HomeMy WebLinkAbout00-01097
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JOANNE CARPENTER, as
Parent and Natural
Guardian of ZACHARY
CARPENTER, a minor,
petitioner
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
V.
EDWARD CARPENTER,
Respondent
CIVIL ACTION - LAW
NO. 2000-1097 CIVIL TERM
ORDER OF COURT
AND NOW, this 24th day of March, 2000, upon
consideration of the Petition of Petitioner, Joanne
Carpenter, as Parent and Natural Guardian of Zachary
Carpenter, a Minor! it is hereby ordered and decreed that
the Petition for Minor's Compromise and Settlement in the
amount of $20,000.00 is approved. Said $20,000.00 shall be
paid to Petitioner as Guardian of this Minor Petitioner and
shall be deposited in a restricted account or certificate
of deposit in a bank, savings and loan, or credit union
which is FDIC insured. The account shall be restricted so
that no withdrawals may be made therefrom prior to March
17, 2006, without further order of this Court. Petitioner
is directed to file proof of said account with the
Prothonotary within ten days of receipt of the settlement
proceeds,
Petitioner is authorized to execute a release in
favor of Edward Carpenter and his insurance carrier, State
Farm Mutual Insurance Company. Provided, however, that
- ..
this release shall have no effect on the rights of
petitioner to any first party benefits he would otherwise
be entitled to claim,
Bn~1
Edward E. Guido,
Barry A. Kronthal, Esquire
For the Respondent
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JOANNE CARPENTER, as Parent
and NATURAL GUARDIAN OF
ZACHARY CARPENTER, a minor,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PA
Petitioner
NO. J.O()()_ 1097 a..;v,"L
CIVIL ACTION - LAW
v,
EDWARD CARPENTER,
Respondent
ORDER
AND NOW, this !b-Ph
day of /YJAiZLA
~dao
I lJSlSl, it
is HEREBY ORDERED AND DECREED .that a hearing op the Petition of
Joanne Carpenter, as Parent and Natural Guardian of Zachary
Carpenter, a Minor, is hereby scheduled forli~ o'{\o~on
h,:/ /J1A/lr.J.. J.~ ..2/116) in Courtroom No., S of the
Cumberland, County Courthouse, 1 Courthouse cSquare,. Carlisle,
Pennsylvania, at which time, all interested parties shall appear
and be heard.
~~
3- t - 00
"RKS
J.
FJLED-OFFtCE
OF ::...':~ P:~;JTI~O;\~OTA.qy
00 n~R -6 PH 12: 55
CU:V;3[;-':~./'>';D COUNTY
PENNSYLVA'\"!lA
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FEB 2 ~2~
JOANNE CARPENTER, as Parent
and NATURAL GUARDIAN OF
ZACHARY CARPENTER, a minor,
Petitioner
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, FA
6 /1' ~/J
NO.;{H/D - I '17 ~
CIVIL ACTION - LAW
v.
EDWARD CARPENTER,
Respondent
ORDER
AND NOW, this
/rF
day of
rI1~
1999,
upon consideration of the Petition of Petitioher, Joanne
Carpenter, as Parent and Natural Guardian of Zachary Carpenter, a
Minor, it is HEREBY ORDERED AND DECREED that the Petition for
Minor's Compromise and Settlement in the amount of $20,000.00
shall be paid to Petitioner, as Guardian of aforesaid Minor.
Petitioner shall deposit the settlement monies in an interest
bearing savings account for the benefit of Minor, where it shall
remain until Minor obtains the age of majority. Petitioner is
authorized to execute a Release in favor of Edward Carpenter and
his insurance carrier, State Farm Mutual Automobile Insurance
Company. The Release shall be in the form of the Release
attached to Petitioner's Petition as Exhibit "E."
.~~ '
-..:
BY THE COURT:
J,
"
BARRY A. KRONTHAL, ESQUIRE
Fa. Supreme Court I.D. No. 55672
BADOWSKI, BANKO, KROLL, KRONTHAL and BAKER
Post Office Box 932
Harrisburg, Pennsylvania 17108-0932
3510 Trindle Road
Camp Hill, FA 17011
Telephone:
Fax:
[717] 975-8114
[717] 975-8124
Attorney for Respondent:
EDWARD CARPENTER
JOANNE CARPENTER, as Parent
and NATURAL GUARDIAN OF
ZACHARY CARPENTER, a minor,
Petitioner
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PA
A '. . "IL-<-..
NO . .:Lcvo - /0'1 'I \..-l.=-t'
CIVIL ACTION - LAW
v.
EDWARD CARPENTER,
Respondent
PETITION OF PETITIONER,
JOANNE CARPENTER, AS PARENT AND NATURAL
GUARDIAN OF ZACHARY CARPENTER, A MINOR,
FOR MINOR'S COMPROMISE AND SETTLEMENT
AND NOW, comes Petitioner, Joanne Carpenter, as Parent
and Natural Guardian ("Petitioner") of Zachary Carpenter, a Minor
("Minor"), and hereby files this Petition for Minor's Compromise
and Settlement, averring the following support thereof:
1. Petitioner is adult individual~urrently residing
at 3608 Alberta Avenue, Mechanicsburg, Cumberland County,
Pennsylvania 17055.
2. Petitioner is acting as sole guardian in that
minor's claim is against his other parent and natural guardian,
Respondent, Edward Carpenter ("Respondent").
3, On, or about, May 9, 1999, Minor was a passenger
in a vehicle being driven by Respondent and was injured when
Respondent's vehicle strvck another vehicle on Orrs Bridge Road
in Hampden Township, Cvmberland Covnty, Pennsylvania. See
Hampden Township Police Accident report, a copy of which is
attached hereto, made a part hereof,~nd marked as Exhibit nA."
4. As a resvlt of the aforementioned motor vehicle
accident, Minor svffered a laceration to his forehead requiring
twenty svtvres to close. X-Rays taken of Minor's cervical spine
were normal. See medical records from Polyclinic Hospital,
copies of which are attached hereto, made a part hereof and
mark~d as Exhibit nB,"
5. Minor was s~bseqvently seen by Dr. Garcia, his
pediatrician, for removal of the svtvres on May 14, 1999. See
medical records from Tan & Garcia Pediatrics, copies of which are
attached hereto, made a part hereof and marked as Exhibit nc,"
6. Since the last visit with Dr. Garcia, Minor has had no
complications, problems, or pain associated with any of the
injvries svstained in the accident. However, Minor does have a
scar on his forehead. See photographs taken on Avgvst 10, 1999,
color copies of which are attached hereto, made a_part hereof and
marked as Exhibit_nD."
7. Minor was born on March 17, 1988, and is cvrrently
eleven (11) years old.
8. Petitioner has made a carefvl and diligent investigation
regarding the facts svrrovnding the accident, the responsibility
therefore, and the natvre and extent of Minor's injvries.
9, State Farm, Respondent's insurer, has agreed to
compromise Minor's claim for $20,000.
10. The aforementioned settlement has been eXQlained at
length to Petitioner and Petitioner has indicated that she
understands same.and has voluntarily agreed touenter into the
settlement.
11, The settlement.is in no way to be construed as an
admission of liability on the part of Respondent, State Farm or
any other persons or entities,
12. State Farm and Respondent hereby request Petitioner to
give them a relea,se in the form that is attached hereto, made a
part hereof, and marked as Exhibit "E."
13. Petitioner believes that the settlement is fair and in
the best interest of Minor.
WHEREFORE, Petitioner, Joanne Carpenter, as Parent and
Natural Guardian of Zachary Carpenter, a Minor, prays this
Honorable Court enter an Order approving the Minor's Compromise.
DATE rff) In
By:
BADOWSKI,
and
Pro
ANKO, KROLL, KRONTHAL
AKER
ional Corporation
KRONTHAL
I.D. #55672
Attorneys for Respondent,
Edward Carpenter
1 ('!
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, "
VERIFICATION
I, JOANNE CARPENTER, as Parent and Natural Guardian of
ZACHARY CARPENTER, a Minor, hereby acknowledge that I have read
the foregoing document; and that the facts stated therein are
true and correct to the best of my knowledge, information and
belief,
I understand that any false statements herein are made
subject to penalties of 18 Pa.C.S.A. Section 4904, relating to
unsworn falsification to authorities.
DATE:
~=~~p
J CARPE ER, a arent
Na ral Guard~an of ZACHARY
CARPENTER, a Minor
and
ElS/18/1999
12:ElS
717-761-7267
HAr,lPDEN T'JWI-lSHIP
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'> PINNACLEHEALTH
CARPENTER, ZACHARY
RM#: PER
MRN: 888-24-1149
CASE: 00990322823
ADM: 05/09/1999
SEP 1 0 1qqq
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POLYCLINIC HOSPITAL
2601 North Third Street
Harrisburg, PA 17110
Emergency Department
HISTORY: This is an 11-year-old boy who was in a motor vehicle accident with his father driving when
he accidentally struck another car. He was not wearing a seat belt and had been bending forward with
a Game Boy electronic game and was thrown forward and struck his head on the dashboard glovebox
area causing a laceration to the forehead anterior scalp area. He presents here in full spine
immobilization, a cervical collar intact. The father states there was no loss of consciousness and no
nausea or vomiting or confusion. The patient arrives here alert, oriented. verbalizing well, with a C-
shaped laceration approximately 6 inches in length across. the forehead frontal scalp area. This is a
I's.~-j flap-type laceration with clean skin margins. The patient is not complaining of a headache. A cross
table lateral C-spine was ,.performed, did not reveal any bony abnormalities or soft tissue swelling.
Neurologically he had' good motor strength of the upper and lower extremities, had no complaints of any
subjective paresthesias,
PHYSICAL EXAMINATION: On initial examination, there was no bleeding from the ears. Ear canals
were clear. Drums appeared to be normal. There was no nasal bleeding or pain noted. Oral exam was
essentially normal. Teeth intact. Mucosa normal. No bleeding noted. The entire exam was otherwise
essentially normal. Palpation of the extremities did not reveal any signs of injury. Chest, abdomen,
back, pelvis were all negative, as well on re-examination sometime later he again presented normally.
TREATMENT: The patient's wound was cleansed with Betadine. 1% Xylocaine with Epinephrine was
used as a local anesthetic, The wound was closed subcutaneously with 5-0 coated Vicryl and the skin
underneath the frontal hair was closed with 6-0 nylon suture, and the skin margins over the forehead
were closed with Dermabond bilaterally.
Again on examination after suturing, the child was awake, alert, and oriented, ambulated to the
bathroom without difficulty, did not complain of a headache. Pupils equal, round, reactive to light. The
extraocular muscles intact. Again on examination of the t~, abdomen, back and pelvis all negative,
Parents were given instructions to observe the child to observe the child for the next 24 hours with head
sheet closed head injury instructions, as well as instructions for care of the wound with suture removal
of the external sutures in 5 days,
DIAGNOSIS: 1)
~
DO: 05/09/1999
OT: 05/11/1999/sl1
0#: 473164
ER REPORT
ER REPORT
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ER REPORT
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TIME OF INJ~ ONSET O~..20MS: Stf'; t:
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o DtsORIENTED
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o SHAlLOW
o lABORED
OWHEEZlNG alaR
oRETRAcnONS
o RAlESlRHONCHt 0 LOR
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SIlO
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a VAGINAL BLEEDING
a NORMAL R.OW
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Cl HEADACHE
Cl STIfF NECK
aOIZZlNESS
C WEAKNESS:
a CYANOTlC
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o ABDOMEN
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o ABRASIONS: AREA:..JJ c!f
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~CERA:nON: ;::;;;v. VS~Rnv (1lO!!'l. severe)
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a COUs:rANT
a INTERMm'ENT
a RAOIA T1NG:
a BlEEDING:
ClBURNS:
a08V10USDEfORMllY
a SWEI.UNG:
aOTllER:
o SHARP
aDUlt
o HEAVY
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TRIAGE NURSE SIGNATURE:
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ASSESSMENT COMPLETED BY:
~} PINNAClEHEALTH
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ADMISSION DATA BASE
DIVISION OF PATIENT CARE SERVICES
EMERGENCY DEPARTMENT
FORM NO. 623'--29 REV. 7196
HMO 0 APPROVED 0 NOT APPROVED
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PUPILS NEURO CHECKS /U/. L~J N 'r..-? "/{r L.. ,~
OATEfTIMF=: RIL RA LA Rl II OTHER INT ,,// ,_ r
.
c
OATE/TlME CONSULTS
NOTIFIED PHYSICIAN/SERVICE TIME seEN INT
.,
" MEDICATIONS
DATE/TlME DRUG. AMOUNT ROUTE SITE INT
o OISCHARGED TO: /~~SPOS1T1ON DmS- 5 -~ ~'MrI.@1::
DISCHARGED IN THE CARE OF: o SELF o SPOUSE ~ PARENT o GUARDIAN
o OTHER:
INSTRUCTIONS GIVEN: .~ YES 0 NO (REASON):
,~~<~:=:~;;;.'::~-~~~~-~,~",:,;':':-:.;'--~:". .:. MODE: ftfAMBULATOR~ WHEELCHAIR o AMBULANCE o CARRIED
.::-::i.t~~~i '- o OTHER:
OA1'EIT1ME VCl.lIME CATH SITE. ,--" SOlUTION" RATE "iNT o ADMITTED TO MEDICAL CENTER
ADMISSIONS CALLED: BED ASSIGNMENT:
BED READY: REPORT CAlLED:
ACLS PROTOCOL: 0 YES ONO ~NIT:
MODE: 0 AMBULATORY 0 aiR ~ , CHER o OTHER:
- .~
DISCHARGE NURSES SIGNAlURE: ,. ~t d...v ,..
PATIENT IDENTIFICATION
~'> PiNNAClEHEALTH ~,~-e~~
Hospitals ) ~c....C--'::;""'5 ~
NURSING PROGRESS NOTES
DIVISION OF PATIENT CARE SERVICES I. \
EMERGENCY DEPARTMENT
F"ORM" NQ 7<'11"3 REV J"f9'=f
CARPENTER, ZACHARY
PA.GE 1.
'l8824U49
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PINNACLEHEALTH AT POLYCLINIC HOSPITAL
RADIOLOGY REPORT
MR#:
SSN:
ADM:
DOB:
BED:
LOC:
88824~1.49
88824~1.49
990322823
03/17/1988
NAME:
CARPENTER, ZACHARY
3608 ALBERTA AVE
MECHANICSBURG, PA 17055
KRJ:EG, ERJ:C
90001
EMERGENCY ROOM. ASSOCIATES
EMR
_CLl!t!OR: _
ORD#:
ATT DR:
REASON: MVA
S
EXAM: 90001-72020 SPINE SINGLE VIEW SPEC LVL- --2011
DATE: 05/09/1999 13:18
_PORTABLE CROSSTABLE LATERAL CERVJ:CAL SPJ:NE - B3.0 HOURS
I"":"
-:',.;;;)'
CONCLUSJ:ON:
No significant abnormality.
further evaluation, a formal
suggested if warranted.
If there is clinical concern for
cervical spine series would be
RESULT: There is no fracture, dislocation, or bone destruction or any
gross bony malalignment~.. The vertebral bodies and intervertebral spaces are
well-maintained and the prevertebral soft tissues are grossly unremarkable.
ICD9: 959.1
D: 05/09/1999
T: 05/10/1999 07:48AM/ALJ
DICTATED BY: MICHAEL J MANDELL, MD
ELECTRONICALLY REVIEWED: 05/10/1999 08:18AM
':;:"-
DJ:AGNOSTJ:C RADJ:OLOGY REPORT
__A_A--=___~__ __.._._ _..--:-.. .--~.....
-I.~"'.J;;,- ,...._. I,.. ....,~_,---
. . ED # , . INSTR~CTIONS TO THE PATIENT 4) PINNACLE~';lH
. The e';;'[11ination and treatment you have ree. -- it in Ihe el)Jerge~ey ,~epartment have been render. an emergency basJ~,(ii. WJii9:r\9l.I~!'!rded
\0 'oe a subs\\\U\e lor. or an eflolt to provide complete medical care.:n= YOU DEVELCP NEW PROBLEMS OR COMPlICA TrONS, CONTACT YOUR
PHYSICIAN OR THIS EMERGENCY DEPARTMENT. S fP 1 0 1C'"
FOLLOW THE INSTRUCTtONS BELOW AS INDICATED FOR YOU R .. .:1'/
- ~I;;C'-;-li'---"
~C~RATIONS,ABRASIONSORBURNS . ~ALlNSTRUCTlOd' '" .... 'h:.:.1.J
c::[; Keep wound clean and dry 24-48 hours. r.I ad rest for _L... _
G) After 24-48 hours wash with soap and water or peroxide. 2. Take aspirin_or Tylenol
9,) Watch for signs of swelling. redness. tenderness. heat or every hours..
drainage. 3. Clear liquid diet - advance as tolerated.
4'..4etanusT~xai tanusdiphtheriagillen (yes).
P(..I.tf'Lgt! ,.-, ~ 4. Drink plenty of liquids,
5. supplemental instrucJion sheet.
FOLLOW-UP CARE EMPLOYMENT/SCHOOL Off ~orkLseh~ until
1. Return to Emergency Department immediately if un""pectedly 1, Return to normal duty on .", -f;J t . i d A Ii
worse or not improved. 2. Return to limited duty on ~ ~_?D1. I ~
2. Emergency Department n ~3. Umitation h .7
3, Family Physi ' Ij , ' :l?R~turnY'sch~o~- /, /
~)SeeOr, ,~~
on at AM/PM. /'i'
5. Call ClinIc between 9 AM - 5 PM we&ays
for an appointment within days at 782-2421.
6. Occupational Medicine - call 782-4239 after 9:00 AM for
<
appointment.
7. Call Kline Family Practice on weekdays at 782.2100 for an
appointment within hrs/days.
8. Call Kline Pediatrics for an appointment in
782-4650.
9. Call cast room at
10. Call employee health within
for follow-up at 782-2551.
I HEREBY ACKNO GE RECEIPT OF THESE INSTRUCTIONS. THAT I HAVE HAD EMERGENCY TREATMENT ONLY, AND THAT I MAYBE RELEASED BEF RE
PROB~ A NO TED, I WILL ARRANGE FOR FOLLOW-UP CARE AS.I HAVE BEEN 1"~ all
X\.} " , DATEY'7.?5 k!.c;,.i /p./
esponsibl6 person A. . Signature
OTHER:
your pending lab tests. 782-4132
LABO~ATO~Y INSTRUCTION: Call the Emergency Department on_
for results of
X-RAY rNSTRUCTJONS' Your x~rays have been read by the Emergency
Physician. For your added protectio~. your x.rays will be reread by our
Radiology Department. If any abnormalities are found that have not been
called to your attention. you or your doctor will be caned immediately.
Sometimes fractures or abnormalities may not show up on x-rays for several
days. If symptoms persist or get worse, call your Physician or return to
Emergency Department. More x-rays may have to be taken.
~1~
<,~
hrs/days
for appointment at 782-2142.
hrs/days for an appointment
~
ysiclan Signature
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LABEL ALL PRE:SCRIPTIONS 0 c ~ z
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.J} PINNACLEHEALTH
~ H~als
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EMERGENCY DEPARTMENT
POLYCUNIC HOSPrTAL
2601 NORTH 3RO STREET
HARRISBURG. PENNSYLVANIA
Phone 717-782-4132
rf& G-c7
,M,D,O,
IN ORDER FOR A eRAM:JNAME PRoDUCf-l:OBEDtSPENSEO. THE PRESCRIBER MUST HANDWRITE
"SRI,ND NECESSA'=lY"'Oft~NO.""EDICAll.Y.NECESSARV-IN THE SPACE BELOW.
-rift" PATIENT INFO~ON
CARPE"TER .ZACHART
9CW322823
03/17/1'188111lC
3&08 4LBERTA AYE 17055
lIEC:iA'lI:SD PA 717-732-1708
IIR 88824114'1 ElIERGEHCY
XE>7/JurO-srJr. FJFlIf
~~Y REALL
PA We, #
DEA No,
TIMES
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AUTHORIZATION FOR TREATMENT - \ consent to the rendering olme<iicel Cere, which mayindU<lediagnostic pr0CF9ures llI1d sutli tnWicaJtreatn
as my attending or consulting physician considers to be necessary. I also understand it is customary, absent emergency or e~~tc!rcurnstances, tha.
substantial procedure will be perfe. med upon me unless or until I have had an opportunity to discuss them with my physician or other health c8r~c5Sional to
satisfaction. Iff am acompetent adult, I havethe rfghtto consent or refuseto consenttoanyproposed procedure to therapeutic treatment. I will not be involved in,
research or experimental procedure without my full knowledge and consent. I understand that the practice of medicine and surgery is not an exact science and I
diagnosis and treatment may involve risks of injury or even death and acknowledge that no guaratltee has been made to me as to the results of any examinatior
treatment in this hospital.
_'RELEASE OF MEDICAL INFORMATION - I hereby authorize PinnacieHeellhSystem, my attending physician and for other physicians associa
with him/herorwhom he/she maydesignatetorelease all or part of my medical record from this inpatient admission to any other health care providers involved in
continuing care and treat"!1ent, to my insurance company and its contractual vendors. Social Security Administration, Health Care Financing Administration ..
third-party carriers and their contractual vendors, or their representatives, for the purpose of collecting insurance benefits so long as I am listed on the accoun
having coverage with such carrier.
PRE-CERTIFICATION REQUIREMENTS - If my insurance company or third-party requires pre-certification, lhen I understand lhat tt is myrespo,
bility to contact them to obtain such certification. EXCEPTION: Medicare. .
ASSIGNMENT OF INSURANCE BENEFITS - I hereby authorize my Medicare and/or medicaJ insuranca benefits payableto me underthelerms of
insurance policies to be paid directly to PinnacleHealth System. If my attending physician and/or other physician associated with him or whom he may desigr
accepts insurance assignment, then t hereby authorize my Medicare andlor medical insurance benefits to be paid directly to those physicians. I understand tl'"
am financially responsible for non-covered services, as well as any deductfbles, coinsurance or amounts in excess ot insurance benefits. f permit a copy ot
authorization to be used in place of the original.
INPATIENTS AND OBSERVATION BED PATIENTS ONLY
~~}
PATIENT SELF-DETERMINATION ACT OF 1990 lA;dvance Directives} -I acknowledge lhat PinnacleHealth System has provided me \
written information on my rights to make health care treatment decisions in compliance with the Patient Self-Determination Act of 1990.
PERSONAL VALUABLES - I understand that PinnadeHealth System provides facilttles forlhesafekeeping of any valuable and enyvaluables kept by
patient are kept at the patient's risk. I hereby accept fun responsibility for any persona effects taken to the hospital room, including such things as dentures. '
glasses, contact lenses, hearing aids and radios.
MEDICARE INPATIENTS ON LY -I certify that the information given by me in applying lor payment under Title XVIII of the SocialSecurily Act. is corre
acknowledge that I have received a copy of" An 'Important Message from Medicare. My signature only acknowledges my receipt of this message from Pinna
Heallhand does not waive any of my rights to request areview ormake me fiablefor any payment. (reafizethat lifetimereservedays areaonce lifetimemaximuf
60 days. If I should use all my full days and co-insurance days, I agree to use my lifetime reserve days for any remaining days.
CHAMPUS INPATIENTS ON LY - 1 acknowledge that I have received a copy of An Important Message from CHAMPUS." My signalureonly acknowled
my receipt of this message from PinnacleHealth System and does not waive any of my rights to request a review or make me liable for any payment.
AUTHORIZATION MUST BE SIGNED BY THE PATIENTS LEGAL REPRESENTATIVE IN THE
[}CA~F A ~INOR. OR WHEN THE PATIENT IS PHYSICALLY OR MENTALLY INCAPACITATED
~_ (fl.~,lk<) -., \~
~re of Patient Date Signed
-
~
Insured/Reiationship ~f other than patient)
Patient is unable t<:l sign because
Hospital Representative
Ai} PINNACLE ,LTH
~ Hosplta
AUTHORIZATION FOR
TREATMENT
PATIENT lDENTlFlCATION
~~_~ "r/Cl7"'" ';"""'"
"
::\.ME~
. ,
lATE COMPLAINT PHYSICAL EXAMINATION DIAGNOSIS TREATMENT
~{J tti,U~ ~. (;' d'-'r % ~.,"~, .
,,11 ~ S'C~ . t:';G)y:.q:' iC.~ ~,..
'lo I/o {,<-lff ~'rr'-I~ -- -~ ./.- - -z..; 'r :; t!:> j,;'
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in foe-clued SJ'fXC l f/i' .
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S'undcu~. ---" - -!~~ - ~-
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. AUG 24 1
rtt:.LtlV
rAN AND r,/\~Cj;\ PEDlA TRieS. t
153 SOI!th ,j2"1 S(!'(u ,-",-
Camy Hill, ~A non "
!CARPENTER I ZACHARY
DATE O~ .IRTH: 3-17-88
..
POl'CY NO .....1ji,' '<-(";;':;</ - 7'5
, ,_..'".....&~.,
DATE/LOSs..... _....,_,_
INSliFlED_..__,___,....
CLAIMANT
PICTUIlE r~o_.,__,___
OATEIHME TAKEN.Jih.Qj.li
BY----1l.t\::~
,.'
WEATHEI!~_..
lOCATION AND VIEW___
COMMENTK__..~..,_____
ADDITIONAL
INFORMATION
DOVER
PICWIIENO_....__
!lATE/TIME TAI<E~L____,_....__
!3Y~_~~_~...=~
WEATHEli____
LOCATION AND VIE~\L_....,.
COMMENT8....,___..,___
ADDITIONAL
INFORMATION OO\lEIl
OUR FILE NO,
CO, ClML__,___
.... -.,"", .__ro-Il'" ..._... "'" ..._ .., ""... "" ...',...,,,..........,..,.... ...~, ".,............ .,~ . ""........',. .~~..... .,. ...__. _.,. '~A_ ._,. _ ." _ ". w, ,_ _... . .,."
'.
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"
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FULL AND FINAL RELEASE
FOR AND IN CONSIDERATION of the sUffiof Twenty Thousand
Dollars ($20,000.00) paid to the undersigned, Joanne Carpenter,
as Parent and Natural GU4rdian of Zachary Carpenter, a Minor, and
other good and valuable consideration, the receipt and sufficiency
of which is hereb~ acknowledged, th~ undersigneq,agrees fully to
release, discharge and hold harmles~ and indemnify Edward
Carpenter, State Farm Mutual Automobile Insurance Company, and
all other persons,-assoc:Lations and corporations whether or not
named herein, their heirs,executors, administrators, successors,
assigns and insurers, and their respective agents, atto=eys,
servants and employees, from any or all causes of action, claims
and demands of whatsoever kind on account of all known, and
unknown injuries, losses and damages allegedly sustained by the
Minor on May 9, 1999, and, specifically from any claims or
joinders, for sole_ liability, contribution, indemnity or
otherwise as a result of, arising from, or in any way connected
with injuries sustained by the Minor, on account of which a Legal
Action was instituted by the undersigned in the Court of Common
Pleas for Cumberland County, Pennsylvania, at Docket No.
, and the def~nse and handling thereof from the
inception of the claim until the date of this Full and Final
Page 2 of3
'" ~ 1 ;!_ ~
-
Release.
The undersigned understands and agrees that the
acceptance of said sum is not an admission of liability by any
party named herein.
It is expressly understood and agreed that this Release
and settlement is intended to cover and does CQver not only all
now known injuries, losses and damages, but any further injuries,
losses and damages which arise from or are related to the
occurrences set forth in the Legal Action noted above and the
handling and defense thereof.
It is further understood and agreed that this is the
complete Release agreement, and that there are no written Qr oral
understandings or agreements, directly or indirectly connected
with this Release and settlement that are not ,incorporated
herein.
This agreement shall be binding upon and inure to the
successors, assigns, heirs, executors, administrators and legal
representatives of the respective parties hereto.
The undersigned hereby declares that he is of legal
age; that the terms of this settlement have been completely read;
that he has discussed the terms of this settlement with legal
counsel of choice; and that said terms are fully understood and
voluntarily accepted for this purpose of making a full and final
compromise, adjustment and settlement of any and all claims on
account of the injuries ahd damages above-mentioned, and for the
Page 3 of3
....... ~-"---
oJ. '- ~_.-
express purpose of precluding 'forever any further or additional
suits, administrative proceedings or any other claims for relief
arising out of the aforesaid claim.
I IN WITNESS WHEREOF, and intending
U"",., feby, I have hereun. to set my hand and seal
~ ,1999.
-- ,
Y"a.. VL- UJi7
~ "eO-)C 0,Llvt- ~ f tfc4
E:''lL\ 1 r-e:S ~ 3 -31 - b30v /
to be
this
aera.. 'YL
J CARPE
Na ral Guardian_of
CARPENTER, a Minor
legally bound
nd '+:it-, day of
.-
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w-__. ;, ,,,,__,,,_
",-
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. -
.
(SEAL)
'Parent and
ZACHARY
Page 4 of3
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