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HomeMy WebLinkAbout96-05748 '- \. ~ .... , . ,':) ... ~ .... LAW OfflCI1S OF: BATT, HALPI1RN & WI11NRAUB BY: MARC 11. BATT, BSQUlRB Identification Number: 14042 Suite 2710 1101 Markel Street Philadelphia. PA 19107-2927 (215) 629-7225 SIV HnANG CHUM, Individually and as parent and natural guardian of PHYDA NY. a minor 119 Maple Lane Belle Chasse, LA 70037 Y. BRIN JO LUNGBR 390 RIch Valley Road Carlisle, PA 17013 and o'RUCn. A. SHBRlff 390 Rll:h Valley Road c~arll~'e, PA 1'7013 , " MAJOR - NON JURY ASSESSMENT OF DAMAGES HEARING REQUIRED, Attorney for Plaintiff COURT 011 COMMON PLBAS CUMBRRLAND COUNTY ~~ TBRM, 1996 NUMBI1R: q~ -57L/8 . . ~ .': PRAI1CIPI1 TO \SSUI1 WRIT OF SlIMMONS , ' I , ' , ., ''f0 THR PROTHONOTARY: .' ,;t Kindly Issue a Writ of Summons agalnstthc Defcndants, Erin Jo Lunger and Bruce A. Sheriff, with regard to lhe abovc-entitlcd action. BATT. HALPBRN & WI11NRAUB ~,,/ BY: 4 . MARC U. BA'n', BSQUIRB Attorney for Plaintiffs Dated: III /,1 /till , I . ~ ~~ t~ ~~ \n ~ t' ~ S i3:a ~ ~ a 1.1"" ~ . () . "ll i\ (\M i c;e 3~ ~ ~ g~ ~ ~ "'-:J ~ g ~~ :!F '" ~ "( '6 ~ ~ ~ ~ .J ,-~ J ... Commonwealth of Pennsylvania County of Cumberland SIV IIEANG CIlUM, Individually and as parent and natural guardian of PIIYDA NY, a minor ! i ! \ 1 I I I I I I y': I r to;' \ t t],; VI. Court of (Jommon Pleaa No, .~.~:.!!?4..Lg.t..Y~.~.1:~F.l!I.......... 19m. III _ _gi'!~J .ft.!'); !.!!~__:_J!!'.1! ..____m__n'___ ERIN JO LUNGER and BRUCE A. SIIERIFF 390 Rich Valley Road Carlisle, PA 17013 To .11=r.Jp..~ 5!. _~1Jng!l.~ _.Il[1!t. Rntgllnl\.~nijl\l!r iff You are hereb)' notified that ,. ~.i-.. '! _ )!~_~ tl.!1.!::. ~H.'!I J _ _ H!t! J Y .i:,l!.\tI~ .UY.. tlJllL.1l P. .PP. rRlJi. {tlltl.. [111. hU'f1.l. .lIP.1l r!t tAI]..Q f Phyda Ny i lhe Plainllll haB commenced an action In _.___.......~_'{!J.__~~J.m.J.m__.__.n__......._n.n.. agaillll )'ou which you are rellui~d 10 def"lId or a defauh Judgment may be entered againlt you, (SEALl Dale _m.9P.tP.~PJ.:.!Q...nm.n 19..7.6 ......_..~1l.~J:~!lQ~_.f~~.){~J.~~.~.............. ProthonOlalY Dy .~. ~.I!~tL/l.2~..n. ~ Deputy ~ c !:i Oal J li r NI'- 0 ~ ,B,~ ,.... all'- '0 0 ...... ... C.... C '0 .S t1~ Ul t-IlIl'l"4 C ~ ~~: lilt: J :. III -Ill: I I'll tal III ,fl; N ~ - ll:H ..l .. ... ~ll: "mtn "0 c - ~~ .... .. III ... "og~ .1"4 ..ret:a.... CIl > 1 ., ..l '1"4 ~~.Illl<, I'- m;~ , u ~ Gl 0 111 o Ill: ' III Z I ~ tal :1:'0 III Zt! _ I'll' aI ~ i~ u~8~c ~ t-Ifi! ~~::I.c: , Cllll :I: fl;H .' l i , i" i I t r , I , r 1 F, 1 I I ! l l r- f. 1 SH~RIFF'S RETURN - REGULAR CAS~ NOI 1~9G-0374B P COltltoNWEALTH 01-" PI::NNSYI.VANIAI COUNTY OF CU"BERLAND CliW1JU.Y.Jff.MiI} .. , VB. IAJ.lim~_ILE!Ull,_,HL~T AI, .. t;T1Wt~_.n.. WI! Jt?'t1.f~L,... ' CU"DERLAND County, Pennaylvania, to law, says, the within WRIT OF upon ,Jdllimm..JillJJL JIJ. defendant, at 710100 HOURS, on 192.\i at _;J~_lUcH_..Y"LLEY ROAD C.ABJ.Uil..1t .J_P. ^_..11~.1 :3.._ , BhDriff or Doputy Sheriff of who being duly sworn according SU""ONS was served ......_..__.. ,_ the the ~ day of November m..-J CU"BERI.AND STEPDAUGHTER County, Pennsylvania, by handing to ERIN ,10 LUNGER. . true and atteated copy of the WRIT OF SU""ONS and at the same time directing H~~ attention to the contents thereof. Sheriff's CostSI Docketing Service Affidavit Surchargl!l 18.00 4.'36 .00 2.00 ~7.4.!lb nARC E DATT 11/06/1996 by ..i\lt' , 4.-.l.l_ 6{;f' I~'" eputy~ er ? Sworn and subsoriborl to bafore me this ..!.~~_ day of ~t""...t.-......., 19....._(~? A. D. _..._.q~P~'th~~1i1fr' , ~,...... the " SHERIFF'S RETURN - REGULAR CAHE NUl 1~~6-0~74a P Clln"UNWI-:^I.TH IW P~:NNSYLV AN I A. Cll JNTY In' CU"IH:RLAND CHUM!) IV m:ANll Vii. I)Jlilmn l.;ntH JI) I~T AI. ,lm:VKI1 wIlIIHl,f:R CUMBERLAND County, Pvnnsylvania, to law, ssys, thIP within WRIT OF uplm .f:lm:OJFf IjRVC~: A dIPfllndant, at 71WJ00 ltOURS, on th. ...Q1h day of NovlPmbllr 19~ft at _~\1'" RICUV^I.L~:Y ROAD g^m,Jpl.~;,1 PA 17013 ,CU"BERLAND County, PIPnnsylvaniB, by handing to ERIN JO LUNGER, STEPDAUGHTER a trulI Bnd attllsted copy of the WRIT Of SUMMONS and at thIP SBmv timlJ dir.cting Iiu:. BUentlon to th.. contllntB thvrllof. J Hheriff or Deputy ShIPrtff of who being duly sworn according HU""UNl2 was lIervlld Sheriff's Cosh. Dockettng Sll'rvice Affidavit ~urcharge So anSWll'rs. 1;;11 2.10 'B.VJVJ ..-]2.0" II, ~hom~' fln'-iiu ~t'~I:S 1 S~p by . ~ }" ,_ II;/. l ~,~:,., ueputy 'Sh~ 13wortl ond lIubBllriblJd to before mil thts Jvf!: dllY ot'--HI,;~'l\'~'v t':l cft. A. D. __ '+'P"Pr~lh~~~'tl~t;- ,~tf.j, '"'" IN TilE COURT Ol~ COMMON PLEAS OF CUMIlElUJ\ND COUNTY, PBNNSYLVnNIA SIV HBANG CHUM, Individually and as parent and natural guardian of PHYDA NY, a minor 119 Maple Lane Belle Chasse, LA 70037 v. CIVIL ACTION NO.: 96-5740 ERIN JO LUNGER 390 Rich Valley Road Carlisle, PA 17013 and BRUCE A. SHERIFF 390 Rich Valley Road Carlisle, PA 17013 AND NOW. 'hi, 1Jo /:.. :.: ::~ consideration of the petition for Leave to Settle Minor'S Action of Phyda Ny, a minor, it is hereby , 1997, upon or compromise a ORDERED that petitioner is authorized to enter into the following settlement with defendants Erin Jo Lunger, and Druce A. Sheriff; the gross sum of Fifty Thousand Dollars ($ 50,000.00) to Phyda Ny; and IT IS FURTHER ORDERED and DECREED that the settlement proceeds shall be distributed ao follows: (a) To, Phyda Ny, for deposit as set forth in the within order. . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 29,192.12 (b) To, Marc E. Oatt, Esquiro, as counsel to Phyda Ny for costs and oxpensos.,..$ 760.07 (c) To, Dr, N,Steinhouse(Jend, Inc.), as payment for outstanding balance., . . . . . $ 3,703.94 (d) To, Del.Vnl.Phyo,Med.Assoc., P.C, as payment for outstanding balance.. . . . . ,$ 1,670,00 (e) To, Marc E, Oatt, Esquire, 8S counsel to Phyda Ny for f006 ................. $ VI, 593,07 'l'O'fAL. . . . . . I . . . . . . . I . . I. . . . . . . . t . , . . . . $ 50 ,000,00 ,-.., ,~ '. Petitioners' counsel io hereby authorized to execute all documentation necessary to purchase savings certificate(s), from federally insured "vin~ institutiono or credit unions, t~2..cz., , in the amount of Jf 1_ E....IIl".",-,.... .11 in). The savings account (s) shall be titled and restricted as (ollows: Phyda Ny, a minor, not to be withdrawn before the minor attains MAJORITY, except for the payment of city, state and federal income taxes on the interest earned by the savings account, or upon prior Order of the Court. Pursuant to Pa. R,C.P, !i2039, counsel shall promptly file with the Court proof of tho establishment of the accounts as herein required by AFFIDAVIT from counsel certifying compliance with this ORDER. Counsel shall attach to the AFFIDAVIT a copy of the bank accounts containing the required restrictions. BY Tim COURT: J. r, "1 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SIV HEANG CHUM, Individually and as parent and natural guardian of PHYDA NY, a minor 119 Maple Lane Belle Chasse, LA 70037 CIVIL ACTION NO. : 96-5748 v. ERIN JO LUNGER 390 Rich Valley Road Carlisle, PA 17013 and BRUCE A. SHERIFF 390 Rich Valley Road Carlisle, PA 17013 PETITION FOR LEAVE TO SETTLE OR COMPROMISE MINOR'S ACTION TO THE HONORABLE, THE JUDGES OF THE SAID COURT I The Petition of phyda Ny Chanthavilay, a minor, by her mother and natural guardian, Siv Heang Chum, and by their attorney, Marc E. Batt, Esquire respectfully avers: 1. Petitioner, Siv Heang Chum, is the mother of the minor phyda Ny. 2. The minor was born on May 15, 1980, and her social security number is 201-100-1118. 3. The minor Phyda Ny Chanthavilay, resides with her husband, Intra Chanthavilay, and her mother-in-law, ThangoU K. Chanthavilay, at 4859 Brittany Court, New Orleans, LA, 70129, independently of phyda Ny's mother, Siv Heang Chum, true and correct copies of the Phyda Ny1s State of Louisiana Certificate of Marriage, are attached and incorporated herein as Exhibit "A". 4. The defendants, Erin Jo Lunger, and her stepfather Bruce A. Sheriff, reside at the above address. _"",-_~o.;:.:- .-.., 5. On October 21, 1994 Plaintiff, Phyda Ny, was a passenger in a motor vehicle owned by Bruce A. Sheriff and operated by Erin Jo Lunger, which motor vehicle was traveling northbound on SR 0034 at or near its intersection with Marsh Road in South Middleton Township, Cumberland County, and which vehicle was caused to veer off of the said highway, strike an embankment, overturn, and strike a fence, as indicated in the Police Accident Report, which is attached and incorporated herein as Exhibit "B". 6. As a result of the aforesaid accident, the minor, Phyda Ny, did suffer fracture of the posterior elements of the cervical spine C3-C6, facial and upper extremity abrasions and lacerations, fracture of the T12, bilateral shoulder strain and sprain, right knee strain and sprain with contusions and edematous, post trauma cerebral concussion syndrome with cephalgia, post traumatic anxiety disorder, and headaches, from which injuries she continues to suffer residual problems. Attached hereto and designated Exhibit "CO are the Carlisle Hospital medical records and reports, BS well as the report and treatment notes of Natawadee Steinhouse, M.D" dated October 22, 1994 through March 31, 199!:J, stating the injuries of the said minor and that she was discharged. 7. As a further result of the accident., the minor, Phyda Ny did incur medical expenses 8S followSl Carlisle Hospital.,..,. ",. .....,.,..,.,. .$2,539.28 RWC Emergency Physician."...,....... ". ..$ 67.41 Carlisle 1magln\l."."."".""".",,,..$ 201.51 Mt. Bolly Spg. Amb".".".".""" 11....$ ;>42,00 ,,-., '""" Global Medical Solutions... ... ...... .... ... 680.00 Dr. Daniel Hely...........................$ 560,00 Ernest H. Coleman... III .,. .....,.... .1' ..,$ 40.00 A.Z. Ritzman Assoc.. It' II' ........,. ... ...$ 142.00 Dr. N. Steinhouse(Act 6) ...... ...... ... ...'4,740.35 Dr. N. stempler.........,...,.....I.......$ 300.00 Del.Val.Phys.Med.Assoc., P.C........ ... ...'1,860.00 TOTAL....... ,.1' t. I................ I'" I .$11,372.61 8. At the time of the aforesaid motor vehicle accident plaintiff was an insured under a policy of motor vohicle insurance with State Farm Mutual Automobile Insurance company (hereinafter "state Farm"), known as claim number 38-7071-112, which policy provided five thousand dollars in first party benefits coverage, and which benefits have been paid and exhausted. A true and correct copy of the state Farm declarations page, exhaustion of benefits letter, and PIP benefits payment log are attached and incorporated herein as Exhibits "0", "E", and "F", 9. The following medical expenses remain outstanding as of this datel Dr. N. steinhouse(Act 6).. ,.. .,.... ...'3,783.94 Del,Val.Phys.Med.Assoc., P.C..,.... .,.$1,670.00 TOTAL.,. 1.1.....'. I' I.... I I"" I" I' t .$5,453.94 10. A settlement has been proposed in the amount of Fifty Thousand Dollars ($ 50,000.00) for plaintiff phyda Ny Chanthavilay, which amount represonts the policy limits of the motor vehicle liability insurance coverage for defendants Lunger. 11. Attached hereto and designated Exhibit "G" is a , rd.. ...., statement, under oath, of the minor's mother, Hiv Heang Chum, certifying the residence, marital status, physical and mental condition, and financial independence, of the minor Phyda Ny Chanthavilay, as well as the parent's approval of the proposed settlement and distribution. 12. Attached hereto and designated Exhibit "H" is a statement, under oath, of the minor, Phyda Ny Chanthavilay, certifying her residence, marital status, physical and mental condition, and financial independence, as well as her approval of the proposed settlement and distribution. 13. Counsel is of the professional opinion that the proposed settlement is reasonable due to the nature of the minor's injuries, the uncontested liability, and the insurance coverage available to the defendants. Affidavit of Counsel is attached hereto and designated Exhibit "I". 14. No entity, other than the medical providers stated above, has a claim or lien against the plaintiff Phyda Ny Chanthavilay. 15. Counsel has incurred the following costs and expenses for which reimbursement is soughtl Dr. Lipnack(records) .,... ..,....,.. ...$ Dr. Stemjden(records). ... .... .,.... .,.$ Lodging f . . I . . . . , . . I . , , . . , . , . . . . If' . . . . $ Photographs. . . . . . . . . f , . . I . . . . . . . . . . . . . $ Prothonotary(filing) .,. ,.....,..... ...$ Sheriff Cumberland cty..........,..".$ F'ederal Express........ I . I . . . . . . . . t . . . $ "ravel. . , f . , . . . . I . . t . . f . . f i . . . . . . . . . . . $ TOTAL. . . f f f . I . f I I . . . I . . . . . . . . . , . I I . . . . $ 190.00 300.00 109.15 29.50 45.50 32.96 13.00 39.96 760.07 ,.- r-., '- 16. Counsel requests a fee in the amount of Fourteen Thousand Five Hundred and Ninety-Three Dollars and Eighty-Seven Cents ($14,593.87) which is 331/3% of the net settlement payable to the minor, Phyda Ny Chanthavilay. A copy of the retainer agreement is attached hereto and designated Exhibit "J". 17. The net sum payable to the minor, Phyda Ny Chanthavilay (after deduction of costs, medical expenses, and attorney's fees) is Twenty-Nine Thousand One Hundred Ninety-Two Dollars and Twelve Cents ($29,192.12). 18. Counsel has not received C'ollateral payments 115 counsel fees for representation of the above plaintiff, Counsel is pursuing an under insured motorist claim agaiost State Farm on behalf of the minor plaintiff. Additionally, State Farm, as the under insured motorist carrier, has consented to the settlement of this third-party action, a copy of which correspondence is attached and incorporated herein as Exhibit "K". 19. Pa.R,C.p. 2039(b), providesl "(b) When a compromise or settlement has been 50 approved by the court, or when a judgment has been entered upon a verdict or be agreement, the court, upon petition by the guardian or any party to the action, shall make an order approving or disapproving any agreement entered into by the guardian for the payment of coullsel fees and other expenses out of the fund crested by the compromise, settlement or judgment, or the court may make such order as it deems proper fixing counsel fees and other proper expenses, The balance of the fund shall be paid to a guardian of the estate of the minor '" "..... or to the natural guardian or to the person or agency by whom the minor is maintained or to the minor". Pa.H.C.P, 2039(b) (1) [emphasis added]. 25. Pursuant to Pa. H.C.P. 2039(b) (1) petitioner Phyda Ny Chanthavilay requests that twenty-five thousand dollars ($25,000.00) of the proposed net settlement to Phyda Ny shall be paid directly to Phyda Ny Chanthavi1ay, and the remaining four thousand one hundred and ninety-two dollars and twelve cents ($4,192.12) shall be placed in a federally insured financial savings institution account until Phyda Ny Chanthavilay reaches majority. 26. In the alternative, pursuant to Pa. H.C.P. 2039(b) (2) the court may order I "any amount in cash of a ... non-resident minor to be deposited in one or more savings accounts in the name of the minor in banks, building and loan associations, savings and loan associations or credit unions, deposits in which are insured by a Federal governmental agency, provided that the amount deposited in anyone such savings such institution shall not exceed the amount to which accounts are thus insured, or in one or more accounts in the name of the minor investing only in securities guaranteed by the the United States government or a Federal governmental agency managed by responsible financial institutions. Every such order shall contain a provision that no withdrawal can be made from any such account until the minor attains majority, except as authori~ed By a prior order of the court. Proof of the deposit shall be promptly filed of rocordl" 27. Pursuant to Pa. R.C. P. 2039 (b) (2) peti tioners request ~ \, r ; i '1 that entire proposed net settlement to phyda Ny chanthavilay shall be dl!posited, in her name, in a federally insured financial savings institution account until phyda Ny Chanthavilay reaches major! ty. WHEREFORE, Petitioners phyda Ny chanthavilay, a minor, and Siv Heang Chum request that they shall be permitted to enter into the settlement recited above and that the court enter one of the attached proposed ordera for Distribution. aATT, HALPERN , WE INAAUB ~ , ;: -)~-- B MARC E. BATT, ESQUIRE ATTORNEY fOR PJ,I\INTI fF IDENTIFICATION NO.1 14042 1101 MARKET STREET, SUITE 2710 PHlLADELPHIl\, PA 19102 (215) 629-7225 ,.- ...." VERIPICATION I, Siv Heang Chum, the mother of the minor, Phyda Ny, the petitioners in this action do hereby verify that the statements made in the foregoing petition to Settle or Compromise Minor's Action are true and correct to the best of my knowledge, information and belief. I understand that the statements in said Petition are made subject to the penalties of 18 Pa.C.S. ~4904 relating to unsworn falsification to authorities. DATE: ~ /;:H /C;? . ~~W~. SIV I C ~ I"-~ '....... VBRIFICATION I, Phyda Ny, the petitioner in this action do hereby verify that the statements made in the foregoing petition to Settle or Compromise MinorIs Action are true and correct to the best of my knowledge, information and belief. I understand that the statements in said petition are made subject to the penalties of 18 Pa,C.S. ~4904 relating to unsworn falsification to authorities. DATE'fh! I r- ,"'"' IIXlftPXT "A" '~ ,...., ~~'~:l:l!,:,..\."'j\;, \."l:\..l.~.'.I,,:l.r,:.' ~:t' '-':~~'~:l~:'="~\""'~l"~~l',\:';\',,l'l r,' ,r' :,' -:I'l'l,',':'~l: ',,:.' ,:.< \"~"" ,~.' ,:l', 'l~l'\',l:" ,;o71:l,r~.'\:,:;:':t':\:,,:..:,:, l. l ~ ,e 1! !l ~ !J g l!l ~ 1 .5 , rJ 0 :s ] .( ! '5 . ~ i ~ 5( ~ I 'ii; W ] I s .~ ~. ~ olJ ~ .... -E ~ '- ~ .. 0 '" ~ . 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"'''Ill "11m , flue ,. i4-.ilwm f'-I'II 'ir~ljr.III_-:iiAt m;L ~ l.J II I \lI1"-U 112~G72 " .'-p'et.' ~'ii'iC.IIGil' '<6oov Tl "E . (iU),', ,ItAlA, IlnO,i!i' _ '. ~AIt!II"I'; '.IIIl..V.,',' :/7)vlcii ". rmHllJ i~ f~O- ijF Mtll"i ""i:~l~i.ll 'I: -1I"ii:I~'" I yUill I WllIl) rttHll11 tll1l1l1lll\':,\ ',' !1M r1" OOUU78t: -.,...............,....-... .... ,...'.. ,..".., ..,-,... 18 IIr~~~~I!~!~'.!!~..~~:!._$'m' l.. ,I~~IJ_P!,. (j~lll~~A,!i.\I/~~.,; ....., 19, "'rDICAI rACllIn ' L~..l11irJnl~ - t: PL'III UMA I U C n t r n 110\1,\1 ^,)II~U_';~... . ~_'.' ' . I~ - ~.L. .}~. ...~ . - . ~'_. '~ij~~-~o-~cp'~j.jt{~=,~'..~.:.."..." ..,._,' ...., ".. 1. J..j),-.~. '1,.1 3 J'j_lt~.;l, {L ..'J.(;fLkl!\l.r~U)JU", ~1~,CIti~.Jil;, !(l?UY1;:~-'11)1 ,;\.'Il7)ti ..t 5.. .~. s... ,~ , . J. , E-l.'t. it 6-_.0_ fl!tbl~,~.J!)~~VJCClI}h(,~"M. J.1J,UI': ~1~i.<?-.. ~- .'i .lL. 'I. -'- L.I:1 l i.9-, . QJ;.JlvlJ\l)~Ju.~IU:n:.l\:tlJhr.:rll'l\,ml~A' WmJ L ~L.. ~.- ~ ,. '1 \ ~ I' 15' 'J,. 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L.stv~_~Cl.R;mzr_Ik'ii~Ji._,<;iJ"!Y..,..m.Ilt:.r..n~)L ... _htLJNML~I1J,I1I...rn.lJ~r.l&TlJ....o,~...NJJlJltL,.sJr.,.silJ1i2J ..':_U:-!\Ltb~_ f!!l?Y~.~J11eJL1\ .CJ\f!.,..~tlr.I\.'ILbLlkTJLhE'-'l!,(L L..:l~-QY. .n1JWiK~- () .... !LIt'" IlJ1o.'U:aliI\7I..of-.crL .IJ\~.:'.., ._on' ..,.......-, ,.,. ---'-'-- --....-....- .lID/MIl /)1 I l--lIlo.J!YlU\~'l:.V.l:Lt1LnA:;.~,_He_.~11IUl,.'.P.'I1.~L(.M.h",..1l.J.1.!QLJ1P{\li-_... ~..J~l1!.1!i..i/!4,"'_cf:... ()S _fuO.SIk:..J.oSi _~l1\9J.~IF_ThL,~ :~-,---,_._._- ....w1J'Mi:&.~..~IIV1l:l\V"'}'oo IlLll~ .:AJv';' .SIt. ,~I1lIlJ),::_U^hl,..*:. ..o:M.. .rulJ~I'i<,I\l.V 1i;.jl.lGiL [wIUAN,ll!;W.l\'-'1),lllltc- ~l:lT N{l \)r,CIi[. .l,?ut.:il. lh:. IVll-/l'.t."" . SI'~IS:. Jl>sur'l,1lI..,lWtR1'I.p"",,)\ doPt),~I)\ ..,. lJVlT.l' L. JlJ'li/J. P.t...r'lJt.lll~~ .\tJJ'".. t1~Gunfti, N,~t'l n,;t.i~t4Y L"1J2Jr, ItH1UIIM.(r , C:OMIIMn 1~'FOI\I)M'Otf . I,LL.'7UIIG IlIrl1I1I.,1^'1I11l U,il1 .. ,'U\'U;, .."\., Q" I . \I!III . i'olln I IlO """ :. !In !~ 11 1111 ,OIV-VIt, ,:mnV WllNUlfll!l "1 Ml 3'11 ~1/fJ ~)lIlJL ffi::;:~~r)I\l'\\ Pi' m~~ ) ,I'"'''}' fl17 m~'1)(t ' PIIOtII h', \I'Ut 11\1 l'ilfHJlI;A ill Iff) iii \:1Il111 ttlJMlll.llll11t~l' II 1I1AlllilllJ Ie II C .. U'."~ ' .u~llL.x,., (XIV!M:J, ffi,v/^-b (IT u,u.y)r~ :J!/l[) Util'} 31/1-/ ~TJ 111\ i\A 4!,\1"1;'1 \'1'.' 1~1'1 ,flil't ~-,tlll', 1~!11I q',l Ilr.1 ' 11111):,' O II 11,1 j t U'II1'> 'U'l U'I:\ ' , ' I 1.1 ? ~ I i I? ,lljl'lllJII!\11l1 11",1' 1,1,- ll'l II!,' I PA'd 1'>- IIJI11',tlll';-llflnll'" " ., '_lllII\'1 '>I It'\l\ I 10," I () 1I'r' 1111111';1' Clll.YHlrt . 1"1 1I~11\ \r.'\ 1,,1 til' I I I Iii II II I tlll 1111\11\':" .~ ^' i I'l' -- ..... "Klltot'l' "C" ..-. ~ fill.rI.fh.CO~ONdal NA I A\\'I\I>I.I. ~I L1NIIOlN.. M 1>, 719 RhawlI SlIrd, I'lulatl"'l'hla, I'A I'JIII, (!ISI H!.Il77 , 101\ , H!.7(,70 M.uch 31, 1995 Ball, Halpern & Welnraub Suite 2710 1101 Market Street Philadelphia, PA 19107.2927 1m PHYDA NY DA: 10/21/94 Dear Mr. Batl: This Is a sunmwy report on Ihe abov!! nallled patl!!nt who IhlS be!!n treating illthls office (or Injuries tl!ceived on the above noted date, INITIAL SUBJECTIVE: This patienl Is a 14 year old (elllale who W,IS a passenger In i1l1 ilutomoblle Ihat WilS Involved in an accidenl. The v!!hicle flipped sevetill t1llles which milde thai accident especially severe. As a result o( this accidenl the patient sustained Injuries 10 her neck, upper and lower back, head ,1I1d (ace, bllillerill shoulders, and Ihe right knee. The patient was taken to the emergency roOI11 at Carl/sic Hospital where she had x-rays laken o( her spinal colul11n, The results indlcaled l11ultlple (ractures o( the cervical and thorilclc spine which were non.dlsplaced. The patienl has provided with a cervical col/ilr .1nd was relcased wllh instructions and l11edlcatlon. Upon prlmilry examin.ltlon ilt Ihis ornce the pallen I seemed to be iI pleasanl younggl : wilh visible contusions .1nd lacerations 10 her (adill tl!glon. The patlenl seel11ed .Inxious .Il1d It \\,.IS laler reve.lled Ihal she hilS been experiencing posllraul11a anxiely since the accident occurred. The patient did hit her head and she has becn !!xperlel1c1ng posllraul11a heddilches but wllhoul ilssocl.lted dizziness or nilusea. There Is no significant pastl11edic.ll hlslory noted. The in ilia I office visit was on 10/31/94, INITIAL OUJECTlVE: Inlllill examinallon revealed severely restricted ranges o( 1110 II on 10 Ihe ccrvical.md lumbar spine with 1110derate 10 severe discol11(ort wllh tanges o( motion, The patient was not asked to per(orm extensive r.mges o( l11ollon eXill11lnallons or physical capacity tests due to the severlly o( her Injuries, Them wem 3 + l11uscll! spilsms .111he cervlc,ll, Ihoracic, .1I1d lumbar regions with 1ll00Jerate 10 severo lendel'lll'ss 10 compression. Contusions 10 ocul,u relllons and (ace wllh 1.ICllratlons, Contusions to ,UIllS wllh lacl!rallolls dllll sulures 10 left upper ilrl11. Contusion and l!dl!l11,ltllllS 10 rlghl kiWI!, Ill'slricll'd left shuuldl!r flexion al <)U/IIIO", extcnslon al 26/50". .Ihducllon .11 <)]/1110". ,lllduction al 22/50", Internal rolatlon at 49/90"/ extl!l'lltll 1'01,111011,114 7/lJ() 0 / re~lrllll'd right shoulder r1l'xlofl illl1lJ/ll10" / exlefl~lon 011 24/50", .lhdlKllon,lt 90/1110", adducllofl ,II 2!i/5()". illll'l'I1,lllllt.lllon 011 47/lJ()", cxterno1l 1ll1.llIofl ,II 4 7/lJOo, Reslricted ril\ht knec (h'xiOfl ill 7U/l !iO", A SlIghl ~cl15ory deficit Is floled to hilateraluppl'l' l!xlrcmilil's o1fld hil,llertll po~h'lllJr Ihil\hs, No ,lltoph\', 110 fibrlllatlofl, [),T,R. ,III 2 -I / heart rail' flOrln,ll, IUl1gs dlw, .lhdol1ll'fl soft, (jl'l1l'r,llilcd l11yolillo1flll'fltl1US Infl,lI11I11,llIol1 10 rlhs ,1I1d dll!st w.llllt'giol1, I"', """ fll,rl ...!'kc(')'I'jt(')Jl(dal N^ 1 ^IV ^DU. ~ I UNIIOlN.. M,ll m RhawlI SIIcd' l'IIIIOIltdl'hla, 1''' I~III' 121S1 H2.B77 , I a~' 142.71170 March 31,1995 RE: PHYDA NY DA: 10/21/94 Page two: INITIAL DIAGNOSIS: 1.Acute cervical slraln/spraln with fraclures 10 C3.G 2.Acute thoracldlumbosacral strain/sprain wllh fraclures 10 T12 3.Bllaleral shoulder strain/sprain 4.Rlght knee strain/sprain with conI us Ions and edemaloUS 5.Multlple contusions, abrasions, lacerations G.Post trauma cerebral concussion syndrome wllh cephalgia 7.Posttrauma anxiety disorder TREATMENT: I Initially trealed Ihe pallenl wllh Ice packs and ullrasound on the first visit, and continued to do so therearter with moist hot packs, ultrasound and eleclrlcal stlmulallon. The pallent was prescribed Naprosyn, Florlcel and Tylenol 3 on occasion as needed. The pallent was advised to keep the shoulders inlhe slings as orten as possible as well as Ihe cervical collar. Ilnlllated a mild therapeullc exercise program which has been performed 10 tolerance. FINAL SUBJECTIVE: The patient has responded to the treatment she I1<1S received and will be released althls lime. She does however, conllnue to experience occasional discomfort and restricted mobility to the neck, lower back, shoulders and right knee bullhls Illay be addressed with conllnued therapeutic exercises performed atlhe palienls home. The IllUSt discomfort Is concentrated at the cervical and lumbar regions. The posl trauma headaches have decreased In bolh frequency and Inlenslty. The patienl Is sllll very dlslraught aboul her Injuries and her fear of riding In automobiles is sllll ralher slrong, The conluslons have been resolved. There Is sollle scarrlngnoled allhe laceration slles, FINAL OBJECTIVE: Final examlnallon revealed reslrlcled cervlc,11 forward flexion al 41/600, exlenslon al 53/750, lert laleral flexion al 32/450, righllaleral flexion al 34/450, lert rolatlon a154/IIOo, righl rolatlon at 5G/IlOo, reslrlcled 11Imb.u forward flexion al 45/GOo, exlenslon aI19/250, lert laler,11 flexion ill 20/250, rlllhtl,lteral flexion ,II 19/250, restricled rlghl shoulder flexion at 12G/lI100, extension .11 35/500, ,lbuucllon ,It DO/I 1100 , adducllon at 36/500, Inlernal rolatlon al (l4/90", extern,11 rot,llIon ,II (15190", restricted left shoulder flexion al 130/1 \100, extension al 36/5()O, abrlucllon ill 127/11100, ilrlductlon .It 37/500, Inlernill rOlallon al G5/90D, external roltllion ,It fl.1190D, reslrlcled right knee flexion al 120/1500, resldu.11 scar tissue. " ,-.. fltUl.fi/(,~1<jt~Ndal NAI AWAIJU. ~I UNllllll~l, M \) 71'1 Rh:IWII Stlccl' I'hilJddl'hl;l, I'A 1'111I. WSI 101.',1177, 1;1\ , H!.7h7() M.nch 31,1995 RE: PHYDA NY DA: 10/21/94 Page three: FINAL DIAGNOSIS: '-S/P cervical strain/sprain with fractures to C3-6 . Improveclto i 65% 2.S/P thoracldlumbosacral strain/sprain with fractures to T12 . Improved to ;l; 70% 3.S/P bilateral shoulder strain/sprain - Improved to :I: 70% 4.Rlght knee strain/sprain. Improved to i 75% 5.Resldual scar lIssue 6.Resolvlng posltrauma cephalgla 7.Posttrauma anxiety disorder CONCLUSION: At this tlmo I am releasing the pallentto home therapy with advlsod therapeutic exerclsos which should facilitate any further rehabilitation, and will prevent any increases of symptomology, The prognosis for a complele recovery is poslllve for the knce and shoulder Injuries and uncertain for the cervical, thoracic and lumbar Injuries. I have advised the patient to return to the orthopaedic specialist, hospital, or this orrlce If the symptomology Increases from this point or If no furlher progress is noted from continued therapeullc exercises at home. Shuuld you have any questions or concerns regarding this pallent, please do not hesllatu to contact me. I thank you for the lime and llllentlon you have extended to this patient, Sincerely, fN-~ J'!4;;, ~lIIC" (//0 N, Slelnhouw, M.D, NSljdw Enclosure Dictated/not read PLEASE DO NOT STAPLE IN THIS AREA .. --.r.-:" -- '0""'''"'0\'10 0'" "0 ..... HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) "'DCA'" IWIOlCAIlINOI IiIIOC:AIO "'tOCAlOhOI C..Io..Nt lIf'1Otll""'''''Ht CH'''~'' lV"'....O, HC" .U.ClllUHQ ,..., GUlIll tcUnlfCAlIUIq PATIENT AND INSURED SUBSCRIBER INFORMATION "" AM ILAI"A If! fI" . "IDOl' 1f\lltlA~ , '''"l'''' OA'I Of 'Ift'" J '''WIlID1 "AWIIV,IT hAM.. ''''" H.....L lillODlI...nlAlJ NY, PHYDA " II .11l.l;ln.I"'U.'''WUlI 115 LIMEKILN ROAD NEW CUMBERLAND ,PA S,S,tI: 201.60.1118 717.761-8925 5 80 ""liD ~H""'ll . ~'W;l~'IO HO j'DUftUQ"".. CHICIl.IOAIOVl,lNQ.UOUll , 'AflIkf'"lL"'IO"'HI'IO''''UAIO . 1...'UIlIOI GIIOIJ' NO 10" OAol" 101"'" OR 'ItA CLAlW NOI tn. lI'OIJI' CHilD OIMI" 38.7071.112 . llUflHOHlHO . D'"Id!IAlIH .IUIU"C' COYIIlAG1tt..UJII,...W, d. f'OUI;,HlkOIIl 10"0 III IlI.W. '''0 AoDfl... NO POUt, DR IiIUICAL ......"'UNCI -,~ I' ",Io, CONDITION fllL.AIIG 10 ''''IURID 11."'''''0'.0 ""0 C:OVIIlIO If .III"O'UI HI""""""" II IHIUJlIO,AOOIlIIIII,JlUl.Ctn,IlAU.,IJ'COOII ;. ""1Il...11......0'YIH' 'II 0 lKJ HO Illll't+OH' HO . "CCIOIH' "1,110 [[] .., CHUoI'Vlll"O"IO"1 D OllilA "Cll'. Out, IIltl"IO 11 ~~~~:~'~:~t~~ll~~:Ji~'\CIlII~I~:I~rDUI~~1:IOHID IIIIAH,HOfIUIY.... IUIUI ., ,AtIU" I 0Il"~'.""If,HIl40H1 IIll/rlUUA1"~AD '''CIl JlmAI IlClHtl'tUI I 'utttC)llllll IH "IU.. 0' 'H' "IDlC'lIN'~1 UtON H't""", ro'AQ(1I1 'HIS r:,"IY ''''50 IlIOUU' ""'''''''1 01 DOVE""'YIH IIHI" IIJfH'" 10 "Ull' 011 0 IHI '."1'1 Yl'HO AGel'" ....10"'..".1 BHOW stOHl 0 SIGNATURE ON FILE 0"'1 SIGNATURE ON FILE IIOH' 0 llHIUflfO O"""IHO"IIIO HASlI"1 "" ....01 .. ~'t.r"':J :.:r:~=l~~C'~vll' '" D." '111,1 tOHfoUllIO YOU .01l1HII " " ....Il'H_'_ ~A' H.U I"Y' 011 'ilt I!H\~~'!G-'.!'te' 10/21/84 tc).~",. 10/28/94 I'.UUIl Il.IHU' OA IHJUA,. GtVl Dun CH en If - =:l~ td WOfUl 1.0 " O.IU Of lOIAl OISAIIl'" 0"1110' '..AllAlOIU.lltlt, ,""" I IHIIIOI,IGIt ,""" I IHIIIOUQH " ....... OII1UUIIllNQ "HYllClAM 011I 0'''1'' \OUAU.. I !"VlllC HIAllH AOI"C'I III ~g:~I::~lMJ\::U~ '0 Hu'.....UU'IOH DIYI .00001tt1D I 04CIl.MID " H'''I..ND ADOIIItU o. 'AtllIlT WHIIII....'W;II IlIHbllllD .1' 01"1" 1.......I.OMI 0" O"ICII " Yl'A' UIOIlAIO'" WQMII ....'0....10 OUtllOI TOOIl Of'1C1I lIIr U- -1.0 tH""0U " . m~D1 QIl"' VAl IlIHtU Dill INJU'" Il.UII OIAOttOI.. 10 'AOClDufll .... COlV..... O,f flUIIIII...t( "'U"'(*'" , J , It ~D'COOl I I t...Ol "'8 B'o , "..llYI'1....HH...O "I NO , -.-----.--------------.. . ."" AUIHOAll"'''OIoll<tO .. . I' e rm.~~,I:Mf~~: rrofL'::~IJivrtOICAlllfl'K;U O..'u....,'u ol" H\I"'YIBU."'" DJoII OI""'ICI ....e' 0 ,""" .. '" '''''", II ~I'1.A'H U"'UIoA~ I...,It:( I OflClACU.."...t:Ul Ol..ntmlll twatcu! o. 0' IIII'ICI " .. cOllt V"'ttl '0' T , 10/31/84 . 03/31/9& SEE ATTACHED DILL , I , , , , , , I , , n m~lw.!.st'ICIA" OIl 1~'~I'!I.clU"..~~'~..!!.IO. n ar.CII'I AUIUH"lHI 1tlO'lflH"lhf Iii 101A1 Clt""GI n '''001011 '.10 I" '.lJ,Het DUt II' I ,. I II [, II" IH.I Hf I A'!rlH" OH 'HI ,u~ "'I .,....' 10 CI,t.1WIOH"lllil "aCIlI 6 120 00 , I 6120,00 HtI ilL." Alii W'OI.., III Iflllt I I (!'a:h1J~~ .n[&] DHU " r~~ll~~I~.~ot~P:\;IIllI- .HOlll.. U"OO, ""M'. 0011"1.""000' # ,dIm, 41as.. (lID " '00" W(,.lIICUAt""O JENO,INC, 161-44-4753 N. Stolnhou80, M,O, 0.11 03/31/9& 719 Rhawn Stroot II 'OU",.IIIHn...ctou..,hQ " 'OUM1"'IUtI"III HlJ Phlladolphla, PA 19111 NYPlt 23.254.6823 '" ." ST1S1071 '",..[, m IIIlVIC, ."'0 ".., 0' 'lfl.ttIIIO', (;011110... tll' 1't.1P, '''PIlOV[O Ill' AM' r.OUNCIL Fall" HCFA.1500 1.&4 Foom OWCP.I600 PHYSICIAN OR SUPPLIER INFORMATION -, - fiul JI;tco?fW?tou NA T AW ADll STUNHOUSl, MoO, 71~ Ilh;I"," ~lItcl .l'h,IJdcll'h'J, I'^ 19111 12111 H2-I117 .IJ" HHI.7U MAACII 31, 1995 PATraNT I PHYO/\ NY 116 LtMEKILN ROAD N~W CUMBERLAND, Ph 17070-0267 hCCtlJENT OIl'l'Il, 10/21/94 CLAIM U, 30-7071-112 ... SUMMARY or CHAROSB ... RBBPONSIBLS PAYOR I STATE FARM 115 LIMIlKILN RO BOX 257 NEW CUMBERLA, PA 17070 ATTORNIlY,BATT, MARC DATE 01' SERVICE PROCIlDURE CODE DESCRI PTlON ..~._~__..___a__._______~________________________________.__.________________________.__ CHARGES 10/31/94 99203, lIHTIAL OFl'lCIl 10/31/94 97010, 110'1' OR COLD PACKS 10/31/94 97035, ULTRA - SOUND 10/31/94 97014 , IlLEC STIMULATION 10/31/94 970351 ULTRA - SOUND 10/31/94 97035, ULTRA-SOUND 11/04/94 970101 1I0T 011 COloD PACKS 11/04/94 970,15, ULTRA-SOUND 11/04/94 97014, 1l1,IlC IlTIMULATION 11/04/04 97035, UL'I'HI\ - SOUND 11/04/94 9'10]5, 1l1,1'IlA-SOUND 11/07/94 99212 , JiGT, l'ATlI>NT Q,V, 11/07/94 9'/010, 110'1' 011 COLlJ tW.'K/J 11/07/04 9'IOJ5, ULTRA-SOUND 11/0'1/94 97014, ELIi:C S1'lMULI\1'lON 11/07/04 97016 , lIl/I'IIA- SOUND 11/0'/ /04 9'101. , lIl.1'IlA- SOUlIlJ 11/11/94 9'/01U, WI'I' Oil COW l'1\(.'K6 DtAaNOBts CODE NIlCK/PACK NIlCK/PllcK SIIOULDIlIIS KNIlIl ALL 100 ALL 20 847,9 20 847,9 20 S40,9 20 844 ,0 20 ALL 20 847, y 20 847,9 20 840,9 20 844.9 20 ALL 50 ALl, 20 847,9 20 847,0 20 840,9 20 844.9 20 ALL :!o NIlCK/PIICK NIlCK/BIICK DIlOULDIlIIS IU'IIlIl NIlCK/PIICK NIlCK/UIICK DIIOUt.IllllIS KNIlIl Iwn;, ['lIl11t1lIW I $4 '10,00 .......A.R...a.........*~.=~.C~~~K.~..~..".~~....~.......~........~.................~.~ ~no,oll I'IIVr~I':NTlll ,011 Illm.. I'lcall' IIIJ~1' "III hq ~11'..y..hll' III IIND INl .111 1 AX '21H4'6611 ---. ,,,-...... jJ,uI J;uo?<jtp1<ated NA T AW ADEI: STElNHOUSE, M,lJ, m Rhawll ~Irc,'l . I'hilalldl'hla, l'A 1911I 12ISI14HI77' I a~ _ 142.7670 ... SUMMARY or cHARGBS ... CONTINUBD DATE OF SERVICE PROCEDURE CODE DESCRIPTION Ml\RCH 31/ 1995 PATIENT. PHYDA NY CLAIM HI 30.7071-112 DIAGNOSIS CODE CllARGES --......-........-----......---------------------------------.-----------.-.------------ 20 11/11/94 11/11/94 11/11/94 11/11/94 11/14/94 11/14/94 11/14/94 11/14/94 11/14/94 11/14/94 11/10/94 11/18/94 11/10/94 11/10/94 11/18/94 11/41/94 11/41/94 11/41/94 11 /41/94 11/21/94 11/41/94 11/25/94 97035, 97014, 970351 97035, 99412, 970101 970351 970141 97035, 970351 97010: 970351 970141 97035, 970351 99212, 97010, 970351 97014 , 970351 970351 97010, ULTRII-SOUND ELEC STIMULIITION ULTRlI-SOUND ULTRlI.SOUND EST. PATIENT O.V. HOT OR COLD PIICKS ULTRII-SOUND ELEC STIMULATION ULTRlI-SOUND ULTRII-SOUND HOT OR COLD PIICKS ULTRA-sOUND ELIlC STIMULIITION ULTIUI-SOUND ULTRlI-SOUND IlST, PIITIENT O,V, Ho'r 011 COLD PIICKS ULTIUI-SOUND ELIlC STIMULIITlON UL1'Rl\.SOUND ULTII/.. GOUIlP HOT 011 COLD PIICKS NECK/IlIlCK NIlCK/IlIlCK SHOULDERS KNEE NECK/BliCK NECK/IlIlCK SHOULDERS KNEll NIlCK/IlIlCI( NECK/IlIlCK SHOULDIlRS KNEE NECK/IlIICK NECK/IlIlCK SHOULDERS KNEll 847.9 847.9 040.9 844.9 IILL IILL 847.9 847,9 840.9 844.9 IILL 047,9 847.9 840.9 844.9 IILL IILL 847,9 947.9 040.9 844,9 IILL 20 20 20 50 20 20 20 20 20 20 20 20 20 20 50 20 20 20 20 20 20 PIIGE' .............................=.......~=c.........a...~..................~.............. 2 CHIIIIOIW 1 $500,00 I'IIYI1EUTI.l, 00 PIlIl., $970,00 Ille~~e make ~1I d'Clk~ I'''y~hlc III I[NIl INC,' III 1 AX flll'l54'bKll '"'"' C' fiul.fiu:<J1(tollated NA T AW ADE!: STEIN HOUSE, M.D, 719 RhawIl SlIccl . philadelphia, I'A 1911I 12111 142.))77 .Ia~. 142-7(,70 ... SUMMARY or CRAROBS ... CONTINUBD DATB OF SERVICB PROCEDURB CODE DESCRIVTION MARCil 31, 1995 PATIENT. PIIYDA NY CLAIM ". 38-7071-112 DIAGNOSIS CODE CIIMGRS -----..---------------------------------------------------------------------------.-.--- 11/25/94 11/25/94 11/25/94 11/25/94 11/28/94 11/28/94 11/28/94 11/28/94 11/28/94 11/28/94 12/02/94 12/02/94 12/02/94 12/02/94 12/02/94 12/0S/94 12/05/94 12/05/94 12/05/94 12/05/94 12/05/94 12/09/94 970351 97014. 97035. 970351 99212, 97010. 97035. 97014. 97035. 97035. 97010. 97035, 97014. 97035. 970351 99212, 97010, 970351 97014. 97035, 97035, 97010, ULTRA-SOUND ELEC STIMULATION ULTRA-SOUND ULTRA-SOUND EST. PATIENT O,V, 1I0T OR COLD PACKS ULTRA-SOUND RLEC STIMULATION ULTRA-SOUND ULTRA. SOUND 1I0T OR COLD PACKS ULTRA-SOUND ELEC STIMULATION ULTRA-SOUND ULTRA-SOUND EST. PATIENT O,V, 1101' Oil COLD PIICKS ULTIlA-SOUND ELEC STIMULATION ULTRA- SOUND UI,TRII-SOUIlD 1101' Oil COLD PIICKS NECK/nACK NECK/nIlCK SIIOULDEIlS KNEE 847.9 847.9 840.9 844.9 ALL ALL 847.9 20 20 20 20 50 20 20 20 20 20 20 20 20 20 20 50 20 20 20 20 20 20 PAGE, .............................a............a~a~..c...................................... 3 CIIAIlGES, $500,00 NECK/nACK NECK/nACK SIIOULDERS S47.9 840.9 844.9 ALL KNEE NECK/DACK NECK/IJACK 1l1l0ULDERO KNEE 847.9 847.9 840,9 844.9 ALL ALL NECK/DACK NRCK/nACK 847.9 847,9 SIIOULDEIW 840.9 844.9 ALL KNEll I'A YMI:NTO , DUE-> $1470.0 .00 1'!cuIC makc all lhnklI'ayahlc III IlND INC. . UJ, 1 AX HH.254'h8H " -. fiulfit.cP?'/W1<aUd NA T AW AIJ[[ STElNHOllSE. M.D, m Ilha,," Slrce! '1'IlIladcll'hla, I'^ 19111 WII H2' Jl77 'I a. , 342.7I,7U ... SUMMARY or CHARGBS ... CONTINUBD DATE OF SERVICE PROCEDURE CODE DESCIHPTION MARCil 31. 1995 PATIENT. PIIYDA NY CLAIM II. 38-7071-112 DIAGNOSIS CODE CIIARGES i I i ,I , I I --------...----------------------------------------------------------------------------- 12/09/94 12/09/94 12/09/94 12/09/94 12/12/94 12/12/94 12/12/94 12/12/94 12/12/94 12/12/94 12/16/94 12/16/94 12/16/94 12/16/94 12/16/94 12/19/94 12/19/94 12/19/94 12/19/94 12/19/94 12/19/94 12/23/94 91035. 97014. 97035. 97035. 99212. 97010. 97035. 97014. 97035. 91035. 970101 910351 97014 . 970351 970351 99J 12. 97010, 97035, 97014 . 97035. 91035, 970101 ULTRA-SOUND ELEC STIMULATION UJ,TRA- SOUND ULTRA. SOUND EST. PATIENT O.V, 1I0T OR COLD PACKS ULTRA-SOUND ELEC STIMULATION ULTRA-SOUND ULTRA-SOUND HOT OR COLD PACKS ULTRA-SOUND EI,EC STIMULATION ULTRA. SOUND ULTRII-SOUND EST, PIITIENT O,V, HOT OR COLD I'IICKS ULTRII-SOUND EI.EC S'rIMULATION ULTIUI- SmiND U1mUl-SOUND 1I0'r OR COLD PIICKS NECK/BACK NECK/BACK SHOULDERS 20 20 847.9 847.9 840,9 20 20 50 20 KNEE 844,9 IILL IILL NECK/BACK NECK/BACK SHOULDERS 20 847,9 847.9 840,9 20 20 20 KNEE 844.9 ALL 20 20 NECK/BACK NECK/UACK 847.9 20 847.9 840.9 844,9 ALL IILL SHOULDERS 20 20 50 20 KNlm NECK/UACK NECK/BACK SHOULDERS KNEE 20 S47,9 847.9 20 20 20 20 840.9 B44.9 ALL PMI'. .................................................a......~.............................. ,00 4 CHAnOES. $500.00 I'AYMF.N'l'O . DUJ~ - > $19'10,0 !'Icalc l1Ia~c ,III dICl~\ I'a'yilblc \uII:NIlINC . II>' r AX UlJ.25.1,1JI12l ,-.. .''"'\ ,~ PROCEDURE CODE /LuI fit~1jW?ltZtea! NA TAW AlJEE STElNHOUS!:. M,lJ, 719 RhawlI Slrrtl .I'h,lalldl'hla.l'^ 1911I 12151 H 2.))77 . I a. . H 2-7670 MARCil 31, 1995 PATIBNTl PIIYDA NY CLAIM II, 38-7011-112 ... SUMMARY or CHARGES ... CONTINUED 01/06/95 01/06/95 01/06/95 01/06/95 01/06/95 01/09/95 01/09/95 01/09/95 01/09/95 01/09/95 01/09/95 01/09/95 01/13/95 01/13/95 01/13/95 01/13/95 01/13/95 01/16/95 01/16/95 01/16/95 01/16/95 01/16/95 97010. 97035. 97014, 97035, 97035, 99212, 97010, 97035, 97014, 97035. 97035, 97110, 97010, 97035. 97014 , 97035, 97035, '92121 97010, 97035, 9701ol, 97035, DESCRIPTION DIAGNOSIS CODE C/lARGES DATE OF SERVICE -.-.----------.---------------------------------------------.--.---.---.----------------- ALL 20 20 20 20 20 50 20 20 20 20 20 30 20 20 20 20 20 50 20 20 20 1l0T OR COLD PACKS ULTRA-SOUND NECK/BACK ELEC STIMULIITION NECK/BlICK ULTRA-SOUND SIIOULDERS ULTRA. SOUND KNEE 847.9 S47.9 840.9 844.Q EST, PIITIENT O,V, 1I0T OR C01,D PACKS ULTRA-SOUND NECK/OACK ELEC STIMULATION NECK/BACK ULTRA-SOUND SIlOULOERS ALL ALL 847.9 847.9 840.9 844.9 UW'RA-SOUND KNEE CYBEX ISO, EXERCISE 1I0T OR COLD PACKS ALL ALL 047.9 047.9 840.9 844,9 ALL ALL 847.9 047.9 840,9 20 ULTRA-SOUND NECK/BACK ELEC STIMULATION NECK/BACK ULTRA-SOUND SIIOULDERS ULTIlA-SOUND KNEE EST, PATIENT O.V, 1I0T Oil COLD PIICKS ULTIlA-SOUND NECK/IlACK ELEC STINULIITIOll NECK/OIICK ULTRA - SOUND SIIOULDEllS PAGE, ..............~a.a~a....aa.a~.a.A.a.=~ne=c.~~Db~a~.a~~A=a=~c~~a=aa.aDc.~.Q=b~~~.a.ad..n ,00 mm-" (, CIIAIlGES, ~510,00 ~~!J90.0 I'IIYMICllTS, I'ka~c lIIa~c all L11l'l~\ pa,vahlc lullNI> INc." III 1 AX UB-lS4'hllll ,'""" /bul.fitcP'ftM<rrM NA T AWADEE STEINHOUSL M.D. 71'1 RhJI>1l ~lrc'" '1'IIIIJJclphIJ.I'A 1'111I 11ISI HHJ77 , I J" Hl,71,711 MARCil 31. 1995 PATIENTI PIIVD/I N'{ CLAIM H. 38-7071-11J ... SUMMARY or CHARGBS ... CONTINUBD DATE OF SERVICE PROCEDURE CODE DESCRIPTION -. -~------_._----------------------------------------------------------------------------- DII\GNOSIS CODE CIIl\RGES 01/16/95 01/16/95 01/20/95 01/20/95 01/20/95 01/20/95 01/20/95 01/23/95 01/n/95 01/23/95 01/23/95 01/23/95 01/23/95 01/23/95 01/27/95 01/27/95 01/27/95 01/27/95 01/27/95 01/30/95 01/30/95 01/30/95 97035. 97110, 9'/010, 97035, 97014. 97035, 97035, 99212. 97010. 91035, 91014, 97035, 91035, 91110. 97010, 970]5, 91014. 91035, 97035. 99212, 97010, 97035. ULTRA-SOUND KNEE CVBEX ISO. EXERCISIl 1I0T OR COLD PACKS U1,TRA-SOUIlD NECK/BACK ELEC STIMULIITION NECK/DACK ULTRA-SOUND SIIOULDERS ULTlllI.SOUND KNEE EST. PATIENT O,V, 1101' OR COLD PACKS ULTRA-SOUND NECK/BACK ELEC STIMULATION NECK/BACK ULTRA-SOUND SIIOULDEIlS ULTRA- SOUIlD KNEE CVIJEX ISO. EXERCISIl IIOT OR COLD PACKS ULTRA-GOmlD NECK/IJACK In,EC STIMULATION NECK/IJACK ULTRA. SOUND SIIOULDERB ULTRA,SOUND KNEll EIlT, PATIIlNT O. V, 1I0T OR COLD PACI<S ULTRA-SOUND NIlCK/IJACK 844.9 /ILL ALL 841,9 847,9 840.9 84~ .9 ALL ALL 8~7.9 847.9 840.9 844.9 ALL /ILL 847.9 847.9 840,9 844.9 /ILL Al,L 847,9 20 30 20 20 20 20 20 50 20 20 20 20 20 30 20 20 20 20 20 50 20 JO PAm:. ....................................................................................... 7 CHAllOIlS I ~520, 00 I'AYI11lNTIl , ,00 I1lJll-' ~]510,0 l'l\'ale lIIake ,111 dlCl~1 pa.vahle 11111.NI) INC' U), 1 AX u21'25"'hH2J ........ ...... ~uI ~a>1<jtP1<n...t€d NA T AWADEL Sl L1NIlOUSL. M.lJ, 719 Ilha\'ill ~lIccl.I'ltlIJJdl'llIJ,!'A 19111 IlISI H2-I177, 1 J' . JoIn/l7ll MAIlCII 31, lUes 1'A'l'llINT I I'IIYDA NY C~AIM H. 3B-7071-11~ ... SUMMARY or CHARGIS --- CONTINUID DATE OF SERVICE I'ROCEDURE CODE -------------------------.-------------------------------.------------......-----.-...-- DESCIlIPTION DIAGNOSIS CODE CIIAIIGES 01/30/95 01/30/96 01/30/95 01/30/95 02/03/95 02/03/95 02/03/95 02/03/95 02/03/95 02/06/95 02/06/95 02/06/95 02/06/95 02/06/95 02/06/95 02/06/95 02/10/95 02/10/95 02/10/95 02/10/95 02/10/95 O~/1]/95 97014, 97035. 97035. 97110. 97010. 97035. 97014, 97035, 97035, 99212, 97010, 97035, 97014, 910]5, 91035, 91110, 91010, 91035. 9'/OH, 91035, 91035. 99212, ELlie STIMULATION NllCK/llACK ULTRA. SOUND SIIOULDERS ULTRA-SOUND KNEll CYBEX TSO, EXERCIBE 1I0T OR COLD PACKB ULTRA. BOUND NECK/BACK ELEC STIMULATION NECK/BACK ULTRA-BOUND SIIOU~OEIIS U~TRA-SOUND KNEE EST, PATIENT O,V, 1I0T OR COLD PACKS U~TRA.SOUND NECK/BACK EI,EC STIMULATION NECK/IJACK ULTRA-BOUND SIIOU~DERS ULTUA-SOUND KNEE CYIJEX lBO, EXEUCISI 1101' 011 cow !'ACKS 20 20 20 3D 20 20 20 847,9 840,9 844,9 ALL ALL S47.9 B41.9 B40.9 B44,9 ALL ALL B47,9 B47,9 B40,9 20 20 50 20 20 20 20 20 30 20 20 20 20 20 60 S44.9 ALL 111,1, 847.9 847.9 B40.9 Ul,TM-BOUNP EI,EC STIMULlll'lON UI,TUII'/lOUND UL1'I\!I.ooUND NECK/hACK NIlCK/lIACK SIIOUWIlUIJ KNEE B44 .9 \lOT, ('IITUmr 0, V, ALL ...._.....M...~.........~........~..~...~..~~......~...~~.k.....d.........ws........... 1'1I0E, U CIlAUClI\n, $r,~O,Oll I'AYMllNTll, ,00 DUE" $4030,() !'ka\l' mOlh' all dln~\ l'aV,lhk 11111 Nil INt -II> I AX N2J.2S".('Il21 ,-. -"'" jf,u! JJ;u:~1<jt()?laW NA TAW AU!:\: SHINIIOLlSL. M.D, 119 KhJWII ~"~d .I'llIIJlldl,hiJ, I'A I'JIII l2ISI HI'1111' 101' I HI,7C.lIl ttt sUMMARY or CHAROJS ttt COHTINtlJD MAIlCII 31. 1995 l'ATlJNTI I'IIVDII NV Cl,II1M H' 30.70'/1-112 DIITE OF SERVICE PROCEDURE CODE DESCRIPTION DIIIGNOSIS CODE C"IIRGES ----...---.-------------.---..----.-.--.----------.------.---.---.-----.----....-------- /ILL 20 20 20 20 20 02/13/95 02/13/95 02/13/95 02/13/95 02/13/95 02/13/95 02/17/95 02/17/95 02/17/95 02/17/95 02/17/9~ 02/20/95 02/20/95 02/20/95 02/20/95 02/20/95 02/20/95 02/20/95 02/24/95 02/24/95 02/24/95 02/24/95 970101 97035' 97014. n035. 970351 97110, nOlO: 970351 97014. 97035. 97035. 99212. 97010. 97035. 97014, 97035. 97035 , 9711 0: 97010. 9'/035. 970141 97035. 110'1' OR COLD PIIC~S ULTRA-SOUND NEC~/OIlCK ELEC STIMULIITION NEC~/OIlCK ULTRA-SOUND slIOULDERS ULTRII-SOUND KNEE CvoEX ISO. EXERCISE 110'1' OR COLD PIIC~S ULTRII.SOUND NEC~/O/lCK ELEC STIMULIITION NECK/OIICK ULTRA- SOUND SIIOULDERS ULTR/I.SOUND KNEE EST, PIITIENT O,V, 110'1' OR COLD PIICKS ULTIIII-SOUND NECK/BliCK ELEC STIMULIITION NECK/OIICK 01,'1'1111- SOUND slIOULDERS ULTRII-SOUND KNEE CVoEX ISO. EXERCISE 1I0T Oil COLD PIICKS ULTlllI - GOUNP IlI.EC BTIMUl,IIT10N ULTIlII- BOUND NEc~/aflC~ NEC~/ll/lC~ SIIOULDEIlO 847.9 047.9 940,9 844.9 /ILL /ILL 847,9 847.9 30 840.9 844.9 20 20 20 20 20 50 20 20 20 20 20 30 20 20 fiLL, /ILL 847.9 847,9 840,9 844.9 IILL IILL 847.9 847.9 840.9 20 20 ....................................................................................... PIIGE. 9 CIIIIRGIlS. 0490,00 PIIVMENTU 1 ,00 DUIl-' 04520,0 I'kalc makc alllhclk\ 1';lyahlc IllllND INC.' IlJ, I AX .2J-254-(,II23 ( Ie- '"'" ~d fitc<)1(W?lrdd NA TAW AOtt SHlNHOUSt. M,O, 719 RhawlI ~\rcrl . Philadelphia, I'A 1911I 121S1 H2.Jl77 'I a.' HZ.7670 MARCil 31, 1995 PATIENT. PIIYDA NV CLAIM HI 38-7071-112 ... SUMMARY or CHARGES ... CONTINUED DATB OF SERVICE PROCEDURE CODE DESCRIPTION DIAGNOSIS CODE CHARGES ~--~-~---~~-~~---~-------~--_._--~------~~._-~._--_._-------_._-~._---~..--~---~..-~~-~~- 02/24/95 02/27/95 02/27/95 02/27/95 02/27/95 02/27/95 02/27/95 02/27/95 03/03/95 03/03/95 03/03/95 03/03/95 03/03/95 03/03/95 03/03/9S 03/06/95 03/06/95 03/06/95 03/06/95 03/06/95 03/06/95 03/06/95 97035, 992121 97010, 970351 97014 I 97035, 97035. 97110, 99212, 970101 97035, 97014 , 97035, 970351 971101 992121 97010, 97035, 97014 I 9'/035, 97035, 971101 ULTRA-SOUND KNEE EST. PATIENT O,V, 1101' OR COLD PACKS 844,9 ALL ALL 847,9 20 50 20 20 20 20 20 30 50 20 20 20 20 20 30 50 20 20 20 20 20 30 PAOIl, ..............u.....~..am=DmmD.c~..a....aa=.D..==...==.~==.t..=..a.a................... 10 ULTRA-SOUND NECK/BliCK ELEC STIMULATION NECR/BIICK ULTRA-SOUND SIIOULDERS ULTRA. SOUND KNEE 847,9 840.9 844.9 ALL ALL IILL 847,9 847.9 CYBEX ISO, EXERCISE EST. PATIENT O.V. 1101' OR COLD 1'lICKS ULTRA-SOUND NECK/BliCK ELEC STIMULIITION NECK/BliCK Ul,TRA-SOUND SIIOULDERS 840.9 Ul,TRII-SOUND KNEE CYUEX ISO. EXERCISE EST, PIITIENT O,V, 1101' OR COLD l'IICKO ULTRA-SOUND NECR/BIICK IlLEC STIMULlI'rlON NIlCK/OIICK ULTRII-SOUND OIlOULDERS ULTRII,COUNIJ KNEE 844.9 AI,L ALL IILL 847.9 847.9 840,9 844,9 CYOEX ISO, EXERCISE ALL CIIIIROIWI $560,00 I'/lYMl,N1'S 1 ,00 lJUl;- , $5000.0 Plca~e make all dlnkl p".I'"hle 1IlIl.ND INC , I.IJ, 1 AX n2j.2S4.lIH21 ,.-.., /""', ...- fiul JI;UOJ!f<<>>'atd NA T AW ADEE SlEINHOUSE. M.D. 719 Kha",,, ~llccl , 1'llIladcll'hla, I'A 1911I 12151 J12-1177 . I a. . 142-7670 MAIlCH 31, 1995 PATIENT. PIIYOA NY CLAIM HI 38-7071-112 ... SUHHARY or CHARaES ... CONTINUED DATI! OF SI!RVICI! PROCEDURE CODE DESCRIPTION DIAGNOSIS CODE CHARGES -----------------------------------------~---------------------------------------------- 03/10/95 03/10/95 03/10/95 03/10/95 03/10/95 03/13/95 03/13/95 03/13/95 03/13/95 03/13/95 03/13/9S 03/13/9S 03/17/95 03/17/95 03/17/95 03/17/95 03/17/95 03/20/95 03/20/95 03/20/95 03/20/95 03/20/95 970101 970351 97014 1 970351 970351 992121 970101 970351 97014 I 970351 97035. 97110 I 970101 97035. 970141 970351 970351 992121 97010, 970351 97014, 970351 HOT OR COLD PACKS ULTRA-SOUND ALL NECK/BACK NECK/EACK SHOULOERO 847.9 20 20 20 20 20 SO 20 20 20 20 20 30 20 20 20 20 20 50 20 20 20 :l0 PAOlI I 11 .........................~......~....u....Q...na.........aa...~."...................... ELEC STIMULATION 047.9 840.9 ULTRA-SOUND ULTIIA-SOUND EST. PATIENT O,V, 1I0T OR COLD PACKS ULTRA-SOUND NECK/BACK KNEE 044.9 ALL ALL 847.9 847.9 ELEC STIMULATION NECK/BACK ULTRA-SOUND SHOULDERS ULTRA-SOUND KNEE CYBEX ISO. EXERCISE 840.9 844.9 ALL ALL 847,9 1101' OR COW PACKS ULTRA-SOUND NECK/UACK ELIlC STIMULATION NECK/BACK ULTRA-SOUND SHOULOEIIS 047,9 840.9 Ul/rRA- SOUND KNEE EST, PATIENT Q,V, 844.9 ALL ALL 847.9 847,9 1101' Oil cow l'ACI<S ULTRA-SOUND NECK/BACK Il'.EC S'I'Jt~UI.ATION NIlCK/UACI< ULTIIA-SOUND SIIOULOIlRS 040,9 CIIIIIWllG. OS 1 0,00 I'll VMllN'J'O 1 DUIl-> (;5590.0 ,00 I'lcalc lIIa~c alllhCl~1 I'Jyahlc lull,NIlINC. , III 1 AX u2J'2S'HR2J r--, '" ~uI fi~'Yw?lrded NAT AWADEE STElNHOUSE, M,D, m IlhawlI Slrccl ,I'llIladclllhla, If A 19111 121S1 142.))17' I a.. 142-7(,70 MARCil 31, 1995 I'ATIBNTI PIIYOA NY CLAIM "I 38-7071-112 ... SUMKARY or CHARGB8 ... CONTlNUBD DATE OF SERVICE PROCEDt1RE CODE DESCRIPTION DIAGNOSIS CODE CIIARGES ---------------------~------------------------------------------------------------------ 03/20/95 03/20/95 03/24/95 03/24/95 03/24/95 03/24/95 03/24/95 03/27/95 03/27/95 03/27/95 03/27/95 03/27/95 03/27/95 03/27/95 03/31/95 03/31/95 03/31/95 03/31/95 03/31/95 03/31/95 970351 97110, 97010, 970351 97014 , 97035, 97035, 99212, 97010. 97035, 97014, 97035, 97035, 97110, 97010, 97035, 97014 , 97035, 97035, 99213, ULTRJI-SOUND CYBEX ISO. EXERCISE KNEE 844.9 ALL ALL 20 30 20 20 20 20 20 50 20 20 20 20 20 30 20 20 20 20 20 100 .........~..~.............~~~e..a.Dc...........a.~~..~~..............Ui................. PAGE, 12 CIII\RGI>S, $530,00 PAyMIlNTS, .00 0 E.> $6120,0 1I0T OR COLD !'ACKS ULTRA-SOUND NECK/BACK ELEC STIMULATION NECK/BACK ULTRA-SOUND SHOULDERS ULTRA-SOUND KNEE 847.9 84';.9 840.9 844.9 EST. PATIENT O.V, 1I0T OR COLD PACKS ULTRA-SOUND NECK/BACK ELEC STHlULlITION NECK/BACK ULTRA-SOUND SIIOULDERS ULTRA-SOUND KNEE ALL ALL S47,9 847.9 840.9 844.9 ALL ALL CYBEX ISO. EXERCISE HOT OR COLD PACKS ULTRJI-EOUND NECK/BACK ELEC STIMULATION NECK/BACK ULTRA-SOUND SIIOULDERS ULTRA-SOUND KNEE FINAL OFFICE VISIT 847.9 847.9 840.9 844,9 ALL I'!calc 111<1kc all d,Ctkl payahlc \0 II.NIl INC, . 11), 1 AX .23.254.(,823 ,pC.' ~(.".,,:,? /l\"'~"'\ (,1 ~ 1l~.IIri'6""'1 ~l'~("l...(h" /1'j1 1'1~ Sl~ ;.'rl t\l~ ie'''' III NO AL,,.ln"flW (f; I( Mt a,. / r- , /1cAd.uv Il'\IJ 11 rli ,6'Wo' /i l..oJ OJ ""'\)0." ~ ~:~::. ~ .~~ , ,;tt" 1 >riljl d o.A." ~uf ~f,~ated NATAWADEE STEINHOUSE, M.D, 719 /thaw" Slreel ' Ptllladelphla, P^ 19111 (215IlU'H77 . Fax # 342,7670 ,/i,1 Jnl,)io-l' {u{JI/'I", {I'{J~{h PIs. @~k; PATIENT INFORMATION FORM lIome phone :1/7 1/1' ('{,W Work 1/: Name: City:Jl1t: (\jJr}";I~ ,c,l?,~e:E1L-Zip: 17{)511 Address: >f71J? /AtA-r.ooII2P-IN; hP- Soc. Sec. 1/: UJI. L(' -filE Date of Birth: '5 ",5' -~ (7 lIeight:.-D-Date of Injury: 11,11./1,/ Sex: ~ Weight: 1']..0 Is the injury work related: Auto related: other: please describe accident in detail, including the areas injured. -1/l~ (I!(, 5/r(~d ancL:1hrn hit 0 1:1/1J Phl/da ",,'3 m1 -/he ~f LtJ W.f' ~CK. Af:tP( 'fhf ('(]( hd ~ .ilpr~'(J. OV~( r?~ ((\/J~f' 0+ ff,17P.S f. veryanp c.row/fcLaut l' '1 ,,"'.. , C I ' \ cF cY d e.r act' ....hc.ulUS JL ~... (. ~,A.", 5 allover her h01lO ~ you have an attorney, Address: City: state:_Zip: If you have insurance, please complete the following: Company Name: ~) "..,.....-,:r 1~--f2- vV\ Addressl_ Policy Holder: Claim 1/1 3B"1cr1 1- II;L City: Policy 1/: state:_Zip: Adjuster Name: NO OFFICIAL FORMS, RECORDS, OR BILLS CAN BE SENT OR COMPLETED UNTIL TRIS FORM UAS BEEN COMPLETED. Patients Signature: .,l..:- ';:':" f/J~{1t.f tAIln1 Date: I/)/ K't/fl{ Parent/Guardian signature for children under leI ;Il\\~/' ,III t..h'I' (<I fit, I r1111tv f 01""'''1 ; ii' h rW' .' Mo j,1ht,,""""" S,u.hf"'''! (1)'14, S J1.l< ~'" \." lin.,":) ,; S' ~ -~ IP ./3.l ~ ., S .^ 1',..11" 11 i ,~ll: .M~,,[ . " r. I' L .. 1_ I "'. - j, I ,..('t, ^~, \... p\.I:",n.., ,\[\ 51",1~ /"h ,,~- f~(w..,1I lS.l'lllilll'l L(-li 1~~1\(l111;1 . '1(l1l.t,Q~,., I. It.. ",,', "t, ''':~ ^11' ~: ,-... ........, , 1 . " Date: Patient Name: rlt~ Oil fl ~ D.o.B. D/A: I~;'/' ~~ , Sex: I. Office: \ R 1 L 53 ...- Subjective: \1;., rl- (~'IIU.hi' D~tl, '~I"Ci.l ,(;qj""~ n' t.'. 1/1:/ A,v,/I(J " r T .., / ....,~I!.,,\I. .." ~F.. Ii.~ ,'I 11" I ht I ' "'I .. r \Ice ~-/.Ir F.J) ,',,:;~ A eO~\'t~ "J"~ I 11u. IllwPI~f\ ll\1l:Co\~ ,Ill p,~..wiJ.t,1 U1,r \\)101+ \1.... \lH'<~A~ '''',l'\llow '1\""" {"eNI.6Ih,,,,,, Sht. hir \1'-' 11a,~ I1c.",!" fA~" S (I~ (l.^c!4\ '^fill- .b,~" i~t ~J,'d.\.\l~I' ; 1)4,1"('''\ to.i!iItJJ()..n... :\IetN uH~NPJ ~l\""\ pI....hrc< C.,."...IMI ,.,..\\,k.(l4' Past history: I 1-. .-;;, " "~d'f~ ,i.. '"""'I " lhl lone;. ~ b\'LI.":' ,~.f e..":'~t,,,:,;'" ':'-11, ~1t, , ,,,./h r1. 'JJo",0' .~h,Il1'" ,'" I"" f~~ ly history: Children: G ,r' ~"11 I'JUo.J ~\,l.^,,,, G- {V \llm"l.t.t- ,;,...,..,)I"lhlfl AI, c<,U!,)(j; ""'n,r.{ .(: (l>1~~',v (, -". t'~itTI '.. " ''''' J " ~,,\ ~ .' ,,~~, " '0,;,) 2 ",,,,,,j.,..~. 1 h".I<', Allergies: G, '",~h~ ifht-l'dBject'i'Jki ,Ill"h';'" Dvw,~:,\ '" ~lli 1/,'1, n "'~I~ h...,,,... (,,,,....,../ {,n/'l>''\-\'' ,,'..t e, L'p,'IIt.., , " ~ ;"c.. "... "'1"')- tl\,{hr'" .1t'Ml\rj ""lltL t".~i'l (~c.;., C,'I"'\II,l)v.' .ltP" ' t./oJl.1 MedicationS: ~ ,,' . I 1.'\l / " (IlI",.t',." I~t.? '~'~<lI'dl"""J /i'll'" l\. 1.<:1('.' I "'lUll'''' " ' ,(W'? () t' t (!i: 11J-tL . (',"M," J' ". "" ('1'"(",,, II"'''''' ." 1t~,\J' tv.; 1"".11 I" ,';.J j"'~"" /rtM.,", ffi I,";"'''; I'J.o)~~~" r.d lif) '" ;pt J ~Jf-<4,', I.: \..: 1,< .. N"'i',( ~1....J"w/)i.."1' (~I.' Ii 1c:1.... /\r/..I". )1;" ,~'Illt ll(~ lv, J/(I-( L' n " ',' Irt, J(l'''''' f1.Lor..c):.Cj Jrm/.. 1':~'1 lift..;' .\j.(, /SilVf}Q. I r..1 ! J"<4l~' " ,~~,,~ ' 'I . . 1'1" ""1' .1t' r 'f h ;r' D'l~ .[. 1(_Ll;" (tl5P l,'pnf'~ 11, tt:.ll c,t.,1 ,..,<i, nkl "i-U ,'.u. "~ ~ ... . ,,, ,(' -,. h~~o, kPI /,(,1 k."" }n,.I'hr,~' ,h('~.., ,"" 11I~'l'j Pathology: J /II,iJ, 11,... ,. P"'''''''''' t'd\1:'"'''' ,oll~, r.M,~~."i 1~"\I'o(A, Jo<(. it ~h""'r ",~I'" "h,S- (n1tt',I, ~l O,(:Fro~'7 n.. }'rot.;.L1"'" Weight: /I' Height: 5'\ 'tj. Alcohol: (; Smoker: e Married: Single: I l,1; ;",/, .'f.4tL, ,-:~1,: '.'1 Review of systems: . ~rnlV ../.1 :"('~ . ' \l'J" - .I<,~ ' VVf ,"" JI$" '1 " /:'M'';l "'3"1 ,Ac.r t="'~,4.";,,G Il; "'~'.l ' 4noJ 1') II ".~ prescr iptions: "tll....~..... t"'" Diagnosis: Treatment: ' (! 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Steinhouse, M.D. 719 Rhawn street Philadelphia, PA 19111 DATE I M:-HJY..~_ 1/.7"}'i . ' -------- I l~-_7...Jy_~ LL:Jl1:!..~ I 'JUtt(~_ ' _'l:l_ut~_ '1t11:!:L~~_ H!fJi.~_ , H1L'IJ..~___ f1t. ~.Ju'fye.d"",,;;f /1.I()t. Patient Treatment Sign In Sheet Z b"'( : ULTRASOUND : HEAT : MASSAGt : CODETRON : ..-' 'w' .~. __~J___=:::____~___~~_________~_~~______~ ---~~_:::_-----~-~~-~~----~---~-~-------~ ') '/.J',-"'" . ---~--_::::_----~--_::_~------___~_J_______::-- -- :1'- :L--: :f., ...:-- --------------------------------------------- : S - :/)1 -- .- : .". -;- --------------------------------------------- --~:-(--:::-----~-~~--~--~-___~Jc_______~ . / . !../. -- . 'i.. ~ .)(--- 'VY. r'7 ..,....-- __~J_______________________________________ ,..- : r A- : )' -- :k...... -------------------------------------------- .,- .1,-. __.( ~ -~~~-----------~-~----~---------~-~------_:: . -- " -- . ( . . 1 .-.....- . 1k....... . . 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Steinhouae, M.D. 719 Rhawn street philadelphia, PA 19111 . . : ULTRASOUND : HEAT : MASSAGE : CODETRON : - -~-{--~------~~--~-~--~----~-~-----~ :{ ___ :'/,.) ,/ I /" IV .-:- ------------------------------------------~ :(.____ :1J -I /' Ie..,.. : -------------------------------------------- :( __ I~"'" I .......--;4' ...:- -[~f-:;--------~~--;-~----~--~-;;------:;- ------------------------------------------- ./\ __ :., ,./: ___: .; 1--. ." -- ~I ' -; - - :~- - - - - -; -;;-?; -- - -~ --; - ~ - - - ----;.- --~--------------------------------------- .- _~~___:::_____~J~____~___~__~_~______~_~ 1,\ ,_ :./ I ,..-- I 'Y ~ -----------------~------------------------- : <_ I W.-t ____: y ...r .-------------------------------------------- :.*" - : Z-' .-": ,..,--: ~ ...v ___l_______________________________________ : (~ -' .-/ 'j. ------------------------------------------- __~_~___::_____~_~_~_~___~___~_SC_______: 10) -- :7,.-'- ,,- l~ ........- -------------------------------------------- . -. 1,'-' ........ 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' :,'" t.~, ~.. ..,':'....., ," .... \\ '" \ f' ~": ~ I ,.'~ ... ... ,. ')L. \>I ,.'" ," .' ,0 t",l,f,1 ..;; o ,";., '~': I.... . ~(,\e, ~,." r'. , \,1 ,( ~.. \I). ~" C ..... t"'1'" ..- " ~,) ,I .....\''" " " .' r. .' ,.. ~ .' .' \ " ~ :.:: ~. ., 'f. .1. w 'l,t. (( .,;,;,. .:.' o <;> o '-> " ... .' " .' ... ,,;: .' ... ", l~" 1'\ r[; ,. .,. c:~ ,.' ':;' ... D i':, .. -:. I'" :s: ~ If ... I,ll '" ')' <) ..... .... \10\ ~\,. .ll " ~ :~~ " .... ,'\ ',' ... r:.: ,( ..:..: oS ~' ,;, ...' ;JI \.100 .' ;.,' ';"," " '-,\' I- f) '~ ~ \r ~ , " \.. ... '\ \ ...... ,. .' ,"" ,", . D' 70nOl r . .. Jot II ~ ..................... NICl'l'1'IKJ D1NH)8ISI Fractured cervical spine. CIder OcIIIllaint:1 Pain in neck. Biatory of Pli:lunt Illnessl 'lhis 14-year-old girl was involved in a lOOtor vehicle accident as an unbelted passerqer in ths back seat. She states that she was thttMl lU'CA1Ili the passen:]er ~t ard injured her neck ani fa- oial area as well as sustainirg lacerations to the left hard ard URJOl' extrem- ity. She was brw:Jht to the carlisle Ilospital Dool'gency Roan ~ she was 8Vllluated ani x-rays of the cervical spine shC1to'lld fractures of the posterior elemants of C-4, 5, ard 6. She was evaluated 1\1rther with cr scan oonfinnirg the fractures. In acklition there aweam to be a fracture of '1'-12. Evalua- tim in the Emergency Roan has failed to derronstrate any neurologio defioit. She is lIdmitted for oontinued iJmdJilization, gradual increase in activity ani fUrther treabrent based on finlirgs. Put: He4loal Historyl No previOJS surgeries or general anesthesia. No medi- , cat:la1S or previOJS psyd1iatr!o oordit:lon. A11uqi88 I None known. He4iaatiOlUlI None. Social Historyl '1he patient is a 9th grade sbxlent in the a.mberlard Valley sd1oo1 district. She recently had been urder the guardianship of her parents since this 1l\lI1mr. '1he patient denies any other medical prdJlel\':h DANIEL P. HELY, H.D. DPHVnw Dl 10/23/94 @ 1107 Tl 10/23/94 n\r~H I'. r~Yo' 100,'/'14 j 'r\ HI AC~~iIROI)k ; O~/I~/~P ~ICHANIC$nURG, PA HfLY,OltHfl P Pj, R2bSb21 10~q09 COHHlRC I H AUTO OI\RLIIlLB 1I0llPITI\L IlIUTOI\Y - .~..... N~, PHVOA MRI 704909 OISCIll\RGE stn-IHlIRV Date oiscJlill'l]ed: 10/24/94 DISCHMOB DlUH)SISI jrJ.5'; (J f Fracture of the posterior elements of the cervical Cjt 0 spine C3-C6. IJ Facial am upper extremity abrasions aJYi lacerations. ,; / ~ Fracture of the T12. g"(JS. 'J.. 8'7J,YO fW.d Elk? ~ I ............. CLINICD\L IlUHHJ\RYI 'Ihis is a 14-year-old girl who was involved in a IOOtor t't' .<" vehicle acoident on the day of adrniosion. she was seen and evaluated in the (i 1:lii' tlIIlllI:'qency roan aJYi fourd to have a fracture of tile cervical spine as well IlS a !(;~~~, fracture of the T12 vertebra. She urderwent evaluation in the emergency roan I~ ,j;';:,,'. with subseqUent CT scan which confi.r1red tile diagnosis of fracture of the pos- " ' .:', tarier elements. She was treated in tile emergency room for lacerations of the i'~t :,:h;:,. left uwer extremity. Her clinical course was stable without evidence of , " ;l"':~;\ neurologic deficit. She is dischargoo with r~ations to continue lilnit- '-4r('" ld activity. M:Jst of her pain is in her low back area. She is advised to i"p'~~' b ' taka 'lYlenol as needed for pain control, rest, aJYi around house activities "II,.' III,,' ally. cervical collar for invrobilization to be rem:wed only for bathlrt;r. She :;.~~f' was given instructions to call1re if at anyt.\Jne problems arise. : ,It VI" , ,.I\.::I~ . .' '.,.. - \ t1",lf -~...,' '~~ '~~I'l" '~~:." t....., \', ,..:~ tl, . ,>~~~~~::i~.'" DPH/lnTW 01 10/24/94 1635 " '~r i! . I ,l' \,,{' TI 10/25/94 .' ~;;,),:, I..... .,l." . 0] Dr Hely 'I' "t..,:;. ' . ..(\~, -' -)1"' .. '~J ,,1" il~\hll '~J., ' .\; . '. ,~ . 'f~\l; " . Lt~ ,.\, 11.:;~{ '~II' '.,' I" I ~ "i , , '.1", .,\\ DlINIEL P. ItELY, M.D. t..... ' .,,),~ 'j . ".11. ,'" J, . ;,'.~ I.' '<;';,j, ", I' '"",r.~\"\r.j , , .' ,,'~ 'fi!~P' , ',' .t,'," l. , ' . . "., .... ~ .."",'I..Jr . . ..{, :1'. ~. ~.',. " .,t', ,." ',' '. {," ()~Ob\l ~~o/~I~~O\lBROO~ DRi'~E \ t~~~~~~~ KECHAHICS8URIl, l'~rUH: IIlLY.OlHlEl P lout'lOq",. ,'i 82bSb21 ' ':" 1 CARLISLE UOSPITALCOHHtRC\ll AUlO SUIOO\RV V I '1'.' ,.'W NY, PHYDA c;mmAL: HEEN1' I Nro(l l1JIfJS I HEARl'1 AIllXtImI ~l ,""'" /"-- MR' 704909 RM' 306 W HlYSIClIL EXI\KINM'I(Jf ..................... 'Ibis is a healthy awearirq, yoon:J, 8dolesoent female. No tememess aver the cranium. 'lherG is wellirq ~- hoot the facial area ani neck. 'lhere awearOO to be M hemataMS at both r!'jes with oonjunctival hEsfOrrhage. Pupils are equall roord ani roactive to light. vlsioo is rot grossly inpalred. Ears - clear, no t:en:\emeBS CHer the posterior aspect of the cranium. Terder 00 the left side. LImited ncl;ioo, ro deViatioo to the trachea. Clear. RegUlar rhythm, 61 ani 62 heard wit:hoot JI'l1I'l1Ul". Soft, non terder, ro organarsgaly. 'lbere are laoerations t:hro.X:Jhc1Jt the left uwer ext:mni- ty. 'lbese were repaired in the )')neI'I1~ Roa\I. Neuro- vaso.t1ar status of both uwer extremities is rormal. 'lbere is ro neurologic deficit in either of the la..oer ex- tremities with good ltllSOle tone, symnetrical rsflexes and ro sensory deficit. 'lllere is also teJljerneSS lX'l palpa- tion of the lo.oer dorsal, uwer lunbar spine. X-ray ocn- fims a OCllpression fracture of tr1. '1his awears to have a stable oonfi9\.1I'lltion on cr scan withOJt 1I\1lTO.IIli- irq hematma or inpirqeroont on the spinal canal. IMPRBSSIct{1 1) rract:ure, posterior elements of C-4,5, ard 6 on the left side, lXJI'Ifinned by cr scan. 2) Facial lacerations. 3) Left uwer extremity lacerations. l'LNf1 IIdmission to the hospital for further treabnel1t basEd on fi.rdirql. .' IY\NIEL P. 11ELY, M.D. tmVnw 01 10/23/94 @ 1107 '1'1 10/23/94 /l \ n" ~ NY. PH Y 0 I ,I Ir/~l/q. ~~Ol HEAOowPROOk DRiVe J O'j/l'j/H ~tCHAHIC$BURO. 'PA ' IIrLY.01Nlrl r :. PARH 82bSb21 10~909 I' OARLIBLB lIoBPITAi.O"" ERe I H AUT 0 IOAL EXAMINATION "" -- Carlisle H~ ital . . . .,. p ~,,:::~~:,:~':: CONV', NIENT CARE/EMERG,ENCV REGISTRATION "....9' 0 21/94 2312 SAt 1:3 4 7 1 82 21 lIIiiiTiiAi.r -;;:i"iiiNl [IA11 iTli.if - tu.,AliUH ...1 n. FC 10/21/94 G.Hl) "G'ii'E'EVY: ROBERT ( 7171761-8925 03 .....1 IH/tllllt11 Lll1tH I DRIVE 17055 14Y F 0 S 05/15/80 000-00-0000 . ~.g fIIlA 'Allhlll~ "",\UV II LAWYER MECHANICSBURG, PA Irt !IEl UN/51: .&[LHO 000-00-0000 17055 ERCIAL AUT9 CARRIER 7 GREEVY, ROBERT BRIEF VISIT Cl.M8 I VISIT CLA8811 VISIT C\.A88 III VISIT C\.A8S IV VISIT C\.A8S V VISIT CONVENIENT CARE I CONVENIENT CARE II MINOR SUTURE MEDIUM SUTURE MAJOR SUTURE INTUBATION IV SET UP OAAOIAC MONITOR PllLVlC EXAM NITRO SET-UP CAlf, &coTCfl SflOAt ARM ~, &coTCU LONG ARM oAIT, &coTCU SHORT LEO OAeT, SCOTCfl LONG tEG WRIST 26700 26710 26720 26730 26740 26750 27020 27026 EOBOt EOB 02 , EOB 03 EOB 04 EOS 06 EOB II EDB 14 EOB \6 26031 28032 26033 28034 03 S MO ALL ADDITIONAL CHARGES ',1',1\ '.., 28037 r ' r - - - - - - - , I II I 70084 I I I I I II I 26000 1..... .J I... _ _ _ _ _ _ _ .1 26048 r - - - - - , (' - - - - - - - - , I II I 70070 I I I I 00001 I I I I 1..._ _.JI...________.J 26014 r - - - - - ,r - - - - - - - - , (t~11 II I II I OXED I I I ,.'- _____.1 I...________.J EXTENllW CIIAI!OE I - r ,r ------, r.XTI'NI1I:1J e;"AIIO[1I 26110 I I I I ,,_...._____,_______ I I I I I II I I... _____.JI...________.1 r --,r- ---,r--------, I I I II I I II II I I I I II I 1.....,___________.1 1...________.1 I...________.J r ,r--------, r--------, I II II I I I I II I I II II I \.. ... ....." . .. '.... ) I.. .J I... _ _ _ '_ .:. _ _ .J ~R.Q6OlIIREV, 7/0.' CAST nOLL, pLA5TEn DIP MONlIon 28018 PACEI! PADS OABTJ101lIEMO SLIDE KIDDE TOUIlNIQUE T OCL PEn roOl r,SIlS TUDE OAUZE PER roOl EO OlAT , PULSE OX , ~I ,Ii': ':;FOR NURSING ASSESSMENT ,~~I!. NURSING DOCUMfNTATlON Stiff T -.~, CO!~NIENT cAnE/EMER1I'NCV R!~ i. LXflH!..Q ':t;l~:;':,' ,'l' I~~I!' , ~J;- I ~~ ,of,,", ',; 'I i ,:' IIl',tlll't CA. (b) Cd'-bc.,j,"^;;V.ojij~I+L~r\~ti;) ~ t tR.A ,-_cp~OC :q;. ~'\-u ,"ipUlf.l urf( " ~/.1 (J ClJ'f!" ^CAJ'A ,.;;t... rtd wMl1- ~-~ f-au-". a~ ;;-q;Y;.lC),'-,t;ac.k-"'Qu;;.:,, C(J e~a ' we~:he>1 (1(.1 \ v.... c' < , U Y:-- '1" r f2.Il~L 0d).4' c "'AA.~~~yCV1l\:~.!\~~ )J:J~clJ7~---j:,.,-:J f)J~ c.O.aCf O~'L l .~~r:i, ~' C" "'" CU\.. vC.Mlu-. We~v-o--'\. A'C~ ~c1~' /'/,I).A'\ flr<t;r(e1 (f)/M, ~ ~ t(ls~r"~\., <t~~l:\ Je~ r (e.A<c.JOlH_'-' u\ra-r W 'Jc..(\1 I <,e - S"I S "';)U."'4'<>'v'":) \~" c~;;.li:AtJJ-., , 'b~ l - - I1-U-- -I""",J.__':;--elt..'-,-;.~-,- K.CU' ""'- <<c - 15, S ..<J .....-O><(,.Iu r ' , LMP: '" 'z \ ' , , II~';J' .. 1 ) " \N- C9't-'\~~ - Z". ~U)tj~;11t1'1I1rmfil{:lA.N Itll :~.1I..'_lft'.I\ll,1 II l.',")'~t.". [] LJ 11 - 110"'[ "'IMlf nOll HI.AJm cervlc& 6JMJ~~ iiMiIiT~'iiiAl.\t /cX-t./J '. MVA INJ T HEACJ LAC 110 4 95030 01 MUtlto tllMrnOVED O COUVWIWT c^,mCF.NTEII INIT. RIlPOHDID OlfirOSlllON mOM TIMI l 1U1ij-f,jj'fi.- ~~- PHYOA l<il'.! ,ll.. 10/21/94 23:2 ER'0606(AEV, 7/0.41 NURSING DOCUMENTATION - EMERGENCY I CONVENIENT DEPARTMENT CARE CEm D.t.I.!O L f,ntywd WIlll: U Police o Poftnl IJ 5011 U Monilor - RhVll1111 ~._.__~__~. nate U O'ygon - [\ Mask, U NC - UM'f ---"1 ~ilc. 5pinallnnnoblh,al,on, :'LI3:.1=',.I,(. __C::.f.l.lUl f:J'Masl" ;;1;-;-1 SilO _ 0 PIOSSlllO Drosslng 0 Olher ,~ lflr.t - Ment.' A.....mant: Moodl^lIccl tJ ^PJllopIlalo ~ Ulunlcd,flal o Defensive o Applflhonslvo o nostlonJCornbnu\lo VI.u.1 AclI,IlV' 00 ___...______ 11 WIlli OlnSSCI ....1 OS _____.__. .__. tl WllhoulOlass.es fi\ N:^ . INITIAL NURSING INTERVIEW: liME: ..1..,:1i>\S---- lMP: _pJM.o..J.t ~;:~~~~~~~~I~~0~TRA~Q~IC~~,~5~~~~~=~~~~~~~.~~~Al.._..,..._._, ~~1J?Rl;t'111.~~f~~s:~5rj~!li~)It.N':,a,~~n, ~;lIt~~I;~mvA~;~~~:.roorLr.jjItItilli1m ~ .tY.!ln . ,1.~L I~--!D-"([":-il " Ir),n1.LCl. \'..L\L&..pci.Lri;:=:'-@,lJ..lwJM p.cl.M.l1 ,pt . ..:t..:il jj~/,A,)jICllLt':LYJ-'-'- PLAN OF CAREl RilTlVI!I P I ml~! 1I0'\l(~1!J1 V;}' ar,~;'~;,IO ~~~IB,' 'k >~(j,~-, Hi, r;.S'~> ~,6I,t-/fjl-' 0 M, alnlahl Polionl Altwoy 'E~ llU:r-~q~-ti.\'p U!P,J~l\)nl:L LI Monllor Cald'OVBleular Slolu. Wr-~JbJ.~;biin(l~ (Ull~Li;~;~~~ l/(.~f/Q= :l ~VKO ~j g:,~:~I~~nllor ~~brh~n Diagnosis _ NOllcoll1Phauc:o, --- -.. 511.111 hlll'ijtlly 1,Il1rn, illllonl U S,illoty Monsulol " .f C n __~ 8011 CAle Oollell tholllJhl PlOtr"!'s. Allin (J noslmlnlS IJ 6ulcldo P,oc8ullonl , , '.. :X;ComlOlI. Al10lahons In ___.II)IHHlhOllllill (rcvOII LJ SoIL UfO Precautions _ AlfWlY Clearance, Inellecllv8 __ Conllnu"Ir.nliOI1 h11lmirt'd _ __ 1111l1ehon, flulo"!1.1 U Side Rnlls Up _ Anll,ly _~~. Copln". Itlotl(ltli~-o . 1t1JIlIV. 1'11101111111 Comlolt MOA81J101 _ Br'lthlng Pallllns, In''''Cllv. ___ rluid VolullIe. AllDIAhO'" III __ KnowlOdlJe OellfA U Pain Conlrol _Cardllc OUtput, Decreasod Onll t.chnnllo, IIIlpn1lf!d MI'h1lily liIlj1l1l1l!d 11 poulllon lor Comlolt _other ^ ..__ luituo 1'()IIU!llnll. All In Olhlll I' I" ... 1Ill1nlO or ~.nn1 r:~plnlll ProCCdlllDI (lIlottonnl Suppor1 Pnlonl 10achlng y'15c11nrgo IflltrU(~lionl 121hO/ - Olhor .,_ ,_. I Olha'_ (J Olho, .... . , \ TEtANUS STATUS: , I, '1 \. I , " 1!. Wilhln 5 Voa.. o 5,10 Vaar. o Moro Ihan 10 Voa,s o Navor . GENERAL APPEARANCE iLSE: Regular 0 Irregular Full 0 Weak ..REQP:el 0 Shallow 0 Ropld 0 A"dlbla j!l.Noim 0 Daop 0 Slow Whoalo o labored 0 SI,ldor lJ Rolr acllons , . ThEATMENT IN PROGRESS ON ARRIVAL I o CPR Down Tlma _ Olin, lJ Airway - 0 O,al, 0 Na.al- SilO o Airway, EndOlrachaal- Size o Airway, Nllolrachaal- Size o IV Solullon 5110 LUn~l~nd'l Righi: 0 nal01 0 Wheezo Jl II 0 Rhonchi 0 Able'" 7'4 A L,Il: o RIlo. 0 WheozlJ lJ RhonchI 0 Absenl o Olhar__ "Laft . o NtA 81.. lJ.5.- 1. · RIICI~ . BI.. ""lEr: z. RIIC~ 3.. .' . a. . a. . . ...... . ElllOttl4tll ,. TRIAGE NOTE: In-ot SliM """'" 01 AIIIY.' II Prlo/Ily I I.l AlS -d DlS i.'! Pllorl'y 11 n Ambul"~/y II P,lon'y 111 I.l Whoelehnl, I} ra'll ",<k I} Camed CllIet Compli'llnl: __ ~~____'____ ~____ ---.. o Friend o Family )lJ Olhor ~~.~~mJlfl~__:;jlJ .-PH':;J 011&0101 Symploms: _ ______.______~__ NUlI!IlO Acllon/Commonls: ...-....-.-.- Childhood hnmunlznllolls: 11 Ul D [J,Novor l,.."nanl plIor 10 AlIivat: {i..1-,fJ 6.:J-.- 11 COLOIl: "tll'Oood If] Palo fiN: Wa'm [J,y ". ' II nlls"cd II Jaundlcod II Dusky o Cyanollo IJ NaUbods o CI,cumolol o locorallon o Edoma II COlli t:I Clnmmy LI EcchymosIS, IJ l1.sh, _.... lntAGE NURSE SIGNA1URE . .. thought: )\ CleartSponljlll(!olll n VAyuorOllconnnctod IJ Oiliorlollllld II Slow 10 AllliWC! .. ~ech: Momory: ,A'i. Normal/Ctoa' ,)( Illlacl IJ 6110nl a Imp.hod I J 1 nlkallvo 0 nocont U flr.pollllvo a OlslanVP.II U Mumbling r .. N ~ o ,t 12 13 OAL: E'poelod I>y IJlsr.ha/go:.._ ...._ H'..._....._ 'H' ._--,. ,-,..' cUA.CJj'ffu~t I d"(~--i.'.:,='=:_~::'~-:'~~~=-',-=. ~..~ ..:- .-,-.".- --"0~ Ll:~.f ~tJ!~___. .. ,... - , . MEDICATIONS ---- .---....-.. -------- ---.- I.tlt' CIlh. 81J:' Tim. SlgnllufI I Mod, tJI- Jr7Y- ,~' 131\,jilli~~Il~ti J!~ "-m~~~= 11m. Slgn,lurl -- ._-- ._~_.._-,_.._.....--'--_._. ..--.--..--- ~._---- '. . EATMENT/PROCEDURES: ','cl~iBP'THERAPYTRE^TMENT_..,'''--~~'',-,...~:._.. . . " = --- -~-oiiTPUT: \\~f~TlM~ " ; TIME____TlME __.___. ~IA~!:_ -- --- , ;~lp~OllYGEN " UMIN___..__-,..__, . riP;!!' -Ami: .-lip,r'O";nl: Urine , !J"INTUBATION. SIZE __ . - liME ," ..-..,...-, ,-'" --- --...... ~' lJ;AIlG'S TIME TIME__ ,'.. liME ,_...,_._... .._"U" -", ..,.... ",- ,---- , , ,.O,tULSE OX TIME liME -' ..--.-'- -..,...,.. .'-'-' -..- ,--- - lJ~lIlW,W. TYPE TIME, -.-----..' ,. .. ,,-" .-- -- -,,-, OnNASOGASTRIC , UDE . SIZE__._ TIME ______ . NOTIFICATION OF: C', GASTRIC LAVAGE AMT __.__ _..._._.__.___. __ 1.1 Ilo!lpill\I Socinl WOI~(" .---.-- llrnl11lty --- ---------- 1.1 ratiee! .... _ - -.....~-_.-------' q, F.OLEV CATHETER. SIZE liME ..-,---..' Ll 1:"." Inlnlvon"on .-.-....-- N,\T, OUT COLOR ..,,, . _._.... - II NUlling '10"'.... ," ...-,., . - ._-- ._._~~---"- .--------.---- . VITAL SIGNS. (J ON Dp MONITOR ( 1 MANUAL -----"--.-- .----., ,---_.. ...._~ .,~_. -- --- - --~- - ------- l1me UP p n NOTES: ' _Ji!~B '''~J~;il(jf~~?ii~J~'\;~i- oir.in; ~J)I - ~ \ " -.ltLL~i~_if~)'_..lf2._/~lll~~{'LO:fQ CO lffi ., ~_n_':~_QJ'lcl. _(I,..lw..!~ ~ ('}1K1/', _L!\.~i~~.... J!'PPk~tiLn_~~dtn o.b/l flL\Lorl^ 1l'~~;a:~4~' -iu.,,,-,w {J3 ~)_:L(~/"'VJ __ "_nJ~,tl~-'tJ~ ..tL 1)L I.U'\ I-n~__..jtL~.. ~~~~ -- rf=nff _Jh./.1j,.!I~'iICJ1YLX((P'AI.. ,-/0- ,6)1 1/3_~__..1o.md.J./..c_ -- ~~ itq,ZfjL{t/ij~~t!lf1L-~:~~---, - ~ DO - -- .p.i:.ll/1JtKfJ'.. 10llL,^i-iUj,u..C:, C!J:/)tJ:i..flPR. -= (,of{., jCt>_ _1j()t.YI{I~.", :\..1 eX'" {]j1i'I.pIULR:-_ LP(,l4..I".J..tl;,,:..'W/fJJL-m EVALUATI)N JND DISCH{\RGE NOTES:. 51.9.~Q'rl0b ~w obo'{f}Sr CL.tlt/~~s_rJi~L*, =o1!D1L..:I"!(Ull~:L' DU. \.elW-. .::..tLLtw..L d1ll_ :s~lc.lLlA-.}t ,- i1t:: --- --.. .....- ' o PATIENT I FAMILV VERBALIZED UNDERSTANDING OF DISCHARGE INSTRUCTIONS, )J Il DJSPOSITION: DISCHARGEI I I WRITTEN INSTRUCTIONS GIVEN '('1i J( Admitted to:" (J ^lflbu111101Y I j ~II lJ Ghf'r.I II UII ~t::J(,.W-- 11 ^",hulnlury C ^51illollcn ;.r1' O!lllty 'I Crull:""! t I ~idllPr fllotlo o For C::MiI,rylllon n Whllolchnll 11 t flf'l1Il II Ahll I'rnhh)lu II 1'1!1~1r. 1111 ~ to: ' . (] ^mlJuton I J I'ul,rr> II \'IflllIlrl C:VIl II :;(1r.11l11lIu1(.11 o rran.f,ned to: Olhol . II V"llJ,lhll.~ 11 CII'ilI IUlll,ll II ""111111.' ___.__d. .... II r...~'m 11 IIcllr;A~1 o Morgue II '''" ~~ PA~BHAME~rM_.....n[j . Emili' Olher Ll Fanllly Ootlor o COlonor o Conlullanl tJ Olhol a OlhOI , ~'I. It!' '.-. , U 00"01111 II OlhfJI ,_ _____ IJ Olhor ._______. 1lllli~j1l;Jty (, 4dL~elJnSU'B SIONATUnE " I...... CURRENI MEDICAtiONS ~,l A:' ;... I' \ " . " , '( , - - --' )I , 1 1\ , , IIMI liP PULSE liE SP Db/5 - i-. I" .""'-, . ' ~", c& Carl~ 1-bipitaI EMERGENCV DEPARTMENT NURSING NOTES lAStTETANUI l00811R NIAD NONE D UNKNOWN D , "'blll'lun r llltl1llihon 3 r"nc:lurl . "Iellll" 6 lJlaloulion 6 {\1"1,"lGlllln , fll,'Ueo"'. nUln e Second Oeg'" DUIn 9 lhlrd.O.ar.. bu," 10 rlln " ConlU.'t'ln 12 We.lIn... 13 Iler,...od Go"Uhon 14 Abunl 6,n"llon HI tdbnlll 16 Oec'flued rul., 11 AhRonl ru'" ie f,,'.I~II' II ,..____._' 10 ~~7 IN1^K[ .___..,._~ . "-"-'''-C''''~9 ..... -'-"--'~('(=-t .-.~ ---, \ -~ X :~.IPUT ~% . J' TEMP, ORAL d RECTAL D COM MEN '6/t10' ES/PROCEDURES (I/. f1r '--- ~-- ---::~- - ~ -- ~ ,.// .......... .\,,' _'__~'_'_' ___~~-~___~ . ,_._~_~__'""'___".""__ .,._...v._~,_~'"____~------ .-, ~,,-. ~ ' \'1 Carlisle Hospital 0)0"1/ NY, PHYDA \,.;;;~ HEAOOWBROOk DR I Vt;J 't. 10/g~:~ ~:~~AHICS8URQ, PA CONSENT TO HOSPITAL ADHI8810N AHD j ~UY.DANllL P PARKE H!DICA~!ATH!NT .r 8l!~~er2~tending1{il~M3. (Dl' C ~ ILk- ; CO"~\'it'c'hAdl'b~lfl1on. 10 '2.' (r;r/ Timo. '1 1. I, (or jJ ~ (f/j1;!:- con.ent to rendering of Duch care, which may inciude routine diagnoDtic procedure. .nd .uch medical treatment ao tho nomDd atten~ing phYDician(D) or other of the hoopital'. medical .taff conDider to be neceooary. (AKI_IPM)_ acting on behalf of) NIIII. or ^ulhnri,rd lI.p,..ftllath. , Buffering from a condition requiring hospital care, hersby 2. I understand that the practice of medicine and ourgery is not an exact .cience and that diagnosis and treatment may involvo rinko of injury, or even death. I acknowledge that no guarantsss havo been mado to me ae to the reoult of oxamlnation or treatment during this hoepitalization. 3. I underotond thatl (AI It is cuotomary, aboent emergency or extraordinary circumstance., that no subatantial procedures are performed upon a patient unlen and until ha or she has had on opportunity to diecueD them with the physician or other health profossional to the patient'o oatiofactionl I P I Bach pationt hae the right to coneent, or to refuoe coneent, to any propooed proclldure or therapeutic coursel and Ie) 110 patient will bll involved in any reBearch or experimental procedure wlthollt hin or I,,'r rull ho"lr1l]o and connant. 4. I underotand that many of tho phynicinno on the staff of thio hoopital, including the attending phyBician(s) named above, arn not r.mployene or agente of tha ho.pital but, rathar, arn independent contractoro who have h....n granted the privilega of uainll it. facilitieo for the coro ond treatment of thoir patiento. Further, I realize that amonll tho.e who attend patients at thlo hoopital t"e medicol, nurolng, and other health care pereonnel in training who, unleoR requllotnd othorwioe, may bo preonnt during patient care al a plrt of their education. Stili or motion plctureR and cloned circuit television monitorinll of patient care aloo may bl! un..d Cor educotionftl pUl'ponoo or for documentation of the cUnical couree unleno a patient ollprr.!noiy l'OqUoOto othnrwin'l. 5. I r~leBoo CARLISI.E lIoSPITAL from all rnoponoibility for all articl.. which I am retaining'or will hovo with mn during my otay at tho hoopital. I underotand thi. include. clothing, hridgework, hlno tooth, eyeglaooen, jllwl!lr/. monoYl radio, ralor or anr othar item kept in my poooooaion. : "ndorotond I mAY d'lllon1t valuab eo in a oafe prov d.d by the hQopitall only if thin in done will thl! honpital RQnuma any renponnibility for the Rd.keepin", . 6. I hnrebr acknowledge that I havr l'llcoivod writ.ten information on the topic. of Patient ~iqhta anr Advance Oll'ectlveo. Date of siCJnat"ro',_.J...Q!r2~;J../.rd____. (SIGHIITII~E OF fATIEtlT) (SIGNATURE or WITNESS) (If patient in un.hlll to connent or In " minor, cllmplote the followingl) Patient lio a minor _ YOArD of ago I lio unAble to connont becauoe II ;1:;L,~(r'L ," '.'" ~4 . '/~I/' . ~ /L-I..~.-\._, ..~~: (SIGNATURE or LEGAl. OUARDIAN lfR ,,\, CLOSEST IIVAILlInLE RE:JlTIVEI h~\', (SIONATURE or xl tllt. WITNIlSS) , . .' .., 4- ' b'.J'{;,.Z?~~,,":' 0'6'00 ~'I. :~/. ~ '-~ :/4.)>.&'6' r~p." "1 ^~",~, ~ 1'1, , /J ',fA ':1";. ":'. '0 ~:" 0&. ""'-t', ~. ' . . ',.:e: 00' ,,", , ^'- ' '0,. t.(. ". (, -or ~cl'O..,:4)oo:""~o:,,, " 6'c:"" e,~4l'Io'~"'lI. .'O~ :tt~.t'O O~ ~e;;"Ot"tI.~,,:t.tO:OOt ~ './ .(4)O .?)~ ~~. OOt 'f' 4. (t, It Dol" .JJ.D 4>0 060_ '.~~.!,~e....(. "~,'Ot 6400"'0 o,;.~ t:; 40() """P"o. ~~4b 0&. ",.'" 0..,." ...o~ ot:~ I> . 0 "'0 ~~ ' ,.f,'i.. ~';f." {, '" ~'.~ .... 4,:0.,:-.,:0...... lq:>", ..t,':t'6'.:1~""O./. ".fA .' 0..,,,, 0(1 0 0", /:: '/I 0 '.I", ~ · ;'1<-"1:. ~ ;r,~~' 40 'Ot. "% '. ""' 01'0 40" V .t': '0./ ~ f.1(1 "';\t'.:, 0 ;'''..,.''~ .~.f. ~ "'....." .~~.. O. . ..~ .... .'.. "', · .. " -. · · -.~ · · -. . .. 0, '., ., , ;~~..... .:,"'!-o.....;-. :-'0;.." ~. ~...:~ ;:.~ ",.:0,0,. ..;-. .f." '....: ...:;0.;....0'" ;'.. ~.~ 0';' ./.... ..;7.. '~.. ./o'.~. "..~.. ~ '.. '..'0. ~. /'.~ ..~ ...;..... ....}....:"" ' .~ '.', 00 ..., .'00,. o. ,~ '. q,..., .", ~ .., ~'.,. ~. .'.....;0,.-... .0"':.. ;~.. ......0"'. -'.. '.~ ;,v.. .~. .....,. 'q J o. .. .'.~ .'. ... ~. ., ,'.. h. ., 0 '.. ... ' .. ..., ~ ". ...... -. -..., '.. ~.o"J ;..'~'\t'.o/.",. .'0, .~:.-.,: "'_ .~. ~.. ?.. ' "'J 0.4) (1 Ot: 0 "", ' .t': "'() ~ "'4).(. ..0....,.., <!-. .0J.'. .J. oj'.,.. .,~. 0..., '. o. ...' "<<., .... "/" '.. .J, 0... ..J.o"'..... '.0 .0 .~. o. .:' ;,;;,; , 'o,."J. ...... ,~. ""o~. ~'o o. .., '.,,'. . .~'~ ' ./(1.:9ot: 0.0. $ ~t: (1~t:"'1t ~. ./(1 './0 (1 (1(1 t:, ., . ":/.'{' · .-.J '0", ... ' .' 0.. . "'. "'. ~'. _.. . .," (..' : '. '.. -. ... '.,..~ ~.". 0 "'. ." '., " .. '. .,~. t ',~~7, .... "'. o. .~ 'J .JJ .'. '''' .~o,/..'...-"r .,.r",; . .t': 0./ 1t'J(I at:" t:~ ol"... 0.... '0/::"'(1 ;'/() "'(1 0... 'Ot: ; '. :~fJ' '....:~; a... ro ^ "'" ()./ Itat: ':.,.. It 0. . '_.. '~. .., " "0 .. '. _'.... '. ". '" ..(; . "'. ()" o~"^ (10. ..,~ '<"'.t: '',.'" .. '0./ <f'"" "a (:L ' "" '<"'. "c'''v '0", 4)0 (1~t "./ '1() 'OI>I>() '0 0" t: t:; "~~(4) Or t: 1tQ,>() (1(1 (1 It... 0"'(1 () () <I'(1q 'OIl t:~ :.$(1 ~ a <9: "" () Ot () I> ~ "a(1(1;()II/Jltt:~/;I"o. Da t:~(1t:()", /::-$0 p / ;>,0../0. 0./" "all. './0.... ~t ~() ~p <9'~"" ~-$ _ Ito.t: ,,() "~,, o~t: t~ . lot: a, () ()6 "" '01: "It, ~<9' " I. (f.. -7)'/0 '.I lz ~~o""c' I I.- ~, l~ Olz <"q". '()ll <r (1" :;.. (10. , ~ o~ o:;-,:t't: '&<9: ~. ()" l:t '0 ""t: (lOt:"0,/, (10q (1 J- "" r. () lOr, aJ" ()o 0... '0.... ~(I < t:L" $ t:; 6 . 0... (:to '/() ~ t r-(l./ o~ "II (1" (1q 60. ~() "(It & t:~& :tll(l; Q,>oZP It...??; t ./0'J ' "~t: 0. 0 o.~ ~'" ar ()..." (I~o/).r~ &(1 0"<9'-$ a... "Ot (1 (1(11> 110.. a" ,.. .... Cuthbertson, M.D. ,\ " .' CliMB tI'IIVSICI^N 10/22/94 115640 DR. OLAUN M.R.1I704909 .. ,.........." . . .~/;\\I~I'! \ ~., ~EPARTM{ ..-oF RADIOL? . \J.@~~W~' ,.:,1\, t ~ 't' ,,\ l~',I::';~",;~IJ~t:;, ','.; , . "" 't') ~".' . ....~, ... I" ' I ' ' ,...r-:{i" ' ',' , ?1~~~~~;6!i!;t. P,O, Box 310' Oorllslo, Ponnsylvanln 17013-0310' 1.800.348.4789. (717) 2:~'~&~)~r:'" '.' :" . A, . '(' ,.., " \"\ '.' ,. "',1 ., '0 '. "} '~ I ' .J8LB IMAGING ASSOCIATES, " hi' \..Jl,.' '~.J' \1' -:, .. . NY, PHYOA (14) 6203 MBADOWBROOK DR. MBCHANICSBURO, PA P.C. mORAOIC DPINB I ~, I Anterior and lateral projeotione of the thoracic epine demonstrate a emall compreeeion fracture of the anterior aepect of the superior articular eurfaoe of '1'10, and a mild kyphotic dsformity of the thoraoic epine at that level. A elight oontour irregularity in the anterior aepect of the upper '1'9 and '1'11 vertebral bodiee aleo euggeete small compreesion fractures. No retropuleed thoracic spinal fragments are evident, and the ante~ior projection showe a normal alignment. Adjacent rib Btru~ures appear grosely intact. I' ..' It I Anterior wedge compression fracturee are suepected from the '1'9 through the 'I'll level. They appear groeely uncomplicated, although they do result in a mild kyphotio deformity. IMPRkSsION: (,., 7: ~~ 0.1 ,.. O-SPINB 8RRIBB Following oroee table lateral views to document cervical anatomic alianment, a full cervical study was performed. Anterior and lateral projeotions are remarkable for lucenciee in the poeterior artioulations on the left from the 03 through 05 levels. No arOBS displaoement is identified, however. Oblique imagee demonstrate preeervation of foraminal patenoy on the left, despite confirmation of fraotures extending through the articular pillars and pedicles from the C3 through the 05 level. 'l'he appearanoe of posterior elemente on the right ie groeely unremarkable. There ie no evidence of deep soft tissue swelling, and diso spaoing remains uniform. IMPRESSION: Non-displaoed freotures of the posterior elemsnts on the left at the C3 tlll'ough C5 levsls. LBPT 1lUHBIIUB No fraoture or other bony abnormality ie eeen. No eoft tissue abnormality is noted. IMPRESSION: RJO Negative left humerus. -OON'J'c!MI/RlhIVSIGI^N " ~ .,.. \'~' , ~)\i " s ......, r..... WOEPARTMf' jl"OF RADIQLcAfti~~';:~:'-"):;"1 " " 'Hospital .' ' 'J "",\" . ,/," , ~.' , .',1 " I.'\:"l'~ ~; ':f , " (;,It \~' t, . . "I"" 1" , ' ....t'ft\'j.,. t....'; . P . " ' I_ , iii6; ~~et Sl~et . P,O, Box 310' Cerllsle, Ponnsylvonlo 17013-0310' 1.800-346-4789 " (717~ 2~~:,W~2~~I~;" , 1'.('11,.":" . ,.,.~i~""" ~..~.,., 0'),,- I' 'I'~l ;1',. ' ,: " ., . J I ... '\i~." \ I' .,,; '.. . ' t 'If. I " . :," 1,\, . " ,I. . , '!oi" '", " .,it .,'1 ',I. ' r PHYDA ,.,1, "..,"tll.':";'I' : '66' '0" ,,' '," :' ' .'..', " "'\':'l'~l'~ 'It" (',: .' . "('.... I', . ; I. '\.I, t It, \.f' ',,' 'QBr21~ CONT"D', ' ;.1 .,}"','.;:, tr,\'~':i~.i . .... it) . I ' '0 f,!#~ i,'f.\ Il,' ,\' . "M:" II ~ . '" I 't',,, .. "1'<< "r", I.'" ',' . ," .,.. ),.' 'I'" ,'" '" \' I ..\ I" .fi"" . "'~i'l',k' " ",'..'h 'Ir.' ,\ .....yBT; ~'" .. ~I ~ J\ l.~l:!;t:t: .~ I \ '. I .nRA ,~, ' ., "",I,,(.,;i':>..,, ' 'Il,! t 'l4. ...\' "::', ' . '.,'.'" ~...f; '.' . .'1' /.l.' t ..ft' r . u","ti:l ~ "re,;'i:1!I soft '.tissus prominenoe about the wrist I but no fraoture.' ";~~,~;~ .',' .' .' ~~~,~'p',~'~~e~e~~,t ie identified. Joint spaoing remains uniform.::',J'!~~g~:'t " ;'f1. '."~;'. " .t~..,t.. HPRBSlhoN:~'.' ",~ :No evidenoe of fracture or diBplacement. ,/~"; ~.."" ',.' "J, " ' Q'_ .1 I 1"\ . \"' ' . : I,' ....i.. I, '. . ..... '..o.J ! ~ /. .\t LBiTtJiAND \~ Ther(.is nc definite radiographic evidence of fracture or dispfaoement. Subtle deneity along the ulnar GSpsot of the diet~ metsoarpals oould rspresent foreign bodies, suoh as glass frasm~nts. This should be correlated with the clinical appsaranos, to confirm or exclude penetrating injuries in this relion. IMPRBSSION: Nc evidence of fracture or displacement. ~d J. Cuthbertson. M.D. RJC/oo T-10/22/94 13:31 , , CllAn I/PIIV!lICIMI t ''0 .'.....~:,.,y\1,.. . ....-ltrJ ....". t " 't'} " ',I ~.t!. <, 1111.1,,1/" . ""I!., @jCarlisle.,'i""")"{""" ~ 4 I .'. .' 'i '~J'" . f~ tl, I . .." 'I' " , ".t ,"" ~ i I', , I 240 MnKEn 8T" PO, BOX to '. .\~ \ I.l(i'~ ,,' CARUSLE, PA.17013-Q310', (i!,~ , " ". . . . " \, ~ , ' ; ~ N. ,: . ,,,,,I.." ' '\ .,': ,I . . ...~-, :.... . ~.." ' ..;':ro:....... . 't' ~;- '.~ I '~'1' # . . . .'I'f-'~ , 1:\;,;~~',1' ~ PHYSICIAN'S ORDERS ;'.:''',:'~~I,' . ,.' ;'" \. . t'- ()I1fU.ns NOTED BY II~o /JL,h~~ c2.~~~~-4~'LBk?; ==4~~-.~ ~d~~_&1~,.,.~k.A.4tle. (.u~~~-l'. ~..f~-t'~.,..._, _._"__" --rcr4~~,-, ,'-....._._,~,_._..,.__.. ~ ~ ~ f "'-t=::. (""I. ,11 l/1I J.1 ~ ~ ~ ~J'rI~ ur~~~:--~~ ~ .-2~4.... ~-d "'!fL-f~-~ J .... ---- ',- -_ _ .. ~-~.~jb:-iJ ;f~L1YJ~'i..JI , -----.-' ,.............-..' ,., ....,....,,_.._.......--..~~T /1~ //.., , /t ~ fI all\\:' __,~_.,_ ,{ __ t_ .~_n~Lo/'n. yPtd~,~,~~-~~ .__.._,u~!,,,t~, .M~_._---, 2l.J , I , ~~BT..rOIlOX31D ~ CAnUSLE. PA, 17013-0310 ',' .;..- OIlIJ[IlS a ~ ~ :5 ~t 1-'<- a ~~:'1'r" 4'~ tii) \ ", ~ ", '.... j '" I '. i ,', ',I ~, l: /' ,. ,. ,- . " . .' " . " . . .' ,/ ./ .---..-. ........ 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Oil 12' Til ;;0 2'f of (Iii 12 Iii To' 2410;1 1ia -------- - - - - - -. - - - - - - -1- -----,--------- - _ DATE /tJ ...~;J -1'1 HOSP/PaSl OP ANl1BIOTIC I 2 200 04 08 12 16 240 no flO 210 200 100 100 110 Oft' 100 -- 100 140 100 110 .,. 110 "'-- 100 J I' .J.,.OO - ,"",," a~o ... r 1IL~ '. 40 00 ;~ ,~ , ~,.,', i!L.. i. .' ., / '" D IlL.! REBP.RATl! FSB8 TJ.\E RESUlT MIOHT /SCALE SHIFT p.o. TUlIEFEEO ~ I 01,16 1&,23 23-01 01.16 15.?3 07.15 r " un TOW, Wll1.TOTAl mo FOlEV I 0"''1 OfWNS 61n TOTAl WI\TOw' PJ Wool"" ,- _.Lo._:-_-3~..__.. _IQ":~1--_. _/~_:a. r Id ,;. 2 " 12 18 20 24 1.- - -, - - ------------- --------1----- ------------ ---. --\-1--------- - ---~-~[.b---I- -=_. , _'<;' a _ -IT ~r -:.... _ _ _ _ =_ l> ~,~ - ~ III 1- ------------ ~QI~~-~~~ffl;- ---- ~I'~ '~ ~. 'J*. ,411 .l _S.:l1l till. ([:2... 1&,23 23.01 16.23 23,01 07,16 1&,23 23-01 23-07 07.15 ------ '- -....- r---r : .. T....i- -1-,- I I . .- ; o IOLII n. ,nO& ~ 10171"4 ~'O] I[IOOM.IOOI "IYlj O~/,~'~D "tC~"IC"U". 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I!!!Ii'J. e ~ INItiALS 610NA runE l,.nAlI ilONA T\JNI LWl....._. LAI,........."'" lO."It"laid 'lO.It~Io....,qllld IIYO.~_ ""I,.It'......"'" no.,tgtlldllold mo. l!<Jil to..-, quiet ...lbO .1IfI....1 UloI,".'''"", "LA. rll'ht 1I1"m lUQ.ItII~lqu.d 1IlO'~_ 111.1,'",..'....,. llA. ..f1l1t..I""" "ua '11U'1t VR'f1 quid ~".:.r L\'l."","1I1 ~:,1. nVl'~"'1ol .,."ro " .lItlultd ~, p.Or'Ir.tI HfV.fjlullVVorn111ng ""'0/11" 10.22.91 ,. ""rig . -. - \ '" \I\'l.ll.~ ~~~~ lit PL.'(d'!II: I{l." ~~ A(.~'~ 7\\~\~ --- Cu,rlislu Hospital Medicatio" Admi"istmticJI/ IlCCCJ1'([ NO/JOJA (IIIiV'''''4) AlltI~I" NO KNOWN PATIENT ALLEROI H..." NY, PHYDA N,.,,.,, 0306-W AI" Ie YRS Su: Femal e III' 62.4 I H 11'1: 116,0 LBS FI.,,,,,/.,,: 008265621 "h,'li,/,,. 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IhM 01\(' q 3 e hOIlI' DnURIA . r.",lul 01 d,".:ull UIlIllhorl MAloDOROUI ' Unptcllll.n1 D' loul 00111 It- OU bllClt""OI . V.g.'1I "'1"" or \lllIlhl.1 ~ 'UHOUIIWHL. 'unduIlllm J., , I ~ I " - ~ ~- ""'-.. . DATE: PEDIATRIC NURSING DOCUMENTATION SHEET I 00 D'!O I."''' ..~';.n'. u,,,,r. , III fI r-r_lI n IN rA'llf~t 01111 mu JI:l I~-- tiN! VOICI~S U~Ol"5 I A~ltJING flOOnnOUI"'! HIll[ nAII~ CAllllGIH ,}.O______ 1lI"'.tn.c~~,[ C,"MONIIOR ------- UI!Jll(tH ~~r!~~TE!l! 150l rllnTO lItlR"PV 1\'SI1( ~.._---- ~r;l~ T E A C It I II G IVI'IlMP ()1F-t ~.!J~!:~ ~~.~Ji.!_nltIGE L~~!'9 Bum'ltm P~~'.'.OI"NGprnpltlG 0, JI f,lowton II[P^RI'HOC ''''!IS! flUtOS______ (1'~EI'l~!' 11^,..nW^91INO ]l~~~ 0/-1-- ,-,1- A) IV liNE P,N\ J{; 11 ' Jj"/~ E PAI1I1IQ M 0 nOCklNG T lie .YY' I nr.^SSUR.tlCE ,\"f 0 .\"(' .7''-' N COllvtns.tlON A Pl^V j , - L IWDAlr. P^R!tlt Ill.!. 1MII' 5 ,^nENl ilEnE lJ tit" u ,^nWICAllEP p SIOlINOVISII P IllIfF 0 rAfIlNl PAnlICtl'AIION It I CAnE " COD! 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P ~lRI[ H(lY,~IHlll P lOLt909 F\2bSb21 COMMERCIAL AU10 . . ~ . , o 1n y '\ Y I ) N J H H " 1 , , I .J t' ..I'':'., C' ,J - L . n. 1 nl 1 i I:XPLANATIONSI MEANINGS I CODES NEURO: I COMA SCALE cour 'JIIllIAIIVt.lOVIJJfU' 01_ " 1 , , , r, " " ,] " - - -, -iiiJlii( Iii ;.CTIOir--- EVES NEVER to '0 !JUnA , OPEN rAI" SOUND MOOS FoltHlnt';1l -- , III Ar.lIvl ~'l'NlO COO, VERBAL NONE INC""" rnlAl( 'LOIO 0"'''''110 1l0UIllACllVt SOUNDS WOODS tClrvln __ 1;UPii5"~i-.- SAIu. [It[N htlUON f1fJOl lOCAl ON'S " ,e ,. , '. IlOtOR NON~ WlHl VIS ~~KJ5 .. 610N AnNon O"AW rA~ . , , "IURDIUf. MOVlMlHt . .4 . NormAl SIIf'"Oth I' . S"~"t,, VrrI'.l.'lf!U .... ,'.Mold_llillu.." .1.fjo'''",!I'1lI'''' 11HAVIO"lllIIPIIWHl AtJltlO 'AIIUle,p un....."1 11f"1lof'I'n ,""ood, hll.\." "'id ,Ill'" rot d"lll.., 191101 1"'PMp'I'I.IOO'l lHTEQUMIHtARYI tUROOR I WNL When ,.", p'oc.l1rd 1I~IUln, Iu IlItQ,,\,\1 ,HI,'lon" WllI'out 1t',h"lQ ..II "'~ lOEM". .1. 6ml_ P.l nol ,.1I111l'd .:1. 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'''I'd tlllfttr on 1n'P"llhan rwOl1urrd h~ liull! 0' ""f' hHlllrl" _ RHONCHI. H.." DnIftIptlI'IOn' t.p"lbon ptodut...."'r II" rtl1\S'"O 1I110llqllll'uroul IIII."UIt. l ItrWlr. ' "' WHIIII. Notar r.tl1l1knt ' mi, bet tI...d on ,nsp".hOrt Iwl "'0'1' [MlIlllln on l''I'''.1100n ..DI WNL -IeIII. I'IOn d'at,ndtd. non Iltlld., !: aOWILIOUNDIIWNL. '10 IIVUlgltlPt>f mmute at I au IUbblRI WHL . Void",; 1l111'tS1111'1f' \h,11 rlt!l1' ,M'll 10 .1mbt" UII". "'111 I,,,,,' ".om;tt't orim ii' "..t~Ot"Ow,tuft C".ld'ln 1 ',d;g111 0- 'ALP".LI. Bitdct" .,Il.ndfld.rId 1.11 nt lmooth "un ml" ,hu.,.".1' ""'~'yJ"11Uh,' , t, "..IQUlNey, VOiding 1nOI' IIl1n "n" q 3 . . hau.t , , DYlU"I... P,tnlul III ddlcull ""nlhol\ !... t.lALODOAOUI. Unp/ltllu",olloulodnl au OIICHAhOI. Vaf'"a1 renlle 0' li.elhl.1 . 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P^'1[NlIIEI1E P^"ENI CAli ED SIOll"DVlSII !'Anun PAfltlCtPA1101'I1U CAn( CODE U MOlllfn r IAIIIII1 fil. s U p p o n T /l!1f. 111m. , rill nil mlMlllrAflll41 o OlllER INII fl\JIISltKlSIArr PI,P^"ENI , , , , -, I"" 1 ~:~I~:.RIC NURSING DOCUMENTATION SHEET 1 ' -.- .-- 1\ g "'lTt '1lINtJIEt,NOlE ANY Clh\NmS, ell,ctE A"PIIO!'RlA" III !>r,I1lf'IIOW. 'UDIHOtUIUi ,rEO OOA9tnoSIOMY lIlVIN[ (INtfUlllk De AMoUNtI 0 ??oo , 'Aln .. roan 'OOlll: n f1[UUIA" P j'IA\",,, NUI15lll "'..UIl "nlOUt An .. "nu,llf N NUCK . p\'1JH)1, ',tOfWUlA In n"tAs1 UtlK I [Ifel lie.... Cl CII MIl '(IIIlU~ 111II1 ^I.IOOlI CALORIE CI IPN PPN fiAEAKf^SI mr ^SS'ST IIl0 IItJNr.N RlSlmr.1 fllIlUS 18uPPER rOur.l nlllns I.IIOP\IMENI SNAr.K ^M I'M liS ~ INlIR.\LrORMUl^ IlJll/l1lCI_,"..._O_,_,I' l __-=_== T R.\T' IOOT1lE IIIl'rll ~ T1fli, T FlUIDS'SIE COOlS) ~ ^I.IOOlIlED N liD IV lINlllS OR P ,r^RENlI IIICK lll~ WWl^' IUlllR "IOWlV IN WIC .UR",'mV DO'lIlClNl . "IAW'D WI WElBURP lIMISIS , AIlO'Jl! 01 '!M{lO IEID - Bii1.f.I..- _ r.OMr 1 PMI1IAI' mr IrAIILNI _~'owt~n tlUO II OIIAlt^RE Y liS C^"E o 1 SKW CARl E IOIlYCM'l II E IlAlnCAllf ~on~_ SPlCIAl OiANRCARI 0100. liDO ;0;00 K:vr\ - ----- .-.-- ----- --.- - I I I i --I -_. ._---- -- ._- - -- --' ------ ------------. .- --- ---- ---- _._--- -~-,~-- -- --- - - ---- --- --~ - -- --_._-- ---- ---- I L I M I N IlIn oroo 1100 liiio-:i300 jiOO :0700- 'lllm"ff1i, 10" coBU A . cot on O. Orr,," Y . 't'ello* 1 ~ t..., II. 1I10*n Bl . nllth wtt. Wholl ..... U.,oon R. "I'd T VOIDING .~ 1-.~ O. o."'~I" CO. CoUlln nrnund S1. 611.. LY .11Uhl 't',lIow bY. n.,~ v,.. LA.lID'" AmbIt , I...... UILJ_ _.-..lIe-=--- 0.. llarkAml1fll 1f:.. Ira en. CII''''''''r p. 1'11I~ OR. 01" '0. DIood, p".Darlllltd o I tINY nu . !l"IUI Bl . SproUl A . A"'tNll t H CA1Ull/fotl't' - COHIIIItNCY: W,W"11"')' 8.Rof! M.MlKOUI, r. Fo/mod L.loo" ,.rltty ....Multl, ! ._-- tt.II.11ltllt.lhMkln'!'1l1Ih, I IbATlli.C.tbU IStOOl .prEAAANet: c.[I,w ",UIKUUt., CD.CkkJd, Cl.CIoIlI.J;edim'flIIP.'.tcl, FL.flet". --r;:;:- 1. ''''"' MA. t(oolAod I ~AE It[lD w_kJ:1_ _OlU___ t/i Sill: 1M. 8m,.." 1.~111,,1I M.Utlfll.,j1j'" l.IA'~~ l@. I IllIii'o IlOURS -17- T liME '1'0 ~ err.r AC 001 I RIl I CIIAIR IWC - -.- - . A :,-=-~ ~ ~ ~ t;I' fJ I ....'.w/lNrAHlBIA'. ~ ~~~t.o J __ }1m &J U ! r.;:';"'~'.l^YROOM "M I Y Imllse "01 ~ ----- ..-, --- ~ -- trAIl' -,----- --- T -- Y IU'Anl/.iIUPEAY ---....- ----- ,--'- 0 I ""'IOOI\'.UPERV --. ,-,-..-, ----- ~ 18UIIN" ilSOlltt' ' ICAOIO" RIIIYOU=II'-€EJ-- ~'-"-- ('in'.,..-- -n', ---".. II ; ~~"UPI'I"ENmAorA'A1{-.. - --,- -'hn:-"~ ..1f== ~ I1mnl ! tAILIII;:8~It::1I ':- ~__ "i$-~~:: -ty--:= i AElII\AIN18IIlItMSI ,...___.," ___ ., ,'-'" ___"_n__' r. IEIIlJf\IPIII~lIot~____,_,__ _ ,,_,.._ d '" ,..,_I' ....--, -"---,-,,,----'--- -.- -- - INn &lnNAfUlIf. 11411 !,IC'lt~^'tJfU j/) ,.:=)~-iT.--:d-;JJ - - ! ~- ~tf~- ;J---- - \ ~ = _=-~=~~= =-'~~=-~~--~ '~m ' ~~\r~~," - -- -- ' : ____ ..____.._,____ l~} ~f"""~ "t!. " .~". ' _,.__ ' -/ co , I _,.~::~., .,-~~~:'_-~~_.. --- - -' -1-= I .jIf I _I i , , .- I --1-- 10 MWE 11~ll f1IHJf~ D'SPOSITION ..-- - ---.-- -- -- - liT PIITOl CHLi , '0'\ w['OOI/BROOK DRlfE I 0 1 :' ;, 11 ~ j ". A O'j/I'j/~O fll CII1HIC$lIURG. I' raRlt 11IlV,~IHlIl r lO~ClO~ 82bSb21 HHERCIlL AUlD 110 0410 '1"" PEDIA TAlC NURSING DOCUMENT ^ nON SHEET i", I I' I I , , ~ ' I , !"""\ "'""\ ,_J ~ Carlisle Hospital &CARLISLEI PA 17013,0310 NURSING AS&ESSMENT FORM ~~ , '~ 'S06" ~'ros'~I~~ovuoO. Oil ,t I ~ ,O/lll.4 ~ .-"IC Pi '~ nll'5/" IIlClIlIlt 8 . PlUE : Il "QUljll' 10QqOq .... 2bSb~ ,. ':Ii 1il<!lIIl~t iI ,l4v1'tCe 1Ii~1. D Ves 0 No .. .. . ~.1t8lI1t "-"fit, Irn&mMlon or doslrcB to IOfl1lul310 jp;' 'Advance Dlrecllve D Vos 0 No \ 1IIIUl lAtA , Dal,olAdm/llioo, lo',;):\''}' _ Dal' ot OI,Ih tl!.-/~ ~nI.d8y. D Sjlouss D ramily D DIhet SpecIfy 0 No o.m /Unbof ol tlospllalilallons IlntlJdes Ca,lIl. & Othe,sl W,lhln 12 _Ihs fllinllO AdmIsslon:.A'f'" . mAlI."~~ -()~.a'a"" PrlSrnlWl.11o. · Ilelll"I~' nesp n'le~.;),~,.[t- NonnaI WI. Pulse na~ _ OIood PIC" ....11J!.:t_ Sca~ nhylhm t,",p --3 (1- IlMIO/WrJrr rOllOlllllOI 1,",' J.rif!- ^II'~I- ~IT TlIOOI t"OTY d1m -taliL~'1 ~tnl"tom ,.d'SId"aUs d 'olllrols ~ limo JJ-'llSllrllO rcg,"ollolls 1fl1OkI"II "IIIIlohons ....OIUmUItICllt lOlllllOI o I'M groome<l D Somewhal dishml.d o UnhygenIc 0 Doos nol apply Conrnrn\s: OIU" O..vIdt I LMP 10 -i,lO' qc PedIIlrltlan Inlanl Ftedlng WAltTl CIIIjHln 1101.1 J!f Ntva Iimok!d D [x.Smoker,O.I. Slopped o Smoktl, tmbel cIgol.lltl pe' day !'ala roc _____,____ OIood type ___'''_ Ilt,P/IDlINlm )2l' Non. D Oc,aslonal ^nwllnl____ o Dally ^",'""I_,,_..__ 1Tft1ll OtUGI )3'No tJ "'s,III1O",--__,_ _____,.,., ,_ ~:l:::~~~':I~~~ ol.....II~sl. ~-=~-::.=~=~~~~__-=-~.~~ Ptoblems wllh .....lh..l. ,,,:{j(~__~::~=::.:'_':=:==~ -e....~_~.___~__~_______..._ Ptovloos medical & psy,!>>alrl' '~ntJ'II01~ ff-,.. =:-:-=-_-~=:~,-::-. Recent lwllhln 30 doysl o'no"WI) 10 Inlr.c't;;~~'I~i~~~~~'10 vo~~~~"- Specify '" _ _......,c "".q..c..,., .. ,... , rOOM NO. 0110 (1/931 MOE I lllll;III/IUlIlIIIIIII 'O"W~. "",1""1 ;Jf.-/+ MIOICllIOI lOW tulNU liME DAlE 2. 3 ~ LIISI DOSC L.lSI DDS( L.lSI DOS( L^,~' DOS( L^,~' DOS( L^,~I DOS( L.lSt DOSC L.lSI DOSE lA!n DOSE 1^,~1 DOSE 5 6 1 8 0, 10 MjJlIClIlONl ,to None D 5,nllo Pharmacy DlloII~ D O,d.id. IllUlIUI TUllIEr D Yes No HIlRI WIfH HWING liD, Ani UT HIIR.; lW D ^ noln,al v~ce A 110I"'01 v~ce o ^ Iot~ vo~. D A Iood volta tJ n"ly Iot~ nol", D 011y IotJd noises o U... ",,11~ar D Does nol hea, IIr,lIi11t1 .~ ~rn"lIhllo hO~lLlol tJ "', D No 1II10N \ W11HGLllIIl ~ -\/1 L ' WIIHOUI 6111111 ;..r5m IlCWsllLlnl e"'TU'1Jb D 5..s "w!jIlinl D 5m o~sl"lcs D 5..s o~slac~' o G.n I,U hUhll,o", tJ,lIk D Con 1," II~II loom dark tl Docs nol se. D Does 1101 see G1.",s "'ought 10 1~'flll.1 0 "'s 0 No COIMUNIUIIl .JlDI ".Q ""bally ,,0 [l1\Ihsh 0 Oll~, ~rltl"ag. o NOli "'hally, h~.ln o Onf'snolcornmlJucalo IlllrnillV ll!'Uuauo MlIlllllllUlr III'l O,lullj' ~" 0 No !lJl)-lIlhrlll a"rr,~.I.' 111111. therJ drll' . ~ "',s tJ No Ollhsolif!nl,lhull II no, hllhUlle IJ 1101(1. UavlUale ~rhaviOl edlibltcd [J I'I.te ' In..llIlIIlM'hm IJ ^lIi1al'd ' lIy",..tlivo. ^n'''''' o ""Sllll' fa,,,,lyIM 11.,,,s. IJ fk!l"pliv. ,1k.IOIhS 01110" hy r~lh'lu/5houllllg III'l .11,11 \\>s 0 I/o 0 O,p,m'd ' hi""" hopel......../ 111111. (hrr.k hiUhl!51 ktvrlnl hr.llllf!liinr.S5 fHlI\r,llIlI$r1('!iS (] Olhnr..__~___ nrSI1Utltls In IllhSOIlr.nllld, UnH!SpOI\$ivO o Vlsu;df^llllIIIllV slimllhlS 01 hehi1vlUllnlll.1I0pli.1le 81 f.1 br.liIr/P,"A fillUlllhlS n*m!if;lllll, wmr. 1I1f!Sl! JllllhlnMlS I'vldonl U CtJlIl:1tll~1I hcl(Jllllhis iUnns? rlVes UNo Mllihli",a"l- __~_~ LO_')'}~'iJ_____._ 0.""/" ... .~ It ,HtDA E Jf OSO.W · MEADOW8ROOK OR" ,,~ ~~~~~~:~ ~~~~'.ICS8URG. P'PARIE :\IlLt:DUllL1' lOuqOq '} '... 82bSb2 '1 o .. r"'\ o _J~ ~ Ibpital &CARLlsLe, PA 17013,0310 NURSING ASSESSMENT FORM IIIOE 3 SOCIAL TT"rt ~- Marilalslalus, (ljuxa' (If.' f .6f~: '\ Rcccllljoss or bleslylo cban9~7 ::"{-rr:t.~::'tiJ J- ~I SlJ.U(1IU1 , SuppDlI perspn ..L}'t~ ,lAd. <"-' Occ\ll'alion U 1I0w do YO\l IID1mally doal wilh pro~lems 7 ((eiJJLH"'L/C~fi t. ~ ;,. .E1JII..I<1It'llA;\)coAJlltIl-o 0 Yos 0 No I, , ). 'AWdMlttfU,nlOr InlormAtlon or dosllCs to 100nlulillO 1 Advance Ol,ocllvo 0 Yoo 0 No . Rebgion/coiltl/alliebels and Iheir slgnihcanco (/ ( PATlI!NT ASSI!IIMI!NT AND DISCHARGI! PLAN PHVSICAL AND MENTAL FINDINGS AT ADMISSION PATlINT CDMPLAINTI AND N,,=~:'~~~~~,~~.~,E~~~,D., i- o Par"Ihe~1 o !Jilin... o SewlI o nlll "'obItms o Altrrltions In 6ensalion _ OOthal R~I~~ """ "",..,.. ..",.,." ..... ''1.None OCollil Cl &l1Olt 01 Brralh ClOthal CardloYuculal............,........,........ o NOll. o D1esll'aln o Palp1t111on1 o Cylno~1 ~ =.'fD ljlJ.~ L ODIhar G~:t~;i~;~::~;,ne;sO&1I.Jilfit{ ~:t;j,j) ~~ 4i ""nltlng ~tlL! lah( tJ No1usca o Diallhea o ConSIiJlo1lion o OolllCulll In SwallowlIlQ o C1'ar'll'lln\l\:~hl o lanyGlouIs o D1ccding o Ollm. idt.: o'n~~;~~JIIt,;~i;~/IIChiIlO "".""...,'.'. ~ o IrC<l,mney o Po1vrla o Noch.1a OIJ~..1a o IJ1ecding o OrlbbllllQ o Orschalll" o Ollmr Ollm, ....,..,..'...... .. ....,..........' ONm.. o 1",illls o 5.",lIlvlll 10 lIOhl o IlIJII.dVi.IOIl o OrpllJl1la o lIoll&eness OOlher D~j.;.~/M;;il~;lh. ,.'".., .",." ."",., 0 None GI,WINOl1. o Mucoos M.mlllanes o Denltns III 1I00p,Ial 0 Yes o No Ju,,~~:~o~O;~;ll;~;; . . , , . ~~' .,. i:i' No 0 None II No. O",rlbe lImlt.d MOITI P.III, COl1lr.cIIJ!I, 11I.lallllily IN 011.. PlObI.ms I ! , I , i GOkU'IR.ptoducliOll ................,,,,,,,, ONune o 1It...1 Change. 'ii'1.8sl M.llslro,! l'erlod f'1 ~ '" r -DI01j1llI.ne. o 11lQ\J1lall..mia Gkln COl1,liIIOl1' (1lI1el descrlpliOl1) tiiliiiJO None t, AllIeslons (J>>1 ,o.t 1, Pres.... Ulcer 3, IInl.es 4. lacelalions 5, Rash II Gcar. 7. UIc." 8, OIher lr l1lP .noll "O,..m. IUnol AllII'AlCl I" 101 ImlD o 6/"""" o ""mIC[ '''''111011 '1t8 Meallirp llundry o 0 IlMlr.le......''II o q~ ., \to INDICAn AN' 100' MARKINGS BY SKIN CONDITION NUMIIR .. \ ~ , .' ! \- ...1",': '" l I\I-I~, ,~ ,.~ . ,_ I '" ,':" t .~,..,.. .. . t '-\ I :~~I " '.,t, :'!''-~\'''' III:.' o Awak.ns ",ql,,"lly Comments , , , o (~ '--) \, "J \ CarliSle Hospital (!21CAI1LISLE, PA 17013,0310 R Q ASSESSMENT FORM I , ! I ,3 ", pK101 E , r,' 030~\1 1.03 RllOO\lllROOl DRIY ~ ~~~~~~:~ ~ECK1"ICSBURG. P1plRKE '\ : MILT :OlllltL1 p lO~90q ... 82tlSb2 I ~,.EII"""""'t~J.lJcellll:ttll. [J Voa 0 Nu ' t 1.1fi~'trurnMtr Information Of doshcslo 101"'111;\10 Advance olroclivo [) VOl f] Nu FUNCTIONING STATUS INfORMATION lAma .. II .. I' .. PI ... liP 1[.....1--1_7' fit II hi II 1M ... .... .ltl aOWlllUICllOI WlII10ut H.ID Med1ll1icijllel'- IlrnIn Hel. - Msc:hInlcIl Ind IlInln tiel. IIBIIlIed Bv Olhsl. 0IK1"': Help r.Ollhnnnl J..::::. .J-... -- --- InUl/lhnC'nl -_._- _I',~~!!~~-- - __ - ___ __, ~~~~~.~~I!!l!~t(~!",_.- -- - -- .~~- ....J1~~~~u<9'!...--_----, ,__ -, ----- __. N"I s.u C", ___ n_ __L- 6pcttty ')'flit Oflll1ll1Y 01 Olhel ltr.gllllCII I-j;"""- 11.: - - I II Dl1l11a I'/IIhllUIllelp Msc:hInlcIllIeIP lWv IUnln tlelp B1Iv Med1lnlc1l Ind jlJna. ~.- IIlhued 8. Olller. II Not Dr.md DeKl"': HaIp tM Ii .. at PI .. ... 'lei IIADDII fUIClIOI ,. " .. I' aM ... .... ,leI -1--- 1,Ii _-- -1-- -- ~' I emlhur.1l1 Itltonlinent I'" 11". (Jo,,'ill\!,k MOI.lh.. Oocl/ll\!.k N'Ulil (Jotly U.y .,Ill H'yhl 1l'lo.~S'" C.'. Hol S.II Call --- [.1 Oe,lr"S.U Car. _ _ _ ___ HIIIS,U C'" _ _ _ ,__ r.Alhelfl!.S8IL~~~!_~__ ~ ____ _..._ _ _.~_~l GnU r.A~~._ __ __, _.___ 611fltllV fweOr.lolllV. _.!!J~'!!.ocv!:~ r."II~~~~~___., _~_,____...,._ "___ II~- -,---- !l1lll/flIDl" tit ., .. I' III .. ..., .nl ". II l=- 7' WItI10IJIHelD Msc:hINtilllelp 0r1Iy IlInlnlielD B1Iv MlthINtiI Ind jUl1l~ 11.,. Spoooftd tWi IK IF, rfd 0IK11b1: jielp ~UII DlIII IL 1--- Uladder "Ail ling (J(hedule tDlun I!UIIUI /;//;//;!j ~W,II",!,I~'~I _"...._.. _~f!~~~~I_~~~t~ !)I!ly ._ _~__-' .., .__ ~___ .._! ~~'.I~!! !j!III_!~.~'1__ ..,_M<or~~"'~" .,,,llko,,,,, ""1' till fil -..- it'~ I 1 lfI ,. .... Ji~ ___ I.r. l~tl2l!'!_'I'!I! ..It ~!~Ii!'I~ ._ -- /_~IHIII,I"!.',,,",r'I, J:.:... ___ UN,wllt! ,0-- __ ._... 11",1' '" l--~ I'/IIhllUIH.lp Msc:hInlcIltlelp ~i 1IInllllielp 0r1Iy t.\IdTInICIj Ind IlInan lielp , ""'" Hot UII lellel noom , bIlCI"': , ..'" ,-., !' " 111/ II,III~III II ,,/1J I:;jll (N~Jt'R:~(,r < -- __ .. ,,' " ILL J ' ve.kj'f(~ """,..,' 1.".., "" ,n_ Dt'\'~'"III" 'DlI"I!II( ,1)~ IJMII'H/V.~ ~ t'(J/J. __ '{4 Mu lJ'Vc<(! " " , ,.l.c ~- __d II 1'" , ,,_. .II "'"" Willi W,lhoolll.1D M"h'OI'IIIIoI' ~, '''n.n ''''10 ()o,lY Moth'"lt.1 ,nd I"n.~ llel. U... Hol Willk Ot'C1IIJe / IIolp WHIIlI W,!h.ulll,11I Moth.ni"III"n Onlv IktlnallIIclI Only Mrc,hlmir:al and IklfT1an linIn I' W1w,led D' Oil.." 0"85 Hol W1..cIWil~. UCSCIIOO: 1I.lp AdaplallOn ! CUIlllllnl W,II.~III,ln M.t1II.ital 1101" Otl, ~j""n011Y M"hll,,,IIOO ,,"'.. llel. 0.., Hili C111l1b 61.,,, O,wlbl IIclp MOllllllllfll MOE. ,. II .. at 1M .. .. ... L,.,~ I III " ..' " .. .. ... .... -- --- - - I, I ' I .. " .. .. .. .. ... .... - l ", / .. " a., ., .......... 00" Oullld. W,'houljl,lp 0..1 (lul,I". W,lh 1I.ln Clluh..." 10 Ibl"" Co"I,...d I. B.d I.d C1l1lr COlli,..." 10 n'd/t",," 6.11 CIIl1I..." 10 B."illll'lllblle L ~p IIII -lit}UiHl'AiTij- ~~"11:rr-- -Ui'P--- 1101I'IC' ntll.lAf1irt~,'I(:rii" 01 t"'O;:^1 IfI(CWJ&f -..--.-------.-.....--." ".. I' -ii- '.,'h' ... ... ..., .,n: __ __ _ _~ FINDINO. tllldlnlill'ndka't . "..d fOllulthtl ......m.nl: ~ .flull~ b.lt, Uth rerun'U.pl ... Ad....td emf '''hld TiWiHiJUnt:iiilil:; lNIl:n0811I{11 UifAlIV I 0""" ..~(;.~~~ r:.;~1t l'l~rt l,,\iJj ~~~'" -1;'Aiitii~t:Tiiii~ -pi }11l1tl;1 ~J.,l. ~ w . I.! .. ..""""'""-. - III c'" ' , III .. a .. i ... r:r t .. 0 l"~ a . a- IlIIl1 01 III :r .., III:. 0 ~. ~ ~' UlA k "1:1'" r o..v ~ ...101- ... a i{ ..... .. ... ,.. ~ ~ I\~ ,.,... co I\:) r..... .au ... i .. ...N.......... ~ 'j" ~ Z ."'....I'\J ... ...... .J ~ - ... ~ ~ ;. ..0...0 - ~ I...... < r., "'Lf' u ~I~f- "a '" ~~'" :IIN'" ...0 ... "N-...ru '" 12 \ ~ ~ ~ CO"... ., ~ I~ .. ~ "'0 0 ~ a_ u ~ 1 ;. -t '~ ~ " J) ~ . ~ I::: ~ 4- I 'f 1 i I \VI ,~~~~ ~ ~ ,~ ~ II \ ~ .~ I~ i ~ ~ I"", j i .;; ~ I~ ~ ' Ie:! '" .~ ~ , , , . !I ~ N ~ .~,;. .. ~ ~l"~ ~ ~a z ,. Cl I. I . iii ~ .; il ~ ~ I~ I!! g I ~ r-~ I ~ ~ !I ~' I.... ~ ~ ... ,I.~~" ~, ; I - :j - -,-- --- i~ :1 ~@ ~.. !'J ~>( \'! . ~ ~'f ~ ~ tJ "" ~ ~ ~ ll-..:.;~--:r ~ r~ ~ .~ ~~ ~.~~ I! ~ ,,. ~ ' I . ,~ ~ .i ~ '~ o~ ------- ~& ~ ~ ,\ "" ~ J~ " ~t ~ t, tt a~~~ ~. 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'1\10P1^0 O.JO UU1UI\MOJ lUo1lHlII 941 tlll'\^TO^Ul ^1l01Ll111Ud 01111011 UOS au puu 'oUln I1TII'\ 19 '\U9lUUl'lTT'l OlUl019nu \\1 9,tll Bo.m10lhtll 'T a^al 98 al(1 IIf/no011{':\ ron al{'" IUO.1) ,:\]OT all'\ uo l3uo1':\IlPloT,:\.1\l .JOT,l!)'\"").! 31\1 JO E'6.1O,\0I1,IJ pO,\l1nl'IIIDO:'l ol'~l'nnll : tlOI:1mmal1l 'Ual al11 uo UOlllO.IOJ J\019~.J1l TIMqe,:\.JIM oln !JUThlL'^''l SIiITllI 1ont:' l3ao1n~o\i.Jif 1I0llIU TO.I911lT no pue '1UllIUUWnU rllWO~IlUIJ a^T':IIlTo.J ul UTUWG.x ll,:\uawSDo1J a.%n~OU.Irl ',:\uapT^O nOTIl Bl {ohOT 9-90 04':\ 111 .xlll{Td o1GTn~I~019 041 JO eJn101101J V 'YO ~9 ,:\uoPl^e nOTIl IlT 9ToTpad ,:\'01 0"" JO o.In',loll.J;! V 'uo1':\urnoT1011l y-1'D pUll {Oh91 1'0 a1n ':19 .JUHTd .JIlTnoT';\019 !lifeT 9l{':I JO o9.Jn10Uo1! po~nUTIUlUOO pUll · TOhOT CO 04':1 ~9 a.In1ou.%J OTOTP9d papTB-1JoT 11 911l.%!lOUowop ooP9wT MopUTM BUOa ',:\UOIU11090.xOUO T9.1nOU Gonpo.Jd 0,:\ 11lUIl0 TIlUTdll .JO IlllpUU.JOJ tl1.Inau !l111 lllJT^TOAIIT ^f/oT0419d Bngsl':\ 1)oa )0 BO\loPThEl ou 9T 0.191\1 ':Inq · OUlaro ,to UOlEH\1UOO OIDt'B ll':\ TM ,:\UB':IlllSUOQ '1iraT 011':\ \10 UOTl'lO.J '(IiOl^.xoo PlW Oll!l .10 109dou Tu.xa~IlT001a':\1l0d 01\':\ III oOllallTIUOo1d onl/BT':\ 'HaS '41\:gno O'lUo1!1SUPluap OlolopUllol onllsl':\ ':IJOS "U9T 0111 110 {9hOT 90 I1P"00141 roo 0111 WO.1J B1UElID9TO .JOT.Ia':lBOd a4':\ \IT Bll.xn109o!J po,:\oadlinll ';0 uOT11l11{llhB .lOX P01Ba"t:,O.I BUM Jipn';\s BII.t 'ofjllT110B ~\(JpIIVI enl1ST1 ':1)09 pun 1oI0plllM alloq lnoq ,:\0 PBlldU.xS0101\d o,IOM BatluWI . MOl h9.J .JO;! pOPT ^O,ld 0.10101 alloT ':I 01\.1 ':\ suooao1 TU':\11f/IlS 91\blTC\0 pUll T1l11T~1l9 .t8 .10 10adsu 1GOW.I9ddn 01{'1 lIf1no.1l\':I Jipoq pl.JqO':l.JOh ZO .10MOT '011'\ WO.I) 'gW1\':IT010l!lTU BnBBT1 ~JOIl pUll Guoq 4,:\oq 1I1l~\ \1001'1""0.1 9.HlM aoBOlDT TI1T)('O UO\,:\OOIl uT4J, llNrdll 'IV'H^lmO ml.l, 110 IlVml ,ToO .T.fIVlI.T.tIOO-HOH '. 01\ (, (fW Il0(11101,ll'l1'l~ tlIW'H) '1\11 0\19111 { 1'l1/i:~(,lOT Vd · OHI1I188IHVHOBH '1111 }\OOUflMOrrVllH 80?lJ ( \1T) VIHHd '1.N ".j'r1 . fJI1,f,V 1 ;~II'J~l\W fJIIlfWIH :'1'1:'1 f'lIlVi) ., A0010l0VH :to 1 JW1HVd30 r' , DEPART~ lNT OF RADIOLOGY ;& ~"~ Co"". "",."Iwm. 17013~310' ,.000.346.,,,. '11171 ".."" llY, PIlYfJA 115040 PAGE 2 - COll'r'D the '1'10 vertebral body ill oons.l.etent w.l.th t.he eUShtly depressed SU1'81'iol' al'tio\l18r surfaos, but the axial naturs of 01' doell not ",o:Il'mit Iloourats ohsraoterization or the 'r11 or 'j'9 ohonsss. Ilrootursll of T9 and T11, if present, are stabl e in, 'leB': t.h no n6111'0108io implicl1t.l.o'llJ b~. c'r arp~t\:'I,noe. A allgh I 1,'pt'e""I.ion of the anterior aepeot of the superior artioular surface of T1D 1s likewise a stable injury with no evidenoe of Ilseociated neurologio or eoft tiesue oomplioations, ~J. Cuthbertson, H.D, flJC/oo T-1D/22/94 13:23 ,..) v RADIOLOGY FILE ORTHOPEDIC SURGERY OF CIlRLISLE, L TO, 816 BELVEDERE STREET CIlRLISlE, Pll 17013 7l71C4HII2 F!d!r.1 10 1 2S-I5.?0628 1It1l11d Sutmnl 03/31/91 - \1h/~1/15 P.gll I Icl ElcOlP Prlnl!dl 01/06/15 4120 PH p.lunl GUlrlhlor --------------.------------------------------------------- ---.-----.------------.-.--------------------------...__e. NY, MOIl PallOI 5203 MEADOWBROOK DRIVE MECHlV/ICSBURG, Pll 17~SS 1/11761-8925 000110\1-0001 nl BP GREEVY, ROBERT AccIIO. 051580PN S&N I ---------------------------------------------------------- --.-.----------------------------------------------------- Ihluranc. Co.pany Policy' GrODp . Olh!l' Info Hold!r Efhcllv. 011.111 ----------------- I I AUTO 387011112 b TArE FARIl~n OWENS -------------------------------------------------------------------------------------------------------------------------------.---- POllIng O.1e Pali!nt Nm Cod. Oucl'lpllon at ,/SI'c Cha.'g!d Open Provid.r PI.c! Cal.1 -------------_.~~---_.._-~~-----~-~~----------------------~-------~----------_.-._-----------~~.~~---------.--------------.--------- 104~~ NY, PHYDA ml0 IREAI SPINE FRACTURE 1,\\0 5.0,00 0.00 HEL Y CHI I OugP. 80500 FRACTURE, CERVICAL SPINE OiagSI 805, FRACTURE, OORsnL VERTEBRA IIml94 AUPT AUTO INSURANCE ~'AVIlENT Inlur -W.53 IIml94 AUTDA AUIO INSURilN1:E ADJUSTMENT Inlur -.:18. H Cu. . 1 1 INJURY SPINE Accll I 0001700-0001 Occurr.nc.. 18/22/1~ Ad.llllon I 10/,,/94 Tolal Ollabillly I Thru InJurylPr.ghlncYI I Conlult!d 1 18/22/9\ Dllchargldl 10/<4/9\ Parllal Dlublllty. Thru E.ploy. Rrlahd. N Curr.nt Balanc!1 Tolall Fro. 03/31/91 Thru 06/09/9S -----------~~--- --~-~~-~~~--_.._---~~----------~.- Account Balanc. 0.00 Chargll I S60.00 OP'h Balanc. 0.00 ~!rlohal Pay..ntl I 0.00 P.rlonal Bal.nc. . 0.00 Inlu.'anc. PaYllnh I -3l1.53 Inluranc. Balanc. 1 0,00 Total P.ymh I -JlI,53 BDdg!1 Balanc. I 0,00 Adjullltnll I -.!18.41 Coll!cllon Bllanc.. 0.00 Colli Paymll I 0.00 Coli, Adjullmh . 8,00 ~ \..,' I OffICE REOJRDS ( PAG \ PArIa'! NAME I h, M~":'" L'-:S:"C\ n\ C:;c V'\ v.r'j~\ VAll: or Phyda is having very little pain. She is continuing with tile Mliladalphia collar. There is flexion and extension of the spine out of the collar without difficulty. She has no tenderness on palpation posteriorly. Planl gentle motion exercises out of the collar on a daily basis. CDntinue with the collar for everything but bathing. FU 4'wks. re-exam and xray AP and lateral . cervical spine. ' Phyda's lumbar spine fracture is somewhat painfuL She has flexion and extension of the spine with some degree of pain. No lateralizing signs in the lower extremities. . Xray lunbar spine lateral view on return visit. DI'H/tls 11'\( 6~ '"'~V 'I" S" S'c-c v ....\;.,0' 'I ~r- c'~~ COt"' r t->\ \ '.....Ii;! Pk ,\~CA' 5 O~\'*- (CI" \\-')~-qq. S\--.e ",)\OL<ci L~~ ,^,,(,G,Ii'f'II", c\\c\ I"tl\::: .~\C\h l.O'/c."<,("V-("cl~.\C! 0-1' O~()\:... o~ l.~\) L'r('.e. \. s.;\O.....\\c~t{A.\, (('("po.., - , . . ,...) ~, lir. MEDICAL SOLU'I'~S, INC, A YELLIN MEDICAL COMb ~~y P.O. BOX 2824 WARMINSTER, PA 18974 (215) 440-7701 INVOICE II~ CLAIM II 38-7071-112 pOLICY II INSURED I Greevy, Robert A, ACC, DATE I 10/21/94 FIRM LD. III 23-2517799 Marc E. Batt Esq 1101 Market St,; Suite 2710 Philadelphia, PA 19107 ..... PATIENT, ..... Phyda Ny 5203 Meadowbrook Drive Mechanicsburg, PA 17055 DATE OF SERVICE 032395 'HICFA' · CODES' DES C RIP T ION UNITS AMOUNT E0720-901 TENS MULTI LEAD lARGER 1'\REA/MULTI PLE NERVE STIMULI\TIOli 1 4 BO. 00 CCI State Farm ADJ: narbiero, Jennifer lIS Lim~kiln Rd, P.O. Bolt 257 TOTALS THIS PACJEI 4BO.00 .. pROVIDER CODEI 054; ZONE: 02 .. .. ALL INFORMATION AND CODES REQUIRED . l OF PROVIDIl:ItS UY l'ENNA INSlJRANCE LAW H IS CONTAINED HEREON, (71777 .... DX: 71B,86 844,9 .... Rx ATTAQ1ED - COpy ON FILE .... .... SIGNATURE ON FILE .... a......................................................D.a.....a................ GRAND TOTALS Charges I 480,00 DUE --_.~ 480.00 Paymentlll aa...........==..........AA........aaa.......................................... .. VJWMr:;mB MJ\DJ!) IN COMPLIANCE WITH 11m PSNNSyr.,vANXA** .. INSUlUINCE AO'r WILL .ntl ACCEP'rED J\B, IWiM!l:N'l' IN FULt. H """""""""'*"""',...""""""""""'". "'H' INVOICES lidr PAIDWl'1'1UN 30 DAYS WILLbR CJIARaIllow.... HUH ONE VERCENT (1\') MONntLY FINANCE l:1tAnaE, ...... #88041995 - _ _ "^lUGlUNIT l ,^U. VI"".' I 1 tANl, CRUltH, WALkER 1 t ,"', 110OO 1 P~OVIDE~I GLOBAL MEDICAL SOLUTIONS, INC. P.O, !lOX 2824 WARHINST!R. fA 18974 Hember. !loard of'Orthotic CertificatIon MSI0NMllHl' or IN5URANallIIlNIlI'rIS I h....., act_odr ....,... 0( ...dldl .q'lp...., IrwJ/o, onhopodl' ......lIfttt(I) .. d"'nihd 01'1 .ht .1I"".d IIM:lite Ind I '..nher IcbowWp 1h.t lam Ind,bted 10 Ih. pnMdtr Mmed lIteM tor ,he .Ift, h.m(.) dutribld. I htnb)' IUlhori" m, 'Uom" Ind/or fnluratK't nnicr 10 ....h dl""l "",...." '0 ,Ilt provl4cr ....'" ._, I 0'10<1 my ."omty .../0. ......"nw tlmUlo pi)' 1M pnMdrr ".med nt'lt rl'OfD .ny rund. "wl"d la MIUCm'"1 01 my chiN. I ,",denl.net thllll no .llIlamt., 'Wlrd is 'on""""'.II. my...., I hi.. . I.pl oI>UIII'" 10 ""y .b, p,..;o" nlm'" 'h. '"n fr.\lDfre Im'"tar 0%'1 demand. I h,"by '''Ihoriu Ihl pl1Mdtr n.m." .bnYI: 10 "Icue 10 mlluQrnt)' IItd/or lnull1nrt nrri" III mcdltal "'*"', rrrllfipdoM ..4 Wormlllon np,IIIII", In, medicI' lrulrnenl. I ,110 "'11 1"" . piloluopy oIlhh .ONmc.',h.Ubt II ..lid II 'h. .rial..!. , 33. ))'F/P ,'\' . . :" . ..'J'~', " ',..... "'D"{ '. '.,~~T"W " '''''''~:'.,,:' .1 ,.' '. (I\~~" -: ' :' '. I ~~ml~r,. . (11".'''''. f.l.'~'W.a.mm.m (11.(....,., .,..w,\.IHIIIH,,~1llIII ItllldMB'D I PHI.IoIlI!lJ'HIA.''','''. uo.. MI.. lI,J;cP~ cu..' ,,~IJ,I"'1WD IWII f'1ji/;' .m.~YoU CaL~r;'7f7 =.;;;.;;;.~_.=-:R{~.. ",r4c- :s -FI:....t;.., ~ 1~~0>. . I TIMES REfILL o \AIEL aueamvnON ,EIlMIIIIJLE 1 IrEAPflI8lO T1lE 1!!.9Jl.P.1!R FOR.h!'Wle.~U~~Q.~Et. We iiW" oh ' J;B~ltfrDlMcAliv'ii"~ Irnl If ' ~ I'l'IIICnOl o ! '"6, INC, A YELLIN MEDICAL COMPluff P,O. BOX 2824 WARMINSTER, PA 18974 (215) 440-7701 INVOICE II, CLJ\IM II : POLICY II : INSURED : Ny, Phyda ACC, DATE: 10/21/94 FIRM I. 0, II: 23 -2517799 Marc E, Batt, Esq 1234 Market Street Suite 2060 Philadelphia, PA 19107-3720 ..... PATIENT: ..... Phyda Ny 5203 Meadowbrook Drive Mechanicsburg I PA 17055 DATE OF SERVICE 120694 'HICFA' · CODES' DESCRIPTION UNITS AMOUNT E0215-P : ELECTRIC HEAT PAD, MOIST 100.00 1 120694 E0245 I DELUXE MOLDED SHOWER STOOL WITH ADJ. NON-SKID LEOS 100.00 1 CCI Marc E. Batt Esq 1234 Market Street Suite 2060 Philadelphia, PA 19107-3720 TOTALS THIS PAGEl 200.00 .. PROVIDER CODE: 054/ ZONE: 02 .. .. ALL INFORMATION AND CODES REQUIRED .. OF PROVIDERS BY ~ENNA INSURANCE LAW .. IS CONTAINED HEREON, .... DX: .... Rx ATTAO~ED - COPY ON FILE .... .... SIGNATURE ON FILE .... cc==aa================ccc=ccc====c=cu==============ccc==========c=~c====a=~D==== GRAND TOTALS Charges: 200,00 Payments: DUE ----> 200,00 C=..CDD==aca=c=c=a========c=aa====aaac=cc=====aaaaaaDacac.ce...=c......a...e.... .. PAYMENTS MADE IN COMPLIANCE WITH THE PENNSYLVANIA .. .. INSURANCE A{,."J,' I'lILL BE: ACCEI?TED 1\$ PAYMENT IN FULL .. 1\ ........ ..H.... 1\...... 1\.......1\...... 1\....... 1\'" .... ....*' INVoICES NOT PAID WInfIN 30 DAYS WILT. BE CHAnOED ...... ...... ONE PERCENT (n) MONTIiL'i FINANCE OIAROE. ...... 1188122194 ........"...........- ._._....._--~....., ...,...-....--...-...-.....- ---.-- ~J' -"- m..onAI, MEDICJ\TJ SOT,lP""9NS, me, 1\ ~c.l.d.J.l1'I I'Ic.U.lU\L LV" ,U~l P.O. BOX 2824 WARM INSTER I PA 18974 (215) 440-7701 "ADDRESS CORREcrION REQUESTED" Feb 24, 1995 RE r Phyda Ny ,-. :;'~UJ j'lt:uUUWUI.UOK UI.'I.VI:l Mechanicsburg, PA 17055 14333 DATE OF ACCIDENTr 10/21/94 Marc E. Batt. Esq 1101 Market St.; Suite 2710 Philadelphia, PA 19107 CHARGES TO DATE I PAYMENTS TO DATE I CURRENT BALl\NCE : 200.00 .00 200,00 Dear Attorney Battl @tFNUMa 629-5940 OUr patient, named above, states that you are their legal representative. Please provide us wlth insurance infonnation so that we may seek payment from the carrier. In the interim, per your client's request, please provide us with a letter of protectlon. Sincerely, JUSTIN SCHMIDT PRE-A11I'HORIZ1\TION DEM', .......................................................................... 6k Ie. Farm In6. (1. I //5' Llmf'!./dff1J 'RoI, pfJ R::;)( ~5"1 NeuJ (ljm~/on-/, PA 17{)'10.0';;5'7 NlG, -kr}f7";;'r 81,.h,'af) (111) 71,/- CJ01Q ,gfl. 707/-1/;J. 'ADJUSTER PHONE 1/ CLAIM 1/ POLlC'{ 1/ SUBSCRIBER I -I;O&-rt ;J, (l,.u V-J YOUR NAME I Iv/ar;kl / N!a,.c! Eo t1./I. I .......................................................................... AGREEMENT OF PROTEC'l'ION I I represent the above named client and agree to protect your interest out of any settlement received. INSURER ADDRESS I CHECK HERE IF YOU I~OULD LIKE COPIES - OF ALL BILLS SENT '1'0 YOUR OFFICE, Marc E. Batt, Esq .. FOR YOUR STAFF'S CONVENIENCE, YOU MAY FAX UR THIS INFORMATION ATI ........... (215) 440-7702 ,/ .-, 1""1 ERNEST H. COL.EMAN, JR,. M,P. .000 MA"~IT e"nET CAM~ NILL, ~INNIYLVANIA \1011 om Ii/) /?S'" PATIENT fJ Add 71)1 RI'"ActIOH to. to.......,......... EXAMINATION"".""".""""" Y'o TREATMENT,,,,,,,,,,,,,,..,,,... .. BUROERT "".."",,,,,,......'..' CoNT^CT L.EN' TOT^L. ....,.... 1/0- NEXT M~T. The A.Z.RITZM:" ~ Associates, Inc.~ " t I I, \1..111'1111\1111'1,'.11.\111 \1 II \l110",\I 1:1, Ill, I'! I ,\ . IiI II \ I" I' " bOPHl' GliEEVY :j;W::\ NEIlIIDIJlcI\DlJI( 1II,r VE . . ,) Z 1<1IZI'1MI MlhlJl INI. I~l::hl I1ECHI',N lCSlclJr,n P,) Ji'o:',t'i PHYIIA NY .~~/1 ~?r __.j~~~I,i~Q~~i.~.~~~)I? _ _.~~. 4::.! .o( 0[TACll10r rOntloN ANII 11[IUIltI Willi \tHIIlIIl Mil I MH,l 71020 ~HEBT.2 VIE:l~B '1100~r RT AIDS MIN HlI'IIIISI'OIlIKIt 1(111 Uj({lJ,lt lAl l'IIIWOf,{5 " Hlllllrf4I~I!llll (,1l1rlllf,vlltIH IlIntl'l 14;'!.00 . ~ rH.~'f".1 ""'IIIIIIIIII 111'11 ,U.lll\111I 1A'''lIlJllLlI 1\ .. O~/20/05 10i51 ~OOl/002 'O'H2 T"TO JEt\1l ISI:, The A.Z. RlTZl\iAN Associates, me DlACiNosnc "^DIOLO('o\' lILTIlAY.lLltlD ~1\fAS' IM^"~N(i 11l,)4,\l1l'1l,ll.tlINrJ.t"t..tJ,u IIMtUI..)& MM'''' "lJ \\'II.I.I^"t~ ~11111\".III,"1 't fll,";lI;1 \0 "111\1~tK "',U 11~'lll"\' r r,.MItH LM tl ..".v.u). 1\1.l.'4NhTU HI' t.:1'l1'UN,It.\If:\r.1 "'II 111.\I\lhl\^""II'11.t.'l' Il'I"":\"..ull't_....*l\IIMt' ~ ROS$MOYNlOfF1CE J!l "JO~_ 1oC,,,,,,,,,*,,,,,, PI< 170~~ ('I\71m,~ 111:-'''' '1iIV~I).t.lU Illl\r^IlDl 11,..k,IM.,l"ttl 111~'t.\III.t'l(tl't~1I \111 to)t. ,'-'); ) t,,\ \l.11,~, ~I [I 101';11,1111'" \1\.\\'^II\,"11I 'I"'~"\' I ;'^~lfl'.f1A~.11 \1 It 1',11,.. "".1,.1 I. N'l( Ill"., III , ,., ~I ~1'''.IM\'llJ II (,I~IU"; .., I, M."{I\r...I....I''''lC.'...,''rl r",'.:'! '\ 1IlII'fUtr'''''.,U!) EAST $1101\1 omCE '.01 N, f..... SImI 1Wr\tWv, PI< 1l\0~ (1IllnS-6n1 wtST SHOII.t Ornel !SOB Tl1NIl' n...d CoIn. lilli, PI< 170\1 17171761,7470 . ~. ~~'~- ~ "'~If"__. .__._~_W.._. _....._......~----. W1680+ November 29, 1994 Natawadeo Stelnhouso, M.D. 2738 W. Lehigh Avunue PhIladelphio, PA 19132 HE: Pbydu Ny M999 20 4564 DcOJ' Of. Stelnhouse: CltEST (2V): 'rhe cardlovDllcular structures arc nonno.l. The lunga are clolU', Thero 18 no pneumothorax. There Is a mUd low thoracic kyphotic curve, but I do not 80e compression deformities of the thoracic vertobra. CONCLUSION: Normal choet. RIGHT RIDS (3V): Twelve rib Bela arc present. No rib fract\.!l'eB or other acute or focl11 rib abnormalltlo8 have been demollJltrntod. CONCLUSION: Normal right ribs. TblUlk )'ou for referring thlll patient to us. 6Incerel)'. ~ Ihnl..k, !\I,o. aSD/mth f ,; 'I' , ~ ,-, /iXHInl'l' "011 r;a'] S-ATE FARM MUTUAL AUTC~" BILE IN, SURANCE COMPANY !""', ......" CON C OR D V I ~ !JL~~~ ,'9})9-.QQ.0.1_ .,___, POLICY NUMOtR - "1',1" " \ .01.\'.,..,.... RENEWAL N TlCE 614 2541-B14-38E FULL PAYMENT BY DATE THIS POLICY IN FORCE AUG 14 94 DUE CONTINUES UNTIL FEB 14 95. $375.10 VEH A COVER^O[,lIMIIS , 1977 CHEVROLET $375.10 LIABILITY: BOOILY INJURY 100.000/300.000 PROPERTY OAMAGE 50.000 263.25 FUNERAL BENEFITS 1 500 1.95 MEDICAL PAYMENT 5.600 45.50 COMPREHENSIVE 24.70 EMERGENCY ROAD SERVICE 2,00 UNINSURED MOTORIST BODILY INJURY 100.0001300.000 UNDER INSURED MOTORIST BODILY INJURY 100.000/300.000 8.80 GREEVY. ROBERT A 5203 MEADOWBROOK MECHANICSBURG PA A-3754-12 DRIVE 17055-6833 F C2 D H U W 1...111...111..111.1..1.1..11..1..1.111111.11.11.....11.1.1..1 28.90 PLEASE PAY THIS AMOUNT. $375,10 Your premIUm IS tMJL'd on 'he (0/4,..,,"9 . . . 1/ not comx', cont,]" your "!letl'. fflfl ell" Cu,., QI .'hoc.. fl your houll"'*J 1 9F304 PRINCIPAL DRIVER IS UNMARRIED UNDER AGE 21. 11ft Ofdl'lary UI, 01 .the.. 1 PERSONAL OR BUSINESS. DRIVEN OVER 7.500 MILES ANNUALLY, (NATIONAL AVERAGE IS 10.000 MILES ANNUALLY.) DISCOUNTS--THE PREMIUM AMOUNT HAS ALR\ADY BEEN REDUCED BY THE FOLLOW NG: (1) MULTlCAR 5 5.48 ( ) ACCIDENT FREE 553.95 THE LAWS OF THE COMMONWEALTH OF PENNSYLVANIA. AS ENACTED BY THE GENERAL ASSEMBLY. ON, LY REQUIRE THAT YOU PURCHASE LIABILITY AND FIRST-PARTY MEDICAL BENEFIT COVERAGES. ANY ADDITIONAL COVERAGES OR COVERAGES IN EXCESS OF THE LIMITS REQUIRED BY LAW ARE PROVIDED ONLY AT YOUR REQUEST AS ENHANCEMENTS TO BASIC COVERAGE, THE PREMIUM FOR BASIC LIABILITY COVERAGE OF 5 15.000/30.000/5.000 AND MEDICAL PAYMENTS COVERAGE OF $ 5.000 IS $ 229.45. THIS POLICY PROVIDES FULL TORT OPTION. 'N~;~I!\I,J... .'.,"', :;~;r:.:r. ,.,~( '~"L'"(,''''~''' .~t(: ,.,1.... :"~r::: ."!'..;:; ':(:;;"i..!~ .:r', .r'SLr&r HiJs:ln J~Chcntjon cr c!c'lIm . . ..,- r'" "'" ,,' ',"-, ,', ,'r ~" ,. """,' -' ',,- "'"r I"' I' ",'," ''','' '," cr :0 -, tl~C! tC~"f1ocnrrent 'er l;p 'C ;~.',;~ ','?'~"'~!"::""~"':.~;'.I'~'.~~;' ~~ l~i ~r.~. ~'; .~~":'.~' S": ':~:( ~'" ,1,..1,...... .'. '4 .. 11.. ," . !l... .. j. I 7k"~ ~ '" I.ItH r'" ~Bnr BOB MAY IIBOhone 717-731-8112 See reverse .ide for Impoltant Information. Please keep thiS palt for your record, 'd&' STATE FARM MUTUAL AUTC JBILE INSURANCE COMPANY ,-., ........ CONCORDVILLE PA"""339-0001 RENEWAL NOTICE ;I,r: ; \ ~ ;. ;':1: ;\, . . .'1: t, 'I ~ COVER^GE!LIMITS VEH 1 1989 HONDA 5292.66 A LIABILITY: BODILY INJURY 100.000/300.000 PROPERTY DAMAGE 50.000 102.72 ~2 ~~~~~~t ~~~~~~~S5~6~80 17:~~ o 50 OED COMPREHENSIVE 30.72 G 250 DEDUCT COLLISION 88,80 H EMERGENCY ROAD SERVICE 2,00 R1 CAR RENTAL/TRAVEL EXP 10.00 U UNINSURED MOTORIST BODILY INJURY 100.000/300.000 8,80 W UNDER INSURED MOTORIST BODILY INJURY 100.000/300.000 28.90 Y2 DEATH INDEMNITY 2,00 654 2603-B25-38E FULL PAYMENT BY DATE THIS POLICY IN FORCE AUG 25 94 --,- .-.-' ~_.'-'-'-_._- DUE CONTINUES UNTIL FEB 25 95. _0..- 5292.66 A-3754-12 GREEVY. SOPHY 5203 MEADOWBROOK DR MECHANICSBURG PA 17055-6833 1",111",111""1,1"',1"111,1"1,,,11,,,11,11,,,,,11,1,1,,1 PLEASE PAY THIS AMOUNT. 5292.66 Your premIum is based on Ih. 10110.."'11 ' . , /I nol """.el, eonlJel your agenl, v.n ClUJ Orr... of .,heft n your hou,thc*j 1 3E903 PRINCIPAL DRIVER IS AGE 25 OR OLDER, THERE IS AN UNMARRIED DRIVER UNDER AGE 25 ATTENDING SCHOOL OVER 150 MILES FROM HOME, YOUNGER DRIVERS INCLUDED IF RATED ON ANOTHER CAR INSURED WITH US, Ofdf\aly us.of.,hell 1 PERSONAL OR BUSINESS, DRIVEN OVER 7.500 MILES ANNUALLY. (NATIONAL AVERAGE IS 10.000 MILES ANNUALLY.) D,ISCOUNTS--THE PREMIUM AMOUNT HAS ALRE~DY BEEN REDUCED BY THE FOLLOWI Gl (1) MULTlCAR 53 .12 (1) ACC IDENT FREE 523.28 THE LAWS OF THE COMMONWEALTH OF PENNSYLVANIA. AS ENACTED BY THE GENERAL ASSEMBLY. ONLY REQUIRE THAT YOU PURCHASE LIABILITY AND FIRST-PARTY MEDICAL BENEFIT COXERAGES. ANY ADDITIONAL COVERAGES OR COXERAGES IN EXCESS OF THE LIMITS REQUIRED BY L WARE PROVIDED ONLY AT YOUR REQUEST S ENHANCEMENTS TO BASIC COVERAGE TH~ PREMIUM FOR BASIC LIABILITY COVERAGE OF $ 15.000/30.000/5.000 AND MEDICAL PAYMENTS COVERAG~ OF 5 5.000 IS $ 89.76. THIS POLICY PROVIDES FULL TORT OPTION. ',II.~A,'l;~jtJ . . .~.,-j :.~(~,:r .',"',': 1;'I;"'ITSl'j .:rC ,',I';' rt_~r~t ~-: rn.;ra ..:r cefrJL.(~ ]r~ :rSL.rer f:lr.s an a~~licatlcn cr cli3lrn ;::r'.'.:',r,; "1",/ :J;;;.) r':(I~'CI,::~;r rl$I.;.JCW'J ,r::r:-,:,::r:n 31'<111. ...r;r:r ~cr'l'ct:cn, :P. SL:t:!tlct te I~r;nscr.ment lor up to }r)',:. , :,,~r:i .t"t.: :a:,~'~r:;r,t .:i :l ITt: .:1 !,.': ~;,:- 5 ~ 5 :1:( 7k"~&~"""Nr'" gent 80B MAY elephone 717-731-8112 See 'everse Slae lor Jmpot1anl mlOrmalJOn Plens. ~eep Ihls pnnlor your record Rf,:NEWAl NOTICE ' ~ STATE FARM MUTUAL AUTOMOBI\-""'.'lSURANCE COMPANY CONCORDVILLE PA 19~39-0001 J~.;Uc. ." ~.,';I,'.II:I.:I- I YOUnCAlll\i[ltlClE 5126.32 I 1977 FORO GRANADA POLICY NUMDEA 694 4530-F21-38 FULL PAYMENT BY DATE THIS POLICY IN FORCE c.\~,,: :l:l; JUN 21 93 DUE CONTINUES UNTIL DEC 21 93, CO'VtnAOEIUMlfS l'I1CMIUM A LIABILITY: BODILY INJURY 100.000/300.000 PROPERTY DAMAGE 50.000 FUNERAL BENEFITS 16500 MEDICAL PAYMENT 5. 00 EMERGENCY ROAD SERVICE 105.28 .84 18,28 I 2.0 I GREEVY. ROBERT A SR 5203 MEADOWBROOK OR MECHANICSBURG PA 17055-6833 ""'1".,'1"",1,'"',',,11,,',,',,,1""",",,,,111,1,1,.1 A-3754-12 F C2 H PLEASE PAY THIS AMOUNT. 126.32 Your premium is bllsed on the lallowmg . . . If 11111 correct, cont.let your due"', 0'''.'' III "'0111\:1. '1\ fOUl tlIlUU"'ul,j CIJ~' 7 F 9 0 ~ PRINCIPAL DRIVER IS AGE 25 OR OLDER. THERE IS AN UNMARRIED DRIVER UNDER AGE 25 ATTENDING SCHOOL OVER 150 MILES FROM HOME. Ord,n.I'f u'.OI v,hlCl, PERSONAL OR BUSINESS, DRIVEN OVER 7.500 MILES ANNUALLY, (NATIONAL AVERAGE IS 10.000 MILES ANNUALLY.) ---------------------------------- See reverie .'de lor Imporlanllnlormallon .ffectlng your In.ur.nce, Ple..e keep 11i,. parI lor your record, -n- I .I. /A~1;t.fJ,fUl ([1,,7';;,(/ liV Ji.~~'I'f1oJ.'(... L' I " Ag.nt BOB MA Y Tel.phone 717-731-8112 DISCOUNTS THE PREMIUM AMOUNT HAS ALREADY BEEN REDUCED BY THE FOLLOWINGl MULTICAR 513,32 ACCIDENT FREE 56,44 YOU MAY BE ELIGIBLE FOR ADDITIONAL DISCOUNTS. SEE THE ENCLOSED INSERT FOR MORE IHFORMATION, DRIVER TRAINING WARNING .., ANY PERSON WHO I<NOWINGlY AND WITH INTENT TO INJURE OR DEFRAUD ANY INSURER FILES AN APPLICATION OR ClAIi\1 CONTAINING AWl F~lSc, INCOMPLETE OR ,\IISlEADING INFORMATION SHAll, UPON CONVICTION, BE SU8JECT TO 1~,IPRI,30n\lcm FOR UP TO SE'ic:'! YEARS MID PAYMENT OF ..\ FINE OF UP TO S 15,000 HE LAWS OF THE COMMONWEALTH OF PENNSYLVANIA. AS ENACTED BY THE GENERAL ASSEMBLY. NLY REQUIRE THAT YOU PURCHASE LIABILITY AND FIRST~PARTY MEDICAL BENEFIT COV~RAGES. NY ADDITIONAL COVERAGES OR COVERAGES IN EXCESS OF THE LIMITS REQUIRED BY LAW AR~ ROVIDED ONLY AT YOUR REQUEET AS ENHANCEMENTS TO BASIC COVERAGE, THE PREMIUM FOR ASIC LIABILITY COVERAGE OF 5 15.000/30.000/5.000 AND MEDICAL PAYMENTS COVERAGE F 5 5.000 IS 5 91. 56, HIS POLICY PROVIDES FULL TORT OPTION. HIS POLICY DOES NOT PROVIDE PROTECTION AGAINST DAMAGES CAUSED BY AN UNINSURED OR NDERINSURED MOTORIST. OXIUUXT "h" " r """" State Farm Insurance ,-...., Companies IfA1I U'M A . __'''''''''w- ,- IHUUHC\. August 16, 1995 Uaul.burg S.,vice Cen'., 116 L1mokiln Rood P,O, 80. 267 Now Cunlborlond, PA 17070-0267 JEND INe N STEINIIOUSE MD 719 RIlAWN S'l' PllILADELPllIA, PA 19111 RE: claim Number: Date of Loss: Our Insured: Your Patient: 38-7071-112 October 21, 1994 Robert A. Greevy Phyda Ny Dea~ Dr. steinhouse: This is to notify you that your patient, Phyda Ny, has exhausted her limits of medical coverage under her auto policy with state Farm Insurance Company. We are, therefore, unable to honor your bill for service. Sincerely, kLL'l/\. .()(Cf d (,l!, (I Kevin Black Claim specialist (717) 774-9072 State Farm Mutual Automobile Insurance company CCI Phyda Ny Marc E. Batt, Esquire Robert May, Agent HOME OFFICES: nLOOMINGTOIJ, ILliNOIS 6111DOOOI f""i'\ f", BXlfIUI'l' liP" " I......... I ,-.. I PAYMENT RECORD I Vh\I(U\. N'/ I) ;;) Co ~ fl.ltc.~d ('\\J b10('\ I~ -D \ j\~ dw I L LL )U L L ~S rA 1'/ L\ ';J.;- (('6 ':j':'J INJURED PARTY ADDRESS CHECK/DRAFT NUMBER LOSS KIND ~..\t~LJ .L~!.t~l~:'J.. _~l;~. I:-'-'lt'~l~ .L~~J.,-~:r_. __~~~.. :t'6:'.']~_ _J;~lp.~!~EL. J.r~Q. :~:3~l .-'.?_'7.l~~L _~~~i:?_ ~'.~C! :9~ _ .lp_'J~ ;J.'j it. Je99._ :~:~ _j~'\::J.~!~J__ __~t;Iy. -J9__.'l;, ..:\~'.lil.odl_ .J.QQ~.. :l~~'L .g~~~~r.. .~.CP... .'.1:~.~ .~.1J.I_:r~.\f__ _Cg~9... .J!t:9~ ;?~~.Q.If~. _ Se9_Q. L.OSS OF INCOME OR SERVICES DATE OF PAYMENT CHECK/DRAFT NUMBER PAYMENT CODE .,) ................ .. ~ ,') .J - -.............. ;J .... 'f'-i:............ _.~..'... .;1 - --:;'" - -- ................ .. --~----- .. -'.....- CLAIM NUMBER ACCIDENT DATE COVERAGE ~~ ' '1(.l"/ I II;) \o..)!.(N C:;L LIMITS fj ,('0 c.. PROVIDER OF SERVICE DATE INCURRED TOTAL PAID TO DATE PAYMENT AMOUNT g~~_l:~":!~~.rJ~~(~..__ l~:~j:~(J _._k-}.':!.'] ______..__ ~~./)!~ J. .ll.(.lV- _ ~.\J?.... 1~..:~.?:']Y _ .~.Lj-,:.~': .......... ~Q!:".l!?1 ~-. .+_1'1~(~~(~... __ l~ ':):~'~l.'L .. o?t: 1; :.'. ~J~ .JJ\?HV. ~(l~.}~ .bn\. t).. __ !~'_~/:~'l~J . _'~.'9. ~~ C(\rL(::.Lt. llu~.(2iio--l 1~/'lL,I%'j J53~,JR '33'1/ ;1(/ \?'~';:~~~:~'~;~~:'~_\~~:01:~:,: ~~\l;~~f; ::Y:~:C}~1: ~:i~):19 ~lqM.M.gL~!0____..__ )?:k.(l.'L ..lI.o9.,.~~. _?S9.1~,1~ ~.1-".RI.\:~0=,n0__.___.____ .\\'.~~1I: .J{l:r~. .~5'L~1. {ql~pPA_~.~g!!______ ~:~~:9?_ .:p?_i{,.~. .~~~_~~~ _0'_(I~_1.-Pr~~_ ~ _ _... _. __.. '~!~I:_'~/pl t. ~_~~: .~~ _?~)-'_~~. .. .L~ 19:.~ ~ '05;),51 ..............-..- .......-........ .............--..---......-......-..-..... ................ ----.--r: .. __ _. .1..1/ 1{!;..... . .................. ............---................................- ................ .................. ........................................-......... .............. ---............ ............................................. .....-...... --.............. .................................-..............- ............. .................. -..-..........................-................ ............- --............. ....-............................................. ....-.......... PERIOD AMOUNT THIS PAYMENT C~~U~tIVE PAYMENT CODe LOSS CODe FROM THROUGH ................ ......................................... ...................... ...................... ....................... ....................... .................... .................... ............... ......_---..........__..~......~ ....~....~~....~.. ..................... ..................~.. ..~.................. .................... .................. .. .... .. .. .. .... ............................. ~ ........ ...................... ..................... .......... ~.... .. .... ............ ~ ~ ...... .................... .................... .... ~ .. ~ .. .... ...................... ~ .. ...... .. .... ~ ..................... ...................... ...................... ..................... .................... .................... .... .. ...... .... ...................................... ...................... ...................... .................. ~.. ...................... .................... .................... .." ...... .. .... ........................ ~...... .. ...... ...................... ...................... ...................... ...................... .................... ................... ...... .. .. .. .... ................ ~ .... .. .... .. .. .. .. .... ...... ~ ~ .. .... .. .... ...................... ...................... ...................... .................... .................... .... .. .. .. .. .... ........................................ ...................... ...................... ~ ~ .. .. .. ~.... .. ... ...................... .................... ........ ~ .. .. .. .. .. .. .... .. .. ...... ........................................ ...................... ............ ~ .. ...... ...................... ...................... .................... ~.................. .. ,... .. .. .. .... ........................ ~ .. .. .. ........ ...................... ...................... ...................... ............... ~.... ~.................. .................... """ /--- IN THB COURT OF COMMON PLBAB OF CUMBERLAND COUNTY, PBNNSYLVANIA SIV HEANG CHUM, Individually and as parent and natural guardian of PHYDA NY, a minor 119 Maple Lane Belle Chasse, LA 70037 CIVIL ACTION NO.: 96-5748 v. ERIN JO LUNGER 390 Rich Valley Road Carlisle, PA 17013 and BRUCE A. SHERIFF 390 Rich Valley Road Carlisle, PA 17013 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF PHILADELPHIA ss Siv Heang Chum, being duly sworn according to law, deposss and says: 1, She is the mother of Phyda Ny Chanthavilay, a minor, born May 15, 1980, and that the said minor was injured on October 21, 1994 when Phyda Ny, was a passenger in a motor vehicle owned by Bruce A. Sheriff and operated by Erin Jo Lunger, which motor vehicle was traveling northbound on SR 0034 at or near its intersection with Marsh Road in South Middleton Township, Cumberland County, and which vehicle was caused to veer off of the said highway, strike an embankment, overturn, and strike a fence. See Exhibit "B". 2, That the injuries eustained by the minor Phyda Ny Chanthavilay, were fracture of the posterior elements of the cervical spine C3-C6, facial and upper extremity abrasions and """ ,-.. lacerations, fracture of the T12, bilateral shoulder strain and sprain, right knee strain and sprain with contusions and edematous, post trauma cerebral concussion syndrome with cephalgia, post traumatic anxiety disorder, and headaches, from which injuries she continues to suffer residual problems. 3. That five thousand dollars in first party benefits have been paid to Phyda Ny's medical providers, by State Farm, and the following medical expenses remain outstanding as of this date: Dr, N, Steinhouse(Act 6) .,.,.,...".. .$3,783,94 Del,Val.Phys,Med.Assoc,, P,C..""... ,$1,670.00 'OOTAL................................ .$5,453.94 4. That the sum offered in settlement for Phyda Ny, Fifty Thousand ($ 50,000.00) Dollars is fair, reasonable and equitable, and it represents the policy limits of the insurance coverage available to defendants. 5. That an underinsured motorist claim is being pursued on behalf Phyda Ny Chanthavilay against State Farm, under the aforementioned policy of insurance. See Exhibit "K". 6. That the sum of Fourteen Thousand Five Hundred and Ninety-Three Dollars and Eighty-Seven Cents ($14,593.87) for counsel fees is fair and reasonable. 7. That Phyda Ny Chanthavilay resides with her husband I Intha Chanthavilay, and her mother-in-law, Thangou K, Chanthavilay, at 4859 Brittany Court, New Orleans, LA, 70129. 8. That Siv Heang Chum does not reside at 4859 Brittany Court, New Orleans, LA, 70129. 9, That Siv Heang Chum does not financially support nor 1"""\ ,-., provide food, nor shelter, for Phyda Ny Chanthavilay or her husband, Intha Chanthavilay, partially or in whole. ~.:. /=-- (IUUM SIV HRANG C tf(Wf ~ > .rWJ/#l, fS'Aftl'ftIJ ~ \\1) 1""'\ /"", IN ~IR COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA SIV IIEANG CHUM, Individually and aD parent and natural guardian of PHYDA NY, II minor 119 Maple Lnne Belle Chassc, LA 70037 v, CIVIL ACTION NO.: 96-5748 ERIN JO LUNGER 390 Rich Valley Road Carlisle, PA 17013 and BRUCE A, SHERIFF 390 Rich Valley Road Carlisle, PA 17013 A F F I 0 ^ V I T COMMONWEALTH OF PENNSYLVANIA DS COUNTY OF PHILADELPHIA Phyda Ny Chanthflvilay, being duly eworn according to law, deposee and eayel 1. She was born May 15, 1980, and nhe wan married to Intha Chanthavilay on September 26, 1996, in New OrIeane, Louisiana, . 'where ahe currently resides, See Exhibit "A". 2, That she wae injured on October 21, 1994 in a motor vohicle accidellt when nhc WilD n pflDDonger in a motor vehicle owned by DrUce A, Sherif. f and operated by Erin Jo Lunger, which motor vehicle wall travell.ng northbound on SR 0034 at or near its interaoction with Marah Road in South Middleton Township, Cumberland County, IInd which vehicle WilS caused to veer off of the aaid highway, atl-ilte fln embnnkment, overturn, and strike a fonce, Hoe Exhibit "0", """" .- 3. That the injuries she sustained were fracture of the posterior elements of the cervical spine C3-C6, facial and upper extremity abraniono and lacerations, fracture of the T12, bilateral shoulder strain and sprain, right knee strain and sprain with contuoiono and edematous, post trauma cerebral concussion syndrome with cephalgia, post traumatic anxiety disorder, and headaches, from which injuries she continues to suffer residual problems, 4. That five thousand dollars in first party benefits have been paid to her medical providern, by State Farm, and the following medical expensos remain outstanding as of this date; Dr, N, Steinhouse(Act 6), ,.,., '...." ,$3,783,94 Del,Val.phys.Med,Ansoc, , p,C""" ,.. .$1,670.00 TOTAL. . . . . . . . . , . . . . . . . . , . . . . . . . . . . . . . . $5,453.94 5. That the sum offered in settlement, Fifty Thousand ,($ 50,000,00) Dollars is fair, reasonable and equitable, and it represents the policy limito of the insurance coverage available to defendants. G. That an underinoured motorint claim io being pursued on her behalf againot State Farm, under the aforementioned policy of insurance, See Exhibit "K", 7. That the sum of Fourteen Thousand Five Hundred and Ninety-Three Dollars and Eighty-Seven Cents ($14,593,87) for counsel fees is fair and reasonable, """ "....., 8. That she resides with her husband, Intha Chanthavilay, and her mother-in-law, Thangou K. Chanthavilay, at 4859 Brittany Court, New Orleans, LA, 70129. 9. That she does not reside with her mother, Siv Heang Chum, at 4859 Brittany Court, New Orleans, LA, 70129. 10. That she does not receive any financial support nor food, nor shelter, for herself nor her husband I from her mother Siv Heang Chum, 11. That she does not receive any financial support, for herself nor her husband, from her mother-in-law, Thangou K, Chanthavilay, 12. That she and her husband pay rent and board to her mother-in-law, Thangou K. Chanthavilay, in order to reside at 4859 Brittany Court, New Orleans, LA, 70129. SWORN TO AND SUa,sCRlI3ED Before me this ~day of ,/' 1997 .'""'\ r m~IlIlIlT "I" \ IN THE COURT or COMMON PLEAS OF ~UHBEI\LAND COUNTY, PENNSYrr'\NIA :.lJ V m:/\NU ('III 1M, lnd j v I dUll I! Y lInd IIIi JlII/llllt Ilnd nlltllrlll \Jllardlall of I'IIYIl/\ NY, II minot 119 MlI(lIH 1.lIlle iloIlo Chlllll"~' 1,/\ '/00]'1 v, CIVIL ACTION NO. : 96-5748 ~;IU N ,lO 1,IJtm~;1( 390 Hlch V/llluy Hoad CII/llnllJ, 1'/\ 1'1011 Ilnd BllllC," /\, llllEIU tT ]90 Rich VIIIloy Road ClIllllllo, 1'/\ \'1013 A F F I D A V I T Mall' t:, Illllt:, I':aqulre, being duly sworn according to l/iW dll(lOIHHI IInd Hays I I, Ill! Iii the attorney for the plaintiff Phyda Ny Chant hav Ilny fwd recommends the settlement due to the fact Lhllt '1IIIIntlrl the proposed settlement represents the policy I \nil t II IIndo! t he de hmdBnts I motor vehicle liability llllllltallCl! . '. . , ThilL lho sum offered in settlement for Phyda Ny Challthllvllay, rifly Thousand dollars ($ 50,000.00) is fair, J IIl1l1onllh I (! nnll oqlll table I and I t partially compensates for tho In1\1t 10/1 Il\lstalned and expenses incurred, in light of plalnl Irl'R ongoing claim for under insured motorist bUllo! 1111, Hee Exhibi t "1<". 8WORl~ TO AND IUPICRI8ED Betore me thh /?f'r day of )/l/t-1' II 97 .... , BATT, HALPERN & NRAUB ~--y- BY' /- C~ C E, BATT, ESQUIRE IDENTIFICATION NO.1 14042 1101 MARKET STREET, SUITE 2710 PHILADELPHIA, PA 19102 (215) 629-7225 ATTORNEY FOR PLAINTIFF N 'A E L HA It; I t PlII HAI;ALl Ulot." Public Cll, IiI fJluladolphil. Pluta County ~ll_': ~t_t~111~~'~~!'J "'.Jl!"' A\lH_1.~.?Q~ ~ t""'l RXIlInI'l' "J" II ~ r'\ t"HlDll' "K" State Farmlnsurance f""'\, Compallles IUU "'1M A INIYUNI~ January 14, 1997 HI"I.burg 8erlll.. Clntlf I 1& Um.klln ROld P ,0, Bo. 2&7 N.w Cumberllnd, PA 17070,02&7 Marc E, Batt Batt, Halpern & Weinraub suite 2710, 1101 Market st, Philadelphia, PA 19107-2927 RE: Claim Number: Date of Loss: Our Insured: Your client: 38-7071-112 october 21, 1994 Robert A. Greevy Phyda Ny-chanthavilay Dear Attoreny Batt: I am writing in reference to your client, Phyda Ny- Chanthavilay. Please be advised that we will waive our subrogation rights against Bruce Sheriff and Erin Lunger. In addition, your client has our consent to settle her liability claim. In response to your letter of January 7, 1997, please be advised that there wera 3 policies in the household on the date of loss. However, pOlicy 694 4530-F21-38 did not have UIM limits, So the total amount available is $200,000 for policy 614 2541-B14-38E and policy 654 2603-B25-38E, Please contact me if you have any questions regarding this matter. sincerely, , L-7 '-(,1,. Ii, :',(}I/!Ji ',\ Amy M. Wolfberg Claim specialist (717) 774-9016 State Farm Mutual Automobile InsUrance company flOME OFFICEBI DLOOMINorON, ILLINOjB 617100001 ,.... f"'\ ", MA.'-Cl Mn "1llA.M It. H"lPlkH MIQIAlL b _U,,"kAllI. AIIlW'A' A. MUf""A.W. ItffUr S eke" WIAHfH It. .......ltu"lrr.;. ;fIt/v ~~'t'.r liJam .9lalpe,VI &, 1fJelill'flllb' SUIrE 2710 1101 MARKET STREET PHilADELPHIA. PENNSYLVANIA 10107-2027 (215) 620,7225 t^~ .2.5' 02D'5940 IUln 110 001 IIAbbON AVENUE COl.\.INCI'&OOO. NI 0'10' lIlO91 .1l4....U7 NEW IWEt OftlCl 'Aw-,pwntD11J1ol1IAl March 17, 19117 Ms. Amy F, Wollberg State Farm Insurance Company 115 Limekiln Road P,O. Do" 257 New Cumberland, PA 17070.0257 REI )nsll~cdl Clalmantsl Your Claim No.1 Date or Atddenll Robert A. GrccV)' Phyda Ny.Chanthavllay 38.7071.112 10121/94 Dear Ms. Wollberg: Enclosed please Ilnd a true ~nd correcl copy of the Petition for Leave to Sellle or Compromise Minor's Action which is belngllled with the Court of Common Pleas of Cumberland County on March 17, 1997, If you wish to oppose or otherwise respond to the within Motion. your answer or the answering memorandum must be llIed with the Court of Common Pleas in accordance with the Rules of Civil Procedure \ MED:sc 1i'",'lo,wre \ / -.. r.q .. , , ; " ! , , 'J ".., ,. ! l - " ""I \ i ../