my Surgeon ol Record hcmrever may change ai the Ixme of my surgery depending on the afaltabdny of Resndents the necessary competence and ummnc krvowlenge the Faculty rnerrber has of me Resnercfs skill and my Based upon me level of ifammg the racqlw member may not be preseni xn the operanng room vor same ol me lasxs performed by he "as der! but wh be reacnly avaliable for for cfmcal porrsons oi my pvuoedum 1u|1Gars1an'dihai other haamw ar? nrouclers nursw Mural assustarts sauden 5 and 'acuny members may be nrwolved my surgery ard :An uw My vmud has za 1.5 lhai the ioliowmg surgacsi n1adx:a! and/ox disgnowa procedures aw planned For me and 1 vomntanly co men* ard autnonze these PROCEDURES and SURGMAL SITE MARKERS as deemed necessary Supenor Sagha! Supfa Lek _g Anwnor infra _l Posvenm Fmnta' "orsa Uppe: Tgmporal Below Je-nzral Lower _j Pas ma! understand thai my may discover other or dffiarem condemns whsoh require addmona! or dvfferem prooaclufes Umm those authurfm my physauan and sduh ZSSUZIBK msiszams ard oiher health care prowdars \o pe'?nrm such owe: procedures whuzh ave advxsansa mek professmna! wdgmam that no warramy or guarantee has been mama to me as in resuw cr cure rf" a 0) paw" or (du not) Pa ms Wen vdiumaniy consent to me uw 01 blood and blood produats as deempd 2 understand that h>i1avvmg and hazards may occur with varxsiman or use of mood and/or blood products 1. Fever . 4. Hepxitos 2. Transfugion reaction. which may kidney fanufe Of anema 5. AIDS (acquired immune dehciency 3. Heart Yuwlure 5- . A 4 Qthav I QI (do) ETE or Cl (do not; Qawgng.. agree Io dorme any human tissue or pans which may he removed A 1 -I fl 5 dunng me 'curse of the oper*unn(s] Of procedurem ln UTSW fm rffseanh oredwalsonai purposes. A undefstanc inai any 0, pans vduch aw not for research Of educatxmal purpose will be cilsposed of by me ACKNOWLEDGEMENTS: gy; wan of is maxed by rm Fw: -and Drug Amnanimzfan (FGA) ls implanted during surgery, 1 und??smm3 that rrfi' number and Social Security number will ba released 10 the menufacluren 3 I understand .hat my name and procr?dure w?1 be pnsraa on the OR Bgard, in a urrvme area o1 Ovemnve Su te I understand thai Cvmp?fw repreSems15ve(s) may be presem during 'my prmzedure io serve as resource personnel 1 understand thai singlemse device# repfooessed by an FDA appmved reprocessing csmer may be used. authorize the Hospital and/or (MSW intake sim phomgraphs, motion p?cxufes. television rransmissbons, and/ar vsdeo-Laped recordings or other images of me or my proceaursto be used lor Xreatmem and internal organization purposes provided my menmy |s nc! revealed by mm pictums nr by descriptive text accompanying them. Such purposes |nc\ude. but ae not Iimited Zo, performance improvement actwides and internal education, Images thax identify' me win be reteasso and! or used the Hospital or UTSW only upon written authorization from me and-' UT my legal lepresemainva. 6) I that egxarnination under anesthesia may be necessary in Iinalize the deiimtive approach (GT my procedure and to lavilhate median) ec\g1ca\ion oi the members ol my heanh care team, induding but not limited lo Residents and studenis unriev me dired supervision nl me Pacuny. Just as there may be risks and hazards in coruinumg my preseni condition without treatment, there are also and hazards vented to the performance of the surgical. medical. anwor dmgnoszic procedures manned ter me. I reallze thai common to sufgical. medrcax, diagnostic procedures is me potential for infeciion. mood c?ots sn vems and mngs, hemorrhage, ailexgm reactions even death, I aiso realize that Xhe inlkawing risks and hazards may Qccur in connection Mm lhis particular prucedurc. (Ta include all msciosures required by Texas Adm?naszrarfve Code, Wtle 25, Par! 7, Chaptef 601 Rule Pafrenr ro india: beside appropnam dzxolosures lor procedures.: E1 0 SRC Pawn: sf naxs Case 3:O7-cv-O1172- ocument16 Filed 33of35 PageID Disclosures ruqulred by T?u? Code, Title 25` Par! 7, Chapter 891, Rule 681.2 CARIMOVASCULAR SYSTEM ENDOSCOPIC SURGERY OF THE THORAX: The followsng shall be in acidlricrn IU risks and hazards of ine same surgery when clone as an Oven procedure: posroparalrve pneumothorax, subcutaneous conversion ol the procedure to an open procecrura. rrocar site complacarions re,g,, hernaroma/bleccilng. leakage ol fluid. or nemre Parser-rr 9 enum lr3rmatlnn_ SYSTEM TREATMENTS AND PROCEDURES - QHOLECYSTECTOMY wim or without common bile explorenon; pancreamrs. in?ury rc the tube between the llver and the bowel. retained stones in the tube between the liver and the Dowel. narrowing or obsrruclron cl the rube berween the liver and Ing bowel. iniury to the bowel anclior inteszinal obstruction arqqecowruggaoecovv Pnocicunesr The mn be in reunion ro nm and Mr I rilriilirdq cr lhe la inrregagbdeminal errumxes leg.. bowel. @?l?39f ?011 ~1seJr*ige2 an W1 cardiac dyslurrclion EAR TREATMENT5 AND PROCEDURES STAPEDECTOMY1 diminished Of bad taste, iolal or partial loss of heurvng in the operated ear. brief! or long-standing ='arm's mme hols requiring more surgery. ringing in the ear 1 RECONSTRUCTION OF AURICLE OF EAR FOR ODNGEHITAL DEFORMITV OR TRAUMA: less than salisfaciory vm-fn ir mee anpsarance ocrmpargm possible elr?malive sxposrxregef implanted material - TYMPANGPLASTY WTTH faciafnerve paralyslel. altered or lose cd rasle, recurrence of original Parremfr r?rrasc disease process. lotal Foss of heermg in operated ear, dizziness. ringing in me oar RESHRATORY SYSTEM TREATMENTS AND PROCEDURES - 5245108.95 LESIDN OF LARYNX, VOCAL CORDS, TEACHER: no risks or hazards assigned al lrus time A., - RHINOPLASTY on NASAL on WITHOUT SEPTOPLASTY: ur skin. bone Of cartilage, of new problems. such as, septal or bruaihing difficulty RESECTIGN (JF NASAL SEPTUM OH NASAL SEPTOFLASTYE persistence recurrence or Pnrzonfx mms: worsening of the obstruction. perroralion ol nasal septum with dryness and external defermily cl me nose ENDOCRWE SYSTEM TREATMENTS AND PROCEDURES THYROIDECTOQMY: injury to nerves resulting kr noarseness or impairmenr ol speech. lniury to parathyroid glands resulting in low blood caldum levels that require emenslve rnadrcalion rn avoid serious degensraxive conditions. (such as cauaracrs_ brittle DOHBS. muscle weakness and muscle irntalniligyl lung requirement cl rnyrosa Pam-lm lrmarais rnedicatian EYE TREATMENTS AND PROCEDURES as REFRACTWE . . ., ANS 1 sumsenv Ann GE lfearmrr ansfor NA surgery. need le: glasses or canracl lenses. requiring the ol lc-ns. lil double vision. partial or total loss ol vision. powible pain FIETSHAL OR WTREOUS GLAUCOMA SURGERY BY ANY METHOD: leqwrirlg l'=wf1 aedmonal andlor surgery. recurrence or sprean ol disease, par-:ral or lclal loss :rl vision REOONSTRUCTNE ANDJOB PLASTR3 SURGICAL PROCEDURES OFTHE EYE AND EYE REGION (BLEPHAROPLASTYQ TUMOH. FORBGN BODY ABSCESS. OH TRAUMA): worsening cr w-Salislacnory appearance. crgatron of aridliinnal problems (such as pour healing or skin loss. nerve damage. painful or unattractive scarring. impairment ol regional organs. such as or lip function recurrence ol Mrs' rn. murals originzil condition REMOVAL OF THE EYE OR lT5 CONTENTS (ENUCLEATION OH EVISCERATTON): requiring Pa--em mines additional surgery, worsening or appearance. recurrence or spread ci disease SURGERY FQH PENETRATWG OCULAR ENJURY, LNCLUDING INTHAOCULAR FOREGN BODY: complications lnmela requiring addrtional lreairrvem and/or surgery. including removal ol the eye. chronic pain. parrial or tow! loss ol vxsron INTEGUMENTARY SYSTEM TFIEATMENTS AND PROCEDURES I HADICAL OR MODIFIED MASTECTOMV (EXCLUDES SIMPLE MASTECTOMY): limitation ol movement uf shoulder and arm. swelling of the arm. loss or me skin ol me chest requiring gran, recurrence ol "sr:e'w1sirrinar? malignancy. if present, decreased src-nsahon or nufrmness ol me inner aspect of the arm and chesl wall vw. el vnegc SRC .9 gs fn.. :Fr ,pm Case 3:07-cv-O1172- ocument 16 Filed 34 of 35 PagelD 94 I PANENY I AND PROCEDURES lC0rtt|nued) - ARMOR PLAEFIC OPERATIONS OF THE FACE AND NECK): worsening or agp?aranoe, ul several additional problems( such as poor healing or sluri loss. nerve damage, painfuirfunaitreclive scarring. impairment of reglanal organs. such os. or lip recurrence ol Pwenls rum the original MALE serum. SYSTEM ORCHIDOPEXY IREPOSITIDN OF TESTIS (ESQ): removal ol atrophy (shriveling) of Ihe wan loss ol Perens :mms function . lnmare OFICHIECTONIY (REMOVAL CF decreased sexual desire, diflicullras wilh penile erecrieri VASECTOMIR of Iesticle, failure to produce permanent MUSCULDSKELETAL SYSTEM TREATMENT AND PROCEDURES AHTHROPLASW OF ALI, JOINTS WITH MECHANICAL DEVICE, MECHANICAL ENTEFINAL PROSTHEIIC DEVICE, GPEN REDUCTION WITH INTERNAL FIXATION, DFI OSTEOTONIW rmgalred functlon such as Y, deij QI an arm wage Jul esb?ping Ircnm ln a viral organ, to heal, removal or raplanememmanyl malarial - LIGANEENFOUS DF JOINT S: Failure rvaconsrructlon Io work, conlinued loosenrng ol me mgenegge anhrilis. wminuad pain. Increased sirflenrng. blood vessel or nerve ingury. casmmic nrirl/nr umrrionai de fly - CHILDRENS omuopemcs (Bone, Jorm; LIGAMENT on gmimn deformiry, aduimrrm sifgafy NERVOUS SYSTEM TREATMENTS ANU PROCEDURES CFIANIOTOMY WHAHIECTOMYI CRANIOPLASTY: addiuonal loss of bmin function including memory. recurrence wmlnuakirm or worsening ol the cundnion that required this operation. stroke. blindness, dealness, ro smell dmrbie coordlnaxion boss, seizures, new or cliflerem pain, numbness and paralysis. impaired muscle runchon MW ma or cevebrgl spinal Iluid leak grim pulential lor and severe haadaches, brain abscess E, Il INTERNAL FIXATICIN OR KEIWE RQQTOFI SPINFAFCORD DIAGNOSIS. PAIN, DEFORMITX MECHANICAL REMOVAL DF TUMOR ABSCESS OR HEMATOMA. (EXCLUDES COCCYGEAL DFERATIONSMI pain, nurf\bPe?, or clurrisiness, impaired muscle ur Impulance. unstable spine. retzurrerlce ar ol the condrlion that required the operalion, inlury lu maror mrrisrs blood vessels PERIPHERAL NEFNE NERYE TRANSPOSITION on TUMOR NEURECTCIMV OR NEUROLYSIS: numbness. muscle Function. or ggalysis, recurranca,-cominnalion or worsening ol the oondirlcin that required mis operation. seizures, new or event bam THANSPIHENOIDAL HVPOPHVSECTOMY OR OTHER PITUITAFIY GLAND OPERATION: spinal fluid leak, rfemessny fur hormone replacerrnenl, recurrence or canixnuarron cil the conditicn Iha! required this nasal I septal qglormriy or perforation, racial numbness am: zirsliguremenr 4 sm new sim ifmrimq I 'sign asirsiosri obstrucu' -sir U, vriimr Imam reeilfr?rwe? or nf Brain possible brain iniury or hemorrhage unm/mv PARTIAL NEPHFIECTOMY (REMOVAL OF PART OF THE KIDNEY), RADICAL (REMOVAL OF KEDNEY MDRENAL ISLAND FOR CANCER, NEPHFIECTOMY (REMOVAL OF KIDNEY), NEPHROLITHOTOMY AND PVELDUTHOTOMY QIEMDVAL OF KIUNEY PYELGURETEROPLASTY (PYELOPIASTY OR RECONSTRUCTION OF TH KIDNEY DRAINAGE SYSTEM, EXPLORATION OF KIDNEV OR PERINEPHRIC MASS. EXPLURATION OF KIDNEY OR PERINEPHFIIC MASS, UREFEROPLASTY GF URETER (TUBE BETWEEN KKDNEV AND BLADDEFI), URETEROLITI-IOTOMV SURCBCAL REMOVAL GF STONEISI FROM URETER BETWEEN KIDNEY AND ELADDEFI), IPEHYIAUDOMPLETE REMOVAL 0 URETER (TUBE BETWEEN KIDNEY AND BLADDERN. UREFEROLYSIS REMOVAL OF URETERUUBE BETWEEN KIDNEY AND BLADDEFI) FRDM ADJACEN TISSUE, UFIETERAL REIMPLANTATIGN (REINSERTING URETEFI (TUBE BETWEEN KIDNEY AND BLADDER) INTU THE BLADDER: Incornpleie remcwai of stovwelsl or tumar if present, of urinary flow, leakage of urine BI surggial site. Iniury to or loss of me kiGney, damage io au}aoem organs. loss of me adrenal Irwm gland; damage toror loss ol uvfalgr. backward How of urine from bladder into ureter PROSTATECTOMY (PARTIAL OR TDTAL FIEJIIOFIAI. OF PROSTATEI: leakage of urine ai surgical she. obstruction In urine Iliovvr incontinence Idililcully with urinary semen passing backward mm bladder. Imam dillwuily with penile erecliun (possible with parllal and probable with tolal proslatectorny - TOTAL (REMOVAL OF URINARY BLAUDEFI): probable loss ol penlle erecuon and in me male. damage to other ad?aoenI organs, this will require an allemaba melhod ol urinary cramage :rl I-wave! Case 3:07-cv-01172-K ocument16 Filed Pa 5of35 PageID 95 I mmim LASR I URINAF-W SYSTEM (Comlnued) mul lmnaw D11 'x als Par en: mnauls =a sn lwan VASCULAR 8 "at nm Lmiwsls r*rlln'1 CYSTECTOMY (PARUAL REMOVAL OF BLADDER) Ieakage U1 urine at surgrcal 5.1? xnconunence urinary backward haw cr cladder mio urerer [tube between mdrsay and bladder) abstructlon of urine flow requzres weanng a bag lor LKIITG cetiecnon URINARY DWERSION GONDUIT GOLON GONDUIT) blood abrformaimes fredrcauon of stones sirrciures or mfecuen routme hrelong meducal evaluanon ieaxage uf mme at sne requnes wearing a bag tar urvne coilaciron URETEROSIGMOIDOSTOMY WLACEMENT OF KIDNEY DRAINAGE TUBES INTCI THE LARGE brood chemzsuy ahnormallixes reqmfing medmauon de/ve\opment of stones or rnfewon vounne melcno medncal evaluation ieakaga of unne ax surgrcaf srle armcurry in holdmg ur\ne rn the rectum OF DRMNAGE TUBE FROM BIADDER) reakwge of unne ax surgzcal she formahon aadmonal SYSTEM TREATMENTS AND PROCEDURE OPEN REPAIR DF AORTIC SUBCLAVIAN AND ILIAC ARTERV OR DCCIJJSIONS AND RENAL AHTERY BYPASS, hemorrhage paraplegaa, kndney damage stroke acute rnfarcnon wmactmon af grail ENDDVASDULAR STENTING OF ANY PORTION OF THE AORTA QLIAC OR CARDTID ARTERY rniury fc vessels that f?qulre rmmedlaie surguzal convfarsron oi procedure IO Oper* pfoceoure faalure to denver slam I endoluminai graft. sient rmgranon paraplegua (for anna procedures urviy) veesw occiusren. pseudo aneurysm nrreversibte kidney damage rmpotenoe (rar abdominal aorta and mac af ary procedures only) siroka (Var carotid artery procedures only) setzure (for carowo' arrery prorzeduras only/>> VASCUIAR hemorrhage embolus pulmonary complumnons shack The may choose ro be/ow specrhc risks and hazanis rn addmm to those #5165 above narcohcs have been 5dl|7m|SfEf6d sue hours of obrarmng consent a phys/clan shaf/ cemly Mar me mairrng capacity to consanf In this procedure srgmue Q1 Phynuan umm Numa 'sawn 'Mum ar have been given an apponumxy to ask my phys|cian(sQ questions about the nature of my condition, used mcluding the use of advanced Iechnoiogy and risks and hazards rnvohred Advanced t-'ch wrurw nr Innes but ws mr to the use of eleclromc SONIC LASER microwave mme frequency and robohcs rechnology iorm has been fuhy axp?amedto me 4 have read rl cr have had read ut to me The blank spares have l)%w1 killed un undersrand the oonxems of thus consent, lhave suffecnem uniormahon 1mm my to gwe mformed oonsem for my planned pr0?eduru(s) NOTE One /ndmdua! musr me signature of the ,nanenf or dacrsron makumg surrngare are 01 Penal! Eur Decaslon-Making Q4 Oblammg Cnmom Pnnxaci Name Sq, ah. ez 0' Samson of Recnni (ua on signed :mr uruneaun) Pun oc, Cxgnuiu 54 P1lfl\Bd *lame Smmn. nr wommns Name Wdnsus ID Numa 1nlel?|BlGf DD NA almmgawe xriiapnam, Q1 bioqdmmibluod pnsduda, me prooadurera be rf. .om s.n~mnom1.n? sn..