HomeMy WebLinkAbout96-06947
Ii
A
..~
,
r-
.':t'
$
1:1
..
i.
,
,
, ,
"
I.
I
'I
Ii
,I'
I
.1 'I
'1
"
d
,
I,:
"i
"
"
.,
,I
" ,
, ~
'I'
'1
, ,
.. ....~
'1
, ,
'Ihi
'~
,
',11
II ~
.,
't,',
~
-.-. ..
... ~
FIFI aACI<2NS'l'OSS, I IW THE COURT OF COI~10W PLE~S OF
Plaintif f I ClINBERLANPCOUN'1'Y, PENWSYLVANIA
I
v. I CIVIL AC'l'ION - I~AW
I
l.UIS HIMM OCASIO, I
Defendant I NO. 96-6947 CIVIL 'l'EHN
ORDlm OF COUR'l'
Al'lD NOW, this hli day of Ootober, 1997, upon oon~ideration
of Oefendant'a Motion '1'0 Compel Answare to Interrogatories/Request
for Produotion of Doouments, a Hule ie hereby issued upon the
Plaintiff to ehow oause why the relief requoeted should not be
granted.
RULE RETURNABLE within 20 duys of servioe.
BY 'l'IlE COUH'l',
J.
Darrell C. Dethlefs, Esq.
355 North 21st Street
Wagner auilding - Suite 205
Camp Hill, PA 17011
Mtorney for Plaintiff _
Charles B. Calkins, Esq.
~isa M. DiBernardo, Esq.
110 South Northern Way
York, PA 17402
Attorneys for Defendant
r-41..:........,~.A lol/Iff"
..J.f.
Ire
.1',\,\
",' I' ',' .... '/',\\1
,. \',
,':,
\"1
C'\ ',II .'
.1
\ ,,\ Lll
I" ~._u
~!.')
,
l\'.I\,,'" ,.'", \\
f,d I. ~'(\ 1,:..1 .J I
.......
..
-<I
4
.
..
,
IN THE COURT or COMMON P~~As or cUMaER~AND COUNTY, PENNSY~VANIA
riti aac~enatoas,
Civil Action - ~aw
P1aintift
vs.
No, 96-6947- 1996
~uis Hiram Ocasio,
Detendant
JURY 'I'RIAL DEMAND~D
p~nlQJMT I S NOTION '1'0 OCNllaL ANSwaRS 'l'0
Ilf'l'aRROaAToaII./RlQUlST rea PRODUOTIO~ 0' DOOUNIIf'l'S
AND NOW, this _ day ot Septembn, 1997, comes the Defendant,
~uis Hiram ooasio, by and throu9h his attoflleyu, Griffith, Btric~ler,
Lerman, Sol~\os & Calkina, and tiles the instant Motion to Compel Answers
to InteJ:fOllatoriea/Requeat for Production at Document a and statelJ aa
follows I
1, On or about December 26, 1996, Plaintiff, li'ifi aackenatoss,
instituted the above action with the filing of a Writ of Sununons, (A
copy of the Writ is attached hento aa Exhibit "A" and incorporated
herein aa though aet forth in full,)
2, Thereafter, on or about April 10, 1997, Plaintiff filed her
complaint, wherein ahe al1ellea to have suffered bodily injury aa a reault
of a motor vehicle accident involving the Defendant, which occurred on
or sbout December 29, 1994, in Lemoyne, cumberland County, Pennsylvania,
(A copy of the Complaint ia attached hereto aa Exhibit "a" and
incor.porated herein aa though aet forth in full,l
3, Defendant, Luis H, Ocaaio,filed hia Anawer and Nflw Matter
with the Court on or about May 22, 1997,
(A copy of Defendant I s
responaive pleading is attached hereto as Exhibit "e" and incorporated
herein as though set forth in full,)
,:;
..
-i
..
.
4, On or al:lout March ;11, 1997, Defendant aervad his initial set
of IIlterrollatories/l\equaat for l'~'Odllction of DOCllJ1lants on t.he l'14int1ff.
(/\ copy of aaid diacovery, latter of tranamittal, all well 1111 the filed
Cartificate of Service, are attachud hereto all Exhibitll "D", "E" and "r"
rellpectively, and incorporllted herein all though lIet forth in full,l
5. Havinq received naither a raaponllo to the al:lova dillcovery nor
a requallt for an ext.enllion of till!a IIftar tha axpiration of 30 daYIl,
counllal for the Dafendant IIroto to l'laintift'lI attorney on Juna 5, 1997
and requellted that counllal contact him wi thin two weekll requdinq the
IItatull of hill cHant' II Anllwerll, or II Motion would ba filed. (A copy of
the June 5, 1997 letter ill attached horeto all Exhibit "G" and
incorporated herain all thouqh lIet forth in full.)
6. Acknowladqinq recaipt of dafenlla counllel'lI June 5, 1997
letter, Plaintiff'lI attornay, by correllpondence dated June 12, 1997,
advhed that hill "offica wall praparinq Anllwarll.. .and,. ,expected to have
tham torwarded IIhortly", (A copy of Attorney Dethletll' June 12, 1997
letter ill attachad heroto all Exhibit "Ii" and incorporatad harein all
thouqh lIet torth in full.)
7, Aqain, havinq neithar raceived (all promised) Plaintift'lI
Answers to discovary, nor an additional requellt for an axtenllion, counsel
tor tha Defendant waa forcad to writa to Plaintiff's couneel on July 17,
1997 and adville counsel that a Motion to Compel would lJe filed if
Datandant t II discovery wall not anllwered on or before July 29, 1997. (A
copy of dafanaa counsal's lettar dated July 17, 1997 is attached hereto
as Exhibit "I" and incorporated harein as thouqh set forth in full.)
B. To date, a date almost ~ months lifter Dafandant initially
servad hill discovery on l'laintiff's counsel, and daspite reoeatad
requasts, no response has been racaived by the Plaintiff.
-
Ibhlblt A
I, -",,"
.
.c
,
4NI
,.
.
'li
,
Exhibit B
.
(
~" ""1' -,,-/. ~.
'.'1< fl$.,
..
A
4
iIiI BACKBHSTOSS
piaintifr,
v,
IH mil COllR'l' OF COMHOH P~1lAS
CUMBIIRI.ANO COtffl'l'Y / PlltfflSThVANIA
NO. 96-6947-1996
l.UIS HIRAM OCASIO,
',I Oerendant,
JURY 'l'RIAI. OaMMOBO
COMPLAXm'
1. Plaintiff Fifi Backenstoss is a resident of York County,
Pennsylvania.
2. Defendant Luis Hiram Ocasio is a an individual residing at
2207 Whispering Pines Orive, Marysville, Pennsylvania,
3. On or about December 29, 19946 Plaintiff Fifi Backenstoss was
the owner of a 1982 Dodge automo ile which was involved in the
accident described herein.
4. On the aforesaid date, Defendant was the owner of a 1981
Chevrolet pick-up truck which was involved in the accident
described herein.
5. On the aforesaid date, at approximately 5: 15 p.rn" Plaintiff
Fifi Backenstoss was entering the roadway in the 400 block of South
Third Street, Lemoyne, Cumberland County, Pennsylvania, from a
driveway in the same block when her vehicle was struck in front by
the Defendant/a motor vehicle which was being operated by
Defendant.
6. The accident was direct ly and proximately caused by the
negligence and carelessness of Defendant, which consisted, among
other things, of the following:
(a) operating his motor vehicle in a careless, reckless, and
negligent manner,
(b) operating his motor vehicle at an excessive rate of speed
under the circumstances I
(c) not having his motor vehicle under the proper control so
as to stop said vehicle within the assured clear distance
ahead (75 Pa, Cons, Stat. S 3361) I
(dl
( f)
(g)
(h)
( i)
.
I
(0)
operating his motor vehicle without. due regard to the
rights, safety, and position of the Pl~intiffl
failing to have his motor vehicle under the proper
control so as to prevent his vehicle from striking the
Plaintiff's motor vehicle!
failing to keep a proper lookout I
failing to use due care under the circumstancesl
failing to notice the motor vehicle of the Plaintiff!
tpon noticing the motor vehicle of the Plaintiff I failing
to yield the right-of-way to thp Plaintiff's vehiclel
(j)
failing to take evasive action in order to
impacting with Plaintiff's vehicle;
(k) failing to apply his brakes in sufficient time to avoid
striking Plaintiff's vehicle;
avoid
(ll operating his motor vehicle in disregard of the rules of
the roadJ the ordinances of Lemoyne Borough, and the laWI9
of the cOl1Ul\onwealth of Pennsl"lvania, including but not
limited to the Motor Vehicle Code, 75 Pa. Cons, Stat. ~~
3361 and 3362;
7. At all times material hereto, Plaintiff Fifi Backenstoss acted
with due care and was not solely negligent.
8. As a result of Defendant's negligence, Plaintiff Fifi
Backenstoss sustained the following injuries, some or all of which
may be permanent! disorder of joints in the hip and pelvis, strain
to the lower back.
9. As a result of Defendant's negligence, Plaintiff Fifi
Backenstoas has suffered great bodily pain and suffering, as well
as mental anxiety and nervousness, to her great detriment and loss,
10. AS a result of Defendant's negligence,
Backenstoss has suffered serious and permanent
treatment of which he has incurred medical bills
a claim is made therefore.
Plaintiff Fifi
injury, for the
and expenses and
11. As a result of Defendant's
Backenstoss has suffered a loss
capacity.
12. As a
Backenstoss
pursuits to
negligence, Plaintiff Fifi
of earnings andlor earning
result of Defendant's negligence, Plaintiff Fifi
has suffered an interruption of her daily habits and
her great and permanent detriment and loss.
'I".'!." "'
Ellhlblt 0
, f't)
I,
" ~. at "'-
.~
,
IN rHS co~r OF COMMON P~SAB OF CUMBS~~AND COUNry, PSNNSY~VANIA
F1t1 BaQ~en.to..,
Civ1l Action - ~aw
PldntHt
v..
No. 96-6947- 1996
~u1. H1ram Qca.io,
O,t,ndant
JURY T~IAL DSMANDSO
lW.'J'IClC TO PLlCAQ
TOI F1t1 Bac~en.toaa, clo Darrell C, Dethleta, Eaqu1re, L~W OFFICES OF
OAR~S~~ C. DSrH~EFS, Wagner Bldg., Ste. 205, 355 North 21at Street
Camp Hill, PA 17011
You are hereby notit1ed to tile a written reaponae to the enoloaed
New Matter w1th1n twenty (20) daya trom aerv1ae hereot or ft judgment may
be entered aga1nat you.
G~IFFITH
L
LERMAN ,
Na
BY,
h r a B. Ca kina
a reme Court H36208
110 a. Northern Way
York, PA 17402
Attorney tor Dehudant i;
Telephone No., (717) 7!7-7602
(~ ::3 '1
'\
.....r -
. .,
r, .
, -: ,:'1
'.
.-.) ,'J
/,
[ ,
.. Sl
r '1
-. .,
.' - ,',
" "
~- "1
.'
.- I.,) ..
....
"
'i
I~ rHS COURr OF COMMO~ P~S~S OF CUMBSIt~D COUNry, PS~NSY~VANIA
Fifi Baok.n.to",
Plaintiff
civil Action . ~BW
VI.
~o. 96-6947- 1996
~uil Hi~am Ooa.io,
Defendant
JURY rRIAL DEMANDSD
O!rE~ANT'S ANSWER AND ~!W MATTER TO PIIAINTIFF/B COMPL~INT
AND NOW, comea the Defendant by and through his attorneys, Griffith,
Strickler, ~erman, Solymos & Calkins, and Charles 8, Calkins, Esquire and
,I
files this Answer and ~ew Matter in response to Plaintiff'S Complaint,
and states as follows I
1,
Denied,
After reasonable investigation, ansWering Defendant
is without knowledge or information sufficient to form a belief al to the
truth or veraoity of the allegatione contained in paragraph 1 of
Plaintiff's Complaint and the same are denied and strict proof thereof
is demanded,
2. Admitted.
3. Denied. After reasonable investigation, answeringipefendant
is without knowledge or information sufficient to form a belief as to the
truth or veracity of the allegations contained in paragraph 3 of
Plaintiff's Complaint and the same are denied and strict proof thereof
is demanded.
4. Admitted.
II. Admitted in part, denied in part. It ie admitted that on or
about Pecember ~9, 1994, at approximately 5115 p.m" PlaintHf w..
entering the roedwey in the 400 block of South Third Street, ~emoyne,
Cumberland county, Pennaylvanis froom a driveway in the alme block, and
thlt Oetendlnt' a motor vehicle Will being operated by the Defendant. It
ie further Idmitted that a colliaion between these two vehicles occurred.
Thlt Plaintiff" vehicle waa at ruck in the front by Defendant' a vehicle
11 denied, On the contrary, It all times relevant hereto, Plaintiff
struck the vehicle opereted by the Defendlnt.
6.
Denied.
It is specifically denied that the accident was
directly and proximately caused by the alleged negligence and
carelessne.. of the Defendant, which consisted, among other things, of
the following I
(a) Operating his motor vehicle in a careless, reakleu end
negligent menner,
(b) Operating his motor vehicle at an exceuive rate of speed
under the circumetancesl
(c) Not having his motor vehicle unuer the proper control so es to
ItOp said vehicle within the as lured clear distance ahead (75
Pa, Cons. Stat. 5 3361),
(d) Operating his motor vehicle without due regard to the rightl,
lafety and position of the Plaintiff,
(e) Failing to have his motor vehicle under the proper atntrol so
sa to prevent his vehicle from striking the Plaintiff's
vehicle,
(f) Failing to keep a proper lookout,
(g) Failing to use due care under the circumstances,
(h) Failinll to notice the motor vehicle of the Plaintiff,
(i) Upon noticing the motor vehicle the Plaint if f , failing to
yield the right of way to Plaintiff's vehicle,
(e) Failing to havlJ her motor vehicle under thti proper control 110
as to prevent hor vehicle from Btdking the Dofendant'lI
vehiCle,
(t) Failing to keep a proper 100koutl
(g) Failing to UBe due CBre undtir the circumBtanceB,
(h) Failing to notice the motor vehicle ot the Defendant I
( i) Upon noticing the motor vehicle the Defendant, failing to
yield the right of wey to Defendant's vehicle,
(j) Failing to take evauive action in order to avoid impacting tha
Defendant'B vehicle,
(k) Failing to apply her brakeu in eutticient time to avoid
Btriking Defendant'B vehicle, and,
(11 operating her motor vehicle in diBrugsrd of the ruleu of the
road, the ordinanceB of Lemoyne Borough and the lawB of the
Commonwealth of PennBylvania, inclUding, but not limited to,
the motor vehicle code, 75 Pa,ConB. Btat. SS 3361 and 336~.
19. Defendant waB faced with a Budden emergency which occurred
when Plaintitf'e vehicle Buddenly, abruptly, and without warning or
notice enter~d Defendant'B path of travel.
~O. Plaintiff' B claimB are barrod and/or diminiBhed with respect
to PennBylvania'a Comparative Negligence Act becauee of the negligence,
caroleBBneBB and rllckleBeneBB of tho Plaintiff as Bet forth in paragraph
u.
~1. Plaintiff haB not BUBtained a seriouB injury ae defined in the
,.
PennBylvania Motor Vehicle Financiel ReBponBibility Law (75 Pa, C.B.A,
5 170~ et seq.)
22. Plaintitf' s claim for non-economic damageB may be barred
becftuBe Plaintiff has elected the limited tort option as Bet forth in the
Pennsylvania Motor Vehicle Financial ResponBibility Law.
23. Plaintiff may have failed to mitigate her damages.
28. It 10, Itate tor each luch policYI!
(a) The name, principal place ot bUlinel1 and telephone number
ot the inlurer,
(b)
inlured,
(c)
,\1 (d)
(e)
thereot,
(t)
The name, addre.. and telephone number ot the named
The policy number/
The ettective datea ot coveraqe,
The amount ot liability coveraqe, Ipecityinq the terml
State whether there are any other proviliona, auch II
medicll pay clausea/ tirst party benetita, uninaured motorist's coverage,
underinaured motoriat' a coverllqe, or other inauranc" payment proviaiona,
which will provide benetita to a party injurad by your vehicle and aet
torth any conditiona, excluaiona or other relevant terma concerning such
additional benetita, includinq the amount(a) ot coveraqe/
(g) The number ot vehiclea covered, it applicable.
.1.... produc. th. following document.!
36. All photoqraphll in the poaaellsion, cuatody or control ot the
Plaintitt, counsel tor Pl.intitt, or any other person or entity acting on
behalt ot the Pl.intitt, includinq any insurers tor the Plaintitt, showinq,
repruenting
or
purportin9
to
lIhow
any
vehiclllll,
localea,
instrumentalitiell, personll, and sny and all other mlltterll related to the
sUbject ~rtters ot this liti98tion.
37." All dia9umll, sketches, drawin98, plana, meallurementll, or
blueprints in the pOllllesllion, cUlltody or control ot Plaintitt, counsel tor
li'leintitt, or any othClr person or entity actin9 on behalf ot said
Plaintitt, includin9 sny insurer ot lIaid Plaintitt, lIhowin9, repreaentin9,
or purporting to lIhow any ot the inlltrumentalitiea, localell, perllonll or
other matters involved in the incident which torms the baaia ot Plaintitt's
complaint.
38. All lItatementll, lIiqned statlllments, transcripta ot recorded
lItatlllmlllnts or interviews, recordllld lItatemlllntll it not tranllcribed or any
lItatlllment ot recorded lItatlllments it not transcribllld vlllrbatim takllln ot any
partillls, perllons, or witneslles aa part ot an inveati9ation ot the happening
or caUSIII ot the incident in question, conducted by, or in the poaslllssion
ot Phintitt, Plaintiff's attorney, inaurers, or anyone 11118e actin9 on
behalf ot thlll Plaintiff.
39. All expert opinion, expert reports, expert summaries, or other
writin9l1 ot experts in the posllession, custody or control ot Plaintiff, or
his/her attorneys or insurers, which relate to the SUbject matter of this
litigation and the incident in question.
40. All documentl prepared by Plllintitf, or by any insurers,
repre.ent.tives/ .gents or anyone acting on behslf ot Plsintiff, except
hil/her attorneys, durinq an investigation of any aspect ot the incident
in question. Such documents shall include any documents made or preparad
up throuqh the present time, with the excluaion ot the mental impreasiona,
conClusions, or opinions r..pectin9 the value or merit of a claim or
deten.e, or respectinq strate9Y or tactics.
(No-6:1 As reterred to herein, "documents" includ.. written, printed,
typed, recorded, or 9uphic matter, hO"lever produced or reproduced/
includinq Qorreapondence, telequms, other written communications/ data
processin9 atoraga units, tapea, contrllots, agreements, notea, memoranda,
analyses, projections, indices, work pspera, studies, reporta, surveys,
diaries, calendars, tilms, photographa, dia9rama, drswings, minutes ot
meetin9S or sny other writing (inclUding copiea ot the foregoin9,
reqardlen ot "Ihethe/.' the parties to whom this requut is addr....d ill now
in the poaaeasion, custody or control ot the ori9inal) now in the
possession, custody or control of ~lsintitt, his/her tormer or present
counsel, agents, employees, otficers, inaurers, or any other person actin9
on Plaintitf'a behalt.)
41. It not other"lise covered by the above ~equeats, tha complete
cleims/inveatigation/aubroqation (tile(a) ot any inaurers ot Plaintitf,
dealinq with the incident in question, with the exclusion of the mental
impreSSions, conolusions, or opinions
Exhibit E
"
Ilchlblt pi
Ilchlblt G
Ilchlblt H
Exhibit I
.
f'
IN TH&l COU/l.'f or COMMON J,lL&lAS or CUMIlI!:~LAND COUN'f'i / PlENNSYLVANIA
Firi Ilackenstoee,
Civil Action ~ Le"l
J,llllintitr
vet
No. 96~6947~ 1996
LuLe Hiram Ocasio/
Detendant
JU~Y T~IAL DI!:MAND&lD
C&lRTIF~CAT&l OF SE~VICE
f' ''1
AND NOW, thill l!E. dsy O~l.lM k-, 1997, I, Lilla M. Di13ernardo,
Illaquire, s mambaI.' ot the firm ot GIUFFI'I'H, S~'~ICI<LIllR/ LEllNAN, SOLYMOS &
CALKINS, Esquires, hereby cartlty thst I hava/ this date/ sarved a copy
ot Detendant's Motion to Compel Answers to Interrogetorias/Requeat tor
J,lroduction ot Documants, by United Statea M811/ addusaerl to the party
or attorney ot racord ss follows!
Derrell C. Dethlefs/ Eaquire
LAW OFFICIllS 011' D/\R~ELL C. DIll~'HLEFB
Wagner 131dg., Stet 205
355 North 21st Street
CSJ1\p Hill/ PA 17011
Gl\IFrITH, STRICKLI!:R, LlllllNAN,
BOLYMOS & CALKINS
IlYx;~~ ~O, IllSQUIRI!:
Attorney tor Defendant
Suprema Court 1.0. No. 56684
110 South Northern Wsy
York, P/\ 17402
Telephona No. (717) 757~7602
~
'1'1 BACKBNSTOSSi
II dntiff,
v.
IN '1'JJII COtmT 0' COMMON PJ,lIM
CUMaIlRl>ANP COlffl'l'Y, IIBNNSVJ,VMIA
NO. 96-6947--1996
~ijIS HIRAM OCASIO,
Pefendant,
.:J1mV 'l'/UAL PRMMPIIP
COMpLAJlfl'
1. Plaintif.f l"ifi J3acl<enl3toss il3 a rel3ident at York CC)unty,
Pennsylvania,
2, Detendant Luis Hiram Ocal3io ia a an individual residing at
2207 Whispering Pinel3 Drive, Marysville, Pennsylvania.
3. On or about December 29/ 19946 Plaintitt Fifi J3ackenstoss was
the owner of a 1982 Dodge automo He which wal3 involved in the
accident described herein.
4. On the aforesaid date, Defendant was the owner at a 1981
Chevrolet pick-up truck which wal3 involved in the accident
del3cribed herein.
5, On the aforel3aid date, at approximately 5r1B p.m./ Plaintiff
Fifi J3ackenstoss was entering the roadway in the 400 block of South
Third Street, ~emoyne/ Cumberland County, Pennsylvania, tram a
driveway in the same block when her vehicle was struck in front by
the Defendant's motor vehicle which was being operated by
Defendant.
6, The accident was directly and proximately caused by the
negligence and carelessneSI3 of Defendant, which consisted, among
other things, of the followingl
(a) operating his motor vehicle in a oareless, reckless, and
negligent manner/
(b) operating his motor vehiole at an excessive rate of speed
under the circumstances;
(c) not having his motor vehicle under the proper control so
as to stop said vehicle within the assured clear distance
ahead (75 Pa. Cons. Stat. S 3361);
operatin!1 his motor vehicle without due re!1ard to the
rights, safety, and position of the Plaintiff,
railing to have his motor vehicle under the proper
control so as to prevent his vehicle from strikin!1 the
Plaintiff's motor vehiclel
failing to keep a proper lookout;
failing to use due care under the circumstances I
tailin!1 to notice the motor vehicle of the Plaintiff;
upon noticing the motor vehicle ot the Plaintiff; failing
to yield the right-of-way to the Plaintiff's vehicle;
failing to take evasive action in order to avoid
impacting with Plaintiff's vehicle;
failing to apply his brakes in sutticient time to avoid
striking Plaintitf's vehicle,
operating his motor vehicle in disre!1ard of the rules of
the road, the ordinances of Lemoyne Borough, and the laws
ot the Commonwealth of Pennsylvania, including but not
limited to the Motor Vehicle Code, 75 Pa, Cons. Stat. 5S
3361 and 3362,
7. At all times material heroto, Plaintiff Piti Backenstoss acted
with due care and was not solely negligent.
(d)
(e)
(t)
(g)
(h)
(i)
(j)
(k)
(1)
8. As a result of Defendant's negligence, Plaintiff Pifi
Backenstoss sustained the following injuries, some or all of which
may be permanentk disorder of joints in the hip and pelvis, strain
to the lower bac ,
9. As a result of Defendant's negligence, Plaintiff Pifi
Backenstoss has suffered great bodily pain and sufferin!1, as well
as mental anxiety and nervousness, to her great detriment and loss.
10. AS a result of Defendant's negligence,
Backenstoss has suffered serious and permanent
treatment of which he has incurred medical bills
a claim is made therefore.
11 . AS a
Backenstoss
capacity.
12. As a
Backenstoss
pursuits to
Plaintiff Piti
inj ury / for the
and expenses and
result of Defendant's negligence,
has suffered a loss of earnings
Plaintiff Pifi
and/or earning
result of Defendant's negligence, Plaintiff Pifi
has suffered an interruption of her daily habits and
her great and permanent detriment and loss.
,
jl
13. Plaintiff haa made demand for compenaation of the aforeaaid
injuriea and loaaea, which Defendant haa failed and refuaed and
atill refuaes to pay.
tfflJlllJlFOllJl, Plaintiff Ji'ifi aackenston dellUlnds judgment against
Defendant in an amount in' e~cesa of Twenty-five Thouaand
($25/000.00) Dollara and 00/100, exoluaive of interest and ooeta.
fully Submitted,
Datel A~ril lQ/ 1997
Die. Dethlefa, Bsquire
Attorney lD~ 58805
Wagner auilding - Suite 205
366 ~orth 21at Street
Camp Hill, PA 17011
(717) 976-9446
Attorney for Plaintiff
, I
IN TH~ COU~T OF COMMON PLEAS OF CUMB~~LANO COUNTY, P~NNSYLVANIA
Fi~i Ilac~enatoaa/
civil Action - Law
Plaintift
VIII.
No. 96-6947- 1996
Luilll lIiram Oceaio,
Oetendant
JUH'i 'l'/HAL ll~MANOli:O
PBFENDANT' S ANSWER ~D NEW MA'l"l'ER Ira PLAIN'J'IFF' S CQMPLAINT
AND NOW, cornes the Oefendant Py and through his attorneys, Grittith,
Stric~ler, Lerman, Solymos & calkina, and Charles B. Calkins, Esquire and
tilea thia Nlawer and New Matter in response to Plaintift's Complaint,
and states as tolloWSI
1. Oenied. Atter reasonable investigstion, answering Oetendant
is without knowledge or intormation sutficient to form a beliet as to the
truth or veracity of the allegations contained in paragraph 1 ot
Plaintiff's complaint and the ssme ore denied and strict proot thereof
iIII demanded,
2. Admitted,
3. Oenied. Atter reasonable investigation, answering Detendent
is without knowledge or information sufticient to form a beliet as to the
truth or veracity of the allegations contained in paragraph 3 ot
Plaintitt's complaint and the same are denied and atrict proot thereot
iIII demanded.
4, Admitted.
5. Admitted in part, denied in part. It ill admitted t.hat on or
about Oecemher 29, 1994, at approximately 0115 p.m., 1'laintitt wall
entering the roadway in the 400 block ot South 'l'hird Street, Lflmoyne,
cumberland County, 1'ennsylvanis from a driveway in the Ilame block, and
that Oetendant' Il motor vehicle wall being operated by the Pefendant. It
ia turther admitted thst a collillion between these two vehicles occurred.
'fhat Plaintiff's vehicle was struck in the tront by Petendant's vehicle
is denied. On the contrary, st all times relevant hereto, Plaintift
struck the vehicle opersted by the Pefendant.
6,
Oenied.
It is specifically denied that the accident wss
directly and pl:"oximately caused by the alleged negligence and
carelessness ot the Oefendant, which consisted, among other things, ot
the following,
(a) Operating his motor vehicle in a cflrelesll, reckless and
negligent mannerl
(b) Opersting his motor vehicle at an excessive l:"ate ot speed
under the circumstanceal
(c) Not having his motor vehicle under the proper control so as to
stop said vehicle within the assured clear distance ahead (75
1'a. Cons, Stat, S 3361) I
(d) Opersting his motor vehicle without due regard to the right a ,
safety and position of the plaintiff,
(e) Failing to have his motor vehicle under the proper control so
as to prevent hia vehicle from atriking the Plaintiff' a
vehicle I
(f) Fsiling to keep a proper lookout,
(g) Failing to uae due care under the ci rcumatances I
(h) Fsiling to notice the motor vehicle of the Plaintiftl
( i) upon noticing the motor vehicle the Plaintiff, tailing to
yield the right of way to Plaintiff'a vehicle I
9. Oenied. It is specifically denied tbat as a rl!llult ot
Oetendant's negligence, Plaintitt suttered great bodily pain and
sut tering, as "Iell as mental anxiety and nervousnellll, to her great
detriment and loss. On the contrary, at all times relevant hereto,
Oefendant operated his motor vehicle in a careful, lawtul and prudent
manner with due care under the circumstances and was not negligent in any
menneI.'. The remaining allegations contained in paragraph 9 ot
Plaintitt's Complaint are denied because, atter reasonable investigation,
answering Oetendant is without Imowledge o/." intormstion sufficient to
torm a beliet as to the truth or veracity ot those allegations are denied
and strict proot thereot ill demanded.
10. Oenied. It is specificlilly denied that aa a result ot
Oefendant's alleged negligence, Plaintift has suffered serious and
permanent injury, for the treatment of whl.ch ahe haa incurred medical
billl9 and expenses and claims made theretore. On the contrary, at sll
times relevant hereto, Oefendant operated hia motor vehicle in a careful,
lawtul and prudent manner with due care under the circumatances and was
not negligent in any manner, The remaining allegationa contained in
paragraph 10 of Plsintitf's Complaint are denied because, atter
reasonable investigation, answering Oetendant is without knowledge or
intormation sufficient to torm a beliet as to the truth or veracity of
those allegations are denied and strict proof thereof is demanded.
11. Oenied. It is specifically denied that as a reault ot
Oetendant's alleged negligence Plaintitt has suffered a loss ot earnings
and/or lose ot earning capacity, On the contrary, at all times relevant
hereto, Oetendant operated his motor vehicle in a careful, lawful and
prudent mann"r with due care ul)der the circumstancea and was not
ne9liijllnt in any manner, 'I'he remsining allegations contsined in
parog/.'llph 11 ot f?l.8intift's complaint al'"e denied because, stter
reasonable investigation, answering Oeeendant is without knowledge or
intormation suteicient to torm a beliee as to the truth or veracity oe
those allegations are denied and strict proot thereoe ie demanded,
l~, Oenied, It is specifically denied that as a resulL oe
Oetendant's alleged negligence, f?lsintiee has suffered an interruption
of her daily habits and pursuits to hel'" great and permanent detriment and
loss. On the contrary, at all times relevant hereto, Oefendant operated
hie motor vehicle in a caretul, laWful and prudent manner with due care
under the circumBtenceB and was not negligent in any manner, The
remaining allegations contained in paragraph 1~ of f?laintift' s Complaint
are denied because, after. reasonable investigation, answering Oefendsnt
is without knowledge or information sufticient to form a belief as to the
truth or veracity of those allegations are denied and strict proot
thereof is demanded,
13. Oenied. On the contrary, at all times relevant hereto,
Oefendant operated hie motor vehicle in a careful, lawful and prudent
manner with due care under the circumstances and was not negligent in any
manner. The remaining allegations contained in psragraph 13 ot
f?laintiff's Complaint are denied because, after reasonable investigation,
answering Oefendant is without knowledge or information sufficient to
form a belief as to the truth or veracity of those allegations are denj,ed
and strict proof thereof is demanded,
"
-,'I
"
',i
."."
"
"
t,'
'iI
,
Ii
'II
, ,'t/,,!
~l.\" .-'f.
J':~i;,',:".a!\~':.';
~'lll!"1.:j1,
I' ',I'
"
"
:1'_,-)'
),';
'L
'I
I,
"
,,'
;:'
"
",lI
.1"
\,-,"
,.\1,'
1.1';
It.
II
I,
JI
.,;
'Ji(
"
,
"
iil
,
,
','I
11';
"
'I'
, '
,
" il
"
,
.,
I!
,
,
"I
;'\
'I
'1 i
"
II
l'li
,
,
',!
q
'r'
,
,
"
" ,
'I
'1,1
,
,
"
, ,
, '" ,
,
"
, '
,
,
iil
i'
"
,;/
"
I'
"
, ,J!
" ,
,
,,"
1'1
,
I
.' ,'1 :'
"
H
,I,
"
17 Denied, T~e avenllenlS Cll'llaJned inl'ar8Mrap~ 17 slale concluslll'IS oflaw
III w~Ic~ a response Is nol required If it were ju.dlcilllly determined Ihal a response were
required. then I~e Plalnllfl' denies t~at ~er Injuries and/or dalJlaMes were caused solely and
directly 18 a result of Individuals or Ilntilles olher than the Delimdalll over whom the
Defendanl ~ad no responsibility or rl!l~tto conlrol I'roof 10 the contrary Is demlmded 11.1
I~e time of Irllll,
18, Denied. The averments co,llalned Inl'araMraph 18 stale concluslo'IS oflaw
to w~lc~ a response Is not required. If it were judlclllJly del ermined thlltll response were
required, I~e l'lalntl/f denies each and every Illleglllion in P'rllgraphs lll( a) through 18(1)
ofthe New Maller, Prooflo Ihe contrary is demlll1ded allhe time oflrllll.
19, Denied, T~e avermenls contained In Parat!rap~ 19 stale conclusions oflaw
10 whlc~ a response Is not required. If it were Judicially determined that a response were
required, the Plalntlll' denlesthall~e l>efe'ldlll1t was faced wllh a sudden emert!ency, T~e
Plalnllll' furt~er denies that her vehicle suddenly, abruptly and wlthoul warnlnt! or notice
entered I~e Defendant's path oflravel Proof 10 Ihe contrary Is demanded at the time of
trial
20, Denied The avennents conlalned in Parag"lph 20 state conclusions oflaw
to which a response Is not required. If il were Judicially determined thaI a response were
required, t~e I'lalntl/f denies Ihal ~er claim Is barred and/or dlllllnls~ed wilh rllspectto I~e
Pennsylvania Comparative Negllt!ence Act. Proot'lo the contrary Is demllnded at the lime
oflrlal,
21. Denied, The averments conlalned in Parat!raph 2 J state conclusions oflaw
10 which a response Is not required. If it were judlcllllly del ermined that a response were
required. Ihe PlalntUl' denies thai she did nOI suslaln serious injuries 8S del1ned by the
r'ennsylvanla MOlor Vehicle Financial Responsibility Law, 1'1'001' 10 Ihe contrary is
demanded atlhe lime of lrial
22 Denied, The .vermenlS clllu.lned In llar.graph 22 slale conclusions onaw
10 which a respon.e Is nol required, If It were Judicially del ermined Ihala responle were
required, Ihe 1)lainllfi' denies Ihal her claim 'or non-economic damages Is barred becaullll
she elected Ihe limited lort opllon as sel Ibrth by Ihe I)e,msylvll/lla Molor Vehicle Financial
llelponllbUlty ""aw. Proot'lo Ihe conlrlU)' II demanded allhe lime ot'lrlal,
23. Denied. The avermenl conlalned In Paragraph 23 slales a conclusion of
law 10 which B response Is nol required, If It were Judicially dete.nlllned Ihal a respon811
were required, Ihe Pllllnllff denies Ihal she fulled 10 mlllllate her damalles, Proof to the
contr.ry II demanded at Ihe lime ot'lrlal,
24. Denied. The avemlenls conlalned In I)aragraph 24 slate concluslollll ot'law
10 which a response Is not required, If II were Judicially delemllned Ihat a respllllse were
required. Ihe Plalnllff denies Ihal she received various henelllS for which she Cllllnol
recover In Ihls proceedhlg. Proot'lo Ihe conlrary Is demanded allhe lime ot'lrial,
25. Denied, The avenllellls conlalned in Paragraph 25 stale conclusions ot'law
10 which a response Is nol required, If II were judicially delermlned Ihal a respolllle were
required, Ihe Plalnllff denies Ihal she suftered Injuries or damages which may have
pre.exlsled Ihls accidenllllld which were nol caused as a result of this accident. Proof 10
Ihe conlrlU)' Is demllllded allhe lime ot'lrial
26. DenIed, The avermenlS contained In Paragraph 26 stale conclusions of law
10 which a response Is nol required. If II were judicially determined Ihal a response were
required, Ihe Plainlllt' denies Ihat she Buffered Injuriel or damages Ihat were nol
aggravated or exacerbated as a result oflhls accldenl, Proof 10 Ihe conlrary Is demanded
allhe lime oflrlal.
II'
!
':;
oij
',,1,
i.,
];1
.1
'I
!,;., I
q)
.{
';1'
"
.'
I'
d
'I
',I'
I,,'
I'
, '
,
1
~
"
, Ii
"
,
I
1
/'
,
'i
"
"
il
I
, I
'I
I'
"
..
.-1, ,I
"
"
I'
, ,
I,
"
Ii
"
"
"
I
,
,
I
; ,I->
"
;1
I
,
, ,
, !'
, '. I
I
, '
"
i
"
", "'~;/'! ,
i ':,'i!I,!!l!!, '",
,'," ",:L i..':;;;JD:
. - ~...."
'><'j
I
,.}'
r'.'
I)
,
',I
.
IN THB COURT 011 COMMON l'J.lIAB
CUMBBau..AND COUNTY, PJlNNSYJ.VAlUA
,J,J BACJ8NSTOSSi CIVJJ. ACTJON ~
P aintift
LAW
v.
NO. 96-6947
J.UJS HJaAM or~JO,
Detendant
J1JJl.y TRJAJ. DIlMANDBD
P~~I~ !!~~B ~~'B lfl~ ~ ~
AHanD t DD a IlI'S R Ii' 10 0 A
AND NON, this ~ day of October, 1997/ comes the Plaintiff,
Fiti 13ackenstoss, by and through her attorney, Darrell C. Dethlets/
Bsquire, and files the following Answer to the Defendant's Motion
to Compel Answers to Interrogatories/Request for Production of
Documents I
By way of further response, the Plaintiff has
the Defendant's Request for Production of
Documents and Request for Answers to Interrogatories. Plaintiff's
Answers to Interrogatories are attached hereto as Exhibit "A".
6. Admitted. By way of further response/ the Plaintiff has
now complied with the Defendant's Rtiquest for Production of
Documents and Request for Answers to Interrogatories.
1. Admitted.
2. Admitted.
3 . Admitted.
... Admitted.
5 . Admitted.
now complied with
IN TH~ COU~T OF cOMMON PL~AS or CU~Il~~LAND COUNTY/ PENNSYLVANIA
Plllintitt
I
I
I
I
I
I.
I
Civil Action ~ ~B"I
No. 9~-6947~ 1996
Ds!endsnt
JU~Y T~IAL DEMANDED
Pwm'l/l'li" S I\NSWJ!JlI3 'l'Q
!J!UNtOQ~'J'O";t.'/~QUl8T 1'0" ,.."O!:lUCTXON 0'
~~'J" or e!!ltnJ/ufl TO "'x.AX~TX~
Bll NO. 1
TOl Fiti Bllckenlltoaa, c/o D/lrrllll C. l.1eth1efa, li:aquJ,re, I'/sgner Bldg., Stet
205, 365 North 2111t Street, Camp Hill, PA 17011
Tho Oetondsnt,
~uia HiraJn Ocasio, by his attorneys/ (l~IFrITH,
ST~ICKtl!:~/ LERMAN/ SOLYMOS & CALKINS, li:aquires/ and Chsrles Il. Calkins,
Esquire, hereby demanda that P1aintitt answer the following interroqatories
under osth purausnt to Pennaylvania ~ules ,)f Civil Procedure 400ii and
Pennsylvsnis ~ule ot r.ivil Procedure 4006 within thirty (30) daYII trom the
aervice hereot. Theile interrogatoriea shall be deemed continuinq so as to
require aupplemental answerll if affianta obtain further intormation bet"leen
the time the anllwers are served and the time of the trial.
.1.... produc. the following document'l
36. All photographs in the posaession, custody or control ot the
Plaintitt, counsel tor Plaintitt, or any othor peraon or entity actin9 on
behalt ot the Plaintitt, including any insurers tor the plaintitt, ahowing,
repreunting
locales ,
purportinQ
to
show
any vehiclea,
or
inatrumentalitiea, poraons/ and any anu all other matters relsted to the
subject msttera ot this litigstion.
Soo Attached photogra~hs.
37. All diagrama, aketchos, drawinga, plana, measurementa, or
blueprints in the possession, cUatody or control ot Plaintitt, counsel tor
Plaintift, or sny other peraon or entity actinq on behsl! at sdd
Plaintitt, including any inaurer ot said Plaintift, showinq, representinq,
or purporting to ahow any ot the lnatrumental1ties, localea, peraons ',1.'
other mstters involved in the incident which torms the basia ot Plaintitt's
Plaintiff does not have in possessien documents reouested
Complsint.
by production number 37.
38. All atatements/ signed statementa/ trans(:l'ipta ot recorded
atatements or interviews, recorded statements it not transcribed or any
statement ot recorded statementa if net tranacribed verbatim taken of any
partiea, peraona, or witnessea as part of an inveatiqation of the happeninq
or cause at the incident in question, conducted by, or in the possession
ot plaintltt, PlaintiH'a attorney, insurera, or anyone elao actinq on
behalt of the Plaintltt. Othor than the r)Qllce report, Plaintiff
has no other statements and/or transcripts in hor
39. All expert opiniorP,o~!t~ilt'~'1!1,\:lorts, expert aummarie" or other
writinqs ot experta in the poaaession, custody or control ot Plaintitt, or
his/her attorneys or inaurera, which relate to the subject matter at thia
litiqstion snd the incident in question. 601' merlical records attached horeto.
In addition, presently Plaintiff does not have any specific
expert opinions/reports or summar1<Js in her possession.
When these reports are obtained, this request will be
supplemented.
40. All documents prepared by I'lsintitt/ or by any inaureu,
representativas, s'Jents or anyone acting on behslf ot Plaintitt, lIxcept
hie/her ettorneys, durin9 an inveatigstion ot any aspect ot the incident
in question. such documents shall include any documenta msde or prepared
up throuCJh the preaent time/ with the excluaion ot the mental impreuions,
ooncluaions, or opinions reapecting the value or merit of a claim or
None. Other than documents
detense, or respectinq atreteqy or tactics. prepared by tho Plaintiff's
nttorncv which documents are not
(NOTEl Aa referred to herein, "docUlnents" includes written, pnnted, sub 1ect
to this
typed, recorded, or ljraphic mat.ter, however produced or reproduced, di s'Jover~
including correspondence, telllgrama, other writtlln co!nmunic;ations, dsta request.
procesaing storaqe units, tapes, c;ontracta, aqreements, notea, memoranda,
snalyses, projectiona, indices, work papera, 3tudiea/ reporta/ surveya,
disries, calendars/ titms, photoqrapha, diagrams, drawinga, minutes of
meetin9s or sny other writinq <including copiea of the toregoing,
regsrdless ot whethllr thll parties to whom this rllquest is addressed is now
in the possesllion, cUlltody or control of the niginall IlOW in the
poasellsion, cuatody or ,- Jntrol ot Plaintitt / his/her former or present
counllel, aqents, employeea, officers, insurers, or any other person actinq
on Plaintitf's behalf.)
41. It not otherwise covered by the above Requeata, the complete
claims/inveatiqation/subrogation Irile(a) of any insurers or Plaintiff,
dealing with thll incident in queation, with the Ilxcluaion ot the mental
imprellsionll, conclusions, or opinionll
None. Other than documonts prepared by Plaintiff's
Attorney which documents are not subject to thls
discovery request.
"
/
/
/
/
;
;- > ~/
, '
/{
:'
, ;,- "
,j
"
"
/
c
"
'//
/'
/"
>
,/
-:/--
/
~
;-' /~
'/
/
>~'
"
u
"
"
"
,
, /
/
'/
:
/ ,
/
"..; .;~.
/
'/
j
'h
/
./.'"/
,
'> ,/
./ >//
/
/'
,//,)/r;
/~/
}
;'/--
/
<t" ,
',f ,.:-/
/"-~
/~~'>...~
'~r/;, ~,
,,'/' " r.</~
. '." ,
',-
/
,
"
/
.
JIlt
..
f
9. Of your own knowledge, what injudu did you receive in the
accident involved in this case?
Back injury, neck injury, and injury to right foot.
Additional information rogarding thQ injurioa can
be obtained from tho medi~Bl recorda which ftre nttached
to the requoRt for production of doaum~nta.
10. Of your own knowledge, list any permanent scars, disfigurements,
disabilities or discomforts growinq out of the within accidQnt.
The Plaintiff auffera from back pain and a atiff neak.
11. Of your own knowledge, plesse set forth the exact nsture of all
other present physical complaints which you allege are attributable to the
injuries which you received in tha accident involved in this csse.
The Plaintiff haa bac~ pain. Back pain preventa the
Plaintiff from lifting anything of any aize or weight.
Back pain alao prevent a the Plaintiff from aittinq for
long perioda of time. Back pAin alao preventa the
Plaintiff from atanding for any length of time.
, .
-
,
12. If you have b..n ho.pitalized by rea.on. of the .ccident herein
.ued upon, li.t the nam.s .nd address.. of sll .uch hospit.l., clinic., or
other medical in.titutions in which you were a patient as a result of thi.
accident, vivlnv the dat.s ,of confinement and the sums of money paid by you
or on your behalt, or owinv to each tor service. to you.
See medical recorda which have been attached to the
Plaintiff'. reaponse to requeat for interroqatories.
As updated recorda are received, thia reaponse and
the requeat for produotion will be supplemented.
13. please set forth the full name and address ot each and every
doctor or other medical person who has attended or ex~mined you as a result
ot the within accident, and the sums of money paid or owinv to esch tor
servioes to you.
(s) Lilt the date, month, and year ot each examination or
attendance by oach such doctor or medical person.
See medical recorda which have beon attached to the
Plaintiff's reaponse to r.equest for interrogatories.
As updated records are reoeived, this fesponso and
the request for production will be supplementod.
~
..
.1.... p~odua. the followtnv doa~nt.1
36. All photographs in the POIsuIsion, custody or control ot the
plsintitf, counsel for plaintiff, or any other person or entity aoting on
behslt of the plaintiff, including any insururs for the plaintiff, Showing,
repruentinll
or
purporting
to
~how
any
vehiclu,
localu,
instrumentalities, persons, and sny and all other matters related to the
subject. mstters of this litillation.
37. All disgrams, sketches,
Boo Attached ~lotographH.
drawinlls, plans, measurementa, or
blueprints in the poaBeasion, cUBtody or control of Plaintiff, counsel for
phintitt, or any other penon or entity actinll on behalf of uid
plaintiff, includinll any insurer of laid Plaintiff, showinll, representinll,
or purportinll t.o show any of the instrumentslities, locsles, persona or
other matters involved in the incident which forms the baBis of Plaintiff' B
complaint. Plaintiff dooa not have in posBeaBion documontH rOQuoatod
by production numbor 37.
38. AU statements, sillned statement., transcript. of recorded
Btatements or interviews, recorded statements it not tranBcribed or sny
statement of recorded statements it not tranacribed verbatim taken of any
partieB, peraona, or witneasea ae part of an investigation of the happeninll
or cause of the incident in question, conducted by, or in the pnslession
of phintift, Plaintiff'a attorney, inaurers, or anyone else acting on
behalf of the Plaintiff. other t.han the police report, Plnintiff
haa no other HtntementB and/or tranHcripts in her
39. 1\11 expert opiniotflo'il\lpfi~9!b!;lorta, expert aummariee, or other
writinga of experta in the pOBsession, cUltody or control of plaintiff, or
hiB/her attorneys or insurers, which relate to the subject matter of thie
litillation and the incident in qlleltion. Soo lIledicnl r,wordH attnched hereto.
In addition, proHontly Plnintiff doeB not have nny Hpeeific
<111pert opin1onH/ruports or BUllllnar10s in h,'r POSHllHHlon.
WhIm theBe reportH are obtained, tht H rLH)lIOl1t, wi tI b"
supplemented.
.
4Q. All documents preps red by I'hintir.f., or by any insuren,
representative., agents or snyone acting on behalf. of plaintiff., except
hi./her .ttorneya, durinQ an inve.tillation of. any aspect of the incident
in que.tion. such documents shall inolude any documents made or prepared
up through the prelllnt time, with the exclusion of the mental impreuion.,
conclusiona, or opiniona rOlpecting the value or medt or. a claim or
Nono. Other than documents
defense, or respecting .trategy or tactic.. propnred by tho Plnintlff's
n~tornev whiGh documqnts are not
(lIOTEI As reterred to herein, "documents' incluBOI written, printed, Bub~oet
to this
typed, recorded, or graphic matter, however produced or reproduced, discovery
including correspondence, telellrams, other written cmrununications, data r~quest.
prooessinll storage units, tapea, contracta, allreements, notes, memoranda,
analyses, projections, indice~, work papers, studies, reports, surveya,
diaries, calendars, filma, photoQraphs, diaQrams, drawings, minutes ot
meeting~ or any other writing (including copies of the foreQoing,
rellardless of whether the parties to whom thia request is addreased is now
in the posseeeion, custody or control of the or1Qinal) :lOW in the
posseasion, custody or control of I'laintif.f, hia/her tormer or present
coun.el, allents, employees, officers, inaurera, or any other person acting
on Plaintiff's behalf.)
41. It not otherwise covered by the above l\equests, the complete
olaims/inveatigation/subNQation (f. 11e (a) of. any insurers of. Plainti tt,
dealing with the incident in question, with the exclusion of the mental
impreuions, conclusions, or opinionl
None. Other than documents propared by Plaintiff's
Attorney which documents ore not subjoct to this
discovery request.
..- ._-~_~r.~..
-'...., _... ,', ' !
,......It
\
\
,
-
d j
CO~11ICl.5
. .
DR. JOHN N. P. JLlN .
K", "."III~ Willi 0""0'''0110 .
221 Brldg. 61.. Ntw Cvmbe,l.nd. I'A 17070
"lion. 717.m.",e
.
OATE (. ~/- ?'r
TO Mt/ll.l 1I1~uJrt1/1C~ Cu.
PATmrr Fl F~ Llt1ch~ll~to~~
EMpLOVER
PROGRrSS RepORT
.......~_.._._-_... ..---
CLArM -
OA Tr OF rNllmy /ONSET 12/29/94
~upptem~~~Repoht
I. 01Lt~ 06 FLut TltetLtJll~M 7/10/95 Odtt 06 Mo~t ReeeM E~am 7 - 'd8 _qfj
t. OI~lg~lIo.1 O-la9110~-LA 6./7. I , 7~ S.l5, 09. t ,
-
3. Upd.11:ed Ola.gIIO~ U,
4.
5.
,
II.
,
6,
I
CURRENT STATUS OF PArrENT,
/l~- Q,vo.1ua.tloll /uu, ~ltoWII'
" SubAtallti.o.1 cUltlco.1 pltogltu~.
1. SubUdlltlo.1 ~IJmptomd.tlc p/tQElIt~,H.
3. Subjective ~ymptOm4 dM gltaduo.ee" dimbttilti,IIEl.
4. Aeu.te ul1eubo.tioll utitll Cl1Jle modl\1li1Nr./ accOltdinof,/.
S. /legIl.U4.lo11 alld tJwLtmellt modeMted I1ceoltclinnt.lI: '_.
6, /.Wr.lad 4tAu.etU/ll1l. wQ,dhlleA4 dlld MuJrom~cuil1lt iIlUolbLUt,/.
~ PItl\ma.tU/te Itl\tuJrll to empt.oymtllt e.tlU ed dwtt e _I1CeJI.bdtiOIl.
~Ot~eJI...:::1::NllIA L I! ~~ M
PllogIIO~'u I
Fl1volt4ble ~ ~ POOh OU4llded
t:1)Ollgoillg tltVlApeutie el1Jle -LA ~lIat'c<Lfid wall lIe-evo.1UtLtioll.
'f:"' r lI.~eommelld Cd)ll? be 'eolltlllued ullilt 911.WeJI. Uabu.Lt!J 06 the 4uppOltflllg 4tAuetuJru
l1Jle l1eILl eved .
3. Pltuv.lded Itecommellded Cl1Jle iA 60ttowed.
4. RaU/tIl lo pltl\-~lIjlJJl!J ~tatu.A dlltlupdted 4holtt1!J.
5. BeealU e 06 pItObdb.lU.t!J 06 llLteJI. degelle!l4.Uve ell411QU ill both diAl! dlld o4AeolU Atlwu,
6. CO/ICUtlQII plVlmdlle/Lt. I do 1I0t exlOeu dll!J challl!u' 111 the 6tltllJle.
7. App4JIeM plted.l4p04~1I9 010. Pa.tient wltl lIeed Cdlte illde6.lltltely.
8. Pa.tlent edll expee,t udeeAbdtlO/1.4 111 the 6u.tLLJIp..
9. Pa.tlent wiU be lI.etuJ01ed t.o wOhh ClA 400/1 ClA the ph!J41eo.1 4tJ1U4 -LA beUeved to "ot
h4ve d deth1melltal 011 ltevell.41/19 e66eet Oil the 101109110414 06 he4l1"I!.
10. OtheJI.
,.-
Automobl.e Accident Queb&ionnalre
"'.... ,nlw.r III qUllllonl compl.l.,y
Our PIII."I r~" 11110'"'1110" 'I conl'~OlO~ conU~e"I'ol wo"..~ 1I"",,'olm.llo,, bOCOijlO w. CI'''''OijQ~ 10 Wlnllo know, I"~ 10ijr,,,IWI/I Will
~llp ijl ~.IIImln. " C~IIOpllCllc Cln h.,p you II W' ~o "olllncI,oly bellov. ymll coMlllo" WIII,upo,,~ "'"IIClo,lly, w. Will "ollCclpl yOUr C'",
I" o,~., 101 UI hI ijM"llln~ YOUI con~IIIQn PloPllly, pi.... bo II ""' .,,~ occuI"e II pOlllbl. w~1I1 compl.II"Q I~" lo,m, T~I"k YllU,
c: 'f'"" T.L _ \. ~ _ .. L c::- MII'I" . ) 0"001.. J _~ J 'om. (>?Cl7J...tr j) J
Nlm'_1--Lr:/_~'2~ 54.J__Gllhl..:u,!~ -C:.slllh_IW/Ll1. Phonl '777' -4LUf.J
A~~,...-)J:)!iiLl26:.ll.-I/DE... Clly-ALeJd.LL1.u;k~ckrJGIIII -f2 _ Zip 17a 7 ~
OCCUPIUO" f\C'"lJ ~ ~Jl.e.__ Who "'''''~ you 10 Oijl oll'co? ._,~("~J\'-
lI/lfliCIl. II c~II~, I"JIl."" hOUltWIII, unemplo\'lfl, relll1l<l)
::"~.J8"19 -.lgt):lS$f~:" YlOr\r- ~~,~~~_._.
5pOUM'1 apOijlt I apou".
F'", Ntm. Goc aoc . ___,___ Employ., ____"
LOc.1I0"
Loc.1I0"
~~'Z-~~{ ,
("
POlicy No"; ?7 "ir Claim No ~ ~~ .::>i:/..JS'I
2,5/./C S.;J.;J/f"f
Insurance
Name Company
Driver 01 vehicle In which you were In/ured 01 applicable)
InsurAnca
Company
Insurance Co, a
Driver of other vehicle (II any)
Pcllcy No, _
Name
Name 0' your l/lsuroncs sdlustor _
Have you retained an attornay? ~ Nc
II so, his name and address. '
You were heading CJ North CJ Esst CJ South CJ West cn
Other vehicle was headed CJ North CJ East CJ South CJ West on
Were police nolllle~? AYes CJ Nc
Were you knocked unoonsclous? LJ Yes )(Np II so, Icr how lo"g?
Vou were e,IICk from CJ Behind CJ Front )( Left Side q Righi Side
Vou were ~ Drlvsr CJ Psssengar CJ Fronl seel CJ Back ~eal CJ USInQ seot belts Cl Ol~er protective devices
W. hat were the time and date of p.....,"''"'" ~~ IG! -,~9 - '1 'L
Where did you 'eel pain Immediately aileI' Ihe accident? ~ 0.. K
Where were you taken otter the accldanl? -N
Whettreetment was given? P~I f"\ uJ:."\~ eQ
Wn any other doc lor cons~ccldent? CJ Ves jJ( No
It so. what wn Ihe doctor's neme?
What WIlS lhe diagnOSIs?
Whallrealment was given? 3u~t'
How ollen did you see the doctor?
How long Ijld you sse Ihe dcctor?
Have you ever had any complaints In the Involved sres before? CJ ves)( Nc
It so. what were Itle complslnts? -~-
Belore the Injury were you cspable of working on on eousl basis With others your age? ~ Ves CJ Nc
Are your work ,activities rostrlcted BB e result of this ~dent? X Ves CJ No
Since this Inlury are your symptoms CJ Improving? A Gelling worse? CJ 5ame?
Pcllcy No,
(street or highWay)
(street or highway)
r D,e" CJ M,D" CJ 0.0" CJ 0.0,6,
~ ~J.er-s .
I~ :>~ H 11\ P '"
0... v.. -,.-e (~
. 'I'U, Ctll,oprICII( "...."h 'Olln"IIIl)". It"
LllnomUIS;.
'0"" HI) '"
T
r.
.
. OR, JOHN 1'1, PIKUl.IN . 221 Brhlg~ Slr~el . New Cumberl1lll4, ~~ 17070 .
;g&HONJ! (7J7~77Lj - ~
STA'J1! 2Jp I~_ oliK PI-IO
ALSTAT S O,OPCI-IJJ.P ~
SOCw. Sl:!CUJUtY .__J"K!sJ -/"n-/c'L'fI_
REFEIUU!O BY 0:::Y'~ "
1'1.... "h""" Ih. 'pp"'pn.l. ho. '0' '"~ ", Ihl rnll''''"~ .ymplnm. whl,h }\I. 110\11 h.ve or h.y, ",.Y1"..ly h.d, W. ....111 .lIlh. '.elI.boUI )OU, hullh bd'
we '''''1'1 ~'QU' ,ue 'nlls IS A CONI'IJ}'IN'W 11I'A"'l1II\~"[JI\T1
111' C hill or N_ lII1 1!VJ~'i. liARS.
00 C Shnuld,,,. C) I' C NO/i1'_ 'llIROAT
o!!c Arm. 000 Aalhm.
o 0 0 Plb""", 0 0 0 Cold.
C oc Ihnd. ClOO C~d ~Y"
00 j( Illp' 000 P,,'n...
00 t !All' 0 Ill'o P.ntal p.r.y
000 /<JII" o)l'fOF-Ararh'
o 0 C ""I COO J!a, PlAth.,..
o 0 ol'lInr,1 rail 'I<1n' CJ a 0 ''Ar 1'101..'
o 0 liPoo, POIlU" 000 ~nllll.d (lIondA
o 0 0 limll<l 0 0 0 "nl.,,'d 'I11"""d
00 C Sp,".1 C',vil',. 00 C f.. Pain
a 0 C 5'''11'" JO'"11 (') 0 0' 1111111 VIIIOII
o 0 0 hr',IIIII'dn...
0Ab1WJ.IN1t!Sl1NAI, CJ 0 0 num ')'rouhl,
00 OIltI"'"1 0' q.. CJ 0 0 Il'y F<VIr
00 C Co',11I 0 0 0 no.,..n....
00 0 CDlo, T",uhl. COO N...I Oh""'''lon
000 ("nlllp.llo11 0 c: 1:1 N",.SI,hledn...
CO Cll1l1nhll COO No..blllll'
COO PlffI"III1I,"lIo11 ceo Sin,' 11I1,,"on
c: 0 C Olll.nll!')" 01 Ahdomrl1 CJ Cl C ~,r Thrml
00 C f.'''lIlve JlulI,,, 0 0 0 TOnllllll1l
o 0 OQ.II OI.dll., T""hl.
o 0 aH'molTho,d.
o 0 01111<111".1 Worm,
OCOJlunIlIC'
000 "'YI,T,.,'hl.
000 NIUI..
o 0 0 plln 0.., Slomo,h
o 0 0 Poor App'III.
o 0 0 Vomllln,
o 0 C VOmlll"1 01 1I100d
ofmllCIV AN~ 01' TIlE rOll OWlNO CONornONS TI'~r YOU HAVV. HJW
o Alroholl.m l!('>>11I 5<1". 0 0011" 0 /II1".m.,.
o All' mil 0 Pllh".. 0 00" 0 /11'111"1. SrI.,.,.I.
o APP'"dlcllll 0 Plphlh.n. :)1t"11 P,...... O/ll,m",
o An'no",I."..I. 0 f""mo a Innurn'A 0 "I.un.y
o Arthntll 0 J:mr,hYMm. 0 Lomh.,., 0 Pn.umonll
o Can'" 0 fpl 'JlIY 0 /II,'.n. 0 I'olio
o Cho,,, /Iff..., m""" 0 /11,..1.. 0 l\hlUmlll' ftw,
lI.vt \llU I~r ha~ rrcV1OU.\ Chl,l,ptl1tIlC ~,.tc',1 -ll.D.. 'f Y 1:...1;. dill or I.., ('11'1 __
00 >..~ h." "rAL1'''.n~ A('cnw~r In""nre'I'.JC5 If YI'.~, ..,Ih ,.".1 ro",",n~? -t1(' 'f)f ex
I. Ihll '" Indolln.1 Ateld'nl cu.? mil ONo ----,-.-- /II.lhool or P.ym.nl'
~~~
~j~
D~,
.llfoo AlI'/JlI
00001111.
o 0 0 ConYljlllon.
o 0 0 OW'"'"
000 F.tnlln.
0001"111""
000 F'''''
OOOJ,..doch,
o opn.o... or Slur
000/.001 01 W"~hl
oRJ'o H.rwu.n..../IJ.p,...'on
cfojJ Hour.IIl'
O~O Numhnl.\6
o 0 0 s",..1J
OOO'rltmDIt
MUIln Jl A JOINT
OOO/ll1hnll.
OOOllu,.llI.
o 0 0 Fool Troubl.
000 \l.ml.
OOll-ow Jl.l,. p.ln
oOol.umbo.o
000 N.ck Pain 0' SUlfn....
o pfO P'IO Betwe.n Sho,ld.1'II
ConfidcnLlal PaUenl CllSC tllslory
CAJUllo.V AIlCUIAP.
000 "'nJ'"'"lol AI1'nu
000 JI,atJ 1I100d ",....u,.
a 0 a)"", lll00d I',....u,.
o 0 0 Plln """, JI"11
000 POll' ('1",,1'"011
o 0 0 II.op,d JI"n 1\..1
o 0 0 SIO\II "..n nClI
000 S"'"1111 of Allkl..
It WI do nDllln",.lv htlllM )ou, CDIIdllloll '
0)' C Rl!SPlRAmll)'
~~ r:. (b,,, Plln
o 0 ChIU"I. Cou~
o 0 Plm",lllJIt'lhl",
000 Spill tn. up 1I100d
o SO SplUln. up Phi.".,
o jIlO WhUlJn.
IIlml
00 0 /loil.
00 0 U",I" l'Aaily
J.! 0 0 n~...
000 HIVII 0' Alllra>'
0110 h'htn,
o 0 0 SklO Il",pllon. (/lNh I
000 V.n"", V,,".
QeU~
C C 0 /l<d. .lIln,
o 0 0 mood I" Unn.
o 0 0 P,.qU'"1 Un","on
coo l:1lII1~lD(iJlllU~
o 0 0 ~dn.\ In'. ell on/51 011'
ceo P'lnl" Unn.llon
000 PIOIIII. r""hl.
o C 0 PUlln Uno.
/'Oil WQMPN ON
000 CDII...I.d n,...1.I
00. Cram", 0' /lIc.,ch.
00 lJ /!.lCUl... /II.nm\l.1 I,'
a a 0 /101 Allh..
ceo Imp'., C)'I'
00 0 LomJllln nlt..1I
000 /II,"o",u...' Symplom'
o 0 0 Pllnl,l M'"I1",.II"n
000 V'Il".1 O''''h.,..
o Sr.Ii.1 PIM'
r:l SI"'.'
oroh,,,,.,,,,I.
o r>>>hOld F.w,
OUI",.
o V'n.,"llll.....
o Whoop' "' ('lIu,h
o CIIh/Ch,ck 0 /IIC 0 \'
.
"/,11I, "",,/: ,_ 1:) ,
"'hili I~ \llIH m",1I1t 1"''''''10111'11'1 .-f!J! E_~a:.. j-fl ~ ~- ___"
lUber ...IlMlrl.,nlll ,~. ...
~". Il1n~ ,.." "lU ,,,. I.", ""1'" m"'V'"n1) ,,,,,.,,",," ,v, )!'ij h'.I~I~''''t "".11'0"' "Ih. pilI'
h.llrllvlllU '''''\'flr \\H', Imllor romp~'1 I~ ro"~Ult1n',1 ~, QI-i1 L-.S;J_
h Ihl' C'\1"I.IlIu," J,II",. plll,"",.wl)' Wll~" .~ a No. ~-C[I,)" I nl l.'MII ."iJ lllt'
h Ih" "".,lIl1n '""ri.nn, ""'n ~\lij' "'~ )Il\~llff ~ :ki)IIII' ~ijll"' 0 ()Ih.r
U"" I"", hI> II h",,"nrr "'ij" t..II~'" J"O'I'1 ~ ~ L fL 7 t:!:1OA"""f1, ~
Whit lJu )\HI hrll...... Il WJ1.lM, With )1H~"
l.lpt IIHllUI npertlltJn' Inlj \1111
Cll.NII' ..IC. ~lij n,", ,,~. 0 ""rvr ",II. C P,",Killm C MuOtI. Il.rl..." C 'I;'r'(~' 0 T""Qijlll,." 0 I"'ijl'"
)Qlll1h """'mll',II. :: Olh.r~1S':~ 11\' 0 I I
F,.qij."." 01 .,"'" """ 0 ""IY 0 /140",", O,..,lr <x1I'1Ci/'t 0' '!J'l'lfl'"r)' lI" I d (n",v',', U'"'ijru
At. 111 "IU, ",III,... __l:vrr>. (' /14.11,..." 0 ("",r"l1Ibl. Lnro"",,".hl. 1>11 \\1U u... 1I..lIool1l'! ([(.,
Arr '\lij "'.n"~ f OJ'''' t"" C 5<11. tll'. 01 nrr So,'.. 0 ^"'. ;ijVI"'"'
II... Illij hun In on 'ijl" 1<'<'.'"'" 1&:1" Ih. ,...1 'u, C In Ih. ru, 5 ,.." 0 0.., 5 ,.." /I,,, 0 Nrvr,
".h;teenhr
H.w yuu h.iJ .n~' olher ptrMJn.1tnlury 0' 'l'tIlJlnL" :: In thr "ut 'ur C In 1/1c-jillbl ~ 'urr:- a lMr ~ 'CI~ ^IO ~Ycr
n.Ot~h.
HI'" \'0" twr hall .n\' MI"'I.1 ur tmollon.lllIMlJ'\Jtra-1 ::"t~ 'hen'.'
II,.. "Ih'" In ",ij' 1.""ly h.. nllnlOl/.",oIlO".I.,,,,nJ.,," :::Y.." Wh."!
fAMILY JlEALTH INFOR~TIONI />Ion, h..llh pmhl.",U,. Ih. ,..ulI or h.,..",,,, 'v,""....~nr....; Ihlll, In'"rmll'''" ahoijl >Ilij' r'mlly m.m!
"'III II" ij" b.It., IC'ij" '" ",ij' 101., h..llh PICtij".
NAME
RJ!LATIONSHIP PAST It PRJ!SJ!N'J' HJ!ALTH PROJJLJ!M
.
0'..
)(,..
'=,,,
~..
0'..
>>"
_.:'\:lJ
X....n
::: 'II
~"
\1....0
"0' No
~ll
1>I'5CI\lII" 1II\1~FU
-3Ht"r rHI tt.& C'DI\ "W~('l{
_" T -
_u-\~~_P:u\ C-C>.I u.;\-.. C \<-
0...18 />I"nlh. 0 Owr 18 Month.
Oo.I8/>1"nlh. 0 0....'18 MOnlh.
10.18 Monlh. 0 (lvr, I" M"nl"
/,,18 MOnlh. 0 (lvr, 18 MOnlh.
/,,18 Monlh. a (lvr, 18 M"nlh.
Ohol8 Monlh. I.! (lvr, I" MUllin.
"""18 Monlh. 0 (lvr, 18 MUnI..
o MOO."I, 0 LJJIlI
o Moo.,.l. )(JJ~I
o Moo.",. . oll~'
Cl Moo.,.,. ~'''~hl
o /l4oorrll' '''llh'
~o 00.,.,. Ll~h'
Mncl'''~ p;l.~.t-
~~~
MNrvr,
'Ci'Nrvr r
01'1"",
o N.w,
ON.....'
0.....'"
o Nrvr,
JlAVI' VOl: I'VJ"l
Ilee", knnde.j unl'onM'l[)lu"
U..~ a tI". 'NlCh, 0' olh" 'UVf"'I1"
I\..n IrlllllJ tlJr a sr,"t or nerve lIIMll"Jrr"
lI.lI 11 'rlclu,.d hllnc"
nun hUAI'lIl1l1nd (or lllher th.n .urJltr,'"
00 VOl:'
Now like Ir1I.Mlnll1r mlnlrall?
Think )'Uu mil; nnlJ \11'"""1 ur ""nCI1I11
",w '" ."'11)' 10 on~ .N8'!
DATI' Of ~b1"
hpln" ...mln,lIun
f)hYllc.1 cumlnillllln
1l100001ral
Chul )(.fu>
SV,",I )(.l\Iy
nllll" )(.l\Iy
U~n' ,....
IIAnn'!;;
/Iln>II,,' 0 IIfI")'
(',,".. rJ II..")'
TOD.em ~lhavY
nNP 01".")'
"..rell. 0 II..")'
Slflp 0 II..")'
AVprllt. 0 II..")'
PI....,III.1I n".III"", '''r~hI,h )"U hov, lI..n tr"lr~ In Ih. J1III JO )11"
C""
~,,,
c,,,
0'",.. Ihon 'J MOnlh.
~.t1A Ihan h f\h",H,&
o l.loU Ihln b (\funlh"
01... Ihon b Ml>ni..
o ,"'.. thin b M""'h.
o ,"'.. Ihon I, MOlllh.
o '''''''h." b MOnlh.
celeb.!
'tI'Non.
'O'Nonr
t:l No".
~'f\on'
. a'Non.
o Nonr
o No".
IN cAsl'rlU' I r,lI'KOi;~c" Ir"'" "v. loy "''''' "' a ,.,.".. or flOM l}lrn. not ""nl 'YI"u, ..!lonn),
,
,DR. J.OHN r P.JL'N
Kup H.a'thy Wh.. OhlloPlactfG .
221 e,ldgl SI,. N.w Cijmbl,l,nd, I'A 17070
/thon. 717077408181
i ~ I
CC, I~).?
~11 '
....
vm: 7, ~J-=-!15:-
',iJ Mtlla. l't6UllJ1IICr Co.
f!i.OGRfSS B.rJ'ORT
PArrENT
E/./PLOYER_
SUpplQ/!l2/1ial R~E.glLt
Fi Fi Ba.dlellh,to6-6
CLAIM.
DATf OF INJURY/ONSET Itm/94
I. Due 06 Fwt TltecLtme,tt 1/10,''/5 Da.te 06 M06t Recent Exarn-J-- 38 -Qs-
t. cllLlgJ.nlll DJ.a.iJ'IOhi6 .10/ 7. I, 7~ r,. ~~, 839.21
3. UpdU2d Dia.g"0-6L6
4 .
,
P",f/.Hnt Subjective Compfa.J.nt6 VJ(t/!\J I~ ;\"\\0 {'!'J~
it~ ~~~~"J C!J:dl!-, NUrV'l r~M:;;~ / - ~~I
.~IN ~lfo.J S./7T1A1~
~1tf/.42M Objeaiv~, Ftndin96~f1\" 'IP~""'Tf?t)P~,
ur~~kD~.~tm~ .., J~t. f{t.lJ.5o.Jr."JdN'
L- I- 'c~ uLI2-I.c.J.... I ~1'IY1Ctl~:r.. L -SdtJP.P+
Lum6,.LJtJ<.1~m6 {?L,J;T7./Jmfl~" . tLl.Kr\S
TntelLim A9flll4vcLt-io,~ o1r Acudellt6__v' .
..
,
5.
6.
~
I
CURRENT STATUS CF PArrENT,
Re- evlllua.tJ.olI ItiLh Mlown I
,. Sub6ta'I.uo.e cl,t/Lic.u: pltuiJlteh6,
~. Sub6ta.ntia.e 6I1mptoma..uc PItOfllt( 66.
3. Subj~,cti.ve 6!!mp~01M dlte gMduaU'1 d imillL6lrillfl.
4. Acute exaceJtbatioll wit" Cdlt~ modeltJ1t~d a.cco"dillof II.
5, Regltf/.46J.olI a.nd tJteiLtmellt modeJtllted a.cCOltdt/1Afll." '"
6. Ma.1lked 6tJtuc,tuJutt wea.klleu a'ld 'If/.UilOmfLloCufdlt iIl6ta.biLitl/.
k-, PItf/.matlJ.lte 1t<<lJ.Itn to ~peO!fn1e'lt cauh ed acute, f/.xaceJtbatioll.
~OtlleJt -;-tulll~L ~X:I"-'M
PIt09n06U,
r-l1volta.ble _ ~\ roo"
~OMOJ.n9 thlVtiJ.pl!tLt,k cdltei-6 i~r/ willi ItI!-eva.1uatlon.
.. 1 1\2comm2nd Cdltc be' continu~d ulltU 9ltWf/./l ~tabUU!! 06 tl,q 6uppoJrtillg 6 t\IlC tUlle6
Me aclt,ieved.
3. Pltovid~d Itecommended CMf/. ~A 60tlowl!d.
4. RetUitn to PM-J.lljlJ.ltlj 6tatu6 alttiC-ipl1ted 6hOltt1I1.
5. Becau6e 06 pltobabiUtlj 06 etUeJt de9~neJta.tJ.v2 C{ll1n91/.6 in botlt dlhc 11.1lr/ 06H0U6 6tltuct,
6. Concu.tion peJtmaneM. I do 'lot Up~ct an!! cl1l1n91/.-6 J.n the. 6utllJte.
7. AppMeM plteciL4p06J.n9 DlD. Pa.tJ.eltt wiU n~ed CMe ~',IIr/f/.6lMt~,e!l.
8. Pa.tJ.ellt can f/.xpect f/.xacf/.l\batlOIL4 in the 6utlli\e..
q. Pa.UeM wiU bl! 1t<<lJ.Itned to wOllk 4.4 600n 4.4 tile phlj6J.ca.1 4tllf/.46 i6 bel1l!ved to no,t
have a. detlt1menta.1 Olt ltevellAing e662ct on till! pltogn06J.A on hl!dtlng.
10. Othu
., "
~T VIEW
GU4lrded
3ddOHE 3NIJIO!W !HL
Nt J ~)Illl J lJllllA J:lV It! NV:l IlOA
'.'r ..~ ....-. h'~." ~')I\' t~:~?1~:)8"
~.
~
f
I,
iE
=
I
~
,1 ~
" ~
. ':.... '"
t~. ~
..: "', r
....,
'I.'
'S
0..' "
-
. .... ~
.. '" , .
0 -, Co r.'
.! - - "
1--
- , :;- ...
'" , ~ '
- -
" - 'r ill
" ~1 =
0 - -
, - ~., ~
-
, - :.J 0
..: - !
,
" ~~
,;:, -
t"
- ,-' ~u
- '" ~
..! ".
" :
- ~ ...
, - 'r" ~
h,
" , ,"
- .'
- - " 'J " ~
- =
,~ I:!. , ~
. , - I..' ..:
" -
'- ~ :Ill I
::i !:: ~ 1J.8
- -
- -
1; -
- :1 ~ .J IYIl
"I.
=: '!: - IV
,0 0 ,"
- - - .:;.
- - - -
::
~
I'~
I
.' T":! ?:':"'Tl:- ~~tJ'~r It:'!1rr.t:ll~1
~c Hl'~3W ~101 8NINYEJNC2
r"",c 1,':11>1 lQ/, "vI31eQ~,:
!JC 3IJC:~ 1'::;;:':: i,N'~ Nt! n0'
?6[na~ !'&~'I~A~ 3~~
J..U-f I C I.J.... ~r1it
3~dOHS ~NIJ!a3W JHL
NI J ~;Il\j J IHIlIA 1:IV 101 NV:) tl()A
ell, . '....:. ~J ,_ ~
':~:]f'I...~:J \']C'_i '".;11PN~:rr ::~.~..
!.- .'1(:'.' ;j1~1: .;_~t.;r.; , .
~I
H~
~
"
~
.'
;-, ~
j;;
, -
" -
:
"-
.
-=
a..
,.
~
~.~ -: r:
- ,... - ..-
_ -<0,...
:;: J '!I
, - -: ' of
~ . -,/
:l _ l,!l
I
...
r.:
i) I =.
1m
~I m
~ ~
f-
~
~ &;~i;
I. ~
-'I
'I~=
, 'N
- - .
- - 'r
..
"
.
;i '. - #
,. -
- ~ -
-
. -
- -
- .
- ~ -
-
'" " r, - -
:r ~ -
::. ':: ' .
- -
~
~
:
-
"
"
"
;J
'"
-
J
I'
,:,
:r
.~
'~I'~'"
OJ "
"II
,l~
:::e
~
!~
~~I
I:
~
~
J
,-101
4.1.8
V~
8V
,
"
'oo ~
-,'
"H"I.'I 3Eto..4~~~ .::;~'1(1:".':;4: ~ .1~:'J'
.,~ '"~ ..':'31_ In'J/ ml,~I~:;:~II::
;JI\':!H ,',..,w no), sw::ac,~,:j
Ole Stl(11,:.::3nl:J ....NI:' 'It! 11;),',
:~_~ ~. J,:. :~-:a~:."'.~'; ;',1 3':J~
";.JI::.. ~ f.1 ,..' .:..;; I :;':'IJ.l..tI::'I"1';: ~rl"':
VW~, Y~~~;~;:~_M:fv~I"~v,
,
~~~YNS~fRfT ~~~~ITAL
~AMP NILE pi 17011
THIS ~MOUNT I OlJI IV
- ----_.~._.._.,.---~.,-.
24.79 021015/96,
r-' ---.-- .,. .......--.-..-,.-- ,.----.---.-
I AMOUNT PAID ~ I IS
,.___. nH_'_' ._____.+_ ."...___ _ ._._+_ --_____
I
~CCOUNT NUMQ~R ~NO N~M~
IIND
'~Y~INI
10
NOLY SPIRIT HOSPITAL
50S N i!16T STR~ET
CAMP HILL, PA 17011
.' ,.,.. ...,.-....' -...... ........._--..
RE~NHI~B'8~IMANOA L
FOP INFORM~TlON ON ~CCOUNT PLPAQ~ C~LL
- -n7~76'F2n8u ---,---
~
" a~~ BH
i &81
I NR 1
110/394
ltNONE"
210S0
NSG
64156800
F E lIAC~E~ST2S$
h~~ ~G~lIE~L~N6~~A 17070
.....................................................................................................................................................
f..~cc ~rl 'tlJlrt, r
"'!lfnl ~il'"'
&,'~'C, 51 In
~t.",r'''1 CI'I
64/!68lJO '1(' '"
R~INHAROT ,AMANDA LYNN
11/08/94 i,"" E,"
o 116/96 '.W ;"".,,, ,II' 1;2 n 6 194
1
OUISTIONS? Pluu alII'
717-76S"i!lS8
CQnl.clr
---- .----....--.---.---. .-.-._-.
ACCOUNT B~L~NC! eSTI~'''fD l~oCPA~ce Due TOTAL PATIENT CR~DIT5
~_____. ____._..__.____ __. ....._.__.____. _.u .. _ n'_ .._ _ u..
I '...J",llII,_Itoois..........
i!4.79
,00
24.79
TR~NS D~Te
Jl!6CAtPftO/'j
~Mou~lr
tt/~8/94
1 8/94
1 8/94
21 6/94
PREVIOUS BALANCE
URINE CULTURE
OIAG FVy UIA
OV-OP F WEST LVS
MEO ASS '( HOSP - OP 071 FMIILY CARE N
. ~ 0
i!9. 0
7. 0
37,00
48,21-
NOR HO SG ACCOlJNT BALANClI i!4. "9
S~~~~i~'EV8~hl~~~fNINH~fl:b~~o~~EN-RECE IVEll AS REQUESTED .-- ----
PLEASE OISREGARD THIS STATEMENT IF YOU HAVE PAID,
,.
I
Pllllllnlll Idd/III 01 IOIU/I/lCI c/ll/lin on bl(~ Ino Clllck IIlII boa 0, PIIIII ollac/lIlOni dollld IInll/ld ilium IIlII polllOl1 WlIIl 10111 pllmlnt
PLIAII PAY THIS AMOUNT OUI SV
Y~sYNS~f~~T ~2~~tTAL
iAHP H1LL P~ 170 1
3B.00 02l2219fll
AMOUNrPAIO ~ II:
IIND
P~Y"IHT
TO
HOLY SPIRIT HOSpITAL
llOS N 21ST SIREn
CAMP HILL, P 17011
,
ACCOUNT NUM8IR AND NAMI 1
~7B6flfl2 I
BACI<ENSTOSS ,FIFI
POR INPOIIMATlON ON ACCOUNT, P~IA8& CA~L I
-2 38
L
~~DHOTl 01l99fl
K SH OT I *NONE*
. Bl 21009
i 717-770-0481
~HRl flSG
67B6/3/32
FlFl Be~I<IiN~T~S
h~e16BN~EREAR~,PA 17070
...................................................................................................................................................,
Pllllllnlll 1001111 01 InlUllnel ehlngll ell ",;. ond ellW 11111 boa Cl Plnll d,'.ell ,'ong doll.d Iln. .nd IlIUln 11111 OOlllon WIlli 10UI Ollm.nt
PLI~SO P~V THIS ~MCUNT I DUI BY
37,0003/1iZ/9/3,
AMOUNT PAID ~ I $
H~LY SPIRIT HOSPITAL
5 3 N 21ST STREET
~ MP HILL PA 17011
lING
mMlNI
10
HOLY SPIRIT HOSPITAL
503 N 21ST S~r.SET
CAMP HILL, pr, 17011
~CCOUNT NUMSEII ~NC NM"E
BACKE~~~3~~l,FIFI
, ~ B+l ~hg~~~.
, ~H_770_04~t030 I
~ HRI HSG
6734271
FIFI Be~KIiN~T~S
ARw16BMBEREAR~,PA 17070
........... ................................
........................... ...,....................... .........................................................
"
,
HOLY BP~R~~ HOB~~~AL
Act 6 of the Automobile Insurance Reform, for the StAte of
PennsYlvania, requires Holy Spirit Hospital to bill your automobile
insurance carrier directly.
We currently do not have all the necessary informacion to bill yeur
insurance. Please complete the following. Your insurance agent
can provide you with this information.
,"
Patient Namel L>, (',' .(,"",'" /..)':
/" T -,'"
_ .r.
Patient Number:
..., . J;;'; ...., _ 'I
..., -,\.......
'. /r
( J,JI''':_)
/
.
I
r-
~ )-.~-
~. -~
Name of AUtomobile Insurance I
AUtomobile Insurance Billing Addressl
Name of Insured I
Pclicy Number I
Clain- Number I
Inllurance Agent's Name I
Insurance Agent's Phone Number I
If we do not receive the requested informaticn, within twe weeks,
this bill will remain your responsibility,
Thank yout
Holy Spirit Hospital
credit Department/Auto Insurance
503 North 21st Street
Camp Hill, PA 17011-2288
Date SentI
/'I'}'
(.) \- ,-
,-' ..;
..; ,~
( ~. (~.J
BUSI 131
Revisedt 1/94
E ~"il".( llll,:N'
,',h'
HEAL TH INSlJl1ANCI CLAIM FORM
I'IV 1111
.
~d I"
E,'UIli'll G~:' Hm "J
11."IlIMIIIIJ.:III)M.Ul:II.lll~'IJlI"IIIlIl"lj"I,.t'lIIl'.'tJ'I'"
C~ J'CAIODMeo,cARE DCHAMPue [~ iE/l
PA TIB!f
~tll\
'~I
714'';~IT;
~ .' I'"
:'1, I~
ATTENTION
'1.1''','''0'
--:---_...
, ~:,..J~,.:t'~
(.\ . ~ I
For your convenl.nc. .ncloud Ie
In Ineurlncl form.
A. SIon your nllm. In blocke
numb.r 12 IInd 13,
,,1':{;t:", B. WrIt. PollcV Numb.re In
J,,'~,.. BOil.. 6 und 8.
PHYSIC
;;--:;r.7" C. Forwurd 10 Ineuruncu
, your
L Compuny,
,~ "'''J.l1 '.' It.n THANK YOU.
:' "",YI" '"
'IJJlJoI,.",UJYfD
lJ",.fJtJIIIlQl,lI,
;il",j,o,-,",";'''~-' -, r "r.;oiiiiffi"-;;;;;,,";;;;;;:;,;;;;;;-';;"',
(,/, I JlU '~4 f r r,c: Hmfl,r,rn
;;11.;.-"-- - .i;;iUiiiUJ "'tlllt;"lltA,,~r;I~-:""W"'~If"'''1
m,ljOf.ilr-' ".'" I
~TrrfrC'-iI1r~~~1~1;r~iiillm-'t".'.it,1'i;iiill,-;rIlIII./' "1.1 /lJ~ UI_ ~...",
l!..-,~ ,hIUJ, )11+1~1 I
m, ,
_....... . ..-.-_.. -. -------....- _.~--_.._.-.----._-_.__.---_._._.. --"'-'---
\.'O~'HIII't-, ~hU'l) III III Ik"/"'UI ..ljl)lltu ,.,,"' ,.11 ",11 /1"10'"
,
IA!IIN'II""H.n"".""
1(1"
1./.',} l',nG~\ F.'IVE:
.--r..............
1UL- ,',", I""
ICCII)'"'
~>; ~~:;~-
r~F1. CUi'1flicl,l.M11
r.'(" 1 1'070
.., ,,," IJ '1'"'""" .,n,,,. ,..,.", :"/1"1"""
''''~'IU''''''' IJI't'i.'tIl'iJlrl"~I' ()n~'M' p, c,..
'"
'......''t.''.,..'; r '["'t'!' 'II"""
___~_:..~___J.!:!!!!E.;:,."'.r'''~II'''''''''''''''''' . '.'"'' j ,. _'.
00',11'1,,,,""
rI!I.I'-.~;~:7Y':-:---'-' 'ii'7.'~I; :,pr!~, '. ! vt~1 !:n~ ~"1J1
"6. '.'"j' "!I:H"".:...
>II
"'"
1
--'-"~---'-'._------I~il~;;"ii.-~~\-
'!::..
Ihl,1. 1.,lIll...,,"
r: . ,;" II ~ " '1'/lf' 'II' .' "'~"", .1..' ,.,
',lot h'" '.'.1 I'iN!)'!I.
,'U""I"II' IMC"lIlhHC'
iI 1)1.. ....tJIUIO'I' Vttlll"~IIl":II""1J O'i:ti,';,', ~'.II CHIC.
l''''
.... ,:;.i
U',W" HILL I~(:. J ;i(JL'
:""'''111
,,'
~ I.' I'.C'" '"" ','1l/AI ,;, "lh,U '1" IIl.~'" 1l1~~-'-IIl''''llllnl' "I "1'IOU','" '.. r<H.,,~I," .'m";ii;~ii'''l' ~ j . t: ." IU rn.J."'l-~
" ,',', I" 1 r',~J',lr: 'i ,. H~II,~J't
"11"
~tr~~r"L
~
"
'1o;==;
,"
~"c::
,..,.,........,.,.,..,.,'.........."..................,.......'
"'IOIt
, "V'''''"I,AUl''''''';
.
il'J:I~'
T' ~,',t:.
f' .: ~I,,~l" I' 1"111 '''''lr;.!OV~mlnlcA~i.."i'iV~~~l7.,.---
I ~~"'c. '1J"r.I., 111 ur: I ;"'H 'JI~JI\
';/ ~..,..~ItN Cl)Ul , . .. .. ' ",""" ."", ""..", ~11I11t-,C'11
I '1 "VII::; , 111)'''''1"1'' ' ..~~..I" I. Ii ~. ~ t IJ... , ~'Ull <:1'11"1\11
:-'1i=i 'Ft:!,) HIlNY;-:;" It, -:\ ',I J'f:~,';::;---' -'-9t~"i":"I-~~;',: .(~I)
'c;.t
I'
. ...h"~."ll
c"'~
.~rfl
1 ,I
......,.......... ,....,..............,.................,................. ,.,.......,...... ..,.,............. ,............,.. ...................."...............,..........,.."".,........".....
.......,......,.....,...... ..,.......................,,,..............,....,..............,,,,........................
......................,. ..,..................-...........,...,..,........ .,..... ..."............... .,.. ...............,..............,........................,.........,..........................
........."........... . ..........,~...
..........................,...
...,....................,..u......,'.._............................ ......................,............................,_..,...".............................
"""""""'''''''''T''''''''
....."........................................,........,.,...........
,
(........'.. ................... ..~..,... ...~... ......,..... ..... .-....... ..... .... .....,..... ... ........ .............~... ...... ....,..... ....j. ...,...........1... .....,.. ............................
, I. I I
r...... '" .....,................. ........,... ............. ........, ................ ....... ...... ..". ......................... . .... .....,.........,.... 'U. ..... ...~..... ........ ........... ........ ......
i
In.'tj...At\J~.Ir.I"'''-I~II.II''l'I''
::.~,'~t,:~.;~~.:.~~~':~r...~~~1', "",,. .,,~ I.
11)1:" I',. ,'.N P ,D. 1,1 1.11 U I\N " rO)
<, . ~','Jr: TUHl" Or,1 I" ll~,
!. ". IA~.lP~"~\
1111,,'0 _
U 'DV""'I''''', ~CClllJ"'t-jll
H::. :iOm j t [$
'r~~eIO' u~'"',. 0' IIII'yltll,'CltCtlllJIO" 'lll,AC_
",1lI~"_1
I :~,!Sa~~~n:n~ltJ11 iJ~1, ~ I '... ""'It
I
:;' -'c~li'--..--..~ii-r..Mi~.io-.
I
;~:.~ '~t!l~..L..._..___._...,_...___~~_
1.1' ~~'~'~~~~fl~~.l 'lI"UlIl, "'Mill ..,Ill"'" ,., ,~tll"
I~" 2, rd17MM'1 ~,GfqJr: !tIC.
.'''>30 r,nTI:.':I'~ 1'~IMfi
I
~E CH M,l C GFI ur, I;
110,,0
I~ .".A,.ClOvl
i rnl ! 1M
I't 'GuI'lIO(I~1, ;1~l.l'ltt~ NO
u ~UU" '''''I,O~'I'l. 0 "I)
)~1'''173'-S>6E.l,t
r"I'. 170r'j[;
"""lvIUIII""""(,l)ullLII,Il"''''ICIUlUl'ly'rtUo
lI'I'lll)vll) . ~ '''I "I Al '" (,"111
""II"(I"I)_n"""IIII"'Wl"".I'II""l,'
Fain' AMA,OP,40e Form HCFA,IIOO IHOI
Fo.m CHAMPUI,IO'
, '
~
-
-
.
'f.r
..
-
,..
''''
'r-
)(
~
~
,
z
~
.
N , ,.
. .
.
< ! .
~. l:
~,
~ .'
,
~ ~
~ :
" ; ~
, I: ~
I
,
,',
,',
-I
,
.
.
,.
;;
"
~
;;
Ir" -
-
"
,',
.:: '"
.... ~
- ,...
. :-.
...,
~ '''l
.~,
~~i
..... ,~: .::
iJ; 'i'
ll:~~ "
..
..
~ It;.
'II.
,',I S:
It
'" :5
,'" ',.
lJ.I<r :1l
'::- ~
1.1..'~
~ ....-. "0
o
.
~:l
: '.
P\)
~~
~~ (.
t
I~
.
~
I ~ I
I
j--"
I
I
!
. "
, ,
" t!
-= " .
E iJ'I
. ~
'A -~----~- -- -
0 , ~
,
'...J r; . l'"
- ~ ~J iJ'I
(ij
.- E ~ ri
~ -
~ . '='
~ ~ i ~
c I:'
" i
r... '-
. c.
Z I'. t- b
... \1.
~ IJ1 I: 1i
. ,). 53 E ~
'= 5 fa
... J.
~ ...
,::,
i~ ~ ~
t;l<t i ! ~
~ I:l:Bl <t I
... W I-
0 (i ~ ~ ~
, i
. r,
N I. '" a ~ 8
...
. :a
< . " w<t
0 ~
\.I....
~ ' "
l= ,
------...
QLV "J~J HQ"JT~L
I ""IOU'" I~':',',~, In .IIT IT
------ C~"~ HILL, 'A
~~~I; o.fJI'It 717 163."4'
~ '1" 13.'.t.7~7 1I/IIf74
~ P~A~--"-----:--;:;'i~~,~:::;;--'-1~~.1-'''''';'------~~~,~~,~~~-~~'--'--,::~.-:-~~--
-IMDH.t:: mr-"---"'r---"'''''-Ii't.-' "lII'jt'"- "lI.4IUl..-......,'--_._-- .,-...--.---.-
!I9JJ...J ,----__""..._,JJ_ !tLJt L,,, !!,_ .T...",..,..__.,.__,,, n" .., ______,.."... .
.---
r
'-,~
oIl,l:
I"JlI'I IACI<I"ITOI
'041/ ItOIl Aya
HIW CUHllltLAND,'A 11070
---,.--:, . ,f ..', - - - " "l!U'
1.....-..... p.--_.__.._......_.._.....,~. ...'..._.._.___..___._......_____.._
I
iJ\j",Il11/'t'd
"
I.
'-.Ill.
I AUTO 1"' 49
. ~AHILY CA"I HITWO
U71T3'401'
1176161416
ACI"Ul
'-'''''Alilll t~ --}fAllt" ETT """D --..--''''''----.,,-
""1 ; I'"
F,EASE RE"URI, T/1I~ n:1R nOI> ',', ~f' ',":1,JI' '. 1,'['1,' /~I().41k t'-((UI'
,
" '
'1'"
---- ~.------._--~._._..--_.-_._..~._-
DETAIL 0' CU""!"T CHA";E', PAY"INTS A"D ADJV8THINTS
4/02 .A'" 1 INJ OlUIOUl1 611.00 6I!!,00
'ALANC! 1f0ltWAltD
0,00
IU""A"V O~ CUII".NT CHA~;~I
CLINIC 510
61,00
42.00
IUI.TOTAL 0' CUR", C~A";E5
61,00
61.00
DIAllNosrsl
116.5
... SEE ATTACHED
PAY"INT II DUI U~ON II.CIIPT OF'THI. ITATIHINT.
YOU HAY IUI"IT THII ~OltH
TO YOU" IHIU"A"CI CA"RII"
fOR ItIIHIUltll"INT. i
61.00
6'1.00
-
I
~EFE~ Al. QUESTIONE TO THE
BlJSlrlE 5fJ CFr.lce
17171 7"3.~' 38
PLEASE SEND PAY~IENT TO
HOLY SPIRIT HOSPITAL
60a NORTH 21 ST STREET
CAMP Hill, PA 1;011,220~
'AY THle A"OUNTI 0.1
i.~.li.:II"JljI.'. j: ,. E '.' It,ll. ',:. ,.,'.' fie '11: 'lSfII.' prJ I
;/-1M~()IJ:- I,,:' P.2titl!( 1',10('/ .,,.If 11.. ,..,11.". ,pnljPAF
,)r; I~ "/::lj.L',,~ :.AflIlIlll. CC 'j('" ~l' ,vI' P,l.~T
r~t .../.Ie ,Ii~ i H".Q','/I, ~t,DUI l!'ir 1,IHIlt' ".9,,11""
(:~vf';'lIJt
. Hc.,..V IPIRIT HOlPI'.AL .
~03 NORTH 211, STIlEeT . CAMP HILL. PA 17011-m8 . TELEPHONE (717) 763-2138
CREDIT AND COLLECTION DEPARTMENT
01101/"
; r
,.,. IACKIH.TO.
'14'" UII ~VI
NlW CU"'IRL~ND,'A 'TITO
ACCOUHT '~L~NCI 3'.00
'ATIIHT HUHIIR 'T"'"
'ATIINT N~ftl '1'1 IACKIN'TO..
~'YOU KNOW THAT YOU ARI DOINI AN INJU'TICI TO YOUR'IL"
WITH"OLDINI YOUR 'AYftINT CAN INJURE YOUR CRIDIT RATINI. A'
'IO,LI ,~" 10 THIV Altl RATID---I' IANMI, RITAIL ITO.II, .ND
OTH'R altlDIT A.IHCI... UNLI., TI"ILY 'AYftINT II "ADI, ,...
ACCOUNT WILL II .I,I.RID TO A COLLIOTION A.IHOV I'D. A~'IIN IV
THlft.
IT:II AN IHIU'TICI TO YDURIILF, .IHD YOUR OHIOM---AND KII, A
'ODD CRIDIT RATI"'.
YOUIlI TRULY,
D. 'ARDHIIl
CIIID IT 0"1' I CI
TU-/&13T
Detach and Return
Patient tlame
CredIt Card (circle one)
Card Number
VISA
PatIent H
MASTERCARD
EXplratloll Date
Cardholders Name
I'
1=.) fJIGAIl1 C]MEOICMU DC,I/lMPU8 [ ,.~'HEI1
!i!,!,~,:H!h~~l!q~I~Y>>!91l!~~JiD!If_q~M~JJ,-rL':':'.:'.": .....::.:==::,:=._
It".... '1' '..-', ~,,"",' '~'I', '..H.-., I """;""11'" IH ."IH' I '''III'
, .
''''''''''I'I'II',J'I,r:
_.__~!:+C.""l)'"
r,',)
II
H ..,Uj:U,:;. .-_.__!Jfl};;Jl.f:Ji~U'JJE~__ __..-J.U_~
.1"II"~.rr"I~1 .',,,,,,, "'''''"~I 1'."t~"U.
J"': l":~ f!IJ(3:3 AVt: ....'.I-1i ...
'1"",1 ,"IiI,,,,,,'f'L ")" '-'A 1""("'1'\ I !;1'nlli:m.ll"n',~~ v "i
,- " . 'r:;.r,,, \ l"r,p r , ./, , .JJ!.L.~lJJ:)'"~'''
., 'i',,'I',,_,' r ! - ~'
'-~~~'.-r'- ~.,. -'~"--'--" ..-...-.. - ___'__'__"'_h_~__....... _ ... .i.___._._w_..__._ __l..__ ._ _
I' ',l ~'.",/+L. 'l'~~"~''':~~'\~~ ~,,::; 11 ~'''fJ:U~''~I',~.I:~r,r''.~~i~~''n'.." I 'l,> 1'1.' CJ)/'j!l,lln", "HAUL' If) III II
It. '''lIlh'' 'N',O~IJI'" !
." i-r:r;(l "
.----.-.-.,j..........
,It-IIL
A TTENT/ON
For YOIJr COnI/II /
an InlSllr8ncB fonr IInCII enc/ouct I,
m,
A. S/rm YOIJr n8 .
nIJmbllr 12 8ndm1" In bloclclS
S 3,
~rlte POlicy NIJm"lIrlS
,"OllBIS 6 end 8. " In
C. ForW8rd to
COmp8ny. YOIJr Inllurance
..
t'
I
i
I II ~((lUl"I
"IIf r----~ IJUn"
.",-.-"-.,,.-._,-...___,~ ___'''_u__,;______~y.
'. I'.' "." " .. '.. '\','1/' tllIl<:I", ,\11.'1,1111 ,It,,,,,,,,,. H'd""'~'"_'
I~ ...':'~.~.,';~.;~ :rf ..:,~~~ r,~~i,t :t::7:r~::~~~~":.~':,r_'~,:~~~~~"':;/:" "N~rI' ",,,,,,,,,
I
I
...""
I"
I
I
..,:!...... _m,~:'J:tJ1/\ [JjEl:.JJlUlI.L" "HI l[Ut~'lJ5___.J.
~.H:\:1~ICI ~HgB. SUPPl-' E ~lN,~,?,~ ~f..r!~(.L----.-.,,\-;;:,.; "fI";;"/" '/r ---,
.... '.;.f\..'~:~[II:~'I.'\HI ,~, ", '''U_\I'II''
.., """.
, . ~.. _~ _... ____...._,.___..____._h + ..._~_.______..._+.___.__. .____
. i"':,'j/','!\':~,,.I. .\ .'Ur'l:t"'LIlI~..""h
-:-~_._-_.+,~
. _, 'I '.11' ~ ",
.U::',
. ___.___...!:.!!~:ll,j'l"
""n'., ",.,'~ ,.....,
",:~
THAN/< 'You,
/',I;"..lnlfl.llrf.,.
----.---iltiCL13~I_l'L-__,,_________..__n_
-~":;j-;:~rl-' . -_,,-,', "'..,". 1II1','I( . '1~"'IH~CO,,,~,~,, .~,~ ~u"" ~I MI".
-.:lJ.J~_..:!.~LIii.J;::fJ:J/il--___.__.t!~lJ.LLCJ~I'lr' H II l. II>A
'.' "'.. .'lllt '''.',. ~, *1\\!IIH"..toIJlI' 11~1I"r.nl)l,1l1 '" (C,~""j '1~' "'I'~"I'~' tol''''U~I' r: 'It rll II~ (<:1111
'.' .,
f I ~ ....
------.
------------rr-T'([~J\,I.VOI.'lu~~f''ii(;(Tl)vIlH 1-J~11';-;-:;:;,t.i;.:;i~..~I~-;j;;:- l~-'
'~tr.1 I'~, "'l!!" I 0110.(,11 L~'I ,JI',',
11~'~I(1 ~1~WjW~I~ r.!)rf ~_~.~"'!._'~""~ 1'~Vlr.'!".Il(,.r;lJlIlr""("
7-"tl"
"
I~'I)'
I".'"
IlL~t,t-Il"<\
,
I.;,iini..............,....,..,........ .......,.
1o\1)TIIl'MI'.""I11liC
tU~ ~.
tlli
','
,,,,'," Dl';;F'L,.CFJ1"icr rNTEI'i",IERnrrJf(,',I_ pre",,:
"
OI~;?J~illl
, .. ~ .1..,ITLP,/
<:IlM1'1P
llltr __.____
"~1!L.,~___,__..._" ",,,_".,
1. ,4
7 ' I t./, I .:l~;
IJHI?;;Wn
I
THIJ,,' SI' ,~F'M_!\r"SWJ:11ifE7rl:'?'.:.?
I
41. .~)f)
,
...,.,....,........,... .......,..,....,..
. ....,.......................", ..... .... ,~...... ,t....... ..""."..,.,
',...,....,..,...........,.........1.........,....................."....
I
'T""""''''''''''
.,.. ........,...."..........""1..'........."...r............,...,...,
, '
."",.""""""",.""..".....i...."".."."",."""...""".."." """,,,.,,,,,,
I '
. ........,.......,..............,l.........:....'..r...'..'.~.."...
, "
,
.,....",.....
!
I
". ...,".".,....,............~.......,..
I '
I
..,......,.... '.......................,................ .........j....... ........,....,....-.".,......
n ~ ',r,H
~~~t7,-...-,:;:jilll~~~'1 ~
--rii' /"1':;-'\"""'1"'
.,,1', _'v,'" It'('~'~I('Ih.'' 11'1 uc"
....,.. ..", ,., ,......,..... ........ ..,..1..... ......., ... ......J......, .., .....J... ....~...,... ........
I
I
U 't'lr.L~li~":;r--t-- U .....OW.t..,r/ ----;r;;,-r;;:-I-~-.-
I
A...~lJLj _.____1J.,,,1l!l.
)1 ~nmM~Nl& 1/..LI.n.Ii".... Mlllllm N(I';1! ,.
PI Z r~nzr1,~N AGE,OC: INe,
49'30 rdTTE:r~ r,OA[1
'111 _L. i~C
,iiI," .I)CI"~ n'~IJIII'~ "-r;
....."'.............1...................'.,........'.
10" " '".' ", H'......~'. .," ",. It.,..., "~'r"
.. to.., "~.,, ~'..It. '"'' ~",~I
(),~N ;":1. LoI,
;,!G,',',;'TUI':f,
HOl'rF.:N:::rF.: rN 1M))
(I'" FIl.r:
Ii<
,
,",Ir '.:.~t.12,~,r:j_1 _
:f 'Nil "'1'1'.1' "'r:~lllJ'II Ill) rl)l,jll I~'L')"'I" I 0 ~'O
It~;) 1.<-' \-\ \",:' I ::(~,I "I 73'"'YI,E'l
_"_",,__ _,_L___,,___
",~~I I)' "1l~ln ...,,': " ", ," ~'II ,1'.1 ,I ~" ~11O. a t'lf-l TI'III.C~
MEeHAN lest,URO
Pt, 170m.':
'OM
,,,"If~'
~~~"Ov.O "'" .l,l. Cr)lJ"CIL ('~ I-JIC't,~L IIn",'~1 .."
1l,"1l')VIOlly ,... "UL'" ,,,.,
."jM,r.I~" .UIolIf-lII"U"O~" ~"jl'-"'I'.
Fo,"' AMA,OP,409 Fo,m HCFA"~OO 14,801
Fo,m CHAMPU~'BOI
,.. AIIIM"IlJlllllM ~I'''II. 10""'. 11Im "" ,IIJ"I"I) flUa .Q~'"
HI)
[,. IOICAIIl []MHlICMIE [JCHAMPU~
, PA 11 ENH 'NiijfliQJ~~B-S9RI]~B1J.tjr9R~F-IjO]f:.:', _~~',~~~::::===
I J..ll..'I..IlIll..'."I.....'"._'."'/I"',.'..',.....1 ,'''''I''''U'''llJIIIIII..
FI f 1,,'tCt\FN::'T()DB ~~
~~i~iTliiii'iiTIfiii';;II'''''t'tt;".., - "I",,lith .,
1 ',Ill I,';! I~U,,:; ,WE ""'II 01. Ji:~"
1',1 -'.; ('Ui'll'FI~I"t'I,NJI F'A J~I070 ~,;nIl':.'I~~~''''J' ,''''
-~::,':,'~!,~c.,__._ .----_' _'____'._'__.___._____ ____=-.L~
, : "1111 "I ~ ... ",I. 11M,.:, r <:VIII',U '~I" ....... ~l "Ionll.",. 11.1 1'1'" r.~'WI',tl"'IH""O If)
.~~ ,-,. '"... ,., ."n'II! t~,., II ,"'h.'I" '1I11""J ",~,,.llt, I
, U"I""Ulllhr.~"',,,,
r---- ~-,,~
'11 L-M" :\ hi)
. 'CC'IU'"
_._.___~.___._._____._________._~__....__~~~_ _~__.g 11'111"
't "A',t..., ~'A "'V'"I',II~IIl'llIlll''' 1111""'11". ,~,......, H""",~,,,,,
.,~.:;i,l.n',';;::,~,~rl r.l,r,~ ~~~~',t'.':I:';;:n~:'n~~~~~~r,.r,~~~;':u;'t;~.:' .,.",., ",...,~, .'
r
,THIA .
.
'O'H""~'H')'o'ln
ATTENTION
For your convenience enclol8d Is
on Insuranoe form.
A. Sign your nome In blocks
number 12 and 13.
I"
.~, .
0""
.-'---.-'--
~,~ ..' :; ~:.' ,/ '-.'l ~j
B Write Polley Numbers In
BOlCel6 and S.
C. Forwsrd to your Inllurance
Company,
I'
:' I, 1'11',.II,Ir;'", ON r:'[u,,:
PHV"5iciA.~(oil-5UPPi:.IER INFORMATION
~.--~:-;r4-1--.-.-~--"'"iU1TI1:i~w.~._.--liTiiimW~t7IC,lf.---
I' ,,'" .. ~';,~:I~"l/;I.rtH,'1 .~Il ,,'111,' .." ,; 'fll ' -'.
'; " I',.'
-~----._----------._--_._-_._.._----..__. - --.--.----.-. -.--
" - '1 ".' I"'hl ,. '. CAtll'" I,.t"cl;I,,,,,,Uh
",'11."",'",.
I
----~-_,_._...__....!!2."L_..______..___._ll'!~~;~.
'. ',.."1 " "''''''''. ,_"'j"',,,, "lIl"IIIIIII1'I.l(I". """"h",'IlHf'"
THANK yOU,
n.22
__,___,__"'_____!.'!!:!):J 1'[-1.1L______________,
:. ',M)I' .,';'1'" (I 1,\~I,.,I, .\1.1"1 UIIYICI.lIl"r.lnllllll.,"'.'_'"""....jI. 1""7
'I' "I' I:' 1-11"::'1','1 i'!:,L, /,/ ,: E:i CM1f" HILL. , "
------- - ..--
.".~II.'. ',p '" ,.....'u ," ".I.lh .'."'l)I"'I'.CI" t:"'UCIU-J"' ,..r'll""''''U'' ,..""...0.....""...." i
,~., I ~, .1, ,t 1"'1 '.......'.1'
I :"un 'II r--- '.ei
i ltl'~~:" ." 'a~
I.;,iio~.........................................,.,., .... ....
I ~tJ,..o'U,~tlf)" ~o
-iT .-- --.-:.---.-.-.-----~'l0...~~r f; e",1I '"I':,"'\"U ~folc~~ iiti';~eu ""II.'J\.~I~ r. I I , I' .. d "'~Ii~.v..
'l CI HJII 'I, ~tlll tC, LJ~ 1 <3I\ol ,
,'W,,: "l:,,, I~~~~~ ~~ CO" -:J ,,,,,,,. "",,,,,,.,,'" ,lOC'''""''""" O'~'!~l'" '''''''' I ,~ar.: i'"
-----;:,-.;.-;::':m-' (Jrn"?"',!c:"/~! 'l'I-IUf.: -,;r-,\P1:,L ,~,', "f:;UI r1NIJ::EI41-;l'1 'Hi.OO, 1 .',
. I Iii ,
. . . . . .. . . . .. . . . ., . . . . . .. ... . . . . . . , .. . .;.. . .. . .. . .. .. . , . . , , ' . . . . . . , .. . . . . . . . . . . . . . . . .. . .. . . .. ~ . . . .. . . . . . . .. J. . . .. . . .. .... .. . . ~ . . . . .. . ... . , . .. . . . . . . . . ., .. . . . .
t't"II11~CIlU'l
T'ml',,',l':rc
::;i" JNr:: :;m~I', IN
I
,...... ................... r..................... ..,....... ~.........~.........., ..................,...
I
"
'...-........-,..................................,.. ..................,. ........................................................~,........,... .."....r..... .....
I : I : i ,
...,."..,..,...........,. '...........................,............................... .................................j.................l........_....................
, ,
.,...,...,... ",,,,,,,"',,,,,,,j."',,,,,,,,.."'.""r".."".,,,,"'.,,,,,,,,""'."..m...."..."..t.............i"..."..!..."+'..m'1.."':.."'''''.'' ",.""
..... .,.,'.' .......,...,.!<........,................................................................................t.........I.......~............................,. .,."........
, : I I I
~;;;;.-;.~~.I-..I~".I'(I.,.t;" IlJJntl-,.----.--l.---.- ,.ljMfif.:.~\:n~I{l;.()..l)"..IIA(.1 :... n '()t.l'i.ChM-Ql-.:~--.hl.j,j~1\J~J;;;O---. Of .......~llJl.,'
l"I,',""'.""!',..'..I.'.,~.."'..J_'I~tg 411,00'.~ t,~~)
"'I"""""",,,,,,,,"I.,,,g, __.o.-__L_._____. ____
J.lllr-I '( (I 1-;, f:d,n~ TCI ~'I,. IJr-~ , t, ti[1 .,~, M JI ~~~W~~~,,~,~lIIJ"lI.11 ""."'1 "'ll~IIU~ I - ','['I I,
':II:,...~'.,n/l~:C: ()N fJ;U:: lO'lJljllllll.....llc\Jnl""O A ~~ f~tr2~'I~N A~.~~~(lC l:NC.
w,l) ?'::~ ",h;'!j 01\9 :~() f;' IT r[ f" ml,~rl
I;~.,l)U"i"',~.HIIIIl)..';O
:::T"l73.'968 t 11ECH,'~N rc;',l.1URf)
10""
- --
..........,................. ,.... ..~............".., .......,,,,.., ,..... ................... ......~.... ..... ....... .......... -........ ...............,...,.....
I n,p)
-:;;~~ W.;OqIJt ~r)
II!; "J l'I'"j41
p,~
I "/1) ~.15~'i
". HI O' 117.~". .','; ! I" .~, ""'.,,, " '} ~ I ".,;on <1" tl.1 ,'el\
_l"'~".'
~'''''O''''lJlI~ "''''''' l"ll'J",ell Ol.IJIOI(', M""'~I '""
,.""1'1'110.... t"'I.......'.. ~,Ur
'1"".(II't'l"Il.",I'tI.'"...'IfJ""C.....I,I'".
Fo,m AMA,Op,40e Fo,m HCFA,ISOO '.,801
Fo,m CHAMPUS,SOI
r','llrJf.. ','I']I IeL"" tll::.: fllfiNT
H~Al..l Ii INbUHANCk CI..AIM fUHM
.'IlUI"t1II1J(IIDNIIl'O"al:lJlrII'lllllrtijIlMlllI"l"ij ""'HH''''
(1111)l'\lI](iJ:(IN ~J
r,v
r JOICAIO I ]MSOICARE [ICIlAMPU5 [ I'HSA "'""","0."
L.J .---1...J _,.1,1, M' .. I1lAoI,
IPATII-a. IN 'ij .ollune IB'R- INPORM 10 _____'H_______________,__________,._..'___,_
1~W!_!J....,~!;/\..-=--JllLI-..BJ.P''''''''''.'''';'------'-I' .~i..''';....=.;" ,c..- - - ---- -~
I i 'll' r .J:iil};;~.1J:JLl~ . ~l'
~.Il5Umll'j'"'.J,".".,'.,.,,.,.., '''.'1,,,11. ""1
'j ',~ ',... :,~ ~'1' I J~'~ ,i3 I~V t::: ~ I "'ioU
~H'." CIJrHwr,'Liti'Jl) F'(~ L",'tr,'() , .,,, ATTENTION
',..a'f'Q",hl,;
fi';llt/" '.I.~'t,.l.,"~',CII'.~~~'fA';jll'.;ftl "'__I "IoII~"MI
i I". ,.~"....tt',.lln!tll''''' 1I1'1.1II~.,'~"..IIl......,.,..".III'
~i
" '.J1HI'I./riI~.tJllll."'t
In C' or-:;;-: hLJ
, "CCIOU11
,,~
I
~
! IJ ~~~,
IlllJh
III "'I'ltH UN ~II.P ""10,", 111\J"..h",,,. 'II'",.... """"""'11'1
1 "',~J/I'"" 'II, ~"''''"''...r "'''''''' ''''111'1I''','''' "'''''''''' ""..,. ,/l" ('I,.".,... /IN.....' "'''''''' II
I II "'~.",,,../,lj"IIO.'''.,~.',.,,.'/lf ..')IMfl.._If.....~..,.Ite.
I
I '~V j ljl,.p'
'-
.',... ':' r':',I-II'\rI't~~~ t"l/oJ f"rLE
. PHYSICIAN OR SUPPLIER INPORMATION
h :..'1 ,~, 11\~/tH~ "III''' t~~"l)lI/ij Oil
... ~ ,\~<r/t~':[\('eLl~' 0"
:,,' ,"',1'1;
OAtl
"1'0" '(:\ ''i~ ~~j
lit fl." 'IA\'(l),,)II~fl"
01)11"1" ..II ,,,,,nl '0,",
I
I".....
'~.II
I
111..fUm '~UlOl'."LI'. .~
l'IlQIr,I ,lllllr ,,'H' 1"lll""
-----..---. -------~..-.'-----_._------.
'I .'.""I,.~"ljl../lI'.,....~ll,"',t:"l)'..f"'.l:l."'J,'. ".,1',""""""""", ,'~ ~lr~11
itn:~w~:;~t~ll(
"IJ.H-Tl'1'-' ~'L 1""101""
;' '...m. ..l.:l.lIlJh 1.,.; ~"'~I.111 \~/lU'IIU'.:t~;;;;;-j";;;;;;;;;;;;;;_;___---.---- -p:;:;;:r.
t' \'''~''i,'it Hn~~~.q'T/':"1 ~l "l~;l' !~,:jl'lr' HI'I t~
I: ~,j.l.,",I.IHCIl""'.IIIC' ''''''.''1.1/111'''..11_ IlIL~U tll"G"')II.'O'flO(U)..IlII"'CQ...r.u,Il.~IlUIIlI"tJ '''.''''''111' I ) II, Il.O. (1.1011
1I1~;Uf,L)f;:f;, r.1F .Jr.JJ:I'lr
For your aonvenlenae Inaloltd I.
In In.urlnel form,
A. BIgn your nlml In b'oak.
num/)Ir 12 Ind 13.
B. Wrltl pollay Numb.r. In
Box.. 8 Ind 8.
C. Forwlrd to your In.urlnal
Complny,
THANK yOU,
II,.:
~t.l'~~l"
"""-
..It=:]
'--J
~
"
';~iQil""'''''''''H'''''''''''''''''''.''''''''''''''''''''
'\liJlIl)It.,,l"Q,,. ~Q
I I C It . .fc~f~~~~I~JI'''-I~~OjU'~ WI.,.CU ell 111;'\.1" I i ,;~ ,I. l"~1 hM'l"
I '~t," 0" ! Ut.~'
fr:Lg ~"l'~lcr r,cifM, r too. I ,P'~A'i'lIJJyl.llli'~ ""~'~'~(~~'WI'U' I 11ltgb~II' 'Il"HI1~! ..~r,,: '0'
" >, ,"':; I IJH l'r:l7(~ 1~'cl_~lr~\,M' ('1'il I ',~4,P') j, i'l
",.,": '.'" :,',',','" ':; ~:"""'.,., 'i" i ;1: i' fi ;;.(:: l'ci"""" 'i i~i j:;;' i,i;~':i L:.' i; 1';' ['~i F:,'L: i:" '~i iN" f ',i 's';"',..."'. ;:,i::': ;'i ~j"'" 'j"'" ';i"""". ..'"""'.'""""".,,.
I I i I I
:':,::,::'::..,::::::::,,::.::,:::r::::::r:::::::::::::::::::r:::::::::::'::::::::::::.:,,'::::.::::::::::::::::r:::::::::::::::::::::T::::r::::::~:::::';::'::::,:::::::::::::,::::,:'
"
rr.-
""""""""""'''''''''''''''~''''''''1''''''''''''''''''''''"''''".."..,"""...,,''''''''''',.,'''',........'r''.''''''',.,''',.,.,...,."",."".,.,"",."""""".""""""",""
I I " "
I ,
.............., ....................~.........~.....................i...................................... .............;-.............,........................ ....... ..... . .............,.
I I I
.."'''''..''1..'..'''';,....'1''..,',..1'''''''',,.,'''''',.,'',.
............. i......... j.......r... .....~....... ~...................... "... ..
I : I I I
" ."~oa-~ ) r' '""V,,,.,.~.-.;;;o.;u.-
4\'~\ I H _~ 4\"....JJ.1L-
)1 ~~~m:~~,I,.OJI.U"~I.,11 ,j."", "Ulll'." ,., ~'.11I'
(,', "( rdTZ~IM, M;,,:.m: If,le,
';",'lO 1',1TH::r~ I;:OMI
~:::::::.:::.::":,::,,,,:::":::::r:::::::r::::',:::,::::::::::
I
,
fu '1c,""'IJIlII:' 'IHIU:I..,.OllIU"LIUI
~~,'~::',,::':~~:.t~,~:'::',.:~~~', "HffiI ..", "
I
",,".i),':,;( ';~. [i1'1,'H!f~I\:,r1D
, ",,,-, Illr~[ ON 1;1 LE.
I."" '
Ilh:''''It;
, ~Oull "'11'" I "':'O\j'" "0
",mmel~I~~lllI. 0"''' 'III.""
'"
~t
... ",11';
U lOuR ''''HO~I'' I 0 "l.l
1"1:" ',;"~I'iO"4\~
23 ",I 73'-'i'6E:<1
E:CH/,"I~ lC:~~IUr~fJ
1 I) /to
r'l'l IlO:,~.,
"~,,CI 0' 11""'1(1 ..~o 'tn t. "'hl(ll' I) II COOl' 0" 'HI "'CIl
flllIf""1I.1
"',"OVIO." ,11.1" COlJllCIL tl" ""I I("~ IlthlCI "0
.""I)II'O.~ 'Il' "'''Lnl (....I
..",."(I,,,l'I AOl,ll"I.t1IUlr)ll. t""""'IJI
Form AMA,OP.408 Form HCFA,1500 IUO)
Form CHAMPU5,501
"I.. ','-It.'! I r
nk~""" HUVnMI_"''' ....""'Mlltl run,..,
/l~~III/tUmJL'lm"'. '.'IJ"'~ tlllihtW,1) O'lalllP.,,,,ij Ullt IIJ"Ii
~;Iml" r '.i:i 1Il1'1 :: I
r --,..-.--.".-"..,..--,..-----,.--..--.-
P TI N Ii I 1JIO la~BM161!MlJl~!91YMIUL._._uu _.___
I '" """";;.""'~"'" ""'HIf'''''',-,,,,,,,,,,,, r .~IlP"'IJ"'lln 'nUll
L. f'n~; l:: f)1',\CI',C:,:/'lqrl: ';(1 U I
~rnll.~~",,.~"",m..,'..FIIftI .,. f'" .... -
~ I)" ': ,,:: r.'I.If.II,) ,wr:: ....r--r-
Ij,,:',~ '::II~'Irt'r;'L..'4tll) F'A 1",'1)","') m mnn~'tI~
Thl'HI,)"'IIJcT,,-
I, ~...llllol.~tlll',I,III."'Cl(l,)~I""\J1 '~IlI"'Mlt"'"''I''''''' .co"ij7jilil.,."i'iJ'iii)i
.~, '.~ 0.....'... ..."ou,.,.,. '."It I' /rI .'1'" ....'1.,..' h~,.....,
L, ~EOICI'IO [JMIOICM1E DCIJI'MPUS L O.THE~
,,,,)
I'Q"~."'ll')~IO
(l~.".!!:2:!L--
'E~ t.~
'rlfll,m
ATTENTION
1":Tm"""IIl,. ......HO"I'.U ,t",o,,' '1I~""llJ". 1~'fII"" .'''' ""''''1
I u1~tt1'tI,';::t~"'/,~,r,; t=~r~r::~'~fI:'~Cr,:;,t~~'r;,~ ll"lIfll ,.,......, II
It ..'I:IOt,.,
",vl!)l
'I~
Fe" YOllr oonvenlenoe enololed III
In Inlllranoe torm.
A. Sign YOllr neme In blookl
nllmber 12 Ind '3.
B WrIte Polloy Nllmbers In
BOlCel 6 end 8.
C. Forward to YOllr Insllrenoe
Compeny.
1- 'l~ . J" I, 1'1
... ,"'111"'" ''''''~<J~~'''
",ce
i'ln,,;p
,
':;C"'I,,,'.l'llf,~: IJ'" nu:
'PHYSICIAN OR SUPPLIE IN ORMATION
;;onrt I~L"a '~~' "If fON",1l
... VII"":.',, ',!~." o.
. ,,",' I
'II itl't 'U'I~1 H.t to II 0"""0' IlJh~OI"'ILI"
tLllt,'~ I'!(J'"
"Q,.,D
p.t,
,~
'~L...:...l
ii1Mf, ~ll:\ ~.~,O~I~~~ I' I.~"
rlll)e~
.
-
.---.
------l.,IIQN __
It "'''''''' c, "l' I ~ .'''lj ~I+' l, C, "" qll I'lll..- IOLJ'I(l ." II~P'" .",,,. Wr~I"
,
I h"hJ~'l"
~'~2
THANK YOU,
1".riCJ:qf'l ^\
~~~U ,,' ''''l:I~I' ~ ~"."f """'le""lhOt"l!) '" .....,I.;.;;.;;;;;-;;~-;-
.I~"O'
",,,,: 'L :';,,; .' ""II.iwe 1::l::i"I'I:r ;',,~: 1'1.11
II ~..~hCII".,..t..1l1 C' '_Utili Oil IIt,,,,,, IIh...'1 D'.""'''II 10n"'HMlllh'l,n~lUlO""I""'hU h~",1j;1 '-1 I "t lJ"lI~ ~"''''.l
"
1",., '''0'00
I ~m~r", .nD '"C
I'::;,~~:;~~':.~~ '~:,""""""""""""""""""""
t ~\'.~j p. 'frl'l~'::Bfti~~tl,\mIOIl:"''' 1I1l~.(1t QK 'I.mIH -~ c I .;.~ ,....I.I..~.
.. 0"1'
lol ,uy 00 ,I IP'..AI,.IJII-IJ.IJA..UIl~",."..'''IL.IJ''H'~'_" I 1J'~lb~~II~ I CU,'II)" lJ~r,. 'r.;, I
'(' ;UIC 1"W~l ,-"r"L,,~f" ';: ,.'f ,'II:: WJ 't"",!'l ";::j IT,"", ,1:'0:, l-i~
......................,..,..........~........ .............,...,.. '.................................................,...~............. .........;............... ..~..... .1.....,.....,., .............
I I ii' i I
I r
~""""""""""""""""""""""'''''''''''''''''''''''''f''''''''''''''''''''''''''''''''''''''''''''''''''''~'''''''''' . 001' ........,.................~..... '1'" ..00.'.....'..........,.
I I: I: I I
"""'"''''''''''''''''''''''''''T''''''''I'''''''''''''''''"'T"""""'''''''''''''''''''''''''''''''''''''''''',''"""""'r""'"':''''''''''''''''','''''':'''''''''"""""""""
..""",..,,,,,,,,.. ""...'"''i'....''..r..''..''..'''''''''';..''..'''''''..''''''''''''''''''''''' """'''..''i'''''''.''....I'''''.''.:''''''''.''''''.-'''''.;.'""""""""""'""
."..'", """.."", ..'''''''''i''''...'']''''''".."".."."-'''".."',,..,,''''''''''',.,''',,.....,,''""'"-''''''''''''',''''''''''''''''''''''''''~''''' ;"""""""""
~""""""""""'''''''''''''''r'''''''' "..'................t.............'..........'.".."."......",,,..,.'t."""""""""""j...,,.,.,.,,.,..i"""'I""""""""""""'"
f"",,"""",.,"""',.,."...'r'....... "......"...."'."T"..".".....'."'.."".:".""""'"""""'1"""""'" .....'..L~"..."~~IJ""".,.""".,.""'.."
1'11IQ,..,VIlI OJ '....IC'...,. O"lI.j"~JlII rI "'ccl'''111I1~'''1'''t It '0''''" c.......'Jr I ~"'I)IJ~I 'AIIl------r;... ....~..."" OVI
"0' ". '''''.00'''''"11''" . I'
. 'I I""" ,.It t~, 11I"'~""I' ,~ '''' ",.M "III" 1'\ "~roo 'I' I "I " 1
tM."'....." "',."",. II,,,.,, ,,'.,~...___... I /"1 ,I,',
I II "-J "., I' '.I"llll;I' '1. I)' Yll ---'''0 J,,,ot/ICIA"'llIlllJ"UIIl'.....IlIIAtllmUI,',C,,tll'
I "~" r 1:..'''1-,.1;.. :'1"1' ! ~,'L,'''~''~,hl'
I ~..:~:,;' H I Ul \~:. l:H.j ,.:.l U~; JO '01J1t II)C'''L IICulln...,..o t. r, N ,I,: ,'il. 1'1 'I
, .....l'I.l"'.rl,i'l'I~; ,I";; ',~O I:" 1..'ll,~'I'
lu.It'O _" .' ,. ..
It 'o~,. ""'1'''' I .cco\,J~r"o U .QV" I""UH'''. I) ,.0
",."\
'...
,I," I.CIWr:::F ft'lCI', F','~J:i'1
iLI,/i'1L",I}CI
'I'
.' "~:i
o
I ",/,CI
lI"':U:t
I I..i
I
W/,i'
111,,1 U,.'/I, 1'(
1.:U,~11
rli':
I ~ :'~:: \ 16 ~.'.;
,t".~':i.i "'.." ,41 ...1. :~~:; /:~
t'II':('HI'INIC::;bUFW
I','.'. I. "','0';'/,:
I I) hO
'H.cl o' IIII__II:I"',..Q ",. 0' "'h'GlI' 0 II (ODnO~ '''I uc.
1l1",,I,.d
,,""I')IIIO'~ AIoI", COIJIlrCIL O~ ~IO'CA" IIII\<IU ..0
..,,"o~.o.' ,... "IAL'" cu.
""'''(1'''1) AO""I"'IIt"U'O"'i;Il.""'UI
Form AMA,OP,401 Form HC'I',1S00 140801
Form CHI'MPUS.SOl
Pllllllnlllljjllll ut InlUllnll chlnlll un blc~ Inj chlc~ Ihll bo. Cl Pllllllllnh Ilono lDlllj IInllnj IIIUIn !hll pUNlon Wllh IUUI Plllnlnl
I'lIA.I PAY THII AIoAOijNr
57.00
M!OijNT PAID ~ IS
~~~YNS~I~+Ts~2~~tTAL
iAHP HlLL PA l70 l
I
,
-j
,
I
~OR IN~O/lIoAATlON ON ACCOUNT PLEASE CALL
17-763-2136
"~ ~~~YNS~f~+Ts~2selTAL
P~Y.IH/ CAMP HlLL, pA hOll
10
ACCOUNT NUIoAIER ANO NAIoAE
7046717
BACKENSTOSS ,FlFl
[a~~ Bf: 2~A~:~
SBI 21030
i 717-770-0481
I~ HRI HSG I
L--. '
7046717
FlFl BACI<ENSTOS
1041/;1 ROSS AVE
NEW CUMBERLAND,PA 17070
'~'"''..'''''.U''H'''.'...'''...'.''H.'''''''''''.'''''''''I...'''''''......,....................................................,.................
A'COUnl NUnlDII 70 4 6 7 1 7
PIl"nIN.n\.J3ACKENSTOSS ,FlFI
$11"" SIIII 0 ~/l3/95 SII'''' fila
SIII'n\1II1 Oil. 0 '1/22/913 llll SIIl.n\1II1 011.
PIU' ND l
03/23/95
Qijl.TIONI? Pi.... C.'II
ACCOUNT 8AU.NCI
37.00
7l7-76!-2130
Con""~
TOTAL PATIENT CREOiTS ___
. 37.00
EBTlIoAATEO IN8URANCE OUE
.00
mt:Ns OAfE " , I
..
OISCRIPTlON
PREVXOUS BALANCE
FVW EST LV!
AIoAOUNT
.00
37.00
03/13/96
OV-OP
H 0 R4 1t0 SG ACCOUNTBALANCI
~h~~~5~B~~~~~Ay~~~yNINH~~~~~~O~071 FAMILY CARE N
PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID.
.00
. H~LYSPIRITHOSP~.AL'
503l'lOIlTH 2ht 5TIlUT . CAMP HILL, PA 17011-2288 . TeLePHONe 1717) 763-2138
CRIDIT AND COLLICTlON DIPARTMINT
004/104191
"IFI IMl<INITOI
11)04' II Roel ~VI
NEW aU"8ER~~ND,P~ 17070
ACCOUNT BA~~NCI J1.00
~~TIENT NU~BER 67J04171
PATIENT N~"E FIFI BACl<EN8TOSS
DO YOU KNOW THAT YOU ARI DOING AN INJUSTICE TO YOUR'~~~?
WITHHO~DING YOUH PAY~ENT CAN INJURE YOUR CREDIT RATING, AS
~EOP~E PAY' SO THEY ARE R~TED---BY BANKS, RETAI~ STORES, ~ND
OTHER CRIiDH AGENCIES. UN~&SS TlHIlI.Y p~YHENT U H~IlE, YOUR
~ceOUNT Wl~~ BE REFERRED TO ~ COLLECTION ~GENCY FOR ~CT10N BY
THEM,
IT IS AN INJUSTICE TO YOUR8E~F, SEND YOUR CHECK---AND KEEP A
GOOD CREDIT RATING.
YOURS TRU~Y,
0, GARDNER
CRI!:DIT OFfiCE
7u-el17
D~tach and Return
Patient Name
Credit Card (clrcl~ one)
Card Number
VISA
Patient H
MASTERCARD
Expiration Date
Cardholders Name
1111' J' I -; ',. ., U,
It"""",,- . ~ l,,; I..
, .~CL.t
QUTP
HOLY SPIRIT HOSPITAL
50- ,. 1\ ST 8T
C" HILL, PA
717 763-21"1
FEI. 13-151&741
"
~,
~ ;-;-;.'"
C
1.71) I 1 ~
"'TH-" E IO'''~
11/21114 f19-0'
-,-
----
I'''''llt,I I,I,IJUU' --f"~-.'.'-:\~;-' -;.' ,.;.;':,-,~- ~,,:I~;~;;:'~~~~~;;r::::~--- --._-,--.--", __W__
1 3." -~-~O"--.'o'i7e-f7Ii51------"- ----r--'.'.----,.--------.
_ -!1..___ I---.__.~--~--_~___'_
~T F__~'.:.:.':' I'''~I
SA C K II t:jjJJI_U,_~'-
."
F I F I BI\CKEHSTOS
1041/2 flOSS I\VE
NE~ CUMBEIILAND,PA 17070
F~:---- ---------,-
,7 ;; I, ' , 'J .. .. ~" I '.' I. \! f I , .., 'I. '" , ." "
_ ...._._._______~_._____._.._..._n.___....,'... _....._.....__.__..,
I AUTO IN6 4~ ~376TlS4Q~~
: I! FAMILY CARE NET~O IS7676tl4S6.
,
hl"'U""l"
""....
"CUIlI..
I I
~---IAME IG'H kARGRE'fi'A--Rll-''''- ".- --------
.
PLEASE RETURN THIS PORTION WITH YOUR PAYMF.NT 7~ ~"" [-::;'" ,'".' ,
(- '.!;' ".,' ~
. r' I'. :C'.
HH\":f
.(m
. "
"Iol.,t
I
~I!TI\IL OF CURRENT CHARIiES, PA'JII1ENTS I\ND
l/U CBC I./IS PART DI01/153011101' lEi 00
31i!!9 ANA, FLUORESCEN01/!5701046 131.00
l/i!!9 RA FACTOR, SCREOli!!5701376 34.00
3/29 SPEC COLLECT FE0125101031 7,00
3/29 LEFT HIP 0167101667 135.00
~/29 OU-op FV~ EST LOI66'0004~ 47,00
ADJUSTMENTS
H: 00
p., I , Q 0
'3 4 ~ 0
7 , ~O
13S00
47. ~O
FOR\,JARO
o 00
SUI1I1I\RY OF CURRENT
L.ABORATORY
DX X-RAY
CLINIC
CHARGES
300
320
510
154,00
131:,00
47.00
154 00
135 ~O
47 00
SUB-TOTAL. OF CURR, CHARGES
JJ6 , 00
336.00
Dlo'\lONOSIS: 719,45:
I
*** SEE ATTACHED
PAYMENT IS DUE UPON R~CEIPT
YOU MAY sUBMIT THIS FqRM
TO YOUII INSUIIANCE CAR IER
FOR REIMBURSEMENT.
I
I
OF!THIS
STA1;EI1ENT
nCt!Il"l,IJErjl rjO ~J'~nl41
OTAL.S
"..Ntl' NLJMI.R
7119307
3
PAY THIS AMOUNT I 0.0
ACL11f!Qtl,l.\, !lId 1 liT lJ ,',II,ll ',1,\. h~ I I ~...:.~~
C~"llllE& f'1r)l P\):lf!~ \"~f" ,."~ "ILl ,'"If 1'ljl:~~"1
nl\ IF It'lliljll,Atjf':F ,;MUII(nf,'" 'i'\! IJ/. ..~,\ iI-.I,'
ntE A~4C)IJtlr5 I)hfJ\'II, LJ'lf,~n f~',/,I.~ltL' '1\\'lllM:
:5~1~E~~LO~~1cV'ONS TO THE PLEASE SEND PAYMENT TO
,71'1113,2131 HOl V SPIRIT HOSPITAL
603 NORTH ~IST STREET
CAMP ~tlLL, PA 17011,22ae
........'.. ............ .......... ,.........".
~"."n1 ~"mb" ~ 786 f3 f3 2
PI"lnlNlml ~ACKE &TOSS ,F IF I
..,,'.. SIIII 11 9 9 1'''''' In.
IIIIlmlnlD111 /\1 ~ 2/9 ft Lllllllllmlnl 0111
Plil~' 1
0~/03l98
58.00
71 7. 7 6 ~ . 21 ~ 8 ~01l1..11
IItlMAlIo INI~~ANCI oUI I TOTAL PArIINT C"loITS
.00
DUUTloH., ~Imt Otll<
~CCClJ~~O.
I .__..___.,___.______.____.
'I
,
T~~NS DATI L__ onC~IPTION
~l~l~~~B B~~a~O~~~p~~~&~el ~ALANCE
--.1.-_..._
''''OUNt
,0 ~
~t:~O
~
I
o R2 HO SG ' AOOOIJNTlA~NIl.
X2~~ ~~C~~N~R~GE~~E~BWt.E~FAt~lk PAYMENT ISN'T POSSIBle:
~8~ AUTO INS H .00 tl~i FAMILY CARE N
PLEASE DISREGARD THIS GTATEMENT IF VOU HAVE PAID.
~8.00
NOW
.00
V"III vo" ,,,,,,t,,.. htl UII., Iht PLIASI PAY THIS AMOUHT ......."lllh. bll.".. .. ..I'mlll )0" 0.,
Any blllnCllJnplld by YQijr InIUII",. Will b. QUI I,om YQij.. Th.n~ yQI.I
...
.
IN THE COV~T or COHMON PL~AS or CVMBE~LAND COVNTY, PENNSYLVANIA
,
\' riti /lackanstoss, civil Action. Low
j,,' plaintiff
, ,
" No. 96-6941- 1996
I va.
" Luia Hium Ocasio,
Defendant JV~Y TIIIAl, DEMANDED
CE~TlrIC^TE or SE~VIC~
AND NOW, thh CfA~~ly of rx:.1{)~, 1991, I, charlu B. Calkinll,
Esquire, a memlJer ot the firm of G~lrnTH, BT~ICI<I.ER, LEl\MAN, SOLYMOS &
CALKINB, Esquires, hereby certify that I have, this date, served a copy of
Det.ndant's Notice of ~ecords Deposition by United Statell Mail, addrellaed
to the party or sttorney of record as followsl
Darrell C. Dethlefs, Esquire
LAW orrlcEB or DA~~ELL c. OE~'HLErB
Wagnar Bld9', Ste. 205
355 North 21st Btreet
Camp Hill, PA 17011
G~U'FtTH B IU
S L 0 ,
BY
C B. AL I B
Attar e fo Defeniant
Bupreme ou t 1.0. No. 36208
110 south Northern Way
York, PA 11402
Telephone No. (111l 751-7602
..
,-'
,
Ii;
i
fWJ JMCl<J!STOSS,
PllIlnU,J
('.QUilT Of COMMON JlI.~S
CUM/mIlI.AND COUNTY, PA
CIVIl. AC;J10N ./A W
v,
No, 96. fj}41
l.UIS HIMM OCASIO,
lMi.'lldllll!
IJRAFrJ/lE 'I'Q SETrJ.f~ J!ND AND DISCQ~TlNuJ!
TOum PRornONOTAI{YI
Please mark lhe docket In regard IU the above - milllei' sellled, ende<<llllld
dlllContlnued,
Jm~ Ie 1J
IUl K, ZeHner. J1'squlre
A!I.tlrn~ far the P1oJritlft'
38QS arlte! Street
1',0. ~q" 368
Call)p Hili, PA /1001
(111) 915 . 9446
AtlUmey ldentitkatloll No, 59262
~
PIPI JJ"'CKJ!STOSS,
PloInllft'
OOURT OF COMMON PI.P.AS
COMBP.RI-....NP COUNty, p,.\
CIVil. AenON . lAW
v,
No. ~6. 6947
LUIS HIRAM OCASIO.
Petimdll.nl
I. BRIAN K. Zl!LLNljR, Ill) hereby certify Ibatl)n Ihls 21.':. day l)f f1.<,'" +-;
1999,1 did IICrvll a true and cOn'eC1 copy ofthe foregoing documenl on all counsel of
~rd by depositinlll1 copy l)f the SlIme In Ihe United Slales mwl. tlrsl clllSs postaae .
prvpald, addressed lot "
Charles B. Cl1lklns,l!Ilquire
110 Soulh Northern Way
York, PA 17402 . 3737
I
BYllt fc_'~ __w-
B an K. Zel nerl..Esqulre
Auxwney for the ",wlldff
3805 Market Streel
P.O. BOll 368
('-IlmpHiII, PA 17001
(711) 975 . 9446
Attorney IdenlltlcaliOl1 No. 59262
"
"
'~ I
....
"
,J
,~
t' .
,\'" ... r.=
1': 1'1
'),' ,.
'" ,,"./ ,.;t.,.
, " .- '.)i l
'r; '-J:_-;,
" r,... , .
, , ):,'1
" "J "-,'1
I !,/"!>
ili 'f'"
II. :!,tJ..
() \11 d
III
,
.