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Home My WebLink About01-05511SARA L. WORMAN, : IN THE COURT OF COMMON PLEAS : OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. GIANT FOOD STORES, INC., . a/k/a GIANT T FOOD STORES,: LLC Defendant : CIVIL ACTION-LAW No. 2001-5511 PLAINTIFF'S ARBITRATION MEMORANDUM Background Mrs. Sara L. Worman is a 62 year-old woman who resides at 522 Springhouse Road, Camp Hill, PA 17011. Mrs. Worman is a retired registered nurse and a certified Christian Educator. Summary of the Accident At the time of the accident, Mrs. Worman was shopping at the Giant Food Store located in Camp Hill, Pennsylvania. Mrs. Worman was walking through the produce section of the store when she was caused to slip and fall on what appeared to be a piece of red pepper that had been squashed on the floor. When Mrs. Worman slipped, she fell harshly and roughly to the ground causing extreme trauma to her leftwrist, neck, shoulders and rib area. Liabili Mrs. Worman was a business invitee and as such Giant Food Store owed her the highest duty of care pursuant to Restatement of Torts, Section 343, They had the obligation to conduct a reasonable inspection of the property to ensure the safety of their customers. Their failure to do this was the direct and proximate cause of the incident which resulted in the injuries suffered by Mrs. Worman. Had Giant Foods conducted a reasonable inspection of the premise they would have been made aware of the condition of the floor and thus, the dangerous condition of the floor would not have been allowed to exist. Medical Care and Injuries Immediately following the incident, Mrs. Worman received emergency room treatment at the Holy Spirit Hospital. X-rays revealed a comminuted T-shaped fracture of the distal radius. Mrs. Worman's left wrist was placed in a short arm fiberglass cast and sling with instructions to keep her arm elevated and iced. A prescription for Darvocet was prescribed, as well as a recommendation to use Advil. Mrs. Worman was also experiencing pain in her chest, hip and rib cage areas. X-rays were taken and no fractures were noted. Mrs. Worman was advised to follow-up with an orthopedic physician to closely monitor the left wrist fracture. Mrs. Worman first presented to Dr. Stephen Dailey of Orthopedic Institute on October 15, 1999. X-rays revealed maintenance of the distal radius alignment. Mrs. Worman was experiencing swelling in her left hand and Dr.. Dailey scheduled her for a follow-up appointment in one week for follow-up x-rays. On October 22, 1999 Mrs. Worman again presented to Dr. Dailey. At this time Mrs. Worman was experiencing increased pain to her rib area, left side. X-rays were again taken of the left wrist which showed proper maintenance of the alignment. Mrs. Worman was instructed to continue moist heat for her ribs, reduce the usage of her sling and follow- up in two weeks with Dr. Dailey. Mrs. Worman next saw Dr. Dailey on November 5,1999. On this date Mrs. Worman expressed her discomfort with the cast and the proximal end and underneath in the area of the ulnar styloid. Dr. Dailey took more x-rays which revealed that the fracture was healing. A follow-up appointment was scheduled in 2Yz weeks at which time it was anticipated that the cast would be removed. On November 19, 1999 Mrs. Worman was caused to see Dr. Dailey before her scheduled appointment due to problems she was experiencing with her whole left upper extremity. Mrs. Worman's cast was removed and she was placed in a cock-up wrist splint with instructions to wear it for the next 1-2 weeks. A three week follow-up appointment was scheduled. Mrs. Worman next saw Dr. Dailey on December 10, 1999 at which time she was experiencing pain in her hand, as well as numbness and tingling. Dr. Dailey diagnosed a probable median nerve irritation from her healing fracture. Mrs. Worman was advised to discontinue the immobilization and work on her range of motion exercises. A one month follow-up appointment was scheduled. On January 14, 2000 Mrs. Worman presented to Dr. Daileywith ongoing complaints of numbness and tingling in both hands, as well as locking of the right middle finger. Upon physical examination Dr. Dailey diagnosed Mrs. Worman with possible bilateral carpal tunnel syndrome and possible right middle finger trigger. An EMG nerve conduction study was ordered. Mrs. Worman underwentthe EMG nerve conduction studyon January 17, 2000 with Ed S. Violago, M.D. The results of the EMG were related by Dr. Dailey to Mrs. Worman at her office visit on February 4, 2000. The EMG revealed bilateral carpal tunnel, right worse than left and triggering right middle finger. Also at this office visit with Dr. Dailey an injection of Celestone and Lidocaine was administered to Mrs. Worman's right middle finger, as well as a prescription for Flexeril. Mrs. Worman elected to proceed with endoscopic carpal tunnel release for the right wrist and possible release of trigger finger depending on results of the injection that she received on that date. On April 18, 2000 Mrs. Worman again saw Dr. Dailey wherein she advised Dr. Dailey that her symptoms of numbness and tingling are now more pronounced on the left side. Mrs. Worman was also experiencing increased pain in her left wrist at the fracture site. Endoscopic surgery was scheduled for the right wrist for April 18, 2000. Dr. Dailey decided to perform the surgery on the left wrist on that date due to the increased symptoms on the left side. On April 18, 2000 Dr. Dailey performed left endoscopic carpal tunnel release on the left wrist at Grandview Surgical Center. Mrs. Worman follow-up at Orthopedic Institute on April 26, 2000 with Dr. Kalenak. She was eight days post surgery. Mrs. Worman related to Dr. Kalenak that she was experiencing immediate relief from the surgery. On May 19, 2000 Mrs. Worman next saw Dr. Dailey wherein she advised Dr. Dailey that about two weeks after the left endoscopic surgery she started to have pain in her wrist and hand. Dr. Dailey suggested she ease up on her activities. Mrs. Worman was still experiencing problems with the right middle finger triggering. Dr. Dailey injected the right middle finger and advised Mrs. Worman she may need to think about trigger finger release if the injection does not provide any relief. A three week follow-up appointment was scheduled. Mrs. Worman's next office appointment with Dr. Dailey on June 16, 2000 at which time Mrs. Worman's related an improvement to the left wrist. She was still experiencing right middle finger triggering. Dr. Dailey recommended that Mrs. Worman give the problem with her right middle finger triggering some time and if it worsens to follow-up with him. Mrs. Worman also treated with Gerald M. Dincher, D.C. at Herd Chiropractic Clinic, P.C for the time period January 14, 2000 through July 6, 2000. Dr. Dincher provided chiropractic services to alleviate the pain and discomfort she was experiencing in her neck, wrist and low back. Mrs. Worman completed a course of physical therapy at Joyner Sports Medicine as prescribed by Dr. Dailey. Mrs. Worman attended 16 physical therapy sessions beginning on September 19, 2000 and concluding on November 3, 2000. The sessions included strengthening modalities, scar management techniques, edema control techniques and a home exercise program. At the time of this incident, Mrs. Worman was a vibrant, active individual who enjoyed gardening, painting and traveling. Following the incident, and until the recuperation from her surgery, she was restricted in all of these activities. Whereas she acknowledges that she can engage in these activities at the present time, she must be careful with respect to what type of activities she performs. With respect to her activities of daily living from the date of the incident until recuperation from the surgeries, she was restricted in manyofherhousehold activities, such as personal hygiene, cooking, cleaning, laundryand yard work. It was necessary for her to rely on her family members and neighbors to do the housework, yard work and grocery shopping. Mrs. Worman continues to experience difficulty in sleeping. Mrs. Worman had to sleep with wrist splints on both hands until early December 2000, was caused to get up and walk around due to pain and numbness and had equipped her bed with neck and shoulder support cushions, as well as extra mattress support. Additionally, Mrs. Worman is frequently caused to sleep on the floor due to the pain and discomfort she experiences throughout the nighttime hours and is not able to alleviate her pain. However she is able to obtain some relief from sleeping on the floor. She is not able to sleep without the aid of prescription muscle relaxers and pain medications. Respectfully submitted, HANDLER, HENNING & ROSENBERG, LLP Date: October 15, 2003 By , W. Scott H Vni 1300 Lingl oad Harrisburg, 110 (717) 238-2000 Attorneys for Plaintiff 10-12-99; s;3APMVOI OnL OcT-1,7,-94TClE, 89:40 Rt•. +..i?+??+?`? FOOD STORES, INC. rsaw.Ix?at?ee Foos croREs MlA7IIt'a F000 MARICE?6 - POSrOMCEDOK249 CARMLF-PA 174IJ FIRST REPORT :7f>2np>695 1AH7 FOODS x110 71 9748597 M 41 a P. B1 1?CUS'?'OMER INCIDENT REPORT UO DO NOT ASSUME RESPONSIBILTfY OR Bodily Injury PAYMENT FOR ANY CLAIMS. Prot+eary Damage PROMISE . Store 4: Phone #: 1/D 17 y 7s-- v5 Fa Store?? o} n"Z //CtNI.?LC?fR C /?f?l f? /?Of! Store Manager's - - FY1Qf? !'r'cs Nerves of ASSOCIATE witnesses: (attach statement) miss, rs Mr. .• . a'aha wo rm crr? BirduWe or Age; SOG31 Security #: . (-I& 3k Address: L ) S n n slit r? Ci & SEate: 11 Zi Code: ??D Home Phone k: Jl If if Minor, Parent or Guardian: Business Phone 11; W Date of Incident: Time Incident rred: Lotion of Incident (Aisle, Dept): g -4q ar 3o PM JfOcAA.& -.- B ! Customers D criptioa of Incident and i&ry or ,? fin. ,/m/` _ L?tn? a11nG? fit- Lc.1/'r3 i? If a Produce item is the cause, did the customer have the same a of Produce in their sho pin catt? - Y / N j Did M sees ill? N If so, what was the size of the smin M ?2 Ap& J/00 e- 51;1& LL- -1L - °- - -- Bid the customer acimowled IS seem the sPtlf prior to the incident? _fgg> Was there an visible debris on the customer's clothing? 1 N [mil S 116 Q _ 4{S What type of footwear was the customer wearies ? v-k -1m,// Yes or N - Ambulance Neoessar y: C-D Weather Conditions: (mark aV that apply) Doctor or Hospital Name: / • - '/, J /rrr d Snow Rain Fair x Ice Free zia Rain Wind REPORTEDBY: ?I YLuQh SLs?s-('f2C/ TITLE: Manager - POM - IPO --Groc_ Mgr - 4th Person - Key Carrier dom (Circle One) DATE REPORTED_ 10 -ra-Y9 Fam 9900 Rm O V97 (FM190o) Ci;u2U a.I ; G a D-72b 1 STORE # f 0!/ AM 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 1100 12:00 PM 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 ?J SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY TIME TIME BY TIME BY TIME BY TIME BY TIME BY TIME [ BY fty)kti W 1911S Al 0/00 /1;0 O 00 . _ 2 6W il)v i5 / F 76V &z- ' z 6 OM+ 1 S_ul m `6 IJiwy ./C Jtl / - °\ 9" °03 ^x( p.a2 /jvu ?v- 4? - 131 06 I)l? ?- . a - t I '?o N-U- 3a /' G 03 " u- Z U-- w /asa3 orl : ?6 1) Hazardous floor conditions found during inspection are to be corrected immediately. 2) Record exact time floor inspection is completed. 3) Inspection is to be conducted hourly by the inspector only! 4) File worksheet in floor inspection worksheet folder weekly. 5) Send inspection worksheets to the Risk Management Department along with Monthly Safety Meeting notes. 6'af?b??.`a •v? ?: Customer Service Manager Print Name Nov 19 1999 Customer Service Manager Signature , Date FORM #941 MARTSON. DEARDORFF-WILLIAMS & OTTO - - - M&,, DW ? ATCORNEYS& COUNSELLORS AT LAW WaLIAM F. MARTSON INFORMATION •ADVICE•ADVOCACY - - JOHN B. FOWLER III ' - - •" EDWARD L. SCHORPP - DANIEL K. DEARDORFF TEN EAST HIGH STREET THOMAS J.' WIILIAMs CARLISLE, PENNSYLVANIA 17013. - - NO V OTTO III TELEPHONE (717) 243-3341 GEORGE B. FALLER JR. * - - - C. RiscH FAcsIMILE (717) 243-1850 - - - R. - - - - CA. ALU owAy INTERNET, W W W.mdW ,COm - - - ANTHONY T T. . LUCIDO CIDO ANTHONY September 1% 2003 *BOARD CERTIMD CIVIL TRIAL SPECIALIST Dale F. Shughart, Jr., Esquire Michael J. Pykosh, Esquire 35 E.. High Street P.O. Box 368 Suite 203 3508 Market Street Carlisle, PA 17013 Camp Hill, PA 17011 James M. Robinson, Esquire 28 S. Pitt St. Carlisle, PA 17013 RE: Sara L. Worman and Jared N. Worman v. Giant Food Stores, Inc., a/k/a Giant Food Stores, LLC N6.2061-5511 Cumberland County C.C.P. Our File Number 9500.153 Dear Arbitrators, We represenTDefendants in -the above matter. In response to your letter dated August 27, 2,003, we enclose the.following pleadi-ngs'and exhibits we intend to introduce into evidence' at the Arbitration Hearing on October 15, 2003: 1. Medical records from Orthopaedic Institute of Pennsylvania and 2. Emergency Room Records from Holy Spirit Hospital. Very truly yours; M S WFallerr F WILLIAM S& OTTO G . GBF/drg Enclosures - cc: W. Scott Henning, Esquire" (w/enc ) Mr. Kevin McCoy (GL9909192) (w/out enc.) - Ms- Pam Hall (D/L 10/12/99) (w/out enc RTILES\DATATILEVMC 5W\vane 1,53.&1 - -- - '- .IN-FORMATION. • ADVICE ' ADVOCACY" . .. -i - SARA L. WORMAN, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. GIANT FOOD STORES, INC., a/k/a GIANT T FOOD STORES,: LLC Defendant : CIVIL ACTION-LAW No. 2001-5511 JURY TRIAL DEMANDED NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 Liberty Avenue Carlisle, PA 17013 Telephone 717-249-3166 or 800-990-9108 HANDLER, HENNING & ROSENBERG a / By 'J W. ott He /g,E I. #22 133 inglesto Harrisburg, PA (717) 238-200Attorney for PI SARA L. WORMAN, Plaintiff v. GIANT FOOD STORES, INC., . a/k/a GIANT T FOOD STORES,: LLC Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA : CIVIL ACTION-LAW No. 2001-5511 JURY TRIAL DEMANDED COMPLAINT AND NOW, comes the Plaintiff, SARA L. WORMAN by and through her attorneys, HANDLER, HENNING & ROSENBERG, by W. Scott Henning, Esquire, and brings forth this Complaint against Defendant GIANT FOOD STORES, INC., a/k/a GIANT FOOD STORES. LLC and aver as follows: 1. Plaintiff, Sara L. Worman, is an adult individual currently residing at 522 Springhouse Road, Camp Hill, Cumberland County, PA 17011. 2. Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, is a corporation registered and established under the laws of Pennsylvania, with a location at 700 Camp Hill Shopping Plaza, Camp Hill, Cumberland County, PA 17011. 3. Defendant Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, is a corporation registered and established under the laws of Pennsylvania, with a registered office 1149 Harrisburg Pike, Carlisle, Cumberland County, PA 17013. 1 4. At all times material hereto, Plaintiff, Sara L. Worman, was a business invitee upon said Premises. 5. At all times material hereto, Defendants, who had exclusive control of said Premises, had allowed a squashed red pepper to remain on the floor in the produce area 6. At all times material hereto, there were no warning signs posted on the Premises warning of the possibility that produce was on or remained on the floor. 7. On or about October 12, 1999, at about 10:30 AM, Plaintiff, Sara L. Worman, was on the Premises shopping. While shopping in the produce aisle, Plaintiff was caused to slip and fall harshly and roughly to the ground due to a squashed red pepper, that was allowed to remain on the floor, causing personal injuries upon the Plaintiff as detailed more specifically hereinafter. COUNT I- NEGLIGENCE Sara L. Worman v. Giant Food Stores. Inc. a/k/a Giant Food Stores LLC 8. Paragraphs 1 - 7 are incorporated herein by reference as if fully set forth at length. 9. At all times material to hereto, Plaintiff, Sara L. Worman, believes and therefore avers, that Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, was in ownership, possession, management and control of the Premises and was responsible for maintaining the safe condition of the property known as a Giant Food Stores located at 700 Camp Hill Shopping Plaza, Camp Hill, Cumberland County, PA 17011. 2 10. The occurrence of the aforementioned incident and the resulting injuries to Plaintiff, Sara L. Worman, were caused directly and proximately by the negligence of Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, by its agents, servants, workmen or employees, acting in the scope of their authority, and employment, generally and more specifically as set forth below: (a) In causing or permitting the floor at Premises to become littered with a squashed red pepper and/or other produce, thereby posing an unreasonable risk of injury to the Plaintiff and to other persons lawfully upon the premises; (b) In failing to make a reasonable inspection of said Premises which would have revealed the existence of the dangerous condition posed by the squashed red pepper, and thereby allowing the same to be and remain a dangerous condition when the Defendant knew or should have known of it; (c) In failing to ensure the floors at said Premises were maintained in a safe condition to prevent injury to the Plaintiff and other persons lawfully upon the Premises; (d) In failing to post a warning sign or device in the area to notify of the dangerous condition on the floor of said Premises; 3 (e) In failing to clean the squashed red pepper from the floor of said Premises so as to avoid the situation in which the Plaintiff slipped and fell; and (f) In failing to maintain the common floor in a reasonably safe condition that would prevent a customer from slipping and falling. 11. Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, had actual knowledge or should have known through the exercise of ordinary care and diligence that there was a squashed red pepper on the floor in the area where Plaintiff, Sara L. Worman, fell. 12. As a direct and proximate result of the negligence of Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, Plaintiff, Sara L. Worman, sustained serious injuries including, but not limited to, extreme trauma to her left wrist, neck and rib area She suffered a comminuted T-shaped fracture to the distal radius of the left arm. 13. As a direct and proximate result of the negligence of Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, Plaintiff, Sara L. Worman, has undergone great physical pain, discomfort and mental anguish and she will continue to endure the same for an indefinite period of time in the future, to her great detriment and loss, physically, emotionally and financially. 14. As a direct and proximate result of the negligence of Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, Plaintiff, Sara L. Worman, has been, and will in 4 the future be, hindered from attending to her daily duties to her great detriment, loss, humiliation and embarrassment. 15. As a direct and proximate result of the negligence of Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, Plaintiff, Sara L. Worman, has, and will in the future, suffer a loss of life's pleasures. 16. As a direct and proximate result of the negligence of Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, Plaintiff, Sara L. Worman, has been compelled, in order to effect a cure for the aforesaid injuries, to expend large sums of money for medicine and medical attention, and will be required to expend large sums of money for the same purposes in the future, to her great detriment and loss. WHEREFORE, Plaintiff, Sara L. Worman, seeks damages from Defendant Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, in an amount in excess of Twenty-Five Thousand Dollars ($25,000.00), exclusive of interest and costs, which is an amount in excess of jurisdictional amounts requiring compulsory arbitration. Respectfully submitted, HANDLER, HENNING & ROSENBERG W. Sao lmI.D. 2130 Li P.O. Box 1177 Harrisburg, PA 177 (717) 238-2000 Dated: Attorney for Plaintiff 5 VERIFICATION The undersigned hereby verifies that the statements in the foregoing document are based upon information which has been furnished to counsel by me and information which has been gathered by counsel in the preparation of this lawsuit. The language of the document is of counsel and not my own. I have read the document and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information and belief. To the extent that the contents of the document are that of counsel, I have relied upon my counsel in making this Verification. The undersigned also understands that the statements made therein are made subject to the penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities. l Sara'C. Orman Date: 11-a'0 1 SARA L. WORMAN, : IN THE COURT OF COMMON PLEAS : OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff CIVIL ACTION-LAW V. No. 2001-5511 GIANT FOOD STORES, INC., a/k/a GIANT T FOOD STORES,: LLC Defendant JURY TRIAL DEMANDED CERTIFICATE OF SERVICE On this 6th day of November, 2001, 1 hereby certify that Plaintiff's Cmplaint with Notice to Defend was served upon the following by U.S. mail, certified delivery: George B. Faller, Jr., Esquire MARTSON, DEARDORFF WILLIAMS & OTTO Ten East High Street Carlisle, PA 17013 HANDLER HENNING & ROSENBERG Date: 11/6/2001 By U W. Sco e nin , Esquire 1300 ingl sto n Road Harris g, P 17110 (717) 238-2 00 ATTORNEY FOR PLAINTIFF F:TU.ES\DATAFU F\M cd...,\153-anal/.I. Creed 1111310109:3244AM Rc,iSM. 11/13/0110:05;57 AM 9500.153 SARA L. WORMAN and JARED N WORMAN, Plaintiffs V. GIANT FOOD STORES, INC., a/k/a GIANT FOOD STORES, LLC, Defendants IN THE COURT OF COMMON PLcEAScOF CUMBERLAND COUNTY, PENNWYLUANIA CIVIL ACTION - LAW=-; _ 2001-5511 JURY TRIAL OF TWELVE DEMANDIM -? DEFENDANT'S ANSWER TO PLAINTIFFS' COMPLAINT 1. After reasonable investigation, Defendant is without knowledge or information sufficient to form a belief as to the truth or falsity of the averments contained in this paragraph. The averments are therefore deemed denied and proof is demanded. 2. Denied as stated. To the contrary, Giant Food Stores, LLC is a Delaware corporation which has a retail establishment at 700 Camp Hill Shopping Plaza, Camp Hill, Cumberland County, Pennsylvania 17011. 3. Denied. To the contrary, Giant Food Stores, LLC is a Delaware Corporation with a registered office at 1149 Harrisburg Pike, Carlisle, Cumberland County, Pennsylvania 17011. 4. Denied pursuant to Pa. R.C.P. 1029(e). 5. It is admitted that the Defendants operated a retail grocery establishment at 700 Camp Hill Shopping Plaza, Camp Hill, Cumberland County, Pennsylvania and had possession and control of the premises. The remaining averments of this paragraph are denied pursuant to Pa. R.C.P. 1029(e). 6-7. Denied pursuant to Pa. R.C.P. 1029(e). COUNT I-NEGLIGENCE Sara L. Worman v. Giant Food Stores, Inc. a/k/a Giant Food Stores, LLC V 8. Paragraphs 1 through 7 of this Answer are hereby incorporated by reference. 9. It is denied that the Defendant Giant was the owner of the premises. It is admitted that Defendant Giant operated the retail grocery establishment and possessed and controlled the premises. 10. It is denied that this incident occurred as a result of the negligence of the Defendant Giant by or through its agents, servants, workmen, or employees acting within the scope of their authority and employment. (a-f). Denied pursuant to Pa. R.C.P. 1029(e). 11-16. Denied pursuant to Pa. R.C.P. 1029(e). WHEREFORE, Defendant Giant Food Stores LLC demands judgment in its favor and dismissal of Plaintiffs' Complaint with prejudice. MARTSON DEARDORFF WILLIAMS & OTTO By c.. `-> I George . Faller, Jr., Esq61fe I.D. Number 49813 Ten East High Street Carlisle, PA 17013-3093 (717) 243-3341 Attorneys for Defendant Date: ?,Lt ? jx - 3, )k 1 VERIFICATION I, TIMOTHY REARDON, Vice President-Risk Management and Support Services of Giant Food Stores, LLC, acknowledge that I have the authority to execute this Verification on behalf of Giant Food Stores, LLC and certify that the foregoing Defendant's Answer to Plaintiff's Complaint is based upon information which has been gathered by my counsel in the preparation of this lawsuit. The language of this Answer is that of counsel and not my own. I have read the document and to the extent that this Answer is based upon information which I have given to my counsel, it is true and correct and to the best of my knowledge, information and belief. To the extent that the content of this Answer is that of counsel, I have relied upon counsel in making this Verification. This statement and Verification are made subject to the penalties of 18 Pa. C.S. § 4904 relating to unworn falsification to authorities, which provides that if I knowingly make false averments, I may be subject to criminal penalties. Giant Food Vice President - Risk Mgt. & Support Services Dated: F:\FILM\DA'FAFILIV? Ucdoc.cuAI56.ms.I CERTIFICATE OF SERVICE I, Nichole L. Myers, an authorized agent of Martson Deardorff Williams & Otto, hereby certify that a copy of the foregoing Defendant's Answer to Plaintiffs' Complaint was served this date by depositing same in the Post Office at Carlisle, PA, first class mail, postage prepaid, addressed as follows: W. Scott Henning, Esquire. HANDLER, HENNING & ROSENBERG 1300 Linglestown Road P.O. Box 1177 Harrisburg, PA 17108-1177 MARTSON DEARDORFF WILLIAMS & OTTO By Y(Ciu&CAI&a5 Nichole L. Myers Ten East High Street Carlisle, PA 17013 (717) 243-3341 Dated: .CQ ?u ?2? 3? ?f)c? I s February 5, 2001 W. Scott Henning, Attorney-at-Law P.O. Box 1177 Harrisburg, PA 17108 RE: Sara L. Worman 161 32 3713 Dear Mr. Henning: Sara Worman is a patient that I had the privilege of taking care of. I first saw her on 10/15/1999. At that time, she had just recently slipped at the Giant Supermarket and fell on a pepper going down on her left side. Her initial complaint was left sided chest pain and left wrist pain. She sustained a left distal radius fracture which was reduced and casted. The reduction was in acceptable position and this was treated with immobilization. After a period of immobilization for approximately six weeks, she had improvement of the pain that she was experiencing and the fracture healed appropriately. When she was seen on 12/10/99, she still had some discomfort in the hand and she also had complaints of numbness and tingling in the left hand. Subsequent EMG and nerve conduction study was consistent with left carpal tunnel syndrome. Her exam was consistent with this diagnosis as well. She subsequently underwent left endoscopic carpal tunnel release on 4/18/2000 and had improvement of her symptoms. It is my opinion that the carpal tunnel is directly related to the injury she sustained when she fell on 10/12/99. The specific injuries related to this would be the left distal radius fracture, that is the side she had fallen on, and left carpal tunnel syndrome. It is also my opinion that at this point, the patient has reached maximum medical improvement. She should not have significant long term sequelae in her left upper extremity from this injury. of course, with any fracture that goes into a joint, there is the possibility O of post traumatic arthritis at some point in the future. With her fracture, this is not likely, however. There is also the possibility of recurrence of carpal tunnel syndrome. I don't suspect the patient will need further II/I?I treatment in the foreseeable future for the left upper extremity. \1 I am not able to assign a percentage of disability of her left upper extremity as I do not have the AMA guidelines available. The only limitation I would see that she would have is possibly some limitation of motion in the wrist so it would be a small percentage of disability for the left upper extremity. VJJv:)?? RE: WORMAN, SARA L. PAGE 2 February 5, 2001 If you have any further questions on Sara Woman, don't hesitate to call me. Sincerely, Stephen W. Dailey, M.D. SWD/mee UJJLJa1. July 19, 2001 W. Scott Henning Handler, Henning & Rosenberg Attorneys At Law P. 0. Box 1177 Harrisburg, PA 17108 Dear Mr. Henning: RE: Sara L. Worman 161 32 3713 This letter is in regards to Sara Worman who is a patient of mine. She was treated for injuries to her left upper extremity associated with injuries she sustained 10/12/99. She developed problems with her right upper extremity involving right carpal tunnel syndrome and right trigger finger. These were treated surgically by me. I do not feel that there is a cause of relationship between her right upper extremity orthopedic problems and her injury which did in fact affect her left upper extremity. If you have any further questions, please do not hesitate to contact me. Sincerely, V V SWD/lmn O Stephen W. Dailey, M.D. n ?9 uUU'v?? 11SH ER FORM REG DATF1 10/12/95+ 11138 PT#: 14098081 MR#s 2015/$12 NAMES WORMAN SARA L SS #; 161-32-3/13 ADLRP-S51 522 9PRINUUMDUSL• RD /CAMP HILL /PA/17011 PHIS 717-761-1839 DIRTHDATE: 04/16/1'3$ ADES 61 SEX; F M5: M RACES 1 UEDS 041030 CMPL.OYER; RaT-VISITING NURSE A OCCOPATION; VISITING NURSE ADDRESS: / / / PH#S 711-233-103'5 CHURCHt PRESPYTERIAN-SILVER SPRINGS AM$: HAM^DE.N EMS COMMENT; EMERGENCY CONTACT INFORMATION NAME: WORMAN JARED REL TO PT: H WORK PH #; 71/-386-5134 ADDRE'SSS 522 SPRINGHOUSE RD /CAMF HILL /PA/17011 PH #1 717-761-1839 NAME: REL TO PTs WGRK PH #s ADORESS9 / / / PH #; CASE INFORMATCON ADMIT DRt 111396 SHARMA RAJANA RES SOURCE; ED PATIENT TYPCt E ATrND DR: 111336 SHARMA RAJANA HOSP SERVs ER3 FINANCIAL CLSS 9 REF"tR DRS VISIT CLINIC CODES ER3 ADMIT DX; ICU-9 DXS COMPLAINTS FALL,LT WRIST INJURY AND LT RI 8 PAIN AMB BRr IN BY; aRr IN BY; tMPLOYEE OF OIA COMMENT; ACE.IDENT INFORMAIION DATE/TIME; 10/12/99 10:20 ACIC INDS O JOB RELATEDt N LOCATIONS DGSCRIP110NS PI 6LIPrED ON A PErPCR AT GIA NT AND INJURVD HER LT WRIST OUA:ANIOR 114EORMAI1ON NAMF.- WORMAN , SARA L ADDRE ss t 522_ SPRINDHOUSE RD /CAMP HILL IPA EW'LnYER; REr CONTACT ADDRESS c PL. AN INSURANCE SUBFCR T BER 1 002 HEALTH AMERICA WORMAN SARA 1NSUR.AODRESSs PO BOX 2 INSUR.ADDOESS: 3 1NSUR.ALORESSt 4 CO 1 P4. PT REL TI] GUARS 5 SS 1t: 161-32-'3713 RD /CAMP H1LL /f A/17011 PH #S 717-761-2809 NAMES PH #s 717-233-1035 IN{SL(RANCE INFORMATION COB POLICY # GROUP # REL PC VFY CARD PRECERT/AUTH # PRECERT PHONE # O 1 20428247102 1022050002 S Y Y - - 2610 PITr9BUROH PA 1%x30 NBUR.ADDRESSS ???F NTSS FMD/COWLEY MED ASSOC (1?1 BEN r NAMES WORMAN , SARA L (aSTERF-D. BY. FHMAK EDITED Q PT#; ERYt VATEs s 5,4a E loo 14098081 MR#S 201782 C / END OF DOCUMEtNY 0^ 4*A I- I 10%k CONSENT TO MEDICAL TREATMENT 1 HEREBY CONSENT AND AUTHORIZE Hoy Spirit Hospital, its agents, and employees, to the rendering of medical eve, which may include routine diagnosis procedures and such medical tr®atment as my attending or consulting physictim considers to be necessary I also under- stand it is customary, absent emergency or extraordinary circumstances, that no substantial procedures will be performed upon me unless or until I have had an opportunity to discuss them with a physician or other health care professional to my astekation If I am a competent adult, I have the right to consent or refuse to consent I understand that the practice of medicine and surgery is not an exact science and that diagno- sis and treatmant may involve risks of injury or even death and acknowledge that no guarantee has been made to me as to the results of any examination or treatment in this Hospital 1 understand many of the physxxans on We staff d Holy Spirit Hospital are not employees or agents of the Hospital, but rather are independent contractors who have been granted the privilege of using these facilities for the care and treatment of their patients Further: I notes this Hospital is a toad ng Hospital and at ths Hospital are health care personnel in training who, unless expressly requested dhemnse. may participate or may be present during my care as part of their education Still or motion pictures and dosed circuit monitoring of patient care may also be used for educational purposes, unless I expressly request otlierwise. I understand that in order to ensure a safe environment for patients, visitors and staff all property on the promises of tit ?iosptfal is subject to reasonable search andlor seizure at any time without further notice (Al RELEASE OF MEDICAL INFORMATION I authorize Holy $pint Hospital to release to requesting health insurance carder(a), their representatives and auditors, and any referring health care providers, such diagnostic and therapautic mtmmatxm (including any +Mormabon relating to treeamerrt for adcoh" and, aubsla= abuse andlor treatment of pWalliatnc disorders. andlor confidential HIV related information. as may be necessary for them to determines beeirt enh- tisment, to process payment claims for health care- services provided during this hospitahzabonftrestment eptsix s, and Sir continuing carekreatment A photocopy or carbon copy of this authorization shall be considered as effective and valid as the original The undersigned also authorizes Medicare, when applicable, to release to another insurance comer, upon thew request, medical information needed to make payment upon that claim 1 understand and consent that the manufacturer of any implantable device inserted by my physician during the eouree of u any/p cedure may be provided, h my identification i rmation, including social security number, as mandated by Federal Law fel Data Signature Relationship to Pattern INSU CE ASS1G MENT OF BENEFITS slat I authorize payment directly to Holy Sprat Hospital and my treating physicians of all benefits payable under my ir= olicos I u end I am responsible to the Hospital for all charges not covered by this assignment STATEMENTTO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDERS, PHYSICIANS AN"ATIENT I request payment of AuNonzed Medicare benefits to me or on my behalf for any services turmahed me by or in Holy Spirit Hospital including physician services 1 authorize any holder of medical and other information about me, to release to Medicare and its agencies any information needed to determine these benefits for related services MEDICAL ASSISTANCE RECIPIENT Intuits My signatures certifies that I received a service or dams from Holy Sprat Hospital and Or on the data listed below 1 understand that payment for this service or dam will be from Federal and State funds, and that any Was claims, statements, or document% or concealment of material may be prosecuted under applicable Federal and State Laws I have read and agree with the above statements 1 have read and undarskand each of ihs ssetfons contained above. l understand ilhaf It signing iWo doourrmd, l am agreeing and providing the au inaftatton/ cons contained In awh of the aban sections whirs ny IlWa are hrcaNd 1 have had tits oppoitual- ty to ask eatlo gar Ihig each tb esctlona and an such qusetlonis lad have bean answered to mp satlafacUon lgriatd ' tfilfin _ ehationship to Patient Time Date 9 Formwheseaed fly Data Signature HOLY SPIRIT HOSPITAL, CAMP HILL, PA CONSENT FOR TREATMENT/ RELEASE OF INFORMATION INSURANCEASSIGNMENT j *R 201932 E o1nlt L :,tt c?rt0U5? &i. fR3 C+?P ,tLL P& 170ti ilsaJt d 7S1-1539 ,v.-?--3713 Sell&ei. dAJAaJ. .,, , a. r , ?l,a v42 '0e: r:Is110a i?J1.19I CHART COPY r" rl? $oiy Sphit Hoapittl HaaltbCam 24 Tr[aja . Date Tune Naoro. ^A DOB. / / _ Age: f ] mde } female '"hw complaint. kikrgy Lost Team Sbot [ ] sous (] uakaa o N of years ?- Vttd Signa T -,__ P _ R. ,mow, BP- wt• Sukectlret Pei Medics[ History Onset: Mantua Madmucioe• Howie Days Oblation :ommouseeas [ ] Aker [ ] Nutatag Dugoom P1su. Expeomd Outmome. Pnorny 1 2 3 Tttaga Compimsd Tngc R N Stgwl t ED PHC Tumo to Exam Room , His Hn [ I Siderafia Op n r"1 I I wait I I BLS I I ALS ( ) LMD Ref DR HMO Appr ( )yes ( ] so Dr uma Preho pkW Ma*/Rx Discharged: C I SuisLctory C I Improved Tune (I Caned I l Expoad i I Dtseharge ns Report CaLL Hts Adscusu n Called Bra. Admitted to At HIS (] Obaetvaum 7tspoauian [ 1 Home [ I AMA C I Morgue I I OR u Hn. FHC (/ 1,49 CHART COPY IWALTRCARE E4 140"8081 W0kNAN SARA IdIZ SPK14GHO CA+1P HILi, G4/1b/143d 1n1-3,-S;t3 L-W'X4 t .aAk I0/I1/9a NR 201982 E L US[ k0 E.i3 PA 17011 7b1-1839 SHARMA RAJANA 401 10428247101 01°0C]044 Stiprmrt Q r. MD(DO HOLY SPIERN HOSPITAL Camp HiB. PA 17011 To; FHC HC24, M.D. From- RX2909 Fax Stiinn 19-12-99 3:24pn o. 1 of 1 ADM. DATE: 10/12/99 Sara is a 61-year-old nurse who presents to the Health Care 24 complaining of pain and discomfort in her left wrist after she fell earlier today in the grocery store area coming out of the grocery store. She fell and sustained an injury on her outstretched left wrist and neurovascularly intact. She was seen and initially evaluated. X-rays shows a comminuted T-shaped fracture of the distal radius with minimal displacement at best at this time. Neurovascular intact. Good pulse, moderate swelling. I have discussed with Sara at length the prognosis and treatment. If over the next several 10 days to 2 weeks of this fracture displaces or shortens, then all bets are off and we have to proceed with a pins -and piaster fixation and or an external fixator to bold it to good alignment. However the alignment right now is very acceptable. I have gone ahead and placed her in a short arm light fiberglass cast to keep her completely immobilized, ice and elevation and I have given her a prescription for Darvocst-N- 100 for pain. She is going to be using Advil in the interim as well and elevation and she will see Dr. Yucha who she has seen in the past for the next 2-3 days for follow up in the office and close monitoring of the fracture for the next 10 days. It is going to take approximately 6-8 weeks to completely heal and she is otherwise doing very well. She will follow up as scheduled. Diagnosis: Distal radius interarticular fracture minimally displaced but needs to be watched closely over the next several weeks. ??li-?G ' "-rte=== Fran'c1s Horner PA-C FH/js D: 10/12/1999 T: 10/12/1999 9198 cc Dr. Yucha Page 1 HOLY SPIRIT HOSPITAL MAHEi NORMAN, SARA Camp Hill, PA MR(#: 201982 17011 ROOK #- ER3 DR.: Horner CONSULTATION REPORT () ;)0G45 w DEPARTMENT OF RADIOLOGY HOLY SPIRIT HOSPITAL PRELIMINARY X-RAY INTERPRETAT ION NAME Wor 4 2q DATE /0-/.?. 9 q EDI"OUSE PHYSICIAN FINDINGS* ED/HOUSE PHYSICIAN "m M mmD ED CHART COPY CHARGE NURSE #2300 AGE 1-1 LOCATION eCe 3 RADIOLOGISY FINDINGS. C&P-A,ty C ve FA- cfr?'-?a? ?oC??s cY 46-5 RADIOLOGIST Holy Spirit Hospital Department of Radiology and Diagnostic Imaging Camp Hill, Pennsylvannla 17011 (717) 763-2600 PATIENT: WORMAN, SARA L DICTATION DATE: Oct 12 1999 1 16P MRS: 201982 TRANSCRIPTION DATE: Oct 12 1999 2 21P SOC see, 161-32-3713 ORD DR: RAJANA SHARMA M D PT TYPE: E ADM DATE: 1611211999 ARRIVAL DATE: 1011211999 LOCATION: ER3- HOSP SERVICE: ER3 'Final Report*** EXAMINATION: LEFT FOREARM (2v), UNILATERAL LEFT RIBS (3v), CHEST (1v) 73090 - Oct 121999 COMMENTS* INDICATION - infuryhrauma There is no previous chest radiographs available for comparison at the time of the dictation Both lungs are dear of arc space or interstitial opacdiea The cardiac silhouette and madiestinsl structures are unremarkable Pleural effusions or pneumothorax are not seen There is no fractures identified There is no fracture identified in the left ribs Ostsobiastlc or osteolyhc changes are not seen The lungs are unremarkable Pleural effusions are not seen There is a comminuted fracture involving the articular surface of the distal radius. There are no fractures identified in the ulna The alignment of the carpal bone is unremarkable CONCLUSION: Normal chest and left ribs Comminuted fracture of the distal radius DICTATED BY: NOBUO NAKAGAWA M D / DG DATE OF EXAM: Oct 121999 SIGNED BY. NOBUO NAKAGAWA M D DATEMME. Oct 12 1999 3 16P OCT 12 1999 D /D C, /1 ' ..,t, rhea! Orders Nabnormal but no action indicated. File Imaging Services Consultation r( f Page t li v 4 wmmmmmw_y Holy Spirit Hospital - Department of Radiology and Diagnostic Imaging Camp Hill, P.ennsylvannia 17011 (717) T63*600 PATIENT, WORMAN, SARA L DICTATION DATE: Oct 121999 1 18P MR#: 201982 TRANSCRIPTION DATE: Oct 12 1999 2 10P SOC SEC: 161-32-3713 ORD OR: RAJANA SHARMA M D - PT TYPE: E ADM DATE: 10/1211999 ARRIVAL DATE: 10/1211999 LOCATION. ER3- HOSP SERVICE: ER3 ***Final Report' EXAMINATION: LEFT WREST (b1) 73110 -Oct 121999 COMMENTS INDICATION-fell Sic views of the left wrist radiograph is obtained There is a comminuted fracture involving the distal radius The fracture lines appear to be involving the articular surface of the rediocarpal joint Mild impaction and angulation is noted There is no fracture identified in the distal ulna The radw-ulnar lent space is widened CONCLUSION: Comminuted fracture of the distal radius DICTATED BY: NOSUO NAKAGAWA M D I DO DATE OF EXAM: Oct 121999 SIGNED BY: NOBUO NAKAGAWA M D DATEITIME: Oct 121999 3 10P OGT 12 1999 wb-, r n. . , , Ai C;.e,* nrcleA t/ abno, mal but n') accwn indicated Fla Imaging Services Consultation Paae1 (, 1t V i JU4U Initial Lae & %•Ray Orders: Labe 1 udn@ *w h0slre I I Acetenmoptmn [ I ESR l I Alcohol [ 1 Glupo9e I I Amyla>relUPaxe I I HCOS I [ I APIT [ I Uver I I Blood Cukurt Profile [ I I BMP I I LNea 1 1 ICBCP I IPTP { ( 1 chip I 1 SalicAte [ I I CRPI [ ] Serum Acetone 1 ( ] Dipomn [ ] Theopllybne I I o1mbn [ I Thyroid Pm01a liadlolaaY I Tox Seven I ) Unite Tox Screen j ThronboVie Labe I Type b Croaa _e of unit I Type 6 Screen I UTA I U"MCas I Wafmnan'e comp 0.0 Screen Time Been: 1 L ?j Camille Re ra or I ) Monitor [ ) ABOf papad M 1 )ENOpagediaI IPwk FWMSS1oWAtterRtp Tx I 102 UMln I )RupineoryTx ( 102 SetuMmn Medications I IV's / Additional Orders '? [1a{4lrlmallM IV: NSS/ DSW/ LN/ DS/A6NB/ DS.SNS Intuseat-cc/hour. Obtain old records. - Wfr k{ bru ?n Ric rr? IT-J` YL9? c f ]AbdADbae Sent l IKUS I IAN" R L ( ]US SPire I ]C4Mda R L [ 1Mwitlmk I ICON Spl" Latent 1 I Nell 1 1 Caw Spina Routlne I I Orkin R L [ Krell Rm I Port I TPA ( IP*W 11 Elbow R L 1 1 Pyaloar. IVP l IFeaa1 'jQaek R L 1 1 Fwnur R L 1 1 Sheuler R L \y ( 1 Freer R L 11 Skull 1] Fact R L/ A l lJ 1 Tillman Faieemr R tv0Y4' S ^ I ]DSpna ki [ )Hand .. R L l TNo1FW A L/? [ ]fag R L I Ilea R Lr?r ) I IHumuua R L 14WWt R Qt I I Krell R L 1 f ]Omit nalargon. Speow ProoWurw: UWeeound [ lAbdowin I IOCamol [ I Duplex Dopplw I I VO Scan [ I0akbloddar I IOlher { I Pe1vb T cuflume nr/CRT11nr. jSiAiSUWAWCuMrs [ ISpNUmCBS [ ICervkM [ ISWOTS I Ichlsmoa [ ]Sled OBP - [ ]OC CUmra [ ISkioIC DMdle [ 1WoundC&S Bllling ClasalScaff", f ILVro11 { )Follow UP ( IAoddwd I 1 Lm'el II [ ] Calla I [ I Medblil 1 ]L"lllt I )Madkel Non4tmerpenoy I ILM11V [ ILm"eIV Holy Spirit Hospital Camp Hill, PA Enarpancy Care Unit Physician Order Sheet ¢ MU REV Ilea JD,W MD s, 140(; F,Urj NR 201982 E YORMAN SARA L St: SPKI rt,H0U5= nL ER3 CAMP "IL. PA {701( L'A/Ib/1938 761-1631 tp]-3:-3113 SHARMA kASANk 6v,i4A4 SAR OOZ ?0428147102. CHART COPY 1 10/12139 li V 0 0 4 ? r e-, Oft, • . 1-% 101 Date: Log-in Tlme Name: - gjle: G ! Tnage Time FMD Time to Exam Room Made of Amval Ari tlato E I6LS L IALS ( I Medical Ccm Ell C IEFCOMPLAINT: INITIALTRIAGE: Plxe Injury occurred I I Home [ ] Industry I J Reorsairm I ] Other Irdormaaonoblainedfrom. PPU&nt _PamhylSO _Peourds ._EATGPstamadIc !drnnhy xvaiu./tt.?n, Triaged to radiology for nabmdb t°Y NO aMNTemp yveml/eol Dlatet Pulses <Ei'Abaant Destination 1JECUt 01 EDP rude color (&ql Crams: MOltled? pain (t- 1 Pemetnaaie PmaeMAJ? Tlme taurvenxaer Temp: C U . PulN: Raeplrstlons. B/P:,/-=t Pulse Ox.: SS 7., Allerglealnoeetldns: ?- L409TOtWMS: LMP Weight ace parUnan Visual Acuity 00 -0131 OU-conarefte lenail Subjectt : Jr. -Z - T / 0lyectlve: Prehoapllal Treatment MedlentlordDose/Freauencil, Last Dow Medicatlorli'Dose/Freauencv. Last Dose C1 kW 1-2 oe, - ' a D r4 u C 4 S Pas MedicaUSurg cal History: 07 41? Hes pauent had exposure b rrlansie4 chidwitox.orTB m past monlM Ara there advance rhreW Veel4.ft1_la copy avadeble'+?? NURSING DIAGNOSIS EXEEg.TED OUTCOMP Carlos Output aleareuonm _improvamentincardiwmtpuldemonsbatadbyimpmwdvs anddfagnosactens Cornron, sllemiron in -..Decrease a relief of d11100(nron Ruld volume, aMemban in _-Improvement in Mud vol devionstmlod by decreaas in symploma of and vol mbalaice pnpmred gas exavige -Improved Use exchange demombided by Inswo nid re"arrbon and veal MgN PatmbayAcnd mledon __Dacn vise in sympmmsmhcsvnpinkcUOn a pstenamim adscbon Knowledge Deaat -Improved IVawletlUe demonstrated by v6naba bon /return damsnstri Aesessmem completed at f/= - I R.N. Data obtained by: M.A Admission Called [) Admission [ ) Obeervamm [ [ Old Records Semi Report Called Admm d n at Hra Tlansferred to at - by Dwpowhon I e [ A[ ] OR at ( I Satisfactory [ I Im I C u ( sae magus at Discharged V ( 1 Monti Instructwm Dlsch eRN. at Holy Spirit Hospital : 4 G ; ^ G31 MR 201482 E Camp Hill, PA 1r0RRA-4 SARA L ECU Nursing Assessment 5:, o?d 11UHOUSZ RD LR3 aM-ecu avysm R.v m,MD all C111P -IL6 PA 17011 6+1161Iy31, 761-11134 141-3.-3713 SHARXA RAJAMA 63AAAA SIR ir02 t041S24110t CHART COPY 1011 Z /4 4 EMERGENCY MMR URGI CENTER DISCHARGE INSTRUCTIONS HOLY SPIRIT HOSPITAL (717) 763.2316 am. (717) 763-2424 n Tba eu,mmrmn and segment you hew: rogaind in der Pmenamcy Cmw linos hem rapdagi on an emergency Wig only. eod are nM mnWed m be a suheumu: fm or at crew W parts eomplea vnLcel care If yon develop new publerm m tomphceuea contact our g r• hil E y il e n mergency Ceonr FOLLOW THE BIMU T10NS CHECKED BCIAW Psgerd Inbtipatlon Pallem hNormaHen alteete Cgpryln loorivad d to realew and keep, j ()Abdominal aaln 0conunomme I (I Ncuhd reaeson (1CpPD r r/Ped Fever B () Allefgis readlmn 1) ComeN abreNOMmergn body , 0 Nook Sus OrIU O Naek Sven 0 U Bore Threat O Raoare 0 Nosebleed ( ) 8prmne and Seem ()As? ()GmrpbnyiMaw Pam ()Cmidh wesM1g ( )Headache 0Ohba Madis ()ThrsaWW Mlaeettlege I Mood Injury () Fedmua Head Injury OTaoOuaho 0 Nd HMWAmmeVlnsecl ( 1 Dares and vomnerigiPed vomtlmg 0 Hypemerewn 0Pedisue Uru ( I URI and CdkN 0 Sum { I DmdAlcohd abusWaddiNwn 0 Chael Pun {) F n 0 ImmumxabWeTarenus 0PID/VD 0 UTr and PyNanapimhe e n mg Coavulmsn O kidney at". ( ) Raeh 0 Other WOUND CARE ( ) May goodly wean over wound in 24 hours with soap and water oir MEDICATIONS () Continue Present meditations except peroxide Do not soak in water, ( ) mange dressing _ times dally Redress with Bamtraan/Neosponn Adwl 1 (sit) 0 fVds got 0 needed for pain, fever and steels area" ( ) Keep wound clean, dry, covered () TelarwoMptarm Booster given an paoregs mavugone for age. Weight (I Use xis fdlogeng manicures according to package S INS, STRAINS, BRUISES FRACTURES meWdiMa fordo the sighed Pont for! dto reduce awaiting Apply roe parks Imsmomandy tor-:-? (ieya to reduoe awelhng 2 - 3 ) Ace wrap or support faradays () Wear sped () At all times unlit oibwwup () The fulloweig medidnea may cause drowesmae ( 1 For acuvrty ea needed DD NOT DRIVE OR OPERATE MACHINERY WHILE TAKING (1 Use sting to support ( ) Use cruchm 1 )As needed, Walght bearing as m)emod 1 ( 1 At %t base NO WEIGHT BEARING FOLLOW.UP This m our raeammendermn or fdlowAt 19your msurmtee (HMO) requires a phyekaan retuned for specialty, I ' NECK/BACK eonwhabon, IT IS YOUR RE&ONSIBILftY TO OBTAIN THE ( ) Wear cervical auger tar support for_dAYS NECESSARY APPROVAL ( 1 Red. word bending, lahng, I Wemlpue edamy for_,daYs (1 Follow-up won () Urgl Career ( ) Apply morel heat for mantas limas dory (I FinalY Doctor beginning In hours i ) WOMat ADDITIONAL INSTRUCTIONS in days for ( ) Follow-up Suhtn removal ( ) • ( ( ) Ott woik/echod farm to (S WgM Duty ty until } ) Cell as soon M possible for appoobtWnt Restrwm 4Q Pmk up your X-Rays from the Radology Depadmem prior to ( ) No gym/sports, until your totow-up appointment Call 763-E890 to haw Bars ( ) Fellow instructions on Woftrlam's COmponsason Form ' 11 Wear We patch or hbum ( ) JAY / ea yourphyaclen jspedel eti -t n "W-rtl•af"'? 4 e- /dri1 OJ ?pG If arse blood recurs. plroh noes hnnly for S mmuoa a g ?Y ombm c usly, ream d bleeding nd otmlro8ad ? 1) Realm to Emargercy Gaoler I, you feel your cmtldton re ,9. ( ) The preacnbed anboac may reduce the ehachveness d especially it / medaelon you era taerendy Iaong Check package ( ) Your blood pressure wan elevated Please have it instructions or consult with Phannoodel - 1B ed by yob PM ^ ( ) The interpretation at your X-Rays we preliminary reading ()Test results have been given to you Take them with you to Yon Nine will be mmnswed by a rediooglat You or your Ina blow-up appomlmont physician wig he contacted rf there is a change in the Test resuns given OCBC OCMP O EKG OX-HAY OOPY dlagnoaie BMP ORECORDSGOPY CHART OGLUC ? () PATIENT VERBALIZES UNDERSTANDING Addmonel Instruction I hereby acknowledge eecerpt of gaging swbuabona and - - - understand them I undershen l that I here had smdrgercf - treahnem III& and that 1 may bs nPoaaad before all of my medical probleriw are pawn or tree I WS arrange for fdlowvgr care ae 1 lisve been mdm It as your respuo l sibil o reply your P ry Ca P scion of this visit W , SIM-11 Perm Da n : SIGNATUR a ; M D D O Nurse RN , 1) AA rr HOLY SPnt1T HOSPITAL EMERGENCY CENTER M3 NORTH 221ST STREET CAMP HILL. PA 17D11428U7171T63e2316_,-, . [ ) Vamga Aledsm, M D 038840, ( ) Robyn Hyntck. D O OS 000.400.1 ( ) RaoJOm Sharma M D 031265-E ( ) Tbomes AMoes. M D 017075E ( ) %claud Luley. M D 029960-E ( ) DAwd Spurner, M D 023502-E r ' t f) Sslvetare Allan. M D 025502E I ) Ptulhp Megurre, M D 015063-E ( )Alan Teplm, M D OM018-E t ( M D 057303-L? ti J l% L () Et Thdl l I ) M 9 . Lawrence Pau <) Ramesh Amro, M 0 016727E cen, ruria D 03 574- f ) Glen Daughtry, D O 090016776E ( ) prank Fmcopro, M D 003643-E ) v)d.Zlmm?cvu?? M E 'I/C/L P UK T'^? e- I i r ( ) Son DuMn, D OS IL ( ) Howard Roderick, M D 040g62- ,?R+ /0?2 4 y1/Ik-CCD$S1-(- DATE E y rwerwvuiplnena Wester 01Wn I ) Use the following medicines a=rdhv to package SP INS, STRAINS, BRUISES, j,FRACfURES instructions me injured part tares days to reluae swelling ld s t red e e en A ic k tl t m tte f w e pac s in n y or ay o uc ng er i ppy a ( ) Aca wrep for support for-days O Wear sptirl l) At all times unel foil-up ( ) The following madames may cause dro"ineae ( ) For aclrwty, as needed DO NOT DRNE OR OPERATE MACFIINERY WHILE TAKING ( 1 Use riling Ire si ( ) Use crutches 'I ) As needed. wagltt bearing as tolerated FOLLOW-UP This our d on for torowyg'fyyo ( ) At all times NO WEIGHT BEARING physi msurenoe (HMO) a phyeuoler, n re1are1 for specialty I requires NECKIRACK masuftelwn. IT IS YOUR KSPONSIBIIITY TO 013TAIN THE ( ) Wear o csl collar for support for-days NECESSARYAPPROVAL () Rest, avoid beading, Idling, stromeew scbvdy for-days () Fdlow.up with 1) Urge Center () Apply moat beet for minutes tares deny () Family Doctor beginning in-hours ( ) WarkNot ADDITIONAL INSTRUCTIONS in days for () FWre O 9utare removal OR waik/whod from to 1 () U ght Duty uMl )Call as won as poaahle for appomtrrerd Fealfucha118 PUc( up your X-Raya firm the Redlology Department prat W a ( ) No gynuePOde Will your followyrp appornlrnsrlt Call 783-28W to have films ( ) Fcame Instructions on Workman's C mpermalwn Form ?JJueedy P1S o r awan h d - J? (1 Weer 9" patch for roue p y Si y 9r}sPeg ? ? ^ C ?? u Ys Ca" - y H ( ) B nose blood retire, pinch nose firmly, for 5 minutes l o Mbnuouayy, return it Weetling not opnlreged 'e P 1Y "`_' () Ratum b Eutargenry Carder 11Ty?1 teal your wrtdhron a rig, ( )The proscribed anhblolln may reduce the eBecaven9ae of eepepely d - metllcati you are currently tawny Check Package () Your blood rseure was elevated Pleaee have A P iwtwn na or mMUR with Phermaael aub () The mtermashon d your X-Rays M PMmuMM feadmg rechecked by your physlden () Teel revues have been gwen to you Take them with you to Your films will be rewawed by a redwleglit You or your the fdlow•up apps arena physician vall be contacted dthem in a change in the Teat result gwen OCBC OCMP OEKG OX•RAY COPY diagnosis OBMP O RECORDS COPY CHART OOLUC ( I PATIENT veR9ALR88 UNDERSTANDING Additional Instructions 1 hereby mmowledge recalpt of ORION mebucbons and understand them 1 understand Ataf I have had emergency - treatment link and that 1 my be released before all of my medu®I pmbhlme are known or I fall ammits for mllb wp core as I he" been talent d R a your repun- adXldy to nobly your P C PI etclan of this vad SI(kNATUR Wof o uelbl9 P?rean! ! Data HOLY SPWT HOSPTTAL EMERGENCY CENTER ( ) Vannha Abrhem, M D 038840L ( ) Thomas Aldaue, M D 0170759 ( ) Selwmre Allson, M D 025502F! ( ) Ramuh Atoms, M D 0167279 ( ) Glen Deuphtry, D O 0.9006776E Ian Dubin, D OS IL IO7i q DATE B I ) Robot Hymck, D O OS (XX4(10 ( ) Richard Luky. M D 029960-6 ( )PWlhp Map.. MD 015063.9 ( ) Lewcu(ce Pad, M D 039524-L ( ) Prank Proi MD 003643•B ( I Howwd RudawL M D 040862-1 ( ) David Spurner, M D 023502E t ) Alin Tephs, M D 03DOlM ( )Havre TbaWu, MD 057303-L MA- 0 (MORSI-L s q0t (j IN OROM Poll A BRAND NAME MODUCC TO BE DISPENSED THE PRESCRIBER MUST HAND WRD'9 "BRAND NECESSARY' OR "BRAND MEDICALLY ti EMARY" MTHE SPACE BELOW DI-ABEL 09U1bl=J1I0N PPRNI&SUILE 170 (5)99) DEA# PA tin2O6*2-V,,b REFILL TIMES 14098081 MR 201982 E WORNAV SARA L = S.1 SPRINGh0US6 RD ER3 CAN? HILL PA 17011 04/16/1436 761-1639 ibl-3[-3713 SNAkMA RA3ANA "nNAN SAR V07 :0428247102 10/11/99 +.iU i052 I --1 HSH RRDIOLGGY RDMIN Fax:717-763-2963 Jan 29 2002 12:30 P.01 HOLY SPIRIT HOSPITAL DEPARTMENT OF RADIOLOGY AND DIAGNOSTIC IMAGING CAMP HILL. PENNMVAHIA 17011 (717) 7632600 PATIENT: NORMAN, SARA DICTATION DATE: 11/16/98 8:42am MRr 201962 TRANSCRIPTION DATE 11/16/1998 08s56AM. SOC SECT 161-32-3713 ORD DR.r PARR. NAE PT TYPE: R ADM DATE. 11/16/1998 08e05AM ARRIVAL DATEe LOCATION MED HOSP SERVICE: CTM M MINATION: CT PARANASAL SIHUSE6-COkML AND TRANSA%IAL-MO HANCED COMMENTSt Indication, Chronic maxillary sinusitis. The fragtal sinuses and frontpnasal recesses are clear. There is only the most minimal hint of mucosal thickening in the left maxillary sinus. The right.m millary sinus It., rorsal. Each ostiomeatal complex appears patent and unobstructed.' Th' etfib&d amuses ere''pdrmal. The sphenoid ' sinuses end'sphenoethmoidal rec'esies'8ire clear. There is no significant nasal septal deviation. No developmental abnormality is seen. CONCLUSION: Except' for a very subtle mucosal thickening in the left maxillary sinus, the study is otherwise normal. DICTATED BY: R.P. A , H.D./dmr DATE. OF EXAM: 11/1 LJrJL503 ler,, ¦ ?r1ning Fj [m, nbarg,«p ATTORNEYS AT LAW Leslie B. Handler, Retired W. Scott Henning David H Rosenberg (PA, FL) Carolyn M. Anner (PA, NY, RN) Matthew S. Crosby (PA, NJ) Gregory M. Feather (PA, NJ) Stephen G. Held Jason C. Imler September 23, 2003 Office of the Prothonotary Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 Re: Sara L. Worman v. Giant Food Stores, Inc. 01-5511 Civil Term Dear Sir/Madam: HARRISBURG OFFICE 1300 Linglestown Road Harrisburg, PA 17110 717-238-2000 1-800-422-2224 717-233-3029 (fax) LANCASTER OFFICE 140A E King Street Lancaster, PA 17602 717-431-4000 DIRECT MAIL TO: 1300 Linglestown Road Harrisburg, PA 17110 www.HHRLavv.com Henning@hhrlaw.com Enclosed please find Plaintiffs Arbitration Exhibits. Please time-stamp the additional copy of the document and return to the undersigned in the enclosed envelope. Very truly yours, HANDLER, HEWr &_OSENBERG, LLP W. Scott W S H/bsv cc: Sara L. Worman George B. Faller, Jr., Esquire (w/enc) Dale F. Shughart, Jr., Esquire (w/enc) Michael J. Pykosh, Esquire (w/enc) James M. Robinson, Esquire (w/enc) A i SARA L. WORMAN, Plaintiffs V. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO.01-5511 CIVIL TERM GIANT FOOD STORES, INC. a/k/a GIANT FOOD STORES, LLC, CIVIL ACTION - LAW Defendants PLAINTIFF'S ARBITRATION EXHIBITS In accordance with Pennsylvania Rule of Civil Procedure 1305(b), the following documents are attached which the Plaintiff intends to introduce into evidence at the time of the arbitration of this case: 1. Medical Records from Orthopedic Institute of Pennsylvania - Dr. Dailey 10/15/99 through 7/7/00 2. Medical Records from Holy Spirit Hospital; 10/12/1999 3. Medical Records from Herd Chiropractic Clinic: 1/14/00 through 7/31/00 '.. Grandview Surgery Center; 4118/00 Narrative Report from Dr. Dailey dated 2/5/01: 5. Supplemental Narrative Report from Dr. Dailey dated July 19, 2001; Medical expense billing summary (with corresponding billing statements); 8. Incident Report. Respectfully Submitted, Date: September 25, 2003 iANDLER, NN & R6SERG, LLP 1 By W. Scott Henning, sgl LD. i#,32298/ f 1300 Lingl st n oad Harrisbur ', A 7110 (717) 238-20, Attorney for Plaintiff Y 1 0RT4c?LLDIC INSTITUTE OF PMTSYLV vii (717) 761-5530 Patient: Sara L. woxmnar_ Char*_ = W 11525206 DOE: 04/16/38 SSD7: 1?1 32 3713 Page - 12 --------------------------------------------------------------- ------- 6/16/2000 STEPHEN N_ DADLEY, M.D. LEVEL THREE k'cv°n' Cc SZC'_ mc: _ - IE:J CE ==C- me'_____ ==ML_ a__o=., and °_..Cifi_ RiSLCr ..?.._ __. _.__ 1.`.- =] Dl: Cr, axam-_azicn z.___._ is -..... -CIIVfIiCB _o. 3-__-__? __- the ha G. __.__s zs some tE__..e__-_Ss -_E --re-- C_ =_.E t ID'_CGl° No flCt_.= C__ F_l1 - =Rts _c and of mCt C..._ ^CL_ `P28n__c_v a- o? _-_ hand and fingers ___ stable, -.SE'_scrv, _fl-:i and ?cSC ?Tc _-:?ams of 7-haz ex=remit a_E with-- -orMa= 1-T.__S. __iC cL_. are 'C l eSi==. ST.ami-at__ __-__CW c= _ r-, _iIlGCC - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- ----------- T _ J ORTH- i)!C ?NSTTTUTE OF ?Er_ISYLv:_._?_ (717) 761-5530 Patient: Sara L. Woman Char- 11_21206 DOB: 04/16/38 SSN: 161 32 7713 Paa 11 -------------- ____5/19/2000 STEPHEN W. DAILE_, A_ LEVEL TWO - - r:_STCH' CP a nc±" ____ enGC.'.CCD'C u__.. ?_L='i -25 and c?__^CIIc •_..Q v..c_.._o ao __ __ ci ..'c _5 riot _=--vine .?_mcneSS ana ---.Qlitna 973_. __ghz middle finger ^c3 .___3_ R''•,'_'IN 0- -4 - _ _ an? ____ __ _ __ C _ ?n?'C _ 11 ry.. _ L ORTh --7-ITC INSTI'T`UTE OF PENNSYL%, -.,A (717) 751-5530 Patient: Sara L. Wo=an Chart 1152=206 DOB: - 04/16/38 SSN: 161 32 3713 Pace 10 ---------------------------------------------------------------------------- 4/12/2000 STEPEEN W. DA'L-Y, M.7. LEVEL TWO =_ta- _adv_s -rac-,_-e. - _--- e- _..__ a':cC `N i1En cPc _e._., er=_ -_Oia -:er :vcL we w;", =vatua__ 5WD/.'kmn 4/18/2000 STSPEEN'?W. DAILE?, M_.C. GR-Z-MVSEW SL-ZC--CPL CENTER - - - - - - 2000 3/25/2-000 ..L y-%NDER K- LzilA{ _ G7.05PS, SERVIC2] V1S:T - ORM- 2DIC INSTITUTE OF PENNSYLVr,IA (717) 761-5530 - Patient: Sara L. Wormar_ - Charms _: 1152420/ DOB: 04/16/38 SSN: 161 32 3713 Page _ 9 -- -- --------------------------- 2/04/2000 STEPEEN W. DAILEY, M.D. _ -_G^7TdPTCi==,- LEVEL TWO - -- OTC-NCST_C TESTS: EMC- and n=_r<;e cohducticn studies as above. Dis05.S: Bi'_ateral car-pal turLTiel, right wcrse --_han =et. 2. Tr+_=cer_ng right middle f_nger. PLAaNT: : discussed the diagnosis and treacme_^_t ctt lords viitthe nat ^_t. S -s would co proceed with endoscopic carpal t_ nel release and thi= -4s tc '--a scheduled for her right wrist. Also -her right middle _ina--r was iniecced todav ,I2 cc...f Ce'_a_tc-._ arc -- l/2 cc. .._ Lidcca_ne withouz e'-J1IIeD h'_-ihe. see hcw this works _`!e__a^_& b/l-i_ let me k'!Cw W^, th°_= we .__r na r ,._ _ _ acai= a= the time of Surcerv. She 'mss iven a m esc_-'t_O^ L=X= m=s.-- CIID/},_r 2000 - THCM2As 1. CANCELLED - - - - - arm.C ma -z __ _._ -t_-_ _ - '_"/ was .000 ___.F W. DA-___. LLTL .AO - - - - - - ---- - - -- -- --- - =- - --= - --- -' e =--___- and -=-- --`^ '- -- _ -- - -° =°e =__e. Se -- -nCreas-- °`..-lass and the e_...e. --- --- - - ---- - --- are _ c0 s`Nltc- =- ___ ___z ___enc%v. W= arrange t- cda'i. 0_ ._..c-: has c_.... ._Hd =_s_ent ____ _c__ '.v__-t 'eS idL'a_ -ram 'e_ ORTh, _'EDIC INSTITUTE OF PEMTSYLL --?Ik (717) 761-5530 Patient: Sara L. Worman Chart 3: 1-1524201 DOB: 04/16/38 SSN: 161 32 3713 Pace = 8 ----------------------------------------------- 1/14/2000 STEPHEN W. DA-LEY, M.D. ------------------ -----_--- LEVEL TREE necative. Tinel's and cemnressicn tests are i5 _D_CSitive or the r1CC!=. She _s unable zc _.c t. a...c tc -. the-stiffness from her distal radius fracture. _ _:e has S=e n u1c_ swelling in the area of fhe flexor tcndors of :'-e ___ _ mifldle at Cne ?-1 Cullev. There is no significant' tenderness c_ todav. Tin=_l's sign at the. elbows and elbow °_-x_c- zest=_ are :_ a-'ve. -- - Sensory, motor, reflex and vascular exams or _naZ ext -c=a7 remity are =- '_ limi*_=_. There are no sk'_n lesions. ;xaciinat_c- t he elbows and shcclder_ - are grossly within normal limits. WRIST n-R5Y'S (RZGrT AND r.ggT; ?aciocraph5 _e-real _ne ccny ___ intact without evidence of fracture cr tissue abnormality is seen. D=-zvG:i05=S:-Pess4hl bila=eral carn_a_ fur=e_ s_r drone. -os=b.. _1^Cer Critter. wiz, °_ec: an _MG .__"c con.d-,cC icn _tudv^tooay wh- back after t%_.t t-o ...___,a_s- S =_ 3;DI0LOGY RESULTS __c_____ __ -/ 04/2000 i9. - 3'v3 TWO I i ORTii__EDIC INSTIT-TJTE OF PENNSYLV,:NIA (717) 761-5530 - - Patient: Sara L. Worman Chart: 11524206 DOB: 04/16/38 SSN: 161 32 3713 Page = 7 -------------------------------- -----------------------------------------_- 11/19/1999 STEPHEN W. DAILEY, M.D. - -CCD7T=lip` RADIOLOGY RESULTS - IMPRESSION: SEE P*OVE C 1-.7Y. - -- -- -- - - SND/ra= 11/23/1999 JAMES R. HAMSF_ER IM CANCELLED The cD_D01ntment was cancelled bV the Dat_ent. -eschedulsd 'C_ 12--i0-cc sam 12/10/1999 STEPFEIT W. DAILEY, M.D. GLOBAL SERVICE VISIT -- _rindle Road OE=i.ce - ---- -___ CCMP .;I_iT:. Sera Wc=ran =-c__ ._a',.. aISC ..as score numcness a=- r ._LA-s we She .._ has __.._ wearinc - her JcC{ = N____ __VC_ __ __I _A: S '-e PGC .--..?...._-. Cz "I CC . 's._.._ C? ?almsr S In e h a s =Z: ?n= a-A -Z-:rest:.'.. Zas_ -fit-L ^ E _ _- - - - -. - n _---a-- ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patie*it: Sara L. Wormam Chart_ 11-524206 DOS: 04/16/38 SSN: 161 32 3713 Paae a G ----- ----------------------- -----------------------_-------`---------------- 11/05/1999 STEPSEN W. DAILEY, M.D. - - _r-aT^_?r?,_ GLOBAL SERVICE VISIT - - - - h ere=orc T _ I would like her z_ Se_ z..e .,_ _ ___.=_= __ plaster with _a-ioaranhs cn __.23/9_. sWD. Kir Faxed to: Briar Quirk, M.D. R7?_D7_0-OGY RESULTS iLEF_- WRIST: Racicaran_hS zoda_ _eveai -.ainze_.a.._e _f °__act'_re. - - _UpR?SS7C)j: S-E P30V_ SY%TD7k_- - 11/_17/1999 STEPHEN W. Dn_TLEY, M.D. REQ=ST FOR RECORDS --- - - 2ffic-- -_ce_ r_cci=_, _ -,-599 = ^r; W. DA=LEY, -LOSAL _ERVIC V' --- - - __- - - - - - - - - - - - - - - - -- - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - CE S S ORTNOrr,DIC INSTITUTE OF PENMISYLG'r?42?? (717) 761 -5530 Patient: Sara L. Woman Chart --1 11525206 DOE: -- 04/16/38 SSN: 161 ------------ -- 32-3713 -- ---- Pace _ 5 - -- -- -- -----_----1-- - 10/22/1999 STEPHEN W. DAITEY, M.D. ------------------ °---------------_- G_LCRAL SERVICE VISIT --- comfortable at this zoinL. pF`JS'C=1 Ehz CP 'nVsicm- e_=M =.7 e aast is i n ...+ neuovaSCUIarly ___=aCL and sine has =cod -_anae _' -...L i..n. DIAGNOSTIC TESTS: R=_diocrap'rs, --WO vi ecus e_ _ n= .__s_ _.._.° ______ maintenance of t__e __ienmanL c-- e =_acture -: uai__. -= ac,.ectan<e. DT__GNOS_S: "!Post le-t distal rad-;,-,S __.__71_Y _.n_ CCnt'_sl., 9LPN: Continue wiL.`. t;^.e mci ._ ..?__ c -_ ___ ,. _: ...,..tcn_a [e-s he_-rr. ca- She Can start wea -ac =-Cm tha s__ ` at .vhich time cat ..-rays. -___ r_er - - _-- _e -_-_ _- '- . aLTOXimate_' ': e e k -;_tH-..__. c -C =a__._S =] ?.-=se JviD/iC__ c_{e._ __ . __ 3ADIOLOGY RESULTS - - - - - - - - - - - - -- _?. ?1 RTJ r J _ _ - _ Ln? ?..a CC_ _ _ .?. .. ORTHOPEDIC INSTITUTE Or PENtiSYLtiANI- (717) 761-5530 Patient: Sara L. WC=an Chart 7_152=206 DOS: - 04/16/38 SSN: 161 =_ 37113 Pace = - -------------------------------------- ------------ `--°------- ----------------'-- 10/15/1999 STSPHEN W. DAILEY, M.D. _ .. _ - -=;ii='__•i;:=_ RPDIOLOC-Y RESULTS - - - wr_sC, show mainLer_ar_ce C_ _..e c_SCa_ -c_ns a_ ..-n- -J_L- anfl there i5 atoroaima . _v ., ., o _ __o__ acceczah e. - IMPRESSION: SEE 1BOVE STUDY. SWD/ca= INITIAL YRACTURE ___ndle Road O_x_C- Cc_E.= -r.'i4D_uIN ..:"'.e 15 ... of v-ar -- _.C. aL..._Cc '_e-.u_c G' a::L Surermar{eL _.. on :-.z: _ ca_n _.e_ ___ ---- ------ ----- :5. -- ------ ---- n= -an - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - a-Z PATIENT INFORMATION SHEET ESTABLISHED PATIENTINEW PROBLEM Chart Number: c/d _ - Date: /Q -!5 -Q Patient Name: -a02mrq?_ s? ?- Last irSt M.1. Birth Date: y -OGAce: 61 Is the condition that you are being seen for the resuit of an injury? Date of In,iurv: /D -ice -c ti ype of injuy: Work uto Other _ if the condition is not the result of an iniurv, da« svinoIoms first sooearec; Descriotion of accident: ?. S.f .'i?U?C.-.P c.d` .:.?/?.c•=-.6'> .,/J...?:..J'' ?^? .' J ?' >--? ...J ?• Ste. If klVorkers' Como: 1-1 11 insurance: ...'cite : oo L-' 7/,f Family Physician: i 4.J ?!! Jn/ Referrnc P*-,ysician: SSm Send letter to: Familv Physician: Refen ine Physician: t ?= Neither Revise 911/99 Me IISr{ ER FORM REG DATF: 10/12/99 il.38 FT#: 14012S0S1 MR#= 201c/c:2 ;NAME: L40RIMAN SARA L SS *X !61-32-3/13 . ADLIRESS: 522 SPRINGHOUSE RD /CAME' HILL /FA/17011 PHii': 717-761-181•;9 -GIRTHCArE= AGE: fat SEX: F MS: M RACE: i=- GEM: C?103C EMP?OYEP: RET-VISITING NLjRSE A OCC,.PATION: VISITING NURSE ,')BURESS: / ; / ?H?'= :11-21".? -103'_ CHURCH, F'RaSFYTERIANY SILVER SPRINGS- AMFs: H.Ahw'DEN EMS COMMENT: EMERGENCY CONTACT iNFOkMATION N(;NE: - WURMAN JARED REL TO PT: H - _WO3'K PH #9 7i /-3S6-713 !• ADDRESS: 22 SFeiINUPDUSE RD /CPMP HILL /PA/17011 PH ;:: ; 17-761-1$•?`' NANF-: ADDRESS" ADMIT DR: 111336 SHARMA P. r TNi} -uR: i 113;:6 SHr1RMA REFCR -O i s A I7h1I r DX , C01,' 'LAI?.IT : FA'r-L_,LT R KIST P:EL TO F'T: w6m,, FH LASE INFOTiP]ATCOii RAJANA R,---G .SOURCE., E.D. PA-t IENT RAJANA HOSP (.-:RV% ER-= EINal%lCiA! 7NJURY AND LT RI S Flp-i'N HMS DR-r- '.N BY: - Cn MENT : BRT TM By: .J •z T=I TIM IO,?i." :n DF SCRirl -n'!: SLXFTI?El ON t< ?EF'Pi=R AT =i:i JN?T AND IN'JUPL: WRI=T S. -•J_I RZ: S - iJ iJ:.GBC i taJi-r7G11{ --;• a?•. <.( - -:_ JuY?F = FEL =: :I ryyE ".rN INSURANCE WORMAN _SARA i<t?.1,[RF?NCc _ IG il?21'?f-} 1 2 ?R, ?C QF'! CARD FREC _RT /ASI ; _: - -_- oHS3PSE " ._ _„MMENTS: FMD/COWLE T MED P.=S .rIEN]-NPANE= WcRI^AN SARA L ? PT4: .FUISTERE.D ?3Y: FHMAK ED:TEB HYc E : T ? 4 J r /4098081 MR 201FS2 C cNrj ^F DoCUM[. Fff I', Date: Name: FMD INITIAL TRIAG E: COMPLAINT: .-, Log-In Time Tnage Time Time to Exam Room ALL Inicrmatfon obtained from. -Patient _Pamily/S o _neccrda -.-2Mi 71sramealu EclrcmRy Evaiua/tle?n Trhsgod to radiology Yo. Deiormity 1 s/ Mo Sl I.TomP Warml CIS1a1 PaiLea (rf "Absent CWtlnabOn J --C::1 51tln Color T JCyanotc; Mattled PLin (1•.1,0) ?9re9chaw Prssen:.YA 7:ma Tama: '7 ? - b Pu iae: Aliergia?.!4';eactlcnsi Lv CCi@^_t;?rfi: :1P: /: /7 / ouis3 Oa.[ i?st Tst3nun: ?Ialri- •?''=/ aaoi?:a maC's'SH rar:lr.:r.[:'J 8lauai Acuity _ s . L' _L'a;roc:rva 1?naas -:211O4301131 i:33tmfr'; ?nedlcrticrraseaFreeuettcv ,';use :?,tectca:icr3DcgsiFrcraLter.?: - mast ?eaicavaurlcal rioUtcr.•. -- - _ - - - - _ .. cadent nac excasure to nw_aslee _^. JcCerCC: Or 7e In :.zt.: =v ??.?..=.re rc=_re ac aCCa atr8ctv<s'? ?• M1 wfatm_ e; ?IJAr,IN • 01IICV0.1P _XPECI'=? OJ-i,.",.`mA Cc1eI8L l: L^. dl[_[9: =r: :'? ?ClLYEri1M1 i'1 .a.? ?C L:1CL: L_T=ar.at_, N ISClCV9C': 9 ,^.n0 ClSarg9tl ???IqR, alIB3:ICp L^. ?:ALrae92 Or rdlBl q OSCCIDfLR - II:C YCIUTE. J:BrECGr? li. =.T.C:LW-1ar.[:? :IL'.a'rI omorst:a1e0 s+^_a=z8o. In SV1^._Ibr^S O: i1L'. voI 'nC81N.L. - MZ.:rea pas .=.enc_ ..TorCVpC C`3] °YTZrC? ]BTCL9?tM. ^/'^.:rL't2C RVCBr1aCGn 20a urJ 91rr? "C':C'IGN/i1C.ld IrIBC.:C' .irate r i ??LrL?9 L. ?•-a . _i:lavneaCa Clan= ?..T.alCV?C Kf.CI\'. Eil Lb ce,-?:5'f3[EL rv ?Erac:ILal:Cn a?Jlr. C2rnCr1°T:..'..^. ASSassmen: cerlmexea at _ . - _- ::aL cotamec _-v: -cmlasmn CaP. - -cm:>;r _.. `zrvarcr ,_ =:eco ?s ces _.. - Feocr, wdx -a.TUCee x _. r- -ars:errec '_ _. _. __ .•..6cosI11C0 ?PAA ( c a[ V <'ss2L:cr> mSTCVeC I ::M, ^L_zceaa ?G^JC'.xreu? Clscnargaa •^? Clscnaroa ins7rucLCVls pis ,ar9e?.N. Hciy Spirit Hcsgitai - - ?;= S 48 Z ?amD Hill. R =_'U Nursina Assessme^ Otj _ .?'2G vot 5la Pw.C MG EP l s Y ,n=- SAR 2 [042'aZ41l]DZ CHART CCPY _ Age: G CONGU{TTO MEDICALTREAt MENT 1 HEREBY CONSENT AND AUTHORIZE Holy Spirit Hospital, its agents, and employees, to the rendering of medical care, which may include routine diagnostic procedures and such medical treatment as my attending or consulting physician considers to be necessary 1 also under- stand it is customary, absent emergency or extraordinary circumstances, that no substantial procedures will be performed upon me unless or until I have had an opportunity to discuss them with a physician or other health care professional to my satisfaction it I am a competent adult. I have the right to consent or refuse to consent I understand that the practice of medicine and surgery is not an exact science and that cltagno- se and treatment may involve risks of injury or even death and acknowledge that no guarantee has been made to me as to the results of any examination or treatment in this Hospital I understand many of the physicians on the stall of Holy Spirit Hospital am not employees or agents of the Hospital, but rather are independent contractors who have been granted the privilege of using these faculties for the care and treatment of their patients Further, I realize this Hospital is a teaching Y.ospast and at the Hospital are health care personnel in training wha unless expressly requested otherwise, may partictoate or may be present during my care as part of their education Still or motion pictures and dosed crcuit monitoring of patient care may also be used for educational purposes, unless I expressly request otherwise. I understand that in order to ensure a safe environment for patients visitor and star al property on the premises of HC4V olrrc Hospital is subject to reasonable search and/or seizure at any time without further notice l RELEASE OF MEDICAL INFORMATION v? I authorize Holy Spirit Hospital to release to requesting health insurance cr rier(s), their representatives and auditors, and any referring health cars providers, such diagnostic and ltrerapeupc mformauon [including arn' mformation rotating to treatment for alcohol and substance Rhuss and/or treatment of oaychlatnc disorders and/or confidential HIv related Informatfon as may be necessary for them to determine bereft enn- lament, to process payment claims for health care services provided during this hosot adzatlonftreatment episode, and for continuing care/treatment A photocopy or carbon copy of this authorization shall be considered as effadive and valid as the ericinal The unaersignec also authorizes Medicare, when applicable, to release to another insurance carver, uecn their request. medical iniormation needed zg n?Ka payment upon that claim I Understand and consent that the manufacturer of any trttprantabia device inserted by my onyslciari during the course oiLrau-sumeryrcrx.:eura may be provided wgh my Identlncarlon/I rma ion, mciudmg social security nurnbec as mandated b,; Federal Law f?1 Ifisf Date Sionature / __ - _ - - Relationsrnp to Patient INSURANCE ASSIGNMENT OF S^ NET s S n? I authorize payment directly to Holy Soint Hospital and my treating pnysic:ars of all benefits pavaefe under my Insurar? jic:es i uraersanc i am responsible to the Hospital for all ciarges not covered bra this assrenment - - _- -?? Irmais/ ;,tai lacy Ti Tv P=4aIT PAJi4iE ti? OF MEDICARE =1 c?i75 TC P 3u3DERS. ? 1'laiClA?PS 1?61c? s reduasi payment cf Authorized Medicare benefits t me or on my danalf =,r any services furnished me by or in'rety Splnt Hosoita; ir,c;uttmg pratimran services I authorize any holder of medical and other-iniorriaucr, aceut me. is release to Medicare and its agencies Env infcrmatic- needed to deiemmne these benefts for related servicss MEDICAL ASSISTANCE RECIPIENT Tv signatures canines that I rscefved a service or Rams Tian Holy E=t Hcsc tal anc . T - 0e :rte date Ilata- Jncersiang thai devmem ror this service or tram will be Tam r•egerrt Ent EL-Ste TUMzc. a_ld -,her anY ralae c:aims. a=°Lmen;s, or cccC^3r:-,s. _ adnceaimant of marnai rnav ce prosecuted under appiica ie, F'9dbrci end State Law-. -ave raga and apme with ins above stitamarim i nave mao an o unpratand oncri tai vie socfons zorrarnna aacve. I unowwanc zta: ay signing %ma cocurr am. i am acrcemc orb providlna the atrdtorizatieti/ cancers eantatned in earn or the eeave secrcons wtasrns my intHaes are i0parad I have nad the coccrtum- w to asp cuesdor'BA"ardinc each of these sections a-in ail suon oueavons aisuea tame osea answemn to my nadirisernon /5tgnarum Whr; try _ - Retadonaitio to Padenr ",.-.:3 ;mte ic11?/ " =^_rm Witnessed FJv_ is Signature -HOLY FOR TRZATMENT/; ?i..-=4SE OF -INFOK',LAT:'OiY :P/SURD NCc'.iSSiGh3!c??? - _ _ ' .i y t i ( i i Srt3aea [: 'dJyy toy I Ma6 x2c iC6Eg f.'N?) C: {ART COPY BOIy Spirtt Hwaitsl El=lthCam 2A Triage y Dat - T N=C. .h.^, (,' :j}:^ ate ''lue! Ca?tuaitat• _ AJC;U J ;.-isc ie:st:as S1:c• j) :?? j ] u:.'.?cyva 0 of y=rs^ ?1?MLJ4C' i n i ) walk i ) HL5 [ 1 ALS (7 L YD Ref OR - =ramnmd iiMeds/R` io FHC HC24, M.O. From- OCZEE2 Fax :tauon iB-12-9? 3:240M D. 1 of 1 ADM. DATE: 10/12/99 Sara is a 61-year-old nurse who presents to the Yealtli care 24 complaining of pain and discomfort in her left wrist after she fell earlier today in the grocery store area coming out of the grocery store. She fell and sustained an injury on her outstretohed left wrist and r_eurovascularly intact. Sh= was seen and initially evaluated. ,-rays shows a comminuted ?-shaped fracture of the distal radius with minima! displacement at best at this time. Neurovascular intact. Good pulse, moderate swelIirig. I have discussed with Sara at length the prognosis and -reatment If over the next several 30 days to 2 weeks c? thi fracture displaces or shortens, there all bets are off and we have to proceed with a pins and plaster _Fixation and or all external '-ixator to hold it in good alignment. However --he alignment riaht now is very acceptable. I have gone ahead and a'_aced her in a short arm light fiberglass cast to keep her ccmpletel'., immobilized, ice and elevation and I have given her prescripticn for Darvoc3t-N 100 for pain. She 1s -going to ._? Lying .advil in the interim as veil and elevation and She :?i'_'_ nee Dr. Yucha who she has seen '-n the past for the next 2-3 davs ?or fallow up ___ the cffiC3 and close mcnitering of the__racture sor 7 :he ne:;t '? days, t acing ta1:e aDDroxlmataly ?_-s weeks 'Lc ^. GL?Dlet°1' ....al and sh9 _H GZi 2r" r-c_ nc_ very 'qe, _zllow u;D as?scheculae. DL?gnw DLStai radius _.:2ra-t cular :racture ^iRi1a1 ,..`.placed nut needs tG be watched Closely over the .next several weeXS. 'J 1S -. 10/.2/1945 _ _ _. Page SPIRIT =OSPI=A; _ NikXE: WOMLkN, SARI. camp Hill, :VA XRO: 201982 17C1: 2CCX #: E.^i.3 DR.: urger C:NSULTATI01I RE'pURT NAME wDr?,-?,c..` p ¢n DATE ED/HOUSE PHYSICIAN FINDINGS- DEPARTMENT OF RADIOLOGY HOLY SPIRIT HOSPITAL PRELIMINARY (GRAY INTERPRETATION CHARGE NURSE X00 AGE L / LOCATION Je RADIOLOGIST FINDINGS. Ll. ,wrrSr r, r l I Z- I EDIHOUSE PHYSICIAN F?.Di0L00;8T :?? =oqm 31 aAorl D C'r,AP; Gw oY Holy Spirit Hospital Department of Radiology and Diagnostic Imaging Camp Hill, P.ennsylvannia 17011 (717) 763-2600 PATIENT: WORMAN, SARA L MR* 201982 SOC SEC- 161.32-3713 ORD DR: RAJANA SHARMA M D PT TYPE: E ADM DATE: 10!12!1999 LOCATION: ER3- DICTATION DATE: Oct 12 1999 1 16P TRANSCRIPTION DATE: Oct 12 1999 2 21 P ARRIVAL DATE: 10!12/1999 HOSP SERVICE: ER3 *°°=inal Report"' EXAMINATION: LEFT FOREARM (2v), UNILATERAL LEFT RIBS (3v), CHEST (1v) 731390 - Oc: 12 19G2 COMMENTS` INDICATION-Inluryhraurna There is no previous chest radiographs available for comparison at the time or the dictation Both lungs are clear of air space or mterstitie(oeacities The cardiac silhouette and madlasanei strum urac are unremarkable Pleural effusions or pneumotherax are not seen There is no fractures identified There is no fracture identified in the left ribs Osteoblastlc or csteolytic changes are not seen ha :uhc are unremarkable Pleural effusions are not seen T nere is a comminuted fracture invowino the articular surface or the disial racluc. T^ere Ere no ^Hc.LTes dentltlac in the 111na Pie alignment of the Carpal 'cone is unremar CcCla y NCLUSION: Normal chest and left ribs Comminuted fracture of the dlsial radius OICTATE_ SY: NOEUO NAKAGAWA M C i CO DATE OF EXAM: Oct 12 1999 SIGNED EY: NOBUO NAKAGAWA M D DATE)TIM'c. cc! 12 1999 3 10P ?: grit F+{2 --wunCrfT?a1 put rp action Indicated. Flie Imaging Services Consultation Page 1 PATIENT, MR#, SOC SEC: ORD DR: PT TYPE: ADM DATE: LOCATION, Holy Splrlt Hospital Department of Radiology and Diagnostic Imaging Camp Hilt, Pennsylvannia 17011 (717) 763*600 WORMAN, SARA L DICTATION DATE: Oct 12 1999 1 1 OF 201982 TRANSCRIPTION DATE: Oct 12 1909 2 10P 161-32.3713 RAJANA SHARMA M 0 E 10/12/1999 ER3- ARRIVAL DATE: 10/12/1999 HOSP SERVICE: ER3 ?'*Final Report*** EXAMINATION: LEFT WRIST (6V) 73:10 - Oet 12 199J COMMENTS INDICATION - fell Six views of the left wrist radiograph is obtained There is a comminuted fracture trvoiwng the c:'tsta radius The fracture lines appear to be involving the articular surface of the radtocarpal joint Mild impaction and angulaiicn is noted There is no fracture identified in the distal ulna The radio-inner joint space is widened CONCLUSION: Comminuted fracture of the distal radius DICTATED BY: NOBUO NAXAGAWA M D " 771 SATE OF EXAM: Oct 12 1999 SIGNED BY: ?10BUO NAKAGAWA jai C DA7Bri)ME: _ct 1,2 1999 2 10F Jr r , `-coon indtcate? aono' ma{ u. .. Imaging Services Consultation Pape 1 f Pitt. 13o4a-I PS" Name W O rm0. n Sara Phone: Home_ - 301 Work ft?lbl X-Ray # JUL 06 2000 - INJ, HERD CLIKIC Camp Hill, PP. ¦ JUN 2."200E' 1 A PEMONAL INJURY QUESTIONNAIRE ff Flame Cnr? ' 'h • 1(hr ,?_ Date of Injury Phone KI L(-? R.-3`') Address ?? n•trt.lan=r?. ? f cl' *n,;--,'II state ;p /10 1 ! Employer's Name o ''d't•:f?'ih1 ?4aoo_t?ttiployer'sAddress - 1 ><Yaur Ins. Co. /I _ a Palley X Agent's Name t ? ,1>idver/Other Vehicle -._--_.. -I Ins. Co. Policy ? ? J T ) o Name I /)r; rr' M7rl,mti7'L' Have you retained an attorney? (X Ye ly Were there any witnessess? (x) Yes ( ) No Name(s) tm t' NATURE OF ACCIDENT: 1. Date of Accident In-I Time of Day -Lo, , L` ,, ? Were you: Driver Passenger ( 1 Front Seat f Sack Seat - ,X-Number of people in your vehicie? Cther vehicle? What direction were ycu headed? ( 1 North ! ) East ( Z South ) VIesi - on (name of sire=_t) - - - - - - What direction was other vehicle headed? ( J Nor-'r ) Es_e South ) Wes; on (name ct stre=_c; -- ?;y Were you srrucx tmm: Seninc 1 Front 1 L=_it siea 1 P.laht side W ere you kncekec unconscious? )?es Nc. it ves. `.or now icng? Were cciica norifiec? re= `No - -- .,. !n yCUf CYIn Waraa. CIe35e Ce5 drtae a41Ca!h; i'-"1.R,. `?t11/:?''1 i 1:;7tCJ.' Ll1{hriii i-+, _ -°: II ??f';L}.?Mq _ ia. 0. Oia yoq h b'e anY'l?hysicat comotaints EE:7.00= E ACCMENT? No. ;i yes.die=_se eescaoe !n ce!a:?. 17. Please eesc.ibe now you re!t: - lt+.oj a. DURING the accidam: ? 6,,n- fi9u1 rltb'Jli issm Mbar l =!r ?'r!?-:¢'1;Y:epd 7!64-,i•lu n,-e, b. IMMEDIATE_Y FTEP. the acc:een[: !^awhl _ c-LATER THAT DAYS -- d. THEN EXTDAY: 12. What are your PRESSNTcomplaints nanasymptoms?1??n!? 61'm,ti Gorv ?l (tT ?7aJH[?rQ(?(?(t<j ?l ??1tnr??t ??e?ia???l ar( ?'? i,?gt?i ?t1d'?t?r113CC?Jr! Lk'?'ic?PPdi?.?" 10, 00 you have any congenital (from birth) factors which relate to this oroblemr- ( )Yes (/ No. If yes, please describe- \\ 1d./ Do you have any previous illnesses which relate to this case?p ? (x) Y?nes ( ) No. If yes, please describe: r t lr SlF("fr"?'r-((A 7/°? cl:?Yi?yi 7 4d ? 71zl'4' "j I l 15. Have you ever been involved in an accident before? ( )'(-a (x) No. If yes, please describe. Including dates) and type(s) of accidents, as well as injury(ies) received. :_ 16. Wh ere were you taken of ter the accident? r-rnL=;)'-?{-T"iP"0 ?'1 I?•`arr? C'?'"•?r? ria i?-fr 1 ` r'ili-• ,.P a I u 17. Have you d=_en treated by another doctor since the accident? (/v Ye=_ ( ) tic. !f yes. please list d cc:crs n_-e ? `?l ' ) f A ' ? ' 3??1( Y ? ' ' ?r ? ? ? "? I ?li k I nK? e r i•r.r?'V 1`,' ?? ^ ?.tlvi3 it a 4 : f i - and addre_ss:. n Zr•/lL i ffY Y r i l An:O ` ' " Z •fZ"i ? T-3 ? " n 'r^" ' , i.JT ? . ?R 1?•Yl •°?yrWng l-r? "&A' What type of trz=tmentdid you receive? s ?_ i ? r 9 hi- s f? ? h l e? ''I' a n ?1 n l 6r m '.. { i. : ?v A a s , a at n ?r LI ?P n l +w a l, a. Sir,ca this nlur; acdurrz^_, are your symp,o-s: rcro+1n9 _, ,r•, _ _a..,z .o. 'H.ave Y. 'cst time from :vork as arz_uR C? Ihiz ec_:dent? )'(e. "Yde. __. ,____ J (?i a. Las; Ca?':^.'orx v..-.a you cane ocmdan sat=c i-. ttmz'c_, from v: cr.¢5 e_ C. ..___. o•sa_z ..a._ w^_.=: _ -ee.,sa.._- - =c-;?cu _nv __-,r.c....n_ _==.a_uit c• .ns niur:" 'J nC•:. .ray-•d. ,.'loll .L' a?i ?'?SZ.; ????'?•6Y•?`a Y.^rJ. .I" - ^'1C' iYi "0'Q l '?K!(Y??? ^:G- '-L'4(?-.- "f"2(YVt? Y•1`r, f'l'3t1/7? `Y;zl rvl -n 7Pll,•"s tl-., -- _ _ _ "!a 1, r,i ri; ?,,, :? i;? a?? ; `^1i;1 I-?'i Ci'?? ?JM,,..,:? .••,r?G ;1.-t? =,, ? ??, -,u•,?.,e -' ,? •'t ? -.. _.. -Ten' E\41? /My:' i 1 fv ,^L!,.; .•i1 l-,t, ? ? ` r"^ .f ^.( ni :%l;%?"'n.>v i1,?,?' •'•'?ot l,'3^fJ.t Ti.4"?l1rA. ?-t;/tGir^n•I cl?? -1- - "1ti 1 r' C?•'Li `^?,cr^ ' IFA,; riM? l2?• wl ? f?, ' _ ??? '`Lill axrz DIAGNOSIS SHEET PATIENT'S NAME DATES /f l CERVICAL LUMBAR. SACROILIAC. & COCCYX 723.2 Cervicocranial Syndrome Cervical Disc Syndrome 723. Cerv cobrachlal Syndrome 29 Cervical Myalgla 723.1 Cervicaiaia 729.2 Cervical Neuralgia, Neuritis, Radicular Neuralaia 723.4 Cervical Disorders, Brachial Neuritis or Radiculitis 353.0 Cervical Plexus Compression 724.9 Compression of Soinal Nerve Root 723,5- Cervical Torticollis 728,6 Cervical Myofascitis 738..-4 Cervical Spondyicsis 336.9 Cervical Neurovascular Compression 347.0- Cervical Sprain/Strain 722.0 Cervical Disc Syndrome 723.2 Cervicocranial Syndrome -.22-2- Degeneration of CeNCai inter- vertebral Disc _ .1 Fain in Thoracic Soine 7 2 .1' Disclacementof Thcracic!rt. Disr \=urIUS er ~,adicuiitis T hcracic ' ,hest Pain _5.C DysDne_ - 'alOitadOns .Verve ROOT Imfaiian/llegene auc- i D=-*ene ation of Thcrac:o !.m. Disc 7'9.46 rain in Lower Ly a Sorain/Strain of Knee Or L= SHOULQEZ3 AND =L EOW 722,2 Dispacement of interveriebral disc 724.8 Disorders of the Lumbosacral or Sacroiliac Joint 724,70 Unspecified DisorderJCocoyx 724.71 Hypermobility of Coccw 724.4 NeurMsorRadiculitis,Lumbesacrel/Lumbar 724.3 Sciatica, Sciatic Neuritis 224,2 Lumbago, (low back pain) ?_. Displacement of Lumbar intervertebrai Disc vilo Myelopathy ..?0.4 Lumbar Plexus Disorder _ 846.0 Lumbar Sprain/Strain - 72210 Prclapse, Protrus'an, Rupture or Herniation of Disc 729.c flammation of the Hip Jcim Cther & UnsDeciffled Disor."-er &'Eacl( 539.C Subluxation 7-2.=-2 - Degeneration of Lumbar,'Lrnbesacrad irtervenebral disc 4nIRiS7 'AN7 AND FINGEPS °59.3 _ - niurvto Wri ..?.,. i^IUrV to 1-12211d - iriuryioNerve mHanccrV', ¢ Zar-wai T unnei Svnarorns Screiriizs rahl c Rend CvnOYRIs.Eursiti5 Tencsncvrts'Wns; ANKLE- F-D0 AND TOES _ _ _.- niurv to Ankle OrF^ct nlStrain of Ankle orai -23.7 Caicaneal Spur 0 .5 Tar_,a Tunnel S,,mdrome ;niurv to Shoulaer 996.3 ..niurv To Ebow 72E.3 - Syncvitis, Bursais. &Tenosnovrtis -bcw -26.10 Synovitis. Bursitis. & Tencsnovais Shcuicer OTHER 530.0 TMJ Subluxation 717.3 Paravertebral Myofascitis 780.7 Fatigue 493.9 Asthma, Bronchial 762.3 Edema 346.9 Migraine Headaches 780.4 Vertigo (Neuropathic) Dizziness 470 Influenza =eowettfnd -_9._52 smuai Painiammcs Men v =.- =Ms - 78 C. nsomnia -..-. _ 3f Comptaints 11 Candida 995..; Allergies, Unspecified pa?. , Food Allergies 737.0 Curvature of Spine 079.0 Viral Infection, Unspecified 477.9 Respiratory Allergy 712.0 Aathriffs 956.1 Spondyiosis 551.3 HiatalHemla 355.0 Sinus ROENTGENOLOGICAL REPORT PATIENT: DATE OF X-RAY: Cervical Soine ( } negative for recent fracture or grass asteocaTnaiccy as visuaiized. ( } Lass of ( ) Severely decreased ( ) Milci, decreased cervical l ordotic curie. ( ) Neeative for discooenic lesion. _ ( ) Apparent cervical myospasm. mild Moderate Severe. ( J Destro - scoiiosis. ( ) Mild { ) Moderate ( } Severe ( ) tf- scoliosis. ( ) mild ( ) Moderate ( Severe ')'Narrowed disc spaces between (croaahment of the neuroforo mira betwER n ??--?? - -esteoartiritis of ` ? i - ( ) Other -` t Thoracic Soine Negative for recent fracture or cross cseo?atncicey es visuaii'<°d. Kyphotic curve appe=ars normal. ( } Apparent myospasm. -- 1 Miid 1 Moderate ( ) Neca-ive for discocenic lesion I - DeXed a: i ) Dexvo s aiiosi Modara[e _e..-_ _- 1 Levo - snoiicsis. ii! ; Macarte i :.e6 z: Narrowed disc spaces b=etween Os--eoarthrids of = Otr:ar - - - _umbar Soine -gatlve TCr r a_ent Tr'c_;'jre or "-oss CSta_ atnc!cc", as vlsua!;' ^ oi c= r- - -- _ - o - -- :=_x -- sccliOsi- Z: ow C1w space p_-..vee!1 70 12= SoCnCVloi!'ntn°ses. a'-Ce i F,icnT ilium routed - - ilium, rc-=_.e>-. 27- Ctner Overview of X-Rav ?:ndines HERD CHIROPRACTIC CLINIC, P .C. 2704 MARKET Si REST/ CAMP HILL. PENNSYLVANIA 17011 _ (717) 737.1681 FAX (717) 731-16^-8 _ ilniula!' ePGG Jnnuu,/ 23, 20,00 I o: MAC Risk Managernerr. ?:_ Barn tavaf T.as; ?a iEC- Date o Injury: '10-12-99 - inci ent ef6 njurr:.= _.l a: G!':,,JT rc-z: %:cres - . eC .- aDe °ardent s .'°ommiain= LOW O?CK oa;sl. 'S2C F: -lc :.iUR=- ?ssi?ciiv2 =iissas SExarrss€aaricrsa: nc e.: r=_s:. e:,c cecre=sec -s-Ce r,: Disability Dam: N/A HERD CHIROPRACTIC CLINIC, C. 2704 MARKET STREET / CAMP HILL FENNSYLVANIA 17011 (7171 7371681 PAX (7M 71 731-1648 MONTHLY PROGRESS RFEFORT PATIENT. Sara Warman DATE GP THIS REPORT: March 31, 2000 THE ABOVE C.4P71ONED PATIENT: asunder active care. ( ; has been released from care. - ( ) has reached a state of maximum medical imp rove me: t for this condition ana has been re!easec from active care. He f She has been advised to return on an as neeaed 5asia or t:e contra! c pain and exacerbations. e 4IS IS NOT MAIN -j=-SVA NC:_ CARE ;S / 3icrs CONDP s ION AT THIS TWE: ?s improving with the present course of treatment. /remains static,, -s retroaressing. ?STEzRIM AGGRAVATIONS OR ACC;DEM7-m' =;::enae? sianaino, stc:inc cr s.ccnir,?. _ %nousenold auti=_s. -duties related to the patien¢ s r=_autar emo,ovment. other (please speeiry) RESENT SUBJECTIVE COMPLAINTS: ?a ?ROGNOSIS: TREATMENT PL47V: This patient is to be seen time(s) a week for the next week(s}, and will then be re- evaluated after _days for his / her existing health status. This patient is l is not disabled from work at this time because of this injury. GERALD M. DINCHER, D. C. SS# 188-44-4403 IRS# 23-2110925 HERD CHIROPRACTIC CLINIC, I? C 2704 MARKET STREET / CAMP HILL. PENNSYLVANIA 17011 (-,17)737-1681 FAX(717)731-1648 MONTHLY FROGRESS RE#'ORT PATIENT: Sara Worman DATE OF THIS REFORT: February 29, 2000 THEE ABOVE CAPTIONED PAT MKT: under active care. _ {) has been released from care. {) has reached a state of maximum medical improve„er:t for this condition ano has been r ;;aasec ,nom active care. He /She has been advised to return on an as I e Cic'^ basis foi :e C i (f^vt cf pain and exacerbations. U HIS IS NOTMANVTIFIVANCE CARH MIS 1 HER C04DITION AT °s.:IS TIME: i3lmprO'dfnCl Wlrn me presenr CDrir e ?-T ;realmen:. { ?r remains static. O is retrogreseina. iN c RIM AGGRAVATIONS OR ACCEEDN xtenaed stano=, sitting crsrcoe!nc. "i nousencid duties. -- - ,`; duties re:ated zo ene parierr.s r?ular emo!ovner=:.. other (please specinr) - PROGNOSIS: TREfl c MEN T PLAN: This patient is to be seen time(s) a week for -,he nexr weeks si, an.: then ce re- evaluated after aays for his 1 her existing health siarus. This patient is / is not disabled from work at this time because cf this iniurv. GERALD M. DINCHE9R, D.C. SS# 188-44-4403 f S# 23-2190925 PREaM T SP389EC7. 19E COMPLAINTS: z HERD CHIROPRACTIC CLINIC, P.C. 2704 MARKET STREET / CAMP HI! L. PENNSYLVAMA 1701 {7173737-4661 FAX(7173 731-1688 MONTHLY PROGPrSS REFORT PATIENT: Sara Worman DATE OF THIS R=OOT: APRIL 30. 2000 (o is under active care. () has been released from care. ( j has reached a staie o'i maximum !nedicai jmi;orovemert ioi this condition and has aee:;; ;,=I= L from active care. He / She has been advised to return on an aS need=_C basis '?' :ne CoiT!'O! C. pain and exacerbations. T;4IS PS NOT MAIN'T S,NI INCE c:Aa _ °3iS I FF-F Cu$t D i dON AT THIS TWE: (1'J is imorov)na wit h he 4resent course c,,, Lre-imer:i. r remains static. i '8 TStTOlres5ln`;. - - - - -TY-EMM AGGF?AVA7?CNS OR ACCIDENTS: e,..encee mancinc, sming or --m-coin nouseno!c c zies._ nudes reiareci tc the oa,lem s r=_cL!tar 2r'1cic ?M t a-: oih=_r (niease speolry) PRESENT SUBJECTIVE COMPLAINTS: _- T REATMENT PLAN: his patient is to be seen ti", e(e) a Weei for the nPXC week(s!. c. :d %-Ml -Inen be re- evaluated after davs for his 1 her existinc hea!tn sraius This patient is I is not disabled from work at this time because cf this injury. GERALD M. DIMCPaR, D.C. SS4 18844-4403 1RSA 23-2110,925 S a w m m N 0 a NG c c? a D m_ 7 x - m m ? Q m G Q_ N N ? ? I w C N L1_ G' N I i ! ? I D l m --4 - \ mi --t n m p n m m m \ m -ice - m m c O x - Z ?- 'S N _ \ 7J w = N ow w co p O Z _. C ? _ I N N C C T -i C_ - r= - p w w m =n t rt - o n p o N O (n - n w-m m _ p E to > ~ y CO C (G O = _- -. ,. - it _ L U T n a L?j _ ' ' me `•-? 31 _? a m v "? Z ? m z E i to 14, _ -c N = Z ° -i N c N c_ m c = ? ca K P ° - c c m ^ N ry, P ° tD ?.? 1 1 y I N A m m Zi UJ C m n p-ac c o x_ ? c (D m N CD ? ? N fO C G7 II m o m ? a c > M c c N < N CL P sD _ P ° n 0 P N ? 07 O N O _ D m _ n tL` v o n co c O N d Z C m ° 0 y m ?m -ia --_c c m W 3 ? ?m•°ym 6 my?? ? ?c3 Nc < a c? m o? m m m c N o z ?- o m m o p ca N- D r c _• n p A N PE? Q Q X m cCJ "7i tp --i ? P m N ? m a ? DQ.. dim n C+ a ? m o P O _° O ?- z N Cp _ -r"- > m n ° n x P C d co n ?_m c c_n < :J R ` c - m r m _ I C V m -? m p z -q p ;V m I I? r 'S7 ?o {f° 11'? ' CD -O R w CL N _ Z - a .o m ? G ? - m. v .6 .a 'Y m N N - CL -_I 0 y _c y m ? o ® ° n c m N _ ° CJ v ? C _ _ - Cy ?`tJ '? t?y? ???: O cn m 0==m Z a o x > - C _ m - -N m C L ? O a 0 > m m v m ma c < ? N y i , n y D D i^ N f C!J O ? a v D _ n m a ? a O co v o m a m ? 9) ? I CJ _ m m ? 3 n N o q N ?? tO Q Z C ° a s ? m ° N ,a ;J a 2 ? a m v ? ? ? N N C _ Q - U] ? CJ m ? (D N N D C ID m ° Z m T ?^ G v m ° ° ° o v Z m L Z _xv fii N ? N r_ > _l m m 3 m ? (J ? Q a = a a Cj C] t f] C v (L _ O _ e q >1 O. O - O G (D t? G m a _ - t ?_- Q7 m m q O j 0 m O t ? -u V ? O i O 0 Z J ? G GRANDVIEW SURGICAL CENTER PATIENT: Sara Worman 21428 OPERATIVE REPORT DATE: 4/18/00 SURGEON: Stephen W. Dailey. M.D. DATE DICTATED: 4/18/00 ANESTHESIOLOGIST: PRE-OP DX: Se--below. DATE TRANSCRIBED: 4/1$%00 POST-OP DX: See-below. PROCEDURE: See below. DESCRIPTION PREOPERATIVE DIAGNOSIS Left carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS Same. PROCEDURE Left endoscopic tunnel release. ANES=SIA LAC. INDICATIONS 1 ne patient is a 6I-year old femaie with moderately se verebilatera carpal tunnel syndrome. She was originally scheduled to have the right side released- and that sty °d -elina better. The left side was worse for her svmpromaticaHy preoperative nc. therefore- we proceeded with a lei endoscopic carpai tunnei release. OPERATIV PROCEDURE The patient was raken to the Operating Room and placed on the operating table in the supine position. and the left upper extremity was sterEeiv prepped and draped in the usual manner. I % Xylocaine with epinephrine with sodium bicarbonate was used to inErrate across the paimar aspect of the wrist and between the thenar and hypornena* eminences. Anproxirnateiv 6 cc of locai anesthesia was in, hated. marking pen was then used to oudine the skin incision ;ust oroximai to the wrist i exion crease overiving the median nerve. and also to outline the axis of the r-ffL- Roger metacarval. The arm was then exsanouinated with the Esmarch bandage. and t_ e pneurnadc tourmquet about the right proYimai upper extremity inf aced to 250 rrtrn of mercury. A transverse skin incision was made at the wrist. Coursing longitudinal veins were electrocoaauiated and divided. The palmaris longus tendon was identined and retracted radialward. PATIENT: Sara Worman DATE: 4/18/00 PAGE: 2 The forearm fascia was opened transversely with the scissors, and then a- flap of fascia developed and retracted distally and palmarly with a skin hook. Scissors were first passed into the carpal canal superficial to the median nerve and deep to the transverse carpal ligament in line with the ring finger metacarpal. Following this. ?he synov_ial stripper- then the canal dilators were introduced. The scope was then introduced into the carpal canal. and the [ransverse fibers of the carpai ligament identified clearly. The distal most aspect of the transverse c=al ligament was clearly seen. Using the thumb7 it was possible to palpate in the palm and to detnonstrat;? the fat at the distal aspect of the transverse carnal ligament. The knife was then elevated approximately one-third of its height, and the d <tirci no t aspect of the transverse carnal ligament (approximately- 1 cm) divided. The kn e was tiaen retracted. Visualization of the distal asnect of the transverse carpal ligament .hen identified a few fibers still intact distally. The knife was elevated oanialiv again and the st fibers divided. The knife was then fully elevated and withdrawn roar the wrist- dividin the transverse carnal ligament. Whh the knife --raced.-the scope was reinserted. and the division of the-transverse ca ai ligament was insoected. It was noted that a recianguiar division of iile ligament had gee accomplished. 71Ls nasina been nert0u eLL the Scone was removed iOm?ne WiLt. _nde: direr:'T,sioP_ me remainin!a r_e`.v fire- o:.tnC rarsverse ..w as li<_'amenI a?Sta! c ii =i incls:or_ were divided sna.' - wnn scLssor=_ and ine- ine cx>_ri21 to me sicn incision : I a ais:ance ci anprcx=m-a:e:'; The wound Was men. Lrllgaied wi-Lh normai saline and closed wT.n a : miiiii_g 1-+) nvlo- succudcular surlre. sierite dressing incor orating Xerollo. ='> ms`s. Kefi x and Was tnen applied. ne iollITileuei was denaied_ and e xceueni cm illarv rent! reiurnec :.. the fi>agenips. - J,e nauent was zransported : good conditio = :?e Recover Rcotn:='_av:g :oierate' -- procedure well. Stephen W. Dai?ay. M.D. - Da-, 13,9886 uYa-nsv[etiv urgery as?? en er 05-009'i _ y, ;_ . ..__ _ _ Operatin Room N ses' Notes =• ' `= =- === g ?r °J2?OTI Dx. ., - - • - -- ° ? Cif` _;- _,.._- :d:"- re-co Dx. ?T 'ost-op Dx. °ost-oo Dx. Dace: OF. = - - ?? 'rccedure - °rocedure - - - TYPE OF AN^ THES!A.: - 3ier S:.= PATIENT ? NE S HE olA O.FD.ER ,ATIOi. = C?ne21 IN O.P. 1 OUT O.P. START END I - ST:,F. T i °_?1D I I i EsiGLCGiS: u? i (G U I /C2 c iy I UP «k O i N I - C- A: r9NA. -.. mac., r ANENT IDENTIFIED °' ALLERG!E=: KNEE_STP.-P L _•,:a r,_ __,, vn o- ? ,'dCUND _ .,- - CONSENT SIGNED S 'DtJRE_? uNGRCSSED? _I I = ' CP SFTE i0ENTIFiED a Y PATENT hG _ "C-' J 'RE-OP ASS`SMENT ?E'd!ENIED 3i r... - _ _ P7A -` _ '.CP.Gc:•N:- --?S-CN C= 7a-, iE'IT ,SSISTANT: ctna- v c- '' ?;T -EF- - _'-_ o'cp , c -SCR -SE-Z, _ nrGVG - GV_ - N SLICES 7711 =_..zrt Sflie:c:r.C = Sicna,uCeS: - ?) - circ: relies: I - - - _71me: Y scrub: reds' L' time: G ( 5 c??LL?1 s?--s Pe, _:. Grandview Surgery & Las enter #05-0091 Y - a Practitioner lntcaoperati.e Order Section `Es J, L, 17011 717,,IE. IIR S2E EYE STAMPER ? < CCSE TIME RCLr E SITE ea: 1M yF Ei 'JAS' A.:L"o < c p Type: _ ? v? ??, ? ? Size: Con^^nv: _ L?z Stickers: _ rlaster ° MA Drains Facks Lcaation - - -- - ' Scecimens: tissues cuitures = irczen = N%A `? 'aemiauet: ?N/A. -c?rmcue: c neaeeo Drzcc - - - -- - _ Riahv;m = ZAr- -- - - - - - - = Ricm. ? - n = essur=: Irrated Inriatea / --- .? -- - De+' as-6? 7e-iatec 9: :otal Tme: -ctal Tine: -- '?-S? _ - - . Catheter lnsened: =aiey =- -Siraiaht _ Ftemcved Dramace Amt. - Coicr - 1 Surgeon Sionature: Date: e7M 2'0 Pe. USi wA Bf Llm WL CO, M.9. , RICHARD J. BOAL, M.D. ROBERT R. DAHMUS, M.D. STEPHEN W. DAILEY, M.D. R JOHN FRANKENY , M.D., F 4 CS. MARK R. ORUBB, M.D. RICHARD H. HALLOCK, M.D. pP.THOPfiD[C 1\STISL'TL JAMES R. HAM5KER, M.D., F.A.C.S. OF PENNSYLVANIA TELEPHONE: (717) 761-55-j0 (800) 834--020 FAX: (717)T37-7 - GREGORYA. HANKS, M.D. ALEXANDER KALENAK, M.D., F.A.C.S. - ROBERT R. KANEDA, D.O., FAC.O.S. RONALD W. LIPPE, M.D., F.A.C.S. JASON J. LITTON, M.D. ERNEST R. RUBBO, M.D. R7LLL1hi J. POLACHECK, JR., M.D. STEVEN. B. WOLF, M.D. THO`LAS J. YUCHA. M.D. ,aww. orthoi nstituteofpa.com .. .?..C.c.z- H=nI'_ing, .CI. =C, __ C ..G'rY_SJt?YC. _1 [J ? C ' J '_ - ___ an 8 °'Lc_ on 1-_2_ ____ _c_z `c rea n r' 011.0M_OIC 511ROCCA : J ADDRESS ALL CORRESPONDENCE TO: 875 POPLAR CHCRCH ROAD, CAMP HILL. PR 17011 CAMP HILL OFFICE HARRISBURG OFFICE GIMP HILL OFFICE HERSHEY OFFICE CAMP HILL OFFICE 39 t6 TRINOLE RD. 450 POWERS AVE. 890 POPLAR CHURCH RD., STE. 108 10 WEST CHOCOLATE AVE.. STE. 105 875 POPLAR CHURCH RD. RE:-WCPM7N, SARA L. PAGE 2 February 5, 2001 SATD/mee Sincerely, __--hen W. Da__ev, 6!.=._ ixanea,1 BALINT BALOG, M.D. RICHARD J. GOAL, M.D. ROBERT R. DAHMUS, M.D. STEPHEN W. DAILEY, M.D. WILLIAM W. DEMUTH, M.D., F,AC.S. JOHN R. FRANKENY 11, M.D., F.A.C.S. MARK R GRUBB, M.D. RICHARD H. tIALLOCK, M,D. JAMES R. HAM5HER, M.D., F.A.C.5. TELEPHONE: (717) 781-5530 ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (800) 834-4020 . FAX: (717) 737-7197 July 19, 2001 W. Scott Henning Handler, Henning L =oseabera rczorneys at Lew P. O. Box 1177 Harrisburg, P=_ 171CE GREGORY A. HANKS. M.D. ALEXANDER KAL£NAK, M.D., F.ACS. ROBERT R. KANEDA, D.O., F.A.C.O.S. RONALD W. LIPPE, M.D., F.A.C.S. JASON J. LITTON, M.D. ERNEST R. RUBBO, M.D. WILLIAM J. POLACHECK, JR_ LLD. STEVEN B. WOLF. M.O. THOMAS J. YUCHA. 11. D, w'ww'.orthomsutute0fpa.COln -B: _a_c _. SIC riRcL ?c3°' \Ir. enL _nC alnec -_ -aL a?rrnareolc su+rcos ieo. ADDRESS ALL CORRESPONDENCE TO: 875 POPLAR CHURCH ROAD. CAMP HILL, PA 17011 CAMP HILL OFFICE HARRISBORG OFFICE CAMP HILL OFFICE HERSHEY OFFICE CAMP HILL OFFICE 3916 TRINDLE RD. 450 POWERS AVE. 890 POPLAR CHURCH RD., 5TE. 108 1 O "''EST CHOCOLATE AVE., STE, 105 875 POPLAR CHURCH ftD. MEDICAL EXPENSE SUMMARY Provider Dates of Service Amount Paid Due Holy Spirit 10/12/99 $721.00 $*696.00 $0.0 $25.00 Orthopedic 10/15/99 thru $1,990.08 $*1,904.20 _ 50.0 Institute 7/7/00 $**85.88 Herd Chiropractic 1/14/00 thru $2,826.00 50.0 12,826.00 7/6/00 Grandview 4/18/00 $3,221.57 S* $ Surgery Prescriptions 1/20/00 S40.00 $**40.00 $0.00 West Shore 4/18100 $390.00 $*192.00 $ Anesthesia TeufelOrthotic 11/19/99 545.00 S*36.00 TOTALS 59.188.65 SUBROGATION CLAIM: Healthcare Recoveries $2,992.92 (amount pending final accounting for related charges - total lien being asserted is $6,665.99 C 16 HCI # A HOLY SPIRIT HOSPITAL 503 N 21ST ST i CAMP HILL PA 1.7011 CYCLE 10/26/99 717 763-2141 B!RfH-DATE OUTP. FEI 23-1512747 04/16/38 7pnC C G WORMAN SARA L 1409808/ __ 10/.2/99 c 522 SPRINGHOUSE RC - , CAM? ` - SH=.R MA R?,JAN? CU .,- .- - ..Rrtcrn- CHARGES. PAYMENTS ., .s?4 "......STh?_?•:-_ _. C 'S7 SCOT 17 _- = EAP _Snl SC' 0? ' SUMMARv OF CURRENT Cn ARGES - - SUPPL:Ez ., .._ CJR... _? =AYHE^!- DUE UFC,4 RcCc = YOU ;^iAY SUBMIT THIS FORM TO YOUR INSURANCE CARRIER - - FOR R=IMBURSEHENT. C T A s 721.00 721.06 14098081 PAY THIS AMOUNT O.CO HOLY-SPIRIT HOSPITAL CAMP HILL, PA Pace Nc. Account Numcer. 1 4 0 9 8 0 8 1 Patient Name: WO RMAN >SARA L Samce Star,: 7 0 / 12/99 Serrme Snc: Sla:ement Date: O I/ 0 5/ 0 0 Last Statement Date. 10/26/ GUESTIONS? Please Call: 717-763-2138 ContacI: ACCOUN-, SALANCE ESTIMATED INSURANCE DUE LCTAI- PATIENT CREOITS 25.00 .00 2-=.6 TRANS DATE DESCRIPTION _ AMOUNT PREVIOUS BALANCE 10/12/99 CAST SCOTCH 4 10/12/99 CAST SCOTCH - '_0/12199 ?UNILAT L=T RIBS 10/12/99 FT F3REARM 22- 10/12/99 LEFT !WRIST _1D.: 10/12/99 =D VISIT LEVE_ --- '=O 12123/99 H AMER FYMT-OF G'D2 HEALT- AMEBIC - 12/23/99 H AMER C/A HOS-3F Q02 HEALTH AMERIC ..o. 0 R HO SG 1 D00023587 ACC'OU'NT BALANCE -HIS BILL REPRESENTS THE AMOUNT NOT PAID BY YOUR INSUP.ANCE RE?3IT PAYMENT TODAY OR CALL 753-9620 =P YOU HAVE DUESTIONS. . 402 HEALTH AMERIC PLEASE DISREGARD THIS STATEMENT YOU HAVE ?AID. Urao vour insurance ras ca,d. the Pi ?AY T-IS AMCUNT recresents the balanca we estimate you owe. Anv oaiance vnca;c tv vour :nsurance wtll to cue from you... Thank you. mm? ,Q uSL DBA ORTH !N TITU'1E OF PA 3916 TRINDLE ROAD' CAMP HILL YA iYOii 717-761-530 TAX-I'D-0:0 3-i67554'! Ahm WoRI` Am 115242 522 SPRINGAGUSE::ROAD ?Ai'P HILL Pm 'i70li - DATE PROC -DESERI'`r.'.T.ION - ""_DR`•"RLACE 10,15,SS -SS02 - OFFICE`:-CALL.' .'. . 'S'WDSO1. 10-'12-S:r_ 'SS024 UY Y2Lu:b'ALL:.. _.._.._ ... .. .........SK;L v11. 29210 OFFICE ' CJUTPT.... VISIT. _..`WD .. 0 zw-1 :-=:' -72100-L"_ .W R'IS!, 'f"'lf'IE1i5 SAN 0 zwn22"&b- 9S2l2 - :IJFFSCE:".ULfTY'•!',' i?I ul '. :•.C.: jSY'J 111 .LO-22=%: 731 0r0f ' is-05-S9 2rS'4175- 2... CAST 'SHOR.T.. _RM ..... 4:JD 'W} ]=520 SPEC! AhZA`72NG-hA TErSWD^ a+.%1--, 99020 -O..A'LL ....._ , .. 'LFF_?.r?_ ___••_G?3r.. ??.J ...T_ vl CH'ARG -LAISR' -""'-- --Swu :01' 4R15'_ _...Y 2LPtY s. ___... Si'l,'. VJ1".: -1- a:'u t,L _._: .... _. ... :,aARGE-'Ll°•d't:P:__._. _.?__ ._...__`ti:JrOi S 1 _5 vhQ, G Q-PAY "-.. ANiST;- Z--VIEWS_.. .. GW'J W. em. _=-04-0 __._. _._ ChnRGE-LATER -"Ewa 01 .._ '@y 'J'ci =_-__ '.r ^_..= ULJZt! Y1S1! ._'. bSS"J 01 *15.uw C OPAY . - i O T AI. CHARGES HEALTH AMERICA PERSONAL CHEON HEALTH ASSURANCE PAOSENT =EALTH AMERICA ADCU .THE'i` I HEALTH ASSURANCE aDjUSTM TOTAL BALANCE DUE DIAGHuSE5: 64%.l SPRAIN AND STRAIN THORACIC E645.0 PLACE OF OCCURRENCE; HOME Eaan FALL ON SAME LEVEL FROM SLIPPING, TRIPPING, OR STU MBLING 726.15 OTHER SPECIFIED DISORDERS OF THE SHOULDER _ E849.6 PLACE OF OCCURRENCE; -PUBLIC BUILDING 2860.0 FALL ON OR-FROM ' STAIRS' OR- STEPS; OTHER - Z5-15-&m CHARGES CtJ.rIJ •i` 1L4J.I%J L' _ `i .,OVJ . v 4.. _.J •i o v'. ¢IL _=.VJI _<_.5,:1 _0.56 64.0-, - _:.EO t 85.1_ .vu 1--A UHIt. 1:1 Y T U T L LF P .a 'JJ V]t: .'.?iG 'PRitl liLG HliAli --- / S / .'v. :gab ''S'AdA 1... 4I%2tilAti 62._ _ -?i= R'li'16i OUSE rlujal) L'hi'2 ?'°'a41LL YA -- ---------- ------ i:SA 'F- Gi; - ------------ JESCRZFTiOH- Lin •,. PLACE, ' !i S'2 Q F L GUI : _Visif E:lSVili On -5 •J.LJU? ...=-SO-,L I'J L3G-1tt-L i s'.HD'L =CQPZ, b4RIET, 5c!/L' _...__.'%.:. _L-ARC: LU= _?c....4.._. Urt --Ai'in -_-- YVZL :!YOIl MHOUI ,.. JY. ii_i'! SiA?_?S L,': S' 0 THE: _ E'.Jh1'_-.S D;: UYYLS'"L1!'t'n'r 9PLJrl1RL12Y Q!YELlHi.t lS' hUL11- _=.:i. _.rr•A±. .'UiYN-L- SYND HO^E _SL __R OR!H INSTITUTE Y 27a POPLAR CHURCH ROAD CAMP HILL PA 1700 = TAX 1D Om 23-187E547 PATIENT: 115 242 WOR MAN SARA: L P. zQL : WAL, 17111 D". ------------ ------- -------- --------- ------- ---- ---------- ----- ---- --- '_.-'00 - -- _` - at 90000 - ._--_....E. . .,... MD DIAGi -- - D51SOO 21 11 TS212 OFF= =7 21 Law 360700--1; 1 To TERSONAL Lis- :1 2E if. 00t .3?2600 1- -;.r.-.mac -cr._,-. __ --_-:_._ _ Of __. 222500 •...c.. .-.ASE. -.C.. _- C ,., _ ?TSEW 77 17 _- =7Er-E.i a _-___. .- ---8: -_-.-_Z- - _ E00 -v. - .W v.AES. As IT -2. 1 _ 27EPREN Z___. - __P18: =.W 770700- _ ETEPSEP 157E? ._ -. 1: ::W: 727.= Fit: :i -E2100 -_- -PEE --`a___ _N-_-___ ____ _ -07 =7 ?IUC tit Ql __ - _ :'Er Par _.•1 L. - - __. :._- .. STEPHEN -+ _ i . _ _- . MD .. _ -6 : 7E7.02 110130 C- _ HASS HEALTH. AS2 272101 __ _E -___ _-_ _- 1013Qk - Ec HQS.7 H. PES. ADj A H of _o_... f n7. 101300 38 _ -. 7.38 MEMBER CO-INS :I 032000 -38 _ PC PERSONAL ChB __ 5 -15.00 =8. __ 22. WE ORIE00 31 1 al 90000 cc 05 .01 - - • ••? STEPHEN W DAILEY MD DIPS: 727.03 - - - 08160QI 40 1 31 99212 OFFICE OUT '3894 17Y 05 40.00 7038 STEPHEN W DAILEY MD DIAL: 726.32 INS CHARGES ONLY CLAIM: I T E M I Z, E D S T A T E M E N T INSURED: STEPHANIE BRADLEY PATIENT: SARA L. WORMAN 13049- 522 SPRINGHOUSE ROAD CAMP HILT • PA 17011 SS#161-32-3713 POL#GL9909192 DATE/INJ: 10/12/1999 GRP# TO: MACRISK MANAGEMENT P O BOX 9227 BOSTON MA 02209-9925 DIAGNOSIS: --_._; CERVICOBRACHIAL SYNDROME': 72971 CERVICAL MYALGIA -__._ LUMBAGO DATE: 05/15/2000 IRS=: 232110925 EMPLOYER: VNA OF HBc= HERO) _ CHIROPRACTIC 2704 MARKET STREET CAMP HILL PA 17011-451- 7171737-1681 F•e._. _ _ _--,4;.: 009 .: !NjURy WRIST J4 ". _NJU ! _.-__ OF LAST -ILL: 05/11/1000 PR' 121006KPK 101 11 DATE CPT DES'"RIPTI&I PnS _O$ Aral- G1114/2000 98947 CMT. SPIINALTHREE TO FOUR REGIONS 01,1412000 91014 ELECT STIMULATION-l'-,'-?iP.TT il'1412000 7204M CERVICAL SPIN@ A-? AMD LATERAL .1-10/2000 72110 _•JMBOSAi. RA ?-P ADD 1ATEFLL -- - 12,2000 98941 'MT; SPINAL. THREE T FOUR PIGIOMS _ _5i2L)r00 57014 LECT,- STIMULATION-iNATT i;)_ 17/2000 92541 CMT SPINAL; THREE TO FOUR, REGION 1117/2000 97014 =:LECT. STIMULATION-i NATT -- -:. 1/15/2000 98941 CMT, SPINAL, THREE TO FOUP REGIONS 10. 01/18/2000 97014 ELECT. STIMULATION-UN:°-_TT. _- _. 01/19/200M 98941 CMT, SPINAL, THREE TO FOUR REGIONS -11 1 A'_;15/2000 9701= ELECT. ;STIMULATION-UNATT 01 19/2000 970:35 ULTRASOUND __ _- »_''1/ 000 98941 CMT. SPINAL, THREE Fr REGIONS _ 01,11/2000 57035 ULTRASOUND 21/2A/2000 98941 MT, SPINAL, THRUM _'.. PnUP REGIONS -- - - ;. 01/24/2000 970:3.= ULTRASOUND 11 it 01126/2000 96941 CMT, SPINAL, THREE TO FOUF REGIONS -_ _ _ 40. 01/26/2000 97014 ELECT. STIMULATION-UNATT. 11 20. 01/26/2000 97035 ULTRASOUND _- - i5 01/28/2000 98941 CMT, SPINAL, THREE TC: FOUR REGIONS 11 _ 1 40. 01/ZS/2000 97014 ELECT. STIMULATION-UNATT. -_ 1 20. 01128/2000 97035 ULTRASOUND 11 15.- 02/02/2000 96941 CMT, SPINAL, THREE TO FOUR REGIONS ;i1 2 1 40.E 02/0-2/2000 97035 ULTRASOUND 11 1 15,i 02/04/2000 96941 CMT, SPINAL, THREE TO FOUR REGIONS 11 2 1 42.(- 02/04/2000 97014 ELECT. STIMULATION-UNATT. it 1 20.i CONTINUED ------------------ SUBTOTAL; 806,( . =?e 1 TNS CHARGES ONLY T E M,I- F u S T A T E M E N T ['LAIN: DATE: 05/1512006:' 'iQSUFEI> _•TErriAN1 BP. ADL,E IRS, 110 PATTE_NT: SARA w)ORMAN 1 97 ''"IN( rC)UBc FC)AD - ?L•C)YER: VN2, i?e'_-^B[_= - - FILT7. 71\7 S-•, rtgNAC ERmF, "' - - 0,c MARKET `1R =_r 7 7 _- __ _. _.?., -- -?_2_L-C1i iN_. V)U - - - _- _ _ _i? r?r t --iliV --? _ ? fjt i VP -T 7 (,y ._N .. TN:; 1'i:D,PE E i[. I+.iU'-' !='Em C-IJiVr - - - -e).. :,22001(0 9-70 :=.=. LrT'_ ySC)UC.. - Gl.li /2[?G)G) LiNy4_ _ [?rtT.i1I?)r- r' )-'y-.JE H: ?"(.) F'1 [):1 t`: FJ_.(?1( )fV __ _ _ :•)G' C?12/25/20VO 4701$ E:LE,' ST IMi)L•ATIi N-UNATT'. _ .i: 02/25/2000 47(13 ULTRASOUNr) 02/28/2000 98941 SPINAL THREE TO FOUR C:MT REGIONS , , 02/28/20100 97014 ELECT. STTMULATION-UNATT. li 1 =Gt.[; 02/1812000 970:;5 ULTRASOUND 11 1/? 15 .4) CC)NTINt )Er) SUBTOTAL: 1,506,0 Page 2 INS CHARGES ONLY I T E M I [. E D S T A ,,, E M P. N T" (::LATM : INSUREL): 8TEP17ANTE- RRADLE PATIEN`T': SARA L. WORNAN i04 c?- .5'PRINGH(iLiSE ROAL - :'AM_ iLL P _,.. LATE ; Vi;? ; 1 '. i 2(4 (AV M,; P K FT_ z", Q I vj A 14 7- T7 T7 7 i UN In ._TRABOIJN-: ..; _. _. 1LTRF.SOUN=' - c .. _ _000 ??.' .. .. 'ar_ .?='?N?, _, :: 4•.: .._ _ _ -,.. _- 2000 - 0- L-p7, INr. _ C _-'2000 _-=._ .. NE^T(:: ACtiTT_ -EF:=__ -:i- - _7 /2000 _L 41_ ..: ^,.m. ?LIITVf _•: - -_ - .. _.)L' ;. _ %2000 ti (% _,= ULTRASOUND v7 r7 /2000 _-.-.-Q) n.INETIA('-7VTTv =EA2.;LT7-1----" - -- -- =v;. 04/12/2000 `5941 CM^; SPINA-L, THREE' _. r'OI;R =h.i=Ic")V _ _ 0 (n ? /l 2 / 2000 o i 0. LiLTRAS()UND 04/12/2000 97530 KINETIC' ACTIVITY REHABILITATTO 04/19/2000 98991 CMT; SPINAL; THREE T(:) FOUR REGIONS 2 1 40.( 04/14/2000 97035 ULTRASOUND t1 l 15.( (CONTINUED ? ' ----------- ------ ------------------------------------------- SUBTOTALr ------- ----2- 235•( Page_ 3 INS CHARGES ONLY CLAIM: I T E M I Z E D INSURED: STEPHANIE BRADLEY PATIENT: SARA L. WORMAN 130497 7,22 SPRINGHOUSE ROAD ::AMP HILL, PA 7011 SS 10'1-:32-=713 POL=CUL`_?y091°_=2 )ATE:TNJ: "_0/_2/10°O GRP? i+"A:'c;ISK MANAGEMENT r _6OX 9227, tiO,'_:Ti)?? I°L' 6}224?i:_isu=. A =`T`AO S l - 3 CERtiIt.:._)BRA(tHIAL SYNDR:)rtE -__ . _ CERUTC:A,L MYAL3IA liMBrC ;. S T A T E R E N T DATE: 05/75/2000 IRS=. 2:32110925 EMPLOYER: VNA OP H5•: HERL) ".HIRC)PRAC:TIi: :-'iQI : _ ? 03 MARi<ET _%TRH:E `_ CAMP -:ILL ?A 1701_--5.-- 16ty'1 r'cty ---. - T DES':::R.I-,,?-C`ti, P(iS' ")S __ =r•:C)U INETI(. _.(. IITY REHAB!- _'5/2000 Sec i) _MT Lr iA:,, .;dE _. ) ?E -i)NS -- - iQl r - 7r,!1 R)Gt =-;i)1= E'L6UT. 3TIML1Lr'.T 7' -L'NA'T_ `. 1 fe Q) (1) e8 ZLf;) ..:''4"' SPIMAL: ' i=?1E - - -;GC) nE" '. 2000 7025. LTRASOUND °10;2¢JGJGi _-:3Si T 17* =(' NE = -- - ----------- TOTAL: s 2,455.E L?T.?Nr"`G! rnC r+ C r4rTr la ., - - - ALL CHARGES/PAYMENTS CLAIM: I T_ E M I Z E D _INSURED: STEPHANIE BRBLEY PATIENT: SARA L. WORMAN 130497 522 SPRINGHOUSE ROAD CAMP HILL PA 17011 SSn162.-32-3713 POL#GL9909192 DATS/INJ: 10/12/1999 GRP# TO: MACRISK MANAGEMENT P-.O SOX 9227 BOSTON MA 02209-9935 DIAGNOSIS: 723.3_CERVICOSRAC3IAL SYNDROME .29.1--CERVICAL bSY_A.LGI . 7250 LUMBAGO S T A T E M N T DATE: OI/17/2001 - IRS#: 232110925 -- E: PLD?EP.:? VNA OF BG HERD C'r"I_T,VPP.ACTIC CLINIC 2704 XY?RIMT STREET ,YIP R2:L Z PA _7011-4531 717/737-1i81 Fax:717/731-1648 T_N.c1`UY TO WRIST - -- 3C: PER-INJURY DATE -OF LAST ILL: .07113/2000 PRY 121006KPK ID# 12006 aamaa=smca==m>a-_sacsaaaaa_.=a:;-====amc-a==aa=a=vela=asa=.samam=aaa:aaaaaaasaaao .;.3T'$ CPT DZSCRIP :C - FOS TO5 .. 3SOII3no >swasascaa^amaaaac:aawmaaamr.aaaaaacaaa=sa¢=aax:moaa@mcc=aaaammma sma.smammavaavmw .r.' _O U .03 05/17/2000 9894_ CRT SPINAL, I E TO 3OUR HEG_d;NS __ s =c.cC 2E/17/2000 97025 ST3.zSOUT_dD 'OC -5 25/3a/200-0 _S__0 CMT SPINAL., ONE TO _,O REGIONS _ - - - __ _ ._ _-.,.c 05/30/2000 97035 JL_ -9oUND _ -- - -=.CC 06/06/3000 98941 CMT SPINAL, ': EE TO _ZUR nEGIONS -- _ _ e0.3 _0/0S/2000 9753C KINETIC ACTIVITY RERABI'__"__710 __ 1 30.00 06/07/2000 97035 -Z:R_aBOUND - -_ -- 1 _5.00 Oo/15/2000 959:0 CRT SPINAL, DAL TO TWO SEG_ONS .._.^_ 00611-512000 9703E ULTtRASOL79D 15.00 06/ 15/2000 97530 KINET_C ACTI `?IT`? R=•A7=Z:=ATID `: -- _ _O.CC 06/33/2000 9894C CYST SPINAL ONE TO !WO :3000NS 11 _ - 2=.0C. 06/23/2000 97035 .ALT AS0l AD 15_ 07/05/2000 98940 CM^- C?INAL ONE To ^_wC _EGIGNS i-- _-_ _ __. _7/0'c/2000 97035 i:T=y$DLD+L -s.CO - 05/25/2000 PA?MENT IN -S .OC OS/2S/3000 ;zyDJ ST I?,. RECORDS _ - 19.00 i a aascsacaaacaaca=cc=aa.a=caaaccasaca=a?caaac=aaxa?ca$ecsasaassacxaa?azasaaasa?saaa TOTAL: $ 450.00 BA ANCE 01/17/2001: $ 2,826.00 s4 ?A/PIVCGA=Csh/ChecWCCMs. Paym-t; CP/VE=Cred:VDebir, IA=irs adj; ^ Lv ?4 3 to 3J(7d DIM'lDQ:3?H _ _ 8b9 LTEGL LL - TZ :60 i68Z/LL/ i0 -- ...,:r•x'r'r.rte:?i;:c!-?.,?-r-•n'1?;'??=?c'^e?::t •". . 71745/41-57,311. - `-PICA r.. .. ., ..... ...... HEALTH INSURANCE CLAIM FOAM PICA •. MEDICARE EOICAID CHAMPUS CHAMPVA -- GROUP FECA' OTHER -- - 1 a. INSURED 'S 1.0: NUMBER (FOR PROGRAM IN ITEM t) -' HEALTH PLAN / BLK LUNG - - - ;dkoicare?J "Via Zip rSponscrs BSNJ, (VA File gJ.r (SSN Or fO);,: (SSN) OOJ L"•}/-} 2. PATIENTS _NAME ILas[ Nama. Frst Nxme. Mlcdle Ininal) • . 'PATIENTS 61RTH DATE: _ SZX ..', 4. INSUP-ED'S NAME Itast Name.F'ust Name, Midi Imtlal) MM.1 OD ., W ;jf]!^;i`lI"1N , 4i>I=d1P 1._,. 04 IlG-' -' E3 . r i : 5. ?ATIBhIT'S ADDRESS N... Street) -' -"-? SFATIENT REi?.TIGNSHIP TO INSURED - T.INSURED'S ADDRESS (No.. Stmoil f.l: l Self `! Soousx %7 Chlitlr Cthcll " '?' F'i- is !' 1u ' ;I IJ:'?: ' ^'?' ?Y .. , , . : • : . i _,T. :aJiATE I3 PA-, ENTSTATUS CITY rSTA.TE- h,,js;l j-I! _ - .I (::, (j rI- ( Slncle? tdarned ! O!her= -c '-S!E==Ctv'c (Inc uC Arxa ca I _ , I COOS T LE PHONE l=UJDE'AREA,000- . I ) ! 9 :mployee FUA-Time Fxr m^-- ?. ? ' ' ) ? . . '., `_ ? ( .. .... .. , /..: 761-: R7 , i Sludant '. ? Student . .,. _. I .. ,..: _ FZD'S NAME last Name. First Name, M:ccle lntiap-' 10. I5 PATIENTSCCNOITION RE'_AiEDTO'. , @ISURED5ROLiCY CROUP ORFECANL'MSER - 1. .L (,S 1'LJG pi 101 ..OT^ER iNSOREC 8 FOLICY OR GROUP NUMBER- ---- . {aE'hPLOYMENT?fOUARE:`ii OR FFBYtOVS'" 's. IhiBUREp'SAAT@FEIRTH + -SE„ - I OD - ?YY 1 EB' ,.C I , My I ? - ED5OA7FOP ?I> SEX - (b AUTO ACCIDENT? - PLACE lSa 7 " b-MFLOYE?'S NAMEO$SCHUIMLNAME A cc I. 1:!! f I AYES . NO ..E F_CYERSt:Aivic OR cOHCOL PIAL!E - :.1 c. CTdER AOCIDE\T? c: NdBUP.ANCE PCAN.NAteLF'ORPF.OGRAM NAt.E: - - 'YEB' '- ??NO -J°>HCE'r',AIV NA0.IE OR?FCGFA^A NAA9E 11? ,F,ESERVEDFOFLCCAL USE ld.!STHEREA..NOTHE9FEALTHEENEFITF:.lI - - .:7•' II , EE' `j=NO .",'X es, ream m am. car,..ele¢em 9 e-a. READ EACCOFFORM SE?CREL^v,'.!PLEIINGS9GNING-fH;SFOF.fd:-:, 113`.IN$U9?^'SCR'AUT'reCRi2E,7iPE950t'S SiOI:ATL'P.=_faulhcnzs 'E:dTGOR A'!OFl_D.=E45ON'SSIGNATR3'lzucwrize.the rete=zoianv me3Jnroheriaomarart aecessarv{.:, pamem. otmaoceaCemffo the uMe.ane c^vscatarshaha: rv .. c2sirilis'. pavmaretq,n•a.'-a=_?!ceneiits'eeha: to nysevmmineWmv.ho zCCCOss asaarmom .serdcesu=sttlbedbetbrc?i.:;;. ?. t..:!'t t?i•! ._.If :i ;%/='. ".,:. ti :+.L t''ihlH Ct 1' l7`tiI_ .. CATE•r - - I SIGNED- v iF UR-a':T. {{ILLNESS (Pirs45ymp!cm) _R. I15. IF PATIENT HAS IiAD'SAA?ECR'Clivl!LgR 0.!fvES°.!tE. OAi ES P:.TIE^IT DNABL°,iC CJCRiC IN CURB°?1T CGCUPATIOP: C:i. .• 4N INJURY IA=de ll OF GIVE FIPST DATE v' MIA OD 'MIA C'u 'i YY '" ,G hA!.iT•'. 'DD' 'YY EAL4f4C.(L".P` I FROM F`IE O=PFF ?'LG -iY51f,,,,N On OTnE95 f,FCE--'. ?'?p.I C. NUh'B=R Or,;R RRINC Pt.:'E'C ?'' 1 ?.F:000ITnE!Z.TICN ?Aw'?['3 rEv :GC 11°=`.'lCc= tdN .. L, .t , DC ............... .. ,..:, 'r, :_ ,? ' ::'^, - h_C1C•-.n .. .. - 1 FFOV ,f TO :, .. ee_- _ .. ._ _ a_'.i2!-_ _.. :>-_._ _=A-24E-E, _,eE *c?ICAiD RE -Y.LSiON- COD= 12?. PRIOR ALITF,O lZATION NU:MSER^' - , OCEDU "t 'IC aOR, RPL 1 I S Cc==b!C[ !_ce/Pe C .' - - - '. AYS [ SD7{.;-' - " IVEO, POP c •c c'r J.s.IC tuns .r - -_ I 'SCt-AAC 04 IFam 1Yf,EMGICCS ? ;-LOCaL US- ,:._ P2 -l : ? i _° L AX'G'w :'Bv S-J E`7 ?.=A-11E SACCOUII :,CCVT ASSGNME`i 28. TOTAL CHARGE AMOUNT PAID 3C.AALAN6E D'Uc 3 2 CdCY) 1 .1 s o c aim 4 ( ` ay la YES ;- NO S --22157? I S, 'Cb0 'sia<<^•s'1= 31 SIGVA UAE OF PHYSICIAN OR SUPPLIER v7. NAME AND ADDRESS Cc FACJLlTY WHERB SER`ACESWERS 33, PHYSICJANS SUPPLIERS BILLING NAMZF,-AVDFESS:Z3P CODE INCLUDING DECREES OR CRECENTIALS RENDEPEO III ether than home or office). S PHONE r I drnmy!nat the statements cn tre reverse i't'd:J(j V.L fELI :''3 (,(YC]'n t ? %?:'!._,:i`>C'. l' I. I'-c7fl C1V1C+t•J JU( tT?'`Ys/' r?l ?.c't•.'.' f. t..u: iriply to this an one are made o part thereor) L? _ , 205 Lit"£t I'1 L'I'J ?o .t?Ve?:111 05 rt' G' JEW f?VFnSL(-IE '. Oq 't9/ OGO E.amp' Hi11a, != 1.7011 taml tfL1.3: 1 13 17OL1 f ,'.. Ik;1cs,.EO S.u:^c7 c.1 L: candaaEr 452-1597 rsi:i - :. iF77M'Y,.'?[-6-L«? 1 ^:?GRPx ' _ (APPROVED SYAMA COUNCIL ON MED16I.SERVICE&03) '„-FOAM IICFA')S00'(J2:9b)' -- r APPROVED OMB-0939.0008 PLEASE PRINT OR TYPE- FORM OWCP1500 FORM RP64c RITE All) NO f It's not just c store. It's a solution.' i'r.,i; rug r+eiire• uli,n?n;c; r n: Store #04818 4957 CARLISLE N MECHANSCSBURG, 17055 (717) 975-0129 Register #1 Transaction "81261 Casnier 048186369 1/20%00 12:31PM RITE REWARD SkV-NCS Customer ?D: ?j SCANNED PHARMACY 2"u.N UP', 71409 SCANNED PHARMACY -- =arc XXXXX„XXXO?7. C2w,9en+ r.U C -encerea =0. ?^ -asn Change -- C 0..7 C.,,lns Pnarm.ac, a- T C y C z? r > Z> °- > ' > - Q_ 2> rC ==>I c - B c z =Z. I HEALTHCARE. RECOVERIES FEDERAL TAX ID: 61-1141758 P.O. Box 37440 TELEPHONE NUMBER: (877) 765-9373 Louisville, Kentucky 40233-7440 PAGE 1 OF 2 CONSOLIDATED STATEMENT OF BENEFITS PATIENT'S NAME: SARA WORMAN HEALTH PLAN: HealthAmerica/HealthAssurance DATE OF INJURY: 10/12199 SERVICE PERIOD: 1115199-8130/01 Sub'iect to change. v FILE NUMBER: CV-204282471020 instructions: - Make checks payable to: Healthcare Recoveries. a /rite the atient's name, SARA ORMAN, and file number, CV-204282471020, on the check. Provider of Service Diagnosis Code Claim Number Date of Service Procedure Code(s) Billed Amt. Paid Amt. COWLEY MED ASC LAB V72.83 OTH SPCF PREOP 23282024 7/14100 1 85021 Automated hemopr S10.00 54.32 7114100 1 8OD51 Electrolvte Dane 337.00: 53.66 DAILEY MD,STEPHEN W 813.41 Fx of radiusfui - - 20521565i 1115199 _ 28075 ApplicaEon of f Si60.D0 553.83 111519-9 73100 X-ray exam of wr 560.00 527.19 11/5199 A4590 SPECIAL CASTING S13A0 S10.40 _ _ 813.41 Fx of radiusfui 20-158625I 11/19199 - - - 731 DD X-ray exam 0""r - - $50.00 527.19 364.0 Carom tunnei sy 1012214484 4112100 98212 Officeloutnatien 540.00 1 514.03 J0702 BE TAMETHASONE AC $8.08 $4.96 727.03 TRIGGER FINGER - 23190664 99213 Officelcutpauen $50.00. S26.48 727.03 TRIGGER FINGER /024107673 26055 Tendon sheath in $828.00 i S189.54 726.32 Enthesopathy ei 1028518081 20605 DrainAniect int $84.00 528.15 J0702BETAMETHASONEAC - $16.16 $10.26-- 354.0 Carpal tunnel sv - --- -- 1029201456; 29848 Wristendoscocyl 51428.00 1 $288.54 Z DC,GERALD M 723.3 Cervicobrachial _ 1023,06370 i °8940 CMT, spinal, 1-2 $35.00 1 517.00 L1EZ P T .JOSE 727.03 TRIGGER FINGER 1029013148 i " " - - 1 HEA' THCARE RECOVERIES FEDERAL TAX in: 61-1141758 P.O. Box 37440 TELEPHONE NUMBER: (877) 765-9373 Louisville, Kentucky 40233-7440 PAGE 2 OF 2 CONSOLIDA 1 ED STA T EMEN T OF BENEFITS) PATIENT'S NAME: SARA WORMAN HEALTH PLAN: HealthAmerica/HealthASsUrarlc= DATE OF INJURY: 10112/99 SERVICE PERIOD: 1115199-8130101 SubJect to cna,ngs. FIL- NUMBER: CV-204282471020 a?structions: - Miake_checks payable to: Healthcare Recoveries. Write tine patient's name. SARA lilft3rRvIMAN. said -hie nurnoer. ' :W-20428247't020. on the cre ::. rOVIder Od SerV6Gv ? Jla?rnO$is Code Ciaim Number ' DMe Of Service .) Procedure Codels) ? Billed Ain:. ? pald '? r:. - 354.0 Caroal tunnel sv ".030720444 0;23700 87729 Phvsical median 380.100 354.0 Carpal tunnei sv :030720445 35100 __ 97799 Phvsicai medici; 8'c0.CO 354.0 Carpaitunneisv 03732253'. 27789 Phvsicai madicin SBD.00 „ - - ,54.0 Caroai tunneisv 1031322502 -77P9 PhySicaPnS 530.00 354.0 Caroai tunnei sv '0320?990° 97799 Phvsicai medicin S30.00 all -r, 229 Phvsical n=_dicir, `iIOLAG0_ 17; CO "r17/OD -_ ,VEST SHt '18100 314.0 Fx carcai ®onets 3908 WHFO?NRIST =-I,'- 264.0 Carpal tunnei sv 95900 Motor nerve test 354.0 Caroai tunnei sv 01810 Anesthesia. iowe :201341 - - -22-2 - 2s7291iv - - - s1a76.e8 - _ ' 4387&:35 _ 32740.87 078016= - S205.00 !28311401 S80.CG Sc'0.00 27724315 20623868 SAE 0C 21255180 X240.00 - -240.00 '?']fl(1 31!1 _ fl -^ 00 9126100 : 01810 Anesthesia, lowe S390.00 3192.00 Total Billed Charges $14,805.36 Amount Received $0.00 Total Paid Charges $6.665.99 if Balance Due 667665.99 1MAFAC Risk Management, Inc. 60CCAMPANELLi DRIVE, BRAINTREE. MA. 02184 Maning Address: P.O. Box 922',?`I'f't9 dMl2?ii ft1DENT REPORT Claim # GL9909192 Giant Locatic Your Flame: !address: Telephone: I(a!- 1c?'"r Datelof Birth: npp .- i D ^a Date of Accident: `!Cr time: 8 - ; it? Soc. Sec # l n t -, n -:s la VUnere did Accident happen: a - L" MbI . Ll Date: 4? ?i1_4d Signature: n ll iJV! C. ;Jame of Store Employee Reported To: lTttl A 1 i o SARA L. WORMAN, : IN THE COURT OF COMMON PLEAS : OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff CIVIL ACTION-LAW V. No. 2001-5511 GIANT FOOD STORES, INC., a/k/a GIANT T FOOD STORES,: LLC Defendant JURY TRIAL DEMANDED CERTIFICATE OF SERVICE On this oZS day of September, 2003, 1 hereby certify that Plaintifrs Arbitration Exhibits was served upon the following by U.S. mail: George B. Faller, Jr., Esquire Dale F. Shughart, Jr., Esquire MARTSON, DEARDORFF WILLIAMS & OTTO 35 E. High Street Ten East High Street Suite 203 Carlisle, PA 17013 Carlisle, PA 17013 Michael J. Pykosh, Esquire James M. Robinson, Esquire P.O. Box 368 28 South Pitt Street 3805 Market Street Carlisle, PA 17013 Camp Hill, PA 17011 Date: HAN & ROSENBERG By W . ott1300 Linglesto Harrisburg, PA 1 (717) 238-2000 ATTORNEY FOR FF SARA L. WORMAN, : IN THE COURT OF COMMON PLEAS : OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff CIVIL ACTION-LAW V. No. 2001-5511 GIANT FOOD STORES, INC., a/k/a GIANT T FOOD STORES,: LLC Defendant JURY TRIAL DEMANDED CERTIFICATE OF SERVICE On this ?j day of September, 2003, 1 hereby certify that Plaintiff's Arbitration Exhibits was served upon the following by U.S. mail: George B. Faller, Jr., Esquire MARTSON, DEARDORFF WILLIAMS & OTTO Ten East High Street Carlisle, PA 17013 Michael J. Pykosh, Esquire P.O. Box 368 3805 Market Street Camp Hill, PA 17011 Dale F. Shuahart. Jr., Esquire 35 E. High Streei Suite 203 Carlisle, PA 17013 James M. Robinson. Esouire 28 South Pitt Street Carlisle, PA 17013 R Dater By i it W.$,dott E 1300 Linglesto,y R, Harrisburg, Pqq'' 171 (717) 238-2000 / & ROSENBERG ATTORNEY FOR PLAINTIFF SARA L. WORMAN, : IN THE COURT OF COMMON PLEAS OF Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA Vs. NO. 01-5511 CIVIL TERM GIANT FOOD STORES, INC., a/k/a: CIVIL ACTION - LAW GIANT FOOD STORES, LLC JURY TRIAL DEMANDED Defendants NOTICE OF HEARING BY BOARD OF ARBITRATORS You are hereby notified that the Board of Arbitrators appointed by the Court in the above captioned case will sit for the purpose of their appointment in the Hearing Room, Second Floor of the Old Cumberland County Courthouse, Carlisle, Pennsylvania, on Wednesday, October 15, 2003, at 1:30 p.m. Dale F. Shughart, Jr., Esquire Michael J. Pykosh, Esquire James M. Robinson, Esquire IJ By:X?)-'5EQ' ND-? Dale F. Sh h r , Jr., Chairman Board of Ar at ors DATE: August 27, 2003 W. Scott Henning, Esquire HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 George B. Faller, Jr., Esquire MARTSON, DEARDORFF, WILLIAMS & OTTO Ten East High Street Carlisle, PA 17013 Michael J. Pykosh, Esquire P. O. Box 368 3805 Market Street Camp Hill, PA 17011 Court Administrator One Courthouse Square Carlisle, PA 17013 James M. Robinson, Esquire 28 South Pitt Street Carlisle, PA 17013 DALE F. SHUGHART, JR. ATTORNEY AT LAW 35 EAST HIGH STREET SUITE 203 CARLISLE, PENNSYLVANIA 17013 Telephone (717) 241-4311 Facsimile (717) 241-4021 OF COUNSEL HAMILTON C. DAVIS August 27, 2003 LEGAL ASSISTANT BONNIE L. COYLE W. Scott Henning, Esquire George B. HANDLER, HENNING & ROSENBERG, LLP MDW&O 1300 Linglestown Road Ten East Harrisburg, PA 17110 Carlisle, Michael J. Pykosh, Esquire P. O. Box 368 3805 Market Street Camp Hill, PA 17011 RE: Sara L. Worman v a/k/a Giant Food No. 01-5511 Gentlemen: Faller, Jr., Esquire High Street PA 17013 James M. Robinson, Esquire 28 South Pitt Street Carlisle, PA 17013 Giant Food Stores, Inc. Stores, LLC The above captioned arbitration, for which the Notice of Hearing is enclosed, is a trip and fall case. I anticipate you will have agreed upon medical records to be submitted by Stipulation, or alternatively, under the Rules governing arbitration. I request that a copy of such records as will be admitted into evidence be submitted to the Arbitrators at least twenty (20) days prior to the date of the hearing. Please do not expect us to be prepared to hear and decide the case if you do not submit this information to us in advance. If you will be having live witnesses, showing videotapes, or having someone read physician's depositions, please advise me, and do not send us such information in advance. Thank you for your cooperation. Very truly yours, Dale F. Shughart, Jr. DFS,JR/bc Enclosure SARA L. WORMAN, : IN THE COURT OF COMMON PLEAS : OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff CIVIL ACTION-LAW V. No. 2001-5511 GIANT FOOD STORES; INC., . a/k/a GIANT T FOOD STORES,: LLC Defendant JURY TRIAL DEMANDED NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 Liberty Avenue Carlisle, PA 17013 Telephone 717-249-3166 or 800-990-9108 HANDLER, HENN N-GG & ROSENBERG By W. Sco Henni Es . I.D. #32 1300 Linglestown oad Harrisburg, PA 110 (717) 238-2000 Attorney for Plaintiff SARA L. WORMAN, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff CIVIL ACTION-LAW V. : No. 2001-5511 GIANT FOOD STORES, INC., . a/k/a GIANT T FOOD STORES,: LLC Defendant JURY TRIAL DEMANDED COMPLAINT AND NOW, comes the Plaintiff, SARA L. WORMAN by and through her attorneys, HANDLER, HENNING & ROSENBERG, by W. Scoff Henning, Esquire, and brings forth this Complaint against Defendant GIANT FOOD STORES, INC., a/k/a GIANT FOOD STORES, LLC and aver as follows: 1. Plaintiff, Sara L. Worman, is an adult individual currently residing at 522 Springhouse Road, Camp Hill, Cumberland County, PA 17011. 2. Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, is a 1 corporation registered and established under the laws of Pennsylvania, with a location at 700 Camp Hill Shopping Plaza, Camp Hill, Cumberland County, PA 17011. 1 Defendant Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, is a corporation registered and established under the laws of Pennsylvania, with a registered office 1149 Harrisburg Pike, Carlisle, Cumberland County, PA 17013. 1 4. At all times material hereto, Plaintiff, Sara L. Warman, was a business invitee upon said Premises. 5. At all times material hereto, Defendants, who had exclusive control of said Premises, had allowed a squashed red pepper to remain on the floor in the produce area. . 6. At all times material hereto, there were no warning signs posted on the Premises warning of the possibility that produce was on or remained on the floor. 7. On or about October 12, 1999, at about 10:30 AM, Plaintiff, Sara L. Warman, was on the Premises shopping. While shopping in the produce aisle, Plaintiff was caused to slip and fall harshly and roughly to the ground due to a squashed red pepper, that was allowed to remain on the floor, causing personal injuries upon the Plaintiff as detailed more specifically hereinafter. COUNT I- NEGLIGENCE Sara L. Worman v. Giant Food Stores. Inc. alkla Giant Food Stores LLC 8. Paragraphs 1 - 7 are incorporated herein by reference as if fully set forth at length. 9. At all times material to hereto, Plaintiff, Sara L. Warman, believes and therefore avers, that Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, was in ownership, possession, management and control of the Premises and was responsible for maintaining the safe condition of the property known as a Giant Food Stores located at 700 Camp Hill Shopping Plaza, Camp Hill, Cumberland County, PA 17011. 2 10. The occurrence of the aforementioned incident and the resulting injuries to Plaintiff, Sara L. Worman, were caused directly and proximately by the negligence of Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, by its agents, servants, workmen or employees, acting in the scope of their authority and employment, generally and more specifically as set forth below: (a) In causing or permitting the floor at Premises to become littered with a squashed red pepper and/or other produce, thereby posing an unreasonable risk of injuryto the Plaintiff and to other persons lawfully upon the premises; (b) In failing to make a reasonable inspection of said Premises which would have revealed the existence of the dangerous condition posed by the squashed red pepper, and thereby allowing the same to be and remain a dangerous condition when the Defendant knew or should have known of it; (c) In failing to ensure the floors at said Premises were maintained in a safe condition to prevent injury to the Plaintiff and other persons lawfully upon the Premises; (d) In failing to post a warning sign or device in the area to notify of the dangerous condition on the floor of said Premises; 3 (e) In failing to clean the squashed red pepper from the floor of said Premises so as to avoid the situation in which the Plaintiff slipped and fell; and (f) In failing to maintain the common floor in a reasonably safe condition that would prevent a customer from slipping and falling. 11. Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, had actual knowledge or should have known through the exercise of ordinary care and diligence that there was a squashed red pepper on the floor in the area where Plaintiff, Sara L. Worman, fell. 12. As a direct and proximate result of the negligence of Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, Plaintiff, Sara L. Worman, sustained serious injuries including, but not limited to, extreme trauma to her left wrist, neck and rib area. She suffered a comminuted T-shaped fracture to the distal radius of the left arm. 13. As a direct and proximate result of the negligence of Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, Plaintiff, Sara L. Worman, has undergone great physical pain, discomfort and mental anguish and she will continue to endure the same for an indefinite period of time in the future, to her great detriment and loss, physically, emotionally and financially. 14. As a direct and proximate result of the negligence of Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, Plaintiff, Sara L. Worman, has been, and will in 4 the future be, hindered from attending to her daily duties to her great detriment, loss, humiliation and embarrassment. 15. As a direct and proximate result of the negligence of Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, Plaintiff, Sara L. Worman, has, and will in the future, suffer a loss of life's pleasures. 16. As a direct and proximate result of the negligence of Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, Plaintiff, Sara L. Worman, has been compelled, in order to effect a cure for the aforesaid injuries, to expend large sums of money for medicine and medical attention, and will be required to expend large sums of money for the same purposes in the future, to her great detriment and loss. WHEREFORE, Plaintiff, Sara L. Worman, seeks damages from Defendant Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, in an amount in excess of Twenty-Five Thousand Dollars ($25,000.00), exclusive of interest and costs, which is an amount in excess of jurisdictional amounts requiring compulsory arbitration. Respectfully submitted, HANDLER. HEW4M & ROSENBERG W. Scott H ?,n I. D. # 32 8 1300 Lin own Ro d P.O. Box 1177 Harrisburg, PA 17 8-1177 ?r (717) 238-2000 Dated: Attorney for Plaintiff 5 VERIFICATION The undersigned hereby verifies that the statements in the foregoing document are based upon information which has been furnished to counsel by me and information which has been gathered by counsel in the preparation of this lawsuit. The language of the document is of counsel and not my own. I have read the document and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information and belief. To the extent that the contents of the document are that of counsel, I have relied upon my counsel in making this Verification. The undersigned also understands that the statements made therein are made subject to the penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities. Sara'C. orman Date: IL-01'01 SARA L. WORMAN, Plaintiff V. : IN THE COURT OF COMMON PLEAS : OF CUMBERLAND COUNTY, PENNSYLVANIA : CIVIL ACTION-LAW No. 2001-5511 GIANT FOOD STORES, INC., . a/k/a GIANT T FOOD STORES,: LLC Defendant JURY TRIAL DEMANDED CERTIFICATE OF SERVICE On this 6th day of November, 2001, 1 hereby certify that Plaintiff's Cmplaint with Notice to Defend was served upon the following by U.S. mail, certified delivery George B. Faller, Jr., Esquire MARTSON, DEARDORFF WILLIAMS & OTTO Ten East High Street Carlisle, PA 17013 HENNING Date: 11 /6/2001 By W. Wurg, 130 Har(717) 238-2000 10 RG ENBE ATTORNEY FOR PLAINTIFF 0 SARA L. WORMAN, : IN THE COURT OF COMMON PLEAS :CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. NO. 2001-5511 GIANT FOOD STORES, INC. a/k/a GIANT FOOD STORES, LLC, Defendant CIVIL ACTION -LAW RULE 1312.1. The Petition for Appointment of Arbitrators shall be substantially in the following form: PETITION FOR APPOINTMENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: W. Scott Henning, Esquire, of Handler, Henning & Rosenberg, LLP, counsel for the Plaintiff in the above action, respectfully represents that: 1. The above-captioned action is at issue. 2. The claim of the Plaintiff in the action is $ 25,000.00. 3. The counterclaim of the defendant in the action is N/A. The following attorneys are interested in the case as counsel or are otherwise disqualified to sit as arbitrators: W. Scott Henning, Esq., Handler, Henning & Rosenberg, LLP, 1300 Linglestown Road, Harrisburg, PA 17110 and George B. Faller, Jr. , Esq., Manson, Deardorff, Williams & Otto, Ten East High Street, Carlisle, PA 17013. WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to whom the case shall be submitted. Respectfully submitted, HANDLER, HENNING & ROSENBERG, LLP By W. WcA ni , Esq. I.D. #32 1300 Li lest wn Ro Harrisbur , A 1711 (717) 238-2000 Attorney for Plainti ORDER OF COURT AN/D? NOW, 2003, in consideration of the foregoing petition, G?jg?q., and Esq., are appointed r , arbitrators in the above-captioned action as pra ?edr. By the Cc rt, ( V1 r IF P.J. 71- rl) ? 11 Q -43 VINb'AOMNIJ .C d V t C) -, D> C= C ,- = ?. S IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No. 2001 -S'911 Civil Action - (XX) Law ( ) Equity JURY TRIAL DEMANDED SARA L. WORMAN and JARED N. WORMAN 522 Springhouse Road Camp Hill, PA 17011 Plaintiff(s) & Address(es) PRAECIPE FOR WRIT OF SUMMONS TO THE PROTHONOTARY OF SAID COURT: Please issue A Writ of Summons in the above-captioned action. X Writ of Summons Shall be issued and forwarded to ( W. Scott Henning. Esquire 1300 Linglestown Road P.O. Box 1177 Harrisburg. PA 17108 (717) 238-2000 Name/Address/Telephone No. of Attorney Co t-, `-I0A_i-? GIANT FOOD STORES, INC. a/k/a GIANT FOOD STORES, LLC 1149 Harrisburg Pike Carlisle, PA 17013 Signature of Supreme Court ID Defendant(s) & Address(es) Date: 9/17/2001 WRIT OF SUMMONS TO THE ABOVE NAMED DEFENDANT(S): YOU ARE NOTIFIED THAT THE ABOVE-NAMED PLAINTIFF(S) HAS/HAVE COMMENCED AN ACTION AGAINST YOU. _ /l Date: ?a rYS b\Y ( ) Check here if reverse is used for additional information 1ROTHON.-55 v 1 9 q J C t .-ry i1 r, v .m?eard-- ? '=vim SHERIFF'S RETURN - REGULAR CASE NO: 2001-05511 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND WORMAN SARA L ET AL VS GIANT FOOD STORES INC ET AL KENNETH GOSSERT , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within WRIT OF SUMMONS was served upon GIANT FOOD STORES INC the DEFENDANT , at 1520:00 HOURS, on the 26th day of September, 2001 at 1149 HARRISBURG PIKE CARLISLE, PA 17013 by handing to HAVEN FISH, LEGAL ADMIN a true and attested copy of WRIT OF SUMMONS together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing 18.00 Service 3.25 Affidavit .00 Surcharge 10.00 .00 31.25 So Answers : R. Thomas Kline 09/27/2001 HANDLER HF.NNING & R(1.4FNBERG Sworn and Subscribed to before By: me this /,S±: day of Cu?< d.ao/ A. D. Prothonotary F:gUES\DATAFILE\Macdoc.cw1153-pra.1/mah Created: 10/05/0104:23:25 PM Revised 10105101 04:34:03 PM 9500.153 . '+. SARA L. WORMAN and JARED N. WORMAN, Plaintiffs V. K IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW 2001-5511 GIANT FOOD STORES, INC., a/k/a GIANT FOOD STORES, LLC, Defendants JURY TRIAL OF TWELVE DEMANDED PRAECIPE TO THE PROTHONOTARY OF CUMBERLAND COUNTY: Enter the appearance of MARTSON DEARDORFF WILLIAMS & OTTO on behalf of Defendant, GIANT FOOD STORES, LLC, in the above matter and issue a rule upon the Plaintiffs to file a Complaint within twenty (20) days from service thereof or suffer judgment of non pros. Defendant hereby demands a twelve juror jury trial in the above captioned action. MARTSON DEARDORFF WILLIAMS & OTTO By G r e B. Fal er, Jr., ui I.D. No. 44813 Ten East High Street Carlisle, PA 17013 (717) 243-3341 Dated: October 5, 2001 Attorneys for Defendant Giant Food Stores, LLC RULE AND NOW, this/D day of ?( - 2001, a Rule is issued upon the Plaintiff to file a Complaint within twenty (20) days from service hereof. Protl onotary 4 CERTIFICATE OF SERVICE I, Melinda A. Hall, an authorized agent for Martson Deardorff Williams & Otto, hereby certify that a copy of the foregoing Praecipe was served this date by depositing same in the Post Office at Carlisle, PA, first class mail, postage prepaid, addressed as follows: W. Scott Henning, Esquire HANDLER, HENNING & ROSENBERG 319 Market Street P.O. Box 1177 Harrisburg, PA 17108 MARTSON DEARDORFF WILLIAMS & OTTO By AdIA Melinda 'A. Hall Ten East High Street Carlisle, PA 17013 (717) 243-3341 Dated: October 5, 2001 u, r e c ? c G rr n s. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY WORMAN Vs. : NO. 2001 5511 GIANT FOOD STORES CERTIFICATE PREREQUISITE TO SERVICE OF A SUBPOENA PURSUANT TO RULE 4009.22 As a prerequisite to service of a subpoena(s) for documents and things pursuant to Rule 4009.22 GEORGE FALLER, ESQUIRE certifies that: 1. A Notice of Intent to Serve the Subpoena(s) with a copy of the subpoena(s) attached thereto was mailed or delivered to each party at least twenty days prior to the date on which the subpoena(s) is sought to be served, 2. A copy of the Notice of Intent, including the proposed subpoena(s) is attached to this certificate, 3. No objection to the subpoena(s) has been received, and 4. The subpoena(s) which will be served is identical to the subpoena(s) which is attached to the Notice of Intent to Serve the Subpoena(s). Date: 11/21/01 GEORGE FALLER, ESQUIRE MARTSON DEARDORFF WILLIAMS TEN EAST HIGH STREET CARLISLE, PA 17013 717-243-3341 ATTORNEY FOR DEFENDANT INQUIRIES SHOULD BE ADDRESSED TO: MEDICAL LEGAL REPRODUCTIONS, INC. 4940 DISSTON STREET PHILADELPHIA PA 19135 (215) By: Christine Janiszewski File #: M280652 I 1 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY WORMAN Vs. GIANT FOOD STORES I No. 2001 5511 TO: W SCOTT HENNING NOTICE OF INTENT TO SERVE A SUBPOENA TO PRODUCE DOCUMENTS AND THINGS FOR DISCOVERY PURSUANT TO RULE 4009.21 DEFENDANT intends to serve a subpoena(s) identical to the one (s) attached to this notice. You have twenty (20) days from the date listed below in which to file of record and serve upon the undersigned an objection to the subpoena. If no objection is made the subpoena may be served. Date: 10/31/01 GEORGE FALLER, ESQUIRE MARTSON DEARDORFF WILLIAMS TEN EAST HIGH STREET CARLISLE, PA 17013 ATTORNEY FOR DEFENDANT INQUIRIES SHOULD BE ADDRESSED TO: MEDICAL LEGAL REPRODUCTIONS, INC. 4,940 DISSTON STREET PHILADELPHIA, PA 19135 (215) 335-3336 By: Christine Janiszewski Enc(s): Copy of subpoena(s) Counsel return card File #: M280652 is COMMONWEALTH OF PENNSYLVANIA COUNTY OF CLU43 RIAND WORMAN Vs. File No. 2001 5511 GIANT FOOD STORES SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 HOLY SPIRIT HOSP, 503 N 21ST ST, CAMP HILL PA 17011 TO: ATTN: MEDICAL RECORDS DEPT (Name of Person or Entity) Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following documents orsph.ing§T _ at MEDICAL LEGAL REPRODUCTIONS T19C, 4940 DISSTON ST., PHILA., PA to dress) You may deliver or mail legible copies of the documents or produce things requested t-. this subpoena, together with the certificate of ompliance, to the party making thi_ request at the address listed above. You have the right to seek in advance the rea.onabla cost of preparing the copies or producing the things sought. If you fail to produce the documents or things required by this subpoena within twenty (20) days after its service, the party serving thin, subpoena may seek a court orde?- cmpelling you to comply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: GEORGE FALLER, ESQ ADDRESS: MARTSON DEARDORFF WILLIAMS ^T-R ISLE ,, PA-z 7013 cr TELEPHONE: -3- SUPREME COURT ID ATTORNEY FOR: 49813 DEFENDANT M280652-01 1110:5101 DATE: Seal of the Court BY THE COURT: Prothonotary/Cfledk, Civil Division a u ?!n 6 Deputy (Eff. 7/97) t WORMAN Vs. ADDENDUM TO SUBPOENA GIANT FOOD STORES No. 2001 5511 CUSTODIAN OF RECORDS FOR: HOLY SPIRIT HOSP Any and all hospital records, including microfilm, microfiche emergency room reports, x-ray reports, out-patient records physical therapy records, and any other information pertaining to: NAME: SARA L WORMAN ADDRESS: 522 SPRING HOUSE RD CAMP HILL PA DATE OF BIRTH: 04/16/38 SSAN: 161323713 ALL FEES MUST BE APPROVED PRIOR TO RECORDS BEING FORWARDED. RECORD CUSTODIAN - COMPLETE AND RETURN [ ] RECORDS ARE ATTACHED HERETO: I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced [ ] NO DOCUMENTS AVAILABLE: I hereby certify that a thorough search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( ) RECORDS / XRAYS have been destroyed Date Authorized signature for HOLY SPIRIT HOSP M280652-01 *** SIGN AND RETURN THIS PAGE *** TO: of Person or Entity) Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following documents orSE-113 E LUDDENDUM at _ MEDICAL LEGAL REPRODUCTIONS, =NC1 8940 DISSTON ST., PHILA., PA (Address) You may deliver or mail legible copies of the documents or produce things requested t•? this subpoena, together with the certificate of owpliance, to the party. making thi_ request at the address listed above. You have the right to seek in advance the rea,onable cost of preparing the copies or producing the things sought. if you fail to produce the documents or things required by this subpoena within twenty (20) days after its service, the party serving thin, subpoena may seek a court orde.- o-mpelling you to cmply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: MAW- GEORGE FALLER, ESQ - ADDRESS: MARTSON DEARDORFF WILLIAMS A?,-rA -7013 TELEPHONE: 2 - 33?3'sS? SUPREME COURT ID . ATTORNEY FOR. 49813 DEFENDANT M280652-02 DATE: COMWNWFALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND WORMAN Vs. File No. GIANT FOOD STORES 2001 5511 SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 ORTHO INST OF PA, 875 POPLAR CHURCH RD, CAMP HILL PA 17011 .11/x5'/01 Seal of the Court BY THE COURT: Prothonotar / erk, Civil Division ?u ?ee?ti Deputy (Eff. 7/97) S WORMAN Vs. ADDENDUM TO SUBPOENA GIANT FOOD STORES No. 2001 5511 CUSTODIAN OF RECORDS FOR: ORTHO INST OF PA ANY AND ALL OFFICE RECORDS, INCLUDING NOTES, CORRESPONDENCE, MEMORANDA, X-RAY REPORTS, HISTORY NOTES, INDEX CARDS AND ANY OTHER INFORMATION RELATING TO ANY EXAMINATION OR TREATMENT RENDERED TO: NAME: SARA L WORMAN ADDRESS: 522 SPRING HOUSE RD CAMP HILL PA DATE OF BIRTH: 04/16/38 SSAN: 161323713 CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN - COMPLETE AND RETURN [ ] RECORDS ARE ATTACHED HERETO. I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. [ ] NO DOCUMENTS AVAILABLE. I hereby certify that a thorough search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( ) RECORDS / XRAYS have been destroyed Date Authorized signature or ORTHO INST OF PA CUMBERLAND M280652-02 *** SIGN AND RETURN THIS PAGE *** COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBhMLANU WORMAN Vs. File No. GIANT FOOD STORES 2001 5511 SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 TO: CAPITAL AREA SURGICAL, 890 POPLAR CHURCH RD #200, CAMP HILL PA 17011 of Person or Entity) Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following documents orSthin gAs;r _ at MEDICAL LEGAL REPRODUCTIONS ,(A9C4ss)940 DISSTON ST., PHILA., PA You may deliver or mail legible copies of the documents or produce things requested b) this subpoena, together with the certificate of caipliance, to the party making thi_ request at the address listed above. You have the right to seek in advance the rea^onable cost of preparing the copies or producing the things sought. If you fail to produce the documents or things required by this subpoena within twenty !201 days after its service, the party serving thi., subpoena may seek a court orde;- cxxtpelling you to carply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: MAW! GEORGE FALLER, ESQ ADDRESS: MARTSON DEARDORFF WILLIAMS CARLISLE, PA 17013 TELEPHONE: 335-3 12 SUPREME COURT ID # ATTORNEY FOR: 49813 DEFENDANT M280652-03 11/USA/O1 DATE: Seal of the Court BY THE COURT: J/J Prothonotary k, Civil Division -4" Deputy (Eff. 7/97) WORMAN Vs. ADDENDUM TO SUBPOENA GIANT FOOD STORES No. 2001 5511 CUSTODIAN OF RECORDS FOR: CAPITAL AREA SURGICAL ANY AND ALL OFFICE RECORDS, INCLUDING NOTES, CORRESPONDENCE, MEMORANDA, X-RAY REPORTS, HISTORY NOTES, INDEX CARDS AND ANY OTHER INFORMATION RELATING TO ANY EXAMINATION OR TREATMENT RENDERED TO: NAME: SARA L WORMAN ADDRESS: 522 SPRING HOUSE RD CAMP HILL PA DATE OF BIRTH: 04/16/38 SSAN: 161323713 CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN - COMPLETE AND RETURN [ ] RECORDS ARE ATTACHED HERETO: I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. [ l NO DOCUMENTS AVAILABLE: I hereby certify that a thorough oearch has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) X-RAYS Date CUMBERLAND M280652-03 ( ) PATIENT BILLING ( ) RECORDS / XRAYS have been destroyed Authorized signature for CAPITAL AREA SURGICAL * * * SIGN AND RETURN THIS PAGE * * * Co1mNWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND WORMAN Vs. File No. GIANT FOOD STORES 2001 5511 SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 TO: of Person or Entity Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following documents o§kV'A7'TACHED E DENDt at - MEDICAL LEGAL REPRODUCTIONS,(Atldress1940 DISSTON ST., PHILA., PA You may deliver or mail legible copies of the documents or produce things requested ?-,, this subpoena, together with the certificate of carpliance, to the party making thi_ request at the address listed above. You have the right to seek in advance the reasonable cost of preparing the copies or producing the things sought. If you fail to produce the documents or things required by this subpoena within twenty (20) days after its service, the party serving this, subpoena may seek a court orde• cxmpelling you to comply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: GEORGE FALLER, ESQ ADDRESS: MARTSON DEARDORFF WILLIAMS eARhISLE, PA 17013 TELEPHONE: 215-335353212 SUPREME COURT ID # ATTORNEY FOR: 49813 DEFENDANT M280652-04 11 /oy'/ O 1 DATE: Seal of the Court PENN REHAB ASSOS, 2151 LINGLESTOWN RD #240, HARRISBURG PA 17110 BY THE COURT: Prothonnotary/ er , Civil Division ?(a- )hu , Deputy (Eff. 1/97) WORMAN Vs. ADDENDUM TO SUBPOENA GIANT FOOD STORES No. 2001 5511 CUSTODIAN OF RECORDS FOR: PENN REHAB ASSOS ANY AND ALL OFFICE RECORDS, INCLUDING NOTES, CORRESPONDENCE, MEMORANDA, X-RAY REPORTS, HISTORY NOTES, INDEX CARDS AND ANY OTHER INFORMATION RELATING TO ANY EXAMINATION OR TREATMENT RENDERED TO: NAME: SARA L WORMAN ADDRESS: 522 SPRING HOUSE RD CAMP HILL PA DATE OF BIRTH: 04/16/38 SSAN: 161323713 CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN - COMPLETE AND RETURN [ ] RECORDS ARE ATTACHED HERETO: I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced [ ] NO DOCUMENTS AVAILABLE: I hereby certify that a thorough search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( ) RECORDS / XRAYS have been destroyed Date Authorize signature for PENN REHAB ASSOS CUMBERLAND M280652-04 * * * SIGN AND RETURN THIS PAGE * * * comuNWEALTH OF PENNSYLVANIA COUNTY OF amERTAND WORMAN Vs. File No. GIANT FOOD STORES SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 2001 5511 WEST SHORE ENDOSCOPY, 423 S 21ST ST STE 102, CAMP HILL PA 17011 TO: (Name of Person or Entity) Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following documents o?.-tka,ingsT at MEDICAL LEGAL REPRODUCTIONS, I$,C, 4,940 DISSTON ST., PHILA., (Address You may deliver or mail legible copies of the documents or produce things requested t•; this subpoena, together with the certificate of ccnpliance, to the party making thi_ request at the address listed above. You have the right to seek in advance the reasonable cost of preparing the copies or producing the things sought. If you fail to produce the documents or things required by this subpoena within twenty (20) days after its service, the party serving thin, subpoena may seek a court orde•- crnpelling you to ccnply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: GEORGE FALLER, ESQ ADDRESS: MARTSON DEARDORFF WILLIAMS nh nr corn T'T-t'r7013 TELEPHONE: SUPREME OOURT ID # ATTORNEY FOR: 49813 DEFENDANT M280652-05 1116,, /O1 DATE: Seal of the Court BY THE COURT: "- e 'w rK 1 ' Prothonotary ' 1 k, Civil Division Deputy (Eff. 7/97) ADDENDUM TO SUBPOENA WORMAN Vs. GIANT FOOD STORES No. 2001 5511 CUSTODIAN OF RECORDS FOR: WEST SHORE ENDOSCOPY ANY AND ALL OFFICE RECORDS, INCLUDING NOTES, CORRESPONDENCE, MEMORANDA, X-RAY REPORTS, HISTORY NOTES, INDEX CARDS AND ANY OTHER INFORMATION RELATING TO ANY EXAMINATION OR TREATMENT RENDERED TO: NAME: SARA L WORMAN ADDRESS: 522 SPRING HOUSE RD CAMP HILL PA DATE OF BIRTH: 04/16/38 SSAN: 161323713 CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN - COMPLETE AND RETURN [ ] RECORDS ARE ATTACHED HERETO: I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. [ ] NO DOCUMENTS AVAILABLE: I hereby certify that a thorough search has been made and that no record of the following documents have ° been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( ) RECORDS / XRAYS have been destroyed Date Authorize signature for WEST SHORE ENDOSCOPY CUMBERLAND M280652-05 * * * SIGN AND RETURN THIS PAGE * * * COMMONWEALTH OF PENNSYLVANIA COQNPY OF CUMBERLAND WORMAN Vs. File No 2001 5511 GIANT FOOD STORES SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT 70 RULE 4009.22 TO: JOYNER SPORTS MED INST, 6301 GRAYSON RD STE 138, HARRISBURG PA 17111 Name of Person or Entity) Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following documents ongsT ED 'XiD JLflr at MEDICAL LEGAL REPRODUCTIONS, I C, A940 DISSTON ST., PHILA., PA (A?ress ) You may deliver or mail legible copies of the documents or produce things requested ?; this subpoena, together with the certificate of ccrrpliance, to the party making thi: request at the address listed above. You have the right to seek in advance the rea,cnable cost of preparing the copies or producing the things sought. If you fail to produce the docunents or things required by this subpoena within twent;. (20) days after its service, the party serving 'thin subpoena may seek a court orde ompelling you to carply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: GEORGE FALLER, ESQ ADDRESS: MARTSON DEARDORFF WILLIAMS GAR1,1SLE PA 17013 TELEPHONE: 3?32I SUPREhE COURT ID # _ ATTORNEY FOR. 49813 DEFENDANT M280652-06 11/0? /ol . DATE: Seal of the Court BY TFE COURT: Prothonotary/01&k, civil Division Deputy (Eff. 7/97) ADDENDUM TO SUBPOENA WORMAN Vs GIANT FOOD STORES No. 2001 5511 CUSTODIAN OF RECORDS FOR: JOYNER SPORTS MED INST ANY AND ALL OFFICE RECORDS, INCLUDING NOTES, CORRESPONDENCE, MEMORANDA, X-RAY REPORTS, HISTORY NOTES, INDEX CARDS AND ANY OTHER INFORMATION RELATING TO ANY EXAMINATION OR TREATMENT RENDERED TO: NAME: SARA L WORMAN ADDRESS: 522 SPRING HOUSE RD CAMP HILL PA DATE OF BIRTH: 04/16/38 SSAN: 161323713 CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN - COMPLETE AND RETURN [ ] RECORDS ARE ATTACHED HERETO: I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. [ ] NO DOCUMENTS AVAILABLE: I hereby certify that a thorough search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( ) RECORDS / XRAYS have been destroyed Date Authorized signature for JOYNER SPORTS MED INST CUMBERLAND M280652-06 * * * SIGN AND RETURN THIS PAGE * * * COW4XMEALTH OF PENNSYLVANIA COUNTY OF akeE:RIAND WORMAN Vs. File No. 2001 5511 GIANT FOOD STORES SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 GRANDVIEW SURGERY CTR, 205 GRANDVIEW AVE, CAMP HILL PA 17011 TO: (Name of Person or Entity) Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following documents gh'irftl ACHED ADDENDUM at _ MEDICAL LEGAL REPRODUCTIONS, Igs, 4940 DISSTON ST., PHILA., PA (A ress You may deliver or mail legible copies of the docunents or produce things requested by this subpoena, together with the certificate of compliance, to the party making th`i_ request at the address listed above. You have the right to seek in advance the reasonable cost of preparing the copies or producing the things sought. If you fail to produce the docunents or things required by this subpoena within twent} (20) days after its service, the party serving 'thi, subpoena may seek a court orde• cm, yelling you to ccmply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: GEORGE FALLER, ESQ ADDRESS: MARTSON DEARDORFF WILLIAMS ;PA 3: 013 TELEPHONE: 215- 2- SUPREME COURT ID # ATTORNEY FOR: 49.813 DEFENDANT M280652-07 11/06-/01 DATE: Seal of the Court BY THE COURT: Prothonotary/C1 k, Civil Division Deputy (Eff. 7/97) WORMAN Vs. ADDENDUM TO SUBPOENA GIANT FOOD STORES No. 2001 5511 CUSTODIAN OF RECORDS FOR: GRANDVIEW SURGERY CTR ANY AND ALL OFFICE RECORDS, INCLUDING NOTES, CORRESPONDENCE, MEMORANDA, X-RAY REPORTS, HISTORY NOTES, INDEX CARDS AND ANY OTHER INFORMATION RELATING TO ANY EXAMINATION OR TREATMENT RENDERED TO: NAME: SARA L WORMAN ADDRESS: 522 SPRING HOUSE RD CAMP HILL PA DATE OF BIRTH: 04/16/38 SSAN: 161323713 CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN - COMPLETE AND RETURN [ ] RECORDS ARE ATTACHED HERETO.I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. [ ] NO DOCUMENTS AVAILABLE. I hereby certify that a thorough search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( ) RECORDS / XRAYS have been destroyed Date Authorized signature or GRANDVIEW SURGERY CTR CUMBERLAND M280652-07 * * * SIGN AND RETURN THIS PAGE * * * CDpMNWEALTH OF PENNSYLVANIA COUNTY OF CUMF;)D) WORMAN Vs. File No 2001 5511 GIANT FOOD STORES SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISODVERY PURSUANT TO RULE 4009.22 DR GERALD DINCHER, 2704 MARKET ST, CAMP HILL PA 17011 TO: (Name of Person or Entity) Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following docuneits o ngtTACIIED - __ SEE at --- MEDICAL LEGAL REPRODUCTIONS, INC, 4940 DISSTON ST., P ILA., ---- (Addddress) You may deliver or mail legible copies of the documents or produce things requested t•, this subpoena, together with the certificate of camI iance, to the party making thi7 request at the address listed above. You have the right to seek in advance the rea.onable cost of preparing the copies or producing the things sought. If you fail to produce the documents or things required by this subpoena within twenty (20) days after its service, the party serving thi, subpoena may seek a court orde,- oaTpelling you to cm-ply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: GEORGE FALLER, ESQ ADDRESS: MARTSON DEARDORFF WILLIAMS n r na- r'-- fr, 7 0 13 TELEPHONE: SUPREME OOURT ID # __- ATTORNEY FOR: M280652-08 49813 DEFENDANT 11/OS/O1 DATE: Seal of the Court BY THE COURT: l c?? Z /C. Opt - Prothonotary/C1 k, Civil Division Deputy (Eff. 7/97) WORMAN Vs. ADDENDUM TO SUBPOENA GIANT FOOD STORES No. 2001 5511 CUSTODIAN OF RECORDS FOR: DR GERALD DINCHER ANY AND ALL OFFICE RECORDS, INCLUDING NOTES, CORRESPONDENCE, MEMORANDA, X-RAY REPORTS, HISTORY NOTES, INDEX CARDS AND ANY OTHER INFORMATION RELATING TO ANY EXAMINATION OR TREATMENT RENDERED TO: NAME: SARA L WORMAN ADDRESS: 522 SPRING HOUSE RD CAMP HILL PA DATE OF BIRTH: 04/16/38 SSAN: 161323713 CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN - COMPLETE AND RETURN [ 7 RECORDS ARE ATTACHED HERETO: I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. NO DOCUMENTS AVAILABLE: I hereby certify that a thorough search has been made and that no record of the following documents'have been located (CHECK THE APPROPRIATE BOX) : ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( ) RECORDS / XRAYS have been destroyed Date Authorized signature for DR GERALD DINCHER CUMBERLAND M280652-08 * * * SIGN AND RETURN THIS PAGE * * * COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND WORMAN Vs. File No 2001 5511 GIANT FOOD STORES SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 VISITING NURSE ASSN, 3315 DERRY ST, HARRISBURG PA 17111 TO: ATTN: PERSONNEL DEPARTMENT (Name of Person or Entity) Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following documents '99i'I'VifT ACHED ADDENDUM at MEDICAL LEGAL REPRODUCTIONS,(&? es4?40 DISSTON ST., PHILA., PA You may deliver or mail legible copies of the docunents or produce things requested t. this subpoena, together with the certificate of ccnpliance, to the party making thi: request at the address listed above. You have the right to seek in advance the reasonable cost of preparing the copies or producing the things sought. If you fail to produce the documents or things required by this subpoena within twenty (20) days after its service, the party serving this, subpoena may seek a court orde,- cxxrpelling you to cm-ply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLONING PERSON: NAME: GEORGE FALLER, ESQ ADDRESS: MARTSON DEARDORFF WILLIAMS CART 1SLE -PA--1-7 013 TELEPHONE: SUPREME COURT I D ATTORNEY FOR: M280652-09 11/0,5,101 DATE: Seal of the 49813 DEFENDANT BY THE COURT: Prothonotary/ 1 k, civil Division ` Deputy (Eff. 7/97) WORMAN Vs. ADDENDUM TO SUBPOENA GIANT FOOD STORES No. 2001 5511 CUSTODIAN OF RECORDS FOR: VISITING NURSE ASSN ANY EMPLOYMENT APPLICATIONS, EARNINGS, LEDGER SHEETS, TIME CARDS REVIEWS, ATTENDANCE SHEETS, ANY AND ALL MEDICAL RECORDS AND REPORTS AND PRE-EMPLOYMENT PHYSICALS, WORKMEN'S COMPENSATION CLAIMS MADE, ANY W-2 WITHHOLDING TAX FORMS, AND ANY OTHER INFORMATION PERTAINING TO: NAME: SARA L WORMAN ADDRESS: 522 SPRING HOUSE RD CAMP HILL PA DATE OF BIRTH: 04/16/38 SSAN: 161323713 CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN - COMPLETE AND RETURN [ ] RECORDS ARE ATTACHED HERETO. I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced ] NO DOCUMENTS AVAILABLE. I hereby certify that a thorough search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX) : ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( ) RECORDS / XRAYS have been destroyed Date Authorized signature for VISITING NURSE ASSN CUMBERLAND M280652-09 * * * SIGN AND RETURN THIS PAGE * * * COMMONWEALTH OF PENNSYLVANIA COUNPY OF CUMBFRIAND WORMAN Vs. File No. GIANT FOOD STORES 2001 5511 SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 TO: of Person or Entity) Within twenty (20) days after service of this subpoena, you are ordered by the court tc produce the following documents o?tbing? at DR BRIAN QUIRK, 4713 LOCUST LN, HARRISBURG PA 17109 MEDICAL LEGAL REPRODUCTIONS, IRC, 4k940 DISSTON ST., PHILA., PA (Address) You may deliver or mail legible copies of the documents or produce things requested t. this subpoena, together with the certificate of ccrpliance, to the party making this request at the address listed above. You have the right to seek in advance the reasonable cost of preparing the copies or producing the things sought. If you fail to produce the docLymnts or things required by this subpoena within twenty (20) days after its service, the party serving thin, subpoena may seek a court orde• cm pelting you to ccnply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: GEORGE FALLER, ESQ ADDRESS: ______---MA, DEARDORFF WILLIAMS Cr"T?u E&LR-,-PA--1-7013 TELEPHONE: 215- 35-3212 COURT ID k-- ATTORNEY FOR: 49813 DEFENDANT M280652-10 11/D? /Ol DATE: Seal of the Court BY THE COURT: Prothonotar C erk, Civil Division _ Q, Q. ?72< f P? Deputy (Eff. 7/97) ADDENDUM TO SUBPOENA WORMAN Vs. GIANT FOOD STORES No. 2001 5511 CUSTODIAN OF RECORDS FOR: DR BRIAN QUIRK ANY AND ALL OFFICE RECORDS, INCLUDING NOTES, CORRESPONDENCE, MEMORANDA, X-RAY REPORTS, HISTORY NOTES, INDEX CARDS AND ANY OTHER INFORMATION RELATING TO ANY EXAMINATION OR TREATMENT RENDERED TO: NAME: SARA L WORMAN ADDRESS: 522 SPRING HOUSE RD CAMP HILL PA DATE OF BIRTH: 04/16/38 SSAN: 161323713 CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN - COMPLETE AND RETURN [ ] RECORDS AREATTACHED HERETO: I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. [ ] NO DOCUMENTS AVAILABLE. I hereby certify that a thorough search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( )"X-RAYS ( ) RECORDS / XRAYS have been destroyed Date Authorized signature or DR BRIAN QUIRK CUMBERLAND M280652-10 *** SIGN AND RETURN THIS PAGE *** COMMONWEALTH OF PENNSYLVANIA COURN OF CUMBERLAND WORMAN Vs. GIANT FOOD STORES File No. 2001 5511 SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 TO: Name of Person or Entity) Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following documents op nXi I ACHED ADDENDUM at _ ¢¢ _ MEDICAL LEGAL REPRODUCTIONS,(AdNNC,4s 940 DISSTON ST., PH ILA., PA You may deliver or mail legible copies of the documents or produce things requested t•, this subpoena, together with the certificate of compliance, to the party making thi< request at the address listed above. You have the right to seek in advance the rea,onabla cost of preoaring the copies or producing the things sought. If you fail to produce the documents or (20) days after its service, the party ompelling you to comply with it. things required by this subpoena within twenty serving this subpoena may seek a court order THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: GEORGE FALLER, ESQ ADDRESS: MARTSON DEARDORFF WILLIAMS ^ --PA--l-7013 TELEPHONE: SUPREhE COURT ID ATTORNEY FOR: 49'813 DEFENDANT BY THE COURT: M280652-11 11/P5/O1 DATE: Seal of the Court HEALTH ASSURANCE, PO BOX 2610, PITTSBURGH PA 15230 e JcZvi W ae? L. _ .. . Prothonotary/ , Civil Division c N o. 72(cL? Deputy (Eff. 7/97) I y ADDENDUM TO SUBPOENA WORMAN Vs GIANT FOOD STORES No. 2001 5511 CUSTODIAN OF RECORDS FOR: HEALTH ASSURANCE ANY AND ALL RECORDS, MEDICAL AND OR ACCIDENT CORRESPONDENCE, NOTES, RECEIPTS, BILLS, ETC., AND ANY OTHER INFORMATION PERTAINING TO: NAME: SARA L WORMAN ADDRESS: 522 SPRING HOUSE RD CAMP HILL PA DATE OF BIRTH: 04/16/38 SSAN: 161323713 ALL FEES MUST BE APPROVED PRIOR TO RECORDS BEING FORWARDED. RECORD CUSTODIAN - COMPLETE AND RETURN [ l RECORDS ARE ATTACHED HERETO: I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. [ ] NO DOCUMENTS AVAILABLE: I hereby certify that a thorough search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( )'X-RAYS ( ) RECORDS / XRAYS have been destroyed Date Authorize signature for HEALTH ASSURANCE CUMBERLAND M280652-11 * * * SIGN AND RETURN THIS PAGE * * * t f i WORMAN Vs. GIANT FOOD STORES File No. SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 TO, PA BLUE SHIELD, 1800 CENTER ST, CAMP HILL PA 17011 ATTN: LEGAL DEPT (Name of Person or Entity 2001 5511 Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following documents oS,tlaingsT,TA$ at MEDICAL LEGAL REPRODUCTIONS, (AddC,4940 DISSTON ST., PHILA., >?A ress) You may deliver or mail legible copies of the documents or produce things requested b, this subpoena, together with the certificate of ccmpliance, to the party making thi_ request at the address listed above. You have the right to seek in advance the reasonablE cost of preparing the copies or producing the things sought. If you fail to produce the documents or things required by this subpoena within twenty (20) days after its service, the party serving 'thi, subpoena may seek a court orde•- crnpelling you to comply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NpmE: GEORGE FALLER, ESQ ADDRESS: MARTSON DEARDORFF WILLIAMS CART 1& L• --I?z7013 TELEPHONE: SUPREhE COURT ID # - - ATTORNEY FOR M280652-12 11/0,-'/()1 49813 DEFENDANT DATE: Seal of the Court COM DNWFALTH OF PENNSYLVANIA COUIM OF CU; fflERJ DID BY THE OOUR7: l u `f-o "e0"'"-4 2=' yProthonotar"y/ , Civil Division 0. Deputy (Eff. 7/97) i WORMAN Vs. ADDENDUM TO SUBPOENA GIANT FOOD STORES No. 2001 5511 CUSTODIAN OF RECORDS FOR: PA BLUE SHIELD ANY AND ALL RECORDS, MEDICAL AND OR ACCIDENT CORRESPONDENCE, NOTES, RECEIPTS, BILLS, ETC., AND ANY OTHER INFORMATION PERTAINING TO: NAME: SARA L WORMAN ADDRESS: 522 SPRING HOUSE RD CAMP HILL PA DATE OF BIRTH: 04/16/38 SSAN: 161323713 #QBD161323713 ALL FEES MUST BE APPROVED PRIOR TO RECORDS BEING FORWARDED. RECORD CUSTODIAN - COMPLETE AND RETURN [ ] RECORDS ARE ATTACHED HERETO. I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. [ l NO DOCUMENTS AVAILABLE: I hereby certify that a thorough search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( j RECORDS / XRAYS have been destroyed Date Authorized signature for PA BLUE SHIELD CUMBERLAND M280652-12 *** SIGN AND RETURN THIS PAGE *** 4 w r (7) C . -rl C. C -U r is F:\FILES\DATAFILE\Maz&o ..,\153-.s 1/.Im Created. 11/13/0109:3144 AM Jtevised 11/43/01 10:05:57 9500,153 SARA L. WORMAN and JARED N. WORMAN, Plaintiffs V. GIANT FOOD STORES, INC., a/k/a GIANT FOOD STORES, LLC, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW 2001-5511 JURY TRIAL OF TWELVE DEMANDED DEFENDANT'S ANSWER TO PLAINTIFFS' COMPLAINT 1. After reasonable investigation, Defendant is without knowledge or information sufficient to form a belief as to the truth or falsity of the averments contained in this paragraph. The averments are therefore deemed denied and proof is demanded. 2. Denied as stated. To the contrary, Giant Food Stores, LLC is a Delaware corporation which has a retail establishment at 700 Camp Hill Shopping Plaza, Camp Hill, Cumberland County, Pennsylvania 17011. 3. Denied. To the contrary, Giant Food Stores, LLC is a Delaware Corporation with a registered office at 1149 Harrisburg Pike, Carlisle, Cumberland County, Pennsylvania 17011. 4. Denied pursuant to Pa. R.C.P. 1029(e). 5. It is admitted that the Defendants operated aretail grocery establishment at 700 Camp Hill Shopping Plaza, Camp Hill, Cumberland County, Pennsylvania and had possession and control of the premises. The remaining averments of this paragraph are denied pursuant to Pa. R.C.P. 1029(e). 6-7. Denied pursuant to Pa. R.C.P. 1029(e). COUNT I-NEGLIGENCE Sara L. Worman v. Giant Food Stores. Inc. a/k/a Giant Food Stores. LLC 8. Paragraphs 1 through 7 of this Answer are hereby incorporated by reference. 9. It is denied that the Defendant Giant was the owner of the premises. It is admitted that Defendant Giant operated the retail grocery establishment and possessed and controlled the premises. 10. It is denied that this incident occurred as a result of the negligence of the Defendant Giant by or through its agents, servants, workmen, or employees acting within the scope of their authority and employment. (a-f). Denied pursuant to Pa. R.C.P. 1029(e). 11-16. Denied pursuant to Pa. R.C.P. 1029(e). WHEREFORE, Defendant Giant Food Stores LLC demands judgment in its favor and dismissal of Plaintiffs' Complaint with prejudice. MARTSON DEARDORFF WILLIAMS & OTTO By Wyll G ge . le , r., E quire I.D. Number 49813 Ten East High Street Carlisle, PA 17013-3093 (717) 243-3341 Attorneys for Defendant Date: I?t? 3??1 VERIFICATION I, TIMOTHY REARDON, Vice President-Risk Management and Support Services of Giant Food Stores, LLC, acknowledge that I have the authority to execute this Verification on behalf of Giant Food Stores, LLC and certify that the foregoing Defendant's Answer to Plaintiff's Complaint is based upon information which has been gathered by my counsel in the preparation of this lawsuit. The language of this Answer is that of counsel and not my own. I have read the document and to the extent that this Answer is based upon information which I have given to my counsel, it is true and correct and to the best of my knowledge, information and belief. To the extent that the content of this Answer is that of counsel, I have relied upon counsel in making this Verification. This statement and Verification are made subject to the penalties of 18 Pa. C.S. § 4904 relating to unworn falsification to authorities, which provides that if I knowingly make false averments, I may be subject to criminal penalties. Giant Food Vice President - Risk Mgt. & Support Services Dated: F TILESIDXWILEIb(ecdoc,cuA156ens.1 NOY 20 2001 I VV? CERTIFICATE OF SERVICE I, Nichole L. Myers, an authorized agent of Martson Deardorff Williams & Otto, hereby certify that a copy ofthe foregoing Defendant's Answer to Plaintiffs' Complaint was served this date by depositing same in the Post Office at Carlisle, PA, first class mail, postage prepaid, addressed as follows: W. Scott Henning, Esquire HANDLER, HENNING & ROSENBERG 1300 Linglestown Road P.O. Box 1177 Harrisburg, PA 17108-1177 MARTSON DEARDORFF WILLIAMS & OTTO By Y(UU& Y1 Nichole L. Myers Ten East High Street Carlisle, PA 17013 (717) 243-3341 Dated: ?,Ucu" ? 3, ooO I 0 Q UQ ? - mf- SARA L. WORMAN, V. Plaintiffs GIANT FOOD STORES, INC. a/k/a GIANT FOOD STORES, LLC, Defendants : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA NO.01-5511 CIVIL TERM CIVIL ACTION - LAW PLAINTIFF'S ARBITRATION EXHIBITS In accordance with Pennsylvania Rule of Civil Procedure 1305(b), the following documents are attached which the Plaintiff intends to introduce into evidence at the time of the arbitration of this case: 1. Medical Records from Orthopedic Institute of Pennsylvania - Dr. Dailey 10/15/99 through 7/7/00 2. Medical Records from Holy Spirit Hospital; 10/12/1999 3. Medical Records from Herd Chiropractic Clinic; 1/14/00 through 7/31/00 4. Grandview Surgery Center; 4/18/00 5. Narrative Report from Dr. Dailey dated 2/5/01; 6. Supplemental Narrative Report from Dr. Dailey dated July 19, 2001; 7. Medical expense billing summary (with corresponding billing statements); 8. Incident Report. Date: September 25, 2003 Respectfully Submitted, HANDLE N & By W. Scott Hen g, s I. D. #3229 1300 Ling st n oa Harrisbur , A 7110 (717) 238-20 Attorney for Plaintiff LLP ORTHO,:r:DIC INSTITUTE OF PENNSYLVEUViA (717) 761-5530 Patient: Sara L. Worman Chart #: 11524206 DOB: 04/16/38 SSN: 161 32 3713 Page # 12 ------------------------------------------------------------------------------ 6/16/2000 STEPHEN W. DAILEY, M.D. -CONTINUED- LEVEL THREE REVIEW OF SYSTEMS: The patient's review of systems, past medical history, family history and social history have been re-evaluated and reviewed. PHYSICAL EXAM: On examination there is no swelling, ecchymosis, deformity or atrophy in the hand. There is some tenderness in the area of the A-1 pulley, the right middle finger. No active triggering. All joints of the hand have a full and pain free range of motion both passively and actively. All joints of the hand and fingers are stable. Sensory, motor, reflex and vascular exams of that extremity are within normal limits. All tendon functions are intact. There are no skin lesions. Examination of the wrist, elbow and shoulder are normal. DIAGNOSIS: 1. Improvement status post left endoscopic carpal tunnel release. 2. Mildly symptomatic right carpal tunnel. 3. Right middle finger triggering which is coming back. PLAN: I told her at this point it makes sense just to wait and see how she does with her right middle finger trigger. She will come to see me on an as needed basis if the right middle finger continues to trigger and gets worse to the point where she would consider another injection or surgical release. SWD/raf cc: Brian Quirk, M.D. via fax 7/07/2000 STEPHEN W. DAILEY, M.D. LEVEL FOUR Tr'_rdle Road Office CHIEF COMPLAINT: Triggering right middle finger. HISTORY OF CO DINT: Sara Worman returns. Sh has increased problems with her right middle finger trigger. It is occur ing everyday and later in the day as well and do (No actually get stuck in/he a flexed position. REVIEW OF SYSTEMS: The atiznt's nevi of systems, past medical history, =amily history and social istory ha e been re-evaluated and reviewed. PH'?SI CAL EXAM: Cn examination t ere -s no swelling, eccnymosis, deformity or a _rophv in the rand. There is der'less over the A-'_ pulley and active 7arggering today all jo/eftlle"x of t hand have a full and pain free range of motion both passively and vely. 1 joints of the hand and fingers are table. Sensory, 'rotor, and vas lar exams of that extremity are within _hin normal limits. 1 tendon function are intact. There are no skin lesions. Examination f the wrist, elbow an boulder are normal. ASSESSMENT: Right diddle finger trigger recalcitr2vt to injections. PLAN: I discuss/d the diagnosis and recommendation of AN,,_pulley release at ORTHu. ?iDIC INSTITUTE OF PENNSYLV,_.,A (717) 761-5530 Patient: Sara L. Worman Chart #: 11524206 DOB: 04/16/38 SSN: 161 32 3713 Page # 11 ------------------------------------------------------------------------------ 5/19/2000 STEPHEN W. DAILEY, M.D. -CONTINUED- LEVEL TWO CHIEF COMPLAINT: HISTORY OF COMPLAINT: Sara returns. She did great for the fist two weeks after her left endoscopic carpal tunnel release and then, with increase in activities and strengthening exercises it started to be aggravated. The right carpal tunnel syndrome is not that symptomatic at this point and she is not having numbness and tingling every day. She is bothered by her right middle finger triggering which has recurred after the last injection. REVIEW OF SYSTEMS: The patient's review of systems, past medical history, family history and social history have been re-evaluated and reviewed. PHYSICAL EXAM:- The incision is well healed on the left wrist. There i-s minimal tenderness and minimal scar tissue. On the right hand there is tenderness over the A-1 pulley of t^:e middle finger and triggering with passive motion of the finger. DIAGNOSIS: 1. Doing well S/P endoscopic left carpal tunnel release with aggravation probably by trying to do too much tcc soon. told her this and she'll slow down her activities and let pain be her guide. 2. Right carpal tunnel svndreme. PLAN: In terms of her right carpal tunnel syndrome I don't th-nk we need to do anything at this point. For her right middle triggering finger I offered her injection again today and this was undertaken ster'_lely. She understands that if it does recur after this injection it is probably a geed idea consider trigger finger release. I'll see her back in three weeks. SWD/kir Faxed to: Brian Quirk, M.D. 6/16/2000 STEPHEN W. DAILEY, M.D. LEVEL THREE Trindle Road Office CHIEF COMPLAINT: Sara Worman returns. ....- is making some -mt._vement wit: her left hand and that is actually nct c,irg her anv croblems at this point. She is having some triggering which has d--relcue7 once again. __ her r'gnt middle finger. The injection helped for while but -= is ccm-ng back slowly. The carpal tunnel on the right -_ essentially aery min''-many symptomatic and therefore we will not worry about that at this -_me. t -J (717) 761-5530 Patient: Sara L. Worman Chart #: 11524206 DOB: 04/16/38 SSN: 161 32 3713 Page # 10 ------------------------------------------------------------------------------ 4/12/2000 STEPHEN W. DAILEY, M.D. -CONTINUED- LEVEL TWO distal radius fracture. I told her that the carpal tunnel takes precedence and when she recovers from that if she is still having persistent problems in her wrist we will evaluate that at that time. SWA/kmp CC: Brian Quirk, M.D. via fax 4/18/2000 STEPHEN W. DAILEY, M.D. GRANDVIEW SURGICAL CENTER April 18, 2000 GRANDV=EW SURGERY CENTER DIAGNOSIS: Left carpal tunnel syndrome PROCEDURE: Left endoscopic carpal tunnel release SWD/kmp CC: Brian Quirk, M.D. via fax 4/26/2000 ALEXANDER KALENAK MD GLOBAL SERVICE VISIT Trindle Road Office Eight days status-post endoscopic left carpal tunnel release by Dr. Dailey. She is actually ecstatic about her results. She states there is very little swelling. She is able to use the fingers without provocation almost immediately post op. She can hold a cell phone which she was unable to do. PHYSICAL EXAM: Incision healing well. No drainage. Minimal swelling and tenderness. PLAN: Continue all activities as tolerated. Judicious use for any heavy activities. Return to see Dr. Dailey in three weeks or so. AK/kir Faxed to: Brian Quirk, M.D. 5/15/2000 STEPHEN W. DAILEY, M.D. REgUEST FOR RECORDS Office notes copied, billed by Quadramed and mailed to HANDLER, HENNING & ROSENBERG, ATTORNEYS AT LAW. elb ORTh.--DIC INSTITUTE OF PENNSYLI._.iA 5/19/2000 STEPHEN W. DAILEY, M.D. LEVEL TWO Trindle Road Office ORTH(...DIC INSTITUTE OF PENNSYLM-,.,IA (717) 761-5530 Patient: Sara L. Worman chart #: 11524201 DOB: 04/16/38 SSN: 161 32 3713 Page # 9 --- ----------------------------------------------- 2/04/2000 STEPHEN W. DAILEY, M.D. -CONTINUED- LEVEL TWO DIAGNOSTIC TESTS: EMG and nerve conduction studies as above. DIAGNOSIS: 1. Bilateral carpal tunnel, right worse than left. 2. Triggering right middle finger. PLAN: I discussed the diagnosis and treatment options with the patient. She would like to proceed with endoscopic carpal tunnel release and this is to be scheduled for her right wrist. Also her right middle finger was injected today with 1/2 cc. of Celestone and 1/2 cc. of 1% Lidocaine without epinephrine. She will see how this works for her and will let me know whether we will release her finger or inject it again at the time of surgery. She was given a prescription for Flexeril 10 mgs., 420 with no refills. SWD/kir Faxed to: Brian Quirk, M.D 3/17/2000 THOMAS J. YUCHA MD CANCELLED The appointment was cancelled by the patient. This was an old post-op appointment as the patient's surgery was post-poned. tj s 4/12/2000 STEPHEN W. DAILEY, M.D. LEVEL TWO Poplar Church Road Office CHIEF COMPLAINT: Sara Worman returns. She returned from her trip and is having more problems actually with her left hand now. The injection helped out with the trigger finger and actually took away all of her symptoms on the right side. She is having increased numbness and tingling on the left side. It does wake her up at night. She has a previous EMG/NCS which was consistent with bilateral carpal tunnel syndrome which is moderate to severe. REVIEW OF SYSTEMS: The patient's review of systems, past medical history, family history and social history have been re-evaluated and reviewed. PHYSICAL EXAM: The left wrist has a positive Tinel's and positive compression. She is unable to do Phalen's do to her past wrist injurv. DIAGNOSIS: Bilateral carpal tunnel syndrome, with the left now being more symptomatic than the right. PLAN: She is already scheduled for the right side to be done April 18 and we are going to switch this to the left side now. We will arrange this today. Of note, she has also had persistent pain in her left wrist residual from her ORTh. MEDIC INSTITUTE OF PENNSYLD.-,,.4IA (717) 761-5530 Patient: Sara L. Worman Chart #: 11524201 DOB: 04/16/38 SSN: 161 32 3713 Page # 8 ------------------------------------------------------------------------------ 1/14/2000 STEPHEN W. DAILEY, M.D. -CONTINUED- LEVEL THREE negative. Tinel's and compression tests are positive bilaterally. Phalen's is positive on the right. She is unable to do a Phalen's on the left due to the stiffness from her distal radius fracture. She also has some nodular swelling in the area of the flexor tendons of the right middle finger at the A-1 pulley. There is no significant tenderness and no active triggering today. Tinel's sign at the elbows and elbow flexion tests are negative. Sensory, motor, reflex and vascular exams of that extremity are within normal limits. There are no skin lesions. Examination of the elbows and shoulders are grossly within normal limits. WRIST X-RAYS(RIGHT AND LEFT) : Radiographs reveal the bony architecture is intact without evidence of fracture or dislocation. No significant soft tissue abnormality is seen. DIAGNOSIS: Possible bilateral carpal tunnel syndrome. Possible right middle finger trigger. PLAN: Continue with her medications. Wrist splints at night. We ordered an EMG nerve conduction study today which will be obtained and I will see her back after that to discuss the results. SWD/raf cc: Brian Quirk, M.D. via fax RADIOLOGY RESULTS WRIST X-RAYS (RIGHT AND LEFT) : Radiographs reveal the bony architecture is intact without evidence of fracture or dislocation. No significant soft tissue abnormality is seen. IMPRESSION: SEE ABOVE STUDY. SWD/raf 2/04/2000 STEPHEN W. DAILEY, M.D. LEVEL TWO Trindle Road Office CHIEF COMPLAINT: Sara Warman returns. She is still having problems with numbness and tingling in both hands, right worse than left. They are numb and tingly almost constantly. It does wake her up at night. Splints have not helped. She also has a right triggering middle finger which bothers her as well. She had EMG and nerve conduction studies which are consistent with mildly severe bilateral carpal tunnel, right worse than left. REVIEW OF SYSTEMS: The patient's review of systems, past medical history, family history and social history have been re-evaluated and reviewed. PHYSICAL EXAM: ORTE_2EDIC INSTITUTE OF PENNSYL4,IVIA (717) 761-5530 Patient: Sara L. Worman Chart #: 11524206 DOE: 04/16/38 SSN: 161 32 3713 Page # 7 ------------------------------------------------------------------------------- 11/19/1999 STEPHEN W. DAILEY, M.D. -CONTINUED- RADIOLOGY RESULTS IMPRESSION: SEE ABOVE STUDY. SWD/raf 11/23/1999 JAMES R. HAMSHER MD CANCELLED The appointment- was cancelled by the patient. Rescheduled for 12-10-99. sam 12/10/1999 STEPHEN W. DAILEY, M.D. GLOBAL SERVICE VISIT Trindle Road Office CHIEF COMPLAIN'S': Sara Worman returns. She is still having some pain in her hand. She also has some numbness and tingling that comes occasionally as well. She has been wearing her cock-up wrist splint. PHYSICAL EXAM: She has some stiffness. 30 degrees of dorsiflexion raid 10 degrees of palmer flexion. She has a positive Tinel's at the wrist and positive compression test mildly. DIAGNOSIS: Probable median nerve irritation from her healing fracture. PLAN: D/C the immobilization. Work on her range of motion activities and follow up in cite month for re-evaluation. SWD/raf CC: Brian Quirk, M.D. via fax 1/14/2000 STEPHEN W. DAILEY, M.D. LEVEL THREE Trindle Road Office CHIEF COMPLAINT: Sara Wcrman returns today. She is having numbness and tingling in both hands especially in the night. She also describes some locking of her right middle finger. She has been wearing the cock-up wrist splint at night and this has not helped significantly. She has also been prescribed a pain medication by another physician. REVIEW OF SYSTEMS: The patient's review of systems, past medical history, family history and social history have been re-evaluated and reviewed. PHYSICAL EXAM: On examination there is no swelling, ecchymcsis, deformity or tenderness about the right and left wrists. The wrists have a full and pain free range of motion without crepitation. There is no distal radial ulnar joint instability. Scaphoid shift and lunotriquetral "shuck" tests are 5 ', ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patient: Sara L. Worman Chart #: 11524206 DOB: 04/16/38 SSN: 161 32 3713 Page # 6 ------------------------------------------------------------------------------ 11/05/1999 STEPHEN W. DAILEY, M.D. -CONTINUED- GLOBAL SERVICE VISIT Therefore, I would like her to see one of my partners for an exam out of plaster with radiographs on 11/23/99. SWD/kir Faxed to: Brian Quirk, M.D. RADIOLOGY RESULTS LEFT WRIST: Radiographs today reveal maintenance of the alignment of the fracture. IMPRESSION: SEE ABOVE STUDY. SWD/kir 11/17/1999 STEPHEN W. DAILEY, M.D. REQUEST FOR RECORDS Office notes copied, billed by Quadramed and mailed to MAC RISK MNCMNT, INC. elb 11/19/1999 STEPHEN W. DAILEY, M.D. GLOBAL SERVICE VISIT Trindle Road Office CHIEF COMPLAINT: Sara Worman returns early. She is having problems with her whole left upper extremity. She returns earlier than I wanted her to for possible removal of the cast. PHYSICAL EXAM: On physical exam she has full range of motion of the fingers. She is not tender over the fracture site after the short arm cast was removed. DIAGNOSTIC TESTS: Radiographs obtained today, 2 views of the wrist, show healing of the fracture. DIAGNOSIS: Healed distal radius fracture. PLAN: Cock-up wrist splint to be worn for the next 1-2 weeks. She will follow up in 3 weeks time. SWD/raf CC: Brian Quirk, M.D. via fax RADIOLOGY RESULTS LEFT WRIST X-RAYS: Radiographs obtained today, 2 views of the wrist, show healing of the fracture. ORTHOzEDIC INSTITUTE OF PENNSYLV1F,,IA (717) 761-5530 Patient: Sara L. Worman Chart #: 11524206 DOB: 04/16/38 SSN: 161 32 3713 Page # 5 ------------------------------------------------------------------------------ 10/22/1999 STEPHEN W. DAILEY, M.D. -CONTINUED- GLOBAL SERVICE VISIT comfortable at this point. PHYSICAL EXAM: On physical exam the cast is in good shape. Fingers are neurovascularly intact and she has good range of motion. DIAGNOSTIC TESTS: Radiographs, two views of the wrist obtained today, reveal maintenance of the alignment of the fracture which is acceptable. DIAGNOSIS: Post left distal radius fracture and contusion left ribs. PLAN: Continue with the moist heat to her ribs. Continue the short arm cast. She can start weaning herself from the sling. I'll see her back in two weeks at which time we'll get x-rays. I told her it would be a total of approximately six weeks immobilization for the distal radius to heal. SWD/kir Faxed to: Brian Quirk, M.D. RADIOLOGY RESULTS LEFT WRIST (2V) : Radiographs, two views of the wrist obtained today, reveal maintenance of the alignment of the fracture which is acceptable. IMPRESSION: SEE ABOVE STUDY. SWD/kir 11/05/1999 STEPHEN W. DAILEY, M.D. GLOBAL SERVICE VISIT Trindle Road Office CHIEF COMPLAINT: Sara Worman returns. She is doing quite well with her fracture. She is having some discomfort with the cast at the proximal end and underneath in the area of the ulnar styloid. PHYSICAL EXAM: The cast is in good shape. There is no erythema of the skin at the proximal end. She has good range of motion of the fingers and she is neurovascularly intact. DIAGNOSTIC TESTS: Radiographs today reveal maintenance of the alignment of the fracture. DIAGNOSIS: Doing well post fracture left distal radius PLAN: Continue the cast for another 2-1/2 weeks at which time the fracture should be healed and the cast will be removed. The patient is headed out of town early morning of November 24th and, therefore, 1 won't be able to see her at that time and would prefer not to remove the cast the Friday. I, ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patient: Sara L. Worman chart #: 11524206 DOB: 04/16/38 SSN: 161 32 3713 Page # 4 ------------------------------------------------------------------------------ 10/15/1999 STEPHEN W. DAILEY, M.D. -CONTINUED- RADIOLOGY RESULTS wrist, show maintenance of the distal radius alignment. Length is ulnar neutral and there is approximately 1-2 degrees of dorsal angulation which is acceptable. IMPRESSION: SEE ABOVE STUDY SWD/raf INITIAL FRACTURE Trindle Road Office CHIEF COMPLAINT: She is a 61-year-old right hand dominant female who was at the Giant Supermarket on Tuesday, slipped on a pepper-going down onto her left side with pain in her left chest area and her left distal radius. She was seen at Holy Spirit Hospital where x-rays were negative for any rib fractures. She had a comminuted intraarticular left distal radius fracture which was reduced and tasted in the ER. She was sent for our definitive care,; REVIEW OF SYSTEMS: The patient's review of systems, past medical history, family history and social history have been re-evaluated and reviewed. PHYSICAL EXAM: On physical exam the cast is in good shape. There is some swelling of the hand. It is neurovascularly intact. The cast does incorporate the ring finger, but there is some space to move the finger and it is neurologically intact. DIAGNOSTIC TESTS: Repeat radiographs obtained today, AP and lateral of the wrist, show maintenance of the distal radius alignment. Length is ulnar neutral and there is approximately 1-2 degrees of dorsal angulation which__ acceptable. DIAGNOSIS: Distal radius fracture interarticularly comminuted with acceptah'-e. closed reduction at this time. PLAN: Ice and elevation. Continue with the immobilization. I will see her-_. 1 week with x-rays on arrival. SWD/raf CORRESPONDENCE (Ref) QUIRK, M.D., BRIAN 10/22/1999 STEPHEN W. DAILEY, M.D. GLOBAL SERVICE VISIT Trindle Road Office CHIEF COMPLAINT: Sara Worman returns. She's had more problems with her contusion to her ribs on the left side than her left wrist which is feelinc { i awn. n*PATIENT INFORMATION SHEET ESTABLISHED PATIENT/NEW PROBLEM Chart Number: ZIS,2 4/0? Date: /0 -/Jr -9 9 Patient Name: $/910e„ L Last First M.I. Birth Date:/t,/ -Ilo-,3R Age: G/ Problem: Is the condition that you are being seen for the result of an injury? _7Vrs Date of Injury: Ze_: -99 Type of injury: Work Auto Other ?c If the condition is not the result of an injury, date symptoms first appeared: Description of accident: o ?? •d??? t ?.?rs? ? Rr6s If Workers' Comp: Employer: Occupation: Address: Insurance: If Auto: Insurance: State: If Other: Insurance: 0. C A14::19 «Li o? c c.'c,y 4A.¢cG? 11-17--36 Ao `? 6.74/710,2 Family Physician: ,elg.J mC??'.Q Ain Referring Physician: Send letter to: Family Physician:._yPs-- Referring Physician: x veA Neither: Revised 9/1/99 mee '2 r'1 r SRC IN BYa LHPLOYEE OF GIA IISri ER FORM REG DATF: 10/12/99 11:38 PT#: 14098081 MR#: 201982 INAMEV WORMAN SARA L SS *. 141-32-3/13 IADDnRESS. 522 SPRINGHOUSE RD /CAMP HILL /PA/17011 PH4: 717-761-1834 'iDIRTHDA;Ea 04/16/11?38 ADE: 61 SEX= F MS: M RACE: 1 OEO: 441030 CMP;..OYEN: RET-VISITING NURSE A OCCUPATION: VISITING NURSE ADDRESS. PH#'. 711-233-10315 ICHUP.CH: PRESBYTERIAN-SILVER SPRINGS AMS: HAMPDEN EMS COMMENT: i EMERGENCY CONTACT INFORMATION NAME, WORMAN JARED REL TO PT. H WORK PH Ma 71/-986-'3134 ADDRESS: 522 SPRINSHOU:3E RD /CAMP HILL /PA/17011 PH 1F; 717-761-1839 I NAME. IADURESS: !ADMIT DR; 111336 ATTND DR: 111336 RE TIR DR; '.ADMIT DX% ICOMPLAINT; FALL,Ll AMH BRT IN BY; CnMMENI: ACCIDENT INFIARMAIION DATE/TIME= 10/12/99 IO:20 ACE: IND: 0 .108 RELATED: N LOCATION: ;DESCRIPTION: PI SLIPPED ON A PErPCR AT GIA NT AND INJURVP HER LT WRIST GUARANIOR INFORMATION NAMP" WORMAN SARA L PT REL,TO GUAR= S SS #c 161-32-3713 ADDRF'SS; 322 SPRINDHOUSE. RD /DAMP HILL IPA/17011 PH #: 717-761-11139 EMF'Ln Y ER u RE T -- CONTACT NAME" AYIDRESS: PH #: 717-233-1035 INSURANCE INFORMATION PI. AN INSURANCE CO [:OF POLICY k GROUP M SUBSCRIBER REL PC VFY CARD PRECF_RT/AUTH 0 PRECERT PHONE # 1 OC12 HEALTH AMERICA 1F&O 1 20428247102 1022CI50002 WORMAN SARA S Y Y - - INSUR.ADDRESS: PO SOX 2610 PITTSBURGH PA 15230 2 I NSUR . ADDRESS; 1N'SUR.ADDRESS: 4 I NSUR . ADD4tESS _UMMENTS: FMD/COWL.P_Y MF-D ASSOC ATIENT NAlntu WORMAN SARA L PT#. .FGI.STERE.I1 13Y: FHMAK EDITED BY: VA'fF; REL l0 PT: WORK PH #: I / ! PH #= CASE INFORMATION SHARMA RAJANA REG SOURCZ: ED PATIENT TYPE; E SHARMA RAJANA HOSP SE:RVA ER3 FINANCIAL CLSr Q VISIT CLINIC CODE: ER3 ICD-9 DX= WRIST INJURY AND LT RI S PAIN q 3,? 3 14098481 MR*n 241932 C / END OF LGCUMf m,( r? ,Oft+ 01-%. Dom: D Log-in Time _ Name: 2?- Age: G 1 ? Triage Time FMD _ -- -a_ 124 63-X_ Time to Exam Room MOO of Arrival Ambulam t I BLS t I ALS 1 I Medical Cg d G IEF COMPLAINT: w. INITIAL TRIAGE: Place injury occurred [ ] Home [ ] Industry [ 7 Recreation [ } Othei information obtained from. -.._Patlsnt _FamllyiS O Records -_EMT/Poramedlc ExtrMnity Evaluation Triaged to radiology for Deform ty No SkinTemp Warm / of Distal Pulses Abeam DestlnatlOn [ ] ECU EDF Skin Color m !Cyanotic/Mottled,. Paint- 0) Pareatheala PMWAJ Time hMUvanaon el rfaturo: Temp:. ).! Pulse: as ions. EVP: /=l Pulse Ox.: o Altergiss7pesctlorim Latex-vas Last Tetanus: LMP Weigh ace Im partlnent Visual Atutty OD -OS 0 U _corr9wve lenses ' Supjecti : _ T / Objective: Prohospltal Treatment MedicationlDose/F uenc Last Dose Medication/Dose/F uen Last Dose C2 I ?f NJ ! U I Pas MedlcaVSurg cal History: CA s ; 161? 4 i Has patient had exposure to measles, chicxenpax or TB in peat montho Are there advance diredmaT.4 Is copy evailahlel- EXPEO_TED OUTCOMES Cardlat Output, aiteretlon in - Improvement in ceniiae output demunamated by improved v a and diagnostic taste Comfort, aileration in -Decrease or rebet of roscomfort Ruld volume, afteraaon in _ Improvement in fluid vei demonstrated by decrease in symptoms of fluid vol moaiarwe ! impaired gas exchange _ Improved gas exchange demonstrated by improved oxygenation and veal Milne PotenWkival intactwn - Decrease in symptoms indcaung Irdecoon or polanpal for mtecoon Knowledge Deficit - Improved knowledge demonstrated by veroe c a icn i ra4urn demoneeadon Assessment completed at !!/ by R.N. Data obtained by: M.A Admission Called (} Admission (} Observation [ ] Old RecoNa Sent Report Called Admitted to at Hm Transferred to at oy ptsposlpon [ ]vHO e ( MA( 7 OR at [ 7 SaLSfactory [ ] Im ed 7 C n [ ] sae morgue at Discharged U [ 1 owonarge instructions Dlsch e'R.N. at Holy Spirit Hospital Camp Hill, PA ECU Nursing Assessment ai1-EGU W eih rev JD, MD aR CHART COPY _'i G' =* C:t J NR 201982 E 1GRMI.I SARA 1 4F'(IrQMOE$a SD LR3 L?4P ll? Ph 1701t G4/161!/3b 761-1039 !bi-3_-3:13 SNU KA, RAJAMA 60NA44 SIR C02 :0425247102 10/1I/99 CONSENT TO MEDICAL TREA) MENT I HEREBY CONSENT AND AUTHORIZE Holy Spirit Hospital, its agents, and employees, to the rendering of medical care, which may include routine diagnostic procedures and such medical treatment as my attending or oonsuthng physician considers to be necessary 1 also under- stand it Is customary, absent emergency or extraordinary circumstances, that no substantial procedures will be performed upon me unless or until I have had an opportunity to discuss them with a physician or other health care professional to my saasfactx n If I am a competent adult, I have the right to consent or refuse to consent I understand that the practice of medlCne and surgery is not an exact science and that diagno- sis and treatrnent may involve risks of injury or even death and acknowledge that no guarantee has been made to me as to the results of any examination or treatment in this Hospital I understand many of the phymans on ft staff of Hoy Sport Howtai are not empbyaes or agents of ttre Hospital, but rather are independent contractors who have been granted the privilege of using these facilities for the care and treatment of their patients Further, I mahze this Hospital is a teaching Hospital and at the Hospital are heahh care personnel in training who, unless expressly requested otherwise, may participate or may be present during my care as part of their education Still or motion pictures and dosed circuit monitoring of patient Care may also be used for educational purposes, unless I expressly request otherwise. I understand that in order to ensure a safe environment for patients, visitors and staff all property an the premises of rit ?icapital is subject to reasonable search and/or seizure at any time without further nottce Thal RELEASE OF MEDICAL INFORMATION I authorize Holy Sport Hospital to release to requesting health insurance carder(s), their representatives and auditors, and any referring health care providers, such diagnostic and therapeuto mformahan (including any information rextang to treatment for alcohol and substance abuse and/or treatment of o- chiatric disorde rs. and/or oonfiden "I HIV related information as may be necessary for them to determine benefit anh- tlement, to process payment claims for health care services provided during this hospllahzation/treatment episode, and for continuing care/treatment A photocopy or carbon copy of this authorization shall be considered as effective and vefid as the original The undersigned also authorizes Medicare, when applicable, to release to another insurance tamer, upon their request, medical information needed to make payment upon that ciaim r understand and consent that the manufacturer of any implantable davioe inserted by my physician during the course ot?gt gu u maybe provided w h my identification] rmation, including social security number, as mandated by Federal Law IM Date Signature Relationship to Patient INSU NCE ASSIG MENT OF BENEFITS dial I authorize payment directly to Holy Spirit Hospital and my treating physicians of all benefits payable under my Insu policies land rstand I am responsible to the Hospital for all charges not covered by this assignment nitial STATEMENTTO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDERS, PHYSICIANS I ATIENT I request payment of Authorized Medicare benefits to me or on my behalf for any services furnished me by or in Hoy Spirit Hospital including physician services I authorize any holder of medical and other information about me, to release to Medicare and do agencies any information needed to determine these benefits for related services MEDICAL ASSISTANCE RECIPIENT Initials My signatures certifies that I received it service or items from Holy Spirit Hospital and Dr on the date listed below I understand that payment for this service or item will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of material may be prosecuted under applicable Federal and State Laws I have read and agree with the above statements I have read and understand each of the sections comalned ahon. I understand that by signing this doourrwM. I am agnahrg and 31ng the aut ho.cansei i aarmrtea in each of txra:attove sscdons vAisre my aro atedIhavehid theopportuni- a 0fon gac oath of ih section s arM ag such quesgons/ad)k/ed trees haat son locilocd tci my w roe i des Wltnag6rJR-- hip to Panar[zatbrd m Time Data &IlZlf 9 Date Signawre HOLY SPIRIT HOSPITAL, CAMP HILL, PA CONSENT FOR TREATMENT/ RELEASE OF INFORMATION INSURANCEASSIONMENT ?1 ttR 201962 E ;tdA L „', i ;?eOUS Rt. ER3 P .IL ?A 17011 „t11oJt.:d 7S[-1639 ,u.-:,_-}771 SMtknl itAJAaA. r.i :k An V0Z `01:$74110$ M MC166ED(7199) CHART COPY ?ON r* Halt' Spirit Hoo*W HealtbCare 24 Triaje Date Tune Name DO$. _I _/ _ Ate; ( ) male "htef Complaint. A Icrgy I-at Tetanus Shot [ ] nom I ] Vital S%w T P _, R. _ BP, Subject"* female e") in N of yon 1 _` WV __ Pau Medical Onset: - Madtanow IpcucesHour Days Obteeove Coasotousness [ ] Alen ( ] *cr Nunes Diagnoses eLZIL Expected Outcome Pnoruy 1 2 3 Tinge Completed Ttuge R N Si1v Discharged: Tune ) Discharge Report Called adnntted to FHC AVR ED FHC Time to Exam Room __„ Hn Firs (] Stdemils op tae _ () S=bcwry (1 Impttrved ] Cnacal I ] EWued Hrs Adauuwn Called Hn. u Hn ( ) Observawc ) Home (]AMA () Morgue [) OR u -HM- CHART COPY r ? []walk j ) BLS ( ) ALS I ] LMD Ref DR HMO Appr () yes ( ] no Dr tmte Prebosoital ,MedslAc PI LET Bxam Dr. CA-mg - MW I t 45 ( ) ED ( ] FHC ( ] Pnvate ) Consult Dr Swusm 0-1 ammo HOLY SPUM HOSPITAL Camp Hill, PA 17011 H:ALTECAM 24 i4-9808J NR 201982 W0l<NAN , SARA L S.2 SPNI'iGN0U5. k0 3 CAOF HIL, PA 17011 04/Ib/1436 761-1634 15)-3,-3713 SNARNA RAJA?A t,,-944 ,JAh 1401, 1042624710i 10/12/93 Yl To: FHC HC24, X.D. From, AX2909 Fax Stauan 10-12-99 3:24pm D. 1 of 1 ADM. DATE: 10/12/99 Sara is a 61-year-old nurse who presents to the Health Care 24 complaining of pain and discomfort in her left wrist after she fell earlier today in the grocery store area coming out of the grocery store. She fell and sustained an injury on her outstretched left wrist and neurovascularly intact. She was seen and initially evaluated. X-rays shows a comminuted T-shaped fracture of the distal radius with minimal displacement at best at this time. Neurovascular intact. Good pulse, moderate swelling. I have discussed with Sara at length the prognosis and treatment. If over the next several 10 days to 2 weeks of this fracture displaces or shortens, then all bets are off and we have to proceed with a pins and plaster fixation and or an external fixator to hold it in good alignment. However the alignment right now is very acceptable. I have gone ahead and placed her in a short arm light fiberglass cast to keep her completely immobilized, ice and elevation and I have given her a prescription for Darvocet-N 100 for pain. She 1s going to be using Advil in the interim as well and elevation and she will see Dr. Yucha who she has seen in the past for the next 2-3 days for follow up in the office and close monitoring of the fracture for the next 10 days. It is going to take approximately 6-8 weeks to completely heal and she is otherwise doing very well. She will follow up as scheduled. Diagnosis: Distal radius lnterartlcular fracture minimally displaced but needs to be watched closely over the next several weeks. Fr a cis Horner PA-C FH/js D: 10/12/1999 T: 10/12/1999 9198 cc Dr. Yucha Page 1 HOLY SPIRIT HOSPITAL NAMEi MORHAN, SARA Camp Hill, PA MR#: 201982 17011 ROOM #: ER3 DR.: Horner OONSULTATION REPORT i NAME WOfmA,ti a.n DATE /0•I.?• EOIHOUSE PHYSICIAN FINDINGS- CMR6E NURSE omo LOCATION Cie 3 1,-r %,h5 EDIHOOSE PHYSICIAN FppM 37 AHED ED CHART COPY DEPARTMENT OF RADIOLOGY HOLY SPIRIT HOSPITAL PRELIMINARY X-RAY INTERPRETATION AGE ' RADIOLOGIST FINDINGS. RADIOLOGIST ze? r Holy Spirit Hospital Department of Radiology and Diagnostic Imaging Camp Hill, Rennsylvannla 17011 (717) 763-2600 PATIENT: WORMAN, SARA L DICTATION DATE: Oct 12 1999 1 16P MR11; 2919$2 TRANSCRIPTION DATE: Oct 12 1999 2 21 P SOC SEC- 161-32-3713 ORD DR: RAJANA SHARMA M D PT TYPE: E ADM DATE; 1011211999 ARRIVAL DATE: 1011211999 LOCATION: ER3• HOSP SERVICE: ER3 *'*Final Report'' 5XAMINATION: LEFT FOREARM (2v), UNILATERAL LEFT RIBS (3v), CHEST (1v) 73090 - Oct 12 1999 COMMENTS- INDICATION- injury/trauma There is no previous chest radiographs available for comparison at the time of the dictation Both lungs are dear of air space or interstitial opacities The cardiac silhouette and madiastmal structures are unremarkable Pleura) effusions or pneumothorax are not seen There is no fractures identified There is no fracture identified in the left ribs Ostsoblastic or osteolytic changes are not seen The lungs are unremarkable Pleural effusions are not seen There is a comminuted fracture involving the articular surface of the distal. radius. There are no fractures identified in the ulna The alignment of the carpal bone is unremarkable CONCLUSION: Normal chest and left ribs Comminuted fracture of the distal radius DICTATED BY: NOBUO NAKAGAWA M D / DG DATE OF EXAM: Oct 121999 SIGNED BY: NOBUO NAKAGAWA M D DATEITIME, Oct 12 1999 3 10P OCT 12 1999 _ k---M D /D (. I ' "'t, rheea nrriers - -?`atrnorrnal but no action indicated. File Imaging Services Consultation Page 1 5 '. Holy Spirlt Hospital Department of Radiology and Diagnostic Imaging Camp Hill, P.ennsylvannia 17011 (717) 763*600 PATIENT, WORMAN, SARA L MR#: 201982 SOC SEC: 161-32-3713 ORD DR: RAJANA SHARMA M D PT TYPE: E ADM DATE: 10112/1999 LOCATION. ER3- DICTATION DATE: Oct 12 1999 1 18P TRANSCRIPTION DATE: Oct 12 1999 2 10P ARRIVAL DATE: 10/12/1999 HOSP SERVICE: ER3 ***Final Report*** EXAMINATION: LEFT WRIST (6V) 73110 - Oct 121999 COMMENTS INDICATION - fell Six views of the left wrist radiograph is obtained There is a comminuted fracture involving the distal radius The fracture lines appear to be involving the articular surface of the radlocarpal joint Mild impaction and angulation is noted There is no fracture identified in the distal ulna The radw-ulnerjoint space is widened CONCLUSION: Comminuted fracture of the distal radius DICTATED BY: NOBUO NAKAGAWA M D I DG DATE OF EXAM: Oct 12 1999 SIGNED BY: NOBUO NAKAGAWA M D DATErnME: Oct 12 1999 3 10P 1xT 12 1988 W),-, D /D.U r hu ' Or08?` ebno mat but n,, action indicated Ftte Imaging Services Consultation Page 1 ? Pitt. 13o4q ? P? Name w o rma n ,sara Phone: Home 7(0 l 3q Work X-Ray # i Camp Hill, PA 5 PEANAL INJURY QUESTIONNAIRE JName Date ofIn?)ury, Phone-i?(-i 93? Address City_(?}r?1>?t I? State Zip Employer's Name 0- h. rrfi, ( ployer's Address IN >?,Your Ins. Co. R Policy If ' Agent's Name ',?Iver/Other Vehicle ((„„ Ins. Co. Policy IF Have you retained an attorney? Y "t1 o Name Were there any witnessess? (x) Yes ( ) No Name(s) NATURE OF ACCIDENT: J. Date of Accident 10 I - C4 Time of Day-L80pul) Were you: ( ) Driver ( ) Passenger ( ) Front Seat /// ( ) Back Seat Number of people in your vehicle? Other vehicle? "Y4,Whal direction were you headed? ( ) North ( ) East ( ) South ( )West on (name of street) What direction was other vehicle headed? ( ) North ( ) East ( 1 South ( ) West on (name of street) Were you struck from: ( ) Behind ( ) Front ( ) Left side ) Right side 7. Were you knocked unconscious? ( ) Yes (A) No. If yes, for how long? B. Were police notified? ( ) Yes ) No I f I 1 - 9. In your own words, please describe accident) M4. ? - an liysical complaints BEFORE THE ACCIDENT? ( ) Yes (Vi No. If yes. please describe in details 11. Please describe how you felt: :? a. DURING the accident:,kl, b. IMMEDIATELY AFTER the accident: c. LATER THAT DAY: d. THEN EXT DAY: 12. What are your PRESENT complaints and symptoms? :? tl1x I FPPr?i-. .j b? K?, h , 13. Do you have any congenital (from birth) factors which relate to this problem- ( )Yes describe: ( DGNo. II yes, please 14. Do you have any previousn illnesses which relate to this case? p (x) Yes J ( ) No. If yes, please describe:: ,,rj-J- • IA IPIJ -Jt' IL-,- ?61rA .. 15. Have you ever been involved in an accident before? type(s) of accidents, as well as injury(ies) received.. u 16. Where were you taken after the accident? *4 17. Have you been treated by an doctor since the andaddress: ( ," Y What type of treatment did you receive? ? ( ?Ye ( ) No. If yes, please list doctor's name _ n .--7 .,, /l, 0 II . 18. Since this injury occurred, are your symptoms: ( ) Improving (X) Getting 'Norse 19. Have you lost time from work as a result of this accident? ( ) Yes / Q "G. if -Yes,.,,p?pi a. Last Day Worked: `14 ? b. Type of Emcicyment: c. Present Salary: d. Are you being compensated for time lost from war.<? ( ) Yes ( J No. II yes..-!ease state type of comcensaticn you ar? receiving: 20. Do you nptice any activity restrictians as a result of this injury? OO Yes ( ) No. !f yes, please describe. in detail: 21 ?ZL- I a0.fE ( )Same ase complete this 7uesticn. ( ) Yes (?) No. If yes, please describe, Including date(s) and SIGNATURE DIAGNOSIS SHEET PATIENT'S NAM E CERVIC AL LUMBAR. SACROILIAC. & COCCYX 723.2 Cervicocranial Syndrome 722.2 Displacement of Intervertebral disc Cervical Disc Syndrome 724.6 Disorders of the Lumbosacral or Sacroiliac 723. Cervicobrachial Syndrome Joint 29 Cervical Myalgia 724.70 Unspecified Disorder/Coccyx 723.1 Cervicalgia 724.71 Hypermobility of Coccyx 729.2 Cervical Neuralgia, Neuritis, 724.4 Neuritis or Rediculitis, Lumbosacral /Lumbar Radicular Neuralgia 724.3 Sciatica, Sciatic Neuritis 723.4 Cervical Disorders, Brachial 24 2 Lumbago, (low back pain) Neuritis or Radiculitis . Displacement of Lumbar Intervertebrai 353.0 Cervical Plexus Compression Disc w/o Myelopathy 724.9 Compression of Spinal Nerve Root 353.4 Lumbar Plexus Disorder 723.5 Cervical Torticollis 846.0 Lumbar Sprain/Strain 728.8 Cervical Myofascitis 722.10 Prolapse, Protrusion. Rupture or 738.4 Cervical Spondylosis Herniation of Disc 336.9 Cervical Neurovascular Compression 729.5 Inflammation of the Hip Joint 847.0 Cervical Sprain/Strain 724.0 Other & Unspecified Disorders/Back 722.0 Cervical Disc Syndrome 839.0 Subiuxation 723.2 Cervicocranial Syndrome 722.52 Degeneration of Lumbar/Lumbosacrai 722.4 Degeneration of Cervical Inter- Intervertebral disc vertebral Disc THORACIC 724.1 Pain in Thoracic Spine 722.11 Displacement of Thoracic Int. Disc 724.4 Neuritis or Radiculitis Thoracic 786.5 Chest Pain 786.0 Dyspnea 785.1 Palpitations 353.3 Nerve Root Irritation/Degeneration 722.51 Degeneration of Thoracic Int. Disc WRIST. HAND AND FINGERS (959.3 ) Injuryto Wrist 955.4 Injury to Hand 955.9 Injury to Nerve in Hand or Wrist 354.0 Carpal Tunnel Syndrome 842.1 SprainiStrain of Hand 726.4 Synovitis, Bursitis, Tenosnovitis Wrist & Carpus ANKLE. FOOT AND TOES LEG AND KNEE 719.46 Pain in Lower Leg 844.8 SprainiStrain of Knee or Leg SHOULDER AND ELBOW 959.7 Injury to Ankle or Foot 845.0 Sprain/Strain of Ankle 723.7 Calcaneal Spur 355.5 Tarsal Tunnel Syndrome OTHER 959.2 Injury to Shoulder 786.2 Bedwetting 996.3 Injury to Elbow 729.82 MenstrualPain/Cramps 726.3 Synovitis, Bursitis, & Tenosnovitis Elbow 625.4 PMS 726.10 Synovitis, Bursitis, & Tenosnovitis Shoulder 780.51 Insomnia 787.9 GI Complaints 01H ER 112.5 Candida 995.3 Allergies, Unspecified 830.0 TMJ Subluxation 693.1 Food Allergies 717.9 Paravertebral Myofascitls 737.0 Curvature of Spine 780.7 Fatigue 079.0 Ural Infection, Unspecified 493.9 Asthma, Bronchial 477.9 Respiratory Allergy 782.3 Edema 712.0 Arthritis 346.9 Migraine Headaches 956.1 Spondytosis 780.4 Vertigo (Neumpathic) Dizziness 551.3 Hiatal Hernia 470 Influenza 355.0 Sinus ROENTGENOLOGICAL REPORT PATIENT: - ?n' G C 1oh eA?.cYL DATE OF X-RAY: Cervical Spine ( ) Negative for recent fracture or gross osteopathology as visualized. ( ) Loss of ( ) Severely decreased ( ) Mildly decreased cervical 1 ) Neaative for discogenic lesion. ( ) Apparent cervical myospasm. ( ) Mild ( ) Moderate ( ) Destro - scoliosis. ( ) Mild ( ) Moderate ( ) L - scoliosis. ( ) Mild ( ) Moderate ( Narrowed disc spaces between C-- (-+-E-ncroachment of t neuroforamina'b ee ( -)-esteoarthritis of Q&L4?A, 4;; 71 , ( ) Other ?111? Thoracic Spine ) Negative for recent fracture or gross ) Kyphotic curve appears normal. Apparent myospasm. j Negative for discogenic lesion. Dextro - scoliosis Levo - scoliosis. Narrowed disc spaces between - Osteoarthritis of Other Lumbar Spine ( ).Negative for recent fracture or gross osteopathology as visualized. ( ) Loss of ( ) Severely decreased ( Mildly decreased lumbar lordotic curve. Apparent lumbar myospasm ( ) ( ) . d ( ) Moderate ( ) Severe. . ( Dextro- scoliosos. Mild { ) Moderate ( 1 Severe. ( ) Lev? oliosis ( ) Mild ( ) Moderate ( 1 Severe. ( rrow disc space between ? ( ) Articular facets appear to be ( ) Spondylolistheses, grade ( ) 1 ( 1 2 ( ) 3 ( ) Right ilium rotated ( ) Left ilium?.ate ( 4-Other a1? Extremities l) Other osteopathology as visualized. ) Mild ( ) Moderate Mild ( ) Moderate Mild ( ) Moderate lordotic curve. Severe. 1 Severe Apexed at 1 Severe Aoexed at ( ) Severe. ( ) Severe. Apexed at ( ) Severe. Apexed at Apexed at Apexed at Overview of X- Ray Findinus 1 HERD CHIROPRACTIC CLINIC, P.C. 2704 MARKET STREET/ CAMP HILL, PENNSYLVANIA 17011 (717) 737-1681 FAX (717) 731-1648 ini#iali Report January 26, 2000 To: MAC Risk Management Patient: Sara Worman Date "of Injury: 10-12-99 y, 1. Incident of Injury: Fell at GIANT food stores on a "red pepper." 2. Patient's Complaints: Low back pain, neck and wrist pain with numbness. 3. Objective Findings (Examination): (+) orthopedic test, and decreased range of motion. 4. X-ray Analysis Summary: Consistent with diagnosis 5.''Dlagnosls: 723.3 ; 729.1 ; 724.2 ; 959.3 6. Disability Data: N/A 11 PATIENT: Sara Worman MONTHLY PROGRESS REPORT DATE OF THIS REPORT: March 31, 2000 THE ABOVE CAPTIONED PATIENT: Lyl;under active care. () has been released from care. () has reached a state of maximum medical Improvement for this condition and has been released from active care. He / She has been advised to return on an as needed basis for the control of pain and exacerbations. THIS IS NOTMA/NTENANCE CARE. HIS / HER CONDITION AT THIS TIME: improving with the present course of treatment. remains static,. is retrogressing. INTERIM AGGRAVATIONS OR ACCIDENTS: (,r"e ended standing, sitting or stooping. ( oUsehold duties. ( duties related to the patient's regular employment. O other (please specify) PRESENT SUBJECTIVE COMPLAINTS: PROGNOSIS: TREATMENT This patient is to be seen time(s) a week for the next evaluated after days for his / her existing health status. This patient is / is not disabled from work at this time because of this HERD CHIROPRACTIC CLINIC, RC. 2704 MARKET STREET I CAMP HILL, PENNSYLVANIA 17011 (717) 737-1681 FAX (717) 731-1648 week(s), and will then be re- injury. GERALD M. DINCHER, D.C. SS# 18844-4403 IRS# 23-2110925 HERD CHIROPRACTIC CLINIC, P.C. 2704 MARKET STREET / CAMP HILL, PENNSYLVANIA 17011 (717) 737-1681 FAX (717) 731-1648 MONTHLY PROGRESS REPORT PATIENT: Sara Worman DATE OF THIS REPORT: February 29, 2000 THE ABOVE CAPTIONED PATIENT: ` (under active care. O has been released from care. O has reached a state of maximum medical improvement for this condition and has been released from active care. He / She has been advised to return on an as needed basis for the control of pain and e)acerbations- THIS IS NOTMAINTIENANCE CARE. HIS /. HER CONDITION AT THIS TIME: O improving with the present course of treatment. (remains static. O is retrogres's1ng. INTERIM AGGRAVATIONS OR ACCIDENTS: xtended standing, sitting or stooping. () sehold duties. ( duties related to the patient's regular employment. () other (please specify) _ PRESENT SUBJECTIVE COMPLAINTS: f PROGNOSIS: TREATMENT This patient is to be seen _ time(s) a week for t he next week(s), and will then be re- evaluated after -? days for his J her existing. health states. This patient is i is not disabled from work at this time because of this injury. GERALD M. DINCHER, D.C. SSf# 188-44-4443 IRSI# 23-2110925 HERD CHIROPRACTIC CLINIC, P.C. 2704 MARKET STREET / CAMP HILL, PENNSYLVANIA 17011 (717) 737-1681 FAX (717) 731-1648 MONTHLY PROGRESS REPORT PATIENT: Sara Worman DATE OF THIS REPORT: APRIL 30, 2000 THE ABOVE CAPTIONED PATIENT: (4e is under active care. () has been released from care. ( ) has reached a state of maximum medical improvement for this condition and has been released from active care. He I She has been advised to return on an as needed basis for the control of pain and exacerbations. THIS IS NOT MAINTENANCE CARE. HIS / HER CONDITION AT THIS TIME: is improving with the present course of treatment. ( )' remains swtatlc. () is retrogressing. INTERIM AGGRAVATIONS OR ACCIDENTS: ( ,) extended standing, sitting or stooping. ( T,,household duties. duties related to the patient's regular employment. () other (please specify) PRESENT SUBJECTIVE COMPLAINTS: .. PROGNOSIS: TREATMENT This patient is to be seen time(s) a week for the next week(s), and will then be re- evaluated after days for his / her existing health status. This patient is/ is not disabled from work at this time because of this injury. GERALD M. PINCHER, D.C. SS4 18844.4403 IRS# 23-2110925 C CD N (D N 00 a N' v 07Q CL 0 x w 3 N (D C 0 v c N N 0 s N c F a) CD m CD ?n N ? m - m CL F Z C CD ? C7 N (D v CD CD G D? c m D) ~ ? O CL v N (D r N N (D CD V O. 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( R y - G. m 33 -4.0 m 0) 0 0) m 33 w N? 3NVi c o 0 O 0 07i p1 Z D _ (n 7 0) 0 n m m m m 31 > (n m ? ? -i a Z ^. o <?gym < • Om m n? g p N °f z D -i m ?m m wmm (`o O Z to O. m m 9 m (D -I o m :3 -+ m CD 0 o ° D 0 M Z N 1 = 3 3 0 m N m D z (D m (D n x, d m Nam C cn o a • m 3 c 17 m 3 U) m ° a m O o. O N N CD (D 3 a -° 3 61 m < (» (D m o o m 61 N N O O CD 7 o. o. m o a? o- m y, d N ? O D7 ? N Q 7• m m m O O? w ON O m 0 M M m O m D -?I z z m D M m a m z O 1 x N m v V / /\ m + 0 S Y T C r SGT ea C A 3 rr ti S V v r r E: F. V r oZ $G r m D -? s O ? s ,4 GRANDVIEW SURGICAL CENTER OPERATIVE REPORT DATE DICTATED: 4/18/00 DATE TRANSCRIBED: 4/18/00 PATIENT: Sara Worman 21428 DATE: 4/18/00 SURGEON: Stephen W. Dailey, M.D. ANESTHESIOLOGIST: PRE-OP DX: See below. POST-OP DX: See below. PROCEDURE: See below. DESCRIPTION PREOPERATIVE DIAGNOSIS Left carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS Same. PROCEDURE Left endoscopic tunnel release. ANESTHESIA MAC. INDICATIONS The patient is a 61-year old female with moderately severe bilateral carpal tunnel syndrome. She was originally scheduled to have the right side released, and that started feeling better. The left side was worse for her symptomatically preoperative and, therefore, we proceeded with a left endoscopic carpal tunnel release. OPERATIVE PROCEDURE The patient was taken to the Operating Room and placed on the operating table in the supine position, and the left upper extremity was sterilely prepped and draped in the usual manner. 1% Xylocaine with epinephrine with sodium bicarbonate was used to infiltrate across the palmar aspect of the wrist and between the thenar and hypothenar eminences. Approximately 6 cc of local anesthesia was infiltrated. A marking pen was then used to outline the skin incision just proximal to the wrist flexion crease overlying the median nerve, and also to outline the axis of the ring finger metacarpal. The arm was then exsanguinated with the Esmarch bandage, and the pneumatic tourniquet about the right proximal upper extremity inflated to 250 mm of mercury. A transverse skin incision was made at the wrist. Coursing longitudinal veins were electrocoagulated and divided. The palmaris longus tendon was identified and retracted radialward. PATIENT: Sara Worman DATE: 4/18/00 PAGE: 2 The forearm fascia was opened transversely with the scissors, and then a flap of fascia developed and retracted distally and palmarly with a skin hook. Scissors were first passed into the carpal canal superficial to the median nerve and deep to the transverse carpal ligament in line with the ring finger metacarpal. Following this, the synovial stripper, then the canal dilators were introduced. The scope was then introduced into the carpal canal, and the transverse fibers of the carpal ligament identified clearly. The distal most aspect of the transverse carpal ligament was clearly seen. Using the thumb, it was possible to palpate in the palm and to demonstrate the fat at the distal aspect of the transverse carpal ligament. The knife was then elevated approximately one-third of its height, and the distinct most aspect of the transverse carpal ligament (approximately 1 cm) divided. The knife was then retracted. Visualization of the distal aspect of the transverse carpal ligament then identified a few fibers still intact distally. The knife was elevated partially again and these fibers divided. The knife was then fully elevated and withdrawn from the wrist, dividing the transverse carpal ligament. With the knife retracted, the scope was reinserted, and the division of the transverse carpal ligament was inspected. It was noted that a rectangular division of the ligament had been accomplished. This having been performed, the scope was removed from the wrist. Under direct vision, the remaining few fibers of the transverse carpal ligament distal to the skin incision were divided sharply with scissors, and then the forearm fascia divided proximal to the skin incision for a distance of approximately 2.5 cm. The wound was then irrigated with normal saline and closed with a running 4-0 nylon subcuticular suture. A sterile dressing incorporating Xeroflo, 4 x 8's, Kerlix and Kling was then applied. The tourniquet was deflated, and excellent capillary refill returned to the fingertips. The patient was transported in good condition to the Recovery Room having tolerated the procedure well. Stephen 4Day., .D . Date SWD/TK:clk/139886 G;anduiew Surgery & Las-,l 'enter #05-0091 Operating oom N.,,ses' Notes/7?u e re-op Dx. k•? l/ aw .a??? /?;M ?2 . yy U?,,7 :53 t re-op Dx. - Dst-op Dx. o Est-op Dix. Date: - OR ;t 7 7 'ocedure ??-? /mot c.2 U / o ocedure ?- J TYPE OF ANESTHESIA: ? Bier Block PATIENT ANESTHESIA OPERATION ? General ? Local IN O.R. OUT O.R. START END START END C] Regional [I Local Stand-By .EF V Sedation fie L/ (? ANESTHES]OGIST: GliLr CRNA:?-,L PATIENT IDENTIFIED ALLERGIES: T LEGS R BEWOUNC WA CONSENT SIGNED UNCROSSED? CLASSIFICATION OP SITE IDENTIFIED BY PATIENT YES EYE LITTER NO PRE-OP ASSESSMENT REVIEWED STRETCHER SURGEON: ?. POSITION OF PATIENT _ Legholder R or L Beancad l uoine Uthotomv Shoulder Roll ASSISTANT: ? Prone 7- Jack-Knife =Arms :ccked at 9,'Car 'i r ? Lateral ] Beach Chair Arm Tacie R of/L OTHER: Ulnar Pads ? Pillow Head l?_rm Board,i L LOCAL MONITOR: _ Donut _ Head Cradle _ Pillow , Knees G Other =Heel Pad RAYTEC LAP OTHER ATR. REG. INJECTION PREP SOLUTION USED: _ N/A SPONGES SPONGES ONGES NEEDLES NEEDLES NEEDL`cS BLADES .III, J Be[atline _ Phisohex RIGINAL r°e?korc-CUNT _11biclens _ Other (Soeclry) I, ADD / i Locztion: i ECCND I SHAVE PREP .AUNT I,, - - 3}" I!I Area ADD DIN iA E_ECTR000AGULANT UNIT:, FINAL / =UNT I -? l GROUNDING PM SITE POWER LEVEL CAA Jurses' Notes: ?i U. -r. T tG?c i BARS: /9 SIPCL:F _ i _ _ _ -> ? / _ , 2 ? , „ .? BOVIE SITE POST-0P _ OK j yam- r SPONGE' COUNT CORRECT: SHARPS COUNT CORREC YES _ YES NO _ NO - NA NA - C-Arm Tech: Patient shielding i. ant'_ Signatures: circ: relief: 97 time: scrub: relief: X0 time: N/A BP7463 Rev 2'% G andvliew Surgery & Laf .;enter #05-0091 :z 9 EE Eu Kd92E Practitioner Intraoperati„e Order Section E# 161-32-3713 AtIP '1ILL1, :A 17011 7?(17,'761-1932 DRUG WA ? DOSE TIME ROUTE SITE DAILEY S 81C Age 6i JLIS ?J?1:6.'10 Y , SEE EYE STAMPER ? t A WA Implants: Type: Size: Company: ID #: Lot Stickers: Plant v Drains Packs Removed Location Specimens: tissues ? cultures ? frozen ? N/A Tourniquet: # WA ? Cuff applied by: . / Tourniquet checked pre-op ? Right Arm eft Arm ? Right Leg Pressure: ` Left Leg -LS Pressure: , 3 /w " Inflated Inflated @:/0 35- V D e ad ?. Deflated @: otal Time: Total Time: Catheter inserted: Foley ? Straight ? Drainage Amt. + Color WA fa' WA? Surgeon Signature: --L4, Date: BPn 1230 REV 2199 } BALINT BALOG, M.D. RICHARD J. BOAL, M.D. ROBERT R DAHMUS, M.D. STEPHEN W. DAILEY, M.D. WILLIAM W. DEMU 11, M.D., P.A.C.S. JOHN R. FRANKEMY II, M.D., F.AC.5. MARK R. GRUBB, M.D. RICHARD H. HALLOCK, M,D. JAMES R. HAMSHER, M.D., P.A.C.S. r Pb ORTHOPEDIC S STTTUTE OF PENNSYLVANIA GREGORY A. HANKS, M.D. ALEXANDER KALENAK, M.D., F.A.C.S. ROBERT R. KANEDA, D.O., F.A.C.O.S. RONALD W. LIPPE, M.D., F.A.C.S. JASON J. LITTON, M.D. ERNEST R. RUBBO, M.D. WILLIAM J. FOLACHECK JR, M.D. STEVEN B. WOLF, M.D. THOMAS J. YUCIIA, M.D. (717) 761-5530 . (800) 834-4020 . FAX: (717) 737-7197 . www.orthoinstituteofpaxom February 5, 2001 W. Scott Henning, Attorney-at-Law P.O. Box 1177 Harrisburg, FA 17108 RE: Sara L. Worman 161 32 3713 Dear Mr. Henning: FE B 2 0 2001 Sara Worman is a patient that I had the privilege of taking care of. I first saw her on 10/15/1999. At that time, she had just recently slipped at the Giant Supermarket and fell on a pepper going down on her left side. Her initial complaint was left sided chest pain and left wrist pain. She sustained a left distal radius fracture which was reduced and casted. The reduction was in acceptable position and this was treated with immobilization. After a period of immobilization for approximately six weeks, she had improvement of the pain that she was experiencing and the fracture healed appropriately. When she was seen on 12/10/99, she still had some discomfort in the hand and she also had complaints of numbness and tingling in the left hand. Subsequent EMG and nerve conduction study was consistent with left carpal tunnel syndrome. Her exam was consistent with this diagnosis as well. She subsequently underwent left endoscopic carpal tunnel release on 4/18/2000 and had improvement of her symptoms. It is my opinion that the carpal tunnel is directly related to the injury she sustained when she fell on 10/12/99. The specific injuries related to this would be the left distal radius fracture, that is the side she had fallen on, and left carpal tunnel syndrome. It is also my opinion that at this point, the patient has reacned maximum medical improvement. She should not have significant long term sequelae in her left upper extremity from this injury. Of course, with anv fracture that goes into a joint, there is the possibility of post traumatic arthritis at some point in the future. With her fracture, this is not likely, however. There is also the possibility of recurrence of carpal tunnel syndrome. I don't suspect the patient will need further treatment in the foreseeable future for the left upper extremity. The percentage of disability according to the AmA guidelines, page 36, is 13 percent for the left upper extremity. If you have any further questions on Sara Worman, don't hesitate to call me. ORIDOPEDIC SURGEON, LTD. ADDRESS ALL CORRESPONDENCE TO: 875 POPLAR CHURCH ROAD, CAMP HILL, PA 17011 CAMP HILL OFFICE HARRISBURG OFFICE CAMP HILL OFFICE HERSHEY OFFICE CAMP HILL OFFICE 3916 TRINDLE RD. 450 POWERS AVE. 890 POPLAR CHURCH RD., STE. 108 10 WEST CHOCOLATE AVE., STE. 105 875 POPLAR CHURCH RD. R r RE: WORMAN, SARA L. PAGE 2 February 5, 2001 Sincerely, Stephen W. Dailey, M.D. SWD/mee BALINT BALOG, M.D. RICHARD J. BOAL, M.D. ROBERT R. DAHMUS, M.D. STEPHEN W. DAILEY, M.D. WILLIAM W. DEMUFH, M.D., F.A.C.S. JOHN R. FRANKENY R, M.D., FAC.S. MARK R. GRUBB, M.D. RICHARD H. HALLOCK, M.D. JAMES R. HAMSHEK M.D., FAC.S. TELEPMONE:(717) 761-5530 GREGORY A. HANKS, M.D. ALEXANDER KALENAK M D FAC 5 I 1P. ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (800) 834-4020 . FAX: (717) 737-7197 July 19, 2001 W. Scott Henning Handler, Henning & Rosenberg Attorneys At Law P. 0. Box 1177 Harrisburg, PA 17108 RE Dear Mr. Henning: ROBERT R. KANEDA, D.O., F.A.C.O.S. RONALD W. LIPPE, M.D., F.A.C.5. JASON J. LITTON, M.D. ERNEST R RUBBO, M.D. WILLIAM J. POLACHECK, JR., M.D. STEVEN B. WOLF, M.D. THOMAS J. YUCHA. M.D. www. o rthoi nsti tuteofpa. co m Sara L. Worman 161 32 3713 This letter is in regards to Sara Worman who is a patient of mine. She was treated for injuries to her left upper extremity associated with injuries she sustained 10/12/99. She developed problems with her right upper extremity involving right carpal tunnel syndrome and right trigger finger. These were treated surgically by me. I do not feel that there is a cause of relationship between her right upper extremity orthopedic problems and her injury which did in fact affect her left upper extremity. If you have any further questions, please do not hesitate to contact me. Sincerely, Stephen W. Dailey, M.D. SWD/lmn MHOYEDIC 5URCEONS. LTD, ADDRESS ALL CORRESPONDENCE TO: 875 POPLAR CHURCH ROAD, CAMP HILL, PA 17011 CAMP HILL OFFICE HARRISBURG OFFICE CAMP HILL OFFICE HERSHEY OFFICE CAMP HILL OFFICE 3916 TRINDLE RD. 450 POWERS AVE. 890 POPLAR CHURCH RD., STE. 108 10 WEST CHOCOLATE AVE., STE. 105 875 POPLAR CHURCH RD. MEDICAL EXPENSE SUMMARY Provider Holy Spirit Orthopedic Institute Herd Chiropractic Grandview Surgery Prescriptions West Shore Dates of Service 10/12/99 10/15/99 thru 7/7/00 1/14/00 thru 7/6/00 4/18/00 1/20/00 4/18/00 Anesthesia TeufelOrthotic 11/19/99 TOTALS Amount Paid Due $721.00 $*696.00 $0.0 $25.00 $1,990.08 $*1,904.20 $0.0 $**85.88 $2,826.00 $0.0 $2,826.00 $3,221.57 $* $ $40.00 $**40.00 $0.00 $390.00 $*192.00 $ $45.00 $*36.00 $ $9,188.65 SUBROGATION CLAIM: Healthcare Recoveries $2,992.92 (amount pending final accounting for related charges - total lien being asserted is $6,665.99 C 16 HCI # A HOLY SPIRIT HOSPITAL 503 N 21ST ST 1 OUTP. FEI # 23-1512747 04/16/38 390n04 WORMAN ,SARA L 14098081 F 61 10/12/V9 522 SPRINGHOUSE RE CAMP HILL,PA 170'! DETAIL OF CURRENT CHARGES, PAYMENTS AND ADJUSTMENTS 10/12 CAST SCOTCH 3 0217204454 64.00 64.00 10i- UNILAT L---, RIBS0136101145 197.00 1S7.QC 10/12 LEFT FOREARM 0136101301 82.00 82.00 10/12 LEFT WRIST 0136101327 110.00 110.00 10/12 ED VISIT LEVEL 011'103011 239.00 239.00 BALANCE FORWARD 0.00 SUMMARY OF CURRENT CHARGES M/S SUPPLIES 270 93.00 93.00 DX X-RAY 320 389.00 389.00 EMERGENCY ROOM 450 239.00 239.00 SUB-TOTAL OF CURB. CHARGES 721.00 721.00 DIAGNOSIS: E649.6 PAYMENT IS DUE UPON RECEIPT OF THIS STATEMENT. YOU MAY SUBMIT THIS FORM TO YOUR INSURANCE CARRIER FOR REIMBURSEMENT. T 0 T A L S 721.00 721.00 14098081 PAY THIS AMOUNT 0.00 HOLY SPIRIT HOSPITAL CAMP HILL, PA Account Number: 14 0 9 8 0 81 Patient Name: WORMAN SARA L Service Start: 10 / 12/ 99 Service End: Statement Date: 01 / 0 5 / 0 0 Last Statement Date: QUESTIONS? Please Call: 717-763-2138 contact: ACCOUNT BALANCE ESTIMATED INSURANCE DUE TOTAL PATIENT CREDITS 25.00 .00 1 25.00 THIS BILL REPRESENTS THE AMOUNT NOT PAID BY YOUR INSURANCE. REMIT PAYMENT TODAY OR CALL 763-9620 IF YOU HAVE QUESTIONS. 002 HEALTH AMERIC .00 PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID. Until your insurance has paid. the PLEASE PAY THIS AMOUNT represents the balance we estimate you owe. Any balance unpaid by your insurance will be due from you... Thank you. TRANS DATE DESCRIPTION AMOUNT PREVIOUS BALANCE 00 10/12/99 CAST SCOTCH 4 29.00 10/12/99 CAST SCOTCH 3 64.00 10/12/99 NILAT LFT RIBS 197.00 `. 10/12/99 LEFT FOREARM 82.00 10/12/99 LEFT WRIST 110.00 ! 10/12/99 D VISIT LEVEL III 239.00 12/23/99 AMER PYMT-OP Q02 HEALTH AMERIC 479.70- 12/23/99 H AMER C/A HOS-OP Q02 HEALTH AMERIC 216.30- RJ 0 R HO SG 1 000023587 ACCOUNT BALANCE 25.00 (i OSL--DBA ORTH INSTITUTE OF PA @5-1 5=@@ -3916; :TRINDLE-:'ROAD- : . •CAMP-HILL PA 17011-- 717-761-5530--? _ ,^TAX-ID 23-1875547 SARA L WORMAN 11524c:__ -- - - _ 522= S PRIHGHOUSE`.' ROAD r' CAMP HILL -PA 17011- _ -DATr-" PROD-- --DESCRIPTIalm - IiR Pt SCE _ CHARGES ,AM-15--'99 . :9902-4 .,? -.:-OFFICE- CALL__ si0-:22=-9: . .--99024. OFFIC?CALL_ SWD @1_ O@ X _0-15 99 99213: _ -OFFICE QU.TPT . VISIT E- SWIS _ 01- 50.00 @-15 r19= . 73100=LT WRIST, '2-1,VIEWS= --SWD"01 60.00 10-22 99212- . °_ OFFICE-GU TPT VISIT E': SWD 40'_00 . Fl 2 -n- ; 73100=LT WRZST;' 2`°°'?7•IELPS - SWU 01 - S@.Q10 1.1.-05f99 29075-58 - '--CAST SHORT ARE . SWD 01 160_00 1i-059 73100-LT WRIS'T', 2-xlIrWS -_ StiID 01 6D.00 3:i-05.5-9_ A4590 '- SP'Ec.IAL'*C'STINGM.EiTE-=SWD 01'-' .13.00_ 1 i=@5 ?J9 95024 OFFICE FALL -° ?sWD 0i' . 00` 94 9 CLATER= CFFARIi ti1TE t SWD 01'- _ 00 31-19 . 731GO-LT WRIST G°ViBiVS _- SWD 02 60.00 1 i-193' = 95024 '°- -=f)F, FICE' CAL:L ^ - SWD 0S "P= 00 12=1099 99024 ^CiFFI,CE BALL - -SWD 0i _ _ 00 =01-14=00 -- .. --FS,WD_ 0r °CLATER--' - -CHAIiGE.`LA'PER--' ._ 06 07`-14=00 '9921 -:_:: -tjXCE..d!}FPT_VISIT' E_SWU OL= _---- 50.00 01-14-00 70100-LT WRIST ;M2--VIEWS- °_SWD 01:'_.___ 60.0@ - ^-°-°-.- -,°?-----LL85:44-CC1-INSURANCE-- 01-14 10 73100_:52_ =-WRIST;--2-?V_IEWS-- . -._',:.SWD 01- 60:00 _..r_. . . 85:44 C0-I14SURAMCE'__, .- _ 02-04-00 CLATER:. -- - ;.CHARGE.-LA'T'ER _ y "SWD• Cd1 00 . 02-04-@0- 99212 • OFFICE-OUTP3 ; VISi1 E S41U 01' 4G? 0rO_. _..,_. 815.00:=00PAY' r,. __,... ... -,TOTAL . CHARGES " ?HEALTH,AMERICA PAYMENT 243.50 -: PERSONAL CHECI{ 40.66 HEALTH.ASSURANCE--PAYMENT 84.01 ;r HEALTH•AMERICA ADJUSTMENT -259.50-. ,;<HEALTH•ASSURANCE :.ADJUSTME -85:11 TOTAL BALANCE DUE- .00 --.DIAGNOSES: 847 :1 SPRAIN. AND STRAIN THORACIC= -,-E84 9:0 PLACE-OF OCCURRENCE; HOME=. E88 5 -FALL OH. SAME-LEVEL FROM SLIPPING, TRIPPING; OR STll ` MBLING --` - - --- "726 .19 , OTHER SPE_GTFIED DISOkDERSOF THE SHOULDER E84 9.6-- -' PLACE- OF- OCCURRENCE;-PUBLIC. BUILDING E88 0_9 FALL ON OR STAIRS- ORS, STEPS;. OTHER _ _-&13.?1--------CEIL_LES'-FRACTUk2B:,-C?LOSE-D--• .. _._ OSL -DEA ORTH INSTITUTE OF PA 05-15-00 3916-.-TRINDLE ROAD CAMP HILL PA 17011 --- -717-761-5530 - - -- - - - - - - - TAX ID #: 23-1875547 -^SARA-- L ? WQRMAH 11&242-- SPRINGHOUSE ROAD - - ---&22L- .-CAMP-HILL PA 17011. ---- - -°_ -°_ - -- - DATE PROC-_ - -DESCRIPTION - UR PLACE -` - v ? w CHARGES- _w? _ _ - 04-12-00-CLATER _ -? °--- --- _--?- ---- --- ---------- CHARGE' -LATER-' - --"-Sh{DO:.:.:--. ---- _ -.00 . 04-12-00--.592.1:2- OFFICE 013715T VISIT _E S_WD 05 - - --- - -d0.00 04-'18-00 29846-L T ENDOSCOPS?, WEIS I SU SW'D 70 " - ' - 1vJ a dm 04-26-00 99024 OFFICE-C'AL'L - - 01 0d .. - .... :. ,. _. -. -TQTAL_. CHAR13SS : ;,.1062:00 -PERSONAL-'CAECK 15:00 ,.TOTAL - FALANCa,-DUE 1053.0[ DIAGNOSES-: . - -- - - 847.1..- -:- -SPRAIN AND STRAIN THORACIC. E849.0 - PLACE=OF-=6CCURRifkgE;:-H-d$fE - - E685°'---: - -FALL-ON.SAME LEVEL FROK* SLIPPING, TRIPPING; OR ST.U MBLING 726:19- QTHER-SFECIF`I-EDDISQkDEI?E-QF -?'rH?-SfIOtiY;73Ek - ES-49:6 -PLACE OF E860_9 FALL-ON OR--PfffSPi `PAS tf S dR STEPS; QTI Ek - - - ---- - 813.41t- COLLES'. FRACTURE,'` CLOSED 3x4•.0 MONQN£URITIS`-6F"JPPEk iillB AND:.:M61IIEURITh?:MULTI- PLEX, CARPAL TUNNEL SYNDROME-:' .7-2703. "._- -TRIGGER°FINGER -(AC?dUIkED) OSL DBA ORTH INSTITUTE OF PA 675 POPLAR CHURCH ROAD CAMP HILL PA 17011 717-761-5530 TAX ID #: 23-18755+7 PATIENT: 115242 WDRMAN SARA L ----------------------------- SERV C DATE INV RP S DR PROC DESC ----------------------------- 11-'27-00 PAT DAL: 32. 3° INS BAL: 1!1103.2!0 0TH DAL: 00 -------------------------------------------------- INS A LINE INVOICE RUNNING-, COMMENT CO C#A PL AMOUNT BALANCE BALANCE ---------------------------------------------- 042600 29 1 32 90000 OC ALEXANDER KALENAK MD DIAG: 354,0 051900 30 1 31 90000 OC l?!1 th2! 00 .i!i STEPHEN W DAILEY MD DIAL. 354,0 051900 31 1 31 99212 OFFICE OUT 9284 12Y 01 40.00 40.00 STEPHEN W DAILEY MD DIAG: 727,03 060700 31 1 PC PERSONAL 1127 12 05 -15.00 25.0n 092600 31 _ HASS HEALTH ASS 174724 12, 2!5 -i4.0Z - 092600 31 1 HASJ H. ASS. !=!DJ .? 05 -12!, 97 00 2! 092600 31 1 $15.00 COP'AY 1 051900 32 1 ..71 . 20600 INJ 3'2'8 4 :2Y 0 1 83. Z110 23, = , STEPHEN W DAILEY MD DIAGe 727.03 092600 32 HASS HEALTH ASS 74724 05 792600 ?E HRSJ H. ASS. AD .J -v9. t!IL 051900 - -i 50702 CELESTONE 928' lc. .'08 'c STEPHEN W DAILEY MD DIAG: 727.03 092600 33 1 HASS HEALTH ASS 374724 90 792600 - HASJ H. ASS„ ADJ 2 05 2!61600 34 _ 31 CLATE CHGE LATER 01 . 0!11 v _! STEPHEN W DAILEY MD DIAG: 727.03 370700 35 ,_, _ CLATE CHGE LATER 7'1 2![I ; '. STEPHEN W DAILEY MD DIAG: 727.03 '170700 37 99214 OFFICE OUT _:? $.. 713 STEPHEN W DAILEY MD DIAG: 727.03 072600 37 PC PERSONAL 1169 _ 0u -_ .00 1 t:! 082100 i HASS HEALTH ASS 36 7 602! 0z 00 3.:,.:712, 082100 ?. 1 HASJ H. ASS. ADJ = 05 78. 00 :.:7i!%' 082100 37 1 HASS DENIED-INCLU DED IN GLOBAL SUR GERY 13, 090600 37 _ REF REFUND TO PT. 7!5 15.:7117! . !?!0 , O'l 090600 37 1 CHECK NO. 23703 080100 38 1 -1 26055 TRIG FIND 9284 16Y 70 828.!Z10 B2$.00 STEPHEN W DAILEt` MD DIAG: 7=7.03 101300 38 1 HASS HEALTH ASS 378101 16 05 -189.54 638.46 101300 38 1 HASJ H .ASS. ADJ 16 05 -591.08 47,3$ 101300 38 1 $47.38 MEMBER CO -INS 16 092000 38 1 PC PERSONAL 509 16 05 -15.01 2) 32.38 -=.38 081600 39 1 31 90000 OC O5 } ( Y! L1Y ? ,. 36 STEPHEN W DAILEY MD DIAG: 727.03 081600 40 1 31 99212 OFFICE OUT 9284 17Y 05 40.00 72..30 STEPHEN W DAILEY MD DIAG: 726.32 INS CHARGES ONLY I T E M I Z E D CLAIM: INSURED: STEPHANIE BRADLEY PATIENT: SARA L. WORMAN 130497 522 SPRINGHOUSE ROAD CAMP HILL PA 17011 SS#161-32-371:3 POL#GL9909192 DATE/INJ: 10/12/1999 GRP# TO: MACRISK MANAGEMENT P O BOX 9227 BOSTON MA 02209-4935 S T A T E M E N T DATE: 05/15/2000 IRS#: 232110925 EMPLOYER: VNA OF HBG HERD CHIROPRACTIC CLINIC 2704 MARKET STREET CAMP HILL PA 17011-4531 717/737-1651 WaX!717/7:31-1645 DIAGNOSIS: 723.3 C.ERVICOBRACHIAL SYNDROME 729.1 CERVICAL MYALGIA 724.2 LUMBAGO 959.3 INJURY TO WRIST FC': PER-INJURY DATE OF LAST BILL: 05/11/2000 PR# 121006KPK TD# 121006 DATE CPT DESCRIPTION ---_---=*-POS TOS--#_====AMO_tNT 01/14/2000 98941 CMT, SPINAL, THREE TO FOUR REGIONS 11 2 1 40.00 01/14/2000 97014 ELECT. STIMULATION-UNATT. 11 1 20.01;, 01/14/2000 72040 CERVICAL SPINE A-P AND LATE RAL 11 1 55.0e;, 01/14/2000 72100 LUMBOSACRAL A-P AND LATERAL 11 1 61 .0 s' 01/15/2000 98941 CMT, SPINAL, THREE TO FOUR REGIONS 11 2 1. 40.00 01/15/2000 97014 ELECT. STIMULATION-UNATT. 11 1 20.00+ 0L/17/2000 98441 C'MT, SPINAL, THREE TO POUR REGIONS 11 2 1 40.00 01/17/2000 97014 ELECT. STIMULATION-UNATT. 11 1 20.00 01/18/2000 98941 CMT, SPINAL, THREE TO FOUR REGIONS 11 2 1 40.00 01/18/2000 97014 ELECT. STIMULATION-UNATT. 11 1 20.00`. 01/19/2000 98941 CMT; SPINAL, THREE TO FOUR REGIONS 11 2 1 ; 40.00 01/19/2000 97014 ELECT. STIMULATION-UNATT. 11 1 20.00 01/19/2000 970:35 ULTRASOUND 11 1 15.00 01/21/2000 98941 CMT, SPINAL, THREE TO FOUR REGIONS 11 2 1 40.00 01/21/2000 97035 ULTRASOUND 11 1 15.00 01/24/2000 98941 CMT, SPINAL; THREE TO FOUR REGIONS 11 2 1 40.00 01/24/2000 47035 ULTRASOUND 11 1 15.00''. 01/26/2000 98941 CMT, SPINAL; THREE TO FOUR REGIONS 11 2 1 40.00 01/26/2000 97014 ELECT. STIMULATION-UNATT. 11 1 20.00 01/26/2000 970:35 ULTRASOUND 11 1 15.00' 01/28/2000 98941 CMT, SPINAL, THREE TO FOUR REGIONS 11 2 1 40.00; 01/28/2000 97014 ELECT. STIMULATION-UNATT. 11 1 20.00: 01/28/2000 97035 ULTRASOUND 11 1 15.00! 02/02/2000 98941 CMT, SPINAL, THREE TO FOUR REGIONS 11 2 1 40.00'' 02/02/2000 970:35 ULTRASOUND 11 1 15.00 02/04/2000 98441 CMT, SPINAL, THREE TO FOUR REGIONS 11 2 1 40.00 02/04/2000 97014 ELECT. STIMULATION-UNATT. 11 1 20.00 CONTINUED C 2 'ID -JC SS G S=?3 S L-'B CCC 5 S -1 = C G SUBTOTAL: 806.00 ?w - Sege ? 1 INS CHARGES ONLY I T E M I 7.. E D S T A T E M E N T CLAIM: INSURED: STEPHANIE BRADLEY PATIENT, SARA L. WORMAN 1:30497 522 SPRINGHOUSE ROAD CAMP HILL PA -17011 SS #1n1-:32-371:3 POL#GL99W9192 DATE/INJ: _0/12/1999 GRP# T(_): MACRTSK_ MANAGEMENT p (.) BOY 4117 T40STONJ MA 02209-99.3= DIAGNOSIS= CE'RVICOBRACHIAL SYNDROME '29._. CERVICAL MVALGTT 1UMBAGO DATE: 05/15/2000 IRS#: 232110925 EMPLOYER: VNA OF HBG HERD CHIROPRACTTC CLINIC: 2704 MARKET STREET CAMP HILL PA 170!_-453- 717/7:37-168T Fc]g;7i7/7:31-"i64l= -..= T i,7JRV TO WRTS" F'( . _?EP-TNJURV DATE OF LAST BTLi.s 05/11/2000 PR# -i21006KPK it)# 121006 DATE CPT DESCRIPTION ? PUS TOR # AMOUNT 02/07/2000 98941 (-MT, SPINAL, THREE TO FOUR REGIONS 11 2 1 40, 014 02107/2000 97035 ULTRASOUND 11 1 15.0(s? 02/07/2000 97014 ELECT. STIMULATION-UNATT. 1 20. 0v 42/09/2400 98941 CMT; SPINAL; THREE TO FOUR REGTONS 11 2 1 40,01: 02/09/2000 97014 ELECT, STTMULATTON-UNATT. 11 1 2000 02/09/2000 470:35 ULTRASOUND 11 1 15.00 02/09/2000 975:30 KINETIC ACTIVITY REHAHILTTATIO 11 1 30,00 01211112000 98941 CMT; SPINAL; THREE TO FOUR REGIONS 11 2 1 40:40x 02/11/2000 97014 ELECT. STIMULATION-UNATT, 11 1 20,04 0211112000 970:35 ULTRASOUND 11 1 15.00 01/11/2000 97.530 KINETIC ACTIVITY REHABILITATIO 1i 1 30,00 02/15/2000 98941 CMT, SPINAL; THREE TO FOUR REGIONS i 2 1 40.0v,, 02/"15/2000 97035 ULTRASOUND 11 1 15.00 02/15/2000 97530 KINETIC ACTIVITY REHABTLITATIO 11 1 30-00 02/17/2000 98941 CMT, SPINAL; THREE TO FOUR RECTONS 11 2 1 40.00 02/17/2000 97014 ELECT: STIMULATTON-UNATT. 11 1 20.00 02/17/2040 97W35 ULTRASOUND 11 1 15.00% 02/17/2000 97530 KINETIC ACTTVTTY REHABILITATIO 11 30.00 02/23/2000 98941 CMT; SPINAL; THREE TO FOUR REGIONS 11 2 1 40 02/23/2000 97014 ELECT. STIMULATION-HNATT. 11 1 20-00 02/23/2000 97435 ULTRASOUND 11 i 15.40 02/25/2000 98941 CMT; SPINAL.; THREE TO FOUR REGIONS 11 2 1 40.00! 02/25/2000 97014 ELECT. STTMULATION-UNATT: 11 1 20,04'. 02/25/2000 9703.5 ULTRASOUND 11 1 15.40 02/28/2000 98941 C`.MT, SPINAL, THREE TO FOUR REGIONS 11 2 1 44.04 02/28/2000 97014 ELECT. STIMULATION-UNATT, 11 1 20:00 02/28/2000 97035 ULTRASOUND 11 14C?' 15.00 CONTINUED SUBTOTAL: 1,506.00 Page: 2 INS CHARGES ONLY I T E M I Z E D CLAIM: INSURED: STEPHANIE BRADLEY PATIENT: SARA L. WORMAN 190497 522 SPRINGHOUSE ROAD _'AMP HILL PA 17011 SS#161-32-:171:' POL#GL9909192 DATEiINi, 10/12/1999 GRP# TU;! MACRISK MANAGEMENT _ BOX 922.7 ROSTON MA 0220=-9935 DIAGNOSIS CERVICOBRACHIAL SYNDROME -_- C'ERVTCAL MYALGIA -_- .:_ LLIMRkGt:: S T A T E M E N T DATE: 05/15/2000 IRS*! 2:12110925 EMPLOYER: VNA OF HRG HERD CHIROPRACTIC CUNTC' 2704 MARKET STREET (.`AMP HILL PA 1701 TNJIIRY Tu WRTS!` PER- TNJURI, -;ATE OF LAST RTLi.: 05/11/2000 PR# 12100hKPK ID# 1110061 DATE CPT DESCRIPTION POS TOS # AMOUNT ----------------- 03%0:;/2000 99212 OFFICE VISIT-LIMITED 11 2 1 30.00 03/03/2000 97035 ULTRASOUND 11 15.00 63/06/2000 99212 OFFTCE VISIT-LTMTTEI7 1 c ? 30-0u, 03/06/2000 97124 MANUAL MASSAGE 1.1 20.00 03/10/2000 98941 CMT; SPINAL, THREE TO FOUR REGIONS 11 2 1 40,00 `:,-;/10/2000 97014 ELECT: STIMULATION-UNATT. 1.1 20.00 03/10/2000 97035 ULTRASOUND 11 1 15.00 03'11612000 98941 ('MT, SPINAL, THREE TO FOUR REGIONS 11 2 1 40,00 03/16/2000 97035 ULTRASOUND 11 1 15,00 03/Ib/2000 97530 KINETIC ACTIVITY REHARILITATIO 11 _ 30.00 03/18/2000 98940 CMT SPINAL; ONE TO TWO REGIONS 11 2 1 35,00 03/18/2000 97035 ULTRASOUND 11 1 15,00 03/18/2000 97530 KINETIC ACTIVITY REHABILITATIO 11 30.00 03/21/2000 98941 CMT, SPINAL, THREE TO FOUR REGIONS 11 2 1 40.00 03/21/2000 97035 ULTRASOUND 11 1 15.00 03/21/2000 97530 KINETIC ACTIVITY REHABILITATIO 11 1 30.00 0:3/24/2000 98941 CCMT, SPINAL; THREE TO FOUR REGIONS 11 2 1 40.00 03/24/2000 97035 ULTRASOUND l"i 1 15.0Cn 03/24/2000 97530 KINETIC ACTIVITY REHABILITATIO 11 1 30.00 03/27/2000 98941 CMT, SPINAL, THREE TO FOUR REGIONS it 1 1 40.00 03/27/2000 97035 ULTRASOUND 111 1 15,00 03/27/2000 97530 KINETIC ACTTVTTY REHABILITATIO 11 1 30.00 04/12/2000 98941 CMT, SPINAL, THREE TO FOUR REGIONS 11 2 1 40.00 04/12/2000 97035 ULTRASOUND 11 1 15,00 04/12/2000 97530 KINETIC. ACTIVITY REHABILITATIO 11 1 30.00 04/14/2000 98941 CMT, SPINAL, THREE TO FOUR REGIONS 11 2 1 40.00 04/14/2000 97035 ULTRASOUND 11 1 h 15,00 / CONTINUED Y SUBTOTAL: 2;236.00 :Page 3 INS CHARGES ONLY I T E M I Z E D S T A T E M E N T CLAIM: INSURED: STEPHANIE BRADLEY PATIENT: SARA L. WORMAN 130497 522 SPRINGHOUSE ROAD CAMP HILL PA 17011 SS#167-32-3713 POL#GL9909192 DATE/INJ; 10/12/1999 GRP# TO: MACRISK MANAGEMENT P O BOX 5227 BOSTON MA 02209-5935 DIAGNOSIS: 723,3 CERVICOBRACHIAL SYNDROME 729.1 CERVICAL MYALGIA 724.2 LUMBAGO DATE: 05/15/2000 IRS#; 2:32110925 EMPLOYER; VNA OF HBG HERD CHIROPRACTIC CLINIC 2704 MARKET STREET CAMP HILL PA 17011-453-1 717/737-1681 Fax:717/737-1648 959,3 INJURY TO WRIST PC! PER-INJURY DATE OF LAST BILL: 05/11/2000 PR# 121006KPK ID# 121006 DATE CPT DESCRIPTION * POS TOS # AMOUNT 04/14/2000 97530 KINETIC ACTIVITY REHABILITATIO 11 1 30.00. 04/26/2000 98540 CMT SPINAL, ONE TO TWO REGIONS 11 2 1 35.0x; 04/26/2000 97014 ELECT. STIMULATION-UNATT. 11 1 20.00,: 05/03/2000 98940 CMT SPINAL, ONE TO TWO REGIONS 11 2 1 35.00 05/013/2000 97014 ELECT, STIMULATION-t_iNATT. 11 1 20.00'1 05/10/2000 98940 CMT SPINAL, ONE TO TWO REGIONS 11 Z 1 35,00 05/10/2000 970.135 ULTRASOUND 11 1 15.00 05/10/2000 975:30 KINETIC ACTIVITY REHABILITATIO 11 1 30.00' ?d TOTAL: S 2,456,00 ALL CHARGES/PAYMENTS CLAIM: I T E M I Z E D INSURED: STEPHANIE BRADLEY PATIENT: SARA L. WORMAN 130497 522 SPRINGHOUSE ROAD CAMP HILL PA 17011 SS#161-32-3713 POL#GL9909192 DATE/INJ: 10/12/1999 GRP# TO: MACRISK MANAGEMENT P O BOX 9227 BOSTON MA 02209-9935 DIAGNOSIS: 723.3 CERVICOBRACHIAL SYNDROME 729.1 CERVICAL MYALGIA 724.2 LUMBAGO S T A T$ M R N T DATE: 01/.7/2001 IRS#: 232$10925 EMPLOYER: 1 VNA OF HBG HERD CHI PRACTIC CLINIC 2704 MAR T STREET CAMP 232E PA 17011-4531 717/717- 81 Fax:717/731-1648 959.3 INJURY TO WRIST PC: PER-INJURY DATE OF LAST BILL: 07/13/2000 PR# 121000KPK ID* 12 06 matwraaasaxaa::aaw.xaat.aesa.:aeeosmmioaa.xxaaraxa r.m:xsma rm:asaasarrraaraaar DATE CPT DESCRIPTION * POE TOS 1# AMOUNT rmmara.raa.axaar.aseaa.mx:r.:aasawm::an:::xx:r.maxa aexaaaa.mmsasaarrmrraaararr• 05/17/2000 98941 05/17/2000 97035 05/30/2000 98940 05/30/2000 97035 06/06/2000 98941 06/06/2000 97530 06/07/2000 97035 06/15/2000 98940 06/15/2000 97035 06/15/2000 97530 06/23/2000 98940 06/23/2000 97035 07/06/2000 98940 07/06/2000 97035 CMT, SPINAL, THREE TO FOUR REGI ULTRASOUND CMT SPINAL, ONE TO TWO REGIONS ULTRASOUND CMT, SPINAL, THREE TO FOUR 92GI KINETIC ACTIVITY REHABILITATIO ULTRASOUND CMT SPINAL, ONE TO TWO REGIONS ULTRASOUND KINETIC ACTIVITY REHABILITATIO CMT SPINAL, ONE TO TWO REGIONS ULTRASOUND CMT SPINAL, ONE TO TWO REGIONS ULTRASOUND 05/25/2000 PAYMENT IN 05/25/2000 ADJUST IA RECORDS FEE 11 2 1 40.00 11 1 15.00 11 2 1 35.00 11 1 15.00 11 2 1 40.00 11 1 30.00 11 1 15.00 11 2 1 35.00 11 1 15.00 11 1 30,00 11 2 1 35.00 11 1 15.00 11 2 1 35.00 11 1 15.00 -19.00 19.00 r? r? 0 sirr aa.amom¦a.mmomxarxa rm aaamSmmmm 2mrx a.ma a. nami. maifmaaaariiaamiamamamrrrrra TOTAL: $ 450.00 B CE 01/17/2001: $ 2,826.00 PA/PK/CCAN=CsWChccWCC/IRA. paymn CWDE=CrodiVDabi;]A=fns adj: 1W Z0 39VIi DIN110a6EH 849TTELLTL TZ:60 T00Z/LT/T0 -,; r s t fl tit 1i IASSUh r r? ' t } i7 C t t?1 3 ,. . s a-vgr?' ,..- FldF RIS,Xal.1F"eCi .,qua F r'r rsrrrt } ? n t sc?• <o , i < - ? ? r ,l T?n,.?T`tT?n"?1.7/5Id7 '37!,*t .• _Lt v.,.,HEA LTH.INSURANCE-CCAIW FORM '? - PICA F T7 OTHER tr_ MEDICARE-'? MEDICAID.- "i CHAMPUSAHAMPVA ''.GROUP ? BLK `(FOR PROGRAM IN ITEM 1a INSUREO'SIO NUMBER _ -}.`!-• .a..-c::: EA4TH PLAN LUNG. H (?A-FPe S) tS$NaP (0l "(SSNI., ,- •.((DI (Medcare,tl. .'(Medea/d, xi Q (Sponao'iS,A ) .t{5''•? '^.'.-r?8?f74-7- 1_ 0x2 1 r 2'.PATIENTSNAME .(Last Named First Name, MiddleJnidap r Zr. PATENT' BIRTH DATE,.. S Y•`:' MM ', DQ YY 'q, INSUREDS NAME {Last Np'ino;, fsf Name. Mlddle,initial)"' 4JOhliF,id : ?nr,A L_:: b4-ll 1,9.56 FFR? -t4dr,lA T't t CIS: ' S.PATIENT.SAODFE55.(NO'.; Street}-; B. PATIENTRECATOQfxS?EYfPTO [NSUREO ,fN,UREC.A,,Fl S(Nu Sveetj k hIG -}'}?}?Lal 22 SF R S@Ifo. Sp'O'L CµC1118[] .'O{her? ct r i?`t t'4 ?"t€?UBt `? - !§ 5 . . - . ...,. u l g . TATE CITY - """ B PATENTSTATUS - -' CITY' -'- ••>. STATE C Z CAMP i-t'cLl_.'.. .` -? P AI snslc? Marn'i?a`, •{? rnher [ f nlHl' H } } R: : i (1 4- ZIPCODE TELEPHONE(Indhde Area Oedej -""' ZIPCODE TELEPHOI•IE'119CLUDE AREA Cbb 174}.1.9.__: EmAloyetl Fu0.Tme Parl Time Q;Sindant Q Student Q - - _ - 177 t 71 y) 761.:k3 a _ 2 o 9: MHEA INSUAEO'STJATJE. Last Name Frsf Name; Mlddla India - t0-rSYATENTSCONDiTON RELATEO'TO" 1'f iNSURED'S - 0 t % DEPOIICYDR GROUPTdUMBER" '. d: OTHER INSF?FIE a.EmPLOYMENT"`(Oll'Ep"iENT OH PREVIOUS)' a. 1N SUAEDS.ifA7E OFElFTTH SEX " 2 IL.f?S t DD '.,YV ' LJ b. OTHER INSUREDSS DATE OF BIRTFP SE,y` b ee - PLACE (S(2te} bAVTO A ACCIDENT - b. MPLOYERSNAME OR'SOHOUlL NAME' +.MM Da YY: e 1.......F n Z b EMPLOY NAMPOR'SCIAC NAME- c:OT,HER ACCIDENT'i' - c. INSURANCE PLAN NAN?';OR PROGRAM NAME __- Z t JN ;:,!.. av t,.,f YES NO -.- ut d,INSURANCEt'_LAN NAME OR PROGRW NAME. - - 11Jd RE5FRVEO FO'RLOCALUSF? d ISTIJErygANOTRER HEAURSENEFIT PLANT' q x ., 't , '?' : -- _ '„ Ferry y •rm , AYES N10 ?_ H s, reium tp and complete item 9 aq1. " REAOBA'CKOFFORM BEFORE OMP?ETNG SSIGNiF1CS'THTS'FORM --'-- 191NSUR8D50RAUTA PERSON'S SICNATl1RE'' theme t2:PATIENT`yb(y AUTHOR?ZED`PFRSONSSTGNATURE:I authw¢elha release of arryine`HeaTototfier iMdpv3Ndrt necessary^ paymantefinedlcalbenefitsto the u?eesignetl physlnan or supplmr for - wprooe4111laim Iaisprequest paymdm of government beneid3 either Aniyself or to the parry Who acceptse§s'gmm?nt' servlce9deswlbedbelmx•:--- r . bebr 52-Li}IIAT1,#}'t? ;.; 6111 ;- TI ._I }J$zE 6 E?1 1 I f C 'i- ? SIGNEO". SIGNED ?-.,- y 14 DATE OF`OfJRRENT ILLNESS(First eymptom) OR - MM D?`YY ' INJURY(Acelder) OR -- 15.IF_PATIENT HAS FfAD SAME 09 SIMILAR ILLNESS; GIVE FIRST DATEv MM -I :01 3'. .16. DATES PATIENT UNABLE TO WORK IN CURRENT000UPATION - :. MM OD W .^' MM i DD. YY ?h, PAEGNANCY(LMP)', FROM. (:. :TO Y7, NAME O,tREFEARfNG PHYSfCIAN Q4OT11ER SOURCE `" fla TD; NUMBEKOE`REFEEIRIIN('a'PH ICfAN f8 HOSPI AERATION OA"fE5 RELATEO`TO:GURRENTSERVICES ,.. ' ' DD' YY M D ' 7' .t }'(G7t,' U!> 7D1It_f , .I M D M1d 1 I,- t FOR.LOCAL SE 19: RESERVEED 20 OUTSIDE LAS' $C4ARGES n '[]YES []NO 21. DIAGN SIS OR. NATURE OF-ILCPESS ORINJURY (RELATE ITEMS iOR4T0 REM'24 BYLINE) L44% 22 MEDICAID RESUBMISSION CODE ORIGINAL REF NO -' ? - " a.xta .} irk Ye ,?{ l z i 'i 7-x.'a4 1 , 'J 23 PRIORAUTHORIEgTI0 -NUMBER 2?: ,. ..: `, e. .•.. i. :' :Y3R "a '.'i1T14 '?^Y," ?i;at*` :"`.dt / Cal" . y _ 24. Asa... - - . .: -:. - r.., ,.8._;: . •D _. ?. .?...-__:' p. _j. ;.. . t .':> E,._f,.,.. ...E '•rG'.: '• H :?..c J -- ' K , - - DA7E(5}'OF SERVICET • Piano - Type PROCEDURES; SERVICE 5;2TRSUPPq 5 - "DIAGNOSIS ','' " 'DAY :Oft EP9 F " RESERVED FOq f ° Frost,} - ' , --of. - 'ExPIaIOv nusu3LCtrcumslances) CODE' SCHAAGES O a y EMG COB LOCAL USE r u MM DII YY. MM DD'- YY . M Be Semis -CPT%HCPCS :l MODIFIER .. NITS Plan t ii!B.I.F.#70(70- a tL€3 £} { i '.- t,v?11 al ' '" L• _, - 1 -#. 1 :;1,R . m!J 2 I 1 1 .. r ? : _ IT 'Yr T: Y•Y •.I ?_I y. Y '1 1.,r I _ '3ti t flu 0S VW 1? _ T- A, 1 V 1 ; ) f B .., r } in IC. T.7l { ! ??LSr f fl• '.. 1 .. ,,. ., „ 25. FEDEFO LT RI,D NUMBER--" SSN EIN . 26, PATIENPSACCOUNT NO,, 27ACCEPT ASSIGNMENT - (F,argovl clam:s se9 back) 'dr DUE. 28 TOTAL CHARGES zt AMOUNTP?IP ;3 BALANCE ..- .l F i 2 .I 5974E3 S Q® ? NO d'l4r^_8 YES /.J S .,3 ?l. sYf $ ? ? S 6F . 31.SIGNATUREOF'PHYSICIANOR'SUPPLIE}T - 32.NAME I A0DRESSOF FACWIYlNRERFSEAYiCE9 VJEA 33'PHVSIC7AN55UPRLIEF758)LC(f?YZi NAM 1ih RES ZIPCODE' ': INCLUDING DEGREES OR:CREDENTIALS ce tylhatlhe eMS On tha erse ' (f REND ER:0(If other Nan hbme ar To+Ny)ce) A >CI L }N"d{1 CiV LL3Ud ; 4EY( XQ &PjH?N # t 7 "t' s t I{' ^ '. ' J' YK' (..nY.30-i 1?'` ,Ct7 4?l?'c{t1 VZCn(+ ` Lf( C aiir t ly toM still a ndnd aremade a partvrereof)'r t "ap , . . ? 7f -{' ?1} a G - , Y ; 1 ?•" / ` - p C?ran . vsc w ?tvonLtn cOS .tirsill?ivxecu Avpnut +J- GYR? I`??ti{?00 ?xrR[3"H'z] x I A i2atx {s ltxl (c?tti T FF? 1 1, 1 r lr;, : ?1N?IETiA sll t".LT1" t t:@nf)B.tlfl ?t. .. S,? 9. '59741.3, n v ? ,... ._,. _, ...-. ... re oovn(rcll ev ernn rni Mrn nu L?CIN6e1'GFR _ VV:F AM0.Y?'--" `'{?i=?_?i r Y°, - .-..-.:i., i we.[...fs:u..FORMHOPAy 500-. G'2-907:.: r.:.2 - APPROYEDOMe --,I,--AFCiRM0WCEl-1500, T-, FORM R?13-15UQ RITE AND It's not just a store. Its a solution Visit car nnfine phar'nmer as Q(11'Lj?? t01'f'.C011 Store #04818 4957 CARLISLE PK MECHANICSBURG, 17055 (717) 975-0199 Register #1 Transaction #81261 Cashier #48186369 1/20/00 12:31PM RITE REWARD SAVINGS Customer ID: 1 SCANNED PHARMACY 20.00 RX# 71409. 1 SCANNED PHARMACY 20.00 RX# 71410 2 Items Subtotal 40.00 Tax .00 Total 40.00 "PAID BY VISA" 40.00 VISA card " #XXXXXXXXXXXX0271 Exp 10/31/02 App # AUTO Ref # 009179 Card Present Tendered 40.00 Cash Change .00 Visit our online pharmacy at drugstore.com 1-800-RITEAID for customer service i O b S Z m p y C r D ? m r m m A Z mom a o y-im m x Z a rn z ?Cp C Z A a = m 0 Z [SI m 9 ;WC 3 m o p m Z p m O ? f ] m a e m O N F O m a ' m Z C C P C F y r?, s W G' V [, r o- vWr rr ?-'? W 3 b r c c tn•. ?•r. 1 2 C r' ? v a - t ? N o -- v u a C W ? A .? .U tS A - N ±? a G v n m C W N G7 ?r 0 0 G D s 2. of 0 ON C? 3 T > o -- - - m ? c G ? rv v ? c?OTC r > > > T'o ?c4 v,0?3 3 ?COPC ? J N J ? O. N H C JJ C" v In O VJi p . m m?'= V r C ?i v` 8 3 - ao a c ac E. ?oGOCc -cl QL W C N '?1 I p. Vii U `p ^ W A p .v1. C = o. u' wm> i ?r>cz 1 n G :: V 59 ? c i c 3v'v J 2 :? J ymN?l U T4 y it Z ` O CD O r ? r `J C J HEALTHQARE RECOVERIES P.O. Box 37440 Louisville, Kentucky 40233-7440 FEDERAL TAX ID: 61-1141758 TELEPHONE NUMBER: (877) 765-9373 PAGE 1 OF 2 CONSOLIDATED STATEMENT OF BENEFITS I'A I ItN 1'15 NAME: SARA WORMAN HEALTH PLAN: HealthAmerica/HealthAssurance DATE OF INJURY: 10/12/99 SERVICE PERIOD: 11/5/99-8130101 Subject to change. FILE NUMBER: CV-204282471020 Instructions: • Makechecks,;;payable to: Healthcare Recoveries. • Wrfte e' iname, SARA WORMAN, and fife number, CV-21282471@20, q the b eck. Prov-10 ' f 6?e"',y';i4 ;e I' " b ag'nosis-Code Claire Number Date dt & r 11 7 Procedure Code(s) Billed Amt. Paid Amt COWLEY ED' LAG V72.83OTH SPCF PREOP 23282024 7114/00 85021 Automated hemo r $10.00 $4.32 7/14100 80051 Electrolyte pane $37.00 $3.66 DAILEY MD,STERHEN W' 813.41 Fx of radius/ul 20521565 11/5199 29075 Application of f $160.00 $53.83 1115199 73100 X-ray-exam of wr $60.00 $27.19 1115199 A4590 SPECIAL CASTING $13.00 $10.40 813A1 Fx of radfus/ui 20756625 11119199 73100 X-ray exam of wr $60.00 $27.19 354.0 Carpel tunnel s 1012214484 4112100 99212 Officelou ' n $40.00 $14.03 354.0 Carpel tunnels 1013111580 4118100 29848 Wrist endos / $1028.00 $288.54 727.03 TRIGGER FINGER 1017119997 5119/00 99212 Office%u lien $40.00 $29.03 5119/00 20600 Drain>in'ect sma $83.00 $28.17 5/19/00 J0702 BETAMETHASONE AC $8.08 $4.96 727.03 TRIGGER FINGER 23190664 6116100 99213 Office/out tien $50.00 $26.48 727.03 TRIGGER FINGER 1024107673 811100 26055 Tendon sheath in $828.00 $18V64- 726.32 Entheso th el 1025518081 8/16100 20605 Drainfin'ect int $84.00 $28.15 8116100 J0702 BETAMETHASONE AC $16.16 $10.26 Carpet tunnels 1029201456 9126100 8 Wrist endosco l $1028.00 $288.54 DINCHER DC,GER 3 Cervicobrachial 1023406370 812100 0 CMT, s innl, 1-2 $35.00 $17.00 DOMINQUEZ PT,J 03 TRIGGER FINGER 1029013148 1012100 9 Ph ical medicin $80.00 $32.00 1014100 9 Ph ical medicin $80.00 $32.00 1016100 1 9 Physical medicin $80.00 $32.00 0 Carnal tunnels 1030720441 10116100 9 Ph ical medicin $80.00 $32.00 0 Carnal tunnels 1030720442 10118100 9 Ph ical medicin $80.00 $32.00 0 Carnal tunnel s 1030720443 10120100 9 Ph ical medicin 97799 $80.00 $32.00 NO HEALTHCARE RECOVERIES P.O. Box 37440 Louisville, Kentucky 40233-7440 FEDERAL TAX ID: 61-1141758 TELEPHONE NUMBER: (877) 765-9373 PAGE 2 OF 2 CONSOLIDATED STATEMENT OF BENEFITS PATIENT'S NAME: SARA WORMAN HEALTH PLAN: HealthAmerica/HealthAssurance DATE OF INJURY: 10/12/99 SERVICE PERIOD: 11/5/99-8130/01 Subject to change. FILE NUMBER: CV-204282471020 Make checks payable to: Healthcare Recoveries. Write the patient's name, SARA WORMAN, and fiie number, CV-2042824711120, on the check. Provider of Service Diagnosis Code Claim Number Date of Service Procedure Code(s) Billed Amt. Paid Amt. 1 354.0 Carpal tunnels 1030720444 10/23100 1 97799 Physical medicin $80.00 $32.00 1 354.0 Carpal tunnel sy 1030720445 10125100 97799 Physical medicin $80.00 1 $32.00 354.0 Carpal tunnels i 1031322581 1 10/27/00 97799 Physical medicin $80.00 1 $32.00 354.0 Carpal tunnel sy 1031322582 1 1013010D 97799 Ph ical medicin $80.00 1 $32.00 354.0 Carpal tunnel s 1032011909 1111100 97799 Physical medicin $80.00 1 $32.00 354.0 Carpal tunnel s 1032011910 1113100 97002 Physical therapy 1 $75.00 1 $8.76 GRANDVIEW SURGERY & 354.0 Carpel tunnels 220134131 4118100 29848 Wrist endoscc 1 $3221.57 ; $2255.10 727.03 TRIGGER FINGER 22729170 8/1/00 26055 Tendon sheath in ! $1876.68 $373.60 GRANDVIEW SURGERY C 354.0 Carpel tunnel s 24303439 9126/00 29848 Wrist endosca / $2740.87 $1534.88 JOYNER SPORTS-BLUE 727.03 TRIGGER FINGER 10278016221 9/19100 97799 Physical median $205.00 $42.00 JOYNER SPORTSMEDICI 727.03 TRIGGER FINGER 1028311401 9121/00 97799 Physical median $80.00 $32.00 9122100 97799 Physical medicin $80.00 $32.00 9/25100 97799 Physical medicin $80.00 $32.00 QUIRK MD BRIAN C 729.5 PAIN IN LIMB 1127724319 8130101 99213 Office/ou atien $56.00 $26.48 TEUFEL ORTHOTIC-PRO 814.0 Fx carpal bonets 20628868 11119199 L3908 WHFO,WRIST EXT.C $45.00 $36.00 VIOLAGO MD,ED S 354.0 Carpal tunnels 21255180 1117100 95900 Motor nerve test $240.00 $127.97 1117100 95904 Sensory nerve to $240.00 $110.21 1/17100 95861 Muscle test, two $300.00 $107.70 WEST SHORE ANESTHES 354.0 Carpal tunnel s 22047305 4118190 01810 Anesthesia, Lowe $390.00 $192-00 727.03 TRIGGER FINGER 22859442 811100 01810 Anesthesia love $325.00 $160.D0 354.0 Carpal tunnels 23222237 9126100 01810 Anesthesia, Iowa $390.00 $192.00 Total BiNed Charges $14,805.36 Amount Received $0.00 AAAC Risk Mana4ement. Inc. 60C CAMPANEW DRIVE, BRAINTREE, MA. 02184 Ma0'mg Address: P.O. Box 922T,&Nf 2 Afti DENT REPORT Claim # GL9909192 Giant Locatic Your Name: Address: Telephone: x^70)-Rat-_)T39 DatetofBirth: Date or Accident: lfl - ? (ij Time: - 10 f, it) Soc. Sec #: t'? l -.3? -31IS- Where did Accident happen: Name of Store Employee Reported To: Date: 0 00022 P( e s SARA L. WORMAN, : IN THE COURT OF COMMON PLEAS : OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff CIVIL ACTION-LAW V. No. 2001-5511 GIANT FOOD STORES, INC., a/k/a GIANT T FOOD STORES,: LLC Defendant : JURY TRIAL DEMANDED CERTIFICATE OF SERVICE On this Z day of September, 2003, 1 hereby certify that Plaintiff's Arbitration Exhibits was served upon the following by U.S. mail: George B. Faller, Jr., Esquire Dale F. Shughart, Jr., Esquire MARTSON, DEARDORFF WILLIAMS & OTTO 35 E. High Street Ten East High Street Suite 203 Carlisle, PA 17013 Carlisle, PA 17013 Michael J. Pykosh, Esquire James M. Robinson, Esquire P.O. Box 368 28 South Pitt Street 3805 Market Street Carlisle, PA 17013 Camp Hill, PA 17011 HANDLER HENNING & ROSENBERG Date: _C? By W. ott 1300 LinglestHarrisburg, P11 (717) 238-2000 ATTORNEY FOR PLAINTIFF `.. c-? ? ?, C. G? T, Z E-.Cl -) t? Z-?.. ? ? t, L? ?' ICJ "'7 `?i ?» ?.; v :_J __ ??? ? ' `? A 9 A' ' 5d)o I Woe'tt on IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. C? V 1 ` ??f I TERM OATH We do solemnly swear (or affirm) that we will support, obey and defend the Constitution of the United States and the Constitution of this Commonwealth and that we will discharge the duties of v G-vav? f?a up <5 w--T-hc a?q Gl a vit sT? our office with fidelity. 1? !1 . C' ar us > C airman AWARD O cn Wehe undersigned arbitrators, having been duly appointed and sworn (or affirmed), make tti '"e folUring award: . Arbitrator, dissents. (insert nai Date of Hearing: Q J? ?Zl Date of Award: (O / 7 NOTICE OF ENTRY OF AWARD Now, the 1.5 day of e066& 2002, at 3 :009, .M., the above award was entered upon the docket and notice thereof given by mail to the parties or their attorneys. Artibitrators'compensation to be to /? Paid upon appeal: Prothonotary $ 290.00 By: D ? r4 (Note: If damages for delay are awarded, they shall be separately stated.) -=U?rYR +&3,}Rbdl1 < ..+ .-.... _ r} ? ?`?+?.?? w¢n... .xt?b ,,;. ?].ur? ezwT'F ='"` ? • -??f ??t ?-4u ?.--?. - per.....`. - - - ` / ?L? ?.. ? T/ / V L ?11.r.,.G,,r?nQ ?,?,? ke.d-k, - ? b ?.tn? yG° DALE F. SHUGHART, JR. ATTORNEY AT LAW 35 EAST HIGH STREET (/fJ SUITE 203 CARLISLE; PENNSYLVANIA 17013 Telephone 241-4311 Facsimile 1771177) ) 241-4021 OF COUNSEL C. DAV S HAMILTON `5 August 27, 2003 W. Scott Henning, Esquire George B. HANDLER, HENNING & ROSENBERG, LLP MDW&O 1300 Linglestown Road Ten East Harrisburg, PA 17110 Carlisle, */50 LEGAL ASSISTANT BONNIE L. COYLE Faller, Jr., Esquire High Street PA 17013 Michael J. Pykosh, Esquire James M. Robinson, Esquire P. O. Box 368 28 South Pitt Street 3805 Market Street Carlisle, PA 17013 Camp Hill, PA 17011 RE: Sara L. Worman v. Giant Food Stores, Inc. a/k/a Giant Food Stores, LLC No. 01-5511 Gentlemen: The above captioned arbitration, for which the Notice of Hearing is enclosed, is a trip and fall case. I anticipate you will have agreed upon medical records to be submitted by Stipulation, or alternatively, under the Rules governing arbitration. I request that a copy of such records as will be admitted into evidence be submitted to the Arbitrators at least twenty (20) days prior to the date of the hearing. Please do not expect us to be prepared to hear and decide the case if you do not submit this information to us in advance. If you will be having live witnesses, showing videotapes, or having someone read physician's depositions, please advise me, and do not send us such information in advance. Thank you for your cooperation. Very truly yours, Dale F. Shughart, Jr. DFS,JR/bc Enclosure v -f00 SOff u? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. d r I TERM OATH We do solemnly swear (or affirm) that we will support, obey and defend the Constitution of the United States and the Constitution of this Commonwealth and that we will discharee the duties of our office with fidelity. a 1? v7 '5' C- .1.I+IJ Ca =z n_ tQ c'-? We;jhe undersigned arbitrators, tFe follb-king award: AWARD V having been duly appointed and sworn (or affirmed), make . Arbitrator, dissents. (insert nai Date of Hearing: Q b Date of Award: / NOTICE OF ENTRY OF AWARD Now, the 15 day of 6p?J4 , 204, at 3 :09? , F .M., the above award was entered upon the docket and notice thereof given by mail to the parties or their attorneys. Artibitrators'compensation to be 15f /,(A 7? x2 anti Paid upon appeal: Prothonotary $ 290.00 By: n (Note: If damages for delay are awarded, they shall be separately stated.) V ' ' "I ryt QU1 /) ?? pp I?io-s6 a3gs 3Ea?m??,-kA? s? ?? [G Utc 0 aYyf ?r 7011 P?rre?T ?? !)Ji? 5?pl#,Pj F'