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CHARLES E. SHIELDS, III
.4.TroRNEY..4.l'.L.4.W
6 CLOlISER ROAD
CO'M' o/l'rlttdt.. and CIoU/M, R04d..
MECHANlCSRURO. PA 17055
GEORGB M. HOUCK
(l9t2<lt91)
TBLEPHONl! (717) 766.0209
PAX (717) 795.7473
Jllcquellne M, Vel'llr1I' Esq.
.I.!Y FACSIMILE 0 L Y - 243-3518
Novembcl' 2, 1998
R. Mark Thomas, Esq.
BY FACSIMILE ONL Y - 697-2J2.2
Michael Schel'CI', Esq,
BY FACSIMILE ONL Y -249-5755
Michael Pykosh, Esq,
BY FACSIMILE ONLY - 975-2309
RE: Al'bitmtion Mceting
Natalic Keyser, ct al. v, Paul Andrcw Miller
Cumoerland County, No, 98-220S.Civll
Dear Sil'lMadam:
Plense be advised that I have been appointed to head thc arbitration pnnel for the nbove
entitled matter. 111m attempting to setup II henring dnte, Given the impending holidny season and
corresponding scheduling problems, it looks like a January 99 date will probably be best. It is .
requested that you look at your January 99 calendars nnd let me know whieh dates will work for
you.
Thank you for your attention to this matter,
Very truly yours.
(~J~a,J()cJ r. cJ..~fcL11t'
Charles E. Shields, III if!.)
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NATALIE KEVSER, .nd
DANIELLE KEVSER
PI.lntl",
v.
I IN THE COURT OF COMMON PLEAS OF
I CUMBERLAND COlJN1'\',PENNS\'LV ANIA
98- ~OS' CIVIL
I CIVIL A(."flON - LAW
PAUL ANDREW MILLER,
Derend.nt
COMPLAIIIiI
AND NOW, come the Plaintiffs, Natalie Keyser and Danielle Keyser, by and
through their attorney, Jacqueline M. Verney, E!;CJuire, and make the following complaint
against Defendant, Paul Andrew Miller, as follows:
I. Plaintiff, Natalie Keyser, is an aduh individual residing at 420 West Keller Street,
Mechanicsburg, Cumberland County, Pennsylvania, 17055.
2. Plaintiff, Daniene Keyser, is an aduh individual residing at 420 West Keller Street,
Mechanicsburg, Cumberland County, Pennsylvania, 17055.
3. Defendant, Paul Andrew Miller, is an aduh individual residing at 1117 Cook/in
Street, Mechanicsburg, Cumberlaud County, Pennsylvania, 17055.
4. On May 29, 1997, Defendant, Paul Andrew Miller, intentionally and with wanton
disregard for the individuals occupying the vehicle drove his automobile into the
driver's side of the vehicle owned by Natalie Keyser and driven by Danielle Keyser.
5. As a resuh of Defendant's intentional and wanton behavior, he was charged
oriminally with aggravated assauh, recklessly endangering another person and
oriminal mischief at Commonwealth v. Paul Miller. No. 97-1196.
12, As. result of the reckless, wanton .nd intentional.ctions of Defend.nt, P.ul Andrew
Mllier, PI.lntiff. Danielle Keyser, requests punitive d.m.ges be assessed.
WHEREFORE, Plaintiff, Danielle Keyser demands judgment in eKcess of$3,000.00
but Dot in e7(cess of$23,000.00, plus costs of this action.
Respectfl.i1ly submitted,
, '
(1---.,_. v~"JIh, Ie /'
~ Verney, Esquire ~
Supreme Ct. ID 23167
44 South Hanover Street
Carlisle, PA 17013
(717) 243.9190
Attorney for Plaintiffs
Date:
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lJAMAag ImpORT
06/03/97 at 15:10
251601197
,
Owner: NATALIE KEYSER
Address: 420 W KELLER ST
MECHANICSBURG PA 17055
1, B SMI7'H F'Ol~D INC.
nm HOUSE THAT SERVICE BUIUl'
1.2'l'H & MARKET S'l'IU:Wl'S
LEMOYNE, PA 17043-0606
(717) 761-6700-321.6
Kl~:YSE:R
D.R. 33089-0000426
Rat: Not 0n File.
Insurance Co.:
Claim No.:
Day Phone, (717) 697-2078..
Other Ph: ( )
DedUctible: $ N/A
91 MERC TRACER LTS 40 WHITE 4-1.8L"FI
Vin: 3MAPM148XMR628226 License: ANY2786 PA Prod Date: 0/ 0 Odometer:
Adj. :
Phone:
Automatic transmission
Power mirrors
Dual mirrors
Cruise control
Stereo
Cloth seats
Aluminum wheels
NO.
--------------------------------------------------------------------------------
Power steering
Tinted glass
Rear defogger
Am radio
Cassette
Bucket seats
Clear coat paint
91528
Power brakes
Body side mOldings
Til t wheel '
Fm x'adio
4 wheel disc brakes
ReCline/lounge seats
01'.
DESCRIPTION OF DAMAGE
QTY
PART
COST LABOR PAINT
MIse
--------------------------------------------------------------------------------
1 PILLARS, ROCKER & FLOOR
2* Repr LT Rocker panel outer panel 1 0.00 2 0 1..5
-~
3 Add for Clear Coat 1 0.00 0.0 0.6
4* Repr LT Center pillar outer 1 0.00 3.0 1.0
s* SET UP FOR PULL 1 0.00 --~ 0.0 F
6 REAR DOOR
7* Repl LT Door shell sedan 1 0.00 1.5 3.2 'I'-ll~
8 Overlap Major Adjacent Panel 1 0.00 0.0 -0.4
9 Add for Clear Coat 1 0.00 0.0 0.6
10* LKQ + 25% 1 0.00 0.0 0.0
11 Overlap Maj or Adjacent Panel 1 0.00 0.0 -0.4
12 Add for Clear Coat 1 0.00 0.0 0.6
13' NEWBERRY 1 0.00 0.0 0.0
14 Repl LT MOlding side wiLTS 1 41..00 0.3 0,0
15* WHITE/BLUE 1 0.00 0.0 0.0
16 QUARTER PANEL
17* Repr LT Outer panel to 3/93 1 0.00 3.0 2.4
18 Overlap Major Adjacent Panel 1 0.00 0,0 ., 0.4
19 Add for Clear Coat 1 0.00 0.0 0.4
20' Repr RT Outer panel to 3/93 1 0.00 3.0 2,4
21 Overlap Major Non-Adj. Panel 1 0.00 0.0 -0.2
22' Add for Clear Coat 1 0.00 0.0 0.4
Page, 1
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,
DAMAGE HEPOR'l'
06/03/97 at 15:10
251601197
KBYSIW
D.R. 33089-0000426
Eat: Not On File,
______~__~___~M"-----~.--~-----..-4--..--..--.,..W...._~_.._...__~_",._..______..__~.._H______
L n SMITH FORD INC.
'I'H1~ HOUSb~ '[,HN[' EmRVl CE BUlI/['
12'1'11 & MARKU:T S'l'RU:E't'S
LEMOYNE, PA 17043-0606
(717) 761-6700-3216
PART
NO. 01'. DESCRIPTION OF DAMAGE Q'I'Y COS'I' I,ABOR PAIN'I' MISe
-------_.._~---------_..----_.._----_....---_..----------..----...----------------------
23 . R EI\R SUSPE:NSION
24 * O/H Rear Suapension l,t Side 1. 0,00 3.S 0.0 M
25* Repl IJ'I' spindIo dIsc brakefl w/o ABS 1 154.22 Incl 0.0 M
26* Repl RT Control arm front 1 90.13 1.5 0,0 M
27* Repl 1,'1' control arm front 1 1.03.95 IneI 0.0 M
28* RepI RT control arm rear 1 108,05 1.0 0,0 M
29* Repl LT control arm rear 1. 108.05 rneI 0.0 M
30* RepI RT Cntrl arm bIt at crssmmbl' 1. 7,05 0,0 0,0 M
31* RepI l,rr Cntrl arm blt at crssmmbr 1. 7.05 0.0 0,0 M
32* RepI L'I' control arm bolt at spindle 1. 4.:\8 0.0 0.0 M
33* RepI LT Strut 1..8L 1 1.09.38 lnel 0,0 M
34 FRONT SUSPENSION
35* Repl Whl algnmnt algn fr whls 1. 0.00 2,0 0.0
36 MISCEl,LANEOUS OPERATIONS
37* RepI Cover Car/Bag 1 0.00 0.2 0.0 '1' - 5.00
38* HAZ. WASTE 1 0.00 0.0 0.0 'I' 3,00
39* CHIP GAURD 1 0.00 0.5 0.0 T_fLJ)..Q
-----.---------------------------------------------------------------------------
subtotal~ =00.;:- 733.06 23.5 11.7 328.50
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I)AMAGE REPORT
06/03/97 at 15:10
251601197
KE:YSF:H
D.H, 33089-0000426
Est: Not On ~ile.
L B SMI'~ FORD INC.
'I'HE HOUEJIi: "IINI' SEHV:rCE: BUIII]'
12TH & MAHKE'!' STHEE'I'S
LEMOYNE, PA 17043-0606
(717) 761-6700-3216
Parts n3.06
Body Labor 15.5 units @ $32.00 496 . 00
Paint Labor 11.7 units @ $32.00 374.40
Paint/l~aterials 11.7 units @ $16.00 187.20
Frame Labor 2.0 units @ $35.00 70.00
Meeh. J,abor 6.0 units @ $44.00 264.00
Sublet/Mise 328.~;0
-------------_..~--------------..-------------
SUBTOTAL
Tax on $ 2453,16 at 6.0000%
"
'i'
2453.16
147,19
-----------------------..--------------------
GHAND TOTAL
$
2600,35
--------------.----------------------------....
INSURANCE: PAYS
$
2600.35
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSUHANCE COMPANY
OR OTHER PEHSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM
CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A
FHAUDULENT INSURANCE ACT, WHICH IS A CHIME AND SUB,TECTS THE PEHSON TO
CRIMINAL AND CIVIL PENALTIES.
Estimate baaed on MOTOR CRASH ESTIHl\TING GUIDE:. Non-asterisk(-) itemsc\re derlvm\ fr(pm the Guido DR2MX91. Dat.lbaso Date ../9'1
Oouble asterisk(....) ltems indicat.e part supplied by a Sllppl1Cl' other than the original oqulpment manufaGtllrer.
CAPA items have been cat'tifjad for fit and finish by the Certifincl l\uto Pal'ts A.BfJociatioo.
EZEst . l\ prOd\lC't of CCC Information Services Inc.
Page: 3
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25446
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nit CIN'IRS, INe.
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CAMP H'I.I., MI7011
1717) 761-2121
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STRAWSER TOWING
105 Meadowbmok Road
New Cumberland, Pa, 17070
REPAIR ORDER
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774.5688
Enola
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DIFFIIINTl^~ ACCISSOtIlS
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-- ., WASH/POLISH Ql\S/OIUOllASr
TOW MISC.
'O'^~ ACCl.llOll6-TlII.l & TUIIS G.UIOl~IOllAH lO,^~ lIaY1C1 MIRCHo\>lDISI'
"-
ImMAfIs AIt KMIlA.OI I HllIl'f AUTHOIJU"f)t( AIQIIIIIP"" 'M)I~ 10... DtlN( o\lc...c WITH HlCU""" M"U,l.-.u, '00 AN() YOUIl fM"O'rm f--- To\)(
OND'. M4nllAL ADOtflONA,~ MA' OPt.",. 410\11 vtHlClI '01 M-'OSU Of lIJ1p<<;, ''''PfCl()Pol at 0111\11'1' AI 101'1' IISk. .\N mc,u MlCHA,NIC, 'If'"
1$ .to:NOWUDCfD 0.. AI(M "tutU ro ,lCUll 'HI AMO\NI Of 1IM113 HffUlO V" cot:)-
""~""IhII(OlIl~"'UIllf1IlQ~~IlItb.t...IlUftIlt~OI'r,,..wfItc,,"plktd.J"'INlII6rH TOTAl.
..',....,,....,~.....'""fII ,,"-';"'~....."i.
OfFl<:ECOPY "".....,D",-L',..~:."i ./.,:....:,1,.. _.._ . "OM U"",
,,~~~,,",l~' <i-i.~-i..u:.'\"'~"""':"j.J...' .., " '.......;... ;..~""~~~~~~~.-u.~::..\.o~~~'o.t.'e.U.\IU:...:.'~~J;J......,.'b.B..~~~~.;.'..::....
, aAY NOTICE '"!QU~p-.....,-" DATE OUT...~/fY../.o/l._IINflLI'( 't
FOR RetURN OF VEHIClEI ) IlllANCH NO. ...oj I 7
RENT.A.C R PI CALL2'1S-_pzoo CONTRACT 2925672
TEMPORAllY SUBStiTUTE AUTOMOBILE RENTAL AGREEMENT - .- ".w'll. Irnmll. conlract No .....
:~'t!;~~~~}7J.~;'- .. '--~==.=~~'- ... .. AEPI~~~~!;;VEHI~LE'~ .._.n~~I~i~A~~H..I~~f..
..2. ~C_.sf:__.. .. u, .... U~II NO~'_'_."~_'H=.'_~"'''_ ~~II NO~..'_:l_'t.'-'-l._ _..~
Clly '. SI.,,=,,,,,, Z,p a Lie NO..:................ ...._ .L..Io. ._N.'Oil,}./;' .".oN1LJo... '... _.
T.lepholle . !.a~{.~---.-LJ't..O.I. OTIif-j''$1 . 1M.~ I4LIf. ..
ay_ <J/ety....._____ _'!f2.?~~..il!'
POIic.yNO(J()lo7t!' 7{)/
Addition.I Drive' (II Cheek 80. "NOn.~ .- -....... O.iOOf Blflh
Licens. No
-sl.ie.-.......-ei..P'D.t.-.-
THIS AGREEMENT IS TERMINATED AFTER THIRTY (30) DAYS OF
RENtAL OR UPON Dl!MAND IY SPIRIT, WHICHEVER OCCURS FIRST.
~._.~ --.-
Liability. coIl,sion, comp,ehensiv. Insu,anc. 10' l.mpota'Y slbslllul.
8u1OmOtMle to be provided bV customer's eJ(isting Inturance, Customer
.eprllStnlS and wa"anl5 Ihat htlshe hu a valid poIrcy 01 aUlomolJl1e li.b,lIly,
conlslon. and comprehenSiVe", 'orce al the time oIlhi$ renlaland will maln1ain
thltss covor.ges during Ihe term ot thIS fOf1lal. II cI,Islorner's illsUlBnce fails tOt
.ny r..son 10 .lford covetage, customO( shall be solely responsible
~,/"V..)
_ '__.d ".. ~~_~_
-.......---.... ...-.
NTAL PAOTECT~.aaVF.RAOE IRPC)
In conslde,.lIon oIlhe paymenl of" per day by Ih.
cullomer, Spin' R,nl,A-(;ar ag,.., nol lo~uslomer 0' hl!lllier
Insuf1ll1C8 company responsible for Iheli,sl $~_._. damage
10 lh. ,"otal .ehlcle, p'_ IIIal Ihe vehl<:le is used end ope,aled in
conlurm'ly wllh the Ierm. 01 lhe 'anlal ag,eement (Cuslome, abuso nol
covered.) CUSlomer I1as Inspecled the rental .ohlole .nd acknowledges Ihtl
~~~:~s~~~~. ~.(~~~ ~"'~;"
Cuslomer dechnes purcha.e 01 "RPC' as stal.d above and ag'... 10 pay
"'rtl RanI-A.Cor 10' damages 10 0' '''0 01 Spi,II's 'enlal vehicle (regardless
01 Ilultl not covered by lhe cuslomer'a coli.Clabla Insurence. Cuslome, has
.nspecled lhe rental ..hlela "nd acknowledges lhal .11 damages a'e noted
Cuslomefs Slgnatu.., ...
'flt ''''. .. "" ..
~ :1-.t,'j(.. It~_~
.~I - -~- - -. ---
AMOUNT
ere.
e4,
_"1,/.... (l'
...-
CASHICKlCC
INTERSTATE VEHICLE OPERATION TO
AUTHORIZEn n~._._.._P ?F._____.
..___..__._~_..... ..._.. .... _5-:.~~~~:mA~NL. __._ _ .
o
a:
~tz
...ii:
-n.
o~
ll!
u
~~82 5101 20~2 80b2
la.., I Il":~/" ~
. ---ii Vf.HICi.EiNSPECTiQN-------
E.le'io'Oamage_._.~.e __.._.__._. _._...__.. ._.. ._.
InlerlorDamage.e.~_._ ........_. ____._
Gla.. Damage . __'___n.
- ,'-'
Gas f_JLL_.!!LJL....fJ Sclera & Tools 7/1'",<:;
~===;=.:=c=..::..=~.-f- f/-' . ....
---4- DAVS 0 .-2!. ~_-1~-=- if '1_
MONTHS 0 ___ _ _ -.tl CJ Q.
(p APe DAVS 0
MISC. CHARGfSKlAF.OITS
SUBlOT AI.
SALESTA,^-l % ......__"_
FLlEl. CHAAGF
TOTAL CHARGES
nlLl TO COMPANY
TAX 10.34.1614162
.~OTAl ...... .!$%'~.~_
~ LESS OEPOSITS
BILL 10 RENfER
---~-_.__._----_.
Renter e.p'~.lty Qcknowledoes and ag(..s that
. No one e)lupt 'Inlll 01 an authollzed licensed driver over the ftgo or 21
may uae or upera'e lhls whk:le.
. Rllel 1(8 bated on calendar days only.
. AMID I shatllMMEDIATEl Y report 6111 a(;cldenlti Of mechanIcal problem!J 10
o!llce.
. PICk-ups between lhe hou('j or 8:00 AM and 3 30 PM Mon. thru rrl,
. V~ation5 01 an)' term 01 'hl~ 8gfeomonll,lotd a/l covorages provldetJ horotl\
. Any (efunds due will be I&sued I,om our Corporato ulllc.:o 10 10 14 day~
follOwing the end ot lho renlal
. ALL CH~tm~S AR~ R~NTlH'S AlSPONSIBILITV. INSllRAN',"
LJ Oue /rom Reoter Ll Due 10 Aenler
n Transle, Rllund 10 .
I have road, undorstalld and agr'110 to bo bound by tho !Ofms Rnd conditions
on both sides oIlhls ro"t.1 agroem"n\. My Ilgnalu,o beloW is conside,.d tc
havo been made on any appflcable credit Clrd voueher Ind I luthorlle Sptfll
10 p,ocess Such .ouche, lor advanca dftpo.ns and all cha'lI". Includlng 18nlal
pa'~lng llcklls and damages 10 ,enl.1 vehl<:~7/.;? A
J4aJlIdD~. ,,,' L I (. (;?r
.
-
.
.
.
c.ill!S.1iliI10 MIJDIC8J.._IlWATMENT
I hereby conscltland llulhorl1.c Holy Spiril Hmtl,llill. lis Ilg~l\ts, undCIITplnyccs, to tlltJ rcru'lcring of Il\cdicnll.'llrC, whkh 11II1}' include rotltlllc dlugnmulc
procedures nnd !luch mcdlclIllnmlmont liS my attending nr L'onsulting physlciU/1 considers to he necessary, lulsn IIl1dculund it Is lJustolllllry I abseil'
emergency or e:<trunrcJlnaty clrcumstunces, dUll no suhshlll1illl prm:cduTcS will he performed \IPOIl me unless or mllll I have IUU.lIIll opportunity to
discuss duml with II physlcillll or olher health ,"'are profcssiullllllO my sutisfllctiull. If 111111 II l.'ompctcnlll\llIlt, I hU\lc the r1~lu In l'nnscllt or rcfusl1
10 con!lcnt In nny proposed procedure or Iherupcntk IrClIl1Ill1nt. I willnnt he involved 1ll1lllY rcscnrch ur cx.pcrimclItal procedure wlthuut lllyfllll knuwledge
and I.'onsenl. I undunlond lhut the prllctlcc of medicine tlnd ~urgcry is 1101 Iln cxuct sdencc null thllt tliu~nusis and tn~atl1lCllt nlilY Involve I'lsk~ of
injury or even death and lIcknowledge thllt no guunmlec hus been mudc tll mc u.~ It) the results of l1ny eXlllllinllliulI m IrcnlmCnI in this. Hn~pilul.
I undersllllKI many of the 11hyslclans on lhe Sluff 01' Holy S\liritllnspillllllrc nnt empluyees or nl~cnts of the 1-llIsplllll, hUI mlher arc lndcpcnllcnt contrnctms
who hUVCl been grunted the privilege of usln~ these fllcilties for thc clIre :lIId treatment oj' their 11lIlictlts. JlUr1hCf, I reullle this HuSpltlll is u teaching
Hnspitaland at the Hospilalllrc heulth care ~lCrsonnel in IfUillill~ who, !lnles!. cxpftJssly re(jllestCt olherwisl\, may purtlcipille 1I1' muy be present during
my cnre ~ p;. t of their edul'lItiun. till or lUotion pictures :lI\d c1uscd.l'ircult television monitoring of 11alienll'uw l1Iuy nlso he used for educatlonlll
purposes \lnl s~ . pressly reql !it otherwise.
(C.., ~\) 1\ iii m I h U') Relllfionllhip
Date . S. n ure ..i.JL!l.llA-(. . .... Tn Pnlienl
RELEASE OF MIlDICAL INFORMAT!illl
I authorize Holy Spirit Hospllalto release to requesting health insmuncc currler(s), thclr rcprescllutlivcs !Iud Iluditors, :lIld uny referring health (.'urc providers,
such diagnosllc and therapeutic information Onduding any infofllmtion rel:ltillg to treatmcnt for l!.l!,;QtillLm1~t;mhstllncc ahuse 110iliJ!Ltr~iU!1Wl11J!f.psvchlatri~
disorders. and/or confldentiilllUY. relatcd infllrmJUiQill, ns may he IICCCS:-inry for them tn lIctCl'lll~nC hellcnt cntltlement; to process pllymcnt c1nirns for
health care services provided during this hnspllnti7.utinn/treutl11cnt episode, lInd for continuing carc/trenllllcnl. ^ photostatic or carhon copy of this
authorizlIllon shall be considered nil effective Itnd valid as the original. The undersigned alsllllllthorilcs Medicare. when ..ppUr-able, 10 release to nnothcr
Insurance carrier I upon Iheir request. medical InfonlllHion needed to make paymellt upon that clulm.
I understand Ilnd consent thut the manufacturer of any implanlable device inserted by my physician during the course of lilY surgcry/prncedure muy be
provided with my identif1CaliOn~fOrmatiOn. includ.ing SOda,1 se,,,,rity number, liS mllndnled by Fcderall.aw,
(('v,. "'L uRl.t:J= I~ 'l}:t11/ Relationship
Date Signa lfe ~..:..._._ xr:L1..J.JJ:.J. . To Putient
INSURANCE ASSIGNMENl:
I authorize payment directly to Hol Spirit Ho~pital ,lIld for physiciuns of all henetits puyuble under my insurance policics. I undtlrstand I am responsible
to tbe Hospital for all charges no covered hy this assignment nnd/or photocopy of this as~igl\l11cl1t.
/Jfl fIIUi ~1 P ht/~' Rcllllionship
Signll Ife _ )11 / II Ul X W. To Palienl
STATEMIlNT 1'0 PERMIT PA ENT OP MEDICARE BIlNEFITS
1'0 PROVIDERS, PHYSICIANS AND PATIENT
I request payment of A1.Ithori1.ed Medicare hcnefus to fIle or on my behalf for nny services furnished lOr. by or in Holy Spirit Hospital including physician
services, IlIulhorizc any holder of medical and othe, information about me, to rclenscd to Medicare and its agencies nny informalion needed to detennine
tbese bell.filS for relaled services,
DATil: SIGNATURE:
HOSPITAl. BENEPITS/PART AIIlPF, DATE:
MEDICAl. BENIlPITS/PART BIIlFF, DATE:
Dale
MEDICAL ASSISTANCE RECIPIIlNT
My slgnlllUre certifies Iball received a service or items from Hnly Spirit Hospitalllnd Dr.. . onlbe dale listed below,
I understand that payment for this service or item will he from Federal and State funds, and that any lillse claims. statements, or documents, or concealment
uf materi,1 may be prosccuted under "pplicabk Federal "nd Slale l.lIws.
I huve read and 'agree with the above statements:
DATE:
RECIPIENT/AGENT SIGNATURE:
REl.EASIl AGAINST MEDICAL ADVICE
This is 10 certify Ihal I, ________, a palienl at Holy Spiril Hospital, am leaving the hospital
againstlhe advice of Dr. _ and the administration, I have heen informed of the risk involved and hereby
relellse Ihe physioian and Ihe hospillll frnm all responsibility nnd legai lillbility,
SIGNATURE: WITNESS:_._
RELATION TO PATIENT: TIME:
OS,
'"1
DATE:
:5)
.. Signalure ,
HOLY SPIRIT HOSPITAL, CAMP HILL, PA
CONSENT FOR TREATMENT/RELEASE OF INFORM,171ON
INSURANCE ASSIGNMENT
J Ob?qg,);~ K:\ 372~48
~~lS(~ .U~"IELLE
4Z0 \I KELLl~ st
U It SlluIH.
E
. . DEPARTMENT' OF RADIOLOGY
. HOLY SPIRIT HOSPITAL
X RAY INTERPRETA,TION
\ } PRELIMINARY.. n I 1/.../
!:I ULv.ll1L oL"'''''.'_
iJ~-<l=-=------';;.,;";;;;;-,;;.",",,,
NAME?~.__._ .
DATE....):
ED/HOUSE PHYSICIAN FINDINGS:
(~ lLu..UL
fAA~<YI~
(~ ~-1(
Cd
Lf-Sh<rulcLOA.. Q
J~
ED/HOUSE PHYSICIAN
'\~",'OIlM ~l',,^OIllD
;'k"::.
ED CHART COpy
.
iJHAHUt: NUl\dl 1f<!;lOO
I? LOCATION_[~-=-__
(,. 7
tA--vtJ
- (/fT....l
~_..---
-...-----
,--
l./v'
frS
,
!
i
,
/'
RADIOLOGISi'-
/~
U
I
~I~
.
4It HOLY !l!RIT HOSPITAL ~
DBPARTMRNT OF RADIOLOGY AND DIAGNOSTIC IMAGING
CAMP HILL, PENNSYLVANIA 17011
17171 7&3-2&00
.
PATIBNT. KBYSER, DANIBLLE
MR. 37254B
SOC SEC. 174~&8-246&
ORD OR,. SO GROUP,
PT TYPB. S
ADM DATB 05/30/1997 12153AM
LOCATION ECU
DICTATION DATE. 5/30/978112AM
TRANSCRIPTION DATB 05/30/1997 08.30AM
ARRIVAL DATB.
HOSP SERVICE. SCU
EXAMINATION. CBRVICAL SPINB IBvl
COMMBNTS, Hlstory--neck pain. MVA.
There Is no fracture or dislocation. There Is cong~nltal incomplete
segmentation of the vertebral bodies of C& and C7. A rUdimentary
Interspaoe Is present anteriorly In this location, In flexion thore is
lome widening of the spaoe between the spinous proae.sel of C5 and C& but
this is probably not related tc the current injury. The exit foramina are
not narrowed. The atlantoaxial joint Is normal.
CONCLUSION. Congenital inoomplete segmentation of the bodies of C& and C7.
No fraoture or dlslDoation of the cervical spine,
"
DICTATBD BY.
DATB OF EXAM,
~~
J,R, Croteau, M.D,/dg
0/1997
~I
~~, I.~
~
Initial Lab & X.RMY Ordera:
~b. / Urine SpllClmen!--
I Io\e.,.mlnophen I I ESR
I I o\~offol ( I Glueo..
I I o\myl..oIL1p... I I HCGS
I IAPTT I Ill.."
I I Blood Cllllur88 Proll/o
I I COO Ilyl..
I I CKMO I PTP
I J OPAO I Aen.1
I 10APt prom.
( I DIll'l'ln I Quinidine
I I Oll.ntln I S.lIeyl.l.
R.dl~
I J O\bdlOb.'r, S.rle.
I Io\nkl. A l
I I Olavlel. A l
I I Oerv, Spine lll...1
1)( Corv, Spine Aou~ne
I I Ohest Atn. / Port / TPA
I IElbow A l
( ! Faotal
I IF.mur A l
I IFlng.r___A l
I I Foot A L.
I I Forearm A L
I IHand A l
I Il~p A L.
I ) HUmttrU8 R L
I IKn.. A l
I J01her:_
S{18Cl.1 Procedure.:
Ult,..ound:
I_men
I Duple' Doppler
J Gallbladder
I IPel,le
Cul/ure.
I Bela Strep AGJ Culluro
) Cervloal
I Offlamydl.
)GCCulluro
I OT Soan 01
) VQ Scan
J Olff.r:
Illlllng Olalllflcallon:
I Ilevell ( I Follow up
I Il....11I I IC..el
~DID
I Il...,.IIV
I I level V
Holy Spirit Hoapltal
Camp Hili, PA
Emergenoy Care Unit
Phyalolan Order Sheet
2o.ecu REV 8196 JD,BA,MD
-
I Sorum AcnlorlO
I Theophyllllltl
I ThVlOld Promo
I Tox Seroen
ITflA labs
Ilype & CrO$s ___If of units
I Type 1\ SflrOf/rl
IlJ/A
IUrineC&S
I Wmkman's Camp Drug SClOon
I Other
IKUO
I liS Spine
I Mandible
I N..al
IOrbll R L.
JP€1lvls
I Pyelogram IVP
I IRiba R l
1>4 Shoulder R ~
(~SkUII
( jSlornum
I IT/Spine
I ITlb/Flb R l
I JToe_R l
I IWrlst R l
TlmAlCRTllnl _ 0/$
-\o'f..ot
'V
I..lImu'QRT/lnl
I Sputum C & s
181001 C& S
ISIOOIO&P
I Slool O. Dlfflell.
jWoundC & S
I Accldenl
I Medical
I Medical Non-Emergency
':'~',
..'
Time Seen:
Cardiac
I } Monilor
I } EKO pagod nl __0_
I j02.__l/Mln
I 102 Salurali(lfl
"""
Re.plratory
I I AOO', pafled al _____
! J Peak rlows f)olore/Allor Hasp. h.
I I Resplralory TK. ___.......____
Medloatlons/IV'a/ Additional Orders
Tim. Oalernme/lnt.
IV: NSSI D5W/ LRI D5/,45NS/ D5,9NS
Inluse at oo/hour,
.... [ J Obtain old reoorda,
... \' \.-I Q.J. <V () CULl/a,.. &/L.
\ UO'Z< --
<."::>
-
-- vi L/ ---
02..~'-I ,
-~
,.
Inltlala: \."L ,l'vMO,. r, .c...-. R.N.
Signature:
, , . U
Inltiala.__Slgnature,
Inltlala: Signature:
Inltlala: Signature:
Slgrlature:__
Date:__
, i,1
"
\ '
n
,'I:
I 1 ". \ ~ " . ))
'f r 13,' l, ' Y
,.),/ll"I)
R.ll.
R.N,
R.N.
YL.~
MD/DO
)\/ J?Z'j4J
. " I [ II (
[
I'
~ ~? f) I
(I.
, .
, ,
'!i~ ~l _ , 70~')
J ,', 7 -:! ! '1 I
{.' '~ij'" ~
Iii )}'IJ1~nl')/O'
, Dati:
.
-
.
~
.
A.....mlnl: Tlml:
VII.I Sign. .
Manila, - -
PhYllol.n A.I.llm.nl - -
02 Slturotlon
Lung A.....m.nt ,
Vllu.IAoulty
DI.gno,"ol:
EKO -
L.b.
PCXRIPort, C.Spln.
S.nt 10 R.dlology
R.turn.d ',om R.dloloay
Proo.du",:
R..plrotory Tr..lm.nl
10.
Fol.y Inlortlon
NO Inl.rtlon
Wound Oore -
SollnUOOUSllnolOrutohes
Mlooell.n.ou.:
p.ln So.', (0.10)
L.vel of OonloloUlnl8S
Sldor.1I1
Inl.k. & OUlput
p.tlent Eduoetlon Inlo
Othor:
lnlllal.:
~ " . ,1.1 l , I. 0 'i. . IA.1I ~,"- , j . 'AA "
1\/I,iIilT,;^. ~ "..III1;~ ,1V.7Lu,..J/ I t\1e... ;o.r~lllj.+.-IT, -:;- ~ PK.t.J\j
1\ . If 1/ .
IJ
IV Thll'IPY
D... Time Amount 90lullon O.thotor
SII. Ro'.
R.to
Conlrol
Condition Att.m t. Inltl./.
Inltl./:
I~~
Initial:
Initial:
Signal ,
Slgnalure,
Slgnalure:
Signature:
j(,,~~'!l.
'lV\)O,No Inllamallon
o 1.Ed.ma
2A.Erythema
2S.Eoohymosls
3.Paln
4.Hs,dness
5.Wormth
R.t.
~
1.AVI
2.SlalMastor
Holy Spirit Hospital
Camp HIli, PA
Emergency Pallent Documentation
.I) 'II J72548 [
, I 'I I Ell E
I LL[~ Sf [eU
I,. '\'J RG t'. 170SS
'I lJ~ bQ7,ZJ7S
.'1'Z4bb [0 "QOUI'
,t.~A'IY "81 0030787010108
, ,....
205 EOU R.vlled 5/98 JD, SR, MD
CHART COPY
j,.L.U" ,,",lJ,", I UlI>U'I\M.... tI",> , j(llL j H)l~.' . /lOLl ,'I'IKII UlJ~I'II,\L
(717) 76J.2JI6;',>~iI7) 763-24(i1 ',' ,", . ,.';,. ;,' I.. .
n.",..,..II..".nd "..;.~'" '''''"d 'n Ih, I\n.,;, 'c~~ Un" (IiCU, ,,,,,; ~",.;" """'''''' "";"",,,;," ....;,:" """d,<I ,.. 1>0 "~~;:.'." <II.." ,.. ,,,...'<1,,
complel~ IIlCdh:IlII:llrll, If )'1111 (lClvolllllllllW prnblem_t llt,CIllJlpllcdlll1lh CUl....CI your Ilhy~icl~1I Ut tho llnlel'~oc, Care Unit lIot.(bw Till! INSTRUenONS ClmCKIlI) bEI.OW.
SPIlCIFIC INSTRUCTIONS: Follow Ihe,e in,.ruclio", if Ihey <li""r
I
WOUND CARE
o RelUm for 'Ulure removlIlln __._ <IllY',
o Change dre"'lIg .
alld apply____ time, II dllY unl,I___,
o Telanu,/dlphlhenahoo'ler given, .
rf) ftlc Pllllent informulion shcet
ruLL.l!W UI' CARE
[I Relurn 10 EClIl "HC 00___ fill' II recheck,
I] See your phy,icilln or 'peclllllSl ifnol heller ill_._dIlY',
Return to ECt1 if unable 10 do so,
I] See I.mlly I compllny phy,lcinn I FHC on _.._for
IJ Ilecheck IJ SUlure removlIl
[J "iek up your ,.rllY' from lhe Radiology Oepl. 011 the 2nd floor
before going to doclor', office. (Call 763..2696 before IIrrlvlI!.)
CI Your blood pressure wa, __. Plea,e gel il rechecked
by your family doclor,
SPRAINSIIJRUISES
o mevnle Injured plIn IIbove heart fOl'__day"
DAce 0 Sling 0 Splint 0 Crulche, for __day,
o Apply: 0 Ice P Helll [J Ailernllte Ice IIl1d heal for
~mhlUtes___times n day until symptom free,
o Wear cervical collar for '~'Y"
MEDICATION INSTRIlC'fIONS
o Take_"splnn. Tylenol or Advil evcry___hollrs,
o me the followhlg (O,T.C, ) medicine,
~: A J.o.t.p en T I r~,J ()c.- ()c...:....
3,
4. Your regular medicines e'cepl
o Do nel dnve or operale IIIlY machinery while Inking
OTHER
AI,lDITIONt\LlNSTRI1CTIOl'l
o Off work I ,chool: From to__.
[I Relllrn III work on ......__,. 0 Lighl 0 Regulur dUly.
o Limltnlion:
o No gym or 'port for _.dny,.
o See Workmen's Compensfttion sheet.
Signntur." p?, \..J4-.~
~ (1
M.D,
R.N.,
PATIENT INFORMATION: PlIlienl informll,!on ,hcel. contain importanllnformalioll III review alld keep,
HOLY SPIRIT HOSPITAL EMERGENCY CARE UNIT
S03 NORTH 21ST STREET CAMP HII,L. PA 17011-2288 (717) 763-2316
( ) Vanllha o\brah.m, M,O. 038840L ( ) Ruben lIynid, D,O. OS 004411O,L
( ) Thoma. Aldou" M.D, Ol7075E ( ) Rlchll,,1 Lilley, M,D. 029960.0
( ) SoIvllore Alr.no, M.D, m5502!! , ( ) Phillip Mnguhe, M.D, 0151J63.0
( ) Ram, e sh Ala, rll, M,O. 016727E ~-"~) Lawrence Puul, M,O. 039.5, 24<1..""'l-,'
( ) Ol~n !?~.4gbtry, D.O. OSIXl6776E ( ) Fra~k Procopio., ,0.003643.0,['\
( ) Jon;Llubln, 0,0; OS 1Xl6991L ) RallJanu Shurma. .D..031165.0.\;.,
DATE -~-~~.." \ " ; "\-"';<:Et:;\\ 'L""
'*
o Abdominal pain 0 Cornclllubra!lionlforelgn bOdy
o Alcohol abu~ 0 Crouplbronchitis
a Allef&ic reaellon 0 Crureh wliJking
(I Animal bite 0 Diarrhea and Vomiting
(I Asthma 0 Drug! Alcohol abuse/addiction
o Back paJn 0 Pcbrile convulsion
o 8Iles.Hurnan/Anlmlllflnsecl 0 Fever
D Bum D Plu
a Ches( paln 0 PraClure
o Conjunctivitis 0 Headache
o COPO --,...elld injury
The Interpret.Uon of your Hay h a preliminary rcpon, The fihlli will be reviewed by II radiololllst and
you or yourdoctot' wlll be Informed If there i, a change In dia8n~li, I hereby acknowledge recelpl of
lhtae lnalructlons Ilnd equlpmenllllld undc!rstand them, I unoor!lland lhall have hlld emergency trutmenl
only and thai I may be relea.ied ~fOf1l 011 ot my medical probleOl~ ilfC known or lrealed, I will mange
rOf tollow up care I., I have been lnnrucled.
SIGNATURE_
DEM..
IN ORDER FOR A ORAND NAME PROnUCTTO liE DISI'liNS!lD, THE
PRESCRIBeR MUST llANO WRITE "PRANO NHC(~,'iS^RY" OR "URAND
MEDlCAl.lY NflCESSARY" IN nHi SPACE nm,ow,
Ul.o\om,
n SlJllSTITUTION I'ERMlf.SmU!
."t.'lI(1~1
[J Hypen..'ion D PIDIVO
D Immunizations/lotanus 0 Ra.h
o Kidney slolles 0 Seizu~-';j.
o Lacerlllion a Sore throat
D Neck strain 0 Sprains and st.rains
Q Nosebleed [J Threalened miscarriage
o Olilis media 0 Toothache
o Pediatric fever 0 URI and colds
Cl Pediatric head injury 0 UTI and pyeloncphrilis
[J P,dllllrie URI D Olber
o I'ed~c vomiling
fvl'PATIENT VERIIAI.IZES UNO.:RSTANDING
"I ('\ " "7 I 11 ~.~I .' \
SIGNATURE: i\ ' " Ii i ;I I' .e = " / Ii)
. -- PaljtnlolR I Penon
( ) David Spurrier, M.O, 02~502.0
( )Aln"T.pli., M,O, O~0018.E
) ElIIIII. r, M,O, 057J03.L
I Zimmerman. M,D. 005636.B
,
,
o
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REFILL
TIMBS
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CfJttlElCA'IE.ill' SER VICE
I hereby certify 1hat a tme and correot copy of the foregoing Answer to
Production of Documents was served on the following person by mailing same hy United
States first class mall, postage prepaid addressed to :
R. Mark Thomas, Esquire
S4 East Main Street
Mechanicsburg, PAI70SS
Pate: 8j I b (<;.3
) ,
--) '-
,'ilL C.....~ l ' V;", . _..,..
J qu ne M. Verney, Esquire '6
44 South Hanover Street
Carlisle, PA 17013
(717) 243-9190
Attorney for Plaintiff