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HomeMy WebLinkAbout09-0406 Metzger, Wickersham, Knauss & Erb, P.C. By: Clark DeVere, Esquire Attorney I.D. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 Attorneys for Petitioners (717) 238-8187 cdvQmwke. com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: KAYLA PRATT, a Minor NO. O4 - qO(, t u? CIVIL ACTION - LAW PETITION FOR APPROVAL OF MINOR SETTLEMENT AND NOW, come the Petitioners, Kevin Pratt and Charlene Pratt, as parents and natural guardians of minor Kayla Pratt, and petition this Court for approval of a settlement of a minor's case in accordance with Pa.R.C.P. No. 2039 and, in support of the Petition, avers as follows: 1. Petitioners, Kevin Pratt and Charlene Pratt, husband and wife, are adult individuals residing at 12 Lois Lane, Mechanicsburg, Cumberland County, Pennsylvania. 2. Petitioners are the parents and natural guardians of minor Kayla Pratt, who resides with them, and who is 17 years old, having been born on September 13, 1991. 3. Minor Petitioner Kayla Pratt has selected Petitioners, as her parents and natural guardians, to represent her interests in this Petition. 408406-1 0 6 4. On April 4, 2007, at approximately 6:35 p.m., minor Petitioner was a rear seat passenger in a 2006 Dodge Sedan owned by Darlene Wilson and operated by Eric Heilner. 5. At the aforesaid time and date, Mr. Heilner, minor Petitioner and two other passengers were traveling north on Creekside Drive, approximately .5 miles from the intersection of Center Street and Magaro Road, in East Pennsboro Township, Cumberland County, Pennsylvania. 6. At the aforesaid time and place, Eric Heilner approached a bend in the road which curved toward the northeast and lost control of the car, causing him to continue traveling north until he collided with a tree stump located off the roadway. A true and correct copy of the police accident report is attached hereto and incorporated herein by reference as Exhibit "A". See also, photographs showing damage to the 2006 Dodge Sedan occupied by Minor Petitioner which are attached hereto and incorporated herein by reference as Exhibit "B" and photographs of the accident scene attached hereto and incorporated herein by reference as Exhibit "C". 7. Petitioner Charlene Pratt arrived on the scene of the accident and took minor Petitioner to the Holy Spirit Hospital Emergency Room where she reported that her daughter was involved in a motor vehicle accident. The emergency room physician noted that Kayla was complaining of severe pain on her face where she had a laceration on her chin. She had a 2.7 cm laceration on her chin and contusions on her chin and forehead. Kayla was given Vicodin for the pain and sent for a CT of her facial bones, which came back negative for any fractures. Following the CT, the laceration was cleansed extensively with Betadine and saline solution, sutured and dressed. The physician recommended that Kayla take Advil for the pain, and to follow up with a plastic surgeon. 408406-1 0 0 8. On April 9, 2007, Petitioner Kevin Pratt and minor Petitioner reported to the Plastic Surgery Center and met with Dr. Yates. At that time, Mr. Pratt reported that his daughter was involved in a motor vehicle accident. On examination, Dr. Yates noted that Kayla had a 2.6 cm laceration on her chin. The sutures were removed from Kayla's chin and the wound was cleansed. Dr. Yates advised Kayla and her father on wound care and scar emollient and recommended returning for possible laser treatment if needed. 9. On October 12, 2007, Kayla returned to the Plastic Surgery Center, after one follow up visit in July. At that time, Dr. Yates took a second photograph and noted that Kayla's scar would not have complete eradication from the use of the scar emollient, and recommended that Kayla return for N-lite laser scar destruction treatments. 10. On October 29, 2007, Kayla reported to the Plastic Surgery Center to begin her N- lite laser scar destruction treatments. Kayla returned to the Plastic Surgery Center on November 26, 2007, December 10, 2007, January 21, and March 17 to receive a total of 5 N-lite laser scar destruction treatment sessions. 11. On March 17, 2008, Kayla returned to the Plastic Surgery Center for a follow up visit concerning her N-lite treatments. On examination, Dr. Yates noted an improvement in Kayla's scar, and recommended returning for a follow up if she was unsatisfied with the results after 180 days. Kayla has had no further follow-ups and no plans to seek further treatment. 12. Minor Petitioner sustained the following injuries as a result of this accident: (a) Laceration on chin 2.7 cm long; (b) Contusions on chin; (c) Abrasion on left forehead; (d) Bruises/abrasions on arms and knees; 408406-1 (e) Jaw pain; and (f) Loss of consciousness. See medical records attached hereto and incorporated herein by reference as Exhibit "D". See photographs taken of minor Petitioner shortly after the accident attached hereto as Exhibit "E"; see also photographs taken of minor Petitioner in April of 2007 attached hereto as Exhibit "F" and photographs taken on June 11, 2008 showing scarring attached hereto as Exhibit "G". 13. The medical bills for Kayla's treatment as a result of the injuries sustained in the accident have been paid by the automobile insurer Erie Insurance Group who insures her parents. The medical bills total $5,987.90. There are no outstanding medical bills or liens. A copy of the medical bills are attached hereto as Exhibit "H" and incorporated herein by reference. 14. At the time of the accident, minor Petitioner was employed part-time as a sales associate for Cookies by Design. At the time of the accident, Kayla made $7.00 an hour and worked three nights a week during the school week for two hours, and two Saturdays a month for five hours. Kayla was unable to work on April 5, April 9, April 14 and April 16, 2007 as a result of the accident. She realized a wage loss of $77.00 to date. See wage loss documentation attached hereto as Exhibit "I". 15. USAA has tendered its $15,000.00 in liability coverage to Kayla Pratt and Petitioners to resolve the liability claim against Eric Heilner and Darlene Wilson as a result of this incident. See tender letter from USAA dated July 24, 2008 and liability insurance declaration sheet attached hereto as Exhibit "J". 16. Erie Insurance Group, the underinsured motorist carrier for minor Petitioner's parents, has also agreed to pay underinsured motorist benefits to minor Petitioner in the amount of $20,000.00. 408406-1 17--? • 17. Petitioners, Kevin Pratt and Charlene Pratt, after consultation with counsel, has determined that it is in the best interest of Kayla to accept USAA's tender on behalf of Eric Heilner and Darlene Wilson and seek Court approval of the settlement. 18. Petitioners, Kevin Pratt and Charlene Pratt, have also determined that it is in the best interest of Kayla to accept Erie Insurance Group's underinsured motorist benefits payment proposal and seek Court approval of the settlement. 19. Counsel was retained by Petitioners to represent Kayla on a contingent fee basis of 25% of gross recovery. A true and correct copy of the Fee Agreement is attached hereto and incorporated herein by reference as Exhibit "K". 20. Counsel's attorney fee at 25% is $8,750.00. In addition, counsel has also incurred expenses in the total amount of $310.28 in pursuing this claim on behalf of Kayla. See itemization of these costs attached hereto and incorporated herein by reference as Exhibit 'T". 21. Petitioners respectfully request that this Honorable Court approve the compromise settlement of this claim with USAA and Eric Heilner/Darlene Wilson (third party claim) and Erie Insurance Group in the total gross sum of $35,000.00, out of which Petitioners will receive the sum of $25,939.72 on behalf of Kayla, and counsel will receive the sum of $9,060.28 for attorney fees and costs. 22. Petitioners propose to place their daughter's settlement proceeds in a federally insured restricted savings account or certificate of deposit at Commerce Bank, a bank, credit union or savings and loan association organized or existing under laws of the Commonwealth of Pennsylvania in the name of their daughter. 23. Petitioners also have been requested to sign the Releases attached hereto as Exhibit "M" and "N" and incorporated herein by reference, upon approval of the settlement, 408406-1 0 0 which would release USAA and Eric Heilner/Darlene Wilson (Exhibit "M") and Erie Insurance Group (Exhibit "N") from any further claims by Kayla or on her behalf as a result of the incident at issue. 24. USAA, on behalf of its insureds, concurs with the filing of this Petition and also seeks approval of the minor's settlement under the terms set forth above without admission of liability. 25. Erie Insurance Group concurs with the filing of this Petition and also seeks approval of the minor's settlement under the terms set forth above. WHEREFORE, Petitioners respectfully request that this Honorable Court approve of the minor settlement and enter a Decree distributing the funds as follows: (1) To be paid to Kevin and Charlene Pratt, parents and natural guardians of Kayla Pratt, the sum of $25,939.72, to be placed in a federally insured and restricted savings account or certificate of deposit, to be marked "not to be withdrawn, assigned, negotiated or otherwise alienated until Kayla Pratt reaches her majority on September 13, 2009, except upon prior Order of the Court"; (2) To be paid to Metzger, Wickersham, P.C., for counsel fees and expenses the sum of $9,060.28; It is further requested that an Order be entered granting Kevin Pratt and Charlene Pratt, as parents and natural guardians of Kayla Pratt, authorization to sign the Releases attached to the Petition. Dated: f l METZGER, WICKERSHAM, KNAUSS & ERB, P.C. By: . az?A Clark DeVere, Esquire Attorney I.D. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 (717) 238-8187 Attorneys for Petitioners 408406-1 VERIFICATION The undersigned hereby certifies that he is the attorney for Petitioners, Kevin Pratt and Charlene Pratt, as parent and natural guardian of minor Kayla Pratt, and that the facts in the foregoing Petition for Approval of Minor Settlement are true and correct to the best of his knowledge, information and belief, and that said matters relating to the Petition for Approval of Minor Settlement are as known to the undersigned as to the clients, Kayla Pratt, by Kevin Pratt and Charlene Pratt, her parents and natural guardians, said knowledge being based upon information contained in the attorney's file in this matter, and further states that false statements herein are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unworn falsification to authorities. Clark DeVere, Esquire Dated: I //(-/ 16!? 408406-1 0 0 VERIFICATION I, Kevin Pratt, as parent and natural guardian of Kayla Pratt, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Settlement, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unworn falsification to authorities. Kevin Pratt, as parent and natural guardian of Kayla Pratt Dated: --d 408406-1 0 0 VERIFICATION I, Charlene Pratt, as parent and natural guardian of Kayla Pratt, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Settlement, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsification to authorities. Charlene Pratt, as parent and natural guardian of Kayla Pratt Dated: 408406-1 0 0 -Pn?i t CRS W0054940 COMMONWEALTH OF PENN J POLI E CRASH REPORTING FORM 11111111 1111 lllli 1111 1111 Can Closed Reportable Crash 500 1 O Ygs ONO a Yes Q No 1 W0054940 12007040095 AgWICYNA101111111 East Pennsboro Township g 1835 J 11 1838 Reviewer 1 1617 1 1 21101 1 Number Precinct InvDate (MM-DD-YW EAST PENNSBORO 04 -? -F2007 0- 1-1 )Od-2 county County Name MunkJgwlitv Munk' al i Name pm,r 21 Cumberland 101 t Pennsboro Township O Sun Q Thu Crash Date (MLA-YYYY) - Crash Time (mil) No of Units le injured VJN*d ' •H > 0* O Mon Q Fri 04 - 04 - 2007 7 1835 1 4 2 0 complete O Tue O sat Form F 0 Wed Q Unk Woritzone Y Complete Q Yes 29) School Bus No Related O Yes No 1 School Zone Related O Yes 0 No N?otltyPE1OTQ Yes No •II1 13 O 4 Way Intersection Q -Y' Intersection Q Intersection Midblock Q -T• Intersection O Traffic Cirde/ Round About O On Ramp Route Number ment (OptionaQ Travel Lanes Speed Limit 02 25 Street Name CREEKSIDE Q Interstate O Turnpike Turnpike State (Not Tumni6% (Eaerniupat O c..,.: O ?:_...._. Route Number meat ( onaq Travel Lanes Speed Limit Street Name &Ila Q Interstate Q Turnpike Q Turnpike Q State (Not Turnpike) (East/We Spur Highway O Off Ramp O Railroad Crossing II ?? 00 O Crossover Q Other North O South Street Ending O East DR z O West O Unknown Q County -- Road . Local Road or Street For Mid-block anshe only. postall House Number and make sure hwKiWl Roadway Strom Name is filled in it uskg this option O Private O Other/ Road Unknown Pagel of 6 Crash Number O North O South S leg c Q East x O West O O Unknown O County Q Local Road Road or Street Q Private Q Other/ Road Unknown tntersecd Rt Num Or Mile P st Or Se ment Marker Or Intersect) Stre o et Nam O 2 O North South Q u Please Enter J e CENTER St Endin ST O E Or Mir a ROTH O West 5 ? Landmarks if Using This Option Intersects Rt Num Or Mile Post Or Segment Marker N ? c 0 North O ' Distance From Crash N or Intersect) Street Name St End' O South O Scene to Landmark 1 (for Crash between MAGARO East O West Landmark 1 and Landmark 2) 7 Degrees Minutes secondii; ..w.? .o.o 6 Latitude: longitude: _o. O Yield Sign Q Police Officer or Lo ra! Device z s licable Q Traffic Signal Active RR Crossing Flagman Traffic O Controls O Other Type TCD O Stop Sign Q Passive RControls O Unknown 3 No Controls O Device Functioning Emergency Improperly O Preemptive Q Device Not Q Device Functioning Signal Functioning Properly O Unknown LAOLGhwil ( (/f 'Not gopr®bk', skip nest of the Lane Clause section) LAKMa m Q North Q East O Not Applicable O Partially 0 Fully Q Unknown DbUlaa O South Q West Tra Yes 0 No Q Detained Unknown Q FORM M "-M (12m) 0 North and South O All O East and West (N,S,E,M Q < 30 Min. S 3060 Min. Q 1-3 hrs Q 3.6 hrs Q 6-9 hrs Q > 9 hours PENNDOT COPY O Unknown ,A CRS W0054940 0 J COMMOibl MALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORWi Page: AA 500 2 ''m use an" 2 Unit No First Neme MI Date of Birth (M"D-YYYY) O1 ERIC 09 11 1989 Delete? Last Name Tale bona Number_ - O HEILNER 7177662460 ? Address / / state Z 326 RAVEN CT MECHANICSBURG PA 17050 Page 2 of 6 Gash Number 7 MOLar ven" In Tylx ? Transport O Hit & Run Vehicle O Illegally Parked O Legally Parked QNon -Motorized Commercial Vehicle in/t Pedestrian on Skates, Disabled From O Yes 0 No Q Pedestrian O in Wheelchair, etc Previous Crash O Train Q Phantom Vehicle Of Yes, Complete Form U IN •a..?.?s.,?.,• ... •e.a..?.:... ,,., c,..._.. :_ w,-b,._,. _... P 28822970 • 1111111101 W0054940 state Class AkohWei uas Susoected Dn%w or Pt deMilan Phtsfol Conifton No Q Illegal Drugs Q Medication NNoppaal Q lIlVal Drug Q Fatigue Q Medication O Alcohol O Alcohol and Drugs O Unknown O Had Been O Sick O Aslee O Unkno p Drinking__ wn Ak" Test Tye 0 Test Not Given Q Breath O Other Prirtrarr Vehkle Code Viohtion Charged? Q Blood Q Urine O nknkr wnif CARLESS DRIVING 0 Yes O No Akoho/ Test Results Q Test Refused Q Unknown Orhw Presence i=Driver Operated 3=Driver Fled Scene Im • Q Test Given, Contaminated Results a Vehicle 4=Hk and Run I i 2=No Driver 9=Unknown _• _ Owrrer/Driver 00=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Police Veh 09-Federal Gov Veh O1 01=Pnvate Vehicle Owned/ OwnedJLeased by Driver 05-PENNDOT Vehicle 08=Other Municipal 98=Other Leased by Driver 03-Rented Vehicle 06-Other State Gov Veh Government Vehicle 99=Unknown Same as WW"W raw% memo Driver Q DARLENE E WILSON or AWIRSS / CitY / State / Zip Vehlde Make *Make Cods 326 RAVEN CT MECHANICSBURG PA 170507050 Dod a 07 VIN Model Year Vehicle Model (see overlay) 2006 SDN um" Plate Reg. State Est Speed VehWe Towed Towed B GJW3371 PA 060 0 Yes Q No MAGAROS fns Insurance Company Polley No Yes Q No Q known USAA CASUALTY 017123716C 71017 Tr?fli q Unit No. of E] T ili 1-Towing Pass. Veh 4=MobiWModular Home 7=Semi-Trailer 2=Towing Truck 5 -Camper 8=Other Tag No Tag Year Tag St ra ng unit 3=Towing Utility Trai ler 6=Full Trailer 9=Unkno s wn Dlrcttfon of a ra *Vehide Position 01 .Movement 16 -Ste Ov rl Special Usaw e ay Vehicle Color Vehfde Tye 05=Large Truck 20=Unicycle, Bicycle, 00 12=Commercial 06-Yellow 12 07=Siver 5Rver O1 01=Automobile 02=Motorcycle 06-=SUV 07=Van Van Tricycle 21=Other Pedalcycle Passenger 00=Not Applicable Cartier 08=Gold 01-Blue 09=Brown 03=Bu3 04=Small Truck 10=Snowmobile 11=Farm Equip 22=Horse & Buggy 23=Horse & Rider 01-Fire Veh 13=Taxi 02=Ambulance 21 =Tractor Trailer 02=Red 10=Orange (!f `02`, Complete Form 12=Construction Equip 24=Train 03=Police 22=Twin Trailer 03=White 11 =Purple M, Section 26) 13=ATV 25=Trolley 08=Other Emergency 23=Triple Trailer D4=Green 12=Other 05=Black 99=Unknown (If Form M , Section 71 `ection , 27) Complete 18=0ther Type Spec Veh 1 g=Unk. Type Spc Veh 98=Other 99=Unknown Vehicle 31-Modified Veh 11-Pupil Transport 99=Unknown Intilel Impact Point Damaoe Indicator Gradient 3=Downhill Road Alionment 12 00=Non-Collision 14=Undercarriage 01-12=Clock Points 15=Towed Unit IKI 0=None 2-Functional 1-Minor 3=Disabling a 1=Level 4=Bottom of Hill "=To of Hill 1=Straight C d ? 2 13=Top 99=Unknown 9-Unknown 2=Uphill p 9=Unknown = urse 9=Unknown FORM x M•500 (12/02) PENNDOT COPY x CRS W0054940 J COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Page AA 500 3 r°' 0n1) 3(?' ,' A 1= 00" p OOe? NoL taA Ca ss en ger/Occ u pant 2=Passenger 01-Driver - All Vehicles 7-Pedestnan 02-Front Seat Middle Position 8-Other 03-Front Seat Right Side 9aUnknown D4-Second Row - Left Side Or 05=Second ??Middle Position Se/t: 06-Second Row - Right Side B F =Female 07=Third Row Or Greater - M-Male Left Side U =Unknown D8=Third Row Or Greater - Middle Position 09-Third Row Or Greater - Right Side tDAa 1Sleeper Section of 0s TNckcab Injured 1 In Other ErKlosed laKdled Passenger Or Cargo Area 2=Major injury 12=ln Open Area 3=Moderate (Back Of Pickup, Etc.) Injury 4- 9 In 13=Trailing Unit 14=110 O V hi l jury n 7 e c e Exterior Unjury, Unk 15-Bus ssenger Severity 98-Other 9aUnknownif 99--Unknown Injury EX= 01-Shoulder Beit wrap And Shoulder Belt Used 04aChId Safety Seat used 05-Motorcycle Helmet Used 06=B' Helmet Used 10=SaBeR Used Improperly 11=Chi Safety Seat Used Improperly 12=Helmet Used Improperly 90altestraint Used, Type Unknown 99-Unknown F Sooft a Use / Not Applicable 01-Front Air Bag Deployed (For This SeaU 02=Side Air Bag by yed (For This Seat) 03=Otlter Type Air ir BagDepDeployed 0. ul6ple Air Bags toyed 05s MOtOrCyCle Eyp Protection 06=11icydist 1Neari rg ElbowXneelpads I 0--Air r Bag Not Dedoyed, Switch On Not 12-Ar B y Not Deploged; Switch Off Unk Swritch Setti 13=Ale Bag Removed 'or To Crash) 19-Unknown If Air Bag Deployed 99=Unknown • II?IIIIYIII G = pplicable 1=Not Ejected 2=Totalh 3=Partially %U4now n H &*iir» Pe,. Page 3 of 6 Crash Number D-Not Ejected / Not Applicable 1=Thro6gh Side Door Opening 2=Through Side window 3=Through %MndsNe(d 4--Through Bads Door S=Through Back Door Tailgate Opening 6=Through Roof Opening (Sunroof/ Convertible Top Down) 7=Thro9h Roof Opening (Convertible ?_V I IRfIV W/l O=Not licable 21-?NotxWt E ofxtritedcaBted y Mechanical Mears 3-Freed By Non - Mechanical Means 8-Other 9-Unknown EMS Agency: EAST PENNSBORO TWP Medical Fadlity HOLY SPIRIT HOSPITAL Unit No Person No Deletes Date of Birib (MM-DD-YYYY) A B C D E F G H I O1 O1 Q 09 - 11 - 1989 1? M? 0? O1 03 O1 1? 0? 1? Name /Address /Phone [I ??r HEILNER, ERIC S 326 RAVEN CT MECHANICSBURG PA 17050 7177 EMS Transport O Yes a No Unit No Person No Date of Birth (MM DD-Y" A B C D E F G H 1 O 1 02 p7 - 17 -11991 2I R ]FO 03 T101 LEE] Name /Address /Phone Same as [ARTY BECHTOLD 52 N OLD STONEHOUSE RD CARLISLE PA 17013 EMS Transport Operator Q Yes WNo O1 03 te7-? Q 09 13 1991 2 F? 4? 03 E 00 1? [6-1 EJ Name /Address /Phone ? OSame pe as KAYLA PRATT 12 LOIS LANE M ECHANICSBURG PA 17050 71749784 EMS Transport Operator 0 Yes ON. Untt No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I O1 Q OS - 17 - 1990 2 1vI 4 06 03 00 1? 0 Name / Address / Phone Santa perator as JEREMY NEVIOS 103 LOUISA LANE MECHANICSBURG PA 17050 717 EMS Transport ? O Operator 0 Yes Q No Unit No Person No 0 0 Delete? Date of Birth (MM-DD-YYYY) B C D E F _G H I Q c?-o- ?oc?c?ooa? Name /Address /Phone El Some as Operator EMS Transport O Yes Q No Unit No Person No Delete? Date of Birth (MM-D0.YYYyI A B C D E F G H I O -? "?? Name / Address / Phone ? Some as Operator EMS Transport Q Yes O No FORM I AA4ft (Ivm) PENNDOT COPY ,t CRS W0054940 Page 4 of 6 0 0 COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM rage AA 500 4 `"e °ny 4-Slush 5=1oe Marmlul Events (Mare, Event) O1:Hit Unk 1 02=Hk Unit 2 03=Hit Unit 3 04= Hk Unit 4 05-HR Unit 5 Oil Other Traffic Unit 07=Hk Deer it Other Animal 09doitision with Other Non Fixed Object 11 =Struck By Unit 1 12-Stnxk By Unit 2 13=Struck By Unit 3 t 4=Struck By Unit 4 15-Struck By Unit 5 16=Struck By Other Traffic Unit 21-Hit Tree Or Shrubbery 22=Hit Embankment 23=Hit Utility Pole 24=HR Traffic Sign 25-HR Guard Rail 2(=Hk Guard Rail End 27-Hit Curb 28-HR Concrete Or L inai Barrier 29=Hit Ditch 171 O-Non-CoAis w 2-Heed On Crash Description ?,arrb FF 1=Ftear End 3=1 Relation to Roil 1 =On Travel Lam 3-Median 2-Shoulder 4=Roadaids ts-DarylYghNL 2 I.i . 3=D y Sh 4-Dusk 4-" B" Pedestrian wi?e I= D?c?) iecBon) 7--M Fixed Object 9=01twAinknown S=Outeide TrafAoway 7=Gore (Ramp Intersection) 6=in Parking Lane 9=urd tovm (Rumination Weather Conditions 0 e C 7 `o t-lo_ rlo 3-Sleitrt (HaID 5=Fog 74leet 8 Fog 9-Unknown D.aain a,=Snew 6=Ratn 3 Fog 8=01h»r it 2=NW, Mud, Dirt, 1=Wet 3=Snow Covered 48 . Unit No T] O1 2 Please Put 3 El o I Events in Sequential Order 4 ? O Harm Event LIR Most? Utility Pole Number Unit No t F? O ?2?F 1 0 Please Put Events in 3 F] O Sequential Order 4 =E] O F' Unit No Harm Event Most Unit No Harm Event nn armful O1 48 O1 48 rv-e n- T _15 Tv -en f VwDiih Do rot nepnt u:s inknr*lior, an nwirpk PaP? mental Or Roadway 1 00 2 3 Potlsmiaf factors 1`00 ftbodal factors 1`00 00=None 11 =Slippery Road Conditions (ke/Snow) 01=Windy Conditions 12=Substance On Roadway 02=Sudden Weather Conditions 13-Potholes 03.0ther weather Conditions 14=8roken Or Cracked Pavement 04=Deer In Roadway 15=TCD Obstructed 05=Obstacle On Roadway I l l Shoulder Or Shoulder Drop Off 06.0ther Animal In Roadway 28=Other Roadway Factor 07=G1are 29=Other Environmental Factor 08=Work Zone Related 99=Unknown Poss(bk Vehicle Fsflurcs M 12=Wipers 00-None 06=Exhaust 13=Driver Seating/Control 01=Tires 07-Headlights 14=Body, Doors, Hood, Etc 02=Brake System 08-SignalgLights 15=Trailer Hitch 03=Steering System 09=Other Lights 16=Wheels 04=Suspension 10=Hom I7=Airbags 05=Power Train 11-Mirrors 18-Trailer Overloaded 19-Unsecure/Shifted Unk Trailer Load No 01 00 z 20=Improper Towing 21=obstructed Windshield k 2 99-Unknown No 1 Indicated Prime Factor Do nor apeat this information on muhiple pages. EIR V D P O ow O Unit No Factor Code O1 24 H EIR is the Prime Factor Type, leave Unit No blank From Wrong ng W/0 :e After_ Stop 11111111al Crash Number 7 W0054940 Phhoonee 10=Fai 0=Failure To Respond To Other Traffic Control Device i t=Taibatmg pn g 13=Illegally Stopn vn On?Read 14-Cal Passing Or Lane 15=Passr& g In No Passing Zone 16-Driving The Wrong Way On 1-Way Street B-Other 30--Hit Fence Or Wall 31=Hk Building 32 Hit Culvert 33-M Bridge Pier Or Abutment 34-Hit Parapet End 35=Hft Didge Ral 36-Hk Bou r Or Obstacle On Roadway 37.Ik Impact Attenuator 38•Hk Fire Hydrant 39=Hit Roadway Equipment 40-HR Mail Boor 41=Hit Traffic Island 42-Hk Snow Bank 43-Hk Temporary Construction Barrier 48-Hit Other Fired O*ct Object 49=Hit Unknown l Fixed r 1.Struck By Thrown Or Fall 52=Pot Holes Or Other Pavement Irregularities 53WacknHe 54-Fire In Vehicle 58=Other Non-Collision 99=Unknown Harmful Event 17=Careless Or Rlegal Backing On Roadway 18. ' ' On The Wrong Side Road 19-Mating Improper Entrance To Highway 20-Mall Improper Exit From Highway 21-Careless ParkingAJnparking 22=OverAJnder Compensation At Curve 23=Speeding 24.Drivkng to Fast For Conditions 25=FaBure To Maintain Proper Speed 26-Driver Fleeing Police (Pal Chase) 27*DriverInexperienced 28-Failure To Use Specialized Equip 92-Affected By Physical Condition 98=0ther Improper Driving Actions 99-Unknown N 01 , 24 z 23 3 ?.4? Nok , z = 3 4 Peidendan Action (P) 03=Working 00-None 04-Pushing Vehicle 01=Entering Or Crossing At 05-Approaching Or Leaving Vehicle Specified Location 06=Working On Vehicle 02-Walking, Running, Jogging, 07=Standing 98%-Other Or Plating 99-Unknown Unit No O1 00 Unit No FORM a M-500 (12M) PENNDOT COPY 4/4/2007 ;rat CRS W0054940 • COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Page AA 500 5 -- -,-y 1 5 r --ww1 %,UrT • 111101011111111 \I/nncwnAn Page 5 of 6 Crash Number mt CRS W0054940 i • Crash Number: W0054940 Incident Number: 2007040095 Cfeel;M 0Mv Page 6 of 6 4 %ofi. 0 0 0 • • 0 0 0 0 0 0 0 0 0 0 0 0 i • Cx klb-+ L • • ti , F. -V, • 0 I 4, COP, e W", s • • b ?? • ?? M4 e #,,? .h 3!! i ---A ?..5[ w , R 0 0 ! 4 r A"o .. S r .l rwn. r• 0 0 9 0 C xk) b`f? • CERTIFICATION The copies of records for which this certification is made are true and complete reproductions of the original or microfilmed medical records of (print name of medical provider) The original records were made in the regular course of business at or near the time of the matter recorded. The certification is given pursuant to 42 Pa.C.S. Ch. 61 Subch. E (relating to medical records) by the custodian of the records in lieu of his or her personal appearance. Patient: Kayla M. Pratt SSN: XXX-XX-0514 DOB: 9/13/1991 Medical Record No.: Number of Pages: Dated: r' Subscribed and Sworn to before me this ZZ,_ day of 01 Q , 2007. Notary Pu is My commission expires on: 1?, / 0) UO.P EALTH OF PENNSYLVANIA Notarial Seal May S. Z.o*. Notary Public Eeditmboro Twp., ctrriberiand county M Cmrr"on Expkes Feb. 10, 2006 ,fr- Member, Pennsylvania Association Of Notaries S` Camp Hill. PA 17011 PATIENT FACESHEET 0 SURGERY A 001-84-0514 04/04/07 19:36 1B1 E ER2 N V T 15 09/13/1991 1 F S METHODIST gAMp j? p An Assoc EO 01/04/07 19:36 ACOMMI PRATT KAYLA M 12 LOIS LANE STUDENT MECHANICSBURG, PA 17055 717 - 773-3873 PHOTOID N GEO CODE 041030 LANGUAGE ENGLISH OCCUPATION PRATT CHARLENE MIM 12 LOIS LANE BLUE SHIELD MECHANICSBURG, PA CENTER ST 17050 CAMP HILL, PA 17011 717 - 697-1531 717 - 975-7265 v 002-68-0363 RELATIONSHIP M PRATT ,CHARLENE 12 LOIS LANE MECHANICSBURG, PA 1 0? 17055 / RELATIONSHIP M ` 11 RELATIONSHIP HOME PHONE 717 - 773-3873 ?Y HOMEPHONE -?? WORK PHONE - WORKPHONE - CODE INS CO PLAN CODE x81 INS CO AUTO INSURANCE 1/0 CY # POLICY # GROUP# GROUP# AUTHORIZATION # AUTHORIZATION # ADDRESS ADDRESS PHONE # VERIFIED PHONE # VERIFIED SUB NAME MI SUB. NAME: PRATT , KAYLA MI M Y REL TO PT PRIORITY REL TO FIT S PRIORITY 1 PLAN CODE INS CO PLAN CODE INS CO POLICY # POLICY # GROUP# GROUP# AUTHORIZATION # AUTHORIZATION # ADDRESS ADDRESS PHONE # VERIFIED PHONE # VERIFIED SUB NAME MI SUB. NAME MI PRIORITY RIEL TO PT PRIORITY SCRIPTION ACC. DATE 1 TIME / IND. PRIVACY NOTICE WEAWRZNG SEATBELT CAR RAW 04/04/07 19:00 A 061205 01 SRS OP REG C OMMENTS HARR..X= UN"69 TO RZSPOND ITTING DX. ADMITTING DR. ATTENDING DR. REFERRING DR. 180018 ED GROUP 180018 ED GROUP J MITTIN C OMPLAINT BROUGHTBY: SEWN'" p I MOTHER MR • PT ACCT 4 545416 29672706 ER1 FR MEDICAL RECORD PRATT,KAYLA M 15 F 17 MVA (s) DATE: TIME. 167 ? on arrival ROOM: O*V - EMS Arrhal EMS trownw n ordered _ HISTOa : ? - s paramedics AG M F _ _HX J -EKAM MITER BY: HP, f J<XR Chief fD 2991A Q? Jun ao orrW lon6Ross in whfele. driver peaenger I tar collision overturned vehicle motorcycle ATV multipi tai de st V `aa(eep ?r?Cpe'`Huse OY1 /?-_ shIdr hip shldr hip head mouth arm thigh arm thigh neck eat abdomen above knee ;dhow knee back upper mid- low farm leg I -arm leg roddting to (R /L) thigh /leg wrist ante wrist ankle hand foot `•. hand foot ssmnlrity of odn: mild assadiftell . lost consciousness / dazed durabon:- moden t e rememberr _ , atrpo comflg to h severe t v seizure 17. = prMnary "S" = secondary none Jam/ shoulder doesn't reca h-°' car seat air bag deployed helmet damage protective clothing thrown from vehicle force low mod. high ambulated at scene direct j1pendr !g I . long extrication ROS loss feeling J power arms / legs i trouble breathhj J t Mtt pain - - - - memory bat matbl r functio ; headache / neap n ddouble vision / hearing loss-. - t fever / illness ;nausea J confirmed w/ horrre test abdominal pain A tali sy:tem: ne?exeapt u marked - ------------- -------- - -------- UL HX s er--_. drug use / abuse- - ' rec lives alone-.- _ -- es at - lives in nursing home----_._ HX nega PAST HX tlve -prior records rre d diabetes Type I Type 1 diet /oral /insul HTN heart M26- n see nurses note - Allergles- - A /ace nurses 0 1996 - 2006 T?efsm, Inc Crock or piece vw beokslesh a fiv" Holy Spirit Hospital Camp Hill, PA John R. Dietz Emergency Center EMERGENCY PHYSICIAN RECORD HYUC rnant M Q tale Reviewed ? Tetanus bomun. um .APP _c covar ( PTA tin ®) / backboard-- Gno acute distress -mild / moderate / severe distress -arodotts / -- HEAD -see diagram-----_ -- _._ . . - no evidence of trauma -Raccoon Eyes I Battle's sign-- NECK -see diagram -Aldn'tender 4"s ROM' -vertebral pogrc-tencia- s_ _muscle spasm / deceased ROM tmom mkili e - --pain on movement of neck -- crioMt nag _mMlbie UWAVI / dktractfng dnjury- -altered mental status _----- -JxM-surgicel pupIII y detect (R / L ) RRL '?k6Ml -unequal pitpAs R rt m L- _mm -EOM entrapment / palwy-._ _ -subconjunetival hemorrhage- _ hemotympanum-_-.--. -_ __.__- sktfnl a?ctcrrdsi , _TM obscured by wax -- -- Inspection Inspection -clotted nasal blood _, -no dental injury -dental Injury / malocclusion. am/ mm -see diagram (on reverse ). _..__ A -Am non-tender -tenderness / seat belt brukft __-_ ,no acchymosis -crepkus J subcutaneous emphysema th sounds nml -splinting / paradoxical movements L?reart sounds nml -decreased breath sounds.- -wheezes / rases / rhonchi_-- -achytardia I bradycardia---- - ^ -- -tender no palpitations _--.- . -see diagram (on reverse )__._ _ Bandar tenderness / guarding / rebound _ _ orrhonsply X40 0 distention -mass / organomegaly-_ _.- --- bowel ands' I RECTAL -perinew hematorm inspection -blood at urethral meatus-_ -call exim decreased rectal tone- -heme negative stool - _no vqftW bleeding NELMO / YCH _confuslon l disoriented.._.. , oriented x3 -facial asymmetry-- - _, _,rffood & affect nml -unsteady / ataxic pit--.--- _ s nml -sensory / moor de kt.___ _ as tested -repeats questions sensation & motor nml s wi. dry -crepitus / diaphoresis.-__ ... _-?- ct ecchymosis._. SAC -see diagram. .- _ ._ .._ .. .. _ _ CVA tenderness -vertebral poimten s s de rn e . - - /o vertebral „CVA tenderness'----.- - ..._ _ _.-_ tenderness muscle spurn / limited ROM,_ Glasgow CQMJa sc= SCORE=- -... _ .. EM.QFep spontaneously (4) to voice (3) to pain (2) none (1) Spracb- nml (5) disoriented (4) inapprop. (3) incoherent (2) none (1) C9etor- nmi (6) localizes (5) withdraws (4) flexor (3) exten (2) none (1) PRATT , KAYLA M 15 F ED GROUP 09/13/1991 S45416 04/04/07 29672ERI 706 Rev. 06 / 22 / 06 Page I of 2 TENMES a umatic vas stable ?non-tender ?'° eoal edema ? ROM'" Tat pulses nml -see diagram 0 _borr/ point-twxlerness _ -painful / unable to bear weight - -pulse deficit--- _ law Fram- _Ilmlced ROM / ligaments laxity- Joint effiWon_ _.,_ PROCEDURES _ WowicLOtseription I R--"--air - - - - - - - - - - - - - - - -, length < 7 tun tok:atlon superficial •subcut. 'muscle linear stellate irregular clean contaminated moderatey/'heo* distal NVT: neuro & vascular status intact no tendon injury ; anesthesia: local digital block mL ; lidoc I% 2% epi / bicarb marcaine 0.25% 0.5% LET 1 ? modems sedation rec1W.!1d; see attached 23d k:ekrkpiaca washed w d minima minimal / ext minimal / • mod. / • ' ^extemive wound explored undermined ; foreign material removed minimal / mod /'extermw pardaby completely 'wound margins revised ' minimal /mod /'extensive multiple flaps aligned no foreign body identified ; repair: Wound with: wokrtdodheeive/ /ateri-W" ? SKIN- # -0 nybn w ! staples I eefhll __ ' 1 rnauress (h/v) ' •SUBCL T. it romic intemtpted naurnt (h /v) , 'may ind_icasc iammediec --------- repair I -, - ardlarn. - comp!ax rVir -- -------------- ' -- XRAYS Dlncerp. by me [)Reviewed by me ODlscsd vv/ rsdWgst ................... -...__. `._._. C-Spine T-Spine LS-Spine Pafr/a _nml / NAD _revar'sal / straightening of cerv. loft docis__- - -no fracture -DJ D % spondy psis / spurring - - _nml alignment -fracture non-? alispJaad -soft tissues nml CXR __rib fracture-.-.-- -_----- - nrnl / NAD Infiltrate / atelectasis no Infiltrates - - _nml heart sae - - nml medlastlrwm OTHFR [JSee separate report LABS _ 61W - rhonnot- except - - - - - - - - - - -Chatttlstties normal except - -, WBC segs_.. __-. W_ Gluc Hgb ? bands _ K 8UN _ i gb lymphs---.._ Cl___ Crest...-_ , ' Platelets HCR_ C02 _.Ca- IIA- normal WBC__._. RdC y bacteria.-... ' '"_urn P=- POS Toxicology ASA._ acetamin_-_. ETOH-_._?.- ; ----------------------------------- I -Zim indicator organ ssrtsrn • equivalent or eu uw m ragriredJ6r organ syWin coin MVA-17 Rev. 06/22; 06 Page 2ot, 2 Medenwr Prn-P.re Tieeweus a aveelea rra rywr s-a.n l+a lAcenlMe AoAbnuNe l??ys? ,r,??y Toe- rwjd an favaose heard PROGRESS Time ` unchanged Improved nod 44 1-N V^ Ft -Initial fracture care provided follow-upon---. ,_Discussed with Dr. Time - wig see patient in: once / FD / ho*" -- - ---- -- i Coum reprd' A"donal history from - - -' (tab /rod 1t?0?le?k? (army caetoker pmmnedio CRIT CARE TIME (eskkirderj sgwntdy bisbk ?roradkuasj ' 30.74 min 75-104 min min ' '--_-------------------------------------------? MVA IDGMAtm OLM arm R I L sprain / strain fracture C elbow R / L neck thwwk lumbar stabilized forearm R / L sacral..__._ r e s t o r a t i ve wrist R / L hand R I L head hip R I L concussion face thigh R/L wash LOC w/o LOC chest knee R I L -- abdomen leg R / L back ankle R / L - shoulder R / L foot R / L home O admitted ICU/CCu O tramferred tank O,erkproved 0stable v v I T __ft3V M/ /NP -Resident / PA / NP's history mviewed, patient interviwwd and amrined Briefly, pertinent HP) Is: My personal exam of patient rsvealr:_ _ Assessment and plan reviewed with resikMm / mWlewl. Lab and ancillary ladies show:- I confirm the diagnosis of _ Cam plan reviewed. Patient will need;- --. Plwe see resident / midlevel note for datAL P+ywdien sk"We Rn i aesardcan avers p'yakien s nak" Ma aeuaned cam al Template Complete ? Add'i kxW T-Shea ? Dictated Addendum PRATT 'KAYLA M 15 F FD GROUP 09/13/1991 ZR1 541416 04/04/07 29672 706 ?I1111l111111111lIII111111lIr sllII1111111lIIIIII111lII1111 ,ulltll? IMM Lob A X-lav Orows: . "N ( I Acwmft$W I) ESR ( I Theop IrA s I I Aoalons (SAGE) I) Gk=n 11 ThMmboW Labs I I Akohol (ALCO) [ I HCGS [ I Tox Sawn [ 1 ArnYlese0l."N [ 10w e f ] UrIft Tox (DOAS) 11APTT HCGS ( ]TSHR [ ) BBH [ 1 HIV I I TYPKCMU _JI of L I I Blood Cultures ( J LIMum (BOR) I 1 BMP ( ) Liver profile 1 1 Type A Sawn 11 CBCP I I Lyas t l UA: I I DIP I I MAG. [ ] CMP ( ) ProBNP ( [ Urift C A S [ j CK,CKMB,TNT [ ] Phwobwb ( ] Urns HCG [ 1 Depdrots [ j PTP ( ] WC SMIM Moo Test ( ) Digwn l 1 SIWAW I I WC Drug Screen [ J Oliudin [ ] Tegretd I ) ONW. R ( I AbdJObo. Serbs ( ) Knee R L l 1 AnWs R L [ ] KLIB ( I Clavicle R L [ I L/8 wo I ] cerv. 501Aa-Roullne (9 view) I I Mu1dWe l 1 Cerv. Spin -APA.sI ( ] weal ( ) Can. SpInw-Ponable Lot (J Orbit R L I ] Chat-Routine or Portable [ ] P" [ ) Ebow R L ( ] Pyelopram fVP f I Facial [ 1 Ribs R L ( ) Femur R L [ ) Shoulder R L ( I Firper R L [ ] Skull ( J Foot R L [ j SMmum ( ] Forum R L I I T/Sww (] Hand R L I J rib / Fib R L ( ] Hip R L [ ] T09 -R L ( ] Humans R L ( ) Wrist R L ( ] Ofher Tinre/CIFITAnt. REASON: wd P S lt iwse ore ww ullrewuw: CT: (W¦WNh aDnWaeC WO.Vinhout) I 1 Abdomen [ 1 AbdomaNPe fvis W WO I [ VO Sr ( J Duplex Doppler [ I BrebVHsad W WO ( j Echo. ( ] Gelbledder ( )Chat W WO cardio ( ]Pelvis ( I Spkal ?p for P [ 1 TmwagkW 4A ( ) MRI San? REASON: ?r Jl'A? T`Am. YtetiVl 8ws+/nNnevlCultww: [ ] Beta Sbep AG RePid [ j Sbol C A S 11 CerviaVGw" O Sbol O A P ( 1 CNamyok I 1 Stoll C. Dfifioie ( I GC Culture [ j Trichomorns [ I X50 (rwid) 11 Wound C A S ( I Sputum C A S ( ) Other IN; 5=06on: PHYSICIAN CHARGE FACILITY CHARGE ( ) Lave) I ( ] Level I [ ) Accident I )Level fI ( I Level II [ ) MWical [ ] Level III ( I Leval III I [ Cae 1 ( ) Level IV ( j Level IV [ j Extended Hra. j )Love[ V ( I LWW V [ l Monitor ( )EKG f 1 O2_ umin. 1 102 S"Awon Inhlala: SI)tnature: RNMA a-le - AWs ( 1 ( j Peak Ffoes BSIOWAIW Rap. Tx. [ 1 Reepfrawy T: cRrriM , e hn. ( J MOW ?: -Lt" l't10 MOMMRNP Time: Holy Spie t Hoapft l PRATT , KAYLA M 15 F Cunp Mill, PA 09/13/1991 ED GROUP ERl John FIDIM Enw9ernay Canter 545416 , 04/04/07 29677706 Phyalclan Order Sheet 206-ECU 12M4 REV. LLW CHART COPY InMeb: Skirwtura: RNIMA jowh? 0 .00MN p --10 GE CURY: 1 2 3 114 6 O Name- 0 Date: 1 1- Mode of Arrival: GALS OBLS OMC r7 POLICE Log In: OWrC OCARRIED OOT male I HER on ACP: Ounknown Onone Prksary tar pW. OEngash OHard of hearing T^?: OOther' Interpreter: Room: CHEF COMPLAINT/WHAT BROUGHT YOU IN TODAY? : AL do" job f]Can'+ Amu due to Wwa ty d pis odrdaoNunebb to peeby OaeM (t)rIN?arw for aaerdany ^hours Odays Owssita Location: 6 f . C ? k rnrerrsity HPI: - 0 1 2 3 4 5 8 9 10 6. 11 c4 CI.L. lux tr .. µM p1? AMM i.?r... Y«?w VMb Vw /y Duration,- Frequency. t:rconstant OintermilleM Character. min i ClSharp 1Dull OBuming 1 in Otabored ON: OAcne .Pressure win ? O r OOral Ufiranic OnesaltlarirgClstridorOretractions CJA1r7NRB Lloaw. g , L ing i7NOn-radiating O ual irregular ORectal 0Axilary Oexpiratory grunt Oaudtbte wheezes ?02 ,Lrmin Ostated RWd M"t ftnature RN Time What relieves pain? CJnDt ' Orest OOther: - * - Awake - Akrl OAppropriab Olds wf;pryONdtK t:obr ?Skin Intact ( AAW) ON JA%1M Extromily: O worcW response OCool ODisphonsk OAbrasion ORash ]fait OCyanot ic Extremil4 cobr:?WNL pla" ?Consolabb. OFbt OTenting ?Ecchyrnosis OBum ODry OCracked 1AWottled OCyaratlc led-Time inappropriate words OPale ORushed OPuncture Wound ON e Skin Temp LWarm OCool hated OUrtoooperetive OPertdatenl OAshen OMoMod O?eMiof?itvulwon Distal Pulse6OPreaantONol pale. OVerbally AbusiveOCombatK* inappropriate cr ingr OCyanotic ?Jaund'ice ONot Cordrolbd Edema rlYes ONo OAnxious OCryirg screaming Location: Deformav D-Yes ONo ODbwbrbd 0Moans b pain E 00 Mae ?No Cltaeld M: _gbDoa,.asalabd by patient f]umtAe to obtsir into due to severity of pt OPVD ?PE OCaneer ONIDDM 171mmurwsupressed conftn/unoble o answer OCAD OCHF OCOPD OSeizures OIDDM OTrensplant ) Exposure to measles, chickenpox or ?Cardisc Stets OHTN OAstltma OThyroid Ooepreasion L7Liver Disease TB in pas! month, Ono Oyes ;. OCABG r3CVA OSmoker OArthritis 009mentia DGERD Q) Advanoed Mactim? S, a! ??i + .' Ognr yes It ! attadied: y;pp-L1yes O Suspected AM r Child sibuse: 1 I. 4 t .Yt ? rM (?]W! (H yes am nonce} ©Last Tetanus/ Onto s ALLERGIES o??x f?c44 5? ChlWhood immunizations (0-1* ) 1 ,}+ ? . OUTO ONot UTn Ounknown LATEX ALLERGY? OYes If ?p rlp?y,,l .. , " OHysterectomy Oust OPatbnt ?Famt OEMS OBotties O MOW tntvroan OMeds retkr?oawn MEDICATION DOSE 1111MATION DOSE MEDICATION DOSE OW r Elevation ONPo OSOW ODnetdng V ?Sai P order sheet OGCoaar OPatiem Masked OSecuft noded / EKG paged O P TAW RN signs" r" COW- sipne L" (9*P11:10*1 EKG done O OR G A E 09PNM RN 1 / - TIME TRI G ferry ?'?? ? ER ? QC ? I Health Holy Spirit Hospital PRATT , KAYLA M 15 F Camp Hill, PA 17011 09/13/1991 John R. Dietz ECU ED GROUP ERl Nursing Aatsssstnsnt 543416 04/04/07 29672706 201-ECU 9/05 12th REV LLW CHART COPY r w Aww'.. 0 "*. •^?ir 44c" p MalM - Await - p AIM App?opolte /.?wyY•?'?^ rrdor } lldn rNeet (?AeMe) w?.?wbw,,,e.rw,e "« Eetrert?y: OtMnlad?eraort WOrda/ response C J(ApI ?Consomb Oft OT M Th , V W ? Bum labasd Jrstaclions ExtrNnMy color OWNL at A kW ineppropdste Opals DRuehed Pirndae Wound Q*ac V L / R OMonled OCysnoec g woods ODuaky Oklaaw Persistent ?Cl'uro0c ?JMaidioe Avulsion OraNeMroncN L! R Skin Temp OWum OCod l ? Vubdy Ablrt w ? Cw6sm ? t' t ' Ontp ptopriab ? Uoo,* DOW ) , r r M? Uprodtsctive Ed s OAnxkNx OC(yktg OCordwed aft sam"WR tg I NNW ema Y a ONo .?CorMtoled U02-urn m vw-- Deformity 13Yes ONO OMlow% to pain Pale OCyuwlic QDr ?Gaclted ONot Controled Ecchymosis DYss ?No Look", ?} OIIMdadN PERL R L Clow neck Size $OOIe Sp , y y.pr ., Odsniee 516 O pain ?? mn Oneck Pain Piapokd O O Speraanmm 666 0btys 3 O&W 3 To verb rzrww d S LwWbn pa4i 4 Disorisrisd * Ofrequsrwy d KhsV Uup nay bvsainl disdmys Sewdty 110 QkM droop Diluted O U On nibnew: Rued U O 2 To pain 4 Flatioo-041110 ttgl 31 YpptapolY 1 No respaw 3 Abnonesl Rsaim w d ODytalrta ;)wtg W dndrp Upaou Jwww 00" SkWish U U a s OHematurfa Obby Oeduna' JinMnnipmt UWU 2 Abrpnaal Exlerriai T OMent n e Oweakww: non-mKi o U 1 No ?ss soullds DOlhu: L am JSOB 1 Pb Rnpaw Oheavy JWA 000ftry rem: Jnaues Uosuriac J?aPid ino"adia6ng DDenies pain hymptoms DDuradonl kstansity Last BM OADdanultender vdslayW irsdisting Onuses OdWdm Ovomiting UconelipshonUHamstemesic Bowel Sounds OdNbtded Ufarn son Ucalt tender R / L EYES UPdn L!R Acuity: 4_1_ Ems Abw T1Nom ObIwed vision L / R R` /,_,_ tUPsin UR Ucorgwbon Usors fed N Txne O• BD udotble vision L / R Uwith tutees Jd sftrge Udrainsp Udrooling I b; W** Canpadat with patient OPhobptrobia L ! R i01her: OEptN" L / R Jdysphaft USR up rig Procedure e4Awed N : oww 1.edama 5.li.attsss 6-am 7. MOUTH= Date Start Stop Amt S*Iiw Sz. SRe Rate Atlpt Cond 1i1tial DeW Time Dnfg / Dose Roule SBe Initial r0 r Date) Time Notes n(tiel S"ftGED /aooompwwd by: JSsj4LFArrlty 00ther / Via: ' orY :Jwlc Janwance ?r 1 /?fJ To: unurskg home JAMA JOR dodw 4 D wMrge insbut iww given to: -Oatierd UFm* . f'ulalt Joetu ) A WI / LAM ROW camod 0 to Rooms Udd records sent to floor Jcbthing stroel done TRANSFER TO, (transfer chsc4 t cwq*b t ondNion: . 24 ?IW rtctory UCAtical JDeceassd to morpw 1 . mprared 1 p Radiology Dept. Co pletion Notification m EAM(s): et c, ti Ian.: -04 PRATT , KAYLA M 15 F c? Date: j :? ° 09/13/1991 ED GROUP ERi 205-ECU WN 11th Rev. LLw 345416 04/04/07 29672706 CHART COPY h11tIlIE6ccy CE"n `l1ItG1 CBNIER y.._. ,:.. ;.. (717) 763.2316 J`% (717) 763-2424 DISCHARGE INSTRUCTIONS HOLY SPIRIT HOSPITAL The ""niff"M and ClaM M YOU lave received m the B`n? COW Mve been co"Wide krhodicaf tare if yon develop new Probleev or corrpidwrige wel sa > mW Pm > ?"tl?ie On -0 61001110&y buis POIAAW TM UPS 09tAkveaded b be a kahbW W fur a an effort to pov* t!t now amom BELOW. ( )Abdomitel pain P-1.f1 ( CflBatflpn: Pasant ki10r111af10n .911 " abrasion f l Aloow reaction ( ) ( 1 AAsiftna *action ( ) Crulch waking I) Book pain ( ) Dislocation V0f lNNrryPed. Vorniting () m ?aVinact () DruglAlooleol &WWaddction gum Pain (i Febrile Convulsion Chost ( ) Corylrrctlvllia ( ) Fever/pod. Fever Flu () CoPD O Flu () Fracture gently wash over wound M 24 hours with soap and walar or ro'" - ._ . edress wri --. *? drossirig tifrlat daily. R ? ate Jt open ti advised.? / Keep wound dean, dry / ovi?ed ( )uncovered Jaevato the lryured pert for- dayy•g?a,to ?reduce sweti g. M Ace Py ic?e packs hMermittently for- leffaye to reduos swelling. () wrap for support for- days. ( 3 use Wear Splint sling I& (el?)pAptt calf tiles until follow-up. () For adiviy as needed, ( ) Use crutches. () As needed, Meighl bearing as tolerated. ( )At:tW tims?. 1?p WEIGHT BEARING NECKAACK ( > wear cervical Pow i?pport for-days, no ( ) Rent, avoid .ding, strenuous adhAty for-days. ( ) Apply Rldat for minutes times dally iQ hours. A "Ooft UCTXM fluid Intake Clear liquid diet. Advance to regular diet as tolerated () Off worklechool from to ( ) Return to work on ( ) Light Duly until: Restrictions: ( ) No gy Wspotto until ( ) Follow instructions on Workmen's Compensation Fort. ( ) Wear aye patch for hours, ( ) If nose bleed recurs, pinch nose fifrrtly for 5 minutes ( ) continuously, return If bleeding not controlled. The Proscribed antbiWichnodicatlon, may reduce 11110 effsctlvar>,p of medication you are ckurrordy taking. Check package instructions or consull with Pharmacist, ( ) The interpretation of your X-Rays are pretirrdnery reading. Your films will be reviewed by a radiologist. You or your Physician will be contacted if there is a change in the diagnosis, by, -Dkvv V ?,?t ( ) Headache- - - ^.. O PffM M &W"nWk Kam( ) d MtiaoaMaga () HYPehen ion f ) Pedabic Now b*,ry () Toothache 1) hnmunkatipyl seams' PIOyBTO () PDOSTD URI () UAI and CWda ( ) Kidney Stones () ( 1 UTI and Pyabnoo lis O Pneumonia OWound Aeshek f R () 24 Hr. Plnanrhecee O Nock Strain ( j Screaeat (> Other • Nosebleed !) HpA potassium oontarlrp foods ( ) oft Media (1 Swains and Shire () MEDICATiONs Suture Can t Removw ( ) t orfOflw present audlaWons enespf; Advil (b+ obn) or TYlern 9 as needed for Pain, over () V to Package Instructions for age and wevit ft Use the "Ming medimm according to package reetrualona: 9: 1101111001" M- ON* so say asues dnapal*mw. ( ) The NOT OM OR OPMAATE 0NNlM1r %MKS TAKMIO: The prescribed oadloatlon, may reduce the or oonvA woPh an GUM* taking, Check package instructions ynr)6aist- POLL 01N J't71fs Is our raeorrwnaldfillon for 0r hove (M01 r***" a plrysiden fahnal t `g K 0yCW R "IMPON>SIBILITY TO ONVAPA THE rrlrrlerrllaAla> Follow-up with; () Urgi Csrller ( ) Occ. APPROVAL. Doctor or S ( for. () Follow-up ( 1 TWO the (? Suture removal ( ) CBC (ta (( "aftft 10 ) X.RAy REPORT () OTHERS IF SOU DO NOT HAVE A FAMILY PHYSICIAN CALL 763-2900 SICIA 1 REFERRAL, ( Cab ae soon as Possible for appcyttrnot Plok up your X-Rays from the Radiology Dapa*fiant prior to your fogow-up appointment. Can 769-2696 in have itims ready, ( } See your physician or spsoWW Y not unproved in ( ) Return to Emergency Center If you feel your oortdition is wor and, especially If ( ) Your blood pressure was elevated. Check with your physician. A copy of your dlohled Emegency Room Reppr! is evoll" b r Physician from Medical R ?RGS•21111W, ?Nilr+gl abea ty m4cal hereby have r? of these' notruotions and un?dsrsatind V. I understand n d before all of m ornorgency medical tnetrnwt g ft and that I may my problarrns are known a traalsd. I wig anarlpe tot folk)wwP pro as I hove been instructed. it is y / SIGN 10 _ / Physician Of this kaMV / t: j ,r., HOLY SPIRIT HOSPITAL JOHN R DIEU EMER . GENCY CENTER 503 NORTH UST STREET CAMP HELL PA 17011.2288 (717) 763.2316 ( ) Thomas Atdous, MD 017075E ( ) ( INIvatme Aifano, MD 025502E MD ( ) ,Inhn P. Judson, MD 038368E t) David Zimnierman ' MD 005636E () Philip Maguire MD 015063E t () Patricia Sti n NP 0 mesh Arora, MD 016727E () k n Dublin DO 006991L , ) () Pushpa Mudan, MD 051514L () Pun Darden, NP SP006066B o g, 3617B Barbm P O Strong, Alp 6 t t t , ( ) Amy Fajardo, MD 420942 () Aaron Palmer. MD 423830 r) Selena DiPaolo. NP VP0052648 k) Lawrence Paul MD 039524L T 0612 Tercu t Teresa Williams, NP OO671RB (> Nikki NP ( ) Kawzyaa Fornuo, MD 417936E , () Natalie Gillis, N (> Howard Rudnick, MD 040862E () Mic OO59 k h J:hnc Wenger, . NP SP005927B () Maripal Garter, MD 046724L ( ) Marlys Hasson MD 072553L () Rrmjana Sharma, MD 03e SPgO r t , O Christine Sheridan P00762 Alan Tealis. MT) I =a mh 12 a U S iF I J u? H a? C u. IL ?a w n =U ICL .- u. Q N U. . - 1 1* 0 0 0 t O ?g 3 O •fl a W o C •y cr a . co J O V = o u H w O Y O ? O ci X ?CK 0 W O W V CK u a, `m co c Zjr i? I-f w °O1+ a ?°. h ? Wh \ h 01 0 0 0 a ? o p, lux E m d ? ? a 0 , Holy Spirit Hospital 0 Department of Radiology and Diagnostic Imaging Camp Hill, Pennsylvania 17011 (717) 763-2600 ATIENT: PRATT, KAYLA M M R#: 545416 SOC SEC: 001-84-0514 ORD DR: SELENA DIPAOLO,CRNP M.D. PT TYPE: E DOB: 09/13/1991 LOCATION: ER1- DICTATION DATE: Apr 4 2007 8:42P TRANSCRIPTION DATE: Apr 4 2007 8:42P ADM DATE: 04/04/2007 ARRIVAL DATE: 04/04/2007 HOSP SERVICE: ER1 ACCESSION: 3095303 "Tinal Report*** EXAMINATION: CT MAXILLOFACIAL WO CONTRAST - 0410412007 COMMENTS: Examination: Maxillofacial CT, unenhanced, transexial and coronal imaging Indication: MVA, pain about the chin and jaw. As seen on the scout film there is soft tissue swelling around the chin with a laceration of the soft tissues. The CT scan shows no definite fracture of the mandible. Some of the images are degraded by metallic fillings. There is no fracture of the mandibular rami. There are no fractures seen around the temporal fossee. No fracture of the alveolar process of the maxilla. There are no fractures seen about the rims or floors of the orbits. There are no fractures seen about the maxillary sinuses, pterygoids or zygomas. There is no fracture of the orbital walls. No fracture or sutural diastasis seen about the nasal bones. There is a very mild degree of scattered mucosel thickening in the maxillary sinuses. Images through the base of the skull show no fractures. No fracture of the carotid canals. The middle ear ossicles are in normal location. There is no hemotympanum. CONCLUSION: Conclusion: Soft tissue swelling around the chin with laceration of the soft tissues. No midfacial fractures. Transcribed by: nic DICTATED BY: HOWARD BRONFMAN M.D. / PSC l0? DATE OF EXAM: 04/04/2007 SIGNED BY: HOWARD BRONFMAN M.D. DATE/TIME: Apr 4 2007 8:45P CONFIDENTIAL: This report contains private patient information. If you have received this report in error, please call 717-9724941 immedlately. Confidentiality Disclaimer: The information contained in this communication may be confidential, is intended for the use of the recipient named above, and may oe legally privileged. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copying of 1h is communication. or any of its contents Is strictly prohibited. If you received this communication In error, please reseed this communication to the sender and delete the original message and any copy of It from your computer system. Thank You Imaging Services Consultation Page 1 • • CERTIFICATION The copies of records for which this certification is made are true and complete reproductions of the original or microfilmed medical records of: (print name of medical provider) P `0,41 C SlJI,r f-q CW kj', U C(- ?Ran A Yo- kS, -m . o . The original records were made in the regular course of business at or near the time of the matter recorded. The certification is given pursuant to 42 Pa.C.S. Ch. 61 Subch. E (relating to medical records) by the custodian of the records in lieu of his or her personal appearance. Patient: Kayla M. Pratt SSN: XXX-XX-0514 DOB: 9/13/1991 Medical Record No.: Number of Pages: Dated: U (?? Subscribed and Sworn to before me this day of Notary Public 2008. &Sao I Opc Print Name: My commission expires on: Case No. Address IL LU 1 J LQIIC • I•ICI.I el. No. 45- S 3 +? Referred By Insurance Co. 0 Sheet of Patient's Name Kayla Pratt Occupation Date 04/09/07 y m DOB 09 13 9iex F S.M.LTP.W.D. c 0 HMO Copay $ O PPO Copay $ w W N Z CD N S N O Pnlinv Nn Hlstecount• Form #3811 800.645-5220 (1299) KAYLA PRATT 0 • ?? •,? /,? li ? .r v:C?ti a Cj.? ? 4? ? _ u - Lc.1 i 61 -7/ i'L Q / Q C -4k, A -Ar cw- i e etoe V ? SBu!Puid put/ SPIA juenbesgnS ,A AoC] •ow e?eQ a? a? L 10 188US eweN s,}ueiIed 'ON ese0 • • CONSENT TO OPERATION PLASTIC SURGERY CENTER, LTD Patient's Name Date b °? 9 I have discussed with my physician, Ci f°S S /!'1 he atom and purpose of an operation which is to be performed on 0 /gte to be ?/'? (4S`e? dPS 'o which he has told `/ He hastldiyiMftitcd tome the nature and purpose of this operaHoa'asd'hai described that part of my body which will undergo this operatic. My physician has fully explained the risks involved and the posdb8ity of complications from the operation- I am aware that no guarantee or assurance as to the results of the operation have - been made and I bave.bem told that no guarantee of results could be made. By signing this corned , I agree that all the.foregaft.bas taken place to my satisfaction. Therefore, :I authorize my pbysician, in addition to any assistants whom he night designate, to perform this operation, together with any preoperative or. podopemdwWreatmeat upon me. I audwize.the operating surgeonto.perfocm any other procedures which be may deem necesary in attempting to improve the condition for which I am being treated or any unforeseen condition that he my eneoanter daring the operatkmL I also comeut to the administration of anestheds, general or local, to be applied by or under the direction of the Anesthesia Department and/or the operating surgeon, and the use of such anesthetics as deemed advisable. I authorize my doctor and/or such assistants as he may engage for this purpose to take such photographs required for pre and post operative analysis-or educational purposes. I authorize my doctor to disclose complete information concerning his medical Endings and treatment for the undersigned, from the initial consultation until date of the eonclWou of such treatment, to those individuals who in my doctors sole determination, are required to receive such information for the purpose of medical treatment, medical quality assurance and peer review. P ent Signature of Witness r Cua,inn or pe n responsible for patient if under age of consent. 0 9 1 • C] Lam. Li =!7 0 0 0 0 0 0 0 0 0 0 e x?) b-14 F • • I 0 0 i • I ---r- ¦ r,wl? G I 0 0 0 0 l---l t ??,+ E-x k I 0 0 MEDICAL BILLING SUMMARY FOR KAYLA PRATT Medical Providers Dates Amount Camp Hill Emergency Physicians 4/4/2007 $1,081.00 TOTAL $1,081.00 PAYMENTS BY ERIE $366.48 PAYMENTS BY CLIENT $0.00 ADJUSTMENTS $714.52 OUTSTANDING BALANCE $0.00 Holy Spirit Hospital Physician Services 4/4/2007 $2,280.90 TOTAL $2,280.90 PAYMENTS BY ERIE $522.17 PAYMENTS BY CLIENT $0.00 ADJUSTMENTS $1,758.73 OUTSTANDING BALANCE $0.00 Quantum Imaging & Therapeutic 4/4/2007 $236.00 TOTAL $236.00 PAYMENTS BY ERIE $58.16 PAYMENTS BY CLIENT $0.00 ADJUSTMENTS $177.84 OUTSTANDING BALANCE $0.00 Plastic Surgery Center LTD 4/9/2007 $200.00 7/25/2007 $95.00 10/12/2007 $95.00 10/29/2007 $500.00 11/26/2007 $500.00 12/10/2007 $500.00 1 /21 /2008 $500.00 TOTAL $2,390.00 PAYMENTS BY ERIE $1,712.22 PAYMENTS BY CLIENT $0.00 ADJUSTMENTS $677.78 OUSTANDING BALANCE $0.00 TOTAL MEDICAL BILLS $5,987.90 PAYMENTS BY ERIE $2,659.03 PAYMENTS BY CLIENT $0.00 ADJUSTMENTS $3,328.87 OUSTANDING BALANCE $0.00 'Kayla Pratt reserves the right to supplement this Medical Billing Summary. 4008721 Page 1 of 1 ,:54 FAX 7177952315 ERIE INS 1a002 J8 Claims Management SYste CSPP191B Medical Management Print Page: 1 Medical Payments Req: S MITH ,K Claim: 010170914080 Ins: KEVIN G PRATT & Claimant: 002 KAYLA PRATT Limit: 5000.00 Paid: 2659.03 CK Amount Payee Service Date H349105 146.78 PLASTIC SURGERY CENTER LTD 20070409 to 20070409 H429399 522.17 HOLY SPIRIT HOSPITAL 20070404 to 20070404 H627578 58.16 QUANTUM IMAGING & THERAPEUTIC 20070404 to 20070404 H710632 366.48 CAMP HILL EMERGENCY PHYSICIANS 20070404 to 20070404 H772963 62.35 PLASTIC SURGERY CENTER LTD 20070725 to 20070725 Z181615 62.35 PLASTIC SURGERY CENTER LTD 20071012 to 20071012 Z247098 359.47 PLASTIC SURGERY CENTER LTD 20071029 to 20071029 Z320686 359.47 PLASTIC SURGERY CENTER LTD 20071126 to 20071126 Z377706 359.47 PLASTIC SURGERY CENTER LTD 20071210 to 20071210 2563285 362.33 PLASTIC SURGERY CENTER LTD 20080121 to 20.080121 CAMP HILL EMERGENCY PHYSICIANS ?HYP PO BOX 13693 PHILADELPHIA, PA 19101-3693 rA V STATFML OFACCOUNT Statement Date: 07103/08 Lw•r M )Wrw.r,eLwn.ar Page 1 Account Summary I Account Balance: 0.00 #BWWFDB #D000000HY1P608284# CHARLENE M PRATT 12 LOIS LN MECHANICSBURG, PA 17060 q _nunt nstall Amount Pending Insurance: 0.00 Amount Due from Patient (Current): 0.00 Amount Due from Patient (Past Due): 0.00 Pay this amount: 0. Please refer to the coupon below for payment Instructions. DATE • DESCW 4nON CHARGE PA)V BY RRSf INS. PAfD eY OTHER FNS. PAV aY PA7BENT AMOUNT ADLASTED DuE FROM Nvs PA BALANCE D4/04/07 1 92284-25 EMERa INJURY EvAL a Mc ATLvL 4 541.00 DX-M.44 SELENA DIPAOLO. NPG 4OLY SPIRIT HOSPITAL 07/02107 ALTO INSURANCE NO RESPONSE FF DM PAYOR 0.00 - 0525/07 AUTO INSURANCE CONTRACTUAL A LOWANCE 422.70- 0&25107 AUTO INSURANCE PAYMENT 11822 - 0.00 04104/07 2 12052 WOUND REPAIR 2."CM FACE ETC 640.00 DXM.44 SELENA DIPAOLO. NPG 4OLY SPIRIT HOSPITAL 07/=7 AUTO INSURANCE NO RESPONSE FI !bM PAYOR 0.00- 094M7 AUTO INSURANCE CONTRACTUAL A .LOWANCE 291.74 - OMSM7 ALTO INSURANCE PAYMENT 248.26- 0.00 important Messages: Totals 1,M.00 O.oo 958.48 - 0.00 714.52 • 0.00 0.00 1 1 This d olamwd Is for Ore d1rod beelrnard andror - "arvwon of care you reanay recNvad km an ErtwryMwy Phy.fcw, at Hoy SW HoePlw. Thew for 5fb pwaa phyeldan en billed asps tally *wn arty hoWN dw9a or otli- prohmia W few for which You may abo be rwponelble Thwafon, ehotAd you mwkv a Ni tom 5a hoWW or other Phyeidena for dwr9w in OnIww"M WM #6 vWk it rill not tndude the Own Bead w lhts aloha . . "Payment Plans" Accepted Question about this statement I /L/ame de Lanes a Wernes9 Call 1400-355,2470 Monday through Fd*y 9:30AM - 4:OOPM. Your auttmtwtad systlmi.accomisods is V.1496M..K,or you-cm sond.a! mil to b/XhjLquaablo,trs®amcvm=m. ... ........ PLMSE DETACHAND 18E'TtM DO"= POR7XW WTTN VOW ROLMANCa: PaymentOue Ry/ 107174100 Amount Due / 10.00 Amount Enclosed 3uarantor. CHARLENE M PRATT 12 LOIS LN MECHANICSBURG, PA 17050 The ft%/ra M kft=@ n h aurae MUM 10 ka vv. plem trLeke erLy oonedlll6rLe awfb add5erre on f!r reveres aki o/tlYr aemL LAM mean I to us. Thank you. Mom o AJIMM rATT 12 LOS LANE %0EpMNCSO AIO PA 17816 YOU MAY PAY THIS BILL WITH YOUR CREDIT CARD PLEASE SEE REVERSE SIDE 08251600000296727[L00000000'0000000000006 If your address has changed, Chet k this box and complete the reverse s/de of this form. Make Chea:Woney Order payable to : CAMP HILL EMERGENCY PHYSICIANS HYP PO BOX 13693 PHILADELPHIA, PA 191014693 082516-4000029672706-06 .`.. - YY SPIRIT HOSPITAL OF _ DATE • men ?°f WE aL, PRREV OF N 21ST ST . CAMP HILL, PA 170i1-E288 800 997-5573 BIRTH-DATE IP&UnD . G9/13/91 E PAnENr NAME PMTIENT NUMBED AN ADIA&SION Ml 01OWME DATE DAYS LERATT KAYLA M 29 7 70 F-1 auAeANroR CHARLENE M PRATT 1 AUTO INS NA"E 12 L.O I S LANE DIE) MECHANICSBURG PA 17050 AMN 01 DIPAOLO SELENA L PLEASE RETURN THIS PORTION WITH YOUR PAYMENT, OATS ovml!•Tm OF S'Emm MTAi, 001Vep1pE EST OOVERA6E EST. COVERAGE WT.004RRAW PDST60 NObrMX SERVICES CODE C?WfS INS. C0 N01 Mla 00. NO z ws.co.N0.3 04 00. N0.4 DETAt OF CURRENT CHARGES, PAYMENTS AN ADJUSTMENTS 4/04 ICODIN TAB 014403006 1.55 1.55 4/04 CE HAGS - 011412355 4.35 4,35 4/04 T MAX•ILLOFACIA013653679 1654.00, 1654.00 4/04 EVEL III FC 011710574 445.00 445.00 4/04 AY REP FACE,EA011730490 176.00 176,00 OF CURRENT CHARGES PHARMACY •250 1.55„ 1.55 M/S SUPPLIES 270 4.35 4.35 CT SCAN 3S0 1654.00 1654.00 EMERGENCY ROOM 450 621.00 6ei.00 AL OF CURB. CHARGES. 12280.•90 1 2280.90 Q? J ? N c p FEDERAL NUMM HOLY SPIRIT HOSPITAL PLEASE SEND PAYMENT V. HOLY SPIRIT HOSMAL AoolTlowu F xulo MAr NEC ENO ;; 503 NORTH 21ST STREET P TN L M WE CAWAft ? CAMP HILL, PA. 17011-2288 THE_AMOIxfTB SHOWN UNDER ES71M U AY90 RRISSIf AMpll(T N% 07128018000333488033 FibLY F' I R I T HOSPITAL 503 W218T ST? ??j ^9672706 131 CAMP HILL, PA 1701i-2288 800--977-857.3 23-1512747, 04,0407.'0404o7 ;PRATT ?KAYLA M le LOIS LANE i.MECHAMIC59URG PA 17055 09131F41 F 5 0404.07 14 1 01 545416 '01 040407 CHARLENE M PRATT IH LOIS LANE A3 228090 45 1900 MECHANICSBURG-PA 17050 250 PHARMACY.,. 040407 1 155 e70 MED-SUR SUPPLIES 040+407 1 435 350 CT SCAN . - • ' 70486 040407 1 165400 450 EMERG ROOM 12058 040407 1 17600 450 EMEFEG ROM . 99283 040407 1 44500 001 TOTAL CHARGES AUTO INS 000029672706 VISIHOSG PRATT, KAYLA M Y Y 228090 R?8090 STUDENT 67344 4 6659 040407 1s 0'(.tiO)u!'1o914Daco CENTER ST ,CAMP HILL PA 170110001 9 1 161 P ARN266A4L DIPAOL O SELENA PARNE664 4L i DIPAOLO SELENA L JAMES L JONES 041107 07193018000333447022 •l - -- N • ERIE INSURANCE GROUP 0 soo W--J v v fi - PO Bog 2013 tl a5 W INSURANCE CLAIM FORM 4901 LOUISE DR I APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE OM MECHANICSBURG, PA 17055 7/1 N 8 PICA E4 1, I&OICARE MEDICAID TRICARE CHAMPVA OROt I OTHER FMA CwAkpUS " ?+ IN ?J( MA 1o1rJle N N ' dcairl / 1 M SSN M ! - 1a. INSUFIED'S 1.0, NUMBER (FOr A: r?r ul tpm tl O e ; 1 ? ( r J ? y ? ( ) ? /A r,wvt ] or ((B?BrIA! RD) 2. PATENTS NAME (Lad Name, Fircl Nn+e, Middle InAbj A FATIENTS BIRTH DATE DD YY IpEA InAIaI, M F S 1 S P TO INSURm ADDRESS (P* at* Sot SDmM OIhw[] RATE B.FA TSTATUS STATT z m*[] Mirded ? Other O TELEPHONE OR"Area Cade I- 21c, CODE TEI?HONE IIIrcAIw AM Cone; UREbs NAME (Lltit 1Q 1$ PATIENTS COem1170N RELATED TO. t t .1NSURED'3 POLICY GROUP CR I VA NLgmmm O a W i HER INSL'RED'S POLICY OR GROUP NUMBER a. EMPLOYMENTT (CLWWl W Prwdouq a ItJ!tupp DATE OF BIT SEX _ 7 ODD ? M? (A l I M? F b OTHER I UREM DATE OF BIRTH b. AUTO A NT7 MM DO I YY SEX PLACE (Sane) l q4ftlml u. EMPLO A LNAME 0 I M? F n YES ? NO L ?.. 1 + a EMPLOYER'S NAME OR SCHOOL NAME c OTHER ACRIORM ?A c. INSURANCE PLAN NAME OR PROGRAM NAME F - YES C]NO IW PdAWLIPANCE PLAN NAME OR PROGRAM NAME tUo. RESERVED MA i 11 a I A __ UYE NO Oyer, rRe'I"o COrr pkk kmf rtl READ BACK OF FORM BEFORE COMFLETIN4 A SIONINO TNIS FORM, ' III: INSUREDS OOkUTWOWD PERBOAlTS 81BNATURE I awixN sec i2 PATIF. NT.4OR AUTHORIZED PERSON S SIGNATURE (eulllwh.. liv rekaor ui any meelad a Ow IMomrem emewry _ P'ymoM o1 A*" bWdk to ft IrlerigMd pAyiklon crcupplicl la' to P=qt Ihk owim. lire to" pepw of ommmrII bMN s mill le ""fir or IQ the p4rw who MV6 saw net S mim dwribee below. Lvmw :IrIGNEO _ DATE _ SIC+NEfT: 71. DATE 0f 15 IF PATIENT HAS HIM MA,AR ILLNESS MM Off. I TY INJIMII' {Aeoeilp) R• GIVE FIRST DAZE M I 1 tYT L6r±4ATES PATI IN AT ON IM I I' Yr PREGINANCY(LMP) I ::fCNnd_ J i TO • INB "mom OR OTHER SOURCE 17% $ =: _ Q 15::yCSPITMMMMAIJLLj1N DATEDLATED TO C FF NTDSDERVICF& i 1 TD r V G t M TO I V I a .. ? 25,'d[tFSICfE•LAB? : cruwac 21 AGNOSIS OR NATURE OF ILLAESS OR INJURY pAeWe 11lrrK 2.4 Of M Ilem 2tE by Linn) 2p REft0MYSSION N0 ORONAL no:. V 0 ? 959 0?? . e:1. PFIUIi AUTHORIZATION NLIYBER '?V 20. A DATE(S) OF SERVICE B. C. D. ?HCCE ES' I S, 0 , MLI' E F. Q ?{ I, J. z r;•,'1T TO RAt>E (Ed,hl'' n: LlnrAUBiCAgImiWIOM) DIAGNOSIS % Im" a l tuo¢aIN M1.1 : I) YT MM 00 YY EMG L:VTm;POS MODIFIEp PONAYER F ^.HARGES ID •-• r t NPI ¢O ¢ lob Zw"Zi .. .. G- .: 6 z I I NPI }`... .:4;T. t• c is `? HIM. - 7 L ?. et ""?" ' ' - , R• :.-• ?'? r .., ..?....? ., r„ r,: _. N., ' •Tw _ _ = ? W K l I I O NPI ..J ?L ?•• - - 1 I Nfl V I I NPI a 26. FEDERAL TAX I.O NUMBER SSN EIN 20. PATIENT'S ACCOUNT NO. 27. .OpB?T .*W r NT7 ? 20. TOTAL CHARtSE E9, AMOtNtTI'AID 30. BALA NCE DUE [In 1 UY" NO i i S I S j S 1 EES IA ORCREDBMO Zq&nWJ OR l mittim-mawwa ri0N INF TION SA. BILLI ID i PN! pTriwWWtaestate nw an um mm" 866 822-8415 eppy to 1Wc WA will are nrde a WIttered.) HOLY SPIRIT HOSPITAL ER QUANTUM I MAG X NG & THERAPEUTIC HOWARD BRONFMAN MD 503 NORTH 21ST STREET PO BOX 62165 C+N DATE CAMP HI NULL InsrrUCDOn M;n1A;i ;ll;op ;1: tuww.nucc.org V J 7 w v v z j(pp(gQ?? >j ?B-0B?B' AY.MS.1 Soo (08'05) 1 1715 "n-W • %ST OURGERY CENTER LTD i GRHIDVIEW AVE 1P HILL, PA 17011 1/763-7814 feral ID : 23-2314196 :ient PRATT. KAYLA 12 LOIS LANE MECHANICSBURG, PA. 717/773-3873 Insurance Company Policy # Group # ----------------- ----------- ------- 1:ERIE INSURANCE COMPANY 010170914080 Q031009620 P. 0. BOX 2013 MECHANICSBURG, PA 17055-0710 ting Date Patient Name Code Description Guarantor --------------------------- 0015477-0001 AI B PRATT, CHARLENE Other Info Holder ---------- ------ PRATT, CHARLENE Qty/Src Charged Page (c) Printed: 04/15/2008 1( AcctID: 0018 SSN : 0363 Effective Dal Open Prov. Place PRATT, KAYLA 99204 NEW PATIENT COMPRHENSIVE OV 1.00 200.00 0.00 YATES OF DiagP: 873.40 LACERATION FACE, UNSPECIFIED IN CHECK INSURANCE PAYMENT Insur -146.78 IN ADJ INSURANCE ADJUSTMENT Insur -53.22 PRATT, KAYLA 99213 ESTAB PAT EXPANDED PROB FOC OV 1.00 95.00 0.00 YATES OF DiagP: 873.40 LACERATION FACE, UNSPECIFIED IN CHECK INSURANCE PAYMENT Insur -62.35 IN ADJ INSURANCE ADJUSTMENT Insur -32.65 PRATT, KAYLA 99213 ESTAB PAT EXPANDED PROB FOC OV 1.00 95.00 0.00 YATES OF DiagP: 873.40 LACERATION FACE, UNSPECIFIED IN CHECK INSURANCE PAYMENT Insur -62.35 IN ADJ INSURANCE ADJUSTMENT Insur -32.65 PRATT, KAYLA 17106 DESTRUCTION LESION-LASER TECH 1.00 500.00 0.00 YATES OF DiagP: 873.40 LACERATION FACE, UNSPECIFIED IN CHECK INSURANCE PAYMENT Insur -359.47 IN ADJ INSURANCE ADJUSTMENT Insur -140.53 PRATT. KAYLA 17106 DESTRUCTION LESION-LASER TECH 1.00 500.00 0.00 YATES OF DiagP: 873.40 LACERATION FACE, UNSPECIFIED IN CHECK INSURANCE PAYMENT Insur -359.47 IN ADJ INSURANCE ADJUSTMENT Insur -140.53 PRATT, KAYLA 17106 DESTRUCTION LESION-LASER TECH 1.00 500.00 0.00 YATES OF DiagP: 873.40 LACERATION FACE, UNSPECIFIED IN CHECK INSURANCE PAYMENT Insur -359.47 IN ADJ INSURANCE ADJUSTMENT Insur -140.53 PRATT, KAYLA 17106 DESTRUCTION LESION-LASER TECH 1.00 500.00 0.00 YATES OF DiagP: 873.40 LACERATION FACE, UNSPECIFIED L J Itemized Statement 04/01/2007 - 04/15/2008 PatID: 001840514 Dob: 09/13/1991 17055 Age: 16 ASI IURGERY CENTER LTD 5 GRANDVIEW AVE 1P HILL, PA 17011 7/763-7814 feral ID : 23-2314196 lien t ------------------------ PRATT, KAYLA ;ting Date Patient Name 03/06/08 03/06/08 17/08 PRATT, KAYLA e # : 1 AUTO CHIN ccurrence: 04/04/07 onsulted : 04/09/07 J7 '^CITENT CHIN °ent Balances ------------- )unt Balance i Balance sonal Balance trance Balance het Balance .ection Balance: 0 0 Itemized Statement 04/01/2007 - 04/15/2008 Guarantor --------------------------- --------------------------- 0015477-0001 Al B PatIO: 001840514 PRATT, CHARLENE Page (c) Printed: 04/15/2008 1( AcctID: 00181 SSN : 0363 Code .-------------------- Description ------------------------------- Qty/Src Charged Open Prov. Place IN CHECK INSURANCE PAYMENT ------------------- Insur ------------------------ -362.33 IN ADJ INSURANCE ADJUSTMENT Insur -137.67 99024 POST OP FOLLOW UP 1.00 0.00 0.00 YATES OF DiagP: 873.40 LACERATION FACE, UNSPECIFIED Acct# : 0015477-0001 Admission : Total Disability : Thru Injury/Pregnancy: Discharged: Partial Disability: Thru Employ. Related: Totals From 04/01/2007 ---------------------- Thru 04/15/2008 -- 0.00 Charges - -------- 2390,00 0.00 Personal Payments 0.00 0.00 Insurance Payments: -1712.22 0.00 Total Payments -1712.22 0.00 Adjustments -677,78 0.00 Coll. Payments 0.00 Coll. Adjustments 0,00 0 • E xti)b".f 1- • WAGE LOSS SUMMARY FOR KAYLA PRATT • Hourly Amount Dates Hours Rate Amount Lost Owed 4/5/2007 2.00 $7.00 $14.00 $14.00 4/9/2007 2.00 $7.00 $14.00 $14.00 4/14/2007 5.00 $7.00 $35.00 $35.00 4/16/2007 2.00 $7.00 $14.00 $14.00 TOTAL $77.00 $77.00 TOTAL AMOUNT OF LOST WAGES TOTAL BALANCE OWED TO KAYLA PRATT *Kayla Pratt reserves the right to supplement this Wage Loss Summary. $77.00 $77.00 4004611 Pagel April 26, 2008 Metzger Wickersham Attn: S. Shahid-Benfer 3211 North Front Street PO Box 5300 Harrisburg, PA 17110-0300 Re: Kayla Pratt Dear Ms. Shahid-Benfer: In response to your request for information regarding our ex-employee, Kayla Pratt, l have the following information for you: Kayla was a part-time employee. Due to her young age and the circumstances surrounding her travel to & from work, she was only able to work three days a week during the school week and worked 4-6 p.m. on her assigned days. She was able to work for five hours on two Saturdays a month. Due to the car accident, she had to miss work on April 5, April 9, April 14 and April 16, 2007. Her lost time was a total of eleven hours for those dates that she was scheduled to work. Kayla's job classification at that time was Sales and she was involved with answering the phone, taking orders, helping walk-in customers, packaging UPS shipments, preparing next day orders and kitchen clean- up. Her average rate of pay was hourly and was $7.00 per hour at the time of her car accident. She never was able to earn overtime as this accident occurred during the school year and she was on limited work hours due to her age. Thus, her total wage loss to our knowledge based on time missed at work would have been $77.00. Since Kayla was a part-time employee, she received no benefits from her employment. . We believe, to the best of our knowledge, that the four days missed were due to the accident. Our records indicate that was the only time required by her to be absent from her job. Her last day on the job was Thursday, June 7, 2007. It was her decision to vacate her position. It was mutually agreed upon for her to do so. If we can be of further service to you, please do not hesitate to contact us. I remain..... Sincerely, Cynthia L. Adams President ker C' ' Design" 4'' " 3300 Hartzdale Drive, Suite 105 - Camp Hill, PA 17011 (717) 763-8883 Fax: (717) 763-1977 - (877) 659-3222 www.cookiesbydesign.com www.cookiebouquet.com • Exh;b;+ S • A- 1 74/2008 9:06:53 AM PAGE 7,1,0 02 Fax Server 9800 Fredericlabmg Road San Antonio, Texas 78288 USAA® CLARK DEVERE 3211 N FRONT ST PO BOX 5300 HARRISBURG PA 17110-0300 Reference: Settlement Packet Confirmation Dear Sir, July 24, 2008 This confirms our offer of $15,000.00 in settlement of the following claim Please note we are in the process of obtaining our insured's permission to release limits. We also are trying to obtain any other insurance information. We will forward information as soon as it is received. Your client: Our policyholder: Claim ##: Date of loss: Loss location: Kayla Pratt Darlene E. Wilson 17123716-7101-2-6856 April 4, 2007 Enola, Pennsylvania We believe this offer represents the fair value of the claim You may submit correspondence or questions to me. My contact information is: Address: P.O. Box 33490 San Antonio, Texas 78265 Fax: 800-531-8669 Phone: 800-531-8722 Ext ##61673 Sincerely, Annette C Benavides Northeast Region United Services Automobile Association 17123716 - 2 - PA - 04/04/07 - 6956 - 9 - P252 9/ 2008 10:14:39 AM PAGE 6002 Fax Server PAGE 5 ADDL INFO ON NEXT PAGE MAIL MCH-M-I ,iL UNITED SERVICES AUTOMOBILE ASSOCIATION RRl\ WAT. nF 4 % 4A RECIPROCAL INTERINSURANCE EXCHAN6E) JSW 2600 Fredericksburg Reed - Son Antonio, Texas 78288 SUN rm T--- POLICY NUMBER 01712 37 16U 7101 7 PENNSYLVANIA AUTO POLICY POLICY PERIOD: (12:61 A.M. standard timel RENEWAL DECLARATIONS EFFECTIVE APR 04 2007 TO OCT 04 2007 TTACH TO PREVIOUS POLICY) ( OPERATORS A Named Insured and Address 01 DARLENE E WILSON 03 ERIC HEILNER DARLENE E WILSON SPC ARNG 326 RAVEN CT MECHANICSBURG PA 17050-2084 ¦s crl tion of s la ¦ s VEN US E* r/ Yr?` L Y WN YEN YEAR TRADE NAME MODEL BODY TYPE IUENTEILATON NUMBER 5 M Wev 05 07 SATURN VUE 2WD UTL 4X2 4D 18000 5GZCZ23D17S843599 7 W 30 5 The Ve6lcle sl described herein Is principal IV pre ed at the above address unless otherwise ststed. ! - i 1- moispic - VEH 04 MECHANICSBURG PA 17050-2084 VEH 05 MECHANICSBURG PA 17050-2084 s p a rov es Oso aowra ¦s w ¦r¦ a prom um Is shoal n ¦ ow. ¦ li egtaerdless, of , the 13 140red by po114!y pTaV1slons ?nd may .dot a oombined may mits s pwn number of ' s• ve ,alas r which m u IIatsd sal cal r d • in I , I a EH VEH VEH VEH COVERAGES LIMITS OF LIABILITY 6-MONTH 7 05 6-MONTH ("ACV" MEANS ACTUAL CASH VALUEI DED PREMIUM D-DED PREMIUM D-DED PREMIUM D-DIED PREMRJM N 0 mou NOU N S NOUN d OLIN 0 BODILY INJURY EA PER $ 15,00 EA ACC $ 30,00 72.79 45.68 PROPERTY DAMAGE EA ACC $ 10,00 91.40 55.02 PART B - FIRST PARTY BENEFITS MEDICAL EXPENSE $ 5,000 42.04 14.26 PART C - UNINSURED MOTORISTS STACKED BODILY INJURY EA PER 15,00 EA ACC 30,00 4.40 4.40 PART C - UNDERINSURED MOTORISTS STACKED BODILY INJURY EA PER $ 15,00 EA ACC $ 30,00 6.72 6.72 PART D - PHYSICAL DAMAGE COVERAGE COMPREHENSIVE LOSS ACV LESS 500 78.64 500 17.30 COLLISION LOSS ACV LESS 500 363.86 500 125.71 TOTAL PRE IUM - SEE F LOWI G PAGE(S) LOSS PAYEE EH 04 DC FIN SVCS AMER LLCC, FARMINGTON HILLS MI EH 05 GENERAL MOTORS ACCEPTANCE CORP, TIMONIUM MD ENDORSEMENTS: ADDED 04-04-07 - A100PA(03) A400CW(02) REMAIN IN EFFECT(REFER TO PREVIOUS POLICY)- A089(04) 5100PA(01) INFORMATION FORMS(NOT PART OF POLICY)- 50PA(03) 5685 12) 39PA 01) 60PA(02 570APA 02 570PA 02) 571APA(05 571PA(0 663PA 4 999PA 18 999PAL( 1) s b le _ . ¦ u scr ors ¦t U SERVICES -- 1 IL A53UUIATIU 1 111111 I I M are cause these presents is be signed by their Attorney-in-Feet on this dote FEBRUARY 27, 2007 Robert G. Davis Attorney- in-Feet 5000 U 0 0 f,kib-4 0 0 CONTINGENT FEE AGREEMENT 1, 14 Gvi„ Pc-n ?- ?- individually and as parent and natural guardian of 1Ce ?, l or.. Qi`o l-E- retain and authorize the law firm of Metzger, Wickersham, Knauss & Erb, P.C., to do whatever they deem necessary or desirable in order to represent me and my d°KS"'f in all claims for compensation and reimbursement for personal injuries, wage loss, medical expense and other damages resulting from an Q e C.r 64., V that occurred on 4/4/2007. 1. ATTORNEY'S FEES: The fee of the attorneys shall be contingent as follows: (a) Twenty-five percent (25%) of gross recovery; (b) SHOULD THERE BE NO RECOVERY BY SUIT OR SETTLEMENT, SAID ATTORNEYS DO NOT HAVE ANY CLAIM AGAINST US OF ANY KIND FOR LEGAL SERVICES RENDERED. 2. EXPENSES OF LITIGATION: I acknowledge responsibility for all expenses incurred on our behalf to pursue our claim/case and my attorney shall be reimbursed out of the balance, after deduction of attorneys fees, of any recovery for all legal expenses which have not already been paid by me. I do hereby agree to pay all expenses incurred by our attorney in the preparation and presentation of this case and do understand that these expenses include, but may not be limited to, costs of medical reports and records, stenographic expenses connected with depositions, expert witness fees, photocopying charges, and mileage charges connected with the rendering of legal services. I understand that I am responsible for payment of these expenses regardless of the eventual outcome of the case and further understand that if our attorney deems it necessary, I may be asked to advance these costs prior to the incurring of any such expenses or the scheduling of any deposition. Page 1 of 3 9 0 3. APPEAL: I hereby further agree that our attorney may charge us reasonable additional compensation if it is necessary to try the case more than once, if the case is appealed, or if proceedings in other courts are necessary because of the change of circumstance of a party or for other reasons. 4. AUTHORITY: I hereby further agree that our attorney is hereby authorized to bring suit or to settle and compromise the claim, to execute all documents pertaining thereto, and to do all lawful acts requisite for effecting the claim on our behalf. 5. MEDICAL EXPENSES AND LIENS: I further authorize my attorney to pay out of any proceeds of settlement or trial any unpaid medical bills or liens for treatments or services or workers' compensation liens made necessary by the injuries sustained in this accident, or back child support payments owed to Pa.SCDU. I understand that my attorney is not guaranteeing the payment of any medical bills or liens, and they remain solely my responsibility. 6. INVESTIGATION OF MERITS OF CASE: I agree that our attorney accepts this employment on the condition that he will investigate this claim, and if it appears to be a recoverable claim, he will proceed to handle the claim; but if, after investigation, the claim does not appear to be recoverable, said attorney shall then have the right to rescind this Agreement. 7. EARLY TERMINATION: I hereby further agree that if I decide to terminate this authority before any settlement is offered or any award is obtained the firm shall be entitled to reasonable Page 2 of 3 compensation for all work done on the case up to that point. I agree that reasonable compensation for Clark DeVere, Esquire, or any other attorney involved in the handling of this case, shall be Two Hundred Dollars ($200.00) per hour, and other employees One Hundred Dollars ($100.00) per hour, or such higher rate as shall constitute his/her standard billing rate at the time that the work is performed, or the agreed upon percentage fee in paragraph one of this Agreement, whichever is greater. 8. WITHDRAWAL: I agree that our attorney may withdraw from this case at any time after reasonable notice to us, and I agree to keep him advised of our whereabouts at all times and to cooperate at all times in the preparation and trial of this case, to appear upon reasonable notice for depositions and Court appearances, and to comply with all reasonable requests made of us in connection with the preparation and presentation of this case. 9. CONFLICT: I also understand that if the investigation reveals that a parent is contributorily negligent in causing the accident the attorney's representation will solely be limited to representing the injured minor and there will be no representation of the parent. I also waive any conflict of interest that may arise by my meeting with the attorney to discuss the case. IN WITNESS WHEREOF, I have signed 2007. Jatay of /-fir. '! , CLIENT: METZGER, WICKERSHAM, KNAUSS & ERB, P.C. ATTORNEY: Clark DeVere, Esquire Page 3 of 3 0 0 ?xti?ti;+ L I ^ 40? • 0 Prebill Number: Originating Timekeeper: Billing Timekeeper: Client: Matter: Practice Class: Billed Through Date: 103082 DeVERE,CLARK GRATKOWSKI, STEPHANIE A. 000092 00810 PRATT, KAYLA v. Erie UP UNINSURED/UNDERINSURED PLAINT. 01/16/2009 Date of Last Bill: 01/01/1900 Date of Last Statement: 01/01/1900 Date of Last Payment: 01/01/1900 Amount of Last Payment: $0.00 ITD Fees Billed: $0.00 ITD Exps Billed: $0.00 ITD Total Billed: $0.00 A/R Aging: 0-30 $0.00 31 - 60 $0.00 61 - 90 $0.00 91 - 120 $0.00 121 & up $0.00 MUST CHECK A BOX BELOW [ ] None [ ] Full Detail (Fees and Expenses) [ ] Expense Only (Hold Fees) [ ] Summary Bill (Summarize Fees and Expenses) [ ] Summary with Expense (Summarize Fees, Detail Expenses) L' 9 METZGER, WICKERS, KNAUSS & ERB, P.C. • P.O. BOX 5300 HARRISBURG, PA 17110-0300 (717) 238-8187 TAX I.D. 23-2871395 SINCE Kayla M. Pratt 12 Louise Lane Mechanicsburg, PA 17050 PRATT, KAYLA v. Erie Kayla M. Pratt v. Erie Insurance January 16, 2009 Billed through 01/16/2009 Balance forward as of invoice dated January 01, 1900 Payments received since last invoice A/R adjustments made since last invoice Accounts receivable balance carried Invoice# 0 CDV Our file# 000092 00810 $0.00 0.00 0.00 $0.00 01/16/2009 Photocopies. 9.90 01/16/2009 Postage. 9.00 $18.90 BILLING SUMMARY Total expenses incurred Total of new charges for this invoice Total balance now due $18.90 $18.90 $18.90 PLEASE MAKE CHECKS PAYABLE TO METZGER WICKERSHAM 0 • Prebill Number: Originating Timekeeper: Billing Timekeeper: Client: Matter: Practice Class: Billed Through Date: 103081 DeVERE, CLARK GRATKOWSKI, STEPHANIE A. 000092 00654 PRATT v. Heilner MP MOTOR VEHICLE PLAINTIFF 01/16/2009 Date of Last Bill: 01/01/1900 Date of Last Statement: 01/01/1900 Date of Last Payment: 01/01/1900 Amount of Last Payment: $0.00 ITD Fees Billed: $0.00 ITD Exps Billed: $0.00 ITD Total Billed: $0.00 A/R Aging: 0-30 $0.00 31 - 60 $0.00 61 - 90 $0.00 91 -120 $0.00 121 & up $0.00 MUST CHECK A BOX BELOW [ ] None [ ] Full Detail (Fees and Expenses) [ ] Expense Only (Hold Fees) [ ] Summary Bill (Summarize Fees and Expenses) [ ] Summary with Expense (Summarize Fees, Detail Expenses) 1MB • METZGER, WICKERSIRM, KNAUSS & ERB, P.C. P.O. BOX 5300 HARRISBURG, PA 17110-0300 (717) 238-8187 TAX I.D. 23-2871395 January 16, 2009 Billed through 01/16/2009 Kayla M. Pratt 12 Louise Lane Mechanicsburg, PA 17050 PRATT v. Heilner Kayla M. Pratt v. Eric Heilner Invoice# 0 CDV Our file# 000092 00654 Balance forward as of invoice dated January 01, 1900 $0.00 Payments received since last invoice 0.00 A/R adjustments made since last invoice 0.00 ............................. Accounts receivable balance carried $0.00 DISBURSEMENTS 04/17/2007 RICHARD F. TOTH, reimbursement for fee for copy of accident report from East 15.00 Pennsboro Twp. Police - 04/16/07. 04/30/2007 CHARTONE, INC., prepayment for medical records from Holy Spirit Hospital. 35.15 04/23/2008 CJ ADAMS ENTERPRISES, INC., DBA COOKIES BY DESIGN, wage loss 58.00 information. 04/23/2008 PLASTIC SURGERY CENTER, LTD., medical records and bills. 10.00 07/02/2008 Photographs (Digital Camera) 23.00 07/03/2008 REIMBURSEMENT TECHNOLOGIES, INC., copies of medical bills from 10.00 Camp Hill Emergency Physicians. 000092 00654 CDV In*e# 0 Page 2 07/24/2008 Photographs (Digital Camera) 19.00 10/29/2008 Photographs (Digital Camera) 23.00 01/09/2009 CLERK OF ORPHANS COURT OF CUMBERLAND COUNTY, file Petition 30.00 for Approval of Minor Settlement. NEON= 01/16/2009 Photocopies. 30.06 01/16/2009 Postage. 24.47 01/16/2009 Long Distance phone calls. 0.70 01/16/2009 Fax. 13.00 BILLING SUMMARY Total expenses incurred Total of new charges for this invoice Total balance now due $291.38 $291.38 $291.38 PLEASE MAKE CHECKS PAYABLE TO METZGER WICKERSHAM 0 0 C,?,??b?+ M 0 0 PARENTS/GUARDIAN RELEASE AND INDEMNITY AGREEMENT USAA® United Services Automobile Association Member Name USAA Numb er L/R Number Date of Loss Darlene E. Wilson 17123716 2 04-04-2007 FOR AND IN CONSIDERATION of the payment to me/us of the sum of ($15,000.00) Fifteen Thousand Dollars and no/100********** the receipt of which is hereby acknowledged, Uwe, the undersigned, father and mother and/or guardian of Kayla Pratt a minor, do forever release, acquit, discharge and covenant to hold harmless Darlene E. Wilson and Eric Heilner his/her heirs, successors and assigns of and from any and all actions, causes of action, claims, demands, damages, costs, loss of services, expenses and compensation, contribution, indemnification, on account of, or in any way growing out of, any and all known and unknown personal injuries and property damage which Uwe may now or hereafter have as the parents and/or guardian of said minor, and also all claims or rights of action for damages which the said minor has or may hereafter have, either before or after he/she has reached his/her majority, resulting or to result from a certain accident which occurred on April 4, 2007 at or near Enola, PA. UWe, on behalf of minor Kayla Pratt, specifically preserve and do not release, acquit or discharge any claim, actions and/or right Uwe have to first party benefits through my/our own automobile insurance policies; social security disability benefits; or any other source for recovery of income loss, work loss, medical benefits, health insurance, disability benefits from any entity, but specifically excluding the releasees and his/her/their liability insurer, USAA. I/We, on behalf of minor Kayla Pratt, also specifically preserve and do not release, acquit or discharge my/our right to continue to make claims and/or recover for uninsured and/or underinsured motorist coverage. UWe, on behalf of minor Kayla Pratt, specifically preserve and do not release, acquit or discharge any claim and/or action Uwe may have against any medical provider for any treatment or lack of treatment, including malpractice. I/We, on behalf of minor Kayla Pratt, do hereby agree to satisfy any and all legally valid liens for medical payments made on her behalf as a result of the accident and hold harmless Darlene E. Wilson and Eric Heilner from any such lien (s). It is further understood and agreed that this settlement is the compromise of a disputed claim, and that this payment is not to be construed as an admission of liability on the part of Darlene E. Wilson and Eric Heilner by whom liability is expressly denied. Should it appear that two or more persons or entities are jointly and severally liable for the said injuries to person or damage to property arising out of said accident, the consideration for this release shall be received in complete satisfaction to the full extent of the fault of release(s), whether proportionally allocated or total, as ultimately determined under the law and for which release(s) are found liable. UWe further agree and acknowledge that the releasees, and each of them, expressly reserve all rights of action of whatever kind against me/us, my/our heirs, executors, administrators and assigns and against said minor on account of, or in any way growing out of the above described occurrence or accident. The payment of $15,000.00 constitutes damages on account of personal injury or sickness in a case involving physical injury or sickness within the meaning of IRC §I04(a)(2). This Release shall be interpreted in accordance with Pennsylvania law. 410909-1 Pagel of 2 • • I/We further state that Uwe have carefully read the foregoing Release and know the contents thereof, and Uwe sign the same as my/our own free act. This Release and Agreement is being executed with the permission of and consistent with the Court Order dated Approving of the settlement. Pennsylvania Statutes, 75-1822 states: "Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine up to $15,000." Executed at , this day of , City/State Day Month Year WITNESSES: Signature Address CAUTION: READ BEFORE SIGNING Legal Signature Kevin Pratt Print Name Signature Address RAP012-0504 Legal Signature Charlene Pratt Print Name PA-D-7101-2-6856/09 410909-1 Page 2 of 2 ALL STATE LEGAL SUPPLY 00. ONE COMMERCE DRIVE, CRANPORWEY 07016 (2) 0 ED/1 • • CLAIM #: 010170914080 RELEASE AND AGREEMENT Under policy # Q031009620 issued by ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY, UWe, claiming coverage for myself/ourselves or on behalf of Kayla Pratt in consideration of Twenty Thousand Hundred ($20,000.00) dollars, which I/We have received, RELEASE AND DISCHARGE ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY from any and all claims, causes of action or other rights which I/We have, have had or could have under the Underinsured Motorists coverage as set forth in said policy, which claims, causes of action or other rights arose or could have arisen as a result of a loss or accident which happened on the 4th day of April, 2007, at or near Creekside Drive, in the county of Cumberland, in the State of Pennsylvania. In consideration of such payment, UWe agree as follows: 1) to assign Erie Insurance Exchange/Erie Insurance Company to my/our rights of recovery against any person(s) or party(ies) legally liable to me/us, to the amount of and for the purpose of the payment noted above; 2) that I/We have not and will not make any separate settlement with nor give any separate release to any person(s) or party(ies) who caused or are alleged to have caused the above mentioned loss or accident; 3) that suit may be instituted by Erie Insurance Exchange/Erie Insurance Company in my/our name; 4) to execute all papers required to commence such suit; and 5) to cooperate in prosecuting any or all actions which Erie Insurance Exchange/Erie Insurance Company may bring to recover from any person(s) or party(ies) for the claims or causes of action which I/We have growing out of said loss or accident. It is expressly understood and agreed that, out of any amount recovered, costs of collection, including but not limited to counsel fees, shall be first paid to ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY. Except in states which apply comparative negligence in determining legal liability, any recovery in excess of collection costs shall be paid to me/us, up to the full extent of my/our loss. In states which apply comparative negligence, any recovery of my/our loss, in excess of collection costs, shall be reduced by a factor equal to the percentage of my/our negligence which contributed to cause the above mentioned accident, before it is paid to me/us. The above provisions do not apply to the settlement with and release of Eric Heilner and Darlene Wilson and his/her liability insurer. ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY waived its subrogation rights against Eric Heilner and Darlene Wilson and consented to the settlement on October 3, 2008. I/We further understand and agree that this RELEASE AND AGREEMENT is inclusive of any and all present and future liens or claims for subrogation against the payments to be made in accordance with this RELEASE AND AGREEMENT. UWe understand and agree that Uwe are responsible for the payment of any legally valid liens or charges for payments made on my/our behalf as a result of this accident against the payments to be made hereunder should any such liens, subrogation, claims or claims for expenses and charges be asserted. This includes, but is not limited to, medical expense liens, worker's compensation liens, ERISA liens, liens asserted by any federal, state or local governmental entity or agency or any medical expense claim. Should any person or entity make claim for payment of any legally valid liens or charges for payments made on the undersigned's behalf as a result of this accident against ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY or their counsel, Uwe agree to indemnify and hold harmless ERIE INSURANCE EXCHANGE/ERIE INSURANCE COMPANY and their counsel from any and all such liens, charges, fees, claims, costs, and interest. The payment of $20,000.00 constitutes damages on account of personal injury or sickness in a case involving physical injury or sickness within the meaning of IRC §104(a)(2). 408R59-1 0 0 This Release shall be interpreted in accordance with Pennsylvania law. I/We understand that this settlement is the compromise of a disputed claim, and that the payment is not to be construed as an admission of liability on the part of the persons, firms and corporations hereby released by whom liability is expressly denied. (CAUTION: READ BEFORE SIGNING) Intending to be legally bound thereby, WITNESS my/our hand(s) and seal(s) this Witnessed by: (Kevin Pratt, father of Kayla Pratt) (Charlene Pratt, mother of Kayla Pratt) STATE OF COUNTY OF : SS day of - (SEAL) - (SEAL) On this day of , before me personally appeared, , to me known to be the person who executed the foregoing instrument, and acknowledged that executed the same as free act and deed. My commission expires Notary Public NOTICE: Any person who knowingly and with intent to defraud any insurance company or other person riles an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. 40RR59-1 0 0 CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a true and correct copy of the foregoing Petition for Approval of Minor Settlement with reference to the foregoing action by first class mail, prepaid postage, this 16 ?'tay of ,,0 c,o?f , 2009, on the following: Annette C. Benavides USAA Property & Casualty 9800 Fredericksburg Road San Antonio, Texas 78288 Erie Insurance Group P. O. Box 2013 Mechanicsburg, PA 17055 Attn: Donald Bottini Claim Representative Clar e ere, Esquire 408406-1 CD i1 ?a 3 JAN 2 9 20096 Metzger, Wickersham, Knauss & Erb, P.C. By: Clark DeVere, Esquire Attorney I.D. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 Attorneys for Petitioners (717) 238-8187 cdv(u»mwke.com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: KAYLA PRATT, a Minor NO. D Q - 10 CIVIL ACTION - LAW ORDER AND NOW, this day of , 20 , upon consideration of the Petition for Approval of Minor Settlement, a hearing is set for .3, 2009, at d+` o'clock P.M. in Courtroom # of the Cumberland County Court House. BY T CO J. 408406-1 cl? N 0 Wd 0C Nvr 6001 Awl"",-, "acl 3it li It Metzger, Wickersham, Knauss & Erb, P.C. By: Clark DeVere, Esquire Attorney I.D. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 Attorneys for Petitioners (717) 238-8187 cdv(a?mwke.com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: KAYLA PRATT, a Minor NO. CIVIL ACTION - LAW DECREE AND NOW, this day of 2009, upon consideration of the Petition for Approval of Minor Settlement, it is hereby ORDERED and DECREED that the Petitioner is authorized to enter into two settlements: (1) for the third party case in the amount of $15,000; and (2) for the underinsured motorist claim in the amount of $20,000. Petitioner is authorized to sign releases for those settlements. The gross settlement amount of $35,000.00 shall be distributed as follows: (1) TO: Metzger, Wickersham, P.C., $8,750.00 for counsel fees; (2) TO: Metzger, Wickersham, PC., $310.28 for reimbursement of costs; (3) TO: Kevin Pratt and Charlene Pratt, as Parents and Natural Guardians of Kayla Pratt, a Minor, $25,939.72 to be deposited into a restricted, federally insured account or 408406-1 certificate of deposit at Commerce Bank marked "No withdrawals prior to age 18 without prior court approval." TOTAL AMOUNT OF DISTRIBUTION: $35,000.00 Counsel shall provide to the Court, within ten (10) days from the date of the distribution of the settlement funds, proof of such deposit. J. cc: Clark DeVere, Esquire - counsel for Petitioner - ('. Annette C. Benavides - USAA Property and Casualty Donald Bottini - Erie Insurance 408406-1 r-a j 74 1 Metzger, Wickersham, Knauss & Erb, P.C. By: Clark DeVere, Esquire Attorney I.D. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 Attorneys for Petitioners (717) 238-8187 cdv(a,mwke.com IN RE: KAYLA PRATT, a Minor IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 09-406 Civil CIVIL ACTION - LAW AFFIDAVIT OF DEPOSIT OF MINOR'S FUNDS The undersigned, counsel for Kevin Pratt and Charlene Pratt, Parents and Natural Guardians of Kayla Pratt, a minor, hereby certifies that the net settlement amount of $25,939.72 as set forth in this Court's Order dated February 13, 2009 was deposited on March 12, 2009 by Kevin Pratt and Charlene Pratt into two Certificates of Deposit, restricted, federally insured accounts at Commerce Bank, marked "the money in the accounts cannot be withdrawn, assigned, negotiated or otherwise alienated from the account until Kayla Pratt reaches her majority on September 13, 2009, except upon prior Order of the Court." Proof of deposit is attached hereto as Exhibit "A". 415583-1 This Affidavit is made subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsification to authorities. METZGER, WICKERSHAM, KNAUSS & ERB, P.C. By: Clark DeVere, Esquire Attorney I.D. No. 68768 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 Dated: March 13, 2009 Attorney for Petitioners 415583-1 dgzk MRR-12-2009(THU) 14;58 Commerce Bank Hampden Ctr. (FRX)717 975 0596 P-002/002 03/12/2009 13:23 FAX 7172949478 M &E HGB PA 1 002 PROOF OF DEPOSIT I, Judy Hoover, Senior Customer Service Representative of Commerce Bank at Mechanicsburg, hereby certify that on this 12th day of March, 2009, a check in the amount of 525,939.72 was deposited today into two certificates of deposit under account #-J-0.36',401 and # 3o3SGS which has been established for Kayla Pratt, DOB: 09-I3-9I, and which are federally insured, restricted accounts. Per the February 13, 2009 Decree of Judge Edward Guido, Judge of the Court of CoT=on Pleas of Cumberland County, Pennsylvania, the money in the accounts cannot be withdrawn, assigned, negotiated or otherwise alienated from the account until Kayla Pratt reaches her majority on September 13, 2009, except upon prier Order of the Court. Witness COMMERCE BANK dy Hoover By: 21?: • America's Most Convenient Banks 1-888-937-0004 commercepc.com Balance information reflects transactions through 8:00 PM on that business day. Some deposits may not be available for immediate withdrawal. Checks and other items are received for deposit subject to the provisions of the Uniform Commercial Code or any applicable collection agreement. 35 1:35 PM # 03/12/09 8 003564 Time Deposit Deposit 510,000.00 184 HAMPDEN CENTER BRA 7 3.3MM 2/08 AC Cat??e Amerke's Most Convenient Banks z 1-888-937-0004 commercepc.com Balance information reflects transactions through 8:00 PM on that business day. Some deposits may not be available for immediate withdrawal. Checks and other items are received for deposit subject to the provisions of the Uniform Commercial Code or any applicable collection agreement. 36 1136 PM 4 03/12/09 8 003565 Time Deposit Deposit $15,939.72 184 HAMPDEN CENTER 3 BR-17 3.3MM 2/08 AC 1 CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a true and correct copy of Affidavit of Deposit of Minor's Funds with reference to the foregoing action by first class mail, postage prepaid, this A,3,`-day of March, 2009 on the following: Annette C. Benavides USAA Property & Casualty 9800 Fredericksburg Road San Antonio, Texas 78288 Erie Insurance Group P. O. Box 2013 Mechanicsburg, PA 17055 Attn: Donald Bottini Claim Representative The Honorable Edward Guido Cumberland County Court House 1 Courthouse Square Carlisle, PA 17013 Clark DeVere,. Esquire 415583-1 ? p rn Z2 s_ ?;