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HomeMy WebLinkAbout00-05083Y PIXIE GRAMM and BARRY GRAMM, as natural guardians of SALENA GRAMM, a Minor, Petitioners V. ROBERT W. REIBER, Respondent IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 00-5083 CIVIL TERM ORDER OF COURT AND NOW, this 24t` day of July, 2000, upon consideration of Plaintiffs' Petition for Minor's Compromise, it is ordered and directed as follows: 1. The proposed settlement is approved; 2. The proceeds of the settlement shall be deposited in one or more savings accounts in the name of the minor in banks, building and loan associations or credit unions, deposits which are insured by a Federal governmental agency, or in one or more accounts in the name of the minor investing only in securities guaranteed by; the United States government or a Federal governmental agency managed by responsible financial institutions; 3. No withdrawal may be made from any such account until the minor attains majority, except as authorized by prior order of court; 4. Proof of deposit shall be promptly filed of record; 5. Plaintiffs are authorized to sign the release attached to the petition. BY THE COURT, J esley Oler, r., J. n -0 10? ?IMNSYl'dAN" A Pixie Gramm Barry Gramm 2515 V alley Road Marysville, PA 17053 Natural Guardians for the Minor Plaintiff Karen Durkin, Esq. Jarad W. Handelman, Esq. P.O. Box 650 Hershey, PA 17033-0650 Attorneys for Respondent :rc PIXIE GRAMM and BARRY GRAMM, IN THE COURT OF COMMON PLEAS as parents and natural guardians of CUMBERLAND COUNTY, PENNSYLVANIA SALENA GRAMM, a Minor, Petitioners NO. ?- ciot v. CIVIL ACTION-LAW ROBERT W. REIBER, Respondent MINORS COMPROMISE ORDER AND NOW, this _ day of , 2000, upon presentation of a Petition for Minor's Compromise, it is hereby directed that a hearing on the merits take place on the _ day of , 2000, at o'clock in the _.m. By the Court: J. a , At I PIXIE GRAMM and BARRY GRAMM, as parents and natural guardians of SALENA GRAMM, a Minor, Petitioners V. ROBERT W. REIBER, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. CIVIL ACTION-LAW Respondent : MINORS COMPROMISE ORDER AND NOW, this day of 2000, upon consideration of the within Petition, and after a hearing thereon, it is hereby ORDERED and DECREED that the settlement among Nationwide Insurance Company, the insurance company for Respondent, Robert W. Reiber, and the Petitioners, Pixie Gramm and Barry Gramm, on behalf of the Minor, in the amount of Two Thousand ($2,000.00) Dollars is APPROVED. Payment of the settlement proceeds shall be made to Salena Gramm on March 25, 2004. Petitioners are authorized to execute a Release in favor of Nationwide Mutual Insurance Company and Robert W. Reiber. Said Release shall be in the form of the Release attached to Petitioner's Petition as Exhibit "E". BY THE COURT: J. , A PIXIE GRAMM and BARRY GRAMM, as parents and natural guardians of SALENA GRAMM, a Minor, Petitioners V. ROBERT W. REIBER, Respondent Al IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. Pv - -?US3 a?a -7,ez ? CIVIL ACTION-LAW MINORS COMPROMISE PETITION FOR MINOR'S COMPROMISE AND NOW, come your Petitioners, Pixie Gramm and Barry Gramm, as parents and natural guardians of Salena Gramm, a minor (hereinafter the 'Minor") and respectfully petition this Honorable Court as follows: 1. Petitioners are adult individuals who currently reside at 2515 Valley Road, Marysville, Perry County, Pennsylvania. 2. Petitioners are the parents and natural guardians of the Minor who currently resides with Petitioners at the above address. The Minor was born on March 25, 1986 and is now fourteen (14) years of age. 4. On November 30, 1999, the Minor was a passenger in a 1999 Sofia Kia owned by your Petitioners, Pixie Gramm and Barry Gramm and being operated by Pixie Gramm, traveling northbound on Rt. 114 just past the I-81 interchange. At the aforesaid time, Petitioners' vehicle was traveling in the right northbound lane of Rt. 114 preparing to make a right hand turn. Respondent was operating a 1994 Jeep Cherokee in the left northbound lane of Rt. 114 preparing to merge into the left turn lane. Respondent swerved toward the right lane to avoid a vehicle coming from his left side and struck the Petitioners' vehicle. The accident was called in to the Silver Spring Township Police Department, but no report was filed. 6. At the aforesaid time, Respondent was insured under an automobile insurance policy issued by Nationwide Insurance Company ("Nationwide") which is an insurance company licensed to transact business in the Commonwealth of Pennsylvania with a place of business at 1000 Nationwide Drive, Harrisburg, Pennsylvania 17105. A true and correct copy of the declaration page of the aforementioned policy of insurance is attached hereto as Exhibit "A" and incorporated herein by reference. 7. Nationwide has offered to compromise this claim in the amount of Two Thousand and 00/100 Dollars ($2,000.00). 8. This Petition is filed as a result of injuries sustained by the Minor. 9. Minor sustained soft tissue injuries as a result of the Accident. 10. As a result of the Accident, Petitioners have made a claim to Nationwide pursuant the provisions of the auto policy under which Respondent was insured. 11. Minor was treated in the Emergency Room of Holy Spirit Hospital and released following the Accident. A true and correct copy the Holy Spirit Hospital medical records and discharge are attached hereto as Exhibit "B" and incorporated herein by reference. 12. Minor received follow up treatment from Shermans Dale Family Practice for treatment of neck pain and numbness in her legs. A true and correct copy of the Shermans Dale Family Practice records are attached hereto as Exhibit "C" and incorporated herein by reference. 13. Minor subsequently sought physical therapy treatment from Central PA Rehabilitation Services. A true and correct copy of the Central PA Rehabilitation Services records are attached hereto as Exhibit "D" and incorporated herein by reference. 14. It is anticipated that the Minor will not receive nor require any future treatment related to injuries sustained in the Accident. 15. To date, the Minor's medical bills have been paid through Allstate Insurance Company, in full. There are no out of pocket medical expenses incurred by Petitioners. 16. Petitioners have made a careful and diligent inquiry and investigation in ascertaining the facts surrounding the accident, the responsibility therefor, and the nature, extent and seriousness of the Minor's injuries. 17. Petitioners believe that the within compromise with Nationwide is fair and in the best interests of the Minor. 18. Petitioners understand that the settlement made pursuant hereto is for the benefit of their minor daughter, and that all monies paid in settlement of this matter as set forth herein are to be held in trust for the benefit of the Minor in a manner approved by this Honorable Court until she reaches the age of eighteen (18). 19. Petitioners request that upon approval of the proposed compromise that they be authorized to execute the Release which Nationwide has requested and is attached hereto as Exhibit "E" and incorporated herein by reference. C Respectfully submitted, JAMES, SMITH, DURKIN & CONNELLY, LLP Dated: 7-/?-00 By: KAREN DURKIN, ESQUIRE Attorney I.D. #29563 JARAD W. HANDELMAN, ESQUIRE Attorney I.D. #82629 P.O. Box 650 Hershey, PA 17033-0650 (717) 533-3280 Attorneys for Respondent . VERIFICATION The undersigned, PIXIE GRAMM and BARRY GRAMM, hereby verify that the facts set forth in the foregoing document are true and correct to the best of their knowledge, information and belief and further state that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904 relating to unworn falsification to authorities. Date: 11?n sib 41()Aa- Pixie Gramm Individually and as a'-' a natural guardian of Salena Gramm Date: L2-22- 215r, p .? ' Bang G Individually and as a a natur guardian of Salena Gramm DEC, -DV 99 (WED) 11:42 CHBG SERVICE CENTER PEL:7112631834 P. 005 5 a FRAN NATIONWIDE MUTUAL CO 01 - 58 37 B S78402 113099 Ol PAGE 0001 RPRT COMP LOSS REPORT AGZNT FRANCIS T GILL, JR. AGT TEL 610.929.9951 ACT 0 0006512 DIST CH MAXI CH ENTITY LOCATION "XT CR REP MEDIA CODE CSR CALL CENTER CSR RRO 91 RPRT DT 113099 PRINT DT 120199 '. AMID BY SARAY<GRAM XTEL 717/957.2624 BTEL 717/574-3416CELL rareeww wYw•.....r.w.ae.wewr...r.erw..ra.wwrw.aa............ I* ............... ww. ROBERT W<REISER ID R/R1 AGE 99 "TEL 717/796.0390 140 PLEASANT GROVE PH TORT F BTZL 717/787-5699 ROAD NUM Or PASSENGERS 00 MECHANICSBURG LOC V10/D VIOL N F U PA 17055 IS29 INJ U VEH COLOR BLACK DR/XOSP U 1,1C R UNK ? DAMAGE PELF DR Y LOSS4 VIM LOG PH RES NIA UNINS VEX N OWNER DRVR ROBERT WtREIBER TEL 717/787-5699292 E DR ADD - MECHANICSBURG PA1705S AGE 9S COUNTY CUMBERLAND AIR BAG U SEAT BELT U COMMENT -140 PLEASANT CRO DUDAL 11/30/9005:12PM 87160 COLL /58FRAN / /HOLD COLL /56FRAN / /SUB COLL /56LANC^M1) /APPRAISAL ONLY /SPLIT ........ r....naewwr w.aaa wrwxw .............wrwwwwsww.....wwwwsw. arYwr......w. www LOG ROUTE 114 MECHANICSB1705SCUMBERLAND LOSS ST 37 , LOBS DESCRIPTION PER CLMT- V1 GETTING OVER TO LEFT LANE AND HE TIME 0001 WAS "ALFWAY IN THE LEFT LANE THAN V1 WAS PUSHED OVER TO THE LANE CAT 00 HE WAS PREVIOUSLY IN AND SIDESWIPED V2 PD N e.ra.waa aearrwwwar.e..........aw.....rrwwwwwrw.rYrYwn.r...........xrrn.wwew.r. NAME PIXIE<GRAMX ID P/91 AGE 31 XTEL 717/957-2624 ADDR - MARYSVILLE PA17053 ZTEL 717/763-1100 CLOG V20/D. VIOL N AIR BAG Y SEAT BELT Y IWO HEADAGKZ DA/H09P MAYAMCEIVETRFATMENTLATER - VEH 1999KIA SAFIA DAMAGE LS.LF DR %4 LoSsB VLOC CWT RIDS: N/A LIC $ PAUNX VEH COLOR PURPLE NDM OF PASSENGERS O1 INS ALLSTATE 09877742712/22 DRIVER PTXXE<OAA-24 AGE 31 DTEL 717/763.1160 OADDR I- MARYSVYLLE PA17053 COMMENT •2515 VALLEY RD *-2515 VALLEY RD BI /S8rRAN / - (OPEN I / PD /SSrRAN / /BOLD. PD /S8LANC-MD /APPRAISAL ONLY /SPLIT / / - e.#ia++r#arwww.w.v.a....•.a...r?••ww+rYWV...... wwww............et.........arwa« NAME SELENA<GRAMM ID S/G1 AGE 13 XTEL 717/957-2624 ADOR - MARYSVILLE FA17053 BTEL 717/763-1100 CLOG VZPAS - VIOL N AIR BAG Y SEAT BELT Y INJ NECK DR/HOSP MAYRECEIVETREATMENTLATER VEX 1999XIA SAFIA DAMAGE DR Y LOSS$ VLOC CWT RES N/A Lic # PAUNX - VXH COLOR PURPLE NUM OF PASSENGERS 01 INS ALLSTATE 09577742712/22 DRIVER PIXIE<GRA M AGE 31 DTEL 717/763-1100 DADOR w. VARYSVILLZ PA17053 COMMENT -2515 VALLEY RD "-2515 VALLEY AD SI /SSFRAN / /OPEN *1...... r Y.... wwarrr•aaswaa..aa.w««wawa+arrr.•wwew«aa.rveee.aYSaeaawwwxwr.+.aar WITNESS No WIT, NO ENT HRAS/DI REFUSAL CLMT CALLED IN NNN e.eaw•rwwa.r..r..wrrYwrr.?ruwrw+YY.rrwaaww.w+a...YrarwwYY.rer•r rr wew...ree...w 1 94 JEEP GR cHERO 1J4G276Y9RC349266 TIN 060001) RENEWAL DATE 11115199 PH INCEPTION DATE 05/16/74 PAY PLAN RED POLICY STATUS 01A ACTIVE FTC ACV COLL SOOD PD 25000 BI 25/50 MEDSEN 5000 INCOME 25000 PUNERL 5000 BLUM 25/50 5 STUI 25/50 6 ENDORSEMENTS ENDORSEMENT'S 2264A 23,91 2357 2356 INSPECTION 00/00/00 CONTINUED DEC.-01'99(WED) II 42 CH6G SERVIC4 CENTER -TEL:71,263'834 P. 006 SSFRAN PH ROBERT RET9ER $6 37 B 579602 113099 01 PAGE 0002 AGENT $ 0006512 •MYli ii.w MWrrrteMrf'riaiaillR iw.aww1la wrawiaitieYYr if ilYf rf warewwwrvsaxiMf wf wwawi• RO 6T PR VOL NO LOSS OT SF C A V L INACT DT PURGE OT VIN6 SS 37 9 576402 12 01 92 01 C C N 0 11 14 93 09 16 94 1S3XA46E9MF6S7276 SO 37 5 578402 11 11 92 01 O J N 0 06 11 93 12 10 93 1C3maS6D4CC164974 •rf wf rfiwwMYY.........4 .............Yfraiwrr w.iWrf.wwa... i.... x......wariffir OR?30•N WORK MLLES 00 SUS USE N ADZ Z USE W DC MC Y LINE 01 CA`TY 021 ?iw'wf rwwYrYf wwwa.......... *.M1 ..frxVwrV ...............fait I..*..... wf arfrwa iw Date. Log-in Time 'It A-1- c Name: Age:_ Triage Time FMD Time to Exam Room MOC16 of Arrival [ lArnbulatiory [ W LS I', ALS : Medtcal Command CHIEF COMPLAINT: INITIAL TRIAGE: Place Injury occurred- I'Vme [ ] Industry [ ] Recreati [ ] Other information obtained from. -,Patlent -Family/SO Records _EM ramedic Extremity Evsiushon Triaged to radiology for Deformity Yes/No akin Temp Warm/Cool DistalPWees Present/Absent Destination Fl£CU [IEDF aide Color Pink/Cyanotic/Mottled Pain(140) Pareatheela Present/Absent Time _l Intervention Si nature - Temp: ua% Pulse- ll Allergle eactlons: Latex- rjc?l - Reap ratlo a BlP: _? Pulse Ox ,?_ N Last Tetanus LMP Weight -scalefestlrr>ate (it Pertinent) VI alA OD 03. 0U ccrwv I Subjective: - m Objective:1 Prehospltal Treatment MedlcatiorllDoseffre uen Last Dow ,Medlcatlotl/Doseff uen Last Dose Pest MedicaNSurgical Hletary: -'- Has pateml had exposure to measles, chickenpox or TS In past mentM Are there a s directives? = Is copy avadableli NURSING OI/ON0e19 EX CarWec output, nitration in - Conlon, allerabon in - Fluid volume aaemticn in - Impaired gas exchange - PotannaVActual refection _ Knowledge Dahgl - PECTED OUTCOMES Improvement in cardiac outiut demonstrated by improved vs and diagnostic tests Decrease OF rehet 01 discomfort !* Improvement in iluvi vol demonstrated by decrease in symptoms or fluid mroal ?PR?`jl ?>. Improved gas exchange demonstrated by improved oxygenation and ntai Decrease in symptoms and ng nnfacbm or potanbel for Infection tin howl darn nalre Verbalization / return demonstration 4^ Assessment completed at Data obtained by, R.N. M.A Gilliq 'T•E i- Admission Called [ ] Admission [ ] Observation [ ] Old Records Sent Report Called Admitted to at Hrs Transfa to at by Disposdion ome ( (] OR at ?istactcry [ itlfAl [ e tie Discharged [ charge Instructions 'Dlscha R N et Holy Spirit Hospital Camp Hill, PA ECU Nursing Assessment 201£CU W7 eth eav JO MO SR CHART COPY I'q J j It - [G na I..?va < ?silt ,SfLEKA S 25i; VIkLt.EII RD ER1 80TSTME PA 17!#53 43123/1456 997-tb14 ]7R-b6-9103 ED GROUP BRA R>! , BARR t14 1vILt97569077 11/30/99 I ADM. DATE: 11/30/1999 CHIEF COMPLAINT: Motor vehicle accident HISTORY OF PRESENT ILLNESS: This 13 -year-old white female presents to the Emergency Room today by car from the accident site Patient states that she was the front passenger in her parents car when they struck on the front driver's side. The patient states that she was wearing a seatbeh and although they have an airbag, it did not deploy The patient states that she did not lose consciousness She was able to extricate herself from the vehicle and was able to ambulate The patient states that she developed neck pain and left shoulder pain within a half hour of the accident The patient was brought to the ER by her father The patient's mother is also here as a patient The patient denies any headache, vision changes, chest pain, or abdominal pain She denies any pain to any of her extremrtes other than her left shoulder PAST MEDICAL HISTORY: Significant for tonsillectomy and appendectomy MEDICATIONS: The patient takes no medications ALLERGIES: No known drug allergies. SOCIAL HISTORY: This 13 -year-old is a Junior High student and lives with her parents She denies the use of alcohol or tobacco products PHYSICAL EXAMINATION: VITAL SIGNS: See nurse's notes GENERAL: This is a well developed and well nourished 13 -year-old female in no acute distress HEAD: Normocephalic Atraumatic EYES: PERRLA Extraocular movements are intact without nystagmus There is no lid lag There is no discharge from the eyes ENT: Ears Tympanic membranes without perforation, injection, or bulging Mouth Ups, teeth, and gums normal. Throat Oropharynx without lesions or exudate Airway patent Nose Nasal mucosa normal Sinuses No sinus tenderness NECK: Supple The patient does complain of pain in the posterior neck and the lateral aspect with palpation I did put a collar on the patient immediately She does not have pain with flexion and extension of the neck, however The trachea is midline There is no lymphadenopathy present The thyroid is nonpalpabie BACK: Nontender to palpation She has no c v a tenderness Page 1 of 2 HOLY SPIRIT HOSPITAL Camp Hill, PA NAME Gramm, Selena S MED BILL PROCEE'17411 MR# 144503 ROOM ER1 FEB EMERGENCY ROOM REPORT DR : NATALIE GILLIS, CRNP ORIGINAL S NAME: Gramm, Selena 5 MR#: 144503 LUNGS: Normal respiratory effort Breath sounds equal No rales, rhonchi, or wheezes CHEST: Non-tender to palpation CARDIAC: Regular rate and rhythm without murmurs, No peripheral edema GI/ABDOMEN: Soft, non-tender, normal bowel sounds, no masses No hepatosplenomegaly GU: Normal SKIN: There is no evidence of rashes, lesions, abrasions, or lacerations EXTREMITIES: Symmetrical The pabent has complaint of pain with overhead lifting of the left arm and also inversion of the left shoulder There are positive pulses peripherally There is no clubbing or cyanosis NEUROLOGICIPSYCHIATRIC: The patient is awake, alert, and oriented z 3 The patient's mood and affect are 'appropriate during the exam The patrenfs short and long tern history are intact MEDICAL DECISION-MAKING: The patient will have Tylenol 850 PO and she will have an x- ray of the C-spine as well as the left shoulder ADDENDUM: The patient had a routine cervical spine as well as a left shoulder Both were negative for fractures or significant soft tissue injury The patient will be sent home She is to follow-up with her family doctor on Friday for reevaluation She is not allowed to participate in gym or sports until reevaluated She can have ice intermittently to reduce the swelling She may also take Tylenol or Advil for pain She is to return if she has increased pain, headaches, or any tingling or numbness to her extremities She stated understanding of these instructions Neck strain secondary to motor vehicle accident NAT LIE GILLIS, CRNP NG/ts DOC # 11435 D 11/30/1999 T 12/0711999 956A 002875 2of2 Camp Hill, PA 17011 NAME Gramm, Selena S MR# 144503 ROOM ER1 DR NATALIE GILLIS, CRNP MED BILL pFIOCES' EMERGENCY ROOM REPORT ORIGINAL FEB 14 2000 CmS CENTEP Initial Lob & K Ray Orders- Labs / U*W 8060ftnea [ ] Acetammophen [ 1 ESR I 1 Tox Screen [ ] Alcohol [ I Glucose ( J unne Tox Screen [ I AmylaselLipase [ I HOGS ( 1 Throrrkbolyoc Labs [ ] APTT [ I Lwer I I Type & Cross __e of units I ] Blood Cultures Profile I 1 Type & Screen [ I BMP [ ] Lyles I I U/A ( I CSCP I I PTP I I unite C& 5 [ I CMP ( ] Salicylate [ ] Workman's Comp Drug Screen [ I CRP] ( I Serum Acetone I I Other ( I Dqx wn [ ] Theophyllne [ I Ddarmn I ] Thyroid Profile ReriMlogy ( ] Abd/Obatr Senea [ ] KUS 11 Ankle R L I I L9 Wine f l Clmela R L [ I Mandble '? "BOWLS" *swiriFlalrr [ 1 Navel S?M [ ]Orblt R L a'r"1fRX!`? [ ] Pelvis [ 1 E bow R L. ( 1 Pyelogram IYP 1 I Faisal 1 I Rfba R L I ] Fanner R L '0i qulaw R jz ( IFlow-Ft L [ Is" ?4? f j Fool R L [ ] Slemum I lrwraaml R L I 1T/Splrw [ ]Hand R L [ ]TIb/Fib R L [ I Hip R L [ 17oe R L [ [ Humerus R L [ ] Wrist L [ I Knee R L - / w'1 'Irlmmmllcil [ ]Other 6 I ? Utlneaund l ] Abdomen ( I CT Scan of ( 1 Duplex Doppler [ ] YO Stuart [ I Gallbladder [ ) Other [ ] Palm T Cutturee hrie/OlTrIlm [ 1 Sete strop AG / Culture I 1 Sputum C & S [ I Cervical I I Stool C& S [ ] ChkvrrAa [ I Stool O & P f IGCCuhdre I 1slow C DIMC410 [ ]WoundC&S Billing ClaSONICK110111: [11 I 1 Follow up [ Amcldent L.l II [ 1 Case 1 [ I Medical I 1 Lexe1111 1 I Medical Non-Emargenay [ ]Level lV [ ] L«a v Holy Spirit Hospital Camp Hill, PA Emergency Care Unit Physician Order Shell 20&ECV REV JM JD eR MD _ _ CHART COPY Time Seen: )01 S Card/eff [ I Monitor [ ] AN'S paged at I 1 EK0 paged at [ ] Peak Flows SaWra/Allar Reap Tx I 102 L/Mln [ IRwpnwryTx 1 102 Saturation Medlcatlons I IV's I Additlonat Orders Obtain Inltiala:__,&_Signeture: ,QS,L,il:2 RN Inltiala: Signature; RN Initials: Signature; R N Initials: Signature; RN Signature: MO1D0 IL{ 3(114 µ,? MR 144503 E c1Ax+l ,SELE111 S 2515 VALLEY It ERI MARYSXILLE PA 17053 03/21/t4S6 957-2624 179-66-9103 E0 GROUP ILL `1..rF_SS ;?AYR ,BARR 914 TML197S Ii/30/94 ' FEB 14 -t. , JO GMS GEN T_ ER Date: Asseumsrd me• vital signs Monitor Physician Assessment 02 Saturation Lung Assessment Visual Acuity Diagnostics EKG Labs PCXRlPort CSpmo Sent to Radiology Returned from Radiology Procedures Respiratory Treatment - - `"' '- Jim Foley Insertion NG Insertion Wound Care hnUOCt/ShnglCrutches Miscellarreaus Pain Scale (0-10) ,... ... Leve) of conswousness sideralls Intake & Output Patient Education Info Daher Time,; Initials: D 0 -4-- 44" Therapy - Rate Initial 4?t:: Signature ?_ condmon codes- R, I ytZU India) Signature o-No Infiamation 3-Pam wW G ontrol• India) Signature i-Edema 4-Hardness § 1fA'tvs G Initial. Signature 2A-Erythema --Warmth C 2StatMagmtA 1O r' - 2&Eachymosis Q. S 1 31714 "J 2 MR 141503 E Holy Spirit Hospital GZAaR SELE1111 S Camp Hill, PA 2515 VALLEY R 0 ER1 Emergency Patient Documentation HA R T SV I L L S PA 13053 03/23/1936 957 -2624 205 ECU Revised 6re6 JD, OR, MO 179-66-9103 E0 GROUP GRARM S&qR 314 TdL197569077 CHART COPY 11/30/99 Holy Spirit Hospital Department of Radiology and Diagnostic Imaging Camp Hill, Pennsgivania 17011 (717) 763-2600 PATIENT GRAMM, SELENA S DICTATION DATE: Nov 30 1999 9 26P MR#: 144503 TRANSCRIPTION DATE: Dec 1 1999 8 29A SOC SEC. 178-66-9103 ORD DR: GILLIS NATALIE M D PT TYPE: E ADM DATE: 11130/1999 ARRIVAL DATE: 08/23/1999 LOCATION. ER1- HOSP SERVICE: ER1 **"Final Report' EXAMINATION: CERVICAL SPINE (2v) 72052 - Nov 301999 COMMENTS INDICATION - MVA Alignment is normal and the disc Interspaces are preserved No bony abnormalities are seen There is no encroachment on the neural foranuna The allento-axial relationships appear normal CONCLUSION: Normal cervical spine DICTATED BY: HAROLD RABIN M D I DLG DATE OF EXAM: Nov 301999 SIGNED BY, HAROLD RABIN M D DATEITIME: Dec 1 1999 9.05A Date IZ q GhL°M p in n Results reviewed by ME-D FEB ? ? zoo© imaging Services Consultation Page 1 Holy Spirit Hospital Department of Radiology and Diagnostic Imaging Camp Hill, Penns$rivanla 17011 (717) 763-8600 PATIENT: MR#• SOC SEC: ORD DR: PT TYPE: ADM DATE: LOCATION GRAMM, SELENA S 144503 178-66-9103 GILLIS NATALIE M D E 11130/1999 ER1- DICTATION DATE: Dec 1 1999 8 30A TRANSCRIPTION DATE: Dec 1 1999 8 30A EXAMINATION: LEFT SHOULDER (3v) 73030 COMMENTS INDICATION - MVA ARRIVAL DATE: 0 8/2 311 9 99 HOSP SERVICE' ER1 'Final Report*** Nov 301999 Examination of the left shoulder reveals no evidence of fracture or dislocation No bone or soft tissue abnormality is identified CONCLUSION: Normal left shoulder examination DICTATED BY: HAROLD RA13IN M D I DLG DATE OF EXAM: Nov 30 1999 SIGNED BY: HAROLD RABIN M D DATEMIME: Dec 1 1999 9 05A iL c late MD/00 asu Its1rev411 iewer by fl -7" ME'D BILL pSOGESS FEB 14 2O C' GMS CENTEr- Imaging Services Consultation Page 1 Holy Spirit Hospital Dept nent of Radiolcj Ind Diagnosti naging Camp Hill, Pennsylvania 17011 (717) 763-2600 PATIENT- GRAMM, SELENA S MR#: 144503 SOC SEC: 178-66-9103 ORD DR: NONSTAFF NONSTAFF M D PT TYPE: R ADM DATE. 11/3011999 LOCATION: MED RA- DICTATION DATE: Nov 301999 1 35P TRANSCRIPTION DATE. Nov 30 1999 1 57P ARRIVAL DATE. 08/23/1999 HOSP SERVICE, USM 'Final Report' EXAMINATION. PELVIC US, TRANSABDOMINAL 76856 - Nov 301999 COMMENTS INDICATION - dysmenorrhea The uterus is normal in size and texture It measures 6 4cm longitudinally and at the level of the fundus 3 3cm transversely and 2 4cm in AP diameter It has a homogeneous texture The endometnum is normal measuring 3mm in thickness (these are transabdommal images only) Tii,- right ovary measures 2 9 x 16 x 2 2cm and the left ovary 3 0 x 1 5 x 3 2cm There are no masses about either ovary There is a small amount of free fluid in the cul-de-sac CONCLUSION. Normal pelvic ultrasound DICTATED BY: BARBARA KUNKEL M D / DLG DATE OF EXAM: Nov 30 1999 SIGNED BY: BARBARA KUNKEL M D DATEMME Nov 30 1999 5 03P MED BILL PROLES, FEB 14 VOID B CE'NT'ER Imaging Services Consultation Page 1 IMERGENTY CENTER URGI CENTER DISCHARGE INSTRUCTIONS HOLY SPIRIT HOSPITAL (717) 763-2316 - (717) 763-2424 - _ Too esamrumn and tmunent you have received in dm &oergencY Ginner have been modered on an emergency baps only. Rod are not intended to be a selective, for or an of ort w provide complain medical care If you develop new Problems or complicamen retied your physician or the Emergency Caner FOLLOW THE INSTRUCTIONS CHECKED BELOW Patient Information- Patient Information shoats contain Important Irdarmallon to review and keep ()Abdominal pain O Alcohol r acti n ( ) Coryunchvi s OCO 11 P"Mod fever ()laceration Secure e o I ) Allergic macticn PD () Corneal abrawaMoreign body () Flu () Familiars (9Wack Strain O Nosebleed OSore Threat () Sprints and Simma I Y Asthma O Back plan () Croup/bronchms ( ) Cnech walking I ) Headache ()Head Injury ( ) Oahe Medan O Pediatric Head Injury () Threatened Miscarriage ( ) Toolhsche ( ) Bdes-Humarl/AnimaA sect O Dearmea and Vomlting/Ped Vomtlmg () Hypertension O Pediatric URI I )URI and Colds ( )Burn ()Chest Pain ( ) Crug/Alcohol ala se/addhctlon f ) Febrile Coreulson I ) immunamora?atenus O Kidney Stowe ( ) MOND 0 Hesh ()UTI and Pyelonsphreis ()Oilier WOUND CARE ( ) May gently wash over wound in 24 hours with soap and water or peroxlds Do not soak in water ( ) Change dressing -limes daily Redress with Bacrtracm/Necsponn and slenle dressing ( ) Keep wound clean, dry, covered () Tetanus/Dipthena Booster given SPRAINS, STRAINS, BRUISES, FRACTURES ()p evade the injured part for- days to reduce swelling ..P<Apply lee parade Intemsttently for-days to reduce swelling ?+ t„ f O Ace wrap for support for-days , ( ) Wear splint l) At all tames until follow-up ( ) For activity as needed } kr v, ( ) Use slang la support ( ) Use crutches () As waded, weight besnng sa tolerated ( ) At all times NO WEIGHT BEARING ) MEDICATIONS ( ) Continue present medications except T79"Use Advil (lbupmlen) or Tylenol as needed for pen-, fever according to package mstruchow for age, weight () Use the following medicines according to package instructions 1 2 3 () The following medremes may cause dmwsanees DO NOT DRIVE OR OPERATE MACHINERY WHILE TAKING FOLLOW-UP This is our recommendalaon for follow-up If your insurance (HMO) requires a physician reterral for specialty NECKIBACK f consultation, IT IS YOUR RESPONSIBILITY TO OBTAIN THE ( } Wear cervical collar for support for-days f NECCEES°gARY APPROVAL 1 )) "Rest, aveatl banding, I strenuous acnwry r -days (7 Fellow-up with ()?6r Ca der r+lnpPly mast h t f minutes times daily (7Famly 0oIta tsegmnmg tin - hors r a () WoikNst AD ZONAL INSTRUC N in I r i GT_ days for (fFdbw-u Moll orvschco(from to O Suture removal ( ) Ughl Duty until O Call as soon as possible for appolydmant radaona / () Pick up your X-Rays from the Radiology Department prior to (KNO gymlapods umii ) a 1?y)Q your follow-up appointment Call 763-2898 to have him ( )Follow Inebucbone an Workmen's Compansalron Fomn (, d1' ( ) Wear eye patch for hours a your physician or specialist if not improved in ( ) If noes bleed recurs, pinch was firmly for 5 minutes ,?'?-- days continuously, return if bleeding not controlled Ret+ + ten to Emsermenav Center 1,you Iaei you conal Is worse mQ I ( ) The prescribed anhbollc may reduce the effectiveness of especially it 'I Y1r u r , , I i ( I r+ ru u Il11. O AQ 1 RU " medication you are currently taking Check package ( ) Your blood pressure was elevated Please have-V instructions or consul) with Pharmacist rechecked by your physician ( I The interpretation of your X-Hays are preliminary reading () Test results have been given to you Take them with you to Your time will be reviewed by a radiologist You or your the follow-up appointment physician will be contacted it there is a change in the Ted results given D CSC D CMP D EKG D X-RAY COPY doemnass - D BMP D RECORDS COPY CHART ? GLUC Additional Instructions _(A-en ( ) PATIENT VERBALIZES UNDERSTANDING I hereby ardmowMedge receipt of these instructions and understand them I understand that I have had emergency treatment gB(y and that 1 may be released babas all of my medical problems era known a treated I will arrange for follow-up care as I have been instructed It is your reepen- elMlary to notify y an of this vied SIGNATURE PaTt or Responalble Person Dale SIGNATURE HOLY SPIRIT HOSPITAL EMERGENCY CENTER cus CENT 503 NORTH 21ST STREET CAMP HILL, PA 170114288 (717) 763.2316 O Vantha Abraham, MD 0388407 ( ) Thomas Mines, M D OI7075E ( ) Salvatore Alfano, M D 025502E ( ) Ramesh Arcane, M D 016727E f ) Glen Daughoy, DO OSOO6776E ( ) Jon Defeat. D O OS OO699tL R ( ) Richard Luley, M D 029960-E ( f Phillip Magn re, M D Of 5063-E f) Lawrence Paul, M D 039524-L ( I Frank Procopm, M D OC3643-E d l Howard Rudnick. M D 040862- dr ( IxanJen8 eamnta,MU U]ILe]-II ( ) David Spur", M D 023502-E f) Alan Tephs, M D 03OOME () planes Thalblra, M D 057303-L David Zimmerman, M D 005536-E SPRAINS, STRAINS, BRUISES, FRACTURES () ovate the Injured pan for-days to reduce sweamg ,RqApply roe packs intermittently for -,days to reduce swelh(g {}LrI [,u f O () Ace wisp for support for_days i, Wear splint ( ) At ell times until follow-up tttt ( ) For activity Be nestled ? k p N ( ) Una sting for support ( ) Uae crutches ( ) As needed mod be iing as tolerated l )At all times; NO WEIGHT SEARING j I ) Use the following medicines according to package ` instructions t 2 3 ( )Tile following medimes may cause drowsiness DO NOT DRIVE OR OPERATE MACHINERY WHILE TAKING FOLLOW-UP This is our recommendation for follow-up If your insurance (HMO) requires a physician referral for specialty NECKIBACK / consuhaton, IT 18 YOUR RESPONSIBILITY TO OBTAIN THE ( ) Wear cervical collar for support for--days NECE ARY APPROVAL (?1 "Rest, avoid banding, IAh strenuous sic" or -days u (' Fellow-up With Q) U Comer f I cv,PpDly {"1'FamAy Ooclor?l3r??-,1 j begmmng meal mmutea braes deity in - rN r s In days for AD IOFNSTRUCT.?.9 to ()Suture removal { ? w hoot/from 1 l () Call as soon as possible for appoinfirrient ( ) Light Duty ty until (I Pick up your X41BYe ofthe Rack Department prior gesmcbons 2 to ( No gyfNapons until a (p'} Q your follow-up appomtmem Call 763--2896 to 10 have have trims (1 Follow instructions on Workmen's Compensation Form d ?' {) Wear eye patch for hours your physician or specialist d not improved in O If now bleed recurs, pinch nose bnnly for 5 minutes days continuously, return d bleeding not controlled Ratum to Errwnl icY (Sartre' diyou teat You condi on is worsens () The prescribed anubi ift may reduce the effectiveness of especially d -t Pf i t j , 11.. i rl t ru ' medication you are currently inking Check package I ) Your blood pressure was elevated Please have a stuccons or conautt with Phatmaast rechecked by your physician () The inlerpletabon of your X-Rays are preliminary reading ( ) Test results have been given to you Take them with you to Your hums wit be reviewed by a ratliotogist You or your the follow-up appointment physician will be comametl if there a a change in the Test results given ? CBC ? CMP ? EKG ? X-RAY COPY diagnosis CISMP ?RECORDS COPY CHART [3GLUC ( ) PATIENT VERBALIZES UNDERSTANDING Additional Instructions Ihereby acknowledge receipt of these instructions and V'1rL(IiA Ikq& A-ULZAJ understand them I understand that I have had emergency treatment g01Y and that I may be released before all of my D , medical problems are known a treated I will emerge for 16 Wow-up care as I.have been, instructed It a your respon- stbtliry to notify of this Vag -^- a NATURE SIG at or Responsible Person /Data SIGNATURE ?-.f i (i .+ 1 Ul LaY f i , 1, c, ,,w P HOLY SPIRIT HOSPITAL EMERGENCY CENTER 503 NORTH 21ST STREET CAMP HILL, PA 17011.2288 (717) 763.2316 f ) Thomas Atdous, M D 017075E ( ) Salvainn: Aifano, M D 025502E ( ) Ramesh Aram M D 016727E ( ) Glen Daughtry, D O OS006776B ( ) 3cn Dubin, DO 08 00699 [L ( ) Howard Rudmck, M D MS62- e. 1 0 1 () Ran)ana Shames, M D 031265-E ( ) David Spinner, M D 023502-E () Alan Teplw, M. D 030019-E ( ) Same Thetbter, M 0 057303-L L) David Zimmerman, M D 005636-E ID O DEAII :3 K q 4rWS'0 T-T W-S IN ORDER FOR A BRAND NAME PRODUCT TO BE MSPENSBD, THE PRESCRIBER MUST HAND WRITE 'BRAND NECESSARY' OR 'BRAND MEDICALLY NECESSARY IN THE SPACE BELOW OLABEL OSUBS7TTUT10N PERMISSIBLE rAyy?,?; YALL EY Iit 0TSYILI. E ('312111'36 I7^-§5-4103 ?'AYM OARR I(i3ai49 RD ERr PA 17053 457-2',24 ED GROUP 814 YNL197569077 178 (5M) 1 Y. 4.7 11 JJ: 7 I -lull 110v .NFU+ar1 HSH ER FORM REG DATE: 11/30/99 19148 PT#: 14307482 MR#S 144503 NAMES GRAMM SELENA S SS #S 178-66-9103 ADDRESSS 2515 VALLEY RD /MARYSVILLE /PA/17053 PH#S 717-957-2624 BIRTHDATE: 03/23/1986 AGE: 13 SEX: F MSS S RACE: 1 GED: 099110 EMPLOYER: STUDENT OCCUPATION: STUDENT ADDRESS: PH#: CHURCHt UNITED METHODIST-SALEM MARYS AMBt NONE COMMENT: EMERGENCY CONTACT INFORMATION NAMES GRAMM PIXIE REL TO PT; M WORK PH #: ADDRESS: 2515 VALLEY RD /MARYSVILLE /PA/17053 PH #: 717-957-2624 NAME: GRAMM BARRY REL TO PTS F WORK PH #s'T37-766-4800 ADDRESS: 2515 VALLEY RD /MARYSVILLE /PA/17053 PH #7'717-957-2624 ADMIT DR: ATTND DR: REFER DR: ADMIT DXs COMPLAINT: INFORMATION REG SOURCES EO PATIENT TYPE: E HOSP SERV: ERL FINANCIAL CLS: T VISIT CLINIC CODES ERL ICD-9 DX: CASE 180018 E GROUP 180018 GRODU\1Pww MVA \l`\? AMS BRT IN BYS BRT IN BY.:FATHER COMMENT: ACCIDENT INFORMATION i DATE/TIMES 11/30/99 17530 ACC INDS A JOB RELATED: N LOCATIONS A DESCRIPTIONS PT WAS RESTRAINED PASSENGER I N AN MVq poq?eg GUARANTOR INFORMATION NAME: GRAMM BARRY PT REL TO GUAR: D SS #: ADDRESSS 2515 VALLEY RD /MARYSVILLE /PA/17053 PH #: 717-957-2624 EMPLOYERS EICHELBERGERS INC CONTACT NAMES ADDRESSS /MECHANICSBURG /PA/17055 PH #: 717-766-4800 INSURANCE INFORMATION PLAN INSURANCE CO COB POLICY # GROUP # SUBSCRIBER REL PC VFY CARD PRECERT/AUTH # PRECERT PHONE # 1 B14 HEALTH ONE 2 YWL19756907 7 669802005 GRAMM BARRY L D Y Y - - INSUR.ADDRESS: PO BOX 890126 CAMP HILL PA 17011 2 MS1 AUTO INSURANCE I/O 1 (19877742712 /22 GRAMM, PIXIE D Y Y - INSUR.ADDRESSS 4930 CARLISLE PIKE MECHANICSBURG PA 17055 3 a0 INSUR.ADDRESSt 03-LN30SWo ?( o?a?s 4 OOOZ 4 t 033 E`-41/1"' INSUR.ADDRESSt COMMENTS; FMD=KAUFFMAN 983008d 1118 03VV (717)243-5444-NOT NOTIFIED YET 'AVM= PATIENT NAME: REGISTERED BY: GRAMM JOKUS SELENA S EDITED BY , PT#: (]14307482 DATES END MR#: 144503 OF DOCUMENT . -- . . CONSENT TO MEDICAL TREATMENT I HEREBY CONSENT AND AUTHORIZE Holy Splint Hospital, its agents, and employees, to the rendering of medical care, which may include routine diagnostic procedures and such medical treatment as my, attending or consulting physician considers to be necessary I also under- stand it is customary, absent emergency or extraordinary circumstances, that no substantial procedures will be performed upon me unless or until I have had an opportunity to discuss them with a physician or other health care professional to my satisfaction if I am a competent adult, I have the right to consent or refuse to consent I understand that the practice of medicine and surgery is not an exact science and that diagno- sis and treatment may involve risks of injury or even death and acknowledge that no guarantee has been made to me as to the results of any examination or treatment in this Hospital I understand many of the physicians on the staff of Holy Spirt Hospital are not employees or agents of the Hospital, but rather are independent contractors who have been granted the privilege of using these facilities for the care and treatment of their patients Further, 1 realize this Hospital is a teaching Hospital and at the Hospital are health care personnel in training who, unless expressly requested otherwise, may participate or may be present during my care as part of their education Still or motion pictures and closed cacixt monitoring of patient care may also be used for educational purposes, unless I expressly request otherwise I understand that in order to ensure a safe environment for patients, visitors and staff all property on the premises of H S n Hospital is subject to reasonable search and/or seizure at any time without further notice Inhtiais ?-- RELEASE OF MEDICAL INFORMATION 1 authorize Holy Spirit Hospital to release to requesting health insurance carrier(s), their representatives and auditors, and any refernng health care providers, such diagnostic and therapeutic information (including any information relating to treatment for alochol and substance and or treatment of MAhiatriy disorders, and/or cooheaah HIV related information. as may be necessary for them to determine benefit enti- tlement, to process payment claims for health care services provided during this hospitafization/treatment episode, and for continuing oaretheatment A photocopy or carbon copy of this authorization shall be considered as effective and vatid as the original The undersigned also authorizes Medicare, when applicable, to release to another insurance carrier, upon their request, medical information needed to make payment upon that clam / I understand and consent that the manufacturer of any implantable device inserted by my physician during the course of may be provided with my identification information, including social security number, as mandated by Federal Law Im INSURANCE ASSIGNMENT OF BENEFITS d I authorize payment duedly to Hoty Sport Hospital and my treaancu physicians of sit beneftts payable under my mawarhoe Fany:mformation I am responsible to the Hospital for all charges not covered by this assignment InitSTATEMENT TO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDERS, PHYSICIANS AND I request payment of Authorized Medicare benefits to me or on my behalf for any services furnished me by or in Holy Sig physician services I authorize any holder of medical and other information about me, to release to Medicare and its ageneeded to determine these benefits for related services MEDICAL ASSISTANCE RECIPIENT Initials My signatures certifies that I received a service or items from Holy Spirit Hospital and Dr on the date listed below I understand that payment for this service or item will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of material may be prosecuted under applicable Federal and State Laws 1 have read and agree with the above statements I have mad and understand each of the sections contained above. I underalland that by sl providtn the horizattow consent contained In each of the above soollons where f( ty to ask or, fdlq ref ass se7tbns and all such questlons asked h Signature Wftneas Astalions ip to lent Time document, I am agreeing and ifed. f have 1 ed the opportun6 !' m tf facgon. HIED SILL PROC FEB 14 20T, HOLY SPIRIT HOSPITAL, CAMP HILL, PA CONSENT FOR TREATMENT/ RELEASE OF INFORMATION INSURANCEASSIGNMENT MW REC 166 BID n7M) CHART COPY cgs cjtN t t 14 ?0'44 $?Z WR 144$03 f u'f$fiff SELENA S 2515 VALLEY to fRI nL;kY3YILLE PA 1TOS] ~712311996 957-2624 179-66-9103 to ORa11P °A M1! 3ARR 61-4 TML 197569077 111]0199 j Diagnostic Radiology Mammography Ultrasound C.T. Scans M.R.I. last>,?)?tt;,, s1. Nov ybodcrlmid PA !7070 (717)774-7351 1790 Ohl 1'rpil Rd. ralt•) . PA 17319 (717)932.2677 41;, ?1'7hm1 Sl. PAMn 'zbl'I'L, 1'A 170.1 t717) 4+>2 :?trr7 M, Q"uth lti'fr Rd, Haliras, YA 17032 1711)9W, 3.)52. X4011 4Iwmherx 1110 'ad. ImiiFhnrg., PA !711! 717 ) 5<,1-Mt? Smdo, i'A 17075 71717.17-1594 4MITH RADIOLOGY, INC. EN9103 Dow E. Brophy, M.D. Shermans Dale Family Practice R.R.2 - Route 850 Shermans Dale, PA 17090 LEFT KNEE & PA ETI A: There is history of tenderness for the past 3 days - Rl0 fractured patella. Dear Dr. Brophy: No evidence of fracture or other recent acute traumatic osseous or joint pathology is seen. IMPRESSION: 1. No fracture. Thank you for referring this patient to our service. ITKS:clk November 27, 1996 RE: Selena Graham DATE Of EXAM: 26 NOV 96 SS#: 178-66-9103 Sincerely, AM Henry K. Smith, D.O. l?". 3p.r1 b: C)Kl ` 91 Holy Spirit Hospital Departtmint" of Radiolog, hd Diagnostic 1, -aging Camp Hill, Pennsylvania 17011 (717) 763-2600 PATIENT: GRAMM, SELENA S DICTATION DATE: Nov 30 1999 1:35P MR#: 144503 TRANSCRIPTION DATE: Nov 30 1999 1:57P SOC SEC: 178-66-9103 ORD DR: NONSTAFF ?ONSTAFF M.D. PT TYPE: R D ti. Gll. S, G ADM DATE: 11/30/1999 ARRIVAL DATE: 08123/1999 LOCATION: MED RA- HOSP SERVICE: USM ***Final Report*** EXAMINATION: PELVIC US, TRANSABDOMINAL 76856 - Nov 30 1999 COMMENTS: INDICATION - dysmenorrhea. The uterus is normal in size and texture. It measures 6.4cm longitudinally and at the level of the fundus . 3.3cn1 transversely and 2.4cm in AP diameter. It has a homogeneous texture. The endometrium is normal measuring 3mm in thickness (these are transabdominal images only). The right ovary measures 2.9 x 1.6 x 2.2cm and the left ovary 3.0 x 1.5 x 3.2cm. There are no masses about either ovary. There is a small amount of free fluid in the cul-de-sac. CONCLUSION: Normal pelvic ultrasound. DICTATED BY: BARBARA KUNKEL M.D. / DLG DATE OF EXAM: Nov 30 1999 C_ SIGNED BY: BARBARA KUNKEL M.D. DATE/TIME: Nov 30 1999 5:03P ?i'p or, FM "h v4 Imaging Services Consultation Page 1 9h Pdpfl?2 P December 16, 1999 RE: AGE: SS#: GRAMM, SELENA 2515 Valley Road Marysville, PA 17053 13 178 66 9103 STUDY: MRI of cervical spine REFERRING PHYSICIAN: William Kauffman, M.D. CLINICAL HISTORY: Numbness in feet and hands MRI PULSE SEQUENCES: 1) Sagittal T1 T2 2) Axial 3D GRE, T2 COMMENTS: There is normal anteroposterior alignment . with marrow signal intensity and remarkable in the cervical vertebra. There is no evidence of prevertebral soft tissue swelling or of intraspinous edema. Anterior and posterior longitudinal ligaments and ligamentum flavum appear intact. The spinal cord shows normal size, position, contour, and signal intensity. There is no compression suggested on the sagittal images and the craniovertebral junction is normal in appearance. There is prominent motion artifact on the volume axials but the T2 axial sequence is satisfactory. The sequence shows no evidence of posterior disc protrusion, central canal stenosis, or abnormality in the spinal cord. There is no stenosis or nerve root compression identified in the foramina. CONCLUSION: Cervical MRI is within normal limits showing no evidence of disc protrusion, stenosis, cord abnormality, or neural compression. Thank you for-referring this patient to us. Sincerely, ? ', 4 Richard Kraus, M.D. RK/ea Name Date of birth i_...__?1_ _._______ ?.. __ ?- 1 ?! PROGRESS NOTES NAME V P /u rn m M?? p 5 mnMW?D SEPa?7t"b fj DATEOF BIRTH Fermedic ] DATE - TIME SUBJECTIVE A CPT CODE OBJECTIVE HT WT T L ASSESSMENT BP P A DIAGNOSIS PLANS a Co o614- C/-N Ce-u-,C--D l6irtftf W AA, © 34 -iw AnD? (?c? K4 t, W. Aer as 9 cu% 7 0 SCc? die s ? ?? ?n? w ARCHIVES Specialty Meetings of Interest Amer. Academy of Family Medicine Society of Teachers of Family Mad FAMILY MEDICINE Boston, MA Sep 21-24,1995 New Orleans, LA May 6-10, 1995 New Orleans, LA Oct3-6,1996 San Francisco, CA April 27- 5/1,1996 FORMEMCO 199312 D WORLDS FAIR DR. SOMERSET N.J. 08873 AheNA4N(42'R:? DATE - TIME CPT CODE SUBJECTNe° / OBJECTIVE AsSESSIwcNT / PLANS S--15-9(r h?tr-fi eK?;? a8 CXI C'a(? n nn .1 4 1 bJ ") d (C- ll _. C:• . 1 S Specialty Meetings of Interest Formedic ( YQo cZ 0 [ O C GJlfi ?Y c ; ?rJ???fJ .] \,p?n (?E (L IZL(4; E?vm rS S?.h,?Yl?o.??-?t-,a?t"w?..,?,'..-.Q...?.,. r ?C .... .. .. C. ? c?z e vL7-e 5 e o L? SC?ro-P /7 c. ? r C, Amer. Academy of Family Medicine Society of Teachers of Family Mod FAMILY MEDICINE Boston, MA Sep 21-24,1995 New Orleans, LA May 6-10,1995 New Orleans, LA Oct 3-6, 1996 San Francisco, CA April 27- 5/1,1996 t ME ATE -`TIIMMEEE CPT CODE DIAGNOSIS (v Iit)q. Aa k, 9 -r 9 94? fuel PnnApp?„d,,,, ? era </-,;25- 9(; /,ii.ee All -7 bab A Phf W-F PROGRESS NOTES • , M F M. STA- ?? S M W D SEP DATE OF BIRTH -r /n / HT - WT..., :.? T It E BP P n q p l9 • • 1".e'? A F®rmedic Hoxazosin mesylate? Scored Tablets 1 mg, 2 mg, 4 mg, 8 mg FMPNLE© FORMEDIC Y 1993 12 D WORLDS FAIR DR. SOMERSET N.J. 08873 J ?-Y` o?e c{ c G? C?x b / ?? ??? y C', cI° -mac Seca < ?» . V - c- ?? c cl'G -z?.r G // ?y .C ? C.? r/?7 r C' ocJi?j c??Q?J? cY ? YG !! ? r ? i. X 0 Ke ?s? Cyr ,,1y Cset?avob Q05 \ 3 `?ette? Mftb,= MUM, s`s ??'3 y`-1ly ® AKIWP% ?doxazosin mesylate) Scored Tablets 1 mg, 2 mg, 4 mg, 8 mg IMMENA 1KR Ro Ag . d;.'?.????.a is..., r6,..... w.,. ?i. I ITHn IN CGAIAnn • . Date of ,?'?C, 1 Iw. k,. s _ _ _ c 6 t C 31a?19?b (IJA # a1?5 -00 M),plaipir P„, &,, _ /,j , ., !n r L q-) -1111v71 ?A}K .c ?n x iod?. -7?P/ L stS xlla /(?-) I (LLYA tk .Z? 6 55oo F,,- l1.,.., blA4 -.- L(-,3-V-7 r ics) S' 7 tt 71 lC/ /Lq j7 MB k zl /a?S?fS® 45-0 11 ? ,o -T Q0 J l / V? ?Er 4 Jy INFANTS' ®s??sr.* bl my'?? 9 MnICO?N®DROPS (??,°_'(?(,?,?',',',',°,,','.MERCK ® i.. sol on s simple... fimethiconu l untitktulent CWNSt M".1 PIIARMu,.r:t'jlc:A s e... I .? m t !©P?, ?cL k o - J51111 44,14- A - -,? -Zo 1 17 "Iba vo-?3'i7 S lr l le2dro?o U -i K?G fl ?f 49123 J U n2 1' w, ?c 1' • !\.Qc.L Oil nn ?I tl'W L I (J.XAA?Y . IL q " l l? L t - a n , C3) CL) ? q ?- I -old -- iw? I '' INMM For • 0111 • „'® m I ON®DR PS ?o?ntimn. mvnoMERCK the ?? ® y$ pl?.••0 YiimthIWRB I®R6flawknt coasr HER PIIARMAI XIMAIb ('(1. ???1"ll ? ?,t2??-, .YrX-UC?ytay?.? ?Q'?'I._uL..,/ ``?_ X11. li/G7 ? 72? 'JYT ?\C[y(/?-., aac5qq w ? 95 --- 1p3?? C'a. ncrav p?ee(SS ?cr.. , ?. .. ?CaSfi 3 _,-(1Qe?5., GV?o_ CIO f'Lv„ ?. C A 3' -2- e-- e., 11ediC Your Supplier of Patient Record Forms PARTNERS WITH PHYSICIANS SINCE 1982 DATE - TIME WT / BSA f- CPT CODE C'? 5 lormedi: ~?C ? ? 6) l c? ven V?c? .b1 la , G1` v cIC . Gb 1 ?Qu, ocC. ?yl?mo _ ?lCn Jq G1 t ? l1 \Lfvk \ hvvunc? e wn r - _. U D _. t ?? aQpq v,K __ Un?k L41P kL (3, tLCL g rely I" y ab i N-T- _ A • Mgt t rdj U ?. ?- fl/LS tk ?U.? ? 1 $ (3 yrs kaltde T s-G,.? ? ens ?? j Oi_ '2 ?c, ^-z, 7r3 r 71LIT of w? edic Your Supplier of Record Forms y PARTNERS WITH PHYSICIANS SINCE 1992 S. i AONE(HOME) DRUG ALLERGIES r / Clinitiorms SS# PAGE # DATE OF ?g f-0, it In{ u.. 9Ri ?+ >f1 }f f.#.- ??u w? ?° «3d ine Ld .,? d ?? ?o.l!? O (<« ?eA?t+ Anr ? 5 c?t%a e.o4 d d.a.? (? ?? --pt.,r.?..w •• ? 1. ? ?? qq Naa 4 .. ?•^411 4-4 - Gv J? w F ? Z y ? oLC .Llti KN- p v nAVA- f?rra? - Ig n? c? a? R . _-T ° (a kI-- 3 (G( Ori 'w cca ec?s Spo ct 1?1'A(Ji V.? ll? 11? / 6wv? (atm i r+ed f i ?} ??. rs lv?u ?t f ?5 A ? hula -420 Pr - Jhf2k Pulp /h;J)a®; ir]-IM ,ri Q Ir V,'.a 010 S t :. „S; ?ay E rr.; too Q3.,: Y `* -? i ss'. yyy?r . wGs»'..gp i? ?,°,i i?t,d?fr' r.? *rs '?, yr f',f k l-Fla4:en..} e.fTMY1 r,..: tG`L.e ,ea. ih azf 66za b 43 C I'Ea)^a?- $ 0 1998 Warner-Lambert Company PD-166-NJ-0291-A1(016) (d(® I 4.. 4_,,v w.. . .- _. RETU( N IN .ENVELOPE PUYIDED., PHYSICIAN CERTIFICATION OF PHYSICAL THERAPY TREATMENT PLAN To:William Kauffman M.D. From:Jennifer Wickard,MSPT Shermans Dale Family Practice Central PA Rehab Services P.O. Box 276 P.O. Box 190 Shermans Dale PA 17090 Shermans Dale, PA 17090 Re:Selena Gramm 178-66-9103 DATE: 12/20/99 Physical Therapy Initiated:12/20/99 Date of Physician Referral:12/09/99 PHYSICAL THERAPIST'S INITIAL EVALUATION History: Pt. is a 13 year old female who suffered MVA on 11/30/99 when she was hit from the driver's side while in a moving position. Pt. now complains of neck pain numbness in upper & lower extremities, headaches, & occasional dizziness. MRIs were negative per patient report. Pt. currently taking muscle relaxant. Pt. su fered knee injury in a previous MVA. Pt's. goal is to participate in cheerleading practice painfree. Ob8-77' ective : AROM: Cervical spine flexion WNL with end-range pain repeated flexion causes pain radiating into the shoulders; extension 2b cm. chin from sternum with end-range pain; R rotation 65 degrees, L rotation 75 degrees; R sidebending 23 de rees, L sidebending 25 degrees. End-range pain with bilateral sidebendin & rotation. AROM bilateral shoulders is WFL except end-range pain with R shoulder abduction, flexion, & internal/external STRENGTH: Weak isometric cervical strength with pain on all resisted shoulder movements (R ggreater than L). ' PALPATION: Siggnificant soft tissue spasm & tenderness bilateral scalenes (L greater than R), bilateral upper & middle trapezius, levator scapulae, cervical paraspinals, & suboccipital musculature. Greater palpable spasm R cervical paraspinals compared to L. SPECIAL TESTS: Positive cervical compression test with onset of dizziness after 3 seconds (L greater than R) & is resolved once head is returned to neutral. TREATMENT: Moist heat/electrical stimulation, therapeutic exercise, & instruction in home exercise program. SHORT TERM GOALS (1-2Wks): 1. Increase AROM cervical spine by 25% with decreased end-range pain. 2.. Decrease end-range pain with active shoulder movements. 3. Decrease soft tissue painful dysfunction to moderate to severe. 4. Independent in home exercise program. 5. Decrease fr,equency,..of.;.headaches & dizziness symptoms. LONG TERM GOALS (6-14Wks): 1. WFL AROM cervical spine ppainfree. 2. WNL AROM bi.lateral.shoulders painfree. 3. Minimal to'no.remaining soft tissue painful dysfunction. 4. Resolve headache .& dizziness symptoms. 5. Pt. will return to`premorbid activity level with minimal to no symptoms. Assessment: Patient present's with loss of ROM with significant soft tissue painful dysfunction. Rehab potential is good for stated goals. Plan: Moist heat/electrical stimulation, soft tissue mobilization, therapeutic exercise, & instruction;in home exercise program. Frequency:3X/Wk Estimated Length of Treatment:30.Days I certify that Selena Gramm is under my care for the treatment of Cervical Pain I authorize, as medically necessary, the'h sical therapy treatment plan outlined above. Periodic re-evaluations'of this patient s treatment plan will be performe myself at least every 30!days or at more frequent intervals as the patien condition dictates. Social and/or vocational readjustment services, unle specified otherw'se, ar not medically necessary for this patient. Signature-.( i DATE:12/20/99 Signature: enni T Pulliam -Kauffman 7243 . by 's PHYSICAL' THSP.APIST'S INITIAL EVALUATION`FOR REFERRING PHYSICIAN'S RECORDS To:William Kauffman M. D. From:Jennifer Wickard,MSPT Shermans Dale Family Practice Central PA Rehab Services P.O. Box 276 P.O. Box 190 Shermans Dale PA 17090 Shermans Dale PA 17090 Re: Selena. Gramm (717) 582-7171 Date:12/20/99 178-66-9103 PHYSICAL THERAPIST'S INITIAL EVALUATION Date of Onset:11/30/99 Prior Hospitalization:From:N/A To: Physical Therap Initiated:l2/20/99 Date of Referral:12/09/99 Mental Status o patient:Oriented to Person, Place, & Time ?Inpatient PT NO Surgical Procedures:NONE Treatment for:Cervical Pain History: Pt. is a 13 year old female who suffered MVA on 11/30/99 when she was hit from the driver's side while in a moving position. Pt. now complains of neck ppain numbness in upper & lower extremities, headaches, & occasional dizziness. MRIS were negative per patient report. Pt. currently taking muscle relaxant. Pt. suffered knee injury in a previous MVA. Pt's. goal is to participate in cheerleading practice painfree. W'ective: M: Cervical spine flexion WNL with end-range pain, repeated flexion causes pain radiating into the shoulders; extension 20 cm. chin from sternum with end-range pain; R rotation 65 degrees, L rotation 75 degrees; R sidebending 23 gain; L sidebending 25 degrees. End-range pain with bilateral sidebending & rotation. AROM bilateral shoulders is WFL except end-range pain with R shoulder abduction, flexion, & internal/external rotation. STRENGTH : Weak isometric cervical strength with pain on all resisted shoulder movements (R ggreater than L). PALPATION: Siggnificant soft tissue spasm & tenderness bilateral scalenes (L greater than R), bilateral upper & middle trapezius, levator scapulae, cervical paraspinals, & suboccipital musculature. Greater palpable spasm R cervical paraspinals compared to L. SPECIAL TESTS: Positive cervical compression test with onset of dizziness after 3 seconds (L greater than R) & is resolved once head is returned to neutral. TREATMENT: Moist heat/electrical stimulation, therapeutic exercise, & instruction in,homexercise program. SHORT TERM GOALS (1-2Wks 1. Increase AROM cervicall spine by 25% with decreased end-range pain. 2. Decrease end-range pain with active shoulder movements. 3. Decrease soft tissue painful dysfunction to moderate to severe. 4. Independent.in home exercise program. 5. Decrease f"ency'of headaches & dizziness symptoms. LONG TERM GOALS"(6-14Wks): 1. WFL AROM cervical°spine ppainfree. 2. ML AROM bilateral shoulders ainfree. 3. Minimal to"no remain soft tissue painful dysfunction. 4. Resolve headache & dizziness symptoms. 5. Pt. will return to premorbid activity level with minimal to no symptoms. iAssessment: Patient presents with loss of ROM with significant soft tissue painful dysfunction. ?ehab potential is good for stated goals. Plan: Moist heat/electrical stimulation, soft tissue mobilization, therapeutic exercise, & instruction in home exercise program. Frequency:3X/Wk Estimated Length of Treatment:30 Days Signature: /J?,-..I , ?, ? 7243 COLA, E: PHYSICIAN RE-CERTIFIC WRN TO:William Kauffman M.D. Shermans Dale Family Practice P.O. Box 276 Shermans Dale PA 17090 Re:Selena Gramm Physical Therapy Initiated:12/20/99 REYIEW, SIGN, AND RAPY TREATMENT PLAN ?r TV ?b ?DYIDE? From: ennifer Wickard,MSPT Central PA Rehab Services P.O. Box 190 178-66-9103 Shermans DalUTEA01%19%00 Date of Physician Referral:12/09/99 Pt. is-a 13 year old female who suffered MVA on 11/30/99 when she was hit from the driver's side while in a moving position. Pt. now complains of neck ppain, numbness in upper & lower extremities, headaches, & occasional dizzl.ness. MRIs were negative per patient report. Pt. currently taking muscle relaxant. Pt'. suffered knee injury in a previous MVA. Pt's. goal is to participate in cheerleading practice painfree. SUMMARY OF TREATMENT AND REHABILITATION STATUS AS'OF: 01/19/00 PROGRESS: Patient has attended 6 sessions of physical therapy with treatment consistil=g of moist heat, electrical stimulation, soft tissue mobilization, therapeutic: exercise, & instruction in come exercise program. AROM cervical spine flexion WNL, extension 22 cm, chin from sternum, R rotation 80 degrees, L rotation 60 degrees, R sidebending 35 degrees, L sidebending 22 degrees; end-range pain with all active cervical movements. Continues with significant soft tissue spasm, edema, & tenderness cervical intrinsics, suboccipitals, bilateral upper trapezius, levator scapulae, & rhomboids. REHAB STATUS: Patient has not been able to attend therapy consistently secondary to recent illnesses. Patient will continue when able. ROM has improved but significant soft tissue painful dysfunction remains. i JA! MAXIMUM'POTENTIAL1':YES- -NO-X Maximum_potential'not,reached secondary to continued painful symptoms & loss of ROM cervical spine.'. Plan: Moist heat/electrical stimulation, soft tissue mobilization, therapeutic exercise, & instruction'-'in home exercise program. Frequency:3X/Wk Estimated Length of Treatment:30 Days I certify that Selena Gramm is under my care for the treatment of Cervical Pain I authorize, as medically necessar ; the: h sical therapy treatment plan outlined above. Periodic re-evalta ions J this patient's treatment plan will be performed by myself at least every 30days or at more frequent inervals as the patient's condition dictates. Social and/or vocational readjustment services, unless otherwise spe .fie/d,/ark not medically necessary for this patient. Signature: ` Ty DATE:01/19/00 Signature:??_ .TPT1T1 r.. Wic arc i?-PISPT W].lliam !Call maf-f an -VI_. IT Uf-1Tl ?i -"?- EVI)[14i 1101, [7L-'Vi'a--_NU I I_:_i.__-- 20DEC 19991_ 2 1 DEC 1990 Treatnlent_Provlct_A: I/I_I f C 13 07 - -- ------- --------- ---- f - ... 2 DEC 1998 r}_. si7vt _. _. _. ............ .__.. ?...__ _?. '?.f`•3t e112 I0Yliadtt, lV 1. ?. s,s , ... 1 . .... ..... .. 12 C DLC a?a- n 1 , _ tug -------- ----- ------- --- -- - -- I t ,30 -DEC-?? -- p crn?- I _ I 1 pt r I ®7/9AY, V14_. Tt"?1'.7.4G., 'rQVir.. N!: /G[ I'/ / (??r PLUM— l- I n y I Jm f Izooa - ? ._.I/U ?C/?_.... r.?..1 .___???'d,.? ..? 1. .-.. ........_-..._ ....._ ? 1? ?i-. c',rn tin 1Ln 41111 arv a •lT __.. .... .... .... ._._._------- f CENTRAL PA REHAULLI.TNTLO(I SERViCIS, INC. ( x ) Physical IE Date: 12J14/99 ( ) Occupational ( ) Speech Patient N Patient: RAMM_,__selena SSN 178-66-9103 Address: 2515 Valley Road DOB: 03/23/86 Age to Mary sville, PA. 17053 _ Phone/Iiome:957-2624 Work Referring Physician: KAUFFMAN, William M -n Onset Date: !t Diagnosis: Record of Treatments ?d0© I 2 3 5 r6F _ [11 12 13 14 15 16 17 18 19 20 21 22 23 24125126127128129130131 i.t At I T A UV X _FEBRUARY MARCH APRIL MAY _ JUNE JULY I AUGUST NOVEMBER DECEMBER W a _J 25. ? ^C OUag? sus Q??Qg? as UlLL J LLI m fA w O Q ??mj J O ? 3ffl S vaam?+ oR y $12 I 3 a i a` a j* r 1 w0 z? OUW 'o m m z w 024 9 Q ? ~ " ? i Y r V/'?? ' { ? a 3 > dZ-'\W ?2Q lJ 22 o /v f W ' U / a Q W J Q Z Qm O O¢v I W X WW I H WW N ¢aZ m OWa4 RELEASE AND SETTLEMENT AGREEMENT This Release and Settlement Agreement ("Agreement') is made and entered into among Salena Gramm, a minor, by her parents and natural guardians, Barry Gramm and Pixie Gramm, and Pixie Gramm and Barry Gramm, as husband and wife; and Nationwide Mutual Insurance Company ("the Parties"). The "Claimant" shall collectively mean Salena Gramm, a minor, by her parents and natural guardians, Barry Gramm and Pixie Gramm, and Pixie Gramm and Barry Gramm, individually, their respective heirs, executors, administrators, personal representatives, successors and assigns, the "Insured" shall collectively mean Richard W. Reiber; and the "Insurance Company" shall mean Nationwide Mutual Insurance Company. 1. RECITALS A. On or about November 30, 1999, on Rt. 114, Cumberland County, Pennsylvania, Salena Gramm claims to have sustained physical injuries as a result of the alleged conduct of Richard W. Reiber in operating his motor vehicle (the "Incident'). In connection with the Incident, the Claimant has asserted a claim against Richard W. Reiber based on negligence. B. The Insurance Company and the Insured have entered into a liability insurance contract which provides that the Insurance Company shall defend the Insured against any claim or suit for damages arising from the Incident, have authority to settle any such claim or suit on behalf of and as agent for the Insured, and shall insure the Insured for such liability subject to the limits set forth in the contract. C. The Parties desire to enter into this Agreement to provide, among other things, for considerations in full settlement and discharge of all claims and actions of the Claimant for damages which allegedly arose out of or due to the Incident, on the terms and conditions set forth in this Agreement. NOW, THEREFORE, it is agreed as follows: U. RELEASE A. Release and Discharge. In consideration of the cash payment referred to in paragraph III. A. the Claimant hereby releases and forever discharges the Insured, the Insurance Company, Nationwide Mutual Insurance Company, and any and all other persons, firms, or corporations from any and all past, present, or future claims, demands, actions, damages, costs, expenses, loss of services, and causes of action of any kind or character, whether based on tort, contract, or other theory of recovery, whether know or unknown, which have arisen in the past or which may arise in the future, whether directly or indirectly, caused by, connected with or resulting from the Incident with the exception of related medical expenses as set forth below. This release and discharge shall be a fully binding and complete settlement among all parties to this Agreement, and their heirs, assigns, and successors. The Claimant acknowledges and agrees that this release and discharge is a general release. The Claimant expressly waives and assumes the risk of any and all claims for damages and expenses which exist as of this date, but of which the Claimant does not know or suspect to exist with the exception of medical expenses as set forth below whether through ignorance, oversight, error, negligence, or otherwise, and which, if known, would materially affect the Claimant's decision to enter into this Agreement. The Claimant further agrees that the Claimant has accepted the considerations set forth in Paragraphs III. A. and B. as a complete compromise of matters involving disputed issues of law and fact. The Claimant assumes the risk that the facts or law may be other than the Claimant believes. It is understood and agreed to by the parties that this settlement is a compromise of a doubtful and disputed claim, and the payments are not to be construed as an admission of liability on the part of the Insured by whom liability is expressly denied. The Parties agree that the Claimant's release and discharge under this Agreement does not release Nationwide Mutual Insurance Company from any and all current or future responsibilities to the Claimant for future payments that would be made under the medical portion of policy number 58 37 B 578402, under the terms and conditions for any such coverage as set forth in said policy. B. Injuries Known and Unknown. The Claimant fully understands that the Claimant may have suffered personal injuries that are unknown to the Claimant at present and that unknown complications of present known injuries may arise, develop or be discovered in the future, including, but not limited to, subsequent death or disability. The Claimant acknowledges that the consideration received under this Agreement is intended to and does release and discharge the Insured and the Insurance Company from any claims for, or consequences arising from, the injuries which allegedly arose from the Incident, except as stated in Section II. A., above; and the Claimant hereby waives any rights to assert in the future any claims not now known or suspected even though, if such claims were known, such knowledge would materially affect the terms of this Agreement. ffi. PAYMENTS TO CLAIMANT, PAYEE AND/OR BENEFICIARY Pa went. The Insurance Company has paid Two Thousand Dollars ($2,000.00) to the Claimant, receipt of which is acknowledged; said sum will be held in trust for the benefit of the Minor Claimant until she reaches the age of eighteen (18). IV. ENTIRE AGREEMENT This Agreement contains the entire agreement between the Claimant, the Insured, and the Insurance Company with regard to the matters set forth in it. There are no other understandings or agreements, verbal or otherwise, in relation to the Agreement, between the parties except as expressly set forth in it. This Agreement is intended to conform with the requirements or Internal Revenue Code Sections 104(a)(2). All provisions of this Agreement should be construed in a manner so as to effectuate that intent. V. READING OF AGREEMENT In entering into this Agreement, the Claimant represents that the Claimant has completely read all of its terms and that such terms are fully understood and voluntarily accepted by the Claimant. VI. INDEMNITY AND HOLD HARMLESS The Claimant does hereby expressly stipulate and agree, in consideration of the aforesaid payments, to indemnify and forever hold harmless the Insured and the Insurance Company against loss from any and all future claims, demands, or actions that may hereafter or at any time be made or brought against the Insured and Insurance Company by the Claimant or by anyone on behalf of the Claimant for the purpose of enforcing a further claim for damages on account of the injury and damage sustained in or arising from the aforesaid Incident; and, The undersigned further agrees to indemnify and hold harmless the Insured, the Insurance Company, and their agents, servants or employees against any outstanding subrogation interest, liens, claims, demands, or lawsuits held or brought by any persons, firm, government agency or instrumentality, Medicare or Medicaid, other insurance companies, employer, collection agency, hospital or corporation, whether known or unknown to the Claimant, who deem themselves entitled to reimbursement out of any settlement or judgment obtained by the Claimant, including costs and reasonable attorney fees incurred in the defense thereof, and, further, the Claimant agrees to satisfy all such liens or claims from the proceeds of the settlement of this case. VII. FUTURE COOPERATION All Parties agree to cooperate fully, to execute any and all supplementary documents, and to take all additional actions that may be necessary or appropriate to give full force and effect to the terms and intent of this Agreement which are not inconsistent with its terms. VIII. DRAFTING OF DOCUMENT AND RELIANCE BY CLAIMANT This Agreement has been negotiated by the respective Parties. The Parties to this Agreement contemplate and intend that all payments set forth in Section III constitute damages received on account of personal injuries or sickness, arising from the Incident, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended. However, the Claimant warrants, represents, and agrees that the claimant is not relying on the advice of the Insurance Company, anyone associated with them, including their attorneys and the insurance broker placing the Annuity Contract as to the legal and income tax or other consequences of any kind arising out of this Agreement. Accordingly, the Claimant hereby releases and holds harmless the Insured, the Insurance Company and any and all counsel or consultants for the Insured and the Insurance Company from any claim, cause of action, or other rights of any kind which the Claimant may assert because the legal, income tax or other consequences of this Agreement are other than those anticipated by the Claimant. The Parties signing this Agreement, and each of them, warrant and represent that no promise, inducement or agreement not expressed in this Agreement has been made to them and that this Agreement constitutes the entire agreement between the parties and that the terms of this Agreement are contractual and not mere recitals. The Claimant represents and agrees that he/she has read the Agreement and fully understand it, and are aware of the propriety and legal effect of executing it, and neither the Agreement nor the compromise and settlement recited in it were induced by fraud, coercion, compulsion or mistake, nor is this Agreement nor the compromise and settlement made in reliance upon any statement or representation of any of the Parties released by this Agreement, or their representatives, agents or attorneys. IX. WARRANTY OF CAPACITY TO EXECUTE AGREEMENT The Claimant represents and warrants that no other person or entity has, or has had, any interest in the claims, demands, obligations, or causes of action referred to in this Agreement, and that the Claimant has the sole right and exclusive authority to execute this Agreement and receive the sums specified in it and that the Claimant has not sold, assigned, transferred conveyed or otherwise disposed of any of the claims, demands, obligations or causes of action referred to in this Agreement. X. COURT APPROVAL The Parties agree that the Claimant will file petitions for all necessary court approvals, that all such petitions and orders shall be in a form satisfactory to all Parties, and that this Agreement will not be effective until such approvals have been obtained. XI. CONTROLLING LAW This Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. Dated Pixie Gramm, individually and as parent and natural Guardian of Salena Gramm, a minor, Claimant Dated: Barry Gramm, individually and as parent and natural Guardian of Salena Gramm, a minor, Claimant Dated: Duly Authorized Representative for Nationwide Mutual Insurance Company APPLICABLE TO PENNSYLVANIA ONLY: For your protection, Pennsylvania requires the following to appear on this form: Any person who knowingly and with intent to defraud any insurance company or other person files 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 such person to criminal and civil penalties. RELEASE AND SETTLEMENT AGREEMENT This Release and Settlement Agreement ("Agreement') is made and entered into among Salem Gramm, a minor, by her parents and natural guardians, Barry Gramm and Pixie Gramm, and Pixie Gramm and Barry Gramm, as husband and wife; and Nationwide Mutual Insurance Company ("the Parties"). The "Claimant" shall collectively mean Salena Gramm, a minor, by her parents and natural guardians, Barry Gramm and Pixie Gramm, and Pixie Gramm and Barry Gramm, individually, they respective heirs, executors, administrators, personal representatives, successors and assigns, the "Insured" shall collectively mean Richard W. •.Reiber; and the "Insurance Company" shall mean Nationwide Mutual Insurance Company. 1. RECITALS A. On or about November 30, 1999, on Rt. 114, Cumberland County, Pennsylvania, Salena Gramm claims to have sustained physical injuries as a result of the alleged conduct of Richard W. Reiber in operating his motor vehicle (the "Incident'). In connection with the Incident, the Claimant has asserted a claim against Richard W. Reiber based on negligence. B. The Insurance Company and the Insured have entered into a liability insurance contract which provides that the Insurance Company shall defend the Insured against any claim or suit for damages arising from the Incident, have authority to settle any such claim or suit on behalf of and as agent for the Insured, and shall insure the Insured for such liability subject to the limits set forth in the contract. CERTIFICATE OF SERVICE I, JARAD W. HANDELMAN, ESQUIRE, do hereby certify that I served a true and correct copy of the foregoing Petition upon the following below-named individual(s) by depositing the same in the U.S. Mail, postage pre-paid at Hershey, Dauphin County, Pennsylvania this 19a' day of July, 2000. SERVED UPON: Barry and Pixie Gramm 2515 Valley Road Marysville, PA 17053 JARAD W. HANDELMAN, ESQUIRE JAMES, SMITH, DURKIN & CONNELLY LLP PIXIE GRAMM and BARRY GRAMM, as parents and natural guardians of SALENA GRAMM, a Minor, Petitioners V. ROBERT W. REIBER, Respondent TO THE PROTHONOTARY: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 00-5083 CIVIL CIVIL ACTION-LAW MINORS COMPROMISE PRAECIPE Kindly mark the above docket settled, satisfied and discontinued as to all parties in this action. Dated: 11/13/2000 Respectfully submitted, JAMES, SMITH, DURKIN & CONNELLY, LLP By: KAREN DURKIN, ESQUIRE Attorney I.D. #29563 7ARAD W. HANDELMAN, ESQUIRE Attorney I.D. #82629 P.O. Box 650 Hershey, PA 17033-0650 (717) 533-3280 Attorneys for Respondent CERTIFICATE OF SERVICE I, JARAD W. HANDELMAN, ESQUIRE, do hereby certify that I served a true and correct copy of the foregoing Praecipe upon the following below-named individual(s) by depositing the same in the U.S. Mail, postage pre-paid at Hershey, Dauphin County, Pennsylvania this 13`b day of November 2000. SERVED UPON: Barry and Pixie Gramm 2515 Valley Road Marysville, PA 17053 JARAD W. HANDELMAN, ESQUIRE JAMES, SMITH, DURKIN & CONNELLY LLP PIXIE GRAMM and BARRY GRAMM, as parents and natural guardians of SALENA GRAMM, a Minor, Petitioners V. ROBERT W. REIBER, Respondent IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 00-5083 CIVIL. CIVIL ACTION-LAW MINORS COMPROMISE PRAECIPE TO FILE RECEIPT TO THE PROTHONOTARY: Kindly file the attached certificate of deposit from Harris Savings Bank with respect to the above referenced matter and pursuant to the Order of Court of July 24, 2000. Respectfully submitted, JAMES, SMITH, DURKIN & CONNELLY, LLP Dated: 11/13/2000 By: KAREN DURKIN, ESQUIRE Attorney I.D. #29563 JARAD W. HANDELMAN, ESQUIRE Attorney I.D. #82629 P.O. Box 650 Hershey, PA 17033-0650 (717) 533-3280 Attorneys for Respondent ,JHARRIS p SAVINGS BANK 235 N. Second St. Harrisburg, PA 17101 0&q THIS CERTIFIES THAT THE ACCOUNTHOLDER(S) LISTED BELOW HOLD A CERTIFICATE OF DEPOSIT ACCOUNT WITH HARRIS SAVINGS BANK FOR THE TERMS INDICATED BELOW: CERTIFICATE OF SERVICE I, JARAD W. HANDELMAN, ESQUIRE, do hereby certify that I served a true and correct copy of the foregoing Praecipe upon the following below-named individual(s) by depositing the same in the U.S. Mail, postage pre-paid at Hershey, Dauphin County, Pennsylvania this 13`" day of November 2000. SERVED UPON: Barry and Pixie Gramm 2515 Valley Road Marysville, PA 17053 JARAD W. HANDELMAN, ESQUHtE JAMES, SMITH, DURKIN & CONNELLY LLP