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HomeMy WebLinkAbout11-3518ROTHONOTAR`c` Christina L. Bradley, Esquire FREEBURN &, HAMILTON ID No. 89107 4415 North Front Street Harrisburg PA 17110 (717) 671-1955 2011 AFR -1 AM 10: 2rt CUMBERLAND COUNTY PENNSYLVANIA Attorney for Plaintiffs COURTNEY RICE, a minor, by ROBERT: IN THE COURT OF COMMON PLEAS, RICE and DEANNA RICE, her natural CUMBERLAND COUNTY, PENNSYLVANIA parents and guardians; ROBERT RICE, in his own right; and DEANNA RICE, in : her own right, Plaintiffs : NO. VI V. MATTHEW CARROLL, Defendant PETITION FOR APPROVAL OF MINOR'S SETTLEMENT AND NOW come Plaintiffs, Courtney Rice, a minor, by her natural parents and guardians, Robert Rice and Deanna Rice, and Robert Rice and Deanna Rice, in their own right, by their attorneys Freeburn & Hamilton, PC, and Petition this Court for approval of minor's settlement: I. PARTIES 1. Plaintiff, Courtney Rice, is a minor born on December 16, 1995, who resides with her natural parents and guardians, Robert Rice and Deanna Rice, at 850 Windy Hill Road, Lot 6, Shermans Dale, Cumberland County, Pennsylvania. 2. Plaintiffs, Robert Rice and Deanna Rice, husband and wife, are Courtney Rice's natural parents and guardians, who reside at 850 Windy Hill Road, Lot 6, Shermans Dale, Cumberland County, Pennsylvania. rte. as71o?a 3. At all times relevant hereto, Robert Rice and Deanna Rice have had and continue to have primary physical custody of Courtney Rice and are authorized to bring this litigation pursuant to Pa. R.C.P. No. 2228(b). 4. Robert Rice, Deanna Rice and Courtney Rice are represented in this matter by Freeburn & 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, Matthew Carroll, is an adult individual who resides at 875 Bower Road Shermans Dale, Cumberland County, Pennsylvania. II. FACTS 6. The facts and occurrences hereinafter related took place on or about September 6, 2009, at or near Bower Road, Shermans Dale, Cumberland County, Pennsylvania. 7. At or about that time and place, Plaintiff, Courtney Rice, was walking with friends on Bower Road. 8. At or about that time and place, a dog owned by Defendant, Matthew Carroll, approached Plaintiff, Courtney Rice, and bit her on her left arm. III. INJURIES 9. By reason of the aforesaid collision and injuries, Plaintiff Courtney Rice suffered painful injuries to her nerves, bones and soft tissues, which include, but are not limited to, a wound on her left arm. See medical records from Carlisle Hospital and Perry Physicians attached hereto as Exhibit "B". 10. The wounds on Courtney Rice's arm has caused scarring. See photograph of Courtney Rice attached hereto at Exhibit "C". 2 IV. INSURANCE 11. At the time of the incident on September 6, 2009, Defendant was insured under a homeowner's insurance policy written by Erie Insurance Exchange ("Erie"). 12. Courtney Rice was covered under private health insurance issued by Aetna. V. MEDICAL EXPENSES 13. As a result of the dog bit incident on September 6, 2009, Plaintiff, Courtney Rice received medical treatment for which the following medical bills were incurred: A. Carlisle Regional Medical Center $ 2,166.16 B. Alexander Springs ER Physicians $ 599.00 C. Perry Physicians $ 69.00 ---------------- TOTAL $ 2,834.16 14. Aetna health insurance has paid the following medical bills, with the balances being written off by the medical providers as insurance contractual adjustments: A. Carlisle Regional Medical Center B. Alexander Springs ER Physicians TOTAL VI. PROCEDURAL HISTORY 15. No suit has yet been filed in this matter. $ 570.00 $ 157.38 $ 727.38 VII. SETTLEMENT 16. Erie, on behalf of Defendant, has offered to make a lump sum payment of $12,000.00 to settle this matter. A true and correct copy of a proposed release is attached hereto as Exhibit "D". 3 17. Plaintiffs, Robert and Deanna Rice, have reviewed the proposed release offered by Erie with their attorneys and are satisfied that they understand all of its terms and the consequences of signing the Release. 18. Aetna has a subrogation lien on this settlement in the amount of $727.38. A true and correct letter from The Rawlings Company, LLC, agent to Aetna, confirming the subrogation lien is attached hereto as Exhibit "E". 19. Freeburn & Hamilton has advanced expenses associated with the litigation in the matter in the amount of $153.05. A copy of the litigation expense print-out of the litigation costs of Freeburn & Hamilton is attached as Exhibit "F". 20. The settlement proceeds would be distributed as follows: a. Total Settlement $12,000.00 b. Attorneys Fee 25% $ 3,000.00 C. Litigation Expenses $ 245.05 of Freeburn &, Hamilton d. Lien of Aetna $ 727.38 e. Net to Courtney Rice, a minor $ 8,027.57 21. The net proceeds to minor, Courtney Rice, will be deposited in a savings account in the name of Plaintiff, Courtney Rice. A hold would be placed on the account so that no transfers or withdrawals can be made from the account until December 16, 2013, when Courtney Rice reaches the age of 18. 22. Plaintiffs believe that this settlement is in the best interest of Courtney Rice because it avoids the risk of obtaining a lesser recovery or no recovery at all. WHEREFORE, Petitioners Robert and Deanna Rice hereby request that this Honorable Court enter an Order: 4 a. Approving the full and final settlement of this action; b. Authorizing Robert and Deanna Rice to sign all documents necessary to accomplish the settlement, including but not limited to the Release, individually and as parents and natural guardians of Courtney Rice, a minor, and all checks; C. Approving the distribution of the settlement proceeds as set forth herein, including the payment of counsel fees and expenses; d. Directing payment of the net funds be made to a custodial savings account be opened in the name of Courtney Rice with Bank of Landisburg. e. Directing Petitioner to file a Praecipe with the Orphans Court of Cumberland County marking this matter settled and discontinued once the $12,000.00 payment has been received and the savings account opened and funds disbursed; and f. Staying all proceedings meanwhile. Respectfully Submitted, FREEBURN & HAMILTON, PC By: Christina L. Bradley, Es ire I.D. No. 89107 4415 North Front Street Harrisburg PA 17110 (717) 671-1955 Date: 04/05/11 Counsel for Plaintiffs 5 VERIFICATION We, Robert and Deanna Rice, individually and as parents and natural guardians of Courtney Rice, hereby verify that we are Plaintiffs in the foregoing matter and that the statements in the PETITION FOR APPROVAL OF MINOR'S SETTLEMENT are true and correct. We understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. Dated: ?/ , -/-& Rice, individually and as parent and natural guardian of Courtney Rice Dated:3 ' ? • ? eta l Deanna Rice, individually and as parent and natural guardian of Courtney Rice ?Xil'??? FREEBURN $ HAMILTON, PC ATTORNEY'S AGREEMENT THIS AGREEMENT entered into this q 44-/ day of September, 2009, by and between FREEBURN & HAMILTON, PC, Attorneys-at-Law (hereinafter referred to as "Attorney") and ROBERT RICE and DEANNA RICE, INDIVIDUALLY AND ON BEHALF OF COURTNEY RICE, THEIR MINOR DAUGHTER, her successors and assigns (hereinafter referred to as "Client"). WITNESSETH: That Attorney, 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 9/5/09 ATTORNEY FEES: In consideration for services so rendered by Attorney, it is hereby agreed by and between the parties hereto that Attorney 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 Attorneys 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 or otherwise, we will be compensated for such work at our regular hourly rates, and for costs incurred. ATTORNEY'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 Attorney 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 Attorney for such expenses if no recovery is obtained. LEGAL REPRESENTATION It is understood that FREEBURN & HAMILTON represents Client with respect to third party 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 Freeburn & 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 & 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 & HAMILTON. Client also understands that other legal matters have time limits within which suit must be brought or actions taken, and that the failure to file suit or take such actions will result in the loss of Client's rights. Client understands and agrees that FREEBURN & 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 FREEBURN & HAMILTON, whereby FREEBURN & HAMILTON agrees to represent Client on such other legal matter. 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. 2 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 Attorney. Client(s) further agree to consider seriously any recommendation for settlement made by Attorney 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). MISCELLANEOUS: Client(s) understand, acknowledge and agree that Attorney does not guarantee the outcome or eventual result of the above claim. CLIENT'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 J received SSI or public assistance benefits, and agrees to immediately notify attorney if Client should receive SSI or public assistance benefits. 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. FREEBURN & HAMILTON, PC By: -(2h iAl n I 6n e% J a Christina L. Bradley, uire 4415 North Front Street Harrisburg, PA 17110 (717) 671-1955 obert Rice Q!, -Zmull M . Deanna Rice 5 . I 1 AUTHORMATM TO DISCLOSE IMALT13 II'IFORIRATI01? Patient Name: Courtney Rice Date of Birth: 12116/95 Address: 850 Windy Hill Road. Lot 6. Shermansdale. PA 17090 Social Security No.: 181-76-9873 We hereby authorize Ca r 1. S(-e R-wE co(, j'c a j Cen t"er- to release health information regarding o minor daughter, to: FREEBURN & HAMILTON. 4415 North Front Street. Harrisbur¢ PA _ 1711_Q 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 all Information disclosed: x Discharge summary --K-Complete chart ?ER and outpatient reports x X-ray reports x History and physical _.2L_Lab reports x Operative and pathology repts -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 _ -Billing Info _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 (HM. 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 already 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 & Hamilton. Permission is hereby granted to Freeburn & Hamilton to p ocopy or scan this authorization and any photocopy thereof shall be as by us an original. Q-i5--oq DATE 01 Cos-oq DATE Wi e - ft ?Vel 21 ??? ROBERT RI E, on behalf of Courtney Rice DEANNA RICE, on behalf of Courtney Rice ADMISSION RECORD wltereAls eewre¦ ANOINT NO. . 3i1 Alexatldat SptMy Roast • CrNaM, PA 1701') W Zi a (717124111-11212 MEDIM . 9944315 0000781935 p A AMT A / I R M NO. PT FC AGE DATE OF BIRTH SEX R 09/06/2009 16:58 0000 El F 13 12/16/1995 F 1 L )CATION PR T S ER I RICE, COURTNEY A 777-77-7777 STUDENT E 850 WINDY HILL RD LOT 6 N SHERMANSDALE PA 17090 PHONE NUMBER T US (717) 275-4858 COUNTY PERRY FILWONSIBLE fl RICE, ROBERT E HJ TOWING U 850 WINDY HILL RD LOT 8 202-58-7681 (717)789-3744 R SHERMANSDALE PA 17090 " U LANDISBURG PA RELATIONSHIP PATIENT US (717)275-4858 FATHER RESP EMERGENCY CONTACT NAME not m household M CY CONTACT PHONE EMERGENCY CONTACT LATIONSHIP TO PATIENT COM RICE, SHIRLEY MENTS (717)789-4134 GRANDMOTHE p9p ED-KE' A Y Pnlv- N PRIVACY T 0 Y MN D Y (3 IJ Y JEL ACCIDENT CIDENT DATE OTHER 9/06/2009 To 105 PLAN HMO POL rcy NUMBER BBRTHYGA DATE OF DIRM 12/16/1995 NA PO BOX 981107 C COURTNEY A N EL PASO TX 79998 (800)624-0756 GROUP NUMBER 00406N GROUP NAPE S I A I N U ` A A NUMOR y OF BIRTH A . // R GROUP NUMBER U NA E A AU IAI N N 3 PLAN U Y U DATE OF BIRTH C INSURED GROUP NUMBER umuljr N AME E w, nu---j A ILY 1 A GUARRACINO, ANTHONY J TROSTLE, LORI C S AUM"ING DIAGNOSIS C ANIMAL BITE PRINCIPAL DIAGNOSIS (The eaidition est9kahad after study to be chiefly responsible for T§EFff= :7 A oceasb,wnp the adm anion of the patient to the HOSPITAL fa caret. COMPLICATIONS COMORBIDITYIIES) PRINCIPAL PROCEDURE HMAT t 20 9444315 0000781936 • Carlisle RegWW AAakM Center . ' . 361 Alexander spring Drive, CedWe. PA 17013 (717)248-1212 Paftt RICE, COUR'TM A DOB: 12116119M POW t 9441315 MRN: 0000761935 Deb M: WO M CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: KMG 09/06/200917:21 RICE, COURTNEY is a 13 year old F that presented to the Emergency Department at 16:58 by WALKING. The patient was triaged at 17:01 with the following vital signs: T: 98.6 PO,'P: 79 Regular , R: 18 Unlabored , BP: 135/081 , SP02: 98 Amt:RA , Pain: 5 Lower Arm . The patient's primary care physician is TROSTLE, LORI C. Chief Complaint -- ANIMAL BITE Exam Time: 17:21. History obtained from: patient. Symptoms came on suddenly. Onset of symptoms was immediately prior to arrival in the Emergency Department. Injury occurred in the street. Patient was bitten by dog. The animal appeared well. This animal is generally known and is seen regularly in the neighborhood. This was clearly an unprovoked attack. Patient sustained multiple wounds. Patient was bitten. Symptoms located in the, The patient states that she was walking down the road when someone brought the dog onto the mad to pull him on his skateboard. The dog is known to be aggressive.. PAST MEDICAL AND SURGICAL HISTORY: KMG 09/06/200917:47 Past Medical History: positive NONE. Restive History: LW: 1 WK AGO,. Past Medical and Surgical histories reviewed. Immunizations: up to date. PHYSICAL EXAMINATION: KMG 09/06/200917:47 Mumlosketetail/Extremity: Left Upper Extremity: Forearm -- Laceration: Simple, neurovascular exam distal to wound intact. Small amount of soft tissue swelling is present. Small occhymosis is present. Mild tenderness to palpation. ED COURSE AND TREATMENT: KMG 09/06/2009 17:50 Procedures: Laceration Repair: Procedure: Wound number: 1. Length of laceration = 2 cm. Area prepared and wound cleansed thoroughly with. Area anesthetized by local infiltration with I% xyloeaine without epinephrine. Wound irrigated with copious amounts of NS. Skin Closure: Wound closed with Ethilon 5-0 suture material. Sutures placed using simple interrupted technique. Number sutures used: 5. Procedure: Wound number: 2. Length of laceration =3 cm. Area anesthetized by local infiltration with 1% xylocaine without epinephrine. Wound irrigated with copious amounts of NS. Skin Closure: , The box like laceration/puncture was pulled together with a modified pursestring suture. Antibiotic ointment applied over suture line. Wound covered with sterile dressing. Physidw 00ox enWon (Pro-MED CNnW Systems, L.L.C.) PrWW on: WOMAN 20:11 Page 1 or 2 . t CarW a Regions! MeftM Center 361 Aiexan W Spring D&O. Cariiste. PA 17013 POW*- ME, COURTNEY A DOB: f tnei" P 16W 0'9444315 MRN: 0000 aloe DM fn: SW 2M CLINICAL IMPRESSION: KMG 09/06/200917:50 l . Dog Bite 2. Laceration, Left Forearm DISPOSITION: KMG 09/06/2009 17.49 Disposition: Patient discharged to home. Condition: Improved. Certified Med Emerg: Disposition date/dme: 09/06/200917:49. Discussed care with patient and family. Explained findings, diagnosis, and need for follow-up care. INSTRUCTIONS: KMG 09/06/2009 17:50 Discharge instructions given to caretaker. Discussed with caretaker who verbalizes understanding and willingness to comply. Prescription(s) written for: Augmentin 875 mg/l25 mg: by mouth twice a day; quantity: 20 (twenty). Patient agrees to follow up with TROSTLE, LORI C. Instructed to obtain follow up care in ten days. Patient agrees to return to Emergency Department immediately if symptoms worsen or fail to improve. Sutures out in 10 days. PHYSICIAN ORDERS (1) ED LEVEL 4 [KMG] ordered at 9/61200918:04 (1) PO Augmentin 500 mg [KMG] ordered at 916/2009 17:52 (1) Augmentin 500mg to go. (KMG] ordered at 9/6/200917:52 (1) Top Bacitracin w bandage [KMG] ordered at 9/6/2009 17:53 (1) Please D/C the PT [KMG] ordered at 9/6/2009 17:53 KEVIN *GOLD _PA-C PA All text in this document clearly marked by K:MG has been authored and legally signed by use of electronic device. 09/06/2009 17:55 ANTHONY *GUARRACINO DO DO This document is legally signed by use of electronic device. 09/06/2009 20:10 Physiden Oocumanlatlan (PM MED Girard Systems, L.L.C.) Pdr4ad on: 0906 2M 20:11 Page 2 of 2 ' 361 Akundar Spit &W* CM018 P 17018 P209 t: RICE, CO1Nt' W DMl:1N10H " P8ft * 9444313 MW: OSOS7S SU Dale In: WW2W [her INC T Ack Initiated Host Time Ph KJAG W VM Please DIC the PT 09/062009 17:56 091068009 17:37 *GOLD PA-C, KEVIN M CopAaent: R ?O W T ? 5 Buibwin w bade Top 09/Q62m 17:56 bfKM 09/068009 17:57 *cloml PA-C, KEVIN M Corm?tt: KMCi W YMPM 17:52 PO °? 09/068009 17:56 MXEI 09/068009 17:57 MKEl *GOLD PA-C, KEVIN IN C.ommgem; . 8MO W 1 09/068009 17:52 Austin 500mE to go, 09/06/2009 091068009 17:56 A17-.36MYJW I *OOLD PA-C, KEVIN m Conmomt: Order Summary (Pro-MED CW" &Alum, L.L.C.) Piloted on: OS/OMAM 1$:04 Pape 1 of 1 301 ANunder SPft DrW% CeeMNL PA 17013 R. COURTNEY Dos: 1?NeWS? PNlent #: >a44gIs MW: 80Or7H !3Q Dm t: alr!=ON PNUS&k Assortment 09/06/200917:19 MKE Roost Assiphment: Patient assigned to room 19. Time of primary assessment: 17:19. PtyciesoeW: Child lives with parents. Child appears to be appropriate for age with care, givea(s). Ssfety: Thm is a responsible adult at the bedside. Bedrails am up to protect pedant from fall. Call light is within reach and patient or family was inshuxed on use. Hod height is at the lowest position. Lttegnmetthtry: Patient presents with an animal bite /sting. Pain or injury is located in the left forearm. Tre atee nts 09/06/200918:01 MKE PO Augmentbt 300 mg hdtlated at 09/06J200917:57 by MKL. FWAtten][KMG]: Augptentin 500mg to go. iu "ted st A9/46/200917:56 by MKL. (WMtten] [KMG]: Top Badtracla w? bandage initiated at 09/06/204917:57 by W(E. [Wrltten][KMG]: Please D/C the PT Initiated at 09/06/204917:57 by MIKE. [Written][KMG]: DispodUm 09/06/2009 18:01 MKE Discharge: Patient left the department at 09/06/200918:01. Patient's disposition is: D/C - HOME. Discharge instructions were given to the patient and given to the parent(s). The patient, family member with patient verbalizes understanding of the discharge inshvctions. Exte riding teaching was moderate, focused on medication administration, follow-up procedures, WOUND CARE FOLLOW UP SUTURE REMOVAL. The condition at discharge is improved. Pain has improved. Vital signs taken at 18:02 were: T: 98.6 PO, P: 80 and is Regular, R: 16 and Unlabored, HP: 128/70, 02 Sat: 99 on RA, pain level is 0 on a 1-10 scale. MELISSA EATON RN All text in this document clearly marked by MKE has been authored and legally signed by use of electronic device. 09106/2009 18:04 Nurse Doc "ftdon (P"ED CW" Systems. L.L.C.) Printed on: 0tJ0aP W 18:04 Pape 1 of 1 srlls/s Rte kwof Msdicsl Cmw PRIORITY. 4 Patent RICE, COURTNEY Pw: 9444315 SsmWrgen# DOB: 12/1611995 AGE: 13YRS sex: F MP*. 0000781935 EDP: *GUARRACINO DO, ANTHONY DATE: 09/06/2009 PCP: TROSTLE, LORI C workerp gyp: Emrp. Rsrerrod: P?rMrrI d Tkos: 16:58 Tripp Tura,: 17:01 Arrival Mods: WALKING Naipht ' WSW 142.5 In. 64.8 kpe. LMP:1 WK AGO Last Tetanus: Acc By. PARENTS Chid ANIMAL BITE complaint V{?i 8lan$ Bdd PRESENTS S/P DOGSITE TO LFA APPROX 30 MIMS AGO Assess; ont MOW SWEATS NO HEMOPTYSIS WEIaHT LOSS NO FEVER ANOREXIA NO SAFETY NO TRAVELIUVED NO KNOW THE ANIMAL YES KNOW THE ANIMAL43 LOCATION yES NO NO Sudden Onset T"mknsnt: G8O App for Age -YES, ImmprMzrNtom l/TD -YES, HekM R in., Head CIr- - Grads - , wO PARENTS Peftb sessment As Peet MsdkW NONE Rdwy. AI mkm: NKDA NONE. %IPDATED WOM, Nurse Slpnshm- ANA T: 98.6 PO P: 79 Regular R: 18 Unmom SP: 135/081 02: 98 % RA Pain INA" ter scale: 5 110 Peen Location: Lower Arm 1*1147 Rev 05/1W ' Carlisle Reglwai Medical Center 351 Alexander Sp ft Drive, Cartble, PA 17013 (717)246-1212 Pdkwd: RICE, COURTNEY DOD: 1211tiiHM Paftnt t. 944315 MRN: OW7819M Dab W obellarge Ina veft s Iliness/Nury & Medicine Topics BITES - ANIMAL (English) LACERATION AND SUTURE CARE (English) AMOXICILLIN CLAVULANATE POTASSIUM (English) Special Instructions Sutures out in 10 days. Referred to: TROSTLE, LORI C, MED Phone:(717)582-2090 PERRY PHYSICIANS SHERMANS DALE, PA 17090 Call today for your follow up appointment in 10 days Your Physician today was: *GOLD PA-C, KEVIN M Acknowledgement I have received and I understand the instructions as described above. (101 C/-"06- Patient or Guardian Staff I? (-r aC, I Date Time Discharge InstruCWM (PrO-MED Clinical Sysoems, L.L.C.) Printed on: 094'08/200917:65 Page 6 Of a 0 /M99)ICAL CBNTBA PATI W CON'T'ACT RECORD 11 ItmemacY_Conuct Please list the pmon(s) you would like us to contact in the event of a medical ernergeney 1. Name Relationship to Patient Home Phone: qB 2. Work Phone: Cell Phone: Permission to discuss details of your account: Yes No Name ?W. VAU Relationship to Patient: Home Phone: work Phone: Cell Phone: Permission to discuss details of your account: Yes ? No 3. Patient is a resident of a nursing home: Yes No-%,/ If yes, name the facility padmt's Rights and Resps??.da"denti Only) I have received a statement of the Patient's Rights and Responsibilities. moo- ? 0i l l ADO I Signa of Patientaesponslble Party Date ?- Dear Patient, To protect patient confidentiality, the following personal identification number has been assigned to you. Medical Information will not be disclosed or discussed with anyone who cannot furnish this number to our staff You may give the number to anyone you wish to have access to your medical information. naps (,,nay Carlisle Regional Medical Center Call (717) 249-1212 and ask to speak to the patient's nurse. (Personal Identification Number) To protect patient confidentiality, the above personal idantification number hss been assigned to the patient. Our staff will not disclose or dispias medical information with anyone who cannot f unish the number written on this card to our statl~ Carlisle Regional Medical Center Call (717) 249-1212 and ask to speak to the patient's nurse. (Personal Identification Number) To protect patient confldendality, the above personal identification number has been assigned to the peitient, Our staff will not disclose or discuss medical information with anyone who cannot furnish the number written on d#a card to our staff. RCnw.w 4lDICI{L CENTER 391 AI*Xbr4W ItPrlnl ROW • CMIisN, PA 470154129 *1717)249-11212 PATIENT'S NAME ACCOUNT W. RICE, COURTNEY A 9444315 CONDITIONS OF TREATMENT AND ADMISSION ATTENDING PHYSICIAN GUARRACINO, ANTHONY J DATE 6 TOM OF ADRIISSION 09/06/2009 16:58 CONSENT TO HOSPITAL CARE AND TREATMENT 1 AM PRESENTING MYSELF FOR EMERGENCY SERVICES OR ADMISSION TO THE HOSPITAL AND I VOLUNTARILY CONSENT TO THE RENDERING OF SUCH CARE, INCLUDING DIAGNOSTIC TESTS AND MEDICAL TREATMENT, BY AUTHORIZED AGENTS AND EMPLOYEES OF THE HOSPITAL, AND BY ITS MEDICAL STAFF, OR THEIR DESIGNEES, AS MAY IN THEIR PROFESSIONAL JUDGEMENT BE DEEMED NECESSARY OR BENEFICIAL TO MY WELL BEING. I ACKNOWLEDGE AND UNDERSTAND THAT MANY OF THE PHYSICIANS ON THE STAFF OF THIS HOSPITAL, INCLUDING THE ATTENDING PHYSICIANIS) NAMED ABOVE, AND RADIOLOGISTS, ANESTHESIOLOGISTS, PATHOLOGISTS AND EMERGENCY PHYSICIANS, ARE NOT EMPLOYEES OR AGENTS OF THE HOSPITAL, BUT RATHER ARE INDEPENDENT CONTRACTORS WHO HAVE BEEN GRANTED THE PRIVILEGE OF USING THE HOSPITAL FACILITIES FOR THE CARE AND TREATMENT OF THEIR PATIENTS. 1 AGREE TO ACCEPT THEIR CARE EVEN THOUGH THEY ARE NOT EMPLOYED BY THE HOSPITAL I UNDERSTAND THAT THE EXAMINATION AND TREATMENT THAT I RECEIVE ON AN EMERGENCY BASIS IS NOT INTENDED AS A SUBSTITUTION OR REPLACEMENT FOR COMPLETE MEDICAL CARE. CONSENT TO RELEASE INFORMATION I HEREBY AUTHORIZE THE HOSPITAL TO DISCLOSE TO INSURANCE COMPANIES, INCLUDING WORKERS COMPENSATION CARRIERS, OR OTHER PARTIES THAT MAY BE LIABLE FOR ALL OR PART OF THE HOSPITAL CHARGES, ALL OR PART OF MY HOSPITAL RECORDS AS MAY BE NECESSARY (INCLUDING ANY TREATMENT FOR ALCOHOL OR DRUG ABUSE OR DEPENDENCEI, TO DETERMINE BENEFITS ENTITLEMENT AND PROCESS PAYMENT CLAIMS FOR HEALTH CARE SERVICES PROVIDED. MEDICARE CERTIFICATION RELEASE I CERTIFY THAT THE INFORMATION GIVEN BY ME IN APPLYING FOR PAYMENT UNDER THE TITLE XVIII AND TITLE XIX OF THE SOCIAL SECURITY ACT IS CORRECT. 1 AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION OR ITS INTERMEDIARIES OR CARRIERS ANY INFORMATION NEEDED FOR THIS OR A RELATED MEDICARE CLAIM. I REQUEST THAT PAYMENT OF AUTHORIZED BENEFITS BE MADE ON MY BEHALF TO THE HOSPITAL OR TO THE PHYSICIAN WHO ACCEPTS ASSIGNMENT. PERSONAL EFFECTS AND VALUABLES I UNDERSTAND THAT THE HOSPITAL SHALL NOT BE LIABLE FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES (MONEY, JEWELRY, GLASSES, DENTURES, DOCUMENTS, CLOTHING, ETC.) UNLESS SUCH ITEMS ARE DEPOSITED IN THE HOSPITAL SAFE. THE HOSPITAL WILL NOT BE LIABLE IN EXCESS OF $50 FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES DEPOSITED WITHIN THE HOSPITAL SAFE. ABOUT YOUR BILL I UNDERSTAND THAT I WILL RECEIVE A BILL FROM THE HOSPITAL FOR PROVISION OF THE HOSPITAL SERVICES, INCLUDING STAFF AND EQUIPMENT, AND FOR ANY SUPPLIES OR MEDICINES UTILIZED. I WILL ALSO RECEIVE A BILL FROM ANY PHYSICIAN WHO PROVIDES PROFESSIONAL CARE TO ME, FOR EXAMPLE, I MAY RECEIVE A SEPARATE BILL FROM ONE OR MORE OF THE FOLLOWING TYPES Of PHYSICIANS WHO RENDER SERVICES TO ME: MY ATTENDING PHYSICIAN OR PERSONAL PHYSICIAN, EMERGENCY ROOM PHYSICIAN, RADIOLOGIST, ANESTHESIOLOGIST, PATHOLOGIST, OR ANY OTHER SPECIALIST. INSURANCE ASSIGNMENT I HEREBY ASSIGN TO AND AUTHORIZE THE HOSPITAL AND PHYSICIANS INVOLVED IN CARE DURING THIS PERIOD OF ILLNESS OR TREATMENT IHEREINAFTER "PHYSICIANS'). OR THEIR DULY AUTHORIZED ASSIGNS TO TAKE ALL NECESSARY STEPS, WITHOUT LIMITATIONS, TO ENSURE THAT ANY INSURANCE BENEFITS OTHERWISE PAYABLE TO ME OR MY ESTATE ARE PAID DIRECTLY TO THE HOSPITAL OR PHYSICIANS. THIS ASSIGNMENT OF INSURANCE BENEFITS INCLUDES BUT IS NOT LIMITED TO BILLING INSURANCE, FILING PETITIONS, FILING SUIT, IN MY NAME OR ON BEHALF OF THE HOSPITAL OR PHYSICIANS, FILING PROOFS OF CLAIM, FILING PROBATE CLAIMS AND FILING GRIEVANCES AND ALL OTHER SIMILAR PROCEDURES, AS MAY BE AMENDED FROM TIME TO TIME WITH THE STATE DEPARTMENT OF INSURANCE. I ALSO AGREE TO PROVIDE AND SIGN ANY OTHER DOCUMENTS THAT MAY BE REASONABLY NECESSARY TO ACCOMPLISH ANY OF THE OTHER PURPOSES. STATEMENT OF FINANCIAL RESPONSIBILITY UNDERSTAND THAT I AM FINANCIALLY AND LEGALLY RESPONSIBLE FOR CHARGES NOT COVERED IN FULL BY ANY THIRD PARTY. 1 FURTHER AGREE THAT SHOULD I NOT PAY THE BALANCE WITHIN THIRTY (301 DAYS AFTER THE DATE OF DISCHARGE, MY ACCOUNT WILL BE CONSIDERED DELINQUENT. 1 AGREE TO PAY COSTS OF COLLECTION, INCLUDING REASONABLE ATTORNEY'S FEES AND COSTS, COLLECTION AGENCY FEES AND COSTS, AND NTEREST WHICH SHALL ACCRUE AT THE MAXIMUM RATE ALLOWED BY LAW. RRAUD 4NY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY, OR FILES A STATEMENT OF CLAIM :ONTAINING FALSE, INCOMPLE°E OR MISLEADING INFORMATION MAY BE SUBJECT TO PROSECUTION UNDER APPLICABLE LAW. MDVANCE DIRECTIVE (FOR ADMISSION TO HOSPITAL ONLY) F I AM TO BE ADMITTED TO IAVEE BEEN INFORMED OF MY RIGHTS TO FORMULATE ADVANCE DIRECT VES. II UNDERSTAND RTHAT I AM NOT p QUIREDETO HAVE AN ADVANCE 11RECTIVE IN ORDER TO RECEIVE MEDICAL TREATMENT AT THIS HOSPITAL. 1 UNDERSTAND THAT THE HOSPITAL AND MY CAREGIVERS WILL FOLLOW 'HE TERMS OF ANY ADVANCE DIRECTIVE THAT I HAVE EXECUTED TO THE EXTENT PERMITTED BY LAW. INITIAL THE FOLLOWING OPTION THAT APPLIES) I HAVE EXECUTED AN ADVANCE DIRECTIVE AND WILL PROVIDE A COPY OF THIS FOR MY MEDICAL RECORD WITHIN A REASONABLE AMOUNT OF TIME I HAVE NOT EXECUTED AN ADVANCE DIRECTIVE AND DO NOT WISH TO 00 80. INIT. (FOLLOW-UP DONE BY 1 WISH TO COMPLETE AN ADVANCE DIRECTIVE DURING THIS HOSPITALIZATION INIT, DATE INIT. CERTIFY THAT 1 HAVE READ (OR( HAVE BEEN READI THE ABOVE CONSENTS AND CERT ICATIONS AND UNDERSTAND AND AGREE WITH THEM. ATE: i ?,O 0,? o-- ,-- MONTH DAY YEAR SIGN URE OF PATIENT OA LEGALLY ALIT RIZED REPRESENTATIVE WITNESS PRINT NAME OF PERSON AeOVe HMA7110 i Mis one 9444315 111iI ftof (ONFJDMM e v ANIMAL BITE REpp 3,0-0 0 fir'.xnive i a?ro// I?Ct our_r . Home A ?`r^ 71 rl WWK fie: P TMN Of • Dog 11111, Pot [ 3 ? t ] (?omu, lira gtaola a +? t ? ?7 Dt?e atttrt: vsoc +C Wit ohtc ?. Aaw sex: ?y Lj) Wu, Awig"w 1dAff to OM dm? Ym (?? ?V?4? Tea: t No [ bA7D Ob (1od?ipMe the d?qe p? ? b?aherab?6 aoanne?; $ wMt aweod ade to bi?x ??t [ j Vict6a°:Rene [ ] Otlrpr t?awel?,'III tto rj Tbir u n: i?t of . ' t ] otter [ 1 Body mad? De?tibe rwamd: ? s1? gnatrent 'lCes ? No i I U DATS Or TbG ': a L 7? cLl F I Deep 06"t 1 F?lq? NLlle of ?Q L,Clit ?? r f COY 7?pe oi'T 13DCV aeeeeed [ 1 Teter (v / Lo ?',S' veooieo PM vexioe 1 ot6?sr 1? sxc US OM,v P ' 7Z 4 171 ? sift - 431 Coom CnrIlk PA 17013 fie: (7I7) 243-5131 ? lYa. I' to AUTHORIZATION TO DISCLOSE HEALTH INFORMATION Patient Name: Courtney Rice Date of Birth: 12116/9 5 Address: 850 Windy Hill Road Lot 6 Shermansdale, PA 17090 Social Security No.. 181-76-9873 We hereby authorize Pe r to release health informatin 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 x Discharge summary ER and outpatient reports x Complete chart --2L-Doctor's orders x History and physical x X-ray reports x Lab reports x Nurses' notes --2L-Psych records x x Operative and pathology repts Alcohol and drug treatment notes x _Progress notes --L -Billing Info x Ambulance, EMS, ELS or ALS records x Consult reports x PT records x Opinions re ard' h g uzg my p ysical 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 already 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 CPR 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 & Hamilton. Permission is hereby granted to Freeburn & Hamilton to p ocopy or scan this authorization and any photocopy thereof shall be as by us an original. to-W-0 DATE to-t3-opt a DATE Wi e ROBERT RI E, on behalf of Courtney Rice Q) I (I ?A "rw 2 _(?2_ DEANNA RICE, on behalf of Courtney Rice 09/17/09 PERRY PHYSICIANS, P.C. Acct#: 215987 Name: Courtney A Rice DOB: 12/16/1995 Sex: F Age: 13 yrs, 9 mos Phone: H (717)-275-4858 W (717)- - Current Mods: No Current Medications Allergies: NKDA BP: 100/58 Ht: 69.25" 69.25" Ht%: >97th Wt: 1441b 6oz Wt%: 94th Pulse: 72 T: 98.2 BMI: 21.2 BMI%: 74th Nurse Note: S/R LEFT MEDIAL FOREARM BITTEN BY DOG 09/05/09 SUTURES PUT IN @ CRMC LIT m-1 09/17/2009 PERRY PHYSICIANS, P.C. 4570 VALLEY ROAD PO BOX 276 Date: September 17, 2009 Name: Courtney A Rice D.O.B. 12/16/1995 Nurse Note: S/R LEFT MEDIAL FOREARM BITTEN BY DOG 09/05/09 SUTURES PUT IN @ CRMC S: DOG BITE 9/5/09 WENT TO Carlisle Regional Medical Center ER. DOG FORM DONE AT ER. DT 2007 TOOK ANTIBIOTICS-- AUGMENTIN Q Vital i : BP: 100/58 Ht: 68.75" 5'8.75" Ht%: >97th Wt: 1441b 6oz Wt%: 94th Pulse: 72 T: 98.2 BMI: 21.5 BMI%: 77th LEFT MID ANT FOREARM WITH TWO LACERATIONS #4 REMOVED FROM MEDIAL AREA #1 REMOVED FROM LATERAL AREA A: SR S/P DOG BITE S/P LACERATION P: SR PT EDUC KEEP CLEAN WITH SOAP AND WATER. RECK PRN No Current Medications Seen B 09/17/2009 1-:21, A??CORD ?7 gar ?? wtG C..+4 CIM't "?.. Al t+tEar+oar ""it Rpits • csntsA, fA ?ttnNt?. MT) 304M 9444315 0000761935 A G9EI"2009 16:59 0000 Ell F 13 12/16/1995 P 1 S FR T i R!:E, :"OURTNEY A 777-77-7777 STUDENT E 856 W111DY HILL RD LOT 6 SHEF.MIi2i3I?ALE FA 17090 "mwmmmwm (717) 275-4858 COUNTY PERRY T T US { RICE, ROBERT E ufipmvtfq HJ '?OOTG u 95C WfNDY HILL RD LOT 8 202-5B-7681 (717)789-3744 LANI} I SSURG PA A pmmmww Mew To FATWW R SHERMAINSDAI.E PA 17090 J us (717)275-4858 FATHER RESP '.. E+aMINC.Y :MNTAC' NAME npt m NptAROMit C25MEF IIEL.A k RICE, SHIRLEY (717} 789-4134 GRANDMOTHE L ©v aid 13 Y' a[I Fy JEL . ACCXW Mf AMOINT DAn OTHER 09/06/2009 1 105 HMO RBRTRYGA 12/16/1995 COURTNEY r A j 981107 PO BOX N - EL PASO TX 79998 00406N NAM (800)624-0756 AUTHOWAViON f Q 1 ?.?. i A N 3 p^1ffj4 Ex *AM ZW ow" C iE ? 9C A6TTUJDNNG AOMMiNG 04, W0 ; j GUARRACINO, ANTHONY J TROSTLE, LORI C R O ANIMAL BITE afAL OS iTttt, cwww-on -wanhad mur sw tr w as rtw y r.taa+ tw 'k'::sam+y the bor"aAft dirty fiptitnt tc the +CVPt1A4OW MW J=KAAZM Mr, +• GE EIa .. . :"t7i4ift.ECATi„'?k5 t3M0146 IVIES I 'R NCiAAL t' O oA A[ _4Atp7 :2:7 iii 43 :5 tii^C 7H?03S 11111 Care ReWMW M adicW CwTW 301 A*xmndw S rkV DOM C& tste, PA 17013 PAN"* M WM COtWTWV A Wft 13lftif4M * 9444915 URN: atnaa star CHIEF COMPLAM/111 S IMY OF PMENT ILLNESS: KMG 09/0&Q M 17:21 RICE, COURTNEY is a 13 year old f that pre d to the Ern WALKING . The ?"?'oY Department at 16:5 by patient was triaged at 17:01 with the following vital signs: T: 98.6 PO, P: 79 Rqplar , R: 18 Unlabored , BP: 135!4813 SP02: 98 Atant:RA , Pain: 5 Lower Arm . The patiea t s primary 1 Physician is TROSTLE, LORI C. Ckief COIRPh" -- AN1lMAL BITE Exam Time. 17:21. History obtained ftm: patient. Symptoms carne on suddenly. Onset of symptoms was imneediatelY prior to arrival in the Emergency went. Injury occwrcd in the street. Patient was bitten by dog. The animal appeared well. This animal is generally known and is seen replarly in the neig#tborhoad. This wu clearly an unprovoked attack. Patient sustained multiple wounds. Patient was bitten. Symptoms located in the, The patient states that she was walking down the road when someone brought the dog onto the road to pull him on his skateboard. The dog is known to be aggressive.. PAST MEDICAL AND SURGICAL HISTORY: KMG 09,106/2009 17:47 Past MedicW History: positive NONE. Reproductive History: LMP: I WK ALSO,. Fast M"cai and Surgical histories reviewed. Immunizations: up to date. PHYSICAL EXAMMATIOI' : KMG 49/0&2L109 17:47 Mat4eu10sketktVE1b=ft: Left Upper Extremity: Foresnm - Laceration: Simple, neurovascular exam distal to wound intact. Small amotmt of soft tissue swelling is present. Small ecchymosis is present. ?Mild to ndemess to palpation. EDP COURSE AND TREATMENT: KMG 09io612oo917:54 Procedures: Laceradern Rt pak: Procedure: Wound number- 1. Length of laceration = 2 cm, Area prepared and wound cleansed thoroughly with .,Brea anesthetized by local infiltration with I% xylocaine without a pinephrinc. Wound irrigated with copious amounts of NS, Skin Closure: Wowed closed with Ethilon 5-0 suture material. Sutures placed using simple into "ed technique. Number sutures used: 5. Procedure: Wound number. 2. Length of laceration -.7 cm. Area anesthe:tiacd by local infiltration with I% xylocaine without epinephrine. Wound irrigated with copious amounts of NS. Skin Closure: , The box like laccmtion/puncture was pulled together with a modified pursestring suture. Antibiotic ointment applied over suture line. Wound covered with sterile dressing. Physician D=tnentetbn (Pro-MEC Qncai Systems L.L.C.! Printed on: 09006209 20:11 ?,s1 of2 ) . cadets Ram Medkat Center 381 Alaauffdw Sprkfp OM. Carlisls. PA 17013 P"Oft ?. COURTNEY A W& t?t'r? W paM?we st sals Wit: ooWMasa D ft IM weM" CUMCAL V40WJ SION: KMG 09/06/200917:50 1. Dog Bite 2. Laceration, Leff: Forearm DI3POSMONs KMG 09/06/200917:49 Disposition: Punt discharged to home. Condition: Improved. Certified Met EftMV Disposition dat"mc: 09/06/2009 17:49. Discussed care with patient and fatally. Explained findings, diagnosis, and need for fallow-up cane. IiiMUC ONS: KMG 09M /2M 17:50 Discharge instructions given to carchd er. Discussed with caretaker who verbalizes understanding and willingness to comply. Prescription(s) written for: Augmentin 875 mg/ 125 mg: by mouth twice a day; quantity: 20 (twenty). Patient agrees to falbw up with TROSTLE, LORI C. Instructed to obtain follow up care in ten days. Patient agrees to return to Emergency Department immediately if symptoms worsen or fail to improve. Sutures out in 10 days. PHYSICIAN ORDERS (1) ED LEVEL 4 [xMG] ordered at 9/6/200918:44 (1) PO Augmentin 500 mg [KMG] ordered at 9/6/2009 17:52 (1) Augmentin 500 mg to go. [KMG) ordered at 9/6/200917:52 (1) Top Bae tracin w bandage [Kmq ordered at 91612009 17:53 (1) Please D/C the PT [KMG] ordered at 9/6/20M 17:53 KEVIN *GOLD PA-C PA All text in this doe" iment clearly marked by KMG has been authored and legally signed by use of electronic device, 09/06/2009 17:55 ANTHONY *GUARRACINO_DO DO This document is legally signed by use of electronic device. 09/06/2009 20:10 Phyltc 3n Documentateon Trn-MED C4nfcai Systems, L.t. 11Printed nn. tloi%,2009 2t?:' T CAN" R gin 11 Mack* Cankw 351 AW anow OW". Call, PA 17013 0.1212 Psdw*: iliM COURTWY 0 i N OMM Pads* & 94445i3 #rgil: 0000?"M Dab M; WMW Sad ISM lHOO T ae Unr 3ft o Ack b"alod Host raw phys KMCs w die F'T 09? 17:56 09? M 17:57 *G(XD_PA-C, KEM M c4nowat KMG w Q9+06/2009 17.53 Tap awwacin w w8war 7:55 1"9 tls r2o0 t7:57 KgE 'Gt?1?D_PA-C, KEVIN M Cow KMG W 1 sawo F 17:52 PO Aapena 500 me 43146 2009 17 S6 a9r G120b4 17:57 'Cit)i.D, PA-C, KEVIN !yl coowmt KMG w 1 09/00M 17-52 Augm to P. 09/0612009 17:56 09!06!2004 17:56 MKIJ i 'GOLD,-PA-C, KEVIN m commatl Ord- Summary {Prn-MED C inics Systems. L.L.C.) Printed M: 0W06r2409 ? 8:154 pays 1 C"f 1 Catssle RrpicnW Medicei Canter 3a 1 AJW=x ar Sp*V 0*6. CNUS*, PA 17013 (717940.1212 PetleaO 1"M COU#t'MY om I1"Wi s PSN" * is MRk 00001°"n Dale in: wow Fediatrk Asse===t 09/MW917:19 MKE Room Asst; Patient assigned to room 19. Time of primary assessment: 17:19. Psycbesecia: Child lives with patents. Child appears to be appropriate for age with cart giver(s). Sammy: Thee is a responsibk adult at the bedside. Bodrails are up to protect patient frm fall. Call light is within retch and patient or fly was instructed on use. Bed height is at the lowest position. tateguml~ntary: Fade t punts with an animal bite/sting. Pain or injury is located in the left forearm. Trutoma 09l0612Qt1918:91 MKE PO Aupwaft .SM mg bdd&W at 09/06J2W 17:57 by MKL. [Wr J jKMGj: Angnuntin 500mg to go. bddaftd at OWO&W0917:56 by.MNE. [Wri tenjjK!V GI: Top Bscitracin w Wadage Wdawd at 04/t16t200917:57 by MKE. [Written[ [KMG[: Please DIC the PT initiated at 09106/200917:S7 by MK'E. [Wrlttenj[KMGj: DisposMon 09/0612009 18:01 MXE Discharge: Patient left the dapartmmt at 09/06/2009 18:01. Patient's disposition is: D/C - HOME. Dirge instructions were given to the patient and given to the pare*.s). The patient, family member with patient verbalizes undemanding of the discharge instructions. Extending teaching was moderate, focused on medication administration, follow-up procedures, WOUND CARE FOLLOW UP SUTURE REMOVAL, The c lition at discharge is improved Pain has improved. Vital signs taken at 18:02 were: T: 98.6 PO, P: 80 and is Regular, R: 16 and Unlaborcd, BP: 128/70,02 Sat: 99 on RA, paint level is 4 on a 1-10 scale. MELISSA EATON RN All text in this document clearly ma rkod by MKE has been authored and legally signed by use of electronic device. 09/06/2009 18:04 Nurse DoCumentafian (Pro-MED OincW Systems, LL C) rpri ntec all: DWL) ,,2 DC9 t t3 N -a,e t -f 1 mum AsiffamouaEgM C811134 ReVana l hkdkat Cent&r PRIORITY- 4 Pa1>er?t RICE, COURTNEY P* 9444315 .%mi-Ulrpnt DOS 12M611995 AGE. 13YRS sex: F MR6: 0000781935 EDP: *GUARIRACtiO_QO, ANTHONY DATE: 09148/IM PCP: TROSTLE, LORI C Wakara GeaApc Emp. fi?irer„d: Proserd TIM.- 16;58 Triaps Tin*. ini Ax v i made: WALKING Heim ` We*t 142.6 b 643 I&OL LMP I WK AGO Last Tetwh*. Am By. P P'& Chief AN1UMtl:WM ca"paimt &M PRESENTS SIP DOGBITE TO LFA APPROX 30 MINS AGO Assearnent N93HT SWEATS NO f IEMOPTYSIS WEIGNTLOSS NO DER ANOREXIA NO SAFETY NO TRAirEL)LI ED No KNOW THE ANIMAL YES KNOW THE ANNAAL S LOCATION YES NO NO Sudden Oniast: Trap6rAnt: Rediabic G&D App. far Age - YES. I+rAXN Utabw UTD - YES, Height It. in., Heart Circ. - Cam.. with PARENTS Aabss meat PaM Medical NONE H sim Ades: NKDA NONE. 'UPDATED 011M, ANA T: 98.0 PO P: 79 Regular R: 18 Ur"bOred BP: 135=1 O& 98 % RA Pain Intansiiy Scale: 5 E 10 Pain Location- Lower Arm 3 ;4.ev 35"1 r"?04 CadWe Regional Metltral utter 381 Alec wow Sprft Drive, Carlisle, PA 17013 (717)249.1212 Padrrtt RICE, COUMNEY 008: 12H*"N Pattwtt dt 0"4313 MRN: DOW 41"S Data in, DNMNWP ktakuooft Ubmu/Iajury & Medicine Topics BITES -ANIMAL (English) LACERATION AND SUTURE CARE (English) AMOXICILLIN CLAVULANATE POTASSIUM (English) Spechti IastImcdons Sutures out in 10 days. Referred to: TROSTLE, I.ORI C, MED Phone:(717)382-2090 FERRY PHYSICIANS SHERMANS BALE, PA 17040 Call today for your follow up appointment in 10 days Your Physician today was: *GOLI)J t-C, KEVIN M Acknowledgement I have received and I understand the instructions as described above. 11/-?? 0 N ____L Patient or Guardian Staff Date Time Ciscttanaa Instr,,?Ctmns (PM-MED Clinical 5ysttrrna, L ±_C ) Pr fltarl On: 1J1 C 1:,'20;?? 17 55 ?!st.6 nt #31XJ% gL P'A IWU 2041SI O MT .. j . 4W Yes l oew?C !tac, I Dew cer s Do. ,r w i MIDtcA? C T't urn U m to 10 *6 "Co' 0' 1. 'M=" WO& tnya Yes Y%nu - 2. Name ROISAOUNW ?padept Hotne PHo®sx WO& bow Cold Yal tf NO Pot sie ID &WM tip YOW aot If yam, pie the Wft al" Odd I b W steoadved s Obwest of tba Pdiast's R.igbta and ReVowibilltieL Date Ftltiy Dear Padctkt' i{tY t. fbHoving pewW i'dg a nor has I To P,.td Migned to Yom me l jvf=Md ! not be disclowd or discussed with sayana who amt ftunisb this number to Ou staf€ mcdicai inforsnartitan, you may give the mmbec to anycme y. ttrlsh to have access to your 0 is= 11 SWO C;srliale Rey MOHW Cm"r (717) 249-1212 and sic to R=k to the ms's mtrsa. (Persottsl l tttificxth`an Number) protect patient can idilF. tba 8W" PM"W OmtW,=dm mbar has bean be 1110 patIML 4siv mutt WiII not disclose cc direurs m Uc l ink matim wilt anyone rvisn conot fniah the number wrinen m tttis cmd to our smff. CW isle: RetgionW Medical Cem Call ('717) 249-1212 vMd ask to speak to the padeRta's t U'W. U s1 Wenditcadon Number) To prntnet patient cxu ndentiW tY. ter sbtawo Pam iacadficatim nurnbw has beAn aaeiped to the pitiont our mfr will not disdoso or discus medical infcrrttUWM With MrM" WtW Canot tiuaish the number written un t4is care to vur staff. 5 c I 1 ?GKt???-r GENERAL RELEASE For the consideration of Twelve Thousand Dollars and No Cents ($12,000.00), receipt of which is hereby acknowledged, I/we release and discharge, and for myself/ourselves my/our heirs, representatives, executors, administrators, successors and assigns, do hereby remise, release and forever discharge Matthew C. Carroll hereinafter referred to as the releasee(s), his/her/their/its heirs, executors, administrators, insurers, successors and assigns, and any and all other persons, firms, corporations, associations, of and from any and all causes of action, suits, judgments, claims and demands of whatsoever kind, in law or in equity, known and unknown, which I/we now have or may hereafter have, and/or which the minor Courtney Rice now has or may hereafter have, especially the claimed legal liability of releasee(s), which liability releasee(s) expressly deny(ies), arising from or by reason of any and all bodily or personal injury and/or property damage known and unknown, foreseen and unforeseen which heretofore has/have been or which hereafter may be sustained by me/us or the minor aforementioned arising out of the accident on or about September 6, 2009, at or near Shermansdale, in the County of Perry, in the State of Pennsylvania, in which the minor aforementioned sustained personal injuries and/or property damage. I/We agree that the consideration set forth above is specifically applicable to and paid to me/us with respect to any and all damage to any property, either real or personal, of mine/ours or the minor aforementioned, and with respect to any and all personal or bodily injury of mine/ours or the minor aforementioned, whether presently known or unknown, foreseen or unforeseen or which may subsequently develop and the consequences thereof, all as arising from the aforementioned accident. I/We further agree that the consideration set forth above is specifically applicable to and paid to me/us with respect to any right of contribution the I/we or the minor aforementioned may have against the releasee(s), his/her/their/its heirs, executors, administrators, insurers, successors and assigns relative to claims of others that may be brought against me/us or the minor aforementioned by reason of said accident. I/We further agree that the consideration set forth above is specifically applicable to my/our agreement that Uwe or the minor aforementioned will not join nor attempt to join the releasee(s), his/her/their/its executors, administrators, insurers, successors and assigns in any capacity, in any action that may be brought against me/us or the minor aforementioned arising out of said accident. In consideration of the aforesaid payment, I/we for myself/ourselves and my/our heirs, representatives, executors, administrators, successors, and assigns do hereby: (1) agree to indemnify and hold forever harmless the releasee(s) and his/her/its/their representatives, administrators, or assigns, against loss from any and all further claims, demands or actions that may hereafter be made at any time or brought against the releasee(s) by me/us or the minor aforementioned, or by anyone in our behalf for the purpose of enforcing a further claim, for which this release is given; REL3 Initials: Page 1 of 2 1998823 1. DOC GENERAL RELEASE (2) warrant that I/we have received no money or other valuable consideration from any other person or persons by reason of any causes of action, suits, covenants, agreements, judgments, claims and demands of whatsoever kind, which I/we now have or may hereafter have, for injuries to person or property arising out of the aforementioned accident or for the other matters for which this release is given. Intending to be legally bound thereby, WITNESS my/our hand(s) and seal(s) this day of NOTICE: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties." WITNESS (Seal) Father-Guardian -- (Seal) Mother -------- - -- (Seal) Minor Claim #010171059560 D. Peron:rgm RED Initials: Page 2 of 2 19988231.130C From Julia McKieman 502-753-6864 To Christina L Bradley Esq. Rawlings Compan37LLC Subrogation Division Page 213 Dale 1113012010 1 37 30 PM Post Office Box 2000 LaGrange, Kentucky 40031-2000 One Eden Parkway LaGrange, Kentucky 40031-8100 Telephone (502) 587-1279 November 30, 2010 Ms. Christina L. Bradley Esq. Freeburn & Hamilton, P.C. 4415 North Front Street Harrisburg, PA 17110 1709 Re: Our Client: Member/Patient: Date of Loss: Our File No.: Your Client: Dear Ms. Bradley Esq.: Aetna COURTNEY RICE/COURTNEY RICE 9/5/2009 09USH 1100612 Courtney Rice Enclosed is a summary of the medical expenses paid by our client on behalf of COURTNEY RICE. Please notify me if any of the charges are unrelated to the accident. If you have information that indicates our client has paid claims not listed on the attached itemization, please advise so we may investigate. Otherwise, this summary is good for settlement purposes for 30 days from the date of this letter. Please be advised that Aetna makes payments to health care providers in a variety of ways, including pursuant to negotiated agreements. Aetna considers the rates it pays for health care services to be proprietary and confidential. This information is contained in the member claims report, which is enclosed. By receiving and reviewing the member claims report (including any updates provided in the future), you thereby agree that you will not disseminate the report or divulge the contents thereofto any entity or person except the parties in this specific lawsuit, and will use the report and information contained therein only in connection with this specific proceeding. Sincerely, Julia H. McKieman Recovery Analyst (502) 753-2734 FAX: (502) 753-6864 jh3 (arawlingscompany. com From Julia McKiernan 502-753-6864 To. Christina L Bradley Esq page: 213 Date. 11130/2010 1.3730 PM From Julia McKiernan502-753-6864 To ChristinaL Bradley Esq Page 313 Date 11130/2010 1 37 30 PM 0 r. c; 1 1K N 0 C4 ch 40 in ch N E c CL 5 N O v q O c N O 0 b w N 43 1+1 111 10 in Rr •H N C h ? ?r°v1w a -H 4J Iq .0 4J c: ri .1.1 10 Z o?l?l+c a m a a a? 3 C 0 A •rl O > O q N C ti 0 t+1 •rt O ? O 1tl a ? Or t H CL W E o a N. V HW cl 3, 0 aU0 ? it p O .k C 11 N U •rl H •rl C 1 0 W 4J H d F a W Ip pa O F 7,' rN•1 p H .O•i U O O? O x H b 14 W W r Q I U H? U to ?7 a L7 1?" N C7 F ?p.7, PPP N U C4 $ ? 9 O W O N pH? r U Ni 01 U N 3c A, ? m 8 op o° Of 8 H W W 14 a°1 a U O o M ti z° w w v v1 O~i pNr U O p O p W O O +) C4 C4 q ?O {\p O p ±r Of 01 HE o 0 F C H O O W A ? ? Q F ch 0) O O ~ F 44 119 M M 3 2 .a k r N r 10 S r N O V d t V C d 3 r d d R d a From Julia McKiernan 502-753-6864 To Christina L. Bradley Esq Page: 313 Date: 11/30/2010 1:37:30 PM f,000,000,0 f ooe00 5-00 V O O ? ? v aa 0 P,: t n NN C r N N A W m , 000000?WCCD w 0 C .g- !!'f fC fC fC 1-: N ? M M N ? H ? 3 N O t0 W m all W co fc0 .. aaaaaaa y Ylt3L w -r- > > > > > > > QQ QQ QQ RR QQ QQ QQ QQQQQ QQ vl w v aaaaaaa V a z 0 F- 0.0 Q a _ ? eo c R ?z mu. W W U. ??UM aa¢QQQQ sj9sssss wwwww" 8888888 E aaa w rr PP'2 ? ? m? m m m m w q?'p?¢???i5 Z t?(?UC?C)UU E 0 Z D b A ? m r M a? Lj o t? O ? a OON ?- OON 00000 N NN,NN t,N N C p 0 am .-.-.-rn mmfDmmmm O F m O) 10 a S Christina L. Bradley, Esquire FREEBURN & HAMILTON ID No. 89107 4415 North Front Street Harrisburg PA 17110 (717) 671-1955 Attorney for Plaintiffs COURTNEY RICE, a minor, by ROBERT: IN THE COURT OF COMMON PLEAS, RICE and DEANNA RICE, her natural CUMBERLAND COUNTY, PENNSYLVANIA parents and guardians; ROBERT RICE, in his own right; and DEANNA RICE, in : her own right, Plaintiffs V. MATTHEW CARROLL, Defendant NO. c `_ N c M Z? ?r -0 rn - <D N ? Q r--M -1p <q ? s. s ?-n X4n C) 5c c ORDER i? o .?v AND NOW, this ? day of ?i 2011, 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. Robert and Deanna Rice are authorized to sign all documents necessary to accomplish the settlement, including but not limited to the Release, individually and as the parents and natural guardians of Courtney Rice, 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 $12,000.00 2. Attorneys Fee 25% $ 3,000.00 3. Litigation Expenses $ 245.05 of Freeburn & Hamilton 4. Lien of Aetna $ 727.38 5. Net to Courtney Rice, a minor to be deposited in a savings account in the name of Plaintiff Courtney Rice with Bank of Landisburg. A hold would be placed on the account so that no transfers or withdrawals could be made from the account until December 16, 2013, when Courtney Rice reaches the age of 18. $ 8,027.57 C. Petitioner to file a Praecipe with the Orphans' Court marking this matter settled and discontinued one payment has been received and the savings account disbursed; and d. Stay of all proceedings. c: ?Christina L. Bradley, Esquire ?Mr. Dan Peron of Mifflin County e the $12,000.00 opened and funds Y THE COURT: J. CAP'sg k? 2