Loading...
HomeMy WebLinkAbout09-3461IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: CIVIL DIVISION AMANDA GROVER, a minor NO. ng-34to1 A-VO i-/" (Jury Trial Demanded) ORDER AND NOW, this day of , 2009, upon consideration of the Petition for Approval of Minor's Claim, it is herby ORDERED that the Petitioner is authorized to enter into a settlement in the gross sum of $35,000. The settlement amount shall be distributed as outlined in the Settlement Agreement and Release and Uniform Qualified Assignment as attached hereto as Exhibit "1." TOTAL AMOUNT OF DISTRIBUTION: $35,000. Counsel shall provide to the Court, within thirty (30) days from the date of this Order, proof of such deposit. BY THE COURT: Distribution to: Kevin D. Rauch, Esquire Summers, McDonnell, Hudock, Guthrie & Skeel, L.L.P. 100 Sterling Parkway, Suite 306 Mechanicsburg, PA 17050 J. Edward and Janet Grover 739 Dogwood Terrace Boiling Springs, PA 17007 Uniform Qualified Assignment and Release "Claimant" "Assignor" "Assignee" "Annuity Issuer" "Effective Date" Amanda Grover Government Employees Insurance Company Allstate Assignment Company Allstate Life Insurance Company This Agreement is made and entered into by and between may be accelerated, deferred, increased or the parties hereto as of the Effective Date with reference to decreased and may not be anticipated, sold, following facts: assigned or ercumbered. A. Claimant has executed a settlement agreement or 4. The obligation assumed by Assignee with respect release dated: ?)_ I ? I r -i to any required payment shall be discharged upon (the "Settlement Agreement") that provides for the mailing on or before the due de.te of a valid the Assignor to make certain periodic payments to check in the amount specified to the address of or for the benefit of the Claimant as stated in record. Addendum No. 1 (the "Periodic Payments"); and B. The parties desire to effect a "qualified assignment" within the meaning and subject to the conditions of section 130(c) of the Internal Revenue Code of 1986 (the "Code"). 6. NOW, THEREFORE, in consideration of the foregoing and other good and valuable consideration, the parties agree as follows: The Assignor hereby assigns and the Assignee hereby assumes all of the Assignor's liability to make the Periodic Payments. The Assignee assumes no liability to make any payment not specified in Addendum No. 1. 2. The Periodic Payments constitute damages on account of personal injury or sickness in a case involving physical injury or physical sickness within the meaning of Sections 104 (a)(2) and 130 (c) of the Code. The Assignee's liability to make the Periodic Payments is no greater than that of the Assignor immediately preceding this Agreement. Assignee is not required to set aside specific assets to secure the Periodic Payments. The Claimant no rights against the Assignee greater than a general creditor. None of the Periodic Payme This Agreement shall be governed by and interpreted in accordance with the laws of the State of The Assignee may fund the Periodic Payments by purchasing a "qualified funding asset" within the meaning of Section 130(d) of the Code in the form of an annuity contract issued by the Annuity Issuer. All rights of ownership and control of such annuity contract shall be and remain vested in the Assignee exclusively. The Assignee may have the Annuity Issuer send payments under any "qualified funding asset" purchased hereunder directly to the payee(s) specified in Addendum No.1. Such direction of payments shall be solely for the Assignee's convenience and shall not provide the Claimant or any payee with any rights of ownership or control over the "qualified funding asset" cr against the Annuity Issuer. Assignee's liability to make the Periodic Payments shall continue without diminution regardless of any bankruptcy of insolvency of the Assignor. 9. In the event tr•e :settlement Agreement is declared terminated by a court of law or in t-)e event that Ma (cof the Code has not been satisfied, ent shall terminate. The Assignee ss.gn ownership of any "qualified funding asset" purchased hereunder to Assignor, and Assignee's liability for the Periodic Payments shall terminate. 10. This Agreement shall be binding upon the respective representatives, heirs, successors and assigns of the Claimant, the Assignor and the Assignee and upon any person or entity that may Assignor: Government Employees Insurance Compan Qy,. t? e ?V / 0"41444 Auf orized Re resentative Title r Claimant: Janet Grover, as P ent alnd ?4atural Guardian of Amanda Grover, a T inor?' j. Claimant: ?- Edward Grosvdr, ds Parent and Natural Guardian of Amanda Grover, a minor Approved as to Form and Content: assert any right hereunder or to any of the Periodic Payments. 11. The Claimant hereby accepts the Assignee's assumption of all liability for the Periodic Payments anc hereby releases the Assignor from all liability for -lie Periodic Payments Assignee: Allstate 'assignment Company Ely: _ ALI(hrazed Representative Title BY: not applicable Claimant's Attorney Addendum No. 1 Description of Periodic Payments Payee: Amanda Grover Benefits: Nine Thousand Fifteen Dollars ($9,015) for four (4) years guaranteed, beginning August 13, 2009 through and Initials: Claimant: (JG) Claimant: = (EG) Assignor: .Ow (GEICO) 6W. payable annually including August 13, 2012. Assignee: (AAC) SETTLEMENT AGREEMENT AND RELEASE This Settlement Agreement and Release (the "Settlement Agreement") is made and entered into this - day of 20 _, by arid betweiAl: "Claimant" .Janet Grover, Individually and as Parent and Natural Guardian of Amanda Grover, a minor Edward Grover, Individually and as Parent acid Natural Guardian of Amanda Grover, a mino)- "Defendant" Jamie L. Grover, Janet Grover, and Edward Grover "Insurer" Government Fmployces Insurance CompanN RECITALS A. On or about.i_uie 7, 2006, Amanda Grover was in in an accident occurring on or near Creek Road, Boiling Springs, Pennsylvania. Claimant alleL s that the accident and resulting physical and personal injuries arose out,af certain alleged nx:g.ligent acts or omissions of Defendant, and has made a claim seeking monetary danlages on account A' those injuries. B. Insurer is the liability insurer ofthe Defendant, and as such. would be obligated to pay any claim made or judgment obtained against Dclcndant, which is covered by its policy with Detendant. C. The parties desire to enter into this Settlement Agreement iii order to provide Fior certain payments in full settlement and discharge of all claims which have. or might be made, by reason of the incident described in Recital A above, upon the terms and conditions set forth below, AGREEMENT The parties agree as follows: 1.0 RELEASE AND DISCHARGE 1.1 In consideration of the payments set forth in Section 2, Claimant hereby completely releases and forever discharges Defendant and Insurer from any and all past, present or Future claims, demands, obligations, actions, causes of action, wrongful death claims, rights, damages, costs, losses of services, expenses and compensation of any nature whatsoever, whether based on a tort, contract or other theory of rccovery, which the Claimant now has, or which may hereafter accrue or otherwise be ::n--yuired. on account of, or may in any way gri)w out of the incident described in Recital A above, including, without limitation, any and all known or unknown claims for bodii?! and personal injuries to Claimant, or any future wrongful death claim of C'laimant's representatives or heirs, which have resulted or may result from the alleged acts or omissions of the Defendant. 1.2 This release and discharge shall also apply to Defendant's and Insurer's past, present and future officers, directors, stockholders, attorneys, agents, servants, representatives, employees, subsidiaries, affiliates, partners, predecessors and successors in interest, and assigns and all other persons, firms or corporations with whom any of the former have been, are now, or may hereafter be affiliated. 1.3 This release, on the part of the Claimant, shall be a fully binding and complete settlement among the Claimant, the Defendant and the Insurer, and dieir heirs, assigns and successors. 1.4 The Claimant acknowledges and agrees that the release anti discharge set forth above is it general release. Claimant expressly waives and assumes the risk of any and all claims for damages which exist as of this date, but of which the Claimant does not know or suspect to exist, whether through ignorance, oversight, error, negligence. or otherwise. and which, if known, would materially affect Claimant's decision to enter into this Settlement Agreement. The Claimant further agrees that Claimant has accepW-J payment of the sums specified herein as a complete compromise of masters involving disputed issues of law and fact. Claimant assumes the risk that the facts or law may be other Ivan Claimant believes. It is understood and agreed to by the parties that this settlement is Li compromise of a doubtful and disputed claim, and the payments are not to be consti ued as an admission of liability on the part of the Defendant, by whom liability is expressly denied. 2.0 PAYMENTS Ill consideration of the release set forth above, the Insurer on behalf of the Defendant agrees to pay to the individuals named below ("Payees") the sums Aldined in this Section 2 below: 2.1 Payments previously made as follows: It is acknowledged that Insurer has previously made payment(s) in the amount of Dour Thousand Two I lundred Forty-seven and 02/100 Dollars ($4,247.02) in satisfaction ol'a medical lien for medical care rendered to Amanda (;rover. 2.2 Periodic payments made according to the schedule as follwNs (the "Periodic Payments"): Payee: Amanda (:;rover Payments in the amount of Nine "Thousand Fifteen Dollars ($9.1)15) payable annually for four (4) years guaranteed, beginning August 13, 2009 throe.; h and including August 13, 2012. All sums set forth herein constitute damages on account of persoml plx5 sical injuries or sickness, within the meaning of Section 104(a)(2) of the Internal Pvvenue Code of 1996, as amended. 3.0 CLAIMANT'S RIGHTS TO PAYMENTS Claimant acknowledges that the Periodic Payments cannot be ;accelerated, deferred, increased or decreased by the Claimant or any Payee; nor shall the Claimant or any Payee have the power to sell, mortgage, encumber, or anticipate the Periodic Payments, orally part thereof, by assignment or otherwise. 4.0 CLAIMANT'S BENEFICIARY . Any payments to be made after the death of any Payee pursuant to the terms of this Settlement Agreement shall be made to the Estate of Amanda Grovor or to such person or entity as shall be designated in writing by Payee, after attaining age of majority, to the Insurer or the Insurer's Assignee. If no person or entity is so designated by Payee, or if the person designated is not living at the time of the Payee's death, such payments shall be made to the estate of the Payee. No such designation, nor any revo(.ation thereof. shall be effective unless it is in writing and delivered to the Insurer or the Insurer's Assignee. The designation must be in a form acceptable to the Insurer or the insurer's Assignee before: such payments are made. 5.0 CONSENT TO QUALIFIED ASSIGNMENT 5.1 Claimant acknowledges and agrees that the Defendant and; car the Insurer may hake a "qualified assignment", within the meaning ol'Section 130(c) ol'the internal Revenue Code of 1986, as amended, of the Delendant's and/or the Insurer's I iahility to make the Periodic Payments set forth in Section 22) to Allstate Assignment Company ("the Assignee"). The Assignee's obligation for payment of the Periodic Pay?ilcnts shall be no greater than that of Defendant and/or the Insurer (whether by.judgnic-nt or a(.1,reement) immediately preceding the assignment of the Periodic Payments obligation. 5.2 Any such assignment, if made, shall be accepted by the Claimant without right of' rc,jection and shall completely release and discharge the Defendant and the Insurer from the Periodic Payments obligation assigned to the Assignee. The Claimant recognizes that, in the event of'sueh an a-,signment, the Assignee shall be the sole obli !or xvith respect to the Periodic Payments obligation, and that all other releases with respe,:1 to the Periodic Payments obligation that pertain to the liability of the Defendant and the insurer shall thereupon become final, irrevocable and absolute. 5.3 Allstate Life Insurance Company will issue a Statement of guarantee that will guarantee the future obligations of'Allstate Assignment Company. 6.0 RIGHT TO PURCHASE AN ANNUITY The Defendant and/or the Insurer, itself or through its Assigner, reserves the right to fund the liability to make the Periodic Payments through the purch<?e of an annuity policy from Allstate Life Insurance Company (the "Annuity Issuer"). The Defendant, the Insurer, or the Assignee shall be the sole owner of the annuity policy and shall have all rights of ownership. The Defendant, the Insurer, or the Assignee may have the Annuity Issuer mail payments directly to the Payee. The Claimant shall be responsible 1i61- maintaining a current mailing address for Payee with the Annuity Issuer. 7.0 DISCHARGE OF OBLIGATION The obligation of the Defendant, the Insurer and/or Assignee to make each Periodic Payment shall be discharged upon the mailing of a valid check in the amount of such payment to the designated address of the Payee(s) named above, or the deposit by electronic funds transfer in the arnount of such payment to an account designated by the Payee(s). If. after the due date. the Payee(s) notifies the Assignee that payment was not received, the Assignee shall direct the Annuity Issuer to initiate a stop payment action. Upon confirmation that such check was not previously negotiated or electronic funds transfer deposited. Assignee shall promptly direct the Annuity Issuer to process a replacement payment. 8.0 ATTORNEY'S FEES Each party hereto shall bear all attorney's fees and costs arising from the actions of its own counsel in connection with this Settlement Agreement, the matters and documents referred to herein, and all related matters. 9.0 REPRESENTATION OF COMPREHENSION OF DOC LMENT In entering into this Settlement Agreement the Claimant repres?:rits that Claimant has relied upon the advice of his/her attorneys, who are the attorneys of his/her own choice, concerning the legal and income tax consequences of this Settlement Agreement; that the terms of this Settlement Agreement have been completely read and explained to Claimant by his/her attorneys; and that the terms ofthis Settlement Agreement are fully understood and voluntarily accepled by Claimant. 10.0 WARRANTY OF CAPACITY TO EXECUTE AGREIi:..ME?NT Claimant represents and warrants that no other person or entity has. or has had, am; interest in the claims demands, obligations, or causes of action relen-cd to in this Settlement Agreement, except as otherwise set forth herein; that Claimant has [lie sole right and exclusive authority to execute this Settlement Agreement and recci,,,e the sums specified in it, and that 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 Settlement Agreement. 11.0 CONFIDENTIALITY The parties agree that neither they nor their attorneys nor representatives shall reveal to anyone, other than as may be mutually agreed to in writing,,any of the terms of this Settlement Agreement or any of the amounts, numbers or terms and conditions of any sums payable to Payees hereunder. 12.0 C:OVERNING LAW This Settlement Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. 13.0 ADDITIONAL DOCUMENTS All parties agree to cooperate fully and execute any and all supplementary documents and to take all additional actions, which may be necessary or appropriate to give full force and effect to the basic terms and intent of this Settlement Agreement. 14.0 ENTIRE AGREEMENT AND SUCCESSORS IN INTEREST This Settlement Agreement contains the entire agreement between the Claimant and the Insurer with regard to the matters set forth in it and shall be binding upon and enure to the benefit of the executors, administrators, personal representatives, heirs, successors and assigns of each. 15.0 EFFECTIVENESS This Settlement Agreement shall become effective immediately following execution by each of the parties. Claimant: Janet Grover, Individually and as Parent and Natural Guardian of Aiiiaiida Grover, a minor Date: 173 ? ? , Amanda's Addre s: Dogwoo Terrace Boiling Springy,:;. P N 17007 Claimant: Edw-41•0 rover, Indivich ally and as Parent and N, u 1, hardian of Ainmida Grover, a minor By: ? .. Date: , Insurer: (:iovernment Employees In,•.i.irance Company By: - / Title: Date: ?- 7- - - --- - IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: CIVIL DIVISION AMANDA GROVER, a minor NO. M - -?yLl O;V(*l Te?* PETITION FOR APPROVAL OF MINOR'S CLAIM (Jury Trial Demanded) Filed on Behalf of the Petitioner, Government Employees Insurance Company Counsel of Record for This Party: Kevin D. Rauch, Esquire Pa. I.D. #83058 SUMMERS, McDONNELL, HUDOCK, GUTHRIE and SKEEL, L.L.P. Firm #911 100 Sterling Parkway, Suite 306 Mechanicsburg, PA 17050 (717) 901-5916 #16837 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: CIVIL DIVISION AMANDA GROVER, a minor (Jury Trial Demanded) PETITION FOR APPROVAL OF MINOR'S CLAIM AND NOW, comes the Petitioner, Government Employees Insurance Company (hereinafter "Geico"), by and through their counsel, Summers, McDonnell, Hudock, Guthrie & Skeel, L.L.P., and Kevin D. Rauch, Esquire, and files the following Petition for Approval of Minor's Claim and in support thereof avers as follows: 1. FACTUAL BACKGROUND 1. This matter arises out of an automobile accident which occurred on June 7, 2006. (The Police Crash Reporting Form of the Pennsylvania State Police is attached hereto as Exhibit "A.") 2. On this date, the minor, Amanda Grover, was a passenger in a vehicle being driven by Jamie Grover, her sister. 3. According to the police report, Jamie Grover was traveling west on Creek Road, Cumberland County, Pennsylvania. As Jamie Grover was attempting to negotiate a curve, she exited the north berm where her vehicle impacted with a tree. (See Exhibit "A.") 4. The driver of the vehicle, Jamie Grover, was traveling approximately 40 miles per hour on a roadway which was zoned for 35 miles per hour. According to the police report, Jamie Grover lost control of her vehicle as a result of "lost traction" and thereby impacting with the tree. (See Exhibit "A.") II. PARTIES 5. Jamie Grover was born on March 17, 1987, and resides with her father, Edward Grover and mother Janet Grover at 739 Dogwood Terrace, Boiling Springs, Pennsylvania 17007. 6. Janet Grover is the mother of Jamie Grover and the minor, Amanda Grover and was owner of the 1995 Nissan Quest which was involved in the above referenced accident. 7. Amanda Grover was born on August 13, 1991, and resides with her father, Edward Grover and mother, Janet Grover, at 739 Dogwood Terrace, Boiling Springs, Pennsylvania 17007. III. ANALYSIS OF DAMAGES 8. As a result of the accident, the minor, Amanda Grover, was transported via West Shore EMS to Holy Spirit Hospital in Camp Hill, Pennsylvania. (Amanda Grover's medical records from Holy Spirit Hospital are attached hereto as Exhibit "B.") 9. On the date of the accident, the Plaintiff underwent a CT scan of the abdomen at Holy Spirit Hospital which showed evidence of a spleenic laceration, but with minimal hemorrhage around the spleen. Additionally, the Plaintiff underwent x-rays of the ribs which showed non-deforming fractures of the left 9th and 10th ribs. 10. As a result of the diagnostic screenings, the minor was transferred to Penn State Milton S. Hershey Medical Center for further evaluation. (Amanda Grover's medical records from Hershey Medical Center are attached hereto as Exhibit "C.") 11. The Plaintiff was discharged on June 11, 2006, with a diagnosis of Grade III spleenic laceration. 12. The Plaintiff returned to Penn State Hershey Medical Center on July 5, 2006, for a follow-up in regards to her injuries. It was noted that the minor was now four weeks out from her spleenic injury and was doing well. It was recommended that she refrain from any significant activities for an additional two months and that the minor need not return unless any additional further problems. (See Exhibit "C"). 13. At this time, Amanda Grover has made a full recovery from the injuries suffered as a result of the instant accident. IV. COVERAGE AND SETTLEMENT 14. Amanda Grover was insured by Geico Insurance, as a dependent under Janet Grover's policy with liability limits in the amount of $100,000.00 per person/ $300,000.00 per accident. (See Certificate of Coverage attached hereto as Exhibit "D.") 15. The minor's parents, Edward and Janet Grover, have agreed to settle the above matter for a total of $39,247.02. (The Uniform Qualified Assignment and Release forms as well as the Settlement Agreement and Release are attached hereto as Exhibit "E.11) 16. A payment in the amount of $4,247.02 was made by Geico directly to the US Treasury/Office of Staff Judge Advocate for a Tricare Lien. 17. The within Petition seeks approval of settlement for the remaining $35,000.00 as provided for in the Uniform Qualified Assignment and Release. 18. The remaining $35,000.00 will be placed in a structured settlement of $9,015.00 annually, guaranteed for four (4) years beginning on August 13, 2009, when the minor reaches the age of eighteen (18). 19. In the interim period, the settlement proceeds will be held in an annuity as GEICO has assigned all future payments obligations to Allstate Life Insurance Company, which is rated A+, XV by Best's, AA by Standard and Poor's, Aa3 by Moody's. 20. A payment in the amount of $35,000.00 was forwarded to Allstate Insurance Company by GEICO on February 2, 2009 for purchase of the above- referenced annuity with a policy number of SSAL23904. (See Correspondence of Allstate Insurance Company date April 10, 2009, attached hereto as Exhibit "F.") 21. The Qualified Assignment and Release has been executed by GEICO as well as the minor Plaintiffs parents. Allstate Insurance Company will execute the agreements once this Honorable Court has approved the settlement terms. WHEREFORE, the Petitioner, Geico, respectfully requests that this Honorable Court enter an Order approving the settlement and compromise of Amanda Grover's claim. Respectfully submitted, SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, L.L.P. By: 6-17. Rauch, Esquire nsel for Petitioner, srnment Employees Insurance Company VERIFICATION We, Edward and Janet Grover, parents and natural guardians of Amanda Grover, a minor, do hereby verify that averments of facts contained in the Petition to Compromise Minor's Claim are true and correct to the best of our knowledge, information and belief. We understand false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904 relating to ur Dated: Dated: #16837 COMMONWEALTH OF PENNSYLVANIA J POLICE CRASH REPORTING FORM Case Closed Reportable Crash 5W Yes Q No 40 Yes Q No Page Crash Number P 1169474 Incident Number Pali[e n Patrol Zone 67+1 010 © o Nam Q e 44 Prednct Investigation Date (MM-DD-YYYY) ?ms_ a LA GF- ? O O Time (mil) Arrival Yirrre f O Inv r Badge Number ???? ti Dt wL 3 Revlellser Number royal Date (MM-DD-YYYY) - 1 15t a o)-?- a C h' p?m Name Munk lpa Munk1 li Name LL;VMAMLA ? 1 Day of tAreek O In Q Thu y.?, hjg pt`?c?E z b Crash Date (MM-DO-YYYY) Crah Tme (mil) No of Units People Inured Kid**if > r 0Mon O fn c 1 Q r L 0 Q c7 -1 Q Tue O Sat Wed Q tlnk odBns O Yes No Worktone&;MN X Q Yes 0 No ? ? ZOne o Yes a No PEUNDOT 40 0 Yes Na R t 291 fnterwO&II Tung O 4 Way Intersection 0 'Y- Intersection O Mul n 0 Off Ramp Q Railroad Crossing a 9WI li O ? Miciblock Q •T- Intersection Q Traffic Circle! 0 On Ram L Round About P 0 Crossover Q Other S" Route Number ! Segmern (Optional) Travel Lana Speed Limit 0 North t ® e O South House Number (il a licable) a? Street Name Street Ending East For mid-block crashes only. Use tal House N ake o mber and West Q- C `" i>1 Y-4 T I I I I I FFT? V--1u1 o Unknown p m s u sure i d P Roadway Strc Name is . lie ti n in if (sing fdle(sing this option Rmte interstate Turnpike Turnpike State County Local Road Private Other/ NaOing 0 (Not Tumpike) O (East/west) 0 spur O Highway 4 Road 0 or Street 0 Road 0 Unknown R ute Number segment (Optional) Travel Lames Speed Limit 0 North o 1 i I1 C? W Su s ?' O Street Name Street Ending ~ East O W est m Unknown ,p ftabV O Interstate 0 Turnpike 0 Turnpike 0 State O County 0 Local Road O Private 0 Other/ (Not Tumoike) (EastMlest) Spur Highway Road or Street Road Unknown Irtte Rt Hum Or Mile Post Or Segment Marker mcaft F th Q N eet ~ t or o South I v O rs t ts St t N Z Please Enter r n e ree ec ame St Ending 0 East TIM E Q West Mgr Information ? ? for ROTH • w Landmarks if Usin g This Option Intersecting At Num Or Mile Post Or Segment Marker "r Q North ] F] R FT 1 Distance From Crash Sire to Landmark 1 . - - N O South v Or Intersect( Street Name St End) 0 East a - --? (For Gash between L o r I I I I 0 West andmark 1 and Landmark 2) x Degrees minutes sewnds, Degrees M - r Latitude: HE 3 '? Longitude: - ' "? 51 ? •V. -? Traffic Control Device Q Yield Sign 0 Police Officer or Flagman Not Applicable O Traffic Signal O Active RR Crossing O other Type TCD 40 No Controls O Improperly Q Emergency ve ?- Traffic Controls 0 Flashing nil O Stop Sign O Passive RR C) Unknown Sig Crossing Controls 0 Device Not O Device Functioning O Unknown Functioning Properly I,M,Chaj Qf -Mot Applicable ', skip mt of the Lane Chwire secfl on) &WLUM eE 0 North Q East Q North and South 0 All Not Appfrcatrle Q Partially Q Fully Q Unknown AhOW 0 South 0 West Q East and West (N-SF-%0 ? TM4 Yes Q No Q Data Unknown No L?kE- 30 M' 'n. 1-3 hrs O 3-6 hrs Q 6-9 hrs Q > 9 hours 0 Unknown FORM it AA400 (12=1 COMMONWALTH OF ICE CRASH REPORTING FORM PENNSYLVANIA Crash Number Page'. POL AA 500 2 DIY ts1 "19 [ _ P 1149474 i I i r. i .E Trar?ohitle in U Hit & Kun vehicle Q lllegdl'ry Perked 0 Legally Parked IO Non - Motorized Commercial Vahlde o x e tlMt Pedestrian Pedestnan on Skates, Disabled From h Q Train 0 Phantom Vehide 0 in Wh etc 0 P lchair C 0 Yes a No , ee revious ras (/f "Pedestrian' or 'Pedestrian on Skates, in Wfseekhar etc', C /ere Form At, swelm 28) (if Yes Complete Form C) Unit No First Name MI Data of Birth (MM-DD-YYYY) ©t 2S Mt E [L 1a3 E°tIs ? Delete? Last Name Telephone N mbar 0 ON 111- -1 9 Address / City / State ZI r s.. t f 10 O Driver Liteme Number state Class AkMolkDrrms acted RcLver or Pedestrian ?hrskal t Qnditbn r e No 0 Illegal Drugs Q Medication Appa Uy Illegal Drug ? Norm Q ? Q Fatigue Q Medication O Alcohol Q Alcohol and Drugs CD Unknown 11ad Been ' 0 Sick Q Asleep iQ Unknown 0 Drink h Alco ol test rune d Test Not Given Q Breath 0 Other V ode Charged? Blood Unknown if Q Urine 0 0 Yes 0 No (` Tess Given Akohol Test #ults Q Test Refused 0 Rem n Driver Presence 1=Driver Operated 3=Driver Fled Scene ?. © Test Given, Contaminated Re ults Vehicle 4=Hit and Rut? s 2=No Orrver 9=Unknown n OwntNDrfver 00=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Police Veh 09=Federal Gov Veh (?' 01=Private Vehicle Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98=Other 5 E- Leased by Dr"r 03=Rented Vehrcie 06=0ther State Gav Veh Government Vehicle 99=Unknown Same as Owner First Name Owner Last Name or Business: Name (If Pedestrian, skip this Section) Driver Q i? p +'?c G.~ Address / City / state / Zip Vhide Make 'make Code - VIN Modell Year Vehkle Model (see overlay) - g ? --_7 N 4 E-4 t4t E Ka r_-3. 0 8 IS h 3 E License Plate Reg. State Est speed Vehicle Towed Towed B ? A] ` 141 IR ) I V I lim Yes ONO S 1)(1 UY ? 1 L v m - 1 .1 1L r nc Lnerance Inc e Company Policy No u ? - Yes (-)No 0 Un- known f ? ?G• t C.D 1 \ t0 ~ %-I ,. trailin 1=Towing Pass. Veh 4=MobileWodular Home 7-Serru-Trailer Tap No Tag Year Tag 5t nit No; 1l 2=Towing Truck 5=Camper 8=Other ? in 3=7owing Utility Trailer 5=full Trailer 9-Unknown niu 9 U Dirrnc7Forr of *Vehide Pasi /a. *Mover»ertt ? 'see al U age rave Overlay Vehide Color Vehide type 05=Large Truck 20=Unicycle, Bicycle, O 0 12=Commercial fl 06=Yellow lb u ?L 07=Silver 01=Automobile 06=SW 7ncyde 02=AAOtorrycle 07=Van 21=other Pedakycfe Passenmerger 01=Not Applicable Ca 0 r V h t-1 08=Gold 01=81ue 09= brown 03=Bus 10=Snowmobile 22=Norse & Buggy 04=Small Truck I Warm Equip 23=Horse & Rider e 13=Taxi 02==AAmbulance 21=Tractor Trailer 02=Red I0=Orange (if "021, Complete Form 12-Construction Equip 24=Tr4in Trailer 08-Other Emergency 22-Twin 23=Triple Trailer 03=White 1 I=Purple 04=Green 12=Other M. Section 26) 13=ATV 25=Trolley (If 70" or "21 ;Complete 18=Other Type Spec Veh 98.-Other is 11 ??p, tt 99_U WnV 05=Black 99=Unknown Form A4. Section 27) 19-Unk. Type Spec Veh 99=Unknown fniNai lmaan Point Damaoe ladkator Gradient 3=Downhill Ro d Afi runent 00=Non-Collision 14--Undercarriage ? - 01-11=Clock points 15-Tow d Unit 0=None 2=Functional 1 Mjnor saWing 1=Level 4=Bottom of Hill 1=Straight 5=Top of 14M ? 2=C d e 13uTop 99=Unknown r- ?e own urve 2=Uphill 9=Unknown 9-Unknown FORM 0 AA-5W 112102) PENNDOT COPY .? COMMONWEALTH OF PENNSYLVANIA Crash Number POLICE CRASH REPORTING FORM • AA 500 3 C r, Page 1149474 1 A 1= d =NI0 A et/Occupant W&JL E oO•None used / , of Applicable G 0--v5Applicable 2=Passenger 7=Pedestrian 01=Driver - All Vehicles 02=Front Seat Middle Position O1=Shoulder Belt Used ' =Not Ejected 02-Lap Belt Used 2=TotalIy E!'ecitd 8z,Other 03=Front Seat Right Side 03=Lap And Shoulder Belt Used 3=Partially Ejected 9=Unknown 04=Second Row - Left Side Or 04=Child Safety Seat Used 9=Unknown Motorcycle Passenger 05=h+btorcyde Helmet Used 05 S d R Mi l P i l U econ ow - - ositio dd e n 06=Biccyycc e He met sed H F;rcnon path: s: F =Female 8 06-Second Row • Right Side 07=Third Row Or Greater • ' O-Safe Belt Used Improperly ' 1=Child Safety Seat Used Improperly I -ThrThrEjected / Not p mine -ough Sr de Doo r r Opening S M=Male U Unknown Left Side Og=ro Row Or Greater - t2=Helmet Used lm 90=Restraint Used, Type Unknown 2aThrough Side Window 3 -Through Windshield CC Middle Position 09=Third Row Or Greater - Right Side 99=Unknown 4aThrough Bade Door 5=Through Back Door Tailgate Opening 5a?P0' ErriliOmenr Two ?? Roof Open (Sunroof/ e Iniu 10-Sleeper Section of Truckcab F 00.None Used / Not Applicable Convertible Top Down) e C 0--Wt Injured I=Killed 2=Major Injury 11=In Other Enclosed Passenger Or Cargo Area 12=In Open Area 01=Front Air Bag Deployed (For This Seat) 7=Through Roof Opening (Convertible 02=Side Air Bag Deployed (For This Seat) 03a0ther Type Air pp Deployed Top Up} U k 9 3=Moderate (Back Of Pickup, Etc.I - n nown 04-Multiple Air Bags Injr:ry I 3=Trailing Unit 05=Motorcycle Eye Protection 4--minor Injury 1a=Riding on Vehicle Exterior 06-Bicyclist Wearing Elbow/KnedPads B=Injury, Unk Severity 15=Bus Passenger 98=Other ID.A1ir Bag Not Deployed. Switch On I 0..N Applicable 11 =Air Bag Not Deployed, Switch Off 1=Not Extricated 9=Unknown if Injury 99=Unknown 12=Air Bag Not Deployed, 2=Extricated By Mechanical Means Unk Switch Setting 3-Freed By Non - Mechanical Means 13=Air Bag Removed (Prior To Crash) B=Other 19=Unknown If Air Bag Deployed 9=Unknown 99=Unknown EMS Agency: Medical Facility: 2.IT Unit No Person No -YYYY) ,H I G Delete? Daft of Birth (MM?-DD CC D E F AA B t gu ? } 1? f I U Name / Address / Phone EMS Tfanspon 4ffsame as operator O Yes Q No Unit No Person No O 1 Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I o ?- rTT5 - °I 1 ??®? 3 0 3 0 0 51Fo? 0 Name / Address / Phone EMS Transport Same as operator dD . ?tUt?3 411 arm- 4W Yes 0 No Unit No Person No CD Delete? Date of Birth (MM-OD-YYYY) A BB C ( D? E H 0 ! l J?l i J F I(UE]t l +m?00F] Nerve / Address I Phono EMS Transport Some as Operator 0 Yes 0 No Unh No Person No Date of Birth (MWDD-YYYY) A B C DD E F G H I DelOete? mrm FE]?LJ_Jmm?FQ Name / Address / Phone EMS Transport Same as ? Operator O Yes O No Unit No Person No m Delete? Date of Birth (MM•DD-YYYY) A . BB-?? C D E F G H I ? - 4?f E m Name / Address I Phone EMS Transport Same Operator 0 Yes 0 No Unit No Person No CD C? Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I 0 DE:IEI CCI CD OFT Name / Address / Phone EMS Transport Same or Operatto O Yes 0 No FORM 0 AA-600 PZ") PENNOOT COPY COMMONWEALTH OF PENNSYLVANIA PO UCE CRASH REPORTING FORM Crash Number AA 500 4 _ ts--11 9 par P 1149474 Cras_e_FVfndon D-Aon-Uision 2-Head On 1=Rear lEnd 3 t R 4-Angle 8= t3 Hii Peda^trinn ti Di = ar ear o ki B R ( rec on) ( ac ng} me ection) 7=HR FoW Object 9411 rNnknown tW tion to Roadway M---% 1=On Travel lanes 3=Median SzOstside Tratkway 7-Gore (Ramp harisection) ,g 2=Shoulder "=Roadside 6-In Parking Lane 9-Unknown is 9g ry ? ? t=Dayllghl 3=EDarfik? Street 2? 5=Dawn 6=? - Unkn°Wj g=OMter . SUee is 4--Dusk '4 Wodier, CQn +s 1'Conddrartse 3=81eet (Hail) 5=Fog 74leet & Fog O=Unknown = I.:..J LJ Main 44now 6=Ratn & Fog 8=00W Road Surface Conditions ")ry Oil ,Mud, Dirt, 4--Slush 6 Ce patches 8--Other 1>cYYet 3-Snow Covered 5-1oe 7=W - Startdrt9 Harm Event UR st tifity Pore Num f © HaffldW Events J#*rn Event 01nHit Unit 1 ) 30-Hit Fence Or Wall 31-Hit Building F Unit No OZ=Hit Unit 1 32=NA Cavort O t -12 m ? 0 03=Hft Unit 3 04=Hit Unit 4 05 Hft U i 5 33-Hit Bridge Pier Or Abutment 34=Hit Parapet End 35 Hi l = n t T 06 Hd Oth ffi U = t Bddge Rai 36 ld llit B O l Please Put 3 m (? Events in Q = er ra c nit 07-Nit Deer 08eHit Other Animal - er Or ou bstac e On Roadway 37=Hit Im act Attenuator U Sequential 09aCollision With Other Non p 38=Hit Fire Hydrant Order 4 m C) ???J? Fi>ed Object 1 t-Struck By Unit 1 39-Hit Roadway Egtnpment 40=Hit Mai Box i is ttt tZeStnnk By Unit 2 13 S U i 3 k 4 )_Nit Traffic island 42 44i = truc By n t = t Snow Bank Hann Event L/R Most7 Utility Pole Number c e 7 m El p 14e5tud; By Unit 4 15=stuck By Unit 5 16oStruck By Other Traffic Unit 43=Hit Temporary Construction Barrier 48=Hit Other F'aed Object $ Unit No 21_Hit Tree Or Shrubbey 494it Unknown Fixed Object w 2 m 22=Hit Embankment 23=Hit UtAi1y Pole U2 i T 24 50=OvertumlRdl Over S1=Struck By Thrown Or Falling b L_,1 ry -H t Sign ject O Please Put 3 m O Events in I I 25diit Guard Rail 26=Hd Guard Rail End 27%Hil Curb 52?ot Holes Or Other Pavement wegulown 532Jacknife Sequential 28=Hit Concrete Or S44in; In Veh+de Order 4 L ? ' fL' JI ? m Longitudinal Barrier 29=Hit Ditch 58= n{ ful ul 99=Unknown Haarmrmf Event FAW Unit No Harm Event PAbst Unit No Harm Event 0 Mt 11 O I r-r-? ?!u! 2"T wen n Driver Actlon (D) 00=No Contributing Action 01 i D D W 17=Careless Or Illegal Backing On Roadway 18=DrMn On The W n Do sat „0'" IM Tarreu iman mAoro wqo ver r = g r as as ro g istracted OZ=Orivmg Using Nand Held Phone sop Of Road 03=thivnng Using Hands Free Phone 19=Making Mproper Ertvirovur+enta!/RDadway 1110ftn al Factors MR) t d 2 3 m 04=Making 11"A U-Turn 05dntpxoper/Careless Turning 06=Turnin From Wr L Entrance To Highway 20-Making Improper Exit f g ong ane rom Highway 00 =hone It=Slippery Road CondmonsOcdSnow) 01 =Windy Conditions 12=Substance On Roadway 07,Proceeeti49 W!O Clearance Aker Stop 21=Careless ParkargNnparking 22=OverAinder 02=Sudden Weather Conditions f 3=Potholes 03=Other Weather Conditions 14=Broken Or Cracked Pavement 04-Deer in Roadwa 15 t d TCD Ob O8=Running a Sign 09=Burrosg Red ht T 10=Failureo Rend To Compensation At Curve 23--Speeding 24=Drivin i Fast For ondit y = s ructe 05=0bstace On Roadway )6=Soft Shoulder Or Shoulder Drop Off 06=Other Animal In Roadwa F 28 0ther Road a Oti er Control Device 11=Tailgating A n r pe 9 2 26? ure le Maintain Pr Ch aDnvec Fleein Police (Pal Ch y = w actor y 07=Glare 29-4ther Environmental Factor 1e 12=Sudden Sbwingl5 p? g t3=iliegaily Stopped OnpR02 g ase) ase) 27-Dnver Inexpenenced e 08=Work Zone Related 99_Unknown 14=Careless Passing Or Lane 28-Failure To Use Specialized Equip 92=Affected B Ph si l C di Cha tion y y on ca ion to Possible Vehicle Failures (y) 12=Wipers 00=None 06=Exhaust 13=0river Seatingkontrol 15=Passing In No Passing Zone 16=Dtrving The Wrong Way On 98-011ier Improper Dnwng Actions 99=Unknown 01=Tires Mieadl>ghu 14-may, Doors, Hood, Etc 02-Brakt System 08-q ear lights 15=Trader filch 03 03-Steering System 0 0 lights 16=Wheels 17=Art s ct 1-Way 5tmet oR 3 ? 2 3 4 Q .Suspension 100-=Horn Horn ta9 O 05=Power Train 11-Mirrors 18=Trailer Overloaded p 19= cUristShrtted Unit Trailer Load 1 2 Unit )--r7 I i I 1 No m 3 4 = 2 20=Improper Tows l? ._.? uni No t m 7 l I t 2{ Unknown held ' 99- t Action (Pl 0 e 03-Working 04?ush L_L?J = 0 11=EnteEntering Or Crossing At f Ming O 05=Approa aching Or Leaving Vehicle 06 :W ki O frrdhriated prime F^-Wr Unit No Factor Code Speci ied Location 02-WaBnwtq Running, jogging or ng n Vehicle 07=Standing r9 mime nn uifornuran on Q l ® Or Playing 999 9-Other E/ R V 0 A 0 0 0 Q If E/R is the Prime Factor Unit No 0 1 Q Q Unit No l t L Type, leave Unit No blank Fora • AA-M 111NT1 PENNOOT COPY r COMMONWEALTH OF PENNSYLVANIA Gnash Number POLICE CRASH REPORTING FORM _ pap p 1149474 AA 500 s IAM 1 , I o .. : i i _ ...... : ......:..._..........._..;......_..:.....-....:......_._€............... ............... ..._....--..........._......._._. _ : . i .._.._:.... _._.. .......... :......_...._..._.._ ........:................. _ ...... : ...._._...........:..........i_....... ..................._...?...-.._.. ;....._ ... .. _ ._. ......... .... ... ..._ ... -... ?......_..;.._-.... ...._.._..., ...;.-. _..i . ......?.... ............................ : i i ....-............ .-- .....?_ ±5 ? ............................ ...................... .... _..... _ ... ... ..... _ .... ....,_.j_......_.i-_ .................i......__?.._.....f_.._.._i. _..._.' -- i E i ....i_...... i. .._3. _ ..........._._......i .................. -...?. p i : + 6 neck; witness Name Address Phone I Nbt?3e: KV 2 Narrative and !"al witnesses: Acddent investigation Notification bsued?O Property Damage Q v1.lt'C , - Cz1.t Qi ?ca.?G ?P- nF v It.] -T4% S Nce,-Ace,,? ice. vr4Lk we.S'LelL vwsr cea f;ML,vp "CZ, ?' ?C-- -- t*o t AR?P?.. "? dt ti? a a C UU1 Ydr?1?""7 7%nep 41 IZ a."T •e ?w2U?,a?cP f{Jrv..??iD A?? t U.tt1.Tr ?P?tLC?Ut?`!? Tir4c. C?1.?E?.. GrrsCeo 1. a.? 't' D.'TG.$? . FMM 0 AA4W 110M PENNDOT COPY I .: 41. Y Outpt Ur . July 5, 2006 Name: GROVER, AMANDA M HMC Number. 7004280 D013: 08f1311991 Date of Servimen, 07!0512006 GROVER, AMANDA M - 7004280 OUTPATIENT LETTER i Jittery DunbalbegW, D.O. 1900 Bridge Street New Cumberland, PA 17070 Dear DunkelbeW. We had the pleasure of seeing Amanda in W=W_ As you are aware, she is a 14year-old female who on June 8th was imlolved in motor vehicle collision and sustained a grade 3 splenlc laceration. She did not require surgery and has been home several weeks with bed mstwbh battmoom privileges. She Is not hWng pain, Is eating wep, having normal bowel movements, and destres to get bads to more activities soon. C)n exan*Mon today, she is healthy appearing in no distress. Chest is clear' to auscultation bilaterally and heart Is - regular rate and rhythm..Her abdomen Is soft, nonbs-rder, and norad tended. No masses are palpeftd. - , . Assessment And Plan:, Amanda Is now 4 weeks out from her splenio k*q and is doing weQ I have discussed with her the need to retrain from signiflowt actini ns until 2 month out from injury. We will not pursue a followup CTs. We do not rased to see her back again although we would be happy to see her if there are further problems or concems. I lave discussed with thern the potential risk of a cyst forming in the spleen overtime, but that 1 feel that this is unWely. They state that they understand. 256669 Signature Lime GC: 190MO Shoot New Cumberland, PA 17070-0000 Sincerely, k Brett W Engbrecht, MD Painted by. Mahanes-Imboden, Amber S Page 1 of 3 .Outpt Ur DROVER, AMANDA M - 7004280 ' PedC Surgery: Drs. Robert Gilley, Peter Dillon, Andreas Meier, Kerry Fa an, Brett echt Coleen =r MS RDIDVD Janet Shields MSN CRNP CS Hershey 717.531-8342 Hbgf1'ork 717-920-6200 BW E /CO DD: 07/06/06 DT: 07/06/06 02:38 Result Type: Outpt Ltr ' Date of Service: July 05, 2006 00:00 Authorizadon Status: Final Author or Import Date: Engbrecht, Brett W on July 05, 2006 19:06 " Verified By. Engbrecht, Brett W on July Oft, 2006 08:25 ? Encounter info: 7227951; HMC, Clinic, 07/05/06 - 07/07/06 Printed on: 07/11/0813A5 (Con*nxx j F17 MVA (5) Nurst+q Assessment Renewed (])Yule Reviewed ? Tetanus mimun UTD PHYSICAL EXAM TIME SEEN- ROOM EMS Arrival Geegeral Appearance _c-collar ( PTA I in ED ) l backboard HISTORIAN: an spouse • ho ute distress _mdd / moderate I severe distress = lert anxious / lethargi5 AGF \`` M IV _HX I -EXAM LIMITED BHEAD -see diagram--- HPI no evidence of _Batde s sign / Raccoon Eyes. trauma chief complaint: MVA Injury to ?ebK. rah, t 4s.a 0 occurred: ?_ ATA position in vehicle: . driver` hart back context: car collision overturned vehicle 3150i ilm (I= mrwoi 1 feff asleep 1 unknown cause) i location of pain I -rte i - injuries : shidr hip shkir hip e head face mouth =w knee + elbow kne neck men \\oJ?" ?f a leg j f-arm leg back upper mid- laver (?PC?110 t ankle i wrist ankle ns&st&g to (R/!J thigh /leg ! hand foot I hand foot severity of pain: sociated symptoms: lost w Dueness /dazed mild duravoe operate remembers- impact coming to hospital severe • seizure site of impact: "FP' = primary condary restraints: none should doesn't recall car seat air bag deployed thrown from vehicle force low mod. high ambulated at scene direct glancing long extrication ROS nq-gc-redid loss feeling / arms I legs trouble breathing/ chest pain nausea I vomiting loss of-bladder-function headache skin-laceration .double vision / hearing loss recent fever if illness SOCIALHX-= ire OH =smo rdrug ' PAST HX '4heguure? Mails- nurses note des see nurses note ®1996- 2W4 T-Svttem, Inc Circle or check a! emal yes backslash N ngal- o' NECK _see diagram ??ih-tender vermbralpomt-tenderness -- .0? less ROM muscle spasm ! decreased ROM, trachea rnidlme amain on movement of neck < n.•J I I E`t' unequal pupils R-_!= L-_.mm k nl- -EOM entrapment/ palsy- EOMI subconjunctivai hemorrhage ENT _ _hemotympanum nml external TM obscured by wax inspection -dotted nasal blood Lno-eental injury dental injury / malocclusion RESP ! CVS d m (on averse ) chest non-tender -dec reach sounds D,fgath sounds nml wheezing 1 riles earl sounds nml splinting / paradoxical movements ABDOMEN _ ee- iagra R reverse) `&n-tender --endece gu*ding/rebound ia, parganomegaly mass if organomegaly GENITAL I RECTAL nmI genital exam _nml vaginal exam _nml rectal exam heme negative stool NEURO/PSYCH V"oriented x3 ?,?"iiood & affect nml '4' 's nml /as tested JJJ sensation & motor nmi Holy Spirit Hospital Camp Hill, PA John R. Dietz Emergency Center EMERGENCY PHYSICIAN RECORD--- •• - • - _perineal hematoma -blood at urethral meadi? decreased rectal tone -confusion / disorientation EOM palsy / anisocoria facial asymmetry -unsteady if ataxic gait sensory / motor deficit GROVER ,?A M ED GROUP 14 F 565516 081131199 _ ?.-- ?• . -- 06/0-7/06- -._2788 _ 539 Page t of 2 s SKIN 3s? diaor -intact crejnws it diaphoresis ?_ -- ._ -_-_- - warm' dry s, BACK see diagram ,.noo CVA vertebral point tenderness Wderness _CVA tenderness • no vertebral muscle spasm 1 limited ROM tenderness EXTREMITIES -see diagram etaumatic bony point-tenderness _?pelvis stable -painful / unable to bear weight vlft;pt n demea 6lal r -pulse deltci ROM ra F. -limited ROM / ligaments laxity I joint effusion / \ ? Ulf) Ulf ?L R? L R ? r R ? L L R Wound Description I Repair length crti location superficial •subcut 'muscle linear stellate irregular dean contaminated modexate 1"heavily - distal NVT: neuro & vascular status trima no tendon injury anesthesia: local digital block mL lidoc 1% 2% ejit / bicarb marcaine 015% 0.5% LET prep: Betadine / nml saline debrided irrigated / washed wt saline minimal/ =mad. / • ^extensive minuno//mod/`extensive undermined wound explored mi anal/ mod. /"extensive foreign material removed `wound margins revised parmly compleWy *vermilion borderaligned minimal/mod /'extensive repair. Wound dosed with: wound adhesive / Demiabond / Aeristr" SKIN- # -0 nylon / profene /staples / ethilon hair ipwd running nnpk motvess (h /v) l •SIlBCUT-# -0 vicryl interrupted nurming =Vk mattress (h /v) XRAYS []interp by me ?Reviewed by me []Discsd w1 radiologist * ' 1 MAD 1 `reversal / straightening of cerv. lordosis_ no fracture ,DJD / spondylosis 1 spurting_ nml alignment soft tissues nml : j i ? C ? R / NAD infiltte atelectasis no Infiltrates nml heart size -nml mediastinum OTHER[]See separate report l"1 t 'r T-Tmdasm PrrapeM Tesdusto S•3wenng BrEa117- Lar4Aawdon A-Abrnme 6-3-rs (e-e•?•r m?wstd ninl?saderak a-sese?et 70 - re ld"" n ai 11114- 0-0 PROGRESS: Tune unchanged Improved m-examined e . QJ`C ?.. pc ill l - Ld -Discussed with Dr. Time willsee patient irc office / ED / hospital ns riling CRIT CARE. 30.74 mai &ARBIF necZ c? 7S-104 mm, mm Admit orders wrrcoen -Additional history from: _Prior records ordered Family caretaker paamedis CLINICAL _ll?lPrSSION: MvA contusion sprain I strain head wrist RIL neck dorsal lumbar fac d R?!• sacral e GA afiao en R / LL thigh concussion back knee R / L with LOC W/o LOC shoulder RI L leg R I L arm RIL ankle R / L elbow R I L foot R / L lacetat on forearm RIL _ DIS*smoN- " Fr6me ? admitted ? transf-d Time [] unchanged proved ? sable ON1 \- r---, ? O tales ? Addri /PA -MD/DO Complete MVA - 17 Pagc 2 nr? Rev 05/09/05 TRIAGE ACUITY: 1 2 4 5 in Lo Name g Date •7• B Mode of Arrlvab 30LS OBLS ? POLICE OYYALKED OWIC OCARRIED OOTHER Age fi male felT+a Pnmwy LenguawKnghsh ?Hard of hearing Triage PCp• w Ounim none OOlher. Interpreter Room: rus CHIEF COMPLAINTiWHATBROUGHTYOUINTODAY? : [PAIN p_T% W"Op • ^ tss ?/y [?1Cerml Mass dime to ser * of pls OB* ' r me for swident) onset PI M DdWs DwOws Loca - ? 9 10 - 0 1 6 7 8 . NIM IY. ? ? •? }o ttent • ? O + is 4• ' _ W!lj 90arp ?Dul ming T ! imaE- min A; ?Ache ?Pressure f M Auto Oreguiar - ?fabored ON. ? scale ?Throbbang ? 13 ympanmc Onasalgaing?:rtndor?retra dons ONRB Oudmaed ORadmatatg?Non-radfallng U i ? ?L d bl h ? O irregular _ m n eezes , i e w O Rectal AxUMTy Oexpiratory grunt Oau R* d Triage S018f um RN- Time 1Mtat rmbevw pain? ne'?.IE y. 1? : ?„i S•a7r !. .,?° ???s t• ', 'a•1?tY? . V+? ;taF* .a. ' .?? ? Coopwadw - Awake • Atert %our date am ?DryONorm. Cdor l (iri_s1510 IRW op h P ?C t IR r ? OrieMed•Parson yan y as E words) response ?Dmaphorelk o Oodiatted-!%ce OOnented-Tlme ^ mteted ?Unooopeatnre ?A ?consdable, QryHpo,,t oTentmng ?Bran: _Dryr Molded rift v* Stan Temp OW ? mnappropftte'words OR& E3Hu- @d ?Pmmetare woad`' palp ?Persdard OAshen. ?Mowea ?laceration/A on ? t DaW ? g ?VerbdyAbusmveOComnbatwe _ ??! Nc mapprortmde cryingl MCyanodc ?Jaunmhce Not es mmirm OAnwous 00ysrg smmng• tion• Debi* OYes ?No ? Dmsanerded ? Moms te osis OYes , pain •,iPRF?HOSP.iT -„•e'?'r',w?,c?: >r-"^'.?•?,??t::t?r?tjiS?TARrY?`'?i?Y,• ?a a ?•:?? `?«'°'' •?' m1A i P Cheoldid, i - e as stated by k M k :1 * jDtaM* t3 0l aUle tp " d l l , =u s ?PE cei ?NIDD f} cam un m? ar CAD ?CHF O¢OPD?^?Seaures OtDlll ?Transplant ?Cardiac Stent ? L M *rna ?Thyromd ODepressan?Liver DLseasmt - • ? QExposmaetomea TB m pa?.mr?ordh? ,! • MD vi. ts, O ?Smoker Amth ?De f?G _^t ? ? 1 cod. , ti yy,Av ? 1 ? Other l ' n l ?' N V INV Sur?erles• S SlesAd t / chgid use: ' '. a ?yee we nurses notes) ' . :i i ' . " ® Last Ydous ?nla ? ! c? ALLERGIES t; t /!S u OO ChNdhood?immuntzatlons piV..) i d D ?N& UTD Ouimkmmomm $DD _ ; ia* LATEX LLERGY? ?Yes ONo (Khip tgnev r0a55yr.) .? a ?Hyoerectomy Mist ?Pakeni ? ? EM ,?Bottles IRMwounknown DAfe* unkwmmm MEDICATION DOSE MED eN DOSE : DICATION _ DOSE TRIAGE INTERVENTIONS Otte / Elevation ?NP OSplmt ODressmg COMPREHENSIVE TRIAGE COMPLETED BY: ?See order sheet OC-Collar OPaden Mae `QSec notified , A-) pN TRIAGE NOTES EKG paged 0 ?T? Sold" Danaconhawsrgrmatwe(d aw) EKGdone D OR DM -0 ' L TIME T13 GE DISPOSITION R 0 QC ? Ocou tional Health - - GROVER I AMANDA M 14 F 08/13/199' Holy Spird Hospital . Camp*P1t f; PNI7011 ED GROUP 2788539: John R. Dietz ECU L565516 06/07/06 Nursing Assessment on,_crli Dior 1Mti RMI 1 I w BILLING Initial Lab 8r X-Riiv Order"s:J :a0f""ov + . ,.•? ( I ESR" ' _ (] Ttrrrpthrlsre 'r .4 ' ,CB? "I momw t+'• a' ( 1 Ao0*fte I) Glucose [ ] T*ombolyW Labs ' .... I ] EKG i ] Ab" (ALCO) [ 1 HOGS () Tox SMM () 02 1 I I Amyl SWLq ese f I Ouanldatwe [ I Urine Tax (DOAS) [ ] 02 Satuiatau i IAPIT HOGS ( )TSHR , ' r ] BBH [ ]MV ( ] Type&Cross_t of units ] Blood Cultures [ ] =PM( BMP J dul Type & Sman l?yGtis%P• - . [ I LyW ' ... ,] i.") DIP( ] DIAG.' ' ?MIp (] ProBNP I ) Unne C & S f ? r ( CI TNr [ J Phenoblirb- [ ] Urme HCG [ 1 Depakole I ] PT' I WC Breath Alpo Test (J Dip=, " 1 1 SakgWe ' l I WC Drq screen W ?( ] Abd/Obstr. Giles [Knee, . (R L [( jAnide R L_ - - [ICUBr( I ] Cimcle R L [ PUS Spine Cerv. Spme••Roulahe (3 view) [ ] iufandib?e [ 1 Spina-APU [ ) Nasal y [ ] Cerv. Spina-Podabfe Lat ( J Oftk R L i I west--Routine or Portable Pelvls [ ]-Elbow R L,,00' [ ] PyebgW 1VP I I Fadel • Rfis Rey [ I Fanur R L [ ] Shoulder R .L [ ] Ffng?t R L (1 Skull [ ] Foot R L. ; . () Sternum (1 Forearm R L. [ j T/Spine [) Hand R L [ I Tb I Erb . R L [ ) Hip R L [ ) Toe R L f IHicme / R I. [) Wast R el.. '?+'I d*. ??- 7imelCRTflnt x REASON. Saecla! Pnoceduries: v ?,? Ultrasound: NET. (Wzwmh sTp o o11t) I I Abdomeq iris W WO I I VQ Scan I ) Duplex Dip ! H VV y We"> E?h- - [ I,GelVedder [) ? ` W WO cuibi 9W ( I Pdlv(s ] Sp fM chest for PE [11 \? `? [ ] TransvapW [ ] Other. [ ] MRI scan Ti me/CRTA REASON: "1 ?j },r`j S-, 0 M, Sueclmetts/Ctiltures: ?`? • ?' ?`t.+r` 1 •. 1 [ l BNa Step AG'Rapid [ ) . toal.6 & S [ l CervicallGenflai [ [ Stool 0 & P' [ J Cldsmydn [ ] Stool C. Ddliale [i ] GC Culture _ ( ) Tac hornonas ` l ] Manospc (rapm Wound C & [ ) Sputum C & S ! 14. tsnnrtg classrncanon: \ ,.- PHYSICIAN CHARGE FACILITY CHARGE • -•4' I Z 1, (]Level I Lft-d 11 [ ] L? Aca deid V LI [ Level IV [ I Exlmx ed Mrs ( I Level V [,, I Level V Ae rat I ] AWS I ] Peals Flows BeforWAIW Rasp. Tx I 1 Respratory TX fAPdimflnnc 14%Pn r AdldAhutnl tlrAnru -• lV / LR/ Dtl ASM D6.9NS Jar 1 S]Zmlalhr i ( ] Obtfn old records [ j Td [ I Pmtocn8r mw r. { V 1 1. ' r' 1 • ?• w r .t ' ( . LI v p L o V1 %N.-Oe lr3 Tea Time: 11D AR (j ADMIT f j OBSEWA7rON [r 11 REG LAR? ] TELEMETRY [ I CRITICAL CARE•t v". AV ADMITTING PHYSICIAN/GROUP: DIAGNOSTIC IMPRESSION: ???? \ p I ials\ Initials: CRITICAL Date: i' 17100694 17100686x GROVER AMANDA M 1 17100058 1 1006788. 1 -- - -° 17100554 71023 5 ED GROUP John R 17100tA 1710 52% 1565516 06/07/06 ? Pr VP _02_1viui?i 2D6-ECU 12104 Rtv. LIw n„uw,c i^r+nv RN/MA 11 dictated ? ?. MD/DO/CRNP I i Of ` r Tft see: ru ' 14 F 08/13/1991 ER1 --- 27885391 .v .k f rr ?i I .1?X 51t t. i. y. .' _- __ "',. ?• '• _ S+ _ i C - Ammke'- Alert arm 01 Color ' IE +. ..• d i? _ _6.'S.."1-.jl 7.. .. N r ht (visible) tad ualabond C ovid ted-Paraon w01dW1 rasporise DOW • ? on • ?F?Sii ME 92C. lk O b k h i ?Hot DTentnp m ac ons ons ? . OEcc re O 0riented-Ttme ioapp olmo ?Pa1e r O• Puncture Waatd D%tmmg L 1 R -1 '?EfWoCW ' a '+'•- ra lAft>khi L / R Slan Temp DWarm DCool it1t 't? ODta k d A d y wa s gdate ? t ? O ?? O c OJaamt6ce ?VeAy'Abanwedcoir?va •t ?td1.;? Oaniootms ?( ctyingl miixeaint ig / • ?' Distal Pu esopmsent?Not patp.' t?e?eeg pave r + old ?No ?Catam>Ne?id / ?02 '' Dyes 91?°- OContiiseti ?jz 4 " e'O fo'pad °?°'C' l]Not Cai f 5Wes ONo ? QDnr DCm*Ad r •° Y i Location, CC?`lJ 9 ?j Dheadache RL R L yy?? yyH L 001111111:111 OMoiWtadilggWri ` EYES MOTOR RESPONSE VERBA DAN neck Size m Dkequm>twy daa e?ge 4 Spofteoas 5 Obeys 5 Ororded Onecb pain PWipar4 D D 3 To Yet1! womand 5 towkZes pain 4 Ownenkd Ourgency °? ftd-p Ofactaldwop DdoW D D 2Topm TFbmwm&dmW 31 ? u 1 No mmmm AbaamdRion marls DDysum o ? Opecer mp DHematuna Dedeme e_ Din Odull r 2 21n O ren ? 77 1 v Dmetenbon t^m1 r., Obiiming pressure Doom. DJVD OSOB r Ohetnry LLjP 1 No Response Dcap4wy, refill. Onatim Opleuntc OWA I (NAt;'-:llte Fa;:j???R .7!•:S?u fd pam A:ymptonis DDuraboof attertstly Last Blot r l ''`"? Did ?... Dnon-mdMV DAbda D 9 O Odiarrhea Dvom6VDoav3dpabonCHanatemems Bowel Sounds D dtctend O j lyMr i? ±a'e'. rr ' mns.'?'+- r,\q?t?:'+•?`"f: Y_• •;?eli ?:.•.w tai. i 'ILI AS???y U tl.?R ew•L.wX!•+. 2Mki ?ErYEzS0 an L / R AmWty L--/- \ Ears Nose 'throat estion Dsore J in UR Dcoo L / R R OW d i i _ urre v s on g d f o tient dh t mo mg n L / R ?wdh Odwlianminage O OdouWa visi OPhotophoNa L / R ?Olhec OEp1St * L I R ?dysphasla On w pa wi PSR'up 32 fill - IV oondmon. i> ?mW ixdama 2_ a a? s?iatanesa t rasnlh T=7eakmB AnoNS Time Amt Solution Sz. Site Rate Atio Cond Intel Time Dm I Do§e Route $As Indrei Z1?S Z Time Notes 0 `_? r • '. AK - TZAL 1299 , tN 4r•4 /?••?? z +S' ?j/` Irdit na>v I Oat - . -1A 089 E; " ?tF??IITtaAfJBS? RANSFER;? r;r ? DISCH /actwmpamned by:DSeH DFamdy 6ther + •a L-f via. ambulatory Owe Dambulance 7 ^l t } 47-3 E v ?w $ f-rc T::?.c-,lam T0: home ?nursmg tome DAMA DOR taother. ?,t is / ?.., Fff r?G 7..2?!?1't^• .- -_ Dwharge utshuchons given to* -riw DPabent ?Family OParent 001her F C_ r.-- _ ADML(/ OBS Report called O _to 12D JkW 7B 16 5 i 19.-- RDOn' t` O* records e t oo Oclottu?g sheet done NSFE To - - 7 y A/ :. R3 transfer checkht complete ?• % it' ' ??r?.•? 1 14 f t ?c v 4o i vl i"?.? n ?A L ectory OCnbcat c]l?o?4tfto vague ,, r " paJr?s le 10 r ? f RN Signature:- ` r? l?C i l Y U Holy Sprat Hospital GROVER , AMANDA M 14 F Camp Hdl, PA 17011 L 08/13/1991 '---- John R. Dietz ECU - ED GROUP ER1 - - --- -- -- ---- ---- -- - - 565516 06/07/06 27885391 Nursing Assessment/Notes 205-ECU 12/04 11th REV LLW BUSINESS OEFICE 11?, ?mw • a- Holy Spt "Nospitai DepartWent of Radiology., .,And Diagnostic aging Camp Hill, Pennsylvania 97011 (717) 763-2600 PATIENT: GROVER, AMANDA•M DICTATION DATE: Jun 8 2006 12:14A ; MR#: 565516 TRANSCRIPTION DATE: Jun 8 2006 12:14A SOC SEC: 999-08-1391 ADM DATE: 06!07!2006 ORD DR: LAURENCE PAUL M D PT TYPE: E ARRIVAL DATE: 06/07/2006 DOB: 08/13/1991 HOSP SERVICE: ER1 LOCATION: ER1 D- ACCESSION: 2909249 ***Final Report"* EXAMINATION: CT ABDOMEN W CTRS 74160 .06/0712006 COMMENTS. Exam: Enhanced CT scan of the abdomen and pelvis History: Suspected splenic injury after an MVA Result- After the intravenous administration of 125 cc of Isovue-300, routine images were obtained from the lower chest through the symphysis. On the cuts through the lower chest, there is no evidence of focal lung infiltrate, pleural effusion, or pneumothorax. Definite fracture is not identified on the bone windowp although several left rib fractures were noted on the accompanying chest x-ray. ' On the soft tissue windows of the abdomen and pelvis, there is evidence of laceration extending through the mid and lower portions of the spleen but there is very minimal associated hemorrhage at this time. There is no evidence of focal hepatic or pancreatic abnormality or laceration. The adrenal glands are unremarkable in appearance. Bilaterally symmetric renal function is noted without evidence of renal laceration. There is no evidence of perinephric stranding or urinary tract obstruction and the urinary bladder is unremarkable in appearance. • t There is some fluid noted within the stomach. Otherwise, the unenhanced bowel is unremarkable in appearance. The appendix is within normal limits and contains air. There is moderate prominence of the endometnum There are findings consistent with an approximately 1.9 x 2.0 cm sized right ovarian cyst and there is a small to moderate amount of nearby fluid in the pelvis. CONCLUSION: Impression: 1 There is evidence of splenic laceration, but with only minimal hemorrhage around the spleen at this time. 2 There is a small right ovarian cyst with endometrial prominence and fluid in the pelvis that is likely of GYN origin. 3. The findings were discussed with the clinical team CONFIDENTIAL: This report contains private patient information. If you have received this report in error, please call 717-972-4941 immediately. Confidentiality Disclaimer The information contained in this communication may be coniidenhal, is intended for the use of the recipient named above, and may be legally privileged. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication, or any of its contents, is strictly prohibited. If you received this communication in error, please resend 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 t, . Holy Spl"- ,yospital , -.aging dnd Diagnostic' diolo f R ' e DeparL. . g, a o nt , Camp Hill, Pennsylvania 17011 (M) 763-2600 PATIENT: GROVER, AMANDA M' ' DICTATION DATE, Jun 8 2006 12.14A - MR#: 565516 TRANSCRIPTION DATE: Jun 820061214A SOC SEC: ORD DR: 999-08-1391 LAURENCE PAUL M.D , ADM DATE: 06/0712006 _ PT TYPE: E ARRIVAL DATE: 06/07/2006 DOB: 08113/1991 HOSP SERVICE: ER1 LOCATION: ER1 D- ACCESSION: 2909249 • DICTATED BY: RICHARD MOSER M.D. I PSC DATE OF EXAM: 06/07/2006 SIGNED BY: RICHARD MOSER M.D. DATErrIME: Jun 8 2006 12.14A CONFIDENTIAL: TMs report contains private patient information If you have received this report in error, please call 717-972-4941 immediately Confidentiality Disclaimer. The infatuation contained in this communication may be confidential, is intended for the use of the recipient named above, and may be legally privileged. It the reader of this message is not the intended recipient, you are hereby notified that any dwssemination, distribution, or copying of this communication, or any of its contents, is strictly prohibited. If you received this communication in error, please resend 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 2 Holy Sp{,'" ' lospital Depari.,.,ent of Radiolog, and Diagnostic _.aging Camp Hill, Pennsylvania 17011 (717) 763-2600 PATIENT: GROVER, AMANDA M' DICTATION DATE. Jun 8 2006 9:46A 8 2006 9:56A J MR#:' 565516 un TRANSCRIPTION DATE: SOC SEC: ORD DR: .999-08-1391 LAURENCE PAUL M.D. ADM DATE: 06/0712006,: PT TYPE: E ARRIVAL DATE: 06/08/2006 DOB: 08/13/1991 HOSP SERVICE:, ER1 LOCATION: ER1D- ACCESSION: 2909311 '. ***Final Report*** EXAMINATION: C SPINE AP AND LATERAL 72040 - 06107/2006 COMMENTS: Examination Cervical Spine, Limited Indication: MVA. AP, lateral and odontoid views of the cervical spine show no fractures. The alignment is normal. The vertebral bodies are normal in stature. There are no subluxed facets. The C1-C2 relationships are normal and there is no precervicai soft tissue swelling. CONCLUSION: Conclusion: Survey examination of the cervical spine negative for fracture. . DICTATED BY: HOWARD BRONFMAN M.D. / PSC DATE OF EXAM: 06/07/2006 SIGNED BY: HOWARD BRONFMAN M.D. DATE/TIME: Jun 8 200610:09A CONFIDENTIAL: This report contains private patient information. If you have received this report in error, please call 717-9724941 immediately. Confidentiality Disclaimer The information contained in this communication may be confidential, is intended for the use of the recipient named abo4e, and may be legally privileged If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication, or any of its contents, is strictly prohibited If you received this communication in error, please resend this communication to the sender and delete the onginal message and any copy of it from your computer system. Thank You imaging Services Consultation Page 1 . Holy Spyi%Hosoital r` Depa>•u.rent of Radiolog, dnd Diagnostic ::.aging Camp Hill, Pennsylvania 17011 (717) 763-2600 PATIENT: AMANDA M GROVER DICTATION DATE:. Jun 8 2006 9:56A , ' MR#: , 565516 - TRANSCRIPTION DATE: Jun 8 2006 9:57A SOC SEC: 999-08-1391 ORD DR: LAURENCE PAUL M.D. ADM DATE: 06/07/2006 PT TYPE: E ARRIVAL DATE: 06/0812006 DOB: 08/13/1991 HOSP SERVICE: ER1 LOCATION: ER1 D- ACCESSION: 2909232 ***Final Report*** ¦ -s I EXAMINATION: PELVIS 72190 - 0610712006 COMMENTS: Examination: Pelvis Indication: MVA Films of the pelvis and show no fracture There is no deformity about the hips. There is no separation at the S1 joints or symphysis pubis. There are no distracted apophyses around the pelvis. Questionable mild soft tissue swelling around the lateral aspect of the right upper thigh and buttocks? CONCLUSION: Conclusion Pelvis and hips negative for fracture. DICTATED BY:, HOWARD BRONFMAN M.D. / PSG DATE OF EXAM: 06/07/2006 SIGNED BY: HOWARD BRONFMAN M.D. DATE/TIME: Jun 8 2006 10:09A CONFIDENTIAL: This report contains private patient information If you have received this report to error, please call 717-972-4941 immediately. Confidentiality Disclaimer The information contained in this communication may be confidential, is intended for the use of the recipient named above, and may be legally privileged, if the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this oommunicabon, or any of its contents, is strictly prohibited. If you received this communication to error, please resend this commurucation to the sender and delete the original message and any copy of it from your computer system Thank You. Imaging Services Consultation Page 1 Holy Spy'" i ospltal ' Depal-L.rent of Radiolog,,.dnd Diagnostic .:.aging Camp Hill, Pennsylvania 17011 (717) 763-2600 PATIENT: GROVER, AMANDA M DICTATION DATE: "Jun 8 2006 9:49A MR#: 565516 TRANSCRIPTION DATE: Jun 8 2006 9:49A SOC SEC: 999418-1391 ORD DR: LAURENCE PAUL'M.D. ADM DATE: 06/0712006 PT TYPE. E ARRIVAL DATE: 06/0812006 . DOB: 08113/1991 HOSP SERVICE: ER1 LOCATION: ER1 D- ACCESSION: 2909233, ***Final Report*** EXAMINATION: LT RIBS UNI 71101 - 0610712006 COMMENTS' Examination: Left ribs 3 views chest 1 view Indication. MVA There are minimally deforming fractures of the left 9th and 10th ribs laterally. There is no pneumothorai, pulmonary contusion or pleural effusion. The lungs are clear and well expanded. The heart is not enlarged and the mediastinum is midline , CONCLUSION: Conclusion: Nondeforming fractures of the left 9th and 10th ribs. Concern for spienic injury? Findings were discussed with Dr Paul DICTATED BY: HOWARD BRONFMAN M.D / PSC , DATE OF EXAM: 06/07/2006 SIGNED BY: HOWARD BRONFMAN M.D. DATEITIME: Jun 8 2006 9.49A CONFIDENTIAL- This report contains private patient information If you have received this report in error, please call 717-972-4941 immediately. Confidentiality Disclaimer. The information contained in this commumcabon may be confidential, is intended for the use of the recipient named above, and may be legally privileged. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination. distribution, or copying of this communication, or any of its contents. is strictly prolubited If you received this communication in error, please resend 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 I!! to ? ? N d O 0 U) C) P-4 u n. N? I T a cl) A I Q O y ? •ca ry U ? N Aa ? 44 w s "i I. t% 1is s; •M•:"Pg •S C. :'s •r 4 J. ?»? dw N S 0 ?,S qc4 as9 oLo 7' Z O U V Q Q Q o° O O ? V5600 o V --. fa U O ~ o vY ? '' Pennsylvania EMS Report Service Name station J Unit Name & No. PM No. Date West Shore BMS B Station BStation -2102218 3065538 06/072006 Incident Location Municipality & Incident Zip PSAP lucid. No. Creek rd/York mad Monroe Township / Williams Grove, 17007 01245 Patient Name Pt. Weft Phone No. Receiving Agency Amanda Groves (717) 249-1698 Holy Sint Hospital Q Street Address - Age Cre w )•.( 739 Dogwood Ten ace 14 Yeah; A #1 Kennedy, Ella HP 145307 -4-a city State Zip DOB A 92 - Boding Spring PA 17007 08113/1991 A 03 PatientNumber 04 Social See. No. Sex A - - Female rm Private Physician ? Driver's License' Out On-Scene Dest. In 911 18.47 I t _ patch Dispatch 18 47 Transporting Assist Units Assist OS Enroute 18 50 Arrive Scene 1902 Response Outcome Medical Command Physician MC Time Contact 19 05 Transported Dart Scene 1912 Arrive Facility 1934 Available [ 2027 In Quarters 20.45 Chief com aint: Mvc. Current Medr. Allergies made W O w Narrative ur Dispatched for a MVC. No pre-arrival information provided. AOS to find a 14 y/o female, secured ??.? on long board, being placed on litter by ems providers. Patient was a restrained passenger of a O mini van which impacted a tree after leaving the road. There was no air bag deployment on the passenger side. There was no loss of consciousness. The patient was complaining of shortness of breath and chest pain. -Pmhx: none Mods: none Ail: NKDA PE: This is a 14 y/o female restrained passenger of a mini van, travelling at approximately 30 t mph, and left the road, impacting a tree. Neuro: AAW x's 4. GCS 15 (4-5-6) PERRL @ 4mm, briskly reacting to light Able to MAE. Patient is complaining of chest, mid back pain, and shortness of breath. Musculo-skeletal. Upper and lower extremities are palpated and visualized to be intact. Pelvis is palpated to be stable to inward and downward pressure. CV: Patient is c/o chest pain 5/10, increasing on inspiration. Heart sounds are crisp S1 S2. Radial and dorsalis pedal pulses are +1-2 palpable, and equal. Extremities are cool with a sluggish capillary refill. Pulm: Respirations are initially tacky, and non-labored due to the patients emotional state. After patient calms, respirations are regular, even, and non-labored. Excursion is equal, trachea midline, airway naturally patent. Lung sounds are CTA. GI: Abdomen is soft, non-tender, and non-distended. .- _Skin-There-are-abrasiorns^ csf _e_mtd s atrium, an across t e pelvic region,-Bteeding_is controlled.=_ --=- - - - _ _ _- _ Y -. _ ---- - - ---- - R x: e .kg, oxygen via non-rebreather mask _at 151 rn. iv LR at a KVO rate Provider_ Prinfed On: 06/07/2006 21:14 -» BMStat Repotting(c) I998-2006, Med-Media, Inc = AillZgtifs Reserved _ " - -?- '-- Page: 1 of 2 7 - Service Name Unit No. PCR No. Date West Shore EMS B Station - 2102218 3065538 06/07=6 Patient Name Date of Birth Social Security Number MCC Medical Command Physlciaa Amanda Grover 08/13/1991 - - TOC to HSH RN. Patient tolerated transport well, with improvement in her chest pain, and no ? change in her vital signs. . - Vl PIV patent upon TOC. . GO a? Timer :P. !R.• ?B Y : r e?•: ;( lss$ow' I J . , . - :. L .. YYGI?tw . • ?; rn .t?ts '"' , ?: ,, t-i c 4 r i'.?: ! ` L .?.• .-0 i.? .-w_. ..• • 1905 Assessment 145307 19.10 10-15 I m AO 1910 Normal EKG -Al sinus , 19.12 72 22 122/92 4/5/6 lartral VS, Resp. Effort- Tachypnea and Non-labored; Pednsron: Normal 19.15 / 11 Assessment-on r 145307 19.21 70 20 128/72 100 4/516 145307 Resp Effort. Normal, Perfusion- Normal 19 26 / / / ALSN 145307 19.31 75 16 129/70 100 4/516 145307 Reap. Bffort. Normal, Perfiuion. Normal O - - Provider Printed On: 0610712006 21:14 _• _EMStat Reporti g(S)1998-2006, Med-Media, Eno =All Rrghts Reservbd-= Pennsylvania EMS Report WEST SHORE EMERGENCY MEDICAL SERVICES • ,rr.--- ' AMBULANCE/MICU ROUTINE TRIPSHEET - Affiliate #: 21022 INCIDENT DATE: TRIP #-. (p(0 INCIDENT LOC: F??2 44. DESTINATION: MUNICIPALITY STATION: VEHICLE#: 1 ;TYP.Ei: QaLS BLS , MICU 1 WAY 2 WAY STANDBY I,,, 4-'- = ; -:- =:PATIEN?'clk1FORMAWiI©K :a ?SendWemtAs •tilfi'fo`mi§fionW'.'! w (Last, R , Middle) NAME: MEMBER: ? Yes No ADDRESS: t } SIX: Maie Female WEIGHT: L15 CB-S CITY: S STATE: DATE of BIRTH: AGE: ./ 41 TELEPHO : ZIP: -, o?) SOCIAL SECURITY #: , c._?:Y°'i.'v"t: ..s'$?a :•?.:+?. .,?„!:?t?ISUf?ANGE;Bc:•BI WNG,INF,DRAIU?ASIO{?1??.-.°? •,•.?f'.?ti7+..•? ? -..v?. r; ,?:.r?.c•! BILL TO: Patient ? Facility Insurance ? Other AUTHORIZATION #: MEDICARE #: ? Parent Guardian POA ? Other MEDICAL ASSIST #- NAME: OTHER INSURANCE: I ADDRESS: POLICY HOLDER'S NAME. CITY: ADDRESS: STATE: ZIP: CITY: PHONE #: STATE: ZIP: CRISIS AUTH. BY: IDENTIFICATION #: GROUP #: REASON Dia Codes WITA SIGNS k UITAL`SI TIME: PULSE: TIME: )I 1r) PULSE: L4 B/P: o B/P: RESP: RESP: l EKG: EKG: S I Li.L% '-V.lTAM1GNS'a•: TIME:0j 33 PULSE: v B/P: O(...f RESP: 1 [j2 EKG: VITAL: ? SIGNS; , TIME: PULSE: B/P: RESP: EKG: NAR E: Chlef Com taint / HPI PMH, Meds, Allergies, Physical Exam, Treatment, Disposition, TOC ` t . U:-"b .L - k - - - c `i V Sb + tgt.`? . . b p -t V SS UOt Imo. t 'S -'b om, r n A o fl: G n v- i Ar% =n dTi i1n 1. • U a• n splm m3 _V_ kE & b. Q Pig-ML AQ)e L4. T l C l - ES ' N 1 r 0' O -T } ? e - - Atel - 119tES`f `?_'Re"s nd`Scene` - '?;En Route',;; F D'estinatior-"?. °Abailable- - - - a'a;11V;a`fin '?irriea° -- 1NITIAt-r '- ;STA?R?yT;4 (f lTl?4!_'f?jf E.iAgfE` F?"''• OUT: 2[4.3W SCENE: DEST: L! 3 IN: Z GE ?,,,' ;RE TURN=MIL:EA , OUT: --r SCENE: DEST: IN:--- - - _ A G NDAy -== = •- - /. } ?,?F.- lia ?l=F?Q- l l r? ?? t LEVEL & CERT#: Pr?rrw P " f R2`3 37 DRIVER - - - _- •-== -?_==: 1 -, -Ar;-l 1 .`T"lP?t 1 i\ c F LEVEL-&;CERT#: Pvrlr ?, ()7y_3i I w ' { Wrw i? GWAR MLVMM OB-13-4991 SSM 9004X-1311 Low X16 Pew caw E Ordered Br. LA REMM PAIR. MA: A*m*w: Refaced BY Diciaiod By: t1WAMW BRDNMM M.U. Act+eesion: 29 m 3 - ADM DX LT RIBS U1+9 DM 06-07-2WS OM" Corl"Ie Neil Flan AL APS-7818699 EXAJii MTIDM: LTRBS UM 71101 COMIriNTS: S mheiocs Left ribs 3 vim dwd i Vbff kidgon: WA Thais ere afnireif detarm?g fradrueg cf the Ieix 990 and 10th ribs imbelr- There is no pno mlromy. prinonmy coal {r . or plera-ai effabn. The Legs an deer and wail expanded. The heart k not e*vgad and to rrexdfasirran is enidGrr; CONCUX31 N: Candasiarc Nandsibaaing nacre of tm k t 91h and i0(h ribs. Caraem forsi>d m ir#ury? Rd'egs were used %M Dr. FWA Codes: Aooe dm CPT ICD 71101 61.02 Approved by_.imnffnr Caste Dl twm Date: Qowdm ms lom ED1p- 8ROVER A MANDA M W131881 ' SW 9984)6-1981 MRIL 586616 PaVm tChswVMW E OuRoW Bx LAURC3IC;E PAUL M.D. Ali mkg R a. - Br Di HOWARD BRONFUlkN M.D. Amesdon: X11 DOS. 06W-M 00-WM ADM = CSPNEAPAND LATERAL (bdeRybr Naft F' I APB-7818997 # DICTATED Or HOWOM BRONFWAN KM # MNED W HOVWkRD BRO FMAN MD. FXAMINAUX C SPNE AP AND LATERAL 72040 COIF BiatidlC &M Ce+VkA Spuie, WA. Codes: AcoessOA CPT JM 72D40 95809 Apyoved by: BWh Wfte/ .D/C- Summary GROVER, AMANDA M - 7004280 Kerry Fagelman, Brett Engbrecht Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP CS Hershey 717-531-6342 Hbg1York 717-920-5200 EG /MKS DD: 06111/06 DT: 06/14/06 09:44 Result Type: D/C Summary Date of Service: 11 June 200612:08 Authorization Status: Final Subject: D/C Summary Author or Import Date: Galka, Eva on 11 June 2006 09A4 Verified By: Meier, Andreas H on 15 June 200614:44 Encounter info: 7177424, HMC, Inpatient, 06/08/06 - 06111106 Printed on: 07/24/06 09:14 (Continued) she d L'c0.t a>- Milton S. Hershey Medical Center -?- - Collura of Meffiffie De artment of Emer enc Medicine Record S UD Qen MD: OEFLITCH CHRISTO MW: 46922 MR#: 7004280' DOB: 01/0111900 •- --- • -• SEX: U INS: SELF PAY Otr --EM - SELF PAY t OOSN: 7177424 VISIT GATE: 07!27/2006 Da O Temp: Oral Rectal Pulse RR BP 02 sat Last dT LMP ED Pathway, Room Time Phystmen Time W. PMH: HPI: ' Meds: ' Apergies: Pain- Y N Location Quad Onset FHx: Carthao ' Y N Dtabetes Y N -- rs ROS: Unobtainabl e - Y N As noted other stems atnre Y N Other. Cono*Aorosk WL ome N Y Fever N Y palls N y Weakness, N Y Fatigue N Y Soe H= ETON Y N Smoker Y N PPD Eyes: Blu vision N Y a N Y E Pain N Y Pholopholua ENT mouth: Sore throat N Y Epalaxis N Y Ear Pam N Y Rtunontma Other } Cardovasat?tr: Chest pan N Y Pleuntic N Y Exertion N Y Pakpttations I a - sP nea - -N- g- -01 *- -N Nausea- rb N-Y Diarrhea NY- - - y g ; d N Skin: cum Y Rash N Leston N Y N Y Ce W: um I Ntmtbress N-Y 5bghng N Y Seizure N Y Syncope Dysphasia N Y Psyduab= Sulddal N Y A voety N Y Ingestion N Y Depresslon N Y Hallucinations N Y Mg , Other. Troponin I• Myoglobm. Physical Exam: Rectal: Hemoctdt (+) (-) Pi`. PTT. • INR: T Btlc AIk Phos: ALT. Amylase -Ups o _ r Studyft ? See stedwd PROGRESS NOTE foraddrtwnal information ORestdt MDM I Differential Dla nosis: 3) 1) 4) 2) 5) 8) 7) 8) . Studyfl2: O Result Procedure Note: EKG: Study 93- O Result: E cou : Trestmwt NOW - G fi; Response. Discharge Instructions: ease go aiW*- to check out secretary atwadmg room desk Follow up with vmthin days. 7) 2) A Fib D 231r ? 4 day ? Chest pain ? Dehydration DVT O 23tr O S day ? 23hrtmuma Relum to emergency department if l 2) i?'.?!'I?'?Res"it?ehUF/UTIP./Sfb'cl?" ii6ht?S°"P 'DIg D 3) m?ii 7ei? ? Regalved Service: Vlltiere: D Improved =<c No change Time, _ = DO Cp'ra form? ?" " PENNSTATE Lr1Gi,lt <+G1tL 7004280 NAFdE: TAAUNA " Of 1&d><dw ?' , i D: D7004I28CD CHRISTO MD#: 46922 ? f M - - ' - 01/01/1900 DOB: . SEX: U _ - INS: SELF PAY SEL-F-PAY - ED TRAumxFtESI')SCITATION-FLOW SHEETIORDER SHEET 7 O l VISIT DATE: 07/27/2008 , 7424 1: 71 DSS DATE TIME RESPONSE STAT PAGED •RESPONSE.LEVEL 1®3 AG E SIX WT " TIME PTARRNED .. ?- ••• - •• " . " , ,,,? a L ' EMS FtERill r • . D } v 4 rEi S JVIED.$ G VEN 4 AMB/hAED°IC f P BP GCS ..I ;_+ HEL-ICOPTEf , RH T_?BAGGED® - MEMBER RM? y ON-SCENE INTERHOSPrrAL C-COLLAR CID/TOWELROLL TRAUMAATTEND CHARTS LABS_ XR • CT LOSS O CON C LONGBOARD/KED . EpATTEyD F SCIOUSNESS:,NO _UNK_Z YES - IF MIN _ MAST • ' ENTRAPPED:')LNO' "'Uwp" --YES -'- fMIN' SPLINT ANESTH.ATTEND. SELF EXTRICATED: YES-_Y:_ NO - SR TRAUMA RES. . . w+?... ° ?. ? _"?" Y 8 - ' ET „? •• ,, ,may r 'ti'C _ s 146 " • a.s e. w rq - CAR _ DRIVER BELTED _ WCTED _ WINDSHIELD DAMAGE 1 . 8PWMEOUS RA - - f _ PICKUP _ PASSENGER _ AIRBAG - # Fr - BROKEN _ FRONT - MIN SEDATED PARALYTIC AGENT IW - TRUCK _ FRONT _ CARSEAT - ROLLOVER SPIDERED -BACK _ MOD. VAN BACK NONE X 02 MASK UMTN -r C l .? - • - - ST WHEEL BENT BROADSIDED - HEAVY ANNULA LJMIN PEDESTRIAN _ BED OF PICKUP - UNKNOWN -UNKNOWN r R _ L _ ASSISTED RATE BVM MOTORCYCLE _ BICYCLE ?- ATV HELMET_ NONE_ UNKNOWN _ RATE AIRWAY(ORAL/NASAL) FALL - FT - GSW - , CAUMM -, ETT (ORAUNASAL) S12E BURN - DIVING - DROWNING - FARM _ INOUSTI '_ SPORT _ STABBING - OTHER' - CRICOTi1YRO1DOTOMY TRACH SIZE iy PMH/PSH .p,f N - A .,?,•• T Q AMt NF: RATED? ;? ? ;? . . •_ . ... r<•_ :: : ?, .. ? LAST TETANUS Y / N .- ,,.,. , Eye+.: ' Op"Ing Rill Ve1l Response Bul Motor r Response ?1 6>rl y ., . ?,, '.. a. - a r?• HEST "'''"` `? '^'_' ._ _''~ :-?•ao - f, AB EN- P vil • ?LABORED-BREATHSOUNDS'R''L" HEA!"OUPI - ' ?_ SOF '-t- v -"-TENDER -z -:STABLE - %"?YEST PRESI ?iT ? ? iPRESENf RK31D YES _10/, UNSTABLE ABSENT 'MUlFLE4 I ?r01S>115 w Y' WHERE ?' PRIAPISM YES CL EAR ? ? 6UADIIYGEtS BLOOD b HERE DIMINISHED _ _ BOLSOUE_ .= MEATUS - ftPITUS PARADOXICAL V O YES CH SYM RI ? YES NO WHERE- . - MET CAL OTTON, ' WJfRE- ' r,v0gW K'y - p: q +l - in t ..•,.ai?-may = .. ? ,. ,.. -- , , , ,? 0* YES ? y 1 uo 4 .,4 PARMS-IS PARATHESIA , PULSES PAIN. PALLOR Y _ PINK ARM+ - ' A . *•/gRNAY•RATFM , 3 3 RA _ i B kE . HOT 2-f YES 0 2 2' • Lff :..... , ... 1 11C - CYANO _ 'fND ?- TIES NO M 1 1-3 -. DRJf =' . MOIST 1pq?y? MIDLINE ro m GCS •r 71C, y ti, 'I, mo , •=r - _ ' -A CxANOTIC ti ?YES _ NO 'C ER U ?«? CE 9 AI F? is ARflIfil. ....+.-+.e,.'?" • • v ERV.?...iw+..w,._- 1,OP?ACTIIf{E ? -? _ - -'- _ - ?dIY?S -?. _ A-A11110 B r y y 3 sUNsNDT YRTUN° ° N SUR PLASTICS -" - - 6 BURN 7. FAJW ~ -- OP - - ^- ' ; r- '`- •_ te a,? - 09ffC1 -3 3- °HWAI6 Tohl Fill Trauma Scorn Original - Medical Record Yellow - Trauma Service Pink - ED MR 690 02/05 ED TRAUMA/RESUSCITATION PLOW SHEET/ORDER SHEET ` l.., ' - - `_ r. ?J_i• -•?• S ' ta:..`.?4'1 -•c.?- 5 • `^` i 3?f ?arwrG. Y i.l=-r?"w2'^" ?.•.{,-.•r+ 7 Y"?S 4 NEU OC4GI.C- •.+4 ..r... ov':_?SZ Y } Al 0. rr u++.no• r' _ ..tM -?` 11 r.r E M11 n. . e?L+c": < rr a..«.r? GN '•L ...& .rai`-..<? q _ o a.t,•, ui ` Time Pupil Size R L Pupil React R L Motor Function RA R' LA LL GCS Time' Cardu}c R P 'B ?.. , - RR 02 Sat f T Warm Lites / B.H. *"Pain Scale Used ON77 l ?k'7l Af7i fY?J W IT - L7 V- - alai ` s Paw 1 4P 7' Adutt 0 t L7 to Ivt or., Nar - 1,7 1) , M (OW i9% Tr Child s?1?FCOIy1CERNy'f< •F - s.Cr"C` C?J . ?V .rrs?r K"7.7' G ! "?? ls?r^y'I _. B.° ?iY•' i L? TIME-- TEMPERATURE COLOR CAPI LLARY REFILL SENSATION MOVEMENT PULSE i ?(??` R y 111 ° . ?t ; ¢ `? t ;.;; `"' '? Tn?."r'..:7. 1?iT?.?6Jy , s i li ??? ` AnF' ??:7t?+ rT. ~.IL ?lir• 7?1i'J: 6" r, • i? o TIME TRAM-1M TIME BACK TfW 1F TRAM 2M rM2 - TRAM-3M TRAI0F TRAM-P T&C 0 U T&S LEGAL URINE DRUG LEGAL BLOOD ErOH OTHER SITE CRITICALVALUES CRmCALVAUJES PREPPED WI POADONE-1 INE DRAWN BY r FOLEY E N HEMP + - ,15 SIZE -L-.-m- . BLOOD AT MEATUS - INSERTED BY . TIME _ } GASTROINi[ES?Ia`' RECTAL; •HEME•' '+ ' - TONE,,,_O GOOD_ __ _ ElDECREASED ? ABSENT PROSTATE ?.NORArtAL - ? ABNORMA DONE BY-- TIME ' - WG (ORA AL) SIZE FR INSERTED BY TIME /NT LE„ TIME - AR.-?PINK-----? OSSBL000- ED-• CC NEDi.--«+- CC - ?P-, 1Rill . - ---RCT=SIZE=ff1=6VP- .-L•Cx...StZE;?yE(R?A E--_-, I1Y1 - =L?f1 -. - - -- lf--a-Y-- ?- P ,g S 0? ONE=BYE - - - ,PAD'-EKG•=*YE - - l?EilR.O i ICP BOLT INITIAL READING-----f HALO DD INTAKE TOTAL Time (?- .Spine Lateral A/P Odontoid, Swimmers CXR ...Pelvis - Cystogram E ktrerhities Cranial Abdomen _ Chest , - ' Other ' Angiogram ... S 1• M "MC 4 AN 4 • 1- ..i" TIME RATE FLOW TIDAL VOL. PEEP , i -=e'a . L-CT OTHE:FiS OUTPUT TOTAL NURSE'S NOTES - ? - irdcLuDes: 1. Asse-rnen* 4. Response -• • • 10Cc.rN? C.I c.f thc? • e Ccx?? 6-7-i-A nnli1?.? ?,,,.tf? ,?.-•6?- ?.,__ .,.r ? . -.'0-. . 2. Plan 5.Ongoing Assessment ? ?- '? _V-ft?', 4 1Cc W kk? 3. Intervention s. Disposition/Final Assessment 6/0 00.?- AQo i 5 ? sr •i , I ?^?1 T C - 1 I I TEMPERATURE ?pp? Irt COLOR REF IL" V?[?LF SENSATION ?C-?SII MOVEMENT E?1 PULSE - .. W Warm- N-Normal -R-Rapid-; - N-Normal ` •AA Acdv -S-Strong C-Cool P-Pallor S-Sluggish Tingling W -Weak W -Weak CD-Cold F-Flushed A-Absent NMumbness . P-Paralysis . A-Absent _i:-Hot C.Cyanotic P-Pain--• and -A-Absent - R-Regular-- I-Irregular Ya..y BVM = Bag Valve Mask LOT = Left Chest'Tube 'NS = Nonnal•Strength•- ET = EndotrachealTube ACT = Right Chest Tube _W = Weakness .- - ABD = Abdemen PH = Pre-hospital FP = flaccid Paralysis RL = Right Leg LOC = Level of Consciousness R = Rigid, LL = Left Leg PMH = Past Medical History DCB = Decerebrate Posture RA = Right Arm BH = Bair Hugger DCT - DecorW,.P -psture - ?ftA? r PI?IL NEACrI1MTN. B - Oink F = Roved S. Sfuppkh D : Dftd N = 11w aWn ADMITTED TO ® _ wREPORT TO- - ^V _ ..qM&OR#014Hw--- -OR•READY- TQ OR-- -?----? „-- .. FAMILY NOTIFIED-Gr-" REt.ATION§HIP' - -- "C ?(I L i?ED,-, Q IVO- "BY D '^ ?0 S-'tSAl9'==--ASPEUG-? - =a_- - - •_ _ ?11AL?.IA?f=ES,.°®:W/PA7IENT'L?]'SgF'_ ,E''C]'W/FiA11711CY-?P'BEL'ON6?I?GS?ORM1lONE"" "f3 EXPIRED CORONER NOTIFIED-4r E-.E,ILIDENC?TO:P.OLICE`.1?YES_.O_NO - - . . BADGE # . _ ,..._. TRANSFERRED TO VIA IOD BALM . R1852,3 CHESS: 0 ABD` G " r - EXTREM:--- _ PENNSTATE _.. ( :.:... FM Mihon S. He, ...ey Medical Center N • E: - AU A 70004T880 0008 ® College of Medicine: 7oo42eo ate: atsszz : 0 7/07/1900 SEX: U ' IN - SELF PAY _ LOC:-EMER - SELF PAY - -- TRAUMA-HISTORY AID PHYSICAL EXAMINATION 005#: 7177424 __-- • ?• _ ' ' VISIT DATE: 07/2712006 i . - - _ ..,„...??.•-.rte, , Date: •?D' Time: re?taum°' - T {,*sCo -Mechan,? o C . Belted? ? Yes ? No ? Airbag ? Pedestrian- 17 MCC ? Assault y d' ? Fall O Bum ? Electncal c ` C . ?.GSW. • .?'Stab •0, Qther ,". t _ :?iriuao=',.: rift., - R.O.S. Field:Niais: P: BP: 'RR: , Immobilization: ' Fluid: tim?.Cl Y,es Loss of Cons`ciousn` es ?•No- field; 'Hotew. , wm"r tv L;91- ON ? um ? steo ? MM' ` ? .. I a e , Wiraia?) atent 13'6bsl'ructed - 'Imd&fed 'CTOfAB AT, El Trach• Alle'i'bzk' Bieatlitng: • Bieath.Lj(ids g?A • Meds: ., • 'C;tculatlon: P`?? BP: RR. • r,%Sat -? IisabfAly: •. .t" ?locaE O Pa10fal ?iUnre'sptinst a 'PMH_ ,,Phicedures: O`NG-Tatie '?.Unnary Cattleter P$H "' '` µQA=1,r - - Ghe'st tube::? nqW ?4ef r N - rLast`Meat: -ate ? uPr• - - .rastTbtanas: s? Tem(z . S +Pti. =:•a9p r. , t . p? `;;- i.2nd lli?l w •,, ,ma, ? ? ,, - - = 7 ?'HEENT?'Head-.1?'• ?'? .? ; 77E7, v 7 ? - • _ ,. • _ • )A, Face: Maxilla:, • _ Man - r T Now f . _ Mouth: Dentures: `' \ J\f '4 1 1 N _ ' •r^ ?t eck Tenderness: _, ,`Cfepihit;:n, ? ?- ?- &Tractiea;ML': !pf ' 7 --0he*Wall:'1endemess:2 •"L`` ' 'Ciepitus: .. -- - bad Tendemess= Tenderness:..?.6, -?.. _ ? .- _ • 7Retda1.?F0 ne?- _ tar6taim""'f adta=- oral= _ -- - - , ?g L ?- - - - na e= ` = --Tifl`? to _ Tlme - a:tn./p.m. orx=OGM Ab -abrasion C t i -con us on ti_ i -? - - -• Odg - Chart MR 611 Rev. 3/98 TRAUMA HISTORY AND-PHYSICAL EXAMINATION Copy- Trauma.Services TRAUMA HISTORY AND PHYSICAL EXAMINATION ¦ 'T .•.!•`s ?'. ? •? t ?t ?? + . :..• E1lffe&Ilty Exam .. M - ' ' :n fi:. t ?• .?. yew • ? LEGEND: L -laosrabon .. ,. f f 1 CNc-closed 1 fracture J ; ofic-open haelure b 'C -contdmon PS nel Cora Inlery Glasgow Coma Sealef'eds W t . : F ?' ? : '` Eii4pemng Trauma Score ariia?',?en/es: ° ? s` 2- Open7o Pain - Heap: Hate SBP MOO 3 to Command/Voice 0- 0 0: 0 . . • • wous ase - 4 efiat`iReo 'T 1=12^ 'i =_Nbw!!"!? -1-1-9 -1-0-49 2:->36 •2-50.69 Seilsary': Pi p4'ck f: " ' Y, . }' '"'?' " ' " h 2: liroampnetn?ble /Moans to P? 3 = 25=5 3'-70.90 3r•I n9'7,opbltelCdestuPau? :10=24 ?>90 Prori p dception ? '4- rhed/Consol abN ` GCs - Ongnted9lnteiacts QTR S ' • 15 1 otor.Reepon'se '1.-;Nonb •.2.0ecenib%e 0°3.-4 ' 1 -5-7 ' 2 - 8-i0 ' ..•r r• z •-, +? .- -? v. -.Oki" C WAhdr?ws" `,?t - - - 3 7113 ? _ .Paid obeys • ' 1?i5 •' ` . },+r -- ?' 'sit .t'1': +?,.• ......... .•.+•• •r •/' - - i..• .t - / '. .?Tutafl• Q/ - r ria• y `Y_ .._ p "+ w+?? _ " L -y` J? /'K? •i:. b "?OYIn -. p. tf T4s .?..-ate ne. ;p -4-s-C sari: ` ` ? -? ?" ' ] t''? ' ' A l e '"-': ` _ a .•? rrn ' ` " •r .rF!+ ? .?•f. •?v rr,+L:lifia ?. F ITI i as : +sr /y ( '? ABl7.°' "?'.? St. !f •.'\J F7? .'T_r,Y,^;?L i•Yr ]...v.. is e.•p --- , - , _ • 1 ALP: ? ? .- -Ica: • .w. ?., ? - • . ETOH:• :??/7 •L?ll7?'? r.. .?i... •?..• T•,,,,,.• ....•A?4•q ..art.. , , •?•W.MK.....w-... r:... ',.? - .t ., • •..ir. ee, .?a •CSpi' - 6cfremities: t- Abdamen' . GAntoid. UpIrm ' T 7 ' ?'- ?_ _? ' ". --..o•._-•- ?n--cv •••?+•?.. .. .?i. `-r?.a?c-is]'ilaN.tn11_•rit _ ??_ - Atteridding Signalure/oateMme MR 611=Rbvw.af 8: TRAUMA HISTORY AND PHYSICAL EXAMINATION ung - unarr G/(?•y'G? Copy - Trauma Servicas I __TI Milton S. Hershey Medical-Center m W- TRAUMA, 7004260 MDL_DEFLITCH CMSTO M08: x6922 College-of Me&&e.---_ - rL000C.-S : 7 28 s ; U - - O -SELF-PAY r1 : SELF PA TRAUMA TEAM SIGN-IN SHEET l#:7E? 742a VISIT DATE: 0712712006 Date TRAUMA LEVEL 1 Trauma Standby paged at hrs TRAUMA NUMBER 2 3 Trauma Response paged at hrs ED Attending Trauma Attendi Trauma Team Leader PG 5 - Senior Trauma Resident PGY 415 Junior Trauma Resident PGY 2/3 Junior Trauma Resident PGY 213 - - - - - Junior"Frauma-Residen PGY-'I- - --- - - --- '55 Mail- 19S-1 Emergency Med. Resident PGY 213 Eme n Med. Resident PGY 1 Trauma Physician Extender Trauma Physician Extender Anesthesiology Attending Anesthesiology Resident Certified Registered Nurse Anesthetist -._.-.--- - . h - - - - era Re T - Radlol Ra.OM - a - a w er - Emergency Medicine EMT Chaplain , OR Technician t Nurse I? Pediatric Critical-Care Attending - - - - - - - - -- - - Pediatric Critical Care Resident o Child Life Specialist ' Trauma Coordinator 1 Case Manager PGY = Post Graduate Year Original Copy - Medical Records Pink Copy - Emergency Dept MR414 Rev. 4104 TRAUMA TEM SIGN-IN SHEET Yellow Copy-Trauma Services _MffitonS.HersheyMedical CaAer :._ -- _ ?? ' --•- -• - -•- (blIage Of t PROGRESS REPORT DATE TIME PROGRESS NOTES ? INPATIENT ? OUTPATIENT NAME -TITLE I `t d tL, yti G?7Cc? -? ho Cez- C, er V 116* C', tz- t"Q ICA AiR 0-2 (U9,) page t of 1 :. j I ? NI?? IYI PROGRESV=REP_ORT__-' Milton S. Hershey Medical Center olleg Medi ?J c PROGRESS REPORT, [ ? d ??Z? DATE TIME PROGRESS NOTES ? INPATIENT OUTPATIENT NAME-TITLE A'ff A 'V f' C i . A.oo MR 6.2 (V9,) Page 1 of 1 `..4.. ...--- ---. ?. ?- - -- nom. ._` _-a- .. •- -•----- 'FV-CA- -,,,,,,,.k It 0 ?o VILA6 ?4?. h?rvt ?? - 4 L a,V? oPk 0 t?" o 33 - 3h, 0- 030-0 , - .? W4 16b w wy`-- X 4 I PROGRESS REPORT VI Milton &HersheyMeclical.Center MR h?#:,7004280 College of Meclicnie --7W''-EELF6PAY -SELF PAY IOC: PROGP.ESS REPORT ' 7177a a Date/Time PROGRESS NOTES. (include Name, Title) b Al ?? `i .ems' r4a ?-: cif 101 ?) G 33- 3 E - Lva w kd 2 0 AMMt-42 MR 6 Rev. 6101 PROGRESS REPORT • _ TT.-S3. <. ? i a fil {. ?Sr? - ?-• __ . _ :Iiwlif?M-E...yh+af _`. =` ? . _ . - ? _ _ - Date; rFim PROGRESS N ? - e) --_- Vra ? S ?lv??dl..i.t/ z ?''?•? G??I?V?/W/l G[? Y^Wi `? ?. ,L? a l a4 to at CI%O 36, Z lzecl. l ) r 1 /V ? 5 33„?i >3K .3 zog" .414 - - -- - - - - c? 4. fOO "Al lG ? c,U.s ?r . MR 6 Rev. 6/04 PROGRESS REPORT _, ?- M PENNSTATE - _ ' NAM_ piOVEH =AM - on. " . e e II Maa: 7004280, DOS: QB/18l1991 ' SEX: F _College of Medicine INS : F- PAY SELF PAY -- - - -- - - -- - --- ---roc:- .-__.. __.__ - . PROGRESS-REPEW 008 7177424 VISIT DATE: 08/08/2W t i I Date?rrime PROGRESS NOTES: (Include Name, Title) 1 (0110100 OG t 90D A.& If 03 -I'm A Y,2 ? &U,-- A 'L: 1? zed ?- A v IV (X?( S A 03 42 ?" • ? 7?? ? 3G.w rs?' Zv MR 6 Rev. 6101 Y11 11 AA PROGRESS REPORT .D/C Summary DISCHARGE SUMMARY Name: GROVER, AMANDA M HMC Number: 7004280 DOB: 08/13/1991 Date of Admission: 06108/2006 Date of Discharge: 06/11/2006 GROVER, AMANDA M - 7004280 This is a 14tyear-old female who was the restrained passenger of a motor vehicle collision for which she was brought to the Hershey Medical Center for evaluation by Pediatric Trauma. On evaluation, she was found to have a grade Ill splenic laceration without other injury. She was placed in the Pediatric Intensive Care Unit and monitored with serial hematocrft and bowel rest. Her hematocrit stabilized at 33-34 and she was started on an oral diet on hospital day number two. She was kept strict bedrest at this point. Her diet was slowly advanced and she tolerated this without nausea or vomiting. On hospital day number three 72 hours after injury, she was allowed to ambulate to the bathroom only and her blood count remained stable. Her pain was minimal and adequately controlled with Tylenol. Throughout her hospitalization, she remained afebnle, with stable vital signs, and with adequate pain control. She was discharged to home on hospital day number four in stable condition. DISCHARGE MEDICATIONS: Include Tylenol orally as needed. DISCHARGE INSTRUCTIONS: Include bedlcouch rest with bathroom privileges only for a two week period. The family was instructed to call Hershey Medical Center for any questions or concerns including fever, temperature greater than 101 degrees Fahrenheit, increased abdominal pain, increased nausea or vomiting, or any other questions. During the daytime they may call 717-531-8342 and during nighttime hours they may call 717-531-8521 and ask for the Pediatric Surgery resident on-call. #220890 Signature Line Review/Sign, Eva Galka, MD Surgical Resident, Department of Surgery Penn State Milton S. Hershey Medical Center PO Box 850 MC H159 Hershey, PA 17033 Review/Sign: Andreas H Meier, MD Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Andreas Meier, Printed by: Battle, Carmen E .ED Summary ED SUMMARY Name: GROVER, AMANDA M HMC Number: 7004260 DOB: 08/13/1991 Date of Service: 06/0812006 GROVER, AMANDA M - 7004280 This is a 14-year-old young lady transferred here from Holy Spirit Hospital. She was in a motor vehicle collision. She was a restrained front seat passenger as,a trauma transport for two issues. One is left-sided rib fractures, number two is a splenic laceration noted on CAT scan. She denies amnesia but she does have loss of consciousness during the accident. I did receive the transfer call and we declared a level 11 Pediatric Trauma alert prior to her arrival. Review of systems is completely negative with the exception of those things noted above. She does have left-sided chest pain. She denies shortness of breath; she denies any palpitations or cough. PRIMARY SURVEY: The airway was patent and she has normal voice, breathing spontaneous with clear breath sounds bilaterally. Circulation: Normal pulses In all extremities. Disability: She is alert, moves all extremities equally. Full exposure was accomplished in the usual fashion. TRAUMA HISTORY: Allergies: Only seasonal, no medication allergies. MEDICATIONS: Zyrtec. PAST MEDICAL HISTORY: Left wrist fracture. PAST SURGICAL HISTORY: Negative. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Denies alcohol or tobacco use. SECONDARY SURVEY: Vital signs stable, afebrile. General: Calm, pleasant, alert and oriented x3. Constitutional: Well-developed, well-nourished. Head: Atraumatic, normocephalic. Eyes: PERRLA, EOMI. ENT: Clear, mucous membranes moist. Neck: No nodes, no JVD, nontender, trachea midline. Chest wail tenderness In the left lateral ribs. Respiratory: Clear to auscultation bilaterally. Cardiac: Regular rate and rhythm without murmurs. GI: Normal bowel sounds, soft, tender in the left upper quadrant. the bilateral lower quadrants of her abdomen. Pelvis: Stable and nontender. . Extremities: Vascular 2+ pulses in all extremities. Skin: No rashes, no lesions. Musculoskeletal: Nontender, no edema. Neurologic: Grossly nonfocal. She has an impressive seatbelt ecchymosis in Printed by: Battle, Carmen E Page 1 of 2 ED Summary GROVEF, AMANDA M . 7004280 Lateral C-spine x-ray was repeated here in the Emergency Department. The results of this is still pending. The CT scans were reviewed by Radiology as well under our direction. PROBLEM LIST: 1. Motor vehicle collision. 2. Left-sided rib fractures. 3. Splenic laceration. At this time this patient's already been admitted to Pediatric Surgery under the care of Dr. Meier. Further information will be available on the documentation of Pediatric Surgery. 216424 Signature Line ---- , Review/Sign: Glenn K Geeting, MD GKG /BH DD: 06108/06 DT: 06108/06 07:03 Result Type: ED Summary Date of Service: 08 June 2006 00:00 'Authorization Status: Final Author or Import Date: Geeting, Glenn K on 08 June 2006 07:03 Verified By: Geeting, Glenn K on 08 June 2006 08:22 Encounter Info: 7177424, HMC, Inpatient, 06/08/06 - 06111/06 Printed on: 07/24/06 09:14 (Continued) F C-spine XR , X-RAY SPINE 1 VIEW- CERIVICAL PEDS PATIENT NAME: GROVER, AMANDA M PATIENT MRN:07004280 PATIENT DOB: 08/13/1991 EXAM DATE OF SERVICE: 06/08/2006 EXAM NUMBER: 1409845 ORDERING PHYSICIAN: GEETING, GLENN Lateral and swimmer views cervical spine GROVER, AMANDA M - 7004280 4 Clinical history: 14-year-old female, motor vehicle accident, C7/T1 junction not seen on outside films Discussion: Comparison is made to prior outside films from Holy Spirit Hospital from the same day. , - Cervical vertebrae are visualized through the anterior aspect of T1. Cervical vertebrae are anatomically aligned. Cervical vertebral body heights and disc space are maintained. The prevertebral soft tissues are unremarkable. impression: Anatomic alignment of the cervical vertebrae through the C7/T1 articulation. Dr. Rebecca Sivarajah is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: SIVARAJAH, REBECCA REVIEWED AND SIGNED: BOAL, DANIELLE DATE DRAFTED: 06/08/2006 03:10 AM DATE OF FINAL SIGNATURE: 06/08/2006 09:15 AM Printed by: Battle, Carmen E Page 1 of 2 s C-spine XR Result Type: Date of Service: Authorization Status: Subject: Author or Import Date: Encounter info: Printed on: 07/24/1 GROVER, AMANDA M - 7004280 C-spine XR 08 June 2006 02:17 Final X-RAY SPINE i VIEW- CERIVICAL PEDS Sivarajah, Rebecca A on 08 June 2006 03:10 7177424, HMC, Inpatient, 06/08/06 - 06/11/06 X 09:14 (Continued) 1 Chest XR X-RAY CHEST PA AND LATERAL VIEWS - PEDS PATIENT NAME: GROVER, AMANDA M PATIENT N RN:07004280 PATIENT DOB: 08/13/1991. EXAM DATE OF SERVICE: 06/08/2006 EXAM NUMBER: 1412104 ORDERING PHYSICIAN: MEIER, ANDREAS PA and Lateral Chest Radiograph GROVER, AMANDA M - 7004280 Clinical History. 14-year-old female post MVA, transferred from outside hospital with reproducible left rib pain. Assess for fracture. . Comparison: None. Findings: The lungs are clear without pneumothorax. The cardiomediastinal silhouette and pulmonary vasculature are within normal limits. There is some blunting of the lateral costophrenic angle, the diaphragm somewhat indistinct. A small amount of pleural fluid cannot be excluded. No definite rib fracture is identified; however, acute rib fractures may be easily overlooked Impression: Questionable small left pleural effusion. Rib fracture not appreciated on the two view chest. No pneumothorax. Dr. Gina M. Creutzburg is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: CREUTZBURG, GINA, REVIEWED AND SIGNED: BOAL, DANIELLE DATE DRAFTED: 06109/2006 10:16 AM DATE OF FINAL SIGNATURE: 06/09/200610:25 AM Result Type: Chest XR Date of Service: 08 June 200618:37 Authorization Status: Final Subject: X-RAY CHEST PA AND LATERAL VIEWS - PEDS Author or Import Date: Creutzburg, Gina M on 09 June 200610:16 Encounter info: .7177424, HMC, Inpatient, 06/08/06 - 06/11/06 Printed by: Battle, Carmen E Page 1 of 1 t Ila JUL 3 1 A 1: 3l' t 4 I ci 4 o? 0, 0.0 0 A 4 ? .4 X A UQ N CO Q ? N `.. t i • La u t r D a; r m r? v e_": 4 t o C s-t A oe ? I' Outpt Ur • , July 5, 200ti i+lmm GROVER, AMANDA M HMO Number. 7004280 _ _ DOE: 0ama 9il Dates of servlow 07/05MM • GROPER, AMANDA M - 7004280 OUTPATIENT LEI I Jeffery Dunk Berger, D.O. 19W Bridge Sb" New mod, PA 17070 Dear Dunked: We had the pie =xe of seeing Amanda in followup. As you are aware, she is a 14 W-M female who on June am was involved in manor vehicle collision and sustained a grade 3 splardc laceration. She did not room surgery and has been home sawal weeks with bed rest rvffh bathroom privileges. She is not having pain, is eating well, . having normal bowel movements, and desires fie get back to more activides soon. On exemiretion today, she is healthy appearing in no distress. Chest is clear to auscultation bilaterally and heart is - _tBguk[ rate and dhythm.. Her abdomen is soft, normjefer, and nondisslended. No masses are palpated. _ Assessment And Plan: Amanda is now 4 weeks out from her splenic injury and is doing well. I hue discussed with . her the new to mirah from significant as ivities until 2 months out from injury. We will not pursue a kftwup CTs. We do not need to we her bank again although we woad be happy to see her if there am further problems or concerns. I have discussed wkh them the potential risk of a cyst forming in the spleen overtime, but fiat I feel that this is wmlffcely. They state that they understand. 256669 Signature Um CC: Jeffery Dunkelberger, DO 1900 Street New Cumberland, PA 17070-0000 Sincerely, k Brett W Engbrecht, MD Painted by. Mahanes-Imboden, Amber S Page 1 of 3 0 .Gutpt Ur GROVER, AMANDA M - 7004280 ' Pediaht Surgery: Drs. Robert C1W, Peter Dillon, Andreas Meier, edit Kerry man, Brett Gree"r MS RDD Janet Shields MSN CRNP CS Hershey 717-531-8342 HWYoik 717-920-5200 BWE /00 DD: 07/05/06 DT: 07/06/06 02:38 Result Type: Outpt Ur Date of Service: July 05, 2006 00:00 Authorbxdon Status: Final Author or Import Date: Engbrecht, Brett W an July 05, 200619:06 Verfied By. Engbrecht, Brett W on July 06, 2006 08:25 Encounter info: 7227951*, HNiC, Clinic, 07/05106 - 07/67/06 Printed on: 07/11/0081SAS (Continued] • h ' PENNSTATE I'M Mon S. Hershey Medical Center College of Medicine To Whom It May Concern: Enclosed you will find all the HCFA 1500 and UB92 claim forms for your insured that was injured in a MVA. Per protocol as determined by the Committee on Trauma, American College of Surgeons, this patient was transported to our facility as a Trauma case. I have included complete Medical Record documentation, regarding the treatment of this patient. Perin State Wilton S. Hershey Medical Center/Penn State Shock Trauma Center is an accredited Level I Trauma Center. In compliance with the Pennsylvania Law (Act 6), all physician charges associated with the treatment of a patient in an accredited Trauma Center are to be paid at 10016 of the billed amount. The charges are exempt from the Medicare reimbursement rate of 110% of Medicare allowable charges. Therefore, please remit your prompt payment within 30 days at 100% of total charges. Thank you for your. time and cooperation acid should you have any questions, please do not hesitate to contact me at (717) 531-1821, from 6am to 2:30pm EST, Monday- Friday. Sincerely, //ncerely, ?' 9491e, (/Q/`/J' ew L, Patient Account Representative Auto Team (Alpha-Split A -G) Enclosure(s) Penn State Milton S. Hershey Medical Center PO Box 856 M.C. A410 Hershey, PA 17033 I- LOO: -VrMT-Gkl =.O FINAL NURSING PROGRESS NOTE Discharge Summary (may be done up to 24 hours prior to discharge). Course of hospitalization: (may write "concur with Day of Discharge Form") • U?lliW ! ?l 10 `' Resolution/Status of each problem on the problem list: ,c.ca, s-u r?q loo c?,#,,,(no St , IP ?tud- ?? ?,m?2• - C (?,S?fru,C?9?s : ?? ?Q?r ba?,ix ?C ? _ _ _ _ 'Medical CtAter TOOazao Mop: a DOB: 08/49/1991 SEX: F INS:-SELF-PAY -- - - - -- -SELF Pi ICU. qV.Fqti ?nS 0 14,6Z-) Date 0114 W1 V Discharge Checklist ..........explain any "no" answer below J 1. Physician order written for discharge:. _ .............. ............. ®Yes0No ._2. 1L-inyasive:lines=artddnbes -notnee a r home care ata rer?xed...r . . ._._*_ - _ N.? -- - - - _ - - - ?, --37 Ica ons brought from home are-mWmed --- - ................... ........ .._ .... ....... _ OYes _ O No o ®NA 4. r _ Prescriptions given to patent orfamil - 7- - - , No= OVA ................................ v ?w v rvH (tiatnroom, closet cabinet, bedside stand, over-bed table checked) 6. Copy of Day of Discharge form given to patient or family .......................... *Yes ONO O 7. Copy of patient education insir u Lions or materials given to patient or family....... 0 Yes O No 8. Follow-up appointment.scheduled or discussed with patient ..................... A Yes O No . O 'NA 9. Is patient weak or unable to walk without assistance? ............. ® Yes. O No O NA If yes, staff member a'ccompanled patient to vehicle....: ............... .. O Yes O No O NA 10. Discharge conversation with patient Includes the following points.......... ® Yes O No O 'NA • Strive forvery good care • Como l Re suNe in the mail -Purpose to improve service and reward staff Explanation for "no" answers: IHial Si nature MR 1014 5/04. Page 1 of 1 FINAL NURSING J -"-- . - - XZZ The yfiltoa S. Hershe• `*tedica[ Center- The College of Medi, .Y PLAN 0E BARE - ORG EST ACTUAL NANE: GROVER, ALUWDA M ??{{ b1D: UEIER ANDREAS H MDN: 26085 `"" °" DDS: 0811311991 SEX: F INS: SELF PAY SELF PAY XTENDING LOr - BRED NAME . IESIDENT Und Injows IRIMARY NURSE AGE ADh1 DATE ' ROOM )RIMARY NURSE FtEASONFON 'RIMARYNURSE ADMISSION t7TENDING N 13M MIS i IURSE CONSUL IURSE CONSULts ;;OClA)_-SEB.Vl E • - ' ?l??r `}y?• %' z7r-{y.},:?:'-rs}t' ADVANC®OIREcnvE ' 1?• '. •.ai ?i•.•`:•? w••i ?. w r i-t' •w•r•W i / YES N D t -r Z - 3ie S .?. :. ?•? CODE SLUE STAiU rI?/ CONDMO .4 s. v :c es'?e 3V t -,::.• ALLERGIES, Ngigl rs4a ' ;. •S•.. •N,wLi. `7N '.Sa. M ' jt•t __-?i*? ai'•?' Yf1?n•e!x-tel••1 V - "`? ?: 4 '•.. , ?... arob(er7tt. t 1? y? (? .L •,• X'4-r J Lit.; - - w r 't a> n : ..S. ti' rte. w?wnntil'?'w..`-,' s 1M9 lnftft 4.(M14, ,?. ILI ISM ' 'fir .,?, • .,.,?•,_ _ 1 `tf ?'?' '6a^S ?• • . ' - _ .-i' t* _ .. V ,,_t:r I.YY n r"?""' } w'?}. C N 1•.'Z j fie. ?' = S? 'tE4rA'. - . 31 7 --r A r , DISCHARG PLAN: ' Hone . O 'Nursing Home J Home With Assistance Unable to determine on admission Other Explain PL,AiV OF CARE MR,763 Rev, 71197 of Care Reviewed w ntfSFgmjicant Outer. CONSULT, , MR#: 7004280 608: 0110111900 SEX: U MO. eel c env SELF PAY-_.. Date Height LOC: EMER ime .W tie I W I 1A k Attending Dr. J/ 0 (S--y # L q Consulted by Emergency Department Dr. Resident/CRNA # PhV dr2l Exam I Assessment & Plan CC• General Appearance Assessment: IVC ? Fall rital Signs: BP b Pulse ASA PS _ E Injuries v - ? MCC ? Other SoO: --? Temp Glasgow Coma Scale = HPI: 47 Intact ? Cervical Collar in place Airwp?yy'' M-"Adequate a-+Iar&d ? Unbelted ? D Difficult ? Loss of consciousness EUW14M --- - O Needs Intubation due to ? - Entrapped 13 0 ? Teeth t Vea OW. ? Needs M AlWgIVent PM Hx: Size R L_ Citrgiation: ? Patient unres onsive due to ? Allergies React R 2- L ? t®/Minimal Blood Loss P Shock Grade 0 ? Drugs Chpd: Clear to auscultation (?, Level of Pain (1-10) `? "C- O Trachea midline Plan: J ? Labored breathing ? Requires Lttubation ? ? AE2WPY to CT Scan - -- ?.-Medical - __ __ _?? _- ____?__ -?--- sumac Pulses full n-C tributing O Tender O - PA P ? Bowel sounds ? SHX. ? Y/ Tobacco CRAW E ties:... - Y Dings Jq/No apparent fx rn n-CHistory: bntribuiing C! ` •Foiey CODE: 99241 99242 99243 99244 .99245 Form 270-106 (1/02) Flowsheet Print Request Patient: GROVER, AMANDA M MRN: 7004280 New R@SUItS Results Hct f 134.8 L 134.5 L f f LivedGI. Amylase f < Urine - ; •.. ?- Color (u) 1 i YELLOW Appear (u) ' SLIGHTLY... Glu (u) NEGATIVE Bill (u) NEGATIVE • Ketones NEGATIVE SG 1.020 Hgb (u) MODERAT... pH (u) 6.0 Prot (u) _ NEGATIVE Urobili ' 0.2 Nitrite (u) i NEGATIVE Leuk Est TRACE UWBC (u) -- ' 5-9 C1RBC (u) ' 10-19 Bact (u) I MANY,@ Blood'Bank ABQ/Rh Antibody Scr _ Spec Expires R Nuinb4 Component Type ` # Units Hotel •. .. ' • .. - , . , . . „ .. , -- •, . Containers received to hold f Studies Spine Chest Summaries Patient Discharge lnstrudons- Patient Dis... D/C Summary D/C Summ... ED Summary , Clinic'Notes Outpt Ltr I f i f Page 1 Printed by: Battle, Carmen E Printed on: 07/24/06 09:13 r Flowsheet Print Request 13=0aw - r.POVFR AMANl7A M MRN- 7004280 New Results Printed on, 07124/06 09 ? 1.7•?•w1i•J:IILI.Iw :'f' •; , 111? ; •!•..' 1 !` •f , f• CBC :; s Hct 34'3 L 133.9 L 132.9 L IavedGl ??' f r 11? t p r. r f ' ' Amylase 1 1 _. ' ? i .. _., • -, „+1 f' ' :?r , . t ? Urine ,' t •f• .rr. • r. _ _ .l' i, i f / Color (u) Appear (u) ! Bili (u) Ketones • i . -f asp . ? f 0pH (u) - Urobili ' Nib- .. i Leuk Est OWBC (u) a RBC (u) Bact (u) r i ABO/Rh I Antibody Scr Spec Expires R Number Component Type # Units Containers received to hold' i i • • •, ?:? ••f „` ,S r rra .St??s f,,• •' •f r'• r •?'•'' '7f:.. ?•Y?S;.t,' rt I` (?•; ,..?•• '.1?•• 'y Spine Chest L chest XR IC-spine XR ,Suriimaries" - 'r; , _ . •..•• ;?; • :, : , Patient Discharge Instructions D/C Summary ED Summary, 'Clinic Notes outpt Ur :13 Page 2 Printed by: Battle, Carmen E I T I Patient: GROVER, AMANDA M 1[?n?{. •?nrt??on Flowsheet Print Request tiour Roc{ Jtr ,e -- ---' I?esults? ••[• '' ,ti - a • ? `t7!!'. :TM,?'? cEfc Hct 33.5 L I , f 130 Amylase ? ! • y [-.• •? ,•h.•. . ^[f •u['?'[: 'rtw... ??. -•.t ?Yti'[ ?l?S•'•1 Urine Color (u) ' Appear (u) Gla (u) BIN (u) Ketones SG 1 Hgb (u) i . pH (u) f Prot u) • Urobili Nitrite (u) r Leuk Est WBC (u) -. -- i RBC (u) _ BB act (u) BloodBank ABO/Rh, ABO/Rh Antibody Scr NEGATIVE Spec Expires " 0611112006 R Number R18523 Component Type RED CELLS ? # Units 2 Hold : '4 r• ;t [,.? r .• [ nttainers received to hold • ' BLUE * I C o ? y . ? Studies t J: [ 2t F iar . .' ' • wly.e ' ,? ., .; Chiest Summanes ? ., f t•, 1. ,.::d'; ?'.;.,???t. 'r? .f. Patient Discharge Instrucdons D/C Summary I ED Summary I .ED Summ... qi Ic Notes - ' . .•. " ?: 1 R ?? outpf Ltr ( i Page 3 Printed by: Battle, Carmen E Pnnted on: 07/24/06 09:13 0 n t SY TEI . v UlVDA ON nt to its authority under Act NO. 1985-45, as amended'. pursuant nz?ealth o pennsy[vania of the commo .f hasgranted accreditation to Fie 32iCton S. 3jershey NedicaCCenter i which has d een surveyed and meets the standards and requirements for accreditation as a aegionaCResource trauma Center October 1, 2004 - Se?t,nber 30, 2007 • President ? . v j ,z Secretary -I t UNIFORM BILL' AOTICE: ANYONE WHO MISREPRESENTS OR FALWIES ESSENTIAL INFORMATION REQUESTED BY THIS'IORM MAY UPON CONVIOTION 13E SUBJECT TO FINE AND IMPRISONMENT UNDER FEDERAL AND OR STATE LAW. Certifications relevant to the Bill and Information Shown on the Face Hereof: Signatures on the faoe hereof incorporate the following certifications or verifications where pertinent to this Bill: 1. If third party benefits are indicated as being assigned or in participation status, on the face thereof, appropriate assignments by tho Insured/beneficiary and signature of patient or parent or legal guardian covering authorization to release information are on f* Determinations as to the release of medical and financial information should be guided by the particular terms of the release forms that were executed by the patient or the patient's It gal representative. The hospital agrees to save harmless, indemnify and defend any insurer who makes payment in reliance upon this certification, from and against any claim to the insurance proceeds when in fact no valid assignment of benefits to the hospital was made. 2. If pat:ent occupied a private room or required private nursing for medical necessity, any required certifications are on file. 3. Phy.,iclan's certifications and re-certifications, if required by contract or Federal regulations, are on file. 4. For Christian Science Sanitoriums, verifications and if necessary re-vrrificat:ons of the patient's need for sanitarium services are on Ve. 5. S gn{ture of patient or his representative on certifications, authorization to release information, and payment request, as r.-quired by Federal law and regulations (42 USC 1935f, 42 CFR 424.35, 10 USC 1071 thru 1086, 32 CFR 199) and, any other applicable contract regulations, Is on file. 6 Thi,; c!a;m, to the best of my knowledge, is correct and complete and is in conformance with the Civil Rights Act c' 1964 as amonded. Records adequately disclosing services will be maintained and necessary information will be furnished to such governmehtal agencies as required by applicable law. 7. For feed:care purposes: If tho patient has Indicated that other health insurance or a state med cal assistance agency will pay part of his medical expenses and he wants information about his claim released to them upon the'r request, necessary authorization is on file. The patient's ;.ignature on tho providers request to bill Medicare authorizes any hold:-r of medical and other information to release to Medicare m_d•cal and non-medical information, including employment c1itus, and whether the person has employer group health insurance, haWity, no-fault, workers' compensation, or other insurance which is responsible to pay for the services for which th-. Medicare claim is made. 8. For Medicaid purposes: This is to certify that the foregoing information is true, accurate, and complete. I understand that payment and satisfaction of this clam will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of a material fact, may bo prosecuted under applicable Federal or State Laws. 9. For CHAMPUS purposes: This is to certify that ! . (a) the Information submitted as a part of this claim is true, accurate and complete, and, the services sham on this form were medically Ind sated and necessary for the health of the patient: (b) the patient has represented that by a reported residential address outside a military treatment center catchment area he or she does not ilve within the catchm=nt area of a U.S. military or U.S. Public Health Service mcd:cal facility, or if th9 patient resides within a catchment area of such a fac,' dy, a copy of a Non-Ava`!abi`rty Statement (DD Form 1251) Is on filo, or the physician has certified to a medical emergency in any instance where a copy of a Non-Ava,lab lity Statement is not on file; (c) the patient or the patient's parent or guardian has responded directly to the provider's request to Identify all health insurance coverages, and that all such coverages are identified on the face of the claim except those that are exclusively supplemental payments to CHANIPUS-determinod bennfas; (d) the amount billed to CHAMPUS has been billed after all such coverages have been billed and paid, excluding Medicaid. and the amount billed to CHA6IPUS is that remaining claimed against CHAMPUS bensfits; (e) the beneficiary's cost share has not been valved by consent or failure to exercise generally accepted b•aing and collection efforts: and, (f) any hosp ta'-based physlc:an under contract, the cost of ;,hose services are a coated in the charges includr>d in this b,1, is not an employee or member of the Uniformed Servicos. For purposes of this certification, an employed of the Uniformed Services is an employee, appointed in civil service (refer to 5 USC 2105), including part-time or intermittent but excluding contract surgeons or other personnel employed by the Uniformed Services through personal service contracts. Similarly, member of the Uniformed Services does not apply to reserve members of the Uniformed Services not on active duty. (g) based on the Consolidated Omnibus Budget Reconciliation Act of 1986, all providers participating in Medicare must also participate In CHAMPUS for inpat ent hospital L ervicti provided pursuant to admissions to hospitals occurring on or after January 1, 1937. (h) if CHAMPUS benefits are to be paid in a participating status. I agree to submit this claim to the appropriate CHAMPUS claims processor as a participating provider. I agree to accept the CHAMPUS-determined reasonablo charge as the total charga for the medical services or supplies I.sted on the claim form. I will accept the CHAMPUS-determined reasonable charge even if it is less than the balled amount, and also agree to accept the amount paid by CHAMPUS, combined with the cost-share amount and deductible amount, if any, paid by or on behalf of the patient as full payment for the listed medical services or supplies. I will make no attempt to collect from the patent (or his or her parent or guardian) amounts over the CHAMPUS-determined reasonable charge. CHAMPUS will make any benefits payable directly to me, if I submit this claim as a participating provider. ESTIMATED CONTRACT BENEFITS -,PS HERSHEY MEDICAL CENTER 500 UNIVERSITY DRIVE HERSHEY, PA 17033 747-531-5218 TAX ID 251854772 DISCHARGE 06/17/06 GROVER AMANDA M GROVER, EDWARD 739 DOGWOOD TERRACE BOILING SPIIN, PA 17007 060806 SPINE 1 VIEW ANY LE VEL 060806 9 PEDS SEMI PRIV ME D/SURG 060806 HEMATOCRIT 060806 HEMATOCRIT 060806 HEMATOCRIT 060806 COMPAT, IMMED SPIN 060806 ABO BLOOD GROUP 060806 ANTIBODY SCREEN 060806 RH TYPE 060806 AMYLASE, BLOOD. 060806 HEMATOCRIT 060806 MORPHINE SULFATE 2 MG 060806 ONDANSETRON 2MG/ML 2ML VI 060806 IV DEXTROSE 5%-0.9 SOD C 060806 ST EXT MICRO 60" IM L BASE 060806 IV DEXTROSE 5%--0.9 SOD C 060806 IV DEXTROSE 5%-0.9 SOD C 060806 URETHRAL CATH PREP TRAY 060606 BAG URINE DRAINAGE 060806 FOLEY CATH, SILIC P ED 10 06OaO6 PULSE OXIMETER SNSR ADL 060806 PULSE OXIMETER SNSR ADL 7177424 130.00 i225. 00 17.00 17.00 17.00 134.00 20.00 45.00 19. 00 42.00 17. 00 3.00 54.45 6.00 7.00 6.00 6.00 4.00 13. 00 i 0. 00 11. 00 11. 00 s • ' - f 06/08/06 06/i1/06 06/OB/06 06/11/06 7247 AUTO INSURANCE P07621687O6 TRICARE 54098Si65 MS HERSHEY MEDICAL CENTER y i 500 UNIVERSITY DRIVE HERSHEY, PA 17033 • 747-531-5218 i TAX ID 251854772 DISCHARGE 06/17/06 GROVER AMANITA M ¦ T 7177424 GROVER, EDWARD 739 DOGWOOD TERRACE BOILING SPRIN, PA 17007 060806 ONDANSETRON 2MG/ML 2ML VI 54.45 060806 CHEST 2 VIEW A/P LA T 138.00 060806 EMERGENCY VISIT. LE VEL 5 559.00 060806 IV PUMP, SINGLE LIN E 3.00 060806 PEDS LEVEL II TRAUM A CARE 1403.00 060806 ROUTINE VENIPUNCTUR E 16.00 060806 BLADDER CATH, SIMPL E 132.00 060806 NONINVAS PULSE OX, MULTI 90.00 060806 ONDANSETRON 2MG/ML 2ML VI 54.45 060B06 ACETAMINOPHEN 325 M G 3.00 060806 T INTERMEDIATE CARE UNIT 1485.00 060806 T INTERMEDIATE CARE UNIT 1485.00- 060806 P PRIV MED/SURG RM 1180.00 06OB06 P PRIV MED/SURG RM 1180.00- 060906 IBUPROFEN 400 MG 3.00 060906 OXYCODONE APAP 1TAB 3.00 060906 9 PEDS SEMI PRIV ME D/BURG 1225.00 060906 URINALYSIS-BASIC & MICROS 36.00 060906 HEMATOCRIT 17.00 060906 IV LACTATED RINGERS 06/08/06 06/11/06 2 06/08/06 06/11/06 7247 AUTO INSURANCE P0762168706 TRICARE 540998165 ,MS HERSHEY MEDICAL CENTER C= °: 500 UNIVERSITY DRIVE ' HERSHEY, PA 17033 • 737-531-5218 TAX ID 251854772 DISCHARGE 06/17/06 GROVER AMANDA M 7177424 DROVER, EDWARD 739 DOGWOOD TERRACE BOILING SPRIN, PA 17007 06/08/06 ' 06/11/06 06/08/06 06/11/06 AUTO INSURANCE TRICARE 3 7247 P0762168706 540988165 1000 6.00 060906 IV INFUSION SETS UN IVERS 8.00 060906 I V SODIUM CHLORIDE 0.9% 6.00 060906 IV DEXTROSE 5%-0.9 SOD C 6.00 060906 IV DEXTROSE 5%-0.9 SOD C 6.00 06006 IV DEXTROSE 5%-0.9 SOD C 6.00 060906 SPIRO INCENTIVE ADU LT 7.00 060906 IV DEXTROSE 5Y-0.9 SOD C 6.00 060906 IV DEXTROSE 5X-0.9 SOD C 6.00 061006 ACETAMINOPHEN 325 M 0 3.00 061006 DOCUSATE SODIUM 100 MG 3.00 061006 9 PEDS SEMI PRIV ME D / SUR G 1225-00 061006 HEMATOCRIT 17.00 061006 DOCUSATE SODIUM 100 MG 3.00 061006 IV INFUSION SET, UN I VER SA 16.00 061006 IV DEXTROSE 5%-0.9 SOD C 6.00 061106 DOCUSATE SODIUM 100 MG 3.00 6884. 35 6884. 35 BECAUSE THIS FORLI IS USED DY VAR:C ,_-WERWIENT AND PRIVATE HEALTH PFOCRAI...$EE SEPARATE i.::ITRUCTIOP.S ISSUED BY APPLICABLE PROGRAM ' NOTICE: Any p. ,on who kn3 v,r Tty nt of e'arr eor+r, tmrq I n j mr.rrfa.?. ?fttJt^fin Qr.rr,y 3r, cc rp or m, ,'_.:?m•a tnfotm:a-on way be guilty of a criminal :.rat pvrr:_habt? uod,:r laa .•nd rr,Zj L,•'.ubf-ct to cs.d p•?a. REFERS TO GOVERti'tENT PROGRAt*3 ONLY tAEDICARE AI:D CH-r.IF U_ PAYt"c-'.T;t AF ' " I t I t ' p t t x r th-Cl raw-rd I: r1 It-. •tr It1' fr 1•. I: : i t -+ l1.' If., ___ -jr:T}' • 't' l C' 11 t.' : r' -i ?, :r •r'_(., iU`'_'tz. .Y?11 .'•j (,(„1 t3rr 3 ,.•r-., jf+_r„ .:. di' + 1 ?, r. _r- .? r •? ri: , t' :it sr. ,i ?_ •(i 't ,t r,_Ur.y C . L: t t, r,:, f •1. • „ '•r• : i , :1:•t c r. ,r. _ . 'r_:t . t• ' t. F , I:'t _ •: .. : t t ?" i • ,: j: • 4:' CFR411244-61 it,.-nrI1 rC,: i I F IV 1) it ,c dC• CHA41PUSp,em;.p.x:IncI tt-pli, ..r,' ],. r. F'h _ i ' :1,:`r f' 1 rCH•? Llj) rd f`.,• p.lt.:d 1 rf . con b} C'r. '•: I r: C: ,: ^7 Ir•• .1 _".._ t + y q: •r t` d IL'(Irtn,ttonoft- f.Iv' C,r-rc'CH'!"gt.1. I 1, r ttl _L i C14If.'7LIS, r:• tY ni- _ p•c•+-,Ttt,t m;R:.plymsrtf•?•F::titt_r•'•' F•c,.l_ it.tctiI c• It it-'.:'n Jc l:::rr, • :-lent' F - : it p'e.,_ a II: r•r:m:cl0or,din Ir._,ad,1.• 1, 1, I, ri11 BLACK LUNG AND FECA CLAP AS Thc•pro'nd:-roan, h. _,I F* it T(-J.•p 1t,i C:. rrr? `I'. fi ,- r••nt,_ ° ,•EI : Lu`,? 'dFECA• •"?- - nl.'r.`"1rL`. 1Fcc•. 1 oic.(In3• I.: GCdiol Sy fa r SIGNATURE OF PHYSICIAN OR SUPPLIER (L'EWCARE. CHA*.1PUS, FECA AND BLACK LUNG) Icl+rbfythatthr^• r.1': . ' ?t7.:ncnitt to-i:. • n 1,-- f:, .^d _- d I-1r : r,'•: h , •ntftr. F .t.. r• -, j..• F. F r? i:.r 1b, r, c f n •: d td•-ntto m,tpful.••, yr ,1,• r. b, r, ,,n; ' r,"•. •111: o. -: C , 1 t, t.!_ : c• CH' ":FLIS _'y ?^,, ' F .' I:.:,-,_r • •F _ , F '? " - r•,'' tria rL" L1'4t gin. For -r!•fJICt•4 to b- ccr_.td d if rn? 1 ^i !0.I F°,, .1 pre', .1: 11 I' •j M,'1 t r• 4 r. 117- it Fy, 1•:r r,. tr^ F I C byh:'hr4rllq?lp}c,,2)1i.yrr,.tE+:-ii-I q-1 r.lhi-.•.'1 Y IF riclacO.••f.1p?y : 'n, r.. ?Itr rmu It •c•t d"F`r : f1_ of**«_ and4?W.. .r.'1 cfn_r,`,r _ -.rcj'it, _ yC'i t: •F`, : n •t1' For WAIVUS cl-sm -,. If At',•rp'td,r: ii(4•,+,, ir_';,,• i.r -r)rt i r.: ...7rra fl:_ .. :,,',IT 1't: fcfl.,.IJ' `r. C .I._.' II. T•-'3, of tn,. Unr,,,d St. G3.,•rnm nt C., j ,"v, ,,71:y, . C't:. l l' • 1 .I C4:. fr: 'd . It, C . I C r 11 11• r, i n •1, •• I-) VZ-C ?• •?'. I FCr LL' I , T I furtt'1:r c, 41dy th d ti- r %*-_ F ,rt•_'rr y .: r, • fcr a E . L' Lv i-r 1 : Jo Ord r No Part B PA1•drG/r.• bt lAt! m q b . p' J vI th, . r, : - I.. j r, i? ', d t, • • !.r 1 I •.:'Ii r..1_: 1l.;,'1 , 142 CPR .124 -<2+ NOTICE A.nyc•,-:.homr',-Vft .ra O't. t-1' ` n•1 ItrF?'rr1 , _ it? f• : ., p r,:- rtt-c-1 F, : i 't„-.] r••:;. db, it - i:rrrirr, t, t,p3r1 G: I. to for.:' .•rtd .rnpr o•rrit rlt u'ra. r •C rl :.-40, F, d r -1 I... NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF t.'ED:CARE, CHA OPUS, FECA, AND BLACK LUNG INFORVATiON iPRI•:PCY rCT.,TATEf.ICNTI ..'? tn•,w'rr.r,i•Jt,Clt. CH i.','U;-IG.Wf, ,'. 1 ... ) ,1 - tc't •• Chl-••t'L?_ FCC '.1E.:I Lvr1 Fm -'smm' R 'n: ty t? r{.11. ]I rr1 _r^r • .'I r i _ .1 1 1, 7. 1 1 7' .' - :.. J .• CFR 411 -`.U it 1 .1'4 44 USC 3101,41 CPR 1tt1 ,t I Itt V_.C 11,71 i 11.• U_ ,i,i1 , I 1 r,1 •Ji i _! U_C •1:I L O 17 That Inform: i• on ,.: Wo n 13 cornp CI 1 r: r1^dcr or n, 1, 1 to;& ', }:J .'f ? tJ C _•• ',T ; _ .r • , cl,ry 4, .. ; :IL , tt r , _ , and r,UFp : )4u r1-:• v.,od r,.' cut:- r...i b, t' •1• p':11 P1 to tr th it p'i•r'-t r yr, rl I : rr .v Thr: rrforrr -.,cm rrt,, I'• O t... n ..,n to Oti'• ` pto%-d of r..J L' •r, -r•. r,r, rr i s I r, t = -rte f, f'-i Fl i,- t d c-r., •r c•q n zzA:-. or FI,! I aT'A:4:. forIn", fit, diI I A,-1-tt Is, lioncIFt d r,1 u. _. it,. Ir _1 i. ,:% 'i rrd t' , 1 .17 I r•f tjF. t'', r. I -ft 'r.1,- c,it•4.1 •'r_: .': r toadrr.ni •rit ,Tt,PreIyrr. ForL•'mal• irr.f;t - r, Yr,tod Y:tT _•? .:'.tti.t r ,e'-1r u' dto.t1-0 rt.'c'd::'c• Ad:i%r.'c.:: u•, :,r.• m d- tt.rcu* rrut r:• u:: far Iri*?'m .i':•, c:'i .t, n ;:' r• .. FOR l:'.1:DICARE CLAIM: E• th„ rlntle rrdnt '11 , I -t rl) C1' Q C.rJi t i C rr • • 11 1r. m . R _,rd r n! J n •, _ ' R. 1,101 C-5 No 177. p: , 37°4,?. 4/t d &,p' 1E 0:9 C'. u;d. r d. -d r, :.tl y FOR OVICP CLAI :1S: D, p- rim it r_f L it 3r Pr,. ' : j -::t C419 74 R F `.1.3 '1:o C•• I:. • cf P. :crd' ' Fvd r Il P• ; 5 N:i :0 W. IF h LZ+ 1505, S• -ESA-5. ESA-6. ESA 12 E414 1t, EE 1::i -- v: a. • J .-Jr. PA. V. d FORCHALIPUSCLAI"IS:FF&J'IFLEFURFG-F;4Si Tot . 0 1, , tvt •i, t•:'rr 1:1r, '••F•G.tJ dl),r,.t't r1 :j,-_r- •'1.1131 p,,r nl, :tr ?•:' fi?-fit of rlr'{ t:r6:i a'td d• ;• rrrtr• +t'3n ti t t ; roc .u p ' r, : .• •1. I_itc `z• 1 t',' RCk!TR:E LISEtSt Irf:•rttt tt 1 hem c: I,,Ti_ . r.1 F. y d,::'Jrr, 7: ra If t, t,... - I to fr, • C. P1 of ,'. •_r r_.1+11 Ir 1i D:;.: Ct P , 'rtt.,'ri H,.rr , , r. • rd c• ? . toi C I:• Cf J _ t[r I --i01 • y I!''JS r. r,. t._ IC 0, Lr,d, r CH CHS1.1F':IA t :nit Ir t. q al:rr .rrr ro . r.., r• 'f th•• C`+'•Ft. Cs Tr-,r•: Fw?lt.r G-1 c•.'- : tl'!S._cr:llrrcfDif•n- rnct.l.:t.3' .1r?l,:.trr• r•.•'R ..r,J' • r. I:% Cn_,' z'Ch -I 't: f',1,:,:- -.;,r rr.j,'.'til..-.,: -_Once- x-pT.,it Cldl r1_.. Jf d t0 t,Qfilft `'' x1r, ,I 1r,11t'• ' rn rf F,7f, t0 .ntip,••tr , r" :t t't • r• {L t 0 i'' , F•'• .7 i3 .:! 3m .t r•'acrd F f r hr,::C,?' . Cs : !C , m f, b rr I-• 1o ct<<:r fad:nl. Lt.,I: Ix:'' f•,r. 1-r1 n3.,:•,,m '•• . ?cr p . d @t r r- I _ rd r' . _'i I F',3.: ct r_• o1 r .rL rt to 't.' -.r :t 01111• ,d,idr..-dice fr.t4d.pint.m.'-,r,. r,rl•1 :1-nr, 4] It, .,' : F 'r•. ...F'c-1 m r•_:,',.t: •?ip11,I„_ ce:'ot:.•,i•1Cft.r 't 'r1c cr1mw.:I iit:tA* i r,'--••?i 13 It.. c;,, :•n t' GHQ!. PW D,Sf Q$?3_.'oh_rt r'y It:. r ? ,:a, t3F 0. •1, •nfcgT-101: 't r• J" 'I C'• I,? np,rr.: IC'rr tj r,. ,.t In: fofN 'T+ a'iin- •e.1 c. ..,•_10% to d b''o.,tfri'.'ir•'r•Op•ri.l .Lw:t,•rtl en .11•r,:L I'?f.t _1:,'_'j,i.::r,7 ':1 H::.' ., t,i''1, t3f.•i `.."i fT.[ 11r, ?:'C.'ltrd•(n •: :, L: J• d or the amautcham, d. _Odp .1pt,ti •-.tr*I IM Lrj •rW Fr: ,r. F L•, t?fl:r `t. ,61 :Cm ._".. r r ofd -rr•L .it ? d, ,t F,,rrn •rt 01 th•: ck•Im F. 'Lr to p o. J r 9r:, I it; -I L • i I tEC 1 C: , 1 t !' , r• i r :ns:r :1 Itt m:,nd'sh3;ylh't)i,3t• 1111 d).,,}r:?;:it .t +- h 'p11rI n ,rci r1 •f:rp,,. ?1Crg:?'t ^t , V tll2 f3 sitSi: E :'J'am yA'_I 1131 USC 3c )1 3312 pro. it. • p. r ;•.. f: .. t. :.? ii tt• ,,'-r,r ,,•, Yelrh t+ ,.: ?r• 0. tP L 1 r3 _'].f tt Crrr,,t• rt•.t'•itr',1 -JPr1.. CyP1c' :• .-iAzlctl_ i t: t; 'r+.), -rar.• t't3.,.n'yI (: r nit, .'trCfG3 rpe..r rr,.-, ??h•.. VEDiCAID PAYLIENTS (PROVIDER CERTIFICATION) Ih"t•'GI ir' :'a }• P` :_'G r. r.• r, t3G _°r •lu , ir,•, ,. '10' : Fr,. d Jt3 111 Lr'c: tt"$ d. .T' :.r11p'J 1:'1!3 L'n rrfCrm-• on w-, xt•-i .-r F. yT C:,,rr d to, p':. _ ^1 :•I .•: :, C' U r' of P . '1 . rd H.,fr r , E•.. _ fr ., r• q_ I Ifvt?l•_r:,i•r ,toaec.ix pty,r at nit- I tr:. l p -,J dF'C1 mf_(tn3 fj.1 T ut'min dryp I, r^_rtt tl' rtli. t1:-..-r.rn . 'itr,•f ,7tt_n Of,1Jtt:onzc d d'dL:hb' . CL n: v. - ct C4 P.., .1-1 nt 3r • rr't cr CO ( ` + I' •l rt dl SIGNATURE OF PHYSICIAN (OR SUPPLIER): I o is', In. t it, r, : • , I 1 It 3. • r, • rn 3::.. irt':..,,: _ d ,r d n,.: t•3 in. t•• 1101 jr'1 F rt r J i., r. rrr•or.-A furnt.I*. i t; R• •,' m, o mpl:,• , 1. r,! r rr, p o-i.11 O.:: C' cn NOTICE Tn- tUC'•'rs 1`,•t f.r, 1_•1•t':r0 -r.-a•, tCVr, •i C.:-,c I I:ra .,,r1t ,l -t- -J . ! I- c. -t...t I-c- F.. rd f ^d' ,^d•`? r,4 C'v -ii: - -n. re :. C•- - 1-. 'i•:1 iri If v I,t- r-c :,: yr."_ 1 Cr _ _ .F,•+, ,Cr; , , hl ClC r•1 iJ tf• F' ., , R r,I • •t ,n •b Ji)r, :.'d t:• .'- - i„'•i`rr:t. :n lr' ` 't'- 1Ct:_t I•) I 111 Ti• ay l}•,, t r . : _it r. (. r, r'. I,, .. ,,, _.i,. t.••1r..:•?•: ry '•rrt a:it,,r ri,.. r iI_rr c, I. +t, re , r- .ii- _'J Icr'.1' a •. .r-?• .rtt 1 f: r, F: C"': 1, 14•:.• 7_`] :I • , E'--• . nii C• ..?r, t•, ',' r.J 21:.•,-11 _:i BECAUSE THIS FORM IS USED BY VARiOU „WERN-MENT AND PRIVATE HEALT•FI PROGRAt1: _E SEPARATE INSTRUCTIONS ISSUED BY APPLICABLE PROGRAMS ' NOTICE: Any person who kno%Wngly files a st3terrt:n) of clsim,aontilmng any misrepre:rhtation or any false. Ipcomplete or misleading information may be guilty of a criminal act punishable under lacy and may 1:9 sub;act to civ7'p7n, ftr?t.: REFERS TO GOVERWENT PROGRAMS ONLY t iEDF'.ARE AtlD CHAk1PU6 PAYfdENTS A p-•ta nt < <inn itur.• rxgU, • t^ t-,:rt pa;m1 nt t• • m I.- ony , 0i,:rav: W..tc•. +?f ..ny ,r`a•mltgl r. ?,: ?ry to pro:-.,:. p:.;• nt i Z ?.+ts.•r f<: Cl : m.,-j!` ntl•?: th.it tn: Hif3rm ;tt:1 p•o.td- d in 6•:4:: • 1 it••cxlh 121_ in.:. ' :cu,. -1- j co r - ' • in tr • c ; e' t t.1_ci;x,• c':..r, ti -.t.thc Iz-_ .n,, r:t; tor.! • +tot".d,•.'.+rr•m•'dw,i: r•ir•:nrr dn:.d ri`o:rr ct,or,.trxlJdr i+.^p`,,r,••: 1"*. tu'. + td :h•tn•rtt.•p,_r anfs.; ,•rpdoy+Knrouph•.'rith _' .n' 'Jr iris- ' b t 1,, r0 t :.tt'`:.U•ti•: r : 4:4r F,_r. vi o• ent• • h1 d„r, f :+• :.ii 'h ,' rr -p`-r k? _ :a p ,, for tt •-•'f. 1Cr,&tch tr ? t t• •a:: rr: i ' •,1t 1 : rr.•L•• E'-,• Sy CFR 411 "Ai II If d m 9 t• co ipl, f d tt p• is 1t'' +J'ho•+z, r•-1, . . 01 tr,: ,r`:•,Tr : zn *o m. • 1 . I.1 p' ri t• , -is-n:r :';osn In M.•d :Jn• u.:tint•d or CH.'%IFUSp -rt up tt?nc, , IY F', -,Iow. % to -cc, ptin r_h.in, x+l•;n',r:•,anotit •C +'x'!:rrnfiR•CHAt.1FtlSWC I1't` ir:r-',.r;,..fl,f•.otcha•,;•, - j !t:. p it r. It.. pen Na- c-4, tar in • d di c ti,• e,ri-wr tic. .+1i nan°o.• r«d r. c•-. C:'r ur in_-, - Y^d 0, d• d,icte- are b"•:' d Lp:1 tai • d;•:ri: d, t rrr.tn,+ on 0111, • r• •d •: ••+• C,'rro ,r or GHAMPUS t .I rn.• rrr d+. •r; f tr i to in t 1' r , r,1.1: t.t:nrh •d CHal.'`3US t : net d h,•,+,Ih w' 1, r.+1r • pre -jr-. ri bl,t n:, t,;- ortfarhe '+flab.:n..fth.pro.,!.dfrrr,lhvrr n•,'ta,lt:'t r.i:• 1-fo•mrtrlGith, p P,:rt':p:;:Gr.1x_J'dt' po.•d 9ntro - Vvwc.,ptortdm In.un•d t,•,+It rr,la S.I,,./.9.nnd11 BLACK LUNG AND FECA CLAIMS TI'•,• prov-6•r, r • •_r to acv p: tl tmaJtil p;+d ti; ti a Cto:xrnrr,:nt,, • p,, n nt'n f+..- S- . F ,' Lu•? ,end FECA,n :tru?tten^ rt,-t:•rdx? r?• :,r• d p•Qs cd,trx' :1d SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE. CHAF.4PUS. FECA AND BLACK LUNG) h::"1`;t^iatth•::?r.cc, -*ty.:no•tth,:fcrm:,, mi.dt•.•Ilyrn:hokd.rdn, -.rjtail-"h+.•P•, ottn.-pal-ni:.:.d%vrep-rrorahyfhrrr..h:•db;rr,-or rr;fum'h•:d nvd,:rttorrypro`.- .-ion. d•+-r.•c,•by rry,•mp:0,?+'und' rtry imm.dt,Jt,•p r• -J,up•r.I-:n + •r, pt, cif ,-r.+::• x•p-x_A; p-1•rrrttr•dby Liz :h . -ecsrCHAMPW r-6 qu`of en Fcr :,: r. tc:.•'a t, a7n?ldarF d .l tnc d' nt to , t phy: •cl to _rpro`s,. ton iI •r.t:,: 1 } th_y rr t: t b' r, rd• n d us, d, r the p f; cun' rt nrdl.Y; p -^a1. d rt•3••"rrr' an b; ht:hrr._rptorx:'.2lthrym:, tb ,1~tlrn, ?a,?.A•hzJ,fhllc•d 1':Ip-.rtof,lct,.rridpF} t?_n',:,•r,cc.3tth.;mi, ttoofknd_conn.cny+turm...hxdtoph}-r7.to. ut'K c.. '•rd 4) th••:?rlc+ : of ranphyr'cll1: mua b•' I1CIJd don ih.•, ph, I:r m c b ll:. ForCHALIPUSclaatnt..Ifirtfiac, rt,fyth.It lfor : ny+,mplot•:'-)*,h3a nd• r, d • r. •:, •.+m rat: n.:fi.•:dut; m•ritwraflr •Unform,_dS'r.t:t :or,ta. I i1x•mployv of tl:•: Ur t-d q +h :- Go.,rnrn,:nt or a corrtr..ct t ipia,, s- ct t 110 Unit--d S• l%- Go.,.rnT nt +: t•-• r c .dun or rr t irif (r0i. r to 5 USC 5523) For e'. ,.?,•Lunq c'a rr- I fa•tn,.r ,:•_r11'yr tai d the n c : p, rf,•,ll d .: ru fur .t El,.c- Lung-r, '.d• d d•:orci: r No Pert B 14••c c tr,; b m.1; top :rd Lilt. . thr. fcrm .. r,-:e,:,• d tv r,-qu •,-d b; e' :•11 I I.: &rd rcq:.1lLLl:, (42 CFR 424 32), NOTICE An; om' who rr • -ri prvr r no ; orf,,*.,t., s •_^ -, ntr.l Inform. •han to r, •:,-'.. • p iy m--nf frail Frd, red funds rx qt.,: -it- d by It "form ma; up_n can: ir-! cn b-• T.t,,ty,,. Ct to fl^,• :tnd ,m,,, -orw-rt ur'd • :,pp'I<. b'• F,.;.,r,,, I.t.v . NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE. CHAMPUS, FECA, AND BLACK LUNG INFORMATION (PRIVACY ACT STATEWFUTl l7: r,- so•r ?rtr••d W CV3 CHahiPUL'• . l10,WP t-r , , :•u leer ,n'. r?., ,', r: r 1, i In th• . JTI 't •c.r c-i cf tn,, 1.1. _+ - or-, CHWPUS FECA end P4.4 Lung p•r•?•.•r - Al's'}n';tocc _•:t,'`: r. •1 1.1 : _'I"itj'.1 1"-.? 1.:7? -41J7$r.Ith•_._ I,`. :•--:ri-.t ar n] 3 42CFR4112411) ,nJ424S!,%)(t-), ••ri 44 USC 3101 41 CFR 101 t t aq ir,d 10 U`40, 107-0 rd 10 •,', 1, U"'.. ,•141 •.t , 1 .110 .20 USC 'j01 , t ,••q 25 USC 113, E O r+: 17 Tn-: mfwm -lion ::: obtain to compl. e cl im , u1d. r the: -,: pro-Irarr . t •. L • d to Id. n?? r you and to d' •••rr ;?• • your + ',1tb ty It I : a? •o used to d^ctd 1f irw z• •n cx s and s upplrx•': you rt-cr4, d air eoir and b; the^,_ pv.?r.+m ; and to in--in, II, )j prop, •r pa,mt r,t I, m, Id Thy rtform. ttt,n m. ry al: 0 b,: n t ,:n to tin,:r p•a: d• r . of • • n rs ^ . c m r . n•• rmcd trw- m •jr:al r• .I• .. tk.+rd h• •a.ih p'.;n; and xuh _r wnantz. uonr. w F+•? • r -s,'1• •rc•, : for ft- t',tr Ctrw •.dilinksi thon 0' Ft•dv-41 p,o, r•.on: that rr q4 r,, oL:. •r trwd p.lrt • • p• t,,. r. to p t; pnm.lryr to Ft:d••ril p-e gr,1m a: •d t+then.r •• nez?: c..,ry t0.dTi1t_••rtr,.:„proq^r•a: Forei;mpl: dm.tyt rn•:,:_: r, todt c- • ,1`arrr.'f?n:•b.ua`+ b-n ft:,ciho. u -•dto.tho:pIYord:ctcrAdd ' irla!d.cb.ure.. n • m.6., thro,.rnh routine. v-. for information conto n•.d •n ; •t, •rr • of n cc•d , FOR MEDICARE CLAIMS: S-w the • natlce• moddy,nrl .,. tt -n No 0170--Sri l . t.tb •d C .m••r f 1 di:;aw C1-*tvn. R s-- wd. pJbl, :r• d ,nth! • Frdrr:d Rr 1 ^rs r Vol 55 Na 177 p,j • 37:•40. VA d S•-'pf 1:: 1') 01 ,% . Uoalsd e-d wp,Jb' t • •d FOR OWCP CLANS: Dip-trtm, nt of Labor Prtc.,cy Act of 1974, R, •pl bl•c't'ton of Notic: • of Sv, !-m; of Records ' F.•d•_•r A Fk i, -t. r Vol 55 No 40 1, od F, •b 26. 15$). S'.t: ESA-5. ESA-6 ESA-12 ESA 13. ESA-33, or.l : ard:d-d and r-p,itlt h i FORCHAMPUSCLAIMS:PRINCIPLE PURPOSEiSrTo!:au:'• ellibilityfarm'•d•cYlc'Prpro-.id•.ibycW,i,m-ourrw-andtoizu' paym_rtofon!:'.k'1 hrn1t of ckq bdI yr and d:.?rml1: hot th:,t fF? s : ?IC• Lppl •_ rcc, r.. •d t; ;t?rrz: d Gi t.:r. R'?,I: E? 51 Iniarm.,tiL?n frt?t d. tin ; .•r,d r• I tt. d dC :r.rrr rt mgt; k : r..,. n to 11 D. •p: of :', •t •r; r .. Afta+'.• the.-C,.-pt of Htt i •1.•rd Hu•n.•n S 'rac-, -md or lh,r Pept of Tran:.portetmn can.,: 9 ••t :..th tn+ r t, ?tt.to•, ._dm•n as,, mw• n:_ par a o:. t t.r d, a CHAT. PU3 CHA'1P•, A, to tn? C• •pf of .fJ .t x !tr r..pr, .: r' d on of th.-S-err'••r;ofDef+'n.:rncivil,YCtron^.loth"In:,•rn,IRrmrt.+l•S•.r,rc•:.p•tr'jt:•cait.,^ttcri.,^-n.,,- crdcon:rlm,rppa*ttr-1.•rk•n.• +n corn,:ctinnwthricatpm-,rt cl.,,•r :. end to Conn- ..Ior.4 Oftrcr in rr cpon_ :• to n t mnE : m: •:'•• • •t Vol— req Jr -I of it,, F, •r vi to •:h7,m d n cod p -1a 1', PEprcp- fe d :,nr:. rri; t: rr. r;•• to other fi d. ml. st.Vr• loc-if. fwiinn wit rrm:•rd ,igvticI+••, prtc Its • bu art,., • rWitn Ind ttl?r.t3J •1 pra.•d, ^• of c?rr , on m ter rrcatmq to rr>•r.:.•rr nt. eE amr. a Jd c +h-n fr ud. pro7r.,m •tu :e. ut zatt -1 n v+ • qu +'.t,r rt., ' r,,. ,, prenr ,in r't_rv t,. IF rd-p .s,1, hater; co•:;d•r.Y. art tt t-n. l • ,. odd c . t :.ry criminal httjat an It'latxd 10 th" opt-r.ittan cf CHAIAFUS p! URES Voh,nt,ry hc- ., r.f:dtyretopio. dx•+r•`o•rr?•rn:rr?r. if[ind_1.1; 1p•i,rr norm ;; n -uRtnd•n+.n.'o'c', m WrYtF:, oi--v-c,-F:on d',:u '•rd b• hrv,tt++•n •tr?nop n:+a urd.,rth •,+3prasntunlaforrt•fu:Irnyto•apply i-&xm,ition Ha:: ., r.f-,d?rx t0furrn hlnform,tUOlr?,y d:17th?rr• att•tl - r, cd• r•_d w the amount cI-ixq•.d :.o+.ld p-r., Yt p,,,mx nt of c,..+m ur+d• •r tl' -: •' prei, im'. F; la•, • to f .err• h ,•i, c-h, r .r ;xr ,.,1*n r.L&1, : n rT, • ar C im r,J-nb r ... , J d I',; p.ty,r,nt of 1h,: chum F.4un t0 pia. der medr: ?I tnt ,r,1i han trrd• r FECA ctl'd t: d m ••j .•a at •lru? tn. It, windatorrthAyouldlu:,f}aaFrc::H1.+t.+ra"t,•rptrt,+l:rr_:p•1_.,I:•fiXpy 1?fr?ryc.?rtr, 'rt;tS•aotil2cBoft`::: C USC2:01- 3312 prov-dt • p,.sn N,_*. icr withholdmj tra , nform .:ton You .hroL1db,-x.var,'ihntPL 1t)]`03.ir,:'Cr?mpu•crtidcfirh ndPr.. yFret.ch:n ActC•'1:': F nYtr ti:r0.:rrrrr ntb:••r`y,rtLrrr ',:nt,:,.,ofcorpvt,•r mat:hx. MEDICAID PAYMENTS (PROVIDER CERTIFICATION) I I•h••••by vklr,.o to keep such r, cord- a:.-1•e n c:'. :a; to dr Clr,v Ee , it•, • • • t •,-t Cf :,• r:.:• . p+o.•d 9 to r•13 .rd.tal.. ur1. r t'- • S• , Tit : XIX pis :in o rd to faint h inform.dtan rsrlardlnq ,,,ny patyrrr•rl. clalTi d fa• pro, ;I-I w:h .. ; . c, :.• : t,'t • S•, t• r c• C p, of H ._.th l1d F'JT. -,.:.r.,:?:• rr ,, r. c,,-: J Ifurth:r,,r1n•,rtoaxept a.ptyrr,ntin fur.irteirrourtp id b, 11- •-M,-,j,c•dpro7r tnf_-I-3., cl.,,rr -:.abmt"•-1for p+,rr :I Led rt., stp•c'N: m v.rntht.,U-c•.pto'I of ear-hor¢, d d:,duct,bl•-, co,nt uracc,J c0 F a, m nt as, im;:.r co: t h +'tr ch. m ,'?•' d it3, r, m•'•':l; -;Ir.,:•9:+ndr::• _,,r,tott h:. 1:1o'tt.:p.;•r-nt._od:r,•: SIGNATURE OF PHYSICIAN (ORSUPPLIER):Ic,rtlfjIwitth' p•rCon:dly furni;,h••d by m,• r;r my •.rrployt_t, und, r my p •r:o'1.+1:0'.rr: .__ •tcn NOTICE Th., slue•rtt,rin^ttr••t:r,nr,•nrtl"t rr•.rn, tr'i ..,r• +:•icer, r• I,ar' ji 1' ,? ?t•,1d'.t'•' :••?to'ri:t°m,. b•fcr,F.d .d:•.t'. fund- end th •t my hire , el um . • tit. m •nt ti, d•-cu l+• n• . cf ca :• ., li •,t r_f tin - A f et n. t, t; pro r.:. ' i : nd •• +Na'w' a:, F,.3 r d o 5t it• , 1., ti ,; , ti G:'B C:-lies ntJr^r..r ?•:.: dlni te• r h', •r.'.a•i R-'a:t ?-+.ct •Jr 1s, rip r r. r. _ r. J +t, r , : - -n ri rk rr tl:n brI Ad: d: C'.., . 4: T, i,'•r• _ •tr- :a, .'t ,t'. :n •.: :l. f,'l• its ,r 10 Tr= :ir,tlf;t r?'r :1 ru•k rfL,tti•rr`•r 'o crlt r, ^V•, r,, r r+ •'F-n _, I.., ?-uii tin - t:, t:.•. ,. - ' r. . : :•`, .. j' , , 1 1. • •,a , , r YJ li t-• - ' 1 t.. t• -, r: ' : l ,rltr :: ti If yr,i t r.. ra; C[r 1 r , ^t•. cen•:, rr•• i to 7C, '.•' f ,:f th, t T I rr n f arG. 1.11iN: f:r•r. F' ] A R dhrr•', '.: ,i 21'.'"14J.- BECAUSE THIS FORM IS USED BY VARIOU. OVERNL+ENT AND PRIVATE HEALTH PROGRAVL' , =E SEPARATE INSTRUCTIONS ISSUED BY APPLICABLE PROGRAMS. NOTICE: Any person y.ho knoy:in ily files a str t.-mmt of clorrn contt Inrn j t_ny misreprmtritat on or. ny fatre, incornp'ete or misleadsrig information may be purity of a criminal act punishzWe under Izlri znx m.,y ba sub,:-0t to civil p `r?.,Ftt^^,. REFERS TO GOVERNMENT PROGRAfn ONLY MEDIC %PE AND CHAMPU'S. PAYLIENTS A p'•, of.. _•n^ t4rv r, . t-,, .t F,,rr, • n1, t - rr•. -d °l: ,C• ' r:'. _ :1 ;j rr.,•mat z-n r- : / to p•ocv, te-C:-,m:1-jC:rfi' ihitMr.I1yr,r.dl_np-G,4'' Iin el:c,-Itrrct.a1121 t•'L ':CUr' .'l3"Tp' ' !1 It -C- ,0 tM,C1,'.- C'•LT1 t,1 r^:1" rt^-'Ur•' sulrrer.z • r, wrllt, w r I• + ,- to 14 c*:. r:. rr Jtc of trd rorirr do: i 4rfc-rr it .5-, +rcLti.^7 t r r -I ' nJ :h tt : •r to • F r-on h. t- • ,_rrfro..p h -arh r) yr.t7Ct•.I sbitrlf,Itd-ftUlt.,:4r1-r:•comp 'n'tl0iorcub•ri-raft.si,re.hch,. r, - p:i It'•.to p.,4c't, :G:•1'dAriCntrl•M,,:••;ni,fi.nom,,• S.r•'-t:: CFR dt 1 24:,u if d,•t11 :1 i : o:••rpb:r,_d Ih• p itr:mf: .1^ dirt t Jihor,z•. r• r, , o! tr •r'cr,n r.cn h it • h, ?I 1 u r, t r -•?rr :r ' Ft?•:.•I fn L' •d ,:rr a--rfr •d cr CHALIFUS P. rt::Ip one t• •t t'l.r'tr• ..%-P1 It. - ct rq- d.a -rw.'3,1c4tt •M it:. •,cir. ror CHAW"USI-c'.1 i•:'r' 1 r,• ,fs•fJ.ch.rr} .3 !n' Nt ' -ri. h • d:d?., b: -•' • i Lpt:•i th c `r,. •J d Jr. ??.,. rt r, ..pcr- h'r r-.!/ for in . d. do.:•+1«• co'r G' ,`- t .I rr:r?].. rt-d - -,r. -, Ccx-Lr. ,r,-, 1d d-Avrrr wl*i c4111, • Mtvc. vu c~ rfe-,r or CHAMPUS t c-J mtt rm, d•, r, 4It- : L _ tn• •n t.-.,, chxr, • • ub'-,m d CHatSPUS 1; ra3t .t h,.:,Itll I". Jr 11C.• p,o ;r. M t ,.,t m41.^.p.tym-•ntforhfM!htrn.•ht.•p-ovrdi.-detrwrthc.ri.,lnfltb I*n r.thIf- •Unexrr d E•_r.•c, .inrorn;ionon tP`p-•I••rt.. F:,ncorttcu'db-po.d.-d in tt-a.v ,t:m' c: pt;,1'-d,a a I .,tk 1a 4, t. 7.'t , id 11 BLACK LUNG AND FECA CLAWS Th: pro•.ral_r ,r,,•-', to : c,,4 pt tr•: m?trot p1 d b; th, Gam., rl:rr r.t.. .,11.,' S- E•l: iC'- 1-vi i .mJ FECA m_tn.:tcn^ It 1.,rdirg •J pro:,• drr,..r1d o1.+3noa: coclirin,.y It- rn. SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE, CHAI`.:PUS, FECA AND BLACK LUNG) . r P•' d. F- .c. .; , dk,m'•r:•,:: r4•f3 {' Ic.'rl+f? ir,atlrl?:, r. Gt_:hu:.nc ltn•'fDrin , fir dic •Ily .,d. r-dn :r ':rt' •h: :I •lr?r}' 9!a^• .:Tr r ^:d f.rr:'i- rr " i•d ' 'n:ld.nttorryprol,._.ion_' r,•c• b/rr;t•tJrr, rmy imm amt.-Fr.,r_t•ur, ;,.c1, :!•4•l••n• ..__ .pr, .:; p:rmr,.db/t.1•dcs•tciCHAilf:ti: rj_,7ut"d•on'- For r• r.ir5 rd b 4:tm;id-', d .1 : Inc ^d nt tou ph,r •r:t 1•i • prof -::no' •'r.r 1) th , ml, it ' ri.^a r., d L^ : r tn: Ft ,' 11. rrm.:d 11r,> rro• at rup, nr'iw'1 byh,: h:rvr_ptojL, ,2Itn'ym,r .tt' ..11rv+ r}r,'. d J"hi :ad 1t. tp-rtcfacL.• r• 'n r.. _ 31tr: f rri1b••olkow-j- carmc -,';fu•r h:•d rlptiy:: Int. ot'r_ .. 'Td 4) th•' - ..i_:•_, of ror,^h, ct t'l. r•,,: t b ' ,ri:'C,d•. i on Ir, Ft, ic. -n . t if - ForCHAMPUSc1,Itm.,.lfurth rccrt,fjthotI(or:•nyi,mploy,^,-) v% ho rr•'id.-d••:r.^, ••r-nr:t:•n• a.r dtt;rihrb,:rof lh:lJ-v!orm•:dS•n:'••or .ic•:rl•,in vrnpl3y:+• of th•. Ur it, d St -,to :, Cot :•mmi nt or . i coritr ict , 'r'p10,.:-e of t,-, • U-111. -d C - C,;,,.r rrt•r -It. 4 Jr. r c . tt.:n c r rr r J-j (r. r, or to S USC 552,JI For Bt. tc*w -Lt r •1 ct: ,fn--. I furth,_ r c•.-rttty ti. It th:• •: r,.-,. -r f: d-..,m,. d :..'L' far a E Lunrl-r.'.,of j di' ord, r Na Part B Lb c=m • tur••nt . m. t, t p• 'd unl. th form , r1 . +.• d . n Q4 d t., , • .%'I i Liz, , rd r•_ -ILL it c , (42 CFR 424 32 1 NOTICE Any on,•r oirn-upnet.nt er1.tt'W'KL4.-:nti:Ainform, tha•ltnri•>•t.:'p,,m•raIrornFrd,r•.Ifurd•n_q„c IAb;tr'fiarMM.IILaancon.l::tontov b,.. -:t to tin • and ,-Fit •onm-nt urrJ-•r auphc •*'•' F<d,•n,! L •r.' NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE, CHAMPUS, FECA, AND BLACK LUNG INFORMATION IPRI:'ACY ACT STATEL IENTI C.•, . r. athorv? J by CIAS CHAVF'U:y • ni O:fCP Jo J Ivr , ', r , i,-1 r• . I-•,-t 'r -n CI tr,- L• I,: ,- CH-V,'Ltr, FECA -- d C•':,r•l, Lv,ni Fr:,.1t-, r.• ALIh:`,tyr+c?1,,1tr':•-&-n .1 :1, 1:•{{,,t 11..' 1. 7, r,Jt••74r.'t 1.'•A--I .,?- •! Id:•CFR411FC!tl 1J4._•4'_rit ('t.•ri 44 IJ:C 3101 41 CFA 1(41 t :rd 11j ULS 10714 cJ 11, •• _ U'?.C ,:1G1 • I a .J '0 U-C '•]1 t a 31 U iC I,11, C O 17 Th„info m: it en :.: ob'.;m to corrpl• •tc eG,rrrt . un•1•.i Jr.- • progr•' a', r' ,:_ J to d' •r! fy yell. •i 1d to d, is rmrr ax , (I•:Ib„tj It i ..; o u..ed to d,-ctdz f tn..• :.•r.:c:• and ,urpl ,•; you r, co., v. d • or* co:, r, •d by thu• • pr,;r}•., T .. ind to cn ,ur. • In, i prcp r r•.,, T:nt I , r '. l Th :• 1rilL+'r a,xin rrt ly :'':•O b • r11.. r t to 4th •r pro, id, ;f • . •r. is c Orr, . r• 'rr• J t: t ,•, r+•, • : t' a, .... t: . '!t" fir • • :1 F •t'.. rd Gtl. _ r o'er miz, hnn:• cr F,,,,, Tr, 1•i,:riC , f^- ln••,t'•C:.,•.iJmr, t,.,,•;?rfF.a:r '.P 4. :-t.tor tor, ti,.r••c" r1i 1p.1 ••_pt,t3PgP-rr err to F. J ':t'E'•:'+r m .:r.d..o`r•,:•r.. •a n-: -' r !o:n,''.:rl•rt:.t rth 'p'Ciir, m For t. ,lrrptt• it In ay t• r' ' Jr,t:'G? :3 •,r,4.?•1,, :'•:n. ""Ito, t• .jCJh df31t. 4_Far. I.rC:.•Gr rjI j0,%; dl :a::.'?. ,1f.• m.:,'r trrmugh routlr t-U: ` for .nicirrr.!fon con'. ir',d rn :y ::•m•_ ui r.cord_ FOR MEDICARE CLAIMS: S 4 th -note- rn^d t,trry'_•,: !rm tJ? 03-70-C'501 U•rd t:.trr •:r t "••a: , • CIJ ^ : R_ce d' ?+4h'r h d In }t .: F, •I R•.•1t- t._r. x'0155 tJa 177. p;t1'• 37541.). V AA S.•pt 12 or.e. Lpd.::d tnJ i• path h,-d FOR OWCP CLAILIS: Di.•p irtmt•nt Gf G tar, Pn.. cy t t o' 1' i74 ' R•:p'Jtl c itu't of rkt c, • of S,' •: m ; •ot R co•d : Fed-r-08•_ p;'•, •r Vol 55113 40 W. •d Fvb tic 159:t. c-,: ESA-5. ESA-6, ESA-12 E:4 13. ESA Z41 or,,-. uod.4t• d. rd r, pt,bi.h:d. FORCHAMPUSCLARAS:PR!h .I ' U1J.E1;i•:F_ctr To, , :u'•}• 44rt :,rte rr-i:,,lc: •?K,o. i dby•:. y+:eL't: '+'rd'•ol,. r •p,, rv_ rt4po?r:.t:•b. hro_rt ci r not I.i/ :rid::, rml•i: tion it+ zt tr .• r:'t4. :ppli•:' rcc, •.• :I •'r_ ..•Jihenz•.d by' :. ?U 14 ISEiSI Inrnrm.,rlun fiord Ci.,lm:.•rld t-.1. rl,'d dncum. of m1y 1;, gr.• n to iF„ • D-pt tof 1', •r r.rr• , Alf.r r : Eh? D pt of H, +tth •nj HLrr.•tn S r. ct : , ind er th-El, tit of Ir.in.-.:r*honcon -:-•rit::itt, in, if 't•'U'Cr;.,r!,Y'rtl_ir .:t•^•, c•1"rl rM4 UrrJ rCH&t.*PUaCHAMFVA.toT^•: C••p.t ,of,tl'tI: ,r_.rr.•rr, rit.,i?lOi ft- •?r, t1'/ZfC•'.: . • n.`i! ,? :Tt t;itt'lr+''rn +R'•.,•fJ •G f.:' G'1. ,f c^', ::1.'l•-:• -i,Jc•?" :m •r L:'ir1: •. '1CC^^ •?e1:.:nr -rt-?'n:1t c' fir. i-A to C•: i'1•, - trip •1 Ott :•: r1 n pao .: t,3 1;Ar'', rr z ' t1 T•'' • r ?,,,- -r Ci T' • K . r?•t t:, .:i Cl1 r r•:C'd F. •1, r'. r?Y'C?r ,•• • dl' t:`G. J'tr. M,4; t'. tT -id ' !o Ott, r t.•d••r.ti ' t,it• ICC:II, for, 3n (13.t•Tim nt •_1•rci. , pr.vat:, bu•r11.:' entr•-'_ -vid rd,.id_i•I F-o.4' r•• of.,2fe. ia, t m-Lt r•. ri ' dln•t to t 1'r' r, nt c•.1 :rr. aalldic:.ton fr„Ld prorrim.ibu;u u?'Pz ,trop r4.::4.:.. QtJ dl}y :,5_ JrinCr , p , r r?ti„ w, pro jr.t•n int, q. itllyd p tidy Ir• ! 110,. CG rd' lat,n of b •n• fit,. .4ndcriI a-d crirrltr:•1 t•t q:4tisn it 1:l,?d to V, • cp,_r,•ir:•n'3f CHAMPUS. ?/Otlrt:+r,+hCa:.'r,f.dlJh•to pro-.-d.--ntGnr-On1:'."Irl? J1il d_I.y.np,,rr.nto•rr1,r..r..tilrJ_n6+itiiC.•IrflvNfOt.,:Cr•t•,Ccp'•tZ'17.:4',.ad n•:rr,nop.-wilt,••,crd. rth••.,prcrtPm:f ,r,Ivirrilo•app'trinform.hol H).,•-.tr.f 4'Jr?l4ftrT' ha?r:rm.,teener_g;,Tanlfrir•m,oicikemi_-, .r-rcV,,,d or 1h : , tmount eh. irq? •d ::outd pr. w: nt p ty ml.•nt of el. ttm•. L nc1'.•1' th,::.-, .ro•}r.,m •. F,1du', • ie hJrnr h : n, oth• r mformiflon, slch a : n.rriu or cL:,m rn.mb•: f• +:ralld deli; p..,m• nt of th • cl. ?i11 F..Ih?r, • to pro,,;d • m_dlc, I irlorrri:tttoi Lrd. r FECA could t- d, d, d :', Ct :'r,.-t'on It,.m'rd.a,rftrtttyGJUllu:,fycuFr;:.iF'/t.l'1:•Iti rp.,rty1 r•p:rtk-for pi,l-•}f:r,.? h:. r, .-r E. ?ia:111L.Boftrr E•o, IS,•.,L't:;?cf.rd3lUaC?C?1 2;1° F a. ci• ri r? fcr .. Ihh,LJ.r n th ' inform •hon 4t-:'PI. it V'. :'J.•4r4, ,1 -.1 R,. -, F'• tCtl , C_r,,-I !- rr .•rT i".?. '', _rr, :'ttj .'1rC`C•aT°.r,.. n ' MED'CAID PAYMZENTS (PROVIDER CERTIFICATION) I h, •r •b 1t-' to i,-. p :.ucti r. •:ord . i ::,r. • n.._ .,t to d, c*:, , t4.,,, t;1 • , rt of , r..cs.'• Fro. •:, d t? ,r i .Id t.; . wt',. r tF. • S- . • : Tit >< I A p':an areJ to tdrnr• h d::d Him.1-I., S r.-co •. rva, rt Qi.•: ?t i ,r, _ :1 it, F,• re cr C, of H-.t ?n . • nft rrr,,4':n n:q .rdrnn Jn/ p.tyrt: n' c' ,•m-d far proud l"J11 «r : it • 7= , Pt (i?r[1: ?t`r }? ,_^ 4 4 rJiG•G7,iTik,tra*. C :T' _4b-ri jfJrp'Ij(r t41?_rif iTpf•3'r.'4n ..?htn, 4 •c• f:l.ri ,:d ?+t,rr`••'ItPltLrd Ih••,.m3an,t`.•dt;;t,lr•t., ' of.:airoriz•.d d•_ducub • co'r .j-an; • crpr.,,r• t-1 '-r - rri:.1t- •.u j h: , .n •,h1•rl SIGNATURE OF PHYSICIAN (OR SUPPLIER): I c• rid; that tn. • r • r: t: r• I _ :• d r4 • It- d : Ily It- yi ?. rT .d : rd rr-c rr;'.o }f ' • h • to +,t trn : p3t,.-d ,Ind r.• ptr,ora:1kirst- h•ib,m. orr/t•rep'ay,_•?u;,:4,•rm/p. r:,r.1olmaf*-l tfOT;CE Tr . .ooC- 1'f is 11h,.iCt•'1•]In'i,rt!t••^:l ,I•_ _v 1!• -I I,.r; •': y•r. rot ,rill' t _1t •I1 _ r. :!,t..t•r^ F.l ;'•' --1 Six. .rrdt-I f •t:i.n. t •t-••,1•; trd:n.r t eve-I- q:ntcf Ir- ,i r,+f.? or It•G'C. :J'•JL- ' F.j.,•,:,5•+,r . J- Wit'-tlrr,i'{• , .p' - t,• d •r. ,•, r••1lvF r.:'d 15.trA, _ _1{r,'.1L-: tti ? '?• t.t'd1Ot.Drcr.i•n.-rit,i'r. or - • r• t -, F'. r: F9 ?': -:I•?'r t :I 4 1' r., 1:, •i _ 1. Tr , J 0%'e :r ._. ru•-t:• r 1_* it- _,r. :n ccit 1. 0 Q -,. TG- for,, r.•,ur ] 1: .:'r•" ,r t-41 ,r':rr.l .1 •_t • .a :•1 d t_• t. (19, 10 r ^. ?. t« ,,: , JL'Il I•"i 1, f• . .. - ','. .,, ,.? ech .1 . I t r. . A;^, r }:.. ,? !., rr _ _P1 p?•r? Y,1 i.. .. 1 i, ip`,:'Ir:' :9 _:,,•: - ,-,r .r ..r:"l•'4 ,:•_•,: •r -,1 t, ,::L,,:, --ttr._t, ., _1 t-1 .. ': ---,1t'-J f:rn.Fl . .r- }? CI!:• t.?-11-..,.• 7-:,•a ;, n', C' .' •1. 11 ,ire;. , t' ,' -,i C1 A4-1, _,l BECAUSE THIS FORM IS USED BY VARIOU, <?VERNMENT AND PRIVATE HEALTH PROGRA1111--* cE SEPARATE INSTRUCTIONS ISSUED BY APPLICABLE PROGRAMS. NOTICE: Any person who knwinrtiy f lcs a st terro. n! of claw rm,conWort!tfg utry writ-sre'presnnt;+tlon or any f a'; o, Incomplete or mts-loading information may be gu:ity of a criminal act punishaWe under law and may Ec sub,,ect to clvll'pm, ftre3. REFERS TO GOVERNMENT PROGRAMS ONLY MEDtO49E AND CHAMPUS PAYMENTS A p ,tt• -,t ? - analJ•t• r• cl, .t•, that P•1,r:rt b, m- ;•• . r^y •J•, : r:•. r•.i.:- ct •n, 1lrrjrm.'•,21 r••:• : +y to ;,cc, t,...! c? em :,nd •. r9r• . •h,.t lb. r•'c -fr :n pio. d, 1 41 E 1 IFrc J1h 12 . tc•• .:%1, ,1 • ^ j t:: r p' In a •..': of t f;' . d , or, • el•: m t,,. pat •r1t 1 11`131V.. , triC^Z._ j, •h•,t?f.6'. "1J t.1 {t:T„nha`:1nrlri0nr;-- Ili-•I:-mth:ro ll:..c•-.1-1 t,7 rJ•,r qt.„rtm-r :•Ont•'i.t.itrpl3j•,rnaup l rlfh ,t111.{ n s o-i t,:t ::orf,, r • :•ftp, n'.,1}n or e11-• r •:`rtth I r.• p. ;'.••- F. ., P n' •,i JfrL f ' _,J• 1 f. t%r icr AF :h tr... ' :.4r.. ci, rn , . rra,'I _ _?• 4' CFR 411 .'_4, tl If d .n rt Corp;. It y till, p it If l' I' r tM 1.Ihc•,z• • f- Of th• ra':•rr • s1 ti t: h , i •, p°• , c• r ;, ftam in f,'• rJ ;,•a ,:: r CH-11.1FUSI: ric,p, cnc t,• p", :,;I,.n?rr.• + to': ' ptr •r_h•o.,q., 1,4.••tnrn it onti`l;-M a^ , ct•rr,rc••CHQt`FUah c'l •,-rr,.i -rd tn• p t•t' r,.pcr Ib'•• C-J, t_'r • n- d. d.-'G• COW t.••'n:•r •mj nir•:o..r, d , • r...:,- Cc1n 1.r,•r,:•• -r .-t• d Ito c',• d J _ .b1., ,a: b'r d t,p : n tt'+.• ct•,rr1. • d••t. a, •r..,'•^ 1 it fh, t1 r} t , G •ru • or CHI MFUS t c J'rc, -IT, •1,• •; 111- i • . Bl,n tT •:i r. : ut^ tit d CHAMPUS 1: rat J h•_•t ti in I:r,,rC., prC Tr,m bit rv..'r .1..:,r ;rtto•h -111ab•.•n,.fr• .p,c+:•d_diFt-ci'1hc1 rt n n 1ih,. it•.•U-.I':rrr, d:• .t: 1-rurm::+crrcnti ,p-',rt p:-.,- or :F:u'dt, p,c.nd-don tio, t••.m- c. pt ar••d tr1 In..xt•,Y 1 ft rr .1.1 I. t•, i, 3.. nd 11 BLACK LUNG AND FECA CLARAS Th. • pro.0 r .,?1r, t., _ h-j : cc, -pt in, , •rr _,unt p »d b{ tho• Cc:, -r-r. rl „ p t,a it in f,1' S: E . Lu,i.Ind FECA r•: trust :,n- r; .1,,d rn r d p•,t_ d_r.. '.nd 01.,:1-I::.t GCd1rrl-,-t:m,• SIGNATURE OF PHYSICIAN OR SUPPLIER (MEMCARE. CHAP?PUS, FECA AND BLACK LUNG) IQ•n,fyth..tthk- :•.r„Icc .r.01,Ynon th,.fc-m:„•rt m._•oc+'yrWco%d.ardn-.>:_.vfv'th••h:.l'nafti••p•t-it:-, J r•rvp-. lif',fam :trdb{rr •t7!:..rv*.,•r:h•d dx' at tom .of. ,c,uJ:`:r.rc• , nop. • urd'•rmiimrt-•,d•p r•-?9, d•UR r.r'ea, _ c`t f.• I'. ... ', • .I - r+ :J,•:.•r,• CrCN.t. ? 1 rp by m/ !? =••p . c'• j F• •t_d f•f f.1- FLi3 rt 1•J•-h :) fv« r. o:, fo Er t:oli,denvi .: Ira'; rt to.t ph, ci to : p"oft •,2r.,l • r.._ 1) th •y rru_t bt rc•rd• "t.d 1,rd- tht, F}:,:: -ins I I?rr • •d11t? p,_r •o•+ i' pup o oon b, hr: F:r!•st';,:orr•t•.?11h ymt. •tt •:.nlrrt+?';rol,,tit,xrlhtr,?r;.•rAtlp •rto`acG:,?,n dphy.ICr. n:•:,•'rlt:?• 'sttn,,; n•u •ftt•_'afFJndsCOrnton'yf?'rjt':d,np'tj''cl r0> '''1 ='- - :•rd 41 t.r_ ? , r: rc.•; of rarrpti, :•a,:ri •, mu: t t „nc1 J d-don inr pt1, • cr t1 •, b:. ForCHPI4PUSc"um..Ifurtrn.rct rtijtri,it Ifrcir .ry, rrplo,v- 1::f ort rd'reJ:,.r.Ic:...irnnat• l•In.•-dul/m,.rrb,:rclUi,Uriforrr:dS•_r tr .oracm:..nerrN of it .. Urt.ttd St -th Co.. rrm, •rt or o c _r tr..ct t ••rplo, t , cf 11- Uri:- d : t ,•. Co.- mm, nt , •.I rr• r c, mAn or mr i :rj In ': r to 5 USC 5535) Fer So.4.-Lur I C'. I.l]' I ftAier er rhIj th it t•7 • `•«m c•: p•. rform, d :., , t- for t F'. t:r Lun.1-rt;Avd di-crd r Ihr. form : n :tr,<d .,_ r•. at ;, d b{ +. 1,n1 t t., :,nd r• •;ul, hcr• : (42 CFR 424 S?t No Fart B tA••ol::c • b fm-1rt:• may b:,p aid unl. t•JtJT',CE An;Gru"•: homrr. prt-•; t•rA'.ori.,t:ah::•+,•^, nn-,lrnfo•m.,hont?r« r:•.,p.t,rr •rtfr;•nF,_a r.fir.nr_ r._,at,• •? Ddb{tt• :;ermm;r; t+pa•1car.. ct8nb•'•;t,b,• :•t to t,r•..tnd'rrpr sans: •1t urnd:r apply.,:tl:k• F, d• r,1i In:. NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF 1:".EDICARE, CHAMPUS, FECA, AND BLACK LUNG INFORMATION (PRIVACY ACT STATEMENTi ,r•• .•ult•: ,?, d t; Go 17, CH I WW - i O'::CP t: , lo, f: • ,-tt•: t 't.n r, i In r,' r• 'r .. n 0 It • t,' -•i : 1n CHAWUS1 FEC4 +rd Lv••q K ^,r r A. M a?I'.:t 1n':rr. :•, . , n .N._-1 .1 1..2, 1,17::.- d i 174 t;' t :?• I, r" a . , r1 r•J i 42 CFR 411 24t t) , nd 4:14 ?;,i) (?a • rd 44 U;•C 1101,41 CFR 101 0 -_q o-A 14 U:.C 107•4 tri W:.. 5 USC .IC)i . t ? •?j 5,t U"C ?01 • t «a 2t IJ15C t 1, E O r+'+-17 Tn`: Irfo•m it on :. '• cb:a n to oomp'?t? cf ion, I,nd. r tho•-': proZratr : , : u ., ? to id1••n91, yc:r and to d '• m 1• • tour «4 !11b11:t j It r, al•,o r,;.•-d to d• •ad•: rf th ? ?•_ r, ict • urd + ucp you rr.,-. I , d :r. ca:,rr:d by tt r prc?r:,m:.: rd to .n sort. tF.tf prop. r pa,rr,: nt, , m..J • Tie tn'crm tIG1 m.. j .+h o h,• q'.. n to o:n, •r p a. d« r : of <<r.1c, • . e 'm•:r • tnr. rm, a• ~,,: _ . m d t r• ., beard- h? +tth p' ,r _ ,rid u'nc r orgi•srza' or e, ct" Fadrr,71 y rc forty r9, ctr..• . tJ r1t 1,_ trahJn of Ft d .r'd pro.I 'on.. tn,d n qt r. oY_ r third p r, , pa{• r tJ p i j prim. rry to F«d- rti prcnr,irn ,,:,d iS Ott •.lL:1:•.• r : C':.:•,1ry to :d•nrn,e •rth ".-prrn;,tr_ Farv,21np'to lima{b •n, •a: rytotir ^'?, 'crrr, t _.rr b.Lttrt'r• `•_,rcJh t.ruc• diaahu p,IJordclor Addotior Id•:• o ura• au • mad, • tl- roan's ro.mno• u_., -for rnfo•mat on %; ,rt-trn •d ,n y t• n1 yof r -Corti.: FOR MEDLCARE CLAI1.1S: SL.: t,,a nctlct• mod fy,nn i :: m F!a 03-70 6501. h; :hi C rrr?r G' d«c, rt• CL 1 r,. Rt .,ord p1,b. ,F, d m iF,? Fed•%r..l R rn^t. r Vol 55 No 177 p.-;- 37549. Wt d. E`:pt 12. 1r*0 or .r t.pd..'-,d rid rtpubk h,:d FOR OWCP CLAIMS: Dcplrt?•-nt of L bor Pro.. c3 Act of 1974 R,:•p Jbl •_..t1on of No'vc: • of 5, -1- in,. of P•t cord, Ft•d.. •a' R- q _f -r Vol St) N? 40. %VtA F,.•b 23 1£:.n S-t- ESA-b. EGA-t;. ESA-12 ESA 13, ESA-;'). or v, t Fdal- d ..rd rtpi./>h• h• d FOR CHAMPUS CLAIf:1S: It?i I FI??P 1 Tat ,.. h,:t . • t 4 q•bih , for m, dr::l cnr • pro. do j by cr; ' ..n ?ovcv, :+nd t? 1:: - p. ,y rr.,,t 4p ;n t : r.,b' %ttmt- rrt of r-i ry•bi•tj ,ird d--towr nition fh.:4 tt,:. r.r: _.. ,IAppl.. - rt I. J .v- :u'•1; v:j toy lit-, ROUTWE U?. dai?'L Inform,riran ftom cot T:.. rd n•I iced d•ictirn- v rr, trr bL'q,., n to tr,• Q •pt of V, t- on. Att,t,^_• trw : D••pt of H,, W'i .,rd Hwr •n S•. n,rcK;. a^d ar le : b r c4 Tr.r;.port tt on con 1 t_ rt ,:Qh It.. •r 1,00cy , tdmri• ',tr.Y .t, r, r;,n. v .:. and r CHA1'1FU3 CHAMPVA. to t a.- Dept of A Itc.• fcr n•pr• rt •!,on of tF Secr,.•=ryofDrft_n• mcivlachar• toth,•Ins rna'R.:, %. S r'c,• pr., v. co Ct=n tr1,,r. :ri,:•.-, rr:•-rr«pe'1rjoa:n',r,fnccrrr_:tnric:dhrt.,coap•n,rt C4nrn•:, •trd fa CanrN+- , •4n: l Othc?lln rt ?pon_c to lrqu n•? • m •d, • ,tt it• u•q::• 't cf m • pr --,;n+a :,° : m ,r rr??id p :rt.4?' App`ep• ?:- d .: r,_ r.?t : rr:,r t,. m,.:'•. to o:n:•r ku" r.d. •.61-:t, loc. it. for, ign noormorni nt in.n-ci _ pn„,t•' bu. •1! : _ tnft'u: .r id trdr.:dui' pro. d e~• pf c: rt•, on rr. ~, r. rrl+t n7 ••? t r• t!, r.•rt e'..1 , tc;Jd.r.tt.cn. fraud. progr m abu:,•, utd¢;Uan rrvrt:•:, ga,'flttr.t:.?ur.tr+c:. p.• r rt:t_:y prorlr•t-1 tn::nrlt;, tr. rd p : t{ I :b I f j, cc xd•naflol of b:r ' 1; : rd c1.,1..rd cr• enrol I I.1, *-on relat-•d to th•- op•r-,tion ct CHAL'FUS Q SC L(1 SURFS. Vo:Jntarir. ho.v .,-r f ;dr,rt• to pro. od , trform,`h,n will ri -alt in t• h{ In F 1,rr• -it or or t; r. -vk,n d=•r•:d of ct , -n 1': th tl : cr t • : •p:•c"t d • ru -d t• •t,:: tF••: r:.-je no jcvi;t.ti, - sindr•rtF prortr 7rri , iar r. it.. Inq to upp ;r inlornsatiart H•?:.r .: r. t:,i u•- t: f?rrr h inrarrr'thon rr ,i ed rry trn• m• •d c,_ I e• :,_• : n r dt •ti or0-.tm3JrrtcF:,rgtd:.(:,Idp-t•:trdpa,m,. motC.'m urd,•rtt--c•prc^riini,F..14',•to0m.h.f;o"•.rint?rmi:an.ucha.r.rn •ardin.n.rr•.r..a,dd :t, pajmc It of it- cl %rn F,alur•• to pro.ldt- rro-dicni inform: t.:1 t:r,i,-r FEGA ccu'd h- d . r rr. •d : I eb `1.:h:n it I: r•: rd•dayth it you Is 11u tI)ouFnosth..t.tnatt• rp:,rtj,•r,-.point: for ptp-nfcr;oJrtr• am- al : :t,on 112eBof lta.Sx,'dSocur11Acf.,r,d31 USC?"01- 2,12 pro, de p: r,d`••: _ for :. It"lo'dinry tF - 1rf?rm -bon YoJ:ha,rl.9b ....rt•th.,tPL.1tJ{)5p3.tn,. Ccrrpw,rrtt:chiig tr.dPnv:tyFr?': acrlra, l_+:_ p. nm•,tr nz.%:rnmrrttov' •fy,rfom '•:nt;::,yafcorcputr or ect•r~ LIED(CAID PAYMENTS (PROVIDER CERTIFICATION) I F .. _ b j . qr•_ . to ktv:p wch rt :rd,,: x r• v: -:,r, to dt -1? fU,I; in— .1 no c` r.1, • p"o. rt d to Ina . tddi, i" u,?:• •r I-. St. . , Ti* ; • hlX p' in xi•d to fL n•-.h Into•mit:e1 r6rl:rd nn .iny roxymrrt: cUiIn-d f.:• pro. ,d rI J:•-e r. _ a . t. t- Er, I • A-1 r•:, cr 0. -;t of H• :th and 14L- r •'.,s• - mt; or, qt., -t IfLnn,.r:,qrc,toow.,pt.a:pgm,.•ntin full. itp -d b;th,- IA -die Ijpiclrenforti-a•• cLj r-?ubr,t*.df;,rp-,,rr rof urd:rn:tproar,m%%-"iitcc•c•_pt'vr Cf,:ttFOriDdd_d4tatl COIrLU"7r:+'.COp.ijT ntori-mil.rco-t-'•t, rr•)Ct11rtr• SIGNATURE OF PHYSICIAN (OR SUPPLIER): t c.•rttf j ih. •t tn:: _ rlcr : l • d ,7? 1:1 • r+ m d:: 't> it ar:.tt:• i z rd nt ary to th F? +:n of tt p +h, ni .rd a• r. p• v.ona"y fi mish.:d by in., or mi tvrp'o,,_ : une:r rr,{ F-r or •1 air, chon NOTICE' Th. , .too.fit{ tF,,t tr•• • f.n notnrt trform •tic•n , or,.. , >,r ,t r d car v I vr: r -,d no .1 R r) -4 -nd "n , :hz:q 0I t•• ? c' ,I- 1, t•, f-0-1 F. C' • +i a ^d St Sr : furl' -rd in t .,r; t.+l• • cl t m.- • 1,r• m« nt or d:?:urr • , c•r c J1r. • rr ni el a fr,t• t ct n ., t. pro :sit dt rd F,,* r,t: u" S t J , to t^ = F-;,-r. rt R r_ . r .r r,. •,r• 7t4 r, .I v) t r :rt 4-fc-rr IIICI L-?' t •i t•i Ot• S -tic, rvrt• r ='--'G.n1 • _iu:..r, F _ _ 1 .. o, F ••- - Tr=.,iG E,c.-W-I ust- f: 1.11 d'. s. ::1ta :'i9• i. 't _ To t t•?1,j!_ : t' :•la_`i :•, "n, iI?.t,•r', IQ -r F. ,:n _ r:1_ ,.71f:., i t:n.••r.Ir. o:' 1_, :,,...,-16,11, _. _ r• tr 1 ,ir - I' 'd,.. :.r,,, -• •,- :, tr t '•r . (• ! rt t_ ' r e•1 tf r. r•_:n pl ?'•` 1:• Ct1_:, r.2-14 . ' J rd. L' .' r .r• , r" t,' ,r,•i ?1.144-11 _11 , DECAUSE TK''S FOR" IS UCED DY 4R.OL # OVER 11MENT AND PRIVATE HEALTH PROGRAF.r EE SEPARATE IMSTRUCTIO'NS ISSUED BY ? APPLtCArjLC FRCGRA73. ¦ , d •.t;.: -'mrnt of dam contz tnir.`l any m .rcpresrmt:,Lon or any f,dsp. fncomp'Mr, or mfc,!o.3d n j Informit on ma; t • nu ii of .t er;'r r+, t .:t F+jn• ;!1: t' ? ur. `r 1.,:. zm$ m.ty t? ctlb,?Ct to Ci•:71)r?t? :t1??^x REFERS TO GOVERN IEUT PaOGRAMS ONLY '•-[' t._1 C 1-t••!. t_1 PA',:TL AF. 't' 7't llr •rta.'1%tr •pi, -•r't rr': -j .i -: .. r, ,, r, .r ,'!:.9r-'.?i r. ,, ./t•7 p. I-:' -, '-j,_ r ti :,I r_ _.. jtlF_ 1Ti 7'112 •ir,_ . r., tT; I'1 T- c -- c1 I'.` ?. ra c' t,1 T-•p. :• r T. rr, _ 7jn}r To _ 1., 11 I::,T ,t :'I Ir.:a-d Frt, -re,;•, lr. ?I'r. ,: '" j: '1 f1S ?1f• :r• '+''i;? f' ?,"i _ : ••I'• :n c,i:l' r 'l' r. -I lz' 1:o I-, tr 'r?'.. :re t: •?` 3: r c! -I r-. f F'Fi ill ' • , I It . •?, r.' , ! 6 !,' ,: '•jr•' ' U'::'C' re • Cf c; ,? r.4:f'r,•6••rRl: , ?luttr.t'-j.S•n•C.'T rr•CH:'.Sr41p1 i'1?-+r r' ,...t :tt,tC -j r t 't a. r:-., I 'j r3r:o,, j r. - C:! ..,.•.r- .j t-., Q - b ?,: . It- t.. r. r 't+=11j1 j,rrdih 1'' _ I, 11., Lr ?•" j Cl{?srcl?L+, r:!.,h t _ F of"',t.l CH r f ,. -!t: I t . " c. _ jt rt •' , •',l .,• ... it:,- U, 'rr dS .:-i ell tr •p: "t t:: -Ijb p ,:... dint- BLACK LUNG AND FECA CLAI.tS Tr 4 r __ I T:. 't j,• j t, t , C+'.• rnrr•.rit . p:gm.nt in It.-, SIn Ejz%Lj ti:1rd FECA r, t,ozt:•1_ n TST Aa ro'4J F••:: -•9 :'G`2ATURE OF PHYS',CIAN OR SUPPLIER (VED)CARE, CHAMPUS, FECA AND BLACK LUNG) I+_ ,•: •, :^,t 1: rt ::.', r.i,: I'dd7^du:, ' ry'crft• h.._'•hc'it i:-1 ntxd..?r-.p.f-rr,-•- dt,r' c':..-•, 1_rr j t,i;,. Ur:l rrr,.,rm •:I„ +? r Cr i, U;rf.._,C'i,..,, ?•,.Q':.-,.'.i +r.Zr% -'fit -rr"- dtt, in vCH:r','PV;. Fi 1 +-_: _1 :3.r?'-, l: pfC`• :•t.•1-,^.•C., 1 ih, fTl., 1t r, ^•:` ra r-^- , It '. f'. ?• 1 ra:47htr:j•r`t"11'i'taf-1 Ct7.•2r,1 p`f. ,'1:. .r.c•.31I'.•fmJ it-0'J. CC,T'r, ,1•_• _ I:'', : •t c'•r: It '-r:.1 iunlr•pY., :.n:tlt" It._- r•_ -:,1 'IP: -,+r[':•,•.t, :3n rd r, d• f. .,T,r•:t•n .. ..•rJL:?P'A1t-yCfi",•Llr`e:-!r d'J'••_ 'C•.lt.'f,'l.rr'?,, 1 U' 7 C:. "r C1T7•Urr'ISt G?. rm--t4ih_rc. icrrr t' r,jr.''t35L1c,-, 5:?_yl Fc,6 Lixi.-I -i -ill- I:raE r Lut1-r, r,dd, .'d.r :, f 1 E !1 t I , t p j t ' li tu:r8 1' h c, ,. d •. r, tl. ', d t•, !'• Airri l ... 'a'i j h ti',Jl.lt.. 1'. (42 CFR 4Z,4 .12• 1T :E ; -, c' ;t- I ' , Ilrylr_.rm tt,:?t•?r+ _ t. p trr rtf•c nF• :.r. 11,:9 •r, q f•.jG, t' '.::nr ,, 4 : tcc-.•: _'rt _t•, :i NOTICE TO PATIEUT ABOUT THE COLLECTION AND USE OF MEDICARE, CHA.MPUS, FECA, AND BLACK LUNG INFORMATION (PRIVACY ACT STATEIMENTI .. rc`-4'1•.-v_ 1U:.cF!: 7 'r r1+:1t. fl. CH='1:"U; FiCCA ,7C.: 1r._. 1,77 11174cft• ---.1t ^i ?Crs 11. 1 id^._ +?pI y t ; 1i =rte 31,11 11 CFR 1,11 1 j 1 11' I_-- C 107'1 ,i1 10 U?•C .1101 t . a .'•1 U:C ')1 • I a Usti 1.1:• C 0 i7 Tr -,.._,.. 7t?c.--- c' , u - j r li• +p-i.-% r m.I•utkdtoid-:nltiy?j.,ajtod-i 'rr:*7-- 1c..r• mr .!1 4_ dto d cjtti•• r. i GJ. . jt, „ .p-4iJ-rC.,11ziIDor •.',mifp•c? rF•me n•,.m.4- Tr : --,rr , 5t c`• r. c ,*r _ o•_rr.: 1' m d,. In k= nJ f- 1't •1 p' .:dCt rc•? z:•a•crF, r l a,;iF, 1 1 rc. it.IP?,U4-'C•-,'t1 ,dF•rt K'r r•taF',iFr,,T; n ' p • i p''= '- ?' -r :7 IT h._'. etl .,t-,r• -,r,iatll.Ch., n'Crr'.:?n '1b:•Ut1'"b ? "•1'CJh...1._•:j10'Ih$. p!11CrC3^.',''r FOR f: EWCARE CLAP n. or r:':. r _ . ', ",1 i, t. • n t:•3 i 0- 7 0-r_._ 51, t'tf i C rr • r V ju: ra C': r R•.:rJ'd p•_t r,• d tit tr '• F. wt _ i R, , _ r, Vol 55 t;:, 17; p , ,t7_,! ';. d E p' 1-, 1cr. up j. dr,-pjb' h d FOR0.,CPCLAI113:C Y.• -1L :r Pr. :,F•a[•t1'i7d'P•pt,tl,z; :n off:c•'•: afti,.f r-cfP,:ard• F._i_r,1R_,-,_•_rf.'c:r5fJ3+?t.':.dF,'?Zs 1' ' _ E- , _ E-'t-G E_ , I" E-_ 13 LG •:J or +.4,:{:-d tn3n'f•,bl •h d FORCHA!rf'UsCLAtrs.•i:FFi:%_ _i_EF 4;W1z-, 1`;LTn,•. 11J. r•" lit, :jt:*mr]ltc'IC't••ptG.•d.dbrt.. •1•ovc.• .•rdtD .'?.i,rr:rtut:i•--t'b h-r rt -' , - - j r, x ' :, is ?? 1: .. '.,,:I - n _ r. d i • :I?rt"e'•r d t•i L,:. F, ;T }I1=rI ., 1- _ - • :7bC-,:' ir,r. dd::•j-r i' Ir,,t-m..nt-5Ih C.12 e':'.S_r.'.Atf .• 1-0 p1 c`F' ..i-,JH.,-r 9C -. _ ,-jc- ' :' Ir e r :1,:_ ' ir 1.'Acr,.,Jrr,rr.tr. f• pai cs0 und.fCHfVFUaCHeMYVA 0.31.1: C' p' utJ., r, I- • •rm of c r., -,c'C it 1,3 -r 'P ru:S.•r..': F',. It'rX,, On. ' , 1Jp 'jC•:- LT 'rr.p3-tr_I. ^ rici-r i.-c' t.. In r. -G -F? r T j'(,: C _ rr, ;_ t31•:4 •'. .(':•.' .4tri•n'i4• 10'i F; 3ihaa`:Y1.t d•_ r,-3i'dF r1 :14;-C?'.1• c 4', rr,,t' r _ • f 1, fir i i' ,::I • . [;,:.. t ' bll :11'.. , f, •nd In3.. ,.'1J-11 p'r;, rr afc.•n•. oR rr , r n I .ttr•t t'3 ITI11. r,.•rf c'_•rr . • - - = t. . -, (. ' • : _ 1; •rt ., -_ t.,Sz 'e:,r,. c,.jA tlr,':• F•.•r(I ...P-,clr-m r.- ,•,. Ii id-p:t,!-N1`,,cc :No--fCiG`C i t'. .fdc. :rI i'r31 c: I r'(''-- ;-. ,:i _ ', r. ! _ '3F i.''' '•r'L`tfT i1•Jnr:11f1•'Jhnd,_1 ? ?p yrr -tC'rr ,r r. +Jr•nr' .•-,'n),,' •'rt i, 1r?•,i.C- , .C..,:•Cid' :v 'j c r',I '1 F .-• r 1:'r• •r'11J =p; ,d::h7'':} H?:., ., r,f''J'• b'.fr. 7l a?.T7tr:'16 7"•Gf i1t ?. dC"I r. _ r1 _?r _•,_ •_ ., c; j. _'jp -'r.,- '.tr':.r,': ,_rj rtf•,..Fra,•,,-^:F1'4'..131r_•rn l,.;jC•F..,- .r..>,r:n•Lih..r r'cr•_ rr..,Tt.r...:.A'jC',ly [.,,T •erlt ,. F ,_ +F':, _ rr _ p'r•(r,.t•cnL`11 FECAcc•J'dt.-c' '••r_jonot}.ir.J: CR • '- , t,:_.; :._ •,: If•f t• 1 -,:Y '? rlil•r, -pi•: Ii:fl+tv'fp,rl"n7liJr,=U't(r,1r;r•!•t ?„ ?1A'i11,'_'L'3G`1i"`.?,Y.-•1? cU(+iAa.,ijs1UvC?:•t1- c C. 1: r._ 'PL ti-_f t 1 C+r:•,•.rG' tr-,) ,tjF'(t., CjFrC'• :'r?3ttf1°. j" t+ ',r IF:f13..•-r;r.^f:rm ' CtC:y'F,JI':r L'EDICAID PAYMENTS (PROVIDER CERTIFICATION) Ir , 1.-• c •r,to ct•CI:•••Ofiiin:,•',•rt0-r.,:•• p•1..••dtana.r'?j,*-u-.',,_rtr. ! •Tt••kltp'.n,irjl3f•J'n h r., •c i ,p.,r -t _ v, 7'-l.":r .t,tn: 5', it, A-,. r:i c• Li,:' cf H i••i -j F,, S ,.(:-,FT ., r-,,I-i .l fl , .? .? _ ?• -. ?+,,- ,•rr,IJ -:J''p 'jb,T' •f.t dt:idlirC.i•:,TI}?+tl's"- C rri .e?'rt°•.jf:rp;,r-"!U': '1: .tp'C' T, :•i ii`" ,• ., f':n -1 - - ii• --- .: C•]•ry _ _ :?X ,:'• -4or .•rnd,rc0't-k rngcrien, SIGNATURE OFPHYS'CIAU(ORSUPPLIER):Ic•rttitr,ttis r.1c,•:•It".d,_tv.•:..vmelz.-,y,i;:.,t•-d. rdn•c rrto W h 1'tiof ttr:p,t r•trdr._ t , `> r I t., r cf r,, , •r; u-.:' ' rri p• ' crol des -nen 1 , 1'_ C= 'i'• '?C_rp': it^? ji' .!F,,r ?' ,7j r a: t,;ft`t.._ t •fr:' F.J 'j<: , T.'a Tr i T .-J rr {t• ,I c - -„'. ird:•7J• : ':cr•: . rt.:1 srr.' r--'f rr,,U p'c :_I' 11_ .- _ +F, i'' '{•?•,, I y',I I P _ 1. I r,I r• _ dt)r,:F '•113 rcc ;0,cnct'•r: .,,:7wi' +-:"c rjn: r T . r, _r: • Tr • trn: r•.;, rr i 1_ .:'r; r' r'T_rrr..•;v U. :a 'Ir i t3 ,' 141 , t•. I :r. r . - : _ I r i.1 - I•„_ r ':,. ho1drF, _.4'q ..,•i.rrr d,'trt J. r9 cc- frt .,'• _ ,+, .I •, ._ - - _ •_ ,. rr _._:, :t lr, i•r•: Q^I, (ir•' •.,. '..^,.f: T?''.,'ll 1' f.-rn Ia f' t. Ct.' .-14-: %t i!! ¦ Government Employees Insurance Company GEICOO ¦ GEICO General Insurance Company ¦ GEICO Indemnity Company gelco.COm ¦ GEICO Casualty Company One GEICO Boulevard ¦ Fredericksburg, VA M CATION OF LAMS To Whom It May Concern: This will certify that Government Employees Insurance Company has issued an automobile policy, 0762168706, to: Janet L. Grover 739 Dogwood Terrace Boiling Springs, PA 17007 that was in effect on the accident date of June 7, 2006 providing the following coverage on a 1995 Nissan, Vehicle Identification Number (VIN) 4N2DN11 WXSD857432: Bodily Injury Liability Property Damage Liability First Party Benefits Medical Expenses Income Loss Funeral Expenses Accidental Death Extraordinary Medical Benefits Uninsured Motorist Bodily Injury Stackable - # vehicles Underinsured Motorist Bodily Injury Stackable - # vehicles Comprehensive Coverage Collision Coverage Tort Option ERS Rental Reimbursement $100,000 per person/ $300,000 per accident N/A per accident N/A per person N/A per person N/A N/A per person N/A per person N/A per person N/A per person/ N/A per accident N/A per person/ N/A per accident N/A deductible N/A deductible N/A per day maximum per accident maximum - fJM4-( Elaine Rensing Continuing Unit Manager G? Date Hl PA (10/03) Uniform Qualified Assignment and Release "Claimant" "Assignor" "Assignee" "Annuity Issuer" "Effective Date" Amanda Grover Government Employees Insurance Company Allstate Assignment Company Allstate Life Insurance Company This Agreement is made and entered into by and between the parties hereto as of the Effective Date with reference to following facts: A. Claimant has executed a set ement agreement or release dated: ? ! I ` (the "Settlement Agreement) that provides for the Assignor to make certain periodic payments to or for the benefit of the Claimant as stated in Addendum No. 1 (the "Periodic Payments"); and B. The parties desire to effect a "qualified assignment" within the meaning and subject to the conditions of section 130(c) of the Internal Revenue Code of 1986 (the "Code"). 6 NOW, THEREFORE, in consideration of the foregoing and other good and valuable consideration, the parties agree as follows: The Assignor hereby assigns and the Assignee hereby assumes all of the Assignor's liability to make the Periodic Payments. The Assignee assumes no liability to make any payment not specified in Addendum No. 1. 2. The Periodic Payments constitute damages on account of personal injury or sickness in a case involving physical injury or physical sickness within the meaning of Sections 104 (a)(2) and 130 (c) of the Code. The Assignee's liability to make the Periodic Payments is no greater than that of the Assignor immediately preceding this Agreement. Assignee is not required to set aside specific assets to secure the Periodic Payments. The Claimant h no rights against the Assignee greater than a general creditor. None of the Periodic Payme may be accelerated, deferred, increased or decreased and may not be anticipated, sold, assigned or ercimbered. The obligation assumed by Assignee with respect to any requiredi payment shall be discharged upon the mailing on or before the due date of a valid check in the amount specified to the address of record. This Agreement shall be governed by and interpreted in accordance with the laws of the State of _ The Assignee may fund the Periodic Payments by purchasing a''qualrfied funding asset" within the meaning of SE!ct:ion 130(d) of the Code in the form of an annuity contract issued by the Annuity Issuer. All rig,its of ownership and control of such annuity contract shall be and remain vested in the Assignee exclusively. The Assignee may have the Annuity Issuer send payments under any "qualified funding asset" purchased hereunder directly to the payee(s) specified in Addendum No.1. Such direction of payments shall be solely for the Assignee's convenience and shall not provide the Claimant or any payee wish any rights of ownership or control over the "qualified funding asset" cr against the Annuity Issuer. Assignee's liability to make the Periodic Payments shall continue without diminution regardless of any bankruptcy of insolvency of the Assignor. 9. In the event ti,e :settlement Agreement is declared terminated by a court of law or in tie event that Ewa'ss,gn (c' of the Code has not been satisfied, ent shall terminate. The Assignee ownership of any "qualified funding asset" purchased hereunder to Assignor, and Assignee's liability for the Periodic Payments shall terminate. 10. This Agreement shall be binding upon the respective representatives, heirs, successors and assigns of the Claimant, the Assignor and the Assignee and upon any person or entity that may Assignor: Government Employees Insurance Compan Aut orized Re resentative Title XIZ40.4 Janet Grover, as Pent alnd atural Guardian of Amanda Grover, a irWY . . V. f -. Claimant: / s. Edward Grdv&, as Parent and Natural Guardian of Amanda Grover, a minor Approved as to Form and Content: assert any right iereunder or to any of the Periodic Payments. 11. The Claimant hereby accepts the Assignee's assumption of all liability for the Periodic Payments anc hereby releases the Assignor from all liability for -.he Periodic Payments Assignee: Allstate assignment Company By: _ Authorized Representative Title By not applicable Claimant's Attorney Addendum No. 1 Description of Periodic Payments Payee: Amanda Grover Benefits: Nine Thousand Fifteen Dollars ($9,015) payable annually for four (4) years guaranteed, beginning August 13, 2009 through and including August 13, 2012. Initials: Claimant: (JG) Claimant: (EG) Assignor: Z?1?__(GEICO) Assignee: (AAC) SETTLEMENT AGREEMENT AND RELEASE This Settlement Agreement and Release (the "Settlement Agreement") is made and entered into this _ day of _, 20 _, by and bctwee-n: "Claimant" Janet Grover, Individually and as Parent and Natural Guardian of Amanda Grover, a minor Edward Grover, Individually and as Parent ar.d Natural Guardian of Amanda Grover, a minor- "Defendant" Jamie L. Grover, Janet Grover, and Edward Grover "Insurer" Government Employees Insurance Compan\ RECITALS A. On or about June 7, 2006, Amanda Grover was injured in aiL ,accident occurring on or near Creek Road, Boiling Springs, Pennsylvania. Claimant allc os, that the accident and resulting physical and personal injuries arose out of certain alleged negligent acts or omissions of Defendant, and has made a claim seeking monetary damages on account of those in B. insurer is the liability insurer of the Defendant, and as such. would be obligated to pay any claim made or judgment obtained against Defendant, which is covered by its policy with Defendant. C. The parties desire to enter into this Settlement Agreement in order to provide liar certain payments in full settlement and discharge of all claims which have, or might be made, by reason of the incident described in Recital A above, upoil tide terms and conditions set firth below. AGREEMENT The parties agree as follows: 1.0 RELEASE AND DISCHARGE 1.1 In consideration of the payments set forth in Section 2, Clainant hereby completely releases and forever discharges Defendant and Insurer from any and all past, present or future claims, demands, obligations, actions, causes ofaction, wwronfful death claims, rights, damages, costs, losses of services, expenses and compensation of any nature whatsoever, whether based on a tort, contract or other theory of recovery, which the Claimant now has, or which may hereafter accrue or otherwise be ::acquired. on account of, or may in any way gri:)w out of the incident described in Recital A above, including, without limitation, any and all known or unknown claims for bodii?! and personal injuries to Claimant, or any future wrongful death claim of Claimant's representatives or heirs, which have resulted or may result from the alleged acts or omissions of tlw: Defendant. 1.2 This release and discharge shall also apply to Defendant's 4ind Insurer's past, present and future officers, directors, stockholders, attorneys, agents, servants. representatives, employees, subsidiaries. affiliates, partners, predecessors and successors in interest, and assigns and all other persons, firms or corporations with whom any of the former have been, are now, or may hereafter be affiliated. 1.3 This release, on the part of the Claimant, shall be a fully binding and complete settlement among the Claimant, the Defendant and the Insurer, and their heirs, assigns and successors. 1.4 The Claimant acknowledges and agrees that the release an"- discharge set forth above is a general release. Claimant expressly waives and assumes the risk of any and all claims for damages which exist as of this date, but of which the Claimant does not know or suspect to exist, whether through ignorance, oversight, error, negllLence. or otherwise. and which. il'known. would materially affect Claimant's decision to enter into this Settlement Agreement. The Claimant further agrees that Claimant has accept:-... payment of the sums specified herein as a complete compromise of matters involving disputed issues of law and fact. Claimant assumes the risk that the facts or law may be other 1han 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 constmed as an admission of liability on the part of the Defendant, by whom liability is expressly denied. 2.0 PAYMENTS in consideration of the release set forth above, the Insurer on hehalf of the Defendant agrees to pay to the individuals named below ("Payees") the sums 01.1a1ned in this Section 2 below: 2.1 Payments previously made as lollows: It is acknowledged that Insurer has previously made payment(;} in the amount of Dour Thousand Two Hundred Forty-seven and 02/100 Dollars i'$41,247.02) in satisfaction of a medical lien for medical care rendered to Amanda (;rover. 2.2 Periodic payments made according to the schedule as follows; (the "Periodic Payments"): Payee: Amanda Grover Payments in the amount of Nine "Thousand Fifteen Dollars ($9.015) payable annually for four (4) years guaranteed, beginning August 13, 2009 throi:rh. and including August 13, 2012. All sums set forth herein constitute damages on account of personal physical injuries or sickness, within the meaning of Section 104(a)(2) of the Internal i?: venue Code of 1986, as amended. 3.0 CLAIMANT'S RIGHTS TO PAYMENTS Claimant acknowledges that the Periodic Payments cannot be ,accelerated, deferred, increased or decreased by the Claimant or any Payee; nor shall they (l".aimant or any Payee have the power to sell, mortgage, encumber, or anticipate the Periodic .Payments, or any part thereof, by assignment or otherwise. 4.0 CLAIMANT'S BENEFICIARY Any payments to be made after the death of any Payee pursuant to the terms of this Settlement Agreement shall be made to the Estate of Amanda Grov,!r or to such person or entity as shall be designated in writing by Payee, after attaining age of majority, to the Insurer or the Insurer's Assignee. If no person or entity is so desigrated by Payee, or il'the person designated is not living at the time of the Payee's death, such payments shall be made to the estate of the Payee. No such designation, nor any revocation thereof, shall be effective unless it is in writing and delivered to the Insurer or the IIISUrer's Assignee. The designation must be in a form acceptable to the Insurer or the Insurer's Assignee before such payments are made. 5.0 CONSENT TTO QUALIFIED ASSIGNMENT 5.1 Claimant acknowledges and agrees that the Defendant ane ; or the Insurer may hake a "qualified assignment". within the meaning of Section 1 30(c) of 1he Internal Revenue Code of 1986. as amended, of the Defendant's and/or the Insurer's 1 iability to make the Periodic Payments set forth in Section 2.2 to Allstate Assignment Company ("the Assignee"). The Assignee's obligation for payment of the Periodic l'a,, merits shall be no greater than that ol'Defendant and/or the Insurer (whether by judgment or agreement) immediately preceding the assignment of the Periodic Payments obligation. 5.2 Any such assignment, if made, shall be accepted by the Clainlant without right of refection and shall completely release and discharge the Defendant and the Insurer from the Periodic Payments obligation assigned to the Assignee. The Claimant recognizes that. in the event ol'such an assignment, the Assignee shall be the sole obli,!or Nvith respect to the Periodic Payments obligation, and that all other releases with respeca to the Periodic Payments obligation that pertain to the liability ofthe Defendant and the Insurer shall thereupon become final, irrevocable and absolute, 5.3 Allstate l,ifc; Insurance Company will issue a Statement 01' 611arantec that will guarantee the future obligations of Allstate Assignment Company. 6.0 RIGHT TO PURCHASE AN ANNUITY The Defendant and/or the Insurer, itself or through its Assigncc., reserves the right to fund the liability to make the Periodic Payments through the purchase: of an annuity policy from Allstate Life Insurance Company (the "Annuity Issuer"). The Iefendant. the Insurer, or the Assignee shall be the sole owner of the annuity policy and shill have all rights of ownership. The Defendant, tine Insurer, or the Assignee may have the Annuity Issuer mail payments directly to the Payee. The Claimant shall be responsible. for maintaining a current mailing address for Payee with the Annuity Issuer. 7.0 DISCHARGE: OF OBLIGATION The obligation of the Defendant, the Insurer and/or Assignee to make each Periodic Payment shall be discharged upon the mailing of a valid check in the amount of such payment to the designated address of the Payee(s) named above, or the deposit by electronic funds transfer in the arnount of such payment to an account designated by the Payee(s). If, after the due date, the Payee(s) notifies the Assignee that payment \,?-as not received, the Assignee shall direct the Annuity Issuer to initiate a stop payment action. Upon confirmation that such check was not previously negotiated or electronic funds transfer deposited, Assignee shall promptly direct the Annuity Issuer to process a replacement payment. 8.0 ATTORNEY'S FEES Each party hereto shall bear all attorney's fees and costs arising; from the actions of its own counsel in connection with this Settlement Agreement, the matters and document!; referred to herein, and all related matters. 9.0 REPRESENTATION OF COMPREHENSION OF DOCUMENT In entering; into this Settlement Agreement the Claimant repres?:rrts that Claimant has relied upon the advice ol'his/her attorneys, who are the attorneys ol'Itis/her own choice, concerning the legal and income tax consequences of this Settlement Agreement; that the terms of this Settlement Agreement have been completely read and explained to Claimant by his/her attorneys; and that the terms of this Settlement Agreement are fully understood and voluntarily accepted by Claimant. 10.0 WARRANTY OF CAPACITY TO EXECUTE AGREEMENT Claimant represents and warrants that no other person or entity has, or has had, an,, interest in the claims demands, obligations, or causes of action relcrred to in this Settlement Agreement, except as otherwise set forth herein, that Claimant has the sole right and exclusive authority to execute this Settlement Agreement and recei,,,e the sums specified in it, and that Claimant has not sold, assigned, transferred, conveyed or otherwise disposed of any of the claims, demands, obligations or causes ofaction referred to in this Settlement Agreement. 11.0 CONFIDENTIALITY The parties agree that neither they nor their attorneys nor repro;entatives shall revc!al to anyone, other than as may be mutually agreed to in writing, any of the terms of this Settlement Agreement or any of the amounts, numbers or terms and conditions of any sums payable to Payees hereunder. 12.0 GOVERNING LAW This Settlement Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. 13.0 ADDITIONAL DOCUMENTS All parties agree to cooperate fully and execute any and all supplementary documents and to take all additional actions, which may be necessary or appropriate to give full force and effect to the basic terms and intent of this Settlement Agreement, 14.0 ENTIRE AGREEMENT AND SUCCESSORS IN INTEREST This Settlement Agreement contains the entire agreement betv\-een the Claimant and the Insurer with regard to the matters set forth in it and shall be bindinU upon and enure to the benefit of the executors, administrators, personal representatives, heirs, successors and assigns of each. 15.0 EFFECTIVENESS This Settlement Agreement shall become effective immediately following execution by each of the parties. Claimant: Janet Grover, Individuallti and as Parent and N?tural Guardian of A?riaiida Grover, a minor By: Date: L.. ,. Amanda's Addre s: 73 Dogwoo Terrace -^ Boiling Springs. P,\ 17007 Claimant: Edwp N of By: Datc: er, Individi ally and as Parent and ;flan of Amoiida Grover, a minor Insurer: Government Employees In,>urance Company By: AD 0 . A"4 ?? -- Title: Date: _-_?- - - ---- W All AL-.AL- * You're in good hands. April 10, 2009 Donna Pease Cambridge Galaher Settlements 30 Hanson Road South China, ME 04358 Re: For the benefit of: Amanda Grover Dear Donna: This letter shall serve as an acknowledgment for receipt of prerrlium in the amount of $35,000.00 on February 2, 2009 for the purchase of an annuity for the above individual. The policy number(s) assigned to the annuitant's case is SSAL2 3904. The above referenced contract will be issued upon receipt and review of all required documents. Sincerely, *Li Lori Rainey Annuity Administration NB-126 Allstate Life Insurance Company 3100 Sanders Road, M36 Northbrook, IL 60062 T800.806.552;; F 847.326 7062 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing PETITION FOR APPROVALL OF MINOR'S CLAIM has been mailed by U.S. Mail to counsel of record via first class mail, postage pre-paid, this day of May, 2009. Edward and Janet Grover 739 Dogwood Terrace Boiling Springs, PA 17007 SUMMERS, McDONNELL, HUDOCK, GUTHRIE $& SKEEL, L.L.P. By: ounsel for Petitioner, Government Employees Insurance Company I IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: CIVIL DIVISION AMANDA GROVER, a minor NO. (Jury Trial Demanded) ORDER AND NOW, this day of , 2009, upon consideration of the Petition for Approval of Minor's Claim, it is herby ORDERED that the Petitioner is authorized to enter into a settlement in the gross sum of $35,000. The settlement amount shall be distributed as outlined in the Settlement Agreement and Release and Uniform Qualified Assignment as attached hereto as Exhibit "1." TOTAL AMOUNT OF DISTRIBUTION: $35,000. Counsel shall provide to the Court, within thirty (30) days from the date of this Order, proof of such deposit. BY THE COURT: J. Distribution to: Kevin D. Rauch, Esquire Summers, McDonnell, Hudock, Guthrie & Skeel, L.L.P. 100 Sterling Parkway, Suite 306 Mechanicsburg, PA 17050 Edward and Janet Grover 739 Dogwood Terrace Boiling Springs, PA 17007 Uniform Qualified Assignment and Release "Claimant" "Assignor" "Assignee" "Annuity Issuer" "Effective Date" Amanda Grover Government Employees Insurance Company Allstate Assignment Company Allstate Life Insurance Company This Agreement is made and entered into by and between the parties hereto as of the Effective Date with reference to following facts: A. Claimant has executed a setqement agreement or release dated:; 1? I c -'1 (the "Settlement Agreement) that provides for the Assignor to make certain periodic payments to or for the benefit of the Claimant as stated in Addendum No. 1 (the "Periodic Payments"); and B. The parties desire to effect a "qualified assignment" within the meaning and subject to the conditions of section 130(c) of the Internal Revenue Code of 1986 (the "Code"). 6. NOW, THEREFORE, in consideration of the foregoing and other good and valuable consideration, the parties agree as follows: The Assignor hereby assigns and the Assignee hereby assumes all of the Assignor's liability to make the Periodic Payments. The Assignee assumes no liability to make any payment not specified in Addendum No. 1. 2. The Periodic Payments constitute damages on account of personal injury or sickness in a case involving physical injury or physical sickness within the meaning of Sections 104 (a)(2) and 130 (c) of the Code. 8. 3, The Assignee's liability to make the Periodic Payments is no greater than that of the Assignor immediately preceding this Agreement. Assignee is not required to set aside specific assets to secure the Periodic Payments. The Claimant no rights against the Assignee greater than a general creditor. None of the Periodic Payme may be accelerated, deferred, increased or decreased and may not be anticipated, sold, assigned or ercimbered. The obligation assumed by Assignee with respect to any required payment shall be discharged upon the mailing on or before the due date of a valid check in the amount specified to the address of record. This Agreement shall be governed by and interpreted in :accordance with the laws of the State of ___ The Assignee may fund the Periodic Payments by purchasing a °qualified funding asset" within the meaning of Section 130(d) of the Code in the form of an annuity contract issued by the Annuity Issuer. All rights of ownership and control of such annuity contract shall be and remain vested in the Assignee exclusively. The Assignee may have the Annuity Issuer send payments under any "qualified funding asset" purchased hereunder directly to the payee(s) specified in Addendum No.1. Such direction of payments shall be solely for the Assignee's convenience and shall not provide the Claimant or any payee with any rights of ownership or control over the "qualified funding asset" or against the Annuity Issuer. Assignee's liability to make the Periodic Payments shall continue without diminution regardless of any bankruptcy of insolvency of the Assignor. 9. In the event tt•e Settlement Agreement is declared terminated by a court of law or in t-ie event that 0(c} of the Code has not been satisfied, ent shall terminate. The Assignee ass.gn ownership of any "qualified funding asset" purchased hereunder to Assignor, and Assignee's liability for the Periodic Payments shall terminate. 10. This Agreement shall be binding upon the respective representatives, heirs, successors and assigns of the Claimant, the Assignor and the Assignee and upon any person or entity that may Assignor: Government Employees Insurance Compan B: Aut orized Re resentative Title r "Ar )cI"( N Janet Grover, as P ent afnd ?Oatural Guardian of Amanda Grover, ainorf Claimant: Edward Grd4r, as Parent and Natural Guardian of Amanda Grover, a minor Approved as to Form and Content: assert any right nereunder or to any of the Periodic Payments. 11. The Claimant hereby accepts the Assignee's assumption of all liability for the Periodic Payments anc hereby releases the Assignor from all liability for -he Periodic Payments Assignee: Allstate Assignment Company tiy: --- Authorized Representative Ti y: not applicable Claimant's Attorney Addendum No. 1 Description of Periodic Payments Payee: Amanda Grover Benefits: Nine Thousand Fifteen Dollars ($9,015) payable annually for four (4) years guaranteed, beginning August 13, 2009 through and including August 13, 2012. Initials: Claimant: (J'G) Claimant: = (EG) Assignor: _&jk_(GEICO) Assignee: (AAC) SETTLEMENT AGREEMENT AND RELEASE This Settlement Agreement and Release (the "Settlement Agreement") is made and entered into this - day of 20 by and betwrc.n: "Claimant" Janet Grover, Individually and as Parent and Natural Guardian of Amanda Grover, a minor Edward Grover, Individually and as Parent and Natural Guardian of Amanda Grover, a minor "Defendant" Jamie L. Grover, Janet Grover, and Edward (:hover "Insurer" Government Employees Insurance Company RECITALS A. On or about June 7, 2006, Amanda Grover was injured in an accident occurrinu, on or near Creek Road, Boiling Springs, Pennsylvania. Claimant alleges that the accident and resulting physical and personal injuries arose out of certain alleged nc-ligent acts or omissions of Defendant, and has made a claim seeking monetary damages on account of those injuries. B. Insurer is the liability insurer ofthe Defendant, and as such. WOUld be obligated to pay any claim made or judgment obtained against Defendant, which is covered by its policy with Defendant. C. The parties desire to enter into this Settlement Agreement iii order to provide liar certain payments in full settlement and discharge of all claims which have, or might be made, by reason of the incident described in Recital A above, upon the terms and conditions set forth below. AGREEMENT The parties agree as follows: 1.0 RELEASE AND DISCHARGE 1.1 In consideration of the payments set forth in Section 2, Claimant hereby completely releases and forever discharges Defendant and Insurer from any and all past, present or future claims, demands, obligations, actions, causes ofaction, wrongful death claims, rights, damages, costs, losses of services, expenses and compensation of any nature whatsoever, whether based on a tort, contract or other theory of recovery, which the Claimant now has, or which may hereafter accrue or otherwise be :acquired. on account of, or may in any way gri)w out of the incident described in Recital A above, including, without limitation, any and all known or unknown claims for bodi ly and personal injuries to Claimant, or any future wrongful death claim of Claimant's representatives or heirs, which have resulted or may result from the alleged acts or omissions of thti Defendant. 1.2 This release and discharge shall also apply to Defendant's and Insurer's past, present and future officers, directors, stockholders, attorneys, agents, servants. representatives, employees, subsidiaries, affiliates, partners, predecessors and successors in interest, and assigns and all other persons, firms or corporations with whom any of the former have been, are now, or may hereafter be affiliated. 1.3 This release, on the part of the Claimant, shall be a fully binding and complete settlement among the Claimant, the Defendant and the Insurer, and their heirs, assigns and successors. 1.4 The Claimant acknowledges and agrees that the release an*,,-', discharge set forth above is a general release. Claimant expressly waives and assumes the risk of any and all claims for damages which exist as of this date, but of which the Claimant does not know or suspect to exist, whether through ignorance, oversight, error, negliL-ence, or otherwise. and which. if known. would materially affect Claimant's decision to enic-r into this Settlement Agreement. The Claimant further agrees that Claimant has accepto'.1 payment of the sums specified herein as a complete compromise of mai:ters involving disputed issues of law and fact. Claimant assumes the risk that the facts or law may be other than 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 Defendant, by whom liability is expressl\- denied. 2.0 PAYMENTS In consideration of the release set forth above, the Insurer on behalf ofthe Defendant agrees to pay to the individuals named below ("Payees") the sums (W-hned in this Section 2 below: 2.1 Payments previously made as lollows: It is acknowledged that Insurer has previously made payment(s) in the amount of in I"our Thousand Two hundred Forty-seven and 02/100 Dollars 134,247.02) satisfaction ofa medical lien for rncdical care rendered to Amanda (-irover. 2.2 Periodic payments made according to the schedule as foliox.-,s (the "Periodic Payments"): Payee: Amanda Grover Payments in the amount of Nine Thousand Fifteen Dollars ($9.015) payable anm.ially for four (4) years guaranteed, beginning August 13, 2009 throe.glh and including August 13, 2012. All sums set forth herein constitute damages on account of personal physical injuries or sickness, within the meaning of Section 104(a)(2) of the Internal 1:.cvenue Code of 1996, as amended. 3.0 CLAIMANT'S RIGHTS TO PAYMENTS Claimant acknowledges that the Periodic Payments cannot be accelerated, deferred. increased or decreased by the Claimant or any Payee; nor shall the Claimant or any Payee have the power to sell, mortgage, encumber, or anticipate the Per) odic Payments, or any part thereof, by assignment or otherwise. 4.0 CLAIMANT'S BENEFICIARY . Any payments to be made after the death of any Payee pursuant to the terms of this Settlement Agreement shall be made to the Estate of Amanda Grover or to such person or entity as shall be designated in writing by Payee, after attaining age of rna.jority, to the Insurer or the Insurer's Assignee. If no person or entity is so designated by Payee, or if the person designated is not living at the time of the Payee's death, such payments shall be made to the estate of the Payee. No such designation, nor any revocation thereof, shall be effective unless it is in writing and delivered to the Insurer or the Insurer's Assignee. The designation must be in a form acceptable to the Insurer or the insur<,r's Assignee before such payments are made. 5.0 CONSENT TO QUALIFIED ASSIGNMENT 5.1 Claimant acknowledges and agrees that the Defendant and; car the Insurer may crake a "qualified assignment", within the meaning of Section 1 30(c) of Die Internal Revenue Code of 1986, as amended, of the Defendant's and/or the Insurer's Iiability to make the Periodic Payments set lorth in Section 2.2 to Allstate Assignment e:'ompar?y ("the Assignee"). The Assignee's obligation for payment of the Periodic Payments shall be no greater than that ol'Defendant and/or the Insurer (whether by judgrr?ent or agreement) immediately preceding the assignment of the Periodic Payments obligation. 5.2 Any such assignment, if made, shall be accepted by the Claimant without right of rejection and shall completely release and discharge the Defendant and the insurer from the Periodic Payments obligation assigned to the Assignee. The Claimant recognizes that. in the event of such an assignment, the Assignee shall be the sole obll.,!or xvith respect to the Periodic Payments obligation, and that all other releases with respe'.:t to the Periodic Payments obligation that pertain to the liability ofthe Defendant w-id the insurer shall thereupon become final, irrevocable and absolute. 5.3 Allstate Life Insurance Company will issue a Statement of (warantec that will guarantee the future obligations of Allstate Assignment Company. 6.0 RIGHT TO PURCHASE AN ANNUITY The Defendant and/or the Insurer, itself or through its Assignee, reserves the right to fund the liability to make the Periodic Payments through the purch.?se of an annuity pc?licy from Allstate Life Insurance Company (the "Annuity Issuer"). Thu Defendant, the Insurer, or the Assignee shall be the sole owner of the annuity policy and shill have all rights of ownership. The Defendant, the Insurer, or the Assignee may have the Annuity Issuer mail payments directly to the Payee. The Claimant shall be responsible !br maintaining a current mailing address for Payee with the Annuity Issuer. 7.0 DISCHARGE OF OBLIGATION The obligation of the Defendant, the Insurer and/or Assignee to make each Periodic Payment shall be discharged upon the mailing of a valid check in the amount of such payment to the designated address of the Payee(s) named above, or Lhe deposit by electronic funds transfer in the amount of such payment to an account designated by the Payee(s). If, after the due date. the Payee(s) notifies the Assignee that payment was not received, the Assignee shall direct the Annuity Issuer to initiate a stop payment action. Upon confirmation that such check was not previously negotiated or electronic funds transfer deposited. Assignee shall promptly direct the Annuity Issuer to process a replacement payment. 8.0 ATTORNEY'S FEES Each party hereto shall bear all attorney's fees and costs arising front the actions of its own counsel in connection with this Settlement Agreement, the matters and document:; referred to herein, and all related matters. 9.0 REPRESENTATION OF COMPREHENSION OF DOCI.MENT In entering into this Settlement Agreement the Claimant represents that Claimant has relied upon the advice of his/her attorneys, who are the attorneys of his/ltcr own choice, concerning the legal and income tax consequences of this Settlement Agreement; that the terms of this Settlement Agreement have been completely read and explained to Claimant by his/her attorneys; and that the terms of this Settlement Agreement are fully understood and voluntarily accepted by Claimant. 10.0 WARRANTY OF CAPACITY TO EXECUTE AGREEMENT 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 relen-cd to in this Settlement Agreement, except as otherwise set forth herein; that Claimant has III,:: sole right and exclusive authority to execute this Settlement Agreement and receive the sums specified in it; and that Claimant has not sold, assigned, transf-erred, conveyed <ir otherwise disposed of any of the claims, demands, obligations or causes of action referred to in this Settlement Agreement. 11.0 CONFIDENTIALITY The parties agree that neither they nor their attorneys nor representatives shall reveal to anyone, other than as may be mutually agreed to in writing,.any of the terms of this Settlement Agreement or any of the amounts. numbers or terms and Wriditions of any sutras payable to Payees hereunder. 12.0 GOVERNING LAW This Settlement Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. 13.0 ADDITIONAL DOCUMENTS All parties agree to cooperate fully and execute any and all supplementary documents and to take all additional actions, which may be necessary or appropriate to give full force and effect to the basic terms and intent of this Settlement Agreement. 14.0 ENTIRE AGREEMENT AND SUCCESSORS IN INTEREST This Settlement Agreement contains the entire: agreement bevvveen the Claimant and the Insurer with regard to the matters set forth in it and shall be bindinL. upon and enure to the benefit of the executors, administrators, personal representatives, heirs, successors and assigns of each. 15.0 EFFECTIVENESS This Settlement Agreement shall become effective immediately following execution by each of the parties. Claimant: Janet Grover. Individually and as Parent and Natural Guardian of Amanda Grover, a minor By: Date: r Amanda's Addre s: 7' Dogwood `l-crrace Boiling Sprin?,zc. PA 17007 Claimant: E:dw.ar rover. Indivich ally and as Parent and N ut41; ' 1ardian of Anrinda Grover, a minor By: Date: Insurer: C.iovernment Employees ln;,urance Company By: ?? - -- T1tIe: J'W Date:_ Y-77 0 ? I n 4'19.5o Pb ATN ko d.15X107 MAY 2 9 2009 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: CIVIL DIVISION AMANDA GROVER, a minor aivil NO. ? 3y(ol TCr/c (Jury Trial Demanded) ORDER AND NOW, this day of , 2009, upon consideration of the Petition for Approval of Minor's Claim, it is herby ORDERED that the Petitioner is authorized to enter into a settlement in the gross sum of $35,000. The settlement amount shall be distributed as outlined in the Settlement Agreement and Release and Uniform Qualified Assignment as attached hereto as Exhibit "1." TOTAL AMOUNT OF DISTRIBUTION: $35,000. Counsel shall provide to the Court, within thirty (30) days from the date of this Order, proof of such deposit. BY,TFIE COURT: Distribution to: ./Kevin D. Rauch, Esquire Summers, McDonnell, Hudock, Guthrie & Skeel, L.L.P. 100 Sterling Parkway, Suite 306 Mechanicsburg, PA 17050 Edward and Janet Grover 739 Dogwood Terrace Boiling Springs, PA 17007 (2o i'er mat?. P Gla?a1 ii?l J. t. , cli T o i Cy IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUN"fY, PENNSYLVANIA IN RE: CIVIL DIVISION AMANDA GROVER, a minor NO. 09-3461 (Jury Trial Demanded) PRAECIPE TO ADD TO FILE Kindly add the enclosed proof of disbursement to the above file. Respectfully submitted, SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, L.L.P. ~~ ~~- By: Kevin D. Rauch, Esquire Counsel for Petitioner, Government Employees Insurance Company ti .~~~ t ~ a e® AI S You're in good hands. STA TEME~'~'T OF G UARANTEE Claimant: Amanda Grover Date: February 2, 2009 Allstate Life Insurance Company (Allstate Life), an insurance company domiciled in the State of Illinois, hereby states the following: Whereas Allstate Assignment Company (AAC), domiciled in the ~~tate of Nebraska, has established certain structured settlement <m-anl;ements and assumed third party payment obligations to injured parties ("Claimants") through Qualified Assignments, as defined in Internal Revenue Code Section 130; and Whereas AAC has entered into a Qualified Assignment.; and Whereas Allstate Life desires to facilitate such structured settlement arrangements; and Whereas Allstate Life guarantees all obligations of AAC to make pavnaents to Claimants under Qualified Assignments. Now, therefore, Allstate Life guarantees that if AAC shall fz.il to m~~ke any payment to the Claimant or Beneiiciary(ies) as required unde;* said Qualified Assignments, then Allstate Life shall make such payment(s) in .ao::ordance with the terms and conditions of the Qualified Assignment promptly after receipt of written notice of AAC's default. In the event that the struc;t:ur~~d settlement agreement is terminated, Allstate Life's obligations under this Statement of Guarantee shall terminate simultaneously. This Guarantee is not an insurance contract and does not guarantee any obligation under an insurance contract. Said guarantee is irrevocable as to the above referenced Claimant. ALLSTATE LIFE INSURA`.'~iCE c~On1]'ANY ~' ~~ _.,, ~, Ron Johnson Assistant Vice President Allstate Life Insurance Company A Stock Company -Home Office Address: Northbrook, Illinois 6~OOE>2 Single Premium Immediate Certain Annuity CONTRACT--This contract is issued to Allstate Assignment Company (called "AAC") in c:or;sideration of the application, a copy of which is attached, and the payment of the single premium. The contract anti the applic,~tion are the entire contract. All statements made in the application are representations and not warr,~nties. N~a statement will be used by us in defense of a claim or to void this contract unless it is in the signed application. Only our officers may change this contract or waive a right or requirement. No agent may do this. Allstate Life Insurance Company (called "we" or "us") will make the payments shown on F'a~:~e 3 to the Measu-ing Life or other payee designated by AAC, provided that the Measuring Life is alive. In addition, if i:he Measuring Life is not living, any payments shown on Page 3 will be made to the beneficiary. This contract stops when all payments have been made. RIGHT TO CANCEL--If AAC is not satisfied with this contract, it may be voided by returnincl it to P.Ilstate Life In- surance Company, Northbrook, Illinois 60062, or our agent. AAC must notify u:; and return the policy by midnight of the 10th day after AAC receives it, Notice given by mail is effective on being postmark.ecl, propc~riy addres:~ed and postage prepaid. We will return the single premium, less any payments already made, within 10 cays after we receive the policy and notice. This is a legal contract between AAC and us. READ THIS POLICY CAREFULLY. COPY Signed for ALLSTATE LIFE INSURANCE COMPANY at our Home Office in Northbro~:~k, Illinois. ~~ Secretary %~ President F'age 1 LU3406 a TABLE OF CONTENTS Contract ................................. Right to Cancel ...................... Schedule of Payments .......... Measuring Life information .... Contract Number ................... Owner .................................... ......... 1 Issue Date ................... .................. ;3 ......... 1 Beneficiary ......................................... ~~ ......... :• Incontestability .................................. ,f ......... :; Minimum Values ............................... .f 3 Non-Participating ............................... .f 3 Non-Assignable ................................. .f Page 2 SCHEDULE OF PAYMENTS Start Date End Date Amount Frequency 08/13/09 08/13/12 $9,015.00 Annually ANNUITANT tNFORMATION Name Sex Date of Birth Measuring Life: Amanda Grover Female 08/13/91 Contract Number: SSAL23904A Owner: A{Istate Assignrnent Company Issue Date: 02/02/09 Page 3 Policy Data Page For LU3406 APPLlCAT1ON FOR STRUCTURED PAYMENTS ~~~J~~~~'~~n Issued by Allstate Life Insurance Company, Yot~ retn,~rroa'x~iuls• 3100 Sanders Road, Suite M36, Northbrook, f L 60062 Phone:1-800-806-5528 Fax:1-847-418-4221 FIC281SSA (X) Allstate Assignment Company, 2920 S. 84th Street, Suite 161, Lincoln, NE 68506 Phone: 1-80()-525-2799 ext. 50E ()Allstate lntemational Assignments Ltd., Chancery House, High Street, Bridgetown, St. Michael E3arbados 8811128 Phone: 1-246-437-6034 () A l A Ltd. Annuity Trust, Chancery House, High Street, Bridgetown, St. Michael, Barbacio:~ B611128 Phone: 1-246-437-6034 Name Gender Amanda Grover __ __ __ t~A (X) F .- Street Address SSN~T'INlITII~J 739 Dogwood Terrace _ i 521-89-0341 __ City State o,.:r..,. e.. .,.,~ PA Birti~date (MM/DD/Y`(W) 08!' 3!1991 Zip 1'007 ~ -- - ~ _~. .• • .. - s . • • Name Gender Birtlidate (MM/DDlYYYY) Street Address SSN/TINl1TIN ~----- - ----- - City -- State Z,P ~-~ • + • . Name Same as Annuitant Gender ~M~- Birtndate (MM/7D/Y`i''YY) -_ _--__-_ -- _ Street Address SSN/TINIITIIV ---- ------ -- City - - _ -~-- State Zip - •~ •- • ~ A. Guaranteed Payments (Include additional payment information on a separate sheet of paper.) Start Date (MM/DD/YYYI~ Type(Certain or Lump Sum) Amount Number of FPayments _ Frequency of Paymer:ts T 08!1312009 Certain $9,015.00 4 annually B. Life Payments {Submit proof of age for Life or Joint Life Payments.) start Date IMMIDDIYYYYI Tvoe(life. lama life, joint) Amount _ Number of FF'aymants __ Frequen.y of Payments FIC281SSA Page 1 of 2 (C2lOS) •. • •.• '- .~• • 1 Birthdate Name , I Estate of Amanda Grover _ __, Street Address ()Primary (} Gontingent SSN/TIN/ITIN City State Zip Relationship to Owner Name Birt`~d~ate %, Street Address OPrimary OContingent S /T'IN/1TtN ' T~ City State Zip ~I Relationship to Owner __ .. ~ S1 + valuable premium r ( n ~Wrll?P'~19n~ttf~ lJBie ~I'~iM/VU/ T T T T J ~• • ~-_ _David Hays for Dan Weberg Cambridge GalGher Setgements . Broker Name (Please Print) cridhlnsurance Services, Inc. Broke- 5ign~ature _Cambridge Galaher Settlements !-1Q~+-rl~- ~.~g~,~ _ Firm 6 TIN FIC281 SSA Page 2 of 2 (0:?/08} . , BENEFICIARY--Unless changed by AAC, the beneficiary is as named in the application. If trrere is no t~ene- ficiary named or living, the beneficiary is the Measuring Life's estate. For purposes of this se~~tion, "living" shell mean living on the earlier of: ] . The day we receive due proof of the Measuring Life's death; or 2. The 15th day past the Measuring Life's death. Unless AAC states otherwise by irrevocably naming a beneficiary, AAC may change the benE~ficiary while the Measuring Life is alive. A change must be made to us in writing. The change must be acce~~table to u~~. Once we accept the change, it takes effect as of the day AAC signed the request. Each change is subjt~ct to any payment we make or action we take before we accept it. Any payments due a beneficiary will be paid on their specified due dates, and will ni;,~t k~e con'~muted or F3aid in a lump sum. INCONTESTABILITY--We may not contest this contract after it is issued. MINIMUM VALUES--The payments provided by this contract are not less than the rl~inimurn values required by the state in which this contract is sold. NON-PARTICIPATING--This contract does not pay dividends. NON-ASSIGNABLE--Payments may not be anticipated, assigned or pledgE~d as coliatE:ral. Payrnent dates and amounts may not be changed, either to provide for earlier payment or longer deferral. 'T'he c~~ntract ha:. no cash surrender or policy loan value. So far as the law allows, all payments to any person named by AAC to receive them are exe!-npt from that person's creditors, debts and contracts, and from seizure or attachment by court order cr othar legal process. Page 4 Single Premium Immediate Certain Annuity .Uniform Qualified Assignment and Release "Claimant" Amanda Grover "Assignor" Government Employees Insurance Company "Assignee" Allstate Assignment Company "Annuity Issuer" Allsttate Life Insurance Company "Effective Date" ~~'-~C/trl,~-~...-`1-.1 ~ ~ a~~`~'~ This Agreement is made and entered into by and between may be accelerated. deferred, ir-,creased or the parties hereto as of the Effective Date with reference to decreased and may not be anticipated, sod following facts: assigned or encumbered. A Claimant has executed a settlement agreement or 4 The obligation assumed by .Assignee w th respec.~ release dated: ~-; t ~ ~ C ` ~ I __ to any required payment shall be disch~irged upcn (the "Settlement Agree e Y') that provides for the mailing on or before the duE~ date of a v;31id the Assignor to make certain periodic payments to check in the amount specified t~ the address of or for the benefit of the Claimant as stated in record. Addendum No 1 (the "Periodic Payments"); and B The parties desire to effect a "qualified assignment" within the meaning and subject to the conditions of section 130(c) of the Internal Revenue Code of 1986 (the "Code"}. NOW, THEREFORE, in consideration of the foregoing and other good and valuable consideration, the parties agree as follows This Agreement shall be governed by and interpreted in accordance with -he laws of the State: of _ ~-~-_~~~__ ____ The ,Assignee may fund tfie Periodic Payments by purchasing a "qualified funding asset" within the meaning of Sectior. 131)(d) of the Code in the form of an annuity contract issued by the Annuity Issuer. All rights of rwnership and control as suc;n annuity c;ontraci 5hali be ano remain vested in the Assignee exclusively. The Assignor hereby assigns and the Assignee hereby assumes all of the Assignor's liability to make the Periodic Payments. The Assignee assumes no liability to make any payment not specified in Addendum No. 1. The Periodic Payments constitute damages on account of persona! injury or sickness in a case involving physical injury or physical sickness within the meaning of Sections 104 (a)(2) and 130 (c) of the Code. The Assignee's liability to make the Periodic Payments is no greater than that of the Assignor immediately preceding this Agreement. Assignee is not required to set aside specific assets to secure the Periodic Payments. The Claimant has no rights against the Assignee greater than a general creditor. None of the Periodic Payments The Assignee may have !:hs Annuity Issuer send payments under any "quaii~`ied funding asset" purchased hereunder directly to the pcyeels} specified in Addendum No.1. Such direction of payments shall be solely far the Assignee's comieniance and shall nat provide the Clai•ant or any payee with any rights of ownership or cantr_I over the "qualified funding asset' or against the Annuity Issuer. Assignee's liability to makE~ the Periodic Payments shall continue wif.hout diminution regardless of any bankruptcy of insolvency of the Assignor. In the event the Settlement Agreemert is declared terminated by a court of law or in the resent lhai Section 130(c) ol~ the Codr~ has not bE:en satisfied. this Agreement shalt terminate. The Assicnee shall then assign ownership cf any "qualifi~^d ~ e i , funding asset" purchased hereunder to Assignor. and Assignees liability for the Periodic Payments shall terminate. 10. This Agreement shall be binding upon the respective representatives, heirs, successors and assigns of the Claimant, the Assignor and the Assignee and upon any person or entity that may Assignor Government Employees Insurance Compan B Aut orized Re resentative r Title Claimant: {~ ~• ~,~~ ~. 1 _ Janet Grover, as P rent nd atural Guardian of Amanda Grover, a ~inprj .` ~ ~ ~/ Claimant: i ._. L--- Edward Grdv2r. as Parent and Natural Guardian of Amanda Grover, a minor Approved as to Form and Content: assert any right herE:undar ar to any of the Periodic Payments. 11 The Claimant hereby accepts the Assignee's assumption of all liabii~ty for the f~eriodic Payments and heresy reaeases the Assignor from all liability for the PE~riodic Faym~~nts Assignee. Allstate Assignment C:omEany___ B ~ ~ ' _ (..v~(~~ _ ' ~ zed RE~presentatr~e Title ~ 1, r ___---- --:.~ By' not applicable _ Cla+mant's Atfomey . 1 ) Addendum No. 1 Description of Periodic Payments Payee: Amanda Grover Benefits: Nine Thousand Fifteen Dollars ($9,015) payable annually for four (4) years guaranteed, beginning August 13, 2008 through and including August: '13, 2012. Initials: Claimant: ! - (JG) Claimant: •= -~'~ (EG) Assignor: (GEICO) Assignee: (AAC) SETTLEMENT AGREEMENT AND RI:LEASI: This Settlement Agreement and Release (the "Settlement Agreement") i.s madf; and entered into this ~ y "`~ day of ~~ ~ r -~, ~; •~, 20i; `( , by and between: "Claimant" Janet Grover, Individually and as Parent and Natural Guardian of Amanda Grover, a minor Edward Grover, Individually and as Parent and Natural Guardian of Amanda Grover, a rninor "Defendant" Jamie L. Grover, .fanet Grover, and F,dward Grover "Insurer" Government Cmployees Insurance Company RECITALS A. On or about ,tune 7, 2006, Amanda Grover was injured in an accident occurring on or near Creek Road, Boiling Springs, Pennsylvania. Claimant alleges that the a~;;cidcnt and resultant; physical and personal injuries are:~se out of certain alleged negligent acts or omissions of Defendant, and has made a claim seeking monetary damages on account of thC1SC 117)LIrICS. l3. ]usurer is the liability insurer of the Defendant, and as such, would be obli~~ated tr• pay any claim made or.judgment obtained against Defendant, which is covered by its poli~~y with Defendant. C. "I•he parties desire to enter into this Settlement Agreement in order to provide far certain payments in full settlement and discharge of all claims which tutee, or might he made, by reason of the incident descrihed in [Zecital A above, upon t.hc~ terms ar-d conditions set forth below. ACI2EEMENT The parties agree as follows: 1.0 RELEASE AND D[SCHARGE 1.1 Inconsideration of the payments set forth in Section 2, Claimant hereby completely releases and (arever discharges Defendant. and Insurer from any and all past, present or future claims, demands, obligations, actions, causes of action, wrongful death claims, rights, damages, costs, losses of services, expenses and compensatic-n of any nature whatsoever, whether based on a tort, contract or other theory of recovery, which the Claimant now has, or which may hereafter accrue or otherwise be acquired, on account or, or may in any way grow out of the incident described in Recital A. above, including, without limitation, any and all known or unknown claims for bodily and personal injuries to Claimant, or any future wrongful death claim of Claimant's representatives or heirs, which have resulted or may result from the alleged acts or omissions of the 1[}efendant. 1.2 This release and discharge shall also apply to Defendant's and Insurer's past, present and future officers, directors, stockholders, attorneys, agents, servants, representatives, employees, subsidiaries, affiliates, partners, predecessors and successors in irltf;rest, and assigns and all other persons, firms or corporations with whom any of t:he former have been, are now, or may hereafter be affiliated. 1.3 This release, on the part of the Claimant, shall be a fully bindirc; and complete settlement among the Claimant, the Defendant and the Insurer, and their heirs, assigns anc. successors. 1.4 The Claimant acknowledges and agrees that the release and discharge se:t forth above is a general release. Claimant expressly waives and assumes the risk of any and all claims for damages which exist as of this date, but of which the Claimant does not know car suspect to exist, whether through ignorance, oversight, error, negligence, or otherwise:, and which, if known, would materially affect Caaimant's decision to enter into this Settlement Agreement. The Claimant further agrees that Claimant has accepted payment of tL~e sums specified herein as a complete compromise of matters involving disputed issuea of law and fact. Claimant assumes the risk that the facts or law may be other thane Claimant believes. It is understood and agreed to by the parties that this settlement is a cocnpromis~~ of a doubtful and disputed claim, and the payments are not to be construed as an admission of liability on the part of the Defendant, by whom liability is expressly denied. 2.0 !'AYMENTS Inconsideration of the release set t~~rth above, the Insurer on behal:r'ol'thc Defi:;ndant agrees to pay to the individuals named below ("Payees")the s~nrs outlined in this Section 2 below: 2.1 Payments previously made as Ibllows: It is acknowledged that Insurer has previously made payment(s) in the amount of Four Thousand Two Hundred Forty-seven and 02/100 Dollars ($4,247.02) in satisfaction of a medical lien for medical care rendered to Amanda Grover. 2.2 Periodic payments made according to the schedule as follov,~s (the "Periodic Payments"): Payee: Amanda Grover Payments in the amount of Nine Thousand Fifteen Dollars ($9,015) payable annually for four (4) years guaranteed, beginning August 13, 2009 through acrd including August 13, 2012. All sums set forth herein constitute damages on account of personal physical injuries or sickness, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986. as amended. 3.0 CLAIMANT'S RIGHTS TO PAYMENTS Claimant acknowledges that the Periodic Payments cannot be accelerated, deferred, increased or decreased by the Claimant or any Payee; nor shall the Claimant or any Payea .. have the power to sell, mortgage, encumber, or anticipate the Periodic Payment:>, or any part thereof, by assignment or otherwise. 4.0 CLAIMANT'S BENF,FICIARY Any payments to be made after the death of any Payee pursuant to the terms of this Settlement Agreement shall be made to the Estate of Amanda CJrover or to such person or entity as shall be designated in writing by Payee, after attaining age of r.lajority, to the Insurer or the Insurer's Assignee. If no person or entity is so designated by Payf:e, or if the; person designated is not living at the time of the Payee's death, such pa}~ments shall be made to the estate of the Payee. No such designation, nor any revocati~an thereof, shall be effective unless it is in writing and delivered to the Insurer or the Insurer's Assignee. The designation must be in a form acceptable to the Insurer or the Insurer's Assignee before such payments arc made. 5.0 CONSENT TO QUALIFIED ASSIGNMENT 5,1 Claimant acknowledges and agrees that the Delendant and/or t:he Insurer may mab:e a "dualilied assignment", within the meaning of Section 130(c) of the Internal R.evcnue Code of 1986, as amended, of the Defendant's and/or the Insurer's liability to rnakc the Periodic 1'aymcnts set lorth in Section 2.2 to Allstate Assignment Company ("the Assignee"). The Assignee's obligation liar payment of the Periodic Payments shall be no greater than that of Defendant and/or the [nsurer (whether by judgment or agreement) inunediatcly preceding the assignment of the Periodic Payments obliga~ion. 5,2 Any such assignment, if made, shall be accepted by the. Claimant without right of rejection and shall completely release and discharge the Defendant and the; (nsurer from tl-~e Periodic Payments obligation assigned to the Assignee. "the Claimant recognizes that, in the event of such an assignment, the Assignee shall be the sole obligor •with respect to the Periodic Payments obligation, and that all other releases with respect to the Periodic Payments obligation that pertain to the liability of the Delendant and the Insurer shall thereupon become final, irrevocable and absolute. 5.3 Allstate [,ife Insurance Company will issue a Statement of Guarantee that will guarantee the future obligations o1~Allstate Assignment Company. 6.0 1tIGHT TO PURCHASE AN ANNUITY The Defendant and/or the Insurer, itself or through its Assignee, reserves the right to fund the liability to make the Periodic Payments through the purchase of an anr..uity polic;r from Allstate Life Insurance Company I;the "Annuity Issuer"). The Defendant, the ]nsurer, or the Assignee shall be the sole owner of the annuity policy and shall have all rights of ownership. The Defendant, the Insurer, or the Assignee may have the Annuit:r Issuer mail payments directly to the Payee. The Claimant shall be responsible for maintaining a currf~nt mailing address for Payee with the Annuity Issuer. 7.0 DISCHARGE OF OBLIGATION The obligation of the Defendant, the Insurer and/or Assignee to make each Periodic Payment shall be discharged upon the mailing of a valid check in the amount of such payment to the designated address of the Payee(s) named above, or 11zc deposit by electronic . . funds transfer in the amount of such payment to an account designated by the .Payee(s). If, after the due date, the Payee(s) notifies the Assignee that payment was -zot received, the Assignee shall direct the Annuity lssuer to initiate a stop payment action. Upon confirmation that such check was not previously negotiated or electronic funds transfer deposited, Assignee shall promptly direct the Annuity Issuer to process a replacement payment. 8.0 ATTORNEY'S FEES Each party hereto shall bear all attorney's fees and costs arising from the actions of its own counsel in connection with this Settlement Agreement, the matters and documents referred to herein, and all related matters. 9.0 REPRESENTATION OF COMPREHENSION OF DO('CII~IENT' In entering into this Settlement Agreement the Claimant represents that Claimant has relied upon the advice of his/her attorneys, who are the attorneys of his'her oven choice, concerning the legal and income tax consequences of this Settlement Agreement; that the terms ol• this Settlement Agreement have been completely read and explained to Claimant by his/her attorneys; and that the terms of this Settlement Agreement are fully understood and voluntarily accepted by Claimant. 10.0 WARRANTY OF CAPACITY TO EXECUTE AGIZEElv1EN'T 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 tl~-is Settleme:~t Agreement, except as otherwise set forth herein; that Claimant has the ~.olc right and exclusive authority to execute this Settlement Agreement and receive tl:ae. sums :;pecilicd in it; and that Claimant has not sold, assigned, transferred, conveyed or otherwise disposed of any of the claims, demands, obligations or causes of action relerred to ii n this Settlement Agreement. 11.0 CONFIDENTIALITY "l~he parties agree that neither they nor their attorneys nor representatives shall reveal to anyone, other than as may be mutually agreed to in writing, any of the terms of i:his Settlement Agreement or any of the amounts, numbers or terms and conditions ~af any sums payable to Payees hereunder. 12.0 GOVERNING LAW This Settlement Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. 13.0 ADDITIONAL DOCUMENTS All parties agree to cooperate filly and execute any and all supplementary documents and to take all additional actions, which may be necessary or appropriate to give full force and effect to the basic terms and intent of this Settlement Agreement. 14.0 ENTIRE AGREEMENT AND SUCCESSORS IN INTEREST This Settlement Agreement contains the entire agreement between the Claimant and tl•~e Insurer with regard to the matters set forth in it and shall be binding upon and enure to the benefit of the executors, administrators, personal representatives, heirs, successors and assigns of each. 15.0 EFFECTIVENESS This Settlement Agreement shall become effective immediately following execution b}~ each of the parties. Claimant: Janet Grover, Individually Arid as Parent and N,~tural Guardian oPAmand~:~ Grover, a minor ~. / Date: ~ ~ ~ ' ~~ _ ____ Amanda's Addre s: 73 Dogwoo Terrace Boiling Springs, P,~1 17007 Claimant: - Edw-dr rover, Individually and as Parent and ~~ Nr ur L, ~ ardian of Amanda Grover, a mini~r - .. ~~ llate: ~ ~' ! ~ r Insurer: Government Employees Insurance Company By: ------------ Title: ~ _ _ __ Uate:~- ~-~ -------- -- 06/~37/280y 1b:.5b tiUf`II`'ItKt r'1C,L!IJNNtLL HUllUc~K UU I HK 1 t ~ 1~k'I (:~g5~b~.7 NU.74t~ Wb` ~ e i f ~'~ , ~I~ 1 ~ V ~0~~ ~A Y - iN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVAMA IN RE: AMANDA DROVER, a minor CiVlt, DIVISION N O. .0~' • 34 to 1 ~V,i 1 Er'~k (Jury Triai Demanded) ORDER AND NOW, this ~ day of , 2Q09, up~an cons~ideratian afi the Petition for Apprgval of MinQr'S Claim, it is herby ORDERED that the Petitioner is authorized to enter into a settlement in the gross sum Qf $35,000. The settlement amount shall be distributed as outlined in the Settlement Agreement and Release and Unifiorm Qualified Assignment as attacheli hereto as Exhibit "1 ." TOTAL AMOUNT OF C~ISTRISUTION: $35,000. Counsel shall provide to the Court, within thirty (30} days from the date of this Order, proof of Such deposit. SY,~iE COURT. .J. Distribution to' Kevin D. Rauch, Esquire Summers, McDonnell, Hudock, Guthrie & Sksel, ~.L,P. 100 Sterling ParKway, Suits 306 Mechanicsburg, PA 17050 Edward and Janet Grover n ~:~ , 739 Dogwogc! Terrace 13oiiing Springs, PA 17007 ~~~ ~~p~ F~Q7~ R~~~~ -'' ~~ ~': ~ ~, PR 7B~~PfrM~ijl Wf18P~i.1 ~1lPf0 Urit4 S6t rit~l han+ ~ - r~ ; ? ;~- :: , . ._. ," ~;~ r-: ~ .. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTI', PEN~JSYLVANIA IN RE: CIVIL DIVISION AMANDA GROVER, a minor NO. (Jury Trial Demanded) PETITION FOR APPROVAL OF MINOR'S CLAIM AND NOW, comes the Petitioner, Government Employees Insurance Company (hereinafter "Geico"), by and through their counsel, Summers, 1~1cDonn~~l1, Hudock, Guthrie & Skeel, L.L.P., and Kevin D. Rauch, Esquire, and files the followincl Petition for Approval of Minor's Claim and in support thereof avers as follows: I. FACTUAL BACKGROUND 1. This matter arises out of an automobile accident which occurred on J~.ne 7, 2006. (The Police Crash Reporting Form of the Pennsylvania State Polic;E~ is attacl'~ed hereto as Exhibit "A."} 2. On this date, the minor, Amanda Grover, was a passenger in a vehicle being driven by Jamie Grover, her sister. 3. According to the police report, Jamie Grover was traveling vrE~st on CrE~ek Road, Cumberland County, Pennsylvania. As Jamie Grover was attE~mpting to negotiate a curve, she exited the north berm where her vehicle impacted with a tree. (See Exhibit ..A „) 4. The driver of the vehicle, Jamie Grover, was traveling appr~~ximately 40 miles per hour on a roadway which was zoned for 35 miles per hour. Acc~~rding to the police report, Jamie Grover lost control of her vehicle as a result of "lost traction" ~~nd thereby impacting with the tree. (See Exhibit "A.") ~ r II. PARTIES 5. Jamie Grover was born on March 17, 1987, and resides with her father, Edward Grover and mother Janet Grover at 739 Dogwood Terrace, Bailing Springs, Pennsylvania 17007. 6. Janet Grover is the mother of Jamie Grover and 'the minor, Amanda Grover and was owner of the 1995 Nissan Quest which was involved in the above referenced accident. 7. Amanda Grover was born on August 13, 1991, and resides with her father, Edward Grover and mother, Janet Grover, at 739 Dogwood Terrace, Bc-iling Springs, Pennsylvania 17007. III. ANALYSIS OF DAMAGES 8. As a result of the accident, the minor, Amanda Grover, was transported via West Shore EMS to Holy Spirit Hospital in Camp Hill, Pennsylvania. (Amanda Grover's medical records from Holy Spirit Hospital are attached hereto as E=:~hibit "B.") 9. On the date of the accident, the Plaintiff underwent. a CT scan of the abdomen at Holy Spirit Hospital which showed evidence of a sple~enic Ia~:,eration, but with minimal hemorrhage around the spleen. Additionally, the Plaintiff underwent x-rays of the ribs which showed non-deforming fractures of the left 9th and '10th ribs. 10. As a result of the diagnostic screenings, the minor was transferred to Penn State Milton S. Hershey Medical Center for further evaluation. (Amanda Grov~r's medical records from Hershey Medical Center are attached hereto as Exhibit "C.") 11. The Plaintiff was discharged on June 11, 2006, with a diagnosis of Grade III spleenic laceration. t ,~ ~ • 12. The Plaintiff returned to Penn State Hershey Medical Cente~ on July 5, 2006, for afollow-up in regards to her injuries. It was noted that the minor 'was now four weeks out from her spleenic injury and was doing well. It was recammer~ced that she refrain from any significant activities for an additional two months and th~~t the minor need not return unless any additional further problems. (See Exhibit "C"). 13. At this time, Amanda Grover has made a full recovery from the injuries suffered as a result of the instant accident. IV. COVERAGE AND SETTLEMENT 14. Amanda Grover was insured by Geico Insurance, as a dependent under Janet Grover's policy with liability limits in the amount of $100,0)00.00 per person/ $300,000.00 per accident. (See Certificate of Coverage attached hereto as E=xhibit "D.") 15. The minor's parents, Edward and Janet Grover, have agreed to settle the above matter for a total of $39,247.02. (The Uniform Qualified Assignment ~~nd Release forms as well as the Settlement Agreement and Release are attached herei:o as Exhibit .. E „) 16. A payment in the amount of $4,247.02 was made by (:~eico directly to the US Treasury/Office of Staff Judge Advocate for a Tricare Lien. 17. The within Petition seeks approval of settlement far thE~ remaining $35,000.00 as provided for in the Uniform Qualified Assignment and Release. 18. The remaining $35,000.00 will be placed in a structured settlement of $9,015.00 annually, guaranteed for four (4) years beginning on August 1:5, 2009, wrien the minor reaches the age of eighteen (18). ! ' ~ ~ 19. In the interim period, the settlement proceeds will be held in .an annuity as GEICO has assigned all future payments obligations to Allstate Lifer Insurar~ce Company, which is rated A+, XV by Best's, AA by Standard and Paor's, Aa3 by Moody's. 20. A payment in the amount of $35,000.00 was forwarded to Allstate Insurance Company by GEICO on February 2, 2009 for purchase of the above- referenced annuity with a policy number of SSAL23904. (See Correspondence of Allstate Insurance Company date April 10, 2009, attached hereto as Exhibit "F.") 21. The Qualified Assignment and Release has been executed by GE1C0 as well as the minor Plaintiffs parents. Allstate Insurance Company will execute the agreements once this Honorable Court has approved the settlement terms. WHEREFORE, the Petitioner, Geico, respectfully requests that th~i:~ Honorable Court enter an Order approving the settlement and compromise of Amanda Grover's claim. Respectfully submitted, SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, L.L.P. ~' ~; ' By: vin-~" Rauch, Esquire unsel for Petitioner, vernment Employees Insurance Company R VERIFICATION We, Edward and Janet Grover, parents and natural guardians of Amanda Grover, a minor, do hereby verify that averments of facts contained in the Pel:ition to Compromise Minor's Claim are true and correct to the best of our knowledge, inforrnation a~~d belief. We understand false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904 relating to ur Dated: "I Z~l U~ Dated: ~~ ~ V~ #16837 r r r , ~' A fir- T~?c ~;:,:u ~ i-rw~~Y~ ~,~Y 2~G~ J4"_ -2 F~~ 2~ 2 ~ ~ ' y (__~ (t(t { 't..! ~ t/.~~~~ )1 tit ~