HomeMy WebLinkAbout00-07551
-. ~ ~', ,
-' 1--,' ",., ,-~'-" 0.: ",""-,'-"-,';; --~---"'I'~-,,- ;"" --~-,,' <-. ,.,__.to- -,- ;" .c."'. ~,_,:".;';;:;J;i ~';";-,i' ",'k-,,:" '-',; ',' ::1:' . ,. ';-:':;:'1
,
"
t.
GARRY L HOCKLEY, a minor, by and: IN THE COURT OF COMMON PLEAS
through his Parent and Guardian, : CUMBERLAND COUNTY, PENNSYLVANIA
SHERRI HOCKLEY,
Petitioners
Vs.
: NO. tJ-o- 7SJ I
~
EAST PENNSBORO YOUTH
ATHLETIC LEAGUE, INC.,
Respondent
ORDER
AND NOW, this
day of
, 1998, it is hereby Ordered that a
Hearing on the foregoing Petition for Leave to Compromise Minor's Action shall be held
on the
day of
, 2000 at
o'clock _.m. in Court Room No.
at the Cumberland County Courthouse, One Courthouse Square, Carlisle,
Pennsylvania.
BY THE COURT:
J.
'H"',
",'I' 0_' I'".,",~".;- I ,.",,-,.1 .,:,,' " ;, ''';~, . '- ',L'"',>'~~; ..",,_c", ;,~, ,'_,,;;;.',{,:, -<J-"-;,'~.' ",,;_ ,
-~
,
,
, .
GARRY L. HOCKLEY, a minor, by and: IN THE COURT OF COMMON PLEAS
through his Parent and Guardian, : CUMBERLAND COUNTY, PENNSYLVANIA
SHERR I HOCKLEY,
Petitioners
Vs.
'1$SI 6;;J 'i~
: NO. ()1) -
EAST PENNSBORO YOUTH
ATHLETIC LEAGUE; INC.,
Respondent
ORDER OF COURT
AND NOW, this ~ day of
Ochi>v
,2000, upon consideration
of the foregoing Petition,
IT IS HEREBY ORDERED that:
1 . The above parties may compromise the action set forth in the Petition to
Approve Minor's Compromise for the principal sum of $15,000.00.
2. Sherri Hockley, as natural parent and guardian of Garry L. Hockley, Jr.,
minor, is authorized to pay the following counsel fees and other costs from the amount
to which said minor is entitled to receive in this action:
a. $3,750.00 to W. Scott Henning, Esq./Handler, Henning &
Rosenberg as reasonable attorney's fees;
b. $231.07 to Handler, Henning & Rosenberg as reasonable
expenses;
c. $27.00 to Quantum Imaging;
d. $2,700 to Ira J. Heller, D.D.S. for estimated orthodontic expenses; and
e,;. .
'=~--~ -ii- -,-~.....--,,~~- -"~'
,
"A ~ 'i ,-, ,,""-
, "
. ~~~f1i--O'
. "',;J~~'^""'" " ,"'~ ";.;.",,,~,' C
'v1NV^lASNN3d
AlNn08 CG~:8J8~n8
S8:11 iiV 0813000
AbV10NOH1U0:1 3H.L :10
..,,,. '-If' rl--I j
:h.Ji:J~"r,-,:J b
.. ~
"'~.-- ~,. .~, ,
"
,
'--""I\",-,"-c..",t,i"":';~;';,','_~'~".'-v;':;i;"""_h_'_."';",;0,.6,..': ," '.-:"''''0'; .'", ';'_'-.
,
)
, .
c. Direct payment of the net funds in the amount of
$8,291.93 from the lump sum payment into an interest
bearing', federally insured Certificate of Deposit or savings
account with Petitioner, Sherri Hockley named as guardian
for the benefit of Garry L. Hockley, Jr., minor. The account
is to be marked "Not to be withdrawn without Court Order
of a Court of competent jurisdiction until minor Petitioner
reaches his/her majority".
BY THE COURT
J
~~J
10:30 -00
RK.s
. ,,-..
.', "-, ,,,,,-,,-'~*""~'_C,__~" ",',-, __,I __"",,-_'1 '--'~- ,'''~-'I--'' --<-"'I,"~- . ,-,;;~-_','~, : ''''"" '''''-'-__O'~;;"'.;S,o;,__,;;;-",__";;'';;<'-''-;'>\H,;:o",, "___.._" 'e'.:i_"J
,)
, .
GARRY L. HOCKLEY, a minor, by and: IN THE COURT OF COMMON PLEAS
through his Parent and Guardian, : CUMBERLAND COUNTY, PENNSYLVANIA
SHERRI HOCKLEY,
Petitioners
Vs.
(t(J - '7.$ S I C-..;;.J I ~
: NO.
EAST PENNSBORO YOUTH
ATHLETIC LEAGUE, INC.,
Respondent
PETITION FOR LEAVE TO
COMPROMISE MINOR'S ACTION
Pursuant to Pennsylvania Rule of Civil Procedure No. 2039, Sherri Hockley, the
natural parent and guardian of minor, Garry L. Hockley, Jr., by and through their
attorney, W. Scott Henning, Esq., HANDLER, HENNING & ROSENBERG, petition this
Honorable Court to enter an Order permitting settlement and compromise of this action
and, in support, aver:
1. Petitioner, Sherri Hockley is the natural parent and guardian of minor,
Garry L. Hockley, Jr., currently age fourteen (14) years old, whose date of birth June
7, 1 986.
2. Petitioner resides with her minor child at 915 Magnolia Court, Enola,
Cumberland County, Pennsylvania.
3. Respondent is East Pennsboro Youth Athletic League, Inc. with an
address of P.O. Box 41, Enola, PA 17025.
!
~ ,~, , w, , " . -" - , . -~"'^e'" ,,', 1::- J.~,_",,~ ~ I_w,,_.- I"""~, " ~ ,;,>",~_:_-,~", ~",,,,,,,~ "-'" ;,""',.-,.-z,;,.~ ',{ .<'~',,, ..-'.,
4. On or about May 18, 1998, Garry L. Hockley, Jr. was riding his bike at
Sheaffer's Park when he was caused to have a serious bicycle accident after riding his
bicycle off a three foot drop-off separating the ball field and the parking lot that was
not clearly visible or marked.
5. As a result of this incident Garry L. Hockley suffered a closed head injury,
severe contusions, lacerations and abrasions to his face area, as well as lacerations to
the inside of his mouth and a tooth that was knocked out and another tooth that was
chipped. Garry was immediately taken to the Holy Spirit Emergency Room and was
treated and released for his injuries. Garry was experiencing episodes of dizziness and
passing out and was taken back to the Holy Spirit Emergency Room one day following
the incident. Garry was subsequently seen by his family dentist and orthodontist for
follow-up care regarding the injuries to his teeth. [A copy of the medical records and
billing statements from Holy Spirit Hospital, Dr. Kravitz and Dr. Heller pertaining to
Garry's treatment are attached hereto as Exhibit n A n .J
6. Respondent has offered the Petitioners a settlement in the amount of
$15,000.00, as full and final settlement of the claim against the Respondent.
7. Petitioners propose to accept the settlement proposal from Respondent
thereby releasing Respondent from any all claims, suits, and other actions arising from
the injuries in the present case.
8. W. Scott Henning, Esq., of HANDLER, HENNING & ROSENBERG. has
been the attorney for the minor in this action and he requests the reasonable counsel
fees of $3,750.00 for services rendered pursuant to a Power of Attorney and
2
,.
Contingent Fee Agreement signed by Petitioners, plus costs and expenses of $231 .07.
The aforesaid figure of $3,750.00 is calculated upon a contingency fee of 25%. (A
copy of said Agreement and billing summary are attached hereto, made a part hereof
and marked, "Exhibit B".)
9. Petitioner believes that this Compromise is in the best interests of minor,
Garry L. Hockley, Jr:
WHEREFORE. Petitioner requests this Honorable Court to:
a. Approve the Compromise above-stated;
b. Authorize the payment of fees in the amount of $3,750.00
and costs in the amount of $231.07 from the funds due the
minor;
c. Authorize the payment of an outstanding medical bill to
Quantum Imaging in the amount of $27.00 from the funds
due the minor;
d. Authorize the payment of $2,700.00 Ira J. Heller, D.D.S.
for the payment of estimated costs of orthodontic work for
the treatment of Garry Hockley, Jr.; and
d. Direct payment of the net funds in the amount of
$8,291.93 from the lump sum payment into an interest
bearing, federally insured Certificate of Deposit or interest
bearing, federally insured savings account with Petitioner,
Sherri Hockley named as guardians for the benefit of Garry
3
, "I~"~ - . ". -"",- " " ,,;0'0 ",,' " ".'F !C- ~- ~ , "'..,'4.,.-_,. ,:-r "<..: , "<"~'.,',-,--~ j-,n",~ '"',,~, '"-' "~;r,~",, . .,~' =L --
.~
L. Hockley, Jr., minor. The account is to be marked "Not
to be withdrawn until minor Petitioner reaches his/her
majority or without the Court Order of a Court of competent
jurisdiction" .
Attorneys for ,etitioner Sherri Hockley
on behalf of her minor child, Garry L.
Hockley, Jr.
4
~^-
",,' ,-,<,-,._-,--,--".,
''I" ~",~',' '__'" -',," - "".^,',""''''''_I~~_~', -~ <;'" "<' ,.,;. < "',< : ".V ,',,", "{;/~,.,:",<<,,"~,-<--,,,~, ::,<,~'c- ;_""'; ~".~_':
'I
I
I
I
.
VERIFICATION
I verify that the statements made in the foregoing Petition for Leave To
Compromise Minor's Action are true and correct to the best of my knowledge,
information and belief. I understand that false statements made herein are subject to
the penalties of 18 Pa.C.S. ~4904 relating to unsworn falsification to authorities.
/
Date r; - cl ~ -(l)
"
"
CONTINGENT FEE AGREEMENT
KNOW ALL MEN BY THESE PRESENTS, that I, Sherri Hockley, Parent and
Guardian of minor child, Garry L. Hockley, Jr., do hereby retain HANDLER AND
WIENER, of Harrisburg, Pennsylvania, as my attorneys in this matter to represent me and
to process, negotiate, arbitrate a settlement or to institute for me in my name, any legal
proceedings or actions that, in their judgment are necessary, against East Pennsboro
Township, or against anyone else as a result of injuries or damages sustained by Garry
L. Hockley in an incident that occurred on 05/18/98.
I agree not to settle, negotiate or adjust the above claim or any proceedings based
thereon without the written consent of my said attorneys. -
NOW, THEREFORE, in conSIderation of the services so to be rendered by Handler &
Wiener, I hereby covenant, promise and agree to pay them for their professional services
rendered, THIRTY.THREE AND ONE-THIRD PERCENT (33 T!3%)of whatever sum is
recovered as a result of settlement without suit; or FORTY PERCENT (40%) in the event
of arbitration, mediation or if suit is filed. I will reimburse Handler & Wiener for any
necessary expenses and costs advanced on my behalf in pursuing my claim.
Counsel reserves the right to withdraw if, after complete investigation, they determine
that there is no merit to the claim.
I ACKNOWLEDGE that I have read, approved and understood the above
Contingent Fee Agreement and I acknowledge having received a copy of the same. The
terms set forth are accepted. '
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 19th day of
August, 1998.
(S_EAL)
errj ackley, Parent and Guardian of
L. Hockley Jr., minor child
~
'"
EXHIBIT
-A
"
"
HANDLER, HENNING & ROSENBERG
September 21, 2000
Billed through 09/21/00
GARRY L HOCKLEY JR
Bill number
203350-00000-002 WSH
OISBURSEMENTS
08/26/98
09!1 0198
11/19/98
09/21/99
01/10/00
07/06/00
09/21/00
09/21/00
09/21/00
09/21/00
09/21/00
BILLING SUMMARY
Arthur A Kravitz MD
HospitaL Correspondence Corp
A8CO
IRA J HELLER
IRA J HELLER
Book Binding Costs
Proth of Cumberland County
Document Reproduction
Document Reproduction
Postage Costs
Postage Costs
25.00
35.00
10.00
20.00
45.00
2.00
45.50
3.00
26.60
9.42
9.55
Total disbursements for this matter
$
231.07
.
* billing timekeeper W. Scott Henning
* date of last biLL
* date of Last reminder
* last bilL through date
* bill type code $-4
* action to be
* O=hoLd entire biLL
* 1=a/r reminder
* 2=bill exps, hold fees
taken
3=summary fees and exp
4=bitl fees and exp
5=summary fees/detail e
*
* current
* 30 days
* 60 days
* 90 days
* 120 days
.
.00
.00
.00
.00
.00
* billing frequency A-12
* last payment
* bitling realization
.
.
o %
*
*
* matter 00000
.
.
. 6619 08/26/98
. 5571 09/10/98
. 5345 11/19/98
. 6983 09/21/99
. 6983 01/10100
. BIND 07/06/00
. 1CUM 09/21/00
* COpy sunvnary
* ISI summary
* POS sunmary
* POST summary
.
25.00
35.00
10.00
20.00
45.00
2.00
45.50
3.00
26.60
9.42
9.55
.
*
231.07
.
.
*
.
. 1CUM 45.50
. 5345 10.00
. 5571 35.00
* 6619 25.00
. 6983 65.00
. 8INO 2.00
. COpy 3.00
. ISI 26.60
* POS 9.42
. POST 9.55
.
Total Disbursements $ 231.07 * 231.07
--~~-------- *
TOTAL CHARGES FOR THIS BILL $ 231. 07 . 231.07
i\;A!'.r:~:; ~
:...:-;[;Di:\i.:'-~=;;; :
dJ:R-i;"o;uAi-C:;:
,::>:r>j_CYI::'::'~ :
A:;:ii);;E.S:; ~
C::-~t)h:C;-j ::
CCij'-i!"!l.::j\;".-~
i\~ r::; \'"1 E: ~
:~:'iDH83~3;:
f\;~i"'~E: ~'-
p, n rl I;' ~:.~:::' :~; ~
'~=d"::;: T :f:rF~ f.
:';-;-",',,\:[: ;:)~:;: ~
;::~~:.:;=:::::~ r)f~;
A[h'1IT OXi
CCif';r'r...A I :\l-j::
." ,""'"
-' '.' ..:.., ~ ,~,-~
.'
t~f"
~ l" ~
l-iGC;':::L.t=~y , ;':1f..;;'<RY , ;f-\'
'il1. 5 rAC~N(;L Z A IJF:
(j,S/(i7;' :;.';:.'~:;b
.(~OE::~
:3Tt:DF:::i'l.: ..t
':"'~~OT::::!;l~At\; .,;'
, "
.,' -.' .:"
,_ , ' '., -_'_ "M ,_,
, ' - ....~~, . \. '-' .
.:::>~i~7'::;'~, ;,,_, "C '(
"'\'.',.','...-
,."'.).,, ,. 'ifjJjJ'
_ ~~"","-l.:"'l ".~
"'Cr(?i .
,:'<It
. ..
-,- ',..... ...,..,..
. ,... 'l' ';c ~ '_"/\..'
~
::.::~:-: :~~:\i-:-
:i' :\,!.'C:'Rt~AT~:ON
fi:::::\lCd_f4
,..
_ ,L
:=;;::;
~'r:'r
.~~~ :7tft1': ~i3;:;::~,~t,~::
C~ECI ~ ,JL,.', {)::-~::~
IF'A/17025
:;cX~ !,';
(\']::::: :':'
n:AC:E~
I
OCCUP~:'~ON: s-rj~n€~~'
J / p~ ~=
A;YjL-:l:; :\i()I\.~::.
'::/l.:--'i i''>\.,'~CT,~Ci!..:;:;~ DR
I'';CC><Li7:Y ~ ::::ii_i~:::r:.tR'=;"!~~-:;':~=~i::~l\JCY' GOt\t':'Ai~;;:I_1. \[1C(i~;~ -;" ;,p!\r
/PA/:. 70:2::-,
i-:(tC~<L.::-:Y , C,",:{~[~:::;:y
: 1':;00 .~ ;::;
"ii.::D
t~:::'r!! ,~.
,:,~: ':;'(71.
M'''{ d6'l
i c:Of):' ::.~
,,,J
~~1'<i8 BRT ~ ;\; BY ~
)3:;- C"y'C~..~:::
ACT.: ::~ [;:'::'i',Jih
'::UI~:f"l;::::'\,'- ~
.,~~' ~/7~:ME: 05/16/9:3 19=30
l",li::!i'=C< ;::I;"~ .,.... 7':t 7-":;'''::;; 7'-<2/2<:'7
/i:",;\:OLA
,.J~ _.. ~:7-7~~8-9562
!~:::
~:::T1:
.. ,
, ,. ..... ~
wor:{;<
'U
,
,
/'
'-'!-, '~:
CA:=;;::': I ".l;=OR~~:A-;~~: Cl~J
:~\t:,U :?C,U:-..:C:,::: ~ -=:- f} '='~~T ~ :~":\iT -:'y:::'(,: ~
, ,...i-1(1'::;P '::;F~'v): -.- -::'~--., ,':::7'l',H'~.-\:r' 'Pii i::" ",:;,.
A~~--0~'"t.- ~/:;;;':::-:"- C;,_ :"J:r:'-;:;;:!D1::.'~ -':::,::;_, ....~CJ~~.T' "-'--
. ~~D-9 DX~ ~
, -,
BHT ",' ,'J Er'l ~ '."':O";-;--:i::.:.;'~
:~cc: I Di=:;\lT :: i\:!,~'Oi-<:~A'1 :;:c::\;
ACe ::\.![.: i"i ,ji:Ji-:, ~~::":....AT::D~ ,'v
i..CC\0,-:-ICii\;~ (}
,:-":F::;C;~ _ :::;.:::: ;.)j\! ~ ..:;' / i_, '-' ~ "-li==':::; 7R~-I_:Bi .;:~. ;,~Ai .i::::: l\:i~i (.:'.j
.-:'l:';';.:{ B:::C:Y'Ci_:':' P\l.,:C=-~:d=:i\i ,'"
\i~~"i- :
;.;D;:-d~;::::3:::;~
:;:::"1;=';_DYC:i:;; ~
ADD;:;;i::;:::::;:::; ~
,'-:'~_Al\:
Sf-:Ei',fi~ 1: :--CiC;:::L.;~__.,{
':;':.:'7) ;"';P;Gi\J,C;I_IA DH
U_:!'M ;\A\\.;(~i:iE~t",,!\~!\:"iw
1 no ,_:CYA C:;: KC:.."
:;: i\::~;Ui;:A(';jC:~ ;_.:_1
:=;ljJ:1SC:,:~ I Ei 1::' i:,:
c: 0 ;"'j;:::A~ 7;"'; C::::NTr:Ai_
;.....CC:<:.H;;V , ::'oi-rE;::':f;':Y
GJjARAN~-OR :~~OR~AT:ON
~::;: .:~i=:L -C C:.\.!A; ~ ~ 0 S:;::;~:t. ~
F,::-1';.lO\ 1-::' .h'Jt::./::,7025 :-,n, ..... 7] 7'-:/::'l.-:!'-')!:!I::,:]
CClr..JTAC7 ;\iA"1;:::~
j~Ai~~H::::=;BUHC~ /F-'A/:' 7:~. :~2
::: 0.::::;U,;\Aj\iCE ':;\~,=Cii:;;i"1(:;7i. Ci'J
:;:: '7:17-f:,~:7-?,:~,:~;7
CCi)2,
)~:!:~i:eUi;'-' =*
;,-"-;;C'C".:,\ ': ::,1_,,' ,\il.;" ..,.
,....:'Ci.~:: C\! :;::::
REi_._ :":;'C '.,;l=Y C~~h::'i f::'H;':: C~~:;:;~;' / A!_' ~';'i
1.9;,)64(:,7":.8
(, y
:'. 97: ~~lO
y
~'".
~ i\i'C;(J;::;~" i~DLIi=~ES:=; ~
;::'D BOX :22!5l'....tA7L::: DR
rj('~;:;:i~ I ~=;BU~1 ~
:='r~
:'.77,0:'::;
)" i>.J8Uh: ~ I~DDF~fE~~:; ~
.,
'.::<
~.
:;' \\I:=';U:''\ ~ A'[i1)l.;,:r:: :::;:3 ~
:- i'..:;:::i, d'~~.. (~~DL,F(:::.::;;~:;.:
l::D!"lf'"rci\i--;w~:;:: Fi"'I.i:1 - ;-:(:'.:::1."
q~::;Ci ,01
~,.-;./~- -,
-r'i~_v e:-'-
i-~"1-~ I 0
- "'-'0'U~
-r'-Cr.:.... ,~
7C-r..,. \
~ ::-'-.., J \
-:::: "C..::;r:to/ \
-- ,......,::::;:,
._V'-t '-", , :
C ...:.:'-""', I,
-..
'" EXHIBIT
J0
i
~C//d7
;:=:g .,: 1::::\1'"( !\.~A)"1!::: ~ ,--'OC:<~,~!- y
REC'i :-~;-7E2!:::D BY ~ 'JA~'U:::;
:,",:~" L~"J ,~'~='-s':1~\:2004~4'~, .~K'" )~
I ' 1- '\/" , L.. 'J"::"" ;..'.. t].... DClCUi"!c"'JI
-~D~""',=:;:, c, ~ ,,-.-----lj--~,L" ':~~~: cj::"~ ,~:S:~9/9~~'."~'RI~\;.,." T:-~:=;/""~ ,;,~~~REG J
. ~ icIQ"
..
f'
.
"
ADM. DATE: 5/19/98
CC
Head injury and passing out.
HPI
This ll-year-old boy was involved in a bicycle accidentlast night. He rode
his bicycle off of a three foot ledge, was apparently knocked out at the time,
and had injuries to his left face. He was seen here and examined last night.
He had x-rays of his face which showed no fracture. He was discharged
with instructions. He also knocked a tooth out and was to see his dentist
today. He saw the dentist today but several times during the day, he would
just fall asleep with no apparent reason. His mother sent him in to brush
his teeth before going to the dentist. She didn't hear him fall but she went
into the bathroom and he was asleep on the floor. Several times in the
dentist's chair, he would just suddenly fall asleep. He says that he has pain
in the left side of his face and in his tooth and somewhat of a headache.
When he walks, he feels somewhat dizzy and slightly unsteady on his feet.
He has had no nausea or vomiting. His visiou is uormal. His mother says
that when he is awake, he is coherent, talks normally, walks normally except
for being unsteady at times. He denies pain anywhere other than his face
and his head.
Nurses notes reviewed.
PHYSICAL EXAMINATION
VITAL SIGNS
Temperature 99.3; pulse 77; respirations 16; blood pressnre 106/54.
GENERAL
He has marked swelling with abrasions of the left side of his face. Pupils
are equal and reactive. Extraocular muscles intact. He has great difficulty
opening his mouth or moving the left side of his mouth because of the facial
abrasions and tbe injury to the left side of bis face.
NECK
Supple and nontender.
HEART
The heart rhythm is regular without murmur.
LUNGS
Clear.
ABDOMEN
Soft and nontender.
Page 1
HOLY SPIJllT HOSPITAL
Camp Hill, PA
17011
NAME: HOCKLEY, GARRY
MR#: 191000
ROOM #: ECU
DR.: Spurrier,
EMERGENCY ROOM REPORT
""--"-',
I;
I
I
,--.
;'--, ..
'~
.~"
!" :..
',"'-
.~
.,-
~
'It' '
"
"
PELVIC
Nontender.
EXTREMITIES
Symmetric. Full range of motion and nontender.
NEUROLOGIC
Finger to nose is normal; reflexes are normaL He is alert and oriented.
CT scan of his brain without contrast shows no abnormality.
After return from the X.ray Department, I had him ambulate in the hall and he ambulated without any
staggering gait or difficulty walking.
DIAGNOSIS
1.
2.
Concussion with brief loss of consciousness.
Post concussion dizziness and disequilibrium.
I discussed the situation with the mother. He win be discharged to home with our head injury instruction
sheel. She will keep him home from school for the next two days and watch him carefully. He will use ice
to his face, wash it well, and put antibiotic ointmeut on aud follow-up either here or with his physician if he
is not better in 2 to 3 days.
?
~I i)llf'i
(U~~~,,~V
David J. Spurrier, M.D.
DS/sz
D: 05/19/1998
T: OS/20/1998
5958
Page 2
HOLY SPIlUT HOSPITAL
Camp Hill, PA
17011
NAME: HOCKLEY, GARRY
MR#: 191000
ROOM #: ECU
DR.: Spurrier,
EMERGENCY ROOM REPORT
PT NAI'lE:
PT LOC:
DIAGNOSIS:
~.J
AF
,.
'I "',,11--
STAT RESULTS FOR
HOCKLEY ,GARRY L JR
ECU ROUT
14:01 05/19/98
SERVICES
NUM.
SEX M
FRO~1
JNQ,ERPRITFl
RAD
PT
12004941
ADM DATE:
ATTN DR:
AGE 11
05/19/98
ED GROUP
ORDER
ORDER DATE/TIME
05/19/98 12:28
SERVICE DESCRIPTION
CT BRAIN \'10 CO
1
OCCR
1
RESULT TEXT
COMMEN~S: A CT SClU~ OF THE BRAIN WAS PERFORMED WITH THE STANDARD P~~ES OF
REFERENCE. THERE IS NO SHIFT OF THE MIDLINE STRUCTURES. THE VENTRICLES
ARE WITHIN NORMAL LIMITS IN SIZE. THERE IS NO EVIDENCE OF AN INTRACEREBRAL
COLLECTION OR INTRACEREBRAL HEMORRHAGE.
CONCLUSION: NEGATIVE CT SCAN OF THE BRAIN.
~
~'lDl Q6 - ~~MD.lD.O.
Date- ~I
Results reviewed by
'.'-,,,,,.
I};;
6LvH8HH
x x
.
,.
t"'.
,. - >
; ,
'.
HOLY
.
SPIRIT HCS?IT.~
ff
.
DEPARTMENT OF RADIOLQGJ ~~D DIAGNOSTIC I~~GING
Cfu~ HILL; PENNSYLVANIA 17011
(717) 763-2600
PATIENT: HCCKL.i:..r, GARRY L JR
MR: 191000
SOC SEC, 200-70-9346
ORn DR., ED GROUP f
PT TYPE: E
ADM DATE 05/19/1998 12,04PM
LOCATION ECU
DICTATION DATE, 5/19/98 12,51 PM
TRANSCRIPTION DATE 05/19/1998 01,56PM
ARRIVAL DATE:
HOSP SERVICE, ECD
EXAMINATION: CT BRAIN SCAN, UNE1'IHANCED
COMMENTS: A CT scan of the brain was performed with the standard planes of
reference. There is no shift of the midline structures. The ventricles
are within normal limits in size. There is no evidence of an intracerebral
collection or intracerebral hemorrhage.
CONCLUSION, Negative CT scan of the brain.
.~
tJaPiY
1. 0- r.., q1 .
p~/,~ /
./ " Ij\..
pcu
~
DICTATED BY,
DATE OF EXAM,
W. B. Miller, Jr., ~~D^/mek
05/19/1998 ~V V
.
initial Lab & X-Ray Orders:
Labs I Urine Specimens
[ ] Acetaminophen [] ESR
[ ] Alcohol ] Glucose
] ,l\myiase/Lipase ] HCGS
] APTT ] Liver
] Blood CLJltures Profile
1 cae ] Lytes
] CKMB ] PTP
] CPRG ] Renal
1 CRP1 Profile
] Digoxin ] Quinidine
] Diiantin ] SalicylatG
Radiology
[ ] AbdlOb~tr, Series
[ ] Ankle A L
I j Clavicle R L
[ ] Carv, S~ine Lateral
[ ] CelV. SPine Routine
[ ] Chest ~tn. / Port I TPA
[]Elbow A L
[ ] Facial
] Femur A L
] Finger R L
] Foot A L
] Forearm R L
] Hand A L
] Hip A L
1 Humerl.lS R L
] Knee R L
] Other:
Special Procedures:
Ultrasound:
[~scan of
[ ] va Scan
[ ] Other:
] Abdomen
] Duplex Doppler
] Gallbla.dder
[ ] Pelvic
Cultures
] Beta Strep AG (Culture
] Cervical
] Chlamydia
] GC Cwlture
Billing Classllication:
( ] Levell ( 1 Follow up
[]Levelll [leasel
[XLevellll
I ] Level IV
[ ] level V
Holy Spirit Hospital
Camp Hill, PA
Emergency Care Unit
Physician Order Sheet
206-ECU REV, 8/96 JD,BA,MD
C-iA.:F CO?Y
.. I
~
-
"
] Serum Acetone
] Theophylline
] Thyroid Profile
] Tox Screen
] TPA Labs
] Type & Cross _# of units
] Type & Screen
] U/A
] Urine C & s
J Workman's Camp Drug Screen
lOther
] KUB
] US Spine
] Mandible
] Nasal
] Orbit R
] Pelvis
] Pyelogram lVP
] Ribs R
] Shoulder R
1 Skull
] Sternum
] T/Spine
JTibl Fib R
I Toe R
lWrist R
L
L
L
L
L
L
Timf'dCRT/lnt
&-~
Time CAT nt. i
jSpU1umC&S
]StooIC&S
] Stool 0 &' P
] Stool C. Difficile
jWoundC&S
[)<t Accident
[ ] Medical
[ ] Medical Non-Emergency
,,~ ..
J_
.
.,
T' ~ _4:.ry ;-~,-:
;me,:....een; :lVl-'---'
Cardiac
I ] Monitor
[ ] EKG paged at
[ ] 02 LJMin.
[ ] 02 Saturation
, , ,~,
A
"'W:;;
'~,''''
.,
Respiratory
] A8G's paged at
] Peak Flows Before/After Resp. Tx.
] Respiratory Tx.
Medications f iV's f Additionai Orders
Time I
IV: NSSf D5WI LRf D5/.45NSI OS.9NS
infuse at cc/hour.
[
] Obtain old records.
o
!JJ o--r--
'DateJTime/lnt. ,1
LI ~L-H) Y\wf'v1~v--.
0u7
c
Q U;~ G
'\- ~I;,Q..'
Signature:
Signature:
Signature:
Signature:
~1 ,J). ) J(f)
;S) '9 Ie!?;,
t I
Initial
Initials:
Initials:
Initiais:
Signature:
Date:
..., -; --,' '-,
't?
1 '1 i -:: J:) f
-;;~ Y L
J .~,
:-> 1 ) 7J 2 :_;,
-J; _
i -i':"j'}b713
\..oc
,
~
PJfJ(J(J_CC;j_
R.N.
R.N.
R,N.
R.N.
MO/OO
~ -::)
,
J;
"I
-'"
't.(
.
t"..,'
,i,&"r"
..;.,'---' .
/' ,,~ ,('0;
-'J -/r-o/ -'j . /7.
- ",,,,., -,J/I
; !.~/JjAJ.u Vi J AI'/
,; , <r-'- 4,' ,~ Po ...rr-, '
FMD: ' iI /-l L ~J-V' . u
Mode of Arrival: [l,"j"Ambuiatory [ ] BLS [ ] ALS [ ] rvledical Command
TRIAGE I CHIEF COMPLAINT: .i u~, I~
'''IT'AL -R'AG".L /. d ',/
d'<f ~ : _' ~ ~; ., '~ { , A,,~'''''''_ ; f /1..'-1)./7: /Yl, ...........~! ~
J'./V'y.. _( ul ~~v ~ ~('l--i!P .
I pr .
Place injury occurred: [ ] Hom~ [ ] Indusiry [ ] Recreation [ 1 Other
lnformation obtained from: ~Patient ~jjY/S.O. _Records _EMT/Paramedic
Extremity Evaluation: Triaged to radiology for:
,I -1
J"-.//./
\I
t
.
,.
Date:
Name:
'Age:
h'
(!
//~'//,:..?
! -' -,
Inage ! Ime: I/'';::- ').../
Time to Exam Room: i ::L.i1 (j
Log-in Time:
1- ( II ~ f-',Ir;,/~u/-~
;-r- #
// -,
(.J. ...-.:::L-f:_I'J
:.?'t.':-'!.-L-\/c..b:.2::t'-
Deformity
Skin Color
Intervention:
Yes / No
Pink / Cyanotic I Mottled
Skin Temp "!\farm / Cool
Pain (1-10)
Distal Pulses Present! Absent Destination: f--:tE"CU [ ] EDF
Paresthesia Present / Absent Time:
/) , j
SignatureV:::- - 1..1 ''"'d ,.-"J (J
B/P:~~' Pulse OX.:
, ASSESSMENT
I
Temp: 7'93 Pulse:
Allergies/Reactions: Latex - Yes
Last Tetanus: LMP: Weight:_scalelestimate (if pertinent)
Visual Acuity: 0.0. o.s. O.U. _Corrective lenses
Subjective: q-rv0-0,,_ tJ52 /MO -A!PoAod} j.,,,i2n~J i,)n t1k .L/)o~ 1'~"'~"';"9
e-0J k-/,( <:>-/;-) J.i.:-. -?' ,n ^, 1 /.",.., T. '/?r, <-+-;;'-k,~ ;( " i. ~ --""-,,,"I/o ~
~/V^CcA-<.< ,w /(/,'7/,/" ~ '" ~~ -:1, -::j. -+-r ' ~. pi-, , ~ / ~ .i. '-'~;I". /l.
/J /J
(
~ ., ^ "d.-
7fT
~I/
Objective:
m~z-
(IA...n
: -. -
/
, ,
{.J
Prehospital Treatment: ~
Medication/Dose/Freauencv
.a-
Last Dose MedicationlDose/Freauencv
Last Dose
Past Medical/Surgical History: .-cJi
Has patient had exposure to measles, chickenpox or TB in past month? ~Are there advance d\rectiveS?~ Is copy available? ~
NURSING DIAGNOSIS EXPECTED OUTCOMES
_ Cardiac Output, alteration in _Improvement in cardiac output demonstrated by improved v.s, and diagnostic tests.
_ Comfort, alteration in _ Decrease or reHef of discomfort
_ Fluid volume, alteration in _Improvement in fluid vol. demonstrated by decrease in symptoms of fluid vol. imbalance
_ Jmpaired gas exchange _Improved gas exchange demonstrated by improved oxygenation and vital signs .'
_ Potential/Actual infection _ Decrease in symptoms indicating infection or potential for infection
_ Knowledge Deficit _Improved knowledge demonstrated by verbalization / return demonstration
Assessment completed at / f!;;k'
Data obtained by:
by
c'YJ
R.N.
M.A
Admission Called:
Report Calle
Disposition:
Discharged:
[ ] Admission [ ] Observation [ ] Old Records Sent
Admitted to at Hrs, Transferred to at by
" e [~AMA [ LOR at , ~~aGtorY'-f...,t1~pr~~ ! Critical [ ] Deceased to morgue at
,/'7,';,,( H-e;scharge Instructions 7'?J 13'isch,;;ge R.N.' ,,.. tJ. ""7/":,.--/,11'-'~
/ / " 1
at
It ~-S-
Holy Spirit Hospital /1:t
Camp Hill, PA
ECU Nursing Assessment
, 1 ;
, , , ~ >
, '. .
" '\ '-
.) -,')
,
201-ECU 5/97 6th Rev, JD, MD, SR
': :U
<",'):
{'}'
CriA;~T CO?Y
,
i
II
,~~\ikn
Date:
.
5/'1-9/<:
Time: ii; J
.
(6
,
,
i.
.
('S/)
!,
.,-,.,,"'~t' :. t.
..~~-- 1
i ",'" ".''''- i
j '__",-- I
..",,"""_.c
"
Assessment:
iyy;/f
Vital Signs
Monitor
Physician Assessment
02 Saturation
Lung Assessment
Visual Acuity
Diagnostics:
EKG
Labs
PCXR/Por1. C-Spine
Sent to Radiology
Returned from Radiology
Procedures:
Respiratory Treatment
Ice
Foley Insertion
NG Insertion
Wound Care
SplintlOCUSling/Crutches
Miscellaneous:
,
,
i
I
,- I' i
.-"'-"'"" I
: i _ "'"' ......-- l
~:;.",'-'"-i
i I 1-' .
, I
, I ',,-_~--; I
, ; ~. I t
/' i __ ~~--- ! ~
_";01-r\ 'i '-,,<'~-
I ~~,-
, -
Pain Scale (0-10)
Level of Consciousness
Siderails
Intake & Output
Patient Education Info
I
I__.._~- I
I
i
i I .~_.-'
~-,' ..
, i ~,"..""-"'.. -- ,
~-,----~
~
~
:'i
11
~
'.1f
~
........-~,...'---
----~----
,
,
I
i
Other: i _-.-
Initials:
Time:. . _. ,2//,
,', A r"" ... .'" --:;, ", . - A"~ ,-;~.'; (Jf)
....,. __A I\--..... ~.I , I!I A _., IJ j, ,_ L.A. J h .J --;.-~r:I;;'{.
_~ 'A.. () rtl(;j/~- _. ~r,LL f, ~,;I,.. /--::. A uH.._
,'I // ___
_.--'-
-,--
.--
\
;;
.
~
c
S
~
IV Therapy
Date Time
Amount Solution
Catheter
Site
Rate
Rare
Control
Condition
Alf!-'.!!~I~!tt
Initials
),
~
I
I
!
--
,-
Signature:
Signature:
Condition Codes::
a-No lnflamaticn
,-Edema
~~
control:
Initial:
Initial:
Initial:
Initial:
Signature: '
~h Signature;6'Q 11-I~I/u!~R;:.J
3.Pain
4.Hardnec~
j.AVI
2_StatMaster
2A-Erythema
2S-Ecchymosis
5-Warrnth
---~--
Holy Spirit Hospital
Camp Hill, PA
Emergency Patient Documentation
',~ '
I ':) \ ~~ 'J -J
E
")0:1"
, ,
J
> ~ \ h
-; :. 2 "'
205 ECU Revised 5/96 JD, BR, MD
,
CHART COPY
"
,,- ..::., :.. 1. ~~
;
_<> ,<.,.,-',"I"-+"'~'~.wo~~.",--,,,,,,,-~.
:-.
~ .-,
E.CU.
(717) 763-2316 '. '
E..DJ:"'.
I:
~
:""" ~' ~ ^ '~. """" ~~"' 'lih.
'-.' ,',_'c,":'
InS"('lIARGE~ISTRU CTION3
. (717) 763-2461'
.'
"", _,' - "C ':--"- ,- ,.,
I1C cxamlnati,on und treu.lm~-DtyoiJ have received ill the Emer~e~~y. re Unit (ECU) 11a:~ been rell _..,.. an emergency basis olliy, ;;ld -~~e not intenJ.od to be u suh;;iil~t~:for~or'an e'1'fort to provide
lmplete medical care, if you develop new problems or complicatIOns contact your physIClltn or the EilJ-'1rgency C:\re Unit. FOLLOW 'THE !NSTRUCTIONS CHECKED BELOW.
d..,-'-.j
Follow these instructions if they differ from the patient information sheet.
FOLLOW UP CARE
o Retum to ECU I FHC on for a recheck,
)8' See your physician or specialist if not better in Z - 3: days.
Return to ECU if unable to do so.
o See family I company physician / FHC on _for
o Recheck 0 Suture removal
o Pick up your x-rays from the Radiology Dept. on the 2nd -floor
before going to doctor's office. (Call 763-2696 before arrivaL)
o Your blood pressure was . Please get it rechecked
by your family doctor,
o Test reports I E,D. record given to patient.
o CBC 0 CPRO 0 Renal Pro. 0 Glue,
o EKG 0 X-Ray Copy 0 Records Copy Chart
ADDITIO STRUCTI N f
Offwor~j! From:':>!}"! to '52-1
o Return to work on 0 Light 0 Regular duty.
o Limitation:
o No gym or sport for _days. Z~
o See Workmen's Compensation shee( V -)'")":,!
~"
Signatures: 'IA1.A./---- M.D,/D.O.
/j
~% "VI JtJ, )r.A...e A:.A'..y-RN.
!,/ {----/
PECIFIC INSTRUCTIONS:
VOUND CARE
] Return for suture removalln. I days.:1.'
] Chancre dressi.nz /AJf/w''-,~ Ln-fr~~ L'i((f
and a;ply Ar-.,s,l..o)h( tt,'l(r tiM~a day until
] Tetanus/diphtheria booster given.
S&v" !.ut>I /.-I^.
V
PRAINS/BRUISES
J Elevate injured part above heart for_days,
] Ace 0 Sling 0 Splint 0 Crutches for_days
J Apply: i/fIce 0 Heat 0 Alternate ice and heat for
;.-zb-~inutes '----- t mimes a day until symotom free,
] Wear cervical c~llar for~days. .
IIEDICATlON lNSTRUCmO~ U r -
J Take~aspirin( Tyle~hl br AdVil}:~ery-1-hours,r{J;, {
] ~ake the following (B..L(:.-Y&'dicili.e,....- i~
2. 1
3.
4, Your regular medicines except
] Do'not drive or operate any machinery while. taking
)THER
i,
HOL~:{ Spn~,j,.T i:HJSP!1'AL
~ ,0
ic
,
~
~
,
o Other
~
,
,
II
r
!
~
,
~
!
"
,
t
i
~
f
j:
;
I
i
,
,
i
l
,
I
n
!
,
J
I
Dateb-/ 1-'7~
:>ATIENT INFORMATION: Patient infonnation sheets contain important information to review and keep.
] Abdominal pain
] Alcohol abuse
] Allergic reaction
JAsthma
J Back pain
J Bites-HumanJAnimalJInsect
J Burn
J Chest pain
J Conjunctivitis
] COPD
o Corneal abrasion/foreign body
o Croup/bronchitis
o Crutch walking
o Diarrhea and Vomiting I Ped. Vomiting
o Drug/Alcohol abuse/addiction
o Febrile convulsion
o Fever / Ped. Fever
o Flu
o Fracture
o Headache
fhe interpretation of your x-ray is a preliminary report, The films will- bg'reviewed by a radiologist and
lOll or your doctor will be informed if there is a change in diagnosis, 1 hereby acknowledge receipt of
here mstrucUons and eqUlprne.nt and understand th.em I understand that I have had emergency treatment
Jnly and thaN may be released before all of my medical problems are known or treated, I will arrange
:or follow up care as I have been instructed.
X Head injury 0 PIDND
o Hypertension 0 Rash
o Immunizations/tetanus 0 Seizure
o Kidney stones 0 Sore throat
o Laceration 0 Sprains and strains
o Neck strain 0 Threatened miscarriage
o Nosebleed 0 Toothache
o Otitis media 0 URI and colds
o Pediatric head injury 0 UTI and pyelonephritis
o Pecif~atnc URl 0 Other
T /<'" /1
l-tI'ATIENTCljE ESUND~~~
,/ ,{/':.:/C;f -/ /
'-.::::b ~/'i///{/ ,
SIGNATURE - ~ '/t/ ./
/'> Patlent or R~~f)l~lble Person
HOLY SPIRIT HOSPITAL EMERGENCY CARE UNIT
503 NORTH 21ST STREET CAMP HILL, PA 17011-2288 (717) 763-2316
: ) Vanitha Abraham. M.D. 038840L ( ) Robert Hynick. D.O. OS 004400-L ( ) David Spurrier. M,D. 023502-E
: ),Thomas Aldous-, M.D. 017075E ( ) Richard Luley, M.D. 029960-E ( ) Alan Teplis, M,D, 0300 -
: ) 'Salvatore Alfano, M.D, 025502E ( ) Phillip Maguire, M.D. D15063-E ( ) Elaine Thallner .. 0573OD-L
: ) Ramesh Arora. M.D. 016727o/~ ( ) Lawrence Paul, M.D. O)9-~-L , ",' , ( ) David Zi~rman. M.D, 00f636-E
; ) Glen Daughtry. D,O, osqo~m6E \! ,,( ) Frank"prOC,OP"i,O'11-, ,K", ",.,,00,,030, 3643-E, ' _,', ,;.",-l"",).'",;/ / ,.(1
: )]OnDubin.D.0./>J699IL ( )RanjanaSh~.~.031/65-E.;\:., V
DATE , /,,,,/,;;:,,,'[' ., , ""~;,'i, A~:: \.
IX ~.r'" /, . / ,;C \
/ (I~i~!~~!~~~>q :l,'{ (}'; ~,,"::::;': ~
'm~uru ~":' ~~"". """'L-
[N ORDER FOR A BRAND Nll-.ME PRODUcrTO BE DISPENSED. THE
PRESCRIBER MUST HAND WRITE "BRAND NECESSARY" OR "BRAND
MEDICALLY'NECESSARY"]}I THE SPACE BELOW.
'J LABEL
o SUBSTITUTION PERMISSIBLE
178(6/97)
1 Y]'14S'H MR
HOrv, ry"ilRRY l
",,;I.\"'!:. .
, C.,
,<)\'0 HGNGll.
'E'~OL~
O'o/07/ISSb
C < ' .
') "\ rl _ 7. C) - 71..1 ~ tI
ig\UUV
JR
c
feu
p \ \ 7025
728-0503
f. D GRC'JP
. , '"l \ 0
~
. :<
.<~'" ~:.\:~ 'T.:;:~~ ~ '-2~~'-~:; :;f'~~-~' ..'
',-, '<' -.'
ADMIT DP:L80018
~TTND DR: 180018
REFER DR:
ADMIT [IX,:
'I:::OMPl..AINT: BICYCLl:;. ACCIDI-'NT
AMB BRT IN BY:
COI"1MENT:
NAj'1F~:,: "-
ADORE'S::;; :
BIRTHDATE:
EMPLCIYf':R:
ADDR,ESS:
CHURCH:
COMME1\lT::
NAME:
~DDRE:3S; :
NAME:
ADDRE::S:3:
--
H I 1.;~~iE~)j~;:~L~~I~i,r AI{' ,l
1'1H #. ') 1 \)O~:)
.. ,.' '.',_.- ,"
':Mt::-:-
it .b,;
>
__ _, J~ATIENJ
, . - -'1"'. '-''.1 'C'A'." V'L" "j'"
rt~_~~.S,l~..;.-) " l.,j, ' ,!:::_K,:.'._-,: ,,,, t:'\
91 5, ,!"1AGNOl~IA DR
Of:. / 071 1 91;:16, AGE:
UNEMf"LOYED
I Nf'"pHMATI ON
SS #~
~OO-70-9:346
/ENOLA IPA/17025 PH ~:
.11 SEX: M MS= S 8ACE~ 1
OCCUPAT I ON: ~~jTUDEl'JT
I I
717-72:3-956:3
C;;::::iJ: 04 l (1';:::'5
"
Ph 'i~:;:
I
PROTESTANT
AMB=
i::.i"il:,RGF:NCY CONTACT INFORMATION
HOC,'::LE,!: ,,,;HEPi,( I L R"'L TO PT: 1'1 ' WOI'(I< F'H '*;
915 1"1{~GNCiLIA DR IENOLA IPA/17025 PH jj:
7 i. '7-1;,57'-..~~6:;:7
71 7-728-9::-:;,~?;::]
HOCKLEY ,GARRY
\":EL TO F'T:
/ I
PH #:
WORl-< :;:'\'1 # ~
,
i
CA:3E
INFORMATION
RI='O SOIJFCi:::,: EO PATIENT TYPE:
HC):7":;i=' SJ:::RV= F.:CU FINANCIAL CL~=,ri I::'
VISIT CLINIC COO~: ECU ROUT
ICO-9 liX:
ED G,ROUP J, ,., ,
c~=ci~g'Jr'1 r10
c:,
BRT IN BY: MOTHER
ACC I DENT I NFCiRMA TI ON
iolieI:E{Il.t1E: 0:5/1'0:,'981,;7::30 ACC'IND:b - ,JOB f'IELATED: ill
DESCRIPTION: BICYCLF ACCIDENT ,
"' "'" '" , ." , ..-.' .. " .. - - ~,~ "!
I\lAME:
AJ:)QRl:'5S: . ,,'
EMPLOYER:
ADDRES:;:; :
PLAN
LOCATION: 0
",}f'iERR I_HOt;:I<LEY
915 MAI3NI)L) A [I,R
LCL i"IANAGsljENT ,",..
, 1 00 ,JOY A C I RI~:LI::
GUARANTOR INFORMATION
PT HEL TO OGAR: 0
/PA/17025 F'H #: '717-721=1-9:=,1;::'
, " .. .~. ~
CONTACT NAi"IE:
IHARRH,BURC~ /PA/17112 f"H #: 717-6~;7-2637
lNSURANCE HJFOR,i"IAT WN
-"'.;. cpa POL I CY .#
REL PC VFY CARD PRECERT/AUTH '*
.;:.,;:. #:
IFNOLA
W::;;URANCF CO
,,' S;UBSCRfBER""
)t ' - "'"'' "". .
GROUP #
:='RECERT PHO,,,=: i*
N
',y
IN:;:;UR. ADDRESS:
N
~~
254,00
E 820. J
;:: 84J.1,i.f
^:;(
I NSUi'( , ADDRESS:
:3; - " ,,' '"
JNSUR.ADORESS:
4
I N:::;UR. ADDRF:::3:;:. "
CARD AVAILABLE, FORI"1 GIVf'J\I
COMMENTS: HC24 ~MD, PT HAS } NSURANCE, NO
TO COMPLETE AND MAIL BAC~
PATIENT NAi"1E~
RECi X ::;TERED BY:
HOCKLEY ,GARRY L ,jR ~
FHMIB EDITED BY:___~____
PT#: /I/q 12002~O~, _~R~:.19~?:~O
IJATE ~ /::/J-j-::__" i7_Nu UJ- LIUl,i.,IIV1Ei\) I
71:06 05/]8/98 ~RGM i._A237E~I~~GS~
fl"
I,
,I . ~ I
~' .
~,-. '. t--'" .~.
.
c.
ADM. DATE: 5/18/98
CC
Bicycle accident.
HPI Garry is an ll-year-old boy who was riding his bicycle and fel! off. It is not clear
from the history whether he ran into a wal! or simply fell onto the ground. He does
not remember details of the accident. There may have beeu a brief period of loss of consciousness but at the
present time, he denies headache, nausea, or vomiting. His mother says his last tetanus shot Was within the
last two years. Nurse's notes reviewed.
PHYSICAL EXAl'VIINATION
Well-developed preteen, somewhat lethargic but easily arousable.
HEAD
There are no scalp lacerations. There is negative Battle sign. There is no tenderness
of the skull.
EYES
Extraocnlar movements intact. Pupils equal, round, reactive to light. There is a
superficial laceration just below the left eyebrow. This is approximately 1.5 em long.
There is no active bleeding. There is mild ecchymosis and periorbital swelling about
the left eye.
FACE
There are multiple abrasions with some tenderness of the left cheek. There is a
superficial laceration of the left cheek just to the side of the left nares.
ENT
Tympanic membranes are clear. There is blood in the external auditory canal.
Nose is nontender. The patient is having mucous discharge from the left nose but
there is no bloody disc barge.
MOUTH There is multiple superficial lacerations inside the left lower lip, a few also inside the
left upper lip with some obvious dirt and debris. None of these lacerations crossed
the vermilion border. The left upper medial and lateral incisors are slightly loose. The left upper canine
tooth is absent secondary to this accident. Mother is fairly certain that this is a deciduous tooth. There is
also a chipped tooth of the left upper first bicuspid. There is only slight ooze from the alveolar ridge.
NECK
Supple, nontender with good range of motion.
BACK
There is no spinal tenderness. There is no posterior rib tenderness.
LUNGS
Clear to auscultation.
HEART
Regular rate and rhythm without murmurs.
CHEST WALL
Tender to the left lower ribs anteriorly.
Page 1
HOLY SPIlUT HOSPITAL
Camp HiI/, PA
17011
NAME: HOCKLEY, GARRY
MR#: 191000
ROOM#: ECU
DR.: Teplis,
EMERGENCYROOM REPORT
,.~',.;"',','. .;,:j, ;,;,,";,_:..':,;,,-';..,~.. .._c
I; ,~l L,"-
I
:,;-':, .,:. ;',;",!,~ ,'J'.;,~,
:",...>,,_':;i-<_'I'.'~",~'.~.;" '>" ._
,~'.' -' ." ., ~. ':\,
'"''-It.,,
;-,,,' :':~'.~~. ",.'"
",:,;,~".~>.
-"-;-~"- '-,
-,. :.;.<..';,..,,::.'~ ."
'" :.~", ','.;-'1. ;'-~
, ,
... ;--._ ,~;'.:',:fk':Z"~ ';~,,"':';--":" ',,,,:,~':~
,~. ,..";i:, ',' _~';:<,_,,';.',
",-- ,,,,,', -,'"
'.',",,-_.,".~-~~,~',,-
"
.~
~'
ABDOMEN
Soft, nontender.
EXTREMITIES
Pelvic rock is stable. He moves all extremities with purpose. There is no tenderness
of the extremities.
X-rays show no evidence of fractured ribs. There is no fluid in his maxillary sinus, no evidence of facial
fractures.
MEDICAL DECISION MAKlNG While in the Emergency Room, the patient's mouth was
rinsed with 1/2 strength peroxide and his wounds were
cleansed with Betadine and antibiotic ointment was applied. The patient's parents have been advised to take
him to see a dentist tomorrow morning.
DIAGNOSIS
1.
2.
Facial contusion and lacerations.
Closed head injury.
DISPOSITION AND PLAN The patient will be discharged home in the care of his parents. He
should apply ice to his face tonight to limit the swelling. His facial
wounds should be cleansed with soap and water and or peroxide daily and Neosporin applied two or three
times a day until the wounds are dry. Mouth should be rinsed three to four times a day with 1/2 strength
peroxide. He should avoid salty or spicy foods and should follow up with his family doctor tomorrow.
~~b
Alan Teplis, M.D.
AT/sd
D: 05/18/1998
T: OS/20/1998
5785
Page 2
HOLY SPIRIT HOSPITAL
Camp Hill, PA
17011
NAME: HOCKLEY, GARRY
MR#: 191000
ROOM #: ECU
DR.: Teplis,
EMERGENCY ROOM REPORT
"
..L. I~
.'
'*W -'11iII ('Wi,
/) f' r}~
'-V", V-J
~ Chief Complaint"
.
tr
.
C'. .
"
"
, !
HPI
, ,
,
Meds: , ,
AllerQies:
Past Historv: - ' " , Diallnostic Results - , C,' -, ,"
EKG- ' ", ' " " ,
,
Family History: X-RAY-ReDort Der Radioloaist/ECU Physician
Social History: " r /,.,- '-'-- ' "
/V ~c; ( VV(i V
ROS: Constitutional Neuro/Psvch ( " ",
Eyes MuscuJosketaJ LAB-
Ears. Nose, Mouth. Throat Intequmentary
Neck , Endocrine
Cardiac Hematoiooic/Lymphatic
Respiratorv Immunoloaic
GI Ail Others Neq
GU Unable to Obtain
Phvsical Exam: I Consult
ConstitutionaUGeneral Contacted @: .
Head
Eyes Progress Note/Medical Decision MakinglRe-examlProcedures
( ) Old Records From Reviewed
Ears, Nose, Mouth, Throat
Neck
Back
Cardiac
Lungs
Chest ,
Abdomen
//1 L 1.~ --I'
GU L/ j C-I V\ I '-
,
Extremities Clinical Impression: ( !v\r I'
Skin 1) ~ c/fJ. (c:r------ jO--- "
;~ ,', ' ' C\7\<ud~':t
Neuro/psych DiSPOSitiOnQ-;.~/.I2...d !O OJ 1.,
Hematoiogic/l ymphalicilmmunologic/Other }JIG
, , I Signalure:~O-=~~~
I ) i <- Ttl T--'< 0" I nf/1^ F t--
~ /1/'-"'2.'/\' :8 /'
HOLY SPIRIT HOSPITAL , -'<", C, " - ,
I" ~ ~ -,
" .. v ,,1 t
CAMP HILL, PA , , ' '\ J (~ Y , ,
c ,
ECU PHYSICIAN ASSESSMENT ':1 : " I' "-') ~CU
' ,~
, l702:S
- , - ' '
.' -
EGU-211 Rev 8/97 (em) - , , j, "
Rev II 8/97 (sa) - ,
.....~rsjng ).oi6t~s Reviewed
Ci-iART COpy
'c
.
e.
PT NA."'lE:
PT LOC:
CLINIC VISIT:
RESULT ID:
PRINT RESU1TS
HOCKLEY ,GARRY L JR
HOSP SRV: ECU
ECU ROUT
051998114808
FOR
RAD
C
12:26 05/19/98 FROM LE38JRRPRiN~L
SERVICES
PT NO:
SEl<:
ATN DR:
ADM DATE:
12002606
M AGE:
TEPLIS ALAi\[ C
05/18/98
11
MD
SERVICE DESCRIPTION:
ORDER NO: 2
UNILAT LFT RIBS
OCCR NO: 1 COLLECTION D/T:
05/18/98
00:00
COMMENTS: LEFT RIBS: I DO NOT APPRECIATE AN ACUTE FRACTURE DEFORMITY. I
DO NOT APPRECIATE ANY PERIOSTEAL ABNOfu~~ITY.
CHEST: THE CARDIAC, HILAR AND MEDIASTINAL CONTOURS ARE NORMAL. THE
LUNG FIELDS ARE FREE OF INFILTRATES. THERE IS NO PNEUMOTHORAX OR EFFUSION
IDENTIFIED.
CONCLUSION: \
FACIAL BONES: THE VISUALIZED MARGINS OF THE ORBITS APPEAR NORMAL. I
DO NOT APPRECIATE AN ACUTE FRACTURE DEFORMITY. THERE IS NO EVIDENCE OF
HEMOSINUS. NO OTHER ACUTE FOCAL .7\BNORMALITIES ARE SEEN.
CONCLUSION: NO ACUTE FRACTURE DEFORMITY APPRECIATED.
,~
,
J
"-, .I
,.
,[, 1-
-~
1-'..'
>"
."""
.
"
..
.r' .
HOLY SP~RIT HOSPITAL
DEPARTMEMT'OF RADIOLOGY AND DIAGNOSTIC
CA~~ HILL, PENNSYLVANIA 17011
(717) 763-2600
(
.
IMAGING
PATIENT: HOCl<LEY, GARRY L JR
MR: 191000
sac SEC: 200-70-9346
ORD OIL: ED GROUP,
PT TYPE: E
ADM DATE 05/18/1998 09:06PM
LOCJl,TION ECU
DICTATION DATE: 5/19/98 11:12am
TRANSCRIPTION DATE 05/19/1998 05:14PM
ARRIVAL DATE:
HOSP SERVICE: ECU
EXAMINATION: LEFT RIBS SERIES (3V), CHEST (IV), FACIAL BONES SERIES (8V)
COMMENTS: LEFT RIBS: I do not appreciate an acute fracture deformity. I
do not appreciate any periosteal abnormality.
CHEST:
lung fields
identified.
The cardiac, hilar and
are free of infiltrates.
mediastinal contours are normal. The
There is no pneumothorax or effusion
CONCLUSION: The chest is within normal limits.
FACIAL BONES: The visualized margins of the
do not appreciate an acute fracture deformity.
hemosinus. No other acute focal abnormalities are
orbits
There
seen.
appear normal. I
is no evidence of
CONCLUSION: No acute fracture deformity appreciated.
DICTATED BY:
DATE OF EXAM:
A.S. JAGANNATH, M.D.~r ,
05/18/1998 i cr-----'
/ 0-:::r~tL.-urru
'CO/hi. C:V ",' y-
r, ;-%
6/,3cC l(jA-/
. ,f[
Initial Lab & X-Ray Orders:
Labs I Urine Specimens
[ ] AcetaminoPhen ] ESR ] Serum Acetone
[ ] Alcohol ] Glucose ] Theophylline
[ ] Amylase/Lipase ] HCGS ] Thyroid Profile
I IAPTT ] Liver ] Tox Screen
[ ] Blood CultlJres Profile ] TPA Labs
[ ICSC ] Lyles ] Type & Cross _# of units
I ]CKMB I PTP 1 Type & Screen
[ ICPRO ] Renal IU/A
[ ] CRP1 Profile ] Urine C & S
[ ] Digoxin ] Quinidine ] Workman's Camp Drug Screen
[ ] Oilantin ] Salicylate lOther
Radiology
[ ] Abd/Obstr. Series ]KUS
[ ] Ankle R L ] US Spine
[ ] Clavicle R L 1 Mandible
[ ] Carv, Spine Lateral 1 Nasal
[ ] Cerv, Spine Routine 10rbi! R L
[ ] Chest Atn. I Port I TPA [ ] Pelvis
[ ] Elbow R L ~ram IVP. ,___
~ ' Ibs_ . R:.CO,
[ ] Femur R L [ ] Shoulder R L
[ ] Finger R L [ I Skull
[ ] Foot R L [ ] Sternum
[ ] Forearm R L [ J T/Spine
[ ] Hand R L [ pib / Fib R L
[ ] Hip R L [ }Toe R L
[ ] Humerus R L [ ] Wrist R L
I ] Knee R L Time./CRT/I#/ Jt CjfY
[ lOther:
Special ProCedures:
Ultrasound:
] Abdomen
] Duplex Doppler
] Gallbladder
[ ] Pelvic
Cultures
] CT Scan of
] va Scan
lOther:
Time/CRT/lnt.
] Beta Strep AG / Culture
] Cervical
] Chlamydia
] GC Cultllre
] Sputum C & S
] Stool C &8
]StooIO&P
] Stool C. Difficile
JWoundC&S
Billing Classification:
[ ] Level] [ ] Follow up
[ ] Level II [ ] Case I
(>I:levellll
[ ] Level IV
! ] Level V
C><t Accident
[ ] Medical
[ ] Medical Non-Emergency
.
(
.
2-- / r;;"
Time Seen: "I Z n
Cardiac
[ ] Monitor
[ ] EKG paged at
[ I 02 UMin.
[ ] 02 Saturation
Respiratory
[ ] ABG's paged at
[ ] Peak Flows Before/After Rasp. Tx.
[ ] RespiratoryTx.
Medications I IV's I Additional Orders
Time
DatefTime/lnt.
IV: NSSI D5WI LRI D5/.45NSI D5.9NS
Infuse at cc/hour.
[ ] Obtain old records.
;11c
WFil
1_-" 'r-
v"'tA.
vi./ ?j v'UI/'--
Ho 'v€--
=--ef
~
--.-,
Initials: """ Signature:
Initials: 0'f- Signatur
Initials: Signature:
Initials: Signature:
Signature:~~~o
Date: S / 55= . r
R.N.
R.N.
R.N,
R.N.
Holy Spirit Hospital
Camp Hill, PA
Emergency Care Unit
Physician Order Sheet
20S-ECU REV. 8196 JD,BR,MD
CHART COpy
1 ,-J :-1 ,--1 ,)
if ,:) C _~ L t y
C; ) ~ !,
': ; :~) '1 ~{
. ~ l 'I R Y L
> ell A C '-?
1'1\000
J ,
E
ECU
L '
,- \
7025
),' '_~ 7 I J ,} '3 ')
? ! : - 7 -) - 9 3 4 ')
723-(,')S3
E!) ';., i) 'F
'~- .::, / I :1. I -:) '1
li!ll~;
.".
,(
.
(
.
Date' ,5"ij'6';k'~';" /11
' . -'./9.' ,,' i ""7' '-7 ,
Name: ;cfiY~, ~ '-;:L i-"'!v t/~J-- ;
FMD: !::f(l ~ t,L,. / /' (/ j
Mode of Arrival: E:-11\mbulato i] BLS [ ] ALS [ ] Medical Command
11RI1l;GE;: CHIEF COMPLAINT: tt.C
INITIAL TRIAGE:
'"' ".Jie:'
/7:
Age:
, /
!!1'?
Log-in lime:
Triage Time:
Time to Exam Room:
Place injury occurred: ,[ j Home [ ] Industry [ j Recreation [ ] Other
Information obtained from: _Patient _Family/S.O. _Records
Extremity Evaluation: Triaged to radiology for:
Deformity Yes I No Skin Temp Warm I Cool
Skin Color, Pink I Cyanotic I Mottled Pain (1-10)
~EMTJParamedic
Distal Pulses
Present I Absent Destination:
Present I Absent Time:
Signature:
B/P/.1.'
[~EDF
Paresthesia
Intervention:
~SES'SMEN~.
Temp: Pulse: / /)3
Allergies/Reactions: latex - Yes I No
Respirations:
! Pulse Ox.:
q 7flJ /1 I<2A
LMP:
O.S.
I
'"
Last Dose Medication/Dose/Fre uenc
Last Dose
Past Medical/Surgical History: ;
I
I
Has patient had exposure to measles, chickenpox orTS in past month? ~Are there advance djrectiv~'o-- \s copy available?_
NURSING DIAGNOSIS EXPECTED O\JTCOMES
Cardiac Output, alteration inl1 (\..r.::-. n LQ c... _improvement in cardiac output demonstrated by improved v.s. and diagnostic tests,
Comfort, alteration in ~~ _ Decrease or relief of discomfort
Fluid volume, alteration in _Improvement in fluid voL demonstrated by decrease in symptoms of fluid vol. imbalance
Impaired gas exchange _Improved gas exchange demonstrated by improved oxygenation and vital signs
Potentiall Actual infection _ Decrease in symptoms indicating infection or potential for infection
Knowledge Deficit Improved knowl d monstrated by verbalization I return demonstration
Assessment completed at
Data obtained by:
by
R.N.
M.A
Admission Called:
Report Called:
Disposition:
Discharged:
[ ] Admission [ ] Observation
Admitted to at
ome[ JAMAI JORat
ischarge Instructions
[ J Old Records Sent
Hrs, Transferred to at by
ft4:Satisfactory [ ] 1m ve ] Critical [ ] Deceased to. morgue at
Discharge R.N. a
.
Holy Spirit Hospital
Camp Hill, PA
ECU Nursing Assessment
._i
'---, ~'~
~ ,; --\ R '( L
,,~ L ! :\
1'11000 E
i'"...
"1:- Y
J ":
"i
ECU
J' 702'5
201-ECU 5/97 6th Rev. JD, MO, SR
,/
'! ,',
72 S - " .~, 3
-~ '.' - ':) '3 4- :)
(r' 1....
CHART COrY
,/,"j'i
Dal~:5t8 ..
Ass~ent: ~
Vital Signs
MOfiitor
Physician Assessment
02 Saturation
Lung Assessment
Visual Acuity
Diagnostics;
EKG
Labs
, PCXR/Port. C-Splne
Sent to Radiology
Returned from Radiology
Procedures:
Respiratory Treatment
lee
Foley Insertion
NG. Insertion
Wound Care
SplinUOCLlSllnglCrulches
Miscellaneous:
Pain Scale (0.10)
Level of Consciousness
Siderails
Intake & Output
Pa.tient Education Jnfo
Other:
,j J i,ULi~~~~
- - ~
~ -', '~ ~
!:irt
"
..
"
.
..
.
Time: i
'"'j 'j"::,
...---
I
i
"'--vir'
'1 ,
Time:. Inilials:
:2//)<". ("1-,,1 ':;; ~ )h) _ '~"); . '. , ~ /> 7 :."
CJ l!.[n4"(: .;1" --vu~...l! k ,,_ ~ ~ - --~ ~ () , ,~\. ~ hP-,..i' c:\., '" "'"
',- ,", 'F;-'. ',~~ ,~.,1."-,.~n~__pl...,L'2 "v<:),~.'-,.~ \...Q-=-"::,~<::>=.",-,-..::l .~
~. ~-,. ~_;;. _ -...\),,-~ c, 0 _'- -,. L5'-........""'-"--~0~d.\. fiT) ~""74-"'c:.;' ;,.;,
\'C'S.\..,\_", ~.1)..' ...",\ Q),,<;.. ...::....-... -,. ^-",,,.,,",~,,, ~,;,\.
0.& ed! <JiJ c....1I iJlJ(p c. <VV'> , ~ '+-/1 ::=; -.....&" <', :ry d :b u..l.d. '^ '
Mt!,-' b~n D" I ,/.. \- r .' ,,.-+,,,,0,li\\lJ\-nif"," ....'-;/(
NT~rn~ R~
Holy Spirit Hospilal
Camp Hill, PA
Emergency Patient Documenlalion
Date
Time
Inilial: ----- nA/I
~J(
Initial:
Initial:
Initial:
Amount Solution Catheter
Site
Control
Condition Attempts
Initials
Rate
Signature'::-" IYi D [) =0 \' "i"-.A
v,",,,,, V.' r
Signal' _~V\ (
Signature: l'
Rate
Condition Codes:
a-No Inflarnation
3.Pain
Control:
-
u
''41Hl'(lI(\Bss E
JS:Warmth
.t~Edema~ '] " .)
: C . !.2A'Erythenii: '" L
~ \ I' "2B-Ecchy.rrlos\s ,.
1 AVI
2-StatMaster
Signature:
ECtJ
-1t~ I 1
;rtit/2i!t,: .
-I-'l!
f1> ";,,,3
f'J!L~ '
! i ' i --~ I
205 ECU Revised 5/96 JD, BR, MD
CHART COPY
,
,-.,,-;.,.,-, :
-'::,:::,;~;g;":~!:,.:::.",,,~"'!Al
J
(-/17~,"':'/~O"'~~~~lf'" Lv,,'. ;fiC'\'"\Ai\.0~'h"L('i;j;';;' .._", _ h'e-c.'. "'"
~ -~ u iH7H) 763-2461'~i B,
rhe eX<lmination o.nd treatment have-received in the Emergenc~' ax::.. L1ml (ECU) have been rcnJ~1td'l'ln.1n emer.;enc'l brms only. ruld are Pot lrltcnded to "e <l sl.1b~tit or oln e'fdrt 1O provide
:ompJete medlC:ll care If you del/elop new problems or comphcatJOns c~ntm;t Yq,!-r iWYS1Clilll or the Emergency C.lre Umt FOLLOW THE lNSTRUCnONS C[-!EcKED BELOW .
SPECIFIC INSTRUCTIONS: Follow these im;tructions if they differ frorp the patient- information sheet.
WOUND CARE, , W 'FOtJ.:\)W UP CARE
o Return for su~ure- re~v,al i"n~ !' _(I d~ys.:[. (~ -;--;r~", )J.?'IA.'tK'J! ,"~ 0 Return to-Eel! ~ FRe on . .. for a r~check,
.Change dre9;SlTIgr_ ,1-'<. U/...-v\/V',\..--J ;';'1 _ /\~..-'~_ ("\ I,__~ f i! 0 See your physIcIan or speCialIst If not better Ill_days.
and apply JV-,")~rn,t./ It.".-., times a day until lYY'...J. ',../ ,I '/p Return to ECD if unable to do so.
D Tetanus/diphtneria 'booster given, / D See family / company physician / FHC on _for
D Recheck D Suture removal
_~ck up your x-rays from the Ra~pt:Orr-1he 2nd tloor
- before going to doctor's office,.(~1763-269vtore anival.)
D Your blood pressure was :::7iea.seget it rechecked
by your family doctor.
D Test reports / E.D. record given to patient.
D CBC D CPRO D Renal Pro. [j Gluc. D Other
D EKG 0 X-Ray CopyD Records Copy Chart
ADDITIONAL INSTRUCTI?N 0110
'10' Off work I school, Pro~' itS to'! ""' '.
, . I
D Return to work on .1 0 Light" 0 Regular duty.
D Limitation:
o No gym or sport for _days,
o See Workmen's Compensation sheet.
/'7"! ~/ ~, / (J ~
~ (/ ~ ___~.~~.;:t:2.. ~V _A ,,/)
Signatures: -"'--i, (--.:.:.-- ,/ ~~ -" / ',-" 1,.'-;'-'
, '----" 1 / '
OTHER S -'2Q. /221/' t'1 r- "To v-..S::JVI/Tj fA-/" Date, t;~ I?> '17~. iL,
~, Sfv- I l~v"J,q '! -e. -'3 ~ c( h-----.~.J / !(JY /
SPRAIl'lSIBRUISES
J Elevate injured part above; heart for _days,
DAce D Sling 0 Splint 0 Crutches for_days
o Apply: ?c:i'}c!,\ D Heat I 9 A)1eruate ice and heat for "
'''-' ~mmutes::t:::JcLtlmes a day until symptom free,
o Wear cervical collar for ~days,
MEDICATION INSTRUCTIONS U
ake_~Tylenol or Advil every~hours.
D Take the following (9,.T.e. ) medicines f:v L/;i/C'
1. 1
2.
3.
'./\
4. Your regular medicines except
o Do not drive or operate any_madtinery while taking
PATIENT INFORMATION:
o Abdominal pain
o Alcohol abuse
o Allergic reaction
o Asthma
a Back pain
o Bites-HurnanlAnimalJInsect
OBum
o Chest pain
a-Conjunctivitis
o COPD
o Corneal abrasion/foreign body
o Crouplbronchitis
o Crutch walking
o Diarrhea and Vomiting / Ped, Vomiting
o Drug/Alcohol abuse/addiction
o Febrile convulsion
a Fever / Ped. Fever
o Flu
o Fracture
o Headache
--'...;; ~~--" -'liter
~
/ '
'~D.iD.O.
\S'J
/0'
'We-;
~
. \~
r-y'l , , f
r~'Gld
(]V
o PID/VD
o Rash
o Seizure
o Sore throat
o Sprains and strains
o Threatened miscarriage
o Toothache
o DRI and colds
R.N.
c- '-1
' ,
..J d'!y
l~ '.. V"(
""'::',(/iC",-_/ h"filCJ
,/ / I '.I"'~ ,
The interpretation of your x-ray is a. preliminary report The films will be reviewed by a radiologist and
you or your doctor will be infonned if there is a change in diagnosis, 1 hereby acknowledge receipt of
these mstructlons and eqUIpment and understand them. 1 understand that r have had emergency treatment
only and that I may be released bef()[e all of my medical problems life known or treated, I will arrange
for follow up care as I have been in;;tructed.
atient or Responsible Person
HOLY SPIRIT HOSPITAL EMERGENCY CARE UNIT
503 NORTH 21ST STREET CAMP HILL, PA 17011.2288 (717) 763-2316
( ) Vanitha Abraham, M.D. 038840L ( ) Robert Hynick, D.O. OS 004400-L
( ) Thomas Aldous. M.D. 017075E ( ) Richard Luley, M.D. 029960-E
( ) Salvatore Alfano, M,D, 025502E (,) Phillip Maguire, M.D, OlS063-E
( ) RameshArora, M.D. 016727E ( ) Lawrence Paul, M,D, 039524-L
( ) Glen Daughtry, D.O. OS006776E X () Prank Procopio, M.D. 003643-E
( ) Jon Dubin. D.O. OS 00699lL ( ) Ranjana Sharma,M'J:l'
DATE X
fY
SIGNATURE
/ ( ) David Spurrier, M,D. 023502-E
( ( ) Alan Teplis. M.D. 030018-E
( ) Elaine Thallner, M.D. 057303-L
( ) David Zimmerman, M.D. 005636-.-E
, .D./D.O.
IN ORDER FOR A BRAND NAME PRODUCT TO BE DISPENSED, THE
PRESCRIBER MUST HAND WRITE "BRAND NECESSARY" OR "BRAND
MEDICALLY NECESSARY" IN THE SPACE BELOW.
l78(6/97)
o SUBSTI'TIITION PERMISSIBLE
o LABEL
DEM
REFILL
~~
1 n,-..,--.,,: .--',
J. ')' I' J' 'J i\,
HOCKLEY .:ARRY L
q]S '4\::;'1'-!OllA D~
- .0,,'
J " ,
J~
E '.! 0 L a
feu
PA 17025
728-9563
ED GROUP
Ob/07/1'i!36
201-7J-g34b
~;fu:""
10/03./0(;; 1.1: 33
1:t7176525004
IRA J HELLER DDS
1ai00l
IRA J. HELLER. D,D.S.
PRAClICE" UMTT15.0 T"O OnTHOootmes
October 5, 2000
To whom lllJ1l.Y concern:
In w: OIlttY Hoddey, Jr., Age 14
.d~ 1'1:. Crdl~d Dr. Apt; A-7
C......~UiUlOP~.W 11Q11
ql5 TYlO3V10\iO bvil.t.
ty10lo.. {b. ,,006
Subject: Proposed orthodontic ClI!<:
Garry was exmnined at this off'lJ)e on October 2, 2000. He was noted to have 4 cowplcte
pc:r1lWIClnt dentition which is marked by significant dental crowding of his upper and'
loww front teeth.
TTeatment to carr<<t ilie dental crowding will requite the p~l!lent of fixed orthodontic
appliances ("btaces'') on Garry's upper and lower teeth. Four p=nnanent side teeth (two
from each jaw) will need to he nmovedduring the initial Btage ofOarry's care in oroer to
provide sufficient space so as to permit the UIlaQwdina; of the ~rnainiIIi teeth.
Active treatment duratioll fur Garry's care has been tentatively estimated at twenty-rour
to twenty-six months in lensth.
The cost of Garry's tJ;eatmeIll $3500.00, includes the oost of llll orthodontic servicea but
~ Qllt illol1lde MY costa incUITed fot ora! surgical services needed to remove his teeth.
This cost alSQ doea not cover the cost of eJl:cessively da1naged appliances due tQ 1\ flIi!ure
to foU<;rw norinal <lietarY restrictions when wearing orthodontic devices.
We have propolled that payment for Garry's col!t ofttes1men1 be anapged as follows:
....Initial monthly payments (2) at $250.00 each (total of$500.00).
....Twenty-two oomecutive monthly paymen\$ oUIOO.OO each (total of$2200.00).
.. ..TbI; remaining balance oftlle cost of care ($800,00) has been estima~ to CODlli!
from. hill insurance plan.
Cedlr 01" MaW, ,j06 Carli,1e 1I000d. Camp Hill, PA 17011- (717) 1~3,"04
401 N. Hawks Rd., H.TrllI:lUr~, p~ 17109' (717) &a2'245e or 783-1104
10/05/00 ll:H
'l!'7176525004
lll~ J IlELLI1R DDS
'.
IRA J. HELLER. D.D.S.
PPA(jTIC1!. UMll'l!() TO ORTHODONTICS
All oftbese figImls ere SlJbject 10 revision depeodelll on iDswance company actions or in.
actions. except rot the overall cost of=e 0($3500,00.
Please feel free to contact the office, $bould you require Wly further information,
Questions te&Drd~ the cost of care should be directed to Mrs. Johnson at 763-lI05,
Mondays 1hNullh Thursdays.
Ira J. Hell.et, D.D.S.
gm
C.o., Cliff ".u, 11<>6 C.~.... Ro.d. Camp HIli, PA 17011. (717)7es.110'
4(J1 N, HouCkl> Rd., H8ffl-50urg. PA 17109 ~ (717) 6S2-24M Of 763-'1<J4
;(I/j
','.
'4] 002
-,
-
P.
I
, ~ 1
JAN 1 9 2000
IRA J. HELLER, D.D.S.
PRACTICE LIMITED TO ORTHODONTICS
January 17, 2000
Handler, Henning & Rosenberg
319 Market Street
PO Box 1177
Harrisburg, PA 17101
Attn: W. Scott Henning, Esq.
In re: Ga:nwL Hockle,yl Jr.
Dear Mr. Henning,
Garry Hockley, Jr. was initially examined on July 15, 1996. At that time his mother was
informed that he had a developing malocclusion which would eventually require
comprehensive corrective orthodontic care. However, at that time, Garry's dentition was
too immature to initiate his projected treatment. Accordingly, Mrs. Hockley was advised
to bring Garry back to the office for further evaluation during February of 1997. The
latter visit was not kept by the patient.
Garry was subsequently re-examined on July 29, 1999, at which visit Mrs. Hockley was
again advised of the need for treatment. It was further recommended that treatment be
initiated at that time, as Garry's dentition had sufficiently matured so as to permit
treatment. Measurements taken at this visit (July 1999) were comparable to those made
of the patient at his July 1996 office visit. Mrs. Hockley did advise me that Garry had a
bicycle accident, striking his upper front teeth, in the period of time between his two
visits.
While the injury sustained by the patient could complicate any orthodontic care, the
accident did not, in my opinion and to a reasonable degree of scientific certainty, create
the need for such treatment. Garry's malocclusion is largely hereditary in its origin and it
pre-existed the date of his accident. There is, however, the increased possibility of the
need for endodontic care (root canal treatment) to the injured teeth, should Garry be
treated. This could complicate any orthodontic care and is the only pertinent sequelae to
the patient which could conceivably arise from his bicycle accident.
$ii1z/# / /fi J
Ira 1. Heller, D.D.S.
gm
Cedar Cliff Mall, 1106 Carlisle Road, Camp Hill, PA 17011' (717) 763-1104
401 N. Houcks Rd., Harrisburg. PA 17109' (717) 652-2456 or 763-1104
C>'~.,ffli
L
.J.lL<.-f.L iii ~ /J .;(. '~ o.!:?!::fft. Yl1,ldM
2- 'a'lIii..- t:b:JL, .<-1.. c..d.P.-"'b ,"", A' 7>< -L ~:;, E _"%_
'71~ ~g /~ ~ < 7 """y .d:
I (c. ,c. G- 'I ~ ...u L 4
& -~ I::-Ln ~ ..J..Q. ~
../J..U . ~ (..S
..J::.. OrA -"_ ,.,,/ /'4, .L-IIt.-{. N. r ^
i1.1lL B~5 ,y --:..:::u::LazL..L .L.
(! 71 Jt II
~ ~-c.2.3. >~0L
2-. ~ L
~ 2...
>,-,
._~- ....
1..
7l1jjjJJl
'I !.
..i
.-:.0\
.L.\
L~
J, ~
,1, ._1,
.
,~ '1:_:j
, ,
., f {
J1Jc.. U{.l L--- ...- rlJ lrl.1.---2-
t/lr-"G...:..::.::...:~ ~
L
;,)P; "'H
..J.LL.k "..... c.c..'
.4L ?-,~
:!.LI ~dL
~ IlJ_ "AlA ,
1ll.:..L Lk ~ w-1:Q frt
.L // ---: l.m.m.. i'L'
I
I
I
I
I
I
I
I
,
I
"
il
I
I
I
I
I
I
I
I
,
i
I
I
I
i
I
;1
I
I
I
,
i
I
I
-
.L
L 1 kJ....
"
~/i.A1 ..:2~ "2- ~
IL' - ~ ~ L'
f'f.idfJ~- 1A.i.L!J. 1li'~
\ // v" \".1
. #---" '6.. oHI\ ~
( ttf1/. - (J.$. ..fJ.J.. OW. . I
~ . / /
-
I I
,
J
t_.
~'-.--,,' ,,;,,_, ~'-' c'
";"""'';'':11
qops b'i
--",)
~,L t:
.~ ~ '-~.,
CHILD PATIENT HISTORY & TREATMENT CONSENT FORM
patient's name: GArn/ -HOc.J::fe \..{ ~}R.
Name and address of perso~(s) responsible for the payment for any services which may be rendered to this patient:
Name: ~rri j-1oct..I-C'-J
Address: qJ5
En cia
?,A J70eJ S
The questioos direct.1y bel" ate asked due to the many instanceS of parental separation and dual insurance coverage.
Mother's name: 5hrJ-n' /-40C-JC.1C;..J Father's name:
Employer: I.e.L (Y)cnoCje(Y)("'Al!- Employer:
Social Security#: lq5 (tJ-.f. it? ( I '? Social Security #:
Phone(work): it,sr) -0)(P3'1 Phone (work):
Phone(home): 1a g CJ~:fi/lllll!!ll!lfl Phone (home):
Name of person who suggested need for an Orthodontic examination
Dr J!e/fVrf2 DI/U pct2lde/7t
Physician's name: Dentist's name: / (, - J' L //7; / &r-
If you have an insurance plan(s) which covers orthodontic services, please list the insurer or union benefit plan
below:
Policy number & Plan or Group number:
Medical History:
l.Is the patient currently under a physician's care?
2.Does the patient have or has the patient had any of the following; Check off any that applies to the patient.
Rheumatic fever Arthritis
Glandular disturbance Allergies
Diabetes Hepatitis
Epilepsy liver problems
Heart murmur Fractures of the jaws
Tonsil Problems TuberculO5is
Organ transplant Kidney problems
Low blood pressure Other problems:
Is the p~tient presentl~ taking any medications? N? If so, w~t? "
3.Maturatlon status: Patient's age: /3 Date of bmh: (j}')' YltJ
Female patients:Has the patient started her monthly penod?
_Yes _No: If yes, at what age? At what age did older sister or mother start?
These answers provide an indication of the amount of facial growth that can be expected.
4.Mother's height: ,/) / Father's height 5' 9 Older sister's Older brother's ht.
S.Male patient's: Has the patient's voice changed as yet?Yes or6) _
6.Male or female patients: Has the patient outgrown a pair of shoes recently? Ie 5 _
Has the patient's height chan~~cL~oticeably recently? IV ()
7.Has the patient ,~d anything about wearing braces? /UU Is the patient ~rned about hisfher
appearance?.-&' Have other members of the family had orthodontic care?~ or NO; Has the patient had
previous orthodQntic care?@or No; Has the patient had speech therapy? Yes or ~How does the patient do
in school? Gcod Has the patient had psychologic guidance or
counseling?@ or NO (All replies will be kept confidential-Please read & sign the back of this form)
NO
I
,'-
d~' " , '
--..;;;..,,!
1NFORMA_~ON REGARDING ORTHODO"fIC THERA!'Y
TO OUR PATIENTS:
AS A RULE, EXCELLENT ORTIIODONTIC RESULTS CAN BE ACHIEVED WITH INFORMED AND COOPERATIVE PATIENTS.
TIlUS, TIffi FOllOWING INFORMATION IS ROUTINELY SUPPLIED TO ANYONE CONSIDERING ORTIIODONTIC
TREATMENT IN OUR OFFICE. WHll..E RECOGNIZING TIffi BENEFITS OF A PLEASING SMILE AND HEALTHY TEETII, YOU
SHOULD ALSO BE AWAJlli TIlAT ORTHODONTIC TREATMENT, LIKE ANY TREATMENT OF TIffi BODY HAS COME
INHERENT RISKS AND LIMITATIONS. TIffiSE AJlli SELDOM ENOUGH TO CONTRAINDICATE TREATMENT BUT SHOUlD
BE CONSIDERED IN MAKING TIffi DECISION TO WEAR ORTIIODONTIC APPUANCES (BRACES). PLEASE FEEL FREE
TO ASK ANY QUESTIONS ABOUT TIllS INFORMATION AT YOUR OFFICE VISIT.
DECALCIFICATION (permanent markings), decay, or gum disease can occur if patients do not brosh their teeth properly and thoroughly
during the treatment period. Exoellent oral hygiene and plaque removal must be performed on a daily basis. The use of dental floss is
recommended. You will be shoM, and advised on proper oral hygiene techniques, if active orthodontic therapy is decided upon.
RELAPSE: Teeth have a tendency to rebound or partially return to their original position after orthodontic treatment. 1bis is called
relapse. This can occur due to the fact that there is no direct connection between the root of a tooth and the surrounding bone.
Additionally, some minor tooth movement can occur due to nonnal pressures and forces that exist in the mouth. Tbe most common area
for relapse following orthodontic care to occur is the lower front teeth. After braces are removed, retainers are placed and will need to
be worn for an additional period of time in order to minim;,e or to eliminate the possibility of relapse. Full patient cooperation in the
wearing of retainers is vital. We always sum treatment with the goal of making the treatment correction as ideal as possible within
limitations posed by patient treatment factors such as growth, cooperation, and the difficulty inherent in the original treatment
problem.When retention is discontinued. some relatively minor relapse will srill be possible. If the patient desires, rlXed or long-tenn
retainers can be placed in onler to eliminale even lhese minor relapse problems. A fixed retainer does however, require addilional
consislenl allenlion to proper oral hygiene.
A NON-VITAL OR DEAD TOOTH is a possibility. A tooth that has been previously traumatized from a deep filling or even a minor
blow can "die" over a long period of time with or without orthodontic treatment An undetected non-vital tooth may become symptomatic
during orthodontic movement, requiring root canal or endodontic therapy.
ROOT RESORPTION: In some cases, the rool ends of the teeth become shortened during treatment. Ths is called rool resorption.
Under healthy circumstances the shortened roots do not shorten the usefulness of the affected teeth. However, in the event of gum disease
in later life, the root resorption could reduce the longevity of the effected teeth. It should be noted that not all root resotption arises from
orthodontic therapy. Trauma, impaction, endocrine (hormonal) or glandular disorders, or causes of a currently unknown nature, can also
cause root resorption or rool shortening.
TMJ: There is a risk that problems may occur in the temporomandibular joints (IMJ). Although this is rare, it is a possibility. Tooth
alignment or bile correction can often improve tooth-related causes of TMJ pain bul not in all cases. Tension, grinding of the teeth, or
clenching of the tecth, appear to playa role in the frequency and severity of joinl pains and joint problems. In moving the teeth to new
positions, the jaws may be uncomfortable for a while.
GROWTH: Occasionally, a person who has grown normally and in average proportiollS may not continue to do so. If growth becomes
disproportionate, the jaw relationships can be adversely effected and the original treatment objectives may have to be compromised to the
point thaI an ideal treatment result becomes impossible to achieve. Skeletal growth dishannony is a biological process beyond the
orthodontist's control but is usually treatable by the addition of surgical treatment
LENGTH QF TREATMENT: The tolal time for treatment can be delayed beyond our original estimate. Lack of facial growth, poor
elastic wear or headgear (nighl brace) cooperation, broken appliances, poor oral cleanliness, and missed appointments are all important
factors which will lengthen treatment time and affect the quality of the treatment result
HEADGEAR (NIGHT BRACE) Instructions must be followed carefully, A headgear is nota toy. A headgear that is pulled outward while
the elastic force is attached to it, can snap hack and poke into the face or into the eyes. Be sore to release the elastic force before removing
the headgear from the teeth. If the patienl needs to wear a headgear, we will provide detailed wearing Instructions. Not all patients need
a headgear and very few patients need to wear a headgear all the way through treatment Adull patients rarely require headgear use.
UNUSUAL OCCURRENCES:Swallowing an appliance, chipping a tooth,dislodging a fIlling, an abs=,may occur - but are rare.
TREATMENT RESULTS:A good treatmenl result requires cooper.tion from everyone - mysc:lf, my staff, and the patient We attempt
to infonn the patient ahead of time of the possibility of complications as well as a reasonable expectation of the treatment results. If you
decide to proceed wilh treatment, please note that the treatment fee is for the perfonnance of the orthodontic care and is nol
dependent upon the treatment outcome. No responsible physician or dentist guarantees a treatment result. We do, however,
guarantee to do our best for our patlenls~ to honestly and fairly provide our services.
I have read the above information, have understanding of its contents, and do realize the risks and limitations of treatment
Signature
Dale
1. ~iJ~99
I"
.,~.l Ie
-J,
. -
,
;. ..; ";,,,,~~
\
y'\ . '71;) ,. . .~
C ~. , -.- '-
INITIAL EXAMINATION AND CONSULTATION - ADUL t/~'Il~.Q)
patient'sNam~_~~~ ~~_ -CaseNumbON7f4-~u~ofBirtn .G.u/n
parentName(lfChlld)~~ r ~ Phon~ rn!).(g.f'7~c2it::,1_ (B./37-.5 3'17
Person Repson~ih]~ fn? Ar.count- /"f,.Il"" -",
Address~ ~ <1"3'2 ~~ I6c ' r 7-- c. -H- /7011
, ,
Chief Complaint
o . /.:J,,' n - ~ '_ "..J.J_,.!.,~,......, =,.' ~,~, '.
Referred by ((name(s)~ ~~(J~ U'
Has patient had previous orthodontic examination?
Do you feel that the patient/parent is shopping?
By whom?
Only wants a consult?
EXISTING CONDITIONS - DENTAL EXAMINATION
C; .E. \l c.. .1 r- '2- C4? tf70
Prior RCT?
Periodontic Status:
Teeth Present ~ 11. <:"7_
~ & rv C- ')..,-.2. ~ ~
Chipped Teeth?
Maturation status: C.A r. 'I
Cooperation estimate
Parent comments:
W.A.
H.A
Dental midlines Nto Facial
IAto Facial A .. I _/ ,/
Occlusion Type: CQ-:a::- ill ~ .1=- '~ I
X-Bite:
Conrib. Med. Hist.
Facial growth direction: Vertical
Functional problems: _ Tonque thrust
~ ~-'~ ;;; t/:2-nt ~
;RELlMINARY TREATME PLAN/DISPOSITION:
Height Data Requested
Active TX:
PI1 o.L.o L< Arch Length: N: - ?mM
IA: -- .,/mPt
~~: f&r~
Horizontal
Mouth breather
High tongue posture
CHG IHHG
,,<on ''5
Plan ofc e: )
Special Problems:
Est. Tx. Time
Retention plan
Fiberotomy:
at 3-4 week intervals
Frenectomy
Fixed retainers:
COST OF CARE (not including extracting teeth or any surgery):
Courtesy and why:
Initial Down Payment:
I:
d
- --",,',,"' ,~ ,"
j~:;
, .
, "
CHILD PATIENT HISTORY & TREATMENT CONSENT FORM
Patient's name: ~I/J!2U ' DCI:: It. vI '
Name and address of person(s) re ponsible for the payment for any services which may be rendered to this patient:
Name: GfUZf?Lj l-IoctJeL(
Address: C ~ 3-5()~ InF Fl. (lQrn bl{l// I!-enn/cl:c
The questicns d~y below o. re. osked due to the many instances of parental paration and dUal~, . ce coverage.
Mother's name: ...j'he yr / Father's name: ~R-/.Z-LI
Employer: Vi) / 002 Kh 0/ I CI.n i 5.. Employer: PR.m
Social Security#: /'?5hC/ &7/ R Social Security #: /8'i ~7-8 7uSh
Phone(work): &5-'7.c?&.3 7 Phone (work): 5d=;? !P 798300(0
Phone(home): 737-...53 V '7 Phone (home): '
Name of person who suggested ne d for an Orthodontic examination and for what reason:
Physician's name: / ~ //7/ I lOin. Dentist's name: C' 'Clf? 'k--
If you have ~ insuran, pli!n(s) which CS\.vers, orthodontic services, please list the insurer or union benefit plan
below: S, .L::e If-a 0en-f Q /
Policy number & Plan or Group number:l8</38/l:;Q5(' CA.e611f Cilz 988t!9A-
Medical History:
1.Is the patient currently under a physician's care? ;1J 0
2.Does the Plltient have or has the patient had any of the following; Check off any that applies to the patient
Rheumatic fever Arthritis
Glandular disturbance Allergies
Diabetes Hepatitis
Epilepsy liver problems
Heart murmur Fractures of the jaws
Tonsil Problems Tuberculosis
Organ transplant Kidney problems
Low blood pressure ,Other problems:
Is the patient presently taking any medications? NO If so, what?
3,Maturation status: Patient's age: 9' Date of birth: 6 - -'}- 86
Female patients:Has the patient started her monthly period?
_Yes _No: If yes, at what age? At what age did older sister or mother start?
These answers provide an indication of the amount of facial growth that can be expected.
4,Mother's height: .5' / Father's height .5 / 9' OIder~er's /) Ice Older brother's ht /) /6-
5,Male patient's: Has the patient's voice changed as yet?Yes or~
6.Male or female patients: Has the patient outgrown a pair of shoes recently? f es
Has the patient's height chan~rd noticeably recently? jlJCJ
7,Has the pat\ep.t said anything about wearing braces? yes Is the patient co~rned about hisfher
appearance?VC5Have other members of the family had orthodontic care?~or NO; Has the patient had
previous orthodontic care? Yes or ~Has the patient had speech therapy? Yes or ~ow does the patient do
in school? Gcx::::> d Has the patient had psychologic guidance or
counseling?Yes or @)AlI replies will be kept confidential-Please read & sign the back of this form)
_-"='I1lII...-........,.....iIliw&I
,~
~-,
,Ii
I
- , . - ~-" ,~ ~" - (-~:-::;
. ,rORMATION REGARDING ORTIIODONTIC TIIERAPY
TO OUR PATIENTS:
AS A RULE, EXCEU.ENT ORTIlODONTIC RESULTS CAN BE ACHIEVED WITH INFORMED AND COOPERATIVE PATIENTS.
TIIUS, 11IE FOllOWING INFORMATION IS ROUTINELY SUPPLIED TO ANYONE CONSIDERlNG OR1HODONTIC
1REA TMENT IN OUR OFFICE. WHlLERECOONlZING 11IE BENEFITS OF A PLEASING SMILE AND HEALTHY TEETII, YOU
SHOULD ALSO BE AWARE TIfAT OR1HODONTIC 1REATMENT, LIKE ANY TREAlMENT OF 11IE BODY HAS COME
INHERENT RISKS AND LIMITATIONS. 11IESE ARE SELDOM ENOUGH TO CONTRAINDICATE TREATMENT BUT SHOULD
BE CONSIDERED IN MAKING TIlE DECISION TO WEAR OR1HODONTIC APPLIANCES (BRACES). PLEASE FEEL FREE
TO ASK ANY QUESTIONS ABOUT TIllS INFORMATION AT YOUR OFFICE VISIT.
DECALCIFICA nON (permanent markings), decay, or gum disease can occur if patients do not brush their teeth properly and thoroughly
during the treatment period. Excellent oral hygiene and plaque removal must be performed on a dally hasis. The use of dentall10ss is
recommended. You will be shown and advised on proper oral hygiene techniques, if active orthodontic therapy is decided upon.
RELAPSE: Teeth have a tendency to rebound or partiallv return to their original position after orthodontic treatment. This is called
relapse. This can occur due to the fact that there is no direct connection between the root of a tooth and the surrounding bone.
Additionally, some minor tooth movement can occur due to no~l pressures and forces that exist in the mouth. 1be most common area
for relapse following orthodontic care to occur is the lower front teeth. After braces are removed, retainers are placed and will need to
be worn for an additional period of time in order to minimize or to eliminate the possihility of relapse. Full patient cooperation in the
wearing of retainers is vital. We always start treatment with the goal of making the treatment correction as ideal as possible within
limitJitions posed by patient treatment factors such as growth, cooperation, and the difficulty inherent in the original treatment
problem.When retention is discontinued, some relatively minor relapse will still be possible. If tbe patient desires, fixed or long-tenn
retainers can be placed in order to elintinate even tbese minor relapse problems. A fixed retainer does bowever, require additional
consIstent attention to proper oral bygiene.
A NON-VITAL OR DEAD TOOTH is a possibility. A tooth that has been previously traumatized from a deep filling or even a minor
blow can "die" over a long period of time with or without orthodontic treatmenL An undetected non-vital tooth may become symptomatic
during orthodontic movemen~ requiring root canal or endodontic therapy.
ROOT RESORPTION: In some cases, the root enda of the teeth become shortened during treatment. This is called root resorption.
Under healthy circUlnstanccs the shortened roots do not shorten the usefulness of the affected teeth. However, in the event of gum disease
in later life, the root resorption could reduce the longevity of the effected teeth. It should be noted that not all root resorption arises from
orthodontic therapy. Trauma, impaction, endocrine (hormonal) or glandular disorders, or causes of a currently unknown nature, can also
cause root resorption or root shortening.
TMJ: There is a risk that problems may occur in the Iemporomandibular joints (TMJ). Althougb this is rare, it is a possibility. Tooth
alignment or bile correction can often improve tooth.related causes of 1M] pain but not in all cases. Tension, grinding of the teeth, or
clenching of the teeth, appear to playa role in the frequency and severity of joint pains and joint problems. In moving the teeth to new
positions, the jaws may be uncomfortable for a while.
GROWTH: Occasionally, a person who has grown normally and in average proportions may not continue to do so. If growth becomes
disproportionate, the jaw relationships can be adversely effected and the original treatment objectives may have to be compromiscd to the
point that an ideal treatment result becomes impossible to achieve. Skeletal growth disharmony is a biological process beyond the
orthodontist's control but is usually treatable by the addition of surgical treatment.
LENGTH OF TREATMENT: The total time for treatment can be delayed beyond our original estimate. Lack of facial growth, poor
elastic wear or headgear (night brace) cooperation, broken appliances, poor oral cleanliness, and missed appointments are all important
factorn which will lengthen treatment time and affect the qnality of the treatment result.
HEADGEAR (NIGHT BRACE) instructions must be followed carefully, A headgear is nota toy. A headgear that is pulled outward while
the elastic force is attached to i~ can snap hack and poke into the faco or into the eyes. Be sure to release the elastic force before removing
the headgear from the teeth. If the patient needs to wear a headgear, we will provide detailed wearing instructions. Not all patients need
a headgear and very few patients need to wear a headgear all the way through treatmenL Adult patients rarely require headgear use.
UNUSUAL OCCURRENCES:Swallowing an appliance, chipping a tooth,dislodging a f1lling, an abscess,may occur - but are rare.
TREATMENT RESULTS:A good treatment result requires cooperation from everyone - myself, my staff, and the patienL We attempt
to inform the patient ahead of time of the possibility of complications as well as a reasonable expectation of the treatment results. If you
decide to proceed with treatment, please note that the treatment fee is for tbe perfonDanee of tbe ortbodontic eaR and is not
dependent upon the treatment outen . N re lISible physician or dentist guarantees II treatment result. We do, bowever,
guarantee to do our best for OIlr pill !s" bonestly and fairly provide our services.
I have read the above information,. . tanding of its contents, and do ize the risks and limitatiOllB of treatmenL
/,
~~t_~-..._~
L_
I
..J,,=,w' _I
.
-~ .~
~~. ~
ATTENDING DENTIST'S STATE"~NT
Carrier name
@
Check One
Dentist's pre-treatment estimate
10.B~2my
11. Group name
TRICARE - Family Member Dental Plan
12, Is patient covered by Dental plan name
another dental plan? :J
... ................,........,....,......"..,..,.....g.y~.~....~~.......,......_....-.-...,........
InsiBCj"j":-g 7bSZno
...~ma.'anCraddras~fcarri!3'r...'.--..................,...... .......
.Le /10. .!)e i1 f-a I
I hereby authorize payment of my group insurance benefits, otherwise payable to me, to the
denlisllisted bel
d0;78-9 (fl
d-~ -96
or) Date
entlst name
L J. HELLER, D. D. S.
21. Is treatment result
of occupational
illness or injury?
22. Js treatment result
ol auto acciden\1
23. Other accident?
24. Are any services
covered by
another plan?
25. If prosthesis, Is
this Initial
placement?
o
es
Date
yes, enter bne desenptian and dates
14. Mailing address
P. O. Box 174
Cily;Si.,.;,ip ,,- '" , ""CedaYCHff-Mall-
Camp Hill, PA 17()(J)1 -0 t1 f
15, Dentist sac, see, or T.J.N. 16, Dentist license no, 17. Dentist phone no.
x
X
X
(If no, reason for replacement)
26. Date of prior
placement
23 2183068
18. First visit date
current series
n a
2 28 96
20, Radiographs and! How
or documentation Many? 27, Is treatment for
enclosed? orthodontics?
26. Examination and treatment plan-list in order from Tooth No, 1 through Tooth No. 32 . Use charting system shown.
TOOTH DESCRIPTION OF SERVICES DATE SERVICE PROCEDURE
NO. OR SURFACE (INCLUDING X.RAYS, PROPHYlAXIS, MATERIALS USED.ETC.) PERFORMED CODE
c lmER M DAY Y
Appliance insertion date
To!allength of treatment
"-'"'
;;<' ldentif{m_hlsjn9~t~h
0< -,;',with"X:' :':~;;,>,
FEE
CHARGED
AMOUNT
PNO
Initial orthodontic visit
2 28 96 D8900
$30.00
~; ~rson who kno.,...;ng'IY files a statement of claim containing any misrepres.entation or any false, !ncomplet~, .misleading information or
conceals for the purpose of misleading, information concerning any facl malena! thereto, may. b~ gUilty of a cnmmal act under state a~d!or
lederal law and may also be subject to c\..,,\\ penalties, \ hel'l?lby certify that the procedures as IndIcated. by date hal/e been completed,
3-4-96
AMOUNT PAID
TOTAL
FEE
CHARGED $30.00
Si nature Dentist
Dale
. Both signatures are required by the FMDP contract or processing will be delayed.
I
557812195
b.--
.Ie,'., J _
t,
. ,,-.'"
.~~,
,. SuPPLEMENTAL OR TREATMENT NUTES
"
Card No.
:::::;......
,I, -? tt,fi 1-11' f 0.,,4 1>. :r,;.) Address "
Name
Date
C;-S~9f P/7> b ~I r')ve-rle/!- /),~..c,~
, , J 1/
,
,
-
,
,
llam l,a3/S4SYCOMl!ll-800,356-6141
,~
~I
1-,
", ! ,- 1 " ~ .:.-., J
,,-- "-'~ ';
(rL
\ , .
" ,
)
.
~~;-;;\ I'\/I\u':-~"p~& ;~~Jt -+r^Z-'~v~~V' 'bf'\[;-fL L rf(\IJL
~~ sh.c>J\.rl} ~p.t ~"'\)V\.-
I'
.~ L.
'~ '"'
JIttill
/
l~"
Date
1,.-:- (J ,.
-:) , f<.
D" \:..io."h.
, SU,
eJiclc
LEMENTAL OR TREATMENT NO. ..::5
Cant Np.
,I ,
;< Address
Co, e.-n .
'^--,
. f--'
~( u; I.,;?
l ~, . tt:.:x"
z
2d )
f}
PI ~'Tn
f;;./3 '6 2.
I/~
rA--vc
to ,-, ,~_.l c/
1-31 q
'1'/ t", c..~
- 1-
,.,/' ~ Oft " _ '
'1/ i\.Q.. ~~ ;),c.
C)l+h,
C'c..lo
"-..1
)
" '--{---,.=--
~r
<- (.J('./~,
~
./
":,:he
J~/]--'
~~ !))k
I
i"-
")
'_, I,
"'" "~'o~;
" SUPPLEMENTAL OR TREATMENT NOTES
Card, No;, ::::;. -.
Name
Date
Address
ILam 1 .03194 SYCQM$l,SOO'356-8141
"
..
Date: 03/30/2000
[ Patient Name:
DATE
12/13/1996
12/13/1996
12/13/1996
02/10/1997
0311811997
04/09/1997
05106/1997
06/10/1997
03/24/1998
04/20/1998
07/25/1998
09/18/1998
09/18/1998
1112411998
09/18/1998
0212211999
04/0511999
04/0511999
04/0511999
06114/1999
10/0511999
10/0811999
1111611999
1211811999
1211311996
1211311996
1211311996
1211311996
08101/1997
08/0111997
08/01/1997
0811911997
02106/1998
02/06/1998
02/06/1998
05/19/1998
03/01/1999
03101/1999
04/05/1999
04/0511999
04/0511999
10/08/1999
Sherri L. Hockley
PATIENT NAME PROVIDER
Sherri L. 3
Sherri L. 1
Sherri L. 3
Sherri L,
Sherr; L
Sherri L.
Sherr! L
Sherri L,
Sherri L.
Sherri L
Sherri L.
Sherri L. 3
Sherri L 3
Sherr; L
Sherri L 3
Sherri L,
Sherri L.
Sherri L. 1
Sherri L. 3
Sherri L
Sherri L. 0
Sherri L 3
Sherri L.
Sherri L.
J. R. (Gary L.) 3
J. R. (Gary L.) 1
J. R. (Gary L.) 3
J. R. (Gary L) 3
J. R. (Gary L.) 3
J. R. (Gary L.) 1
J,R.(GaryL) 3
J, R. (Gary L)
J. R. (Gary L.) 3
J. R. (Gary L.) 1
J. R. (Gary L) 3
J. R. (Gary L) 3
J. R. (Gary L,) 3
J. R. (Gary L)
J. R. (Gary L,) 1
J. R. (Gary L.) 3
J. R. (Gary L) 3
J. R. (Gary L.) 3
...L~ . I
"
HISTORY REPORT
Drs. Kravitz & Miller DMD
TRANSACTION DESCRIPTION
00272 Bitewings-two films
01110 Prophyiaxis-adult
00110 Initial Oral Examination, Deleted - DO NOT USE ..Use 015
Check Payment
Check Payment
Check Payment
Check Payment
Check Payment
Check Payment
Check Payment
Check Payment
00272 Bitewings-two films
00220 intraoral-periapical-first fiim
Check Payment
02161 Amai9am-four surfaces, permanent
Check Payment
Check Payment
01110 Prophylaxis-adult
00120 Periodic oral evaluation
Check Payment
Balance Refund
09997 Missed Appointment Fee
Check Payment
Check Payment
00272 Bitewings-two films
01120 Prophylaxis-child
01203 Topical application of fluoride (prophylaxis not included)-c
00110 Initial Oral Examination, Deleted - DO NOT USE...Use 015
00120 Periodic oral evaluation
01120 Prophylaxis-child
01203 Topical application of fluoride (prophylaxis not included)-c
Check Payment
00120 Periodic oral evaluation
01120 Prophylaxis-child
01203 Topical application of fluoride (prophylaxis not included)-c
00140 Limited oral evaluation- emergency exam problem focused
00140 Limited oral evaluation- emergency exam problem focused
Cash Payment
01120 Prophylaxis-child
01203 Topical application of fluoride (prophylaxis not included)-c
00120 Periodic oral evaluation
09997 Missed Appointment Fee
. '~ ,
Page:
DEBIT
14,00
39.00
23.00
18.00
12.00
85.00
42.00
22.00
4.00
25.00
14,00
17,00
12,00
23,00
17.00
17.00
12,00
22,00
25.00
17.00
25.00
20.00
25.00
17.00
22.00
25.00
Total Debit $
Total Credit: $
Balance: $
;"
.-til
",""'
CREDIT
50,00
24,00
30,00
25,00
13.00
34.00
30.00
25.00
50.00
65.00
68,00
64.00
25.00
25.00
46.00
20,00
594.00
-594.00
0.00
..... ,'..,
tl,.2.uen1::utTI ft"Isgin and
Therapeutic:: .A..s$cciot:::es, In<=_
Th.. Me"ll'eO' Corpor"tlon 01 m.. A,2; FH"fZMAN Assoc''''os. ,,,(:, $. R.-><lkl'<>9Y AUo.::\alOS 01 Yo".,. p.c.
~...O"lJmtlDcn",RD..o.SUI1"'2 YO""'p", '''~
(BOOI52!}.7e2~ .1'1,,767,'13" . Fw. ,7'71 7e-o,"~:I
~u~"u~IMl~[j0Ju .
I "'U "'I .,,~
P6/22/98 .. ~
"......,"'.._~'. _..,=..\"'..:..'101'.10'(..., '.
PB3248- ~/SP ::J~ I $ ~J!:;ji:~J
PATIENT IGUAI=tANTOR
HO , ~y L JR
9~5 MAGNOLIA DR
ENOLA, PA ~7025
:'.
"
.~., , !"11 j '. ,'.' .-.
HOCKLEY, G!\.RRYL JR
'':''1'
25~79280
".J' "',1, ' . r' .~ ~
. " ,.,l.tl.. _~. ' ,I. /"
AMOUNT PAID $
---el -=~ctl= ae..T.1l..Bli~_QBJ;IO~ ,WI):1j YOUR REMITTANCE.
A
A:'"
:....,
.'
70:3.5026
,'3,1.03;2&;'
a:La:nc..' ;fojrWard 3l~': l<!I::;..-t:
ACIAL BO~CO~L
IBS' vr;rrL~12v:~(.',.i?A CHES
.', . '-., 'h'" " .t.
'?I.'!,(
CD
. ;?:~C;.:~}::;;T:'~,{~'
~w~~ N:m t1Q9' '.
1..-''''4''- '
~.h')~~ :~;dtf',
,,; ,',' '".",~" ,'.. ,
I" . ni-~' .. q, '....1
,., .,., 'II!!;,'"
,il- ~: :11'"
.",1 I("
05/1.8/98
05/1.8/98
54.0'
58.0
:. ::r~t~:~7:f1'~~r:~,~:,.~
"" ", ~,. 'I',h'
_.~-,
""
<
.. ~ -I
,:.d.,'
.\:'
L I .~,.
,~' ,t
"
:l~2.00
I.OCA"T'ION cooes
o -O""ICE. 0'" .G1~I"PAT,,,,'.T "'C;>l;o"''rAL ~I<; -$K1l.t,.F.:D NIJRSe FAC
IH'IN""T1EN'r HOSPITAL lL 'INDEf"ENC>ENT LAB I'lH _NUF'lSING HOME
E"l .EMERGENC'~ ROOM
P .P..."'I'lMAc;:V
,~~?, 00
tis is a statement for serv2ces provided by
antum _~maging & Therapeutic Assoc.
':lase contact us with yO'1..:l.r itlsurance inro:qnat:ion
pay the ba~ance ~n full, Thank you.
\
;
\
i.
I
!
-
I~~
,
HOLY SPIRIT HOSPITAL
, .
TEL '717-763-2932
4,. ~
Hel
TYP~ OF
alLI.
OATe' OF
,.~~v, 91tl
I;.,
_,I
,-
~" ,-."
Jan 11,99
5:52 No.002 P.OS
. ,~ ", ,
HOLY SPIRIT HOSPITAL
503 N 21ST ST'
CAI'IP lULL, PA
717 76J-2t 41
FEX. 23-15te747
rlU\1Q
not! ~
e I RTH-DA TE 1I0SP, NO.
06/07/86 9-00
D^~ 01' !'JIlL
HIS.
Q E
OCKLf:Y
,"UAR PH:
p"'fIENT NAME
.PATII:Ni' NUM6C:R
Y L Sit
717-728-9563
1200260
ADMISSION DATE DISCHARGE OATI;
05/18/98 05/19/98
OM$
OUT PATIENT
'.
C.O,B. INSURANCS COMPANY NA.Me ()FlOW' NUMA(.\ POl.1CY NUMIiER
-
GUAFlAHYOR
SHERi'll HOCKLEY 1 HEALTH CENTRAL 195646716
NAoMI! 915 MAGNOLIA DR
'NO ENOl-A,PA 17025
AtlCR'e"SS TI::I'1..1S ALAN C MD
PLEASE RETURN THIS PORTION WITH YOUR PAYMENT. 7~ ~ I
CAtl::
'OS7EO
I SS'RVICE
coDe
TOTAl..
CHARGES
DESCRIPTION Of
HOSPiTAl.. SEFlV1CES
)ETA L OF CURRENT CHARGES, PA'MENTS ANt
vIa ICE PACK LGE 011412166' 5.75
;/18 UNILI\T I.FT RIBS0136101145 171,00
il18 FACIAL aONES 01:3610230~ t51.00
;/1a Ell VISIT LEVEL 0117103011 197.00
IALM CE FORWARD
11.11'1/11 Rl' OF CIJRRENT CHARGES
MIS SUPPLIES 270
DX X-RAY 320
EMERGENCY ROOM 450
5.7S
322.00
197. 00
:U9-' OTAL of CURR. CHARGES
524.75
GUAI RELATIONSHIP:
ACC DATE: OS/ta/9S
DIAjNOSI$:
o
SEX:
TIlE'
TYPE' 0
854.00
!\MOUNT OF I $
PAYMENT .
asy, eOvE:MOE EaT, COVI!"AGI;: E$f. COV!;lR;\GE eST, CC)VERAoe;
INS. Co. NO,! tNS. CO. NO,1 INS. CO, ~O.::J INS. CO. NO,4
PATIf.N'r
AMOUNT
ADJUSTMENTS
5.75
171.00
151.00
t 97.00
524.15
524.7
5.75
:322.00
191.00
524.75
GUAR NO:
7:;H PI1 PlACE' 0
EMPl REL: N
f!OEAAllDl!NT. NO, 23.15127~1
PAYI1ENT IN FULL IS EXle;CTED WI'HIN 30 04Y5.
TOT II L S
p~T1GNT NUMBER -T
120026061
524.75
AEPEA AI.L. QUESTIONS TO THE
aUSINESS OFFICE
(717) 763-2138.
1049.50 '
524.1
~LEASE SEND PAYMENT TO:
HOLY SPIRIT HOSPITAL
I
,....." "..............,1 ....~,....... ~...nr,......
~P(~~.r~qN..:'~ ,f.~ ~~I'~T_ ~[!..LH'!Stt-!A:y, .Elf. ~~(;f':~?~f\~;9t:, ~~
WOLY SPI~IT HOSPITPL
lilL;(l( l(bJ-L~vL
DATE OF (l'llL
DATf 01'
PRfV, !JILL
h~_Y SPIRIT HOSPITAL
!i03 N elST 8T
CfIl'll' HILL, I'll
717 763-eHl
FEl. 23-1512747
(Q?JID
17 0 I I . ~_'rlJ
IHRiH-U"1 TE "OS~, NO,
06/07/86
...Ii
OISOHAnGE'CATE DAYS
0,0,6, INSURANCE COMPANY NAME (If'lOLI!'NI,JMIlIiFl POLICY NUMaER
'.
I1f,lARAUTO/'l
SHliRRl 1I0CKLF.Y 1 HEALTH CENTllAL 1'15646718
NAME "S I1AGNOLIA Oft
,"0 ENOLA,"" noes.
AUORfi:iS SpURRIER DAVID 1'10
PLEASE RETURN HilS PORTION WITH YOUR PAYMENT. 7~ ~ I ^~,RUJ'JN~' I $
'}A'IE
)STEO
t)[SCRI1-'110N OF
liOSPIlAL SeRVICES
I SERVICIO
GOPIi
TOl'AL
CHAf-lGES
l:ST, COVEiAAC:lE ~~T, COVEMG~ 'f:ST. COVEl'W1E I:ST, OOV~R:AGE
INS, co, NO.1 INS, co. NO.2 INS, CO, NO.3 INS, CO, NO.4
f>AlIENT
AMOUNT
!nAlI. OF CURRENT CHARGES" pA'\II'IENTS ANt
119 ICE PACK SI'IL 011412167' $.75
119 CT BRAIN WO CONO'3613610~ 7eS.00
119 EO VISIT L~VF.L 0117103011 t97.00
AOJUSTI'IENTS
5.7$
res.oo
I'H.OO
ALA~Ct FORWARD
0.00
I.IM"/ RY 01' CURRENT CHARGES
M/9 SUPPLIES e70
OT SCAN 350
EI'IERGENCY ROOM 450
5.75
125.00
197.00
5.75
125.00
197.00
J8'-1orAL OFCIIRR. CHARGt::S
'27.'15
ge7.75
HAGNosrs:
959.01
PAYl1f:Hl' IS DUE UPON RE CEIPT OF THIS 8TA' El'll"NT.
YOU "'1'1'1' SIISI'UTTHIS FCRM
"0 YOUR INSURANCE CARf IER
FOR REIMBURSEMENT.
f'EOOAAl,. 'VENT. NO. l/3-,S1214?,
:.....lL'" A '- J
PATIENT NVMt!!:;R
1\
'2r.TS 927.79
~O~f~il~~LOW~g'ONS TO THE PI.EASEi SEND PAYM~NT TO;
rr1Tl7&3~i3e, HOl'( SPIRIT HOSPITAL
01-'1' SPlRlT HOS"rT./\L
/HIP ~IH.'-. F'I<
503 NORTH 21 S1" STREET
CAMP HILL, PA 1701H~<!8B
I PAY THlS MIOUNT (1.00
hDOIT"lONP.!. PATI5Nl' BILLING MAY Pf:;. NeC*8SA1~v FOR ANy
C;HAf-'I~fJJs NOT f10STEO Wi--liN d/'ll! 91~\.WAS PRE.J>'t-lED
~~~~A',!~,&~~rol"Wll'''<:'N"~" i~tl"M".~NIi<I6'.I'lN8:
. ., .
. ..
,
flM~ ? "_
T=_
~',
~I
.
~I,
,-~ "~- ,
M.l
HOLY SP I R IT HOSP ITAL
HeI II A
lyPEOF {)ATE OF PilL !>A'IEOF
alLL t'HEV. BILL
O\./TP.
.C-..,.4
Q C; PATIEN'f ME
H CKLEY GARRY L JR
TEl :717-763-2932
]an 11.99
5:52 No.002 P.06
hvLV SPIRIT HOSPITAL
503 N 21ST ST
CAMP HILL, PA
717763-2141
FEI # 23-1518747
11011
lHRTH-DATE
o ~7lr'n'9 6
~Q
HOSt>, NO,
9-00.
1,l.()20459
ADMISSION I;)ATIi PISCHARGE D^TF. DAYS
PATIENT NUM9E:!'i
J)$122198
C.O.B. INSlIRANOE C2.~r'.~NY NAMF. GROUP NUMflHI Pot-lOY NUMm]~
GtJArt~NTOR
SHERRI HOCKLEY 1 HEALTH CENTRAL 195646718
NI\MJ: ~15 MAGNOLIA OR
,"0 ENOLA,PA 17025
.M'3{lm;:~s. SHARMA RAJANA MO
"".1 - j '1,,~ n I AMOUNT OF [$
PLEASE RETURN THIS PORTION WITH YOUR PAYMENT, f~ ~ ",YMENT
DAT!;i D~eC!'lIPTION OF I Sfl-lVlOE 'rOTAL ESL COVeRAGE 1;5T, COVERACl!: EST. COVE'RAag ~ST. COVi:tW3E PA1lENT
'oST~l) HOS~l At SERVICr<S CODE CHARG!'S INS, CO. NO.1 INS, co., NO.2 INS, CO. No,;! INS, CO, NO,4 AMOUNl
-
lETAIL OF CURRENT CHARGES, PA' MENTS ANt AOJUSTM~ NTS
;/28 OV LEVEL II EST0118100081 41.00 41.00
IALA~ CE FORI.lARD 0.00
>UMM~ RY OF CURRENT CHARGES
CLan c S10 41.00 41 .00
;US-' OTAL OF CURRo CHARGES 41.00 41.00
DIAG NOSIS: 9<:0
PAYMENT IS DUE UPON RE CEIPT OF THIS STA' EMENT.
VOU MAY SUBMIT THIS Fe RM
TO YOUR INSURANCE CARF IER
FOR REIMBURSEMENT.
FEUli-I'lAL lD~NT, NO. i!.3.1S12'147
T o T A L S 41.00 41 .00
p,ll.TIEN1 NUMBER I f:\EFEA. ALL OUESTIONS TO THE PLEASE SEND PAYMENT TO: I pAY
BUSINESS OFFICe; 'THIS AMOUNT 0.00
'aOa0459 I (7\7) 763-2\38. HOLY SPIRIT HOSPITAL.
IONAl PATIENT I3ll.1.lNG MAY llt: NEOCE.99AHY FOR ANY
HOLY SPIRI'T HOSPITAL
r^MP I"TI I "'^
t "~ to
503 NORTH 21ST STREET
CAMP Hill. PA 17Ql1-2288
0e~nOl:s NOT POSTED WHeN THli> alll WAS rnt;PARf;'O
01'1 If INSURANCE OAtlr1I!::~S DO N01 PAY "NY PART OF
TH~ AMOUNTS SHOWN \JNDfH--1 ESTIMATt'D INSUMNOt\
r'....,'rnll(;f'
,., .. ~ .,
HOLY SPIRIT HOSPITAL TEl :717-763-2932
" " ~
HCI # A hvLY SPIRIT HOSPITAL
lYPE or: DATE Ol'tl/l.l I)A1EOF 503 N 21ST ST
BILl.. fAEV. BILL
CAMP HILL, I'A
717 .763-a141
OUTF'. FEI 1I e3-1S127'l7
-<,"'~
Q \; flA1IENl ME P....TIENT NUMflEJl
HOCKLEY GARRY L JR 12020459 11
J an 11,99
5:52 No.O~2 1'.00
. · rDlB
17011 ~
BIRTH-DATE HOS'.NO.
0l;1"~ ,/'66 <)-00,
^OMISSION OA~ tJISOHARGE D^TF. DAYS
OS/2a1"98
~
C,Q.B, INSUFWlCE COt:!!'ANY NAMf. t;I'lOUP NUMIIH! PO~lCY NUMOIiR
aUAr1Il,NfOR
SHERRI HOCKLEY 1 HEALTH CENTRAL 19S64~7'8
N^Mt. 915 MAGNOLIA OR
,"0 ENOLA,PA 170e:S
At)O.c:US SHARMA RAJANA MO
".,/ - j -?A' I AMOUNT OF I $
PLEASE RETURN THIS PORTION WITH YOUR PAYMENT. I~ "yO<<- PAYMr,NT
O^Te
)OSTED
D~aCRIPTION OF
HOSPll AL se:RVlC~S
I
Sl-'tlVlOE
COCE
'iOTAL
CHMGGl>
~sr. COVJ:;A^GF,
INS. CO, NO,'
EST, COVERAGe
INS. co, N().2
EST. COV~RAGf;
INS. CO. NO.$
tf;T, COVERAGE
lNS, co, NO,4
f-'A1IENT
AMOUNT
)ETAIL OF CURRENT CHARGES, PA~MENTS ANt ADJUSTMENTS
;/e:e OV LEV!;:L T.I EST01181000S1 41.00 41.00
lALA~ CE FOR\MRD
0.00
)UMM~ RY OF CURRENT CHARGES
CLINIC 510
41.00
41.00
;U6-' OTAL OF CURR. CHARGES
41.00
41.00
DIMNOSIS:
geo
PAYMENT IS DUE UPON RECEIPT OF THIS STA~EMENT.
YOU MAY SUBMIT THlS FeRN
TO YOUR INSURANCE CAR~IER
FOR RElMBURSEMENT.
FEU!fPlAL IO!2NT. NO. 2').tSl~7<l7
TOT A L S
PATI!:"'" NUMBER J
1 eoa0459 I
41.00
41.0Q
REFER All QUESTiONS TO THE
BUSINESS OFF1C~
(717) 7e3'?13B.
PLEASE SEND PAYMENT TO:
HOLY SPIRIT HOSPITAL
503 NORTH 21ST STREET
CAMP HILL, PA.17011-2288
I PAY THIS AMOUNT
0.00
HOLY SPIRIT HOSPITAL
ri\MPHTII Pf:,
ADDIlIONAL PATIENT Elll I 11'JG- MAY at: NECli98AI-lY FOR ANY
CHARGF.S NOT POSTED WHtN THI(i 11.11 \. WAS rnEOPAR(,D
0'" jf INSURANCE CARHIERS DQ NO' PAY ^NY PAAT Or
THl; AMOUNTS SHOWN UNOf.R eSlIMATI:O INSLJI'lANCC
r.r",rnM",..