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Home My WebLink About07-0670Metzger, Wickersham, Knauss & Erb, P.C. By: Clark DeVere, Esquire Attorney I.D. No. 68768 P.O. Box 5300 3211 North Front Street Hamsburg, PA 17110-0300 Attorneys for Plaintiffs (717) 238-8187 cdv(a~mwke.com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: EBONY THORNTON ~~ PETITION FOR APPROVAL OF MINOR SETTLEMENT AND NOW, comes the Petitioners, Eric and Mary Thornton, as parents and natural guardians of minor Ebony Thornton, and petitions this Court for approval of a settlement of a minor's case in accordance with Pa.R.C.P. No. 2039 and in support of the Petition avers as follows: 1. Petitioners, Eric and Mary Thornton, are adult individuals residing at 20B West Glenwood Drive, Camp Hill, Cumberland County, Pennsylvania 17011. 2. Petitioners are the parents and natural guardians of minor Ebony Thornton, who resides with them, and who is 9 years old, having been born on August 22, 1997. #369772 3. Minor Ebony Thornton has selected Petitioners, as her parents and natural guardians, to represent her interests in this Petition. 4. At all relevant times hereto, Claims Management, Inc. is the claims adjusting service for Wal-Mart Stores, Inc. at 6520 Carlisle Pike, Mechanicsburg, Cumberland County, Pennsylvania, 17011. 5. On June 27, 2007 at approximately 8:20 p.m., Ebony and her mother, Mary Thornton, were shopping at the aforesaid business address of Wal-Mart. 6. Ebony was walking down what they believed to be aisle 11, "toilet paper aisle", when Ebony fell backwards and hit the back of her head on the floor. Mrs. Thornton picked her daughter up off the ground and noticed that Ebony was laying in water and the back of Ebony's shirt was wet. 7. As a result of this incident, Petitioners made a claim to Wal-Mart. 8. As a result of the incident, Ebony was taken to Holy Spirit Hospital on June 28, 2006, where the physician reported that Ebony sustained a possible subtle fracture of the radial head of the right elbow. 9. At the hospital, Ebony was provided a sling and instructed to follow with her family physician. A true a correct copy of the hospital records are attached hereto as Exhibit "A" and incorporated herein by reference. 10. On July 3, 2006, Ebony was seen at the University Physicians Group as instructed for her injury. An x-ray was performed which revealed some cortical irregularity at the radial head. Ebony was instructed to continue wearing the sling and return in one week. 11. On July 18, 2006, Ebony returned to the University Physicians Group. At that point, the physician discussed with the family an MRI of the right elbow for a definitive 369772-1 diagnosis. Ebony was to be referred to orthopedics if the MRI is positive or her symptoms failed to resolve. A true and correct copy of the University Physicians Group's records are attached hereto as Exhibit "B" and incorporated herein by reference. 12. On July 21, 2006, Ebony was seen at Central PA MRI. At that time, they performed an MRI of the right elbow and the report stated no evidence of a fracture was present. A true and correct copy of the Central PA MRI report is attached hereto as Exhibit "C" and incorporated herein by reference. 13. Ebony has not received any further medical treatment after July 21, 2006. She does not have any plans at this time to seek additional treatment. 14. The medical bills for Ebony's treatment as a result of the injuries sustained in the fall have been paid or are pending for payment by Aetna. The total medical bills are $1,575.50. A copy of the of the medical billing summary outlining the medical bills sustained and the source of payment for those bills is attached hereto as Exhibit "D" and incorporated herein by reference. 15. The Rawlings Company on behalf of Aetna has asserted a lien of $388.99. The Rawlings' lien has been negotiated to $282.02, which amount will be paid back in satisfaction of the lien. A copy of the letter dated January 9, 2007 from The Rawlings Company accepting the reduced sum is attached hereto as Exhibit "E" and incorporated herein by reference. 16. Ebony also has an outstanding balance with the following providers: (a) Central PA MRI - $965.00 (b) Holy Spirit Hospital - $75.00; and (c) University Physician Group $20.00. The balances will need to be satisfied. 369772-1 17. On behalf of Wal-Mart, Claims Management, Inc. has agreed to pay $7,500.00 to Ebony and Petitioners to resolve the liability claim against Wal-Mart as a result of this incident. 18. The Petitioners, after consultation with counsel, have determined that it is in the best interest of Ebony to accept Claim Management's offer on behalf of Wal-Mart and seek Court approval of the settlement. 19. Counsel was retained by Petitioners to represent Ebony on a contingent fee basis of 25% of gross recovery. A true and correct copy of the Fee Agreement is attached hereto as Exhibit "F" and incorporated herein by reference. 20. Counsel's attorney fee at 25% is $1,875.00. In addition, counsel has also incurred the following expenses in pursuing this claim on behalf of Ebony: Filing Fees $ 55.50 Photocopies 11.16 Postage 10.44 Fax 26.00 Medical Records 59.59 Travel for Investigation 21.30 Total $183.99 21. Petitioners respectfully request that his Honorable Court approve the compromise settlement of this claim with Claims Management, Inc. and Wal-Mart Stores, Inc. in the gross sum of $7,500.00, out of which Petitioners will receive the sum of $4,098.99 on behalf of Ebony, The Rawlings Company will receive the sum of $282.02, Central PA MRI will receive the sum of $965.00, Holy Spirit Hospital will receive the sum of $75.00, University Physicians Group will receive the sum of $20.00 and counsel will receive the sum of $2,058.99 for attorney fees and costs. 22. Petitioners propose to place their daughter's settlement proceeds in a federally insured restricted savings account at a bank, credit union or savings and loan association 369772-1 organized or existing under laws of the Commonwealth of Pennsylvania in the name of their daughter. 23. Petitioners also have been requested to sign the Release attached hereto as Exhibit "G" and incorporated herein by reference, upon approval of the settlement, which would release the Wal-Mart Stores and Claims Management, Inc. from any further claims by Ebony or on her behalf as a result of the incident at issue. 24. Petitioners also desire to discontinue the action filed in this matter upon filing of the Proof of Deposit with the Court. 25. Claims Management, Inc., on behalf of Wal-Mart Stores concurs with the filing of this Petition and also seeks approval for the minor's settlement under the terms set forth above. WHEREFORE, Petitioners respectfully request that this Honorable Court approve of the minor settlement and enter a Decree distributing the funds as follows: (1) To be paid to Eric and Mary Thornton, parents and natural guardians of Ebony Thornton, the sum of $4,098.99, to be placed in a federally insured and restricted savings account or certificate of deposit, to be marked "not to be withdrawn, assigned, negotiated or otherwise alienated until Ebony Thornton reaches her majority on August 22, 2015, except upon prior Order of the Court"; (2) To be paid to Metzger, Wickersham, P.C., for counsel fees and expenses the sum of $2,058.99; (3) To be paid to The Rawlings Company on behalf of Aetna for medical expense lien, the sum of $282.02; (4) To be paid to Central PA MRI for outstanding medical bill, the sum of $965.00; (5) To be paid to Holy Spirit Hospital for outstanding co-pay, the sum of $75.00; and (6) To be paid to University Physicians Group for outstanding co-pay, the sum of $20.00. It is further requested that an Order be entered granting Eric and Mary Thornton, as parents and natural guardians of Ebony Thornton, authorization to sign the Release attached to 369772-1 the Petition, and discontinue this action upon filing of the proof of deposit of the sum for the Minor as set forth above. METZGER, WICKERSHAM, KNAUSS & ERB, P.C. By: ~ -~T~ _ ~ Clark DeVere, Esquire Attorney I.D. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 (717) 238-8187 Attorneys for Petitioners Dated: February 1, 2007 369772-1 ~~,b J~" ~ cE~ Ac~x The copies of records for which this certification is made are true and complete reproductions of the original or micQrafiIme,~d ~medica.~,l~~recrords of (print name of medical provider) ~~~/~.~ 7~t"~LIgY ~/~7~0,~ The original records were made in the regular course of business at or neaz the time of the matter recorded. The certification is given pursuant to 42 Pa.C.S. Ch. 61 Subch. E (relating to medical records) by the custodian of the records in lieu of his or her personal appearance. Patient: Ebony Thomson SSN: 211-76-6308 DQB: 8/22/1997 Medical Record No.: Number of Pages: a/p Dated: ~3 L Subscribed and Swom o before me ~ ~Y of 2006. ~, _ _ 0„ Notary Public zs . ~'/T My commission expires on: ~ / l Q~ ~ ~ t ~~~ 8 COMMOMN~TM ~ PENNSYLVANIA Pahia~( East Pen My ~ririoR E~hes AAar.17, ZOC 08 Memfer, Psnn Association Of Notaries THORNT(?N ,EBONY J 20B W GLENNWOOD DR UNEMPLOYED CRMP HILL, PA 17011 717 - 728-0809 - QEO CODE PHOTO ID N OCCUPATION THORNTON ,MARY MI 20B W GLENNWOOD DR RED LOBSTER CAMP HILL, PA CARLISLE PIKE 17011 MECHANICSBURG, PA 17055 717 - 728-0809 717 - 763-1760 99~_99_999y RELATIONSHIP D KANISH THORNTON ,MARY 20B W GLENNWOOD DR CAMP HILL, PA ~ C/ 17011 ~~ b RELATIONSHIP M RELATIONSHIP `"'~^+ HOME PHONE 717 - 728-0809 HOME PHONE - ~~~~ WORK PHONE - PHONE - CODE 407 INS CO A>rTnm/usHC tH~io PLAN CODE INS CO / CY # HHxxR7z~ POLICY # ~ (,~ ~C~ (,/ " r QROUP # US2285930050010 GROUP # ~ ( AUTHORIZATK>rl # AUTHORIZATION # ADDRESS pp BOX 5367 ROCKFORD IL 61125 ADDRESS PHONE N VERIFIED PHONE # VERIFIED SUB NAME TxoRNTON ,t+IARY MI Y SUB. NAME: MI n PRIORITY 1 PRIORITY PLAN CODE INS CO PU-N CODE INS CO POLJCY # POLICY # BROUP # GROUP # AUTHORIZATION # AUTHORIZATION # ADDRESS ADDRESS PHONE ~ VERIFIED PHONE # VERIFIED SUB NAME MI SUB. NAME MI PRIORITY PRIORffY SCRIPTION ACC. DATE /TIME /IND. PRIVACY NOTICE F ALL 06/27/06 19:00 O 07 28 03 O1 OPR TIH C OMMENTS /' ~[. wnn~oNmt ~x Acc~~ MITTIN(3 DX. ADMITTING DR. ATTENDING DR REFERRING DR. lsoole sn oROtrP leoois ITTING PLJ11 HT BY: ALL FATHER MR • ~~ L*R1 THORNTON ,EBONY J 201-ECU &/OS 12th REV L1.W ~ ~.. Pi AL"~:1# ~~ Z 8 F utln.l w, a x L.ba [ ] Aoetarrrirrophen [ J ESR [ ) TheophylHne ( ) Acetone (SAGE) [ ]Glucose [ ] Thrarrbolylic Labs [ 1 AkxrFwl (ALGO) ( ]HOGS ( ] Tox Screen [ 1 ~e ( ] ~ [ 1 urine Tox (pOAS} ( ]APTT HCGS ( ]TSHR 1188H ( ]HIV [ ] TypeRCross _8 of urrila [ 1 Blood ~-~ (] + 1~) [ ] BMP ( ] LNer profile [ J Type 8 Saeen [ ) CBCP ( )Lyles [ ] UA: [ ]DIP ( j DIAL. [ ] CMP [ ] ProBNP ( j Urine C 8 S ( J CKCKMB,TNT ( ] Phenobarb ( ]Urine HCG ( ] D I ] PTP ( ] WC Breath Alto Teel [ ] Digoxin [ ) Saiicylate [ ] WC Drug Srreen ( ] Dliantln [ ] Tegretol ( ]Other; ( ] AbdJObstr, Series [ J Knee R L [ ] Anlde R L ( ] KUB [ ]Clavicle R L [ 1 ~ ~ [ 1 Cerv. Spine-Routine (3 view) [ ! ~ [ ] Cerv. Spine-APllat [ ] Nesel [ ] ~• SpYre-Portable Lot ( ]Omit R L ~ i [ ~~~ ~ () Pens I 1 PYe~m IvP ~j [ [ ] Rbs R L [ ]Femur R L 13~ 35 [ ] Stwulder R L [ ]Finger R L [ ] Skull [ ]Foot R L [ ] Sternum [ ]Forearm R L [ ] T/Spine [ ]Hand R L [ ] Tib /Fib R L ( ]Hip R l [ ]Toe R L { ]Humerus R L ( ]Wrist R L [ ] other: rmercx~Tnm, AEASON: d iaes t?aecld Proa UNraeound: : CT: (W.Wlth oonaae~ Wq.Wlgrout) [ .) Abea-rerr [ 1 ++ W +'~ [ ] VO scan [ ]Duplex Doppler [ ] BrelMired W WO [ ] Ecla- [ ]Gallbladder [ ]Chest W WO cardiogram [ 1 PeMs [ )Spiral cheat hx PE [ 1 Transvagnal [ ] OMrer. [ J MRI Scan Tbrre/CRT/im. REASON: Inax-alCul-urss: )Beta Strap A(3 Rapid ] Cervk:aUGenHel lh ] GC Culture ) Manosiwt IrePM) J Sputum C & S ] Slod C 6 S ]StodO&P ] Stool C. l>Ilfldle J Tricfrorrronae ] Wound C 8 S ) Other: n9 ass PHYSICIAN CHARGE FACILITY CHARGE [ ] Level I [ ] Leval I [ J Accident [ ]Level II [ ]Level II [ ] Medical [ 1 Level III [ ]Level III [ ] Ceae t [ ]Level IV [ j Level IV [ J Extended Hrs. [ 1 Level V [ ]Leval V Holy Spi-It Hwspftai Camp Hill, PA John R. Diafz Emerpsrtcy Canter Phyaiclan Ordsr Shut 208-ECU 12/04 REV. LLW Cardlsc ( ]Monitor ( ]EKG { ] rn r m,in. [ 102 Saturation [ ) ABG~a [ ]Peak Rows Before/Atter Reap. Tz. [ ]Respiratory Tx Ysdialtiott s / Ms ! Aiiatlotlttl Ortisrs N: N ! LR/ D5I . D5ANS WOACYOAnfuta an mWhr [ ]Obtain old ncorda [ ] Td [ ) Probowl Inlilalad tor. Q~^ Ov.o. head b~adr TI Dit4CFI~tAQE ! 1 ADMIT ! 1 OBSEAVATitDAi [ ]REGULAR TELEMETRY CRITICAL CARE ~tDA1TTTt111C~ PNY$/GAN / QROUP: GNOSTIC /MPRESSIOAI: Initials: Signaturo• RN/MA Initials: Signature: RNlMA t;Rnrcac ~F h~.~,~i~ n t A ,. f Ju Signature• ~4 `T~' ~~ v ~ 1N~P Dab: ~~.~ ~ Time: ~ ~ !'"~ THORN'PON ,EBONY J ED GROUP ;460635 06/28/06 8 F 08/22/1997 ERl 18003903 CHART COPY ,M:1,', t„rr•t„?~ ~ ,ii ' . "rte iSil !.. it , t:t:::::t:.;; it'j:• . -Awake - Abrt ^Appropriste ^ rm O ^ . Cola kin kttact (vINWa) l]ern~neblwY unteeared Extrem words) response ^Cod ^Dlaphoredc ^AtNasion ORaeh ^eMar Did'idor ~ ^Consdable, ^Hot ^Tendng ^Eoclrymoeis ^Bum ^labored oretracdone Extremity cobr.^WNL Tlnrs inappropriate ^Pale ^Flushed ^Purtcture Wountl ^vvtreezing L / R ^Motded ^Cyanotic ^Agitated wards ^Dusky ^Motded ^Laceretkxt/ Avulsion ^releslrhorxhi L / R Skin Temp ^Wann ^Cool ^ Uncooperedve ^ Persistent ^Cyanotic ^Jaundke ^cough Distal PulsesOPreaent ONot palp. ^VsrbaNyAtwsiveOCombadve inappropriate ~~t:":;t:.. tQgNMi.~`;,. ^productive Edema ^Yes Ofb ^Anxbus ^Crying crying! ecr~ming ^Pink /Moist ^Controlled g02_Umin vita Deiomrty ^Yes ^No ^ Contused ^Moans to pain ^Pale ^Cyanotlc ^Not Contrdled Etxirymosis ^Yes ^No ^D ^Credted Location: %Sa ~a .. Score •" , ` .,........ . ~ ^denhe ^headache ^PERL R L EYES MOTOR RESPONSE YERBAL ^denies s/s ciuredvai uMonftor/rtrythm: `bCheat pain ^stMi neck Size_mm,_mm 4 Spontaneous B Obeys 5 Oriented utrequency dk~neroe area: unedc pain Plnpdnt ^ ^ 3 To verb commend 5 Localkes peke 4 Disoriented ^u ~ u ~ uvapinal d~echerge Severity !10 ;]facial droop Dilated 7 J 2 To pain 4 FlexicmwiCrdrawel S Ineppropriek ^ ri a Dl's Uvapirel bleed' e9 :] P~ ^COns18M ^ehazp gnumbr>ass: Fixed 7 0 1 No respaise 3 Abrx~rmal Rexion words UHematuria ^tdey ]edemn• ulntermllteM ^dull Sluggish u u ~ Abnormal Extension 2 Incompreharmi>le ^reteMan presern_it Uburtung Upreswre Dweakness: non-reactiveu u 1 No response t]Other. LMP ^ND C:ISOB ]heavy 1 ~ UWA ^cspillary refill: Jnausea ^pleuridc ' „ ~rapkl anon-raaating ^Denlea pain !symptoms UDuradoN ~ Last BM inteneiry L]Abdomen tender ]delayed rradiedng ^neusea ^diarrhefl ^vomfing UyrorradpationUHemetemesis Bowel Sounds ^distended ^finn Usofl UcaN tender R 1 L ~•;, : . ~ . 1 ~ r ~ ' , Aloes 7trroat ^Pain L! R Acuity: L____J.~.. Ears EI'ES d b ~~,. L `~ DWurred vision L ! R R_l~ UPein LIR Ucongestbn osore Complete y. SRN Time:.~"~ udouble vision L / R :]vrfth lenses ^dscharge ^dreinage ^droding ^Call bell within h DCompanion wide patient DPhotoptabia L 1 R [:10ther. OEpletaids L ! R ^dysphsrsfa ^SR up x2 ^ER procedure explained IV eonditlar. o=rw krnanr k~ion 1~riertrfl z b s=nera,ese a.warmtn ~ MEDICAT 10N8 Time Amt Sdution Sz. Site Rate A Coed Initial T'ane 0 !Dose Route Sffe Initial Time Notes ~ ,: Radioiepy De .Completion Notiflca tion 11 ,i Exam(:): ~~ Inft f~!; . ~~ Date: Time: ,~-~...~ ~ --:,~z.;~a:~-:~:~:~e.~.,uvest~.s,:,.a~~~ ~.:~., Signature Initial y: din 1i ,err • 4:' t .. ;.. •~. ,,..~,,..ti.. . :: .• o e~Otrtpanied by::)SeM 3FernNp^130ther Via: uletory Uw/c ^ambulerxe To: nursing home JAMA ^OR bother. Discharge irtsdnicdons given to: 'al a~ OFamity UParent UOdter ADAItT / OBS Report Caged ® to Rooms uokl records sent to door clothing sheet done TRANSFER TO: Jtransfer cheddist cornpiete CondNion: s~Y UCridcal ^Deceased to morgue Ulm r 10 RN 81 6~ Holy Spirit Hospital THO ON ,EBONY J 8 F Camp Hill, PA 17011 08/22/1991 n ED GROUP NursNtg AsssssmorttlNotes ZB003903 1460635 06/28/06 205-ECU 12104 11th REV. LLW CHART COPY Holy Spi>i it >iospital Department of Radiology and Diagnostic Imaging Camp Hili, Pennsylvania 17011 (717) 763-2600 PATIENT: THORNTON, EBONY J MR#: 460635 SOC SEC: 211-76-6308 ORD DR: RAJANA SHARMA M.D. PT TYPE: E DOB: 08/22/1997 LOCATION: ER1- ~a~~ 6~°~ DICTATION DATE: Jun 28 2008 3:15P TRANSCRIPTION DATE: Jun 28 2008 3:15P ADM DATE: 06/28/2006 ARRIVAL DATE: 08/28!2006 H03P SERVICE: ER1 ACCESSION: 2922288 ***Final Report*** EXAMINATION: RT ELBOW 73080 - 06/28/2008 COMMENTS: exam: Tvro•view right elbow History: Fall Findings: 2 views of the right elbow are smooth without comparison. There is a vary subtle irregularity of the radial metaphysis which may represent any occult fracture. However there is no elbow joint effusion to support this diagnosis. Clinical correlation is recommended. CONCLUSION: Impression: Possible subtle fracture of the radial head for which followup x-ray in 1014 days could be performed for further evaluation to exclude occult radial head fracture. DICTATED BY: ELIZABETH BERGEY M.D. / PSC DATE OF EXAM: 08/28/2006 SIGNED BY: ELIZABETH BERGEY M.D. DATE/TiME: Jun 28 2006 3:15P F"7 z-~,~ ~ '~ ~~~ ~ cr ~.e.~1 *`~~ ~~ ~ ~ ~~ .~- CONFIDENTIAL: This report contains private patlent Infortrratkm. If you have received this report In error, pl~se call 717-972.4941 Immediatey. ConfktentiplHy Diedelmer: The infomratlon contained in this communication may bs ooniktentlal, k Mtended for the use of the redpbnt named above. and may be IegaUy privileged. If the reader of this rrreasage is not the intended recipfsnt, you era hereby notMed that any dlaesmination, distrlbutlon, or copying of this communication, or any of Its contents, is atridiy prohibited. If you received this oarrmunicstiat in error, please reaend this communication to the sender and•delete the original message and any copy of It from your computer system. Thank You. Imaging Services Consultation Page 1 F.MERGENCT CF,NTER i.)RGJ CFV''~R (717) 763-2316 ~ (717) 763=?~?.4 OISCNARGF, 7NSTRTtCT[ON~ HOLY SPIRIT HbSPPI'A>J T ba'x only and art not irttettded to be a stthstiwte for or an effrxt to provide the crrmination anti nentntent you ba"c •+eceitct: m the 8tnagertey Cents' have txrat n;ndercd m an emergency w our phyxietian or the Emergmey Center. FULLOW TIC WSIRUC'TTONS CHECKED 9ELOW, comae' ti c,mtplete mrdical uuv. II' y,m develq~ y au t,~w proMenrn ur eornpliea Patient Intormatbn: Pattjettt Im`ormatio Sn ~ t„orttain Important Irttormef<lon~ R~ end Keop()Threatened Miscarriage OAbdominal pain ( ~ Gomeal abrasion ()Headache ()Toothache OHead injury OPediatric Head Injury ()Alcohol reaction ic reaction ()Aller (t Crouplbrortchltis ()Crutch walking () HypeflBnSien () Pedlaltlc URf () URI and Colds () UTI and Pyelonephrilis nus {) PID/STD /T t f g ()Asthma (1 Dienhea and Vomiting t'ed. Vomlting e a on () Immunizat ()Wound Recheck O Kidney Stones OPneumonia O Dislocation l) Beck pain ()Bites-HumanlAnlmaUlnsect () Drug/Aloohol abusa/actlkxion O ~~ bids O Rah O 24 Hr. Pharmadea Ynt ()Other ceretion ()Seizure i) l (1 Bum () Febrile Corrvulsion F a () Hi h tassium containing tooda l) Neck Strain OSore Throat O 9 Po OChest Paln ever O FevadPed. l) Fl ~,) Nosebleed O Sprelna and Strains ()Conjunctivitis u OFracture ,) Otitls ~~ () Suture Care & Removal O COPD MEDICATIONS WOUND CARE { )May gently wash over wound in 24 hours with soap and water or ( )Continue pte:etrt medications except: peroxide. ( }Change dressing times daily. Redress with Baataan/Neoeporin { ~~a~ ~I to~peckage sfitctioneafor age andrwelght, etc. and sterile dressing o- leave tt open tt advised. d {) uncovered r () () Use the following medicines according to package instnrctions: l )Keep wound clean, d e cove ry 1: SPRAINS, STRAWS. BRUISES, FRACTURES ~.,lf~fgyete the injured part for ;^. days to redt~ awellin3. ,.(-3 apply ice parts intnrmlttenUy for ~L days to redrxo3 swelling. ( )Ace wrap for auppoR for_ days. ( )Wear splint () At all times until follow-up. ()For activity as treaded. (.Use sling for su~Q°rt. ( )Use crutdres: () As needed, weight bearing as tolerated. ( ) At all times. NO WEIQHT BEARING NECKlBACK ( )Wear cervk~l collar for support for .days. ( )Rest, avoid bending, lifting, strenuous activity for ~ days. ( )Apply moist treat for minutes tines dally beginning in hours• ADDITIONA!_ INSTRUCTIONS ( )Encourage fluid Intake ( )Clear liquid diet. Advance to regular diet as tolerated ( )Off work/abhool from tc () Retum to work on ( ) UgM Dutyvntil: Restrictions: ( ) No gym/sporte until ( )Fellow lnstnrctions an Workmen's Compensation Fonn. ( )Wear eye patckr for trouts. () If nose bleed'recure, pinch nose firmly for 5 minr,ttes continuously, carom H bleeding not cantr+olled. ( )The prescri eM(blotic/medication, may reduce the effectirreness of m ion you are currently taking, Check package inatntcfiorte or uit with ptrarmaciat. ( e interpretation of Your X-Rays are preliminary reading. Your fllrns will be reviewed by a radiologist. You or your Physician will be oontaeted tt there is a grange In the diagnosis. 2: 3: ( ) Tfte followirrp nrsdicirrss may cause drortrsNrssa: DO NOT DRIVE OR OPERATE MACHINERY WHILE TAKING: The prescribed antibloticlntedie~tion, may reduce the ellectiveness of medication you are currently taking. Check package instructions or consult with pharmacist. FOLLOW-UP This is our rocotnm~datJo~~ ~b~ Yt•.oorutrsuttatlon. Insursrtoe (HMO) requlrw a physic R 18 YOUR RESPONSIBILITY TO OBTAIN THE NECESSARY ApppOVAL ( )Fellow-uP w~: (} Urgi Center () Occ. Health/Comperry Doctor ( ) Femliy Doctor or in days for: () FoNow-up ( )Suture removal ( )Take the following test results to Your physidan. ( ) CBC () CMP (} EKCi () X-RAY REPORT ()OTHERS VF YOU DO NOT HAVE A FAMILY PHYSICIAN CALL 763.2900 FOR PHYSICIAN REFERRAL. ( )Call as soon as poas~le far appdrttment ( ) Pkdc up your X-Rays from the Radiology Department Prior to your folJQw-up appointment. Call 763-2696 to have film ready. .. ~ : , (,.1~e~your physkaert or specialist 'd not improved in _~.._ days. ,~ ( ) Retum to Emergency Center tt you feel your condition is worsening, especially if ( )Your bkrod pressure was elevated. Check wtth your physician. ~~~ r, l., A copy of your dictated Erttegency Room Report la avaflatrle to your Phyaidan from Medical Records (763-24!30), tt trot ~Iready aent• Cllnicai knprssslons: `a I hereby acknowledge receipt of these irtatructione and understand them. I understand that I have had emergerxy treatment or- C a--d that 1 may be released before aN of my medical problems are known or trued. I wAl arrange for fellow-up care are I hsve been inatnxted. ft is my responsibility to no1Hy my Primary f;,gare Physican of this vlstt. ; SIGNATURE: ~~ P' ~~ 81GNATUfiE: Dee ~ Person RSTANDING TIEN7IREggON$lBLE PERS VERBALIZES ItN[~F SI ATURE• /'f ~ ~ r Date • ~~ AOLY SPIRIT HOSPITAL JOHN R. DIETZ EMERGENCY CENTER 503 NORTH 21ST STREET CAMP HILL, PA 17011-2288 (717) 763-231fS _ MD 038368E (> David Zimmerman. MD 005636E Judson P h () J ( ) 'llwmas Aldous, MD 017075E (> ()Salvatore Alfano, MD 025502E MD , . a o ()Philip Magtriro, MD 015063E ()Barbara Soong, NP VP003617B () ()Teresa Williams, NP TP006126B NP SP0060(i6B m Darden OP ( )Ramesh Aorta, MD 0.16727E c) DO 006991E ( ) ]on Dublin (> Pustrpa Mudar;. MD OS15I4L <) Aaron Palmer, MD 423830 , a OSelena DiPaolo, NP VP005264B ONikki Wallace, NP TP006718B NP SP0059276 c > Jane Wenger , ( )Amy Pajar~, MD 420942 OLawrence Paul, MD 039524E , ONatalie Gillis, () KaTatzytts F+etti'ato, MD'~417936E () fioward Rudnick, MD 040862E ...L.lldj9 ( ) ~^. Bev SP00~ ( ) Maripat Gattcr. MD 046724E <) Ranjana ShannaAMT~ ~~ can P007624 SPRAINS,, STRAIN8, BRUISES, FRACTURES the Injured part for~days to reduce swelling. .Lice packs Intermittently for-.tLd~ to reduce swelling. ( )Ace wrap for support for days. ( ) W,sar splint () At all times untll folbw-up. ()For activity as needed (,a°Oee sling for ~P~°r4 ( )Use cn~tchea: (1 As needed, weight bearing as tolerated. ( ) At all times. NO WEIGHT BEARING NECKlBACK ( )Weer cervical collar for support for days. ( )Rest, avoid banding, lifting, strenuous activity for days. ( )Apply moist heat for minutes times daily beginning in hours. AODITIONAI INl3TRUCT10N8 ( )Encourage fluid intake ( }Clear liquid die4 Advance to regular diet as tolerated ( }Off worklechod from to () Retum to work on ( ) Ught Dury•t1r~Ul: Restrk:tbns: ( ) No gyrNsports until ( ) Fotbw inetnktbna on Workmen's Compensation Form. ( )Wear eye patch-for houre. () ff nose bbed'iecurs, pk-ch nose flrrnly for 5 minutes corstinuousyr, return H bleeding not controlled. ( )The antlbiotidrtbdicatlon, may reduce the eeectlveness of you are currently taking. Check package instntdions or k with Phamte(4st. ( e interpretation of your X-Rays are. preliminary reading. Your films witl be reviewed by a -edido9fsl. You or your Physician will be contacted ff there is a change in the diagnosis. 3: ( )The folWwing marJfdn.. they eaa(se drowsiness: DO NOT DRIVE OR OPERATE 111ACHWERY WHILE TAKING: The prescribed n, may reduce the effeollveness of medicwtlon you are curtently faking. Check package instructions or consult wftlt Pharmadst. FOLLOW-UP This is our recomrrNndsdlon for folbw-up. k your irnuranoe (HMO) roquires a phydohrt referral for specWty corteuMagon. R IS YOUR RESPONSIe1LITY TO OBTAIN THE NECE38ARY APPROVAL. ( )Follow-up with: () Urgi Center () Occ. HeelttJCompeny Doctor ( )Family Doctor or in days for: ()Follow-up ( )Suture removal ( )Take the idlowing test results to your physician: ( ) CBC () CMP { I EKG () X-RAY REPORT ()OTHERS 1F YOU DO NOT HAVE A FAMILY PHYSICIAN CALL 783-2900 FOR PHYSICIAN REFERRAL. l )Cell as soon a$ possible for appointment ( ) Pk4c up your X-Rays from the Radiology Department prior to your fat appointment. Call 763-2~6 to have films ready. ~ ~phyaiden or specialist M not improved in ~ ` , .days. ( ) Relum to Emergency Center ff you feel your condition is worsening, especially if ( )Your blood pressure was elevated. Check with your physician. ~ ~~ (.)r"~' I A copy of your dictated Emegency Room Report is available to your Physician from Medical Records (763-2880), ff not Iready s5ent. ~f Glnical Impntaalons: _ :i-y~• I hereby acknowledge receipt of these Inetrtrctlons and understand them. 1 understand that i have had emergency treatment ordy and that I may be released before all of my medical problems are ivlown or treated. i will artartge for follow-up care eta I have been inetrtxxed. It is my reeponsibAity to r-otify my Primary Ca)'e of 1Me visit. ~ r; :~~ . ~l fi SK;AIATURE: ~ - Phyeleien tiMP ~ StONATURE: ~ ~~ q~ Dats ~ T1ENrJRE~ONl;i)BLE p~VERBALIZES yN ~'TANDINO Nurse ~e HOLY SPIRTf HOSPITAL JOHN R. DIETZ EMERGENCY CENTER 503 NORTH 21ST STREET CAMP HILL, PA 17011-2288 (717) 763-2316 ( )Thomas Aldous, MD 017075E () ()John P. Judson, MD 038368E ()David Zimmerman. MD 005636E ~ ~ ~~ Sing, ~ VP003617B ( ) Salvatore Alfano, MD 025502E MD MD 016727E <) esh Arora ( )R ()Philip Maguire. MD 015063E () O Pushpe Madan; MD 051514E OPam Darden, NP SP006066B , , ()Teresa Williams. NP TP006126$ ' , am ()ton Dublin, DO 006991E ()Aaron 4'alraer, MD 423830 ()Selena DiPaolo, Nl' VP'005264B MR 039524E ()Natalie Crillis, nce Paul w ()L P006718B () IJildd Wallace, NP 7 ()Jane Wenger, NP SP005927B ( )Amy Fajardo, MD 420942 , a re ( ) Katarz}ms Perraro, MD 417936f3 ()Howard Rudnick, MD 0448673- ..- SP'00 ~ ) ( ) Maripst Getter, MD 046724E ~ Bev () Ranjana S P007624 ( ) Marlys Hasson, MD 072553E ~~~ . () (71ristine S 009 ()Alan MD 1 DATE SIGNATUREf ~ ~M.D./D.O./NP DEA# W ORDER POOR A GRAND NAMfi PRODUCT TO BE DISPfiNSP.D, THE PRESCRIBER MUST HAND WRITE "BRAND NECESSARY" OR "BRAND A~DICAI.[-Y NECESSARY" RV 'fHE SPACE BELOW. OLABEL OSIJBSTITU'IION PFRMiSSIB1E REFILL TIMES THORNTON ,EBONY J r ED GROUP f~,60635 06/28/06 8 F c'y+ 08/22/1997--_~ ERl 18003903 178 (111114) CONSENT TO MEDICAL TREATMENT i HEREBY (:ONSENT AND AUTHORIZE Holy Spirit Hospital, its agents, and empk>yees, ro the rendering of medical care, which may include routine diagnostic prooedtxes and such medical treatment ps my attending or consulting physician considers ro be necessary. I also understand it is cx~tanary, absent emergency or extraordinary dreur,etar,oes, that no aubstarrtial procedures wAl be performed upon me unless or untN I have had ~ opportunity b discuss them with a physidain or other health care professional ro my satisfaction. If l am a competent adult, 1 have the right b consent or refuse ro consent. I understand that the practice of medicine and surgery is not an exact sdence and that diaDrtosfa and treatrrrent may involve risks of injury or even death and admowledge that rro guarantee has been made ro me es to the results of any examination or treatment in this Hospital, I understand merry of the physidans on the staff of Holy Spirit Hospital are not erttptoyes~s or agents of the Hospital, but rather are independent oorrtraobrs who have been granted the privilege of using these tadlities for the care and treatment of lhei- patterns. Further, I realize this Hospitd b a teaching Hospital and at the Hospital are health care persomel N'r tralrtktg who, unless expressly requested otherwise, mny paAk~peate or may be presern during rtry care as part of their education. Stlll a motion pictures and dosed circuit monitoring of patient care may also be used for educational purposes, unless I expressy request otherwise. I understand that In order to ensure s safe envkonment for patients, visitors and staff all property an the premises of Hour Spirit H is subject to reasonable search artdlor seizure at any Ume without further notice. RELEASE OF MEDICAL INFORMATION I authorize Hoiy Spirit Hospital to release b requesting health insurance carrier(s), their representatives and auditors. and any referting health care providers, such diagnostic and therapeutic infornation (including and infonration relating ro treatmern for and/or treatrrant d orders. and/or coMidantlel HIV relat@~ lnbrmation, as may its necessary for tt-em to detemdne benefit entitlernsrrt; ro process payrrtertt dsims for health care servkres provided during this hospitallzatioNtreatmern episode, for crontinuing caraRreatrrrern, and hospital operetkms. A photocopy or carbon Dopy of this authorizaliort shall be considered as efferxive and valid as the original. The undersigned also aulftorizes Medicare, when applicable, to rek~ase ro another insurance carrier, upon their request, medical Information needed b make payment upon that claim. I understand and consent that the manufacturer of any implantable device insetted by mY physidarr during the course of my surgery/procedure may be provkied with rtry Iderniflcation information, indudhg soda) security number, ash by Feitera4J!.aw~ ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES J I have received a copy of the Notice of Privacy Practk~es. The Notice deacxibea how my health inbrnation may be used or disdoaed. I understarxf that I should read It c:arefuly. l am aware that the Notice may be changed at any time. I may obtain a revised co y of the Notice by contacting this Organization's offices or on this Organization's websfte at www.hsh.org. Milk 7' INSURANCE ASSIGNMENT OF BENEFITS t authorize payment dNedly ro Hoy Spirit Hospital and my treating physidans of all benefits payable under my insurance policies. 1 understand I am responsible to the Hospital and physk~ans for al! charges not covered by this assignmern. b11Mr1U C STATEMENT TO PERMR PAYMENT OF MEDICARE BENEFITS TO PROVIDERS, PHYSKxANS AND PATIENT I request paymern of Authorized Ntedkrare benefits ro me or on my behalf for any servk~es famished me by or in Hoy Spirit Hospital including physk~an sendces. 1 authorize arty holder of medics! and other information about rne, to release to Medicare and its agencies any infortnatktn needed ro determine these benefits for related servk~s. Initials MEDICAL ASSISTANCE RECIPIENT My signature rrertiffes that I received a service or items from Hoy Spirit Hospital and Dr. on the date listed bek>w. I understand that payment for this servk.e or item wiH be from Federal and State funds, and that arty false dafrrts, statements, or documents, or corxrealment of material may be prosecuted under appikxtble Federal State Laws. I urxieretand that certain tests and procedures may not be reimbursed by Federal and State funds and that I may be responsible for non covered charges. Also, 1 agree that ii at the time of service, ff I am not eligible for Medk~f Assistance, l will be responsble for balances owed to Hoy Spirit Hospital. Initials 1 have rand and understand eadh of the sections contented above. I understand tttart slyntnp b doarntent, I am aprwlrq and pravkllnp the a rrondinsd fn each of the a sectlons tthr aro located. I haw had tM opportunity to ask quest repardinq sack of tors and I such qusstl swered to Wiry satl:faf;tlort. SigASRw+a '~ WRness RNstlonship to Pstlent Tams _--t-_v DnKs,~~"U~ HULC~ HILL, PAITAL + MR#: 4fi0fi35 FOR TREATMENT/RELEASE OF INFORMATIO INSURANCE ASSIGNMENT PT#: 26003803 NAME: THORNTON ,EBONY J r+rEn arc,as tooroa> ~ ,... . 06 Upper Eztrcmity Injary (a) ARM ~ SH~OULDER TIME SEHV: ~ R Z Z _ EMSAnivof opal lnspeedon tender HISTORIAN: patient ~ paramedic ,ROM AGE ~ M ~ J'T- _HX / DUM LIMITI~ BY: HPI chief eomoiaird: h~ to: laic hand wrist elbo shoulder ooHar-bone dunWon / occu~nd: ~: Just prior to arrival home todsy nai~lbor's ~-'~~ Y 1 nnprk days Pl'A ~ .,_ 1 .._e. rsce diagram -tenderness so/t-fie /bony _ -,swelling! ecchymosis _fimited ROM _deformky arm ) l ~ I sdtool ~ ` n'~~ ~ ~• r park ~•^'~ T' 7'eeaeme street ry..tiGtJwlivj ~ S = 5vveli'my mild race were - ~ ` 1 fall blow incised crushed burn ~ ~M ! di:tiliy s , PA~T!}gf ~7~ ~rlt>~r injury other p~+gblems l~eds• no'n~e / ~~ ~ YIIak Revlerred ~,J Tetanus imnwn. UTD Gaaarrd Appoarantx mild /moderate /severe distress /o distress ert _anxious EXTREMl17E5 HAND see diagram~ ~rltapecdon - -tenderness so(t-dssue /bony / der ~ ! ~ defort n - ~' WRIST ,see diagram ,,,cnfif inspection underness soJ~dssue / berry tenon-tender tenderness in anatomical snuff baoL„_ _nr~l ROM wrkt pain on axial thumb load ~ _swellinB / ealtynwslt _ilmited ROM _deformiry FOREARM / ee^r! ELBOW _~'e/bony _nml inspecdon _ ectlsyrnosis -non-tender _ inmi ROM d try _ 6~ 1996 - 2004 T-S /nc. Circle or check fives, bockt/arh Ives. Holy Spirit Hospital Camp Hill, PA John R. Dietz Emergency Center EMERGENCY PHYSICIAN RECORD .~ -•-- _•.- ~ ~_v ~~~ i ~` ti ~ / NEURO/VASClTENDON ~s6isation intact -sensory /motor deficit lrffotor intact Lr1'o vascular promise -pallor /cool skin / abnml cap refill _ _ ndon function -pulse defick rodiaf uMar normal _deflek in tendon funetlon __ THORNTON , EBOI3Y 3 8 F 08/22/1997 ED GROUP ERl 1460635 06/2$/06 Za003903 Page 1 of 2 SKtN~' d -diapFwretk /cool / do YS ^~ ~ radfol .~ ~' ~~ 'p' ~' me ~ by me ~ hand wrist f+~-aarm umatis ~~ NERD 1 ftrN'f ~ ,, _swelUn~ / ecchymosis ~ NECKI t3;tRCK tenderness ~nmi inspsceion ~svvetlir~ / eori>ymosis -yen-oender GHE,ST _ , . ! _tend+flrtress .C+~ resp'+ disae:: sweliMg % eo~nOSis ~~=obi~der ~breadl stairnml. .._tend+s. rauardipe sting ntu; set~dd s aiserw cwdbaett v-ddti ~pir~on._:.. forei~ body.r+enrarri# "itli ~ incitien UpperExtnamity injury - 06 Psge 2 ot2 Rev. 05/09/05 ..,+ o fracwre -dislocation -nml alignment _soft-tissue sweNing -no foreign body _pcsidve arroerior ~d sign foreign bod ~d ~ -fracture Other study: PROOREBS: Tlrne unchan8ed improved re-examined _~ i~ _referred w / discwsed wide Dr. T~ wig sae patlat in: of-ioe /i:D /hwplml In ~ . ~ • Ak~ed Assault / L shoulder forearrn wrist Hematioma arm ~ hand Sprain /Stain Laccratfon Fracture R / L radius dkmf/sho/t/prwasrrwl Disloation uirn diaaf/~//ubrorstybJd Cones fracture humenrs ~/shoJt/praxirrwl/~ Orsro moN- ®home ^ admkted ^ nms '?N tDONDITION- ^ urKhanged ^ knp+oved ~ stable 1VP/PA AID DO ^ Dicraxd Addendum ~Templa~e ~ ^ Add On Temp THORNTON ,EBONY J 8 F ~ 08/22/1997 ED GROUP ER1 3460635 06/28/06 28003903 ~- hybrt ~ ~x .Outpt Note THORNTON, EBONY J - 1560721 OUTPATIENT NOTE Name: THORNTON, EBONY J HMC Number: 1560721 DOB: 08/22/1997 Date of Service: 07/03/2006 The patient seen today in followup after having fallen at Wal-Mart. She had chronic pain in her right elbow. She is taken to the emergency room at Holy Spirit Hospital where x-ray was performed which showed a possible subtle fracture of the radial head with recommendations fOr followup x-ray for possible effusion present and soft tissue swelling. On physical examination today, the child is seen with a sling initially. Removal of the sling reveals the patient ro be continually tender over. the lateral epicondyle. Her weight today is 117.4 pounds, temperature 97.6, blood pressure 98/76, pulse 80, and respiratory rate 14. Lungs are clear to auscultation and percussion. Heart is in a. regular rhythm and rate without murmur, gallop, or rub. Examination of her right elbow shows minimal point tenderness over the right lateral epicondyle. X-ray was performed today with the patient waiting and is~reviewed with Radiology and reveals some cortical ~' irregularity at the radial head. INITIAL IMPRESSION: Possible radial fracture versus contusion. PLAN: 1. The patient is to continue in a sling. No~casting will be performed at this time because of no blatant fracture present. 2. Return in 1 ~nreek. 255163 Signature Line Review/Sign: Barbara L Hoffmann, MD BLH /CO DD: 07/04/06 DT: 07/04/06 11:47 Printed by: Hoffmann, Barbara L Page 1 of 3 Outpt Note THORNTON, EBONY J - 1560721 OUTPATIENT NOTE Name: THORNTON, EBONY J HMC Number: 1560721 DOB: 08/22/1997 Date of Service: 07/18/2006 The patient is seen today in followup of her elbow injury. She is feeling some better than she had been at her last visit although she continued to have swelling of the elbow. She has been complaint with the use of the sling and with limited movement. She continues to have minimal tenderness over the I'ateral malleolus and does maintain normal range of motion, however. She is able to use her arm, hand, and wrist fully. On physical examination, her weight is 117.6 pound, temperature 97.4, blood pressure 96/58, pulse 82, and respiratory rate 16. Range of motion of her elbow is good. There is some residual swelling in the elbow area and there is minimal point tenderness over the lateral malleolus. ASSESSMENT: Contusion with possible real fracture, right elbow and with 50% improvement since last visiting. PLAN: r' 1. MRI right elbow for definitive diagnosis. 2. Refer to Orthopedics if MRI is positive or patient's symptoms fail to resolve. The case was discussed in depth with the patient's father who was present throughout the visit. 278364 .i Signature Line Review/Sign: Barbara L Hoffmann, MD BLH /CO DD: 07/18/06 DT: 07/19/06 03:36 Printed by: Hoffmann, Barbara L Page 1 of 3 Outpt Note THORNTON, EBONY J - 1560721 OUTPATIENT NOTE Name: THORNTON, EBONY J HMC Number: 1560721 DOB: 08/22/1997 Date of Service: 08/28/2006 The patient is seen today in followup for obesity and hyperinsulinism. Sirice her last visit, she has grown one-half inch and she has gained just 3 pounds. She has been abiding by her diet, and she has recently begun soccer and cheerleading. On physical examination today, her weight is 120.8 pounds, height is 53-3/4 inches, temperature is 97.4, blood pressure 120/62, pulse 78, respiratory rate 16. Lungs are clear to auscultation and percussion. Heart is in a regular rhythm and rate without murmur, gallop, or rub. ASSESSMENT: 1. Obesity under treatment. 2. Hyperinsulinism, improved. _ PLAN: t. Continue current plan of care. 2. Recheck approximately 6 months. 344974 -: Signature Line I Review/Sign: Barbara L Hoffmann, MD BLH /CO DD: 08/28/06 DT: 08/30/06 08:30 Printed by: Hoffmann, Barbara L Page 1 of 3 DATE g_ 2- ~ ~-~ PAIN ASSESSMENt G 7 G A^E YOU EXPERIE --c i ON A SCALE FROM 1 T010 VJGP~ST CAIN: ---~'-" LEAST PAI ' YE PAIN RELIEF ACCEPTABLE? Date & Time 3',.53 Patient Name Date of Birth / SS# v Who Called pCp Pharmacy Name !Phone # FJMO/Ins. Urgent H ~ ~'~/w~ ~ q a~a~~7 fit' G- a MESSAGE Diagnosis r'r ~J'~'1. Y'-O~ c( U-S ~~ Orders/Labs/Meds Stren th SIG AMT Refills S' a'~-DAD Appt. Info / Auth. # PCP Signature Date By / / e Tak Messa g e ~ Date / / Time am. p.m. ~ --- ~ - PAIN ASSESSMENT sA.TE'(OUR PAIN ON A SCALE FROM 1 T010 D ~nm•~,n- A~~~ERa.rE PAIN: ~~rc ~n ,~ YOUR r^^.!"! RELIEFACCEP?AE;.E? YE5 NO ~, University Physician Group 3 Flowers Drive • Mechanicsburg, PA 17050 NARRATIVE PROGRESS NOTE Form 5046-04 Patient Identification Patient Name Uer ~c ,,~-~-p Birthtiate ~ • ~- Z- - ~ ~ Page DATE PAIN P.SSESSPlfENT AFE YOU F.);PERIENCINf nqf"~ Yv;. ~•~ rrid H u~n~~ F~ OPv1 1 TO 1 4 ;;T rt~~l ~Ei;iT PialN: ~~ ~~ ARE YOU IXPERIENCING PA NoESSMENT ' ~'' ~4,~^uT °AJN. ~~ FROM 1 T010 ~_ EAST PAIN: vni • - ~ ~ _~- YES NO Date & Time ~ 7/~/D~ ~ Patient Name ~ ~~ Date of Birth ! SS# ~ /~~q7 Who Called PCP H /W Pharmacy Name /Phone # HMO/Ins. Urgent ~ MESSAGE Diagnosis Orders/Lab /Meds Stren SIG AMT Refills /~ °'~ ~" t .s Appt. Info / Auth. # - PCP Signature ` Date By .Message Taken By / / © , ~~~ ~~"' .. Date / / Time am. p.m. Patient Identification University Physician Group 3 Flowers Drive • Mechanicsburg, PA 17050 Patient Name ~~~ h ~ c 'J-~° Birthdate ~ ~ Z.Z " q '~ NARRATIVE PROGRESS NOTE Page Fonn 5046-04 Holy Spirit Hospital Departm~_.t of Radiology and Diagnostic Ima;;:~..g Camp Hill, Pennsylvania 17011 (717) 763-2600 PATIENT: THORNTON, EBONY J MR#: 460635 SOC SEC: 211-76-6308 ORD DR: RAJANA SHARMA M.D. PT TYPE: E DOB: 08/22/1997 LOCATION: ER1D- DICTATION DATE: Jun 28 2006 3:15P TRANSCRIPTION DATE: Jun 28 2006 3:15P ADM DATE: 06/28/2006 ARRNAL DATE: 06/28/2006 HOSP SERVICE: ER1 ACCESSION: 2922288 r__....._.___ *'"~Final Report"*" EXAMINATION: RT ELBOW 73080 - 06/28/2006 COMMENTS: exam: Two-view right elbow History; Fall Findings: 2 views of the right elbow are smooth without comparison. There is a very subtle irregularity of the radial metaphysis which may represent any occult fracture. However there is no elbow joint effusion to support this diagnosis. Clinical correlation is recommended. CONCLUSION: Impression: Possible subtle fracture of the radial head for which followup x-ray in 1014 days could be performed for further evaluation to exclude occult radia ea rac ure. DICTATED BY: ELIZABETH BERGEY M.D. / PSC DATE OF EXAM: 06/2812006 SIGNED BY: ELIZABETH BERGEY M.D. DATElTIME: Jun 28 2006 3:15P .3 ~~~~~"4~ CONFIDENTIAL: This report contains private patient information. If you have received this report in error, please call 717-972-4941 immediately Confidentiality Disclaimer: The information contained in this communication maybe confidential, is intended for the use of the recipient named above, and may be legaly privileged. If the reader of this message is not the intended recipient, you are hereby notffied that any dissemination, distribution, or copying of this communication, or any of its contents, is stricty prohibited. If you received this communication in error, please resend this communication to the sender and delete the original message and any copy of it from your computer system. Thank You. Imaging Services Consultation Page 1 RE: THORNTON, EBONY DATE: 07/21 /2006. 20B W Glenwood Dr APS#: .. 45824 Camp Hill, PA 17011 DOB: 08/22/1997 SS#: 211-76-6308 AJ .f............~.........,....~.w.,..,.W..,.,..,_,..... ~.... ~ ...._._ .......~ . STUDY: MRI of the right elbow REFERRING PHYSICIAN: Barbara Hoffmann, MD CLINICAL HISTORY: Swelling. Injury. Evaluate for possible fracture. PULSE SEQUENCES: PD/T2 axial; PD fat sat/T1 corona/; T2 sagittal COMMENTS: Comparison is made to radiographs from 6/26/06. There is no significant joint effusion identified. Visualized portions of the proximal radius appear normal. There is no evidence of fracture of the radius. The capitellar radial articulation is normal. The distal humerus demonstrates increase signal in the trochlear ossification center. Most likely this is due to incomplete ossification and in this age group is a normal variant. There is no suspicious injury to the medial or lateral extensor or flexor tendon regions. The medial and lateral epicondyle areas are normal. The proximal ulna is within normal limits. CONCLUSION: No evidence of fracture. Presumed incomplete ossification of the trochlear ossification center as a normal process in this age group. If any further imaging is desired, a single radiograph of the contralateral elbow for comparison would confirm that the trochlear findings are a normal variant. The current examination does not show any suspicious change to suggest occult radial fracture. , Thank you for referring this patient to us. Sincerely, Anand S. Jagannath, M.D. ASJ/sh ~a~elinitiai ~ y ~~ ,. ~mal .~ Abnormal _ ~. No acfion indicated ._.. PJormal Letter .~ Nurse (Order .._ Pt Notified of Results .~.. Pending RE: THORNTON, EBONY DATE: 07/21/2006 20B W Glenwood Dr APS#: .45824 Camp Hill, PA 17011 _ DOB: 08!22/1997 SS#: 211-76-6308 AJ ...w..,..,~,..~....,.....~.u.~....,._~~...,.....W.,,,_ .. ~ .._...... .._v~.,.. STUDY: MRI of the right elbow REFERRING PHYSICIAN: Barbara Hoffmann, MD CLINICAL HISTORY: Swelling. Injury. Evaluate for possible fracture. PULSE SEQUENCES: PD/T2 axial; PD fat sat/T1 corona/; T2 sagittal ..n.. _,..,.~a. .,...,.,.~~~.~...v..__..... ....M_._........ww.._W~._....,.:._,_~,_._...~~..w._..~..~ COMMENTS: Comparison is made to radiographs from 6/26/06. There is no significant joint effusion identified. Visualized portions of the proximal radius appear normal. There is no evidence of fracture of the radius. The capitellar radial articulation is normal. The distal humerus demonstrates increase signal in the trochlear ossification center. Most likely this is due to incomplete ossification and in this age group is a normal variant. There is no suspicious injury to the medial or lateral extensor or flexor tendon regions. The medial and lateral epicondyle areas are normal. The proximal ulna is within normal limits. CONCLUSION: No evidence of fracture. Presumed incomplete ossification of the trochlear ossification center as a normal process in this age group. If any further imaging is desired, a single radiograph of the contralateral elbow for comparison would confirm that the trochlear findings are a normal variant. The current examination does not show any suspicious change to suggest occult radial fracture. Thank you for referring this patient to us. Sincerely, Anand S. Jagannath, M.D. ASJ/sh Patel{nitiai ~~ 1- ~~ . ~ma[ ._._ Abnormal ~~~ ~ .__, No action indicated _.,Jormai i_etter ._ Nurse J Order ._ f t Notified of Results _.,. Pantlin~ ~Jiil di~cur. at +_ x~'b`} ~ SUPPLEMENTAL MEDICAL BILLING SUMMARY FOR EBONY J. THORNTON Medical Provider(s) Dates Amount s Holy Spirit Hospital 06/28/06 431.50 TOTAL $ 431.50 PAYMENTS BY AETNA $ 248.63 ADJUSTMENTS $ 107.87 OUTSTANDING BALANCE (CO-PAYS) $ 75.00 University Physicians Group 07/03/06 $ 74.00 07/18/06 74.00 TOTAL $ 148.00 PAYMENTS BY AETNA $ 90.72 ADJUSTMENTS $ 17.28 PAYMENTS BY CLIENT $ 20.00 OUTSTANDING BALANCE (CO-PAYS) $ 20.00 Central PA MRI Center 07/21/06 965.00 TOTAL $ 965.00 PAYMENTS BY AETNA ~pErrnirrc~ $ 965.00 Quantum Imaging 07/21 /06 $ 31.00 TOTAL $ 31.00 PAYMENTS BY AETNA $ 10.80 ADJUSTMENTS $ 20.20 TOTAL MEDICAL BILLS $1,575.50 PAYMENTS BY AETNA $ 350.15 PAYMENTS PENDING W/AETNA $ 965.00 PAYMENTS BY CLIENT $ 20.00 ADJUSTMENTS $ 145.35 OUTSTANDING BALANCES $ 95.00 *Ebony J. Thornton reserves the right to supplement this Medical Billing Summary. 364365-1 -Created 10/04!06 Page 1 of 1 1-IC I• # A Ht]L~' SPIRIT HOSPITAL. PAGE No. TYPE OF D SG3 N 21ST ST ® 1 BILL DATE OF BILL PREY. BILL CAMP HILL, PA 17011 CYCLE 071G5.'Ob 717 763-2136 BTRTH-DATE HOSP.NO. uUTP. FEI # 23-1512747 0$/22/97 9G004 >1 E PATIENT NAME PATIENT NUMBER SEX AGE ADMISSION DATE DISCHARGE DATE DAYS u , urn , ~.t~t_~r~Y J r~ ~ I ~ ~ C.O.B. INSURANCE COMPANY NAME GROUP NUMBER POLICY NUMBER GUARANTOR MARY THORN~~ON 1 USHC BHXF~JZD NAME 20L W OLENNWOOD DR CAMP HILL PA 17011 AND ADDRESS - _ / '' AMOUNT OF PLEASE RETURN THIS PORTION WITH YOUR PAYMENT. ~G,ui ~~~ PAYMENT ~ DATE DESCRIPTION OF SERVICE TOTAL EST. COVERAGE EST. COVERAGE EST. COVERAGE EST. COVERAGE PATIENT POSTED HOSPITAL SERVICES CODE CHARGES INS. CO. NO.1 INS. CO. N0:2 INS. CO. N0.3 INS. CO. N0.4 AMOUNT aET,AI OF CUFtRENI" GHARGEB, PA't ENTS AND ADJUSTME TS :,/26 RM SLIM i~1ED 6114122725 6.50 6.50 x/28 IGHT ELBOW 013501294 201.00 201.00 ;/28 E~JEL IT FC 0117f05727 95. DO 95. OD :~!2B 'D LE~.1EL I I PC 0117303934 124. DO 129.00 ALAN E FORWARD G. GO ~tIMMA Y OF CURRENT CHARGES MrS SUPPLIES 276 b. SO a. 50 17X: X-RAY 326 201 . GD 201 . DG EMERGENCY RI~t7hi 456 95. GO 95. GCi GLINIC SiD 129.00 129.00 UB-T TAL OF CURR_ GN'ARG~S 431.50 431.. 50 , ~ . DIAL; _.. OS IS : .... .,. ,'c3,_ 1 1 _.__ . , - :~ 9>_r:S'': B _::, PAYE'sF~NT S LslfE. UPC3t••I RE 'EIPT rJ' F ;HIS STF~,'T MENT. YOi,I MAY SUBt~iIT THIS FO .M TG YOUR Ih~iSivIRANf'E CARR ER FOR REIMLUR.3EMENT. FEDERALIDENT.N0.23-1512747 T O T A L S 431.50 431.50 PATIENT NUMBER REFER ALL QUESTIONS TO THE PLEASE SEND PAYMENT TO: i 28G034~'3 BUSINESS OFFICE t7n~ 7ss-zisa. HOLY SPIRIT HOSPITAL PAY TH T S AMJUhal' ~~.•UC) ADDITIONAL PATIENT BILLING MAY BE NECESSARY FOR ANY _ 503 NORTH 21ST STREET CHARGES NOT POSTED WHEN THIS BILL WAS PREPARED HOB Y~ `3 F'' . ~i^(i I ~^~-I`-iF' 3. i 'iL_ OR IF INSURANCE CARRIERS DO NOT PAY ANY PART OF _ CAMP HILL, PA. 17011-2288 THE AMOUNTS SHOWN UNDER ESTIMATED INSURANCE G A~F' H i LL ~ F'= COVERAGE. Holy Spirit Hospital 503 North 21st Street • Camp Hill, PA 17011 • (800) 220-0290 October 10, 2006 Your Account With: Holy Spirit Hospital Account#: 28003903 For: Admission Date: Total Due: Ebony J Thornton 06/28/06 $75.00 Hours of Oaeration (EST) Mon -Wed Sam - 9pm Thu - Sam - 6:45pm Fri - Sam - 4:45pm Dear Ebony J Thornton: Is there some reason you have failed to contact this office? This is our third attempt to contact you by mail. We have also attempted to reach you he telephone. You should know that your failure to respond to this letter will cause us to consider further collection efforts. We remain committed to working with you to resolve this account. As indicated in our previous letters, we would prefer payment in full but if you are unable to remit the entire balance due, our representatives are prepared to work with you to reach a mutually acceptable payment schedule. Please call this office at 1-800-220-0290 today and speak with one of our representatives. To assure proper application of your payment, please attach the bottom portion of this letter to it. If you wish to pay by credit card, please complete the required information on the reverse side of this letter. If you have insurance that may pay all or a portion of this debt, please complete the information on the reverse side of this letter and return the entire letter. Sincerely, Holy Spirit Hospital ***Detach Lower Portion And Retum With Payment*** IONFIR110193 Account#: 28003903 Total Due: $75.00 PO Box 1388 Mt. Laurel NJ 08054-7388 RETURN SERVICE REQUESTED October 1 Q 2006 2ROU3903 1)3 796865 47903 Holy Spirit Fiospital PO Box 822183 Philadelphia PA 19182-2183 I~~rlll~l~r~~~lll~~l~~~l~l~~l~l~~~lll~~l~~rll~l~~l~~~ll~~l~~ll I~~~III~~~lll~~tll~ll~~~ll~tlll~~~II~~II~I~~I~~~I~III~~~~I~I.I Mary Thornton 20B W Glenwood Dr Camp Hill PA 17011-1138 OOOD28DD39D3D010000000750000100735000000011302 STATEMENT OF PHYSICIAN SERVICES ~ENNJ-~A-TE MARY THORNTON KANISH 20 WEST GLENN WOOD DRNE The Milton S. Hershey Medical Center APT B The College of Medicine CAMPHILL PA 17011-1138 AccouNT # 1580721 -~- IF ANY QuESTbNS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES P'R+DCF3IDRE "Q1AG DATE ~~ CODE . QTY , `DESCRIPTION :. -y ..., »> PATIENT: EBOhBf J TIDRFIITRI ]560721 A 08/28/06 * 04!14/06 A 04/14/06 A 0,8/28/06 07/03/06 07!20/06 07/20/06 O7/2d106 99213 99213 278. dD 813.52 ~ of 2 STATEMENT W1TE: 10/03/06 LAST STATEMENT DATE: 08J29/06 FED TAX ID #251857035 il~tS~ CHAI2C+E PA'YIYfEti'1'! ~A:tt~~R ADJt~STMEt~tT BJILA~iCE 7176874 PERFMiFED BY: BARBARA L HOFFMAFN !~ PENN STATE FAMILY HEAL PLACE OF SVC: SATELLITE CLINK OUTPATIENT VISIT EST 74.00 AETNA PAYMENT' 45.3b- AETNA HP CONT ABJ 8.64- AOVANCE PREPAY PAYMENT 20.Od- O.DO 7290181 PERFORIED BY: BARBARA L HDFFNANN MD PENH STATE FAMILY HEAL PLACE OF SVC: SATELLITE CLIMC OIJIPATIENT VISIT EST 74.00 AETNA PAYMENT 45.36- AETNA HP CDNT ADJ 8•~- BALANCE AFTER IN'S~ 20.00 ~ 07/03/06 730TO.RT 959.3 PERFORlED BY: MICHAEL A HULSE DD DIY OF DIAG RADIOLOGY ELBON ANTERDPOSTE LAT AEH 170.00 FOREARM ANTEROPOS LATERAL AEH 176.00 ~ ~ INDICATES NEN FINANCIAL ACTMTY SThCE LAST BILL. IF YOU HAVE ANY QIR.STlllhlSi ABO<1T TIE ALIT YQRI INSIARANCE COMPANY PAID, CONTACT TIEM DIRECTLY. FOR ANY OTTER QUESTIONS REGARDAB; YQUR BALANCE, PLEASE CONTACT OUR OFFICE. IF PAYMENT HAS BEEN MADE, THAN( YOU AND DISREGARD THLS BILL. PLEASE NOTE: TO KEEP YOUR ACC.QBR' GJRRENTs OUR POLICY IS TO APPLY YQUR PAYMENT TO-THE OLDEST OUt'STAND~ BALANCE. TNANK YOU FDR l1SING MSilC PHYSICIANS b'ROUP FOR YouR PHYSICIAN SERVICES. IF YQJ NAVE ANY QUESTIONS REGARDING THIS BILL, PLEASE CONTACT US AT 717-531069 DR 800-254-2619 BEi1EEN 8;OOIW AND 5:30PM MONDAY Ti~H NEDNESDAY OR BETMEEN B:DOAM AlD 4:30PN TH<ARSDAY AND FRIDAY. CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK ~ENNSTATE !51 The Milton S. Hershey Medical Center . The C'.oI1ege of MediclOe MARY THORNTON KANISH 2.0 WEST GLENN WOOD DRIVE APTB CAMPHILL PA 17011-1138 ACCOUNT # 1560721 2 of 2 IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES CeI)URi,); 1~~~"': ,d STATEMENT DATE: 10/03/06 LAST STATEMENT DATE: 08/29/06 FED TAX ID # 251857035 BALKE SlItIARY RE~I8LE PARTY AEH AETNA 1ft) ttH GUARANTOR RESlQl)IBILITY POLItY I B811CLJZD12l8S93 TOTAL $ 346.00 $ 20.00 BN MSHUe PHYSICIANS GROUP BIWNG SERVICES POBOX 854 HERSHEY PA 17033-0854 ~_JMe9RTA~n tJ.,CASE I}ET~eH..AffD "/:TURN BOTT1H!.P.ORTION OF $T~TE"6"'T E" Yl?~ P..4~1!!. STATEMENT DATE: GUARANTOR llESPON$IBILrTY: 10103106 $ 20.00 MINIMUM PAYMENT: $ 20.00 00001560721 UP 0000000000002000100306 1...11.1.1...1.1.11...1..1..1111.11....11..11....11..11.1..1.1 M~ MSHMC PHYSICIANS GROUP To: PO BOX 643313 PITTSBURGH PA 15264-3313 00000656 02 MARY THORNTON KANISH 20 WEST GLENN WOOD DRIVE APT B CAMPHILL PA 17011-1138 MfC VISA DISC : ~i'~~j?'-:;____U'l_ _ _ EIIII:_ 1560721 --:_:~ rJFFfCE USE OHLV CHECK ONE FOR CRmlT CARD PAYMENT, PLEASE flU-IN INFORMATION BELDW EXP DATE .;0:",,\ jj L~-, \~-~~,= 20.00 10124106 He: F6BO CARDHOLDER NAME (PRINT) CREDIT CARD SIGNATURE MSHMC PHYSICIANS GROUP o CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRE~ON~~N ~~ ._ .I....v _, NOV-87-2006 13 30 QUANTUM IMAGING 717 932 395 P.02 ACCT#_45824 R/P:THORNTON, EBONY SERVICE DATES (MMDDYY) FROM: 01/01/1900 TFiRU: 12/31/2099 INS CO:WALMART PAYOR CODE: 4 STMT CODE; 0 CURR.CHARGES: 965.00 CREDITS: .00 BALANCE: 965.00 NOTE:SLIP/FALL INJURY wALMART TICKET# PATIENT PT PRV DATE PROC DESCRN FEE PC MC BILLED REF PFiY 669233 EBONY OFF AJ 07/21/06 73221 MRI UPPER 965.00 40 0 08/14/06 834452 DX: 959.3 T/C AESCRYPTION REFERENCE DATE AMOUNT REC # THCC BILLED COM HARD COPY 08/14/06 .00 362738 TOTAL P.O2 b'+ ~ ~x~i 01/09/2007 17:32 RAWLINGS COMPANY -~ 17172349478 ~~e ~ bS C0111~a11~ LLC Subrogation Air; ision January 09, 2007 N0.490 DJQ2 Z,(>;;1sv1L1.I:, KS:~~rLC:t;ti' 40?~1-727 ~,~)iLEI'kiOhE (3~2) 5~,7-1279 Mr. CLARK. DEVERE 3211 NORTT~ FRONT STS=E'Z' P_O. $O~ 5300 ~q,RR1SSURG, FA 1.7110 0300 Re: Our Client: Aetr~a Metr-be~rlPatient: Iv1ARY KANISH-TkiORNTON/EBONY THO1tNTON Date of Loss: ~l27/2006 Our File No.: 06IJSH0900412 Xour Client: MARY ZCANZSH-THORN"1'ON/EBONY THORNTON Dear Mr. DEVERT: etiter will con~n dur agreebneirt to settle the above-referenced matter. We have agt'eed that try client's 'flits 1 claim for medical bentefits shall be settled in return for $2address:lease make your check payable to Tb,e Raw pugs Company atad ianail xt to my attention at the fouowrug Tha gaoQlings Company ATTN: Jon F . Rash File No.: 06[TS1~090U41z Subrogation j)ivision P.O. Sox. 740027 Louisviiie, KX; 402Q1-7427 I€the above statement does nat accurately reflect our agreement, please notify me ranmediately. Otherwise, 1 loop forward to receiving payzpeat within the next 30 days. Thank you for your cooperation izt this z~natter. Six-cerely, `~ ~ ~--- Jora l:. Kash Recovery Analyst (502) 814-2665 FAX: 502-753-7327(502) 587-1493 j fiC@rawlingscompany_cosn ~>., ~ ~ S ~xkil%t F CONTINGENT FEE AGREEMENT I, ~~„ ~rrt ~» individually and as parent and natural guardian of ~-~y~_~j,~!„ ~,,, retain and authorize the law firm of Metzger, Wickersham, Knauss & Erb, P.C., to do whatever they deem necessary or desirable in order to represent me and my .~~ in all claims for compensation and reimbursement for personal injuries, wage loss, medical expense and other damages resulting from an ~.~r that occurred on ~Z 7,L0,(~ 1. ATTORNEY'S FEES: The fee of the attorneys shall be contingent as follows: (a) Twenty-five percent (25%) of gross recovery; (b) SHOULD THERE BE NO RECOVERY BY SUIT OR SETTLEMENT, SAID ATTORNEYS DO NOT HAVE ANY CLAIM AGAINST US OF ANY KIND FOR LEGAL SERVICES RENDERED. 2. EXPENSES OF LITIGATION: No G yy,~~~ ~,,~ Gx~~.v~ c~w~ss Q R~Caves~ I acknowledge responsibility for all expenses incurred on our behalf to pursue our claim/case and my attorney shall be reimbursed out of the balance, after deduction of attorneys fees, of any recovery for all legal expenses which have not already been paid by me. I do hereby agree to pay all expenses incurred by our attorney in the preparation and presentation of this case and do understand that these expenses include, but may not be limited to, costs of medical reports and records, stenographic expenses connected with depositions, expert witness fees, photocopying charges, and mileage charges connected with the rendering of legal services. I understand that I am responsible for payment of these expenses regardless of the eventual outcome of the case and further understand that if our attorney deems it necessary, I may be asked to advance these costs prior to the incurring of any such expenses or the scheduling of any deposition. Page 1 of 3 3. APPEAL: I hereby further agree that our attorney may charge us reasonable additional compensation if it is necessary to try the case more than once, if the case is appealed, or if proceedings in other courts are necessary because of the change of circumstance of a party or for other reasons. 4. AUTHORITY: I hereby further agree that our attorney is hereby authorized to bring suit or to settle and compromise the claim, to execute all documents pertaining thereto, and to do all lawful acts requisite for effecting the claim on our behalf. 5. MEDICAL EXPENSES AND LIENS: I further authorize my attorney to pay out of any proceeds of settlement or trial any unpaid medical bills or liens for treatments or services or workers' compensation liens made necessary by the injuries sustained in this accident. I understand that my attorney is not guaranteeing the payment of any medical bills or liens, and they remain solely my responsibility. 6. INVESTIGATION OF MERITS OF CASE: I agree that our attorney accepts this employment on the condition that he will investigate this claim, and if it appears to be a recoverable claim, he will proceed to handle the claim; but if, after investigation, the claim does not appear to be recoverable, said attorney shall then have the right to rescind this Agreement. 7. EARLY TERMINATION: I hereby further. agree that if I decide to terminate this authority before any settlement is offered or any award is obtained the firm shall be entitled to reasonable compensation for all work done on the case__up _to that point. I _agree .that reasonable_____ _ Page 2 of 3 compensation for Clark DeVere, Esquire, or any other attorney involved in the handling of this case, shall be Two Hundred Dollars ($200.00) per hour, and other employees One Hundred Dollars ($100.00) per hour, or such higher rate as shall constitute his/her standard billing rate at the time that the work is performed, or the agreed upon percentage fee in paragraph one of this Agreement, whichever is greater. 8. WITHDRAWAL: I agree that our attorney may withdraw from this case at any time after reasonable notice to us, and I agree to keep him advised of our whereabouts at all times and to cooperate at all times in the preparation and trial of this case, to appear upon reasonable notice for depositions and Court appearances, and to comply with all reasonable requests made of us in connection with the preparation and presentation of this case. 9. CONFLICT: I also understand that if the investigation reveals that a parent is contributorily negligent in causing the accident the attorney's representation will solely be limited to representing the injured minor and there will be no representation of the parent. I also waive any conflict of interest that may arise by my meeting with the attorney to discuss the case. IN WITNESS WHEREOF, I have signed below on this ~ day of ~c vc-~ , 2006. ~ ~ ~~Q CLIENT: METZGER, WICKERSHAM, KNAUSS & ERB, P.C. ATTORNEY: arlc DeVere~ Esquire _. ____ _ _ ___ _ Page 3 of 3 ti b%~" ~ ~x RELEASE AND INDEMNIFICATION AGREEMENT We, Eric Thornton and Mary Thornton, parents, next friends and natural guardians of Ebony Thornton, a minor, for the sole consideration of Seven Thousand and Five Hundred and 0/100 Dollars ($7,500.00), receipt of which is acknowledged, do and on behalf of the executors, administrators, successors and assigns of Ebony Thornton and for ourselves, release and forever discharge Wal-Mart Stores, Inc. and Claims Management, Inc. and their past, present and future officers, directors, stockholders, attorneys, agents, servants, representatives, employees, divisions, subsidiaries, parent corporations, affiliates, partners, insurers, predecessors and successors in interest and assigns, and all persons or entities related thereto who are liable for their actions or omissions of and from any and all past, present, or future claims, demands, obligations, actions, causes of action and rights whatsoever, whether known or unknown, whether based on a tort, contract, constitutional violation or other theory of recovery, including, but not limited to all foreseen and unforeseen claims for bodily and personal injuries, property loss, loss of use, economic loss, medical and other expenses, loss of consortium, loss of enjoyment of life or any future wrongful death claim arising out of, connected with or any way resulting from the. incident which occurred on or about 06/27/2006 at Store No. 1886 in MECHANICSBURG, PA, which resulted in claim number 5004776. It is understood and agreed that this settlement is a compromise of a disputed claim and that the payment made is not to be construed as an admission of liability on the part of the party or parties being released, and that said releasees deny liability therefore and intend merely to avoid litigation and buy their peace. We declare and represent that the injuries sustained by Ebony Thornton and the derivative damages sustained by us are or may be permanent and progressive and that recovery from these damages is uncertain and indefinite and in making this release, it is understood and agreed, that we rely wholly upon our own judgment, belief, and knowledge of the nature, extent, effect, and duration of said injuries and liability for the injuries and this settlement is made without reliance upon any statement or representation of the party or parties released or their representatives or by any physician or surgeon by them employed. We further agree to indemnify, protect, and hold harmless the parties released in this Agreement and their insurers, agents, servants, successors, heirs, executors, administrators, and assigns from and against any and all claims or actions for damages, costs, or expenses which are now pending or which may at any time be brought by any person or party because of payments made on our behalf as a result of the aforesaid incident. We agree that if we or Ebony Thornton, a minor, have collected any money, payment or benefit under any kind of insurance policy or if any federal or state agency has made any payment or provided any benefits, including Medicaid or Medicare benefits, to us, to Ebony Thornton, a minor, or on his/her behalf, or if we or Ebony Thornton, a minor, have received any medical services from any hospital or doctor as a result of the incident mentioned above and the insurance company, federal or state agency or hospital or doctor is legally entitled to reimbursement or has legally valid subrogation or lien rights, then we agree to hold harmless and indemnify the parties being released under this Agreement and their liability insurance carriers, if any, from and against any such legally valid claims for reimbursement and/or subrogation or lien rights. It is understood and agreed that this indemnification agreement specifically includes all costs and expenses, which may be incurred by the parties released in the event of any further claim or claims against them because of payments made on our behalf arising out of the above described incident. It is further agreed that in the event any other party or parties are responsible to us or Ebony Thornton, a minor, for damages as a result of the above-described incident, or any matters related to the incident, the execution of this Release and Indemnification Agreement shall operate as a satisfaction of all claims we or Ebony Thornton, a minor, have as against such other party or parties to the extent of the pro-rata share of the liability of the parties being released, and this Release and Indemnification Agreement shall operate as a reduction, to the 369903-1 Page 1 of 2 extent of the pro-rata share of the released parties' fault, of the damages recoverable against all other tortfeasors. While continuing to deny liability, the parties being released and any other unnamed parties shall be considered joint tortfeasors for the purposes of this Release and Indemnification Agreement and any Contribution Among Joint Tortfeasors statute. It is the intent of this Release and Indemnification Agreement to comply with the provisions of the Uniform Contribution Among Tortfeasors Act and any similar statutory scheme that may apply in the forum state. We further declare and represent that no promise, inducement or agreement not expressed in this Release has been made to us, and that this Release contains the entire agreement between the parties, and that the terms of this Release are contractual and not a mere recital. We state that we have read this Release and Indemnification Agreement; We state that we are competent, under no legal disability, and fully understand the consequences of our actions and are acting for the benefit of and in the best interest of Ebony Thornton, a minor. The payment of $7,500.00 constitutes damages on account of personal injury or sickness in a case involving physical injury or sickness within the meaning of IRC §104(a)(2). This Release shall be interpreted in accordance with Pennsylvania law. Father, Next Friend and Natural Guardian of Ebony Thornton Mother, Next Friend VERIFICATION STATE OF PENNSYLVANIA COUNTY OF and Natural Guardian of Ebony Thornton ss. On the day of 2007, before me personally appeared and ,parents of Ebony Thornton, to me known to be the persons named in this Agreement and who executed this Release and Indemnification Agreement and acknowledged to me that they voluntarily executed the same. (SEAL) My Commission Expires: Notary Public 369903-1 Page 2 of 2 VERIFICATION I, Mary Thornton, as parent and natural guardian of Ebony Thornton, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Settlement, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsification to authorities. ~~ Mary Th rnton, as parent and natural guardian of Ebony Thornton Dated: ~2 y l ~ 369772-1 VERIFICATION I, Mary Thornton, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Settlement, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsification to authorities. Mary ornton t Dated: ~Z y ~o ~ 369772-1 VERIFICATION I, Eric Thornton, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Settlement, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsification to authorities. y Eric Thornton / Dated: Y~`~l ©~ 369772-1 VERIFICATION I, Eric Thornton, as parent and natural guardian of Ebony Thornton, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Settlement, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsification to authorities. Eric ornton, as par nt and n al guardian of Ebony Thornton Dated: X121(/ o `~ 369772-1 VERIFICATION The undersigned hereby certifies that he is the attorney for Petitioners, Eric and Mary Thornton, as parents and natural guardians of minor Ebony Thornton, and that the facts in the foregoing Petition for Approval of Minor Settlement are true and correct to the best of his knowledge, information and belief, and that said matters relating to the Petition for Approval of Minor Settlement are as known to the undersigned as to the clients, Ebony Thornton, by Eric and Mary Thornton, her parents and natural guardians, said knowledge being based upon information contained in the attorney's file in this matter, and further states that false statements herein are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsification to authorities. ~~ Clark DeVere, Esquire Dated: ~ /~ o~ 369772-1 CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a true and correct copy of the forgoing Petition for Approval of Minor Settlement with reference to the foregoing action by first class mail, prepaid postage, this 15' day of February, 2007, on the following: Claims Management, Inc. P.O. Box 1288 Bentonville, AR 72712-1288 Attn: Susan Jensen Clar eVere, Esquire 369772-1 (~ ~j-,~( "` ~ ~' o~~ W ~ ~'? --- i t 1 ~J ~ ('~. ~ r _. ~ ~ ~ } 'o ~, ~ _~ , -~- '~ .1 _~7 ~i~r? _. i .g- '-~. ~~ 1 FEB 0 6 2007 ~ y Metzger, Wickersham, Knauss & Erb, P.C. By: Clark DeVere, Esquire Attorney I.D. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 Attorneys for Plaintiffs (717) 238-8187 cdv~mwke.com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: EBONY THORNTON ~` v~` ~~~~ No. o ~t L'Yd DECREE AND NOW, this ~ day of ~, 200 upon consideration of the Petition for Approval of Minor Settlement, it is hereby ORDERED and DECREED that the settlement for the gross sum of Seven Thousand Five Hundred Dollars ($7,5000.00) is APPROVED. Counsel fees and expenses are found to be fair and reasonable and are also approved as set forth below. The distribution is directed as follows: (1) To be paid to Eric and Mary Thornton, parents and natural guardians of Ebony Thornton, the sum of $4,098.99, to be placed in a federally insured and restricted savings account or certificate of deposit, to be marked "not to be withdrawn, assigned, negotiated or otherwise alienated until Ebony Thornton reaches her majority on August 22, 2015, except upon prior Order of the Court"; (2) To be paid to Metzger, Wickersham, P.C., for counsel fees and expenses the sum of $2,058.99; 369772-1 (3) To be paid to The Rawlings Company on behalf of Aetna for medical expense lien, the sum of $282.02; (4) To be paid to Central PA MRI for outstanding medical bill, the sum of $965.00; (5) To be paid to Holy Spirit Hospital for outstanding co-pay, the sum of $75.00; and (6) To be paid to University Physicians Group for outstanding co-pay, the sum of $20.00. Eric and Mary Thornton, as parents and natural guardians of Ebony Thornton, are authorized to sign the Release, attached to this Petition, and discontinue this action. Proof of Deposit of the amount set forth in paragraph 1 above shall be filed within 20 days of the negotiation of the settlement payment. J. cc: Clark DeVere, Esquire -counsel for Petitioner ~~ j~ a ~~~ 0 7 Susan Jensen -Claims Management, Inc. 369772-1 i I .. 11 ~ r. s ~, r^... 7t_ S _.. ,`>~ Metzger, Wickersham, Knauss & Erb, P.C. By: Clark DeVere, Esquire Attorney I.D. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 Attorneys for Plaintiffs (717) 238-8187 cdv _ mwke com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: EBONY THORNTON NO.07-670 CIVIL TERM PROOF OF DEPOSIT In accordance with Pennsylvania Rule of Civil Procedure 2039 and Judge Hess' Order of February 8, 2007, the undersigned is filing a photocopy of the Certificate of Deposit of $4,098.99 of the settlement proceeds in the above matter which were deposited on April 2, 2007 at Members 1St Federal Credit Union in the name of Ebony Thornton, "not to be withdrawn, assigned, negotiated or otherwise alienated until Ebony Thornton reaches her majority August 22, 2015, except upon prior Order of the Court." The photocopy of the Certificate of Deposit and letter dated April 2, 2007 from Members 1St is attached hereto as Exhibit "A". METZGER, WICKERSHAM, KNAUSS & ERB, P.C. By: Clark De ere, Esquire Attorney I.D. No. 68768 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 Attorney for Plaintiff Dated: April30, 2007 375608-1 EF~~y~k ~ ARR-10~~2001 TUE 10 16 AM MEMBERS 1ST CAMP HILL FAX No. 7171611591 P~002 ~1rIEM.BERS 1'~ P$pp~ALCItbDI'P 17NION ~~ Account Summary for Account 0000303582 THORIVTQN,ESONY Account 0000303582Court Ordered Name Prime: EBONY THORNTON Lookup 96: ACH 303582000 Comment: FUNDS FROZEN UNTiL 8/22/2015 Note: 1 Note Share ID Q0: SAVTNG5 5.00 Hold: General expires,08/ZZ/15 ~00~00 Share ID 40: 60 MONTH CERT 4,093.99 Hold: General expires 08/22/15 1.,000,000.00 Transfer: Maturity to 0000303582 S 00 0,00 App ID 00; A MEMBERSHIP APPLICATION In Progress Note: 2 Notes 5000 Louise Dxxve ~O• Bow 40 Mechanicsburg, Pezxxzsylvaz~ia 17055 (717) 697-1561 urw~vzx~.ez:tzbezslst.org St MEMBERS 1't PEDERAL CREDIT UN[ON ~~~ 1 To ~J hOr~ ~C r~o,-~ C~I1C,~xn , ~~e~a~c~ n`~ ~bon~. 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Harrisburg, PA 17110-0300 Attorneys for Plaintiffs (717) 238-8187 cdv mwke com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: EBONY THORNTON ~~~ No. o ~ -L'Yd ~! v ~ ~~T . DECREE AND NOW, this ~ day of ~~~`'" '~ 200 upon consideration of the Petition for Approval of Minor Settlement, it is hereby ORDERED and DECREED that the settlement for the gross sum of Seven Thousand Five Hundred Dollars ($7,500 :00) ~•is APPROVED. Counsel fees and expenses are found to be fair and reasonable and are also approved as set forth below. ~ The distribution is directed. as follows: ~~~~ 0 1'1n\ 5 WCIS ~ V1a-Q,~-~Gp i ntv ~ 10-2 ~~ ~~Yd ~ ~ ~r (1) To be paid to Eric and Mary Thornton, parents and natural guardians of Ebony Thornton, -the ruin. of $4,08.99,. to_ be placed in a federally insured and restricted ~-~' .savings account or certificate of deposit, to be marked "not to be withdrawn, assigned, negotiated or otherwise alienated until Ebony Thornton reaches her l majority on August 22, 2015, except upon prior Order of the Court"; (2) To be paid to' Metzger,~yickersham; P.C., for counsel fees and expenses •the sum of $2,058.99; ~' ~ • CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a true and correct copy of Plaintiff's Proof of Deposit with reference to the foregoing action by first class mail, postage prepaid, thisio k-day of April, 2007 on the following: Claims Management, Inc. P.O. Box 1288 Bentonville, AR 72172-1288 Attn: Susan Jensen The Honorable Kevin Hess Court of Common Pleas of Cumberland County 1 Courthouse Square Carlisle PA 17013 METZGER, WICKERSHAM, KNAUSS & ERB, P.C. Cr~~~ ~%iarx tie v ere, Esqui- rZs-~- 375608-! C~ ~_ ~' ~ ~ -rq _~ rt~~ ~ r~~.r; ~~a ~` ~ _. 4: ~" ~ ~~; ~ . ~~ °" ~