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Oler, Jr., J. Wesley, Jud~e
From: OORERD@Nationwide.com
Sent: Tuesday, October 14, 2003 2:59 PM
To: woler@ccpa.net
Cc: tdixon@ccpa.net; ejbjr@adelphia.net; blpw@att.net
Subject: Sorrentino v Jameson
Dear Judge Oler:
This matter is listed for pretrial conference tomorrow in your Chambers at 9:30 am; I am writing with the consent
of Mr Balzarini on behalf of the Plaintiffs. Ms Alford is representing Mr Sorrentino in his capacity as an Additional
Defendant with respect to the claims of Plaintiff, Mary Sorrentino and it would appear her attendance tomorrow
would be unneccessary in view of the developmenls noted herein.
The claim of Plaintiff, Mary Sorrentino has been settled for the Plaintiffs policy Iimils demand of $50,000.00 today,
pending underinsured motorist carrier consent.
As to the claim of Plaintiff, Ralph Sorrentino, the Defendant extended a revised settlement offer of $30,000.00
eariier today and counsel for the Plaintiffs is presently attempting to contact his clienls to review this new offer.
Counsel did not seem optimistic he would be able to reach his clienls before he had to commence his travel to
Cariisle this l!ftenioon, but expressed interest in further discussions with me before the pretrial conference
tomorrow morning.
The further attentioh of the Court to this matter is most appreciated. Thank you, Don
10/14/2003
<U ' "M ~',_.
,
OCT 0 9 2003
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Brigid Q. Alford, Esquire
Supreme Court J.D. #38590
G. Edward Schweikert IV, Esquire
Supreme Court J.D. #81976
BOSWELL, TINTNER, PICCOLA & ALFORD
315 North Front Street
Post Office Box 741
Harrisburg, Pennsylvania 17108-0741
Attorneys for Additional Defendant Ralph J. Sorrentino
MARY A. SORRENTINO, and
RALPH Jr. SORRENTINO, her
husband,
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYL VANIA
PLAINTIFF
v.
: NO. 2000-CIVIL-03313
KELLY ANN JAMESON,
DEFENDANT
: CIVIL ACTION - LAW
v.
RALPH Jr. SORRENTINO,
ADDITIONAL DEFENDANT
: JURY TRIAL DEMANDED
ADDITIONAL DEFENDANT RALPH SORRENTINO'S
PRETRIAL MEMORANDUM
Pursuant to Local Rule 212-4, Additional Defendant Ralph Sorrentino respectfully submits
the following Pretrial Memorandum.
1. STATEMENT OF BASIC FACTS AS TO LIABILITY.
Additional Defendant Sorrentino incorporates herein by reference the Facts set forth in
Plaintiffs' Pretrial Memorandum.
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2. STATEMENT OF BASIC FACTS AS TO DAMAGES.
Additional Defendant Sorrentino incorporates herein by reference the Facts set forth in
Plaintiffs' Pretrial Memorandum.
3. STATEMENT OF PRINCIPAL ISSUES OF LIABILITY AND DAMAGES.
A. Is Additional Defendant Sorrentino liable, in whole or in part, for the iJ1iuries
and damages sustained by Plaintiffs?
B. What is the amount or proportion of damages, if any, for which Additional
Defendant Sorrentino is liable?
4. SUMMARY OF LEGAL ISSUES.
None anticipated at this time.
5. IDENTITY OF WITNESSES TO BE CALLED.
Ralph Sorrentino; Mary Sorrentino
6. LIST OF EXHIBITS;
None anticipated.
7. CURRENT STATUS OF SETTLEMENT NEGOTIATIONS.
See Plaintiffs' Pretrial Memorandum.
8. ANTICIPATED SCHEDULING CONCERNS.
Defendant Jameson has noticed the Videotape Deposition for Use at Trial of David Baker,
M.D., her IME physician, for the afternoon of Monday, November 3, 2004, thereby making the start
oftrial on that date logistically impossible.
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Additionally, the undersigned counsel is presently scheduled to select a jury and participate
in an anticipated 2-day trial on November 3 and 4, 2003 in the United States District Court for the
Middle District ofPeunsylvania. Pressley v. Finch, No.1 :CV 02-0588. As a result, she respectfully
requests that jury selection and the trial of this case commence no earlier than Wednesday morning,
November 5, 2003.
Respectfully submitted,
Brigid Q. lford, Esquire
Supreme Court J.D. #3859
G. Edward Schweikert IV, Esquire
Supreme Court J.D. #81976
BOSWELL, TlNTNER,PICCOLA&ALFORD
315 North Front Street
Post Office Box 741
Harrisburg, Pennsylvania 17108-0741
Attorneys for Additional Defendant
Ralph J. Sorrentino
By:
Date: I()!~IOJ
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CERTIFICATE OF SERVICE
I do hereby certify that I have served a true and correct copy of the foregoing Additional
Defendant Ralph Sorrentino's Pretrial Memorandum by placing the same in the United States Mail,
first-class, postage prepaid, at Harrisburg, Pennsylvania, addressed as follows:
Edward J. Balzarini, Jr., Esquire
Balzarini & Watson
3303 Grant Building
Pittsburgh, PA 15219
Attorneys for Plaintiffs
Donald R. Dorer, Esquire
Jacobs & Saba
214 Senate Avenue, Suite 503
Camp Hill, PA 17011
Attorneys for Defendant Jameson
By:
Date: 1017/D3
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00HB-001J52
.
LAW OFFICES OF JACOBS & ASSOCIATES
214 SENATE AVENUE, SUITE 503
CAMP HILL, P A 17011
TELEPHONE NUMBER: (717) 731-0988
A TTOR.NEY FOR DEFENDANT
.
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYL V ANlA
Mary A. Sorrentino and Ralph J. Sorrentino, Her Case No.: 2000-03313 Civil Term
Husband,
Plaintiffs
vs.
JURY TRIAL DEMANDED
Kellyann Jameson,
Defendant
vs.
Ralph J. Sorrentino, Additional Defendant
PRE-TRIAL CONFERENCE MEMORANDUM OF DEFENDANT, KELLY ANN JAMESON
I. LIABILITY ISSUE SUMMARY:
This lawsuit arises out of a multi-vehicle accident occurring on Apri119, 1998 on
Interstate 79 near Star City, West Virginia. The Defendant, Kellyann Jameson, then operating
a 1995 Subaru Legacy, was traveling in the left lane of Interstate 79 in a northbound direction
when she slowed to turn left into an "emergency vehicles only" turnaround lane after realizing
that she had missed her exit on her way to her place of employment. At the same time, the
Plaintiff, Ralph Sorrentino was operating a 1991 Nissan Sentra behind the Defendant's vehicle,
and was unable to avoid striking the rear of the vehicle operated by Defendant, whereupon the
Sorrentino vehicle came into contact with yet a third vehicle in the right lane. Plaintiff, Mary
A. Sorrentino was a passenger in the vehicle operated by her husband. At the time of the
accident, the Defendant was a resident of Mechanicsburg, Pennsylvania, attending school in
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West Virginia. The Plaintiffs were, and are, residents of Blasdell, New York (near Buffalo,
New York), but typically reside in Florida during the winter months.
A true and correct copy of the West Virginia Uniform Traffic Crash Report form for
the subject motor vehicle incident of April 19, 1998 is attached hereto as Exhibit" A" for the
reference purposes of the Court during the Pre-Trial Conference.
II. DAMAGES ISSUE SUMMARY:
The position of the Defendant with respect to the medical injuries claimed by Plaintiffs
is essentially as set forth in an independent,medipal examination report of David C. Baker,
M.D. dated May 6, 2003 (less enclosed medical literature) pertaining to Plaintiff, Ralph
Sorrentino and an independent medical examination report from David C. Baker, M.D. dated
July 7, 2003 pertaining to Plaintiff, Mary A. Sorrentino. For the further reference purposes of
the Court during the Pre-Trial Conference, these reports are attached hereto, respectively, as
Exhibits "B" and "C".
III. PRINCIPLE LIABILITYIDAMAGES ISSUES:
Please see Sections I and 11 hereinabove.
IV. PRE-TRIAL LEGAL/EVIDENTIARY ISSUES:
The legal recoverability of medical bills incurred by the Plaintiffs who are non-resident
of the Commonwealth of Pennsylvania may require pre-trial resolution by the Court if a
stipulation of counsel is not reached with respect to such issue in advance of trial.
nil;
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Y.....WITNESSES:
1. Plaintiff, Mary A. Sorrentino (as on cross-examination)
2. Plaintiff, Ralph J. Sorrentino (as on cross-examination)
3. Defendant, Kellyann Jameson
4. Officer Vie Propst, Monongalia County Sheriffs Department
5. David C. Baker, M.D. (by videodepositions)
The Defendant reserves the right to list and/or can such other and further witnesses as
may be listed by all other parties hereto, including any treating healthcare providers of
Plaintiffs, upon reasonable notice to counsel.
VI. EXHIBITS:
1. Records of Quaker Medical Associates
2. Records of Lawrence H. Fink, M.D.
3. Suncoast MRl Center
4. Fitness Sports & Physical Therapy, P.C.
5. Mercy Hospital
6. Andrew C. Matteliano, M.D.
7. Buffalo Neurosurgery Group
8. Buffalo Spine & Sports Medicine, P.C.
9. Northtowns Orthopaedic, P.C.
10. Dr. James J. Dragonette
11. Western New York Orthopaedic and Spine Therapy
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12. Bram Riegel, M.D.
13. Brian C. James, M.D.
The Defendant reserves the right to list and/or present such other further exhibits as
may be listed by counsel for the other parties hereto, or to otherwise supplement this listing
upon reasonable notice to counsel for the parties.
VII. SETTLEMENT NEGOTIATION STATUS:
The Plaintiffs have demanded the tendering of applicable insurance policy limits of
$50,000.00 with respect to the claims of both Plaintiffs. The Defendant has previously
extended an offer of $10,000.00 to Plaintiff, Ralph J. Sorrentino and $15,000.00 to Plaintiff,
Mary A. Sorrentino. It is believed that Ralph J. Sorrentino, in his capacity as an Additional
Defendant herein, has denied liability for the occurrence of the subject motor vehicle accident
and has not extended any settlement offers as to damages and injuries claimed by Plaintiff,
Mary A. Sorrentino.
By:
D aid R. Dorer, Esquire
Identification No. 39126
Attorney for Defendant, Kellyann Jameson
Date: October 10. 2003
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3 Si..,gle 1.I1i1 U'uCIt (2 1lX1Ml5 or mc.-e tire. C P
.cOS~.,g!eU'1itllu:k(30ttnCf.U:..) T
5 OTn.:ckWlI.'1tre;lar O~ne X-
6 OTn..-ck etaclor onl!l' (Bobtail) eOl RaSt'il.ICTlc:flS:
'~Trac:.o(Wi:h5Gmi.ltlll~1Il" ~ 8
e Ttac:.or wi\l'l dO>.Jblllllrai!fJtl ~ ~OM
9 Trac::or w~.h ltl~ ttiUGt' M
1 Olhet . Un~l. ~o cbs.sity
CARGO 800..- TYPE HAZARDOuS MATERIAL
1 ~ 8u~ PlACARD. 8 'rei SPILl. 8 '"
2 Varlon:;!\)slM.1l:oJl; tj'ZS' N.
3 Car;:lt<!l'.k
4 F'lalt.lIoj NamGlcro4 D~il
r. .. ,:"" g:~.~!ty, 9 N.m"'"''''
-/'h t.. \1 tiUMtOTt~~rpott t D13.T.cadC(B(lX.~/
V" '~GaIC~oetRGrUI. 10Ig~N" (
1. "~~' (L.r.it Balow) ftem aCl~;:.~e __
T~'lIlf\\'I I' --,,'-' ,
j'";.r 1~::Z~:&.it- sle..-,hCr 2<I;;;;;~~~a
7L/ ' , ;~lfil,*,
LIGHT
'~D.'I!;Iht
2 Dark
3 Dark.ArtJ.
rlClall.lghll
'8 Dusk
5 OS'Nn
SCREENING INFOlWA nON:
VEHICLE ~~~) I ; CARRIER INFORMATION SOURCE;
Don 10Stlipp;,gPapet. 20VthlclGlSido
1 2" " li 6 30 Log&ok 40Dnver 1500:h6r
CARRieR NAME
NUMBER OF OUALIFYlNG VEHICLES
I~NOLVED.
T~wiIh60rm"Or8tlre"
or a Haz MatPlac:atd
ADORES$
BUSGl.dllll";n&eltocauy
160rmOl'epe!!IlXl"
CllY
usaOT
I STATE I
ICCMC
ZIP
NUMBER OF: -=-
PenonIS\.:s:a!."tIngi
tal8linll.rie.
Plll'lonl IT:INpotUld 101
IMMEOlATE mec:lle.al
ttealmOflI
STATE .II
GW'"
NUMBeR OF AXLES PER UNIT
......
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I':
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COUNTY
CRASH 'gState PQIiCe 3l2)Sftarilt
HRS. REPORTeD BY' 2 Qy~'" 4COttll~r
, OR TOWN
.,
PAGE OF
...J 'Flt~bty
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IF NOT A.T
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IFLOCAilON CAN ,BE DE RI
SPECIAL RERi:RENCE
OR (j1~PS COOR'CjNA.TES
OffivE S FULL., E
...? R--
,
No
SOSAI_ re: 0IVl"N
I.) Yel 0 RefUSed Test
~o NolOfter6d
DRIVER Gotn? ~i; 1....lu:.d
ACTION, rtlm!ng Right
3 Tumt bft e
OWNER'S FUlt NAMe G SA."E AS DRIVER
8 BREATH , 8 URINE
PBr OTKER
P"ldng 10 M..glng
P;lr1Clld 1 f S'.cY9ing or bppil'lg
12 S~:)~ od 1ft Tl'lIfl"te Lane
(i,tlS,wE AS DRIVER CITY
Nrr
"
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Entaringort..1I&1I1nllOriv....-ay
Pvlfinll Out from P~l'I;'~lee
0'JM!f SEE N,l.RRA-TI
srATE
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OF .
99'999
NI1
OAMAGEOAREA l PT_ Of
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@UNDERCARRIAGE :
@NONElNON. 10
APPARENT 11
(9 OTHEFtlUNKNQIN:\: l2 ~
@ AlL "'R~S 13
14
STATE ZIP
OIRECTIONTRAVEL: N~O~ R01JfE t~ TOT^~oCcuP,'NTS
~ltumlng,enterdl~lIdlCl"'S ........::--.ON(OI'Str..., :ZOASOVE OFTHISV=-,..:oClE.
BeFORE l\trn. '-"~ e..'I -
T eo DUE 0 OA AGE TON 0 y,
Ov,.. ~N' ,vII
IUSURANCE COMPANY
IV'r (}"
AUT. OtlA911JTY ",YOS
INSURANCE. 0 Uo
CONTRl'3UTINO
CIRCUMSTANCES;
I~CneorMo.~l
.4 0 OT.u111lng Lines Improperly
S 8 Following Too ClcAl~
6 Oisre-gardedTtaltie:Contlcf._
1 gOkl'NCI1HWeRightafWar
5 Failure tu MlintainContrQl
a Crillir.g Ullder Minimum Speed
10 No Signal orlmprapillr Sillr'lir
" 8 Turning Imprcp. erl)' 18 ~ Criller Undor Influence
12, Passlnglmproperty 19 Pededri.nUnclerlntlqence
138pa{king~rlr ~ S~PanrMttt
141 BaddnglmpreJlorlV . '21 O\hel~yOo~Cl:t:l
tS~A.vciIdII\IIAnimllllr~ 22 ph!lYlo".Ao:ident
15 OIstr.lc;\janlnlideVehicle 23 l.eftofCoilnlet.
17 Wall<ingVlclation - 24 O".."tet(SEENARRATI\'.E)
ADDRess CITY
D
R
I
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t'" No Impro~rOrilling
2 (") ElooIedlng Speed l.imit
3 () Exceeding Sa!e Speed
o
DRlV~ LICENSE MBER.
COL STATe:
Jr. Opeliltcl"a
Le::alT.el'sPerm,
1
2
3
OWA
ION CHARGE
EiY TEST G, EN
8R!fu~dTe5t
~Lot.,OIfl!lrcd
I )G~ngSlrll:;ghtA."read
2 Turnln'ilR!g~
3. TurniJ '..eft e
OItINER'S FULL NAME O>>ME"'S DRIVER
D
I..'dYes.
U~lo
En:ering or L~avi~ Cl'lveway
PulilngOlitfult':l!:larlQngSp3c:.
OIhflr EE NAAR,.tl,Tl"
STAiE ZIP
DRIVER
ACTION:
1<
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1 g
2 m
3
4
S
,
7
.
6}~~RIACE "
~ NONE/NOtr.---.. 10
APP.ARENT l'
(BtOTHERlUNKNO'NN 128
@ MoL AA=AS 13
140
OIREC:TIONTR"':'EL. N6.0E ROUTE
pllu:mng. e';'I~~r direction sOOwON (Or $(rell
eEFORE rn
iCNIEO CUE TO A
OVl!$" Otlo
c: , OF ~ G
?99?99
TO'/IED TO.
o
POLICY NO
A
AUTO LIABILIT'l' 8 v"
INsuRANCE. No
CONiRI'3UTING
CIRCUMSTANCES:
:Checkonfl Of M
4~Ch.anging:L;,IneiII'l'tpfOpOIIy
5- FollcMm9 Too C"'-ly
e Dlllt!glrddTraffieContrcL
1 _ DldrlolHalleRIghtofW..y
, ~ Failure 10 Mlltntaln Cant/cL
S Driving Under Minimum S;leed
fO "'oSignIIO/ltn~perSflli1a1
"~nlr:ojng Improperly
11 Passing IMProPerly
13 P2lnillg!mpo:I.Ilcrly
14 B;l.ckfngl~f'Q.Ilol'lY
15 Avcidlng Mimalor Vehldo
Hl OimclloltlnsldeVetlicte
11 w.roeing'V"lQlafI,on
'gHot per Dti...in; .",
1 E..ceedlngSpeedUmit
3 Ellceedlnll Safe $'p'eecf ~
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DAMAGEC PROPE8.TY OTHER THA~ vtHICLE.S (DeSC~ AS COMP!.er~y AS POSSIBLE)
"......
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em
I U ,Olt PAVEMEN.T OR f1::ET
I 86650FPA~OGE
STA" ZIP
~iR'SAA\te. u Olt1er{PIGQsaUtt}
n DOH
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SEATINGi
OCCUPANT?ROTECTION
INJURY ClASSIFlCAnON
FIRST AJO BY
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lo.st.epllrSed[On
8 . flCVC~" 11 . OIMf'Enclo.ufj:! Pu~ttn;o'lr Am'"
Cargo /totOJa . 1 . Non. lnslild"d
p. P.4u1r18n 12. Other Unen~~d P~m;er Am 2- None Uwd
E.EflglnucIRR/Trl,n) Car-QaAr...~ 3.LlpB..ilOn~.,.U5ecl
M. Molotcydl, SnQW- 13 _ Flid~g In/On Trailing Unit 4 - SI'ICulc!llt Boll anI)'
ll'lQbne.etc.. 14~Ridi:1g,OnV~hic:lei 5.LaPlnclShouldo,Behlhlfld
t . DrIYGf' Ek\8rior _ 5. ChAd Sakll:.' Seat
4 . p;1Ssenger One ~S. Unknown _ 7 - Helmet, ClaslsslShield
7 - PilSSl!IInger two 16. OUle: rSEE RAARATNEI ". Unknown
A1RBAG DEPl.OYEl e.lf:crEO TRAPPED/EXTRICATED
1 ".: 'I", 2 ~ No 1 . No 3. Partially 1 . NO! Trap;:led 3. TrapPedIMol ElI';ncaled
J:. Not 4qui;!"<L 2. VllIt .4 . Un<.ncwn 2. TrappQdIE:.:tr:CllIQd 4. UtIknown
. VEHICLEFIRE UCCURRENCE HAZARDOUS CARGO
'Ien. .: Veh. II: -= Veh. It: Veh.':
O()NCoF'II1IIOccUI'nnca 08f'lCoFcreOCCU'l'6r0l oQNo 08'"
I (~ Flte Oeeurre4 I ~irll 0c:Is1cr.:l I ayes t Yel ORIVER
_ _ - 20Un~own 20Unkl'lClwn---io
MeCllCAlLYTAANS?ORl'EO
~
~
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A. B~eodin\J Wour.a, Distort,::! Mcrnlll!lr. or Had 10 ile
Carried from Scene
e - Druiu.. AbrulllllS.. Swel~ng, limping. Etc.
C - No VilSibl. Iril.llY BIf. Com?lllir.l of P&It1 or
Momentary UnconsdQUs:l8l1.
O.Notkljurtld.
I.N""q
i.Pollct
3.Emd(;/I~y
.......
Techrllcillln
4-0OClotI Nuru
S-Reteu6SquBd
B.tlel~It'lICrew
1.P(ll'ar.'l~ie
1 . No 2. Y.u. 3. Refus&d A - Unknown e. Unknown
VEH SEAT oce. AIR- EJEC~ T'AAPI iN. FIRST MED
NO, lNG PROY BAG TED: EXTrll JURY A:D iRAN
, .E) L 1 J_ ~_ ~ 1-
T' .
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NAME 1
P I ~"I.~ ''''/'_.Il
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NV
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o INJURi::O TAKEN TO.
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IAI,/ ~c;-<v.!!s:jll'/
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1'1 Z2- L
edsuv.~rrNUMaER
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PEDESTAlAlIl ACTiON,
Clclhttlg OUght ODarle
I'WotE OF WITNESS
II~JURED TAKEN BY:
- I ~
'8 Cronin; 81lrrteluction. '38 'M1fkh;on PaffNnll1t\M:h Tlal'& 5Q S\&,dll".g on Payamsn! 181N:lrk.lng on PllV8tTIGnl
2 CrosSing Nolat Inlslliiii21,on" I/la1ki'IgGn PlI1Iamenlf'acinll T:affie aU PlByingen Pavement 8 Olhe: on PlIy,,",enl
. . ADDRE.SS CITY STATE ZIP
Ii NalonP.1~lilmDnt
PHONE NUMSER.
~;:; KUN rUHM NUMl R
/'
H
W
.
W
ROADWAY ROADWAY CHARS. ROAD TYPE TRAFFIC CONTROL. VlStON OBSCUREO BoY
SURFACE 1 ~ Slraighl and Lovl!tl 1 0 Step SI;n 88 None v.~.3
'~Oty ~ Sll3igtJIllIl'lCiGtadQ t~BlacktaP 20lafti S' t 9 0Ih --
2 Wel 3 Slraighl at H~h:tl!lsl 2 Concrete 3 ~ ~elclICSI;'~~ ec .., 0 8 N~ Obscure;:! 7 ~ 0 H,Uu~:
3 Snow 4 Curve and t.GvoI 3 Bride. 4 OfrlCM Fli!l;r.'lan 20 Rllm. S~, leo B ~ Palked VlIhlcle4&1
4 0 lco 5 CUNa and Graa .. Gr3'lel 5 RR Gates. Sicnnls. on VVlnclsnleld 9 Mavin; Vehide(s)
, 8 Mudd\, 6 OJ/V1I '" H~lctllsl. 5 Dirt 5 CGtIItNdion ZONl 3 ~ ~ Ttus. Bushes 10 911r.dlng Headilghls
e Haz. Mal 7 Skal;:hl afId I\olln; 6 OtI'.er. 7 SehocI b':e .. Sui\dlogl$) 11 Blindin;-Sun(rgM
7 Olher 8 SagCuve . 8 y~ 5 Embanlunent 12 Other
ES CLEARLY MARKED? "O'VES NO - FUNCnONING? No 6 SlglCoan::l 13 U:'Iknown
LUr&RtoHT'TURN VEH. SEQUENCEoFevetrrSIU$llI,C0d4,atR:;hl) N L I ~J..' 1~,~1'"
o ~ ~ illliJ' rn corn 01~QtCOnlc~ 11loN~.......l\I/Ilor....,...a 3:-LumluftfjghtJll;lpQ1l
'~ReatEnd ef o~ 3' Q2oCnlQcanla/tllMncd'ltll-17.pednVbIl >>.uur.VpM
2 HaodOn 11 - :::::;::::nl ~::~lI.kllru,.,o1l ~~=:g
3 SaI\14IDitltClion Olor LEFTf11JAN' o~r VEH. O$.R--enlarrMdwy 21loP"adlllOlorwlllel. 31S-C1IItI
SIClOlwipo "0' 0 ::'OV~' CD rnrn Q8oOlA1l'.ltIl 1I.f\1t,..:l/T'r.1n U.CUI
400pp. Olreo:tion ~ 11 12 074ewr'.io~,ordr_\s 2WoIIhlal ~I-Wankm~nl
Siduwl~ 0 r --c;j ::::=ID~ ~~~::~~ ~~~~~~~
T '8Raar.IC).Roal' ~ 0*. FhlEYlllll S.~ncIEvant TIIlrdEwlt '''''t:Ile.YlI~r lC-J1dCtolIl1t :zs.1l~Plnpal.1\d 'I.Tre.
y 6 SlngltVthi::ltCras:h 13 144- 15- MQSTHAA.MFUI.E'JENT n.oowabilll\ll'lHJl 1S.1t~ni1 '2,RFlc:t~~~$ip.1.>1
P. 700tMr RtCHTT\..RNS - VEH.I: [ill] VEH.': CD 12.e.p;tIQJS1s~1.'I 2NkllrdnJIIet U.B~'1r:lrIQ
O.ol).Q. - *' l$oll\d11dClu.&l"'llter"",'~, 2I.Gu.lIl",h~d 44-Tr&."Ii;III.a.1d
E 1'- 04 n 4- n,J,. 0 "",- ':::J. l4.Sblpptdlnlnft'ol:lIr.. 2LMldl&rl-batrler 4S.f1nhy.lulll
16 11 ;sot: 11 "t 20~ -L _ 1~C!llItnallccllllea ~:::~~~l ~~I";:,~a~:,~
SCREENING INFOfl,'U.TlON: VEHICLE NUMBER II CARRIeR lN~OftMAT10. N SOURCE: VEHlCl.E -CONFIGURAtiON COt. TYPE ENDeRS,
c 00000010Shrpp:.ngPapllr. ':<10 Vehide Std. l~Arrt4--tltltlo'Ohlcto OA ~H~:""
o NUMBEROF'QUAlIFYINGVeIiICL.E;S 1 2 3 -4 6_ 6 30 logBook "'OOl'i~.![ ~OOther 1 Bus 8'
M INVOl.VEO - - CARRIER NAr.tE. 3 Single ur'JI1N;k (2: lXlule CI' mQ('lt rtG' C
M -4 gSinl'lla unllll'\l:k (3 or ma'. L'lin)
Tt'l..lCkswi:hSot11l0rali'81 5 TflJClr.",olhlra~Qr 0 NXlIt
E cr. Haz Mal Plaea'd ADORESS. . 6 TNCk lrader only (Bobtail) COl ReSTRrCllONS
R 7 TtadarWllhseml.1:iilIJer 8 8
c Butos dosignod Ie ca:ry B OTloIclClr wat:1 coclm trailers
I 16ormorltpel"ons _ CITY TSTATET ZIP 98Trac:torwilhlt~llIltai"rs ~1 ~on.
A 1Q Oltlar-Unabla[ocl.utly
L. NUMBER or. ._.. USOOT - ICCMC _ CARGOIlODYlYPE HAZAROOUSMATERIAL
C PortClr.sSlJstalni."Tg ~ ~B~enclO$llc!b~ PLACARD: 8 ~:,t ~ SPill. -8~'
f.1hli,fnj'Jriel STA~' _..~
A ,I" - ..,."un. 3 Calia lank
R P\'!rsOnl ttan.ponocl fer "'..... j:la!bllld NamG Of 4 Olgit
R :~~~~Te.me:ra __ NUMSEROFMLeSPERUNIT ..". li~$: O~~:~rg6, ~:~~rr~Q.(:
;: I I 0" U" 7 1.-i,I,,,,," ~/
~: =~~W:;ll=:; . .:D~~~,c;ra~~~ ~~~:u:,~1t/ _
~ plowlr3d.uslslanot _ Tn~ Tr.lclrl Tlll'ttZ TrtlV'i il)li I~.J_ -'.
~ NNdE OF "VE7")'^TING OFFICE. tPI.", P';"') NUMOO' r NAME OF ~1Lt~~~~ ;~ "/ I O.R I NUMBGl
c:: U 1<... 1lf.d :-:,~.., ~ ILl rn-rrJ.1M;2</;':; w,,;iJ'y )"~rt/1J WVOY/O()OO
!Jl '"....,...~""'''."''lo''''my'''\I.dg.m'"'."'~ " ~":>~ '".-:e-- 0A~/.q1~
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5 Snawin;-
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NUM6ER Ll aD Cnlsswt
OF LANES: -, W:Re
MANNER OF COWSION:
I,IGHi
'~Daytighl
2 0""
1 Oark,MI-
ficlalLlg!1t1S
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S.TATEMENTS OF INVOLVED DRIVERS AND WITNESSES (IF AVAILABLE)
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STRUCt<, TRAme CONTROLS: SKtDMAA:KS, ETC. _-
'''PORTAKT: KtJMBER ll-ie veHIClES AC<:OR01NG.TO ll-iE veHICle NUMBeRS ON lHe FRONT PA9E.
DRAW ARROW POINTlNG
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DAVID C. BAKER, M.D., F.A.C.S.
19 Brookwood Avenue, Suite 104
Carlisle, P A 17013
(717) 243-9010
Tax ~D# 25-1750671
Board Certified in Orthopaedic Surgery
Member American Academy of Orthopaedic Surgeons
May 6, 2003
Donald R. Dorer
Jacobs & Saba
214 Senate Avenue, Suite 503
Camp Hill, PA 17011
RE: RalphJ. Sorrentino
Dear Mr. Dorer:
Thank you for allowing me to perform an Independent Medical Evaluation on Mr. Ralph
Sorrentino. The following report is based on review of the records, history and physical
examination.
RECORDS REVIEWED:
1. IME of Dr. James, December 9,1999.
2. Records of Quaker Medical Associates, Orchard Park, NY, Primary Care
Physicians.
3. Records of Dr. Matteliano-Physiatrist.
4. Records of Caroline Craig-Physical Therapist.
5. Records of Dr. McAdam-Physiatrist, Orchard Park, NY.
6. X-ray report 7/17/00.
7. X-ray report lumbar spine, 9/30/98, Mercy Hospital, Buffalo.
8. MRI report, Diagnostic Imaging Associates of Western New York, 7/8/98.
9. CT scan report, lumbar spine, 6/9/98.
10. X-ray report, lumbar and cervical spines, 4/19/98.
11. Emergency Room report, Mercy Hospital, Buffalo, 4/19/98.
12. Police report from motor vehicle accident.
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Page 2
RE: Ralph J. Sorrentino
HISTORY AS RELATED BY THE PATIENT:
Mr. Sorrentino is a 67-year-old male who states that on April 19, 1998 he was involved in
a motor vehicle accident. This occurred in West Virginia when he was driving to his
place of residence in Buffalo, New York.
He states that the car he was driving was hit broad-side on the passenger side. He states
his car was totaled, however, he did continue driving and returned to Buffalo that day.
He states his car was totaled.
He presented to Mercy Hospital in Buffalo. That Emergency Room record was available.
He had tenderness of the cervical spine and tenderness in his lumbar spine with no
neurologic deficits recorded. The diagnosis was cervical strain and lumbar strain.
Mr. Sorrentino states he then went to Quaker Medical Center, his primary care provider.
They apparently saw him on 4/21/98 and recorded that he had been involved in a motor
vehicle accident two days prior. They recorded that he had pain across his shoulders, base
of the cervical spine, but did not record any neurologic deficits. His visit on 5/18/98 again
recorded "still complains of back pain and pain radiating across shoulders" and they
recorded that he was still in physical therapy. They discussed at that time seeing an
Orthopaedic Surgeon.
Mr. Sorrentino is not clear which physician he saw next. The records I have are from Dr.
Matteliano starting in 1999. It appears that he did see a Dr. McAdam who is with the
Buffalo Spine and Sports Medicine group.
The September 242, 1998 visit with Dr. McAdam records "on physical examination,
lumbar movements are pain-free. Slump testing is negative. The patient has persistent
low grade pain which may be discogenic in nature. I prescribed a lumbosacral air belt."
He went on to state "I have not scheduled a follow-up appointment with this patient."
It was after therapy that he started seeing Dr. Matteliano. Dr. Matteliano apparently is a
Physiatrist. His notes of July 20, 2000 record that an EMG was negative.
Diagnostic studies done up to that point included a CT scan which was reported as
negative as well as an MRl done on 7/8/98 which was reported as showing a "small focal
left or central L5-S I disc protrusion, not obviously contacting nerve roots. Degenerative
discs were seen at L2-L3 and LJ-L4.
He states he was seeing Dr. Reigel. There are records from Dr. Reigel in Florida. Those
records from Florida indicate that he saw Dr. Reigel as well as Dr. Weitt.
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RE: Ralph 1. Sorrentino
PAST AND CURRENT SYMPTOMS:
Mr. Sorreptino states that initially he had pain in his neck and between his shoulder blade
as well as in his back and into the left posterior thigh. He states that his neck is better. He
still gets some back pain between his shoulder blades. He does not have any radiation of
leg pain with coughing or sneezing. He does not have any pain radiating below his knees.
He has no bowel or bladder problems. He does not have any right leg pain.
TREATMENT:
Mr. Sorrentino has been treated with pain medications and he takes Hydrocodone,
although he states they do not help his pain. He has not had epidural injections or surgery.
PAST MEDICAL HISTORY:
Patient has been an Insulin dependent diabetic for twenty years.
MEDICATIONS:
Humulin Insulin, eye drops, Effexor (anti-depressant), and Protonix.
EXAMINATION:
Examination reveals no visible abnormalities of the thoracic or lumbar spines. No
deformity such as accentuated thoracic kyphosis or accentuated lumbar lordosis. He has
no scoliosis. There is no skin dimpling or hairy nevi. He walks with a normal gait
without an antalgic component to his gait, sciatic list or Trendelenburg component to the
gait.
He is able to toe and heel walk, but no evidence of weakness in L5 or S 1 distributions.
Range of motion of the lumbar spine is actually quite excellent for his age. He gets
within one hand breadth of the floor on forward flexion. Extension is to 300 and right and
left lateral bending of200 in each plane.
There is no thigh or calf atrophy, measured equal distant points above and below the
superior and inferior pole of the patella bilaterally.
Knee jerk reflexes are 3/4 bilaterally. Ankle jerk reflexes are equal bilaterally.
He has no detectable weakness in L4, L5 or S I nerve root distributions bilaterally.
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RE: Ralph J. Sorrentino
Left straight leg r;iise test reproduced left hip pain at 700. Right straight leg raise test was
negative. Reverse straight leg raise test was negative bilaterally.
RELEVANT REPORTS:
MRI report of 7/8/98 reports a "small focal left of central L5-S I disc protrusion, not
obviously contacting nerve roots." CT scan report of 6/9/98 was reported as normal.
EMG was referred to Dr. Matteliano's notes of July 21, 2000 as being negative.
Review of the primary care physician's notes, records of 5/22/95 record bilateral low
back pain and an x-ray was ordered at that time. It was also noted "refuses PT."
The family doctor's records of 1/6/97 also record "complaints of back pain, center of
lumbar spine with flexion." I do not have any records predating this, but would be happy
to review them if they were available. Multiple records from 1995, 1996, and 1997 also
recorded complaints of fatigue.
Also in the records it appears that a family doctor "intake form" that is dated 5/6/94 also
records a positive answer to the question of "have you recently had leg cramps or pain?"
A positive response to the question, "have you recently had swelling or pain in the
joints?" The intake form also under chief complaint records, "patient also diabetic,
glaucoma, patient for general check-up. Pain in back region, patient has a history of
kidney stones."
IMPRESSION:
Chronic back pain.
DISCUSSION:
It is important to note that Mr. Sorrentino complains of back pain, yet his previous
medical history include complaints in 1994, 1995 and 1997.
It is important to note that his MRI reports nothing that is unusual for someone his age.
Disc herniations are present in 10-35% of the "asvmptomatic population." Degenerative
discs are even more common and present in 80-90% of people in this age group without
back pain. That study is enclosed.
It is also important to note that Dr. Matteliano reports a negative EMG.
I disagree with Dr. Matteliano who describes his symptoms as being a left Sl
radiculopathy. A radiculopathy will manifest itself either with a positive EMG or with
leg pain that radiates below the knee. This does not meet the criteria for a radiculopathy.
He has back pain and pain radiating illto the left posterior thigh.
Page 5
RE: Ralph J. Sorrentino
Also, we do know that persistent back pain is rare after motor vehicle accidents. 1 have
enclosed an article where the long term complaints of people involved in a motor vehicle
accident is reported. "Symptoms such as neck pain, headache, subjective cognitive
dysfunction, psychological disorders and low back pain were studied. It was the
conclusion of this study that "no one in the study group had disabling or persistent
symptoms as a result of the car accident. There was no relationship between the impact,
severity and degree of pain. A family history of neck pain was the most important risk
factor for current neck symptoms than logistic regression analysis." The study went on to
conclude "our results suggest that chronic symptoms were not usually caused by the car
accident. Expectation of disability, family history, contribution of pre-existing symptoms
to the trauma may be more important determinants for the evolution of the late whiplash
syndrome. "
I think Mr. Sorrentino does suffer from back pain, however, I think that back pain pre-
existed. His MRI and reported EMG did not show anything other than age related
changes which we know can occur in the general population.
If you have any questions, please feel free to contact me.
"Sincerely,
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David C. Baker, M.D.
Enclosures:
"Magnetic Resonance Imaging of the Lumbar Spine in People Without Back Pain." The
New England Journal of Medicine. Volume 331, July 14,1994, Number 2.
"Abnormal Magnetic-resonance Scans of the Lumbar Spine in Asymptomatic Subjects."
The Joumal of Bone and Joint Surgery, Vol 72-A, No.3, March 1990.
"Natural evolution of late whiplash syndrome outside the medicolegal context." The
Lancet, Vol 347, May 4,1996, pp 1207-1211.
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DAVID C. BAKER, M.D., F.A.C.S.
19 Brookwood Avenue, Suite 104
Carlisle, P A 17013
(717) 243-9010
Tax ID# 25-1750671
Board Certified in Orthopaedic Surgery
Member Americ_an Academy of Orthopaedic Surgeons
July 7, 2003
Donald R. Dorer
Jacobs & Associates
214 Senate Avenue, Suite 503
Camp Hill, PA 17011
RE: Mary Ann Sorrentino
Dear Mr. Dorer:
Thank you for allowing me to perform an Independent Medical Evaluation on Ms. Mary
Ann Sorrentino. The following report is based on review of the records, history and
physical examination.
RECORDS REVIEWED:
1. Records of Lawrence H. Fink, M.D.
2. Records of Suncoast MRI Center
3. Records of Fitness Sports & Physical Therapy PC.
4. Records of Mercy Hospital
5. Records of Andrew C. Matteliano, M.D.
6. Record of Buffalo Neurosurgery Group.
7. Records of Buffalo Spine & Sports Medicine, PC
8. Records of North towns Orthopaedics, PC.
9. Record of James J. Dragonette, M.D.
10. Records of West em New York Orthopaedic and Spine Therapy.
II. Records of Bran Riegel, M.D.
12. Police Accident Report.
- A. 1 6 2003
Page 2
RE: Mary Ann Sorrentino
HISTORY AS RELATED BY THE PATIENT:
Ms. Sorrentino is a 66-year-old female who on April 18, 1998 was involved in a motor
vehicle accident while traveling with her husband. This occurred in West Virginia. They
continued to drive to their place of residence which was in Buffalo, NY.
Ms. Sorrentino states that she was seen in the Emergency Room. That emergency room
record was not available. She states that within two days she was seen by her family
doctor who is Dr. DeBerney.
Dr. DeBemey who is her primary care doctor referred her to physical therapy at Fitness
Sports. The letter from them on May 5, 1998 indicates that Ms. Sorrentino was
complaining of neck and lower back pain that developed later on the day of the accident.
Ms. Sorrentino states that her initial complaints were pain in the neck and in the anterior
aspect of the neck that radiated' from her right earlobe into the right shoulder blade. She
also had low back pain that did not radiate into any lower extrernity.
Records from the Fitness Sport and Physical Therapy PC indicate that she attended
therapy there until June of 1998. The last note status that she was doing better, gradual
increase in CfT-US AROM (cervical, thoracic, lumbar spine active range of motion).
We do not have any other records from them.
The next health care provider that she saw was Dr. Frederick McAdam from Buffalo
Spine and Sports Medicine, PC. He saw her on December 16, 1998. He recorded that
she had been in Florida undergoing physical therapy. Dr. McAdam mentions that he
asked her to obtain a spine surgery opinion.
His opinion, based on a letter of July 1998, states "probable lumbar disc herniation,
probable right L5 radiculopathy, lateral lumbar shift, cervical thoracic dysfunction,
possible right rib dysfunction."
The records of Dr. McAdam show he saw her in September of 1998 and also in
December 1998.
She also apparently had procedures done by Dr. McAdam prior to this in July and August
of 1998 consisting of epidural steroids as an outpatient at Kenmore Mercy Hospital.
The MRI of August 4, 1998 records degenerative changes of L4 to the sacrum. It is
recorded as showing "focal bulging, prominent disc herniation is seen at L4-S 1 level on
the left, indicative of disc herniation." It is important to note that by this time the patient
was complaining of right leg pain.
Page 3
RE: Mary Ann Sorrentino
While in Florida she was seeing a Dr. Brian Riegel and apparently he saw her in October
of 1998. Dr. Riegel is a Physiatrist.
At that October 1998 visit he was complaining primarily of right lower extremity pain
"into the lateral aspect of her thigh to her lower leg." He recorded "she could think of no
provoking accidents."
Dr. Riegel treated her with physical therapy.
She was also complaining of pain in the right cervical paraspinous muscle. No radiation
into the right arm.
They apparently kept treating her into the spring of 1999 and then started treating her
again in the fall of 1999 and have continued to do so during the winter season when the
Sorrentino's are in Florida.
In May of 1999 back in Buffalo Ms. Sorrentino sought the opinion of Dr. James
Egnatchik who is a Clinical Assistant Professor of Neurosurgery at the State University
of New York in Buffalo.
It was his conclusion in his letter to Dr. McAdam of May 4, 1999 "I had a long
discussion with Mary Ann about the options open to her at the present time. She has an
appointment to see you this week. I can not recommend surgery on her left-sided disc
herniation since this did not correlate with her symptoms. Nor do any of her symptoms
seem serious enough to warrant surgical intervention at this time."
Nerve tests were done in January of 2000 by Dr. Riegel which concluded "this was an
essentially normal EMG/nerve conduction study of both lower extremities." Also during
2000 she apparently saw a Dr. Dragonette who I believe is a chiropractor. She also
attended Western New York Orthopaedic and Spine Therapy under the direction of Dr.
Matteliano.
Another MRI performed on November 30, 2001 reports a left paracentral disc protrusion
at L5-S 1 and degenerative changes in the discs above that. There is some confusion based
on the reports of the other MRI done in 1998 where they list the disc herniation at L4-Sl.
It is possible that this person does not have a fifth lumbar vertebra. It appears that the
disc herniation was at the lumbosacral junction whether that is L4 or L5 I can not say.
Further evaluations included a cervical spine of January 2001 which showed degenerative
changes at C4-C5, C5-C6 and C6-C7 with no evidence offocal disc herniation.
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Page 4
RE: Mary Ann Sorrentino
Apparently the last physician she saw was Dr. Lawrence Fink who is a Neurosurgeon in
Sarasota. His. diagnosis was lumbar intervertebral disc protrusion and lumbar
spondylosis. He recommended lumbar spine surgery including an anterior interbody
fusion at the L5-S 1 level.
SOCIAL HISTORY:
Ms. Sorrentino is retired. She spends winters in Florida and summers in Buffalo.
MEDICATIONS:
Inderal (heart palpitations), Darvocet (mild narcotic pain medication), Relafen (anti-
inflammatory).
PAST MEDICAL HISTORY:
Positive for mitral valve prolapse. Negative for asthma, diabetes and hypertension.
CURRENT SYMPTOMS:
Ms. Sorrentino says she has had a variety of symptoms since the accident and include
pain at the right sternoclavicular joint. She states that her neck pain and stiffness are
improved although she still has pain about the shoulder blade and some residual neck
pain and stiffness. She has back and right leg pain. She states the right leg pain goes into
the lateral thigh, side of calf and radiates into the right great toe.
She states that she can't swim as well or get on her hands and knees to do her floors the
way she was able to before. She states she has difficulty sleeping on her back.
EXAMINATION:
Examination of the cervical spine area reveals prominence of the right sternoclavicular
joint. She has no other visible abnormalities about the neck or shoulders. In particular,
there is no spinal deformity. She has slight accentuated thoracic kyphosis and accentuated
lumbar lordosis which is common in women her age. She has no paraspinous muscle
spasm in the cervical or thoracic area or the anterior strap muscles.
Range of motion of the cervical spine is age appropriate with 500 of forward flexion, 200
of extension, 200 of right and left lateral bending and 300 of right and left lateral rotation.
Page 5
RE: Mary Ann Sorrentino
She has no muscle atrophy or wasting about the shoulders or either arm with no atrophy
measured equal distal points above and below the superior pole above and below the
elbow crease.
I can not detect any neurologic deficits in either upper extremity with particular attention
to strength in the deltoid, biceps, triceps, wrist extensors, wrist flexors or hand intrinsic
muscles.
There is no scapular winging.
Both shoulders demonstrate an intact rotator cuff with no restricted motion. There was
mildly positive Hawkins and Neer tests on the right shoulder.
The 2002 note from Northtowns Orthopaedics PC records a visit for rotator cuff
tendinitis at that time.
Examination of the lumbar spine reveals no visible abnormalities to the lumbar spine.
There is no skin dimpling, hairy nevi or other deformity.
Range of motion is age appropriate with 300 of forward flexion, 200 of extension, 200 of
right and left: lateral bending.
She had no thigh or calf atrophy. There is no reflex asymmetry in knee or ankle jerks.
She had no detectable weakness in L4, L5 or SI nerve root distributions bilaterally.
Straight leg raise test did not reproduce pain in a dermatomal fashion.
Both hips and both knees move comfortably.
DIAGNOSTICS:
EMG of January 2001 was reviewed and this was of the lower extremities. It was
negative.
MRI report lumbar spine 11/30/01 shows disc protrusion of L5-S1 eccentric to the left,
degenerative changes above that in the thoracic spine.
Cervical spine of 1/19/01 reports degenerative changes at C4 to C7. CT scan of the
sternoclavicular joints, 1/19/01, shows degenerative changes of the sternoclavicular joint,
slightly greater on the right than the left with some soft tissue swelling.
c,
.
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Page 6
RE: Mary Ann Sorrentino
MRl of the lumbar spine of 8/4/98 shows degenerative changes at L4-S1 with a
"prominent diffuse circumferential disc bulge which is focally eccentric and bulging to
the left of the midline."
IMPRESSION:
With respect to the neck pain, I do not think any permanent changes occurred. She has
degenerative changes in the spine. It is not unlikely that she experienced a certain period
of pain. I think given the fact that there were no fracture dislocations, disc herniations,
etc. that the residual discomfort she has is age related degenerative changes.
She has degenerative changes at the right sternoclavicular joint manifested on the CT
scan as well as by prominence on examination. The etiology of this is not clear. I did not
see this mentioned in Dr. McAdam's early note of May 1999. A sternoclavicular
swelling can be post traumatic or a spontaneous degenerative problem: Also, I could
not fmd where the therapist she saw on May 5, 1998 into June of 1998 recorded any
complaints of pain from the sternoclavicular joint. Post traumatic subluxation or injury to
the sternoclavicular joint is often quite painful at the time of the injury. I can not state
with medical certainty that this is related to her accident. It does remain a possibility.
With respect to her lumbar spine, she has pain in her right leg and yet there is a disc
herniation eccentric to the left. I agree with the Neurosurgeon who saw her in Buffalo in
May 1999 where he states that "her left-sided disc herniation did not correlate with the
patient's current symptoms." In other words, to remove it would notchange her right leg
symptoms.
It is important to note that her right leg symptoms are just that. She has subjective
complaints of pain, but no evidence of any neurologic deficits. Also, her pain pattern is
not quite consistent with disco genic radiculopathy in that those patients have more leg
pain with sitting that is relieved with walking. Also, her right leg pain is not consistent
with a spinal stenosis or arthritic radiculopathy in that those patients who have leg pain
with ambulation that is relieved with sitting and forward flexion.
In summary, I would state that her right leg pain is unexplained.
I agree with the Neurosurgeon in Buffalo who saw her and could not explain her right leg
pain. According to Ms. Sorrentino, however, this right leg pain did develop two days
after the accident and it was at least temporarily associated with it.
I think the development of her right leg pain is the result of the motor vehicle accident.
However, I do not think the right leg pain is necessarily reflective of a disc herniation that
occurs on the left side of her spine. We do know that 15% of the population who have no
....
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Page 7
RE: Mary Ann Sorrentino
back symptoms whatsoever will demonstrate disc herniations on their MRI's and this
herniation at her lumbosacral junction could easily have been present prior to the
accident. Given the fact that her symptoms are on the right and the herniation is on the
left, I can not tie it to the accident. Therefore, I do think her unexplained right leg
symptoms that are associated with no restricted motion and no measurable neurologic
deficits with a negative EMG are related to the accident. However, I do not think they
are related to any spine problems. I think at this time it would be most appropriate to
assign a diagnosis of right leg pain of unknown etiology to that diagnosis.
In summary, I think the patient sustained pain as a result of the motor vehicle accident.
However, 1 do not see much residual measurable impairment. She does have a prominent
right sternoclavicular joint which could be related to degenerative changes at that joint.
Her shoulder functions well and she has no upper extrernity neurologic deficits or
abnormal scapulothoracic motion. She does complain of pain in these areas as do
approximately 10-15% of the women in her age in this country.
With respect to her back, she has had an increase in back pain and this undefmable right
leg pain that seemed to increase after the accident. I could not state that her back MRl's
reflect a pattern of injury nor do I think they correlate with the symptoms that she has.
This is not to say that I do not think she has the symptoms she is complaining of. I just
can not correlate them to the MRl nor could I correlate the MRl to a motor vehicle
accident.
I hope this has been helpful. If you have any questions, please feel free to contact me.
Sincerely,
~
David C. Baker, M.D.
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00HB-00052
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LAW OFFICES OF JACOBS & ASSOCIATES
214 SENATE AVENUE, SUITE 503
CAMP HILL, P A 17011
TELEPHONE NUMBER: (717) 731-0988
ATTORNEY FOR DEFENDANT
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
Mary A. Sorrentino and Ralph J. Sorrentino, Her
ase No.: 2000-03313 Civil Term
Husband,
Plaintiffs
vs.
Y lRIAL DEMANDED
Kellyann Jameson,
Defendant
vs.
Ralph J. Sorrentino, Additional Defendant
CERTIFICATE OF SERVICE
Donald R. Dorer, Esquire, hereby certifies that he is the attorney for the Defendant
herein, and that he caused a true and correct copy of the attached Pre-Trial Conference
Memorandum of Defendant, Kellyann Jameson to be served by regular first class mail upon:
Edward J. Balzarini, Jr., Esquire
Balzarini & Watson
3303 Grant Building
Pittsburgh, PA 15219
Attorney for Plaintiffs
Date: October 10, 2003
Brigid Q. Alford, Esquire
Boswell, Tintner, Piccola & Wickersham
315 North Front Street, P.O. Box 741 t .
Harrisburg, PA 17108-0741 - . /
Attorney for Additional D ~nt "[ / /
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Donal . Dorer, Esquire
Attorney for Defendant
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IN THE COURT OF COMMON jLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
MARY A. SORRENTINO and RALPH
J. SORRENTINO, her husband,
CIVIL ACTION - LAW
No. 2000-03313 Civil Term
Plaintiffs,
vs.
PLAINTIFF, RALPH J.
SORRENTINO'S PRE-TRIAL
STATEMENT
KELLYANN JAMESON,
Defendant,
Filed on
Plaintiffs
behalf
of
vs.
Counsel of Record for this
Party:
RALPH J. SORRENTINO,
Additional Defendant.
Edward J. Balzarini, Jr.,
Esquire
PA LD. #34320
Balzarini & Watson
Firm No. 013
3303 Grant Buildinq
Pittsburgh, PA 15219
(412) 471-1200
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PLAINTIFF, RALPH SORRENTINO'S PRE-TRIAL STATEMENT
I. STATEMENT OF THE CASE
This is a civil action for money damages. The action
arises from a motor vehicle collision. The collision
occurred on April 19, 1998. The collision involved two (2)
automobiles.
The collision occurred on Interstate 79 near
Morgantown, West Virginia. The defendant, Kellyann Jameson,
resided in Mechanicsburg, Pennsylvania, at the time of the
collision while attending college in Morgantown, West
Virginia. The plaintiffs, Ralph Sorrentino and Mary Ann
Sorrentino, are husband and wife. At the time of the
collision, they resided in the Buffalo, New York area.
The cause of the collision was the defendant's attempt
to make an illegal U-Turn on the interstate. The defendant
was traveling north on 179 and missed her exit. She was
traveling to her job, and was late for work. It was 11:45
a.m. Rather than traveling to the next exit and re-entering
the southbound lanes of 179, the defendant attempted to
make a U-Turn on a gravel crossover between the north and
southbound lanes. As is typical on an interstate highway,
the crossover is clearly marked as prohibited for use by
private vehicles.
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The defendant had been traveling north on 179 in a
line of traffic. The speed limit in this area is 70 m.p.h.,
so all vehicles were moving at a high rate of speed. The
plaintiff, Ralph Sorrentino, was driving his automobile
behind the defendant, Kellyann Jameson. With no warning and
without applying any turn signal, the defendant's vehicle
came to a sudden stop. Unknown to the plaintiff, the
purpose of the stop was so that the defendant could make
her illegal left-hand turn onto a gravel crossover which
connected the north and southbound lanes.
The husband plaintiff had to attempt to stop his
vehicle, and when it became obvious that he would not be
able to get his vehicle stopped, he swerved his vehicle to
the right to avoid a collision. In the process, he collided
with a vehicle traveling in the right-hand lane. The
defendant has conceded in her deposition that she was aware
before she attempted to make her left-hand turn that it was
illegal. She also conceded that she is unaware as to
whether or not her turn signal was on at the time she
attempted the left-hand turn. Plaintiffs will testify they
had no indication of the illegal turn.
As a result of the collision, plaintiff, Ralph
Sorrentino, sustained a lumbar disc herniation at L5 Sl.
His disc herniation has been treated conservatively. He has
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incurred medical expenses of approximately $13,500.00, all
of which are recoverable under the applicable law.
II. DAMAGES CLAIMED
a. Medical Expenses
Mercy Hospital (4/19/98) .....................................................................$
( 6 / 9 / 9 8 ) ........................................................................
Southtowns Radiology Assoc. (4/19/98 )..............................
( 6/9/98 ) .................................
Great Lakes Emerg. Physicians (4/19/98)........................
David Deberny, M.D. (4/21/98 - 6/3/98)...........................
Fitness Sports & PT (5/5/98 - 6/30/98)...........................
Andrew Matteliano, M.D. (7/13/99 - 5/31/01)............
Diagnostic Imaging Assoc. (7/8/98 ).......................................
Francis D. Mezzadri, M.D. (4/21/98)....................................
James Dragonette, DC (5/3/01 - 10/25/02).....................
Buffalo Spine & Sports Med. (7/21/98-12/16/98 )...
Hamburg Phys. Therapy (7/15/98 ).............................................
Bram Riegel, M.D./Spine, Sports & Rehab. Spec.
( 1 0 /2 9 / 9 8 - 3 / 2 0 / 0 1 ) ..............................................................................
Daniel J. Knapp, DC (12/9/02 - 6/30/03 )........................
Brian C. James, M.D. (12/9/99)...................................................
Dr. Dower (1/31/02) ....................................................................................
Pre scr i ptions......................................................................................................
TOTAL:
182.74
429.00
72.11
140.44
114.00
75.67
1,168.92
270.69
733.05
157.00
1,802.57
255.24
141. 90
3,706.24
2,975.62
650.00
310.00
278.14
$ 13.463.33
In addition to the Items of Special Damage, plaintiff
will claim damages for pain and suffering, future
medical/surgical expenses, impairment of earning capacity
and damages for embarrassment and humiliation which the
plaintiff has endured and will endure in the future as a
result of the injuries he has sustained.
The plaintiff
will further contend that he is entitled to be adequately
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compensated for past, present and future loss of his
ability to enjoy the ordinary pleasures of life.
Plaintiff reserves the right to supplement and amend
the Items of Special Damage set forth above, correcting or
adding any expenses or losses, at any time, up to and
including the time of trial.
III. LIST OF WITNESSES
a. Liability
Plaintiff may call the following witnesses as to
liability at the trial of this action:
1. Ralph J. Sorrentino
69 Slate Creek Drive
Bldg. 69, Apt. 11
Cheektawaga, NY
2. Mary Ann Sorrentino
69 Slate Creek Drive
Bldg. 69, Apt. 11
Cheektawaga, NY
3. Kellyann Jameson
750 North Dearborn Street
Apt. 408
Chicago, IL
4. Barbara Weinberg
91 Heathwood Road
Williamsville, NY
5. Julie Weinberg
91 Heathwood Road
Williamsville, NY
6. Sgt. Vic Propst
Monongahela County Sheriff's Dept.
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Plaintiff reserves the right to call as witnesses any
or all of the liability witnesses listed by defendant in
her pre-trial statements. Plaintiff also reserves the right
to call any witnesses named or identified by any party to
this action in Interrogatories, Answers to Interrogatories,
depositions, Pre-trial Statements, statements or any
pleading filed in the subject litigation.
Plaintiff
reserves the right to supplement this list of witnesses at
any time up to and including the time of trial.
b. Medical, Condition and Damaqe
Plaintiff may call the following medical, condition
and damage witnesses at the trial of this case:
1. Ralph J. Sorrentino
69 Slate Creek Drive
Bldg. 69, Apt. 11
Cheektawaga, NY
2. Mary Ann Sorrentino
69 Slate Creek Drive
Bldg. 69, Apt. 11
Cheektawaga, NY
3. Rhonda pietras
1356 Independence Drive
Derby, NY
4. Dean Sorrentino
1537 Union Road
West Seneca, NY
5. Joseph Sorrentino
62 pine Court North
West Seneca, NY
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6. Yvonne Sorrentino
11230 pratham Road
East Concord, NY
7. Andrew Matteliano, M.D.
235 North Street
Buffalo, NY
8. John pollina, Jr., M.D.
3671 Southwestern Boulevard
Orchard Park, NY
9. David Deberny, M.D.
Quaker Medical Associates
3560 North Buffalo Road
Orchard Park, NY
10. James Dragonette, DC
4735 Southwestern Boulevard
Hamburg, NY
11. Frederick B. McAdam, M.D.
Buffalo Spine & Sports Medicine
3871 Southwestern Boulevard
Suite 110
Orchard Park, NY
12. Caroline M. Craig, MS, PT
Hamburg Physical Therapy
230 Buffalo Street
Hamburg, NY
13. Robert Anstett, PT
Fitness Sports & Physical Therapy
4063 North Buffalo Road
Orchard park, NY
14. Terry J. Whieldon, PT
Fitness Sports & Physical Therapy
15. Any present or former therapist
of Fitness Sports & Physical Therapy
who provided care to the plaintiff
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16. Bram Riegel, M.D.
Spine, Sports & Rehab Specialists
5580 Bee Ridge Road
Bldg. B
Sarasota, FL
17. Christine Weot, M.D.
Spine, Sports & Rehab Specialists
18. Richard D. Thomas, M.D.
Diagnostic Imaging Associates
of Western New York
1630 Maple Road
Williamsville, NY
19. Any present or former radiologist/
x-ray technician of Mercy Hospital
who provided care to the plaintiff
20. Daniel Knapp, DC
3982 Bee Ridge Road
Building H, Suite H
Sarasota, FL
i
21. Brian C. James, M.D.
1830 South Osprey Avenue
Suite 100
Sarasota, FL
22. R. Kotha, M.D.
c/o Mercy Hospital
565 Abbott Road
Buffalo, NY
23. Dr. Jerald P. Kuhn
Diagnostic Imaging Asc. WNY
P.O. Box 8000, Dept. #5
Buffalo, NY
24. Francis C. Mezzadri, M.D.
3560 N. Buffalo Rd.
Orchard park, NY
Plaintiff reserves the right to call additional
medical, condition and damage witnesses whose names and
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addresses will be furnished to defendant's counsel at or
before trial of this above-captioned action.
Plaintiff reserves the right to call impeachment
and/or rebuttal witnesses to the extent that same may
become necessary at the time of trial.
IV. EXHIBITS
Plaintiff may offer some or all of the following
exhibits at the trial of this action:
1. police Accident Report;
2. Medical records;
3. Medical bills;
4. x-rays/radiological films;
5. Life Expectancy Tables;
6. Anatomical models;
7. Anatomical diagrams;
8. Any of the medical records
pertaining to the plaintiffs;
9. Photographs of the plaintiff's
vehicle;
10. Photographs of the accident
scene.
Plaintiff reserves the right to supplement and amend
this list of exhibits up to and including the time of
trial.
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v. WRITTEN REPORTS OF OPINION/EXPERT WITNESSES
Copies of the following medical records and reports
are attached hereto:
1. Office notes of Andrew C. Matteliano,
M.D.;
2. Medical report of Frederick B. McAdam,
M.D. dated July 1, 1998;
3. Medical report of Frederick B. McAdam,
M.D. dated September 2, 1998;
4. Medical report of Frederick B. MCAdam,
M.D. dated September 24, 1998;
5. Medical report of Frederick B. McAdam,
M.D. dated December 16, 1998;
6. Office notes of Fitness Sports &
Physical Therapy;
7. Office notes of David Deberny, M.D.;
8. Office notes of James Dragonette, DC;
9. Office notes of Bram Riegel, M.D./
Spine, Sports & Rehabilitation Specialists;
10. Office notes of Dr. Daniel J. Knapp;
11. Emergency Room records of Mercy Hospital
for the admission on 4/19/98;
12. Radiology Report of Mercy Hospital
dated 6/9/98;
13. MRI Report of Diagnostic Imaging
Associates of Western New York dated
7/8/98;
14. Hamburg Physical Therapy records;
15. Medical report of Brian C. James, M.D.
dated December 9, 1999.
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It is hereby certified that true and correct copies of
the above medical records have been furnished to counsel
for defendant with a copy of this pre-trial statement.
VI. STIPULATIONS OF THE PARTIES
Plaintiff requests a stipulation regarding the medical
expenses set forth in the Pre-trial Statement.
VII. ADDITIONAL MATTERS REQUIRED BY LOCAL RULE
a. Legal issues regarding admissibility
of testimony/exhibits
Plaintiff contends that all medical expenses incurred
by the plaintiffs are recoverable. Plaintiff is not aware
of the defendant's position regarding this issue, but
attaches hereto as Exhibit 1 letter to defense counsel from
plaintiffs' counsel containing numerous Pennsylvania
decisions which support the plaintiffs' position in this
regard.
b. Current status of settlement negotiations
The defendant is insured with a policy of liability
insurance which provides for bodily injury limits of
$50,000/$100,000. Plaintiff has submitted a settlement
demand to Nationwide Insurance for $50,000.00 as to the
claim of Ralph Sorrentino and $50,000.00 as to the claim of
Mary Ann Sorrentino. No settlement offers have been
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received as of the time this Pre-Trial Statement was
prepared on October 8, 2003.
Respectfully submitted,
BALZARINI & WATSON
/
BY
Plaintiffs
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CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the
within PLAINTIFFS' PRE-TRIAL STATEMENT was served
counsel for defendant this ~ day of Q..d:;;{J-V\
2003, by first class mail, postage prepaid.
upon
,
BALZARINI & ~SON
BY F'(
Attorneys for Plaintiffs
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BALZARINI & WATSON
ATTORNEYS AT LAW
3303 GRANT BUILDING
PITTSBURGH. PENNSYLVANIA 15219
(412) 471-1200
FAX: (412) 471-8326
April 25, 2003
FEDERAL EXPRESS
,
Donald R. Dorer, Esquire
JACOBS & SABA
214 Senate Avenue
Suite 503
Camp Hill, PA 17011
Re: Sorrentino vs. Jameson, et al.
Dear Mr. Dorer:
Following our recent telephone conversation, I am
submitting the following information" regarding the issue of
the recoverability of the Sorrentinos' medical expenses in
the above-referenced case.
My research discloses a long line of Pennsylvania cases
holding that where an action for damages arising from a motor
vehicle collision is brought in Pennsylvania, but the
collision occurred in another state, Pennsylvania will apply
the law of the state in which the collision occurred. While
this was holding in Milkovich v. Bune, 371 Pa. 15 (1952), it
has been reapplied to a series of cases. The most recent case
I was able to find was Miller v. Gay, 323 Pa. Super. 466
(1983). r did not, however, research at the county level.
In the present case, the collision obviously occurred in
West Virginia. The defendant was residing in West Virginia.
~he plaintiffs are non-residents of Pennsylvania. I will
contend that West virginia law is applicable.
No medical expenses were paid for the plaintiffs under
the pennsylvania Motor Vehicle Financial Responsibility Act.
I will, therefore, argue that the Pennsylvania act has no
applicability in the within action.
Exhibit 1
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BALZARINI & WATSON
Donald Dorer, Esquire
Page two
April 25, 2003
In Smith v. Klein's Bus Service, Inc., No. 94-7154 (E.D.
Pa., February 10, 1997), the Federal Court held that benefits
paid by an out-of-state insurer are not subject to Sl722 of
the Pennsylvania Motor Vehicle Financial Responsibility Act
which precludes the recovery of required benefits.
In Reeder v. Younq, 48 D&C 3rd, 432 (1988), the Court
held that the preclusion against pleading and recovering
under Sl722 of the Financial Responsibility Act is .applicable
by its terms to "persons eligible to receive benefits" which
includes people who operate motor vehicles registered in
Pennsylvania and are required to purchase insurance in
Pennsylvania. This would obviously not include the
Sorrentinos.
In addition,! believe the following county level
decisions hold that an out-of-state plaintiff who brings an
action in Pennsylvania is not precluded from recovering first
party benefits that have been paid by a collateral source,
even when the accident occurred in Pennsylvania. For a case
involving an accident outside of Pennsylvania, the argument
would obviously be even stronger. Shillitio-Patterson v.
Neuccio-Rohrer v. Richards, 117 Dauphin Co. Rep. 393
(September 15, 1997); Morqenstren v. Southern woodenware,
Inc., 75 Lancaster L. Rev. 608 (October 23, 1997); Jenkins v.
Stuck, 115 Dauphin Co. Rep. 94 (1995); Fernandes v. Horne, 53
Somerset L.J. 119 (1994).
As I believe you are aware, West Virginia does not have
any type of full or partial no-fault statute and it still
applies the collateral source rule to auto accident cases.
The medical benefits in this case are substantial, I
have enclosed an itemization of Ralph Sorrentino's expenses
in the amount of $13,557.75. I have enclosed an itemization
of Mary Ann Sorrentino's expenses in the amount of
$43,337.52. I have determined that these expenses have been
paid in part, and that while some of the providers are
requesting addi tional amounts, I do not believe they are
entitled to them. State Farm, which paid the expenses under
the Sorrentino's policy, has provided me with an itemization
'of what they have paid to each provider. I have provided you
with the itemizations. A majority of the providers have
accepted the allowance in full. A couple, whom I think are
mainly chiropractors, have attempted to claim additional
amounts, but I believe that since they have accepted the
allowance, they are not entitled to bill the Sorrentinos for
the additional amount.
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BALZARINI & WATSON
Donald Dorer, Esquire
Page three
April 25, 2003
There may be a question in the Sorrentinos' case in
Pennsylvania as to whether they can recover only the amount
accepted by the providers. Yet even if they are limited to
this amount, however, I believe it is sufficient to justify
payment of the policy limits.
After you have had a chance to review these materials,
could you please contact me. I am hopeful, we can resolve
this case without the ongoing dispute regarding a medical
eXaIllination. I am sending these by overnight mail because of
the problem we have regarding the pending medical
eXaIllination.
,
Please call if you have any questions or require
anything further to evaluate the claim.
Very truly yours,
BALZARINI & WATSON
./
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Jr.
Enclosures
cc: Brigid Q. Alford, Esquire
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PHYSICAL MEDICINE & REHABILITATION
ELECTROMYOGRAPHY
PHYSIATRIC FOLLOW-UP VISIT
RE: RALPH SORRENTINO
DATE: MAY 31., 2001.
POLICY#: 61.24701.-52D
CASE#: 522092-063
SS#: 090-26-961.5
DOA: 4/19/98
DIAGNOSIS: Status post flexion/extension injury to
lumbosacral spine with musculoligamentous
disruption at L5-81. disc herniation, left 81.
radiculitis.
He is still having back pain; there is radiation of the
buttocks and posterior thighs, and down the legs, but not
into the feet. He has bending pain; he can bend to 600.
There is continued radiation down the left leg that is more
prominent than on the right. He has left S1. radiculopathy
from disc herniation at L5-S1.
This man is stable at this point, he is still stiff and his
low back is sore. He can use the Soma if necessary. He
will continue on daily exercise. He will be seen in three
months.
tJ;; ,~
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Andrew C. Matteliano, M.D.
ACM:alc
cc: Paul William Beltz, P.C.
State Farrri Ins.
Rehabilitation of Orthopaedic and Spine Disorders. Electromyography and Nerve Conduction Studies.
Injured Worker Case Management, Functional Capacity Evaluations
235 NORTH STREET, BUFFALO, NY 14201
PHONE: (716) 882,0726 FAX: (716) 882-3484
ANttffiW C. MATTELIANQt.'1.D.
M.Sc., F .A.A.P .M.R.
PHYSICAL MEDICINE & REHABILITATION
ELECTROMYOGRAPHY
PHYSIATRIC FOLLOW UP ViSIT
RE:
RALPH SORRENTINO
DATE:
JULY 21, 2000
POLICY#:
CASE#:
ss#:
DOA:
6124701-52D
522092-063
090-26-9615
4/19/98
Diagnosis:
Status post flexion/extension injury to lumbosacral
spine with musculoligamentous disruption at L5-S1
disc herniation, left S1 radiculitis.
He is still getting back pain which radiates into the buttocks and
posterior thighs. There is flattening of lordosis. He still has
tenderness in the low back. He had an EMG exam which was negative
for frank motor radiculopathy. He has a disc herniation which is
still symptomatic and has pain down his left and right legs. He
can use Soma. He has been doing as much walking as he can as well
as riding an exercise bike and he should continue with this. This
is a chronic condition. The low back disc herniation is permanent.
H~ll bee~i~~~~ for follow up.
1.. L, .l ~I\\
Andrew C. Matteliano, M.D.
ACM: jps
cc: Paul William Beltz, P.C.
State Farm Ins.
Rehabilitation of Orthopaedic and Spine Disor~,ers. Electromyography and Nerve Conduction StudieS
Injured Worker Case Managemenl,. Functional Cap-achy Evaluations
235 NORTH STREET, BUFFAW, NY 14201
PHONE: (716) 882,0726 FAX: (716) 882-3484
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ACJ>REW c. MATTELWO, M.D.
M.Sco, F.A..4.P .M.R.
PHYSICAL MEDICINE & REHABILITATION
ELECTROMYOGRAPHY
PHYS1A'l'Rll,; ~'ULLUW Ul'" v .1.".LL
RE:
RALPH SORRENTINO
DATE:
OCTOBER 12, 1999
POLICY#:
CASE#:
SS#:
DOA:
612460152D
522092-063
090-26-9615
4/19/98
Diagnosis: status post flexion/extension
spine with musculoligamentous disruption at
left S1 radiculitis.
injury to lumbosacral
L5-S1 disc herniation,
He is still getting pain into the buttocks; there is still
flattening of lordosis. He has forward bending to 600. The
straight leg raise continues to be negative. He ha some tightness
and soreness in the back. He can use the Soma. He has been doing
his home exercises daily. He continues to have his symptomatic L5-
S1 herniated disc from the trauma. We will follow him
conservatively.
Cf1-. C. ~~~\
Andrew C. Matteliano, M.D.
ACM: jps
cc: Paul William Beltz, P.C.
state Farm Ins. Attn: Katie Travis, Rep.
Rehabilitation of Orthopaedic and Spine DisordeR,. Electromyography and Nerve Conduction Studies
Injured Worker Case Management, Functional Capacity Evaluations
235 NORTH STREET, BUFFAlO,NY 14201
PHONE: (716) 882-0726 FAX: (716) 882,3484
~u
~ c. MATTELIAN-oM.D.
. M.Sc., F.A..4.PM.R.
PHYSICAL MEDICINE &: REHABILITATION
ELECTROMYOGRAPHY
PHYSIATRIC FOLLOW-UP VISIT
RE:
RALPH SORRENTINO
DATE:
AUGUST 17, 1999
POLICY#:
CASE#:
ss#:
DOA:
612460152D
522092-063
090-26-9615
4/19/98
Diagnosis: Status post flexion/extension
spine with musculoligamentous disruption at
left S1 radiculitis.
injury to lumbosacral
L5-S1 disc herniation,
Ralph is still getting some pain into the buttocks and into the
legs. There is still flattening of lordosis. There is still lower
thoracic and lumbosacral tenderness.
His side bending has improved to some extent. He is bending 700.
Straight leg raise is negative.
He is stable. He is doing his exercises at home. He does get some
tightness and soreness in the back and we will try him on some Soma
to see if this makes any difference for him. He will continue to
follow up and I will see him in two months.
a-!~ C :f).,~,
Andrew C. Mat'tU~,
ACM: jps
co: Paul William Beltz, P.C.
State Farm Ins. Attn: Katie Travis, Rep.
Rehabilitation of OrthopacQlC and Spine Disorden. Electromyography and Neove Conduction Studies
Injured Worker Case Managemen~ Functional Capacily Evaluations
23S NORm SI'REET, BUFFAlD, NY 14201
PHONE: (716) 882-0726 FAX: (716) 882-3484
"
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RE:
~nw C. MATTELIAN' M.D.
M.Sc., F.iL4.P.M.R.
PHYSICAL MEDICINE & REHABILITATION
ELECTROMYOGRAPHY
INITIAL PHYSIATRIC EVALUATION
RALPH SORRENTINO
DATE:
JULY 13, 1999
POLICY#:
CASE#:
ss#:
DOA:
6124601520
522092-063
090-26-9615
4/19/98
This is a 63 year old male who presents in my office at the 235
North Medical Center on 7/13/99.
At that time he gave a history of injury in an auto accident that
occurred on 4/19/98. He was the driver of a vehicle, the vehicle
he was driving was cut off by another vehicle and there was a
collision and he injured he injured his low back.
He had diagnostic work up and MRI and I reviewed the films and the
report. MRI was done on 7/8/98 and does show a left L5-S1 disc
protrusion. He has had back pain which radiates into the posterior
thighs on both sides. .
This man has had physical therapy and he is had modification of
activities at home. He cannot handle lifting or any repetitive
bending. He is retired from his job at the steel plant.
His past medical history indicates that he is an insulin dependent
diabetic for 25 years. He also has glaucoma and takes ocular
medications on a daily basis. There is no hypertension, no heart
disease or thyroid or asthma problems. He does not have allergies
to medicines. He has had previous kidney stones but nothing
recently. No problems with the stones for the last 12 years.
On physical exam he is ~lert, ~riented and cooperative. He could
follow a three step command, he has intact cranial nerve functions.
Stands 5'5" tall and weighs 152 pounds. The extremities show no
evidence of any cyanosis, clubbing or edema.
Upper extremity reflexes all 2+ and symmetrical, there are no
strength deficits in the upper extremities. Sensation is intact.
In the lower extremities he does show some reflex deficit at the
left ankle at 0, right ankle 1+, mild stocking type sensory loss on
both sides. There is some left sided S 1 sensory loss as well.
There is no major motor weakness in the legs. He does not have any
areas of muscular atrophy. Straight leg raise is negative.
Reflexes at the knees are 2+ on both sides.
Rehabilitation of Orthopaedic and Spine Disorden.- Electromyography and Nerve Conduction Studies
Injured Wacker Case Management,. 'Functional Capacity EvaluatioDS
23S NORTIl SfREET, BUFFALO, NY 14201
PHONE: (716) 882-0726 FAX: (716) 882-3484
-~~
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RE: RALPH SORRENTINO
7/13/99
PAGE: 2
The low back shows flattening of lordosis and this is quite
prominent. He can only bend to 600. There is incomplete reversal
of lordosis. He has diffuse tenderness in the lower thoracic area
and down through the lumbosacral area, most of the tenderness at
the lumbosacral junction on the left. Side bending is restricted
by one half. Extension to 150.
IMPRESSION
1. Status post flexion/extension injury to lumbosacral spine with
musculoligamentous disruption at L5-S1 disc herniation, left
S1 radiculitis.
RECOMMENDATIONS
1. He will continue with analgesics as necessary and he has home
exercises that he has been taught and he can do these. He is
fairly trim with his weight so this is not a problem. I feel
that he should just do the conservative program at this point.
As a direct result of this injury, he is left with a permanent
disability. He has chronic low back pain now. If he cannot
tolerate his symptoms, he can be evaluated for surgical treatment
to the low back with discectomy at L5-S1.
I will see him again in two months for follow up and assess his
condition at that time.
~c. .
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Andrew C. Matteliano, M.D.
ACM: jps
cc: Paul William Beltz, P.C.
State Farm Ins. Attn: Katie Travis. Rep.
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Quaker Medical Associates
3560 North Buffulo Road
OrclJardParlc, New York, 14127
(716) 662-8510
. D Medicare
}e'( No Fault
o Workman's Compensation
Patient ' RaJ f'-
Date . 'f-/30/"l8
I ~
Last date seen if /2., /'1 &- .
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Time b~~
f
Location
Age r~
~.~ ~'b1,'C-L
I
'-M"~J
T
BP {'2-2-{1'8' P R'~
R IlD
WT
...,J+v 1')-\1/" A 4-11'\ ( 'l~ elt>
F ~ ld, NLo-L ("...;~" ~ JILM
h";,p -+- ~. ~h-'1 ~ .~~
Chief Complaint:
',a+.~d..-u-t... 4-
.0.....-'-' k.'; \ '4.A--
r-- ,
Patient's History:
''''''-;,;.
l, .'
,. ..~,',., ''- "
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, ",,,,~,'.,'f",,''',",, ".
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. ' '~"i '), - ",:" i, "', :~; :": "i' . , ',;:,,, -,
. DHead',
,.ti:Eye~ ,,'.:
DEars
D Nose
D Throat .
,
D Neck'
D Chest
o Abdomen
o Extremity ,
D Musculoskeletal
o Neurological.W/I.fL.
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Recommendations! Referrals:
.
,
Diagnosis:
Sir: Mvt+- .
Lo-- L r ~,,-~k. r ( s:S:- j--
~
Workman's Compensation/No Fault: -
o working,)/
D not working ~ Estimated d8.teofreturn to work: .
*Time: * Please refer to guidelines
Expected dat~ to return for follow-up: ~ .(V\
'.
~.~~
-- ,~"
c~,
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t'
,
MULn-8YSTEM~
probJem..f""""/ - I to j buIJci3
""l'anded problem-foouscd; 6 or more buDets
detailed - 6 ...... 2 buD... eaoh or
2 or more ...... 12 bullets tota1
comprebellsive - 9....... 2 bulkts each
DATE: r..,. 11 CIl1EF COMPLAINT:
~1-"''''-/O'''h\Al aAb _
o
if>-'i
- -QUAKER MEDICAL ASSOCIATES
PROGRESS NOTE
~ h hlVA
~ 4- f'T
,/) - l
NAME 7lLI A .--r:',_,
a.ft> !u-u ~ MEDS:---1l /"l;-_"',~
~ J" k":' "("""'" NPH !J(,h 4-.",J
;:,J(_U_ oS ~~ ;U"Jb'
TEMP
PULSE-
~
RESP / 6
BP /J6/-.1J
WT /f" l.f-it
HT
..J - nonna1 =
significant findings: .
0- BULLET 0" AREA
- NECK
Neck
Thyroid
RESPIRATORY . 0
Respiratory effort 0
Percussion: of chest _ 0
Palpation of chest 0
Auscultation oflungs 0 /
) CARDIOVASCULAR 0--:::
, . - Palpation ofh~ 0
Auscultation ofheart 0
Carotid arteries 0
Abdominal aorta 0
Femoral arteries 0
Pedal pulses 0
, EXtremities (edema,. -
varicosities)"'"' . ~
. CBEST/lmEAST/"---=--=
Inspection of1iIeasts 0
Palpation ofbreasts
.axillae 0
Mammogram date~IesuI -Hx
GASTROINTESTINAIJ
ABDOMEN
Abdomen
(mass, tenderness) 0
Liver and spleen 0
Hernia 0
Anus, perinenm, _ 0
Stool fur ocwlt hlood
GENITOURINARY 0
MALE
Scrotal contonts
Penis
APPEABANClE ~-r
Vital signs 0
EYES ~
Conjunctivae, lids 0
Pupils, irises 0
Opthamoscopic exam of optic discs, posterior
segments' 0_
-, EARS, NOSE, MOura,.../"
!~-\ TImOAT ~ .
'.J Ears, nose (extenmI) 0
Otoscopic exam of auditory canals
tympanic membranes 0
Hearing :.:::::'::: ., 0
Nasal ~.septum, ""':",-- . ',j'
tW-bmates-'-':;~ '0. .-' ;i,,: ',,"
'. -';~=~;~lDSaliv~gJands,~;mdsO~~;~;'~:i~~~.
. 0
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Digital rectal e:<am of prostate D
FEMALE
External genitalia, vagina D
Urethra D
Bladder ' ~
Last pap and result
LYMPHATIC
Palpation oflymph nodes in two or more:
Neck: D
Axillae D
Groin D
Other D
MUSCULO SKELETAL 0
Gait and station D
Digits and nails D _
:Exam of joints, bones, and muscles of one or more of the fo owmg; head and'Iieeld spine, nos, pe!'ris f right upper extremity f left upper
exIremity f right lower extremity f left lower extremity. Each Iimst include: -
Inspection orpaIpation - (m;""];gmnent, asymmetry, crepitation, defects, '""n......""s, masses, effiJsions)
o
Range of motion - (pain, crepitation. contractnre)
D
Stability - (4islocation. subluxation. laxity)
o
~USCle strength ~atrophY, abnonnal movements)
InSpection of skin and subcutaneous tissue
o
Palpation of skin 3eous tissue - , " ,
~::,'E:(~dr:'~ "
- ~~.," D' - . - --
PSy=itc' -. -~
Judgment, insight' 0
Time, place, person orientation
o
Recent and remote memory
o
D,
-
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,
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Mood and affect
TIME;
o See additional progress note for extended cOUllSeling notali,
-~
fast ld9tory - ChaIlges since last appt
Allergies: NKA
Surgery: NoIYes
Ji'amlly hbtory - ChaIlges since last appt.
Family illn""",,,: None; CA HTN
SigDiIicaotc:lJangeS inheal1h offamilymemb= ljolYes
80dal hbtory. ChaIlges since last appt.
Smokll NoI Yes
REVIEWED BY:
IUnesses; NoIYes
HO"lpih,lh...tinns: NO/YeS
.
Heart disease
Diabetes
Olbor
Driak NoI Yes
SinglelMalriedfW-._Divorced
PrAGNOS!S;
1\IDfNP
r-
..........
--
URlNALYSIS
Spec. gmvity
Leukocytes
Nitrite
pH
Protcin
Glucose '
Kolones
UrobiIin~gen
Bilirubin
Blood
~
EXl'ECTED DATE TO RETURN FORroU.OW.UP;
"
il_"~i,
i'i
~uffalo Spine & sport?MediCine, P.c.
July 1, 1998
RE:
MVA:
8S#:
Ralph Sorrentino
4198
090-26-9615
David Deberney, MD
3560 N. Buffalo Road
Wtteretl1e Orchard Park, NY 14127
season never ends_ ,..~:"
Dear Dr. Deberny:
Oavij L Bagnaft, M.O,
Michael C. Geraci, Jr., M.D.
Nancy R, Lembo, 0,0.
rrederick B, McAdam, M,D.
,)eff R, Paven, 0,0
9 LimeslOl1O Dr.
Wlmamsville, NY 14221
(716) 626.()()93
Fax (716)62&-9193
3671 Southwestern Blvd.
SUIIe 110
orchard Par~ NY 14127
(716) 626-0093
Fax (716) 626-9193
APPOINTMENTS
also avaiiable
in
Batavia
and
Niagara Falls
(716) 62&0093
Fax (716) 626-9193
Mr. Sorrentino was seen for an evaluation on 7/1/98. As you know, he is a retired 62 year old right-banded
e who has been troubled with low back pain since his involvement in a motor vehicle accident in April 1998.
t that time he was a seatbelted driver whose vehicle wa.~ involved in a front-end collision and then struck
adside. He had no loss of consciousness but did develop low back'pain. Since that time his low back: pain
worsened. He experiences it intermittently. He is troubled by walking and mowing his lawn. He has some
mnbnessltingling in his limbs at times. He is on no medications. He has undergone SOIIie physical therapy.
Past medical histmy is remarkable for only minor low back aches. He has diabetes mellitus and glaucoma,
e is on insulin, Timoptic and Glucophage. He has had a cholecystectomy in the past.
Family histOlY is remarkable for cancer and arthritis.
Review of systems reveals he has difficulty sleeping. He has had hepatitis and kidney stones in the past.
e is married.
On physical examination, he is 5'5" and weighs 154 lbs. His blood pressure is 132/91, with a pulse of
8 bpm. His posture is remarlaible for level shonlders and iliac crests. He has pes planus bilaterally. He has an
reased thoracic kyphosis. He has a forward head carriage. Lumbar extension causes mild pain. Cervical
otious are pain-free. Forward flexion test is positive on the left. Hip range of motion is full and pain-free.
e has tightness ofhis latissimus dorsi and hamstring muscles. Manual muscle test reveals normal strength.
tendon reflexes lI1ll.good and symmettic. Sensation to pinprick is difficult to interpret. Straight leg raising
d femoral stretch testing are negative. He has a left-on-rigbt backward sacral torsion.
A CT scan of his lumbar spine from 6f9f98 reveals annular bulging atL3-4 and L4-5 with a triangular
anal. .
This patient's low back pain may be related to the following factors:
1) Possible atypical spinal stenosis.
2) Facet and/or sacroiliac joint pain.
3) Lumbopelvic dysfunction.
4) Muscle imbalances.
I've discussed my general impressions with the patient. 1 am obtaining an MRl scan ofhis lumbar spine.
've ammged for physical therapy with an emphasis on manual therapy.
I've asked this patient to call me after his MRl scan,. I will keep you abreast ofhis progress.
Very truly yours,
f)1eltted1J1It nat '-l!IIt ~"t by !:eifiltg
To ..wold delllY III IIIIIlIIng.
< '~"
Frederick B. McAdam, M.D.
PMRC 161215-9
State Farm Insurance
OP
Received BUff PIP
JUL 27 199B
David Debemey, MD
Where tile 3560 N. Buffalo Road
""~"'_'''o<I!... On:harilPmX,NY 1412/
IJl!VijL8agnalI,M.D.
Mit.aelC.Genlci.Jr,MD.
NarCy R. Lembo, 0,0.
Frederick a McAdam, M.o.
JelfR. PaveIl, 0.0
9Umes1one Dr.
WIIIiamsviIIe. NY 14221
(716) 626-0093
Fax (716) 626-9193
" .
,.
.' ,- i ~,!
o lffalo Spine & SportOJledicine, P.c.
September 2, 1998
RE:
MVA:
ss#:
Ralph Sorrentino
4/98
090-26-9615
Dear Dr. Deberny:
Mr. Sum;utiuo was seen in follow-up an 9/2/98. He reports pezsistent low back pain which is worse
. . .. . .
occasions only because ofhis intercurrent hand surgery.
On physical ~..non, lumbar movements are pain-free. Slwnp testing is negative.
This patieIlt has:improved in mAnl\gir1g his low back pain ..........iRl}' to a small disc protrusioa At this point
I have gone over a home exercise program including walking and pelvic clocks.
I have not scheduled a follow-up visit with this patient.
v cry truly YOUIS,
Dle!llted brrt nOt teIld. ~ant by ~l!CfeWg
To lI'1l11d dl!lllyln lIJlI/IIng.
Frederick B. McAdam, M.D.
PMRC 161215-9
3171 Scull-. Blvd.
SIiiIlll10 FBM/bsr
0Id1aJd Park, NY 14127
(716) 626-0093
Fax (716) 626-9193 CC: State Farm Insurance
OP
APPOINTMENTS
aIsoavaiJable
in
Ba1avia
and
N1agaJa Falls
(716) 62&0093
Fa.< (716) 626-9193
8fp .[
t119$
ReceIved BUFF PIP
OCT 0 2 1998
I.
,
-'"""''D.._
JS-"!::;:'"':'::' ".~..
. ' , 'J('''' "I ' ,~
>;Fl~%l~
"
ctuffalo Spine & sporf?Medicine, P.c.
September 24, 1998
1
,\
'..',
David Deberny, MD
3560 N. Buffalo Rd.
_,Or~hard Park, NY 14217,
RE:
MVA:
SS#
Ralph Sorrentino
4/98
090,26-9615
Where the
season ~r ends_
Dear Dr. Deberny:
David l. BagnaU, M.D.
Mr. Sorrentino was seen in follow up on September 24, 1998. He reports persistent low grade back pain.
He is on medications. He is on a walking program,
Nancy R. Lembo, D.O.
Frederid< 8, McAdam, M,O.
Jeff R. Pavel~ 0.0
On physical examination, lumbar movements are pain-free. Slump testing is negative. This patient has
persistent low grade pain which may be discogenic in nature, I have prescribed a lumbosacral air belt.
I have not scheduled a follow up visit with this patient.
,"
Very truly yours,
9 limestone Dr.
Waliamsvale, NY 14221
(716) 626-0093
fax (/16)626-9193
Dictated but not mad, Sent by
Secretary to avoid delay in mailing
"
Frederick B. McAdam, MD
PMRC 161215-9
3671 S_slarn BIv<I.
SUIIa 110
Olth~rd Par~ NY 14127
(/16) 126-0093
Fax (/16) 626-9193
FBMlbs
cc: State Farm Insurance
APPOINTMENTS
also avanable
In
Balavla
and
N~gam Falls
(716) 626-0093
Fax (716) 626-9193
Received BUFF PIP
OCT 0 9 1998
,
,'-"'l~ _.
Where the
season never ends...
David L Bagnal, M.D.
Michael C. GeIad, Jr, M.D.
Frederid< B. McAdam, M.D.
Jeff R. PavelI, 0.0
9 UmesIons Dr.
William,YIlIe, NY 14221
(716) 62&0093
Fax (716) 626-9193
3671 SouIhwes1llm Blvd.
Suile110
Orchant Park, NY 14127
(716) 62&0093
Fax (716) 626-9193
APPOINTMENTS
also available
in
Batavia
and
NiagOlllFaIJs
(716) 626-0093
Fax (716) 626-9193
'fiJ
~ "-~<'i!lo,
Ouffalo Spine & Sport04edicine, P.c.
December 16, 1998
RE: Ralph Sorreotino
SS: 090-26-9615
DOl: 4/98
David Debemy, MD
3560 N. Buffalo Rd.
Orchard Park, NY 14217
Dear Dr. Deberny:
Mr. S011"eDtino was seen io follow up on December 16,1998. He reports contioued low grade back aching.
His back aches wheo he sleeps. He is on no medications.. He is on a home exercise program.
On physical examination, lumbar flexion causes mild pain. He has an impiogemeot sign of his right
shoulder.
This patieot seems to be managing his low back pain. He is troubled by right shoulder and hand paiD.. He
will beseeiog Dr. Wheeler io follow up.
I have not scheduled a follow up visit with this patieot unless the need arises.
Very truly yours,
Dictated but not read. Sent by
Secretary to avoid delay in mailing
Frederick B. McAdam, MD
PMRC 161215-9
FBM/bs
cc: State Farm Insurance
Received BUFF PIP
[;i8 2 9 i333
--~
, ~
'., Fitness ~ 0
~Oft$
~.. & Physical Therapy,P'C,
0"
~ '
DATE OF BIRTH 1/- '> - "3 ->
PATIENT'S "
LAST NAME ~ot2.fiE"'T /-';0
FIRST NAME
f2A-c? t+
...., .,..,.......LA.ST NAME... ."...".~: 0"""'" ,,'w.c', ,,,,,FIRsr.NAME.,.. .,,'."'.' "..,",' . ,,,. I,
PATIENT'S SOCIAL SECURITYNUMBER('") C(d- .2..(p-9("1 <;
PARENT'S ss# (It appl icable)'
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Company
Lfo ,.v( A-ILl.e> cue.. Ave. Stl"'eet
f1L.tl-5c./Q (/ Ci ty
J)e~ '--IGR.. (c: State
~ '-I .;;L1i5 Zip
x!:L 90 "I Phone
Stl"'..et
City
State
Zip
Phone
REFERRING PHYSICIAN
o~
Deb':>/? LJ'-I
f
ARE YOU CURRENTLY WORKING
Ye.s~
WHAT IS YOUR INJURY OR CHIEF COMPLAINT OF PAIN?
vftC'/i:/l..-4-L.
HAVE YOU EVER HAD
uldea. {/
Yes 0
e~L"7 '> A/~c. k
f;'-,","-
.".,liAVE. YOU ,EVER BEEN,T8A.CHIRORRACTOR, ?/,'''''' Yes~'
ARE YOU CURRENTLY ON MEDICATIONS?
Yes/No
"r"<,_I_.:,,'
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I F YES, PLEASE LIST THEM
**********************************************************
Me d i c a, 1 His t 01"' Y
Please cil"'c~e the tollowing that I"'elate to YOU.
Heal"'t di sease
Allel"'gies
Pregna,n':y
StroKe
As t hma
PacemaKer ~a~
Kigh Blood Pressure
'"
. 4063 North Buffalo Road
Orchard Park, New York 14127
716..662-2949
(')
"
-~- ---
o
----
'UAKER MEDICAL ASSOCIATES
___ Internal Medicine I PediatriCS
DAVID R. DEBERNY, M.D,
KATHLEEN T. GRIMM, M.D.
. FRANCIS C, MEZZADRI, M.D,
GALE L. O'CONNOR, M.D,
TERENCE p, O'CONNOR, M.D" Ph.D.
JEANETTE E, CAMPBELL, P.N.P.
3560 N. Bultalo Rd.. Orchard ParK, N,Y. 14127
, "'N~~~ ':,~e(\'(>" 'SO ~ -\. \. ^ 0 Age -
" ., ~ I
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DEMBD 3791678
OEA #BG 5213575
DEA#BM0931B75
DEA #BO 2509935
DEA #BO 2731570
DEA #F 380261,1
(716) 662,8510
~ \o~~ll \\,~
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Terry John Whieldon, P.T.
May 5. 1998
3560 N, Buffalo Road
Orchard Park . NY 14127
RE: Ralph Sorrentino
In it i aI' E~'al uat i on
Deal" 01". DeBerny:
Ralph was initially evaluated and treated regarding your
diagnosis of 101.,' bacK/hip/51 joint pain. He was involved in an t"l',JA on
4/1';>/98, and c/o constant bilater'al hip pain, in additio.n to bilater'a1
lumbosacral pain which radiates through his posterior thighs. Patient
also c/o bilateral cervical pain which radiates through the upper
trapezius areas in addition to numbness in the right deltoid insertion
ar'ea. He r'epor.ts his symptoms ar-E' incr.eased Ij.Ji th for-vJard tr'unK
flexion. He denies a prior history of cervical 01" back/hip problems.
'.",'^-'.
Ob.jec.t ively" Hal ph demonstra tes..a,.kyphot i c, pc-!;-tur'e w i.th a
. forward' hea'do' 'Poor'''fac'et' mob'i l"i ty 'is' not'ed"in.the cervi cal and' upper
thoracic segments. Cervical AROM is WNL for forward flexion, 0-10
degrees for bacKward extension, and 0-20 degrees for right and left
side bending, 0-45 degrees in right rotation and 0-60 degrees in left
r'otation. Right s~oulder flexic.n is limited to 145 degrees (patient
reports history of bursitis). Bilateral upper strength is 2+/5
throughout. TrunK AROM WaS WNL throughout. LE strength 3+/5.
Bilateral KJ reflexes Were equal.
The assessment of Ralph would ir,clude DJD of the cer'vical and
lumbosacral spine.. The STG is to decrease cervical and lumbosacral
pain through moist heat, electrical stimulation and ultrasound. The
LTG will be to improve cervical and lumbosacral mobi1 it)', posture and
tr'unk strength through gentl e m.B.nual therapy and exer.c i se pr'ogram as
tolerated.
Si ncer'el }',.
Roberta An ste t t, "p., T ."
RA/maw
. 4063 North Bulfaio ROad
Orchard Park, N&w York 14'i27
716-662-2949
.~
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-
i f)oNAL INJURY QUESTI0NNAl..
NAME: ..;;:#~~ DatcOf^CCidcnt~9R
Where did accident ha en? De*ribe thc ac 'ident in ed//.
"z..- />>
-I / #- a-d 'i?-Tl
was your position' the car?
~ . rivcr: if Drivcr were your hands onthc steering wheel? 0 LeIt 0 RightJ'f Both
J Passenger: If passenger, were you silting in 0 Front 0 Right Rear I] Lell Rcar
Did your vehiclc strike another vehicle \:rY es Q,j No
Was your vehicle struck by another vehicleJ(Y cs 0 No
I\ngles ufimpacl... First Collision: 0 Front \il3ack 0 Left 0 Right
If Second Collision: 0 Front 0 Dack 0 Len ~ Right
Were you wearing a seat bclt?Jii(Yes 0 No
Did you brace for impact?Jil! YesO No ... J"lll braced with my hands 0 r braecu with my fcct
Which way were you facing at the lime ofimpact... ~straight ahcad 0 Len U Right
Did you strike anything in vehicle at time ofimpact? jI:l"Yes 0 No
~fyes, specil)< what part of your body struck what: ie... head chesl chin sholllt!"r Righl/.!&!LKnce
U Steering Wheel , U Dashboar.d .
o Windshield!.kLle.r: J"/1j ~f H, t 0 Roof
,;gLen Side Door. 0 Right Side Door
?Left Side Window. n Right Window
o Othcr
Did the scat back bend / break? 0 Yes ~ No
mmediatcly following the accident, how did you feci? 0 dizzy/dazed 0 disoricnted 0 uncon~ciolls
A nervous YXnauscous f upset 0 wcak 0 Other
)id you go to hospital .Q'Yes 0 No Were you admilt99 ~~le hospital'! 0 Yes )?1 No ifycs how 1\'llg?
rfyou went to hospital, when? 0 At time ofaeci/lrfi~'D Next day
I-low did you get to hospital~/ 0 Ambulance 0 Police Car I)l Private Transportation
Namc of Hospital: ~ ~ c V' >4Ic If;--tt /
Attended by Dr. ' I ?
.. what treatment was given?
Dnone Dplaeed in a cervical collar y!x-rayed 0 given stitches OlJandagcd
o given pain medication Ogiven instructions regarding concussions
Dgiven instructions regarding sprains and strains D.j'hysical Thcrapy
Dinstl"lI~led to call a Orthopedic Surgeon [Elinstruclcd to call a privalc physician
Drcferred to this office for trcatmcnl 0 Other
lave you SCCI\ any otber doctor as a result of tbis aecidcnt}Kl Yell 0 No
~,,",,_ \ ~t~~::.~
.
. .
L"_
,
""'
L _ _ ~ M" ~Jlw"
Name:
Ol'LICATION FOR TREATMENT
(I'LEASE l'IUNT)
S/</<?EA-7/.v u
fU..d c~ v<... City: i3l;{Ls j"e (1
o
Homel'l1l1l1e: fc}3 C(tJ(j4
Social Security #: (/70 2- c;,. "1 ~ !,.,;-
Work Phone:
.--------
Today's Date: S- - 3 -.. d (.
Slate: /Jy Zip: IV::'L/(
DateorBirth: //- J- :)/;-
(t;f~f.,Y~,(/ )
( /
Address:
Referred By:
U-</~
Occupation: -
Marital Status: 0 Single ?M31Tied 0 Divorced
Spouses Name: ,kl,tfJ2,'/ A/I JJ
How will payment be made:
Cash Workers Compensation
__ Check /X No fault/Auto Insurance
Nmllc ofCompallY and Address:
Employer:
o Widowed 0 Separated
Health Insurance
Crcdit Card
Primary Care Physician's Name:
Arc YOll currently working? 0 YES ~ NO
If no: rcason for unemployment and Date last worked:
;I?.p~/.>..../
,
*..* WERE YOU HURT AT WORK? 0 YES )it NO
**** WERE YOU HURT IN AN AUTOMOBILE ACClDENT?
Present Complaint/Reason for Seeking Care in this Office:
)& YES 0
d../r:! ./. L-e
NO
What caused yuur symptoms to begin?
/ "
! /2.c-' /; /--<p-n--z.-.
Whell did your symptoms begin?
Pains are: 0 Sharp )'f Dull/ Achc 3' Constant lia On and Off 0 Other
Please mark the exact location of your pain onthc diagram bclow.
Please show any pain refelTaI patterns,
,{ ,
!i \I
(PLEASE COMPLETE REVERSE SlOE)
^ -~,. ~ :ir"~
o
.'
,
SoutlttOWIIS Clliropractic Office
Dr. James J. Dragonette
Dr. Joseph N. Dragonette
4735 Southwestern Blvd.
Hamburg, NY 14075
(716) 648-6161
r;LAlM # CLAIM CASE # DATE OF INJURY NATURE OF INJURY CLAIMANTS
SS#
CLAIMANT 1?oJ.oh $JeeLf.JTJi\J6
l3.MPLOYER .
(NS. CARRIER
IN THE EVENT I FAlL TO PROSECUTE THE CLAIM FOR NO-F AUL T FOR THIS
CONDITION, OR IT IS DETERMINED THAT THIS IS NOT A NO-F AUL T CASE, 1
HEREBY AGREE TO PAY SOUTHTOWNS CHIROPRACTIC
AT 4735 SOUTHWESTERN BLVD., HAMBURG, NY 14075 THEIR USUAL AND
CUSTOMARY FEES FOR SERVICES RENDERED TO THE ABOVE CLAIMANT IN THE
ABOVE IDENTIFIED CASE.
DATE 5~ -"'> -c?/
SlGNATURE~!. ~..:,;
-p
If signed by other than claimant, print below: name, address & relationship to the patient.
Name
Address
Relationship
-
-.
IN\ IlL CONSULTATION RECLi D
() (J n ~ _ I MAY 3 2001
PATIENT: K4J fh. ~6J:.KZNfTntX)ATE:
C.C.! HISTORY: C D C-(5Y"'St, _ 6, ~
/,<.J .It,, ,JJI.er"", rH f3 Lr:- fc
{Co -."..
/7 (PL/
I SIGNS & SYMPTOMS: I
HEAD, NECK, SHOULDERS:
.,."
~2::J;UL
THORACIC SPINE:
/'~ -to - Tf.
LOW BACK, HIP:
CCJY1YT @,;?1a.-..:, 13-51 4~
EXTREMITIES:
P-take. $
- ,)G.'r IAlter_ltf @Let "'......,6vtCH ---7/(;."(74.
'AJuJl'( J/lJ,c"f-. !
,.J~,?l,
-""""" ~ ~'~~,--
~JQENTTREATMENTCANvcr
Name:Kdph -2U<:.4il'1o Date: MAY 3 2001 File# }9&4
c.c. & SYMPTOMS:
- CCS">-7ST @ I~ 7(0-712
- II " II L?-S(f(~
- ,)c<. Ix rNfer,~ f ft @ l.e: .,., ~..,.5J-1&55 --;!Jo- A(.-....<Ld
- c;lf,cp.;.l.~(f ~~'7 ;it 70 ~") ..'-'....~~
HISTORY OF ONSET: SUPPORTS:
~ 20 (<-'
0V1 'II f1 /11/'
/'1 V't4-
l.r-'4,1.t.,
oc l ury~1!
LUMBICUSH
L.B.S.
C. PILLOW
DIAGNOSIS:
.-Jll./[<1'1~' 0
JI~ ~1<;,lO
fr;7. I
8"3'i1 Z I
REFERRALS:
ICE PAK
TX: PLAN
C. COLLAR
"1 J.Y'~I
SIGNIFICANT X-RAY FINDINGS:
TOTAL DISABILITY DATES:
LIGHT DUTY DATES:
REMARKS:
)0 ((
4T~rI ~
IV V
.
131<31,'21382
13:32
.
nERCr ., RHi ~ %"86181
.d.
,
- .~ , -
e
MERCY HOSPITALorBUFFALO
565 Abbott Rd Buffalo. NY 14220
l'lU.b:-l.:.t t,ll:l~14
o
Radiology Sel'"l'ices Result Repl)rt
NAME; SORRENTJNO. RALPH
RAD/MRII: 453342
PRDER#:
NSIROOMfI;
ORDERING DOCTOR:
ATrBNDJNG DOCTOR:
ALTBRNATIl DOCroR:
ADDmONAL DOCTOR I:
ADOmONAL OOCTOR2:
ADDmONAL DOCTOR 3:
ADDmONAL LOCATION:
90001
DOB: 09114/1962
ADMISSION#: G80026481
ORDERED fOR: 09/30/199808;S9AM
RADlDEPT:
XRM
zrmL MOLLY
ZIlTELMOLL Y
ZlTTELMOLLY
ZlTI:EL MOLLY
EXAM REASON: RIO F.B.
EXAMINATION: 09l301l 998 L-S SPINE. AP & LAT
FUll. RESULT:
_ Limited views of the lumbar spine were obtained in anticipation of an MRI examination.. These demonstrate
margmBl osteophyte formation most pronounced at U. The intervertebral discs axe relatively preserved. Th<ere is
llQ evidence of a compression fracture.
IMPRESSION: MILD LOWER LUMBAR SPONDYLOSL').
EXAMINATION: 09/30/\998 ORBITS COMP
FULL RESULT:
_ A limited ct scan of the orbits WlIS obtained 10 exclude a metallic foreign body prior to MJ.U imaging. None
was visualiud.
END OF REPORT
READ BY:MARY L. roRKIEWlCZ, MD.
ELEC"I'llONlCALL Y SIGNED BY:GERALD J. lOYCE, M,D,
DICTATED: 09130/1998
TRANSCRIBED BY: LCI
TRANSCRIBED DATE: 09/30/1998 08:54PM
r~
,.--
.~
NAME:
R () ~e
Q I (J h 00tf'-etH-f/'7{)
.
. DATE:
SEP 2 4 [ii,'
DISABILITY: T P
SUBJECTIVE:
~ L,~. <'tel. L3 -5 { f~
- --r;,'7f''r-E };,hC.
-V.O Lt?< h ~,...,b ~ {,.."L
R.O.M.:
T L
LEVELS:
C
HOME:
ICE'
HMP:
AVOID:
SUPPORT:
OTHER:
T
/'oj /( flt>> T
L / I
~......
~~ " ""'"'iw:<
FILE # ,<11.4
o
ONSET:
RETURN:
OBJECTIVE:
BP I
TTF 710//1
(,3--51((<=>
PLAN:
s:p, it \ fF?;r,
SERVICES: I ~
CMT ~
HMP
ICE
STM
TPT
LF.
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EX. EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
(.)r1 STATIONARY
( ) IMPROVED
( ) REHAB PHASE
COMMENT:
"DATE:
OCT 1 2001
DISABILITY: T P
SUBJECTIVE:
-(fiXe; '7 Ylvf/\oo t. ove.-- "'-'y....J
$,UT .....0 'Y1'-"vVLl,nes 5 t;;'/"(y'
~ 5.<>,,-,,-. L 'li3lT-1"",~E
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T L
HOME:
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AVOID:
SUPPORT:
OTHER:
LEVELS:
C
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ONSET:
RETURN:
OBJECTIVE:
BP I
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L 5-'.5 ( 1c-
PJ-AN:p:A le"v'~7 hol'< Fe/..,
It- lh(/ iV'.f.:,'-#"V -otkr<#IJe
SERVICES: EX. EVAL
CMT K TX
HMP PNF
ICE STRETCH
STM EXERCISE
TPT EXAM
LE NUTRTN.
U.S. OTHER
14.> ~ 1:, - rr/I.f .IM:~
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ASSESSMENT: c,S.,~J.
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( ) EXACERBATED
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( &-STATIONARY
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( ) REHAB PHASE
COMMENT:
c- C' ( ,
/of,
"DATE:
DISABILITY: T P
~ECTIVE:
~ S6Vi
C Ofi E 5 'CiF A-11
lC STikif hU::'lq -L-NS I
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\....u,
LEVELS:
C
R.O.M.:
T L
HOME:
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AVOID:
SUPPORT:
OTHER:
T
L
p
ONSET: .
RETURN:
OBJECTIVE:
BP.';I'CS,s l'lCTc~) ,r:;/i!V( --Iv/lei
PLAN:
SERVICES;
CMT
HMP
ICE
STM
TPT
LE
U.S,
ASSESSMENT:
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COMMENT:
EX. EVAL.
TX
PNF
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EXAM
NUTRTN.
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NAME:
fALf7/-1
AUG 31
Y')~~- ~JI JQ
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'DATE:
DISABILITY: T P
R.O.M.:
T L
T i 0/1 / '?~-r
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L
'DATE:
SEP 17'.!
DISABILITY: T P
SUBJECTIVE:
- ~ l,'!', LS-/~/ t~
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R.O.M.:
T L
LEVELS:
C
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. DATE:
SEP . 1 9 ? :0:
DISABILITY: T P
HOME:
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SUBJECTIVE:
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LEVELS:
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AVOID:
SUPPORT:
OTHER:
0"
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FILE #
/ q 0,'i 0
ONSET:
RETURN:
SUBJECTIVE:-OV :>5 il._,f-,,:--;ie rI' '!Jf100?
~S'otUz. L,G, "'4..il/~C~5T
- 7 -5rrv~ Arly 1- f;,.k;,~If.
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LEVELS: HOME:
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AVOID:
SUPPORT:
OTHER:
OBJECTIVE: ((,t, h~,,"(' Tri'r / TTF L '! S f~~
BP Hlftr'~l(jiJ1t<(3,I'; (uJ!.)-~ SlJ!fU!J)iS'f'f'6.";
vJ~"-l - 01< i !Ef'1'rH'E1' "',ahl"" -0/</ !4.114;"-<-<.<-
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L._~........~~ (rf) ,Jo~' /..A--o ~
r ""
PLAN: - c<r4 c C<' 2.1' ...."'7 - """- f<""': lu~J.,'i
SERVICES:
CMT
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STM
TPT
I.F.
U.S.
ONSET:
~
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PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ASSESSMENT:
I I NEW COMPLAINT
I I EXACERBATED
( ) REGRESSED
(X) STATIONARY
lA-I IMPROVEDLv_b /<,"/~.
( ) REHAB PHASE
COMMENT:
"y'
RETURN:
OBJECTIVE:
BP I
PLAN'
SERVICES: L---
CMT ""
HMP
ICE
STM
TPT
I.F.
U.S.
ONSET:
OBJECTIVE:
BP I
PLAN:
SERVICEy
CMT
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STM
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I.F.
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,- - ,1
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NUTRTN.
OTHER
ASSESSMENT:
( I NEW COMPLAINT
( I EXACERBATED
( I REGRESSED
( <;tSTATIONARY
I ) IMPROVED
( ) REHAB PHASE
COMMENT:
RETURN:
Tr'F L 'f--5 { ,?-~
{;/o,J 170 -(2
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TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ASSESSMENT:
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COMMENT:
NAME:
tiLtH ~/'<0UTlgj
. ""'~
~ .
~--,,'
FILE #
/9&,'1 0
ONSET:
'DATE:
AUG 3 ,"1:1 i
DISABILITY: T P
SUBJECTIVE:
- (j;;;(i5 h"""",b T.clj ->,.f"~
-l,4.~~l+ ""j";; v-,J..,k
-TSf'lVC "'<-kg (ru-/2.
R.O.M.:
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C ICE:
HMP:
T AVOID:
(0 "f). 11C5-r SUPPORT:
,
L OTHER:
. DATE:
AUG 1 a :nn
DISABILITY: T P
SUBJECTIVE:
'- S-qLe !-,6, -nv &,
!JvVVcb.~ {,.to- .
R.O.M.:
T L
LEVELS:
C
HOME:
ICE'
HMP:
AVOID'
SUPPORT:
OTHER:
~
'DATE:
AUG 2 9 Del
DISABILITY: T P
SUBJECTIVE:
.- T -SptiV€ 5 ~!I- 1,$,SCJftf. .
RETURN:
OBJECTIVE:
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L ]-51 (~
PLAN:
SERVICES:,
CMT ~
HMP
ICE
STM
TPT
LF.
u.S.
ONSET:
C or,+ 2;< vJtA
EX. EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
(j) STATIONARY
( ) IMPROVED
( ) REHAB PHASE
COMMENT:
RETURN:
OBJECTIVE:
BP I
PLAN:
SERVICES: .1.---
CMT
HMP
ICE
STM
TPT
LF.
U.S.
ONSET:.
TlF '-3-5 / 1~
'h..xe,,( TI'I'I
EX. EV AL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
(~STATIONARY
( ) IMPROVED
( ) REHAB PHASE
COMMENT:
RETURN:
OBJECTIVE:
BP I O1xecl "T70("
TfF t-r-)(4~
PLAN:
R.O.M.: T L LEVELS: HOME: SERVICES, K EX. EVAL. ASSESSMENT:
C ICE. CMT TX ( ) NEW COMPLAINT
HMP: HMP PNF ( ) EXACERBATED
~((I AVOID: ICE STRETCH ( ) REGRESSED
SUPPORT: STM EXERCISE (-0 STATIONARY
L OTHER: TPT EXAM ( ) IMPROVED
IF NUTRTN. ( ) REHAB PHASE
U.S. OTHER COMMENT:
NAME:~
JUL
- ,"0
56' /"ll?l1/1 n n
FILE # I C:l!,/!
, f
24 ('\l'l!
. DATE:
DISABILITY: T P
ONSET:
SUBJECTIVE:
~~.
OBJECTIVE:
BP I
L \ /3, (~2.1'7'
F51'fVE <A' ~(~ 11~<A,ff-.
PLAN:
R.O.M.:
LEVELS:
C
SERVICES:
CMT ~.
HMP
ICE
STM
TPT
LF.
U.S.
T L
HOME:
ICE'
HMP:
AVOID:
SUPPORT:
OTHER:
T
to/If ,4Cf3T
, /
L
ro~
'DATE:
JUL 2 5 '''WI
(1"'1
ONSET:
DISABILITY: T P
SUBJECTIVE: C-A~
<-AJ~ L ,6- 5~ <I!-,\
OBJECTIVE:
BP I
r
t;y
PLAN:
-
",0 (~J r'rvE ~----.;
R.O.M.:
LEVELS:
C
HOME:
ICE'
HMP:
AVOID:
SUPPORT:
OTHER:
SERVICES: ~
CMT
HMP
ICE
STM
TPT
LF,
U.S.
T L
T /0/11 Pt1y(
L I 1
~.~-'" ~'g;;,
<I
RETURN:
irr:- t. 3 -5 / {~-:">
hI e,/' 'j;oj/I
EX. EV AL
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
( 'tJ STATIONARY
( ) IMPROVED
( ) REHAB PHASE
COMMENT:
RETURN:
r /F L 3- s/1<~-:>
fi..,,=f (10(11
EX. EVAL
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
( -I,-tSTATIONARY
( ) IMPROVED
( ) REHAB PHASE
COMMENT:
'DATE: JUL 3 1 ;,'001 DISABILITY: T P ONSET:. RETURN:
SUBJECTIVE: OBJECTIVE: TTF no -/2
~e>ne TIV/P.. BP I
L ?'-sf.{ ~
5c€f" L ,6. LJ-S( 'I-~
PLAN:
R.O.M.: T L LEVELS: HOME: SERVICES; EX. EVAL ASSESSMENT:
C ICE' CMT Y TX ( ) NEW COMPLAINT
HMP: HMP PNF ( ) EXACERBATED
T ro/(/ AVOID: ICE STRETCH ( ) REGRESSED
/lib ., SUPPORT: STM EXERCISE (41 STATIONARY
L r f OTHER: TPT EXAM ( ) IMPROVED
LF. NUTRTN. ( ) REHAB PHASE
U.S. OTHER COMMENT:
NAME: #1LPf-I ,S~V"/fot"]~;-]()
. DATE: JUL 1 1 " DISABILITY: T P
SUBJECTIVE:
X"",,-<2.- T--7"" )-e
(c:> @) /("'-'<-R-!..
/L..s, t-ih.~
R.O.M.:
T L
LEVELS:
C
T
/O-{L #o~T
L I
'DATE:
JUL 1 8 ,'[\i!
DISABILITY: T P
SUBJECTIVE:
-I." h-...,~ L~ 24'1
-5em.L. L-~, LJ-5/@
R.O.M,:
T L
LEVELS:
C
T
IO-(J..to~T
L
HOME:
ICE:
HMP:
AVOID:
SUPPORT:
OTHER:
- 4-11~ 1"'11
HOME:
ICE'
HMP:
AVOID:
SUPPORT:
OTHER:
-'jjr.IiIlIlmiIlI'~
FILE # 10V)
o
ONSET:
RETURN:
OBJECTIVE:
BP /
7[F
Tlo -/2
L ;-5 ( ( 'f-;>
PLAN:
SERVICES:
CMT ...5.:--
HMP
ICE
STM
TPT
I.F.
U,S.
EX. EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN,
OTHER
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
(~TATIONARY
( ) IMPROVED
( ) REHAB PHASE
COMMENT:
ONSET:
RETURN:
OBJECTIVE:
BP /
ft' '!.ec,( Tlo -/ Z
- '
(71- L"3 - Site"-'>
PLAN:
~
SERVICES:Y
CMT
HMP
ICE
STM
TPT
I.F.
U,S,
EX. EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ASSESSMENT: '
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
( <trBTATIONARY
( 17"IMPROVED
( ) REHAB PHASE
COMMENT:
'DATE:
JUL 2 0 '.
RETURN:
DISABILITY: T P
SUBJECTIVE:
- YtO '! ~,v"'h~ r-cor "Ta/'(
-To/"V?/"!!' SC'IU' 04,~ 0vT
over&le-u. rJJtT4. ,
R.O.M.:
T L
LEVELS:
C
T
IO-fl- "f,;;;r
L '
HOME:
ICE'
HMP:
AVOID:
SUPPORT:
OTHER:
ONSET:,
OBJECTIVE:
BP / TlF 13-::5/ f<-' 9
r1X~( Ti'eJ-/2..
PLAN:
SERVICES: .
CMT <t'
HMP
ICE
STM
TPT
I.F.
U.S,
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
( <Y STATIONARY
(4!'MPROVED
( ) REHAB PHASE
COMMENT:
EX. EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
NAME: fa /Ph ,JOf'/1-YI!1n9
JUL 320m
'DATE:
DISABILITY: T P
f{/v..,j, -7 ,-..a..
HOME:. .
ICE:
HMP:
AVOID:
SUPPORT:
OTHER:
T
I () I 1/ tJo;, r
L I 1
, DATE:
JUL 6 ~'Y':
DISABILITY: T P.
SUBJECTIVE:
__ Sa"'-'2. T -:;11'~t IC;5,
.---ittlf$- t:v-.-dl ):-~ <%-~lk5
CtIV{- ~ t 1-0,...... (~IuLj/
R.O.M.: C T L LEVELS: HOME: .
I C ICE.
I HM~
IT.; AVOID:
(0 II oaT SUPPORT:
L ( f OTHER:~
~\,!iiT.
~C1~SJ\\ _
'DATE:
JUL
9 '''.'0.1
I..l"
DISABILITY: T P
SUBJECTIVE:
hu Coh~ (u~,
I"
~'~
'~I
FILE #
/4tt!
o
ONSET:
RETURN:
OBJECTIVE:
BP /
J;~..( If fi 2
trr:: t.. ;--)/ " e--;7
PLAN:
SERVICES: ~.
CMT
HMP
ICE
STM
TPT
LF.
U.S.
EX. EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
( 6fSTATIONARY
( ) IMPROVED
( ) REHAB PHASE
COMMENT:
ONSET:
RETURN:
OBJECTIVE:
BP /
h/(ecI Tfrj/c
(TrO/51 f"C'->
PLAN:
SERVICES: ~.
CMT
HMP
ICE
STM
TPT
LF.
U.S.
ASSESSMENT: ,
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
( ~TATIONARY
( ) IMPROVED
( ) REHAB PHASE
COMMENT:
EX. EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ONSET: .
RETURN:
OBJECTIVE:
BP /
TTF L 3-j(1~
IT/f!ll-
PLAN:
C~~"fvJq
R.O.M.: T L LEVELS: HOME: SERVICES: . EX. EVAL. ASSESSMENT:
C ICE. CMT K TX ( ) NEW COMPLAINT
HMP: HMP PNF ( ) EXACERBATED
T AVOID: ICE STRETCH ( ) REGRESSED
/0(" ilh{ SUPPORT: STM EXERCISE ( X)'STATIONARY
L I OTHER: TPT EXAM ( ) IMPROVED
LF. NUTRTN. ( ) REHAB PHASE
u.S. OTHER COMMENT:
NAME: ~l!f11 ,');;(ir~(f-t'f?;()
JUN 1 1 ;'001
. DATE:
DISABILITY: T P
T
(0 -II fJP5T
L I
HO E:
ICE'
HMP:
AVOID:
SUPPORT:
OTHER:
Wt hv WI
. DATE:
JUN 1 3 {Wi
DISABILITY: T P
SUBJECTIVE:
- uy .. -.....u ---? k""-<<-o
-{.,(?,. d-C"o
I---t;/,,"E S<ftU@rft{ft
R.O.M.:
T L
LEVELS:
C
HOME:
ICE'
HMP:
AVOID:
SUPPORT:
OTHER:
T
/0-11 tf.::H
L /
-~,
. DATE:
JUN 1 8 ,'001
DISABILITY: T P
SUBJECTIVE:
_ Thorl((ll YIfA-E 5frll
t r~' 5f-Tlf <!(SYISf. ~ (
/'K
v, S: HOME:
ICE'
HMP:
AVOID:
SUPPORT:
OTHER:
FILE # (fi~-1
ONSET:
~-- v~ " ~ ~ 1,;;L
0....
"- .-
RETURN:
SUBJECTIVE: .. j, r T d .: L~.. OBJECTIVE:
_ J... ' .{?, 5e-/l..€.../.fJ"H5T "'..... jot "'. I~ BP /
- T., 1'''''<= ~ sf,//vlu/Iy buf-
hC7( Covlsl f ..."1 &'5 /iJ~e <>-,.1./
PLAN:
- '1v Le. h u...,.~ He ~
C T L LEVELS:
I C
I
I
TtF 117//
[ 3-f/ '(
rc/
SERVICES:
CMT
HMP
ICE
STM
. TPT
I.F.
U.S.
% EX. EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
( TSTATIONARY
( O1IMPROVED
( ) REHAB PHASE
COMMENT:
ONSET:
RETURN:
OBJECTIVE:
BP /
"(IF (rt./
LyS((~
PLAN: c.~ ~~.Jklfl/
SERVICES:k
CMT
HMP
ICE
STM
TPT
I.F.
U.S.
ONSET:
OBJECTIVE:
BP /
PLAN:
EX. EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
( <tf"STATIONARY
( ) IMPROVED
( ) REHAB PHASE
COMMENT:
RETURN:
'rrF T1cf//
LJ-S/~""?
SERVICES; k'
CMT
HMP
ICE
STM
TPT
I.F.
U.S.
EX. EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
( ~TATIONARY
( ) IMPROVED
( ) REHAB PHASE
COMMENT:
" ~ IlIl!i!iiIlIlIi
NAME: ~ L .fJ ;-1
JUN
" ~K fFi\l!)O
2001 DISABILITY: T P
. DATE:
SUBJECTIV~ >O>'t-e lei t> (.&1 E5 " (. <oo..iZr 7-<:
v ,,/,Nvt?
(]PL,f3,f, t'2ef.<.A.<<,,~s C<~q (~'Ir
tJ,J{ ~ L0 ~A; ,c _
R.O.M.:
T L
LEVELS:
C
HOME:
ICE:
HMP:
AVOID:
SUPPORT:
OTHER:
. DATE:
JUN 6 2001
DISABILITY: T P
o
FILE # / t;j (JJ
.
ONSET:
OBJECTIVE:
BP I
Jli:i&!J;,
RETURN:
TfF2 T'I-~
((U -/2
L3--S I <( ~~
I!j~~/:;/;
PLAN:
SERVICES: K
CMT
HMP
ICE
STM
TPT
I.F.
U.S.
EX. EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ONSET:
SUBJECTIVE: ' ;; / / /. / . /. . ~ OBJECTIVE:
_:nO )""'"<-- [b( D/4rl"f ./,Me (P-f< BP I
- L .".,,-(2
v.. v
(t.5'~S( 1~
&, h t/Wl6lMt!J> fzl
R.O.M.:
T L
HOME:
ICE'
HMP:
AVOID:
SUPPORT:
OTHER:
LEVELS:
C
T
lo-re. VI
I
L
. DATE: JUN 8 20rll
DISABILITY: T P
. SUBJECTIVE: r-^- ~TG.A"e5 C.c Co (5 /lv'7'
bv?lv f-td1t ~ fa.-.:.. ft....... fJ, r: -I,el.
- L .13 'fIP t--~ ~ jrvWlJ, To {I.< J -17,74,
R.O.M.:
T L
LEVELS:
C
HOME:
ICE'
HMP:
AVOID:
SUPPORT:
OTHER:
T (0-(1. ()(b r
( ,
L
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
( .J.f.sTATIONARY
( ) IMPROVED
( ) REHAB PHASE
COMMENT:
RETU.RN:
~f If T (O-n..
t 3-YI f ~'>
PLAN:
SERVICES:
CMT
HMP
ICE
STM
TPT
I.F,
U.S.
~
EX. EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ONSET:.
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
(-\;tSTATIONARY
( . ) IMPROVED
( ) REHAB PHASE
COMMENT:
RETURN:
OBJECTIVE:
BP I rrP T/o-n
L3-j,.;~
PLAN: C~
SERVICES~
CMT K'
HMP
ICE
STM
TPT
I.F.
U.S.
Zr- vV/::/.
EX. EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
~ hr"v /?~Pl:
/
ASSESSMENl'
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
( c\-jSTATIONARY
( ) IMPROVED
( ) REHAB PHASE
COMMENT:
NAME: 4Lf~:f ~)t:/'K<Tlm
MAY 2 1 2001
. DATE:
DISABILITY: T P
SUBJECTIV~. .
- ~ T-5f~ f t -$, "G1J
~ 5--h/( 1A45 c1~ffr~,,17 ,j.'f'7 7'
ro1o-.'1d V-Ia...U, ! 2f.'-'i ...-.-6,.e)f
R.O.M.:
T L
HOME:
ICE:
HMP:
AVOID:
SUPPORT:
OTHER:
LEVELS:
C
T
10 -I 2. >/bYT
I
L
. DATE:
MAY 2 5 21;\1:
DISABILITY: T P
SUBJECTIVE:.-".h.
-7~ -) ~'~ (~J",-L &!fe.
5f'Y5 vv ft-J f I?
- }1ofr rldtff I/."'?-Ife/ l~fjv1 lief,.
{ItA ~ f J..;
R.O.M.:
. DATE:
MAY 29 2001
DISABILITY: T P
SUBJECTIVE: L .i
- '0. )(J~ ~ Ce'i~ @)!/IvW!b-?;>l(ruiJ.
- ~7 -r---SI'v<E
R.O.M.: T L LEVELS: HOME:
C ICE'
HMP:
T f"r AVOID:
10-(1. SUPPORT:
L OTHER:
FILE #
ONSET:
OBJECTIVE:
BP I
PLAN:
SERVICES: ~.
CMT
HMP
ICE
STM
TPT
I.F,
U.S.
ONSET:
OBJECTIVE:
BP I
PLAN:
SERVICES:
CMT -.1.-
HMP
ICE
STM
TPT
I.F.
U.S,
ONSET:
OBJECTIVE:
BP I
PLAN:
SERVICES:
CMT ~
HMP
ICE
STM
TPT
I.F.
U.S.
~'- "
,<~-~ ~~;,'
/1ttf 0
RETURN:
7IF TfU-I2.
t 3 --:5 I (/<; 'i7
EX. EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
(0 STATIONARY
( ) IMPROVED
( ) REHAB PHASE
COMMENT:
RETURN:
iff: L3-5( (.c--->
Tlf)- i2
EX, EV AL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
(.11 STATIONARY
( ) IMPROVED
( ) REHAB PHASE
COMMENT:
RETURN:
T7F- TIC! -t<?
L "'-51 (.& "...
EX. EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
( ~STATIONARY
( ) IMPROVED
( ) REKAB PKASE
COMMENT:
NAME: ;e;L~h ..5};J?K'elqfjn~ 0
MAY 9 2001
"DATE:
DISABILITY: T P
~
~,
FILE # /1t-4
o
ONSET:
RETURN:
SUBJECTIVE: L / p OBJECTIVE:
- <!15 ...~",",-I, ""'-" d'l S'-' -r;,I<--?K""'-'.I BP I
- L</~3. Scn.e@L3-51
~ Le'5s T~M( -r-~I7'r'C I~
R.O.M.:
T L
~~~!l;=E:
HMP:
AVOID: ~
SUPPORT:
OTHER:
LEVELS:
C
T
(0-/2 /lelsr
,
L
"DATE:
MAY 1 1 ZOO1
DISABILITY: T P
SUBJECTIVE;.. T-'-..s'P''''';;.5",,-<- .$4-, II <"0SY0.!> T J, uT
Ie:;.., IN.feMe.
~ he! ove-J.I cJ,,().~ ;. .L6/i
Cr/o,Jv'15
R.O.M.:
LEVELS:
C
HOM!;:,.
ICE' >1'f7'1r:
:~~~' "
SUPPOR
OTHER:
T L
T
/0"/2. de6t
L 'I
TTF I/O'-/~
L 3-5/~<---"",
PLAN:
SERVICES: I "
CMT ~
HMP
ICE
STM
TPT
I.F.
U.S.
EX. EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
( ~STATIONARY
( ) IMPROVED
( ) REHAB PHASE
COMMENT
ONSET:
RETURN:
OBJECTIVE:
BP I
Tr ,- 1/0 -, ( Z
I p-
i '3 -5/ ~c-'"
PLAN:
V"L1. 0V1. F: it,
SERVICES: ,""
CMT ~
HMP
ICE
STM
TPT
I.F,
U.S.
EX. EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( )REGRESSED
( -:!TSTATIONARY
( ) IMPROVED
( ) REHAB PHASE
COMMENT:
"DATE: MAY 18 2001 DISABILITY: T P ONSET:. RETURN:
SUBJECTIV,=-I" ..,J 90 ""'" T -<---y"" . '-, 61. OBJECTIVE: ,TIT
BP I T/c -(.!:.
I'~ ~ ....' L J.. S I f<:'-'>
2r. - ~ ~ 1.5{.ltll~..,ff
r@ t.v...,J.'<S~. PLAN:
- 'FJ: rl'f <LV; rfdvll (C<ftofS
T l lEVELS: HOM3: SERVICES: EX. EVAL. ASSESSMENT:
C ICE 4jrt<. E? CMT ~" TX ( ) NEW COMPLAINT
HMP: HMP PNF ( ) EXACERBATED
T AVOID:$. ICE STRETCH ( ) REGRESSED
{iJ-/l.- rOST SUPPORT: STM EXERCISE (~) STATIONARY
L OTHER: TPT EXAM ( ) IMPROVED
I.F. NUTRTN. ( ) REHAB PHASE
U.S. OTHER COMMENT:
-. ~~~"~'"'
ff1 C
NAME: L-Ph, ~R!e,,,finD
FILE It fit, ~
o
. DATE: !jAY 3 ZQQl
DISABILITY: T P
ONSET:
RETURN:
SUBJECTIVE:
.:?CE C'o-.-<>,-,if S/-(Ol
OBJECTIVE:
BP / SEer G <f"~ S-/3/0i
PLAN: 3-2-1
R.O.M.: T L LEVELS: HOME: t SERVICES: EX. EVAL. ASSESSMENT:
C ICE' j' I!fbt - CMT ~ TX ( ~NEW COMPtlNT
HMP: / HMP PNF ( ) EXACERBA ED
T 4-r AVOID: 4&..;' ICE STRETCH ( ) REGRESSED
IO/rZ SUPPORT: STM EXERCISE ( ) STATIONARY
L ( OTHER: TPT EXAM X ( ) IMPROVED
,
LF. NUTRTN. ( ) REHAB PHASE
u.s. OTHER COMMENT:
. DATE:
MAY 4 2001
DISABILITY: T P
ONSET:
RETURN:
SUBJECTIVE:
?70 C t1"'~
......~
OBJECTIVE:
BP /
TTF
710- Tic
L 3--S I (<!'-;">
PLAN: iF ~, >7 ~T .....vIe':'".
v....{o'"
R.O.M.: T L LEVELS: HOME: SERVICES~ EX. EVAL. ASSESSMENT:
C ICE' ~ r:- CMT TX ( ) NEW COMPLAINT
HMP: HMP PNF ( ) EXACERBATED
T AVOI~ ICE STRETCH ( ) REGRESSED
,oj 12. pDST SUPPORT: STM EXERCISE ( ~STATIONARY
L . I OTHER: TPT EXAM ( ) IMPROVED
LF. NUTRTN. ( ) REHAB PHASE
U.S. OTHER COMMENT:
"DATE:
MAY 7 2001
DISABILITY: T P
ONSET:.
RETURN:
SUBJECTIVE:
- T-Stl,vE "L~ koser- hvr
S-{-rl! (O....q Xl<-e
-).,0 t. ~"t1. .....; L, .'3jLep-
R.O.M.: T l LEVELS: HOME:
C ICE' ~A r:
T fcF {Z t1I7.l r ~:~.
L I' OTHE;~
OBJECTIVE:
BP /
TTF 1(0-/7
i]-51 i<<---'>'
PLAN:
ASSESSMENT:
( ) NEW COMPLAINT
( ) EXACERBATED
( ) REGRESSED
(-\1 STATIONARY
( ) IMPROVED
( ) REHAB PHASE
COMMENT:
SERVICES:
CMT <'('
HMP
ICE
STM
TPT
IF
U.S.
EX, EVAL.
TX
PNF
STRETCH
EXERCISE
EXAM
NUTRTN.
OTHER
-
"-.liW-"~:i':
NAME:~Lt:Jh ~'J~K'er?tf7()
,
Height: Weight:
C!':RVICAL EXAM
'.jDDA TE:
I3P: I
3 2001 FILE #_ .~.f
Age _ Dominant Hand:
NOTES:
L
MAY
R
Cervical Comnression + -
Cervical, Distraction + -
Max. Foram. Comn, + - R L
Valsalva's + -
O'[lonahues + -
Shoulder Deoression + - R L
5010 Hall + ,
Georne's Test + - R L
Cervical ROM Normal Actual Painful
Fle)tion 50 Y N
Extension 60 Y N
Richl Lal Flex 45 y N
LeflLal Flex 45 y N
Rinht Rotation 80 Y N
Lefl Rolalion 80 y N
Lumbar ROM
Fle)(ion 90 4u : ,'V' N
Extension 30 10 N
Rin"' Lal Flex 25 10 N
Lefl Lal Flex 25 ftT I rlN
LUMBAR EXAM
Minor's sl n
B Test
e fToe Walk
Ex\' Halllcus
Milgram's
SLfl
Bra ard's Test
Bowstrin Test
Valsalva's
Gillis
El's
Nachlas
Fabre
Hoover's
Bowel/Bladder D s.
DernUllollles
I'.
I'alpalion Findings:
TTf
(/0 -- T 12
L-J-.5( 1~
PAIN
(No Pain) 0 I 2 3 4 5
') 10 (Worst Pain)
Reflexes
R1uht Left Rh,ht Left RIghI Left
C5 t I t I L2 t I t 1 Triceps
C6 t I t I L3 t l?r " I BiceDs
C7 t 1 t 1 L4 I I Brach.
C8 t I t I L5 ,AI+_ I Patellar t2. rZ
'"V117"'r
T1 i I i 1 S1 i I i I Achilles n -f"L
~, ......,""~_&-t,
State Farm
C
Insurance
o
Companies
STAn fARM
,.
INSURANCE
o
February 1, 2002
PO Box 1071
Buffalo, NY 14240,1071
716,635-6000
James Dragonette,
4735 Southwestern
Hamburg, NY 14075
DC
Boulevard
RE: Claim Number 52-2092-063
Date of Loss April 19, 1998
Our Insured Ralph J. Sorrentino
Patient Ralph J. Sorrentino
Account Number: N01964 **FINAL REQUEST**
Date(s) of Service: 8/10-10/1/01
Dear Dr Dragonette, DC:
We have received your bill for treatment rendered to the above
patient on 8/10-10/1/01.
There will be a delay in payment of your bill. We need the
office notes assoicated with this claim.
please call me if you have any questions or wish to discuss this
further.
Sij.relYW
~~kOWSki
Claim Expediter
(716) 635-6008 Ext.
State Farm Mutual Automobile Insurance Company
Your acceptance of our request for your services and your
performance of those services are expressly conditioned on and
subject to your agreement that: (1) you will not use customer
information we provide for any purpose other than the specific
services we are asking you to perform, and (2) you will disclose
or share customer information we provide only to the extent
necessary to accomplish the services that we request.
HOME OFFICES: BLOOMINGTON, ILiJNOIS 61710,0001
J',
,1!l;1;iffl!'!V.
cSc~~~ 0
DR. JAMES J. DRAGONETTE
DR. JOSEPH N. DRAGONETTE
4735 Southwestern Blvd,
Hamburg, NY 14075
(716) 648-6161
February 4, 2002
Lisa Malikowski
State Farm Insurance Companies
P.O. Box 1071
Buffalo, N.Y. 14240-1071
RE: Patient: Ralph Sorrentino
Claim Number: 52-2092-063
D/A: 4/19/98
Dear Lisa Malikowski,
Pursuant to our phone conversation of today's date please
accept this letter as a cbrrection regarding the diagnosis on
past bills submitted for Mr. Ralph Sorrentino. As we discussed,
we had the wrong diagnosis listed for Mr. Sorrentino on previous
claims sent. The correct diagnosis is as follows:
1.) 724.4 Lumbar Radiculitis
2.) 846.0 Lumbar sprain/strain
3.) 839.20 Lumbar subluxation
4.) 847.1 Thoracic sprainlstrain
5.) 839.21 Thoracic subluxation
Future claims, if any, for Mr. Sorrentino will reflect the
correct diagnosis. Also, please find attached copies of all daily
office notes regarding treatment in this office. Should you require
any additional information please feel free to contact me at my
office.
JJD/sd
DC
enc.
~- -
""'~",",,"~\1i\"
NEW Yor'-.oTOR VEHICLE NO-FAULT W ~NCE LAW
W DENIAL OF CLAIM FORM W
(For Persona/Injuries Sustained On and After 1211f77)
ro INSURER: ~?mplete this form, including ite":, 31. S~nd 2 copies to applicant. Upon the request of the injured person, the insurer should send to the
Injured person a copy of all prescribed claIm forms and documents submitted by or on behalf of the injured person.
Name and Address of Insurer or Self-Insurer
State Farm Insurance Claim Office
Po Box 1071
Buffalo, NY 14240-1071
"AU'"''
A
'"'''UNCi,
For American Arbitration Association Use Only
A, POlicyholder B. Policy Number
Ralph Sorrentino 6124-701-520
F. Applicant for Benefits (Name and Address)
Dr. James Dragonette
4735 Southwestern Boulevard
Hamburg, NY 14075
C. Date of Accident D. Injured Person
Ralph Sorrentino
E. Claim No.
52-2092-063
G. As Assignee
1. [8] Yes 2.0 No
TO APPLICANT: SEE REVERSE SIDE /F YOU WISH TO CONTEST THIS DEN/AL
YOU ARE ADVISED THAT FOR REASONS NOTED BELOW:
o 1. Your entire claim is denied as follows:
[]] 2. A portion of your claim is denied as follows:
D A. Loss of Earnings: $ D D, Interest: $
~ B, Health Service Benefits: $ 517.80 D E. Attorney's Fees: $
D C, Other Necessary Expenses: $ D F, Death Benefit: $
REASONS FOR DENIAL OF CLAIM: (CHECK REASONS AND EXPLAIN BELOW IN ITEM 31)
POLICY ISSUES
D
D
D
D
D
D
3. Policy not in force on date of accident.
4. Injured person excluded under policy conditions or exclusions.
5. Policy conditions violated.
6. Injured person not an "Eligible Injured Person".
7. Injuries did not arise out of use or operation of a motor vehicle.
8. Claim not within scope of your election under Optional Basic
Economic Loss coverage.
LOSS OF EARNINGS BENEFITS DENIED
D
D
9. Period of disability contested:
Period in dispute: From
10. Claimed loss not proven.
o 11. Exaggerated earnings claim of $
D 12. Statutory offset taken.
D 13. Other, explained below.
OTHER REASONABLE AND NECESSARY EXPENSES DENIED
14. Amount of claim exceeds daily limit of coverage. 0 16. Incurred after one year from date of accident.
15. Unreasonable or unnecessary expenses. D 17. Other, explained below.
per month denied.
Through
D
D
D
D
18. Fees not in accordance with fee schedules.
HEALTH SERVICE BENEFITS DENIED
o 20. Treatment not related to accident.
D
21. Unnecessary treatment, service or hospitalization:
From Through
~ 22. Other, explained below,
COMPLETE ITEMS 23 THRU 30 IF CLAIM FOR HEAL TH SERVICE BENEF/TS IS DENIED
19. Excessive treatment, 'service orl1ospitalization:
From Through
23, Provider of Health Service (Name, Address and ZIP Code) . 25. Date of Bill 28, Amount of Bill
Dr. James Dragonette I. 6/28/01 to 8/9/01 $ 517.80
4735 Southwestern Boulevard 28, Date Received by Insurer 29. Amount Paid by Insurer
Harnburo, NY 14075
24. Type of Service Rendered 7/7/01 to 8/17/01 $00.00.
Chiropractic 27. Period of Bill 30. Amount in Dispute
5/18/01 to 8/3/01 $ 517.80
31. Slate reason for denial, fully and explicitly (allach extra sheets if needed):
Further consideration will be given upon receipt of office notes. These have been requested on
two occasions. If you have any further information you wish to submit, we will reconsider our
position.
PHONE NO. (7161
160,4';40.1'; 11,1~99
635-6029 EXT:
(NF,10 Eff 12,01,1999)
Katie Travis, Claim Specialist
Name and Title of Representative of Insurer
cc: Ralph Sorrentino c/o Attorney Paul Beltz
DATE: October 23, 2001
Page 1 0 2 (Continue on Page 2)
,',
";"!I...-,;;
NEW YO~ "e.. OTOR VEHICLE NO-FAULT II
DENIAL OF CLAIM FORM
(For Personal Injuries Sustained On and After 12/1n7)
fO INSURER: Complete this form, including item 31. Send 2 copies to applicant. Upon the request of the injured person, the insurer should send to the
injured person a copy of all prescribed claim forms and documents submitted by or on behalf of the injured person.
Name and Address of Insurer or Self-Insurer ·
For American Arbitration Association Use Only
State Farm Insurance Claim Office
Po Box 1071
Buffalo, NY 14240-1071
...".....
A
~NCELAW
'''"'''U'''~
A. Policyholder
Ralph Sorrentino
B. Policy Number
6124-701-52D
C. Date of Accident D. Injured Person
Ralph Sorrentino
E. Claim No.
52-2092-063
G. As Assignee
1, o Yes 2.DNo
F. Applicant for Benefits (Name and Address)
Dr. James Dragonette
4735 Southwestern Boulevard
Hamburg, NY 14075
TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO CONTEST THIS DENIAL
YOU ARE ADVISED THAT FOR REASONS NOTED BELOW:
o 1. Your entire claim is denied as follows:
[RI 2. A portion of your claim is denied as follows:
D A. Loss of Earnings: $ 0 D. Interest: $
[19 B, Health Service Benefits: $ 517. 80 D E. Attorney's Fees:
o C. Other Necessary Expenses: $ 0 F. Death Benefit: $
REASONS FOR DENtAL OF CLAIM: (CHECK REASONS AND EXPLAIN BELOW IN ITEM 31)
POLICY ISSUES
D
D
D
$
D
D
D
3. Policy not in force on date of accident.
4. Injured person excluded under policy conditions or exclusions.
5. Policy conditions violated.
6. Injured person not an "Eligible Injured Person".
7. Injuries did not arise out of use or operation of a motor vehicle.
8. Claim not within scope of your election under Optional Basic
Economic Loss coverage.
LOSS OF EARNINGS BENEFITS DENtED
D 11. Exaggerated earnings claim of $
D 12. Statutory offset taken.
o 13. Other, explained below.
per month denied.
D
D
9. Period of disability contested:
Period in dispute: From
10. Claimed loss not proven.
Through
OTHER REASONABLE AND NECESSARY EXPENSES DENIED
o 14. Amount of claim exceeds daily limit of coverage. D 16. Incurred after one year from date of accident.
o 15. Unreasonable or unnecessary expenses. 0 17. Other, explained below.
o 18. Fees not in accordance with fee schedules.
D
21. Unnecessary treatment, service or hospitalization:
From Through
[19 22. Other, explained below.
COMPLETE ITEMS 23 THRU 30 IF CLAIM FOR HEAL TH SERVICE BENEFITS IS DENIED
19. Excessive treatment, service or hC?spitalization:
From Through
HEALTH SERVICE BENEFITS DENIED
o 20. Treatment not related to accident.
D
23. Provider of Health Service (Name, Address and ZIP Code) . 25. Date of Bill 28. Amount of Bill
Dr. James Dragonette 6/28/01 to 8/9/01 $ 517.80
4735 Southwestern Boulevard 26. Date Received by Insurer 29. Amount Paid by Insurer
Hambura, NY 14075
24. Type of Service Rendered 7/7/01 to 8/17/01 $ 00.00
Chiropractic 27. Period of Bill 30. Amount in Dispute
5/18/01 to 8/3/01 $ 517.80
31. State reason for denial, fully and explicitly (attach extra sheets if needed):
Further consideration will be given upon receipt of office notes. These have been requested on
two occasions. If you have any further information you wish to submit, we will reconsider our
position.
cc: Ralph Sorrentino c/o Attorney Paul Beltz
DATE:
PHONE NO. (716)
160,4540.15 11,1999
October 23, 2001
635-6029 EXT:
(NF,10 Eff.12-01-1999)
Katie Travis, Claim Specialist
Name and Title of Representative of Insurer
'"'""'1Iiti.
"'-'r~Rt--
o
State Farm Insurance
.
Companies
STAn FARM
A
INSURANCI
.
October 10, 2001
PO Box 1071
Buffalo, NY 14240,1071
716,635,6000
James Dragonette,
4735 Southwestern
Hamburg, NY 14075
DC
Boulevard
RE: Claim Number 52-2092-063
Date of Loss April 19, 1998
Our Insured Ralph J. Sorrentino
Patient Ralph J. Sorrentino
Account Number: N01964
Date(s) of Service: 8/10-10/1/01
Dear Dr Dragonette, DC:
We have received your bill for treatment rendered to the above
patient on 8/10-10/1/01.
There will be a delay in payment of your bill. We need the
office notes assoicated with this claim.
Please call me if you have any questions or wish to discuss this
further.
Sincerely,
) c~-,fl\~~kl?
tlsa Malikowski for Katie
PIP Expediter Claim
(716) 635-6029 Ext.
Travis
Specialist
State Farm Mutual Automobile Insurance Company
lam
Your acceptance of our request for your services and your
performance of those services are expressly conditioned on and
subject to your agreement that: (1) you will not use customer
information we provide for any purpose other than the specific
services we are asking you to perform, and (2) you will disclose
or share customer information we provide only to the extent
necessary to accomplish the services that we request.
HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001
~ ~.
" ~
-
~"~, U1ili'
.
State Farm Insurance
CD
Companies
STATE FARM
A
IfrrlSURANCI
o
September 20, 2001
POBox 1071
Buffalo, NY 14240,1071
716,635,6000
James Dragonette, DC
Attn: Billing Dept.
4735 Southwestern Boulevard
Hamburg, NY 14075
RE: Claim Number 52-2092-063
Date of Loss April 19, 1998
Our Insured Ralph J. Sorrentino
Patient Ralph J. Sorrentino
Account Number: N01964
Date(s} of Service: 5/18 - 8/3/01
Dear Dr. Dragonette:
We have received your bill for treatment rendered to the above
patient on 5/18 - 8/3/01.
There will be a delay in payment of your bill, Office notes are
required for processing. FINAL REQUEST BEFORE DENIAL
Please call me if you have any questions or wish to discuss this
further.
Sincerely,
f.,( n n_ . ~
[~U
Katie Travi
Claim Specialist
(716) 635-6029 Ext.
State Farm Mutual Automobile Insurance Company
Your acceptance of our request for your services and your
performance of those services are expressly conditioned on and
subject to your agreement that: (1) you will not use customer
information we provide for any purpose other than the specific
services we are asking you to perform, and (2) you will disclose
or share customer information we provide only to the extent
necessary to accomplish the services that we request.
cc: Ralph Sorrentino
Atty. Paul Beltz
HOME OFFICES: BLOOMINGTON, ILLINOIS 61710,0001
-
""'-'"
~e
State Farm Insurance
.
Companies
STATE fARM
A
INSURANCE
.
August 21, 2001
PO Box 1071
Buffalo, NY 14240,1071
716,635,6000
James Dragonette,
4735 Southwestern
Hamburg, NY 14075
DC
Boulevard
RE: Claim Number 52-2092-063
Date of Loss April 19, 1998
Our Insured Mary Ann A. Sorrentino
Patient Ralph Sorrentino
Account Number: N01964
Date(s) of Service: 5/18-8/3/01
Dear Dr Dragonette, DC:
We have received your bill for treatment rendered to the above
patient on 5/18-8/3/01.
There will be a delay in payment of your bill. We need the
office notes assoicated with this claim.
Please call me if you have any questions or wish to discuss this
further.
Sincerely,
f;S0 (Y)~hv~)~
Lisa Malikowski for Katie Travis
PIP Expediter Claim Specialist
(716) 635-6029 Ext.
State Farm Mutual Automobile Insurance Company
lam
Your acceptance of our request for your services and your
performance of those services are expressly conditioned on and
subject to your agreement that: (1) you will not use customer
information we provide for any purpose other than the specific
services we are asking you to perform, and (2) you will disclose
or share customer information we provide only to the extent
necessary to accomplish the services that we request.
HOME OFFICES: BLOOMINGTON, ILLINOIS 61710,0001
<-, ~~L
fD
o
AIM NO 52-2092-063
POLlCY NO 6124-701-520
LOSS DATE
4/19/1998
PAYMENT NO 1 28310999 J
DATE 2/27/2002
AMOUNT $844.64
TIN 52-161343554
:':,:~::etJy~:f~':"-e,.::b~~dr:li':' t,:l::6r{:::':'-':: :::-:.:;::::>:::::':::::...,--:\)}{tt\::}::::\\,:\i\(j1i:)uni/': \\}t6'C :\Pir')::Cct
ERSONAL INJURY PROTECTION $844.64 051 2
"
ENTERED BY O'MARA, ROSE
AUTHORIZED BY TRAVIS, KATIE
PHONE (716) 635-6029
MARKS RE:RALPH SORRENTINO #N01964-020802A 005:5/3-10/1/01
If"'" ,...
A
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY
N.V....NCl
.
NORTH ATLANTIC OFFICE
BALLSTON SPA, NY
BUFFPIP Z8-378 L049
THE ADIRONDACK TRUST COMPANY 50-288/213
SARATOGA SPRINGS, NY
1 28 310999 J
2/27/2002
ISURED SORRENTINO, RALPH
CLAIM NO 52-2092-063
LOSS DATE 4/19/1998
t***************.************************************EXACTlY EIG~T HUNDRED FORTY-FOUR Arm 64/100 DOLLARS $::~::W:;*:t.::W::~:'~:::8::ijif!<:',S:4:
ry to the .
Irderol: JAMES DRAGONETTE, DC ON BEHALF OF RALPH J. SORRENTINO
4735 SOUTHWESTERN BOULEVARD
HAMBURG NY 14075
APPROVED BY
LAIM NO 52-2092-063
POLlCY NO 6124-701-520
LOSS DATE
4/19/1998
PAYMENT NO
DATE
AMOUNT
TIN
1 28310999 J
2/27/2002
$844.64
52-161343554
""'\I$\i~bi".i;Jji;.ed.'.fjiin))' """"""\"}'\"\\}},}'I'I",,)\iiiQUiif"}'\:,"COL ""hIed':
PERSONAL INJURY PROTECTION $844.64 051 2
RETAIN STUB FOR RECORDS
AUTHORIZED BY TRAVIS, KATIE
PHONE (716) 635-6029
EMARKS RE:RALPH SORRENTINO #N01964-020802A 005:5/3-10/1/01
.
"
c~......
~, . ..:..r:!i;';
CD
State Farm Insurance
.
Companies
STATE FARM
A
IKS\SI\A.NCt
@
May 24, 2001
305 Cayuga Rd,
Suite 180
Cheektowaga, NY 14225
716,635,6000
James Dragonette, DC
Attn: Billing Dept.
4735 Southwestern Boulevard
Hamburg, NY 14075
RE: Claim Number 52-2092-063
Date of Loss April 19, 1998
Our Insured Ralph J. Sorrentino
Patient Ralph J. Sorrentino
Account Number:
Date(s) of Service: 5/3 - 5/11/01
Dear Dr. Dragonette:
We have received your bill for treatment rendered to the above
patient on 5/3 - 5/11/01.
There will be a delay in payment of your bill. Office notes are
required for processing.
Please call me if you have any questions or wish to discuss this
further.
Sincerely,
~~ it: //LtN\ \ jp
Katie Travis
Claim Specialist
(716) 635-6029 Ext.
State Farm Mutual Automobile Insurance Company
HOME OFFICES: BLOOMINGTON, ILLINOIS 61710,0001
--~
,- ~"-
,-, O~t ~ -- _eo
e
Bram RIegel, M.D~ P.A. 0
Cu-Is1IDeJ. Weot, M.D.
Spme mil Sports )I""......
RehablIltatlon
PATIENT REGISTRATION FORM
PATIENT INFORMATION:
r
NAME: f2.,ALP/-I ;f)opl2rJJ(/jJ()
ADDRESS: It", 1(J ~'c. ,e'",~y /b/P-I
CITY: ,SO I'f,f It ..s D fir
socw.SECURITY #: 01 () :z /; 1 h / r
I
DATE OF BIRTH: I / -}- 3-S-
PIA.C.I OF EMPLOYMENT: -- f e. ];'.r r ..'
EMPLOYERS ADDRESS:
SPOUSE: ~V41/AL S',e~e/<lll'A/O
SPOUSE'S EMPLOYER: PI' -r. i' p. .L
HOME PHONE: 9.,.23~5 ~ '3
~
STATE:h A ZIP: ..34:;1. 3 /
WORK PHONE:
AGE: UrJ- SEX:M MARTIAL STATUS:
.
SPOUSE'S DATE OF BIRTH: -5l:z /.!3 7
.
SPOUSE'S OCCUPATION:
...................................................*...ttt*t*........................................,
GUARDIAN QRl"'D..n1\( RESPONSIBLE FOR PAYMENT
NAMIb" ,,,: socw. SECURITY:
,
ADDRESS:
CITY: STATE: ZIP:
EMPLOYER:
ADDRESS:
CITY: STATE: ZIP:
.............................................*...*.*.................*................................
PHONE:
PHONE:
r
INSURANCE JINll'OItMATlON:
PRIMARY INSURANCE"
_MEDICARE _WORKCOMP LAUTO _PRIVATE
INSURANCE COMPANY: ...srh--re... rite t>l 7Af~
POUCYBOLDER: t(}J;:>J.. C/- Mtre.y /};v,,} St>f!&-A/1!NO
SECONDARY INSURANCE:
POUCY BOLDER:
PHONE:
1 a1dhDdre ~ RII...!, ,M.D. aodIor 0IrIIdI0e J. Weot. M.D. to r r -, UIf -'nI Jnformadun, rec:GI'lk or ll-ft1II to JIQ
___~, ph,ylildm, aodIor -.y .ttorney.
I........ .~,_~.... - 1l"<..1 senkes to be paid dtreedy to 81'_ RIegel, M.D.. P.A.
1 taM ..~WIItf 1or.,,_I- reprdIess ofUlf arIJUnry ~tIon of~" _~n_ wtdt..,.
.-.~~a.....:...,l':'
II........, , """'r .........0oll: 1--.,. daat .........tIon ..... by _ID apMJDa lor pl,JIIllll't IIIIIIer TItle xvm of
lie SocIal L-B,.u.;.w..I.-.....,or Its iIdm'<r ~~...tes or ClII'I'Ien UIf IDfonIatIon lllldedlor... or . related Medk:ue
cIaIIa. I......,.... . . . """",.,.1IIe lor PL" . . .. 01' ......tIon Iia........ dIIC _.. 01' .",.Wl.'tK --. ~ . . .. 01'
OI'Ir-..~tIIl,...-. ~ toUMlrtre lor JIllYIIIeIIi lor -. 1 ftlIUllltdaat GIll aIID .ppIJ to aayoaer IIIIIa'aIII:e 1
..,...... v
....."... DO............ -.- e rt ~.
~TR. /O--d-f-1i5
~
~ ~ ",",'
o
GENERAL HEALTH AND MEDICATIONS
o
ARE YOU CtlRRENTLY TAKING ANY MEDICATIONS? NO / YES
IF YES, WHAT MEDICATIONS ARE YOU TAKING? ~'/......-;:;;- U:/U,L~j - f?L.'/~'r ~J'A/
DO YOU HAVE ANY ALLERGIES? Vb
HAVE YOU EVER HAD: (IF YES, CHECK LINE BY ANSWER)
ANY TYPE OF COUGH OR WHEEZING
- BEEN TROUBLED OR TREATED FOR AN ULCER
- HAD BLOODY OR BLACK STOOL
- ANY HISTORY OF SKIN CHANGING COLOR AFTER CONTACT WITH JEWELRY OR OTHER METU
--;:; GLAUCOMA ~
- ANY SERIOUS MOtJ'l'H, THROAT OR LARYNX PROBLEM
- A HEART ATTACK OR. CHEST PAIN
.V' JAtJNDICE OR HEPATITIS
..I:L LIVER PROBLEMs
KIDNEY PROBLEMS
- BLOOD CLOT IN LONG OR LEG
- MIGRAINE HEADACHES
~ SEIZURES
DO YOU SMOKE? Y YES NO
DO YOU DRINK? ~ES ..!:::...NO
..
IF YES, HOW MANY PACKS PER DAY? "I-5~~~
/NO
HAS YOUR PAIN CHANGED?
YES
-
CHECK THE AREAS OF YOUR ORIGINAL P~BACK'
_NECK __SHOULDER _ARMS LEGS
OTHER
DOES YOUR PArN rNCREASE WI:TH ANY OF THE FOLLOWl:NG ACTrvrTrEs 8e.val/ ""';1
_SITTING _STANDING _WALKING REST _OTHER ><. /lIMne HD"'~ W.K""'j AC:T.,,,;;;'e
ScJc.~ irS.
fI1() w/...." "P ,-",,,, N
P).l'r<-J)NC,-
DOES YOUR PAIN OR SYMPTOMS IMPROVE WITH ANY OF THE FOLLOWI:NG
SITTING STANDING WALKING K REST OTHER
;;; LONG HA;; YOU HAD T;; SYMPTOMS-;- (j //9 /'9 l!
f" _' .
PLEASE DESCRIBE ALL PREVIOUS TREATMENT YOU HAVE RECEIVED FOR THIS CONDmON. INCLUDE
PHVSICI14NS, CHIROPRAcrORS, PHYSICAUMASSAGE THERAPIES, ETC.
IN~C DE DATElSPECIALI.~~..~:rION -'- _ M,.. .
~:==::;m...,.?~~_:~. .~ = =~:; 7:.~~ ~_~U
3 _:-.. ':J I, , Q ~ _._
~: .
PLEASE CHECK THE FOLLOWING DIAGNOSTIC TESTS WHICH HAVE BEEN PERFORM~D FOR YOUR
CONDITION:
TEST
,2LX-RA VS
,2LMRI
DISCOGRAM
EMG
APPROX.DATE
<(//"1/98
TEST
. cr SCAN
MYELOGRAM
BONE SCAN
OTHER
APPROX. DATE
DO YOU ~E Ai. RECULAR HOME EXERCISE PROCRAM FOR VOUR BACK?
_VES A-NO
PLEASE LIST ALL PAST BACK AND NECK SURGERY:
DO YOU HAVE DrFFICULTY SLEEPING?
YES
X-NO
-..
.
-~,-,
. .
o
o
ACC~ DlFOJlMATION
DAft Ol!' ACCIDENT: '1/;,}/9 B TYPE OF ACCIDENT:LA11'l'O WOlUt RELATED OTlllilR
I I --
II!' W/C, EMPLOYER AT TD<lE OF ACCIDENT:
PLEASE DESCRIBE YOUR J:NJURY?
PLEASE LIST DAft/DAftS Ol!' ANY OTHER INJURIES:
HAVE YOU BAD BACK OR NIilCK PROBLIilMS IN THE PAST, PRJ:OR TO THIS J:NJURY?
iYES _NO
DESCRDlE BRJ:IilFLY.: A71A;", L' PI' 01, Ie.m e s
0\8 THE ONSET OF YOUR CURRENT PAJ:N ..fL'GPMJUAL OR SUDDEN?
WHICH ANSWER BEST DESCRIBES THE CHARACTER OF YOUR PUN?
Y MJ:~ EXCRUCIATING SEVERE
REL;tEVED BY OTHER
DO YOU HAVE ANY OF TIIIil I!'OLLQWJ:NG?
IIElIDAC'RIilS
---m:CK PAIN
-SHOULDER PAIN
ARM OR FJ:NGER NUMBNESS, TJ:NGLJ:NG OR WEAKNESS?
RIGHT
OR
LEFT
_LEG PAJ:N OR NUMBNESS
LOW BACK PUN
---uPPER BACK PAJ:N
-m.ADDER OR BOWEL PROBI.ENS
OTHER COMPLAJ:NTS:
RIGHT
OR
LEFT
. ("'LEASE CBECK THE TYPE OF TREA~NT YOU HAVE BAD FOR YOUR BACK OR NECK.
MlIDE NO
HELPED WORSE CIlANGE
HOT PACKS
---uLTRASOUND
-ICE
----w.sSAGE
-ELECTRICAL STD<<tJLATION
---rENs UNIT
--aooy MECIlANICS TRAJ:NJ:NG
-STRIilNGTBIilNJ:NG EXERCISES
-AEROBICS OR CONDITIONING
-GRAVITY J:NVERSION
~TJ:ON
-sED MST
-CHIROPRACTIC TREA~NT
--aIOFEEDBACK
-LOCAL TRIGGER POJ:NT J:NJECTION
-.ePIDURAL STEROID J:NJECT. (ESI)
~ACET JOJ:NT J:NJECTION
-.mcx BRACE
-ACUPUNCTURE
-ANTI-~TORY MEDICATION
~SCLE RELAXANT MEDICATION
-ANTI-DEPRESSANT MEDICATION
_OTIIER
ARE YOU CURRENTLY RECEIVJ:NG ANY OF THE ABOVE TREA~NTS:
_YES _NO IF YES, PLEASE CIRCLE THOSE YOU ARE MCEIVJ:NG.
ALL OF THE ABOVE DlFOJlMATION BAS BEEN COMPLETED BY ME AND TO THE BEST OF MY lINOWLIilDGE IS
ACCURATE.
SIGNED DATE
_~._ -- L_
" ~
~~~-<;j<
,.
o
o
FINANCIAL POLICY
Dear Valued Patient:
As a courtesy to you, we will file your insurance, providing that:
A) The insurance policy is in effect and valid.
B) The policy will cover the procedures performed.
C) Yo~ pay us at the of service for any deductible amount not met,your
des~gnated co-=payment or percentage of charges incurred and/or for
any procedures not covered by the policy.
D) You provide the receptionist your insurance card, valid drivers license,
and/or other form of picture I.D. for copying and identification
purposes.
E) A mailing address and phone number for claims must be noted on the card
or must be provided by the patient prior to or at the time of the visit.
We cannot file your insurance without an address and phone number to
ver~ry e~igibility.
***************************************************************************
If your visit'is due to a Workman's Compensation claim:
A) This visit must be author~zed pr~or to your rirst visit.
~) You must provide us with all applicable above information, in addition
to a copy of the "Notice of InjUry" report, with the date of injury and
a claim number.
C) The name, address and phone number of your employer at the time of the
accident.
*******************~*******************************************************
If your visit is a result of an Auto Accident or Personal Injury case:
A) You must provide us with all app.L1cao.Le aoove ~nrormat~on, ,~n addition
to your attorney's name, address and phone number. Also, a copy of the
accident report. .
B) If you do not have or are not hiring an attorney, you must provide the
insurance company name, address, phone number, and policy number
necessary to verify coverage and file your claim.
C) In special situations, a letter of protection is accepted. This does
not release you of the responsibility of payment of our full Charges.
***********************************************************TWTW************
If we experience any difficulty collecting from your carrier:
A) We will ask yo~o contact them and inquire about the delay and/or non-
payment of your incurred charges.
~) We may ask you to pay your claim and be reimbursed directly from your
inSurance company.
***************************************************************************
***1 UNDERSTAND THAT MY INSURANCE IS BEING FILED AS A COURTESY, AND THAT I
AM. STILL RESPONSIBLE FOR ANY E3ALANCES LEFT BY THE INSURANCE; I ACCEPT FULL
RESPONSIBILITY FOR PAYMENT OF CLAIMS FOR THE ABOVE MENTIONED PATIENT.
Dr. Riegel reserves the right to charge for appointments broken or canceled
unless 24 hours notice is given.
Thank you for your cooperation.
I have read and understand the above financial policy.
Patient/guarantor signature:
Patient Name:
Date
~ ~ ~
~,
. '~
'"'--.,
,.,
.--
WM.
". ~
.
'0
Bram Riegel, M.D.
Spine, Sports & Rehabilitation Specialists, P.A.
Certified by the American Board of Physical Medici:he & Rehabilitation
Certified by the American Board of Independent Medical Examiners
Certified by the American Academy of Pain Management
5580 Bee Ridge Rd" Bldg, B
Sarasota, Fl. 34233-1505
(941) 379-8237
Fax: (941) 379-8348
e-mail: wecare-<l;spine-sPorls.com
RALPH SORRENTINO
FOLLOW UP VISIT .
JANUARY 24, 2002
Mr, Sorrentino returns for reevaluation, He was last seen on 1/19/01, The patient continues to complain
of low back pain, Pain level currently 7 on a scale of 0-10, The patient ahd I discussed a trial of
chiropractic care with regards to low back pain, The patient is not taking any medication with regards to
low back pain,
The patient remains under the care of Dr. Mitchell, a Sarasota gastroenterologist, with regards to hepatitis
C, The patient's Rx medications include insulin, eye drops, and Paxil. It is my understanding that Paxil
is being prescribed for depression, The patient completed his scheduled sessions of therapy under my
direction and has already been taught a HEP,
.
Physical Examination: Vital signs were stable, Chest clear to auscultation, CVS S 1 and S2,
Abdomen benign, Extremities negative CEC, Skin was normal,
Neurological evaluation included motor strength testing which was 5/5 bilaterally, Sensory examination
was without any acute changes, DTR's were 2+ bilaterally except for the ankle jerk refl~es which were
1 + bilaterally, SLR negative bilaterally,
ImDression:
.-
1, Multiple medical problems, .
2, Low back pain associated with underlying disc disease and spondylosis,
,.
.
Plan:
'f
1, The patient should continue to follow up with all of his other physicians,
2, No NSAID's secondary to hepatitis C,
3, The patient should continue to perform a HEP,
4, I referred the patient to a chiropractic physician with regards to low back pain,
5, Return to the office in three months or pm.
BRAM RIEGEL, M.D.
So.\: s.:
(Dictation transcribed but not read)
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EVAL-R Ji:VALPREP~DBY: '
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PROG -L , ' , -K.-: ~ Tre9t<nent Plan ~ [hI"
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, · : -." - " rmlthepatientUl1Cl'--
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'Do., rlv\C,eJJBram Riegel, M.D.
I Center Gate Office Park
:3 5 q _ ~ 11'1 55BO Bee Ridge Road, Bldg, B
5arasota, Florida 34233
(941) 3 79-B23 7
Name ~LLl\->V\ Sorce f\~n (l Date \ - d L\-OOl
Address
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Refills 0 1 2 3 4 5 DR.
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5580 Bee Ridge Rd" Bldg, B
Sarasota, FI. 34233-1505
(941) 379-8237
Fax: (941) 379-8348
e-mail: wecare@spine-sports.com
Bram Riegel, M.D.
Carlos A. Diaz, M.D.
Spine, Sports'& Rehabilitation Specialists, P,A.
Certified by the American Board of Physical Medicine & Rehabilitation
Certified by the American Board of Independent Medical Examiners
Certified by the American Academy of Pain Management
c
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RALPH SORRENTINO
BRIEF NOTE
MARCH 16,2001
I extended therapy twice/week x4 weeks under my direction, Therapy is medically necessary,
BRAM RIEGEL, M.D.
. BR/sd
.
'.-"
.
rr-'-'.-'",:
. ',,:,~
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"This inform","'n has beer, disclu..d to you from. re~o!<j",
w1lOse ,confident'ality is ,protected by state law, Stl!til1il.\Y
prohlbr~ you from makirg any further OisCIOSUr&S of sUCh ,
j\1fflYma1ion without .speciiic written conser,! of'the
~~W.~r&~~~~s bra~o.::~
;.,_,~_"_'''''>~':'-:;-.'',W--;-_O'' ;_.",__,._,'__~_ __"_.
c,._
Bram Riegel, M.D. C
Carlos A. Di'az, M.D.
Spine, Sp'orts & Rehabilitation Specialists, P.A.
Certified by the American Board of Physical Medicine & Rehabilitation
Certified by the American Board of Independent Medical Examiners
Certified by the American Academy of Pain Management
o
5580 Bee Ridge Rd" Bldg, B
Sarasota, Fl. 34233-1505
(941) 379-8237
Fax: (941) 379-8348
e-mail: wecare@spine-sports.com
RALPH SORRENTINO
FOLLOW UP VISIT
JANUARY 19, 2001
Mr, Sorrentino returns for reevaluation. He was last seen on 2/28/00, The patient's most troublesome
problem continues to involve low back pain, The patient has completed his scheduled sessions of therapy
under my direction and reports good results, The patient would like to have therapy extended,
"
The patient remains under the care of Dr . Mitchell, a Sarasota gastroenterologist, with regards to hepatitis
C, Dr. Mitchell has the patient on Rebetrol, Interferon, Insulin, and eye drops,
Phvsical Examination: Vital signs were stable. Chest clear to auscultation, CVS S 1 and S2,
Abdomen benign, Extremities negative CEC, Skin was normal,
Neurological evaluation included motor strength testing which was 5/5 bilaterally. Sensory examination
was without any acute changes, DTR's were 2+ bilaterally except for the ankle jerk reflexes which were
1 + bilaterally, SLR negative bilaterally.
Impression: The patient is a 64 year old white male with a past medical history ofNlDDM x 30 years,
glaucoma, and hepatitis C, The patient was involved in a MY A on 4/19/98 which led to low back pain,
.
The patient complains of low back pain associated with bilateral lower extremity radicular symptoms,
A lumbar MRI demonstrated a small left paracentral disc protrusion at L5-S 1 associated with an annular
tear as well as mild degenerative disc disease at L2-L3 and L3-L4. The patient's signs and symptoms are
consistent with low back pain associated with underlying disc disease and spondylosis,
Plan:
1, The patient should continue to follow up with all of his other physicians,
2, No NSAID's secondary to hepatitis C,
3, I prescribed therapy 3x/week x4 weeks under my direction,
4, I called Dr. Mitchell and left a message with regards to whether or not the patient can faithfully take
Glucosamine Sulfate and MSM,
5, A future diagnostic consideration includes performing EMG/NCS of both lower extremities,
6, A future therapeutic consideration includes referring the patient back to Dr, James for a series of
lumbar ESI's,
7, Return to the office in one month,
~.~ "'i!If-,
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BRAM RIEGEL, M.D/~
:~I
BRlsd/3
1b1s illfOr_n, h~S !leer, Jiscloc.d to you fio~ -;ecotd;
, '.' ;l6lll:tnf'dent'ahly J~ ,protected. bJl sliite law: SlIlt /liw'
p.... .. u from. ma1<m~ a~'y furt."er disclosures of such
_....\V;~~tsp~CIlJ~ wr~lten.:on.sent of~be. .
Brian James, M,D. .' .~, Illllihl~rl11a!J.onpel1alns or as 'OtIieflIIlSG
" .. ., .' '~5ySllll9MW.' '.
~-.- ""'-:".~:"-C::~- ~~t,."';;';::"7">":;'-_.
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Briim'Riegel, M.D. A
Spine, Sports & Rehabilitation Spe'Mlists, P.A.
Certified by the American Board of Physical Medicine & Rehabilitation
Certified by the American Board of Independent Medical Examiners
Certified by the American Academy of Pain Management
o
5580 Bee Ridge Rd" Bldg, B
Sarasota, Fl. 34233- I 505
(941) 379-8237
Fax: (941) 379-8348
e-mail: wecare@spine-sports.com
RALPH SORRENTINO
FOLLOW UP VISIT
FEBRUARY 28, 2000
Mr. Sorrentino returns for reevaluation, He continues with essentially unchanged pain complaints, The patient
has completed his scheduled sessions of PT and NMT under the direction of Mr. David Rogerson and reports
good results. The patient would like to have therapy extended. The patient is not interested in undergoing
lumbar ESI under the direction of Dr. James.
The patient informed me that he will be returning to Buffalo, NY on 4/1/00, The patient will be trying to sell
his home which is located in Buffalo, NY. The patient plans on returning to Sarasota during October 2000
or sooner if her sells his home,
~
Physical Examination: Physical examination included soft tissue palpation, There were no acute changes
noted..
Impression: The patient is a 64 year old white male with a past medical history ofNIDDM x 30 years,
glaucoma, and hepatitis C. The patient was involved in a MY A on 4/19/98 which led to low back pain,
The patient complains of low back pain associated with bilateral lower extremity radicular symptoms, A
lumbar MRI demonstrated a small left paracentral disc protrusion at L5-S I associated with an annular tear as
well as mild degenerative disc disease at L2-L3 and L3-L4, The patient's signs and symptoms are consistent
with low back pain associated with underlying disc disease and spondylosis. Rule out lumbosacral
radiculopathy,
-.......
Plan:
1, The patient should continue to follow up with all of his other physicians.
2. Continue Flexeril on a pm basis.
3. No NSAlD's secondary to hepatitis C.
4, I extended PT and NMT 3 x per week x 4 weeks under the direction of Mr. David Rogerson, I requested
that the patient be made completely independent in performing a home exercise program, Therapy was
ordered with strict diabetic precautions,
5, A future diagnostic consideration includes performing EMG/NCS of both lower extremities.
6, A future therapeutic consideration includes referring the patient back to Dr. James for a series of lumbar
ESI's.
7, The patient will be going to Buffalo, NY on 4/1/00 iII1d returning to Sarasota during October 2000,
8. Return to the office during October 2000.
BRAM RIEGEL, M.D.
BR/sd/3
(dictation transcribed but not read)
~'
ilrl~:<;,
Bram Riegel, M.D.
Spine, Sports & Rehabilitation Specialists, P.A.
Certified by the American Board of Physical Medicine & Rehabilitation
Certified by the American Board ofIndependent Medical Examiners
Certified by the American Academy of Pain Management
c
0.'
,
5580 Bee Ridge Rd" Bldg, B
Sarasota, Fl. 34233-1505
(941) 379-8237
Fax: (941) 379-834f
e-mail: wecare@spine-sports,corr
RALPH SORRENTINO
CONSULTATION
JANUARY 24, 2000
Mr. Ralph Sorrentino is a 64 year old white male who was involved in a MV A on 4/19/98, The MV A led to
low back pain, The patient came under the care of a family practitioner. Therapy was prescribed,
The patient continued to complain of low back pain and came under the care of Dr. Weot a Sarasota PM&R
Specialist. Dr. Weot treated the patient from 10/29/98 - 11/17/98, Dr. Weot reviewed a lumbar MRI that had
already been performed and described it as demonstrating some abnormalities, Dr. Weot prescribed PT and
NMT under the direction of Mr, Matthew Frey and Ms, Roseanne Davis, The patient apparently had a
problem with the physical therapist and did not want to continue, Dr. Weot also evaluated the patient for right
wrist pain and right shoulder pain, Dr. Weot diagnosed the patient with adhesive capsulitis of the right
shoulder and RSD of the right wrist. Dr. Weot ordered x-rays of the right wrist and right shoulder. Dr. Weot
also prescribed Neurontin. The patient stopped seeing Dr, Weot.
The patient came under the care of Dr. James, a Sarasota Pain Management Specialist. Dr, James did not
perform any injections, The patient apparently complained of low back pain to Dr, James. Dr. James
recommended additional therapy and referred the patient to my office for consultation,
The patient presents for further recommendations, He is pleased to report that his right shoulder pain and right
wrist pain are doing a lot better, The patient's main problem currently involves low back pain, The patient's
low back pain radiates into both lower extremities, The patient's low back pain gets worse with exertional
activities such as walking and painting,
The patient used to live in Buffalo, NY, The patient is now in the process of moving to Sarasota, FL on a full-
time basis, The patient is trying to sell his house located in Buffalo, NY. The patient sees Dr. Yea, an Osprey
Family Practitioner. The patient also sees Dr. Corrosante, a Buffalo, NY Gastroenterologist and Liver Disease
- Specialist.
Past Medical History: As per the HPI. NIDDM x 30 years. Glaucoma, Hepatitis C,
Past Surgical History: Gall bladder surgery, Repair of depuytrens contracture of the right hand,
Social Historv: The patient is retired, The patient smokes several cigarettes per day and does not drink
alcohol.
Current Medications: Insulin, Kosoft, Flexeril.
Allergies: No known drug allergies,
Other Health Care Providers: The patient sees Dr, Yea, an Osprey Family Practitioner. The patient also
sees Dr,. Corrosante, a ButIalo, NY Gastroenterologist and Liver Disease Specialist.
Radiological Imagin~ Studies: I reviewed a lumbar MRl dated 7/8/98. There was a sma,ll !e~t paracentral
disc protrusion at L5-S I associated with an annular tear, There was also mild degeneratIve diSC disease at L2-
1.3 and L3-L4, The above was confirmed by the radiologist's report,
.
~-
-
,..
~-~-1f'\;;
RA~PH SORRENTINO
CONSULTATION
JANUARY 24, 2000
PAGE 2
o
o
Physical Examination: Physical examination included lumbar range of motion testing, Lumbar flexion
was the most painful arc of motion tested, The jolt test was essentially negative bilaterally,
Neurological evaluation included motor strength testing which was 5/5 bilaterally, Sensory examination
revealed pinprick to be decreased on the right lower extremity in a stocking glove distribution to the level of
the knee, Pinprick was decreased on the left lower extremity in a stocking glove distribution extending above
the knee. Pinprick was grossly intact on both upper extremities. DTR's were 2+ bilaterally except for the
ankle jerk reflexes which were 1+ bilaterally. Straight leg raising was negative,
Soft tissue palpation was performed, The patient localized his low back pain to the lumbosacral triangle and
posterior superior iliac spines bilaterally,
Impression: The patient is a 64 year old white male with a past medical history ofNIDDM x 30 years,
glaucoma, and hepatitis C, The patient was involved in a MY A on 4/19/98 which led to low back pain,
......--
The patient complains of low back pain associated with bilateral lower extremity radicular symptoms, A
lumbar MRI demonstrated a small left paracentral disc protrusion at L5-S 1 associated with an annular tear as
well as mild degenerative disc disease at L2-L3 and L3-L4. The patient's signs and symptoms are consistent
with low back pain associated with underlying disc disease and spondylosis, Rule out lumbosacral
radiculopathy.
Plan:
1.
2.
3,
4.
5.
6,
~
7,
8,
9,
The patient took his lumbar MRl with him back to the radiology center.
The patient should continue to follow up with Dr. Yea with regards to medical problems,
The patient should continue to follow up with Dr. Corrosante with regards to hepatitis C,
Continue Flexeril on a pm basis.
No NSAID's secondary to hepatitis C.
I prescribed PT and NMT 3 x per week x 4 weeks under the direction of Mr. David Rogerson and Mr,
Ryan Moore, Therapy was ordered with strict diabetic precautions.
A future diagnostic consideration includes performing EMG/NCS of both lower extremities,
A future therapeutic consideration includes referring the patient back to Dr. James for a series oflumbar
ESI's,
Return to the office in one month.
BRAM RIEGEL, M.D.
BR/sd
(dictation transcribed but not read)
~~~ ..," ~~'",-- <",,,~ 'lll!tlli-j
BRAM RIEGEL, M.D., P.A.
Spine. SportS Medicine. ElectrodiagncO
Certified by the American Board of Physical Medicine & Rehabilitation
Bram Riegel, M.D. . Christine ). Weot, M.D.
o
5580 Bee Ridge Road, Bldg. B
Sarasota, Florida 34233
Phone (941) 379-8237
Fax (941) 379.8348
RALPH SORRENTINO
RECHECK EXAMINATION
NOVEMBER 17, 1998
Today I had the opportunity to see Mr, Sorrentino in recheck examination secondary to lower back
pain, The patient states that his back pain is unchanged from previous exam, He is unhappy with
the physical therapy, stating that he does not want to undergo modalities such as electrical
stimulation; he does want to have a more aggressive program, He also states that he does not want
to do a home exercise program,
His right wrist pain and swelling continues,
"'-'
REVIEW OF SYSTEMS: The patient's blood sugar is not well controlled,
PHYSICAL EXAMINATION:
Musculoskeletal: The patient has no tenderness of his lumbar paraspinals bilaterally, He has full
range of motion of his lumbar spine, Straight leg maneuver is negative from the seated position,
Examination of his right hand and wrist does show decreased motion in flexion and extension of
his right wrist. Also, there is some redness and edema but no increase in warmth, Shoulder range
of motion, is significantly decreased in all directions of range of motion, and he has pain with
ranging the right shoulder.
Neurological: Manual motor testing in the lower extremities revealed full muscle strength, Deep
tendon reflexes were +2 at patella bilaterally and absent at ankles bilaterally,
L-
IMPRESSION: Mr, Sorrentino is a 62 year-old gentleman who was involved in a motor vehicle
accident on April 19, 1998.
1, Lumbar strain,
Z, Right wrist RSD,
3. Adhesive capsulitis of the right shoulder,
fLAN:
1, The patient should continue his physical therapy under the direction of Matthew Frey and
Rosanne Davis, He should receive therapy two times a week for the next four weeks, I will
speak with Mr, Matthew Frey and increase Mr, Sorrentino's program to a more aggressive
approach, However, it was discussed with Mr, Sorrentino that much of the benefit will come
from his own use of the exercises at home with a home exercise program and, in addition to
the time that he spends here in physical therapy, he must spend additional time at home with
what he is taught at physical therapy,
Z, I am requesting an x-ray of his right wrist and right shoulder,
,-'~
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RALPH SORRENTINO
RECHECK EXAMINATION (continued)
NOVEMBER 17, 1998
3, I am starting him on Neurontin 300 mg q day x 1 day, and then 300 mg b.i,d, x 2 days, and
then 300 mg t.i.d,
4, I will see back in recheck examination in three weeks,
CHRISTINE J. WEOT, M.D.
.
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(Dictation transcribed but not read)
cc: Dr. McAdam
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,BRAM ,RIEG~L, M.D.,tp.A. G)
Spine' SpolU J1edicine . E1~rodiagn\Ub
Certified by t/leAmerican llqard of Physical Medicine & Rehabilitation
, Bram Riegel, M.D. · ChristIne J. Weot, M.D.
.
5580 Bee Ridge Road, Bldg. B
Sarasota, Florida 34233
Phone (941) 379-8237
Fax (941) 379-8348
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RAU'H SORRENTINO
CO;NSULTAT,ION
OcrOEER 2jr 1998
l1ISTORY OF ~SENT IL~Nl~s: Today I had the opportunity to see Mr. Ralph Sorrentino, a 62
year-old gentlewan, in consultation secondary to lower back pain, Mr. Sorrentino was involved in
a motor vehicle ~dent on 4/19/98, He was the restrained driver of a 1991 Nissan that was on the
Interstate trave1ip.g approximately 70 mph, A car made a V-turn in front ofhim on the freeway and
hebfoadsided tJiat car; his car was then pushed into another lane and struck by another vehicle, He
no~ the imme,c;liate onset of back and bilateral lower extremity pain in the posterior aspect of his
leg.; He went ~p the emergency room where x-rays were taken; he was given medication and
diScharged, His back pain continued, however the radiation resolved, He did seek treatment with his
family physiciaq ,and 'went through a course of physical therapy that mainly consisted of modalities
and no exercisejDstruction, He did receive a couple weeks of therapy where they worked on giving
him a home ex~rcise program, however he states he has just received instruction on one specific
. 1'.
ex(l1:Clse. ,
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Currently, Mr. ~orrentino's back pain is located across his back. It is intermittent. It is increased with
any type of ~vity such as bending or lifting. He has no radiation into his lower extremities. No
n~bness or tingling. No bowel or bladder incontinence,
, r
SOCIAL HISTO,Jty: Mr, Sorrentino is manied, He has foUr adult children. He lives in Boston but
spends the seasQn in Florida, He is retired from working a steel mill and also carpentry work. He
does use tobac~o, 4-5 cigarettes per day, He does not use alcohol.
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PA~T MF<!)ICA{. HISTORY: Non-insulin dependent diabetes x 25 years. He has been on insulin
..,
for $he past few years. He states his blood sugars are fairly well controlled, Past medical history
alsQ includes g4\ucoma and hepatitis C,
',r,.." I'.
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PA!Q' ~URGICAL HISTORY:' Cholecystectomy, Repair of right hand Dupuytren's contracture.
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O~J;!FNT MEWCATIONS: Humulin insulin, Timoptic eye drops.
, ,
AL\<ERGIES: ! There are no known drug allergies,
" I
" !
JF.fIEW OF SX~TE~: Mr. Sorrentino states that he has significant right-sided wrist pain
and.: he is unable to move his wrist. This happened a few weeks ago and has been getting
incr~g1y woise, He has also noted a redness to his right hand. Otherwise, review of systems is
ne~tive, :
,
t ('
PHYSICAl, EX~MINATTON: Mr. Sorrentino appears older than his stated age of 62 years, He
is pleasant and 'cooperative through the entire exam, He does wear a right wrist brace,
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CONSULTATION (continued)
OOODER 29, 1998
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M'IIculoskeletlfJ: The patient has full flexion of his cervical spine, somewhat limited in extension,
and tulllateralJlending bilaterally, Range of motion is pain-free, He has no tenderness over the
cen1cal paraspiila1s. He has full range of motion of his lumbar spine but pain with lateral bending
bilaterally. He bas some tenderness of his lumbar paraspinals bilaterally. Straight leg maneuver is
negimve from :the seated position, The right shoulder had decreased range of motion in all
directions and Rain with range of motion. Examination of his right hand does show some redness
and edema; ~ is no increase in warmth. He is tender over the hand. He has very limited range
of motion of hi,a wrist to both flexion and extension, only a few degrees.
NelJrological:), The patient is alert and oriented x 4, Cranial nerves 3-12 were grossly intact.
MaQual motor testing revealed full muscle strength in the shoulder abductors as well as the elbow
extensors and ~xors. On the left he had full str~gth in the wrist extensors and flexors, however
I was unable to'test these on the right secondlll)' to pain in the wrist, Finger extensors scored 4-/5
(likIIly secondaIy to pain), He had full strength in his lower extremities including hip flexors, knee
flexors and exiensors, dorsiflexors, and EHL, Deep tendon reflexes were at biceps, triceps,
brachioradialis: and patella, and absent at ankle bilaterally. There is no Babinski sign present,
Sensoiy exam 'Vas decreased to pinprick in a stocking distribution in the lower extremities, He had
an Jpcreased s~!lsation to pinprick on his right hand, On the left he had decreased sensation to
pinprick in a glpve distribution.
,,- <4.:' The paf:ent has anonna1 gait.
't _
STlJJlIES Dol'W: I did review a radiologist's report of an MRI of his lumbar spine dated
7/08/98, It did,show a smal1 disc protrusion at L5-S1 with no obvious contact with nerve root.
There was also: degenerative change at L2-L3 and LJ-L4.
"
\.
TM19lJs-"noN: ~ Mr. Ralph Sorrentino is a 62 year-old gentleman who was involved in a motor
vehicle accident on April 19, 1998,
" i F
1. '.Lumbar stiiUn,
2. ~Right wris~' pain that is most likely RSD,
3. 'Adhesive <;llpsulitis, right shoulder,
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RALPH SOBRENTINO
CONSUlLTA'fION (continued)
OCTOBER 29, 1998
"
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3, 'I would ljke to start Mr. Sorrentino on Gabapentin. We have discussed this option and he
wishes to think about it at this time.
4, I will see him back in recheck examination in one week.
"-/
" " i' H
opusTINE ilJ. WEOT, M.D.
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(DiFtion tr~cribed but not read)
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Bram Riegel. M.D. C
Spine, Sports & Rehabilitation Specialists, P.A.
Certified by the American Board of Physical Medicine & Rehabilitation
Certified by the American Board of Independent Medical Examiners
Certified by the American Academy of Pain Management
.
5580 Bee Ridge Rd., Bldg. B
Sarasota, FI. 34233-1505
(941) 379-8237
Fax: (941)379.8348
e-mail: wecare@spine-sports.com
January 24, 2000
Brian James, M.D.
1830 S. Osprey Ave., Ste 100
Sarasota, FL 34239
RE: Ralph Sorrentino
Dear Dr. James,
Thank you for referring Mr, Ralph Sorrentino to my office. As you know, he is a 64 year old white male who
was involved in a MV A on 4/19/98. The MV A led to low back pain. The patient came under the care of a
family practitioner. Therapy was prescribed,
The patient continued to complain oflow back pain and came under the care of Dr. Weot a Sarasota PM&R
\...I Specialist, Dr. Weot treated the patient from 10/29/98 - 11/17/98, Dr. Weot reviewed a lumbar MRI that had
already been performed and described it as demonstrating some abnormalities. Dr. Weot prescribed PT and
NMT under the direction of Mr. Matthew Frey and Ms, Roseanne Davis. The patient apparently had Ii
problem with the physical therapist and did not want to continue. Dr. Weot also evaluated the patient for right
wrist pain and right shoulder pain. Dr. Weot diagnosed the patient with adhesive capsulitis of the right
shoulder and RSD of the right wrist. Dr. Weot ordered x-rays of the right wrist and right shoulder, Dr. Weot
also prescribed Neurontin, The patient stopped seeing Dr. Weot.
The patient came under your care and did not perform any injections. The patient apparently complained of
low back pain and you recommended additional therapy and referred the patient to my office for consultation.
The patient presents for further recommendations. He is pleased to report that his right shoulder pain and right
wrist pain are doing a lot better. The patient's main problem currently involves low back pain, The patient's
low back pain radiates into both lower extremities. The patient's low back pain gets worse with exertional
........,. activities such as walking and painting,
The patient used to live in Buffalo, NY. The patient is now in the process of moving to Sarasota, FL on a full-
time basis. The patient is tryirig to sell his house located in Buffalo, NY. The patient sees Dr. Yea, an Osprey
Family Practitioner, The patient also sees Dr. Corrosante, a Buffalo, NY Gastroenterologist and Liver Disease
Specialist.
Past Medical History: As per the HPI. NIDDM x 30 years. Glaucoma. Hepatitis C,
Past Surgical History: Gall bladder surgery. Repair of depuytrens contracture of the right hand.
Social Histo'Y: The patient is retired. The patient smokes several cigarettes per day and does not drink
alcohol.
Current Medications: Insulin, Kosoft, Flexeril.
Allergies: No known drug allergies,
Other Health Care Providers: The patient sees Dr, Yea, ~ Osp~ey Family ~ra~titioner. The patient also
sees Dr. Corrosante, a Buffalo, NY Gastroenterologist and Liver Disease Specialist.
~ "
. .
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Page 2 - January 24, 2000 0
Letter to Dr. James
Regarding Ralph Sorrentino
o
Radiological Imagiur Studies: I reviewed a lumbar MRI dated 7/8/98. There was a small left paracentral
disc protrusion at L5-S 1 associated with an annular tear. There was also mild degenerative disc disease at L2-
L3 and 13-L4. The above was confirmed by the radiologist's report.
Ph,ysical Examination: Physical examination included lumbar range of motion testing. Lumbar flexion
was the most painful arc of motion tested, The jolt test was essentially negative bilaterally.
Neurological evaluation included motor strength testing which was 5/5 bilaterally. Sensory examination
revealed pinprick to be decreased on the right lower extremity in a stocking glove distribution to the level of
the knee. Pinprick was decreased on the left lower extremity in a stocking glove distribution extending above
the knee. Pinprick was grossly intact on both upper extremities. DTR's were 2+ bilaterally except for the
ankle jerk reflexes which were 1 + bilaterally, Straight leg raising was negative.
Soft tissue palpation was performed. The patient localized his low back pain to the lumbosacral triangle and
V posterior superior iliac spines bilaterally.
Impression: The patient is a 64 year old white male with a past medical history ofNIDDM x 30 years,
glaucoma, and hepatitis C. The patient was involved in a MY A on 4/19/98 which led to low back pain,
The patient complains of low back pain associated with bilateral lower extremity radicular symptoms. A
lumbar MRI demonstrated a small left ,paracentral disc protrusion at L5-S 1 associated with an annular tear as
well as mild degenerative disc disease at L2-L3 and 13-14. The patient's signs and symptoms are consistent
with low back pain associated with underlying disc disease and spondylosis, Rule out lumbosacral
radiculopathy.
~
1. The patient took his lumbar MRI with him back to the radiology center.
2, The patient should continue to follow up with Dr. Yea with regards to medical problems.
-/ 3. The patient should continue to follow up with Dr, Corrosante with regards to hepatitis C.
4. Continue Flexeril on a pm basis.
5. No NSAID's secondary to hepatitis C.
6. I prescribed PT and NMT 3 x per week x 4 weeks under the direction of Mr. David Rogerson and Mr.
Ryan Moore. Therapy was ordered with strict diabetic precautions,
7, A future diagnostic consideration includes performing EMG/NCS of both lower extremities.
8. A future therapeutic consideration includes referring the patient back to you for a series oflumbar ESl's.
9, Return to the office in one month.
Thank you for the opportunity to participate in the care of this patient.
Sincerely yours,
~1MJ
Bram Riegel, M,D.
BR/sd
(dictation transcribed but not read)
-'-
BRAMRIECiEL, M.D.) P.A. C
Spine. SPOI1$ Medidne . E1~rodiagnosls
Certified by the American I19ard of Physical Medidne & Rehabilitation
Bram Riegel, M.D. . Christine J. Weot, M.D.
.
5580 Bee Ridge Road, Bldg. B
Sarasota, Florida 34233
Phone (941) 379-8237
Fax [941) 379-8348
\.....;
v
October 29, 19\98
'f-
Frederick B, ~cAdam, M,D.
3671 Southwe,tern Blvd
Orchard Park, .NY 14127-1749
i' {,
;
De<lf Dr. McA{1am,
, I
RE: RAT.PH SORRFNTTNO
~ '
TO(jay I had th~ opportunity to see your patient, Mr, Ralph Sorrentino, a 62 year-old gentleman, ,
in consultation secondary to lower back pain, Mr. Sorrentino was involved in a motor vehicle
accident on 4/19/98, He was the restrained driver of a 1991 Nissan that was on the Interstate
traveling apprpximately 70 mph. A car made a V-turn in front of him on the freeway and he
broadsided thai: car; his car was then pushed into another lane and struck by another vehicle, He
noted the imm~te onset of back and bilateral lower extremity pain in the posterior aspect of his
leg. He went to the emergency room where x-rays were taken; he was given medication and
discharged. Hi~ back pain continued, however the radiation resolved, He did seek treatment with
his family physician and went through a course of physical therapy that mainly consisted of
modalities and" no exercise instruction. He did receive a couple weeks of therapy where they
worked on giviug him a home exercise program, however he states he has just received instruction
on ,one specwq" exercise.
~\
Currently, Mr,jSorrentino's back pain is located across his back, It is intermittent. It is increased
with any type of activity such as bending or lifting, He has no radiation into his lower extremities,
No numbness ~r tingling. No bowel or bladder incontinence.
"
1
S9-l;TAT. 1fTST~V: Mr, Sorrentino is married, He has four adult children, He lives in Boston but
spends the seaspn in Florida. He is retired from working a steel mill and also carpentry work. He
does use toba.GCo, 4-5 cigarettes per day, He does not use alcohol.
, ~ '
'. I;
PJ\ST MF.DlCAL HISTQ.RY: Non-insu1in dependent diabetes x 25 years, He has been on insulin
for the past fey., years. He states his blood sugars are fairly well controlled, Past medical history
also includes glaucoma and hepatitis C,
, 'I:
PAW STlRGIC~L HISTORY: Cholecystectomy. Repair of right hand Dupuytren's contracture.
~RF.NT MF.pTCATIONS: Humulin insulin., Timoptic eye drops,
A I.I.ERGTF.S: j There are no known drug allergies.
,.
REVIEW OF SYSTEMS: Mr. Sorrentino states that he has significant right-sided wrist pain
and he is un~ble to move his wrist, This happened a few weeks ago and has been getting
increasingly worse. He has also noted a redness to his right hand. Otherwise, review of systems is
negjttive. ,
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PAGE 2 - OCTOBER 29, 1998
LEm TO ~ERICK B. McADAM, M.D,
REGARDING Rf.LPH SORRENTINO
!'
"
I'
PHYSICAL EXAMINATION: Mr, Sorrentino appears older than his stated age of 62 years. He
is pleasant and:, cooperative through the entire exam, He does wear a right wrist brace.
Musculoskeletal:, The patient has full flexion of his cervical spine, somewhat limited in extension,
and full lateral bending bilaterally. Range of motion is pain-free. He has no tenderness over the
cervical paraspipals, He has full range of motion of his lumbar spine but pain with lateral bending
bilaterally. He has some tenderness of his lumbar paraspinals bilaterally. Straight leg maneuver is
negative from;the seated position, The right shoulder had decreased range of motion in all
directions and pain with range of motion, Examination of his right hand does show some redness
and edema; the{e is no increase in warmth. He is tender over the hand. He has very limited range
of motion of bfs wrist to both flexion and extension, only a few degrees,
Nellrological:l The patient is alert and oriented x 4, Cranial nerves 3-12 were grossly intact,
Mapual motor ~ting revealed full muscle strength in the shoulder abductors as well as the elbow
ext\mSOrs and flexors, On the left he had full strength in the wrist extensors and flexors, however
I was unable tO,test these on the right secondary to pain in the wrist. Finger extensors scored 4-/5
(likely secondaTy to pain), He had full strength in his lower extremities including hip flexors, knee
flexors and extensors, dorsiflexors, and EHL, Deep tendon reflexes were at biceps, triceps,
brachioradiali~, and patella, and absent at ankle bilaterally, There is no Babinski sign present.
Sensory exam was decreased to pinprick in a stocking distribution in the lower extremities. He had
an increased sensation to pinprick on his right hand, On the left he had decreased sensation to
pinprick in a glove distribution,
Gatt: The pa,~ent has a normal gait.
I
i
STVDIES Do~: I did review a radiologist's report of an MRI of his lumbar spine dated
7/08/98. It diq show a small disc protrusion at L5-S1 with no obvious contact with nerve root.
There was a1soi,degenerative change at L2-L3 and L3-L4,
i
IMPRESSION:!: Mr. Ralph Sorrentino is a 62 year-old gentleman who was involved in a motor
vehicle accident on April 19, 1998,
.-,_~ :t ! f
L; Lumbar strain.
2.i~Right wnsi pain that is most likely RSD,
3. ), Adhesive y~psu1itis, right shoulder.
, r
PLAN:
1. I am startil)g Mr. Sorrentino in physical therapy under the direction of Mr. Matthew Frey and
Ms, Rosanne Davis, He will receive physical therapy two times a week for the next four
weeks,
~:
.-~ -~,'.
CD
.
PAGE 3 - OCTOBER. 29, 1998
LETrER. TO ~ERICK B, McADAM, M,D.
REGARDING Ri\LPH SORRENTINO
'I'
2. ~ I am requ~ting an x-ray of his right wrist.
3, ' I would like to start Mr, Sorrentino on Gabapentin, We have discussed this option and he
, : wishes to think about it at this time,
4.' I will see 1\im back in recheck examination in one week.
\.....-' i
I appreciate th~ opportunity to participate in the care of your patient. I will keep you updated as
,
to bis progres~.
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Sincerely Your~.
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Chris' J. W~ot, M.D.
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Patient:
Preca1ltions:
SPINE, e>RTS & REHABILITATION SPEOu.tSTS; P.A.
, DRAM RIEGEL, M.D.
5580 Bee Ridge Rd., Bldg. B, Sarasota, FL, 34233 '--
, (941) 379-8237 Fax: (941) 379-8348 f/.
PHYSICAL THERAPY PLAN OFTREATME~
Diagnosis:
L(j (l
Specilll wlnlCtions:
Past Medical/ Surgical History:
Insurance Type: MlC W IC
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Frequency: ~ -.( Uv ~
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LOP SELF PAY Co-Pay (
Duntion: LJI~/( .r
STARt OF TRBAT.MENT:
LONG TERM GOALS:-! ~ fI': '"
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SHORT TERM GOALS:
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TREATMENT PLAN - Effective Date:
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S. Activities of Daily Livin2
7. Olbcr:
_Ergonomic AsseslmeDtl Training
_Postw'lll Awareness I Training
_Home Exercise Pro~
_Phonophoresis I IODlOphoresis
_Physical Reconditilllling
_Cold Packs
Trliaicm Manual
Tnu:liou Mer.han;.;al
1. Heat Therapy
_Moist Hot Pack
_Ultrasound
2. Electrical Stimulation
_High Voltage E1ectricaI Stimulation
_inlcrfcrcnti&l
_EIectrii: Muscle Stimll1alion
v_T.E.N.s.
3. Matwa1 Therapy
_Massage
_M:yo~ R.eIcase
4. Therapeutic Exercise
_ Flexibility Program
_Aerobic I Cardiovascular
_Strengthening
_PROM I AROM
6. Stabilization Program
_Cervical
_Thoracic
_LIIlIIbar
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Ovenll Progress: Satisfactory
, Unsatisfactory
Excellent
~~ytac.~ ~D-
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To Be Comp,letecl by Pbysiciaa:
.:::;; certify and authorize that the avove therapy treatme
Pbysieiau. Siglllltllre Required
Physical Therapist Signature
;
Date
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SPINE, e>RTS & REHABILITATION SPEOLISTS, P.A.
BRAM RIEGEL, M.D.
5580 Bee Ridge Rd., Bldg. B, Sarasota, FL. 34233
(941) 379-8237 Fax: (941) 379-8348
{/ /fr~
Patient:
Precautions:
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PHYSICAL THERAPY PLAN OF TREATMENT
(wY\tM J!v-f
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Frequency:
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LOP S~LFPAY C7Z
DuratiOn:4 V'I. ,
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Special. InstructiOIllS:
Past Medical I Surgical History:
Insurance Type: MlC W IC
START OF TREATMENT:
LONG TERM GOALS:---1-L~ p
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SHORT TERM GOALS:
II ft)y.
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TREATMENT PLAN - Effective Date:
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1. Helll Therapy
~oist Hot Pack
p;ltrasound
2. Electrical Stimulation
_High V oltagc Electrical Stimu1ation
_Interfe~
,'. -7'Electric Muscle Stimulation
G _n:.N.S,
~ Therapy
~Yora:cw Release
4, Therapeutic Exercise
_ Flexibility Program
_Aerobic I Cardiovascular
..s...,Strengtbening
-+pROM I AROM
5, Activities of Daily Living
~ilization Program
~caI '.
~oraCic
.y.tumbar
7. Other:
~gOnOmiC Assestmentl Training
, stural Awareness I Training
Home Exercise Program
_ Phonophoresis I Iontophoresis
_Physical Reconditioning
~old PacIes
_Traction Manual
_Traction Mechanical
Overall Progress: Satisfactory
Unsatisfactory
Excellent
Physical Therapist Name
Physical Therapist Signature
To Be ~~y Physician:
(MY and authorize that the avove therapy treatment is medically necessllI)'.
Physician Signature Required ' Date
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A IIrhori7arinn J')ate~
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SPINE, SPORTS, & REHABILITATION SPECIALISTS, P.A.
BRAM RIEGEL, M,D. CARLOS DIAZ, M,D.
5580 Bee Ridge Road, Bldg. B, Sarasota, FL 34233 ,
(941) 379-8237 Fax: (941) 379-8348
THERAPY PRESCRIPTION' REFERRAL' TREATMENT P
. I certify, ' the w.at:m;en:t as beinf medically ~ssaIy,fOr the patient under
() r) ~ h .___f(r~ 1100 DIagnoSIS:
bS,,, J ( ,
Precautions: \J Cardiac \J Seizures \J Osteoporosis
\J Anticoagulation 1:1 PVD \J Hip
Special Instructions:
Past Medical' Surgi<;al History:
Insurance Type: Me MA
. Frequency:
Start Treatment:
Patient:
LONG TERM GOALS:
_:.l.c1'
r ;/ /v1V\ ~
tJjjJ
IIllf(f)
lJ<J
\J Weight Be
\JSurgical
\J Pulmonary
\J Other
HMO LOP GOvr SEL~ PAY Co-Pay
[S wU / '
-
Eval & Treat: \J PT \J OT \J NMT
SHORT TERM GOALS:
Duration:
TREATMENT PLAN - Effective Date: .
1. Heat Therapy
Moist Heat
e-UltrasoWld
;1pcJ1
2. Electrical StjmU1.tjOD
_ High VolIage Electrical Sriml.l.t;on
Interferential
_ Electric,Musclc Stimnl:ltinn
_ T.E,N,S. (No T.E.N.S. ifMC),
>;' Therapy
ellIolDllSClllar 'I'bcrapy
Mynf.~.l RcIeise
_ Joint Mnhi117111tion .
_ Special Instructions:
Physician Sit:nature:
4, Therapeutic Exercise
_ Flexibility Program
_ Aerobic I Cardiovascular
_ Strengthening
_ PROM) AROM
.
5. Activities of Daily Uving
6, Stabilization Program
_ Cervical
~ ~racic
7' Lumbar
,,'
I_I
7, Other:
_ Ergonomic Asse5~m~nt I Training
AOstural Awareness I Training
Home Exercise Program
, _ Phonophoresis I Igntophoresis
_ Physical Reconditioning
_ Cold Packs
_ Traction Manual
Traction Mechanical
NellIolDllSClllar R.cxducation
_Gait Training
_ Aquatic Therapy
:1 ;
NOlE: Tre.tment Plan subject to change pending therapist evaluation.
f..",_..
~<.~;,,~-'"
Physician Orden: Initial Tre.atm"nt Continue Treatment _ Change Treatm"nt
Tx Prot:ress: _ Satisfact&y "-'", _ Unsatisfactory _ TX; HEP,c&-Discharge Summary
_ Ext",nrl'Xf Tre:l~eI't Requiii!t~ F"ll"On.: ' : i
, "ThIs informatkln, has ~aer, Jisclo,.d to you frO~(eCOi~S,
prdhibi~ you om nia ng ny further disclosu'res of such
. '". .
. I.....:.' l' .
P8rsI\tl ill' Insuc Tor ali.on pertains or as titheiWis. I
pam; ted 'State Law.'Date:' ,
.,...;...:.'-::;,""-~- ---",
= . ,-
, , -~', uo~~ss ITreatment ~ LW5 e
"'; " ":':'," , "Billing Code:~o-Pay:
,patient:~~~ ~OO'(\~~-'7~,"- Date:~
Patient indicates hislher condition is _ signific~fb~~ _ slightly better,
L about the same, _ slightly worse, _ significantly worse since last visit.
'. Pain (,./. 110" 'Func~onal capability % of pre-injury or pre-event status..
HEP:_complilll1t, _ partially compliant, -.:..... non-compliant, ::L. NI A
Notew~rthy Changes:
Conclusion:
'".
" ,.<kM ~_tI br ..'," l.e.il<J iii" j'ol/owbrg II'tlltmats to ftlllctJoIIlll/Jllmprollt! /h.qff,cI4d 111III($) 11/
IIC~~~II/t /h, p"'~ .,rowi 1r,lIImeIIt pilllllll/d Cutlflclllloll ol"""lclll II'CWIty:
.1 Evaluation or Monthly Progress Report
units 97032 Electrical Stimulation - No TENS if Medicare
= units 97033 Iontophoresis
",' . ' . ' units 97035 Ultrasound
~ts 97110 Therapeutic Exercises
units 97112 Neuromuscular Re-education
-
units 97116 Gait Training
" . ~ts97140 Manual Therapy (Do not use this code for Florida Work Comp.)
.' "'__units97250 Myofascial Release / Soft tissue mobilization (Florida Compo only)
" _ units 97265 Joint Mobilization (Florida Comp, only)
_ units 97530 Therapeutic Activities (Florida Compo only)
_ units 99211 Outpatient Visit
".,.In,a4di~on, Patient received: .#It. .,s,....:>> IJ-- d~... P;)~'
,...' '" Fmding~ I Exercise Log / Treatment Areas: ~ d"..1l-/"':. ~A.,~.t ~~: : : : '
. '
IM'; Jt:e;b~<!, ?,:..I.!&, filj~~~ Mr/1fll1fe ~,(" ,(JJJ .(,t(';l;:L_
f"L'1:.1 .~~(+- ""--,' j'f ,pllwl.e~ ' , .
111,,1.
,
.;.iT<?taLtuneJ)~tient spent in therapy is I hour minutes. I unit = 1,5 q1~.
.. \<
Post T~: Patient indicates hislher condition is _ significantly better, /s~i~tly
beiter, _ about the same, _ slightly worse, _ significantly worse, . . . . , '
Post Tx Pain c;.. /10. Today's progress toward functional objectives 10 ~ .%~ .
,
," 'Post Tx Remarks: '
, Next visit: ./ continue following treatment plan, modify program Within
existing treatment plan, change treatment plan (requires physician approval). .
, ly1:odUlcation I Changes: .4d" .fiJJ!.~ ~ '
Set-up I Prep: tiff IN t-/r ((Nf.1 ~if, T,:
'S~~e, Sportl," Rehablll~UolI Spec~~ts, p.".1/2001 Prepared by:(K
mo llco lU4i1 BI41, B . SIIUOII, FL 342;3.JOUlHTOWNS
~...,. U09rl2000 'Ilm" HeN b JlfOI*'lY rANUDn'I\AMIl' T'hef'P't C'''tIf,lnc. ~i*'\lhprohibi"ed
"<,, .
"
" '"
-
.."
,-~"- ~
.IiOIWii~HRillII~~L[.....l~.
~>l."
EVALUAli )1 PROGRESS REPORT
PLEASE SIG ,..NO FAX TO (~141) 37908348
,
NECK FLEX, EXTEN . ROTATION LATBEND PATIENT: ({jJ/ ~II J;' ,R,1L , '77Jn
EV AL - R ./ Physician: Ptt 7;~~ Date: c;I/l9/o/
EVAL.L '/ /' W; JfNf.
Diagnosis:
PROG - R / Prescribed Visits: 12- Actual Visits:
P:ROG . L T~ent: ./ ~a1 Therapies ,/"HEP
New Goal. R /' Exercises Activities./'.iM I MFR
New Goal. L - v1\Iodalities - Other -
UPPER EX. ABD FLEX EXTEN I-ROT E-ROT PRO SUP Patient indicates: bislber condition is
EVAL-R - _ improving, _about the same,
EVAL.L .../" . ~ getting worse.
V Eva! Pain 1 5 10
PROG- R .-/ ProgPain 1 5 10
-.;OG- L V ' . Goal Pain 1 5 10
Goal . R ./ Overall Progress: %
New Goal - L 1 Rehab Potential:
BACK FLEX EXTEN ROTATION LATBEND
.. EVAL.R , 'is' ' \0"
, · t:: \;S'>
100:, =..:., , '
EVAL-L J {T' 10
FROG - R
FROG - L
New Goal. R
New Goal. L
HlP I KNEE FLEX EXTEN I.ROT E~ROT
j!VAL-R
EVAL-L
FROG - R
PROG . L .
NewGoal.R,
New Goal. L ,
FOOT DORFLEX PLA FLEX E~ION INVERSION
EVAL.R
EVAL.L
PROG . R .
PROG . L
New Goal. R .
c ~ '" .-, I.
New Goal. L .'.
O~RTESTS:' ~ ' ,.1...1. - "" ,
- ~:;:{r5 : S " rb " iIIform
"'- ~~~-connden!ialily 'is:prolecled y
- '",
rJ (f'J f',A,.J (!J QV;\PJ e tf;"< prohllllfs you from makirQ any fu he
OTHER DEFICI'l'S: ff>T: p~ I ~_~,S'" :" tl
.:~
SPINE, SPORTS, & REHAB SP~AILlSTS, P.A.
Bram BIegel, M.D.' ~ Diaz, M.D.
5580 Bee Ridge Rd. B1dg. B . Sarasota, FL 34233 . (941) 379-8237
REP: _ Compliant _ Partially Compliant
Non-Comp1iant Not Applicable
STRENGTH Evaluation
(0-5) L
./
I
I
Pros<eos Now Goa1s
R L R L
FUNCTION:
GOALS: ~ Achieved, _ Partially Achieved
Not Achieved
,JJ;VALPREPAREDBY:
:1-
PROGRESS REPORT BY:
RECOMMENDED PLAN OF CARE:
Colitinue Treatment Plan
Change Treatment Plan
Changes:
r - y?" ~r--'"
Frequ~y: ".'~ ',~
Comm<:J'tS;, "
yotJ. ~t.. being medically necessary
Ie law! ~.'tbe patient uner my care,
r '!tIosurW.... .
enQJ~ . !~Ignature:
etl '
Law.' '/Jk Yo I
Duration:
,,~"':,:__,_,,'_,.""""~.'-_e"_'
.-..;.,~~~. ---"':--"
~...
- ~,
~ .,,J~,!l;;\t:-
Progress I 1 reatment p".., '1 / ,
:0 Q30\5, '8_
- _ <, Billing Code:WCo-Pay:~
Patient :-~'r"'~rt-et\-tlM n" ~b._nate:~
Pati91t indicates hislher condition is _ significant yetter, _ slightly better,
-L about the same, _ slightly worse, _ significantly worse since last visit.
Pain ~ 110. Functional capability % of pre-injury or pre-event status.
HEP: _compliant, _ partially compliant, _ non-compliant, _ NI A
Noteworthy Changes: ,.r; \7<.\ 'IJ F cJ -I-k. ~.j., waIL fK-,.,'^'" I)., c:: fctJ..;r'
. I
Conclusion:
Plllimt p/lrtklpllled In /I1Idlor received the following "e/llmen" 10 funcIlon/l1/y Improve Ihe II/!ected /lretI(s) In
/lccord/l1lc~ wUh the ptlyslcllln /lpprovel1 tre/llmen/ pl/ln /Inti certl//C/lI/on OJ mel1lc/ll necessuy:
Evaluation or Monthly Progress Report
units 97032 Electrical Stimulation - No TENS if Medicare
_ units 97033 Iontophoresis
units 97035 Ultrasound
~ units, 9711 0 Therapeutic Exercises
units 97112 Neuromuscular Re-education
units 97116 Gait Training , " " , " "
'1:'" units 97140 Manual Therapy (Do not use this code/or Florida Work C;~~p'.) <,
_ units 97250 Myofascial Release 1 Soft tissue mobilization (Florida Com"R: only), : ' , :
_ units 97265 Joint Mobilization (Florida Comp, only) : " <, : , , :
( '.'
_ units 97530 Therapeutic Activities (Florida Comp, only) , , ,
'1 ,
-L units 99211 Outpatient Visit ' "
In addition, Patient received: ' , , ,
Findings / Exercise Log 1 Treatment Areas:
ar'i &+o.~~ 0.((,
_PJJiML ~EP. p~(lQj
Il!l"
,
111("
, "1
t eYi
Total time Patient spent in therapy is hour minutes. I unit = 15 min.
Post Tx: Patient indicates hislher condition is _ significantly better, _ slightly
better, _ about the same, _ slightly worse, _ significantly worse.
Post Tx Pain 110. Today's progress toward functional objectives
Post Tx Remarks: t. a\ ~((l t
Next visit: -0ontinue following treat~ent plan, modify progr within
existing treatment p!aG, _.' change treatment plan (requires physician approval),
, .
Modification / ChangesjUN l'.i 2am
Set-up / Prep:
tiOUTHTOWNS
SpiDe, Sports, " Rehabilitation Specialists, P.A.
SlIO IUc Ridge Bldg, B . S"""la, FL 34233
WGItcoIM..,. I~ Fonn&tled Nett i. propertJ' or NtulOmUICUllr Thenpy CeIIlC!', 1m:, Unluthorind un prohibin~.
v
3~ f'.. "
%
Prepared by:
!fih:
a PA
~ - ~ ~ "
>~ '
,,~6r~_
Progre"/~entN~)q3~; \~OfIOI ~
,t\", , Billing Code paPay:
Pat;int: \<>\O...\~'n ~(,Y'O~YiC) Dx: 7 .0 ate:6\ (~\al
,a . ';)
Patient indicates his/her condition is _ significantfybetter, L slightly better,
_ about the s~e, _ slightly worse, _ significantly worse ~ince last visit,
Pain --1.4-/10. Functional capability ~o % of pre-injury or Pfe-event status.
HEP: _compliant, _ partially compliant, ~ no~-co~~~iant'l ~ NI A ,
Noteworthy Changes: ~II ao l' ~O III ~ (''''ll~nO'
Conclusion: -n#A.ec,<,,^ ^Ctlllc,.Jn110S~ -<'/Qxu<"- <f)i ~).
PIllIent plll'lklpllled In IIIldl" ncdved the foUowlng trelllments to functionally Improve t1je lIjfected area(s) In
accordllllce with the phJ1sk:1IIIl approved tnatment pllllllllld cmiflcatlon of medical nec Ity..
_ Evaluation or Monthly Progress Report
units 97032 E,Iectrical Stimulation - No TENS if Medicare
_ units 97033 Iontophoresis
units 97035 Ultrasound
:;t.. units 97110 Therapeutic Exercises ::::
_ units 97112 Neuromuscular Re-education ,I '.' : : "
_ units 97116 Gait Training ,
~ units 97140 Manual Therapy (Do not use this code for Florifla Work ComlO:'
_ units 97250 Myofascial Release I Soft tissue mobilization (I1lorida Com;Vlr-!y)
_ units 97265 Joint Mobilization (Florida Camp. only) I '
_ units 97530 Therapeutic Activities (Florida Camp. only)
-L units 99211 Outpatient Visit
In addition, Patient received:
Findings I Exercise Log I Treatment Areas:
~ b'
,bL
'lL,
, ;Jj
)",
, ,
"" .'
.
, ,
"
I'J' 'I
,
)I!));
)'ll
, ,
Total time Patient spent in therapy is --L hour
. ~.
. .
better, _ about the same, _ slightly worse, _ significantly worse.
Post TxPain ~ 110. Today's progress toward functional obj ctives - %
Post Tx Remarks: l' ~'" 5~
Prepared by:
I
I
,
~ I .:..~ ~_
SPINE, SPORTS, & REHAB SPEiiliULISTS, P.A. ,',',
BramBlcgel,MJ).' " ,C~M.D. ' ,
SS80 Bee Ridge Rd. B1dg. B . Saiasota, FL 34233 . (941)379-8237
NECK
EVAL.R
EVAL-L
PROO ,R
PROG -L
NewGoal.R,
New Goal. L
UPPER EX.
EVAL.;R
EVAL-L
PROO- R
~.";'"~
New Goal. R
II;GOal-L
BACK
" EVAL.R
EVAL.L
PROQ . R
PROG - L
New Goal. R
New Goal. L
HIP I KNEE
EVAL.R
EVAL.L
~-R
PROG-L'
New Goal, . R '
New Goal. L
PRO' ", SUP ' . +'ent iDdicaltes: bisIher condition is
. , " improving, _about, the same,
, . 'getting worse, ' ,
E+Pain '1 's 10
. ~gPain 1 ,. S 10 '
r....ll>oin l' ~ 10
~I' ;'=- " ....' ""
,I. '. ' I
Overall Progress: . 0/0
~ Potential: .
-. ~i mp1iant -. Partia11. . ' 'y COl'1pli.nt )
N9D-<:omp1iant _ Not Applil:able
STRENGTH. , BwlUIliaIl ~ Now 00IIa
(0-5) ! R L R L R L
~'L4.t.v I ~\5Ir Cl,'(
'.lilT
" \;'"lll/' I
FLEX,
EXTEN' ROTATION LATBEND
~~'--~Wt." "~- - "~i1fliijjjWllUii~~riIi~iI;iJi~~~" '~JiilI"."-r- lll. .h~"'lIt-"'~~~"'"",,",",",Hc
EVALUATW-' I PROGRESS REPORT
PLEASE SIGN, .,'W FAX TO (94'1) 379-8348
.
" ~'~\" t:.. l
PATIENT:"'/ n -....nff NY ",",v
Physician']), I ~ t9. t- \ Date:::<- II" hi
. DiAgnosia: "l 1-1. , \ '6 11... \.-( .1- I
1 .
, Prelctibed vUlts: \7_ Actual Vlsits:Jl-
'Treatment: ' Manual Therapies .:L BEP
" ::L Exen:iIes lx Activities, _ JMJ MFR
, _. ModaIitl~ __ 'Other ' .
..
.
, ABD
FLEX EXTEN' I. ROT E . Rb'r
I
.
I~
.
~~~: ,', '~'r\\u-(nl~t.
CIA. m,:,r ~1'.~ W:' 0\~L'
". r ~'v- ~,.... 7 l~ 1'Yl'"',
, "
, ,
GoALS: ~ .)L PartiaI1YAchicved
"
FLEX
, ROTATION 'LATBEND
IS" ' '10'
\~ '16'
~. , " ,;)o~
~'SJ' ';)0'
EXTEN
f.DC)....' · IS'"
'- .,,,,,*,"'"
1<';"
..],:) .
FLEX'
I - ROT
.
E~ROT'~:
,EXTEN '
'.,
, ,
.
FOOT OOR FLEX ' PLA FLEX, EVERSION iNvERsION'
EVAL-R
EVAL-L'
PROG-R'
PROG -L
NewGoal-R.
New Goal- L
S:;I... -) ,c:to
OTlltR DEFICITS:
:;.,,,~,__,,-,__",,,__c-~"t"_.
11'
._'-=""-:~~,,,,,,-_.
~ - -UIr -
liaWlll~\'.,
.....~
:.) ! ~
\..01
__w I __
, t}:) _ ' C' _ , Billing Code:~qo-Pay:
Patient: !f"P.~'0" "- T)~ y\\\("O Dx: ~~\O ~ate::3liSIOL
Patient indicates his/her condition is significantly bettt', I slightly better,
-;- about the s~e, --:- slightly ~~rse, _ significan~l~ wor~ince last visit.
Pam .J:2JIO. . Funct~onal c~pab1l1ty. % ofpre-mJury.or ~re-event status.
HEP: _comphant, partially complIant, -:..- non-comphantr_ N/A .
Notew~rthYChanges~O boJc {Y11(\ ~O " sri'1Mr::, 1~ pa~f1.
Conclusion: Q.C -' e0Ct9 ~..o:=" 6,,, I
I
Plllknt ptII1k/ptlled In wuJlOl 1ICd\Ie1l the jo/l(1wlng tnlltme1llS to jtlnctkmllll,p /mpl0J/e '1'e II/fected _($) In
/lCCflrIItw:. willi the plly,/CIM /lPp1flJ/e1l trelllment pIM /11111 certl/klllwn oj metUcttl necjlty:
-L Evaluation or Monthly Progress Report I, " , ' , .
_ units 97032 EJectrical Stimulation - No TENS if Medicare I ' ,
_ units 97033 Iontophoresis
units 97035 Ultrasound
.2:= units 97110 Therapeutic Exercises
units 97112 Neuromuscular Re-education .,
units 97116 Gait Training " : , " " "
r runits 97140 Manual Therapy (Do not use this code for Flon(ia Work Comp.) , , , ,
-:- ~ts, 97250, Mrofasciaf ~el~ase / So~ tissue mobilization (llorida C011Jp.'lPnly) " "
.,....tC! 97"lt:.l:, Jo.nt !\.A'''b'll:r.ahon fF,'lo..,An r'."..m "nl'v\
_ -..._ . _""." ......_ ..,.1..,... _. '\; :. f ."""- _TJ.,.l'-" .., J
_ units 97530 Therapeutic Activities (Florida Compo only)
_ units 99211 Outpatient Visit , I
In addition, Patient received: ,
Findings I Exercise Log I Treatment Areas: (2.(. &.:bJ \J...O.....-\i~ . G ~ I ~
1:;,"' ~\~ b;P\,:~~~ l*b';;;;~;),
\".~ It'. J cAAj Qr<"> \-\~i'"
Total time Patient spent in therapy is hour {O:;> mmute,. 1 wiit = 15 min.
.. Post Tx; PaLiClut illl:1i~*s hisihcr condition is _ significantly ~ettp.r, s~~.... .. .... d
better, _ about the same, _ slightly worse, ---,. significantl)1 worse.
Post Tx Pain (") /10. Today's ptogress toward functionalobjrcnves
Post Tx Remarks: ,\=-( L. \ .., ~ ~ ,I ~ '
Next visit: continue following treatment plan, ' mo~ progdin within
existing treatment plan, change treatment plan (requires lfhysician~prova1).
Modification / Changes: I 11
-..-....--Set-up/Prep:::.(,'~" u m-=: "-~tc.i;;;<.:'j" +..~~:t.-u-Tc~ unm
Spin, Sportll, " RebabilltatioD Specialists, P.A. Prepared bY:!~ { Qr~ r It"
mo IIoc IU4ao Bldl. B . SItUOII, FL 34233 I
WMl:rflm,f Wl'1 J.IOQ/7noo Form.'IM! NIlI~ i, proper!y ofNeuromulcut.r TheraJlY ("enler ln~ tln.uthoriud lilt prohibiMd
, Progress / Treatment N(j:)
'.
c;3~...'J
_...
l; "
%
1_II~lB~I~.m.PI _liIkkl~liIl_ -~
,
~
-
,"~ --~..il,~1i<L",
",~ " '1J0~) ,
'~PrO~ess'/TreatmeritNoCJ ' . ' ".,
, , ,,: ."",,", ',', ",' ',' . Billing Code: ,'Pay' '
,,;:',PatiCnt::~~\?~SD~~N.~tiPx: "i:2. '~ate:~(
, "'.:Pati~ indicates hisIher OOD~tion is----:signifi~an~y ~~~ghtly be~.
, , ~abo~the ~e. ~slightly ~orse. ---:Slgniti~y worse Fce last VlSlt.
Paul~lO. !UD.Ctlonal ca~ability ~% ofpre~mJury ~r Pfr-ev, ent status.
HEP:___compliant, L.Partiany compliant, _non-compliant, _N/A '
, NotewOljhyChanges:, ',,-' '"Z' ' . " "
, Qmclusion: \\ ," r:', "I Iv '
~ ptIIt/d,ptIIlft/ lIr lIIIIV"'~ 1M ~ "'KINJIR,-II! loill.~,*~.il1 ~ ~ Iff(IIdiiJ tlNlll(s) , "
iII~w_~wiIIIlM~.prt1Ml~wpIM_~.(}IIf(,rlJlltIl :' ,', '
, ,~E~~nor ~oothly Progress Report' - , " '
, ~unit:s 97032,EJectrical Stimulation - no YENS if Medicare '
~unitS 97033 Iontophoresis '
_units 97035 U11;t'asou.nd
" 2::...units 9711 o Therapeutic &ercises
, UDits97J.12New-omJlsc\llarRe-education
~,,_., .
, _units, 97113 AQ," _, Therapy (Do not use this code With, 97111'0) ';'"
, , 'unitst"l7116 Gait T . . " ' ' "",
_____ . 7rauung , ' ' ' , ,
2... units'97140 MauualTherapy (Do not use this codejor Florit!f Work C011JPJ', ''''
, , __units 97250 Myofascial Rel~e / Soft tissue mobilization (Fk rilia Comp~on~) i
'. ,___units 97265 Joint MObi1i7.l1tion (Florida Compo onl)l) ~ "'"
~UDits9-7530',1'her.aPeutic Ac,tivities (Florida Compo onl)l) ,
~imitl992110utpati~tVisit' " ,,' '
" In addition. Pl1tient r~ived: ' ~
'FiDdinpi Exercise Log I Treatment Areas:
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, beUer.~abQl1ttbe 'same. ~slightly worse..~signifiClUltly rorse. ':' ,',
'PostTX~aiI1 tHcl' !10':T~~y,sprogressto~ard:C~~~Obj~tiVeS 'I .i %.
Post Tx~ewll.Tks: ~YI - R'I..o. -\.- .,a\ ~ ,1Jgo,). w
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.Slll!ie, Sponi, II R~...hll..~tIA;: Spet'I.II"~, PoA", '.,: . Prepareg by: ,
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b!'Ill,~:
t
.dd P. Kuhn, MD.
ilsan Afshani, M,D.
Paul Montgomery, MD,
AnneD. Ehrlich, M.D.
Steven L: Christensen, MD,
Dilip E. Gole, MD.
p""""nnp. Oliverio, M.D.
Jan S. Najdzionek, M,O.
David J. Martin, MD.
. r . 'gnostic Imaging Associat4
Of Western New York, P.C.
1630 Maple Road
Williamsville, NY 14221
716-636-1902
Fax:
716-636-1367
James W. Backstrom, MD.
Steven L. Bezinquc, 0.0,
Mark J. Pisaneschi. MD.
Gregol}' T. Tymc:hak, MD.
Bruce P. Hall, MD.
Richard O. Thomas, MD.
John J. Januario, M.D.
Charles 1. Riggio, M,O,
,
/i
., .
,
,;.'
MRI OF THE LUMBAR SPINECONT
RE: SORRENTINO, RALPH
v
The STIR images show no evidence of bone edema. There is no fracture or posterior
ligamentous complex injury is evident.
IMPRESSION: 1. SMALL FOCAL LEFT OF CENTRAL L5-S1 DISC PROTRUSION,
NOT OBVIOUSLY CONTACTING NERVE ROOTS,
2. MILDLY DEGENERATE DISCS AT L2-3 ANDL3-4.
Thank you for this referral.
Sincerely, '
v
RT/lf
dot 7/819
Preliminary until signed
~:
Richard D.Thomas, M.D.
204842-9 CR
,
lif 6 r.J,
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-
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"- , Iera1d p, Kuhn, M,O.
".Ebsan Afshani. M,O,
Paul Montgomery. MO,
Anne D.Ehrlich, M.D.
Steven L, Christensen, M,O,
Dilip E. Gole. M,O,
Roseanne Oliverio. M.D,
Ian S. Najdzionek, M,D,
David 1, Martin, M.D,
CD
r . ,gnostic Imaging Associatet>>
Of Western New York, P.C.
1630 Maple Road
Williamsville, NY 14221
716-636-1902
Fax:
716-636-1367
lames W. Backstrom, MD.
Steven L, Bezinque, D.O.
Mark 1. Pisaneschi, M.D,
Gregory T. Tymchak, M,D.
Bruce P. Hall, M,D.
Richard D. Thomas, M.D.
Iohn 1. Ianuario, MD.
Charles 1. Riggio, M.D.
Dr. Frederick McAdam
9 Limestone Drive
Williamsville, NY 14221
~\\ :\:~'; 1 ""lIJ\
lli1 \J..H_ .), ~"'''.f ill}
RE: SORRENTINO, RALPH
_..____m_._....___._..__. DOB 11/5/35
98-0852
EXAM DATE: 7/8/98
/
V
Dear Dr, McAdam:
MRI OF THE LUMBAR SPINE
INDICATION: Disc disease versus stenosis. The patient has a history of MVA in April
of 1998 and has low back pain radiating down each leg,
TECHNIQUE: T1, T2 and STIR sagittal images, T1 and T2 weighted images.
FINDINGS: Assuming five lumbar vertebrae, the tip of the conus is normally
positioned behind L 1, The conus is normal in signal and morphology, There are no
abnormal masses within the distal thecal sac.
v' The appearances at T11-12, T12-L 1 and L 1.2 as well as L4-5 are normal.
At l2-3 and 3-4, there is mild desiccation of the disc. Each of the discs bulges mildly
and diffusely. The central spinal canal and exit foramina remain capacious. The facet
joints and f1avalligaments appear normal.
At L5-S 1, there is desiccation of the disc. There is posterior high intensity zone indica-
tive of annular tear. There is a small left paracentral focal disc protrusion. There is no
definite nerve root contact, although there is potential for contact with the left S1 nerve
root, which is very close to the small disc protrusion.
(continued)
~
- u .
~ ~
._Ii<i.!l,~","
Jewd P. Kuhn, M,D.
Ehsan i\fSbani, M,D.
Paul1l4ontgomety, M,D.
~e D. Ehrlich, MD,
Steven L. Chrislensen, M.D.
Dilip~. Gole, MD,
'Roseanne Oliverio, M,D.
Jan S, Najdzionek; M.D.
David J. Martin, M.D.
~gnostic Imaging Associates C
'OfWesternNewYork,P.C. '-,
Dr. Frederick McAdam
9 Limestone Drive
Williamsville, NY 14221
1630 Maple Road
Williamsville, NY 14221
, 716-636-1902
Fax:
716-636-1367
I"" 't' ';0;', 'ii' \!/ '".." lID
t L..; "" L.., ,,0 '-'lID
Su\.. 1 3, i~I~\\
RE: SORRENTINO, RALPH
--------------------------- DOB 11/5/35
98-0852
EXAM DATE: 7/8/98
James W. Backstrom, M,D,
Steven L, Bezinque, 0.0,
Made 1. Pisaneschi, M,D.
Gregoty T. Tymcbak, MO,
BruceP. HalI,M,D.
Richard 0, Thomas, M,O.
John J, Januario, M,D,
Charles J, Riggio, M.D.
v
,
Dear Dr. McAdam:
MRI OF THE LUMBAR SPINE
INDICATION: Disc disease versus stenosis. The patient has a history of MVA in April
of 1998 and has low back pain radiating down each leg.
TECHNIQUE: T1, T2 and STIR sagillal images, T1 and T2 weighteqimages,
FINDINGS: Assuming five lumbar vertebrae, the tip of the conus is normally
positioned behind L 1, The conus is normal in signal and morphology. There are no
abnormal masses within the distal thecal sac.
IV
The appearances at T11-12, T12-L 1 and L 1-2 as well as L4-5 are normal.
At L2-3 and 3-4, there is mild desiccation of the disc. Each of the discs bulges mildly
and diffusely. The central spinal canal and exit foramina remain capacious. The facet
joints and f1avalligaments appear normal.
Atl5-S 1, there is desiccation of the disc. There is posterior high intensity zone indica-
tive of annular tear, There is a small left paracentral focal disc protrusion. There is no
definite nerve root contact, although there is potential for contact with the left S1 nerve
root, which is very close to the small disc protrusion.
(continued)
.
-
,..,
~",,-',"i':
Jerald p, Kuhn, M,D,
Ehsan Msbani, M.D,
FaulMontgomery, M.D.
Anna D. Ehrlich, M,D.
, Steven L. Christensen, MD.
Dilip E, Gole, MD.
Rosel).l111e Oliverio, MD,
, Jan S, Nl\idzionek, MD.
David J. Martin;M,D,
CJ'1gnostic Imaging Associates.
Of Western New York, P.c.
1630 Maple Road
Williamsville, NY 14221
716-636-1902
Fax:
716-636-1367
James W. Backstrom, MD,
Steven L, Bezinque, D.O.
Mark J, Pisaneschi, M,D.
Gregory T. Tymcbak, M,O,
BruceP. Hall, MD.
Richard D, Thomas, M,O.
John J, Januario, M,D,
Charles J, Riggio, M,O,
MRI OF THE LUMBAR SPINE CON'T
RE: SORRENTINO, RALPH
The STIR images show no evidence of bone edema, There is no fracture or posterior
v ligamentous complex injury is evident. .
IMPRESSION: 1. SMALL FOCAL LEFT OF CENTRAL L5-S1 DISC PROTRUSION,
NOT OBVIOUSLY CONTACTING NERVE ROOTS,
2. MILDLY DEGENERATE DISCS AT L2-3 AND L3-4.
Thank you for this referral.
Sincerely,
~'
Richard D. Thomas, M.D.
204842-9 CR
V RTflf
d-t 7/8/9
Preliminary until signed
.
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FAX COVER SHEET
DATE ,. J.5-9'7
FROM 0~
TIME
TO CQ",~LM- D~,,~.M
.
BRAM RIEGEL, M.D.
CHRISTINE J. WEOT, M.D.
5580Bee Ridge Rd"Bldg.B
Sarasota, FL 34233
COMPANY ~' ~
v
PHONE (941) 379-8237
FAX (941) 379-8348
PHONE
FAX
~/ 3 - 7'7"1-7777
Number of pages, including cover sheet I
v
THE DOCUMENTS ACCOMPANYING TIllS TELECOPY TRANSMISSION CONTAIN
CONFIDENTIAL INFORMATION, BELONGING TO THE SENDER THAT IS LEGALLY
PRNILEGED. TIllS INFORMATION IS INTENDED ONLY FOR THE USE OF THE
INDIVIDUAL OR ENTITY NAMED ABOVE. IF YOU ARE NOT THE INTEND
RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY DISCLOSURE, COPY,
DISTRIBUTION, OR ACTION TAKEN IN RELIANCE ON THE CONTENT OF THESE
DOCUMENTS IS STRICTLY PROHIBITED. IF YOU HAVE RECEIVED THIS TELECOPY
IN ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY TO ARRANGE FOR
RETURN OF THESE DOCUMENTS.
RE: ~ ~ cW1.I..~ (' f# 5.;1 .;) 0'1 do C?t>!3
MESSAGE: Our office is in receipt of your request for additional information on the above
referenced patient. Dr.Riegel and/or Dr, Weot will be happy to review the patients chart and
address the specific issues you have inquired about. However, there is a $ &.;;;..:::1 pre pay fee,
Please forward fee to: BRAM RIEGEL, M,D., P A, and a response will be promptly dictated.
Thank You,
. ..,..,:r
Po::kJ ~ ~ ~ ~ /1-17'9%. p;:kJ,wt>-4 ,
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State Farm Insurance
.
Companies
STATI 'A."
A
INSU"ANCE
e
Christine Weot,MD
5580 Bee Ridge Rd Bldg. B
Sarasota, FL 34233-1505
Stat8 Farm Insurance Claim Office
P.O. Box 9608
Winter Havsn, FL 33883
(813) 979-7700
(800) 577-8466
January 22, 1999
RE: Claim Number:
Date of Loss:
Our Insured:
Your Patient:
Account No:
52-2092-063
April 19, 1998
Ralph J. Sorrentino
Ralph J. Sorrentino
REIMA010
Dear Dr.Weot:
~ State Farm is in receipt of your bills for date of service
11fl9f98, on the above patient. In order to update our file,
please provide the following information so we may properly
review future expenses:
1. Has the patient had a positive response to your treatment
provided to this date?
2. Has this response to treatment modified your treatment plan?
If yes, in what way?
~
3. Please provide your current treatment plan for this patient.
Please include documentation of specific positive findings
which would support this treatment plan.
4. When do you expect the patient to reach Maximum Medical
II1Iprovement?
If you have any questions regarding this request, please do not
hesitate contacting me.
State Farm Mutual Automobile Insurance Company
Medical Authorization
HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001
-_ "'_ '''~~,'.'.~'' .v ""UP""" "NY AND ALL FORMS TO AN'illllllfR PARTY OR /NSURfR /F SUCH /S NfCfS:
, ~f!lF~CT /TS RIGHTS OF RfCOVfRY POfD FOR UNDfR THf NO-FAULT LAW. W
THIS FORM IS SUBSCRIBED AND AFFIRMED BY THE APPLICANT AS TRU~ UNDER THE PENALTIES OF PERJURY.
Any pe:&~i1 \','\.':: ~.,:-''';::;::' 3"'l: wj:-~ ;n~e~t t::' re~..?;..'c <:,"'Y ''''1su''ance cO;:1pa~y o~ ether ;;~rso:i :ilc-s 2:1 application 10;' :ns~rc.n~e cor,t6
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subject mctD~ .. e-:' ;:,' -? V' s~a'.~j ;...::. .. ,. ~.r ~:::,: ~ viola~ion.
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AUTHORIZATION FOR REtEASE OF WORK AND OTHER LOSS INFORMATION
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This Authorization, or photocopy thereof, will authorize you to fumish all information you may have regarding my wages, salary, or
loss while employed by you, You are authorized to provide this information in accordance with the New York Comprehensive l
Vehicle Insursnce Reparations Act (No-Fault Law).
~*~
Name I ' or Type}
/I-ZrL
Signature} . .r
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Social Secur1ly NumDer
Data
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AUTHORIZATION FOR RELEASE OF HEALTH SERVICE OR TREATMENT INFORMATION
.
This Authorization. or photocopy lhereof. wUl authorize you to furnish all infonnallon you may have regarding my condilIon while under your observatio
lreatment including the history obtained. .-ray and physical findings, diagnosos, and prognosis. You are authorized to provide this infonnation in accordE
WltIl the New York Comprehensive Motor Vehicle Insurance Reparations Act (No-Fault Law).
R 41 ,pJ/ So./eRoC'A.ff /Ida
Name (Print or Type)
~<~~ ~L;;.-
Signature'"; ,,;'
Date
7%'19;1
'If lhB spp/icanf is a minor, pat9Tlf or guardian should sign snd Indica/a capacity and relationship.
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INSURANCE VERIFICATION
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Appt. Date /0-;1"'1 -'9/
Time: .3: If/)
Patiellt~s Name: -11...,.. () /l 1. " ~.A n.-r'~ ~ ~ ..,'s
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Home# q~3 -Sf.,~3
PlIIient's' 0;0.8. 11- ~ ' 3.<
8.8.# 0"10 -",2 ~ - 911>15
1).0...\. '-I~I ~ -&1 f' Type of Accident c;; J _ -r..,
MO/D.\'IYR
Referred by: ~. -7?tc/'Jt..r...,h ---...A,; Phone# 3l;, 7/iJ> -&>1I>7--JY3~' It-. /l..:J ,-TJ"'d .
~e\'ious Treatment:
X-Rays:
Records:
Pt to bring:~
Pt to bring: /\
Insured's Name:
Insured's SSN
jg.
Phone: /- -97'9- 7733
Ins. Carrier: ~ ~
Billing Address: -jJ. d). ~
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Adjustor: ~'3" ~.t ...Cb.....,.,.:o..,
l\IanagedCare: lDlPolicy#:
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Claim#: 5,,2..:l oCJ;l 0 (0.3
C'o\'erage: fJ I () /6D %
Deductible: -
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Initial ~ Date lo--'f.o-"'IJ"
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DR. DANIEL 1. KNAPP
SIGN IN SHEET
PATIENT'S NAME DATE
VISIT #
f? ftd <} ::2b
' kt_ (,~) ~ /I ~ 7[~'f-'/
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Please advise us if your insurance, address, or condition has changed
since your last visit.
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DR DANIEL J. KNAPP
SIGN IN SHEET
PATIENT'S NAME DATE
VISIT #
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since your last visit.
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CASE MANAGEMENT # 0/0 d:{ ;J rC'- ~
PATIENT: '"R 0...1 ph :Sorr~.J..(J. )(') May call patient at work_
WC C MC @ BC EMI other Ve.w '
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Date of Initial Visit / z... -1- 07... Date of Accident 4 -19 - '78 fi
Re-Exam IPART
Release Date
Work Dis, Date
u.S
C-o PA Y
0l 0-'1- tF-
Work Return
X-Ray/MRI Date:
(C) m (2.:r "1/1 <;J
Other Testing:
(C) 'CT ~/1~ ([;)X -R-A'-{ S/c17
$4/CJ? @) ~hj
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0-1 J.+ER:
Massage Rx:
From' To From To
From To From To
From To From To
Referrals:
Records Requested:
cast HiS~ ER Surgery Dr's, X-Rays
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CARD CARD REPT A TINY
ATINY
ADRES,
DOA 0 t-f - I q - I q q ~
PATIENT NAME: )tALi 1+ SO ere.. t iJil!J (j
INSURANCE COMPANY: _C:::: TAl E rA If/WI
'" ~.' \ - CLAIM#: odd, () q~O ~ \
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\Y'(\\...'I\\~v'rY\iADJUSTOR NAME: K.s.Li t:~VI ~ Tel #:~ - r.o ?--s- ~ 0;)-9
~,4'f+.. ADDRESS: PO,:bDXllLu 1 ~VHY;;Ll) ,NY \4d4D~ID7/
PIP: $ 6~ i !till MEDPAY: $ Y DEDUCTIBLE:$ D ~~' ,)J 0 r~ vL(
Benefits Exhausted? DATE: IME DATE: ~ If'b --nn--lfiL tJ.,rf6'f:JY.J1
Disability Dates start end ~~ 11' IS\) \ 0\)1.),
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ENTER INTO COMPo Y OR N\...l rrlt 'Mt:):> ,
NIlI Es \"iIU--
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PI Verification Sheet
ACCNT #
SECONDARY INFORMATION
2) Insurance Owner
Name;
Insurance Company
Address
Telephone #:
CLAIM #
3) Major Medical
Name:
Insurance Company
Address:
Telephone #:
CLAIM #:
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THERAPEAUTIC EXERCISE PLAN
NAME:/2.al ph Sarrenf.-1'nl)
CYSEX USE
SETTINGS: seat arm rpm kg/m/min work rest forward reverse cycles
MULTI-NECK / SHOULDER STACK WEIGHT
SETTINGS: motion
weight
reps sets position
MULTI-HIP STACK WEIGHT
SETTINGS: motion
weight
reps sets position
HYDRAFITNESS KNEE FLEXION/EXTENSION
SETTINGS:
/'J.. ,f& -Off
10 rep max
1 '~
goal flexion goal extension reps
RJ 3
sets
08
@6
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OTHER:
"
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BraID Riegel, M.D. C- 0-
Spine, Sports & Rehabilitation Specia " P.A. 5580 Bee Ridge Rd" Bldg, ]
Certified by the American Board of Physical Medicine & Rehabilitation Sarasota, Florida 34233-150,
Certified by the American Board of Electrodiagnostic Medicine (941) 379-823'
Certified by the American Board of Independent Medical Examiners Fax (941) 379-834
Certified by the American Academy of Pain Management e-mail: wecare@spine-sports.con
Certified in Pain Management by the American Board of Anesthesiology/American Board of Physical Medicine & Rehabilitatio
RALPH SORRENTINO
FOLLOW UP VISIT
FEBRUARY 20, 2003V
Ralph returns for reevaluation. He continues to complain of low back pain, The patient remains under
the care of Dr. Knapp and is currently being seen lx/week. Pain level currently 3 on a scale of 0-10. The
patient is taking Roxicodone 5 mg po q day pm and reports partial pain control.
Physical Examination: Vital signs were stable. Chest clear to auscultation. CVS S 1 and S2.
Abdomen benign, Extremities negative CEC. Skin was normal,
Neurological evaluation included motor strength 5/5 bilaterally. Sensory examination pinprick decreased
on both LE's in a stocking-glove distribution to the level of the knees. Pinprick grossly intact on both
DE's. DTR's 2+ bilaterally except for the ankle jerk reflexes which were 1 + bilaterally, SLR negative
bilaterally,
Soft tissue palpation was performed. There was maximal tenderness overlying the L5-S 1 disc space as
well as the left and right PSIS.
Impression:
1. Low back pain associated with underlying disc disease and spondylosis.
2. Multiple medical problems,
3. Hepatitis C,
Plan:
1. The patient should continue to follow up with Dr, Knapp with regards to spinal problems,
2. The patient should continue to perform a HEP,
3, No NSAID's secondary to hepatitis C.
4, The patient should continue to take Roxicodone 5 mg po q day pm.
5. Return to the office in three months.
BR/sd
(Dictation transcribed but not read)
/""
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BRAM RIEGEL, M.D.
cc: Dr, Daniel Knapp
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Bram Riegel, M.D. 0 _, ._
Spine, Sports & Rehabllltation Speciali P.A. 5580 Bee Ridge Rd., Bldg.
Certified by the American Board of Physical Medicine & Rehabilitation Sarasota, Flor,ida 34233-150 '
Certified by the American Board of Electro diagnostic Medicine (941) 379-823 '
Certified by the American Board of Independent Medical Examiners Fax (941) 379-834
Certified by the American Academy of Pain Management e-mail: wecare@spine-sports.cOl
Certified in Pain Management by the American Board of Anesthesiology/American Board of Physical Medicine & Rehabilitatic
RALPH SORRENTINO
FOLLOW UP VISIT
JANUARY 16,2003
Mr. Sorrentino returns for reevaluation. He was last seen on 1/24/02. The patient is currently under the
care of Dr. Knapp, a Sarasota chiropractic physician,
The patient's multiple medical problems are unchanged, The patient's low back pain is the same or
worse. Pain level currently 3 on a scale of 0-10,
Physical Examination: Vital signs were stable. Chest clear to auscultation, CVS Sl and S2,
Abdomen benign. Extremities negative CEC, Skin was normal,
Neurological evaluation included motor strength 5/5 bilaterally. Sensory examination pinprick decreased
on both LE's in a stocking-glove distribution to the level of the knees. Pinprick grossly intact on both
DE's. DTR's 2+ bilaterally except for the ankle jerk reflexes which were 1 + bilaterally. SLR negative
bilaterally,
Soft tissue palpation was performed, There was maximal tenderness overlying the L5-S 1 disc space as
well as the left and right PSIS,
Impression:
1. Low back pain associated with underlying disc disease and spondylosis.
2, Multiple medical problems.
3, Hepatitis C,
Plan:
1. The patient should continue to follow up with Dr. Knapp with regards to spinal problems,
2. The patient should continue to perform a HEP,
3. No NSAID's secondary to hepatitis C.
4. I prescribed Ultram 50 mg po t.i.d. pm. Dispense #30,
5. I prescribed Roxicodone 5 mg po q day pm. Dispense # 15,
6. Return to the office in two weeks.
BRAM RIEGEL, M.D.
BR/sd
(Dictation transcribed but not read)
cc: Dr. Daniel Knapp
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'Bram Riegel, M.D.
Spine, Sports & Rehabilitation Specialists, P.A.
Certified by the American Board of Physical Medicine & Rehabilitation
Certified by the American Board oflndependent Medical Examiners
Certified by the American Academy of Pain Management
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5580 Bee Ridge Rd" Bid
Sarasota, Fl. 34233-1
(941) 379-8
Fax: (941) 379-l
e-mail: wecare@spine-sports,
RALPH SORRENTINO
FOLLOW UP VISIT
FEBRUARY 28, 2000 ,
Mr, Sorrentino returns for reevaluation. He continues with essentially unchanged pain complaints. The patient
has completed his scheduled sessions of PT and NMT under the direction of Mr. David Rogerson and reports
good results, The patient would like to have therapy extended, The patient is not interested in undergoing
lumbar ESI under the direction of Dr. James,
The patient informed me that he will be returning to Buffalo, NY on 4/1100. The patient will be trying to sell
his home which is located in Buffalo, NY. The patient plans on returning to Sarasota during October 2000
or sooner if her sells his home, '
.~
Physical Examination: Physical examination included soft tissue palpation, There were no acute changes
noted, ,
Impression: The patient is a 64 year old white male with a past medical history ofNIDDM x 30 years,
glaucoma, and hepatitis C, The patient was involved in a MV A on 4/19/98 which led to low back pain,
The patient complains of low back pain associated with bilateral lower extremity radicular symptoms, A
lumbar MR1 demonstrated a small left paracentral disc protrusion at L5-S 1 associated with an annular tear as
well as mild, degenerative disc disease at L2-13 and 13-L4, The patient's signs and symptoms are consistent
with low back pain associated with underlying disc disease and spondylosis, Rule out lumbosacral
radiculopathy,
Plan:
I, The patient should continue to follow up with all of his other physicians.
2, Continue Flexeril on a pm basis:
3, No NSAID's secondary to hepatitis C,
4, I extended PT and NMT 3 x per week x 4 weeks under the direction ofMr. David Rogerson, I requested
that the patient be made completely independent in performing a home exercise program, Therapy was
ordered with strict diabetic precautions,
5, A future diagnostic consideration includes performing EMGINCS of both lower extremities,
6, A future therapeutic consideration includes referring the patient back to Dr, James for a series of lumbar
ESI's,
7, The patient will be going to Buffalo, NY on 4/1/00 and returning to Sarasota during October 2000,
8, Return to the office during October 2000,
BRAM RIEGEL, M.D.
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(dictation transcribed but not read)
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Bram Riegel, M.D. 0-
SpllU~, Sports & Rehabilitation Spec. .,sts, P.A.
Certified by the American Board of Physical Medicine & Rehabilitation
Certified by the American Board of Independent Medical Examiners
Certified by the American Academy of Pain Management
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5580 Bee Ridge Rd" Bldg, B
Sarasota, Fl. 34233- 1505
(941) 379-8237
Fax: (941) 379-8348
e-mail: wecare@spine-sports.com
RALPH SORRENTINO
CONSULTATION
JANUARY 24, 2000
Mr, Ralph Sorrentino is a 64 year old white male who was involved in a MV A on 4/19/98, The MV A led to
low back pain, The patient came under the care of a family practitioner. Therapy was. prescribed,
The patient continued to complain of low back pain and came under the care of Dr, Weot a Sarasota PM&R
Specialist. Dr. Weot treated the patient from 10/29/98 - 11117/98, Dr, Weot reviewed a lumbar MRI that had
already been performed and described it as demonstrating some abnormalities, Dr, Weot prescribed PT and
NMT under the direction of Mr. Matthew Frey and Ms, Roseanne Davis, The patient apparently had a
problem with the physical therapist and did not want to continue. Dr. Weot also evaluated the patient for right
wrist pain and right shoulder pain, Dr. Weot diagnosed the patient with adhesive capsulitis of the right
shoulder and RSD of the right wrist. Dr. Weot ordered x-rays of the right wrist and right shoulder. Dr. Weot
also prescribed Neurontin, The patient stopped seeing Dr, Weol.
The patient came under the care of Dr. James, a Sarasota Pain Management Specialist, Dr. James did not
perform any injections, The patient apparently complained of low back pain to Dr. James, Dr. James
recommended additional therapy and referred the patient to my office for consultation,
The patient presents for further recommendations, He is pleased to report that his right shoulder pain and right
wrist pain are doing a lot better, The patient's main problem currently involves low back pain, The patient's
low back pain radiates into both lower extremities, The patient's low back pain gets worse with exertional
activities such as walking and painting,
The patient used to live in Buffalo, NY, The patient is now in the process of moving to Sarasota, FL on a full-
time basis, The patient is trying to sell his house located in Buffalo, NY. The patient sees Dr. Yea, an Osprey
Family Practitioner. The patient also sees Dr. Corrosante, a Buffalo, NY Gastroenterologist and Liver DiSease
Specialist.
Past Medical History: As per the HPI. NIDDM x 30 years, Glaucoma. Hepatitis C,
Past Sur~ical History: Gall bladder surgery, Repair of depuytrens contracture of the right hand,
Social History: The patient is retired, The patient smokes several cigarettes per day and does not drink
alcohol.
Current Medications: Insulin, Kosoft, Flexeril.
Allergies: No known drug allergies,
Other Health Care Providers: The patient sees Dr, Yea, an Osprey Family Practitioner. The patient also
sees Dr. Corrosante, a Buffalo, NY Gastroenterologist and Liver Disease Specialist.
Radiological Imaging Studies: I reviewed a lumbar MRI dated 7/8/98" There was ~ sm~lleft paracentral
disc protrusion at L5-S I associated with an annular tear, There was also mIld degeneratIve dISC dIsease at L2-
13 and 13-L4, The above was confirmed by the radiologist's report,
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Board Certified Radiologist
American College of Radiology
~JonB.th81l ft. .Miller, M:D,,~'
1275 Delaware L\ venue
Buffalo. New York 14209
Telephone (716) 883-3333
A<credited
America;' College of Radiology
Mammographic lmaging Center
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Gale 1. O'COHnor
3560 No,' Buffalo Street
Orchard park, NY 14127-1934
RE:
SORRENTINO RALPH 97-3130
DaB: 11/05/35 'EXAM: 06/18/97
CERVICAL SPINE
AI', lateral and both oblique views of the cervical spine reveal the vertebral
bodies to b~ intact. There is a straightening of the normal cervical
lordosis.. The ihtervertebr~ 1 di sc spaces mai ntai n thei r verti ca 1 hei ght, The
intervertebral foramen are unremarkable. There are no apical pleural tumors
or rib erosions,
IMPRESSION:
STRAIGHTENING OF THE NORMAL CERVICAL LORDOSIS.
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Thank you for your kind referral.
SiOb1Y
Jonathan H. Miller, M,D" P,C,
Radi 01 ogi st
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cc:Robin Lazar-Miller, M,O,
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THIS REPORT IS BASED UPON THE RADIOLOGIC EXAMINATION AND CORRELATION WITH THE CLINICAL FINDINGS IS ESSENTIAL
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\,Jerald P. Kuhn, MD,
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Ebsan Afshani, MD.
Paul MontgomeIy, M,D.
Anne D, Ehrlich, MD,
Steven L. Christensen, MD,
Dilip E. Gole, MD,
Roseanne Oliverio, MD.
Jan S, Najdzionek, MD,
David J, Martin, MD,
~lgnOStiC Imaging Associates O.
""-bfWesternNewYork, p.e.
1630 Maple Road
Williamsville,NY 14221
716-636-1902
Fax:
716-636.1367
James W, Backstrom, MD,
Steven L, Bezinque, D,Q,_
Mark J, Pisaneschi, MD.-,
GregoryT. Tymchak, MD,
Broce p, Hall, MD.
Richard.D. Thomas, M,D,
John J. JanUllrio, MD.
Charles J. Riggio, MD,
/
Dr. Frederick McAdam
9 Limestone Drive
Williamsville, NY 14221
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RE: SORRENTINO, RALPH
DOB 11/5/35
98-0852
EXAM DATE: 7/8/98
---..............-
Dear Dr. McAdam:
MRI OF THE LUMBAR SPINE
INDICATION: Disc disease versus stenosis, The patient has a history of MVA in April
of 1998 and has low back pain radiating down each leg.
TECHNIQUE: T1, T2 and STIR sagittal images, T1 and T2 weighted images.
FINDINGS: Assuming five lumbar vertebrae, the tip of the conus is normally
positione.d behind L 1. The conus is normal in signal and morphology. There are no
abnormal masses within the distal thecal sac.
The appearances at T11-12, T12-L 1 and L 1-2 as well as L4-5 are normal.
, ,
At L2-3 and 3-4, there is mUd desiccation of the disc. Each of the discs bulges mildly
and diffusely, The central spinal canal and exit foramina remain capacious, The facet
joints and f1avalligaments appear normal.
At L5-S1, there is desiccation of the disc. There is posterior high intensity zone indica-
tive of annular tear. There is a small left paracentral focal disc protrusion. There is no
definite nerve root contact, although there is potential for contact with the left S1 nerve
root, which is very close to the small disc protrusion.
(continued)
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",JeraldP. Kuhn, MD.
Ehsan Afshani, MD.
Paul Montgomery, MD,
Anne D. Ehrlich, MD,
Steven L, Christensen, MD.
Dilip E. Gole, MD,
Roseanne Oliverio, MD.
Jan S, Najdzionek, MD,
David J. Martin, MD,
CD "{gnostic Imaging Assodat
," 'OfWeslJern New York, P.
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James W,Backstrom, MD~
StevenL.,Bezinque, D,O, .
Mark J.l1isaneschi, MD,
Gregory t, Tymchak, M,r ,
Bruce P,1Iall, MD,
Richard ID, Thomas, MD,
John J. Jlp1uario, MD,
Charles 1. Riggio, M,D,
1630 Maple Road
Williamsville, NY 14211
716-636-1902
Fax:
716-636-1367
MRI OF THE LUMBAR SPINE CONT
RE SORRENTINO, RALPH
The STIR images show no evidence of bone edema, Th re is no fracture qr posterior
Iigamentollls complex injury is evident.
IMPRESSION: 1, SMALL FOCAL ILEFT OF CENTRAL 5-S1 DISC PROllRUSION,
NOT OBVIOUSLY CONTACTING NERVE ROOTS..
2. MILDLY DEGENERATE DISCS AT -3 AND L3-4.
Thank you for this referral.
RT/lf
d-t 7/8/9
Preliminary until signed
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REPORT
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MERCY H.TAL
OF RADIOGRAPHIC EXAMINATION
NAME: SORRBNTINO, RALPH
X~RAY NO: 9413495
DATE: 06/09/98
i
CA@ENO.: 7760677
ROOM NO.: OP MAC
E.Q",:1l/0S/35
BXAM, CT LUMBAR SPINE W/O CONT
--------..-
-----...---...,.:-,...
DAVID R DEBERNY
M.D.
RADIOGRAPHIC REPORT
CT SCAN OF THE LUMBAR SPINE
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Appropriate axial sections were obtained through the
intervertebral disc spaces at L3-4, L4-5 and L5-S1 without the'
administration of IV or intrathecal contrast agent. There is no
evidence of focal disc herniation. No ev~dence of lumbar stenosis
is demohstrated. Significant facet arth:;:-,opathy is not detected.
IMPRESSION: NORMAL CT SCAN OF THE LUMBAR SPINE.
GJ/dk
0.: 06/10/98
t: 06/10/98
23:25
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GERALD .:JOYCE,
ROENTGENoLOGIS
Report is to be considered
a preliminary report until
signed by the Radiologist
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REPORT OF P.1\DIOGR1\PHIC EXAMINA'IlON
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~AM8: SORRENTINO. ~,LPH
X-Rl\Y NO: 9411'19."
M.TE: 0,1/19/98
CA:-C;F, NO,.: 77i4~7[:j
ROO,l NO" ER
0007327
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EXAM: CERVIC SPINE ,1\.1' & ~,TRL)
LUMBOSACRAL/COMP
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,~bDTQGR^PHIC REPORT
C1;',p,VTCAT, SPINE
F"rontal and
tracture or
ident Hied.
lateral views of the cervic<:11 spine :r.eveal no
rnalalignrnent, Si<)nificoJr.t spondylosis j B not
No DOf.t tio:3uC pathology .L::I ~een.
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"f':PRESSION:
TWO V IE"J El'.Al~IN!\TJON OF' THE CERVICAL SPINE.
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7:01
'1': 4/20/98
7,51
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Report tfl t:o be considered
a pn:~lirnlnary 't"epcrt Ul1.til
signed by the Radiologi3~
[:.
LL~BOSACRAL SPINE
a cul.::. are inc::i.denta.Lly noteci. There are five
luniliar verlebral bodieR. No fracture or malaligwl~nt is seen.
The intervertebral disc spacp.:s and lurribosacral ~l.i.gnment are
pr~served. There is an or.c?lRlona.L marginal osteophyte.
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IMPRESSION; 1. MiLD SPONDYLOSIS.
2. NO ACLJ'f);; LJ88J::OUS PATHOL,OGY OR SrGNIFrCAl,T
DE'JENERA'l'IVI;; DISC DISEASE,
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, ROENTGENOLOGIST 'h
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Initial Report
Name: Sorrentino, Ralph ",\0-1/ '
Date: December ~,2002 @ \"'"
Occupation: Retired .
Referral: Massage therapist
SUBJECTIVE:
1, Lower back pain, central, legs feel weak
Onset: MVA 4/19/98
Pain Scale: 0 -- 7
Quality: Achey, weakness
Timing: Intermittent, variable throughout day
Aggravating Factors: Any physical exertion, lifting
Improving Factors: Chiropractic care
Medication: Patient will provide list
Prior Conditions: None
Prior Treatment: Chiropractic care, Dr, Dragonet, orthopedic opinion, Dr. Italiano,
recommended ESI, declined, physical medicine specialist, Dr. Riegel, physical therapy
sessions when patient is back in Sarasota
Family Doctor: Dr. Gale Oconnen, Orchard Park, NY
Medical History: Cardiovascular: negative, Respiratory: negative, Gastrointestinal:
negative, Kidney: negative, Liver: negative, Diabetes: Type II, Arthritis: Trigger fingers
right, beginning on left Surgery: Right trigger fingers, cholecystectomy, Cancer
negative, Stroke EN, Allergies: negative
Social: Married
Family History: Noncontributory
Exercise: None
Vitamins/herbs: None
Diet: Alcohol: negative, Caffiene: Yes, Tobacco: negative
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P,2 Sorrentino, Ralph 12/9/02
Daniel Knapp, D,C,
Accident Description: impact; multiple angles, seat belts; yes, air bags deployed; no,
LOC; no, head position; forward, aware of impact; yes, medical treatment; went to
Mercy Hospital on his own x-rays, medication, released, symptoms after the accident;
lower back pain
Diagnostics: Lumbar x-rays -- Mercy Hospital, lumbar MRI, unsure of study location,
disc herniation reported
Current care: Dr, Dragonet while at home, Dr. Riegel while in Sarasota
OBJECTIVE:
Inspection/ROS: age: 67, height 5 '5", weight 160, BP 144/84, pulse 78,
temperature: 96,3, respirations: 15, no I'Idventitious lung sounds, no murmurs, no
supraclavicular or carotid bruits, no extremity cyanosis, diaphoresis, multiple small
areas of ecchymosis anterior shins, no erythema, or temperature asymmetry, skin -- no
significant trophic changes lower extremities, +0/5 edema, EN, mild bilateral leg
atrophy, no abnormal pain behavior
Posture/Gait Pelvis and shoulder low on the right, hypolordotic, right thoracic
curvature, gait unremarkable
Palpation: no lymphadenopathy, peripheral pulses +2, bilateral moderate paralumbar
hypertonicity, lumbosacral, thoracolumbar, lower cervical tenderness reported,
hypertonic left quadratus lumborum
Subluxation/Fixation: L45, L5 S1 extension, left lateral bending, bilateral rotation T5 6
extension, right lateral bending, C5 6 left lateral bending
ROM: Thoracolumbar flexion 60, pain returning after repetitions, extension 10,
stiffness, same with repetitions lateral bending left 10, right 15, side gliding negative
Neurological: No paralysis, tics, tremors, MSR's +214, Babinski downgoing, no clonus,
sensory intact to light touch, vibration, and pin prick, motor +5/5 dorsiflexion/plantar
flexion
Orthopedic: spinous percussion, tension signs negative, very tight hamstrings on SLR,
non-radiating lower back pain with Kemp's bilateral, Homans' negative, mOdified,?liD,..,..,-
positive bilateral quadriceps tightness (/Y
Functional Strength: Hip extension 4/5 left, and 3+/5 right, abdominal curl -- fail
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p, 3 Sorrentino, Ralph 12/9/02
ASSESSMENT:
1, Reported accident related lumbar disc disorder
2, Lumbar/thoracic/cervical segmental dysfunction/subluxation
3, Trunk and extremity weakness
PLAN:
1, Obtain prior MRI study
2, Order lumbar x-rays to assess DJD
3, Spinal manipulation/mobilization
4, Trunk stabilization and extremity strengthening exercise instruction
5, 3/week, 1 week, decreasing in frequency progressively
GOALS: long term, 6 weeks
1, Decrease pain levels and painful ROM
2, Restore passive joint function and muscle length
3, Prevent disability
4, Improve strength and endurance
Sincerely,
Daniel Knapp, D,C" C,C,R.D,
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NAME: Rcc. 10 It.... ,'3,....~~ Re"!,:P /Iv!::)
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CURRENT COMPLAI~:
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DATE:
/.7- -f'~d2-
PREVIOUS SIMILAR CONDITION: YES @
, ONSET: fall cauto accid~ work unsure
date or approximate time present
PAIN SCALE: 0 -10 0= NO PAIN 10 = UNBEARABLE
BEST: 'f) WORST: CURRENT:, 7
QUALITY: stiff~~harp burning tingling numbness Eak0
other:
TIMING: constant intermitl
time of day n' ,
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AGGRAVATED BY: ~ ~;Jd'-~-h ~J L!:j~- tLd~;L
IMPROVED BY: C!--H I ~f'acllc- CaA2.e. .'..
MEDICATION: kr>ve-. It-./t:.;,..
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FAMILYDOCTOR: .on, a-4-/~ @t!.tJ'hner. r::M..?!iCULj 1JkbY
MEDICAL PROBLEMS: CIRCLE IF POSITIVE: Heart Lung Bowel Urinary
Explain: ,~~Lh~-~J~ C-~fiu<?d/77~
SURGERIE~""7~~ ~ - ~a~<-..u..-/r- t-1")f....4--.R-
CHIROPRACTI; CARE~~~LA"'d S?!(
EXERCISE.;- ~ --
VITAMINS OR HERBS: W
DIET: cf1rJ{,-f;J!fi),lO Alcohol ye0TObacco ye~
HEIGHT.t75/ WEIGHTLbD AGE~
DANIEL KNAPP, DC 3982 BEE RIDGE RD BLDG H, SUITE H SARASOTA, FL 34233
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~
.'~ DANIEL J, KNAPP, D,C, .
3982 Bee Ridge Road ,.,. -
Building H, Suite H
Sarasota, FL 34233
(941) 925-2211
Current Complaints:
Use the symbols in the box to the right to mark the location and the type of pain or sensations you are feeling:
>- >> > Aching Pain
>- XXX Burning Pain
>- -- - Numbness
>- 000 Pins & Needles
>- 1/ II Stabbing Pain
For Face or Head Pain:
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/ DANIEL KNAPP D.C.
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Sarasota, FL 34233
(941) 925.2211 FAX (941) 91
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INFORMATION ONLY FOR ENTITY NAMED
If joOlI c/Q 1IQt r<:<<rive all pqse. ar If ~u II""", <my ather problem. wi 'thi. transmittal please inform u.
Immediately, 11Ii5 FO<:$;ml~e <t>ntains prtvfle!~ and oonfidentlalln matianintended anly for tn,. use of
tIte Individual or entl!y named obave. If t~e reader of the faaimil.e '. not the 'ntefK1f1d p.rcipient or the
employee or _t ,esponslble far delivering It to the intended dplent, you are advised that any
dlssemilllltiofl (lr cnpy/FIJ of this faa/mile Is strictly prchibitea, If u have rrtwved thIs foalm'l. in
error ple_ MtlN I5lJy telephone and matI the or/!IMI f<><<lmlle the maiUng add...... listed above.
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DA.EL KNAPP D.C. .C.R..
3982 Bee Ridge Road Building H Suite H
Sarasota, FL 34233
(941)-925-2211 FAX (941) 925'": '15/:1.
AUTHORIZATIONFORr. DI 'ORMATION
FAX # /,
To'
#Pa s
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Oate:
Requesting FAX transmittal of~ollowing records:
POO'MN=. ~~o
Patient Signature , 5.5,#
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~- ~l" IS-
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:J CERVICAL X.RAYIMRI/CT
Cl THORACIC X-RAY/MRI/Cr
a LUMBAR X-RAY IMRllcr
Cl ElP/PELVIC X-RAYIMRI/CT
o HEAD X-RA YIMRIICT
o SHOULDER X-RAY!MRlICT
~ ELBOW X-RAYIMRIICT
~ wRrST X-RAYIMRIICT
Cl KNEE X-RAYIMRlJCr
~O
_ B NE DENSITY
_ B NE SCAN
E ECTRODlAG;.<OSTIC
L WORK
H SPITAL REC.
FICE NOTES
L RECORDS
o HER:
This authorizes the physicians. hospiWs, lllld all anendlUlls and in ~ncc companies to furnish full ilnd
oompkle medical records ",,01 Wfolllllltien hereby required b)' D I], l<.11app, D,e, C,C.R.D, This
'lllthOrization alse ineludes a rcqueSI for dupJlcates of all hospitlll r' ords, X.R.1Y. !VIR reportS and any
information im,!u\\ing opitllons, Said ChllOpmclor bas been lInlh 'ed \0 \like ~11 Slcps necessary to
secure the coUcctioJllhereof, For putpOse of obCJlinJng'medical rd~, a duplicate of this dOCllment
shall be deemed the equlvalem of the original. ALL PRIOR AU RJZATIO"l HEREBY
CANCELLED,
If you do nol receive aU pages or if you have any other problems 1\' Ii this tranmlinal please infoml us
immediately, This Facsimile contains privileged and oonIidemial " ormation intended only ror the use
, cflhc indn'iclual or entity namecl above, !fth. render of the fucsi~ e is not the il11cndcd percipiem Or
the employee or agem responsible for delivering ilIa the intenclect ciplont, you 'lTe ,,(l,ised mill any
dissemination or copyin; of this facsimile is &1tictly proh.1bifec!. 1f u have :re:::eived Ihis: fac5imilc in
i error please ROWY us by telephone and m:ill the origil1<ll facsimile rhe muiling adOre,,", listed above,
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DANIEL KNAPP, D.C., C.C.R.D
3982 Bee Ridge Road Building H, Suite H
Sarasota, FL 34233
(941) 925-2211 FAX (941) 925 I qs/Z.
~I
FAX
III
FAX # /-7/0- ffd-.,~/3~/2-
TO:'n?Mtft! ~3 L.> #Pages'-:;'
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Fr~, ~ Date: /d--/C)- Q).,
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RE: J (L(? ~) ,)S MAPA/l!-.-tA-1 ()
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INFORMATION ONLY FOR ENTITY NAMED
If you do not receive aU poses or if ~u have any other problems with this transmittal please inform us
immediately. This Facsimile amta/ns privile!1ed and confidential information intended only for the use of
the individual or entity named above. If the reocler of the facsimile is not the intended percipient or the
emplDyee or l1!1ent responsible for deliverin!1 it to the intended redplent, ~u are advised that any
dissemination or copying of this facsimile is strictly prohibited. If ~u have received this facsimile in
error please notify us by telephone and mall the ori!1lnal facsimile to the malUng ocIdress listed above,
(t') / rJoo.;2
.,
DANIEL KNAPP, D,C" CCRD
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TEGt, ,TlVEIINNOVATIVE HEALTH CARE
SARASOTA INTEGRATIVE REHABILITATION
Certified Chiropractic Rehabilitation Board Oualified hiropractic Orthopedics EMG Biofeedback McKenzie Practitioner
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39B2 Bee Ridge Road Buildin9 H, Suite H Sarasota, FL 34233 19411925-2211 Fax (9411 925-9512 eMail: DKMMI@ADL,CDM
"~~~,
!lfllEL KNAPP, D.C., C.COQ
3'182 Bee Ridge Road Building H, Suitt.
Sarasota, FL 34233 _
(941)-925-2211 FAX (941)-925-: 15/;;),
AUTHORIZATION FOR MEDICAL INFORMATION
FAX #
To:
#Pages
From:
Date:
Re:uesting FAX transmittal of t~ollowing records:
P"'omN,m, ~}Z.:eu~OB
PatIent SIgnature ,/~r S,S,#
o CERVICAL X-RAYIMRI/CT
o THORACIC X-RAYIMRI/CT
o LUMBAR X-RAYIMRI/CT
o HIP/PELVICX-RAYIMRI/CT
CJ HEAD X-RAYIMRI/CT
o SHOULDER X-RAYIMRI/CT
o ELBOW X-RAYIMRI/CT
o WRIST X-RAYIMRI/CT
o KNEE X-RAYIMRI/CT
BONE DENSITY
BONE SCAN
ELECTRODIAGNOSTIC
LAB WORK
HOSPITAL REC.
OFFICE NOTES
ALL RECORDS
OTIffiR:
This authorizes the physicians, hospitals, and all attendants and insnnmce companies to furnish full and
complete medical records and information hereby reqnired by Daniel J. Knapp, D,C, C.C,R.O, This
anthorization also inclndes a request for duplicates of all hospital records, X-Ray, MR reports and any
information including opinions, Said Chiropractor has been authorized to take all steps necessary to
secure the collection thereof. For purpose of obtaining medical records, a duplicate of this document
shall be deemed the equivalent of the original, ALL PRIOR AUTIIORIZATION HEREBY
CANCELLED,
If you do not receive all pages or if you have any other problems with this transmittal please inform us
immediately, This Facsimile contains privileged and confidential information intended only for the use
of the individual or entity named above, If the reader of the facsimile is not the intended percipient or
the employee or agent responsible for delivering it to the intended recipient, you are advised that any
dissemination or copying of this facsimile is strictly prohibited. If you have received this facsimile in
error please notifY us by telephone and mail the original facsimile to the mailing address listed above,
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Legal Name ,8-~ Sd Jl2../2es.,(, A/ CJ Birth Date: / / - 5""' --5irAge-y
Please Provide Nick Name/& Madden Name (To research prior med, records if needed),
Social Security Number c9rtJ.-U-<J"f-r Marital Status: 8'@D W
Florida Address~9'.1 5lIchl!:'Y N. ?d. City ~)-~Ai Zi? '31.f,J-"3/
Permanent Address &JOT Street Address if P. O. Box given above:
Cell Phone#
Yes Provide # if Yes
ext,_
Sign Both Items Below / Must Provide Signature For Today's Treatment:
I hereby authorize Dr, Daniel J, Knapp to administer chiropractic treatment as deemed
necessary to my minor child or myself.
~~
/ -:2--r; - P Z.
Date
Name of Child
I understand and agree that regardless of my insurance status I am ultimately responsible
for my account for professional services rendered. If insurance fails to make payment
within 60 days of billing I will make payment to the doctor if necessary. I maY then
research payment problems and the insurance company may then directly reimburse me,
I am responsible for understanding and tracking my insurance limitations, maXimums,
and requirements including pre-authorizations, This applies to ALL insurance policies,
I am responsible for providing this information to this office, I will also report any
changes in address, phone number, and insurance status. I understand this office will
attempt to gather billing information for me, but they are limited to my written contract
and not bound by verbal verification,
/& tJ;!. -?: Lu-
Patien egal Guardian
Date I Z- - '7-0 z--
Daniel}, Knapp, D,C., 3982 Bee Ridge Rd, HIH Sarasota, Fl. 34233 941-925-2211
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DAILY NOTES
Patient 10#: 3152
Patient Name: Ralph Sorrentino.
Date: Mo.nday, April 14, 2003
SubjecUve: Lower back, midback pain, nearly daily, decreased fntensity, more mobility since starting therapy
Objective:
Inspection: Hyperlo.rdotic, posture. -- partially impro.ved
Palpatio.n: Hyperto.nicity, tenderness quadratus lumbo.rum,
. Subluxation/fixation: C5 6. bilateral lateral bending, T, 6. 7 extension, L5 S1 extensio.n
ROM: Cervical full, lumbar flexio.n 60 degrees, extensio.n 25 degrees, lateral bending left 20, right 20
Strength: Hip extension 5/5 left, 5/5 right
Other: Maigne's Maneuver negative, Kemp's positive bilateralT modified. Thomas positive. bllateral quadriceps
Assessment: Lumbar disc diso.rder, multiple spinal subluxatio.ns, pest-traumatic
PlanlTreatment: Manipulation after o.verpressure established no peripheralization, to.lerated well, EMS 0 --
150, interferential, lumbar, heat, to. to.lerance, 1 unit
frequenc.y: follow"up with chiropractor at home
update:
Daniel Knapp, D,C" C,C.R.D,
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DAILY NOTES
0-
Patient 10#: 3152
Patient Name: Ralph Sorrentino
Date: Wednesday, Mareh 26, 2003
Subjective: Lower back, midback pain, nearly daily, improving intensity
Objective:
Inspection: Hyperlordotie, posture -- improving
Palpation: Hypertonicity, tenderness quadratus lumborum,
Subluxation/fixation: C5 6 left lateral bending. T9,10 extension, L5 S1 extension, rotation on the right
ROM: Cervical full, lumbar pulling with flexion, 50 degrees, extension 25 degrees, lateral bending left 20,
right 20
Strength: Hip extension 4+/5 left, 4+/5 right, imprQ.\ling \umbar e><t.m..iorumduranca
Other: Maigne's Maneuver negative, Kemp's positive bilateral, modified Thomas positive bilateral quadriceps
Assessment: Lumbar disc disorder, lower extremity weakness, multiple spinal subluxations, post-traumatic
PlanlTreatment: Manipulation after overpressure established no peripheralization, tolerated well, EMS 0 --
150, interferential, lumbar, heat, ~ toIeraACe., 1 unit
frequency: 2/month
update: 2 weeks
Daniel Knapp, D,C., C,C,R.D,
-=--".,
0-
0-
t>~OG~ESS NOTES
Patient 10#: 3152
Patient Name: Ralph Sorrentino
Date: Monday, March 10, 2003
Subjective: Lower back, midback pain, neck stiffness, constant, variable, more good days
Objective:
Inspection: Hyperlordotic, posture -- more erect
Palpation: Hypertonicity, tenderness quadratus lumborum, lower cervical hypertonicity, tenderness
Subluxationlfixation: C5 6 lefllateral bending, T5 6 7' extension, L5 S1 extension, bilateral rotation
~OM: Cervical full, lumbar pulling with flexion, partially improved with repetitions, extension 25 degrees,
lateral bending lefl20, right 20
Strength: Hip extension 4+/5 left, 4+/5 right, improving lumbar extension endurance
Other: Maigne's Maneuver negative, Kemp's positive bilateral, modified Thomas positive bilateral quadriceps
Assessment: Lumbar disc disorder, lower extremity weakness, multiple spinal subluxations, post-traumatic
PlanlTreatment: Manipulation after overpressure established no peripheralization, tolerated well, EMS 0 --
15('), interferential, lumbar, heat, to tolerance, 1 unit, therapeautic activities: Hydraritness knee extension
frequency: 21month
update: 4 weeks
Daniel Knapp, D,C" C,C,R.D.
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PROGRESS NOTES
Patient 10#: 3152
Patient Name: Ralph Sorrentino
Date: February 24, 2003
Subjective: Lower back, midback pain, neck stiffness, still evident, but has shown definite
improvement
Objective:
Inspection: Hyperlordotic, posture -- more erect
Palpation: Hypertonicity, tenderness quadratus lumborum, lower cervical hypertonicity,
tenderness
Subluxationffixation: C5 6 left lateral bending, T5 6 extension, L5 81 extension, bilateral
rotation
ROM: Cervical full, lumbar pulling with flexion, partially improved with repetitions, extension 25
degrees, lateral bendillg left 20, right 20
Strength: Hip extension 4+/5 left, 4+/5 right, improving lumbar extension endurance
Other. Maigne's Maneuver negative, Kemp's positive bilateral, modified Thomas positive
bilateral quadriceps
Assessment: Lumbar disc disorder, lower extremity weakness, multiple spinal subluxations,
post-traumatic
PlanlTreatment: Manipulation after overpressure established no peripheralization, tolerated
well, EMS 0 -- 150, interferential, lumbar, heat, to tolerance, 1 unit, therapeautic activities:
HydraFitness knee extension
frequency: 2/month
update: 6 weeks
Daniel' Knapp, D.C" C,C,R.D,
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PROGRESS NOTES
Patient 10#: 3152
Patient Name: Ralph Sorrentino
Date: February 19, 2003
Subjective: Lower back, midback pain do much better, neck stiffness, no extremity referral
Objective:
Inspection: Hyperlordotic, mild hip flexion contractu res much improved
Palpation: Hypertonicity, tenderness quadratus lumborum, lower cervical hypertonicity,
tenderness
Subluxation/fixation: C56 left lateral bending, T5 6 extension, L5 S1 extension, bilateral
rotation
ROM: Cervical full, lumbar pulling with flexion, partially improved with repetitions, extension 25
degrees, lateral bending left 20, right 20
Strength: Hip extension 4+/5 left, 4+/5 right, improving lumbar extension endurance
Other: Maigne's Maneuver negative, Kemp's positive bilateral, modified Thomas positive
bilateral quadriceps
Assessment: Lumbar disc disorder, lower extremity weakness, multiple spinal subluxations,
post-traumatic
PlanfTreatment: Manipulation after overpressure established no peripheralization, tolerated
well, EMS 0 -- 150, interferential, lumbar, heat, to tolerance, 1 unit, therapeautic activities:
HydraFitness knee extension, exercise instruction: Wall slides, 15 repetitions, BID, avoiding
kne,e .pai n
fr~uellcy: 1/week
update:
Daniel Knapp, D,C., C,C,R,D,
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PROGRESS NOTES
Patient ID#: 3152
Patient Name: Ralph Sorrentino
Date: February 10, 2003
Subjective: Lower back mailing of the right today, midback pain
Objective:
Inspection: Hyperlordotic, mild hip flexion contractures improving
Palpation: Hypertonicity, tenderness quadratus lumborum, right thoracolumbar, lower cervical
hypertonicity, tenderness
Subluxation/fixation: C5 6 left lateral bending, T56 extension, L5 S1 extension, bilateral
rotation
ROM: Cervical full, lumbar pulling with flexion, partially improved with repetitions, extension 25
degrees, lateral bending left 20, right 20
Strength: Hip extension 4/5 left, 4+/5 right, improving lumbar extension endurance
Other: Maigne's Maneuver negative, Kemp's positive bilateral, modified Thomas positive
bilateral quadriceps
Assessment: Lumbar disc disorder, lower extremity weakness, multiple spinal subluxations,
post-traumatic
PlanlTreatment: Manipulation after overpressure established no peripheralization, tolerated
well, EMS 0 -- 150, interferential, lumbar, heat, to tolerance, 1 unit, therapeautic activities:
HydraFitness knee extension, exercise instruction: Wall slides, 15 repetitions, BID, avoiding
knee pain
frequency: 1/week
update: 1 week
Daniel Knapp, D,C" C,C,R.D,
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PROGRESS NOTES
Patient 10#: 3152
Patient Name: Ralph Sorrentino
Date: February 03, 2003
Subjective: Lower back, midback pain and not as pronounced as a last week, ~
'~
Objective:
Inspection: Hyperlordotic, mild hip flexion contractu res improving
Palpation: Hypertonicity, tenderness quadratus lumborum, left, right thoracolumbar, lower
cervical hypertonicity, tenderness
Subluxation/fixation: C56 left lateral bending, T5 6 extension, L5 S1 extension, bilateral
rotation
ROM: Cervical left lateral bending 40, lumbar pulling with flexion, partially improved with
repetitions, extension 25 degrees, lateral bending left 20, right 20
Strength: Hip extension 4/5 left, 4+/5 right, poor lumbar extension endurance
Other: Maigne's Maneuver negative, Kemp's positive bilateral, modified Thomas positive
'bilateml i;!uadriceps
Assessment Luml:;>ar disc disorder, lower extremity weakness, multiple spinal subluxations,
posl-traUl1l1'llt!<;;
PlanfTreatmentWlahipu1ationaTler overpressure established no peripheralization, tolerated
well, EMS 0 -- 1::;0> interferential, Jumbw, heat, to tolerance, ,1 unit, therapeautic activities:
, 1'lytlrafitne'5S 1mee- ,,)(t"ll::;ion~ise-instruction: Wall slides, 15 repetitions, BID, avoiding
knee pain
frequency: 1/week
update: 1 week
Daniel Knapp, D,C" C,C,R.D,
.
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PROGRESS NOTES
Patient 10#: 3152
Patient Name: Ralph Sorrentino
Date: January 20, 2003
Subjective: Lower back, midback was aggravated from hanging shelves, rested more past
week, improving
Objective:
Inspection: Hyperlordotic, mild hip flexion contractures improving, greater on the left
Palpation: Hypertonicity, tenderness quadratus lumborum, left, right thoracolumbar
hypertonicity, tenderness
Subluxationlfixation: C5 6 left lateral bending, T5 6 extension, L5 S1 extension, bilateral
rotation, left lateral bending
ROM: Cervical left lateral bending 40, lumbar pain with flexion, partially improved with
repetitions, extension 25 degrees, lateral bending left 20, right 20
Strength: Hip extension 4/5 left, 4/5 right, abdominal curls -- improving, poor lumbar extension
endurance
Other: Maigne's Maneuver negative, Kemp's positive bilateral, modified Thomas positive
bilateral quadriceps
Assessment: Lumbar disc di$order, lower extremity weakness, multiple spinal subluxations,
post-traumatic
Planrrreatment: Manipulation after overpressure established no peripheralization, tolerated
well, EMS 0 -- 150, interferential, lumbar, heat, to tolerance, 1 unit, therapeautic activities:
HydraFitness knee extension, exercise instruction: Wall slides, 15 repetitions, BID, avoiding
knee pain
frequency: 1/week
update: 1 week
Daniel Knapp, D,C" C.C.R.D,
. ,-
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PROGRESS NOTES
Patient 10#: 3152
Patient Name: Ralph Sorrentino
Date: January 13, 2003
Subjective: Lower back, midback aggravated from hanging shelves, legs still feeling very
weak
Objective:
Inspection: Hyperlordotic, mild hip flexion contractu res improving, greater on the left
Palpation: Hypertonicity, tenderness bilateral quadratus lumborum, greater left, right
thoracolumbar hypertonicity, tenderness
Subluxation/fixation: C5 6 left lateral bending, T5 6 extension, L4 5, L5 S1 extension, bilateral
rotation, left lateral bending
ROM: Cervical left lateral bending 40, lumbar pain with flexion, partially improved with
repetitions, extension 25 degrees, lateral bending left 20, right 20
Strength: Hip extension 4/5 left, 4/5 right, abdominal curls -- improving, poor lumbar extension
endurance
Other: Maigne's Maneuver negative, Kemp's positive bilateral, modified Thomas positive
bilateral quadriceps
Assessment: Lumbar disc disorder, lower extremity weakness, multiple spinal subluxations,
post-traumatic
PlanlTreatment: Manipulation after overpressure established no peripheralization, tolerated
well, traction: Continuous passive motion, thoracic, 111mbar, 1 unit, EMS 0 -- 150, interferential,
lumbar, heat, to tolerance, 1 unit, therapeautic activities: HydraFitness knee extension,
exercise instruction: Wall slides, 15 repetitions, BID, avoiding knee pain
frequency: 1/week
update: 2 weeks
Daniel Knapp, D,C" C,C,R.D,
~/
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PROGRESS NOTES
Patient 10#: 3152
Patient Name: Ralph Sorrentino
Date: January 06, 2003
Subjective: Lower back pain aggravated from increasing house work, wife has been ill
Objective:
Inspection: Hyperlordotic, mild hip flexion contractu res improving, greater on the left
Palpation: Hypertonicity, tenderness bilateral quadratus lumborum, greater left, right
thoracolumbar hypertonicity, tenderness
Subluxation/fixation: C5 6 left lateral bending, T5 6 extension, T11 twelve rotation on the right,
L4 5, L5 S1 extension, bilateral rotation, left lateral bending
ROM: Cervical left lateral bending 40, lumbar pain with flexion, partially improved with
repetitions, extension 10 degrees, lateral bending left 20, right 20
Strength: Hip extension 4/5 left, 4/5 right, abdominal curls -- improving, poor lumbar extension
endurance
Other: Maigne's Maneuver negative, Kemp's positive bilateral, modified Thomas positive
bilateral quadriceps
Assessment: Lumbar disc disorder, lower extremity weakness, multiple spinal subluxations,
post-traumatic
PlanfTreatment: Manipulation after overpressure established no peripheralization, tolerated
well, traction: Continuous passive motion, thoracic, lumbar, 1 unit, EMS 0 -- 150, interferential,
lumbar, heat, to tolerance, 1 unit
frequency: 1lweek
update: 3 weeks
"
"
Daniel Knapp, D.C" C,C,R.D,
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PROGRESS NCrfES
Patient 10#: 3152
Patient Name: Ralph Sorrentino
Date: December 30, 2002
Subjective: Lower back pain has been doing much better
Objective:
Inspection: Hyperlordotic, mild hip flexion contractu res improved on the right, greater on the
left
Paipatlon: Hypertonicity, tenderness improving bfiaterai quadratus lumborum, greater ieh
Subluxation/fixation: C5 6 left lateral bending, T5 6 extension, L4 5, L5 S1 extension, bilateral
rotation, left lateral bending
ROM: ,Cervical left later~1 bending 40, lumbar pain retumjngfro~ flexion mild, better with
repetitions, extension 10 degrees, lateral bending left 20, right 20
Strength: Hip extension 4/5 left, 4/5 right, abdominal curls -- improving, poor lumbar extension
endurance
Other: Maigne's Maneuver negative, Kemp's positive bilateral, modified Thomas positive
bilateral quadriceps .
Assessment: Lumbar disc disorder, lower extremity weakness, multiple spinal subluxatiqns,
post-traumatic
PlanlTreatment: Manipulation after overpressure established no peripheralization, toleratl3d
weil, therapeautic activities: Hydrai"itness knee extension -- see rehab pian, ultrasound
continuous 1 Mhz, 1.4 watts/cm2, 1 unit lumbar, EMS 0 - 150, interferential, lumbar, to
tolerance, 1 unit
frequency: 1/weEi'k
update: 4 weeks
Daniel Knapp, D,C" C,C.R.D,
~~
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PROGRESS NOTES
Patient ID#: 3152
Patient Name: Ralph Sorrentino
Date: December 23, 2002
Subjective: Lower back pain mostly on the left today
Objective:
Inspection: Hyperlordotic, mild hip flexion contractures improved on the right, continued on the
left
Palpation: Hypertonicity, tenderness improving bilateral quadratus lumborum, greater left
Subluxation/fixation: C56 left lateral bending, T56 extension, L4 5, L5 S1 extension, bilateral
rotation, left lateral bending
ROM: Cervical left lateral bending 40, lumbar pain returning from flexion mild, same with
repetitions, extension 10 degrees, lateral bending left 15, right 20
Strength: Hip extension 4/5 left, 4/5 right, abdominal curls fail, poor lurnbar extension
endurance
Other. Maigne's Maneuver negative, Kemp's positive bilateral, modified Thomas positive
bilateral quadriceps
Assessment: Lumbar disc disorder, lower extremity weakness, multiple spinal subluxations,
post-traumatic
Planrrreatment: Manipulation after overpressure established no peripheralization, tolerated
well, therapeautic activities: HydraFitness knee extension - see rehab plan, ultrasound
continuouS 1 Mhz, 1.4 watts/cm2, 1 unit lumbar, EMS 0 -- 150, interferential, lumbar, to
tolerance, 1 unit
frequency: 1lweek
update: 5 weeks
Daniel Knapp, D.C" C,C,R.D,
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PROGRESS NOTES
Patient ID#: 3152
Patient Name: Ralph Sorrentino
Date: December 20, 2002
Subjective: Lower back pain has ~~ement, feeling looser, legs not as weak
Objective: ~
Inspection: Hyperlordotic, mild hip flexion contractu res noted
Palpation: Hypertonicity, tenderness improving bilateral quadratus lumborum, greater left
Subluxationlfixation: CS 6 left lateral bending, TS 6 eXtension, L4 5, LS S1 eXtension, bilateral
rotation, left lateral bending
ROM: Cervical left lateral bending 40, lumbar pain returning from flexion mild, no grabbing,
eXtension 10 degrees, lateral bending left 15, right 15
Strength: Hip eXtension 4/5 left, 4/5 right, abdominal curls fail, poor lumbar eXtension
endurance
Other: Maigne's Maneuver negative, Kemp's positive bilateral, modified Thomas positive
bilateral quadriceps
Assessment: Lumbar disc disorder, lower eXtremity weakness, multiple spinal subluxations,
post-traumatic
PlanfTreatment: Manipulation after overpressure established no peripheralization, tolerated
well, therapeautic activities: HydraFitness knee eXtension -- see rehab plan, ultrasound
continuous 1 Mhz, 1.4 watls/cm2, 1 unit lumbar, EMS 0 -- 150, interferential, lumbar, to
tolerance, 1 unit
frequency: 1/week
update: 6 weeks
Daniel Knapp, D,C" C,C,R.D,
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PROGRESS NOTES
Patient 10#: 3152
Patient Name: Ralph Sorrentino
Date: December 16,2002
Subjective: Lower back pain feeling discomfort more on the left today, legs still feel weak
Objective:
Inspection: Hyperlordotic, mild hip flexion contractu res noted
Palpation: Hypertonicity, tenderness para lumbar musculature, including quadratus lumborum,
greater left
Subluxation/fixation: C5 6 left lateral bending, T5 6 extension, right lateral bending, L45, L5
S1 extension, bilateral rotation, left lateral bending .
ROM: Cervical limited left lateral bending, lumbar pain returning from flexion, extension 10
degrees, lateral bending left 10, right 15
Strength: Hip extension 4/5 left, 3+/5 right, abdominal curls fail, poor lumbar extension
endurance
Other: Maigne's Maneuver negative, Kemp's positive bilateral, modified Thomas positive
bilateral quadriceps
Assessment: Lumbar disc disorder, lower extremity weakness, multiple spinal subluxations,
post-traumatic
PlanlTreatment: Manipulation after overpressure established no peripheralization, tolerated
well, therapeautic activities: HydraFitness knee extension - see rehab plan, ultrasound
continuous 1 Mhz, 1.4 watts/cm2, 1 unit lumbar, EMS 0 -- 150, interferential, lumbar, to
toleranCe, 1 unit
frequency: 2/week
update: 3 weeks
Daniel Knapp, D,C" C,C,R.D,
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PROGRESS NOTES
Patient 10#: 3152
Patient Name: Ralph Sorrentino
Date: December 13, 2002
Subjective: Lower back pain, longer improvement after adjustment, legs stili feel weak
Objective:
Inspection: Hyperlordotic, mild hip flexion contractu res noted
palpation: Hypertonicity, tenderness paralumbar musculature, greater left
Subluxation/fixation: C56 left lateral bending, T56 extension, right lateral bending, L4 5, L5
S1 extension, bilateral rotation, left lateral bending
ROM: Cervical limited left lateral bending, lumbar pain returning from flexion, extension 10
degrees, lateral bending left 10, right 15
Strength: Hip extension 4/5 left, 3+/5 right, abdominal curls fail, poor lumbar extension
endurance
Other: Maigne's Maneuver negative, Kemp's positive bilateral, modified Thomas positive
bilateral quadriceps
Assessment: Lumbar disc disorder, lower extremity weakness, multiple spinal sUbluxations,
post-traumatic
PlanfTreatment: Manipl.llation after overpressure estabfished no peripheralization, tolerated
well, therapeautic activities: HydraFitness knee extension -- see rehab plan, ultrasound
continuous 1 Mhz, 1.4 watts/crn2, 1 unit lumbar, EMS 0 -- 150, interferential, lumbar, to
tolerance, 1 unit
frequency: 2/week
update: 3 weeks
Daniel Knapp, D,C., C,C,R,D,
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PROGRESS NOTES
Patient 10#: 3152
Patient Name: Ralph Sorrentino
Date: December 11, 2002
Subjective: Lower back pain, partial improvement after adjustment, legs still feel weak
Objective:
Inspection: Hyperlordotic, mild hip flexion contractu res noted
Palpation: Hypertonicity, tenderness paralumbar musculature, greater left
Subluxation/fixation: C5 6 left lateral bending, T5 6 extension, right lateral bending, L45, L5
S1 extension, bilateral rotation, left lateral bending
ROM: Cervical limited left lateral bending, lumbar pain returning from flexion, extension 10
degrees, lateral bending left 10, right 15
Strength: Hip extension 4/5 left, 3+/5 right, abdominal curls fail, poor lumbar extension
endurance
Other: Maigne's Maneuver negative, Kemp's positive bilateral, modified Thomas positive
bilateral quadriceps
Reviewed 7/8/98 MRI report with patient -- small focal left L5 S1 disc protrusion
Assessment: Lumbar disc disorder, lower extremity weakness, multiple spinal subluxations,
post-traumatic
PlanfTreatment: Manipulation after overpressure established no peripheralization, tolerated
well, therapeautic activities: HydraFitness knee extension -- see rehab plan, ultrasound
continuous 1 Mhz, 1,4 watts/cm2, 1 unit lumbar, EMS 0 - 150, interferential, lumbar, to
tolerance, 1 unit
frequency: 3/week
update: 2 weeks
Daniel Knapp, D,C., C,C.R,D,
0.- ~_.'~~ -""14I,C!
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Sorrentino, Ralph
3152
December 09, 2002
SEE REPORT
TREATMENT TODAY: manipulation after overpressure established no peripheralization,
tolerated well, ultrasound continuous 1 Mhz, 1.44 watts/cm2, 1 unit lumbar, EMS interferential
o -- 150 Hz, heat, 1 unit lumbar
RECOMMENDATIONS:
Up to date lumbar x-rays to establish DJD -- refer to Midtown
Begin exercise instruction next visit
3/week -- 1 week
Daniel Knapp, D,C" C,C,R.D,
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DR KNAPP'S PATIENT PRIVACY COMPLIANCE STATEMENT 06/18/2002
:
Disclosure of your protected health infDrmatkm without authorization is strictly limited to
defined situations that include emergency care, quality assurance activities, public health,
and law enforcement activities, Any other disclosures for the purposes oftreatment,
payment or practice 0perations will be made orily after obtaining your consent. You may
request restrictions on disclosures,
RECORDS:
All patients "sigrt in" in their own treatment file upon anival, This is not required and is
a self-imposed privacy step webave,utilized for years, This keeps a near aCCurate
history of visits, cancellations, no shows, and rescheduled appeintments, Other patients
do not witness your appointments,
All Patient Records are availableataflytitne for patient's review, You may inspect and
receive copies Dfyour records witi)in30days of request, There may be a copy cost for
this propess, It dollar per page for the first 25 pageS and $0.25 per additional page,
You may. request changes to yourrec<irds, Our practice bas the right to accept or deny
your request based on etlii.cal; legal, and medically necessary terms,
All X-rays, and MRI's are returi).ed to the facility or patient from where they were
delivered to us, W~do not store X-rays in this facility for duration of time, We will
request, upon patient's signature, report of findings from facility and keep this as part of
your permanent record.
Staff records all phone calls via a phone message book, phone log sheet, appoimment
sign-in sheet, or create a, written record on file as the sitUation requites, AU informatioil
is dated, timed if appropriate, and signed off. Staff Will only contact patients at their
residence unless written instroctions are provided to do otherwise,
All Patient Records are secured agllinstJoss, destroction, unauthorized access,
unauthorized reproduction, corruption; or da.IUa,ge,
All medical insurance/and billingteeorqa are retained for seven (7) years.
All discarded reCords contai!i4ls patieilts infQrmationl\fe shredded inCluding scratch
, paper, phone messages, etc, All P,l, Work Comp, And lM,E, records areretained for
, longer unspecified time, All patient receive II receipt wi billing information, This is
available prior to innial' exam upon request. '
A Standard and Procedutebas been stipulated for disposition of medical records, in the
event the practiceis.wld or closed, , All patients will be notified of the sale/takeover of
practice, Patients will be given 30 days to obtain their files before tralisition to !few
ownership, . , "
OurprtlCtice isrequired to abide by this notice,: We havetherlght to cli.angethis notice in
the future, Any revisions will.be prominently displayed, You may file a complaiIit about
privacy violations by contacting our Office Manager, , '
UNA.UTHORIZ:W DUPLICATION OF THIS FORM IS J1,LEGAL: . ~
-:I.l"\\+(,,,,J"'" ~
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PATIENT NAME: ILALP-1J. SO crt G NTI}J ()
INSURANCE COMPANY: _S' TAl' E rA f 1M
1\ I CLAIM#: Sdd, () q~ 0 to 'J,
Ir\t.t\&\'\r :
M.\)y\",.\~'W"{))ADJUSTOR NAME: Tel #:~ - ~ ,~- Co OJ. S
W,4'f+.. ADDRESS: Pu ,:bD;G lOll, ~V Ht;iLlJ \ NY I L/ d4D -I Di/
*- PIP: $ 6~ I ru?J MEDPAvt\f DEDUCTIBLE:-FD ~~' ,)jO ~t:'\VLT
Benefits Exhausted? DATE: IME DATE: ~"Ac;, ---riJr'~L tAt{Bf};,v .
Disability Dates start end IJ~ 'lr IS IJ 1 IJ\JD .
" ,
ENTER INTO COMPo Y OR NW fTlt YVlED,
N\J) Es Nl/..-L--
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~ CARD ~ ATTNY
PI Verification Sheet ACCNT # ..3 J S 2.. DOA
ATTNY
ADRES,
SECONDARY.INFORMATION
2) Insurance Owner
Name:
Insurance Company
Address
Telephone #:
CLAIM #
3) Major Medical
Name:
Insurance Company
Address:
Telephone #:
CLAIM #:
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. NEW YORK MOTOR VEHICLE .
NO-F AtlctlftSURANCE LAW
I>.PPLlCl>.lION FOR MOTOR VEHICLE NO-FAUL1.,_.:NEFITS
Date"",
Policyholder
. Policy Numbllr
Date 01 Accident
Fli(I Number
~.
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To bnablJ us 0 detennine If you are entliled to benefits under New York No-Fault Law, please complete t
IMPORTANT 1. To be eljgible for benefits you must complete and sign this application.
INSTRUCTIONS, 2. You must also sIgn al! authorizations.
3" Return promptly with copies of any bills you have received to date,
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~lph,Sorrentino
40 Karlowe Avenul!
Bl&sdell. NY 14219-1720
vI/ ~jY1
1Il~Y'" fY" ;P
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Return To:. .~-T~T~:f,.~,R.M,:
st~t~~- . , . ,
bf"iA 'rr.."t.
Claim f:lepresentative
{MakfenName)
.Phone : Home
Number i <7 /~ ) ,
,'tOO
. ,
"",
Dale or Sll1h
Sodal Securlty Number
//I...5t35cJ9o-:J..t.- ---
Brief Oescrlpt1on of Aeeldent
Je.l1e c ,
~"'Jb_"Y""rj"lu.lJL_~~~'qt:~+~ '
,>?luLi/81t!- fM'Uf?eS- J..owee-l ()fP~e btH_ -l.e..S
Identity of ve lefe you occupied or
operated at the time of the accident /.5' S . nJ S
This vehlple was: g An automobile 0 ,A motorcycle. 0 A truck 0 A bus or school bus
Were you the drIver of the motor vehicle? rsa Yes 0 No
Were you a passenger In the mo~or vehIcle? 0 Ves 8 No
Were you a petfestrian? 0 Yes ~ No
Were you a member of our pcllcyholder" hotis~Ii()'d? '0 Yes 0 No
Db you or a relatIve wIth whom you reside own '8 motor vehicle? ~ Yes 0 No
Were you treated by a docto~s) or other person(s) furnishing heallh se!'llces? 181 Yes 0 No
Name and address of such docto~s) or petson(s): Jj",sp,'r ,,:rL -./Jr. .:;;, Nt> S
: Year
i '11
If you were treCl:ted at a hospftal(s) were you an:
Date of admission
Bno
t4~"'-o
Din-patient
tf},y. t q. I a. '7
Hospttal's name and address
Amount of health blHs to date $
Will you have more health treatment?
I8l. Yes 0 No
At the tlme of your BC:Cldent were you In the course of your employment? 0 Yes ~. No
Old you lose time from work? 0 Yes :sa- No If yes. how much time?
Were you receiving unemployment benefits at the time of the accident? 0 Yes ~ No
What are your average weekly earnings? $
16$-4194 NY.S Rev, S.-94 Printed k'I U.S.A. 0--
CONTINUE ON REVERSE SIDE
-.-------
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cuPUCA1E
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- The Sunshine State _ '\
LlcENSE N.:.MBER
8653-730-35-405_0
RALPH JSORRErfrlNO
1648 STICKNEY POINT RIl APTl02
SARAsoTA, FL 34231_
Bllmf DM'E SEX HGr. REST. ENDORSE.
11-8&-36 M 646 A
ISSlIEO
11~
EXPJRES
11_
ll\. SAFE DRIVER '
H030037
of a mctor vehicfe con5litutes consent to any liObriely test required by law.
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DanielJ. Knapp, D.C.
Sarasota Integrative Rehabilitation
3982 Bee Ridge Rd., Building H, Suite H
Sarasota, FL 34233
tel. 941.923.3728 fax. 941.925.9512
POWER OF ATTORNEY AND MEDICAL RELEASE
POWER OF ATTORNEY TO ENDORSE CHECKS AND/OR TO SIGN ANY PIECE OF PAPER WHICH WILL
ENHANCE OR EXPEDITE PAYMENT TO PROVIDER FOR SERVICES RENDERED, INCLUDING BUT NOT
LIMITED TO A RELEASE OF MEDICAL RECORDS md ASSIGNMENT OF BENEFITS( AUTHORIZATION TO
PAY.
Know by all these present that 1be unde:rsigne.d has made., constituted and appointed, 2.nd by these presents does hereby
make, constitute and appoint Daniel J. Knapp, D,C. and/or Sarasota Integrative Rehabilitation and any of it's duly
authorized agents and employees as and to be the undersigned's true and lawful attomey for and in the undersigned's lliUne,
place and stead to endorse any and all checks, drafts at money orders which are made payable to the undersigned alone or
to the undersigned and the said Daniel]. Knapp, D,C. and/or Sarasota Integr1l;tive Rehabilitation, which checks, drafts or
money orders are made payable for services which have been made by Daniel J. Knapp, D,C.jSarasota Integrative
Rehabilitation, at the request or with. the knowledge and approval of the undersigned andlor maker of the check, draft or
money order.
Furthermore, the undersigned allows Daniel]. Kw.pp, D,C./Sarasota Integrative Rehabilitation or any of its agents to sign
any paper that will be necessaty to enhance, expedite and/or allow payment to said provider. This may include llffidavirs of
non~owneIShip of vehicles, insurance forms and other statements.
The urtdersig1lf"d by these presents does {'jve and erant the said Daniel]. Knapp D.C. /Sarasota Integrative Rehabilitation
as attom~ the full pouter and ~nthrmty to do and perform all and evet;y act wllatsoevp.r requisite and np.c~~saty to be dorie
in and about the J?l"Pmfses as fully to aU intents and pUq>Dses as the undersigJled might or could do to persongllv present
insofar as the endorsing and ca'thing of said checks are concerned as well as ltt\v other docump.ot
MEDICAL RELEASE
A photocopy of this documetlt: shall be sufficient to authorize any person having records of medical treatment, services,
or supplies pertaining to me):O release troe copies of same to Daniel]. Knapp. D.C.jSmsota Integrative Rehabilitation or
any insurer providing coverage to me in connection with the processing of any claim fat: benefits ~ by me or by the
assignee herein. A photocopy of this document shall be as binding as m original sigwlture page,
The undersigned does hereby mtify md confum "">' md all actions taken by the said attomey iD. accoromce with this
special power and which the said attomey shall do or cause to be done by virtue of these presents.
ASSIGNMENT OF BENEFITS
Hereby authorize
e of Ured/Patient) {Name of Insurance Carrier)
to make me c.l benefits payments otherwise payable to me for sernces rendered by Daniel]. Knapp, D.C.jSarasota
Integrative Rehabilitation, but not to exceed the c:harges of those services, payable to and mailed directly to:
Bfl}7lf me JrJ
I,
Daniel]. Knapp, D,C.
Sarasota Integrative Rehabilitation
3982 Bee Ridge Rd., Bldg, H/ Suite H
Sarasota, FL 34233
Furthem>ore, I hereby IRREVOCABLY ASSIGN to Daniel]. Knapp, D,C.jSarasota Integrative Rehabili,:,tion ~e rights
and bet1etits under any policy of insurance, indemnity agreement, or any other collateral source as defined In Flonda
Statutes for my service md or charges provided by Daniel J. Knapp, D,C.(Smsota Integrative Rehabilitation.
IN WITNESS WHEREOF the =de",igued hove hereunto set then: hands, this C;-'day of I zj 6 4-.
I:lr~ rR-Jf '3"R/!~LJ~
f5!\. SIGN!\. , P NT'S NAME (pLEASE PRINl)
.
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E. D. PHYSICIAN
RAC.E. EM? HQ, \}' 1.8,. RIVE,D
C(~'ITHOLIC W 411...1\
PATIENT 5.S. # r ,-.. ,', '-., -..... ,'"
.} ';--1,/'- Lo-\i.~:l::)
ICD-9 CM CODES
iZ}~21.9
PAT~~ DRUG:;!\.LLEflG'(il.
.lc.1>..ld_.L...-II'
A:i3495
INSilRANCE..CO.Jt1. . I' ..-
Uln' NU I" ~iL L I
'''S~~ANP< "0, #2,_, -II "',
Ul .1.1-11:1 bl.:J_V
. BlC CONTRACT #
COMMFflJS ,^, ,- "'1-' ,^, L.
.l:.\J.Lj"'!~:' "..I-j
POLICY #
~~1~~~~~'!T I NO; r;~FILF'H
,~~~r.(~7\!T I N [!} j''i tl i\ Y
BIS CLASS SUBSCRIBER
~;.iTl~~SHIP
,.~ ~- ....'
COUNTY
MEDICAID #
SUB~~'1~f;~'6 f_,'\ 1=}
.. I '- _._.1 ',..; .1._.
"iNN ;~ytj?,7~'Y:"
SUBS.~1il~8.~Rfr:"~' ~:; .:~ ,.-',
V''''~_'oJ'", I .....,.. '..~
o:t
SHOULDER PAIN,LWR BACK AND POSTERIOR THIGH
BlC EFF.
Pi',IN
p"r klj;S BELTED
DRIVER IN 3 CAR MVA TODAY AT 1300 IN MORGANTOWN ,W...VA
mr. NO FAtL.
.
. . -.
1>
CONDITION ON
ADMISSION
9
GOOD 0 FAIR 0 POOR ALLl'RGll'S:
9,..,~ t,vC/l/IG- >ke..1-
NKA
TIME:
neBe
DABG
DSMA'
DSMA12
OISO ZYMES
UA
OSEE ORDER
SHEET
o
o
o PTtPTT
DAMYLASE
OCARDIACWU
.
DCUlTURE
o URINE
DBlOOD
DTHROAT
DOTHER
.,
DEKG
~MP:
.
!
t)
X
R
A
Y
/ '
V(j~'~ J
vis'
. QJ1 }?
I
M
p
'.
~
tu.<-
c. -,B-bS
~
I 4L{iu&
M
E
D
t
I
V
S
:3
DIAGNOSIS:
o M.D.
~ SIGNATU
~ EDMD
SiGNATURe
o UNSTABLE AT
TIME OF DISCHARGE
: DTTo.5ee
OdTO.SCC
I DISCHARGING RN
!:::I(.;NATII~l=
..; / d-2J
~
i L.J HYPERTET 250 u
'-~.:".~" ..,"..
',-""':.'IJ".'" -.
_ _ ......_ ,~.. ,p", ,'- --,. '.-
_,-/./-"_ "_'-,, -" . - ", -=;>,;;;.-'i..:.=;,,~. .,,' _ ~;~~,O :":'-;' ,_ __;'l::-::.:.:r'.;~~/S--c" -'! .,,, .-' _'~_ .<-"_ . ,-' . ,';_'_-;":::)
) be- ~l:C:' ::.~~: o,-n.'l".<?<:':;l.;-a- mi~,lle:li ~;~ vi::-e~ i'~l:::>, :.;e ;,~:V'f>l"'! ,.) t112 ' . :.~ '~l:''''' t m~::;.ei~t ,r:.,;;' ,',,:,"~r.E';<:; -.)' 1'" 2. :".l..:-t,. .;.:1, "::'L':''';-'' 3ti.t _ . "";..!~:lC"f
:.~E::~; ~;~1~;~ '~~Z~~~;~::~~~FE~::S~~?'~:~:r~~~;:i~,:;2~~~;Ef~'~~~,~: L~;::~1J;:~:1:':~~~~:~~;i:.~;~::'" l:':,-,;:~:,':':';!:~~
!O~er{ie:-:cy rrearr.:er.t of :;;1l';:1 physiC$.i ,,;.on;j:l~C;.<_; f,Ck;lO'Nl(;cge tha; no 9i.lait.~..::as !"',aw Q~~r; f11t:.Ce 1.0 'TIe .;.~::; ;r,a ....dect :)f ";'..,.;.:", ,...,,;;;::ip . .;.11.~ .~:;'CCCi.rss
md tr~atlilem 'O! ST.Y CO;"lditicn.
~-;-.
-" ~
.
~'.:~;2:q ~- -
:r-r.:.~-~~ i ~
..
"
,
.
C;,
,
" -
.
"0 be used by. s:;QmpetE:m adult patients.
~UTHORlZATltJ;'li FOR EMERGENCY TREATMENT: Where Patls)1t-is Un~ble tv Sign or is Under Ag~:
_amihe
.(re~ati6nshlpl
. cl
....liO is cver:under ~ -g years ~d: (cross eu!' thC':<;s l.ot ap;)licable)
(patient's name)
Nllc has '/olu;"\~arily -:orne to tile Emergency Dep:artrn.el~t ot this medical faci!i[)-'.
/'-lho has- beerLbO'Ollght to the Emergency Departmen(of ~r.is rr.edf-cnl fa~mty at my dir&c!1on,
~o\'ho has comi1 tc the Emarcertcy Department of this rne~icaI ~acmty .Linder the l,?l1OvAn~ circu:Tlstance_s:
f}!ORt:;:A,Tl0ri3J RELEASE t,,1EDiCAL lN~O?MAT!ON: ! .1eroby consent tliat 1Tl}' E, D. j:;!iysician 0; :nis_ raci!1tj :nay rL:flirS:1 'nfcrMatlcn 0Oilta;n'ild in the
ent medj~J record kept by this facilily in the- COurse- of hosplta;i'j;aJfon 10 ar,y lhlrd party which may be fjab;~ for m,. hospilal or mec:cai expenses :.;l1ce- l1. C9!i!ract
'ering :T\~ a's 11".8ured or as a covered member or the insured uniLor under a govemment progr3m provIding fer payment of ::'>uch ex~nses. snd to i.ny health'
e facility .or agency to 'Nhich application for tra;1sfe( in accorcan.-:€ with r=ederal or Sbte t3'<hs or Regu!ations. may i1e mar..!$, r:'1iS ;;1forl"'lc-:t!on 01:::Y also be ..
rei for d.ata col!~.r;Jlon fo, ,.-esearch purposes. . - -
THORIZ.A:tIOt',{TO'PAY INSURANCE 8ENEFITS: ( r~ereby author!ze tl19.1.ar.y insurance c-snafi!S lor se!'viccs i?ndered '0 me in this f<:lci!it"j b~ paid qlrectly
h.is ~acmty in arr ;;>;fl1ount no~ ':;xceecin~ ;is cu:;:;tcmar/ charges far s~ch se1"Vice.s._l unaerslai:O that! a!.fo 1ha~cja'!i respor:sible :0 this fadity ~r any clIstomary
u'ges nm paid by vir:u~ .of ti~~S authorization. \ also authcrtze the Hospitai to apply any Creult Ba!ar.ce whlcb may j~\'e;op- to ar,y ')ther O~t;;lt 8e~f,nce owing.
JANC1AL AGRf;.EMENT: I hereby agree that in consideratlor::..ottbe- ser:ices to be -renpered ~ :me, T st"~ll pay tr,~ account of ':.I-:a medIcal ~cmty and Emerger.cy
part'1ient .PI1Y!i~Ian Group in accordance Wi\j1 notes and terms .of the, hospital and Emergent~y Gep~.rtrn~i}t ?hysic1an Group for seftllces rendered. Slloa!d
account become deUnquent and. require the services of ~n_ettoJr:.ey fer collec':icn, J shall Eay reasonabie attomey fees and ::::oTIactfcn expenses.
-, .... :
IR PATIENTS ENTITLED TO MEDiCARE BENEF1TS: ! cc.rtJy that the information given by me in applying ter payment unde~ Title XVlI1 of ~he Social Security
( is correct. i ~lJthorlze.any noider of meclical or other information abciut ).;~ to release ~o the Social Sec~lrlJ:l-j Adrnlnistratic'0 a'1d Heatth ('....are FlnancL'1Q
ministration QLl.s_~nlen-necii:1rie-s or carriers <:<I1Y informalion (leeded for thIs or a rdated Medicare claim. I.'request mat payment of authorized !JeQef.'is aa made
my behalf- I ~ign me- ben?fits payable for physician ~erV)ceS to ti1€ physician or J~rg?fllzatiOI1 furnishing servlce.s Of authorize such physicIan or orgafltzatioh
submit a claim to Medicare iOf payment for me.
.LUASLEZ AGB.EEt.J1Et\lT: The' Medica! F:!cility, having. provided zuilab-le depositories for dentures, .contact leilSe$~ money, ie'{~elry and other personal
longings during my confinement. 11",8reby waive any clalrr. against s-aid hospital arising OL:f of the loss {rom anY-~l)se wh3.tsoB>!er of any valuable including
t not limited to-, c~ntlJms."cOi1tact lense mone jewell e,nd other personai belongings J may not deliver to said 00spilal for safekeeping in its 6epcsitones,
.
;r!ENT SlGNAT1)RE
.'
I
-"t.:t<' )-.
P-atlent's gent or representative
Relatfonship to f5alient
- , .,
LEAVING H L AGAINST MEDICAL ADVICE
lereby certify th.ilt I fully understand and acknowledge '!hat I am leaving the hospital against the adVIce of the l?.i1ysician or Surgeon in ch.arge t:f my case. I
lve been inforrn.J#d_ oI the risks involved and I hereby agree to release and not \'1Qld the hospital. it's agents, or servants or my physician or surgeon responsible
r"~ny harm o.r.injury that may result because I have [eft the hospital._ .
IGNED
(PATIENT SIGNATURE)
DATE
WITNESS
DATE
, -
---
TIME
TIME
RELEASE OF rlESPONSiB1LtTY FOR, REFUSAL OF TREATMENT
request that no be used on me qr administered to me during this hospitalization.
hereby reletUie tne l1ospital, its personnei, a."ld .the E(l16tgency Rcom ph)!~i::!3.n from 9.l'"!y responslbiIlfy whatever' for unfavorable reat!ions or any unto'tyard
~sults du.s to my refusallo permit the appnce,ticn of same.J have been fully advised of and 1 understand the possible consequences ot such refusai o!,!Jl1Y part.
.
lGNED
____ DATE ___._....::..~ WITNESS
'(?!\il~i'f, 51GN.Aj~jRE)
DATE
TiME
TIME
,--
N:::lme:
~~/{" ','
.fcraxt4nO
&,?-
77/7<s75
" Mercy Hospital ~f Buffalo
'EWet...eiia'ibe6amliienf~ICna:lili:~~:m::::!!!::Hn!!j:::!!:::::F,i~\jj~:'b.f,~H::H: Chan'
Fill in, check boxes, or circle items as appropriate. Complete all sectIons.
. .. ::I .
NO
Age f Sex
Chief Complain
Addressagrach
<'22~
male
female
Unknown
wounds
Location
o.Ii sensation
6/102 c-Z
numbness tingling
/7e.C4 0;;.<1./ :6AC-~
paralysis
Seatbelts: Y~N 0 lap oulder '
Windshield broken: YON ~ Auto damage location: p-d..
Ambulatory at scene: Y Gl-1fb
Pre-hospital care: nfa.e-IV 0 02 0 Card. Monitor 0 Spinal Immobilization 0
Other. pCP/~&j~/ A//t// t'!L,,~('p ,,,. k~1
Mech, of InjUry:
REVIEW OF SYSTEMS:
NEURO: '" LOC
Seizures
RESP:
SKIN:
Weak I DiZzy
Motor changes
Sensory changes
SOB
GI:
Bruising
Diaphoresis
Abdominal Pain
car
motorcycle 0 bicycle 0 pedestrian 0
~/__#AJ
t::W'
1~d'4v k,tt.
Uhbbt~j'n~'6i~kd:ti'E?io~, ,',', "', ":;,,,:,::,,:::::: <:"':':.->:;?/,,:\U:-::-::,::
YON a-tXlNSTITUTIONAL:
YON ~ Hypothermia YON 9-::::
YON ra--CV: Hypo I Hyperte"sio" YON ~
YON ~ Tachy f Bradycardia YON ~
YON ~ Chest Pain YON ~
y 0 N.,~ Active Bleeding YON g--
YON eJ'GU:. Bowellncontinence YON G:l'
YON CJ"" Bladder Incontinence YON if-
YO N '~1:7('SY~~n.,sm~!~",;':e~i'th;:,
Describe any positive findings:
Y' . NO: ' "
Cj~.,>?p~~n7"-
o
Neuro: ~seizures Intracranial Bleed CVAffIA
Resp, Disease:~COPD Asthma Bronchitis
CV Disease: ~ Angin~1 ASCVD
Other. none HTN~a Cancer Blood f Immune disorder
Anticoagulants Psych Disorder
Describe:
FAMILY HISTORY,
Heart Oz., Diabetes
CVA, Tumor, HTN
ICB, Seizures
Other.
Other f Describe:
YO
YO
YO
N --t:J:
N 0
N
SOCIAL HISTORY:
y cr-NO
YONe:l_
YON -er--
Y"',
Describe:
Smoker
ETOH I Drug use
Recent stress
Other.
ppd
This form is to assist the physician's documentation of clinical care and judgment. It Is not Intended to supplant that judgement or create a standard of care,
@ 1997-8 Emergency Consultants,lnc.
.
.
~x '>:;re~,4//lcJ
~yt-- I; 2.-
77/i/r7s
,. MercvHospita'1 of Buffalo
A~~~[~~~llilliwwl1illwl~1~mRI*~lQ~~l-~~&[Ji~~i~~~~iliJ~~llii~~~~~~t~ Nalne:
Si ns of inju : laceration abrasion ecch masis other: /'f./'(7.;"] e
"lns~f~t'on:,~r;l;::~e;~urns(::~',.': ,::::::;~..
~;Y~;U':'. .':;':T""':' . , ,.. .,,<,..
,Cnla} :;~H8d;;';~b ,'lbteri6/
,.. iiiJ">;'abrtdriri,,Ui ,., '
Skin
HENT'
'EyE!;
Chait#'.
n/a
n/a
n/a
n/a
Induration
mild
moderate
severe
PaHent 10-
emaciated
obese
cool diaphoretic ale c notic hot
Addressograph
subq nodules ti htenin
+
'C:; c.i=LridF
abnormal
Neck.
~. -~ "'.
:'.::.n'ta~~,:: ::':ab"normgli" : masses:,:':
,..'iJ")'~b~;.,~~r *
: 'Cr,e ::itu~... dieal'deviation Sub emph serna
,c:~:-6'7
Resp
c:v
Ai
Palp 'on: normaj
Auscultati
Palpatio
Vascular Pulses: n/e
':GJ~::C:
n/a
abnormal:
retractions use of accesso muscles
n/a abnormal:
rotected:
Ga reflex: present
n/a
absent
nla
n/a
abnormal:
abnormal:
crepitus
subq emph sema
gallop
rub
murmur
n/a abnormal: PMI
Femoral: R """'-- +
L ~ +
'jjij,idihg! )t::~;,;j:::,;<i:;,t~~.d~'~:~~::i,~:{::/"
~ound. ,
. ;org'Emcime9aly,:
confused 0 lace 0 time 0
unconscious 0 ain unresponsive 0
n/a abnormal: anxious a itated fiat depressed quiet
Neuro - abnormal:
abnormal:
nla abnormal:
abnormal: n/a abnormal
orma abnormal: +
Back/Flank rmal P'~7:
ExtremIties G/no~ abnormal:
Pelvis ~ abnormal:
Other
C-Spine
T-Spine
LS-Spine
CXR
KUB
Cardiac Monitor
EKG
CT/MRI
~
, ,
nla Order Nml Abnl
oZrr-D
o 000
o ~raCJ
0000
o 000
o 0
o 0
000 0
CBC
SMA-7
Amylase, Lipase
Drug Screen, ETOH
PT / PTT
Type and Screen/Cross
ABG's
UtA
EP cardiac monitor interpretation;
EP interpretation of; X-Ray
EP interpretation of; EKG
TREATIVIENT GIVEN:
Oxygen
IV Fluids
Other:
Describe;
L/min,
~
n/a
Time;
Time:
Time;
CVP Line
<(m.:'::ihutEI~'>,
..m__".._ _...
,..,','.'..-._,:-:.-,:,
""'::"':::;::<:>,:'.-.,:';,:-.
...'.-.--,.,:...
~ ~ .
~~-""",'
'~-,
0000
0000
0000
0000
0000
DO
DODD
o .\J'1J ~
ut'o>c.--
OA~A
#~c
? 7/<1 J/f-
r' '
'J&r:r~,/z/{/t c
Chart ft.:
Palient iD:
Addressograph
nla Order Nml AMI
Peritoneal Lavage
Ultrasound
OTHER:
DODD
DODD
CJ X-rays discussed with radiologist
EKG comparison Y CJ N CJ
Describe:
Blood Produc~
Medications n/a'
Intubation Peritoneal Lava e
See Procedure QualChart ,. 0
PA supervision note: Physician attests performing: Review of Hx. 0 Pertinent PE 0 Medical Decision Making Q
Unchg,
Unchg,
Unchg,
Impr, Worse
Impr, Worse
Impr, Worse
Possible Unlikely
DlFFERENTIAlllIAGNOSIS:
Head / Faciai Injury / Fracture
Neck / Spinal Injury / Fracture .,
Chest Injury (Tension Pneumo, Flail, Tamponade)
Other:
~
o
Name;
Name;
,
Possible Unlikely
...er-- Abdominal Injury (Ruptured Viscus,Solid Organ) 0
o Upper Extremity Injury / Fracture 0
~ower Extremity Injury / Fracture 0
a-
e--
g--
3 ~~"-'
2
,,1ft
Name:
Name:
Comments:
to: Home CJ Nursing home CJ Police CJ Parents CJ Other
Within; 24 hours 0 1.2 days 0 2-3 days%,
Orders Written 0
Transfer form completed: 0
Lab results 0 Diagnosis'lEI Need for fOIlOW-Up.jl'
other CJ Describe: . ,
o ee supplemental sheet for additional EP notes
At:
am pm
"l.
At:
am pm
At:
At:
am pm
am pm
DISPOSITION;
,PA rev, 3/17/98
~~
...~
I U ~
ti;J:1
o
MERCY HOSPITAL
o
,.
REPORT OF RADIOGRAPHIC EXAMINATION
NAME: SORRENTINO, RALPH
X-RAY NO: 9413495
DATE: 04/19/98
CASE NO.: 7714575
ROOM NO.: ER
0007327
B.D. :11/05/35
EXAM: CERVIC SPINE (AP & LATRL)
LUMBOSACRAL/COMP
J.ROGERS/T.OCONNOR
M.D.
RADIOGRAPHIC REPORT
CERVICAL SPINE
Frontal 'and
fracture or
identified.
lateral views of the cervical spine reveal no
malalignment. Significant spondylosis is not
No soft tissue pathology is seen.
IMPRESSION:
NORMAL TWO VIEW EXAMINATION OF THE CERVICAL SPINE.
LUMBOSACRAL SPINE
Right renal calculi are incidentally noted. There are five
lumbar vertebral bodies. No fracture or malalignment is seen.
The intervertebral disc spaces and lumbosacral alignment are
preserved. There ig an occasional marginal osteophyte.
IMPRESSION: 1. MILD SPONDYLOSIS.
2. NO ACUTE OSSEOUS PATHOLOGY OR SIGNIFICANT
DEGENERATIVE DISC DISEASE.
TDV/dg
D: 4/20/98
7:01
T: 4/20/98
7:51
t/:Ld iJ,(~'G ,.
;r'~EVANNA, MD
. ROENTGENOLOGIST .b '
Report is to be considered
a preliminary report until
signed by the Radiologist
5C.
.~
-
<~~~
-
~ ' L"
.......... ....,_.~=
~"~"', '~~:i\_'
MERCY HOSPITAL
Dept. of Laboratory Services .
73::2 7. .,
Drd. t,oca ti'on : ER
Patient Name: SORRENTINO, RALPH Birthdate: 11/05/1935
Pt. Address: 40 MARLOWE AVENUE Telephone No: 716-823-9084
BLASDELL NY 142190000 Ordering Phys: KOTHA, RAVI
*********************************************************************************************
Sebbott Road Buff~/O, New York 14220
Page No.
1
.
Copies to:
Accession No:
Comment:
KOTHA, RAVI O'CONNOR, TERRENCE P
98-109-00616 Drawn Date/Time: 04/19/98 2020
BILATERAL SHOULDER PAIN, LWR BACK AND POSTERIOR THIGH PAIN , PT WAS BELTED
DRIVER IN 3 CAR MVA TODAY AT 1300 IN MORGANTOWN ,W. VA
URJNALYSIS - ROUTINE
SOURCE
COLOR
APPEARANCE
SPEC GRAVITY
pH
GLUCOSE
BILIRUBIN
KETONES
RANDOM
YELLOW
CLEAR,
1.015'
6.5
TRACE *
NEG
NEG
(STR-AMB)
(CLEAR)
(1. 001-1. 030)
(5.0-8.0)
(NEGATIVE)
(NEGATIVE)
(NEGATIVE)
BLOOD
PROTEIN
UROBILINOGEN
NITRITE
LEUK. ESTERASE
NEG
NEG
NORMAL
NEG
NEG
i
j
,
,
(NEGATIVE) j
(NEG-TRC )1
(<= l.O) ::
(NEGATIVE) !
(NEGATIVE) 1
1
;
,
i
1
j
.
.
,
It':
,If:, R
. S' .;.....
f,
'.
'"
o
~
o
~
'"
o
z
"
II:
o
"-
..'
Footnotes
* = Abnormal
.
DR. RAVI KOTHA
ECI PHYSICIAN GROUP'
Patient Name: SORRENTINO~ RALPH
Med Record #: (00000)000413495
Pt. Account #: 007714575
Printed:
20APR98 0127
End of Rpt.
.r,"
. I
-'"
M ~""
~ .~ ~
~M_~~,,~
o OTHER
-'
h ) rC'-c/(
TRIAGE TIME PATIENT #
/97'D . .
AGGOMPANI'ED &;/4 .
BY:
'? UP TO DATE SMOKER:
, ONO ES ONC
PATIENrs NAME / .-.1
':>0 /" r-8r? /),"'-0 ~,
o EMERGENT I 0 NQN-URGENT 1'1 ~ ARRIVED
TRIAGE: URGENT n' [J ~~ECTIVE IV BY:
IADMVITAL /;fO?:,./) O""-V }/o!
SIGNS: BP /"lv T ~/ /' PRATE /v
/'J'''''~";;!i-
/ v J ...J)
uD
DATE
0';1/1' ~j?
LIMP
LAST
TETN,
DATA SOURCE:
CHIEF #7//LL
COMPLAINT: /' Y /7 (2 ~
ASSESSMENT: 4 y
/l..,"#,,'
LEVEL OF
CONSCIOUSNESS: 0 COMATOSE OSEMI COMATOSE ODROWSY
LERT
'f'A/<7l
~,.p:
PAST
HISTORY:
ONONE
-'
MENTAL ~LERT ~RIENTEO ODISORIENTED o UNRESPONSIVE
STATUS:
o OTHER PUPILS:
SKIN: DORY 0 RASH ODIAPHORETIC 0 OTHER
COLOR: NL OpALE OFLUSHED OCYANOTIC OOTHER
RESP: c;:Ii:JORMAL 0 DYSPNEA 0 APNEA 0 OTHER
BLEEDING: 0 CONTROLlEO 0 NOT CONTROLLED IA
EMOTIONAL STATE: AlM o RESTLESS o CRYING
OANXIO,US o ANGRY o COMBATIVE
INTERVENTION:
ALLERGIES: ONE
.
pRESJ;NT
MEDS:
o NONE
ud;"
VISUAL ACUITY:
DNA
CORRECTED: 00
.
UNCOARECTED:OD
TRIAGE .-<:h... -??
SIGNATVRE;/'/A:?r' .h#
OS OU
OS OU
, /%--
TIME:
WEIGHT - CHilDREN UNDER 1 YEAR
W9?%
.~
...:..E
"
TIMEIlNlTlAL I Bp I TEMP I PULSE I RESP I MEDICATIONS & FLUIDS I 1IME I ROUT,E I SITE I EFFECT I NURSE
l..AB AND TIME II MISC. AND TIME I XRS
cac pT/pTT EKG CHEST- D PA/LAT. D
UA AMYLASE ABG ABD,-D FlTIUpRIGHT D
CHEM, ISOENZYMES SKULL; C-SpINE
OTHER PELVIS; EXTREMITIES
CULTURE OTHER
N
M
~
~
N
RN SIGNATURE I INITIAL I RN SIGNATURE' I INITIAL
lALi'\I,...^1 nr::f"'Ai')i'\C'
- , > '
c
MERCY HOSPITAL
o
- ,
REPORT OF RADIOGRAPHIC EXAMINATION
''--.
NAME: SORRENTINO, RALPH
X-RAY NO: 9413495
DATE: 06/09/98
CASE NO.: 7760677
ROOM NO.: OP MAC
B.D. :11/05/35
EXAM: CT LUMBAR SPINE W/O CONT
DAVID R DEBERNY
M.D.
RADIOGRAPHIC REPORT
CT SCAN OF THE LUMBAR SPINE
Appropriate axial sections were obtained through the
intervertebral disc spaces at L3-4, L4-5 and L5-S1 without the
administration of IV or intrathecal contrast agent. There is no
evidence of focal dis'c herniation. No evidence of lumbar stenosis
is demonstrated. Significant facet arthropathy is not detected.
IMPRESSION: NORMAL CT SCAN OF THE LUMBAR SPINE.
GJ/dk
d: 06/10/98
t: 06/10/98
23:25
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GERALDvJOYCE,
ROENTGENOLOGIS
Report is to be considered
a preliminary report until
signed by the Radiologist
"
......... ,- ~-
"- JU;/'~
Jerald P. Kuhn, M.D.
Ehsan""Af~ MD.
Paullo4ontgomeI)', M.D.
t>.nne D. Ehrlich, M.D.
Steven L. Christensen, MD.
Dilip~. Gole, MD.
'Roseanne Oliverio, MD.
Jan S. Najdzionek; M.D.
David'J. Martin, MD.
C)..goOStic Imaging Associates
, Of Western New York, P.C.
o
~.
James W. Backstrom, M.D.
Steven L. Bezinque, D.O.
Marl<: J. Pisaneschi, M.D.
GregoI)' T. Tymchak, M.D.
Bruce P. Hall, M.D.
Richard D. Thomas, M.D.
John J. Januario, M.D.
Charles J. Riggio, M.D.
1630 Maple Road
WiIliamsville, NY 14221
, 716-636-1902
Dr. Fr~derick McAdam
, 9 Limestone Drive
Williamsville, NY 14221
Fax:
716-636-1367
1~~t::':~~~~1
RE: SORRENTINO, RALPH
_________._____.________.__ DOB 11/5/35
98-0852
EXAM DATE: 7/8/98
\....;
Dear Dr. McAdam:
MRI OF THE LUMBAR SPINE
INDICATION: Disc disease versus stenosis. The patient has a history of MVA in April
of 1998 and has low back pain radi~ting down each leg.
TECHNIQUE: T1, T2 and STIR sagittal images, T1 and T2 weighteqimages.
FINDINGS: Assuming five lumbar vertebrae, the tip of the conus is normally
positioned behind L 1. The conus is normal in signal and morphology. There are no
abnormal masses within the distal thecal sac.
L'
The appearances at T11-12, T12-L 1 and L 1-2 as well as L4-5 are normal.
At L2-3 and 3-4, there is mild desiccation of the disc. Each of the discs bulges mildly
and diffusely. The central spinal canal and exit foramina remain capacious. The facet
joints and flavalligaments appear normal.
At L5-S1, there is desiccation of the disc. There is posterior high intensity zone indica-
tive of annular tear. There is a small left paracentral focal disc protrusion. There is no
definite nerve root contact, although there is potential for contact with the left S1 nerve
root,which is very close to the small disc protrusion.
(continued)
_.......'"~......'"'_.,. ,,-~.'~ .'~'~""t II"'~-''''-~"*~,.
Jerald P. Kuhn, M.D.
Ehsan Afshani, M.D.
Paul'Montgomery, M.D.
Anne D. Ehrlich, MD.
\ Steven L. Christensen, M.D.
Dilip E. Gale, MD.
R05el!JlIle Oliverio, M.D.
. Jan S. NlIidzionek, M.D.
David J. Martin, 'M.D.
... ..gnostic Imaging Associates 0,
Of West em New York, P.c.
1630 Maple Road
WiIliamsville, NY 14221
716-636-1902
Fax:
716-636-1367
James W. Backstrom, M.D.
StevenL. Bezinque, D.O.
Mark J. Pisaneschi, M.D.
Gregory T. Tymchak, M.D.
Bruce P. Hall, M.D.
Richard D. Thomas, M.D.
John J. Januario, M.D.
Charles J. Riggio, M.D.
MRI OF THE LUMBAR SPINE CONT
RE: SORRENTINO, RALPH
The-.STIR images show no evidence of bone edema. There is no fracture or posterior
v ligamentous complex injury is evident. .
IMPRESSION: 1. SMALL FOCAL LEFT OF CENTRALL5-S1 DISC PROTRUSION,
NOT OBVIOUSLY CONTACTING NERVE ROOTS.
2. MILDLY DEGENERATE DISCS AT l2-3 AND L3-4.
Thank you for this referral.
.
,
Sincerely,
~
Richard D. Thomas, M.D.
204842-9 CR
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d-t 7/8/9 ,
Preliminary until signed
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,Physical~rherap~ PC.
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f:'!le initi1\l "~~.lJ.ll~-!.1 tOloh (l:HG)
1)7/\7,'88 .. S",'relltino, fl,
r.ti~,,'. caMel led, ha'-ill! I;hut pains. CCHC)
07/20/88 - Sorr..,ntino. R.
rationl. report.. having "'Jrgery "0011 for hie ,'ight hand. lr\llpectlon not.... 1.4 FRS right,
righl. on l..rt 15!l.Cr\"', Treatment included "tr.tch to thl! hllmetr"inge with eclatlc nerve
Il\obi 1 iZ3,tione, fectus f..mor;", pidforll\ill, mUllcle energy tec"niq"e!l for the above, and
initi.te!:! prone P""""-'Jp"'. CClie)
07/22/98 - Sor~entino, R~
FaUent canc~lll:!d. (CHC)
"
230 BUI'FALO ST.. HAMBURG, NY '~075 716-648-5211
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3671 Sculhw!!6te~n Boul~vard, Suite 110
Orchard rark, NY 14127
INITIAL ,EVALUATION: R.,LT'B SORRENTINO
DOEll
POL:
I 1/05/35
612470152D
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04/191"88
52-2092-063
Dea." Dr. HcAc>-aml
0" 07/11.$..'98, rea.lph 80,......entiI10, was eeen for initial phYllical
the""p,' ";"al~.~tit"" ",n<::\ tr.....tJft!!nt with.. diagnoai.. of pos.ible
atyp,,-al joirlt pain, r.!uel!lUonable ..tenosis, ANDT, left 011 right
h"dcw~lI-d 1.01'" iOI1 , al1d m...."'''''I...r imbalances. Tide 62 yel!u" old lIlale
....pm.l.!'! havi'1g an t1VA 04/18/98, cl....I;lI'ibing his ell'" being totaled
.fl..r 11" \lOa.. hit thr..e timee, He ..tated that he experienced low
,bg,ck and poe...,,"ior thigh pain bilaterall)' after the time, of the
a",eldent, ,"," w!! II e... a "puleed" feel in!! in the pOl!lterior leg
hil"t"r"lly. He et.at!!d he aleo had some neck pain and right upper
.,,,t...."'ity ..~'mptom. ..e well. He did receive ph).sleal therapy at
the tim!! from ILt a diff.rent clinic and elaled that hie neck pain
d",cT",aeed b~,l hie r'ight sho.,lder, arm, and low baclk pain
pe."sist..d. H.. elates the symptoms have gotten p,"o!i\l"eeeively mOl'"
"ell!we. P....u...l\ll)., he d..scribes some pain In the right upper
9)(tremity b._.t pain ie ~l"edaminantly in the lumbo..acral r1!lgion
hi lat.."," 1 Jy into t.he hlpe. The pat IImt ratea lhe intensity
I"a,ngit'g f,-om 0"8/10 ,:m a ecale where 0 ia no pain and 10 115 t.he
w'.)rst pain. He etat"s nothing eaeee the symptoms and tha.t
crol.l,~h i ng ,'Oll I t i on6 aggr'ava t e the eymptome. He finds It d I ff i cI.11 t
to ari~e from a crouohed position euoh as with planting
v..g..l~bl!!B. rHH/PSH: ia remarkable for diabetes. glaucoma.
hepstitie, ch~l..cy..t!!olomy approximately 20 years aio, an~ kidney
el.o""'a SPi""ol<imal.~ly 15 Yl!lars ago, ae W'!l1.l as ... right ha.nd 'problem
for' which he wi 11 "0011 undergo aurger)'. CurrlOnt lIIedioation.
inolude Ine",lin and otb..r dlab..tie medication. and Temoc~ic for
the glaw~~m~. The pati1!lnt doee report havins an x-r...y and HRl of
the I'~w h...ok.
Db j.!!.!<.!J~~Q!l..!!..'!!!.!!!!!n L
('o..tw".l
15ho'-lld~t.,
kyphosis,
PSIS. a,r"ld
....nftlyei'" in ..tllncHng: elevated a.l~d anterior I"isht
mild trunk ehift to the right, in'~r,eaeed lower thoracic
o..ereaeed lLl1t1ba,r lel'dosie, ""'perio!' left i\.iae ere..t IO.nd
f~ot. pronation bilater.lly, left ~reater than right.
"
230 BUFFALO ST" HAMBUFlG. NY 14075 716-648.6211
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Trl.mk ROM: fl..xion f'inge<rUpl! to ankl..e with no complaint...;
.."ten",ion - moderat.. lindt.ation.. eep..."lally In the upp.... lumb",..
eplne; "ide bending mild limitation bllat.e..ally; rotation
moderate to eevere limitation bilat.erally. Hoderat.e limitation i..
noted with hip internal rolation bilaterally,
ra 1 pat. i tIn: There i e t i lilhtn...... in t.h.. ham..t... ing.. with decreaeed
.."I..tio nerve mobilit.), right. greater than left. t.ililhtneSi!< in 1.h..
,-eol...... {!!!mor'!e, l..ft. g!"eater thal1 right, wit.h femo!""I ".WV!!!
tension. and t.ight plrlformi.
Neurological exam: Hy~tomee: O..crea..ed elrengt.h hip flexion 4-/5.
Light t,.uch !!!q'1111 bilat..rally, DTRe - U11abll,to elioit. aohilles
reflex bi lat.erally.
Special Teets: Decreased st*ndin8 balance is noted pati!!!nt
cln~ble to p~u-fC>l"m one-leg;\ed stance witho...t hand SUppOI.t. There
ie a poeitive one-legged ..t.ork te..t bilaterally. In supine. there
is al1 "-lle\fated I'i~ht. iliac creet. ASIS. medial malleol...... and
pubic tubere1e. There are motion restrictions in th.. thoracio and
lvmb...,- lIpine wi~h T10 FRS right with aseocill.ted tenderness in
,right TIO para..pinal". L4 ERS left. and L1 ERS risht,
^........"'Dl~mt,
Thie p.stlent pr"eaenl.e with 1'05 t 1.41' a 1 devlatlone. selective
I imit.at.;en" in t,.....,.,k ROH. I'I",eel.. imbalance" in the trunk and lower
e-"'t'"emiU...., de'~'.eas"d balance, alIa deer"eased accessory mot.ion in
'.he thoraoic lumbal" spine with a pelvic Sirdl.. imbalance, and
advere.. neyrodynamic teneion in the lower extremities.
5TG..:
], Improve m'-'50ul"r balance.
2. Improve t'"'..lnlt ROt!.
3. Impl"ov" aOCeSSOI"Y mot. ion in the t.horac i 0 and I umb"r sp ine
and re-align pelvie Sirdle.
4. Imp,'ov.. post....,""l "lignm!!!nt.
f,;. . Inc'-""5" etandil18 balance.
f\. J nit i ..t e home exf!tI'C i se pr'o,1.I-am and pastura I awaren.eee
trainl".,
L TO...: Opt ima I J,.....,ferme.I1e", of AOLa with ru I I pa i nfr.e fIloh I Ii ty or
the tru~k with good p~etural awarenees, good trunk stabilization,
""d imp'"o'"",o;i otand iflg halanc!!!.
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Treatment. Plan: R~,lrh SOlT..ntino wi II be "".n l. Lw, initially,
T...."'tm.nt will eOI'Biel of modallti.s prn. m~'ofa.."i..1 ,-..I...a...
t,ohniqf.Jee, ml,,IIscl'iit ~r'el'e!)' teeht1iqu.@a, ne\.ct"od)'n.a.rnio rnobi 1 izat.ion,.,
fl..:<ibilitj! ",<err;.....s, I,alane. tl'aininil. trvnk stabilization
i!:t;e,..r:i.~F.7t r;~ndit~ionillg 9:<l.!rci5g, poelure..l a,W8.t"enee" training. and
a home ~xer~iee prog'.am.
D,', tk^de.m, thal\!\ :''':>'..1 fo,' the kind referral of this palien'l,
f'rof""..ionally,
CIl("/lk
'b.,.~~ Carol In" H. Craig. liS, PT
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RALPH SORRENTINO
DECEMBER 9, 1999
INDEPENDENT MEDICAL EXAM
CHIEF COMPLAINT: Back and leg pain.
HISTORY OF PRESENT ILLNESS: Mr. Sorrentino is a 64-year-old gentleman
who was involved in a motor vehicle accident on April 19, 1998. He
denies loss of consciousness. He did go to the emergency room. X-rays
were obtai ned and he was rel eased wi th muscl e rel axants. He has an
intermitte~t dull aching back and lower extremity pain. On the Magill
pain diagram, he colors in his lumbosacral spine at L4 to L5 radiating
down both lo~er extremities in an L5-S1 distribution to just above the
pop 1 i tea 1 f-ossa.~" He rates is 3 out of lOon the vi sua 1 analog scale.
It is aggravated by flexing and extending. He denies bowel or bladder
dysfunction or any paralysis. He rates his sleep pattern as poor due to
the pain.
He has had physical therapy, but
and feels that it did not help.
help slightly.
he did not get along with the therapist
He has had muscle relaxants which did
PAST MEDICAL HISTORY:
glaucoma.
Significant for diabetes, hepatitis, and
PAST SURGICAL
cholecystectomy.
unremarkable.
HISTORY:
He is
Significant
an ASA II.
for
His
hand surgery and
anesthetic history
a
is
SOCIAL HISTORY: He denies tobacco or ethanol use.
CURRENT MEDICATIONS: Include insulin, Cosopt and Relafen.
ALLERGIES: Darvon and hydrocodone.
PREVIOUS TESTS: Tests to evaluate his pain include a lumbosacral MRI
which indicated a focal L5-S1 disk protrusion. He is referred to me for
an Independent Medical Exam.
PHYSICAL EXAMINATION: He has a mildly positive sitting straight leg
raise bilaterally with decreased sensation to pinprick in a bilateral
L5-S1 distribution to the popliteal fossa. He has good range of motion
with moderate spasm and mild diffuse lumbar tenderness. particularly in
the multifudus triangle. Deep tendon reflexes are 1-2/4 and equal
throughout. He was able to heel-to-toe walk and did not have an
antalgic gait.
(continued)
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Page 2 - December 9, 1999
Independent Medical Exam
Regarding Ralph Sorrentino
HEENT: Within normal limits.
NECK: Without JVD,
LUNGS: Clear bilaterally.
HEART: Regular rate and rhythm.
ABDOMEN: Positive bowel sounds.
EXTREMITIES: Without clubbing, cyanosis or edema.
ASSESSMENT: Lumbar radiculopathy.
RECOMMENDATIONS: I would recommend that he also have a trial series of
lumbar epidural steroid injections and to continue physical therapy.
Brian C, James, M.D.
BCJ:kam
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IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY,
PENNSYLVANIA
MARY A. SORRENTINO and
RALPH J. SORRENTINO, her
husband,
CIVIL DIVISION
No. GDOO-000268
Plaintiffs,
Issue No.
vs.
PLAINTIFFS'
TRANSFER CASE
COUNTY
MOTION TO
TO CUMBERLAND
KELLYANN JAMESON,
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Defendant.
Code: 001
Filed on
Plaintiffs
Behalf
of
Counsel of Record for This
Party:
Edward J. Balzarini, Jr.,
Esq.
Pa. I.D. #34320
BALZARINI & WATSON
Firm No. 013
3303 Grant Building
pittsburgh, PA 15219
(412) 471-1200
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PLAINTIFFS' MOTION TO TRANSFER CASE TO CUMBERLAND COUNTY
AND NOW, come the plaintiffs, Mary A. Sorrentino and
Ralph J. Sorrentino, her husband, by their undersigned
attorneys, Edward J. Balzarini, Jr. and Balzarini & Watson,
and move this Honorable Court for an Order transferring the
within action to the Court of Common Pleas of Cumberland
County, and in support thereof aver the following:
1. This is an action for personal injuries arising
from a motor vehicle collision which occurred in the State of
West Virginia.
2. The defendant resides in Cumberland County,
Pennsylvania.
3. Jurisdiction and venue exist in the Court of Common
pleas of Cumberland County, Pennsylvania.
WHEREFORE, the plaintiffs respectfully request this
Honorable Court enter an Order transferring the within action
to the Court of Common Pleas of Cumberland County,
pennsylvania,
BALZARINI tWA~ ,
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BY
Attorneys
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CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the
within PLAINTIFFS' MOTION TO TRANSFER CASE TO CUMBERLAND
COUNTY was served upon counsel for defendant this ~o~ day of
March, 2000, by first class mail, postage prepaid.
BALZARINI &
BY
Attorneys
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IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY,
PENNSYLVANIA
MARY A. SORRENTINO and
RALPH J. SORRENTINO, her
husband,
CIVIL DIVISION
No. GDOO-000268
Plaintiffs,
vs.
KELLYANN JAMESON,
Defendant.
ORDER OF Cm;: /... /
AND NOW, this ~ day of ~
Motion to transfer the within action to the Court of Common
2000,
the
pleas of Cumberland County is granted, and the Prothonotary
is directed to forward the file in the within action to the
Prothonotary of the Court of Common pleas of Cumberland
County.
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IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY,
PENNSYLVANIA
MARY A. SORRENTINO and
RALPH J. SORRENTINO, her
husband,
CIVIL DIVISION D
No. GD ZOO?;- 2- (, if
Plaintiffs,
Issue No.
vs.
COMPLAINT
KELLYANN JAMESON,
Code: 001
Defendant.
Filed on
Plaintiffs
Behalf
of
Counsel of Record for This
Party:
Edward J. Balzarini, Jr.,
Esq.
Pa. :j:~P. #34320
BALZARINI & WATSON
Firm No. 013
3303 Grant Building
pittsburgh, PA 15219
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IN THE COlJRI' OF CCMMJN PLEAS OF ALLEGHENY COUNI'Y, PENNSYLVANIA
MARY A. SORRENTINO and
RALPH J. SORRENTINO, her
husband,
CIVIL DIVISION
NO.
Plaintiffs,
rnMPLAINT
vs.
JURY TRIAL DEMANDED
KELLYANN JAMESON,
Defendant.
,/
Wl'ICE 'ID DEE'EHl"
You have be<>...n sued in court. If you wish to defend against
t..'le claillls set fo:ct..':1 in the following pages, you must take action
within tw-enty (20) days after this ccrnplaint and notice are served,
by entering a writte!1 appearance personally or by attorney and
filing in writing with t..':1e court your defenses or objec-...ions to the
claims set forth against you. You are warned t..'1at if you fail to
do so the case may proceed wit..'lout you and a judgment may be
entered against you by the court without further notice for any
money clai1red in the ccrnplaint or for any other claim or relief
requested by the plaintiff. You may lose rroney or property or
ot..':1er rights important to you.,
. YC:U SBCOID TAKE THIS Pl\PER 'ID YCIJR I.AWYER AT CN:E. IF YUJ
00 ror EAVE A ~ CR CANN:rr 1\FEtlID ONE. GO 'ID CR 'l'.ELEPl'lC:NE THE
OFFICE SEr FORI'H BE:I.CW 'ID FIID cx:rr WEIERE YUJ CAN GEl' HELP,
Li'\WYER ~~ SERVICE
THE ALLEGHENY COUNTY BAR ASSCCIATION
920 cm-coUNI'Y BUILDrn:;
PITI'SBURGH, PENNSYLVANIA 15219
(412) 261-0518
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COMPLAINT
AND NOW, come the plaintiffs, Mary A. Sorrentino and
Ralph J. Sorrentino, her husband, by their undersigned
attorneys, Edward J. Balzarini, Jr. and Balzarini & Watson,
and complain against the defendant, Kellyann Jameson, as
follows:
COUNT I
MARY A. SORRENTINO vs. KELLYANN JAMESON
1. The plaintiffs, Mary A. and Ralph J. Sorrentino,
are individuals, husband and wife, residing at 40 Marlowe
Avenue, Blasdell, New York 14219.
2. The defendant, Kellyann Jameson, is an individual
who at all times relevant hereto resided at 26 Irongate
Court, Mechanicsburg, Cumberland County, Pennsylvania 17055.
3. At all times relevant hereto, the defendant,
Kellyann Jameson, was the owner and the operator of a 1995
Subaru Legacy automobile, which is hereinafter referred to as
the defendant's vehicle.
4. At all times relevant hereto, the wife plaintiff,
Mary A. Sorrentino, was the owner of, and Ralph J. Sorrentino
was the operator of, a 1991 Nissan Sentra automobile, which
is hereinafter referred to as the plaintiff's vehicle.
5. The events hereinafter complained of occurred on or
about April 19, 1998 at approximately 11:45 a.m. on
Interstate 79, near Star City, West Virginia, at
approximately the 156 mile marker.
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6. At the above-mentioned time, date and place, the
husband plaintiff, Ralph J, Sorrentino, was lawfully and
carefully operating the plaintiff's vehicle in a northerly
direction on Interstate 79, when the defendant, Kellyann
Jameson, operating the defendant's vehicle in a northerly
direction on Interstate 79, suddenly brought her vehicle to a
stop in the left-hand lane of 1-79 in an attempt to make a U-
turn into the southbound lanes of 1-79, thereby causing a
multiple vehicle collision, which resulted in the hereinafter
described injuries and damages to the plaintiffs.
7. The collision described above and the resulting
injuries and damages were a direct and proximate result of
the recklessness, negligence and carelessness of the
defendant, Kellyann Jameson, as follows:
a. In attempting to make an illegal U-turn
from the left-hand northbound lane of
1-79;
b. In illegally and improperly bringing her
vehicle to a stop on a limited access
highway;
c. In slowing and/or stopping the defendant's
vehicle in a manner which created an
obstruction to traffic on the involved
limited access highway;
d. In failing to signal and/or to properly
signal the defendant's intended movement
of her vehicle;
e. In violating the minimum speed regulation
for the involved limited access highway;
f. In suddenly and without proper warning
slowing and/or stopping the defendant's
vehicle so as to cause a multiple vehicle
collision;
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g. In operating the defendant's vehicle in
an inappropriate and unsafe speed under
the circumstances.
8. As a direct and proximate result of the negligence,
recklessness and carelessness of the defendant as described
above, the wife plaintiff, Mary A. Sorrentino, sustained the
following injuries, all of which are or may be of a serious
and permanent nature:
a. Injury and damage to the nerves, joints,
intervertebral discs, blood vessels and
surrounding soft tissue of the cervical
spine;
b. Injury and damage to the nerves, joints,
intervertebral discs, blood vessels and
surrounding soft tissue of the lumbosacral
spine;
c. Right shoulder trauma;
d. Trauma of the right clavicle;
e. Head trauma.
9. Solely as the result of the aforesaid injuries, the
wife plaintiff has sustained the following damages:
a. She has suffered and will suffer great pain,
suffering, inconvenience, embarrassment and
mental anguish;
b. She has been and will be required to expend
large sums of money for medical and
surgical attention, hospitalization,
medical supplies, surgical appliances,
medicines and attendant services;
c. She has been and will be deprived of her
earnings;
d. Her earning capacity has been reduced and
permanently impaired;
e. Her general health, strength and vitality
have been impaired;
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f. She has been unable to enjoy the ordinary
pleasures of life.
WHEREFORE, the wife plaintiff, Mary A. Sorrentino,
claims damages of the defendant, Kellyann Jameson, in a sum
in excess of TWENTY FIVE THOUSAND ($25,000.00) DOLLARS.
COUNT II
RALPH J. SORRENTINO. her husband. vs. KELLYANN JAMESON
10. The husband plaintiff, Ralph J. Sorrentino,
incorporates by reference paragraphs 1 through 9, inclusive,
with the same force and effect as though set forth at length
herein.
11. That solely as a direct and proximate result of the
negligence of the defendant, the husband plaintiff has been
damaged as follows:
a. He has been and will be required to
expend large sums of money for surgical
and medical attention, hospitalization,
medical supplies, surgical appliances,
medicines and attendant services in
endeavoring to care for his wife;
b. He has been and will be deprived of
the earnings and services of his wife;
c. He has been and will be deprived of
his wife's aid, comfort, companionship,
assistance and consortium.
WHEREFORE, the husband plaintiff, Ralph J. Sorrentino,
claims damages of the defendant, Kellyann Jameson, in a sum
in excess of TWENTY FIVE THOUSAND ($25,000.00) DOLLARS.
4
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COUNT III
RALPH J. SORRENTINO. her husband, vs. KELLYANN JAMESON
12. The husband plaintiff, Ralph J, Sorrentino, was the
operator of the plaintiff's vehicle at the time of the events
complained of above.
13. The husband plaintiff, Ralph J. Sorrentino,
incorporates all preceding paragraphs of the Complaint with
the same force and effect as though set forth at length
herein.
14. As a direct and proximate result of the negligence,
recklessness and carelessness of the defendant, as set forth
above, the husband plaintiff, Ralph J. Sorrentino, sustained
the following personal injuries, all of which are or may be
of a serious and permanent nature:
a. Injury and damage to the nerves, joints,
intervertebral discs, blood vessels and
surrounding soft tissue of the lumbosacral
spine;
b. Injury and damage to the nerves, joints,
intervertebral discs, blood vessels and
surrounding soft tissue of the cervical
spine;
c. Hip trauma;
d. Shoulder trauma.
15. Solely as the result of the aforesaid injuries, the
husband plaintiff has sustained the following damages:
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a. He has suffered and will suffer great pain,
suffering, inconvenience, embarrassment and
mental anguish;
b. He has been and will be required to expend
large sums of money for medical and
surgical attention, hospitalization,
medical supplies, surgical appliances,
medicines and attendant services;
c. He has been and will be deprived of his
earnings;
d. His earning capacity has been reduced and
permanently impaired;
e. His general health, strength and vitality
have been impaired;
f. He has been unable to enjoy the ordinary
pleasures of life,
WHEREFORE, the husband plaintiff, Ralph J. Sorrentino,
claims damages of the defendant, Kellyann Jameson, in a sum
in excess of TWENTY FIVE THOUSAND ($25,000.00) DOLLARS.
COUNT IV
MARY A, SORRENTINO vs. KELLYANN JAMESON
16. The wife plaintiff,
Mary A.
Sorrentino,
incorporates by reference paragraphs 1 through 15, inclusive,
with the same force and effect as though set forth at length
herein.
17. That solely as a direct and proximate result of the
negligence of the defendant, the wife plaintiff has been
damaged as follows:
a. She has been and will be required to
expend large sums of money for surgical
and medical attention, hospitalization,
medical supplies, surgical appliances,
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medicines and attendant services in
endeavoring to care for her husband;
b. She has been and will be deprived of
the earnings and services of her husband;
c. She has been and will be deprived of
her husband's aid, comfort, companionship,
assistance and consortium.
WHEREFORE,
the plaintiffs claim damages of the
defendant, Kellyann Jameson, in a sum in excess of TWENTY
FIVE THOUSAND ($25,000,00) DOLLARS.
JURY TRIAL DEMANDED.
BALZARINI
7
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AFFIDAVIT
~'m OF PENNSYLVANIA
ss:
CXXlNI'Y OF AlUGHENY
BEFORE ME, the undersigned authority, personally appeared
Mary A. So=entino
who, being first duly
s=rn according to law, deposes and says that the facts set forth
in the foregoing
Complaint
are
.... true and correct to the best of (~er) knowledge, information
and belief,
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Mary A. Sorrentino
SWORN TO AND SUBSCRIBED
Before me this &Y1J... day
of ~y ,l!r<tq.
~.,~,,~,
Notary Public ~. ~JlrJv,'d^- .
, ~<tV; >>t' J4P~
;i:",\\~'iJ;;;.. MARIE B. CULLER
V:t @....~;; MY COMMISSION H CC 698143
,11 ~i,~.~1 EXPIRES: December 21, 2001
.,I -,.:'t O'lf....~~ Bonded Thru Notary PubUc unllelWriterS
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AFFIDAVIT
cc::t-MJNVlEALTH OF PENNSYLVANIA
ss:
CCUNI'Y OF ALLEJ:;!iENY
BEFORE ME, the undersigned aut.'1ority, personally appeared
Ralph J. Sorrentino
who, being first duly
s...orn according to law, de;>oses and says that the facts set for-J1
in t.'1e foregoing Complaint
are
true and correct to the best of (his~ knowledge, inrorrration
and telief.
x
SWJRN TO AND SJESCRIBED
Before me this 3:J '*'-- day
of k,,"//l_u.br ,19 .9...!L.
~~
Notary Public .' ~ "63-fo,....dA- L,' ~ ~
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'''''''.. 1MI\1E B. CU'c'cE~a743
,~*,.r"ii;;c, MY COMMISSIOIU 1
,.: '.Q.1., I!XI'IIIES: Docember, 21,2tll
%;!~o/ BondY lbN NoWY MIlo lJnjeIWlI1BlS
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NonCE OF SUlTTO SHERI F ALLEGHENY C~CtJ 0
Yon are he!~eby notifiebd that(fion reiflste:lieeiJ in this case '
COMPLAINT has een 1 ~ th
a" ' , d to ?~~ on or belore e
amt you ~eqU1fe ~ ~./. l!9 20""
!:/:. day of ' '
M1CHAELF. COYNE, PROTHON~~~
) SHERIFF
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SURCHARGE
MILEAGE
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IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY,
PENNSYLVANIA
MARY A. SORRENTINO and
RALPH J. SORRENTINO, her
husband,
CIVIL DIVISION
......
13
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No. G D L ~ - 2....
Plaintiffs,
Issue No.
vs.
COMPLAINT
KELLYANN JAMESON,
Code: 001
Defendant. .
Filed on
Plaintiffs
Behalf
Counsel of Record for This
Party:
>- Edward J. Balzarini, Jr. ,
N . !--,.,- Esq.
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e;::::> Pa. I.D. #34320
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en C)'"Z Firm No. 013
N :r::l:iJ
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H <I: "'o<"'-tu pittsburgh, PA 15219
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<=> ~:( (412) 471-1200
ATTEST
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PLAINTIFF
MARY A. SORRENTINO and
RALPH J. SORRENTINO, her husband
VS.
KEIJ,YANN JAMESON
ALLEGHENY COUNTY SHERIFF'S DEPARTMENT
436 GRANT STREET
PITTSBURGH, PA 15219,2496
PHONE (412) 350-4700
DENNIS SKOSNIK
Chief Deputy
PETER R. DEFAZIO
At. She'liff
flj{ 2000
CASE# 6f:l ~~0~~'r
EXPIRES ZUI-J i'rrJ
o SUMMONS/PRAECIPE rO--"-
o SEIZURE OR POSSESSION '~ \
XI NOTICE AND COMPLAINT C7";:::~v
o REVIVAL of SCI FA
o INTERROGATORIES 19U
o EXECUTION, LEVY OR GARNISHEE~ lI,
o OTHER "J \
ATTY. Edward J. Balzarini, Jr., Esq.
ADDRESS3303 Grant Building
Pittsburah. PA 15219
DEFT.
ADD. DEFT.
ADD. DEFT.
GARNISHEE
ADDRESS Defendant KELLYANN JAMESON - 26 Irongate Court,
Mechanicsburg, ,Cumberland Countv, PA 17055
MUNICIPALITY or CITY WARD
DATE: January 4
ATTY'S Phone (412) 471-1200
INDICATE TYPE OF SERVICE, ~ PERSONAL 0 PERSON IN CHARGE III DEPUTIZE 0 CERT. MAIL 0 POSTED 0 OTHER 0 LEVY 0 SEIZED & STORE
Now. this 4th da of Jan I, SHERIFF OF ALLEGHENY COUNTY, PA do hereby deputize the Sheriff of
Cumberland County,to execute this Writ and make return thereo1 according to law
NOTE: ONLY APPLICABLE 0 WRIT OF EXE TION: N.B. WAIVER OF WATCHMAN - Any deputy sheriff levying upon or attaching any property under within writ may
leave same without a watchman, in custody of whomever is found in possession, after notifying person or attachment without liability on the part of such deputy herein
for any loss, destruction or removal of any property before sheriff's sale thereof.
Seize, levy, advertiss and sell all the personal property of the defendant on the premises located at:
MAKE
MODEL
MOTOR NUMBER
SERIAL NUMBER
LICENSE NUMBER
I hereby CERTIFY AND RETURN that on the
SHERIFF'S OFFICE SE ONLY
day of , 19 0Y)
o'clock A.M.lP.M. Address Above/Address Below. County of Allegheny, Pennsylvania
at
I have ser~e in the manner described below:
Defendant(s) personally served.
Adult family member with whom said Defendant(s) reside(s). Name & Relationship
o Adult in charge of Defendant's residence who refused to give name or relationship.
o Manager/Clerk of place of lodging in which Defendant(s) reside(s).
o Agent or person in charge of Defendant(s) office or usual place of business.
o Other
o Property Posted
Defendant not found because: 0 Moved 0 Unknown 0 No Answer 0 Vacant 0 Other
o Certified Mail 0 Receipt 0 Envelope Returned 0 Neither receipt or envelope returned: writ expired
o Regular Mail Why
You are hereby notified that on
Possession/Sale has been set for
, 19
, levy was made in the case of
, 19
at
o'clock.
ATTEMPTS
YOU MUST CALL DEPUTY ON THE MORNING OF SALEJPOSSESSION BETWEEN 8.30 . 9.30 A.M,
SO ANSWEF\S
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, This is PI#t.A:"{/VL, f,/ \ ,
Please check before \
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I~TER R. DEFAZIO, Sheriff
, ,: G-
BW'<': .
,.': / __/'Uo-- Deputy
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D'J" ~.. '~R,rF
IstrICtt'i-Mt" !~
Additional Costs Due $
on writ when returned to Prothonotary.
satisfying case.
"'V ~'
White Copy' Sheriff
Yellow, Sheriff
Pink Copy' Attorney
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AL~EGHENYCOUNTY SHERIFF'S' DEPARTMENT
436 GRANT STREET
PITTSBURGH. PA 15219-2496
PHONE (412) 350,4700
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P~TER R. DEFAZIO
....',ShilJin
DENNIS SKOSNIK
Chief Deputy
MARY A. SORRENTINO and
PLAINTIFF RI\LP!I J. SORRENTINO, her husband
VS. CASE# (;, D - 2.e-e::. 0 - z.~ 5t'
DEFT. KELLYANN JAMESON g~0R~~ONS/PRf~1jE 0<.) rU-'~
ADD. DEFT. 0 SEIZURE OR POSSESSION """'l."
ADD. DEFT. IKI NOTICE AND COMPLAINT " C7';::::! 00
GARNISHEE 0 REVIVAL of SCI FA --- Q U - _
~ ' 0 INTERROGATORIES ~~I' 0'-'
ADDRESS llf>fp.nr'JanL KF.T.T.VI\NI'J .T~'iF:SON - 26 Trongate (burt, 0 EXECUTION, LEVY OR GARNISHE~
Mf0.hanicshnrg, C'l,mhPr]and Count.y, PI? 17055 0 OTHER ' J
MUNICIPALITY arCITY WARD' ATTY. F..&vard J.' Balzarini. Jr., EsQ-.
DATE: Januarv 4 f9{ 2000 ADDRESS 3303 Grant'RuHding
ATTY'SPhane' (412)1471-1::106 Pittsbm:'ilh. FA 15219
INDICATE TYPE OF SERVIC~'iPERSONAL'b PERSON IN CHARGE'~ DEPU11ZE DCER.T. MAIL'O PO. ED1D 0 c ER 0 LEVY DSEIZEO & STORE
Now. . s 4th: . ". of Jan .I, SHERiFF'OF ALLEGHENY:9: NY, p,...do hereby deputize the Sheriff of
T . " "-'~Gounty to execute ~hi iw~/a d mak return thereof according to law
NOTE: ONLY APPLlCAaLE-Q' ,\\fRIT OF EXE UTION': N.S. WAIVER O,f'WATCHMAN - Any deputy sheriff levyfu.g'4ponjlr atta ing any property under within writ may
leave same without a~watchman(in cu~tody at whomever is found in possession, after notifying person or attachment ~thout ability on the part of such deputy herein
for any loss, destruction or rel"lfo/al ~f an~'iProperty before sheriff's sale'thereof. !
Seize, levy, advertise and ~I all t~~ pef~-9nal property of the defendant on the' premises located at:
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MAKE
'f
;,;;:;;;:
MODEL
MOJOR NUMBr;;R ,,! ii,
SERIAL NUMBER
LICENSE NUMBER
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I hereby CERTIFY AND RETURN th~t ~n the
rf
,
SHERIFF'S OFFICE. USE ONLY
day of f , 19 'Y":
o'clock A.M.lP.M. Address Above/Address Below. County of Allegheny,-Pennsylvania
at
I have served in the manner described below:
'0 Defendant(s) personally served.
o Adult'family member with whom said Defendant(s) reSide(s)~ Name & Relationship
o Adult,fn charge- of Defe_ndant's residence,who,refus:ed to give Q:ame or relationship.
o Manager/Clerk of place,of lodging in which Defendant{s) reside(s).,__
.',' '. ' . " ,,' '
o Ager\for person in charge of Defendant(s) office or usual place of business.
o Other
o Property Posted
Defend,ant not found because:
q;tertifie~Mail 0 Receipt
o Regular Mail WI1Y
o Neither receipt or envelope returned: writ expired
!
.-
o Moved 0 Unknown ",:0 Not.Answer
'. '
o Envelope Reterned :.. .
o Vacant 0 Other
,.
1'6u are hereby notified that on
Possession/Sale has been set for
, 19
, levy was made in the case of
. 19
at
o'clock.
YOU IIIUSTCALL DEPUTY ON THE MORNII,IG OF,SALE/POSSESSION BETWEEN 8:30.9:30 A.M;
ATTEMpTS,
I I
PETER R. DEFAZIO, Sheriff
Additional Costs Due $ , This is placed
on writ when returned to Prothonotary. Please check before
satisfying case.
By
:\\)uty
i :..
District
1........-- ~
White Qopy - Sheriff
'v
Yellow. Sheriff
Pink Copy - Attorney
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CASE NO:
SHERIFF'S RETURN - REGULA~
2000-00030 0 \.J
".if..
COMMONWEALTH OF PENNSYLVANIA:
. .
COUNTY OF CUMBERLAND
SORRENTINO MARY ET AL
VS
JAMESON KELLYANN
DAVID MCKINNEY
, Sheriff or Deputy Sheriff of
Cumberland County, pensylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE
was served upon
JAMESON KELLYANN
the
DEFENDANT
at 1848:00 HOURS, on the 18th day of January ,2000
at 26 IRONGA~E COURT
MECHANICSBURG, PA 17055
by handing to
KELLYANN JAMESON
at~uejand attested copy of COMPLAINT & NOTICE
together with
and at the same time directing Her attention to the contents thereof.
Sheriff's Costs:
Docketing
Service
Affidavit
Surcharge
So Answers:
18.00
6.82
2.50
.00
.00
27.32
~~~
R. Thomas Kline
me this J 9.#
,
day of
01/19/2000
BALZARINI & WATSON
fr~~
Deputy Sheriff
By:
Sworn and Subscribed to before
T l
PATRICt.NMl ' 10nd County
, Carlisle .6oro, cumb;~~ember 17, 2001
My CommiSSion Expires
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IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA
MARY A. SORRENTINO and
RALPH J. SORRENTINO,
her husband,
Plaintiffs,
vs.
KELLY ANN JAMESON,
Defendant.
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CIVIL DIVISION
No. GD 2000 - 268
Type of Pleading:
PRAECIPE FOR APPEARANCE
Filed on behalf of Defendant
Counsel of record for this party:
SHARON L. BLISS, ESQUIRE
PA I.D. No. 52668
JACOBS & SABA
400 Southpointe Boulevard
Southpointe Plaza I, Suite 420
Canonsburg, PA 15317
(724) 873-2833
JURY TRIAL DEMANDED
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IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA
CIVIL DMSION
MARY A. SORRENTINO and
RALPH J, SORRENTINO,
her husband,
Plaintiffs,
No. 2000 - 268
vs.
KELLY ANN JAMESON,
Defendant.
PRAECIPE FOR APPEARANCE
TO MICHAEL F. COYNE, PROTHONOTARY:
Please enter my appearance on behalf of the Defendant, Kelly Ann Jameson, in the above
captioned matter.
Respectfully submitted,
JACOBS~
BY:b ~
Sharon L. Bliss, Esquire
Attorney for Defendant
,
o
o
CERTIFICATE OF SERVICE
Undersigned counsel hereby certifies that a true and correct copy of the within PRAECIPE
FOR APPEARANCE was served upon all counsel ofrecord on the #- day of February, 2000,
by United States, first-class mail, postage prepaid, to:
Edward J. Balzarini, Jr., Esquire
Balzarini & Watson
3303 Grant Building
Pittsburgh, PA 15219
Respectfully submitted,
JACOBS & SABA
By:
*~?J
~n L. Bliss, Esquire
Attorney for Defendant
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IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY,
PENNSYLVANIA
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MARY A. SORRENTINO and
RALPH J. SORRENTINO, her
husband,
Plaintiffs,
vs.
KELLYANN JAMESON,
Defendant.
c_-</
CIVIL DIVISION
No. GDOO-000268
Issue No.
NOTICE OF SERVICE OF
INTERROGATORIES AND REQUEST
FOR PRODUCTION AND
INSPECTION OF DOCUMENTS
Code: 001
Filed on
Plaintiffs
Behalf
of
Counsel of Record for This
r" Party:
, Edward J. Balzarini, Jr.,
Esq.
Pa. I.D. #34320
BALZARINI & WATSON
Firm No. 013
3303 Grant Building
Pittsburgh, PA 15219
(412) 471-1200
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NOTICE OF SERVICE OF INTERROGATORIES AND
REOUEST FOR PRODT1CTION AND INSPECTION OF DOCUMENTS
TO: MICHAEL COYNE, PROTHONOTARY
This is to advise that an original and two copies of
plaintiffs' Interrogatories 1 to 15 and a copy of plaintiffs'
Request for Production and Inspection of Documents were served
on counsel for defendant by first class mail on February 7,
2000.
BALZARINI & WATSON
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/
for Plaintiffs
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REPORT
CDRDOCT
Allegheny County Prothonotary
Civil Docket Report
CASE 1D GD-00-000268
PAGE 1
RUN DATE 05/08/00
RUN TIME 08:44 AM
CASE NUMBER
CASE CAPTION
FILING DATE
COURT LOCA
TYPE TION
--
CASE
TYPE
J
------------------- ---------------------------------------------------------------
GD-00-000268
*****CASE TRANSFERRED TO CUMBERLAND COUNTY*****
05-JAN-2000 GD
PO
MV
J
~ Party Name
Alias Name
PLTF Sorrentino, Mary A.
PLTF Sorrentino, Ralph J.
DEFT Jameson, Kellyann
DATY Bliss, Sharon L.
PATY Balzarini Jr., Edward J
PLTF Plaintiffs, All
SHRF Sheriff - Allegheny County,
Filinq Date Filinq Party
Docket Entry
05-JAN-2000 Sorrentino Mary A.
Complaint
Returnable 2-4-00
28-JAN-2000 She~iff - Allegheny County
Sheriff Return
Defendant served with Notice of Suit & Complaint
on 01/18/00.
07-FJJB-2000
Jameson Kellyann
Praecipe for
by Sharon L.
Appearance
Bliss.
08-FJJB-2000 Plaintiffs All
Notice of Service
of Interrogatories and Request for Production
and Inspection of Documents upon Sharon Bliss
Esq. on 02/07/00 by first class mail.
14-APR-2000 Plaintiffs All
Order of Court
Dated 04/06/00. Ordered that Motion is granted
and the Prothonotary is directed to forward the
file in the within action to the Prothonotary
of Cumberland County. Strassburger J.
08-MAY-2000 Plaintiffs All
Case Transferred
As per Order of Court dated 04/06/00. Case is
transferred to Cumberland County, Pa.
Strassburger, J.
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYVLANIA
CIVIL ACTION - LAW
MARY A. SORRENTINO and
RALPH J. SORRENTINO,
NO. 2000-03313
Plaintiffs,
vs.
KELLY ANN JAMESON,
Defendant.
JURY TRIAL DEMANDED
PRAF,CTPF. FOR F.NTRV OF APPF,ARANCF,
Please enter my appearance on behalf of Mary A. Sorrentino and Ralph J. Sorrentino, the
Plaintiffs in the above-captioned action.
Respectfully submitted,
/'
By /
iam C. Adrian B
1. D. No. 35510
Kristina A. Bange, Esquire
I. D, No. 77940
Attorneys for Plaintiffs
2125 South George Street
Vork,PA 17403-4830
(717) 846-1600
Date: G (/...- \'1/" J
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYVLANIA
CIVIL ACTION - LAW
MARY A. SORRENTINO and
RALPH J. SORRENTINO,
NO. 2000-03313
Plaintiffs,
vs.
KELLY ANN JAMESON,
Defendant.
JURY TRIAL DEMANDED
CF,RTTFTCATF, OF SFRVTCF
I, William C. Adrian Boyle, Esquire, the undersigned Attorney for the designated
parties in the above-captioned action, do hereby certifY that on (..,).,..) -".. ~~J ,a true
and correct copy of the Praecipe For Entry of Appearance was served by mail, postage
prepaid thereon, upon the following persons at the following addresses:
Sharon L. Bliss, Esquire
JACOBS & SABA
400SouthpointeBoruevard
Southpointe Plaza I, Suite 420
Canonsburg, P A 15317
Attorney for Defendant
Edward J. Balzarini, Jr.
BALZARINI & WATSON
3303 Grant Building
Pittsburgh, PA 15219
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Date: "" V"
By
W . am C. Adrian Bo e,
1. D. No. 35510
Kristina A. Bange, Esq.
1. D. No. 77940
Attorneys for Plaintiff
2125 South Queen Street
York,PA 17403
(717) 846-1600
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LAW OFFICES OF JACOBS & SABA
214 Senate Avenue, Suite 503
Camp Hill, PA 17011
Telephone Number: (717) 731-0988
Attorne s for Defendant, Kell ann Jameson
MARY A. SORRENTINO AND RALPH J.
SORRENTINO, HER HUSBAND,
PLAINTIFFS
IN THE COURT OF COMMON PLEAS
CuMBERLAND COUNTY, PENNSYLVANIA
No. 2000-03313 CIVIL TERM
vs,
KELLYANN JAMESON,
DEFENDANT
CIVIL ACTION - LAw
JURY TRIAL DEMANDED
ENTRY OF ApPEARANCE
TO THE PROTHONOTARY:
Kindly enter my appearance in the above-captioned matter on behalf of the Defendant,
Kellyann Jameson. The Defendant reserves the right to otherwise plead in this matter.
Respectfully submitted,
COBS & SABA
By:
Donald R. Dorer, Esquire
Attorney for Defendant, Kellyann Jameson
Identification No. 39126
Date: June 22. 2000
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OOHB-00052
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LAW OFFICES OF JACOBS & SABA
214 Senate Avenue, Suite 503
Camp HiD, PA 17011
Telephone Number: (717) 731-0988
Attome s for Defendant, Kellann Jameson
MARy A. SORRENTINO AND RALPH J.
SORRENTINO, HER HUSBAND,
PLAINTIFFS
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
No, 2000..03313 CIVIL TERM
VS.
KELLYANN JAMESON,
DEFENDANT
CIVILAcTION-LAW
JURY TRIAL DEMANDED
CERTIFICATE OF SERVICE
Donald R. Dorer, Esquire, hereby certifies that he is the attorney for the Defendant herein,
and that he caused a true and correct copy of the attached Entrv of ADDearnce to be served
by regular first class mail upon:
Edward J. Balzarini, Jr., Esquire
Balzarini & Watson
3303 Grant Building
Pittsburgh, PA 152
Donald R. Dorer, Esquire
Attorney for Defendant
Date: June 22. 2000
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
MARY A. SORRENTINO and
RALPH J. SORRENTINO, her
husband,
CIVIL DIVISION
No. 2000-03313
Plaintiffs,
NOTICE OF SERVICE OF
INTERROGATORIES AND REQUEST
FOR PRODUCTION AND
INSPECTION OF DOCUMENTS
vs.
KELLYANN JAMESON,
Defendant.
Filed on
Plaintiffs
Behalf
of
Counsel of Record for This
Party:
Edward J. Bal zarini, Jr.,
Esq.
Pa. I.D. #34320
BALZARINI & WATSON
Firm No. 013
3303 Grant Building
pittsburgh, PA 15219
(412) 471-1200
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NOTICE OF SERVICE OF INTERROGATORIES AND
REOUEST FOR PRODUCTION AND INSPECTION OF DOCUMENTS
TO: CURT LONG, PROTHONOTARY
This is to advise that an original and two copies of
plaintiffs' Interrogatories 1 to 15 and a copy of plaintiffs'
Request for production and Inspection of Documents for the
accident of April 19, 1998 were served on counsel for defendant
by first class mail on July 6, 2000.
BALZARINI & WATSON
BY
Attorney for Plaintiffs
li'mill.mim~_~iiLii<lll!iII.@liimK::!!M!'illMIJIJ1t1;ol!:l~iM'~l~m~_~~::*lll!llIlYJ.~itl\I' 1 ..........''l~~1 ".~
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OOHB-00052
LAW OFFICES OF JACOBS & SABA
214 Senate Avenue, Suite 503
Camp Hill, PA 17011
Telephone Number: (717) 731-0988
Attorne s for Defendant, Kell ann Jameson
MARY A, SORRENTINO AND RALPH J.
SORRENTINO, HER HUSBAND,
PLAINTIFFS
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
No. 2000-03313 CIvIL TERM
VS.
KELLYANN JAMESON,
DEFENDANT
CIVIL ACTION - LAw
JURY TRIAL DEMANDED
NOTICE
YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set
forth in the following pages, you must take action within twenty (20) days after this Answer of
Defendant, Kellyann Jameson, to Plaintiff's Complaint with New Matter and New Matter
Pursuant to Pa.R.C.P. 2252(d) and Notice are served by entering a written appearance
personally or by attorney and filing in writing with the court your defenses or objections to the
claims set forth against you. You are warned that if you fail to do so, the case may proceed
without you, and a judgment may be entered against you by the court without further notice
for any money claimed in the Answer of Defendant, Kellyann Jameson, to Plaintiff's
Complaint with New Matter and New Matter Pursuant to Pa,R.C.P, 2252(d) or for any other
claim or relief requested by the Plaintiff. You may lose money or property or other rights
important to you.
YOU SHOULD TAKE TIllS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
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OOHB-00052
LAW OFFICES OF JACOBS & SABA
214 Senate Avenue, Suite 503
Camp Hill, PA 17011
Telephone Number: (717) 731-0988
Attorne s for Defendant, Kell ann Jameson
MARy A. SORRENTINO AND RALPH J.
SORRENTINO, HER HUSBAND,
PLAINTIFFS
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
No. 2000-03313 CIVIL TERM
VS.
KELLYANN JAMESON,
DEFENDANT
CIVIL ACTION - LAw
JURY TRIAL DEMANDED
ANSWER OF DEFENDANT, KELLYANN JAMESON,
TO PLAINTIFFS' COMPLAINT WITH NEW MATTER AND NEW MATTER
PURSUANT TO P A. R.C.P. 2252(D)
1. Admitted.
2. Admitted.
3. Admitted.
4, Admitted.
5. Admitted.
6.- 17. Denied. These paragraphs are generally denied pursuant to Pa.R.C.P.
~1029(e).
WHEREFORE, the Defendant respectfully prays this Honorable Court to dismiss
Plaintiffs' Complaint, and to enter judgment against the Plaintiffs and in favor of the
Defendant.
.'~, --'"","",,',
NEW MATTER
18. Paragraphs 1 through 17 are incorporated herein by reference, and made a part
hereof as if set forth in full.
19. Plaintiff's claims are barred in whole or in part by the provisions of the
Pennsylvania No-Fault Motor Vehicle Insurance Act and/or the Pennsylvania Motor Vehicle
Financial Responsibility Law.
WHEREFORE, the Defendant respectfully prays this Honorable Court to dismiss
Plaintiffs' Complaint, and to enter judgment against the Plaintiffs and in favor of the
Defendant.
NEW MATTER PURSUANT TO P A.R.C.P. 2252(n) OF DEFENDANT,
KELL YANN JAMESON AGAINST PLAINTIFFS
20. Paragraphs 1 through 19 are incorporated herein by reference, and made a part
hereof as if set forth in full.
21. The motor vehicle accident as described in Plaintiffs' Complaint was a direct and
proximate result of the negligence, carelessness and recklessness of Plaintiff and Additional
Defendant, Ralph J. Sorrentino, which consisted of the following:
A. Driving a motor vehicle in careless disregard for the safety of persons or
property;
B. Failing to have his vehicle under proper control so as to prevent the same from
colliding with other vehicles;
C. Failing to keep aware and maintain a proper lookout for the presence of other
motor vehicles lawfully on the road;
D. Failing to operate said vehicle with due regard for the highway and traffic
conditions that were existing on which he was or should have been aware;
E. Driving a motor vehicle at an excessive rate of speed; ,
22. The Defendant, Kellyann Jameson joins Plaintiff, Ralph J. Sorrentino as an
Additional Defendant herein pursuant to Pa.R.C.P. 2252(d) solely to protect the Answering
Defendant's right of contribution and/or indemnity and avers that Plaintiff and Additional
Defendant, Ralph J. Sorrentino is solely liable, jointly and/or severally liable or liable over to
Plaintiff or any other party to this action to whom Defendant, Kellyann Jameson may be found
liable.
~
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.'
WHEREFORE, the Defendant respectfully prays this Honorable Court to dismiss
Plaintiffs' Complaint, and to enter judgment against the Plaintiffs and in favor of the
Defendant.
Respectfully submitted,
. Dorer, Esquire
Attorney for Defendant
Identification No. 39126
Date: July 6. 2000
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OOHB-00052
LAW OFFICES OF JACOBS & SABA
214 Senate Avenue, Suite 503
Camp Hill, PA 17011
Telephone Number: (717) 731-0988
Attorne s for Defendant, KeIl ann Jameson
MARY A. SORRENTINO AND RALPH J,
SORRENTINO, HER HUSBAND,
PLAINTIFFS
IN THE COURT OF COMMON PLEAS
CuMBERLAND COUNTY, PENNSYLVANIA
No. 2000-03313 CIVIL TERM
VS.
KELLYANN JAMESON,
DEFENDANT
CIVIL ACTION - LAw
JURY TRIAL DEMANDED
VERIFICATION
I, Kellyann Jameson, verify that the statements made in the foregoing Answer of
Defendant. Kellyann Jameson. to Plaintiffs' Complaint with New Matter and New Matter
Pursuant !to Pa.R.C.P. 2252(d) , which are within the personal knowledge of the undersigned,
are true and correct, and as to the facts based on the information of others, the undersigned,
after diligent inquiry, believe them to be true. And further, this Verification is signed on the
recommendation of my attorneys, who advise me that the allegations and language in this
document are required legally to raise issues for resolution at trial, by the Court, or by
continuing investigation and preparation for trial. I understand that some of these allegations
may prove inappropriate after investigation and trial preparation are complete and I leave the
determination of these matters to my attorneys on their advice.
I understand that all statements herein are made subject to the penalties of 18
Fa.C.S.A. ~4904, relating to unsworn falsifications to authorities.
Dated: 1..&/ ()U,1rf)
I I.
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OOHB-00052
LAW OFFICES OF JACOBS & SABA
214 Senate Avenue, Suite 503
Camp Bin, PA 17011
Telephone Number: (717) 731-0988
Attorne s for Defendant, Kell ann Jameson
MARy A, SORRENTINO AND RALPH J.
SORRENTINO, HER HUSBAND,
PLAINTIFFS
IN THE COURT OF COMMON PLEAS
CuMBERLAND COUNTY, PENNSYLVANIA
No. 2000-03313 CML TERM
vs.
KELL YANN JAMESON,
DEFENDANT
CML ACTION - LAw
JURY TRIAL DEMANDED
CERTIFICATE OF SERVICE
Donald R. Dorer, Esquire, hereby certifies that he is the attorney for the Defendant herein,
and thathe caused a true and correct copy of the attached Answer of Defendant. Kellvann
Jameson. to Plaintiffs' Comolaint with New Matter and New Matter Pursuant to PaRe.P.
2252( d) to be served by regular first class mail upon:
Edward J. Balzarini, Jr., Esquire
Balzarini & Watson
3303 Grant Building
Pittsburgh, PA 15219
Date: Julv 6. 2000
onald R. Dorer, Esquire
Attorney for Defendant
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
MARY A. SORRENTINO and
RALPH J. SORRENTINO, her
husband,
CIVIL DIVISION
No. 2000-03313
plaintiffs,
PLAINTIFFS' REPLY TO NEW
MATTER
vs.
KELLYANN JAMESON,
Filed on
Plaintiffs
Behalf
of
Defendant.
Counsel of Record for This
Party:
Edward J. Balzarini, Jr.,
Esq.
Pa. I.D. #34320
BALZARINI & WATSON
Firm No. 013
3303 Grant Building
Pittsburgh, PA 15219
(412) 471-1200
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PLAINTIFFS' REPLY TO NEW MATTER
AND NOW, come the plaintiffs, Mary A. Sorrentino and
Ralph J. Sorrentino, her husband, by their undersigned
attorneys, Edward J. Balzarini, Jr. and Balzarini & Watson,
and reply to the New Matter of the defendant, Kellyann
Jameson, as follows:
1. The averments of Paragraph 18 of the defendant's
New Matter constitute an incorporation by reference of
denials to the Complaint, Plaintiffs aver that no response
is required to these denials under the applicable Rules of
civil Procedure.
2. The averments of Paragraph 19 of the defendant's
New Matter are denied.
It is specifically denied that the
plaintiffs' claims are barred in whole or in part by any
provision of the Pennsylvania No-Fault Motor Vehicle
Insurance Act and/or the Pennsylvania Motor Vehicle Financial
Responsibility Law.
WHEREFORE, the plaintiffs claim damages of the
defendant, Kellyann Jameson, in a sum in excess of TWENTY
FIVE THOUSAND ($25,000.00) DOLLARS.
BY
Attorney
"
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AFFIDAVIT
aM1JNWEALTll OF PENNSYLVANIA
ss:
o::xJNI'Y OF AI..LEl::;HENy
BEFORE ME, the undersigned authority, personally appeared
Edward J. Balzarini, Jr., Esq.
who, being first duly
S'nCInl according to law, deFQses and says that the facts set forth
in the foregoing
Plaintiffs' Reply to New Matter
are
..., true and correct to the best of (l1is~ kncwled e,
and belief.
...
StDRN TO AND SUB~FD
Before me this /1 day
Of~ ,f~
N~1!i ~
.
Notarial Seal
Usa M. Domer, Notary Public
, ,Pittsbu'llh, Allegheny County
My Commission Expires Sept. 12,2002
Member, Pennsylvania Association of Notaries
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CER'l'IFICA'l'E OF SERVICE
I hereby certify that a true and correct copy of the
within PLAINTIFFS' REPLY TO NEW MATTER was served by~rst
class mail, postage prepaid, upon the following this ~day
of July, 2000:
Donald R. Dorer, Esq.
214 Senate Avenue
Suite 503
Camp Hill, PA 17011
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ROLF E. KROLL, ESQillRE
Pa. Supreme Court I.D, No. 47243
MARGOLIS EDELSTEIN
Post Office Box 932
Harrisburg, Peunsylvania 17108-0932
Telephone:
Fax:
E-mail:
[7171 975-8114
[7171 975-8124
rkroll@mar!!olisedelstein.com
Attorney for:
ADDITIONAL DEFENDANT
MARY A. SORRENTINO and
RALPH J. SORRENTINO, her husband,
Plaintiffs
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
CNIL ACTION - LAW
v.
KELLYANN JAMESON,
NO. 2000-03313 CNlL TERM
Defendant
v.
RALPH J. SORRENTINO,
Additional Defendant
JURY TRIAL DEMANDED
PRAECIPE
TO THE PROTHONOTARY:
Kindly enter the undersigned's appearance on behalf of Additional Defendant, Ralph J.
Sorrentino.
Respectfully submitted,
By:
, Esquire
Attorne .D. #47243
Post Office Box 932
Harrisburg, PAIn 08-0932
(717) 975-8114
Attorney for Additional Defendant
,'--
.
CERTIFICATE OF SERVICE
I, Jessica Bates, an authorized representative of Margolis Edelstein, hereby certifY that I have
served a true and correct copy of the foregoing document upon all counsel and parties of record this
15 ~ day of September, 2000, by placing the same in the United States First Class Mail, postage
prepaid, at Camp Hill, Peunsylvania, addressed as follows:
Edward J. Balzarini, Jr., Esquire
Balzarini & Watson
3303 Grant Building
Pittsburgh, PA 15219
Donald R. Dorer, Esquire
Law Offices of Jacobs & Saba
214 Senate Avenue, Suite 503
Camp Hill, P A 17011
By: _~ R;cdW
ljsslca Bates
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ROLF E, KROLL, ESQIDRE
Pa. Supreme Court I.D. No, 47243
MARGOLIS EDELSTEIN
Post Office Box 932
Harrisburg, Pennsylvania 17108-0932
Telephone:
Fax:
E-mail:
[717] 975-8114
[717] 975-8124
rkroll(a)mareolisedelstein.com
Attorney for:
ADDITIONAL DEFENDANT
MARY A. SORRENTINO and
RALPH J. SORRENTINO, her husband,
Plaintiffs
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
CNIL ACTION - LAW
v.
KELLYANN JAMESON,
NO. 2000-03313 CNIL TERM
Defendant
v.
RALPH J. SORRENTINO,
Additional Defendant
JURY TRIAL DEMANDED
REPLY OF ADDITIONAL DEFENDANT RALPH J. SORRENTINO
TO DEFENDANT KELLYANN JAMESON'S NEW MATTER
AND NOW comes Ralph J. Sorrentino by and through his counsel, Margolis Edelstein, to answer
the New Matter of Defendant Kellyann Jameson pursuant to Pa.R. C.P. 2252( d) as follows:
20. Paragraphs 1-19 of the Sorrentino Complaint are incorporated herein by reference as ifset
forth in full.
2la-e. Denied. These allegations of Defendant Jameson's New Matter are denied as conclusions
oflaw and are further denied pursuant to Pa.R.C.P. 1029.
22. Denied. This allegation of Defendant Jameson's New Matter constitutes a conclusion of
law and accordingly, no pleading thereto is required.
>---
-, ,
- -.-.'.-' - ~,c.,iM'::1
WHEREFORE, Additional Defendant Ralph 1. Sorrentino demands judgment in
his favor and against Defendant J arneson with costs of suit assessed to Defendant J arneson.
Respectfully submitted,
S EDELSTEIN
By:
Ro fE. Kr , Esqu re
Attorney LD. #47243
Post Office Box 932
Harrisburg, PA 17108-0932
(717) 975-8114
Attorney for Additional Defendant
"-.
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VERIFICATION
-"
I, Ralph J. Sorrentino, have read the foregoing Answer to Defendant Jameson's New
Matter which has been drafted by my counsel. The factual statements contained therein are
known by me and are true and correct to the best of my knowledge, information and belief.
This statement and verification is made subject to the penalties of 18 Pa. C.S.A. Section
4904, relating to unsworn falsifications to authorities, which provides that, if! knowingly make
false averments, I may be subject to criminal penalties.
Date: / fJ- d - cJ cJ
,
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CERTIFICATE OF SERVICE
I, Jessica Bates, an authorized representative of Margolis Edelstein, hereby certify that I have
served a true and correct copy of the foregoing document upon all counsel and parties of record this
~ day of October, 2000, by placing the same in the United States First Class Mail, postage
prepaid, at Camp Hill, Pennsylvania, addressed as follows:
Edward J. Balzarini, Jr., Esquire
Balzarini & Watson
3303 Grant Building
Pittsburgh, PA 15219
Donald R. Dorer, Esquire
Law Offices ofJacobs & Saba
214 Senate Avenue, Suite 503
Camp Hill, PA 17011
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RALPH J. SORRENTINO, her husband,
Plaintiffs
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
v.
KELLYANN JAMESON,
NO. 2000-03313 CIVIL TERM
Defendant
v.
RALPH J. SORRENTINO,
Additional Defendant
JURY TRIAL DEMANDED
PRAECIPE TO WITHDRAW APPEARANCE
TO THE PROTHONOTARY:
Please withdraw the appearance of RolfE. Kroll on behalf of Defendant.
STEIN
By:
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RolfE. Kroll, Esquire
AttomeyLD. #47243
Post Office Box 932
Harrisburg, PA 17108-0932
(717) 975-8114
PRAECIPE TO ENTER APPEARANCE
TO THE PROTHONOTARY:
Please enter the appearance of Bridget Alford on behalf of Defendant. Sorrentino.
Boswell, Tintner, Picolla & Wickersham
By: ~2. &f-
Bri~lfor ,Esquite
315 North Front Street
Harrisburg, PA 17101
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MARY A. SORRENTINO, and
RALPH J. SORRENTINO, her
hnsband,
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
PLAINTIFF
v.
: NO. 2000-CIVIL-03313
KELLY ANN JAMESON,
DEFENDANT
: CIVIL ACTION - LAW
v.
RALPH J. SORRENTINO,
ADDITIONAL DEFENDANT
: JURY TRIAL DEMANDED
CERTIFICATE OF SERVICE
I do hereby certify that I have served on this date a true and correct copy of the foregoing
Praecipe to Withdraw Appearance and Praecipe to Enter Appearance on the following by first-
class mail, postage prepaid and addressed as follows:
Edward J. Balzarini, Jr., Esquire
Balzarini & Watson
3303 Grant Building
Pittsburgh, PA 15219
Attorneys for Plaintiffs
Donald R. Dorer, Esquire
Jacobs & Saba
214 Senate Ave, Suite 503
Camp Hill, PA 17011
Attorneys for Defendant Jameson
Brigid
Date: August 16,2001
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CERTIFICATE
PREREQUISITE TO SERVICE OF A SUBPOENA
PURSUANT TO RULE 4009,22
IN THE MATTER OF:
COURT OF COMMON PLEAS
MARY A, & RALPH J.SORRENTINO,HER HUSBAND
TERM,
-VS-
CASE NO: 2000-03313 CIVIL
KELLYANN JAMESON-VS-RALPH J,SORRENTION
As a prerequisite to service of a subpoena for documents and things pursuant
to Rule 4009.22
MCS on behalf of
DONALD R. DORER, ESQ,
certifies that
(1) A notice of intent to serve the subpoena with a copy of the subpoena
attached thereto was mailed or delivered to each party at least
twenty days prior to the date on which the subpoena is sought to be
served,
(2) A copy of the notice of intent, including the proposed subpoena, is
attached to this certificate,
(3) No objection to the subpoena has been received, and
(4) The subpoena which will be served is identical to the subpoena which
is attached to the notice of intent to serve the subpoena.
Jj~~.J)~}~.
MCS on behalf of
DATE: 05/06/2002
DONALD R, DORER, ESQ.
Attorney for DEFENDANT
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
IN THE MATTER OF:
COURT OF COMMON PLEAS
MARY A. & RALPH J.SORRENTINO,HER HUSBAND
TERM,
-VS-
CASE NO: 2000-03313 CIVIL
KELLYANN JAMESON-VS-RALPH J.SORRENTIoN
NOTICE OF INTENT TO SERVE A SUBPOENA TO PRODUCE DOCUMENTS AND
THINGS FOR DISCOVERY PURSUANT TO RULE 4009.21
STATE FARM INSURANCE COMPANY
INSURANCE
TO: EDWARD BALZARINI, JR., ESQ.
BRIDGET Q. ALFORD, ESQUIRE
MCS on behalf of DONALD R. DORER, ESQ, intends to serve a subpoena
identical to the one that is attached to this notice, You have twenty (20)
days from the date listed below in which to file of record and serve upon the
undersigned an objection to the subpoena, If the twenty day notice period is
waived 0][ if no objection is made, then the subpoena may be served, Complete
copies of any reproduced records may be ordered at your expense by completing
the attached counsel card and returning same to MCS or by contacting our local
MCS office,
DATE: 04/15/2002
MCS on behalf of
DONALD R, DORER, ESQ,
Attorney for DEFENDANT
CC: DONALD R, DORER, ESQ.
SUE HAVERSTICK
- 00HB-00052
- 5837C7092894/19
Any questions regarding this matter, contact
THE MCS GROUP IRe,
1601 HARKET STREET
#800
PHILADELPHIA, PA 19103
(215) 246-0900
DE02-184260 906BO-C02
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
MARY A. SORRENTINO & RALPH J.SORRENTINO,
HER HUSBAND
VS
File No. 2000-03313 CIVIL
KELLYANN JAMERSON
VS
RALPH J.SORRENTINO
SUBPOENA TO PRODUCE DOCUMENTS OR THINGS
FOR DISCOVERY PURSUANT TO RULE 4009.22
TO: CUSTODIAN OF RECORDS FOR: STATE FARM INSURANCE COMPANIES
(Name of Person or Entity)
Within twenty (20) days after service of this su~oeni!.-Y!!u arLordered by the court to produce the following documents or
things: Sl'E A1TACHED
at
MCS GROUP INC., 1601 MARKET ST., #800, PHILA.,PA 19103
(Address)
You may deliver or mail legible copies of the documents or produce things requested by this subpoena, together with the
certificate of compliance, to the party making this request at the address listed above. You have the right to seek, in
advance, the reasonable cost of preparing the copies or producing the things sought.
If you fail to produce the documents or things required by this subpoena, within twenty (20) days after its service, the party
serving this subpoena may seek a court order compelling you to comply with it,
THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON:
NAME: nONAT,n II nOllER, ESO.
ADDRESS: 214 SENATE AVE., STE 503
, CAMP HIn, PA 17011
TELEPHONE: 215-246-0900
SUPREME COURT ID #:
A TIORNEY FOR: DEFENDANT
DATE: {Jr-.tLl(, .s .J.06~
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Seal of the Court
(Eff, 7/97)
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EXPIANATION OF REQUIRED RECORDS
TO: CUSTODIAN OF RECORDS FOR:
STATE FARM INSURANCE COMPANY
3091 WILLIAMS STREET
CHEEKTOWAGA, NY 14227
RE: 90680
MARY ANN SORRENTINO
CLAIM NUMBER: 52-2092-0631 FIRST PARTY FILE
POLICY NUMBER: 6124 701 C15 520
DATE OF LOSS: 4/19/98
INSURED: RALPH SORRENTINO
Any and all claims files.
Dates Requested: up to and including the present.
Subject: MARY ANN SORRENTINO
411I MARLOWE AVENUE, BLASDELL, NY
Social Security #: 056-30-7230
Date of Birfth: 05-02-1937
Date of Loss: 04/19/1998
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PRAECIPE FOR LISTING CASE FOR TRIAL
(Must be typewritten and submitted in duplicate)
TO THE PROTHOIDrARY OF CUMBERLAND COUNTY
Please list the following case:
(Check one)
(XX) for JURY trial at the next term of civil court.
for trial without a jury.
-----------------------------------------
CAPTION OF CASE
(entire caption must be stated in full)
MARY A.i SORRENTINO and RALPH J.
SORRENTINID, ,ther'2husband
(check one)
(~~ ) Civil Action - Law
Appeal from Arbitration
(other)
(Plaintiff)
vs,
KELLYANN JAMESON
The trial list will be called on
and October 7, 2003
Trials conmence on November 3, 2003
( Defendant)
pretrials will be held on Oct. 15, 2003
(Briefs are due 5 days before pretrials. )
vs.
RALPH J. SORRENTINO
(The party listing this cal>e for trial shall
provide forthwith a copy of the praecipe to
all counsel, pursuant to local Rule 214.1.)
No, 03313 Civil Term
~2000
Indicate the attorney WhO will try case for the party who files this praecipe:
Edward J. Balzarini, Jr., Esq. - MARY A. SORRENTINO and RAIlPH J. SORRENTINO, Pltfs.
Indicate trial counsel for other parties if known:
Donald R. Dorer, Esq. - KELLYANN JAMESON, Deft:;"
Brigid Q. Alford, Esq. - RALPH J. SORRENTINO, AddU. Deft.
This case is ready for trial.
Si_, ~fJ:/'
Print Narre: Edwar J. ~lzarini,
Jr.
Date: July 22, 2003
Attorney for:
Plaintiffs
.
.
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the
within PRAECIPE FOR LISTING CASE FOR TRIAL was served by
regular mail upon the following counsel this ~lday of
-% ,2003:
' Donald R. Dorer, Esquire
Jacobs & Saba
214 Sena,te Avenue
Suite5()3
Camp Hill, PA 17011
Brigid Q, Alford, Esquire
Boswell, Tintner, picolla
& Wickersham
315 North Front Street
Harrisburg, PA 17101
BALZARINI & WATSON
BY
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IN THE CODRT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
MARY A. SORRENTINO and RALPH
J. SORRENTINO, her husband,
Plaintiffs,
vs,
KELLYANN JAMESON,
Defendant,
vs.
RALPH J. SORRENTINO,
Additional Defendant.
CIVIL ACTION - LAW
No. 2000-03313 civil Term
NOTICE OF TELEPHONIC
DEPOSITION OF LAWRENCE
II.. FIDi"L\:, H.D.
Filed on
Plaintiffs
behalf
of
Counsel of Record for this
Party:
Edward J. Balzarini, Jr.,
Esquire
PA I.D. #34320
Balzarini & Watson
Firm No. 013
3303 Grant Building
Pittsburgh, PA 15219
(412) 471-1200
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NOTICE OF TELEPHONIC DEPOSITION
TO: Donald R. Dorer, Esq. and Brigid Q. Alford, Esq.:
PLEASE TAKE NOTICE THAT the telephonic deposition upon
oral examination will be taken of LAWRENCE H. FINK, M.D. at
the offices of Balzarini & Watson, 3303 Grant Building,
Pittsburgh, Pennsylvania, 15219, on Thursday, October 16,
2003 at 2:00 p.m. at which time and place you are invited to
attend and participate.
The scope of said deposition will include inquiry into
all facts concerning the within action and all other matters
relevant to the issues raised in this case for the purposes
of discovery and/or use at trial.
BY
Attorney for Plaintiff
BALZARINI
NOTICE OF SERVICE
A true and correct copy of the within Notice was sent by
regular mail to the attorney for the defendant on September
16, 2003.
BALZARINI
BY
Attorney
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
MARY A, SORRENTINO and RALPH
J. SORRENTINO, her husband,
CIVIL ACTION - LAW
No, 2000-03313 civil Term
Plaintiffs,
vs.
NOTICE OF VIDEOTAPE
DEPOSITION OF ANDREW
C. MATTELIANO, M.D.
KELLYA}rn JAMESON,
Defendant,
Filed on
Plaintiffs
behalf
of
vs.
Counsel of Record for this
Party:
RALPH J. SORRENTINO,
Additional Defendant.
Edward J. Balzarini, Jr.,
Esquire
PA LD. #34320
Balzarini & Watson
Firm No. 013
3303 Grant Building
Pittsburgh, PA 15219
(412) 471-1200
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NOTICE OF VIDEOTAPE DEPOSITION
TO: TO ALL COUNSEL OF RECORD:
PLEASE TAKE NOTICE THAT the videotape deposition upon
oral examination will be taken of ANDREW C. MATTELIANO, M.D.,
at the doctor's offices located at 235 North Street, Buffalo,
New York, 14201, on Tuesday, October 28, 2003 at 5:00 p.m.,
at which time and place you are invited to attend and
participate.
The scope of said deposition will include inquiry into
all facts concerning the within action and all other matters
relevant to the issues raised in this case, for the purposes
of discovery and/or use at trial.
HALZAR,", 200
BY
Attorneys for Plaintiffs
NOTICE OF SERVICE
A true and correct copy of the within Notice was sent by
telefax to the attorneys for the defendant on October 1,
2003.
BALZARI~W TSON
BY
Attorneys for Plaintiffs
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BALZARINI & WATSON
EDWARD J. BALZARINI, JR., ESQUIRE
3303 GRANT BUILDING
310 GRANT STREET
PITTSBURGH, PA 15219
TELEPHONE NUMBER: (717) 731-0988
(ATTORNEY FOR PLAINTIFFS)
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYL VANIA
Mary A. Sorrentino and Ralph J. Sorrentino, Her
Husband,
Case No.: 2000-03313 Civil Term
Plaintiffs
vs.
Kellyann Jameson,
Defendant
JURY TRIAL DEMANDED
vs.
Ralph J. Sorrentino, Additional Defendant
PRAECIPE TO SETTLE, DISCONTINUE AND END
TO THE PROTHONOTARY:
Please mark the above-captioned case settled, discontinued and ended.
Date:
11/')/"
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BALZARINI & WATSON
By: f#(~-li
Edward J. B' ar , Jf., EsqUIre
3303 Grant Building
310 Grant Street
Pittsburgh, PA 15219
Court I.D. ~,.~ 2.0
(Attorney for Plaintiffs)
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LAW OFFICES OF JACOBS & ASSOCIATES
214 SENATE AVENUE, SUITE 503
CAMP HILL, P A 17011
TELEPHONE NUMBER: (717) 731-0988
ATTORNEY FOR DEFENDANT
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYL V ANlA
Mary A. Sorrentino and Ralph J. Sorrentino, Her Case No.: 2000-03313 Civil Term
Husband,
Plaintiffs
vs.
Y TRIAL DEMANDED
Kellyann Jameson,
Defendant
vs.
Ralph J. Sorrentino, Additional Defendant
CERTIFICATE OF SERVICE
Donald R. Dorer, Esquire, hereby certifies that he is the attorney for the Defendant
herein, and that he caused a true and correct copy of the attached Praecipe to Settle, Discontinue
& End to be served by regular first class mail upon:
Edward 1. Balzariui, Jr., Esquire
Balzarini & Watson
3303 Grant Building
Pittsburgh, PA 15219
Attorney for Plaintiffs
Date: November 18, 2003
Brigid Q. Alford, Esquire
Boswell, Tintner, Piccola & Wickersham
315 North Front Street, P.O. Box 741
Harrisburg, P A 17108-0741
Attorn." ro, Addltim-r;
Donald R. Dorer, Esquire
Attorney for Defendant
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