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Home My WebLink About03-2892CINDY S. HOKE, individually and as parent and natural guardian of AMY HOKE, a minor, Plaintiffs KRISTIE SULLENBERGER and FREDERIC SULLENBERGER, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW PLAINTIFF'S PETITION FOR COURT APPROVAL OF MINOR SETTLEMENT PURSUANT TO Pa.R.C.P. 2039 1. Plaintiff is Cindy S. Hoke, the natural mother and guardian of minor Amy Hoke, age 17 (D.O.B. 7/14/85), who both reside at 784 Lancaster Avenue, Enola, Pennsylvania 17025. 2. Defendant Kristie Sullenberger is an adult individual residing at 24 Lancaster Avenue, Enola, Pennsylvania 17025. 3. Defendant Frederic Sullenberger is an adult individual residing at 24 Lancaster Avenue, Enola, Pennsylvania 17025. 4. On September 13, 2002 minor Plaintiff Amy Hoke was operating her vehicle northbound on East Penn Drive (State Route 1015) when a vehicle operated by Defendant Kristie Sullenberger and owned by Defendant Frederic Sullerberger traveling southbound on East Penn Drive, failed to yield the right of way and turned in front of the Hoke vehicle at the intersection of Magaro Road resulting in a collision. 5. As a result of the aforesaid collision minor Plaintiff Amy Hoke was injured in the following particulars: a. Deep laceration to forehead. b. Nerve damage in area of forehead location. c. Bruise on right leg. 6. Minor Plaintiff Amy Hoke received medical treatment for said injuries in the following particulars: a. Transported by ambulance from accident scene to Holy Spirit Hospital, Camp Hill, PA. b. Admitted to Holy Spirit Hospital in the evening of September 13, 2002. Underwent operation on forehead laceration September 13, 2002 described as: "Debridement of stellate laceration of the forehead with complex wound repair involving the frontalis muscle, subcutaneous tissue and the skin martin." (Dr. Robert Wolf). c. Discharged September 14, 2002. 2 d. Follow up visit with Robert E. Wolf, M.D. (plastic surgeon) September 20, 2002. Dr. Wolf notes: "Excellent. Sutures removed. The incisions are healing nicely. Instructed on massage therapy." e. Follow up visit with Dr. Wolf September 25, 2002 in which he notes: "Doing well. The lacerations are healing nicely. There is still a very prominent healing ridge along the middle portion. Instructed on continued massage therapy." 7. Medical expenses in the amount of $1,529.87 have all been paid by the first party insurer, USAA. 8. Defendant Kristie U. Sullenberger was insured for automobile liability insurance with Prudential Property and Casualty Insurance Company with policy limits in the amount of $250,000 per person and 500,000 per accident. 9. Plaintiff and Defendants have entered into a settlement whereby Defendants have offered and Plaintiffs have agreed to accept the sum of $30,000.00 in full settlement of Plaintiff's claims against the Defendants. 10. Plaintiff believes that the settlement is fair, reasonable and in the best interest of minor Plaintiff Amy Hoke, her daughter, and further believes that the settlement is fair and reasonable. Furthermore, minor Plaintiff's father, Kirby B. Hoke, also believes that the settlement is fair, reasonable and in the best 3 interest of his daughter and has signed the verification appended hereto but he has not joined as a Plaintiff herein because of his commitment to the United States military. 11. Attached hereto, marked as Exhibit "A", and incorporated herein by reference are the medical records for Amy Hoke's treatment. 12. Attached hereto, marked as Exhibit "B' and incorporated herein by reference is the police accident report for said accident. 13. Attached hereto, marked as Exhibit "C' and incorporated herein by reference are photographs of the injury to Amy Hoke. 14. Upon Court approval of said settlement, Plaintiff agrees to provide to Defendants a signed Release in the form as set forth on Exhibit "D" attached hereto. 14. There are no counsel fees or expenses to be deducted from the 5settlement sum. 16. Pursuant to Pa.R.C.P. 2039 Plaintiff respectfully requests that this Court approve said settlement and direct that until the minor reaches the age of eighteen (18), the settlement sum be deposited in one or more savings accounts in the name of the minor in banks, building and loan associations, savings and loan associations or credit unions, deposits which are insured by a federal 4 governmental agency, provided that the amount deposited in any one said savings institution shall not exceed the amount for which accounts are thus insured, or in one or more accounts in the name of the minor investing only in securities guaranteed by the United States government or a federal governmental agency managed by responsible financial institutions. Furthermore, no withdraw shall be made from any such accounts until the minor attains majority, unless authorized by a subsequent Order of Court. 17. Proof of the deposit shall be promptly filed of record. 18. Upon Court approval of said settlement Plaintiff shall execute the form of release attached hereto as Exhibit "~" and mark the within action settled and discontinued on the docket. WHEREFORE, Petitioner respectfully requests that this court enter an Order approving the settlement and compromise as set forth herein. Respectfully submitted, Date: Cindy S. Hoke, parent and natural guardian of Amy Hoke, a minor, pro se 5 EXHIBIT "A" Pennsy'. ania EMS Report Narrative DISPATCH - AMR I-al WAS [~ SPATCHED CLASS 2 TO EAST PENN DR AND MA( ?ARO I} FOR AN MVA Wl'l-H IN.q [RIE$. 'rRERt WAS NO PI* LNI-X)RMA*I'ION PROVIDED EN-ROLrI'~ '1'O TItE MYA. CC - PT ADVISED OF IlEAl} PAIN W T 1 NO OT IER COMPLAINTS. PT DENIED ANY Di~'.?,INESS, NAUSEA. VOMI'I~N(]. C}I]:2;T. NF~K, BACK OR IFFFFFFFFF~TR~MITY PAIN. ]ri' HI'I- lrf ADVISED TIIAT ^ VEIIICi.E TURNED INTO T]I~ PATH OF THE VEHICLE SHE WAS DPd'V]~O. TI II,l PT ADVISED CONSCIOUSNESS. MEDS - NONE ADVISEO. PE - Iff WAS CA{m4.AND BREATHING: SKIN WAS W;MLM. PINK AND DRY; PT ItAD A LACERATION OF ABOUT I · ON IlER FORE H~.AD WI'l?[ 'rHR I~t.I :.1-,'1) [ N ,,J BE}NO CONTROL] .El~, EYES WERE PEARl .; NECK WAS C21,EAR OF UNY ~AIN OR DEI-YOR Ml'fU,;5: (}COD RANOE OF M{~]ON WH'H {'~} AND (-) PI q3ES. · Pennsylvania EMS Report 20:37 / % ASSE,~SMI~rf 145413 FI' WAS Al .R£^DY IN A C4,'OLI ,AR AND t2-~ PINI~ WAS B]~ INO HF! .1~ ~:~ / % FI,ACF~ ~ O~'O ~B ANI ) ~:45 I % ~D'~ ~ LFI'I'ER US1NO A 4 C~W ' - I'E~ON LIIrIIC~Y ~..~0 92 18 12~ % NORM LOADRD ~ ~ ~. 14~413 '-- ~ ASSE~VFI'AI.~ ~PI .WI'El) 2~:02 I % ~D PA'I'CH 145415 21:0~ g~ ~) 14~) % NORM 2~ ~S, ~IW.D Ol~ AT 145413 Page: 2 of 2 PLASTIC AND RECONSTRUCTIVE SURGERY Length of Disability Code Fee ROBERT E. WOLF, M.D From: Page 1 of 2 Monday, October 21, 2002 7:10:48 PM ADM. DATE: 09/13/2002 PREOPERATIVE DIAGNOSIS: 10 cm complex stellate laceration of the forehead with partial skin avulsion in three places of the forehead. POSTOPERATIVE DIAGNOSIS: OPERATION: Debridement of stellate laceration of the forehead with complex wound repair involving the frontalis muscle, subcutaneous tissue and the skin margin. SURGEON: DR. ROBERT V~)LF - ASSISTANT: DATE: 9/13/2002 ANESTHESIA: INDICATIONS: This 17-year-old white female was involved in a motor vehicle accident and presented with a 10 cm complex stellate laceration in the midportion of the forehead above the right eyebrow. This laceration extended down to the frontalis muscle to the periosteum of the frontal bone. Photographs were taken prior to any surgical repair. The wound was anesthetized and then cleansed with Betadine and saline. The necrotic wound edges were d~brided and skin margins were fabricated to allow approximate reclosure. At first, the underlying frontalis muscle was repaired using interrupted stitches of #6-0 nylon suture. Once the frontalis muscle was reapproximated, the underlying subcutaneous tissues were reapproximated using interrupted stitches of #6-0 nylon suture and the skin margins were then adequately reapproximated using interrupted stitches of #6-0 nylon suture. The entire repair was performed under Ioupe magnification. There were three areas of skin avulsion which were reapproximated to the best of my ability at this time. She was instructed to apply Bacitracin ointment to these sutures and avulsed areas two times a day and to follow-up in my office in one week following the treatment. She tolerated the procedure without difficulty. She was released to home that evening. HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 Page 1 of 2 NAME: Hoke, Amy E MR#: 205699 ROOM: ER1 RECORD OF OPERATION COPY TO: ROBERT E. WOLF, M.D. ADM, DATE: 09/13/2002 CHIEF COMPLAINT: The patient was sent here with an MVA. Unrestrained driver of a vehicle which when she'hit another car, she struck her forehead area against the windshield. The patient has no alcohol on board, denies loss of consciousness. Denies other area of pain other than minim, al neck stiffness. No back pain, extremity discomfort. PHYSICAL EXAMINATION: Vital Signs reviewed on nurse's notes CONSTITUTIONAL: Responsive female with the above complaint. HEAD: There is no scalp trauma. On the forehead however, there is approximately 8-10 centimeter complex laceration involving the forehead. There is no other evidence of facial trauma. NECK: Full range of motion with only minimal stiffness, without tenderness. CHEST: There is no chest pain or back pain, no discomfort on palpation. EXTREMITIES: Upper and lower extremities have full range of motion. NEUROLOGICAL: Alert and oriented to person, place, and time. Cranial nerves intact. Sensory and motor function normal. Reflexes symmetrical. PSYCHIATRIC: Mood and affect appropriate. INTERVENTION: The patient had a cervical spine x-ray which was negative. The patient was seen by Plastics, Dr. Wolf, who did a complex suture repair. The patient will follow up in his office in one week and was given Skelaxin for muscle stiffness and Darvocet overnight. DIAGNOSIS: Cervical strain, forehead laceration. Plastics consulted for that. Page 1 of 2 HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 EMERGENCY ROOM REPORT NAME: Hoke, Amy E MR#: 205699 ROOM: ER1 DR.: LAURENCE H PAUL, MD COPY · NAME; MR#: Hoke, Amy E~ 205699 LP/ct DOC #: 273275 D: 09/13/2002 T: 09/21/2002 11:11 P 330598 CC: Signed LAURENCE H PAUL, MD 09/26/2002 22:56 LAURENCE H PAUL, MD Page 2 of 2 HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 EMERGENCY ROOM REPORT NAME: Hoke, Amy E MR#: 205699 ROOM: ER1 DR.: LAURENCE H PAUL, MD COPY ' CONS'LJLTATION 'REPORT ~'OCONSULT (WITH CARE) [] CONSULT ONLY REPORT REQUESTED REGARDING DIRECTED TO: NOTIFIED By HOLY SPIRIT HOSPITAL OATE Depa~n ~,TIENT: HOt(E, AMY E R#: 205699 3C SEC: 188-68-7662 RD DR: LAURENCE PAUL M.D. I' TYPE: E OB: 07/14/1985 :)CATION: ER1- Holy Spirit Hospital of Radiology and Diagnostic Im'~=~ing Camp Hill, Pennsylvania 17011 (717) 763-2600 DICTATION DATE: Sep 14 2002 9:29A TRANSCRIPTION DATE: Sep 14 2002 9:59A ADM DATE: 09/13/2002 ARRIVAL DATE: 09/14/2002 HOSP SERVICE: ER1 ***Final Report*** XAMINATION: CERVICAL SPINE 72052 - 091'13/2002 COMMENTS: INDICATION: MVA. "- AP and lateral views of the cervical spine were obtained, Cervical vertebral body stature and alignment are maintained with no fracture. There is no prevertebral soft tissue swelling or disc abnormality. There is no bony lesion. CONCLUSION: Negative limited two-view spine, .DICTATED BY: CHRISTINE GOULDY M.D. / RJL DATE OF EXAM: 09/13/2002 SIGNED BY: DATE/TIME: CHRISTINE GOULDY M.D. Sep 14 2002 12:24P ~esults revie~d by M.D./D.C. Imaging Services Consultation Page I ADM. DATE: 09/13/2002 PREOPERATIVE DIAGNOSIS: 10 cm complex stellate laceration of the forehead with partial skin avulsion in three places of the forehead. POSTOPERATIVE DIAGNOSIS: OPERATION: Debridement of stellate laceration of the forehead with complex wound repair involving the frontalis muscle, subcutaneous tissue and the skin margin. SURGEON: DR. ROBERT WOLF ASSISTANT: DATE: 9/13/2002 ANESTHESIA: INDICATIONS: This 17-year-old white female was involved in a motor vehicle accident and presented with a 10 cm complex stellate laceration in the midportion of the forehead above the right eyebrow. This laceration extended down to the frontalis muscle to the periosteum of the frontal bone. Photographs were taken prior to any surgical repair. The wound was anesthetized and then cleansed with Betadine and saline. The necrotic wound edges were d~brided and skin margins were fabricated to allow approximate reclosure. At first, the underlying frontalis muscle was repaired using interrupted stitches of #6-0 nylon suture. Once the frontalis muscle was reapproximated, the underlying subcutaneous tissues were reapproximated using interrupted stitches of #6-0 nylon suture and the skin margins were then adequately reapproximated using interrupted stitches of #6-0 nylon suture. The entire repair was performed under Ioupe magnification. There were three areas of skin avulsion which were reapproximated to the best of my ability at this time. She was instructed to apply Bacitracin ointment to these sutures and avulsed areas two times a day and to follow-up in my office in one week following the treatment. She tolerated the procedure without difficulty. She was released to home that evening. Page 1 of 2 HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 NAME: Hoke, Amy E MR#: 205699 ROOM: ER1 RECORD OF OPERATION ORIGINAL · NAME: Hoke, Amy MR#: 205699 /SZ DOC #: 2~1678 D: 10/07/2002 T: 10/21/2002 4:06'P 345905 cc: ROBERT E. WOLF, M.D. ROBERT E. WOLF, M.D. Page 2 of.2 HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 NAME: Hoke, Amy E MR#: 205699 ROOM: ER1 RECORD OF OPERATION ORIGINAL Initial La~ ,& X-Ray Orders: Labs ] Acetaminophen I Acetone (SACE) ] Alcohol (ALCO) ] AmylaseA-ipase BBH Blood CuRures BMP CBCP CMP CRP1 Digoxin Dilantin Radiolo.qy [ ] Abd/?bstr. Series DOAS ESR Glucose HCGS Liver Lyres PTP Thee I Ankle R L _.~la¢cle R L ,.~ Chest Rt n.~-~'Pm1'~'TPA Elbow R L Facial Femur R L F~'ng er , R L Foot R L Forearm R L Hand R L Hip R L Humerus R L Knee R L Other: ~EASON: Thrombolytic Labs Tox Screen [ ] Udne Tox Screen TSHR UA: [ I DIP [ ] DIAG. ] KUB ] L/S Spine ] Mandible ] Nasal Orbit R L Pelvis Pymogram IVP Ribs R L Shoulder R L Skull Sternum T/Spine Tib / Fib R L Toe R L Wdst R L Tirne/CRT/Int Special Procedures: Ultrasound: CT: (W=With contrast; WO=Without) [ ] Abdomen [ ] Abdomee~Pelvis W WO [ ] VQ Scan [ ] Duplex Doppler [ ] Brain/Head W WO [ ] Echc- [ ] Gallbladder [ ] Chest W WO cardiogram [ ] Pelvic/ [ ] Spiral c~e~t for PE Transvaginal [ } Other: Time/CRT/Mt. REASON: Specimens/Cultures Beta Strep AG Rapid Cerv[caFGenltal Chlamydia GC Culture Monospot (rapid) ] Sputum C& S I StoolC & S ] Stool O & p Stool C. Diffic~le T~ichomonas ]Wound C & S ]~Othec Billing Classification: PHYSICIAN CHARGE FACILITY CHARGE [ ]Levell i ]Leve~l [ ]Acckiem [ ] Level II [ ] Level II [ ] Medical [ ] Level IV J ] Level IV [ ] Extended Hrs. [ lLevelV [ ]LeveIV Holy Spirit Hospital Camp Hill, PA John Fi. Dietz Emergency Center Physician Order Sheet 206*ECU REV 10/00 ~ Cardiac [ ] Monitor [ ] EKG [ ] 02 L/Mia [ ] 02 Saturation Respiratory [ } ABG's [ J Peak Flows Before/After Resp. Tx. [ ] Respiratory Tx. Medications / IV's / Additional Orders IV: NSS/D5W/LPJ D5/.45NS/DS.9NS WO/KVO/infuse at mis/hr [ ] Obtain old records [ ]Td [ ] Protocol initiated for: Initials:__ Signature: RN/MA Initials:--. Signature: RN/MA Dictated: Half [ ] Completed [ ] , CI~ITICAL CARE: hrs. Diagnostic Impression: 7! Consultim Si~c Date:. Name: /-7 Mode of Arrivah B~I..ALSrq Other[] T P Triage Chief Complaint -~{~')(' :-.,,)/~ ~' Pre-Hospital Care: M/C [] Vital Signs: BP/Z.~p~'~/ R ~ Rh~hm: Airway []Nasal []Oral F']ETI Size Oxygen DN/C E]NRB [] % IV Therapy: Dextrostick: Medications: 'Splint ~kboar~ EMS Signatur~//~ PMH Checklist: None[] Mt[] HTN [] CAD [] CHF[] ASTHMA [] CA,NCERE~ STF~OKE~;;t Surgeries[] Other E3 <:~ Allergies Latex Allergy Yes [] No/.[:;]/ Immunizations: UTD[] Not UTD[] Tetanus LMP HOH[] Speaks Enqlish: Yes[] No[] Treatment @ Triage TrJg In: "~'~ f/ age: Room: Advanced Directives Yes [] ,/¢ A~ached / Yes [] N,~[] Exposure to measles, chxn pox. Yes[] No[] PAIN ASSESSMENT Intensity Scale '7 /10 Adult.~' Wong Baker[] Ch~iracter/~ Ache/Z Dull [] Sharp Pressure [] Burning [] Throbbin~ ~< Radiatin Frequency What relieves Pain?~ Triage Notes: Medications: Info obtained by: EMT[] Medic[] List[] Bottles[] Patient[] Dose Meds Dose Meds Unknown[] · -- Injury: Place Occurred: Home/~3 Location On Body:~-~r~=~ Adult/Child Abuse: Do yotu,~eel safe? Yes [] Nc~]) Quickcare [] Ccc Health [] Crisis [] Tdage Dispositij~ ~,Ur~ Completed by ~ ._..Jr ~./ LJ~,~RN MA ~'~/f, ~5 Time Meds Dose Skin Color: WNL _.~ Mot'tied [] Cyanotic [] Skin Temp: Warm[] Cool[] Distal Pulses: Yes[] No[] Edema: Yes[] No[] Deformity: Yes[] No[] Ecchymosis: Yes[] No[] Triage to Radiology at Holy Spirit Hospital Camp Hill, PA 17011 John R. Dietz ECU Nursing Assessment CHART COPY ' Appearance: heado ache ~) PERL {~ stiff neck Size [~ neck pain Pinpoint FI facial droop Dilated [~ numbness: Fixed E~weakness.~ Sluggish non-reactive GLASGOW COMA SCALE Status: ~Res/piratory: [~ uncooperative ymmetrical ~)confused ~anxious r~Jabored -Iwheezing L / R ~)appropriate ~rales/rho~3chi L / R [~)delayed Ficough ~lproductive ~]restraintJseclusion.flow sheet F302__L via % Sat Glasgow Score: // -~'~ FI Durafion/ intensit~ [~ nausea ~)diarrhea ~J vomifing :~ consfipation ~lHematemesis Last aM Bowel Sounds (~Abdomen tender. CIdistended FIfirm ~lsoft Trauma ~N/A Location__. ~pS ~,~TOR RESPONS~55~RBAL (~1 Other: LMP Eyes Ears NURSING A~ ~ -- I · GU / GYN Cardiovascular [~ urethral ~1 Monitor/rhythm: area: Severity __/10 ~frequency discharge ~pacer [~constant ~sharp ~lurgency ~vaginal discharge ~ledema: ~intermitten/[~dull [~ Dysuda FIvaginal bleeding ~burning [~ heavy n Hematuria [~foley ~JVD [~SOB [~ pleudtic ~lretention present # -1 capillary refill: ~nausea ~rapid ~ldelayed ~non-radiafing L ~lradiating [~congesfion [~ sore Acuity: L__/__ FIEpistaxis L / R {~dysphasia Fiwith lenses Signature Initial Notes Notes Holy Spirit Hospital Camp Hill, PA 17011 John R. Dietz ECU Nursing Assessment/Notes SFER OR DISCHARGE · by:./"~/~x~ · .':~mbulatory nwfc [~ambulance to: ~'?~'ome Onursing ~bme r~AMA OOR C~other; ~E~d~'scharge instructions given to: ~5'atient ,[~family Oparent Oother: .~,~9~rbalized understanding of d/c instructions OReport called ~. to ~old records sent to floor Ficlothing sheet done F~transferred to_. E)consent signed Condition: · "~atisfactory to morgue RN ;MERGENCY CENTER URGI CENTER DISCHARGE INSTRUCTIONS HOLY SPIRIT HOSPITAL , (.717) 763-2316. !(7.17) 76~-2424 Patient Information: Patient Information sheets contain important information to review and keep, ( ) Abdominal pain ( ) AIcoho~ reaction ( ) Allergic reaction { ) Asthma ( ) Back pain ( ) Bites-Human/Animal/Insect ( ) Burn ( ) Chest Pain ( ) Conjunctivitis ( ) COPD WOUND CARE Corneal abrasion/foreign body ( ) Headache ( ) Pain Managemem ( ) Threatened Miscarriage Croup/bronchitis ( ) Head Injury ( ) Pediamc Head Iniury ( ) Toothache Crutch walking ( ) Hypertension ( ) Pedimric URI ( ) URI and Co,ds Diarrhea and Vomding/Ped Vomiting ( ) Immunization/Tetanus ( ) PID/STD ( ) UTI and Pyelonephdtis Disloca~on _ ( ) Kidney S~ones ( ) Pneumonia ( ) Wound Recheck Drug/Alcohol abuse/addiction ( )Lablynthitis ( )Rash ( )24 hr Pharmacies Febrile Convulsion ( )Laceration ( } Seizure ( )Other Fever/Ped. Fever ( } Neck Strain ( ) Sore Throat Flu ( )Nosebleed ( )Sprains and Strains Fracture ( )Otifis Media ( )Suture Care & Removal MEDICATIONS ( ) May gently wash over wound Jn 24 hours with soap and water or peroxide. Do not soak in water. ( ) Change dressing times daily. Redress with Bacitracin/Neospodn and sterile dressing. ( ) Keep wound clean, dry, covered. ( ) Tetanus/Diptheda Booster given. SPRAI~IS, STRAINS, BRUISES, FRACTURES ) Elevate the injured part for__ days to reduce swelling. ) Apply ice packs intermitlently for days to reduce swelling. ) Ace wrap for support for days. ) Wear splint ( ) At all times until follow-up. ( ) For activity as needed. ) Use sling for support. ) Use crutches: ( ) As needed, weight bearing as tolerated. "- ( )At all times. NO WEIGHT BEARING NECKJBACK ( ) Wear cervical collar for support for__days. ( ) Rest, avoid bending, lifting, strenuous activity for__days. ( )Apply moist heat for minutes times daily beginning in hours. ADDITIONAL INSTRUCTIONS ) Off work/school from to ) Return to work on ) Light Duty until: Restrictions: ) No gym/sports until ) Follow instructions on Workmen's Compensation Form. ) Wear eye patch for hours. ) If nose bleed recum, pinch nose firmly for 5 minutes continuously, return if bleeding not controlled. ) The prescribed antibiotic may reduce the effectiveness of medication you are currently taking. Check package instructions or consult with Pharmacist. ) The interpretation of your X-Rays are preliminary reading. Your films will be reviewed by a radiologist. You or your physician will be contacted if there is a change in the diagnosis. Additional Instructions: ( ) Continue present medications except: (~-)'[Jse Advil (Ibuprofen) or Tylenol as needed for pain, fever acc/ording to package nstructions for age, weight. (~--) Use the following medicines according to package ( ) The following medicines may cause drowsiness: DO NOT DRIVE OR OPERATE MACHINERY WHILE TAKING: FOLLOW-UP This is our recommendation for follow-up. If your insurance (HMO) requires a physician referral for specialty consultation, IT IS YOUR RESPONSIBILITY TO OBTAIN THE NECESSARY APPROVAL. (:~ollow-up with:,- ( ) Urgi Center ~.~,o/:,- ( ) Family Doctor in -~ ~d~._~s for: ( ) Follow-up ( ) Suture removal ( ) Call as soon as possible for appointment ) Pick up your X-Rays from the Radiology Department prior to your follow-up appointment. Call 763-2696 to have films ready. ) See your physician or specialist if not improved in days. ) Return to Emergency Center if you feel your condition is worsening, especially if the pain increases despite pain relief medication. ) Your blood pressure was elevated. Please have it rechecked by your physician. ) Test results have been given to you. Take them with you to the follow-up appointment. Test results given: I~CBC ~]CMP []EKG []X-RAY COPY []BMP ORECORDS COPY CHART ~]GLUC. A copy of your dictated Emegency Room Report is available to your physician Irom Medica Records (763-2660), if not already sent. I hereby acknowledge receipt of these instructions and understand them. I understand that I have had emergency treatment onlv and that I may be released before all of my medical problems are known or treated. I will arrange for follow-up care as I have been instructed. It is your responsibility to notify your Pdmary Care Physician't)f this visit. Clinical Impressions: ( ) PATIENT VERBALIZES UNDERSTANDING Date ( ) Apply ice packs intermittently for__days to reduce swelllng. ( ) Ace wrap for support for days. .( ).VVear,spEr~t ( ) At all times until follow-up. ( ) For activity as needed. ( ) Use sling for support. ( ) Use crutches: ( ) As needed, weight bearing as tolerated. ( )At all times. NO WEIGHT BEARING NECK/BACK ( ) Wear cervical collar for support for__days. ( ) Rest, avoid bending, lifting, strenuous activity for__days. ( ) Apply moist heat for minutes- times dairy beginning in hours. ADDITIONAL INSTRUCTIONS ) Off work/school f~om to ) Return to work on ) Light Duty until: Restdcfions: ) No gym/sports unti~- ) Follow instructionston Workmen's Compensation Form. ) Wear eye patch for hpurs. ) If nose bleed recurs, pinch nose firmly for 5 minutes continuously, retum if bleeding not controlled. ) The prescribed antibiotic may reduce the effectiveness of medication you are currently taking. Check package instructions or consult with Pharmacist. ) The interpretation of your X-Rays are preliminary reading. Your films wilt be reviewed by a radiologist. You or your physician will be contacted if them is a change in the diagnosis. Additional instructions: ( ) The following medicines may cause drowsiness: DO NOT DRIVE OR OPERATE MACHINERY WHILE TA~lNG: FOLLOW-UP This is our recommendation for follow-up. If your insurance (HMO) requires a physician referral for specialty consultation, IT IS YOUR RESPONSIBILITY TO OBTAIN THE NECESSARY APPROVAL. (v~ollow-up with: /~ ( ) Urgi Center ~.~ ,(.~/o/t~' ( ) Family Doctor in -~ a~ for: ( ) FO~Ow-up ( ) Suture removal ( ) Call as soon as possible for appointment ) Pick up your X-Rays from the Radiology Department prior to your follow-up appointment. Call 763-2696 to have films ready. ) See your physician or specialist'if not improved in days. ) Return to Emergency Center it you feel your condition is worsening, especially if the pain increases despite pain relief medication. ) Your blood pressure was elevated. Please have it rechecked by your physician. ) Test results have been given to you. Take them with you to the follow-up appointment. Test resuits given: DCBC I-ICMP E3[~KG E] X-RAY COPY E3BMP [:]RECORDS COPY CHART [:]GLUC. A copy of your dictated Emegency Room Report is available to your physician from Medical Records (763-2660), if not already sent. I hereby acknowledge receipt of these instructions and understand them. I understand that I have had emergency treatment only and that I may be released before all of my medical problems are known or treated. I will arrange for follow-up care as I have been instructed. It is your responsibility to notify your Phmary Care Physician of this visit. Cdnical Impressions: HOLY SPIRIT HOSPITAL EIVlERGENCY CENTER ( ) PATIENT VERBALIZES UNDERSTANDING SIGNATURE: \~'i' ' Pat'ent or Respon{ible Person SIGNATURE: ~-~% Date f' M.D./D.O. Nurse RN 503 NORTH 21ST STREET CAMP HILL, PA 17011-2288 (717) 763-2316 ( ) Vanitha Abraham, M.D. 038840L ( ) Jon Dubin, D.O. OS 006991L ( ) Lawrence Paul, M.D. 039524-L Thomas .~Idous, M.D. 017075E Salvatore Alfa. no, M.D. 025502E Rameah .-~-ora, M.D. 016727E Glen Daughtry, D.O. 06006776E Nicolau DaCosta, M.D, 053288-L DATE ( ) M~lys Hasson, M.D. 072553L ( ) Jolm p. Judson, M.D. 038368-E ( ) Etched Lulcy, M.D. 029960-E ( ) PWlfip ?,taguire, M.D. 015063-E ( ) Pushpa Mudan, M.D. 051514L ( ) Howard Rudnick. M.D. 040862-L ( ) Ranjana Sharma. M.D. 031265-E ( ) Alan Teplis, M.D. 03001R-E ( ) David Zimmerman, M.D. 005636-E () SIGNATL'RE M.D,/D.O, IN ORDER FOR A BRAND NAME PRODUCT TO BE DISPENSED, THE PRESCRIBER MUST HA. ND WRITE "BRAND NECESSARY" OR 'RIL&ND MEDICALLY NECESSARY" IN THE SPACE BELOW ~LABEL DEA# -REFILl TIME O SUB STITUTION PERMISSIBLE CONSENT'TO MEDICALTREATMENT I HEREBY CONSENT AND AUTHORIZE Holy Spirit Hospital, its agents, and em¢oyees, 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. 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 satisfaction. If I am a competent adult, I have the right to consent or refu_%e.~to cons.~nt: ~ understand that the practice of medicine and surgary is not an exact science and that diagno- sis and treatment may involve risks of injury or ~ven de~th 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 p~ysicians on the staff of Holy Spirit Hospital are not employees or agents of the Hospital, but rather are independen~ contractors who have been granted the privilege of using these facilities for the care and treatment of their patients. Further, I realize this Hospital is a teaching Hospita{ and at the Hospital are health 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 closed 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 on the premises of Holy S~jtal is subject to reasonable~ search and/or seizure at any time without further notice. Initia~s~ RELEASE OF MEDICAL INFORMATION I authorize Holy Spirit Hospital to release to requesting health insurance carrier(s), their representatives and auditors, and any referring health care providers, such diagnostic and therapeutic information (including any information relating to treatment for alcohol and substance abuse and/or treatment of osychiatric disorders, and/or confidential HIV related information, as may be necessary for them to determine benefit enti- tlement; to process payment claims for health care services provided during this hospitalization/treatment episode, and for continuing care/treatment. 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 carrier, upon their request, medical information needed to make payment upon'that claim. I understand and consent that the manufacturer of any implantable device inserted by my physician during the course of my sur~5~r(~cpCure may be provided with my identification information, including social security number, as mandated by Federal Law. Initi~ INSURANCE ASSIGNMENT OF BENEFITS I authorize payment directly to Holy Spirit Hospital and my treating physicians of all benefits payable under my insurance policie~/f"unCemtand I.~m responsible to the Hospital and physicians for all charges not covered by this assignment. Initials'"'~.,~ (~ .~ STATEMENT TO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDERS, PHYSICIANS AND PATIENT I request payment of Authorized Medicare benefits to me or on my behalf for any services furnished me by or in Holy Spirit Hospital including physician services. I 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. Initials MEDICAL ASSISTANCE RECIPIENT My signatures certifies that I received a 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 understand that certain tests and procedures may not be reimbursed by Federal and State funds and that I may be responsible for non covered charges. Aisc, I agree that if at the time of service, if I am not eligible for Medical Assistance, l will be responsible for balances owed to Holy Spirit Hospital, Initials f have read and understand each of the sections contained above. I understand that by signing this document, I am agreeing and providing the authorization/consent cont{~ined in each of the above sections where my initials are located. I have had the opportuni- ty to ask q.~'~regardi~ eachjol t_h.e~[,~ sections and all such questions asked¢~/~been j~vered to my satisfaction' RelationshiptoPatient'-'/.L/~"~"-/'~ ~L_.,/"I Time !) ('~//~ Date~//-~-~ HOLY SPIRIT HOSPITAL, CAMP HILL, PA CONSENT FOR TREATMENT/RELEASE OF INFORMATION INSURANCE ASSIGNMENT CHART -_ Z EF; --- -=; :'E ~H 33: ..=.--- .:h ' -E Z FAT:EHT ,-';'FE; :- FiUA;CiAL C,'__='; T 'CONS JLf R£PORT / [~'OCONSULT (WITH CARE) [] CONSULT ONLY REPORT REQUESTED REGARDING DIRECTED TO: DATE TIME HOLY SPIRIT HOSPITAL David C. Leber, M.D., F.A.C.S. Robert E. Wolf, M.D., EA.C.S. 2807 North Front Street Harrisburg, PA 17110 PATIEN'I~ PROGRESS NOTES Name Account No. DATE PROBLEM EXHIBIT "B" !02 ! o "~ Pc) Hoke 784 LANCASTER AVE 7025 -i 36S2LK$02600 iIENOLA htt~://www~d~t6~tat~a~us/~rash~nsf/Print?~p~nAgent&a~2~2~6456~=~u~DMS~6~c-=~... 9/20/02 Page 2 of 8 d &nd S41vCk i hrtp://www.dot6.statc.pa.us/crash.nsf/Pvint?OpenAgent&a=2002064560t=lu=DMS11600c=V*... 9/20/02 Pa~e 3 AA453 I CO¢,A~O~T~ 0¢ PENJ~SYLVAF,!~A 101 i ISULLENBERGER LANCASTER AVE 21547057 IW0002824 ! [784 LANCASTER AVE 27262665 PENHOOT COPY h[tp://www.dot6.state.pa.usYcrash.nsf/Print?OpenAgent&a=2002064 560t= l u=DMS11600c=!A... 9/20/02 Page 4 ,of 8 ~ ,~.~ ~., ~bM~~ a B~ C D ~ - F G H I ~,~,~o ~-~-[~gaz ~~1103 1~.o3~~ Io2=~,~.,~1~ o [02 1-106 1-l]s85, ..... ~OY~ O~ http://www~d~t6.stat~~pa~us/~rash~nsf/Print?~penAgent&a=2~~2~6456~t=-~u=DMS~~6~~c=~~..~ 9/20/02 '.' '. Page $'of8 http://www.dot6.state, pa.us/crash.nsf/Print?OpenAgent&a=2002064560t=lu=DMSi 1600c=~... 9/20/02 Page 6 ¢f8 ---I P ENNDOT COPY http://ww'w.dot6.state.pa, usdcrash.nsffPrint?OpenAgent&a=2002064560t=lu=DMS11600c=~3... 9/20/02 J ~.~ C4~ pLr'/~SYL.VAHI& Page ? ~f 8 lW0002824 J E~.~t Pennsboro EMS Holy Spirit Hospital h ttp://www.dot6.state, pa.us/crash.nsf/Print?OpenAgent&a=2002064560v= 1 u=DMS l 1600c=~X... 9/20/02 Crash Number: W0002'824 Incident Number: 2002-09-0335 Page 8 o.f 8 East Penn Dr (SR1015) ht~p:/~w~ww~d~t6~state~pa~us/crash.nsf/Print?~penA gent&a=2~2~6456~- ~ u=DMS ~ ~ 6~c-- ~3... 9/20/02 EXHIBIT "C" EXHIBIT "D" RELEASE OF ALL CLAIMS KNOW ALL MEN BY THESE PRESENTS: That for and in consideration of the payment to the undersigned of Thirty Thousand Dollars ($30,000.00) and other good and valuable consideration, the undersigned, Cindy S. Hoke, parent and natural guardian of Amy Hoke (D.O.B. 7/14/85) and on behalf of Amy Hoke, a minor, and in her own right, does for herself, her heirs, successors and assigns, and on behalf of Amy Hoke, hereby release, acquit, and forever discharge, Kristie Sullenberger, Frederic Sullenberger, Prudential Property and Casualty Insurance Company, and their subsidiaries, servants, agents, employees, officers, heirs, representatives, successors and assigns of and from any and all past, present and future actions, causes of action, claims, demands, damages, costs, loss of services, loss of use, expenses, compensation, third party actions, suits at law or in equity, including claims or suits for contribution and/or indemnity, of whatever nature, and all consequential damage on account of, or in any way arising out of, an accident that occurred on or about September 13, 2002 at the intersection of East Penn Drive (SR 1015) and Magaro Road in East Pennsboro Township, Cumberland County, Pennsylvania. The undersigned understands that this settlement is the compromise of doubtful and disputed claims raised jointly or individually by, or on behalf of, Cindy S. Hoke EXHIBIT "D" RELEASE OF ALL CLAIMS KNOW ALL MEN BY THESE PRESENTS: That for and in consideration of the payment to the undersigned of Thirty Thousand Dollars ($30,000.00) and other good and valuable consideration, the undersigned, Cindy S. Hoke, parent and natural guardian of Amy Hoke (D.O.B. 7/14/85) and on behalf of Amy Hoke, a minor, and in her own right, does for herself, her heirs, successors and assigns, and on behalf of Amy Hoke, hereby release, acquit, and forever discharge, Kristie Sullenberger, Frederic Sullenberger, Prudential Property and Casualty Insurance Company, and their subsidiaries, servants, agents, employees, officers, heirs, representatives, successors and assigns of and from any and all past, present and future actions, causes of action, claims, demands, damages, costs, loss of services, loss of use, expenses, compensation, third party actions, suits at law or in equity, including claims or suits for contribution and/or indemnity, of whatever nature, and all consequential damage on account of, or in any way arising out of, an accident that occurred on or about September 13, 2002 at the intersection of East Penn Drive (SR 1015) and Magaro Road in East Pennsboro Township, Cumberland County, Pennsylvania. The undersigned understands that this settlement is the compromise of doubtful and disputed claims raised jointly or individually by, or on behalf of, Cindy S. Hoke and Amy Hoke and that payment is not to be construed as an admission of liability on the part of persons, firms and corporations hereby released by whom liability is specifically and expressly denied. This Release contains the entire agreement between the parties hereto and the terms of this Release are contractual and not a mere recital. Furthermore, this Release and the settlement described herein is subject to approval by the Court as required by Pennsylvania law and rules of Court. In the event that the settlement as set forth herein is disapproved by the Court, the undersigned agrees to reimburse the parties released herein any and all sums contributed towards the settlement described herein. The undersigned further states that she has carefully read the foregoing Release, has had the assistance of counsel in the review and execution of the within Release, and this Release is executed as her own free act. IN WITNESS WHEREOF, I have hereunto set my hand this day of ,2003. Cindy S. Hoke, in her own right Cindy S. Hoke, as parent and natural guardian of Amy Hoke, a minor STATE OF PENNSYLVANIA SS COUNTY OF CUMBERLAND Personally appeared before me, a notary public, in and for said State and County, the undersigned, who being duly sworn according to law, deposes and says that the facts set forth in the foregoing Release of All Claims, are true and correct to the best of her knowledge, information and belief. Sworn to and subscribed before me this day of ,2003. Cindy S. Hoke, in her own right and as parent and natural guardian of Amy Hoke, a minor Notary Public (SEAL) VERIFICATION We, Cindy S. Hoke and Kirby B. Hoke, verify that the statements made in the foregoing document are true and correct to the best of our knowledge, information and belief. We understand that false statements herein are made subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsification to authorities. Date: Date: Kirby B. Hoke CINDY S. HOKE, individually and as parent and natural guardian of AMY HOKE, a minor, Plaintiffs KRISTIE SULLENBERGER and FREDERIC SULLENBERGER, Defendants : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : : CIVIL ACTION - LAW PRAECIPE FOR ENTRY OF APPEARANCE TO THE PROTHONOTARY: Kindly entry my appearance on behalf of Defendants Kristie Sullenberger and Frederic Sullenberger in the above matter. Respectfully submitted, NESTICO, DRUBY & HILDABRAND, L.L.P. Karl R. Hildabrand, Esquire Attorney I.D. No. 30102 840 East Chocolate Avenue Hershey, PA 17033 (717) 533-5406 (717) 533-5717 Attorney for Defendants CINDY S. HOKE, individually and as parent and natural guardian of AMY HOKE, a minor, Plaintiffs KRISTIE SULLENBERGER and FREDERIC SULLENBERGER, Defendants : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : CIVIL ACTION - LAW : NO. O3- ; ACCEPTANCE OF SERVICE I, Karl R. Hildabrand, Esquire, counsel for Defendants, hereby accept service of the Writ of Summons in the above matter on behalf of Defendants, Kristie Sullenberger and Frederic Sullenberger. Respectfully submitted, NESTICO, DRUBY & HILDABRAND, L.L.P. Karl R. Hildabrand, Esquire Attorney I.D. No. 30102 840 East Chocolate Avenue Hershey, PA 17033 (717) 533-5406 (717) 533-5717 Attorney for Defendants CINDY S. HOKE, individually and as parent and natural Guardian of AMY HOKE, a minor Plaintiffs : IN THE COURT OF COMMON PLEAS OF · CUMBERLAND COUNTY, PENNSYLVANIA : 03-2892 CIVIL TERM KRISTIE SULLENBERGER and FREDERICK SULLENBERGER, Defendants ORDER OF COURT AND NOW, this ~ dayof ~t_~ , 2003, hearing on the Petition for Court Approval of Minor Settlement is set for 11:00 a.m., Monday, July 21, 2003, in Courtroom No. 2. Edgar B. Ba~-~,, Cindy S. Hoke 784 Lancaster Avenue Enola, PA 17025 Karl R. Hildabrand, Esquire Nestico, Druby & Hildabrand 840 East Chocolate Avenue Hershey, PA 17033 ~NVA'i~gNNZ'~d CINDY S. HOKE, individually and as parent and natural guardian of AMY HOKE, a minor, Plaintiffs KRISTIE SULLENBERGER and FREDERIC SULLENBERGER, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. ~ $ - 2 ~' ~' Z. ~L ~ PRAECIPE TO SETTLE AND DISCONTINUE TO THE PROTHONOTARY: Kindly mark the above action settled and discontinued. Date: Cindy S. Hoke, individually and as parent and natural guardian of Amy Hoke, a minor, pro se (") C) 0