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HomeMy WebLinkAbout11-3371IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: DONOVIN M. ESPENSHADE, a Minor, by and through his parents and natural guardians, HARRY ESPENSHADE and JENNIFER ESPENSHADE, Petitioners. R0222284.1 CIVIL DIVISION ?- 331( ( l vl No . . PETITION FOR COURT APP C? OF THE SETTLEMENT OF THE CLAIM OF A MINOR COUNSEL FOR ALLSTATE INSURANCE COMPANY: DIANA M. O'CONNELL, ESQUIRE PA I.D. #206795 ROBB LEONARD MULVIHILL LLP Firm I.D. #249 BNY Mellon Center 500 Grant Street, 23`d Floor Pittsburgh, PA 15219 (412) 281-5431 D ov,? agaoo ? # a57asq IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: DONOVIN M. ESPENSHADE, CIVIL DIVISION a Minor, by and through his parents and natural guardians, HARRY ESPENSHADE and JENNIFER ESPENSHADE, Petitioners. No. ' 1 - 5?7 t el,4) PETITION FOR COURT APPROVAL OF THE SETTLEMENT OF THE CLAIM OF A MINOR TO: The Honorable Judges of said Court AND NOW, come the Petitioners, Donovin M. Espenshade, a Minor, by and through his parents and natural guardians, Harry Espenshade and Jennifer Espenshade, and Allstate Insurance Company, by and through Allstate's counsel, Robb Leonard Mulvihill LLP and Diana M. O'Connell, Esquire, and pursuant to Pa. R.C.P. 2039, move this Honorable Court to approve settlement in compromise of the above action for the following reasons: 1. Minor-Petitioner, Donovin M. Espenshade, is fifteen years old having been born on August 22, 1995, and resides with his parents and natural guardians, Harry Espenshade and Jennifer Espenshade, at 1550 Williams Road, Lot 76, Mechanicsburg, Pennsylvania 17055-9799. 2. This claim arises out of a dog bite incident which occurred on or about May 2, 2009 at or near property owned by Michael Regal, 1267 High Street, Boling Springs, Pennsylvania 17004. 3. At that time, a dog owned by Michael Regal bit Donovin Espenshade, on the face, injuring Donovin's nose and underneath his lip. R0222284.1 4. As a result of the dog bite, Donovin Espenshade was brought to Holy Spirit Hospital where his lacerations and wounds were sutured. He returned on May 3, 2009 for a wound re-check. (See true and correct copies of medical records from Holy Spirit Hospital, attached hereto as Exhibit A.) Donovin followed up with Mark S. Boland, a plastic surgeon, on May 4, 2009, May 8, 2009, May 12, 2009, July 7, 2009, January 6, 2010 and January 29, 2010. Sutures were removed on May 12, 2009. (See true and correct copies of medical records from Dr. Boland, attached hereto as Exhibit B.) 6. Color photographs of Donovin's residual scarring are attached hereto as Exhibit C. 7. At all times material to this incident, Michael Regal was insured through a policy of liability insurance issued by Allstate Insurance Company (hereinafter "Allstate"), which provided coverage for bodily injury pursuant to which the herein referenced settlement proposal was made. 8. Harry Espenshade and Jennifer Espenshade, as parents and natural guardians of Donovin Espenshade, and Allstate, have mutually agreed upon a settlement wherein Allstate has tendered an offer of settlement in the amount of $15,549.55; $2,799.55 of which represents out-of- pocket medical expenses, with the remainder representing compensation for pain and suffering. 9. Robb Leonard Mulvihill LLP and Diana M. O'Connell, Esquire, have been retained by Allstate in order to obtain Court approval of the herein-referenced settlement. 10. Harry Espenshade and Jennifer Espenshade wish to have this settlement approved by the Court. 11. Said settlement proceeds will be distributed as follows: R0222284.1 a. $1,079.04 paid directly to Ingenix Subrogation Services to satisfy the lien asserted by it for all medical bills which have been paid on behalf of minor, Donovin Espenshade. (See a true and correct copy of the medical payment summary from Ingenix, attached hereto as Exhibit D.); b. $1,720.51 paid directly to Harry Espenshade and Jennifer Espenshade, the parents and natural guardians of minor, Donovin Espenshade, for any and all outstanding and reimbursable medical bills. (See a true and correct copy of the medical expenses incurred by Harry Espenshade and Jennifer Espenshade, attached hereto as Exhibit E); c. $1,500.00 paid directly to Donovin Espenshade for school and other expenses; and d. $11,250.00 paid directly to Harry Espenshade and Jennifer Espenshade, as parents and natural guardians of the minor, Donovin Espenshade, to be placed in a federally insured, interest-bearing account, not to be withdrawn until the age or majority, or by further order of court. 12. Harry Espenshade and Jennifer Espenshade, as parents and natural guardians of Donovin Espenshade, specifically agree and understand that the $15,549.55 settlement will settle any and all claims for bodily injury coverage under Allstate Insurance, Claim No. 5133646686, that may potentially arise out of the incident which occurred on May 2, 2009, and they will execute the settlement agreement and general release attached as Exhibit F. 13. All costs and fees associated with obtaining Court approval of the herein settlement shall be born by Allstate Insurance Company. 14. Counsel for Allstate, Diana M. O'Connell, Esquire, will file a Proof of Placement of the Proceeds of the Settlement with the appropriate Court department within thirty(30) days from the date of execution of this Court's Order. 80222284.1 WHEREFORE, Allstate Insurance Company, and Harry Espenshade and Jennifer Espenshade, parents and natural guardians of Donovin Espenshade, respectfully request that this Honorable Court approve the settlement, according to the form of the attached Order. Respectfully submitted, Robb Leonard Mulvihill LLP By: Ca,'o, ?,` Diana M. O'Connell, Esquire Counsel for Allstate Insurance Company R0222284.I l l1...1 ?1 t? 1 PATIENT FACESHEET Heukh SYFtem NF Camp Hill, PA 17011 ?I?e, 3*>r43i I MN CLAS 175-76-9553 DATE OF BIRTH RACE SEX 7OMAN 05/02/09 18,31 ui t CHRCH / k. PHEF AM!!U ? eRI 3iS1?64'S 0 3] 08/]2/1995 1 ?A ADM CONNECTION TO ANY O [AOix4*. rINIKI I.m IJNKNC bb HEU VA t / I IME EWP rmca ev 08/02/09 18,37 -"°NADm't3 r.rSPI NSiURDB DONOVIN M 1550 WILT.TAMS CaitfjvF+ Ifu LfYV 7 P CItTi Il T I 1 MF,CHANTCSBIJRC, PA 17055 A P f L NO T 717 - 609-31.2.2 PHOTOID N 5 t? rw GEO CODE LANGUAGE ENGLISH OCCUPAI v u ESPENSHADS sR HARRY MI p8 C, / ] 1550 WILLIAMS GROVE RD LOT 7 LIM BOLT FACTORY wN To MECHAAIICSBUR(;, BA 17055 A p AO MECFIANZCSBURG, ty PA 27055 R 717 - 609-3122 06 RELATIONSHIP wR 0,10 O G I a.D 9 EN wT CA N T v t ESPENSHADE J=E M-IFER 1550 WILLIAMS GROVE MECHANICSBURG, PA 17055 RELATIONSHIP M HOME PHONE 717 - 609-3122 MRK PHONE - sc EN RT e K.T , i , fiELA710N?.StiIP HOME PHONE - WORK PI LONE - PLAN CC1DE GIs INSIM uNiTED HBALTN CARH UCY Y PLAN CODE iNS CO H 300726308 , K POUCY M S p Y GROUP # 0109501 AUTHORIZATION* N GROUP # nl ADDRESS U a AUTHf)RI7AT10N +t PO BOX 740000 AT7.AD]pA oA ]0]74 N ADDRESS .C PHONE! M SUB NAME ssPENBHADS .7R , HARRY MI vEmFoLL) c e• PHONE N VERIFIED BELTOPT a PRIORITY 1 Y SUB. NAME; MI PLAN CODE INS CO LREL .El T PRIORITY .i POUCY A . l PLAN CODE INS CO O a GROUP II N. P UCY M or AUTHORIZATION # 3 GROUP 11 a A AUTHORIZATION M N ADDRESS ; ADDRFSS C s PHONES SUB NAME VL-J-LIFIED NR PI IONC M MI F` SUB. NAME VERIFIED PRIORITY MI _ LSCRIPTION ~" PRIORITY NT c.:_ DOO It NOSZ/LID ACC. DATE / E / IND. PRIVACY NOTICE MMENT3 05/02/09 18>103 O 05012009 01 ER ICEM 7flY Ef,IO?r.s !Im Tmoms No ALT AL)MI I11NQ DX . ADMITTING R ATTENDING Mn. REFERRING DR 1auula ED GROUP ADMII'i1NG COM 180018 ®GR slTS BROUG AM8 - FATHER MR 0 P ERl ER 341438 MEDI 4 34519648 Q £SPENSHADE,DONOVIN M 13 Aq EXHIBIT 17 21 Animal Bite (4) I Nursing Assossmerit Reviwved Itall Ravi ewred 'I otanus immun_ U 1 U DATE: TIME: JcF? on arrival PHYSICAL EXAM ROOM: _ EMS Arttvai GENOAL APPEARe NGF- EMS treatments o 1-IISTORIAN: dofd spouse paramisdict AGE z HX / __- VfAM LIMITED BY: HPI 09/ rhlef c2MAIR= Bite bnf _ FitCi _ QViUrrad' st for to arrival i where - home school eY Park Yeste'daY ` - wo art street animal: g cat other. family pet neighborhood animal unknown animal Apptamnce arondro? red appeared ill unknown Animal's Immrrnirarian statue ?UT? roe Immunised GgWrvatkirVCoptune._ ifs m Lis kn a served f IOo animal ulrknowm imc captured allinl:rl Control iltriifled enntext of Vick: "unpmwoked" attack provoked attack (sae below) airpr weed att P [er.d woknel's dortta+rl animals Athtlne to sn other. ESJ?a ": screeched mucous membrane cornet _ --- loeatl In head neck shoulder R I L chest abdomen hip R I L back ( opper mid. logs) RUF I UE RLE LLE rsv10 loss fe~power prWi/ legs tinjtljs>R•f nunlihrielydlstally h.adache /neck pain double vision / lyaring ba rUWAft / vom nt_ r freebie breath-ing % cheat pain loss of bladder runctlon ' suspected f$ (skin lac) i recent fever / illness r - - - - - - - - - - - - - - - - - -i 80CIAL HX smoker drug use / abuse _ 1 rocmttETOH lives alone ' -...re ? --mom Irves In uuninlj I,wne ,. fAlIIIILY HX nesawe_.... r ...--------'--' ----?----.-?Z?_-----J PAST HX Jsegatty see nurses nom for Meds and Allergies HTN heart dsaoaso - /996 - ?006 T Svsf Inc UnYtr yr a/rnlF u rnwrt k p qc Holy Spirit Hospital Camp 14111, PA John R. Diaz Emergency Center EMERGENCY PHYSICIAN RECORD Flo acute distir a derate / severe distress -alert arur owill lethargic SKIN ??=sca dlagrom it It?.ca - NFOU`RO, / VASCULAR / TENDON no vaxcular _abnml color / ww mth / cap refill-,---.._ omplrornlse -pulse d" urleisted x3 _discirkested to person / pktee / time mtn.. on anent -sensory / motor defltit _ 4CN's nml as tested -facial droop ROM nml -ROM limited by pain / tendon injury PSYCH _,•,-deprewdiffeec mood / affer-t nmll?lf see i r ? s :HEAD/EENTC`.Se3?d-------------- -- ----i _normocephalk. !»OM pahiy ! anisocoria ' ewumetle TM obscured by corumen ( R / L) ' PERRL -post surgleal puplllery defect( R / L ) :;-e a Ids / con)un. - r uninjured r -ENT nrni external ' inspection ! NECK -see diagrans efnlnjured, ; i nml inspection r CHEST see diagram - ?4lnlnjurcd h / l / , •_w oezos ro es rhonchl nml inspection ; i 91 (ABDOMEN) _me diagram , uninjured, _ nml Inspection r lion-tender ' _ 011MI bowel sndsa ; BACK see diagram __ 1 -inlnjured, l i i rrn nspection _ ... i EXTREMITIES ,-Juninjured, see diagram ' r run[ inspection foreign body suspected ; ;1no fnfecrinn-jnlnt penetration 11f _pected -------------- - ---- ._- - 7- r - 4 /f-s?G?/lrr?riv.?l?? ?? Ir ?fjJI.J _- ? I, _ _ Ja ?.w 0V /fF?Y. i??ti 1Indedlog tndkoterorgan {tnteet • egvaralent nr rx4r/tirx,w rryoLer/fa organ swtera waver F:l;1+M.C1TIADE , DONOVIN M 13 M 08/21/1995 RT] t;ROUP ERR 341438 05/02/09 34519645 lice. Iih / 7.7106 PW 1 of 2 L t l ? L R G -??0-l PROCEDURES 1??1? 3o.ss.- ?r?'C. _ ,t}r'-- _ _ _ - - - - - - - _ ? Wound Description! Repair - ?f 1,?../ ; ' length can location *wbcut "mu2rJe li near puncture stellate irregular ' Clean cone {yl i distal NVT: 11 111 n1 & s>uttalarya? no tendon ir4ury i a th l nee a: _ e dlgital block rnL Ifdoc 2aG Icarta ntarpkw 0.25'A 0.5% LET i I C3 co lo us sedation required: see attached 23d template ? P-P. r ' tietadine/n6r ilioe.e? 3ewr` E..f-? Wpo' at fc err .e y 1 i .r r ' eatertr rninirnul / ern ^CMCndYe axplor undermined {+?? 1 torargrt magrlal eel i Y l / ' ua n tw mod. / erientaw r parthidr c,nnpletelywound margins reviasdVT &%f0V ' minima/mod. / cxtcns&c multiple flaps sillined no fnra4P4Vrw{y identified /- repair. Wound dosed wide wound Qdheslve /Dermobond /strrfLstnps 1 SKIN- p nn prolene /copies / °SUBCUT- -0 viGryi__„_ _.. ' MUSCLEJFASCIA- u -:---- O vieryl 'May Indicate intermediate repair. -may indleao co- mplex rep akr ; PROGRESS 'rirlie unchanged Improved re-examined utlll?) l;tiurr \ ) / / ? l? t ) L (! / R R L T?Pr?.ltrnrn lhtL?eNK TatlMrsr ?ixsalee 1•YCahyramla n..lYrre r?-dSw?.wlen Laa.t.aur.wa Mwbrrl.e M4iwir All `+.IIeM re-sw1Y rr.rws...?r w sMNe PW-pear/..e wo??n.f JCRRY$ ?Inurp. by me []Renewed W.;. -ad Yd nadiolaxist nml J NAD soft daaue swelling / deficit _no fracture fracture / dislocation _nrnl alignment ' r _,nmf soh tissue i OTHER. - [r?5re se orate report ? Animal 13116-21 R.-...06/22/06 Pa 2u12 ----P--_----- _nlbies vacelne serira implam'nrerl `iliklal fracture care provided: follow-up on _Rx given Discussed wlda Dr. Time WIN see Patient hr of?'icc/ED/bosplmf Animal Bite head R / L forearm Vii?d?b , R/L hand ound t R ! l_ wrist ( Cat abdomen K / L thigh Site scratch back K I L leg R / L arm R / L ankle R I L foot IMPOSITION- home ? admhted ICU/CCU ? transferred T1m C n tpe o vaid [I suable /PA/NPSfOI AyURE o...c. r?r"a"Syory-revlowed. patient interviewed and examined ?+M?'. percirterac E{PI rC I`tr Peraend exam of patient revealm Assessment and phn reviewed with resident / midlevel. Lab and aneiNary Studies show I eoniirrn thy.. Care plan { t w1p rtesd: turned caars overet Physic- sionef . Rr- / A s&ptpraed owe at ?'?crriplwr,e Cnrttplete 0 Additional T-Shen ? Dictated Addendum F.SPRNSHADE . DOIJQV M M 13 Zl ED CTtf]UP U8/22/1-1)95 341430 Ora/02/09 F-R 3;519649 fill 1?Ig11111illlllllllIIIIJI llldiiijbiplunllulllltilutllulllflulllnl JOI IN R. DIETZ EMER9ENCY 4aN I hK DISCHARGE INSTRUCTIONS HOLY SPIRIT HOSPITAL Th (717) 972-4300 e ell mtnahon and trc Fu.e mrrtwd in the 231,otgemy Coder have h- mnrkTnd4jn* an smear complrrs medical rant. If yam devs ar'm' bads only. and an not rutandad to be n sutr B roe an eifnA to ryrmr+r lop new problems of enmplie?tinrs contact gran phyertAa or the Cmer enc Center FOLLOW TM p ' ' E a y . 3y t Rl}Cl7ptdS CH tiEC1CEO BELOW, . Patient Information: Patiottt information Shoats Contain important Attwnwtlon to Retrietfi and Keep. () Aheirminal pain () Cannoned Ylaarion Headache ( ) Pain Mann omarn ( ) Tt ( )Al h l oc o location () r;nwepmramnitis (1 Ailerglc nvaatkat () Crutch wallin p weatened Miscarriage < I lead Irtlury () Pediatric head lojuy () Tuuttwclw f ) g 13 Bst.k pain l) CbloOatloteld VamAkrWPWL Vorniting auk p 7 ) Hypertanslan (} P.W I,lc URI {) URI and Colds () ImmufdtaflonlTotanua I) PIWSIU (} IITI And Pyelcrwphrilia () !) B arlatVArMmeNnnrtrl If ` nrug0Aloohol dbuwalrwkllclkxt ) Bum I ) Febrile Convulsion KkIney Stoma () Pneiattutda () Wound Remock ( it ? .- I) Ranh () V4 Hr. f'hertnacias ( } Ghost Pain () revar/Ped. Fever I) Cor4unplivfiile Flu I ft".- ( ) Sosivizure re Throat () Otf•rer (} N WA ( ) Sore I) Hrfln pnlaASlrun containing foods () COPD ( Fracture WOUND CARE t and Stminti () Ofitle Mama (Suture e Caro srtemoval ( ) ( ) May gently wash over Wotnid in 24 huurs with coop and water or peroxide . MEDICATIONS i continue present medleations except- ( ) Change dressing - tktws daily. AudrLww with Sac(traain/Neoeporln and startl d i 1,l"? IJM ArMI (Iht+pmrten) or Tylenol an needed for i f e ress ng or leave it open It adwhited. ( } Keep wound clean, dry ( ) covered ( ) uncovered pa n, ever annording to prackapte Instructions for age and are () Use the faucet ?? etc. SPRAINS, STRAINS, BRUISES, IrRACTURLrS ( ) EkNeft the ktjured part for-days to reduce sweling. ( ) Apply loo packs intormntently for-days to rectum va mung. ( ) Aaa warp for support for._ days. ( ) Wear wAi t ( ) At all tknon unto rollow-up. (? For hrlivuy as needed ( ) use wing for auo ( ) use crutches: ( )% needed, weight tearing an tolerated. ( ) At ull limo. NO WEIGHT BEARING NECKIBACK ( ) Wear commi miter for support tor_days. ( } Rost. avoid bending, filling, strenuous activity tor_days. ( ) Apply.. lois. host for_ minuwa times daily beginning In hulas. ADDITIONAL INSTRucTiows tj' 7 nocumgo Nuld Intake ( ) Clear Nquld diet. Advannn to miguWr diet as tolerated ( 1 OM workJeohool from to ( ) Retum to work an () Light Duty until RawIlr lion ( ) No gyrnisports anti ( ) Follow InstrmAkrim un Workmen's Componeadon Form. ( ) Wear aye patch fw haurp ( } It none bWAJ recurs, pinch nose firmly for 6 mktutoo ( ) rdinuIme pretaion of you?.R not ar ruvlkrd The Your AIMS will her ?? y re rtetrriaMSd by a ratadogtet You w yum ywr Physlulen Will bo contacted it Intern is a change In Ire dlagnosW& 1 s•?l r' gal/?G' 7orvl no medicMs according to package Inabuetion& L• 2: 3: ( )Tits following medicines may cause d?owsme".. DO NOT DRIVE OR OPERATE MACHINERY WHILE TAKING: Tlw prescribed antlbioLO/medloatlont may raduno the nffeothenese v1 tnudita?6on you arc currently taking. Check package Instructions of ooneuit with Pharmacitti. FOLLOW-UP This is our recommendation for foltew-up. K your Insurance (HMO) requlres a physician referral for specialty consultation. 1( IS YOUR RESPONSINU Y TO OBTAIN THE NECES"RY APPROVAL 1 Fallow up with: ( ) Urgf Center ( ) roe. rbekWCompeny Dootor Family Doctor or g. .«. in days fur: ( )Full,,, -up .Q`?if:!?.ir ( ) Suture removal .e.. ?. ( ) fake the tolia itg lost results to your physician: () C13C () CMP () EKG ( ) X-RAY REPORT ( ) CIT"j=nn •L .` IF YOU DO NOT HAVE R FAMILY PHYSICIAN CALL iH i 1uj1 f??jjf 7 FOR PHYSICIAN REFERRAL- ( ) C' no nn nrtmn as possible for appoinuront f` G- fr ??.tkaij'fly Pick , ( ) Pick up your X-Rays burn On Rrcralagy Department print in your foNoia-yep aPpoi+IrruenL Cal 7632606 to have films ready. ( ) Sea your physician or specialist if not Improved in n days, earl I Naium to Enwf enoy Center It you feel your cw>dil(o is wpsgdn0. especially I! U z yp 't ( ) Your tripod ?- ?j preesue was elevated, chock with your physician. of A copy led LmeOenry Room Re t I por s available to your ia from ? eels (703-MOO) If t aVrlW lait , y p . n coli?ow! F" I hereby acknoWfodge receipt of theaa inetiuc6ene and undersolnd thtem. I understand that 1 haves lmd witarrywicy treatment r .=Or that I may bn rteleesed before as of rely rnecocal problems are r?-. or tr t d -- on o . I will arrange for follow-up pre as 1 e bean InttMuoled. It to oily responsibility to noti alciatn of a" vlsk. SIGNATU RE --- sKiNATUArs, '? .- .?- 4•-?3:?',?"'1 •j :L. f? 7 • r Y f/ O PATIENT r •?-• -°N' teLEi PERSON VERBALIZES UNDERSTANDING SIGNATURSr n Dole HOLY SPIRIT HOSPITAL JOILN K. DIETZ 94VIERGENC:Y CENTER 503 NORTI'( EIR'T STREET CA14LP WLI. PA L70LA-2283 MID 971-4300 ( I SWvelom Alfann, MD 02130219 ( ) Vevin-.yearn McGann. DO 010969 ( ) David Zi-.„ rmitn, ),,FD 005636B ( ) Ilwt esa Willlamr, NP I P006126R ( ) Ramesh Aram. WID 0167279 ( ) Purhpa Mndan, MD 051514L ( ) ? ) ( I Nikolas J. Baran. DO 03004697L ( ) Aamn Palmet, MD, 423330 ( ) L onautc !tort, NP TP003409b < I Denise Bolmw%lo. 1'AC MA0018761 c I r-uks Lhotlan. DO 0313145 t ) I nwrence Paul. Nm 039324L c I s"an D.C.ton. NP SPOO76: 8 (1 William uucimer, PAC: PAA052332 ( I Nieolaa DaCuata. MD 0332HBL ( 1 Ericka PoweD. MD 4711145 () Pnrn Darden. Np.5P006(>66B ( ) Matthew A Wtmtio. PAC MA0009691. t 3 Jon Dubin. DO 033288L ( ) Ranjans Shaam MD 0312618 () soleria DiPanlo, NP,VFU"261B ( ) Jcrl}ry t lnrmn, PAC SLAM 1306 ( I Robert P.ttlinaar, LCD 027460E ( ) Christina Sheddan. DO 009537L - ( ) Natalie Gillla, NP TPOO6092B ( 1 Michele Karcxew3ki, PAC: MA002935L t I Amy Pajudo, MD 420942 ( ) Barry S1vctnr, MD 032793EL () AtichoW.. Llalr-. NP VP005355B ( ) Philip 111a8u1n,, MD OL5063L' f ) .flan Teplla..MD 11300188'. s=*-3,0*nn1i Mat.1ln,i3all. NP 3P00092 SIGNA'L'URB M.DJD.OJNP DUA0 RbFII L TIMES _ / _ _ M O_RDRR TOR A D NU V( N- 6 BB aUPHNSED• THR PRESCRIFINIt MLWI IL7kNVWflI'9RAN NDC69SAR1^' OR "DRAM) MPDICAMY NECESSARY' IN nW SPACR BBLAW. 01-ABEL OSlT&VTr MON FRRMLSISMI II 170 (2!091 • SV961sve 60/zo/so acttipe., L Ha anoao cia ' S66I/2G/8o W CT X N]:AoNo(7' 3rI1YxSN$as8 0 lnltlal Lai I~ x-pay prdNS- I I Aoctommophon () eSR I I I heophylrru [ I Acetone (SACS I 1 Gfumose ( I ThromholyllC Labs l I Ar»hd (ALCU) I I HL;US [ I Tux Swam 1 ) Amyleewl We- [ ) Ou.111ntwa I I UMe Tox (DOAS) { ] API I HcGS f I TSHR [ f 89H [ I HIV [ J Tvp"cross?a at units [ 1 Hlood Wtures I I LElhum (BOB) I I amp [ J Liver prase I I Type i Screen I I COOP ( I Lyles ! I UA' 11 f11P ( I DIAG. I I CMP I I Preamp [) Udne C i 8 I I CKCKMB.TWT I I PhonoWb (J Ilmtr. "r ( I Umpehats I I PTP I I WC Bremh Alco Teel I ! D*Wn I I sa&-Vwob [ I Vic Drug Swann l l DA"n [ I TwpAul I I Other RANN9100 [ 1 AbdJOhvr. Serlee ( I Knee n L I I Ards R L [ I KUB f I ClaWale It L [ 1 L8 split. I I Carr. 9PhW-4W1Akm (3 view) [ ) mamma, l 1 CWv- R"-AP/Lat , [ J New 1 1 Cerr. SOw -Ponoble Lat I I Oft A L ( I Chest--Rowime or Pork"g, ( I Pelvis E 1 Elbow R L I I Pysbgram lVP f l Facial 1 1 Rbs R L. (1 demur H L J I Shoulder R L 11 Rnger R L t I Skull I l Foot R L [ 1 Swum I I froreann R L I I TBiire [ I Hand R L ( J Tb / Fib R L 1 1 Hip R I t l TOO - R L [ 1 Ht" WW R L If l Win R L I IOdm: REASON; TrnarCRTnm._- . - -- uk asw.w: CTI (W-With wo;e" wMwltnera) I] Abdomen l 1 Aedolna W44 W WO f 1 VQ San l 1 DMASS Doppler ( I 13r*41*ad W WO 1 1 Echo- f I Gallbladder [ 1 Cheal w WO CerdWgram I I PeMS [ 1 yells ohael for PE 1 1 Tmrnwaainal [ ] O*w. I ) MRI Sam TnmS CRTAnL REAAM ?oestnssneAC?.n. ! I Data Seep Ali Rapid [ 1 Stool CA B I I CwMC@l1G0n td I I Stool O i P [ 1 C2ftmydla [ I Snot C. D mare f I GC Curve 1 I Tfkhomcnaa 11 Monospol papirl) ( I WOUnd C a S t I Sputum C a s ) 1 Other oil" we oat . PHY-WiAN CHARGE FACLRY CHARGE f I Level I ( I Laval 1 J I Accident ( I Level If [ I Lewd it 1 I Medkel i 1 Level Irt 11 Level m I I Cass t f 1 Level IV ( I Level N [ I Extended Hm. I I Lrrvel V [ ) Level V Holy Spun Hasp"$ Camp Hill, PA 'PAC ag ( j Mordar f I EKG It 1 O? r main. I 102 9alumlb ) 0 fl w-A-tOry [ 1 AFUs [ I Peak Hews SelorelArter rlesp. Tx. I ) Respirukny Tx. -.eorcaso oOamNOiss Tim rta WV's / Additlond Orders r .. .. ;:t;. .. PHYSICIAN.OFMRS ?a"•• 1 .gNti w01KV01lrlfuse rb li/hr Obtsin ow''cords [ I Td ProtocW wanted tor, Qva rssd back tiOif I l AV Mr f) yAT/0M R T/1,l?Taw r I CRITIOAL CAFLH [PP#YSPC/4N/GROUP. D - trNaala: CRfWAP CARS . 9 !I Dkrawd Dsts Cj Tlnse: ?• T ?"" ESP. Li1H3HADF. , jiON0V2N ,y 1 . 3 M FD GROUP 08/22/1995 John R. Dints tlmarpenoy canter 341438 F:R1 Phyeleian Order Sheet 05/01/09 34D1964S 206-EC-lb 12104 REV. LLW CHART CCW R PIMA ???y oq HOLY PATIENT FACESHEET j- -7 • •vu,u. ,dawn. - MPOICAUPJKCORW Camp bill, PA 17011 !, _ r 3 su e 175 -76 q55? !)57).1104 18.20 iAl 1r, Epl = +S. 1' sassXaea.. ' . OAT E F R PRFr nIl.A N7f' MM fICU L)Alt/ 11M1= »7 HE Li Y , Q 1,3 OH/22/199q 1. y :i NO CONVICTION TO ANY O 11mR?P. TPTRn OR 1M. Lob 05/03/09 1Br59 '1,P•. 1?abTC FSPEN`./HAL3E 1JUNOVIN M p a A 1550 WILLIAMS GROVE HI) LLYV 7 A C11T.J,Lf 11 L• 9CU NILSriURp, PA T P 1 P 7055 1:? No eP T 717 - 609-3122 PHOTO ID N Te - QED CODE LANOUAQE ENGLISH ?.R OCCUPATION u RSPENSHADF 7R HARRY M) a v RI 1550 WILLIAMS GROVE RD LOT 7 Ufa SOLI FACTORY A ? MRCHANICSBURG, PA 17055 •P v5 r Na No ' M=HANICSBVRG, PA 17055 0 717 - 609-3122 TE R 0 R RELATIONSHIP O R ESPFNSHADE JENNIFER a0 1550 WILLIAMS URUVX Eq aN MECHANICSBURG. PA Mo RT 1,7055 ¦N ' 3A T N° RELATIONSHIP M ca A 40 T RELATIONSHIP C r i HOME PHONE 717 - 609-3122 Z HOME PHONE - WORK PI ICNE - . RK PHONE - PLAN CODE qls IN O I I NTTRn 11RALTII CARR PLAN CODE INS CO 1 FOUCY M 0007263A8 I POLICY N a GROUP N OL95901 GROUP M * • AUTHORIZATION # ,A1 FIs AUTHORIZATION 4 ADDRESS Po WX '1401M0 AITA 'rA an 303'/4 R2 ADDRESS •c PHONE# VEIIIFIFn SUS NAME P.RPr' m^nR an , 11ARRV MI Y C ! PHONE# VERIFIED Rr=LTOPr PRIORITY 1 SUB. NAME: M I PLAN CODE INS CO AELToPrr PI1(Ot1f7Y 1 POLICY M PLAN CODE INS CO 7 POLICY s s u a GROUP N AUT IORLZATION N a_ - GROUP # A + U W 4 AUTHORIZATION M ADDRESS . ADDRESS C P 1.1iONE # VERIFIED PHONEY 3UD NAME MI ! VERIFIFn 3UB NAME PR10fi1TY + MI PRIORITY ACXNDENT ESORiPTION ACC. DA TE / T1Me / IND. PRIVACY NOTICE SITE 05/02/09 19:00 O OSO L2Q0? 07 L•'x H1.7 COMMENTS ROT AAr,R TO R85lOND= FWD TM12M uD AIM vxGMC NO NO CAADS ITTING UX. ADMITTING OR ATTENDING DR. REFERRING: DR . leoola na onovr 1eaola L.u cixtlUL+ ' HI I UCiHT DY' AMBU CE nRNn [•HRf,R np F+Rl 341438 34621484 ER MEDICAL RECOR10 ESPENSHADE,DONOVIN M 13 M 23 Suture Removal / Wound or Burn Recheck (3) DATE -.?" ' TIMC: .?Ky? V ?_/L. _ Q un +r 1 iv?l A ROOM: _ EMS Arrival EMS t4«,rmo,rs -d--d HISTORIAN: atl spouse, paramedic AGE-? 691 F -- - C'<HX / _EX/KM LIMITED BY: HPI a In ED f other ED: erdn ago eeratbn rc 1&D of abscess burn dressing reties 1M pr NPu? /f->tittf /w4 i.• n ?lI.Q?RtiSIl1?= ??ro omphin r+aln fwvwr rhllLr redness / d?1s lnRr numbneaa ! weakness PAST HX , negative see nurses note for Mads and A". diabetes Type I Type 2 diet /arof /insulin HTN heart disease nrurs" Assessment Kavlewed 1'eunus immun. UTO PHYSICAL EXAM GENERAL APPEARANCE Flo acute distress -mild / moderate / severe distress clam -anxious / lethargic NEURO / VASCULAR / TENDON 40* no vascular compromWs _eew dlagrsam sensation nml sensory / motor deflc-K -&o tendon Injury -tendon Injury(nml ROM) Tabnml color / warmth / cap refill -pulse ddldt ?SK-,IN Ie* diagram - A healing wound _arythlerna ,<no infection --purulent drslnape .-MnPhangids wound dehiscence _warmth / t*ndernass -healing cellulhis / abscess _expendtng eeluhtia r .-increased swelling/ erythema ?_lymphanglgs / adenepathy._ - ?r:aling burn _inrreaseA swelling / erythema 11 r +•r t i' 44 i 4 y -, d4 mraswrat orpms pvtem It or ssiauwsrar regutrvd jnr n I-- ?tat-w -am 9P6 hae?s/ash n r7r.ea. H01y Spirit Hospital C;tilup Hill. PA John R. Dietz t merpenay Center EMERGENCY PHYSICTAN RF.CURDz; r 7 ?, ? .7 pU r 11 err 1 L R 111 L R L It L T-Tvadvrnm PrT-Fgdm Teade oa, S-Swdara i.-TnAr..Mb Lau+Laar-fioo A-A/rWM /-sere flif-Mhkor/ W-odtl M-4-8rdrm s?rr.rr-) PROCEDURES & PROGRESS sutures / staples removed by nurse / physician / PA / tech- drain removed from abacess cavity dry sterile drossina applied by nurse / physician / PA / tech burn drassbrga appliwl by bursa / physician / PA / tech antibluilc adminiatured IV / IM / topical _Rx given ... 1N1E;AL IMPRESSION Suture / Staple Removal Tendon Inlury Laceration - ruchada Na rve brlury Cupulltis - mclrack Burn - recheck Cutaneous Abscess - r eele s ClRntsnmQ?N.?P, Iwme ? adnsitted tGU /tlli Q tr.n-lrred? unchanged A improved ['stable / PA / AIP SJGNAr1IRE patient Interviewed and rnamined. My Paso+v exam of palant reveals: Auessmant and plan rovlowod wide resident/ midrovol. Lab and ancillary studies show- . I confirm the dY-fin s o - Care Plan wl tux wail need Pkase see ribldellit / 4 I note for details _ gllrratura _, It77 ? turrn0 care over atM Pkys'aws Skgmrture RT/ d assr+raerf care at 45p"mPlate Compreto Additional T-Sheet ? Dktated Addendum ESI NSHAU1i r L)UNovin H 13 M 08/22/1995 ED GROVP ER1 341438 05/03/09 34511484 Suture Rcmovid / Wound or Burn Recheck - 23 Rev. 06 / 22 / 06 Pops I of I ? lnltlal tab a!i X t7 rdara• Labs I I Acelaminopiwr [ ]ESA [ ) 7heophyNkw i 1 AealafN (SACEF ( I 01mme ( I Th-Matync Laps ( I Alcohol (ALCO) f I HCa8 I I Tor Screen [ I A,uyI-wA Nrsrr I I Ot-Moline ( ) Wine Toe (00AS) [ IAPTT HcGs [ IISHH 1 19BH f 1 HIV [ ] TywaCrwa - I of urdta 1 I Hrwr" r mans ( ) I "Ilium (90R) t 1 amp ( ) u- prom ( J Type A s meen [ I CMP J J Lyls ( I UA: I I DIP I I DIAa. [ 1 cUP I I pfu"p [ I UgbO C a s I I CK.C$A4MTNT ( I Ptwwbwb 1 I LIdm I ICU I I DaC"te [ 1 PTP I I WC eromth Moo Toot [ I 01,110rul [ I saAeNw [ 1 WC Drug sere" 1 1014" f 1 Taaeml [ J Oaur A.eYefeay I I Abd./Obak. 9edp I I Kn.e R L. ( I Adds R L ( I Kt1B [ 1 Clavide R L [ 1 L IS %4w 1 1 re- sow-ROL&W (9 wow) I 1 Merdble i 1 Gen. BPhW-APILet [ it' I 11 Cwv. spun--partable L,t t 1011311 R L I I Chft-RaWr» or PcMMW ( I Pah ( 1 Ebow R L. [ I Pywow m IVP [ I Feaal ( ] Ribs R L I I I- R L [] ShWkIw R L. I I Rnger R L ( I SMA l 1 Feat R L [ ) Smmurn ( 1 Roromm R L [ ) T/awe 11 /taw It L I I Tb / Pb R L l 1Ho R L I JToe R L [ I Humerus R L I I~ R L I I On- REMON: - TitnrX.RT/Int. AMEN Esamm UhrMOww: cr. tw-wm ca-mat wo-wm w,n [ 1 AbdunRn F I AbdurneWpaMe W woo ( ) VO Sem, S 1 DW- D*pier [ I B-Irdl"eed W WO I] RM. [ I aerblad w I I Cheat w wo cardlogram [ I P" I I a" cheat for PE ( I Tmrev gbw I I Other. [ I mm scan REASON: T)mw1CAT/1nL y?PeCNnena4aralffrie a; L I NU Seep AG Repld ( ] Stad O a r% E 1 Oervimmw lal I I Sloe) O a P [ I C MmnydW I I sad a Dencyo r I ac cult.. [ 7 T#Wh manes 11 Malw" [J"Am ( I w«aw C a s [ I SWAM c as [] Olhr. _ n9 : PHYMM&N CHARGE FAt4 M "JIGS [ I Level I t) Leval I [ j Aeddw* [ J Level it [ I Level If [ 1 MedloW [ 1 Level In r I Level III I few" " t I Led IV [ I Level IV [ 1 Extonded Ma. [ ) Lwel V I I Level V Holy Splrft Hosphal Camp HUI, PA 0 Cardl.a ( I hlonrTor ( JFK4 [ 102_.___ Vrrrln 1 102 Srrkmu(an 0 • Re9plretory [ 1 AD&e L I rneM Ftoenl RO*VWAner Re-4p. Tx, L I Respha"ory Tx_ QW7OR Onlrr Te ' ..., ..... a.. o •, ... . PHYSICIAN O DEft; y?sz (r - mow awrr IV_ NSSf DSW Dfl/.46N 05 W-49 WO/KVOAnhm at mla/ly ( 1 ObtWn old rmmde r ]Td Pfotooef W&Nftd for. C1vo6 road back Timm _ f L &*0MC A*" t 1 Aomrr t 10swRVAmum LLREQUILAR TELL MI TRY I-LCMTICAL CARE ADM"TNM PNYSUCI/IN/CIRONIt OfAf3I1f0.RD7C Inithow. lnitfats: _A- OP47MAL CARE, Dote: t I DMbtad =Z--, LMSFfA0Z , DONVVIN M 13 M 1MW00?CRNP a I 08/22/199! John F IL Ea wsency Canbw ED GROUP MRI Phyaloton Order shoot 341438 05/03/09 34511484 208FOU 12004 TIEV. LLw CHART COPY -JOHN RP (RI OSPIT jCN?'Y'CENTER DISCHARGE INSTRUCT(ON9 HOLY •: ,? ? ? (717)2-4300 The ezam,n+,nerr and I.eulrrrnlr yod.have rer4wd to Ilte 9ererlene„,CorrLLY'linAt heed crair-i no Nr rorr,xrtK:y bucir only. unit ere not taicadod to be a wew,n,tr rcr w r« effun to provide caopine mWkd r If you develop raw I.nhMma or carryluaQwy caring yme phyekir( or Lire P.tauCency r'mrv. ML I ow TIM nasIMI II?N ..q ..,,e....e...,.,. ,.... Patient Abdominal palie Alcohol () reaction Comsat f) cprbra t?n ( )A14argic reaction () Avihme () Griner!, walldng () DWnlrra wed VomMMWrod. Vomitlng () Sauk pain rjb%Irv:A*2n () Brrww-Ht3mar61Anlmau?wwiA I) Drug/Abohol abusoteddidion () B ear Cheat Wien () I-abrse Convulsion () FuverMsed Fever coniunctiving . () ( ) Fracture WOUND CARE i ) May ConittV wash over wound in 24 hours vdth amp and water or peroxide. ( ) Ghettos drst"no - -lines dtcily. Rrdrwev with BadiraGrVNoosporin and storffe dressing eir leave, it open It advised. 1 a Keep wound aonn, dry .14 covered ( ) u waywrd SPRAINC STRAINS, BRUISES, FRACTURE3 f )elevate fire Irt(ura0 vrrt furl days f0 nsdunw aweuing. ( > Apply ice packs Intsemitlontly for-days to reduce awelfn9. I ) At* wrap for support ftx.._ Uwyv. ( } Wear splint ( ) At all lines until follow-up. l) For activity ne nrvrded. l } Una Sling for auppwt.A ( } Lon rn,tches { } s n.edra, walyl,( twaring 30 tolonorod ( ) At all tires. NO WEIGHT SEARING NECK/BACK ( ) wow cervical otAM lot support for _ days f ! Merit, avoid banding. rrting, abenuous an" for days. ( ) Apply moist heat for minutoo _. times dally hegirining Inltuura. ADDrrXMAL INSTRUCTIONS ?? raga Will intake ( ) kit re, quisatoa from Advance to regular dial as Inino fwd to ( ) Realm to work on ( ) Light Duty until: Aeanletialm ( } )roll w??w until ( ) ftkr Instructions on Workman's Compenaatim Form. wow "* () pd h M nom bieeICU , Trdy pirleit note f4ttnllr for 6 m(nutos cordinuclusly, rattan it Needing not controlled l ) The Ifaefpretatlai of your X-Rays are preliminary reading. Your fans will bo mviowed by a M4110109181. You or your Phyeddart will bo contacted It mare Is a ehanpe t, the diagnaels. -7 1 MIQUTATURE• lion to Review and Keep. Pain Managornnnt () Threatened Mtacardatre Pediab(c Hoed hqujy P ()Toothache ediatric tim PID/BTD () URI and Colds () UTi Ard Pyelonephriss Pneumonia Ranh l) Wound Rodiocit () 24 lir. Phemraciss Seizure l) Other )Burr Thropt. { J ( ) I ogh potassium contaln4,4 f„udu > Suture Cara a Rortrovat I) Head+h:l?s f) F1nad rnjoay f ) Hypononmon (f)) ImmunizaidutdTalanuo ( J, tt () iVeck 3troe ( ) Nowbkod ' t f ) n Alin Media MEDICATIONS' ( ) Contir-Lo; preoont mbdicatlon t ewe": I Ise Advil (thupilAal,) err Tylenpl a Mad.0e fnr pain, fever according to package frishuetkaer fur age and weight, otc, I Ise the tollowirM Rlledir keen according to poekage 4tstnidiona tr ) The following madlolnes may came drowakwss: DO NOT DRIVE OR OPERATE MA401-101"Y WHILE TAKING- Tho preacrihad antibloHcJm"cation, may reduce the effectlvonomu of ---.Orion you are ewtently taldrM. Chock patAilige buuinictione. r consult with Pharmacist. FOLLOW-UP This Is our recommendation fur follow-up. it your Insurance (NIUO) rwqufuros a physician roterred tar spoolaUy ooriauit con. IT ill YOUR RESPONSIBILITY TO OBTAIN THE NiCiIISSARY APPROVAL. ,M Folbw-up with: ( ) Urol Curtin ( ) Ooo. HoofthM".rropany Elector t l'Famly Onctem nr In tiny,"for. (,TFolkw-up/ U/7i Gr'l o ?'? ( )Suture reritoval ( ) Take the foNo vIng teat roculto to your phyeleinn: ( ) CSC, ( ) CMP ( ) EKG ( ) X-RAY REPORT (} OTHERS IF YOU DO NOT HAVF A FAMILY PHYSICIAN CALL. 7e3-299 FOR PHYSICIAN REFERRAL. ( ) Call as soon AS poadbie for appointme ill ( ) Pick up your X-Rays from tho Radiology DepartirnaM prior to Your brow-up appolmmant. C.edl 783-2oge to have films ready. ( ) see your physician Of epe,elellst C Are irnp ovad in Rotum to l'errlergsricy Comtor it you fee( your corlditio is wors"riti, espeoda"v W ( 1 Your blood pressure was olovntod. C hm* with your physicisrr. A copy of your d(datad Enlegen4 Fluum R y apart in mvnlXlbla to your Phyablan Iron hMdicel Records (783-28M). It not ' awry, Csnlcal lanpresalona:4l,,110 Cam' I harspy "knuwledge racnipt of rhea" bud"LICAMs and iexh viand them. I uncleretsfild Ural I have had orrnxooncy treatrnent off( and that f rtmry m released befaa an of my meeBoal prohfems are known or treated. I will arrange for follow-up osro as 1 hit". hewn instructed. It is let responsibility (urrt pflRiOfk.?Jt'YAk?an INS vtslf. y SIGNATUR rRiYel ell r i?r a -''' ell FNeOa y^ ( )AATIt7iT? p BCE 30f1 VEA6ALig8 wtrr aNa f? Page 1of 1 •0`}7Pt`YOid eSmartlog Request 70`P%3?4t:i -iY /)q YX)ACJf?}b. • Details 26057: Holy Spirit Hospital 117090 Susan Iarkman ............. .......... ........................ Log ID: 44875360 Associate#: 117090 26057: Hol Spirit Location: Y Requester Information Hospital i i Phone: 717-609-3122 Name: Harry Espenshade i Type: Jr Patient Special Project 1550 Williams Grove Address; Road City: Mechanicsburg Stale- 6 PA-17055 4 Lot Zip-. Patient Information ' Received Date: 12! 13!2010 First Name: Donovin M Last Name: SsN: r 175-76-9552 Mod Rec No: Chart Location: Perm File Die at Service: Complete Date: Pending Enter Date: Delivery Method: HIPAA reportable disclosure: Attention of ; Forms Sent: Comments: Entered by: Paper Scanned Billable Type: Y Paper Pages: 0 Email: DOB: 08122/1995 Claim Patient Acct Reprocessed : Pay On Site: N Micro Pages; 0 Espenshade 341438 5/2/09 To 5/3/09 12/13/2010 07:28:49:am Mail 117090-Susan Kirianan-Associate Electronic Scanned: Palimd Request Reason: Special Project Page Count Known: N Electronic Pages: 0 Correspondence History ......;3:?t4iisc•..::;:;__,:;:.;:;ji:ii;i::3:i.;3:?.;?.•; :3:;;>;;..", :, :..?.?..::, :..? ::....,?:.-.,:..... OFFICE VISITS MARITAL 51m1wl"I MS DATE OF / I BIRTH Formedjw PHONE (H) ] (O) REFERRED BY INSURANCE DRUG ALLERGIES NAME 1?h GY x`71 ? lltc?.E ADDRESS OCCUPATION / EMPLOYER MEDICATIONS DATE DIAGNOSIS HT WT BMI BP p T ° PT CODE a 1, m If ??/ I G y ? m' ? . ??cy`r?;t. ?7d??'? %n-?`tf??? /1? ?L? ?J7/ / ?? 1?76? . ?,/?? 7/7/0 ?e ? : ???... Just Ask FOG to heClp more men talk EXHIBIT FLOMAx m °°°a'° s d ?. mmmon side effects are dirmW abnormj ejaculation, and fhYl . Demm Resoiwtrs P=% * t& 2006 r3 teeY mp, tau da G FaAV. v ot vemn vegmeat otme?: ape?+adv?alnyy?¢es.2o?:z3?-2?s. lA ? ••••• ® Photo Mounting Sheet Insured/Owner: Espenshade Company Claim Number 5133646686 Policy No. Not Provided Our File No. 1746781 Date Taken 11/8/2010 Film: ? Polaroid Negative Digital Adjuster: Terry McLaughlin EXHIBIT 1 1 Insured/Owner: Company Claim Numt Our File No. Film: ? Polaroid -_[ Photo Mounting Sheet r 51 _ 17467 Negative -Ij Digital Date Taken 11/08/10 Terry McLaughlin Claimant. Clai says scar is at arrows. ? asp y ''r'S 0 Photo Mounting Sheet c: so" Insured/Owner: Espenshade Company Claim Number 5133646686 Policy No. Not Our File _No. 1746781 Date Taken 1 Film: LJ Polaroid LJ Negative J Digital Adjuster: Terry McLaughlin Photo Mounting Sheet Q Insured/Owner: C:sNC"" ""C - Company Claim Number 5133646686 Policy No. Not Provided Our File No. 1746781 Date Taken 11/08/10 Film: ? Polaroid Negative digital Adjuster: Terry McLaughlin AUKU ?t Insured/Owner: Photo Mounting Sheet Company Claim Number 5133646686 Policy No. Not Provided Our File No. 1746781 Date Taken 11/08/10 Film: ? Polaroid Negative Digital Adjuster: Terry McLaughlin Photo Mounting Sheet RUIFU Insured/Owner: Espenshac Company Claim Number 5133646686 Our File No. 1746781 Film: ? Polaroid Negative Digital Adjuster: 4'r t1. ? .vim. Fax Server 11/16/2010 11:27:18 AM PAGE 1/002 Fax Server INGENIX.. AN002-022012125 Technology Drive Eden Prairie, MN 55344 www.ingenix.com DATE:Tuesday, November 16, 2010 TO: WILLIAM LATCH; FAX:2152938437 FROM: Jason Slatten, SUBJECT: 10 5 5 8 2 7 9 Fax Number: 866-540-5935 Total number of pages including cover sheet: 02 NOTES: YOUR CLAIM #: 5133646686 The information contained in this facsimile message is privileged and confidential information intended only for the use of the individual or entity named above. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify us by telephone, and return the original message to us at the address indicated above via U.S. Postal Service. We will be happy to reimburse you for the postage. EXHIBIT Fax Server 11/16/2010 11:27:1£3 AM PAGE 2/002 Fax Server P N N U a? N z Q 0 U3 N N N m ? o v a N T p0p 0 < v v ? = I 2 0 m m a n n < 0 v v c _n 0 N (A + N a ?{Upp S o o° o c X W d a {N? p 3 MM Y N J O O m N O U fN ? ° o NO NO ? c 00 Ja 00 L t3 ? ? O v1 d ? ? `? N N S 8 $ O ?D n d z O Z O O m CD a co V V ? fJ O W W O m ? m ??pp O m V (J O y f O co N b o n OwONO =mmmm ACZCZ 00000 vnOAO ,)Coco nrw ory o , 0-nOn, ?a„a,,, nomom? > z c R ` n n m= m rn v vn Dingy 0o N Cl) N lD ?(ID a o ZoorT c ?. v3?n:n? 7 c j 7 cn , Z3 xocp cl:? CO (D N CANO=., 7 NON 0 O m V O CO X03 OQ z K ?C-4Q n O? . or, C O O Fi? ?p n• ? VAVM n z GI Co a-O 0= as J i 1 J O c" -4 4, fh O co b b X 0 4a 0 Mark S. Boland,DQ,FACOS 840 Sir Thomas Court Harrisburg, PA 17109-4839 (717)541-8898 Patient Receipt Page: 1 Printed: 03104/10 11:23 Donovin M Espenshade Patient Number: 8133 1550 WILLIAMS GROVE RD LOT 75 Mechanicsburg, PA 17055 Home Phone. (717)609-3122 008: 08/2211995 Trans Date Entered Amount Transaction Type Pmt Zype/Rewon Chock Mote Um I mim•Numben --158511 i.}.. 8?.=.aa - 2I• -'09 2 _ _Y_ . 41_ 8308/0198301 0 U _ _ H2Mon 00072 2) Ins: 1) ALST/Non 928248102 01 05/04/09 05/04109 1 99242 12 O 228.00 1 225.00 101.00 0.00 0.00 124.00 124.00 Pmosdure: Oonsultation of.--- paraded 1110008 11109109 61.00 4 Self Pay Check ck#279 sio 03/04110 03104110 50.00 4 Self Pay Check ck 289 AMK Total: Donovin M Esportahade 226.00 225.00 101.00 0.00 0.00 124.00 124.00 Criteria: Ali Records L2=the Cross Reweroae "refeni 1o the nuarberud d%0=16 cvdrs on the 018101 fine above it(Nmir4) P0S is Pro+,+ii i IMemet Pleoe of service code Indlcaft whore the procedure wau rendered. verages have posrod to date. in Pd K 0 an tbCf an coPSI" Mv3oW Y EXHIBIT Mark S. BOlanc,. ,FACOS £340 Sir Thomas Court Harrisburg, PA 17109-4839 (717)541-8898 Patient Receipt Page: 1 Printed: 03/04/10 11:23 Donovin M Espenshade Patient Number: 8133 1550 WILLIAMS GROVE RD LOT 76 Mechanicsburg, PA 17055 Home Phone: (717)609-3122 DOB: 08/22/1995 Trans Date Entered Amount Transaction Type Pmt Type/Reason Check #/Note User Line # Dates ot Service Prv Procedure DxRef •• Claim Number. 15852 Diagnosis: 1) 873.30 2) 709.2 3) 4) Ins: 1) ALST/Non 928248102 2) UH21Non 000726308/0199501 01 05/04/09 05/04/09 1 99242 12 0 225.00 1 225.00 101.00 0.00 0.00 124.00 124 00 Procedure: Consultation office/expanded hx . 11109109 11/09109 51.004 Self Pay Check ck#279 SJB 03104/10 03/04110 50.00 4 Self Pay Check ck 289 AMK Total: Donovin M Espenshade 225.00 225.00 101.00 0.00 0.00 124.00 124.00 Total Amotitif.Paid B:': l?atiaiik . Criteria: All Records Legend: Dx is the Diagnosis Cross Reference and refers to the numbered diagnosis codes on the claim line above it (l imit--4) POS Is Provider's internal Place of Service code indicating where the procedure was rendered. Pt Pd Is the amount paid by the patient Ins Pd is the total amount of all coverages have posted to date. ' Mark S. Bolanc ),FACOS 840 Sir Thomas Lourt Harrisburg, PA 17109-4839 (717)541-8898 Patient Receipt Page: 1 Printed: 12/06/10 14:18 Donovin M Espenshade 1550 WILLIAMS GROVE RD LOT 76 Patient Number: 8133 Mechanicsburg, PA 17055 Home Phone: (717)609-3122 DOB: 08/22/1995 Trans Date Entered Amount Transaction Type Pmt Type/Reason Check #/Note User lap Claim Number. 16099 Diagnosis: 1) 709.2 2) 3) 4) Ins: 1) ALST/Asgn 928248102 2) UH2/Asgn 000726308/0199501 01 07/07/09 07/07/09 1 99212 1 O 100.00 1 Procedure: Office visit, focused hx.w/ other 0.00 0.00 0.00 100.00 Total: Donovin M Espenshade 100.00 0.00 0.00 0.00 0.00 0.00 100.00 Total Ari n' i Paid B ',.patient:; r `O p, Criteria: All Records Legend: Dx is the Diagnosis Cross Reference and refers to the numbered diagnosis codes on the claim line above it.(li POS is Provider's internal Place of Service code indicating where the rocedure w d d mit--4) p as ren ere . Pt Pd Is the amount paid by the patient Ins Pd is the total amount of all coverages have posted to date. ` Mark S. Bolana FACOS s 840 Sir Thomas Court Harrisburg, PA 17109-4839 (717)541-8898 Patient Receipt Page: 1 Printed: 12/06/10 14:17 Donovin M Espenshade Patient Number: 8133 1550 WILLIAMS GROVE RD LOT 76 Mechanicsburg, PA 17055 Home Phone: (717)609-3122 DOB: 08/22/1995 Trans Date Entered Amount Transaction Type Pmt Type/Reason Check #/Note User Claim Number. 15854 Diagnosis: 1) 873.30 2) 3) 4) Ins: 1) ALST/Non 928248102 2) UH2/Non 000726308/0199501 01 05/12/09 05/12/09 1 99212 1 O 100.00 1 100.00 100.00 0.00 0.00 0.00 D 00 Procedure: Office visit, focused hx.w/ other . 12/02/09 12102109 100.004 Self Pay Check 54.00 AMK Total: Donovin M Espenshade 100.00 100.00 100.00 0.00 0.00 0.00 0.00 Total Atl?d By Patio ' . 0! Oaf Criteria: All Records Legend: Dx is the Diagnosis Cross Reference and refers to the numbered diagnosis codes on the claim line above it.(limit=4) ' POS is Provider s internal Place of Service code indicating where the procedure was rendered. Pt Pd is the amount paid by the patient Ins Pd is the total amount of all coverages have posted to date. Mark S. Bolan., ; FACOS 840 Sir Thomas Court p? Harrisburg, PA 17109-4839 (717)541-8898 Patient Receipt Page: 1 Printed: 02/15/10 14:59 Donovin M Espenshade Patient Number: 8133 1550 WILLIAMS GROVE RD LOT 76 Mechanicsburg, PA 17055 Home Phone: (717)609-3122 DOB: 08122/1995 Trans Date Entered Amount Transaction Type Pmt Type/Reason Check #/Note User :Line # Dates ot Service Prv Procedure DxRet •POS Charge Unt Apprv d Pt Pd In s Pd Adjusted Pt Due Balance Claim Number. 15853 Diagnosis: 1) 873.30 2) 3) 4) Ins: 1) ALST/Non 928248102 2) UH2/Non 000726308/0199501 01 05/08/09 05/08/09 1 99212 1 O 100.00 1 100.00 100.00 0.00 0.00 0.00 0.00 Procedure: Office visit, focused hx.w/ other 01/06110 01/06110 50.00 4 Self Pay Check ck # 284 AMK 01129/10 01129110 50.004 Self Pay Check ck #287 AMK Total: Donovin M Espenshade 100.00 100.00 100.00 0.00 0.00 0.00 0.00 Tota1'Affi6untPald:B Paden Md'WW1'00.00 Criteria: All Records Legend: Dx is the Diagnosis Cross Reference and refers to the numbered diagnosis codes on the claim line above it.(li md=4) POS is Provider's internal Place of Service code indicating where the procedure was rendered. Pt Pd is the amount paid by the patient. Ins Pd is the total amount of all coverages have posted to date. Jennifer Espenshade 1550 Williams Grove Rd. Lot 76 Mechanicsburg, PA 17055 627800 1 <m? January25, 2010 $ Amount Remltwl TO ENSURE PROPER CREDIT PLEASE DETACH AND RETURN THIS PORTION OF r -- - -- • - •-??_ _.__ .. -- _ ••- ..... ._ . _ __. _ _ . THE STATEMENT WITH YOUR PAYMENT - ___.. NN P y w YI .rN•r I. o 01 11? 4 • T rl irM.ry .- ' rM . .IIMi4AY' T/rW IYM:ITyyMw.%h •M.CC1 ?r t• L ry Y. Y 'IWi4N M W ?p M W 'ma „ •H . 4r"F •fY 1 ?Y.r YR r1'Nrrx4'J?MpwN'PI T?4 ??y yy r.•.1Y -w }N I'A L' iKr 12/25/2009 PREVIOUS BALANCE 135.00 12/30/2009 Prophylaxis - Adult (Rlm 48200) Donovin 65.00 190 00 12/30 2009 Comp Oral Ev"ew Or Estab Patient (CH, 48200) Donovin 50,00 . 240 00 12/30/2009 Fluoride Adult (CUM 48208) Donovin 20.00 . 260.00 12130/2009 4 81te-wing X-rays cam 400) Donovin 37.00 297 00 01111!2010 Insurance Check Payment (pm 40=) Danovln -161.00 . 138 00 01/11/2010 TRANSACTION WRMFF Donovin -1.00 , 135.00 01/18/2010 Amalpsm -1 Surface (OM 48284) Donovin 69.00 204 00 -. 01/25/2Q10 •.' Insuranco ( 'Faymarit (CIM 4.5-fa4) gPWM.. _40.80 . 1 2Q 53 01/25120110 TRANSACTION VI,IRITEOFF Donovln -1.00 . , . 1612Q A; ... .1 W-1 162,20 0.90 0.04 0.00 1f2.20 135;00 27.2Q H. DougW Cluck OMD;110tialiM Rq , Gamy 1711µ. FA 1tIM 1' ; . , : , Flat ?a?htl X!!)7? tr+A?l??!!l!aDN A!! ! IgFlt (N vA4?. V'!°°!?. , . ? : '-•----- , , Z0 39Vd ._.. ....:.,:.....,nn•v.•rurnrr.,u rrn..nr4n•r.n•:rnnun:ioocnnone d 3?SITdV0 XVW30I-u0 b9ZbEbZLTL tZ:ZT 0T0Z/t7TJL9 ACCOUNTS RECOVERY BUREAU, INC. P.O. Box 6768 • Wyomissing, Pa. 19610-0768 . January 30, 2010 CREDITOR: Mechanicsburg Fam Practice-Piruiacle Hith FOR: Donovin Empenshade ACCOUNT # BALANCE ACCOUNT # BALANCE --------- ------------ --------- ------------ 2175769522-3 15.75 TOTAL : 15.75 THE SUBJECT ACCOUNT HAS BEEN REFERRED TO US FOR COLLECTION. TELEPHONE: (800) 220-1622 or (610) 750-8450 THE IMPORTANT RIGHTS INCLUDED BELOW APPLY TO EACH ACCOUNT INDIVIDUALLY AND YOU HAVE THE RIGHT TO DISPUTE ANY OR ALL THE ACCOUNTS INCLUDED IN THIS NOTICE. UNLESS YOU NOTIFY THIS OFFICE WITHIN 30 DAYS AFTER RECEIVING THIS NOTICE THAT YOU DISPUTE THE VALIDITY OF THIS DEBT OR ANY PORTION THEREOF, THIS OFFICE WILL ASSUMB THIS DEBT IS VALID. IF YOU NOTIFY THIS OFFICE IN WRITING WITHIN 30 DAYS FROM RECEIVING THIS NOTICE THAT YOU DISPUTE THE VALIDITY OF THIS DEBT OR ANY PORTION THEREOF, THIS OFFICE WILL OBTAIN VERIFICATION OF THE DEBT OR OBTAIN A COPY OF A JUDGMENT AND MAIL YOU A COPY OF SUCH JUDGMENT OR VERIFICATION. IF YOU REQUEST THIS OFFICE IN WRITING WITHIN 30 DAYS AFTER RECEIVING THIS NOTICE, TUTS OFPICH WILL PROVIDE YOU WITH THE NAME AND ADDRESS OF THE ORIGINAL CREDITOR, IF DIFFERENT FROM THE CURRENT CREDITOR. THIS COMMUNICATION IS FROM A DEBT COLLECTOR AND 13 AN ATTEMPT TO COLLECT A DEBT. ANY INFORMATION OBTAINED WILL BL USED FOR THAT PURPOSE. IN1109001911MOVIrr PLBASI~ DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT INQUIRIES TO: PO BOX 3496 TOLEDO, OH 438137 50724-dµ62 Please check box if below addnre is irmect, 31' ? and indicate chanpe(e) on reveres a&. 0101 ?rh{?I?'?II'Irlllll?ll???l?lll?l?il?l?llld{gll??lnll?l?"111 JENNIFER F.SPENSHADE 1650 YVIL LIAMS GR RD 76 MECHANICSBURG, PA 17055.9799 q° PAYM10 6Y MPAYMMARD VISA Del AFRICAN CARD UGM0 M R PAYMENT No =° =L3 DISCOVER VISA AMERICAN EXPREN CARD RFAM - A U/1 ffirNA rURE W. DATE 0' 30" $ C9 1-106MO.0 05 ' - - - AMOUNT UNCLOSED $ .w...?.o..o.b.m. -?- 4UM= 30724440Y7000J4IUA=0'f ?I?'I?rl,l1?1?'?'I11'i?lllr?llllyrll??l??ll?ll??l??rl?l'???I{r?l ACCOUNTS RECOVERY BUREAU, INC. PO BOX 70266 PHILADELPHIA, PA 19176-0256 01100290307013020100500000015752 STATEMENT OF MEDICAL SERVICES LAST STATERM !DATE: 12/23/09 PINNA?HEALTH ON ? `: U401 eta NO ABJUCI113IBa 00.60 111311a11C OALANCrF s 039.00 YM BALANWt 010.0• If Aep Qpsstlans. P1Mfe CA11Now ; NM AT 717-2=-8060 OR 1-800-361i-6229 to • 2.709054 imumum YOUR CH111M3H PAYFATIM AAAXFMQNM BALANCE BALANCE >» PAT ffs BOMIN ESPENSHOHE OP NI= no PEBRf0 M AT: FAMQrL.Y CAW F W: 10BGINIO INi FA ILY PM -OFF= VI ?Y P1`-t11t 3----- -- - T9:OO" _ 6T.?i4^ 'T:N?O- °- - X1.110" PHOCEDOE: 99m 01ASSOZS: 706.1 long e9 T1dWJE &A SPLT 31-3 YO IN 19.00 19.00 PN : 90471 OIANN=k N04.81 ?? ?i?? p {?_ J? Esps? ! 1?77?1I.lilli¦ 1I Ii1.M¦.I rO WUM PA?/NEi? IN FJLL 15 RBCX4= NO ? O IM • 101 DAYS OF M WW OF TUB B=LL& YOM A iCOW HILL BE 81F TO A COLLNICTM MOW. IF PAYS BY CHWE CAM PLEA00 EWIAHMI TW TWO MIAIT SECMTY CODE LOCATED ON THE OAM OF V= CARD. MOK YOU F13R UMM IPriONID A HEALTH NE'DECAL SEIVIC113. 00 OFF]oCIE MM AM DOW TO ?brOOPN, NAY, MKgNO AY, FUMY AM n 8;38[01 TO 6t00NM1 T?Y AND TIY 0 e 0 A_?----?-?? Imo..... PAGE 1 OF 2 Pl.?.r.rr.r pu..?r.¦r En lVgNA U HL46LTH MW SVCS PO Sol W6 ELONISSURG PA 171W 1286 ADDRESS SERVICE REQUESTED Chat* bast and order any a0ron or JENNIFER EsrIENSHADE 1.659 WILLIAMS OR RD 076 IECHANICSBURG PA 17955 Ju Paul 111114311211941 11111 1111111111 PINNACLE HEALTH FED SVCS PO BOX 1286 HARRISBURG PA 17108-1266 +7f:7i7,f77JT1 +77"TT 0Tf27lbT1112 HC: I2H9 Maim Ceerdc PsymWe TO PINWL6 HEALTH MED SYCS STATEMENT OF MEDICAL SERVICES LAST STATEIEIP QATE: 30/2d?09 PINNACLEHEALTH M IQIARipn.- 021.00 prav NEM PAYI®ffS; 087.90 elL NO ACJRI8TMMM-. 071.60 INSURUM VALAIR.- 039.00 : If Am Qusstlonso nos" rantoots pwa A7 7'17M23S-4960 OR 1-600-50-•6229 YOUR BALANCE 025.76 FED TAX ZO 0 25170905+1 INSURME YOM CH PAYIEM A&W$T WM BALANCE SAtA ;E »s PATMWt DOIWZN OS',Pp1cE;1RM OP RlE = "ED PWONM AT., FANZLY CAFE IECiIAN tSOj s PEEFVl BY: W82MUCSOM FAMILY PR= *1W16/09 OFFICE V=T %T PI' LVL 3 79.00 67.40- 1.60- 10.00 PNOCIMMt 992x„1° KAIeNOESS. 746.1 1W16/09 =NFLIJYr7+n SPLT 4 YRS Im 19.00 19.00 PROCEMM1 906" OZAB M=s YOM 10/x.W09 ADM VAC?T= Iff-O iE{,A M 20.00 20.00 PInGEDUg t 90471 OXAsTSs Y04.81 EPSW PEA AT: FAKLY CAN wWwrmcM= _ 01f r I ?111N11?l1IILEmy 07ATAN ENW-OWMr VE EP 12-17 0.01 0.01 PROCEOM -. EPWr E=ABIIOd ; V20.9 97/27/09 YFC AM REP A-2 19.73 1.5.71 PIgCEBI C i0O00? OZACNOB=St VORi.3 'it *07/27/09 EPA 12YR-17M Wr 90.00 20.00- 70.00- 0.00 V 1 l- SAGE 1 OF 2 r .? phpw dmmh .r ? wa 1NY'rereee lD PO am I IOW% W PA 111A8-1Zli6 ADDRESS SERVYCE REgUESTED Chock boot and oft any aWvws or Irmurarm caned 3" on how* HC: I2HQ Uake Check PByabft TO PINNACLE HEALTH MED SVGS Ir.r?I?ralarllllrrrlulrrrrllulrllr.Inllr.I?.I.?II....I?II JENNIFER ESPENSHADE PINNACLE HEALTH !ED SVCS 1550 WILLIAMS OR RD 676 PQ BOX 1286 MECHANICSBURG PA 17055 HARRISBURG PA 171081286 REVENUE d1i Dear Harry Espenshade Jr: Total Amount Due : $ 1,853.25 Please be advised that the above referenced account has been placed with our office for the purposes of recovering the monies that are owed to our Client by you for the healthcare that was provided. It is our understanding that you have been previously contacted regarding this unpaid debt and it has now been sent to us for resolution. If you have already paid this, kindly provide proof of payment, otherwise, please review your records and reply accordingly. Thank you in advance for Your attention to this matter. Your resolution is appreciated b.• SEE BELOW. Should you have any questions or comments, please contact us at (866)-790-8734. We will be glad to assist you. We are also :available by email at ciitolnerear Ca)_.r vengecollect.com.; payments may be made at www.pavrevenue?alleet.com. Sincerely, Collection Dertment (866)-790-87T4' di HOLY SPIRIT HEA HOLY SPIRIT HEA Date : 05/24/10 RE: SEE BELOW Revenue Collect Account : 0005258849 (lri "na ount(O $1,800.00 $53,25 Charge(Affl (s) $.00 $.00 Total Amount Due: Amottritt Due $1,800,00 $53.25 $1,853.23 - -1Tifs 66mmaiiiad6n is?rom a°ct6Fi[ collector. its r?otiticatiotris-an-att+empr to- otiuct-j-d+ebt and-am -iniorniatiotrobtatrred will be used for that purpose. Meng" make burr r ddM'" 4r4V*M 111MUgh %imkm P.O. Box 2103 ""a ''ERN AIL; Mechanicsburg, PA 17035-2103 ? CAWA14 JUX;k N90NA111R1it 111111'1111'1 Date: 03/24110 C'I AIM05251249l3M Iimn930CKKKU647!(xXa. K0j4 `?`-'r ?idlll?I?Illrlllllldl?lrrr'?rr??ll?l+Ilrrl???tlrl!lI?..I?Ill.ll Harry- Espenshade Jr Donovin Espenshade 1550 Williams Grove Rd Mechanicsburg, PA 17055-5349 CREDITCAKI) Kl'!?!lSFR t{?I'IkA'I'lulrl),\'11e -?,.....? I'.\YN IIiNTAAluUNT: scColan. Cool; Rmunwe Collect Accuuut: (1X752510 l olal Amount DuL, $ 1,853,25 11101111.111.... 1A.I.1...1.1111111111111111111ki I Revenue Collect P.O. Box 2103 Mechanicsburg, PA 1 705 5-2 1 03 f'It A z,1 CAMP HILL EMERO NCY PHYS-ICIA PO SOX 13693' . PHILADI=LRHIA, PA 19101-,93 ' Ir«?IIItNlllnr.I;li,Jill'tlrlfullnb111f1t?61???i1lr?rlbl ? #B I]Pl???QQ??.??b5l?clb'4S*?1?6• UVPI F. #D0Q00QHYP2G0-480W HARRY gSPENSHAM JR 1550 WILLIAMS GROVE RR LOT .7 MECHANIC313URO PA 17065.5540 91 TEMENJ OE ACSeQUNT• (4) State ord Date: Se ember 13, 21009 ACCOUNT NUMBER'. HY 34519645 Patient Name:' DONOV M ESPENSHADE 'rax io a: 20.4667340 Account dance: 3'200.00' Amount PindUg tnsurenoi: $0.00 Amount Due From Patient (Current): $0.00 Amount Due From Patient (Past•Dule): $200.00' ` Pay.This Amount: $206.04--_j YOUR ACCOUNT IS NOW SERIOUSLY PAST DUE, AND A DELINQUENCY ' REVWW IS BEING CONDUCTEDc•'.Please rotor to coupon below: w p; yment. insthxtibn;: , ACC ip; t DeftiprFr r l P010 Wy Ampynt out From 17 Flrstl I PatkK Ad Irwjr~ BALANCE P?08 1 120tf1 YJCIUNO ftFP ???M FAQE S50p,Q6, OYATSdO.pW !µ ?pNQlf IpLY gPltslT riQel?ITAL . • Ihl?i!R7!M? PgYfM16NT' S:g7e.20 5118.nD 0SIA7f0o 2. •2¢ gMIM INM..Y EVAl. #, ti01,00. MtiMrd YL 8 _.` . - - - TAI _.,. __. pftgip A6 1114 rAItAN? MQk1' SfjINT Met" ... r0T AM ;I-man: $- moo m.oo $400 ;0-00 .. mgo Moo ?nrpo?tt I-. ?. . . T* GOWnerlt ill for to inlet VMc+Ai041!nQfar WPwyh*m of OWO yr?t rppaivad from an Ph Ian at Molt' SWR•Mwpltal. Tlw ft" for #& PR#40 PWSWM Mrp1KMIWy trrxq Mr fiOapKPI p a oYMrw ? N t Wdah MGM AMo bo ?lt mrom rlrouW yQu rafelw a WII RwnLw hocpkW or 0.*W pllyrrloMtll (a of I?NQNb M1 M1Mj?PP WAh?yz K . ( 1S ,Nr* 4 an ltli? uWrmaf "paymer# Plats!' Accepted Qufasti064 0gl?lt•thW4ii hiiinOnt? 1 Llama do Lungs a Viernes.? 0411 :1 AQ• 50 7O MAt1day thlroi<tph Friday 9:30AM -..4:00PM- Your aukorn#ad. rytt tetra Sege": a90 is 0301-.34519640, or you can send emaitto • 4111109,.41?lutions?lrt?trs.cortt. • . •. lNease dotuh•and retu'm bottom portion •vMh your remittance. HARRY ESPENSHADE JR STAIMMCNT OF ACCOUNT. 1550 W UJAMS' GROVE RD LOT 7 Stalernent Date: SoOmber 13 2009 MECHANICSBURG PA 47056.53417 ACMUNT NUMB R: 19845 Y YOU MAY PAY THIS BILL WITH YOUR CREDIT CARD Patient N OVIN PLEASE SEE REVERSE SIDE. PayrrWtt : PAST DUE Malta check/ Money ON" Payable to', Amount duo: JM.00 ARMUM Enotosed: 6"llhbr?r,Illl???r,dl?rllrrlb?61?,??IL6??11 Th.nda' w'"? :r out IIW . , Wert ro b8% Plot" mm m? a"`ya u.. CAMP HILL EMERGENCY PHYSICIA PO BOX-138M PHILADELPHIA, PA 19101.3693 MTM uNG'SPHEALTHCARE 000T,aE3t1 i m1 0726 ATTM HEALTH CLAIMS ATLANTA GA 30374 C3 If your address has. changed, check this box and complete the reverse side of this form 0625160000C ;119645000200000000000000004 4-.f:7'4.C4.7J T1 i.7•TT f]Tf]7 14.T /lfl Holy Spirit Hospital 503 North 21" Strut * Camp Hill, PA 17011 * (800) 596-9997 June 24, 2009 Your Account With: Account #: For: Admission Date: Total Due: Dear Harry Espenshatle: Holy Spirit Hospital 34519645 Donovin Espenshade 05102/09 $53.25 s letter is to A111 M M bM M-fAMnced viii ja Holt/t/ .pint HospItel. Out records indicate that there is an outstanding balance remaining on this account. Please remit payment in full upon receipt of this letter. It has always been the continuing goal of Holy Spirit Hospital to serve the community as a full service health cam facility front the time of a patient's initial care through the account's final resolution. If you have any questions regarding this account, please feel free to call this office at 1-800-596-9997 and speak with one of our representatives. Thank you for choosing Holy Spirit Hospital for your family's health care and for resolving this outstanding balance promptly. To assuro proper application of your payment, plead attach the bottom portion of this letter to it. if you wish to pay by credit card, please complete the required information on the reverse side of this letter. If you have insurance that may pay all or a portion of this debt, please complete the information on the reverse side of this letter and return the entire letter. Sincerely, Holy Spirit Hospital **•L)aW,h WW&X K)MUa And Ruunt With Paynaaal" Account #: Total D1le; ONFOU l0 Pc) Box 1022 Wixou1 Ml 48393-1022 June 24, 2009 34519645-191 184918137 Il?llll'11111t?ll'III11111?+111IIIl11lI11I11'11'111+Illl+Ill?l«I Harry Esponbhude 1550 Williums Grove Rd Mwhanicsburg PA 17053-5349 34519645 $53.25 lluly Spirit Hospital 1K) Box 822183 11hiladolphia PA 19182.2183 111111161111111111111111111111111$ 1111111111111111111111111111 WNt,3lu m 191 DO©a34519645001000OODa53250alO0735000000011309 The Spirit of Caring # 800-9 3 For A cou t InAw=ation, Pkmw t oN 3009974673 Trusaction Deft Daariptim Amount PREVIOUS BALANCE .00 05/03/09 LEVEE. I FC 129.00 OS/22/09 UNITED HEALTH CARE P 1118 UNITED HEALTH -66.05 08/22/09 UNITED HLTHCARE C/A 1115 UNITED HEALTH -46.44 C 10, ,V^ 1 33 (a L L ?7b, P0 1.11),.4 `2S24810?. FAdmaSd hwaftao Dow A11 Total Patient C YOUR INSURANCE HAS BEEN BILLED.THIS IS YOUR CURRENT BALANCE. YOUR PAYMENT IS DUE UPON RECEIPT. THANK YOU. 015 UNITED HEALTH 00 PUEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID. 34521484 AOM DT; 060300 DSH DT: 'NONE' HOLY SPIRIT HOSPITAL s0~ 21022 SO N 21ST STRE ST 717-60"122 CAMP HILL PA 17911 # MR: MSG 1651 11 06/07/09 ADDRESS SERVICE REQUESTED I V5e.89 ? has pa?dt.Pjrre a= *w^wbOn Make Check Pan too To: HOLY SPIRIT HOSPITAL • Tba CVV3 N mbw is tM ha 3 dW% m tM huh of ywr aril nut, ty yw xlWm? 013018934 001 0.53 34521484 HARRY ESPENSHADE JR 1550 VALUAMS GROVE RD LOT 76 MECHANICSBURG PA 17053-9799 l??ylil.l.yy??llly?l?y?l?ll HOLY SPIRIT HOSPITAL P.O. BOX 8=183 PHILADELPHIA,PA 191822183 000034S2l484DGlOO000aUl6Sl00100735000000011302 ?wwwairwwrwrrrw +ww - y Holy Spirit Hospita T TRIT 503 N 21 ST STREET YOUR INSURANCE HAS BEEN BILLED.T"IS YOUR CURRENT BALANCE. YOUR PAYMENT IS DUE' tECEIPT. THANK YOU. Q15 UNITED HEALTH .00 °e PLEASE 013REGARD THIS STATEMENT IF YOU HAVE PAID. .... . yerr ABU DT: 060M 34519845 DSH DT: *NONE' p S HOLY SPIRIT HOSPITAL sB: 21020 PENSHAD6 ,DONOYIN M o6/b7/09 E 503 N 21ST STRF.TT 717-NO-3122 0 a M 11 E?a C AMP HALL PA 17011 . # HR: MSG 87SA3 ADDRESS SERVICE REQUESTED s Check b= if Yyoqb?// iOAreas 94== rmaNon stake Check PayiWs TA: HOLY SPIRIT HOSPITAL ? his CharlgeO.PINSe make • Trove CVV2 NmW r Ift MR 3 W&W as td rra of yaw ari[ rare, r7 „!tr des 001118933 001 0.53 34519645 HARRY ESPENSHADE JR 1550 WILUAMS GROVE RD LOT 76 HOLY SPIRIT HOSPITAL MECHANICSBURG PA 17055.9799 P.O. BOX 822183 PHILADELPHIARA 19182-2183 0000345196450010000001>5325001007350000D0011304 78HoLy sma 7U Sptrh of Caitng Holy Spirit Hospital kl? 503 N 21 ST STREET CAMP HILL PA 17011 800-997-8573 For A,eep W lohnm", Ple?e CON MMJ 974IS73 -- fitwMChn Dale Dewiltiw Aa?oauK PREVIOUS BALANCE .00 05/82/09 930 CR seem / 7.00 OS/02/09 LEVEL II FC 204.00 05/02/04 LAY REP FACE,EAR,NOSE,LIPS-7.S C 2066,00 05/22/09 UNITED HEALTH CARE P Q15 UNITED HEALTH -212.99 05/22/09 UNITED HLTHCARE C/A 41S WILTED HEALTH m4Ay..7; 4 1+N. 1' w ) ?. La, 4-c ?. RELEASE OF ALL CLAIMS KNOW ALL MEN BY THESE PRESENTS: That the Undersigned, HARRY ESPENSHADE and JENNIFER ESPENSHADE, parents and natural guardians of DONOVIN ESPENSHADE, a minor, being of lawful age, for and in consideration of the amount of FIFTEEN THOUSAND, FIVE HUNDRED, FORTY-NINE and 55/100($15,549.55) DOLLARS to be deposited in a federally-insured, interest-bearing account, until Donovin Espenshade reaches the age of majority, in accordance with Pennsylvania Rules of Court and the Court Order approving said settlement, and other good and valuable consideration, receipt whereof is hereby acknowledged, does hereby and for their heirs, executors, administrators, successors and assign release, acquit and forever discharge MICHAEL REGAL and ALLSTATE INSURANCE COMPANY and their agents, servants, successors, heirs, executors, administrators and all other persons, corporations, firms, associations or partnerships of and from any and all claims, actions, causes of action, demands, wrongful death and survival actions, rights, damages, costs, loss of service, expenses and compensation whatsoever, which the undersigned now has or which may hereafter accrue on account of or in any way growing out of any and all known and unknown, foreseen and unforeseen bodily and personal injuries and property damage and the consequences thereof resulting or to result, arising out of, in any way, a dog bite incident that occurred on or about May 2, 2009. It is understood and agreed that this settlement is the compromise of a disputed claim, and that the payment made is not to be construed as an admission of liability on the part of the party or parties hereby released, and that said Releasees deny liability therefore and intend merely to avoid litigation and buy their peace. R0225608.1 The undersigned hereby declares and represents that the injuries are or may be permanent and progressive and that recovery therefrom is uncertain and indefinite and in making this Release, it is understood and agreed, that the undersigned relies wholly upon the undersigned's judgment, belief and knowledge of the nature, extent, effect and duration of said injuries and liability therefore and is made without reliance upon any statement or representation of the party or parties hereby released or their representatives or by any physician or surgeon by them employed. The undersigned hereby agree to defend, indemnify and hold harmless the named Releasees herein, their attorneys, representatives, executors, administrators, insurers, heirs, successors and assigns, of and from any loss, claim, liability, cost or expense by anyone claiming entitlement to the settlement proceeds, including claims for medical expenses, welfare benefits, medical benefits, or other sums wherein a subrogation, interest or lien is claimed, including any amounts claimed to be due under the law, state or federal regulations, or contracts. The undersigned further acknowledge that all obligations to satisfy such liens or amounts claimed are that of the undersigned. The undersigned further declare and represent that no promise, inducement or agreement not herein expressed has been made to the undersigned, and that this Release contains the entire agreement between the parties hereto, and that the terms of this Release are contractual and not a mere recital. THIS PART HAS BEEN INTENTIONALLY LEFT BLANK R0225608.I Page 2 of 3 The undersigned intends to be legally bound hereby in accordance with the terms and provisions of the Pennsylvania Uniform Written Obligations Act. THE UNDERSIGNED HAS READ THE FOREGOING RELEASE AND FULLY UNDERSTANDS IT. Signed, sealed and delivered this day of , 2011. Witness (SEAL) Harry Espenshade, Parent and Natural Guardian of Donovin Espenshade Witness (SEAL) Jennifer Espenshade, Parent and Natural Guardian of Donovin Espenshade 80225608.1 Page 3 of 3 VERIFICATION I, Harry Espenshade, parent and natural guardian of Donovin Espenshade, a minor, verify that I am authorized to execute this verification and that the statements made in the foregoing Petition for Court Approval of the Settlement of the Action of a Minor are true and correct to the best of my knowledge, information and belief. Date Harry Espens ade, parent and natural guardian of Donovin Espenshade, a minor R022562?.1 VERIFICATION I, Jennifer Espenshade, parent and natural guardian of Donovin Espenshade, a minor, verify that I am authorized to execute this verification and that the statements made in the foregoing Petition for Court Approval of the Settlement of the Action of a Minor are true and correct to the best of my knowledge, information and belief. e d Jonifer Espenshade, parent and , tural guardian %4 Donovin Espenshade, a min r R0225623.t IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: DONOVIN M. ESPENSHADE, CIVIL DIVISION a Minor, by and through his parents and c natural guardians, HARRY ESPENSHADE and rn-n JENNIFER ESPENSHADE, MM ? r -0 -Orn 371 ?' ? n - Petitioners. No. <Q -Z -n :zc) a r orn ORDER OF COURT AND NOW, this I p day of 41 av?l , 2011, upon presentation in open Court and it appearing that settlement between the parties is in the best interest of the Minor, Donovin Espenshade, said settlement is hereby approved pursuant to the following terms: 1. Donovin Espenshade, a minor, by and through his parents and natural guardians, Harry Espenshade and Jennifer Espenshade, have settled with Allstate Insurance Company for a total amount of $15,549.55, and said settlement shall be distributed as follows: a. $1,079.04 paid directly to Ingenix Subrogation Services to satisfy the lien asserted by it for all medical bills which have been paid on behalf of minor, Donovin Espenshade; b. $1,720.51 paid directly to the parents and natural guardians of minor, Donovin Espenshade, for any and all outstanding and reimbursable medical bills; C. $1,500.00 paid directly to Donovin Espenshade for school and other expenses; and d. $11,250.00 paid directly to Harry Espenshade and Jennifer Espenshade, as parents and natural guardians of minor, Donovin Espenshade, to be placed in a savings account or certificate of deposit in a federally insured bank, savings and loan association or credit union. The savings account or certificate of deposit shall be marked "NOT TO BE WITHDRAWN UNTIL THE MINOR REACHES THE AGE OF MAJORITY [18] OR BY FURTHER ORDER OF COURT;" R0222284.1 2. Harry Espenshade and Jennifer Espenshade, as parents and natural guardians of Donovin Espenshade, are permitted to execute the release attached hereto as Exhibit F for injuries sustained by Donovin Espenshade as a result of the May 2, 2009 dog bite incident; and 3. Counsel for Allstate will file a Proof of Placement of the Proceeds of the Settlement with the appropriate Court department within thirty (30) days from the date of this Order of Court. BY THE COURT: VIII, iam M. O'Connell, Fq_ No R0222284.1 Nlq ?` 41,111 Da X IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: DONOVIN M. ESPENSHADE, CIVIL DIVISION a Minor, by and through his parents and natural guardians, HARRY ESPENSHADE and JENNIFER ESPENSHADE, Petitioners. No. 11-3371 PROOF OF PLACEMENT OF SETTLEMENT PROCEEDS COUNSEL FOR ALLSTATE INSURANCE COMPANY: DIANA M. O'CONNELL, ESQUIRE PA I.D. #206795 ROBB LEONARD MULVIHILL LLP Firm I.D. #249 BNY Mellon Center 500 Grant Street, 23rd Floor Pittsburgh, PA 15219 (412) 281-5431 -j -? N ?C:) wd ?. sv r-, r 80237133.1 T IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: DONOVIN M. ESPENSHADE, CIVIL DIVISION a Minor, by and through his parents and natural guardians, HARRY ESPENSHADE and JENNIFER ESPENSHADE, Petitioners. No. 11-3371 PROOF OF PLACEMENT OF SETTLEMENT PROCEEDS Pursuant to the attached correspondence from Metro Bank of Mechanicsburg, settlement funds relative to the above action were placed with Metro Bank, 5032 Simpson Ferry Road, Mechanicsburg, PA 17055, pursuant to the terms of the Order of Court dated April 1, 2011. Respectfully submitted, Robb Leonard Mulvihill LLP By 4C0,0 )k), Jr 'C-?? Diana M. 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