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HomeMy WebLinkAbout10-3581T THE I?R TH0, ,TARy 2010 JUN -I PM 2: 58 CUMSERL ,:r) COUNTY PD"N Aig JERRY MELLOTT, V. PETER BRIGGS IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 10 - Z68 f 0'1ViI`TP.rm CIVIL ACTION - LAW JURY TRIAL DEMANDED NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO OUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET :FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY LAWYER REFERRAL SERVICE Court Administrator Cumberland County Courthouse Carlisle, PA 17013 (717) 240-6200 (5D 0x.00 PA ATY`/ e 7n 1'l 2, ?q (g qaq Plaintiff Defendant NOTICIA LE HAN DEMANDADO A USTED EN LA CORTE. Si usted quiere defenderse de estas demandas expuestas en las paginas siguientes, usted tiene viente (20) dias de plazo al partir de la fecha de la demanda y la notificacion. Usted debe presentar una apariencia escrita o en persona o por abogado y archivar en la corte en forma escrita sus defensas o sus objeciones a las demandas en contra de su persona. Sea avisado gue si usted no se defiende, la corte tomara medidas y puede entrar una orden contra usted sin previo aviso o notificacion y por cualguier gueja o alivio gue es pedido en la peticion de demanda. Usted puede perder dinero o sus propiedades o otros derechos importantes para usted. LLEVE ESTA DEMANDA A UN ABODAGO IMMEDIATAMENTE. SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO, VAYA EN PERSONA O LLAME FOR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. CUMBERLAND COUNTY LAWYER REFERRAL SERVICE Court Administrator Cumberland County Courthouse Carlisle, PA 17013 (717) 240-6200 By: -7 Joseph J. Dixon, EAttorney ID No. 28290 126 State Street Harrisburg, PA 17101 (717) 236-8515 Attorney for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA JERRY MELLOTT, V. Plaintiff PETER BRIGGS CIVIL ACTION - LAW NO. xx xx xxxx JURY TRIAL DEMANDED COMPLAINT AND NOW, this t, j/ day of , 2010 comes the Plaintiff, Jerry Mellott, by and through his Attorney Joseph J. Dixon, Esquire who respectfully avers as follows. 1. The Plaintiff is Jerry Mellott, an adult individual who resides at 813 Meyerstown Road, Gardners, Adams County, Pennsylvania 17324. 2. The Defendant is Peter Briggs, an adult individual who resides at 210 Frost Road, Gardners, Cumberland County, Pennsylvania 17324. 3. The facts and occurrences herein took place on or about the 21 s` day of July 2008 at approximately 4:13 p.m. on Frost Road in South Middleton Township, Cumberland County, Pennsylvania. 4. At said time and place, the Plaintiff, Jerry Mellott, was operating a Harley Davidson motorcycle traveling south on Frost Road. 5. At said time and place, the Defendant, Peter Briggs, was operating a 1993 Gleaner Combine traveling north on Frost Road.. 6. • At said time and place, the Defendant, Peter Briggs, was operating the combine in a position which covered both lanes of traffic. 7. At said time and place, the Defendant, Peter Briggs, drove his motor vehicle up a hill covering both lanes of traffic. Defendant 1 At said time and place, the Plaintiff, driving his motor vehicle in the opposite direction suddenly saw the Defendant's motor vehicle in his lane of traffic. 9. The Plaintiff attempted to swerve to avoid the motor vehicle in his lane of traffic but could not and ended up striking the left hand side of the Defendant's motor vehicle. 10. Said striking and collision caused severe personal injuries to Mr. Mellott. These injuries include but are not limited to the following: the injuries are multiple trauma with upper left extremity abrasions and contusions. - cervical and thoracic strain sprain - laceration of the left foot - contusions and abrasions of the left leg - fracture of the distal phalanx left ring finger - fracture of the middle finger and little finger on the right - fracture of the middle phalanx right little finger - comminuted fracture of the right fifth finger - comminuted fracture of the long and ring fingers on the left - lumbar sacral strain sprain - aggravation of degenerative disease in the cervical and lumbar spine - 2 cracked ribs - permanent nerve damage down the left leg from the knee down into the calf 11. The injuries sustained by the Plaintiff were not, in any way, caused by his own actions or conduct. 12. The incident described in this Complaint was caused by the negligence and carelessness and reckless conduct of the Defendant which consists of the following: a. Failure to drive a motor vehicle in its' correct lane of traffic; b. Failure to have any safety or warning devices on a motor vehicle while it is in the opposite lane of traffic; C. Failure to have any warning devices whatsoever to alert people that a motor vehicle is in their lane of traffic; d. Failure to have a flagger ahead of the motor vehicle when it is moving in the wrong lane of traffic; e. Failure to have any sound warning devices on a motor vehicle when it is in the wrong lane of traffic; f. Failure to keep alert and maintain a proper watch for the presence of other motor vehicles on a highway; g. Failure to keep proper and adequate control of his vehicle; h. Failure to drive a vehicle with due regard for highway and traffic conditions which were existing and of which he was or should have been aware of, i. Driving a vehicle upon a highway in a manner endangering persons and property and in a reckless manner with careless disregards to the rights and safety of others and in violation of the Motor Vehicle Code of the Commonwealth of Pennsylvania. 2 13. The plaintiff believes and therefore avers that he will have permanent residual problems as a result of the accident. 14. As a result of the injuries sustained from the accident, the Plaintiff has incurred medical expenses and in the future will incur additional medical expenses, the total amount of these expenses are unascertained at this time. 15. As a result of the injuries sustained in the incident described in this Complaint, the Plaintiff has missed time at work. He has had to use leave and has sustained a loss as a result of it. The total amount of this loss is unascertained at this time. 16. As a result of the negligence, carelessness, and recklessness of the Defendant, the plaintiff has suffered loss of the value of his Harley Davidson motorcycle. The total amount of this loss is $5,590.21. 17. The Plaintiff believes that the conduct of the Defendant described in this Complaint constitutes outrageous conduct and a reckless indifference to the rights of other persons on the highway. This conduct entitles the Plaintiff to an award of punitive damages. WHEREFORE, the Plaintiff prays this Honorable Court enter judgment against the Defendant in an amount in excess of Fifty Thousand Dollars ($50,000.00) Respectfully submitted, By: `,----, Joseph J. Dixon, Esquire Attorney ID No. 28290 126 State Street Harrisburg, PA 17101 (717) 236-8515 Dated: Attorney for the Plaintiff 3 VERIFICATION I verify that the statements made in this ?D "p/ /t / .Y, are true and correct. I understand that false statements herein are made subject to the penalty of 18 Pa. C.S. §4904, relating to unsworn falsification to authorities. Dated: d? .• F:~FILES\ClientsU3924 BriggsU3924.1.prel Revised: 7%15!10 2:16PM 13924.1 ~~~~f Tin ~1 i l: ~ r'y (~r ~~r ~ .. ~.~"of1~ George B. Faller, Jr., Esq 're ZOID ~ P~~ { ~ ~{ { {~: MARTSON DEARDORF . WILLIAMS OTTO GILROY & FALLER MARTSON LAW OFFIC S LD. 49813 ~~4~._,,i ~ ,1~~~ ~ _ - ~ ~' ~ 10 East High Street '-'~~ 1!xe `~'~' ' ` ~ Carlisle, PA 17013 (717) 243-3341 Attorneys for Peter Briggs JERRY MELLOTT, IN THE COURT OF COMMON PLEAS OF Plai tiff CUMBERLAND COUNTY, PENNSYLVANIA v. ~ NO. 10-3581 . • CIVIL ACTION -LAW PETER BRIGGS, De dant JURY TRIAL DEMANDED PRAECIPE TO THE PROTHONO RY OF CUMBERLAND COUNTY: Enter the appear ce of MARTSON DEARDORFF WILLIAMS OTTO GILROY & FALLER on behalf of Def ndant in the above matter. Defendant hereby demands a twelve juror jury trial in the above cantione action. By MAR LAW OFFICES I.D. No. 49$13 Ten East High Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Defendant Dated: 7/15/10 ' 'r A 1, I, Nichole L. CERTIFICATE OF SERVICE an authorized agent for Martson Deardorff Williams Otto Gilroy & Faller, hereby certify that ~ copy of the foregoing Praecipe was served this date by depositing same in the Post Office at PA, first class mail, postage prepaid, addressed as follows: Joseph J. Dixon, Esquire 126 State Street Harrisburg, PA 17101 MARTSON LAW OFFICES By t Nichole L. Myers Ten East High Street Carlisle, PA 17013 (717) 243-3341 Dated: 7/15/10 JERRY MELLOTT, Plaintiff v. PETER BRIGGS Defenc~nt IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 10-3581 CIVIL ACTION -LAW : JURY TRIAL DEMANDED ANSWER TO DEFENDANT'S INTERROGATORIES DIItECTED TO PLAINTIFF 1. (a) Jerry D. Mellott (b) None (c) None (d) 813 Myerstown Road, Gardners, PA 17324 (e) Factory worker, PPG Ind., Park Drive, Carlisle, PA (f) 03/06/1954 (g) 166-46-3970 (h) None (i) Carlisle High School 2. (a) Aetna Insurance Company, Policy No. BBJ1S85A (b) Jerry D. Mellott (c) Health Insurance (d) Health Insurance coverage (e) Not that I know of (f) No response required ;~=> ~i ~~ ~ ~` ? ~ s : ! ~ . a r"~' ~:~ -o ~': ~~ W ~ a 1 3. I was riding my motorcycle on a country road when Mr. Briggs was operating a piece of farm equipment which was protruding into my lane. I could not avoid the farm equipment and a collision occurred and I did sustain injuries. 4. No witnesses 5. Not applicable 6. Not that I am aware of 7. None, other than the police report attached to Request for Production of Documents filed contemporaneously with this document. 8. No 9. No 10. No 11. Unascertained at this time 12. Unascertained at this time 13. See photos attached to Answer to Request for Production of Documents filed contemporaneously with this document. 14. Unascertained at this time 15. No 16. No 17. No 18. Yes 19. (a) Owner, Terry D. Mellott (b) No passengers (c) Harley, 883, 1992 20. (a) None (b) No repairs done 2 (c) See estimate attached to Answer to Request for Production of Documents filed contemporaneously with this document. (d) No (e) None 21. (a) Going home, time was 3:50 PM (b) Going home from work (c) -No stops (d) Yes (e) Sunny and dry 22. I was driving in a safe manner going south on Frost Road in my lane of traffic. Mr. Briggs' combine was taking up both sides of the highway, traveling northbound on the same road. As I came over a hill, I was confronted with his vehicle and did everything I could to avoid it, but a collision occurred. 23. No 24. See averments in Complaint. By way of further answer, Mr. Briggs did nothing to warn people traveling on the road that his vehicle was on the opposite lane of traffic. There were no flags, no cones, no flashing lights. He also had no person with him to warn people at the top of the hill. 25. I believe Mr. Briggs was 100% negligent. 26. I do travel that road sometimes. 27. I worked 8 hours that day, from 8 AM to 4 PM, with co-workers at PPG Ind. 28. No 29. No 30. No 31. None 32. No 3 33. No Respectfully submitted, By: Joseph J. Dixon, Esquire Attorney ID No. 28290 126 State Street Harrisburg, PA 17101 (717) 236-8515 Dated: ~ 3 C~ Attorney for the Plaintiff 4 VERIFICATION I verify that the statements made in this ~~ ~/ ~i~1 ,are true and correct. I understand that false statements herein are made subject to the penalty of 18 Pa. C.S. §4904, relating to unsworn falsification to authorities. Dated: ~ l CERTIFICATE OF SERVICE AND NOW, this ~D~C1 day of~j~~ , 2010, I, Joseph J. Dixon, Esquire, hereby certify that I have served a true and correct copy of the foregoing Answer to Defendant's Interrogatories Directed to Plaintiff, this day by depositing the same in the United States Mail, first class, postage prepaid, in the Post Office at Harrisburg, Pennsylvania, addressed to: MARTSON DEARDOF WILLIAMS OTTO GILROY & FALLER MARTSON LAW OFFICES GEORGE B. FALLER, Jr., ESQUIRE TEN EAST HIGH STREET CARLISLE, PA 17013 The Law Office of Joseph J. Dixon, Esquire By: JOS J. DIXON, ESQUIRE ATTORNEY ID #28290 126 STATE STREET HARRISBURG, PA 17101 (717) 233-8757 ATTORNEY FOR PLAINTIFF BLED-()~-~1CE Q~ 'MF ~o~T' ~.,~,~~~, 'j0 SAP -7 P~9 3~ ! 0 ~w, ,. CUMBE ' ~ ~~'~ CUUI~TY PDVNSYLVANl~t JERRY MELLOTT, IN THE COURT OF COMMON.PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaint~f . NO. 10-3581 v. . CIVIL ACTION -LAW PETER BRIGGS, . JURY TRIAL DEMANDED Defendant . ANSWER TO REQUEST FOR PRODUCTION OF DOCUMENTS AND NOW, this ~ day of , 2010, comes the Plaintiff, Jerry Mellott, by and through his Attorney, Joseph J. Dixon, Esquire, who respectfully responds to the Request for Production of Documents as follows: 1. None available other than Police Report attached hereto and marked Exhibit A. 2. See attached photos attached hereto and marked Exhibit B. 3. None available. 4. Unascertained at this time. 5. None available 6. See attached medical records and medical bills attached hereto and marked Exhibit C. 7. None available 8. No response required 1 Respectfully submitted, By: Joseph J. Dixon, Esquire Attorney ID No. 28290 126 State Street Harrisburg, PA 17101 (717) 236-8515 Attorney for the Plaintiff Dated: f/' EXHIBIT A rw-ovu i n . Incident Number. Hot-17n0o6 COIt11110t1Vd@a~'th Of Pe1111SyiV8nla PAGE 1 .crash Involves: Police Crash Report REPORTABLE CRASH IxJI Q Fatality ~ Hit and Run ~ Commen;lal Vehicle ~ State Pollee Vehicle Q Local Pollee Vehicle Q WA Q Work Zone Q AN ~ Snowmobile Q CommomNealth Vehicle Q Local Gov Vehicle ~g p,ge~y Name Case Closed Patrd Zone Investigation Date a PA STATE POLICE -CARLISLE YES ZO 07/2112008 Dispatdt Time Artival Time Investigator Badge Number ~1 16.13 „~_. ~B:3e ~~ ANdIYKA. ...r.o.acw M X0761 ApprOV21 D2t@ Reviewer Reviewer Badge Number a 07/23/2008 YUNK, JOHN G 3D 07831 Date of Crash Time of Crash Day of the Vu~aek Crash Description 07/2t/2008 16:06 ~. MONDAY SIDESWIPE (OPPOSITE DIRECTION) County Munidpality CUMBERLAND SOUTH MDDLETON TWP Weather Conditions Relation to Roadway r NO ADVERSE CONDI'ilONS ON TRAVEL LANES I lluminatlon Road Surface Conditions v DAYLIGHT DRY # of Units # of People # of Injured # Killed Fa1AS Agency Medical Facility ~ 002 002 001 000 YELLOW BREECHES CARLISLE HOSPrfAL Schod Bus Related School Zone Related PennDOT Notified Type d Intersection Special Location NO NO NO MIDBLOCK NOT APPLICABLE Work Zone Work Zone Type Wherein Wbrk Zone ~ NO S Speed Limit Workers Present Officer Present Vubrk Zone Charaderisfics ; Lane closure ^ D~ ~ ~~ houlder ^ Interrrdt for O ~~ ^ Route Signing Route Number Segment Number Travel Lanes Speed Limit Orientation LOCAL ROAD OR STREET T534 02 25 MPH NORTH $ House Number Street Name St Ending `~ FROST ROAD rL t~ Route Signing Route Number Segment Number Trevel Lanes Speed Limit Orientation ~ Used in Intersection Crashes SVeet Name St. Ending 1' Route Number Or Mile Post Terrths Or Segment Marker Ramp Use Only Feet ~` 3010 00476 , ~ eet Er~din Mil O T th ' e Street Name g r es en s i ~ ~ GOODYEAR ROAD ~ ~ r Route Number tX Nkle Post Tenths Or segment Marker Ramp use Orly ~ ~ T532 The above entry IS the distance from the Crash 1 s i • sweet Name ng tream End Scene to Landmark 1 I 9 FANUS ROAD ~ ~s Minutes Seconds Dedmal Degrees Minutes Seconds Decimal Latitude: 40 02 38 914 Longitude: ~ 77 10 48 524 . ~ G Traffic Contrd Device Traffic Contrd Functioning ~ F NOT APPLICABLE NO CONTROLS ~ ~ Lane Closed Lane Closure Direction Treffic Detoured Estimated Time Closed 9 NOT APPLICABLE Environmental /Roadway Potential Factors (E1R) Factor 1 Fadnr 2 Factor 3 NONE e Flrst Harmful Event in the Crash Most Hamdul Event in the Crash Unit Number HamMil Event Unlt Number Harmful Event 001 HIT UNIT 2 001 HIT UNIT 2 Indicated Prune Fadbr Unit umber Prime Factor Drivx Actbn ~ DRIVER ACTION 001 OTHER IMPROPER DRMNG ACTIONS ~ Prime Factor EnviromentallRoadway Prime Factor Vehide Failure Prime Fodor Pedestrian Adbn ~ W Road Surface Type Special Jurisdiction Printed At: PA State Pollcs -Carlisle 06/09/2009 08:59 AM ,Page 1 Forth #: N02-1777006 .,,-, Incident Number: Hoe-!moos Commonwealth of Pennsylvania PAGE 2 Crash Involves: Police Crash Report REPORTABLE CRASH DUI ~ Fatality ~ Hit and Run ~ Commercial Vehicle ~ State Police Vehicle Q Local Police Vehicle WA Q Work Zone ~ ATV Q Snowmobile ~ Commonwealth Vehicle Q Local Gov Vehicle Unit Number ype Unit Conxrrerdal Vehicle 001 Motor Vehicle in Transport No First Name MI Last Name Suffix DOB Telephone Number JERRY ~ D MELLOTT omoer~eas (~+s~ sss-sass Street Address City State Zip Code 813 MYERSTOWN RD GARDNERS PA 17324 Gender Uoense Number License State Class ratan to Owner/Driver ~ MALE 16379747 PA C/M 03/07/2010 PRIVATE VEHICLE OWNED/LEASED BY DRNER Driver Presence Physical Condition Primary Vehlde code vdatlon Person Charged DRNER OPERATED VEHICLE APPARENTLY NORMAL 4703 YES Alcohd/Drugs Suspected Test Type Alodwl Test Results NO TEST NOT GNEN Driver Action OTHER IMPROPER DRMNG ACTIONS Pedestrian Action Pedestrian Signals Pedestrian Cldhing Pedestrian Location 1st HamKul Event Lett or Right Side Most Hamful Utlity Pde Number HIT UNIT 2 Y~ 2nd HamrTul Event Left or Right Side Most Harmful Utility Pde Number 3rd Harmful Event Left or Right Side Most Hamrful Utlity Pde Number 4th Harmful Event Left or Right Side Most Hamitul Utility Pde Number 1 •a 1 A JERRY owner mi U1M1er L.aSt Name Or Business Name x D MELLOTT Street Address City State Zip Code 813 MYERSTOWN RD GARDNERS PA 17324 Vehicle Type Spedal Usage Government Equipment Number MOTORCYCLE NOT APPLK:ABLE Model Year Vehicle Make Vehicle Model Vehicle Cokx VIN 2003 RAREFY-DAVIDSON SCREAMING EAGLE BLACK 1HD4CAM153K454483 se Plate Reg. State Est Speed Vehicle Towed Towed ey ABV25 PA 035 NO i Insurance Insurance Company Policy Number ~~~ ~~ YES STATE FARM INSURANCE 7038104072 09!30/2008 'redion of Travel Vehicle Position Vehicle Movement Initial Impact Pdnt SOUTH RIGHT OF TRAFFICWAY GOING STRAIGHT 10 O'CLOCK Damage Indk~tor Gradient Road Aligrxnent Possible Vehicle Failures FUNCTIONAL LEVEL STRAIGHT NONE ~ # of Units Type Unit 1 Tag Number Tag Year Tag State r~, 3 0 ~ Unit Make Unit ~ Type Unit 2 Tag Number Tag Year Tag State 1- 01690 cc NO ' NO NO v W 4M1AYN 1 f YEg Driver Helmet Type NO HELMET Helmet Stayed On? NO DOT/Snell Designaton? NO Eye Pratectlan? YES long Sleeves? NO Long ParNs? YES Over Ankle goofs? YES assenger Helmet Type Helmet Stayed On? DOT/Snell Designation? Eye Protection? Long Sleeves? long Pants? er Ankle Boots? 3 ~', Passenger? Helmet? Head Lights? Rear Reflectors? Printed At: PA State Ponce • Carlisle 06109!2009 08:69 AM Pege 2 Form #: H02-1777006 rw-avv i n IncidenE Number: H02-1777006 Crash Involves: Q DUI Q Fatality WA O work zone Commonwealth of Pennsylvania PAGE 3 Police Crash Report REPORTABLE CRASH Q Hk and Run Q Commercial Vehicle Q State Police Vehlele Q Local Police Vehicle Q ATV Q Snowmobile Q CommomMeakh Vehicle Q Local (iov Vehicle Unit Number Type Unk Conunerdal Vehicle 002 Motor Vehicle to Transport No First Name MI Last Name SufFx DOB Tel ephone Number PETER BRIGGS osi»i~e4a (~i~ asaa~os SIfCeCt,°lddfeSS Gty State Zip Code 210 FROST RD GARDNERS PA 17324 Gender Uosnse Number Uoense State Class ration Owner/Driver MALE 18471182 PA A 04/01/2010 ~ Driver Presence Physical Condkion Primary Vehicle Code Vitiation Person Charged DRIVER OPERATED VEHICLE APPARENTLY NORMAL NONE NO Alcohd/Drugs Suspected oohol Test Type Alcohol Test Results w NO TEST NOT GIVEN Driver Action NO CONTRIBUTING ACTION Pedestrian Action Pedestrian Signals Pedestrian Clothing PedesMan Location 1st Harmful Event Left or Right Side Most Hamrful Utility Pole Number STRUCK BY UNIT 1 YES 2nd Harmful Event Left or Right Side Most Harmful Utility Pde Number 3rd Harmful Event Left or Right Side Most HamNul Utility Pde Number 4th Harmful Event Lett or Right Side Most Harmful Utility Pde Number Owner First Name Owner MI Owner Last Name or Business Name x PETER BRIGGS 210t C e Z FROST RD GARDNERS A 17324 Vehicle Type Spatial Usage Govermrent E quipment Number FARM EQUIPMENT NOT APPLICABLE Model Year Vehicle Make Vehicle Model Vehicle Cdor VIN OTHER M3 SILVER OOOM K24893H 83 Ucense Plate Reg. State Est Speed Vehicle Towed Towed By NONE 010 NO nsurance Insurance Company Policy Number Expiration pate NO iredion of Travel Vehicle Poeitian Vehicle Movement Initial Impact Point NORTH RIGHT OF TRAFFICWAY GOING STRAIGHT 10 O'CLOCK Damage Indicator Gradient Road Alignment Possible vehicle Failures MINOR LEVEL STRAIGHT NONE ~ # of Units Type Urut 1 Tag Number Tag Year Tag State r 0 ~'.t Unit Make Unit Owner c e Type Unit 2 Tag Number Tag Year Tag r Unit Make Unk Owner Engine Size Passenger? Saddle Bag/Trunk? Trailer? Driver Eduption? ~ ~ ~ Driver Helmet Type Helmet yeti ? DOT/ I Designation? Eye Protection? Long Sleeves? Long Palls? Over Ankle Boots? Passerger Helmet Type Helmet Stayed On? DOT/Shell Designation? Eye Protection? Long eaves? Long Pants? Over Ankle Boots? Passerger? Helmet? .fl Head Ughts? Rear Relledors? a __ Printed At: PA State Police - Carilale 06/09/2009 08:59 AM Page 3 Form #: H02-1777006 AA-500 TX IncidenYNumber: H02-1777006 Commonwealth of Pennsylvania PAGE a ,crash Involves: Police Crash Report REPORTABLE CRASH O DUI O Fatality O Hk and Run O Commercial Vehicle O smte Police Vehicle O Local Police Vehicle Q WA O Work Zone O ATV O 3novrmoblle O CommonwreaRh Vehicle O Local Gov Vehicle Unit # Person No. First Name MI Last Name Suffix DOB 001 001 JERRY D MELLOTT 03/06/1954 treat Address City Spate Zip Code 813 MYERSTOWN RD GARDNERS aA ,7aas Phone Number EMS Trans ort P T p erson ype Gender Injury Severity (717) 528-8857 YES DRIVER MALE MODERATE INJURY '~ Seat Position Safety Equipment 1 ~ DRIVER -ALL VEHICLES NONE USED /NOT APPLICABLE ~ Safety Equipment 2 Exfric~tion NONE USED I NOT APPLICABLE NOT APPLICABLE Ejection Ejection Path NOT APPLICABLE NOT EJECTED/NOT APPLICABLE ~ Unit # Person No. First Name MI Last Name Suffix DOB 002 002 PETER BRIGGS 03/31H942 eet Address city State 21p Code 210 FROST RD GARDNERS PA 17324 ~ Phone Number EMS Transport Person Type Gender Injury S everity (717) 648-3208 NO DRIVER MALE NOT INJURED Seat Position ~~y Equipment t DRIVER -ALL VEHICLES NONE USED /NOT APPLICABLE Safely Equipment 2 Extrication NONE USED /NOT APPLICABLE NOT APPLICABLE Ejection Ejection Path NOT APPLICABLE NOT EJECTED/NOT APPLICABLE PAMed At: PA State Pdice -Carlisle OBJ09lZ009 08:59 AM Page 4 Form #: H02-1777006 AA-50o TX ~ncidenCSiumber: Crash Involves: I AAt Hdly Springs eao appox. 5 miles This incident occurred as the operator #Z was operating a 1983 Gleaner Combine traveling north on Frost Rd and operator #1 was operating a Harley Davidson traveling south on Frost Rd. Operator #1 tried to go around the Combine that was taking up most of the roadway. Operator #1 then struck the left front side of the Combine continuing and striking the left rear tine of the Combine. Operator #1 suffered moderate injuries from the crash and was transported to Carlisle Regional Medical Center via Yellow Bnreches Ambulance. The Combine received minor damage. The Marley Davidson was disabled resulting from the crash. This crash occurred as Unit #1 was traveling south on Frost Rd. Unit #2 was traveling north on Frost Rd. Unit #2 was taking up the majority of the roadway due to the size of the unit. Unit #1 tried to go around Unit #2 making contact with the left front end of Unit #2 before striking the rear left tire of Unit #2. Upon arrival at the scene, Tpr. OTT and I observed Unit #1 at final rest in the upright position off of the roadway on the southbound lane of Frost Rd facing Hoe-lmoos Commonwealth of Pennsylvania PAGE 5 Police Crash Report REPORTABLE CRASH Printed At: PA State Police -Carlisle 06/09/Z009 08:59 AM Page 5 Forth fk. H02-1777006 DUI ~ Fatality Q Hk and Run Q Commercial Vehicle Q State Police Vehicle Q Local Police Vehicle Q WA a Work Zone Q AN U Snowmobile Q Commonwealth Vehicle Q Local Gov Vehicle Incident Number: H02-7777006 Commonwealth of Pennsylvania PAGE 6 crash Involves: Police Crash Report REPORTABLE CRASH DUI ~ Fatality Q Hk and Run Q Commercial Vehicle Q State Police Vehicle Q Local Police Vehicle Q WA Q Work Zone ~ ATV ~ snowmobile Q Commonwealth Vehicle Q Local Gov Vehicle east. Unit #2 was at final rest in a field off of the northbound lane of Frost Rd. facing the northeast direction. Physical evidence observed at the scene consisted of minor damage to the left front end of Unit #2 and minor d9n19Qo !o !ho lofk rrar' tirr of Unit #2. Other physicwl evldsnce conalated oT moci®rato damage t0 the right handle bar of Unit #1 a broken right rear turn signal light, and a flat front tine to Unit #1. On 07/21/08 at approx. 1635 hrs., I spoke with the operator of Unit #2 at the scene. Operator #2 stated that he was traveling north on Frost Rd. in Unit #2, he stated that he was traveling approx. 10 MPH. Operator #2 stated that he didn't see Unit #1 until it was too late. He stated that Unlt #1 struck the left front end of Unit #2 and the rear left tire of Unit #2. On 07/21/08 at approx. 1720 hrs., I spoke with the operator of Unit #1 at Carlisle Regional Hospital. Operator #1 stated that he was traveling south on Frost Rd. at approx. 35 MPH. He stated that he viewed-Unit #2 taking up most of the roadway. He stated that he tried to go around Unit #2 and his left leg and left arm struck the rear left tire of Unit #2 causing him to lay his Unit down. Operator #1 stated that he suffered moderate pain to his left leg, left arm, pain to his neck and back. Unit #1 received moderate damage and Unit #2 received minor damage. Operator of Unit #1 suffered moderate injury and was transported from the scene to Carlisle Regional Medical Center via Yellow Breeches Ambulance . Printed At: PA Stats Police - Carlisle 08/09/2009 OS:58 AM Page 6 Form *: H02-1777006 EXHIBIT B ~~~ ~~ ,,' ~^ ~ xxv~, }+^`~ " ~ ~ e'~ ~ "ak. .u .; , y ~i d r^ P - ~`: S~ °~~ r~^~ k, ,..,. ., 3 ~ 'R.I-4 ~ v ~. ~... ,:kf r ~ ~ # ~,~ v~ S , . > ~... . . x ~Vn +'~ ~ ~, • ~ , - y ~k . - ~~ ~ y s,;+ ~~ :~ ea;~zr a~ ~~~ ~~; ~~~ ~ gym. .~ 3F..~~L. -:~ ,~ ,~,,Y~ EXHIBIT C 717 960 3524 medical records fax 'i ~ ~ 2 0 ~ ~ `r''~'~~`~ ti ~ ~` ~ - G1-•ESti X18 : R?p Py : i l~IS' ~''ele~~cc~'~ ~~~ . (Quantum Medical Raclic:+)~ti'J PHONE (678) 90d-2599 FAsC (ti'1l) >t)•d-:75~I * *PRELIMtNARY ttEP4[~`~ •:~~~~~`~` k Received: 721/20088:23a)D PM EST Reac~• ~;%1tZ0U8 13.45:32 Pivi IST Facil• :Carlisle Regional MC Status: Emergency Room Study: CT C-Spine w/o Contrast Name: MELLOTT, JERRY Sttxljr Count. i Patient infcrltryttatit~r; Male Doh: a~rosil9s~ Indications/Nistow~ ; MVA, NECK PAIN ~~;Rt~l: Impressions: 1. No fracture or malalignment of the cervic~li spine 2, degenerative changes at C1-C2, as well as ttt C4-C5 ~ ~• : ; a.~::. C~-S7 • 3, partial opactflcation of sphenoid sinuses h ician. Scott Pretorius, MD s~,.~~ i~,~t~ir~; ~~ectr>vnlc:ar;- sl fneu' sy firer read: Physician: Signature:: Electron: c° :.i ~ ~ t-~,ri~~' 6y Piease circle the score that best summarizes your findings as it perinin:: t. th:. ,r: gcii! patient care setting 1-Concur with interpretation 2-Difficult diagnosis, not ordinarily e.~pectcd to be made 3-Diagnosis should be made most of the timr 4-Diagnosis should be made almost everytime-misintarpretati~ •z. ~f ii:u.iin,~, Reason: 71 7 860 3524 medical records fax CARLISLE REGIONAL, MEDIA'%:l. Ci~',N'~~sR 3 61 ALEXANDER SPRINGS ROAD CF:Fa.: _ SI; L P ~i 1 '? U "1 ~; (717) 960-1663 RADIOLOGICAL INTERPRL~1.•r.'"!`TGr! PATIENT NAME: MELLOTT JERRY D X-RAY#: 1074414 EXAM DATE: 7/21/2008 ORDERING: PATRICIA L FRIERSON MD- ATTENDING: KATIE J MILLER MD 717 ~ r;r.. CONSULTING : ~ `~ 5 - ~ - i- HISTORY: MVA MVA CT OF THB CERVICAL SPINE WITH SAGITTAL h~i:i t:~;?RC}NAL RSCONSTRIICTIONS - 7/21/08: INDICATION: MVA. DIAGNOSIS: 1. Degenerative disease of the spine. 2. No evidence for fracture. 3. Mucous membrane thickening involvin,r COI~ZSN'P Axial sections of the .cervical .spine wer,~ ol3tair)ed. and coronal reconstructions were perfo~•„~:,;". ~"gittal There are degenerative changes involvin~~ chc; cervical narrowing of most of the interspaces. ::~r,~,:cli a~~tei-.ior ;pu11se r~~eh present and there are small posterior ~:h,_,~.•s ,.t C',_C6. ., The vertebral bodies are btherwise norr,r:i:: iri ,3c~~t;ure ~tl~d alignment . The retropharyngeal :;oft t 9. rs ~ ~.:_~;:; ; thickness , ai.'~~ iorm~~ _~" ,1 There is no fracture or bony dest:ructit~n There are lobular soft tissue masses imrc.,_.virig the sphenoid sinuses compatible with mucous membrane t.t:ic~kt;n~ng Or ~~etent:ion cysts. - t '~, REVIEWED AND SIGNED ~ 1 ROBERT F HALL II, MD f INTERPRETING PHYSICIAN DATE DICTATED: 7/22/2008 DATE TRANSCRIBED: 7/22/2008 9:46 DATE SIGNED: 7/22/2008 13:36:18 TRANSCRIPTIONIST: JXS 3450074 E R CT CERVICAL W/0 CONTRAST CT 3D RECONSTRUCT SI11~LE PA~' `~ 1 C>F' 1 ML•'U REC if ; 1.U7441~ ACCOtT(T ii : 9407903 D•0•E• : 03/U6/195~1 / f~~~0id ~ ER .- ~i ~~. / ,. / / / ~~~ 'p'~~:.nc_~id sirr.t.es. 717 960 3524 medical records fax -~~~ •!7 %fi Oi-% Ci %OOf) 1~l%I CARLISLE REGIONAL MEDIC~t F, C;,p~•t'.~k 361 ALEXANDER SPRINGS ROAD CAb`.LI ELI, PA '17U:l5 (717) 960-1683 RADIOLOGICAL IN'I'ERPRE 1'~ _~I' ~Cl~f PATIENT NAME: MELLOTT JERRY D X"~Y# ~ 1074414 EXAM DATE: 7/21/2008 ORDERING:' PATRICIA L FRIERSON MU- ATTENDING: KATIE J MILLER,MD 717 295-5~r;; CONSULTING: HISTORY: MVA CROSSTABLE CSPINE TO CLEAR Mi:'L REC ii :~07491~'t X~CCOtRvT i~ : 99 079,x;; D . G. b .: 03/U6 /~,xJS:~ CROSS TABLE LATERAL CERVICAL S P IME TWO V r _~•I - 7 / 21 ~' G II INDICATION: ~A, DIAGNOSIS: Degenerative disease. CONII~ISNT : Hypertrophic spurs are present involving I_h~ cE:rvical. :pine , The vertebral bodies themselves are norln,r~. ~.t•t stature ~~nd alignment and the retropharyngea~. soft ; .>-::s.-~~a;; axe nor;,lal in thickness. CT scan will be performed. R VIEWED AND SIGNED ROBERT F HALL II, MD INTERPRETING PHYSICIAN DATE DICTATED: DATE TRANSCRIBED: DATE SIGNED: TRANSCRIPTIONIST: 3450068 SPDYE SINGLE V>EW.pNy LEV 7/22/2008 7/22/2008 9:46 7/22/2008 13:36:13 JXS E.R. E~::r~ " :, ~) F' 1 717 960 3524 CARLISLE REGIONAL MEDIC't~,L CxiJ'~'~It 1 5 ii ! 361 ALEXp,NDER SPRINGS ROAD CAILI.. ~:SL,I pA 17015 RADIOLOGICAL .TNTERPRh":~'t.".'IGP;r PATIENT NAME: MELLOTT JERRY D X-RAY#: 1074414 EXAM DATE: 7/21/2.008 ORDERING: PATRICIA L FRIERSON MD- ATTENDING: ,KATIE J MILLER,MD 717 245-S5C)5 CONSULTING: ' HISTORY: MVA MVA FNS VIE~i LOI~IDOSACRAL SPINE - 7 / 11 / 0 8 : INDICATION: 'MVA, DIAGNOSIS: Transitional lumbosacral junction. Mx'I:~ RFC ~; 107441~I ACCOUNT 11: 940790;3 R~~OK : ER '. i COH~IEN'r Transitional lumbosacral junction is pr.~~3;nr probably representing sacralization of L5. The lumbar vertebral bodies are norrnal i.i 5:~,:~tt,r•e anc :;;lign:nent.. The pedicles and .appendages are unremal,._~;_~1~:~ . REVIEWED AND SIGNED ROBERT F.HALL II,MD INTERPRETING PHYSICIAN DATE DICTATED: DATE TRANSCRIBED: _ DATE SIGNED: TRANSCRIPTIONIST: 3450098 SPINE LtJA~AR CONS W/OBLIQ medical records fax 7/22/2008 7/22/2008 9:46 7/22/2008 13:36;19 JXS E.R. PA~i::' Z C)F 1 717 960 3524 CARLISLE REGTONAX, MEDI~,~~ ~., C~1r!";'i.It 4(3 t fi 07 ;,~, 7itq,i 361 ALEXANDER SPRINGS ROAD CAF,;_:SL£•. Z>]~ 1701; (vim) ~6o-i6a~ RADIOLOGICAL INTERPRE'I'~~:T''~pi;( 1ri//! PATIENT NAME: MELLOTT JERRY D X-RAY#: 1074414 MEC) R~;C if : 1074114! EXAM DATE: 7/21/2008 ACC"c~U2vT it : 940790& ORDERING: PATRICIA L FRIERSON MD- D•O•H~~ 03/CiS,/195~~~ ATTENDING : KATIE J MILLER, MD 717 l4 5 - 5 ~ Ci :; ~` I'.UGid ' ~ R ~/ CONSULTING: HISTORY: MVA MVA Two vlEw noRSAr. sPIN$ - ~/21/os: rnedical records tax --. IlJDICATION: NIVA. DIAGNOSIS- • ;Minor` wedging of upper dorsal vertebra 1 ~ _ d .F , CObII~N'P: There is very minor wedging of one 'of ~;.~~; uY_~pei° dorsal vprti~bral bodies, probably T4 ~' This could be devti~ __,pr,t~nt.al, hor~~ver, the ;;possbi`1•~y of<-a minimal;.",compression fr:~~~~:u?°~~ cannot bey excluded. If' clinically warranted, fart%r-r ev;~lua~ic>n wot~lcl be beneficial. The dorsal vertebral bodies are otherwi ~~ ;~ nU:e•mal im s c ~: tar. e and alignment. The pedicles are intact. REVIEWED AND SIGNED ROBERT F HALL II,MD INTERPRETING PHYSICIAN DATE DICTATED: DATE TRANSCRIBED: DATE SIGNED: TRANSCRIPI"IONIST 3450099 SPINE THORACIC 1V 7/22/2008 7/22/2008 9:46 7/22/2008 13:36:20 JXS E.R. PAC:. 1 OF 1 717 B60 3524 CARLISLE REGIONAL MEDI~I~ L: C.~y'i'cSit 17 %/ 3 61 ALEXANDER SPRINGS ROAD CARl.::i: SI;F P;~ 17 Q 15 X717) 960-1683 RADIOLOGICAL INTERPRETI! T'`~01J PATIENT NAME: MELLOTT JERRY D X-RAY#: 1074414 EXAM DATE: 7/21/2008 ORDERING: PATRICIA L FRIERSON MD- ATTENDING: KATIE J MILLER,MD 717 245-5565 CONSULTING: HISTORY: MVA MVA FODR VIEWS OF LgFT KNEE - 7/21/Q8: INDICATION: MVA. DIAGNOSIS: No abnormalities. r9L~ 12E~~ rf : 107441, ACCOUNT it ; 94 ~ a'90,t D.C.B.: 03/• /1y5~_ FtOb?~! : C ~~~`~ ~: , There is no evidence for fracture, bony ..:t:s~~z•uc°r~ion or joint effusion, REVIEWED AND SIGNED ROBERT F HALL II,MD INTERPRETING PHYSICIAN DATE DICTATED: DATE TRANSCRIBED: DATE SIGNED: TRANSCRIPTIOI42ST 3450190 KNEE COMPLEI'g 4+ VIEWS medical records fax 7/22/2008 7/22/2008 9:46 7/22/2008 13:36:19 JXS E.R. 71 7 B60 3524 medical records fax . -' .w 4U q5 07-2•'~-2000 1~3/ll CARLISLE REGIONAL !VIEDIC~~t_; C_,''~'1'_Ir, 361 ALEXANDER SPRINGS ROAD CF.F,I;L^ p; 17U1> (717) 960-1683 RADIOLOGICAL INTEP.PRE'i't~:`!'.~UA! PATIENT NAME; MELLOTT SERRY D X-RAY#: 1074414 EXAM DATE; 7/21/2008 ORDERING: PATRICIA L FRIERSON MD- ATTENDING: KATIE J MILLER,MD 717 245-5~0: CONSULTING: HISTORY: MVA MVA MED REC !~ : 107447.E ACCUUNT r ; 940790E. U.r.II.: 03/U6/1J5, RUC~19: ER ~~ ~~~~ l~ Z~II2BS VIEWS OF LEFT FOOT - 7/21/08: INDICATION: MVA. DIAGNOSIS: No evidence for fracture. COMET: . There is a spur at the insertion of tht~ :;.~tii a 1:; rerldor; ir,tr.~ the calcaneus. Bony relationships about the foot are o+.-.i~~x~r;~ se unrern~i~:•kablc with no fracture or dislocation. REVIEWED AND SIGNED ROBERT F HALL II,MD INTERPRETING PHYSICIAN . DATE DICTATED: 7/22/2008 DATE TRANSCRIBED: 7/22/2008 9:46 - DATE SIGNED: 7/22/2008 13:36:19 TRANSCRIPTIONIST: JXS 3450192 E.R. FOOT MMnVV 3V PAG'L 1 c)F 1 717 960 3524 rnedfcal records fax "•4J 5fi 0%-75-2uGt2 CARLISLE REGIONAL MEDIC~L._. '~Lh~''1;IZ 3 61 ALEXANDER SPRINGS ROAD CARL, "L Li !~l1 17 O 1 S (717) 960-1683 RADIOLOGICAL IN'PERPRr~'?'A'!''~g7 PATIENT NAME: MELLOTT JERRY D X-RAY#: 1074414 EXAM DATE: 7/21/2008 ORDERING: PATRICIA L FRIERSON MD- ATTENbING: KATIE J MILLER, MD 71i 245-55C:~. CONSULTING: HISTORY: MVA MVA TFII2SE VIEWS OF .LEFT WRIST - 7 / 21. / 0 8 INDICATION; MVA, DIAGNOSIS: Soft tissue swelling. ti/ii h1'EJ REC' !~ : 10'1191; AC~;C.'iI?VT ;~. 94!~~9G;' RC)Ut~~ : ER ~~-~ ,..r~ COMMEN'P There is soft tissue swelling lateral to f_he di.ta1 raciius. The carpal bones .are intact with no frG~rc.~_:rt• ray' disloc<<tion. REVIEWED AND SIGNED ROBERT F HALL II, MD INTERPRETING PHYSICIAN DATE DICTATED: DATE TRANSCRIBED: DATE SIGNED: TRANSCRIPTIONIST: 345019"4 WRIST COMPLETE MiN 3 Y 7/22/2008 .7/22/2008 9:46 7/22/2008 I3:36::l9 JXS E.R. PIa;:!; 1 Q1' ;;. 717 960 3524 medical records fax •49: t 2 t,7 2!i•2UUtt CARLISLE REGIONAL MEDICr~.i. ;~~i`d'~d'F~;t 361 ALEXANDER SPRINGS ROAD CA3;:.,'::;.L!~~ L~J~;. 17015 (717) 960-1693 RADIOLOGICAL INTERPREi'Ai':CO1~1 PATIENT NAME: MELLOTT JERRY.D X-RAY#: 1074414 EXAM DATE:. 7/21/2008 ORDERING: PATRICIA L FRIERSON MD- ATTENDING: KATIE J MILLER,MD 717 245-550:; CONSt7LTING HISTORY: MVA MVA TWO VIEW CHEST - 7/21/08: INDICATION : MVA. DIAGNOSIS: No abnormalities. 2~)12~. ME7D REC ~#: lU'"1441=l. AC'CUUIVT ~# : 99 0'? 9 G 8 D.G,B.: .03/06 •`' 951 RC~O~1: ER //~.. ,` ~'/ CO~A'IBNT The lungs are clear and the Goatophrenic~ :: u?.c::~ :ire ~h~irp. The heart and mediastinal structures arc: r;oa:-fua'? , R VIEWED AND SIGNED ROBERT F HALL II,MD INTERPRETING PHYSICIAN DATE DICTATED: 7/22/2008 DATE TRANSCRIBED: 7/22/2008 9:46 DATE SIGNED: 7/22/2008 13:36:19 TRANSCRIPTIONIST: JXS 3450195 E.R. CHEST' PA do LATERAL VItA,.rJUT £~9TTt~M R,AD~tDL~GY F3elVrMdBf~ Meth! C~>tt+~r X50 ih~:,,ut l~ottvm itt~ld, Carl~1~, RA'~T4'13 Phone 71T ~-0071 Fax T1T 2~5=0"!841 R. ROY/J_, !411.0. KEITH S. P!l11EiQY, hRQ. M. DANE WAU.~CH, E1.D, Report Details Patient Name: Date of Birth; Patient ID: Procedure: Report Text RIGHT HAND (3 views) l_EFf HAND (3 views) MELLOTT, TERRY 3/6/1954 H6305 BIL HANDS 73130/73130 History: motorcycle accident Procedure Date: Accession: Referring Physician Procedure ID: H10H FIELD AND OPEN MRI COAiPUTB?'iO11OtiRARHY ULTICA~ONOORAPiiY 8i01100R'AI'11Y D10tlAL MMMY00RAPtfY L>eXJI IgG11E inrr IbYAtY91S DIARiN06TiC RAD104AE~Y 7/24/2008 71747 Branscum, George 39562 On the right there is a comminuted fracture of the tuft of the 5th finger. A bone fragment extends distally to near the skin and just peripheral to this there is a small foreign body on the skin. There is also a nondisplaced chip fracture at the base of the middle phalanx involving a portion of the articular surface. On the left there are comminuted fractures of the tufts of the long and ring fingers. The fracture involving the ring finger is moderately splayed. No additional fractures are seen. IMPRESSION: Fractures of the tufts of the left long and ring fingers and the right 5th finger. Fracture at the articular margin of the middle phalanx of the right ring finger. David R. Royal, M.D. DRR/sim T:07/24/08 Thank you for referring your patient to Walnut Bottom Radiology. Signed by: Royal David JI {! ., ,.. ~ ~ LI ~ r, ~~ f .1 f 1j Sr° s~F jLL.ll ~ ..~ ~Nf ! Y ~~Y~ - -- .~__, Date Signed: 7/24/2008 4:50:29 PM Page OFFICE RECORD MIRA ORTHOPEDICS Name MELLOTT, JERRY D. 7/24/08 OFFICE VISIT: This patient was involved in a motorcycle accident on 7/21/08. He apparently came up over a hill on a rural road and there was a big combine across both lanes of the road, He couldn't avoid hitting it. He hit on a large tire that threw him off apparently to his side. He had multiple abrasions and closed injuries. He was taken by ambulance to the hospital. They evaluated him extensively with x-rays of the neck, back, left wrist that was contused, the left leg but not the hands. He also sustained a large laceration on the plantar aspect of his left foot. With a negative evaluation he was sent home and referred to his family physician, Dr. Branscum, who saw him today. Dr. Branscum ordered x-rays of the hands. I had a chance to review these and they showed tuft fractures essentially undisplaced of the ring and middle fingers of the left hand and little finger of the right hand. He also has a chip fracture at the volar aspect undisplaced at the PIP joint of the right little finger. He has been given Percocet for pain, did pretty well at home. The pain is subsiding now in all areas although persistent in the upper cervical spine, mid back, hands and somewhat in his left posterior upper calf as well as plantar aspect of his left foot. He has multiple abrasions on the left leg and one in the lateral right abdomen. He said his fingers feel tight at the tips. They were quite swollen and uncomfortable especially in the middle and ring fingers left hand over the last day have improved. EXAMINATION: His gait is slightly antalgic on the left lower extremity due to his foot. His posture is good. Upper extremity range of motion is good proximally. The hands show subungual hematomas of the ring and little finger of the left hand that are srhall and not particularly painful at this point in time. There is no deformity. The right little finger shows no subungual hematoma but swelling and contusion in the distal segment with some tenderness, no deformity. Neurovascular status is intact in both hands. There is tenderness at the PIP joint of the right little finger volarward but he has good range of motion without deformity or crepitus. IMPRESSION: 1. Multiple trauma motorcycle accident with multiple abrasions and contusions of the trunk, left upper extremity primarily, cervical and thoracic spine strains, laceration left foot, contusions and abrasions left leg, fracture undisplaced distal phalanx left ring and middle fingers and right little finger, fracture undisplaced PIP joint middle phalanx right little finger. RECOMMENDATION: I told Gerry ;that I dori't think he is going i:o need surgery 'or any special splinting of his fingers, just soft tissue management as indicated. ~ ~'1/e would like 'to review and get all of his x-ray reports and continue with his activities as tolerated but considerable elevation of the upper extremities and lying down with some elevation of the left lower extremity yet. He follows up with Dr. Branscum next week and I would like to see him in two weeks for re-check, sooner if needed. AJM/kas cc: Dr. Branscum MIRA 4RTHOPEDIC'S Medical Farts Building Suite 206 220 Wilson Street Carlisle, PA 17013 ORTHOPEDIC SURGERY Allan J. Mira, M.D. Duane A. Stroup, PA-C Phone 249-7400 PATIENT INFORMATION SHEET PATIENT: ~~ ,~(%D ~ (- DATE: 7 ja Y r ~ ~ DIAGNOSIS: INSTRUCTIONS: ~61,1M lJ ~~~i , u~ .tip .~Cz~~., ~,. ~ 1 cuc. a~til~.~ u.,-~-~%~L~ ~e.d~.c~c ~-i~ ~ ~..~ks Patient's Signature r`;~~1(l~~,C~~", 8!13108 OFFICE VISIT: This patient is seen in follow up. He is improving overall. He has one area that is still uncomfortable in the thoraClC spine area that appears to be at the costo-transverse region of approximnt®ly Ts. it .g okay to percussion. It is painful with deep breath although on auscultation I did not hear any click or rub or diminished breath sounds. The wrists are still sore and we took x-rays of both of them today to evaluate for passible occult scaphoid fractures and they are negative, see separate dictation. His legs are functioning well. He still has some contusion and abrasion that is tender on the posterior aspect of the left calf that is improved. Neurovascular status is intact. His gait is satisfactory. IMPRESSION: Multiple trauma motorcycle accident with multiple abrasions and contusion ,of the trunk, left upper extremity primarily, cervical and thoracic spine strains, laceration left foot, contusions and abrasions left leg, fracture undisplaced distal phalanx left ring and middle fingers and right little finger, fracture undisplaced PIP joint middle phalanx right little finger. RECOMMENDATION: I would like to get a bone scan to evaluate for occult fractures particularly of the spine, suggested continuing anti-inflammatory medication and re-check and review the situation next week, sooner if needed. AJM/kas 8/21/08 OFFICE VISIT: This patient is seen in follow up. He had his bone scan taken and it is correlating with his symptoms pretty well. The left ring and middle fingers tuft areas are inflamed and this corresponds to his subungual hematoma and tuft fractures. Those films were done at Belvedere and he is better, a little tender yet in the subungual area of the ring finger more so but it is improving and no cellulitis is noted. The right little finger DIP and PIP show activity and they are still a little but uncomfortable although his range of motion is good and the finger alignment is good. The right wrist is the most symptomatic area in the upper extremities and it is sort of diffuse wrist pain palmarward and dorsally, not really localizing over the scaphoid or pisiform but those two areas on the scan show some increased uptake. In reviewing the films retrospectively those areas do not show fracture however. The left leg is still symptomatic posteriorly about one-third of the way above and below the knee. It looks all right. There is an abrasion and contusion over the Gerdes tubercle region of his left knee which has slight increased uptake on the bone scan and that is the only area in the lower extremities that looks at all like some correlation, probably a bone bruise. Walking is well. The back pain is still bothersome. I noticed that today when he was getting up and down off the table for examination and it is tender just a little bit to the right of the midline at what. now appears to be a little higher than T8, probably T5, and tender to palpation without stepoff but looking carefully at the bone scan there is some increased uptake in that area as well. For that reason we are going to get an MRI of that area. ,ferry is improving. He is ambulatory. I told him I think he is going to do well overall. We would like to see him next week for re-check after getting an MRI of the thoracic spine and on return next week we want to get AP, lateral and scaphoid views of the right wrist and x-rays of the right little finger and the left middle and ring fingers. He is still off work which requires heavy lifting and it may be several more weeks yet till he gets back. AJMIkas !r ~' : 7r ~ ~ra"n s~un~ ~.- ~,.. ORTHOPEDIC SURGERl• Allan J. Mlra, M.D. Duane A. Stroup, PA-C %1 PATIENT: r,~`;tlU~ lj~~C~ ~ ~=- DATE: c.~ ~ ~`~1~;_^n~ ~~,~~ MIRA ORT'FIOPEDICS Medical Arts Building Suite 206 220 Wils9n Street Carlisle, PA 17013 PATIENT INFORMATION SHEET Phone 249-7400 DIAGNOSIS: INSTRUC710NS: 4'x'1..(' ,_~ (' Lv2~ . ., .~ _ _ ~(ru/~ 2 ~ cat ~2 -~- ~t,~ r Patient's Signature ORTHOPEDIC SURGERY ALLAN J. MIRA, M.D. M1RA t5~'~"~~~~i~~CS Medical Arts Building Suite 20C- 220 Wiison Street ca.-i.s~~, rA tvoia Phone (717) 249-7400 XRAY INTERPRETATION 8/13/08 JERRY MELLOTT BOTH WRISTS, 5 VIEWS SERIES- Five-view series are taken for both wrists secondary to motorcycle accident and pain in the region of the snuffbox bilaterally. On the views of the left wrist there is no evidence of fracture, subluxation or abnormal soft tissue swelling. X-RAY IMPRESSION: No significant abnormality left wrist. On the views of the right wrist, there is no evidence of fracture, subluxation or abnormal soft tissue swelling. X-RAY IMPRESSION: No significant abnormality right wrist. Allan J. Mira, M.D. AJM/kas From. Carlisle Reg.h'E~,Ctr, r \+l11\~ JLL 1\L\ _ ~?} ~4..,~'lL 08!?.4/08 '1:23 ;' 0';r;l .I1 V11 361 ALEXANDER SPRINGS t1L. I'IL V l ~,~;'~, ,., RDAs) Cn~: \, L..15 1 I., ~ i c PA 17C~1~~ . (717; _ jr;'-~i6$;: _ , khDIOLOGICAL INTFRPRE=I~~~ '~Y(11 PATIE~~T NAME: X'RAY 122784T JERRY D EXAM DATE: 8/13/2008 ~ MEU REC ACCOUNT ~~: 1~:2iL-'4 ~~: 78301~i9 ORDERING: ALLAN J MIRA,MD 249 -7400 6.. 0 / U6/19~-4 ATTENDING: R~0~.1 ~ ~ CONSULTING HISTORY: WRIST PAIN %"` WRIST PAIN MAB ! ~'~ ( ~ .. ~ ~J . _.._ ____ BILATERAL ~IRISTS, SIX VIEWS CLINICAL HISTORY: Bilateral wri st p~ i ~ . COMMENT: Radiographs of the wrists ?~ i ; : 1,: Z;r~~ , ly ~7~~~e~r iiorrna l with no bony degenerative change or o ~~-. ~;~ ;i,ri~.rmal i ty , Alignment is anatomic. IMPRESSION: Negative radiographs of the wrists. REVIEWED AND SIGNED CHRISTOPHER LADD,MD INTERPRETING PHYSICIAN DATE DICTATED: 8/13/2008 DATE TRANSCRIBED: .8/13/2008 17:41 TRANSCRIPTIONIST: MW 3397156 ORDERING FAX N!tGE i G i= ~i ,i. ., ! From:-Carlisle Reg.Med.C~r. ;-,~~} 24~-1212 08/i6;08 10:?6 ~~.01~~~2 361 ALEX~..JER SPRINGS ROAD CI~Ri_l SSE. P,, 1701:; (7?7) ~oU`i78 r.ADIOLOGICAL INTERPRET:-i"I~J[1 PATIENT NAME: MELLOTT JERRY D i~I.:.D REC ~ : 1l27f3~: X-RAY~~c 122784 ;?CGGUIV i ~' ;'t'33f!:5~ EXAM DATE: 8/15/2008 ORDERING: ALLAN J MIRA,MD 249-7400 '1~U•B•~ O3~U6i1~5~! ATTENDING: RQON!: HO[' CONSULTING HISTORY: TRAUMA ACCIDENT TRAUMA ACC I rJ!=[~[T WHOLE BODY BONE SCAN CLINICAL HISTORY: Pain in multiple ~,i ~:~~;, :recent motorcycle accident. RADIOTRACER: Tc-99m HDP 29.4. mCi incr~avcn~~~.i:,ly. COMMENT: Whole body .and spot images :- ~r•e ;>-_i.t~ i ned ,t 1 e~ st three hours post injection of the rad~i;;~.:r~act~^. At the right -wrist there is a f'oc.al a~~ ~ of i r~creas~:, ~,ptake seen ei them of the tri quetral or pi si f'~a:~~;i i~c,,-,;~_; , A~i ~ o, t[1erEy increased uptake at the region of the ,w ; .; La 1 :•adi us ;, r' scaphoi d bone. I do note recent negative wri s ~. :~•.:.{di Lg~~apirs , 1-r,i s coal ci indicate bone br.ui si ng. Fol l owup rad i ~~,Irai~l~i, ;~ re re~:o~rnnendei`i. Focally increased uptake is present at pie Gi ~Lal interphalangeal joints of the third anJ ('ou,~~ti~ digits of the left hand and of the fifth digit of tPi~ ridr7t hand. T1'iesc, may all be traumatic. The appearance of the extremities i s ,~ t;i<,r•:Jr-i s a pnysi ~.~1 ogi c . There i s degenerative type uptake of i;~~ .~; s [:e+~noal avi cul a r jai rats in the shoulders. There is no abnormal ~:•,pir.e uptake or eviden~~•~; of a pelvis fracture. The scapulae an~1 i~u;i~c.r i appear intact a:~ do the- 1 ong bones of the 1 ower extrem~i l :~s , ~i-mere ~i s nil 1 d degenerative type uptake at the 1 ater~a'I :::om~~;a rtment of the 1 of c knee. Traumati c change cannot be exc1 a,1:~~d :~t th~i s s~i te, C~~iJTIMUC~) ON ~AGC 1 - , t a .. 4 y CA .SLE REG~O-~,-,~_ :~iI~~;~~:__ ~+.~i~'~ Z 361 ALEXA~rOER SPRINGS RUAD CAk:_ ~ ~,i._~; rA 1I0"l5 (.717) 96U-168;3 RADIOLOGICAL INTERPR~:,T,1~~ IOf~d PATIENT NAME: MELLOTT JERRY D X- RAY~~: 122784 EXAM DATE:, 8/15/2008 ORDERING: ALLAN J MIRA,MD 249-7400 ATTENDING: CONSULTING HISTORY: TRAUMA ACCIDENT TRAUMA ACC I [3' rl1 - however. a !~ i,iEU ki~C ~'~: 1;~~z7~q i~,Ct;OUi~T ~~: i:8:'~~~;q C~. G. B.: O~i06i 19,4 O0N1; HOF IMPRESSION: Probable traumati c changes i nvol ve thc, :~!;~r,~::is . Any c~~tn~:r~ fi ndi r;c is more likely degenerative, REVIEWED AND SIGNED CHRISTOPHER LADD,MD INTERPRETING PHYSICIAN DATE DICTATED: 8/15/2008 DATE TRANSCRIBED: 8/15/2008 17:28 TRANSCRIPTIONIST: MW 3392882 ORDERING FP,k i~r;GE ~~ OF 2 :YFT i x: ~~ 1,/I 1~i""YpkY'2(k7pi 7~lt:~ ' - `11RCB Foy t 3t G I~ .4~ap;-:~fltR 7_`:i4 -~Ll~ I.I~ RE~ICIf+i~ 14'~C~i ' F,7TFG I~~~ I~~TftVIT`Y+ l ' ~~ ~i'C ~~ ~':C I~fTff~151(`r' ti ~ Ik r i~ ~ ~j~,A ~ 4r r~ h fa ~ , . . . 3.. „~~ ~ti 1i~-~ ~ ,. ' r. A r {' ~ ~- l~! r2 .i: ~ y .. .. T ~ y %' ..'Z . S x" ~ J K ~ t {{ _ ,fA ;T~ ~ !jam k !.. ~~ ~.~ A. . ,;~.y z . r q ~,. Ff 1 ; _,. i. ro k '~( ~~p Y ~r~,~ ~4y'' ,#~ t'.. =.X„ L i'tf.. 1.. S ~: ~!' .~ ~• I ~ ~' ,~, rf . ~~ .. , rt. ~ H~~' ~ - V . ;: `~ ..1 ; . ~tu~ ~ °5. ~ ~ ` •~;. ,~_ .. ...... 1 a 411. V Cd Y 'f V' V ~ ., ~ ~, b ,, ^d wrr.W. /~ . ,~af~..: MIRA ORTHOPEDICS Medical. Arts Building Suite 206 220 Wilson Street Carlisle, PA 17013 ORTHOPEDIC SURGERIt Allan J. Mira, M.D. Duane A. Stroup, PA-C PATIENT INFORMATION SHEET PATIENT: , '~~ ~ ~+ ~: DATE: , , , ... _ .. DIAGNOSIS: M. ;;~ J.. 4_ `SLR 'rr r,, ,., [~'~~ ,~ ~ ~';. • _ 4 t INSTRUCTIONS: .. r!, ~~ - ... ... sf Rd.~~, , {' ~ ~ ' a {! Phone 249-7400 Patient's Signature From: Carlisle Reg.Med.Ctr, t7i~`? 24~~-1~12 ...+..r+..~ V/11 - JLL 1\L41 V11 l1L 1'1 L.Ul l.J". L. \, Lit 1 ~_ 361 ALEXALJER SPRINGS RG,~7 ra;;r. (;.,~E ;~,, 170'! ~ (117) 960-1683 ~~ADIOLOGICAL INTERPRE~i~..~fION PATIENT NAME- X- RAY~ff EXAM DATE: ORDERING: ATTENDING: CONSULTING HISTORY: .PAIN PAIN MELLOTT JERRY D i2z~a~t 8/25/2008 ALLAN J MIRA.MD 249-7400 T-5 T5 MRI OF THE THORACIC SPINE CLINICAL HISTORY: Persistent thorac,ie 08,"f /08 11:15 ' , O~ r r)/ riFo ~t~c ~ : `i»~~~! ~.~couN r ~: 7I3:i~14~) .OOM: NJ° ~..._ _, spine pair!. TECHNIQUE: Sagi ttal T1. T2 and 1 nVC~r ~~~ or! rc~~_:over•y i n!ages . Axial T2 images. COMMENT: The T2/FLAIR. sequence demor!:> i:r~; tee a fe:~~ 1 eve~l s o~f the upper thoracic spine with T2 high ~„ gnal. This is most evident within the T5. T4 and T3 verter~!~ai bo;:iies. To a Messer extent i t i s present within .the T6 ar!ci ~~ 1 ver~ Lebr~a 1 bocli cs . There does appear to be some 1 oss of r:-~: ql!t c~~i' the ~~ 4 verteb.~al body. The appearance i s consistent wi i f ~ir~~ G~~t i ve t;r evill vi ny compression fracture of T4. Early pr~e~.c,;r!i;re_ ;i ~~ie c:ar!des may explain 'the signal abnormal i ty within i i!e c~tl~ r ver~, ebra1 bodies described. I n a patient of this age t i. ; s ~i s ~.rn un ~~; ua 1 Fi nd i ;!g ; however. I do note a recent history uf' r;os~cr ,~ei~icli~ acc~ider!t and therefore this may be traumatic bcric: raarr~uw ede~ua of these thoracic vertebral bodies. Th-ere is r. c': ~~11;I c:~~.~idencc o~i= a fra~~k fracture other than the mild compressi~~r~ -;'racture a described. There i s no spinal stenosi s. There i s a riorrnal appc~ar-i n~) thoracic spinal cord. Degenerative disc cr!anges are n!ild. IMPRESSION: There i s evidence of bone marrow eder~a ~~ru!7~ -1~3-'f7 . Th i s i ncl udes a smal 1 superior' endplate corr. (.,r~e~~ s ~i coil de-Par;~!i ty of Tq , In the setting of a recent motor vehi c , c' ~,cc1 cien t l i;he f i ndi nc)s are consistent with bone bruising and r: sc!u 11 tr;~un!: ti c C~JNTIhIL~ED ()N PAGE 2 P.~? C~ ISLE REGI£IPtAL M~UCr`.L (;E~' R 361 ALEXhwDER SPRINGS ROAD CAf?l.I~yLE r'A 170:15 (717) 960-1683 ' RADIOLOGICAL INTERPRE~T~~,~1"?ON PATIENT NAME: MELLOTT ~3ERRY D ;-;Ei) REC ~~; "1..27?S~i X-RAY~~: 122784 ,<~,C(:OUh,T ~~: CIS?,?_113 EXAM DATE: 8/25/2008 ~:.O.B.: 03!GG;`15~~I ORDERING: ALLAN J MIRA,MD 249-7400 :OOM: ~IU1' ATTENDING: CONSULTING HISTORY: PAIN T-5 PAIN T5 . compression -fracture. There i ~ ~no spi r:.l ~tc~nosi s •r net;ral foramen narrowing evident. REVIEWED AND SIGNED CHRISTOPHER LADD,MD INTERPRETING PHYSICIAN DATE DICTATED: 8/25/2008 DATE TRANSCRIBED: -8125/2008 15:2? TRANSCRIPTIONIST: MW 3370256 ORDERING FAX PAGE 2 ~:F 2 • ti. 1 ~ vw, -.al 1 IJ~C nCy.neu.~,~l . : 1111 ) L'ty'1L1L UO)JUIUtS 11:8.8 t'.U1)U1 Vl11~ JLL I\LUlVll /"{L 1'iL V1 \i /'~L' VLI111 361 ALEXA. DER SPRINGS ROAD CARLISLE 1 17015 (717) 950-1683 !, IOLOGTCA,_ NTE-<-PRFTATION PATIENT NAME: X- RAY~~- MELLOTT JERRY D 12784 MED REC ~~: 122784 EXAM DATE: $/29/200$ ACCOUNT D.O.B.: ~~e 7834779 03/06/1954 ORDERING: ALLAN J MIRA.MD 249-7400 ROOM: MAB ATTENDING: CONSULTING JR GEORGE P BRANSCUM,MD 243-1515 HISTORY: FX RT WRIST AND FINGERS FX RT WRIST, RT 5TH FINGER, LT 3RD/4TH FINGER MAB RIGHT FIFTH DIGIT, TWO VIEWS HISTORY: Followup for fractures. COMMENT: Two views of the fifth digit demonstrate a nondisplaced tuft fracture. There is n~o additional bony finding other than mild degenerative chiange of the proximal interphalangeal joint. REVIEWED AND SIGNED CHRISTOPHER LADD,MD INTERPRETING PHYSICIAN DATE DICTATED: 8/29/2008 DATE TRANSCRIBED: 8/29/2008 16:45 TRANSCRIPTIONIST: MW 3359218 CONSULTING FAX PAGE 1 OF 1 V. ~~ r ~ um. 1,ar i I~IC nC .I'ICU.4Lr y ~~~~./1!i) C'ty-1L1L Ud/JU/Ud 11~UU I'.UllUl t,nr JAL iC~,~'i V11nL c•rr_~lt -'~1_' ~,+Ln r , . 361 ALEXA,.~ER SPRINGS ROAD CARLISLE r ~ .. 17015 (717) 96p-1683 ~ ?OLOGICR,L ;{°; E;s.PRE%A7~ION PATIENT NAME: MELLOTT JERRY D MED REC ~~: 122784 X-RAYS: EXAM DATE: 122784 ~ 8/29/2008 ACCOUNT ~~: 7834779 ORDERING: ALLAN J MIRA.MD 249-7400 D.O.B.: ROOM: 03!06/1954 MAB ATTENDING: CONSULTING JR GEORGE P BRANSCUM.MD 243-1515 .HISTORY: FX RT WRIST AND FINGERS FX RT WRIST, RT 5TH FINGER, LT 3RI)14TH FINGER MAB LEFT THIRD AND FOURTH DIGITS HISTORY: Followup for fractures. COMMENT: There are no radiographs for comparison. There are comminuted tuft fractures of the third and fourth digits.. They are nondisplaced. These two digits are otherwise intact. IMPRESSION: Nandisplaced tuft fractures of the left third and fourth digits. REVIEWED AND SIGNED CHRISTOPHER LADD,MD INTERPRETING PHYSICIAN DATE DICTATED: 8/29/2008 DATE TRANSCRIBED: 8/29/2008 16:45 TRANSCRIPTIONIST: MW 3359217 CONSULTING FAX '~ PAGE 1 OF 1 ORTHOPEDIC SURGERY ALLAN J• MIRA, M.D. XRAY INTERPRETATION 8/29/08 JERRY D. MELLOTT RIGHT WRIST, 3 VIEWS AP, lateral and scaphoid views of the right wrist show no evi Particular attention is paid to the region of the hamate and areas lighting up someyvhat on the bone scan but in IooN overlap or undisplaced fracture line with possibility of orn although f would expect it to be more evolution of fracture overlap. X-RAY IMPRESSION: No definite fracture or other abnorm AI1an J. Mira, M.D. MIRk ~?R'T~I~L~PEDR~~ Medical R its $~ilding Suite 206. 220 Wilson Street Carlisle, PA 17013 Phone. (71.7) 249-7400 9ence of fracture, slight soft tissue swelling. ~isiform as well as the scaphoid with those ing at it I am not sure whether it .is bone in the triquetrum as a linear line visible healing if it were so I do think it is bony right wrist. AJMlkas 11 um. -,ar ; i~serorceu,reU.t,~i~ ~,j,~;,~~~1i.l.),:t'F`1-1LiL UtSl3UlUtS lU:~! F'.UllU1 ,. 1.J71• JLL t\LV1 VI't J1L 1'IL U1\..CtL MLIt t ~ 361 ALEXA. DER SPRINGS ROAD CARLISLE 1.. 17015 (717) 960-1683 )?OLOGiCA~ Ir'€:`~PRE~ATiCtt PATIENT NAME: MELLOTT JERRY D MED REC X- RAY~~: 122784 ACCOUNT EXAM DATE: 8/29/2008 D.O.B.: ORDERING: ALLAN J MIRA,MD 249-7400 ROOM: ATTENDING: CONSULTING JR GEORGE P BRANSCUM,MD 243-1515 HISTORY: FX RT WRIST AND FINGERS FX RT WRIST, RT 5TH FINGER. LT 3RD/4TH FINGER MAB RIGHT WRIST, THREE VIEWS CLINICAL HISTORY: Followup for fractures. ~~: 122784 ~~: 7834779 03!06/1954 MAB COMMENT: 'The right wrist is anatomically aligned. There is no wrist fracture evident. IMPRESSION: Negative wrist. REVIEWED AND SIGNED CHRISTOPHER LADD.MD INTERPRETING PHYSICIAN DATE DICTATED: 8/29/2008 DATE TRANSCRIBED: 8/29/2008 16:45 TRANSCRIPTIONIST: Mw 3359219 CONSULTING FAX PAGE 1 OF 1 <:~ ~ I Iuw, gar i i,ie rcey.iheu.~~r. ~.,# ~I1{.1 L`t y-1L!t UtSlSUl Uti 1U:55 I'.U1(U1 V I'~1' JLL I\LUl V11 !"tL I'IL Vlli lt'1L ~ <. LII 1 361 ALEXAI.-~ER SPRINGS ROAD CARLISLE ' r.. 17015 1717) 960-!1683 liOLOC;CP-~L 1,°d Ti RPRETATIOh PATIENT NAME: MELLOTT JERRY D MED REC ~~: 122784 X-RAY~~: EXAM DATE: 122784 8/29/2008 ACCOUNT D.0.6.: //: 7834779 03/06/1954 ORDERING: ALLAN J MIRA.MD 249-7400 ROOM: MAB ATTENDING: CONSULTING JR GEORGE P BRANSCUM.MD 243-1515 HISTORY: FX RT WRIST AND FINGERS FX RT WRIST, RT 5TH FINGER, 'LT 3f~D/4TH FINGER MAB THORACIC SPINE, TWO VIEWS CLINICAL HISTORY: Followup for fractures. COMMENT: Radiographs were obtained entered at the T4 level as per the requesting physician. 'Two mild superior endplate compression deformities are seen of upper thoracic vertebral bodies. Because of the cone-dawnlnature of these radiographs, they cannot be definitively number;. However, they would be anticipated to be in the region of the fourth thoracic vertebral body. These appear to be anterior; column superior endplate compression deformi ti es with only imi ni nial 1 oss of height of these two vertebral bodies. REVIEWED AND SIGNED CHRISTOPHER LADD,MD INTERPRETING PHYSICIAN DATE DICTATED: 8/29/2008 DATE TRANSCRIBED: $/292008 16:45 TRANSCRIPTIONIST: .MW 3359220 CONSULTING FAX! RAGE 1 OF 1 Page OFFICE RECORD MIRA ORTHOPEDICS Name MELLOTT, JERRY D. :3654 8/29108 OFFICE VISIT: This patient is seen in follow up. He is now 5 weeks since his injury. He continues to have some back pain in the upper thoracic posteriorly. His fingers are improving. The wrist is loosening up some on the right side although he is still somewhat uncomfortable and stiff with weakness of grip. A new set x-rays are taken today of the right wrist that shows no evidence of fracture, slight soft tissue swelling. Particular attention is paid to the region of the hamate and pisiform as well as the scaphoid with those areas lighting up somewhat on the bone scan but in looking at it I am not sure whether it is bone overlap or undisplaced fracture line with possibility of one in the triquetrum as a linear line visible although 1 would expect it to be more evolution of fracture healing if it were so l do think it is bony overlap. X-rays of the fingers, ring and middle on the left and little finger on the right show tuft fractures that are in satisfactory position. Clinically the middle finger on the left shows no pain at all, resolving subungual hematoma. The subungual hematoma is resolving in the ring finger as well, still a little bit tender but no inflammation. On the little finger on the right side there is the healing fracture at the base of the middle phalanx at the PIP joint. Clinically this is not tender and he's got full range of motion. There is a wound that is healing on the dorsal aspect of the D!P joint of the little finger slightly ulnarward that does not show up as any foreign body on the x-rays although it feels as though there may be a foreign body in there that might just be scar tissue. The left leg is improving although he still has some discomfort in the posterior aspect of the lower thigh and upper leg. There is no abnormal swelling. His gait is good. Review of the MRI now of the thoracic spine confirms that there is compression fracture of a minor degree of what appears to be T4 and T3. I looked back at the plain films done at the time of the injury and also added new coned-down plain films in that area that do confirm some wedging there consistent with the minor compression fractures. The pedicles appear to be intact. IMPRESSION: 1. Compression fractures T3 and T4, healing, stable thoracic spine. 2. Healing fractures tufts left ring and middle finger and right little finger. 3. Healing fracture middle phalanx PIP joint right little finger. 4. Bone bruise~or contusions right carpal bones, improving. RECOMMENDATION: l told Jerry to increase his activity now with aerobics, perhaps swimming, walking and do some stretching of his upper torso, begin some light {ifting, getting ready to go back to work. He is not ready at this time. I think it looks like it is going to be 2 to 4 more weeks. We would Pike to see him in about 2 weeks for clinical check, sooner if needed. AJM/kas ~.: . 9/11/08 OFFICE VISIT: This patient is seen in follow up. His fingers are doing much better. The right wrist is still problematic. He has some limitation in dorsiflexion at about 45 degrees. It is uncomfortable diffusely in the wrist including the radial styloid dorsally. His bone scan and plain films were reviewed again. They showed some increased uptake at the carpal bone area but the x-rays are negative. Since this has been going on so long I think we ought to get an MRI and look far navicular or lunate derangement, perhaps first dorsal compartment problem. His leg is improved considerably. There is a little bit of numbness in the medial MIRA ORTHOPEDICS IVi~dical Arts l~iiilding Suite 206 220 Wilson Street Carlisle, PA 17013 ORTHOPEDIC SURGERY Allan J. Mira, M.D. Duane A. Stroup, PA-C PATIENT: ~ ~~ ~~ l DATE: ~~~'~ l~ DIAGNOSIS: / INSTRUCTIONS: PATIENT INFORMATION SHEET J Phone 249-7400 ~t~c~n. ~t-~~2~k - c~u ~~t,~?.~e~`- C~CG~Gc~i~ ~~ Patient's Signature ,~,,,~,,,~ From: Carlisle Reg.Med.Ctr. (117) P49-~~12 09/ll/OS 12:20 P.01/02 361 ALEXAlrOER~SPRINGS~ROADuCARLISLE~PR~`17015 (717) 950.-;.583 RAGIULOGICAL iNTcRPRETATION PATIENT NAME: MELLOTT JERRY D MED REC X-RAY~~: 122784 ~ 1227$4 EXAM DATE: 9/16/2008 Accovn-r ~. 7838717 ORDERING: ALLAN J MIRA.MD 249-7400 D•O•g•~ 03/06/1954 ATTENDING: ROOM: CIS CONSULTING HISTORY: RT WRIST BONE BRUISE BONE BRUISE CONTUSIONS RT WRIST R/0 FX MRI OF THE RIGHT WRIST WITHOUT CONTRAST - 9/16/08: INDICATION: 54 year-old man with persistent posterior right wrist pain status past motorcycle accident on 7/21/08. RESULTS: There are no prior studies for comparison. Correlation is made with the plain x-rays obtained on 8/29/08. MRI was performed on a 1.5 Tesla magnet utilizing corona/ and GRE sequences, STIR sequences, T1 weighted sequences. sagittal and axial T1 weighted sequences. axial fat saturated T2 weighted sequences. A cutaneous marker was placed over the area of tenderness by the patient. The caronal STIR sequences were repeated for patient motion, but there is still degradation of the images. The marrow signal intensity is grossly normal. There is increased edematous signal intensity involving the dorsal radioscapholunate ligament best seen on axial series 7, images 8-10. No ev-idence for tear. There is also increased fluid signal intensity in the pre styloid recess of the TFCC, near the meniscal homologue as seen on corona/ series 4, image 11, axial series 7. image 6. The remainder of the musculotendinous structures and ligaments appear grossly intact. No abnormal subcutaneous soft tissue CONTINUED ON PAGE 2 P.02 CARLISLE REGIONAL MEf_1ICAL CENTER 361 ALEXANDER SPRINGS ROAD CARLISLE PA 17015 .(717) 960-1683 RADIOLOGICAL INTERPRETATION PATIENT NAME: MELLOTT JERRY D MED REC ~~: 122784 X-RAY~~: EXAM DATE: 122784 9/16/2008 ~ ACCOUNT ~~: 7838717 ORDERING: ALLAN J MIRA.MD 249-7400 D.0.6.: ROOM: 03/06/1954 CIS ATTENDING: CONSULTING. HISTORY: RT WRIST BONE BRUISE BONE BRUISE CONTUSIONS RT WRIST R/0 FX collection is seen. There is abnormal widening of the scapholunate interval measuring up to 5.2 mm in transverse diameter on series 2, image 10. IMPRESSION: 1. There are findings consistent with at least a partial thickness tear along the ulnar attachment of the right triangular fibrocartilage complex. 2. There is widening of the scapholunate ligament consistent with a tear of the scapholunate ligament. - - _~____ 3. There is a moderate sprain of the radioscapholunate ligament without other evidence for tear in this region. 4. The marrow signal intensity is otherwise grossly normal without evidence for significant bane bruising or occult fracture. REVIEWED AND SIGNED RHONDEY HARFORD. MD INTERPRETING PHYSICIAN DATE DICTATED: 9/16/2008 DATE TRANSCRIBED: 9/16/2008 15:56 TRANSCRIPTIONIST: JXS 3320299 ORDERING FAX PAGE 2 OF 2 09/17/08 ALEXANDER SPRING REHAB INC. Page: 1 Key: aptfrm Appointment Form (c) Nlisys ALEXANDER SPRING REHAB INC. 1 TYLER COURT, SUITE 200 CARLISLE, PA 17015 717/245-2341 Patient Patient ID: PT DOB: 03/06/54 MELLOTT, JERRY 813 MYERSTOWN ROAD GARDNERS, PA 17324 Telephone: 717/528-8857 Work Ph: 717/486-3366 0002721-0001-1 Acct lD: 2721E AR: WP BT: S MELLOTT, JERRY 813 MYERSTOWN ROAD GARDNERS, PA 17324 Telephone: 717/528-885 7 Work Ph: 717/486-3366 Insurance Company Policy # Group # Other Info Holder Effective Date(s) (P)SEI~~TRY INSURANCE 51 C693640 MELLOTT, JERRY 11/13/07 - (S)AETNA BBJ1S85A 215152 $30 COPAY MELLOTT, JERRY 01/01/03 - ...Date. Time Provider Office Type Case Case Description `,Appt Note AuthProc Description #Used/#Auth AuthProc Description ~1`e~' 09 ? .."'U~8 9:OOa CF -CHRISTOPHER FISHER 1 IE -~ ': ~ " ~ ~,3 10:OOa FL - FLUIDOTHERAPY 1 FL _ " _ _ = ? 0:30a EM -ERIN METCALFE 1 RX -_ . _ . : _ ~ 11:30a FL - FLE:IDOTHERAPY 1 FL -_ . :: - . - ' ?~:~JOn Sp - pR[~~1ROSE, STEPHANY 1 RX Guarantor ". ~ __ =_ - ='_.'.~OTHERAPY 1 FL :..._ CI= - Ci- ~i~ t OPHER FISHER ~ R,Y #Used/#Auth ,o ~~ u / F ~~ . '~' r <.' r, ,; l.- , y „~~ . 4 ~~~~ ~~~ 9111 /08 continued... upper left calf which suggests the possibility of basical{y saphenous nerve irritation from contusions that he had in the mid thigh and in the thoracic spine area t1e IS Silll i6rid8r St the GOStOti'8f1SVefS@ JunCi1011 OC lateral side to the right at about T4. I told Jerry these symptoms would likely persist for up to 3 to 4 months after the accident. Because of his lack of appropriate function to get back to work at this time and some deconditioning I would like to recommend physical therapy and the MRI of the right wrist. He is to continue his home exercises that we have talked about in the past and he is still not able to go back to work. I would Pike to see him in 2 weeks for re-check. His back to work might be delayed as much as about 4 weeks from now yet. AJM/kas cc: Dr. Branscum 9/25/08 OFFICE VISIT: He is much better in all areas. He had physical therapy to his right hand. Strength is now very good, range of motion is about 90% of normal. His back is improving. Leg is improving and the fingers are improving. I think he can go back to work now next week. He was given an okay for that without restrictions. I would like to see him in 4 to 6 weeks for re-check. AJM/kas MIRA ORTHOPEDICS Medical Arts I~uilding Suite 206 220 Wilson Street Carlisle, PA 17013 ORTHOPEDIC SURGERY Allan J. Mira, M.D. Duane A. Stroup, PA-C PATIENT: !1 ~~~ ~-~ DATE: ~ c2J/b~ DIAGNOSIS: INSTRUCTIONS: PATIENT INFORMATION SHEET `~~'~l ~' ~~,~:~a~~ ~ wt~k alt `~'~.~~~ ~: r~ GG~u LPL G~:. 1 ~ !~ GL(.~L~ . r~ ~c1~~c~ ~~?~t.. ~~~~~ . Phone 249-7400 Patient's Signature Oct. 6. 2008 10.23aM PPG N o. 4131 P. 3 U MIRA OlR'>r'H~PEDI~S .MEDICAL ARTS BUILDING ~ ' 220 Wilson Street Suite 2Q6 Carlisle, PA ~ 7013 •(717} 249-7400 ~"' has been Under my cars from to school ~ (~~'~ and is able to return to ~on work ~- »emarks: ~~d5ly~ Signature ~ , a8~y' 91~n ~ Oct. 6. 200 10:23AM PPG 1 Mellott, Jerry #874 Coates Processor No. 4131 P. 0 Off work since 7-22-0$ Motorcycle /farm combine accident Laceration It foot, P`rx distal tuft fingers left hand and 2 frx rt small finger, neck and back pain Fr~c. rib. ' ~7r Branscutn and Dr Mira ~~ ~~d )n~~~ ~. /~~ ~~ IyGew~ ,,FGS ~ ~l~S I-¢GOz^e''~~ ~'"/~A""' 7 r ~~) /~~ a• ~ 1/1 ~ /"~ S e ~~~'~' d~ O/" u 4' ~ n l.~ YT' `.cGlhP~ ,~~s~ k;~ ~,,,t, y~r ~/~ c..Gc .~3rP 'gy'p/~ ~' 7z, ~ -~- ~ s ~~ . y~:ve.Z E s 5 J~ s~~7~ ~~i ,fie. r•~'~"""~ ~"`(f'F-' /V v re ~ ~ r~ ' ~t~~V /~'~p'm ~~~... _ , ~___ ~~-•f/~7I~V~~.~Yf~~'~~~~~v. .,.af<.,~_.i:.:-,... ,.q~s m!?"F~Y`t.f'""R§'y~ a.+YYf tG` This patienf is seen in follow up. He continues to have some .numbness in the medial upper calf left leg since his accident. It is no better. It is annoying ocpasicn~!6y just because it is strange but it has not been a functional problem for him. It is in the area just distal tri the large abrasion/contusion that he had. Clinically, I find no funetionaf deficit. The calf musculature is good. He has hypesthesia in an area measuring approximately 6" in greatest diameter in the ~.apper posteromedial calf. His gait is good. His spinal symptoms have now none. He continues to name sorr,@ pain in his right nand intermittenity every 3 or 4 days. He may have a pain that develops in the hypothenar region, mid palm region or basal thumb region that may last for 8 or 10 hours. He's got goad function of his hand with that and between those times and no numbness of the fingers, no pain proximally. He said overall his wrist feels pretty well and he is fully capable between these episodes. Currently he is not back to work since he was laid off a week after he had gone back and they do expect to be able to go back in the next month or two and he feels he could do his former work. EXAMINATION: Examination of the hand shows good range of motion, .good grip. Finger injuries have recovered to his satisfactory plateau and essentially normal function. IMPRESSION: 1. Status post motorcycle. accident. 2. Persistent hypesthesia medial calf left leg secondary to blunt cutaneous nerve trauma. 3. Pain, right hand persistent secondary to ligamentous injuries right hand from motorcycle accident. RECOMMENDATION: At this time i recommend no specific treatment. I think the prognosis in the hand is ane that may improve. The prognosis on the calf is one that may improve yet within the next 12 months but beyond that if it is not better it wi{I be permanent. There is no way to predict that at this point. We don't think there is any treatment to affect it. Jerry may return to work when work is available without restriction. I would like to see him in 6 months fora re-check, sooner if needed. AJM/kas ,.,: ~~, _~ \ ~, ,- ~~ ~_~: .,,., ~.,,. 4~v~ ~.,.~~e rna ~eiao~aay~aa m(;5 taltcrUi' @j 006/006 CERTY~~ ~. ~ATi®N ~„ CUSTC~..JI`~'~.N ~(~ vs_ I am thc authorized Custodian of Records For: MIRE ORTEOPEDICS and T have the authority to certify the attached records of: JERRY MSLLOTT 813 1[Y8RSTONA 'RD GARD278RS PA 17324 SSA: X7CX-7qC-3970 .DOB: 03/06/54 [KBDIt.AL] Being duly sworn according to law, I hereby certify, depose and say that these rf:~;ords were .searched and reproduced in my presence at my direction. These records were prepared in the ordil~ iary course of business by authorized personnel on or about the time of the event or-act and careful search for i::ie records has been made by me or under my direction. Therefore, these records constitute all the records cd: said individual described above. I HEREBY CERTIFY THAT THE FOLLOWING IS TRUE AND CORRECT: ~ ~~ ** A: I HAVE ATTACHED ^~ - '- ~o~' PAGES l --~ _, ~~ OF X RAYS. ~ ~~,~Z.S~- B: THIS INCLUDES ALL MATERIAL REQUESTED.. C: THIS INCLUDES ALL CORRESPONDENCE BE'T'WEEN ALL FAC.17.,ITIES. ' D: I DAVE ATTACHED THE PATIENT INFORMATION SHEET OR I](b SHEET WHEN APPLICABLE. E: PRIOR APPROVAL REQUIRED PIT FOR >~ANI7 OVER. ALL QTHER PROVIDERS FOR ~~. aVEl+y:"'~ n •" '" Sig3cz Here No Records „No X-Rays _ Records Dcstroyed After "!"ears X-Rays Destroyed After _ Years Other It is to be understood that this does not mean that the requested information dog:; not exist under another speIling or another. name. However, with the information furnished to our offic:~: and to the best of my knowledge, I certify the above to be a true and accurate statement. Date Signature - MU~T.SIGN AND R]E'I'URN THIS PAGF;u 1.83 3 12-Y ~'E01 -0412683 :ii 1 3 2 6- L O 2 ,THE DOCUMENTS REQUESTED ARE NOT IN OUR POSSESSION DUE T() 'THE FOLLOWING: From: Welter Sims 502-753-6935 To: JOSEPH DO(ON Page: 1!2 Date: 512612010 9:03:42 AM Rawlings Company LLc Subrocatiox~ Diri~i~n Post Office Box 2000 LaGrange, Kentucky 40031-2000 One Eden Perlcwny LaGrange, Kentucky 40031-8100 Telephone (502) 587-1279 TELECOPY To: JOSEPH DIXON Our File No: JERRY MELLOTT Fax Number: 1717-233-5860 From: Walter Sims Phone: 502-614-4861 Fax: 502-753-6935 Email wls a~awlingscompany.com Subject: 0 8U SA 120 03 47 Pages: 2 Message: Confidential Healthcare Information Enclosed Healthcare information is personal and sensitive information, and you, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Disclosure of this information without additional patient consent or as permitted by law is prohibited. Unauthorized disclosure or failure to maintain confidentiality could subject you to penalties described in federal and state law. IMPORTANT WARNING: This message is intended for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this information is STRICTLY PROHIBITED. If you have received this message in error, please notify us immediately and destroy the related message. From: Wager Sims 502-7536935 To: JOSEPH DIXON Pege: 1R Da[e: 5!28!2010 9:03:42 AM From: Wafter Sims 502-7536935 To: JOSEPH gXON Page. 212 Date: 5/28/2010 9:03:43 AM Rawlings CompanyLLc Subrogation Division Post Office Box 2000 LaGrnnge, Kentucky 40031-2000 Orxe EdenParkwny LaGrange, Kentucky 40031-8100 T.S.pi,on. (302 SS7_ 1 279 May 28, 2010 MR JOSEPH DIXON ATTORNEYATLAW 126 STATE ST HARRISBURG, PA 17101 Re: Our Client: Member/Patient: Date of Loss: Our File No.: Your Client: Dear MR DIXON: Aetna JERRY MELLOTT/JERRY MELLOTT 7/21/2008 08USA1200347 Jerry Mellott As you know, our client has asserted a claim for medical expenses paid on behalf of JERRY MELLOTT. Please take a few minutes to provide the current status of the matter. For your convenience, you may fax your response to the number listed below. Thank you for your cooperation. Sincerely, Walter Sims Senior Recovery Analyst (502) 614-4861 FAX: 502-753-6935 wls~rarawlingscompany.com Comments: From: Wafter Sims 502-7536935 To: JOSEPH gXON Page: 2/2 Date: 5128/2010 9:03:43 AM II IIIiI I ililliiliillii it 1111 ho Box G7o15 HARRISBURG. PA 1710E-7015 RETURN SERVICE REQUESTED 12/08/U8 NATIONAL RECOVERY AGENCY (717)S~U-5GU5 (800) 3GU-4319 tN tit:: ~-LLt.ow sRELCxt;s I:~ts •ro~t:~.:ar,•tocnvT D~4'.: sR4.92 1CCTfi: 1'R(N10714 DATE OF SF,RVICE: U'1i21'0R SEND TO: UF8Z00/028 201 53342469 0000432/OOQ5 NATIONAL RECOVERY AGENCY IrrrIII...irrqrrrlr1.Irrllrlrrrlirrrrrlllrrirrrrllrrlirrlrlrl Po Box 67()15 Jem- D Mellott HARRISBURG_ PA (71(~-7013 S13 Mverstowm Rd Inrlllrulurllllrnrllrrlnrlllnrnrllrlrlnrlrll Gardners. PA 1732-t-9G18 Dear Jem~ D Mellott. Your account has been fontiarded to this office for collections. The balance shown above includes interest of 5.00 along R~ith collection charges of 5.00. This is a formal demand upon you for payment of this debt. This is an important matter. which needs to be resolved. and requires your attention. liy resoh~ing this matter. you wi}I make continued collection efforts unnecessary. These efforts may include calls. letters and/or reporting to the credit bureaus. Our demand for payment does not affect your right to dispute this debt. Unless you notifi~ this office within 30 da~~s after receiving this notice that you dispute the validity of this debt or am' portion thereof, this office will assume this debt is valid. If You notify this office in writing ~r~ithin 30 days from receiving this notice. this office will: obtain Verification of the deaf or obtain a co{n~ of a judgment and mail you a copy of such judgment or verification. If you request this office in writing ttnthin 3U days after receiving this notice. this office will pro~~ide you vt~th the name and address of the on>atnat creditor, if different from the current creditor. * BeIoFV is a listing of all accounts included in the total amount due listed above: 1'ELLOIV BREECHES EMS 1'8000714 07/21 /08 584.91 Unless you dispute this debt. your payment should be made directh• to this office for prompt credit to your account. Atwenty-dollar sen7ce charge will be added to all checks returned to us by your bank. Should ou uesire a receiut. a seiC addressed. stamped envelope is required. For payment options please see reverse side of this notice or visit our secure Website at «~v~v.nationalreooverv.com. The ouroose of this communicauon is to collect a debt and any information obtainer! ~~~ill be used for that trurpose. Sincereh•. NATIONAL RECOVERY AGEivt ~ This communication is from a debt collector. ~`**1'lease contact your account representative NRA HOUSE MIDICAL at extension G7~48 re~ardine this :;::ttN2nr. ~TRA/ALS-28 ` ~~ ,. ,~ t ~ rnaA ID #: uFSZao ~~~ t. _ .~~ Catls to or from National Recovery Aeencv may oe monitored or recorded ror auattn' asslr^°-~. PLEASE SEE REVERSE SIDE FOR A+iPORTANT INFORMATI<:. Yeliow Breeches EMS, tnc. PO Box S18 CAMP HILL. PA 17001 Phone #: (8001367-0512 Federal Tax ID: 25-17682fi6 ;,,;,~,~;~;: JERRY MELLOTT ; _; : ,z ; _ _ .>.: 403o NMI Y8000714 INS' ::,~.-. ~~,.,:,.~,:~~, AETNAUSHC BBJ1S85A ... _ _ _ ., . 07/2112008 Y$000714 .. _ . AREA OF 38 FROST RD CARLISLE REGIONAL MEDICAL CTR JERRY MELI.OT7 813 MYEI23TOVYN RU ..;..-_ f..• ;:.:~ _,. INJURY-MULTIPLE SITES GARDNERS, PA 17324 ~. PAIN -MULTIPLE SITES __........._ ,i +;.~.fi"`.1Y'f`1~.f~S i.d1., f,;~`iriijiti.?t. I `'3_...`t' . Yyf. i:!fr... - ~'' ? BLS EMERGENCY A0429 ! 1.0 368.87 388 a7 MILEAGE' A0425 14.0 i 6.f?4 92.96 CERVICAL COLLAR A0382 , 1.0 40.5F3 ~ 40.58 UXYGEIti A0422 j 1.0 44.34 44.34 Total CharaeR x•'15 v _. _ ,_. _:_ ..... ~- $548.75 4.:~`f±~,Gi'4 €~?..E^!Pf!s`s ~s.~?Ft~CalU4~.xf ±x.:.3`...3 ~ C`, ,'!"3.: s". ._s `.v.."k?t i`-s''i~f~!i._. .. MELLOTT, JERRY D Y8000714 v ~-- ~'~ fw €~,' z ` 4030 KI + r ,e t~.r3 08/15/2008 `. A CLAIM FOR THIS INVOICE HAS BEEN SENT TO YOUR INSURANCE.PAYMENT MAY BE MADE TO YOU. PLEASE REMIT PAYMENT TQ US. 'It-TANK YOU. 546.75 ~° „ ~- ? vvr ~ V 14 ' Yeiiow Breeches EMS. inc. PO Box 51B CAMP HILL. PA 17001 TATEMENT OF ALEXANDER SPRINGS EMER PHYS PO BOX 37720 PHILADELPHIA, PA 19101-7720 °o rn to w Statement D~ ACCOUNT NUMBE Patient Name: JERRY D MELL Tax IC Account Balan Amount Pend Insuran Qv Amount Due Fn Patient (Currel ~ni~~~nr~u~~n~~i~t~u~~~~~n~~nu~~~~u~nr~~~n~~n~~~~~ ~,, Amount Due Fn 031212-0000094079084-04 Patient Past Du #BWNJFDB ~~i~~ Pay This Amou w #OOOOOOOCLL118495# 0.~ ~ ~ PLEA JERRY D MELLOTT ~ "PAYMENT DU 813 MYERSTOWN RD ~ `~ ~ please refer to GARDNERS PA 17324-9618 ~ ~ 0 I ~ ~ ~~~, , .yccou nr ueta~,r +-~ Date # Description Charge Paid By Paid By Paid By An First Ins. Other Ins. Patient Ad' 07/21/08 1 11000 DEBRIDEMENT, <10% BODY $126.00 SURFACE DX:892.0 DR. MILLERlCARLISLE REGIONAL MEDICAL ENTER - t0101/08 AUTO INSURANCE NO RESPONSE FROM $-0.00 PA'!OR 11114/08 INSURANCE PAYMENT $-36.63 07/21108 2 99284-25 EMERG INJURY EVAL 8 $569.00 MGMT-LVL 4 DX:892.0 DR. NIILLER;CARLISLE REGIONAL PAEDICAL ENTER 10101/08 AUTO INSURANCE NO RESPONSE FROM $-0.00 PAYOR 11/14/08 INSURANCE PAYMENT $-133.82 07!21108 3 71020-26-26 EMERG INTERP CHEST 2 $34.00 VIEWS "' etna-:did not pay.yc~ur claim ilk full ' 1~ou m y call eft ~ '~~-~,~ telf them ydu are being balance hied` I you as Aetna t4 PAY ts` full,"Aetna will likely send you a ~haeck'f rthe b lance.' , f"yaiu d . rE heck, please forward the check t the. ad re6S 11 fed bel 41f ~hi ,~ ~ °~~~remain yt~ur~t-~i. ~ 4tjr~rtil .t?a et~t'f~ m 3rd TOTALS: CGNTINUED CONTINUED CONTINUED CONTINUED CON important Messages: This statement is for the direct treatment and/or supervision of care you recently received from an Emergency Physician at Cadisle Regional N private physician are billed separately from any hospital charges or other professional fees for which you may also be responsible. Therefore, hospital or other physicians for charges in connection with this visit, it will not include the items listed on this statement. "Payment Plans" Accepted Questions about this statement? / Llame de Lunes a Viernes Call 1-800-355-2470 Monday through Friday 9:30AM - 4:OOPM Your automated system access code is 947-94079084, or you can sen billing_questions@emcare.com. Please detach and return bottam portion with your remittanc+ JERRY D MELLOTT STATEMENT OF ACCI 813 MYERSTOWN RD Statement Date: Novembe GARDNERS PA 17324-9618 ACCOUNT NUMBER:CLL940~ YOU MAY PAY THIS BILL WITH YOUR CREDIT CARD Patient Name: JERRY D MELLOTT ' PLEASE SEE REVERSE SIDE. Payment Due By: 12!12/08 Make Check/Money Order payable to: Amount Due: $524.55 e..,.,~~.,~ Cnnlncn.t. f ~~1 A BIOMET COMPANY P.O. BOX 8500-41335 PHILADELPHIA, PA 19178-1335 FAX (800) 524-0457 Account Number 2097383 Invoice Number 957672 Service Date 08/21/2008 Balance Due 24.28 12/ 16/2008 **********AUTO**MIXED AADC 170 T29 P1 JERRY MILLOTT 813 MYERSTOWN RD GARDNERS PA 17324-9618 ni~~~nl~n~~u~~I~I~n~~~~u~~~nu~~~~n~nn~~u~~n~I~~ Please be advised that there appears to be an outstanding balance remaining for orthopedic products provided to you by ALLAN MIRA MD. PRODUCT(S) DISPENSED: DELUXE CANVAS COCKUP SPL. 10" At this time we are asking that you remit payment of $24.28 at your earliest convenience to clear this amount from your account. If you have any questions, please call us at (800) 254-0072, or you can E-Mail us at customerservice@ebimed.com Thanking you in advance for your prompt attention. DETACH HERE. KEEP TOP PORTION FOR YOUR RECORDS. RETURN BOTTOM PORTION WITH YOUR PAYMENT. i~ `:l ~l, S C Account Number 2097383 Invoice Number 957672 Service Date 08/21/2008 Balance Due 24.28 :k ~ JERRY MILLOTT ~' ~''.~ <1~813 MYERSTOWN RD M' :*. c, GARDNERS PA 17324 K ~ I ~ M -~. 00957672 000002428 0 cooos~ea ^ Check Enclosed -Make payable to EBI ^ Visa ^ MasterCard ^ American Express Account Number. Expiration Date Name on Card Signature fV "`~.'ic~U~l~ MEDICAL ClNTER 361 Alaxand•r Sprlrty Road • Cafllsla, PA 1 701 3-81 29 • (717) 24&1212 CREDIT RECEIPT NO: 978605 DATE: 1 t /20/2008 TIME: 10:23:58 MELLOTT, JERRY D 7838717 11 /20/08 30.00 PA1'IEN1' NAMpJ'rYf'E Eil~ . PAY1>:N'C NtlAEAiEN En4sE ,... ,:.. 7gANi3Jit`7ic)N e ~ », COMMENTS: PYMT. BY CREDIT CARD/MASTER CARD For service rendered on: 09/16/2008 THANK YOU ~~ Cashier Sigr~ature , /f Illli~l~nl~~l~lllnllnlnll~lnn IIIIIIIII~IIf81B~llllllll~llllllllll~ 8991210 7838717 C~ p • ~' 11/20/08 HEALTH MANAGEMENT ASSOCIATES DA04 COID: 858 AC CO V N T ~Ik 7 9 3 0 '7 1 7 ~= S C HARG E AC C O VIV T S R E C E S VAB L E R E C OR D PAT NAME: MELLOTT, JERRY D ADMIT: 09/16/08 FINANCIAL CLASS: P I GAR NAME: MELLOTT, JERRY D DISCHARGE: 09/16/08 CONTRACT FREQ: S'T'REET: 813 MYERSTOWN ROAD LAST PAY: 10/30/08 MAIL RETURN: ADDR-2: PROGRAM: PAT TYPE: OM CITY: GARDNERS PA 17324 CONTRACT: .00 PAT SEX: M PHONE: (717) 528-8857 COUNTRY: US CURR BAL: 30f00 GAR SEX: M EMPLOYER: PPG TOT CHARGES: 1,641.80 AGENCY CNCL: R CODE DATE INSURANCE AGENCY BAL: .00 1: 967 :LO/30/08 508.96- CODE PLAN DATE STAT POLICY IVO 2.: 105 10/30/08 1,102.84- 1: 105 HMO 10/30/08 1,641 P BBJ1585A 3. 2, 4. 3. 5: LST ACTN: Pl 10/31/08 3: 00/00/00 PAY AUD l: I4 10/06/08 4: 00/00/00 PROCESS REVIEW PAY AUD 2: PP 10/02/08 5: 00/00/00 DATE USER DATE ARTRAC ASSGN: 10/06/08 RETN 00/00/00 REASON 11/05/08 RTRC 00/00/00 Sys Ltr 03 11/05/08 11/03/08 RTRC 00/00/00 NXT ACTN *PT IS RESPON FOR $30.00....RTW 1:1/03/08 RTRC 00/00/00 REVIEW *PER NOTES 10/31/08..INS PAID.. 11/03/08 RTRC 00/00/00 PT RESPON FOR BAL .................RTW 1=UP,2=PT,3=GAR,4=INS,5=UB,6=HIS,7=RTN,B=CMTI,9=CMTU,IO=DET,II=LOG,ENTER=FW 11/?_0/08 PAGE 001 HEALTH MANAGEMENT ASSOCIATES DA17 COID: 858 CARL I S L E R E G 2 0 N AL M E N= CA L C T R A S O F 1 1/ 1 9/ OS PATIENm: MELLOmm, JRRRY D F/C: F P/T: O DSC CODE: O1 A/C: 7838717 ADMISSION: 09/16/08 DISCHARGE: 09/16/08 ----------------------------------------------------------------------------- CHG DATE DPT REV BAT# HCPC M1M2M3M4 CHGCD DESCRIPTION QTY AMOUNT ----------------------------------------------------------------------------- 09/16/08 494 610 8 73221 RT 89675 MRI EXT UP JT WO 1 1,641.80 ----------------------------------------------------------------------------- TOTAL CHARGES 1,641.80 TOTAL: CASH> 1,102.84- ADJUSTMENTS> 508.96- BALANCE> 30.00 SELECT: REV= * DEPT= * CHGCD= * DATE/MDCY= * TO/MDCY= CMD:I=DAR,2=PAT,4=SUMMARY,5=TOP,6=END,7=RETURN,8=BACKWARD,I2=UPD,ENTER=FORWARD '~~~s~ ~~(~~~, PO I3c~x 4l UO M E D I C A L C E N T E R Carlisle, PA.17013-41 UO November 05, ?008 zsa~•~ ~s STATEMENT 006077051 JERRY D MELLOTT 813 MYERSTOWN ROAD GARDNERS PA 17324 DEAR JERRY D MELLOTT Thank you for choosing Carlisle Regional Medical Center for your ~ healthcare needs. We value your use of our facilities. Your insurance company was billed and has paid according to the 4 benefits of your policy. However, there is a patient balance due ~" which is indicated above. Your payment is important to the efficiency of the hospital and our attempts to hold down costs. Please mail your check or money order today. For your convenience, we accept Visa, MasterCard, Discover and American Express (see below). If you have additional insurance information which you have not previously provided, please notify us immediately. Furthermore, if you are not able to pay this account in full at once, please contact us for payment arrangements. If you have questions regarding the balance of this account, please do not hesitate to call us at the number shown below. Thank you for your prompt attention to this matter. If you have already made payment, please disregard....and thank you. PLEASE RETURN LOWER PORTION WITH YOUR PAYMENT CARLISLE REGIONAL MEDICAL CENTER PATIENT REPRESENTATIVE 800 381-9160 8:30 A.M. TO 5:00 P.M. POA 03 PATIENT: JERRY D MELLOTT PATIENT #: 7838717 BALANCE: $30.00 ADM. DATE: 09/16/08 PATIENT: JERRY D MELLOTT PATIENT #: 7838717 BALANCE: $30.00 ADM. DATE: 09/16/08 ** CREDIT AUTHORIZATION ** VISA (_) MC EXP DATE (_ CARD # )DISC ( . )AMX (_) _) VIN## ( ) 1 CARLISLE REGIONAL MEDICAL CENTER P.O. BOX 4100 CARLISLE PA 17013-4100 PMT AMT ( _ SIGN 03 *CALLS/INQUIRIES MAY BE MONITORED FOR QUALITY CODITROL* 173 ALLAN J. MIRA, M. D. 220 WILSON STREET SDITE 206 CARLISLE, PA 17013 ADDRESS SERVICE REQDESTED >39239 7009388 U01 092096 JERRY D. MELLOTT 813 MYERSTOWN RD GARDNERS PA 17324-9618 5261-1-1 S~~'~~'~~~I~IT 11615 539a TH30 AMOUNT CREDIT CARD PAYMENT CREDIT CARD Exp. Date: CARD NUMBER Security Code: CARDHOLDER NAME SIGNATURE REMIT TO: ALLAN J. MIRA, M.D. 220 WILSON ST STE 206 CARLISLE PA 17013-3697 I~~~Illt~~llit~~~~tllt~lltt~ll~~llt~l~l~~i~t~lrltlt~ll~~~tltll PLEASE RETURN THIS PORTION WITH PAYMENT Office Phorte Number Statement Date Your Account Number Page No. Patient Balance. SHOW AMOUNT _(717) 249-7400 10/29/08 5261-1-1 01 30.00 PAID HERE CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT ~~~ 91108 MIRA CPTs 99213 -24 OV EST. PAT. LOW-NOD S J MELLOTT 65.00 OF -24 719.43 91208 AETNA FILED 92208 AETNA PAYMENT -26.00 9ZZ08 AETNA ADJUSTMENT -9.00 30.01 1~V4` ......r ~.. .. FOR YOUR CONVENIENCE WE ACCEPT VISA & NAS ~ `. `'t TERCARD ~~ ~. Statement Date: 12/22/08 PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALL G OUR OFFICE: 5261-1- CURRENT 30-60 DAYS 60-90 DAYS > 90 DAYS TO IN3 PENDINQ lEN LANCE AY THIS AMOUNT 30.00 3 00 0. 30.00 SEND INQUIRIES /PAYMENTS TO: ALLAN J NIRA,'M.D. (717) 249-740.0 220 WILSON STREET YOIIR ACCOUNT'IS SERIOUSLY PAST 9UITE,206 DUE. PLEASE CALL OQR OL+'FICE CARLISLE, PA 17013 IMMEDIATELY TO AVOID'F[JRTHER 'IRS'#s 23-2119685 COLLECTION ACTIVITY'. 31854 7072494 031855031855 00001/00001 920966902 NOTE: Charges and payments not aooeanna nn this StarAmanT wiu annaar nn Hoyt m~mti~~ cr~m.,,o.,r MIRA ORTHOPEDICS Medical Arts Building Suite 206 220 Wilson Street Cazlisle, PA 17013 ORTHOPEDIC SURGERY Allan J. Mira, M.D. 'Duane A. Stroup, PA-C Phone 249-7400 PATIENT INFORMATION SHEET PATIENT: ~ ,"~,L~t~i I'//~..~1P~~ DATE: y/~~ ~~~~ DIAGNOSIS: '~,.~~1 '{~ ,'}'~-i~~- '2'~i,j (~'C.~(,.. CLCr G~~..t:~1r ~ ~~GZ~~ '~'~~.,L~I~.~`7(,G'`~'Z 1 (~ ,~'7~1GG~,'.. `2e. G~pl-~~-~~~~L'-c. ~ry~~`~ CZti~. Gl, ~C`'~lc.s ~;r., ~~ ~'Y~t.~ . 4 /i .. , i INSTRUCTIONS: `~~:~~,i!CIc_ G2~ ~? ,r~'Yl G~`1,~~.~.~...~ ~ /7,~ " -~ll6t~l>G(1~~.e, . Patient's Signature Ian J. Mira, M.D. MIRA ORTHOPEDICS sane A. Stroup, PA-C MEDICAL ARTS BUILDING C No MD014478-E TELEPHONE: 717.249-7400 SUITE 206 . . 220 WILSON STREET ACCOUNT NUMBER -. No.-23-2119685 CARLISLE, PA 17013 X261 1'IENT NAME ADDRESS ~ PHONE Mt:;LLU'1''1', J'~t't12Y u. uARDNIri,?~, !'~A i'~';~2~ X28-885'/ 3PONSIBLE PARTY ADDRESS PHONE M>rLLL7'1''1'f .7,v'RHY la. LiAttl:?Nl::tt«a~ F'A 1'/~~~ 528-885'/ DIAL SECURITY NO. 5EX CURRENT OVER 30 DAYS OVER 60 DAYS OVER 90 DAYS OVER 120 DAYS OVER 150 DAYS TOTAL IN COLLECTION 1bb-4b-3y'/(d M -d, 4~rt0 v]. tvtlJ ~1. 4b(b td. t11~d fZt. tdtl~ ld, tDV1 0, rDr11 rD, fDID BIRTHDATE EMPLOYER REF. PHY. TODAY'S DATE Id:3/tde/54 YPI; iNDUS'1'12i1r5 1~AiL1rY M 4/tDy/~d': PLACE bE ~ERVIC,E: ~T-pOFFICE ( )NURSING HOME ( )CARLISLE REGIONAL MEDICAL CENTER '-`•i ` :~, `~';_;;. ^; ( ) fiMERGENCY ROOM ( )SURGERY CENTER ( )DATE ADMITTED ( )DATE DISCHARGED NEW PATIENT FEE ESTAB. PATIENT FEE SURGE RY: DATE FEE FRACTURES: DATE FEE 99201 Minor () 99211 Minor () 20670 Removal Buried _ Superficial () 223_ Fract. vert. body w/ 8/ cast or brace 99202 Low () 99212 Low () 20680 Removal Buried - Deep () 23500 - Fract. Clavicular w/o Manip. _ 99203 Mod () 99213 Mod ~ "'"() 29870 Arthroscopy, Knee Diagnostic () 23600 Fract. Humeral Neck w/o Manip. 99204 Mod/High- 99214 ModlHigh- () 29877 py, Arthrosco Knee Debridement () 24650 _ Fract. Radial Head w/o Manip. 99205 Hi h 9 ) 99215 High wlCartila a Shavin g g () 25600 - Fract. Colles w/o Manip. - Vo Show () 29874 Arthroscopy, Knee, Removal () 25605 Fract. Colles w/Manip. - Vo Charge Office Visit Loose Body () 25622 Fract. Carpal Navicular 99058 Office Visit Emergency () 29881 Arthroscopy, Knee, Partial Meniscectomy w/o Manipulation - () 25111 Excision, Ganglion, Wrist () 26600 Fract. Metacarpal wlo Manip. - =1CE CONSULT: DATE FEE () 26410 Extensor Tendon Repair, () 26605 Fract. Metacarpal wlManip. - ifirmatory Once/Other OP Hand Single () 2672_ Fract. Phalangeal Proximal - 9927_ () 9924_ () 26418 Extensor Tendon Re pair, - w/Manip. -w!o Manip. - Finger Simple () 27760 Fract. Medial Malleolus, SPITAL CARE -INITIAL () 27236 Fx. Femur, Prox., Neck w!o Manipulation 992 - () 27244 Open Treatment Intertrochanteric () 27786 - Fract. Lateral Malleolus, SPITAL CARE -SUBSEQUENT Fracture w/o Manipulation - 99231 Low () 64721 Decompression Carpal Tunnel () 28470 Fract. Metatarsal w!o Manip. - 99232 Mod () 27130 Arthroplasty, Total Hip () 27808 Fract. Bimalleolar, Closed 99233 High () 27447 Arthroplasty, Total Knee w!o Manipulation - 9923_ Discharge Mgt. Day () 23412 Repair Rotator cuff c Acromioplasty () 27818 FX Trimalleolar w/Manip. - () 29888 Arthrescopy, Knee, ACL () - VSULTATION: DATE () 29848 Arthroscopy, Carpal Tunnel (I 9925 9925 Ligament - ERRING PHYSICIAN - () 29826 Arthroscopy Shoulder CASTS & SPLINTS: DATE - Decompression () - ECT/ASPIRATION: DATE () 26055 Trigger Finger Release () - 50 Inj. Tendon Sheath _ Inj./Asp. Joint CTABLES MEDICAL REPORTS: DATE - J1030 Depomedrol/40 () Med ReporULetter - J1040 Depomedrol/BO () Copies Med. ReC. - J3301 Kenalo gper 10mg () Review Med. Rec. - J0702 Celestone () Deposition () - _.. ,. . . =ut-..-..~.~ ,t ~ 1 ICD-9 MISCELLANEOUS: DATE ALLAN J. M.D. ' MO~NTHS~ PRN I ......-.t''lY ~~~ ~LANCEFORWARD 0 CHECK 0 CASH PAYMENT ~ AY Date of Service DER EXTREMITIES 73000 X-ray Clavicle, Complete 73030 X-ray Shoulder-Minimum 2 Views 13060 X-ray Humerus 2 Views (3070 X-rpy Elbow AP a Lpterpl 73080 X-ray Elbow Complete Minimum 3 Views 73090 X-ray Forearm AP & Lateral 73100 X-ray Wrist AP 8 Lateral 73110 X-ray Wrist Complete 73120 X-ray Hand 2 Views 73130 X-ray Hand-Minimum 3 Views 73140 X-ray Finger/s-Minimum 2 Views NER EXTREMITIES 73510 X-ray Hip-2 views x3520 X-ray Hips-Bilateral-2 Views Each Hip 8 AP Pelvis ( ) 72170 X-ray AP Pelvis ( ) 73550 X-ray Femur AP 8 Lateral ( ) 73560 X-ray Knee AP 8 Lateral () 73562 X•rayKnae-Minimum 3 Views ( ~ 73684 x-ray /creep-complete ( ) 73590 X-ray Tibia 8 Fibula-AP 8 Lateral ( 73600 X-ray Ankle-AP 8 Lateral ( 73610 X-ray Ankle, Complete-Minimum 3 Views ( 73620 X-ray Foot-AP 8 Lateral ( ) 73630 X-ray Foot-Complete-Minimum 3 Views ( ) 73650 X-ray Calcaneus ( ) 73660 X-ray Toes SPINE ( ) 72040 X-ray Spine, Cervical, AP 8 Lateral ( ) 72050 X-ray Spine, Cervical, Minimum 4 Views BALANCE DUE ~ • ( ) 72052 X-ray Spine, Cervical, Complete-ObliqueaJFlex/Ext ( ) ]2080 X-rpy Spina. Thor-cplumb-r. Stpndinp (Scol'ro.i.) ( ) 72070 X-ray Spine, Thoracic - AP 8 Lateral ( ) 72100 X-ray Spine, Lumbosacral, AP & Lateral ( ) 72110 X-ray Spine, Lumbosacral, Complete ( ) 72114 X-ray Spine, Lumbosacral, Comp Intl Bending Views 0 0 . 0 0 . 0 0 . 0 0 . o 0 . I+l co . ~o a+ . N ao . n m o o . 0 0 . 0 0 . 0 0 0 0 0 0 . 0 0 0 0 0 0 o 0 N 0 o 0 O q O~ (? N .~1 N .i ~O ei N .~ ~O 1~'1 N Ot f~'1 m . W 10 W m O ~D N .-1 . O1 t/~ . ~O m W I[) . O f~l . ~O N . 01 vY . W .~i . N m . 01 vl ~ i N fA Vl N N f? ~-1 f~1 V f/} tlY ~-1 f? (? f/> N ~-1 .~ b a a? F o O o O O O o O 0 O 0 O ~o 01 o O r GD ~r N o O 0 O 0 O 0 O 0 O 0 O 0 O 0 O o O m N o O y 7 C q O a 1!1 ~fl O 1f1 O n O ~f) ~O N N Of 01 t0 W 10 N 0 O l0 O In In V~ f+l o M n ~O ELI tf1 t0 O of O Irl n o O V~ m ~ i t? N tlY f? y ~-1 ~ t? Ifl ~ f+1 ~ ~O w N ~ tl) N N ~ N N t? 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M 0 O 0 N N O N 7 C V LL c ea a O V N N m t C d Q ~O 1f1 M t0 to O 3 ~. 'C x F- N d' M O O N Q N O Y V d t V V 7 O C d 7 C N_ t 3 d N t0 d a q N O ~ M ,.{ ~ N .d W .~ ro a ~j °o ~ O ~ N yJ ~ ~ N m ~ O' bi r- ,~ w ~a~o~~ ~ vb 8 ' ~ a~ ~ aa ~ N H ~ Ifl W m ~ ~ a~ ~ ~ ~HN ~ O O H q + ~: W m ~ tll 41 Q ~ H as a H a ~ U p ~ N N H O a ~ U 01 v o o ~ o m~ ~ a ° ~' q o a ~Uy a ,~ o mwo~G A aW a b~NO ~ v xayN a ~~aa ~ a 8 0 H OD H W N b .,~ o N a E H O oH O ~ F ~ r n °D a N m ~ o z° N a e a ~ r' N ~ ~ ~j U o dp o ~ ~ H m ~ W W ~ Q N \ J Q a ~ w z N ~, ~g ~ ~ o o w w H fl. Qn N eh 0 0 O N N O c UL A C l0 Q O V N 3 m r C m Q ~O r M l0 N Z '~ k iv M M O O N_ Q OD O .1C V d t v L O C O d C H t .N L 3 d H d a Yellow Breeches EMSy Inc. PO Box 516 CAMP HILL, PA 17001 Phone #: (800) 367-0512 federal Tax ID: 25-1768266 ~~aa~lf~i~,. ,~,~~~~~: JERRY MELLOTT ~r,~,zF.+~~~@~„~i:`~~_: AETNA USHC BBJ1S85A Y8000714 JERRY MELLOTT 813 MYERSTOWN RD GARDNERS, PA 17324 Ptk'Y'ilrNl" I~IUMR~FI: ~i~i~~.. ~~I~~~E~~. T@@47 E: UI"~~,~~@_L: @"d~C)IUE: TCl:, F{9F; ~d~ ~~: 4030 YS000714 07/21 /2008 ~'~ ~~ ~~ ~, ~ II~~~~ --._ 1 IBAL IBAL. AREA OF 38 FROST RD CARLISLE REGIONAL MEDICAL CTR INJURY-MULTIPLE SITES PAIN -MULTIPLE SITES JESCRIF~TION Oh ~@-!AF?faF: i'~U?.PdT@~'Y ~ U~iO"@ Pr^~ICir AMOUNT" ~ _ ~ ~ ` .... ._.._M_._._._. _ _. ~_..~-. _~~ BLS EMERGENCY A0429 1.0 F 368.87 368.87 ~' MILEAGE' A0425 i 14.0 ~ 6.64 ~ 92.96 CERVICAL COLLAR A0382 ~ 1.0 ~ 40.58 ~ 40.58 I OXYGEN A0422 ~ 1.0 f j 3 44.34 ~ 44.34 I E !~ C d ~ ._._...u.___._..___~.... -.~..~- _ ~_..__~- -- _~ _....~._.._m._ -- - ~ Total Charges 546.75 --- -- --- - - - DESCRIPTION OF PAYMENT RECEIPT P~a,YMcNT DATE AiUiOUEdT Insurance Payment -AETNA -USE FOR ALL 37268655 09/03/2008 " q { I s c...,_.__ ~_.__._..__~ _ _.... -- __ 461.83 otal Credits 461.83 PLEASE PAmY TFIIS laMOUNT ~.-~,W ~ X84.92 ! ~._.______________._. a..~~...._._____~ DETACH ALUNG Pri~FURMA`iION AND RETURN STUB WIT@-9 PAY@U~iWNT -~ MELLOTT, JERRY D Y8000714 AMOUNT ®u~ PA"i`lN'I" lil~!hTJdC=:: 4030 CALL NUfiIiBEF°i AMUUNT ~ PAT@Ei\I`1' @t@@.9iVIG'ER: CHILLING UATL_: 09/30/2008 ENCLUSED This account is now PAST DUE!! Payment must be received WITHIN 10 DAYS. Collection process will begin. 84.92 Yellow Breeches EMS, Inc. PO Box 516 CAMP HILL, PA 17001 ~,al_~s ~~.~~R~ 1 0/ 1 3/ 0 9 PAGE 0 0 2 HEALT H MANAGEMENT AS S oC S AT E S DA 1 7 CO S D. 8 5 8 CARLISLE REGIONAL MEDICAL CT R AS OF 10/12/08 PATIENT: MELLOTT, JERRY D F/C: F P/T: E DSC CODE: O1 A/C: 9407 --------- 908 ---- ---- ---------- ADMISS ------------ -- ION: 07/21/08 DISCHARGE: 07/21/08 ------- CHG DATE --- DPT ---- REV ---- BAT# HCPC ---------- - M1M2M3M4 CHGCD --------------- ----------- DESCRIPTION -- ------ QTY ----------- AMOUNT 07/21/08 428 320 8 73110 LT 73110 ---------------- WRIST MIN 3V ------ 1 ----------- 307.28 07/21/08 429 350 8 76376 17200 CT 3D RECONSTRUC 1 522.31 07/21/08 429 352 8 72125 72125 CT CERVICAL W/O 1 1,100.75 07/21/08 412 250 5200 02850 BACITRACIN DINT 4 113.28 07/21/08 412 250 5200 06210 CEPHALEXIN HCL 5 1 6.91 07/21/08 412 250 5200 41970 PERCOCET 5/325 T 6 35.82 07/21/08 418 250 6 11455 SALINE NORMAL 25 1 6.65 07/21/08 418 270 6 26890 'PRAY LACERATION 1 55.38 07/21/08 480 450 6 99283 00515 ER DEPT INTERMED 1 602.23 07/?_1/08 480 450 6 90471 97005 DT INJECTION 1 108.97 07/21/08 412 250 5200 20620 LIDOCAINE HCL 1$ 1 12.16 --------- ---- ---- ----------- -------------- ------------------- TOTAL CHARGES ------ ---------- 5,399.01 TOTAL: CASH> 538.00- ADJUSTMENTS> 4,861.01- BALANCE> 0.00 SELECT: R EV= * DEPT= * CHGCD= * DATE/MDCY= * TO/MDCY= CMD:I=DAR ,2=PAT,4=SUMMARY,S=TOP,6=END,7=RETURN,8=BACKWARD,I2=UPD,ENTER=FORWARD 10/13/OS F-iEALTi3 MANAGEMENT ASSOCSATES aaa04 coxa= 858 ACCOUNT #: 94079 08 DISCHARGE ACCOUNTS RECEIVABLE RECORD PAT NAME: MELLOT T, JERR~C D ADMIT: 07/21/08 FI NANCIAL CLASS: P I GAR NAME: MELLOT T, JERRY D DISCHARGE: 07/21/08 CONTRACT FREQ: STREET: 813 MY ERSTOWN ROAD LAST PAY: 09/16/08 MAIL RETURN: ADDR-2: PROGRAM: PAT TYPE: E1 CITY: GARDNE RS PA 17324 CONTRACT:. .00 PAT SEX: M PHONE: (717) 528-8857 COUNTRY: US CURR BAL: _00 GAR SEX: M EMPLOYER: PPG TOT CHARGES: 5,386.85 AGENCY CNCL: R CODE DATE INSURANCE AGENCY BAL: .00 1: 980 07/21/08 12.16 CODE PLAN DATE S TAT POLICY NO 2: 967 08/22/08 4,861.01- 1: 105 HMO 08/22/08 5,399 P BBJ1585A 3: 105 08/22/08 438.00- 2: 4,: 10.0. 09/16/08 100.00- 3: 5i LST ACTN: P1 08/25/08 3: 00/00/00 PAY AUD 1: DP 08/22/08 4: 00/00/00 PROCESS REVIEW PAY AUD 2: I1 08/06/08 5: 00/00/00 DATE USER DATE ARTRAC ASSGN: 09/09/08 RETN 00/00 /00 REASON 09/10/08 RTRC 00/00/00 Sys Ltr 03 09/10/08 08/21/08 858029 00/00/00 PT RESP 100.OO.SLM 08/06/08 LM 09/05/08 FOLLOW UP 08/06/08 SR 00/00/00 SUBMITTED CLAIM WITH UB AND DENIAL FROM AUTO INS 1=UP,2=PT,3=GAR,4=INS,5=UB,6=HIS,7=RTN,8=CMTI,9=CMTU,IO=DET,II=LOG,ENTER=FW C.farP~ f~~ ~-~~ -o S 1 0/ 1 3/ O B PAGE O O 1 HEALT H MANAGEMENT AS S O C =ATE S DA 1 7 CO S D c B S B CARLISLE REGI ONAL MEDICAL CTR AS OF 10/12 /08 PATIENT: MELLOTT, JER RY D F/C: F P/T: E DSC CODE: O1 A/C: 9407 --------- 908 --- ----- ----- ----- ADMISSI ---------------- ON: 07/21/08 DI SCHARGE: 07/21/08 CHG DATE --------- DPT --- REV ----- BAT# ----- HCPC ----- M1M2M3M4 CHGCD ---------------- ----------------- DESCRIPTION ----- --------- QTY -------- AMOUNT 07/21/08 412 250 5201 17730 ------------ HYDROMORPHONE 1M --------- 1 -------- 6.04 07/21/08 412 250 5201 90714 36300 TET DIP TOX ADUL 1 80.49 07/21/08 418 272 7000 11019 DSG KERLIX ROLL 3 14.01 07/21/08 418 270 7000 12725 BANDAGE CONFORM 1 29.89 07/21/08 418 270 7000 24487 PAD ABD HH NON21 3 73.12 07/21/08 918 272 7000 25973 DSG SPONGE 4X4 S 6 39.90 07/21/08 428 320 8 72020 02289 SPINE SINGLE VIE 1 307.28 07/21/08 428 320 8 73564 LT 19001 KNEE MIN 4V 1 505.22 07/21/08 428 320 8 73630 LT 19845 FOOT MIN 3V 1 307.28 07/21/08 428 320 8 72070 22485 SPINE THORACIC 2 1 325.55 07/21/08 428 320 8 72050 33102 SPINE CERVICAL M 1 531.22 07/21/08 428 320 8 72050 33102 SPINE CERVICAL M 1- 531.22- 07/21/08 428 324 8 71020 71020 CHEST PA & LATER 1 307.28 07/21/08 428 320 8 72110 72110 SPINE LUMBAR MIN 1 531.22 CONTINUED ... SELECT: R EV= * DEPT= * CHGCD= * DAT E/MDCY= * TO/MDCY= * CMD:I=DAR,2=PAT,4=SUMM ARY,5 =TOP,6=END,7=RET URN,8=BACKWARD,I2 =UPD,ENTE R=FORWARD 10/13/08 PAGE 001 HEALTH MANAGEMENT ASSOCIATES DA17 COID: 858 CARLISLE REGIONAL MEDICAL CTR AS OF 10/12/08 PATIENT: MELLOTT, JERRY D F/C: F P/T: O DSC CODE: O1 A/C: 7838717 ADMISSION: 09/16/08 DISCHARGE: 09/16/08 CHG DATE DPT REV BAT# HCPC M1M2M3M4 CHGCD DESCRIPTION QTY AMOUNT 09/16/08 494 610 8 73221 RT 89675 MRI EXT UP JT WO 1 1,641.80 ----------------------------------------------------------------------------- TOTAL CHARGES 1,641.80 TOTAL: CASH> 0.00 ADJUSTMENTS> 0.00 BALANCE> 1,641.80 SELECT: REV= * DEPT= * CHGCD= * DATE/MDCY= * TO/MDCY= * CMD:I=DAR,2=PAT,4=SUMMARY,5=TOP,6=END,7=RETURN,8=BACKWARD,I2=UPD,ENTER=FORWARD 9 -~~ _ d~ r~ Fez' 10/13/08 idEALTK MANAGEMENT ASSOCIATES DA04 COID: 858 ACCOUNT #: 7838717 DISCHARGE ACCOUNTS RECEIVABLE RECORD PAT NAME: MELLOTT, JERRY D ADMIT: 09/16/08 FINANCIAL CLASS: P P GAR NAME: MELLOTT, JERRY D DISCHARGE: 09/16/08 CONTRACT FREQ: STREET: 813 MYERSTOWN ROAD LAST PAY: 09/16/08 MAIL RETURN: ADDR-2: PROGRAM: PAT TYPE: OM CITY: GARDNERS PA 17324 CONTRACT: .00 PAT SEX: M PHONE: (717) 528-$857 COUNTRY: US CURR BAL: 1,641.80 GAR SEX: M EMPLOYER: PPG TOT CHARGES: 1,641.80 AGENCY CNCL: R CODE DATE INSURANCE AGENCY BAL: .00 1: CODE PLAN DATE STAT POLICY NO 2: 1: 105 HMO 10/02/08 1,641 O BBJ1S85A 3: 4: 5: PROCESS DATE USER 10/08/08 RTRC 10/06/08 RTRC 10/02/08 858026 10/02/08 858026 2: 3: LST ACTN: I4 10/06/08 3: 00/00/00 PAY AUD l: PP 10/02/08 4: 00/00/00 REVIEW PAY AUD 2: 00/00/00 5: 00/00/00 DATE ARTRAC ASSGN: 10/06/08 RETN 00/00/00 REASON 00/00/00 (SB) Line Busy 10/07 22:41 00/00/00 Sys Ltr 47 10/06/08 00/00/00 ;PAYOR 105 HMO STAT B:O INSAMT 1641: 1641 00/00/00 F/C F :P LACT LFRQ CAMT .00: .00 1=UP,2=PT,3=GAR,4=INS,5=UB,6=HIS,7=RTN,8=CMTI,9=CMTU,IO=DET,II=LOG,ENTER=FW 9407908 ~ nnn nnn1II1I11N II111111111111111111111 III~III IIIII~II'~IIII'~III'INI~IIII~IIII'I 8991210 II ~ CARLISLE REGIONAL P.o. eoX a~oo M E D 1 l'. A L C E N T E R Cid(~IS~@, PA 17013-4 t 00 ADDRESS SERVICE REQUESTED JERRY D MELLOTT r 813 MYERSTOWN ROAD ~ GARDNERS PA 17324 ~in~~~n(~n~~ul~~~l~n~~~~m~~nm~~~n~nn~~n~~n~(~~) 007852 858HMA 002586R ~~ PATIENT: JERRY D MELLOTT PATIENT #: 9407908 BALANCE: 5100.00 ADM. DATE: 07/21/2008 DEAR JERRY D MELLOTT We would like to take a moment to say "Thank You" far selecting CARLISLE REGIONAL MEDICAL CTR for your recent hospital visit. We deeply appreciate your confidence in our ability to care for you and hope your visit with us was as pleasant as possible. Your insurance company was billed and paid 9438.00. This leaves a balance of S100.00 due from you. The balance can be paid at the hospital, or you can mail in a check, money order, or your credit card information on the form below. If you have additional insurance information that you would like billed, or have any questions please contact our hospital business office. CARLISLE REGIONAL MEDICAL CTR is a full service facility, and should you have any questions about the service available, please feel free to call at 1717) 960-1680, Again, we would like to thank you for selecting the services of CARLISLE REGIONAL MEDICAL CTR It is'our privilege to serve you. QUESTIONS, PLEASE CALL: (717) 960-1680 PATIENT: JERRY D MELLOTT PATIENT #: 9407908 BALANCE: 9100.00 ADM. DATE: 07/21/2008 IF PAYING BY CREDIT CARD, FILL OUT BELOW _ ^ MASTERCARD ~p y~q DISCOVER 081M1~ VISA ^ AMERICAN EXPRESS CARD NUMBER VIN M SIGNATURE EXP.DATE STATEMENT DATE PAY THIS AMOUNT ACCT. aY CARLISLE REGIONAL MEDICAL CENTER 361 ALEXANDER SPRING ROAD CARLISLE PA 17015-9129 ~ul~~~ul~~~n~u~~~~~+,~~,~nu,~~n{7{~,~n~~~nu~'~{n~~~ ~~ CARLISLE REGIONAL P.o' eCX a~oo M E D [CAL C E N T E R Carlisle, PA 17013-4100 ADDRESS SERVICE REQUESTED 0 a °` GARDNERS JERRY D MELLOTT 813 MYERSTOWN ROAD PA 17324 In~llin~lnlln~l~l~lnil~ln~llm~~iilulnnllnliul~l~l DEAR JERRY D MELLOTT uu,ase u~nnnn 001823E W r `~~ 1 PATIENT: JERRY D MELLOTT PATIENT 8: 7830149 BALANCE: 530.00 ADM. DATE: 08/13/2008 We would like to take a moment to say "Thank You" for selecting CARLISLE REGIONAL MEDICAL CTR for your recent hospital visit. We deeply appreciate your confidence in our ability to care for you and hope your visit with us was as pleasant as possible. Your insurance company was billed and paid 5182.02. This leaves a balance of 530.00 due from you. The balance can be paid at the hospital, or you can mail in a check, money order, or your credit card information on the form below. If you have additional insurance information that you would like billed, or have any questions please contact our hospital business office. CARLISLE REGIONAL MEDICAL CTR is a full service facility, and should you have any questions about the service available, please feel free to call at C717) 960-1680. Again, we would like to thank you for selecting the services of CARLISLE REGIONAL MEDICAL CTR It is our privilege to serve you. pUESTIONS, PLEASE CALL: C717) 960-1680 PATIENT: JERRY D MELLOTT PATIENT #: 7830149 BALANCE: 530.00 ADM. DATE: 08/13/2008 IF PAVING BY CREDIT CARD, FILL OU7 BELOW STERCARD ® a COVER :w gq AMERICAN EXPRESS CARD NUMBER VIN I ODRT" SIGNATURE EXP.DATE STATEMENT DATE PAY THIS AMOUNT ACCT, p CARLISLE REGIONAL MEDICAL CENTER 361 ALEXANDER SPRING ROAD CARLISLE PA 17015-9129 I~~~III~~~III~~~~~~II~I~I~i~l~~~~~il~~l~ll~i„~Ilr~r~~lll,,I~I ~/ ~~~~~~ 007852 858HHA 001975R REGIONAL P.o. eox a ~ 00 mt F1) I C A L C F. N T E R Carlisle, PA 17013-4100 ACIDRESS SERVICE REQUESTED JERRY D MELLOTT ~ 813 MYERSTOWN ROAD .o ~ GARDNERS PA 17324 L~~IIL~,I~~II~~~LI~L~ILL~~II~~~~JILJ~~~~II,III„LLI PATIENT: JERRY D MELLOTT PATIENT #: 7832149 BALANCE: 530.00 ADM. DATE: 08/25/2008 V ~~ ~~~ ~~ ~, ~ DEAR JERRY D MELLOTT We would like to take a moment to say "Thank You" for selecting CARLISLE REGIONAL MEDICAL CTR for your recent hospital visit. We deeply appreciate your confidence in our ability to care for you and hope your visit with us was as pleasant as possible. Your insurance company was billed and paid 51,102.84. This leaves a balance of $30.00 due from you. The balance can be paid at the hospital, or you can mail in a check, money order, or your credit card information on the form below. If you have additional insurance information that you would like billed, or have any questions please contact our hospital business office. CARLISLE REGIONAL MEDICAL CTR is a full service facility, and should you have any questions about the service available, please feel free to call at (717) 960-1680. Again, we would like to thank you for selecting the services of CARLISLE REGIONAL MEDICAL CTR It is our privilege to serve you. QUESTIONS, PLEASE CALL: (717) 960-1680 PATIENT: JERRY D MELLOTT PATIENT #: 7832149 BALANCE: S30.00 ADM. DATE: 08/25/2008 IF PAYING BY CREDIT CARD FILL OU7 BELOW ~ Y ® 0 n- 0 +~ M ASTERCARD COVER ~ V ISA ERICAN EXPRESS CARD NUMBEp VIN N SIGNATURE EXP.DATE STATEMENT DATE PAY THIS AMOUNT ACCT. M CARLISLE REGIONAL MEDICAL CENTER 361 ALEXANDER SPRING ROAD CARLISLE PA 17015-9129 I~„III„Iil~~~~~,ll~l~l,l~l~~~~~ll~~l,ll~l~~~ll~~~~~lll~~l~l ~~ Ml DICAL CENTC0. 3s1 Alexander Sprlny Road • CaHisle, PA 17013-9129 • (717) 249-, z, z CREDIT RECEIPT NO: 975897 DATE: 09/24/2008 TIME: ~o:zz:a2 MELLOTT, JERRY D 7834779 09/24/08 30.00 PAtIENt NAMEttYPEtix Ih1tlN PAtI~-t. lt~EtP7 pAT1ENY NUfd9ER 47ATE TRAN6AC'fltlN ~~~ '' 1' t .;::> N N w 1EN7 COMMENTS: PYMT. BY CREDIT CARD/MASTER CARD For service rendered on: 08/29/2008 THANK Y U Cashier $'ignatur r IINInINflIIIhI~NNINNIIIInlllnlllll IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 8991210 7834779 ~ CARLISLE REGIONAL P.o. eoX 400 Af E D I C A L C E N T E R Carlisle, PA 170 t 3-4100 ADDRES~ SERVICE REQUESTED JERRY D MELLOTT 813 MYERSTOWN ROAD a °D GARDNERS PA 17324 ~u~~~~m~~i~~n~~~~~~u~~~~ui~~nm~~~n~nn~~n~~n~~~~) y+001978L~ PATIENT: JERRY D MELLOTT PATIENT ~k: 7834779 BALANCE: S30.00 ADM. DATE: 08/29/2008 ;~(~.~ i~~~ ~~~ v' `,~ DEAR JERRY D MELLOTT / We would like to take a moment to say "Thank You" for selecting CARLISLE REGIONAL MEDICAL CTR for your recent hospital visit. We deeply appreciate your confidence in our ability to care for you and hope your visit with us was as pleasant as possible. Your insurance company was billed and paid 5504.33. This leaves a balance of 530.00 due from you. The balance can be paid at the hospital, or you can mail in a check, money order, or your credit card information on the form below. If you have additional insurance information that you would like billed, or have any questions please contact our hospital business office. CARLISLE REGIONAL MEDICAL CTR is a full service facility, and should you have any questions about the service available, please feel free to call at (717) 460-1680. Again, we would like to thank you for selecting the services of CARLISLE REGIONAL MEDICAL CTR It is our privilege to serve you. QUESTIONS, PLEASE CALL: (717) 960-1680 PATIENT: JERRY D MELLOTT PATIENT #: 7834779 BALANCE: S30.00 ADM. DATE: 08/29/2008 IF PAYING BY CREDIT CARD, FILL OUT BELOW ___ f.AASTERCARD __ _____ ® DISCOVER IAS'f~ SA __ MERICAN EXPRESS CARD NUMBER VIN M - SIGNATURE EXP.DATE STATEMENT DATE PAY TNIS AMOUNT ACCT. N CARLISLE REGIONAL MEDICAL CENTER 361 ALEXANDER SPRING ROAD CARLISLE PA 17015-9129 ~u~~~~m~~~nnn~~~~i~,~~lnu~lln~~~~~lml~n~u~~~n~i~ 7832149 Inlip~lllnl~lllhhlni~~nihllllllli IIIIIillllllllllllllilllillllllllllllllllilll 8991210 ~V r~-tONAC- NtDICAI. CLHTLR 96t Alexamtar Spring Road • Cartlsla, PA 17013128 • (71T) 241i-1212 ~ MEILOTT, JERRY D ~ 7830254 COMMENTS: PYMT. BY PATIENT CASH For service rendered on: 08/15/2008 ~Gti ~ SCct a~ CREDIT RECEIPT NO: 974167 DATE: O8/t 5/2008 TIME: 09:53:45 08/15/08 30.00 THANK YOU Cas er S nature IN~I~~n~n~IIIIiIIN IIIIIIhAII~li~ll~~lldplllllinll 8997270 7830254 ~~ R&GK)NAL ME~ICAt "N~re" 361 Alexander Spring Road • Carlisle, PA 170158129 • (717) 249-1212 CREDIT RECEIPT NO: 975545 DATE: os/1 s/ZOOs T{ME: 10:25:59 MELLOTT, JERRY D 7830149 09/16/08 30.00 PATIEfiI~ NAM~f1'YF'E.Ai NQIf=PATfEN'K ..1i~~~tP't <' pAT1EtV'F HUMBER; [#AtE .. ' 7kAllBi~l*Y-ON, .<; .:h# .. ..» 1wR/12 ^ , >'. Cflpfi COMMENTS: PYMT. BY CREDIT CARD/MASTER CARD For service rendered on: 08/13/2008 TH K YOU shier Signa r IlllinNlNIIiIIIiIIIiIIIIINUIligf1111111 IlililiillillifhmlllllnilllllNlll~illll 8991210 7830149 .... STATEMENT OF ACCOUNT (1) ALEXANDER SPRINGS EMER PHYS Statement Date: October 5,.2008 PO $OX 37720 ACCOUNT NUMBER: CLL94079084 PHILADELPHIA; PA 19101-7720 Patient Name: JERRY o MELLOTT - Tax ID #: 26-2419497 Account Balance: $847.00 - Amount Pending _ Insurance: $0.00 ~ Amount.Due From ~ Patit3nY(Current): $847.00 ~nf~~~~u~u~~up~pTp~n~~~~up~~nnl~~~n~nu~~u~~n~~~~~ Amount Due From ' 031212-0000094079084-04 Patient Past-Due : $0.00 #BWNJFDB Pay This Amount: $847.00 #OOOOOOOCLL118495# PLEASE REMIT PAYMENT BY JERRY D MELLOTT - "PAYMENT DUE BY".DATE. THANK YOU. 813 MYERSTOWN RD Please refer to coupon below for payment GARDNERS PA 17324-9618 instructions. Account Detail Date # Descnppon Charge aid ey aid By Paid 8y Amount Due From PA I Fist Ins:> Other Ins. Patient A usted Insurance- BALANCE 07/21/08 ] 11000 DEBRIDEMENT, X10% BODY 3126.00 SURFACE DK8ti2.0 DR. MILLER/CARLISLE REGIONAL MEDICAL ENTER 10/01/08 AUTOINSURANCE NO RESPONSE FROM 5-0.00 5126.00 PAYOR Gii2t - P8i-25 EMERGiN3UR'tEVALB _._._ :r. _.- -Siio9:~J _. ..._ _.-~_._..,_. . __ .__ _.... ..:... MGMTIVL4 DX:892.0 DR: MILLFILCARLISLE REGIONAL MEDICAL. ENTER 10!01/08 AUTO INSURANCE NO RESPONSE FROM S-0.00 5569.00 PAYOR 07!21/08 3 71020-28.26 EMERG INTERP CHEST 2 ^ $3q,00 _ .VIEWS OX:923.3 DR. MILLEIi/CARUSLERECIONAL MEDICAL ENTER 10/01!08 AUTO INSURANCE NO RESPONSE FROM 3.0,E 334 ~ - PAYOR 07/21/08 4 72100-2&2B EMERG INTERP 5,00 ; LUMBOSACRA62 VWS - DX:724.5 DR. MILLER/CARLISLE REGIONAL MEDICAL ENTER 10/01!08 AUTO INSURANCE NO RESPONSE FROM !-0.~ ~ PAYOR 07/21/08 5 731-26-26 EMERG INTERP WRISTZ $25.00 VIEWS. DX:892.0 DR. MILLERlCARLISLERECIONAL MEDICAL ENTER 10/D1/OS AUTO INSURANCE NO RESPONSE FROM 5-0.00 E25.00 TOTALS: coNrwuED coNTpaIED cONTMUED coNnNUED cafTwuED CONTpfl~O CtNiTINUm Important Messages: . This statement is for the direct trealrtterd and/or supervision of care you recently received from an Emergency Physk3an at Carlisle Regional Medical .Center. The fees for this private physician are biped separetely from arty hospital charges or other proNrssional fees for which you may also tie resportsrble. Therefore. should you receive a bill Nom Me hospital or other physfclans for charges in earmection wlh this visit. d wpt not include the items C~stsd on this statement "Payment Plans" Accepted Questions about this statement? / Llama de tunes a Viernes? Call 1-800-355-247D Mondayahrough Fridayy 9:30AM -4:OOPM. Your automated ystem access code'is 947-94079084, or you can send email to biHing_questions@emcare.com. Please detach and return bottom portion with your remittance. _ _ __ _ .. JERRY D MELLOTT STATEMENT OF AC .nt ttvr 813 MYERSTOWtJ RD Statement Date: October 5, 2008 GARDNERS PA 17324-9618 ACCOUNT NUMBER:CLL94079084 YOU MAY PAY THIS BILL WITH YOUR CREDIT CARD Patient Name: JERRY D MELLOTT PLEASE SEE REVERSE SIDE. Payment Due By: 10/26/08 Make ChecklMoney Order payable to: Amount Due: $847.00 Amount Enclosed: (n~~~~~~niu~~~~nnn~~~nr~~np~u~~~~~fnn~r~~ ALEXANDER SPRINGS EMER PHYS PO BOX 37720 PHILADELPHIA, PA 19101-7720 The insurance information in our file appears below, Please make any corrections and/or additions on the reverse side of this form and return k to us. Thank you. JERRY 813 MYERSTOWN RD GARDNERS PA 17324 ^ If your address has changed, check this box and complete the reverse side of this form 0312120000094079084000847000000000000001 Account Detail 7 CLL94079084 'Pa e 2 of 2 Data # Description Charye Paid By Paid By _ Paid By Amount Dua From <PATIEN First Ins: - Ofher Ins: Patient Ad'ustetl Insurance BALANCE PAYOR 07121/08. 6 73620-26-26 EMERG INTERP FOOT 2 $25A0 C VIEWS o DX:892.0 DR. MILLER/CARLISLE REGIONAL MEDICAL ENTER ~ ..10101108. AUTO INSURANCE NO RESPONSE FROM $.0 ~ ~ PAYER , b2$ ~ !J 07/21/08 7 -72040-26-26 EMERG INTERP XRAY $3q,00 NECK DX:724.5 DR. MILLER/CARLISLE REGIONAL MEDiI.AL ENTER 10/01/08 AUTO INSURANCENO RESPONSE FROWI $-0.00 S34A0 PAYOR TOTALS: ssa7.oo so.oo So:oo $o.oo $o.oa so.ao 3847.00 G78TCE8K New Address: Insurance: Address 1: Address 2: City: State: Zip: Telephone: ^ MEDICARE ^ MEDICAID ^ OTHER Credit Cards: ^ Ysa ^ Mastercard ^ American Express I I I I I i l l l l l l l l l l i i l i NAME AE R APPEARS ON GR~ -ALL GRC16 V I I I-I I I I I-I I I I I-I I i l l '' II '' II VISA/MASTERCARD NUMBERS ONLY L-_I~ 3-DIpR Number from Beek of VbNMastercerd V I I I-I 1 1 1 1 1 1-I V I I I AMERICAN E7fPRES3 NUMBER ONLY V I I I oA~it~ a4N~ ,bs C~ I ( I I I I I I I EXPIRATION DATE -ALL CARDS Company Name: Address 1: Address 2: City: State: Zip: Telephone: Plan Holder Name: Relation of Patient: ^ SELF ^ SPOUSE ^ CHILD POLICY #: GROUP #: F0101 BELVEDERE MEDICAL CORPORATION _ 850 WALNUT BOTTOM RD CARLISLE, PA 17013-3698 (717) 243-3120 Visit Receipt September 08, 2008 Patient Information Responsible Party Information TERRY D MELLOTT JERRY D MELLOTT 813 MYERSTOWN ROAD 813 MYERSTOWN ROAD GARDNERS, PA 17324 GARDNERS, PA 17324 Visit: 700866 Provider: BRANSCUM, JR, GEORGE P Location: DRS OFFICE at BMC Upin: 640423 Fed Tax ID: 231869105 Diag 1) 250.00 DIABETES UNCOMPLICATED TYPE II (NIDDM) Diag 3) Diag 2) V03.82 PNEUMONIA PNEUMOCOCCAL VACCINATION Diag 4) Date CPT CPT Description Charges Payments Adjustments 07/18/2008 90732 PNEUMOCOCCAL VACCINE, ADULT $28.00 $0.00 $0.00 07/18/2008 90471 IMMUNIZATION ADMIN, SINGLE $25.00 $0.00 $0.00 07/18/2008 99212-25 OFFIt:;E/OUTPATIENT VISIT, EST $60.00 $0.00 $0.00 07/18/2008 99212-25 Copay PT Check $0.00 $15.00 $0.00 07/22/2008 99212-25 Capitation Automatic - 99212-25, $0.00 $0.00 $45.00 OFFICE/OUTPATIENT VISIT, EST 08/04/2008 90732 AETNAHMO, #73851081 (08//01(2008), 90732 $0.00 $28.00 $0.00 08/04/2008 90471 AETNAHMO, #73851081 (08//01/2008), 90471 $0.00 $10.00 $15.00 Total: $113.00 $53.00 $60.00 Baiance Due: $0.00 Pending Insurance: $0.00 Thank You. Future Scheduled Appointments: Page: 1 BELVEDERE MEDICAL CORPORATION 850 WALNUT BOTTOM RD CARLISLE, PA 17013-3698 (717) 243-3120 Visit Receipt September 08, 2008 Patient Information JERRY D MELLOTT 813 MYERSTOWN ROAD GARDNERS, PA 17324 Vislt#: 701714 Provider: BRANSCUM, JR, GEORGE P Upin: 840423 Diag 1) 924.9 CONTUSION Diag 2) Responslb/e Party Information JERRY D MELLOTT 813 MYERSTOWN ROAD GARDNERS, PA 17324 Location: DRS OFFICE at BMC Fed Tax ID: 231869105 Diag 3) Diag 4) Date CPT CPT Description Charges Payments Adjustments 07/24/2008 99212 OFFICE/OUTPATIENT VISIT, EST $60.00 $0.00 $0.00 07/24/2008 99212 Copay PT Check $0.00 $15.00 $0.00 07/29/2008 99212 Capitation Adjustment for AETNA - 99212, $0.00 $0.00 $45.00 OFFICE/OUTPATIENT VISIT, EST Total: $60.00 $15.00 $45.00 Balance Due: $0.00 Pending Insurance: $0.00 Thank You. Future Scheduled Appointments: Page: , 1 BewECetRE nnen~cAL coRPORaTioN FAMILY PRACTICE-DEPARTMENT rr,7~ 243-1s~s ~D# 2s-i8ss~os 850 WALNU f l3V 1 1 VM HVAU CARLISLE, PA 17013 BRANS PROVIDER UM, JR, GEORGE P 0 gV ppTEg TI~,,~E ~ P2~~008/01:45 PM PLACE I~S'~~~ ati B SIT # ~ 701714. ACCT NO. /PATIENT NAME S76SO1 /ERRY D MELLO7T DOB X- VISIT CO ADDRES~13 MYfiRSTOWN ROAD GARDNERS, PA 17324 HOME Pl~t~l~i) 52$-8857 ~~~'P6-3366 ~#166.46-3970 PRAE NA 8 BBJ1S85A AUTH. # COPAY _ ~1 `J SE~gf ~>~ MEDICAL 510693640580 PRECERT # PREVIOUS 6ALANCE ~0 I REF. PHYSICIAN .'NEW PATIENT / OFFICE VIS{TS Cavell 99201 Level 2 99202 Level 3 99203 Level 4 9920a Level 5 99205 Physical Age 65 and over - 99387 Physical Age 40-84 99386 . .Physical Age 18-39 99385 Physical Age 12-17 99384 ' Physical Age 5-11 99383 ' 'Physical . ~a:ss.?. - :99382 Level 1, 99211 Level 2 99212 Level 3 99213 Level 4 99214 Level 5 99215 Physical Age 65 and over 99397 Physical Age 40.64 99396 Physical Age 18-39- 99395 Physical Age 12-17 99394 Physical Age 5-11 ..99393 Physical Age 1-4 99392 Physical Age under 1 99391 Nursing Home Emp P/E 00077 EPSDT S0302 • -BS/BC/KEY/(4ATI?`'HP (V72.3t) S0610 BSl6C/KEY/GATE EP (V72.31) S0612. edicaie , helvic•(V762) ~ _ ~ ~ G010t Medicare -Pap (V76.2) 00091 PPD (V74.1) 86580 Admin. Fee (V_ ~ 90471 Admin. Fee (V_._„) 90472. Aduit Td (V06.5) 90714. Comvax (V03.61 + V05.3) 90748 DTaP (V06.1) 90700 Flu (V04.81) 90._ Flu Medicar® /BS GOOOB-AD t i nuMt ttuwt;rtr+rsut uxr t~uv~ ^ DO NOT SUBMIT TO INS. LE ACCIDENT ,_ a PRINT OuT cLAtarFOw~t - Gardasll ` (vo1.~9) ~ 9os4s Hepatitis 8, 0.19 yrs.... (V05.3) 90744 Hepatitis B, 20 + yrs. (V05.3) 90746 Hap 8 Medicara /BS 00010-AD .. Hib (V03.81) 90645. MMR (VO6.A)' ~' ` '94707 Meningococcai (V03.89) 90734 . Pneumovax (V03.82) -90732 Pneumo Medicare i'BS 00009•AD Polio. (V04.0) 90773 Prevnar (V03.82) _90669 Tdap (V06.1) 90715 VariveX (V05.4) 90716 zostavax (V05.8) 90736 zosiavex Medicare co3n~ QTHER tNJEETjONS: Allergy Injection (1) 95115 Allergy Injection (>7) 95117 .Thar./: Diag InJ Ad 90772 B12 J3420 - Repo. Medrol J2930 Depo Provata J7055 Insulin J1815 Kenalog J3301 Phenergan J2550 Prolixin J26$0 Talwin J3070 1C Blood Orx;utt Feces 1 day 82272 Blood Occult Feces 3 day 82270 Fingers0dc Glucose 82948 _._. Hematocrit 85013 " KOH Skin /Hair /Nail 87220 Repitl Strap . 878$0 Urinalysis; Dip 81002 Urmafysis; Micro 81000 Urine HCG 81025 Wet Mount • Microgram 87210 OFFICE PROCEDURES: A~PY 46600 Aspiration Sm. Joint- 20605 RETURN APT. W r 0 U Aspiration Lg. JOlnt 20870 Audiometry 92551 . BMD 78977 Bums 160_ Destruction of Lesions 1st 17000 Destrudion.of Lesions 17003 Ear. Irrigatlon 89210 EKG 93000 Evatwatxxt-Sub-Hematoma 11740 Excision of Leswn (Benign) 114_ Excision 9f leeion (Malignant) 118_ Excision ofi Nail Excision of Tags to 15 11730 .11200 Hematoma,.Simple 10140 I ~ D Abscess, Simple 10060 I & D Abscess, Comp. 10061 Inj. of Tendon Sheath 20550 Lacerations 12_ MMSE 98115 Nebulizer CPT 94640 PiaakeN 9aeainp Ala (V76.41) G0102 Pulse Oximeter 9476 Punc, Asp., Abscess f 0160 Pund1 Biopsy 111,_...: Removal of FB, Simple 10120 Removal of FB, Comp. 10121 Shave Biopsy 113_ Spirometry, 940_ OsteopalMc Manipulative Treat+ned 989_ Consult 992_ Aircast Walking. Control Splint- - --!4350 Application of Fxrger;SpOni 291$0 Application of Short Ann 29125 Fx Care 2 Sling _ A4565 Splint (Medicare Q4051) A4570 Unnaboot 29580 W rist. Code-up Splint L.391 d After Hours 9905_ o CASH ^ GHECK TODAYS CHARGE ^ vlsA TODAYS '' ^ M/c PAYMENT ~ ~ ~ ^-MAC TOTAL ^ DISC BALANCE BELVEDERE MEDICAL CORPORATION 850 WALNUT BOTTOM RD CARLISLE, PA 17013-3698 (717)243-3120 Visit Receipt September 16, 2008 Patient information Responslb/e Party Information JERRY D MELLOTT JERRY D MELLOTT 813 MYERSTOWN ROAD 813 MYERSTOWN ROAD GARDNERS, PA 17324 GARDNERS, PA 17324 Visit: 702011 Provider: BRANSCUM, JR, GEORGE P Location: DRS OFFICE at BMC Upin: B40423 Fed Tax ID: 231869105 Diag 7) 924.4 CONTUSION EXTREMITY LOWER MULTIPLE SITES Diag 3) Diag 2) Diag 4) Date CPT CPT Description Charges Payments Adjustments 07/30/2008 99212 OFFICE/OUTPATIENT VISIT, EST $60.00 $0.00 $0.00 07/30/2008 99212 Copay PT Check $0.00 $15.00 $0.00 07/31/2008 99212 Capitation Adjustment for AETNA - 99212, $0.00 $0.00 $45.00 OFFICE/OUTPATIENT VISIT, EST Total: X60.00 X15.00 X45.00 Balance Due: ;0.00 Pending Insurance: $0.00 Thank You. Future Scheduled Appointments: Page: 1 BELVEDERE MEDICAL CORPORATION 850 WALNUT BOTTOM RD CARLISLE, PA 17013-3698 (T17) 243-3120 Visit Receipt September 16, 2008 Patient Information Respons/b/e Party /nformat/on JERRY D MELLOTT JERRY D MELLOTT 813 MYERSTOWN ROAD 813 MYERSTOWN ROAD GARDNERS, PA 17324 GARDNERS, PA 17324 Visit: 702621 Provider: BRANSCUM, JR, GEORGE P Upin: 640423 Diag 1) 924.9 CONTUSION Diag 2) Location: DRS OFFICE at BMC Fed Tax ID: 231869105 Diag 3) Diag 4) Date CPT CPT Description Charges Payments Adjustments 08/14/2008 99212. OFFICE/OUTPATTENT VISIT, EST $60.00 $0.00 $0.00 08/14/2008 99212 Copay PT Check $0.00 $15.00 $0.00 08/15/2008 99212 Capitation Adjustment for AETNA - 99212, $0.00 $0.00 $45.00 OFFICE/OUTPATIENT VISIT, EST Total: $60.00 X15.00 $45.00 Balance Due: $0.00 Pending Insurance: $0.00 Thank You. Future Scheduled Appointments: Page: 1 BELVEDERE MEDICAL CORPORATION 850 WALNUT BOTTOM RD CARLISLE, PA 17013-3698 (717)243-3120 Visit Receipt September 08, 2008 Pafienf Information Responsible Party information JERRY D MELLOTT JERRY D MELLOTT 813 MYERSTOWN ROAD 813 MYERSTOWN ROAD GARDNERS, PA 17324 GARDNERS, PA 17324 Visif#: 703932 Provider: BRANSCUM, JR, GEORGE P Upin: 840423 Diag 1) 924.9 CONTUSION Diag 2) Location: DRS OFFICE at BMC Fed Tax ID: 231869105 Diag 3) Diag 4) Date CPT CPT Description Charges Payments Adjustments 08/28/2008 99212 OFFICE/OUTPATIENTMSIT, EST $60.00 $0.00 $0.00 08/28/2008 99212 Copay PT Check $0.00 $15.00 $0.00 08/29/2008 99212 Capitation Adjustment for AETNA - 99212, $0.00 $0.00 $45.00 OFFICE/OUTPATIENT VISIT, EST Total: $60.00 $15.00 $45.00 Balance Due: $0.00 Pending Insurance: $0.00 Thank You. Future Scheduled Appointments: Page: 1 ~. BELVEpERE MEDICAL CORPORATION FAMILY PRACTICE DEPARTMENT (717) 243.1515 (D#.23-1869105 B50 WALNUT BOTTOM ROAD CAF3L)SLE, PA 17013. BRANSC pR IDER M, JR, GEORGE P 0 T T ~~`1b~ ~0~:~~~M PLAG F Fb~s+~`~ at BM VISIT # 703932 ,ACCT. NO. /PATIENT NAME 576507) , /ERRY D MELLOTT i DOB EX VISIT ADDRE~ MYERSTOWN ROAD GARDNERS, PA 17324 HOME P 528-8857 wC~~~l{~~=3366.. SSi°166-46-3970 PAETNANSSBJI~~SA RUTH.# CQPAY ~15 SECONDARY INSURANCE PRECERT # PREVIOUS BALANCE ~0 !REF. PHYSICIAN REASON FOR VISIT ADMITiDiSCHARGE DATES/DOI O DO NOT SUBMI7 TO INS. 2 WK F/U p PRINT OUT CLAIM FORM • NEW PATIENT/ OFFICE VISITS Gardasil (V01.79) 90649 ` Aspiration Lg. Joint ' 20610. .. Levgt 1 99201 (V05.3) Hepatitis B, 0-19 yrs. 90744 Audiometry.. 92551 ' ' Level 2 99202 Hepatitis B, 20 + yrs. (V05.3) 90746 8MD 76977 Level 3 99203 Hep B Medicare /BS 60010-AD Bums 160_ Level 4 99204 Hib (V03.81) .90645 _ Destntctiott of lesions 1st 17000 Level 5 99205 MMR (V08.4) 80707 D~truclionof Lesions 17003:, ,: Physical Age 65 and over 99387 - Meningococcal (V03,89) 90734 Ear lrrigafior- 69210 ~- Physigi Age 40-64 99386 Pneumonax (V03.82) 90732 EKG 93000 Physipl Age 18-39 99385 Pneumo Medicare IBS 60009-A0 Evacuation-Sub-Hematoma 11740 Physical Age 12-17 99384 Polio (V04.0) 90713 - Excisionof i:esion (Benign) 114_. Physical Age 5-11 99383. Prevnar (V03.82) 90669 Excision of Lesion (Malignant) 116_ Physical Age 7-4 99382 TdaP (VO6.1) 90715 Excision of Nail 11730 Physical Age under 1 99381 Varivax (V05.4) 90716 Excision of Tags to 15 11200 fST'P/tTiENT / OFFICE VISITS Zostavax (V05.8) 90738 Hemetoma; Simple 10140 Level-l 99211 Zostavax Medk:are 60377-AC1 1 & D Abscess; Simple 10080 _. Level 2 99212 I & D Abscess, Comp. 10061 Level 3 99213 OTHER INJECTIONS: Inj. of Tendon Sheath 20550 Level 4 99214 Allergy Injection (ij 95115. Lacerations 12T . Level 5 99215 AllergyJnject(on (>1) 95117 MMSE 96115 Physical Age 65 and over 99397 Theo / Diag Inj Ad 90772 Netwlizer CPT 941340 ' Physical Age 40-64- 993913 B12 J3420 Prosdab Screenig BCJBSaledcare (V78.34) 60102 .Physical Age 18-39 99395. Depo Medrol J2930 Pulse Oxkneter 9476_ Physical Age 12-17 99394 Depo Provera J1055 Punc. Asp:, Abscess 10160 Physical Age 5-11 99393 Insulin J1815 : Punch;Biopsy. 111T Physical Age 1-4 99392 Kenalog J3301 - RBSnovel of F8, Simple 10120 ., Physical Age under 1 99391 Phenergan J2550 Removal of FB, Comp.. 10121 Nursing Home Emp P/E 00077 Prolixin J2680 Shave Biopsy 113_„ EPSDT 50302 Talwin J3070 Spirometry 940_ 'GYNECOLOGICAL i=XATViS LABORATORY OsteopalhicMar~{wlatlveTrealrnent 989_ BS/BCIKEY/GATE NP (V72.31) SO610 Blood Occult Feces 1 day 82272 Consult 992_ BSBC/KEY/GATE EP (V72:31) S0612 Blood Oxutt Feces 3 day 82270 SLINGS. SpL1NTS. $tIPPLIES: Medicare.- Pelvic (V76.2) 60101 Rngerstidc Glucose 82948 Alrcast Walking Control Splint 1:4350 Medicare -Pap (V76.2) 40091 Hematocnt 85013 Application of Finger Sp1iM 29130 'IMMUNIZATIONS: KOH Skin /Hair / Naii 87220. Application of Short Arm 29125 PPD (V74.1) 86580. Rapid Strep 87880 Fx Care 2! Admin. Fee N. _..) 90471 Urinalysis, Dip 81002 Sling A4565 Admin. Fee (V_.J 90472 Urinalysis, Micro 81000 Splint (Medkare Q4051} A4570 Adult Td (Y06.5) 90714 Untie HCt3 81025 Unnaboot 29580 Comvax (V03.81 + V05.3) 90748 Wet Mount -Microgram 87210 Wrist Code=up Splint L3914 DTaP (V06.1) .90700. C~F(GF PSOCEDURES: _ After Hours 9905_ Flu (V04.8f) 90_ Anoscopy 46600 _ FIu Medicare BS G0008•AO Aspiration Sm. Joint 20605 RETURN APT.. ~I CASH CHECK TODAYS CHARGE w o vlsA ^ M/C TODAYS PAYMENT ~~ ^ Mac ^ DISC TOTAL BALANCE /4-L: DER SPRINGREHAB lndividu~l Solutions for Every Body 1 Tyler Court Suite 200, Carlisle, PA 17015 Phone: (717 245-2341 I.D.#: 23-2427706 Patient Name: o r t 6V • a Service ~[~ PT ' O Phase 3 Received for. $ ^ Payment on Account ^ Co-pay, dates: ~_ ._ _ ; ALEXANDER SPRING RENAB INC i TYLr.R COURT SUITE 200 CARLISL: PA 17013 717.245-23x1 !Serchant 1D: 800001963340 Tere ID: 00215277 Ref q: 0001 Sale ~~~~~~~~~~~~3332 h4SrEfiCaRi~ E>ltrv tiet~od: Slliaed fatal: ~ g3,34 ^ other 09!24!63 10:14;42 I>iv ~; 366601 APRr Code; 66B89B B~arvd; Online Batch: 000096 . ~ - Tota1 Payment of $ ~ # ~ ~ ~ ,: ^ VS D MC ^ Cash ^ Check::# Custorcr Coav ,._.,..._ :~a ~.~ Received by: a . ,; Date + ..... _ ,_ ALEXANDER ALEXANDER SPRING RENAB INC S('RINGREI~AB 1 TYLER COURT SUITE 280 CARLISLE PA 17013 Individual Solutions for Every Body 717-245-2341 1 Tyler Court Suite 200, Carlisle, PA 17015 Mrrchant ID: 800801903390 Teri ID: 08115277 Phone: (717j 245-2341 Ref q: 0001 LD.#: 23-2427706 Patient Name: ~ a l e r s r~ Service: ~l PT ^ Phase 3 .__~AS1ER~i}~- -~DtrY h?t~fA~; ~ 1 ' d _ ~ ~ e Received-.for: - _ total: 3 60 00 Payment. on Account , r+ Co-pay, dates: ' { f Vr" i r 1 ~'~ ~ ~ - 09!18!36 16:64:4 .~~`~• ,~ ,, ,~ }~ . ~~ - ~~ _~..-, In4' ~: 660301 6apr Code; 833008 ^ other 4aarud; 4~1itte Batch; 600054 Custooer Coax i. Total Payment oh $ ~' ~.' ~ { ~ , ^ VSL`7 MC ^ Cash D .Check # .Received b ~~ t r' t, ~ y~ ~ Date: . , PN J. MIRA P.C. ICQL AtRTS BLDG., SUITE 206 MlILSON STREET LISLE, PA 17013 '/2q9-7400 eral ID : 23-21.19655 Tent Itemized Statement 01/01/1993 - 09/09/2008 MELLOTT, JERRY D. PatID: Page: 3 (~) M~ ~•. Printed: 09/09/2008 8:49 AM Guarantor 0@05261-0001 H4 SS AcctID: 5261 ~ - MELLOTT, JERRY D. SSN ; ~ vice Date(s) Patient Name Code Description ~~~~-Qty/Src Charged~ ~~Open~ Prov.--- Place Case# DiagP: 726.2 SYNDROME,IMPINGEMENT SHOULDER ~ ~ ~~ 01/03 MECLOTT, JERRY D. NC NO CHa4GE OFFICE VISIT 1.00 0.00 0.0@ MIRA 'OF DiagP: 726.2 SYNDROME,IMPINGEMENT SHOULDER '02/03 MELLDTT, JERRY D. 99213 OV EST. PAT. LOW-MICD SEV. PROS 1.00 65.00 0.00 MIRA OF 3 DiagP: 726.2 SYNDROME,IMPINGEMENT SHOULDEF 06/03/03 CASH CASH PAYMENT - THANC YOU! Incur -20.00 06/13/03 Al!S!iCP AETNA PAYMENT Insur -26.00 06/13/03 AUSHCA AETi+W ADJUSTMENT Insur -19.@0 17/03 MELLOTT, JERRY D. 99213 OV EST. pAT. LOW-MpD SEV. PROB 1.00 65.@0 0.00 MIRA OF 3 AETNA COPAY DiagP:. 726.2 SYNDROME,IMPINGEMENT SMOULDER 07/28/03 AIfSHCP AETNR PAYMENT Incur -26.00 07/25/03 AUSHCA AETNA ADJUSTMENT Insur -19.00 10/01/03 GASH CASH PAYMENT - THANK YOU! Prsnl -20.00 17/03 MELLOTT, JERRY D. CANCEL APPOINTMENT CANCELLED. 1.00 0.00 0.00 MIRA OF DiagP: 726.2 SYNDROME,IMPINGEMENT SHOULDER 'd~~ MELLOTT JERRY , D. 99202 OV NEW PAT. LOW-hIOD SEV. PROS 1.00 73.00 0.00 MIRA DiagP: 719.44 PAIN JOINT HPND CASH .CASH PAYMENT -THANK YOU! Insur -20.00 AUSHCP AETTy4 pAYMErTf Insur -53.00 MELLOTT, JERRY D. 26750 FX PHALANX DISTAL W/0 MANIP 1.00 203.00 0.00 MIRA DiagP: 516.02 FX PHALANX DISTAL, CL06ED AU~P AETNA PAYMENT Insur -136.00 A11r51iCP AETNA PAYMENT Insur -b.00 PJJ'~!CA AETNA ADJUSTME!T Incur -62.00 MELLOTT, JERRY D. 99213 OV EST. PAT. LOW-NfOD SEV. PROS 1.00 65.@0 30.00 MIRA DiagP: 724.2 PAIN LOW CiACK DiagS: 719.43 PAIN FOREPRM/WRIST 08/22/08 AU~ICP AETNA PAYMENT Insur 08/22/0!3 Al1SIIG4 AETNA P~QJL~STMENT Insur 13)08-0/14/0$ MELLOTT, JERRY D. 73110 XP,AY WRIST COMPLETE MIN. 3 V -2.00 30,00 -26.00 -9.00 0.00 MIRA OF 4 OF q OF 4 OF q AN J. MIRA P.C. iICAL ARTS BLDG.. SUITE 206 ~ WILSON STREET .LISLE, PA 17013 '/249-7400 eral ID : 23-21J.9685 Itemized Statement 0i/mi7i~ - ~/a9/zoos ~ien t MELLOTT, JERRY D. PatID: .Page: 4 Printed: @9/@9i2@08~~~8 50 AM Guarantor 0006261-0001 HA SS AcctIO: 5261 MELLOTT, JERRY D. ~ ; vice Date(s) Patient Name Code Description ~~~~ Qty/Src Charged Open Prov. Place Case# DiagP: 719.43 PAIN FOREARM/WRIST ~~_~ ~~_~ -__~ _______-,_ DiagS: 719.43 PAIN FOREARM/WRIST ~/~/~ Al15HCP AETNA PAYMENT Insur -18.00 08/22/08 AUSHCA AETNA ADJUSTMENT Insur. -12.00 21/08 MELLOTT, JERRY D. 9921q OV EST. PAT. MOD-HI(~-I SEV PROS 1.00 118.00. 0.00 MIRA OF DiagP: 724.2. PAIN LOW EsAgC . @8/21/08 ~ CASH CASH PAYMENT - THAN YOU! Prsnl -2@.00 ~/@2/0$ AUSt~CP AETNA PAYMENT Insur -54.00 09/92/08 AUSHCA AETNA ADJUSTMENT Insur -44.00 29/08 MELLOTT,•JERRY D. DISABIL DISABILITY FORM FEE 1.@0 5.0@ 0.00 MIRA OF DiagP: 724.2 PAIN LU4J BACK 09/02/08 CASH CASH PAYMENT =THANK YQU! ~ Prsnl -5.00 "L9/08 MELLOTT, JERRY 0. 73110 XRAY WRIST COMPLETE MIN. 3 Y 1.00 15.00 15.00 MIRA OF q DiagP: 719.43 PAIN F~tEARM/WRIST 29/08 MELLOTT, JERRY D. 22305 VERTEBRAL PROCE~ FRACTLRE 1.0@ 538.00 538.00 MIRA OF 4 DiagP 805.2. FX VERTEEsR,4 THORACIC (CLOSED) e # 1 AUTHORIZATION Acct# : 0005261-00@1 ccurrence: Admission : Total Disability : Thru Injury/Pregnancy: :onsulted : Discharged: Partial Disability: Thru Employ. Related: N e # : 2 AUTHORIZATION ccurrence: Ansulted e # : 3 AUTHORIZATION ccurrence: onsulted Acct# : 0@05261-0001 Admission Discharged: Acct# 0005261-0001 Admission Discharged: Total Disability Thru Injury/Pregnanty: .Partial Disability: Thru Employ. Related: N Total Disability Thru Injury/Pregnancy: Partial Disability: Thru Employ. Related: N AN J. MIRA P.C. Itemized Statement IICAL ARTS BLOG.. MITE 206 01/01/1993 - 09/09/2 00E Page: 5 wn5av ~TReEr ~ . <<> M~.,.. 'LISLE. PA 17@13 Printed: 09/09/20@8 8:50 AM '/249-7400 feral ID : 23-21.19685 ~ient Guarantor MELLOTT, JERRY D patlD 0005261-000@ HA SS AcctID: 5261 ---~~--w ~M~~ - MELLOTT. JERRY D. SSN , vice Date{s) 'Patient Name ------~--~ Code -~ Description-- ~-~~~ q Src ^Charged ~~- Open Prov~ P1ace~Case# e # : 4 FINGER INJ/AUTH Acct# :0005261-0001 occurrence: 07/21/08 Admission : Total Disability Thru Injury/Pregnancy: Ansulted : Discharged: Partial Disabilit • Thru y• Employ. Related: N rent Balances ~ Totals From 01/@1/1993 Thru 09/@9/20@8 :cunt Balance 583.00 .Charges. w^-_~- 8330.E rn Balance 5.00 Personal Payments : -135.00 •sonal Balance 30.00 Insurance Payments: -3041.54 ;urance Balance : 553.00 Total Payments -3176.54 get Balance 0.00 Adjustments -4570.46 .lection Balance: 0.00. Coll. Payments 0,~ Coll. Adjustments : 0,00 CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT 31308 LdIRA CPT: 99213 -24 OV EST. PAT. LORI'-MOD S J NELLOTT 65.00, 30.00 OF -24 724.2 31508.- AETNA FILED 32208` AETNA PAYNENT- -26..00 32208° AETNA ADJUSTD4ENT -9.00 31908 Da27i7~ CPTs 32305 \7SRTa8A7-L PROCa88 FRP.CTIIAa J lSyyLOTT - 536.00- 30.00 OF 805.2 INSURANCE COPAYblENT DUE 10308 AETNA.FILED 31108. AETNA PAYbIENT -150.00 31108 AETNA ADJU3TD~ENT -358.00 i ~- __ x `! ~S \~~ .. ~ ~. ,. ~ + \~ _ /~ t - - ~~' %•~ k ~ i ,, ~' `r ., r ';' _ l t ,f ~~ :CARD ttemen4 09/19/08 PLEASE INDICATEYOUft ACCOUNT NUMBER WHEN CALLING OUR OFFICE: te: 5261-1-1 CURRENT 30-60 DAYS 60-90 DAYS > 90 DAYS" TOTAL IN3 PENDING ~AYtTfSAM OUNE 30.00 30.00 60.00 0.00 60.00 ~tD INQUIRIES /PAYMENTS TO: I,LZ1tN J. ldIRA, m.D. (?17) 249-7400 220. WILSON STREET YOUR INSURANCE HAS PROCE38ED 3IIITE 206 YOUR CLAW, BALANCE SHOWN. IS CARLI3LE, PA 17013 YOUR RE$PON$ISILITY. PROMPT IRS #a 23-2119685 PAYMENT. IS E7CPECTED. 1485 3971916041496 041496 00001!00001 ~~~ NOTE: Charges and payments not appearing on this statement wilt appear on next month's statement. 9209651 t 02ti Man J. Mira, M.iD. )uane A. Stroup, PA-C .IC. No. MD014478-E .D. No.-23-24.19685 MiRA ORTHOPEDICS MEDlCALARTS BUILDING SU(TE 20E TELEPHONE: 717-249-7400 220 WILSON STfitEET CARLISLE, PA 17013 1 ~/\,-j i~~ +/ X![xxxxxxxx OCTAL SECURITY NO. SEX.. CURRENT OVER 30 OAY5 OVER 60 DAYS OVER 90 DAYS OVER 120 DAYS OVER 150 DAYS TOTAL IN COLLECTIC BIRTHDATE EMPLOYER REF. PHY. TODAYrS DA 'tx (G~OFFICE (,)NURSING HOME ( )CARLISLE REGIONAL MEDICAL CENTER ~,. ( ( )EMERGENCY ROOM ( )SURGERY CENTER ( )DATE ADMITTED { ) -DATE~I~CI~4~i ~l) -~ - NEW PATIENT FEE ESTAB. PATIENT FEE ~ 99201 Mirror ~) 99211 Minor `' 99202 low ~ ~u-~{-) 99212 Law 99203. Mod () 99213 Mod _ 99204 ModJHigh_ () 99214 ModrHigh_ 99205 High ,_ {) 98215 High ) No Show No Charge Office vsR 99058 Office Visit ErrbrgetlCy , 1FFICE CONSULT: DATE FEE :ortfsmatory OrtkxJOtlfer OP 9927_ () 9924_ _ IOSPITAL CARE -INITIAL ) 892_ - IOSPITAL CARE -SUBSEQUENT 98231 Low 99232 Mod _ 99233 High 9923_ Disdtarge Mgt. Day _ :ONSULTATK)N: GATE 9925_ 9925 ~_ CEFERRING PHYSICIAN VJECT/ASPIRATION: DATE 0550 Inj. Tendon Sheath 06_ InjJAsp. Joint ) __ _ VJECTABLES J1030 DapomsdroV40 J1040 Depomedrou80 _ J3301 Kertatog per tOrrtg _ ) J0702 Celestine SURGERY: DATE FEE () 20670 Removal Buried _ Super8dal _ () 20680 Removal Buried _ Deep _ ( ). 29870 Artluoscopy, Knee Dfagrtostic _ () 29877 AMroscopy, Knee Debridentent w/Cartilage Shav)rtg () 29874 y4rtluosoopy, Knee, Removal . Looss. Body _ () 2§881 luthroscopy, Knee, Patties Meniscedomy _ () 25111 Excision. Ganglion. Wrist _ () 26410 Extensor Tandon Repak, Mend Single () 26418 ExtensorTendon.Repak, Finger Simple O 27236 Fx. Femur, Prox.. Neck - i () 27244 Open Treatment InterirochaMeric Fracture _ () 64721 Decorttpression Carpal Tunnel _ () 27130 Arttxoplasty, Total Hip _ () 27447 Arthroplesty, Total Knee () 23412 Repa'r Rotator calf c Aeromioplacty _ O 29688 Artfxoscopy, Knee, ACL () 29848 ANvosoopy, Carpal Tunnel _ Ligament () 29826 Arthrosrnpy Shoulder Decompression O 26055 Triggor Finger Release . - . O - O MEDICAL REPORTS: DATE () Med Report/lefter () Copies Med. Rec. () Review Med. Rec. i () Deposition O /7(- ~ l.(-~-(n ~ l3 ' :-RAY Date of Service _ r 111.tx x.l_n~. Pt /AY!! //~0/A'N~ ~/,L.~7,L(1!,(/J~,p )PPER EXTREMITIES - O 72170 X-ray AP Pelvis ) T3000 X-ray Clavicle, Complete () 73550 X-ray FemurAP 8 Lateral 73030 X-ray Shoulder-Minimum 2 Views () 73560 X-ray Knee AP 8 Lateral ) 73080 ' X-ray Humerus 2 Views (.) 73562 X-ray Knee-Mir)imum 3llews 73070 X-ray Elbow AP 8 Lateral () 73564 X-ray Knee-Complete 73080 X-ray Elbow Complete Minimum 3 Views () 73590 Xtay Tibia 8 Fifwla-AP S Laterel 73090 X-ray For~rm AP 8 Lateral () 73600 X-ray Ankle-AP 8 Lateral 73100 x-ray VwffitAP 6 Lateral () 73610 X-ray Ankle, Complete-Minimum 3 Views 73110 X-ray ylitlst Complete O 731320 X.rdy Foot-AP 8 Lateral 73120 X-ray. Hand 2 Views (} 73630 X-ray Foot-Complete-Minimum 3 Views 73130 X-ray Harxf-Mwixrwm 3 Yews O 73650 X-ray Calcaneus r } 735130 X-ray Toes 73140 X-ray FingeNa-Minimum 2 VM~••- ~ .O1ft/ER EXTREMJFi;lE3 7351n v --•~ ~" -, ~r-ray Spina, Cervical, AP 8 Lateral av Some. Cervical. Minimum 4 Views AL;~N J. lai~tA. M.D. ICD-9 RECALL _ DA oLWEE _ MONTHS _ PF TOTAL BALANCE FORVI(ARD O CHECK CASH PAYMENT ALANCE DUE FRACTURES: DATE ~ V U () 223 Frad. vent. body w/ 8< cast r brace () 23500 Frad. Clavicular w/o Manip: () 23600 Fret. Humeral Neck w!o Manip. (.) 24650 Frad. Radial Head wlo Manip, O 25600 Fred. Cones w/o Manip. O 25605 Frad. Cones w/Manip. () 28622 Frad. Carpal Navicular w/o Manipulation () 28800 Fred. Metacarpal w/o Manip. () 26605 Fred. Metacarpal wlManip. O 2672_ Frad. Phalangeal Proximal _ wlManip. _ w!o Manip. () 27760 Fred. Medial Malleolus, wlo Manipulation () 27786 Fract. Lateral Nlalleolus, wlo Manipulation () 26470 Fred. Metatarsal wro Manip. () 27808 -Fred. Bimalleolar, Cbaed w/o Manipuaalion O 27818 FX Trimalleolar wlManlp. () O _. CASTS 8 SPLINTS: DATE () - O - MISCELLANEOUS: DATE O O ( ) 72052 X-ray Spine, Cervical. Complete-ObliqueslFlexlExt ( ) 72069 X-rav Sphe, Tharamhxnbar, standing (ScoGosis) ( ) 72070 x-ray Spine, Thoracic - AP & Lateral ( ) 72100 X-ray Spine, Lumtxxsacral, AP 8 Lateral ( ) 72110 X-ray Spine, LumDoaaaal, Complete ( ) 72114 X-ray Spine, Lumboaeerel, Comp Ind Bending Vroo .. .•. ,clan J. Mira, M.D. MIRA ORTHOPEDICS luane A. Stroup, PA-C MEDICAL ARTS BUILDING IC No MD014d78-E SUITE 206 TELEPHONE: 717-249-7400 . . 2ZO WILSON STREET ACCOUNT NUMBER D. No.-23-2119685 CARLISLE, PA 17013 5161 \TIENTNAME ADDRESS ~31~ !''IY1r12`~'~'t'1.]Wld h!1?. PHONE MlrLLLi7'~P .Ilr121tY !s. LiAIt17Ni':1~5 Y'A i'/;.i'.~4 J2L'3-t3 ti J'/ SPONSIBLEPARTY ADDRESS 813 MY1;t25'1'L]WN ttL1- PHONE Mr'LLU'1"1' .JlatttiY Ll. I.aA1t1JN!':tt«~ t'A 1'/;3~?4 ti~t3-gg' Ah:'1't+lA ti13.f15ti~lA :21~i1~i'~ S~tl} CLII'AY H(e ~CIAL SECURITY N0. SEX CURRENT OVER 30 DAYS OVER 60 DAYS OVER 90 DAYS OVER 120 DAYS OVER 150 DAYS TOTAL IN COLLECTIC . . _ . - . r3'! wd M ~ 5 . to td fel . tel (d r4. 777th 0 . te~d11 fel , tZIrD (11. (b 0 y5 , ~ dD . (~ YU5't'-I.:IY lrXP. BIRTHDATE EMPLOYER REF.PHY. TODAY'S DA' Y " N UST ~ -iES 13AiLSY Wfi/11/ PLAGE ~ S R h6E( (~,,YOFFfCE ( )NURSING NOME ( )CARLISLE REGIONAL MEDICAL CENTER ~ ~ ~ ,'~ ,-y` t y j'... ( )EMERGENCY ROOM ( )SURGERY CENTER ( )DATE ADMITTED ( )DATE DISCHARGED NEW PATIENT FEE ESTAB. PATIENT FEE SURGERY: DATE _._._ _..__ FEE FRACTURES: DATE FEE ) 99201 Minor - O 99211 Minor t) 20670 Removal Buried _ Superficial O 223_ Fract. van. body w18r cast or brace 99202 Low (j 99212 Low () 20680 Removal Buried - Deep () 23500 _ Fred. Clavicular wro Manip. I 99203 Mod () 99213 Mod - {) 29870 Arthroscopy. Knee Diagnostic () 23600 _ Fract. Humeral Neck wfo Manip. 1 89204 Mod/High- ~ 99214 ModrHigh_ ( j 29877 Arthroscopy, Knee DetNidement O 24650 _ Frad. Radial Head wro Manip. 99205 High (1 89215 High - w/Cartil a Shavin a9 4 () 25600 _ Frad. Cones w/o Manip. - NO Show ( { 1 29874 Arthroscopy, Knee, Removal O 25605 Frad. Cones wrManip. - ) No Charge Office VisA '' ~~: ~ Loose Body O 25622 Frad. Carpal Navicular 1 99058 Once Visit Emergency () ' 29881 Arthroscopy, Knee, Partial Meniscedomy w/o Manipulation - () 25111 Excision, Ganglion, Wrist () 26600 Frad. Metacarpal w/o Manip. - =FtCE CONSULT: DATH FEE () 26410 Extensor Tentlon Repair, () 26805 Frad. Metacarpal w/Manip. mfinnatory Olfice/Other OP Nand Single O 2672_ _ Frad. Phalangeal Proximal 9927_ () 9924_ () 26418 Extensor Tendon Repair, _ _ w/Manip. _ w/o Manip. ~SPITAL CARE -INITIAL Finger Simple () 27760 Frad. Medial Malleolus. 992 () 27236 Fx. Femur, Prox., Neck wro Manipulation - _ _ - O 27244 Open Treatment Intertrochanteric O 27786 Frad. Lateral Malleolus, ~SPtTAL CARE -SUBSEQUENT Fredure wro Manipulattor. - I 99231 Low O 64721 Decompression Carpal Tunnel O 28470 Frad. Metatarsal w/o Manip. - 1 99232 Mod O 27130 Arthroplasty, Total Hip O 27808 Frad. Bimalledar, Closed ) 99233 High _ - O 27447 Arthroplasty, Total Knee w/o Manipulation ) 9923_ Discharge Mgt. Day A _ - (j 23412 Repair Rotator cuff c Acromioplasty O 27878 _ FX Trimalleolar wfManip. - (j 29868 Arthroscopy, Knee, ACL O ~NSULTATION: DATE O 2g84g Arthroscopy. Carpal Tunnel ( ) _ 1 9925_ _ 1 9925 Ligament - _ .PERKING PHYSICIAN A () 29826 Arthroscopy Shoulder CASTS 8 SPLINTS: DATE i ^ - Decompression () - ,_ - JECTIASPIRATION: DATE () 26055 Trigger Fltger Release () - __ - X550 Inj. Tendon Sheath i6_ Inj./Asp. JoMt 1 1 -- - O - - t) - MISCELLANEOUS: DATE JECTABLES MEDICAL REPORTS: DATE 1 Jto30 Dapomedroua0 () Med ReporUletter '- 1 J1040 Depomedrol/80 _ O Copies Med. Rec. ~ __ 1 J3301 Kenalog per t Omg ___ () Review Med. Rec. ~~ ~~ I J0702 Celeslone ~ O Deposition ,• :k AGNOSIS: tCD-8 RECALL: -DAYS WEEKS ~ MONTHS , PR '/1y.4:3 1'Ai-N b'U!tlrA12M/WR15'!' t "lly.4;3 1'AlN r'URlrAtiM/1{lt~l~'1 2 ~`w•..._...TOTAL RAY Date of Service _- ~) ! ? :I R ~ , ; ',~ •' ' ! . 't'.- ~:_ • _ PER EXTREMITIE3 ' 73000 X-ray Clavide, Complete ) 73030 X-ray Shoulder-Minimum 2 Views ) 73060 X-ray Humerus 2 Views 73070 X-ray Elbow AP 8 lateral ) 73080 X-ray Elbow Complete Minimum 3 Views 73090 X•ray Forearm AP & Lateral 1 73100 X-ray Wrist AP & Lateral 1 73110 X-ray Wrist Complete 173120 X-ray Hand 2 Views 173130 X-ray Hand-Minimum 3 Ylews 173140 X-ray Finger/s-Minimum 2 Views )WER EXTREMITIES 173510 X-ray Hip-2 views i 73520 X-ray Hips-Bilateral-2 Views Each Hip & AP Peivi~ 72170 X-ray AP Pelvis ~ '~ .r' ,.,,'~, 73550 X-ray Femur AP $ lateral "-' ; ' >- ~' "` 73560 X-ray Knee AP & Lateral 73562 X-ray Knee-Minimum 3 Views 73564 X-ray Knee-Complete 73590 X-ray Tibia & Fibula-AP 8 Lateral 73600 X-ray Ankle-AP & Lateral 73610 X-ray Ankle, Complete-Minimum 3 Views 73620 X-ray Foot-AP & Lateral } 73630 X-ray Foot-Complete-Minimum 3 Views 73650 X-ray Calcaneus 73660 X-ray Toes SPINE ( ) 72040 X-ray Spine, Cervical AP 8 Lateral i 72050 X-ray $puie Cervical. Minimum 4 Views ~ BALA CE FORWARD CHECK ~ CASH PAYMENT BALANCE DUE ( ) 72052 X-ray Spine, Cervical, Complete-ObliquaslFbx/Exl ( j 72069 X-ray Spine, Thoracokmtbar, Standing (Scoliosis) ( ) 72070 X-ray Sp~e, Thoracic -AP 8 Lateral ( ) 72100 X-ray Spine, Lumbosacrat, AP 8 l.a:aral ( ) 72110 X-ray Spine, Lumtwsacral, Complete ( ) 72114 Xtay Spine, l.umbosacral. Comp Ind Bending View 411an J. Mira, M.D. wane A. Stroup, PA-C _IC. No. MD014478-E _~____...._.~_ .D. No.-23-2119685 ~'' 'ATIENT NAME 1'11::LLL)'!`'1', ,r'„llrt't!tY Jj, Ar:'1'111A .. ~. MIRA ORTHOPEDICS MEDICAL ARTS BUILDING SUITE 206 220 WILSON STREET CARLISLE. PA 17013 111:3 P1Y1rK5'i'U~!!9 t{ll. uAHUri~1ti4~. 1~A titiJiStic;A TELEPHONE: 717-249-7400 ~cb i l i'3:=~ I it18-1385'/ ~1~i1.`.i~ ~~t8 CL:)NAY SOCIAL SECURITY NO. SEX CURRENT OVER 30 DAYS OVER 60 DAYS OVER 90 DAYS OVER 120 DAYS OVER 150 DAYS TOTAL IN COLLECTI( PL]5'P-UN h'XP. BIRTHDATE EMPLOYER .~ REF PH'i TOUAY'SDA N1) '7'N1~;5 _ i__ )3AiL1rY ra8/:~yy ru~~,cyr a~rcvrc _ - ~ (;f/'OFFIGE ( )NURSING HOME ( j CARLISLE REGfON~'.L MEDICAL CENT{:R ;_~,.,~~~'i = ~~ )EMERGENCY ROOM ( )SURGERY CENTER { )DATE AGMiTTEG ___ ( )DATE DISCtiARGED NEW PATIENT FEE ESTAB. PATIENT FEE SURGERY: DATE _________ ___ FEE _ FRACTURES: DATE FEE 39201 Minor {) ggy11 Minor O 20670 Removal Buries - Supe;f~ciai I) 223_ Fran, van. body w1 &~ cast or brace 99202 Low O 99212 Low O 20580 Removal Buried _ Deep ~ O 23500 _ FraCt. Clavicular w/o Marip ) 99203 Mod () ) ~~ ~~ h ig ( 89213 Mod 99214 M O 29870 Arthroscopy, Knee Diagnostic O 23600 . - Fract. Humeral Neck w/o Manip. ) 99205 High () odMigh~ 99215 High (j 29877 Arthroscopy, Knee Debriderttent () 24050 - Fract. Radial Head wto Ma ' n+P - w/Cartllage Shaving (1 25800 Fract. Cones w/o Mario. ) Nd ~~ () 29874 Arthroscopy, Knee. Removal () 25605 _ Fract. Cones w/Manip. I!to Charge Ottree Visit LoD~ BAY ,- () 25622 _ Fract. Carpal Navicular tJ9058 Office Visit Emergenq () 29881 Arthrosoopy, Knee. Partial Meniscedomy w/o Manipulation 25111 Exclsfon. Ganofion. Wrist i) 26600 _ Fraa. Metacarpal wio Manip. rFFICE CONSULT: DATE FEE O 26410 Extensor Tendon Repair, +) 26605 _ Fract. Metacarpal wltr1anil;. onrirmatory Offics/Otlrer OP Hand Single r j 2672 Fract. Phalangeal Proximal 9927_ _ (} 9924_ () 26418 Extensor Tendon Repair. _ _ _ wliAanip. _ wlo Manip. iOSPITAL CARE - INITU~L Finger Slmple t) 27?60 Fract. Medial Malleolus, ) 892_ {) 27236 Fx. Femur. Prox., Neck wlo Manipulation O 27244 Open Treatment Intertrochanteric O 27?86 _ Fract. Lateral Mafleolus, bSPITAL CARE -SUBSEQUENT Fracture -_ wio Manipulation 99231 Low __ () 64721 Deession Carpal Tunnel ! 1 28x70 _ Fract. Metatarsal w/o Marr;c ) 99232 Mod () 27130 ArMuoplasty, Total Hip - t) 27806 _ Frad. Bimalteolar. Gcsac } 99233 Htgh (} 27447 Arlhroplasty, Total Knee ~ w/o Manioulatxm 9923_ Discharge Mgt. Uey O 23412 _ Repak Rotator cuff c Acromioplasty ____ O 27818 _ FX Tnmalleolar wrMart.: ONSULTATION: DATE O 29888 ArBtroscopy, Knee. ACL t) ___,_ ,._ _ _ } 9925_ () 28848 Arthroscopy, Carpal Ttpmel () - _ .--_-- - ) 9825_ Ligament _ EFERRING PHYSICIAN () 2»826 Arthroscopy Shoulder CASTS 8 SPLINTS: GATE Detx>mpression ~ ~ _ JJECTIASPIRATION: DATE )550 I T d St O 26055 _ Trigger Finger Rxleasa - I 1 __ tee - nt. en on th ]6 In)lAsp. Joint t J - PAISCELLANECUS: DATE ---- t 1 _-._.- ---- .____ ----- - IJECTABLES MEDICAL REPORTS: DATE J103o DepomedroV40 () Mad ReporULetter J1040 DepomedroV80 () Copies Med. Rec. ) J3301 Kenabg per tOmg () Review Med. Rec. J0702 Celestone '--' O Dep~ttwn ' ` i Icas '/:24. ~ PAIN Ll]W BACK 1 2 i- __. ~; -RAY Date of Service PPER EXTREMITIES ) 73000 X-ray Clavicle, Complete ] 73030 X-ray Shoulder-Minimwn 2 Views ) 73080 X-ray Humerus 2 Views ) 73070 X-ray Elbow AP & Lateral 73080 X-ray Elbow Complete Minimum 3 Views 73090 X-ray Forearm AP 8 Lateral 73700 X-ray Wt7stAP 6 Lateral ) 73110 X-ray Wrist Complete 73120 X-ray Hand 2 Views ) 73130 X-ray Hand-Minimum 3 Views i 73idu X-rav Finaeris-Minimum 2 Views DWER EXTREMITIES 7351 U X-ray n~p-z viewe 73520 X-ray Hips-Bilateral-2 Views Each Hip 8 AP Petvts 72170 X-ray AP Pelvis 73550 X-ray FemurAP ~ Lateral ) 73560 X-ray Knee AP 8 Lateral 73562 X-ray Knee-Minimum 3 Views 73584 X-ray Knee-Complete ) 73590 X-ray Tibia & Fibula-AP 8 Lateral 73600 X-ray Ankle-AP & Lateral 73610 X-ray Ankle, Complete-Minimum 3 Vie~rrs 73620 X-ray Foot-AP & Lateral ) 7363D X-ray Foot-Complete-Minimum 3 VieLS s ) 73650 X-ray Caicaneus 7 T36E~ X-rar Taes () 720ou r-ray ~,ne.:,e»,u:::. ,>...•.....,. O 72050 X-ray Soule. i:ervtcal LAm~mam a ':~~e•:: s AL,IeATV J MIR,A, M.D. 'RECALL: -DAYS •• . `- WEcKS _ MONTHS roTAL ~ ~.L"tc 6ALANCE FORWARD CHECK '~ CASH PAl`MENT BALANCE DUE t ) 72052 X-ray Spore, Gerricat Complete-Ob6vueslFlex/Ext ~. 1 72069 X-ray Spine, Tho-awivmbar. Standing (Scotiosis) I ~ 720; 0 X-ray Spine, Ttaracic - AF' 8 Laterel 7210 X-ri:r Spire. Lumbos;~:ra.AP 6 ! areral i'r'21*~.? x-revSrnne. Lurrbos~=.cra: Gomciete . c i is n-rsv ~pme. wm:wsexa, ~.ar,.E: ~^~ "-... A BIOIMEf COMPANY P.O. f30X 850-41335 PHILADELPHIA. PA 19178-x335 FAX (8OD) 524-0457 Account Number 2097383 Invoice Number 957672 Service Date 08/21/2008 Balance Due 24.28 10/ 14/2008 **********AUTO**MIXED AADC'170 T12 PI JERRY MILLOTT 813 MYERSTOWN RD GARDNERS PA 173249618 ~~~III~~~I~~Ii~~~l~l~l~~li~l~~~il~~~~~lll~~l~~~~ll~~ll~~l~l~ Please be advised that there appears to be an outstanding balance remaining for orthopedic products provided to you by ALLAN MIRA MD. PRODUCT(S) DISPENSED: DELUXE CANVAS COCKUP SPL. 10" As a courtesy to you we have submitted a claim to AETNA --HMO--. To date, your Insurance Carrier has either paid a portion of, declined or ignored our request for payment. At this time we are asking that you contact your insurance carrier or remit payment of $24.28 at your earliest convenience to clear this amount from your account. If you have any questions please contact us at (800) 254-0072, or you can E-Mail us at customerserviceCebimed.com Thanking you in advance for your prompt attention. I _.-. -- _ _ .. ,.._.... .__. , __~._ ._._. DETACH, HEgE KEEP TOP PORTION FOR YOUR RECORDS., RETURN BOTTOM PORTION WITH YOUR PAYMENT. ,_ . _ _ , _ A00024p5 Account Number 2097383 Invoice Number 957672 Service Date 08/21/2008 Balance Due 24.28 JERRY MILLOTT 813 MYERSTOWN RD GARDNERS PA 17324 Payment Options ^ Check Enclosed -Make payable to EBI ^ Visa ^ MasterCard ^ American Express Account Number Expiration Date Name on Card Signature 00957672 000002428 0 .AN J. MIRA P.C. Itemized Statement QCAL ARTS BLDG., SUITE 206 01!01/1993 _ 09/09I20~9 I wIlS01'I STREET .LISLE, PA 17013 '/249-7400 era! ID : 23-2119685 dent MELLOTT, JERRY D. 813 MYERSTOWN RD. GAR.DNERS, PA 717/528-,7 PatID: Dob: 03/06/1954 17324 Age: 54 Guarantor Page: 1 Printed: 09f09f200~6 8:50 AM 0005261-0001 MR 5S AcctID: 52618DD 8LREAU OF DISABILITY SSnI ; 1171 5. CAMERON ST. ROOM 20e HARRISBURG. PA 171@4 800/932-0701 vice Date(s) Patient Name Code Description ~~ Qty/Src Charg w 0 en Prov. Place __._ __________.__._~___~..._________....~____--~ _.w_~ ~_~...._,.~._ _.....~.. ed__...... p ~._~___ ^Caself '16/03 MELLOTT, JERRY D. MEDREP MEDICAL REPORT PrD/qt RECORDS 1.00 20.98• 0.00 MIRA OF DiagP: 726.2 5YPDROME,IMPINGEMENT SHOULDER x/18/03 C#iECK CHECK PAYMEM - THPJ~K YOU! Prsnl -20.98 'rent Balances bunt Balance rn Balance . •sonal Balance Durance Balance Iget Balance lection Balance: Totals from 01/01/1993 Thru 09/09/200 0.00 Charges . 0.00 Personal Payments 0.00 Insurance Payments: 0.0b Total Payments 0.00 Adjustments . 0.00 Goll. Payments Coll. Adjustments -20.98 0.00 z0.9B -20.98 0.00- 0.0@ 0.00 .AN J, h1I v'1 P.G. iICAL riG:TS i~LC6. , `'~IJITC 20~ ~ WILSOh~ S1"Pir,T .LISLE, PA 1.74i1~ era..]. ID : 13-2115'Sr ient MFLL01'T, JEPJtY D. O1? MYERSTC;'rIN RD, C~R(?PdERS, PA 717/524s-EG~;7 PatID: Doh: 03/4iv/1954 1r':M'..4 Ag~:54 Itemired Statement o~/ei/zr~Q - ~.1/aa/~o~o Ins,ur4~nc~• Company Pa.l.:icy Id Group # I:AFTNI'ti E~3J1S~, z1515Z P.O. a0X 11ZS BLUE BFLI., PA 19412 v.i.c~ Date(s) P,~tient hdame Coda Deseripti.on Page: 1 (c) Mi ,ys Printed: Il/24/24~"~ 4:32 PM Guarantor 0Qr05?51-4~i01 MA SS AcctlD: 5161`T~~,~ M[LLOTT, JC,2RY D. ,~,c,N , 013 MYERSTOWN RD. ('~4RDNEnS, PA 17314 717/52Pw7 Other Info 'Molder I:f1'ective Date(s) ~1Q COPAY H!~; MELLOTT, JERRY D. 4j1/Ga./493 - ___~~ 4/493 MEL!ATT, JEPJiY D. ~~4'11 OV NE4J PAT. L04•d-~ SEV. PR.C~r3 DiagP: 71~.~!<~} PAIhd JOIPJI I-JWD 37/15/Q3 CA`~W GASd~d PAYI~EhdT - '1~IPJt!It YOU! ~'-/454/QO ALJa7•dGP AETNA PAYhICNT ~<1/~ MELLOTT, JERRY D. Z67.50c FX P}lALP1YX DISTAL 4df O MAh?IP Diaa,P: 31G.@z FX r'M11LAPfX DISTAL, GLO:',ED ?~0/494/G?r; AU:d•iCP ACTh•~A PAYh1;7'dT X0/0"~~4''~j Al1rf,CP AETNA PAYMEt~r 4fa/t1~1/aS AU~dCA AETNA A~DauSTMENT !.3/47B MCLLOTT, JE":RY D. ~a7.13 OV CST. PF?T. LtNrd-ham SEV. PItOa Dit~gP: 711.1 PAIN L 04d l? C~ia,S: 71D.43 PAIN Ft~';EARM/4~;IST 10f 11/F.yJ P,LI',al-~P RETNA PP,YMEr~T '~121f(~.3 AIJ~-~A AETPdA ADJUSTNEh~fT ?~/75/GaJ GCP CREDIT CPw?D PAYhiCNT ~3/0c,--0~3/J.1/4Yu' MCLLOTT, JERRY D. 73110 ?{RAY WRIST COMPLEI"E hl.l'N. 'a V DiagP: 719.A3 PAIN FC~CPFM/4J"IST DiGzgS: 7.U.43 PAItd FOREARM/WP,IS7 :~/1z/ae~ A~.J~a-r<;P aETrIA P,~Yr~ar N3/Z1/01 ALp~•ICA AEThdA ADJL~STP1Er~lT ?a./Dt1i MrLLO'fT, JERRY D. 991a.4 OV CST. PAT. h'IOD-HICdi SEV PR(~ DiagP: 714.2 PAIN LOW GaG1C ?~3/Z1/a',S GA4"n•I CAS1-! PAYMEhdT - Ti-iP~ha~ Y~.l! 9~/49z,~r~,~ AU rrP ,aerNa Pf~~YMENT ~?~02~493 AIJr~t-~~A AETi~~~1 A~IJUSTh1EhdT 'gf ~ MuI.LCJTT, JCRR`f 6. DIS:~~6IL DI~~IBILI7Y I'OftM ~~EC Qty/Sre Charged Open Prov, Place Case# 1.4941 73.00 Incur Insur 1.00 14}3,049 Insur Insur Insur 1.490 5.5,00 4).49© MIRA `1Y/, l'f~ -53. ~A49 0.049 h1IRA -13.00 "5.490 -62. 41.00 MIRA OE OF ~ OP ~ Insur Insur Prsnl z.~~ 30.490 Insur Insur a..44~499 tts.~a Prsi~l Insur Insur -zs.¢~ -9.440 -34!.04} 0.00 MIRA -10,4949 -a.1.00 0.00 MIRA -149.49Q -54.00 -44.00 o~ ~ DF a..4ur) 5.00 0,00 MIP,A O .AN J. MIR~~~ P.C. ~ICI~.I_ N:TS [tLCSG. , SULTE 2.+3E; V~IL4~,?I4 ~TfiGk:7 :LISLE, Pl". 17013 '/u4S-7~1@@ feral ID : 2~--2119G~ dent ~ MELI.OTT, JERRY D, Itemized Statement Page: ? A7J01f2,00£y - 11J2~If2tlQ+fl (c) Misys ~r.tnt~d: 11iza/z a:3z ~ GUarantpr 0@05261-@001 I-~ SS AcctlD: 0261 PatID: MELLOTT, JERR'f D. ,~ . vice Bate(s) Patient Narne Code C>Lscription Qty/Src Charged Open Pron. Place C«seii DiagP: 72.2 PAIrd LCd~J eAa~; ___-____._.~_-..~...__ ____.___..___..______ ..__.~._________ 09/07./0c, G~`.;~i GA~,-I PAYMENT - TI-IAd~C Y~J! Prsn1 --5.@@ 7..9f@t'~ MELLOTT, JEP,R`i D. 7311@ XRAY WRIST COMPLETE MI13. 3 V 1.@@ 10.00 @.@@ MIRA OF A DiagN: 719.A3 PAIN FC~4EARh1/I~IS7 ~7,~51/11/@3 A~U`,~!GA AETh~A ADJUSTMENT Insur -10.@0 29/t~ MELLOTT, JE!iRY D. 22305 YERTE6P,AL PROCE~~ FRACTURE 1.00 538.00 0.@@ MIRA OF ~ It~l1;~ICE COPAYMENT DUE L~f.agP: aPf.2 FX VERTEE~~a Tl-IORACIC (CLOaEBa @9/13./08 P,l1~ICP AETNA PAYMENT Insur -15@.@~e3 09/11./&?~3 A~ICA AETNA ADJUSTMENT Insur -358.00 @`!Ir25/rg CCP CREDIT CAI~.D PAYMEh~T Prsnl -x,00 it/~ MELLOTT, JE(LRY D. X213 OV .EST. PAT. LOW-t'q0 SEV. PROt3 1.@@ 65. @@ 30.t~A MIRR OF 4 DiagP: 719.13 PAIN FOREARM/WRIST Q'Gr2'/~ Pi1<~ICP AETtJA PAYMENT Insur -26.@0 7i`3~''2/0u AU`.;f!CA AETNA ADJL~TMENT Insur -9,00 2.5~'t?~; MELLOTT, JERRY D. hC NO Cf~'~GE OFFICE VISIT 1.00 0.00 0,00 MIRA OF ~1 DiagP: 719.23 PAIN F~EARhI/4~RI~t 3@/G'~ MELLOTT, JE!~RY D. CAh~CEL APPOINTMENT CANCELLED 1.@0 O.G~ @.@@ MIRA OF 4 DiagP: 719.A3 PAIN FD;tEAP~hi/4~2IST e ~ : 4 FI!5 !GER Ih!J/RUTH Acctq : 00052tr1-0001 ccurr~.~nce: 07/23./0E3 Admission : Total Dis<~bility : Thru Injury/Pregnancy: onsulted : Discharged: Partial Disability: Thru Emplcy. Related: N rent c;•xlan,~~es )Urli f~~Iarlce . n C~~.lance , yonsU. Bra.I.anc(.~ uranc~; ~alanr.~ get &+lanc~. Iection Oalance: 3@.@Ql 30.00 30.00 Q.P~ 0.00 0.00 Tntuls Fran 07/01/Zt~ Thru 3.1/2A/Zt~g Charges : 1112.,0@ Personal Payments : ~-IP+~~.@@ Insur~:nce Payments: -4.00 Total Payrrr`nts -57~.~ Rdjustments -509,00 Goll. pdyhk~nt5 @.@0 Gol_l.. Ad.iustments : @.00 .Ahl J. h1lRrti P.G. QCAL A~TC GLDG.. MITE 200 } ~'ti~~:~~ ..°~~~~C~ .I.ISLF, PA 17013 '1'~~J~-7~0G'~ oral. IF? : Z3w21.1~~; iei1'C r~~LLarr, Jc4RY Q. 3.13 MYfRSTQ4~q'd PAD. Cdr^,IJhI~S, PA 7].7,15?.G_'Gt~7 PatID: Dob: 03/06f J.954 17:x; ~! Age: 54' ~ vice Gate(s) Patient P~ame •rent Gal,>.nces :punt nal.r.nce n G~'alanc~~ . ~sonal ~~..l.~,ne.:~ ura.nrn 5al.ance : 'g.?h "a]..anc'~'~ . 1F.cti..on ~~.:l~x~ice: Gode Description totals Fran 07/01/Z00? Thru 11f2G/2008 0.@0 Charges . 0.00 Person~~l Payments : 0.00 0.00 Insurance Payments: 0.00 0.00 rntal Payments 0.00 Adjustments . 0.00 Co.J.].. Puy<ir~nts Gol.].. A!ijustinents : Itemized Statement m~loilzm~ - iil~al~0m~ Page: 1 (~~ ylisys F~rinted: llf 24f ~~ Q:32 FT1 Guarantor 00~5zb1-0001 r~ ss E:~.Q2kAU OP DISA~STLIrY 1171 S. CAhiER~! Sr. POQM 200 hPRRI.~l1P~G, PA 1710A 300f"37-.0701 Qty/Src Charged 0.00 0.00 0.00 0.00 0.00 AcctlD: 5261BDL? SSN peen Prov. Plane GaseH .fstd J. hlfR,~~ P.G. JICtIL AST'' "ELI3G. , a1ITE 2.C.:~G ~ 4~a.L,~~G'f~ ;~T~,~t'T ;LISLfT, P~~~ 17p.13 Y/2n1~...7A pvl ie r~~..l, J D : ?..3-21165 i~nC It£(II:iZ.d .~itcltE?fnEnt a~Ioilzc~ae - i~/~al~ MEI.I.OTT, ;TERRY D. PatID: ?.1,3 MYERSTO4~lN RD. Dob: 03J06/1954 GA(~.1~`dE~~S, f'A 17324 Age: 54 717 f 528-~"~7 ~ vise Date(s) Patient Name 15Jc?~ 09'1.5/08 Cade Descri.pta.on AcctID: 5261MR ~~'~ qty/5rc Charged Open Prov. Place Case# MELL.OTT, JEi,RY D. MEDREP MEDICAL REP~tT P~lD/OR REf~F?D5 1.00 82.b0 0.00 MIRA DiagP: 719.43 PAIN FOREARM/WRIST CIP COMMERCIAL I1V.~URpJ•!CE PA11~1ENT Insur -82.60 rent 8al.ance:~ ount u4,la.nce n F~~.l~Anee sonal Eal.ancc~ : urance hkai.ance : get BaJ.ancn l.rct,ion P`alancA: Totals From 07/01/2003 Thru 1ij24/2006 0.0@ Charges . 0.00 Personal Payments 0.00 0.00 Insurance Payments: -62.60 0.00 Total Payments 0.00 Adjustments 0.00 Coll. Payments Call. Adjustments Pz,ge: 1 prin~~~: 9.if 2~~2A~~~ .~:~~ ;~~ Guarantor 0005261-0001 t'FZ ,G P1CS GROUP 300 LAWYERS BUILDIf~G PITTEI3l.6RLL,~I, PA 15219 412/642-4420 62.60 -82.60 0.00 O.Q~ 0.00 OF ~V rW j ~1~/- 9 ,Q ~~ ~ t~s ~ m ~ tm m ^~ ~ ~ c~ x ~~ L -~ ,_, -i N C - C -i X X O ~ O+ x Z ! ~ 3 ' -~' 3 [Il a 0 -rC -< Z n ~k d -i x etc N r-t o-r 9 Z 'L' ~ O y p y a* t!1 -i .t -1 m m --t C'7 N 9C C= N ~ ~c C7 ~ Z 3 S 70 < Q N w z C f s ~ a .. C < .a TO ty C77 t71 ~ ic G ~ m O O o 0 Z ..~. o ~ ~ * ~ ~ C S C~ N S O~ c a . A a ~ .i+. ` { ~ W ~ tJt W £ T C ' ~~ O .~ pc 't` ~ ~ O 1 N O . ~ tb m O~ ~ ~ ~ ~~ _ N ~ N rP7 n 00 .] - O O W -~.. "t1 O _ m Nc ~ ~ m O O n ~ -, - ~ -+ G O b iQ -i tJt ~ S O ~~ ~ Z9 a - ~ 03001 O tT. N .~- O -i -~Q C 00 ~ s O N ~O M z Z ~! m T O :±IT ~ W .. n ~ E n ~ Q ~,.,,,,~ ,~ N W ~ N ~ . N x ~ .+. X K - ~a cn ~ h -, oo .-. c o o ~ ~ ~ ~ w ~ C N Z 3 ~ N ~~' Q -+ . 01 Ip fl O A Q~ 1p .. 8 ` ~ ~ 00 m -v fD 7~ P a c ~ T m a rrt ~ rrt r < - ~ X c~ -+ vt s o w c c x i o ~c x o c m r ~ . z v: a o cn ou ~ s crt ~ x a N te r: ~ N~ m or --~ n ~n N t-. m o ~ ~ .a 6 ~~ ~ m i~ _ ~ z -.r o ~ ~s -+ c -o z H os ~ ~ m ~ ~ ~o a o - ~.-~-. ~ ~n z -+ C S N < Z N = 01 ~ A ~ C7 xt N ? ' O - ~ _ ~` O w pt ' N .a T1 C T Z S -< O a ic ~ 00 W g O •~ ~ a-t O m oo Ri 01 ~ N ~ GL N t f0 ~ N m l7 Z C X C7 0Q ~ -a -. N cn a cn m z ,-+ o ~ ~ .~ - - c~ ao _ c'3 - ,-.~ a a ~ to a cn O C G C7 2 x -1 O, ayc = -~. v a to o = +p ,~ ~ ~ ayc z Z ~ < z -t c aye st cn rn t'~+ 3--. S N f7 ~ N ~ ~ O O O ~iC ~ -t N z a ~; ti o m a. ~ z - ~ ~ ~ 0 310 1o as ayc tx~ o .+ c. , C ~ ~ ..~ o N 10 ~ 1[i a z . £: t'y m to r>a < -i a m a o con ~ ye arc .ra o ;r; .. ~' *-.t c .- c n < • • ~ ~ S oto .~ a = A m ~6 N ^ ~ f V V; N O ~ N . z .L' 1 N v= z ~' 0 s o N' 'P • Tir/ tr c m s~ '+ ~ m ~ 4 .~ ~~~'~O~ ~ 70 ~H ~ =~~og ~ ~ a " ~ H ~~ M CO pN ~ O pp ~2 I ~1 ~1 h 0 Vi j~ 00 t0 po ~9 0~1-p ~ m @ o ~ ~ ~ Q my~mm O ~ ~ caaoc ~aoc ~wo+ c~i ~ ~ ~ ~ v a xoxaa~o.~o~a s~~ '~ r ~ ~ ~ ~ ~ -' n1- ~~ y m . ~ ~ ~ o r - -.~ ' "' '' s ~o~iw ~ q m OZO~ ' (i1j ~ ~c ~ ' °t + a a ~° ~ ~D 1 ~ it '• n wwt ~r i v' s ~.'~ e r o O 00 O O O O O! O-~J ~ /~? ~:~/ C rrJC _ 7- a? 1- 08' ~~/•6~ dX~cddc~.e CAS ~ ~ a3 - 08 ~ is ~ ~~P~~rC,~ ~a ~ vs 7 _ ac~_ D~ g /o• ~~ ~ra~rp.~fy/.N~ CV's. - e~ ~' O ~ ~ OQ Q /Co F~/v~ r,~c/ y 'lG C7 ~- a s' - o ~ ~ ~ ~ ~ ,~o~ rR~~ ><y /,~..~ ~ /- war D~ ~ ~, oo d 1 ca f ~ ~~~ ~.r ~ ~w'~~ ~- _ ~r ~~~ rR~ p ~r j ~, ~,~~ •~ ~- ~ - !! THAk~ vll~; WAL*MART Save money. Live better.~- SUPERCENTER MANAGER ANGELA SIERER ( 717) 258 - 1250 STi 2574COPiI00~3123~TE~V40ITRft 07699 R%x 678103? D3ESQTY 1H q.00 0 SUBTOTAL 4 00 TOTAI 4.00 ~R7~~~~`~' CHANGETDUE 0 00 # ITEMS SOLD 1 TCt 1536 3184 9288 0323 3986 I~I~~N ~ IIYNI ~~~ A. ~:>~ Head for back to school. ~?- our beat-ln-class prices, 08/28/08 .21:02:16 /~~c:tdF~N~ WAL*MARTf Save money. Liv" tter.W SUPERCE"' YE SELL FOR ~ MANAGER ANGELR SIEkcR ( 717) 268 - 1260 ST8 2574 ~'iI0~00E01679NTE1«~40ITR; 07619 RX8 6780969 D38 QTY iH 4.00 0 - CMK SUBTOTAL 4.00 >'~ CASH TTFT.N~D 4.00 ~ecb~ CHANGE DUE p;p~p # ITEMS SOLD 1 TCi 6023 2067 1866 6282 2169 I II All sou need for back t At our best-in-class PrLci~l' 08/28/08 16:18:36 ~" ~SY- n 4' VERIFICATION I verify that the statements made in this ____a ,q-~, ~ ;-yj , aze true and correct. I understand that false statements herein are made subject to the p-enal~ of 18 Pa. C.S. §4904, relating to unsworn falsification to authorities. Dated: CERTIFICATE OF SERVICE AND NOW, this ~R1J day of S ~~, 2010, I, Joseph J. Dixon, Esquire, hereby certify that I have served a true and correct copy of the foregoing Answer to Request for Production of Documents, this day by depositing the same in the United States Mail, first class, postage prepaid, in the Post Office at Harrisburg, Pennsylvania, addressed to: MARTSON DEARDOF WILLIAMS OTTO GILROY & FALLER MARTSON LAW OFFICES GEORGE B. FALLER, Jr., ESQUIRE TEN EAST HIGH STREET CARLISLE, PA 17013 The Law Office of Joseph J. Dixon, Esquire By: J H J. DIXON, ESQUI ATTORNEY ID #28290 126 STATE STREET HARRISBURG, PA 17101 (717) 233-8757 ATTORNEY FOR PLAINTIFF IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Jerry Mellott Peter Briggs RULE 1312-1 10-3581 Plaintiff NO. C C? 3 ?tr? VS ss C . i G 's ?? . 2 tV W ? Defendant 3 . The Petition for Appointment of Arbitrators shall be substantially *QR tO Following form: _< a PETITION FOR APPOINTMENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: George B. Faller, Jr., Esquire , counsel for the Tigil*ff/defendant in the above action (or actions), respectfully represents that: 1. The above-captioned action (or actions) is (are) at issue. The claim of plaintiff in the action is $ within arbitration limits The counterclaim of the defendant in the action is N/A The following attorneys are interested in the case(s) as counsel or are otherwise disqualified to sit as arbitrators: George B. Faller, Jr., Esquire, MARTSON LAW OFFICES Joseph J. Dixon, Esquire WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to whom the case shall be submitted. Respe ly s ' ed rge B. Fal , Jr. ORDER OF COURT rrt? O? C) M CXf-aori- Oq 7 C*R. -*G ktz- ,Z(13 L' lb AND NOW, L , 20(x/ , in consideration ofth foregoing petition, Esq., and 7 J.?-/?.I CL ?? lrhl Esq., and ,.// /,u - Esq., are appointed arbitrators in the2bovsf ra captioned action (or actions) as prayed for. ryl CO M rn x ? -*x r- 0n; By the Court , tp c.C G -1o Kevi A. Hess, P.J. G _J1 .; CJ (_ Fi?J /??16Lr A4eL- -?- Plaintiff In The Court of Common Pleas of Cumberland County, Pennsylvania No. 10 - -!- Defendant Oath Civil Action - Law. We do solemnly swear (or affirm) that we will support,, obey.and defend the Constitution of the United States and the Constitution of this Commonwealth and`that we will discharge the duties of our office w'th fidelity. ) S ianature SS igna J 19 LOWeI L K - Wks Name (Chairman) Gafg, ihYvwc alck Law Firm c GUJSe t PC- t Address 9atc, f o u >joe- M43 City, Zip Md iSS? F L?l? lle?tr Name ?Y1 ?1? n? M ?l =C- Law Firm q56 wainuf ?uNum Qd Address SU1'C ?tf?U? I?SI PR ??oIS City, Zip Award NeCA? Name d I c Law m Address 10 L City, Zip We, the undersigned arbitrators, having been duly appointed and sworn (or affirmed), make the following award: (Note: If damages for delay are awarded, they shall be separately stated.) D p ! & 1 A:cJt, rned i CCL( a nG? b S= -fw ?/Un?.,' ft? c Date of Hearing: 12 Date of Award: ?- . Arbitrator, dissents. (Insert name if applicable.) Notice of F Now, the D/-<A day of 'OR;, -3 20 // , at l6? :5'/ , h .M., the above award was entered upon the docket and notice thereof given by mail to the parties or their attorneys. Arbitrators' compensation to be aid upon appeal Prothonotary 3-,50 .0d Deputy By: OUF Y([ _1 HE f RO'yf??' ? i.}{?`??.#?ly??(-?{?TH c?+???{ ?- p${yin{?: Y _., O{tl lMO?I y ?lv? P AND CUIJNI)' 'U%?YLVAWIA e 13 . ka lre,,r? L d p t`"S rtt - ,lew L f I OF THE pRQ OF NO TAA 14 UEB `3 Am l/: 06 CUP1BERLq D PENNSYLVA D NIA, JERRY MELLOTT, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. No. 10-3581 PETER BRIGGS, CIVIL ACTION - LAW Defendants JURY TRIAL DEMANDED PRAECIPE TO SETTLE, DISCONTINUE AND END Please mark the above-captioned Writ settled, discontinued and ended. Respectfully submitted, By: - 4!?_ ?-- Date: --7- Joseph J . Dixon quire , Attorney No. 28290 126 Staie S reet Harrisburg, PA 17101 (717) 236-8515 Attorney for the Plaintiff CERTIFICATE OF SERVICE 1. Nichole L. Myers, an authorized agent for Martson Deardorff Williams Otto Gilroy & Faller, hereby certify that a copy of the foregoing Praecipe was served this date by depositing same in the Post Office at Carlisle, PA, first class mail, postage prepaid, addressed as follows: George B. Faller, Jr., Esquire MARTSON LAW OFFICES Ten East High Street Carlisle, PA 17013 Joseph J. Dixon, Esquire 126 State Street Harrisburg, PA 17101 MARTSON LAW OFFICES By - Nichole L. Myers Ten East High Street Carlisle, PA 17013 (717) 243-3341 Dated: 2/3/12