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TROY SHAFER, a minor, by
TODD SHAFER and JOANNE
LESCALLEET, parents and
natural guardians,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
V.
CATHERINE R. BROWNAWELL,
Defendant
and
MIRIAM LEON,
Defendant
and
STATE FARM,
UIM Carrier
No. 00-1676 CIVIL TERM
IN RE: MINOR'S COMPROMISE SETTLEMENT
ORDER OF COURT
AND NOW, this 5th day of April, 2000, upon
consideration of the foregoing Petition, it is ordered and
directed that the settlement of this action for the lump
sum amount of $115,000.00 is hereby approved. Counsel fees
and expenses as submitted are allowed, and distribution is
dictated as follows:
To Graham & Mauer, P.C., counsel fees $38,295.00
To Graham & Mauer, P.C., costs $ 1,557.06
To Joanne Lescalleet, parent of Troy
Shafer, for out of pocket expenses
$ 1,320.36
To Medical Assistance
$ 5,533.30
To Troy Shafer
$68.294.28
TOTAL
$115,000.00
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The amount of money paid to Troy Shafer shall be
deposited in a restricted account(s) or certificate(s) of
deposit in a bank, credit union, or similar institution
which is insured by a Federal government agency. Any such
account(s) or certificate(s) of deposit shall be restricted
so that no amounts may be withdrawn therefrom without
further order of court until June 6th, 2008. Petitioners
are directed to file with the Prothonotary proof of the
opening of said restricted account(s) or certificate(s) of
deposit within ten days of the receipt of the check.
Petitioners are authorized to sign any releases
deemed appropriate by their counsel to settle this action.
By
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Edward E. Guido, J.
Lisa J. Mauer, Esquire
For the Petitioner
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GRAHAM & MAUER, P.e.
By: LISA 1. MAUER, ESQUIRE
Attorney J.D. 65426
The Commons at Valley Forge
Suite 22, P.O. Box 987
Valley Forge, Pennsylvania 19482
610/933-3333
Attorney for Plaintiff
TROYSHAFER,ammo~by
TODD SHAFER and JOANNE LESCALLEET
parents and natural guardians
Plamtiff
COURT OF COMMON PLEAS
v.
CUMBERLAND COUNTY
CATHERlNE R. BROWNA WELL
Defendant
No.: 00-1676
and
MIRIAM LEON
Defendant
and
STATE FARM
DIM Carrier
In Re: TROY SHAFER, a minor
PRAECIPE TO SETTLE. DISCONTINUE AND END
TO THE PROTHONOTARY:
Please mark this matter SETTLED, DISCONTINUED and ENDED.
Date: May 10, 2000
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Received May-15-00 12:27 from 7172439649 ~ 16109830570
MAY.,~ I2lI2l 11:27 FROM'PASTATESANKCARLISLE 7172439649 TO: 16112l9S312l5712l
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^ ~/15/00 NessAq. Maintenance
TRO~ SHAFER eIr number......
Type options, press Enter. Account number..
D-Ce1ete C-Co11ateral 1-9-Severity Level
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C~POSIT SHALL Be ~ESTRIeTED SO THAT NO AMOUNrS OF
MONEY MAY BE WITHDRAWN THEREFROM WITHOUT FURTHER
ORDER OF THE eOURT UNTIL ,TUNE 6. 2008
ORDER OF THE COORTON FILE AT CARLISLE
FS"'Maintenance
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MAR 21 20000
GRAHAM & MAUER, P.C.
By: LISA J. MAUER, ESQUIRE
Attorney I.D. 65426
The Commons at Valley Forge
Suite 22, P.O. Box 987
Valley Forge, Pennsylvania 19482
610/933-3333
Attorney for Plaintiff
TROY SHAFER, a minor, by
TODD SHAFER and JOANNE LESCALLEET
parents and natural guardians
Plaintiff
COURT OF COMMON PLEAS
v.
CUMBERLAND COUNTY
No.: 00-/1-7(,. C(.)~lY~
CATHERINE R. BROWNA WELL
Defendant
and
MIRIAM LEON
Defendant
and
STATE FARM
DIM Carrier
In Re: TROY SHAFER, a minor
ORDER
AND NOW, this ,.,.,.J day of ~
, 2000, it is hereby ORDERED
and DECREED that a hearing on Plaintiffs Petition for Leave to Compromise Minor's Action
will be held on the fi day of A-'If..,' / ,2000, at /:()(/ ~m. in Courtroom .5 of
the Cumberland Country Courthouse, Carlisle, Pennsylvania. C""" .,.",J.. ~ ht ~
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GRAHAM & MAUER, P.C.
By: LISA 1. MAUER, ESQUIRE
Attorney lD. 65426
The Commons at Valley Forge
Suite 22, P.O. Box 987
Valley Forge, Pennsylvania 19482
610/933-3333
Attorney for Plaintiff
TROY SHAFER, a minor, by
TODD SHAFER and JOANNE LESCALLEET
parents and natural guardians
Plaintiff
COURT OF COMMON PLEAS
v.
CUMBERLAND COUNTY
No.: tJ-tJ - I {, 71.. Cu;J / ~
CATHERINE R. BROWNA WELL
Defendant
and
MIRIAM LEON
Defendant
and
STATE FARM
DIM Carrier
In Re: TROY SHAFER, a minor
ORDER
AND NOW, this
,2000, upon consideration of the
day of
foregoing Petition, it is hereby ORDERED that the settlement of this action for the lump sum
amount of One Hundred Fifteen Thousand Dollars ($115,000.00) is hereby approved, counsel
fees and expenses are allowed, and distribution is dictated as follows:
TO: TROY SHAFER, a minor,
$ 115,000.00
. 15,000.00 paid by Leader Insurance
Company, insurer of Miriam Leon
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,
. 50,000.00 paid by State Farm, insurer
of Catherine R. Brownawell
. 50,000.00 paid by State Farm, VIM insurer
of Troy Shafer's mother, J. Lesca1leet
TO: GRAHAM & MAUER, P.C.
For counsel fees (one-third)
38,295.00
TO: GRAHAM & MAUER, P.C.
For costs
1,557.06
TO: JOANNE LESCALLEET, parent of
Troy Shafer, for out-of-pocket expenses
1,320.36
TO: MEDICAL ASSISTANCE
(Reduced from $8,299.95)
5,533.30
Net to Client
68,294.28
BY THE COURT:
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GRAHAM & MAUER, P.C.
By: LISA J. MAUER, ESQUIRE
Attorney I.D. 65426
The Commons at Valley Forge
Suite 22, P.O. Box 987
Valley Forge, Pennsylvania 19482
610/933-3333
Attorney for Plaintiff
TROY SHAFER, a minor, by
TODD SHAFER and JOANNE LESCALLEET
parents and natural guardians
Plaintiff
COURT OF COMMON PLEAS
v.
CUMBERLAND COUNTY
No.: 01J _ It. 7(P ~ I.v--
CATHERINE R. BROWNA WELL
Defendant
and
MIRIAM LEON
Defendant
and
STATE FARM
VIM Carrier
In Re: TROY SHAFER, a minor
PETITION FOR LEA VE TO COMPROMISE MINOR'S ACTION
TO THE HONORABLE, THE JUDGES OF THE SAID COURT:
The Petition of Todd Shafer and Joanne Lescalleet, parents and custodians of a minor,
Troy Shafer, respectfully represents that:
1. They are the parents of Troy Shafer, a minor, age eight, who was injured on
February 11, 1999, while struck, as a pedestrian.
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2. Troy Shafer, a minor, currently resides with his mother, Joanne Lescalleet, at 11
Cooper Circle in Carlisle, Cumberland County, Pennsylvania 17013.
3. On the date of this accident, Joanne Lescalleet had a limited tort State Fann
automobile insurance policy with $10,000.00 in medical coverage and $50,000.00 in
underinsured motorist protection.
4. Todd Shafer resides at 5 N. High Street in Newville, Cumberland County,
Pennsylvania 17241.
5. Plaintiffs parents, Todd Shafer and Joanne Lescalleet, were never married to each
other.
6. This Petition is brought in Cumberland County and the accident also occurred in
Cumberland County, Pennsylvania.
7. This accident occurred when Catherine R. Brownawell, a driver, stopped her
vehicle to wave Troy Shafer across the road to get the ball he was playing with, which had rolled
across the road.
8. While crossing the road, Troy Shafer, a minor, was a struck by a vehicle traveling
toward Catherine R. Brownawell and, driven by Miriam Leon
9. As a result of the aforesaid incident, Troy Shafer sustained numerous injuries in this
motor vehicle accident, including comminuted fractures of the left and right femurs, bums to his
face and legs, a fractured jaw, loss of a permanent tooth, and a head injury.
10. Troy Shafer was initially flown to the Hershey Medical Center, where he received
significant treatment, including multiple surgeries.
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11. Troy Shafer sought further care after being released from the hospital from Randy
M. Hauck, M.D., Lee S. Segal, M.D., Comfort Care - Home Therapy, Alexander Spring Rehab,
James Keams, D.D.S., and Peter Pizzutillo, M.D.'
12. Troy Shafer's medical treatment has not been completed as of the date of this
Petition. His permanent tooth has not yet been replaced.
13. Plaintiffs medical bills totaled more than $50,000.00 as of October 15, 1999, prior
to his final course of physical therapy. (See "Exhibit An, attached hereto.)
14. The first $10,000.00 of medical bills was paid by Joanne Lescalleet's State Farm
policy. The remainder ofthe bills were paid by Combined Insurance Company of America,
Conseco Health Insurance Company, Health Central HMO (with a $10.00 co-pay per visit, paid
by Joanne Lescalleet) and Medical Assistance.
15. As ofJanuary 19, 2000, the total amount paid by Medical Assistance was
$8,299.95. While not all of the medical bills had been processed as of that date, Medical
Assistance agreed to accept $5,533.30 as payment in full for satisfaction of their lien. (See
"Exhibit B", attached hereto.)
16. Attached as "Exhibit C" are receipts for the out-of-pocket expenses that have been
incurred for treatment of said minor, all of which have been paid in full by Plaintiff's mother,
Joanne Lescalleet.
17. Counsel was retained upon a 33.3% contingent fee basis by Petitioner. (See
Attorney Justification, attached hereto as "Exhibit on.) Additionally, counsel has incurred the
following expenses:
Carlisle Police (Report) 15.00
Hershey Medical Center (bills) 15.00
Photo Haven (accident scene) 17.51
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The Camera Shop
(develop photos of client's injuries)
Staples (photo enlargements)
The Print Shop (copy medical records)
Recordex (Hershey Records-
inpatient stay & first surgery)
Minors' Compromise fee
North Middleton Township
(Zoning Ordinance)
Alexander Spring Rehab (med. records)
Comfort Care (medical records)
Kearns & Ashby (dental consult)
Peter Pizzutillo, M.D. (medical records)
llershey Medical Center (x-rays)
Staples (copy x-rays)
Recordex (records of Dr. Segal)
Recordex (second surgery records)
James Druecker, PE
(engineer evaluation of roadway)
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26.21
5.26
19.46
124.15
45.50
28.20
16.99
34.00
35.00
16.33
63.00
6.30
19.78
69.37
1,000.00
Total $1,557.06
18. Defendant Miriam Leon was insured by Leader Insurance with a $15,000.00
liability limit.
19. Defendant Catherine R. Brownawell was insured by State Farm with a $50,000.00
liability limit.
20. Troy Shafer was insured by his mother's State Farm policy with $50,000.00 in
underinsured motorist coverage. (See Joanne [Stouffer] Lescalleet's declaration sheet, attached
hereto as "Exhibit E".) Troy Shafer's father does not have auto insurance.
21. Petitioners and counsel recommend approval of the lump sum amount of Fifteen
Thousand Dollars ($15,000.00) with Defendant Miriam Leon's insurance company because this
amount represents the full limit of the tortfeasor's policy. See letter from Leader Insurance
Company, dated March 30,1999, attached hereto as "Exhibit F".
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22. Petitioners and counsel also recommend approval of the lump sum amount of Fifty
Thousand Dollars ($50,000.00) with Defendant Catherine R. Brownawell's insurance company
because this amount represents the full limit of the tortfeasor's policy. See letter from State
Farm Insurance Company, dated October 11,1999, attached hereto as "Exhibit G".
23. Petitioners and counsel also recommend approval of the lump sum amount of Fifty
Thousand Dollars ($50,000.00) with Petitioner's own insurance company because this amount
represents the full limit of the petitioner's underinsured motorist benefit. See letter from State
Farm Insurance Company, dated November 29,1999, attached hereto as "Exhibit H".
WHEREFORE, Petitioners pray that an Order be entered approving the compromise
allowing counsel fees and ordering distribution.
GRAHAM & MAUER, p.e.
By:
Date: March 17, 2000
-~~, .
GRAHAM & MAUER, P.C.
By: LISA J. MAUER, ESQUIRE
Attorney LD. 65426
The Commons at Valley Forge
Suite 22, P.O. Box 987
Valley Forge, Pennsylvania 19482
610/933-3333
Attorney for Plaintiff
TROY SHAFER, a minor, by
TODD SHAFER and JOANNE LESCALLEET
parents and natural guardians
Plaintiff
COURT OF COMMON PLEAS
v.
CUMBERLAND COUNTY
CATHERINE R. BROWNA WELL
Defendant
No.:
and
MIRIAM LEON
Defendant
and
STATE FARM
VIM Carrier
ATTORNEY VERIFICATION
In my professional opinion as counsel in this matter, I believe that the proposed
settlement in the lump sum amount of One Hundred Fifteen Thousand Dollars ($115,000.00) is
reasonable under the circumstances. The proposed settlement reflects the limits of the
tortfeasors' policies and the only underinsured motorist policy which insures Troy Shafer, a
minor, for the injuries he sustained in the February 11, 1999 auto accident.
GRAHAM & MAUER, P.C.
By:
Date: March 17,2000
. 4.
Notary Public
GRAHAM & MAUER, P.C.
By: LISA J. MAUER, ESQUIRE
Attorney LD. 65426
The Commons at Valley Forge
Suite 22, P.O. Box 987
Valley Forge, Pennsylvania 19482
610/933-3333
Attorney for Plaintiff
TROY SHAFER, a minor, by
TODD SHAFER and JOANNE LESCALLEET
parents and natural guardians
Plaintiff
COURT OF COMMON PLEAS
v.
CUMBERLAND COUNTY
CATHERINE R. BROWNA WELL
Defendant
No.:
and
MIRIAM LEON
Defendant
and
STATE FARM
VIM Carrier
AFFIDAVIT OF GUARDIAN
I, Joanne Lescalleet, certifY that:
1. I am a parent and custodian of Troy Shafer;
2. Troy Shafer has had medical treatment for the injuries sustained in the incident
which is the subject matter of this action and may require additional treatment in the future; and
3. I approve the proposed settlement of a lump sum payment of One Hundred Fifteen
Thousand Dollars ($115,000.00) and the distribution thereof.
~ C4
J~ '-(<" . ~fla1111+
~e Lescalleet
F"t>.6
,2000.
. ,
~,,' ,
GRAHAM & MAUER, P.C.
By: LISA J. MAUER, ESQUIRE
Attorney I.D. 65426
The Commons at VaHey Forge
Suite 22, P.O, Box 987
Valley Forge, Pennsylvania 19482
610/933-3333
Attorney for Plaintiff
TROY SHAFER, a minor, by
TODD SHAFER and JOANNE LESCALLEET
parents and natural guardians
Plaintiff
COURT OF COMMON PLEAS
v.
CUMBERLAND COUNTY
CATHERINE R. BROWNA WELL
Defendant
No.:
and
MIRIAM LEON
Defendant
and
STATE FARM
VIM Carrier
AFFIDAVIT OF GUARDIAN
I, Todd Shafer, certity that:
1. I am a parent and custodian of Troy Shafer;
2. Troy Shafer has had medical treatment for the injuries sustained in the incident
which is the subject matter of this action and may require additional treatment in the future; and
3. I approve the proposed settlement of a lump sum payment of One Hundred Fifteen
Thousand Dollars ($115,000.00) and the distribution thereof.
~s~.
Todd Shafer .
pqfQrem'~i'-&oo.YOf nad... ,2000.
. ~ 10 UOII8\OOSSV l!fUIlI\lASuU8d 'J9QWIIW
c-- .-- aoo' ~ S9J!dx3 u~sslWWo:>Aw .r
qwn:J hdMl UOlOJPPJrI_'
I oUqnd AteioN ')(:I0ISBU4a::l'~ euov !I
. IBes 18!J8l0N I
---
,;,.,-,.. ~
0-' "'~.
Troy Shafer
Auto Accident of February 11, 1999
Medical Bills through October 13, 1999
Hershev Medical Center
02/11199 Helicopter $ 2,869.00
02/11/99 Hospital (Inpatient) 18,420.20
02/12-19/99 Physician Services 4,317.80
02/11/99 Radiology 1,400.00
02/11199 Orthopaedics 6,352.00
02/11199 Anesthesiology 1,260.80
02/18-19/99 Pediatric Cardiology 6,455.80
03/05/99 Plastic Surgeons 1,847.60
03/02/99 Radiology 100.00
04/01/99 Radiology 100.00
04/01/99 Physician Charges 180.00
10/15199 Hospital (Inpatient) 7.390.00
$ 50,693.20
-""~
"" ~
, .
\IMFOR'
SERVices
OUTPATIENT
AHll ADllftiSS OF INSURED
JOANNE STOUFFER,
11 COOPER CIRCLE
CARLISLE
CWM!lATE
PAGE NUM8EI\
PA 17013
N. .
03/03/99
PEIIlOp COVERED BY THIS CLAIM
02/11/99
1
02/11/99
lON TO PATIENT sac.... SEOURIIY NUMBER
MOTHER 172-62-5057
:LAIM TO
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE PA 17013
INSURl\NCE CQMP_ NAME
AUTO INSURANCE
GROUP POUCY HOlJlEfl
STATE FARM INSURANCE
l,ffNAME
tAFER TROY E
it INsuRANCE INDICATED BY HOSPITAL RECORDS
OF INSURED
ACCOUNT NUMBER
00973391-9043
GROUPIPOUCY, ~UMBEfI
38J176022
MIS
s
I CEATlFlCATE/SUBSCRlBER NUMBER
I 7286S72E1l38A
IE
OBIS
1.9 INJURY-SITE NOS
_ PI\OCEIlURES
RELATION TO PATIENT
I
I
.
I
INSURANCE CARRIER
I
I
I
I
GROUPJPQlJCV NO.
I
I
I
I
CEAT JSUasc:RIS. NO.
I
I
I
I
HI TED WORKRELATEO
NO
ACClDl!NT!lATE a TIME
I
I
ATIENOt~ PtlYSIaAN
49201
KYM A.
AMBULANCE MILEAGE FEE_..
27 AT 60.00
XV CATH SUPPLY CHARGE ALS
PULSE OXIMETRY
EACH
AMOUlIIT
, -
1,620.0C
3.QQ.
44.00
TOTAL CHARGES
2,869.00
-,
-"
-
""
~M FOR,
SERVICES
AND ADDReSS OF IH8URED ClAIM DATE PAGE NUMBER
JOANNE STOUFfER, 03/18/99
11 COOPER CIRCLE SM01
CARLISLE PA 17013 PERIOD COVERED BYlHlS ClAIM
," 02/19/99
02/11/99 .
'IDN TO PAnliNT I SOCIAl. SECURITY NUMBER INSURANCE COMPANY NAME
MOTHER 172-62-5057 AUTO INSURANCE
:LAIM TO GROUP PClUCY HOUlEA
JOANNE R STOUFFER
11 COOPER CIRCLE STATE FARM INSURANCE
CARLISLE PA 170n
GllOUP/I'OUCY NUIotIIER I CER1lf1CATElSUBSCRIBER NUMBER
",' . I
38J176022 I 7286572E1138A
NT NAME I:OUNT NUMBER ~~ DATE ~ ~ SEX I MIS ,~ lots 0'2119/99
IAFER. TROY e '0973391-9042 "6/n6/9'. M S AOM 02111/99
A INSURANCE INDICATED BY HOSPITAL RECORDS RELATION TO PAnENT INSURANCE CARRIER GAOUP/pouCY NO. CEAT JSUBSCF4lB. NO.
OF INSURED I I I I
I I I I
I I I I
IE I ! ! I
IDSlS
~
..01 FX FEMUR SHAFT-CLOSED 802.21 FX CONOYL PROC MANOIB-CL
ICAL PROCEDURES
O~~~1/99 79.35 OPEN REDUC-.INT FIX FEMUR
02 11/99 79.35 OPEN REOUC-INT FIX FEMUR
:KlRE1.}.lED WORK AEU\lCD It' DATE a11ME JIATTE>lDlNG PHYSICIAN I
rES NO ciUll/99l 0'4:00 26076 CILLEY. ROBERT
VICE [lATE REF. NO. DESCRIPTION AMOUNT
SUMMARY OF CHARGES
'-"! ' ...~ ..........
0,0.1 PEDS INTENSIVE CARE.. 1 DAYS AT 1, 72.50~", 1,!2~.o.Q
Q01 PEDIATRIC, SEMIPRIVATE Z DAYS AT 525.0,0. 1,050. Q.Q,
OOJ,. PEDIATRIC-PRIVATE 5 DAYS AT 695.00 3,475.00
250 PHARMACY 615.59
25't PHARMACY 27.~1
260, I.V. SOLUTIONS 14.00
. ,.,
21:Q MED/SURG SUPPLIES ~.44. 120
300. LABORATORY 1,012.0.0
320 RADIOLOGY " 1,553.9,9.
324 RADIOLOGY, OX CHEST X-RAY l~,8. C.c
351 RADIOLOGY-CT HEAD 1, OQ,), 0.0
352. RADIOLOGY-CT BODY 1,50.4.0,0.
360 OPERATING ROOM 2,321.0.0,
370 ANESTHESIA 62.00
-
T 39], BLOOD ADMIN/TEST ~.\.5 . Q.O
410 RESPIRATORY THERAPY 1,003.9.0,
420 PHYSICAL THERAPY 66S.o.'i
43Q OCCUPATIONAL THERAPY 69 00
.~ . ... .'
450 EMERGENCY ROOM I,09~.QO
636, CHEMO/OTHER PHARMACY 130. Q,Q
730 EKG 79.00
, ~ .
TOTAL CHARGES 18,420.20
INPATIENT
.
~=
-,-, ~
"~ "~" - ~
= :-",'
i PennState. Geisinger
Health System
JOANNE It STOUFFER
11 COOPER CIRCLE
CARLISLE PA 17013
" <- " ,: -~. " , .
ACCOUNT # 973391
MY QIIE&TIOI4!1. "LEASE CONTACT: HERSHEY MEDICAL CENTER BILLING seRVICES
PROCEDURE DIAG
CODE CODE
ITIEHf I TROY E SHAfER
~99 9925UIH 80Z.20
~99 '923:5.11II '5'.8
"997355026.61: Y6i.4
.", 7355026.76 Y66.4
~" "231.11II aoZ.20
I"~ "2:5Z.1111 95'.8
'" "231.11II 802.211
", "232.11II '5'.8
'99 71148026. GC '59.8
'" 70111126 '59.8
'" 73621126
'5'.8
99 7360026
'5'.8
QTY
'733'1
DESCRIPTION
101 3
STATEMENT
IlATE: 03/03/99
LAST ITATEMEIlT
IlATE:
INS
FED TAX 10 # 236291113
CHARGE PAYMENTI GUARANTOR
AD~USTMENT IAl.AHCE
AUT lZ0.00
AUT 128.00'
AUT 511.lIII
AUT 50.00
AUT 64.00
AUT '0.00
AUT 64.00
AUT '0.00
AUT 181.00
AUT 70.00
AUT
50.00
36118749042
PERFDRIIED BY I DIY PLASTIC RECONST SURG
PLACE Of SYC: INPATIENT
PERFORHED AT: ItH HERSHEY MEDICAL CENTER
HERSHEY PA 17033
INITIAL INPT CDNSULTATIlW
PERFDRHED BY I DIY PEDIATRIC SURGERY
PERFORMED AT: ItH HERSHEY MEDICAL CENTER
HERSHEY PA 17033
DAILY IIOSPITAL CARE '
PERFDRIIED BY: DIY OF DIAG RADIOLClGY
PERFDRHED AT: ItI1 HERSHEY I1EDICAL CENTER
HERSHEY PA 17D33
FEIIIR (THIGIIl lINE JOINT
PERFDRIIED AT: ItH HERSHEY MEDICAL CENTER
. HERSIIEY, PA 17033
FEIIlR (THIGH 1 lWE JOINT
PERFOIUlEO BYI DIY PLASTIC RECONST SURG
PERFDRIIED AT: ItH HERSHEY I1EDICAL CENTER
HERSHEY PA 17D33
IIOSP VISIT BRIEF CC
PERFDRIIED BY: DIY PEDIATRIC SURGERY
PERFORHED AT: ItH HERSHEY MEDICAL CENTER
HERSHEY PA 17D33
DAILY ItllSPITAL CARE
PERFDRHED BY I DIY PLASTIC RECDNST SURG
PERFDRIIED AT:"" HERSHEY I1EDICAL CENTER
HERSHEY PA 17033
IIOSP VISIT BRIEF tc
PERFDRHED BY I DIY PEDIATRIC SURGERY
PERFDRHED ATI"" HERSHEV MEDICAL CENTER
HERSHEY PA 17033
DAILV IIOSPITAL CARE
PERFORHED BV I DIY OF DIAG RADIOLClGY
PLACE OF SYCI OP HOSPITAL
PERFDIUlED ATI ItH HERSHEV MEDICAL CENTER
HERSHEY PA 17033
CT ORB SELLA POS FOS ~H
PERFDIUlED ATI ItH HERSHEY MEDICAL CENTER
HERSHEY PA 17033
MANDIBLE >4 VIENS
PERFORMED AT;' HIt HERSHEV MEDICAL CENTER
HERSHEY PA 17D33
FOOT LIllITED
PERFDRHED AT I ItH HERSHEY I1EDICAL CENTER
HERSHEV PA 17033
KLE LIltITED
AUT
SO.OO
........-...,........
.-
-
..
--~
iUilllL~
,
,
~ PennState Geisinger
, HealtJi System
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE PA 17013
ACCOUNT # 973391
: ANY QUESTIONS. PLEASE CONTACT: HERSHEY MEDICAL CENTER BILLING SERVICES
TE PROCEDURE DIAG
CODE CODE
'15/',
"231.NH IOZ.ZO
'1"" "23Z.57 IOZ.tO
'1"" "231.NH '5'"
17/" Z1453.NH aOZ.lO
'171" "%lUH 959.a
'1719' Z1453.AA aoz.zo
181'9 "Z3Z.NH '59.a
18/" '3010
,
Lam 7l010Zi
959.1
181" 710Z0Zi
786.09
. "" 7lDZOZi
959.8
QTY DESCRIPTION
PERfORMED BV: DIY PLAsTIC REClIlST SURG
PLACE OF SYC: INPATIENT
PERfORMED AT: HH HERSHEV MEDICAL tENTER
HERSHEV PA 17033
HOSP VISIT BRIEf CC
PERfORMED AT: HH HERSHEV MEDICAL CENTER
HERSHEV PA 17033
HOSP VISIT INTER CC
PERfORMED BV I DIY PEDIATRIC SURGERV
PERFORMED AT: HH HERSHEY HEDICAL CENTER
. HERSHEV PA 17033
DAILV HOSPITAL CARE
PERfORMED BV: DIY PLASTIC REClIlST SURG
PERfORMED AT: HH HERSHEY MEDICAL CENTER
HERSHEY PA 17D33
fRAC HANDIBULAR OPEN " HA
PERFORMED BV: DIY PEDIATRIC SURGERV
PERFORMED AT: HH HERSHEV MEDICAL CENTER
HERSHEY PA 17033
DAIL V HOSPITAL CARE
PERFORMED BY I illY OF ANESTHESIA
PERFORMED AT: HH HERSHEV HEDICAL CENTER
HERSHEV PA 17033
13 TRT OPN HAND FRAC NIIIANIP
PERFORMED BY I illY PEDIATRIC SURGERV
PERFORMED AT: HH HERSHEV MEDICAL tENTER
HERSHEY P~ 17033
DAIL V HOSPITAL CARE
PERfORMED BV: DIY PEDIATRIC CARDIOLOGV
PLACE Of SYC: OP PHYSICIAN
PERfORMED AT: HH HERSHEV HEOICAL CENTER
HERSHEV PA 17033
EtG ELEtTRlICARDIIlGIt ClII'IPL
PERfORMED BV: DIY OF DIAG RADIOLOGY
PLACE Of SYCI INPATIENT
PERfORMED AT: HH HERSHEV HEDICAL CENTER
HERSHEV P A 17D33
tllEST 1 VIEN
PERFORMED AT: HH HERSHEV HEDICAL CENTER
HERSHEY PA 17D33
CHEST Z VIENS FRlIHT ILAT
PLACE Of SYt I OP HOSPITAL
PERFORMED AT: IIH HERSHEV MEDICAL CENTER
HERSHEY P A 17033
CHEST 2 VIENS FRlIHT ILAT
&AlANtE I TROY E SHAFER $0.00
CATES NEll fINKIAL ACTIVITY SlICE LAST BILL.
R CKAllGES BILLED TO YOUR INSURKE COHPM<<. 'J883. 20
'.
PAGE
2 at 3
STATEMENT
DATE: 03/03/99
I.A$T STATEMENT
DATE:
INS
FED TAX ID # 236291113
CHARGE PAYMENTI GUARANTOR
ADJUSTMENT BALANCe
AUT
64.00
AUT
'0.00
AUT
64.00
AUT 1896.00
AUT 64.0D
AUT 81Z.80
AUT '0.00
AUT ' 'i0.00
AUT
AUT
AUT
50.00
70.00
70.00
-
,~
-,,,,,,,,,",",,,,
"'"
~ PennState Geisinger
, Health System
PAGE
STATEMENT
\lATE: 03/03/99
LAST STATEMENT
ACCOUNT ## . 973391 \lATE:
'ANY QUESTIONS. PLEASE CONTACT: HERSHEY MEDICAL CENTER BILLING SERVICES FED TAX ID ## 236291113
TE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENTI GUARANTOR
C~ CODe . AD~USTMEHT BALANCE
THIS ST ATEHEHT IS FOR PROFESSIONAL SERVICES ONLY. IF YOU HAVE
ANY QUESTIONS REGARDIN; INSURANCE PAYIlENTS CooACT THE CWANY
DIRECTLY, THE AI'KUrr LISTED IN THE PAnENT COL~ IS YOUR
RESPONSIBILITY. IF PAYIlENT HAS BEEN HADE, PLEASE ACCEPT llUR
THAt<< YllU AND DISREGARD THIS REQUEST.
,JOANNE R STOLlFFER
11 COOPER CIRCLE
CARL/SLE PA 17013
301 3
PCFZ
QUEsnONS, PLEASE CALLI 17171 531-5D69 DR I"'DO-~-2619
TEHPORARY CHANGE OF PAnENT I~UIRY HllURS
.IIlHDAY - FRIDAY -- 8100 AN - ltllS PH
i
,
I
,
I
I.
I
I'
RESPONSDLE PARTY
AUT AUTO INSURANCE
IIlIll GUARANTOR RESPONSIBILITY
POLICY I'
7286572EI138A*38J176022
TOTAL
$ 4317.80
$ 0.00
Fi 973391
ERSHEY MEDICAL CENTER
BII.UNG SERVICES
080X 854
ERSHEY PA 17033-0854
'MWT ANTI Pt~u.Ra4et.MJ!JJ.fIJ/!JJ!A.P.'!.T.9JL1!.9.!lI!.9.!t!U.!I~.![~.fNT WI.T.I!.r.9.!1JJ.el!.'!-'~fNT .~
STATEMENT DATE. GUARANTDR RES'DNIIIII~ITY'
113/03/99 $ 0.00
PENN STATE GEISINGER
HERSHEY HCBS HS61
POBOX 854
HERSHEY PA 17033-0854
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE PA 17013
E DIIt,
"eKECK OKE
FOR CREDIT CARD PAVMENT, PLEASE FILL IN INFORMATION BELOW
',-", , "'....
.....: ':
_M/C
VISA
-DISC
973391
, :>11.' \.),_.~ ':....;, :'
CARD NUMBER
EXP DATE
6S0
MND
CARDHOLDER NAME (PRINT)
. ~';;;:'i'.';,\.'
.J
STATEMENT OF PHYSICIAN SERVICES
.,
. .
~.~.. :::-,
;
i"'-!,~,'''">''''
PennState Geisinger
Health System
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE I>A 17013
LolIt!
.~ \ i,,/i/r\P,(P
PAGE
1 01 6
STATEMENT
DATE: 06/14/99
LAST STATEMENT
DATE: 06/02199
FED TAX ID # 236291113
CHARGE PAYMENT' GUARANTOR
ADJUSTMENT BALANCE
ACCOUNT # 973391
~ IF ANY QUESTIOllS. PLEASE CONTACT: HERSHEY MEDICAL CENTER BILLING SERVICES
DATE PR~~gEuRE gb~~ . QTY DESCRIPTION INS
>>> PATIENT: TROY E SHAFER '733'1
02111/99 7101026
959.1
02111199 7101026 959.1
02111199 3648'.GC 959.8
02111199 7045026,GC 959.8
02/1119' 7210026.GC 959.8
02111199 72114026.GC 959.8
02111/9' 7219226.GC 959.8
02111/99 7416026,GC 959,8
02111/9' 7101026.GC 959.8
02/1119., 7207026.GC 959.8
02/11/99 27506.HH 820.8
04/09/99
02/1119' 27506.QK 820.8
04/09/99
05/04/99
3608749042
PERFORMED BY: DIY OF DIAS RADIOLOGY
PLACE OF SVC: OP HOSPITAL
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY P A 17033
CHEST 1 VIEH
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY PA 17033
CHEST 1 VIEH
PERFORMED BY: OIV PEDIATRIC SURGERY
PLACE OF SVC: EMERGENCY RlllIM
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY PA 17033
CVP CATH PERCUTAN OYER 2
PERFORMED BY: DIY OF NUCLEAR MEDICINE
PLACE OF SYC: OP HOSPITAL
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY P A 17033
CT HEAD UNENHANCED
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY PA 17033
SPINE LIHlDS ANT /POST LAT
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY PA 17033
SPINE CERVIC ANTIPOS LAT
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY P A 17033
CT PELYIS UNENHANCED
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY P A 17033
C T ABDlll1EN ENIIANCED
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY P A 17033
CHEST 1 YIEH
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY P A 17033
SPINE THOR ANT/POS LATER
PERFORMED BY: DEPT OF ORTHOPAEDICS
PLACE OF SVC: INPATIENT
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY PA 17033
2 FX FEM SHFT SPICMP OPREo
INSURANCE PAYMENT
PERFORMED BY: DIY OF ANESTHESIA
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY P A 17033
20 OP TRT CLlOP FEM SHFT FR,
INSURANCE PAYMENT
MA CONTR AFTER PRI INS
MAl
50.00
MAl 50.00
MAl 420.00
MAl 180,00
MAl 70.00
MAl 70,00
MAl 200, DO
MAl 240.00
1MiP
MAl 50.00
MAl 70,00
6352.00
6352,00-
0.00
1260.80
479.'\7-
781.:\3-
0.00
o CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
-
-
~~~~
'-'" ~. -
, - . - -'-
STATEMENT OF PHYSICIAN SI;RVIC.ES
~
~ PennState Geisinger
... Health System
F1J IF ANY QUESTIONS, PLEASE CONTACT: HERSHEY MEDICAL CENTER BILLING SERVICES
DATE PROCEDURE DIAG QTY DESCRIPTION
CODE CODE
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY P A 17033
02/11/99 27506.QX 820.8 20 OP TRT CLIOP FEM SHFT FR,
05/04/99 MA ClINTR AFTER PRI INS
PERFORMED BY: DIY OF DIAG RADIOLOGY
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY P A 17033
02/11199 7217026 959.8 PELVIS ANTERPOSTER
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY PA 17033
KNEE LII1ITED
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY P A 17033
02/11/99 7356026
959.8
02/11199 7356026.76 959.8
02/11/99 7355026 959,8
02/11199 7355026.76 959,8
02/11/99 99291 786,09
02/12/99 99251,NH 802.20
02/12199 99233.~H 959.8
02/12/99 7355026,GC V66.4
02/121997355026.76 V66.4
02/12199 99291 786.09
02/13/99 99231."H 802.20
02113/99 99232.HH 959,8
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE PA 17013
PAGe
2 or 6
ACCOUNT # 973391
STATEMENT
DATE: 06/14/99
LAST STATEMENT
llATE: 06/02199
FED TAX ID # 236291113
CHARGE PAYMENTI GUARANTOR
ADJUSTMENT BALANCE
INS
630.40
630.40- 0.00
MAl
40.00
MAl
50.00
KNEE LIMITED MAl 50.00
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY PA 17033
FEU (THIGH J ONE JOINT MAl 50. 00
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY P A 17033
FEl'AlR (THIGH 1 ONE JOINT MAl 5D. 00
PERFORMED BY: PEDIATRIC CRIT & INT CARE
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY P A 17033
CRIT CARE 1ST HR UNSTABLE MAl 249.00
PERFORMED BY: DIY PLASTIC RECDNST SURG
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY P A 17033
INITIAL INPT CONSULTATION MAl 120.00
PERFORMED BY: DIY PEDIATRIC SURGERY
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY P A 17033
DAILY HOSPITAL CARE MAl 128.00
PERFORMED BY: DIY OF DIAG RADIOLOGY
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY PA 17033
FEI1JR (THIGH J ONE JOINT MAl 5D. 00
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY PA 17033
FEI1JR !THIGH J ONE JOINT MAl 50.00
PERFORMED BY: PEDIATRIC CRIT & INT CARE
PERFORMED AT: HH HERSHEY MEDICAL CENTER
HERSHEY P A 17033
CRIT CARE 1ST HR UNSTABLE MAl 249.00
PERFORMED BY: DIY PLASTIC RECDNST SURG
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY P A 17033
HOSP YISIT BRIEF CC MAl 64.00
PERFORMED BY: DIY PEDIATRIC SURGERY
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY P A 17033
DAILY HOSPITAL CARE MAl 90.00
o CH~C~X AND_J::.III!ER ,ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
. "~~< ~~- - - < .~:
STATEMENT OF PHYSICIAf.fse'FfvlcES-
~ PennState Geisinger PAGE
JOANNE R STOUFFER 301 6
~ Health System 11 COOPER CIRCLE
CARLISLE PA 17013 STATEMENT
DATE: 06114199
LAST STATEMENT
ACCOUNT # 973391 DATE: 06102199
HU IF ANY QUESTIONS. PLEASE CONTACT: HERSHEY MEDICAL CENTER BILLING SERVICES FED TAX ID # 236291113
DATE PROCEDURE DIAG qTY DESCRIPTION INS CHARGE PAYMENTI GUARANTOR
CODE CODE ADJUSTMENT BALANCE
PERFORMED BY: DIY PLASTIC RECDNST SURG
PERFDRI1ED AT: HH HERSHEY MEDICAL CENTER
HERSHEY PA 17033
02114/99 99231.NH 802.20 HOSP VISIT BRIEF CC HAl 64.00
PERFORMED BY: DIY PEDIATRIC SURGERY
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY PA 17033
02114/99 99232.NH m.8 OAILY HOSPITAL CARE HAl 90.00
PERFDRI1ED BY: DIV OF DIAG RADIOLOGY
PLACE OF SVC: OP HOSPITAL
PERFORMED AT: HH HERSHEY HEDICAL CENTER
HERSHEY PA 17033
02115/99 7048026.GC 959.8 CT ORB SELLA POS FOS UNEH HAl 181.00
PERFORMED AT: HH HERSHEY MEDICAL CENTER
HERSHEY PA 17033
02/15/99 7011026 959.8 MANDIBLE >4 VIENS HAl 70.011
PERFORMED AT: HH HERSHEY HEDICAL CENTER
HERSHEY PA 17033
02115/99 7362026 959.8 FOOT LIHITED HAl 50.00
PERFORMED AT: HH HERSHEY HEDICAL CENTER
HERSHEY PA 17033
02115/99 7360026 m.8 ANC.LE LIHITEO HAl 50.00
PERFORMED BY: DIY PLASTIC RECDNST SURG
PLACE of SVC: INPAnENT
PERFORMED AT: HH HERSHEY HEDICAL CENTER
HERSHEY PA 17033
02115/99 99231.NH 802,20 HDSP VISIT BRIEF CC HAl 64,00
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY PA 17033
02116/99 99232.57 802.20 HDSP YISIT INTER CC MAl 90.00
PERFORMED BY: DIY PEDIATRIC SURGERY
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY PA 17033
D2I16199 m31.NH m.8 DAILY HOSPITAL CARE MAl 64.DO
PERFORMED BY: DIY PLASTIC RECDNST SURG
PERFORMED AT: HH HERSHEY MEDICAL CENTER
HERSHEY PA 17033
02117199 21453.NH 802.20 FRAC MANDIBULAR OPEN N MA HAl 1896.00
PERFORMED BY: DIY PEDIATRIC SURGERY
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY PA 17033
02117199 99231,NH 959.8 DAILY HOSPITAL CARE HAl 64.00
PERFORMED BY: .DIY OF ANESTHESIA
PERFDRI1ED AT: HH HERSHEY MEDICAL CENTER
HERSHEY PA 17033
02117199 21453.AA 802.20 13 TRT OPN HAND FRAC NlHANIP HAl 812 .80
PERFORMED BY: DIY PEDIATRIC SURGERY
PERFORMED AT: HM HERSHEY HEDICAL CENTER
HERSHEY PA 17033
02118/99 m32.NH 959.8 DAILY HOSPITAL CARE MAl 90.DO
o CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
~ ~~._- "
- '~" ~~
STAT~MENT OF PHYSICIAN SERVICE.S
---,I _"
~ Pe~nState Geisinger
.. Health System
ACCOUNT # 973391
13 IF ANY QUESTIONS, PLEASE CONTACT: HERSHEY MEDICAL CENTER BILLING SERVICES
DATE PROCEDURE DIAG nTY DESCRIPTION INS
CODE CODE"
PERFORMED BY: DIY PEDIATRIC CARDIOLOGY
PLACE OF SYC: OP PHYSICIAN
PERFORMED AT: HH HERSHEY MEDICAL CENTER
HERSHEY PA 17033
02118199 93010 EOG ELECTROCAROIOGH COMPL HAl
PERFORMED BY: DIY OF DIAG RADIOLOGY
PLACE OF SYC: INPATIENT
PERFORMED AT: HH HERSHEY HEDICAL CENTER
HERSHEY P A 17033
CHEST 1 YIEH
PERFORMED AT: HH HERSHEY MEDICAL CENTER
HERSHEY P A 17033
CHEST 2 VIENS FROO/LAT
PLACE OF SYC: OP HOSPITAL
PERFORMED AT: HH HERSHEY HEDICAL CENTER
HERSHEY P A 17033
CHEST 2 YIENS FROO/LAT
02118199 7101D26
959,1
02118199 7102026
786.09
D2/19/99 7102026
959.8
70.00
03/05/9' 16015,RT 802.20
03/05/9' 12004.RT 802.20
03/0519' 2D650.RT 802.20
D3/D5/9' 01200.QK 802.20
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE PA 17013
9733919050
PERFORMED BY: DIY PLASTIC RECONST SURG
PLACE OF SYC: SURGERY - SHORT STAY
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY PA 17033
BURN TREAT DRESS/DEB H AN
PERFORMED AT: HM HERSHEY MEDICAL CENTER
HERSHEY PA 17033
SIM REP TR LH 7-12
PERFORMED AT: HH HERSHEY MEDICAL CENTER
HERSHEY PA 17033
INSERT/REMOVE HIRE PIN
PERFORMED BY: DIY OF ANESTHESIA
PERFORMED AT: HM HERSHEY MEOICAL CENTER
HERSHEY P A 17D33
8 ANEI ALL CLSD PRllC/HIP JNT
PAGE
4 of 6
STATEMENT
DATE: 06/14/99
lAST STATEMENT
DATE: 06/02199
FED TAX ID # 236291113
CHARGE PAYMENTI GUARANTOR
ADJUSTMENT BALANCE
40.00
MAl
50.00
HAl
70.00
HAl
<;"'10 +.. 1-... \ :
if/t104~. ~
HAl 637.00
MAl 335.00
~t>
\%v..~'
HAl 370.00
MAl 505.60
03/02/9' 7355026.GC Y67.4
D3/02l9' 7355026.GC Y67.4
D3/02l99 99D24 719.45
9733919D62
PERFORMED BY: DIY OF DIAG RADIOLOGY
PLACE OF SYC: OP PHYSICIAN
PERFORMED AT: HR HHe - REHAB
HERSHEY P A
FEMUR (THIGH I ONE JOINT
PERFORMED AT: HR HHC - REHAB
HERSHEY P A
FEMUR I THIGH I ONE JOINT
PERFORMED BY: DEPT OF ORTHOPAEDICS
PERFORMED AT: HR HHe - REHAB
HERSHEY P A
POST-OP FOL-UP YISIT
9733919D92
MAl
50.00
MAl
~\oo
50.00
D.OO
0,00
o CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
..- -- "
- ~~~"'"--'-
" ,--~,
"
STATI;MI;NT OF PHYSICIAN SEf!VlfI;S
!S
.,
JOANNE R STOUFFER
11 COOPER CIRCL~
CARLISLE PA 17013
. . ..PIIOI:
PennState Geisinger
Health System
5 af 6
ACCOUNT # 973391
STATEMENT
DATE: 06/14/99
LAST STATEMENT
DATE: 06102199
FED TAX ID # 236291113
CHARGE PAYMENTI GUARANTOR
ADJUSTMENT BALANCE
~ IF ANY QUESTIONS. PLEASE CONTACT: HERSHEY MEDICAL CENTER BILLING SERVICES
DATE PROCEDURE DIAG
CODE CODE
04/01199 7355026.GC Y67.4
04/01/" 7355026.GC Y67,4
04/01/99 99024
820.8
$0.00
QTY DESCRIPTION
PERFORMED BY: DIV OF DIAG RADIOLOGY
PLACE OF SVC: OP PHYSICIAN
PERFORMED AT: HR HMC - REHAB
HERSHEY P A
FElIJR 1 THIGH I ONE JOINT
PERFORMED AT: HR HHe - REHAB
HERSHEY PA
FEI'lJR 1 THIGH I ONE JOINT
PERFORMED BY: DEPT OF ORTHOPAEDICS
PERFORMED ATI HR HMC - REHAB
HERSHEY PA
POST -oP FOL -UP VISIT
BALANCE: TROY E SHAFER
INS
HAl
...-
50.00 f!;\ (j)
HAl
50.00
0.00
0.00
INDICATES NEN FINANCIAL ACTIVITY SINCE LAST BILL.
THIS STATEMENT IS FOR PROFESSIONAL SERVICES ONLY. IF YOU HAVE
Am QUESTIONS REGARDING INSURANCE PAYMENTS CONTACT THE ClII1PAm
DIRECTLY, THE AHlIlM" LISTED IN THE PATIENT COLLttl IS YOUR
RESPONSIBILITY. IF PAYHENT HAS BEEN HADE, PLEASE ACCEPT OUR
THAt<< YOU AND DISREGARD THIS REQUEST.
FJD6
QUESTIONS, PLEASE CALL: (717) 531-5069 DR 1-800-254-2619
TEMPORARY CHANGE OF PATIENT I~UIRY HOURS
I1llNDAY - FRIDAY -- 8:00 AM - 4:15 PM
o CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
,-
~
-.~
""[j
ST,4TI,;~1ENT OFPH,!,SICI,4N SERVICES
.
,
PennState Geisinger
Health System
JOANN!;. R. STOUFF!;R
11 COOPER CIRCLE
CARLISLE PA 17013
PAGE
601 6
ACCOUNT # 973391
NO IF ANY QUESTIONS. PLEASE CONTACT: HERSHEY MEDICAL CENTER BILLING SERVICES
DATE PR~~g~RE g~~~ QTY DESCRIPTION INS
STATEMENT
DATE: 06/14/99
LAST STATEMENT
DATE: 06/02199
FED TAX ID # 236291113
CHARGE PAYMENTI GUARANTOI
ADJUSTMENT BALANCE
BALANCE SUt1ARY
RESPONSIBLE PARTY
MAl PA MEDICAL ASSISTANCE
l!llll GUARANTOR RESPONSIBILITY
POLICY .
8901441884!l
TOTAL
t 8503,40
t 0.00
_,.__,_._..____.___...JJ1!!f9!$JA!!.!L!!gAn.p.f.T.~.!;!L~!!P..ll€I.Y!J!!.ll.9.T.r.p.!;'!!.91!rl.P.!U1UI.AT.'-M!1I1UYJ.rJL.Y.9.!I!l,fA.rM~!lLL
ISF8 973391
HERSHEY MEDICAL CENTER
BILLING SERVICES.
" 0 BOX 854
HERSHEY PA 17033-0854
STATEMENT DATE,
06/14/99
GUARANTOR RESPONSIBILITY:
$ 0.00
Mall
To:
PENN STATE GEISINGER
HERSHEY MCBS HS61
POBOX 854
HERSHEY PA 17033-0854
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE PA 17013
FFlCE U$E ONL Y
... CHECK ONE
FOR CREDIT CARD PAVMENT, PLEASE FILL IN INFORMATION BELOW
:~'<;,"''(:FK1j,f,
M/C
VISA
=DISC
973391
CARD NUMBER
EXP DATE
,'f~J'i,,~~,
.:' ,,:...\~_ 'Ii :>."" '3 j~~.r;,>,:'EE:S:;:-=
CARDHOLDER NAME (PRINT)
.........._...~
,~~~~::.:.,..
o CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORREC"!I~IIlS ON BACK
'~'"~, -
'""I>i"-~~
CU>.IM DAle
PIl\GE NUMBER
ANNE STOUFFER,
11 COOPER CIRCLE
CARLISLE
PA 17013
1
mON TO PATIENT
04 01 99
INSURANCE COMPANY NAME
,-
04 01 99
MO HER
.Q.AlMTO
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE PA 17013
STATE FARM INSURANCE
GROUP/POUCY NUMBER
I CERTlFlCAlE/SUBllCRlBER NUMBER
I
'7
EN1 NAME
HAFE T OV E
eR INSURANCE INDICATED BY HOSPITAL RECORDS
E OF INSURED
NE
INOSIS
RElATION TO PAlIfNT
I
I
,
I
I
INSURANCE CARRIER
I
I
I
I
,
GROUP/POUCY NO.
I
I
,
I
.
CERT JSUBSCAIB. NO.
I
I
I
I
,
7.4 FOLLOW-UP EXAMINATION. FOLLOWI
GICAI. PIIOCEllUAl!S
89.27
FEMUR
AMOUNT
180.00
2 AT
90.00
EACH
TOTAL CHARGES
180.00
.,
.
;':&4\;[,1-'
~~ J:'~nn~tate \Jelslnger
ItPl Health System
DETAILED STATEMENT OF
HOSPITAL Accourn
PLeASE REFER TO PATIENT'S NAME AND ACCOUNT NUMBER ON ALL INQUIRIES AND CORRESPONDENCE.
BILL TO'
~OANNE R LESCALLEET
11 COOPER CIRCLE
CARLISLE, PA 17013
MAKE CHECK PAYABLE TO, HMC
MAil TO: P.O, BQX 853
HERSHEY, PENNSYLVANIA 17033-0853
MAPA
FEDERAL 10# 23-2891807
IMPORTANT: PLEASE DETACH AND RETURN THE TOP PORTION OFTHIS STATEMENT WITH YOUR PAYMENTTO ASSURE PROPER CREDIT, WRITE ACCOUNT NO, ON CHECK.
INSURANCE PORTION IS ESTIMATED
ACCORDING TO THE INFORMATION --"I
SUPPUED BY YOUR INSURANCE CARRIER ..
CHARGES
120
ROOM-BOARD/SEMI
:595,00
59:5. 00
0,00
TOTAL ROOM CHARGES
:595.00
595,00
0,00
ANCILLARY CHARGES
250 PHARMACY
259 DRUGS/OTHER
260 IV THERAPY
270 MED-SUR SUPPLIE
300 LABORATORY/LAB
320 DX X-RAY
360 DR SERVICES
370 ANESTHESIA
420 PHYSICAL THERP
424 PHYS THERP/EVAL
490 AMBUL SURG
710 RECOVERY ROOM
TOTAL ANCILLARY CHARGES
;,-;'.:",I,:'~, ~~r;r)' fd
\.J I V," t 'Ii ~ ;;~. . 'C
283.30 283.30 0.00
4,20 4,20 0,00
12.00 12, 00 0,00
88.00 88. 00 0.00
192.00 192.00 0.00
252.00 252. 00 0,00
4478.00 4478.00 0.00
877. 50 877. 50 0.00
102,00 102.00 0.00
144.00 144.00 O. 00
76.00 76,00 0.00
286.00 286.00 0.00
6795.00 6795,00 0.00
"~", ' .::
f':_(~'nl 2~,:r:;~;t(;'j.'r-~nrl (.~:-~~{(~~;:~~1., kw 'four racer'l~: :.:~(~~
w t:ij' :,"-',;.,X i<n;'~-; ::::~[(j;\ .:Z:~:;' ;-~':iquired b~1 Aci -;>)
:ii.' .~',:."I :: r ).-:: ,_ ;.- "'I''';' ,......l. 1'''" l.~t \".-. ,.... "', :r-...."/:'l"I.. f'\ ~..'" : :
".,',-",~". . "0'-'- .'.; ...'~.'... VLt,.,~ ,.....I....tlitt.:<.; I:Jj\".:llt ....A:..,':.,\'..;:.
n<~>:-;i,)n
. . "
l;':C ~.)(:!~{;:;.
S;;-:.~'S' ~IO:.! r:b\;t':- ?!:";;::ig'(.~,d ':r..'~:r kit;:LJ;);,\G8 b~,~ngmS 'ie:- ">~~}
U' I~"v;.,::".;;-i;' ;.;(;.':i if":.j :::;d .::.,.:</~:;.;~j r:(,;t tu uGed to C!;'...::TI
if<'::,: :'..:.: Ii> 'eri~~;:!~':> ~!'~' '~- h;:~ "/.;~'~ fl~{e.:::,d'/ r;jld:~!niUBd a clairJ1 ~;)
V"".?.:f In,)-:.~ :~ ~'.::<;''>~~:, (~~! >'./Cl)i. ;::2,;TdL it ':OU h3.ve (::i"]"/
~iL:',i1iOC';,J':;:'i .;)'6LJ~sTj,~~s1?~hiS bill, please call
Inli;p.h:fi~NTS:'''t''u '~r, [; .1" ".""err'5's1:5069
CUfOTAL _
INSURANCE COMPANIES:
531-5218
ESTIMATED
INSURANCE PAYMENT DUE _
7390, 00
0,00
V142 (REV. 7/97) VER-N
PATIENT PAYMENT DUE
,
-
l.--
11i!dl',,",.
---..
.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCiAl OPERATIONS
TPL SECTION CASUALTY UNIT
PO BOX 8486
HARRISBURG, PA 17105-8486
January 19, 2000
GRAHAM & MAUER PC
LISA J MAUER ESQUIRE
THE COMMONS AT VLLY FORGE
SUITE 22 PO BOX 987
VALLEY FORGE PA 19482
Re: TROY SHAFER
CIS #: 890144188
Incident Date: 02/11/1999
Dear Ms. Mauer:
Enclosed please find the Department.s updated statement of claim. As
you will note, the amount of our claim is $8,299.95.
i'
As we discussed, upon completion of the updated statement, I reviewed
this case with Ron Hill, Casualty Unit Manager. After review, it was
concluded the Department would not waive its claim. We will, however, agree
to reduce the amount of our claim by 33 1/3%, bringing the amount due to
$5.533.30.
If you have any further questions, please contact me.
your cooperation in this matter.
..
Thank you for
Sincerely,
s~ -f:1l~
Susan E Naylor
TPL Program Investigator
717-772-6265
717-772-6553 FAX
Enclosure
l_
~ '..h
- """'......!!ii'b
Troy Shafer's
Out-of-Pocket Expenses
Paid by Mother, Joanne Lescalleet
Date of Service DescriptionlPayee Amount
Deck for Wheelchair Access $ 1,183.36
04/07/99 Crutches 17.00
04/07/99 Alexander Spring Rehab co-pay 10.00
04/09/99 Alexander Spring Rehab co-pay 10.00
04/12/99 Alexander Spring Rehab co-pay 10.00
04/14/99 Alexander Spring Rehab co-pay 10.00
04/19/99 Alexander Spring Rehab co-pay 10.00
04/23/99 Alexander Spring Rehab co-pay 10.00
04/28/99 Alexander Spring Rehab co-pay 10.00
04/30/99 Alexander Spring Rehab co-pay 10.00
05/05/99 Alexander Spring Rehab co-pay 10.00
05106/99 Alexander Spring Rehab co-pay 10.00
05/11/99 Alexander Spring Rehab co-pay 10.00
OS/20/99 Alexander Spring Rehab co-pay 10.00
Total 1,320.36
-~
,,,,",, ~
~
".~
"';
Page No,
of
Pages
\
,
f,^~rJ.f)l-, L- c.I
PROPOSAl SUBM'rreD TO
'I '"
~c:;;.-G,
ITR~ET
C,
:rry, STATf ana ZIP CODE
~. ,,'
., ".'"
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<.. c:~,
r jt:.""
H~L~!~.~.~~~ !.!0~.~~ '~:1?RC\!Er~.J~ENT
2273 New~i1i" Rd,
CARLISLE, PA 17013
(7l7i 776.7590
-I",... ~jo..".",.
" -
PHONE
DATE
(!> 0/'
CIJ.--
\.
/
'-' , .'
I/O,"
JOB NAME
"
JOB lOCATION
~CI'tITECT
DATE OF PLANS
JOB PHONE
~e nereby submit specilications and estimates tor:
/3" ,/d."..,
,
f-e-pl~<. ,,,}
rc..""fi> C'V\
sl) hy St'l( blt"cA.. Ttih,....,
I "" :> ' .). e .... }. ~1{ 6-c..h , ({ c... I / q ,; "'7
o.I~,-..... S t~c- of'- oI.N.-f:..
(;- 1( ,h .{.'l'l. f S' {"'Vi
S [.( I "'6 VI ~ C <. f ! c '..::,
l, ~ ~ 00,
t /114< le___ '<'< /$
:tIll r3. :1 ~
'1
I I
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V [II
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,I
i
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J
01
l \ r.2
./-.
I
({jet ?
We Propose hereby to furnish material and labor - complete in accordance with above specifications. for the sum of:
//Y3.3<;
dalla,s ($
),
Pa~ment 10 be made as follows:
All malerial is guaranteed to be as specilied. All work to be completed in a workmanlike
manner aCCOrding to standard practices. MV aht1ration or deviation from above specilicalions
involving extra costs will be execulea only upon written orders, and will become an extra
charge over and above the ostimale. All agreemenls contingent upon strikes, accidents or
dela)'s beyOnd our conlrol. Owner to carry lire, tornadO and olher necessary insurance. aLlr
walk-e,s aut fLllly covered by Workman's Compensalion Insurance.
Authorized
Signature
cZ~-
/(; ;~7
-1Ic.,..e.,,,;.'.,. '-.?/
,
Acceptance of Proposal - The above prices, specificalions
and conditions are satisfae:t.,ry ap~ arfl ~er~by accepted. You are authorized to do the
work as specified. Payment WIll be made a~ oUtlined abO\le.
Note: This proposal may be
withdrawn by us if not accepted wlth}n
}<l,.x./'v~"" 'A" J< VI..'(JU.A./0
.j . I\,
,
days,
Signa,t!Jre
Date of Acceptance:
gig.nature
JOANNE R. STOUFFER
355 BURGNERS RD,
CARUSLE. PA 17013
ptlSfa,(''f&
60-472/31 f I
27 . 481
J.d~ 19Q'}
Pay to theA. n n , IL\'
Order of uu:..u 1'\ '1m b.L lV'y-r I $ \ \ ~ ~. 310
DhP -\-r11\i{}1>.-0 01\...LhA ,,,,,,line! .l~(U Q/ld ~,jq1itW [!]=-":"
Fina%~~I~''l.20Q227t8 .. 2(j-io t~303 t44t /
.._'-~ .. j /
For Cda~'-J2 ' ..J.,. 1 J ,'.'1
1:0:1 ~ :loa.? 201: 000 ~ 2 b ~ 2~';- 0a.8 ~ i"oooo ~ ~B:I HII"
,
J
~~
~
~~
,0
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r.:::)
~
~
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Q)_lll!..,~ ._.,'
,', 1:(I(:'f'l"~AI):1. '(l,:\S6- ~0-120 9~L220Q217
U .",' '. l." 0 .170""0 OT~O r>TL'770Q'7b
. - t.J - y<::..l i;1' ,..:..,..... .:::.., v
1:13X I WiDE- **'k*' <1'1 I Hd - 8<:1.c!
,-. ~,,",;
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ALEXANDER SPRING REHAB, INe.
27 BROOKWOOD AVE.
CARUSLE, P A 17013
PHONE (717) 245-2341
I.D,/I 23-24m06
l1"roy Sha./u'
L
FOR PROFESSIONAL SERVICES
C'LLtC.tt eS
I
-.J
,$ IT 00
PAYMENT
'A ~~/J-;
~
REC'O BY
DATE
-
AleXander Spring Rehab, Inc.
27 Brookwood Avenue, Carlisle. PA 17013
Phone: (717) 245-2341
1.0.#: 23-2421706
Patient Name:
jA()~ -Ilho{,u
Service: Pr
Date:
teceived for:
e..o --jXll-f ~ 4h~
$
Ji), -
j".-
Total Payment of: $ L U
Ll Cash ttl Check # "IC}3
leceived by:
4?
Date:~
Alexander Spring Rehab, Inc.
27 Brookwood Avenue. Carlisle. PA 17013
Phone: (717) 245-2341
1.0.#: 23-2427706
Patient Name: \ ~ s\
Date: l.\ \-a.: I\~ Service: iT
;:V;;\r '-\\\~~t\
$
\O<!>Y-
\,.'.OU
Total Payment of: $ \.J -
Ll Cash ro...eheck #~
\ r I
.iI"I<-,
.'" .
-. ,
~ "-~';&,-,;.
Alexander Spring Rehab, Inc.
27 Brookwood Avenue. Carlisle. PA 17013
Phone: (717) 245-2341
1.0.#: 23-2427706
Patient Name:
4.JJhaeu--
Service: PI
Date:
Received for:
C-o-p~ ~ L.j/q~
$
10.-
$ 10. --
Total Payment of: _
~ Cash Ll Check #
Received by:
~
Date: 1/0/9}
.
._-'''_.-'_..~.
Alexander Spring Rehab, Inc.
27 Brookwood Avenue. Carlisle. PA 17013
Phone: (717) 245-2341
1.0,#: 23-2427706
Patient Name: \~6~....J
Date: 'i \ '4 <\'1 Service: ~\
Received for: ,\i , \ I \ 1 ' ,
~-t>~ ,") ...... \
$
\CJO~
Total Payment of:
r...... ..J
$ lu
~~l
Ll Cash CJ...eileck #
. _"'k'"~_
Al~a.nder Spring Rehab, Inc.
27 Brookwood Avenue. Carlisle, PA 17013
Phone: (717) 245-2341
1.0.//: 23.2427706
Date: ~ \,~ \ I\~
Servic;:::YT
~v~~04 ~",\ \\ ~
$
V:::J ..~
o~
Total Payment oC: $ \ \J
o Cash ~klI -.::;() \
Received by:
~C:,
Date:~
Alexander Spring Rehab, Inc.
27 Brookwood Avenue. Carlisle. PA 17013
Phone: (717) 245-2341
1.0.//: 23-2421706
Patient Name: \ ~Sv+
Date: ~ \ do. \ ~ Service: --=ts\.
leceived Cor:
$
()U
\0-
~-~Q-
Total Payment oC: $
Cl Cash o-oleCk //
\ 0<'>
~-
S(1)
eceivrn Iw,
\ze"
\r \,\~ I (V'\
now
~ ~~
. ..,Bk_
Alexander Spring Rehab, Inc.
27 Brookwood Avenue, Carlisle, PA 17013
Phone: (717) 245-2341
1.0.//: 23-2427706
Patient Name: \ 4 ~
Date: '1.. \d.1l:\<\ Service: ~T
Received Cor:
$
\~
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Alexander Spring Rehab, Inc.
27 Brookwood Avenue. Carlisle. PA 17013
Phone: (717) 245-2341
1.0,//: 23-2427706
Patient Name: TeDLl SHIlFEe
Date: Lit olqq
Service:
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Phone: ('717) 245-2341
1.0.//: 23.2427706
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27 Brookwood Avenue, Carlisle. PA 17013
Phone: (717)245-2341
1.0.#: 23.2427706
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Dale: 51 (,p ! <(q Service:
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Alexander Spring Rehab, Inc.
27 Brookwood Avenue. Carlisle. PA 17013
Phone: (717) 24S-2341
1.0.#: 23-2427706
Patient Name: T~DY 'SHf\'fHZ
Dale: S/.)~tQCj Service: Pr
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In re: Troy Shafer
Justification of Attorney's Fees
.
Resolve Liability Issues
This case stems from an automobile accident in which one driver motioned Troy
Shafer, an eight year old, across the road to get his ball while another driver struck him with her
vehicle. The insurance companies for both drivers argued that Troy's negligence was the cause
ofthis "child dart out" case.
.
Counsel retained a road design engineer and accompanied him to the scene of the
accident to take measurements and photographs of the scene of the accident in
order to determine whether or not there was a cause of action based on faulty road
design or improper sight distances. The expert determined that there was no such
liability.
.
Counsel reviewed the township ordinance in order to determine whether there was
a possible cause of action against the trailer park for driveway design or setback
violations. No ordinance violations were found.
.
Counsel researched case law pertaining to the liability of waving drivers involved
in motor vehicle accidents. Pennsylvania law does not necessarily attach liability
to a waving driver, even in the case of a minor. Counsel had to convince the
insurance companies of the two tortfeasors of the merits of the theory of liability
based on the facts of this particular case.
2. Overcome the Limited Tort Threshold
Troy Shafer lives with his mother, Joanne Lescalleet, who had elected the limited
tort option on her automobile insurance policy. (See her declaration page attached hereto as
"Exhibit E".) After overcoming the liability issue with the insurance companies, counsel had to
convince them that this minor's injuries did overcome the limited tort threshold in order to obtain
multiple recoveries. Counsel conducted extensive negotiations with State Fann, insurer of
Catherine Brownawell (waiving motorist), who remained firm in their initial offer of $40,000.00
for many months.
In addition to preparing an extensive demand package, counsel arranged for a consultation
with a dentist who specializes in the treatment of children, in order to substantiate Troy's loss of
a permanent tooth and the need for future treatment.
, - -~
-,",.,
- "", , -,"-'
1i1!.!,
3. Handle Insurance Coverage Issues for Medical Bills
The medical bills associated with this accident exceed $50,000.00. The medical
benefits available on Joanne Lescalleet's automobile insurance policy were $10,000.00. While
Troy Shafer's mother, Joanne Lescalleet, also purchased two small limited purpose insurance
policies (Combined Insurance Co. and CONSECO) and Troy's father, Todd Shafer, had coverage
under an HMO for several weeks during the course of treatment, the total amount of coverage
available under all of these policies was far less than the total amount of all medical bills.
As a result, counsel assisted Mrs. Lescalleet in applying for BLUE CHIP (for
which she was later determined to be ineligible) and Medical Assistance, since she did not have
the assets available to pay the unpaid balance. Counsel also assisted Mrs. Lescalleet in securing
benefits under her two small insurance policies.
Counsel worked extensively with the Hershey Medical Center Billing Department
and Medical Assistance in an effort to ensure that the bills were timely processed without going
to collection.
4. Search for Additional First and Third Party Insurance Coverage
Counsel reviewed insurance coverages of other family members and unrelated household
members in order to determine whether any additional insurance was available to cover Troy's
first party medical bills. None were found to exist.
Counsel also contacted the insurers of both defendants in order to determine whether these
two drivers were covered by other automobile insurance policies or umbrella policies. No other
policies were found.
5. Assist Family with Obtaining Medical Treatment
Several months after Troy's initial leg surgery it became apparent that his leg had not
healed properly and he was unable to walk without a significant limp. His surgeon
recommended another surgery and Troy's family wanted to seek a second opinion. Counsel
obtained information on physicians and billing procedures at both St. Christopher's Childrens
Hospital and Shriner's Hospital in Philadelphia, which enabled the family to obtain a second
opinion from Peter Pizzutillo, M.D., a pediatric orthopaedic specialist. Dr. Pizzutillo agreed with
the surgeon and the second leg surgery was performed.
Counsel negotiated payment arrangements with James Kearns, D.D.S., a dentist
specializing in the treatment of children, in order for Troy to have a consultation regarding his
loss of a permanent tooth.
6. Negotiations Regarding Medical Assistance Lien
Counsel asserted a hardship claim to Medical Assistance requesting that they
waive their lien due to serious fInancial consequences to Troy Shafer's family as a result of this
accident. While Medical Assistance denied a complete waiver, they agreed to reduce the lien by
33 1/3% instead of the customary 25%.
7. Investigate Possible Subrogation Claims
In addition to the known lien held by Medical Assistance, it was unknown whether the
HMO which paid for part of Troy's therapy also had a right of subrogation. Counsel confirmed
that the HMO available through GS Electric, Todd Shafer's employer at the time, was not part of
an ERISA plan, thereby extinguishing any subrogation claim against Troy's settlement.
"~ ~.
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55CH7
04-05-1999
DECLARATIONS PAGE
MATCH 00498
I,
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A
STATE FARM MUTUAL AUTOMOBilE iNSURANCE COMPANY
ONE STATE FARM D~
CONCORDVILLE PA 19339
POLICY NUMBER 728 6572-E 1'-38B
POUCYPERIODNOV 11 19980MAY 11 1999
i,
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.
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NAMED INSURED
00498 38-6162-5 5
STOUFfER. JOANNE R
355 BURGNERS RD
CARLISLE PA 17013-8921
111,11I11,11I11,11I111111,1111,1,111111,111I11,1,1,,1,1,1111,1
'"
I..'
DO NOT PAY PREMIUMS SHOWN ON THIS PAGE.
SEPARATE STATEMENT ENCLOSED IF AMOUNT DUE.
DESCRIBED YEAR MAKE
VEHICLE
1 1991 DODGE
MODEL
BODY STYLE
2DR
VEHICLE IDENTIFICATION NUMBER
CLASS
DAYTONA
1B3XG4435MG114242
1D00101
COVERAGES (AS DEANED IN POLICY) SEE REVERSE SIDE FOR IMPORTANT MESSAGE
lYMBOL'PREMlf;f8f~ '\'11~I~~\-OF fl~BJ~ YIP R OP E R T Y DAM AGE LI A B I L IT Y
LIMITS OF LIABILITY-COVERAGE A-BODILY INJURY
. EACH PERSON. EACH ACCIDENT
50.000 100.000
LIMITS OF LIABILITY-COVERAGE A-PROPERTY DAMAGE
EACH ACCIDENT
50.000
$19.11 MEDICAL PAYMENTS
LIMIT OF LIABILITY-COVERAGE C2
EACH PERSON
10.000
C2
$32.73
$76.03
$1.69
$6.27
.
COMPREHENSIVE
$500 DEDUCTIBLE COLLISION
EMERGENCY ROAD SERVICE
UNINSURED MOTOR VEHICLE
LIMITS OF LIABILITY-COVERAGE U
EACH PERSON.
50.000
UNDERINSURED MOTOR VEHICLE
LIMITS OF LIABILITY-COVERAGE W
EACH PERSON.
50.000
EACH ACCIDENT
100.000
D
G500
H
U
W
$20.16
F
$.61
FUNERAL BENEFITS
LIMIT OF LIABILITY-COVERAGE F
EACH PERSON
2.500
EACH ACCIDENT
100.000
22
$5.29
$268.82
$268.82
LOSS OF INCOME
TOTAL PREMIUM FOR POLICY PERIOD NOV 11 1998 TO MAY 11 1999
TOTAL CURRENT 6 MONTH PREMIUM FOR NOV 11 1998 TO MAY 11 1999
------------------------------------------------------------------------------
EXCEPTIONS AND ENDORSEMENTS
6038F AMENDMENT OF DEFINED WORDS. WHEN & WHERE COVERAGE APPLIES.
LIABILITY. UNINSURED & UNDERINSURED MOTOR VEHICLE & PHYSICAL
DAMAGE COVERAGES & CONDITIO~S.
THIS POLICY PROVIDES LIMITED TORT OPTION.
COUNTERSIGNED_ _ _ _ _ _ _ _ _ _ _ _ _
THIS IS YOUR DECLARATIONS PAGE,
PLEASE ATTACH ITTO yOUR AUTO POLICY BOOKLET, BY _ _ _ _ _ _ _ _ _ _ _ _ _ _ 6162-382
YOUR POLICY CONSISTS OF THIS PAGE, ANY ENDORSEMENTS, AND THE POLICY BOOKLET, FORM 9838. 6 PLEASE KEEP TOGETHER
REPLACED POLICY 7286572-38
1Il1lTl VOL
155-4976 PA 4
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~INSURANCE
The Leader In Seniee and Value
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March 30, 1999
Lisa J. Mauer, Esquire
The Commons at Valley Forge
Suite 22
PO Box 987
Valley Forge, PA 19482
OUR INSURED: Miriam Leon
DATE OF LOSS: 2/11/99
CLAIM NUMBER: 5005486
YOUR CLIENT: Troy Scafer
Dear Ms. Mauer,
,
,
I,
i,'
This will conflnn my offer of $15,000 to settle your client's claim. This offer is for full and tinal
settlement your client's bodily InJury claim arising out of this loss. Please be advised that in order to
settle this claim we will require a release signed by both parents as well as court approval of me
settlemenL
I look fOlWard to discussing this matter with you again soon, so we may amicably settle this matter
with your c1ienL Please feel free to contact me If you have any questions.
Sincerely Yours,
f~
Joseph Dillon
Claims Advisor
/Jny penson who knowingly and _ _10 injwe "'defraud any inaurer filea an appliaUiDn or cIoim c:onIoining _false, in<:orI\pIete or misleading
info- shall, upon conW:lion, be subjected to imprioonmentfor up to se_ yeant and JH'!I'RB"t of ajiM of up to $ 15,000.00.
3607 Rosemollt Avellue, Suite 202 . Camp Hill, PA 170llL
(800) 254-6855. (717) 975-3660. fax (717) 975-3663
Transport Insurance Company. TICO Insurance Company. Leader Managing General Agency
Leader Insurance Company. Leader Specialty Insurance Company. Leader Preferred Insurance Company
, d Oct-11-99 13:25
~~~'ibj!l.I99 liON 13: 34 FAX 774 2113
,
I
I State Fa rm
I
from 774 2113 4 16109830570
STATE FARII CLAIII
Page 1
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.
Insurance Companies
October 11, J.~99
SUta FMm II1IUt.nce
116 UllIoklln /lQod
PO Bel< 2G1
No... CUrnbl,rollll p" 170,o.c267
Lisa J. Mauer
Graham & Mauer, P,C.
POB SS7
Valley Forge, PA 19482
RE: Claim Numb~r:
tlate of Loss:
Our InsureQ:
Your Client:
J8-J1Sl-400
February 11, 1~g9
Catherine R, Brownawell
Troy Shafer
Dear Ms. Mauer:
As we discussed today, State Farm is willing to offer your client
our insured's policy limits of $50,000 to settle his injury
claim, We will need court approval of this settlement. ~f you
have any questions please feel free to contact roe.
State Farm Mutual Automobile Insurance Company
HOME O'F1C!S, BLOOMINGTON. 1L.L.INOI6 el710.o001
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R~c~jv~d Nov-29-99 15:26 from 774 2113 ~ 16109830570
, 14'2E1..1.99~ MON 14,38 FAX 774 2113 STATE FARH CLAIII
1'/
,
I State Farm Insurance Companies
I
pag~ 2
III 002
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November 29, 1999
$_ Farm lnourange
1 1. Umlklln ROlli
1'0 iIClx ZI7
New C"m.o~.nd PA 17070.0Z67
1.:l.8a Mauer
Graham.. Mauer, P.C.
Suite 22, POBox 987
Valley Forge, PA 19482
RE: Your Cl:l.ent:
Our Insured. I
Our Claim No. :
Date of Loesl
Troy Shafer
Joanne R. Stouffer
J8-J176-022 ***Sene via fax.. regular mail*
February 11, 1999
Dear Attorney Mauer:
Thie confirms our telephone oonversation of today. State Farm
offers your cl:l.ent, Troy Shafer, the $50,000 Un:l.nsured Motorist
Coverage policy l:l.mits availa~le on Joanne Stouffer's policy,
You advised you would'doo the necessary to seCUre the Court
Approval. Upon reoeipt ot the Court order, we will forward our
payment. If you have'any questions, please give us a call,
Jackie Rav: nel
Claim Spec1al:l.st
(717) 774-9078
J(
State Farm Mutual Automobile Insurance Company
HOME OFFICES: 8LOOMINGTON.ILLINOIS 01'10.0001
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GRAHAM & MAUER, P.C.
By: LISA J. MAUER, ESQUIRE
Attorney I.D. 65426
The Commons at Valley Forge
Suite 22, P.O. Box 987
Valley Forge, Pennsylvania 19482
610/933-3333
TROY SHAFER, a minor, by
TODD SHAFER and JOANNE LESCALLEET
parents and natural guardians
Plaintiff
CATHERINE R. BROWNAWELL
Defendant
and
MIRIAM LEON
and
Defendant
STATE FARM
UIM Carrier
Attorney for Plaintiff
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
No.: / 7c,
In Re: TROY SHAFER, a minor
PETITION FOR LEAVE TO COMPROMISE MINOR'S ACTION
TO THE HONORABLE, THE JUDGES OF THE SAID COURT:
The Petition of Todd Sharer and Joanne Lescalleet, parents and custodians of a minor,
Troy Shafer, respectfully represents that:
1. They are the parents of Troy Shafer, a m'mor, age eight, who was injured on
February 11, 1999, while struck, as a pedestrian.
2. Troy Sharer, a minor, currently resides with his mother, Joanne Lescalleet, at 11
Cooper Circle in Carlisle, Cumberland County, Pennsylvania 17013.
3. On the date of this accident, Joanne Lescalleet had a limited tort State Farm
automobile insurance policy with $10,000.00 in medical coverage and $50,000.00 in
underinsured motorist protection.
4. Todd Shafer resides at 5 N. High Street in Newville, Cumberland County,
Pennsylvania 17241.
5. Plaintiff's parents, Todd Sharer and Joanne Lescalleet, were never married to each
other.
6. This Petition is brought in Cumberland County and the accident also occurred in
Cumberland County, Pennsylvania.
7. This accident occurred when Catherine R. Brownawell, a driver, stopped her
vehicle to wave Troy Shafer across the road to get the ball he was playing with, which had rolled
across the road.
8. While crossing the road, Troy Shafer, a minor, was a struck by a vehicle traveling
toward Catherine R. Brownawell and, driven by Miriam Leon
9. As a result of the aforesaid incident, Troy Sharer sustained numerous injuries in this
motor vehicle accident, including comminuted fractures of the left and right femurs, bums to his
face and legs, a fractured jaw, loss of a permanent tooth, and a head injury.
10. Troy Shafer was initially flown to the Hershey Medical Center, where he received
significant treatment, including multiple surgeries.
11. Troy Shafer sought further care after being released from the hospital from Randy
M. Hauck, M.D., Lee S. Segal, M.D., Comfort Care - Home Therapy, Alexander Spring Rehab,
James Kearns, D.D.S., and Peter Pizzutillo, M,D.
12. Troy Shafer's medical treatment has not been completed as of the date of this
Petition. His permanent tooth has not yet been replaced.
13. Pla'mtiff's medical bills totaled more than $50,000.00 as of October 15, 1999, prior
to his final course of physical therapy. (See "Exhibit A", attached hereto.)
14. The first $10,000.00 of medical bills was paid by Joanne Lescalleet's State Farm
policy. The remainder of the bills were paid by Combined Insurance Company of America,
Conseco Health Insurance Company, Health Central HMO (with a $10.00 co-pay per visit, paid
by Joanne Lescalleet) and Medical Assistance.
15. As of January 19, 2000, the total amount paid by Medical Assistance was
$8,299.95. While not all of the medical hills had been processed as of that date, Medical
Assistance agreed to accept $5,533.30 as payment in full for satisfaction of their lien. (See
"Exhibit B", attached hereto.)
16. Attached as "Exhibit C" are receipts for the out-of-pocket expenses that have been
incurred for treatment of said minor, all of which have been paid in full by Plaintiff's mother,
Joarme Lescalleet.
17. Counsel was retained upon a 33.3% cont'mgent fee basis by Petitioner. (See
Attorney Justification, attached hereto as "Exhibit D".) Additionally, counsel has incurred the
following expenses:
Carlisle Police (Report) 15.00
Hershey Medical Center (bills) 15.00
Photo Haven (accident scene) 17.51
The Camera Shop 26.21
(develop photos of client's injuries)
Staples (photo enlargements) 5.26
The Print Shop (copy medical records) 19.46
Recordex (Hershey Records-
inpatient stay & first surgery) 124.15
Minors' Compromise fee 45.50
North Middleton Township
(Zoning Ordinance) 28.20
Alexander Spring Rehab (med. records) 16.99
Comfort Care (medical records) 34.00
Keams & Ashby (dental consult) 35.00
Peter Pizzutillo, M.D. (medical records) 16.33
Hershey Medical Center (x-rays) 63.00
Staples (copy x-rays) 6.30
Recordex (records of Dr. Segal) 19.78
Recordex (second surgery records) 69.37
James Dmecker, PE
(engineer evaluation of roadway) 1,000.00
Total $1,557.06
18. Defendant Miriam Leon was insured by Leader Insurance with a $15,000.00
liability limit.
19. Defendant Catherine R. Brownawell was insured by State Farm with a $50,000.00
liability limit.
20. Troy Shafer was insured by his mother's State Farm policy with $50,000.00 in
underinsured motorist coverage. (See Joan_ne [Stouffer] Lescalleet's declaration sheet, attached
hereto as "Exhibit E".) Troy Shafer's father does not have auto insurance.
21. Petitioners and counsel recommend approval of the lump sum amount of Fifteen
Thousand Dollars ($15,000.00) with Defendant Miriam Leon's insurance company because this
amount represents the full limit of the tortfeasor's policy. See letter fi.om Leader Insurance
Company, dated March 30,1999, attached hereto as "Exhibit F".
22. Petitioners and counsel also recommend approval of the lump sum amount of Fifty
Thousand Dollars ($50,000.00) with Defendant Catherine R. Brownawell's insurance company
because this amount represents the full limit of the tortfeasor's policy. See letter from State
Farm Insurance Company, dated October 11, 1999, attached hereto as "Exhibit G".
23. Petitioners and counsel also recommend approval of the lump sum amount of Fifty
Thousand Dollars ($50,000.00) with Petitioner's own insurance company because this amount
represents the full limit of the petitioner's undednsured motorist benefit. See letter fi'om State
Farm Insurance Company, dated November 29, 1999, attached hereto as "Exhibit H".
WHEREFORE, Petitioners pray that an Order be entered approving the compromise
allowing counsel fees and ordering distribution.
Date: March 17, 2000
By:
GRAHAM & MAUER, P.C.
iLi~a JJMauer~squire/
Xttomey for Plaintiff
GRAHAM & MALrER, P.C.
By: LISA J. MAUER, ESQUIRE
Attorney I.D. 65426
The Commons at Valley Forge
Suite 22, P.O. Box 987
Valley Forge, Pennsylvania 19482
610/933-3333
Attorney for Plaintiff
TROY SHAFER, a minor, by
TODD SHAFER and JOANNE LESCALLEET
parents and natural guardians
Plaintiff
CATHERINE R. BROWNAWELL
Defendant
and
MI~AMLEON
and
Defendant
STATE FARM
UIM Can/er
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
NO. ~
ATTORNEY VERIFICATION
In my professional opinion as counsel in this matter, I believe that the proposed
settlement in the Imp sum amount of One Hundred Fifteen Thousand Dollars ($115,000.00) is
reasonable under the circumstances. The proposed settlement reflects the limits of the
tortfeasors' policies and the only underinsured motorist policy which insures Troy Shafer, a
minor, for the injuries he sustained in the February 11, 1999 auto accident.
GRAHAM & MAUER, P.C.
By:
t.~. Mau~/Esquire
Attorney folt~Plaintiff
Date: March 17, 2000
Notary Public
GRAHAM & MAUER, P.C.
By: LISA J. MAUER, ESQUIRE
Attorney I.D. 65426
The Commons at Valley Forge
Suite 22, P.O. Box 987
Valley Forge, Pennsylvania 19482
610/933-3333
TROY SHAFER, a minor, by
TODD SHAFER and JOANNE LESCALLEET
parents and natural guardians
Plaintiff
CATHERINE R. BROWNAWELL
Defendant
and
MIRIAM LEON
and
Defendant
STATE FARM
Attorney for Plaintiff
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
No. ~
AFFIDAVIT OF GUARDIAN
I, Joanne Lescalleet, certify that:
1. I am a parent and custodian of Troy Shafer;
2. Troy Sharer has had medical treatment for the injuries sustained in the incident
which is the subject matter of this action and may require additional treatment in the future; and
3. I approve the proposed settlement of a lump sum payment of One Hundred Fifteen
Thousand Dollars ($115,000.00) and the distribution thereof.
Joar~e Lescalleet
,icwo m.~~~/oc,,,_-V~r~ me this/? day o f ,~co ~. ,2000.
GRAHAM & MAUER, P.C.
By: LISA J. MAUER, ESQUIRE
Attorney I.D. 65426
The Commons at Valley Forge
Suite 22, P.O. Box 987
Valley Forge, Pennsylvania 19482
610/933-3333
TROY SHAFER, a minor, by
TODD SHAFER and JOANNE LESCALLEET
parents and natural guardians
Plaintiff
CATHERINE R. BROWNAWELL
Defendant
and
MIRIAM LEON
and
Defendant
STATE FARM
UIM Carrier
Attorney for Plaintiff
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
No.:
AFFIDAVIT OF GUARDIAN
I, Todd Shafer, certify that:
1. I am a parent and custodian of Troy Sharer;
2. Troy Shafer has had medical treatment for the injuries sustained in the incident
which is the subject matter of this action and may require additional treatment in the future; and
3. I approve the proposed settlement of a lump sum payment of One Hundred Fifteen
Thousand Dollars ($115,000.00) and the distribution thereof.
Todd Shafer/
Swound Su.bs~d h~fore me this &ay of ///~ , 2000.
~ / ~-. I~ ~noo I;ue~,~<~uno "dr&!. uolell~l~ ~no$
Exhibit A
Troy Shafer
Auto Accident of February 11, 1999
Medical Bills through October 13, 1999
Hershey M.:lieal Center
02/I 1/99
02/11/99
02/12-19/99
02/11/99
02/11/99
02/11/99
02/18-19/99
03/05/99
03/02/99
04/01/99
04/01/99
10/15/99
Helicopter
Hospital (Inpatient)
Physician Services
Radiology
Orthopaedics
Anesthesiology
Pediatric Cardiology
Plastic Surgeons
Radiology
Radiology
Physician Charges
Hospital (Inpatient)
2,869.00
18,420.20
4,317.80
1,400.00
6,352.00
1,260.80
6,455.80
1,847.60
100.00
100.00
180.00
7.390.00
$ 50,693.20
FOR SERVICES
OUTPATIENT
JOANNE STOUFFERt
1! COOPER CIRCLE
CARLISLE
MOTHER
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE
TIENT NAME
~HAFER TROY E
19.9 INJURY-SITE NOS
PA 17013
oz/11/99 ~z/11/99
AUTO INSURANCE
STATE FARH INSURANCE
PA 17013
38J176022
~ NUMBER ~RTH OA~TE SEX
009T339~.'-90~.3 06/~6/9(~ H I~ I
; 7286S72E1138A
/11/9;q071100~
/11/9~00711002
/11/99Q0711007
/11/9g00711093
l'~cee~&;r~ ~^T~r~AIC~aLNESSt KYM Aa
DE~RI~ON
LIFT-OFF PATIENT CHARGE FLIGHT
AMBULANCE NILEAGE FEE..
27 AT 60.~ EACH
Iv CAT. SUPPLY CHARGE ALS
PULSE OXINETRY
TOTAL
CHARGES
AMOUNT
1~202.0.C
1~620,.0C
4~., O0
CLAIM FOR SERVIGES
INPATIENT
JOANNE STOUFFEKt
11 COOPER CZRCLE
CARLISLE
PA 17013
~'rloN TO PATIENT
MOTHER
JOANNE R $TOUFFER
11 COOPER CIRCLE
CARLISLE
PA 17013
~HAFER TROY E
Ct. NM RTE
~2/11/99 ~2/19/99
AUTO INSURANCE
)NE
!leO1 FX FEMUR SHAF/-CLOSEO 8(~2,21
~C.~_..N.. PROCF. OUR~
(~2/11/99 79e35 OPEN REOUC~XNT FIX FEHUR
02/11./99 79.35 OPEN REOUC-ZNT FIX FEHUR
DENT R~ATED WOl~( RELATED I; ~JDENT DATE & TIldE ~ ~ ATFENO~ FH~BW.L~H
YES NO 2/11/9~ 04: 26~76 CILLEY. ROBERT
RVICE DATE REF. NO. DESCRIPTION
SUMMARY OF CHARGES
STATE FARM INSURANCE
NUMBER
38JI76~2~ ; 7286S?2EX118A
DiS ~2/19/99
FX CONDYL PROC MAND[B-CL
AMOUNT
OiQI PEDS INTENSIVE CARE
001 PEDIATRICt SEMIPRIVATE
00~ PEDIATRiC-PRIVATE
2SO PHARHACY
25~ PHARMACY
26q leVe SOLUTIONS
270 NED/SURG SUPPLIES
300 LA~ORATORY
320 RAOIOLOGY
324 RADIOLOGYt OX CHEST X~RAY
351 RADIOLOGY-CT HEAD
35~ RADIOLOGY-CT BODY
360 OPERATING ROOM
370 ANESTHESIA
39~ BLOOD ADHIN/TEST
&lO RESPIRATORY THERAPY
· 20 PHYSICAL THERAPY
~30 OCCUPAT[ONAL THERAPY
~SO EMERGENCY ROOM
63~ CHEHO/OTHER PHARMACY
730 EKG
1 DAYS AT
2 DAYS AT
5 DAYS AT
Z,Z2S,qO
695.00 3~475,00
615,59
Z7.~1
t B.eO
62.~0
· 0.o
~fO9~e~O
130.~0
TOTAL CHARGES 181~e20.20
; PcnnSmte' G._e_is_inger
Hea~h S~tem
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE PA 17013
ACCOUNT # 9~391
: ~Ny OUESTIO#S. pL,EA~E CO#T~K:T: HERSHEY MEDICAL CENTER BILLING SERVICES
TE PROCEDURE DJAG
CODE CODE QTY DF~CRIPTION INS
FA12Fd~II'~ TROY E SNA~ER ~73591
3~0874904)
PERFORHED BY: DZV PLASTZC R~CONST ~JRG
PLA~E OF SVC~ INPAI~ENT
PERFOR~D AT: HH HEE~HEY ~DZCAL CENTER
HERSHEY PA 170~
12/$9 $9~I,NH ~OZ,ZO XJdXI'XAL XIFT COI~4JLTAT'XON AUT
PERFOPJ, ED BY: DXY PEDXATRXC S4JRG~EY
PEEF&°.J'-':D AI'I HN HEILSHEY HEDXCAL CEJ~rT~E
HERSHEY PA '17033
L~/'J') ')~Z33oNfl 9~9,8 DAZLY HO~OXTAL CARE , AUT
PEEIrm~HFD BY: DZV OF' DXA8 EADXOLOGY
PERFOPJED AT: ~ HERSHEY HEDXCAL CENTER PA X7033
PER~D AT: ~ K~EY mDXCAL CE~R PA 17033
PERF~O BYJ DZV PL~C ~ ~
PERr~O AT: ~ HE~EY ~OZCAL CE~R
PA 27033
PAGE
1or 3
STATEMENT
DATE: 03103199
LAST STATEMENT
DAT~
FED TAX ID # 236291113
PAYMENT] GUARANTOR
CHARGE ADJUSTMENT BAJ, ANCE
120,00
12J.00'
.60.00
.60.00
3/99 9~J~l.~ 8OZ.ZO HOS; VXSXT BILTEF CC AUT
PEEFOIUEO 8Y: OXY PEOXATILTC SURGERY
PEEFOFJEE) AT: Ig4 HERSHEY PEDZCAL CENTER
HERSHEY PA 17033
3/99 9~JZ3Z.NH 969.8 DA~LY NOSPZTAL CABE ALIT
PERFOEHED BY: DXV PLASTXC ~CiX~IST SURG
PEEFOm'ED AT: ~ HERSHEY HEDZCAL CENTER
PA X7033
PEEFW'IED BY8 DXV PED'rAI'RXC S~GERY
PEEFO~fI"D ATI HH HEP. SHEY ~DZCAL CENTER
HERSHEY PA 17033
~/90 FJ~3Z.~ 959,E EjLTLY HOSPXTAL CARE AUT 90.00
PEEFOPJ'ED BYs DZ¥ OF DXAG RAOXOLOGY
PLACE OF SVCI OP HOSPXTAL
PERFORHED XT: I~1 HER,SHEY HEDXCAL CENTER
HEP,3HEY PA 17033
~ ~ SELLA POS FO~ ~NEH
PERIrOmED AT: HH HERSHEY ~DZCAL CENI'ER
PA 17033
PERFORfIED A1'4' Hff ~ILSHEY flEDZCAL CENTER
~P,,SH£Y PA 27033
FOOT LXJ(ZTED
PERFiX~H~D AI'z H~ HERSHEy IEDZCAL CENTER
HEKSHEY PA 17033
AHU.~ LZKZTED
~95 704~OZ6.GC 959.8 AUT
/09 70110~6 959.8 AUT
/99 73600Z6 959.8 AlT
64,00
90.00
lBl. O0
?O.O0
50.00
50.60
STATEMENT OF
PennState Geisinger
Health System
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE PA 17013
ACCOUNT # 973391
IF ~JdY QUESTIONS, PLEJ~E CONTdV~T: HERSHEY MEDICAL CEHTER BILLING SERVICES
)ATE PROCEDURE DIAG
CODE CODE I~TY DESCRIPTION
~16/99 99Z32.57 ~Z.ZO
~./X7/99 2X4~.~ 802.20
/17/99 21453.AA 802,Z0
93010
PERFOIUEO BY: OZV pLkSTZC gECCHST SUg;
PLACE OF SVC: ZNPATZENT
PERFOii~ED AT; H~ HERSHEY HEDZCAL CENTER
HERSHEY PA 17033
HOS~ VZS."T BILTEF CC
PERFORHED ATt Hid HEP,~HEY IEOZCAL CENTER
HERSHEY PA 17033
~ VZ~T ZNT~fl CC
PERF~IED AT: ~ ~R~E¥ ~En'[¢~L ~ENTER
PERF.'lED BYz DZ¥ PL~TZC REC~t~T ~JR~
PERFUMED ~T~ ~ gEP.~E¥ ~DZ~AL ~ENTER
HEll, HEY PA 17033
IrRAC HAHDZBULAR OfEH N HA
PE~D 8Y~ DZ¥ PEDZATRZC SUP. G~RY
PEP. FOf~[D AT-' HI( HERSHEY HEDXCAL CENTER
HEI~)HEY PA 17033
DAZLY HOS~ZTAL CARE
PERFOIIHED BY~ DZV OF AHESTI~SZA
PERFOSHED AT~ ~ HERSHEY ~DZCAL CENTER
HERSHEY PA 27033
TRT OfN HAHD FRAC
PERFmU4ED 8Y~ O~¥ PEOZATP. ZC SWGERY
PEEFOfJI[O ATf Hid HEP. SHEY ~DZCAL CENTER
HERSHEY Pk X7033
DAZLy HOSPZTAL CARE
PERFOImEP eYt DZV PEDZAT1LTC CA.qDZOLOGY
PLACE OF SVC~ Of PHYSZCZAH
PERFiXUtED AT~ ~ HERSHEY HEPZCAL CENTER
HERSHEY PA 27033
EC~ ELECTROCAJWZOG# COffPL
PERFOm~D 8Yf DZV OF DZA6 RAOZOLOGY
~J&/99
PLACE OF
PERFORJED
. CHEST 1
PERFOi~ED ATt
7~.09 CHEST Z VZENS
PLACE OF
PERFOEHED
'1&"99 ?lO20Z&
ZNPATZENT
Hi( HERSHEY ~DXCAL CENTER
HERSHEY PA 17033
Ig4 HERSHEY HEDXCAL CENTER
HERSHEY PA 17033
FP. ONT/LAT
Of HO~OXTAL
Hid HERSHEY IEDXCAL CENTER
HE P, St~Y PA 17033
FIWHI'/LAT
E SHAFER 40,00
INS
19/99 710202& $68.8 CHEST 2 V~ENS
BALAHCE: TROY
PA~E
2or 3
STATEMENT
DATF~ 03103199
LAST STATEMENT
DAT~
FED TAX ID # 236261113
PAYMENT/ GUARANTOR
CHARGE ADJUSTMENT BALANCE
d4.00
90.00
d4.0O
X896,00
6~.00
812.60
90.00
40.00
70,00
70.00
PHYSICIAN SERVICES
PennState Geisinger
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE PA 17013
ACCOUNT # 673391
IFANY QUESTIONS. SakE&SE CONTACT: HERSHEY MEDICAL CENTER BILLING SERVICES
)ATE PROCEDURE DIAG
COD~ CODE CITY DESCRIPTION INS
PAGE
3or 3
STATEMS:NT
[~,TE: 03103199
L,AJT 8TATEM fJIT
DATE:
FED TAX ID # 236291113
PAYMENT/ GUARANTOR
CHARGE ADJUSTMENT BALANCE
TH,TS STATEHENT ZS FOR PROFESSZONAL SERV'ZCE$ ONLY. ZF YOU HAVE
MY GUESTZOt~ REG~UtDZNG ZIGURMCE PAYHEF[TS C04TACT THE COtfPANY
DZRECTLY. THE ~ LZSTED ZN THE PATZENT COLUHi4 Z$ YOUR
RESPONSZBZLTTY. ZF PAYHENT HiS BEEN H~U)E) PLE.4$E ACCEPT OUR
TH.Va( YOU ~ DZS~EGARD TH,TS REQUEST.
iNE$1/01G, PLE&fE CALLs (717) ~31-.60&9
TE~ORL~y CIUHGE OF PATZEEr Z~UZRY HOURS
H~AY - FP/OAY -- 8:00
&HCE SUI'I4UW
RESFONSX6LE PARTY PO~Z~ J' TOTAL
IUl' IUT0 Z. HSUEtNCE 7~*6~672,Ell~6Ai56J1760;~ $ 4517.80
~ OUAE~TOE RESPOIqSZ~T'I~ ,~ O.OO
,~ IMP~RTANT~ PLEA$1~ OETACN ,~ND /tHTURN ~OTTOM PORTION OF ST4 TEMENT W)T~ YOUR PAY~gNT .~
BF6 073301 ~99 $ O.O0
HERSH~ MEDI~ CEN~R
BI.HQ
P 0 BOX gM
PENN STATE GEZSZNGER
HERSHEY NCBS HS&Z
P O BDX
HERSHEY PA 17033-0854
JOANNE R STOUFFER
11 COOPER CZRCLE
CARLZSLE PA 17015
ONLY
F6BO
DMND
__M/C
__VISA
__DISC
FOR CREDtT CARD PAYMENT, PLEASE fill. IN INFORMATION BELOW
CARD NUMBER EXP DATE
CARDI"IOLDER NAME (PRINT)
CREDIT CARD SIGNATURE
r e~.':~'~',,'~,*~ ~gW R I I I: :THIS 'ACCOUN [dl ON CHECK
973391
$ 0.00 I
T~mouNm~
'~~ PAYARt , ~TO. ~..~ ~'~'~'~'
PSGC
PennState Geisinger
Health System
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE PA 17013
DATE PROCEDURE DIAG
CODE CODE
>>> PATXENTI TROY E SHAFER
ACCOUNT # 973391
~ IF ANY QUESTIONS. PLEASE CONTACT: HERSHEY MEDICAL CENTER BILLING SERVICES
QTY DESCRIPTION
973391
3&O87HgO~Z
PERFORflED BY: DI¥ OF DTAH RADTOLOOY
PLACE OF SVC: 0P HOSpTTAL
PERFORHED AT: HH HERSHEY HEDICAL CENTER
HERSHEY PA 17033
0~/11/99 71010Z6 959.1 CHEST 1 VZEH
PERFORHED AT'* HH HERSHEY HEDICAL CENTER
HERSHEY PA 17033
0Z/11/99 710101& 9-69.1 CHEST I VZEN
PERFOlU~ED BY: DT¥ PEDTATRIC SURGERY
PLACE OF SVCI EHERGEICY ROOH
PERFORHED AT: HH HERSHEY ~DTCAL CENTER
HERSHEY PA 17033
07./11/99 3&~9.GC 9.69.9
01/11/99 70H$0Z&.GC 9-69.8
02/11/99 7210026.GC 959.9
02/11/99 720~,016.GC 959.~
0~2~99 7~19~26.~ 959.8
0~1~99 7416016.~ 959.8
0~11/99 71010~6.~ 969.8
0~1~99 7107016.~ 9~9.8
0~/11/90 27-606.NH 8~'0.8 2
0H/09/99
02/11/99 27-60&.QK 820.8
04/09/99
0S/0~/99
2O
CVP CATH PERCUTAN OVER Z
PERFORHED BY: DIV OF NUCLEAR HEDICTHE
PLACE OF SVC: 0P HOSPTTAL
PERFOI~ED AT: HH HERSHEY HEDZCAL CENTER
HERSHEY PA 17033
CT HEAD L~IE~AI~ED
PERF~D AT: ~ HEIt~EY HEDZCAL CEI~TER
HERSHEY PA 17033
SPTNE LUHBOS ANT/POST LAT
PERFOHHEO AT: HH HERSHEY fiEDTCAL CENTER
HERSHEY PA 17033
SPZHE CERVXC ANT/POS LAT
PERFmUlED AT: ~ HERSHEY HEDZCAL CENTER
HERSHEY PA 17033
CT PELVX$ ~EHHANCED
PERIrORHED AT: I~1 HERSHEY HEDZCAL CENTER
HERSHEY PA 17033
C T A~DOHEN EHIIAHCED
PERFORHED AT,' HH HERSHEY HEDZCAL CENTER
HERSHEY PA 17033
CHEST I YXEN
PERFORHED AT/ ~ HERSHEY HEDZCAL CENTER
HERSHEY PA 17O33
SPZHE THOR ANT/POS LATER
PERFORffEO BY: OEP1' OF ORTHOPAEDICS
PLACE OF SYC: THPA1/ENT
PERFORHED AT: ffH HERSHEY HEDICAL CENTER
HERSHEY PA 17033
FX FEH SHFT SP/CHP OPRED
INSURAHCE PAYItENT
PERFORHED BY.. DTV OF AHESTHESlA
PERFORHED AT; HH HERSHEY HEDTCAL CENTER
HERSHEY PA 17033
OP TRT CL/OP FEH SH~T
ZRSU~ANCE PAY~NT
HA CONI'R AFTER PR! T~
INS
HA1
HA1
HA1
HA1
HA1
HA1
HA1
HA1
HA1
HA1
CHARGE
SO,O0
$0.00
4ZO.O0
150. OO
70.00
70.00
ZOO. O0
2HO. O0
50.00
70.00
63-62. O0
1260.80
PAOE
1of 6
STATEMENT
DATE: 06114199
LAST STATEMENT
DATE: 06102/99
FED TAX ID # 236291113
PAYMENT/ GUARANTOR
ADdUSTMENT B~NCE
&3-62.00- 0, O0
479.47-
781,33- O. O0
STATEMENT OF PHYSICIAN SERVICES
PennState_Geisinger
Health System
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE PA 17013
ACCOUNT # 973391
HI IFANY QUESTIONS, pLIEASE CONTACT: HERSHEY MEDICAL CENTER BILLING SERVICES
DATE PROCEDURE DIAO
CODE CODE QTY DESCRIPTION
PERFORHED AT: Hid HERSHEY HEDZCAL CENTER
HERSHEY PA 17033
820.8 Z0 0P TRT CL/OP FEid SHIT
0~/12/99 2760&.(IX
06/06/99 idA COflTR AFTER PR~ INS
PERFORHED BY: DTV OF DIAG RAOTOLOGY
PERFORtlED AT-' HH HERSHEY HEDZCAL CENTER
HERSHEY PA 17033
0~'/11/99 7ZlTOZ& 969.8 PELVIS AHTERPOST~R
PERFO~"iEO AT: Hid HERSHEY idEDICAL CEHTER
HERSHEY PA 17033
0~11/99 73660'/6 959.8 KNEE LzPLTTED
PERFOfUtED AT: lin HERSHEY HEDTCAL CENTER
HERSHEY PA 17033
0Z/11,"99 73660Z6.16 959.a IOiEE LTHITEI)
PERFORHED AT: HH HERSHEY HED'rCAL CENTER
HERSHEY PA 17033
0~/11/99 73~026 969.8 FEHUR (THZgid) ONE JOINT
PERFORHED AT-' Hid HERSHEY HEDICAL CENTER
HERSHEY PA 17033
02/11/99 73550~'&.76 959.8 FEHU~ (THISH) ONE .JOINT
PERFONflED BY: PEDIATRIC CRIT & INT CARE
PERFOPJ'IED AT.' HH HERSHEY flEDZCAI, CENTER
HERSHEY PA 17033
0:Mll/99 99:~91 786.09 CRZT CARE 1ST HR UNSTABLE
PERFORflED BY: DTV PLASTIC RECONST SURG
PERFORHED AT: HH HERSHEY HEDICAL CENTER
HERSHEY PA 17033
0~'/1~99 99~K1.HH 802.:~0 TI~TZAL INPT CC~SULTATZON
PERFORHED BY: DZ¥ PEDIATI~TC SURGERY
PERFOI~D AT: HH HERSHEY PED'rCAL CENTER
HERSHEY PA 17033
0~*/1~/99 99233.H~ 959.8 DA.TLY HOSPITAL CAKE
PERFORIdED BY: DI¥ OF OTAG RABIOLOGY
PERFORI~D AT: Hid HERSHEY PEDTCAL CENTER
HERSHEY PA 17033
02/1~/99 73660:~6.GC ¥&&**6 FEHUR (THTGfl) C~ JOZNT
PERFONJ'ED AT: ~ HERSHEY HEDTCAL CENTER
HERSHEY PA 17033
0~12/99 73550:~'6.76 ¥66.,~* FEHU~ (THZSH) K dOTNT
PERFORHED BY: PEDZATI~C CRTT & 1NT CARE
PERFORHED AT: Hfl HERSHEY HEDICAL CENTER
HERSHEY PA 17033
0~'/1~,'99 99~'91 786.09 CRIT CARE 1ST HR UNSTABLE
PERFOI~ED BY: DT¥ PLABTIC RECC~GT SURg
PERFORHED AT: Hid HERSHEY idEDTCAL CENTER
HERSHEY PA 17033
0~13/99 99Z31.#H 80:~.~'0 HOSP VISTT BR'rEF CC
PERFOI~D BY: DT¥ PED]'ATR.TC SURGERY
PERFORHED AT: HH HERSHEY HEDTCAL CENTER
HERSHEY PA 17033
0~13/99 99~'32.idH 959.8 DAZLY HOSp'rTAL CARE
INS
IdA1
HA1
IdA1
idA1
idA1
idA1
idA1
idA1
idA1
idA1
idA1
HA1
CHARGE
630.60
40. O0
60.00
60. O0
60. O0
50.00
269. O0
120. O0
128.00
60. O0
50.00
240. O0
66. O0
90,00
PAGE
2of 6
STATEMENT
DATE: 06114199
LAST STATEMENT
DATE: 06102/99
FED TAX ID # 236291113
PAYM ENTI GUARANTOF
ADJUSTMENT BALANCE
630.60- O. O0
STATEMENT OF pHysICIAN~ERvICES
PennState Geisinger
Health System
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE PA 17013
ACCOUNT # 973391
~ IFANY QUESTIONS, PLEASE CONTACT: HERSHEY MEDICAL CENTER BILLING SERVICES
DATE PROCEDURE DIAO
CODE CODE OTY DESCRIPTION
02/14/99 99232.#H 969.8
02/1/99 70~0Z6.(;C 959.8
02/I/99 7011026 959.8
02/1/99 T36Z026 959.8
07./1/99 7360026 959,8
02/16/99 99232.57 802.20
02/16/99 99231.Ml 959.8
07./17/99 21453.1dH 802.20
02/17/99 99231.PM 959.8
02/17/99 21453.AA 802.20
02/18/99 99232.NH 9.~9.8
PERFORHED BY: DX¥ PLASTIC REC0NST SURG
PERFORHED AT: HH HERSHEY mEDICAL CENTER
HERSHEY PA 17033
HOSP VZSXT BRIEF CC
PERFORfED BY: DXV PEDIATRIC SURSERY
PERFOPJ,'~D AT: HH HERSHEY HEDZCAL CENTER
HERSHEY PA 17033
DAILY HOSPITAL CARE
PERFm~ED BY: DX¥ OF DXA6 RADIOLOGY
PLACE OF SVC: OP ffOS~XTAL
PERFORHED AT: HH HERSHEY HEDXCAL CENTER
HERSHEY PA 17033
CT ORB SELLA POS FOS UN~H
PERFORHED AT: ~ HERSHEY HED~CAL CENTER
HERSHEY PA 17033
HAHDXBLE ~ ¥XENS
PERFORHED AT: HH HERSHEY HEDXCAL CENTER
FOOT LXffZTED
PERFORI~D AT:
A~LE LXI~TED
PERFORflED BY:
PLACE OF SVC:
PERFORIED AT:
HERSHEY PA 17033
~ HERSHEY HEDXCAL CENTER
HERSHEY PA 17033
DXV PLASTIC RECCHST SUnG
INFA'T*XENT
HH HERSHEY HEDICAL CENTER
HERSHEY PA 17033
13
HOSP VXSXT BRIEF CC
PERFORHED AT: Hff HERSHEY HEDXCAL CENTER
HERSHEY PA 17033
HOSP VZSXT INTER CC
PERFORHED BY: DXV PEDXATRXC SURGERY
PEHFORHED AT~ Hfl HERSHEY HEDICAL CENTER
HERSHEY PA 17033
DAILY HOSPITAL CARE
PERFOPJI~D BY: DXV PLASTIC RECC~ST SURS
PERFORHED AT: HH HERSHEY HEDXCAL CENTER
HERSHEY PA 17033
FRAC HANDXBULAR OPEN N mA
PERFOP. HED BY: DXV PEDIATRIC SURSERY
PERFORff~P AT: HH HERSHEY HEDXCAL CENTER
HERSHEY PA 17033
DAILY HOSPITAL CARE
PERFORHED BY: DXV OF At~STHESXA
PERFDJU~ED AT: HH HERSHEY HEDXCAL CENTER
HERSHEY PA 17033
TRT OPN HAHD FRACN/H~XP
PERFORfED BY: DXV PEDIATRIC SU~RY
PERFORHED AT: HH HEIL~EY HEDXCAL CEHTER
HERSHEY PA 17033
DAILY HOSPITAL CARE
INS
HA1
HA1
HA1
HA1
HA1
mAX
HA1
HA1
mAX
HA1
HA1
HA1
CHARGE
64.00
90.00
181.00
70.00
60.00
50.00
64.00
90.00
64,00
1896,00
64.00
812,80
90,00
PAOE
3or 6
STATEMENT
DATE: 06114199
LAST STATEMENT
DATE: 06102J'gg
FED TAX ID # 236291113
PAYMENT/ GUARANTOR
ADJUSTMENT BALANCE
STA'I-EMEN I' OF PH¥.~,ICIAN SERVICES
PennState Geisinger
Health System
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE PA 17013
ACCOUNT # 973391
~1~ IF ANY QUESTIONS, PLEASE CONTACT: HERSHEY MEDICAL CENTER BILLING SERVICES
DATE PROCEDURE DIAG
CODE CODE QTY DESCRIPTION
INS CHARGE
PERFO~IED BY: DTV PEDIATRIC CARDIOLOGY
PLACE OF SVC: OP PHYSICIAN
PERFOPJ4ED AT: HH HERSHEY HEDZCAL CENTER
HERSHEY PA 17033
02/18/99 93010 ECG ELECTROCARDIOGff C0HPL HA1 ¢0.00
PERFORHED BY: DIV OF DTAG RADTOLOGY
PLACE OF SVC: INPA~ENT
PERFOP, HED AT; HH HERSHEY ~DTCAL CENTER
HERSHEY PA 17033
02/la/99 7].01026 9.69.1 CHEST I VZEH HA1 .qo.o0
PERFORHED AT-' HH HERSHEY HEDICAL CENTER
HERSHEY PA ].7033
02/19/99 7102026 786.09 CHEST 2 V~ENS FRSNT/LAT HA1 70.00
PLACE OF SVC: OP HOGPITAL
PERFOIIHED AT: HH HERSHEY HEDICAL CENTER
HERSHEY PA ].7033
02/19/')9 7102026 9.69.9 CHEST ~' VIEHS FRSNT/LAT HA1 70.00
03/0.6/99 ].6016.RT 902.20
03/06/99 1200¢.RT 902.20
03/06/99 206~O.RT 802.20
03/05/99 Ol200.qK 902.20
8
9733919050
PERFOI~ED BY: DIV PLASTIC RECONST SURG
PLACE OF SVC: SURGERY - SHORT STAY
PERFOI~IED AT: HH HERSHEY HEDICAL CENTER
HERSIIEY PA 17033
BLaH TREAT DRESS/DEB # AH HA1 637.00
PERFORHED AT~ HH HERSHEY HEOICAL CENTER
HERSHEY PA ].7033
SIN REP TR I.H 7-12 HA1 33.6.00
PERFOP, H~D AT; HH HERSHEY HEDICAL CENTER
HERSHEY PA 17033
IHSERT/REHOVE HIRE PIN HA1 370.00
PERFORHED BY: DZV OF AHESTHESIA
PERFORatED AT: ~ HERSHEY HEDICAL GEN'~R
HERSHEY PA 17033
AHE/ALL CLSD PROC/H].P JNT HA1 ~05.60
03/0~'99 73.6JO26.GC V67.¢
03/0?./99 73S.6026.GC V67.¢
03/0~99 9902¢ 719.¢6
9733919092
PERFORflED BY: DIV OF DIAG RADIOLOGY
PLACE OF SVC: OP pHYSTCTAN
PERFORtIED AT: HR HHC - REHAB
HERSHEY PA
FEI, lUll (THZSH) ONE ,JOINT
PERFOGI, ED AT: HR HHC - REHAB
HERSHEY PA
FEHUR (THIGH! ONE JOI~T
PERFORHED BY: DEPT OF ORTHOPAEDZCS
PERFORHED AT: HR HHC - REHAB
HERSHEY PA
PI~T-OF FOL-UP VISIT
HA1 .60.00
HA1 .60.0O
9T33919092
0.00
PAOE
4of 6
STATEMENT
DATE: 06114199
LAST STATEMENT
DATE: 06/02/99
FED TAX ID # 236291113
PAYMEHT/ GUARANTOR
ADJUSTMENT BALANCE
b
\o°
0.00
[] CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON RACK
STATEMENT OF PHYSICIAN SERVICES
PennState Geisinger
Health System
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE PA 17013
ACCOUNT # 973391
~1~I IFANY QUESTIONS, PLEASE CONTACT: HERSHEY MEDICAL CENTER BILLING SERVICES
DATE PROCEDURE DIAG
CODE CODE QTY DESCRIPTION
04/01/99 735.60:~& .GC V$7.4
04./0]./99 7'~..qoz&.GC V67.4
~/01/~9 990Z4 8~'0.8
PERFORHE9 BY: DTV OF DZAG RADTOLOOY
PLACE OF SVC.' OF PHYSTCTAN
PERFORHED AT: HR HIC - REHA~
HERSHEY PA
FEHUR (THIGH) ONE JOIHT
PERFORYlED AT.' HR K - REHAS
HERSHEY PA
FEffJR (THZSH) ONE JOZHT
PERFOAHED BY: DEPT OF GHTHOPAED];CS
PERFORHED AT: HR HI'lC - REHAB
HERSHEY PA
POST*.*OP FOL-UP V~$TT
BALANCE.' TROY E GHAFER $0.00
INS
CHARGE
SO.O0
$0.00
0.00
· INo'rCATES N~N FTNANCZAL AC'I/V~TY STYE LAST BTLL.
THIS STATEHENT TS FOR PROFESSTGHAL SERVICES ONLY. ZF YOU HAVE
ANY (~UEST~ONS REGARD*~NG INSURANCE PAYHEHTS CONTACT THE CGHPANY
OZRECTLY. THE AHOUNT LTSTEO ZN THE PA*r/EI~' COLLH, I TS YOUR
RESPGHS'rBTLTTY. TF PAYIdEI~T gAS BEEN N~)E, PLEASE ACCEPT OUR
THA,'~, YOU AHD DZSREOARD THZ$ RE~IUEST.
Ird06
~Sl'IONS, PLEASE CALL: (717) .631-.F,069 OR 1-800-L~-Z&I9
TEHPORARY CHANGE OF PATTENT ZI~U~*RY HOURS
II~IDAY - FR/DAY -- 9.'00 AH - 4:16 PH
PAGE
5o~ 6
STATEMENT
DATE: 06114199
LAST STATEMENT
DATE: 06102/99
FED TAX ID # 236291113
PAYMENT/ GUARANTOR
ADJUSTMENT BALANCE
0.00
CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON
STATEMENT OF PHYSICIAN SERVICES
PennState Geisinger
Health System
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE PA 17013
ACCOUNT # 973391
HI tF AnY QUESTIONS, PLEASE CONTACT: HERSHEY MEDICAL CENTER BILLING SERVICES
DATE PROCEDURE DIAG
CODE CODE OTY DESCRIPTION INS
PAGE
STATEMENT
DATE: 06114199
LAST STATEMENT
DATE: 06102199
FED TAX ID # 236291113
CHARGE PAYMENT/ GUARANT¢
ADJUSTMENT BALANCI
BALAHCE SUI'I~ARY RESPGUSZBLE PARTY POLICY ! TOTAL
HA! PA HEDICAL ASSISTANCE 890!~1M~ $ 8503.40
~ GUARANTOR RESPONSIBILITY $ 0.00
~, tMPOnTA~.T..;.~.&.E..~.SE DETACH AND nETunN eOTTO~ POnT/ON Or STATFJ~.~I~.)YI.~..II.Y_q.U.[p.~V_.td..g.N.T. ~
STATEMENT DATE~ GUARANTOS RESPONSIBILITY:
BF6 g73391 06114199 $ 0.00
HERSHEY MEDICAL CENTER
BILLING SERVICES
P O BOX 854
HERSHEY PA 17033-0854
Mall
PENN STATE GEZSZNGER
HERSHEY MCBS HS6!
P 0 BOX 856
HERSHEY PA
orrtct USE ONLY /CHECK ONE
__M/C
__VISA
DISC
HC: F6BO
TYP: DMND
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLISLE PA !7013
17055-085q
CARG NUMBER EXP GATE
CARDHOLDER NAME (PRINT)
~'*~ ;~!~:~ WRITE THIO ACCOUNt4 ON CHECK,~;
973391
f~PAY THIS ~AMOUNT'~~ ~~:
$ o.oo
CREDIT CARD SIGNATURE
PSGC
CHECK BOX AND ENTER ANY ADDRESS ORINSURANCE CORRECTIONS ON RACK
.~,,e'OANNE STOUFFERs
COOPER CZRCLE
CARLtSLE PA
MOTHER
JOANNE R STOUFFER
11 COOPER CIRCLE
CARLZSLE
SHAFER TROy F
TRIER INSURM~ICE INDICATED BY HO~PIT,N. RECORDS
17013
172-62-5057
ONE
67~4 FOLLO~-UP EXAMINATZON~ FOLLOW!
0'~/01/99 89,27 SKEL XRAY-THIGH/KNEE/LEG
04/0~,j~99 88.27 SKEL XRAY-TH~GH/KN;E/LEG
NO --. 2~1~3 SEGALt LEE
~/01/9900307308 FEMUR
2 AT ed.~o EACH
o~/61/e9 ~/ol/ge
AUTO ~NSURANEE
STATE
PA 17013
FARM ZNSURANCE
PAGE NUMBER
I 7286572El138A
I
AMOUNT
180.00
TOTAL CHARGES
t'enn ta[e L elslnger
· ' . DETAILED STATEMENT OF
HOSPITAL ACCOUNT
Health System
rllllililtriY~
[..TROY E SHAFER
J 3~4089 J io/15/9'~ J io/ie-,,"~'9 J io/=5'/~Y~,
PLEASE REFER TO pATIENT'S NAME AND ACCOUNT NUMBER ON ALL INQUIRIES ANC CORRESPONDENCE.
i1~11 i '
OOANNE R LESCALLEET
2! COOPER CIRCLE
CARLISLE, PA i7013
MAPA
MAKE CHECK PAYABLE TO: HMC
MAIL TO: P.O. BOX 853
HERSHEY, PENNSYLVANIA 17033-0853
FEDERAL ID# 23-2891807
IMPORTANT: PLEASE DETACH AND RETURN THE TOP PORTION OF THIS STATEMENT WITH YOUR PAYMENT TO ASSURE PROPER CREDIT. WRITE ACCOUNT NO, ON CHECK.
JNSURANCE PORTION IS ESTIMATED
I~ ACCORDING TO THE INFORMATION
32~*~L 08~/ SUPPLIEO BY YOUR INSURANCE CARRIER
ROOM CHARGES
ROOM-BOARD/SEMI
5~5.00 5~5.00 0.00
TOTAL ROOM CHARGES
595.00 595.00 0.00
ANCILLARY CHARGES
250 PHARMACY 283.30 283.30 O, O0
259 DRUGS/OTHER 4.20 4.20 0.00
260 IV THERAPY 12.00 12.00 0.00
270 MED-SUR 8UPPLIE 88.00 88.00 0.00
300 LABORATORY/LAB 192.00 192.00 0.00
320 DX X-RAY 252.00 252.00 0.00
360 OR SERVICES 4478.00 4478.00 0.00
370 ANESTHESIA 877.50 877.50 0.00
420 PHYSICAL THERP 102.00 102.00 0.00
424 PHYS THERP/EVAL 144.00 144.00 0.00
490 AMBUL SURG 76.00 76.00 0.00
710 RECOVERY ROOM 286.00 286.00 0.00
TOTAL ANCILLARY CHAROES
6795.00 6795.00 0.00
~,".~r r ~.' .:'(: . · ; ~, .. , .......... ffVOt~ have~;,- ·
.. .......... .-QUES~ON~,m~ b h, please call O~TAL ~
' PA'I IENT~: 53 T:50~ ESTI~TED
INSU~NCE COMPANIES: ~1-5218
/ :J~/(J. (3U'
INSURANCE PAYMENT DUE -
) 73c?0. O~
O. O0
PATIENT PAYMENT DUE )
Exhibit B
GRARAM & MAUER PC
LISA J MAUER ESQUIRE
THE COMMONS AT VLLY FORGE
SUITE 22 PO BOX 987
VALLEY FORGE PA 19482
COIdMONW EAJ. TH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
January 19, 2000
Re: TROY SHAFER
CIS #: 890144188
Incident Date: 02/11/1999
Dear Ms. Mauer:
Enclosed please find the Department's updated statement of claim. As
you will note, the amount of our claim is $8,299.95.
As we discussed, upon completion of the updated statement, I reviewed
this case with Ron Hill, Casualty Unit Manager. After review, it was
concluded the Department would not waive its claim. We will, however, agree
to reduce the amount of our claim by 33 1/3%, bringing the amount due to
$5,533.30.
If you have any further questions, please contact me. Thank you for
your cooperation in this matter.
Enclosure
Sincerely,
Susan E Naylor
TPL Program Investigator
717-772-6265
717-772-6553 FAX
Exhibit C
Troy Shafer's
Out-of-Pocket Expenses
Paid by Mother, Joanne Lescalleet
Date of SetMce
04/07/99
04/07/99
04/09/99
04/12/99
04/14/99
04/19/99
04/23/99
04/28/99
04/30/99
05/05/99
05/06/99
05/11/99
05/20/99
Description/Payee
Deck for Wheelchair Access
Crutches
Alexander Spring Rehab co-pay
Alexander Spring Rehab co-pay
Alexander Spring Rehab co-pay
Alexander Spring Rehab co-pay
Alexander Spring Rehab co-pay
Alexander Spring Rehab co-pay
Alexander Spring Rehab co-pay
Alexander Spring Rehab co-pay
Alexander Spring Rehab co-pay
Alexander Spring Rehab m-pay
Alexander Spring Rehab eoopay
Alexander Spring Rehab co-pay
Amount
$ 1,183.36
17.00
10.00
10.00
10.00
10.00
10.00
10.00
10.00
10.00
10.00
10.00
10.00
10.00
Total 1,320.36
Page No. of Pages
~ SUilMffTED TO
2273 Newvifie
CARLISLE, PA 17013
(717) 776.7590
PHONE
JOB NAME
JOB LOCATION
a.RCHITECT DATE OF PLANS
:.~e I~ereey suDmil specifications aaa eshmaleS tot:
/3,, ,/,~,,? s /)
DATE
JO6 PHONE
We Propose hereby to furn sh material and labor -- complete in accordance with above specifications, for the sum of:
Nora: Thi~ orapo~nl mn~ be
Acce ance of Pr osal _....~.,,.., s~cificalions
,
a~ Cotillions a~ Sali~la~l~[y ~ ar~ ~y accepled. ~u are a~lhorized to do the Signatura
work as specifiC. P~ym~l ~1 be ~ade a~ ~ined ab~.
$ignalure
clays.
JO&NNE R. STOUFFER
355 BURGNERS RD.
CARUSLE, PA 17013
481
^[FXANDER SPRING REHAB, INC.
27 BROOI~OOD AVI~.
C.2dllIS~, PA 17013
PHONE (717) 245-2341
I.D. # 23-2427706
FOR PROFESSIONAL SERVICES
PAYMENT
Alexb. nder Spring Rehab, Inc.
27 Brookwood Avenue, Carlisle, PA 17013
Phone: (717) 245-2341
LD.#: 23-2427706
Alexander Spring Rehab, Inc.
27 Brookwood Avenue, Carlisle, PA 17013
Phone: (717) 245-2341
LD,#: 23-2427706
Received for:
Received for:
To~ Payment of: $ ~0. ""
ac h Ch k #
Alexander Spring Rehab, Inc.
27 Brookwood Avenue, Carlisle, PA 17013
Phone: (717) 245-2341
I.D.#: 23-2427706
Received for:
Received by:
Total Payment of: $ /0, ""
~]"Cash ~ Check #
Date: Lff/~/t~
Alexander Spring Rehab, Inc.
27 Brookwood Avenue, Carlisle, PA 17013
Phone: (717) 245-2341
I.D.#: 23-2427706
Patient Name .'?=~--~ ~x.=.~
Received for:
$
Total Payment of: S
Total Payment of: $ ~ (.D o o
Alex~mder Spring Rehab, Inc.
27 Brookwood Avenue, Carlisle, PA 17013
Phone: (717) 245-2341
I,D.#: 23-242T'/06
PaUent Name?'T-~~~_)
Alexander Spring Rehab, Inc.
27 Brookwood Avenue. Carlisle, PA 17013
Phone: (717) 245-2341
LD.#: 23-2427706
Received for: $
ToUU Payment of: $ \ ~oy.-
Total Payment of: $
[3 cash [3.~eck #
Alexander Spring Rehab, Inc.
27 Brookwond Avenue, Carlisle, PA 17013
Phone: (717) 245-2341
LD,#: 23-2427706
ReCeived tot:
Alexander Spring Rehab,/nc.
27 Brookwood Avenue, Carlisle, PA 17013
Phone: (717) 245-2341
I.D.#: 23-2427706
Received for:
eceived hv~
Total Payment of: $
f3 C~sh O-e~k #
Total Payment of: $ t~.{~
Cash {~ Check # ~.~--'j~
Alexaixder Spring Rehab, Inc.
27 Brookwo~l Avenue, Carlisle, PA 17013
Phone: (717) 245-2341
I.D.#: 2:3-2427706
Alexander Spring Rehab, Inc.
27 Brookwood Avenue, Carlisle, PA 17013
Phone: (717) 245-2341
I,D.#: 23-2427706
Pa"e.,N,.ne: 'T~O'4 S/-I,qFc4E.
Received for:
Received for: $
~eceived by:
Total Payment of: $ /0 ' a ~
Received by:
To,., Pay,nentor: s 10. t~
a c~ ~ Check # ~ t I
Da,e: 51 ~/Oq
Alexander Spring Rehab, Inc.
27 Brookwood Avenue, Carlisle, PA 17013
Phone: (717) 245-2341
I.D.#: 23-2427706
D.= ,~/ttlqq s~r~,ce: er'
eceived for: $
Co-. P~Li ~c12_ Wtt t 6. dD
Alexander Spring Rehab, Inc.
27 Brookwood Avenue, Carlisle, PA 17013
Phone: (717) 245-2341
I.D.#: 23-2427706
Received for:
Total Payment of: $
,.. r- / , ~h"'~/"
Total Payment Of:
oe~ · ~ee~. 5IS
Exhibit D
In re: Troy Shafer
Justification of Attorney's Fees
· Resolve Liability Issues
This case stems fi.om an automobile accident in which one driver motioned Troy
Sharer, an eight year old, across the road to get his ball while another driver struck him with her
vehicle. The insurance companies for both drivers argued that Troy's negligence was the cause
of this "child dart out" case.
Counsel retained a road design engineer and accompanied him to the scene of the
accident to take measurements and photographs of the scene of the accident in
order to determine whether or not there was a cause of action based on faulty road
design or improper sight distances. The expert determined that there was no such
liability.
Counsel reviewed the township ordinance in order to detemaine whether there was
a possible cause of action against the trailer park for driveway design or setback
violations. No ordinance violations were found.
Counsel researched case law pertaining to the liability of waving drivers involved
in motor vehicle accidents. Pennsylvania law does not necessarily attach liability
to a waving driver, even in the case ora minor. Counsel had to convince the
insurance companies of the two tortfeasors of the merits of the theory of liability
based on the facts of this particular case.
2. Overcome the Limited Tort Threshold
Troy Shafer lives with his mother, Joanne Lescalleet, who had elected the limited
tort option on her automobile insurance policy. (See her declaration page attached hereto as
"Exhibit E".) At[er overcoming the liability issue with the insurance companies, counsel had to
convince them that this minor's injuries did overcome the limited tort threshold in order to obtain
multiple recoveries. Counsel conducted extensive negotiations with State Farm, insurer of
Catherine Brownawell (waiving motorist), who remained firm in their initial offer of $40,000.00
for many months.
In addition to preparing an extensive demand package, counsel arranged for a consultation
with a dentist who specializes in the treatment of children, in order to substantiate Troy's loss of
a permanent tooth and the need for future treatment.
3. Handle Insurance Coverage Issues for Medical Bills
The medical bills associated with this accident exceed $50,000.00. The medical
benefits available on Joanne Lescalleet's automobile insurance policy were $10,000.00. While
Troy Shafer's mother, Joanne Lescalleet, also purchased two small limited purpose insurance
policies (Combined Insurance Co. and CONSECO) and Troy's father, Todd Shafer, had coverage
under an HMO for several weeks during the course of treatment, the total amount of coverage
available under all of these policies was far less than the total amount of all medical bills.
As a result, counsel assisted Mrs. Lescalleet in applying for BLUE CHIP (for
which she was later determined to be ineligible) and Medical Assistance, since she did not have
the assets available to pay the unpaid balance. Counsel also assisted Mrs. Lesealleet in securing
benefits under her two small insurance policies.
Counsel worked extensively with the Hershey Medical Center Billing Department
and Medical Assistance in an effort to ensure that the bills were timely processed without going
to collection.
4. Search for Additional First and Third Party Insurance Coverage
Counsel reviewed insurance coverages of other family members and unrelated household
members in order to determine whether any additional insurance was available to cover Troy's
first party medical bills. None were found to exist.
Counsel also contacted the insurers of both defendants in order to determine whether these
two drivers were covered by other automobile insurance policies or umbrella policies. No other
policies were found.
5. Assist Family with Obtaining Medical Treatment
Several months after Troy's initial leg surgery it became apparent that his leg had not
healed properly and he was unable to walk without a significant limp. His surgeon
recommended another surgery and Troy's family wanted to seek a second opinion. Counsel
obtained information on physicians and billing procedures at both St. Christopher's Childrens
Hospital and Shriner's Hospital in Philadelphia, which enabled the family to obta'm a second
opinion from Peter Pizzutillo, M.D., a pediatric orthopaedic specialist. Dr. Pizzutillo agreed with
the surgeon and the second leg surgery was performed.
Counsel negotiated payment arrangements with James Keams, D.D.S., a dentist
specializing in the treatment of children, in order for Troy to have a consultation regarding his
loss of a permanent tooth.
6. Negotiations Regarding Medical Assistance Lien
Counsel asserted a hardship claim to Medical Assistance requesting that they
waive their lien due to serious financial consequences to Troy Shafer's family as a result of this
accident. While Medical Assistance denied a complete waiver, they agreed to reduce the lien by
33 1/3% instead of the customary 25%.
7. Investigate Possible Subrogation Claims
In addition to the known lien held by Medical Assistance, it was unknown whether the
HMO which paid for part of Troy's therapy also had a right of subrogation. Counsel confirmed
that the HMO available through GS Electric, Todd Shafer's employer at the time, was not part of
an ERISA plan, thereby extinguishing any subrogation claim against Troy's settlement.
Exhibit E
55CH? 0~-05-1999
NAMED INSURED
DECLARATIONS PAGE
MATCH 00&98
ONE STATE FARM DR
00498 38-6162-5 5
STOUFFER, JOANNE R
355 BURGNERS RD -
CARLISLE PA 17013 8921
CONCORDVILLE PA 19339
POUCYNUMBER 728 6572-E11-$BB
POLICYPERIODNOV 11 19980#AY 11
h,dlhllllh,l.dhdhh,hhh,,d,h.lhhhdd,h,hl
DESCRIBED YEAR MAKE MODEL ~ODY STYLE
VEHICLE
I 1991 DODGE DAYTONA 2DR
1999
2
DO NOT PAY PREMIUMS SHOWN ON THIS PAGE.
SEPARATE STATEMENT ENCLOSED IF AMOUNT DUE.
VEHICLE IDENTIFICATION NUMBER CLASS
1B3XG4435MG114242 1D00101
C2
P
GSO0
H
U
F
Z2
SEE REVERSE SIDE FOR IMPORTANT MESSAGE
LIMITS
LIMITS OF LIABILITY-COVERAGE A-PROPERTY
EACH ACCIDENT
50,000
$19.11 MEDICAL PAYMENTS
LIMIT OF LIABILITY-COVERAGE C2
EACH PERSON
· 10.000
$~2.7~ COMPREHENSIVE
$76.0~ $500 DEDUCTIBLE COLLISION
$1.69 EMERGENCY ROAD SERVICE
$6.27 UNINSURED MOTOR VEHICLE
LIMITS OF LIABILITY-COVERAGE U
EACH PERSON,
50,000
$20.16 UNDERINSURED MOTOR VEHICLE
LIMITS OF LIABILITY-COVERAGE g
EACH PERSON,
50,000
$.61 FUNERAL BENEFITS
LIMIT OF LIABILITY-COVERAGE F
EACH PERSON
2,500
S5.29 LOSS OF INCOME
DAMAGE LIABILITY
OF LIABILITY-COVERAGE A-BODILY INJURY
EACH PERSON. EACH ACCIDENT
50.000 100.000
DAMAGE
EACH ACCIDENT
100.000
EACH ACCIDENT
100.000
S268.82 TOTAL PREMIUM FOR POLICY PERIOD NOV 11 1998 TO MAY 11 1999
$268.82 TOTAL CURRENT 6 MONTH PREMIUM FOR NOV 11 1998 TO NAY 11 1999
EXCEPTIONS AND ENDORSEMENTS
6038F AMENDMENT OF DEFINED gORDS, gHEN & gHERE COVERAGE
LIABILITY, UNINSURED & UNDERINSURED NOTOR VEHICLE
DAMAGE COVERAGES & CONDITIONS.
THIS POLICY PROVIDES LIMITED TORT OPTION.
APPLIES,
& PHYSICAL
COUNTERSIGNED
THIS iS YOUR DECLARATIONS PAGE.
PLEASE ATrACH IT TO YOUR AUTO POLICY 800KLET. B Y
YOUR POLICY CONSISTS OF THIS PAGE, ANY ENDORSEMENTS. AND THE POLICY BOOKLET, FORM 9858 · 6
REPLACED POLICY 728657Z-~B
MIJTI_ VOt
O 162-382
PLEASE KEEP TOGETHER
Exhibit F
LEADER
The ~ader In S~rviee and Value
March 30, 1999
Usa ,1. Hauer, Esquire
The Commons at Valley Forle
Suite 22
PO Box 987
Valley For~, PA 19482
OUR INSURED: Miriam Leon
DATE OF LOSS: 2/11/99
CLAIM NUMBER: 5005486
YOUR CLIENT: Troy Scaler
Dear Ms. Mauer,
This will confirm my offer of $1S,O00 to seuJe your client's claim. This offer is for full and final
settlement your client's bodily inlury claim arising out of this loss. Please be advised that in order to
settle this claim we will require a release signed by both parents as well as court approval of the
se~Jement.
I look forward to discussing this matter with you again soon, so we may amicably se~e this matter
wi~ your client. Please feel free to contact me if you have any questions.
Sincerely Yours,
Clahns Advisor
3607 Roaemont Avenue, I~uite 202 · Camp H/II, PA 17011
1800) 254-6855 · i717) 975-3660 · fax (717) 9756663
Transport Insurance Company * TICO Insurance Company * Leader Managing General Agency
Leader Insurance Company · Leader Specialty Insurance Company · Leader Preferred Insurance Company
Exhibit G
Rgcaived 0ct-11-99 13:25 froe 774 2113 ~ 16189g39570 [0/[1/~ MON 13:~A FAX ??A ~115 sTATE FARM CLAIM
State Farm Insurance Companies
Lisa J. t'4auer
O~a,~.am & Mauer,
page I
Po ~x 2~7
Cl&imNu~er:
Date o~ Loee=
35-~[8[-400
Ca~ae~ne ~, S~owne. well
Troy Sharer
As we discussed =oday, S=ate Farm ia willin~ tc offer your clien=
our ~neured'. policy limita of $50,000 to settle his lnJur~_
claim. We wall need court approval o~ this eeC:lament. I: you
have any quea~ione ~leaae feel free to con, act me.
S=a=e Farm Mutual Automobile Insurance Co, any
NOMi OI~IC~!~I; BLOOMINOTON. ILUNOI~ 811710,0001
Exhibit H
froa 774 2113 ~ 16109830570
Received Nov-29-99 15:26
~72~t9~ ~0~ 1~:~8 FA,~ 774 2113 STA'i~ F,~ CLAZ~
Farm Insuran¢o ¢ompani
page 2
~oo2
~ove;~)er 29, 3,999
St, et~ I~rm lM(a'inOe
11S limekiln ROi#
PO Box ,357
New Cumbeltand PA 170700267
Lisa M&uer
OrAham & Mauer, P.C.
Sui=e 22, P 0 Box 987
V&lley For~e, PA 19482
Your Clten=:
Our Insured~
Our Claim No.:
DAte of Loss~
Troy Sharer
Joanna R. S=ouffer
36-J176-022 ***Sent via fax & regular mail*
FebruAry 11~ 1999
DeAr A=Dorney Mauer;
offer~ your cllAnt, Troy Sharer, the $50,000 ~n~nsure~
Coverage policy limi=s avAilAble on Joanna S=ouf~er°s policy.
You advised ~ou would do =he necessary =o secure =he Cour=
Appr~v&l. Upon recelp~ of =he Cour= Order, wa will forward our
pAymen=. If you have any ques=tons, ~leass give us A call.
Claim specialist
(717) 774-9070
FArm Mu=uA1 Automobile InsurAnce Co,any
HOME OFIRCE6: SLOOMIN{3TON, ILLINOIS ~1710.0001
GRAHAM & MAUER, P.C.
By: LISA J. MAUER, ESQUIRE
Attorney I.D. 65426
The Commons at Valley Forge
Suite 22, P.O. Box 987
Valley Forge, Pennsylvania 19482
610/933-3333
TROY SHAFER, a minor, by
TODD SHAFER and JOANNE LESCALLEET
parents and natural guardians
Plaintiff
CATHERINE R. BROWNAWELL
Defendant
and
MIR/AM LEON
and
Defendant
STATE FARM
UIM Carrier
MAR e 1 2000~
Attorney for Plaintiff
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
In Re: TROY SHAFER, a minor
ORDER
AND NOW, this ~9-~~ day of ~
,2000, it is hereby ORDERED
and DECREED that a hearing on Plaintiff's Petition for Leave to Compromise Minor's Action
will be held on the _~_ day of ,i~,~,/~,, '] , 2000, at ~/:0a ~.m. in Courtroom ,~ of
the Cumberland County Cou~ouse, Ca~lisle, re~msylv~a. C~,,l ~ ~~
GRAHAM & MAUER, P.C.
By: LISA J. MAUER, ESQUIRE
Attorney I.D. 65426
The Commons at Valley Forge
Suite 22, P.O. Box 987
Valley Forge, Pennsylvania 19482
610/933-3333
TROY SHAFER, a minor, by
TODD SHAFER and JOANNE LESCALLEET
parents and natural guardians
Plaintiff
CATHERINE R. BROWNAWELL
Defendant
and
MIRIAM LEON
and
Defendant
STATE FARM
Attorney for Plaintiff
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
No.: cc-a- /C7C
In Re: TROY SHAFER, a minor
ORDER
AND NOW, this day of ,2000, upon consideration of the
foregoing Petition, it is hereby ORDERED that the settlement of this action for the lump sum
amount of One Hundred Fifteen Thousand Dollars ($115,000.00) is hereby approved, counsel
fees and expenses are allowed, and distribution is dictated as follows:
TO: TROY SHAFER, a minor, $115,000.00
· 15,000.00 paid by Leader Insurance
Company, insurer of Miriam Leon
TROY SHAFER, a minor, by :
TODD SHAFER and JOAi~NE :
LESCALLEET, parents and :
natural guardians, :
Plaintiff
V. :
CATHERINE R. BROWNAWELL, :
Defendant :
and :
MIRIAM LEON, :
Defendant :
and :
STATE FARM, :
UIM Carrier :
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
No, 00-1676 CIVIL TERM
IN RE: MINOR'S COMPROMISE SETTLEMENT
ORDER OF COURT
AND NOW, this 5th day of April, 2000, upon
consideration of the foregoing Petition, it is ordered and
directed that the settlement of this action for the lump
sum amount of $115,000.00 is hereby approved. Counsel fees
and expenses as submitted are allowed,
dictated as follows:
To Graham & Mauer, P.C., counsel fees
To Graham & Mauer, P.C., costs
To Joanne Lescatleet, parent of Troy
Shafer, for out of pocket expenses
To Medical Assistance
To Troy Shafer
TOTAL
and distribution is
$38,295.00
$ 1,557.06
$ 1,320.36
$ 5,533.30
$68,294.28
$115,000.00
The amount of money paid to Troy Shafer shall be
deposited in a restricted account(s) or certificate(s) of
deposit in a bank, credit union, or similar institution
which is insured by a Federal government agency. Any such
account(s) or certificate(s) of deposit shall be restricted
so that no amounts may be withdrawn therefrom without
further order of court until June 6th, 2008. Petitioners
are directed to file with the Prothonotary proof of the
opening of said restricted account(s) or certificate(s) of
deposit within ten days of the receipt of the check.
Petitioners are authorized to sign any releases
deemed appropriate by their counsel to settle this action.
Lisa J. Mauer, Esquire
For the Petitioner
:lfh
By th~
Edward E. Guido,
GRAHAM & MAUER, P.C.
By: LISA J. MAUER, ESQUIRE
Attorney I.D. 65426
The Commons at Valley Forge
Suite 22, P.O. Box 987
Valley Forge, Pennsylvania 19482
610/933-3333
~ROY SHAFER, a minor, by
TODD SHAFER and JOANNE LESCALLEET
parents and natural guardians
Plaintiff
CATHERINE R, BROWNAWELL
Defendant
and
MIRIAM LEON
and
De~ndant
STATE FARM
UIM Carrier
Attorney for Plaintiff
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
No.: 00-1676
In Re: TROY SHAFER, a minor
PRAECIPE TO SETTLE. DISCONTINUE AND END
TO THE PROTHONOTARY:
Please mark this matter SETTLED, DISCONTINUED and ENDED.
L~,. ~ii~R,~squire
Attorney IIYNo.: 65426
Date: May 10, 2000
~J:lglO$@~OS70
NO. 030507
Z a§ed
Received May-15-00 12:27 from 7172439649 ~ 16109830570
MAY-~5 00 11:~? ~ROM:PA~TATE~ANK~ARLI~LE 717~439~49 T~:1~109830570
3/15/00 M~esaqe Nain~enanoe
TROY SHA~ER CI~ numDer ......
Type options, preSS Enter. Account number..
D-Delete C-Collateral 1-9-Severity Level
Collateral
Severity
Level
DEPOSIT SMALL SE RESTRICTED SO THAT NO AMOUNTS OF
MONEI MAY BE WITHDBAWN TMERE~RO~ WITHOUT FURTHER
ORDER OF THE COURT UNTIL JUNE 6, 2008
ORDER OF THE COORT ON FILE AT CARLISLE
page 2
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IN THE COURT OF COMMON PLEAS
OF CUMBERlAND COUNTY, PENNSYLVANIA
CIVIL ACTION -lAW
ROSEMARY LYONS, INDIVIDUALLY AND
As EXECUTRIX OFTHE ESTATE OF RALPH
LYONS,jR., DECEASED,
DOCKET NO. 00-1677 CIVIL TERM
Plaintiff
vs.
LORRAINE YURCIC and
HOLY SPIRIT HOSPITAL,
Defendants
JURY TRIAL DEMANDED
ORDER
AND NOW, this
-:1'
day of
7J~t../
,2004,
the Case Management Order is entered to reflect the following:
1. AU discovery in this case shall be concluded no later than November 1, 2004.
2. The Plaintiffs expert report shall be forthcoming on or before December 1,
2004.
3. The Defendants' expert reports shall be forthcoming on or before January
31,2005.
4. Any rebuttal expert reports shall be forthcoming on or before February 15,
2005.
5. Any and all dispositive motions shall be filed on or before February 15,
2005.
By THE COURT . /
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R.j. MARZELlA & ASSOCIATES, P.c.
BY: CHARLEsW. MARsAR,jR., ESQUIRE
PENNSYLVANIA SUPREME COURT 1.0. No. 86072
3513 NORTH FRONT STREET
HARRISBURG, PA 17110-1438
TELEPHONE: (717) 234-7828
FACSIMILE: (717) 234-6883
ArrORNEYS FOR PlAINTIFF, ROSEMARY
LYONS, INDMDUAllY AND As EXEClITRlX
OF THE ESTATE OF RALPH LYONS. IR.
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
ROSEMARY LYONS, individually and
As Executrix of the Estate of RALPH
LYONS,JR., Deceased,
DOCKET NO. 00-1677 Civil Term
Plaintiff
vs.
LORRAINE YURCIC and
HOLY SPIRIT HOSPITAL,
Defendants
JURY TRIAL DEMANDED
STIPULATION TO EXTEND DEADLIINES
It is hereby stipulated and agreed between the above-captioned parties that
deadlines set forth in the Case Management Order dated June 4, 2004 are changed as
follows:
1. All discovery in this case shall be concluded no later than November 1,
2004.
2. The plaintiffs expert report shall be forthcoming on or before December
1 , 2004.
3. The defendants' expert reports shall be forthcoming on or before January
31,2005.
4. Any rebuttal expert reports shall be forthcoming on or before February
15,2005.
5. Any and all dispositive motions shall be filed on or before February 15,
2005.
RESPECTFULLY SUBMllTED,
MARSHALIL, DENNEHEY, WARNER,
COLEMAN & GOGGIN
(1~ " ;,7
By: ~
MICHAEL D. PIPA, ESQ
AlTORN~(IDNo. 53624
R. J. MARZELlA & AsSOCIATES, P.c.
2
CERTIFICATE OF SERVICE
I, Meredith A. Marzella, hereby certify that a true and correct copy of the
foregoing document was served upon all counsel of record this ~ 0t day of
(ll OJ- rY\ h Q)\,
, 2004, by depositing said copy in the United States Mail at
Harrisburg, Pennsylvania, postage prepaid, First-Class delivery, and addressed as follows:
MICHAEL D. PtPA, ESQUIRE
MARsHALL, DENNEHEY, WARNER, COLEMAN & GOGGIN
4200 CRUMS MIll. ROAD, SUITE B
HARRISBURG, PA 17112
COUNSEL FOR DEFENDANTS, LORRAINE YURClC & HOLY SPIRIT HOSPITAL
R.j. MARzELIAE~AsSOCIATES, P.c.
By:l 11 0 A ~ r1 L
- ~ -
MEREDITH A. MARZELlA, LEGAL ASSI
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R. J. MARZELLA & ASSOCIATES, P.C.
BY: Charles W. Marsar, Jr., Esquire
Pennsylvania Supreme Court I.D. No. 86072
3513 North Front Street
Harrisburg, PA 17110-1438
Telephone: (71 7) 234-7828
Facsimile: (71 7) 234-6883
Attorneys for Plaintiff, Rosemary
Lyons, individually and As Executrix
.!lHite .Rslateco!RalllhLYOns,Jr.
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
ROSEMARY LYONS, individually and
As Executrix ofthe Estate of RALPH
LYONS, JR., Deceased,
DOCKET NO. 00-1677 Civil Term
Plaintiff
vs.
LORRAINE YURCIC and
HOLY SPIRIT HOSPlT AL,
Defendants
JURY TRIAL DEMANDED
PRAECIPE TO SETTLE AND DISCONTINUE
To the Prothonotary of Cumberland County:
In accordance with P.R.C.P. 229, kindly mark this action, docket number 00-1677,
settled and discontinued as to all Defendants.
Dated:
)17 {z& 105'
.
.
CERTIFICATE OF SERVICE
1, Adam G. Reedy, hereby certifY that a true and correct copy of the foregoing
document was served upon all counsel of record this 27th day of October, 2005, by
depositing said copy in the United States Mail at Harrisburg, Pennsylvania, postage
prepaid, First-Class delivery, and addressed as follows:
Michael D. Pipa, Esquire
Marshall, Dennehey, Warner, Coleman & Goggin
4200 Crums Mill Road, Suite B
Harrisburg, P A 17112
R. J. Marzella & Associates, P.C.
BY~ c~
. Adam G. Reedy
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