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However, the 1990 amendments to the PMVFRL made a substantial revision to
!
I
under the PMVF'RL.
91722, The section now provides:
In any action for damages against a tortfeasor or in any uninsured
or underinsured motorist proceeding, arising out of the
maintenance or use of a motor vehicle, a person who is eligible to
receive benefits under the coverage as set forth in this
subchapter, or workers compensation, or anv proQram, Qroup
contract or other arranQement for pavment of benefits as defined
in 91719 (relatinQ to coordination of benefits shall be precluded
from recovering the amount of benefits paid or payable under the
subchapter, or workers compensation, or any program, group
contract or other arrangement for payment of benefits as defined
in91719,
75 Pa, C,S,A, 91722 (emphasis supplied)
Thus, the Act 6 Amendment clearly broadened the effect of the preclusion
Recently, the United State District Court for the Eastern District of
section to include not only individuals who received first party benefits from a policy issued
pursuant to the PMVFRL, but also to any individual receiving payment of their medical bills
or reimbursement of their wage loss, These Amendments were a substantial departure from
the common law "Collateral Source Rule", As such, it is submitted, that the legislature
wished to preclude the "double recovery" that was available under the PMVFRL prior to
1990,
Pennsylvania had occasion to interpret the preclusion provisions of 75 Pa, C,SA 91722, In
Austin v, Dionne, 909 F,Supp, 271 (E.D. Pa, 1995), (a copy is attached as "Exhibit A") a tort
action was brought by a New Jersey resident against a Pennsylvania resident to recover
compensation for injuries allegedly sustained in an automobile accident that occurred on
Interstate Route 95 in Philadelphia, PA. The Plaintiff had received reimbursement for lost
Respectfully submitted,
By: or-
James G, Nealon, III, Esquire
Atty. 1.0, #46457
301 Market Street -- 9th Floor
P.O. Box 865
Harrisburg, PA 17108-0865
(717) 232-9900
NEALON &
<
~
~
909 F,Supp, 271
Pens, Plan Guide P 23925R
(Cite us: 909 F.Supp. 271)
Joseph und Mury AUSTIN, 1'lulnUffs,
v,
Churles mONNE, Defendunt.
Clv. A. No. 95-359.
Uniled Slates Distriet Coun,
E,D, Pennsylvania,
Dee, 7, 1995,
AUlomobile accidem viclim brought altion againsl
alleged lon-feasor 10 recover damages after
rcceiving personal injury proleetion (PIP) bene fils
and wage loss benefils under employer's disabilily
insurance policy, Alleged ton- feasor moved to
preclude evidence of lost wages, The District
Coun, Eduardo C, Robreno, J" held thaI: (I)
Pennsylvania law against double recovery applied to
issue of righl to recover for lost wages, and (2)
Employee Retiremem Income Security Ael (ERISA)
did nol preempt Pennsylvania's bar against double
recovery afler receiving disabililY insurance benefits
for injuries caused by aUlomobile accident.
Motion gramed,
[I) ACTION Q;:;;:>17
\3k17
Under Pennsylvania choice of law rules, if law of
either jurisdielion may be applied wilhoUl impairing
governmenlal inleresls of jurisdiction whose law is
not bcing applied. no connicl exisls between
respeclive laws of each jurisdiction. and eoun should
apply law of forum,
[2] ACTION Q;:;;:>17
13kl7
Under Pennsylvania choice of law rules, if one of
two jurisdiction's governmemal interesls would be
impaired by application of other jurisdiclion's law,
false eonnict arises; in other words, if neilher
jurisdielion's governmemal inlerests would be
harmed when applying law of one jurisdiction,
whose in Ie rests would be impaired if its laws were
nol applied, connicl is false,
[3J ACTION Q;:;;:>17
13kl7
Under Pennsylvania choice of law rules, true
connict arises only if, no mallcr which jurisdielion's
law is applied, governmemal imeresls of jurisdiction
I'u~e 1
'I
~ !
whose law is nol applied would he impaired; if lrue
connicl exists, coun musI determine which stale has
greater inleresl in applicalion of ils law,
[4] AUTOMOJ1lLES Q;:;;:>229.5
48Ak229,5
L1W of Pennsylvania as forum state governed
automobile aecidenl victim's right to recover lost
wages from alleged lori-feasor after receiving
personal injlJrY proteclion (PIP) bene fils under
aUlomobile insurance policy; sinee amoum payable
as lost wages under PIP coverage was excludable
under both New Jersey and Pennsylvania law, law of
eilher jurisdiction could be applied wilhoul injuring
governmemal imerests of the olher, and there was no
connict. N.J,S,A ! 39:6A-12; 75 Pa,C,S, ~
1722,
,
...
(5) AUTOi\lOUlLES Q;:;;:>229.5
48Ak229,5
New Jersey law that amounlS recoverable under
employer's disabililY insurance policy can also be
recovered as wage loss in action againsl lon-feasor
arising from automobile accidem is in true connict
wilh Pennsylvania Motor Vehicle Financial
Responsibility Law (MUFRL) prohibiling double
recovery wilhout exception, and, Ihus, Pennsylvania
connict of law rules required coun to determine
which state had greater imeresl in application of its
law; if Pennsylvania law were applied, New
Jersey's imeresl in preserving double recovery in
automobile accidems cases from nonautomobile
insurance policies would be impaired, and if New
Jersey's laws were applied, Pennsylvania's interest
againsl double recovery would be impaired,
N.J,S,A, 2A:15-97; 75 Pa,C,S,A, ~ 1722,
(6) AUTOMODlLES Q;:;;:>229.5
48Ak229,5
Pennsylvania's MOlor Vehicle Financial
Responsibility Law (MUFRL) prohibiting double
recovery, rather than New Jersey law permilling
aUlomobile accidem victim 10 recover lost wages
from alleged ton-feasor despile recovery for them
under employer's disabililY insurance policy, applied
10 New Jersey viclim's Ion action against
Pennsylvania alleged ton-feasor arising out of
accidenl in Pennsylvania; victim was employee in
Pennsylvania, New Jersey's permissive view of
double recovery in aUlomobile accident cases
appeared 10 be resull of gap in legislalive scheme.
rather than aniculalion of strong policy, and
[
~
,
Copr. <0 West 1997 No Claim 10 Orig, U,S, GOVI, Works
909 F,SuPP, 271
(Cite os: 909 F.Supp. 27t)
overwhelming number of contacts were associated
with Pennsylvania, N.J ,S,A, 2A: 15.97; 75
Pa,C,S,A, 1722; Restatement (Second) of
Connicts of Law ~ 145(2),
(7) UAMAGES ~59
115k59
ERISA did not preempt provision of Pennsylvania's
Motor Vehicle Financial Responsibility Law
(MVFRL) that barred automobile accident victim
from receiving from alleged tort-feasor double
recovery for benelits paid by disability insurance
policy issued to victim's employer; prohibition
against double recovery did not pertain to amounts
paid or payable to victim under disability policy,
tort-feasor was source of funds seeking protection,
and victims were not attempting to shift liability to
the employee welfare benelit plan, Employee
Retirement Income Security I 514(a), 29
U,S,C,A, ~ 1144(a); 75 Pa,C,S,A, ~ 1722,
[7] STATES ~18.4I
360k18.41
ERISA did not preempt provision of Pennsylvania's
Motor Vehicle Financial Responsibility Law
(MVFRL) that barred automobile accident victim
from receiving from alleged tort-feasor double
recovery for benelits paid by disability insurance
policy issued to victim's employcr; prohibition
against double recovery did not pertain to amounts
paid or oayable to victim under disability policy,
tort-feasor was source of funds seeking protection,
and victims were not attempting to shift liability to
the employee welfare bene lit plan, Employee
Retirement Income Security I 514(a), 29
U,S,C,A, ~ 1144(a); 75 Pa,C,S,A, ~ 1722,
.272 Benjamin Kuby, Klovsky, Kuby & Harris,
Philadelphia, PA, for Plaintiffs,
Kevin R, Mc Nulty, German. Gallagher &
Murtagh, Philadelphia, PA, Vaughn A, Booker,
Philadelphia, PA, Timothy E, Games, German,
Gallagher & Murtagh, Philadelphia, PA, for
Defendant.
MEMORANDUM
EDUARDO C, ROBRENO, l>istrict Judge,
Plaintiff Joseph Austin ("Austin") is a New Jersey
resident employed by Philadelphia Newspapers,
tnc" ("PNI") in Pennsylvania, He was injured in an
automobile accident in Pennsylvania while on
I'uge 2
personal business, As a result of the accident,
Austin sought lost wages through his automobile
insurance policy and through supplemental payments
for wage benefits under his PNI disability insurance
policy,
Defendant Charles l>ionne ("Dionne") has filed a
motion in limine seeking to preclude plaintiffs from
introducing at trial evidence .27: lost wages
which have been paid or arc payable to Austin under
his automobile and disability insurance policies,
l>ionne argues that collecting benefits from a
tortfeasor as well as from Austin's insurance policies
constitutes double recovery, a practice barred under
Pennsylvania law,
On the other hand, plaintiffs contend lItat New
Jersey law applies in this case, and that, under New
Jersey law, double recovery is permitted in cases
involving automobile accidents, Furlltermore,
plaintiffs argue that, even if Pennsylvania rather than
New Jersey law applies, ERISA preempts
Pennsylvania law because Austin's benefits have
been paid pursuant to a self-funded disability
insurance policy provided by PNI under a collective
bargaining agreement. Finally, plaintiffs contend
that. under ERISA, unlike Pennsylvania law, Austin
is entitled to collect from more than one source,
The Court finds that, under Pennsylvania's choice
of law rules, Pennsylvania law applies to lite
interpretation of first party payments under
plaintiffs' PIP automobile insurance policy, as well
as the employer's disability insurance policy, In
addition, the Court concludes that ERISA does not
preempt the Pennsylvania law barring double
recovery, Under the facts of this case, Pennsylvania
law neither interferes with nor regulates a claim by
or against lite PNt disability insurance policy
operating under ERISA,
The following facts are undisputed, Plaintiffs
Joseph and Mary Austin are New Jersey residents,
Austin is employed as a pressman at the Philadelphia
Inquirer, At the time of the accident. Dionne was a
resident of Pennsylvania,
On February 10, 1993, at approximately 4:45 p,m"
Austin was proceeding south on Interstate Route 95
in Philadelphia, Pennsylvania, in his pick-up truck,
At the same time, Dionne was travelling south on
Interstate Route 95 in his own vehicle, Dionne's car
Copr. <C> West 1997 No Claim to Orig, U,S, Gov!. Works
909 F,SuPP, 271
(Cite 3._: 909 ....Supp. 271, .273)
collided wilh lhe back of Austin's lruck, causing
Auslin 10 suffer soft tissue injuries 10 his neck and
back,
Following the accidenl. Austin missed
approximately 52 weeks of work, He sought losl
wages in the amounl of $5,200 under his automobile
personal injury protection ("PIP") coverage with
Prudenlial Insurance Company. which have nol been
paid to dale. but which plainliffs COnlend arc
payable, In addition, Auslin received $520,57 per
week from February 10, 1993, 10 January 9, 1994,
from his PNI disability insurance, This coverage is
provided under the collective bargaining agreemenl
between Philadelphia Newspapers Union Local 16
and the Philadelphia Inquirer,
II
(A)
Plainliffs cOnlend that New Jersey law applies to
lhis case, Defendanl disagrees, arguing ins lead thai
the law to be applied is lhat of Pennsylvania,
Because lhe case involves contacts which impacl
more than one jurisdiclion, the Court must choose
between the relevanl laws of the two jurisdiclions,
See Robcn A, Leflar. American Connicls UlI ~ 2,
al 3 (3d cd, 1977),
In a diversity aClion, "tile choice of law rules of the
forum slate [determine] which state's law will be
applied," Shuder v, McDonald's Corp" 859 F,2d
266, 269 (3d Cir,1988) (ciling Klaxon v, Slenlor
Electric Mfg, Co" 313 U,S, 487, 496, 61 S,CI.
1020. 1021, 85 L,Ed, 1477 (1941)), Accordingly,
lhe Court will apply Pennsylvania's choice of law
rules,
In Griffith v, United Air Lines, Inc" 416 Pa, I,
203 A,2d 796 (1964), the Pennsylvania Suprcl.:e
Court abandoned the traditional lex loci delicli
connicts rule for "a more flexible rule which pennits
analysis of the policies and interesls underlying the
particular issue before the courl." Id, 203 A,2d at
805, In commenling on the devclopmenl of the rule
set forth in Griffith. the Third Circuit slated.
ITlhis new connicls melhodology has evolved inlo
a hybrid approach that "combines the approaches
of bOlh Reslatemenl II (conlacts eSlablishing
significanl relationships) and 'interesl analysis'
(qualilalive appraisal of the relevanl Slates'
policies with respect 10 Ihe cOnlroversy),"
.274 Lacey v, Cessna Aircraft Co" 932 F,2d 170,
187 (3d Cir,1991) (quoting Melville v, Am, Home
Puge 3
Assurance Co" 584 F,2d 1306, 1311 (3d
Cir,1978)),
[II Under Pennsylvania choice of law rules and the
method of analysis established in Griffith, lhree
outcomes may obtain, First, if lhe law of either
jurisdiction may be applied withoUl impairing the
governmenlal inlerests of the jurisdiclion whose law
is not being applied, no connict exists between the
respective laws of each jurisdiclion and lhe court
should apply the law of the forum, See Eugene F,
Scoles and Peter Hay, Connict of Law: ~ 2,6, at 17
& n, 8 (2d cd, 1992),
(2) Second, if only one of the two jurisdiction's
governmenlal interests would be impaired by the
application of the olher jurisdiclion's law. a "false
connicl" arises, Lacey, 932 F,2d at 187,
"Although IWO jurisdiclions have nominal COnlaClS
with the transaction, only one jurisdiclion is truly
concerned with the result," Kuchinic v, McCrory,
422 Pa, 620, 624 n, 4, 222 A,2d 897, 900 n, 4
(1966), In olher words, if neither jurisdiction's
governmental inlerests would be hanned when
applying the law of the one jurisdiction. whose
inlerests would be impaired if its law were not
applied, the conniel is "false," [FN I)
FNI. The eoneepl of "false connicl" is derived
from the scholarship of ProCessor Brainerd Currie.
See Brainerd Currie, Selmed Essays on lhe
Conniet of Laws 189 (1963), Professor Corrie
dcnned a false connict in the following manner:
-(willen one of (WO states relatcl1 to :1 case has a
legitimate interest in the application of its law ami
policy amllhe other SIJ.lc has none, there is no real
problem; clearly the law of the interesled state
should be applied," Id,
(3) Third, a "Irue connict" arises only if, no mailer
which jurisdiction's law is applied, the governmental
inlerests of the jurisdiclion whose law is nol applied
would be impaired, L1cey, 932 F,2d at 187 n, 15,
"If a true connicl exists, the court must detennine
which stale has lhe grealer inlerest in lhe applicalion
of ils law," Id,
The Courl shall now apply the Pennsylvania connicl
of law analysis to bOlh the automobile and disability
insurance policies in queslion,
(I)
[41 Both parties agree that the amount payable to
plaintiffs under PIP lost wages benefits in an action
Copr. Cl West 1997 No Claim 10 Orig, U,S, Govl. Works
909 F ,Supp, 271
(Cite us: 909 F.Supp. 271, .274)
against Ihe tOrlfeasor is excludable under both New
Jersey and Pennsylvania law. See Plaimiffs' Pre.
Trial Memorandum, doc, no, 20, at 5; Defendanl's
Memorandum in Support of His Motion in Limine,
doc, no, 19, al 3, Because the law of either
jurisdiclion may be applied wilhout injuring Ihe
govemmemal imerests of lite other, Ihere is no
connicl. See 75 Pa,Cons,Slal.Ann ~ 1722 (1995);
39 N.J,Slal.Ann 6A-12 (West 1994), [FN21
Therefore, the Court musI apply Ihe law of
Pennsylvania, the forum slate,
FN2, Pennsylvania MOlor Vehicle Financial
ResponsibililY Law ~ 1722 provides.
In any action for damages ". arising out of lhe
maimenance or use of a motor vchich:, a person
who is eligible to receive benefits under the
coverages set fonh in this subchapter. or workers'
compensation. or any program. group contract or
other arrangement (or payment of benefits as
defined in section 1719.., shall be precluded from
recovering Ihe amoum of benefilS paid or payable
under Ihis subchapter. or workers' compensation.
or any program, group contract or olher
arrangement for payment of benefits as defined in
seclion 1719,
75 Pa,Cons,SIaI.Ann, ~ 1722 (1995),
New Jersey MOlor Vehicles and Traffic
Regulalions, Sublille 2, 6A.12 provides in
peninem pan,
[E) vidence of the amoums colleclihle or paid .., 10
an injured person. including lhe amounts of any
deduclibles. copayments or exclusions... otherwise
compensated is inadmissible in a civil aClion for
recovery or damages for bodily injury by such
injured person.
39 N.J,SIaI.Ann, ~ 6A-12 (WesI1994),
(2)
[5] The Court now lurns 10 whelher a conflict exists
belween New Jersey law and Pennsylvania law
regarding the exclusion of wage losses recovered
under the PNI disability insurance policy,
Under New Jersey law, in an action by an injured
plainliff againsl a lortfeasor, collaleral source
benelits arc excluded from damages Ihal may be
submined 10 a jury, 2A .275 N.J,Sta!.Ann, ~ 15.97
(West 1994), [FN3] Yet, all aClions brought
pursuant to Ihe provisions of Tille 39 (actions
relaling 10 mOlor vehicles and Iraffic regulations) are
exempt from this general exclusion of collateral
source bene filS, Id, The effect of exempting molor
vehicle accidents from Ihe general prohibilion
against double recovery is, as the New Jersey
Puge 4
Superior Courl has recognized, 10 make available to
a plaimiff in an automobile accident "addilional
benefits" from an employer's voluntary supplememal
insurance plan, O'Boyle v, Prudential Ins, Co, of
Am,. 241 N,J,Super, 503, 509, 575 A,2d 515, 518
(\990) (declining 10 "injecI some lurking judicial
suspicion Ihat a betler policy [against double
recoverYl could or should be engrafled on Ole
slatulory scheme"), Thus, under New Jersey law,
despite lite facI lItat double recovery is prohibited in
all other conlexts. in an aClion against a lorlfeasor
relating 10 an aUlomobile accidem, the amounts
recoverable under an employer's disability insurance
policy are not excluded from wage loss calculalions,
FNl Seclion 2A: 15.97 provides in pcninem pan,
In any civil aClion broughl for personal injury or
death, except actions brought pursuant to the
provisions of p,L. 1972. c, 70 (C, 39:6A-l el seq,).
if a plaintiff receives or is emitlel.l to receive
bencfils for Ihe injuries allegedly ineurrcd from any
olher source other than a joint tonfcasor, the
benefits, mher than workers' compensalion benefits
or Ihe proceeds from a life insurance policy, shall
be disclosed 10 Ihe coun and Ihe ame thereof
which duplicates any benelic contJinel.l in the awanJ
shall be dcducled from any award recovered by Ihe
plaillliff....
2A N.J,SIaI.Ann, ~ 15.97 (WesI1994),
By contrast, Pennsylvania law prohibits double
recovery willtom exception, Und,! 1722 of lite
Pennsylvania Motor Vehicle Financial Responsibility
Law, "in any aClion for damages againsl a
tOrlfeasor," a parlY is precluded from "recovering
lite amount of benefits paid or payable under... any
program. group contract or other arrangement for
payment of benelils," 75 Pa,Cons,Slal.Ann ~ 1722
(1995), As lite Third Circuit has recognized, ~ 1722
reOects Ihe Pennsylvania legislature's goal of
prevenling double recovery from bOlh an employer's
disability insurance fund and a lortfeasor, See
Travitz v, Northeast Dep'l ILGWU Health and
Welfare Fund, 13 F,3d 704, 710 (3d Cir,1994)
(finding that plaimiff atlempted 10 circumvent
purpose of bo ~ 1722 and disability insurance
conlraCI's exclusion clause), Therefore, applicalion
of PeJnsylvania law in the present case would result
in excluding from plaintiffs' wage loss calculations
the amounls already recovered from Austin's PNI
disabililY insurance policy,
In short, if New Jersey's laws were applied,
Pennsylvania's inlerest against double recovery
would be impaired, The converse is equally lrue, If
Copr, <Ci Wesl1997 No Claim 10 Orig, U,S, Gov!. Works
909 F,Supp, 271
(Cite us: 909 F,Supp. 271, .275)
Pennsylvania law were applied, New Jersey's
interest in preserving double recovery in automobile
accident cases from non-automobile insurance
policies would be impaired, The Court finds that
this conflict is a "true- one, since the governmental
interests of one jurisdiction would be impaired if the
other state's law were applied. and vice.versa,
[FN4] Lacey. 932 F,2d at 187 .27f 15, The
Court must now decide whetller New Jersey or
Pennsylvania law applies to this case,
FN4, An argumem could be made that. in realilY,
the: Coun is confronted with :I. -false conflict"
since bulb New Jersey and Pennsylvania policies
appear aligned againsl douhle recovery, Even ir
the Coun were to find the existence of a false
conflict. however. iLS ultimate conclusion woullJ
remain the: same.
In Kiss v, Jacoh, 138 N.l, 278, 650 A,2d 336
(1994), the New Jersey Supreme Coun found that
'ItJhe legislalure's purp<1Se in enacling N.l,S,A,
2A: 15.97 was 10 do away wilh Ihe common,law
collateral-source rule Iwhich) permits :1 (On victim
to retain collateral benefits ... in addition to an)'
amount 11131 the victim might n:CQvc:r from that
derendam." Id, 650 A,2d al 337, Despile the New
Jersey Supreme Coun's aniculalion of a slrong
Slale policy against douhle recovery, Ihe facI
remains that the state legislalUn: Idt a gap in its
laws. by explichly exempling Tille 39 aClions from
the scope or Tille 2A:15 Douhle recovery
remains available from non-automobile insurance
policies in tilt: context of molor vehicle accidents.
notwithstanding New Jersey's efforts Mto effect cost
containment- in -insurance-type benefits: Id. 31
338; see also O'Doyle, 241 N.l,Super, al 509, 575
A,2d al 518 (declining 10 "engrarl" . "beller
policy" 3gainst double recovery onlO (he SlJtulOry
scbeme),
Yet, precisely because of the New Jersey
legisl'lUre's general policy against double
recovery. a pany could argue Ihal "only
(Pennsylvania'sl govemmemal imerests would be
impaired by Ihe application of [New Jersey's) law"
which pennits double recovery, lacey. 932 F,2d
al 187, Pennsylvania's slrong policy againsl double
recovery has already been expressed 11m ~,h
1722,
(B)
16) Under the Griffilh method of an. lysis, a court
must examine both the contacts establishing
significant relationships, as set forth in Restatemenl
(Second), and Ihe governmental interesls and
policies of the stales pertinent to Ihe controversy,
Lacey, 932 F,2d at 187; Griffith, 203 A,2d at 805,
I'uge 5
Section 145 of the Restalement (Second) of Connicts
of Law directs a court to consider Ihe following
contacts ill order to determine the applicable law;
a) the place where tlle injury occurred,
b) the place where the cOllduct causing the injury
oecurrcd,
c) Ihe domicile, residence, nationality, place of
incorporation and place of business of the parties,
and
d) the place where the relationship, if any,
between the parties is centered,
Restatement (Second) of Conflicts of Lal ~ 145(2)
(1969), Austin's injuries and Dionne's conducl
causing the injury both occurred on Interstate Route
95 in Pennsylvania, Dionne's residence is in
Pennsylvania, While both plaintiffs reside in New
Jersey, Austin is employed at Philadelphia
Newspapers, Inc.. under whose collective bargaining
agreement he claims entitlement to disability
payments,
In addition, as this Court has discussed in the
previous section, Pennsylvania has an articulated
policy against double recovery and a strong interest
in conlaining the rising costs of automobile insurance
for its residents, By contrast, New Jersey's
permissive view of double recovery in automobile
accident cases appears to be the result of a gap in the
legislative scheme rather than an articulation of a
strong policy favoring double recovery in all such
cases, See supra nole 4; cf. Kiss v, Jacob, 138 NJ,
278,650 A,2d 336,337-38 (1994) (finding intent "to
prohibit duplicative recovery by plaintiffs" when
New Jersey legislature drafted 2A NJ,Stat.Am ~
15.97), Clearly. application of New Jersey law
would defeat Pennsylvania's policy against double
recovery, Although the converse is likewise true,
the Court finds that the policy in New Jersey
permiuing double recovery has been less robustly
expressed than in Pennsylvania,
Under the contacts prong of Ihe Griffith analysis,
the Court concludes that an overwhelming number of
contacts are associated with Pennsylvania, not New
Jersey, Moreover, after assessing "the policies and
interesls underlying the particular issue before the
court," Griffith, 203 A,2d at 805. Ihe Court finds
that Pennsylvania "has the greater interest in the
application of its law," Lacey, 932 F,2d at 187 n,
15, Therefore, the Court shall apply Pennsylvania
law 10 plaintiffs' claims under the PNI disability
insurance policy,
(C)
Copr, iCI West 1997 No Claim to Orig, U,S, Govt. Works
'I
909 F,Supp, 271
(Cite us: 909 F.SuPII. 271, .276)
171 The Coun shall now consider whether ERISA
preempts 1722 under the facls of Ihis case,
Application 0 ! 1722 would prevelll the AUSlins
from recovering damages from Dionne once they
have recovered from the PNI policy, If, however,
ERISA preemplion operates to proscrib< ~ 1722, the
Auslins would recovery doubly, TIle Coun finds
dlat ERISA preemplion is not implic:lled here
because the operation 0 ~ 1722 in this case neither
shifts liability from Dionne to the ERISA-qualified
PNI plan nor interferes with the administration of
Ihe plan,
(I)
Plaintiffs contend that, even if Pennsylvania law
were to apply, ERISA preempts the applicability of ~
1722 to the PNI disability insurance policy, Under
ERISA, an "employee welfare bencfit plan" is
defined as
any plan, fund, or program ..' established or
maintained by an employer or by an employee
organization, or by both, to the extent that such
plan, fund, or program was established or is
maintained for the purpose of providing for its
panicipants or their beneficiaries, through the
purchase of insurance or otherwise .., medical,
surgical. or hospital care or benefits, or benefits in
the event of sickness, accident. disability. death or
unemployment.. ..
29 U,S,C,A, ~ 1002(1) (Supp, 1995), Funhermore,
ERISA covers, with cenain exceptions, .277 FN51
"any employee benefit plan if it is established or
maintained (1) by any employer engaged in
commerce or in any industry or activity affecting
commerce; or (2) by any employee organization or
organizations representing employees engaged in
commerce or in any industry or activity affecting
commerce; or (3) by both," 29 U,S,C,A, ~ l003(a)
(1985),
FN5, Plaimifrs comend Ihallhe exceplions lis led in
~ 1003(h) are nOI applieahle 10 Ihe PNI plan, See
Plaintiffs' r-.1c=moranllum Contra Motion in Limine
Filed hy Defendam Seeking 10 Preclude Proof of
Loss of Wages Under Malar Vehicle Financial
Responsibility Ael, Seelion 1722. in Third Pany
Aelion, dated Seplember 8. 1995. at (unnumbered)
4, Ahsem any .lIeg.lion by Ihe defend.1ll to Ihe
cOnlrary. the COUrI will deem (he exceptions
inapplicable here.
Three ERISA statutory provisions control the issue
of preemption, First, thc preemption clause
PURe 6
prohibits state regulation of employee welfarc
benefit plans which qualify under the .bove
provisions:
Except as provided for in subsection (b) of this
section (the ERISA savings c1ausel, the provisions
of this subchapter ..' shall supercede any and all
State laws insofar as they may not or hereafter
relate to any entployee benefit plan described in
section 1003(a) of this title and not exempt under
section 1003(b) of this title,
29 U,S,C,A, ~ 1144(a) (1985), Second, the savings
clause expressly reserves the power of insurance
regulation to the States: "[elxcept as provided in
subparagraph (B), nothing in this subchapter shall be
construed to exempt or relieve any person from any
law of any State which regulates insurance, banking,
or securities," 29 U,S,C,A, ~ 1144(b)(2)(A) (1985),
Third, the deemer clause provides,
Neither an employee benefit plan .., nor any trust
cstablished under such a plan, shall be deemed to
be an insurance company or other insurer, bank,
trust company, or investment company or to be
engaged in the business of insurance or banking
for purposes of any law of any State purporting to
regulate insurance companies, insurance contracts,
banks, trust companies, or investment companies,
29 U,S,C,A ! 1144(b)(2)(B) (1985), Acting in
concen, the preemption, savings, and deemer
clauses prcvent state regulation of ERISA- qualified
cmployee benefits plans. but reserve the regulation
of insurance, banking. or securities to state laws,
See Travitz, 13 F,3d at 709,
Defendant argues that the PNI pian is not "self-
funded" and therefore falls in its entirety outside the
scope of ERISA preemption, See, c,g.. Travitz v,
Northeast Dep't ILGWU Health and Welfare Fund.
818 F,SuPP, 761. 764 (M,D,Pa,1993) (discussing
whether defendant-benefits fund is self-insured and
qualifies under ERISA), aff'd 13 F,3d 704 (3d
Cir, 1994), The panics have quarreled cxtensively
over this issue, This bailie of affidavits is of no
impon since, even if the Coun were to find that the
plan is self-funded, the Court has concluded tI ~t
1722 is not preempted by ERISA in this case,
(2)
Consideration of whethe ~ 1722 is preempted by
ERISA must begin with a review of the decisions of
the United States Supreme Coun in FMC Corp, v,
Holliday, 498 U,S, 52. III S,Ct. 403. 112 L.Ed,2d
356 (1990), and of the Third Circuit in Travitz, 13
F,3d 704,
Copr, <D West 1997 No Claim to Orig, U,S, Govt. Works
909 F,SuPP, 271
(Cite us: 909 F.SUPII. 271, .277)
In FMC, 498 U,S, al 54.55, III S,Ct, al 406, the
defendant.employee reeovered medical expenses
bOlh from an ERISA.qualilied insurance plan and
from the tortfeasor for injuries sustained by his
daughter in an automobile accident. The plaintiff.
employer sC'lghl reimbursemenl from the employee
on behalf of Ihe self-funded heahh care plan,
maimaining thaI, under the insurance agreement, it
was entitled to subrogation of the amounts whieh had
already been disbursed to the employee by the
tortfeasor.
The employee argued that, under then.effect; ~,
1720 of the Pennsylvania Motor Vehicle Financial
Respunsibility Law. 75 Pa,Cons,Stat.Anr 11720,
[FN61 the employer ' .27 prohibited from
exercising its subrogation rights to the employee's
claim, The Supreme Court held that ERISA
preempted ~ 1720 prohibilions against subrogation
by qualilied self. funded employee benelits plans.
because the "clear intent [of Congress was] to
exempl from direct slate insurance regulation ERISA
employee bene lit plans," Id, al65, III S,Ct. al 411
(emphasis added),
FN6, Section 1720 or Ihe Pennsylvania Motor
Vehicle Financial ResponsibililY Law, entitled
.subrog::uion.. provided
In actions arising out of the mainlcn:mce or use of
a molor vehicle, there shall be no right of
subrogation or reimbursement from a claimam's
ton recovery with respect 10 workers'
compens:uion benefits, benefits available under
seclion 1711 (relaling 10 required benefits), 1712
(relating 10 availability or bcnefilS) or 1715
(relaling 10 availability or adellimils) or
bene fils in lieu Ihereof paid or payable under
scclion 1719 (relaling 10 coordinalion of bene filS),
75 Pa,Cons,SL1I.Ann, ~ 1720 (erfeClive OClober I.
1984) (repealed Aogust31, 1993),
III Travitz, 13 F,3d at 70.1, the plaintiff.employee.
who had been injured in an automobile accident.
sought double recovery of medical expense, from
her union benelits program and from the tortfeasor,
Ahhough Ihe defendant.union's health care fund paid
a portion of the plaintiff's medical expenses. the
fund ceased advancing benelits to the plaintiff when
she refused 10 reimburse the fund for expenses
which she had already recovered from the tort feasor,
The plaintiff.employee contended thaI Ihe damages
collected from the lortfeasor were for pain and
suffering ~nd thus were not duplicalive of medical
expense benelils receivable from Ihe union fund,
"uge 7
The employee argued thaI, under Pennsylvania
Motor Vehicle Financial Responsibility La" ~ 1722,
75 Pa,Cons,Stat,Ann I 1722. recovering damages
for pain and suffering from one source and medical
payments from another did nol constitute double
recovery.
Relying on the Supreme Court's teaching in FMC
that ERISA was intended to exempt ERISA.qualilied
plans from direct stale regulalion, the Third Circuit
concluded ~tat "[slection 1722 of the Pennsylvania
Motor Vehicle Financial ResponsibililY law or any
state SlalUle that allempts 10 shift liability for medical
and health care benelils to a plan. group contracl, or
other arrangement operating within the meaning of
ERISA is preempled by it." 13 F,3d at 710
(emphasis added), Therefore, because the effect of
the Slate's prohibition against double recovery was 10
prevent the employee benelilS plan from exereising
its subrogation righls against plaintiff, ERISA
preempled ~ 1722, Id,
Based on FMC and Travitz. plaintiffs argue Ihal
ERISA mandales preemption 0 ~ 1722 in all cases
where al least one source of recovery is a qualilied
plan, The Court disagrees, The holdings in FMC
and Travitz, in the Court's view, arc much less
broad than plaintiffs contend, Instead, the Court
Iinds that preemption ( I 1722 is implicated only
when applicalion of the prohibition againsl double
recovery has the effect of regulating, and interfering
Wi~l, claims by or against an employee benelils plan
operating under ERISA,
Applying FMC and Travilz to this case, the Court
Iinds that th 1722 prohibition against double
recovery docs not pertain to amounts paid or payable
10 Joseph Auslin under the PNI disability insurance
policy, [FN7] Rather, the source of funds seekin ~
1722 protection is the tort feasor, Dionne, Plainliffs
arc nol allempting to shift liability to the PNI plan,
Instead, the Austins seck double recovery by
collecting the same benelits from Dionne that they
havc already collected from the plan,
FN7, Neither pany has argued Ihal Ihe PNI
employee benefilS plan is entitled 10 subrogalion of
the amounts paid by Dionne (0 Austin.
In other words. application ! 1722 would not
result in interference with the PNI disability
insurance plan here; il would merely prevenl
collection of a windfall by Auslin, The Court sees
no reason why Pennsylvania's policy of prohibiting
Copr, <Ci West 1997 No Claim to Orig, U,S, Govt. Works
909 F,SuPP, 271
(Clle 0.': 909 F.SUIIII. 271, Oi78)
double recovery should not be given full effecl. so
long as doing so docs not shift Iiabilily to the PNI
fund operaling under ERISA, (FN8)
FN8, Ahern'lively. lhe Coun noles Ihal .n
c:x~c:pliol1 (0 ERISA (HccmpliulI may alsn he
applic.ble here since Ihe errCCl I 1722 on Ihe
PNI pl.n is "100 lenuous. remOle, or peripheral..,
10 wJrranl a finlling 111:11 the law 'relates la' the
pl.n,' Travilz. 13 F,3d al 709 (eit'lion omined);
see .1", KeyslOne Ch'plcr. Associated Uuildcrs and
Comr.clors, Ine, v, Foley, 37 F,3d 945. 954.55
(3d Cir, 1994) (holding thaI. ahhough Pennsylvanl.
minimum wage law could not refcr specifically 10
ERISA pl.ns or accord Ihem speciallrealmem. law
conferred broad authority exercisable in a manner
eonsislem wilh ERISA), TII 1722 prohibition
ag.ill5t double recovery arreCIS only Ihe relalions
belween a plan beneficiary. Austin, and an oOlside
p.ny, Dionne, who Is clearly a "principal
ERISA emity." Tr.vilz, 13 F,3d at 710 (citalion
omiucd). Moreover. the statu Ie regulates lort
recovery. an area of *lr.Ulilional exercise of stJle
Puge 8
aUII,orilY," Id, In short. no pan or lhe rederal
scheme under ERISA is dislurbcd,
0279 III
In the presenl case, Austin receivcd wage loss
paymenls in the amount of S520,57 per week under
his employer's disability insurance policy from
February 10, 1993, tu January 9, 1994, Under
Pennsylvania's choice of law rules, Pennsylvania
law applies to the inlerprelation of first parly
paymenls under plaintiffs' PIP automobile insurance
policy, as well as the employer's dis.bililY insurance
policy. Moreover, ERISA docs nOI preempl the
Pennsyl'lania law barring doubte recovery,
Accordingly, defendant's mOlion seeking to preclude
atlrial plaimiffs' evidence of any losl wages paid or
payable by the PIP automobile insurance policy and
by the PNI disability insurance policy shall be
gramed,
END OF DOCUMENT
Copr, 0 West 1997 No Claim to Orig, U,S, Gov!. Works
;$*1If1.k'l~~~~!~lim~~~~J11~~f;\t~~lt~i~V~~t~[~~~~~}~:~}:!~~f~;~~~'~t~ttti"~lfj~~l~!{~I~f~~~~;
SYLVIA ROBERTS,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
Plaintiff
v.
MARY McLAUGHLIN,
NO. 97-1662 Civil Term
Defendant
JURY TRIAL DEMANDED
PLAINTIFF'S PRE-TRIAL MEMORANDUM
I. FACTS/LIABILITY
The instant action arises out of a June 30, 1995 motor vehicle
accident. At the time of the accident, Sylvia Roberts was a front
seat passenger in a vehicle being operated by her ex-husband, Ted
Roberts. The Roberts' vehicle was stopped in the drive-thru line
at the Mcdonald's Restaurant, 6200 Carlisle Pike, Silver Springs
Township. While the Roberts vehicle was stopped, it was rear-ended
by the Defendant.
Defendant has admitted liability for the instant motor vehicle
accident.
II . DAMAGES
As a result of the accident, Mrs. Roberts sustained a cervical
sprain and whiplash injury.
At the time of the accident, Mrs. Roberts was a citizen of the
State of Oregon. Mrs. Roberts' own vehicle, as well as the vehicle
she was occupying at the time of the accident, were registered and
11 0 152 /MLM
'~l",::r,,'
:~~~~r.r>:.r .'
insured in the State of Oregon.
Oregon insurance law and Mrs.
Roberts' automobile insurance policy provides for subrogation for
medical benefit payments. As such, Mrs. Roberts is entitled to
plead, prove and recover her medical bills herein.
III. STATEMENT AS TO PRINCIPAL ISSUES OF LIABILITY AND DAMAGES
Given Defendant's admission of liability, Mrs. Roberts submits
the only issue for determination by a jury will be the amount of
damages to be awarded.
IV. SUMMARY OF LEGAL ISSUES
Admissibility of criminal conviction of a potential witness
that is more than ten years old.
V, WITNESSES
1. Plaintiff;
2. Ted Roberts;
3. Gregory Reese, D.C., via deposition; and
4. Mrs. Roberts' mother.
Plaintiff will supplement this list, if necessary, in a
reasonable time prior to trial.
VI, EXHIBITS
Medical Bill Summary.
Plaintiff will supplement this list, if necessary, in a
reasonable time prior to trial.
, !
I, I
,
SYLVIA ROBERTS
PLAINTIFF
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNA
, ,
1/
"
,
,
v,
NO, 97.1662
CIVIL ACTION . AT LAW
MARY McLAUGHLIN,
DEFENDANT
: JURY TRIAL DEMANDED
PRETRIAL MEMORANDUM OF THE DEFENDANT, MARY McLAUGHLIN
I. Background
This Civil Action arises out of an automobile accident that occurred on June 30,
1995, in the drive-thru line at a McDonald's restaurant on the Carlisle Pike, Silver
Spring Township, Cumberland County, Pennsylvania. At that time and place,
Defendant, Mary McLaughlin, was operating a 1992 Chevrolet Cavalier. Ms.
McLaughlin had ordered her food and was pulling forward when she came in contact
with the rear of a 1982 Mazda Pickup Truck in which the Plaintiff, Sylvia Roberts, was a
passenger. There was no damage to the McLaughlin vehicle and little, if any, damage
to the vehicle in which the Plaintiff was a passenger,
Defendant admits that the accident was caused by her negligence. Defendant
disputes whether the accident was a substantial factor in causing any injuries sustained
by the Plaintiff,
II, Damages
Defendant contends that the Plaintiff suffered no injuries as a result of the
accident. There was little damage to either of the vehicles. The police were not called
and Plaintiff received no medical treatment at the scene. In support of her position,
Defendant will call an engineer and a chiropractor to testily that the forces involved in
the accident are not capable of causing injuries,
III, Statement As To Principle Issues of Liability and Damages
Defendant has admitted negligence. Defendant disputes whether the accident
was a substantial factor in causing any injury of the Plaintiff.
IV, Legal Issues
Defendant contends that the medical bills for Plaintiffs treatment are not
recoverable pursuant to 75 Pa.CSA ~1722. Although the Plaintiff had a policy issued
pursuant to Oregon law, the conciusion contained in the Pennsylvania Motor Vehicle
Financial Responsibility Law still applies. See Austin v. Dionne, 909 f Supp. 271(e.d.
PA 1995).
V, Witnesses
Respectfully submitted,
1. Defendant, Mary McLaughlin;
2. J. Ronald Salling, P.E.;
3. Robert Cunningham, D.C.; and
4. William White.
VI, Exhibits
1, Photographs of the Defendant's vehicle; and
2. Medical records of the Plaintiff.
VII. Settlement
An Arbitration Award was entered in favor of the Plaintiff in the amount of
$1,500. Defendant would pay the Arbitration Award to settle this claim. However,
Plaintiff appealed the Arbitration Award.
NEALON ~R\
~~~d2
By:
James G. Nealon, Esquire
Atty, 1.0.#46457
301 Market Street -- 9th Floor
P.O. Box 865
Harrisburg, PA 17108-0865
(717) 232-9900
SYLVIA ROBERTS
PLAINTIFF
v,
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNA
: NO, 97.1662
: CIVIL ACTION - AT LAW
MARY McLAUGHLIN,
DEFENDANT
: JURY TRIAL DEMANDED
MEMORANDUM OF THE DEFENDANT REGARDING
THE EFFECT OF THE PRECLUSION CONTAINED IN
75 Pa.C.S.A, 91722
It is anticipated that the Plaintiff will seek to introduce into evidence medical
bills that were incurred for treatment that the Plaintiff received subsequent to the accident.
All of the bills have been paid by Dairyland Insurance Company pursuant to a policy issued
under Oregon law, Dairyland is apparently asserting a subrogation lien for the bills.
Regardless, it is submitted that the Plaintiff cannot recover the amount of the medical bills,
Prior to the 1990, the preclusion contained in the PMVFRL provided:
In any action for damages against a tortfeasor arising out of the
maintenance or use of a motor vehicle, a person who is eligible to
receive benefits under the coverages set forth in 91711 (relating
to required benefits) or the coverage set forth in 91715(a)(1.1)
relating to availability of adequate limits, shall be precluded from
pleading, introducing into evidence or recovering the amount of
benefits paid or payable under 91711 or 91715(a)(1.1). This
preclusion applies only to the amount of benefits set forth in the
~1711 and 91715(a)(1,1).
Under the law in effect prior to 1990, the Plaintiff's position in the instant case
would have merit. Clearly the act only applied to preclude the introduction into evidence
and recovery of medical bills or wage loss paid pursuant to a policy of insurance issued
disability insurance policy. Defendant filed a Motion in Limine to preclude the introduction
into evidence of the amounts paid or payable either under the auto policy or the disability
policy. The Court analyzed the issue, appropriately, as a conflict of law issue, Although
I
I
wages through his New Jersey Automobile Insurance Policy as well as an employer's
under New Jersey law, first party wage loss benefits are not recoverable against a tort
feasor, "in an action against a tortfeasor relating to an automobile accident, the amounts
recoverable under an employer's disability insurance policy are not excluded from wage loss
calculations", Id, at 274. The Court then analyzed the effect of 91722 of the PMVFRL:
By contrast, Pennsylvania law prohibits double recovery without
exception, " As the Third Circuit has recognized, 91722 reflects
the Pennsylvania Legislature's goal of preventing double recovery
from both an employer's disability insurance fund and a
tortfeasor,
Id, citing Travitz v, Northeast Department ILGWU Health and Welfare Fund, 13 F,3d 704,
710 (3d, 1994),
Since the Court found a "conflict" between New Jersey and Pennsylvania law,
the Court proceeded to perform an analysis pursuant to Griffith v, United Airlines Inc" 416
Pa, 1, 203 A.2d 796 (1964) to determine which state's law should be applied, After
performing the Griffith analysis, the Court concluded that Pennsylvania law must be applied
and the Plaintiff could not recover either the amount paid under the automobile policy or
under the disability policy,
<
~
~
9091',SuPP, 271
Pens, Plan Guide P 23925R
(Cile us: 909 F.Supp. 271)
Joseph und Mur) AUSTIN, l'lulnllffs,
".
Churles mONNE, Defendunl.
Clv. A. No. 95-359.
United States District Coure,
E,D, Pennsylvania,
Dec, 7, 1995,
Automobile accident victim brought aClion against
alleged tore-feasor to recover damages after
receiving personal injury protection (PIP) benefits
and wage loss benefits under employer's disability
insurance policy, Alleged ton- feasor moved to
preclude evidence of lost wages, The District
Coure, Eduardo C, Robreno, J" held that: (I)
Pennsylvania law against double recovery applied to
issue of right to recover for lost wages, and (2)
Employee Retirement Income Security Act (ERISA>
did not preempt Pennsylvania's bar against double
recovery after receiving disability insurancc benefits
for injuries caused by automobile accident.
Motion granted,
[tl ACTION ~17
13k17
Under Pennsylvania choice of law rules, if law of
either jurisdiction may be applied without impairing
governmental interests of jurisdiction whose law is
not being applied, no connict exists between
respective laws of each jurisdiction. and coun should
apply law of forum,
(2) ACTION ~17
13k17
Under Pennsylvania choice of law rules, if one of
two jurisdiction's governmental interests would be
impaired by application of other jurisdiction's law,
false connict arises; in other words, if neither
jurisdiction's governmental interests would be
harmed when applying law of one jurisdiction,
whose interests would be impaired if its laws werc
not applied, connict is false,
(3) ACTION ~17
13kl7
Under Pennsylvania choice of law rules, true
connict arises only if, no mailer which jurisdiction's
law is applied, governmental interests of jurisdiction
I'uge 1
whose law is not applied would be impaired: if true
conflict exists, coun must determine which state has
greater interest in application of its law,
14) AlITOM08lLES ~229.5
48Ak229,5
Law of Pennsylvania as forum state governed
automobile accident victim's righl to recover lost
wages from alleged ton-feasor after recciving
personal injury protection (PIP) benefits under
automobile insurance policy; since amount payable
as losl wages under PIP coverage was excludable
under both New Jersey and Pennsylvania law. law of
either jurisdiction could be applied without injuring
governmental interests of the other, and there was no
connict. N,J,S,A ! 39:6A-12; 75 Pa,C,S, ~
1722.
151 AUTOMOBILES ~229.5
48Ak229,5
New Jersey law that amoulllS recoverable under
employer's disability insurance policy can also be
recovered as wage loss in action against tore. feasor
arising from automobile accident is in true connict
with Pennsylvania Motor Vehicle Financial
Responsibility Law (MUFRL) prohibiting double
recovery without exception, and, thus, Pennsylvania
connict of law rules required court to determine
which statc had greater interest in application of its
law; if Pennsylvania law were applied, New
Jersey's interest in preserving double recovery in
automobile accidcnts cases from nonautomobile
insurance policies would be impaired, and if New
Jersey's laws wcre applied, Pennsylvania's interest
against double recovery would be impaired,
NJ,S,A, 2A:15.97; 75 Pa,C,S,A, ~ 1722,
[6] AUTOMOBILES ~229.S
48Ak229,5
Pennsylvania's Motor Vehicle Financial
Responsibility L1W (MUFRL) prohibiting double
recovery, rather than New Jersey law permining
automobile accident victim to recover lost wages
from alleged Ion. feasor despite recovery for them
under employer's disability insurance policy, applied
to New Jersey victim's tort action against
Pennsylvania alleged ton-feasor arising out of
accident in Pennsylvania; victim was employee in
Pennsylvania, New Jersey's permissive view of
double recovery in automobile accident cases
appeared to be result of gap in legislative scheme.
rather than aniculation of strong policy. and
Copr, <0 Wcst 1997 No Claim to Orig, U,S, Gov!. Works
, I,.
f;
,
'I
909 F,SuPP, 271
(Cite us: 909 F.Supp. 271)
overwhelming number of comacts were associated
wilh Pennsylvania, N.J,S,A, 2A:15.97; 75
Pa,C,S,A, 1722; Restatemem (Second) of
Connicls of L1W ~ 145(2),
(7) DAMAGES ~59
115k59
ERISA did not preempl provision of Pennsylvania's
Motor Vehicle Financial Responsibility Law
(MVFRL) that barred automobile accidem viclim
from receiving from alleged tort. feasor double
recovery for bene filS paid by disabililY insurance
policy issued to viclim's employer; prohibition
againsl double recovery did nol perlain 10 amoums
paid or payable to viclim under disabililY policy,
tort. feasor was source of funds seeking protection,
and viclims were not allempting to shift liability to
lhe employee welfare benefil plan, Employee
Reliremem Income Security I 514(a), 29
U,S,C,A, ~ 1144(a); 75 Pa,C,S,A, ~ 1722,
(7) STATES ~18,41
360k18.41
ERISA did nol preempt provision of Pennsylvania's
MOlor Vehicle Financial Responsibilily Law
(MVFRL) lhal barred aUlomobile accident victim
from receiving from alleged lort-feasor double
recovery for benefits paid by disability insurance
policy issued 10 victim's employer; prohibition
againsl double recovery did not pertain to amounts
paid or payable to victim under disability policy,
tort. feasor was source of funds seeking prolection,
and viclims were not altempting to shifl liability to
lhe employee welfare benefil plan, Employee
Reliremem Income Security I 514(a), 29
U,S,C,A, ~ 1144(a); 75 Pa,C,S,A, ~ 1722,
.272 Benjamin Kuby. Klovsky, Kuby & Harris,
Philadelphia. PA, for Plaimiffs,
Kevin R, Mc Nully, German, Gallagher &
MurtJgh. Philadelphia, PA. Vaughn A, Booker,
Philadtlphia, PA, Timolhy E, Games. German,
Gallagher & Murtagh, Philadelphia, PA, for
Defendant.
MEMORANDUM
EDUARDO C, ROBRENO, District Judge,
Plaintiff Joseph Auslin ("Austin") is a New Jersey
resident employed by Philadelphia Newspapers,
Inc,. {"PNI") in Pennsylvania, He was injured in an
aUlomobile accidem in Pennsylvania while on
I'nge 2
personal business, As a result of lhe accidem,
Austin soughl lost wages through his automobile
insurance policy and through supplemental payments
for wage benefits under his PNI disabilily insurance
policy.
Defendant Charles Dionne {"Dionne") has filed a
mol ion in limine seeking to preclude plainliffs from
inlroducing at trial evidence .27: 10Sl wages
which have been paid or are payable 10 Auslin under
his automobile and disability insurance policies,
Dionne argues lhat colleeling benefils from a
lortfeasor as well as from Austin's insurance policies
constitutes double recovery, a praclice barred under
Pennsylvania law,
On lhe olher hand, plaimiffs comend that New
Jersey law is" nder New
Jersey law, uble recover is ermlll
vll1g automo I e ace , Furthermore,
plall1ulls argue that, even if Pennsylvania ralher lhan
New Jersey law applies, ERISA preempts
Pennsylvania law because !.Ils1in's benefits have
been paid pursuam to a self-funded disability
insurance policy provided by PNI under a collective
bargaining agreemem, Finally, plaintiffs conlend
lhal, under ERISA. unlike Pennsylvania law, Auslin
is entitled to collect from more than Ont' SOIlT~.
The Court finds lhat. under Pennsylvania's choice
of law rules, Pennsylvania law applies to lhe
imerpretation of first party paymems under
plaimiffs' PIP automobile insurance policy, as well
as lhe employer's disabilily insurance policy, In
addition. lhe Court concludes lhat ERISA docs nol
preempl lhe Pennsylvania law barring double
recovery, Under the facts of this case, Pennsylvania
law neither imerferes with nor regulates a claim by
or againsl lhe PNI disability insurance policy
operating under ERISA,
The following faClS arc undisputed, Plaimiffs
Joseph and Mary Austin arc New Jersey residems,
Auslin is employed as a pressman at the Philadelphia
Inquirer, At the time of the accidenl, Dionne was a
residem of Pennsylvania,
On February 10, 1993, al appruximately 4:45 p,m"
Auslin was proceeding soulh on Imerstate Route 95
in Philadelphia, Pennsylvania, in his pick.up truck,
At lhe same lime. Dionne was travelling soulh on
Interstale Route 95 in his own vehicle, Dionne's car
Copr, 0 West 1997 No Claim to Orig, U,S, Govt. Works
909 F,SupP, 27i
(Clle Il~: 909 F,Supp. 271, '273)
collided with the back of Austin's truck, causing
Austin to suffer soft tissue injuries to his neck and
back,
Following the accident, Austin missed
approximately 52 weeks of work, He sought lost
wages in the amount of $5,200 under his automobile
personal injury protection ("PIP") coverage with
Prudential Insurance Company, whieh have not been
paid to date, but whieh plaintiffs contend arc
payable, In addition, Austin received 5520,57 per
week from February 10, 1993, to January 9, 1994,
from his PNI disability insurance, This coverage is
provided under the collective bargaining agreement
between Philadelphia Newspapers Union Local 16
and lhe Philadelphia Inquirer,
II
(A)
Plaintiffs contend that New Jersey law applies to
lhis case, Defendant disagrees, arguing ins lead that
the law to be applied is lhat of Pennsylvania,
Because lhe case involves contacts which impact
more lhan one jurisdiction, lhe Court must choose
between lhe relevant laws of the two jurisdictions,
See Robert A, Leflar, American Connicts La\ ~ 2,
at 3 (3d ed, 1977),
j
In a diversity action, "lhe choice of law of the
forum state [determine w IC state' e
at"lie , uder v, cDonald's Corp" 859 F,2d
2 6, 269 (3d Cir,1988) (citing Klaxon v, Stentor
Electric Mfg, Co" 313 U,S, 487, 496, 61 s,Ct,
1020, 1021, 85 L.Ed, 1477 (1941)), Accordingly,
the Court will apply Pennsylvania's choice of law
rules,
In Griffith v, United Air Lines, Inc" 416 Pa, I,
203 A,2d 796 (1964), the Pennsylvania Supreme
Court abandoned lhe traditional lex loci delicti
connicts rule for "a more flexible rule which pennits
analysis of lhe policies and interests underlying the
particular issue before the court," Id, 203 A,2d at
805, In commenting on the development of the rule
set forth in Griffith. the Third Circuit stated,
ITJhis new connicts methodology has evolved into
a hybrid approach that "combines the approaches
of both Restatement II (contacts cstablishing
significant relationships) and 'interest analysis'
(qualitative appraisal of the rclevant States'
policies with respect to the controversy),"
'274 Lacey v, Cessna Aircraft Co" 932 F,2d 170,
187 (3d Cir,1991) (quoting Melville v, Am, Home
Page 3
Assurance Co" 584 F,2d 1306. 1311 (3d
Cir,1978)),
[1) Under Pennsylvania choice of law rules and the
method of analysis established in Griffith, three
outcomes may obtain, First. if the law of either
jurisdiction may be applied wilhout impairing the
governmental interests of the jurisdiclion whose law
is not being applied, no connict exists between the
respective laws of each jurisdiction and the coun
should apply the law of the forum, See Eugene F,
Scoles and Peler Hay, Connict of Law: ~ 2,6, at 17
& n, 8 (2d cd, 1992),
[2J Second, if only one of the two jurisdiction's
governmental interests would be impaired by the
application of lhe other jurisdiction's law, a "false
connict" arises, Lacey. 932 F,2d at 187,
"Allhough two jurisdictions have nominal contacts
wilh lhe transaction, only one jurisdiction is truly
conccrned wilh the result," Kuchinic v, McCrory,
422 Pa, 620, 624 n, 4, 222 A,2d 897, 900 n, 4
(1966), In other words, if neither jurisdiction's
governmental interests would be harmed when
applying the law of the one jurisdiction, whose
interests would be impaired if its law were not
applied, the connict is -false," [FN11
FNI. The concept of "faise conni,," is derived
from Ihe scholarship of Professor Brainerd Currie.
See Draincrtl Currie. Selected Essays on the
Connict or Laws 189 (1963), Proressor Currie
denned a false conniel in the following manner:
-(willen one of two states related to a case has a
legitimate interest in the application of its law and
policy and the olher state has none, there is no real
problem; clearly the law of the interested stale
should be applied." Id,
131 Third, a "true connict" arises only if, no malter
which jurisdiction's law is applied, lhe governmental
interests of lhe jurisdiction whose law is not applied
would be impaircd, Laccy, 932 F,2d at 187 n, 15,
"If a true connict exists, the court must determine
which state has the greater interest in the application
of its law," ld,
The Court shall now apply the Pennsylvania conflict
of law analysis to both the automobile and disaLility
insurance policies in question,
(I)
[4J Both panics agree that lhe amount payable to
plaintiffs under PIP lost wages benefi.s in an action
Copr, 0 West 1997 No Claim to Orig, U,S, Govt. Works
909 F,Supp, 271
(Clle u.~: 909 F,Supp. 271, .27~)
against lhe tortfeasor is excludable under bOlh New
Jersey and Pennsylvania law, See Plaintiffs' Pre-
Trial Memorandum, doe, no, 20. al 5; Dcfendam's
Memorandum in Support of His MOlion in Limine,
doe, no, 19, al 3, Beeause lhe law of either
jurisdiclion may be applied WilhoUl injuring the
governmental interests of the Olher, Ihere is no
connict. See 75 Pa,Cons,Stat.Ann ~ 1722 (1995);
39 NJ,Stat.Ann M-12 (Wesl 1994), [FN21
Therefore, lhe Court must apply the law of
Pennsylvania, lhe forum stale,
FN2, Pennsylvania Motor Vehicle Financial
Resp<lnsibililY Law ~ 1722 provi~es,
In any action for damages ... arising out of the
maintenance or use of a motor vchicle. a person
who is eligible 10 receive benefits under the
coverages sce forth in this subchapter. or workers'
compensation. or any program. group contract or
other arrangement for payment of benefits as
~efine~ in seclion 1719 .., shall be preclu~e~ from
recovering the amount of benefits paid or payable
under this subchapu:r. or workers' compensation.
or any program. group contract or olher
arrangement for payment of benefits as defined in
seclion 1719,
75 Pa,Cons,SIOI.Ann, ~ 1722 (\995),
New Jersey MOlor Vehicles an~ Traflie
Regulalions. Sublille 2, 6A-12 provi~es in
peninenl pan,
IElvi~ence or Ihe amoums colleclihle or pai~ .., 10
an injured person. including the amoullIs of any
deductiblcs, copaymenlS or exclusions... otherwise
compensated is inadmissible in a civil action for
recovery of ~amages for bouily injury by such
injure~ person,
39 N.J,SIOI.Ann, ~ 6A-12 (Wesl 1994),
(2)
(5] The Court now lurns 10 whelher a connicl exists
belween New Jersey law and Pennsylvania law
regarding the exclusion of wage losses recovered
under the PNI disability insurance policy,
Under New Jersey law. in an action by an injured
plaintiff against a tortfeasor, collateral source
benefils are excluded from damages lhal may be
submined to a jury, 2A .275 NJ,Slat.Ann, ~ 15-97
(West 1994), [FN3) Yet, all aClions broughl
pursuant to the provisions of Tille 39 (actions
relating 10 molor vehicles and traffic regulations) arc
exempl from this general exclusion of collateral
source benefits, Id, The effect of exempling molor
vehicle accidents from Ihe general prohibilion
against double recovery is, as lhe New Jersey
Puge ~
Superior Courc has recognized, to make available to
a plaintiff in an aUlomobile accidenl "additional
benefils" from an employer's volunl:try supplemental
insurance plan, O'Boyle v, Prudential Ins, Co, of
Am,. 241 NJ,Super, 503, 509, 575 A,2d 515, 518
(1990) (declining 10 "injecl some lurking judicial
suspicion thai a bener policy [againsl double
recovery) could or should be engrafted on the
stalUlory scheme"), Thus, under New Jersey law.
despite lhe fact Ihal double recovery is prohibited in
all Olher contexts. in an aClion againsl a lorcfeasor
relaling 10 an automobile accident, lhe amounts
recoverable under an employer's disabililY insurance
policy are not excluded from wage loss ealculalions,
FN3, Seclion 2A: 15-97 provi~es in peninen! pan,
In any civil aClion broughl for personal injury or
death. except actions brought pursuam to the
provisions of p, L,1972. c, 70 (C, 39:6A-1 el seq,).
if a plaintiff receives or is entitled (0 receive
benefits for Ihe injuries allege~ly ineurre~ from any
other source other than a joint tonfeasor, the
benefits, other than workers' compensation benefits
or the proceeds rrom a life insurance policy. shall
be disclosed to the coun and the amc thereof
which duplicates any benefit contained in the award
shall be ~e~UCle~ from any awar~ recovcre~ by Ihe
plaintirr....
2A N.J,SIOI.Ann, ~ 15-97 (WesI1994),
By contrasl, Pennsylvania law prohibits double
recovery wilhoUI exception, Und,! 1722 of the
Pennsylvania MOlor Vehicle Financial ResponsibililY
Law, "in any aClion for damages against a
torcfeasor," a parcy is precluded from "recovering
the amount of benefils paid or payable under.., any
program, group contract or other arrangement for
payment of benefils," 75 Pa,Cons,Slat.Ann ~ 1722
(1995), As the Third Circuit has recognized. ~ 1722
refiecls lhe Pennsylvania legislalUre's goal of
preventing double recovery from both an employer's
disability insurance fund and a tortfeasor, See
Travitz v, Northeast Dep't ILGWU Health and
Welfare Fund. 13 F,3d 704, 710 (3d Cir,1994)
(finding that plaintiff anempled to circumvenl
purpose of bo : 1722 and disability insurance
contracl's exclusion clause), Therefore, application
of Pennsylvania law in the present case would result
in excluding from plaintiffs' wage loss calculations
the amounts already recovered from Austin's PNI
disabililY insurance policy,
In short, if New Jersey's laws were applied.
Pennsylvania's intereSl against double recovery
would be impaired, The converse is equally true, If
Copr, 0 West 1997 No Claim 10 Orig, V,S, Govt. Works
909 F,SupP, 27.1
(Cite us: 909 ....Supp. 271, .275)
Pennsylvania law were applied, New Jersey's
imerest in preserving double recovery in automobile
accidem cases from non.aUlomobile insurance
policies would be impaired, The Coun finds Ihat
this connict is a "lrue" one, since the govemmemal
imeresls of one jurisdiclion would be impaired if the
other Slate'S law were applied. and vice.versa,
(FN4) Lacey. 932 F,2d at 187. .27t 15, The
Coun musl now decide whelher New Jersey or
Pennsylvania law applies to this case,
FN4, An a'gumelll could be made thaI, in realilY,
Ih~ Court is confronted with a -ralse connicl:
,ince bolh New Jersey and Pennsylvania policies
appear aligned againSl double recovery, Even if
the Coun were 10 find the exiSIC:nce of a false
conniel. however. its ultim:uc conclusion would
remain lhe same.
In Kiss v, Jaeob, 138 N.l, 278, 650 A,2d 336
(1994), Ihe New Jersey Supreme Coun round thai
"(llhe legi,lalOre', purpose in enacling N.l,S,A,
2A: 15,97 wa, 10 do away wilh Ihe common, law
coll:ucral.source rule (which) pennits a ton victim
to rClain collateral benefits ". in addition 10 any
amount that the victim might recover from that
defendalll." Id, 650 A,2d al 337, Despile the New
Jersey Supreme Coun', aniculation or a 'Irong
,Iale policy against double recovery. Ihe facl
remains thai Ihe Slale legislalure len a gap in ils
laws. by explicilly exempling Tille 39 actions from
the scope of Tille 2A: 15 Double recovery
remains available from non-automobile insurance
policies in the context of motor vehicle accidents,
notwithstamling New Iersey's efforts -10 effect cost
conl3inment- in -insurance-type: benefits" Id. at
338; see also O'Boyle, 241 N.l,Super, al509, 575
A,2d al 518 (declining to "engran- a "beller
policy. against double recovery onto tlu: statUlory
scheme),
Yet, prccisely because of Ihe New Jersey
Iegislalure's general policy against double
recovery, a pany could argue thaI .only
(Pennsylvania's] govemmemal imereslS would be
impaired by the appliealion or (New Jersey's) law.
which permilS double recovery, lacey, 932 F,2d
al 187, Pennsylvania's mong policy againsl double
recovery has alrcatly been expressed tlm ~.h
1722,
(B)
[61 Under Ihe Griffith method of analysis, a coun
must examine bOlh the con lac IS eSlablishing
significanl relalionships, as set forth in Reslalement
(Second), and the governmental inlerests and
policies of lhe Slales pertinent 10 the controversy,
Lacey. 932 F,2d al 187; Griffilh, 203 A,2d at 805,
I'uge 5
Section 145 of the Reslalement (Second) of Connicls
of Law direcls a court to consider the following
contacls in order 10 delermine the applicable law:
a) the place where the injury occurred,
b) t~e place where lhe conduct causing Ihe injury
occurred,
c) the domicile, residence, nationalilY. place of
incorporation and place of business of the parties,
and
d) Ihe place where the relalionship, if any,
belween lhe panies is cemered,
Restalement (Second) of Conflicts of La\ ~ 145(2)
(1969), Austin's injuries and Dionne's conduct
causing the injury both occurred on Inlerstate ROUle
95 in Pennsylvania, Dionne's residence is in
Pennsylvania, While both plaintiffs reside in New
Jersey, Austin is employed at Philadelphia
Newspapers, Inc" under whose collective bargaining
agreement he claims entitlement to disability
payments,
In addition, as this Coun has discussed in the
previous seclion, Pennsylvania has an articulated
policy againsl double recovery and a strong intereSI
in containing the rising COSIS of automobile insurance
for its residents, By contrast, New Jersey's
permissive view of double recovery in automobile
accidem cases appears to be the result of a gap in the
legislative scheme ralher than an aniculalion of a
strong policy favoring double recovery in all such
cases, See supra nole 4; cf. Kiss v, Jacob. 138 NJ,
278,650 A,2d 336, 337.-38 (1994) (finding intelll "to
prohibit duplicative recovery by plainliffs" when
New Jersey Legislature drafted 2A N,J,StaLAru ~
15.97), Clearly, applicalion of New Jersey law
would defeat Pennsylvania's policy against double
recovery, Although the converse is likewise true,
the Coun finds that the policy in New Jersey
permilling double recovery has been less robuslly
expressed than in Pennsylvania,
Under the contaclS prong of the Griffilh analysis,
the Court concludes that an overwhelming number of
comacls are associaled with Pennsylvania, nol New
Jersey, Moreover, after assessing "Ihe policies and
interests underlying the particular issue before the
court," Griffith. 203 A,2d al 805. the Court finds
Ihat Pennsylvania "has the grealer interest in the
application of its law," Lacey, 932 F,2d at 187 n,
15, Therefore, the Coun shall apply Pennsylvania
law to plaintiffs' claims under the PNI disabililY
insurance policy,
(C)
Copr, <0 Wesl 1997 No Claim 10 Orig, U,S, GOVL Works
il
909 F,SuPP, 271
(Cite us: 909 F.SuI'P' 271, *276)
[71 The Court shall now consider whether ERISA
preempts 1722 under the facts of this case,
Application 0 ! 1722 would prevent the Austins
from recovering damages from Dionne once they
have recovered from the PNI policy, If, however,
ERISA preemption operates to proscrib( ~ 1722, the
Austins would recovery doubly, The Court finds
that ERISA preemption is not implicated here
because the operation 0 ~ 1722 in this case neither
shifts liability from Dionne to the ERISA.qualified
PNI plan nor interferes with the administration of
the plan,
(I)
Plaintiffs contend that, even if Pennsylvania law
were to apply, ERISA preempts the applicability of ~
1722 to the PNI disability insurance policy, Under
ERISA, an "employee welfare benefit plan" is
defined as
any plan, fund, or program .., established or
maintained by an employer or by an employee
organization, or by both, to the extent that such
plan, fund, or program was established or is
maintained for the purpose of providing for its
participants or their beneficiaries, throogh the
purchase of insurance or otherwise ..' medical,
surgical. or hospital care or benefits, or benefits in
the event of sickness, accident, disability, death or
unemployment." ,
29 U,S,C,A, ~ 1002(1) (Supp, 1995), Furthermore,
ERISA covers, with certain exceptions, .277 FN5]
"any employee benefit plan if it is established or
maintained (I) by any employer engaged in
commerce or in any industry or activity affecting
commerce; or (2) by any employee organization or
organizations representing employees engaged in
commerce or in any industry or activity affecting
commerce; or (3) by both," 29 U,S,C,A. ~ l003(a)
(1985),
FN5. Plaintiffs conlend thai the exccplions lisled in
~ 1003(b) are nol applicable 10 Ihe PNI plan, See
Plaimiffs' Memorandum Camra MOlion in limine
Filed by Defendant Seeking 10 Precl",Je Proof of
Loss of Wages Under MOlor Vehicle Financial
ResponsibililY Act. Scclion 1722, in Third Party
AClion, daled Seplembcr 8, 1995, al (unnumbered)
4, Absent any allegation by the derendant 10 Ihc
contrary. Ill: Court will deem the exceptions
inapplicahle here,
Three ERISA statutory provisions control the issue
of preemption, First, the preemption clause
I'uge 6
prohibits state regulation of employee welfare
benefit plans which qualify under the above
provisions:
Except as provided for in subsection (b) of this
section [the ERISA savings clause]. tile provisions
of this subehapter ..' shall supercede any and all
Stale laws insofar as they may not or hereafter
relate to any employee bcnefit plan descrihed in
section l003(a) of this litle and not exempt under
section 1003(b) of this title,
29 U,S,C,A, ~ 1144(a) (1985), Second, the savings
clause expressly reserves the power of insurance
regulation to the States: "[e)xcept as provided in
subparagraph (B), nothing in titis subchapter shall be
construed to exempt or relieve any person from any
law of any State which regulates insurance. banking,
or securities," 29 U,S,C,A, ~ I I 44(b)(2)(A) (1985),
Third, the deemer clause provides,
Neither an employee benefit plan .., nor any trust
established under such a plan. shall be deemed 10
be an insurance company or other insurer, bank,
trust company, or investment company or to be
engaged in Ihe business of insurance or banking
for purposes of any law of any State purporting to
regulate insurance companies, insurance contracts,
banks, trust companies, or investment companies,
29 U,S,C,A ! 1144(b)(2)(B) (1985), Acting in
concert, the preemption, savings, and deemer
clauses prevent state regulation of ERISA. qualified
employee benefits plans. but reserve the regulation
of insurance, banking, or securities 10 state laws,
See Travitz, 13 F,3d at 709,
Defendant argues that the PNI plan is not "self-
funded" and therefore falls in its entirety outside the
scope of ERISA preemption, See, e,g" Travitz v,
Northeast Dep't ILGWU Health and Welfare Fund,
818 F,Supp, 761. 764 (M,D,Pa,1993) (discussing
whether defendant.benefits fund is self.insured and
qualifies under ERISA), aff'd 13 F,3d 704 (3d
Cir, 1994), The parties have quarreled extensively
over this issue, This banle of affidavits is of no
import since, even if the Court were to find that the
plan is self.funded, the Court has concluded tl ~:
1722 is not preempted by ERISA in this case,
(2)
Consideration of whethe ! 1722 is preempted by
ERISA must begin with a review of the decisions of
the United States Supreme Court in FMC Corp, v,
Holliday, 498 U,S, 52, 111 S,CI. 403, 112 L.Ed,2d
356 (1990), and or the Third Circuit in Travitz, 13
F,3d 704,
Copr. <D West 1997 No Claim to Orig, U,S, Govt. Works
909 F,SuPp, 271
(Cite us: 909 F.Supp, 271, .277)
III FMC, 49H U ,S, at 54-55, III S,Cl, at 406, the
defelldam.employee recovered medical cxpenses
bOlh from all ERISA''1ualiOed illsurauee plall and
from the tort feasor for injuries sustained by his
daughter in an alllomobile accident, The plaimiff.
employer sought reimbursemem from the employee
on hehalf of the self. funded health care plan,
maintaining that, under tlte insurance agreemem, it
was emitled to subrogation of the amounts which had
already been disbursed to the employee by the
tortfeasor,
The employee argued that, under then-effect; ~,
1720 of the Pennsylvania Motor Vehicle Financial
Responsibility Law, 75 Pa,Cons,Stat,Anr I 1720,
IFN61 the employer ' .27 prohibited from
exercising its subrogation rights to the employee's
claim, The Supreme Court held that ERISA
preempted ! 1720 prohibitions against subrogation
by qualiOed self-funded employee beneOts plans,
because the "clear iment (of Congress was] to
exempt from direct state insurance regulation ERISA
employee beneOt plans," Id, at 65, III S,Cl, at 411
(emphasis added),
FN6, SOCIion 1720 of Ihe Pennsylvania MOlOr
Vehicle Financial Responsibility Law. entitled
.subrogation, . provillcd
In actions arising out of the rnaimenance or use of
a mOlor vehicle, Ihere shall be n" righl of
subrog:uiol1 or reimbursement from a claimant's
tort recovery with respect to workers'
compensation benefits. benefits available under
section 1711 (relating I" required benefits), 1712
(relaling 10 availability or henefils) or 1715
(relaling 10 availabililY of ad.. limits) or
benefils in lieu Ihereof paid or payable under
section 1719 (relating to coordination orbenelits).
75 Pa,Cons,Stal.Ann, ~ 1720 (effective OClober I,
1984) (repealed August 31,1993),
In Travitz, 13 F,3d at 704, the plaimiff.employee,
who had been injured in an automobile accidem,
sought double recovery of medical cxpenses from
her union benefits program and from the tort feasor,
Although the defendnm-union's health care fund paid
a portion of the plaimiff's medical expenses, the
fund ceased advancing benefits to the plaintiff when
she refused to reimburse the fund for expenses
which she had already recovered from the tort feasor,
The plaimiff-employee comended that the damages
collected from the tortfeasor were for pain and
suffering and t~us were not duplicative of medical
expense benefils receivable from the union fund,
..uge 7
The employee argued that, under Pennsylvania
Motor Vehicle Financial Responsibility Ll\\ ~ 1722,
75 Pa,Cons,Stal.Ann ! 1722, recovering damages
for pain and suffering from one souree :md medical
payments from another did not constitute double
recovery,
Relying on the Supreme Court's teaching in FMC
that ERISA was imended to exempt ERISA-qualified
plans from direct state regulation, the Third Circuit
concluded that "lsJection 1722 of the Pennsylvania
Motor Vehicle Financial Responsibility L1W or any
state statute that attempts to shift liability for medical
and health care benefits to a plan, group comract, or
odler arrangemem operating within the meaning of
ERISA is preempted by il." 13 F,3d at 710
(emphasis added), Therefore, because the effect of
the state's prohibition against double recovery was to
prevent the employee beneOts plan from exercising
its subrogation rights against plaimiff, ERISA
preempted ~ 1722, Id,
Based on FMC and Travitz, plaimiffs argue that
ERISA mamlJtes preemption 0 ~ 1722 in all cases
where at least one source of recovery is a qualified
plan, The Court disagrees, The holdings in FMC
and Travitz. in the Court's view, are much less
broad than plaimiffs contend, Instead, the Court
finds that preemption ( I 1722 is implicated only
when application of the prohibition against double
recovery has the effect of regulating, and imerfering
with, claims by or against an employee benefits plan
operating under ERISA,
Applying FMC and Travitz to this case. the Court
finds that th 1722 prohibition against double
recovery docs not pertain to amounts paid or payable
to Joseph Austin under dIe PNI disability insuranee
policy. (FN7] Rather. the source of funds seekin ~
1722 protection is the tortfeasor, Dionne, Plaimiffs
arc not attempting to shift liability to the PNI plan,
Instead, the Austins seck double recovery by
collecting the same benefits from Dionne that they
have already collected from the plan,
FN7, Neilher party has argued Ihal Ihe PNI
employee henefils plan is entitted 10 suhrogation or
the arnoums pah) by Dionne to Austin.
In other words, application ! 1722 would not
result in imerference with the PNI disability
insurance plan here; it would merely prevem
collection of a windfall by Austin, The Court sees
no reason why Pennsylvania's policy of prohibiting
Copr, 0 West 1997 No Claim to Orig, U,S, GOVI. Works
SYLVIA ROBERTS,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
Plaintiff
v.
NO. 97-1662 Civil Term
MARY McLAUGHLIN,
Defendant
JURY TRIAL DEMANDED
PLAINTIFF'S POINTS FOR CHARGE
AND NOW comes Plaintiff Sylvia Roberts, by and through their
attorneys, Angino & Rovner, P.C., and provide the following jury
instructions which she moves the Court to read to the jury.
Date~ ~ Iq~
ANGINO &
126324/MLB
/'
1. Based on the evidence and applicable law in this case and
the Defendant's admission of liability, I hereby direct you to
return a verdict finding Mary McLaughlin negligent, and thus,
liable to Plaintiff for her injuries in an amount of monetary
damages which you will determine by applying the law of monetary
damages, which I will explain to you in detail, to the evidence
which you have heard.
2. A person need not anticipate that another will act
'lIIl:;"" 7
negligently,
"'"
-
po.?
130 A.2d 90 (1957).
Gross v. Smith, 388
(
3. In order for the Plaintiff to recover in this case, the
Defendant's negligent conduct must have been a substantial factor
~4."'V'\ .
in bringing about the~. This is what the law recognizes as
legal cause.
A substantial factor is an actual, real factor,
although the result may be unusual or unexpected, but is not an
imaginary or fanciful factor or a factor having no connection or
only an insignificant connection with the accident.
Pa. SSJI (Civ) 3.25; Whitner v, Loieski, 437 Pa. 448, 263 A.2d 889
(1970) .
4. In civil cases such as this one, the plaintiff has the
burden of proving those contentions which entitle her to relief.
When a party has the burden of proof on a particular issue,
his contention on that issue must be established by a fair
preponderance of the evidence.
The evidence establishes a
contention by a fair preponderance of the evidence if you are
persuaded that it is more probably accurate and true than not.
To put it another way, think, if you will, of an ordinary
balance scale, with a pan on each side.
Onto one side of the
scale, place all of the evidence favorable to the Plaintiff; onto
the other, place all of the evidence favorable to the Defendant.
If, after considering the comparable weight of the evidence, you
feel that the scales tip, ever so slightly or to the slightest
degree, in favor of the Plaintiff, your verdict must be for the
Plaintiff. If the scales tip in favor of the Defendant, or are
equally balanced, your verdict must be for the Defendant.
In this case, the plaintiff has the burden of proving the
following propositions: that the Defendant was negligent, and that
that negligence was a substantial factor in bringing about the
accident.
If, after considering all of the evidence, you feel
persuaded that these propositions are more probably true than not
true, your verdict must be for the Plaintiff.
Otherwise, your
verdict should be for the Defendant.
Pa. SSJI (Civ) 5.50; Sisk v, Duffv, 201 Pa. Super. 213, 192 A.2d
251 (1963); Reist v, Manwiller, 231 Pa. Super. 444, 332 A.2d 518
(1974) .
6. In general, the opinion of an expert has value only when
you accept the facts upon which it is based. This is true whether
the facts are assumed hypothetically by the expert, come from his
personal knowledge, from some other proper source or from some
combination of these.
Pa. SSJI (Civ) S.31,
.----'
9. The broad term "pain and SUffering" includes a wide range
of not only physical, but also emotional reactions to injuries and
their consequences. In calculating damage for pain and suffering,
you may place a value on the following:
(a) Mental pain and distress;
(b) Fear;
(c) Shock;
(d) Emotional suffering;
(e) Anxiety;
(f) Frustration;
(g) Degradation;
(h) Loss of the feeling of well-being; and
(i) Limitation on activities.
Niederman v, Brodskv, 436 Pa. 401, 261 A.2d 84 (1970); Walsh v.
Brody, 220 Pa. Super. 293, 286 A.2d 666 (1971); Corcoran v. McNeal,
400 Pa. 14, 161 A.2d 367 (1960).
IO. The Plaintiff is entitled to be fairly and adequately
compensated for such physical pain, mental anguish, discomfort,
inconvenience and distress as you find she has endured, from the
time of the accident until today.
,. ~'"A
~/~. .,-'
, ~
Pa. SSJI (C~v? 6.01E; ederman v. Brodskv, 436 Pa. 401, 261 A.2d
84 (1970); BOI.i~o' v. Ponist, 518 Pa. 162, 542 A.2d 516 (1988).
12, The Plaintiff is entitled to be fairly and adequately
compensated for such physical pain, mental anguish, discomfort,
inconvenience and distress as you believe she will endure in the
future as a result of her injuries.
.-------"
Pa. SSJI
(1970) ;
v. Tavlor, 440 Pa. 186, 269 A.2d 486
688 F. Supp. 1030 (E.D. Pa. 1988).
I
I
I
15. The Plaintiff is entitled to be compensated in the amount
of all medical expenses reasonably incurred for the diagnosis,
treatment and cure of her injuries in the past.
These expenses,
as alleged by the Plaintiff, amount to $6,645.00; an exhibit will
be submitted to you, itemizing these costs, for your consideration
during deliberation.
Pa. SSJI (Civl 6.01A.
16. The Plaintiff is entitled to be compensated for all
medical expenses which you find she will reasonably incur in the
future for the treatment and care of her continuing injuries.
Pa. SSJI (Civ) 6.0IB; Murohy v. TaYlor, 440 Pa. 186, 269 A,2d 486
(1970); O'Malley v. Peerless Petroleum. Inc., 283 Pa. Super. 272,
423 A.2d 1251 (1980); Pratt v, Stein, 298 Pa. Super. 92, 444 A.2d
674 (1982).
,
17. If you find that the Plaintiff's injuries will continue
beyond today, you must determine the life expectancy of the
Plaintiff. According to statistics compiled by the United States
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Department of Health, Education and Welfare, the average life
expectancy of all persons of the Plaintiff's age at the time of
accident, sex and race was 26.4 years. This figure is offered to
you only as a guide, and you are not bound to accept it if you
believe that the Plaintiff would have lived longer or less than the
average individual in her category. In reaching this decision you
are to consider the Plaintiff's health prior to the accident, her
manner of living, her personal habits and other factors that may
have affected the duration of her life.
Pa. SSJI (C~ ~~osche v. McCov, 397 Pa. 615, 156 A.2d 307
(1959); Mess v. B~qhl~, 409 Pa. 551, 187 A.2d 168 (1963); ~,
Life Expectancy, Vital Statistics of the United States, (1988) Life
Tables.
18, It is not an issue in this case nor are you to concern
yourselves with how any verdict will be paid. Your verdict must
fully compensate the Plaintiff for all injuries, past, present and
future that she has sustained.
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20. As you heard, Dr. Carver has testified that Plaintiff
Sylvia Roberts had a pre-existing condition which consisted of
degenerative changes in her neck.
Although Plaintiff had this pre-existing condition, this does
,
,
not mean that she is not entitled to recover for those additional
injuries which either activated a dormant condition or aggravated
an active impairment and made it worse.
If you find that
Plaintiff's condition was aggravated or activated by this accident /
you may award her such monetary damages as you feel are entitled to
compensate her. The law has determined that a Defendant must take
the victim as she finds him.
Lebesco v. Southeastern Pennsvlvania Transp. Authoritv, 251 Pa.
Super. 415/ 380 A.2d 848 (1977); Freer v. Parker, 411 Pa. 346, 192
A.2d 348 (1963); Fretts v. Pavetti, 282 Pa. Super. 166, 422 A.2d
881 (1980); Gever v. Steinbronn, 351 Pa. Super. 536/ 506 A.2d 901
(1986) .
WITNESSES
NAME
DIRECT
CROSS
REDIRECT
GREGORY REESE, D.C.
BY: MR. SADLOCK
3, 9 57
RECROSS
J
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.
BY: MR. NEALON
6 (ON QUAL.)
33 I
EXHIBITS
EXHIBIT NO.
PRODUCED & MARKED
1. LITERATURE
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STIPULATION
It is hereby stipulated by and between
counsel for the respective parties that reading,
signing, sealing, certification and filing are hereby
waived.
GREGORY REESE, D.C., called as a witness,
being duly sworn, testified as follows:
DIRECT EXAMINATION
BY MR. SADLOCK:.
Q Would you state your full name, sir?
A Gregory Todd Reese.
Q And what is your occupation, sir?
A I am a chiropractor.
Q Can you explain for the jury your educational
background?
A Starting with most recent, I've completed
chiropractic college in Davenport, Iowa, earning a
doctorate in chiropractic degree. Previous to that, I
did some undergraduate studies at Wright State
university and got an undergraduate degree at Kettering
College of Medical Arts which was an associate in
science and in respiratory care.
Q In terms of your chiropractic education, how
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2 A It is -- when I was going through it, it was
3 a 12 quarter program which would be equivalent to a
4 four year.
5 Q You mentioned you also -- first of all,
6 Doctor, what school was that at?
7 A That was Palmer College of Chiropractic.
8 Q You mentioned you also had some course work
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15 A And in respiratory care.
16 Q What type of course work would you have taken
17 for that degree?
18 A That was -- I did two semesters there of
19 general studies; and then I did six semesters of
20 science and studies in respiratory therapy.
21 Q Throughout your educational background,
22 Doctor, have you taken any course work in anatomy,
23 physiology, things of that nature?
24 A Yes, in fact, I have my transcripts if you'd
25 want to just verify anything.
at Wright State College?
A Uh-huh.
Q And what was that course work in?
A Organic chemistry.
Q And you indicated also that you have an
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Q Doctor, have you also had training and
experience in taking and/or reading X-rays?
A Yes, I have.
Q Are you currently licensed, Doctor?
A Yes, I'm licensed in chiropractic.
Q When was that obtained?
A Let me think. 1990 for the State of
Pennsylvania. I also have a license for the state of
Iowa and Illinois, but they were not currently up to
date.
Q Is that because of the proximity to where
Palmer Chiropractic is located?
A Yes.
Q Do you hold any other certificates, Doctor,
relative to your profession as a chiropractor?
A I have a certificate for -- licensed
certificate for use of physical modalities in this
office which is separate from my chiropractic.
Q Doctor, how long have you been in practice?
A I have been in private practice since the
Fall of 1990. I graduated from chiropractic Bchool in
October of 1989.
Q Doctor, do you routinely take course work for
continuing education purposes?
A Yes, I do.
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Q Doctor, as part of your practice, have you
treated patients who have been injured in motor vehicle
accidents?
A Yes.
Q And does that include treating patients who
have been injured in high speed impacts as well as low
speed impacts?
A Yes.
Q And does that include treating patients who
have had neck injuries from motor vehicle accidents?
A Yes, it does.
Q Doctor, have you previously testified as an
expert in your field and as a treating chiropractor?
A Yes, I have.
Q Doctor, is Sylvia Roberts a patient of yours?
A Yes, she is.
MR. SADLOCK: At this time, I'd like to offer
Dr. Reese as an expert in the field of chiropractic
care as well as being Ms. Roberts' treating
chiropractor.
CROSS EXAMINATION ON QUALIFICATIONS
BY MR. NEALON:
Q Doctor, you mentioned that you graduated
chiropractic school in 1989 and began private practice
in the Fall of 1990; is that correct?
7
A Yes, it is.
Q Since that point in time when you've been
private practice, have you been certified by any
National boards?
A I was certified by the National Board of
Chiropractic previous to opening my office. That was
done in the last year of chiropractic school in 1989.
Q Is there any boards that certify people after
they've been in private practice for chiropractors?
A
Yes, there's different specialty boards.
you want to become a chiropractic radiologist, you'd
have to be certified by that board.
If you want to
become a chiropractic neurologist, you have to be
certifi~d by that board. There would be a practicing
chiropr.actor. You have to be certified by the National
Board of Chiropractic Examiners which I hold.
Q Okay. Have you sought to become Board
certified by any specialties since starting private
practice?
A No, I haven't; but there's some other reasons
for that. Par.t of it is the -- I go to seminars that
lead to board certification; but I will never become
Board Certified because I don't take the Saturday
portion.
I don't take class work on Saturdays for
religious reasons so --
in
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o Now, Doctor, you were asked about your
experience with treating people involved in low speed
and high speed accidents. Have you had any mechanical
engineer training?
A No, I haven't.
o Have you had any training in determining the
forces involved in an accident?
A Yes, we have.
o What training have you had on that?
A In college, we took a course called
biomechanics.
o Was that a one semester course?
A I believe it was. And I've taken -- I have
eight hours of -- eight semester hours of physics that
would deal with vectors and forces.
o Okay. Where was that taken?
A Kettering College.
o You were asked if you treat people who have
been injured in automobile accidents. I would also
imagine you've treated people that have neck pain or
back pain from causes that are not automobile
accidents.
A Yes, that's true.
o People get neck pain from all variety of
reasons; is that true?
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A Yes, that's true.
MR. NEALON: That's all I have on
qualifications.
MR. SADLOCK: Take a break and see if that
article is in.
(Break taken from 11:46 to 11:57 a.m..)
DIRECT EXAMINATION
BY MR. SADLOCK:
Q
Doctor,
you've indicated Sylvia Roberts is a
When did you first see Ms. Roberts
patient of yours.
in your office?
A The first day of treatment was on 7/5/95.
Q And at that time, did Ms. Roberts provide you
with a history of why she was in your office?
A Yes, she came in complaining of neck pain and
pain in the mid back region on the right side. She
stated that the history of this present illness began
after she was involved in an automobile accident which
occurred on 6/30/95.
Q Now, did Ms. Roberts explain to you the
mechanics of the motor vehicle accident of June 30,
1995?
A
Yes, she did.
And what was that?
Q
A
She said that she was stopped at the pick up
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window at McDonalds and the car was struck by a second
vehicle in the rear end.
Q Was Ms. Roberts a passenger of the vehicle?
A Yes, she was.
Q Doctor, is it your understanding that at the
time of the accident and immediately prior to the
accid~nt Ms. Roberts was not suspecting the accident to
occur?
A Yes, from my understanding.
Q So in other words, she wasn't braced or --
A No, she was not.
Q And you indicated, Doctor, that on that date
on July 5th, 1995 Ms. Roberts presented with some
complaints of pain in her neck and upper back area; is
that correct? Is that correct?
A Yes.
Q And prior to the accident, did Ms. Roberts
discuss with you -- provide any history as to how she
was fpeling before the accident occurred?
A She states that she was physically doing fine
before the accident.
Q No complaints of neck pain, upper back pain?
A No, I asked her on that; and she said there
was nothing.
Q Did you then conduct an examination, Doctor?
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A Yes, I did.
Q And what was involved with that?
A I did range of motion testing both with
active range of motion and I did resisted range of
motion testing. I did palpation of the neck and upper
back region. I checked her neurological status by
checking her deep tendon reflexes, the sensory
examination and the motor examination. And I did a
baseline measuration of hers arms and forearms.
Q What were the results of those examinations,
Doctor?
A
The neurological examination was normal.
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did that in the upper extremities. On range of motion,
she had pain; and initially, she had relief with
extension of her neck. She had pain with forward
flexion of the neck, and that was due a great deal when
she bent forward. Right lateral bending increased pain
in the right side of the neck at the approximate level
of the C6 vertebra.
Left lateral bending, she had increased left
neck pain at the same level, at the C6 level. And left
rotation was pain free, and right rotation increased
pain in the right area of the C6 vertebral body. On
resisted range of motion testing, she had pain in the
lower cervical spine with extension; and she had pain
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in the suboccipital region with cervical flexion.
Correlating this with palpation, she had
tenderness in the left anterior cervical triangle in
the front of the neck. She had bilateral C5-C6 and C6
dash C7 paravertebral tenderness and muscular
tightness. And she had tenderness over the right side
of T6.
Q Did you formulate then, Doctor, an initial
diagnostic impression?
A Yes.
Q And what was that?
A I diagnosed her with a cervical sprain
injury, and my initial concern because of her age was
to rule out any previous pre-existing degenerative
changes in the neck.
Q When we talk about cervical sprain, Doctor,
we're talking about the neck obviously, correct?
A Yes.
Q And what does that then mean to have a sprain
of the neck?
A A sprain is involving the ligaments that
connect the bony structures of the neck together~ and
that would include -- I could name the ligaments if you
want.
Q If -- just finish in lay terms. Explain it
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as best you can what happens.
A Between two bones you have to connect those.
You do have some muscles connecting them, but what
prevents bone from moving too far is a ligament. And
in the spine, we have the cervical disks that you can
consider a ligament. They also cushion the vertebras,
and it provides some spacing of the bones. Also you
have ligaments such as you would have in your ankle if
you sprained your ankle. You have similar ligaments in
the neck. And there's numerous ones.
I could -- major ones are you have joint
capsule ligaments, you have posterior/anterior
longitudinal ligaments. You have the ligament in
flabellum, and you have interspinous ligaments in the
neck. And all these structures work together to limit
range of motion so it's not -- your neck doesn't become
unstable.
Also I should say if someone has a sprain,
they probably -- they probably have some strain injury
also to the muscle; and it could just be
Q And Doctor, I believe you indicated that Ms.
Roberts was not aware that an accident was going to
occur when -- is that correct?
A That's correct.
Q Can you explain, Doctor, from your experience
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and your training the effect of the body during a rear
end motor vehicle accident? And I believe in this case
the testimony of the Defendant is that it may have
occurred at maybe 10 miles per hour, and the Defendant
has an expert that indicates 7.8 miles per hour.
A Yes, I -- talking with her, I got the
impression it was around that range. You want to know
like what happens to the body?
Q To the body, correct.
A The patient stated that she felt her head go
forward and then backwards. That may be different, you
know, depending upon how people perceive things; but
initially from my understanding, your torso goes
forward which is taking the head forward. The head is
then going to go backwards, and then you're going to
have an alternate movement of that going forward then.
So actually, you have a forward motion, head
going backwards as the body is going forward and then
the opposite direction again which is why they call it
a whiplash because sometimes -- your head is sitting on
top of your torso. And it's like taking a carrot stick
and whipping it, and sometimes you can break it if you
hit something. The momentum is increased at that part
of the body. More momentum goes through the neck then
it would say through the lower back.
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Q That seems reasonable, Doctor, in that the
head has weight to it above on the neck; is that true?
A Yea, and in example, juat looking at some
clinical, I used to work in a rehab hospital. And we
had a man that fell over backwards, and he broke his
neck because of this carrot like action. He had
ankylosing spondylitis which is like having
degenerative disk disease but affecting every single
vertebrae about where they become immobile.
Because the upper neck is the -- the only
thing that moved, the momentum was increased; and it
snapped his neck. And he became paraplegic as a -- I
don't know if that has any insight to what may happen.
Q In terms of describing the movement of the
body, Doctor, is there a difference in a person who is
aware and expecting the accident to occur versus
someone who is unsuspecting the effect on the body?
A Yes.
Q And what is that?
A You have a chance to brace yourself; and --
and you can -- can tense your muscle. Also if someone
who is well muscled, same type of thing. They tend to
have more protection there as opposed to someone who
doesn't. But similar thing they have almost like a
brace on because they have so much muscle. Someone
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I else who isn't as muscular, if they know it's coming,
2 they can brace their muscle and make due with what they
3 have. It reduces the movement of the head.
4 Q How would you describe Ms. Roberts' body
5 type?
6 A Let's see. She's at the time of injury,
7 she was 56 years old. So I when people come in that
8 the female is postmenopausal, I do suspect
9 osteoporosis. Because of the way her neck moved, I did
10 suspect degenerative changes which she did, indeed,
11 have. She's not well muscled. She would just be a
12 typical female in that age category.
13 Q Slight neck type size?
14 A Yeah, small neck.
15 Q Doctor, after the first initial examination,
16 did you recommend a course of treatment?
17 A Yes, I did.
18 Q And what was that?
19 A Basically physical therapy in the office.
20 Q Did you recommend any diagnostic studies?
21 A Yes, we obtained cervical X-rays.
22 Q And why was that, Doctor?
23 A I wanted to rule out degenerative changes
24 plus after auto accidents I like to do
25 flexion/extension studies. If there's a really, really
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2 wasn't suspecting that, but there's always the
3 possibility of something else. But the main reason was
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12 was from the X-ray; and these were later shown to be a
13 little more extensive when we did an MRI.
14 0 Now, those changes, can they could Hs.
15 Roberts exist before the accident with those changes
16 and be symptom free?
17 A Oh, yes, there's -- there's no correlation
18 between X-ray findings of degenerative changes and
19 people with back pain. None whatsoever. Someone can
20 have a back that's full of arthritis and you can ask
21 them do you have any pain and they say, oh, no, I feel
22 great.
23 A lot of times is what happens someone all of
24 the sudden develops neck pain. They go to the doctor,
25 and they say you have arthritis. They put them on
the degenerative changes, trying to see if she had it
and to what extent.
0 And did she?
A Yes, she did.
0 To what extent?
A I would consider -- let me look at the
thing. Just off the top of my head, I would say it was
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medication. The week before they didn't have any pain,
and the months before they didn't have any pain. The
arthritis doesn't come on overnight so there's no
correlation with x-raying the amount of pain. And so
even though they had these degenerative changes
previous to this, she was pain free.
Q What significance if any, Doctor, is there to
the existence of the degenerative changes and the
cervical sprain and the movement of the body during the
rear end accident?
A Two different things with that. The first is
with degenerative changes you get a hypomobility of
segments in the neck where they don't move as much as
they -- as they should. That's in one case. In
another case, a joint may start to degenerate because
it's moving too much.
So maybe the hypo or
hypermobility with a degenerative change.
The second thing is is if they are not moving
as much and you get a rear end collision and now the
impact is going to the neck -- normally we have seven
vertebral bodies that make up the cervical spine from
the bottom. Of the biomechanical standpoint, we look
at the first two thoracic as making up part of that
curvature also.
So if you add those, you have nine
vertebral bodies.
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When the neck moves into extension and then
into flexion in a normal person, you have nine segments
taking the force. It -- take someone who has
degenerative changes say between two vertebral
segments. Now, you've lost two of them, They become
one motion where you lost one because they become one
motion unit now. And so the ones above and below are
going to take a brunt of the injury to make up for that
loss of motion.
If you have two different levels of
degenerative changes, then you go from three segments
movable segments now to one movable segment. And
so it's a what would you call it? Well, any ways, it
increases the amount of force in the neck; and
therefore, the amount of damage that can occur wotrld be
greater.
Q Less ability to withstand the impact --
A Yeah.
Q -- and force of the injury?
A That would be one consideration. The other
consideration is if you have a segment that is maybe
hypermobile that has degeneration and you go putting a
force through that, it's going to become symptomatic
and painful in many cases.
Q Is that what you feel happened with Ms.
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Roberts?
A Yes.
o Doctor, you indicated that your treatment
plan you recommended physical therapy?
A Yes.
o What was involved with Ms. Roberts' therapy?
A Well, initially, it's just to try to calm
down symptoms. I believe we used -- it was a couple
days after the accident. So we started using some heat
on the spine, ultrasound, some electric muscle
stimulation to reduce muscle spasms.
I started her on early range of motion
exercises. And then as she improved a little bit, we
started her with exercise for the neck with some
resistance and after she was tolerating the range of
motion exercises.
o with what frequency did you treat Ms. Roberts
initially?
A I believe initially I saw her -- I'd have to
look on the calendar to verify. But I think it was
three times a week frequency.
o Did you continue to treat Ms. Roberts through
the end of 1995 then, Doctor?
A Yes, I did.
o And how would you assess her progress to the
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end of that year with regard to her complaints, your
findings and your diagnosis?
A Would you repeat that once more?
Q Sure, maybe I'll just break it down and make
it a little bit easier.
A Yeah.
Q You indicated you saw her through the end of
1995~ is that correct?
A Yes.
Q Through that time period from your initial
examination to the end of the year, were Ms. Roberts'
complaints consistent or the same throughout?
A They were the same. She was -- she had made
improvement. She definitely made improvement. The
symptoms became less constant or episodic. However,
when she was getting headaches at that time, they were
still severe in quality~ but the headaches were also
not as frequent.
Q How do headaches relate to a neck injury?
A To neck injury. Well, they just came out
with a new classification of headaches. They threw out
the old one. There's basically four types, You have
migraine with aura, migraine without aura. You have
cervicogenic headache which means the headache is
coming from the neck structures, and then you have
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tension headache.
And what happens getting into the anatomy and
physiology here is the neck is painful, but the brain
is perceiving it as head pain.
It's confused because
the location of the -- of the nuclei of the trigeminal
nerve which supplies sensation to the head is very
close to where the lower motor neurons come into the
spinal cord and synapse with the upper motor neurons so
there's a spillover. And the body gets confused of
where the pain is coming from, and that's why it's
called a cervicogenic headache.
Q Now, Doctor, from the first evaluation
through the end of 1995, did your examination and
examination findings verify Ms. Roberts' complaints?
A
Yeah, they
they -- my objective findings
all correlated with her subjective complaints. There
was no bizarre mismatch.
Q I believe, Doctor, you indicated earlier that
Ms. Roberts also had an MRI; is that correct?
A Yes.
Q Was that on your referral?
A Yes, it was.
Q And why was that, Doctor?
A Because she wasn't -- even though she had
improved, she wasn't to where I wanted her to be; and I
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just wanted to see what was complicating it. I knew
there was degenerative changes there; but I wanted to
look for -- look into it more and see if there was
actually a disk that might be causing some problems.
Q After the MRI, was there any change in your
diagnosis or recommended treatment?
A There was no change in my recommended
treatment at that point. It verified what was seen on
the X-ray. We had suspected -- I noted in my X-ray
report that the canal size was at the lower limits of
normal. It confirmed that she did have mild spinal
stenosis. It also showed which you can't see on X-ray
it showed that the -- that the two levels -- one more
so than the other -- there was impingement upon the
thecal sac which is a sac that covers the spinal cord.
Q You mentioned some terms I'd like to just get
explained in lay terms for the jury. You mentioned
that the canal size was small. What does that mean?
A Well, all your -- there was -- vertebral
canal is what houses the spinal cord. So all your
information for your feet to work and everything and
for you to feel your feet working has to go through the
cervical spine and through the vertebral canal all the
way down through.
If you start to have impingement upon that,
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you're going to start affecting some of the tracts of
the spinal cord. And I did not find any -- any of the
tracts being impinged. Otherwise, I would have had
some other findings on exam. But that's -- that's the
main thing. It can cause some neurological deficits in
the future.
Q You also mentioned a stenosis. What does
that mean?
A That is where the canal is being narrowed.
It's the narrowing of the canal. That's the word they
use for it.
Q Is there any significance in those findings
to your diagnosis of the whiplash injury that Ms.
Roberts sustained?
A Well, when someone has canal stenosis,
they're going to feel better with their head in the
extended position. When -- or I'm sorry, the opposite
of that. They're going to feel their head better in
the flexed position. In an extended position, it's
going to narrow the canal even more. And with canal
stenosis, you could have some radicular symptoms with
it.
It's kind of hard to say is this coming from
canal stenosis or is it just coming from the
structures. But if she did have pain that was -- say
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there's scapular pain that she was coming complaining.
If that was coming from the canal stenosis, she would
get relief with her head in flexion; and it would be
made worse with it in extension.
But then when you have a sprain injury on top
of it where it hurts to put your head in a little bit
of flexion, you can't extend for that. And therefore,
that makes that pain there all the time because there's
nothing you can do to compensate for it. A lot of
patients that I have that have cervical stenosis they
do have to keep their head in a slight forward
posture.
And if you have -- like I said, if you have
an injury on top of that that makes that painful just
to do that, then you're trying to decide what has more
pain, if the pain I have in my back or the pain I have
in my neck when I try to relieve that.
So there's a
correlation there, a little bit.
Q Doctor, you mentioned that Ms. Roberts at
your direction had X-rays and an MRI. Was it
reasonable and necessary in your opinion to refer Ms.
Roberts for these tests?
A Yes, yes.
Q Doctor, did you see Ms. Roberts at all in
1996?
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A Let me just see what date it is. The answer
is yes. I'm just trying to find the date if you want
the exact date.
Q If you can just describe and summarize for
the jury the nature of the treatment in 1996.
A Well, I -- in the beginning of January, I
released her from active care because I thought she was
at the maximum level of improvement she was going to
reach; but I instructed Ms. Roberts that if the
symptoms would worsen from the point that they were for
her to return to the office and we'd take a look at her
and render some treatment. So that -- that's what the
treatments were for from that point on. It was for any
worsening of symptoms.
Q Aggravations, exacerbations, that kind of
thing?
A
Yeah.
Q Now, you mentioned that she reached a maximum
level of improvement. Does that mean, Doctor, that as
of that date in January of 1996 Ms. Roberts was back to
her physical condition in June of 1995 before the
automobile accident occurred?
A No, it -- what it means is that -- that she
would not have any further improvement by rendering
more treatment.
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o In what you just mentioned, Doctor, in terms
of there being aggravations or exacerbations of Ms.
Roberts' condition, is -- is that consistent with her
original injury that you diagnosed?
A Yes.
o Do you feel that that is likely to continue
in the future for Ms. Roberts?
A Yes, I do.
o Now, did you also see Ms. Roberts in 1997?
A Yes, I did.
o Was that for the same reasons as we just
described, for aggravations or exacerbations of her
condition?
A Yes, it was. It was.
o Did you see Ms. Roberts at all this year,
199B?
A Yes, I have.
o And when was that, Doctor?
A January 12th.
o And was it just the one visit on the 12th?
A I saw her on the 9th originally, and then the
12th was a follow-up visit.
o Was that the last time then you had contact
with Ms. Roberts?
A Yes, it was.
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Q Can you explain for the jury why Ms, Roberts
was in to see you on January 9, 1998 and January 12,
1998.
A She came in on the 9th. She had increased
cervical spine pain, and she had complaints that her
headaches were increased in the back of her head
region. And she was having pain down into the right
posterior shoulder.
Q Those complaints consistent with your
original diagnosis?
A Yes, it is.
Q What treatment did you provide for Ms.
Roberts at that time?
A I utilized deep heat therapy, electric muscle
stimulation to the neck and upper back; and I did some
mild manipulation and mobilization to the lower
cervical spine.
Q What does that mean, Doctor?
A I just gently took the neck and took the
joints and moved them around a little bit to free them
up, to help restore cervical range of motion which she
reported having improved afterwards.
Q Doctor, at any time during your course of
treatment with Ms. Roberts, did she relate to you any
activities that affected her injury?
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A Yes.
o Can you explain that for the jury?
A Well, the main one that comes right out in my
mind is reading. She's -- she's an avid reader. She's
unable to hold her head down for any length of time
without having increasing symptoms. And the symptoms
are increased neck pain, not -- not mid back pain.
o Is that consistent with your original
diagnosis, Doctor?
A Yes, it is.
o Doctor, I believe I read in your chart that
at one time you provided Ms. Roberts with some home
exercises; is that true?
A Yes.
o What type of exercises would she have been
instructed on?
A Range of motion exercises.
going to have to look and get exact.
Let me -- I'm
I know one for
sure was range of motion exercises. And I had her
doing some neck extension exercising, use Necksys. And
that I believe those are -- those are the two main
one. But we started with the range of motion, and then
we progressed to using the Necksys mach~ne.
o Doctor, is weather at all a factor for Ms.
Roberts in terms of her injury or her complaints?
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A Yes, I believe so.
o Can you explain that?
A Weather affects people who have problema.
When you have active arthritic problems, the barometric
pressure changes. And the joint structure is a closed
structure. So the barometric pressure drops outside.
The closed structure is going to expand, okay, to try
and equalize the pressure inside and out.
And when you have that, that is just like you
have swelling in the joint; but you don't. It's just
pressure change. And that pressure change is going to
put small nerves, things like that are going to get
irritated; and they're going to sense pain.
o Doctor, what do you believe is Ms. Roberts'
prognosis?
A With injuries to the cervical spine and it
relates also to lower back, the longer people are
having symptoms from the original date of injury, the
worse the prognosis is. In her case, she was still
very active six months from the time of the accident.
And from that, I -- I gave her a poor prognosis of
having complete recovery.
However, I thought that she should reach
functional recovery within two years from the time of
the accident. And what I mean by functional recovery
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meaning that she could do normal activities of daily
living. She may have discomfort with it, but she can
do it.
Q But you did indicate that she had a poor
prognosis for complete recovery?
A For complete recovery, yeah.
Q Doctor, do you have an opinion within a
reasonable degree of chiropractic certainty whether the
injuries that you diagnosed for Ms. Roberts and treated
her for and discussed with us here today are directly,
causally related to her June 30, 1995 motor vehicle
accident?
A Yes.
Q And what is your opinion, Doctor?
A I believe that it -- it's directly related,
Q Doctor, your office was kind enough prior to
the deposition to provide copies of your bills for
services provided to Ms. Roberts. And according to my
math, those bills total $5,575. First of all, Doctor,
when you treated Ms. Roberts, was she charged your
customary charges?
A Yes.
Q And
MR. NEALON: I just want to make an objection
on the record in depending on how the judge rules
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regarding this legal issue.
MR. SADLOCK: Go ahead.
MR. NEALON: We don't believe the medical
bills as recoverable because of the current state of
Pennsylvania law.
I'm -- I'm assuming you're going to
ask several questions; and I have a continuing
objection to those. And I may also ask questions on
them, but they would be withdrawn if the judge rules in
our favor.
BY MR. SADLOCK:
Q Fine. Doctor, again, just those were your
customary charges for Ms. Roberts?
A Yes, they are.
Q And are they your usual charges for the
service provided to Ms. Roberts?
A Yes.
Q Do you feel the charges were directly,
causally related to treat Ms. Roberts' accident-related
injury?
A Yes, they are.
Q And do you feel that the charges or actually
the treatments were necessary to restore Ms. Roberts to
some level of functionability and decrease in her pain?
A Yes, they were.
Q And you feel they were your reasonable
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charges?
A Yes.
MR. SADLOCK: Thank you, Doctor. I have no
further questions at this time.
(Discussion held off the record.)
CROSS EXAMINATION
BY MR. NEALON:
o Doctor, you said you first saw Ms. Roberts on
July 5, 1995; is that correct?
A Yes.
o And at that point, you took a history from
her; is that right?
A Yes.
o And in determining what is the cause of Ms.
Roberts' problems, the history is important to you; is
that right?
A Very much so.
o And in other words, you have to find out what
she's linking the accident to before you're able to
determine or you have to determine what she's linking
her injuries to before you're able to determine what is
the true cause of her injuries; is that right?
A Yes, I mean if I can give an example. I
can't examine a person and say, oh, you've boon in an
auto accident.
I can't do that.
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A Yes.
Q -- in her neck; is that right?
A Yes.
Q And that's important for you to determine
whether the accident was the cause of her pain and
subsequent treatment; is that right?
A You look at I was looking at not just the
day before I was looking at what her neck was like for
the previous six months, a year before that.
Q Okay. And especially with a woman with these
degenerative changes, that would be important to you;
is that right?
A Yes.
Q And I think you said you did an X-ray and an
MRI and both of those showed degenerative changes in
the neck?
A Yes, they did.
Q And those degenerative changes predated this
accident; is that right?
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Yes, they did.
For instance, there was some discussion here
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4 showed. That was -- predated this accident; is that
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6 A Let me just think here what the radiologist
7 said. The -- I -- the impingement I think they said
8 was from the bony encroachment. Yes, so that predated.
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And the spinal stenosis, that's a
10 degenerative condition also?
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Yes.
So that predated the accident?
Yes.
Now, you were asked some questions as to
15 whether someone with a degenerative condition would
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16 necessarily have pain. And I think you said there's no
17 absolute correlation between the two; is that right?
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That's correct.
But you'll agree with me the conditions that
20 Ms. Roberts had that pre-existed this condition would
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21 be capable of causing pain in her neck; is that right?
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Yes, if they were -- if they were flared up
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Q
All right. Now, were you aware that she had
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A Yes, I was. I put that in my -- I believe
that was in my first report.
Q And she injured her neck in that accident?
A I believe it was ten years previous.
Q And she needed treatment as a result of that
accident, didn't she?
A That I'm not -- I'm not aware of what
treatment she had for that.
Q Would that be important?
A She may have -- not really. What's
important -- what was mainly important was that she was
pain free for the time previous to the auto accident,
the second one.
Q Did she tell you how long the symptoms from
the first accident lasted?
A She might have. I would have to review.
Q You want to check and see if you have any
information on that?
A Let me find my first report. Okay. I do
have it. She was treated for a year and a half
following the first accident.
Q All right. That's a fairly significant
amount of time, isn't it?
A I don't have the frequency down of how
often. It's not -- you know, if she had a course of
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treatment say for three months would be reasonable and
then she had some supportive care after that, you know,
it -- if it was three times a week for a year and a
half, that would be a lot of care; but I don't have any
record of
a And to try and correlate it though, for
instance, you you reached a determination in January
of '96 just six or four months after this accident that
her prognosis for returning to complete recovery was
poor?
A Uh-huh.
a And that was because of the length of
treatment she had which was only four months, isn't
that right?
A Not just the length of time but the length of
time that had past.
a And that was only a four month period of
time?
A Well, you have all of July, August,
September, October, November, December, six months.
a Okay. So because of a problem that lasted
for six months, you were of the opinion that her
prognosis for returning to complete recovery was poor?
_MR ~ABLOCK: I'll object because ~ duu'~
b.a:l::i:.eve that was the t.esl:imul1.l' testimony The
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p.rognoBi!l i!l ferm~d at th.i.tl po'i-nt-in-t1.-me-based-on--
~hll ta'-e-lrl:me-nt. trom Juue-------J~orT!T9:)tlirough January'-
, n~t~asea-o~-rhe init'i~per~od of time.
THE WITNESS: Can I add something? The
literature --
BY MR. NEALON:
Q I just want to back up a second because you
wrote a letter.
A It was based upon
Q I'm going to show you a letter dated
January -- January, 1996. There's two of them.
A Yeah.
Q Let's just go through this one step at a
time, and then you'll have a chance to explain it. But
you wrote two letters in January, 1996 regarding her
condition
A Uh-huh.
Q -- is that right? And this is about six
months post accident; is that right?
MR. SADLOCK: Which one is that?
THE WITNESS: January 31st, that would be --
that would be seven months post accident. You know, I
definitely based my opinion after six months of
treatment. That
BY MR. NEALON:
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Q That's what I was driving at.
A That, however however, to date looking at
her condition, it verifies my assessment. And the
basis of making that assessment after six months isn't
based upon something that I picked out of the air.
It's based upon what current literature states is the
prognosis of someone who is still having pains. You
know, the amount of symptoms she had six months
afterl...ards.
Q Okay. All right.
A And the level of her function six months
afterwards.
Q
I understand that.
If she needed treatment
for a year and a half after this earlier accident
condition, we arrive at the same correlation that her
prognosis for complete recovery from that earlier
accident is poor.
MR. SADLOCK: I'll note an objection.
without no foundation,
ecord to
The's no
nothing in
was for a year
treatment
the records
and
Your
doctors that she saw so we
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M
ition.
THE WITNESS:
If I can add something about
that, I don't know what her neck looked like.
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It could
very well be that the degeneration she has in her neck
now is due to that first accident. Okay. And -- and
because there's two types of osteoarthritis, one is
primary and one is secondary. And secondary
secondary occurs as a result of -- of an injury or an
accident.
But the point is that even if ~he had that
degeneration, that's the body's way of adap~ing to
something; and it was -- it was calmed down,
It was
totally silent from her history.
It wasn'~ -- it
wasn't active.
So it was this auto a~cident that
that put that into a flare up.
BY MR. NEALON:
Q All right. Now, Doctor, I want to focus on
the mechanics of the accident you testified about. I
think you said that the -- the basic understanding is
that the neck goes back first and then forward?
A No.
Q That's not true?
A I don't know if -- I don't know if I would
if I would be the best person to comment on that
because it's not something I reviewed right before
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this.
Q I'm asking you for your own understanding.
You said you took courses in biomechanics and physics?
A It's
Q What is
A From my understanding, it seems that the
torso goes forward; and with the torso going forward,
the neck is going forward with it. Okay. So the neck
is going forward; but in relation to the torso, the
cervical spine is going into extension.
Q Extension meaning backwards?
A Backwards but the whole body is going forward
which the patient perceives himself as going forwards.
Okay. And then after, the neck goes backwards so you
almost have an exaggeration. You have something going
where the torso is going forward and then back like
this (indicating). And so the patient perceives her
head going forward, but it actually is going in
extension in relation to the torso.
Q Okay. And that's your understanding in the
mechanics that will provide what you call a whiplash
injury?
A Yeah, the actual term is cervical
acceleration/deceleration injury; but whiplash is
Q The torso might go forward a bit but neck
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goes backwards and then after --
A The neck is going forward with the torso, but
it's going backwards in relation to the torso.
Q Okay. And then the neck goes forward?
A As the torso is going backwards.
Q Now -- can I have my letter back? I think
you took a history from Ms. Roberts the day you saw
her; is that right?
A Yes, I did.
Q And I'm looking at a letter that you wrote on
July 7, 1995.
A Okay. That would be the -- let me see. I
saw her on --
Q July 5.
A Okay. July 5. It should be dated the same
day unless I wrote it unless I wrote it -- got
behind in my letters; but it's concerning the 7/5 date.
Q Right. And the history she gave you was that
she stated she was a passenger in a car in which she
was stopped -- which was stopped at a McDonalds drive
through window when they were rear ended by a second
vehicle.
A Okay.
Q Is that correct?
A Yes, it is.
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Q And then your report goes on to indicate that
she states that she felt her head go forwards and then
backwards at the time of impact.
A Yes.
Q Is that right?
A Yes, but you understood what I said about why
she must have perceived it that way, that the torso and
head were going forward together but the neck was going
in extension in relation to the torso.
Q Okay. I understand why she might have
perceived it that way. But looking at the history
that's contained in this report, that's inconsistent
with what would normally occur as a result of a rear
end accident, isn't that right?
A It's consistent. The head is going -- the
head is going forward. The head is definitely going
forward. It's going forward, and it's going into
extension would be the best way of stating it. It's
translation, but it's extension at the same
forward
time.
Q
A
part.
Q
go?
Okay.
It's a matter of perception on the patient's
Now, the report -- how far forward did she
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A Well, you have people -- well, I don't know
how far forward she would have went. But of course,
people -- when people are in an accident, they -- you
know, you hear of them hitting their head.
Q That didn't happen here?
A No.
Q In fact, she told you she was wearing her
seat belt?
A Yeah.
MR. SADLOCK: Objection. Move to strike.
It's not admissible. Use or failure to use a seat belt
is not admissable for any purpose in this Commonwealth
so I move to strike any reference to the seat belt
either in the question or the answer.
MR. NEALON: Okay. You've answered the
question, I believe. She indicated to you she was
wearing a seat belt?
MR. SADLOCK: I move to strike.
MR. NEALON: You have a continuing
She indicated she was wearing her seat
objection.
belt?
THE WITNESS: Yes.
BY MR. NEALON:
Q And she explained to you that she did not hit
her head on any part of the car?
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A Yes.
Q So her head didn't strike the headrest or
anything like that?
A No.
Q Now, Doctor, would you agree with me that not
every rear end accident can produce injury?
A True.
Q I mean there has to be sufficient force.
A I agree. I've been in two accidents myself
rear ended, and I have not been injured to any degree
in either of them. One was significant as far as
damage, and the other one was minor. And I had
passengers in bQth instances, and the both instances my
passengers were injured quite a bit.
Q So there -- I take it there has to be
sufficient forces on the body to produce the changes
that you've described so that injury can occur?
-MR.-,SADLOGK-:--I--'-l-!-Qb-ject jutlL Lv Lhe I1B-6 nf
rm-surncren1:-.---I-me-all Lhat. can mean difI",..en-t--
20 -trh-ih':jtl Lo-d-rfferent-peop-le.
21 -ME,! NEALON: 'l'hiR is-c-rvtltl, Rrch. I meu-I\-_
2 2 me-on.
23 THE WITNESS: Sufficient for that
24 individual.
25 BY MR. NEALON:
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Q Okay. Now, prior to this deposition, I
believe you tried to get some literature on low
velocity accidents; is that right?
A Yes, I've I've read on the subject myself;
and I've always known that low velocity impacts can
cause significant damage. However, I didn't have
anything right in my -- on my fingertips that I could
reference to so we did obtain that.
Q And where -- and prior to the deposition
then, you provided to counsel two chapters of a
textbook
A Yes.
Q -- on this subject?
A Yes.
Q Is that right? And where did you get the
textbook from?
A I got that from a brother of mine that's a
chiropractor in Jacksonville, Illinois; and he faxed
that to me this morning.
Q So you rely on this?
A Actually, I have a book, Foreman and Croft,
which is where I actually got my understanding of low
impact velocities from. I have not read that all the
way through. I just read the highlights of it.
Q Based upon what you read though, it's
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consistent?
A It's consistent with what I've read in the
past, yes.
Q Okay. And so you would rely upon these types
of articles in YOUt professional training and your
treatment of patients?
A Yes, as a clinician, you -- you glean
information from all different sources.
Q Okay. I want to go through a couple things
in this -- in these materials. And if you don't mind,
I'd like to mark it as Exhibit 1 so that we have a copy
of it.
A Okay.
Q Now, first of all, I'm going to look at this
Chapter 2 which is entitled biomechanics; and it says
the history of whiplash biomechanics. And down in the
third paragraph, it indicates or I'm sorry, the fourth
paragraph, it says, quote, the first physicians to
report on whiplash believed it to be primarily an
injury of flexion.
A Uh-huh.
Q And then what does the article go on to
state? Can you just read that to the jury, please?
A Where do you want me to start reading?
Q It was not --
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A It was not until 1955 that Severy, et al,
first recorded on film the biomechanics of whiplash
injuries and recognized that hyperextension followed by
hyperflexion was a correct sequence of events in
whiplash injuries.
Q Okay. So that initially the clinicians and
the doctors felt that the injury was caused by flexion
or going forward of the head; is that right?
A They thought that the -- yeah, that the
reason why damage was done was due to flexion, yes.
Q But then the testing that was done revealed
that it's actually initially hyperextension which is
the can you define hyperextension?
A The -- the reason why they originally thought
that it was flexion is because that's how people
perceive it.
Q Okay.
A Because, again, it goes back to what I'm
saying about the torso and the head are going forward
but the neck is -- is extending in relation to the
torso and the patient doesn't perceive that.
Q All right. Can you define hyperextension?
A Hyperextension. Well, extension of the neck
is tipping your head backwards. Hyperextension is
going further than normal extension. And it can -- it
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can include going to the point of causing ligament
damage.
Q
So in other words, hyperextension means
extending the neck to its normal range and then beyond?
A Yes.
Q And that's what produces the injury to the
neck muscles and the structures?
A
Actually from my understanding
I don't
know what this is saying here. But from my
understanding, you have injury with both flexion and
extension type injuries.
Q Fair enough.
A Both flexion and extension can cause
injuries.
Q
I was going to get on to the next point.
says the body first goes into hyperextension followed
by hyperflexion?
A Yeah.
Q And I take it's the same thing now. Flexion
meaning the neck goes forward, hyperflexion meaning it
goes forward to its normal range and then beyond?
A Yes.
Q Okay. And that's the mechanics of a whiplash
injury?
A Yes.
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U Now, this article goes on to report that
there was some testing done of low velocity impacts;
and there's a heading in here on Page 8, low --
injuries from low velocity impacts. And they talk
about four test subjects that underwent low velocity
impacts; is that right?
A Like I said, I haven't read it all the way
through; but point out to me and I'll read it.
Q Let's go through. They mention Test Subject
No.4.
A Okay.
Q Okay. That's -- that's -- we're going to go
through four people. And the first one they call Test
Subject No.4. what does the report indicate regarding
Test Subject No.4?
A Okay. Even in these extremely low speed
collisions and even though the tests were done in a
experimental setting, some of the test subjects had
symptoms from their collisions. Test Subject No.4
noted no symptoms at all related to his six test
exposures. Beginning about 45 to 60 minutes after Test
2, Test Subject No. 1 reported a twinge of discomfort
at the posterior base of his neck which lasted about
two hours.
The discomfort was gone by the time of his
51
1 participation in Test No. 3 and did not recur later.
2 Test Subject No. 2 noted the onset of achiness in the
3 paraspinal musculature at the base of his neck the
4 morning of test day 12, after participating in a total
5 of six test runs during the preceding two day test
6 period. His symptoms lasted about four to five hours
7 and resolved without recurrence.
8
Test Subject No. 3 reported onset of mild low
9 and mid neck discomfort over the area of C6-C7 and T1
10 vertebra and discomfort in his trapezius musculature on
11 the morning following his three test runs on day 10.
12 The pain was gone the next day, but he continued to
13 have mild discomfort on extreme neck extension and
14 lateral flexion until it gradually resolved during the
15 next three days.
16
Q
Okay.
So this -- this article that you
17 provided to us, this chapter from the textbook,
18 apparently had to test subjects going through multiple
19 low speed impacts?
20
But to note the next paragraph, it says
A
21 robustly healthy men.
22
I was going to get to that. But these
Q
23 individuals some of them went through six -- equivalent
24 of six accidents and had no injuries?
25
Yes.
A
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Q And the most there was was an individual who
went through three that is equivalent of motor vehicle
accidents in one day and he had some pain that lasted
three days?
A Uh-huh.
Q All right.
A Yes, and and that goes along with what I
find in the office here. I I have people who come
in and I see them two times and they're better and
they're gone. But these are young, healthy people.
Q That were middle-aged men?
A Yeah.
Q That's what they indicate?
A Okay. I have people in that category too.
Q Ms. Roberts would fall into the category of a
middle-aged woman?
A Yes. What is middle aged?
Q I'm just trying to compare it to the article
you provided to us.
A The point of the article is a reference to
the amount of G's that goes through a person's spine is
equated to be up to as high as 5 G's at --
Q Up to 5 G's on these test subjects produced
no one with complaints that lasted more than three
days?
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A But the point is that the G's because --
because if 4 G's was on that person. You take someone
who is frail and they have 4 or 5 G's on them, that --
that's a point of bringing up the information.
Q Okay. Now, can stress playa role in
someone's neck condition and experiencing headaches?
A What I usually tell people is that stress is
not is not the cause of something; but rather if you
have something that's -- that's wrong and you're under
stress, it will make the symptoms magnified a little
bit.
Q Were you aware that Ms. Roberts was suffering
from some severe stress?
A Yes.
Q Okay. And what did that have to do with it?
A She had a death of her son a year previous.
Q Okay. So something like that could magnify
headaches, magnify neck pain?
A Yes, however, she did not have any neck
pain. She was under stress before the accident and she
didn't have any neck pain.
Q That you know of?
A That I know of.
Q All right. Now, did you review any of the
records of the doctors that were treating her for her
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problems coping with her son's death?
A No, it's not it's not my area of expertise
so it wouldn't have -- by reviewing them, I wouldn't
have learned anything that would have been beneficial
to her care as far as -- it wouldn't have changed my
treatment.
Q Would it have been important to know what
symptoms she's complaining of to those doctors?
A I -- from her history, I know symptoms that
she was having. I assume they were the same ones that
she would have told them.
Q I'm going to show you a report -- some
records of a Dr. Singh. Are you familiar with Dr.
Singh from up here?
A I know of him. Is he a Geisinger Medical
Center doctor?
Q He may be affiliated. His office is actually
in Shamokin.
A Okay. Yeah.
Q I'm going to show you a report dated 9/1/95.
Dr. Singh was apparently going to treat Ms. Roberts for
some depression.
A Okay.
Q And I don't see any reference, and you can
review this if you wish. But I don't see any reference
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to the automobile accident in his report of September
1, '95 or of any neck pain; is that right?
A Uh-huh.
Q You have to answer yes.
A I'm sorry. Yes. Yes, I don't see any
unless unless you
Q In fact, there's a statement about two-thirds
of the way down that says, quote, medically there are
no problems reported which are being actively treated,
closed quote. Is that what the report says?
A Yes, it does.
Q And that's inconsistent with what she's
telling you that she's having neck pain and headaches
during that same period of time?
A It would be inconsistent, but I'd like to add
I read a lot of reports from medical doctors and their
histories are wrong. So I take that -- I don't put a
lot of emphasis on that.
Q Okay.
A It just tells me he might not have taken a
good history because she obviously had neck pain. And
I get a lot of reports back where medical doctors won't
even mention that a person is being treated by a
chiropractor. There may be some underlying bias
there.
,
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Q
Now, Doctor, as I understand it, by January
2 of '96 about six or seven months post accident, you had
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4 improvement; is that right?
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A
Yes, that's in regards to -- to continuing
6 with any further treatment in this office for an active
7 -- I mean like I said I didn't totally -- I didn't
8 totally abandon her.
If you have flare ups of symptoms
9 and it gets -- but I thought that home exercises and
10 home therapy would be doing the same thing that I was
11 doing here in the office.
12
Q
And since that period of time which was
13 approximately two years ago by my count, you saw her
14 six times in 1996; is that right?
15
A
I can count them.
Is that -- that sounds
16 probably about close to --
17
Q
I'm just going by the report that Mr. Sadlock
18 provided to us. And you saw her only one time in '97;
19 is that right?
20
A
Yes.
21
Q
And you saw her twice more about ten days
22 ago; is that right?
23
A
Yes.
24
Q
Was your deposition scheduled by that time
25 when she came back to you again?
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A When did we schedule? I think it was
scheduled -- it was the '97 one was October of '97.
It wasn't scheduled at that time.
Q But the two most recent visits your
deposition had been scheduled already?
A Yeah, but I had questioned Ms. Roberts. I
told her that a deposition was coming up, and she
wasn't aware of it.
MR. NEALON: That's all I have. Thank you.
REDIRECT EXAMINATION
BY MR. SADLOCK:
Q Doctor, I have a few questions in follow-up
if I may.
A Okay.
Q Whether from a chiropractic standpoint or
with a medical doctor, is there a difference between
active treatment or maintenance or preventive
treatment?
A Oh, yes.
Q Can you explain that, please?
A Active treatment is when you're treating
someone and you have goals in mind. You're trying to
relieve some type of symptomatology. Maintenance
treatment I don't engage iu in this office. That is
where you're treating someone who has no complaints,
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trying to just keep them healthy.
Supportive care -- if you want all the
definitionB, supportive care would be where if you
withdraw treatment, the patient status gets worBe. So
you're not trying to prevent it. You're just trying to
support their level of function by care; and you know,
you see them every so many weeks.
And then the treatment for flare ups, that's
actually active care. But it's not regimented. You
just treat them for the flare, and then you're
dismissing them.
Q So when Mr. Nealon asked you questions about
MB. Roberts' treatment from an accident ten years ago
perhaps then lasting a year or a year and a half,
it's -- it's posBible, is it not, that a small
percentage was active treatment whereas other
percentage -- much higher percentage was maintenance
treatment?
A It could have been.
Q Which is not even necessarily treatment?
A Yeah, exactly. And some chiropractors they
do a lot more of that; but again, I don't have the
records.
Q And Doctor, as I understand, there's been a
lot of discussion today in your deposition about the
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59
motion of the body and the perception of the individual
during an accident in which you indicated the head or
the perception may be that the head is going forward.
But were you saying that while the head may be going
forward the neck itself, the structure of the neck, is
going backwards?
A Yeah, because really if you use your chin as
a point of reference, your chin is going forward but
your occipital bone is going backwards. And your
shoulders are going forward so you are -- the patient
perceives themselves as going forward and then they're
going backwards. And -- and so that motion -- and it's
so quick; and you're trying to think what happened by
the time and --
Q Now, Mr. Nealon asked you questions about
hyperextension and hyperflexion. Is it necessary to
have an injury to the neck for -- to have
hyperextension or hyperflexion?
A Reword that.
Q Sure, Mr. Nealon in his Cross Examination
talked to you, I believe, from this article involving
and using the terminology hyperextension of the neck
and hyperflexion of the neck. Must there be
hyperextension of the neck to be an injury to the neck?
A To be an injury, no, no, not at all.
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However, there's different degrees of hyperflexion,
too, and to the degree you have ligaments that are
actually pulling off the bones and they're causing
avulsion fractures.
Q Now, at the time of this accident, I believe
Ms. Roberts was 56 years old and obviously a female
then just as she is now. Would you consider 56 middle
aged? And I ask that without intending to offend
anyone on the jury.
A You know, that -- I -- I don't really put
people in a category. But when I look at someone,
she's postmenopausal. I usually look at -- look at it
from that standpoint rather than categorizing them in
an -- an age. But it's the fact that she's
postmenopausal.
At age 56, she's what, seven years away from
Medicare so she's late middle aged if you're going to
put her in the category.
Q And again, the study that was referenced by
Mr. Nealon during Cross involved robustly healthy men?
A Yes.
Q Robust, that connotates a large body size or
at least
A Or well muscled maybe.
Q And again, during Direct Examination, you
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61
indicated that the effects of an accident on the body
were different based on muscle type or body structure;
is that correct?
A Very much so.
Q And Ms. Roberts . not robust?
~s
A No, she isn't.
Q Now, in this article, it appears to me that
at least from the brief portion that was referred to
during your deposition there was no follow-up with
these individuals involved in the tests months or years
after the accident or the testing; is that correct?
A Not that I'm aware of, no.
Q And Doctor, correct me if I'm wrong. The
individuals involved in this test appears to me were
aware that the testing was going to occur and that
there was going to be a rear impact; is that correct?
A I think in some of them they were and some of
them they weren't; but I think that -- the point of the
article was to show the amount of G's that would be
experienced. And then second, that they noted the --
the effects that the persons felt. And I think they
said the G's can be as high as -- high as 18; but
somewhere between 8 and 18 or 5 average.
Q It also appears, Doctor, from again my
reading of the study that the testing was done in
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movements of inches as opposed to a vehicle traveling
in this case around a drive through window many, many
feet prior to an impact; is that correct?
A I would have to read it a little bit more
thoroughly.
I think what you're saying is -- is
correct.
MR. SADLOCK: Thank you, Doctor.
I have no
further questions.
~
MR. NEALON:
I don't have any follow-up.
,.
(Whereupon, the deposition concluded at 1:02
p.m.. )
(Literature, nine pages, produced and marked
Exhibit No. L)
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./
63
,
COUNTY OF PERRY
I
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,
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:
SS
COMMONWEALTH OF PENNSYLVANIA
I, Bobbi Hahn, a Notary Public, authorized to
administer oaths within and for the Commonwealth of
Pennsylvania, do hereby certify that the foregoing is
the testimony of GREGORY REESE, D.C..
I further certify that before the taking of
said deposition, the witness was duly sworn; that the
questions and answers were taken down stenographically
by the said Reporter-Notary Public, and afterwards
reduced to typewriting under the direction of the said
Reporter.
.
I further certify that the said deposition
was taken at the time and place specified in the
caption sheet hereof.
I further certify that I am not a relative or
employee or attorney or counsel to any of the parties,
or a relative or employee of such attorney or counsel,
or financially interested directly or indirectly in
this action.
I further certify that the said deposition
constitutes a true record of the testimony given by the
said witness.
IN WITNESS WHEREOF, I have hereunto set my
hand this 24th day of January, 1998.
NOl,wal St'ill "
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Bobbi Jo ahn, RPR
Notary Public
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GREGORY REESE, D.C.
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Index Page 4
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HUGHES, ALBRIGHT, FOLTZ & NATALE
717-540-0220\717-393-5 I 01
Index Page 5
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HUGHES, ALBRIGHT, FOLTZ & NATALE
717-540-0220\717-393-5101
Index Page 6
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HUGHES, ALBRIGHT, FOLTZ & NATALE
717-540-0220\717-393-5101
Index Page 7
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subjective (I) 50:13 50:15 50:(8 torso IISI 14:13 )4:21 type ('1 4:16 15:22
22:16 50:19 50:20 50:21
subjects (4) 50:5 50:22 5):1 51:2 41:7 41:7 4):9 (6:5 16:13 29:15
41:16 41:19 41:25 49:11 57:23 61:2
50:18 51:18 52:23 51:4 51:5 51:5 42:2 42:3 42:5 types (ll
suboccipitahl) 51:8 51:11 51:18 21:22 40:6
12:1 43:7 43:9 48:19
52:23 61:14 47:4
subsequent [I) 34:12 tcstified PI 48:21 typewriting (I) 63:10
succcss (1139:23 3:8 total (21 31:19 51:4
6:12 40:18 typical(ll 16:)2
such (21 13:8 63:15 testimony ('I 14:3 totally III 40: 13 56:7
sudden III 17:24 37:25 37:25 63:7 56:8 -U-
suffering (I] 53:12 63:17 tracts [21 24:1 24:3
sufficient 141 45:8 testing(.) 11:3 11:5 training (61 5:1 ultrasound III 20:10
45:16 45:19 45:23 11:24 48:11 50:2 8:4 8:6 8:9 unable (I) 29:5
summariZC(11 26:4 61:11 61:15 61:25 14:1 47:5 undef[ll 53:9 53:20
supplies III 22:6 tests [l) 25:22 50:17 transcripts [I) 4:24 63:10
support (I I 58:6 61:10 translation III 43:19 undergraduate 121 3:21
textbook PI 46:11 trapczi us (I I 51:10 3:22
supportive PI 37:2
46:16 51:17 traveling III 62:1 underlying III 55:24
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HUGHES, ALBRIGHT, FOLTZ & NATALE
717-540-0220\717-393-5101
Index Page 9
Multi-Page 1>'
understand - yourself '
GREGORY REESE, D.C. :
understand 141 39:13 WCCkll1 IH:I 20:21
43:10 56:1 58:24 37:3
understood (II 43:6 WCCkSll1 5H:7 f.
underwentlll 50:5 weight[11 15:2
unit(l) 19:7 whatsocverll) 17:19 .'
University (I) 3:22 whereas III 5H:16
unless (4' 42:16 42:16 WHEREOF II) 63:19
55:6 55:6 whiplash 191 14:20
unstable [II 13:17 24:13 41:21 41:24
unsuspeeting(11 )5:17 47:16 47:19 48:2
4H:5 49:23
up I") 5:9 9:25 whipping(11
17:1 18:21 18:23 14:22
19:8 28:21 35:22 wholelll 41:12
38:7 40:15 52:22 window(]1 10:1
52:23 53:4 54:14 42:21 62:2
57:7 wishlll 54:25
upper 111 10:14 10:22 withdraw (II 58:4
11:5 11:13 15:10 withdrawn (I) 32:8
22:8 28:15
UPS"I 56:8 58:8 within (3) 30:24 31:7
used (2) 15:4 20:8 63:6
using I]) 20:9 29:23 without (61 21:23
29:6 39:19 39:23
59:22 51:7 60:8
usual II) 32:14 withstand II) 19:17
usually (2) 53:7 60:12 witness 191 3:7
utilized II) 28:14 38:4 38:21 40:2
44:22 45:23 63:9
-V- 63:18 63:19
VIII 1:3 WITNESSES (I) 2:1
variety (I) 8:24 woman (2) 34:16 52:16
vectors (II 8:15 word (I) 24:10
words (3) 10:10 33:18 ,
vehicle (10) 6:2 ,"
6:10 9:21 10:2 49:3
10:3 14:2 3):11 worse (') 25:4 30:19
42:22 52:2 62:1 58:4
velocities (II 46:23 worsen (I) 26:10
velocity 1'1 46:3 worsening III 26:14
46:5 50:2 50:4 Wrightl2) 3:21 4:9
50:5 wrong (]I 53:9 55:)?
verified III 23:8 61:13
verifies (II 39:3 wrote 1'1 38:8 38:15
verify (]I 4:25 20:20 42:10 42:16 42:16
22:14
versus (I) 15:16 -x-
vertebra (2) 11:19 X-ray (6) 17:12 17:18
51:10 23:9 23:9 23:12
vertebrae (I) 15:9 34:20
vertebral (6) 11:23 x-raying II) 18:4
18:21 18:25 )9:4 X-rays 131 5:2 16:2(
23:19 23:23 25:20
vertebras II) 13:6
visit(21 27:20 27:22 -Y-
visits (I) 57:4 yeaql]l 4:4 7:7
21:1 2(:11 27:15
-w- 34:15 36:20 37:3
waived (II 3:5 39:14 39:21 53:16
58:14 58:14
ways II) 19:13 years IBI 16:7 30:24
wearing (3) 44:7 36:4 56:13 58:13 \
44:17 44:20 60:6 60:16 61:10
.-'
weather (2) 29:24 young III 52:10
30:3 yourselflll 15:20
HUGHES, ALBRIGHT, FOLTZ & NATALE
717-540-0220\717-393-5101
Index Page 10
IAH-22-90 THU 11 ''50 A'-- '
....--....fESE ':AI1ILV CHI.,I>.OPI>.ACTI 2"""''50931
LowVDloCl1y BIomeoha"lca
~cit1iEf!wrl
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Laws of Physics
^ prim" 011 IhI b,u/c r.rw, "Iphpl" IIwzt -t'ply to whip/o'B i1~urln.
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I
\ \....--ifO,",1\llDl1 .
. IRon x wloci',. 0'
! M..",v.
To lIuly undeuland whlpluh InJutlea and law vdoclly collillont, we muel flrll
wlderlrand the bu!c laws uf )lhy.l'" thlt der.mlne how two bodl.. Interacl when they
colllde. 1he following" . lummary of three of lht:'~ fundament~ concepts: conservation of
nlomel\lum, ao:e1crlllon, amllnClIIL'~'
Momentum
1he momentum, or "motion elIC1'1lf: of an abl""tll "Iud to the man of an abJcct (01)
nlultlplled by It I .duclty (V)__IIImlWll .. mY. 11" (Oncepl of momenlum I. eaelly .hown
with two CIII of the .ame wolghl (1,000 "S). Lel'~ ,"y Ihal the fl.1I car Ilt.avellng at 10
mph, or 4.16 mcteu/l<lC.
j
"1""
Prom the equation for momentum. them
M~1.000kg x M6m!lec-4,460kg'm!se<:.
Now, leu uy we have another c:ar, again of 1.000 kill but thle Ume II Ie moving al 20
I1Iph. or 8.93 metera/eC!:.
Prom the equnllon fo. momentum, Ihem
Me 1.000kg X 8.93 m/lec-8.930 kg.m/se<:.
~,
Therefore, lhesccond car, while It hill thl ume welghl L' the 0[11, II moving twice IS fllSl
and contalns lwia lU rrllllB'nngy as thenrsl. We would Sly that the8CCOnd vel1lcle has lwler
''''/Itomrnllllll.
MomMtum Is oIso ploportlonal to forclt-a largeI' momentum "Iuds a IlfgCl' folCe. If both
vehicles Wele to collide with anothCl' c:ar. the se<:olld ar wouhl 11""11111\1 twlco III much
force'" would the flral.
C'.nIlllrvlltlon of Momlntum
Newton'e Third Law of Motion ellles thaI tho momentum In any colli lion must In:
COIUCI'Ied. ThIs Is the colUervatlon of morpClltUlll. 111at IU,ln a mUlsJon between two
objccu. thl mom."'Um (or cn.OIgy) that ...1.,. b.rure I comllon muat e.xItt aner the
collision.
Let'llook al thleln Itl..IS of a rCill end coUlsloll. nclow. we have two vehlclea. Vehicle ^
la stopped at a red Ughl. Vehicle B II cJo.lngln 011 Vehicle A from behind 014.16 m/sec: (10
I1Iph). Both vehicles welgh 1,000 kg (2,200 lb..). he IhI, point, before the two cara c.olllde,
wa have the foUowlng momentum,.
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.JAH-22-98 THU tile1 AIr-"1tEEGE ,FAHILIU I ----
_____ _____~ C'I~OPRACTI 2r ~~0931
P.03
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Low Valoolly Blomechllnlca
We agNn haYelwo vehicle.. Vehlcle^ is. slellonary car, wllshlns 1.000 kg (2,200 Ib,).
vehlcI. B. lh. vehlelelhal real.end. Vehlcl. A (known.. the "Bullel Vehlcle"), I. moving
at 10 mph (1.46 m/-) bUllulluck Ihal welghs 4,000 kS (8,800 lb.).
e.""'pl6 Il
Me" 1,000 k8 ~ 0 m/.cc Mb .. 4,000 ksx 4.411 m/I<<
M. a 0 kS'm/see Mb.. 17,810 kg'm/lee
Pre-colllllon MomenlUm .. 17,840 kS'm/see
por the slk. of Ihl. exam pi.. Ie,'. ..sum. Iha, ,h. ..I....:lly of /he truck declauu 5~. 10
5 mph (2,23 m/sec).
o
MOMENTUM BE FORB a MOMBNTUM AP11!R
mAY" + m.V'. u mAY" + maY.
11,840 kg.m/I": a 1,000 kgx X m/str.1- 4,000 kS~ 2.23 m/see
11,840 kg'm/.ec" 1,000 kS~ X m/,l!C + 8,Q',OkS'm/se>I:
8.920 ~.I:'m/ft": .. I,QOO kg X X m/e..:
V. .. S.92 m/.ee
In thIe exlll1lpl.. Ihe velocity of Vehicle A haslncr...ed from 0 m/_lo 8.92 m/..." or 20
ml,h.1bl, wculd be Ihe equlvalenllY Vehld. A belns roar.."dO<! by. cor ,,( Identical mill
at 40 mphl Thu., nOl only mu.l speed b. consIdered in rear-end collision., but Ill"" lhe
rupectJve .ue of the vehlcleo.
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AV
I1Il!1o Dlot colllllon. wlrh rAlft of equAl ffiM', Vehicle A eJlperlenced change In velocity of
2.23 m/se<:; In Ih. second example wllh Ihe lIuck hilling lhe C(ll', Vehlcle A experIenced a
8.92 mlscc change In velocity. This chillS. In velocity, known mathematically as Av
(pronounced Dclla V) Is Ibe key 10 undemandins whiplash InJulles, and Ibe next concept
ot motlnn, known M ",cderatlon.
Acc.leratlon
We'ro 011 (:mUltu with lhe IMllng cf lll:~~ICfadon. Accd""ulon. malhcmo1lcolly, II limply 4
c/lll1tgt in .,leeity D~" Apnlod ./tim" and 1& exprcoeed IS:
lie Av/At
AV . a (hung. iu
vtlociry
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Lel'e say ,hat In eumpl. II. th.rroo,fu of energy between the tWD vehlcllll!l look pllCe In
lOOmlllllccond.. or.l.econd.. (Th1.1, a common e1ap.ed time rare for vehlcleo In rear.
end collllloll8.) The average ""celefadon would be:
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2.23nt ( 500
a=
.lscc
a ~ 22.3 m/.tt:-'
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JAH-22-9D THU 111~3 A~EEOE FAHI~V CHIROPRACTI 2~~~0931
I
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"Mol' pr~itionlTJ 41'
nol truly fontlliar wi'"
N,w'on', laws.
i "1".;lIIly IU ''''y apply
I " .,111<11/., CDIlIsionl
, V'''' dyrumti<l of
: o""'ldlll moliolL whllt
: ''''y MI" lid/lid in ,I..
! .!i4grwi1 and ",.lmIrtI
ofinJun.s wirhin ,'"
''''/'fofl'''i,
dju/plint.. IIIly rar,1y
q..wify ,'" fOT" and
l7Ionuntum Ylet".
rowing INII injllt/II. ~
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LoW V.I\>Olly Dlom4IohtlnlOI
Biomechanics
wluu O/DIT' rlurin,z- r...,-.IIII ",Uisio,," owl wAy.
Th. Hlltory of Whiplash Slom.chanl"
Whlpluh InJurlca O(e not a new phenomeJ1I-<l' EVert n<<""",lly related to automobll...
In {I<:t, the Drat cas.. oC'whlpluh' wlUe known aJ "Rallway SpIn.,. and occurred In people
who hod been In trRln rnlllatons. With no reody explanation why << peraon should be
.u1Tulns {rom paln whlUlllothlns wa.s obviously wrong, rallroad com pan lea uaumed thlt
people WCle mallnsedns and {ulns thelr conditIon {or a financlalreward.
The Unlted 5tatea Navy. howaYllf, could not blame thelI pllou Cor aerlous dl..blllty after
bclnslaunched {,om calapults on aJrctaft cllrler.. The forc.. were '0 violent that pllor.
would hlark out Coc a fIN( .econd., alld accldenta rcaulled. The Navy qulckly Installed head
rcsUafnlllllld ahould..: ham_os to protecllheir plloll.
It took more thlll1 50 more year. before aula manuCeclUIU' wue required 10 Install heod
restralnllln automobiles.
The Orst physlclllll' 10 report on whiplash belIeved It to be prlmlllly an Injury ofJltxi~. It
was not until 1955 that Sever}' If aJ" first recorded on film the blomechlllllCl ofwhlpJash
InJuclu IIlld recogniIed thlt hypCleJllmSlon, followed by hypedlexlon. was the correct
sequence of evCll~ In whiplash inJuries.
Hlgh.tech Cll/neru IIlld scceleromelCl. (devlc... for recording (l (orces) now provide
resC8(Chet. with sophlstlcaled tool. with which to study low ImpllCt colll.ion.. U.ing these
.tudles. as well a.s the baelc understlllding of the law. of physics In cAapt.r 0111, we Clll
now dhx:uas the biomechanics of thase colli.lons.
Basic Slom.chanlcs
The followIng Is a step-by-step progrCSJlon ofwh.t happen. to Ihe hum8l\ body when
subjected 10 a rear-end collisIon. The data for thl. Is bl.Sed on the wOlk ofSevery. which h..
bea1 confirmed by numerous "udIClln lhe 1..,1 few years.
StlVery Identified tlta ""'Ie motIon. oCthe huml\Jl heod dUllnS whiplash. They conslot of I)
the .tartlng positIon of the head, 2) extension of Ihe neclc, followed by 3) nexlon of the
neck. Th..e tasearchers studied a human volunteer In two collision., with reu car pre-
ImpllCt voloclti81 018 ,7 aM '1.01 mllCII per hoVI, ThuG"l tUIl wu most rcprCDontatlv. of s
(eaf-end mlllslon with IIll unprepared occvpan', bee.use In the .econd run the teat aubJecl
anticIpated the collisIon ond tensed hi. n.ck to lessen \he Imp"". The rcJearchClO rec<",I..J
a maxImum htad G force of 5.0 In the 8.2 mph collision. while the car only experienced a
2.0 (l Coree.
S.very chaned the ""IIIMCcoffolCef erthe heecl, shoulder, and Cllt. and thl. date I. very
Informative (FlS 2-A). A' you can see,. the car regch~ Its maximum acceleration at
approxlmolely \10 m.. It I. not until thI. time that the ehoulder bcslns Its eccelerallon
forward, II/Id not unlll160 llU Ilftn lmpatlthlU the head begins to accelClat..
lbIs point I. cdUcal, as It help. explain why heed Injury can occur In a relatively mInor
collision. Remember that A " liv/lit. SInce the velodty of the head must eventually catch up
to the velocIty of the front car, and .lnce the hud hu Ie.. time to o<<oIeclll due to the
Inertial mu' of the beed (that I.. ths head continues to remain alallonary due to Ita
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JAH-22-90 THU 11:e3 A~ ~~EO
",u.. E, F~~::'f_, ~~I~~.~~ACTl ,21He0931
P.06
Inertia), 6t \1 10\011"1". AI WO saw In the PhYllea chljlter, the smaller Ihe 61, the greaterlhc
accelerltlon Cor II Slveo 6V. In Severy'a atudy, the maximum at;telerlllon of Ihe head was
much h1sherlhan oC Ihe vehlcle-2.5 times higher.
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0 ~ Ii il 53 ~ R ~ Iil 53 ~ ~ ~ '~ ft ~ a ~
- - - -
-+-l1Old
___lIl>cM11dtr
_'ronlC.,
Fiflor. loA. A"orA old... ,,,,IItAlioi1' <{IM,er body, .."'p..1 sMoCtL" wuI ""op"" "..<1. Noll ,''' lim, J./"l
bctwu.'IIIII 0/<016,""" wd .._, of 1M rlwuldu ond "'..L F_ Sml)'. n
'-
s....ery puhllahed hla Iludy In 1955, and used II 194\ and 1947 Plymoulh In Ihelr
tJlperlmanu. obvloully, tIt",e lI_vo beu1 chang.. In CII dMlen &mIIUl!4,urinR toehnolollY
Ilnce Ihor time, l'orl\lnarely, we hive more lecen! .tudlealhll build upon Ihl, work.
One of Ihe bell .erlca of IIUdiClII mil by McConnelI1l41",1IIn Ihe.e .tudlce, Ih.
researchen u.ed more modern vehlclea (1986 Dodg. 600 convCl:llble, 1984 Buick Regs!,
1984 Ford Club Wagon. 1984 GMC 1500 pickup), and .tudled many more variables Ihan
:>every w"," odJlg '" In 1"55.
Sovery only Irudled Ihe G forees In jun me ugjltal plane-front ro b:ack. McConnell was
Ible ro a110 Iludy G forecaln Ihe axial plan<>-up and down. They a110 measured horlzonral
and v<<tlcal movemenl as compared to .tatlonary gtldllnes. and cervical exten,lon Ind
flexion. The rcault II I very detall..! picture of what happem In ft low Ipeed ~llIllon.
Detailed Biomechanics
The followlnsll a lummary orme dirrercnt phl3e8 of motion Ihat occured during Il test
rear-end colli lion, at a Ipeed of 5.7 mph, The motions observed It. a composite of the
detalled findings of McConnell."Th. dellils of this colllllon are llIumaled in Plgure 2.B.
'Phale 1 _ 0 to 100 m1l1lsccond31 The clr mov.. forward 2-3 Inches during Ihls phase, but
Ihe subject'. body remalns motionless fOI the nrat 50 ms. The IUbJCCIS hip and low back
Itart 10 move focward with thllleat at 60 ms, G PO""'": Upper cesvlcal .plne II accelerlled
upwenl3t .30, thtn quickly to 1.8 G upward and forward.
Pha.. 2 _ 100 to 200 milli...:ond.. Tho ceetb:u:k I_helll" mllClmum nexlon of abouIIO"
Clom it.lorlsJnal poaldon.the subJ<<I"uppcr body begins to move forward and upward. The
head and neck remaln ltatlonary until about 120 m3 when. 'u the IUbject'1 hips Ind tlunk
ro,e UPWlrd on a path parallel to the rwwllld flexed IUlback, his neck appwed 10 be
..hilly ~ol\\ple.sacd end .ttalQhtcnro M th~ top of lhe cuvtcallplne beS"" moving upwllld
and tCllWard with reapcct to tho forward moving vchld..' Then Ihe head belllO to rotate
and 11ft. At 160 m3, the upper torso moves Corward and upward, pullins the bue of the
neck InlD tenllon and IWIlI to move the head forwar<\ as Ihe occiput moves toward the
hc..llr.Al. G potellsr At 120 ml, the lOp of the cer;lcaI spine II ICceleuted forward and
upward al about 4.3 G. "A" forward G, sccderatlon continues, Ihe top ohh. c..vle..! "pille
G,acceler1tlon rever... from a + 1.2 G, po.llIv. (upward) peak &1150 mllUlccolld. to I
'I III ""k rlf'p<lI"
tlXjally _".."d
and straighlllltd...
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Phase t 300 10 400 mlllla~nd.: The subject's body I. b&.Sl~ally moving wllh Ihe seat al
this point. The tell.lon on Ihe nrek Clom the tlghlened shoulder reaualnt ~r...loM a forward
de::eleratlon orlhe h...J, unlU the head r_he.s lIS moat CO[Wa!d po.ltlon al about '100 ms.
G Porces, The (on:es drop clolor 10 normal lovol. at thl. phue. with maximum G (orcel
being about 1.7 C when the head I. recovEring from nexlon.
phase 5 _ SIlO to 500 mllll.econd.. Subject I. noW moving It the lime speed as the car,
although tho hip. and ahouldon .... .bout 1.& Inchaa higher Ihan Ihor were beCore tho
culll.lon. () porcea. Back to normal. aa tho hlllld la now moving with the ren of the body.
InJurl... From Low VlIloclty lmpad.
This deulled analysis or low .peed real.end colllalons provlde. IOme Important Inslgl\l8:
I. Evcoln these l'JIuemely low speed collision., and oven though the teoU Wete dono In II
""1,,1l'lmCtltal8ol11ng. .ome oflh" ICAt subj~ts had symptoms from their collision..
"Test .ubJect number" noted no sympto/1ls 81111 related to hi. 6 lest expo.ures.
Beginning sbout 4S to 60 minutes after Tost 2 [with II deltl V of 4.0 mph), leat aubJcct
numb<< I repotled a 'twinge' of discomfort at the poSledor base of his neck which
lasted about two hours.lbedlacomCort was gone by the LImB of hi. palliclpatlon In teot
number 3 and did not recur later. Teat subject numbel 2 noted the onset of 'achiness'
in thB paruplnal musculamre at the base of his nock the mornlng oftest day 12, afler
participating In a total o( 6 test runs during the pre<<dlng two day teat period. iii.
symptoms luted about 4-5 hours and reoolved wlthoul recurrence. 'rest aubJccr number
3 reported tho onset o( mild low and mld.neck discomfort over the area of C6, C7 ;and
n vertebra and discomfort In his trapezius musculature on tho morniog followIng his
,hree IMr mn. on day 10. The pain we" SOne the next day. but he continued to have
mild dl.culllfuit on extrema nIC\: u,en,!on .rulIRfera! ncxloo untlllt Rradually resulvtO
during Ihe next lhef't: days."
2. Tho toct subject. were "rnhllRtly h~lhy nllddle-aged men" with no prcexlstlne
degl!/leratlvo changes-the leut likely group o( people to suffer from whiplash InJuries.
Despite this, thr"" subje::u did have symptom.. albel' mild. leadIng tho ees~rchcrs to
.t~td Ihat this. "Indl~:>.t.d that ther~ wM an Injury mochanlsm th., was not d"l'l!lldent
upon exceeding the physiologic limits o( ~ervlcal mollon."
3. 'Ihus, one o(the mu.t.tlllarkable conduclons I. that Injurl.s rr..'\ul,lng (rom low speed
colll.lons Ite not technlcally whiplash Injuries-as whiplash, as we commonly know It,
requlru hyperex,enslon or hypernexlon of the ccrvlcalsplne. In none o( these teal runs
were Ihe physiologic IImlta of cervical mo,ion reached. The researchers suggest that
vartl~a1 motion, ~omblned wllh hotlzontal mo,ion, m.y be responsible. . [S)ln~e
forward acceleratlon becomes 10 dominant In Ihe often .tudled hJgher .peed rearend
colll.lon, analy.ls o(cest subject vertical motion has been generally Ignored."
Tho Relationship S.twlllln IJlIIta V and (! ~orc.s
The results Cram various othec expedmen,alstudies have ahown a consl$ll!/lCY of G forces
(or low Im!"",l MIIIslons, Ualng the data (rom Szabo,/ ~I" we nnd Ihe following
relatlon.hJp.ln Piguro 2.C. Norc that, as was previously mentloned, head acceleration a arc
.Ignlflc:antly hlghet than car accelerations. (Velocities are OlCpressed In miles per hour.)
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Jn~I-:Z:Z-91l TWU 11 ::5:5 n~lilillli I'nI>lILY CWIROPRnCTI :Z~~:5(j)9~1
Low Voloolty Blomeohonloll
TClt No.
I
2
3
4
5
Bullet V
8.9
9.1
S.O
9.3
8.S
Tustt 6V
5.96
~.7S
4066
6.21
5.H
Tuset G
6.5
6.2
4.4
7.0
6.5
f/gur.2.C
nend G
IU
11.1
16.6
13.\
17.2
G/6.v
2.50
2.02
3.58
2.10
3.22
G/Bullet V
1.66
1.28
2.08
1.41
1.50
Poollns data from II wide r8llge of source.. we can alro graph Iho rello between Impact
velocity lIIId h~ G fOltu (Flgule 2-D).
II
11
V
nwJ
Amrmli....
, In a 1'<<...
I
I
I
1
.
I
i
1
; V
,I
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Aa.vu(n)
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Oaubo (HI
.-\141
aVlnuen .
10
Flgur.2.D
Aa we can see, while there Is 0 sen"lul Ill:"J llttween Impact velocity and G Corc.. thlltlhe
hl!lld experlencCll, thue Ole allO mllllJl vadables that can rCluJtln much higher G forces at
the aeme Impacl.peed. Note that for 6 mph. we have G Corces that range from 4G to 14G.
Whtn en In,uranco: company c1alm. that no InJul)' took place In 8115 mph collision because
the Gforcee Wete too low to CIlU.elnJury~we can clearly show that thIs 15 .peclous
algument. Because G forces can vary wlddy from accldenllo llCcldent (1IO we wlll.ee later).
we have no way ofknowlns the exact forces that occur In any 'InslClaccldent.
Now that we have IOme Idea of the fOlc.. that occur dUflnSlow velocity fur-end
colllalon,. let', now exemlne whit effect these forces can haY1!l on the body.
!
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Impad V.r.dly. in m/In prr h.ur
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MEDICAL BILL SUMMARY
Orl
SYLVIA L. ROBERTS
D.O.A. 06/30/95
January 21, 1998
GREGORY T. REESE. D.C.
07/05/95
07/07/95
07/10/95
07/12/95
07/14/95
07/17/95
07/19/95
07/21/95
07/26/95
07/28/95
07/31/95
08/02/95
08/04/95
08/07/95
08/09/95
08/11/95
08/21/95
08/22/95
08/23/95
08/25/95
08/28/95
08/30/95
09/01/95
09/05/95
09/07/95
09/13/95
09/15/95
09/18/95
09/20/95
09/22/95
09/25/95
09/27/95
09/29/95
10/02/95
10/04/95
10/06/95
10/09/95
10/11/95
115496!AVS
PLAINTIFF'S
EXHIBIT
~
I ' ~ ' If) !.It~
$ 117.00
130.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
80.00
80.00
80.00
80.00
80.00
82.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
95.00
80.00
82.00
~
,
GREGORY T. REESE. D.C. CONT'D.
10/13/95
10/16/95
10/18/95
10/20/95
10/23/95
10/25/95
10/27/95
10/30/95
11/01/95
11/06/95
11/10/95
11/13/95
11/20/95
11/21/95
11/29/95
12/04/95
12/06/95
12/29/95
01/04/96
02/01/96
02/22/96
04/24/96
07/22/96
08/12/96
08/15/96
10/14/97
01/09/98
01/12/98
82.00
80.00
82.00
80.00
82.00
82.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
82.00
82.00
200.00
97.00
97.00
82.00
82.00
82.00
81.00
79.00
67.00
$
5,575.00
RADIOLOGICAL ASSOCIATES
01/05/96
$ 125.00
$ 125.00
SUNBURY COMMUNITY HOSPITAL
01/05/96 $ 945.00
$ 945.00
GRAND TOTAL:
$ 6,645.00
311 Hoffer
SYLVIA ROBERTS,
PlaintJ ff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
97-1662 CIVIL
IN TRESPASS
V.
MARY McLAUGHLIN,
Defendant
llLRE;~EIRIALC.01JfERENCE
A pretrial conference was held before the Honorable
George E. Hoffer, P. J. on Wednesday, Jonuary 7, 1998.
In this auto accident case, Richard A. Sadlock,
Esquire, represents the plaintiff; and James G. Nealon, III,
Esquire, represents the defendant.
It is a reoI' end collision occuring at a fast food
drive in window on private property. Liability is admitted by
defendont. Plaintiff sustained a whiplash type injury and she
claims approximately $5500.00 in chiropractic expenses.
Plaintiff is insured under Oregon law and plaintiff claims that
low allows SUbrogation for the medical expenses, and thot is
part of her Jury claim,
Each side will hove four challenges in what appears to
the court to be a one to one and a half day case.
Mr. Nealon may have a conflict with the trial date,
but he indicates someone from his office will certainly appear
to defend at the appropriate time,
By the Court.
G
CV\___________.,__
feff, P'V'
Richard A, Sadlock, Esquire
For the Plaintiff
James G, Nealon. III. Esquire
For the Defendant
Prothonotary
Court Administrator
: In t f
NEALON & GoVER
, .,'
\."" :
ATrORNI;YS AT l.AW
--'
301 MARKET SlllEET . 9"' flOOR
r.o, nox B6S
IlARRISUURG, I'ENNSYLVANIA 17I0R
717.2.\2,9')00
717.2-II,62S.\
fAX, 717.2.\6,9119
:,
May 29, 1997
;). -:J;li: I
"
, ,
. '
, I
,
, '
Dr. Gurdial Singh
239 W. Commerce Street
Shamokin, PA 17872
J
.
RE: Sylvia Roberts
008: June 12, 1939
SS#: 197-30-9374
,
.
Dear Records Custodian:
You are being served with a Oeposillon Nollce and Subpoena for you to bring the
records referred to in the subpoena for examination by the undersigned at the time and
place indicated,
If you would prefer, you may in advance of the deposition date send us photocopies of
the records, With such photocopies, please include your statement for the cost of
preparing same which we will promplly pay. Upon receipt of such photocopies by this
office, your deposition appearance will be canceled and the subpoena withdrawn.
Your cooperation in this mailer is appreciated, Should there be any questions, please
telephone the undersigned at the above number.
v
~
ce:.
J es G. Nealon, III
NEALON & GOVER
JGN/slm .
Enclosure
cc: Richard A. Sadlock, Esquire (W/enclosures)
.
JAMES G, NEALON III . MA1TIIEW R, GOVER' BRIAN W. PERRY
A rRorl".'i~IONAL CORI'ORATION
THIS CONFIDENTIAL INFOHMATION
IS BEING RELEASED FOR YOUR
PROFESSIONAL USE ONl. Y
ROBERTS, SYLVIA
09/01/95 Sylvia Roberts is a
school teacher by profession.
evaluation of her depreesion.
55 year old, divorced, white female,
Is referred by Dr. Pagana because of
Mrs. Roberts reports that she had a seventeen year old son who died
in June of 1994, of an automobile accident. In Jenuary of 1995,
she took an overdose and wes hoepita1ized in Oregon. She also
spent time in e mental health unit. Recently, she came to this
area and was seen by Dr. Pagana. Who had been treating her with
2010ft 50mg daily, Ativen 1mg twice a day, and Trazadone 150mg at
bedtime. She still feels very depressed. She feels extremely
guilty. She feels that ehe is responsible and guilty for her sons
death because she did not change the tires on his cer. She left
him alone after having been exceptionally and extremely close for
most part of their life. She has a hard time living without him,
feelings of joining him, but no thoughts of suicide or any
intentions or any plans at this time. She brought some pictures in
which sees images of some other individuals through the black and
white background. She seems to have been believing that these are
there for support to her. They appeared there after the picture
was taken. She has a strong preoccupation with guilt.
Any prior history of depression is denied.
Her father died in 1951, had alcoholism. Mother is living. She
has one brother, 55. Who epparent1y also attempted euicide when he
wae having some difficulty with his wife. No other history of
~comPleted or attempted suicide ie known to her.
Medicall there are no problem which are being actively
rea e .
Mental stetus examination revealed that Mrs. Roberts is fairly well
built, well nouriehed white female. Who is very tearful, very
depressed end asking othere if she is responsible or guilty for her
sons death, but she never the lees feels a lot of guilt and relates
and unueual amount of cloeeness to her son. She had never left her
son out of her sight. Thet he was also in the same school where
ehe taught. She says "He was my whole life. He had all the love
in the world. I am guilty." There is a possibility of visual and
auditory illusione and possibilities of guilt to the proportions of
delutlions. There is significant psychomotor retardation.
Orientation and memory ere fair. Judgement is effected. Insight
is present.
~~VP."t^r-Rla lHPRESSIONI 1.
2.
Major Depression
RIO Major Depression with mood
congruent psychotic features.
THIS CONFIDENTIAL INFORMATION
IS BEING RELEASED FOR YOUR
PROFESSIONAL USE ONLY
ROBERTS, SYLVIA
PAGE TWO
09/01/95 RECOMMENDATIONS I To increase the Zoloft to 50mg twice a
day and continue Ativan and Trazadone. In addition to that it is
suggested that she also receive individual and group counseling
through the Alternate Counseling Services in Selinsgrovp., PA.
Where the patient resides. See her again in two weeks for
medication management. ~
GU~iJl N. Singh, M.D.
09/15/95 Mrs. Roberts denies any improvement with the increase in
the Zoloft. She was not able to make any connection with the
individual therapist. She also found out the name of another
therapist in Lewisburg area. About whom she heard some good
therapeutic working ability and is going to try to make contact
with thst therapist. Continues to be very much preoccupied with
her son. With strong feelings of guilt to the proportion of
possible delusions. Zoloft will be tried at 75mg twice a week and
if Zoloft up to 200mg daily does not bring significant relief,
anti-psychotic medicine will be edded. Recheck in two weeks.
Gurdial N. Sith, rJ
09/29/95 Mrs. Roberts continues to feel depre~sed. Today would be
her sons nineteenth birthday had he been living. She continues to
feel sad and grieved about that, with a significant sense of loss.
Beginning to feel a little better in the afternoon. She also found
Carol Blank for individual counseling with her beginning next
Tuesday as a firet appointment. Her Zoloft is increased to 100mg
twice a day and this in addition to therapy if does not lead to
significant relief, lower dose of anti-psychotic medic n ill be
added. Recheck in two weeks. fl,
Gurdi~. Singh, M.D.
10/13/95 Mrs. Roberts reports that after the second dose of
Zoloft, which is during the noon and afternoon period, she
generally starts to feel better. Mornings are still very
depressing, very preoccupying with her son. She has been seeing
Carol Blank and so far seen her twice in the last two weeks. More
time will be given to therapy before making any changes to the
current medication regime of Zoloft 100mg twice a day and
appointment will be scheduled in four weeks. ./J. ~~
Gurd~~iSingh, M.D.
11/10/95 Mrs. Roberts has been unable to see her therapiet because
of therapiets illness, at the present time. She continues to feel
very depressed, very much preoccupied with her sons death and
extreme feelings of guilt. Which touches delusional proportions.
Therefore, at this time Trilafon 2mg twice a day will be added and
recheck in two weeks. ~M I.~
Gur~ I ~ _ingh, M.D.
THIS CONFIDENTIAL INFORMATION
IS BEING RELEASED FOR YOUR
PROFESSIONAL USE ONLY
ROBERTS, SYLVIA
PAGE THREE
11/24/95 Mrs. Roberts ie very nicely dressed and kempt. She feels
better with the addition of Trilafon. She is currently thinking of
going away to the area where she had lived most of her life with
her son. For whatever reasons, but she feels that she must do
this. She will contact me upon her return.
Gurdial N. Singh, M.D.
01/03/96 Mrs. Roberts reports that she had~~triP and she
seemingly made some peace regarding loss of her son. Initially
appeared to be better, but then before leaving depresses and
tearful again. She is going to start seeing her therapist again,
tomorrow on a weekly basis. It should help. Overall, there seems
to be an improvement, although there are four different kind of
medicines being used along with psychotherapy. Recheck in two
weeks. -.1 L\
GUrd& ;t',vSi.1lgh, M. D.
01/19/96 Mrs. Roberts was unable to
traveling.
keep the appointment due
GUrdia~.~, M.D.
01/29/96 Mrs. Roberts is a little brighter in her mood. Same is
observed by her therapist. She continues to tend to blame herself.
That in some way she is responsible for the loss of her son.
Medicines are continued as before. There do not appear to be any
particular side effects. She is currently on a weekly individual
therapy and she will be reseen for medication manage~e~in three
weeks. ,LA I..V;:,_
Gr5Fi~~ N. Singh, M.D.
02/19/96 Mrs. Roberts continues to feel a significant lose of her
son. Unable to forget about it and being very much preoccupied .
Having a lot of experiences to support as if he is not deceased.
Recently she missed her seesion with her therapist and~did not
help her. Recheck in three weeks. Il_
Gu~l. . Singh, M. D.
to
03/11/96 Mrs. Roberts did not keep the
call otherwise.
scheduled appointment, nor
G"1'~ '.D.
_ .h
THIS CONFIDENTIAL INFORMATION
IS BEING RELEASED FOR YOUR
PROFESSIONAL USE ONLY
ROBERTS SYLVIA
PAGE FOUR
03/22/95 Mrs. Roberts is nicely dressed and kempt. She appears
better. She forgot her last appointment. She had an old card from
the previous month. She scheduled this appointment and kept it and
reported some forgetfulness. It was reported to her that it is
possible that it could be secondary to the Ativan use on a chronic
basis and she is advised to adjust the dose to .50 mg. QID with the
eventual possibility of tapering it off. She is strongly
recommended to continue individual therapy ps that would be the
best treatment for her grief. With the help of medicines, her
depression seems to be somewhat improved and a monthly followup
will be provided for medication managemen~. A ~
~fl~' Singh, M. D.
04/19/96 Mrs. Roberts is reported by her therapist to be becoming
calmer and feeling better. She feels somewhat better, although
continues to have a severe significant preoccupation with the loss
of her son in a variety of ways in rememberinath~s ~n~ a variety
of waye of experiencing this. ~~ .
Gurdi ' H. Singh, M.D.
05/10/96 Miss Roberts is complaining of weight gain. She appears
well. She seems to be improved and appsrently, the therapy must be
helping her. At this time, due to the weight gsin, mostly drugs
contributing toward thet would be the Trazodone and Trilafon. Will
try to withdraw the Trilafon by using one a diY ~o w weeks and
then discontinue. Recheck in one month. /1",
GurdtJi . Singh, M.D.
06/17/96 Mrs. Roberts is feeling more guilty and more depressed at
this time. Apparently, this is the month when her son died two
years ago and at the same time the discontinuation of Trilafon is
not helpful which was done because of concerns of weight and this
time we will try Navane, 2 mg. BID. Aleo the patient is not
keeping her appointments with her therapist who is doing her best
to accommodate her. She has a tendency tO~l gu 1ty ae if she
murdered her son.
Gu N. Si gh, M.D.
07/15/96 Mrs. Roberts did not keep this scheduled appointment.
She hod her mother call for the same. ~ 1 ~
GUrdia1,~ngh, M.D.
07/25/96 Mrs. Roberts has not been keeping her appointments with
her therapist. She missed her last appointment and is not giving
adequate notice. She is feeling depressed and ran out of her
prescription and did not call to get it filled. She has been
feeling guilty. She is still pre-occupied with her son. We
discussed about the regularity of treatment which was beneficial to
her in the past and that she should do the same now. If she cannot
afford weekly therapy, she should perhaps~~i e least bi-
weekly therapy.
Gu ~ a N. Singh, M.D.
THIS CONFIDENTIAL INFORMAIIUN
IS BEING RELEASED FOR YOUR
PROFESSIONAL USE ONLY
ROBERTS, SYLVIA
PAGE FIVE
08/22/96 Mrs. Roberts is having good days and bad days. She
talked about the idea of changing medicines but at the same time
she realizes that the loss of her son is so great that she is bound
to have some sadness and some tearfulness on an ongoing basis
because she was eo close to him that they were hardly ever alone.
She seemingly has no particular problems from taking the Navane as
opposed to Trilafon. Recheck in one mont~'DA ~
G~(ii'--'" (~ingh, M.D.
09/26/96 Mrs. Roberts is having a lot of trouble dealing with the
loss of her son. Her guilt is to the proportions of delueione.
She said that Trilafon was more helpful. She had stopped the
Navane and went back to Trilafon 2 mg. twice a day. Considering
the extent of her suffering, she is advised to tolerate the weight
gain and take at least two Trilafon a day. tfficheCk in one month.
Gur a ~h, M. D.
10/24/96 Mrs. Roberts continues to feel at she is guilty of
killing her son and that she should be punished. She feels that
she doee not deserve to feel better and that may be the reason why
she is not keeping up with her individual therspy with her
therapist. She also gives the reason of coet, which has been a
bare minimal set by the therapist. Medicines are kept at the same.
She is strongly encouraged to have some relief which she gets from
the therapy. She herself, at times, feels guilty. At times she
thinks that she is not. ~ A A ~
Gurdial . iri9lY, 'if: D.
..-
12/9/96 Mrs. Roberts continues to mourn the loss of her son and
continues to blame herself. Generally, in appeerance she seeme
better. She has not restarted on individual~~e~a~YA ,
Gurdial N. Sintil ~~
01/06/97 Mrs. Roberts continues to grieve the loss of her son.
She continues to have a tendency to blame herself. She has
good and bad days. She also complained of a lot of nausea.
will be encouraged to use only 100 mg. of Zoloft for the next
and then to give me a cell. D ...1\ ..An--"
Gurdial N. ~~,~.~'
02/03/97 Mrs. Roberts is very well dressed and kempt. She
continuea to blame herself and feel guilty for the lOBS of her son.
She remains feeling a lot of closeness to her son. She is advised
to attend some grief support groups. She did not go back to
individual therapy. She thought that perhaps a chenge in
medication will help, which I did not agree with. She is already
using four different medications: antianxiety, antipsychotic and
two antidepressant medications. j
Gurdial N. n h, ~
03/03/97 Mrs. Roberts reports that she wa l;lving with her ex-
husband who left her. She is quite sad and d~pressed. A week ago
some
She
week
THIS CONFIDENTIAL INFORMATION
IS BEING RELEASED FOR YOUR
PROFESSIONAL USE ONLY
ROBERTS, SYLVIA
PAGE SIX
03/03/97 she had cut down the Zoloft to 150 mg. daily and she also
had gradually tapered off of the Trilafon. Taking the Zoloft 150
mg. daily, Ativan 1 mg. twice a dsy and the Trazadone 150 mg. at
bedtime. This is still a significant amount of medications. To
see whether the discontinuation of the Trilafon would have an
effect on her incressed crying. She is scheduled in three weeks.
GUrdial~ ~~' M.D.
03/24/97 Mrs. Roberts seems to be feeling better with the lower
dose of Zoloft and the discontinuation of the Trilafon. Her affect
at this time seems to be the best of all the time that she has been
known to me. She seems to be lees tearful, although still
preoccupied with her son. Recheck in three weeks.
Gurdial N. Sin~ ~
04/14/97 Mrs. Roberts is feeling very depre~ and very tearful.
She is feeling guilty regarding the lose of her son. She feels as
if she killed him. Her Zoloft will be tried at 100 mg. twice a
day. Recheck in two weeks. ~ A/\
Gurdia1 N. ~~ M~D.
04/28/97 Mrs. Roberts continues to feel very responsible for the
loss of her son. Recheck in three weeks. She did increase the
Zoloft to 100 mg. twice a day and that did ~1?~~ to some extent.
Gurdial N. ~~~~D.
05/19/97 Mrs. Roberts is sticking with the Zoloft 100 mg. twice a
day and she is euggested to keep taking it at that dose end not
alter it. She did reduce the Trazadone end she did not feel any
problems. She is sticking with the Ativan also. She seemed less
troubled this time. She joined some church related activities
which have been helpful to her. Recheck ~~~~~eks.
Gurdial N. ~r~ V"~'
'Intem,.t1onal Heallhcare Consullanl~, Inc.
., [I H c))
P.O. Do. 7019, MBrlellll, GA 30065.1019
P.O, 11".42726. Cincinnali. 01145242,0726
P.O. Du. 312. Middlcl"wn. PA 17057
P,O. lIu. 48250. 1'1. Worth. TX 76148,0250
(770) 916,0061
(513) 942.2237
(717) 985.1667
(817) 428,3320
MS. PATRICIA A. HOFFMAN
ALLSTATE INS. CO.
6345 FLANK DRIVE
SUITE 1000
HARRISBURG, PA 17112
12/3/96
SYLVIA ROBERTS
II : 155205793
II : 01-0047807
Date
RE
CLAIM
IHC
Dear MS. HOFFMAN :
On Oct 30 1996, we received the above referenced consultation
request for Impact Analysis. This evaluation is based on the
documentation provided to us and general principles of accident
reconstruction and physics. The medical assessment is additionally
based on the general standards of care in the profession, and if the
provider wishes us to consider additional information concerning the
clinical status of the patient, he should submit copies of those
pertinent documents to be forwarded to us for evaluation during the
appeal period.
This 57-year-old female was involved in a most minor rear-end
collision on June 30, 1995. The records indicate that they were at a
window of a McDonald's drive-in restaurant, stopped and waiting for
their food to be given to them, when a vehicle approached from the
rear and struck their vehicle in the rear. There is a recorded
statement from the patient stating that she sought no medical
attention prior to consulting Gregory Reese, a chiropractor on July 5,
1995. We have no clinical data from Dr. Reese other than a HCFA 1500
claim form indicating a diagnosis of a cervical sprain and C5-C6 disc
degeneration which obviously preexisted this accident.
An Impact Study has been performed on this particular collision
indicating that the striking vehicle was traveling at approximately
7.8 miles per hour at the time of the collision and this speed would
have produced g forces in a range of from 0.7 g's to 2.7 g's to the
occupants of the vehicle and this range of g forces is well within a
range that is experienced by people in everyday activities in life and
is not known to cause injury. This range of g forces is specifically
compared to a testing procedure known as a "slap on back task." This
testing procedure is performed by having a volunteer test subject
being slapped on the back, such as would be received when being
greeted by an old friend, with instrumentation attached recording the
head motions in a forward to rear direction. The range of g forces
generated from this activity ranges from 0.5 g's to 2.7 g's. Again,
t.his is totally inadequate to have caused injury and, in addition to
this, this ~atient specifically states that when struck from the rear,
her head f~rst went forward and then rearward. This is exactly the
opposite effect that would occur when being struck from the rear.
It is the opinion of this reviewer that the forces generated from this
impact were totally inadequate to cause injury and I would recommend
denial of this claim in its entirety as not causally related.
1
'{
,lnlemMllonallfeallhcare Consu\lants, Inc.
[I H C)
r.o. BOI 7019, Marletla, GA J0065.1019
r,o, BOI 42726. Cinclnnali. 011 45242-0726
r.o. BOI 312. Middletown. rA 170S?
r_o, BOI 48250. Fl. Worlh, TX 76148.0250
(770) 916-0061
(513) 942.2237
(717) 985.1667
(817) 428.3320
Date: 12/03/96
Patient : ROBERTS, SYLVIA L.
.
Page:
Provider REESE, GREGORY
18 COURTYARD OFFICES
RT. 11&15
SELLINSGROVE, PA 17870-
(717) 743-2342
File No. 01-0047807
Provider Charges/Reviewer Allowance
Date Code Service Charge Allowance
-------- ----- ------------------------------ ------------ ------------
07/05/95 99203 OV/NP EXPANDED $55.00 $.00
07/05/95 97010 HOT OR COLD PACKS $20.00 $.00
07/05/95 97014 EMS $20.00 $.00
07/05/95 97035 US $22.00 $.00
07/07/95 99213 OV/EXPANDED/EP $35.00 $.00
07/07/95 76140 FILM READING $35.00 $.00
07/07/95 97010 HOT OR COLD PACKS $20.00 $.00
07/07/95 97014 EMS $20.00 $.00
07/07/95 97124 MASSAGE $20.00 $.00
07/10/95 99212 OV $20.00 $.00
07/10/95 97010 HOT OR COLD PACKS $20.00 $.00
07/10/95 97014 EMS ND $20.00 $.00
07/10/95 97035 US $22.00 $.00
07/ 12/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
07/12/95 97010 HOT OR COLD PACKS $20.00 $.00
07/12/95 97014 EMS TTEND $20.00 $.00
07/12/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
07/14/95 99212 OV/FROBLEM FOCUSED $20.00 $.00
07/14/95 97010 HOT OR COLD PACKS $20.00 $.00
07/14/95 97014 EMS $20.00 $.00
07/14/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
07/17/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
07/ 17/95 97010 HOT OR COLD PACKS $20.00 $.00
07/17/95 97014 EMS $20.00 $.00
07/17/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
07/19/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
07/19/95 97010 HOT OR COLD PACKS $20.00 $.00
07/19/95 97014 EMS $20.00 $.00
07/19/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
07/21/95 97010 HOT OR COLD PACKS $20.00 $.00
07/21/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
07/21/95 97014 EMS $20.00 $.00
07/21/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
07/26/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
07/26/95 97010 HOT OR COLD PACKS $20.00 $.00
'-l
i
I
I
I
:I
1
,International Healtbcare Consultants, Inc.
. [I H C)
P.O. Dox 7019, Marietta, GA 30065.t019
r,Q. nox 42726. Cincinnati. 01145242-0726
r.O,Dox 312. Middletown. PA 17057
P,O, Dox 48250. FI. Walth. TX 76148-0250
(770) 916-0061
(5\3) 942-2237
(717) 985.1667
(817) 428-3320
Date: 12/03/96 Patient . ROBERTS, SYLVIA L.
.
Pagel 2
Provider REESE, GREGORY
18 COURTYARD OFFICES
RT. 11& 15
SELLINSGROVE, PA 17870-
(717) 743-2342
File No. 01-0047807
Provider Charges/Reviewer Allowance
Date Code Service Charge Allowance
-------- ----- ------------------------------ ------------ ------------
07/26/95 97014 EMS $20.00 $.00
07/26/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
07/28/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
07/28/95 97010 HOT OR COLD PACKS $20.00 $.00
07/28/95 97014 ELECTRICAL STIM/UNATTEND $20.00 $.00
07/28/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
07/31/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
07/31/95 97010 HOT OR COLD PACKS $20.00 $.00
07/31/95 97014 EMS $20.00 $.00
07/31/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
08/02/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
08/02/95 97010 HOT OR COLD PACKS $20.00 $.00
08/02/95 97014 EMS $20.00 $.00
08/02/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
08/04/95 99212 OV/PFOBLEM FOCUSED $20.00 $.00
08/04/95 97010 HOT OR COLD PACKS $20.00 $.00
08/04/95 97014 EMS $20.00 $.00
08/04/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
08/07/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
08/07/95 97010 HOT OR COLD PACKS $20.00 $.00
08/07/95 97014 EMS $20.00 $.00
08/07/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
08/09/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
08/09/95 97010 HOT OR COLD PACKS $20.00 $.00
08/09/95 97014 EMS $20.00 $.00
08/09/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
08/11/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
08/11/95 97010 HOT OR COLD PACKS $20.00 $.00
08/11/95 97014 EMS $20.00 $.00
08/11/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
08/21/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
08/21/95 97010 HOT OR COLD PACKS $20.00 $.00
08/21/95 97014 EMS $20.00 $.00
08/21/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
08/22/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
,{
Inlemalional Heallhcare Consullanl~, Inc.
. [I H c]
P.O. 001 7019, Minella, GA J0065.1019
P.O. BOI 42726, Clnclnn.li. 011 4~242-0726
P,O. BOI 312. Mlddleluwn. rA 170~7
P,O, BUI 482.~O, Fl. Worth, TX 76148-0250
(770) 916-0061
(~13) 942-2237
(717) 985-1667
(817) 428-3320
,
"
I
~I
.
Date: 12/03/96 Patient : ROBERTS, SYLVIA L.
. Page: 3
Provider REESE, GREGORY
18 COURTYARD OFFICES
RT. 11&15
SELLINSGROVE, PA 17870-
(717) 743-2342
File No. 01-0047807
Provider Charges/Reviewer Allowance
Date Code Service Charge Allowance
-------- ----- ------------------------------ ------------ ------------
08/22/95 97010 HOT OR COLD PACKS $20.00 $.00
08/22/95 97014 EMS $20.00 $.00
08/22/95 97350 KE $20.00 $.00
08/23/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
08/23/95 97010 HOT OR COLD PACKS $20.00 $.00
08/23/95 97014 EMS $20.00 $.00
08/23/95 97530 KE $20.00 $.00
08/25/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
08/25/95 97010 HOT OR COLD PACKS $20.00 $.00
08/25/95 97014 EMS $20.00 $.00
08/25/95 97530 KINETIC ACTIVITIES $20.00 $.00
08/28/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
08/28/95 97010 HOT OR COLD PACKS $20.00 $.00
08/28/95 97014 EMS $20.00 $.00
08/28/95 97530 KINETIC ACTIVITIES $20.00 $.00
08/30/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
08/30/95 97010 HOT OR COLD PACKS $20.00 $.00
08/30/95 97014 EMS $20.00 $.00
08/30/95 97530 KINETIC ACTIVITIES $20.00 $.00
09/01/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
09/01/95 97010 HOT OR COLD PACKS $20.00 $.00
09/01/95 97014 EMS $20.00 $.00
09/01/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
09/05/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
09/05/95 97010 HOT OR COLD PACKS $20.00 $.00
09/05/95 97014 EMS $20.00 $.00
09/05/95 97530 KINETIC ACTIVITIES $20.00 $.00
09/07/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
09/07/95 97010 HOT OR COLD PACKS $20.00 $.00
09/07/95 97014 EMS $20.00 $.00
09/07/95 97530 KINETIC ACTIVITIES $20.00 $.00
09/13/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
09/13/95 97010 HOT OR COLD PACKS $20.00 $.00
09/13/95 97014 EMS $20.00 $.00
I 09/13/95 97530 KINETIC ACTIVITIES $20.00 $.00
~
. International Healthcare Consultants, Inc.
((I H c]
P.O. DOl 7019, Marletla, GA 30065.tO%9
P_O. BOI 42726, Cincinnati, 011 45242-0726
P_O. DOl 312. Mlddlelown. PA 17057
P.O, 80148250, fI. Walth. TX 76148-0250
(770) 9%6-006%
(513) 942.2237
(717) 985.1667
(817) 428-3320
Date: 12/03/96 Patient . ROBERTS, SYLVIA L.
.
Page: 4
Provider REESE, GREGORY
18 COURTYARD OFFICES
RT. 11& 15
SELLINSGROVE, PA 17870-
(717) 743-2342
File No. 01-0047807
Provider Charges/Reviewer Allowance
Date Code Service Charge Allowance
-------- ----- ------------------------------ ------------ ------------
09/15/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
09/15/95 97010 HOT OR COLD PACKS $20.00 $.00
09/15/95 97014 EMS $20.00 $.00
09/15/95 97530 KINETIC ACTIVITIES $20.00 $.00
09/18/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
09/18/95 97010 HOT OR COLD PACKS $20.00 $.00
09/18/95 97014 EMS $20.00 $.00
09/18/95 97530 KINETIC ACTIVITIES $20.00 $.00
09/20/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
09/20/95 97010 HOT OR COLD PACKS $20.00 $.00
09/20/95 97014 EMS $20.00 $.00
09/20/95 97530 KINETIC ACTIVITIES $20.00 $.00
09/22/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
09/22/95 97010 HOT OR COLD PACKS $20.00 $.00
09/22/95 97014 i::MS $20.00 $.00
09/22/95 97530 KINETIC ACTIVITIES $20.00 $.00
09/25/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
09/25/95 97010 HOT OR COLD PACKS $20.00 $.00
09/25/95 97014 EMS $20.00 $.00
09/25/95 97530 KINETIC ACTIVITIES $20.00 $.00
09/27/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
09/27/95 97010 HOT OR COLD PACKS $20.00 $.00
09/27/95 97014 EMS $20.00 $.00
09/27/95 97530 KINETIC ACTIVITIES $20.00 $.00
09/29/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
09/29/95 97010 HOT OR COLD PACKS $20.00 $.00
09/29/95 97014 EMS $20.00 $.00
09/29/95 97530 KINETIC ACTIVITIES $20.00 $.00
10/02/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
10/02/95 97010 HOT OR COLD PACKS $20.00 $.00
10/02/95 97014 EMS $20.00 $.00
10/02/95 97530 KINETIC ACTIVITIES $20.00 $.00
10/04/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
10/04/95 97010 HOT OR COLD PACKS $20.00 $.00
10/04/95 97014 EMS $20.00 $.00
i
-Inlernlltional Heallhcare Consultants, Inc.
- [I H c]
P.O. DOl 7019, Martetta, GA 30065.1019
p_o, nOI 42726. Cincinnati, 011 45242-0726
p_o, nOI 312. Middletown, PA 17057
P,O_ nOI 48250. FL WOllh. TX 76148-0250
(770) 916-0061
(513) 942-2237
(717) 985.1667
(817) 428-3320
Date: 12/03/96 Patient ROBERTS, SYLVIA L.
Page: 5
Provider REESE, GREGORY
18 COURTYARD OFFICES
RT. 11&15
SELLINSGROVE, PA 17870-
(717) 743-2342
File No. 01-0047807
Provider Charges/Reviewer Allowance
Date Code Service Charge Allowance
-------- ----- ------------------------------ ------------ ------------
10/04/95 97530 KINETIC ACTIVITIES $20.00 $.00
10/06/95 99213 OV/EXPANDED/EP $35.00 $.00
10/06/95 97010 HOT OR COLD PACKS $20.00 $.00
10/06/95 97014 EMS $20.00 $.00
10/06/95 97530 KINETIC ACTIVITIES $20.00 $.00
10/09/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
10/09/95 97010 HOT OR COLD PACKS $20.00 $.00
10/09/95 97014 EMS $20.00 $.00
10/09/95 97530 KINETIC ACTIVITIES $20.00 $.00
10/11/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
10/11/95 97010 HOT OR COLD PACKS $20.00 $.00
10/11/95 97014 EMS $20.00 $.00
10/11/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
10/13/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
10/13/95 97010 HOT OR COLD PACKS $20.00 $.00
10/13/95 97014 EMS $20.00 $.00
10/13/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
10/16/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
10/16/95 97010 HOT OR COLD PACKS $20.00 $.00
10/16/95 97014 EMS $20.00 $.00
10/16/95 97035 ULTRASOUND, EA 15 MIN $20.00 $.00
10/18/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
10/18/95 97010 HOT OR COLD PACKS $20.00 $.00
10/18/95 97014 EMS $20.00 $.00
10/18/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
10/20/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
10/20/95 97010 HOT OR COLD PACKS $20.00 $.00
10/20/95 97014 EMS $20.00 $.00
10/20/95 97530 KINETIC ACTIVITIES $20.00 $.00
10/23/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
10/23/95 97010 HOT OR COLD PACKS $20.00 $.00
10/23/95 97014 EMS $20.00 $.00
10/23/95 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
10/25/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
10/25/95 97010 HOT OR COLD PACKS $20.00 $.00
'l
, International H<Dlthcare Consultants, Inc.
[I H c]
P.O. Do. 7019, Manella, G^ 30065.1019
P,O, 00.42726. Cincinnati. 011 45242-0726
P.O. Do. 312, Middletown. P^ 17057
P.O, Do. 48250. Ft. Wollh. TX 76148.0250
(770) 916.0061
(513) 942-2237
(717) 985.1667
(817) 428-332ll
Date: 12/03/96
Patient : ROBERTS, SYLVIA L.
Page:
6
Provider REESE, GREGORY
18 COURTYARD OFFICES
RT. 11&15
SELLINSGROVE, PA 17870-
(717) 743-2342
File No. 01-0047807
Provider Charges/Reviewer Allowance
Date Code Service Charge Allowance
-------- ----- ------------------------------ ------------ ------------
10/25/95 97014 EMS $20.00 $.00
10/25/95 97530 KINETIC ACTIVITIES $22.00 $.00
10/27/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
10/27/95 97010 HOT OR COLD PACKS $20.00 $.00
10/27/95 97014 EMS $20.00 $.00
10/27/95 97530 KINETIC ACTIVITIES $20.00 $.00
10/30/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
10/30/95 97010 HOT OR COLD PACKS $20.00 $ .00 '
10/30/95 97014 EMS $20.00 $.00
10/30/95 97530 KINETIC ACTIVITIES $20.00 $.00
11/01/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
11/01/95 97010 HOT OR COLD PACKS $20.00 $.00
11/01/95 97014 EMS $20.00 $.00
11/01/95 97530 KINETIC ACTIVITIES $20.00 $.00
11/06/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
11/06/95 97010 HOT OR COLD PACKS $20.00 $.00
11/06/95 97014 EMS $20.00 $.00
11/06/95 97530 KINETIC ACTIVITIES $20.00 $.00
11/10/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
11/10/95 97010 HOT OR COLD PACKS $20.00 $.00
11/10/95 97014 EMS $20.00 $.00
11/10/95 97530 KINETIC ACTIVITIES $20.00 $.00
11/13/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
11/13/95 97010 HOT OR COLD PACKS $20.00 $.00
11/13/95 97014 EMS $20.00 $.00
11/13/95 97530 KINETIC ACTIVITIES $20.00 $.00
11/20/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
11/20/95 97010 HOT OR COLD PACKS $20.00 $.00
11/20/95 97014 EMS $20.00 $.00
11/20/95 97530 KINETIC ACTIVITIES $20.00 $.00
11/21/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
11/21/95 97010 HOT OR COLD PACKS $20.00 $.00
11/21/95 97014 EMS $20.00 $.00
11/21/95 97530 KINETIC ACTIVITIES $20.00 $.00
11/29/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
'"
.Inlern1l11onallleallhcare Consullanls, Inc.
[I H c]
P.O. DOl 7019, Marletla, GA 30065.1019
P,O, BOI 42726. Clncinnlti. 011 45242-0726
P,O, DOl 312. Mlddlelown. PA 17057
P.O, BOI48250. Ft. WOllh. TX 76148-0250
(770) 916.()()61
(513) 942-2237
(717) 985-1667
(817) 428-3320
Date: 12/03/96 Patient . ROBERTS, SYLVIA L.
.
Page: 7
Provider REESE, GREGORY
18 COURTYARD OFFICES
RT. 11& 15
SELLINSGROVE, PA 17870-
(717) 743-2342
File No. 01-0047807
Provider Charges/Reviewer Allowance
Date Code Service Charge Allowance
-------- ----- ------------------------------ ------------ ------------
11/29/95 97010 HOT OR COLD PACKS $20.00 $.00
11/29/95 97014 EMS $20.00 $.00
11/29/95 97530 KINETIC ACTIVITIES $20.00 $.00
12/04/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
12/04/95 97010 HOT OR COLD PACKS $20.00 $.00
12/04/95 97014 EMS $20.00 $.00
12/04/95 97530 KINETIC ACTIVITIES $20.00 $.00
12/04/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
12/04/95 97010 HOT OR COLD PACKS $20.00 $.00
12/04/95 97014 ELECTRICAL STIM/UNATTEND $20.00 $.00
12/04/95 97530 KINETIC ACTIVITIES $20.00 $.00
12/06/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
12/06/95 97010 HOT OR COLD PACKS $20.00 $.00
12/06/95 97014 EMS $20.00 $.00
12/06/95 97530 KE $20.00 $.00
12/06/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
12/06/95 97010 HOT OR COLD PACKS $20.00 $.00
12/06/95 97014 ELECTRICAL STIM/UNATTEND $20.00 $.00
12/06/95 97530 KINETIC ACTIVITIES $20.00 $.00
12/29/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
12/29/95 97010 HOT OR COLD PACKS $20.00 $.00
12/29/95 97014 EMS $20.00 $.00
12/29/95 97035 ULTRASOUND, EA 15 MIN $22.00 - .-0"\
:;t.v'..}
12/29/95 99071 EDUCATIONAL SUPPLIES $16.00 $.00
12/29/95 99212 OV/PROBLEM FOCUSED $20.00 $.00
01/04/96 99212 OV/PROBLEM FOCUSED $20.00 $.00
01/04/96 97010 HOT OR COLD PACKS $20.00 $.00
01/04/96 97014 ELECTRICAL STIM/UNATTEND $20.00 $.00
01/04/96 97035 ULTRASOUND, EA 15 MIN $22.00 $.00
02/01/96 79070 0 $200.00 $.00
~
.Inlcnlallonal Hea\lhcare Consul\JInts. Inc.
" (I H C)
P,O, DOl 7029, Marietta, GA 30065.1029
1'.0,11"142726, Cloclnnali, 011 45242.0726
P.O, Do' 312, Middletown, PA 17057
P,O. 1101 48250, Fl. WOllh, TX 76148-0250
(770) 916.0061
(513) 942-2237
(717) 985-1667
(817) 428.3320
Date: 12/03/96
Patient: ROBERTS, SYLVIA L.
Pagel
provider REESE, GREGORY
18 COURTYARD OFFICES
RT. 11&15
SELLINSGROVE, PA 17870-
(717) 743-2342
File No. 01-0041807
provider Charges/Reviewer Allowance
Date code Service Charge
Allowance
------------
-------- ----- ------------------------------ ------------
------------
------------
$5,104.00
------------
------------
------------
------------
The narrative contains the rationale for denials listed in the
recommended allowance column. Allowances are the actual billed
charge and are not the prevailing rates for that geographic area.
prevailing rates are available upon request for most therapies.
$.00
8
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MEDICAL TREATMENT SUMMARY
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MEDICAL BILL SUMMARY
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MEDICAL BILL SUMMARY
OF
SYLVANIA L. ROBERTS
D.O.A. 06/30/95
July 1, 1997
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GREGORY T. REESE. D.C.
07/05/95
07/07/95
07/10/95
07/12/95
07/14/95
07/17/95
07/19/95
07/21/95
07/26/95
07/28/95
07/31/95
08/02/95
08/04/95
08/07/95
08/09/95
08/11/95
08/21/95
08/22/95
08/23/95
08/25/95
08/28/95
08/30/95
09/01/95
09/05/95
09/07/95
09/13/95
09/15/95
09/18/95
09/20/95
09/22/95
09/25/95
09/27/95
09/29/95
10/02/95
10/04/95
10/06/95
10/09/95
10/11/95
$ 117.00
130.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
82.00
80.00
80.00
80.00
80.00
80.00
82.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
95.00
80.00
82.00
"
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115496/AVS
~REGORY T. REf;SE, D.C. COID"D.
10/13/95
10/16/95
10/18/95
10/20/95
10/23/95
10/25/95
10/27/95
10/30/95
11/01/95
11/06/95
11/10/95
11/13/95
11/20/95
11/21/95
11/29/95
12/04/95
12/06/95
12/29/95
01/04/96
02/01/96
02/22/96
04/24/96
07/22/96
08/12/96
08/15/96
82.00
80.00
82.00
80.00
82.00
82.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
80.00
82.00
82.00
200.00
97.00
97.00
82.00
82.00
82.00
$ 5,348.00
J,UDIOLOGICAL ASSOCIATES
01/05/96
$ 125.00
$ 125.00
S!1NBURY coMMlJJSJ'fY HOSNrAL
$ 945.00
01/05/96
$ 945.00
GRAND TOTAL:
$ 6,418.00
MEDICAL REPORT OF
GREG REESE, D.C.
Dr Gregory Reese
Chiropractor
18 Courtyard OlTcs
Selinsgrove, Pa 17870
(717) 743.2342
March 31, 1997
Angino & Rovner, P_C_
4503 N_ Front St
Harrisburg, Pa 17110-1708
ATTN: Richard Sadlock
RE: Sylvia Roberts
DOl: 6-30-95
SS#: 197309374
Dear Attorney Sadlock;
I received your letter dated March 7, 1997 in regards to Sylvia Roberts_ I hope
this report will help to answer your questions and bring you up to date with Sylvia's care
in this office_
Ms_ Roberts was first seen in this office on 7-5-95_ She presented with chief
complaint of cervical spine pain as well as back pain which was located in the right mid
thoracic region. Her initial diagnosis in this office was that of cervical sprain injury_ This
injury was complicated by degenerative changes to the C5-C6 disc space_ Treatment
consisted of physical therapy to her neck and upper back region_ She received
approximately six months of treatment in this office. She improved over the coarse of this
time period, however, she did not make as much progress as was hoped_ An MR! study
was obtained on 1-5-96; this revealed degenerative changes at the C3-C4 and C4-C5.
cervical disc space levels which appeared to be worse at the C4-C5 level. At the C3-C4
level, she had posterior osteophytes as well as~ssible dIsc hermalloij, There was
similar changes at the C4-C5 level to a greater gree_ There appears to be some pressure
on the thecal sac posteriorly from these changes, however, the posterior osteophytes
appear to be equally responsible for the pressure as is the disc herniations. These changes
did not appear to effect any of the nerve roots of the cervical spine.
The frequency of treatment in this office from July through December 1996 was
approximately three times per week for July, August, September and October, she was
then seen two times per w~ek in November and then only three visits for the month of
December_ During 1996 she was seen once in January, once in February, once in April,
once in July and twice in August Treatments in 1996 were on a PRN basis nnd were for
any flare-ups of symptoms_ -
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Sylvia Roberts
(2)
March 31, 1997
The last dates of treatment in this office was on 8-12-96 and 8-15-96 and wp.rp. for
el'acerbation's ofneck.J)aiD-At that time she had difficulty holding her head upright due
to the pain she was experiencing,
To date her condition has never been fully resolved, however she is at what 1 feel to be
maximum medical improvement l:Ier treatment in this office is on a PRN basis only for
exacerbation of the neck pain_ I believe the patient will continue to have exacerbations of
neck pain for years to come_ Ms_ Roberts has moved out of the area, so I have not been -
~ 101lowing her condition_ Future treatment may be required and based upon the treatment
frequency of 1996, she will probably need treatment of six to twelve times per year for this
condition in the future, although this is only a estimate_ I believe her prognosis is poor for
a complete recovery due to the fact that she has a large amount of disc degeneration in her
neck as well as the possibility of two disc herniations- Estimate for the cost of future
treatment five hundred to one thousand dollars per year, if her symptoms continue to be as
active as they were in 1996_ To the best of my knowledge Ms. Roberts was symptom
free in regards to neck pain and headaches before this accident occurred. The disc
degeneration did not occur from the accident, this was preexisting. However, it may
provide a reasonable explanation of why her recovery has been complicated. In my
opinion her neck injury and headaches she has been suffering are dire
cervical strain injury an cervtca art us w ich orrurred from the auto
accident ~
c;- Enclosed, please find copies of all progress notes and reports from this office_ If
you have any further question please feel free to contact us_
Sincerely;
~\:)k~
Gregory Reese, D_C_
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GREG REESE, D.C.
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MEDICAL RECORDS AND BILLS OF
PROGRESS NOTES
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RTS 11&15, SELINSGROVE, PA 17870
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PROGRESS NOTES
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PROGRESS NOTES
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PROGRESS NOTES
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ER
D
GENERAL DIAGNOSTIC
X.RA Y REQU( ON
SUNBURY COMMUNITY,HOSPITAL
350 North Eleventh Street
Sunbury, PA 17801
(717) 286.3466
OP INPT
[W D
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ROber.. Sylvia L.
130 S. Front St. Apt 210
Sunbury, PA 17801
286-3138 (mother)
511 197 30 9374
008; 6-12-39
Dr. Reese
89852
8S'4@
EXAM;
MRI C-spine
mkt
1:40pm 1-5-96
SIP MVA, neck pain, ? abnormalities.
CUNICAL INFORMATIONISYMPTOMS:
RAOIOLOOY REPORT:
dtl 1-5-96
PKT/klw
MRI C-SPINE.
Multiple 5 mm. sagittal T1, fast spin eoho sagittal T2 and axial T1
weighted Images were obtained. No prior studies available for oomparlson.
Films show normal height of the oervloal vertebrae. No evldenoe of any
aoute oompresslon fraoture. Mild dlso degenerative ohanges present at C-3-
4-5 Interspaoes with smal I osteophyte formations. Sagittal view shows
extrlnslo pressure along the anterior aspeot of the theoal sao at the level
of C-3-4 and C-4-5 Interspaoes well demonstrated at C-4-5 and also noted on
axial view at the same level suggesting oentral dlso herniation with
questionable superimposed osteophytosls from arthrltlo ohanges. The
,pressure at the level of C-3-4 most probsbly seoondary to osteophytosls
with questionable smal I oentral dlso bUlging. No other evldenoe of any
acute herniation. There Is minimal spinal stenosis at the level of C-4-5.
Visualized spinal oord shows no other significant abnormality.
IMPRESSION. Central disc herniation at C-4-5 with mild spinal stenosis at
the same level. Extrlnslo pressure at the level of C-3-4 anteriorly
suggests osteophytosls. arthrltlo ohanges with questionable small oentral
dlso bulging. Cllnloal oorrelatlon advised. If prior x-rays available for
oomparlson they would be helpfUl.
~^J
P.K. TILVA, M.D.
M2. SEDLOVSKY, M.D.
Dr. Gregory ~se
Chiropraclor
18 Courtyard Ores
. Rt', 11&15
Sellnsgrove, Pa 17870
717.743-2342
September 13, 1995
PATIENT: Sylvia Roberts
SS#: 197-30-9374
CLAIM #: 1552005793
DATE OF INJURY: 6-30-95
Dear Sirl Madam;
Ms. Sylvia Roberts continues to be treated in this office for comPlaints of neck, and upper
back pain and inlermittent headaches. Her symptomatology is reduced approximately 40-500/0 from
initial presentation. Her headaches BIC not constant at present, but BIC currently intermittent and lire
less severe in nature then fuat appeared. .
. On examination, she had pain in her neck and upper back with cervical extension. She had
palpable mid and lower cervical pnrovertebrol tenderness and muscular tightness. Vertebrol motion
of the C6 and 1'2 vertebrol seS"'""t. was decreased. She had palpable 1'2 paravertebral
tenderness/tightness. Neurologically her upper extremities remain intact.
Assessment: Her statis is improving with improvement in her cervic.a1 range of motion as well
as a decrease in severity ofnecl:: pain and a decrease in frequency in severity of headaches. .
Plan of(rIYIlml'f'lt: Will continue witli therapy to the neck. Strength""ing exercises have been
started for her neck and we will continue with these. Will reevaluate her condition in four weeks.
Prognosis is guared at this time.
'.
S~YL
Gregol}' Reese, D.C.
Dr Gregory Reese
Chiropractor
18 Courtyard orrcs
Stllnsgrove, Pa 17870
(717) 743-2342
May 8, 1996
Attorney Hugh Benson
106 Market St.
Selinsgrove, P A 17870
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RE: Sylvia Roberts
SS#: 197309374
DOl: 06-30-95
Dear SirlMadam;
This is to up date you on Ms. Sylvia Roberts condition. Since my last report to
you I have seen Ms. Roberts in this office on 2-22-96, and again on 4-24-96. Both time
she presented with an increase in cervical spine pain. She stated that she continues with
episodic neck pain. She states that she does have good days when the pain is much less.
She states however, that she does continue using the cervical collar for support when she
reads. She states she continues with difficulty driving a car, and states she has difficulty
looking behind her while driving, as she must turn her whole upper body.
I encourage Ms. Roberts to continue with home exercises as this will be essential
for any further degree ofimprovement. Enclosed please find copies of progress notes. If
you should have any questions regarding her condition please contact us.
sinq:L
Gregol}' Reese, D.C.
.'.
Dr Gregory Reese
Chiropractor
18 Courtyard orrcs
Selinsgrove, Pa 17870
(717) 743.2342
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July 22,1996
RE: Sylvia Roberts
SS#: 197309374
DOl: 6-30-95
S~~~
Gregol}' Reese, D.C.
Dear SirlMadam;
Ms. Sylvia Robert presented to this office today 7-22-96 with chief complaint of
increased neck pain an~ neck stifli1ess. She stated that she had been doing better with
these symptoms until recently when they started to increase. She denies have any trouble
with headaches. She also denies any radiating arm pain.
On examination, she had mid and lower cervical paravertebral tightness and
tenderness with associated decreased motion at these levels. She had bilateral trapezius
tenderness and tightness as well. Range of motion was approximately fifty degrees with
right and left cervical rotation.
Assessment is that of exacerbation of neck pain which is related to her auto
accident which occurred on 6-30-95.
Plan of treatment; she was treated with heat and electric muscle stimulation to the
neck an trapezius muscles bilaterally as well as with ultrasound to the cervical
paravertebral musculature. This was followed with range of motion exercises for the
cervical spine. She was released back to a pm status of care, and instructed to continue
with home exercises. .
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AflflROV[O m'lI C:iB vc:~
P(EASE
DO NOT
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IN THIS
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HEALTH INSURANCE CLAIM FORM
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I MEDICARE MEDIC"'ID Ct....MPUS CtlM.lI'V'" GIIUUP FlCA OTtiER 'ollflSUIlEOSIO NUMBER iFon PROGRA'.' I~j H~!.' , I .
tif"'L TIl PtAll DLK lWiG CL#l552005793
DIMlH1C.J1"1 nIM1>.J,O:,J<I'I[] ISPCrlS,",'JSSN, r-jIV.tF"oI'! n. (SSNor ID. [J (SSNi D(/{l)
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MM 00 "
-LfLS~" 06 12 39 "'II ,[}(] McLaugh1en Marv
5 PATlHHSADORESS lt~o. St'lIlllj 6 PATI[t;T RElATIQtlSlllP TO It.SUREO 1 ItlSUREDSAOORESS\No S,r('ell
SflII 0 Spou~ot::J Ch.I(]~ Othll'D
CITY I STAT[ 8 PMIEtH STATUS CITV JSTATE
S,"".[] M,I'f.ll<lD """[1
ZIPCOOE I TrEPHO)E (tndullll Are.. Codltl ZIP CODE TELEPtiONE (INCLUOf ARE.\ CODE,
EmpIO~tffi[-J FU'I.T"'r"'D PJrt.T,mItD ( )
St...dlln! Sludol~1
9 OTHER ItISUREO S NAME ILul tla'l'1e. F,fll NJme, "'Ma~e IMI.lI) 10ISPATIWTSCm,DlTIONRElATEOTO II ItlSURED S POLICY GROUP OR FECA NUMBER
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a OTHER INSURED S POLICY OR GROUP NUMBER a EMf'LOVMEtlP ICURRENT OR PREVIOUSI a INSUREDSD~TEOFBIRTH 5"
MM DO VV
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MM 00 vv MD 'n ~VES 0"0
c EMPLOVER S tlAME OR SCHOOl ""ME c OtHER ACCIOErH1 c ItiSURANCE PLAN NAME OR PROGRAM NAME
iJ YES ~J"O
d IrlSURAfICE PLAN flAME OR PROGRAM flAME 1011 RESERVED FGR LOCAL USE d IS THERE ANOTtiER HEALTH BWEFlT PLAN'
DVES 0,,0 "Y~s relufn!O and corrp't'~Q ,l~'l'l 9 a :::
READ BACK OF FOAM BEFORE COMPLEmlO & SIOtlltm THIS FOAM. 13 INSURED S OR AUTHORIZED PERSOtl 5 SlmlATU~E I.hl~orlh
12 PATIENT S OR AUTf~RIZEO PERSOtl 5 SIGtlATURE I auTI'cr,u !~" lett'J~oJ cl .Ilt /TIedeal:, C~""f '~IJ'~Jl,Vrl r~CC~Ufy p.l,mc." 01 med.coll oo"!!!.l~!o If!! I.illdolrs'<1n...d phf~C .,., 0' L~pl... ':'
",'C""'M c":m "50 '",.M' ""m", 0' '"''A'''"''''' ",," m,,,'"'' ". ~,rt, .", "",', mooc,,,, ser'oCl!Sdt'SCfO<!llfJ'Off
"'0' L ~"-/. re,I C-
5'0"'0 ". lull ~;:: om lJ7/oS"/f:5" STGtl(Q .,L1 lll~
I" DATE OF CURRE:'~~ ILLNESS IF,,\! s~mp!aml OR '5 IF PATlErH HAS HA~,~~"'E O~'!:iII.'llAR ILLNESS 16 OATES PATtEr~J9ABLE TOWORK ItlCURROH OCCUPAJtO~j
PolM 00 9Y "'JURV IAcc<Clm!) OR GIVE FIRST DATE '-".1 00 YV MM [' VV MI., 00 YV
06 30 5 PflEGtiAtiCYILMPJ FROM TO
17 NAME OF REFERRltiG PHVSICIAt, OR OTHER SOuRCE I.a 10 flU/.l0ER OF REFERRi!m PHYSICIMl 18 UOsPITAtlZATlQrl DATES RELATED TO CUAF1ENT SER'beES
PolM 00 VV MM DO VV
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19 RESERVED FOR LOCAL USE 2Q OUTSIDE LAB' S CHARGES I
DYES 0"0 I 1
21. OIAGtoOSISOR NATURE OF ILLNESS OR INJURY IRELATE ITEMS '_2.30R4 TOI1EM2~E BVW;EI ~ 22 MEDICAID RESUDMlSSIOtl
CODE I QRIGIP/AL REF. ~O
T
I LB42.CLcervica1 sprain 3 L--._ 23 PRIOR AUTHORllATIQfl flUMBER
0 2 I 722.4 C4-C5 disc deg . L--.
" A 0 C 0 , , 0 H I J K
Fto~TE1SI OF SEAVICETo Pl.lCU Trpe PROCEOURES. SERVICES. OR SUPPLIES DIAGrlQSIS AVS I';.PSO RESERVED FOq
" " !Elpl,M Unusu.1! ClfcumSlar.ce~J CODE S CHARGES OR Film,l~ EMG coo LOCAL USE
MM 00 VV MM 00 VV ISl!fVoC IS(,fV'Cl CPluCPCS MODIFIER UNITS Plan
I _07 . _05 '1<; 3 99203 I OV NP exoan ed 1-2 55 00
07 05 95 3 97010 HP 1-2 20 00
2 07 05 95 3 97014 I ENoS 1-2 20 00
07 05 95 3 97035 US b! 22 00
3 07 07 95 3 99213 10V.expanded 1-2 3500
VI VI !:J5 ,j 'VL'1V FHm reaCl1n ~-2 ,j:J vv
07 07 95 3 97010 1~~1S 1-2 20,00
. .<0-00
VI V/.!:J5 ,j >1/014 ~-.<
07 07 95 3 97124 I Nassage 1-2 2000
, .d)~V
07 10 .95 j "''''''1L VV 1-"
,07 10 95 3 97010 I HP 1-2 2000
25 FEDERAL TAX I 0 flUMBER S5N EIN 26 PATIEtH S ACeOUm tlO 2~ ACCEPT ASSlGW.'ENP 28 TOT^L CllARGE 121 AMOUm PAtO 30 DALMICE CUE
IFof IlO~1 ct,l'm~. see bJckl
163-58'0267 IXIO o v's 0 "0 s 'A7 00 s 00 s 287 00
31 SlGtlATURE OF PHVSICIMl OR SUPPLIER 1 32 flAME AND ADDRESS OF FACIlITV WtiERE SERVICES WERE 33 PHVSICIANS SUPPLIER S BIlliNG ~~AME. ADDRESS ZIP CODE
INCLUDING DEGREES on CREDEtHtAlS AENDERED lit O!hef ltlJn homo Of o'loCal & PHONE'
II certify lh.' Itle SI,1!('men!lonltll1revefse GREGORY T. REESE, D.C.
9-i":"L~~"''';~/t1r 18 Courtyard Offices At. 11 & 15 -Selinsgrove, PA 17870
Telephone: (717)743-2342
RE604347 I GRP,
SIGNED DATE I PINI
~
~
(APPROVED BV AMA COUfiClL Ofl MEDICAL SERvICE 8 881
MId. by MKli,,1 Arts Pun
C,'lon/," 1-101)12'1179
PLEASE PRINT OR TYPE
FORM HCFAI~ (12-90)
FORM OWCP.I500 FORM RRSI500
ll~l1-r~n
U.. .,'~ r~..Ic.. "414~ 'I......~'~. '111~ 'It' It."
APPROVEOCl._U C'JU OOJ8
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; PICA
, MEDICARE MEDICAID CttAMf'US WAMPVA tinow' ~[CA OHiEn 1.1 It;suREO 5 1 0 t;UMOEH \FQH PROGnAM IPI ITEM 11
r'l HEAlTll PlA!l DUo: lUtlG CL# 1552005793
"'] (M..a,-.J'to., [] 1~'<'J..:.1<11J [~E'JS~,'YI r--J I~'''F.I", IJ - _ISSNOIIOJ r~~
2 PAII(}lT 5 tjAME (L,HtNJ'T"t, f'llt tum, Mdd" In 11.111 3 PATI[tll 5 llJlTti DAn SEX .. INSURED 5 FlAME (L.nt tlJ'l" F,flt N,I"'V, "'4\1,11 In !,j')
Robert Sv1via 06 ~o2 '39 I.'il ,:x] same
-
~ PATIWTS ADDRESS 1111), 51,~.11 6 flAIIEtH RfLATlQt,SfilP lOINsum:o r ItlSuREo S ADOflESS Ill' SI'l''''1
130S Front St.Apt 210 5'" CO] s'''''[l ChoOd[] 0l~",~-'1
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City I:TATE 8 PATIHH STATUS CITV I STATE
Sunbury Pa S,nQteD !,I,lIlII'dD O""C]
III' CODE I TrEPtiO)E We'~de Aru COd"1 lif'CODE 1 TELrttOfIE rlCLUoE AREA CODE)
17801 EmploY'dO ruuT'rr"fJ pallT,mlln
_ Stud"nl . 5tu(!o~n' ,
9 OTHER IUSUFlEO S fjAME ILall tla"'" F"" tlJ~' t,l,r);]tv IMI.1II 10 IS pATIHlI 5 CQtIDIIlml IlElAIEo TO 1 I IllSURED S POliCY GRJUP OR fECA NUP.lBEFl
. OTHER INSUREDS POlICV OR GROUP ~IUI,-eER .1 EMPlOV"'EtH' ,CUnnUH OR PREVlOUsl a 1P15Ul1EDSDATEOFBlRHi 5"
M'" 00 "
om [xl..o MD '0
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tI OTHER INSUREDS D.\TE OF B:RTH 5" tI AUTO ACCIQ[tlP PlACE Ist"'lt) tI E"'PLO'ERS NAt.IE OR SCHOOt. flAt,IE
MM 00 " "n [J'" [JtlO
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c EMPlOYER 5 flA'.IE OFlSCHOOl NAMl cOTtiER ACCIOEtlP c ItlSuRMI:E PLAN flM.'E OR PROGRAM NAME
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d ItlSURAtICE PLAN NAME 0'1 PHQGRAI,I flAl,IE 10<1 RESERVED FOR LOCAL USE d IS T'"'ERE A~,onjER HfALTtl eWEnT PLAN'
r- YES [l "0 lI)'rlrt'!w'nloarodeo<rCt't,.!p"'9.1d
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READ BACK Of FORM BEFORE COMPLET1tlG.. SIGrllNG THIS FORM 13 It,SUI1[Q 5 OR AUH.CR.-ZED PEASOtl S 51(',tlATURE 1 aJ~rc"za
12 PATIEtH 5 :m AUTttORtZED PERSON S 5IGW..TURE I a..~~~"z" 1~1t ,~I+!Ha 01 J<\t no"d':.ll Of cth.., ,r,!~If"'J~ on nt'e'H,l', p,l,...~nl e' 1T'.,d :.11 b..~"ta 10 !~... ut'1{fcr~'9"i.'d P~'I\C'a" 0' \"poJ l!f leI
10 pll)CI!U l~l ~ ell 'l'1 'a';oltq~l:'st PJrm"nl ol;:,l"r,nf'1'1 tkr.."S t';t~fr 10 (1':,S,,'1 or to I~I' p~r1r __'10 .UtI'C'S .lH'1"IT'l'"t Sol". cnd~~CIt;...dt),,'o'"
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SIG~jEO signature on file QATE 07-05-95 SI:.;';ED signature on file
14 DATE OF CURAEtlT ~ IlltiESSlf,rsts,rrp'='"lIOR 1; If pATlEm tiAS tlADSAME OR S;t,lILAFllll!IESS Ie Dol, TES rATI(plT U'IAeLE TO ,',OR..: It I CURREflT OCCUPATIO"
dll' 3'a 9'5 I~UURV (Acc>dltnt' OR GIVE fiRST DATE "'''' OD " M'.I DD " "M OD "
PREGtlAtICYlll.lPj rrl~!.I TO
17 t/Al.IE OF REFERRlllG P,ffSICIAlj OR OWEA SOuRCr; 17.1 10 ',UI.IEER CF REFEFlRI~,Ci ptHSICIA'l 19 H:)SPITA~IZATlml OATES RELATED TO CURREtH SER'JICES
P.".I OD " MM DD "
H1CI,I TO
19 RESERvfQ fOR LOCAL USE 20 0'JTS1DE LABl S CHARGES
U"S [lNO I I
21 OIAGtlOSIS OR NATUFlE Of ILUIESS Ofllf'JUAY IRELATE ITEMS 1.2.3 OR 4 TO ITE'-' 2~E BY LI~jEI t U. '.'ED.CAIO RESUB'-'iSSIOtl
CODE I OAIGlflAL REF 'lO
, LB42.o.. cervcia1 sprain 3 L-,_ 21 PRIOR AUTttOAllATICtl "UMBER
2 ,722.4 C5-C6 disc deg . L-.
" A B C 0 E , G H 1 J K
FuPmATEIS/Of StRVICETo Pld:e Trpe PROCEDUFlES. SERVICES OR SUPPLIES DIAGtlOSIS u~!;) "D RESERvED fOA
" ,I (E_pld'" Un~~\I.ll C"CumSlJl'\ClIS) COO, SCHARGES GR fJ"'oIr EMG COB LOCAL USE
P.o'.I OD " 1.1'.1 DD " .....~. ..ro< cpr Hcpes MODIFIER UWTS P:".,
07 .10 95 3 97014 I EMS 1-2 20 00
07 10 95 3 97035 I US 1-2 2200
07 12 95 3 99212 OV 1-2 20 00
07 12 95 3 97010 I HP ~- 20 00
07 12 95 3 97014 EMS 1-2 20 00
g~ 12 95 3 97035 I US 1-2 22 00
14 95 3 99212 OV 1-2 20 00
UI 14 ~:, 3 97010 I HP 1-2 20 00
07 14 95 3 97014 EMS 1-2 20 00
07 14 95 3 97035 I US ~~2- 2200
07 17 95 3 99212 OV 1-2 20 00
25 fEDERAL TAX I 0 tlUMBEFl ssrj E"I 26 PATIENT S ACCOutH NO 2T ACCEPT ASSIGtoI.lEtl1' 23 TOTAL CHARGE 12'3 AMOUNT PAID 30 BALANCE DuE
163.58.0267 [XI[] [JO~~~.1 rj~~~. bJekl I 77h 0" I "" I ~~<; ""
31. SI~f~ATUAE OF PtiVSICtMl OR SUPPLIER JZ /tAME MlO ADDRESS OF FACILITY WltERE SERVICES WERE ]1 PtnSICIMl5, SUPPLIER 5 BilllfjQ tlA"'E, ADDRESS liP COOE
ItlCLUDltlG DEGREES OR CREDEtlllALS AEtlOEREO (1Ioln'"1l1Jrll10mllOfoNiCfll &. PHONE'
Ilc."llyll1.1!I!1eSl"temenl\OI\INIIlf'llr~8 GREGORY T. REESE, D.C.
,pp1t 10 ltl"b<il arocl 01"mold. 01 p.l'1I11PfOol}
~ -l fl-~. 9 -/r"11 1BCoultyard Offices RI. 11 & 15- SelinsgrovlI, PA 17870
T.I.phon" (717) 743.2342
RE604347 I GRp,
51GflED DATE Pltll
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"
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~
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(APPROVED BV AMA COW;CIL ()tl MEDICAL SEnVICE 8 831
Mrd. by Mfdiul Arh Pun
C"lolIl". IIOOJ1I217'
PLEASE PRINT OR TYPE
FORM HCFA.I500 (lBO)
FORM OWCP-I500 FORM RRBI500
IIMU-'nlU
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PICA.
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HEALTH INSURANCE CLAIM FORM
PICA
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I MEDICARE MEDICAID CtlAMPUS CHAMP\fA GflQUP fleA OIllEIl ., ltj5UIlEOSIO PIUI.IIlEIt IFQI1PIIOGIlAI.IINlfll.llj
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2 PA11lPH SUAME (LUI N~m". F.J,t ~IJm. M,QOllllrl,l.JI) J PATlll.T ~U,HTtl DAll SE' ~ ltj5URl13 5 '.A"~[ \Ln!tI.'....II, F,rst fl'~'u l.h"ltl'lI t1Q'J'I
MI.l DO YV
Roberts SYlvia 06 12 39 ",n 'Ii same
5 PATtEtlT 5 ADDRESS 1'10. SH.ul, f PAT,OH AHAIlQtj5HII' TO ItlSuRED 1 1'15UR[D S ADDRESS Itlo Slrll!l)
130S Front St. Apt 210 5.;1 CK s~"~'~J CI'IIO[: Olt'llrr-\
, ,
CITY I STATE a PATIE!lT STATUS CITY 1STATE
SunburY PA 5'~IIID Mml~D 0".'[1 ,
ZIP CODE I TrEPtlO)E lll\Cl;"de Aru CO(l') liP CODE I 1Hr'lONE )PICLUDE AREA CODE) I
17801 EI'T'P'C,oKlO F..II.T"""O PJrtTlme[-)
Sl;;d,rll . Sl\Odtnt .
9 OTHER INSURED S tlAME lLoUt N"m.. F,r" PI""",, M,dO'.In.!."JI tJ ISPATIEr/TSCOtlOITIQtlRELATEDTO t 1 INSURED 5 POlICY GROuP OR FECA tfUMOER
. OTHER ItlSURED S POliCY OR GROUP PlUMOER .1 E"'PlOmE~H'ICURREtITORPREYIOU51 . ltl5UfleoSDA,TEOfBIRTtI SEX
MM DO 'tV
DYES [i\"0 MO '0
b OTHER INSURED S DATE OF GIRTH SEX e AUTO ACCIDENP PLACE (S!.1'~, D EM PLOVER S tl"',IE OR 5CMOO\.. flAME
"M DO yy Mn 'n XJVES 0"0
.
, EMPLOYER 5 PIAME OR SCHOOl flAME C OTt-ER "'CCIDE'IP C Itl$URAtlCE PLAN NAME OR PROGIlAM ~lAJ.lE
liYES lX"O
d ItlSURAtlCE PLAP4 flAME OR PROGRAM tlAME 1:0 flESERvEOFQRlOC^l USE d IS Tt~ERE MjQTtJER 'lEAL TH BWErIT PLAN'
nYES Cl "0 "Y.. rl'h.," 10 .1~d corrplele ,:...n 9 ,1 d
READ BACK OF FOAM DEFORE COMPLETltIG & SIGPllPlG TlUS FOAM. ,) II/SUIlED 5 OR AUTHORIZED PERSOtl S SIGNATURE 1..~~hC":e
12 PATlEtH S OR AUTHORIZED PERSall S SIGt/AWRE 1.1..'1':0"11' It,:, rT _no!' " "", rr~j(,}1 0' o!~..r .,..'O/"'J::n "<lees"", p.l,m<l"IOI""d":JIbt>r,,IIS'Oth~"'fl<l"rS-Q"lldph,S"'')r'lCI'~PP erlCI
10 ploc.n 1t'l<S C!.1m I ,I,!,O rl'Quut p.1,mo!'~1 cIIP.f!"r.merl t"re'!S IHh"r'~ -,\~' cr 13tt.. P.l"!, ""0 J:~"~!\ ,)\I'J~rr..rt St'r~.ce' deler t't.'l"l bt>'-''''
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SIGtlED siqnature on file DATE 07-05-95 SIGt/EO sin nature on file
'4 DATE OF CURRE'H ~ ILLNESS (FIISII,mpIOm) OR 15 I~ ;l,\ll(1H tlA5 ~IAD SA'.'E OR S:I,',~AR IllNESS 16 DATES PATIEIlT UlIA,DLE TO WORK IN CURROll OCCUPATIO"
O~' 3'1f 95 ItlJURY IAcc'derlll OR G".E fIR$T DATE ,"",\ DO yy 1.11,1 DO yy ,,~'" DO yy I
PAEGNAtlCVILMPj fROM TO !
11 PIAME OF REfERR;tjQ PHYSICIAN OR OTHER SOUnCE 1101 10 'IU','BERO" REFERRlt,G PtH51CIAN HI ~iOSPITAlIZATIONDATE5RELATED TOCURRENT SERlJlCES
I.ll.! DO yy ",..I DO yy
fROI.! TO I
I') RESERlJED raR LOCAL USE 20 OUTSIDE lAB' S CHARGES
nVES [1"0 I I
21 DIAQrlOSIS OR tlATUFIE OF ILWESS OR INJURY (RELATE I1EMS 1 2 J oru TO 11EI.I 2~~ 0'1' lIr,E) t 22 MEDICAID RESUOMISSICtl
CODE QRIGltlAl REF NO
I I8!lLOservica1 sprain , L-._ I
2J PRIOR AUTll0RIZATIOtl tlUMBER
2 LZ22A...c5-C6 disc d, 'L-.
,. A . C 0 E , Q H I J ,
Ff09nATE(S) OF SERVICETo PlJ~. T,,,, PROCEDURES SERVICES OR SUPPLIES DIAGtlOSIS DAYS: fit) RESERVED FOR
01 0' (E.p1J1 ~ U"ul<lJI C"C1Jf"lll,)"'e~) CODE $CHA,AGES DR FJlm,t, EMQ CO. LOCAL USE
MI.l DO yy MIA DO YV " , " CPT HepC 5 MODIFIER Utl1TS PI,)n
I 07 17 95 3 97010 IHP 1-2 2000
07 17 95 3 97014 I~MS 1-2 20 00
07 17 95 3 97035 US 1-2 22 00
07 19 95 3 99212 OV 1-2 2U UU
07 19 95 3 97010 I HP 1-2 20 00
07 19 95 3 97014 EMS 1-2 2U uu
07 19 95 3 97035 I US 1-2 22 00
07 21 95 3 97010 liP 1-2 LU uu
07 21 95 3 99212 I OV 1-2 20 00
07 21 95 3 97014 EMS 1-2 20 00
07 21 95 3 97035 I US 1-2 22 00
25 FEDERAL TAX I 0 NUMBER SSt, EI'1 ! 26 PATIWTSACCOUNTNO 21 ACCEPT ASSIGNMENT' 28 TOTAL CtlARGE 12') AMOUtH PAID 30 DAl,4,PlCEDUE
lFo' 00'01 Cl" m~.IU bJckj 226 00
163.58-0267 OOfJ OVESONO s 226 00 s 00 s
" SIQrlATURE OF PHY51CIAP4 OR SUPPLIER i 32 NAME MiD ACDRESS OF FAC1LtIY YmERE SERlJlCES WERE JJ PHY$ICIMIS. SUPPLIER S BILLING "AME. ADDRESS. ZIP CODE
1~ICLUDltlG DEGREES OR CREDEtHlAL5 ' AEtlOERED II! C:~"'I th,)~ ho""" 0' O".ce) & PHONE'
tlcef'l,t,ltIJlttt.fS!Jlcmentsonlt'lIrhel,,, GREGORY T. REESE, D.C.
~""'IO"""'''...''m'd'''''"'''''OII ,
L~(. Cj.f/"W 1 8 Courtyard Offices At. 11 & 15 - Selinsgrove, PA 17870
Telephone: (717) 743-2342
RE604347 IORP'
SIGNE~ DATE' Plt~.
~
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IAPPROYEO DY AM" CootlCIL ON MEDICAL SERVICE 8 BSI
MId. by Mtdiul Arts Pit"
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PLEASE PRINT OR TYPE
FORM HCFA.I500 (12-90)
FORM OWCP.l500 FORM RRB,l500
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HEALTH INSURANCE CLAIM FORM
tFOn f'HOGrl"M Itl In!'! II
5 PATIENT S ADORESS IPlo Streit)
130S Front St. Ant. 210
CITY
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2 PATIENT S t~AI.'E (lut fj..'\"e F"s! 'j.l<T1l1 t,trklle h11J11 J P~,~I[.tll gJIII\T~.fATE SO. .. Itl5URED S t~AI.lE ILul Ndme. F",I 'l.1mu M-dIJ'u Inoh1'1
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6 PATIENT RElAtiONSHIP lOlf/SlJRED
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ZIP CODE
S'noh.D
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g OTHER INSURED 5 N"'.lE IL.SI NJme. F,'sl NJrf'lf, M-d<JIIIIMIJiJ
a OTHER INSURED S POLICV OR GROUP NUMaER
. EMPLOVMENT' tCURRWT on PREVIOUSl
b OTHER INSUFiEDS DATE OF BIRTH
MM DO VV
DYES
b AUTO ACCIDENT'
GUYES
c OTHER ACCIDENT'
DVES [X~lO
lCd RESERVED FOR LOCAL USE
SEX
IU"O
PLACE ISl.1hlJ
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0"0
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c EMPLOVER S tIAt.'E OR sc..()Ql tlAME
d ItlSURAJICE PL.Mj ~I"-','E OR. PROGRAM tlAME
READ BACK OF FORM DEFORE COMPLETING & 51GNma THIS FORM
12 PATIENT S OR AUThORIZED PERSON S SIG/llPoTUflE 1.1~!t-~' ze the 'l'ifoa<e ol.lny med<:.ll 0' C'fe' ,~rOlm.1T>cn "I!CCSSJ"f
10pr:Xe~s t!1, CIJ m I a'w II:<;...e,' ~Jlft,erl 0Igo,el"I'1I;Iol botrtl IS l!llt-el 10 ml'uil 0' 10 ltlt> p.u1f l'IfO JCCl'pI5 oISS1<}"meol
bt!:o...
SIG/lED
sionature on file
DATE
7-5-95
14 OATEOFCURRErlT ~ ILLNESS tfllSI Stmp:O'"l OR
MM 00 V"( 11UURV (AcCldl!"U OR
06 30 95 PREGtWICVILMPj
17 NAME OF REFERRI!.:; PHf5ICIA!1 OR OTHER SOURCE
15 IF PATIENT tiAS HAD SA',IE OR SI"lILAR ILLtlESS
GIVE FIRST DATE "",I 00 VV
1101 10 flUI.lBER OF REFERRitlG PIlYSICIA',
19 RESERVED FOR LOCAL. USE
21, DIAGNOSIS OR tjATURE 0= ILWESS OR IfUURV lREL.ATE ITEMS 1,2,3 OR 4 TO HEM 2~E BY LItlE) t
, tll!l2.U.-cervical sprain J L-__
.-
~ 2 I 722 .4 C5-C6 disc deg
~
24 A 0
, OATEISI OF SERVICE, Pl.1ce
fom 0 01
MM 00 VV MM 00 YV >'o'oC\
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T~pe PROCEDURES. SERVICES. OR SUPPLIES
01 tElpla,nUfllJSuaIClfcumsl..1ncesl
fW CPT HCPCS ' ),IOOIFIER
99212 I OV
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97014 I EMS
~/Uj~ us
99212 I OV .
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97014 I EMS
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99212 IOV.
97010 HP
97014 IEMS
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DIAGtIOSIS
CODE
07 26 9!
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07 26 9!
2 07 26 9!
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07 28 95
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07 28 95
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07 . 31 95
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25. FEDERAL TAX I 0 tlUMBER
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163-58-0267
21 ACCEPT ASSIGNMEUl'
IFo'go..tcla'm~.lI'UbJclo.l
[I YES n "0
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RHlOEREO (II 01hl!f IhJn homo 01 oNiC'l
: 26 PATlWTSACCOutlTNO
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INCLUDING DEGREES OR CREDtNTlALS
(1 c.ftlty thaI ~. S1Jl,m'fl!S en mil f1hl!lle
~'''u::.~~:~'~''~;~1~
"'ll j
SIGNED DATE i
/APPAOVED 0'1 A.vA COU~jCIL 0/4 MEDICAL SERVICE 8 eal
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CITV I STATE
ZIP CODE I TELrHOrlE rCLUDE AREA CODE)
11 INSURED S POlICV GROUP OR FECA 'IUMDEA
.1ltlSUREOSOATEOFomTH
MY DO VV
SEX
P..o
b EMPLOYER S NAME OR SCHOOL NAME
'n
c It~SURMICE PlAt4 NAME OR PROGRAM NAME
d IS THERE AtlOTHER HEALTH DENim PLAtP
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13 INSURED S OR AUTHORIZED PERSON S SIGNATURE I a'~I!1O'H'
p.1tml!~tolmed.CJlbll"ItIIISI01l1el.;fldersQrlt'dph1slc'a"orsl;PCI"rrOf
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16 OATES PATIEUT utlADLE roWORI': ltl CUqREtH CCCUPATlQrl
M'" 00 YV MM 00 YV
FROM TO
18 HOSPITAL.1IATION OATES RELATED TO CURRENT SERVICES
MM 00 YY MM 00 VY
FROM ro
20 OUTSIDE LAD' S CHARGES
DYES ONO I I
22. MEDICAID RESUDMISSIQt,
CODE I ORIGltlAL REF NO
2J PRIOR AUTHORIZATION NUMBER
,
G H
D'!S EPSOI
OR F.lm,l~
UNITS Plan
I J
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RESERVED FOR
LOCAL USE
EMG COB
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2000
20 00
20 00
2200
2000
iU.VU
20 00
U.VV
20 00
20 00
20 00
29 TOTAL CHARG~ \29 AMOUNT PAID
I ~~A:nn I nn
33 PHVSICIAN'S, SUPPLIER'S BIlliNG NAME, ADDRESS. liP COOE
& PHONE'
GREGORY T. REESE, D.C.
18 Courtyard Office. RI. 11 & 15- Sellnlgrov., PA 17870
Telephone: (717) 743.2342
RE604347 I
PIN' GRP'
30 OALANCE DUE
I
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FORM HCFA.I!lOO (12.901
FORM OWCP.I500 FORM RRO.I500
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PICA
HEALTH INSURANCE CLAIM FORM
PICA
~
~
1 t,lEOIC"II( M[QICAIO CIlAMPU5 CtiAMr....... GIlUUI' ILeA OTtl(f1 1.1 1I15UHWSIO NUMBER IFOR PROGIIAP,IIIlnW I,
Jj[ALtllPlAII mt<.lutm CLI 1552005793
lII.lIJCJf,', QiV'''l1(J-d II (-') ISj""'~"fI5S~~~'I_IJ_~~_~~~j~~_~'iS'-j1 [ -] flDi
2 PATlltll S tjAME 1L ,nl fUrTllI f ,'~I tlJr'H' !."<111M IrIMI) J 1~1~1,(tH 6(~IIIT~.pA I( 50 ~ ltl!.UR[D 5 NAMt (l,ut N,IIl'Q F,ut'lo1mB Mll'I'lt 1f'llIJll
"oherts Sylvia 06 12 39 ,,' I-I 'r-x same
- -
!l PATlwr5AOORlSS(tlo, SUnll 6 rATIOlT flUA TIOtl~;IIIP TO l'ISUIlLO 1 IflSUREO 5 ADORESS ltlo. StrlllllJ
RR5 Box 221A "'l~ s",,,.[] CM(] O'h"[]
CITY 15TATl- II PA11[tlT STATUS CITY I STATE
Selinsgrove Pa ,- ] MJlfIHd[] O,,"C]
S'NJ"L_
ZIP CODE I TttPIlO)t (I""lull" A,1I.1 CO<1\11 ZIP CODE 'jTEl,PtIOtIE )tIClUDE "REA CODE
17670 ['l'pIOJlt1n FU1IT,mer-j f'd11Tlmll[1
5tlidonl , Slud.mt __
9 OTHE:R ltl$unEO 5 'lAME IlJ\l tl,mf Fll$l tumll !.Mil" 1M ,111 10 ISI'ATIEtlT SCOtlOlTIQfl REl"nO TO 11 ltISUI1(D 5 POliCY GROUP OR FEC'" tlUI.IB[R
. ortiER INSURED 5 POliCY OR GnOUp 'jUt,lBER oJ EI,IPlOYMEfjp ICURrtEtH OR PI1(....IQUS) oJ ItlSUREOSOATE or OIRTU SEX
1.1',1 00 VV
DVES 2'J"0 "0 'l]
b OTtiER ltlSUREO S DATE OF B;ATtl SO b AuTO '-'CCIDWT' PLACE (S',I!") b EMPlOY[11 S 'l-"l,l( on 5CtlOOL flA.ME
MI.I 00 vv "n 'r-1 [~lvES [~"O
c Et,IPlO'l'EI1 S tlAl.lf OR SCtiOOl NAME c OTtIER A~CIOErlP c ItlSURAtlCE PLAN tlAME on PROGRAM NAME
I 1m [X ~ ~.o
a INSURANCE PlMI ~IAME OR PROGRAM NAME l()l RESER....ED fOfllOCAl USE d IS "fEnE AtIOlHEIl tlEALTU UWEnT Pl.AtP
READ BACK OF FORM BEFORE COMPLE1INa7siai~tjo HIlS FORM []VE5 [l "0 IIt'I' f1.lufllIOoJndcomlllt!'t!,h'<l\9" ~
'.1 IljSUflEO son AUtllORIIED PEnSO'1 5 SIGtj" rUIlE I'-'J.t.,o,,:~
12 PATIEt.T 5 OR AUTHORIZED PERsorl S SIGIl"tuRr l.1~~hO":'ltl" fe'''I;~ cl ,1nl m~>1.c.11 01 On,.., ,nlcmJIM nI'Ce~\a'f JJ.ll'l'l1nCoIlT'tlJoCdlb"!1tllUl0ChOfV10tl'I-9"te,jllhf\(I,I'lOl',lJP.,I",,;,
10 poeen Ih.S CIJ m I oI:W rl!'q\.ut polImenI 01 'J'J-.l"rfT't'~1 b<f~~I,t1l",r,,'lo 11'/\lt 0' 10 Cht P,I'I, 111'0 dce....'S .1U'll"'Tl..nl S"'~o(lI~dt!)(l.~dlw.:O""
b~lO...
SIGljED signature on file DAtE 7-5-95 """EO signature on file
U DATE OF CURREtlr ~ llLtlESS IF"11 Sr'1"ptQrTlI OR 15 IF PATIOH HAS HAO 5At,'( OR SII,llllln IlWESS l(i OIlTESPATI[tH WIABlE 10 WonK Irl cunREtH OCCUPATIO'.
d6' 3'6 9"5 IflJURYl"cc,dO:I1I)on GIVE f:nSTOA.TE MI.I 00 VV W.l DU VV I.lM DO v,
pnEGlj"tlCYllMPI FIlOt.! TO
17. tlAI,'E OF REFERRI~lG PHYSiClAtl OR OHtER SOURCE I1J to tIUI,liJEROF IILF[Wll'ir,PH'l'StCtMI IIJ HOSl'lTAtlZATIQtj DATES RHAIED 10 CURREtlT SEI1....IClS
MM DO " 1.1',1 DO "
FROM TO
19 RESER'JEO FOR lOCAL USE 20 OUTSIDE lAD? 'CHAnGES
[]VES r-~ I
21 OIAmlOSIS OR tlATURE OF IllflESS on I'UUllV IRElATE HEt.l5 1 2 J OR" TO lIEM 2-1E BV lltl[, t 22 MEDICAID IIESueI.l15510~~
CODE I ORIGINAL REF tlO
, LB47_ O-cervical sprain , L--. -
23 PRlon AUtHORllATIOII tlUMOEr!
2 @2 iI C5-C6 disc dea , L
" A . C 0 , , 0 " , J K
F,[lmATEISIOF sER....leETo PIJce T,,,., pnOCEOUI1ES. SEFl'v'ICES DU SUPPLIES DI"GtIOSIS AVS jmD' RESERVEDFC=l
,I " (E.pl,}." UI1~'UJt C'fc:um\IM>ce11 COO, SCIlARGES on Fam,tt "'0 co. lOC"lUSE
,,'M DO " """ DO ,V S..r,... c^~" CPT Heres MODIFIER UNitS Plan
07 31 95 3 970~US 1-2 22 00
, -:3 992 Ov 20 00
VtI Vi ~: 1-":
06 02 9 3 97010 I HP 1-2 20 00
2 v8 ~~ :;=2
Vi Ij 97014 EMS 20 00
, 06 02 9: 3 97035 I US 1-2 22 00
06 04 95 3 99212 10V 1-2 20 00
, 06 04 95 3 97010 HP 1-2 2000
06 04 95 3 97014 I ~~1S 1-2 2000
, 06 n4 qs 3 97035 US 1-2 2200
06 07 9: 3 99212 OV 1-2 20 00
, OB 07 9< 3 97010 I HP 1-2 20'00
25 FEDERAL TAX I 0 NUMBER SStl EIII 26 PATI['H5 ACCOutn toO 21 ACCEPr ASSIGNMENT' 28 TOTAL CIIAnGE \29 AMOUNT PAID 30 B"tAtlCE DuE
nOtOO.tcIJ'm~'I~fbJCto.l
163-56.0267 lXi[] . YES [] "0 s 226 00 s 00 s 226 00
JI 51GtlATURE OF PtlYSICIAtI OR SUPPLIER 31 IlAME AND ADDRESS OF FACILITY WIIEI1E SER....ICES WERE JJ PtiVSICI"tj S. SUPPLIER S BilLING NAME. ADDRESS. ZIP CODE
CtlClUOltlG DEGREES OR CREonm"tS flOmEREO (II Olh~t ,tlJn homlf 01 011"" &PttOflE'
11Cllft,ltlt\all".stJT,m"nllonl~1I1f;.~tllW GREGORY T. REESE, D.C.
applf'oln.Sb41'l'ld.lI.m,)dll:lp.\ltltlOlllOtI
~ k~. ~-/~"ir lBCourty.tt1Offices R1.11 & 15-S.lin,grov.,PA 17870
T.r.phona: (7171743-2342
REB04347 I Gnp,
SIOtjEO"" DATE PIN.
:
~
IAPPRO....ED DY AMA COWICll Ot~ MEDICAL SERVICE 8 eal
MId. b, Medic.lAt1s P,.n
Ctlll.nl," IIO)UI2179
PLEASE PRINT OR TYPE
fORM HCf"l~ (12901
fORM owcp.am fORM RRB,l~
llt(ll.l~n
u.. .,'~ I .,'OCt. 11"'\ 1.........,1 00 II"" 1101- ,,"t
pLEASE
DO NOT
STAPLE
IN THIS
AREA
~...
PICA
Roberts Sv1via
5 PAlIEtH 5 ADDRESS (No, SlrtHll)
a OTHER INSURED 5 POLlCY on GROUP NUMBER
b OTHERINSUAEOSOATEOFOIRTH
MM DO YV
SEx
Mil
c EMPLOYER 5 NAME OR SCHOOL NAME
Ii ItiSURANCE PLAf4 NAME OR PROGRAM t~AME
APPROvED 01)0 C9)t1 coos
HEALTH INSURANCE CLAIM FORM
6 PAllun RElATlOfIStllP TO 11l5UREO
5('11 [iJ SpouslID Chlldf] Ol~ffO
8 PATIENT STATUS
s,,,,"ll
M'lJlloaD
Olne'D
1 MEDICARE MEDICAID CHAMPUS CtiAMPvA GllQUP fEe" OTHER la INSURED 5 I 0 NUMUER
HEALHi PlM, OLK lOt.G r""1
J /"'tdCJI"1 [J ,,I,I#(jICJ.d '} n (S;:O"50fS 55"') rl (VA FIIIl' 1/ n j55NorlD) i -J"/SSN} I I /lDI CL# 1552005793
2 PATIENT 5 '4AME (lnl N.amll, Fill' 'l,lrre l.\.dd'lIlr'h!,,)IJ J Pp'~~IE::~H 8001AT~fATl SEX 4 IfjSUREOS'lAME (lntNJmQ. f<r"tlJme. "':dd:t:lll'l,!i.ll/
06 12 39 M n ' Ixl
RR5 Box 221A
CITY I STATE
~ Se1insarove IPa
liP 7;~70 I T;LEPtiC)E llnclude Area Codtrl
9 OTHER INSURED 5 NAME (Lasl ~lame, F,"1 NJ,me, f.4,(jdleln.tialf
Empla~Odn Full.T,men Part.r,men
LJ 51udenl LJ Sludenl LJ
10 15 PATlEfHSCONDITlOtl RELATED TO
a EMPLOYMENP (CURRErH OR PREVIOUS)
'n
II YES
b AUTOACCIDWP
[X YES
c OTHER ACCIDEtlP
llYES [J(]"O
ICd RESERVED FOn LOCAL USE
[X1"0
PLACElSI,U)
ll"o
READ BACK OF FORM BEFORE COMPLETma & SIGtlINQ THIS FORM.
12 PATlHH S OR AUTHORIZED PERSON S SIGrM,TURE 13ut"cr,ze Ihe 11I'o.',lSlI or 3n! mlldcal Of alh"r 1111:rn"J!.cn MCeS\.l'f
IJ proceu Ih.s cIJ,m I also IfQ\JUI pJlme~1 at gO'.ernmllr.1 oeM!.11 e,mllr 10 ml~ell or 10 IIle pJf!t """0 i1ccepU dH'l)r.rT'<!nt
b"IOW
SIG"Eo signature on file
14 DATE OF CURRENT. ~ ILLflESS (F,'SI11rT'CtOmIOR
~~ ~~ Y1~ ltlJURY l"'c,ct'n!) OR
Ilh :itJ "'t'1 PREmlANCVoU,lPJ
11 flAME OF REFERRING PHYSICIAN OR OTHER SOURCE
19 RESERVED FOR LOCAL USE
DATE
7-5-95
l!l IF PATIENT HAS HAD SAME OR SIMILAR lLUlESS
GIVE FIRST DATE MM DO VV
11.1 10 NUMBER OF RHERRlNG PHYSICIAN
1 L8Q ,(Lcervica1 sprain
21 CIAG/laSIS OR NATURE OF ILLtlESSOR ltlJURY (RELATE HEMS 1.2.3 OR 41OHE1.l2.&E BYl1tIEf ~
T
3L-,_
,
~ 2 I 722 ,4 C5-C6 disc deg
~
2.& ABC
, DATE(S) OF SERVICE, PIJce T~pe
lam a ot 01
MM DO YY MM DO YV l"tl~'''IIc::..;:''"
, nQ 07 9
08 07 ,95
2 08 09 95
08 09 95
3 08 09 95
08 09 95
. 08 11 95
OB 11 95
, 08 11 95
08 11 95
,08 21. 95
25 FEDERAL TAX I 0 NUMBER
SSN Elt,
163-58-0267
rx:o
31 SIGNATURE OF PHYSICIAU OR SUPPLIER
I~~CLUDING DEGREES OR CREDENTIALS
Ileerl,tylhatth.Slatemlnllonltlelherse i
q;: 'rt:~';~d' 'P"''''';'~( t ~J-
SrGN!;O DATE
/APPROvED BY AMA COUriCIL ON MEDICAL SERVICE 8 881
MId. by Medlul Arts Pre"
C..lDiJ""I-JOO.n..217't
'L-,
o
PROCEDURES, SERVICES. OR SUPPLIES
(E_plain Ul'luSU.11 C'fCumll.vlces)
CPT'HCPCS I MODIFIER
97014 I EMS
97035 IUS
99212 OV
97010 IHP
97014 EMS
97035 US
99212 I OV
97010 IHP
97014 EMS
97035 US
99212 I OV :
E
DIAGNOSIS
CODE
1-2
1-2
1-2
1-2
1-2
1-2
1-2
1-2
1-2
1-2
1-2
,21. ACCEPT ASSIGtlMWP
(ForOa'o"l t1dlm:;.SHbJc"-l
, : 0 YES II "0
: 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
RE~lOERED III other Ihdn home 01 oHiCe)
,20 PATrENTSACCOUNTtlO
PLEASE PRINT OR TYPE
PICA
{fOil PROGRAI.lI~lITEM II
same
1 IUSURED S ADDRESS (flO . Sl,eilll
CITV I STATE
ZIP CODE I TELrHmlE )NClUOE AREA CODEI
II IUSURED S POltCY GROUP OR FEeA NUMBER
a INSURED S DATE OF BIRTH
MM 00 YV
SEX
"ll
b EMPlQVEn S tlAME OR SCHOOl NAME
'll
c ItlSURANCE PLAN NAME OR PROGRAM ~MME
d IS Tt1ERE ANOTHER HEALTH BENEFIT PLAN'
DYES 0 NO IIy" letufn 10 and earT'pll<11' ,Iem 9a.d
13 INSURED S on AUTHOR'ZEO PERSONS SIGNATURE I aulnc'Lze
pJ~ment at med'e.ll bene!:lla Ine ul'ldefslgned phI'S'CIJ." Of suppl,tlf 10'
servIces descflblMl bolaII'
SIG"Eo signature on file
16 OATES PATIENT UNABLE TO WORK IN CURREUT OCCUPATION
MM 00 YY MIA DO YY
FRO'.1 TO
18 HOSPITALIZATION OATES RELATED TO CURRENT SERVICES
MM 00 YV MM DO YY
FROM TO
20 OUTSIDE LAD'
S CHARGES
I
llYES DNo I
22. MEDICAID RESUBMISSION
CODE I ORIGI~lAL REF. NO
23 PRIOR AUTHORlZATIO'. NUMBER
,
G H
DA!5 E.PS~l
OR F.1m,'~
UWTS PI.m
, J
K
RESERVED FOR
LOCAL USE
EMG COB
S CHARGES
20 00
22 00
20' 00
20 00
2000
2200
20 00
20 00
20 00
22. 00
20,00
28 TOTAL CHARGE 129 AMOUNT PAID
S 226 00 I s 00
33 PHYSICtAN S. SUPPLIERS BILLING NAME_ ADDRESS. liP COOE
& PHONE'
GREGORY T. REESE, D.C.
18 Courtyard OffIces At. 11 & 15 - Sellnsgrove, PA 17870
Telephone: (717) 743-2342
RE604347 I
PIN' GRP.
30 BALANCE DUE
s
226 00
FORM HCFA-l500 (12.901
FORM DWCP.l!lOO FORM RRB.I~
m'.ll-I~ll
Ul.II ..l~ (n,,~ II'I'~ 1J.~10f '1I1"\ldl.llll:
APPRQ'wED 01,18 :i3a C,:C9
pLEASE
DO NOT
STAPLE
INTHIS
A"REA
~..
; PICA
!.~~"-\'_~. ~~v~-;, ';.-4<-_~:~_- ~~
HEALTH INSURANCE CLAIM FORM
PICA
~
1. MEDICARE MEDICAID CtiAMPUS CHAMPVA GROUP FlCA OTHER '.I INSURED SID NUMBER IFOR PROGHA'.'IN ITfl.II,
nt In/ 'ni n n HEAlTtiPlANnBlKIUttOnt CL#l552005793
tA.lN<,Ir, I' /Mrtd'eJd II iSPll"$O'-S S5NI (VA F,III "I r5SN or 10/ /SSNI (ID/
2 PATIENT 5 rlAME IlastNJme. FilS! N3mtt. Mddle IMoJI) J fA TIWT S BIAW DATE SEX 4 lrlSURED 5 ~lAME ILill1 ~lilme. f,.sl NalT'e MMIl I~\id.:
Roberts Sylvia "'M 00 " "n Fltl
06 12 39 same
5 PATIENT 5 ADDRESS 1~~O. 51r'lIl) 6 PATlWT AELAflorlSHIP TOlflSURED 7 IFlSURED 5 ADDRESS itlo. Slrc"1
RR5 Box 2211'. Seil [] SpouseD C",ldO OlhllfD
CITY 1STATE II PATIENT STATUS CITY jST'\IE
Selinsarove Pa SongleD MJrr'edD 01""0
ZIP CODE 1 '(LEPHO)' """," A'" Cod" ZIP CODE I TElrHONE )rIClUDE APEA CODEI
17870 E""p!o~edD FilII-TimeD PdrtTlmttD
S,udent S!~denl.~
9 OTHER INSURED S flAME (lasl NJme. FlrSI Name, M.ddlelM.llt 10lSPATIErHSCOtlQITIONRELATEOTQ II. INSURED S POliCY GROUP on FECA FlUMBER
J OTHER INSURED 5 POliCY OR GROUP NUMBER ,) EMPlO'r'MENT' (CURRENT OR PREVJOUS) a INSUREDS DATE OF BIRHt SEX
"" 00 'V
[JYES ~NO "0 FC]
b OTHER INSURED 5 DATE OF BIRTH SEX b AUTO ACCIDENT' PlACEISUlel b EMPLOYER S FlAME OR SOIOOl N-'''''E
W.t. 00 " >An 0"s r JI<O
. Fn
c EMPLOYER 5 PIAME OR SC~.OOl flAME c OTHER ACCIDWP c INSURANCE FLMl rW.1E on PROGRAM NAME
0"5 [gJI<O
d INSURAtlCE PLAtl NAME OR FROGA"'.' rlAME led RESERVED FOR lOCAL uSE d IS THERE ANOHIER HEALTU BEPlEflT PLAtP
n"s f] 1<0 II)'" lel~f"'oat"dO"'C'e:",:~<:'I9ad
READ BACK OF fORM BEfORE COMPLETING & SIGfmlG THIS fORM. IJ ItlSURED S OR AUTHORIZED PERSO'1 S SIGr;,l,rURE I .I.ltt"or lot
12 PA T1EflT S OR AUTHORIZED PERSON S SIGrlATURE I a~t"r..ltle 'htl re-"l\'" of J'lt med",.ll or O!hl!l.,'I,)fmJ~ on n@Cl"HJr~ p.l,m..nlolm"d,c.11b!l".,r,1110 IhdUnd"S'llno.'dc-,IC;Jr::'s"cc:,!l'~'
I,) prOC.U IhoS ctJ,m lollS') fe'QlJesl p.l,1"lll"l or 1l0~elnml!n' b~r"f,ts I!I!h'!f 10 "',Si!,r or 10 lhe p.lflt ...~O JCCep:s JSS'Il"~enl ser.tCeSdtl\4:r;Do"lJb!llc1l'
teloO'W
SIGrlED signature on file DATE 7-5-95 SIGrlED signature on file
'4. DAlE OF CURREm: ~ ILLNESS IF'I~t S~l'T'ploml OR 15 IF PATlEtIT HAS HAD S,l,I,lE OR SI'.'llAA IlUlESS 16 DATESPATlEPlT UtlABlE TOWORr( IN CURRErjf OCCUPATIOtl
Qgl 3'8 95 INJURY IA:;c>dt!nll OR GIVE FIRST DATE ""~l 00 " "" DO " MM 00 "
PREGrlAr~CYILMPI FROM TO
17, ~lAME OF REFERRlrlG PHYSICIAtl OR OTHER SOURCE 17" 10 NUMBER OF REFERRlrlG PHYSICIAN III HOSPITAlIZATJO'l OATES RElATED TO CURRHlT SER"ICES
'-".l 00 " Mt.l DO "
FROM '0
'9 RESERVED FOR LOCAL USE 20 OUTSIDE LAB" S CHARGES
DYES 01<0 I I
21, OIAmlOSISORNATUPE OF IlUlESSQR ItlJURY (RELATE ITEMS t.2 J OR.4 TO ITEM2~E BYL!tjEj t 2Z MEDICAID RESUBMISSION
CODE I ORIGINAL REF NO
I MLQ -.eervical sprain , L-,_ 2J PRIOR AUTHORIZA TJor~ flUMBER
2~4 C5-C6 disc deg, 'L-.
" A 0 C 0 , F 0 H I J K
FrJ'':TE(SI OF SERVICEro P~lce ,,,. PROCEDURES SERVICES OR SUPPLIES DIAGNOSIS AVS I~PSO RESERVED FOR
" " (E.pI3'n UI'1~t\jJI C'lcumslJI1CIISl CODE S CHARGES OR Fam~~ '''" COB LOCAL USE
MI.I 00 " 1.11.1 00 VY (';...".., s";.." CPT HCPCS MODifiER urms P.,
, 08 21 : 95 3 97010 I HP 1-2 2000
08 21 95 3 97014 I EMS 1-2 2000
208 21 95 3 97035 US 1-2 2200
08 22 95 3 99212 I OV 1-2 20 00
,08 .2295 3 97010 HP 1-2 20 00
08 22 95 3 97014 EMS 1-2 20 00
.08 22 95 3 97530 ! KE 1-2 20 00
08 23 95 3 99212 I~V 1-2 20 00
, 97010 HP 1-2 20 00
,08 23 95 3
08 23 95 3 97014 I~MS 1-2 20. 00
,08 23 : 95 . 3 97530 KE 1-2 20' 00
25 FEDERAL TAX 10, NUMBER 55" EIN 26 PATIEfHSACCOUtlHlQ 27 ACCEPT ASSIGNMEflP 211 TOTAL CHARGE I 29 AMOUNT PAID 30 BALANCE DUE
If 0/" oo~l cl.1 m~. tee tlJc~1
163-58-0267 IX] [] [] YES [J 1<0 I ?":(1(1 I nn I 222 00
JI SIGtIATURE OF PHYSICIAN OR SUPPLIER 32 flAME AND AOORES5 OF FACilITy WHERE SERVICES WERf; 33 PHYSICIANS. SUPPLIER S BILUFlG FlAME. ADDRESS ZIP CODE
INCLUDING DEGREES OR CREDENTrALS RErlOERED III W'er Ihart "ome or o~cel & PtiOOE ,
(Jce"'~thallh'Sl3IementSDr'llhere~l"ISe GREGORY T. REESE, D.C.
~pply '([;'~""" m'd' 'P"",""..', 18 Courtyard OtlIc.a At. I' & 15- SaUn.grova, PA 17870
);).l" ~-fHr Talaphon.: (717) 743-23.\2
AE604347 I GRP'
SrGNECP DATE Plm
.,.
~
~
.,.
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8 eel
MId. br Med'"1CI1 M.a Pr.ss
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FORM HCFA.15OO 112.90)
FORM OWCP.15OO FORM RR6.15OO
n,.,'-'714"
u.. '""'~ 1~..loOt"IIH"~I..I\""I,,*"~,
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, MEDICARE MEDICAID CtW.lPUS CltAP,lP....A Gll0UP fECA OHlER ., lPtSUREO 51 0 NUMBEn IFOli PROGllA", lt~ ITEM IJ
h r__lIlEALTllflLArl OLKLUNO .
rAlrt"~Jllt'/ [J 1I.1.'iI....Jd .1 r-=l rSp.JnJ;)I'S 55,'il r~) IV4 f,'...) -- (55"101/01 n (5SNJ rL eLl 1552005793
2 PATIEtn s t~AME IL~\1 tjJm, F,'\1 'jJ"''' M"<J'u In'I,,\lt 3 1~~I~IIHH tUinT~-PATE SEx " t~tSUI1.EO 5 fjA'.IE ILut Pl"m, hsttlJ'rol M.cJ'" Ir,t.JI)
Roberts Sylvia 06 2 39 ,,' n , :Xl same
5 PATIEfjT 5 ADDRESS l~lo, 51rloll/ C. PATIHH RElATIQflSlllP TO ItlSURED 1 IttSURED 5 ADDRCSS ltla S:,,,,t1
RR5 Box 221A s." IRI S'M'D c',"D 0'"":=1
CITY I :TATE 8 PATIENT STATuS CITY I5TATE (
Selinsgrove Pa S'no1eD M"rr,~ [J ~"
Qlh"U i
ZIP CODE I ';LEPHO)' I'''''''''.... COO" ZIPCOOE I TEL(PHOtlE )tICLUOE AREA COOEI .
17870 E",PIO~l'dO FUI),T<m,O PJ"T'/T'tI,~ (
Sl",dl'" _ S:~eltn' I ,
9 OTHER INSUJlEO S tlAME (l.ll\1 UJrT''' F.tl' fjJm._ Melel!' 'n",all 10 15 PATIENT S COtlOIHOURELAtED to I' INSURED S POLICY GflOUP OR fECA rIU'.lDEA I'
Ii
"
I,
. OTHER IflSURED S POliCY on GROUl> tlu"'OER . EMPLOYMENT' ICURREtH OR PRe....IOuSI . INSURED S DATE OF BIRHl SEX Ii
MI.1 DD vv
DVES Q<]"O "'0 '[]
tl OTHER 1~ISURED 5 DATE OF OIRTH SEX tl ,lUtOACCIOE'.P PLACE <S'.1!.' D EMPLOYER S UAME OR SCHOOL t1AME If
MM DD " '.'11 'II [E YES 0"0 ::
c EMPLOyER 5NA'.IE OR SCHOOL tIAl.'E c OTt-<ER ACCIDE'IP c 1'6URAtICE PLA~1 rlAI,IE OR PROGRAM tlAME I ~
D'ES [xl "0 "
,;
d ".5URAtlCE PL"" tW.lE on PflOOIlAI.l NAME lOd RES(U\I[;O Fon LOCAL USE d IS HlERE "'lOT tiER HEAL TH BENEFIT PLAN' "
:--iYES n ." ")'u 11M" 10 ."d coorp~et~ IhH'l ,) J d I
READ BACK OF fORM BEfORE COMPLETl11Q & slowua THIS fORM. '] HISURED 5 OR AUTHORtZED PERS0'1 S SIG~j"TURE I ,1'J!~C':"
12 PATI[tlT S OR AUTtIORIZED PER50~1 5 SIGfIAtuRE I J"'~"'C'l~ ,,,.. ''''''.n.. 0',1'" me<:lC.11 Of D:"'~II"lc.mJ~~" ....oK..HJ'1 PJ,"'...., D. rrtel c.f t..~,,' II ~3'hlt u"ell"~'9~('d P~,\, .1n Of I',>;;:,." I;;, i
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signature on file 7-5-95 S'G"'Dsionature on file I
SIG/IEO DATE 1
14 D~Te OF CURRHH ~ ILlt4ESS ,F fs!s,rr'CU~110n 15 IF PATIENT HAS HAD SAt.IE OR SII.IILAR ILlMSS '6 0.1. TES PA TIErH U'1.l,BLE TO WaR" I'. CURREt.T OCCUPA TIOP' ,
A~ ~OD g~ Ir~JURY IA:c C......'I OR GI\lE FIRST DATE I.II,! DO VV 1....1 DO " M'" DD VY I.
PREG'.A/IC'1'IU,lPj FROI.I TO
11 tlAME OF REFERRIIIG PtiVSICIAtI OR OTHER SOUllCf; 17J 10 r.UMUEROFREf[RRIIlGPtlYSICIM. 18 HOSPlTAllZATIQrI DAt[S RELA T[O TO CURREtlT SERVICES
t.'1.1 DD VY t,'1,1 DD VY
FRO'" TO
19 RESERV[O FQn LOCAL use ~J OUTSIDE LAB' SCHARGES
i:l "s n"o I I
" DIAGtlOSIS OR rlMUflE OF ILLMSS on I'UURY iRHATE ITEMS I 2] OR" TO ITfI.! :?.&E OY L1NEI ~ 22 I.lEDICAIORESUBMtSSIO'1
CODE I ORIGINAL REF tlO
847-,0_ T
, cervcia1 sprain J L-._
23 PRIOR AUTHORllATIOt4 tlU!.lOER
, 1122-4 _c{-C6 disc d >nen"'J::<! . ; nn 'L-.
" A 0 0 D E , a .. , J K
F,cllnATEiSI OF SERVICETo PI.1e" TfPIJ PROCEDURES SERVICES OR SUPPLIES OIAGliOSIS cAYS "SDI RESERVED FOR ,
01 " IE.pIJ:nUn~S\JJIC'IC\Jm"Jn{"1 CODE SCHAROES OR Fam,'y Eva COO LOCAL USE i
-"1.1 DD VY 1.11.' DD VV So'", I Sf'r. CPT HCPC') MODIFIER UtllTS PIJ" .
08 25 95 3 99212 I OV 1-2 20 00 i
,
, !
08 25 9~ 3 97010 I HP 1-2 20 00 ,
08 25 9' 3 97014 EMS 1-2 20 00 I
, !
08 25 95 3 97530 I Kinetic El 1-2 20.00 ;
08 28 95 3 99212 OV 1-2 20 00
J DB 28--gS ,j ~7U1U HI' l-,l lU UU
08 28 95 3 97014 I EMS 1-2 2000
.
08 28 95 3 97530 IKE 1-2 2000
,08 30 95 3 99212 OV 1-2 2000
08 30 95 3 97010 HP 1-2 20 00
,08 30 95 3 97014 I EMS 1-2 20 00
,,~ fEDERAL TAX I 0 tlUI)Bffl 55'; [It. "6 PATIEtH S ACCOUrH NO 27 ACCEPT ASS1GN",[tIP 28 TaTALCtlARGE 1"9 AMOUfjTPAIO 30 BALANCE DUE
IX: rl (FOf oo~t cn~ Itl! t).)c.) , 2'0 nn' 00
163.58.0267 [J YES .. "0 . 220 00
]1 5IG'4ATURE OF PltYS1CIAtl OR SUPPLlEIl 31 t.AME AND ADDRESS OF FAC'L1TY WI1ERE SERVICES WERE 33 PtiVS'C1AN S. SUPPL'ER 5 BllllUG tlAME. AODRESS, liP COOE
ItjCLU<>lIlQ D[GIlHS OR CFl[DnmALS REtIOEREDtllolr."rlh,\nhomlloroIlCtr) &PHOflE'
IIClt1.ltltl,llth.II.I'.IT>f'nllo<\lhtr'",,'W GREGORY T. REESE, D.C.
~~'''[;::~'~:''''''~~;'t '1) 18 CoUnylrd OffiCII Rt 11 & 15- Sellnlgtove, PA 17870
Telephone: (717) 743-2342
RE604347 IORP'
StmjED' OATE' Pltl'
HEALTH INSURANCE CLAIM FORM
PICA
~
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IAPPRO\lro 0'1' AI.IA COU'.CtL or. ',t[OICAL SERVICE 1I1l1l1
MId, by Ioltdlul Arh p""
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PLEASE PRINT OR TYPE
FORM tlCFA'l~ 112901
fORM QWCP-I500 FORM RRB-I500
'1"11,'110111
U.. .'!~ In.flll'. .,lln ,~""""'IIII' UU&4IM~ Mil,
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HEALTH INSURANCE CLAIM FORM
PICA
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1 MEDICARe MEDICAID Ct1AMPUS Ct~AMPVA GROUP f-lCA OHiER 1.llNSUFlEQSlD NUMUEn Iron PROGR"-M IN ITEM II
jlA/rId""'.') n 1"'tKl"::d"f1 IJ n ISponso" SSNI n I~'" F.'d . tjEAL Hi PLAN 11 (llK lUtlQ
o (SSNorlOi ISSf/1 r-j 1101 CL# 1552005793
2 PATIENT S flAME (Lall N.lme. hll NJ~.. "MOl, lnol,all J f'ATIENT SBIRhi DAlE SEX 4 IflSUnED 5 flAME Ila~l Ndmll. Flrll NJmll. M-dol(J lnol'.II)
n~'" 00 YV
Roberts Sylvia -12 39 IAn '1Xl came
5 PATlEUTS ADDRESSiNo. Slretll 6 PATIE/lT flElATlONSHIP TOlflSURED 7 INSURED S ADDRESS tNo Slr811lt
RRS Bo" 221A SO" [Xl s",,"'C] C"'d[] C1~llfD
CITY I STATE 8 PATIENT StATUS CITY I STATE
Selinsnrove Pa S,,,,,.'[J Mdlf'I;!dO "'-"0
ZIP CODE I T;LEPHO)E jlncturj" Area COde I ZIP CODE I TElrHONE )"CLUDE AREA CODE I
17870 EfT'P'oledO FUllT,mllO PJr1T,mllO
St",denl Sruclerl
9 OTHER INSURED S NAME (LoUt fldme. FII[( fl,lme. f,4.dcl1tlln.t>olIJ 10 ISPATIEfjT SCOtlDITlON RELATED TO 11 ItlSURED 5 POLICY GROUP OR FEeA rlUMBER
laTHER INSURED 5 POliCY OR GROUP NUMBER a Et,IPLOYME/lT' ICURRWT OR PREVIQUSl a ItlSUREDSDATE OF Bmori SEX
"" 00 VV
DVES !XJ"O "0 '0
tI OTHER INSURED S DATE OF BIRTH SEX tI AUTO ACCIDENT' PLACE (St.lhtl tI EMPLOYER 5 flAME OR SCHOOl flAME
MM 00 VV IAn 'n LxiVES 0';0
c EMPLOYER 5 flAME OR SCHOOL flAME c Oft-tER ACCIOUH' c ItlSURAtlCE PLM4 'lAME OR PROGRAM NAI.,IE
DYES IX] ';0
cl INSURAt~CE PLAN NA.ME OR PROGFlAI.l flAME lad RESERVED FOR LOCAL USE lJ IS THERE AtlOTHER HEALTH BENEFIT PLAt"
DVES 0,,0 n)'1U reluln 10 olnd complll~l! ,lem 9 a d
READ BACK OF FORM BEFORE COMPLETINQ & SIGtlLtlO THIS FORM. IJ INSURED S OR AUTHORIZED PERSON S SIGNATURE I.1U!nOfIZII
12 PATlEtH S OR AUTHORIZED PERSON S SIGtlA TUnE 1.1lJlhO':~ l~ r!"J,<' ct .I"', medcal or other ,n!O'rfJ!.on r":l!uar~ pa~ml'nl Or ml'lJ'Colllll'l'1e!.ts 10 It'll uncl"rS'Ol'1ed pn~s",a~ 01 suppl.t'llof
10 prOCltH In" Cld.m I also IlI'QUUl pJ~ml'nt 01 gO~l'll'1menl Ol'n<!! U e tr", IJ rTll'~"'.f or ro ItHI pJ", ",t'J dCCt'pt, aH"J"~MI 5el~'Ct'5 dl!5Wbl'd 0.,10....
below
SIGNED sianature on file DATE 7-5-95 SIOPIED .";nnat.",.,, nn file
u DATEOFCuRREUT. ~ IlUlESSjF'f515~mprom)OR 115 IF PATIErjT HAS HAD SAME OR SIMilAR IlltlESS 16 DATES PATIENT UNABLE TO WORK It~ CURRENT OCCUPA TiOt~
MM DO YY INJURY jAcoclenll OR GIVE FIRST DATE W.I 00 yy FROM MM . 00 YY TO MM 00 YY
~~~ PREGNANCYILMPI
7. rlAME REFER- ltlG PHySICIAN OR OTHER SOURCE T'7d 10 flUl.1BER OF REFERRllle, PHYSICl.l.Il la HOSPITALIZATiml OATES RelATED TO CURRENT SERVICES
MM 00 VV "" 00 Vy
FROM TO
19 RESERVED FOR LOCAL USE 20 OUTSIDE lAB? S CHARGES
DVES 0"0 I I
21 DIAOPmSIS OR r~ATURE OF ILLNESS OR INJURY. (RELATE ITEMS 12 JOR 4 TO ITEM 2.aE BY L1N() ~ 22 MEDICAID RESUBMISSION
CODE I ORlGltlAL REF. NO
1. L8!l2,Q. cervical sprain 3 L--,_ 2J PRIOR AUTHORIZATlOt4 NUMBER
2 I "7??11 "~_"C: ;"'__ e---'-- , L--.
" . C 0 E , G H , J K
FIJ'mATEISIOF SERVICE To PIdCd 1,,. PROCEDURES SERVICES. OR SUPPLIES DIAGNOSIS fllA'S ;SO RESERVED FOR
" " tElplanUn~5u"IC,'cumsldl'1ce51 CODE S CHARGES OR Fam,lt E"G COB LOCAL USE
lAM 00 VV "" 00 VV .r/II m CPT HCPCS MODIFIER UMTS PM'
1 nR . ~() Q~ . ~ lilt> ,_? ,n nn
09 01 95 3 99212 OV 1-2 20 00
209 ' 01 95 3 97010 I HP 1-2 20 00
09 01 95 3 97014 EMS 1-2 20 00
309 01 95 3 97035 I US 1-2 22 00
09 05 95 3 99212 OV 1-2 20 00
,09 05 95 3 97010 I HP 1-2 20 00
109 05 95 3 97014 EMS 1-2 20. 00
,09 05 95 3 97530 I KE 1-2 20 00
9 07 95 3 99212 OV 1-2 2000
,)9 07 95 3 97010 I HP 1-2 20:00
2S FEQE;RAL TAX I 0 NUMBER ssrl EIN 26 PATIEtlY 5 ACCOurlY NO 27 ACCEPT ASSIGNMENT? 28 TOTAL CHARGE \29 AMOUNT PAID 30 BALANCE CUE
lFofgovl cl.1.m~ St'etlaCk)
163-58-0267 IX] [I [l YES 0 "0 s 222 00 s 00 s 222 00
31 SllJNATURE OF PHYSICIAtl OR SUPPLIER ' J2 NAME MIO ADDRESS OF FACILITY WHERE SERVICES WERE 3J PHYSICIAN S. SUrPLIER S BILLING NAME. ADDRESS ZIP CODE
ItlCLUDtfjG DEGREES OR CREDENTIALS , FlErlQERED (II OHlelltlJn home Of or!.e.) & PHONE.
II cer1Jly lhalltle ,Idlemenl' on lntt fherSIt GREGORY T. REESE, D.C.
~"'~..m""~"'m""'1 18 Courtyard Offices At. 11 & 15- Sellnsgrovl, PA 17870
~. 'l-tHr Telephone: (717)743-2342
RE604347 I GAP'
SIGN 1 DATE PINe
~
~
(APPROVED BY AMA CCUtlCIL ON MEDICAL SERVICE 8 eel
1.I1d. br Mtdlul Arb Pr,..
C"I04-""I<<JO.UUI7t
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FORM HCFA.l500 112.901
FORM OWCP-l500 FORM RRB.I5OC
ll').lU-,l't4l1
UN ..t~ f~..IoOt 11414' ~_"'I" U4144IMW..",
M'J'nO'wEDO'.'[l 0)).'1 OCed
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HEALTH INSURANCE CLAIM FORM
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, MEDICARE '.'EOICA 0 CIlAI,ll'U5 Ctl.Al,API/A t11l0UP HeA OhiER ,. INSUHEDSID flUI,lU[.R \fOfi PIIOGHAM l~ll1[M II
11 jMfldCJ'" I, ill"'t(h:,I:: 'IL] /Sj:.:nlv' I SSfJl [ 'lEAlTIlf'lAtI[_]OIKlutIGn CL# 1552005793
] (VA f,:" '!_.o~SSt~: 1(" - IS91! rlOI
2 PATIHH S fIA'.IE llnl tfA-' f,'\1 f4,1"''' f.l(l\1" 1(1'1,.111 J "ATllrlt 5 UIfW. DAlE Sf' 4 It.SUREOS'.AMEll,HI'~.m,, f"l!tlJmll,'.l.dClllnU'\
Roberts Sv1via 0'6 102 '39 " II f xl same
S PATIHH S ADDRESS I';:! S""'fll 6 PAtlnlT RHATlm.51iIP TO I'.SUREO 7 IflSURED S ADDRESS INo SI'f'1f11
RR5 box 221A S",II LX] sPOu~"n CIl,ld~] 01Ile,C]
C1TV I STATE 8 PATI[tH STATUS CITY ISTATE
Selinsgrove Pa r-] f.lJII"d[] OI"eIO
s./'IQIIL
ZIPCQOE -I T(LEPll0)[ ,,,,,,"". ...,. C""., ZIP CODE -I-TEl,PHOtlE relUOE AREACOOEI
17870 Emp'o,t1D FU'IT"T.II[J p"'T,m.[] j
_ S'OIdllnl _J SI"c1"~1 ,
If OTHER ltlSURED S rlAI.lEl,asl tlal"le. F,,.l tlJm" MId<J','n'lall 10 IS PATIEtH S COI.DITlOtI RElATED TO 'I INSUREDS POLICY GROUPOR FECA 'lUMBER ,
.. OTHER INSUREO S POliCY OR GROUP '.UMBER a EMPLQYt.lEtH' ICURREtH OR PREVIOUSt a ItlSUREDSO.\tEOF BIATH SEX
I.lM 00 "
[]m @NO MD 'D
b OTHER l~lSU;;EDS DATE C; 81RTH SE' b AUTOACCIDEtlP PLACE (Sl.\~el b EMPLOYER S PlAME OR SCHOOl 'lAME
Mt.l 00 " GJm [=NO
"il ' r-1
c EMPLOYER S '.A~.'E OR S.:i-iOQl 'lAME c OTH[R AeCIOEtlll C lHSURAtICE PlAt' flAME OR PROGRAM 'lAME
iJYES lv:"O
" ItlSURAIICE PLAP, t,AI.'E CoR PI1OGRA'.' t.AME ICd RESERVED FOR lOCAL USE " IS THERE "'IOTHER tlEAlTH B[tIEFIT PLAP4'
[J YES CillO It)'... 1..IOIrnIOa..jcO"":)'~Ie'lem3dd
READ BACK OF FORM BEFORE COlo'PLETlNG & SIQN1tlG THIS FORM. IJ INSUJ1ED 5 OR AUTHORIZEO PERSOtl S SIG~..'TURE I aul"o',Zt
12 PATIE'iT S CA AUTi-iORIIEO PERSall 5 SIGtIATURE t J~l~-:":" 1~11 'l.':",lS/J cl J.., l'l"l.'d',11 Of O'~~I ,(1';'I"1J!.cn (1~l!S\.Vy p,Jy,"\!"1 01 rrfdc.\1 tw.nt!r,l~ 10 Itllll.."dv1s'O"eo .,"I;\.(.ldn 01 S"PP'II' 10'
r~ c:r:ctS\ l'l \ C~.\"!' I J'.':; .~~UI p.lym~nl or (p't.pm""l bo!r'lIl_t, l!,l~e' 10 m,.e,r 0' I" lilt! pJ't, 10' 0 JCCI"~'S J~\~"/T',,,,"I \t"'~'C"S dots.:! o..'<f te'o",
~ION
SIGtIED sianature on file DATE 7-5-95 SIGttED sinnature on file',
14 DATE OF CUARD.T ~ '~UIE 5S lr"~l s,"'p::ml OR 15 lr PATlEtH HAS HAD SA'.IE OR Slr.nAR ILU.ESS 16 OATES PATIErn UllA6lE TO ViORI': IflCURREfjT OCCUPATlOll
MI,' 00 yy 1'lJURY lAcc'dl!n!1 OR GWE FIRST DATE "".1 00 " W,l 00 " '.1'.1 00 YV
ne:. ~O--9o PREG'jAtlCYIW?j FROM TO
17 tlA',tE OF REFEflR,IIG PI" f51GIMI OR OTHER SOURCE l1J I 0 tfUt.'El~R OF REFERRI~;G flHYSICIA~1 111 HOSPITALIZATION OATES RELATED TOCUPREtjT SER"IICES
MI.l 00 " MM 00 "
FROI.' TO
l':l RESER'.ED FOR leCAl L.SE 20 OUTSIDE LAB' S CHARGES
DYES DNa I I
2'- OIAGrlOSI$On tlATURE or IlllIESSOR IfUURY [RELATE ITEMS I 2 30R4 TO ITEM 2JE BY llt,EI t 22 MEDICAID RESU8t,ltSSIOtl
CODE I ORIGINAL REF tlO
I l84'7..O-cervica1 sprain 3L-,_ 23 PRIOR AUTHORIZATION NUMElEA
2 1l22-4--C5-C6 di ",. d""oner"H nn , L-.
" . . C 0 E , G H , J K
Frc9:TEISIOF SER'{:CETo Platt! T,,. PROCEDURES SERVICES. OR SUPPLIES DIAGtIOSls IDAYS PsO RESERVED FOR
" 5 ~~,... IE.pIJ,n Un~SuJI C'rculT'SlJnceSl CODE S CHARGES OR Fam~~ EMG COO LOCAL USE
"" DO " 1.1I.1 00 " ~"~-cf CPT HCPCS ..tOQIFIER UNITS Plan
,09 07 95 3 Q7014 I EMS 1-2 20 00
09 07 95 3 97530 I KE 1-2 20 00
209 13 95 3 99212 OV 1-2 20 00
09 13 95 3 97010 HP 1-2 20 00
309 13 95 3 97014 I E~lS 1-2 20 00 I
09 13 95 3 97530 KE 1-2 20 00
,09 15 95 3 99212 I OV 1-2 ?n nn
09 15 95 3 97010 I HP 1-2 20 00
,09 15 95 3 Q7nl'; EMS 1_? ?n nn
09 15 95 3 97530 I KE 1-2 20 00 I
, ,
25 FEDERAL TAX I 0 'lu'..eER SSlj EIIl 26 PA TlUlT S ACCOUtlT tlO 2;' ACCEPT ASSIGNMENP 28 TOTAL CHARGE 12 9 AMOUNT PAID 30 BALANCE DUE ,
IfOI90'o1Cn~.seeb.1C"'1 1
163.58.0267 !Xl [] o "S _ NO S ~n" "" S fin S ~"''\ "" i
31 SIGtlATURE OF PHYS1CI"1l OR SUPPLIER 32 NAME ArlO ADDRESS OF FACilITY W~ERE SERVICES WERE J3 P~IYSICIAN S. SUPPLIER S BILLING tlAME. ADDRESS. ZIP CODE I
INCLUDltlQ DEGREES OR CREDENTIALS AEflOERED II! Ollll!! 111M Ilomlf or 011 eel &PtiOflE.
[tCII,MI L"IJIll"'''.~t!'T'e''lsc''I'''eut~''tw GREGORY T. REESE, D.C.
~':rc:~=~:""'";~~f .~, 18 Counyard Offices RI. 11 & 15- Sellnsgrove. PA 17870 ,
Telephone: (717) 743.2342
RE604347 I GRP,
SIGNED DATE PI'" ,
~
~
.,.
(APPROVED BY AMA COUtIClL Otl MEDICAL SERVICE 8 BS)
MId. by Mtdlul Alh PIt..
C..lolll," IIO)UI1II1
PLEASE PRINT OR TYPE
FORM HCFA,I'SOO (12.90)
FORM OWCP.l!lOO FORM RRB"l!lOO
fI1ot11-f1"M:J
\JM .'1~ l~...IoPf 1111&\ '..........,) 00 fill" \MhuO
APPIlOVED OMU OllJ8 COC8
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HEALTH INSURANCE CLAIM FORM
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/M,f1C':IIfH) jMIM,':.Jd ..' ,S.,.,1sJlsSSN} fVAF,itt.' 1 155/'JO"~ ,S5NI [1 liD} eLl 1552005793
2 PATIENT SNAME llut Nd"". F"Sl NJmtl. M,ddl" In,hal) J PATIEtH S U1f1rH DATE n SEX .. ltlSUHEO 5 NAME (lnl NJIT1" f,',t'lJm. M.dJ',I"'MII
1.1',1 00 vv
Roberts Svlvia 06 12 39 M 'Xl same
5 PATIENTSADDRESSI~jO.Str"lI 6 PATIEtlT RElATIONSHIP TO IflSURED 7 ItjSURED 5 ADDRESS ltl,) SlI.,11
RR5 Box 221A 5'" ex spo",o c"~D OlhlllO
CITY I STATE 8 PATIENT STATUS CITY I STATE i
Selinsarove Pa S,ooteD M,trr,+ldO OIt1etO .
liP CODE I ',""'O)E .'""," XI<' Cod., ZIP CODE I TElrllOt'E )flCLUDE AREA CODEI .
17870 ErrllIO}edO Fuu.TlmllO part,T,m"o [
_. Student Slud'lll (
9 OTHER l~lSURED S NAME ILa~t flam,. F",t N.lme M-dO',lM,al1 10 ISPATIEtHSCONDlTlOt~RElATEDTO II 1~ISURED S POlICY GFlOUP OR reCA NUMBER !
,
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MI.l DO VV !
DVES []NO "0 '=:1
l) OTHER 1~ISUREDS DATE OF BIRTH SEX b AUTO ACCIDEUP PLACE (StJhJl l) EMPLOVER 5 flAME OR SCtiOOL fjAME !
MM DO VV 'n
Mil IX] YES DNO
c EMPLOYER 5 flA',IE OR SCllOOl NM,lE C OTt1ER ACCIOENP c INSURANCE PLAN NAME OR PROGRAM t/AME t
DVES 6l]NO i
i
d If.SURANCE PLAtl tjAME OR PROGRAM NM.IE 10tl RF.SCR'JEO FOR LOCAL USE d IS THERE ANOTHER ~IEAL TH BEf~EFIT PLAfj1 I
nYES DNO It)'.. '"ll.l"'1 10 and COfT'pl...llt ,I,,'" 9.ad
READ BACK Of fORM BEFORE COMPlETlflG & SIGNINO nus fORM. IJ It/SUR ED 5 OR AuTHORIZED PERSall S SIGNATURE I a~:' :"18 ,
,
12 PATiEflT S OR AUTHORIZED PERSCtl S SIGNATURE I JUlhOll1tllN 1&I~JS~ clal'ly med.c.-II Of oTr...llnlJrmat'OIl npCUUJf/ p.l~mN'I 01 nHIU,C,11 bur>l)f,a t~ ln8 urw:h'f~'9lled phyS.C1.lI'I 0' ~t.:tle' I,,'
to ploc..." th,' C\Jm I alw 'l'Qt.UI poIl...,r.1 ot go,emm,.,t b.c>"fl,!> tl,lhtllO m ,.1>' 01 10 Ii'll! p.1l1y ",t.o o1:CtlpU aU"1nm"nt \11"""t-',dll~r,bt.>db>'IQ...
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SIOtlED sionature onfile DATE 7-5-95 SIGtjED sianature on file
14 DATE OF CURREtH ~ IlUlESSIF,'''s,mpt::rn)OR 15 If PATIEtn liAS HAD SAI.'E OFl SII,IILAA ILLNESS Iii OATES PATlEtH utlADLE TOW.....,;:< III CUilREtH OCCUPATIO' I J
M" DO ;V~ It'JUAY IAwoe.,,) OR GIVE FIRST DATE MM DO VV MI.l DO VY MI.l DO YY
06 ~o CJ PREGPlA,'jCYjLMPj fROM TO
17 NAME OF REFERRltlG PHYSICIAtI OR OTHER SOuRCE 17.1 10 tlUP.lOER OF REFERRltlG PHYSICIAN 18 HQSPITAUZATlOtl OATES RELATED 10 CURRENT SERVICES
MI.l DO VV W.I DO yy
fROM TO
19 RESER'JED FOR LOCAL USE 20 OUTSIDE LAD1 S CHARGES
DVES DNO I I
21 DIAGtmStS OR tlATURE OF ILLNESS OR IljJUFlY [RELATE HEMS 1 2.3 OR 4 TO ITEt.l2.(E BY lINEl ~ 22 MEDICAID RESUBMISSIOU
CODE I ORlGINAL REf ~lO
I LBll.Q.cervical sprain 3 L---._ 23 PRIOR AUTtlOAIZATION rlUM8ER
2 L722. 4-C5-C6 disc d >aeneration . L---.
" X B C 0 E F Q H I J K
flODr:TEtS)OF SERV1CETo Pl.1C8 ,,,. PROCEDURES. SERVICES, OR SUPPLIES DIAGPlOSIS r[fAYS IEPSo' RESEmED fOR I
Q~"'l fJ~'h IE.pl.1ln UI'l~SU;,1t C.'cumstJncesl CODE S CHARGES on Famll1 EMQ COB LOCAL USE i
M" DO VV MI.I DO VV CPT HCPCS MODIFIER UtllTS Po,
I OCJ 1A o~ < OO?,? I nv 1-' ?n nn j
I
09 18 95 3 97010 HP 1-2 2000 i
09 18 95 3 97014 I EMS 1-2 2000 I
!
09 18 95 3 97530 I KE 1-2 20 00 ;
hQ ?Cl Q~ ? OO?,? nv. ,_? ?n nn ,
p9 20 95 3 97~~0 HP 1-2 20 00 I
b9 20 95 3 970 4 I EMS 1-2 ?O 00
9 20 95 3 97530 KE 1-2 20 00
, 9 22 95 3 99~V 1-2 20 00
,,, ;a y:, 3 97 tp 1-2 2U,00
)9 22 ;95 3 97014 I EMS 1-2 20.00
25 FEDERA,L TAX I 0 flUI~BEA SS~1 EIU 26 PA TlEUT S ACCOUNT NO 27 ACCEPT ASS1GNMENP 28 TOTAL CHARGE \29 AMOUNT PAID 30 BALMlCE DuE
1 jFOlgO~ln:l.'eeb.1clo.) 220 00 , 00 220 00
163.56-0267 000 o YES NO S ,
31 SIGNATURE OF PHVSICIAN OR SUPPLIER I 32 t4AME AND ADDRESS OF FACILITY WHERE SER'JlCES WERE 33 PHYSICIA~j 5, SUPPLIERS BIlliNG flAME. ADDRESS, liP CODE
ItlCLUDING DEGREES OR CAEOErlTlALS RENDERED III othllllh.tn tlome 01 ollJ(ltl & PHONE'
IIClrtlly tMlttle \tatem~ll!sonthete~ers" GREGORY T. REESE, D.C.
applyIOltl'\b<Il"'fld",m~C:Il' P,1I11h'f~oll
s~L ~ o!;E'f-~~ 18 Courtyard Officea At 11 & 15 - Sann.grove, PA 17870
, Telaphone: (717) 743-2342
AE604347 I
PI~I' GRp,
6
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IAPPROVED 0'1' AMA COUfjCIL 0" ',IEQICAL SERVICE 88s)
MId, b7 MtdiUI Alt. PrtU
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FORM HCFA,I!lOO (12,90)
FORM OWCP.I500 FORM RRD.l500
U,.Il-'1Wll
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HEALTH INSURANCE CLAIM FORM
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1 MEDIC~RE MEDICAID CHAMPU5 CIIA"'''VA l.:.1I0UP HCA OTHER 1.1 Itj~UIl[O 51 0 ~jUI,lD[n IFOR PRQGltAt.lltl 11[1,4 Ij
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2 PAIlEttI 5 NAME Il.lSI N,1m. F.rSl N,1fT'a "',(:<:'a 11101..111 J l'ATlltll ~lllllhlOATL SE' .. ItlSURED S ttAME ll.ul tlJmll, f,r" flJmtt M.dCl'lIln,l-,111
"".1 1~1 39
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5 PATIENT 5 ~DDRESS I'lo. Slr""1 Ii flATI[tH FlElATIOtlStUl' TOt'l$UIl(O 1 lllSURED 5 AODR[$5 ltlo. Sht/all ,
,
RR5 Box 221A s""[Xl ';"'""0 C,,<[ 1 "'""[::J I
CITY I STATE 8 PATlEtH !.iTATUS CITY I STATE
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ZIP CODE I '("PHOjE ,I",",. '<0' C",., llPCOOE I TElrHONE ,'lCLUDE AREA CODEI i
17870 Emplc,t>drJ FU'l TImlin Pd1Tlnlll[l
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9 OTHER lflSURED S NAPJE IL.u1 tlJm. F,ISI'l.lm. t,I,OJ'.IOll'.Ilj 10 IS PATlUH S COpmlTION flELATEO TO 11 INSURED S POliCY GROUP OR FECA NUM8ER I
,
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. OTHER ItlSUREO S POlICY OR GROUP ,mp.18EA . E"'PlOY"'Et~P lCURREfH OR PREVIOUSl .. Itl$UREOSDATE OF D1RTH SEx
MM DO VV
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MM DO vv Mn 'n OSv'S Ct'O
C EMPLOYER 5 NAME OR SOiOOl NAME c OTHER ACCIDHlP c ltlSURMlCE PlAtI NAME OR PROGRAM flAME I
OVES ~:"O I
II Itl$URAtlCE PLAN flAME on PROGRAM flAME lOd RESERV[D FOR LOCAL USE II IS THERE AtlOTHER HEAL TH BEtlHIT PLA"" ,
IJYES rJ"O "r" IIl'urI'110,tr'ldco""p'~!lIIIt!"l9a d i
READ BACK OF FORM BEFORE COMPLETlUO & SIGtllflO THIS FOAM. I] l'ISUflED 5 OR AUTHORIZED PERSOPI S SIQflATURE I ,)u!~O"''l
12 PATlEPH S OR AUTHORIZED PEASOtl S SIQflATURE I oluIhCIIZ@ lhe "1~fIJse ot .I'll medcal 01 otllol! IIIIJ'r".I:On ~.'!CIl,ur1 p,lll"l:nlOlnlt'dc.ll!l1''1Ut.!,'olhllUndcI''Q'1(!dph""IJr1015UPP:'O,101
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siqnature file 7-5-95 signature onfile ,
SIGIlED on DATE SIGPj[Q ,
14 DATE OF CuRRHH ~ tLLMSS IF.r" s,""ptom/ OR 15 IF PATIErH HAS HAD SAME Or! S:I"I,\..AR IllNESS 1(, OATES PATI[tlT UPlABlE TO WORK IflCURRENT OCCUPATION i
~~ ~\\ V~~ l~UURY (ACCK!,'ntJ OR GIVE FIRST DATE '.ll.l DO n "'M 00 YY M'" 00 YY
PR[GN,uICYILMPI FRO'.' TO ,
17 '~AME OF REFERRltlQ PHYSIClAtl OR OTHER SOUlteE 17.t 10 tmP.lBEROFAEFERnlrjGPtiYSICIMl 18 HOSPlTAUZATIOPI DATES RELATED TO CURREflT SERVICES ,
'-'1.1 DO VV MM DO VV
FROM TO
HI RESERVED FOR LOCAL USE 20 OUTSIDE LAD' S CHARGES
DVES 0"0 I I ,
21 DIAGPmSIS OR tl"TURE OF ILLNESS OR INJURY IRElATE ITEMS 1.2,]OR 4 TO lTEP.l2~E BY LItlE! ~ 22 MEDICAID RESUaMISSIQtl ,
CODE I ORIGINAL REF_ NO ,
1 L847-, 0- cervical sprain ' L-,_ ,
2J PRIOR~urHORllATIOtl tlUP.IDEA
2 I 777. A ""-('Ii <1; ,,- .;I'"\n of L-.
" A C 0 E F G H I J K
Flo~ATE(SIOF SERVICE To PI.tce T,.. PROCEDURES SERVICES OR SUPPLIES DIAGtlOSIS DAYS ",Ul RESERVED FOR I
" " IE.plJ.,nUn~sualC"CulTl\tJ.lICe'l CODE S CHARGES OR Fam.11 EMG COB LOCAL UZE
MM DO VV MIA DO VV ......OCt ,,~, CPT HCPCS MODIFIER utilTS Po,
09 22 95 3 97530 I KE 1-2 20 00 I
,
09 25 95 3 99212 IOV 1-2 20 00
209 25 95 3 97010 HP 1-2 2000
109 25 95 3 97014 EMS 1-2 20 00
309 25 9 3 97530 IKE 1-2 20 00
09 27 95 3 99212 10V 1-2 20 00
,09 27 95 3 97010 HP 1-2 20 00 ,
09 27 95 3 97014 I EMS 1-2 20 00
,09 27 95 3 97530 KE 1-2 2000
09 29 95 3 99212 OV 1-2 20.00
,09 29 95 3 9701~ 1-2 20 00
25 FEDERAL TAX I 0 tlUP.ADER SS" Elt! 26 PATlENTSACCOUNT tlO 21 ACCEPT ASSIGWAWl' 28 TQTALCHARGE I Z9 AMOUNT PAID 30 BALA'~CE DUE
iXlCI . (FOI Qo.l (lJrr.~ seo bJ(Io,J 22000
163-58-0267 [J YES 0 "0 . 220 00 . 00 .
31 SIGPlATURE OF PHYSICIAN OR SUPPLIER ]2 tlAIIE AtlO ADDRESS OF FACILITY WHERE SERVICES WERE J] PHYSICIAN S. SUPPLIER 5 (lllLlNG NA"'E. ADDRESS. ZIP CQOE
INCLUDING DEGREES OR CREDWTIALS R[fleERED III other IhJn hOme 01 o~toCel & PtiOtlE'
(IClIf'lllylho1llh."ollllml!nlsonlhere,,'ne GREGORY T. REESE, D.C.
'PJlI1!OlhISt/ltl.1nd.romoldeap.lItlhllreoll
~L~ ~;,r7V 18 Courtyard OffiCII At. l' & 15- Sellnsgrove, PA 17670
Telephone: (717)743-2342
RE604347 IORP'
Plfl,
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IAPPROVED (lY AMA COUNCil ON MEDICAL SERVICE 8 881
MId. by Mf'diUl Arts Pm.
e,'loll"" 110:>1112111
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fDRMttCFAI~ 11290J
FORM OWCP.l~ FORM RRB-l!lOO
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AP"RO~ED 0"'6 c..m coed
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n I"'fd<.lf.'j n 14lfHtc.Jd'j n ISP.Jns~.SSN) r'-l {\'AF.!e'~ IS5NcIIDI [J (S5NJ ~ ~LLJ.Wno~793
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1.11.1 DO YV
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S PATlWTSADDAESSOlO.S1rull 6 PATIErn RELATIONSHIP TOltiSUREO 7 INSURED S ADOIIESS (No. Slll"'l
RR'i Rnx "1 "- Sell [;] SpouseD Ch'd~ OlhllfD
CITY I STA.TE 8 PATIWT STATUS CITY I STATE
C:p];n"g"nHo p~ 5."""0 "'.I"'f'dO Q!tltnD
ZIP CODE TElEPHONE l'nel.Jd' Aru COdol liP CODE TElEPHONE ,INCtUDE AREA COOt
17870 ( ) EI'I"P':IltdO Full.TlIT>t1D polr1T'm"D ( )
_ Studenl Stullpnl._
S OTHER IUSUREO S NAME ILast fl,lme, f"" 'lJm.. "',dd'eIM,)I) 10 IS PATIENT S CONDIfIQfI RELATED TO 11 INSUREO S POlICY QFlOUPOR FECA ~IUt.1BER
III OTHER It.SURED S POlICY OR GROUP 'IUtJBER a EP.lPlOVP.lEtH' (CURFlEtlT OR PREVIOUS, ,) INSURED 5 DATE Of BIRTH SE' I
MtJ DO YV '.'0 FQ
r:J YES Lf:lNO I
b OTHER INSURED S DATE OF BIFlTH SE' b AUTO ACelDEtll' PLACElSIJtttl b E"'PLOHR S m.I.4E OR SCtlOOt !lAME
M~.l DO yy Mn Fn ~Y[S iJNO
c E''!PLovER 5 tlAME OR SCHOOl P.AME C OTHER ACeIDEtIT' c IUSUAAPICE PtAPl NM,IE OR PROGR"'.' .....ME !
Om r;:J"0
d IfISURA~lCE PLAN PlAME OR PROGRAM rjAME led nESERVEO FOR LOCAL USE II IS THERE AtlQTHER tiEAtTH BEPjEFlT PlAtj"l I
nYES 0"0 "r" r",'\o'" 10.~"corrp,,'.'It''''' 9 .I e I
,
READ BACK Of FOAM BEFORE COMPL.ETING .. SIGPllPlG THIS FOAM. lJ IIl5URED S OR AU1tionIZED PERSOfl 5 SlmlATUrlE I d~""O' u
12 PATIEtH S OR AUHionlZED PER50fl S SIGtlATURE 1...,/~o":1f ltle 1f''''J'''' C! J~~ r-edColI c' OU'lI' ,~'';frTlJ:",>'II'It'Ce~~lrl pJ/'1"Cr., C' "'('d'C,1' toIf'I!'~S to IT'll \orl:l...s ;~~ C~" C'J~ 0' S~t;l' ",' ';' ,
l:) pi'O<:",SllhS CIJ,m I a'so rt'Qu,,'1 pJ)menl ot lJO.l!mmt'f'l1 bo!ntl'ls Uhlir 10 mtSlr! or II) l~lt P,l"I"t,o a~CfplS d''''l''merl sur<,<es (hncl,ood bvlO....
".-
SIGNED "" DATE - - ~- SIGtjED -- "", I
1.& OATEOFCURREPH ~ ItlNESSIF,r"S~mpl::m)OR 15 IF PATIEtH 14AS HAD SAME OFl SII,\~LAR ILUlESS 16 !JATES PATlEtlT !Jf1ADlE TO 'NORt< l~l CURRHIT OCCUPATIO'.
tJl,I 00"tV INJURV lAccrd""1l OR GIVE FIRST D4.TE '-".1 DO yy Mt.l 00 '1'1 1,11.1 00 yy !
06--3" nc::. PREQ~lAfICY(LMPI FROM TO
17 rlAME OF REfERFlIIIG PHYSICIA" on OTHER SOURCE 17.1 10 flU'.'BEROF REFERFW,G PHVSICIMj 18 HOSPITAlIZATlOtl OATES RELATED TO CURREtlT SERVICES
MI.l DO yy "1'.1 DO yy
FROM TO
19 RESERVED FOR LOCAL USE 20 OUTSIDE LAB' , OU,RGES
Om DNa I I
" DIAmlDSIS OR flATURE OF ILltiESS OR l~~JUR'!' IRELATE ITEI.'S 1.2.J OR.& TO ITEt.l2.&E BV LltjEJ t 22 t.lEDICAID RESUBMISSION
CODE I ORIGINAL REF fiO
t 84'7-0-eervica1 sprain ,L-,_ 23 PRIOR AUTHORllATfOfl PlUMBER
2 n~~ A "'~-f'!LdisC-de en 'L-.
" A 0 C 0 E F G " I J ,
fr~ATEISl OF SERVICETa Place T,,. PROCEDURES SERVICES, OR SUPPLIES DIMtlOSIS oA!S PSoI RESERVED FOOl
,I " (E.pl,)." Un~$l,Ial C'Ic\)m~IJ"'tUJ CODE SCHARGES OR hrT"1r Et.lG COO LOCAL USE
"'~ ..I DO yy t.lt.l 00 yy P.....,. S".....' CPT HCPCS MODIFIER UMTS Plan
, 09 ' 29 95 3 97014 I EMS 1-2 20 00
09 <9 95 3 97530 ItE 1-2 2000 I
2 10 02 95 3 99212 OV 1-2 2000
--
10 02 95 3 97010 I HP 1-2 20 00
, n no Q~ , n7!l14 ~u~ L~ ~n n~
10 02 95 ~3 ~~;~~ I ~~ 1-2 ~g gg
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10 04 95 3 97010 I HP 1-2 20 00
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10 ,04 95 3 97530 I KE 1-2 20 00
6
2~ FEDERAL TAX I 0 ~lU'''BER SS~l EI" : 26 PATIEtlT S ACeOUIlT NO 27 ACCEPT ASSKitlM(NP 28 TOTAL CHARGE 129 AMOUNT PAID 30 BALAflCE DUE I
oOlgovtn~.U.b')c"l
163.58.0267 IXJn VES .,.0 S ?nn 'nn I nn I ono 00 ,
,
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JI. SIGNATURE OF PHYSiCIAN OR SUPPLIER ! 32 flAME AtiD ADDRESS OF FACILITV WtiERE SERVICES WERE 3) PHYSICIANS. SUPPLIER S BILLING NAME. ADDRESS. ZIP CODE I
INCLUDtNG DEGREES OR CREDE~mALS RENDERED (11 olhl!ll~dll tlome 0' 0"<'1 & PHONE.
l'cel1,fflhall"'etl"I~.nISOlltt1l1rllY.lSe GREGORY T. REESE, D.C. ;
apply loth'tb,ilaodar.m.ade.a p.lr1lhereol I \
, 18 Courtyarll 0111,.. AI, 11 & 15 - Sello.grov.. PA 17870
~ ~ I-'f.<f~ r.lephon.: (717)743-2342
AE804347 IORP'
,
SIGNED DATE , P11l'
~
"
-.
(APPROVED BY AMA COU~lCIL0" MEDICAL SERVICE 8 68)
MId. b7 Mtdlul Art. p,...
C,JIlI"'''" ItoO-UlllIt
PLEASE PRINT OR TYPE
FORM HCFA.l500 112.901
fORM OWCP.I500 FOR'" RRB-l'!lOO
'l~ll-'~:J
U.. .,!ft (~,H:'" 'I&IU 11"",""+4'01 'Itl~ '..' Iffll
APPRovED OM6 09)8 ~C8
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HEALTH INSURANCE CLAIM FORM
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I, "'EDICAnE "'EOICAIO CHA"'PUS CHAMPYA GIIOUP FlCA OHlER I' Itl5uAEO 5 I U fjUl,H~[fl l~onPIl()GIlAl.llt.lTLI.l II
) n I 'n' n HEALTH PLAt' aLK LutlG 1552005793
11"'Id""'II) ,A.ltid~J<I.1 ISponSO(fSSNI n /VAF,III./ ISSNOIIO! [] tSS~'1 ~l [':'t, CL#
2 PAT:C;tH S'lAME iLut N,Jme, fltsl "3mlt, lol'OIl',lMI,JI) 3 PATIErH SOlfHtlQA.TE SE' J ItISUR[O 5 NAME tLut "..me hSl Name. "'odd:"''',l-a',
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!l PATIEtH'S ADDRESS (tla . Slr,,') 6 PAlIEtH RELATlOIlSHtP TO IflSUREO 7 ItlSUREDSAODRESS\tIO Slr""'H
RR5 221A SallG SpouuD CtI'kJ~ ,"
Box O"~.r ...._1
CITY ISTATE 8 PAllENT STATUS CITV ISTATE
S,,,,'.O M,moed 0 "''''0 ;
Selinsnrove Pa I
ZIPCOOE I TrEPtlO;E tlncJude Ale" COd'} ZIP CODE I TElrHOt~E )t~CLUDE A"EA COOEl
17870 EmPlo~"dD FuIlTlm'O p.artT.m,~ I
Stud.!"t _ SluC:~~1 L J ,
g OTHER INSURED 5 NAP.lE (LUl ",mo. forst Name. l.I'Odle In<!I.1I) 10 IS PATIENT SCONOITIOtl RELATED TO 11 ItlSuRED S POliCY GROUP OR FECA NUMBER ,
;
I OTHER It~SURED S POliCY OR GROUP NUMBER a EMPLOVMENT' (CURRENT OR PREVIOUS, ,) IflSUREOS DATE OF BIRTH SEX ,
I.IM 00 "
O'ES 00"0 "0 '0
b OTHER INSURED S DATE OF BIRtH SEX b AUTO ACCIDEtlf1 PLACE 15'<1'4) o ft,lPLovER S NAME OR SCHOOL NAME
"Y 00 " "n 'n IjJm .0"0
c: Et.lPLOYEn S NAME OR SCHOOl 'lA'-'E c: OTHER ACClOftjP c ItlSURAIlCE PLAN NAME OR PROGRAM NAME
DYES {~tjO
d ItlSuRAtlCE PLMl 'l.Al.tE OR PPOGRAM flA'-'E 10<1 RESERVED FOR LOCAL USE d IS THERE ANOTHER HEALTH BENEFIT PLAN"
DYES [1"0 "r..lftvlnI0.1rodcorrp:elflle.,,9.ac:
READ BACK Of fORM BEFORE COMPLETING & SIONltlO THIS FORM. I] 1I15UREO S OR AUTHORIZED PERSON S SIG~.ATURE l.a:.n':l"
12 PATIENT 5 OR AUTHORIZED PERSOU 5 SIGtIATURE I al,!l'\(lflzethlt I\'Ie.l~e 01.1"1 mt'dc.1l 0/" Olhell"r,JflTl.lIOr rt"ceB.1.f J:.1t"'ent ct r't,<!,C.11 bo!~~'.!S 10 II'It vr'ldil\lJf1tJd phys,,'.!n 0' '~P~ e'lc'
ta p10ceu rh" clJ<m I also reqtJtll pJ,m"", ar go.t.r.men. blIne!U t.mer 10 /TIy\elt Of 10 l"Ie PJrtl""'hO J:C:'-'J:!l ,U~ 'i~'T'..~r se~.,c"d...s.:rt~bo!':....
telaII'
SIG"ED sianature an file DATE 7-5-95 SI::;'rlEO signature on file
U DATE OF CURREt4T ~ IlUlES51F..sl \ymptcm) OR 15 IF PATlEfH tlAS HAD SAME OR Slr,"LAR !LU.:5S 1S DAtES PAT,ftH UtlABLE TO WORK Itl CURRWT OCCUPATIO~j
MM 00 " l~lJURV fAccJdt"f11l OR G1YE FIRST D'AtE I,tl.l 00 " 1.1'.1 DO VY MY 00 YV
6 30 95 PREG'l,A,tlCYILMPI FRO',I TO
17 NAME OF REFERAltlQ PtWSICIA~1 OR otHER SOURCE 17.:1 I D 'lUMBER OF REFERRltlG PHYS'CI,l.', 13 HOSPITAlIlATIOt. OATES RelATED TO CUARE'" SEA'.ICES
Jon,I 00 " MM 00 "
FROI,I TO
19 RESERVED FOR LOCAL USE 2J OuTSIDE LAB' S CHARGES
DYES 0"0 I I
21 DIAGtlOSfS OR NATURE OF ILUlESS OR IIlJURY IRELATE ItEMS 1.2.3 OR 4 TO ItEM 2~E BY UtlEI ----, 22 MEDICAID RESUCMISSION
,fML.9, .f,ervica1 sprain T CODE I ORIGlrlAL REF NO
3 L-._ 2] PR:JR AUTHORIZATION NUMBER
,l1L9. C5-C6 disc degeneration 'L-.
" A 0 C 0 E , G H , J K
FloDmATEISI OF SERYICETa PI"" T",. PROCEDURES, SERVICES. OR SUPPLIES DIAG~lOSIS O~!' "0 RESERVED fOR
~?' 0' (E. plain Un~$u.1t C'fCvm~!.1nc:esl ceDE SCHARGES OR Fam.ll EMG COO LOCAL USE
"'1,,1 00 " ,m 00 " " S..rv1C1 CPT HCPCS 1.l0QlflE R utllTS Plan
1 10 06 9' 3 99213 I OV exoand'" 1-2 35 00
10 06 9~ 3 97010 I HP 1-2 20 00
10 06 9' 3 97014 EMS 1-2 20 00
10 06 9' 3 97530 I KE 1-2 20 00
hn no 00 . aa?1? nlf '-' ?n'.nn
10 09 95 3 97010 I HP 1-2 2000
11n no a<: ., 0"7'" A F:M~ 1_? 20 00
I~g . ~~ . ~~ 3 97530 KE 1-2 2000
3 9921' I OV 1-2 20 00
10 11 95 3 97010 I HP 1-2 20 00
10 '11 95 3 97014 EMS 1-2 20 00
25 FEDERAL TAX I D NUtADER SStj Elt, 26 PATIENT S ACCOUtH'lO 2r rCCEPT ASSIG~,"'HlP 28 TOTAL CHARGE I~. A'-'QU'" PAID ]0 BAl)J.CE OUE
~n 10IQO-.1Cn,;,seet.1:-1
163.58.0267 ,0 YES . tjO S 235 00 s 00 s 235 00
31. SIGNATURE OF PtiYSICIAf, OR SUPPLIEA : 32 tlAME AND ADDRESS Of FACILlTV WttERE SERVICES WERE ]) PHYSICIAN S. SUPPLIER S BILLING NAME. ADDRESS. ZIP CODE I
INCLUDING DEGREES OR CREDENTIALS RnlOERED (II OlhDlltl,ln tIOmt 01 olfote) &PHOf'le.
11c:.rtof1IhalIh8'1.1!emenl'onltl.,t~tr$' GREGORYT. REESE, D.C. i
u:rr:~'~"'":~~~~~ 18 Courtyo.td OffiCIIS Rt. 11 & 15- Sellnsgrove, PA 17870
T.r.phon.. (717) 743-2342 i
RE604347 I
SIGflED DATE PIN. GRP' I
3
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.
.,.
.
(APPROVED BY AM"" COUt~CIL o'~ MEDICAL SERVICE 8 SS)
MId, br Mldi,,1 Arb Pun
C..toll"" II(X).JUll71
PLEASE PRINT OR TYPE
FORM HCFAISO) (12901
FORM QWCP.l500 FORM RRB.I500
'l~n_':t4Jl
\I.. __I~ I~..""" '111U 'I.......,' ~ 'III~ ,.....'11
I. I.1EOICARE MEDICAID CHAMPUS CHAI.IPVA GHOul' HCA OTIIEf! 1.1 IIj5UR[O 51 D flUMBEn (FOR PROGRAI.I.~~ ITEM I, I
I' ,nl .n, rI .IEAlTHrlA'1 DlklWI(j CL# 1552005793
/1.t1tlJ'C.JI.., 1",.,d'..Jd II ,SponSlJI,SSNI 11~'Af""j .-IIS:i~JOI/OI f] ISSNI 11,/01
2 PATIENT StlAME Ila,I tlJ.m. F,nl tI.am. M,('ld'.IM,\I) ] PATIEN! SD,HhtOAf( SEK . I~~SURED 5 tl"',lE (L.HI 1jJ.fY'.. F"" fl.Jm. Mod(l:"IM'.J!i
'-".1 00 yy
Roberts Sv1via 06 12 39 "n ,n same
5 PATIWTSADORESStNo. SlIt"'l) Ij PATIEPjf f~ElATIONSHIP TO ItlSUAEO 1 INSURED S ADDRESS Itll). SU..II I
RR5 Box 221A s" ~ s'M'D c'.O Olrefn
CITY I STATE 6 PATI[tjT 5T"1US CITv TSTATE
Selinsqrove Pa S,rg"C] M.lrr,~D o""C]
ZIP CODE I TtEPtiO)E (lroclud, A,... Ced'l ZIP CODE -\ TfLrHOtIE )NClUDE AREA COoEI
17870 Er1PIJI&dOfuIIT'''''OP.a"T,rl\IlD
_ Slw:l.I11 _ St:..('l'''IO-_
9 OTHER INSURED S ~~AI,lE \lUI N.afT" ""1 Nam., M,Q(I',1M .11 I: IS PATIENT S COPjOITlQlj R[LATEO TO 11 ItlSURED S POLtCY GROUP OR FEeA NUMBER
a OTHER INSUREDS POliCY OR GROUP NUMBER a E',tPLOvt,1WP (CURREtlT OR PREVIOUS, . I'/SURED S DATE OF BIRTH SEK I
"" 00 yy
:JYES [1"0 "0 '0
.~
tl OTHER IIISUREOS DA,TE OF BIRTH SEK t AUTO ACCIOENP PLACEISl.lT"1 tl EMPLOvER 5 'lAME OR SCHOOl NAME i
"y 00 y, ."n 'Ii 1$ YES ;:JPIQ
I
c EMPLOVER S ~lAt,lE OR SCHOOl NAME c OTHER ACCIDEtH') e 1~ISURANCE PLAU NAME OR PROGRAM NAME I
DYES XJ"o
d INSURAtICE PLAN NA,ME OR PROGRAM tlAME ':" RESHWED FOR LOCAL USE d IS THERE At.OTHER HEALTH BENEFIT PLAtI' i
DYES D"o Hy., 't!MnIOoll~dcolT'p.e!.","'').d
READ BACK OF FORM BEfORE COMPLETitla & SlaNINa THIS fORM. 1] 'Pl5UREO 5 OR A,UTHORIZED PERSOtj 5 SIQtMfURE 100:.llhofllt I
12 PATIEfH 5 OR AUTHORIZED PERSOfI S SIGNATURE I i1~'~:':' T~~ r~ dif el ,}'t lI'&dC,\1 Of ertlel ,r,IJtr~,}t.;" neceu,t', pJ,m,ml 01 !"'~d.CJI t..r",t,lS 10 1l'111l,JndllrS~f1'd phy,,,,,tn 0' Sl..pp/;..tO'
10 pl"OCtH Ih,S C'J.m I ,}ISO ,tq~uI pJ.""lenlo' g;l,em""O!I'l t:.,".'Ti' ::'t" I: -,st"~ 0'10 \:'.., PJ'I, An,oJ .tCce:ltS .UQ!\ITO!rl St'''''4"CeSCe"rto.''d~!04f !
tl"I.:l4f /
SIGPlED siqnature on file DATE 7-5-95 SlG~,jED siqnature on file !
14 OATE OF CURREfH ~ ILLflESS IF'fS! 'tmpToml OR 1'5 IF P.\TIEtlT HAS HAC SAI,I(; OR SIMILAR Ill~.ESS 16 OATESPATIEPjT UtIABLE TOWQRK IUCURREPH QCCUPATlCtl I
og'" 360 95 IPUURY IAttlder,H OR GI',EFIRSTOA:TE W.l 00 YV MM 00 yy "".1 00 yy ,
PREGNMlCYtWP, FROM TO I
11. NAME OF REFERRltlQ PHVS.CtAtI OR OtHER SOURCE 17,} I::: r;UI.l2ER OF REFERRiljG PHYS!CIAtI 18 HOSPITAliZATiON OATES RElATED TOCURREUT SERVICES
YY 00 yy ','~.l 00 yy
FROM TO
19 RESERVED fOR LOCAL USE 200UTSIOELAB' S CHARGES
DYES 0"0 I j
21 DIAGtlOSISOR NATURE OF IlLflESSOR ItlJUHY IRELATE ITEI,lS1 2 l OR.& TOlTEM2~E BYlINEl t 22 MEDICAID RESuBMISSIO'1 I
CODE I ORIGI~IAL REF NO
, ~0_cervica1 sprain , L-._ 2] PRIOR AUTHORIZATION NUMDER
2 ~22 4 C5-C6 disc degeneration .
" A B C 0 , , 0 H I J K
F,09,,A,TEISI OF SERVICE To Place Typ~ PROCEDURES SER'JICES. OR SUPPLIES DIAGPlOSIS IUAV::; t"U/ RESERVED FOR
<.~' " lE.plarU'uSloaIC.fCl,JmsIJnc:tsl CODE S CHARGES OR Fam>ly 'YG COB LOCAL USE
YY 00 YV MM 00 yy .' ..< cpr HCPCS 1- MODIFIER UWTS PO"
I In 11 0' ':l 97035 I US 1-2 22 00
0 13 95 3 99212 I OV 1-2 20 00
2 0 13 95 3 97010 HP 1-2 20:'00
...0 13 95 3 97014 I EMS 1-2 2U UU
,1013 95 3 97035 US 1-2 2200 ;
,
10 16 95 3 99212 I OV 1-2 20 00 I
10 16 95 3 97010 HP 1-2 20 00 I
10 16 95 3 97014 I EMS 1-2 20 00 i
In 11;' Ot; ':l liS l_? 70 00 /
,
10 18 95 3 99212 I OV 1-2 20 00 I
10' 18 95 3 97010 HP 1-2 20 00
25 FEDERAL TAX I D NUMBER SSN Eltl , 26 PATIENT S ACCOWlT PIQ . ~fCEPT ASSIGNMENP 28 TOTAL CHARGE 129 AMOUNT PAID JO BALANCE DUE
Ol' go~1 n" 'Hi OJc"'l
163-58-0267 [xl[j YES tlO S 224 00 s 00 s 224,00
Jl, SIGNATURE OF PHYS'C'A" OR SUPPLIER :11 flAME AND ADDRESS OF fACILITY WHERE SERVICES WERE JJ PHVSICIA~' S. SUPPLIER S BILLING NAME, ADDRESS. ZIP CODE
INCLUDING DEGREES OR CREDENTIALS REPjOERED (II "I"" lP'ar\ hom, Ol' ot!.c'1 & PHONE I
II ClIlI,fy Ihal \he Slalerr,.n15 an l~e "~lIlSe GREGORY T. REESE, D.C.
apply 101M b<lIand OIfe mad".. p.tfllhtfeolj
&~ I-Y-7(' 18 Ccurty.rdOl11ctl RI." & 15 -S.lin'Qrov., PA 17870
T.I.phono: (717) 74J.2~2
, AE604347 I GRP.
SIGNED DATE , PI~l'
APPRO"EO OMB O'Jl! 00C6
PLEASE
DO NOT
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INTHIS
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~
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HEALTH INSURANCE CLAIM FORM
PICA
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IAPPROVED BV AMA COUNCIL 0" MED!CAL SERVICE 868l
MId. by Mtdic,l Art. Pre"
C..loll"" 1<<GJ1UI7t
PLEASE PRINT OR TYPE
FORM HCFA. I 500 (l2-90J
FORM OWCP.I500 FORM RRB.I500
"..n-tltolu
tJ"."r\("""""'Il'ln!J~"""","'fl'I"t"'MIII
APPROvED OMD 09]8 OOClI
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IN THIS
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~...
HEALTH INSURANCE CLAIM FORM
PICA
PICA
~
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1 "'EOICARE MEDICAID CUAMPUS C~W.'PVA GHOul' HeA OlIiER 1.1 IUSUREQ 5 I 0 ~lu~DEn IFon PROGRAM '" IT[M 11
Ii' 'r; 'n' n n ""llHP"" 110'KlU"01-1' CL~ 1552005793
1\,..d...1"I'11 , IV"d'::J'<1 6j (Spons"" SSNI (\'A F,r.. 61 (SSfJ oJ' IDJ ISSNJ - "DJ
2 PATIE~jT 5 flAME lLJ\1 n.lfU F,t,l fIJ'11It. M,dl.lle IO<II.!.II J PATI[NtSBIHTHOAT[ SEA .. ItISUR(O S tIM.'E (L~.I 'IJmlf Flf$! fjJmQ. '.l,ddllt Im',all
Roberts Sv1via 01;'" l~D 39 ...n Fli same
~ PATIENTSADDRESSi'10.S~'eel1 6 PATlEtH RELATION5~1IP TO INSUflEO 7 1~ISUREO 5 ADDRESS 1'.Q, St'llet) IS~
RR5 Box 22l.A S~'II g] SPOloIseO C'1''d[1 Olt1ef-J
CITY ITATE 8 PATlUH STATUS CITY
Selinscrove Pa 5''''''0 M.:1fhltdD 01t1elD
ZIP CODE I TrEP~iO)IE llnclloldlt AfU COOe, ZIP CODE I TElrHOtIE )NCLUDE ARE^COOEI
17B70 Emp101e1 ~J FIoIU.Tlmtl [] P.Jr1,T,meO
l _ Slloldllnl SrlJd...>f1I"
9 OIHER ItlSURED 5 NAI.IE llasl ~lame. Frf!t N.lme, Mdd!llln,l<JII 10 IS PATIEtH 5 catmllio" RelATED 10 11 I"SURED S POliCY GROUP OR FECA NUMDER
I OTHER a.SURED S POLICY OR GROUP NUMBER a Et.IPLO'l".~EfH' lCURREtH OR PREVIOUSl .ltlSUREDSOAIEOFBIRItl SEX
"'1.1 00 vv
DvES t:\)NO "'0 FO
b OTHERI~iSUREDSDATEOFBiRTH SEX b AUTO ACCIDENf7 PLACEtSIJleJ b EMPLOYER 5 NAME OR SCtiOOL tjAME
"'M 00 vv ",n Fn ~YES .:.=1"0 :
c EMPlOVER S ~IA'.~E OR SCHOOL NAME cOTtiER I.CCIDEtlP c Irl5URMlCE PLAt~ 'lAME OR PROGRAM NAME i
::J VES D"O
IJ I!ISURAt,CE PLA~l 'W.IE on PROGRAM NAME ICd RESERVED FDA LOCAL USE d IS THERE ANOTHER HEAL TH BENEFIT PLAN' ,
DVES 0"0 It}',. le!umIO.1"dtomp1t'11l,lllm9;\d
READ BACK OF FORM BEFORE COMPlETltlG & SIGPllflG THIS FORM. 13 INSURED 5 OR AUTHORIZED PERSOII S SIGrIATURE 1.1JH10ILZI
12 PATlEtH 5 OR AUTHORIZED PERSON S SIGrIATUAE I alol~nc':e l"e ft"t' ne 01 anf ~4!dO:,ll 01 ol~ef infOfmation nece's.lry pJ,mtlnl 01 mo!tJ C.l! b>l~tll.li 10 1t1t1 ur.ders'O"ed phyS'C'MI 01 Juppl'il1lor
l:l plOCUS In;s "~~ I J so tt-:;.~11 pJ,mef1! 01 oo~e'n"'...ntlNntl.1S t,I"",'lo mr't'11 0' IJ lr., P,l'lf "'''0 acct'pls .1Ss"J'lrr.....nl so"VocesdeK't"db",lo~ ,
te,)N I
siqnature on file 7-5-95 signature on file I
S:QrIED DATE SIGtIED I
'" DAtE C!: CURRE"lT ~ ILUIESSlF,lsts1rT'pIOmJOR 15 IF PATlEfH HAS HAD SAME OR SIMilAR IlUlESS 16 DAlES PAnEtH Utl"BLE TO WORK If~ CURRENT OCCUPATlOII
O~".I 300 9'5 Irl/JRY IAcc'dllnll OR GI'o'E FlRSTD'\IE MM 00 VV "-'". 00 VV "-'M 00 VV
PREGtlAttCYllMPj FROM TO
11. flAME CF REFERRlr;':'; PHYSICIAtI OR OTHER SOURCE 17.1 10 'lUMBER OF REFERRltlG PHYSICIAN IS HQSPITAlIZATIQtI OATES RELATED TO CURREflT SERVICES
MM 00 VV MM 00 VV
FROM TO
19 RESER','ED FOR lOCAL USE 20 OUTSIDE lADl 5 CHARGES
DVES 0"0 I I
21 DIAmlOSISOR tlATURE OF ILLNESS OR INJURY IAElATE HEMS l.lJOR 4 TO ITEM 24E BY Lltlel ~ 22 MEDICAID RESUB'.lISSIOt~ i
CODE I ORIGINAL REF. NO
1 ~~~ervica1 sprain J 1-..._
23 PRIOR AuTHORIZATION NUt-IDER
2 722 4 C5-C6 disc degeneration , 1-...
" A B C 0 E F G H , J K
Ftc~"ATE~SI OF SERVICElo Place Type PROCEDURES SERVICES. OR SUPPLIES DIAGNOSIS DAYS EPS01 RESERVED FOR ,
01 "A~'~' iE.pla,n U"~SUolI C1fcumstJ.nces) CODE S CHARGES OR Fam,ly EMG COO LOCAL USE I
"''' 00 VY MM 00 VV ". CPT HCPCS MODiFIER UNITS Plan
10 18 95 3 97014 I EMS 1-2 20 00 !
1
10 18 95 3 97035 IUS 1-2 22 00
210 20 95 3 99212 OV 1-2 2000
10 20 95 ~ ,n v,,"v HP 1-:,( .diOu
J 10 20 95 3 97014 I EMS 1-2 20 00
10 20 95 3 97530 KE 1-2 200U
,10 23 95 3 99212 I OV 1-2 20 00
10 23 95 I~ 97~~0 I HP 1-2 20 00
5' n ~, · a~ 970 4 EMS 1-2 20 00
10 23 ,95 3 97035 I US 1-2 22 00
,
25 FEDERAL TAl( I D tlUI.'BER S5" EIN '26 PATlEtHSACCOUtlU.O 27 ACCEPT ASSIGtlMENP 2B TOTAL CHARGE 12 9 AMOUNT PAID 30 BALANCE DUE
tFoIOOYl tl.l,ms.seeb.1ckl
163-58-0267 000 D YES 0 "0 s 204 00 s 00 s 204 00
31 SIGNATURE OF PHYSICIAN OR SUPPliER ' J2 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERe JJ PHYSICIAN S, SUPPLIER S BILLING NAME. ADDRESS, ZIP CODE
ItiClUDING DEGREES OR CREDWTlAlS RENDERED tll OlhUf than home Of ofh:el & PHOt~E ,
Ilt.rt:tylhlll"lslllt~,"rsonlh'"...else , GREGORY T. REESE, D.C.
g:([~:'d""rtlh'~~'~_f~ , 18 Courtyard Offices RI. 11 & 15- Sellnsgrove, PA 17870
Telephone: (717)743-2342
RE604347 I GRP,
SIGt/EO DATE i pm.
7
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IAPPAOVED BY AI.'A COuriCll ON MEDICAL SEIWICE B BB)
Mid. b7 MHf\(11 ArU Prm
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PLEASE PRINT OR TYPE
FORM HCFA.I500 112901
FORM OWCP.l500 FORM RRD.l!lOO
'1'1-111- 'rMlI
lJw .,I~ f".,,,,~ '1414\ r~~~\OI' 'HI&tIW~M.1I
APPRO\lED OMD C9J8 COC15
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00 NOT
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HEALTH INSURANCE CLAIM FORM
PICA
PICA
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I "'EDICAJlE MEDICAID CttAMPUS CHAMPVA GJlOUP flCA OTtlEH '.lIN~UIlEDS'O NUMUER (fOfI PflOQRAM III ITE:.M 11 I
n 11 ~lfAlnl PlMl rlUlK lutH~ r- ,
~;,.c.l'If'II-lIMPO'.CJd.l n tSponsJ',SSN! tV..4 Fo,'", Ifl /SSNo,'DI {ssm -l/IDI CLD 1552005793 I
2 PAT1EfH S flAME Ilont fU'1'l,. f'fs' ft.l"" Moddl" IMJ.llf J PATIErlT 5l\lfHtl DATE SEX .. Itl5URlO 5 NAME; (l.nl fl.1m,. filii flo1rT1t;l P,Jddlt;lln,h.ll) I
...1.1 DO YV _,
Rnh^~.c S..,..b 06 12 39 "j- '[-1 same
5 PATIUHSADDRESS,tto.Slr"'1 6 PAlJEtH RELATIONSHiP TO'tlSUAED 7 IflSUflEDS AOOflESS(No , Slrlllltl i
RR5 Box 221A 50.1 fXl Spou,eO Ch,ld[] o1he'D
CHV I STATE 8 PATlUH STATuS CITV I STATE I
Selinsarove Pa S,,,,,{] ..brflOdD 01""' [] ,
,
liP CODE I TrEPI4O)E tI/'It-lu!!o) AfllJ Codll) llPCOOE I TElrtiONE )tlClUDE AREACODEI I
17870 Errp'o~lId[l FI,jII.To",lIO Pdrl-Tomll[J 1
. Slud!!nl .- Stlldllnl . ,
g OTtlEn ItlSURED 5 tlAME Ilnl fl<lfT'lI F,rlt tl.lme M.dc'.tn,ILall 10 IS PAlIEtH 5 COtlDlTION RELATED 10 11 Itl3URED S POliCY GROUP on FECA NUMBEfl :
I
a OTHER ItlSURED S POliCY OR GROUP tjUMBER a EMPlOYI.IWP lCURREtH OR PREVIOUS) .. ItlSURED S DATE OF OIRTH SEX I
MM 00 VY
:=J YE S rfJ"O "0 '0 I
I
tl OTHER INSUR(O S DATE Of f]IRTH SEX b AUTO ACCIOWP PLACE (!i!.1ltll b EMl'lQ'([fI S tlAME. on SCHOOL flA'.IE I
"" DO YV Mn 'n Ll;]VES - :
"0
'.-'
c EMPLOYER S tiAI.IE. OR SCHOOL f~AI.lE C OTtlER ACCIDErH' C INSURAtlCE PlMI UAME OR PROGRAM tlAME
[] YES n"o
a ItlSURAtlCE PlA~1 flAME OR PROGRAM rlAME 'Cd FlESERVEO fOR LOCAL USE d IS THERE ANOnlER HEAL TH BENEfIT PlAtl'
[]YES 0,,0 lI)'e"l!rurntoardcolTplete Ihl'" gad
READ BACK OF FORM llEFORE COMPLETING & 510NI"a THIS FORM. IJ IflSURED 5 OR AUTHORIZED PERSOPl S SlmjATURE l.ll.l~cr:tI
12 PATIENT 5 OR A:;THORlZED PERSOtl S SIGtlATURE l.luln"lItl! rho:! fe',!.!s'! 01 a"y ml!dC.l1 0' OIr-.~llnr;)trr'.lr.~n ntcesurr P,11T'1I'n, 01 fT1t!'d (,11 tl.!n~!'" 10 thu Undflfs.ored ph~';c.an Of I'.~::: Ilf 1::1'
10 precns \11>$ C'1m 1 also 'l'QI..!sl p.l,ITl!nt,1 gO~l!rnlnl!rl tl!rt'~.ts tfllhC' 10 m,ud or 10 thot p.1r!y ",1\0 acc.l:'pls ass'U"motfll SI'f.ICIISdl!sc',botdtlIlIO,o,
tli!IO""
SIGtlED sianature on file DATE 7-5-95 SIG~jEO sianature on file
U DATE QFCURRWT ~ IlUlESS IF,'SI 51mpl0:'llj OR 1S If PA TIE-PH HAS HAD SAP.lE OR SIMilAR ILLNESS 16 DATES PA TlEm ut~AOlE TO WORK." CUAREm OCCUPA liON
"1M DO VV IljJURY lAce_dent) OR GI\lE FIRST DATE MM 00 YV MI.' DO VV MM DO VV !
06 30 95 PREGNAPIC'I'llMP, FRO,", TO
17. flAME OF REFERRING PHYSICIAtl OR OTHER SOURCE 17.1 I D r.UMOER OF REFERRING PHYSICIM~ Ie tlOSPITAlIlATIOtl DATES RElATED TOCURREtH SERVICES
"''-' DO VV MM DO VV
FROM TO i
19 RESERVED FaA lOCAL USE 20 OUTSIDE LAO' S CHARGES I
oVES 0"0 I I
21 DIAGNQSISOR NATURE Of IllflESSQR IflJURY. (RELATE ITEMS 1,2.3 OR~ TO ITEI.I2~E BY LINE) t 22 MEDICAID AESUB"'ISSIO~1
CODE I ORIGINAL REF NO
I 1847 9_cervical sprain J L--,_ 2] PRIOR AUTHORIZATiON rtUMBEA
2 1722 <l C5-C6 disc degeneration 4 L--,
24 A B C 0 E , G H 1 J K
Ffo9nATE(S/OF SERVICETo Pl,lce T~pII PROCEDURES. SERVICES. OR SUPPLIES DIAGrIOSIS D~~S EPSO RESERVED FOR
Ic:~~ I 01 IElplaLn U".~SlJill C'feumSlances) CODE S CHARGES Fam.ly EMG COB LOCAL USE
Mt.l DO VV M'-' DO VV ~, CPT,HCPCS MODIFIER UNITS Plan ,
1 In ?~ at; ~ aa~' ~ I ('IV 1-2 20 00
10 25 95 3 97010 LHP 1-2 20 00
2 In ?~ ao ~ a7n1 " EMS 1-2 20 00
10 25 ~: 3 97530 KE 1-2 22 00
J o 27 95 3 99212 I OV 1-2 2000
10 27 95 3 97010lHP 1-2 20 00
4 10 27 95 3 97014 EMS 1-2 2000
10 27, 95 3 97530lKE 1-2 20.00
,10 30 .95 3 99212 OV 1-2 2000
10 30 95 3 97010 HP 1-;l ;lU,UU
,10 30 95 3 97014 I EMS 1-2 2000
2S FEDERAL TAX I D NUMBER SSN EIN 26 PATIENT S ACCOUNT tlO 27 ACCEPT ASSIGNMENP 28 TOTALCtlARGE \2 9 AMOUtH PAID 30_ BALANCE DUE
[)(]O tFofOOv'l Clil1m:;,seeb.1Ckj
163-58-0267 o YES 0 "0 s 220 00 s 00 s 220 00
31. SIGNATURE OF PHVSICIAN OR SUPPLIER 32 NAME AND ADDRESS OF FACILITV WHERE SERVICES WERE 3J PHYSICIAN'S, SUPPLIER S BILLING ~IAME. ADDRESS. ZIP COOE
INCLUDlf~a DEGREES OR CREDErlllAl5 AEfmEREO III othe' lh.1n home 01 on,ce) & PHONE.
llcfrtllythallh. Il.1tem,""on lt1e re~els. GREGORY T. REESE, D.C.
~"tok~~'~""::~.~~ 18 Courtyard Offices Rt. 11 & 15- Sellnlgrove. PA 17870
, Telephone: (717) 743.2342
! RE604347 I GRP,
SIGrlED' DATE PIN.
~
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~
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(APPROVED B'I' AMA COUNCIL Cfj MEDICAL SER\lICE e 88)
MId. br Nldiul Arts Pun
elll"'''" IICOUUI1'
PLEASE PRINT OR TYPE
FORM UCFA-l!)()() (12901
FORM OWCP.I!>OO FORM RRO.l&lO
'1"'1l-'~J1
\h...l~t"..~lltl",.,.--.edIOl,,"I4II..~...11
PLEASE
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OHiEn Iii Irl5UREDSIO 'lUMBER
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I MEDICARE MED!CAID CHAI,lPUS CHAMP'.'A GROUP FEeA
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2 PATIENT 5 NAME ILAl! NJm~, F,n, '..1111" ""dljtu IMI,):, J Pp"~~IEW8oDIR'~\OATE SEx
06 12 39 M n r n
Roberts Sv1via
5 PATlEtHS ADDRESSINo, StleI"1
6 PATIENT AHA TtONSttlP TO INSURED
Stili ~ SpoUSlID Ch'ld[J Q1"tlID
8 PATIENI STATUS
RR5 Bolt 221A
":' CITV
~
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Selinsqrove Pa
ZIP CODE 1'(ElEPHO)4E jlf"Cludlf AI"" Cod')
17870
9 OTHER INSURED 5 NAME Il,ut NJ.me. F,ts' tl.1m., M,,,,,relno!lolll
ErflPiQYlldn FUII.Y1mIfO Pdr1T1m"n
_ _ Studen, _, Sludolr'l1 _
10 tSI'''TIENf 5 CONDITION RElATED TO
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. EMPLOYMEPIP (CURRHlT OR PREvlOUSI
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.. IPjSUREO 5 NAME IL.I\1 Pl,Jme F'"I N.\rnll', "-"dd1tf IM,,}11
same
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CITY I STATE
liP CODE I TEL(PHONE )'lCLUDE AREA CODE)
II IrlSURED S POLICY GROUP OR FECA NUMBER
o OTHER INSURED 5 OATE OF BIRTH Se.:
MM DO YY ...........,
Mi I
c. EMPLOYER S NAME OR SCUOOL NAME
a INSUREDS DATE OF BiRTH
MM DO YY
~NO M[]
PLACE ISlMtI) b EMPLOYEIl S NAME on SCIlOOl NAME
'[I
d INSURANCE PlM~ NAME OR PROGRAM NAME
:=lYES
b AUTO ACCIOENT1
~YES
c OTHER ACCIDEPIP
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12 PATIENTS OR AUTHORIZED PERsorl S SIGr~ATURE I <l1.o'nOlll!! l~f rlJ'~.t5" 01 ant meac,}1 or Ol~tlf u:IO'mJ:,cn rt!:end1y
leptO':ess ln's cl.a'm, I al~ reqlJUI p.1)I'rt'nl olgoyt'tnmenl bent"'I~.'ltlt'IIOM,5{'" or 10 Irep,\rlf IfohO accepts .l5soynl"'<t1'1
bel~-.IW
SIGNED siqnature on file
U DATE OF CURRHlT ~ ILLNESS IF"" syrrplom) OR
MM 00 YY IP~JURY lAce denn OR
06 30 95 PREGNAtlCYILMPI
11. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
DATE 7-5-95
IS IF PATlEtH liAS HAD SAME OR SIMILAR IlUjESS
GIVE FIRST OA:TE I.IM 00 YY
17.1 10 NUMBER OF REFERRING PIWSICtMI
19 RESERVEDf'OA lOCAL USE
21, OtAGfjOSISOR NATURE OF ILLNESS OR ltlJUAy IRE LATE ITEMS 1.2JOA4 TO ITEM 24E BYLINE) ~
I. ,847 9_cervica1 sprain , L-._ T
~ ,1722 <I C5-C6 disc
~
" .
Froo,:.TEISI OF SERVICETo
00 YY MM 00
degeneration 'L-.
BCD
Pl.1ce Type PROCEDURES, SERVICES. OR SUPPLIES
01 01 IE.pIJ,n U~usual C.,cumstdncesl
YY ~""'~I C:;prl"'~ CPT,HCPCS I MODIFIER
97530 I KE
99212 I OV
97010 HP
97014 I EMS
97530 KE
99212 10V.
97010 HP
97014 ,EMS
, nc: .
99212 10V
97010 HP
25 PATlEtlT'SACCOUPH NO
E
DIAGNOSIS
CODE
>1M
,10
11
,11
11
,11
11
,11
95
95
95
95
95
95
95
11 06 95
5 1.1.01; ,Q'i
11 10 95
,11 10: 95
25 FEDERAL TAX I 0 NUMBER
30
01
01
01
01
06
06
3
3
3
3
3
3
3
3
':\
3
3
SSN EIN
1-2
1-2
1-2
1-2
1-2
1-2
1-2
1-2
1-?
1-2
1-2
21 ACCEPT ASSIGPI'.IENl'
(Fofgov! C1J,m:. see bJck)
[] YES n NO
, 31 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE
RENDERED (II othof IhJn hO'Tltor otl.ce)
163.58.0267
~O
31. SrGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I "f1lty 1t13f lhe sl..1lemenls on Ihe reyerse
[ply l~hiS boll ~ndattmJde.. Pdf1lhettoll
\\1.,..,~ '-'(-~~
SIGNED DATE
(APPROVED BY AMA COUNCIL ON MEDrCAl SERVICI: 8 sa)
MId. by Medial Arts PttU
Cdloft"" 1-'O().J%'ll7'
PLEASE PRINT OR TYPE
SEX
c ItlSURMICE PLAtt tlAME OR PROGRAM NAME
a IS THERE AtIOTHER HEAlTtl BENEFIT PLMl"
[J YES Cl "0 It Y" rell.rn 10 and CO/flpll:!hl ,Tern 9 a a
IJ l~lSURED S OR AUTlIOHlZED PEASO" S SlGtJATURE 1,1...1Mf'ZIl
p.I,I'T't:"I1 (:1 fTll'I1'C.l1 tC'lul,lslo IhOl undt1tslOJned ph),.".]1'I Cf Sl.lpp;;t'r I~'
5~"";Ctl' dll5.Cr.b.'dD"loN
SIGr.EO
signature on file
Hi OATES PATlEtlT urlABlE TO WORK It4 CURRENT OCCUPATION
1.'1,1 00 YY MM DO VY
FROM TO
la tlOSPITALrZATION OATES RELATED TO CURREtlT SERVICES
MM 00 YY MM DO YV
FRO~1 TO
20 OUTSIDE LAB" S CHARGES
[]YES 0"0 I I
22 MEDICAID AESUBMISSION
CODE I ORIGINAL REF NO
2J PRIOR AUTHOfllZA TrOtl tlUMBER
S CHARGES
G H
DA YS i~PSD
on Fdmllt
UNITS PI.1n
EMG COB
I J
K
RESERVED FOR
LOCAL USE
20 00
20 uu
20 00
20 00
2000
20 00
20 00
20 00
?(Lnn
20 00
20 00
2a TOTAL CHARGE 129 AMOUNT PArD
I 220 00 I s 00
JJ PHYSICIM~ S, SUPPLIER S BilLING NAME. ADDRESS. lIP COOE
& PHOtIE .
GREGORY T. REESE, D.C.
18 COUrty8rd ottices At. 11 & 15-SaUnlgrove, PA 17870
Tel.phon" (717)743.2342
AE604347 I
Pill' GRP'
JO, BALANCE DUE
s
22000
FORM tlCFA 1500 (12901
FORM OWCPt5OO FORM RRB.15OO
1l'lo4.1-lmn
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IN THIS
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HEALTH INSURANCE CLAIM FORM
PICA
~
~
1 MEDICARE I.lEOlCAIO CtjAMPU$ CHAMPVA liHOUP fLCA OhiER 1.. Itl!;UHLD S t U NUMUEfl (fOil PRQGIlAl.! !~I1TEM II ,
'-1 tl[AlTtif'lAt, BLK1UflG 1552005793
[J l"'ed,.t'cU/ n l"'lItJ"dd Ii Il'SM'UOI,SSNj r- IVAf,ltI '~__'S~NC"~~_O ISSN! [+J IIVI CLK
2 PATIENT S 'lAME Il",' fl"mtl F"II 'i.lm", M,dllllt 1"<1...111 J PATIUlfSllllHHIJAfl SEX " IN5UlllO 5 'IAt,l[ (lolsl tl.l.!'t1 FoISt tU"''' 1.4.(1<1., In'!..ll! I
MM DO yy ,
RobpJ:tIL9y1 V ia 06 12 39 M 0--'-0 same
~ PATIENT S ADORES5lNa . SHutl {) l'ATIUH R[lATIOW;IlIP TO Itl5Umo 7 INStJR[O S ADOfl(5S t140 Slr.,,,11
RR5 Box 221A 5..11 r-xl SpoUSfI[J Ctl.l.{-] 01""'[]
CITY ~ TIAlti'lf STATUS------ CITY I SlATE
Selinsqrove SOI'Ilht [J M.lfhll(l [J OIh," []
ZIP CODE I T;LEPtlO)E Ilocl<A<J Ar... COO"! ltI'COD[ I TnrtiOflE )tJClUDE ARtACODEI
17870 [n,plorl'1Jr 'J FutlT,m"r'] ...oI!'.TII""lh]
SI"d<J'll _ Slud.ml . .
~ OIHEn INSUllEO 5 'lAME ILul 'l"me, First N.lmtl J.l,(Jdle 10'11.111 tJ 15PAfiirif~cmIOIIIOp;nElAr[O 10 - 'I ItlSUH[Q S POliCY GflOUP OH f rCA t.UI,IBER
II OTtlER INSURED 5 POliCY OR GROUP NUMDER il EMPlOVMEPlP IcunRnH OR PlllV'IQUSI iI IPlSW1(Q 5 OA TE Of OtnrH SEX
MM DO YV
..--1'ES [~NO . "'[j , [~
b OTHrR lNSUREOSOATE Of BIRTH SE' b AUTO ACCIDOjf' PLACE 151011111 b EP.lPLOYER 5 tlAI.lE OR SCHOOL tlM.IE
MM DO VY Mn '0 If.!VES -::'10
C EP-,lPLOVEH 5 'lAME On SCHOOL NAME c OTllER AC IDEPH') c: lflSUAAt4CE PLAN 'lAME OR PROGRM.I 'lAME
[J V'5 lUNO
lllNSUllANCE PLAN 'lAME 011 PROGRAM NAME lCd RESEHvEOfOn LOCAL USE II IS TtlEAE ANOTtlER .1EALTH BEPlEflT PLAtP
DVES o NO ,,)'.., '..I:"'"llc"rdCO"'t':~IIl"t'm9,]tt
READ BA.CK OF FOAM BEFORE COMPLETltlG & SIGNING THIS FOAM. 13 lf~SUREO 5 OR "UHionIZED PERSCPl S SIG'/ATUR,= I Ju!hc":e
12 PATIENT SOA AUTHORiZED PERSONS SlmlATURE l,]u!ho"leINi re'''Hl! 01 ""r rf:edcal or 011'>11 ,,,I"'fT'ilhou "l'<:I!SS-1rr pJ,-mllrll 01 m~d'C.ll t.e"tt!,ls 10 lnllll"dl!'S ~nl'd ~rl)\'CtdO or suPP' ". I;,
10 plocess lhlS (I.l'm I also t!!Quest pJ~ml!nt oIIlO~t'rr.r"e"l b'!r1l.'Hs I.!her 10 1"l~\1l11 0110 lhe p.l'lf "'~.o .1ccI'pIS .J\Slll"m~nl sl.'rv,cesdt's.;'.tl'dbtlloN
botlow
Slm~EO sianature on file DATE 7-5-95 SIGmo signature on file
'04 DATE OF CURRENT ~ ILWESS (F"sl symplom) OR 15 IF PATI['H HAS HAD SAME OR SIMILAR IllflESS 16 OATES PATtENT UNABLE TO WORK I~j CURRErH OCCUPATIQrI
OE/ 00 YY INJURV (AcCodt!nll OR GIVE FIRST O~TE MI.l 00 VV MI.l DO yy "'I~.' DO YV
30 qc;, PREmlAtlCYILMPj FROM TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17.l I D 'lUMBER OF REFERRING PHYSlC1Ml 18 HOSPITALIZATION OATES RELATED TOCURRErH SERVICES
MP.l DO VV P,",' DO VV
FROM TO I
19 RESERVED FOR LOCAL USE 20 OUTSIDE LAB' 5 CHARGES ,
DVES 0"0 I I ,
21 DIAGNOSIS OR NATURE OF ILLtlESSOR INJURV IRE LATE ITEMS 1.2 Jon" TO ITEt.l24E BV LINEI ~ 22 MEDICAID RESUBP.lISSIOPl
CODE I ORIGINAL REF NO
I 1847 .a_cervical sprain , L-,_ 23 PRIOR AUTHORIZATION NUMBER
2 1722 f! C5-C6 disc degeneration 'L-,
24 A 8 C 0 E , G H 1 J K
F'o~TE(SI OF SERV1CETo Plolce Type PROCEDURES. SERVICES. OR SUPPLIES DIAGNOSIS OA~;, i~~;~; RESERVED FOR
01 01 IE,pla,,, U"iSU.11 C,rCllmSlances) CODE S CHARGES OR EMG COB LOCAL USE
MPA DO VV MM 00 VV SI!rv , 'N CPT HCPCS MODIFIER UNITS PO,
,11 , 10 95 , 3 97014 I EMS 1-2 20 00
,
11 10 95 3 97530 I KE 1-2 20 00
211 13 , 95 3 99212 OV 1-2 20 00
IJ..L J.,j ~:J ,j ~/UJ.U n.. J.-~ LV .UU
11 : 13 : 95 3 . 97014 I EMS 1-2 20 00
,
11 13 9:. ,j KE J.-~ "-u .uu
11 20' 95 3 99212 IOV 1-2 20,00
,
11 2u ,,~ l,j "'UJ.U n.. J.-~ "-U:UU
S 11' 20' 95 3 97014 I EMS 1-2 20:00
11 20 95 3 97530 KE 1-2 "-u:uu
, I
6
25 FEDERAL TAX I 0, NUMBER SSt~ EIN , 26 PATlEPlT 5 ACCOUNT NO ! 27 ACCEPT ASSIGNMENT1 28 TOTAL CHARGE I~ AMOUNT PA,ID 30_ BALANCE DUE
! (Fo(OO~1 cl",m~. seeb.lck)
163-58-0267 [~]D .OVES 0"0 S S
31. SIGNATURE OF PHVSICIANOR SUPPLIER 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33 PHYSICIANS. SUPPLIER S BilLING ~lAME. ADDRESS. lIP CODE
INCLUDING DEGREES OR CREDENTIALS ; RUmERED (II elher than homo er OHiCe) & PHONE.
II CtlrtlfylhalIhtlSlalementsonlho'Eh'If5e GREGORY T. REESE, D.C.
gJt:~'~'"h:~0~'9~ 18 Courtyartl ONlce. Rt. 11 & 15 - S.lIn.grova, PA 17870
Telephone: (717) 743.2342
RE604347 I GRP,
SIG~IED DATE I PIN.
~
~
..
(APPROVEO BY AM'!' COUtlCll ON MEDICAL SERVICE 8 8&)
MId. by M~lul Arts P'"s
C.lloII-l," 1,t(X)U"ZI19
PLEASE PRINT OR TYPE
FORM HCFA.l!1OO 112-90)
FORM OWCP.l!1OO FORM RRBl500
U"lI- .tMlI
lh. ..1~1~.tCe>eII<ll,~~]" tltl&4 IM.1 win
APPIlOVEO 01.'8 09)8 C~:d
PLEASE
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HEALTH INSURANCE CLAIM FORM
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(Mfdi:,JI.'J /AfK1c,Jd.1 (Sponsc,sSSN) I\'AF,I(I ',1 -- fSSNOIIO/ r-j ,SS,o,J1 ~ linl
2 PAllENT 5 NAME IL.uINoIm, hsl NJmtt. MdJ'e IMloIl, J "A Ti04I S UIAlli UAIl SE'( 01 Iti5UHEO S NAME \lont 'jJme Fit" fl.1'T1tt. M'.loJ!" Ir,t .11) I
o(I.4M no yy
Roberts Sv1via 6 12 39 " I-l ' c-I same
~ PATIENT S ADDRESS (No. S:I"l) 6 PATIUH RHATIOfi51fP TOIN5U~t.O ~ ItlSUREO S ADOII[55 (tlo SU"oil)
I
RR5 Box 221A S"II>CJ 5DOu\or] Ch,ldrJ '-l
C!~,,'.__
I STATE 8 PATIEtll STATUS - I STATE
CITY CITY
Selinsorove Pa s,,,,"[j ""''''.[1 0'.. [J
liP COOE I TrEPHO;IE 11",Ilil1lf .\l'M Code, :PCCD[ I '''("''ONE )'lClUOf ""A COO"
EnlP'Oledrl Fun T,meO P,J': T"'..-,] ,
17870 I
.... Student _ _ St~e'~I! j
9 OTHER INSURED S NAME IloUt Uame. f,rst tl"m.. ModdlU IM'al, 10 IS PATIWt SCOfIOltlOtl RElATED TO , 1 ItjSUREO S POliCY GIlOUP all FCCA tlUl.lUER I
,
I
a OTHER INSUREDS POLICY OR GROUP NUMBER a EMPlOYMUlr'tCURRWT OR PP::'.'tOUSI I ItjSUREDS OAt( OF BIflItI 50. I
[il"O f,tl,l 00 yy
D'ES "'rJ , r:
, I
b OTHER INSURED S DATE OF BIRTH SE' b AUTO ACCIOUIP PI..t,CEISllf.! o EI,IPLOVEfIS tlAME. 011 SOl00L ~l"'.I[ ,
"" 00 yy , "n 'n cS. YES OliO !
c EMPLOYER S NAME OR SCI100l NAME c OTHER ACCIDWP : ItlSURANCE PLMI NAME OR PROGRAM NAME I
D'ES xO"O
II INSURANCE PLMI tlAME OR PROGRAM ~lAI.lE IOd RESERVED FOR LOCAL USE :l IS THERE MjOTHER IlEALTH BEtlEfll PLAIP
DYES OliO Hr.' Ifl",,,, to and cc"'p't/le ItUfT' j I a I
READ BACK OF fORM BEfORE COMPLETlUQ & SIGNING THIS fORM. '] INSURED S 0.1 AUTHORIZED PERSON S SIGtlATUR(; l,lul"c':\I .
12 PA llENT S OR AUTHORIZED PERSON S SIGtlAlURE I author,ze 11'le1",1~.u, cl "n~ mltdc.u or Olht<,.nlorm,J:,:' ~t:eH"r, p'!,mer.1 cf ml!'j'CJI btlnoMs to II''' un(h!l).g'100 phIS C..Vl or ,,,,Pt' <t' ler
to prlX"S thIS cla,m l,t'so re-:;~esl pol,menl 01 Q:lv,rnml'nl ~"er.1s ,,!he' to mysellOl 10 the p.lrly ....110 acc('plS aH ;~-,,~r sN.,ces d~s.c'~d 0010","
"'..
SIGtlED sianature on file DATE 7-5-95 SIGtlED signature on file !
14 DATE OF cunRUH ~ ILLtlESS IFlfsl symploml on 15 IF PATIENT HAS !fAD SAME OR SII,l:l":; IL~'iESS 16 DATES PAllEtll UflABLE TO WORK IU CUnnE'l', OCCUP'" T:C~j
6"'" 3000 95Y IIjJUAY fAcClde,," OR GIVE fIRSTD'ATE Mt.l 00 y, I.lM 00 yy "... 00 y, i
PAEGtl,\tlCYlWP/ fROM TO
17. NAME OF REFERRING PHfSICIAN OR OTHER SOURCE 17.1 10 flUMBER OF REfERRI~IG PtlYS,:'~~' 13 1l0SPITAUZATIO" OATES RELATED TO CUAREtlT SERVICES
W" 00 yY "",I 00 yy
fROt.. TO
19 RESERVED FOR LOCAL USE 2J OUT SID'=. lAB' S CllARGES
DYES OliO I I
21. OIAGtlOSIS OR flATURe OF tlWESS OR INJURY. IRE LATE ITEMS 1.2.3 OR" TO ITEM Z4E BY L1NEI + .22 MEDICAID AESUBMISSlor~
CODE I ORIGlt~AL Ref fjO
l.~, ~ervica1 sprain , L-,_ ,
2) PRIOR AUlIlORllATIOtI NUMBER I
,1lU. C5-C6 disc degeneration 'L-,
" . 8 C 0 E , G " 1 J K
FrJ>mATEISI OF SERVICETo Plolce T,,. PROCEDURES. SERVICES. OR SUPPLIES OI.l.O';OSIS ,OA' EPSO RESERVED fOR
" " IE_pla." Un~SU.lrCIIClJmstJnces) CODE S CHARGES OR Fam.r, EMG C08 LOCAL USE
MM 00 yy MM 00 yy " " CPT HepCS I.lDDIFIER UNITS Po, ,
99212 I OV 1-2 20 00 I
1 11 21 95 3
11 21 95 3 97010 I HP l-l 20 00
,11 21 95 3 97014 EMS 1-2 20 00 ,
11 21 95 3 KE l-l 20 00
,11 ' 29 95 3 99212 I OV 1-2 20 00
rrr 29 95 3 HP l-l ~O\J{J
,11 29 95 3 97014 I EMS 1-2 20 00
III 29 95 .3 97530 1\'" l-l ~O\){J
12 : 04 ,95 3 99212 I OV 1-2 20 00
,
12 04 95 3 97010 HP 1-2 20 00
, I EMS
,12 '04 '95 3 97014 1-2 20 00
25 fEOERAL TAX I D 'lUMBER SStl EIN ,26 PATlEUTSACCOUtHtlQ 27 ACCEPT ASS:G'.I.lWP ZEI TOTAL CHARGE 129 AMQUPlT PAID 30 BAWiCE DuE
tFo. go~1 CI",,,..~ lee MellI
163-58-0267 [RJ[J , n 'ES 0 110 I 220 00 I 00 I 220 00
31. SIGNATURE OF PHYSICIA" OR SUPPLIER 32 flAME AND ADDRESS OF FACILITY WHERE SERv:CES ,^ERE 3) PtlYSICIAtl S. SUPPLIER 5 BILLING UAI.'E. ADDRESS, liP COOE
IflCLUDltlG DEGREES OR CREDENTIALS A[tlOERED I" Olr." tt1"n homo Of oN"" &PIiOtlE,
{ICtrtlly lhaltll. slaltm,n!S en tho IltVGfJe GREGORY T. REESE, D.C.
~~".m'''''''"Ih'''OII , 18 Courtyard 0lfIc.. RI. 11 & 15 - Sal~lg'ova. PA 17870
< "-'1-'r/r i Taraphona: (717) 743.2342
! RE604347 I nAP'
SIGNED DATE PIN'
~
~
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(APPROVeD BY AMA COWlCrL ON MEDICAL SEnvlCE 8 BSI
Mid. b)' ""fdal Arta Pr'lS
CtlloIlrK IIl>>JlI-lI7t
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FORUHCFA1'!lOO 0290)
FORM OWCPI~ FORM RRBlm
u,..u-.:t<6lJ
U....r~I~.._.1'14"........"..'I.I..\..-.....
PLEASE
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, .PICA
HEALTH INSURANCE CLAIM FORM
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, F 0 H , J K
OIAG!IQSIS O~!S "SO, RESERVED FOR I
CODE S CHARGES OR Fam,ly 'MO COO LOCAL USE
UNITS Pldl'l I
1-2 2000 ,
,
1-~ ~u uu
1-2 20 00
-1;...2 ~u uu
1-2 20 00
l-l lOllu
1-2 2000
l-l ~u uu
1-2 22 00
1 Ml;OICARE MEOlCAIO CtlAMPUS OiM.'f'''''' (~fiUUf' fleA
.--. . .-. H(AI lli I'LAtl Ill~ llJN(j
li (Mt'd-C.1/It" I 11""t'd,t-old I) t IISjXJllWS 55N) 111\'.1 r'o" ~ J_(.:.:~'~~~l~lj~j-J~~)_
;1 PAllEN I 5 flAME ,la~1 N,lm\t. Fl/$l NJntll_ M,(jlj'lIlrJ'.}11 --rnA TIUlI S (liIHlt (lA IE__ 5[
Roberts Sylvia 10'6' f~ v:l9 I,' II _~lJ_
$ PATIOlT 5 ADDRESS ltlo. Str"lIll ') PATI[NT RElA'K)".SltIP TO IIj~jlJ'l{D
RR5 Box 221A
5..11 L_~ SfI'lll\{ -J C"':'l~ _] O'~~<--l
a "AlIE1.1-siA~------'-
1
-'TSTATE
Se1insgrove I Pa
liP CODE 17870 I ';lEPHO)E tlr(l..doj A.t'J CO~l
9 QhiEn INSUREDS tlA/'!E il.HI N.lme, F"" 'Iii"''' t.llll'01I'1t,.I,
lrf'l-lo,l1d ~l Fy' T""Il( ~ P.I'l T ~oI"-1
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1-1"0
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b OTtiERlflSUnEDSDATEOFDlrml so.
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1.11 I Fr"
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c EMPLOYER 5 flAME OR SCtlOOl NAME
c IfISURAt/CE PLAN flAME OR Pf1QGIlAM NA'''E
[1m ~]"o
led RE":lEI\V[D FarllOCAL USE
READ BACK OF fORM DEFORE COMPlETltIO" SIGWIlG THIS FORM,
1~ P'\ IIEtlT 5 011 AUTHORIZED PERsm. 5 StGtlATUA[ I o11J~~'~':" 1~'1 r~.. t,.. 01 01'" m...dit:.1! or Olt'll' ,"lo/ln.l1,01l r..:l!S\.111
I,) plOCIlU tl'.\ 1:1am I al~o leQlJl'~1 pat""!'ll cr ~ovt'lnlTt!n' t""t!Tl~ f i~"1 To) m,Sl'il or 10 l~fj p.lIl, oloho "CCt'l-il~ .J5~o<;;rTl'rl
twlo-,Jlf
SIGNED
siqnature on file
7-5-95
DATE
U DATE OF CURREflT ~ IlLPJESS tr.r~l \'"'P~019l1 OR
..J..u.1 Jl.o 'f...Y5 Iwun't tACCod>;!r.l) on
utJ JU ':1 PREGflArlCY(lMPI
17 flAME OF REFERRlflG PttvSICIAU on OTHER SOURCE
'I '5 If PATIDH UAS HAO SAI,1E OR Slt.IILAR ILLtlES5
G"IE nAST DAT~ "'''' DO YV
I' ,,' '0 "U','"'' OF W'''",,,o P"vs,c.."
19 RESERVED FOR LOCAL USE
21 DIAGt.OSI$ OR tlATURE OF ItltlESS on ItlJUAf IRE tATE nu~ I 2 30R4 TO ITEM 24E BVlltIEI---'
, ,847 ,~cervica1 sprain , l_. _ T
~ 2 1 722 4 C5-C6 disc
~
" A
Fro~TEISIOF SEf1V1CETo
Mt.l 00 YY WA 00
degeneration
o C
PI.1CII T~ce
01 01
VY fOr.., S"''tc
'L-.
o
PRocmuRts SERVICES. OR SUPPLIES
CP T I~~~~ Un~\ut~~I~~E~~.t'lC""l
, 12 04 95 3 975~E
112 06 95 j ~92r )V
,12 06 95 , 3 97010 !HP
III Utl ~:J j ~70r" eMS
, 12 06 95 3 97530 ~
112 29 95 j 99212 )V
.12 29 95 3 97010.J{P
12 29 95 j 970Pl ::MS
,12 29 95 3 97035 I US
6
25 FEDERAL TAX I 0 'lUMBER
I
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26 PATIENT 5 AGCOUm NO 27 ACCEPr ASS:GW.lENP
lFo' god cta,m~. \eeb.'c.~1
[l YES 0 "0
32 'lAME MOO ADDRESS Of FACILITY \'rnEAE SERVICES weRE
RErmEREO (t! om>;!, thJn homo 0' office)
163.56.0267
fX] [I
31 SIGNATURE OF PHY!..IC1M,OR SUPPLIER
l~lClUDtNG DEGREES on CREOHHtAlS
II certl'tlMllhu\1.11emenl\onttltlIlJ',('I':iO
[pit 10 lri boll and ar,ffi.Jd0.1pJrllhNeo1,
\G.,....~ ,_'I.f"
SIGNED DATE
IAPPROvED OY AM" COUflell 01' MEDICAL SERVICE 8 66.
MId. by Mtdiul Arts p,...
C~'lol"" IIOOU"llt
PLEASE PRINT OR TYPE
0111[11 I.lltI5UREDSID NuMlllll II 011 1'1l0GIlM,l III 11lM II !
CLj 1552005793 I
___________________1
.& lI,'jUfllO~; flAt.l[ Ild\l f"I"'" f'or~l f..l'l'" '.!'Il'hll'''';'':1 I
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, l!l!JuRED'i AOOll[ 5~ I~l[) 511111'11
.1 l~jSUREDS DATt:: Q!: DlfHtl
!.1M 00 yy
so.
MD F[]
II EMPlO1'EH S UA"'E 011 SOIOOl flAME
c ltlSURMICE PLAN flAME OR PROGRAM flAME
d 15 THERE AtIOTHER t,EALHl DEtlEnT PlA~P
rlYES [l NO If)'.. felufntoarldcomp.I!''''lcm!),ld
I] ItlSunEO S OR AUTtlORtZEO PEASON S SIGtlATURE I il:Jlrlc'.ze
pJyrrl'''IOlmt'dCJlbtlnt'r,l\tJIt''lur.dl!r\'I)f\OOph,S.CI.\'l or\up"'<,,Ior
\1'1'"."'" C,,-,5Chl)l!dbelow
S!O"EO signature on file
16 DATES PATI(tlT urlAOlE TO WORK ItlCURRHH OCCUPATIO!l
MM 00 yy MI,I DO YY
FRG'" TO
18 ttOSPITALII^Tlml DATES RELATED TOcunREtH SERVICES
1,11.1 00 YY Ml,l 00 yy
FROM TO
2~ OUTS.DE lAD' iCtiARGES
DvES ~
22 MEDICAID RESUDl.llSSIOfl
CODE
ORIGI~lAL REF NO
I
23 PR'OR AUTtmAIZATIO" ~lUMElER
28 TOTAL CHARGE
S 182 00
29 AMOUNT PAID
S 00
30 BALANCE DUE
182 00
s
33 PtiYSICIAN S. SUPPLIER S BllLI~m N"I.lE. "DORESS III' CODE
& PHONE'
DR. GREGORY T. REESE
18 COur1ylrdOff1c.. Rtl1 & 15 -SIUnlllrov., PA 17870
T.I.phon.: (717) 743-2342
RE~7 I
PIN' GRP'
tORM HeFA l!lOO (12901
FORM owep.lsoo FORM RRD l!lOO
I
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PO BOX 767
CANYONVILLE OK
97417
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15 PATIEUT STATuS
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, '0"'6 ~Cl.. 't.Y ItI:uRtIAcc.dclIllGR
,j U ~ 5 Pf1EG~IAtICV,LI.lPI
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DATE
15 IF PATIENT HAS 14,\0 SM1E OR SII.tILAR ILlflES5
GIvE FIRST DATE t.lt.. 00 VV
1,J 10 flUtl3ER OF R[FERRlrlG r,WSICIAtI
n RESER',rED FOR LOCAL USE
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970101
970141
975301
99212\
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1
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1
12 04 9!
12 04 9'
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12 04 95
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12 06 9!
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ROBER100-00 rx YES n "0
3Z flAME MIO ADDRESS OF FACILITY WHERE SERVICES WERE
RENDERED III e,her th.IM homo 0' OIl'Clll
25 FEDERAL TAX I 0 flUt.tBER
3
ssrl Eltj
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37-1255119
[Jrxi
31 StmlATURE or PHYSICIAll OR SUPPLIER
IIlCLUOltlG DEGREES OR CR[DEtmALS
(1ceft',InJtl~eltJ't'"....rllonlflllrhtllSO
~'R:..'m"""'I,"""OII
5'C"ED 02 0608.6
IAPPROV[Q BV AM" COUtlCIL Ot. MEDICAL SERVICE 8 eel
MldltrMtdiuIArhP"..
PLEASE PRINT OR TYPE
" ItlSURED 5 tlAME ILasl Ndme. FllSt Name, I..l,Qdillln".)11
-. ~VT.vIA
1 It.5UnED S ADDRESS INo . Strollll
BALDHILL RD RR1
CHV
IStAIt:
FRENCHVILLE PA
IIET~~~)";;;AR~A~;D~'
II lPiSURED S POLICY GROUP OR FECA NUI.mEA
liP CODE
16836
a IllSURED 5 DATE OF BIRTH
!.1M 00 yy
06 12 39 "0
D EI.1PLOVER S tlAME OR SCHOOL flAME
SEX
'x~
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HOLLAWAY INS
d IS THERE AflOHiER HEALTH BEtlEFIT PLAN'
o YES ex tlO "yeos rctvm to ard temp'>!l" ,tllm <) ad
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se...'cesdosc..bedDe;O....
SIGNATURE ON FILE
SIGllED
1'.3 OATES PATlErlT ur~ABlE rOWORK IN CURRENT OCCUPAtION
PM.I 00 VV MI.' 00 VV
fflOM TO
\8 HOSPITALIZATIOn OATES RELATED TOCUFlRENT SER'/ICES
MI.t 00 VV t.1M DO VV
FRQl.1 TO
20 OUTSlDE lAB" S CHARGES
DYES [X"o I 1
22 MEDICAID RESUBMISSION
CODE I ORIGINAL REF. NO
23 PRIO~ AUHiORIZATlON rlUMBER
,
G H
D~!::i 1t:_P::iuT
OR Famdy
UNITS Plan
I J
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RESERVED FOR
LOCAL USE
S CHARGES
EMG COB
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20 00
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2n nn 1
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30 BALANCE DuE
28 TOTAL CHARGE
21 AMOUm PAID
s 120 00 s n nn s 1?n. no
33 PHYSICIAN S, SUPPLIER S BtlLlNQ NAME, ADDRESS. ZIP CODE
A rHOt~E.
DR GREGORY REESE
18 COURTYARD OFFICES
SELINSGROVE ~A 17870
p"" 'iw, 743-2~42
JUnMHCFAl!lOO 11200)
FORM owep 15>00 FORM RRD 1500
11,"1: .~1l
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APPRoveo OMB O~J8 0008
J
HOLLAWAY I, _
PO BOX 767
CANYONVILLE OK
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2 PATlENTSNAI,.lEILuIN.IIrT>. rllllu.1f!'18....d(J'1IIn.h.)lj J f~~IE~.'6cP"H~.fATE SEX
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: PICA
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CIT~RENCHVILLE T;~'
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02 06 96
SlatlED
1.& DATE OF CURREtH ~ 'LLPIESS (F,'!.I S/mpl:;:"', OR
'0...16 1:00 't:!5 IIlJUR't' (A:;c'Cl'''n OR
,j ':1 PREmlAflCY,L',IP,
11 flAI.lE OF REFERRING ;::l1ys:crM~ OR OIllER SOURCE
DATE
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GIVE FIRST O,\TE 1,11.1 DO YY
Ii., 10 f.UI.mER OF REFERRING Pt1't'SICIM,
19 RESERvED FOR LOc.:.~ ~SE
21 OIAGPiOSISORflATU;:;~OF IlLPlESSOR I'UURY IRfLATE ITEMS 1230R4TOlTEM2lE D'(W~Et +
, ~7_0 J L-,_
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, 12 06 9' 3 C
, 12 06 9! 3 C
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PROCEDURES, SERVICES, OR SUPPLIES
CPTI~~~~~ Un~sui)~~til~~Es~J.ncesl
970141
975301
I
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CODE
1
1
25 FEDERAL TAX I 0 M,;'.'E~R
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l~;)' Q".I CIJf9l~ 11tU b,IC~l
ROBER100-00 rX Y(S [1"0
32 "AI.IE AND AODlIESS or r ACIlITY Wlt(fIE SERVICES WERE
RUWERED III Olh" Ifl.1O "0"''' 0' 0"<,,1
37-1255119
31. SIGPl"TURE OF PliYS:C:A~' on SUPPLIER
IIlClUO;f4G DEGREES Cl\ CRED[t~TlAlS
[(lC~'tINltf1"lollw...'~.'onlhlt'e,It'S'"
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5K;'" 02 060,96
,APPRovED IIY A'.l.\ ~GlJ'jCll n'l '.![OICAL SFrl\lIC[ tI ~1I1
Mid bJ' IoI,ehul Arh P,,,.
PLEASE PRINT OR TYPE
p,eA
If OR PfIOGflAI.' lrl ITEM I,
.. INSURED S NAME IL.nt fj.ame Fill Pldl'T'Q I,MIlI" 1".t,..I,
ROBERTS STIoVIA
1 If~SURED 5 ADDRESS INo 511e,h
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lJ ItlSUREoS OR AUTHQRtZED PERSOflS SIGll.\TURE I i)\J" =, U
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SIGNED
16 OATES PATI[fjT UPIABlE TQWJRI( I" CURREI,T OCCUPAT,Ol
"".' DO YY '.".1 00 YV
FROt.' TO
18 HOSPITAlIZATIO/l OATES RElATED TO CUnREm SERVICES
"'..' DO YY "'.., CD VY
FROM TO
20 OUTSIDE lABl
SCHARGES
1
DYES ex"o I
n MEDICAID RESUB!.'ISSIO~1
CODE I OAIGltlAl REF '.0
23 PRIOR AUTtl0RIZAIlOtl flUMBER
F G H 1 J K
0'!5 '501 RESER','ED FOR ,
SCHARGES OR folm,'y EMa coo lOC~LUSE i
UNITS P'ol"
20 nn ,
20 00 1
\19 AMOutlI PAID 30 (]AlAtIC[ DuE. .
40 00 I 0 00 I 4JLQQ:
J] PIlV51CtAflS SUflPll[n S "llUPi(j flA"'E. ADOllE55 Ill' CODE
"""01'.[_
DR GREGORY REESE
18 COURTYARD OFFICES
SELINSGROVE PA 17870
."" ?.li", 743 - 2342
28 TOTAL OMRG[
louMlle'" 1'11".1) tllrJl.)1
Inrll.' (h',Cfll~)) I Of II.' 1111111',1))
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PICA
..
APPAO....W 0"'0 09)11 0006
HOLLAWAY 1. .
PO BOX 767
CANYONVILLB OK
97417
HEALTH INSURANCE CLAIM FORM
1'leA
1 MEOICAll( MEDICAID CliAMI'US CtlA"'P'.'" LHOUP 'U;,\ Q"llIl 1,1 Ir.~lJrH:U51 0 FlU....tJUI IfOIlI'IIOC.flM,' rtjllt '.' IJ
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2 PAIIEtH S NAME tl.nt NJm.. f,'~t NJmlt. ..Mdt. IMIJII J I~~,~IUH gJllfl1~'p"IE Sf J( . INS\)IIl() 5 NAME [l.nl tl.lmll. r ",' N,I'l'.. '" 'Milt IM..II)
ROBERTS SYLVIA 06 1L3.~~-'-DC .ROI:lSRTLS.Th"lIl\
~ PATIENT SADonESSlf~o SU.lI!j 6 PATr(NIIIHATlO'tSHI" TO Itj<jUlllD 1 IMlJllEOS ADOII[SS ltlo SIIt/tll)
BALDHILL RD RR1 S."I] s'~""'I] O,.>[] o'""lx BALDHILL RD RR1
~ CII~RENCHVILLE I ;~E'aP^T~~~,~~~~ILJ~""".", [I .G:~;- ~~~~N_C~IL~E_ J:;~
liP CODE 1'("8'P1"40')" 2""6""31.1<1 ""4"6c02"61 1II'coor I Tll[("8"ol"'4')'NCUJ(ll AlIlA CODE)
16836 ,",p""'r: I ~~:',:';,TI '~~::,:;;'i] 16836 263 4626
\.l OTHER It,SUAf.D S NAM[ Il.HI N.l"l" f.r'l ~1.l""tI M dO'" IMJt) 10 IS PA Tlr~jt s c6tili-ITIQtIlIUATTb-jo--- II ItjSUIl[[J 5 POliCY OflOUP 011 FlCA 'lU"'Ol n
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READ BACK OF FORM BEFOAE COMPLETltIO & SIGNING THIS FOAM.
'2 PATIE~lT 5 C~ AUttlORI[EO PERSQt, S SIGtlATURE ',lI"lr-CI1:e It.. h=IIJJ~~ C, Jf'f I'!"lJdCJt or ct',t" H..,I;'I'!"]~:f' r"::l!\~,I"t
I", Ilr;c,>, lh.! cu,m I also request C"1m~rt ot gJ;~f"I'it'''1 benel.!S e 'Ill'f to "';...., or III 11'p. p.I'I/....I1O J~~..t." a;~,~..fT'.."t
D~I,;....
SIGtlEo
14 D^TE OF CURREtIT ~ ILLflESS IF.rst s)'rrt'C"', OR
W.' 00 VY INJURY IAcc,.j~f1t) eR
PREGNANCY1LP.IP,
17 tMME OF REFERRltlG PHYS1CIO\U OR OTtiER SOURCE
19 RESERVED FOR LOCAL USE
02 06 96
Oo\T(
, S IF PAtlEtlt tio\S HAO SM.'E OR SI'.',LAA ILUIE 55
GIVE FIRST DATE M'" 00 yy
I ~J 10 ,.uMBER or flEFERRltlG PHl'S'C'MI
2t 0IAG~lOS15 OR UATURE OF IlL~ESSOR ltlJURY (RElATE ITEMS I 2 JOA" TO ITEM 24E BV llrjE) ~
1 I 847,.Q J 1--._ T
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00 YV MM DO
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Place Trill!
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".1.1
, 12 29 9! 3
, 12 29 9! 3
J 01 04 91 3
. 01 04 91 3
, 01 04 91 3
-
r, 01 04 91 3
~5 f[DERAL TAX 1 0 'lUMBER 59. Wl
. , G H , J K
nlAmlOSIS DAYS EPSO' RESERVED FOR I
on Fd",!11 i
CODE SCI-I,\RGES UNITS Pl..1n EMG coo LOCAL USE
1 , ~ nn , i
,
!
1 20 00 1 ,
!
1 ,
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,
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20 00 1 ,
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(ElplJnUnusuJIC"cumSIJrlCIISJ
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992121
992121
970101
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970~_5.L
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pl,:"'".."1 ul tl"1~l'.ll !It''It!.IS 10 Iflu lJ..tl~fS g....d p~.,S,C,.l" :. ~~POI lOt 10'
\l'f'.'~"'S ",,\(;r,l:tod bt!'",',,"
SIGNATURE ON FILE
S'C,!,EO
Iii OATES 1'.\ TIE tiT UNABLE TO \'/ORK I'l CURRWT OCCUP^tIQtj
'.1M DO YY !,1M 00 YY
FRe'.' TO
16 ~jOS?IT AUlA Tim/ OATES RElA TED TO CURFlENT SEf1VICES
1.1'.1 DO VY /.11.1 DO VY
FADM TO
20 OUTSIDE LAEP S CHARGES
D'ES ex"O I 1
22 MEO_CAIO RESUOMtSSIOtl
CODE I ORIGINAL REF NO
2J PAIOR AUTtIQAllATIOtl tlUMBER
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DR GREGORY REESE
18 COURTYARD OFFICES
SELINSGROVE ~A 17870
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DR GREGORY REESE
18 COURTYARD OFFICES
SELINSGROVE PA 17870
7iL,"I, 743-2342
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CODE I ORIGltlAl REF NO
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o cei'U,II'lJI1M S"l\l'':"''~U on t~e III~OI5d GREGORY REESE
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SELINSGROVE PA 17870
SIC"EO 03 0108..6 Pill' i~.743-2342
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97 00 s 0 00
3J Pti'tSICIAN 5 SUPPLIER S (JILLltlQ NAME. ADDRESS. liP CODE
bR:o/"l;REGORY REESE
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SELINSGROVE ~A 17870
PI,,, -/a.;~. 743-2342
28 TOTAL CHARGE
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97 00
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SIG~IEO DATE SIG'IEO
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SUNBURY COMMUNITY HOSPITAL
GENeRAL DIAG"'OSTIC
X.RAY REQU. .ION
SUNBURY COMMUNITY HOSPITAL
350 North Elovonth Stroot
Sunbury, PA 17801
(717) 288.3488
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Rob~, ", Sylvia L.
130 S. Front St. Apt 210
Sunbury, PA 17801
286-3138 (mother)
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DOSj 6-12-39
Or. Reese
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EXAM;
MRI C-spine
89852
ea-m
1:40pm 1-5-96
CLINICAl.INfORIoCATIONtSYMPTOMS:
SIP MVA, neck pain, ? abnormalities.
mkt
RADIOLOGY REPORT:
dtl 1-5-96
PKT/klw
MAl C-SPINE.
Multiple 5 mm. sagittal Tl. fast spin echo sagittal T2 and axial Tl
wolghted Imagos wore obtained. No prior studies available for comparison.
Films show normal height of the cervical vertebrae. No evidence of any
acute oompresslon fracture. Mild disc degenerative changes present at C-3-
4-5 Interspaces with small osteophyte formations. Sagittal view shows
extrinsic pressure along the anterior a~pect of the thecal sac at tho level
of C-3-4 and C-4-5 Interspaces wel I demonstrated at C-4-5 and also noted on
axial view at the same level suggesting centra) disc herniation with
questionable superimposed osteophytosls from arthritic changes. The
pressure at the levol of C-3-4 most probably secondary to osteophytosls
with questionable small central disc bulging. No other evidence of any
acute herniation. There Is minimal spinal stenosis at the levol of C-4-5.
Visualized spinal cord shows no other Significant abnormality.
IMPRESSION, Central disc herniation at C-4-5 with mild spinal stenosis at
the same level. Extrinsic pressure at the level of C-3-4 anteriorly
suggests osteophytosls, arthritic changes with qucstlonable smal I central
disc bulging. Clinical correlation advised. If prior x-rays available for
comparison they would be helpful.
\A,J
P.K. TILVA, M.D.
MEDICAL Bill OF
RADIOLOGICAL ASSOCIATES
IKE CHECKS PAYABLE TO:
RADIOLOGICAL RSSOCIAT~q
PO [cOX '.08 pr~ACTICINI .T SU~IBUr~Y HOSP
DANVILLE PA 17821
THIS BILL IS FOR THE
PHYSICIAN CHARGE ONL.:
cor(p WI
Account No. Amount CUI
0043666 125 00
Dale Amount Enclolld
(:);:1 HI r~~, ,I
'1
SYLVIA L ROBEIHS
TO: 1 am S Fr~O~1T ST
APT 210
SLJI'IBURY PA 17801
O,lach O.IQ"" al P.rforal,on Olnd Reluln Ihl' Po~ on Allh Pilymenl
o,t. Or. PaU.nl Nam. Proc. Cod. D,.crlptlon Ollg. ChtglJPav lI.mBlllne
BILL NGI QUIRIES 0 ~ QUESTIO ~S PLEASE REFER TO BACK OF T IS STATE MENT
I. 05 '3E>0207 SYLVIA 721111 I'IRI SPINE CERVICAL W 0 E81'3 125 00 125 01
COIHRAST
Account Number BILLING INQUIRIES 800.522-4759
, l 800.326.8369 PAY THIS AMOUNT
, 0WI3&E,& 125 0
HOURS: 9:00 .12:00 AND 1:00.4:00 MONDAY THRU FRIDAY
· PAYMENTS RECEIVED AFTER THE 30TH OF THE MONTH WILL NOT APPEAR ON THIS STATEMEt\
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. Q7-lib6.? &-V-d ,~
,
I
~
I
"
I
I
SYLVIA ROBERTS,
v.
MARY McLAUGHLIN,
Defendant
JURY TRIAL DEMANDED
.'
!
COMPLAINT
1.
Plaintiff Sylvia Roberts is an adult individual, who
f-
resides at RR 1, Box 269, Frenchville, Clearfield County,
Pennsylvania.
2. Defendant Mary McLaughlin is an adult individual, citizen
of the Commonwealth of Pennsylvania, who resides at 526-C West
Simpson Street, Mechanicsburg, Cumberland County, Pennsylvania.
3. The facts and occurrences hereinafter related took place
on or about June 30, 1995, between 12:00 p.m. and 1:00 p.m., in the
drive-thru line at the McDonald's Restaurant, 6200 Carlisle Pike,
Silver Spring Township, Cumberland County, Pennsylvania.
4. At that time and place, Plaintiff Sylvia Roberts was a
passenger in a Mazda pickup truck being operated by Ted Roberts,
and was stopped in the drive-thru line at McDonalds.
5. At that time and place, Defendant Mary McLaughlin was
operating a 1992 Toyota Camry and was also in the drive-thru line
at McDonalds, and was directly behind the Roberts vehicle.
l08847/CLM
6. At that time and place, Mr. Roberts's vehicle was at a
complete stop, as they were at the takeout window waiting to pick
up their order.
7. At that time and place, Defendant Mary McLaughlin
operated her vehicle at a high rate of speed and violently struck
the rear of the Roberts stationary vehicle.
B. The foregoing accident and all of the injuries and
damages set forth hereinafter sustained by Plaintiff Sylvia Roberts
are the direct and proximate result of the negligent, careless,
wanton, and reckless manner in which Defendant Mary McLaughlin
operated her vehicle as follows:
(a) failure to keep alert and maintain a proper watch
for the presence of other motor vehicles on the
highway or in a parking area;
(b) failure to apply her brakes in sufficient time to
avoid striking the Roberts vehicle;
(c) failure to travel at a safe speed;
(d) failure to keep a proper watch for traffic on the
highway or in a parking area;
(e) failure to take reasonable evasive action to avoid
the accident;
(f) failure to drive her vehicle with due regard for
the highway and traffic conditions which were
existing and of which she was or should have been
aware;
(g) failure to keep proper and adequate control over
her vehicle;
2
SYLVIA ROBERTS
PLAINTIFF
v.
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNA
: NO. 97.1662
: CIVIL ACTION - AT LAW
: JURY TRIAL DEMANDED
MARY McLAUGHLIN,
DEFENDANT
Respectfully submitted,
NOTICE
TO: Sylvia Roberts, Plaintiff and her attorney
Richard A. Sadlock, Esquire
ANGINO & ROVNER
4503 N. Front Street
Harrisburg, PA 17110
YOU ARE HEREBY NOTIFIED, that the New Matter set forth herein contains
averments against you to which you are required to respond within twenty (20) days
after service thereof. Failure by you to do so may constitute an admission.
NEALON & GOVER
'ar~
By:
James G. Nealon, III, Esquire
Atty. 1.0.#46457
301 Market Street -- 9th Floor
P.O. Box 865
Harrisburg, PA 17108-0865
(717) 232-9900
NEW MATTER
16. Any damages to which the Plaintiff is entitled are to be reduced in
whole, or in part, in accordance with the Pennsylvania Motor Vehicle Financial
Responsibility Act, 75 Pa. C.S.A. ~ 1701 et seq.
Respectfully submitted,
NEALON & GOVER
By, . C\' QJCJ7
James G. Nealon, III, Esquire
Atty. I.D. #46457
301 Market Street -- 9th Floor
P.O. Box 865
Harrisburg, PA 17108-0865
(717) 232-9900
AND NOW, this 17lh day of April, 1997, I hereby certify that I have served
the foregoing Answer with New Matter on the following by depositing a true and correct
copy of same in the United States mails, postage prepaid, addressed to:
Richard A. Sad lock, Esquire
ANGINO & ROVNER
4503 N. Front Street
Harrisburg, PA 17110
James G. Nealon, III, Esquire
SYLVIA ROBERTS
PLAINTIFF
v.
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNA
: NO. 97.1662
: CIVIL ACTION . AT LAW
MARY McLAUGHLIN,
DEFENDANT
: JURY TRIAL DEMANDED
PRAECIPE
TO THE PROTHONOTARY:
Please enter the undersigned's appearance on behalf of the Defendant,
Mary McLaughlin, with regard to the above-captioned matter.
Respectfully submitted,
NEALON & GOVER
LL'
{.'!l. - (77(J?
By:' ~
James G. Nealon, III, Esquire
Atty. I.D. #46457
301 Market Street -- 9th Floor
P.O. Box 865
Harrisburg, PA 17108-0865
(717) 232-9900
.
AND NOW, this 16th day of April, 1997, I hereby certify that I have served
the foregoing Answer on the fOllowing by depositing a true and correct copy of same in
the United States mails, postage prepaid, addressed to:
Richard A. Sad lock, Esquire
ANGINO & ROVNER
4503 N. Front Street
Harrisburg, PA 17110
~
James G. Nealon, III, Esquire
Dated: 04/16/97
,
-.
SYLVIA ROBERTS,
Plaintiff
IN THE COURT OF CO~~ON PLbAS OF
cmIBER~ijD- COUNTY, PEm/SYLVANIA
v.
1'0.97-1662
CIVIL
19
MARY McLAUGHLIN,
Oefendant
RULE 1312-1. The Petition for Appointment of Arbitrators shall be substantially
in the following form;
PETIT-ION FOR APPOINTIlENT OF ARBITRATORS
TO THE HONORABLE, THE JUDGES OF SAID COURT:
Richard A. Sadlock, Esquire , counsel for the plaintiff/deiendant in
the above
l.
2.
action (or actions), respectfully represents that:
The above-captioned action (or actions) is (are) at issue.
The claim of the plaintiff in the action is Sup to $25,000
The counterclaim of the defendant in the action is
The following attorneys are interested in the cnse(s) as counselor nre other-
uise disqualified to sit as arbitrators: James G. Nealon, III, Esquire,
counsel for Oefendant
WHEREFORE, your ?etitioner prays your Honorable Court to appoint three (3)
arbitrators to whom the case shall be submitted.
Ric
t~cdt
Sa
, Esquire
ORDER OF COURT
AND NOW, ai:../'I tA.5 , 1997 , in consideration of the
foregoing petition, &f)~~ FA/Jail.. Esq., /)'J,'c),ALl. C),F1ZJ/l
Esq., and ~ L SA E.f?AI!.J ,ESq.~ are appointed arbitrators in the /
above-captioned action (or actions) as prayed for.
jJ. e Court,
~\~
.~~
P. J.
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eruted O:IJ06"~\Ol40<<
SL YVIA ROBERTS,
PlaintilT
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
I
MARY McLAUGHLIN,
Defendant
NO. 97-1662
CIVIL ACTION - LAW
I
If
vs,
TO: Richard A. Sadlock, Esquire
ANGINO & ROVNER
4503 N. Front Street
Harrisburg, PAl 7 I 10
James G, Nealon, Ill, Esquire
NEALON AND GOVER
30 I Market Street, 9th Floor
P.O. Box 865
Harrisburg, P A 17108-0865
NOTICE OF HEARING
YOU ARE HEREBY NOTIFIED that the undersigned aribtrators appointed by the Court in
the above captioned mailer will meet for the purpose of their appointment Friday, November 7, 1997
beginning at 2:00 p.m. in the second floor hearing room of the Old Cumberland CountyCourthouse,
Carlisle, Pennsylvania, at which time and place you may appear and be heard. together with your
witnesses and counsel, if you so desire,
DATED: September 17, 1997
!/v,A "'._ .a"} /l/~ JIi
~7 4U VW-U;l I \
,
George B. Faller, Jr., Esquire - Chairman
Michael A. Scherer, Esquire
Anne M,Shepard, Esquire
cc: Court Administrator's Office
Cumberland County Courthouse
Carlisle. PA 17013
SYLVIA ROBERTS
IN THE COURT OF CCMMCN PLEAS
~T ,~"" '~O"""'I.ffTf"r =,msVT ~!.., ~II~
''''\Ji'~....l~' ,J .....1.1.:. _, .. .....1 ~ ...... _.
v.
MARY McLAUGHLIN
No. 97-1662 Civil Term
NOTICE OF APPEAL
FROM AW..JID OF ::OP.RD CF A.liEJ.'l'_'(/l.'!'ORS
TO 'i'':'=; ?RCTECNCTJl3Y:
No'tice is given t~t Plaintiff Sylvia Roberts
e?peals :'::'00
the aVa1'd of the boua of eI'bitretcrs entered i::. t::.is case on
November 7, 1997
A jury trial is demanded L]1. (Cheek~ cox if a jury trial ~s
dernar.ded . Ct~e!"Nise ju..ry trial is ~.-ai 'led. )
I hereby certify ti'..at
(1) tr.e compensation of' the eI'bitretors r..as '.:leen ,;aid, or
...
~. (Stri!re out the "napplic
cJ.euse . )
. Sad ,EsQuir~ .
... _ .r,ttorr:e:r Ior Appellant
,l~: '!'he. demand for ju...ry trial on a;::peal
from com~lsory arbitration is g~~rned
by !M.e 1007.1 (b).
('.:l) No aff'ida 'lit or '/eri:'icat ion is ::-e ~ ~ec .
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v.
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNA
: CIVIL ACTION. LAW
! ,
;~
I,
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: I
SYLVIA ROBERTS,
Plaintiff
MARY McLAUGHLIN,
Defendant
: NO. 97.1662
: JURY TRIAL DEMANDED
VERDICT SLIP
~
1. Was the negligence of the Defendant, Mary McLaughlin, a
...
",b"""", f'~:: '" """9'"9 ,"",llh, P"'""W::'1-
~
,
t'
(IF YOU ANS\\1m QUESTION NUMDER I "No", TIlE PLAINTIFF CANNOT RECOVl,R ,\NO YOU SIIOULD NOT
ANSWER QUESTION 2 ,1.,,1> YOU SIIOlll.D RE1lJRN TO TIlE COURTROOM.)
~
,.
2. State the amount of damages, if any, sustained by the
Pain and SUffering
$
$
Plaintiff as a result of the accident for:
Medical Bills
Dated: j. /YdlCU:)j 3/ de; 8
\ " IdL '1?;.f'UIt )VUJC/u
OREPERSON