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09-5999
Metzger, Wickersham, Knauss & Erb, P.C. By: Clark DeVere, Esquire Attorney I.D. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 Attorneys for Petitioners (717) 238-8187 cdv(a),mwke.com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: DEREK FORGIE NO. Oq - 5n9 li?vi 1?°rrM PETITION FOR APPROVAL OF SETTLEMENT OF MINOR'S CLAIM Derek Forgie, a Minor, by Ashley Harris, Parent and Natural Guardian of Derek Forgie, by and through their undersigned counsel, Metzger, Wickersham, Knauss & Erb, P.C., respectfully petition this Court for approval of a settlement of a minor's case in accordance with Pa.R.C.P. No. 2039 and in support of the Petition aver as follows: 1. Petitioner, Ashley Harris, is an adult individual residing at 9 Brandywine Drive, Mechanicsburg, Cumberland County, Pennsylvania. 2. Petitioner is the parent and natural guardian of minor Derek Forgie, who resides with her and his step-father, and who is 9 years old, having been born on February 3, 2000. 3. Minor Petitioner Derek Forgie has selected Petitioner, as his parent and natural guardian, to represent his interests in this Petition. Minor Petitioner Derek Forgie's biological father, Justin Forgie, has been in and out of prison for the past six years and Petitioner has had primary custody of Minor Petitioner all his life. In addition, by Order of Court dated May 4, 394258-1 2001, Petitioner was granted sole legal custody of Derek. (See Exhibit "J" attached hereto and incorporated herein by reference). 4. This case arises out of a dog attack on February 28, 2008 at or about 3:50-4:00 p.m. at the residence of Ann and Josh Auxer located at 4135 Kittatinny Drive, Mechanicsburg, Pennsylvania, 17050 (hereinafter "Residence"). 5. At the aforesaid time and place, minor Petitioner, Derek Forgie was at the Auxer home. They were making hot dogs and Ms. Auxer's son was handing a hot dog over to minor Petitioner. The Auxer's dog, Tyson, jumped up and bit Derek on the upper lip and scratched him. See Department of Health Animal Bite Report attached hereto and incorporated herein by reference as Exhibit "A". 6. After the incident, the dog was euthanized at the Willow Mill Veterinary Hospital. See letter dated February 29, 2008 attached hereto and incorporated herein by reference as Exhibit "B". 7. Derek was taken to the emergency room of the Holy Spirit Hospital at approximately 4:20 p.m. where it was reported that he was bitten by his babysitter's dog. On examination, the doctor noted that the bite occurred on the upper lip and the lip was avulsed. The doctor recommended that minor Petitioner be taken to the Hershey Medical Center for further treatment, as they were not equipped to handle the injury Derek sustained. A call was made to the Hershey Medical Center informing them that Derek was arriving at their facility and advising them of the extent of the injury. 8. The Hershey Medical Center Emergency Room medical records indicated that Derek had a couple of superficial abrasions over his neck and lower jaw. His upper lip had a large laceration with a partial avulsion in the middle of his lip, 3 cm in length on the outside and his 394258-1 • • laceration extended to the buccal surface of his upper lip. The plastic surgery department was consulted and they sutured the lip. Augmentin was prescribed and Derek was instructed to follow up with the plastic surgeon in 5 days for the suture removal. 9. On March 4, 2008, Derek returned to the Hershey Medical Center to have the sutures removed from his lip. On examination, the doctor noted the laceration was healing well and removed the sutures. The doctor then placed steri-strips on the laceration and instructed Derek's parents to apply the tape as needed and to return on a needed basis. 10. On June 10, 2008, Derek reported to Dr. Wolf of Cosmetic Surgery by Wolf, P.C. At that time, it was reported that Derek was bitten by the babysitter's dog and had to undergo reconstruction of the vermillion. On examination, the doctor noted marked hyperemia of the scar and thickening. The doctor took photos of the scarring and recommended laser treatment to reduce the scar tissue and thickening. The options were discussed and an appointment was scheduled to undergo a laser treatment. 11. On August 19, 2008, Derek returned to Dr. Wolf to undergo his first laser treatment. Derek underwent the procedure without any complications. 12. On September 8, 2008, Derek returned to Dr. Wolf to undergo his second laser treatment. Derek again underwent the procedure without any complications. At that appointment, the doctor informed him he did not need to return for three months. 13. On December 1, 2008, Derek returned to Dr. Wolf. At that time, the doctor noted the scar tissue had softened nicely and no laser treatment was needed. The doctor recommended that Derek return in February for a one year check-up. 14. On February 27, 2009, Derek returned to Dr. Wolf. At that time, the doctor noted the upper lip was healing nicely and released Derek from his care to return on an as needed 394258-1 0 0 basis. Minor Petitioner has not had any further treatment for the injuries she sustained in this dog bite. See medical records attached hereto as Exhibit "C" and incorporated herein by reference. 15. Photographs of Derek taken immediately after the attack and at different intervals during his treatment are attached hereto and incorporated herein by reference as Exhibit "D". 16. Ann and Josh Auxer were covered by homeowner's insurance through Nationwide Property & Casualty Insurance Company at the time of the incident. 17. Nationwide Property & Casualty Insurance Company has offered $75,000 to minor Petitioner to settle his claim for the within incident on behalf of Ann and Josh Auxer. Nationwide previously made a payment of $1,000.00 under the medical payments coverage to the minor Petitioner and the $1,000.00 would be deducted from the $75,000.00. 18. Derek's's medical expenses arising out of the attack on February 28, 2008 total $2,753.40. Nationwide has paid the medical payments coverage of $1,000.00 of which $615.00 was applied to the outstanding medical bills with Cosmetic Surgery by Wolf, P.C. The remainder was placed in trust and will be applied to any outstanding medical bills and/or medical liens. See medical billing summary and medical bills attached hereto and incorporated herein by reference as Exhibit "E". 19. Highmark Blue Shield has paid to date medical benefits in the amount of $1,019.55 and they have asserted a lien. See Consolidated Statement of Benefits attached hereto and incorporated herein by reference as Exhibit "F" 20. The Petitioner, after consultation with counsel, has determined that the total proposed settlement and the gross sum of the recovery is $75,000 is in the best interest of Derek to accept and to seek a Court approval of that amount at this time. 394258-1 LI 21. The Petitioner has retained the services of the law offices of Metzger Wickersham to represent her and Derek and has agreed to pay a twenty percent (20%) contingent fee to said attorneys. A copy of the Contingent Fee Agreement between the Petitioner and her counsel is attached hereto, incorporated by reference herein and marked as Exhibit "G". Counsel's attorney fee at 20% would be $15,000.00. 22. The Petitioner has further agreed to pay out of the recovery any and all costs incurred or advanced on Derek's behalf The amount of the costs that were incurred and advanced by Metzger Wickersham total $266.35. An itemization of these costs is attached hereto, incorporated by reference herein and marked as Exhibit "H". 23. Therefore, the following are the deductions from the gross recovery of $75,000: TOTAL AMOUNT OF SETTLEMENT $75,000.00 Attorney fees $15,000.00 Attorney expenses $ 266.35 Highmark Blue Shield $ 1,019.55 Balance of medical payments $ 385.00 Dr. Wolf's bills paid $ 615.00 $17,285.90 $57,714.10 24. Petitioner proposes to place her son's settlement proceeds in a federally insured restricted savings account or a certificate of deposit at a bank, credit union or savings and loan association organized or existing under laws of the Commonwealth of Pennsylvania in the name of her son. 394258-1 25. Petitioner has also been requested to sign the Release attached hereto as Exhibit "I" and incorporated herein by reference, upon approval of the settlement, which would release the Ann and Josh Auxer and Nationwide Property & Casualty Insurance Company from any further claims by minor Petitioner or on his behalf as a result of the incident at issue. 26. The Auxers, through the liability insurer, Nationwide Property & Casualty Insurance Company, concur with the filing of this Petition without admission of any liability or the damages and also seek approval of the minor settlement under the terms set forth above. 27. Petitioner will file an Proof of Deposit of Minor's Funds with the Court within ten days of distribution of the proceeds. WHEREFORE, Petitioner, Derek Forgie, a Minor, by Ashley Harris, his Parent and Natural Guardian, respectfully requests that this Honorable Court approve of the minor settlement and enter a Decree distributing the funds as outlined above. Respectfully submitted, METZGER, WICKERSHAM, KNAUSS & ERB, P.C. By: /?__ Clark DeVere, Esquire Attorney I.D. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 (717) 238-8187 Dated: August N, 2009 Attorneys for Petitioner 394258-1 0 0 VERIFICATION I, Ashley Harris, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Settlement, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unworn falsification to authorities. Ashley Harris, e t and Natural Guardian of Derek Forgie Dated: S- U-69 394258-1 L? VERIFICATION The undersigned hereby certifies that he is the attorney for Petitioner, Ashley Harris, as parent and natural guardian of minor Derek Forgie, and that the facts in the foregoing Petition for Approval of Minor Settlement are true and correct to the best of his knowledge, information and belief, and that said matters relating to the Petition for Approval of Minor Settlement are as known to the undersigned as to the clients, Derek Forgie, by Ashley Harris, his parent and natural guardian, said knowledge being based upon information contained in the attorney's file in this matter, and further states that false statements herein are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unworn falsification to authorities. Dated: g?a?l?4 Clark DeVere, Esgmre 394258-1 0 0 CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a true and correct copy of the foregoing Petition for Approval of Minor Settlement with reference to the foregoing action by first class mail, prepaid postage, this 24 0- day of August, 2009, on the following: Ann and Josh Auxer 4135 Kittatinny Drive Mechanicsburg, PA 17050 Barbara Noce Nationwide Property & Casualty Insurance Company P. O. Box 2655 Harrisburg, PA 17105 c Clark DeVere, Esquire 394258-1 Exk1i;i-4 i PLEASE FAX TO: (717) 241-3171 Cumberland County State Health Center 431 E. North St. r DEftTMENTOF Carlisle, PA 17013 j Phone: (717) 243-5151 HEALTR Fax (717) 243-3171 ) ...in pursuit of good health ANIMAL BITE REPORT CONFIDENTIAL - PA DEPARTA1ENT OF HEALTH VICTIM'S NAME i':'X Age_ Parent (if minor child) Last- First ? i ?- l.5 Address l a 3 7 f}„ r S ; ??; JD tz `?5 b? '1 t. ?/ { County. C., :,, art Street Phone (Home) 71 ;? --C 519 City (Work) 691 j) 3 i cl _ ( t:i ? J J Address and Phone Number of victim for the next 10 days if different than above " OWNER'S NAME 'XfsT, +i nr: Phone (Home) (Work)C'?17) Last .,First _ ?..._?. IC` C . Address ?ZCounty u;r`1 i 11i4; Street City Type of animal: () Dog ail Cat [ ] Other [ ] If other, what type of animal r 13tyiV () Pet Stray [ ] Wild [ ] Bree"1? p Color hto;_.,1 rv Age f 2--Sex Date of Last Rabies Vaccination animal vaccinated prior to that date? O Yes ?<No [ ] G C eterinarian's Name V?) i I 1 i ?? hone Address 701 DATE OF INCIDENT (Indicate the date bite occurred) O Place bite occurred: () Owner's home [pJ? Victim's home [ ] Other [ ] If other, what location? What caused animal to bite? (Describe circumstances) _? ?- This is a: () Bite Scratch [ ] Other [ ] Part of Body Affected per?Z L- Q Describe Wound. O Skin Broken:: Yes [ ] No (] If Yes, Superficial [ 1-ep [ ] Other DATE OF TREATMENT Facility Where Treated Name of Physician Phone Type of Treatment: O Wound Cleansed [ ] Antibiotic [ ] Tetanus [ ] HRIG [ ] HDCV (Rabies Vaccine) [ ] PCEV (Rabies Vaccine) [ ] Other [ ] Comments: Person Completing Form: Name Phone Address Rev. 112000 DOH - 40 LOG # Ddate Report Received #4 fx?,? i WILLOW MILL VETERINARY HOSPITAL 1 1 WILLOW MILL PARK ROAD MECHANICSBURG, PA 17050 TELEPHONE: (717) 766-7981 February 29, 2008 r ;, 4 44 To whom it may concern, "TYSON", a Shar Pei, owned by Ann Auxer of 4135 Kittatinny Drive in Mechanicsburg, PA was euthanized at our office this morning. If you have any questions regarding this matter, please feel free to call. Sincerely, Jennifer D. Gilbert Ll 1] ?.J 0 ?x 0 • CERTIFICATION The copies of records for which this certification is made are true and complete reproductions of the original or microfilmed medial records of: (print name of medical provider) The original records were made in the regular course of business at or near the time of the matter recorded. The certification is given pursuant to 42 Pa.C.S. Ch. 61 Subch. E (relating to medical records) by the custodian of the records in lieu of his or her personal appearance. Patient: Derek A. Forgie DOB: 2/3/2000 Medical Record No.: Number of Pages: Dated: Pri t am . Subscribed and Sworn to before me / this aVAJ day of , 2008. Notary P . is My commission expires on: ewer No" Poft CM?1?110?OrM?. Mir Co?M?Non ??Mt ? 1t. ? . swam ?`_')HOLY ,SPIRIT PATIENT FACESHEET ri e3 an ?)ySiem MEDICAL RECORD# C Hill, PA 17011 428310 SURGERY DATE SOCIAL SECURITY NO NURSE STA ROO 4/BED A. )MIT DATE / TIME HOSP SRV PT TYPE CLINIC CODE PATIENT ACCT # 202-78-4199 I 02/28/08 17:10 ERi E ER1 31691843 IN CLASS AGE DATE OF BIRTH RACE SEX MS CHURCH / R. PREF AMBULANCE ADM REG DATE / TIME CONFID REG BY F 8 02/03/2000 1 M S NO CONNECTION TO ANY 0 tMbl*ATIFIED OR UNKNO EF! 1 I 02/28/08 17:16 N ADEMG FORGIE DEREK ANDREW 1237 HUNTERS RIDGE DR AM CHILD , I 1 IMECHANICSBURG, PA Tp F 1''050 IL , 0 EO _/ - 732-6919 PHOTOID N Y T R GEO CODE LANGUAGE ENGLISH OCCUPATION HARRIS ASHLEY MI GE 1237 HUNTERS RIDGE DR UM MECHANICSBURG, PA R F 17050 AL CAMP HILL, PA 17011 717 - 732-3830 OR R RELATIONSHIP M R HAINES MELISSA C 9 BRANDYWINE DR EC N MECHANICSBURG PA T , 17050 EN RT ' A A T RELATIONSHIP P N RELATIONSHIP T i tE PHONE 717 - 697 -2819 Y 2 HOME PHONE - VvoRK PHONE WORK PHONE PLAN CODE 311 INS CO BLUE SHIELD PLAN CODE INS CO POLICY # ZAR112151810001 N POLICY # GROUP # s GROUP # # AUTHORIZATION # R # AUTHORIZATION # ADDRESS PO BOX 8903.73 CAMP HILL PA 17089 N2 ADDRESS 111 PHONE # VERIFIED PHONE # VERIFIED SUB NAME FOP.GIE , DEREK MIA Y E SUB. NAME: MI REL TO PT S PRIORITY 1 REL TO PT T PRIORITY PLAN CODE INS CO PLAN CODE INS CO POLICY # I POLICY # GROUP # s GROUP # # AUTHORIZATION) # # AUTHORIZATION # s ADDRESS R A4 ADDRESS PHONE # VERIFIED C PHONE # VERIFIED SUB NAME MI E SUB. NAME MI REL TO PT PRIORITY REL TO PT PRIORITY ACCID ENT ESCRIPTION ACC. DATE / TIME / IND. PRIVACY NOTICE { OG BITE ON LIP AT BABYSITTER 02/28/08 15:45 H 2/28/08 V01 ER EMG OMMENTS --- )X ELIG DMITTING DX. ADMITTING DR. 180018 ED GROUP 1 ATTENDING DR. 180018 ED GROUP V?1?f?" lAJ REFERRING QR. 159707 1 f DMITTING COMPLAINT BROUGHT BY: AMBULANCE SERVICE: IG -^.E ON LIP MOTHER MH 9 428340 ERl ER MEDICAL RECORD FORGI DEREK ANDR!-:V'! PT AGGT # 31691843 8 M. • ?? Date: ZI TRIAGE ACUITY: 1 C.? 4 5? Mode of Arrival: OALS CBLS DMC POLI Lo in Name: r. C CE g : A9 e: X ' ale female DW/C DCARRIED DOTHER lime -- Primary Language: 4 ish ? Hard of hearin Triage- PCP. ?C l n i C? l ?unknown f lnooe OOth g t ? ?• er: erpreter: Room: ye -? rxne l,t I.cF C PLAINT / WHAT BROUGHT YOU IN TODAY? PAIN HISTORY O pt. denies pain -? / ?Can't Assess due to severity of pis conditionl n bl t ?B b set (Dafe/Time for accident) Oho rs Odays Oweeks u a o answer e y a Location: ? Intensity: HPI: - 0 1 2 3 4 5 6 - 7 8 9 10 1 ,ML I, Uib Y-- F- wa- WIK,-, w- Duration Frequency: Dconstant Dintermittent Character: G. PULSE 112- TEMP C?r_ Il0 RESP Onormal O a /min SPO % WEIGHT ? ?Sharp Drell ?Buming DArhe ?Pressure min Dlabored ON: 0scale liputo ?regular ?Oral panic ?n sal flaring ?stridor get tions ?A ?NRB ?astimatae OThrobbing ?RadiatingONon-radiatin ? Manual D irregular D Recta Axill ry a pig tory grunt taut:1 wheezes ? 02 _Umin i;*ated g Rapid Triage Signature RN Time __? What relieves pain? 7/ \ r ?nothing Drest OOther: OBJECTIVE DATA: 0 See Nursing Assess. page Unable to complete due to: D Severity of Patient Condition D CPR fn progress D Uncooperative Opt. Clothing NEURO/ BEHAVIOR CHILD SKIN MUCOUS MEMBRANES MUSCULO-SKELETAL Dn/a O Cooperative - Awake - Alert ? Appropriate ?Warm 0Dry C Norm. Co lor ?Sktn Intact (visible) DPink / Moist Extremity: DOriented-Person words/ response DCool DDiaphoretic ?Abrasion ?Rash DPale DCyanotic Extremity color:?WNL 0Oriented-Place DConsolable, OHot DTenting DEcchyrnosis DBurn ?Dry OCracked OMottled OCyanotic ?Oriented-Time inappropriate words ?Pale DFlushed OPuncture Wound DBleeding On/a Skin Temp ?Warm OCool ?Agitated DUncooperative ?Persistent ?Ashen DMottled DLaceration/Avulsion OControlled DistafPulses ?Present C, Not palp. ?Verbally Abusive 0 Combative inappropriate crying/ DCyanofic DJaundice DNot Controlled Edema DYes ONo DAnxious OCrying screaming Location: Deformity OYes DNo ? Disoriented ? Moans to pain vv? Ecch rtlosis DYes ?No PRE-HOSPITAL HISTORY SCREENING -' Signs: ?Pre-nosp EKG done I PPAH Checklist: T tQr as-stated by patient I I Durable to obtain info due to severity of pt Pulse Resp ?iAl DPVD CPE ?Cancer DNiDDM ?lmrr.unosupressed i condition/unable to answer Rhythm: DCAD ?CHF ?COPD ?Seizures DIDDM OTransplant I <7 Exposure to measles, chickenpox. or Airway: OCard ac Stert ?HTN ?Asthma OThyroid DDepression DLiver Disease TB in past month? /?no Dyes ?Nasal pOral ?ET( Size: DCABG DCVA ?Smoker DArthritis DDementia DGERD C Advanced DIrecti4es? ," Oxygen: Room air sat % Other: ro Dye-` ?NC Umin I attached: Dyes ?Non Re-breather % Surgeries: O Suspected Adult / Child abuse; IV Therapy, oo Dyes Dextrostick: - (If yes ee nurses notes) Medications: ® Last Tetanus ALLERGIES: C Childhood Immunizations o to ?ASA 81mg - 4 tabs p.o. ` r y / ?Cervical Immob. Device ?Collar LATEX ALLERGY? DYe?B CUTD DNot UTD ?unknown @ LMP ;t,>ssyr/ ?Backboard ?Splint: DHysterectomy ?List DPatient 11 Family ?EMS OBottles DDosages unknown DMeds unknown MEDICATION DOSE MEDICATION DOSE MEDICATION DOSE TRIAGE INTERVENTIONS Dice / Elevation ONPO ?3plint DDressing (COMPR S 1 E C1 TED B : DSee Physician order sheet ?C-Collar- DPatient Masked OSecunty notified i? ( I ?r 11; TRIAGE NOTES EKG paged @ - EKG done ° 'siv?Tnage RN signature ` Daia Coliertion signature (it applicable) OR 3E DISPOSITI RN -TIME i ? ER C3 Occupational Health V PP)T,RN signature i I-. n_:_:. - :.-1 ORGIE , DEREK ANDREW 8 by 201-ECU 9.+05 12th RFV LLVV , -y ?F" . -op.- Camp Hill, PA 17011 John R. Dietz ECU Nursing As3essment . , \'A ED GROUP 428310 n +C 02/03/2000 E?? 1 02/28/08 31691843 Initial Lab & X-Ray Orders: Labs Cardiac Respiratory [ j Acetaminoohen [ J ESR [ ) Theophylline ( J Monitor ( ] ABG's [ ) Acetone (SACE) [ J Glucose [ ] Thrombolytic Labs [ ] EKG ( J Peak Flows Before/After Resp. Tx. ( j Alcohol (ALCO) t ) HCGS [ j Tox Screen [ ] 02 Umin. [ ) Respiratory Tx. { ) Amylase/Lipase ( ] Quantitative [ ] Urine Tox (DOAS) [ ) 02 Saturation [ ]APTT HCGS ( ]TSHR [ J BBH [ j HIV [ ) Type&Cross _k of units Medications / IV's / Additional Orders [ ] Blood Cultures [ ] Lithium (BOR) DOCTOR Order NURSE Given [ ] BMP { ] Liver profile [ ] Type & Screen Tirm PHYSICIAN ORDERS TKM [ j CBCP [ J Lytes ( ] UA: [ J DIP [ J DIAG. IV: NSS/ DSW/ LR/ D5l.45NS/ D5.9NS [ J CMP ( ) ProBNP ( ] Urine C & S WO/KVO/infuse at mis/hr [ j CK,CKMB,TNT [ J Phenobarb [ ] Urine HCG [ ] Depakote ( } PTP [ j WC Breath Alco Test [ J Obtain old records ( ) Td { ] Digoxin [ ] Salicyiate [ j WC Drug Screen [ J Dilantin [ J Tegretol [ j Other: [ J Protocol initiated for: Radio)oaV [ J Abd./Obstr. Series ( ] Knee R L [ ] Ankle R L [ ) KUB [ J Clavicle R L ( J US Spine [ J Cerv. Spine--Routine (9 view) ( J Mandible [ J Cerv. Spine--AP/Lat [ ] Nasal [ J Cerv. Spine--Portable Lat [ ] Orbit R L ( J Chest--Routine or Portable ( J Pelvis ( J Elbow R L [ ] Pyelogram IVP [ J Facial [ ) Ribs R L ( ] Femur R L [ ) Shoulder R L [ ) Finger R L [ ] Skull ( ] Foot R L [ ] Sternum [ j Forearm R L [ ) T/Spine [ J Hand P. L ( ] Tit) i Fib R L [ j Hip R L (] Toe R L ( ) Humerus R L [ } Wrist R L [ } Other: TimeiCRTlini.. .__ REASON: Special Procedures: Ultrasound: CT: (W=With contrast; WO=Without) ( ] Abdomen I ] Abdomen/Pelvis W NJO [ ) VQ Scan [ ) Duplex Ooppler [ ] Brain/Head W WO ( ] Echo- [ ] Gallbladder [ ] Chest W WO cardiogram ( ] Pelvis [ ] Spiral chest for PE ?v.c read back ( ] Transvaginal 1 ] Other: [ ] MR! Scan Time/CRTllnt. REASON: Time: j) DISCHARGE [J 'ADMIT j J OBSERVATION [ ] REGULAR [ ] TELEMETRY [) CRITICAL CARE tures: e ?eci ADMITTING PHYSICIAN/ GROUP: / 1? 35 B [ j Beta a Strap 5trep AG Rapid ( ] Stool C 3 S ( ] Cervical/Genital ( ] Stool 0 & P DIAGNOSTIC I87PRESSI N: [ ] Chiamydia [ ] GC Culture ( J Stool C. Difficile [ j Trichomonas C J [ ] Monospot (rapid) [ J Wound C & S I ) Sputum C & S [ j Other. Billing Classification: PHYSICIAN CHARGE FACILITY CHARGE Initials:. Signature: RNJMA ( ] Level I [ ) Level I ( ) Accident ( J Level li [ J Level tt ( ] Medical Initials: Signature: RN/MA ( ]Level lfl ( J Level (it [) Case I CRITICA rs. (J Dictated [ J Level IV [ ] Level IV [ J Extended Hrs. O/CRNP Signatur M DD/D t ) Level V [ ) Level V M ? 7- V V Time; (? D t a e: FORG2E DEREK ANDREW g M Holy Spirit Hospital 03/2000 02/ Camp Hill, PA rr r, ED GROUP ER1 John R. Dietz Emergency Center 428310 02/26/08 31691343 Physician Order Sheet NEU BEHAVIOR CHILD eritive - Awake - Alert ?Appropriate SI N' Warm ryQ7Gorm Color ?Skin intact (visible) RESNWORY - mm i MUSCULO•SKELETAL N/A n _ . ;s ym metr cay unlabored Extremity: ted-Person words/ response ?Cool ?Diaphoretic ?Abrasion ORash Oclear ?stridor deed-Place ?Consolable, OHot OTenting ?Ecchymosis OBurn 01abored ?retractions Extremity color:OWNL anted-Time inappropriate OPale ?Flushed OPuncture Wou ?wheezing L / R ?Mottled OCyanotic [i Agitated O Uncooperative words OPersistent ODusky ?Mottled 11)'aceratio /Avulsion ?Cyanglic ?Jaundice i, 11 / ?rales/rhonchi L / R Ocough Skin Temp ?Warm OCool Distal P lses?P t ON t l ?Verbally Abusive OCombative inappropriate- , M US MEMBRANES ] I g Na? Oproductive u resen o pa p. Edema []Yes ?No O Anxious ? Crying crying/ screaming Pink / Mo sty ntrotied 002_L/min via_ Deformity OYes ?No ?Confused ?Moans to pain OPale 'OCyanotic ONot Controlled Ecchymosis ?Yes ONo ?D CraC ed Location: %Sa , NEURO ONIA GLASGOW COMA SCALt 14..j Score GU/ GYN CARDIOVASCULAR "; enie ?headache ?PERL R L EYES MOTOR R P VERBAL Odenies s/s Ourathra - OMonitor/rhythm: Chest pain ?stitt neck Size 4 Spontaneous 6 Obeys 5 Oriented ?frequency discharge area: Oneck pain Pinpoint ? O 3 To verb command 5 Localizes pain 4 Disoriented Ourgency ovaginal discharge Severity /10 al droop Dilated ? 0 2 To pain 4 flexion-withdrawal 3 Inappropriate ODysuria Ovaginal bleeding ?pacer 0constant ?sharp ibness: Fixed 00 1 No response 3 Abnormal Flexion words ?Hematuria ?foley Oedema: ?intermittent Odull Sluggish 0 O 2 Abnormal Extension 2 Incomprehensible ?retenton present ?buming ?pressure Oweakness: non-reactive? 0 1 No response sounds 00ther: LMP OJVD OSOB Oheavy 1 No Response ON/A Ocapillary refill: ?nausea Opleuritic GASTROINTESTINAL ?rapid Onon-radiating ODenies pain /symptoms ODuration/ intensity Last BM_ -?Abdomen tender Q delayed 13 radiating Onausea Odiarrhea ?vomiting 0constipation OHematemesis Bowel Sounds_ ._Odistended ?firm soft ?calf tender R L EENT Pk4tilwsis ?NIA NURSING ASSE ME / ?. i EYES O Pain L / R Acuity: LEars Nose Throat r i ?bl d i L / R ROP i UR )7 4 - ur e v s on a n ?congestion Osore - Com feted by: R ime Odouble vision L / R ?with lenses Odischarge Odrainage Odrooling all bell within reac ?Compa ' with patient OPhotophobia L / R ?Other: 0Epistaxis L / R Odysphasia OSH up x2 procedure explained IV condition oond : O=no inflammation/complication 1=edema 2=erythema 3=etch mosis 4= in S=hardness 6=warmth Ueakin MEDICATION S Date Start Stop Amt Solution Sz, Site Rate Attpt Cond Initial Date/ Time Drug I Dose Route Site Initial I Date/ Time ,] . Notes / - / v /? {'?' ?I i lure Initial lgn• r itial . lam; t a JT) _ __ _ I _ 7t L/ b.MCHARGE DADMIT ROBS OTRANSFER t t " ?L DISCHARGED /accompanied by:OSelf dNr1Ir oOther r k ' t .? i \ ! , Via: n ,Iul ory Ow/c Oambulance A , af To: ?nursing home ?AMA OOR i S { Uother: ischarge instructio S (Jiver! to: it OPatient ilL OParent 00ther _ _ ADMIT/ OBS Report called @____to_ - ? I Room# I I 0otd records sent to floor ?clothing sheet done t i TR.4NS0: Otransfer checklist complete Condition --{ Satisf Ecry OCritical ? 7ased to morgue i Dimpr ved;- phi sc e n ; I 1 - RN Sl9natur ?r _ Holy Spirit Hospital - Camp Hill, PA 17011 FORGIE , DEREK ANDREW S M f r A . , 02/03/2000 I John R. Dietz ECU v .. ? . Nursing Assessment/ Notes ED GROUP ER i 205-ECU 5/06 111h.:'Rev. L LW 428310 02 /28/08 31691943 rim Reason for Transfer C-,0-0 Patient Co ition I . The patient has been stabilized such that within reasonable medical probability, no material deterioration of the patient's condition. or of the unborn child(ren), is likely to result from transfer. 2. The patient's condition has not stabilized. 3. The patient is in labor. - ansfer Requirements The receiving facility, 2. 3 personnel for atment as ?c O 1?amc(1'itlrJPhone No. (Name has available space and qualified Date The receiving fagMfy has agre to accept sfer and to provide appropriate medical treatment as acknowledged by: P-?- ?M 5r3 I- g ?; 7- ( ZAp Psician Name/Phone No. ro ria edical records of the examination and treatment of the patient are provided at the time of transfer. lnitia as completed Time The patient will be transferred by qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures. Transport Agency Provider Certification I have examined the patient and explained the following risks and benefits of being transferred/refusing transfer to the patient: Based on these reasonable risks and benefits to the patient and/or the unborn child(ren), and based upon the information available at the time of the patient's i ertify that the medical benefits reasonably to be expected from the provision of appropriate medical treatment at another edi facili o ei c increased risks, if any, to the individual's medical condition from cffe ing the fcr, Signature of physician or othfr qualified medical person Date Title 1 roRGIE DEREK P,NDREW02/0382000 ER1 EL' GROUP 02/28/08 31691843 4,28310 PLEASE FAX TO: (717) ?, 6171 Cumberland County State Health Center 431 E. North St. i DEWTMENTOF Carlisle, PA 17013 Phone: (717) 243-5151 HEALTH.* Fax (717) 243-3171 in pursuit of good health ANIMAL BITE REPORT 11 CONFIDENTIAL - PA DEPARTMENT OF HEALTH ge ? Parent (if minor child) VICTIM'S NAME A 1 Last- First ress iCie,,. tree city County V-w )A,, S) t Phone (Home). 7/ 3 ' _ U 9 (Work) ( 1 2 9 Address and Phone Number of victim for the next 10 days if different than above 7 S-6' 4? 7_ m i l OWNER'S NAME ? Avxe .-,zz ti Phone (Home) (Work)(_')1 j) ?.SL "'/6C1 Address A/ -First y t,n -e N C.? . r..: , _s. ?U -i ti J(J JZCounty C r? _c ?Ati?i Street city Type of animal: () Dog Cat [ ] Other [ ] If other, what type of animal _ () Pet [)) Stray [ ] Wild [ ] / Bree 1 , Wk_ ,L) e. Color b rni. j tJ Age L -Sex P) Date of Last Rabies Vaccination 1 r7 s animal vaccinated prior to that date? O Yes No [ ] `?.f nnanan's Name d),eX--t&one _ Address DATE OF INCIDENT (Indicate the date bite occurred) t? Place bite occurred: () Owner's home Lpl"_ Victim's home [ ] Other [ ] If other, what location? What.caused animal-to bite? (Describe circumstances) ?_- A .'? ?.`? :''i yL-. ' This is a: () Bite V,? Scratch [ ] Other [ ] Part of Body Affected Upat_r L-g- Describe Wound: () Skin Broken : Yes [ No [ ] If Yes, StrpeViM't4___Deep [ Other ZD D DATE OF TREATMENT Facility Where Treated a - Name of Physician Phone S3 . n Type of Treatment: () Comments Wound Cleansed [ ] HRIG [ .l Other [ J Person Completing Form: Name Address _ Rcv.1/2000 Antibiotic [ ] Tetanus [ ] HDCV (Rabies Vaccine) [ ] PCEV (Rabies Vaccine) [ ] Phone 1'k CX" 7 ?" t DOH - 40 OG#_ ___ Daate Rcporr.Reccived Ace wrap for support for days. Wear splint ( ) At all times until follow-uf .or activity as needed . Use sling for support Use crutches: ( ) As needed, weight bearing as tolerated. ( -)At all times. NO WEIGHT BEARING NECK/BACK ( ) Wear cervical collar for support for days. ( ) Rest, avoid bending, lifting, strenuous activity for days. ( ) Apply moist heat for minutes times daily beginning in hours. ADDITIONAL INSTRUCTIONS ( ) Encourage fluid intake ( ) Clear liquid diet. Advance to regular diet as tolerated ( ) Off work/school from to ( ) Return to work on ( 1 Light Duty until: Restrictions: ( ) No gym/sports until ( ) Follow instructions on Workmen's Compensation Form. ( ) Wear eye patch for_ hours. ( ) If nose bleed recurs, pinch nose firmly for 5 minutes continuously, return if bleeding not controlled. ( ) The interpretation of your X-Rays are preliminary reading. Your films will be reviewed by a radiologist. You or your Physician will be contacted if there is a change in the diagnosis. j r DO NOT DRIVE 00,1? MACHINERY WHILE TAKING The prescribed antibiotic/medication, may reduce the effectiveness of medication you are currently taking. Check package instructions or consult with Pharmacist. FOLLOW-UP This is our recommendation for follow-up. If your insurance (HMO) requires a physician referral for specialty consultation. IT IS YOUR RESPONSIBILITY TO OBTAIN THE NECESSARY APPROVAL. ( ) Follow-up with: () Urgi Center ( ) Occ. Health/Company Doctor ( ) Family Doctor or in days for: ( ) Follow-up ( ) Suture removal ( ) Take the following test results to your physician: ( ) CBC ( ) CMP ( ) EKG ( ) X-RAY REPORT O OTHERS IF YOU DO NOT HAVE A FAMILY PHYSICIAN CALL 763-2900 FOR PHYSICIAN REFERRAL. ( ) Call as soon as possible for appointment ( ) Pick up your X-Rays from the Radiology Department prior to your follow-up appointment. Call 763-2696 to have films ready. ( ) See your physician or specialist if not improved in days. ( ) Return to Emergency Center if you feel your condition is worsening, especially if ( ) Your blood pressure was elevated. Check with your physician. A copy of your dictated Emegency Room Report is available to your Physician from Medical Records ,(763-2660), if not already sent. Clinical Impressions: I hereby acknowledge receipt of these instructions and urrdeistand them I understand that I have had emergency treatment only and that I may be released before all of my medical problems are known or treated. I will arrange for-follow=up care as I have been instructed. It is my responsibility to notify-,my Primary Care Physician of tt%is visit - SIGNATURE: -Pbysician MD/DO/CRNP SIGNATURE: Patient or Responsible Person Date ( ) PATIENT/RESPONSIBLE PERSON VERBALIZES UNDERSTANDING SIGNATURE: Nursa RN HOLY SPIRIT HOSPITAL JOHN R. DIETZ EMERGENCY CENTER 503 NORTH 21ST STREET CAMP HILL, PA 17011-2288 (717) 9724300 ( ) Salvatore Alfano, MD 025502E O Kevin-Sean McGann, DO 010969 ( David Zimmerman, MD 005636E O Theresa Williams, NP TP006126B ( ) Ramesh Arora, MD 016727E <) Pashpa Mudan, MD 051514L ( r ) _ ( ) Nikolas J. Baran, DO OS004697L O Aaron Palmer, MD 423830 ( Lorraine Bock, NP TP003409b ( 1 Denise Behowski, PAC IvU%001876J ( ) Luke Cheden, DO 0313145 (> Lawrence Paul, MD 039524L (> Susan DaCosta, NP SP007624B William Buckner, PAC MA052332 ( ) Nicolau DaCosta. MD 0532881. O Ericka Powell, MD 424145 O Pam Darden, NP SF(066B O Matthew A. DiRodio, PAC MA000969L ) Jon Dubin, DO 053288L <) Ranjana Sharma, MD 031265E O Selena-DiPa PDOSZb4B (? Jeffrey Horgar, PAC MA051.306 t ) Robert Ettlinger, MD 027460E O Christine Sheridan, DO 009537L O Natoe Gilhs; INP TP006082B O Michele Karczewski, PAC MA(X)2955L ( ) Amy Fajardo, MD 420942 O Barry Spector, MD 032793E':" CMich'lle-Hale,•INP VP005355B ( ) ( ) Philip Maguire, MD 015063E O Alan Teplis, MD 1930018);'. f ).Dennis' 14acDo°agall, NP SP009M2 DATE } SIGNATURE M.D./D.O./NP DEA# REFILL._ TIMES IN ORDER FOR A BRAND NAME PRODUCT TO BE DISPENSED, THE PRESCRIBER MUST HAND WRITE "BRAND NECESSARY- OR "BRAND MEDICALLY NECESSARY" IN THE SPACE BELOW. L.-. IiEL DSUBSTITUTION PERMISSIBLE F E DEREK ANDREP' 8 M, 02/03/2000 ER" ED GROUP 31691843 428310 02/28/08 178 (10/07) CONSENT TO MEDICAL TREA1MENT 1 HEREBY, CONSENT AND AUTHORIZE Holy Spirit Hospital, its agents, and-em plPyfts, ItO- Monde ngt 6fanedical+caM Whichrnayiigcitx,* routine diagnostic procedures and such medical treatment as'my attending or consult g physician=nsldems b ,,be .liecesssiy l:alsq ,una?r stand it is customary, absent emergency or extraordinary circumstances, that no substantial procedtaras nilll epaj. ?_ Tmaid yfpr n me rraless a1 . u have had an opportuntty'to discuss them with a physician or.other health care...prdfwwional.#o •try:&t un f'1l?muaxcarripait>nstaaddlt; . ha. - the right to consent or refuse to consent. I understand that the practice:flf:rrredidne;anef- ery:ir,!r'0 pan 0(9zt40ier1aei idbAdisgno- sis and treatment may involve risks of injury or even death and acknowledge that no guarantee has %:;n mad* e1D 813'to fve t+esults eff silty examination or treatment in this Hospital. %l. _I I understand many of the physicians on the staff of Holy Spirit Hospital are •notsmpioyees..dr agents &f ,;the Hnspital,;bat rather+rendependent contractors who have been granted the privilege of using these facilities for the care and treatment -of iheirpabents ?t_"r; i ?1frl?llt° this Hospital is a teaching Hospital and at the Hospital are health care..personnel in training who, unless expressly requested 0 1 Oie Tweei msW peAcipate or may be present during my care as part 'of !heir education: Still or motion,:pictures and -dlosetlcftaft monltonng of patient :r;are maya ,Iso `be used for educational purposes, unless I expressly request otherwise. I )rstand that in order to ensure a safe environment for patierds, visitors and staff ail -property .on-the premises of Hal '~Sp' pftal, is su.-,.ct to reasonable search and/or seizure at any time without further notice. i nitials ) RELEASE OF MEDICAL INFORMATION - I authorize, Holy Spirit Hospital to release to requesting health insuranoe:c inier4is); their't+epresentatives :and. auditors, and:. i.tofiair ing health care providers, such diagnostic and therapeutic information ;(including any* ifnforrnstiun relating to treatment ter atopol and snb6t e,,abuse and/or treatment of nsv hickorders and/or corifidubaIV teloog intorrnation as may be becessary for them -to determinWbeneflt -enti- tlement; to process payment claims for health care services prodded Outing this hospitalizatit?nltreatment'$pisode, for con-01;169 care/treat- ment, and hospital operations. A photocopy or carbon copy otAhis ,authorimbon shall be consi*od -as effective and valid.astthip.ortg1"" The undersigned also authorizes Medicare, when applicable, to -release to another, insurance .carder !'upon their request, medical 4Zrmationi eed- ed to make payment upon that claim. I understand and consent that the manufacturer of any implantable device inserted by my,physician durrg the course of my•su?g ry/ Fedure may be provided with my identification information, including-social securily number, as mandated by ?dsral Law. 1 ', 11 i J initial ACKNOWLEDGEMENT OF RECEIPT OF NO71CE OF PRIVACY:PRJ?CTICES I have received a copy of the Notice of Privacy Practices. The Notice desc4bee flow my health information may be used or disclosed. under- stand that I should read it carefully. I am aware that the Notice may be ela'arigeti at.arr time. I 'may obtain a revised copy Of-the Not ,by,con- tacting this organization's offices or.on this Organization's webdte atwww:hsh.org. V/t , initials it TRANCE ASSIGNMENT OF BENEFITS I authorize payment directly to Holy Spirit Hospital and my treating physicians of d benefits payable under my insurant e:policies. I nciersta?td I am responsible to the Hospital and physicians for all charges not coy i by.#his assignmer>t Initials i STATEMENT TO PERMIT PAYMENT— OF. MEDICARE BENEFITS TO PROVIDERS, PHYSICIANS AND PATIENT I request payment of Authorized Medicare benefits to me or on my behalf for, any services furnished me by or in Holy Spirit Hospital including physician services. I authorize any holder of medical and other information about me, to release to Medicare and its agencies any information needed to determine these benefits for related services. Initials MEDTC7AI_ ASza19 ANCE RECIPIENT My signatures certifies that i received a service or items from Holy Spirit Hospital and Dr. on the date listed below. I understand that payment for this service or item-will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of material may be prosecuted under applicable Federal and State taws. I understand that certain tests and procedures may not be reimbursed by Federal and State funds and that I may be responsible for-non covered charges. Also, l agree that if at the time of service, if.l am not eligible for Medical Assistance, 1 will be responsible for balances owed to Holy Spirit Hospital. Initials _ I have read and understand each of the sections contained above. I understand that by signing this document, I am agreeing and providing the authorization/ consent contained in ,each of the above sections where my initials are located. I have had the opportunl- ty to ask quest' ns regarding :?=7 hese sec tions'.and all such questions asked haveA3een nswered to my satisfaction. 11 Signature % C?? _ Witness Relations p to Patient r 1 -L -f k''''' Time Date 2--•L`-"-' -4- ?-z-- HOLY SPIRIT HOSPITAL CAMP HILL, PA 17011 1 FORG?E DEREK ANDREW 02/0382000 ONSEN.7 FOR 7 RE :TIME V RELEASE OF r FORA:L5TJON ER.1 IIdSi'P? CEASSIGAMMEAT ED GROUP 31691843 ! 426310 02/28/08 Please List All Current Medications: (Include all over-the-counter, vitamins, samples, herbs & other supplements). Please keep any medications with you and show them to the nurse. Name of Medication Dosage, Route (by mouth, cream, etc.), Frequency Medication is Taken Time Medication Taken Last time you took this medication? I - I i I Patient has brought a legible, complete medication list that is copied and attached to this form. ALLERGIES? '? No ? Yes, list all allergies and reactions: Allergic to Latex? No ? Yes " i Source of Data: ? Patient i 0 Family ? EMS ? Bottles ? List Patient's Pharmacy: E It c I ( I C? i _`? (!?? (1 01 Patients Family Physician: Patient's Signature: Date/Time: 4C-C', Family Signature and Relationship if patient unable to sign: )--- - 0 Patient unable to sign and family not available ? Unable to clarify medication ute or frequency at time of interview Practitioner Name Printed, Name Stamp, (MD/1301 A/ NPf N)i Practitioner Signature (MD/DO/PA/CRNP/RN): $HOLY HOLY SPIRIT HOSPITAL Camp Hill, Pennsylvania 17011 "HOSPIT A L The Spirit of Caring Medication History Form Form MR 204 Rev. 10/07 FMC 10,07 3 FORGIE DEREK ANDREW 8 M 02/03/2000 ED GROUP ER1 428310 02/28/08 31691843 I?Q ?q _ 1 21 Animal Bite (4) ig Assessment Reviewedff Vitals Reviewed Lanus immun. UTD YSICAL EXAM A I --- 11 L.)ATE,i Z 6? TIME: (gc ? on arrival GENERALAPPEARANCE ROOM: EMS Arrival o ute distress -mild / moderate / severe distress--_- EMS treatments ordered _ ert anxi I lethargic HISTOW: patient sp a paramedics SKIN - ee diagram AGE M / F -intact HX / EXAM LIMITED B-2- HPI ? NEURO /VASCULAR /TENDON no vascular abnml color / warmnth I can refill of comolaint• Bite occurred: where: jssf-pNr to arrival home school tod nr's park yesterday A s eet ma do , at other: ani family neighborhood animal unknown animal Appearance o animal appeared well appeared ill unknown on: T unknown not immunized nimal's lMMuadagygVANisJ Observation/copture.. animal Fs-known; can be observed for 10 days animal unknown; not captured animal control notified. --- context of attack: "unprovoked" attack "provoked" attack (see below) a nimal entered animal's domain animals fighting_ la in - teasing anima!-___ `her of in'ur : bitte scratched mucous membrane contact = locatio iuurr. head ce ,eck shoulder R / L chest a domen hip R / L back (upper mid- lower) RUE LUE RLE LLE compromise _pulse deficit oriented x3 -disoriented to person / place / time - sensation intact -sensory / motor deficit - CN's nml as tested -facial droop _ -ROM nml -ROM limited by pain / tendon injury PSYCH -depressed affect mood I affect nm! anxious --------------- HEAD / EENT --------------------------------- -see diagram- ; _normocephalic, -EOM palsy / anisocoria atraumatic _TM obscured by cerumen ( R / L)-? ' - _ post-surgical pupillary defect ( R / L } -eye lids / conjun. eye -- -- uninjured ENT nmi external inspection NECK _ -see diagram. ----__ --uninjured, nrnlinspection CHEST -see diagram -^_- -uninjured, _wheezes / rates I rhonchi_ nml inspection GI (ABDOMEN) _see diagram--.--_ -_ uninjured, ROS - ` nml inspection los cling! ovJecarms /legs trouble?reathing / chest?ain -non tender tinghnum ss distally ._ ; loss of budder function -- _nml bowel snds* headac /neck ?n suspetfed FB (skin lac). ; BACK see diagram , _ double'ision / hearing loss-.- recent`f?•er / illness nauft%-4xnmtt? ' -uninjured, - - - - - - - - - - nml inspection -_- ------_----------- - ------------ ' SOCIAL HX smoker drug use / abuse 1 t EXTREMITIES re OH lives alone -uninjured, _see diagram--- iv s at ho lives in nursing home nml inspection -foreign body suspected- ' MILY HX X _negative no infection -joint penetration suspecteds L ---------------' ---------------------? --------------------------------------------- PAST HX _negative see nurses note for Meds and Allergies HTN heart disease - 4 el? -- nderiine indicates organ spsren; * equivalent or minimum req:rrrecl for Organ srsten: (Mn+• B )6-2006 T-Smiem, Inc. Circle h k Hospital affirinatilles, backslash rl) ne atives. FOKG}E .DE?V- ?7RE W21, 0 ?/? 000 Holy Spirit Camp Hill, PA 31b 91s43 John R. Dietz Emergency Center ED GP OUP 02/ 2B % De, EMERGENCY PHYSICIAN RECORD 42831° 12ev 06 122 / 06 °aRe ; of'' i 1 1Fi_'JLt YLL 1 l???l \ 1 1 uU0 t1Ul)u Ij ?l tl?jl L R L PROCEDURE • ----D-es------cription I "Repair ir ---------------------------- Wound I I ength cm location superficial *subcut muscle linear puncture stellate irregular ; clean contaminated moderately/*heovily distal NVT: neuro & vascular status intact no tendon injury anesthesia: local digital blork _ mL lidos I % 2% epi / bicarb marcaine 0.25% 0.5% LET ? conscious sedation required; see attached 23d template prep: Betadine / normal saline irrigated / washed w/ saline debrided minimal / mod. /*extensive minimal l *mod. ^extensive wound explored undermined A foreign material removed minimal/mod./ extensive ? partially completely wound margins revised minimal / mod. /*extensive multiple flaps aligned no foreign body identified repair: Wound closed with: wound adhesive /Dermabond/steri-strips SKIN- # -0 nylon / prolene / staples l ethiion_ *SUBCUT- # •0 vicryl MUSCLFIFASCIA- # -0 vicryl _ i- *ma indicate intermediate re -pair - -may indicate complex repair _ _ _? PROGRESS Xmkf=_f -of imp - a ... ?- - -TTV -rates vaccine series implemented -initial fracture care provided: follow-u on _Rx given- -Discussed with Dr.__ Time will see patient in: office /ED /hospital hea c R / L forearm R / L hand :ration cture Wound chest R / L wrist Dog Cat abdomen R / L thigh Bite Scratch back R I L leg R / L arm R / L ankle R / L foot DISP 0-home ? admitted ICU/ CCU ? transferred Time 10 - unchanged improved 2-96b-le b 2? --RESIDENT f A / NP SI ATURE -Resident / PA / NP's history reviewed, patient interviewed and examined. Briefly, pertinent HPI is: My personal exam of patient reveals: Assessment and plan reviewed with resident / midlevel. Lab and ancillary studies show: I confirm the diagnosis of _Care plan reviewed. Patient will need: Please see residue midlevel note for details. T=Tenderness P(T-Point Tenderness S-Swelling E=Ecchymosis B-Burn C=Contusion Lac-Lacerstion A-Abrosion M=Muscle sposm M-puncture wound Physician (0 =wilhnut m-wild mod=moderate sv-.setvre) Eromple- Tsv - Tentlerness on polpalioo (severe) --------------------------------------- Pysician XRAYS ?Interp. by me ?Reviewed by me ?Discsd wl radiologist i ernplate _nml / NAD -soft tissue swelling / deficit f f ture / A I- d RTI # turned care over at Signature RTI # assumed care at Complete E) Additional T-Sheet [3 Dictated Addendum no raccure _ rat is ca on _ nml alignment ANDREW 8 M _nml soft tissue FORGIE DEREK 02/03/2000 OTHER ?See. separate report ; FR1 ----------------------------------- ----- -- 06 316918 Animal Bite - 21 Rev. 06 / 22 / 06 Page 2 of 2 ED GROUP 02/28/ 428310 L R E E PENNSTATE • • Milton S. Hershey Medical Center IV College of Medicine Penn State Milton S. Hershey Medical Center Penn State College of Medicine P.O. Box 850, Mail Code: HU24 Hershey, PA 17033-0850 Attn: Shelley Shahid Metzger, Wickersham, Knauss 3211 North Front St. Harrisburg, PA 17110-0300 RE: 1723823 FORGIE, DEREK A Total pages enclosed: 2 -Co April 21, 2008 TEL: 238-8187 The copies of. The Milton S. Hershey Medical Center,records for which this certification is made are true reproductions of the original paper and electronic medical record, which are housed in the Milton S. Hershey Medical Center. The original records were made in the regular course of business at or near the time of the matter recorded. This certification isgiven pursuant to 42 Pa. C, S, Ch.61/subch E (relating to medical records)by the custodian of the records in lieu of his/her appearance. Health Information Services Penn State Milton S. Hershey Medical Center Sworn to and subscribed before me this ? day of 20U g CONIWIC14WEALTH OF PENNSYLVANIA Notarial Seal Kathleen Bock, Notary Public Derry Twp„ Dauphin County My Commission Expires Oct. 26, 2009 Member, P,-mnsylvania Asso^iation of Notaries Not ry Public An Equal Opportunity University Page 1 PO BOX 853 • MR328 (REV 9100) HERSHEY, PA 17033 +----------++-----------++----------++-------++--------++----++---++---++-+ 01723823 f19540190 1102/28/08 1105M:53 P11ROOMjBED11EMER11ECU117RC11AJ +----------++-----------++----------++-------++--------++----++---++---++-+ +-------------------------++---++----------++---++--++----++---++---++----+ NAME 1FORGIETDE EK A liSmEXIIBIRTHDATE02/03/200OIJAGE8IIMSS?IMRSAJIVREII 11NREL RP 1 +-------------------------++---++----------++---++--++----++---++---++----+ +--------------------------------++--------------------++---++------------+ 1PATI1237ENT HUNTERSERIDGE DR 11MECHANICSBURG HPA J+--------------------------------++--------------------++---++------------+ +------------++---------------------------++---------------++-------------+ 1 PT PHONE EMPLOYER EMPLOYER PHONE 717 732-69191IPT 11 11 +------------++---------------------------++---------------++-------------+ +--------------------------++-------------++-------------++---------------+ 1HARRISTASHLEY H717 0N732-6919 11WORK PHONE 1121 0UNTY 1 +--------------------------++-------------++-------------++---------------+ + ------------------------------------------------------------------------- + INSURANCE INFORMATION NAME POLICY # GROUP NUMBER SELF PAY +--------------------------------------------------------------------------- +-------------------------------------------------------------------------+ I REGISTRAR SPI I + ------------------------------------------------------------------------- + +------------------------------------------------------------------------- + (COMMENTS I + ------------------------------------------------------------------------- + +------------------------------------++-----------------------------------+ (ATTENDING PHYS 1 11 ATTENDING PHYS 2 1 f 46358 GEETING GLENN K 0 +------------------------------------++-----------------------------------+ +------------------------------------++-----------------------------------+ FAMILY PHYSICIAN REFERRING PHYSICIAN DAVIS KENDRA M SELF REFERRED 506 SOUTH STATE ROAD NO REFERRING/FAMILY PHYSICIAN ?MARYSVILLE PA 17053 I) 1 717 957-2212 FAX: 717 957-2052 FAX: ------------------------------------- +---------------------------------- --+ PENNSTATE HERS Y PiM. Milton S . ershey ® Medical Center AUTHORIZATION FOR TREATMENT IN THE EMERGENCY DEPARTMENT AND RELEASE OF INFORMATION NAP, IE, DEREK A MD: *-NG GLENN K MRd: 1723823 DOB: 02/03/2000 INS: SELF PAY LOC: EMER DOSII: 8540180 MD#: 46358 SEX: M SELF PAY VISIT DATE: 02/28/2008 The undersigned has presented for evaluation and treatment in the Emergency Department. All treatment and procedures determined to be necessary will be performed by physicians and other members of the clinical staff. Authorization is hereby granted for such treatment and procedures. The undersigned has read the above authorization and understands the same and certifies that no guarantee of assurance has been made as to the results that may be obtained. I hereby assign and authorize payment directly to the Penn State Milton S. Hershey Medical Center. I authorize any holder of medical or other information about me to release to my insurance carrier and its agents any information needed to determine these benefits or benefits for related services. I acknowledge that the Penn State Milton S. Hershey Medical Center Privacy Notice has been provided to me. INSTRUCTIONS: Please read all of the above. An authorization for treatment must be signed before treatment can be given. Authorization must be signed by the patient, or by an authorized person in the case of a minor or when the patient is physically or mentally incompetent. DATE: AM - ?? PM TIME: 4/ SIGNED: or (authQr)zed person) Relationship to Patient: J o+?A _A/ Witness: ? Privacy Notice Given-Patient unable to sign ? Privacy Notice Given-Patient declined to sign AUTHORIZATION FOR TREATMENT IN THE EMERGENCY DEPARTMENT MR 1012 Rev. 1/08 Page 1 of 1 AND RELEASE OF INFORMATION 1111111111111111111 IN IIII 111111111 IIII Name: DEREK FORGIE MRIJJ723823 Patient Visit Summary DEREK FORGIE has been given the following list of patient education materials and follow-up instructions: Patient Education Materials: Custom LACERATION, FACE SUTURED Medication Reconciliation Injury & Illness DOG BITE Medications & Drugs AUGMENTIN Follow-Up Instructions: Follow-Up With: Address: When: Your Primary Care Provider Within 5 to 7 days Comments: Have the sutures taken out in 5 days. I, DEREK FORGIE, have received the above patient education materials/instructions and have verbalized understanding: Patient Si ture Date Provid?r Signature Date MRN:1723823 FIN: 09540190 Name: DEREK FORGIE 6 of 6 Feb/28/2008 19:31:19 MRN: 1723823 PENNSTATE HERSHEY Department of Emergency Medicine Record MR 818 Rev. t NAME: RGIE, EREK A MD: 0 GLDENN K MRi 23 DOB: W/2000 INS: SELF PAY LOC: EMER 00Sk: 6540180 MD4: 46358 SEX: M SELF PAY VISIT DATE: 02/28/2008 Da e 09 Temp: Oral Rectal Pulse pp / 7 1 n,RR S(?is.O BP ima 02 sat Last dT LMP ED Pathway Room 7 7?n Time C 7?uX PMH: BJ?? HPI: _ G f ? Mods: 71v- OL& y ? 4 lergies: Pain: Y N Location Quality Onset FHx: Cardiac Y N Diabetes Y N Radiation Quanti /10 T j Factors ROS: Unobtainab le - Y N As noted, others stems ne ative Y N Other: Constitutional: Wt. Chan e N Y Fever N Y Chills N Y Weakness N Y Fatigue N Y Soc Hx: ETOH Y N Smoker Y N PPD Eyes: Blurry vision N Y Diplopia N Y Eye Pain N Y Photophobia N ENT, mouth: Sore throat N Y Epistaxis N Y Ear Pain N Y Rhinorrhea N Y Other: Cardiovascular: Chest pain N Y Pleuritic N Y Exertion N Y Palpitations N Lalaorato ` Studies Respiratory: Cough N Y Sputum N Y Dypnea N Y Orthopnea Wheezing N Y GI: Abd. Pain N Y Nausea N Y Vomiting N Y Constipation Diarrhea N Y Neutrophil GU: Hematuna N Y D suria N Y Frequency N Y Vaginal D/C N Y Incontinence N Y Atypicals Musculoskeletal: Arm pain N Y L. ain N Y Back pain N Y Le swelling N Y Skin: Rash N Y Lesion N Y N Y Ca Neurological Numbness N Y Tingling N Y Seizure N Y Syncope Dysphasia N Y Psychiatric: Suicidal N Y Anxiety N Y Ingestion N Y Depression N Y Hallucinations N Y Mg Other: Troponin I: Myoglobin: Physical Exam: Rectal: Hemocult (+) (-) PT: PTT: ' INR: T. Bili: Alk Phos: ALT Am ylase: Lipase: a ?j U/A: U-HCG (+) (- ) n ? _ /• _ _ '/ ? J d / ? Drug Screen: , /& 1CA4 ? ? rrw 4 - Cultures: Blood 1 2 Urine 44W Ah 2? L iv-a-01 V / Radiotoetr. (cF+edrbox if radiolo ist interpretation) ' OP Study #1: ? See attached P )(OGRESS NOTE for additional information: ? Result: MD / Differe al Di nosis: ) 6) 1) 7) Study #2: 2) 5) 8) ? Result: Proceduire Note: Study #3: EKG: ? Result: ED course: Treatment: ell d&tji2 ' . It f Thne Consuk / Time Response: 2) Diagnoses- Inpatient Pathway Initiated: ' A. Fib ? 23hr ? 4 day ? Chest Pain ? Dehydration Discharge Instructions: Please go directly to check out secretary at waiting room desk /-D DVT ? 23hr ? 5 day ?Com. Acq. Penumonia ? 23hr trauma ? Cellulitis within days. Follow up with Prescriptions i/ Ma dlcat ions: Return to emergency department if ( "?? ? O 1) / ?"t r?/1(C K /V 2) GX 3) t 9i Aftendin-a Signature Didetion Number Di e . AdrW ion Transfer ?/? /"r?c.J ? ? Resolved ? Improved ? No change Service: Time: here: ? Cobra form 1111811 VIII 11111111111111111 IN 1111 Header Page Patient Name: FORGIE, DEREK A Date of Birth: 2/3/2000 12:00:00 AM Medical Record Number: 1723823 Financial Number: 09540190 Admission Date: 2/28/2008 5:53:00 PM Discharge Date: 2/28/2008 8:50:06 PM Patient Type: Emergency Facility: HMC Patient Location: HMC EMER Destination: Hershey Medical Center Reason: Legal Requester: Hershey Medical Center Date and Time Printed: 4/2/2008 5:03:39 AM Printed By: Tice, Cindy L Device: hisu2g30007 PENNSTATE 0 Milton & Hershey /Medical Center College of Wdicine Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 Patient Sex: Male Date of Birth: 213/2000 Patient Location: EMER, , Visit Number: 09540190 Visit Type: Emergency C o n s u l t a t i o n R e p o r t D o c u m e n t Modified Document Electronically Signed by: per contribution per contribution Signed By: Sathyendra, Vikram M (3/10/2008 3:29:08 PM); Geeting, Glenn K (3/1/2008 4:23:45 PM) CONSULT Name: FORGIE, DEREK A HMC Number: 1723823 DOS: 02/03/2000 Date of Service: 02128/2008 lief complaint is dog bite to the face. HPI: Derek is an 8-year-old male who was bitten by a dog earlier at his baby sitter's house, He sustained a laceration to the upper border of the right lip. Dr. Naren was called to confirm that the dog was up to date with vaccination. The dog has been otherwise behaving well. PAST MEDICAL HISTORY: The patient is otherwise healthy. His immunizations are up to date. MEDICATIONS: The patient was recently on amoxicillin for a sore throat. His last dose was yesterday evening. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: Noncontributory. FAMILY HISTORY: Is noncontributory. REVIEW OF SYSTEMS: As above. PHYSICAL EXAM: On physical exam, the patient is alert, awake, and oriented. He was not in any acute distress. On exam of his head, the patient had superficial deep laceration into the upper right border of the lip. His vermilion border was fairly well intact. There does not appear to be penetration into the oral mucosa. There are no other injuries noted on physical exam of the head. He has no tenderness to palpation over the frontal maxillary sinuses. His mandible is stable, intact. His maxilla is stable and intact. There is no more blood in his mouth. There is no blood in the nose. His extraocular muscles are intact. 13SESSMENT: The patient is an 8-year-old who sustained a dog bite to the lip. Date Printed: 41212008 Time Printed: 5:03 AM 0 0 PENNSTATE Elm W Milton S. Hershey Medical Center Coilegge of Medlidine Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 I C o n s u l t a t i o n R e p o r t D o c u m e n t Modified Document Electronically Signed by: per contribution per contribution Signed By: Sathyendra, Vikram M (3/10/2008 3:29:08 PM); Geeting, Glenn K (3/1/2008 4:23:45 PM) PLAN: We sutured the patient with 5-0 Vicryl and 6-0 nylons. MINOR PROCEDURE NOTE: The parents were informed of the fact that this is a very minor injury and that it could be sutured easily in the ER. We informed them of the risk and benefits of sewing up the laceration. They agreed to have suture the upper border of upper lip. We proceeded to inform the patient and the family of everything we are doing. We initially used 1 % lidocaine with epinephrine approximately 3 cc, which were injected into the laceration. After achieving sufficient anesthesia, we did mark the patient and wash the patient with normal saline. We washed laceration with approximately 300 cc of normal saline. The patient had no pain at the time. Next, we proceeded to thoroughly prep and drape the incision. .Afterwards, we started to approximate the border using 5-0 Vicryl deep sutures. Once achieving adequate approximation, we started to proceed and insert 6-0 nylon supefcial stitches in an interrupted manner. We achieved good approximation of the upper lips. We then put bacitracin over the laceration. We informed the patient to follow up in our clinic in approximately 5 days with Dr. Boustred for a suture removal. He was given Augmentin by the ER staff for a total of 10 days. He :ceived 1 dose prior to discharge from the emergency room. Overall, the patient tolerated the procedure well and was stable prior to leaving the ER. 315093 I corroborated this H&P with a personal eval, supervised all management and the disposition. Wound management Date Printed: 41212008 Time Printed. 5:03 AM 0 0 PENNSTATE Mon & Hershey Medical Center College of Mediane Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 C o n s u l t a t i o n R e p o r t D o c u m e n t 1 Modified Document Electronically Signed by: per contribution per contribution Signed By: Sathyendra, Vikram M (3/10/2008 3:29:08 PM); Geeting, Glenn K (3/1/2008 4:23:45 PM) directly supervised by me. GG Review/Sign: Sathyendra, Vikram M, MD Review/Sign: Geeting, Glenn K, MD VMS /CO DD: 02/29/08 DT: 03/01/08 08:40 Date Printed: 41212008 Time Printed: 5:03 AM PENNSTATE • • 10 Mton S. lbrshey Medical Ceder College of Medicine Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 E m e r g e n c y D e p a r t m e n t N o t e D o c u m e n t Final Document Electronically Signed by: Geeting, Glenn K 2/29/2008 3:53:30 PM ED SUMMARY Name: FORGIE, DEREK A HMC Number: 1723823 DOB: 02/03/2000 Date of Service: 02/28/2008 This is a 19-month-old girl with a chief complaint of dog bite. HISTORY OF PRESENT ILLNESS: He was sent here from another hospital to treat a dog bite to his face that happened this evening. Apparently the dog was a Shar-Pei named, "Tyler." He was bitten in the face by the babysitter's dog. :) initial history, the dog's shots were up-to-date with vaccinations. The dog is up-to-date with vaccinations and had been otherwise acting healthy and behaving normally. He had a laceration of his upper lip and no other injuries. He has otherwise been healthy and had no complaints. REVIEW OF SYSTEMS: Completely negative with the exception of those things noted above. PAST MEDICAL HISTORY: Unremarkable. IMMUNIZATIONS: Are up-to-date. MEDICATIONS: Amoxicillin-last dose was yesterday for a sore throat. ALLERGIES: No known medication allergies. FAMILY HISTORY: Unremarkable. Physical Examination: Vital signs: Unremarkable, afebrile. General: Calm, pleasant, alert and oriented x3 Constitutional: Well developed, well nourished Face: He has a couple of superficial abrasions over his neck. His upper lip had a large laceration with a partial avulsion in the middle of his lip, 3 cm in length on the outside and his laceration did extend to the buccal surface of his upper lip. Teeth and gums were intact and normal and nontender. PROCEDURE NOTE: Plastic Surgery was consulted immediately upon his arrival in the emergency department. We discussed the possibility of a procedure of sedation with the family, but decided first to attempt local anesthesia, which etas very well tolerated by the boy. Plastic Surgery performed the closure, which was supervised directly by me. Good Date Printed: 41212008 Time Printed: 5:03 AM 0 r? Milton S. Hershey Medical Ctnter College of Medicine Patient Name: PORGIE, DEREK A PSUHMC MRN: 1723823 E m e r g e n c y D e p a r t m e n t N o t e D o c u m e n t Final Document Electronically Signed by: Geeting, Glenn K 2/29/2008 3:53:30 PM anesthesia was accomplished using local infiltration. The wound was copiously irrigated and closed in a layered closure with both buckle surface, muscular, deep, absorbable sutures and cutaneous nonabsorbable sutures. The procedure was well tolerated. Good alignment of the vermillion border was accomplished. IMPRESSION: 1. Dog bite. 2. Upper lip laceration. DISCHARGE INSTRUCTIONS: Follow up in the Emergency Department within 5 days for a suture removal. Return to the Emergency Department for infection, fever, pain, change in mental status or other concerning symptoms. At the request of Plastics, he was given an initial dose of Augmentin 400 mg here and 400 mg b.i.d. for the next 5 days to go. 15182 Review/Sign: Geeting, Glenn K, MD GKG /LKG DD: 02/28/08 DT: 02/29/08 00:24 Date Printed: 41212008 Time Printed: 5:03 AM • • Mon & Hershey Medical Center College of Wdiane Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 { H e i g h t / W e i g h t - M e a s u r e m e n t Procedure Patient Weight Units kg Ref Range 2/28/2008 Thu 0 6:06:00 PM 22.680 Date Printed: 41212008 Time Printed: 5:03 AM 0 0 Ntiiton S. Hershey Medical Center CoUege of W"dne Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 A I I e r g i e s Substance: NKA Update Dt Tm Updated B 2/28/2008 6:06:58 PM Dick, Tamme S Category: Dm ; Reaction Status: Active; Type: Aller ; Date Printed: 41212008 Time Printed: 5:03 AM F'ENDSTATE • 0 Mon S. Hershey Medical Center College of Wdidne Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 I N a m e H 1 s t o r v 1 Name Begin Effective Date/Time End Effective Date/Time FORGIE, DEREK A 2/28/2008 5:58:56 PM Current Date Printed: 41212008 Time Printed.- 5:03 AM PENNSPATE is E Milton S. flet*ey Medical Center College of W&cine Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 M e d i c a l A d m i n i s t r a t i o n R e c o r d Date Printed: 41212008 Time Printed: 5:03 AM Patient Name: FORGIE, DEREK A • • MRN: 1723823 SCHEDULED MEDS amoxicillin-ciavulanate(Augmentin 400 mg/5 ml oral) 400 mg (Order Id = 299723941.00) 400 mg, oral susp, PO, ONCE, Routine, 02/28/08 20:00:00, 02/28/08 20:00:00, Amoxicillin 400 mg-Clavulanate 57 mg/5 ml Order Entered By: Geeting, Glenn K Pharmacist: Leiby, Amy accepted on 02/28/08 19:37 ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) amoxicillin-clavuIanate 400 mg-57 mg/5 ml syr(Augmentin 400 mg/5 ml oral) 5 mL = 400 mg (Order Id = 299723941.00) 400 mg, oral cusp, P0, ONCE, Routine, 02/28/08 20:00:00, 02/28/08 20:00:00, Amoxicillin 400 mg-Clavulanate 57 mg/5 ml Product Note: Pt specific refrigerate Order ModifiedNerified By: Leiby, Amy ACTION(S) CHARTED @ ADMIN TIME(S) ADMIN DETAIL(S) Med Given 02128/0819:47 02128/0819:50 amoxiciliin-clavulanate 400 mg PO Perform:Satteson, Emily A Complete 02/28/0819:47 Performed By: Satteson, Emily A U r? u Milton S. Hershey Medical tenter College of Med dne Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 E D T r i a g e F o r m ( P F) ED Triage Form 02/28/08 06:06 pm Performed by Dick, Tammey S Entered on 02/28/08 06:10 pm ED Triage Complaint Chief Complaint Dog bite to face. Sent from another facility for plastic surgery to see. Mode of arrival-ED Ambulatory Pre-Hospital treatments? No Abuse No Pregnancy Status N/A Last Tetanus <5 Years Nursing Home Resident No ED Physician Notified-abuse No During last month felt down or depressed N/A During last month felt little interest N/A Allergy Reaction 1. NKA Triage Vital Signs Temperature Route Oral Temperature 36.8 DegC Heart Rate 99 bpm Respiratory Rate 20 br/min Oxygen saturation 100 % -xygen Therapy None Patient weight 22.680 kg Weight 22.680 kg Weight Method Estimated Glasgow Coma Scale/ED Eye Opening Response Peds Coma Spontaneously Best Verbal Response Peds Coma oriented and converses Best Motor Response Peds Coma Obeys Pediatric Coma Score 15 Peds Medical Hx I Peds Medical HX I HEENT Denies: Patient Peds Medical HX I Gastrointestinal Grid Denies: Patient Peds Medical HX I Cardiovascular Denies: Patient Peds Medical HX I Gent Grid Denies: Patient Peds Medical HX I Respiratory Denies: Patient Peds Medical HX I Musc Grid Denies: Patient Peds Medical Hx II Denies Endocrine History Ped Denies: Patient Peds Medical HX II Hemat Grid Denies: Patient Peds Medical HX II Neuro Grid Denies: Patient Peds Medical HX II Behavioral Grid Denies: Patient Date Printed: 41212008 Time Printed: 5:03 AM 0 • 11+fiilton S. Hershey Medical Center College of Medidne Patient Name: FORGIE, DEREK A *NOT VALUED* Denies: Patient Peds Medical HX II Onc Grid Denies: Patient ED Triage Tracking DCP Generic Code Tracking Reg. Status Triage Time Tracking Group Visit reason Tracking Acuity PSUHMC MRN: 1723823 Start 02/28/08 18:09 EMER Trk Gp Animal Bite 3 I E D A s s e s s m e n t ( P F) 1 ED Assessment Form 02/28/08 07:47 pm Performed by Satteson, Emily A Entered on 02/28/08 07:48 pm Nursing Narrative/ED ED Narrative 1 1950: Pt. given PO Augmentin as per orders. D/C instructions explained to and signed by pt.'s mother. Pt.'s mother verbalized understanding, denies questions. Pt. ambulatory to checkout in NAD. E. Satteson, RN P a t i e n t E d u c a t i o n ( E D) ED Pat Edu Penn State Milton S. Hershey Medical Center Emergency Department Discharge Instructions Name: DEREK FORGE Chief Complaint: Animal Bite DOB: 02/03/2000 MRN: 1723823 Visit Date: 02/28/2008 17:53:00 FIN: 09540190 Current Date: 02/28/2008 19:49:04 Address: 123 UNKNOWN UNKNOWN PA 111110000 Phone: (717)732-6911 Primary Care Provider: Name: Phone: Emergency Department Care Providers: Date Printed: 41212008 Time Printed: 5:03 AM PENNSiATE • Milton S. Hershey Medical Center College of Hedge Patient Name: FORGIE, DEREK A PSLHMC MRN: 1723823 Primary Physician: Geeting, Glenn K Secondary Physician: IMPORTANT: We examined and treated you today on an emergency basis only. This was not a substitute for, or an effort to provide, complete medical care. In most cases, you must let your doctor check you again. Tell your doctor about any new or lasting problems. We cannot recognize and treat all injuries or illnesses in one Emergency Department visit. If you had special tests, such as EKG's or X-rays, we will review them again within 24 hours. We will call you if there are any new suggestions. After you leave, you should follow the instructions below. Date Printed: 41212008 Time Printed: 5:03 AM 0 0 Uffiton S. Hershey Medical Center College of Medicine Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 Follow-Up Instructions DEREK FORGE has been given these follow-up instructions: Follow Up With: Where: When: Your Primary Care 5 to 7 days Provider Comments: Have the sutures taken out in 5 days. Date Printed: 41212008 Time Printed: 5:03 AM PENNSTATE • Mon S. Hershey Medical Center CoUege of iV,ix. dne Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 SMOKING is a major health issue. -Smoking greatly increases the risk of heart disease, cancer, and stroke. -If you and your family don't smoke, contine this healthy choice! -Remember to avoid secondhand smoke. -If you or anyone in your household does use tobacco products, please follow any smoking cessation advice/counseling you received while in the hospital. -If you would like more information about how to live tobacco-free, please call one of the numbers below. PSHMC Smoke Cessation Program 1-800-243-1455 Pennsylvania QUITLINE 1-877-724-1090 Are you or someone you love at the risk of suicide? eek help as soon as possible by contacting a mental health professional or by calling: NATIONAL SUICIDE PREVENTION LIFELINE AT 1-800-273-8255 (TALK)/1-800-273-8255 Patient Education Materials DEREK FORGIE has been given the following patient education materials: ABX MEDICATION: AUGMENTIN Augmentin (generic: ampicillin + clavulanate) is a penicillin type of antibiotic. DIRECTIONS FOR USE: Take Augmentin with food to avoid stomach upset. Take the medicine at regular intervals. If the label says "EVERY EIGHT HOURS", this means THREE times per day. Doses don't have to be exactly eight hours apart, but you should take three doses a day, in the morning, afternoon and at bedtime. Take all of the medicine until it is gone, even if you are feeling better. This will assure that the infection is fully treated. WHAT TO WATCH FOR: Date Printed: 41212008 Time Printed: 5:03 AM PENNS ATE 0 N Alton S. Hershey hU iical Center College of Nle&dm Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 POSSIBLE SIDE EFFECTS: Nausea, diarrhea, anxiety, dizziness --> Contact your doctor if any of these symptoms persist or become severe. White spots in the mouth (thrush), vaginal itching or discharge --> Contact your doctor. ALLERGIC REACTION: Rash, itching, swelling, trouble breathing or swallowing --> Contact your doctor or return to this facility promptly. ********** IMPORTANT ******`*** MEDICAL CONDITIONS: Before starting this medicine, be sure your doctor knows if you have any of the following conditions: -- Allergic reaction to Cephalosporin or Penicillin-type drugs in the past -- Current infection with mononucleosis -- Breast feeding DRUG INTERACTION: Before starting this medicine, be sure your doctor knows if you are taking any of the following- drugs: -- Allopurinol, Probenecid WARNING: -- In rare cases, this medicine may block the effect of BIRTH CONTROL PILLS. Therefore, to be safe, use another form of contraception during the menstrual cycle(s) in which you are taking this medicine. -- DO NOT DRIVE, ride a bicycle or operate dangerous equipment while taking this medicine until you know how it will affect you. (NOTE: This information topic may not include all directions, precautions, medical conditions, drug/food interactions and warnings for this drug. Check with your doctor, nurse or pharmacist for any questions that you may have.) ENVIR DOG BITE If a DOG has bitten you and the wound is deep enough to bleed, an INFECTION may occur. Therefore, you should watch for the warning signs listed below. HOME CARE: 1) Watch the wound for signs of infection listed below. 2) In certain types of bites, antibiotics may be prescribed. Begin taking these as soon as possible, as directed until they are all gone. RABIES PREVENTION: If you live in an area where rabies occurs in wild animals, the rabies virus can be passed to cats and dogs. An infected animal can pass the rabies virus to you during a bite. 1) If a HEALTHY looking PET DOG has bitten you, it should be kept in a secure area for the next 10 days to watch for signs of illness. (If the pet owner won't cooperate with you, contact the Animal Control Dept.) If the animal becomes ill or dies within ten days, contact your County Animal Control Dept. at once. The animal must be tested for rabies. If the animal stays healthy for the next 10 days, then there is no danger of rabies in the dog or you! 2) Animals fully VACCINATED against rabies (two shots) are at very low risk for the infection. However, because human rabies is almost always fatal, ANY biting pet dog should be kept in confinement for 10 days as an extra precaution. 3) If you were bitten by a STRAY DOG contact the Animal Control Dept. They can provide information on capture, quarantine and animal rabies testing. Date Printed: 41212008 Time Printed: 5:03 AM PENNSTATE Milton S. lknhey Medical Center College of Medicine Patient Name: FORGIE, DEREK A PSUHMC MRN: ] 723823 4) If you are UNABLE TO LOCATE the animal that bit you, and if rabies exists in your region, you must be evaluated for the rabies vaccine series (six shots over four weeks). Contact your doctor or return here promptly. 5) All animal bites should be reported to the County Animal Control Dept. If you were not given a form to fill out, you can report it yourself by calling. FOLLOW UP with your doctor as advised. Most skin wounds heal within 10 days. However, an infection may occur even with proper treatment. Check yourself every twice a day for TWO DAYS for the signs of infection listed below. RETURN PROMPTLY or contact your doctor if any of the following occur: -- Spreading redness -- Increased pain or swelling -- Fever over 99.57 (375C) oral -- Colored fluid draining from the wound Injury & Illness LACERATION, FACE A LACERATION is a cut through the skin. This will require stitches if it is deep. HOME CARE: 1) If a bandage was applied and it becomes wet or dirty, replace it. Otherwise, leave it in place for the first 24 hours, then change it once a day or as directed. 2) Sutures were used, clean the wound daily: -- Wash the area with soap and water. Use Hydrogen Peroxide on a cotton swab (Q tip) to loosen and remove any blood or crust that forms. -- After cleaning, apply a thin layer of Neosporin or Bacitracin ointment. This will keep the wound clean and make it easier to remove the stitches. Reapply the bandage, if any. -- You may shower as usual after the first 24 hours, but do not soak the area in water (no tub baths or swimming) until the sutures are removed. FOLLOW UP: Most facial cuts heal in five days with no problem. However, even with proper treatment, a wound infection sometimes occurs. Therefore, check the wound daily for the warning signs listed below. STITCHES should not be left in the face for more than five days; otherwise, permanent stitch marks may form. RETURN PROMPTLY or contact your doctor if any of the following occur: -- Increasing pain in the wound -- Redness, swelling or pus coming from the wound -- If sutures come apart or fall out or if Steri-Strips fall off before five days -- If the wound edges re-open -- Fever over 100.07 (37.8'C) (oral) Medications & Drugs Medication Reconciliation (Medication Review) Date Printed: 41212008 Time Printed: 5:03 AM PENNSTATE • 0 NOR W Nihon S. Hershey Medical Center College of Wdiane Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 During the ED visit today, you provided us with a list of the medications that you are taking. The person(s) caring for your today has reviewed the medication information available. If you received a new medication or prescription, your provider has insured that it is appropriate to take that medication with the list of medications you provided. It is important to note that there may be interactions with some medications, including over-the-counter medications, so that you should take medications at the recommendations of your physician or pharmacist and only in those doses prescribed. All medications should be reviewed with your primary care physician at your follow up visit Date Printed: 41212008 Time Printed: 5:03 AM Ll Milton S. Hershey Medical Center College of Medicine Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 Patient Visit Summa DEREK FORGIE has been given the following list of patient education materials and follow-up instructions: Patient Education Materials: ABX AUGMENTIN ENVIR DOG BITE Injury & Illness LACERATION, FACE SUTURED (CUSTOM) Medications & Drugs Medication Reconciliation (CUSTOM) Follow-UD Instructions: -oolow Up With: Where: When: ti our Primary Care 5 to 7 days Provider Comments: Have the sutures taken out in 5 days. I, DEREK FORGIE, have received the above patient education materials/instructions and have verbalized understanding: Date Provider Signature Date Patient Signature MRN: 1723823 FIN: 09540190 Date Printed: 41212008 Time Printed: 5:03 AM PENNSTATE 4F Milton & Hershey Medical Center College of Medicine Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 1 O r d e r s S e c t i o n 1 Mnemonic Action Order Status Type of Order Document Infusion Stop Order Completed Patient Care Date/Time on EMAR Ordering Physician Order Placed By SYSTEM SYSTEM Review Information Nurse Review, Not Reviewed - Order Details 02/28/08 19:29:43, ONCE, Stopping On 02/28/08 19:29:43 L/LiS/LUUiS i:/Y:4s YM: Uocument lntusion Stop Date/ Time on EMAR Mnemonic Action Order Status Type of Order Discontinue IV Order Completed Patient Care Ordering Physician Order Placed By Geetin , Glenn K Geetin , Glenn K Review Information N/A Order Details 02/28/08 19:29:00, ONCE, Stopping On 02/28/08 19:29:00 memonic Action Discharge from ED. Order Ordering Physician Geeting, Glenn K Review Information Nurse Review, Not Reviewed - Order Details Dt: 02/28/08 19:29:00, Routine Order Status Order Placed By GeetinQ, Glenn K Type of Order Patient Care Mnemonic Action Order Status Type of Order Discharge ED Order Completed Order Sets Ordering Physician Order Placed By Geetin , Glenn K Geetin , Glenn K Review Information N/A Order Details N/A Date Printed: 41212008 Time Printed: 5:03 AM PENNSTATE 0 0 Milton S. Hmhey Medical Carter College of Mad i ne Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 Mnemonic Action Order Status Type of Order amoxicillin-clavulanate 400 Order Completed Pharmacy mg-57 m g/5 ml s r Ordering Physician Order Placed By Geetin , Glenn K Geetin , Glenn K Review Information Nurse Review, Not Reviewed - Pharmacist Verify, Accepted - Leib y, Amy, 2/28/2008 7:37:58 PM Order Details 400 mg, oral sus p, PO, ONCE, Routine, 02/28/08 20:00:00, 02/28/08 20:00:00, Amoxicillin 400 m -Clavulanate 57 m g/5 ml Mnemonic Action Order Status Type of Order bu ivacaine Order Completed Pharmacy Ordering Physician Order Placed By Contributors stem, PYXIS01 Contributors stem, PYXIS01 Review Information N/A Order Details injection, Pyxis, ONCE, 02/28/08 18:51:45, Physician Stop, 02/28/08 18:51:45 Mnemonic Action Order Status Type of Order lidocaine-e ine brine Order Completed Pharmacy Ordering Physician Order Placed By "ontributor system, PYXIS01 Contributors stem, PYXIS01 .aview Information N/A Order Details injection, Pyxis, ONCE, 02/28/08 18:51:45, Physician Stop, 02/28/08 18:51:45 Mnemonic Action Order Status Type of Order Physician Consult Request Order Completed Consults Ordering Physician Order Placed By Geetin , Glenn K Geetin , Glenn K Review Information Nurse Review, Not Reviewed - Order Details STAT, Requested Dt: 02/28/08 18:23:00, Service: Plastic Reconstructive Surgery, Reason: dog bit lip, I have or will contact the physician directly, Geetin , 310003 Mnemonic Action Order Status Type of Order ED Nursing Charge Order Discontinued Patient Care Ordering Physician Order Placed By SYSTEM SYSTEM Review Information N/A Order Details Request Dt: 02/28/08 17:58:58 2/26/2UU8 8:828:828 FM: ed nursing charge Date Printed: 41212008 Time Printed: 5:03 AM 0 0 PENNSTATE Milton & Hershey Medical Center College of Medicine Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 D e p a r t S u m m a r v If E D I 1 Depart Summary Penn State Milton S. Hershey Medical Center Emergency Department Depart Summary PERSON INFORMATION Name FORGIE, DEREK A Age 8 Years DOB 2103/2000 12:00 AM Sex Male Language PCP Marital Status Single Phone (717)732-6911 MRN 1723823 Visit Id Acct# 09540190 Visit Reason Animal Bite Specialty Enc Type Emergency Mad Service Emergncy Medicine Referred by Track Group EMER Trk Gp Discharge Tracking Id 6180621 Checkout 2/28/2008 7:48 PM Checkin 2128/2008 5:53 PM Acuity 3 Dispo Type Routine Dsch Arrival 2/28/2008 5:53 PM Reg Status Start LOS 000 01:55 .ddress: 123 UNKNOWN UNKNOWN PA 111110000 DIAGNOSIS ANIMAL BITE; LACERATION WITH STITCHES; LACERATION, FACE POWERFORMS SCHEDULING PHYS DOC NOTES DEPART REASON INCOMPLETE INFORMATION PROVIDER INFORMATION Dale Printed: 41212008 Time Printed: 5:03 AM 0 0 PENNSTATE Emm IV Milton & Hershey Medical Center College of Medicine Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 Provider Role Assigned Unassigned Geeting, Glenn K Physician 2/28/2008 6:09 PM Khan, Sufana J R.E.S. 2/28/2008 6:32 PM EVENTS INFO RMATION Event Name Event Status Request Date/Time Start Date/Time Complete Date/Time Arrive Complete 2/28/2008 5:53 PM 2/28/2008 5:53 PM 2/28/2008 5:53 PM Triage Complete 2/28/2008 5:53 PM 2/28/2008 6:10 PM 2/28/2008 6:10 PM Arrive Registration Complete 2/28/2008 5:53 PM 2/28/2008 5:53 PM 2128/2008 5:53 PM Registration Request 2/28/2008 5:53 PM Arrive MD Bill Complete 2/28/2008 5:53 PM 2/28/2008 5:53 PM 2/28/2008 5:53 PM MD Bill Request 2/28/2008 5:53 PM Arrive Dictate Complete 2/28/2008 5:53 PM 2/28/2008 5:53 PM 2/28/2008 5:53 PM Dictate Request 2/28/2008 5:53 PM Arrive PT Belongings Complete 2/28/2008 5:53 PM 2/28/2008 5:53 PM 2/28/2008 5:53 PM Bed Assign PT Belong Complete 2/28/2008 5:53 PM 2/28/2008 6:09 PM 2/28/2008 6:09 PM Arrive Bed Assign Complete 2/28/2008 5:53 PM 2/28/2008 5:53 PM 2/28/2008 5:53 PM Bed Assign Complete 2/28/2008 5:53 PM 2/28/2008 6:09 PM 2/28/2008 6:09 PM Arrive Med History Complete 2/28/2008 5:53 PM 2/28/2008 5:53 PM 2/28/2008 5:53 PM Med History Request 2/28/2008 5:53 PM Arrive Update Attend Complete 2/28/2008 5:53 PM 2/28/2008 5:53 PM 2/28/2008 5:53 PM Update ED Attending Complete 2/28/2008 5:53 PM 2/28/2008 6:09 PM 2/28/2008 6:09 PM MD Assess Complete 2/28/2008 6:09 PM 2/28/2008 6:09 PM 2/28/2008 6:09 PM RN Assess Complete 2/28/2008 6:09 PM 2/28/2008 7:48 PM 2/28/2008 7:48 PM Resident Assess Complete 2/28/2008 6:09 PM 2/28/2008 6:32 PM 2/28/2008 6:32 PM Date Printed: 41212008 Time Printed: 5:03 AM 0 0 PENNTATE Milton S. f k s y Medical Cutter College of Wffldne Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 Patient Belongings Request 2/28/2008 6:09 PM Request Consult Complete 2/28/2008 6:24 PM 2/28/2008 6:30 PM Consult Request 2/28/2008 6:30 PM Rx Complete 2/28/2008 7:06 PM 2/28/2008 7:47 PM Discharge/Transfer Complete 2/28/2008 7:29 PM 2/28/2008 7:47 PM LOCATION INFORMATIO N Arrival Nurse Unit Room Bed 2/28/2008 5:53 PM EMER Waiting Room 2/28/2008 6:09 PM EMER T1 128/2008 7:48 PM EMER Check Out ORDERS INFORMATION Start Time Order Type Status Stop Time Provider 2/28/2008 5:58 PM ED Nursing Charge Patient Care Ordered 2/28/2008 5:58 PM SYSTEM 2/28/2008 6:23 PM Request Consult Consults Completed 2/28/2008 6:30 PM Geeting, Glenn K 2/28/2008 8:00 PM amoxicillin- clavulanate Pharmacy Completed 2/28/2008 7:47 PM Geetin , Glenn K 8 2/28/2008 7:29 PM Discharge (ED) Order Sets Completed 2/28/2008 7:47 PM Geeting, Glenn K 2/28/2008 7:29 PM Discharge from ED. Patient Care Completed 2/28/2008 7:47 PM Geeting, Glenn K 2/28/2008 7:29 PM Discontinue IV Patient Care Completed 2/2812008 7:47 PM Geeting, Glenn K Document Infusion 2/28/2008 7:29 PM Stop Date/Time on Patient Care Completed 2/28/2008 7:47 PM SYSTEM EMAR Date Printed: 41212008 Time Printed: 5:03 AM PENNSTATE r A lton S. l1er*y Medical Cmter College of Malone Patient Name: FORGIE, DEREK A PSUHMC MRN: 1723823 MEDICAL INFORMATION Allergy Info: NKA Prescriptions Given DISCHARGE INFORMATION Discharge Disposition: Routine Dsch Discharge Location: PATIENT EDUCATION INFORMATION Instructions: DOG BITE; AUGMENTIN; LACERATION, FACE SUTURED (CUSTOM); Medication Reconciliation (CUSTOM) Follow up: Follow-Up With: With: Address: When: ,ur Primary Care Provider Comments Have the sutures taken out in 5 days. 5 to 7 days Date Printed: 41212008 Time Printed: 5:03" PENNSTATE NAME: O3 E, DEREK A MD: N? J10 I MRi: 3 OrAL" Milton S. HerI. Medical Center DOB: 0-, !2000 INS: MIGHMARK BS College of Medicine LOC: PRS 006#: 8548460 PROGRESS REPORT A0!! : 27060 SEX: M INDEMNITY VISIT DATE: 03!04!2008 Date/Time PROGRESS NOTES: (Include Name, Title) X O O '&v U -a- ?? Zzo t ? n ^ n i1 ? v u v v _ - MR 6 Rev. 6/01 Page 1 OF 2 111111111111111111111111111111 PROGRESS REPORT PENNSTATE NAV j&IE, DEREK A R Milton S. i ershey OGERIO I MR#: 1723823 Medical Center INS: 02/03/2000 NS: HIGHMARK BS LOC: PRS OOS#: 8548460 INTERDISCIPLINARY EDUCATION RECORD (IER) MD#: 27060 SEX: M INDEMNITY VISIT DATE: 0310412008 May be used by all disciplines to summarize and communicate patient teaching. Hospital Day is optional. May be used to refer to specific teaching outline on plan of care. List pamphlets, handouts given to patient in each section. Initial Assessment of Patient's Ability to Learn: ? Emotional ? Physical ? Cultural/Religious ? None (Explain areas that may impact teaching) ? Motivational ? Cognitive Limitations ? Language pock i Learning Preferences: ?Orittenerbal ? Demonstration ? Group Audio Visual Other Q Z W Document areas that may Impact teaching: o education required at this time: Date Initials strategy Key: V = Video W = Written D= Discussion Demonstration Evaluation Key: C = Competent R = Review . t cm M c E -I ;z k e we 0 i U) i Followin instruction the atient and/or si nificant other (list) will: g , p g Pre and Post Surgical Instruction sheets reviewed W C with patient. Includes general instructions, day of D surgery instructions, medication orders and special instructions. Required Garments W C D Aspirin Sheet Reviewed W C D Brochure given if applicable W C D mmai MR-157 -_ Rev 7/04 INTERDISCIPLINARY EDUCATION RECORD (IER) (Number will be assigned by Nursing Practice Committee after Approval) Initial 111111° III11II 111111 OF IN III 111111111 INTERDISCRINARY EDUCATION RECORD (IA Assessment updates if necessary: strategy Key: V =Video W = Written D= Discussion Dem = Demonstration Evaluation Key: C = Competent R= Review ) Q. t c .. c rn Ch y to ? 0 H M O a 0 _ Q f- Z ul l- O Home Care Instructions reviewed, including W C a-? dressing changes, supplies needed, and call orders D maiai lnlual initial -("8, h 37- Rev 7104 INTERDISCIPLINARY EDUCATION RECORD (IER) (Number will be assigned by Nursing Practice Committee after Approval) PENNSTATE Milton S. Hershey Medical Center College of Medicine PEDIATRIC HEALTH ASSESSMENT NAME: FORGI EK A MD: NEVES RL 0 I MR#: 1723823 DOB: 02/0312000 INS: HIGHMARK BS LOC: PRS DOS#: 9548460 PAD#: 27060 SEX: M INDEMNITY VISIT DATE: 03104/2008 Mother's Name Father's Name: OCL-i"Q", v, J - ?k , r l S Occupation: I nS L,lx tu/AC-'- Occupation: Parents Marital Status: Married ?` Single Widowed Divorced Living Together Separated 3t Parental involvement in child care: Father es ? No other O / No What language do you or your child best understand Who lives in the household VV"'(V- ) b<1 c? Family Physician or Pediatrician: How do you or your child best learn: a. One on One Instruction b. Audio Visual Information c. Written Information d. Group Instruction e. Demonstration/Practice f. Other Is your child exposed to anyone who uses tobacco? es No Does anyone in the househould consume alcohol?[ms's / No Ab+ IV"\ Who? YI v Yti? :z Does anyone in the household use any other substances Yes / IOIf yes, type Is your child afraid of anyone? Yes C) Has your child ever been physically or emotionally hurt by anyone: Yes Are there pets in the household?s / No Type: C G`t Water type?4/ Well Ct,u??-?r (cam ??. d yaj t?' School District School Concerns: Yes C /ik Does your child wear a bike helmet? eo/ No Does your child use a car seat, booster seat, or seat belt? es No Do you or your child have any special needs we should be aware of so that we can better serve you? w` e Updated Reviewed By MR 888 Rev. 2/06 (Page 1 of 2) 11111111111111111111111111111111 IN OVER PEDIATRIC HEALTH ASSESSMENT ODIATRIC HEALTH ASSESSMEN. Previous Surgery Complications Date N v ??G Name of Current Medications: Nv i , .? ?? LwS byS? tJ-?- Does your child have allergies? Yes If yes, please list: Medications: Enviromental: Has the patient ever had or experienced any of the following: Painful voiding / urinating Yes / Rheumatic fever Yes / Bed wetting Yes / Heart murmur Yes / o Urinary tract infection Yes / Palpitations Yes / Chest pain Yes / Asthma/wheezing Yes / High blood pressure Yes / Bronchitis Yes / Fainting Yes / Pneumonia Yes / Sleep Apnea Yes / Difficulty swallowing Yes /a Tracheotomy Yes / Diarrhea Yes / Home oxygen therapy Yes / Reflux Yes / Shortness of breath Yes / Blood in stool Yes / -? Constipation Yes / Seizures Yes / Food allergies Yes / Numbness arms Yes / Weight loss Yes / Numbness legs Yes / Weight gain Yes / Poor circulation Yes / Unsteady gait Yes / ee / No., Difficulty speaking Is your child toilet trained? Ye / Headaches Yes / Rashes Yes / Has your child had the chicken pox? / No Immunizations up to date / Nj Could you be pregnant Yes /V' Family Medical History: Childhood Deaths Yes / No Diabetes / No Stroke / No Cancer te/ No Hypertension e / No Heart Disease Yes / Anemia/Blood Yes / Anesthesia Complications Yes / Disorders 0(S !l Y?] N Hakr1 S Name of Person Completing Form 1/hic11-H'A-b1L Relationship to Patient Signature of person who and discussed above with the provider. Asthma Yes /* Seizures Yes / 40' Arthritis C' / No Date ,5/1 /0 Date MR 888 Rev. 2/06 (Page 2 of 2) 1111111111111111111111111111111111111 PEDIATRIC HEALTH ASSESSMENT uJ-WO- 1G. 00 rrsuri-UosmeLIC Surgery l11-7b?-7??L? 'I'-085 P002/002 F-456 • Sheet of Case-No. Patient's Nams E Lc c? Address Date Tel. No. Referred By Occupation DOB Sex ji- SAITPAD. Q Q HMO Copay $ Insurance Co. ? PPO' Copay $ Moq Maim To Policy'No. A>l VO_r C2 r a m3. W.7 erssDo-4XA ur m UJ-lJ J- W--? 1L . D0 TO: FROM: DATE: RE: rmuuj-uosmeT1C Surgery 0 71'1-'Ib?-'I L T-085 P001/002 F-456 • SHELLY METZGER/WICKERSHAM LAW FIRM ELAINE ROBERT E. WOLF, MD's OFFICE March 5, 2009 DEREK FORGIE Per your request • x16'} ? TAKEN BY CLIENTS ON MARCH 1, 2008 • • 1 ?a ai.cl IV s1K.: • • I 0 • • 1 I m IW r 0 TAKEN BY CLIENTS ON MARCH 5, 2008 0 0 • 4 0 y 9 i TAKEN BY METZGER, WICKERSHAM ON MARCH 25, 2008 0 • r, ??f d? ?j ' rql .F Vew • • k 10. I'll a,: • v t • 0 TAKEN BY DR. WOLF'S OFFICE JUNE 10, 2008 00 a) 2) 0 00 LL O C) .Y N ^`, O W T- V?l I Eff U) U Q LL 0 LLi (1) 0 0 W a TAKEN BY METZGER, WICKERSHAM ON MARCH 19, 2009 0 0 E,wi(f C 0 9 MEDICAL BILLING SUMMARY FOR DEREK FORGIE Medical Provider(s) Dates Amount(s) Holy Spirit Hospital 02/28/08 $ 112.00 TOTAL $ 112.00 PAYMENTS BY HIGHMARK BS $ 70.56 PAYMENTS BY CLIENT $ 0.00 ADJUSTMENTS $ 41.44 OUTSTANDING BALANCE $ 0.00 Hershey Medical Center Hospital Side 02/28/08 $1,030.40 03/04/08 N/C TOTAL $1,030.40 PAYMENTS BY HIGHMARK BS $ 673.88 PAYMENTS BY CLIENT $ 0.00 ADJUSTMENTS $ 356.52 OUTSTANDING BALANCE $ 0.00 Hershey Medical Center Physician Side 02/28/08 $ 996.00 03/04/08 N/C TOTAL $ 996.00 PAYMENTS BY HIGHMARK BS $ 230.11 PAYMENTS BY CLIENT $ 0.00 ADJUSTMENTS $ 765.89 OUTSTANDING BALANCE $ 0.00 Cosmetic Surgery by Wolf, P.C. 06/10/08 $ 75.00 08/19/08 465.00 09/08/08 25.00 12/01/08 25.00 02/27/09 25.00 TOTAL $ 615.00 PAYMENTS BY NATIONWIDE $ 615.00 PAYMENTS BY HIGHMARK BS $ 0.00 PAYMENTS BY CLIENT $ 0.00 ADJUSTMENTS $ 0.00 OUTSTANDING BALANCE $ 0.00 TOTAL MEDICAL BILLS $2,753.40 TOTAL MEDICATION/MISCELLANEOUS EXPENSES + 0.00 GRAND TOTAL $2,753.40 TOTAL PAYMENTS BY NATIONWIDE $ 615.00 TOTAL PAYMENTS BY HIGHMARK BS $ 974.55 TOTAL PAYMENTS BY CLIENT $ 0.00 ADJUSTMENTS $1,163.85 OUTSTANDING BALANCE $ 0.00 415602-1 created 3113109 Page 1 of 1 *Derek Forgie reserves the right to supplement this Medical Billing Summary. HCI # A GY SPIRIT HOSPITAL PACE NO. TYPE OF BILL DATE OF UATE OF BILL PREV.BILL CYCLE 03/06/08 OUTP. N 21ST ST CAMP HILL, PA- 17011-228$ 800 596-9997 BIRTH-DATE HosP.NO. FEI 4 23-1512747 02/03/00 39000 OF ATT DESCRIPTION OF SERVICE TOTAL FST. Co ERAGF EST. COVERAC.F EST. COVERAGE EST. COVERAGE PATIENT . SERVICE HOSPITAL SERVICES CODE CHARGES INS-C0. NO. I INS.CO. NO. Z INS.CO. NO. 3 INS.CO. NO. 4 AMOUNT GET,;' L OF CURRENT CHARGES, PAY ENTS AN) ADJUSTME NTS 02/28 LEVEL II FC 0117105727 112.00 112.00 BALAN CE FORWARD 0.00 SUMMA RY OF CURRENT CHARGES EMERGENCY ROOM 450 112.00 112.00 SUB- OTAL OF CUR.R. CHARGES 112.00 112.00 DIAG NOSIS: 873.43 959.09 PAYMENT IS DUE UPON RE EIPT OF THIS STAT EMENT. YOU MAY SUBMIT THIS FO RM TO YOUR INSURANCE CARR IER FOR REIMBURSEMENT. T 0 T `A L S 112.0 0 112.0 0, PATIENT' NUMBEk PLEASE REFER 1'O PATIENT ADDITIONAL PATIENT BILLING NAY BE NECESSARY AT ' 69 84 - 3 T POSTED WHEN TH]S ST E- NUMBER ON ALL INQUIRIES FOR ANY CHARGES NO PAY THIS AMOUNT 0 00 1 AND CORRESPONDENCE. KENT WAS PREPARED. OR IF INSURANCE CARR3ER5 nn ?nr uav •w ua nF TNF ANnmr SNGWN HOLY S P I R I T HOSPITAL UNDER ESTIMATED INSURANCE COVERAGE. CAMP HILL, PA Page 1 of '_ "'ORG=, D; ,.. K H?' :<' VJ 7, u;.1?4_ - C2/[L? /21 ? 3a2S'.S U /CF/2Uc? _ P c , , 1 z 2 7 2 f l E f f, c HOLY SPIRIT HOSPITAL 3 PATIENT CONTROL NO. 503 N 21S- ST 31691843 131 EMENT COVERS PA 1-7v 1 1- 2 2 8 8 5 FED. TAX N0. 16 ST CAMP HILL , PR 800-596-9997 23-1512747 022808 022808 1 11 FAIT ENT NAME 13 PATIENT ADDRESS FORGIE DEREK ANDREW 1237 HUNTERS RIDGE DR MECHANICSBURG PA 17050 14 RIRTHDATE IS it tl ADMISSION TO 71 xI 23 MEDICAL RECORD N0. D DR STAT 11 CONDITION CO'OES 31 02032000 M S C2280811-71 1 01 428310 32 OC CURRENCE 34 OCCURRENCE 36 OCCURRENC E SPAN 7 Con )CODE DATE CODE FROM THROUGn 05 022808 T e !c ASHLEY HARRIS 39 V ALUE CODDE ? ' 41 V CODE ALUE CODES AMOUNT 1237 HUNTERS RIDGE DR - A3 112 0 MECHANICSBURG PA 17050 4Y kEV.CU 43 DESCRIPTION 44 HCPCSiRATFS 45 SERV.DATE 46 SERV.UNITS 47 TOTAL CHARGES 40 NON-COV'D CHRUS 49 45 EMERG ROOM 99282 022808 1 112100 i I I 1 001 TOTAL CHARGES 112100 50 PAYER 51 PROVIDER NO. 54 PRIOR PAYMENTS S5 EST. AMOUNT DUE 56 BLUE SHIELD PBSHM378 1522 Y Y 112 0 57 I • 58 1NSUREll'S NAME I REL 60 CERT. - SSN - HIC. - ID NO. 61 GROUP NAME h?. INSURANCE GROUP NO. FORGIE,DEREK ANDREW 18 ZAR112151810601 63 TREATMENT AUT,IORIZATION CODES FY Eyc 65 EMPLOYER NAME 66 EMPLOYER LOCATION CHILD CAMP HILL PA 17011 67 PRIN DI4G C OTHER DI.AG' . =U==? "/ CODE 7Z CDDt 74 CORE vnnF 0 76 IUtl.U11G. CU 77 E-CODE 1B r ? E_ 7Y P 00 PRINCIPAL CODE PROCEDURE 1.1 O1'NE0 PR CEDURF DATE pp 414 ATI'END1N0 PHYS. 0A604 DIPAOLO SELENA L 0TmkR PRO C --Om CF.OURF 011418 PROCEDUlL1 ? E 77 9 OTMLii PHYS. ID frt7 r ? 84 REMARKS L U E SHIELD DTFIER PHYS. :e PO BOX 8812 85PROVIDER REPRESENTATIVE- 86 :DATE CAMP HILL PA 17011 X'JAMES L JONES 030608 Page 1 of 1 • 0 SELECTED DETAIL DATA SVC FAC: HOSG 04/02/08 0635 PT NO: 31691843 FORGIE DEREK ANDREW MR NO: 428310 ACCT TYPE: 0 REG: 02/28/08 DSCH: FC: S PT: E EXP IND: ACCT BAL: .00 ------------------------------------------------------------------ PAGE NO: 1 ACCT BAL B11 V PT BAL .00 .00 .00 SVC POST SVC CD INS CD-DESCRIPTION/COMMENT-REF DATE AMOUNT 031908 031908 143560 1 HMRK BS OP PMT -70.56 031908 031908 266999 1 HMRK BS OP C/A -41.44 -------------------------------------------------------------------------------- PF14) SEL PT (PF3) SELECT DTL (Prll) ACCT CASH (PF15) RETURN TO PT OVERVIEW ' (PF10) ACCT CMNTS PF16 D/E PAQDTLO! • 0 MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 Statement on: 04/15/08 at 08:44 AM Guarantor: HARRIS ASHLEY 1237 HUNTERS RIDGE DR MECHANICSBURG, PA 17050-0000 Patient: FORGIE DEREK A Visit #: 9540190 ------------------------------------------------------------------------- Date I Svc Code I Description Units Debits I Credits 02/28/08 46361 INT REP FACE EAR EYE 1 595.00 02/28/08 46471 EMERGENCY VISIT, LEVE 1 411.00 02/28/08 245553 LIDOCAINE 1 ML 2 3.60 02/28/08 245710 BUPIVICAINE 10 ML 1 3.90 02/28/08 274287 AUGMENTIN 400MG ORAL 5 10.90 02/28/08 622023 IRRIGATION SOD CHL 0. 1 6.00 03/09/08 910050 BLUE SHIELD PAYMENT H -1 673.88- 03/09/08 930119 BLUE SHIELD CONT ADJ -1 356.52- * - Not posted Balance: I 0.00 ------------------------ Z- `""° STATEMENT OF PHYSICIAN SERVICES -7 ??h?? ASHLEY HARRIS 1 ---- -- ---- 1237 HUNTERS RIDGE DR The Milian Hershey I4cdical Center MECHANICSBURG PA 17050-8169 STwTEME KI he College of Medicine PATE: N) jj ?lI?E LAST SThTE&IENT ACCOUNT # 1723823 PATE: IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID k 2.2857035 DATE PROCEDURE CEDE 'QTY ?1?E Kll i W CHARGE PAYMENT/ GUARANTOR'. ADJU$`RdIENT Bk1t WCE »> PATIENT: DEREK L FORGIE 1723823 9540190 PERFORMED BY: GLENN K GEETIFG MD DIV OF EMERG KUi PLACE OF SVC: EMERGENCY ROOF{ 02/213/08 99213.2E 073.43 EMERGENCY VISIT .40.33 03/12/01 BLUE SHIELD PAYMENT* 75.DD- 03/12/01 B SHIELD CWrRACTUAL ADA 55,DD.- I I 02128108 12052 1173.43 INT REP FC ER LP 2-5 03/12/06 BLUE SHIELD PAYMENT* 03/12/06 B SHIELD CONTRICiUAL IESA . C1I'? 155.Ik?- AD.* 700.89 I C E 9D.00 INDICATES 14W FINkCIAI[. ACTIVITY SIDE LAST BILL. IF YOU HAVE ANY IWESTIONS ABOUT THE ANNE YOUR INSURANCE COMPANY PAID, CONTACT THEM DIRECTLY. FOR ANY OTTER QUESTION;; REGARDING YOUR BALANCE, PLEASE CONTACT OUR OFFICE. IF PAYMEW HAS BEEN MADE, THANK YOU AND DISREGARD THIS BILL. PLEASE GIVE TO PCF2 THINK YDU FOR USING MSHMC PHYSICIANS GROUP FOR YOUR PHYSICIAN SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL, PLE?ISSE CONTACT US AT 717-331-5069 OR 800-254-2619, BE111EEN B:DOAM AM) 5:30PM MIWAY THBt0= NEUMESDAY OR BETIEEN B:DOAM AND 4:3DPM TUMAY AND FRIDAY. '' „f [)CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTION.?ON BACK .RR?6AIEMENT OF PHYSICIAN SERVICES" I Aa ::ti t" F, in m PAGl' )F_l NSTA.TL ASHLEY HARRIS 4 01 2 1237 HUNTERS RIDGE DR 19 The Milton S. Hershey Medical Center l1RECHANICSSURG PA 17056-5768 _ -?- STWEMENT The College of Medicine DATE: 04115106 LAIST STATEMENT AzCOUNT # 1723823 WE: IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES E,ED TAX ID ## 251857035 PAYMENT/ GUARANTOR DATE iPROCh RE DIAG QTY DESCRIPT N CHARGE CODE CODE 'ADJUS'TMENT BALANCE B&I-RCE St WARY RESPWSIBLE PARTY POLICY 8 _ TOTAL. jeer GUARLWOR RESPOWaILITY $ 0.00 10POR7ANT: PLIFASE HTACH AND RETURN v.OTTON POR710N OF STAL999NT WIN YOUR PAYME'11'r???_? _ STATEMENT DATE: GUARANTOR RESPONSIBILITY: MINIMUM PAYMENT BFC 04115108 $ 0.00 $ 0.00 MSHMC PHYSICIANS GROUP BILLING SERVICES P 0 BOX 854 HERSHEY PA 17033-0854 00001723823 UP OOOG 000000000000041508 t??.16{?L?ILt?{{???I??L111...11>,1??1{IIILII?IIIIILI??tll Koff MSHMC PHYSICIANS GROUP ASHLEY HARRIS Ta. 1237 HUNTERS RIDGE: DR PO BOX 643313 MECHANICSBURG PA ;17050-9169 PITTSBURGH PA 15264-3313 ICE USE ONLY CHECK ONE FOR CREDIT CARD PAYMENT, PLEASE FILL IN INMRMATION BELOW 11 1 1 1 1 1 1 1 1 1 E 1 1 1 1 1 El 3823 M/C CARD NUMBER EXP DATE VISA DISC CARDHOLDER NAME (PRINT) FOSO DMND P: CREDIT CARD SIGNATURE MSHMC PHYSICIANS GROUP ?. Y .. -':.c '. _-......._. ;fa:. M :r ;:u, •wr4L9>'.w.rt'r. JG 77. j 55 ? CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK I ; 0 m N=ALTH INSURANCE CLAIM FORM JVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08105 0 r, 2E El VIC:}:EE` ?.AP: Y Ct ECM OC izT'rN - STEF'Ht--JJI E S ATED' SKI HARRISBURG PA 17110-e,30UP a a PICA PICA [TT MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1 1a. INSURED'S I.D. NUMBER (For Program in Item 1) . CHAMPUS HEALTH PLAN BILK LUNG (Medicare #) ? (Medicaid #) 1:1 (Sponsor's SSN) (Member ID#)17 (SSN or ID) 0 (SSN) }; (ID) 20 27 84 -19 4 PATIENTS NAME (Last Name, First Name, Middle Initial) 2 3. PATIENT'S BIRTH DATE SEX. 4. INSURED'S NAME (Last Name. First Name, Middle Initial) . F~?ti'<GIE. L>LFt£I? MM DD E] G C9:?31 0 *tCtCM }; F H ARRI S ASHLEY 5. PATIENT'S ADDRESS (No., Street) 6, PATIENT RELATIONSHIP TO INSURED 7 INSURED'S ADDRESS (No., Street) 1'3'7 ?,UNTERS RIDGE D1F:IV12 Self El Spouse E] Child Other? 1237 HUPTEkS fiIUGE I)RI?'I; CITY STATE 8. PATIENT STATUS CITY STATE rj H . I l ? U ; G; F' 1; Single 1, Marred Other N E t : p U R E ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) 11 e C Q .? n) 7 r, C D y rt F7 Full-Time Pan-Time Employed? ? ? c 1 . CII _I ?1 ?1? ? ;. ? 5 17 l Student Student 9 OTHER INSL)RED'S NAME (Last Name. First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO 11. INSUREDS POLICY GROUP OR FECA NUMBER I C OTHER INSURED'S POLICY OR GROUP NUMBER a a. EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH SEX LI B . YES 5 NO MM , DD , YY 4` 1C)`?i4 M? F i 0 b. OTHER INSURED'S DATE OF BIRTH SEX b AUTO ACCIDENTS PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME - MM OD I YY I D M F[] YES NO 2 c EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME ? } YES NO METZGEF k'ICf:EFf?HAM LI INSURANCE PLAN NAME OR PROGRAM NAME d 10d RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? < . F YES }4 NO If yes, return to and complete item 9 a-d. 0 READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary 12 payment of medical benefits to the undersigned physician or supplier for . to process this claim I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. 'GNED STF- L!lL U P F F T I T' DATE 1 ?1s- S SIGNED c7r-h1ATIMP, FiN, FT1 i -)ATE OF CURRENT: ILLNESS (First symptom) OR '5. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, YY DD TE MM GI FIR T 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM i DD YY MM DD Yy MM DD i YY 4 INJURY (Accident) OR , , VE DA S i psi ?,p I •T+OC1 PREGNANCY (LMP) FROM TO ; NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17 17a 1E HOSPITALIZATION DATES RELATED TO CURRENT SERVICES . - - - - - - - - - - - - - - - - - - - - - - MM i OD t YY MM I 00 I YY Wnl-j- , ROBERT E 17b. NPI 1E ?gt?13m3 FROM TO I 19 RESERVED FOR LOCAL USE 20 OUTSIDE LAB? S CHARGES DYES I{ NO I X00 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (Relate Items 1,2.3 or 4 to Item 24E by Line) --} 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23 PRIOR AUTHORIZATION NUMBER 4. L- 2 L - . . 24. A. DATE(S) OF SERVICE B C. D. PROCEDURES. SERVICES, OR SUPPLIES E. F G. H. I. J. -e C From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS J SRS Eesffr ID. RENDERING MM DD YY MM DD vv SERVICE EMG CPT/HCPCS MODIFIER POINTER $C ARGES UNITS FV OUAL. PROVIDER ID, It e tF-' 1t' t8 CtG" 10 108 11 99201 1 'S 'AIL 1 1 NPI 161?y01'303 s C, NPI -------------- NPI 0 u NPI C s e 1 NPI _ C --- ---------------- I , NPI ? 25 FEDERAL TAX I.D. NUMBER SSN EIN 26 PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29, AMOUNT PAID 30. BALANCE DUE 7"+f ? .?: 0tn?r?3'1 (For govt. claims, see Deck) NO :f YES ? NO $ %71 C, $ it71 ,%1 (7j $ ?`'. i(,l? SIGNATURE OF PHYSICIAN OR SUPPLIER 32 SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH. k 7 1 E27- 23 INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse C Gr E M E T I C' E U R G apply to this bill and are made a part tnereof.) I S57 CENTER C TF.EET tiCIPrE.r:T i_ WSLT` MID ? CAMP 111'"L PA 1?01 i SIGNED JUCC Instruction Manual available at: www.nucc.org APPROVED OMB 0938-0999 FORM CMS-1500 (08/05) • MET2GER WIC OSHAM T 15?? P 0 BOX 5300 w HEALTH INSURANCE CLAIM FORM ATTN: STEPHANIE GRATKOWSKI ¢ A^"ROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 HARRISBURG PA 17110-0300 U YIGA YIGA 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER Ia. INSURED'S I.D. NUMBER (For Program in Item 1) CHAMPUS HEALTH PLAN BLK LUNG (Medicare #) [] (Medicaid d) (Sponsor's SSN) 1:1 (Member ID#) ? (SSN or ID) 0 (SSN) © (ID) 202784194 2. PATIENTS NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) FORGIE o DEREK ' &,'J: 260 X F? HAR'RIS ASHLEY 5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 1237 HUNTERS RIDGE DRIVE Sell Spouse Child Y other 1237 HUNTERS RIDGE DRIVE CITY STATE 8. PATIENT STATUS CITY STATE Z MECHANICSBURG PA Singled Married Other MECHAHICEBURG PA C ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) Q 17050 (717)732 6919 Employed Full-Time Part-Time 17050 (717} 732 6919 X 0 Student Student O 9. OTHER INSUPED'S NAME (Last Name. First Name, Middle Initial) 10 IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER U. Z C a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH SEX W YES 7NO DD t YY .. 14' 1GB/a M? F? b OTHER INSURED'S DATE OF BIRTH SEX i MM DO YY b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME Z M F? ?YES NO a ZZ c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME H LYES ?NO lrEr,'2GER WICKERSH&M W Z d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? Q YES M NO H yes, return to and complete item 9 a-d. a READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for ocess this claim. I also request payment of government benefits either to myself or to the party who accepts assignment to pr services described below w belo. SIGNED SIGNATURE ON PILE DATE 08 19 2008 SIGNED SIGNATURE ON FILE DATE OF CURRENT: ILLNESS (First symptom) OR 'M DD YY INJURY A id t) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, MM DD GI E FIR YY T D T 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM ( cc en PREGNANCY (LMP) , V A S E DD YY MM DD Y FROM TO 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a, ( 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES WOLF, ROBERT E 17b. NPI 1Cr199C?1 X03 - - - - - - - FROM MM DD YY TO MM DD i YY 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES YES NO 000 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (Relate Items 1,2,3 or 4 to Item 24E by Line) 22. MEDICAID RESUBMISSION CODE ORIGINAL REF NO 10 -: 421 v . . 1 3 < 23. PRIOR AUTHORIZATION NUMBER 2. L-- . 4, L- . 24. A. DATE(S) OF SERVICE B C D. PROCEDURES, SERVICES, OR SUPPLIES E. F. G. H. I. J. Z From To PLACE DF (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSDT ID. RENDERING 0 MM DD YY MM DD YV SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES LINTS fP QUAL. PROVIDER ID. # Q 0$ 19 ? eel u7a ? 19 ? 08 11 j Q',2 12 5 1 50 '00 1 NPI 3 b1'??01?03-- M Z 08 19 08 08 19 ! 081111 17113E I I 1 415 X00 1 ---- NPI --------------- 1E19901303-- w --- ---------------- J a NPI a --- ---------------- NPI O Z S NPI 2 ---------------- 2 NPI ? 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE 2U2116724 ?7-1 ajolse3L-,OL IFOr govt. claims. see back) YES ?NO El 4E5 00 1 0 0G 465 007 :IGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO 8 PH JCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse C rG ' r COSMETIC SUR apply to this bill and are made a part thereof.) 1 857 CERIrEK ? ?TREE7 ? ROBERT E WOLF IiD C:ANP HILL FV, 17011 ; 744 C SIGNED (R.S,. L -? - NIUCC Instruction Manual available at: www.nucc.org APPROVED OMB 0938-0999 FORM CMS-1500 (08/05) WCMS-1500-1 I'IH!C-1J-C.v_'!..'7 1J• C' rC Vri,, .y??n•-. '._n iCl7H l.'-Hli'I? H I 1 G`'r !_CCOC ?': CJ"7" rn C 1500 METZGER WICKERSHAM W P-ALTH INSURANCE CLAIM FORM P o Box 5300 Q ATTN: STEPHANIE GRATKOWSKI a JVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 HARRISBURG PA 17110-0300 PICA PICA I ?r 1, MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a INSURED'S 1.0. NUMBER (For Program In [ism 1) CHAMPUS HEALTH PLAN BLK LUNG (Medicare M) ? (Medicaid A) [:] (Sponsor's SSN) [] (4fember ID/) 0 (SSN or ID) E] ON) /iDl ''02784194 2, PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENTS BIRTH DATE SEX 4. INSURED'S NAME (Last Name, Rral Nome. Middle Initial) FORGIE.DEREK MM D3' g0(VL)d Fu HARRIS- ASHLEY S. PATIENTS ADDRESS (No„ Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 1237 HUNTERS RIDGE DRIVE Sslf[:] Spouoe? ChIld® oths,0 1237 HUNTERS RIDGE DRIVE CITY STATE B. PATIENT STATUS CITY STATE z MECHANIC Single ® Married El Other MECHANIC; PA 0 ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) ? 17050 (6919 Employed? Studen e? Stueertmi a 170,50 ? 717 732 6919 p B, OTHER INSUREDS NAME (Last Name. Flint Name, Middle Initial) 10.. is PATIENT'S CONDITION RELATED TO it INSURED'S POLICY GROUP OR FECA NUMBER u Z Ul e. OTHER INSURED'S POLICY OR GROUP NUMBER a, EMPLOYMENT? (Current or Previous) a. INSURED'S DATE OF BIRTH SEX Ix YES ®ND MM t DD ? YY 021 141 1984 M D F ® ? _ b. MM OTHER IDD RED'SYVATE OF BIRTH SEX h AUTO ACCIDENT ! PLACE (State) b EMPLOYFR'S NAME OR SCHOOL NAME G 1 I M F 11 YES 12 NO a c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c INSURANCE PLAN NAME OR PROGRAM NAME Z I YES ?NO 5d ET ER WICKER HAM F d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? a YES ® NO H yes, retum to and complete item 9 ad. READ BACK OF FORM BEFORE COMPLETING & SIGNWG THIS FORM. 13. INSUREDS OR AUTHORIZED PERSON'S SIGNATURE 1 authorize 12, PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authodt:e the releaac of any medical or other Inlormatlon nocc=ry payment of medical benefits to the undersigned physician or supplier for to pprocess this claim, I also request payment of government benefits either to myself or to Me party who accepts assignment services described below. bebw SIGNED DATE SIGNED ,A DATE OF CURRENT; ILLNESS (Finn a tom) OR W ' 1S, IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, MM D W 16, DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YV MM DD W N i OD I INJURY (AaJdent OR , PR GNANCY LMP D i GIVE FIRST DATE 1 i 1 TO 1 FROM I I ( ) E l I 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a 16 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES . -- - -. - ------------ ------ MM 1 DD I YV MM I DO I YY 17b. NPI FROM TO I I 19. RESE VED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES DYES NO 000 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (Relate Items 1;2,3.or 4 to Item 24E by Lino) -- --1 22. MEDICAID RESUBMISSION y CODE ORIGINAL REF. NO. 1. I R7?. 41? 3. Lr_ . 23, PRIOR AUTHORI2ATION NUMBER 2, 4. L_ . 24, A. DATE(S) OF SERVICE B C, 0. PROCEDURES, SERVICES, OR SUPPLIES E. F. 0. H. I. J. Z From To RACE OF (Explain Unusual Circumstances) OIAGNOSIS DAYS ?vsp'r NR ID, RENDERING O MM OD YY MM DID Yv SERVICE EMG c MgECS I LAP IIEI.E POINTER S CHARGES u B Prn DUAL, PROVIDER ID, If Q cc I 11 I ' $I t 1 1 I Sg? 11 Mq' A' 081 0gi O A i IM ___ NPI -.._ .._ C r :1 U. 2 l .1 NPI LU -- _------.:..,..---- a i t I I I (' t I 1 , ' NPI N ---- ---------------- Ic I I I NPI O -- --------------- z V t 1 I r T 1 t i I I , I I I r i I , 1 NPI rn . 1~ I { NPI 25. FEDERAL TAX I.D. NUMBER SSN EIN 29. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 26. TOTAL CHARGE 29, AMOUNT PAID 30. BALANCE DUE 208916724 El ® 006031-01 For 90A. dalme. sear beak) YES 7 NO S 25 100 $ 25 ' 0 = 0:00 31, BIGNATURE OF PHYBICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFOFiMAT10N 33 B! NG PROVIDER INFO & PH. it 7 1 7637333 INCLUDING DEGREES OR CREDENTIALS t osmy that the statements on the reverse COSMETIC SURG BY WOLF ply to this bill and are made a part thereof.) 1857 CENTER STREET ROBERT E WOLF MD CAME H11-1. PA 17011 SIGNED 03/&9/09 a1821218926 b. NUCC Instruction Manual available at: www.nucc.org APPROVED OMB 0938-0999 FORM CMS-1500 (08/05) WCMS-1500-1 i'IHN-1J-CUU7 l-J • GO rru?I• r1Lr"rH UI'IGIaH ?„LH1I'I'- H i 1 (cf41cfcfbb ? L1: C_,4-1:'4 (?3 F', 9 01 t 150 07 MMETZGER WICKERSHAM Ir ?'-ALTH INSURANCE CLAIM FORM ATT P N: Box STEPHANIE GRATKOWSKI ? OVEO BY NATIONAL UNIFORM CLAIM COMMITTEE 08!05 HARRISBURG PA 17110-0300 v PICA PICA 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER In. INSURER'S I.D. NUMBER (For Program In Item 1) CHAMPUS HEALTH PLAN BILK LUNG ?D) (Medicare M) ? (Madiald rP) (Sponsara SSN) 1:1 (Member IDN) ? (SSN or 10) El (SSN) C3i 202784194 2 PATIENTS NAME (Last Name, First Name, Middle Ialtfal) 3 PATIENTS BIRTH DATE SEX 4. INSUREDS NAME (Last Name, First Name. Middle IntW) ORGIE DEREK F 001® F? 021 031 20 HARRIS ASHLEY 6, PATIENTS ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) 1237 HUNTERS RIDGE DRIVE Sell?Spousa?Child N Oft,, 1237 HUNTERS RIDGE DRIVE CITY STATE e, PATIENT STATUS CITY T E Z Single© MamcdD other T CHANICSBUR ME PA C) ZIP CODE TELEPHONE (Include Area Code) - ZIP CODE TELEPHONE (Include Area Code) 4 17050 717 732 6919 Enrolayd? s d nl El ? s d 17050 (717) 7 9 0 tu e e 19 32 6 9. OTHER INSURED'S NAME (Last Name. First Name, Middle Initial) 10 IS PATIENTS CONDITION RELATED TO- 11 INSURED'S POLICY GROUP OR FECA NUMBER LL Z G a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Currerd or Previous) a. INSURED 'S DATE OF BIRTH SEX LY YES ® NO MM I DD I YY 021 14: 1984 M ? F [R Z b. OTHER INSURED'S DATE OF BIRTH SEX MM I DO 1 YY b. AUTO ACCIDENTS PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME 0 M F 11 YES NO I 1 c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME ®YES El NO METZGER WICKERSHAM W d. INSURANCE PLAN NAME OR PROGRAM NAME 100 RESERVED FOR LOCAL USE d. IS THERE ANOTHER AEALTH BENEFIT PLAN? Q DYES ®NO ff y.., return to and complete hem 9 &-d a READ BACK OF FORM BEFORE COMPLETING 8 SIGNING THIS FORM. 13. INSUREDS OR AUTHORIZED PERSON'S SIGNATURE I authorize 12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authoriza the release of any mad cal or other Information necessary to rolass this claim. 18150 reque31 payment of government bensffts either to myself or to the party who accepts aaatgnment l b poymont of mad,cal benefits to the undersigned phyardan or supplier for services described below.. ow. e SIGNED DATE SIGNED qT1"-b1-AT.URV- 11711H R11117 DATE OF CURRENT- ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 'M DD YY N RY A 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION I I I I JU CCident)) OR GIVE FIRST DATE MM I DO YY L PREGNANCY W) MM I DD I YY MM i DO i YY FR r I T i O I , OM 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM t DO I YY MM I DO 1 YY 17b, NPI 6 990 i 303 FROM TO I I 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? 5 CHARGES DYES N} NO 000 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (Relate Items 12.3 or 4 to Item 24E by Line) 22 MEDICAID RESUBMISSION CODE ORIGINAL REF. NO 1. 87 !4 3 3. } 23. PRIOR AUTHORIZATION NUMBER 2.. 4. L_ , 24. A. DATE(S) OF SERVICE B C D, PROCEDURES, SERVICES, OR SUPPLIES E; F. G, H I. J. Z From To PLACE OF (Et?laln Untlaus] circumstances) DIAGNOSIS ohs VWT 4 ID: RENDERING O MM DD YV MM DD YY SERVICE EMG T PCS I MODIFIER POINTER $ CHARGES uNm; 7 Cw DUAL: PROVIDER ID. M P ' Gal 12: Oil l 99211 , 4 4.,5eQ1_i ...- NPI -.-------_..__...- 1619901303 0 Z r r 1 1 I i r i ---- NPI ---------- -____ r - W IL r t , i 1 .I i NPI IL U) -'-------------- NPI 0 r r r , , , , --- ------ Z NPI V --- ---------- ' i NPI Q. 25, FEDERAL TAX I.D. NUMBER SSN EIN 25. 26. PATIENTS ACCOUNT NO 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE - 29, AMOUNT PAID 30. BALANCE DUE 208916724 ?® 006031-01 (For pout. tleims. we bock) F%fl YES 1:1 Na X If 25!09) $ 0 0 S 25X00 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO d PH, M 7 1 7637 INCLUDING DEGRI E80R CREDENTIALS INCLUDING ? 'i certify that the statements on the reverse COSMETIC SURG H W LF pply to this bill and are made a pan thereof.) 1857 CENTER STREET ROBERT E WOLF MD CAMP HILL PA 17011 SIGNED 03/&-&/09 -' ° -1821218926 ° NUCC Instruction Manual available at, www.nucc.org APPROVED OMB 0938.0999 FORM CMS-1500 (08105) WCMS-1500-1 0 ExA lax server b/ZU/200U 1:41:43 PM PAGE 5/005 Fax Server HEALTHCARE RECOVERIES FEDERAL TAX: 61-1141758 P.O. Box 34060 TELEPHONE NUMBER: (800) 889-3534 Louisville, Kentucky 40232-4060 PAGE 1 OF 1 CONSOLIDATED STATEMENT OF BENEFITS PATIENT'S NAME: DATE OF INJURY: SERVICE PERIOD: EVENT NUMBER: DEREK FORGIE 2128/2008 2/28/2008-2/28/2008 6340264-6338298 Subject to change. Instructions: • If remitting payment, make checks payable to: Healthcare Recoveries. • Write the patient's name, DEREK FORGIE, and event number, 6340264-6338298, on the check. Provider of Service Diagnosis Code Claim Number Date of Service Procedure Code(s) Billed Amt. Provided Benefits CAMP HILL EMERGENCY 873.40 OPEN WOUND FACE 08077534304 2/28/2008 99282 EMERGENCY DEPT V $254.00 $45.00 HOLY SPIRIT HOSPITA 873.43 OPEN WOUND LIP 08071544800 2/28/2008 450 EMERGENCY ROOM $112.00 $70.56 MILTON S HERSHEY ME 873.43 OPEN WOUND LIP 08065763962 2/28/2008 250 PHARMACY $3.60 $2.35 2/28/2008 259 PHARMACY $6.00 $3.92 2/28/2008 250 PHARMACY $14.80 $9.69 2/28/2008 450 EMERGENCY ROOM $411.00 $268.79 2/28/2008 450 EMERGENCY ROOM $595.00 $389.13 THE MILTON S HERSHE 873.43 OPEN WOUND LIP 08566538408 2/28/2008 99283 EMERGENCY DEPT V $140.00 $75.00 2/28/2008 12052 LAYER CLOSURE WO $856.00 $155.11 Total Billed Charges $2,392.40 Amount Received $0.00 Total Benefits Provided $1,019.55 Balance Due $1,019.55 0 Ek4i4lef 6 CONTINGENT FEE AGREEMENT 1, Ash /e /-farm s individually and as parent and natural guardian of Gk - ?r-? f G retain and authorize the law firm of Metzger, Wickersham, Knauss & Erb, P.C., to do whatever they deem necessary or desirable in order to represent me and my ,- in all claims for compensation and reimbursement for personal injuries, wage loss, medical expense and other damages resulting from an that occurred on 2/28/2008. 1. ATTORNEY'S FEES: The fee of the attorneys shall be contingent as follows: (a) Twenty percent (20%) of gross recovery; (b) SHOULD THERE BE NO RECOVERY BY SUIT OR SETTLEMENT, SAID ATTORNEYS DO NOT HAVE ANY CLAIM AGAINST US OF ANY KIND FOR LEGAL SERVICES RENDERED. 2. EXPENSES OF LITIGATION: I acknowledge responsibility for all expenses incurred on our behalf to pursue our claim/case and my attorney shall be reimbursed out of the balance, after deduction of attorneys fees, of any recovery for all legal expenses which have not already been paid by me. I do hereby agree to pay all expenses incurred by our attorney in the preparation and presentation of this case and do understand that these expenses include, but may not be limited to, costs of medical reports and records, stenographic expenses connected with depositions, expert witness fees, photocopying charges, and mileage charges connected with the rendering of legal services. I understand that I am responsible for payment of these expenses regardless of the eventual outcome of the case and further understand that if our attorney deems it necessary, I may be asked to advance these costs prior to the incurring of any such expenses or the scheduling of any deposition. Page 1 of 3 3. APPEAL: I hereby further agree that our attorney may charge us reasonable additional compensation if it is necessary to try the case more than once, if the case is appealed, or if proceedings in other courts are necessary because of the change of circumstance of a party or for other reasons. 4. AUTHORITY: I hereby further agree that our attorney is hereby authorized to bring suit or to settle and compromise the claim, to execute all documents pertaining thereto, and to do all lawful acts requisite for effecting the claim on our behalf. 5. MEDICAL EXPENSES AND LIENS: I further authorize my attorney to pay out of any proceeds of settlement or trial any unpaid medical bills or liens for treatments or services or workers' compensation liens made necessary by the injuries sustained in this accident, or back child support payments owed to Pa.SCDU. I understand that my attorney is not guaranteeing the payment of any medical bills or liens, and they remain solely my responsibility. 6. INVESTIGATION OF MERITS OF CASE: I agree that our attorney accepts this employment on the condition that he will investigate this claim, and if it appears to be a recoverable claim, he will proceed to handle the claim; but if, after investigation, the claim does not appear to be recoverable, said attorney shall then have the right to rescind this Agreement. 7. EARLY TERMINATION: I hereby further agree that if I decide to terminate this authority before any settlement is offered or any award is obtained the firm shall be entitled to reasonable Page 2 of 3 compensation for all work done on the case up to that point. I agree that reasonable compensation for Clark DeVere, Esquire, or any other attorney involved in the handling of this case, shall be Two Hundred Dollars ($200.00) per hour, and other employees One Hundred Dollars ($100.00) per hour, or such higher rate as shall constitute his/her standard billing rate at the time that the work is performed, or the agreed upon percentage fee in paragraph one of this Agreement, whichever is greater. 8. WITHDRAWAL: I agree that our attorney may withdraw from this case at any time after reasonable notice to us, and I agree to keep him advised of our whereabouts at all times and to cooperate at all times in the preparation and trial of this case, to appear upon reasonable notice for depositions and Court appearances, and to comply with all reasonable requests made of us in connection with the preparation and presentation of this case. 9. CONFLICT: I also understand that if the investigation reveals that a parent is contributorily negligent in causing the accident the attorney's representation will solely be limited to representing the injured minor and there will be no representation of the parent. I also waive any conflict of interest that may arise by my meeting with the attorney to discuss the case. IN WITNESS WHEREOF, I have signed below on this :26 day of , 2008. CLIENT: METZGER, WICKERSHAM, KNAUSS & ERB, P.C. ATTORNEY: Clark DeVere, Esquire Page 3 of 3 0 • EXA,L,-f H 8/24/2009 12:49 PM 0 0 Page 1 of 2 92-00762 / Auxer, Mr. Josh SETTLEMENT MEMORANDUM RECOVERY: RECOVERY Nationwide Insurance RECOVERY Nationwide Insurance $ 74,000.00 $ 1,000.00 $ 75,000.00 DEDUCT AND RETAIN TO PAY: Metzger Wickersham Toth, Mr. Richard F.; Copy of Deed ChartONE, Inc.; prepay med rec - HMC ChartONE, Inc.; prepay med rec - Holy Spirit Cosmetic Surgery by Wolf, P.C.; Payment of medical bill Cosmetic Surgery by Wolf, P.C.; Payment of medical bill Cosmetic Surgery by Wolf, P.C.; Payment of medical bill Cosmetic Surgery by Wolf, P.C.; Payment of medical bill Metzger Wickersham; Digital Photographs Metzger Wickersham; Fax Metzger Wickersham; Photocopies Metzger Wickersham; Postage Cumberland County Prothonotary; File Petition for Approval Total Due Metzger Wickersham DEDUCT AND RETAIN TO PAY TO OTHERS: Highmark Blue Shield Metzger Wickersham Metzger Wickersham, Atty Fee Total Due Others: Total Deductions: Total Amount Due To Client Less Previously Paid To Client Net Amount Due Client: $ 2.00 $ 54.89 $ 35.86 $ 75.00 $ 465.00 $ 25.00 $ 50.00 $ 16.00 $ 23.00 $ 33.48 $ 22.62 $ 78.50 $ 1,019.55 $ 385.00 $ 15,000.00 $ 881.35 $ 16,404.55 $ 17,285.90 $ 57,714.10 $ 0.00 $ 57,714.10 8/24/2009 12:49 PM • 40 Page 2 of 2 92-00762 / Auxer, Mr. Josh I hereby approve the above settlement and distribution of proceeds. Metzger Wickersham will pay out of the recovery the medical bills and liens listed above. I acknowledge that any further medical bills or liens not reflected in this Settlement Memorandum are solely my responsibility to pay. I also acknowledge my obligations to pay back any child support owed out of the distribution before any other liens or funds are distributed to me. Date Ashley Harris, Parent and Natural Guardian of Derek A. Forgie • f 7174125039 NATIONWIDE INS. . Nationwide Insurance 07:46:12 a.m. 08-28-2009 3 /3 0 RELEASE OF ALL CLAIMS CLAIM NUMBER: 58 37 HP 063704 02282008 01 FOR AND IN CONSIDERATION OF the payment to me/us the sum of ($75.000.00) dollars, and other good and valuable consideration, I/we, being of lawful age, have released and discharged, and by these presents do for myself/ourselves, my/our heirs, executors, administrators and assigns, release, acquit and forever discharge Ann & Josh Auxer and any and all other persons, firms and corporations, whether herein named or referred to or not, of and from any and all past, present and future actions, causes of action, claims, demands, damages, costs, loss of services, expenses, compensation, third party actions, suits at law or in equity, including claims or suits for contribution and/or indemnity, of whatever nature, and all consequential damage on account of, or in any way growing out of any and all known and unknown personal Injuries, death, and/or property damage resulting or to result from an accident that occurred on or about 02-28-2008 at or near Cumberland County PA. I/we hereby declare and represent that the injuries sustained may be permanent and progressive and that recovery therefrom is uncertain and Indefinite, and in making this release and agreement it is understood and agreed that 1/we rely wholly upon my/our own judgment, belief and knowledge of the nature, extent and duration of said injuries, and that I/we have not been influenced to any extent whatever in making this release by any representations or statements regarding said injuries, or regarding any other matters, made by the persons, firms or corporations who are hereby released, or by any person or persons representing him or them, or by any physician or surgeon by him or them employed. I/we understand that this settlement is the compromise of a doubtful and disputed claim, and that the payment is not to be construed as an admission of liability on the part of the persons, firms and corporations hereby released by whom liability is expressly denied. It is further understood and agreed that I am responsible for the payment of any lien or charges against the settlement sum, including but not limited to Worker's Compensation liens, liens of the Department of Public Welfare or liens arising out of any other form of public assistance. Should any person or entity make a claim for payment of any liens or charges against the released parties, I hereby agree to indemnify and hold harmless the released parties, from any and all liens, charges, fees, attorney's fees, cost, interest and other sums. it is agreed that distribution of the above sum shall be made as follows: $74,000.00 ($75,000 less $1,000 Medical payment issued to your client 512812008 )upon receipt of signed executed release and Court Apgroval of Minor's Compromise Settlement. This release contains the ENTIRE AGREEMENT between the parties hereto, and the terms of this release are contractual and not a mere recital. I/we further state that I/we have carefully read the foregoing release and know the contents thereof, and I/we sign the same as my/our own free act. WITNESS In the presence of: Name Address Name Address State of County of hand and seal this _ day of , 20 CAUTION! READ BEFORE SIGNING Your Signature (SEAL) Your Signature On this day of 20 - Before me personally appeared to me known to be the person... described herein, and who executed the foregoing instrument and he/she acknowledged that he/she voluntarily executed the same. My term expires 20 Notary Public (SEAL) Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties. J` b; f MAY032001? ASHLEY N. BRETZ, : IN THE COURT OF COMMON PLEAS OF Plaintiff : CUMBERLAND COUNTY,PENNSYLVANIA V. NO. 2001-1791 CIVIL TERM JUSTIN FORGIE, MELISSA, : CIVIL ACTION - LAW RAINES, and TIMOTHY M. : IN CUSTODY PRESTON, Defendants ORDER OF COURT AND NOW, this Y" day of , 2001, upon consideration of the attached Custody Conciliation it is ordered and directed as follows: 1. The prior Order of Court dated March 27, 2001 is hereby vacated. 2. The Mother, Ashley N. Bretz, shall have sole legal custody of the child, Derek Forgie, born February 3, 2000. 3. Mother shall have primary physical custody of the child with the maternal grandmother and her fianc6e, Melissa Haines and Timothy M. Preston, having periods of partial custody as follows: A. Beginning Friday, May 4, 2001 at 4:00 p.m. to Sunday, May 6, 2001 at 4:00 p.m. and alternating weekends thereafter from Friday at 4:00 p.m. to Sunday at 4:00 p.m. B. In addition, two evenings per week to correspond with Mother's work schedule from 5:00 p.m. to 9:00 p.m. as agreed by the parties. Mother shall supply her work schedule to Melissa Haines and Timothy M. Preston as soon as practicable after receipt thereof. 4. Father, Justin Forgie shall have periods of supervised custody as agreed by the parties. It is understood however, that Father's periods of custody shall be during the times that Melissa Haines and Timothy M. Preston have custody, unless otherwise agreed by the parties. 5. Defendants, Melissa Haines and Timothy M. Preston, shall provide transportation unless otherwise agreed by the parties. VINVAIASNN3d AiNnoo c?? -? rvn? 2S t::GI •I.j iT_ rtiY""W IU 16 r 0 0 6. This Order is entered pursuant to an agreement of the parties present at the Custody Conciliation Conference. The parties may modify the provisions of this Order by mutual consent. In the absence of mutual consent, the terms of this Order shall control. BY THE COURT, J. cc: Joan Carey, Esquire - Counsel for Mother Cara Boyanowski, Esquire - Counsel for Melissa Haines and Timothy M. Preston Justin Forgie, Pro se Keystone Job Corps Service Foothills Drive P.O. Box 732 Drums, PA 18222 i ` O? gfioq,6*jz j,1-eo5 IX ?,? vd vim' 81+ ? Metzger, Wickersham, Knauss & Erb, P.C. By: Clark DeVere, Esquire Attorney I.D. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 Attorneys for Petitioners (717) 238-8187 cdv(a),mwke.com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: DEREK FORGIE 5-9q9 NO. DECREE AND NOW, this day of 2009, upon consideration of the Petition for Approval of Settlement of a Minor's Claim and Distribution of Proceeds, it is hereby ORDERED and DECREED as follows: 1 2 3 The proposed compromise and settlement of claims is approved; The proposed allocation of proceeds as agreed to by the parties herein is approved; The settlement proceeds shall be distributed as follows: TOTAL AMOUNT OF SETTLEMENT (a) To be paid to Ashley Harris, parent and natural guardian of Derek Forgie, $57,714.10 to be deposited into a restricted, federally insured account or certificate of deposit marked "No withdrawals prior to age 18 without prior court approval."; (b) To be placed in escrow the total amount of $1,019.55 for the asserted Highmark Blue Shield lien; (c) To remain in escrow the $385.00 paid by Nationwide for $75,000.00 394258-1 outstanding medical bills or for the payment of any liens; Petitioner's counsel shall attempt to negotiate a reduction in the amount of any outstanding medical bills or liens. After resolution, the balance of monies remaining shall be distributed to Petitioner for the benefit of Derek Forgie. (d) To be paid to Metzger, Wickersham, P.C. for counsel fees and expenses the total sum of $15,266.35. 4. Ashley Harris, as Parent and Natural Guardian of Derek Forgie, is authorized to execute all necessary releases, checks, and distributions in final compromise and settlement of the within claim; 5. Petitioners shall file with the Court within ten days of the distribution of the proceeds a Proof of Deposit of Minor's Funds. BY THE COURT: J. cc: v Clark DeVere, Esquire, Counsel for Plai iffs Metzger, Wickersham, Knauss & Erb ' 3211 North Front Street .?y /rt'a.tLCL Harrisburg, PA 17110 / (717) 238-8187 l 4// (717) 234-9478 (fax) Email: cdv(c?mwke.com Barbara Noce Nationwide Property & Casualty Insurance Company P. O. Box 2655 Harrisburg, PA 17105 (717) 671-3526 (717) 412-5049 (fax) June and Josh Auxer 4135 Kittatinny Drive Mechanicsburg, Pa 17050 394258-t FILED--C,,F 1CF OF T MOWONOTARY 2H9 SEP --4 PM 2: 32 CUMB&,-•'f4LD COUNTY PENt TVAN A Metzger, Wickersham, Knauss & Erb, P.C. By: Clark DeVere, Esquire Attorney I.D. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 Attorneys for Petitioners (717) 238-8187 cdv mwke com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: DEREK FORGIE NO. 09-5999 Civil Term AFFIDAVIT OF DEPOSIT OF MINOR'S FUNDS The undersigned, counsel for Ashley Harris, Parent and Natural Guardian of Derek Forgie, a minor, hereby certifies that the net settlement amount of $57,714.10 as set forth in this Court's Order dated September 4, 2009 was deposited on November 16, 2009 by Ashley Harris into a Certificate of Deposit at Members 1St Federal Credit Union marked "No withdrawals prior to age 18 without prior court approval." Proof of deposit is attached hereto as Exhibit "A". 431937-1 This Affidavit is made subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsification to authorities. Respectfully submitted, METZGER, WICKERSHAM, KNAUSS & ERB, P.C. By: Clark DeVere, Esquire Attorney I.D. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 (717) 238-8187 Dated: November , 2009 Attorneys for Petitioner 431937-1 NOV-16-2009 MON 09:46 AM M1ST ENOLA FAX No. 7171281277 P-002 At Enola 392 East Penn Drive Enola PA 17025 Inquiriae Call: -717-728-1299 Acct }00x808 FoRGIE,DZREX A Eff: 11116109 Date: 11/16/09 Tlr: 0303 Tim*: 9:37am Depeait to 60 MONTH CERT 0040 Prev Bal: 0.00 Katurity date: 11/15/14 Amount: 57,714.10 New Bal; 57,714,10 Seq; #374137 Check Received 57,714.10 Authorized by ID Source: Cj Drv Lic [] SigCard ? Known ? other Current Certificate PX0motiona: 11-Month To=; 1.25% APY 19-Month Farm: 1.503; APY open yourr today! DEREK A FORGXR St MEMBERS 1st FEDERAL CREDIT UNION Clark DeVere, Esquire P.O. Box 5300 3211 North Front St Harrisburg, Pa 17110-0300 Dear Clark DeVere, Esquire: Re: Derek Forgie 11-13-09 Members I" Federal Credit Union has established an account for 57714.10. The funds in the account have been placed in a Certificate of Deposit and frozen until 2-3-2018. The enclosed document shows the account name and the restriction placed on those funds. Please contact us for any additional assistance. Any questions or further communications should be directed to Gregory P. Schank, VP of Branch Operations at 1-800-283-2328, extension 6003. Respectfully, -44 A Lapadat Members Service Representative enclosure REV. 6/30/08 CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a true and correct copy of the foregoing Proof of Deposit with reference to the foregoing action by first class mail, prepaid postage, this dyOI-day of November, 2009, on the following: Ann and Josh Auxer 4135 Kittatinny Drive Mechanicsburg, PA 17050 Barbara Noce Nationwide Property & Casualty Insurance Company P. O. Box 2655 Harrisburg, PA 17105 Clar eVere, E431937-1 Ei_E_.? r OF THE Ps N OTARY 2009 PLOY 25 F 3: 56