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z p, Christina L. Bradley, Esquire FREEBURN & HAMILTON ID No. 89107 4415 North Front Street Harrisburg PA 17110 (717) 671-1955 christinab@pa-injurylawyer. com 0~ i,F~~;c`~}r~ NOTAft Y 2Gf~ OCT 20 P~ 12~ C6 ~~J~~9S~t~~A~' ~[; OUNTY Attorn~~~~~1l~~~f,~S, ~ A AVERY SAINT BON, a minor, by GREGORY SAINT BON AND CHRISLEI'~1E SAINT BON, GREGORY SAINT BON in his own right, and CHRISLEI'~TE SAINT BON in her own right, Plaintiffs v. FIRST CHURCH OF GOD, Defendants IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No. la - ColoBa Civ~l~~ PETITION FOR APPROVAL OF MINOR'S SETTLEMENT AND NOW, come Plaintiffs, Avery Saint Bon, a minor, by Gregory and Chrislene Saint Bon, his natural parents and guardians, and Gregory and Chrislene Saint Bon in their own right, by their attorneys, Freeburn 8v Hamilton, PC, and petition this Court for approval of minor's settlement. I. P TIES 1. Plaintiff, Avery Saint Bon, is a minor, born December 25, 2007, who resides at 28 East Locust Street, Mechanicsburg, Cumberland County, Pennsylvania 17055. 2. Plaintiffs, Gregory Saint Bon and Chrislene Saint Bon, husband and wife, are Avery Saint Bon's natural parents and guardians who reside at 28 East Locust Street, Mechanicsburg, Cumberland County, Pennsylvania 17055. ~9a. oo pn ~nY c~ l I83a 2# a ~l9 q~s . '~ 3. At all times relevant hereto, Gregory and Chrislene Saint Bon have had and continue to have primary physical custody of Avery Saint Bon and are authorized to bring this litigation pursuant to Pa. R.C.P. No. 2228(b). 4. Gregory Saint Bon, Chrislene Saint Bon and Avery Saint Bon are represented in this matter by Freeburn 8v Hamilton, PC based upon a contingent fee agreement of 25% of the gross settlement proceeds, plus expenses. A true and correct copy of the Attorney's Agreement is attached hereto as Exhibit "A." 5. Defendant, First Church of God, is a Pennsylvania non-profit organization, with a principal place of business located at 28 East Main Street, Mechanicsburg, Cumberland County, Pennsylvania. II. FA TS 6. The facts and occurrences hereinafter related took place on or about July 27, 2009, at approximately 10:10 a.m. at Finkenbinder Park, Green Street, Mechanicsburg, Cumberland County, Pennsylvania. 7. At or about that time and place, Plaintiff, Avery Saint Bon, was enrolled in the Church of God Learning and Play Center, and under the supervision and control of Church of God Learning and Play Center, through its agents and employees who were 'acting within the scope and course of their relationships and employment by Defendant, and in furtherance of Defendant's business.. 8. At or about that time and place, Plaintiff, Avery Saint Bon was climbing the ladder of a sliding board at Finkenbinder Park. 9. At or about that time place, Plaintiff, Avery Saint Bon fell from the sliding board landing on his left wrist. A copy of the Incident Report Form is attached hereto as Exhibit B. 2 III. INJURIES 10. By reason of the aforesaid incident, Plaintiff, Avery Saint Bon, sustained an injury to his left wrist/arm in the nature of a left wrist fracture. 11. Plaintiff, Avery Saint Bon, received medical treatment at Heritage Pediatrics, Orthopaedic 8v Spine Specialists and Seidle Hospital following the incident. Copies of Avery Saint Bon's medical records are attached hereto as Exhibit "C". 12. Plaintiff, Avery Saint Bon, was last examined at Orthopaedic & Spine Specialists for his injuries related to this incident on August 26, 2009. A copy of the treatment note from Orthopaedic 8v Spine Specialists dated August 26, 2009, is attached hereto as Exhibit "D". IV. INSURANCE COVERAGE 13. At the time of the incident, Defendant was insured under a policy of insurance issued by Cincinnati Insurance Company. V. MEDICAL EXPENSES 14. The medical charges for Avery Saint Bon's medical treatment are set forth below, with copies of the medical bills attached as Exhibit "E": a. Pinnacle Health $ 244.00 b. Heritage Pediatrics $ 54.00 c. Orthopaedic 8v Spine Specialists $ 849.00 d. Quantum Imaging $ 38.00 Total $ 1,185.00 15. Plaintiff, Avery Saint Bon is covered under private health insurance through I$ighmark Blue Shield. Highmark Blue Shield did not pay any of the medical bills for Avery Saint Bon due to deductible on the policy. Insurance contractual adjustments were made to the medical bills. 3 16. Plaintiffs, Gregory and Christlene Saint Bon, have paid the following sums not covered under the Highmark Blue Shield health insurance policy: a. Pinnacle Health $ 20.00 b. Heritage Pediatrics $ 21.00 c. Orthopaedic 8v Spine Specialists $ 29.00 Total $ 70.00 Copies of the medical bills reflecting the co-payments by Gregory and Christlene Saint Bon are attached hereto as part of Exhibit "E". 17. Plaintiffs, Gregory Saint Bon and Christlene Saint Bon, are responsible for the following outstanding medical bills not covered by Highmark Blue Shield: a. Pinnacle Health $ 145.17 b. Orthopaedic 8v Spine Specialists $ 669.16 c. Quantum Imaging $ 15.00 Total $ 829.33 Copies of the outstanding medical bills are attached hereto as part of Exhibit "E". VI. PRpCEDURAL HISTORY 18. No suit has yet been filed in this matter. VII. SE~'TLEMENT 19. Cincinnati Insurance, on behalf of Defendant, has offered to make a lump sum payment of $6,000.00 to settle this matter. A true and correct copy of the Proposed Parents-Guardian Release and Indemnity Agreement is attached hereto as Exhibit "F"". 4 20. Plaintiffs, Gregory and Christlene Saint Bon, have reviewed the proposed Release offered by Cincinnati Insurance with their attorneys and are satisfied that they understand all of its terms and the consequences of signing said Release. 21. Freeburn and Hamilton have advanced the expenses associated with the litigation in the matter in the amount of $125.08. In a good faith effort to resolve this matter, Freeburn 8v Hamilton has agreed to waive reimbursement of its litigation expenses in this matter. 22. The settlement proceeds would be distributed as follows: a. Total Settlement $6,000.00 b. Attorneys Fee 25% - $1,500.00 c. Unpaid Medical Bills - Pinnacle Health $ 145.17 -Orthopaedic 8v Spine Specialists $ 669.16 -Quantum Imaging $ 15.00 d. Gregory and Christlene Saint Bon for out-of-pocket medical bills/expenses $ 70.00 e. Net to Avery Saint Bon, a minor $ 3,600.67 to be deposited in a savings account in the name of Plaintiff Avery Saint Bon with PNC Bank. A hold would be placed on the account so that no transfers or withdrawals could be made from the account until December 25, 2025, when Avery Saint Bon reaches the age of 18. 23. Plaintiffs believe that this settlement is in the best interest of Avery Saint Bon because it avoids the risk of obtaining a lesser recovery or no recovery at all, and avoids further expense and delay of litigation and pays Plaintiffs' outstanding medical bills. 5 WHEREFORE, Petitioners Gregory and Christlene Saint Bon hereby request that this Honorable Court enter an Order: a. Approving the full and final settlement of this action; b. Authorizing Gregory and Christlene Saint Bon to sign all documents necessary to accomplish the settlement, including but not limited to the Release, individually and as parents and natural guardians of Avery, a minor, and all checks; c. Approving the distribution of the settlement proceeds as set forth herein, including the payment of counsel fees; d. Directing payment of the net funds be made to a custodial savings account to be opened in the name of Avery Saint Bon with PNC Bank; e. Directing Petitioner to file a Praecipe with the Orphans Court of Cumberland County marking this matter settled and discontinued once the $6,000.00 payment has been received and the savings account opened and funds disbursed; and f. Staying all proceedings meanwhile. Respectfully Submitted, FREEBURN 8s HAMILTON, PC By: Christina L. Bradley, Esqui~e I.D. No. 89107 4415 North Front Street Harrisburg PA 17110 (717) 671-1955 Date: 10/' 19/ 10 Counsel for Plaintiff 6 jr ~i~ X~ FREEBORN & HAMILTON, PC ATTORNEY'S AGREEMENT THIS AGREEMENT entered into this _~d*' day of August, 2009, by and between FREEBORN ~ HAMILTON, PC, Attorneys-at-Law (hereinafter referred to as "Attomey") and GREGORY SAINT BON and CHRISLENE SAINT BON, INDIVIDUALLY AND ON BEHALF OF AVERY SAINT BON, THEIR MINOR SON, his successors and assigns (hereinafter referred to as "Client"). WITNESSETH: That Attomey, for the consideration hereinafter stipulated, has undertaken and does hereby undertake and agree with Client(s) to act as legal counsel in negotiating settlement of third party claims and/or claims for uninsured or underinsured motorist benefits, and if the same is not effected, in bringing, conducting and prosecuting actions, including but not limited to, actions for uninsured and Underinsured motorist benefits against all parties that they determine may be liable for damages as a result of the personal injuries which occurred on or about 7/27/09 ATTORNEY FEES: In consideration for services so rendered by Attorney, it is hereby agreed by and between the parties hereto that Attomey shall be compensated as follows: TWENTY-FIVE PERCENT (25%) of gross recovery if your case is settled before papers are filed with the court to list it for trial. "Gross recovery" shall mean the full amount of settlement proceeds or the full amount of verdict, including any pre judgment interest, without reduction for expenses or costs advanced or incurred. THIRTY-THREE AND ONE-THIRD PERCENT (33 1/3%) of gross recovery after papers are filed with the court to list it for trial. If the proceeding is not the type of proceeding where papers are filed with the court to list it for trial, then commencement of trial is when the hearing begins. If Client(s) receive, via settlement or litigation, a dollar amount that includes reimbursement for Attorneys' fees, compensation of Attorneys shall be based on the percentages as set forth above. Any award of attorneys' fees that is required by law or order of Court to be computed on an hourly basis shall be billed at Two Hundred and Fifty ($250.00) Dollars per hour for Attomeys and Ninety Five ($95.00) per hour for law clerks and paralegals. If you enter into a structured settlement agreement, our fee will be based on the applicable percentage determined as above, applied to the sum of any cash paid in settlement plus the present cash value of the structured portion of the settlement, and payable in full from the cash portion of the settlement. If any additional work is required by us after resolution of the case, either as consultants, witnesses ~r otherwise, we will be compensated for such work at our regular hourly rates, and for costs incurred. ATTORNEIi"S LIEN:. Attorney shall have a lien for attorneys' fees and for costs advanced and expenses incurred on any sum or sums recovered, whether by settlement or judgment. Should this agreement be breached or otherwise terminated by Client prior to the resolution of the claim, Client shall reimburse Attorney for any costs advanced by Attorney up to the time of the breach or termination, and Attorney shall have a lien on any sum or sums finally recovered in the amount of TWENTY-FIVE PERCENT (25%) of any settlement offer in existence at the time of Client's breach or termination. In order to secure payment of the said fee, Client hereby assigns the said sum to Attorney out of the proceeds finally recovered. Should Attorney discharge Client or withdraw on the grounds set forth below, Client shall reimburse Attorney for any costs advanced by Attorney up to the time of discharge or withdrawal,. and Attomey shall have a lien on any sum or sums finally recovered in -the amount of TWENTY-FIVE PERCENT (25%) of any offer of settlement in existence at the time of discharge or withdrawal. In order to secure payment of the said fee, Client hereby assigns the said sum to Attorney out of the proceeds finally recovered. EXPENSES: Any necessary and reasonable costs advanced by Attorney in the preparation and presentation of Client's claim, and all expenses attendant thereto, shall be reimbursed from the proceeds of any recovery. Except as set forth above with respect termination of this agreement prior to resolution of the case, Client shall have no obligation to reimburse Attomey for such expenses if no recovery is obtained. LEGAL REPRESENTATION It is understood that FREEBURN & HAMILTON represents Client with respect to third parry claims and/or underinsured or uninsured motorist claims only, and that FREEBURN & HAMILTON does not represent Client with respect to any other matter including but not limited to property damage claims, insurance claims, claims for governmental benefits such as social security benefits, or workers' compensation claims, unless and until a separate written agreement is signed by both Client and FREEBURN & HAMILTON, whereby Freebum 8 Hamilton agrees to represent Client on such other matter. In particular, Client understands and agrees that discussion of other legal matters with any representative of FREEBURN 8 HAMILTON, including it's attorneys , or staff or statements made by staff or attorneys of FREEBURN & HAMILTON regarding other legal matters do not constitute an agreement by FREEBURN & HAMILTON to represent Client concerning such other legal matter or that FREEBURN & HAMILTON will take any action to protect Client's rights with respect to such other legal matters. This provision cannot be modified by oral statements or by conduct on the part of FREEBURN 8~ HAMILTON. Client also understands that other legal matters have time limits withi~ which suit must be brought or actions taken, and that the failure to file suit or take such actin s will result in the loss of Client's rights. Client understands and agrees that FREEBURN 8~ HAMILTON will not file suit or take any action to protect Client's rights on any other legal matter unless and until a separate written agreement is signed by both Client and FREEBU & HAMILTON, whereby FREEBURN & HAMILTON agrees to represent Client on such other legal matter. 2 We will try to keep you currently informed of the status and progress of the case, but if at any time you have questions or concerns about the case, please feel free to contact us. We will furnish you with copies of pertinent documents and correspondence in a reasonably timely manner. You agree to keep us currently informed as to your condition and any pertinent developments that come to your attention. The decision to file suit and to list for trial shall be made by you in consultation with us. We will make a reasonable effort to retain significant papers in the file for a reasonable period after the conclusion of the matter. All of our work product will be owned and retained by us. Original documents and other tangible things furnished to us by you will be returned to you at your request at the end or our work and upon payment of any sums due us, unless such items are consumed in the course of our work. Legal representation contemplated herein does not include appeals or post trial motions, but is limited to work up to a verdict or award. We shall have the right but not the obligation, to prosecute or defend any appeals or post trial motions or both that we, in our sole discretion, deem expedient, economical or advisable, or to decline to do so in which event the representation provided for herein shall be ended. SETTLEMENT PROVISIONS: Client(s) will not settle, adjust or compromise the above claim, or any proceedings in connection therewith, without the advice and written consent of Attomey. Client(s) further agree to consider seriously any recommendation for settlement made by Attomey and not to unreasonably withhold consent to such settlement. DISCHARGE OR WITHDRAWAL: In the event that Attorney subsequently determines that the claim or suit lacks merit, or Client(s) unreasonably withhold consent to any bona fide settlement recommendation made by Attorney, or Client(s) refuse or fail to cooperate with Attorney, or Client(s) conceal or misrepresent facts regarding the above claim, or Client(s) commit a breach of this Agreement, Attorney shall have the right to terminate his services upon giving reasonable notice to Client(s). MISCELLI~,NEOUS: Client(s) understand, acknowledge and agree that Attorney does not guarantee the outcome or eventual result of the above claim. ~LIENT'S OBLIGATION TO PROVIDE INFORMATION TO ATTORNEYS Client agrees to promptly notify attorney with respect to any information that relates to Clients' claim such as changes in Client's medical treatment or employment, changes in physical condition, and any witnesses, documents or other things that might be relevant to Clients' claim. In addition, Client has advised Attorney that Client has has not filed for bankruptcy and agrees to immediately notify attorney if Client should file for bankruptcy. In addition, Client has advised Attorney that Client has has not received SSI or public assistance benefits, and agrees to immediately notify attorney if Client should receive SSI or public assistance benefits. In addition, Client has advised Attorney of any potential liens that could be asserted against any recovery, including those listed below, and agrees to immediately notify Attorney if this information should change or if Client becomes aware of the possibility of any liens: YES NO 1. Child or spousal support obligations? 2. Medicare benefits? 3. Veterans benefits? 4. Public Assistance benefits of any kind? 5. Private health insurance? 6. HMO, PPO or other health benefits? 7. Disability benefits? 8. Workers' Compensation benefits? 9. Unpaid medical bills? 10. Other possible claims against recovery? Client Initials ~ ~' Client has does not have medical coverage in addition to automobile insurance. If so, client has _ has not provided attorney with medical coverage information including a copy of card. Client agrees to provide information about all medical coverage to his/her medical providers at the time of medical service. List each and every motor vehicle (including motorcycles) owned by or furnished for the use of anyone who lived in your household at the time of the accident. Vehicle Registered Owner Relationship Ins. Co & Policy No Client Initials ~ 4 IN WITNESS WHEREOF, the parties hereto, intending to be legally bound, have hereunto set their hands and seals of this Agreement, in execution thereof, the day and year first above written. FREEBORN 8~ HAMILTON, PC By: Christina L. Bradley, Esq e 4415 North Front Street Harrisburg, PA 17110 (717) 671-1955 itn s i Gregory aint Bon >~ Chrislene Saint Bon 5 ` r/ ~~ ,~ // ~~ {''~ ~~ I~vCIDEIVT REi'ORT FOr1..~ ' S5 PA CODE CHAPTERS 3270.20 & .182 (7); 3280.19 & .182 (7); 3290.17 & .182 (7) THIS FORM CAN BE USED TO MEET THE REPORTING REQUIREMENTS FOR ACCIDENT, INJURY, ILLNESS, HOSPITALIZATION, EMERGENCY ROOM TREATMENT, DEATH OR FIRE NAME OF FACILITY ~" ' ~ - TELEPHONE NUMBER - ~48'B' t r r~ - c ~ p FACILITY ADDREStS_ ~ ~' ~ t f_ !'~. ~~ I ~0~~ NAME F H ~~ ' SE~ ^ F BIR~ TE _ ~1 CHIL ADDRESS ' ~ ~ ~ L,/ , ME OF PARENT ~ NUMBER T EPHON ~v ~ ( `~ PARFAI DDRESS ,V\ PARENT NOTIFIED BY - TIME NOTED ~ AM U M u -~ S~R~ ~ v~ i'~ S~~S ~'~ IUD ~~~ Li ~~~ FIR$'T--AID GIVEN BY FACILITY _ ~~ NAME OF LOCALAUTH RiTY NOTIFIED OF INCID TELEPHONE NUMBER ADDRESS TREATMENT PROVIDF~D BY TELEPHONE NUMBER.. ADDRESS ~- ~~ ~~ ~, NATURE OF TREATMENT `~ ~~ C'~ REQUIRED FOLLOW-UP ` We SIGNATU E OF A. ITY RSON OMPLETI RM TITLE AT i t ATURE F PA DA • • • • ~ ~ • • NOTIFY R GIONAL DAY CARE OFFICE WITHIN 24 HOURS DATE of NOTIFICATION TIME of NOTIFICATION NAME OF THE REGIONAL dAY CARE STAFF PERSON NOTIFIED MAIL OR DELIVER WRITTEN REPORT TO REGIONAL OFFICE WITHIN 72 HOURS ~~~ ~ Q t.~.~,u.~w ~..- ~ ~ - off. SI RE OF FRCI TY PERSON WHO MADE THE NOTIFICATION TITLE WHITE-PARENT COPY !CANARY-FACILITY COPY 1 PINK-CHILDS FILE COPY (GOLD-REGION COPY CY 866 8/( ALL-STAY E''LEGAL 800-222-0510 ED11 FECVCLED 1 ~/ 1 l 'T C ~, x~ RICHARD E. FREEBURN STEPHEN A. SCHNEIDER LAWRENCE F. BARONE CHRISTINA L. BRADLEY ROBERT D. HAMILTON (1967-2005) Christina L. Bradley Writer's Extension: 9 ChristinaB@pa-injurylawyer. com Attn: Patient Accounts Heritage Pediatrics 3720 Market Street Camp Hill, PA 17011 October 26, 2009 ~~~~~~ I ~~~.~s ~ t!. C~Ei ~ ~; RE: Avery Saint Bon BY:____________________ SS#: 155-17-5120 DOB: 12/25/2007 Date, of Accident;- 7/27/09 Dear Madam or Sir: \~ f~~~~~~ Our firm represents Avery Saint Bon in connection. with injuries he suffered on July 27, 2009. I would appreciate it if you would please provide me with a billing statement of your accident-related charges and payments made to date: So that you know that our office is authorized to receive this information, I have enclosed a properly executed medical authorization. Please bill our office directly for any copying charges you may incur with regard to this request. Your cooperation in this matter is greatly appreciated. Ve~,v truly yours, d' Chrstina L: Bradley. CLB/jad Enclosure c: Mr. -and Mrs. Gregory Saint Bon 4415 North Front Street, Harrisburg PA 17110 www. pa-inj urylawyer. com (717) 671-1955 • -Fax: (717) 671-1960 • (800) 303-8005 Your Personal InJury and Workers` Compensation Attorneys AUTHORIZATION TO DISCLOSE HEALTH INFORMATION Patient Name: Avery Saint Bon Date of Birth: 12 / 25 / 06 Address: 28 East Locust Street, Mechanicsburg, PA 17055 Social Security No.: 155-17-5120 We hereby authorize ~e r ~ to release health information •.c S our minor daughter, to: FREEBURN & HAMILTON, 4415 North Front Street, Harrisburg PA 17110 The information to be disclosed to and used by the above for the following purpose: Litigation This authorization is for the following dates of treatment: FROM Anv and all TO Anv and all Information disclosed: x Discharge summary x Complete chart x Doctor's orders x ER and outpatient reports x X-ray reports x Nurses' notes x History and physical x Lab reports x Psych records x Operative and pathology repts x Progress notes x Billing Info x Alcohol and drug treatment notes x Consult reports x PT records x Ambulance, EMS, ELS or ALS records x Opinions regarding my physical or mental condition Other We understand that the information in this health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. We understand that we have the right to revoke this authorization at any time. We understand that if we revoke this authorization we must do so in writing. We understand that the revocation will not apply to information that has akeady been released in response to this authorization. Unless otherwise revoked, this authorization will expire in 90 days. We understand that authorizing the disclosure of this health information is voluntary. We can refuse to sign this authorization. We need not sign this form in order to assure treatment. We understand we may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. We understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If we have questions about disclosure of this health information, we can contact Freeburn 8v Hamilton. Permission is hereby granted to Freeburn 8v Hamilton to photocopy or scan this authorization and any photocapy thereof shall be as by us an original. o ~at~ ~9 DATE W' DATE GREG6R~'SAINT BON, on behalf of Avery Saint Bon ~~ ~ ~~ CHRISLENE SAINT BON, on behalf of Avery Saint Bon Provider History: Chief Complaint •-~ Vitals: Age:aCU ~- ! ~ ~ Wt: (~-' Ht: BMI: HC: HR: RR: Temp: BP: / Visual Acuity: Far R 20/ L 20/ Near R 20/ L 20/ Corrected Uncorrected .Color: Nl Abnl LE9d d~7PRt7(IOTAira• T1nnP ~CPP h~rlrl ~~~ TB risk questionnaire Done (see back) Developmental eval: _ Done (see sheet on left side of chart) Physical Exam: /= done ,~° General Aoaeazance (well or ill appeazing over/under wei t) ~ Z Head (anterior fontanelle facies symmetry size) E yes (pupils red reflex fundi movement conjunctiva Ears (canal TM external hearing cerumen) Nose (septum turbinates) Throat (pharynx tonsils teeth gums tongue) Neck (masses nodes thyroid) Chest (s mmetry, breasts accessory muscles retractions) Lunes (auscultation resp rate) Heart (rhythm murmur rate femoral pulses) Abdomen (spleen, liver. masses bowel sounds appendix bladder) Genitalia (male testes female anal) Pelvic (PAP yes/no, hymen labia vagina ovaries cervix uterus) Extremities (RU. LU. RL LL ROM hips gait strength tone) Neurolo¢ical (DTR's cranial nerves motor sensory balance) Back (scoliosis kidney~ercussion, lordosos, kyphosisl Skin moles rashes color erfusion birthmazks h dration Assessment: ~~ ~-- Medications: Immunizations: DaPT/Polio/Hep B Rotavirus PneumoC Influe~pza Meningococcal HPV Tdap Labs: Hgb Lead(.,lu U/A (dip) U/A (micro) Urin Stool Cult Stoo10 Preg Test Bili (tot & dir) _... . Provider Signature: Hib Hep A MMR/Varivax DaPT IPV MMR Varicella Hep B PPD e culture RST Hemoccult Tympanogram Audiogram CBC/diff Blood cult F.SR Comp. Met. Prof Trig/Chol Return: days, wks, mo, yr, prn To do next visit: i G Patient Name: L~~q ~ i /'! ~-~ U~ D.O.B.: ~2-~s -U~- Date of Visit• 'v~ ~ ~' Heritage Pediatrics Office Evaluation Sheet Page ~~~~~r~ Specific Fikdmgs "'Y'a' 0 C~ „~ ~~ ,gyp ~ - I wS i ~~ v~"~ ® d~ / - Tanner _ ;~~./~ ~~' (~ -Tanner _ ~~ Patient 1[nstraclions: _ ~ U S S a C!n kt.~' C,6.~~ Acetaminophen: mg q _hrs Dose now? Y N Ibuprofen: mg q _hrs Dose now? Y N !/"L'!/LUU~ ~:L;S:~V YM -U4VV rru~ i yr 1 PINNACLEHEALTH Syste. Radi. gy Imaging Report MR#: SSN: ADM: DOB: BED: PTCLASS: 910049711 910049711 000100025042 12/25/2006 AGE: 2Y MMS- O FOS NAME: SAINTBON, AVERY 28 E LOCUST ST MECHANICSBURG, PA 17055 ORD DR: STAGG, RICHARD D ORD#: 90001 ATT DR: STAGG, RICHARD D PCP: UNKNOWN, DR REASON: pain injury COMMENTS: ~`"*Final Report"** FREDRICKSEN DIAGNOSTIC DEPARTMENT PROCEDURE: FDI - 4563 -WRIST COMP MIN 3V LEFT PROCEDURE DATE: Jul 27 2009 2:37PM ACCESSION#: 6254239 EXAM: Left wrist, 4 views History: Trauma Results: There is evidence of greenstick fractures of the distal radius and talna. The ulnar fracture demonstrates minimal posterior angulation. No significant displacement is evident. The bony architecture is preserved. IMPRESSION: Greenstick fractures distal radius and ulna with mild posterior angulation of the ulnar fracture. DICTATED: (07/2712009 02:35PM) TRANS: (PSC/PS) ON: 07/27/2009 14:36 INTERPRETED AND REVIEWED BY: THOMAS J. PIETRAS, D.O. ELECTRONICALLY SIGNED: 07/27/200914:36 In the event of any questions regarding this report, a Quantum Radiologist can be reached by phone at 932-8030. ~b~ %~~~ 1~~ ~~ ~ Y: ................---- Study interpretation provided by QUaI]tUM Imaging 8 Th@I'BpBIItIC ASSOCIat@S- If you have received this document byfacsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is stricty prohibited. If you have received this communication in error, please notify us immediatey at: 1-717-782-3240. Printed: July 27, 2009 3:27 PM RICHARD E. FREEBURN ~ ~] ~ EPHEI!i A. SGHNEIDER WRENCE F. BARONE RISTINA L. BRADLEY-. ~~~ O ~ 2U~9 OBERT D. HAMILTON (1967-2005) H1~,~/~IL O ___------Christina L. Braille Y: ---------- y Your Personal Injury and Workers' Compensatiorf Attorneys Writer's Extension: 9 ChristinaB@pa-injurylawyer.com ..August 25, 2009 Attn: Medical Records Heritage Pediatrics 3720 Market Street Camp Hill, PA 1701,1 RE: -Avery Saint Bon SS# c ~ 155-17-5120 DOB: '12/25/200? .Date of Accident:.?/27/09 Dear Madam or Sir: AUC . 2 6.2009 8Y:_._. This is to advise that"our firm -represents Avery'Saint Bon in connection with injuries he suffered on July. 27, 2009.' I. would greatly appreciate it if you would provide me with a copy ~ of any and all medical records, that you -may have concerning- Avery Saint. Bon from ?/2?/09 to the .present, including but not limited to histories ,taken, office notes, .nurses notes, .diagnostic reports, .reports of other health. care providers,. etc. In addition, `please provide rrie with copies of any letters or notes with regard. to communications .from or to any; other person or entity including insurance representatives with regard to my client's injuries. In addition, please provide me with a ,billing statement of your accideat- related charges and paymeats made to date. • So that you know that our office is authorized to receive this information, I have. enclosed a properly executed medical authorization. Please bill our office directly for any copying charges you may incur with regard to this request. Your cooperation in this matter is greatly appreciated. CLB/jail Enclosure c: Mr Very truly yours,. y ~~r~ °`°~-~ Christina L. Bradley (/ Mrs. Gregory Saint Bon ~~ ~--- ~~~~Q r -,~ ~~;~ 441.5 North ~x'ont Street, Harrisburg PA 17110 (717) 671-1955 • Fax: (7.17) 671-1960 www. pa-inj urylawyer. com • (800) 303-8005 l~ AUTHORIZATION TO DISCLOSE HEALTH INFORMATION Patient Name: Avery Saint Bon Date of Birth: 12 / 25 / 06 Address: 28 East Locust Street Mechanicsburg PA 17055 Social Security No.: 155-17-5120 We hereby authorize to release health infc S our minor daughter, to: FREEBURN & HAMILTON 4415 North Front Street Harrisbur¢ PA 17110 The information to be disclosed to and used by the above for the following purpose: Litigation This authorization is for the following dates of treatment: FROM Any and all TO Any and ail Information disclosed: x Discharge summary x Complete chart x ER and outpatient reports x X-ray reports x History and physical x Lab reports x Operative and pathology repts x Progress notes x Alcohol and drug treatment notes x Consult reports x Ambulance, EMS, ELS or ALS records x Opinions regarding my physical or mental condition _ x Doctor's orders x Nurses' notes x Psych records x Billing Info x PT records Other We understand that the information in this health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIS. It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. We understand that we have the right to revoke this authorization at any time. We understand that if we ~ revoke this authorization we must do so in writing. We understand that the revocation will not apply to information that has akeady been released in response to this authorization. Unless otherwise -revoked, this authorization will expire in 90 days. We understand that authorizing the disclosure of this health information is voluntary. We can refuse to sign this authorization. We need not sign this form in order to assure treatment. We understand we may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. We understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If we have questions about disclosure of this health information, we can contact Freeburn 8v Hamilton. Permission is hereby granted to Freeburn 8v Hamilton to photocopy or scan this authorization and any photocopy thereof shall be as by us an original. S•a5 •oq DATE Wi s ~.a5.09 DATE W' GREG SAINT BON, on behalf of Avery Saint Bon CHRISLENE SAINT B9i~, on behalf of Avery Saint Bon Provider History: Chief Complaint ~r'1 /~ ~ _ .n C Vitals: Agee Wt:!~~ Ht: BMI: HC: HR: RR: .Temp: BP: / Visual Acuity: Faz R 20/ L 20/ Near R 20/ L 20/ Corrected Uncorrected Color: Nl Abnl L d ti D li k ea ques onnaire. -one (see ac) TB risk questionnaire: Done (see back) Developmental eval: ,Done (see sheet on left side of chart) Ph sical Exam: /= done ~ y z General Appearance (well or ill appearing, over/under weight) 0 'a ~ ~° F° z Head (anterior fontanelle, facies, symmetry. size) Eves (pupils. red reflex, fundi, movement, conjunctiva Ears (canal, TM, external, hearing, cerumen) Nose (septum, turbinates) Throat (Qhazvnx, tonsils, teeth, gums, tongue) Neck (masses, nodes, thyroid) Chest (symmetry, breasts. accessory muscles, retractions) Lungs (auscultation, resp.rate) Heart (rhythm. murmur. rate, femoralpulsesl Abdomen (spleen, liver, masses. bowel sounds. appendix. bladder) Genitalia (male, testes, female. anal) Pelvic (PAP yes/no, hymen, labia, v eina, ovaries. cervix. uterusl Extremities (RU, LU, RL. LL, R.O.M., hips, gait, strength, tone) Neurological (DTR's, cranial nerves. motor, sensory, balance) Back (scoliosis. kidneypercussion, lordosos, kyQhosis) Skin (moles rashes, color,perfusion, birthmarks, hydration) Assessment• • .~-.. Medications: Immunizations: Previous reaction? _~' ,N Explain ~G~~~r~ Specific FihcCings ~~ _ ~~ '`'~ ~O ~'S ~(~~ ® dJ~ /'~ ~ _ j„ ~/'~" Tanner _ E~~./~~C~' ~~J' (~ -'Tanner _ Patient Instructions: ~ ~ U S S ~i ~ s -~' C-6-~L.. Jt,c..o ^ o ~- ~ du~.i.~:f.<.~s, mil' e...a~-vim ti.e ~YV~-e-e~.x c~ri ~,ui„~.~J ~ ~j~,e~i~.'`-~d ~~/1~~~,,,fff Acetaminophen: mg q _hrs Dose now? Y N Ibuprofen: mg q _hrs Dose now? Y N DaPT/Polio/Hep B Rotavtrus PneumoC Hib Hep A MMR/Varivax DaPT IPV MMR Influenza Mezungococcal HPV Tdap Varicella Hep B PPD Labs: Hgb Lead GCu U/A (dip) U/A (micro) Urine culture RST Hemoccult Tympanogram Audiogram Stool Cult Stool O j~ Preg Test Bili (tot & du) CBC/diff Blood cult ESR Comp. Met. Prof Trig/Chol J~ Return: days, wks, mo, yr, prn Provider Signature: v'"' `M To do next visit: ,-, c Patient Name: LL.u-~7 SC1 i h ~-~ Cl~ D.O.B.: f ~-~-~ U~-- Date of Visit: "a ~ ~ J Heritage Pediatrics Office Evaluation Sheet Page ~' . ~~...~ .... .,.. .. ...........~ .~.. ...~. ..... ... ..- ~, _ ~ .. ... .. .. ,. ..y.. _ ~. _ .. ... .. .. .. _ ~ECEIVE~ AUG 1 2 2009 BY: Orthopaedic ~ Spsne 8PECIALIBTS DOS: 08/05/09 ORTHOPAEDIC AND SPINE SPECIALISTS, PC Acct: 150061 Avery Saintbon DOB: 12/25/2006 Sex: M SSf: Age: 2 Subjective CC: Presents for follow up of left wrist pain. HPI: Presents for follow up. Wrist pain is minimal in the short arm cast after one week. He is doing fine. No other complaints of pain. I confirm that I have reviewed the Medical Health History Questionnaire which includes review of systems, past mecical, soaal, and family history dated 07/27/2009 and no changes were noted. Objective Exam: Const: Appears the stated age, well developed and well nourished. No signs of acute distress present Lymph: No palpable or visible regional lymphadenopathy. Musculo: Wrists: Cast is intact and neurovascular status is intact. Cast is secure. Skin: No ecchymosis or rash located on the upper extremities. Neuro: Sensation grossly intact to light touch. Xray Interpretation: X-rays taken in the office today, AP and lateral of the left wrist, demonstrates good position of the fracture of the left distal racius with torus fracture. DX: Healing fracture left cGstal radius. Plan: Recommend elevation, protection and range of motion and return pm. Seen by. ~~a~ ~~~ Peter J. VanGiesen, M.D. Electronically Signed cc: Kathleen Mary Zimmerman M.D. 08/12/2009 ~ ~~~ ~I ~~ PJVlkks _ ~., _ --~ Urthopeedic ~ Spine gY:___ _ __-- -- - `-' SPECIALISTS DOS: 07/27/09 ORTHOPAEDIC AND SPINE SPECIALISTS, PC Acct: 150061 Avery Saintbon DOB: 1225/2006 Sex: M SSA: Age: 2 Subjective CC: Patient presents with left wrist pain. HPI: This 2 year dd male presents today for orthopaecic consultation at the request of Zimmerman for treatment of left wrist pain. The patient has had left wrist pain for 1 day. The patient does recall an injury while at daycare today. He was climbing up the slide and slipped and fell off the slide. Raciographs have been obtained at Pinnacle Health which revealed a greenstick fracture. Motrin is used for pain management. -~"-'---------._ I confirm that I have reviewed the Mecical Health History Questionnaire which includes review of systems, past mec6cal, soaal, and family history dated 07272009. Objective F~cam: Const: Appears well developed and well nourished. No signs of acute distress present. Lymph: No palpable or visible regional lymphadenopathy. Musculo: Wrists: The patient is alert and oriented and complaining of pain about the left distal radius. Slight swelling about the cstal radius and ulna. Full range of motion of the fingers, elbow and shoulder. Normal neurological. He has full grip strength and no evidence of compartment syndrome. Skin: No ecchymosis or rash located on the upper extremities. Neuro: Alert and oriented x3. Mood is normal. Affect is normal. Sensation to light touch is intact on the upper extremities. Reflexes: DTR's are 1+ bilaterally. No pathologic ankle clonus. Xray Interpretation: AP and lateral of the left wrist demonstrates minimal displaced fracture of the left c6stal radial and ulnar metaphysis. DX: Right distal racial and ulnar metaphyseal fracture. Plan: Recommend s_h~rt~arm~cast, elution, Motrin as already prescribed by mom. Return in one week for recheck and x-ray~o sling for this youngs er an pro ec on. ~,_.--~-----.-_._.~ -~_ Seen by: "~,.- \ Peter J. VanGiesen, M.D. ~~ Electronically Signed -~ ~-'~ 07 .82009 ,.'"~~ cc: Kathleen Mary Zimmerman M.D. PJVlkks r r v r r c.vvv ~ ~., vv ra~a vzvv r~~~a.. 1, va .r. PIN'NACLEHEALTH Syste- Radi. ~y Imaging Report MR#: 910049711 NAME: SAINTBON, AVERY SSN: 910049711 28 E LOCUST ST ADM: 000100025042 MECHANICSBURG, PA 17055 DOB: 12/25/2006 AGE: 2Y ' ORD DR: STAGG, RICHARD D BED: MMS- ORD#: 90001 PTCLASS: O FOS ATT DR: STAGG, RICHARD D PCP: UNKNOWN, DR REASON: pain injury COMMENTS: ***Final Report*** FREDRICKSEN DIAGNOSTIC DEPARTMENT PROCEDURE: FDI - 4563 -WRIST COMP MIN 3V LEFT PROCEDURE DATE: Jul 27 2009 2:37PM ACCESSION#: 6254239 EXAM: Left wrist, 4 views History: Trauma Results: There is evidence of greenstick fractures of the distal radius and ulna. The ulnar fracture demonstrates minimal posterior angulation. No significant displacement is evident. The bony architecture is preserved. IMPRESSION: Greenstick fractures distal radius and ulna with mild posterior angulation of the ulnar fracture. DICTATED: (07/27/2009 02:35PM) TRANS: (PSC/PS) ON: 07/27/2009 14:36 INTERPRETED AND REVIEWED BY: THOMAS J. PIETRAS, D.O. ELECTRONICALLY SIGNED: 07/27/200914:36 In the event of any questions regarding this report, a Quantum Radiologist can be reached by phone at 932-8030. ~~~~~ 141} ~~F°.~...~ r ~,; -~ ~Y: ____________________ Study interpretation provided by QU8/1~u/11 ItT78glpg 8 Therapeutic ASSOCIates. If you have received this document by facsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is stricty prohbited. If you have received this communication in error, please notify us immediately at: 1-717-782-3240. Printed: July 27, 2009 3:27 PM d, PINriIACLEHEALTH !9! SEP 1 •.1009 1~~ B Y: ----------•--------- SEIDLE HOSPITAL 120 S. Elbert Street Mechanicsburg, PA 17055 717 795-6662 i, . Date: (^ (-~ / . RE: C~>`Gtxift~~~~Y~- CONFIDENTIAL -This information is confidential and is to be used. for your purposes only. .Any replication ofi this information by your facility is prohibited.. u/, . We are enclosing medical information recently'requested on the above named patient. ~' _ A statement, •signed~ and dated by the patient; authorizing the hospital to release this. information, vtrill ~. be necessary~before. a report can be sent. If the patient is a minor, or unable to sign the. authorization the authorization must be signed by the parent; next of kin, or legal guardian. ~~, THE AUTHZ7RIZATION MUST BE DATED WITHIN THE LAST 90~DAYS~AND AFTER THE TREATMENT DATE TO BE VALID! _ A search of our files has failed to reveal a record of the above named patient having been treated at this~~facility.•. We will be glad to make a further search if you will be kind enough to furnish the following information: Correct Name: of Patient Date of Birth Dates of Treatment ~ Social Security # - According to our records, the information requested on the above. named patient was forwarded to you on If not received, kindly submitanother request. It is the policy of this office to provide medical records for the previous two (2) years: If other information is requested, .please specify what medical information is necessary.. IIVe do no# provide copies of-recor'ds that were forwarded to this office..These should tie requested from the original source. The enclosed medical records reflect this policy. ~. Other t Thank you, ~~~ ~ Corresponden echnician r Fertn 46203 f01%991 PM SAINTBON,, AVERY C-Enc #100025042-OPT-M1tIS-7/27/2009 ED Facesheet - 7/29/2009 - 1 pg MEDICAL RECORDS ~ II~~IN~~~~~f ~ d~ PINNACLEHEALTH TIME OUfi Hospitals ^ FIRSI~PLACE ~ MR: ""t049711 CASE: 100025042 PHYSKYIIN LEVEL OF cA,RE: Non-ED PhyslClan: S/lINTB~N ,AYIERY NI p I Iv MED. EMER. ^ Y ~ Ager Hours DATE: 07127!09 DOB; 12!25!2006 v ~ ^ Private Attending - III o Crltkal Care A Ph IY: 717 620-8159 AGE: 2 DR: MEDICAL RECORDS REOUESTEO ^ vES ^ No ~ °E" IF ACCIDENT, WHERE OCCURRED / G~f ~~ 1 Q1 ~ ~~ M~K ~ I~IUI*1 ~i~"'~~NWARD D C.C. PER PTJ9IGNIFlCANT OTHER FAMILY PHYSICIAN TIME I ' _- (/ V TIME DR. NJ ~ CONDRION ON ARRNAL POLICE NOTIFlED BY: GOOD FAIR ^ p00R CRRICAL DOA YES NO ^ VITAL 31GN9 AT TRIAGE ^ VRAL SIGNS IN DFFT. BP P R T ALLEfIGIES• K NOTE PHYSK;IAN'9 REPORT IFIPI, IMPRESSION + T>n TETANUS: > , c5 YEARS, OTNEF l ~- ~-.- c~ / /'' ! ~ d- .4 1, w!Z c ~i - ,~ Gam'' ~ %'4 ~ ~ -b- ~ ~~,r ? i fit-' ~ -6- C7,i f1I Y ~<d L~----c~ Cam. -' ~f----. ~ N~ : --_..... a -..._. T N- CONSULT ^ NAME TIME OICTATEO TIME ROOM R DIAGNOSTIC IMPRESSION SERVICE/MD ^ ADMITS ^ 77iANSFER BED TYPE D -UP C ONDL4CHARGE R OTHER PHYSICIAN'S AS616TANi/MEDICJIL STUDENT E.D. PFiY3 OTHER LASE DIS. DATE RESIDENT PRNATE N LAST ER REG. GUARANTOR NAME GUARANTOR EMPLOYER INFORMATION PREVAL ,CHRISLENE HOM - - .WORK - CLAREMONT NURSING HOME 10Q10 CLAREMONT RD NOTIFICATION NAME I RREVAL CHRISLENE PATIENT EMPLOYERtNFORMATION , HoM - woRK - CHILD HOSP SERV AREAS TO VISIT DIAG. CODE RELIGION PATIENT # TE TIME AGE DATE OF 81RTH S M R SOCIAL SECURfIY # PR F/C MEDICAL RECORD # DOC # v ~ PATIENT NAM AND ADDRESS INSURANCE CO. NAME GROUP NO. POLICY NUMBER SUEtSCRIBER NAME SAINTPON ,AVER 28 E LOCUST ST', GA 17055 ' HOME717-E,2Q1-81 .CJ9' MECHANiCSPUR WORK - - :-"38/PPS RF'O P / / / 253201' ZAR11430621 0 MII" r lir r r --~ ---- ~ T:~TUrI Page 1 of 1 SAINTBON,, AVERY C-Enc #100025092-OPT-MMS-7/27/2009 ED Physician Orders - 7/29/2009 - 1 pg .. .. .. i» Date Tlme LEVEL OF INTEN OE;: (PN~~ ~mP~ ~ dal of IMsnslty Ortl~r Form Tor any Lv~ n•v) z7 0 / 0 Allergies: ` ~ ' `' ~ ~ ' roc ores k Supplies L.ab Time: Initials: Drug Levels Cultures Radiology ~ DCardiac Monitor ^ ABG ^ Glucose D Acetaminophen ^ Blood x Tlme ^ECG D Acetone ^ Hepatic Panel - ^ Aspirin ^Chlamydia Initials: ^Nasogastric tube ^Foiey Catheter ^ Am lase ^ ALT/AST ^ H&H ^ Lactic Acid ^ Carbamazepine ^ Digoxin ^ GC GC/ l Portable: ^C-spine ^Straight Catheter C Ammonia ^ Lipase ^ Lithium Ch amydia ^ (ene amp} ^CXR ^Pelvis pIV: ^ BMP ^ Ma nesium g ^ Phenobarbital D ~erpes Spine:^ C ^ T ^ US ^ Cardiac ^ Myoglobin ^ Phenytoin ^ Sputum ^ Ankte L R ^ BNP ^ PT/INR ^ The+ophylline ^ Stool D CXR ^Os LPM ^ CK -Total ^ CK - MB ^ PTT ^ Qual HCG ^ Urine Tox. ^ Valp'roic acid ^ Stool - C-diff D Elbow L R cial ^ F ^Pulse Oximet ~' ^ CK -Index ^ Tro nin I o D Quant HCG di R t C Blood Bank ^ Throat/strep ^ Urine a ^ Femur L R ^Non-invasive P ^ CBC w/auto diff ac p ar ^ ^ CK -Total ^ T & Cross ^ Wound: ^ Finger L R ^ Foot L R COHbg ^ COHbg ^ CK - MB ^ Type 8~ Screen ^Peak Flow ^ Forearm I_ R pN t b T t ^ Comp Met Panel ^ CK -Index ^ Rh Factor D Hand L R men : e rea ^ CRP ^ Troponin I Bedside Testing Hip L R t'-"J ^ D-Dimer (DVT) p Electrolytes ^ TSH ^ Sed rate D BGM ^ PTlINR . ^ Humerus L R ^ ETOH ^ Urinalysis ^ CG4+ ^ Qual HCG (urine} ^ Nasal ~ ^ Chem 8+ ^ Troponin I ^ Knee L R ^ KU8 If ST Elevation MI ^ Thrombolysis (Order sheet) ^ Ob Series O STAT Cardiology Consult with (PreCath orders) ^ Pelvis AMI ASA 325 mg po ^STAT, ^ Given PreHospital, ^ Taken at Home ^ Ribs L R Orders ~~ Blocker O Metoprolol _mg IV qT minutes X 3 (do not give if BP<_and/or HR<~. ^ Shoulder L R ^ Metoprolol ,mg po ^ Carvedilol_mg po {if EF anticipated to be under 40°k) ^ Skull ^ TiblFib L R Diuretla: ^ Furosemide mg IVP, ^ Bumetanlde mg IVP ^ Wrist L R CHF If urine output <200mL within 30 minutes consider redosing Symptom Orders IV Vasodllating Agent: 1V D Nitroglycerin mcgimin ^ C7 Acute ^ Vital Signs q 15 minutes C: IV: 0,9 NSS ~ 50 mUhour ^ t3GM ^ Stroke Alert Team Stroke ^ Strict NPO until dysphagia evaluation called ~ Time: ^ US: Orders ^ Aspirin 300mg PR x 1 dose ^ VenouS Doppler: L Notify physirtian if: SBP >180, DBP >105, change in neuro status. Date Time Additional Orders: ^ MRI: ^ V Q Scan D Other: Physician's signature: PINNACLEHEALTH Hospitals EMERGENCY DEPARTMENT PHYSICIAN'S ORDERS MR: ""'049711 CASE: 100025042 SA/NTBON ,AVERY nn DATE: 07/27/09 DOB:12/26/2001i Ph #: 717 620-8159 AGE: 2 DR: Form INV 30747 (06108) MR ED2502 (InD) Page 1 of 1 SAINTBON„ AVERY C-Enc #100025092-OPT-MMS-7/27/2009 ED Report - 7/29/2009 - 1 pg ACCT#=00100025042 .NSCRIBED DATE=07/29/2009 14 ~ UDN= 2684375 SAINTBON, AVERY C RM#: MRN: 910-04-9711 'CASE: 0010002.5042 DOB: 12/25/2006 ADM: 07/27/2009 PinnacleHealth System P.O. Box 8700 Harrisburg, PA 17105-8700 EMERGENCY DEPARTMENT CHIEF COMPLAINT: The patient is a two-year-old male who comes to Seidle Hospital FirstPlace complaining of injury to the left wrist. HISTORY OF PRESENT ILLNESS: Three hours ago he fell off a slide .and injured his left wrist. He has not used his left hand since then, complaining of pain. Ice was applied but no pain medicine was given. REVIEW OF SYSTEMS: Negative for cardiovascular, respiratory, gastrointestinal, or urogenital complaints. PAST HISTORY: NO ALLERGIES. No medicines on a regular basis. No surgery. FAMILY HISTORY: Diabetes. SOCIAL HISTORY: Lives at home with his parents. PHYSICAL EXAMINATION: Vital signs: Blood pressure was not obtained, pulse 120 as he is crying, respirations 22, not labored, temperature 98.3. Well-nourished, well-developed two-year-old male who is fussy and does seem to be in some kind of discomfort. The left wrist is swollen, obviously tender, and he will not move the wrist. EMERGENCY DEPARTMENT PHYSICIAN TEST INTERPRETATION: EMERGENCY DEPARTMENT COURSE: DISPOSITION: He needs an x-ray. Our x-ray machine is broken. The mother is given a prescription for the x-ray. She is to go and get it taken right away. If it is fractured, then he needs to see an orthopedic doctor. If it is negative then ice four times a day for ten minutes, Tylenol or Motrin for pain. Use of the hand as tolerated. Follow up with the family doctor. DIAGNOSTIC IMPRESSION: Injury to the left wrist. c: PCP UNKNOWN Signed by STAGE MD, RICHARD on 11-Aug-2009 08:44:03 -0400 RICHARD D. STAGE, MD Patient: Avery Saintbon DD: 07/27/2009 DT: 07/29/2009 /acz D#: 2684375 Page 1 of 2 SAINTBON,. AVERY C-Enc #100025092-OPT-MMS-7/27/2009 ED Nursing Assessment - 7/29/2009 - 2 pg n~tp• -~ 1 ~~r TRIACaE Tp~AE' t CAT GORY T • , -?>. • P- Z Q R• 2 Z, 8/P _r---. AU_EROIES IV ~~~ CURRENT ME0.S PMH L.M.P. TETANUS HX r A Vl VISVALACUITY O.S. O.D. WEIGHT ~ ~ / S . !~ INITIALASSESSMEN7 ~~ t ../1/Wo ~"C G ~ .~~~ ~ ~! ~o7 ~t,~,~ ~~-C.~l ~~1.. . ~ ~ ~ 1,,~ c ~ Gt/~'~~ rQ~•G/ PAI TIME T P R P bn on Diseharpe. - o ndit NOTE propmaa, Complicatbns, Conaultations, Instructions, C ~~ f ~ rVV~ ~ 1'~rs- ~,L !~ Y s ~ S S 5 ~ FO 1v J 1 ~ r d7 \~ /wQ ~, PINNAC.~LEHEALTH Hospitals FIi~STPLA E NURSE ASSESSMENT Fdni OtiaR~90 (06b9} InD '~ SEIDLE HOSPITAL 120 S. FIIb~R Strut Machaniubury, PA 17055.8591 Patient IdanWfa~~tilIo~~n I~I~~I~~Illp~' MR: * * "04971 1 CASE: 100025042 SA/N760N ,AVERY M DATE: 07/27/09 DOB: 12/25/2006 Ph#: 717 620-8159 AGE: 2 DR: Page 1 of 2 SAINTBON~ AVERY C-Enc #100025092-OPT-MMS-7/27/2009 ED Nursing Assessment - 7/29/2009 - 2 pg I~~~~ Page 2 of 2 MR: """049711 CASE: 100026042 SA/NTBON ,AVERY M DATE: 07/27/09 D08:12/25/2006 Phi: 717 620-8159 AGE: 2 SAINTBON,. AVERY C-Enc #100025042-OPT-MMS-7/27/2009 Radiology Report - - 7/29/2009 - 1 pg PINNACLEHEALTH System Radiology Imaging Report MR#: 91©04971 i NAME: SAINTBON, AVERY SSN: S1Q048T11 28 E LOCUST ST ADM: 000100025042 MECHANICSBURG, PA 17055 DOB: 1 212 512 0 0 6 AGE: 2Y ORD DR: STAGG, RICHARD D BEO: MMS- ORD#: 90001 PTCLASS: O FOS ATT DR: STAGG, RICHARD D PCP: UNKNOWN, DR REASON: pain injury COMMENTS: ***Final Report'r'k'' FREDRICKSEN DIAGNOSTIC DEPARTMENT PROCEDURE: FDI - 4563 -WRIST COMP MIN 3V LEFT PROCEDURE DATE: Jul 27 2009 2:37PM ACCESSION#: 6254239 EXAM: Leff wrist, 4 views History: Trauma Results: There is evidence of greenstick fractures of the distal radius and ulna. The ulnar fracture demonstrates minimal posterior angulation. No significant displacement is evident. The bony architecture is preserved. IMPRESSION: Greenstick fractures distal radius and ulna with mild posterior angulation of the ulnar fracture. DICTATED: (07127!2009 02:35PM) TRANS: (PSCIPS) ON: 071271200914:36 INTERPRETED AND REVIEWED BY: THOMAS J. PIETRAS, D.O. ELECTRONICALLY SIGNED: 07!27/200914:36 In the event of any questions regarding this report, a fluantum Radiologist can be reached by phone at 932-8030. 1( Study interpretatlo provided by QUBAlUm Irll8glpg d~ Therapeutic ASSOCf8f6S. If you have received this document by facsimile, the Informatlon co tamed In this transmission is privibged and confidential. If the reader of ibis message Is not the intended recipient, you are hereby notl8 that any dissemination, distributlon, or copy of this communication is strictly prohibited, if you have received this communication in rror, please notify us immediately at:1.71T-7a)2-3240. Printed: July 27, 2109 2:41 PM Page 1 of 1 SAINTBON„ AVERY C-Enc #100025092-OPT-MMS-7/2'7/2009 ED Patient Instruction Sheet - 7/29/2009 - 1 pg r . v~-r.••,~R+,y4;y;.: •n~v.,,.,,..,,...nr.7`"~`,. "?paxS'"'! hi!'Z~;3F•-~~:°~,i'}~'ai~r;11!!`1Y $df~l.-^i~? ".n5~7~?:~~.~'~i"ta"r a.' MR: '""049711 CASE: 100025042 SA/NTBON ,AVERY M DATE: 07!27!09 D08:12l26l200f3 Ph#: 717 620-8159 AGE: 2 ' ~ P~NN~-cLEHEn~.TH FitskPlace ' Heaitb Care (717 T95-6656 DR: __._..._.. _... __... ,.o,~,,,.„,o,,,,,,,.,.,,•-. INSTRUCTION TO THE PATIENT The examination and treatment you have received In the FlrstPlace Center has been rendered on an urgent basis only, and are not intended to be a substitute for, qqr an ettprt to provide complete medical care. IF YOU DEVELOP NEW PROBLEMS OR COMPLICATIONS, CONTACT YOUR PHYS1CIdN"OR RETURN TO AN EMERGENCY DEPARTMENT IF YOU BECOME WORSE IN ANY WAY. AS INDICATED FOR LACERATION, ABRAlS10NS OR BURNS , ^ Keep wound dean end dry 2440 hours. ^ After 2448 boars wash with soap and water or peroxide. ^ watch for signs of swelling; terxfemees, redness, h~atpr: _, ~,~( r dreinage ~- return to FlrstPlece ff any of these signa'bccur. ~ ^ Return to Flrstl~lece to have your sabres removed. ~~'gterw,s Toxiod/Tetanus diphCrorls given fires SPRAINS, BRUISES, AND FRACTURES ^ Elevate afiecldd part on pillow and rest. pack on e.Abcted part for -YF/141a1~~ 1 rrt4~ytea ofM~" ^ Wear aCe wrap for Rewrap daily. ^ Use crutches•fibf days. ^ Begin to bear weight on day. ^ If affected part trecomee blue. cold, numb, or swollen or palydul, return to the Emergency Departmerrt. ^ Wear sling for dtiys. Use spikrt for days. ^ No heavy Ilftlng for - ^ Use wane paoka for 30 minutes at a time every hours. MEDICAL INSTRUCTIONS ^ Bed rest for ^ Teke Tylenol or Ibuprofen every hours. ^ If a child has fever. A. dress Aghtly - don't cover with blankets; ' B. give plenty of fluids -offer small amouna irequenty; C. give Tylenol or Motrin M temperature higher then ^ Ck~er liquki diet - advar~esa.Jofereted. ^ Drink plenty of liquids. EYE INJURIES ^ Do not drive or operate machinery uMll ^ Return to FtstPlsce Heatlh Care or family plrysk:ien . -bring sunglasses. ^ Avoid bright BgFas, T.V. and prolonged readkrg for hours. ^ Eye medication HEAD INJURIES Our physidans have found no evidence at this time of serbua injury and do not feel !hat hospital admiaelon Is necessary. However, conditicns may chsnge wlth~ the next 12 to 24 hours (or even longer). Please go to E D. knmedietely if any of the foilowing occur. 1. Mantel confusion 2. DilAcuky in arousing, (The patbnt should lie awakened every 2 hours during the first night.) 3. Pereistent repeated vomitlng (once or twice Is not uncommon). 4. Severe. oontlnued headache. 5. Stiffness of neck, fever. 6. Trouble wtlh speech, balance, vision, weakness of eRher arm or leg. 7. Bloody or dear fluid dripping from the ear or nose. 8. Convulsions (fits or seizures). ' FOLLOW UP CARE Return 1o FkatPlaoe ^ pow-up wBh family physician ^ Sea Dr. on at AM/PM EMPLOYMENT ' ^ Return to nomrel duty on ^ Lirnlted duly from unto Limltadon ~'I ^ See Occupations! instructlonai sheet ^ OTHER ~r~ ~ ~f~~~~ ~~~ ~~t ; ~.~ X-RAY INSTRUCTIONS: Your z~reya have been read by the FlrstPlace Health Care Physkian. Your x-ray will be reread by the Radiobglat and you will ba notified of any abnormalities which have not been called to your sKention which requires further tollo+r up. Sometimes fractures or abnonnslitfsa may not show up on x-rays for sbverel days. M symptoms persist ~ get worse, call your Ptrysk~an for further foAow up. LABORATORY INSTRUCTIONS: Coil FiretPlece for resuk of your pendYrg tab testa. SIGNATURE8 ~ 1 HERBYACIWOVVLEDGE RECEIPT OF THESE INSTRUCTIONS AND R.N. UNDERSTAND THFJiA. l UNDERSTAND THAT I HAVE HAD URGENT TREATMENT ONLYANDTHAT I MAY BE RELEASED BEFORE ALL _"~--MAD.. MY MEDICAL PROBLEMS ARE IWOWN OR TREATED. i WILL ARRANGE F F -UP EAS I BEEN INSTRUCTED. r•«~ oeeeei (~wrel tomiwly aNV ze» x,o Signature: Patient oT responsible person Date Page 1 of 1 y P:' ,'ENT HEALTH HISTORY QUESTION' ARE 'The following information is very important to your plan of care. Please take time to fully and completely fill out this important information. We are counting on you. Please comp ete every section. Do not leave any blanks. _ APPT NAME: ~Q~/ ~•n +~ DOB: ~ Z- 25 ^~ ~' AGE: Z DATE: ~ 2~ HT: WT: ~~ ~ • S ~ ~-~ SEX: ~M F ~ght hand dominant ^ Left hand dominant MARITAL STATUS: Single Married Widowed Divorced OCCUPATION: FAMILY DR: REQUESTING DR: OTHER TREATING PHYSICIANS: YOUR MEDICAL HISTORY-Please mark every line DO YOU HAVE NOW OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? YES NO Comments YES NO Comment Anemia ^ e' Hepatitis 1 Liver Disease C ~ Anxiety G ~ High Blood Pressure ^ Asthma C [~' High Cholesterol G Back Disorder ^ ~ Kidney Disease ^ Blood Clots C ~" Lung Disease C [~ Blood Disease ^ C3' Mental Disease ^ 4 Blood in Urine G ~ MRSA/Serious Infection C C~ Cancer(Location) G ~ Neuropathy ^ a Change Bowel Habits^ ~' Osteoporosis ^ Ca- Colitis/Irritable Bowel ^ Cr Prostate Problems ^ C~' Coughing Blood ^ G Rectal Bleeding ^ ~ Depression C ~ Shortness of Breath C C~' Diabetes ^ C~ Stroke G C-~ Emphysema ^ G Swollen or Painful Joints ^ C3- Epilepsy /Seizures ^ (~ Thyroid Disease ^ ^' Gallbladder Disease^ ~ Ulcers ^ ^- Gout C e' Venereal Disease /STD ^ [~ Fainting ^ ~ H{VIAIDS C [~ Rheumatoid Disease ^ Q Heart Disease" ^ C~ Wounds not healing properly^ ~ Chest Pain ^ C Other: Heart Failure /CHF ^ o Irregular Heart Rate ^ ~ NAME: C .r`~'6 Have you ever been diagnosed with sleep apnea? : ~O DYES DRUG ALLERGIES or ADVERSE REACTIONS: ~10 ^ YES -Please list: IF YOU ARE ALLERGIC TO ANY OF THE FOLLOWING, PLEASE CIRCLE: ~~, 4i SHELLFISH IODINE X-RAY DYE EGGS POULTRY FEATHERS LATEX* NICKEL LIST ALL MEDICATIONS (INCLUDE SUPPLEMENTS) and Include Dosage: ^ NO Medications ~~t~ YOUR MEDICAL HISTORY Contlnued -Please mark every arse HOSPITALIZATIONS: !a'No ^Yes-please explain Year SURGERY (TYPE): [3~l~l0 ^Yes~--please explain Hospital FAMILY I SOCWL HISTORY -Please mark every area Do you have a F ILY history of: Cancer (Location 1 Diabetes Heart Disease Hlgh Blood Pressure Stroke Thyroid Disease Malignant Hypeethermia Other Diseases Blood ClotsBlood Diseases (Factor Vy, etc YES No Comments ^ ~- r~ o- ^ ^ LT D [3' ^ o' ^ C~ ^ ~ YOUR PERSONAL HABITS: Do you.... YES NO Smoke? /Use any tobacco products? ^ ~ if ever, when did you stop? Use aicohoN? ^ e" Were ypu ever a heavy drinker? ^ t~ Use iilegaW drugs? ^ C3~ 2 If YES, Please explain: NAME: REVIEW OF SYSTEMS -Please mark every area Have you recently'been troubled with any of the following symptoms? YES NO YES Double /Blurred Vision 0 Indigestion C Hoarseness ~ Jaundice ^ Nosebleeds C Vomited Btood ^ Irregular Heartbeat 0 Decreased Urine C Chest PainlPressure ^ Pus in Urine ^ Cough G Pain while Urinating ^ Dizziness ^ Back Pain ^ Swelling of Feet* C Joint Pain ^ Shortness of Breath* o Leg Pain C Anxiety ^ Paralysis ^ Wheezing ^ Black Stools ^ Abdominal Pain C Fainting C Blood in Stools ^ Q' Headache ^ Change in BMs ^ I~' DepressionlWorry ^ Constipation ^ ~' DifFiculty Swallowing ^ Diarrhea C C~ n The above information is true and correct to the best of my belief. ~~' Pane nature (Parent or uardian for nor) Date P ysician CLINICAL ASSISTANTIREVIEWERlNITIALS: NO 3~/~ ~re !Data 12lU3/2008 3 Date: 07/27/09 HEALTH HISTORY UPDATES -ORTHOPAEDIC AND SPINE SPECIALISTS, PC Name :Avery Saintbon Acct: 150061 Sex: M DOB: 12/25/2006 Age: 2 years This document refers to the Medical Health History Questionnaire scanned as a separate document dated 07/27/2009 The following are the signatures and changes for confirmation of reviewing and updating the Health History Questionnaire. Medications: None. Allergies: NKDA 07/27/09 - I confirm that I have reviewed the Medical Health History Questionnaire which includes review of systems, past medical, social, and family history dated 07/27/2009 Q!Y'114~ Peter J. VanGiesen, M.D. Electronically Signed 07/27/09 DOS: 07/27/09 ORTHOPAEDIC AND SPINE SPECIALISTS, PC Acct: 150061 Avery Saintbon DOB: 12/25/2006 Sex: M SS#: Age: 2 Subjective CC: Patient presents with left wrist pain. HPI: This 2 year old male presents today for orthopaedic consultation at the request of Zimmerman for treatment of left verist pain. The patient has had left wrist pain for 1 day. The patient does recall an injury while at daycare today. He was climbing up the slide and slipped and fell off the slide. Radiographs have been obtained at Pinnacle Health which revealed a greenstick fracture. Motrin is used for pain management. I confirm that I have reviewed the Medical Health History Questionnaire which includes review of systems, past medical, social, and family history dated 07/27/2009. ' ive Exam: Const: Appears well developed and well nourished. No signs of acute distress present. Lymph: No palpable or visible regional lymphadenopathy. Musculo: Wrists: The patient is alert and oriented and complaining of pain about the left distal radius. Slight swelling about the distal radius and ulna. Full range of motion of the fingers, elbow and shoulder. Normal neurological. He has full grip strength and no evidence of compartment syndrome. Skin: No ecchymosis or rash located on the upper extremities. Neuro: Alert and oriented x3. Mood is normal. Affect is normal. Sensation to light touch is intact on the upper extremities. Reflexes: DTR's are 1+ bilaterally. No pathologic ankle clones. Xray Interpretation: AP and lateral of the left wrist demonstrates minimal displaced fracture of the left distal radial and ulnar metaphysis. DX: Right distal radial and ulnar metaphyseal fracture. Plan: Recommend short arm cast, elevation, Motrin as already prescribed by mom. Return in one week for recheck and x-ray. No sling for this youngster and protection. Seen by: Peter J. VanGiesen, M.D. Electronically Signed 07/28/2009 cc: Kathleen Mary Zimmerman M.D. PJV/kks /27/2009 3:23:50 PM -04100 PAGE 1 OF l PIN{UACLEHEALTHSystam Radiology tmagmg Report MR#: 9100497 1 NAME: SAlNTBON, AVERY SSN: 9100497'{1 28 E LOCUST ST ADM: 000'100025042 MECHANICSBURG, PA 17055 DOB: 12125!2006 AGE: 2Y ORD DR: STAGG, RICHARD D gED; ~S. ORD#: 90001 PTCLASS: O FOS ATT DR: STAGG, RICHARD D PCP: UNKNOWN, DR REASON: pain injury COMMENTS: *"'Finai Report*"* FREDRICKSEN OtAGNOSTIC DEPARTMENT PROCEDURE: FDI -4563 -WRIST COMP MIN 3V LEFT PROCEDURE DATE: Jul 27 2009 2:37PM ACCESSION#: 6254239 EXAM: Left wrist, 4 views History: Trauma Results: There is evidence of greenstick fractures of the distal radius and ulna. The ulnar fracture demonstrates minimal posterior angu}anon. No significant displacement is evident. The bony architecture is preserved. IMPRESSION: Greenstick fractures distal radius and ulna with mild posterior angulation of the ulnar frac#ure. DICTATED: (0712712009 02:35PM) TRANS: {PSC/PS) ON: 07/27/200914:36 INTERPRETED AND REVIEWED BY: THOMAS J. PIETRAS, D.O. ELECTRONICALLY SIGNED: 07/271200914:36 In the event of any questions regard'mg this report, a Quantum Radiologist can be reached by phone at 932-8030. ~1~~ ~~ r: t ~,,.,..• :=;r . .`' ~~ ~Y: ___-----.._-__...__.-- Study interpretation provided by Quattttlm lntaging & Therapeutic ASSne3attas, K you have received this document byfacswnlle, the lnforrnation contained in th'i is transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any drlsseminatlon, distribution, or copy of this communication is strictiy prohbited. If you have recelved this communication in error, pleasle notiy us immediatey at: 1-717-762-3240. ^.,••,,a. ~~.•.~~ ~nrw 9.97 GAA ORTHOPAEDIC AND SPINE SPECIALISTS, PC 1855 POWDER MILL ROAD YORK, PA 17402-4723 July 27, 2009 Avery Saintbon was seen at OSS for an orthopedic condition. ~s~ac ~ Yay, . 1~ • ~ Physician Signature: Peter J. VanGiesen, M.D. DOS: 08/05/09 ORTHOPAEDIC AND SPINE SPECIALISTS, PC Acct: 150061 Avery Saintbon DOB: 12/25/2006 Sex:MSS#: Age: 2 Subjective CC: Presents for follow up of left wrist pain. HPI: Presents for follow up. Wrist pain is minimal in the short arm cast after one week. He is doing fine. No other complaints of pain. I confirm that I have reviewed the Medical Health History Questionnaire which includes review of systems, past medical, social, and family history dated 07/27/2009 and no changes were noted. ' tive Exam: Const: Appears the stated age, well developed and well nourished. No signs of acute distress present. Lymph: No palpable or visible regional lymphadenopathy. Musculo: Wrists: Cast is intact and neurovascular status is intact. Cast is secure. Skin: No ecchymosis or rash located on the upper extremities. Neuro: Sensation grossly intact to light touch. Xray Interpretation: X-rays taken in the office today, AP and lateral of the left wrist, demonstrates good position of the fracture of the left distal radius with torus fracture. DX: Healing fracture left distal radius. Plan: Recommend elevation, protection and range of motion and return prn. Seen by: Peter J. VanGiesen, M.D. Electronically Signed cc: Kathleen Mary Zimmerman M.D. 08/12/2009 PJV/kks All-ST ATE°"IEGAI 800-2[Z-0510 ED11 RECYCLED ~~ ~ J ,X~;a~~ i ~~ DOS: 08/26/09 ORTHOPAEDIC AND SPINE SPECIALISTS, PC Acct: 150061 Avery Saintbon DOB: 12/25/2006 Sex: M SS#: Age: 2 'ec ive CC: Presents for follow up of left wrist pain. HPI: Presents for follow up. Wrist pain is minimal, about 3 1/2 weeks after fracture. I confirm that I have reviewed the Medical Health History Questionnaire which includes review of systems, past medical, social, and family history dated 07/27/2009 and no changes were noted. b' iv Exam: Const: Appears the stated age, well developed and well nourished. No signs of acute distress present. Lymph: No palpable or visible regional lymphadenopathy. Musculo: Wrists: The fracture is clinically united. Full range of motion and neurovascular status is intact. Full range of motion of the left elbow. Skin: No ecchymosis or rash located on the upper extremities. Neuro: Sensation grossly intact to light touch. Xray Interpretation: X-rays taken in the office today, 2 views of the left wrist, demonstrate a united fracture of the left distal radius and ulna. DX: United fracture left distal radius and ulna. Plan: Recommend wrist corset, active range of motion, protection and return in 3 weeks if symptomatic. Mother informed. Seen by: ~~`~• ~M~ Peter J. VanGiesen, M. D. Electronically Signed 08/28/2009 cc: Kathleen Mary Zimmerman M.D. PJV/kks %, i~ SAINTBON,. A~/ERY C-Enc #100025092-OPT-MMS-7/27/2009 Blue And White - 8/14/2009 - 1 pg ~tT~R FI~;y { 7,17 ~ ~~0 B I a9 ;S_O_8j( INSUIGNCL CONPARY NAM! GROUP RfA1BLR POLICY RUNBLR ................... wARANron CHRISLENE PREVAL '~~'~''' BSHM 0001 AR11430621 ~ 28 E LOCUST ST woDALSS MECHANICSBURG PA 17055 I I ~ ~STAGG RICHARD D I ~ ~ ~ i ....... S Y rrrrrrYWrr~ 0 ..iv .; ;:, E :: '. . .:. ;. PAYMENT 12 O[ 0 SlRVICL TOTAL 1ST. COVCRAOI LST. COPLAAUL EST. COV[AAR! EST. COVLRAO! SlRVIC! HOSPITAL SlAVICES COD! CFW1068 INS.CO. R0. 1 INS.CO. N0. 2 IRS.CO. N0. 3 INS.CO. N0. AMOUNI DETA L OF CURRENT CHARGES, PAY ENTS AN ADJUSTME TS 07/27 6661347 001 4.00 4.00 ICE PACK 00000 fl U ~5'~~ LS 07/27 6663808 001 VST ACCID EPF 07/27 6664000 001 EP G 3 ppg VIS T 07/27 6665107 001 34.00 34.00 BY; - VST ACCID EPF T/F 99202 -___ -'-'- -----_ 07/27 6665222 001 68.00 68.00 VST ACCID EPF P/F 99202 07/27 4314563 001 138.00 138.00 WRI T COMP MIN 3V - LT73110LT 07/27 0011502 001 20.00 20.00- PMT CREDIT CARD CE FORWARD SUMMF~RY OF CURRENT PAY/ADJ Y OF CURRENT CHARGES 60 OUTPATIENT VST RD RADIOLOGY SUB-710TAL OF CURR. CHARGES 0.00 20.00 I I I I 20.00- 106.OOI 106.00 138.00 138.00 244.001 244.00 GUA RELATIONSHIP: P SEX: F UAR N0: 9100497 1 ACC DATE: 07/27/09 TYPE: 5 TI E: 10:00 AM PL CE: EMPL REL: DIA NOSIS: 813.44 719.43 __ _ _ PATICITT NUMBER PLlAS AEYlR TO PATIEKT ADDITIONAL PATI®TI BILLIRO MAY S! NlCESSAR7f - 1UQ©Z5 ~~ ~ ..AY THT~ A'M{?'U~IT 0 f~0 AND EDRRESPORDlII~UIRIlS !~T ~ P~REPEAREDN.~OR ~ INSURARC! ICAARICRS ', DO ROT PAY ANY PAl[T OF THE AMOUNTS SHOW P I NNAC LE HEAL' H HOSPITALS UNDER LSTIMATlD INSUautcE covlRABL. HARRISBURG, PP1 Page 1 of 1 B3 08/31/0,9 ACCT# 150061 PH# (717)-620-8159 LEDGER CARD & MAJOR MEDICAL HISTORY FROM: 07/27/09 T0: 08/31/09 PAGE 1 AVERY SAINTBON ORTHOPAEDIC AND SPINE SPECIAL ISTS, PC C/0 C HRISLENE PREVAL 1855 POWDER MILL ROAD 28 EA ST LOCUST STREET YORK, PA 17902-9723 MECHANICSBURG PA 17055 (717)-898-9800 LAST PER PD: 529.00 on 08/26/09 LAST BIL: 08/19/09 CURRENT 30 60 90 120+ YTD NCHG: $820.00 INS# 29 = HIGHMARK PPO BLUE _TTL BAL: $791.00 193.00 698.00 0.00 0.00 0.00 YTD PPAY: 529.00 Cov: (*NOne, !Some) _ ASIGN'D $791.00 193.00 698.00 0.00 0.00 0.00 YTD OPAY: $0.00 DR #-NAME I.D. # COLL (Z): 50.00 0.00 0.00 0.00 0.00 0.00 159-DME 23-1717 421 WC/NF(W): $0.00 0.00 0.00 0.00 0.00 0.00 7-VANGIESEN, PET 23-1717 921 PEAS (*): $0.00 0.00 0.00 0.00 0.00 0.00 FEE DIAG DIAG DIAG PER CHG RECORD# FROM/TO DATES PATIEN T CPT/HCPCS DESC SCH #1 #2 #3 L D I A CLAIM CHARGES RECEIPTS BALANCE 392791A 07/27/09 AVERY FX RADIUS DISTAL C 25600 813.92 03 7 29 Y 08/03/09 $470.00 $970.00 MODIFIERS: LT 392790A 07/27/09 AVERY OFFICE CONSULTATIO 99293 813.92 03 7 29 Y 06/03/09 5168.00 $168.00 MODIFIERS: 57 392789A 07/27/09 AVERY CAST SUPPLIES/SAC/ Q9012 813.92 03 7 29 Y 08/03/09 $10.00 $10.00 MODIFIERS: LT 392766A 08/05/09 AVERY X-RAY WRIST 2 VIEW 73100 V59.19 O1 7 N N 08/07/09 $58.00 MODIFIERS: LT 412392A 08/26/09 AVERY CREDIT CARD(CK#VISA) PAYMENT O1 7 N 529.00 392787A 06/13/09 AVERY HIGHM DEDUCT(CK#992166093) PAYMENT O1 7 N $0.00 392788A 08/13/09 AVERY Accept Assig ADJUST O1 7 N $-29..00 $0.00 392785A 08/05/09 AVERY OFFICE VISIT/POST 99029 V59.19 O1 7 N N $0.00 $0.00 912390A 06/26/09 AVERY X-RAY WRIST 2 VIEW 73100 V54.19 O1 7 29 Y 08/28/09 $58.00 $58.00 MODIFIERS: LT 912391A 08/26/09 AVERY OFFICE VISIT/POST 99029 V59.19 O1 7 N N 50.00 50.00 412567A 06/26/09 AVERY WRIST SPLINT/GORSE L3908 813.92 O1 159 29 Y 08/26/09 $85.00 $85.00 MODIFIERS: GA LT .......... .............. .......... ....................... ...... ............ ............................................... GROSS CHARGES: $899.00 .......... TOTAL ADJUSTS: -29.00 TOTAL BALANCE: 5820.00 29.00 791.00 ASSIGNED BALANCE: $791.00 COLLECT BALANCE: $0.002 WCOMP/NF BALANCE: $O.OOW PERSONAL BALANCE: $0.00* VISIT COUNT: 3 SIGNATURE: PLEASE NOTE: FOLD AT "_" MARKS FOR STANDARD #10 WINDOW ENVELOPE. THE ABOVE INFORMATION REFLECTS ONE ACCOUNT MEMBER ONLY, 'AVERY ' Nov. 12. 2009 3:03PM No, 0269 P, 1 {heritage Pediatrics 372A Market Street ~ Crn~ A. Sh~~, Mp Camp Hill, PA 174N Kotklxrr M. Zimmuman, MD 717-909-4670 Lon R, Descher-e, MD fax 717-909.4675 ~ulie A. Lundblod, cxr~ ~°~[e~~pier fl•an~i~ni~t~af Page This telecepy is befng transmitted from the office of Heritage Pediatrics. If you have arty questions regarding this transmission, please call the number above, f~A'I'E:~ J TO: ~•~- FAX NUMBER: ~~lr / 91,~~ NUMBER aF pA~ES: (INCLIf~ING COVER) G(?MMENTS: ~ ~~ PEaSON i=AXING: ~l%~~•~' CONFiC~ENT(AL{TY NOTlCE:1'ha documents accompanying this transmission contain confidential intormatfon belonging to Heritage Pediatrics that is legally privileged, The information is intended only for the use of the individua{ or entity named above, if you are not the intended recipient, you ere hereby notified that any disclosure, copying, distribution ar the taking of any action in reliance on the contents of this information is stric#iy prohibsted, - If you have received this transmission in error, please notify us by telephone immediately to arrange for return of the original documents to us. Sg410M FbRM N4 (A106) lNav.12. 2009 3:03PM Heritage Pediatrics p0 Box 12942 Philadelphia, PA 19976-0942 {797 909-4670 Chrislene A Pteval 28 Et3st Locust 5tneet Mechanit~.sburg, PA 17055 Patl'~ ~~ $tNo. 02b9,n f P. 2 Thunsl.,,~, November 12, 2009 $21,00 Payment Type; ~]Gheck ^Visa ^ Masxercard ^ Discover Account # Explrptioh Date I 1 _ . _ _ Slgnsture [fete J / N~C11 snQ p11Yt 11/111 Rafl~ch trsnsaotlons posUtl tllrouah 11H?/ZOOa tor?A~999 Avery C S~nt9on(340409uKnhleen M 2lmmerman MADJF~Ot;01S4 Lacstron: Herltape PsdlatHcs D7i27/2D09 Ufl1ce / Outp>3lient Vlelt Esreblished Patient Problem Focused 564.00 1.00 S24.oo 530.00 07127f2009 Payment fi+om Freest, Chrislene A $D.OD (530.00) QtlJ05/2009 Contractual Adjustment from Blus Shield 0992162 (53.OD) 50.00 08!0512009 Payment from t3iue shield 0992162 50.00 50.00 08/05!2009 Transferirom Insurahce 0992162 ($21.DD) 521.OD The balenoe is your deduclbk which i6 not covered by your insurance. However, K ycu are enrolled in an HRA or HtSA please contact your pten edmirristntor prior to making payment. This will avoid an overpayment cn your account. 60.00 X21.00 $0.00 $0.00 ~ $O.OD $0.00 $21.00 $0.00 121.00 50.00 $21.00 Prompt payment la greatly appreciateclt Heritage Pediatrics * PO i3ox 12942 • PhOadelphia, PA 19176-0942 * (717) 909-4670 Patient Ledger Patient ID: 340409 Avery C 5aintBon Total Charges: $54.00 Birthdate: 12/25/2006 28 East Locust Street Total Payments: $30.00 Phone 1: (717) 620-81 59 Home Mechanicsburg PA 17055 Total Adjustments: $3.00 Phone 2: Insurance Balance: $O.oo Patient Balance: $21.00 Vtaft Company Doctor FaeNity Ticket Number 3ervlee Code DsscriptJon Units Fse Insurance patiartt 07/278008 HarRage PsdiaMes 2]mmsnnan MD, Kathleen M PBDS HP080184 . s14.00 UnepseMled closed trscsse a carpel bone 078712009 Paytnerd so.oo (530.00) 07/27/2009 98212 Ollipe / Outpeuerk Visit Established Patient Problem Focused 1.00 554.00 524.00 130.00 081058009 Corkractwl Adjustment (53.00) 50.00 08/058009 Payhtent 50.00 50.00 08/05/2009 Transrer from Insurance (521.00) 521.00 Notes: Tire balano0 is your daductlble which is not eovarod by your tnsraarroe. However. K you are enrolled in an HiZA or HSA please sarrtact your plan edmihistrator prior to rnekinq payment. This will avoid an overpayment on your examt. Vlsk TotaUt3alanee Due 10.00 S2t.o0 SeNcbd 1/(slt Totals 10.00 S21.a0 Qmou t~- ~ tl dui +~ s vas ~ ~- ~,~- Rcsp~1S~ trJLo Qo~r 1110?l2008 3:45 pm Heritage Pediatrics Page 1 of 1 Patient Ledger eutc o~-sociates 629D Lowther Road LEWISBERRY, PA 17339 Phone: (877)932-5955 Fax: Tax ID#:251792806 Account Ledger 112713 - SAINTBON, AVERY s of 11/4/2009 12:30:16P Date Ref. Phys. Physician Procedure Charges Payments Adjustments Balance Paysource Ins Plan # 08/10/2009 Payment $0.00 $23.00 BCBS ADJ HIGHMF Payer: HIGHMARK PPO I Chk#: Chk Amt: $0.00 07/27/2009 STAGG, RICHARPietras, Thomas J -WRIST MIN 3 VIEWS $38.00 538.00 S0.00 523.00 515.00 Account Total: 538.00 90.00" $23.00 SiS~O Due From Insurance: 50.00 Due From Patient: 915.00 ~~ ~~~i~r' ~ ~ 2~~'9 I, B Y: -------------------- Page 1 of 1 NOU;04-2009 12:52 CORPORATE OFFICE 629D LUWTHBR RD LEWISBBRRY PA 17339-922a Telephone: 717 938-2765, ext Z3z Fax; 717 932-3095 QUA~NTIT~VI IMAGING FAQ 70: Christina Bradley Firoirn~ Nicob Feathers Fax: 717$71-1880 Pa~sc 3 (Including Cover Sheet) RE: Avery Sairrt Bon Date: 11/4x2009 lanclosed is the invoice for the medical/billing records you requested. We require payment in advance before we send items oui~ Once payment is received, the items will be mailed UPS per HIPAA guidelines. P e bg,~dvised that h W pur curre t p,~lics~r_e¢ardingh~o n,, f h ital/f ciii t edical cor bill ll h ds a ~~ ,e~ow has inf rmatian. You mus or ima s. t g it~~ng r~p provi , a ~Ity o t still contact the hose, ital[~ty Q,~ts as we . as t ing e for cope a ctu lm s We are unabl~~rovide bi ling recar~s~rg t e yea OQO. We a~logi~e for the into ve a ce If you have any questions please call me Monday through Friday 8:00 to 4:00. Please also note the phone number to reach me has changed. Thank you, Nicole Feathers This fax is intended only for the person or entity to which it is addressed and may contain confidential and/or privi egad material. Any review, retransnussion, dissemination or other use of, or talcit~ of any action in re~ianco upon, this information by persons or entities other than the intended rxipienc is prohibited. ', If you received this in error, please contact the sender and destroy any hard copy you have received. P . 01 NOV~4-2009 12 52 P.03 • , ,• ~ ' ; .CHARD E. FRESBU~tN ~ ~ , • •BTET~iEN A. SCttNDtA~It , ' , ~ •~ ~ J~r~.,i \ '' ' LAWRENCE F. BARONE ~ ' • , 1 ~~ CFiRI871NA I.. •DRAAL4Y~ , . r ~J~~~T~~~~ 1 ROBERT' D. FIAMI].TON (1967-2005) • 1' • ' Ctuistina L. Bradley , .Your Personal I~ury.and Worke7s' Compensation Attorneys ~ Wrlc~r's Extension: 9 , ~ ', ' , ' ChristiizaH~~a-~jurylawjrer.com ' , ' , • • • . ' ~ ~ OCtObC.T 26, 2008 '. Attn. ' Patient AcaouAts ~ ,• ~ , ' , Quantum ,~ma~ig ~ilfing Departmrent . . ~ ' . ~ • ' ~29'.I9'L.:c~atlicr. Road '' . ,f , , . ~,; ; •,~~ , • • , , , • , t , . ' , • ', • Lcaisbc~y,''PA 1`7`~3~ ' ''~ ; •; ' :,•' ;• ~ • .r , ' • ' ' : • '. ' ', , . . • ' ' • , ' ' ;i, 5~5"+~. ,•~~e ~~~•'~~1;.~`~in.`;•a. .i'. ~.~~'\•~~. 'o:..~.~,i y%''' '~"ti;i .<.:~ ~.:.,;'. `Y'. ~tZ ' '•N(!,v;~':;~. ' .~.A ~;.~.• •r~ Y , ~• ~~ ..,~ ,S r.,! 'Y ~4" 1~f J~;:.+,~,5 ,y .\• "/~i, ~'~~.~t''~6{ ;~tt,h>~i.±.;! ~ r'. ,~t~wf:~'FGc`rkRr~y': S ~~ ~'~ f:~~• 5 :~.:,~.. ~a. ~,~~i'.'t•' 'S j 5',a S'1;^~',`t b~~::»y}«;t"r,, !.a "• •~\,~L';~t• ~.• ~^ 1{~' 5.'~., ;k~:, ;,~M ~~ '•'.!•f~ ,I:J., ; i 1; . ~. • r.; ' .•! t5w,i`;,t ^~~~~~t ~/. ' .. ` ~ _~• ,i:4$ ~ II~ •~',.,s^ ; ,7,~~,i~1rN.~~''4•" ,,, •,. ~ r. 'v1 'Yit', ~ .'1"^ ~ r "?r'•' ~~ ;1. • i. 4~t ' ~ Dattel o>~` Alocideatc 7/ X7/,04 • • , . • • ~ . D'eair Madam ~ Sir:• ~ 1 • ' ' , . ,~ . .Taus' is to' advise 'that our Srm represents ~ Avery, Saiitlt • Bon in connectibrt witi,'t • • , , injuries •he . suff'ered' on. July Z7, 2009. I ~wo~d grcatlY apprecigte'•.it •if yoi~ wotild • ~ ~ ' . gtoa3da ane with 7onr itsm~d bivin~'it~itt~ent sho~wii~ ahar~es and 1-arinerita~ , ` ' . ' . , ' mpda;~n•7/x7/09 to the present. ~ , ' , ; . ' •, , , ' ' • So that'you know'that our office is authorized to receive this ,information, Zhave • ' , • ~ . ernGlo'sed. a properly' executed medical ~uthprization. Please bill •our office, directly for ' ' .' ~Y capying,oharges,y~ou may incur with'regatd to this request. •~ , ' • Yot~ dooper~ttion iu'this matter' is ~~tty appreciated. •• .. . , ' ~' . r. .••1r. 5'I• • •5 'r{ •.I rr~l; I5 )'~• • r~ .j'~ ','r;N . ,~1• ~ ~• ` ..J •f• , '~,..',~~ IJ~~~ ~1. ry,'1••"~l/''~ •nli• ti.~(!In',,''1.,. ~ r~•1'•11' '`l\~_~'y;,~i ,i(".»~ ~r,`,3'n , ,r, •;5.,,•,'".a,•„~ , ,• I 1~ . , '~•1••" ~ ~iill~tu~ L~ 'Dra,~lry' r 1 ~ ' , c: ~ Mz-. aa~d 1Vfrs. • Grcr Saint Hwz ~~ ' , '. , .• ~ , , •. .. ,~ , r ---- --, -- - -- - . ~, ,~.~_ , ' . ' 4415 North' Frosit $tieet, Harrisburg' PA 17110• , ' www.pa=iiijury),avP'yer,c+Am ' ' • . ~ . (717)'671-1955 • flex: (717) 67T~196Q ' ~' (800) 303x8005 .'' ,• 1, ' . • • TOTAL P.03 FEB-09'-2010 16:15 From:PHR00M FAX 7177419623 To: 17176711960 Paee:1~7 Orthop~ediC ~ Spine SPECIALISTS FACSIMI~.,E T~~A1~TS]ViISSItJN bate: ~ o/o Time: # of pages (including cover sheet) 7 Fram; Jlutlic G~ro~cost--Manancr of Paticn~ Recounts Direct Dial for questions: 71~-747-$~Sy Comments: ORTHOPAEDYC & SPINE SPECIALISTS, PC Phone: qty-$q/8-.Soo, >;xt. 4539. Receiver Fax: l `7~ 1.~~ ~ y t ~' ~ 9 ~p~ Contact sender in case of transmission problems. p'ax: n~-vai-x867 This facsimile contains confidential information which may also be legally privileged and which is intended only for the use: of the receiver. If you are not the intended receiver you arr. hereby notified that you are prohibited from disclosing thi.~ in#onnation and should take immediate ac:tinn to deliver this facsimile to the intended party within your facility. If you have receivel<i Chic facsimile in error, please oontaet the sender immediately and destroy the copies you have received. 18SS Powder Mill Road York, PA 17A42 717-84$800 FEB-09=2010 16:15 From:PHR00M FAX Attn: Patient Accounts - Orthopedic 8s Spina Specialists 18SS Powder Mill Road York, PA 17402-4728 7177419623 To: 17176711960 Pa9e:2~7 F ISDa~~ '~~ ,~ 3 2DtD R-cHAR~ s. ~Rr~euRN 9TRyHH:N A. 3t:HNhIDER ~.AW~tGNCw N: OARONF; . CHR15T(NA L. BRAVLEY ROARRT D. !ftAMILTON (1067-20h5} chzdstine~ L. $raaiey Writer's extension: 9 ChristinaB(ir~pa •in ju lylawyer. com February 3, 2010 R~: Avery Safat Boca, . $$~1: i~fifi-1'T-$,x.20 DOB: l2/Z!g/Z047 ,?ate of Accideat: 7 / 27 /.'09 Dear Madam ar Six: This is to advise that our frrm represents the above-referex)ced patient in eonn.cetion with injuries su#fercd~ iiY azi accident; It is our understanding that your offices prodded medical services to our client. 'Y'b-ia i~ aot ~- ~te~~g~, fox cotiies o#' bfl4~ ` This Ictter is to simply canfitm that Sue in your office has adysed us that the amount of your outstanding medical bill is $. ~(~Gg . lG~,,~;~~,, 3~r~ We. are relying on t17is iraform~itio». for purposes of making a settlement dcxnttnd. Therefore, if tha.s ixiformaiibn ir; not correct, you must inform us immediately, 1f we do not hear from you within eve {5) business days from the date of Lhis letter, we will proceed with the assumption that the information contained hereis-, is Accurate. Very truly yours, i ~.~a,d.Rrs.- Christina L. Bradley_ O CI:B/jad c: Mr. & iVlrs. Cxregory Saint Ban 4415 North Front Street,. Harrisburg PA 17110 www:pa-injurylawyer.com (717) 6711955. •. Fax: (,717) 671-196f) i (800) 303-8005 Your Penonw iniury aed Workers'' Compensation Attornel'ItF' FEB-09=2010 16:15 From:PHR00M FAX 7177419623 To: 17176711960 Pa9e:3~7 Jr; U?/(iy/7 r1 ACt7;1 11j00 b1 FMM t~71r-b3U-11159 LL•DGiZk r:nxu t'RUM: UO/O~J/Oii ,"V: UZ/Uyr10 ~nc9r 1 AVERY SnrrLT'NUN Ukl%UL'AEDI~ AN6 Sp1P1E :;PECIRLI^T PC !:/U C' HSISLENC PRF.VAT. 1tisS FOWDFR MILL ROAD ?8 tAS'1' LOCUST ?TRFF~T YORK, PA 17.103-112:7 MECNANTCSBURC: Pn 77055 ('r17l-8~8-4800 L.?ST PCR P7: 5a9,UU Gn Dn/?6/09 ~A:~'I BIL: 11/17/G9 CC~RRENT 3C r+0 ~0 1?0+ YTD N~:IiC,: :'154.42 7NS1 i9 - IIiCi11MARK PpfJ BLUR 11L 1Lo.L: 5659.16 1b4.4? O.OU U.00 u.00 514.74 YTD FPTa: 50.00 160 ~ FrS-Dirggt Collect eL'i1teN'C• X0.00 t1.OG 0.00 0.00 (?.irn 0.00 YTD OFAY: $O.UtI •168 - FCA PRFnnr.l.t'.cT t:fJLt. (7!: ;669.16 154.42 0.nrt O.Gu 0.00 51a.'ra (:nv: (•NCi7e, !Snmg1 Wt:/NF(w!: 50.UU G,QO o.00 u.DO O.00 O.bo wl 1-rt~Me 1.D. + FER^ 1 * 1 : SU . UU 0.00 17. (tip O. UC 0. ,7;7 rJ . UU 7 VAVGIESCN, v~ ~i 33-1 11'!•721 ls4-DM6 33-1'r17/21 ~'k:E GIAC rirr~: DIAL rr:K ('Hr~ Rft'AR~I t'KUM/TO AnTF.; PATIENT Cfi7/HCC('D DE: C. ;'~::H rtl f? N) CL 1 A CLAIM ~:M?Jlf;p$ R!a'EiFT.^, RTi.nyCE YUU125A 07/3'!/09 AVERY t'7G RADIUS DISTA.1. !; >>EiUU tl13.4) U:i ? 169Y 13/lU/oy SgTQ.OU M(LDlFIERS: LT 7!7G436A lU/CI/09 AVFkT HIGIM AF:UUI:1 l~K4N93.!1 Yyfifi) FAYMl:NT 03 7 N 50.00 :!UOe3'/A lfilfil/09 nvkHY Ar:Ca`.{n( Ae~oig ADJUZT G3 1 N $-li~.tt(1 $395.(tU7 YG042A 07/37/09 AVERY Ofc'1c-E raN^;itTATIU :+93a:1 H7'i.1~ 117 7 169Y 1?/70/09 :168.00 MODIFIER;':: 5 i 300423A 70/01/09 AVERY NTr,RM LeuurTlcKAyv~13B001 PAYMENT 03 ! N g0,UU 3004?aA 10/G1/09 AVLHY nr:CE+pt Assig ArnrllST' 03 ! N s-•li.nn cl:+s.UU2 3iUg19A Ci9/26/09 AVERY x-RY1'f WRl:l 3 VIEie ?7100 V:i4.19 O1 ! 169Y 17/70/0:1 rsu.oo MOOTFa-ER."+L LY 3U091C?A P9/03/C•9 AY<:HY HTGHM ULL`UC'T(f'KNyy~1Rf:3471 PAYMENT G1 1 N :•0.00 7Ui147.7n 09/03/Uy AVERY anr,.aT+t AsBiy i~D.ill6:i' 0, 7 N $-39.60 539.OUZ if7i741fA X18/2b/U9 AVERY Wxlc:7 i FORFhRM Et L1JUb tl13.4? O1 154 169Y 13/lU/(;y 58.5.00 MOLLIFIERS: feP. i l 70A117p 09/03/041 AVERY HI~3HM Dr•.nUi]'l (C'KNJ821tlR:147} FAYMltNl' O1 154 N 50.00 iC14418P. U9/07/G9 nVFxY' Arrr':yr. A:;rig Al:•JUST O1 104 N .°,-9.3b $00- /IZ Ib:+2b6A 02/:'3/lU AVERY ..^+~RV1C! CHAR~I•: at~HV1 U7 7 169Y 0 2 /0 311 11 X159.42 5159.42'L GKUu:i C1IARCT.$: 593.43 • •, • • •' 'r(rrAL nn,rUgpSr -266.?.G TOTAL BALANCE: SRfi4.1G 4.QU 669.1f n„rrNel, BALANCE: t:OLl.r,r;l• BP,LAN['6: pfiGr.lfr- • WC:UMF/NF BALTNC.i'L Sa.UUK FEn:ONAL DRTJINC,'k': ~q,p(~~ vI5IT COUNT: 1 IGNRTVRE: LE11~E HOTEL F'ULD AT "_" NARKS FDR :TANDAR~ 110 WINDCW ENVFI,ppt, TILE P.DOV6 1N121RMATION RF.FLtlC'I'8 UNE A~=:7O0NT MtiMBka( ONLY, '' qe.~~...~. R, aoo9 d~ FEB-09=2010 16:15 From:PHR00M FAX 7177419623 To:17176711960 Pa9e:4~7 02/09/lU ORT110PAEpIC 1~ND SPINE SPECIAL'I'STS, PC Page ' Notes for At:c:~utit # 150061 - SAINTBON, AVERY Ddl.e Type Note 12/09/U9 COLL AUUEU '1'0 YRECOLLECTIONS LIST...SH 4466 3a°la ~- °y'~O.a`d ~ `~'~`~` Dau.~-' d 7~3,'a oo9 FEB-09=2010 16:16 From:PHR00M FAX 7177419623 To: 17176711960 Pa9e:5~7 QRTHOPAEpIC AND SPINE SPEGIALISTS, PC 9855 POWDER MILL ROAD YORK, PA 17402723 FINANCIALIPAYMENT PQLICY Thank you for choosing Qrthopaedic & Spine Specialists as your health care provider. We are committed to the success of your medical treatment and care. For your convenience, we have answered a variety of commonly asked questions regarding our financial policy. If you need further information about any of these policies, please ask to speak with one of our staff from our patients accounts department. How May I Pay? We 8ccept payment by Crash, personal check, VISA, Mastercard, and Discover. A $25.00 fee will be charged for all returned checks. Do I Need a Relerrat? If you are a member of an HMO that we participate with, you will need a referral form from your primaryry care physician. Your HMO requires us to obtain a referral form regardless if another pf +s ,nvoived or not, i.c., workers' compensatwn or auto insurance. 1,fyou da not~Y~,~for~itt Which Plans Do You Contract With? Please see the attached list. What Is Myy Financial Responsibility? Insurance is an agreement between you and your insurance company, We do not become involved in disputes between you and your insurance company regarding deductibles, co-payments, non-covered or denied services. Your financial responsibil+ty depends on a variety of factors, explained below. Durable medical equipment (splints, crutches, slings, etc.) may not be covered under your insurance policy and will become your responsibility +f denied by insurance. What if My Child NeQds to bs Treated? A parent or legal guardian must accompany patients who are minors {under age 18) on the patient's first visit. The accompanying adult +s responsible for payment of the account, according to the policy outlined below. If a minor attends foNow up appointments on their own, the cams payment policy will apply. May I RocQive a "discount" on any of my charges? We receive many requests to disoount our fees from patients who are uninsured or underinsured. In order to address those needs we have developed a "Prompt Pay Policy" that may be applied when charges are paid in full at the time of serve. This does not apply to co-payments or co-insurance which are a requirement from your insurance company, Please ask to speak to one of our Patient Accounts representatives if you think you may qualify for this discount. FEB-09=2010 16:16 From:PHR00M FAX 7177419623 If You Have; You are Responsible For: Commercial Insurance Also known as indemnity, re~ular insurance or an 80 /o - 20% plan For a minimum payment of 20% of the total for services rendered will be due at the time of service. HMO ~ PPO PLANS with which we sre a articipattng provider. Please see attached list.) if th~3~tYlGesyou receiv._e are sove,~bv the plan: Alt applicable co-pays and deductibles are "required" at the time of service. .If the serviresyou receive are net steed by the~nlan: Payment in full is "required" at time of service. "MAMSI-RADIOLOGY To know if you may have radiology SERVICES services performed in this office. Some MAMSI plans will 11pt contract with OSS for radiology services. MAMSI may require you to have your x-rays, MRI, or C7 5can et another facility. HMO & PPO Plans that we do not participate with. For payment in full at the time of SeNICe. Point of Service Plan or Out of Network Plan To: 17176711960 Our Staff Will: Pase:6~7 Submit your insurance claim for you. WC will assist in any pre-certification orpre-authorization rocess necessary. e will Collect all payments that are due following your visit. Submit your insurance claim for you. We wits assist in any pre-certification or pre-authorization process necessary. We will collect all payments that are due following your visit. If ca-pays are not paid at time of service a re-billing fee will be applied. Bill you for radiology services not covered by your insurance. Submit your insurance claim for you We will collect all payments that are due following your visit. For payment of the patient responsibility, Submit your insurance claim deductible, co-pay, non-covered servicES for you. We will collect all payments is due at time of service. that are due following your visit. MEDICARE If you have regular Medicare, and have Submit your insurance claim not met your $1315 deductible, you will be billed for any balance due. for you as well as any claims to your secondary insurance. Payments for any services not covered by Medicare are to be paid at the time of service. If you wish to be on "automatic crossover' for your secondary insurance, you must call your secondary insurance to set this up, AUTO INSURANCE Providing accurate and complete policy and Call to verify your coverage. Submit claim and accident information for your auto insurance, including your agent's name and your insurance claim for you. telephone number. You must also provide your health insurance information in the event your policy has exhausted. FEB-09=2010 16:16 From:PHR00M FAX 7177419623 To: 17176711960 Paee:7~7 If You Have: You aro Responsible For: Our Staff Will: WORKERS' Providing accurate and complete COMPS;NSATION infomlatron including your claim number, date of accident, and a contact name and number from your place of employment. You must also provide your health insurance information in the event your claim is denied. A PER3gNAL BALANCE: verity that we are an approved panel provider. Call to confirm that your claim has been reported and to verify your claim number. We will submit your claim and all required information. or NO INSURANCE A minimum pa ment of $100.00 Will counsel you should you at time of service if you have no have a need for a payment insurance. A personal balance on your or other payment atxount will require a Q]l01112um monthly arrangements. payment of $60.00. Personal balances must be paid in full within (6) months. M is fmpoctant to the pphysicians of OSS that our patfenta romafn informed aNbout our practice. Our physicians have financial fnteroat In the OSS Ambulatory Su ary Cantor, Ima~fnQ Gunter, and 7'horapy Center. You have a chofco whether or not you wish to receive aervlces~n th~ao facllltlva. I have read, understand, and 8~nae to !hs above Financial Policy. !understand that charyss not covered by my inauranco, as well ea applicable co-payments acrd deductfbloa, aro my respons/bfllty. I authorfsa my Insurance benef/ts to be paid dfroctly to Orthopaedic b Spine Specialists 1 authorize Orthopaedic 8 Spine Speclapsfs to roisaae pertinent m~cfica/ Informat/on to my insure»ce company w~+afiregaeated,-or to-tacllitate~paymerrtota' c7STin. ' .~~' ^___- _ _ f under stand that my account may ba fumed over to a collection apency after 60 days artd will be asses sses d as 30'i6 collection fie. I will be responsible to pay the collection fee si+ould that occur. Patient 5i~nature or Parant/Guardian for Minor Patient 07/27/2009 Date Patient Name: Avery Sr3lntbon 03/i0/YO 09: i1 AK ^edent: via VSI-FAX Fax# (717)-747-2956 Page 1 of 2 s145698 8 FAX COVER SHEET TO NAME: C OM PAN Y FAX PHONE: FROM NAME: COMPANY: VOICE PHONE: FAX PHONE: SENT ON: PAGES: SUBJECT: FREEBORN-HAMILTON ATTORNEY CHRISTINA BRADLEY 7176711960 MICHELE MYER~~~T ORTHOPAEDIC AND SPINE SPECIALISTS, P 1855 POWDER MILL ROAD YORK, PA 17402-4723 (717}-848-4800 (717}-747-2966 03/10/10 09:10 AM 2 PER REQUEST FROM PATIENT'S MOTHER. THANK YOU. Confidentiality Note: The infomation being prov~ded with this fax may contain protected health information as defined by Federal laws and regulations. This infonmatio is intended only for the use of the individual or entity named above. It is being faxed to you after appropriate suthorizati~n from the patient or under circumstances that do not require patient authorization. You are obligated to maintain it in asafe, secure and confidential manner. Re-disclosure without additional patient consent or as permitted by law is prohib ted. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties under Federal and State law. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this fax in error, please notify the sender immediately to arrange for the return of these documents. Please contact the sender, at the above contact information, to verify receipt or if you have any problems with the tronemiecinn of this fA~r 03/10/t0 09:11 AM ^edent via VSI-FAX Fax# (717)-747-2986 Page 2 of 2 #145698 B= AVERY SAINTBON ORTHOPAEDIC AND SPINE SPECIALISTS, PC C/0 CH RISLENE PREVAL 1655 POWDER MILL ROAD 28 EAST LOCUST STREET YORK, PA 17402-4723 ME CHAN I CSBURG PA 17055 (717)-646-4 800 LAST PER PD: $29.00 ~ 08/26/ 09 LAST BI L: 11/11/09 CURRENT 30 60 90 120+ YTD NCHG: $154.42 INS# 29 = HIGHMARK PPO BLUE TTL BAL: $669.16 0.00 154.42 0.00 0.00 514.74 YTD PPAY: $0.00 169 = PCS-Direct Collect ASIGN'D $0.00 0.00 0.00 0.00 0.00 0.00 YTD OPAY: $0.00 * 168 = PCS _ PRECOLLECT LOLL (Z}: $669.16 0.00 154.42 0.00 0.00 514.74 Cov: ( +NOne, SSome) WC/NF(W): $0.00 0.00 0.00 0.00 0.00 0.00 DR #-NAME I.D. # PEAS (•}: $0.00 0.00 0.00 0.00 0.00 0.00 7-VANG IESEN, PET 23-1717421 154-DME 23-1717421 FEE DIAG DI AG DI AG PER CHG RECORD# FROM/TO DATES PATIENT CPT/HCPCS DESC SCH #1 #2 #3 L D I A CLAIM CHARGES RECEIPTS BALANCE 261906A 07/27/09 AVERY FX RADIUS DISTAL C 25600 813.42 ... . 03 7 169Y 12/10/09 ......... $470.00 ......... .......... MODIFIERS: LT 261907A 10/01/09 AVERY HIGHM DEDUCT(CK#992213800) PAYMENT 03 7 N $0.00 281908A 10/01/09 AVERY Accept Aeeig ADJUST 03 7 N $-175.00 $295.002 281903A 07/27/09 AVERY OFFICE CONSULTATTO 99243 813.42 03 7 169Y 12/10/09 $166.00 MODIFIERS: 57 281904A 10/01/09 AVERY HIGHM DEDUCT(CK#992213800) PAYMENT 03 7 N $0.00 281905A 10/01/09 AVERY Accept Aeeig ADJUST 03 7 N $-33.00 $135.002 7500579H 07/27/09 AVERY CAST SUPPLIES/SAC/ Q4012 813.42 03 7 29 Y $10.00 MODIFIERS: LT 7500580H 10/01/09 AVERY HIGHMARK PPO(CK#992213600} PAYMENT 03 7 29 Y $0.00 7500561H 10/01/09 AVERY ACCEPT ASSIGN ADJUSTMENT 03 7 29 Y $-10.00 $0.00 7368841H 06/05/09 AVERY OFFICE VISIT/POST 99024 V54.19 O1 7 N N $0.00 $0.00 7368842H 08/05/09 AVERY X-RAY WRIST 2 VIEW 73100 V54.19 O1 7 29 Y $58.00 MODIFIERS: LT 7368843H 08/26/09 AVERY CREDIT CARD(CK#VISA) PAYMENT O1 7 N N $29.00 7366844H 06/13/09 AVERY HIGHM DEDUCT(CK#992166093} PAYMENT O1 7 29 Y $0.00 7368845H 06/13/09 AVERY ACCEPT ASSIG ADJUSTMENT O1 7 29 Y $-29.00 $0.00 281900A 08/26/09 AVERY X-RAY WRIST 2 VIEW 73100 V54.19 O1 7 169Y 12/10/09 $58.00 MODIFIERS: LT 281901A 09/03/09 AVERY HIGHM DEDUCT(CK#992186347} PAYMENT O1 7 N $0.00 281902A 09/03/09 AVERY Accept Aeeig ADJUST O1 7 N $-29.00 $29.002 281697A 08/26/09 AVERY WRIST & FOREARM SP L3908 813.42 O1 154 169Y 12/10/09 $65.00 MODIFIERS: GA LT 281898A 09/03/09 AVERY HIGHM DEDUCT(CK#992186347} PAYMENT O1 154 N $0.00 281899A 09/03/09 AVERY Accept Aeeig ADJUST OS 154 N $-29.26 $55.742 7368840H 08/26/09 AVERY OFFICE VISITJPOST 99024 V54.19 O1 7 N N $0.00 $0.00 281896A 02/02/10 AVERY SERVICE CHARGE SERVI O1 7 169Y 02/02/10 $154.42 $154.422 ......... .............. ............ ........................................ ............................ GROSS CHARGES: .......... $1003.42 ......... .......... TOTAL ADJUSTS: -305.26 TOTAL BALANCE: $698.16 29.00 669.16 ASSIGNED BALANCE: $0.00 COLLECT BALANCE: $669.162 WCOMP/NF BALANCE: $O.OOW PERSONAL BALANCE: $0.00• VISIT COUNT: 4 SIGNATURE: PLEASE NOTE: FOLD AT •_• MARKS FOR STANDARD #10 WINDOW ENVELOPE. THE ABOVE INFORMATION REFLECTS ONE ACCOUNT MEMBER ONLY, 'AVERY ' ALL STATE LE3AL SUP?L.Y CO.ONEC;!>MMERCE DRI`.'E CRA NEORD. NEW JERSEY O]O1S l2~ EDi1 s~ ~X~~~,~ / // PARENTS-GUARD/AN RELEASE AND INDEMNITY AGREEMENT FOR AND IN CONSIDERATION of the payment to me/us of the sum of Six Thousand dollars and no/cents Dollars ($ 6,000.00 _~, the receipt of which is hereby acknowledged, V/we, the undersigned, father and mother and/or guardian of Averx Saint Bon - a minor, do forevet release, acquit, discharge, and covenant to hold harmless First Church of God and Cincinnati Insurance Company heirs, successors, and assigns of and from any and all actions, causes of action, claims, demands, damages, costs, loss of services, expenses, and compensation, on account of, or in any way growing out of, any and all known and unknown personal injuries and property damage which we may now or hereafter have as the parents and/or guardian of said minor, and also all claims or rights of action for damages which the said minor has or may hereafter have, either before or after he has reached his/her majority, resulting or to result from a certain accident which occurred on or about the 27 day of Jul~_ , 2009 , at or near plaxground Firtkenbinder Park Green Street Mechanicsburg Cumberland County, PA _ I/we further promise to bind myself/ourselves jointly and severally, my/our heirs, administrators, and executors to repay to the said First Church of God and Cincinnati Insurance Company heirs, successors, and assigns any sum of money, except the sum above mentioned that he/she/they may hereafter be compelled to pay on behalf of said minor because of the said accident. It is further understood and agreed that this settlement is the compromise of a doubtful and disputed claim, and that this payment is not to be construed as an admission of liability on the part of First Church of God and Cincinnati Insurance Company by whom liability is expressly denied. I/we further state that I/we have carefully read the foregoing release and know the contents thereof, and I/we sign the same as my/our own free act. WITNESS In presence of hand and seal this day of 20 CAUTION: READ BEFORE SIGNING day of (SEAL) (SEAL) STATE OF _ COUNTY OF On this 20 ,before me appeared SS: to me personally known, and who acknowledged the execution of the foregoing instrument as free act and deed, for the consideration set forth therein. My Commission Expires Notary Public Any person who, !with intent to defraud or knowing that he is facilitating a fraud agains an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. CL-'1230 (7/00) Christina L. Bradley, Esquire FREEBURN & HAMILTON ID No. 89107 4415 North Front Street Harrisburg PA 17110 (717) 671-1955 christinab@pa-injurylawyer. com AVERY SAINT BON, a minor, by GREGORY SAINT BON AND CHRISLENE SAINT BON, GREGORY SAINT BON in his own right, and CHRISLENE SAINT BON in her own right, Plaintiffs v. FIRST CHURCH OF GOD, Defendants OF i`HE PROTHOI tVOTARY 2~~0 OCT' 2S AM 8:44 CUMBERLAND COtJMTY Attorney for P1ai~i1~NS YLVANIA IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. I D - ~0~08a C1V~ 1~L11'1y ORDER AND NOW, this ~~~ day of C/ C~f~~ 2010, upon consideration of Plaintiffs' Petition for Approval of Minor's Settlement, Plaintiff's Petition is APPROVED and it is hereby ORDERED AND DECREED that: a. Gregory and Chrislene Saint Bon are authorized to sign all documents necessary to accomplish the settlement, including but not limited to the Release, individually and as parents and natural guardians of Avery Saint Bon, a minor, and all checks; b. Distribution of the settlement proceeds as set forth in Plaintiff's Petition for Approval of Minor's Settlement, is approved and funds to be distributed as follows: 1. Total Settlement 2. Attorneys Fee 25% - 3. Unpaid Medical Bills -Pinnacle Health - Orthopaedic 8v Spine Specialists - Quantum Imaging 4. Gregory and Christlene Saint Bon for out-of-pocket medical bills/expenses 5. Net to Avery Saint Bon, a minor to be deposited in a savings account in the name of Plaintiff Avery Saint Bon with PNC Bank. A hold would be placed on the account so that no transfers or withdrawals could be made from the account until December 25, 2025, when Avery Saint Bon reaches the age of 18. $6,000.00 $1, 500.00 $ 145.17 $ 669.16 $ 15.00 $ ?0.00 $ 3,600.67 c. Petitioner to file a Praecipe with the Prothonotary of Cumberland County marking this matter settled and discontinued once the $6,000.00 payment has been received and the savings account opened and funds disbursed; and d. Stay of all proceedings. BY THE COURT: ~~ 2 AVERY SAINT BON, a minor, by GREGORY SAINT BON AND CHRISLENE SAINT BON, GREGORY SAINT BON in his own right, and CHRISLENE SAINT BON in her own right, Plaintiffs V. FIRST CHURCH OF GOD, Defendants c AVERY SAINT BON ACCOUNT AGREEMENT Z By, Pennsylvania:' J ?d rTt? ?a fW?HEREAS, a copy of a Order Approving Minor's Settlement has been provided to I? r &n IL V I I?' Q I i Pennsylvania; and, WHEREAS, the net settlement proceeds in the sum of $3,755.09 has been deposited in a bank account in the name of Avery Saint Bon with ics Y , Pennsylvania (hereinafter referred to as the "Avery Saint B((??on Bank Account");'and, ???,,,?r i WHEREAS, TIC , r)(411? ffle( (r , Pennsylvania is insured by the FDIC. A? Y Pennsylvania, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. ??-(o (0 8a '?' zr- -acs C) AGREEMENT !"1J 0 0113 c-? N) co -tr c; a r? agrees that a hold will be placed on the Avery Saint Bon Account so that no transfers or withdrawals can be made from the account until Avery Saint Bon attains his majority, except as authorized by a prior Order of Court. ATTEST: By l Print Name and Position with Bank COMMONWEALTH OF PENNSYLVANIA Notarial Seal Barbara I Miller, Notary Public Medwftbm em, Cumberland CountY Cammbsi n Bq*u Aug. 31, 2014 I my Member. PennsvlvaNa Association of Notaries X11, ? Christina L. Bradley, Esquire FREEBURN & HAMILTON ID No. 89107 4415 North Front Street Harrisburg PA 17110 (717) 671-1955 christinab(a pa-injurylawyer.com FIL' FILED-OFFIC; OF THE iy TI'IaOTI.,CII?€Ci , rr,t, 2010 DES 5 1 ?.010 DEC 28 PM 3. E 1 CUMBEI U N T Y CUMBERLAND COUNT'' PEN II Attorney f644ff'N'VLVAN1A AVERY SAINT BON, a minor, by GREGORY SAINT BON AND CHRISLENE SAINT BON, GREGORY SAINT BON in his own right, and CHRISLENE SAINT BON in her own right, Plaintiffs v. FIRST CHURCH OF GOD, Defendants TO: Prothonotary IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 10- (COSH PRAECIPE TO DISCONTINUE Kindly mark the above-captioned matter settled and discontinued. Respectfully Submitted, FREEBURN & HAMILTON, PC By:alAl?j d 0," Christina L. Bradley, Esoire I.D. No. 89107 4415 North Front Street Harrisburg PA 17110 (717) 671-1955 Date: 12/22/10 Counsel for Plaintiff