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HomeMy WebLinkAbout99-076011? I IN THE COURT OF COMMO PENNSYLVANIAN F CUMBERLAND COUNTY NICHOLE A. SENTZ-BROWN Plaintiff V. CIVIL ACTION - LAW No. Civil Term Q9- '71-01 JURY TRIAL DEMANDED Gtn cr;?? PrytQ/d IN . loq.r- Z8 s4- 53 W 3reehn ?o/• p1?, /?,IIySPr nqs, ?n I ?oz, cay-li.,lt, ?A 17013 PRAECIPE FOR WRIT OF SUMMMONS GREGORY A. GRIFFIE and DONALD W. TACK Defendants TO THE PROTHONOTARY: Issue a writ of summons in the above matter. Date: December2l, 1999 KNAUER & ASSOCIATES, L.S.C. David W. Knauer, E quire 1/4? Attorney for Plaintiff Attorney I.D. No. 21582 411-A East Main Street Mechanicsburg, PA 17055 (717) 795-7790 U G. cl ? _ n cl, ?b n1 V Commonwealth of Pennsylvania County of Cumberland Nichole A. Sentz-Brown VS. Gregory A. Griffie 28 E. Pine Street Mt. Holly Springs, PA 17065 Donald W. Tack 53 W. Yellow Breeches Road Carlisle, PA 17013 Court of Common Pleas No. --------- 99 _7601 Qiy_i7 Tom" - t9-- - Civil-Action ---law To -Sireg_firi.ffie-andlbnald_kL_Tar-k----_- You are hereby notified that Nichole A. Sentz-Brown •------------------------------------------------•--------- the Plaintiff has commenced an action in ------ ittil-Actian_ -iaw- against you which you are required to defend or a default judgment may be entered against you. (SEAL) ---------- Lurtis-R._ Iong--------------------- Prothonottaryy Date December 21 .......... 19_ 12 IUY Deputy 7 ??s ? ? ro o I P4 w A U j f v M •.1 lJ N U) •--I U i Y W C 4 r f '4 N W '-I CD N l P + ko N N 0 N04 E°yoa Ii N a % rn1 a we 3?H U 7 N R W T -I ,- $'i i ? U N C co pp m Id i i i Lo 41 Lo q i a) r t3l N 3' W U ? i N ? I •r l ` tlp a; yI m 7 m m P i 4J-0 rul I > U ? O Uj ?a'F I?H z i Z O N C] U d 1 NICHOLE A. SENTZ-BROWN, Plaintiff V. GREGORY A. GRIFFIE and DONALD W. TACK, Defendants IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 99-7601 CIVIL TERM CIVIL ACTION - LAW JURY TRIAL DEMANDED PRAECIPE FOR APPEARANCE TO: Prothonotary Please enter the appearance of Richard H. Wix, Esquire, of the firm of Wix, Wenger & Weidner, on behalf of Defendant Donald W. Tack in the above-captioned matter. WIX, WENGER & WEIDNER By drlCl' j, N • Li,- Richard H. Wix, I.D. #07274 Attorneys for Defendant 4705 Duke Street Harrisburg, PA 17109-3099 (717) 652-8455 Dated: I'lal x`10 g u l u . z V U p t •f`: SHERIFF'S RETURN - REGULAR CASE NO: 1999-07601 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND SENTZ-BROWN NICHOLE A VS GRIFFIE GREGORY A ET AL Sheriff or Deputy Sheriff of CPL. MICHAEL BARRICK ' Cumberland County, Pensylvania, who being duly sworn according to law, was served upon says, the within WRIT OF SUMMONS the TACK DONALD W , on the 22nd day of December , 1999 DEFENDANT at 0018:49 HOURS at 53 W YELLOW BREECHES ROAD by handing to CARLISLE, PA 17013 DONALD TACK ?- together with a true and attested copy of WRIT OF SUMMONS o the contents at the same time directing His attention tthereof. Sheriff's Costs: 6 00 Docketing . .00 Service 00 Affidavit . 8.00 Surcharge .00 1 041 So Answers : R. Thomas Kline -. 12/23/19'. DAVID KM Sworn and Subscribed to before BY: mthis ? day of t CASE NO: 1999-07601 P SHERIFF'S RETURN - REGULAR COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND SENTZ-BROWN NICHOLE A VS GRIFFIE GREGORY A ET AL CPL. MICHALE BARRICK , Sheriff or Deputy Sheriff of Cumberland County, Pensylvania, who being duly sworn according to law, says, the within WRIT OF SUMMONS was served upon GRIFFIE GREGORY A the DEFENDANT , at 0017:58 HOURS, on the 22nd day of December , 1999 at 28 E PINE ST (EAST) MT HOLLY SPRINGS, PA 17065 by handing to GREGORY A. GRIFFIE 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: So Answers: Docketing 18.00 Service 4.34 Affidavit 00 Surcharge 8.00 R. Thomas Kline .00 30.34 12/23/1999 DAVID KNAUER Sworn and Subscribed to before By: f me\(?his? day of Deputy riff X- C/fItiI-Ar A.DC7 i U Wi: mr. IN THE COURT OF COMMON PLEAS, CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION NICHOLE A. SENTZ-BROWN, Plaintiff V. GREGORY A. GRIFFIE and DONALD W. TACK, Defendants File No. 99-7601 CIVIL TERM PRAECIPE AND RULE TO FILE X A COMPLAINT A BILL OF PARTICULARS TO THE PROTHONOTARY/CLERK OF SAID COURT: Issue rule on Plainti f to file a Complaint in the above case within twenty days after service of the rule or suffer a judgement of non pros. DATE: March 30, 2000 NOW, / 2 ( aa_c 1 .3 ? -, (NOTE: File in duplicate) Signature: 1 ` A J? Print Name: Richard H Wix, FG=- Attorney for: Defendant Tack Address: 4705 Duke Street Harrisburg PA 17109-3099 Telephone No: (717) 652-8455 Supreme Court ID No.: 07274 ,$®U? RU E ISSUED AS ABOVE. P othonotary Deputy PROTHON.-12 CC) cn LU O CD U IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA NICHOLE A. SENTZ-BROWN Plaintiff V. GREGORY A. GRIFFIE and DONALD W. TACK Defendants : CIVIL ACTION - LAW No. 99-7601 Civil Term JURY TRIAL DEMANDED NOTICE TO DEFEND AND CLAIM RIGHTS 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 LAWYER REFERRAL SERVICE Court Administrator Cumberland County Courthouse One Courthouse Square Carlisle, Pennsylvania 17013 (717) 240-6200 NOTICIA Le han demaandado a usted en la corte. Si usted quieie defenderse de estas demandas expuestas en las paginas siguientes, usted tiene viente (20) dias de plazo al partir de la fecha de la demanda y la notificacion. Usted debe presentar una apariencia escrita o en persoa o por abogado y archivar en la corte enforma escrita sus defensas o sus objections a ]as demandas en contra de su persona. Sea avisado que si usted no se defiende, la corte tomara medidas y puede entrar una orden contra usted sin previo aviso o notificacion y por cualquier queja o alivio que es pedido en la peticion de demanda. Usted puede perder dinero o sus propiedades o otros derechos importanted para usted. LLEVE ESTA DEMANDA A UN ABOGADO INMEDIATAMENTE. SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFICIENTE DE PAGAR TAL SERVICIO, VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PAPA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. CUMBELAND COUNTY LAWYER REFERRAL SERVICE Court Administrator Cumberland County Courthouse One Courthouse Square Carlisle, Pennsylvania 17013 (717) 240-6200 David auer Attorney for Plaintiff Attorney I.D. No. 21582 411-A East Main Street Mechanicsburg, PA 17055 (717) 795-7790 Date: April 20, 2000 IN THE COURT OF COMPS NPLEAS OF CUMBERLAND COUNTY NICHOLE A. SENTZ-BROWN Plaintiff CIVIL ACTION - LAW V. GREGORY A. GRIFFIE and DONALD W. TACK Defendants No. 99-7601 Civil Term JURY TRIAL DEMANDED COMPLAINT 1. The Plaintiff Nichole A. Brown is an adult individual with an address of 1550 Williams Grove Rd. Mechanicsburg, Pennsylvania. 2. The Defendant Gregory A. Griffie is an adult individual with an address of 28 E. Pine St. Mt. Holly Springs, Pennsylvania. 3. The Defendant Donald W. Tack is an adult individual with an address of 53 W. Yellow Breaches Rd. Carlisle, Pennsylvania. 4. At all times relevant herein, the Defendant Gregory A. Griffie was the owner and operator of a certain 1995 Jeep Cherokee. 5. At all times relevant herein, the Defendant Tack was the owner and operator of a certain 1996 Dodge Caravan. 6. At all times relevant herein, the Plaintiff was a passenger in Defendant Griffie's aforementioned Jeep Cherokee. 7. On or about December 27, 1997, Defendant Griffie was operating his vehicle at the intersection Burnthousc Rd. and Old York Rd., when his vehicle came into a sudden and violent collision with the Defendant Tack's vehicle and a vehicle owned and operated by Jeffrey C. Barrick. 3 8. As a result of the collision, Plaintiff suffered severe and sundry injuries to her person including but not limited to injuries to her neck, back, causing headaches and other injuries. COUNTI BROWN v. GRIFFIE 9. The Plaintiff incorporates herein by reference thereto paragraphs 1 though 8 of the within Complaint as if more fully set forth herein. 10. The Defendant Griffie was careless, reckless and negligent in that he: a. failed to keep a vigilant look out for oncoming traffic that had the right of way; b. failed to see Defendant Tack as he was proceeding through the intersection; c. failed to yield the right of way to the Defendant Tack's aforesaid vehicle; d. violated the Pennsylvania Motor Vehicle Code Section 3323(b); c. was otherwise negligent. 11. In the alternative, the Defendant Griffie is solely or jointly and severally liable with the Defendant Tack and is responsible for the injuries the Plaintiff has suffered as aforesaid. 12. The Pennsylvania Comparative Negligence Act is applicable in this action as to the apportionment of liability between and among the Defendants. 13. Solely as a result of the Defendants' aforesaid carelessness, recklessness and negligence the Plaintiff suffered severe and sundry injuries to her person 4 including but not limited to injuries to her neck, back, causing headaches and other injuries. 14. Solely as a result of the carelessness, recklessness and negligence of the Defendants, the Plaintiff has suffered the following element so past and future damages recognizable under the law of the Commonwealth of Pennsylvania including but not limited to: a.) pain and suffering; b.) medical expenses; c.) emotional distress; d.) enjoyment of life; e.) other damages recoverable under the law of the Commonwealth of Pennsylvania. WHEREFORE, the Plaintiff demands judgment in her favor and against the Defendant in an amount in excess of the amount for mandatory referral to arbitration. COUNT II BROWN v. TACK 15. The Plaintiff incorporates herein by reference thereto paragraphs 1 though 14 of the within Complaint as if more fully set forth herein. 16. In the alternative, the aforesaid collision was caused either solely by the careless, reckless, and negligent conduct of the Defendant Griffie and/or jointly with the carelessness, recklessness, and negligence of the Defendant Tack as hereafter set forth. 5 17. As the Defendant Griffie was proceeding through the aforesaid intersection, the Defendant Tack carelessly, recklessly and negligently so operated his vehicle so that it came into a sudden and violent collision with the Defendant Griffie's vehicle. 18. The Defendant Tack was careless, reckless and negligent in that he: a. failed to keep a vigilant lookout for oncoming traffic; b. failed to see Defendant Griffie as he was proceeding through the intersection; c. failed to yield to the Defendant Griffic's vehicle; d. violated the Pennsylvania Motor Vehicle code; e. failed to use caustion as he approached and entered the aforesaid intersection f. was otherwise negligent. 19. Solely as a result of the Defendants' aforesaid carelessness, recklessness and negligence the Plaintiff suffered severe and sundry injuries to her person including but not limited to injuries to her neck, back, causing headaches and other injuries. 20. Solely as a result of the carelessness, recklessness and negligence of the Defendants, the Plaintiff has suffered the following element so past and future damages recognizable under the law of the Commonwealth of Pennsylvania _ including but not limited to: a.) pain and suffering; b.) medical expenses; c.) emotional distress; 6 d.) enjoyment of life; c.) other damages recoverable under the law of the Commonwealth of Pennsylvania. WHEREFORE, the Plaintiff demands judgment in her favor and against the Defendant in an amount in excess of the amount for mandatory referral to arbitration. Date: April 20, 2000 Respectfully submitted, KNAUER & ASSOCIATES, L.S.C. avi 4W.uerKEsqu re Attorney for Plaintiff Attorney J.D. No. 21582 411-A East Main Street Mechanicsburg, PA 17055 (717) 795-7790 7 IN THE COURT OF COMMON PLEAS F C A BERLAND COUNTY PENNSYLVAN NICHOLE A. SENTZ-BROWN Plaintiff V. GREGORY A. GRIFFIE and DONALD W. TACK Defendants CIVIL ACTION - LAW No. J!9- 76oICivil Term JURY TRIAL DEMANDED CERTIFICATE OF SERVICE I, David W. Knauer, hereby certify that I did this 20th day of April, 2000, serve a true and correct copy of the Plaintiffs Complaint on all counsel of record by United States mail, first class, prepaid addressed as follows: Richard Wix, Esq. Wix, Wenger & Weidner P.O. Box 845 N. Second St. Harrisburg, Pennsylvania 17108-0845 Gregory A. Griffie 28 E. Pine St. Mt. Holly Springs, PA 17065 t/ 1 avid W. Knauer, Esquire Attorney for Plaintiff Attorney I.D. No. 21582 411-A East Main Street Mechanicsburg, PA 17055 (717) 795-7790 -_ ,?, . . ?. ... ,, . , ?' ?- -.. .i ?-' . .1 . ?-_. - ? C _ , y !J i; .. •- -i C? J MARTSON DEARDORFF WILLIAMS K OTTO - IMI{NYUONI•AIMtL•AIMtALT TEN EAST HIGH STREET ". CA RLI SLE, PENNSYLVANIA' 17013 NICHOLE A. SENTZ-BROWN, : IN THE COURT OF COMMON PLEAS OF Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 99-7601 CIVIL ACTION-LAW GREGORY A. GRIFFIE and DONALD W. TACK, 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 Gregory A. Griffie in the above matter. Defendant hereby demands a twelve juror jury trial in the above captioned action. MARTSON DEARDORFF WILLIAMS & OTTO By Gc rge B. Faller, Jr., Esquire I.D. No. 49813 Ten East High Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Defendant Gregory A. Griffie Dated: May 1, 2000 CERTIFICATE OF SERVICE I, Nichole L. Myers, 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: David W. Knauer, Esquire 411 A East Main Street Mechanicsburg, PA 17055 Richard H. Wix, Esquire WIX, WENGER, WEIDNER, FENSTERMACHER & GUNNISON 200 Prince Street Harrisburg, PA 17109-3099 MARTSON DEARDORFF WILLIAMS & OTTO sy ??C.?w C t ?i ?YYI Nichole L. Myers Ten East High Street Carlisle, PA 17013 (717) 243-3341 Dated: May 1, 2000 MARTSON DEAROOW WILLIAMS & OTTO . IvtDw?O INIOElN11UN•AIM[E•AIA?4AiY TEN EAST HIGII STREET CARLISLE. PENNSYLVANIA 17013 NICHOLE A. SENTZ-BROWN, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. GREGORY A. GRIFFIE and DONALD W. TACK, Defendants NO. 99-7601 CIVIL ACTION-LAW : JURY TRIAL OF TWELVE DEMANDED DEFENDANT GREGORY GRIFFIE'S ANSWER WITH NEW MATTER AND NEW MATTER PURSUANT TO PA. R.C.P. 2252(d) TO PLAINTIFF'S COMPLAINT TO: NICHOLE A. SENTZ-BROWN, Plaintiff, and her attorney, DAVID W. KNAUER, ESQUIRE AND DONALD W. TACK, Defendant, and his attorney, RICHARD H. WIX, ESQUIRE YOU ARE HEREBY NOTIFIED TO FILE A WRITTEN RESPONSE TO THE ENCLOSED NEW MATTER WITHIN TWENTY (20) DAYS FROM SERVICE HEREOF OR A JUDGMENT MAY BE ENTERED AGAINST YOU. 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. Admitted. 3. 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. 4. Admitted. 5. 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. 6. Admitted. 7-8. Denied pursuant to Pa. R.C.P. 1029(e). WHEREFORE, Defendant demands judgment in his favor and dismissal of Plaintiffs Complaint with prejudice. COUNTI BROWN v. GRIFFIE 9, The averments of paragraphs I through 8 of this Answer are hereby incorporated by reference. 10-14. Denied pursuant to Pa. R.C.P. 1029(e). WHEREFORE, Defendant demands judgment in his favor and dismissal of Plaintiffs Complaint with prejudice. COUNT II BROWS CK 15. The averments of paragraphs 1 through 14 of this Answer are hereby incorporated by reference. 16-20. Said averments are directed to a party other than the answering Defendant and no response is required. j. , Defendant demands judgment in his favor and dismissal of Plaintiffs WHEREFORE Complaint with prejudice. } NEW_ MATTER 21. The averments of paragraphs 1 through 20 of this Answer are incorporated herein by } reference. 22, The Plaintiff s claims are barred by the applicable Statute of Limitations. 23. The Plaintiffs recovery is barred or reduced by the Pennsylvania Motor Vehicle fi Financial Responsibility Law as amended. 24. Plaintiff or her representatives chose the limited tort option by signing a valid t selection form. j. 25, Plaintiffs injuries do not involve death, serious impairment of bodily function or permanent disfigurement. WHEREFORE, Defendant demands judgment in his favor and dismissal of Plaintiffs i, Complaint with prejudice. NEW MATTER PURSUANT TO PA R.C.P. 2252fdl 26. The averments of Plaintiff's Complaint, which averments have been specifically denied, are hereby incorporated for the limited purpose of this cross claim. 27. If Plaintiff is entitled to recover from any party, which is expressly denied, then Defendant Donald W. Tack is alone liable to Plaintiff or liable over the Defendant Gregory A. Griffie by way of contribution and/or indemnity or arejointly and/or severally liable to Defendant Griffie on account of his own negligence or other liability producing conduct as alleged in the pleadings. 28. If Defendant Griffie is found liable to Plaintiff, which liability is expressly denied, its liability is secondary and passive to the liability of Defendant Tack whose liability is primary and active. WHEREFORE, Defendant Gregory A. Griffie demands judgment against Defendant Donald W. Tack for all sums that maybe adjudged against Defendant Griffie in favor of Plaintiff; and in the alternative, Defendant Griffie demands judgment against Defendant Tack for contribution and/or indemnity for the appropriate part of the amount of damages and costs awarded to Plaintiff, if any. WILLIAMS & OTTO By Gorge B.'Faller, Y, Esq I.D. Number 49813 Ten East High Street Carlisle, PA 17013-3093 (717) 243-3341 Attorneys for Defendant Gregory A. Griffie Date: 5111160 VERIFICATION The foregoing Answer with New Matter to the Complaint is based upon information which has been gathered by my counsel in the preparation of the lawsuit. The language of the document is that 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 my counsel, it is true and correct to the best of my knowledge, information and belief. To the extent that the content of the document 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. Section 4904 relating to unsworn falsification to authorities, which provides that if I make knowingly false averments, I may be subject to criminal penalties. 4 ,, - a- Bwt,-' Gregory A °Gr ie CERTIFICATE OF SERVICE I, Nichole L. Myers, an authorized agent for Manson Deardorff Williams & Otto, hereby certify that a copy of the foregoing Defendant's Answer with New Matter and New Matter Pursuant to Pa. R.C.P. 2252(d) to Plaintiff's Complaint was served this date by depositing same in the Post Office at Carlisle, PA, first class mail, postage prepaid, addressed as follows: David W. Knauer, Esquire 411 A East Main Street Mechanicsburg, PA 17055 Richard H. Wix, Esquire WIX, WENGER, WEIDNER, FENSTERMACHER & GUNNISON 200 Prince Street Harrisburg, PA 17109-3099 MARTSON DEARDORFF WILLIAMS & OTTO By, Nichole L. Myers Ten East High Street Carlisle, PA 17013 (717) 243-3341 Dated: 5-I ql C''U C r r' C^ ?l L, < O C7 -) CD ?; NICHOLE A. SENTZ-BROWN, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 99-7601 CIVIL TERM GREGORY A. GRIFFIE and CIVIL ACTION - LAW DONALD W. TACK, Defendants JURY TRIAL DEMANDED NOTICE TO PLEAD To: Nichole A. Sentz-Brown; and David W. Knauer, Esquire, Attorney for Plaintiff You are hereby notified to plead to the enclosed New Matter within twenty (20) days from service hereof or a default judgment may be entered against you. I'I WIX, WENGER & WEIDNER By ?r ACAnrQ ??? - Richard H. Wix, Esq., I.D. #07274 Attorneys for Defendant Tack 4705 Duke Street Harrisburg, PA 17109-3099 (717) 652-8455 i j Dated: vZ000 i l NICHOLE A. SENTZ-BROWN, Plaintiff V. GREGORY A. GRIFFIE and DONALD W. TACK, Defendants IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 99-7601 CIVIL TERM CIVIL ACTION - LAW JURY TRIAL DEMANDED DEFENDANT DONALD W. TACK'S ANSWER WITH NEW MATTER AND NOW COMES the Defendant, Donald W. Tack, by his attorneys, Wix, Wenger & Weidner and sets forth the following Answer with New Matter to Plaintiff's Complaint. 1. Admitted. 2. Admitted. 3. Admitted. 4. Admitted. 5. Admitted. 6. Admitted. 7. It is admitted that an accident occurred on December 27, 1997, which involved Defendant Tack's vehicle. 8. Denied. 9. Defendant incorporates herein by reference his answers to paragraphs 1 through 8 of Plaintiff's Complaint. 10. Admitted. 11. It is admitted that Defendant Griffie is solely responsible to the Plaintiff. 12. The allegations of paragraph 12 set forth a conclusion of law to which no answer is required. 13. Defendant Tack has no knowledge of Plaintiff's injuries, and proof thereof is demanded. 14. Defendant Tack has no knowledge of Plaintiff's injuries, and proof thereof is demanded. 15. Defendant incorporates herein by reference his answers to paragraphs 1 through 14 of Plaintiff's Complaint. 16. Denied that Defendant Tack was negligent. 17. Denied. 18. Denied. 19. Denied. 20. Denied. NEW MATTER 21. The accident referred to in Plaintiff's complaint was caused solely by the negligence of Gregory A. Grif fie. 22. The Plaintiff's claim is barred in whole or in part by the provisions of the Pennsylvania Motor Vehicle Financial Responsibility Law. 23. The Plaintiff's claim is barred in whole or in part by the provisions of the Pennsylvania Comparative Negligence Law. Respectfully submitted, WIX, WENGER & WEIDNER B y ID# 07274 Richard H. Wix, Esq., Attorneys for Defendant Tack 4705 Duke street Harrisburg, PA 17109-3099 (717) 652-8455 Dated: j' ?(?-01000 2 VERIFICATION I, Donald W. Tack, have read the foregoing Answer with New Matter which has been drafted by my counsel. The factual statements and/or denials contained therein are true and correct to the best of my knowledge, information and belief. I am authorized to make this verification. This verification is made only as to the factual averments contained therein and not to legal conclusions and averments authorized by counsel in his capacity as attorney for the party or parties hereto. This verification is made subject to the penalties of 18 PA. C.S. Section 4904, relating to unsworn falsification to authorities which provides that, if I knowingly made false averments, I may be subject to criminal penalties. Date: J'/&-Co 000 Donald Tack ?I it CERTIFICATE OF SERVICE AND NOW, this 16th day of May, 2000, I, Richard H. Wix, Esquire, of the firm of Wix, Wenger & Weidner, attorneys for Defendant Donald Tack, hereby certify that I served the within Defendant Donald W. Tack's Answer with New Matter this date by depositing a copy of same in the United States mail, postage prepaid, in Harrisburg, Pennsylvania, addressed as follows: David W. Knauer, Esquire KNAUER & ASSOCIATES, L.S.C. 411-A East Main Street Mechanicsburg, PA 17055 George B. Faller, Jr., Esquire MARTSON DEARDORFF WILLIAMS & OTTO Ten East High Street Carlisle, PA 17013 WIX, WENGER & WEIDNER By Richard FI. Wix, Z.D. #07274 Attorneys for Defendant Tack 4705 Duke Street Harrisburg, PA 17109-3099 (717) 652-8455 I( MARTSONILLIA\IS & OTTO - - DEARDORFF MDW&O INIIIYJI\I I?\N ? AIINU. AIA\N:MI TEN EASE HI@I STREET CARLISLE. PENNSYLVANIA 17013 NICHOLE A. SENTZ-BROWN, Plaintiff V. GREGORY A. GRIFFIE and DONALD W. TACK, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 99-7601 CIVIL ACTION-LAW JURY TRIAL OF TWELVE DEMANDED STIPULATION OF COUNSEL IT IS HEREBY STIPULATED AND AGREED by and between counsel for Defendant Gregory A. Griffie and counsel for the Plaintiff Nichole A. Sentz-Brown that: 1. The subparagraph (e) of paragraph 10 of Plaintiff's Complaint shall be stricken. 2. This Stipulation is to be filed with the Prothonotary and it is agreed that no action or approval by the Court is necessary or required. ICNA & ASSOCIATES, LSC By ? avid W. Knauer, Esquire I.D. No. 21582 411-A East Main Street Mechanicsburg, PA 17055 (717)795-7790 Attorneys for Plaintiff Dated` ;?G MARTSON DEARDORFF WILLIAMS & OTTO By G?r e . F er, ., s ire .. No. 49813 Ten East High Street Carlisle, PA 17013 (717)'-)43-3341 Attorneys for Defendant Gregory A. Griffie CERTIFICATE OF SERVICE I, Nichole L. Myers, an authorized agent for Martson Deardorff Williams & Otto, hereby certify that a copy of the foregoing Stipulation of Counsel was served this date by depositing same in the Post Office at Carlisle, PA, first class mail, postage prepaid, addressed as follows: David W. Knauer, Esquire 411 A East Main Street Mechanicsburg, PA 17055 Richard H. Wix, Esquire WIX, WENGER, WEIDNER, FENSTERMACHER & GUNNISON 200 Prince Street Harrisburg, PA 17109-3099 MARTSON DEARDORFF WILLIAMS & OTTO By.J? ?L *d Nichole L. Myers Ten East High Street Carlisle, PA 17013 (717) 243-3341 Dated: ??? ?? v L=. Ci ?'. __ Ji._ Cil ? ? ` '` r ?, C' .- is-'- ?.. _ u _ _^ ? C: C] `, ?. , IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA NICHOLE A. SENTZ-BROWN Plaintiff : CIVIL ACTION - LAW V. GREGORY A. GRIFFIE and DONALD W. TACK Defendants No. 99-7601 Civil Term JURY TRIAL DEMANDED PLAINTIFF'S REPLY TO DEFENDANT GRIFFIE'S NEW MATTER 22. Denied as alleged. Plaintiff avers to the contrary that this is a conclusion of law to which no reply is required pursuant to the Pennsylvania Rules of Civil Procedure and strict proof thereof is demanded at time of trial. 23. Denied as alleged. Plaintiff avers to the contrary that this is a conclusion of law to which no reply is required pursuant to the Pennsylvania Rules of Civil Procedure and strict proof thereof is demanded at time of trial. 24. Denied as alleged. Plaintiff avers to the contrary that this is a conclusion of law to which no reply is required pursuant to the Pennsylvania Rules of Civil Procedure and strict proof thereof is demanded at time of trial. 25. Denied as alleged. Plaintiff avers to the contrary that this is a conclusion of law to which no reply is required pursuant to the Pennsylvania Rules of Civil Procedure and strict proof thereof is demanded at time of trial. PLAINTIFF'S REPLY TO NEW MATTER PURSUANT TO PA.R.C.P. 2252(d) 26.-28. Do not apply to the Plaintiff Respectfully submitted, KNAUER & ASSOCIATES, L.S.C. 1 Gu u 6 David W. Knauer, Esquire Attorney for Plaintiff Attorney I.D. No. 21582 411-A East Main Street Mechanicsburg, PA 17055 Date: May 23, 2000 (717) 795-7790 r , IN THE COURT OF COMMON LEA OF CUMBERLAND COUNTY PENNSYLVANIA NICHOLE A. SENTZ-BROWN Plaintiff V. GREGORY A. GRIFFIE and DONALD W. TACK Defendants CIVIL ACTION - LAW No. 99-7601 Civil Term JURY TRIAL DEMANDED CERTIFICATE OF SERVICE I, David W. Knauer, hereby certify that I did this 23rd day of May, 2000, serve a true and correct copy of the Plaintiffs Reply to Defendant Gregory Griffie's New Matter on all counsel of record by United States mail, first class, prepaid addressed as follows: Richard Wix, Esq. Wix, Wenger & Weidner P.O. Box 845 508 N. Second St. Harrisburg, Pennsylvania 17108-0845 George B. Faller, Esq. Martson Deardorf Williams & Otto Ten East High Street r`ariisle. PA 17013. David W. Knauer, tsqunu Attorney for Plaintiff Attorney I.D. No. 21582 411-A East Main Street Mechanicsburg, PA 17055 (717) 795-7790 ?. _ ?; ?? _ ?_ ?- ? ?? = ; ? ? ?.?-: -- ?=- - ?,, `_ ,: ? --, y; ii ` PJ lL ? ?"1 V L? lJ 1 ?' :..... I NICHOLE A. SENTZ-BROWN, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 99-7601 CIVIL TERM GREGORY A. GRIFFIE and CIVIL ACTION - LAW DONALD W. TACK, Defendants JURY TRIAL DEMANDED FIRST REQUEST FOR PRODUCTION OF DOCUMENTS TO: Nichole A. Sentz-Brown; and David W. Knauer, Esquire, Attorney for Plaintiff AND NOW, this 16th day of May, 2000, pursuant to Pennsylvania Rules of Civil Procedure 4009, as amended, comes Defendant Donald W. Tack, by his counsel, WIX, WENGER & WEIDNER, and requests said parties to produce for inspection, examination and copying, at the law office of counsel for the requesting party, not later than thirty (30) days after service of this Request, the following documents: 1. All statements, signed statements, transcripts of recorded statements, interviews or affidavits of any person or witness relating to, referring to, or describing any of the events surrounding the alleged accident in question as referred to in Plaintiffs' Complaint, including those relating to the happening of the accident or to Plaintiff's* injuries or losses. 2. All expert opinions, expert reports, expert summaries or other writings of experts in your custody or control or in the custody or control of your attorney, insurer, or anyone else acting on your behalf, which relate to any aspect of the subject matter of this litigation. 3. All reports, opinions, records, correspondence of all physicians, osteopaths, chiropractors, or other practitioners of the healing arts who have treated, examined or consulted with you at any time. 4. All hospital records relating to you, both before and after the date of the accident, up to the present time. 5. All bills, invoices or statements of charges from all physicians, osteopaths, chiropractors, hospitals, medical associates, or other medical practitioners, relating to treatment, examination or consultation of you, associated with injuries or conditions allegedly sustained in the accident in question which is the subject matter of this litigation. 6. All written records or writings of whatsoever kind in your care, custody or control or in the care, custody or care of your (Plaintiff's) employer, evidencing or dealing with lost wages, lost income or reduced earning capacity allegedly sustained by you as a result of the accident in question which is the subject matter of this litigation. 7. All photographs, plans, drawings, sketches or diagrams in your possession, custody or control, or in the possession, custody or control of your attorney, your insurer, or anyone else acting on V your behalf, dealing with any aspect of this litigation, including but not limited to the vehicles, instrumentalities, or accident site, involved in the accident in question which is the subject of this litigation, including injuries sustained by you. Such documents shall include any documents made or prepared up through the present time, with the exclusion of the mental impressions of you attorney or his conclusions, opinions, memoranda, notes or summaries, legal research or legal theories, and those documents prepared in anticipation of litigation by your representative which would disclose the representative's mental impressions, conclusions or opinions respecting the value or merit of a claim or defense. S. All documents prepared by you, or by any insurer, representative, agent or anyone else acting on your behalf, except your attorney, during or as part of an investigation of the accident in question which is the subject matter of this litigation, including injuries sustained by you. Such documents shall include any documents made or prepared up through the present time, with the exclusion of the mental impressions of your attorney or his conclusions, opinions, memoranda, notes or summaries, legal research or legal theories, and those documents prepared in anticipation of litigation by your representative which would disclose the representative's mental impressions, conclusions or opinions respecting the value or merit of a claim or defense. 9. Copies of your Federal Income Tax Returns for the five (5) years preceding the date of your accident and up to the present time. : As referred to herein, "documents" includes (NOTE Pd, printed, typed, recordor graphic matter, g correspondence, produced or reproduced, includin ing however telegrams, or written communications, data process storage units, tapes, contracts, agreements, notes, memoranda, analyses, projections, diaries, calendars, films, photographs, diagrams, drawings, minutes of meetings, or any other writing (including copies of any of the foregoing, regardless of whether you are now in the possession, custody or control of the original) now in the possession, custody or control of you, your former or present counsel, agents, employees, officers, insurers, or any other person acting on your behalf). * In a death case, all references herein to Plaintiff's losses, injuries, etc. shall mean Plaintiff's decedent's losses, injuries, etc. WIX, WENGER & WEIDNER BY ?' Richard H. Wix, Esquire Attorneys for Defendant Tack 4705 Duke Streeet17109-3099 Harrisburg, r (717) 652-8455 NNPLEAS OF CUMBERLAND COUNTY IN THE COURT OF COMMON NICHOLE A. SENTZ-BROWN Plaintiff V. GREGORY A. GRIFFIE and DONALD W. TACK Defendants CIVIL ACTION - LAW No. 99-7601 Civil Term JURY TRIAL DEMANDED 1. Plaintiff °t aware of any statements other then those in the police report. See attached police report. 2. Plaintiff has not yet decided what experts she will use at trial. 3. See attached. 4. See attached 5. See attached 6. See attached 7. See attached 8. See attached 9. See attached. Date: November 6, 2000 Respectfully submitted, KNAUER & ASSOCIATES, L.S.C. Nano angel J. Byerry, }s9uu A orney for Plaintiff// Attorney I.D. No. 679 411-A East Main Street Mechanicsburg, PA 17055 (717) 795-7790 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NICHOLE A. SEXTZ-BROWN, Plaintiff V. GREGORY A. GRIFFIE and DONALD W. TACK. Defendants CIVIL ACTION - LAW : No. 99-7601 CIVIL TER'`I JURY TRIAL DEMANDED CERTIFICATE OF SERVICE 1. David W. K.:tauer. hereb\` Ce; ifv that I did this 6th day of November, 2000, serve a true and correct copy of the Plaintiffs ans•.vers to Defendant's Discovery or, all counsel of record by United States mail, first class, prepaid addressed as follows: Richard H. Wix, Esquire Wix, Wenger & Weidner 4705 Duke Street Harrisburg, PA 17109-3099 (For Defendant Donald W. Tack) George B. Faller, Esq. Manson Deardorf Williams &: Otto Ten East High Street Carlisle, PA 17013. David W. Knauer, Esquire Attorney for Plaintiff Attorney I.D. No. 21582 411-A East Main Street Mechanicsburg, PA 17055 (717) 795-7790 r A} :...;?... ? J _., NICHOLE A. SENTZ-BROWN, Plaintiff V. GREGORY A. GRIFFIE and DONALD W. TACK, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 99-7601 CIVIL ACTION-LAW JURY TRIAL OF TWELVE DEMANDED DEFENDANT GREGORY GRIFFIE'S REQUEST FOR PRODUCTION OF DOCUMENTS DIRECTED TO PLAINTIFF TO: NICHOLE A. SENTZ-BROWN, Plaintiff, and her attorney, DAVID W. KNAUER, ESQUIRE AND NOW, this 14th day of September, 2000, pursuant to Pa. R.C.P. 4009, as amended, comes the Defendantby his Attorneys, MARTSON DEARDORFF WILLIAMS & OTTO, Ten East High Street, Carlisle, Pennsylvania, and requests Plaintiffs to produce for inspection, examination and copying, at the above office, not later than thirty (30) days after service of this Request the following documents: 1. All photographs in the possession, custody or control of Plaintiff, counsel for Plaintiff, or any other person or entity acting on behalf of Plaintiff, including any insurers for Plaintiff, showing, representing or purporting to show any vehicles, locales, instrumentalities, persons, property, and any and all other matters related to the subject matters of this litigation. 2. All diagrams, sketches, drawings, plans, measurements or blueprints in the possession, custody or control of Plaintiff, counsel for Plaintiff, or any other person or entity acting on behalf of Plaintiff, including any insurer of Plaintiff, showing representing or purporting to show any of the instrumentalities, locales, persons or other matters involved in the incident which forms the basis of Plaintiffs Complaint. 3. All statements, signed statements, transcripts of recorded statements or interviews, recorded statements if not transcribed or any statement or recorded statements if not transcribed verbatim taken of any parties, persons or witnesses as part of an investigation of the happening or cause of the incident in question, conducted by, or in thepossession of, Plaintiff, Plaintiffs attorney, insurers or anyone else action on behalf of Plaintiff. 4. All expert opinions, expert reports, expert summaries or other writings of experts in possession, custody or control of Plaintiff, Plaintiffs attorneys or insurers, which relate to the subject matter of this litigation and the incident in question. 5. All documents prepared by Plaintiff, or by any insurers, representatives, agents or anyoneactingon behalfofPlaintiff, except Plaintiffsattomeys, duringan investigation ofanyaspect of the incident in question. Such documents shall include any documents made or prepared up through the present time, with the exclusion of the mental impressions, conclusions or opinions respecting the value or merit of a claim or defense, or respecting strategy or tactics. (NOTE: As referred to herein, "documents" includes written, printed, typed, recorded or graphic matter, however produced or reproduced, including correspondence, telegrams, other written communications, data processing storage units, tapes, contracts, agreements, notes, memoranda, analyses, projections, indices, work papers, studies, reports, surveys, diaries, calendars, films, photographs, diagrams, drawings, minutes of meetings or any other writing (including copies of the foregoing, regardless of whether the parties to whom this request is addressed are now in the possession, custody or control of the original) now in the possession, custody or control of Plaintiff, Plaintiffs former or present counsel, agents, employees, officers, insurers or any otherperson action on Plaintiffs behalf.) 6. If not otherwise covered by the above Requests, the complete claims/investigation/subrogation/no-fault file(s) of Plaintiff or any insurers thereof, dealing with the incident in question, with the exclusion of the mental impressions, conclusions or opinions respecting the value or merit of a claim or defense, or respecting strategy or tactics. 7. All documents in the possession, custody or control of Plaintiff, Plaintiffs counsel, insurers, or anyone else acting on Plaintiffs behalf, dealing in any way with all injuries, damages and losses sustained by the Plaintiff. This should indicate, but not be limited to, bills, invoices, estimates, appraisals, inventories, reports and all other documents relating to the damages alleged in Plaintiffs Complaint. 8. Ifany document orclass of documents is being withheld on the basis ofany privilege, identify the document or class of documents, the date or dates of the documents, its author or originator, as well as the privilege which is being asserted. MARTSON DEARDORFF WILLIAMS & OTTO TGcorge B. Fa er, Jr., Es i e No. 49813 ast High Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Defendant CERTIFICATE OF SERVICE I, Jennifer L. Kelley, an authorized agent for Manson Deardorff Williams & Otto, hereby certify that a copy of the foregoing Defendant Gregory Griffie's Request for Production of Documents Directed to Plaintiff was served this date by depositing same in the Post Office at Carlisle, PA, first class mail, postage prepaid, addressed as follows: David W. Knauer, Esquire 411 A East Main Street Mechanicsburg, PA 17055 MARTSON DEARDORFF WILLIAMS & OTTO Byl' nnife . I elley Ten East High Street Carlisle, PA 17013 (717) 243-3341 Dated: September 14, 2000 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA NICHOLE A. SENTZ-BROWN Plaintiff : CIVIL ACTION - LAW V. GREGORY A. GRIFFIE and DONALD W. TACK Defendants No. 99-7601 Civil Term JURY TRIAL DEMANDED Plaintiff's Reply to Defendant Griffie's Request for Production of Documents 1. See attached 2. See attached police report 3. Plaintiff is not aware of any statements other then those in the police report. 4. Plaintiff has not yet decided what experts she will use at trial. 5. See attached 6. See attached 7. See attached Date: November 6, 2000 Respectfully submitted, KNAUER & ASSOCIATES, L.S.C. Nat anael J. Byerly, qui A rney for Plaintiff Attorney I.D. No. 85679 411-A East Main Street Mechanicsburg, PA 17055 (717) 795-7790 IN THE COURT OF CO.NIMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NICHOLE A. SENTZ-BROWN, Plaintiff GREGORY A. GRIFFIE and DONALD W. TACK, Defendants CIVIL ACTION - LAW No. 99-7601 CIVIL TERM JURY TRIAL DEMANDED CERTIFICATE OF SERVICE 1. David W. Knauer. hereby certify that I did this 61h day of November, 2000, serve a true and correct copy of the Plaintiffs answers to Defendant's Discovery on all counsel of record by United States mail, first class, prepaid addressed as folloNvs: Richard H. Wix, Esquire Wix, Wenger & Weidner 4705 Duke Street Harrisburg, PA 17109-3099 (For Defendant Donald W. Tack) Georee B. Faller, Esq. Manson DeardorfWilliams & Otto Ten East High Street Carlisle, PA 17013. iAt? /w David W. Knauer, Esquire Attorney for Plaintiff Attorney I.D. No. 21582 411-A East Main Street Mechanicsburg, PA 17055 (717) 795-7790 ti ... ___ .: ri ?l? ?- ,_- ,:: ?;: : ,-- - . .?. J ti i... ' •. t._f'.I I1 ? ? 1 ? L1 ?i ./ NICHOLE A. SENTZ-BROWN, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 99-7601 CIVIL TERM GREGORY A. GRIFFIE and CIVIL ACTION - LAW DONALD W. TACK, Defendants JURY TRIAL DEMANDED DEFENDANT DONALD W. TACR'8 INTERROGATORIES DIRECTED TO PLAINTIFF - SET I TO: Nichole A. Sentz-Brown; and David W. Knauer, Esquire, Attorney for Plaintiff PLEASE TAKE NOTICE that you are hereby required pursuant to Pennsylvania Rules of Civil Procedure, Rules 4005 and 4006, as amended, to file the original and serve upon the undersigned a copy of your Answers and objections, if any, in writing and under oath to the following Interrogatories within thirty (30) days after service of the Interrogatories. The Answers shall be inserted in on s the space provided. , the remainder of the Answer shall follow We a Interrogatory, supplemental sheet. These shall be deemed to be continuing Interrogatories. If, between the time of your Answers and the time of trial of this case, you, or anyone acting in your behalf, learn of any further information not contained in your Answers, you shall promptly furnish said information to the undersigned by Supplemental Answers. WIX, WENGER & WEIDNER By \IV?G?Lr? Richard H. Wix, Esquire I.D.# 07274 4705 Duke Street Harrisburg, PA 17109-3099 (717) 652-8455 Attorney for Defendant Tack Dated: S- 1f0-aOn INTERROGATORIES - SET I 1. State your full name, address, Social Security Number and date of birth. ANSWER: 2. If you have at any time during your lifetime been admitted as a patient in a hospital for any illness, accident, ailment or condition, state names and addresses of hospitals in which you were confined or treated, the conditions for which you were treated, and the dates of your hospitalization. ANSWER: 3. State the name and address of any doctors or other health care personnel who have examined or treated you for injuries received in the accident referred to in your Complaint. ANSWER: 4. If you were involved in an accident previous or subsequent to the accident complained of in this action, state where and when the accident took place; the nature and extent of your injuries and conditions resulting from such accident, including whether or not the injuries or conditions were temporary or permanent, and the names and addresses of the doctors who attended you. ANSWER: 5. If you have ever filed an action against any person for damages for personal injuries, other than this action, state the caption of the case, including the name of the person you sued, the name of the Court, and tern and number of the action. ANSWER: 6.: State. the: names: and-- addresses. of each employer or business for whom you have worked during the five year period preceding this accident, including the nature of your duties and I'•, the dates when you were engaged in such employment. ANSWER: 2 7. What were your gross and net earnings for the five year period preceding this accident, and the years subsequent to this accident, on a weekly or monthly basis? ANSWER: 8. Set forth in detail any and all expenses.-and.-losses which you claim resulted from the accident;-. which: form the: basis of this suit, stating the nature of the same and the names and addresses of the parties to whom the bills were incurred. ANSWER: 9. State the name and last known address of all persons from whom you or anyone acting on your, behalf:. has..obtained. any report, statement, memorandum or. testimony.- concerning.. the-;. accident or damages resulting therefrom. which. is-involved- in,. this cause of action. ANSWER: 3 10. State the names, addresses and relation of any persons who are financially dependent upon you, in whole or in part for their support, giving the ages of all such persons and relationship to you. ANSWER: 11. State the names, ages, present addresses and occupations of all of your children and your spouse. ANSWER: 12. State specifically each. and.. every.. area of.. your: body that was physically injured in the,. accident- referred•to in. your complaint, including a complete description- of. each. such. injury and your present condition-as 'to'each• such: injury. ANSWER: 4 13. If you still suffer pain from any of your injuries and conditions resulting from the accident referred to in your Complaint, state specifically the frequency and nature of the pain and the injuries from which it emanates. ANSWER: 14. Set forth the manner-in which any of your disabilities resulting from the accident referred to in your complaint have or will affect your earning capacity in the future. ANSWER: 15. What is the name and- lastt known.'address: and-. present whereabouts, if known, of each person whom you' or anyone acting in your behalf knows or believes to: have. witnessed.-said accident. ANSWER: 5 16. What is the name, last known address and present whereabouts, if known, of each person whom you or anyone acting in your behalf knows or believes to have any relevant knowledge of the conditions at the scene of the accident existing prior to, at or immediately after the sane? ANSWER: 17. Give the names and addresses- of'any witnesses known to you or your counsel whose names were not given in answer to Interrogatories Nos. 15 and 16, including but not limited to your medical witnesses, whether or not you intend to call any of said persons as witnesses at trial. ANSWER: 18.''Set?forth- each residence address you have. lived at in the past ten years, stating the specific dates applicable to each such address. ANSWER: 6 19. If you have any permanent scars or disfigurements resulting from any injury sustained in the accident referred to in your complaint, please state a description of the scar or disfigurement and whether any plastic or reconstructive surgery has been performed or is contemplated. ANSWER: 20. If you have sustained, as a result of the accident, any medically determinable physical or mental impairment which has prevented or will prevent you from performing all or substantially all of your customary daily activities, state the nature of the impairment which prevents you, from performing such activities and what activities you are no.. longer able. to perform. ANSWER: 21. State whether you have been unable to perform satisfactorily all duties required of you in your employment since the date of the accident, indicating with particul 7 those duties which you were unable to perform and the names and addresses of all persons having knowledge of such facts, including your supervisors and employers at the time of such incapacities. ANSWER: 22. State. the name and address of. the: company: or- other persons to whom any claim has been presented by you or anyone acting on your behalf for no-fault benefits or medical and surgical benefits or loss of income alleged to have resulted from the accident referred to in your complaint. ANSWER: 23. State the identity, address and qualifications of any expert witnesses you expect to call at trial. ANSWER: 8 24. As to each person identified in the preceding Interrogatory, state the substance of the facts and opinions to which he or she will testify, and a summary of the grounds for his or her opinion. ANSWER: WIX, WENGER & WEIDNER i BY -? Attorneys for Defendant I i .! 4705 Duke Street Harrisburg, PA 17109-3099 (7 17) 652-8455 1 ' 9 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA i.i NICHOLE A. SENTZ-BROWN Plaintiff V. GREGORY A. GRIFFIE and DONALD W. TACK Defendants CIVIL ACTION - LAW No. 99-7601 Civil Term JURY TRIAL DEMANDED Plaintiff's Answer to Defendant Donald W Tack's Interrogatories Set One 1. Nichole Ashley Brown Formerly: Nichole Ashley Sentz Also know as: Nikki Brown, Nikki Sentz Address: 150 Williams Grove Rd. #129 Mechanicsburg, PA 17055 SS#: 178-60-0827 2. Plaintiff had tonsils removed in or around 1990. Plaintiff does not recall any other treatments, but will supplement if she remembers. 3. Chiropractor Dr. Rochelle Casses Emergency Room Carlisle Hospital Dr. Bradford Wood Family doctor Please see records for details. 4. Plaintiff has been in no other accidents. 5. Plaintiff has not filed any other actions 6. Prior to accident Plaintiff was a college student. See W-2 forms for brief work history. April 1999 - July 1999 Mulberry Child Care Camp Hill, PA 17011 July 1999 - 2000 Learning and Play Center Mechanicsburg, PA 17055 March 2000 - Present Children's Family Center: Messiah Village Plaintiff is in the process of changing jobs due to the injuries suffered in the accident. 7. See attached W-2 forms. 8. See attached 9. See attached Police report 10. None 11. Jason Stewart Brown 21 years of age 12. Hips out of place, neck and shoulder injuries, wrist injury. Plaintiff reserves the right to supplement this answer 13. Plaintiff still suffers from neck pain and occasional leg and hip pain. Plaintiffs pain is constant. Plaintiff reserves the right to supplement this answer 14. Plaintiff has been forced to change careers due to the injuries sustained in the accident. 1 i J I i 15. See attached police report. 16. See attached police report 17. See attached police report 18. 5 Trine Ave. Mt. Holly Springs, PA 17065 1986-July 1999 112 West Green St. Apt. #2 Mechanicsburg, PA 17055 July 1999 - January 2000 Present Address January 2000 - Present 19. None 20. Plaintiff is unable to carry out her duties in child care due to injuries suffered in the accident. 21. Plaintiff has been unable to perform her duties satisfactorily. She is unable to lift children and heavy items. 22. Prudential Insurance See attached for more information. 23. Plaintiff has not yet decided what witnesses she will call at trial 24. Plaintiff has not yet decided what witnesses she will call at trial Respectfully submitted, KNAUER & ASSOCIATES, L.S.C. r N anael J. Byerly, quire ttorney for Plaintiff Attorney I.D. No. 85679 411-A East Main Street Mechanicsburg, PA 17055 Date: November 6, 2000 (717) 795-7790 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NICHOLE A. SENTZ-BROWN, Plaintiff V, GREGORY A. GRIFFIE and DONALD W. TACK, Defendants CIVIL ACTION - LAW No. 99-7601 CIVIL TERM JURY TRIAL DEMANDED CERTIFICATE OF SERVICE I, David W. Knauer, hereby certify that I did this 6th day of November, 2000, serve a true and correct copy of the Plaintiff's answers to Defendant's Discovery on all counsel of record by United States mail, first class, prepaid addressed as follows: Richard H. Wix, Esquire Wix, Wenger & Weidner 4705 Duke Street Harrisburg, PA 17109-3099 (For Defendant Donald W. Tack) George B. Faller, Esq. Manson Deardorf Williams & Otto Ten East High Street Carlisle, PA 17013. A A, David W. Knauer, Esquire Attorney for Plaintiff Attorney I.D. No. 21582 411-A East Main Street Mechanicsburg, PA 17055 (717) 795-7790 ?r ??: , . ,, ??;i -,_: -- ;? __ ,=i ? ?: _- ? '_ " ' ::?? ?:: ;:_ '= '-? NICHOLE A. SENTZ-BROWN, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA NO. 99-7601 CIVIL TERM v. CIVIL ACTION - LAW GREGORY A. GRIFFIE and DONALD W. TACK,De£endants JURY TRIAL DEMANDED DEPEND ?NT DONALD W. TACK'S INTERROGATORIES DIRECT TO: Nichole A. Sentz-Brown; and David W. Knauer, Esquire, Attorney for Plaintiff PLEASE TAKE NOTICE that you are hereby required pursuant to Pennsylvania Rules of Civil Procedure, Rules 4005 and 4006, as a cop amended, to file the original anderve up in w he un a s g under oath of your Answers and Objections, if any, days after to the following interrogatories within thirty (30) Ys serted service of rovid d. Ifa there is The insufficient spaceetonanswer an provided. the space Interrogatory, the remainder of the Answer shall follow on a supplemental sheet. ator If, Anto be swers and Interro These shall be deemed of gt ial eof this between the time of your further case, you, or anyone acting in your behalf, learn of any m tly information not contained in furnish said information to Answers. your Answers, you shall pro p the undersigned by supplemental WIX, WENGER & WEIDNER BY Richard H. Wix, Esquire I.D.# 07274 4705 Duke Street Harrisburg, PA 17109-3099 (717) 652-8455 Attorney for Defendant Tack Dated: 5'16-A00 INTERROGATORIES SET II (MOTOR VEHICLE ACCIDENTS) 1. If you are a named insured under any policy of motor vehicle insurance, state the name and address of the insurer, the policy number, your tort selection, the amount of your liability coverage, and the amount of your underinsurance coverage. ANSWER: 2. If the vehicle in which you were an occupant was insured under a policy of motor vehicle insurance, state the nine: and address of the insurer, the policy number, the tort selection, the amount of liability coverage, and the amount of underinsurance coverage. ANSWER: 3. At the time of the accident referred to in your complaint, state whether you or Your spouse were the titled owner of any motor vehicle. ANSWER: 4. If you answered "yes" to Interrogatory No. 3, for each vehicle state: a) The titled owner of the vehicle;, b) The year, make and model of the vehicle; c) d) The The V.I.N. motor number of each vehicle; vehicle insurance policy applicable to each vehicle; e) Whether any of the vehicles were not insured.at the time of the accident referred to in your complaint. ANSWER: - 2 - 5. If you are, or were, eligible to receive benefits for medical expenses or income loss under any policy or motor vehicle insurance, Workers' Compensation, Social Security Disability, Medicare, Medicaid, or any program, group contract or other arrangement for payment of benefits for any pecuniary loss for which you are making a claim, state the following: a) The name and address of the insurer and the policy number, plan number or group contract number; b) The amount of any benefits paid to you or on your behalf for medical expenses and/or income loss. ANSWER: 3 - 6. Have you at any time, or are you currently preparing or maintaining any records, notes, logs, ledgers or diaries that in any way describe your injuries, treatments or activities since the accident referred to in the Plaintiff's Complaint? a) If you answered "yes" to the above question, where are said documents located? b) If you will do so without a Motion to Compel, please attach a copy of said documents to the answers to the Interrogatories. DATE: .5- /G-L ODb BY: WIX, WENGER & WEIDNER ,'R-C O,t / LYx Attorneys for the Defendant 4763D'uke7.' street Harrisburg, PA 17109 (717) 652-8455 - 4 - IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA NICHOLE A. SENTZ-BROWN Plaintiff CIVIL ACTION - LAW V. GREGORY A. GRIFFIE and DONALD W. TACK Defendants No. 99-7601 Civil Term JURY TRIAL DEMANDED Plaintiff's Answer to Defendant Donald W Tack's Interrogatories Set Two 1. At the time of the accident, Plaintiff was a named insured under her father's (Allan Sentz) policy. She is presently is a named insured on an Aetna health insurance policy and a Geico auto policy. See attached for specific information. 2. Vehicle in which Plaintiff was passenger was owned by Leslie and Gregory Griffie. The car was insured by Auto Insurance Company of Hartford Connecticut See Police Report 3. Plaintiff was a titled owner of a vehicle. The ownership of a car by Plaintiffs spouse is not relevant to this case. 4. a. Allan Sentz and Nichole S. Sentz-Brown b. 1990 Ford Taurus c. See attached forms d. See attached forms e. Plaintiff does not know whether the vehicles involved were insured. She did not own any of the vehicles involved in the accident. See attached police report. 5. See attached insurance information. 6. No Respectfully submitted, KNAUER & ASSOCIATES, L.S.C. Nathanael J. Byerly squire Attorney for Plainti Attorney I.D. No. 85679 411-A East Main Street Mechanicsburg, PA 17055 Date: November 6, 2000 (717) 795-7790 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NICHOLE A. SENTZ-BROWN, CIVIL ACTION - LAW Plaintiff V. No. 99-7601 CIVIL TERM GREGORY A. GRIFFIE and DONALD W. TACK, JURY TRIAL DEMANDED Defendants CERTIFICATE OF SERVICE I, David W. Knauer, hereby certify that I did this 6th day of November, 2000, serve a true and correct copy of the Plaintiff's answers to Defendant's Discovery on all counsel of record by United States mail, first class, prepaid addressed as follows: Richard H. Wix, Esquire Wix, Wenger & Weidner 4705 Duke Street Harrisburg, PA 17109-3099 (For Defendant Donald W. Tack) George B. Faller, Esq. Martson Deardorf Williams & Otto Ten East High Street Carlisle, PA 17013. c ?l.GUf/16 David W. Knauer, Esquire Attorney for Plaintiff Attorney I.D. No. 21582 411-A East Main Street Mechanicsburg, PA 17055 (717) 795-7790 ;ii ci c U NICHOLE A. SENTZ-BROWN, Plaintiff V. GREGORY A. GRIFFIE and DONALD W. TACK, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 99-7601 CIVIL ACTION-LAW JURY TRIAL OF TWELVE DEMANDED DEFENDANT GREGORY GRIFFIWS INTERROGATORIES DIRECTED TO PLAINTIFF TO: NICHOLE A. SENTZ-BROWN, Plaintiff, and her attorney, DAVID W. KNAUER, ESQUIRE Enclosed are Interrogatories propounded by Defendant to be answered under oath by the aforesaid Plaintiff pursuant to Pa. R.C.P. No. 4005, within thirty (30) days from the date of service hereof. A copy of said Answers shall be served upon counsel for Defendants at the address below. These Interrogatories shall be deemed to be continuing Interrogatories and if, between the time of your Answers to said Interrogatories and the time of trial of this case, you or anyone acting in your behalf leam of any further information not contained in your said Answers, you shall promptly furnish said information to the undersigned by supplemental answers. As used herein, the words "accident" or "occurrence' refer to the event or events described in your Complaint and all related events and circumstances. The word "you" or "your" includes your attorneys, representatives, insurers, and all others purporting to act on your behalf. Unless otherwise specified, response to the following Interrogatories shall give the requested information for the period from December 27, 1997 to the present (hereinafter sometimes referred to as the "time period"). It is hereby certified that a true and correct copy of these Interrogatories was mailed to counsel for the Plaintiff on this date by the undersigned. MARTSON DEARDORFF WILLIAMS & OTTO By- K eorge B. Fall r, Jr., s ui e Ten East High Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Defendant Date: September 14, 2000 Interrogatory No. 1 For each health care practitioner Plaintiff has seen since the date of the incident (whether in connection with the injuries suffered in the incident ornot), provide the identity of same, the purpose of seeing practitioner, the number and inclusive dates of each visit, a description of all medication recommended or prescribed, a description of any treatment received or recommended, a listing of any charges incurred and the identity of the person or entity paying same if not Plaintiffs. ANSWER: Interrogatory No. 2 Identify any health care practitioner that you have seen for ten (10) years prior to the incident in question, including but not limited to, your family physician and give the name and address of each. ANSWER: Interrogatory No. 3 State whether, as a result of the said occurrence, you required any medical or vocational rehabilitation services; that is, services necessary to reduce disability and to restore the physical, psychological, social and vocational functions, including but not limited to: medical care, diagnostic and evaluation procedures, physical and occupational therapy, other necessary therapies, speech pathology and audiology, optometric services, nursing care under the supervision of a registered nurse, medical social services, vocational rehabilitation and training services, occupational licenses and tools, and transportation necessary to secure such services. If so, state fully: The names and addresses of all medical, rehabilitation facilities, hospitals and/or clinics at which you were examined or attended; the names and addresses of all individuals and physicians who attended or examined you; the date of each treatment; and a description of the treatment received. ANSWER: Interrogatory No. 4 State fully all the injuries you claim to have suffered in or as a result of the said occurrence. ANSWER: Interrogatory No. 5 As to the injuries claimed in Interrogatory No. 4, have you ever experienced or been treated for the same or similar condition? ANSWER: Interrogatory No. G State fully all elements of economic loss, and the dollar value thereof, that you claim to have suffered in or as aresult of the said occurrence. As part of your answer, state specifically, any claims for loss of income, past, present and future, explain how that was computed, and provide the inclusive dates of all time lost from work, whether full time or part time. ANSWER: Interrogatory No. 7 if you still suffer pain from any of your injuries and conditions resulting from the incident, state specifically the frequency and nature of the pain and the injuries or conditions from which it emanates. ANSWER: Interrogatory No. S What future reasonable and necessary professional medical treatment and/or care do you claim you will require as a result of the said occurrence? ANSWER: Interrogatory No. 9 Was any investigation made of the accident or accident scene by you or by anyone acting on your behalf after the accident? if so, then for each such investigation, kindly state further: (a) The date and time it was made; (b) The name, address and employment of the person who made it; (c) The date and present custodian of any report concerning the inspection or investigation; (d) The identity of all persons interviewed as part of the inspection or investigation; and (e) A description of any exhibits, including, but not limited to, photographs or drawings prepared in connection with the investigation or inspection. ANSWER: Interrogatory No. 10 Please identify each of your employers, state the inclusive dates of employment and your gross and net earnings on a weekly or monthly basis for the period beginning five years before the accident to and including the present. With respect to each such employment, please describe your job duties and responsibilities. ANSWER: Interrogatory No. 11 If you have filed a Federal, State or Local Income Tax return for any of the five calendar years preceding the accident or any year since, please state whether copies were kept or subsequently obtained, and, if so, identify every person who has, or at any time had, a copy of sane. Alternatively to an answer, you may attach complete copies of each return as filed, to include, without limitation, all schedules, W-2, 1099's and other attachments. ANSWER: Interrogatory No. 12 d of you in you have been unable to perform satisfactorily all duties require indicating state whether said ccurrence employment and all activities of daily living since the date of trm and the names and addresses your ouwereunabletop family, of with all persons particularity having those knowledge and activities Y our supervisors, fellow employees, wledge of such, including y concerningthe friends and the like. State further the identity of any phYsician?vho has advised you limitations or duration of any such disability. ANSWER: _ ®Ri'?C6RffitS1? I Interrogatory No. 13 Please state the name and address of any insurer, auto or otherwise, which you believe provides coverage, whether first party, third party, primary, secondary, contingent worker's compensation or other, for any injury or loss arising out of the said accident, and state further the owner of the policy, the type ofpolicy, a description of any claim made, the nature of the coverage, the limits of each coverage applicable, the nature and amounts of any benefits paid by any such insurer and a description of any claim that was denied in whole or in part. ANSWER: Interrogatory No. 14 Identify any medical expenses which you have incurred which have not been covered by a collateral source (i.e. first party medical coverage, worker's compensation, Blue Cross/Blue Shield, etc.). ANSWER: Interrogatory No. 15 Please identify each person you expect to call as an expert witness at trial and state the subject matter on which each person is expected to testify. ANSWER: Interrogatory No. 16 As to each person identified in your answer to the preceding interrogatory, please state the substance of the facts and opinions to which lie is expected to testify and the grounds for each opinion.* Signature of Expert *A report, personally signed by your expert, may be furnished in lieu of your answer to this interrogatory. If you elect to furnish reports in lieu of an answer, then please indicate in the space above the date of each such report and the persons by whom they were prepared. Interrogatory No. 17 Identify every person known to you who claims to have seen or heard any of the parties make any statement or statements pertaining to any of the events or happenings alleged in the pleadings. ANSWER: Interrogatory No. 18 Identify every person known to you, who you belicvc may have knowledge concerning: (a) The happening of the accident; (b) Any fact or circumstance pertaining to the accident; or (c) The conditions at the scene at, or immediately before or after, the time of the accident. ANSWER: Interrogatory No. 19 Have you, your attorney, or any representative ofyou or your company entered into or been a party to any releases, stipulations, understandings or agreements regarding your liability for the claims which have been made in this case? ANSWER: l j Interrogatory No. 20 cted or pled guilty to a crime? If so, list the court, the offense and y plea. Interrogatory No. 21 Have you ever, either prior to or after the incident, made a claim for a personal injury or worker's compensation? Ifso, describe the circumstances surrounding the claim including the name of the party against whom the claim was made and their insurance company. ANSWER: Interrogatory No. 22 State your full name, any aliases, prior names, nicknames and your social security numbers and date of birth. ANSWER: COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND Nichole A. Sentz-Brown, being duly sworn according to law, depose and say that the facts set forth in the foregoing Answers to interrogatories are true and correct. Nichole A. Sentz-Brown Sworn to and subscribed before me this day of 2000. CERTIFICATE OF SERVICE 1, Jennifer L. Kelley, an authorized agent for Manson Deardorff Williams & Otto, hereby certify that a copy ofthe foregoing Defendant Gregory Griffie's Interrogatories Directed to Plaintiff was served this date by depositing same in the Post Office at Carlisle, PA, first class mail, postage prepaid, addressed as follows: David W. Knauer, Esquire 411 A East Main Street Mechanicsburg, PA 17055 MARTSON DEARDORFF WILLIAMS & OTTO nnifer I1'. {eilei Ten East High Street Carlisle, PA 17013 (717) 243-3341 f Dated: September 14, 2000 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA NICHOLE A. SENTZ-BROWN Plaintiff CIVIL ACTION - LAW V. GREGORY A. GRIFFIE and DONALD W. TACK Defendants No. 99-7601 Civil Term JURY TRIAL DEMANDED Plaintiffs Answer to Defendant Gregory Griffie's Interrogatories 1. Chiropractor Dr. Rochelle Casses Emergency Room Carlisle Hospital Dr. Bradford Wood Family doctor Please see records for details. 2. Dr. Bradford Wood Yellow Breeches Family Practice Boiling Springs, PA 3. See #1 4. Hips out of place, neck and shoulder injuries, wrist injury. Plaintiff reserves the right to supplement this answer 5. No 6. Plaintiff was unable to drive following the accident. Plaintiffs father drove her to school for approximately three months following the accident. 7. Plaintiff still suffers from neck pain and occasional leg and hip pain. Plaintiffs pain is constant. 8. Chiropractic treatment 9. See police report 10. Prior to accident Plaintiff was a college student. April 1999 -July 1999 Mulberry Child Care Camp Hill, PA 17011 July 1999 - 2000 Learning and Play Center Mechanicsburg, PA 17055 March 2000 - Present Childrens Family Center: Messiah Village Plaintiff is in the process of changing jobs due to the injuries suffered in the accident. 11. See attached 12. Yes. Plaintiff is unable to lift the children. Plaintiff is unable to lift the required objects at work. 13. Leona Hagen, Husband, immediate family. Plaintiff can supply the names of other witnesses if necessary. Plaintiffs Fathers Policy - Prudential Plaintiffs present Health Insurance Plaintiffs Car Insurance now- Geico Plaintiffs car insurance at time of accident 14. See attached bill records 15. Plaintiff does not know 17. None 18. See police report Mt. Holly Springs Fire Department Plaintiff knows of no other witnesses to the accident or to the events at the scene of the accident. 19. No 20.. No 21. No 22. Nichole Ashley Brown Formerly, Nichole Ashley Sentz Also known as Nikki Sentz or Nikki Brown SS# 178-60-0827 150 Williams Grove Rd. # 129 Mechanicsburg, PA 17055 Respectfully submitted, KNAUER & ASSOCIATES, L.S.C. 4forthanael jBI Esq e orney I.D. No. 85679 Att 411-A East Main Street Mechanicsburg, PA 17055 Date: November 6, 2000 (717) 795-7790 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NICHOLE A. SENTZ-BROWN, CIVIL ACTION - LAW Plaintiff No. 99-7601 CIVIL TERM GREGORY A. GRIFFIE and DONALD W. TACK, JURY TRIAL DEMANDED Defendants CERTIFICATE OF SERVICE 1, David W. Knauer, hereby certify that I did this 6th day of November, 2000, serve a true and correct copy of the Plaintiffs answers to Defendant's Discovery on all counsel of record by United States mail, first class, prepaid addressed as follows: Richard H. Wix, Esquire Wix, Wenger & Weidner 4705 Duke Street Harrisburg, PA 17109-3099 (For Defendant Donald W. Tack) George B. Faller, Esq. Martson Deardorf Williams & Otto Ten East High Street Carlisle, PA 17013. G/1 David W. Knauer, Esquire Attorney for Plaintiff Attorney I.D. No. 21582 411-A East Main Street Mechanicsburg, PA 17055 (717) 795-7790 To: Prudential Ins. From: Rochelle Casses, DC Re: Nichole Sentz Claim" : 29500016-08009 Date: December 31, 1997 To Whom it May Concern, On December 31, 1997 Pfs. Sentz Dresented herself to my clinic with a chief complaint of Cervicalgia. She is also experiencing thoracic pain, lumbago, and Left wrist pain. All of the previous symptoms she has experienced since a motor vehicle accident on December 27, 1997. An examination was performed as were full spine x-rays. Ms. Sentz suffers from a diagnosis of cervical acceleration- deceleration syndrome secondary to a C7 subluxation. She also has a subluxation of T4 and L3. The following care plan is recommended: monitor and adjust 3X per week for 8 weeks holding trigger point contacts in the trapezius and L1-5 paraspinal muscles. A re- evaluation will be performed at the end of this time to determine if further care is needed. Sincerely, Rochelle Casses, DC S"' Casses Chiropractic Clinic 313 S. Hanover St. Carlisle PA 17013 717-249-0055 CASE#. 5f5 /A, 01:rl-IOPEDIC &NEUROLOGICAL E1Ai`IINATIONS NA\4E 5d AGE DATE IIEIGII"1' S'/ WEIGHT /S Z $ p _ !!Y 3 POSTURE _ head tilt high h0U high S shoulder rZ= high iliunla= foot rotation= DORSOLUNIBAR RLN'GE OF MOTION norm RONI flexion 75-90 211 extension 30 25- Lt lat. flex. 35 10 Rt. lat. flex. 35 &6 Lt. rotation 30 ,Is Rt. rotation 30 11?f RE-FLEX ES (none =0; sluggish = 1+; normal = +2; slightly increases = 3+; hyperactive = 4+) Achilles L 4 z R -12 Patellar L 7- R 4 v ORTROPEDIC TESTS Triad of Dejerne (?U-- (+ Minor's Sign ...,U (+ Laseque's Braggard's Cont1•alateral SLR Milgranls Nachlas Ely's a CU GAIT good_,.,' bad -- explain LEG CHECKS prone rt. -- It. -Dr +D CS BCS supine rta lt. vain(level) Adam's Advancement Temp's , Trendelenburg ?? Other tests perfortrte? Dermatomes (if t Comments: other CERVICAL RANGE OF 1`10.1'10\t norm ROM flexion E0 extension SS Lt. lat. flex. 40 2-0 Rt. lat. flex. 40 yo Lt. rotation 70 -Cep Rt. rotation 70 U? REFLEXES Triceps L-4R Biceps L?2- R ORTHOPEDIC TES'T'S Foramina Compression : stir Cervical Distraction (-) Shoulder Dep •essoi-O-L Q SOTO Hall De (+) Other tests berfonmed:.-,,,,.,-' Denmatornes (if tested); Comments/other: SPINAL ANALYSIS L ?/lZ Le?-2,R a nain(level) T7 c4 , - Tz vertebrae palpation x rnv listines Rt ilium Lt ilium Signature of Sacnuu ?I RADIOLOGY REPORT CT MR[ Date: /-z 3/'9 7 Film(s) on file CERVICAL SPINE: ? AP 01APOM LI-LAr CI lit / Lt Oblique 0-Flexion ss ostcopathology (?) Negative for recent fracture or gro as visualizcduilitarv^ (• reversed Lordotic curve normal / mildly / moderately decrease([; ( )' Scoliosis: ( )Mild ( WOCICT;uc t )acvcrc• Narrowed Disc space(s)bctween Ostcoirthridsat: Ncuroforaluinal Encroacluncul bctn'cca: Other: THORACIC SPINE: 0-t%P L9'-LAT ? Other_____ (? Negative for recent fracture or gross oslcopathology as visualizcd. Kyphotic cone is: ( ) \,Or,,,, (? TFI}'Po ( ) FI} pcr- Scoliosis: ( ) Mild ( ) Modcrue ( ) Scvcrc; Apcxcd at NarrovvcdDisc spacc(s) Ostcoanhritisat:_ Other: LUMBAR SPINE: 6'AP FLAT ? Rt / Lt Oblique 17 Other (/)'Negative for recent fracture or gross osteopathologyas visualizcd. Lordotic curve is: ( ) Normal (Mildly ( ) Severely increased or Decreased Scoliosis: (/) NUld ( ) Moderate ( ) Severe; Apcxcd at 1-z NarroNvcd disc space(s) between Ostcoarthritis at: Ncuroforan»nal Encroaclu lent between III( ) IV( ) Spondylolisthesis (Meyerding) Grade I( ) It( ) Lumbosacral (1,5/S 1) angle: degrees cal. \Vcight-bearing: ( )Normal ( )Anterior ( )Posterior EXTREMITIES:= OTHER: SUBLUXATION(S) (Medicare) Consultation Recommended/Scheduled With: Date: Reason: C`.1'Estcnsion L Attending Physician's Signature F•101 (Ra is d 2M N.nidnr It I nn,r fn In n1 •n?n'155 ra??l!®®?1?11?®If® RADIOLOGY REPORT CT MRI Date: /-Z -3/-9 7 Film(s) on file CERVICAL SPINE: 17 AP d?YAPONI E}LAT 17 Rt / Lt Oblique ( vfNcgative for recent fracture or gross ostcopathology as visualized. Lordotic cure normal / mildly / moderately decreased: ( )"military" (11 reversed Scoliosis: ( )Mild ( )Moderate ( )Severe: Apcxcd at Narrowed Disc speee(s)bemcen osicoanllritisat: Neuroforan»nal Encronchnient bct%vccn: THORACIC SPINE: O-AP 1'F-EA'r ? Other (? Negative for recent fracture or gross ostcopathology as visualized. Kyphotic curve is: ( ) Normal (V' Mypo- ( ) Hyper- Scoliosis: ( ) Mild ( ) Moderate ( ) Severe: Apcxcd at Narrowed D i sc space(s) bcuvccn 0sicoarhritis at: LUMBAR SPINE: H'AP SLAT E3 Rt / Lt Oblique ? Other (() Negative for recent fracture or gross ostcopathology as visualized. Lordotic curve is: ( ) Normal (,,)'Mildly ( ) Severely Increased or Decreased Scoliosis: (?) Mild ( ) Moderate ( ) Severe; Apcxcd at La Narrowed disc space(s) between 0stcoarthritis at: Neuroforaminal Encroacluncnt between Spondylolisthesis (Mcycrding) Grade I( ) II( ) Ill( ) IV( ) Lumbosacral (L5/S1) angle: degrees Wcight-bearing: ( )Normal ( )Anterior ( )Posterior tilt EXTREMITIES:' OTHER: 0-17Icxion 0-atension SPINAL ANALYSIS OCC -1 K/ At {, f Ax ct C3 C4 I C5 C6 r_ C7 ??Y f Ti T2 I T3 T4 R lal C T S T6 T7 PkT T8 9 T10 T11 T12 LI L2 L3 L4 L5 Sac R III Ex L III N Coe SUBLUXATION(S) (Medicare) Consultation Recommended/Scheduled With: Date: -4 4-Ze Attending Physician's Signature F-101 (Revised 3-94) Ro wdm H .1 Rees rn twi w,1W PEt.,ONAL INJURY OUESTIONNAIR. Name Addres /-7 -3/- 97 .:' oyr? Phone( 7l7) State 81 Zip / Age 7V Birthdate 1, 1 Ia?l -7'1 Sex F SIS N Employer's Nam 15 SST Jul r Employer's Address Yeurlns.Co.- lRlJ17?77/)L Policy# Agent's Name L KJLL/f7?1 Name on Policy (If other than self) 41- Al P 2,2zi?? Policy N Responsible Party's Name Address City Policy Holder's Name ATTORNEY Name AWL- e 'ILKTi -A.aEe n W'E/JcP Address City Were there any witnesses? V-)Yes ( )No Name(s) La State Zip Policy N Phone( Slate p?- Zip NATURE OF ACCIDENT: 1. Date of Accident iQL- 7V7 Time of Day s 'L-x'1'1 2. Were you: ( ) Driver (Xj Passenger ( ) Front Seat to Back Seat 3. Numberof people in yourvehicle? 4- Were you wearing seal belts? YCJ 4. What direction were you headed? 1 L( ) North ( ) East ( X) South ( ) West on (name of street) 23",r AI/7%,?-c -42)AD 5. What direction was other vehicle headed? ( ) North a) East ( ) South ( ) West on (name of street) 9T /7'Y 6. Were you struck from: ( ) Behind ( ) Front ( ) Left side (yj Right side 9. Were police notified? (? ) Yes ( )No '' `` ? ? p p _ D a /? 10. In your own words, please describe accident: ,V&j, /?f MLLE' ClfiL GL( uSZLL[SU_. ,..1L ?y mph Other car 415, mph 7. Approximate speed of your car Y w long? 8. Were you knockedunconsclous? ( )Yes No If es for ho 1110? ( ) Yes No If yes, please describe in detail: 11. Did you have any physical complaints BEFORE THE ACCIDENT? ? 12. Please describe how you tell: a. DURING the ac b. IMMEDIATELY c. LATER THAT D d. THE NEXT DAY 13. What are your PRESENT COMM. .,ts anrf oms? -. t 14. Do you have any congenital (from birth) factors which relate to this probln? ?a ( )Yes (7?D. If yes, please describe: 15. Do you have any previous illnesses which relate to this case? 16. Have you ever been Involved in an accident before? ( ) Yes type(s)of accidents, as well as injury(ies) received. 17. Where were you taken after the accident? 18. Have you been treated by another doctor since the accident? and address: _ "e? What type of treatment did you receive?.Lr0zr-- - ?; ( ) Yes (bfNa? If yes, please describe: ( ) No If yes, please describe, including date(s) and (? ( )No 19. Since this injury occurred, are your symptoms: ( ) Improving 20. CHECK SYMPTOMS YOU HAVE NOTICED SINCE ACCIDENT: IX J adache ? Irritablity Neck Pain Chest Pain , ? Numbness in Toes O Neck Stilt zlness ? Sleeping Problem ? Shortness of Breath ? Fatigue s ? Head Seems Too Heavy Pain ? Pins 8 Needles in Ar ? Depression ms ? Nervousness ? Pins 8 Needles in Legs ? Tension O Lights 50:her Eyes C3 Loss of Memory ? Numbness in Fingers Symptoms Other Tha Ab ? Ears Ring n ove-4z?2 f s 21. Have you lost time from work as a result of this acc ident? ( )Yes a. Last Day Worked: b. Type of Employment: c. Present Salary: d. Are you being compensated for tim t from work? ( )Yes you are receiving: 22 D o you notice any activity restrictions as a result of this injury? k Y /s ( ) No If yes, please describe, In detail: 23. Otherpertinent information: ??DATE 9-2 .2,3335 C•106 R.de, N J, Rea, ca. (aw) v. (/ - If yes, please complete this question. ( ) No If yes, please state type of compensation ( ) Getting Worse ? Face Flushed ? Buzzing in Ears ? Loss of Balance ? Fainting ? Loss of Smell ? Loss of Taste ? Diarrhea If yes, please list doctor's name k)S e ? Feel Cold ? Hands Cold ? Stomach Upset ? Constipation ? Cold Sweats ? Fever SIGNATURE Confidential Patient Health Record DATE I.D. NO. PERSONAL HISTORY Name: Address: //?C yz City: State/Prov: Per Zip/Postal Code; 17U66' Home Phone: Birth Date: Age: _/_S Sex: ? M ?QF Social Security ;# Driver's License Number: Social Insurance n Circle One: Marred 9iingP 05 Widowed Divorced Separated Business Employer: S7r'nc'hr7 Type of Work: Business Phone: Spouse's Social Security n Name of Spouse Spouse's Social Insurance R Spouse's Employer Business Phone Type of Work Referred To This Office By: Name and Number of Emergency Contact: Who Is Responsible For Your Bill, You and Personal Health Insurance (Name) and Ages of Children 1 'VJ1L-LA `2EA rZ Relationship; Nc. CSpouse :..Workers' Comp. -? Auto Insurance D Medicare ? Medicaid Health Card CURRENT HEALTH CONDITION Purpose of This Appointment OF C4,? Other Doctors Seen For This Condition: 'Yes CNo Who? rLaMYli111) WDDD a)411 L j' 1 67LY2) _ Type of Treatment: EXAM1AIAT1W Results: When Did This Condition Begin?_7 Has This Condition Occurred Before? ? Yes Y, No Is Condition: ?Job Related X'Auto Accident E-.Home Injury GFall EOther: Date of Accident: 90 Time of Accident: Have You Made A Report of Your Accident To Your Employer: DYes CNo Drugs You Now Take: GNerve Pills ?Pain Killers/Muscle Relaxers ?Blood Pressure Medicine ?Insulin ClOther Adol Do You Wear A Shoe Lift? %Yes ENo - 04'THV 1M,VZE_S Do You Suffer From Any Condition Other Than That Which You Are Now Consulting PAST HEALTH HISTORY Please Check and Describe: Major Surgery/Operations: ?Appendectomy I Tonsillectomy ?Gall Bladder ?Hernia ?Back Surgery ?Broken Bones ?Other Major Accident or Falls: ' Nc 7-P472I TNifN L151 & D 4Ptli/E Hospitalization (Other Than Above): Previous Chiropractic Care: A' None ? Doctor's Name & Approximate Date of Last Visit Below are a list of diseases which may r- ,m unrelated to the purpose of your appe'-Iment. However, these questions must be o nswered carefully as these p,,. ems can affect your overall course of c. , practic care. CHECK ANY OF THE FOLLOWING DISEASES YOU HAVE HAD: ? Pneumonia ? Mumps )S ? Influenza Pleurisy INTAKE ? Coffee ? Rheumatic Fever i ? ;!d Small Pox Chicken Pox ? Arthritis ? Tea o ? Pol ? Tuberculosis ? Diabetes ? Epilepsy ? Alcohol ? Whooping Cough ? Cancer ? Mental Disorders ? Cigarettes ' ? Anemia ? Heart Disease ? Lumbago ?K White Sugar ? Measles ? Thyroid ? Eczema Have you been tested HIV positive? C, Yes !A No CHECK ANY OF THE FOLLOWING YOU HAVE HAD THE PAST 6 MONTHS: MUSCULO-SKELETAL CODE Low Back Pain i Pain Between Shoulders Neck Pain III Arm Pain Ler-T u:0_ISr ? Joint Pain/Stiffness ? Walking Problems ? Difficult Chewing/Clicking Jaw ? General Stiffness NERVOUS SYSTEM CODE ? Nervous ? Numbness ? Paralysis ? Dizziness ? Forgetfulness ? Confusion/Depression ? Fainting ? Convulsions ? Colciff'ingling Extremities ? Stress GENERAL CODE ? Fatigue N,Allergie!Asrtt"'?? ? Loss of Seep ? Fever ? Headaches GASTRO-INTESTINAL CODE ? Poor/Excessive Appetite ? Excessive Thirst ? Frequent Nausea ? Vomiting ? Diarrhea ? Constipation ? Hemorrhoids ? Liver Problems ? Gall Bladder Problems ? Weight Trouble ? Abdominal Cramps ? Gas/Bloating After Meals ? Heartburn ? Black/Bloody Stool ? Colitis GENITO-URINARY CODE ? Bladder Trouble ? Painful/Excessive Urination ? Discolored Urine C-V-R CODE ? Chest Pain Short BreatfPc51 ? Blood Pressu a Problems ? Irregular Heartbeat ? Heart Problems ? Lung Problems/Congestion ? Varicose Veins ? Ankle Swelling ? Stroke EENT CODE ? Vision Problems ? Dental Problems W Sore Throat 9 Ear Aches ? Hearing Difficulty Stuffed Nose MALE/FEMALE CODE ? Menstrual Irregularity S1 Menstrual Cramps '? Vaginal Pain/Infection ? Breast PaiNLumps ? Prostate/Sexual Dysfunction ? Other Problems n ? .?F i? i FEMALES ONLY: ??( When was your last period?)'. Are you pregnant? ? Yes No ? Not Sure Please outline on the diagram the area of your discomfort FAMILY HISTORY The following members have a same or similar problem as I do: ? Mother ? Father ? Brother ? Sister ? Spouse ? Child DO NOT WRITE BELOW THIS LINE CHIROPRACTIC ANALYSIS:?(", &ieziC3?L,QI/V /7 DIAGNOSIS: Patient Accepted:\VYes ? No ? Referred Dodfor's Siqnature r{ 9 i' I j t?? ?i I 19hT; G7 &MC 1'1:1-1 HK I1HL 1?C1'::=•J7:JlG 10 1!1'f/77!'fyJ r,L+-'aw Page: 1 Document Name: cae*y Sardner PACES CLAIM SUFFIX DISPLAY - SCREEN 3 NEI•,CO (MORE) CLAIM 29500016 SFX A X/S 14A CLMT NICP.OLE SE14TZ NAME ADDRESS CHECK NO DATE AMOU972 TECH P/E TYPE P/? SC ROCHELLE CASSES 313 S I:AI:0 09482562 031398 3.32 00-105 24 C 3 GASSES ROCHELLE D.C., 12/31/97-1 /5/90IN EREST DUE ROCHELLE CASSES 313 S HILNO 09459G20 030498 664.00 00-105 21 C ROCHELLE CASSES D.C., 12/31/97-1 /5/98 XRAYS, CHIRO,OV PT RESERVE INCREASE 030390 1503 08-009 13 INC RES RHC EMERGENCY PH 13 3800:^.10 09455650 030390 129.00 08-105 21 C RWC EMERGENGY PH SICIANS,ANTHONG GUARRACINO M.D., 12/27/ 97 XRAY SPINE, ER V ROCHELLE GASSES 313 S NANO 09452135 030296 675.00 08-119 21 C R CASSES,DC 1/19-2/9/90 PT YELLOW BREECHES PO BOX 100 09398698 020698 200.00 08-119 21 C *** YELLOW BREECHES EMS 12/27/97 AMBULANCE TRANSPORT CARLISLE IMAGING PO BOX 100 09391275 020498 22.05 08-108 21 C PY.%;T FOR SPINE XRAY(MOD 26) RED $20.95 DR DAVID RO :•AL 12/27/97 ROCHELLE CASSES 313 S NANO 0939127.1 020498 159.00 08-108 21 C . MT FOR CHIRO SVCS 1/7-1/12/90,1:0 RED DR ROCHELLE CASSES,DC IT PF2 TO PACE -OR- EATER Co%• AND NEXT CLAIM- S.X- NEXT SCREEN- (CONTINUED) Dace: 3/29 0 Time: 09:11:01 A:•1 ••-••------ II AR 29 .2030 11:13 FR FRUCEHTIFL 1E3o8°_07072 TO 17177557793 P. 03/04 Page: 1 Document Name: cathy ?ACES CLAI)•1 SUFFIX DISPLAY SCREEN 3 NEMCO (I{OREI CLAII.1 29S000IG SEX A '+./S NA CIMT NT_CFiOLE S--!IT7. ADDRESS CHECK NO DATE ,L'•:OUNT TECH P/E 'PYP ?/T SC NAME C ROCHELLE CASSES 313 S 1L'+NO 10055603 111198• 21PTOOOO8-IDIG 25 CASSES CHIRO,DR CASSES-DC,6/29•,7/10-9/'- /98, , LASSES ROPRAC 313 S HMO 09760778 070998 360.00 08-100 21 C PYMT FOR CHIRO SVCS 5/4-6/15/98 NO RED DR ROCHELLE CASSES,DC CASSES CHIROPRAC 313 S HADIO 0962598G 051498 150.00 08-105 21 C CP.SS£S CHIRO CLINIC, ROCHELLE CASSESD.C., 4/3/98"4/27/9 I•]ANIPSILATION L' ampolh ROCHELLE CASSES 313 S "rANO 09574409 042298 5.8.00 08-117 22 DR.CASS=S/DC 3/6-3/30/98 PT,CHIRO SERVICE., NO REDUCTION C ROCHELLE CASSES 313 S NANO 09506766 032598 385.00 08-118 21 ROCHELLE CASSES DC DOS 2/11/90-3/2/98 PT --NO RED. C CARLISLE HOSPITA 246 PARKEP- 09.185399 031698 156.76 08-108 21 PYMT FOR ER ROOM & SVCS 12/27/97,RED BY MEUPAT1i(BILL $320.00)CARLISLE HOSP HZT PF2 TO PAGE -OR- ENTER COI.2.1? T1 NEXT SC EEN- (CO.NTINUED) NEXT CLAIM- SF:C- Date: 3/29 O Time: 09:10:55 At4 ._ iii.. .._. 1'I1;ft 23 2000 11:13 FP. PFODEPfrIfL Page: 1 Document MlmmH: cathY Jardnei 13C^03507072 TO 17177557743 PACES CLAi1•I SUFFIX DIS?LYY - SCREEN 3 NENCO P.04/04 CLAIM 29500016 SFX A K/S NA CLMT NIrHOLE SE14TE NAME T,DDRESS CHECK 1:0 DATE A14OUN'T TECH P/E TYPE P/T SC YELLOW BREECHES 1.358 LUTST 09343405 011598 37.00 08-118 21 C YELLOW BREECHES FA14 TRACT/B.NOOD DOS 12/29/97 SUS SUS OV c!o ?tv?x'u"c"s'?uar 'u NO P.DDITIONAL TRANSACTIONS EXEST :1nXT CLAIX- SFX- NeXT SCR _1- Date: 3 29 0 Tia:e:09 i 11: T7 .V4 " +k* TOTrL PAGE.04 :r* _1 Pu,R 29 2000 1113 FR FF.UDENTIF.L pace; 1 Document Name: cagy gardier :E2ic937372 TO 17177557793 P. 03134 PACES CI_*III SUFFIX DISPLAY •- SCREED 3 NE:4C0 (?:ORE) CLAL•I 29500016 SPX A c/S I:A CU-IT I:IC 0L3 SENTZ NA-!E ADDRESS CHECK NO DATE Xe.ou.\i TECII P/E TYPE ?/T SC R0CI7ELLE CASSES 313 S iLA170 10055603 111193 7 210.00 03-116 25 C CASSES CHIRO,DR CASSES-DC, 6/29.,7/10-9/1•:/9B,?T,IIO RED C313 S W00976077SH070998 M 360.0018-100 21 C PYMT FOR CHIRO SVCS 5/•:-6/15/98 I:0 RED DR ROG?ELLE C?SS3 S,DC CASSES CR_TROPRAC 313 S FwNO 09625986 051458 150.00 08-105 21 C CASSES C4IR0 CLINIC, ROCFELLE CASSES D.C., ?i/3/90-4/27/5 8_[.:.NI-rULnTIG:7 ROCRELLE GASSES 313 S FANG 09574409 04,2292 6•:Q 00-08-117 21 C DR.CASSES/DC 3/6-3/30/98 PT,CHIRO SERVICE. , NO REDUCTI0I7 ROCKELLE CASSES 313 S ?.7NO 09506766 032598 385.00 08-118 21 C ROCF•ELLE GASSES DC DOS 2/11/98-3/2/98 PT - -NO RED. CARLISLE %OSPITA 246 PAPA R 09485399 031698 156.76 08-108 21 C P1^.:T FOR ER ROOM 8 SVCS 12/27/97,R3D BY 14EUFATd (iiILL $338.00)CARLISLE HOSp __ PF2 TO PAGE -OR- C0:•2•?\7 NEXT CLAIM- S1.F.-XT SC.-.='',- (CO:TI:aT'D) Date: 3/29 0 T.tme: 09:10:55 P.M mom.«.,i..ar:.:. .... re lECC?Sa7072 TO '17177557793 PIRR 29 2000 11:13 FR Fr. ..li NTIRI_ Page: 1 Document Yan- e: Cathy ja_Vie:: PACES CL:AiX SG^e_IX DISPLAY - SCREE27 3 1VEN.C0 SFX A /S \A CL:•iT :7ICHOLE SENTZ CII+IId 29500016 tiAl i.DD4ESS C'r_ECK NO DATa i-N.Ou_. TECH ?/ ?ti BE a/T SC C YELLOW B..4EECHES 1358 LDTZT 09393609 013 2 37.00 Oll 2'_ C YELLOW BR-S °A74 ?1Z<?C?/H.i:CGD DO.S, 12/.'9/97 SUB OY 1:0 ADDITIOWAL TRANSACTIONS EXIST NEXT CL;Ll::- N=-XT SCR.=--N- Date: 3 29 0 Time:••b9 ** TOTFiL PP.CE.04 +'? 1G1C7U'i U'fG IU L'!1'(Po7fY7.J Page: 1 Document Name: Cathy gard.•1er PACES CLAIM SUFFIX. DISPLAY - SCREEN 3 :31-iCO (1EORE) CLAIM 25500016 SFX A F:/S NA CL!4T NICECLE SENTT. IM143 ADDRESS C%ECN NO DATE AliOU:^ TECE P/E TYPE P/T Sc ROCF7ELLE CASSES 313 S FiAVO 09482562 031398 3.37 08-105 2.1 C a LASSES ROCHELLE D.C., 12/31/97-1 /5/90I1?TEREST DUE ROC::CLLE CASSES 313 S IUtiO 09459628 030498 66.1.00 00-105 21 C ' ROCF•-ELLE GASSES D.C., 12/31/97-i /5/58 X.RAYS, CHiRO,OV PT E--SERVE 117CREASS 030390 1503 08-009 13 INC RES RWC EMERGE-= P 13 BRCOKWO 09455650 030390 529.00 08-105 21 C RWC EN3RGENGY P-`iiSICIi.NS, ANTECNG GUA.%RACINO 1.1.7., 12/27/ 97 XRAY SPI! rz,ER V ROCHELLE CASSES 313 S HAND 09452135 030256 675.00 06-119 21 C R CASSES,DC 1/19-2/9/98 PT :zLLOLi 3REEC:ES PO BOX. 100 09398698 020698 200.00 08-119 21 C *+• YELLOW PiREECF-ES EIdS 12/27/97 A,3J°.ANCE TRANSPORT CARLISLE IMAGING PO BOX 100 09391275 020598 22.05 OB-108 21 C P .%*. FOR SP=E XRAY(Y.OD 26) RED $20.95 DR DAVID ROYAL 12/27/97 ROCHELLE CASSES 313 S R.ANO 05391274 020455 159.00 08-108 21 C PYJ/.T FOR C?IRO SVCS 1/7-1/12/90,"0 RED DR ROCHELLE CASSES,DC d:T PF2 -0 PAGE -CR- EhiER CO'r24AND NEXT C*_,It1- S---X- 1.X SC:?EE)7- (C017TI1.'UED) Date: 3/29 0 Tuce: 09:11:02. P.:: •°° PLEASE l1PLC?IJ "M APPROVED 01.10 09360009 DO NOT STAPLE IN THIS AREA r1 7-iPICA HEALTH INSURANCE CLAIM FORM PICA rTI-1 1 MEDICARE MEDICAID CHAIAPUS CHAMPVA GROUP FECA OTHER HEALTH PUN BLK LUNG Ia.INSURED'SI.D.NUMUEN (FOR PRGGRAMIU ITEM 1) rv pAe,4:w r/ IA!xrap rl (Sponsors SSNJ I-l (VAF,'e s) (SSN or IDI N( RDI (SS ! R : 1 2 9 S 0 0 016 - 0 8 0 0 9 2 PAT l1A 1C T3 E3 Itame, FUn Nama, L:.m:9InWIJ 3.PATIENT DART H DATE 0 , YY SEX MIA 4. INSURED S NAME Wsl Name, Furl Name. 6,4019 Initial ) Sentz Nichole P ? 0 6. 2 2 6' 79II 1 f-1 Sentz Alan Pamela •. PATIENT'S ADDRESS tile. Street) 6. PATIENT RELATIONSHIP TO INSURED 7JNSURED'SAODRESSp+o.,S119et) 5 Strine Ave. Sell I] Spouse] chAaD Omerl] CITY STATE S. PATIENT STATUS CITY STATE 14t Holly Springs PA S:n?IeG (nailed l] Olney ED ZIP CODE TELEPHONE pntlude Area Cme) WOODS TELEPHONE (INCLUDE AREA CODE) 17065 (717)486-5822 Employ J FueTmo Pzn•Tlmeo Sh"ant L?1 $IUC9n1 'J 9. OTHER INSURED S NA!AE(Last Name. Firm Name, Maze initial) 10. J5 PATIENTS CONDITr( RELATED TO: IIANSURED'S POLICY GROUP OR FECA NUMBER a OTHER INSUREDS POLICY OR GROUPNUIt5ER a. EIAPLOYMENT7(CURRENTOR PREVIOUS) a. INSURED'S DATE OF BIRTH SEX 11 YES 13NO LJ MIA 1 DD , YY ' I M F ' I I o.NAMER D. DSUREDSDATE OF BIRTH SEX D.AUTO ACCIDENT? PLACE (See) p. EIAPLOYER'S I:AIIE OR SCHOOL NAME I IA Fn I YYES I]NO IPA , C. EMPLOYERS NAME OR SCHOOL NAME e. OTHER ACCIDENT? c.INSURANCEPIANNAMEORPROGRAMNAI.IE ? YES 3NO I a. INSURANCE PLAN NAME CR?Rq;RUA NAME 104. RESERVED FOR LOCAL USE 9. IS THERE ANOTHER HEALTH EENEFIT PLANT I YES CD NO ttyu.Ieturnloan4ompleleeam9ad. READ BACK OF FORM BEFORE COMPLETING 6 SIGNING THIS FORM. 12 PATIENTS OR AUTHORIZED P'RSON'S SIGNATURE laulnmae mtsraleate of any r,.eOCal or polar inmrmall0n necessary 17. INSURED'S OR AUTHORIZED PEEAS04 S SIGNATURE I aulMD:e Ia sulcess his cl. .I also Ill Aliment of 9ovemirenl Denefas either to my5e11 or to lots party, who ai:cepl5 assignment payment el medical oehoNs to me llmaraiL'ned pny39an or f'JppWr lot soil Co:[eK9 pelpW Won. , SIGNED S1 nature_on_fi.le DATE 01/05/98 SIGNEDSignatUre on file 01/05/ 14 DATE OF CURRENT: ILLNESS IFirsl sympmm) OR A ,p yy INJURY (ACCi0ln1J OR 1'1 2. 9Y 15. IF PATIENT HAS HAD SAME Ofl SIMILAR ILLNESS. GIVE FIRST DATE MM I DD I YY 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION IAM , DO I YY MIA DD / PREGNANCY(LIAP) , , YY FROM TO I I 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. 1.0. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MIA I DO , YY MM r DD , YY FROM I I I TO 19. RE SE RV E D FOR LOCAL USE 20. OUTSIDE LAB? SCHARGES DYES I]NO 21. DIAGNOSIS CRINATURE OF ILLNESS OR INJURY. RELATE ITEMS 1,2,308 4 TO ITEM 24E BY LINE) 22. MEDICAID RESUBMISSION 1. L.aLZ.? 3. L83.9..21 CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER ' p .s 2. L=33..07 4. LO-U. 2-0 24. A OATEISI OF SERVICE To Flom 8 Place f C Type f D PROCEDURES, SERVICES, OR SUPPLIES E E DIAGNOSIS F G GAYS H EPSD I J K RESERVED FOR a IAM DO YY MIA 00 YY o $eMl o Serviev ( xplain Unusual Circumstances CPTIHCPC$ MODIFIER ) CODE SCHARGES OR UNITS Famey Plan EMG COB LOCAL USE 1 12 ; 31 197 0 It, 97250 1 9: 1234 1" ! 25 100 01 !02 ;98 I 0 I Y r, = 98941 t 1234 %' , I 28 100 I 3 01 '02 198 0 1 1! 97250 s• 1234 Lg 25 100 01 105 ;98 1 1 0 M 1 . 98941 1 G 1234 1'j 28 100 5 01 ; 05 ;98 0 97250 1 j`•' 1234 41 25 100 E 12131 197 1 1 0 . i 95999 1 SEMG t:'. 12391 150 100 25.FEDERALTA%I. D. NUMBER SSN EIN 25-1723340 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? F or -dams, see Well 28. TOTAL CHARGE 29. AIAOLINT PAID 70. BALANCE DUE 0858 [ YES El NO $ 281 00 s 0 100 s 281 00 31. SIGNATURE OF PHYSICIANOR SUPPLIER INCLUDING DEGREES OR CREDENTIALS 32. NAME AND ADDRESS Of FACaITY WHERE SERVICES WERE 7 RENDERED (it other man home or orkal 3. emYSICIAN'5,5UPPLIER'SBILLINGt4MAE.ADDRESS,ZIPCODE P (I canny mat the statements on me rarerats a l 6 HONEe ROCHELLE CASSES D.C. pp y to this Wit am are made a part moroof.J , 313 S. HANOVER ST. CARLISLE,PA 17013 Telephone (717 249-0055 .' SIGNED DATE MEDICARE ID /CA748496 I PINS GRPr IaPPRGVFORY aria Crrvfll l I.FRICnI CFRVIrE.q eRI PI FA 5F PRINT OR TYPE FORM HCFA4500112901 PLEASE •? M APPROVED Cr.T3 015311 0008 DO NOT STAPLE IN THIS AREA (-j,-PICA HEALTH INSURANCE CLAIM FORM PICA FT- 7-t MEDICARE MEDICAID CMFLlPUS CHAMPVA GROUP FLCA OTHER 10. MSURED'S I.D. NUMBEn (FOR PROGRAM IN ITEM 11 HEALTH PLAN FLIT LUNG (Mw q p5/e0,cad • cme s_o5olYSSrJ) IVA Fee q (ssm0,10) n (SS!'.) ( nDl 29500016-08009 2. PATIEI R'S NAMEILast Namo, Fnl Namo, M,dd:a In,uap Sentz Nichole D. PATIENTS BIRTH OAT E SEX 0':/6 Cfid: - 4.111SURED'S NAME IWsI Name, First Name, M,ac:a IrtUaf) 2 L1 f I F Sentz Alan Pamela 5. PATIENT'S ADDRESS INo.. Scoot) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS INU., Snao I 5 Strine Ave. Sea?s,wso ch-lcE other[] same CITY Mt Holly Sprin s STATE PA e. PATIENT STATUS CITY STATE g sn2ND Umnad? anerD ZIP CODE 17065 TELEPHONE incbea Aea Cad.) 717 486-5822 Emplq FIObLmel Pan-Time ZIP 000'c TELEPHONE (INCLUDE AREA COOCI ( ? Swdanl Swdenl ? S. OTHER INSUREDS HAI.IE it Name, F,lel Name, l.6Cme Initial) 10. IS PATIEN i S DNNDITIGII ELATED TO: 11. 114SURED'5 POLICY GROUP OR f ECA NUMIJ(.11 a OTHER INSUREDS PO IC O . Y L R GROUP NUMBER a. EMPLOYMENT? ICURRENT OR PREVIOUS) a. INSURED 'S DATE OF BIRTH D YES f 1 ;a 5FN laid I DO I YY ?7 P o. OTHER RISURED'S DATE OF BIRTH L.J L 1 SEX MM OD YY b. AUTO ACCIDENT] PLACE (State) D. WAPLOYLRS NAME OR SCHOOL NAME ' I LIn F DYES DNO u C. CUPLOYERS NAME OR SCHOOL NAME C. OTHER ACCIDENT] C. INSURANCE PLAN HAVE 011 PROGRAM NAIAE DYES NO e. INSURANCEPLANNAIAEOR PROGRAM NAME 1 Co. RESERVED FOR LOCAL USE e. IS THERE A!IOiNEn HEALTH BCNEFITPLAN? HEAD BACK OF FORM BEFORE COhiITNG B SIGNING THISFORM []YES ? 110 Ilya, nlmn IY and eo,ep,HUbm 9 ro. ' , 12 PATIENT'SOR AUTHORIZED PERSON'S SIGNATURE lac:h:u:a the release cl arry madeal Or a:nor ih!alm:an ne:assary b PIccess m;3Clam,la!so racaesl payment0pmeneowlbeneLis armor to m self or to V.e pan n , wha a'ce :s a 13.INSURED S OR AUTI!ONZCl7 PERSON a TOGNA I Use I"the; palmenl al mu:Kdl peM!eNa1M e?4el HyneJ pnl lKaegµ 1. ! I p e1 a y t ssig ment p bell servltea described WIG.. SIGNED---Signature onfile DATE 01/05/98 SIGNEDSignat_ur 9071 filo 91/05/ M. DATE OF CURRENT: ILLNESS IFest symoom) 08 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. L11•!2 Cj'7 INJURY(Aaoent) OR GIVE FIRST DATE MM I DD I YY , 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MIA DD YY PREGNANCY(LMP) I i TO MM i ?DDD I try FROM 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE l7a. TO. NUMBER OF REFERRING PHYSICIAN 16. HOSPITALIZATION DATES REWE0 TO CURINI HIT 61111VIC9 8 MM r ' 00 ' YY TO MM I OD I ' YY FROM I I 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAST ICIA109B DYES []NO 21.OMGI105150R NATURE OF ILLNESS J ITZ 2AE BY LINE,--1 ORINURY.(RELATE ITEMS 1.2.30R,IT6 1: 1 22. MEDICAID RESUBMISSION 7 1. 8847 ,0 a839 2-1 CODE ORIOIIAL 1110' 110 29. PRIOR AUTHORIZATION NUMBER 2. 1839_ . Q] A. R 1 Q 2D 14. A B C F, DATES) OF SERVICETO Place Typo 0 PROCEDURES, SERVICES, OR SUPPLIES F TJxy-S LTSOI •1 if ---- HAM DO YY MIA 00 YY orv Servl'e im, CPT/HCPCSUnuseHODIFIE9Rarces) DIAGNOSIS CODE $CHARGES NIT WIIiG Femal Plan CM0 CDII It[ VCD FOR LOCAL Use 12:31 97 0 99205 251 1k; 1234 } 135 :00 2 12:31 .97 0 i 95851 251 F' 1239 30 :00 12: 31 :97 ' 0 1 1 '( 72050 ( p 1239 100.00 12;31:97 1 0 72070 ?- 1234 50100 - - - - 6 12:31 :97 : 0 72100 1234 f 50 100 - - - - 1 12:31 :97 0 ii 98941 : 1234 y - - - -- 28 :00 25. FEDERAL TAX ID. NUMBER SSN EIN 26 PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT] 2 For goo. cN,ms sad bad) 25-1723340 0. TOTAL CHANGE JI NAOUNI PAID 20 OAWIC@DUE ?3 0858 YES (] il0 O $ 393 100 1 0 100 1 393: 00 LSIGNATUREOF PHYSICIANOR SUPPLIER R.IIAM.EANDADORESSOFFACILlT %'•,ERESERVICE5 W'EIE 0 INCLUDING DEGREES OR CREDENTIALS RENDERED (il emorMan game cr cr.,ce) 7. PIIY61CIAN TO. 6UPPI.EH 5 BILLINO NAME. ADOOCSS, ZIP CODE aI cernly Nat me sta!omen6 on mo towlse pp y 10 This bill also are made a Pan marwt.) APIIONE9 ROCHELLE CASSESI D.C. 0 U S, HANOVEII ST. CARUSLEIPA 17017 Tolephons (717 210.0055 MEDICARE)On SIGNED DATE CA116196 _ P NI PPnnarn nY.I.u rrt?rrn rn I IF Fir, I, rn•TrF;I PI F I cF nqN IT nn rYP r• I F,rPP IIF r A 1 Af.1 n+..,, PLEASE D e v=,TWA .123 DO NOT STAPLE IN THIS AREA -1'I-,PICA APPROVED ONE-0939 OX3 HEALTH INSURANCE CLAIM FORM PICA r 7n I j1, MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER ta.INSURED'SI.D.NUMBER (FOR PROGRA1AINITEM II I (L11T:•wId pfodcad r) (Spdnewf SSNJ (VA Fee I HEALTH PLAN ELK LUNG (ss4 Cr107 ISSN) (IDJ 29S00016-08009 '2.PATIENT'S NAk1E ILaa Namo. Fnsl Nar,.e.lliddl0lnAgp 7.P'AIENTS IRTYDATE SEX 4. INSUREDS NAIME(Last Name. Fort Name, lAlod!e Inaap j Sentz Nichole nQ 26 79 1'1 F- Ff>1 Sentz Alan E Pamela j 5. PATIENT'S ADDRESS (No., Sueeq 6. PATIENT RELATIONSHIP TO INSURED 7, II<SURED'S ADDRESS (IM. Sueaq 1 5 Strine Ave. S61 11 spease?cnJ:0 Onw? same ICITY STATE S. PATIENT STATUS CITY STATE Mt Holly Springs PA s:r,!eMamed? Oe? Q C I 'ZIP CODE TELEPHONE prc!0e Area Coca) ZIP CODE TELEPHONE IINCLUDE AREA CODE) 17065 (717) 986-5822 Em ow Faa.rre1--: PaO Time p' y ? ? O 5:adom L} 5mepm S. OTHER INSUnEDS NAAE (Lau Namu, Frst Namo. L6m:e lnmap 10.15 PATIENT'S CO::DITION RELATED TO: 11.114SURED'S POLICY GROUP OR FECA NUMBER D' Z I O [a. OTHER INSUREDS P OLICY OR GROUP NUI,16ER a. EIAPLOYMENT?(CURRENT OR PREVIOUS) a. INSUREDS DATE OF BIRTH SEX U.1 Q ?YES LL331-11+0 MIA I DD I YY M ? F ? Z O OTHER INSUREDS DATE OF BIRTH SEX VIA I DD I YY O. AUTO ACCIDENT? PLACE(Swo) e. EMPLOYERS NAME OR SCHOOL NAME p 1 -1 1 j IAF Fn 1i'YES ?NO LP?J Z Q APLOYERS NAME OR SCHOOL NAME C. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME _ 1 ?YES ONO Jul 1- :d INSURANCE PIJ.N NAME OR PROGRAM NAME I IW RESERVEDFORLOCAL USE J. IS THERE ANOTHER HEALTH BENEFIT PLAN? a ?YES ? NO B y.,,onOn b and comp:alenem 9 ad. READ BACK OF FORM BEFORE COIAPLEPNG b SIGNING THIS FORM. '12.PATlEr.TSORAUTHORIZEDPERSONSSIGNATUFi' la0m4:aeu•elo'easaelmy med•sa!c'cmer into:mas:nne:aszary 13. INSURE D'S OR AUTHORIZED PERSON'S SIGNATURE I*V:hon:e pAymont of moo,cal tenales eme undemi9ned pnys¢Ian w suppler lu 1 I0p'wBs In6CIYm.Ialso rMaest palment OL g3wernenl tene:Mse.Iner la mysta or one Can, wne accepis a:3,;n.men1 SON405 COXnD00 Wo,`. u1ow. SIGNED __,S,i'gnatur-e pILfile DATE _01/.14/9.8_ SIGNED .Si natu=e-on_fi1e.41/14!.9 114 DATE OF CURRENT: ILLNESS (First symptom) OR 1'If ppq, yy INJURY (ACCIoun00R j 12' L / `17 15.1E PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVEFIRSTDATE MIA 1 OD 1 YY 16. DATES PATIENT UNABLE TOWORK IN CURRENT OCCUPATICN MM 1 00 I YY MM I DO ' YY 9' : PREGNANCY( LIAP) FROM 1 I TO I I 117. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE I7a. ID. NUMBER OF REFERRING PHYSICIAN 16. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM , DO 1 YY MIA 1 DO 1 YY 1 FROM I I I I TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB7 S CHARGES E]YES ?NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2.7084 TO ITEM 24E BY LINE) 22. E CODE DICAID RESUBMISSION 1 1.1847 0 3. 81 39 .21 Y ORIGINAL RE F. NO. 1 2 839 9 7 27. PRIOR AUTHORIZATION NUMBER . L 1 . . 4. a3R.20 24. A B C 0 E f G H I J. K Z DATE(S) OF SERVICE Fr wn TO Pace of T or q PROCEDURES, SERVICES, OR SUPPLIES (E.ptYln Unusual Circumstances) DIAGNOSIS DAYS OR EPSD Family RESERVED FOR O H" u61 DO YY MM DD YY erv¢ rv,c e LPL'HCPCS ODIFIER lA CODE $CHARGES UNITS PMn EMG COB LOCAL USE Q i 1 7198 0 : '98941 + ' 1234 C 28 100 0 01 07 ;98 0 1 {: ?97250 17 1234 t I 1 LL 25 00 W O1 09 98 0 1 98941 1 g 1234 ' ! 26 100 $ i 01 ' 09 198 I 0 l ; 4 197250 1 : 1234 ; I ? 25 100 N 0 . 101: 12 198 0 1 98941 T, ; j z 1234 28 100 . 2 101 12196 1 1 0 1 97250 kk 1234 E:! 25 100 0 . 25.FEOERALTA%I.O.NUMBER SSN En( 2 5 -1723340 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? For go". cta:ms. Sao tack) 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE ?P1 0858 YES [] NO $ 159 100 $ 0 100 s 159 100 31. SIGNATURE OFPHYSICtANCNSUPPLIER INCLUDING DEGRE EG OR CRE DENTIALS 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED (1I dinar man home or cmce) 33.PHYSICIAN S. SUPPLIERS BILLING NAME, ADDRESS. ZIP CODE b (I cerbly mat the statemems on mo me erso f MUELIE CASSES D.C. apply 10 tins tMl and are mace a pan mo,epl.) , 713 S. HANOVER ST. CARLISLE, PA 17013 Telephone VI 249-0055 MEDICARE IO 7CA748496 . SIGNED "GATE PINS GRPI T 4nrrr„qn nY A m. rnunrn nN l.lrrarAl SFr:•Irr RRV PI FA CF PRINT n r? TYPF FOPMHCFAn500112-931 w PLEASE S DO NOT STAPLE IN THIS AREA APPROVED OII(l 0939 DODO rI A I I I ` URANCE CLAIM FORM C PICA - HEALTH INS OTHER IFOR PROGRAM rte 11B1A 11 HU1+ 10. Ia .INS , N!EOICARE L:EDICND CHAlAPUS LHAMPVA I HEALTH PLAN 13L. LUNG (SS1q 1101 2S9SO -O8O 00 0E O9 6 . ?IAN4cnaq?NAec?a'U 0) (Sponsor's SSA) IVA reaq (SSNO'10) DATE I D PAIIENT'SBIR SEA i.ItlO nt' 1amo. 1f.4a1a mdaq ( ImW 11 l2. PATIENTS NAME ILa51 tUm-, FILI Hama, LlieCl- 1 X ^ 3. ^ oA1 .1 20e ;7Y IA FX, y Sent2: Alan& Pamela 6 _ 1 1 b Sentz Nichole , 6. PATIENT RELATIONSHIP To INSURED 7.11 :SUREDS ADDRESS {NO.. Saem) S.PATIENT'S ADDRESS/NO., Sleep S.110 s,,,,,O OhcaD Ofill? same STATE 5 Strine Ave STATE B. PATIENT STATUS CITY CITY Holly Springs PA Sin;u? 1Aarn4? Olt,, 21P CODE TELEPHONE (INCLUDE AREA CODE) mt. ZIP CODE TELEPHONE (IntlOCa NOa CWo) 5822 486 ? Employ e0 Fun•Tlma SOnlimit ? SmDam t au t EA - 17065 (717) O. SPATIENT'SCONDITIONPEUTEO I 11.INSUREDSPOLICY GROUP OR FECA HUAI MJOIa heal) 9. OTHER INSURED S NAME (Last Ham- Fimt -- 1 IO.I CY OR GROUP NUMBER (CURRENT a. EMPLOYIMENI7(WRRENT DR PREVIOUS) 000 IBYYH 11? SE% F? a . IN5UREMIA DATE OF a. OTHER INSUREDS POLI YES c NO J i i ME PUCE (Slats) O. AUTO ACCIDENT? a. ELIPLOYEB'S NYJAE OR SCHOOL NA 0. OTHER INSURED S DATE OF BIRTII SEX YY DD IA YES ONO ti Ai I ? , M A {NSURANCE PLAN NAME OR PROGRAM NAME a E PO YER'SNAME CA SCHOOL NAI.I c. OTHER ACCIDENT? YES NO . NEFIT PLANa = RESEPS'ED FOR LOCAL USE tOC c. 15 THERE / MOTHER HEALTH BE -. •NSURANLE PUN NAME OR PROGRA!A NAME V . YES NO IfYU.ewm is anC mmyee rem9 a4. l READ BACK OF FORM BEFORE COMPLETING G SIGHING THIS FORM. one=al or e..ar lnlper..amnnecessOry GNI 13. IKSUREDSS OR AUTNOA ZED PERSON'S SIGNATURE 12010/126 0.hales M Ina unders -2-es pn, ys• pp!at 10, payment of medical I any ;12.FATIENTS OR AUTHORIZED PERSON'S SIGNATURE 111.1111:6 me 2ema Payment of9NATUR cl;pneAts a+.o-r to mysaa orto lna pant "n0 aaceps assgnmenl In's clan l also 144est PaY xess . l I'll's aese"D-a Ceb". 2/11/6 O p 0.1.. 98 >gnature on file 0 p I Signature on file 2/11/ DATE 0 l SIGNE OCCUPATION ENT TO WORK IN SIGNED ILLNESSIFastsymplom) OR TO MM OYY 15. IF PATIENT HAS HAD SAME OR SI!AURILLNE55. 16. DATES PAT 1. DO NABYY TO i DO I YY IA ti. DATE OF CU RRENT: G_9-n INJURY IACCb(n11GR IAjA2 LM PI CY L + I GIVE FIRST DATE M 1 I FROM I ! N DATES RELATED TO CURRENT SEflVIC • . ( PREGNAN UFLE REFERRING PHYSICIAN OR OTHER SO 1]a. I.D. NUMBER OF REFERRING PHYSICIAN Ie. TAHOSPITALIZATIO M 1 DD i YY MIA i DO I YY TO 17. NAME OF FROM 20. OUTSIDE LAB7 19. RESERVED FOR LOCAL USE CIYES E]NO ATURE OF ILLNESS ORINJURY. tREUTE ITEN151,2.]OR4T0 ITEM 24E BY LINE) R 22. IAEDICAITT RESUBMISSION ORIGINAL REF. NO. CODE N 21.0IAGNOSISO 1. (_847. 0 X1839 07 D.1839. 21 23. PRIOR AUTHORIUTION NUMBER .. 1839.20 K H J D E F DAY P D RESERVED FOR JR ES.SERVICES.ORSUPPLIES DIAGNOSIS OR Family Ell, COB LOCALUSE nces) CODE SCHARGES UNITS Plan :CSUnusui1A0 0 ER 4 01:19:98 0 1.) •J98941 . 47 1234 28100 I 97 250 ' ' 1234 25 00 01 19; 98 0 . ' 21 98 0 '398941 1234 28 00 01 0 :1'97250 1234 25 00 Oli 21;98 I . 1 98941 Ci 1234 ! 2800 1 i 01' 23:98 0 . I: 25100 01 23 98 1 1 0 : :TAX I NUMBER SSN EIN D 1197250 1234 7. 26. PATIENT'S ACCOUNT NO. 2 Fm EPTGim9,'W?E1A]ck) 2=TOTAL E E DUE 2 AMOUNT OPMD00 3f DA159 1 0 . . 25. FEDERAL 8 ,? , I[A YES ? N OO 159 f ' 25-1723340 ?[x 085 ERE SERVICES WERE T _ E AD ESS O FACILITY SIICI ?S.SUPPLIER'S BILLING NAME, ADDRESS. ZIP CODE 37. 6 HY 6 . NATURECFPHYSICIANORSUPPLIER 31 SIG INCLUDING DEGREES OR CREDENTIALS 2 .uAM W DR PHONE ROCHELLE CASSES, D.C. D tend, mat Inc SiaMments on Ine revers' to Nis bill am nine mle0 a pan lne+Ool.I ! appl 717 S. HANOVER ST. CARLISLE, PA 17017 y I Telephone O1 249-0055 E 10 (CA748496 C - MEDI AR PIN' GRPI i SIGNED - DATE FORIAHCFA•15DO 02901 n urrr,:::Fn nY nlv. rnuvn•1 HLR'Rlnaal SFn:nrFRPRI PI FASF PRINT nn 7YPF ? L ' _._. A it y,•,,,?, ,.. :. HEALTH INSURANCE C I APPROVED CMBM38 0M0 li PICA 7-17E-01 E ARMEDICAID CHAleVUb "" (MeWea:lQ (SFantor't SSIl) r'1 IVA Fill 1) r 11EAL7HPLAN BLKLUI:G X (SSNisi ISSM (1D) 00016-08009 295 Jdoln1wq , l i 0? 00 ) IAIWAllu l w < PATIENT'S BIRTH DATE ] EX .. ame, . ,t 1.l Namo . IItSOIi ED S 7.r711elmtm8 PAiIF.NT6 NALLE Mast Namu. F, . MIA DO I YY S 06? 26. 79 1A F(` Sentz PAmela & Alan entz Nichole S 6. PATIENT RELATIONSHIP TO ntSUR[O 7 .IN$UnED'S ADDRESS (No. S110-1) . PA ADDRESS INa.SVUeN S :ner0 x311 sv:ne0 Chili ame 5 Stride Ave. C STATE ITY STATE B. PATIENT STATUS CITY Att. Holly Springs P A Ty?r Sm;.eL1 Llanme11 O'er? TELEPHONE (INCLUDE AREA CODE) ZIP CODE TELEPHONE OWudo MOa CW-11 486-5822 717 Z s ParoTime EmpbyeC El FsulbTmceimpm s:nbem ? IPCDOE ( ? I ) 17065 ( IS PATIENTS CONDITION RELATED TO: 1 10 1. IN:SURED'S POLICY GROUP OR FECA NUMBER 9. OTHER INSURED S I:AIAE (Last Name. Fast Namu, M.bclo Initial) . a GROUP NUMBER OTHER INSUREDS POLICY OR a. E1dPLOYIIElrt7(CURRENi OR PnEV10USl TOO OF BIRTH SEX ? A. INSURED MIA D? YY hl? F 11 YES 1110 'CJ i I PLACE (State) AUTO ACCIDENT? b b. EMPLOYER'S NAME OH SCHOOL NAME o 07HER INSURED '5 DATE OF BIRTH SEX mm DO YY . EYES 111:0 LPA J I IAn F OTHER A0CDENT7 c c.tNSUFW:CEpL t;t; IAEORPROGRAAINAIAE Ic. EMPLOYERS NAVE OR SCHOOL NNAE . ?YES T$ali0 101 RESERVED FOR LOCAL USE cII THERE AI: OTHERHERLTH BENEFIT PLAII? a RSURANCE PW+NAIAE OR PROGRAIA NAIF_ 11yE5 ? NO MysA.ro:urn to on?w'nplo:ai:om9a4. READ BACK OF FORM BEFORE COMPLETING b SIGN114G THIS FORM. mwcal or niter tnbrmascnbececsory ase al an l 13 . INSURED'S OR AUTHORIZED P ERSON SIGNATURE Ialnanie pay. oni at mbSG?I benelds to Tito unamslonaepnysk+an or supplier br y e 12 PATIENT'SORAUTHORREDPERSOMSSIGNATURE la• .,:, mo re mmem WnaLs either to myself ono the parry was xsepts asPOnmpnt f Mini serves Eesrnbo0 wbw. 90io u Vaess m:sham. I also leanest payment o Lwow. file 0?/11/96 DATE sIGNESiianature on file 02L119 -'- Si nature on SIGNED . TION CUP ENT R R „_ OR 1E PATIENT HAS RAD AME OR Sill ILLNESS. 15 A OC AI A ENTTOUNABLE TO WORK IN CUI 16.OATESPAT Ia DATE OF CURRENT: ?ILLttE55 (Fpsl symptbml (Aimcenll OR INJURY 1 D . GIVE FIRST DATE mm , DO YY ' FROM I ' TO I r 12. 29 97 PREGNANCY(L)AP) S SRELATEOTOC HOSPI 1B A 128 T I+AME OF REFERRING PHYSICIAN OR OTHER SOURCE 17 17a. TO NUMBER OF REFERRING PHYSICIAN . MIA 001 YY YY OD D MIA , . FROM I TO 20. OUTSIDE LAO? SCHARGE$ 19. RESERVED FOR LOCAL USE 110 ?YES 11 OR INJURY. (gEV.TE ITEtAS 1,2.7 ORa TO ITEIA OIAGNOS16OR NATUREOFILLNESS 21EBYLII:E1-1 21 RESUBMISSION ORIGINAL REF. HO. 22. MEDICAID I . l 847.0 3. ''039 1 ? 23. PRIOR AUTHORIZATION NUMBER 9 2. 083a. a7 K. R 1 -' 2D E F G H I J K D C 2+. A 0 CE Place Type PROCEDURES, SERVICES, OR SUPPLIES DIAGNOSIS DAYS PSD RESERVED FOR On Famuy EMG COB LOCAL USE E OATEISI OF SERVI From To bl of (bplain plain Unusual Orcvmmancos) CODE fCMARGES UNITS Plan WA DD YY MM DD YY rv ervc. CPTMCPCS IAODIFIER I ?'h 0 98941 1234 28 00 01 ,26 9 - r : 01 i26 98 0 S 97250 1234 ( I 25 00 ; • ,j 01'28 98 98941 1234 ! 28: 00 3 .01 ;28 ;98 0 Ti ' 97250 1234 1 25, 00 • I 502 :02 '.98 0 I 98941 F, 1234 "• 30- 00 ' 25; 00 .98 0 j } 97250 : 1234 5 02 ;02 1ATIEOT'SACCOU14 110. 27. ACC NT ASSIGNMENTe N 26 E U I. TOTAL CHARGE 29. AMOUNT PAID 30.BALANCE DUE . I R SSN 75 FEDERAL TAXI D.NUM l I'll sue wc IY6s rJ NO 14 $ 161 00 f 0 00 s 161 00 25-1723340 11[x] 0858 AMEAND ADDRESS OF FACILITY WhERE 5ERVICES YIEHE 2 APIS,SUPPLIEn'SBILLIFJGNAPAE.AODRE5G. 21P CODE I 77. 1 .N 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 3 INCLUDING DEGREES OH CREDENTIALS RENDERED pl omor Lean soma or o"KOl I NON 8 ROCHELLE CASSES, O.C. (I tend, mm the sutemenls on tyro nrerw 313 S. HANOVER ST. apply to In:s bit am are mad, a pan lnbrwl! CARLISLE, PA 17013 Telephone (71T124WSS MEDICARE IO CA7484% PR+e GRP. 4G!:EO DATE rnnr.I HCFA 1500 112-01 P^rd.:'TnnYHPrrin;rll r'11rFNr,I'rn"IrFAFM PI FA CF PRIJJT FIN TYPF 0111®A?I?A PLEASE 00 NOT STAPLE IN THIS AREA APPROVED CMD 09]i00p8 HEALTH INSURANCE CLAIM FORM Rm. r=1 It MEDICARE MEDICAID CHAMPUS CNAMPYA GROUP • FECA OTHE IIF.ALN PLAN BLK LUNG R fa,U:SUREDBI.D.NUMBEn (FOR PROGRAM INITELI I) yAmmeLUe) pfaaKaaq Ispansw's s5N1 PA F?aq (ssl/mm) (ssrq X !mI 29S00016-08009 Z.PA7]ENiSNA1•IE ILasINam., Frst Namm LhlTa ln.baq 3 PATIENTS BIRb10ATE , , OD , YY SEX YINSUREO'SNFIf.E Wi111ame, Fnsi Nama. I,4dE:0 Iwal I ) Sentz Nichole b 06 26 7911n F41 Sentz Alan b Pamela 5 PATIENT'S ADDRESS 1140. Street) 6.PATIEtITAEIATIORSM:PTOIa$UAED 7. INSUREDS ADDRESS IND. Smell 5 Strine Ave Sa,I? sp.a.? Cnn,SL] Omo,? same CITY STATE e. PATIENT STATUS CITY STATE tdt. Noll S rin s PA 51npl8Ex3 1.!uoW? omm? ZIP CODE 1 TELCPHONE JIWad. Ama CW.) ZIP CODE TELEPHONE ONCLUDE AREA CODE) 17065 (711 486-5822 Lma Empl.VW Fa .Tima?7 R ? 61.danl p? I aEUnt ? 901 HER IfISUFLO S NAME ILA,( Mara. FISI Name. Maoo maaaf) 10. IS PATIEN I S CO.•:M OIIREDTD: TE 11.INSURE D'S POLICY GROUP OR FECA NUMBER a OTH ER INSUR ED'S PO IC OR G . L Y ROUP NUM.BE A a. E MPLOYM E NT?(CURREN T OR PREVIOUS) A. INSURED 'S DATE OF O WITH ?YES ?NO SEX MIA 1 OD , YY A? F ? aATMER B:SUPED'S DATE CF BIRT H )AM 00 YY SEX , .AUTO ACCIDENT? PLACE (State) B, EMPLOYER S NAME UK SCHOOL NAME IAn F 11YES ?NO L-P Aj C. EMPLOYERS NAME OR SCHOOL NAME C. OTHER ACCIDEM? C INSURANCE PLAN NAUAE OR PROGRAM NAME ?YES R]N0 I 1 aINSURANCE PLA!?NAIVE On r"It 1%. RESERVED FOR LOCAL USE ?YES ? NO H yes, Ialarn to and comyos nom 9 ad. f BEAD BACK OF FORM BEFORE COMPLETING a SIGHING THI6FORM• 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE lug>n:e ma r,Ieaa o: any nW.;ilucmnn:darr R :n re:essa 1 3.IN5URE05 OR AUTHORIZED PERSONS SIGNATURE I ac1M.n:e .. . ry laprocasslMCIam I aHOUgRst payment e!poaemmem*enems nNart(I n"O of 101:1, pale .)A ax&p:s a:sgnmasl pap-lens of mea<sl aenaLS la lne unamstpneo pnysaanm:.pp:.arlm Wit., .enICOS Ees<ntrea eebw. SIGNED. Signature on file DATE 02/11/98 SIGNED Signature on file 02/11 j4. 14 DATE OF CURRENT: ILLNESS A""symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 1MEL .2L7p ,gfy 'INJURY (A= n1 Oq GIVE FIRST DATE MM r OD r YY 16. DATES PATIENT UNABLE TO%YORK ifI CURRENT OCCUPATION A PREGNANCY(LMP) ! ! MM r DD r YY MM r OD r YY FROM TO 17, NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBEROFREFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM I DO , YY MM , DO , YY FROM ! I , I TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LA B? $CHARGES ? YES ?NO 21, DIAGNOSIS OR NATURE OF ILLNESS ORINJURY. (gELATE ITEMS 1.2.70Ra TO ITEM 2aE BY LIRE) _ 22. MEDICAID RESUBMISSION ? 184•] 0 1 CODE ORIGINAL REF. NO. 3.1839.3.1 23. PRIOR AUTHORIZATION NUMBER z. LB39. 7 a. 1 R 1 Q 2 . A A B C F, WEIS)OF SERVICETO Plats Type D PROCEDURES. SERVICES, OR SUPPLIES E OIAGIIOSIS F G DAYS H P50 I J K MM DD YY MIA DO YY of .n 1 of Sam (EapMm Unasoal Orcvmstances) CPTMCPCS CODE f CHARGER OR Famil e EMG COB RESERVED FOR LOCAL USE MODIFIER UNITS PM 1 02:04:98 0 ^98941 1234 +. ! 30,00 2 02;04;98 0 . ti97250 = 1234 ( 25 00 3 02. 06 98 0 1 '98941 1 x' 1234 F 30100 02106!96 0 97250 61234 11 ' 25,00 02 0 98 0 99215 25 1234 02109;98 90;00 5 0 ?98941 1234 30100 02 09 98 0 :97250 ,1234 c 25;00 L 0209 98 1 0 =95999 SEMG 1234 15000 a 25 FEDERALTA%I. D. NUMEER SSH EIN 26. PATIENT'S ACCOUNT 140. 27. ACCEPT ASSIGN LIE NT7 2 ? For 000.tlsms. sae Lich) 2 5 -172334 0 8. TOTAL CHARGE 29. AMOUNTPAID 30. BALANCE DUE , , ? 0858 0 YES rj No 3 S G s 40 0 s 0 00 s 405 :00 I 1. UATUREOFPHYSICIANORSUPPLIER 32.1:AIAEAr:DAUURESSOFFACD.ITYYMERESEAVICESV/ERE 3 INCLUDING DEGREES OR CREDENTIALS RENDERED pi omur roan NOmenalKel 3.PHYSICIAN 'S,SUPPLIERS BILLING NAME, ADDRESS, ZIP CODE LP O U cen,y wl me statements on ln...verso NE A H 2PPI1 Ia m1s CAI AM are made a pan ma.ecl.) ROCHELLE CASSES D.C. r 013 S. HANOVER ST. CARLISLE,PA 17013 Telephone (7M 249-0055 MEDICA E / SIGNED DATE R ID CA748/96 IAFFnOVr0 BY AMA CONmOt CN rNCAI SPRVtCE R eEl PLFA3F PRINT OR TYPF FOnIAHCFAn50D 111501 PLEASE ) ~ ?9'° M 00 NOT STAPLE IN THIS AREA I-j- ( -:PICA APPROVED OM.D 0938.0009 HEALTH INSURANCE CLAIM FORM PICA L MEDICARE MEDICAID CHAMPUS ' CHAMPVA r Ft u?wr ??.. ..., _ HEALTH PLAN ELK LUNG N Cr f01 ISSfa ODl (SS .......__..___.._..._ „ 2950001608009 n s SS:YI (VA ?(A4a?cyro rJ IEtra.:od rJ ISpOnsw . J . lAbd:u 1o440 t N me Fast Name ' ME 2. PATIENT'SNA!AEIWst N3MU7I MNama,lmadiA lnroal) 7. PAA ENT DSp 1RTY O TE SE% (Los a . . a. INSURED S NA 05 26 79 1.1 F0 Sentz Alan Pamela Sentz Nichole ' 5. PATIENT'S ADDRESS IN-. SUNS) 6. PATIENT RELATIONSHIP TOWSURED S ADDRESS (NO. SOVeO j 7. INSURED San? saousa?ctulcxr7 Dmar? same 5 Strine Ave. STATE CITY STATE B. PATIENT STATUS f CITY I PA smw-gl Manad? Uner? Mt Holly Springs TELEPHONE (INCLUDE AR EA LODE) ZIP CODE TELEPHONE B1},do Aura OWN ZIP CODE 17065 (71? 486-5822 Employed Fult l'm0 S. ime ? studam:? PAR T1 ? ( ) 90THER0+SUBEDS NAME (Last Nama. Foss Name. Mipdro m?uaq 19. r5 PATIENT6 CONDITION RELATEDTO: 11.II:SURED'S POLICY GROUP OR FECA NUTABEfl a. OTH E R INSUREDS POLICY DR GROUP 14UPABEFI a. E1APLOYMENT?(CURRENT OR P REVIOUS) a. INSURED'A DATEEDOF' BY1TH SEX ?YES GRID I I IA? r ? , I D, OTHER INSURED 'S DATE OF BIRTH SEX B AUTO ACCIDENT? PLACE (Slate) 0. EMPLOYER'S NALIE OR SCHOOL NAME ?AM DD YY I M F ^ YES ?NO L12AJ ' 1 I ROGRAM NAME C. EMPLOYER'SNAIAE OR SCHOOL NAME e.OTHER ACCIDENT? C. INSURANCE PLAN NAME OR P YES:O 2 d INSURANCE PLAN NAME OR PROGRAM NAME FORLOCALUSE IDd. RESSR d. IS THERE ANOTHER HEALTH BENEFIT PLR:? I ?YES ? NO It Y.S. velum to and OOmPletna:em 9 24- READ BACK OF FORM BEFORE COMPLETING S SIGN 1140 THIS FORM. 13. INSURED 'S OR AUTHORIZED PERSONS SIGNATURE I au.holae 12 PATIENT'S OR AUTHORIZED PERS014 S SIGNATURE Iau:ocn:e tnele'ease of any medial a caner lnlcrmanan rmcetsay payment d rned,cat oanatls to tno urgers:^,no] pnyskan or suppsef for toplate$$thscla..I also'K7esf payment or pavernmonab6neLls enter 10 mystA or to the party Ww a=ea:s assujnmenl sorvbes a95Umod eebr/. helan, SIGNED-S3. nature cln f1-1_P DATE -0.3/0-4/-9-8- SIGNED 519nature On file 03/04_, ,,.DATE OFOURRENT: ILLNESSIFuslsymplom)OR 15.1E PA TI ENT HAS HAD SAME OR SIMILAR ILLNESS. DD YY 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION DO I YY MIA r DO ` YY MIA IAN ?+Q Y,y INJURY IACCbaOB OR LMPI PREGNANLY 2 '9 2 I GIVE FIRST GATE IAA I I FROM TO ( ! ( / 1 14AIAE OF REFERRING PHYSICIAN OR OTHER SOURCE t7a. I.O.NUMB'aR OF REFERRING PHYSICIAN 17 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES DD YY YY MIA N M DD . , A , I FROM I I TO 1 r 19. RESERVED FOR LOCAL USE 20. OUTSIDE LA B? $CHARGES DYES ?NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1.2.3 On 4 TO ITEM 24E BY LINE) -? 22. M EDICAID RESUBMISSION ORIGINAL REF. NO. CODE I 21 34 E iI R47•0 . L . 7. 23, PRIOR AUTHORIZATION NUMBER 0 7 8 3 9 20 4. LB 32 2. L- - - - 24. A ATEIS) OF SERVICET o B Placa C Typo - . D PROCEDURES, SERVICES. OR SUPPLIES O ' E DIAGNOSIS F G (ppS H FoR-PS rney I EMG J LOB K ' RESERVED FOR LOCALUSE a Fr m IAA DD YY NAM DO YY 01 Sarv of Servi a eel (EsDWm fCY111eL'A CPTi(HCPCSUnusualMODIFIER CODE SCHARGES UNITS Plan 02, 11!9 98941 1234 f 30:00 ' 9 tt : 1 : 02; 11 f 98 : 0 9725 1 1234 1 00 : 25 2 I a ? p i 2' 16!98 0 ? ' 98941 1234 ! ! 3000 ' 3 02'.16;98 ( + 9725CI 1234 k 25100 1 3 •1 ( 30: 00 02: 18! 98 0 9894 1234 • 02: 18; 98 : 0 I 97250 123" • L 25 00 6 25 FEDERAL TAX I. D. 14UTABER SSN EIN 26.PATIENT'SA000UNTNO. 27. ACCEPT A55IGNIAEN17 IF" goo. dams, see WO) 1 28.TOTALCMARGE 29. AMOUNT PAID 70. BALANCE DUE 25-1723340 ? I 0858 ?x YES n NO S 165:00 s 165100 s 0: 00 31. SIGNATURE OF PHYSICIAN OR SUPPUE R 32. NAME AND ADORE SS OF FACILITY WHERE SE RVICES WERE 33.PHYSICIAN 'S• SUPPLIERS BILLING NAME, ADDRESS, ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDERED (11 other than nom. cr oche) aPHONE A ROCHELLE CASSES, D.C. 11 tunny that the statements an me remrso apply to 1Ns Is It AM are made a ptn 11101001.) 313 S. HANOVER ST. CARLISLE, PA 17013 Telephone (I1 249-0055 M EOICARE ID ICA748496 SIGNED DATE Pt1Ir GRPr FOR 1APPROvrnnY AJAACOIJ4f.11 GNVEDICAL SFRVICF RESI Pf FASr PRINTnR TYFORM HCFA•1500112 YJ) PLEASE DO NOT STAPLE IN THIS AREA APPROVED 0410.0938 OOOB I I 111.^ nCA1L in IIVJUH/i1V l:C I:LAIIVI rUHM PICA FFn J 1. I:.EDICARE MEDICAID CHAIAPUS CHAMPVA GROUP FECA OTHE HEALTH PLAN BLK LUNG R I.I.MSURED'SLD.NUMBER (FOR PROGRAM IN ITEM 11 IAIW.t:11e r) (41WCael rl ($pensa'S IS?!/ (IA fLUr ) (SSNOl1D1 Iss:l1 I'D) 29S00016-08009 2 PATIENiSNN/E LLaM Name, Fr.I Namo, IA0."re Intel) i h 3. PATIENT'S BIRTH DATE SEA AO D? Yy - C.INSURED'S NAME Last Name, Fuss Name. MwSO Ina,al ) Sentz N c ole d 6 79 4L I 1 Ff:i Sentz Alan b. Pamela S. PATIENT'S ADDRESS (NO. Slow) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED 'S ADDRESS (No.. Street; 5 Strine Ave Sal El Spo+®0ch'ICQ Ome1? same CITY STATE B. PATIENT SI ATUS CITY STATE _ Ht Holly Springs PA Sm21a?Z] Matrons Othu([] C 21P CODE TELEPMGNE(IMJede NOa COdo) ZIP CODE TELEPHONE (INCLUDE AREA CODE) a ? 17065 (717) 486-5822 Employed Fad-Ti o Pnsme SNdaht Son' n 0 9. OTHER INSUREDS DAME (Last llama, Fusl Nama, Md9u lnmap 10.ISPATIENTSCONOITIOARELATEDTO: 11. INSUREDS POLICY GROUP OR FECANUMBER a z a a. OTHER INSURED 'S POLICY OR GROUP NUMBER a. EMPLOYMENT7(CURRENT OR PREVIOUS) a. INSUREO'S DATE OF BIRTH SEX C I'Ll YES tJ Sr11W I I MIA I DD I M[- F N OTHER INS RED 'S D z O. U ATE OF BIRTH SEX MIA I DD YY D. AUTO ACCIDENT? PLACE(S:ato) O. EM PLOY ER '5 NAME OR SCHOOL NAME C I I I M Fn `{ YES ONO PA a C. EMPLOYERS tAME OR SCHOOL NAME C. OTHER ACCIDENT? C. INSURANCE PLAN NAME OR PROGRAM NAME YES 40 W 0. INSURANCE PLAN NAME OR PROGRAM NMlE 'ad RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? a I YES [3 NO Nyo,(a?um la a'Id aomplel9 nom Bad. HEAD BACK OF FORM BEFORE COMPLE71HO&SIGNING THIS FORM. 112 PATIENTSCRAUTHORMEDPERSOYSSIGIIATURE IaLtmrre the release of any maY:.Y Or c:nenebrmawnru:e::a. 7 13.I::SUR ED'S OR AUTHORIZED PERSON'S SIGNATURE I au:npn:a f l NA ..- j 10P`O::1%A wm.I a'w ( w+est payment of government oonetts eunano myself pr to me part' w:a accepts a5s,;nmonl payment o p mW CJI DOnobis to the unaws; ned physican or su py servcas descnxd Desow oebw. . 1 SIGNED Signature on file DATE 03/04/98 Signatureon file 03/09/98 I Yi Ic DATEOFCURRENT: ILWESS(FrtUsymPlom)OR 112' 2T :91 INJURY(Accwant) OR L 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MIA OD ( YY $,GrJED 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD PREGNANCYLMP) I I I I I YY I FROM I I TO I I 1 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.0. NUMBER OPREFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM I DD I YY MM I 00 I YY iii FROM I I I I TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES 11YES EINO 2t. D1A G NO 515 0 R NATURE OFILLNESS OR INJURY.(FELATE ITEMS 1.2.3 OR 4 TO ITEM 24'c BY LINE) AID RESUBMISSION D u' p ? ?s l 1 I L$aL7 0 $34 COD E ORIGINAL REF. NO. . ... 3. L .21 23. PRIOR AUTHORIZATION NUMBER 2. 4. [839. 20 2a. A FIOm TE(S) OF SERVICE To B Pwce at C Typer of D PROCEDURES. SERVICES, OR MSUPPLIES UOYSY Os) E DIAGNOSIS F G GAYS OR H EPD F J I J K RESERVED FOR Z Di. 4VA DO YY IAA DD YY rveO 0, a IAODIER CPTMCPCS CODE SCHARGES UNITS am y Plan EMG COB LOCAL USE Q 021 20;98 1 0 1 :98941 T 1234 a . 30 100 0 . 02! 20 198 0 1 197250 ` 1234 ; 25 100 A o s. r W 02! 23;98 ; 0 ( '498941 234 f 30;00 02; 23;98 0 797250 r 1234 F 251 00 O 0 n' ` 02 27 98 02' ; 0 ; ,;98941 ':. . 1234 . 30100 5 y 27 98 0 1 197250 : 1234 25100 U 03 02 96 0 ^98941 ;11234 30;00 03102;98 i'97250 1 11234 M 25100 a l $FEDERAL I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNM ENT 7 For Don. claims A. Dark) 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE , 25-1723340 ?[ 0858 YES n NO s 220 100 S 0100 s 220 0 31. SIGNATUREOFPHYSICIANCR SUPPLIER 32.14AME AND ADDRESS OF FACILITY WHERE SERVICES WERE 3 INCLUDrtIGOEGREESORCREOEIrtIALS RENDERED (11 ether than home or cn.co) ]. PHYSICIA?J'S,SUPPLIER'S BILLING NAME, ADDRESS, 21P CODE SPHO PHO 0 cendy mat me swtaments on Inamr*,Mr apply to this D.II and ate made a pan thereat.) NEa NE LLE LE CA CASSESI D.C. 1 ' 313 S. HANOVER ST. i CARUSLE,PA 17013 _ Telephone R1 249-0055 MEDICARE ID ICA74840 SIGNED GATE P IN: I ORPI 'T • Iannrn:•FnRY1.r.1< rr.IIRfh r.NMrnIr4 Frn•nrr R SAt PI FAcF PFNNT.117 TVPF FORM HCFA-1500 112.501 t ru ?', - A PLEASE DO 140T STAPLE IN THIS AREA APPROVED OM9 VIM DXB t4F=Al TH INSURANCE CLAIM FORM PICA t I FTFI l ,EoiCARE MEDICAID CHAMPUS 1 DT11LR CHAMPVA G NG E K O Ia. II:SUREO'S LO.NUTAOLR (fOR PROGRAM IN ITEL11) . I. ITH PIAN L LU EA (A"n' arpq IAtpd.cadq (S,2-nirY 551!) (VA Ate 1) :I pr ID) (SSIr) ?(10) 29S00016-08009 LPATIENT'SNAG!E IIaA Namo, firs)Namo, LLpalp ma gl) OSpl OATS SEX 4. INSUREDS NAIAE (lain)NamaName, IJ:oelp lml.aq Sentz Nichole 26 79''1 n F? Sentz Alan & Pamelg 5PATIENTS ADDRESS(No. Street) FELATIONSHIP TO INSURED 7. INSURED S ADDRESS INO., Street) 5 Strine Ave. SX.SeOcn.l:[} 0.nel? same CITY STATE B. PATIENT STATUS CITY STATE Mt Holl S rin s PA S,,1,Q LmNea? Oaaf? j EPHONE (INCLUDE RREA LOGE) E ZIP CODE TELEPHONE(Incluop Aea Coo-) L 21P CODE , 17065 (717) 486 -5822 Emp:oyud Fu:4Tmo?'-?I Part•Lmo ? s:aaan1 Sluon, ? ( , 9. OTHER mSUREDSNAME1tasl Name, Fnsl Name- IA?pp:n lnNaq 90. IS PATIENTS CONDITION RELATED TO: It. INSURED SPOLICY GROUP OR FECA NUTABER Q OTHER INSURED 'S POLICY OR GROUP NUMBER a a. EMPLOYMENT7(CURRENT On PREVIOUS) a. INSURED 'S DATE OF BIRTH SEX YY MIA DD i . C] YES QN0 i i M[j F ? a. OTHER INSUREDS DATE OF BIRTH SEX o. AUTO ACCIDENT? PLACE ESU10 e. EMPLOYER'S NAIAE OR SCHOOL NAME 'I IAM DD : YY I M F ^ X'?YES ?N0 LA/'U i OR PROGRAM NAME c EMPLOYER'S ?;AVE OR SCHOOL NAME C. OTHER ACCIDENT? c. INSURANCE PLAN NAME I El YES ?NO aIN.SURANCE PLAN NAME OR PROGRAM NAME 1M. RESERVED FOR LOCAL USE O. IS THERE ANOTHER HEALTH BENEFIT PLANT El YES E] NO H yea.lesumuaM COmpes pent 9 as i READ BACK O F FORM B EFO RE COMPLETIN08 SIGNING THIS FORM. ma}on nacrosar r ini l m 17. IN* SUAE0 S OR AUTH0R12 ED PERSOr-SSIGNATUflE1a hiahZe nt el meoul CerwLts to the umers;nes physician Or supper lot m f or c e L PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I aumaae lhaleleas. of any meJ4a 12 pay e . to process lns clean.) also m4uest payment el government oenelt5 erner to mycen or to me parry no accepm asupnmem Servbm pascnoca aglow, oelon•. SIGNED Rignature on fi r? DATE -0-4/-O1h.8 SIGNES-i Ildt?T -e on fl1P 0.4 ]...9 DATE OF CURRENT: ILLNESS (First symptom) OR 15. W PATIENT HAS HAD SAME OR SIMILAR ILLNESS 14 DD YY . 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION DO I YY MIA DO i YY MM . T L pp0, yy INJURY EAccooenl) OR LMP i PR GNANCY I GIVEFIRSTOATE MIA I TO i i FROM ) E I NAME OF REFERRING PHYSICIAN OROTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 17 10. HOSPITALIZATION DATES RELATED TOCURRENT SERVICES YY MM I DO I YY OD MIA . I I I TO I I FROM I 19.RESERVEDFORLOCALUSE To OUTSIDE LAB? $ CHARGES E]YES C] NO 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEIM51,2,70R4T0ITE1A 24S BY LII:E)-? 22. CODDE AID RESUBMISSION ORIGINAL REF. NO. 847 0 839 21 Y 1 % D' L-'- ORIZATION NUMBER R T , . -- AU H 23. PRIO 07 839 81 39 20 A . 2. ) 24. A DATE(S) OF SERVICET 8 Puce C Top . . D PROCEDURES. SERVICES. OR SUPPLIES, E DIAGNOSIS F G DAY 0R H PSO Family I EMG J COO K RESERVEDFOR LOCAL USE O From MIA OD YY MIA 00 YY al - of . a Explain Unusual Oltvm:uneas) CPTMCPCS ,MODIFIER LODE S CHARGES UNITS Plan 03 06 :98 I 01 ''• ll S 98941 r ' 1234 F 30 00 03 :06 ;98 0 1 4 97250 1239 f i 25 00 2 03:09 :98 0 , q 98941 : 1234 301 00 2 r l 03;09 98 0 : ! , 97250 C 1234 25. 00 4 03 :13 :98 0 l y5 3 98941 1234 I 30: 00 5 4. 03:18 X98 0 98991 !? 1234 301 00 L 25 FEDERAL TAX I D. NUMBER SS14 SIN 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? on a) U 211 TOTAL CRARGE 29. AMOUNT PAID 30. BALANCE DUE 25-1723340 ?® I 0 NO 0858 RYES 9 170 001$ 0 !00 5 170 b0 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 72. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE GB. PHYSICIAfS,SUPPLIER'S BILLING NAME.; IESS. ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDERED (it omerthin home of olpce) yp?Q{'j LE GASSES O C ES 11 lenity that %no Stalefna1115 en me NIVORW , , . . HAHOYER 717 S ST. apply to win bill and we made apan lnplppL) . CARLISLE, PA 170 13 Telephone (71 249-0055 MEDICAREID CA748496 SIGNED DATE Pill. I GRP# ru:ea nw• o.... n• +?? UPPRDVEDRV h!AAf.OIINCII O:l IAFDICAI SFFVCF flE°I PI EASE PR(NTlTR TYPE PLEASE! b'J DO NOT STAPLE IN THIS AREA APPROVED 04I0A9M 0i HEALTH INSURANCE CLAIM FORM PICA rm 1. IABDICARE MEDICAID CHAMPUS CHAMPVA GROUP - -FECA 0711EF HEAL LI PLAN ELK LUNG la. R:SURED'SI.RNULUCR (FORPROGRAIAII(ITEh1p (A4a•avsq pAla.?v q Ispunsa'sssrJ) 14,Al ii (ssrJOr+O) Jssrv) 11D7 29500016-08009 2. PA 71ENT S NAME In. Name, F?si f:amo, IAg9w initial) Sentz Ni h l 3. PARENTS BIR711 DATE IA•1 D Yy SEX b ? a.lflSURED'SNAME La ItJamo, Fitt Nama, 1,!g90 In.UaI 1•% ) c o e f ? 79 IA F F Sentz Alan S Pamela 5. PATIENTS.,DCRESS IRO, SOnoU 6. PATIENT RELATIONSHIP TO INSURED 7, INSUREO'S ADORE SS(No, Seem) 5 Strine Ave. SucE] Speuse?ChiijDc CH.,0 same CITY STALE &PATIENT STATUS CITY STATE My Holly Springs PA Single Mmued Dane, ZIP CODE 1 TELEPHONE thi Area Cole) ZIP CODE TELEPHONE (INCLUDE All EA CODE) 17065 V17)486-5822 Employed Q F=9Y1 p,n•THQ lJ Stu:unt LI SluOnnl 0 1 I 90THE00:SMEDS NA61E 11a:t?Jame, Fwst Nama, 1Ai mean 10. IS PATIEN T'S CONDI 1 ION HELATED TO. (,.INSUREDS POLICY GROUP OR FECA NUTABER , I OTHER INSUREDS POLICY OR GRO 4 P N TAOER , U U a.El.%PLOYIAENT7ICURREIIT OR PREVIOUS) a. INSURED S DATE OF BIRTH I wES 93I:D SEX Ii I ' DD I ' YY M F i b CTHER 114SURED'S DATE OF B RT E:J 0 . I H SEX MIA DO YY , N. AUTO ACCIDENT? PLACE (Stan) b. EIAPLOYER 5 NAME OR SCHOOL NAME T•-? 1 1 I IA F I I E YES 0tJO PA, C EMPLOYER 5 NAIVE OR SCHOO N'AIAE , L C. OTHER ACCIDENT? C. INSURANCE PLAN NAIVE OR PROGRAM NAME F YES ?NO u O. INSURANCE PLA!+NRIIE OR PROGRAM NAME lOa.RESERVED FOR LOCAL USE C. IS THE RE ANOTHER HEALTH BENEFIT PLAN? I READ BACK OF FORM BEFORE COMPLETI110 A SIGNING THIS FORM YES NO H yea, locum to an0 compete rem 91 9 C . 12 PA71EIt T'SOR AUTHORIZED PERS014 S SIGNATURE l a,;non:e lrw re:ease of any mental w o'lnnnla•mab:n once;say 13. 1 FIED'S OR AUTHORIZED PERSONS SIGNATURE I sumo me a f 10 Protest, 00 f4wn.1 ab0rnQue51 payment of povemin.re whis Owner to mysall or 1, the W'ly who...p i, as?Jhim p yment o mndW wne!ns to me uneol:gnN pnyaKSan or wpy?a, I0r ONO., sOrvKes Co5COMG below. SIGNED Signature on file oATE04 O1 98 SIGNEISianatuire on fi a 04 /01 ,IAnOaAT E OF CURRENT: ILLNESSIFlISICynni OR 1S. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. R GIVE FIRST DATE MIA DD Yy llLl ? 9 I - . 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION i ; PREGNANCYILIAP? FROM MM i DD I YY LAM 1 OD I Yy TO I 1 17. NAME OF DEFERRING PHYSICIAN OR OTHERSOURCE 17a.1.0.NUMBER OFREFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENTSERVICES MM ' OD , YY TO MM , DO I , YY FROM I 19. RESERVED FOR LOCAL USE 2D. OUTSIDE LAST SCHARGES E)YES ONO 21. DI : 9 01 NATURE Of IL1 1::i! OR INJURY. (RELATE ITEMS 1,2,30Ra TO IT EM 24E BY LINE) -- 22. CAID RESUBIARSION 847 ? 0 897 83921 T ?OOE ORIGINAL REF. NO. 39 Q7 ? 234 PRIOR AUTHORIZATION NUMBER z. _ a. 1839 20 2a A B C D F,oD,nATEISI OF SERVICETO TO PIACe Typo PROCEDURES, SERVICES, OR SUPPLIES E F G DAYS H PSD I J K !AN DD YY MM Yy of Sew, of (E.plaln Unusum C rcumHancesl ke CPTrHCPCS MODIFIER DIAGNOSIS CODE $ CHARGES OR UNITS Famil y Ton EMG COB RESERVED FOR LOCALUSE 03;20;98 0 98941 i' 123 1 4 30 00 03; 23 :98 ! U !!.98941 P. 1234 30 00 03; 30 ;98 0 I198941 ( •" 1234 pI 30 00 03; 30 ;98 0 1-"99213 251 1234 €.; 38 00 03;30 ;98 1 0 95999 SRMG 1234 1 150 ;00 1 I' FS. FEDERAL TAX I.O.NUMBER SSN EIN 2G. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 2 25-1723340 0858 For OOH. Calms, sou WC) 8.70TAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE YES M No 31 SIG s 278 00 $ 0 .00 s 278; OQ . NATUREOFPIIYSICIANOR SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICESWERE 3 INCLUDING DEGREES OR CREDENTIALS RENDERED pt other than home or oe,cc) 3.PHYSICIAN 'S,SUPPLIERS BILLING NAME, ADDRESS, ZIP CODE P Cemly Ina] the statements on me mrmso P pNE A ? apply 10 m6 bit am ate mace a Nan mewl.) R CHELLE CASSES, D,C. 313 S. HANOVER ST. CARLISLE, PA 17017 _ S G E Telephone(71?•J 249-OOSS - MEDICARE ID WA7A8496 I N D CATS P INe I non. IeMnrn/FDRY aHSffi11N(•Il D!r VFMr'r•I CFfi'nf.F PPP,( PI F-ISFPRINTi TYPE FDRIA HCFA•1500112.901 - - of ; llaltiJ:.!'.'i '. r + ?ss.I yG/1.11 APPROVED CMD 0536 0:08 -, PLEASE DO NOT Prudential Ins. STAPLE 520 B roadhollow Rd. INTHIS (/ ? ?{y?Fr?y?7a Melvi lle, NY 11747 , AREA Iv.LSL1 waa ME HEALTH INS URANCE CLAIM FORM PICA ? ITGR PROGRAIA IN IIEIA II '-'-J-PtCA S ID OCMO 09 GROUP RCA OTHER ra U:SURFO 8 ?I I MEDICARE MEDICAID O11A1.IPUS CHAMPV A HEALTHPLAR ULKLU14GV f5sn) J• UD/ D 0 6-0 0 1 v9S00 J IMrc.rlluq pAeccud q ISNnsar'A SS.V7 IVAA I IS5!ld I IENTD:RTH.ATE T A P ] < c:SGREG S NAME µasl Name Fnsl Name, A!.o0v moaq ll PATIENTS NAVE (1.2't Name. Fnsl Namo, 1,40d'a lnlap hole N ee [ n . S[ %F r V 2-) 6 g ?7 V Sentz, Pam j ic entz, j Saem) ' SPATIENTRELATIONSHIP TO INSURED 7 IUSUREDS ADDRESS Uia., S11-01) Trine Ave. 5 J S ADDRESS Mo. patlE rlT Trine Ave. X Oa 5,11 Spoosa? CnJaD ?n? T TE lS STATE 9.PATIENTSTATUS CITY Holly Springs Mt A S PA E Jc. Holl Springs y PA S•n9(vU IAmmd Olnel . L -I ffEEL-E -PHONNE(IY.CLUCE AR EACODE) b ??Ob T EPHONE (I / 17 486-58 ' (22 Empa,ea? FI;A•T,ma PartTuco? unt Sl ZIPCOOE I 17065 I I ` ) L ; u SWdam IS PATIENT 51-,, 0IO4 RELATED TO: 10 11, u4SURED'S POLICY GROUP OR'"I" NUMBER OTHER rttSUREDS NUAE a>I Nama Fnl Namo. IA.Od1. lmalIf T . C entz, Nicho c a. OTHER INSURED S POLICY OR GROUP NUmSER a. EMFLOYI.IENT?(CURRENT OR PREVIOUSI YES nNO a wSUFE 510Af^?E?F DIr,R II? SE% F El L El I AUTO ACCIDENT? PLACE (51.1161 O 0. EMPLOYER'S NAIAE OR SCHOOL NAIAE o.OTHER INSUREDS DATE OF BIRTH SEX YY FP--I IAA DD - . X PA DYES ?NO I 1. : I PA F 1 I INSURANCE PLANI:A1AE 0fl PROGRAIA NAIAE c.EMPLOTER'S NAME DR SCHOOL NAME c.OTHERACCIDEIZT? YES NO c. Prudential Ins. ? RESERVE? FOR LOCAL USE iW IS THE FE ANOTHER HEALTH BENEFIT PLA:: a.INSUflutLE PLAN NAME OR FFOGRAIA NAA!E . wE U NO I,y... lo:u,n,o and na7latanam 9 a•O. HEAD BACK OF FORM BEFORE COMPLETIN G 6 SIGHING THIS FORM. sJ^/ l d t] II:SUFEO'SORAOTHOR2ED PE RSON'SSIGNATUREIaumml:e bls tome undars?9ned pnysuanol wpyer m par en! It 4-4.1 A c 12. PATIENT S CF AUTHORIZED PERSON SIGNATURE GNATUR nl don't is e "'I 9 1 est ' a a acce9s assGamanl panl wn m" to 10,563 no me .eed aelaw es aesor Ke 10 p y t]Pl .Islmscum. 11 Dalaw on File . Signature On File _28 _gg GATE09 nature SIGNEDSig._.... _.____-__..-.•-- SIGNED SIMILAR ILLNESS TAE O IF PATIENT HAS HAI S 15 CUMIAENT OpCUP YYON . 16 DATES PATIE pp NAULL TO VIORK I TEFL UPRCT; ILLNESS Ifi1s11Ymp:om) OR 1 '? ,?p',^I 9•Y INJURY(AmnionU OR A . DO 'Y GIVE FIRST PATE TD PAPA ! FROM • PREGNANCY(LMP) SOURCE 1 D. NUTAB'cR OF REFERRING PHYSICIAN 171 15.HOSPITALIZATION DA TES RELATED TO Mm REHTDD VI YEYS YY DD 17. NAME OF REFERRING PHYSICIAN OR OTHER . I TAM I TO FROIA ! 0. OUTSIDE LAB? S CHARGES I 19. RESERVED FOR LOCAL USE YES ffiNO RY RELATE ITEIA5,2]ORaTOITEId 24E BY LII:EI -, 22.1-1E AID RESUBIA1540N ORIGINAL FEE. NO. 1. DIAGNOSIS OR NATURE OF ILLNESS OR INJ. .l 839.21 T 839.07 31 _ a?a ?n Q, I . V 2.L-._ 24A O C a. 1 D ESOfl SUPPLIES SERVICES E OSIS p G OATS H PSD n F I J K - RESERVED FOR F DATE(5)OF SERVICE FMm To PIaCO el Tyra of . . PROCEDUR IE.pLls Unusual Cecumstances) DAGN CODE SCHARGES OR UNITS y am Plan EMG COB LOCAL USE IAA OD YY PAPA DD YY Servca Servin• CPT•HCPCS MODIFIER 30.00 1 2 1723340 L 4 27 98 4 ;27 98 11 1 98941 1234 Lasses I 1234 00 30 • 1 2 1723340 104 !03 ;98 09; 03 j98 11 1 98941 . Casses I ' ' 4 3 00 1 2 1723390 .98 06-98 04+06 04 11 1 9 4 Cassses I 2 1723340 04 • 13 98 4: 13 : Lasses 5 i 5 25 FEDERAL TAX ID. NUMBER , SSN EIN 25. PATIEIR'S ACCOUNT NO. 2ZIFO, 9EOPT A,9miiua alT i,l 26. TOTAL CHARGE Z9. A1.10UNT PAID 1r ? BO Q? ]0. BALANCE OUE S 150 00 251723340 n ISENNI000 Ire YES ? Lo ) s S .1. Ali ADD RESS. ZIP CODE 31. SIGNATURE OF PHYSICIAN OR SUPPLIER ]2. NAIAE AND hDOPE55 OF FACKIIT r,ncnc a. ..-... .•.}..F•?•-p.----•------ P:CLUDWGDEGREESORCREDENTIALS RENDEREDpleteennannemecrcnco) cAT99LD Chiropractic Clinic (Iceneylnallna:Iatements ontnewolsu 313 South Hanover Street app'(Io Ina 5d and aro maaa a P.an In ,1001) ICasses, Rochelle L Carlisle, PA 17013 P428 q8 1„51723340 IGRP. SIGNED '•UAT TOru NrrASm n2sn1 Ir0PAnVFOBY AVArnla{PII nR1•FDICa1 fiFp••IfF Pf' 0M PI FAnF Pnwr orz TVPF _' IRI®1®I?® I?Ir1?1? APPROVED CIAD 0311 0005 ,. LIEUI6pnc ,.,c..•.••••• 1? _.. IAIvW.]d A) 1 1 ISrJnmr's 551-0 IVA Fiu q 5. (No, SVeetl 1 486-582 INSURED 'S DATE OF BIRTH SEX DD YY I IA 1 F Prudential ins. 520 Sroadhollow Rd. Melville, NY 11747 HEALTH INSURANCE CLAIM FOI FECA OTHER SER ELK L@ :G (SSN) X nDJ 29500016-08009 SEX a. ,,&e D'S NAIAE IL]SI N]me, firs IA F fxl Sentz. Pam P TO INSURED 7. ILSURED'S ADDRESS I1I0.. SIIL'e1I Su:lU 5PaYau Us,,.ul .0 AYr PATIENT STATUS CITY S.rlu[ u]Inud Mt . H ZIP CODE EmP10,0dr-I PoIbT1murA 17065 a. EMPLOYMENT7[CURRENT OR PRE'JIOUS) a. 11 YES fY NO - 5. AUTO ACCIDENT? L? PLACE ISla:el T Lx- YES NO LPA _ c OP@RACCIOENT•s o i M PICA m •: y IFOR PROGRA,.UH ITEM 11 I i.1mU. tliaElY ln:i]II STATE I s PA (. (PHONE (INCLUDE AREA CODE) 717}486-5822 ECA NULIOER F L L SEX la 11 F M 5 :. EMPLOYER'S NAI.IE OR SCHOOL NAME OYES Lt,O Prudential ins. :Od. DESERVED 7LCCAL a15THERE ANOTHER IIEALTHBEHEFIT PLAN? iI!:SURANCE PLAN NAME OR PROGRAM NAIAE YES NO Ityea. mlYrn taand wmpeto nem 9 a.d. READ BACK OF FORM BEFORE COMPLETING 6 SIGNING THIS 130N50RED' SON'S SIGNATURE I.-non:o 12. PATIENT S OR AUTHORIZED P E PEONS SG+RenA u R2 sNeaar]1ar ser Cesl deswWdlOe!aw'ISmine unders2ned pnracan or SYPpl?el al at fnod mwacos ma <Mm.l aso,eR+esl Par o 06-16-98 Signature on File Got Signature on File DATE SIGNED SIGNED -'- 1.11A MM I DD YY Ia. DATE OF CURRENT: ILLNESS (Frsl symp!om) OR 15. GIVE TENT DATE AD!rAAMEOOSIYYPILLNES5. 16.DATES PATIENT DD YY UNABLE TO WORK IN CUM OCCUPATION FIRST IA 111 l? YY7 , INJURY (Amdc-l) OR , I PRDI1 i L L ?`JJ PREGNANCYILIAPI Va. 1.0. NUAISERCFREFERRINGPHYSICIAN 18. NOSPIMIA 2ATIODN DA YYS RELATED TO CMR?EN OO RVI YYS 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE FROM I I TO ! 19. RESERVED FOR LOCAL USE I[e I-IYESNI_X NO 1,1839:07 1,2.9 OR 4 TO ITEM 2--E BY LNEI ----7 839.21 Y 3.1 '.- ORIGINAL REF. NO. V A B PUCe C Type IPROCEDUF.ES. SERwCES.OR SUPPLIES DIAGNOSIS DAY5 PSO OR Fam" EMG COB RESERVED FOR LOCAL USE DATE(S) OF SERVICE Flom To of of IEr DI].n Unusual Ceeumst]nwsl CODE SCHARGES UNITS Plan MIA OD YY IAM DD YY ervIN som. CPTMCPCS PAOOIFIER 25172334 05;04 ;98 05:0498 11 1 98941 1234 30.00 1 Casses 1234 30.00 1 25172334 05:11 ;98 05; 11 ; 98 11 1 .98941 asses 1234 30.00 1 25172334 0 05 18 !98 05: 18 98 11 1 :•98941 asses U 00 1 30 1 25172334 05 22;98 05:22;98 11 1 98941 1234 . asses 06'01 ;98 061 01198 11 1•'98941 1234 30:.00 1 25172334 S Casses 1234 30.00 1 25172334 06 : O8 198 06: 08 ; 98 11 1 '98941 PATIE14T'5 ACCOUNT NO. 26 2'L a miG ieo Eau p PTC FO 2d.TOTAL CHARGE 29. AMOUNT PAID 90.BAUINCE DUE 25.FEDERALTAx IMNUMBER SS14 EIN . 0 I 1 l r YES .l I ? NO $ 180.00 = 01.oo = 1ao'.o0 251723340 El SENNI00 AIVE AND ADDRESS OF FACILI TY 1Y11EPE SERVICES WERE `'S,SUPPLIER'S BILLING NAME. ADDRESS. ZIP CODE 77. S PH 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS 72. N RENDERED BI Gino, Inn, nomo Yl Pneel ONE Casses Chiropractic Clinic II COIUIy 1,31 ,e SLIements on We loveiGe 313 South Hanover St reet $?p?,Ujo1n15 p,1.T,vSalo?aJe ai,>it5 ogt.l yy 113+CCll ll.. lLL1 LL CC Il C 1 Carlisle, PA .17013 061698 PIN, 251723340 rare SIGNED - DATE FORM 16FA4500 112.901 ,APPROVED BY AMACOUNCIL ON MEDICAL SERVICE 61E61 PI. F.ASE PRINT OR TYPE -1? '•" "' • PLEASE APPROVED CL•B C93a03Z5 - QY,Y,?'J#( SAW 00 NOT Prudential Ins. STAPLE 520 Broadhollow Rd. -:? ..MOVE. mTmnmm9m= THIS AREA Melville, NY 11747 A HEALTH INSURANCE CLAIM FORM . PICA F71 ;PICA I-ECA G OTHER MEDICARE MEDICAID CHAMPUS CHAMPVA 1 P la INSUREDS I D. NUI.aER (FOR PROGRAM 114 ITEal 11 { . "'0a"a a) (me-q 15panS-IS55NJ HEAL PUN IVA rde s) issmoND1 !J") X 101 29S00016-08009 ' ATIENTSl+AIBEILast Nama,first Name, L!.Oa'e ln.Wp 2.P 3 PATIENTpp ITY DATE SEX 4. INSURED S NAME ILasi Name. tam Name, r.!.aoa lnta!I i. tz Nichole 061 26, 79 I•I n F X Sentz Pam C 5. PATIENT'S ADDRESS (No., Sueot) 6. PATIENT REUTIONSH P TO INSURED 7. INSURED 'S ADDRESS 1r+o. Street) .,,. Sm?SPaasa?CmL:D Otam? 5 Trine Ave. 5 Trine Ave. T TE CITY STATE S. PATIENT STATUS A CITY S rin s lt S PA s.nra[X m.r.m Crna,0 Mt. H011Y Springs PA p g Mt. Ho AP CODE TELEPHONE pnUuae Ale. Cole) ZIPCODE TELEPHONE (INCLUDE AREA CODE) (717) 486-5 065 06 822 Empuraa Fall.rlme Pan.T"no swaern ? sIV' 17065 (717) 486-5822 17 BER ' IS+SUREDS NALtE (Last Namo, Rnl damp. lf.?ol:o lm 9. 5ay 10.5 PATIENTS CONDITIOI+RELATEDTO: S POLICY GROUP OR FECA NUM It.INSURED ntz Nichole S C L e a. OTHER INSUREDS POLICY OR GROUP NuMuhh a. EM PLOYI.I ENT? (CURRENT OR PREVIOUS) a. INSUR ED'A DATE OF e:nTH SEX DO Yy ?YES LNO F 02; 22; 55 rlED D. OTHER INSURED 'S DATE OF BIRTH SEX D. AUTO ACCIDENT? PLACE (5:asa) 0. EMPLOYER'S NAME OR SCHOOL NA1.1E MM GO i YY I !A^ F LYES ?NO LPA? I I. EMPLOYER'S NAME OR SCHOOL NAI.E c. OTHER ACCIDENT? I. INSURANCE PLAN NAME OR PROGRAM NAME ?YES ?•r+0 Prudential Ins. F' It INSURANCE PLAN NAME OR PROGRAM-NAME Iy. RESERVED FCRLOCALU5E a. IS THERE ANOTHER HEALTH BENEFIT PUN? C' ?YES u NET (ryes. return to all cemP!ete llpm 9 Is d, I READ BACK OF FORM BEFORE COMPLETING S SIGNING TH15 FORM. 13. INSURED S OR AUTHORIZED PERSON S SIGNATURE I au:ncn:e 12.PATIENT'S OR AUTHORIZED PERSON S SIGNATURE Ia a:o:r,emole'esse of any mea:a!or-:net mLlmPMOn nrais.ry Payment of meecal-onus to lne unaossgnea pnyscan or sup;vel ter top onus In45!am. I a!so lMYeal Payment.1 gz .cmP! p 1 '..ms exw to In, WI or U 114 party Nno a:CaPls asn9nmenl 16-98 6 e0O2CS 4.sUAaC aolaM nature On File Si a" Signature On File o 0 - g SIGNED DATE ______-_ --_-- SIGNED C 11 ILLNESS (First symptom) OR 14. DATE O 15. IF PAT IENT HAS HAD SAME OR SIMILAR ILLNESS. OD I YY MIA 16. OATES PATIE NT UNABLE TO WORK IN CURB ENT OCCUPATION MIA DO YY MM : DD 1 YY MIJ INJURY(A4Cem) OR d PREGNANCYILfy P) 12 17 W I GIVE FIRST DATE TO FROM _ ; . 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a, ID. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION OATES RELATED TO CURRENTOSDERVI ES FROM TO 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $CHARGES ?YES [?;NO 21, DAGNOSIS OR NATURE OF ILLNESS OR INJURY. (REU TE-ITEMS 1.2.3 OR ITO ITEM 24E BY LINED 22.C6EDD_CAID RESUBMISSION ORIGINAL PER NO. 839.07 839.21 T L ?•_ 3'L-•- 23. PRIOR AUTHORIZATION NUMBER 1847.0 2 L_839_20 . 24. A DATE(S) OF SERVICET B PMto C Type 0 PROCEDURES. SERVICES. OR SUPPLIES E DIAGNOSIS F G DAYS H Fa I J COB K RESERVED FOR LOCAL USE 2 a 1 a F, n v ntasl Un P T CODE S CHARGES UNITS Plao ENW a ILIA DD YY MM DO YY Se Rl Se, ' I MODIF ER CS CP rHC 2 06 08:98 06:08:98 11 1 ('95999 1SEMG 1234 150.00 1 25172334 mc - Casses 2 06115 198 06; 15198 11 1 . :98941 1234 30:. 00 1 25172334 u 3 i Q C 2 a 5 M O i I g ' I • 625.FEDERAL TAX I D.NUVBER 15SN EIN 26. PATIENTS ACCOUNT NO. 27. ACCEPT ASSIGNMENT? For 904, clatms. see mcM I 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE 251723340 ? [] r SENNI000 r? 1 ^ YES ? NO s 180;.001S 0. 00 s 180'.00 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE PHYSICIAN 'S,SUPPLIER 'S BILLING NAME, ADDRESS. ZIP CODE 33 . INCLUDING DEGREES OR CREDENTIALS RENDERED Inotnennan Hama e, e!NCe) 3. .,P Clinic ractic "AaS SNeS Chiro p C.IWr Nat me statements on me 10'arse Sip"fiseldklJalecff2k'3ygl1 p 313 South Hanover Street 061698 Carlisle, PA '17013 ,N. 251723340 OFF. 7 SIGNED DATE !APPROVED BY AMAC01:NC6L 014 I:EDICAL SERVICE rum PI EASE PRINT 017 TYPE rost.I HCFA Ism D:sm m PLEASE "-- DO NOT STAPLE IN THIS AREA -. I -PICA :I AIED,CAI,E mECICA,D CHAR.PUS CHALIPVA 1'--1 releaea?e/1 n ILlea(a,a q n IS?anSOrk SSNJ I? I" Frb q n A PPROVED OMIT C53e,wca A. Prudential ins. j' 520 Broadhollow Rd. w Melville, NY 11747 U' HEALTH INSURANCE CLAIM FORM PICA r-, Y ELK LUNG 15S'p L+1 .re' n•? i2 ^• I:A,AF 5n :'a^• n ln.: aU S?nl?z, rficiiole' (pry 3PFbr'Tat i" ^n.E • I:b Y,7? 5``?x n F I ___..._. n z; PaTn• ^. ? INURED 7 RE 6.PA 1?,?p9An G9E . JNS1Ll AVre SVee9 C E S:rzea IS'Ai,",,J"5An' 5 l Y 1 ne 51?ve . c [:] yen O S,e::e? Cn cr.m .w[ STA¢ ' ` B.PA@NT STATUS ' Nt. Holly Springs suTA hit. Holly Springs ! ^ OOna S J ': L I' E NC•{J3f?I R TELEP J '- 71 ( S'?Z?l I- reLS?Yf'7'Enn:?(8'G"-(S$22 f65 1h? . v PamL:nc JL -X F 300 1 1!065 ( 0 d A cj I v me1? Emp,apa? Slawnt Ll Swanm ? p a IaSE?"1?2aRE1 lACf11?1t mn.fP >mn. l•!mTe lmnaq 10, IS PATIENT 5 CONDITION RELATED TO. I I.INSUREDSPOUGY GROUP OR FECA NUIdnFn Z O W S E O - T E5 INSUREO j r SE% URED S POLICY OR GRCUP NUMS ER VI I U ELIPLOYIAEIIT?ICURREI+TTFR i E te I a F G O Z YES NE ? ER'S NAVE OR SCHOOL NAME 0 E RED 5 DATE OF BIRTH SE% oAUtO ACCICX. 1? PLACA,,: OC::PLOY Z U YY F J r1 YES ?NO I a n I IA n ' _ L1 1- I I"LV-OFf RAM NAME Z ? ° 0 NAI:E CA SCHOOL NAM e OTHER ACUCENit X • w )51 lllJ?) 1?1: 1n 11C.EMPL YES NO H' Q a INSURANCE PLAN LAV,, CRPROGRAIENAI.,E 1G4 . RESERVED FOR LOCAL USE a. IS THERE ANOTHkI HEALTH BENEFIT PLAN' QQ. i YES 1:0 If ye; Item,,, Aeomp'ela nam 9 a•a. ,a READBACKOF FORM BEFORE COMPLETING 651GNIND THIS FORM. a Iaulnan:e ti 1NSOREDSORAUTHOR2'cOPERSON'S SIGNATURE aalwntLlsm me wan,:gneapnCsconpr suPpLn for MO!m(m ry acm(n:e:•.e ea:O elmymeacalee c;cennb:matan oects ;O PALE6i 5CF.U:nORRED FER50r:5 SIGRATURE I rt naE'ESr?°+Ona'Pi°lel?ntL:st,mt, 1. m,ttn a,bme p:Ov3.?'34?9&nmtnl b,Iaat:53i . payme :trv,Le:ae??gnature On File g pebn. T SIGNED DATE ILLNESSIF151:Ymp:oml OR 15.IFPATIENT HAS NADSAmEORSO.uLARILLNESS. ' - _?_._..________-----_..-- SIGNED. 16.DATE$PAT,ENTTEUNABYY TOWORKIN CU/AIFENT DECUP YYION j RF[?! ? I IN. TAG INJURY IACOetntl CA GI'JE FIRST OATS L'J•1 DD YY MR CJ YY a r TO FROM \ PREGNANCYILNAI 17.NANE OF REFERRING PHYSICIAN OR OTHER SOURCE 17 1D1.NUIEBEROF REFERRING PHYSICIAN 1a.HOSPRALIZATOEN DATES RELATED TOCAfPRENTE?ERVI YES FROM TO ' ' SCHARGES 20. OUTSIDE LAD? X IS RESERVEDFCALOCAL USE YES [NO 21.DL.8r3.95 C01,•TURE OF ILLNESS OR INJURY. (RELATE I7EM51.2.3 C8JPITEAj' EBY LINEI--1 22' CODE AID RESUBA!ISSICN ORIGINAL REF. NO. 11. , . 0' L_' - 20 839 27. PRIOR AUTHORIZATION NUMBER . 847.0 2. 1-.- F G H I J K Z A B C D E .I C •• DATES) OF SERVICE Puce TTpe PROCEDURES. SERVICES. OR SUPPLIES n l Cn t s DIAGNOSIS SCHARGES DAYS OR EP Famd7 EIAG COB RE$ E :s,% F ts 12 44 Fmn To cI pl mms a ct IErplam UwSna l IAODIFIE R CODE UNITS Plan 12 1 n! YY MM OD YY h Sem ervire CPTM PCS 1)-? C u 07 10 98 98 10 07 1 1 98941 1234 3Q.00 251723343 u . , 107 20.98 07 20, 98 1 1 98941 1234 30.00 25172334 0 25172334 I08 03 98 08 03, 98 1 1 98941 1234 .00 3 It • r 5 2 F p;.J, y? Ip U1.1CER S51J EOyyy. ?yP????y7S bVCCryJNT NO 127. CEPT ASSIGNMENT? • 2 ?/E3 4a 7. 1211 NN1U rIX17a.1. cn,s. see MCI I ? YES ? NO 29. AMOUNTP ID 0 70. DALA.NC.F.DUFOO 28, TOTAL CU 1LV oo Q 5 1LL UU' $ $ ? I l r 31. SIGNA1URE OF PHYSICIAN OR SUPPLIER 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 1,pp 0? ,? 33r7t;YSI;.IAQTB.-chiWD i 1(:Ll&mC11i11 L: X RCNOERED III ane, man namn m cmcel ::C L uO,NG DEGREES on CREDENTIALS 313 South Hanover Street I C ( S> (i?t01MSi??AOt?ana11V+'1?ILII PA 17013 Carlisle 081498 , 251723340 nn.,rn nATf I _ IGRP. PoN/ .=?nrvanl'Y..,•(rn..:r,, r,Ir'(r:r:.I rrwlirrp?Fm PI rA SF nmff.ln Tl'nc FORM IICFA 1500 112 901 APPROV ED G6•B 0935 OY_9 Prudential Ins, 520 Broadhollow Rd. Melville, NY 11747 HEALTH INSURANCE CLAIM FORM PICA 7- OTHEH I 1MEDICARE MEDICAID CHAMPUS CHAMPVA GRO FECA P I.T.IRSUREDSLD.NUMBER IFORPROGRA61MHE1.11) j' IG .. PLA!I ?IA10Cd:srcq IAbCCaragnlSPant.r's $$f:1 nIVAFAe r) ISSNC1101 0f55l:1 1-1;(101 l ' 29S00016-08009 I' ' 2PAI:EIIT SNAME ILaa Namo, FUal Name. 1.14ca lnrag 3. PAbEN1SB'.RIYDATE SEX i.l!:SUREOSI:ALIE ILa:I Name. F.rsl l:am°, IACC'°InPap ? Sentz, Nichole (PI) 06 26 X19 M FrX Sentz, Pam i' 5 PATIENT' S ADDRESS {NO. SUUB 6. PATIEf4TRELATIGNS111PTORi$Un ED 7.INSUREDSADORES^alr:o.S:m LIj 5 Trine Ave. s°nQsya,:el]ch-<?C 0:,er0 5 Trine Ave. CITY STATE B. PATIENT STATUS CITY STATE Me . Holly Springs P s..y°Ex ?)--a El Omer El Mt- Holly Springs PA a ZIPCOOE TELEPHONE IIndlCe Aura CpCe) ZIP CODE TELEP11ONE(INCLUDE AREACODE) I 17065 71 486-5822 Emp''0Ye° J `'nem°G74 sia?eni?? 17065 717) 486-58: 22 5 OTHER.USUREDS NAME IUM Name. F,I%l Name, 1.14ae ew.aq 106 PATIENT S CONDITION RELATED TO. 11. INSURED 'S POLICY GROUP OR FECA NUMBER Sentz, Nichole (PI) i u a OTHER INSURED S POLICY OR GROUP NUMBER a. EMFLOYMENTI(CURRENTCFi PREVIOUS) a INSURED 'S DATE OF BIRTH SE): ? DYES 0`0 "62 'h Y?5 M F EX LJ D OTHER INSUREDS DATE OF BIRTH SEA o. AOTOACCIOENT? PLACE(S`.m01 2 D EMPLOYER'S NAME OR SCHOOL NAME MIA DD YY Mn Fn ' rXyEs nr.o PA. Doctor Jim Grove 4 c. EMPLOVERSNAME OR SCHOOL NAME c OTHERACCIDEN77 D. INSURANCE PLAN NAME OR PROGRAM NAME El YES 674:0 Prudential Ins. f a. INSURANCE FLAN NAIVE OR PROGRAV Y.AME 160 RESERVED FOR LOCAL USE C IS THERE ANOTHER HEALTH BENEFIT PLAN? ? OI 11 YES [2CNO 11 yes.IOwm n am comp;e:enem 9aC. READ BACK OF FORM BEFORE COMPLETING 6 SIGNING THIS FORM. 13 INSURED 'S OR AUTHORIZED PERSON'S SIGNATURE I autnome 7 FATIENTSCRAUTHORIZEDPERSOI:'SSIGNATURE IS_:nCea lceuleme0an, m0acalu<:n0rb: ea:•cnc..cessa:Y pa,r..enl of meCKil DeceDSlOtne cnpar5.gnep pny5.uan Or SUppl.eNor I'I u prOCes IDS C:An.I also mQutll pa,mem Dl ga.emmenlcenebS ey„0na H,ISO ono Ile ;An, NO 2CCep:i a::.3arper•1 10-21-98 LQ10n'' Si Fil t serv.ces Clsencea celCw. nature on File Si gna ure on e g SIGNEDDATE SIGNED i 14 DATE OF CURRENT: ILL14ESS IFnsl symptom) OR 15. IF PATIENT HAS H.ADSAME On S1141I.AR ILLNESS. Y INJURY (ACC4.HR OR GIVE FIRST DATE MIA , OD YY M' ' C ? 16. DATES PATIENT UNABLE TOYIORK IN CURRENT OCCUPATION MIA , OD , YY VIM , DD , YY . ? 2 27 97 FROM TO PREGNANCY(LMP) 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D.NUdBERCF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM , DD YY MM I DO , YY FROM TO 15 RESERVED FOR LOCAL USE 20. OUTSIDE LAB? SCHARGES j DYES L30 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 12] CR 4 TO ITEM 24E BY LINE) -, 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. ')' 839.07 839.21 3 L . _._ 23. PRIOR AUTHORIZATION NUMBER 2 ( 847_0 a ( 839_20 2a A D C D E F G H I J K Z FODnATEIS) OF SERVICETO Place Type PROCEDURES. SERVICES. OR SUPPLIES t C DIAGNOSIS DAYS OR PSD Fam" RESERVED FOR C F' MIA DD YY IAIA OD YY of emm DI 9erv w rtr mOances) am unamal (E,p CPT'HCPC9 MODIFIER CODE SCHARGES UNITS y Plan EIAG COB OCALUSE 08 21'96 08 21: 98 1 1 98941 1234 30.00 25172334a asses 09 14;98 09 14;98 1 1. 98941 1234 30.00 25172334a a ° 3 - a D 2 a C 51 L a ° 7 I I 25 FE DE RAL TAKID. NULIBER S514 EIN 25 ?PAIJENi SACCOUNT NO. 77 ACCEPT ASSIGNIAEHT? 20. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE I I jFO, god. claims, tau Da[A) 251723340 ?[JX SENNI000 [Xres (? No $ 60.00 s 0.0 $ 60.00 31. SIGr:ATUIE OFPIIYSICIANORSUPPLIER 132. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE . PHYSICIAN S. SUPPLIERS BILLING NAME, ADDRESS. ZIP CODE 33 ,NCLUDING DEGREES ORCREDENTIALS RENDERED III OCennan be,.. m 0:101 ? y ractic clinic 99Yds Chiro 0 cen.1, may Ile 3Mlements on 11.0 re,,Iey p L 1 313 South Hanover Street 102198 Carlisle, PA 17013 SIGNED I DATE I PIN, I GAP. 7 :.nnr.DVFnfiY a:•A enm:rn.rn M•rr,cAI rFRVICFem, Pt. F4sFPR1NT OR TYPF rcPmVCFA-15110112981 s F PLEASE 4nl_r xnya//'iF,g1Y,d ?:1{,:v;!.u tYY`.1l' A rPRCVEOOIID :.93? C".:B GO NOT Prudential Ins. STAPLE 520 Broadhollow Rd. THIS AREA Melville, NY 11747 P:CA HEALTH INSURANCE CLAIM FORM PICA -T 11 MEDICARE MEDICAID CnAMPUS CHAMPVA GROUP FECA OTHER la.l!ISUREDSID.NULIBER tFORPROGRAIAINHE6!t! -? IAt.acaro s) pttc ca d/J (Spcn,o/s SEN.) n IVA Fie r) F-1 n 11951 oOIAV RjSSN' XNO) 29500016-08009 2. PATIEIIISNA'AE Slaai!lame. F eflyc:u. e...... lnu.y i 3 PAnIWH S BIRTn DAIL SEA -X 1'B6 6 96 Y79 a. INSUREDS NAMEILast NamA. Flml Namo. I.l.aa'.e lml.aq P chole (PI) Sentz, N 11 n F( Sentz, am 5 PATIENT S ADDRESS IN.. Sv..:t 6. PATIENT FELATICiNSHIP TO INSURED ?,NSURED'S ADDRESS INC. SVe1!I 5 Trine Ave. s--' El sp-s, IJ cn,:1G? D:,erE] 5 Trine Ave. Ij CITY STATE 8. PATIENT STATUS CITY STATE Mt. Holly Springs ° S'I,;Q !mnaa? O:ner? Mt. Holly Springs PA = ZIP CODE TELEPHCNEPN.zuA'a Cool) ZIP CODE TELEPHONE INCLUDE AREA CODE) ?i 17065 71 486-5822 Empto,el F:,:I-T. morr Pan.Tlme ? 17065 71 486-5822 AueOnl L_ e_!aaem C 5 WeER INSURED 'S NAME Lau Name. Fast N." L!ape ll.:a) 1015 PATIEN 15 CON DITION RE LAI E D T O. n. INSUAE 0 S POLICY GROUP OR FE CA NUMBER Sentz, Nichole (PI) C U. a. OT HE R INS U R E DS FOL ICY OR GROUP NUMSE R a.E!.!PLCYA!ENT?tCURRERTORPRE'JIOUSI a. INSURED S DATE OFF BIRTH SEX 2 ?YES GYNO LJ I? M10 2 D22 Y55 'D F rX L y 2 o. OTHER INSU RE D'S CATE OF BIRTH SEX D AUTOACCIOENTI PLACE (S%,w) o. EMPLOYER S NAME OR SCHOOL NAME p 1441 DO YY F J?'ES ?NO PA Doctor Jim Grove n e EMPLOYER'S NAME OR SCHOOL HAMS c. OTHER ACCIOENT? C. INSURANCE PLAN NAME OR PROGRAM NAME z YES G7i:o Prudential Ins. ? C NSURANCE PLAN UAL!- CA FROGRAIA NAME 101 RESERVED FOR LOCAL USE a.IS THERE ANOTHER HEALTH BENEFIT PLAN? I ? E]YES 111NO ity,a. return to ana comp:e:e ram 9 a•a. READ BACK OF FORM BEFORE COMPLETING 6 SIGHING THIS FORM. 13. INSURED 'S OR AUTHORIZED PERSON'S SIGNATURE I aamor.:a 12 PATIENT S CR AUTHORIZED PERSON S SIGNATURE Ia.:eon;e;n.arleaae 11 a,, meual er c:^.ennbrraso, rearsar, palmerael memeal 00,04, lntna,'aam. oo P""W,, al suppnerbr Il press mro•ta,m lasauy.eRpa,ment UCm(mm0ra eeet4s x.lner lor.,sxaulo;te part' r.ra ,:cep's ass?naem ! • . Si nat re n F 10-21-98 l s0mces casrngaa aelaw. S t r File e : . g u o i e igna u e on SIGNED.. DATE______- 1a DATE OF CURP.ENP ILLNESS IR41 s)mulaml OR !.1?'Z 7 Y97 d INJURY IACC.COMI OR 15 IF PATIENT HAS HAD SAME OR SIMILAR ILL14ESS GIVE FIRST DATE "M DD YY 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION t.I!A , DU YY MIA I DD , YY' ,L PREG14ANCY(L4PJ TO FROM t?.NAI!E OF REF ERRING PHYS!CIANOR OTHER SOURCE 17a.ID.tIUTASEROFREFERRINGPHYSiC!AI4 18 . HOSPITALIZ ATION DATES RELATED TO CURRENT SERVICES MIA 1 DO , YY MM DO , YY FROM TO 15. RESERVED FOR LOCAL USE 5 CHARGES 20 OUTSIDE LAB ? ? 11 YES LINO di 21. DIAGNOSIS OR NATURE GF ILLNESS OR INJURY. IREL -,E ITEI.!S 1.2.3OR c TO ITEIA 2AE BY UeE) 22. 0E AID RESUSMISSION 839.07 839.21 7 ORIGINAL REF. N0. 00 23. PRIOR AUTHORIZATION NUMBER 847.0 839.20 4, L 3i A B C D E F G H I a N 2 i Fr,(aATE51 OF SERVICET Place Type PROCEDURES. SERVICES, OR SUPPLIES DIAGNOSIS DAYS EPSD RESERVED FOR O I mm DO YY MM DO YY of er.?a/ at Sen. (E.plapn Una,Ol Cilcvr races) CPT.HCPCS LIODIFIER CODE ,CHARGES OR UNITS Fa A, Pon EAIG COO ee r Q 08 21 98 08 21. 98 1 1 98941 1234 30.00 25172334 0 09 14,98 09 1498 1 1 98941 1234 3Q.00 25172334 z x w 09 14 98 09 14;98 1 1 99213 25 1234 38.00 25172334 $ N CIC I O Z a U) t i N } a I r I 125 FECERAL TAX I.D. NUI.IBER SSN EIN 26 PATIENT'S ACCOUNT NO 22, A CE PT Rl sms?i?m INTI 22 TOTAL CHARGE 29 AMOUNT PAID 30. BALANCE DUE ' O 251723340 ?GX I SENNI000 YES n No s 98.00 s 0.0 6 98..00 31, SIGNATURE OF PMYSICIANOR SUPPLIER 132 NAIVE AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN 'S.SUPPLIER 'S BILLING NAME. ADDRESS. ZIP CODE INCLUDING DEGREES CA CREDENTIALS RENDERED RI ena ln]n home a once) 11 4 mat 111. wm n C.1 r5' ^§ Oards Chiropractic Clinic . , meleversa l ws o 0 Svgnaq--umo,--a?naIP-,jqe) I 313 South Hanover Street 102191 Carlisle, PA 17013 SIGNED -DATE I PN, IGAP, •r .: nom^cr•p.. :;Yfh!.r': TI••I"'af4 r,,./.fF".." PI A'ACF PFTI!JTrV)TVPG rnmAHfFA 1son H7 ,a. Eevinyfvanln EMS Report 5oma14= tmtco No Wo mNa Dom YdlanvSmsd sEMS 2101101 9710990 12.27.1997 hvaA N ee 11-U of Nv+d 5'.1 Sewu7l+x 1 t:amt.ad pbr* Nlcdt Spaa 06/26!79 178-600827 Tmx P R B hm Tmstnxm Providar 18.55 110 16 140/02 Pckm pl=d on Ima tpke hoaad wm CHYs in At, ALL Pad." owe 190 1110 16 1241Q ?tmd vital iM P14ct At Pa6ord omb14 19:07 100 14 122/Q Afrivad at ill3h HotpftJ, Al. Patrad 09" - 0 Iv%IMdtAtlN,ix . Pep 2 • )y Y i ?f Y EMT. 094976 Ftdlorv, • :? .Y..? WAMAqAftA=idmu NaM .flotii i.ll _. _: Baer, Crm /-E ?i • d.4i ys?r...rt , 5^ sli i. ?s 1 '?l Vf r3¢ ft :. .i r C ° ..e2..d.. - !n .y .. r .Ji • .. af....... ? : s!?4: _.l. i a„i ? r.1..- _.'.. ?., .. .. !. C4criWe HM W .. w 00731 110 16 140/82 4•9 s: NOW P? 0riml ' 6. pboo j 12/27/1997 •20:39 717406097 YELLOW BREECHES EMS • -- PAGE 04 Penf2flytvandn EMS Repot sanmNa ... ladisotNa llantwHams; + 2101101 ' . 9710990 12.27.1991 Y ISMS ?,. v. rsdtry sa :., Btiisihoulti Rood and 114 21908 CuLib H6apilal .. F t+ r phew No Age Dead tent: rre $at OAM em . - Sorts -? • 1(717)43 6.5822 18 06126/79 176604827 P tteea Mime . aka rca 3 Triad Avenue AMI Baer, Cam B 094976 Dispatch 1939 Cpl ear lip Ad2 Weidner, h., Robert A Primer 18.38 t ML Holly SPw PA 17061• AN3 Arrfw" 18.43 MAI 09W 5? 1856 MIAW Arrive Fm 19:07 tM Uo•Srst Da0. In Amisbrr 19.29 5030 50533 30539 50546 In 0-e rs 19:45 Clrlaf : Pain in chest end shoulder duo to eat belt twao -- Anapta (meda): node pax "BP ElFwb C Harr Attlim not on madicmion for esthrna Narrative. Dispatdro l due I to auto accident with Fire *M moil W. Modit: 83. Unkn own Ir judea, unknown tntravroa . Arrived on the scwo to End 4 pstieras out of the vsldde 3 velicks brrolved, 1 on it's fide i i HPI' Poknt Is a rear feat pastacr4 r with sat bth( lap and ahoidder coniNnatlon) on. Vehicle was a joep Cherokee which rolled onto its side dkr being struck by amber vehide PeNonn stated tM area hanging by the seatbeh tdhr *A wreck and then crawled out of the vehicle. Patient wu wanking around slier accident. Al found patient ruing on the roar of another veldda coMlainiv4 of neck, shoulder, hip end drat pah TIP. Al uamod C•spine stabilization white A2 applied a necklet collar. Patient was placed on it long board with C1D's in placed and placed faro the ambtdorm. PE. Patient Is an 18 year old Rznale who is eonsciou alert and oriented, MARL, exbco tic3 utvamrktbl6, JVD, ^1D. • trouble baddas Patient did complain of neck pain, chest pain, hip pain, and shoulder pain Patient stated sbe fell an tM pain was from tM tat belt. Al did notim tome brush bum marb on padema IeR hip, and dso acme redness on the padeata right shoulder area. Padent did not complain of pain upon pafpuioo to the ribs, sternum a hips. owl no crepinta vru reeked Patian wu ebk to move an extkee a wen Al monitored patlads vital figs whist an route to Cattiest Hospital Yrtda aFmrs ramelned stable thrcugtrout tranrpart Arrived at Carlisle Hospital and gave report to C R. Nursing staff Patine eleued to their tare Ambulmrce 191 returned to station without Awther inddeot. Note: Padw stated the vehicle the was In was on Bumt6ouss Road headed South. BON d. : J Carlisle Hospital 'and Health Services CONSENT TO HOSPITAL. ADMISSION AND MEDICAL TREATNSYT Name of Attending Phynician (n) : (BM) 1,2 T Date of Admission: o - /. Time: (AM) - acting on behalf of) 1. I, (o ? Name Of Amhorlxed Reprraeahtire suffering from a condition requiring hospital care, hereby Noma Ot Patient consent to rendering of such care, which may include routine diagnostic procedures and such medical treatment an the named attending physician(s) or other of the hospital's medical staff consider to be necessary. 2. I understand that the practice of medicine and surgery is not ar exact science and that diagnosis and treatment may involve risks of injury, or even death. 1 acknowledge that no guarantees have been made to me as to the result of examination or treatmene: during this hospitalization. 3. I understand that: i (A) It is customary, absent emergency or extraordinary circumstances, that no substantial procedures are performed upon a patient unless and until he or she has had an opportunity to discuss them with the physician or other health professional to the patient's satisfaction; (B) Each proposed patient has the therapeutic consent, and procedure or to refuse consent, to any (C) No patient will be involved in any research or experimental procedure without his or her full knowledge and consent. 4. I understand that many of the physicians on the staff of this hospital, including the attending physician(s) named above, are not employees or agents of the hospital but, rather, are independent contractors who have been granted the privilege of using its facilities for the care and treatment of their patients. Further, I realize that among those• who attend patients at this hospital are medical, nursing, and other health care personnel in training who, unless requested otherwise, may be present during patient care as a part of their education. Still or motion pictures and closed circuit television monitoring of patient care also may be used for educational purposes or for documentation of the clinical course unless a patient expressly requests otherwise. 5. 1 release CARLISLE HOSPITAL from all responsibility for all articles which I am retaining or will have with me during my stay at the hospital. I understand this includes clothing, bridgework., false teeth, eyeglasses, jewelry, money, radio, razor or any other item kept in my possession. I understand I may deposit valuables in a safe provided by the hospital; only if this is done will the hospital assume any responsibility for the safekeeping. 6. I hereby acknowledge that I have received written information on the topics of % Patient Rights and Advance Directives. D to of Signature: - (.?3vG"c!/'C !? " .' n IONATORB OP TIE // BIONATURE 08 WITNEB9i ?h (If paticn is unablo to consent or is a minor, complete the following:) ? Pacin_nt (in a minor years of age) (ia unable to consent because): _ SIGNATURE OF LEGAL GUARDIAN OR SIGNATURE OF WITNESS CLOSEST AVAILABLE RELATIVE) w.,e Carilole Hospital - Emergency Dopartm-%:7 BEN CH LE 248 Parkor St. Cer1181e, PA 17013 (717) 248.6500 112/271 $i 8 m t DISPOSITION SUMMARY Patient cc"''Z NICHOLE ~ Age/DO& SS # Current Ph: CURRENTAddress Zip. Medical Record: 91 7809 Arrival: 12/27/97 8:210m Disch:12/27/97 8:22om Disposition: MD ED: Anthony J Guarracino. DO PMD: Res/PAINP: Joey L Wisner. PA-C PMD Ph: DX #1: Cervical Strain ICD.9 #1: 847.0 #1 Dx Engl: SPNECK.ESW #1 Dx Span: SPNECK.SSW .. Follow-up: WOOD BRADFORD J 1358 LUTZTOWN RD. YBFPC 1 BOILING SPRINGS. PA F/U MD Ph: 717258327.4 _ t F/U DR: Other Instr. ICE AND GENTLE RANGE OF MOTION EXERCISES. MOTRN AS DIRECTED ON THE BOTTLE AND RETURN IF ANY INCREASED PAIN OR ANY NEW SYMPTOMS E' MY SIGNATURE BELOW INDICATES: it > I have received and understood the oral instructions regarding my current medical problem. > I will arrange follow-up care as instructed above. > I acknowledge receipt of the written instructions as outlined on this and any previous page(s). I wiifead and review these instructior)s. Staff (Wilriess) Signature a?? " IV FLUIDS TYPE/AMT. SRE TREATMENT/ PROCEDURE TIMES ? RESP. TREATMENT TIME TIME TIME TIME ? AIRWAY. TYPE TIME SIZE ? NASOGASTRIC TUB 517.E __ TIM SITE _ ALIT IN, AMTOUT__ ? EY SIZE TIME COLOH__ TIME R rrnwt sl L++?+CR F:' 'MEDICATIONS Mad. Dose Route Time: Slpneture ,,'," IV TOTAL . TOTAL TOTAL TOTAL I ION OF: ? Ii0•.pi -'+ l' u .. JOrgCf ? Family ? Family Doctor ? Po:cO _ ? - LO Coroner = TOTAL INTAKE; _ _ ? Cnps IntCrveneOn 'Mant = OUTPU ? IJursmy Home ? - `I Other____ = VITAL SIGNS. ? ON Bp MONITOR Time EP I P R NOTES. = EVALUASION ANq DISCHARGE NOTES: TIMES: EKG C%R _ -- TADS DRt.Y:N _ UA _ ADO U PULSE OX ? PATIENT/FAMILYVERRALIZ - DISPOSITION: -DISCHARGE, nafANDING OF DISCHARGE INSTRUCTIONS. ?z ? Admitted to: ? Uttor ? WRITTEN INSTRUCTIONS GIVEN 11 Ce ? Sall '-carried .?amily ?For Obeorvatlon. A'Ambufato r 11 Abd Problem O Allergic Reaction El Crutches 13 Eye ? OCUSpIinVCast F) UR y ? Friend lo: ? Ambulatory with Assistance O Police ? Transferred td: ' - - i ? Whbolch l Ant I sthm Bito N' ?Favor .W-08pmfn 11 AnGblohic I ? UTI ? VomilinglDiarrhoa o r ' O VRluables_ - - ? Ambulance- - _ ? Back Gonomi . Fie Injury ? Burn O ? WOlkr'SChoOJ Excuse ? Wound Co 1 1 ? fdorpu - : ' ? Monitored Lifter - ------ 7' • Muno 11 Chest ? Kltl Shona ? Mu sclle e Slrni ro ? Proscription -'---- ' ? Other PATIENTS NAME n - Clear Liquid, 11 ? Nsaitl ? Other ? Verbal Instructions By 94 " 'J 41 b,-1---lL P`-._ NURSES SIGNATURE AN rill 11(imlital NURSING ? t N • EMERGENCY DEPARTMENT 11 • r ...--. n 'Z_ Cyl.t, NAME' -?•a-- TRIAGE NOTE: Tdaga Status Mode of ARlvol `' DatE Arrived WM .. .. , ?ZC hvv nd Fdo t ROOM N .-----? A?? E I - Priority I. C) (3 Priority ll . ? ALS C GO Ambulatory . Pollco Family Porerlt 1??] r ; M B JRAL SIG T ?JCJ it lit . Wheelchair LJ ONor !, P ,• t-1 P nor . y . ALLERGIES:' -, NUS STATUS: phial Complaint: , ars ? 5.1G Ye ilhin 5 Yoars CURRENT ME DICATIONS o Yoare Moro than 10 ? Nvor L q I 2. 7. 7. 5. 7. _- a. g. Onset of Symptoms: Nursing Action/Comments: Childhood Immunizations: ? UTD ? Never ? ;?r Treatment Prior to Arrival: PULSE: RESP: ?Shailow ?Rapid ?Audibto '. . ."7 ? Regular ? Irregular ? Normal ? Deep ? SloW Wheez.o .. ? Labeled ? Stddor ? Retratdons , ' ? Full Owe k COLOR: ? Dusky ? Cyanotic ? Good ? Flushed ? Nallbede ? Palo ? Jaundiced ? Circumctal SKIN: ? Cool ? Warm [_1 Clammy n Dw M Rash TREATMENT IN PROGRESS ON ARRIVAL: ? CPR Down Time min C] Monitor • Rhythm Hato y V V ? Aimay • ? Oral O Nasal • Sue__ ? Oxygen • ? Mask, ? NC • UMin ? Airway. Endotmchoal • Size _ inal Immobilizatio ' [3 Airway. Nasotrachcal • Size ? Mast Vital Signs: - Size C] Pressure Crossing 1-1 Other [3 IV • Solution S10 _ POX: Pu pit Sizsc Lung Sounds: R,ehe? Palos? RnoncN N mat Mental Assessment: Mem'Try ? WA ? Whzazn ? Absonl ? U,mmbhbd .oodi All - - Thouehi: 1 • 4 ® l ropnote ?flaaNSpon:anoouf I??IOrmaUGOLd I4ght•S:a Reaction Loa• Size ?r'a Reaction Y1'•'A r INITIAL NURSING REVIEW: REASON FOR VISIT; PAST MEDICAL HISTORY" G OD OS %'Mnoal Glasses ? MEDICAL ? NA 0 10 PATIENT PROBLEM: Nursing Diagnosis _ Coping, Ineffective Impaired ' Airway Clearance, InoNocuvo ° - '' Fluid Volume, Alterations in: - Gas Exchange; Impaired _ Noncompliance =Noncompliance • Sall Caro Deficit :. Anxiety, Breathing Pertains, Ineflod" Hypenhormla (Favor) _ Skin Integrity, Impaired, wdisc Output Decreased Infecticin,Polantial. l -Thought Process Alt In: In ' Tissuu Paduslon All omroiL Alleredons In:-.. ( _ Injury, Potentia . _ Communicason Impelled RZD I dY • r _ Knowlodg -Other OUTCOME(OOAL Far ;fed by Dischargo '. ? ` /!/ ?? NATORE z r r NURSES SIG .. .. ?A¢?tr.4. ? y. J... ?n .., r -? ...f >. Vim . .,f ... ,. ._..t. ?. Loa: ? Ragas ? RMnthi ?mal ? mmW vial C] VaguoIDisconnoctod Snore mp? vrrizdzo ? Absent El Gmmished ? Dolonsno ? Disoriented ? Talkative ? Reeenl 2 • . 5 Visual Activity: ? Applehons140 ? Slon to Answor ? Repetitive ? Distant Pmt :7 1 ? 13050055-CombRIND [] Mumbling a e I SOUnostAuu; To Palpation re ? NA Hypo ? Hypur AN OF CARE: ` Maintain Patient Airway E Monitor Cardiovascular Status ? IV ? BP Monitor ? EKG ? Cardiac Monitor Safety Measures ? Restraints ? Suldide Precautions ttt Solzure Precautions F" Sldo Rells Up ?{-C.-Iomlorl Measures Peln Control Posiaon for Comfort 'r Prepare for Exam Explain Procedures - h Emotional Support } Petlonl Toaching ,- Discharge instructions .IQ..Carlisle Hospital DEPARTMEwt OF RADIOLOGY and:Health Services 246 Parker Sfieet,. P.O. Box 310 • Carllsle, Pennsylvania 17013-0310 . (717) 249-1212 CARLISLE1IHAGING ASSOCIATES, P.C. SENTZ,.NICHOLE A. 18Y 12/27/1997 5 TRINE 'AVENUE X-RAY 052130 MT.HOLLY ,'SPRGS, PA 17065 MED. REC. #197609 DR. GUARRACINO - S.R. CERVICAL SPINE There is slight kyphosis which may be due to normal variation or some muscle.spasm. Alignment is otherwise normal, and the interspaces and foramina are maintained. No fractures or cervical ribs are noted. IMPRESSION: Nothing remarkable seen. DAVID R. 4OYAL, M.D. DRR/eh T: 12/28/1997 08:39 am ,. f CrS0.?71PHy i i tR ' f. ram CARLISLE HOSPITAL 14EPARKERSTREET CARLISLF.PA 17010.091n CnuvPUIP1JTCnoeieuconeswv T{@. ease sKvO Oll a nr nue? un? i. ". "We$.' , U eM `• •i NVIISI•q U MMENT: FOR NURSING ASSESSMENT SEE NURSING DOCUMENTATION SHEET ?a:i TIME - HISTORY SH: FH: TttSM..a [lAM 1175 f TIME V I DER I LD INTERPRETATION OF: _ LA B S: 1952 ..?..:., " / P f /LC cv, r C,- Kr: E: ,,,., 6g4,IIDQ : T ll ? t NONE. .OVs I10ME O09 TIWI$ OTHER 'Dar ..WKY55 ^ may. ?Y"1 nu[VOSOUxt h V' toHClnov oN o-savYa[ - . 13 SMIE,?hMPROYEO . i.sruHrcn vrJt . DISPOSITION FROM ED. CID ENT .? CARE CENTER • . .n Ans. rq.' ..R?n?'!:::..,:TIMRi :•::it RLSPONDCD .. HVR PRSSENGER.RT INR PAIN ROLL OVER SHOULDER 95027 O1 .. 39020 mrsq.40 9L`????,?YZfir NICHULE` ' {'` ?`•' r rco o,lanue ,ee:^nncw.q,Y w.,so A C T : fl L.2 12/27/97 19:14 18.Y F/N S R a[ Jl Ai • r I'. .. 1 r i r'.tir .?. 'I .:.rte°•L;l I,i `' r? T L. _. { AZ,L.z.C•s1i?.. uxl. ) •.a{.(IK _,ay.t?anC. . ?.S<.a.. r • t aTl fi; i. SENTZ, NICHOLE A. MR #197609 1212711997 a CHIEF COMPLAINT: Motor vehicle accident. HISTORY: 18-year-old white female restrained rear seat passenger in an motor vehicle accident. She was struck. She states that she has some right perineck pain and that is it. PHYSICAL EXAMINATION: Fully immobilized. Glasgow coma scale 15. HEENT: Normocephalic, atraumatic, PERL, EOMf. ENT clear. Neck: Some right base of the neck and trapezius pain. No posterior element tenderness. Lungs clear. Heart: Regular without murmur or rub. Abdomen is nontender without trauma. Extremities: Without weakness and deformity. Neuro: No gross motor or sensory deficits. C-spine series was obtained per request of family and was negative as interpreted by myself except for some straightening and cervical lordosis. DISCHARGE INSTRUCTIONS: Per cervical strain instructions. DIAGNOSIS: Cervical strain secbndary to motor vehicle accident. AJG/bjw D: 12/27/1997 - 08:20 pm T: 01/07/1998 71 Anthony J. Guarracino, D.O. : Y Page 1 of 1'. CARLISLE HOSPITAL ORIGINAL. EMERGENCY ROOM RECORD Carlk+le Hospital ,; and Health Services '246 PuLuStmet A C.TILI[. PA 17013-0310 • 717-245.500 CONVENIENT CARE/EMERr.PBIf:v 92Pr:IQT6A- _ Ka twre:TrYE 12/27/97 19:14 e+ EAH W LYGIRPIV PAtiCHT PAT iP, 3 !K /G 40 75 RN Alx 0 Ao _ - A ??0[[,?iki3 ''g0a91;9i '41 ? .11SNpA[uu[...,.. .' 11RrHR/.C[ A[G:4n cAr[I w( LCICAfKH PEr[. tan[.HO. •',.. PA 12/27/97 / v LRCM/WIIY4 C14QCE'A -4- 19Y---F W-13 QHT /OnQR[YRO/LR AEiN, . 06/26/79 • « KR1?lc $^ "`(, . ? c', ''178 60.=0827 .` 1? .?(QL•h, ;SRR,INOS,'PA17065 ' HAY[rAOO/rtslrn.vrt//auTrnrooa/!wa[c.r_ -J ou.wwT(«s [YPtrnTn SENTZ, ALAN R. APPLETON PAPERS INC 5 TRINE AVE 186-38-6764 CAMP HILL, PA 17011 MT HOLLY SPRINGS, PA1J065 H.W[/ACgI{!!/R4.CrKUwt: SOG![f,rn EVLAWIC.N Wv SENTZ, PAMELA (717)486-5822 ' 18 SENTZ, ALAN R. 03 14tNUrC[ CW V {p'1 Y[Sa MSWA'![ COMMERCIAL AUTO r[xgvrw veer ? to /A:Tnww MVA PASSENGER RT SHOULDER GUARRACINO, ANTHON J PAIN ROLL OVER MOOD, BRADFORD J =AAVEM /. 8q 9 -t? IT; BRIEF VISIT 26700 CAST ROLL. PLASTER 28075 , .. ADDITIONAL CN/LRGIES'-'?y.',°;•', CLASS I VISIT 28710 B/PMONITOR 28037 i---""""° -'""------ ----------------- CLASS it VISIT 28720 PACER PADS 79064 i CLASS III VISIT. 26730 GASTRO/HEMO SLIDE . i 26060 v CLASS N V ISIT 28740 KIDDETOURNIOUET 28048 -------- ---------- `, -------------- "" -"' CLASS V VISIT 26750 OCL PER FOOT i 79670 CONVENIENT CARE I 27020 F.S.83. 80081 t CONVENIENT CARE II 27025 TU BE GAUZE PER FOOT 26074 -'°--- '°----------- ------------------ MINOR SUTURE EDS O7 ED STAT ESTAT i i ' MEDIUM SUTURE EDS 02 PULSE OX POXED i MN SUTURE EDS 03 EXTENDED CHARGEI 28760 --------------------- ? ?- __ ""__""""" INTUa ATION EDS G4 EXTENDED CHARGE II 26770 i i P EDS 06 r [ i [ MONITOR E0311 ------------°-- .__-_-__-°-_------'' XAM EDS 14 E F ---°- i ? [ -------• v ------------------ ? -------------------- _---------------' T•UP EDS IS CAST. OTCH SHORT ARM 26031 A- ------ P ----------------- -------' CAST, SCOTCHIONO ARM 28032 [ [[ ------7---- E -------""-"""'_"-" T CAST. SCOTCH SHORT LEG 26033 { i rr [ CAST, SCOTCH LONG LEO 28034 ? 7-7 . ----------------------- =------' ' ,.. e,a coa.cuo CARLISLE 24c' -rA NER ST -C i%i3S7 C:.RLl$LE, in:1[.-co-___'?'ivMWU"cv:r:i Hach -}u,: inw. .u01 mao ?A 1701:-OCC'0' no. .rout. __ ___ 717-212-2520 !23-21;1105;0723991072399 11 1 -1- i $ENTZ 1:?COLE 1.1 131 1 -ANOVER S DI_L_LSSURG, PA, 17C Peraste?-nt[mua aw:umv---vo., r:.,n nvtaar.eco.o eo. :. :? :iuxnocceci: SEN-Z ERIC 31 :'7 19A.NOVER ST DILLSEURG, ?A, 17019 402 1 ULTRASOUND 001 TOTAL CHARGES ? I I •s u BLUE CROSS 361 e e c v.wamcu ova u.<wvwvs .u:.v..... .n u.a enm .no,.a c.ucn 76770 I =? 2661.00 2661.00 i I APPROVED OVS 1.0.0114.75 IIL ??tr i I i 1 I A vaw«ru ' mcl ova I' r 'n I I ? 1 /..!/, TO OVECILAY SIICEI S POLICE INFORMATION COMMONWEALTH OF PENNSYLVANIA POLICE ACCIDENT REPORT =R 142- 97 (0 c4 3 i2•4GIJIGY I{VAE t...2-1 STATE t?or_IC-E . !] STAMM a PAIROI 2NI'E ?5 ?_j1CfTON, lrtLAx Y2tzo ? L?? M UADGL M'L( X720 •6 DVE UY N.VYE ,7-t.' c. L?Ye L .NEB HI;61,LI>6-yez r VbESTIGA qu 5 ANR:': Al DAIE 11 ?-7 q•7 1!.I1 I8 52_. . ACCIDENT INFORMATION CATL 1Z12-.1f47 SAP II IWEOF •2 I'LIRLN DAY latio NI VNIIS 3 O 1'ALED fA 11N.IRTn y F41: FROP v 16 DO SEHC?us'.E 10 L NCMO,jD IRCU TLE SLLNiY ?•lII UNIT 1 00 I ;„'I YX 11 Yx 11 ,1 2- -IV.fCR1µ5 Y I!? ' PiR?PtNN r X-- UNIT # 7 A lE0/ALr Y u' ]r REC (? ._.-- ?n •?'[?'/ PAUCDY „ - PIAIE lJEUS SJ 6L'il'L` 39 PA TnLEO TATC v nI 501oL?Q73B OUPTn 4 DNl1ER (-ESLLE E• f GR6b?Ry p. GP?FFI E AI OWIER FDIXiL55 28 E• PIRIE ST - CITY. CITY. STATE , 1_ AzmOOE I'AT FI.,0L.L%( SMNV S ?A C70(os :]YEAR 45 AIW[ 1 i5 MODEL • NOT 16 RNs BOGY TYPE) lrttT?-IJIC..(?[,? Y /Y N VII. it BOGY - j196PECSW. j - TY- _55„ ti9'111C1C USAGE V OALERSNB: •]O. viRNLIUPACT 61 VEHICLE 1]7. TRAM -POVR 3 STATUS O SPEED ID S] VEHCLF - ry ORPITR ?]S GREEN GRADLNT I PRr cr..rc I I , ' rm.ner,.I EPORTADLEI _j F[H+DDl VSE OrAr ACCIDENT LOCATION ML3 El?U1zJ (? _ w 2( 711AUr4C • AITY COOS ---- tJ 1C1?(IJ S or-3 TL-W e .. ?-AZ- S ROADWAY INFORMATION 12 ROUTE 140 OR ??] ???? .? \ !] -1 si N(1.T H41.1L W, OLD Lr/cKlL I?-LJ.._s f`?..1 ?. __... 7I SPEED IN IYPE Iii ACCESS LIMN ? rj NIGIVIAY 0 . _. COHIRCt-L--... INTERSECTING ROAD: 75 NOVA. Na ON s•1.1E1 NAOI j3JQNT1ioJS1=, RA, _T --_ _ 2! SP:IU 26 tWE' CES9 h. ACCESS 111.111 y5 IIIC16VAY C> - CDMIRDLj--- IFNOTATINTERSECTION: ]5 CNOSSSTFFETOR SLOLIENT LL;Rr.CN )I DNICIKHI 3201SiAKE -_-?-? I N:IUsNE N S E VI (POUSnL Et my :Y U?Sl AI2F ^:AS _ _ -_ 11V.SURCD _ ESIU.WCD ]] IWJTC 141044Pr VIIERSECTING +IINE D CONTROL DEVICE ;0, 13" ; UNIT # 2 I511C41LV Y N )r VLG ?-r USTAATE 'AR..LU+ PL6IED?Z ?SD E .. i.. cA.__ Pa 1111E (PIT Of STATE'.:,, LARGS LO53 . . aU ONRER ....• • •_ BOER W. ?K 11 ADDRESS 53 t~1. YE1L W a Sej ?S 12 CITY. 5141E ZIODE CA( JLE PA ] 9'0 L 14L3......- --- 1?oDC as MODEL •IrIDf .a6.965. O Ud0 BODY TYPE) 1C?.?Y Y M -HLJ 9LJ i) BODY.. - 1u SPECIQ. -• L 49. VEMiCLE TYPE OMERSHP :LP 1uPACt e?. POINT ACT 13I U.E Q ,VEHICLE I.52.T -- . POVIi I'Z - STATUS -SPEED ED _ ] VEINCIE r5%DRNER i - DR-NE-R-- ? ram?ruT I !• PFCVUrc ?l I f nn.mnnu I I•°.:^•'•c^ / .1 S-1 :b DRIVER -2 p?Ip n INIIBER Zy ?g, Z Zo 11UAIBEH I 8 (_I q 0c, - a D(lNER SB ORP I N"^ E C-9 CRY AL-L0-1`J GRIFFIE MIE pol?pL?._LJ•_.TP 59. DRIVER 59 ST- _AD0 u.28..Er..PLarc .... ADOHE. 53.4t1:.y L.?.f3 r16 DER 1. CRY.STATE , OITV,STiSSTE AzPCODE p••LT Flot_LS( SPfZtrYSS& LAS AnxDDE CAAUSL•E_PAY J- 161 i]l 62:11MEOFn7 I JE 6] 1 e.... 61 SEX 1 62 .041E u /.- o _ Y :' : D x , cuss 6i CARRIER - -?- W. CARRIER AOORESS 69 CITY, STATE 6 ZIPCODE MI5 (I m5) . - ?PUC 1 to usbOT -I-, A :}I ON'.A ? R. VEII. rl].CA WE - co1a10. II. ppm ARDOUS ? I7RFEEASEOFHRZI.uT _ 751IO.OF _ __ i..16.IV ;nIAIS Y 0 110 UII&0 MLEs , IAI ?519i!o4 PAGE:.01- D 1- 1.1 ._._ I.1_N U LRAU PanDOT•BHSTE 001651 COMMONWEALTH OF PENNSYLVANIA l POLICE ACCIDENT REPORT N' ,ATT.: REFER 10 OVEFIAY S11EEIS REPORTABLE. x• I1I11.11EPORIAOLEI'_! o[wlom u5E 4AY POLICE INFORMATION l ACCIDENT LOCATION 1.ICCUCT Z 11? 2. AGENCY I NAME TSIAlI01V?----- PRECVICT i 6 4PM67AD DY ILCA•ESIKATION I Mir 71 AUIIKIPALIIY ._. _ .... ._...... - C i. PATROL PRINCIPAL ROADWAY INFORW ZONC -- - - -- --- UADSE 77 ROUIEIIO OR IIUMULR SIHCCT NAME ._.. ._.._ .- ]f E GAUGE 73 SPCCO ACC ?.'i. M'E GUMBLR LIMIT MIGIMAY _ j.'- FAIR 6 ARRIVAL INTERSECTING ROAD: DIAL -..... _... . ACCIDENT INI I )6 ROUTE SIR( EIP DR Sln(l NA61E _ :! SI'CCD 'LCCI WAIT - IIKi1fA'AY ?'-'?CON • 11 TIME OF 17 UpIABER AY 01 U11.35 • 11 IKRLCD II I IIIJURE0 15 PRY, PRGP AcCNF_NI Y 11 16 DIDLSHKtE HAVE TOM it tEUKIL UA'AAOE REWM Tl) FROM THC S CIILI n.IfJl•r ""3 2 Urat3 UNIT 2 1 10141 . 7. LIODF RAI E Y X I1 ', Y N 3 -5EV1 RL VGII) I4IAR000S '11 1E. IR nI:LXII_ _ -_.. __. ___-_ . LuiERV1S Y' 11 PNCPC uIY ! It ! UNIT #3 IF NOT AT INTERSECTION: ffi EROSS STREET OR - 31 CKC11011 InOM SNE N S E YI FROM SITE 11 GSTAIICE 1VAS ..-.._- _ _ M[/SURCO ESTIMATED ?..? Y CGISIRVCIISrI ]5, TRAFFIC PRUKIPAL BRERSEEC 0NE - CONTROL DEVICE i LL UNIT # 2 •M LEGALLY Y N:]l RCG PA V EFKX 183 b P191 E :V. ILUALLY Y M II rvL4. PARKED''.... PLATE ^- ..._- TITLEO :39 OW.OF.STATEVPr L ?4 20'?$2."i1 STATE O39 PA UT UT TITLE OF $T Al IL Vn1 - ii6. i0. I!•••`SEISAN ?? 1""< AB OKTICR _.. . ., JI. 410'.YtICR ADORE ADIXiESSTPJ u3E2ry 7R ADDRESS ... _ .. .... _..-•- _ - ,if CITY. STATE 4 CITY. STATE 6 ZIPCO D E } r 11OU-Y SPR4 i,?s -eA'10bS 671KODE _ _ .. :13 YEAR /-Y i1W?L?AXE FbO 1 A C- 4 V ? ,I YEAfr AI IAAALE -.._ • . 1115 ?1-S. YODEI:,FID VT Y x N U11K. YTYPE ?NaI ? 15 MODEL .IIWt BODY TYPE) 16. INS: 1 ? Y ? No IIiCU r Y I BOO ) !Il. bbbrSPECIAL 1; 1-9 VEHICLE _ ii OOOY ... SPECNL _. - 19.IVENKIE I' TYPE ? __ USAGE O ` OY•11ERSIHP TYPE • USAGE C -' TMVEE 57 simuNLOAPACT 1rS1. VEIIKIE I5]. TRAVEL 1O P11TUL IMPACT ?1 ,VEf11 LE T - 1 SPEED STATUS I. POM -_ 12 I .51. VE/1iIX.'• 54. DRNEi r_I SPEED 00 r!; DRIVER I PoItR l1.?EMKLE_ STA US _ I HDRIVER __r _ SSIC%LNE ?Q ?, uA ' "PA - IYJMOER . . f . . Ss. DRIVER ?EFf'•ze"/ IIAME 59. DRIVER B L.tBE.DR, ADDRESS YIJ N CLASS GI"I •- Y:: : CL ' !6LCARRIER 0 CARRIER 6l:CAHREA - - •..- __. fd. CARRIER ADDRESS _- AGGRESS ... SSTATE CIfY 69 - -- - 69.CITY.SIATE . . BZWCODE ... _... aZIPCOOE_ _ - To. usoor 1 Ilic . "POE 1 T6: usbOT i i]'c%IiGf) ... _. f 11 OYJ,Tt - -"_ 'n'VCIi !Il? COFIf10. - BODY TYPE A . - m0c. OF' ' S 15, IQ. C •ib. NAZ ARDOUS IYR ll. RElEASC OF II I IIO. AXLES WTERMS. .. V O N? UIIKO ,•, AXES _--•_ M45 (11955 PACE: Q 2::it91; 65 - 001652 !e RESPONDING ELLS ACLNCr r YLU ,ne,} 2?4542E1-eS__..._____.._ INCIDENT #: Z=4710 19 ucogn FACILITY C1AQU5*(-E I-bvt' ACCIDENT DATE: / 27 SO. pLDRE WFORSNTgM ADf:I,E55 C 0 E F N I K L M A R --(ji vif's ?Cb D 0 o 0 0 Z iu?La.?1Ct.rr=GER 21I Q.?IaE ST- Ml'FIaL.Y5r72yYs ?7. 3 ?t t3 M'.18 I , I , , _ f .D_£uxtJS v1E7`I.?srrT,tCu.T(5 4svdl?rs dL _y_ 3 3 co I(p F 1R :3 .I .? NICKIS?.frt.5s7wK PYE 1.7 rr1«w.s+K_r3411!LS.YSL?B M x'13 . I.. ;. 0 0 3F 1513 ' I f Plr _ 3?+L?YEt???113?SFFIUr ?J D o c LT I .. 66 OLLGRAM 57. OP. ?el.4lWVU1gN 13 82.r.EAWER p S„J ° ' e]: ROAD SURFACE ' ..' 3 I2l ITU%4- IHPPGT {. f I IS Y 1131. PEIWSYIY/JIN SCIgOI I]ISIRCI i 2 Z IF APPLICABLE) ) Z FJA ,e5 DE5CRWIDNOF DAMAGEOI`RCPERTV ,/./. OID l(nXe? n zus F Q OMILR TIT By. NARRAi NE- IDEMWY PRECIPITATING EVENTS. CAUSA7ION FACTORS, SEQUENCE OF EVENTS, WITNESS STATEM573. AND PROVWEAODFTgNAt QETALLS. LM INSURANCE INFOR"TION AND LOCATION OF TOWED VEHICLES.. IF NNOWNL_, M t _T .^_^r ••¢?C?_q S_JN'LT_(il_ I.JLS_3?>-Dl?? 1'^+R .7D N 9uwlr!{et THIS Ara :?0?516/3A'L:71'LG. u:? 2?>•?EcTt?: W1T2L a?1'OkCLI:I •1• L. r F?l ..uc CLS7•RQUNO o e rr"'FO_??^?:?uawNA_pO avw'1 YI>t?u ?e,.>? I,.xF(,?1_wrs_s?v , Nt eN y])-TI{ OAS y9 _LX.._121?I-L11.?{/L1E(? SM AS TD 11b3- +-SL•11T 7[??{..FiZF'GA T'S7"R(.CJLSJtT IS-ZwLT-5ID /AVIT6)I Spy,) 00 '(?XSE.1t2II35ED_4YER cr?iD_7TS cf?F1311??{[A?1=LI) S R sF NIT T ?j?j.{?-'fD 12.?$LBIJ_0'?l.'L S.SsCT ?IIF C`v ??? ?U .-C TLAS Ir]7"eRS T[ot.1, ,A??7? <DVJ 9^' - _ ._? ._m nA.,e .n o?cT 1 - ,SIT ' T of ?u?LCr ;INSURANCE COMPANY G-r-r. -rte IMFORMAIIQN (}.? FAy S„? OFj,^l-!/OF'V. t_.f ._.; INFORIMTION i,-_,__?-tip TI IT POLICY 233 SX C0 3k ..W7 tgr UNI 7 NO T I POLIO X09 , .7102 - 1 ^38 H 1 N __ AULMLSb . ".__. __.. NE XIE ADDRESS ESSE9 1LLME UA YA7NE vommoro. VIOLATION'S YI A gNNUM (MY ) 7 2,Nr it NOL1E i 00 91. PROBABLE 92. IYPE , 93 RESULTS UOIEST 91. PROBABLE 92. TNPE ? W.iRf5UU5 NO TEST USE TEST O _ USE ' 1E51 -- 41.VNE571CATION COAPLETE7 . REFUSE REFUSE lvlRll O 0 0.--%,-7 URK Utlrt23 D I I ?.--°/AU UKK YES 2Dn M45 Jim) 251 .9064 PACE:O ... - Pw.WT•BNSTE 001653 IS RESroIael... _. AGENCY L.-._.__. . _. - INCIDENT k: L4 z- 7 19. MEDICAL FACILITY ACCIDENT DATE: IH2 W. PEOPLE Iona ATIOl6 A IT C 0 E F G ruuE ADOI 5 _ ^ .L 5 ! o . T, 2 F 13 F ` N I 7 K L u + I 2 7 rWaa •rrc? 53 W. Y?I6:)?CS r? Gx?rsrGrN?w_- o ° o c? o c l ° •p 3 1 It 1'133 B o ?T ' ' CL-I V&o'TiG! 31s F132 3T1 0•sc?sn.,)3r/ucK18U3CKrYDRt?uYsxwtirrAr?zs_ L( 9 2 (3 o f r3.?LL M i!°t?31.L..°.T?nNd ??K(SUdFR7YV2.nr-?f ri s?f}r7, . o o o iL 0 0 3.1 Ze l.lP i 3. I. .°.. SdCL+f? 8e7L IB ucLVrIX Kr/tu,Y51',t? S. 17xs ° ° 0 3 0 0 66 OWCRAIA 'e1. LLUMUTATION e7. WT .HER ! EJ. RCAp SURFACE j81. PEIWSttV41W SCIIpOL CISTRCT IF APPLICABLE) • W OESCRIPT10110F CAMAGEDPROPERTY ;OWtrtA '- 1 • u. NARRATIVE • IDENTIFY PRECIPITATING EVENTS. CAUW ION FACTORS. SEOUENCE OF EVENTS. WTTNESS STATEUENTS. AND PROVIDE AOORIOMAL DETAILS.L INSURANCE,INFORMATIONA7IDLOCATION OFTOWED VEHICLES. IFMOWN. O J Ii17'r,RvFEtr1ED ,L7 Ltu•TE 17?.?1.?47 nT-IS.S.S . ?.S ,.-..•.?_...?.__ ..__ 1fV'? d-'?1?!E?_S17,tT'£J. PS?6S_-W:oWYcIK?? J1 F•YT v.+1 .t D G( .••-eg,`iF•s?7Ed P?vr??e 12.?L11425?J+?B sT ea..) . oL?-1?ELfK.32?.._.Af. HL ./:?IjLD/,E1ff??..S2Ff_ ?i E?'r .J JALI r ! f ltct r. 9U IL4 N FRCraT of M1La.-I-i£-1?1?7°..STF2 FLJFY.A?LUT_LT1FIM SOD L Li-r- A?r CP(ICSLIit SCIi+T?-? M- 93o eM5 i?6e?F.rEJ VIE eiGT- WAS ac.- AC-- rvtC F•Tra EHM lINSVMHCE I ANY rn . ` a.. INSURANCE COMPANY IMF ? vU P INFORMAT r ION If uHIT ! POLICY - UNIT POLICY oZ 9 C _ N ? N 0 0375 N. I PHONE WTTNES5E3 NAME -_. AMPESS . V u 11 u, A w Nr1uM f e4Y ) -- E --- - LIa T'') lurt9 1 -- ----`-- 91. PROBABLE 97.-1YPE ' 9] RESUliS Ip LEST 9f PROBASIE 97..ttPE 9). RESULTS USE TEST U6E - TEST LuUO TEST 91.eNESTIGATION REFUSE I tMR t I 0._ -% URK lum 7 (_J REFUSE I 1 0 N COMPLETE Y - ._ U K YES NO May 01.951 - ... r . • ._.... __ n___, t I.t•c. F Po T-[IILSTE . • IV A (zc?REFER IooiEr AYs1Ens 001654 COMMONWEALTH OF PENNSYLVANIA PAR CONTINUATION SHEET REPORTABLE 39 •:CN nEFORIAME O IW=T Emy NT ACG?Cf NI GGUxFY 2( WNK.IF ZpZ Nu a 2'971043 nAIF 127 1 pSGN ?ioilYAltaff • USE a/LP AY • ] 511EL I 1V1 CODES D C D E F G NAIL- ADO.,ESS 11 1 J K I Y L L H U.N Mirn. y It n? LY. BD.CESCPoBEYKKAIONS 99. SEGtK)•1 NU1.®EftS ICNLY 1F G11.AfK3ED) 1C NIC uw 1 a 0 .42 0 0 • `'N` 91. 4EK4tQE USE 99. TWE TEST 99. + SULIS ONO IE51 fEf uSE ':: `", 91. i.OP.IBLE USE 9t. IYFE TfST 0. ESULTS No TEST REFUSE p1.IM/ES7K,ATFY1 H ETE COI UwT 1 O 0._ _/e O uNK UNIT 1 O O.__Yo O INK . YES NO M45C Rm PACE: 0_5. CENTER FCR PICHNAYSAFETY GElc® PANI LY AUTOMOBILE POLICY RENEWAL OECLARATI0115 GEICO INDEMNITY COMPANY THIS ISADISCRIPIION Or YOUR COVI:RAGE 5'LtiOl1'UStuln:\vrnuc.Chr.YyC,hnsr.,Ntanla^! 2UAt5 I'Ll'ASErFK.I'rollYOORRECORDS 'IIiLIiPDbuE: 1.800-841.3000 rAx: i i?0•Z85•:iii PAGRT POLICY PERIODFRONI 0•-3•02.00 TO 02 .r, 1?:01A.NLLOCAL TINIEATTHEADDRESS OFTHENANIED INSURED. THE INSURED VEHICLE(S) IVILL BE REGULARLY GARAGED IN THE TOII'N AND STATE SHOII'Ni IN ITEM I, EXCEPT AS NOTED HERE: POLICY NUNIBER: UO - 59 - i .ASON :TEWART t1iCaO! E ASHL:. „=Al•:Il 1550 !!! t T !- GRC'7E RD L0- t?ECH=.NICSBUR; P1. 1705: .:- DATE ISSUED: 0--15.00 ITE•NI I: NAMED INSURED AND ADDRESS CONI'RAcTTYPE: A30P.A UNIT ENDORSEMENTS: !'EH i :,a»31 CR=.lli CRA10 CRAB :,.;431 :R:.115 CR.IC :...;-= ' - ' ' ' ' ' ' ' • .INIPORTANT NIESSAGES' ' ' " • ' ' • ' ' ' :AS A GEICO FANIILY AUTO POLICYHOLDER, IVHEN YOU OR YOUR SPOUSE (IF RESIDING (PITH YOU) RENTS A CAR IN THE UNITED STATES OR CANADA, THE RENTAL CAR IS COVERED UNDER YOUR GEICO POLICY. THE SANIE POLICY PROVISIONS AND CONDITIONS, COVERAGE LIMITS AI D DEDUC. TIBLES THAT APPLY TO YOUR PERSONAL CAR ALSO APPLY TO THE RENTAL CAR. IF YOU HAVE NIORE THAN ONE CAR INSURED. THE RENTAL CAR IVOULD BE COVERED Y1'ITH THE BROADEST (HIGHEST LINDTS, LOIVEST DEDUCTIBLES) COVERAGES INCLUDED ANYIVHERE ON YOUR POLICY. RENIENIBER, CONIPREHEN'SIVE:1\D/OR COLLISION COVERAGES ARE EXTENDED ONLY NVHE\ YOU CARRY THESE COVERAGES ON YOUR OIVN VEHICLES. INIPORTAN'I': IF YOU CARRY NILZTI-RISK COVERAGE, THE NIECHANICAL BREAKDOIVN CONIPONENI' DOES NOT EXTEND TO RENTAL VEHICLES. AtJY PERSON WHO KNOWINGLY AVD WITH INTENT TO IIJJURE OR GE""BAUD ANY INSURER FILES AN APPLICATIO14 OR CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION SHALL. UPON CC`,'ICTION, BE SUBJECT TO IMPRISONMENT FOR UP TO SEVEIJ YEARS AND PAYMENT OF A FIN: OF UP TO $15,000. PLEASE REVIEW THE REVERSE SIDE OF THIS PAGE FOR COVERAGE AND DISCOUNT INFORMATION THE GEICO PROPERTY AGENCY :AN ARRANGE FOR YOUR HOMEOWNER'S. RENTER'S AND CONDOMINIUM OWNER'S INSURANCE NEEDS. JUST CALL TOLL-FREE AT 1.888-300.9500. REFINANCING? LET US PROVIDE THE NEW HOMEOWNER'S POLICY YOU NEED. IIISURED COPY U•31-DP (19) OVER GEICO INDENINITY CONIPANY POLICY NUNIBER: IJO.59-77 DATE ISSUED: 04-16-00 PAGF2 RATED VEHICLE CLASS STATE t 93 FORD 1:=.CP52U2PA323871 0-L _:l•IP!P S PA 2 90 FORD 1FACP52'1:lL%!3532! COVERAGES LIMITS OR PRE.IIIUJIS CnccragVapplicswherealFtmium0r0.00isslrDW11 DEDUCTIBLES VEIiI VEI12 VEF13 1Dr tbv cebidc aon11Y INJURY LIA.3ILITY 117 ,n EACH PERSON/EACH OCCUPKENL_ PROPERTY DAMAGE LIABILITY FIRST PARTY BENEFITS UNINSURED I.10T0r.ISTS!'r!7TH STACKING EACH PERSONiEACH ACCIDENT UNDERINSURED F?OTC'F::ST 1;[iH STA.C<i'+: EACH PERSON;_;Cc :-.CCiDE;li COMPREHENSIVE COLLISION RENTAL REIMBURSEMENT EMERGENCY ROAD SERVICE _r Orr -3.70 73.70 O=TIO`i Y ..1.20 81.20 S!C0.3rl;S300.000 _%.60 41•^? 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M X y _ _ _ e y °oN ¢ J L7 L O n $ Z S,ZN6 ?k ON f7 ?fDZ7 :CMU 0UZ .03< yj' T ?UNU N O :y n N N . fD 3 N C rC C N N n O n N N f0 i i i i O f N O O S fn E i C C F i SW i d ' L ? e 1 ! o z I?NIF -I i a T VI -w ?o [H t e0 l [LL V? ?+ M c ?p€ g Q m a m W J O CL N 6 Z s O ? y m N { K K m z 0 J ? ? V Q N W1 7 'j 0:9 r¢ u UN.w I N m n a z I,- m ?f• x;• m O 0 e i m n= m m m ' vnpea, nps, Omer cam0. [ rmern me a m..,,,, 2228.67 257.87 Corp. ',tULBERRY CHILD CARE :ENTERS 718 ALLIED DRIVE DEDHAM MA 02026 ?A? rA*blate riling copy YY ?? Wage and Tax QQt® Statement a rs.eapo. ?.y lbtrl4d nlVi emMgrer5Y41ncorM lu aeP na ra -,'ICHOLE SENTZ i TRINE AVE '.1T. HOLLY SPRINGS,PA 17065 u - ?• '•F C b y M ?? ? .. ? / ° 5. O A p O u ? C I r ? q S .. ^ T 6E §O or n N. to ? G C1 u[O v Y a n w: , L N a. • g = ° e iy. e . E^ c c ` 6 y o cr- uY. N E z o o ?i; ? cc m W O € n .' am u y o. H c - E n c ° J E w a n 3r ?r CD n 5 ? . o ?_. ems: o v o nx 9Ir l p ? g- -? Y ? 1 u N • Z `5 N ? N < Z N 'L T 2 N y Q rYj C'1 N` S 2f d e S_ O Imo. 1? ?? i .. i f J H rI: y J . V C _ ? u J . c -? = n J. C H ? U _ y v .? 7 C E E G s,'^• ? • G I C 7 r ? N ...r N J _ i a o :! N C c is a _. ' U c.- o u ° - n ° u Yz? N ?]T Y=c y$Yy$Uu .4 ' b Y -Ch= T 4 ? gg F OYb L O u O Qr'~J 0$ u2?? E Bel c?uN c? coo ?yN 1 NT Y r-q X I..' Y C V A 0 U cn Z M M to I I I i ?J ti --.----`STATEMENT I\li CASSES CHIROPRACTII 5?U • UD '?oi po 1 313 S. 11ANOVER S7 J CARLISLE. PA 1701 9-0 / U / TELEPHONE 1717) 249-0055 `U(U f71frV (- Nichole Brown O 1550 Williams Grove Rd.Lcj-iD,,) t•techanicsburg,PA. 17055 L _1 STATEMENT CASSES CHIROPRACTIC CLINIC 313 S. HANOVER ST. CARLISLE. PA 17013 TELEPHONE 1717) 210-0055 I 1999 Nikki Brown (Sentz) 15:50 W,A11!1.»5 Gro.•Li Rc,,Ct 1-CTJ ,z9 L Mechanicsburg, PA. 17055 J nar n a 1-1 i1 ss E , CREDITS BALANCE DATE FAMILY MEMBER PROFESSIONAL SERVICE CHARGE PAYMENTS ADJ. BALANCE FORWARD O i 3' - - o `Z` - ' 15 1 Y4 2o) -7/m CLCI, I CV, /s rvt. - uk 2 - - v FR.m 1625 PAY LAST AMOUNT IN THIS COLUMN v ADJ• ADJYSTMENT M. MAYOFACPLRELEASE SC- SUP PORTS CERVCAL CON• CONSULTATION MISC - MISCELLANEOUS SL• UPI0RiS lOMBAR CP• COLD PACC OV• OFFICE VISIT AL A PAYS. CERVICAL EC• ERROR CORRECTION SEA• RE-EXAMINATION AFL• AMYS.FULLSPINE EG• SENO RDA• RECEIVED ON ACCOUNT XL• FRAVS, LUMBOSACRAL EX - EXAMINATION 911. REPORTS AT• XMVS.TNORACIC NP• NOTPACA PA. EXERCISES 7 r.J CIV 'rti?' e. STATEMENT CASSES CHIROPRACTIC CLINIC 313 S. HANOVER ST. CARLISLE. PA 17013 TELEPHONE17171 240.0055 I Nikki Sent2 5 Trine Ave. Pit. Holly Springs, PA 17055 L 1998 I ?I I Purina FAMILY CREDITS BAL NCE DATE PROFESSIONAL SERVICE MEMBER CHARGE PAYMENTS ADJ. A BALANCEFORWARD D U .0: " [ ? •?l I I I '_ 26 FRem Ie:R PAY EAST AMOUNT IN THIS COLUMN Q ADl•ADJUSTMENT M- MI.YOfACUm RELEASE SC• SUPPORTS CERVICAL CON• CONSULTATION MISC. MISCELLANEOUS St. SUPPORTS LUMBAR CP•COLD PACK OV• OFFICE VLSE' %C. X-RAYS. CERVICAL EC• ERROR CORRECTION FIX• RE EXAMINATION XFL• X RAYS. FULL SPINE EO:SEND ROA• RE[ENED ON ACCOUNT XL - X RAYS. LUMBOSACRAL EX EXAMINATION FIT. WORTS X{• X-AAYS.THORACIC HP• NOT PACK %R • EXERCISES STATEMENT 1998 GASSES CHIROPRACTIC CLINIC 313 5. HANOVER ST. CARLISLE. PA 17013 TELEPHONE 17171 249.0055 n I Nichole Sentz 5 Strine Ave. Nt Holly Springs, PA. 17065 -" L DATE MEMBER PROFESSIONAL SERVICE CHARGE pAYME i5 ADJ. BAUNC? BALANCE FOR1VARp //• a w I V.` 5 I- I OSI I - • ? ' / w _ ;? Uv 3? 'lr? a r j? ' ' r! 3 I ; • lrt ,- ?. ,3 , 3? ? 1/_ I k-A' n ? 33 3/, )v '?5 / 4S z; 3 4;Y/?6 cv/ a! ?rz? .. •? "" , PAY LAST AMOUNT IN THIS COLUMN Q ADJ-ADJUSTMENT RPT-REPORTS XT-X-HAYS, THORACIC OV-OFFICE VISIT RDA- RECEIVED ON ACCOUNT MISC-MISCELLANEOUS CON-CONSULTATION S-SUPPORTS EC- ERROR CORRECTION EX-EXAMINATION XC-X-RAYS, CERVICAL XR-EXERCISES M-MASSAGE XFL- X-RAYS. FULL SPINE EG-ENG XL- X-RAYS. LUMBOSACRAL .` 1 /J PZ j; flE01T5 i STATEMENT 19 9 6 GASSES CHIROPRACTIC CLINIC 313 S. HANOVER ST. CARLISLE. PA 17013 TELEPHONE 171712»0-0055 I Nichole Sentz 5 9trine Ave. Mt. Holly Springs, PA. 17065 L J PT DATE FAMILY MEMBER PROFESSIONAL SERVILE CHARGE CflE01T5 pAYSlElvis ADJ. DALFNCE BALANCEFORWARD D " y/ s°$ q& v/ ?ai i , -- j r .. ? I I I y I ? 514 I , s E r ? I y?.? I / 3 , ? +r g l uz $5Zt- ?Vl r ,Jl% 6/9 6_0 v l¢ X113 _ S/ _?s w form l63f YPl lA]I nmvunr m n.._....-_..... - ADJ•ADJUSTMENT RPT•REPORTS XT - X-RAYS, THORACIC MISC. MISCELLANEOUS OV•OFFICEVISIT RDA• RECEIVED ON ACCOUNT EC - ERROR CORRECTION CON• CONSULTATION S•SUPPORTS CERVICAL XC- X-RAYS XR•EXERCISES EX•EXAMINATION M•MASSAGE , X-RAYS. FULL SPINE XXL EG ENG X-RAYS. LUMBOSACRAL STATEMENT 1 9 9 CASSES CHIROPRACTIC CLINIC 313 S. HANOVER 5T. CARLISLE. PA 17013 TELEPHONE 17171249-0055 DATE l/ y? . r.m leis Al I cc Nichole Sentz 5 Strine Ave. STATEMENT GASSES CHIROPRACTIC CLINIC 313 S. HATOVFR ST. OARLISLE:• PA TELEPIIONE 17171 240-0055 1 r Nicroie Sent' 5 Trine Ave. 17065 rtt. Hoiiy Springs,pA' J 1998 RPT•REPORTS mo,-•• RR",IVn • ERROR CO AOJ•ADJUSTIAENT ft0A•RECEIVED ON ACCOUNT EC %R• EXERCISES OV. OFFICE VISIT S - SVgA OST CERVICAL EG ?ENG CON - CONSULTATION XC. X. E%.EXAIAINATION XFLX' LUN. OSACRAL 1,1.1ASSAGE XL•X RAYS, ??d rtlghGhAX - `d/'LEi%00 B '7 D Jqm Prudential 11:40 PAGE 1/2 RightFAX Fax Transmittal Fax: 17177959345 T0: ALAN From: Jennifer Purgatorio at phone #: 1-800.437-5558 Date: Tuesday, September 26, 2000 11:38:22 AM Pages: 02, including cover NOTES: The information contained in this facsimile message is confidential information intended for the use of the addressee listed. If you are neither the intended recipient nor the employee or agent responsible for delivering this message to the Intended recipient, you are hereby notified that any disclosure, copying, distribution, or the taking of any action in reliance on the contents of this facsimile information is strictly prohibited. If you have received this facsimile in error, please notify us immediately by telephone to arrange for return of the documents to us. Prudential Frc'rai FrGr..y cd Cn• 6avrse Carpry ?cbr;Gr:tr of ht Fnders _avrae CWT Ky a: pr-,er:rr Polity Number. 288A]34710 Agent Contract: 895602 INSURED NAME: ADDRESS: SENTZ ALAN R AND PA\EELA I 5 TRr\*E AVE MT HOLLY SPRINGS PA 17065 LETTER OF EXPERIENCE Mr. and Mrs. SEI\TZ; This is in response to our recent telephone conversation. Please let this serve as documentation that you are insured with Prudential Property & Casualty Ins. Cc from 10/16/95 to 10/16/00. Our records indicate you had: No losses during the above time period LOSS DATE AT FAULT NOT AT FAULT DESCRIPTION OF LOSS / \AVIE OF DRIVER 319199 COMPREHENSIVE 118199 COMPREHENSIVE 3/8/98 ® COMPREHENSnT 12/27/97 ? MEDICAL PAYNIEI\TS/ NO COLLISION $3687 If you have any questions, please feel tree to call are Client Services Unit at 1-800-437-5556 Prudential Insurance DATE THER PMT DR/FREQ PAT: ??j•`/,?1? s„? PATU ?s8 EXT l,7.3/- 97 ?_,(?_r r / /l ! /L ra / Fix. 77-97 ? / -- ti- :/ .-?•.? !ti? /, l.?? Lev?/ ? 7.,.,/ I -.. _ Rx. n i-J f/IC/L •r .?!?.'X/.!.•. ?_ R/[/G _7__ i-? `?O 'F/ L[5 Lf' /.J? ?--?D -! _71, h ry ??J Dpi L Rx• Rx• ,-l c-1rY? ?'? - j L4- _1 11P I ?r .... . rL k/? _. .. .. -- ? - S '.?i?- °_ t .?( lJJIL I IHU wr Rx o f^_ j ___ ?Ya _.. 31_(j7' fr!_v_I.sC?''!• ..?iF- .:d _ ._ . _._ Rx. qx i % -.? - .Q .c6 1 ? ??;.;iL •?R,.< <o Nl.:yd ? R' ??••-?? -? -7L. •b `I • ?? ?? Rx. ri /!M ??/t - a s c J ?/ Rx. ? L a . 'J L6 L2 y vlr Rx. xJK_?c4nn, 1v.?... . •.fi?=?,..ti/?.Ge?r.6.......__ ?f L ?! ... / Rx• O)o `t•? IRS L tp _..... _.__ Rx• ' f ?Fi?: ?. ? ? -/c - -ri``? - ?1 L 3vKJ? . s _o n P .. n r Rx. ? ?. - e -20 -98 .[B L Rx. iv 11h M h1? -. iyorov r Rx• n ?L C J '.J4 x -4;t . ` y y ...d : - s .2 ;73 Rx• rl-..? o) ? ? 'S•i 4- LY it 27 Rx. _ -i-i ?_- 1 Rx• 7L'[_ ?N ???If 7r. ° 1L tr ?4; ' ? L` L 4d -- - 3 -9 - Ji A - ?,G ) ?? Rx• ? it T a b ?/ zru w- 3_? u as 3-/ ?(' zv o c?cav ??-,? 3 -ate -9?' ?? ?? ? .f'. -? Rx•/ - - ' 3? 8 ? -1 GC ., ti c to -.z 3 I rxr ;, II x J / c ?v«e..e _IxtLL?lyLi _L_? ?if1? - ? _ 7 Ire I x s -» ,?.m a7 s%Y -5r Rx' 5--?? - y' SF Z Rx. /4JT?c <alr/-9d' v? Rx. a? C v 0I"' DATE THER PMT FREQ PAT:-4L,, ,j- f PAT# EXT " ,•, lie_ - - S • G Y- 7Y ? %L , •- o,-? cl{Q' Rx• X u//G I J i his =9 Q 2 e+? - Rx. G -a9 - ?rr,LS •ze ....x. Rx•/ r1 ai? _ ? Rx- ? ?• 7- ?c v Y z? _ 97 ?,i f5 F.•.1 Rx. ff J9. { 5?9P / S ` I d?f5 Rz• h .L 3• • Z/- 9Y rrLG-x _ Rx- n 7-/Y "?S? 1 k m9 _?U..Cf}?• vii J? 1 ? J Rx. Rx. Rx. Rx• Rx. Rx. Ax. Rx- -- Rx• Ax. _ Rx. Rx- Rx• Rx. Rx. Rx. Rx. Rx. To: Prudential Insurance From: Rochelle Casses, DC Re: Nicole Sentz Claim 29500016-08009 Date: October 16, 1998 To whom it may concern. As you are attare, %,Is Sentz has been under my care since December 31, 1997 for a cervical sprain-stain injury secondary to a C7 subluxation. On September 14, 1998 a re-evaluation was performed and a thirty-day conditional release from care was issued. As of today Ms. Sentz is released from my care for the said injury. Sincerely, Rochelle Casses, DC .... Casses Chiropractic Clinic CASE-. 313 S. Hanover St. a s? Carlisle PA 17013 717-249-0055 OFM-IOPEDIC &NEUROLOGICAL EXAi\IBNATIONS N:\IN 3E AGE /?'_DATE HEIGHT WEIGHT is2 /fir POSTLJRE head tilt high eai/ high shoo high foot urtation DORSOLLJ?IB.\R RANGE OF MOTION none RONI flexion extension Lt lat. flex. Rt. lat. flex. Lt. rotation Rt. rotation ---90 REFLEXES (none =0; slugP01-1 = +; normal = +2; slightly increases = 3+; hypel-active = 4+) Achilles L R Patellar L ORTHOPEDIC TESTS Triad of Dejerne Minor's Sign Laseque's Braggard's Contralateral SLR Milgrams Nacl-flas Ely's (-) (+ (-) (+ L R L Jk 30 35 35 30 GAIT good Uad eX LFG CHL-CIS orone rt. - It. -Dr+D CS PCS supine r71t._ pain(level) (-) (+ L R L R E.E?., I X 11 le '?aJL 42- ?-/tom 9d" Adam's Advancement L hemp's L Trendelenburg L Other tests performed Derniatomes (if tested Comments/other CERVICAL RANGE OF MOTION 1101711 RON I flexion 45 extension _>5 Lt. lat. flex. 40 Rt. lat. flea. 40 Lt. rotation 70 Rt rotation 70 REFLEXES Triceps L_R Biceps L_R ORTHOPEDIC TESTS Foramina Compression : straight le---D R Cervical Distraction (+) Shoulder Depressor 0 L ?R SOTO Hall M- (+) Other tests Denuatonies (if tested): Comments/other: SPINAL ANALYSIS vertebrae oaloation x-rav listings cl c2 C i C4 Z c5 cc, Sacrum Signature of doctor: To: Prudential Ins. From: Rochelle L. Casses, DC Re: Nichole Sentz Claim n: 29500016-08009 Date: March 30, 1998 To whom it may concern, As you are aware, Ms. Sentz has been under my care since December 31, 1997 for a cervical sprain-strain secondary to a C7 subluxation. Today a re-evaluation as well as an SEMG were performed by myself (see enclosed reports). Although her condition is improving, further care is needed at 1X per week for 6 weeks. A re-evaluation will again be performed at this time. Feel free to contact me with any questions or concerns you may have. Sincerely, Rochelle L. Casses, DC Av? Casses Chiropractic Clinic CASE# ?3P 313 S. Hanover St. Carlisle PA 17013 717-249-0055 ORTHOPEDIC &NEUROLOGICAL E1AININ:\TIONS _ / j/, L,/-, :\G E_/,f DATE /l/ar. zn '9d'_ NAME 111-r HEIGHT s,y,. WEIGHT 1,aRds a POSTURE head tilt 0 high ear high shoulder 0 high ilium foot rotation- GAIT good bad explain LEG CHECKS orone rt. -It. -D _L,- +D CS- GCS supine rt..lt._ DORSOLLIMBAR Ra.\'GE_OF MOTION 1101111 ROB I flexion 7>-90 Eo extension 30 Lt lat. flex. 3S Rt. lat. flex. 35 --fo Lt. rotation 30 :s- Rt. rotation 30 'A?- tlain(level) REFLE\ES (none =0; sluggish = 1+; normal = +2; slightly increases = 3+; hyperactive = 4+)N Achilles Lt a. R r z Patellar L , z• R •ry ORTHOPEDIC TESTS Triad of Dejerne .J7 (+) - - -- Minor's Sign L (+)-?- Laseque's ?- R ?--- Graggard's U L 0 R Contralateral SLR eL (P R - Nlllgrains C? (+) - R Naclllas El ' L C7 L R y s O Adam's Advancement hemp's Trendelenburg Other tests per (+) Dermatomes (if Comments/other, CERVICAL RANGE OF i`IOTION norm RO \ I flexion 45 extension 55 so Lt. lat. flex. CFO Rt. lat. flex. 40 r -5- Lt. rotation 70 Rt. rotation 70 REFLEXES Triceps 1++ R *z Biceps Liz R Z windevel) ORTHOPEDIC TESTS Foramina Compression : straight rQ Cervical Distraction (-) (+) ?' _ z Shoulder De r ssor *-L OR R/ SOTO Hall (+) i Othertests perfonued: [I / / Dernratomes (if tested): Continents/other: SPINAL ANALYSIS vertebrae valuation x-ray listin-'s /./, ?Z14 S-L? 3-_7.9, Rr Muni Lt ilium Signature of doctor: ?7?" date.-3v -yam Saaum SENTZ, NICHOLE Standard Deviation ID: 858 Mon Mar 30, 1998 Static EMG Scan 25 - 500Hz Action: Neutral Posture: Seated Scale: 100uV 9.5 ® 9.7 - - C C - - 5.0 El C X5.4 19.9 IBM EM 21.2 - - C C6 - - 10.3 11.4 X3:3 8.2 T 19 3 - - T T s T . - - 8.5 ? T T+ 12.3 - - T T s T - - 7.9 q• T s 18 - - T T ? T - - T a X6.4 18.8 T T 20.6 - - T11 T T11 -.- 14.9 9 0 L t T 11.2 . L 2 L 6.1 12.9 ® L2 L 3 L 4 L ? 7.5 X19.5 L9 S L 10.7 !21.7 13.7 iNORMATIVE DATA i 25 - 500Hz Scale: 100uV 3.8 0 C1 C1 3.9 - C C 4.4 ? C El 4.3 C 9.2 C5- 0 4.1 C 4.B C C 4.6 4.9 T1 T + T1 4.9 5.0 - T T T 5.0 - T T T - - 6.5 ? T T s T El 6.4 8.9 ? T T F-I 8.2 T T T -F 9.6 Q T B 0 9.5 T T T ;10.0 O -TU T TI T 10:0 _ - 9.8 T-17 L I T 9.8 8.7 L L 2 L 8.6 ' L L 6.1 ? q ? 6.2 4:2 4 s; S . - -_ ? R 4 4 To: prudential Ins. From: Rochelle L. Casses, DC Re: Nichole Sentz Claim x: 29S00016-08009 Date: February 9, 1998 To Whom it May Concern, As you are aware, Ms. Sentz has been under my care since December 31, 1997 for a cervical sprain-strain secondary to a p condition C7 subiuxation. ay, med by m selfd(seeaenclosedureports).WeAlthough herfO was performed by my is improving, further care is needed at 3X per week for 2 weeks formed and 2X per week for 4 weeks. A re-evaluation will again be performed at this time. If you have any questions or concerns please feel free to contact me. Sincerely, Rochelle L. Casses, DC f Casses Chiropractic Clinic CASE# ,P37 313 S. Hanover St. Carlisle PA 17013 717-249-0055 ORTHOPEDIC &NE•UROLOGICAL LXANm\'ATIONS NADIE /y ?? :1GE iY DATE -?- 9' 98 HEIGHT S-2` _WEIGI-IT isz POSTURE head tilt high ear high shoulder high ilium foot rotation DORSOLUMB:?R R?\GL- OF MOTION GAIT good bad explain LEG CHECKS urone rt. It. -D +D CS BCS supine r`r-4-•It._ noun ML! pain(level) flexion 75-90 s-o extension 30 Ac- Lt lat. flex. 35 Rt. lat. flex. 35 Lt. rotation 30 .1c Rt. rotation 30 ? REFLEXES (none =0; sluggish = 1+; normal = +2; slightly increases = 3+; hyperactive = 4+) Achilles L t z R ' Patellar L '" z R ?- ORTHOPEDIC TESTS iad of Dejerne T r ?J Minor's Sign Laseque's L Braggard's L Contralateral SLR v L Milgranrs (-) Nachlas L 0 Ely's 0 LO } L t - S/ s l•-s o "--•- - Adam's Advancement hemp's Trendelenburg Other tests uer Dermatonies (if Comments/other (+ (-? LG R ?L? R O L? R CERVICAL RANGE OF MOTION norm RONI vain(level) flexion 45 Alo _ extension SS ,sa Lt. lat. flex. 40 E ._._-- Rt. lat. flex. 40 Lt. rotation 70 ?r ----_ Rt. rotation 70 ko REFLEXES Triceps L --F2- R T Z Biceps L -+z- R -r z -7X ORTHOPEDIC TESTS Foramina Compression : straight L G R G Cervical Distraction (0 (+) Shoulder De essorp I Q 1 /4, _ T SOTO Hall (+) Other tests DerformPrtc Dermatomes (if tested):, Comments/other: SPINAL ANALYSIS vertebrae L?aloation x-rav listines Lt ilium Signature of doctor i Fti: LJ 1 Sacnmi SENTZ, NICHOLE (Standard Deviation ID: 858 lJ Mon Feb 09, 1998 Static EMG Scan 25 - 500Hz Action: Neutral Posture: Seated Scale: 100uV 3.3 [] C1 C1-1 ? 3.9 13.4? C C F C C - - ® 7.4 4.3 ? C 16.8 C C - - 6 6.0 0 T1 T f T L4.o 6.3 T 8.5 15.1 T5 T s T a T S T TS 19.8 5.5 ? T T z T 7.3 El 8.7 T T; T 10.8 - - 124.9 T T 20.7 T11 T T11 - 111. 4 ?] T L 1 18 .91 6.1 LJ L L 2 L - - 1 .2 ® L4 L 4 L 5 L L4 0 3.9 - - 11:9 S S 1 L 6.5 7.6 NORMATIVE DATA 25 - 500Hz Scale: 100uV j 3.8 ? Cl C1 ? 3.9 - - C C - - 4.4 ? C C ? 4.3 - - C4 C - - j 4.2 ? C C ? 4.1 - - C - - 4.8 C C 4.6 9.9 T1 T+ T1 H 9.9 5.0 - T T T 5.0 - - T T s T - - 6.5 ? -T-T- a T T ? 6.4 _ T 5 8.4 O T T T ? 8.2 r 9.6 T s - 0 9.5 T T 79- 10.0 Q T T T10 10.0 - - T T - - 9.8 T L T 9.8 8.7 L L 2 L 8.6 LT- 6.1 El L ? 4 L ? 6.2 L L 5 L ? ? 4.4 II S S 1 S II 4.4 SENTZ, ?symmetry table, Sit/Neutral in freq. nand 25 - 50OHz 0DF PSD NTTSD NORIM uV SITE _ u9 NORM _NSD PSD oDF --> I 1.6 3.8 I 4.4 _ Cl __ 1-6.7 3.9 _ 1_.8 I ++++++ I 2781 -> I _ 1 ; . '! 5.7 - C3 - - 18.1 4 3 - 1 7 1 ++TT1+_+ 1 - 21p1 -->, 1.0- _ _ _ _].2 i - -5.2 C5 5.7 11.1 1.O 1 j T 101 -->I ++++++ 1 1.9 4.8 !34.5 C7 54.6 4.6 2.0 1 _++++++ 1 581 402 . _ a•_ 2 4 9 I1 T1 3.5 I 9a., -9.6 1381 I TTTT 2.0 _ I 5.0 I 16.7 i2 7.0 5.0 ) _2.9 < 2401 ++++++ 1 3.0 6.5 136.0 T4 1 10.6 1 6.4 ! 3.2 1 + 1 <--1 9 ! 3.5 8.4 6.8 TG 6.6 1 8.2 3.5 -->: 4.1 9.6 10.8 T8 1 12."0 9.5 4.5 17, 761 ++++++ 4.2 !10.0 55.0 T10 1 31.3 10.0 1 4.3 1 ++++ <--! 38 ' ++++++ 4.5 9.8 46.5 T12 33.6 9.8 4.4 ' +++++ <--' 76 TTTTTT 4.1 0.7 37.1 Ll 21.4 O.6 .0 T+r 4 _ ? 291 ' ++++++ 3.1 6.1 80.4 L3 20.5 ! 6.2 3.4 ++++ <-- 105 ++ 3.2 5.2 11.8 L5 5.7 5.3 3.5 <--' -> T 2.7 ;.5 9.0 S1 100.4 _ .Y 2.8 . T 1017 ..EY: uV = Scan NOR., = Normal data NSD = Normal Sta ndard Deviation PSD = Patient Standard Deviations (from normal) oDF = Percent Diffe rence Mild Moderate Severe 402% 138% 240% 2% 76% 38% 76% 291% 105% Patient: SENTZ, NTCHOLE Static EEG Scan SSN: 1D: 858 Static-Scan, spinal on 47ed Dec 31, 1997 10:00 AM Seated/Neutral in freq. band 25-500Hz Scale shown = 0.0 - 100UV Left Sites 4.4uV Cl 5.7uV C3 5.2uV C5 34.5uV C7 17.8uV Tl 16.7uV T2 36.OuV T4 6.8uV T6 10.8uV T8 55.OuV T10 46.5uV T12 37.7uV L1 "o0.4uV L3 11.8uV L5 9.0uV S1 within !SD (or no norm)=20 +1SD= Left Sites 3.BuV Cl 4.4uV C3 4.2uV C5 4.8uV C7 4.9uV T1 S.OuV T2 6.5uV T4 8.4uV T6 9.6uV T8 10.0uV T10 9.8uV T12 8.7uV L1 6.luV L3 5.2uV L5 4.4uV S1 Right Sites Cl 16.7uV C3 18.luV C5 5.7uV C7 54.6uV T1 3.5uV T2 7.OuV T4 10.6uV T6 6.6uV T8 12.8uV T10 31.3uV T12 33.6uV L1 21.4uV L3 20.5uV L5 5.7uV S1 100.4uV +2SD= EM +3SD= -1SD= Right Sites C1 3.9uV C3 4.3uV C5 4.luV C7 4.6uV T1 4.9uV T2 5.OuV T4 6.4uV T6 8.2uV T8 9.5uV T10 10.OuV T12 9.8uV L1 8.6uV L3 6.2uV L5 5.3uV S1 4.4uV SENTZ, NICHOLE ID: 358 Wed Dec 31, 1997 Action: Neutral 4.4 ?? 5.7 5.2 U 34.5 Il36 1 6.8 ? 10.8 U x'55-0? J 51 46. 37.7 ao:? SOanaaHia -7 u f;?aL.LUJJ 90 , Static EMG Scan 25 - 500112 Posture: Seated Scale: 100UV DATA 3.8 4.4 4.2 4.8 4.9 5.0 6.5 8.4 9.6 10.0 9.8 8.7 6.1 5.2 4.4 f S 1 5 - 5 18.1 ? 5.7 154.6 7.0 1.0.6 6.6 12.8 31.3 33.6 21.4 i am 20.5 r-i 5.7 kale: 3.9 4.3 4.1 4.6 4.9 5.0 6.4 8.2 9.5 10.0 9.8 8.6 6.2 5.3 4.4 :Its .L J. _ [.'1 !•H ].r. .. N.. r: ...r. /:rr:.• t [ [[;.•rf r:. l:L:[ P.[ L. • .. C: _. • I 1 --------- ---- l.n •1'SI •It: .. .. fI L t--.z t- c ... _ pt!.. . ` II[ r? . ... r.. _ .'3L It ... .. ? •. • ..+ -J+r ?.+.. + .dam G+ ? •Gf: 'l+? L•i•G!' r. .. .. li. C:•f'Mif :. .. [ .... r.. ..• i C •'.•J: 1 r.: r - .c. J :!Y • •• ? 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UP 'C L uA%In D: 33 ^. a?:. r tv ^>tr l^: r.tCr: p. v.ur T:r: .LPI:IS t> r:l E.I. 3i. n. ?It ••. 9e tt Y•r : .L:> !••P.^.C TR.Ix: YEU. ..tic, EI,,:Un n•Y li n •J E ' ^ I',l rr:• CHU •r.r • n: c:r cr:v la :lon . oe L'ev 3•• i e••••ny .<ct.ret .•FFnv lc::cn V :n..r rere E. .r xrc r.9r. r;t•:rin4 r rre :p 1, L </rL D+:nivEe •e.:r A::r aert:•: :a•l: <•r c^ .< en rna ie Y. roe Sr .r< •e ler ::' .a b. ;E •1: e+ . •.r Cr•t:) i. ,. G• • _•,YEV• 5>:I<'/. r r Lllil I :II I I:I!'I I!Illi; Ili ll!I it II l ira :hl :II II!I lull I I I : a . my., Prudential Prudential Property and Casualtc Insurance Company A Subsidiary of The Prudential Insurance Company of America PAGE I or 4 Named Insured: Sentz :Van R and Pamela 1 PO Box 429 Policy Number: 28 SA134710 Hinsdale IL 60522 Policy Period: Apr. 16, 1999 :o Oct. I(i. 1999 12:01 a.111. at place of garaging Sentz Alan R and Pamela J Customer Service Office: (300) -137-5556 5 Trine Ave To report a claim, please call: (S00) •137-3535 Mt Holly Springs PA 17065-1144 Your local Prudential office: DONALD C KILLIAN LU-I'CF Your Car Policy Renewal Declarations Cars Covered By Your Policy Car Year & Make Model Body Type I 1988•Ford Taurus GL Sedan 4D 2 1996 Ford Cntr GI/S Sedan 4D 3 1990 Ford Taurus GL Sedan 4D 4 1993 Ford Tempo GL Sedan 4D The car(s) described abo%c arc principally kept (garaged) at the above address unlc Imponant Messages. Identification Number IF?.BP3242JA204155 IFALP653STK17777S I1 FACP52UXA1___21 2FAPP36X4PB138669 s odtenrise stated in Licensed Operator(s) Resident In Your Household Surcharge Points Date of Birth Name 00 01/26/52 1 Sentz Alan Rav 00 02/22/55 2 Sentz Pamela Junc 00 10/16/76 3 Sentz Justin 00 06/26/79 4 Sentz Nichole A If any licensed driver in household is not listed. please call the Customer Sen•ice office prcvided above. PAC 681 F.D. 1i93 AE15-005770 PP.G E 2 of 4 Police Number: 23 SA134 i10 Discounts, Credits. And Surcharges Applied To four Premium Discounts S Credits Annlies to Deluxe Package Discount Your police Driver Training Discount Driver(s) d Claim Free Discount Your police .Multi-Car Discount four police Safety Device Discount Car(s) 2. 3. Y Companion Police Discount and Companion For Life Your policy Discount have been applied to die premium. Important Messngc(s) That Apply To Your Policy First Pam Benefits includes: Medical Expenses S 101000 Income Loss. S 1,000 per month up to a total of S :.000 First Pam' Benefits provided without Funeral Benefits IF THIS POLICY PROVIDES COLLISION COVERAGE FOR ANY VEHICLE. THAT COLLISION COVERAGE ALSO EXTENDS TO VEHICLES RENTED. UP TO A MAXIMUM OF 30 DAYS. Full Tort applies to all cars listed on the Police. IMPORTANT: Your policy premium may have changed due to rating by make and model of your car. Please check the vehicle description shown. Your policy is free of any accident, conviction or inexperienced driver surcharge. The stacking referred to in PAC 4/PA Uninsured Motorists applies to all cars listed on the policy. The stacking referred to in PAC 5/PA underinsured Motorists applies to all cars listed on the policy. Rental Car Coverage, referred to under "Our Obligations to You (Part 3)" Of your policy, applies for Car(s) 1. 2. 3. 4. J'AC 681 ED. U93 990.116-990312 I ,re Prudential LIIII1i11'IIt IIu PAGE 3 of 4 PDlicN, Number: 28 S:U34710 Listed below and t?'idtin "Important Messages" arc Four policy coccragcs, limits- and premiums. If a premium charge does not appear, that coverage is not pro% ided. Your Coverage And Limits Premiums Coverage Limits Liability - Bodily Injury S100.G0U Each Person S_00 000 Each Accident . Liability - Property Damage 000 550 Each Accident . Uninsured Motorists - Bodily Inju ry Each Person 5100.000 Each Accident 5300.000 Underinsured . lotorists - Bodily I njury Each Person S100.000 Each Accident 5300.000 First Party Benefits Collision Deductible -Car 1 S 500 Deductible - Car 2 S 500 Deductible -Car 3 S 500 Deductible - Car 4 S -500 Comprehensive (G=FR Nnshld Glass Cov) Deductible -Car 1 S 50-G Deductible -Car 2 S 30-G Deductible -Car 3 S 50-G Deductible - Car 4 S 50-G Towing - Each Occurrence S=0 Rental Car Coverage Total Premium Per Car Car 1 Car 2 Car 3 Car 4 S 3•} S 113 S 3.4 S 109 S N S 64 S 28 S 59 S 3S S }= 5 43 S 43 II S a S 9 S 9 I 1(t 5 _ S 4; S 24 S 5 I I S -_ S 133 S 37 I S 83 ? S Il S == S 12 S 26 S I S 2 S 2 S '- S la S 14 S 14 S 14 S 215 S 480 S 223 S 399 TOTAL POLICY PRENIIUAi" 51,317 Premium amount includes applicable discounts. credits. and surcharges. AE15-00577 PAC 681 Ell. 1198 1 PAGE 4 of 4 Police Number: 28 SA 134710 Your Policy Forms & Endorsements Your policy is made up of your most recent Declarations and the forms and endorsements listed below. Forms and endorsements being made part of }.our police tcidt this transaction are provided in separate booklets or are indexed and reproduced on pages tyhich folloty: Mandatory Policy Forms and Endorsements Car Policy. Parts I. 2, and 3 Applicable policy parts are those for \dllch a premium charge is shown in the Declarations. Pennsylvania Special State Provisions PAC I86 Ed. 4iS6 PAC 226 PA Ed. MS Car Policy. Parts 4, i. 6 and 7 Applicable policy parts are those for %\hich a premium charge is shomt in die Declarations. Optional Endorsements None PAC 190PA Ed. 7i94 Lien holder/Loss Payee Information Car Territory I Rating Symbol Class Code I Not On File 040 S SI1220 2 Peoples State Bank PO Box 1000 E Berlin PA 040 S S43S20 3 Farmers Trust Co I W High St Carlisle PA 010 a SI 1120 4 Not On File 1 040 3 SS4S20 Countersi-ned by: 0/ PAC 631 ED. l/98 ?e?1i' INDEX Endorsements that are named on your Declarations page form a part of of your policy and are our policy with this subject to all of it s provisions. Those listed below are made part isions y transaction. Please refer to the following paces for . their prov FOR YOUR INFORMATION PAGE NUMBER PCO-3129PA , ENDORSEMENTS PAGE NUMBER PAC-4007 3 =21GXE AE 15-005772 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NICHOLE A. SENTZ-BROWN, Plaintiff V. GREGORY A. GRIFFIE and DONALD W. TACK, Defendants CIVIL ACTION - LAW No. 99-7601 CIVIL TERM JURY TRIAL DEMANDED NOTICE OF DEPOSITION Please be advised that on May 11, 2001, at 2:30 p.m., the Plaintiff will take the deposition of both the Defendants Gregory A. Griffie and Donald W. Tack, at the offices of Knauer & Associates, 411-A East Main Street, Mechanicsburg, Pennsylvania, before a person authorized by law to administer oaths. The oral examination will continue from day to day until completed. You are invited to attend and participate in this examination. Date: March 23, 2001 Respectfully submitted, KNAUER & ASSOCIA'T'ES, LSC David W. Knauer, Esquire Attorney for the Plaintiff Attorney I.D. No. 21582 411-A East Main Street Mechanicsburg, PA 17055 (717) 795-7790 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NICHOLE A. SENTZ-BROWN, Plaintiff V. GREGORY A. GRIFFIE and DONALD W. TACK, Defendants CIVIL ACTION - LAW No. 99-7601 CIVIL TERM : JURY TRIAL DEMANDED CERTIFICATE OF SERVICE I, David W. Knauer, hereby certify that I did this 23`d day of March, 2001, serve a true and correct copy of the Deposition Notice on all counsel of record by United States mail, first class, prepaid addressed as follows: Richard H. Wix, Esquire Wix, Wenger & Weidner 4705 Duke Street Harrisburg, PA 17109-3099 (For Defendant Donald W. Tack) George B. Faller, Esq. Martson Deardorf Williams & Otto Ten East High Street Carlisle, PA 17013. (For Defendant Gregory A. Griffie) '7 r7 David W. auer, Esquire Attorney for Plaintiff Attorney I.D. No. 21582 411-A East Main Street Mechanicsburg, PA 17055 (717) 795-7790 I f, lG io: Q.. u 1 Z 1% N C_ - 11 _1 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY SENTZ-BROWN Vs. NO. 997601 GRIFFIE & TACK 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 B 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 : 5/24/01 File #: M274187 GEORGE B FALLER, ESQUIRE MARTSON DEARDORFF WILLIAMS TEN EAST HIGH STREET CARLISLE, PA 17013-3093 717-243-3341 ATTORNEY FOR DEFENDANT INQUIRIES SHOULD BE ADDRESSED TOt MEDICAL LEGAL REPRODUCTIONS, INC. 4940 DISSTON STREET PHILADELPHIA PA 19135 (215) 335-3590 By: Christine Janiszowski IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY SENTZ-BROWN Vs. GRIFFIE & TACK I No. 997601 TO: NATHANAEL BYERLY RICHARD WIX 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: 5/2/01 GEORGE B FALLER, ESQUIRE MARTSON DEARDORFF WILLIAMS TEN EAST HIGH STREET CARLISLE, PA 17013-3093 ATTORNEY FOR DEFENDANT INQUIRIES SHOULD BE ADDRESSED TO: MEDICAL LEGAL REPRODUCTIONS, INC. 4940 DISSTON STREET PHILADELPHIA, PA 19135 (215) 335-3336 By: Christine Janiszewski Enc(s): Copy of subpoena (s) Counsel return card File #: M274187 COMMIMEF L"I OF PENNSYLVANIA COMM OF CUMBERLAND SENTZ-BROWN Vs. File No. GRIFFIE & TACK 997601 SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 YELLOW BREECHES EMS, 405 FORGE RD, BOILING SPRINGS PA 17007 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 or ngs- _ at MEDICAL LEGAL REPRODUCTIONS ,(A dssqq 7940 DISSTON ST., PHILA., PA You may deliver or mail legible copies of the documents or produce things requested h, 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.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•- t=pelling you to comply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: GEORGE B FALLER, ESQ ADDRESS: _ MARTSON TEARDORFF WILLIAMS -CARj1SL'S,-PA-17013-3093 TELEPHONE: SUPREME COURT ID # 215-335-3212 ATTORNEY FOR: 49813 DEFENDANT M274187-01 DATE: any, S?f the Oou nt -- (Eff. 7/97) ADDENDUM TO SUBPOENA SENTZ-BROWN Vs. GRIFFIE & TACK No. 997601 CUSTODIAN OF RECORDS FOR: YEI.I.0%% BkEECHES EMS ANY AND ALL OFFICE RECORDS, IN"':." :NJ NOTES, CORRESPONDENCE, MEMORANDA, X-RAY REPORTS, HIS7---.! NOTES, INDEX CARDS AND ANY OTHER INFORMATION RELATING TO ANY EXA7!:N;, :JN OR TREATMENT RENDERED TO: NAME: NICHOLE A SEN-.FFJWN ADDRESS: 150 WILLILAM GRI'VE RD #129 MECHANICSBRG DATE OF BIRTH: 06/02/79 SSAN: 178600827 CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - RECORD CUSTODIAN - COMPLETE AND RETURN I ) 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 YELLOW BREECHES EMS CUMBERLAND M274187-01 *** SIGN AND RETURN THIS PAGE *** CaMHX WEALTH OF PENNSYLVANIA COUNTY OF CL BERIAND SENTZ-BROWN Vs. File No. GRIFFIE & TACK SUBPOENA TO PRODUCE DOCLkENTS OR THINGS FOR DISODVERY PURSUANT TO RULE 4009.22 997601 CARLISLE HOSP, 246 PARKER ST, CARLISLE PA 17013 T0: 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 gSEEATTAUHED "DENDUM at -?- _. --- MEDICAL LEGAL REPRODUCTIONS (A(3*Sss?140 DISSTON ST., PHILA., PA You may deliver or mail legible copies of the documents or produce things requested h; 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 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 party serving this subpoena may seek a court orde.- (20) days after its service, the annPelling you to comply with it. . • . THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAPE: GEORGE B FALLER, ESQ ADDRESS: _ ..+..+. ZGN EARDORFF WILLIAMS CARLISLE, IJA 7013-3093 TELEPHONE: SUPREME COURT ID # 215-335-3212 ATTORNEY FOR: 49813 DEFENDANT M274187-02 DATE: Seal of the Court (Eff. 1/97) ADDENDUM TO SUBPOENA SENTZ-BROWN Vs. GRIFFIE & TACK CUSTODIAN OF RECORDS FOR: CARLISLE HOSP No. 997601 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: NICHOLE A SENTZ-BROWN ADDRESS: 150 WILLILAM GROVE RD #129 MECHANICSBRG DATE OF BIRTH: 06/02/79 SSAN: 178600827 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 or CARLISLE HOSP CUMBERLAND M274187-02 *** SIGN AND RETURN THIS PAGE *** COM44DNWFALTH OF PENNSYLVANIA COUNTY OF CUMIBFRIAM SENTZ-BROWN Vs. File No. 997601 GRIFFIE & TACK SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISOOVERY PURSUANT TO RULE 4009.22 STATE FARM MUTUAL INS CO, ONE STATE FARM DR, CONCORDVILLE PA 19339 TO: **SUBPOENA ENCLOSED** (Nave of Person or Entity) within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following docunents ors tbinas A: TTACHED ADDENDU_ at MEDICAL LEGAL REPRODUCTIONS ,(AWess1940 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 canbliance, 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•- crnpelling you to comply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: GEORGE B FALLER, ESQ ADDRESS: _ ^"acmcr)m ni•nnnnRFF WILLIAMS -PA?7013-3093 TELEPHONE: SUPREME OM RT ID # 215-335-3212 ATTORNEY FOR: 49813 DEFENDANT BY THE COURT: M274187-03 DATE X7 Znr%i Prothonotary/Cler vil Division : S6al of the Court -T- Deputy (Eff. 7/97) ADDENDUM TO SUBPOENA SENTZ-BROWN Vs GRIFFIE & TACK No. 997601 CUSTODIAN OF RECORDS FOR: STATE FARM MUTUAL INS CO RE EAND ALL RECORS, MEDICAL AND OR , BILLS, ETC. , AND ANY OTHERAINFORMATIONRPERTAAIINING TOOTES, NAME: NICHOLE A SENTZ-BROWN ADDRESS: 150 WILLILAM GROVE RD #129 MECHANICSBRG DATE OF BIRTH: 06/02/79 SSAN: 178600827 POL #6094262E31 38H; INSD: DONALD W TACK (CO-DEFENDANT); DOL: 12/27/97 ALL FEES MUST BE APPROVED PRIOR TO RECORDS BEING FORWARDED. RECORD CUSTODIAN - COMPLETE AND RETURN RE, CORDS ecords that,to ATTACHED he best of my kx owldge, information and of as custoan belief all documents or things above mentioned have been produced. ( ) r no record ofrtheyfothat a llowinghdocuments search have ( ) has DOCUMENTS been made and AVAILABLE. been located (CHECK THE APPROPRIATE BOX) : ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( ) RECORDS / XRAYS have been destroyed Date El! 1: orlZO signature or STATE FARM MUTUAL INS CO CUMBERLAND M274187-03 * * * SIGN AND RETURN THIS PAGE * * * COM4[II AJ.714 r>f' PENNSYLVANIA OOUNTY (W CIPM RIAND SENTZ-BROWN Vs. File No. 997601 GRIFFIE & TACK SUBPOENA TO PPM-gX DOCU ENTS OR THINGS DI °' p-P:' NT TO RULE_ g0pg,2Y CHILDTIME CHILDCARE, 5C A: ER SPRING RD, CARLISLE PA 17013 TO: ATTN: PERSONNEL DEPT (Narrie c? person pr' Entity) Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following document.,; or SEE 341TXCI?MEND???-- at MBDICAL LBOAL RBPRODIICTIONS SA 7gCeCS-.}940 Idr 3 DISSTON ST., PR=LA pj - You may deliver or marl legible copies of at the documents or Produce things requested h; this subpoena, together with the certificate of ecrrpliance, request You have to the party making this the address listed above, advance the reale cost of preparing the copies or producing the thithe ngs right to seek in sought. king a If you fail to produce the docvrents or things required by this subpoena within twenty (201 days after its service, the party serving thin, crnpelling you to conply with it. ubPoena may seek a court orde. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF TF£ FOLLCWIN0 PERSON: NAME: GEORGE B FALLER, ESQ ADDRESS: _ ---- RFF WILLIAMS TELEPHONE: E%-17013-3093 SUPREME COURT ID # 215-335335-212 ATTORNEY FOR M274187-04 49813 DEFENDANT DATE: 2 sisal of the_Court - BY T>9 OMATr: Division (Eff. 7/97) ADDENDUM TO SUBPOENA SENT. BROWN Vtv Gf,:FFIE & TACK No. 997601 CUSTODIAN OF RECORDS FOR: CHILDTIME CHILDCARE ANY EMPLOYMENT APPLICATIONS, EARNINGS, LEDGER SHEETS, TIME CARDS REVIEWS, ATTENDANCE SHEETS, ANY AND ALL MEDICAL RECORDS AND REPORTS AN:) PRE-EMPLOYMENT PHYSICALS, WORKMEN'S COMPENSATION CLAIMS MADE, ANY W-2 WITHHOLDING TAX FORMS, AND ANY OTHER INFORMATION PERTAINING TO: NAME: NICHOLE A SENTZ-BROWN ADDRESS: 150 WILLILAM GROVE RD ##129 MECHANICSBRG DATE OF BIRTH: 06/02/79 SSAN: 178600827 CERTIFIED PHOTOCOPEES 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 CHILDTIME CHILDCARE CUMBERLAND M274187-04 LwY * * * SIGN AND RETURN THIS PAGE * * * TO: CpppepNWEALTH OF PEDIIIS'tZVANlA COUNV OF QJ ID SENTZ-BROWN 997501 Vs. File No. GRIFFIE 6c TACK NA TO PRODUCE DOCL-WNTS OR THINGS mn SOOVERy PURSIIAN7 TO RULE_ 4?9 •?2 FIRST CHURCH OF GOD, 28 E MAIN ST, MECHANCISBURG PA 17055 ATTN: PERSONNEL 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 orSngA:TT-? 1 __.._... at Birc &940 DISSTON ST., raisin., _-- MEDICAL LEGAL REPRODUCTIONSI[A ets) You may deliver or mail legible copies of the documents or produce things requested t.: this subpoena, together with the certificate of corpliance, 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•• onnVelling you to camply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: GEORGE B FALLER, ESQ ADDRESS: _ MARTSMI nFARnnRFF WILLIAMS --iCARV1S-bB-,-W-37013-3 093 TELEPHONE: 215-335-3212 SUPREME COURT ID q ATTORNEY FOR: 49813 DEFENDANT BY Ca?T' M274187-05 r.1„rl ivil Division DATE - S1 of them Depusy (Eff. 1/97) ADDENDUM TO SUBPOENA SENTZ-BROWN Vs. GRIFFIE & TACK No. 997601 CUSTODIAN OF RECORDS FOR: FIRST CHURCH OF GOD 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: NICHOLE A SENTZ-BROWN ADDRESS: 150 WILLILAM GROVE RD #129 MECHANICSBRG DATE OF BIRTH: 06/02/79 SSAN: 178600827 CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN - COMPLETE AND RETURN [ I 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. [ I 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 Aut orize signature or FIRST CHURCH OF GOD CUMBERLAND M274187-05 *** SIGN AND RETURN THIS PAGE *** Con4X MALTH OF PENNSYLVANIA axwry OF CUMBIRum SENTZ-BROWN Vs. File No. 997601 GRIFFIE & TACK SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 GIAND FOOD STORES INC, 1149 HARRISBURG PK, CARLISLE PA 17013-0249 TO:. ATTN: PERSONNEL 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 doc rents or things: -" SEE ATIACHED ADDENDUM at MEDICAL LEGAL REPRODUCTIONS ,(A ss7940 DISSTON ST., PHILA., You may deliver or mail legible copies of the domments or produce things requested t•) this subpoena, together with the certificate of carpliance, 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 docunents or things required by this subpoena within twenty (20) days after its service, the party serving thir? subpoena may seek a court orde•• crnpelling you to ocis ly with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NM'E: GEORGE B FALLER, ESQ ADDRESS: 14ARTSON D RD RFF WILLIAMS TELEPHONE Z'ARI,T=,-- A -I 7 013 - 3 0 9 3 SUPRETE COURT ID # ___215-335-3212 ATTORNEY FOR: 49813 DEFENDANT M274187-06 DATE: 2 ??,.? S al o the Coin (Eff. 7/97) ADDENDUM TO SUBPOENA SENTZ-BROWN Vs GRIFFIE & TACK No. 997601 CUSTODIAN OF RECORDS FOR: GIAND F(X H)STORES INC ANY EMPLOYMENT APPLICATIONS, EAYN:N":S, LEDGER SHEETS, TIME CARDS REVIEWS, ATTENDANCE SHEETS, ANY AN: A:.:. MEDICAL RECORDS AND REPORTS AND PRE-EMPLOYMENT PHYSICALS, W'_+KMK.N'S COMPENSATION CLAIMS MADE, ANY W-2 WITHHOLDING TAX FORMS, AND AX'i :"HER INFORMATION PERTAINING TO: NAME: NICHOLE A SENT[. BROWN ADDRESS: 150 WILLILAM GROVE RD #129 DATE OF BIRTH: 06/02/79 SSAN: 178600827 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 GIAND FOOD STORES INC CUMBERLAND M274187-06 * * * SIGN AND RETURN THIS PAGE * * * J CUICNWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SENTZ-BROWN Vs. File No. GRIFFIE & TACK SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DI=VERY PURSUANT TO RULE 4009.22 TO: MULBERRY CHILD CARE, 3710 TRINDLE RD, CAMP HILL PA 17011 ?........_ .,.,.,n,......„ ., nm of Person or Ent within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following documents orS n9AT1:kCHE1) DENDUM at -- - - -- MEDICAL LEGAL REPRODUCTIONS (AMbst 940 DISSTON ST., PHILA., PA You may deliver or mail legible copies of the.docupents br produce things requested t:; this subpoena; together with the certificate of"'c6npliance, 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 reduired by this subpoena within twenty (20) days after its service, the party serving thin subpoena may seek a court orde•- ampelling you to comply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FCLLONINC) PERSON: NAME: GEORGE B FALLER, ESQ ADDRESS: _ Mnnmenn. nvaannRFF WILLIAMS L=, PA 17013-3093 TELEPHONE: SUPREME COURT ID # 215-335-3212 ATTORNEY FOR: 49813 DEFENDANT BY OOH?: M274187-07 - Prothonotary/Cler ivi'l Division DATE* ' r/ S dal o Court -- - - Deputy (Eff. 7/97) i ADDENDUM TO SUBPOENA SENTZ-BROWN Vs. No. 997601 GRIFFIE & TACK CUSTODIAN OF RECORDS FOR: MULBERRY CHILD CARE 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: NICHOLE A SENTZ-BROWN ADDRESS: 150 WILLILAM GROVE RD #129 MECHANICSBRG DATE OF BIRTH: 06/02/79 SSAN: 178600827 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 MULBERRY CHILD CARE CUMBERLAND M274187-07 *** SIGN AND RETURN THIS PAGE *** SENTZ-BROWN Vs. GRIFFIE & TACK 014UNWFALTH OF PENNSYLVANIA COUNTY OF Cl1NIDERIIIlID File No. SUBPOENA TO PRODUCE DOCt1!ENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 997601 CHILDRENS FAMILY CTR, 100 MT ALLEN DR, MECHANCISBURG PA 17055 TO: ATTN: PERSONNEL 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 ors t;lyings* MHED. ADDENDUM at _ 7940 DISSTON ST., PHILA., PA MEDICAL LEGAL RHPRODUCTIONS,(AWdss4 You may deliver or mail legible copies of the documents or produce things requested-, this subpoena, together with the certificate of caipliance, to the party making t.hi_ 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 tent} (20) days after its service, the party serving thin subpoena may seek a court or-de.- compelling you to comply with it, THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: GEORGE B FALLER, ESQ ADDRESS:? MADTCrIM DEARDORFF WILLIAMS upicLISLS',-PA -17013-3093 TELEPHONE:- SUPREME COURT ID # 215-335-3212 ATTORNEY FOR: 49813 DEFENDANT BY /'?/E COURT: M274187-08 Prothonotary/O erk(0ivil Division DATE: -?-- S1 of the Court /1 !s Deputy (Eff. 7/97) SENTZ-BROWN Vs. GRIFFIE & TACK ADDENDUM TO SUBPOENA No. 997601 CUSTODIAN OF RECORDS FOR: CHILDRENS FAMILY CTR ANY EMPLOYMENT APPLICATIONS, EARNINGS, LEDGER SHEETS, TIME CARDS REVIEWS, ATTENDANCE SHEETS, ANY AND ALL MEDICAL RECORDS AND REPORTS W 2 WITHHOLDING PRE-EMPLOYMENT TAX PHYSICALS, , AND WO ANY OTHER INFORMATION PERTAININGETO: NAME: NICHOLE A SENTZ-BROWN ADDRESS: 150 WILLILAM GROVE RD #129 MECHANICSBRG DATE OF BIRTH: 06/02/79 SSAN: 178600827 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. [ ) h a DOCUMENTS been made and `that Eno record ofrtheyfothat a llowinghdocuments search been located (CHECK THE APPROPRIATE BOX) : ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( ) RECORDS / XAAYS have been destroyed Date Authorized signature or CHILDRENS FAMILY CTR CUMBERLAND M274187-08 * * * SIGN AND RETURN THIS PAGE * * * -- ?•> __ ?, ;: - - ;. __ ; _ ,. , ?_, -- .._.?? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NICHOLE A. SENTZ-BROWN, Plaintiff V. GREGORY A. GRIFFIE and DONALD W. TACK, Defendants CIVIL ACTION - LAW No. 99-7601 CIVIL TERM JURY TRIAL DEMANDED PRAECIPE TO MARK THE DOCKET SETTLED ENDED AND DISCONTINUED TO THE PROTHONOTARY: Mark the docket settled, ended and discontinued in the above action. Respectfully submitted, KNAUER & ASSOCIATES, L.S.C. David W. Knauer, Esgmrc Attorney for Plaintiff Attorney I.D. No. 21582 411-A East Main Street Mechanicsburg, PA 17055 Date: September 6, 2001 (717) 795-7790 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NICHOLE A. SENTZ-BROWN, Plaintiff V. GREGORY A. GRIFFIE and DONALD W. TACK, Defendants CIVIL ACTION - LAW No. 99-7601 CIVIL TERM JURY TRIAL DEMANDED CERTIFICATE OF SERVICE I, David W. Knauer, hereby certify that I did this 6th day of September, 2001, serve a true and correct copy of the within Praecipe to Mark Docket Settled, Ended and Discontinued on all counsel of record by United States mail, first class, prepaid addressed as follows: George N. Faller, Jr., Esquire Ten East High Street Carlisle, PA 17013 David W. Knauer, Esquire Attorney for Plaintiff Attorney I.D. No. 21582 411-A East Main Street Mechanicsburg, PA 17055 (717) 795-7790 r «? u?C • '? ?_? ?=r' ' °- f_lJ ? ? G? G .](:C _ .5 `_?.??,.. e.. iii 7_ a t.u :?_ - ?,a :*?r_ N ' CJ ? U ?? ., ?.?