HomeMy WebLinkAbout00-03376
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LYNN AND WILLIAM STOWMAN,
Parents and Natural Guardians of
MITCHELL STOWMAN,
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
Petitioners
v.
No. dO - 2271:.
Ciu~l7-~
WAL MART,
Respondents
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AND NOW, this ~ day Of~, 2000, upon consideration of the
foregoing Petition, it is hereby ordered that:
1. The parties may compromise the action upon the terms of the proposed
compromise set forth in the attached Petition.
2. Lynn and William Stowman, parents and guardians of Mitchell Stowman, are
authorized to settle the aforementioned action on behalf of the minor child and are
authorized to pay counsel fees and costs in the amount said minor child is entitled to
receive in this action as follows:
(a) $750.00 to Stephen G. Held, Esquire for counsel fees;
(b) $ 107.65 to Handler, Henning & Rosenberg as costs;
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(c) Direct payment of $2,142.35, in accordance with the Compromise above-
stated; and
(d) Proof of Deposit to be submitted to the Court.
BY THE COURT:
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LYNN AND WILLIAM STOW MAN,
Parents and Natural Guardians of
MITCHELL STOWMAN,
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
Petitioners
v.
No. 01J _ 331& ~ I-t-v<-
WAL MART,
Respondents
PETITION FOR LEAVE TO COMPROMISE
MINOR'S ACTION
Pursuant to Pennsylvania Rule of Civil Procedure No. 2039, the Parents and Natural
Guardians of minor. Mitchell Stowman, petition This Honorable Court to enter an Order
permitting the settlement and compromise of this action and in support thereof, avers the
following:
1. The Petitioners, Lynn and William Stowman, are the Parents and Guardians
of minor child, Mitchell Stowman, who was born on January 19,1993.
2, Respondent, Wal Mart, is the Defendant and a claim is being made under
the bodily injury coverage.
3. Petitioners reside with their minor child, Mitchell Stowman, at 38 Palmer
Drive, Camp Hill, Cumberland County, Pennsylvania.
.
5. Mitchell was six years old at the time, He was seen at Holy Spirit Hospital
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4. Said minorchildwas injured in an accident on July 7,1999, whereby the child
was impaled by a pronged fork which fell from a display when at the Defendant store,
which caused scarring on his leg.
and was treated for the laceration. His medical expenses were $352.75 and have been
paid in full by Petitioners health care plan. Records from Holy Spirit Hospital are attached
hereto as Exhibit "A" and incorporated herein.
6. An offer has been made to settle the aforementioned claim in the amount of
$3,000, which your Petitioners believes is fair and adequate,
7. Stephen G. Held, Esquire of HANDLER, HENNING & ROSENBERG,
pursuant to the Contingent Fee Agreement and as attorney for said minor, requests
reimbursement for expenses of $107,65, marked as Exhibit "B". Also, despite what is
noted on the Contingent Fee Agreement, which is attached hereto as Exhibit "C", we will
be taking a 25 percent attorney's fee in the amount of $750.00.
9. Petitioner further requests this Honorable Court to order the remaining
balance of $2, 142.35 recovered on behalf of said minor to be placed in a Federally insured
savings account in Petitioners' name, that is marked "Not to be withdrawn unless by Order
of Court or until Mitchell Stowman has reached the age of 18."
1 O. Petitioners believe that this Compromise is in the best interests of the minor,
Mitchell Stowman,
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WHEREFORE, Petitioners request that This Honorable Court enter an Order
approving the settlement and compromise, allowing counsel fees and ordering distribution
as set forth in the attached order of Court.
Respectfully submitted,
Date:~O
HANDLER, HENNING
& ROSENBERG
By ~.. ~,kt"i"
1.0. No. 72663
319 Market Street
P.O. Box 1177
Harrisburg, PA 17108-1177
Attorney for Petitioners
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HSH ER FORM REG DATE: 12/02/99
NAME: STOWMAN ,MITCHELL S
ADDRESS' :a8 PALMER DR
BIRTHDATE: 01/1~/1993
EMPLOYER:
ADDRESS:
CHURCH.
COMMENT:
UNITED METHODIST
18:47
PT#:
14:318190 MR#: 416435
SS #: 402-45-7102
/CAMf' HILL /PA/17011 PHil<: 717-7(,1-5171
4 SEX: M MS: S RACE: 1 OEO: 041045
OCCUPATION. CHILD
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AMI:!: NONE
AGE'
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PH*.
__ EMERGENCY
STDWMAN ,LYNN
38 PALMER DR
GUARANTOR INFORMATIoN
PT REL TO GUAR' 0 SS It. 161-40-7131
/eAMP HILL /PA/17011 PH #: 717-761-5171
CONTACT NAME'
/ / /
INSURANCE INFORMATION
COB POLICY It GROUP It
REL PC VFY CARD PRECERT/AUTH It PRECERT PHONE It
1 YWL16160713 1 022422010
o Y Y
ELMERTON AVE HARRISBURG
NAME:
ADDRESS:
NAME'
ADDRESS:
STOWMAN ,WILLIAM
38 PALMER DR
ADMn DR. 180018
ATTND DR' 180018
REFER DR'
ADMIT OX,
COMPLAINT: LLQ ABD
AMB BRT IN BY:
COMMENT'
EO GRO~
ED OR01P
PAIN
DATE/TIME.
DESCR I PTt ON.
NAME.
ADDRESS'
EMPLOYER:
ADDRESS:
STOWMAN ,WILLIAM
38 PALMER DR
MESSIAH COLLEGE
PLAN
INSURANCE CO
SUBSCRIBER
1 B14 HEALTH ONE
STOWMAN ,WILLIAM
INSUR.ADDRESS. 2500
2
INSUR.ADDRESS.
'3
INSUR.ADDRESS.
4
INSUR.ADDRESS:
COMMENTS' DR LONG FMD
CONTACT INFORMATION
REL TO PT: M WORK PH #'
/CAMF' HILL /PA/17011 PH ti: 717-761-5171
REL TO PT: F WOR~ PH #'
/CAMP HILL /PA/17011 PH #: 717-761-5171
CASe: INFORMATION
M REG SOURCE. EO PATtENl' TYPE: E
\J HOSP SERVo ERl FINANCIAL CLS: B
VISIT CLINIC CODE: ERl
ICO-9 DX:
BRT IN BY' FATHER
ACCIDENT INFORMATION
ACe: IND. .JOB RELATED:
LOCATION'
PH *,
PA
17177
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PATIENT NAME: S,OWMAN ,MITCHELL S PT#' 1~~~431S190 MR#. 416~
REGISTERED BY: FHMIB EDITE::D BV: 77 DATE: II '1'f1 END OF DOCUME 1)
EXHIBIT 2. FRnM ~rm~ FRRFn~F 1
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CONSENT TO MEDICAL TREATMENT
I HEREBY CONSENT AND AUTHORIZE, Holy Sprr~ Hospital, Its agants, and employees, to the rendenng of medlcal cere, whIch may Include
routine dIagnostIc pl'OCedures end such medlcellrea1ment as my allendonll 01 consultm{/ phYSICian consldere 10 be necessary I also under-
stand 1\ I. clIIlt<lmaf'l, absent emergency or Qll\racnllnal"j wcuma\al'lCeS, that no subslanllal procedures Will be pertormell upon me unless or
unbl I have had an opportunl\y 10 diSCUSS them Wrth a phYSICian or other healfl1 care professional to my sallefactlon If I am a competernt adult, I
have lhe rlghlto coneent or refuse to conaent I undenlland Ihat the p,actoce of medlane and surgery IS not an exact science and thai dlllgno.
SlS and trealmenl may Involve nsks of InjUry or even death and acknowledge thai no guarantee has been made to me as 10 Ihe /&Suits of any
exarmnebon or trealmenl m ltus Hospital
I undenlland many of the physlClll/1S OtIthe slaft of Holy Sptn! HospIlaJ are not employees or B!l8nlll of the Hosprtal, but rather are Independent
conlractors who haw been granted the prIVIlege of using these faalilles for the care and lreatmel1t of their pallents Further, I realIZe ttus
Hospllalls a leachtng Hospital aJd at ,the Hospital are health Cara personnel In tralmng who, unless expressly requested othll1Wlse, may parlJclpale
or may be present dunng my care as part of their educatIOn 51111 or mollon plc\ures and closed ClrcU~ momlonng of pallen! care also be
used for educabonaJ purposes, unless I expressly request otherwise
I understand thai In order 10 ensure a safe enVllonmenl for pallents, VISItOrs and staff all properly on the premises of Holy Italls
subJBClto reasonable Silarch and/or seizure al any time w~hout further notice 'mllals
RELEASE OF MEDICAL INFORMATION
I aulhonze Holy Sprrlt Hospital to release 10 requeslmg health msurance camerCs), therr representatIVes and audllors, end any relemng health
care prOVIders, such dIagnostIc and therapeulJc Informallon (IncludIng any Informabon relabng 10 treatment for alcohol and subslence abuse
Rndior I_Imem of DSVChlalnc disorders. end/or ""nnilentlal HIV relBled Inform'l~on. es, may be necessary for them to determlnebenebt enti-
tlement, 10 process payment claIms for heallh care. serviceS proVIded durong thIS hosprtallzabonllrealment episode, and for contmumg
carell,ealmenl A photocopy or carbon copy of thiS aulhonzabon shall be considered as effacbve and valid as the OrigInal The undetslgned
also authorizes Medlcara, when applICable, to release to another Insurance cartier, upon Ihalt request, medlcallnformallon nee to make
payment upon thai. cllllm
I understand and consent thaI the manulac:turer of any Implantable device Inserted by my physlCl8n dl/nng Ihe course of my
may be provided woth my Idenllflcallon mformallOll, Including sacllll security number, as mandaled by fedaral laW Inlba/S
INSURANCE ASSIGNMENT OF BENEFITS
I authonze payment dIrectly to Holy Splnl Hospltal and my treating phySiCIans of all benellls payable under my Insurance pol.CIBS I understand
I am responSible to the Hospllallor all charges not covered by thiS assignment
Inllllll$
STATEMENTTO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDERS, PHYSICIANS AND PATIENT
I request paymenl of Authorozecl Medocare benehts to me or on my behalf for any servICes fumlshed me by or In Holy Splnt Hospllallncludlng
phySICian saMCBS I aulhonze any holder of medICal and olher Informallon aboul me, to release to Medicare and lis agencIes any Information
needed 10 deterrrune Ihese bene',ls for relaled services
MEDICAL ASSISTANCE RECIPIENT Imllals
My signatures certlf1es thai I receoved a servIce or Items lIOrn Holy Splt~ Hospital and Or on the date listed below
I understand Ihat payment for thiS seMce or Ilem Will be from Federal and Slate funds, and thel any false claims, stalements, or documents, or
concealmenl of malerlal may be prosecuted under applicable Federal and Slale Laws
I have read and agree With the above statements
I have I'8IId end unde
provldlnglhe authOl'lzatlo '
tv to ask questions
Signature
ReIalIon8hlp 10 Patient
r the aeetlona contained above. I unclar8t8nC! that by "lining this dOcument, I am BlIrealnll end
talnad In _h of the above aeclIon8 wh.,.. my rnllllila a1'8located. I have haclltl8 opporlunl-
h '...aactlon.anclaU such q=:~ my 88lIafactlon
11me I ~ ~r () DIlle 1'0/0/9 f
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HOLY SPIRIT HOSPITAL, CAMP HILL, PA
CONSENT FOR TREATMENT/ R&AASE OF INFORMATION
INSURANCEASSlGNMENT
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Time 10 Exam Room
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P I ury oc:curnd' I ] Homo ] Induolly [ J Rocreatlon [ J Oll1or
Information obtained from _Pallenl _FamllyJS 0 _R.cord. _EMTIPar.medlc
_..11y EvllI....lon Trla;edlo nldlOIogy lor
o.formfty Yes I No Skin ntmp Warm I CcIo1 DI~ Pu.... Preaent I Absent
SIl;;ln Color Pink I Cyanotlc I Monied Pain (1.10) pareBth..la Presen11 AbMnt
Inlel\l8ntJon
DM1Inotlon [J ECU I J eDF
Tim.
Sl Iura
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Temp '. ,-pul.
AII8rglesIReaCl,,{ns. La
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Y1eual Acuity
Weigh! __lsIes1Imat8 (It plll1lnenl)
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SubJective:
ObJective:
PreI1oopl181 Tre.bnenl
Med" 10 '
Last Dos,liMtdlcatlolllDGeelF, uen
Last Dose
Past MeclicaUSurglcBI History'
Has patient had exposure to measles. chickenpox or TB In past month? Are there advance dtrectN88? Is copy available?
_NUASINt;li t:MMliNOsaa: I!!~~D QI.JT'edIllIi."1
Ca , aneratIOn In ...=...:=imp,~utput ltemons1l'l\'ied by lTTlpttM3d Y 8 and- diagnostic teatS
omfort, alteration In ~ase or 18llaf of liSCClmfort
FlUltI volume, 8ltenmon In _'.ovemem m tlultl \101 demonstrated by decruse In aymptoma of IIuld vol unbalance
ImpallVd gas excha"9" _ lmproyed gas exchange demonstrated by lfflPRIVSd OOt)'gfiInatlOll and villi SignS
PotentlaVActuaJ nr\&clIon _ Decrease aymP1O!'n8 mdlOBbng Infectlon or pgtenttal tot mfectlOn
Knowledge DehClt lmp, OwI,9dge ,demons1rated by w!ball:QbOn I rebJrn d,monsInlbon
ABBessmenl complBled at
Data obtained by.
AdrmsslOn Called I 1 AdrmsslOn [ J Oboerva',on
Report Called ~ AdmItted 10 at
OlSposrtlon ..< Home t J. ~MA I ] of>. at
Discharged 1'7."l. 19-':J lliblScharge Instl'UCllOns
by
[ laid Recorda Sent
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M'SabsfactofYl1I p dl
DIscharge R.N.
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by
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Holy Spirit Hospital
Camp Hill, PA
ECU Nursing Assessment
tit 1
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ADM. DATE: 12/02/1999
CHIEF COMPLAINT: Abdominal pain
HISTORY OF PRESENT ILLNESS: 6 -year-old white male here WIth his father The patient
began having left lower quadrant abdominal pain after school today It doubled hIm over HIs
father noted him to be In a fetal position when he came home from work at about 1800 hours
There has beel]; no nausea or vomiting He did noleat dinner tonight He was well dunng
school today There has been no fever HIS bowel movements were normal and regular
although he did not have one today, but he did have one yesterday There has been no urinary
symptol11s No history of prevIous or Similar problems
PAST ""EDICAL HISTORY: Essentially unremarkable No surgical hIStory He has had a cold
recently and he was taking some cold medrcallons but he had none of those today
The patient states that the pam IS all gone now as I am Initially seelOg hIm
PHYSICAL EXAMINATION:
VITAL SIGNS: See nurse's notes
GENERAL: Alert No acute dIStress
HEAD: Normocephahc Atreumallc
EYES: Con/unellva Without discharge or In/eellon Lids Without leSions PERRL
ENT: Ears Tympanrc membranes Without perforation, InJeellon, or bulging
Mouth LipS, teeth, and gums normal
Throat Oropharynx Without leSIons or exudate AJrway patent
Nose Nasal mucosa normal
Sinuses No sinus tenderness
NECK: Supple, symmetncal, non-tender, no lymphadenopathy Trachea midline ThyrOid non-
palpable
BACK: No vertebral spine tenderness No c v a tenderness
LUNGS: Normal resplratory effort Breath sounds equal No rales, rhonchi, or wheezes
CARDIAC: Regular rate and rhythm Without murmurs, ectopy, rubs, or gallops No pedal
edema
GJ/ABDOMEN: Increased bowel sounds are heard The abdomen IS very soft There IS
subjective tendemess diffusely on the left side There IS no guarding whatsoever There IS no
rebound tenderness No mass or organomegaly
HOLY SPIRIT HOSPITAL
Camp HIli, PA
17011
EMERGENCV ROOM REPORT
Page 1 of 2
NAME Stowman, Mltchelt S
MR# 416435
ROOM ER1
DR RICHARD F LULEY, MD
ORIGINAL
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MR#:
Stowman. Mitchell S
416435
GENITALIA: Normal male 80th testicles descended No hernia
SKIN: Nonnal color and turgor No rashes or lesIons
EXTREMITIES: Symmelncal Full range of mobon Equal tone and strength No JOint
tenderness or effusIon No clubbing or cyanosIs
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ASSESSMENT: Abdominal pain now resolved r reassured father I diSCUSsed sIgns of
appendlcills that would prompt a return VISIt such as increasing constant pain partIcularly If on
the nght~lIde and especially With vomiting Recheck pm
RICHARD F LULEY, MD
RLlts
DOC # 11832
D 12/02/1999
T 12/08/1999 1 41 P
003466
HOLY SPIRIT HOSPITAL
Camp HIli, PA
17011
EMERGENCY ROOM REPORT
Page 2 of 2
NAME Stowman, Mitchell S
MR# 416435
ROOM ER1
DR RICHARD F LULEY, MD
ORIGINAL
Initial Lab .. x~ Orders:
LttbIJ/ LII'IM'R.:d.....
[ J A""am,ncphen [ I ESR I Tox Screen
[ JA'cohol [ JGllJOOSEl [ J Unne TQX Screen
I I ''''Y''SeIllp... [ I HCGS [ J Thrombolyllc labs
I JAPTT l 1 liver I 1 Type &. Cross _# 01 Units
[ J Blood Cultures ProfIle I I Type & Screen
I IBMP I Lyles [ J UlA
[ ICSCP I PTP , [ )lJnneC&S
[ ) CMP ISa~I.l'! " r J WOMan s Camp Drug Screen
[ JCRPl I )S.rumAce1one I I Other -
[ I OJ9OXln [ 1 Th<l""hylm.
[ J OtlantlO [ J Thyro<l Profile
""'o/OflY. ~
[ l'bdIOlle~ 5..... I lKUa
I JAnkIe R L I ] US Spine
( ]C""clo R L I )flIIandtble
{ IC&<VSllII\&l.olllral I INIl80l
[ ] Cerv $c:Nne Routine I ]OrbIC R L
( Jen... Rln I Po" I_ I )""'11I8
[ ]abow R L [ ] Pyelog..m IVP
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I I Femur R L [ JShoulder R L
[ lFlnger R l I I stwII
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[ ] For'88rm R l ( IT/SpIne
[ IHend R L [ ITlb I Fib R l
[ ] Hip R l I ) Too R L
[ ] Humerua: R L [ ]Wnsl II L
I JKMO R L
I lOther T1rnAlCRTllnt
Spec,,,, ProcedUIN:
Ultruound
]Abdamen
I Duplex Doppler
) Gsllblsdder
Jf'eI"'"
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[ I Bo1II StropAG/Cu,,"",
( lCerY""
[ JClltomyG'.
[ IGCC'-'lure
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VlSUo! Acuity
Dlagn",,~c.
EKG .. , ,
Labs ~
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Sen. to RadIolOgy
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Date Time Amount SOIUdan Call1eter SIte Rate COntrol Candldan Atlemuts Initial.
IMlal Slgnalure
IMlal Signature
I",~al SJgnatUre
IMI," Slgnalur
COndition Code.' Rate
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Holy Spirit Hospital
Camp Hili, PA
Emergency Patient Documentation
l"f '11 ~l qJ 1111 41U35
srOWIIIH .IIITCHtLL S
38 I'Il.1IEll DI
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40Z-45-710t
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EMERGENCY CENTER VIGI CENTER
(717) 763-2316 - (717) 763-2424
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DISCHARGE INS'tRucnONS
-
HOLY SPIRIT HOSPITAL
The exSJrnnltioD l\tId lreallnCDl: )'au have rec:erved UJ !he I!mazxa>>q Comer nave bee!ll'llIJdtncI on an MlQpDl:y Gds only m:I lI!e no~ mrnded to be .. .lublblUle tcxr 01" an effort to pmYJd~
compJc~ medical care H yw devdop pew problems or ~ comaLt your pbYIl\:W'o or the ~ ~ 1'OI..J.OW 1lfE lNST.RVcnONS CHSCXED BELOW
P- Inform_ PIlIon! Infonnatlan._ CC1ntolt\ '"'I>ON".! In~ to _1Illd"';"
( ) Abdominal pam () ConJUnctlVllls . (4FIveffpe8 Fever ( ) LaC.l1IIbon
( ) AIc:ohoI ",..non () COPO () Flu () Nee' straIn
( ) ^"ergll:l reaction ( ) Comeal atlra$ronlforelgn body ( ) Fracture ( ) Noubleed
( I Asthma ( ) Cn>uplb""oIuto6 ( ) Headach. ( ) OlIn. Medra
( ) Back pain ( ) Crutch walklng ( ) Head InjUry ( ) Pedtatl'lO Head l"IlJry
( ) Bltlila-Humarv'AnllTl8Vlnsect ( ) Olarrhea and VOmltrngIPed Vomrtlng ( ) HypertenstQn < ) Pedl8lllc VRI
( ) Bum ( ) DlUg/AICOhol abU8eladdlcbo' ( ) lmmu'lZa~on/Teta'U' I ) PIOIVD
I ) Chest Pa,. ( ) Fabnlo Conyulol", ( ) Kidney Ston.. ( ) Rasn
WOUND CAFlE MEDICATIONS
( ) May g.ntIy waoh cwo, wound.. 24 hou18 w~h soap and water 0' ( ) Conllnu. pre..nt -.. """"PI
peroxide 00 not soak R'1 wBter
( ) Change dtestlimg _ times dally Redress WIth Bacrtnll;l/n/NeospOM
ana stenia dl'8Sllng
I ) Keep wound <:I~. dry, co_ () T.tan...IO<p1I1a.... _ gIVen
SPRAINS, STRAINS, BRUISES. FRACTURES
( ) Ekwate the InJUred part for_days 10 reduce swellIng
( ) Apply ICe !'Soks 'nterm_y for _"eyo to redll"" swelhng
( ) Ac. wrapfo, .upport for _ daye
I ) Wearspllnl () At wi limes untrllollow.up
( ) For acb\llly as needsa
I ) uoe allng for support
( ) Uso crulCheo () As noeda<f. w.,ght baonng ao tol..mOd
( ) '" all bmoo NO WEIGHT BEARING
NECK/BACK
( ) Wear C8lVlcaJ collar for support for _ days
( ) Rost. aYOtd bendOlg. Irftrng. .lranuous aClJ~ty fo, _ days
( ) Apply mo~t heat for minutes limes dally
beglnnmg 1(1 haUl'S
ADIltTlONAI. INSTRUCTIONS
( ) 011 _school from
( )l.IghtOulyU,bl
Aestnctsona
( ) No gym'o"".. unbl
( ) Fallow Instructlans on Workmen's Compensation Fonn
( ) Wear eye patch. for hours
( ) tf nose bleed recurs, pInCh nose fllmly for 5 mmutes
cont\rnIo~, retum rf bleedll'\g nol: <X)Otr'Olled
( ) The prest:nbed antlblO\lc may reduce the enectJveoess ~
medlctltlon you are currently taklng CheQk paCkage
msuucUons or consult WIth PharmaClBl
{ } The Interpre1atlon of you, X-Rays are prelmmary I1J8d\1'1g
Your films will be reViewed by a raddoglSl You or your
physlcran WIn be contacted If ttwre IS a change In 'he
diagnOSIs
to
AddrtJonal Instructions
I )G,.i-r
( ,
J
Ll \l,-t.-.,
161' 1.f1{)
, 6
()Selzure
( ) Sore Throat
( ) SPfBlns and Strains
( }Threalened MlSt8mage
() Toothacho
()URIanr.lCoklo
( ) un on. Pyek>..""nt~
() OIhor
( ) uoa AdYli (lbuprof.n) or Tylenol.. __ for plllll. laver
according to pack8ge matructtona fer .. wetght
( ) Usa1ha follOWIng madlCl_ _"'9 "" peekage
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1
2
3
( ) Th. following modocmas may _... drowans..
DO NOT DRIVE OR OPERA71; MACHINERY WHILE TAKING
FOLLOW-UP Thl. lS our recommendation for toDow--up "your
InsUrance (HMO) requIres. a physICIan referral for spec;aaity
consultatocn, IT IS YOUR RESPONSIBILITY TO OBTAIN 7HE
NECESSAIlY APPROVAL
( IFoIIow""P_
In
( ) UIgl C.,,",
( ) Famdy Iloctof
(}-
days far ( ) FoIID'rMlp
( ) SuIure I1IIJl<>'IaI
( ) Call as soon as pOSSlbld tor appantment
( ) Pick up your X,Flays from iIIo RadiOlogy Depa/llTHln1 prior to
your follow-up apPOlntm.nt Call 7ll3-26lI8 to he... _
ready
( ) See your ph)'IICtar1 or spGCfBUet " not ImproYGd In
days
MRstum 10 Emeroe/1CY Center If you teet your
e!pecl8lly If j -ze"2L<<...~ ...'
( ) Your blood pr8B8UI'& was elevated PI: have It V(" ~ ~
...- by your physlCl8l\ L
( I Teet results h...IIe.n gNan to you T.... them _ you to (f
llla 1oI1ow-up appotnlmOllt
Taot _Ita gIVon DC8C DCMP DEKG DX-flAV COPY
~ DllM'" DRECOROS COPY CHART DGLUC
~n~TVmm~UN~R~ANDlNO
ereby acknowtedge recetpt of lt188B rnatn.lcbons and
u_.them I undelStand that I ha.. hod omargency
traatmani !l!lIx and Ihat I may ",I...od balD'" 011 of my
medICal prd3fems IV8 or I Will arrange for
follow-up care Bt Em I cted It 18 your respon.
..btllly to 0IC\8tl of thlO YlOll
SIGNATURE
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SIGNATURE
F'h)'OlC1Il/1
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t'L-ll.
HOLY SPIRIT HOSPITAL EMERGENCY CENTER
S03 NORTH 21ST STREET CAMP HILL, PA 17011.2:188 (717) 763-2316 MD 031265-1'
( ) _ H)'Illck. DO OS 004400-L ( ) RanJ_ 5bamla.
( ) Vamlha AbnhAm, M D 03884m. ( ) RJdJanl LuI M D 029960-6 ( ) Do.,d Spumer, M D 023502-6
( ) Thomas Aldou.. M D OI7075E "l'. ( ) AIslI Tq>h. M D 03001.,1l
{ ) _=lfano. MO 025S02E ( ) ~~bp ~,;,:g ~;~'::.LB ( ) Illame Thldi_. M D OS7303-L
( ) - .. MD OI6727E () wn:oc. au, M 0 0036U.l! nDovul Zuot1k=taP. MD _'fI
( ) Oleo Daugh 0 0S006776E ( ) Fran!< Pt<ocoPl". _
~:: Dub.., DO 006991L ( ) IIow.,Ud RudA" ~
R "-
-. -- ---
, ,"'.......o.u>I"-"tlUIa111d. OCJQatef gNBT'I
, J\.JBflI'lJ'lel<<lOWlf'\gm8OlQ\Mts~gtop8Q'f.B.iO
IOstructtOnll
1
2
a
( ) The following medICInes may cause drowSIness
DO NOr DRive OR OPERATE MACHINERY WHilE TAKING
SI'R"INS. &1RAINS, BRUISES, FRACTURES
( ) Elevate the Inlured part ror _ days to reduce 8WlJf1lng
( ) Apply Ice pacb IJ'1temtlftently for _da)'$ 10 redUCl8 sweJ~ng
l ) I\C$ wrap for suppOl1lor _ days
( ) W..r ""hnt (l "" ell 1..... \lIl1lIloIlow-llp
( ) For ectIvlly as needed
( ) Use s1'ng for "",port
( ) Use CflJld'kts {} As needelCi. weight beanngi .. IOJerated
( ) I>J ell..... NO WEIGHT BEARING
NECK/B"CK
( ) W9ar cel'VIcsl collar for support for _days
( ) Rest, ayOld bending, bftJng, BtrSnuDUS actIVity for _dap
( ) "pplY lIlOIst heel for m,n"''' bme. d8JIy
beglmmg In hours
ADDI11OW\L IN5TRUCl1ONS
( ) Off _school Irom to
( ) Loght Duly unbl
Aestnctlons
(lMG~unIl\
( ) Follow mtruchons on Wotkmen's ComPensabOI"l Fonn
( ) Weor .ye p_ for hours
( ) tf nose bleed recurs, Pinch nose fmnty for 5 mmutes
ool11muousfy. rebJm If blEledmg nor conrrolled
( ) Th4 PftIscnbecj anllbJotJc may reduce the e1fectlYenesa of
medlCatlDO )'Ol.I ere CUfflllntty talong Check pack~
In&U\tC\Ions 0'1' Ctmsult "'"'" PharmaQS\
( ) ThEllnl6rpretabon of your X-Rays ere pl'8l1mlnaty reading
Your ftfms Wftf be retmWed by a radIOlOgISt You or yoUf
phy81clan will be .contacl:EId " there 1& a change In the
diagnOSIS
FOLLOW-liP thiS rs our recomrnenOB1!cn for follow-up If your
msurance '(HMO) requ... a phy8\C1en "".rrollor epooIaIIy
consultJlt1on.1T IS YOUR RESPONSIBILITY TO OafAlN THE
NECeSSARY APPROVAl
( lFollow-up...th
In
( )Urg,Cenler
( ) Fam,ly Doctor
( lWort(Ne1
days for
!.)G..i,.
I
)
,,'
t
c:...l ~1._
1),1.--1.1 d I
( lFoIIOW-up
I ) Suture removal
( ) c.u as socn .. poIl81b1e lor .__
( ) P1CII Ill> your X-Rays rrom ttl8 R8d101cgy Dspertmenl poor to
your follow-up appt)lnlmen! Call 163-2696 to have fll'n!
ready
( ) S.. your physIC'''n or speCi8l1Sl . nollllll"',.oo 'n
days
~Rstum to Emergency c.nter you 'eel your ~.
EJSPeclallylf 1 1C 1 .'\".
( JYOIlrbloodprosoureweselevlll9d he">8rt 1I",,~
""hecked by your phy8tclan L
( ) Test Iesuhs have been gIVen to you Take them wrlh you to lJ
IhO follow-up opPOI_
T..t leaults 91VOn 0 cae 0 CMP 0 eKG 0 X,RA Y COPY
~ OBMF' 0 RECORDS COpy CHART DClLUC ,
PATIENT VERBALIZES UNDeRSTANDING
oby ocknowledg. 'llOOIpt of these _ons and
understand them I undelOtend thet I have had 8mergency
treatm.nt llDJl( end Chot I may reI.ased before ell 01 my
medlC&\ pl'Otltema are 1m or I w~1 arrange for
k111ow-up care 88 B n U1 oted filS your respon--
Slbilrty to nD4fY ur Pn ran of thIS VIsit
Addfnonallnstructlons
SfGHA11IRE
111 ))
\ ~ J. 71
SIONA11IRE
PhyslCIS11
, . ( {
M DO Nurse RN
HOLY SPIRIT HOSPITAL EMERGENCY CENTER
S03 NORTH 21ST STREET CAMP HILL, PA 17011-2288 (717) 763-2316
( ) Vamtba Abraham. M D 038840L ( ) Raben Hymck. DO OS 004400-L
( ) Tho""" Aldous. M D 01707SE ( ) R"bord LuI.y, M D O299til).E
( l SoIv Alflll1O. M 0 025Sll2E ( ) P1ullq> Maguire. M 0 OIS063-E
( l Ram..h M P 0161278 ( l La....... Paul, M D 03!1S24-L
( ) Glen Daugb 0 OSOO6716E { } Prank ProcOPIO, M D 003643-B
(lJonPubln.DO 00699IL (lHowordRudmcl<.MD 040862,
PATE
8<
()RSIlJ....SbIU1ll~MD 03J2fi5.E
( ) D.!tvld Spumer. M D 023S02-E
( ) Alon TophI, M 0 0300 {8.E
( ) Blame Thallner. M 0 OS1303-L
) DaVId Zunmennan. M 0 lJ05636..E
SIGNA lURE
REFILL
TIMES
[J LABEL
a SUBS'ITI'U11OK PERMlSSlBLE
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"'"
1.:)1 ~lqJ HR 4\bUS
~'O"'\" ,KITCHELL S
\'?ll~E1D~
( . "p J II
lIJI)/I'l9)
02-4,-7102
~ 1 0"\\1\ 1 . W I
J tl02/H
E
PRESCRInER. MUS'l' HAND WRITE . SRAND
MROICALL Y NECESSARY IN mE: SP BLOW
--
ERI
fA 1701/
701-5171
EO O~OI)P
Rl4 Y"ll&lb07Ill
178(5199)
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HAND~ER, HENNING & ROSENBERG
-May 24, 2000
Bi L Led through OS/24/00
Bitt number
204208-00000'003 SGH
MITCHELL STOWMAN
38 PALMER DRIVE
CAMP HILL, PA 17011
DISBURSEMENTS
01/04/00
04/24/00
OS/24/00
OS/24/00
OS/24/00
OS/24/00
OS/24/00
OS/24/00
BILLING SUMMARY
Correspondence Management
Photography Costs
Proth of Cumberland County
Document Reproduction
Document Reproduction
Mileage
Postage Costs
Postage Costs
32,99
15,00
45,50
2,20
3.00
4,23
3,96
,77
Total disbursements for this matter
$
107.65
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.
* billing timekeeper Stephen G.
* date of last bill
* date of last reminder
* last bill through date
* bill type code 5-4
* action to be
* O=hoLd entire bilL
* 1=a/r reminder
* 2=bill exps, hoLd fees
Held
taken
3=summary fees and exp
4=bill tees and exp
5=summary fees/detail e
.
. current .00
. 30 days .00
. 60 days ,00
. 90 days .00
. 120 days ,00
.
* billing frequency A-12
* last payment
* bilting realization
.
.
o %
.
.
* matter 00000
.
.
. 5057 01/04/00 32.99
. PHOT 04/24/00 15,00
. 1CUM OS/24/00 45,50
. COpy surrmary 2,20
. ISI summary 3.00
. MILE summary 4.23
. POS summary 3,96
. POST sUDlJ1ary .77
.
.
. 107.65
.
.
.
.
. 1 CUM 45,50
. 5057 32,99
. COpy 2.20
. ISI 3,00
. MILE 4.23
. PHOT 15.00
. pas 3,96
. POST .77
.
Total Disbursements $ 107.65 . 107,65
------------ .
TOTAL CHARGES FO~ THIS BILL $ 107.65 . 107,65
EXHIBIT
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ALl-sTATELE&ALSUPPL'l'CO. _
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CONTINGENT FEE AGREEMENT
KNOW ALL MEN BY THESE PRESENTS, that we, William Stowman and Lynn
Stowmam, iJ;1dividually and on behalf of Mitchell Stowman, a minor, do hereby retain
HANDLER,'HENNING & ROSENBERG, of Harrisburg, Pennsylvania, as my attorneys to
negotiate for an adjustment or to institute for my son, in our name, any legal proceedings or actions
tbat in thei~ judgment are necessary, in connection with my claim against Wal-Mart or anyone else
for damages as a result of injuries or damages sustained by Mitchell Stowman.
I agree not to settle, negotiate or adjust tI,e above claim or any proceedings based thereon
witbout the written consent of my said attorneys.
NOW:, THEREFORE, in consideration of tbe services so to be rendered by HANDLER,
HENNING '& ROSENBERG, I bereby covenant, promise and agree to pay them for tbeir
professional services rendered, THIRTY-THREE AND ONE-THIRD PERCENT (331/3%)
of wbatever >lulu is recovered as a result of settlement ,,~tbout suit; or FORTY PERCENT (40%)
of whatever sum is recovered aHersuit is filed or in the event ofarbitration or mediation. I will
reimburse HANDLER, HENNING & ROSENBERG for any necessary expenses and costs
advanced on my bebalf in pursuing my claim. 1 also authorize counsel to destroy my file three
(3) years after the case is closed.
Counsel reserves the right to witbdraw if they desire to do so, for any reason(s) they deem
proper.
I ACKNOWLEDGE tbat I bave read, approved and cmderstood tbe above Contingent Fee
Agreement and I acknowledge having received a copy of tbe same. The terms set forth are accepted.
IN WITNE S S WHEREO F, I have bereun set my hand and seal tIns
Otctcc , 1999. ~
CJJJ.Qd'
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William Stow)'nan, Indi\~ ua yan
On BebaH of Mitchell Stowrnan, A Minor
22- day
(SEAL)
,0'yc- 2/fd:M
(SEAL)
\
" ynn'Stmvma'n, Individually and
On Behalf of Mitchell Stowrnan, A Minor
EXHIBIT
CJ
All-8TATE lf6Al SUPPlY 10.
_;_',,"0' ~ ~^ ~ ^-.,~ ~ ~"" '"'"~. ,'~,~ "_~""'~,,"'.~___,".__' .' ;,j
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AND NOW, this \ ~O<ff.-- day of
, 2000, I hereby certify that I have,
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CERTIFICATE OF SERVICE
fh 0 .d'
(
on this date, served the within document upon defendant's counsel and all counsel of
n
record by sending a true and correct copy of same to them via first class, United States
H
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mail, postage prepaid, and addressed as follows:
Greg Wilkerson
Claims Management, Inc.
P.O. Box 8083
Bentonville, AR 72712-8083
(Claim #: 01-99-742312)
HANDLER, HENNING
& ROSENBERG
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By:
1j)d-l/l;J(~ W~O; r
Patricia J, Koh ein