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11-3774
J- 6 C ?? i 1 ? _. iEE p ?'E???SYL????1a IN THECOURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION 1VAN SHIRK and LYDIA SHIRK, As Parents and Natural Guardian of NEIL F. SHIRK Petitioners V. ROBERT G. KOSER, Respondent i No. 11- 37 7 N 60 PETITION FOR COURT APPROVAL OF MINOR'S SETTLEMENT PURSUANT TO PA.R.C.P. 2039 ORIGINAL AND NOW, comes the Petitioners Ivan Shirk and Lydia Shirk, parents and natural guardians of their minor son Neil F. Shirk, who hereby petition the court for approval of the instant settlement of Minor Petitioner's personal injury action and, in support thereof, avers as follows: 1. Petitioner, Ivan Shirk, is the parent and natural guardian of Minor Petitioner, Neil F. Shirk, who was born on April 19, 1992. The family resides at 2033 Rittner Highway, Shippensburg, Pennsylvania 17257. 2. Petitioner, Lydia Shirk, is the parent and natural guardian of Minor Petitioner, Neil F. Shirk, who was born on April 19, 1992. The family resides at 2033 Rittner Highway, Shippensburg, Pennsylvania 17257. 3. Respondent, Robert G. Koser, is an adult individual residing at 130 Springfield Road, Shippensburg, Pennsylvania 17257. ctfik $ga.np o ?f e - , ??/-? 4. The instant action arises out of a motor vehicle accident which occurred on November 2, 2010 on Stoughstown Road near its intersection with McCullough Road, in Shippensburg, Pennsylvania. 5. On November 2, 2010, Minor Petitioner was riding his bicycle on the side of the roadway when he was struck from behind by a motor vehicle being operated by Respondent, Robert G. Koser, specifically a 1997 Pontiac Transport minivan. Mr. Koser was operating the Pontiac in a southerly direction on Stoughstown Road when the front passenger area of the minivan struck the Minor Petitioner, causing him to be knocked into the adjacent farm field. 6. As a result of the collision, Minor Petitioner was taken to Hershey Medical Center where he was diagnosed with contusions, abrasions to the face and a fractured left tibia. 7. Minor Petitioner's treatment in the emergency room included x-rays of his right and left knee and test; and CT scans of the head/facial bones and chest/abdomen were also taken. All were read as normal with the exception of the left knee x-ray which revealed the tibial fracture. Attached hereto as Exhibit "A" are emergency room records of Minor Petitioner. 8. In the days and months following the accident, Minor Petitioner's facial abrasions and tibial fracture facial gradually healed. On or about February 7, 2011, Minor Petitioner seen by Dr. William Henrikus of Hershey Medical Center and he reported no complaints and indicated that he had resumed normal activities, including farm work. Minor Petitioner discharged by Dr. Henrikus at the February 7, 2011 appointment. (Attached hereto as Exhibit "B" is the Outpatient Note from the February 7, 2011 visit.). 9. Petitioners, Ivan Shirk and Lydia Shirk have paid directly to the medical providers various sums for the Minor Petitioner's medical treatment, which sums total $42,246.10. Petitioner Ivan Shirk was able to negotiate reduced bills with the medical providers. Attached hereto as Exhibit "C" are the medical bills with handwritten notes indicating the amounts paid by the Shirks. 2 10. At the time of the aforementioned accident, Respondent, Robert G. Koser, was operating a 1997 Pontiac Transport minivan which was insured under a motor vehicle policy issued by Progressive Insurance with liability limits of $100,000.00 per person. A copy of the declarations sheet for Respondent is attached hereto as Exhibit "D" and made a part hereof by reference as though set forth at length herein. 11. As a result of the aforementioned accident, it is believed and, therefore, averred that Minor Petitioner has achieved maximum medical improvement from the injuries sustained and that no physician has imposed any restrictions on his activities of daily living, either at home or at school. 12. In full and final settlement of any claim to be advanced on behalf of Minor Petitioner, Neil F. Shirk, Petitioners, Ivan Shirk and Lydia Shirk have accepted Respondent's offer to settle for the amount of medical expenses paid by Petitioners which amount equals $42,246.10 and Petitioners have expressed their intention to sign a Release of all claims in consideration of acceptance of said amount. A copy of the proposed Release is attached hereto as Exhibit "E" and made a part hereof by reference as though fully set forth at length herein. 13. Petitioners have been advised of their rights to negotiate additional sums for the pain and suffering and loss of life's pleasures of the minor Neil F. Shirk and have declined to exercise those rights and request that they receive reimbursement of their medical expenses, only. 14. Petitioners understand that approval of the instant settlement will preclude and prevent any future recovery from Respondent or his insurance carrier, Progressive Insurance, for any damages of any nature as a result of the November 2, 2010 accident on behalf of either Petitioners Shirk, individually, or their minor son. 3 15. As Petitioners Ivan Shirk and Lydia Shirk, are not represented in this matter and there is no outstanding claim for attorney's fees. Petitioners have, however, been advised that they have had the opportunity to consult with an attorney regarding the terms of the proposed settlement, as well as, the filing of the instant Petition and they have indicated that they are not inclined to do so. 16. Petitioners believe and, therefore, aver that the instant settlement is in the best interests of the minor pursuant to Pa. R.C.P. 2039 and respectfully requests that this Honorable Court approve the instant settlement. 17. In consideration of the fact that Petitioners, Ivan Shirk and Lydia Shirk have accepted Respondent's offer to settle for the amount of medical expenses that have already been paid by Petitioners which amount equals $42,246.10, Petitioners request that this amount be paid to them directly to reimburse them for these expenses. Petitioners hereby request a waiver of any requirement that the settlement proceeds be placed in a Federally insured, interest bearing account in the name of the minor Petitioner until he should attain the age of eighteen (18) years. WHEREFORE Petitioners Ivan Shirk and Lydia Shirk, Parents and Natural Guardians of Minor Petitioner, Neil F. Shirk, respectfully request that this Honorable Court approve the aforementioned settlement. ? Date: By: LL1Y1J" 4 ? Petitioners Ivan Shirk and Lydia Shirk, Parents and Natural Guardian of Neil F. Shirk, a minor 4 PENNSTATE HERSHEY Milton S. Hershey Medical Center i Patient Name: SHIRK, NEIL F MRN 7508612 ................................................................................................................ Musculoskeletal................................................................................... RESULT STATUS: Final DOCUMENT SUBJECT: PORTABLE X-RAY KNEE 1-2 VIEWS LEFT - PEDS ELECTRONICALLY SIGNED BY: SERVICE DATE/TIME: 11/2/2010 17:37 EDT PORTABLE X-RAY KNEE 1-2 VIEWS LEFT - PEDS PATIENT NAME: SHIRK, NEIL F PATIENT MRN:07508612 PATIENT DOB: 04/09/2002 EXAM DATE OF SERVICE: 11/02/201.0 EXAM NUMBER: 6603735 ORDERING PHYSICIAN: SANTOS, MARY C EXAM: Portable AP and lateral radiographs of the left knee CLINICAL HISTORY- 8-year-old struck by car COMPARISON: None FINDINGS: On the All view there is an offset of the bony cortical margin in the region of the tibial spines, likely fracture, although no bony abnormality is seen on the lateral view. The patient does have a moderate sized joint effusion. No other abnormality noted IMPRESSION: Strongly suspect fracture through the tibial spine, midportion of the proximal tibial epip"ays s, seen ^nly on the AP view. Recommend repeat evaluation and computed tomography for confirmation DICTATED: BOAL, DANIELLE REVIEWED AND SIGNED: BOAL, DANIELLE Date/Time Printed: 2/28/2011 04:32 EST Page 20 of 2.3 Printed By: Tice,Cindy L PENNSTATE HERSHEY PM. Milton S. Hershey 1W Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 ................................................................................... Musculoskeletal DATE DRAFTED: 11/02/2010 05:56 PM DATE OF FINAL SIGNATURE: 11/02/2010 05:56 PM Date/Time Printed: 2/28/2011 04:32 EST Page 21 of ;.3 Printed By: Tice,Cindy L PENNSTATE HERSHEY 1Tt1_ Milton S. Hershey VF Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 ......................................,........._...,..................,,,.....,....,.....,...,,......,.,,.......,.........,.,.,,.,.,.....,......................,..,,..,.,.,..,..........,...,....,...,.,.....,,.....,,.....,,,,.,,,............. .......... ... Head/Neck :.............................................................,,,.,.,,......................... ........ .,...,.,.....,.......-..,.........................,,..................... ................,.................. .._--.............. ........... ------ RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: SERVICE DATE/TIME: Final CT HEAD WITHOUT CONTRAST PED 11/2/2010 10:13 EDT CT HEAD WITHOUT CONTRAST PED PATIENT NAME: SHIRK, NEIL F PATIENT MRN:07508612 PATIENT DOB: 04/09/2002 EXAM DATE, OF SERVICE: 11/02/2010 EXAM NUMBER: 6601006 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER EXAM: Head CT without IV contrast. CT of the facial bones without contrast. CT of the cervical spine without contrast. CT of the thoracic spine without contrast. CT of the lumbar spine without contrast. CLINICAL HISTORY: 8-year-old male status post trauma. Pedestrian struck by car. COMPARISON STUDY: None. TECHNIQUE: A routine head CT was performed with 4.5 mm sequential axial images processed using both brain and bone algorithms without IV contrast. A routine helical CT of the facial bones was performed imaged in sequential 1.3 mm axial slices using soft tissue and bone algorithms. Routine sagittal and coronal reconstructions were performed with 2 mm sequential slices. A routine helical CT of the cervical, thoracic, and lumbar spine was performed from the skull base through T1 imaged every 1.3 mm using soft tissue and bone algorithms. Routine coronal and sagittal reconstructions were performed. FINDINGS: HEAD: There is no acute infarct, hemorrhage, mass-effect, or midline shift. There is no ex,ra-axial fluid collection. The basal cisterns are patent. The ventricles are normal in size and configuyatip. The calvarium is intact. The orbits are unremarkable. The paranasal sinuses and mastoid air cells are well aerated'. , J'ie.e is radiodense debris within the frontal scalp. FACIAL BONES: The orbits, orbital contents, and visualized paranasal sinuses are unremarkabi?.' There is no evidence of facial bone fracture. The skull base is intact. The mastoid air cells are normally aerated.,,, Visualized portion of the calvarium is unremarkable. There is soft tissue contusion over the left cheek, and forehead. Again noted is radiodense debris within the frontal scalp. Date/Time Printed: 21128/2011 04:32 EST Page 16 of 33 Printed By: Tice,Cindy L PENNSTATE HERSHEY FXT Milton S. Hershey Meckal Center Patient Name: SHIRK, NEIL F MRN 7508612 .................................................................... ............. .. ....... ...... ............... ........................... ....................... Head/Neck ... . . ....................... -111111111111111 ....... . ....... . . .. . . . . . ....... . . .... . . . . . . . ..... . . ... . . ................................ . . ...................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . ............ . . CERVICAL SPINE: The alignment of the cervical spine is maintained. There is no subluxation. There is no fracture. The posterior elements are intact. The facets are normally aligned. The vertebral body heights are maintained. The central canal and neural foramina are patent at all levels without osseous impingement. The paravertebral soft tissues are normal. THORACIC SPINE: The alignment of the thoracic spine is maintained. There is no spondylolisthesis or dislocation. There is no evidence for fracture. Posterior elements are intact. The vertebral body heights are maintained. The facets are normally aligned. There is no evidence for osseous impingement of the central canal or neuroforamina. The paravertebral soft tissues are unremarkable. LUMBAR SPINE: The alignment of the lumbar spine is maintained. There is no spondylolisthesis or dislocation. There is no evidence for fracture. Posterior elements are intact. The vertebral body heights are maintained. The facets are normally aligned. There is no evidence for osseous impingement of the central canal or neuroforamina. The paravertebral soft tissues are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. 2. Contusion over the left cheek and frontal scalp, with radiodense debris within the frontal scalp. 3. No acute trauma to the cervical, thoracic, or lumbar spine. Dr. Rebecca Roller is the dictating resident. Finalized report status indicates the signing attending has reviewed the images and report, and agrees with the interpretation. Preliminary report status should be regarded as NOT interpreted by the attending radiologist. DICTATED: THAMBURAJ, KRISHNAMOORTHY REVIEWED AND SIGNED: THAMBURAJ, KRISHNAMOORTHY DATE DRAFTED: DATE OF FINAL SIGNATURE: 11/02/2010 10:50 AM Date/Time Printed: 2,128/2011 04:32 EST Page 17 of 33 Printed By: Tice,Cindy L PENNSTATE HERSHEY FM- Milton S. Hershey qF Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 .................................................,...................... ......................... Chest . .... ..................... . . ........ . ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......................................... ................ ...... . . . . . . . ............... . ...... . .. . . .......................... . . .... . . . . . . . ....... . . ........... . RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: SERVICE DATE/TIME: Final CT CHEST WITH CONTRAST-PED 111212010 10.05 EDT CT CHEST WITH CONTRAST PED PATIENT NAME: SHIRK, NEIL PATIENT MRN:07508612 PATIENT DOB: 04/09/2002 EXAM DATE OF SERVICE: 11/02/2010 EXAM NUMBER: 6601022 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER EXAM: CT OF THE CHEST', ABDOMEN AND PELVIS CLINICAL HISTORY: 8-year-old male stnick by car COMPARISON: No prior CT examination available for review; portable chest radiograph from earlier today. TECHNIQUE: A helical CT of the chest, abdomen and pelvis was performed during dynamic bolus administration of IV contrast. The scans were imaged every 3 mm using lung and abdominal algorithms. FINDINGS: Chest: There is no pneumothorax, pneumomediastinum, or acute aortic injury. There is no focal air space opacification, pleural effusion or evidence of pulmonary vascular congestion. There is no axillary, supra-clavicular, mediastinal or hilar lymphadenopathy. The heart is normal in size without pericardial effusion. Normal thymus tissue noted. Visa`alized thyroid is normal in appearance. Abdomen: Punctate calcification noted within the left lobe of the liver without associated mass. The gallbl?cldf1,, spleen, bilateral adrenal glands, pancreas, and kidneys are normal in appearance. Nonobstructive bowel gas pattern. There is no free fluid or lymphadenopathy within the abdomen. Abdominal aorta is normal in caliber. Date/Time Printed: 2/28/2011 04:32 EST Page 14 of 33 Printed By: Tice,Cindy L PENNSTATE HERSHEY Milton S. Hershey qF Medical Center t. Patient Name: SHIRK, NEIL F MRN 7508612 . . .. . . .. . . . . . .. . . . . . .... . . . . . . . .. . . .. . . . . .... . . . . . . . . .. .. .: ................... . . . . . . ....... .. ....... Chest Pelvis: Bladder is normal for degree of distention. Tiny amount of free fluid within the pelvis. There is no lymph aden op athy. - Bones: No fracture identified. IMPRESSION: 1. No evidence of acute traumatic injury on the CT chest, abdomen, and pelvis. 2. Tiny trace fluid within the pelvis. 3. Calcification within the left lobe of the liver, which may be secondary to granulomatous disease versus prior trauma. Dr. Martha Showalter is the dictating resident. Finalized report status indicates the signing attending has reviewed the images and report, and agrees with the interpretation. Preliminary report status should be regarded as NOT interpreted by the attending radiologist. DICTATED: BOAL, DANIELLE REVIEWED AND SIGNED: BOAL, DANIELLE DATE DRAFTED: 11/02/2010 10:22 AM DATE OF FINAL ,SIGNATURE: 11/02/2010 10:30 AM Date/Time Printed: 2/28/2011 04:32 EST Printed By: Tice,Cindy L Page 15 of 33, n PENNSTA E HERSHEY FXT Milton S. Hershey VP Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 ...................................................................................................................Musculoskeletal :.... ........................................................................................................................................................................................................:............................................. ........................... RESULT STATUS: Final DOCUMENT SUBJECT: PORTABLE X-RAY KNEE 1-2 VIEWS RIGHT - PEDS ELECTRONICALLY SIGNED BY: SERVICE DATE/TIME: 11/2/2010 22:51 EDT PORTABLE X-RAY KNEE 1-2 VIEWS RIGHT - PEDS PATIENT NAME: SHIRK, NEIL F PATIENT MRN:07508612 PATIENT DOB: 04/19/2002 EXAM DATE OF SERVICE: 11/02/2010 EXAM NUMBER: 6603881 ORDERING PHYSICIAN: SANTOS, MARY C EXAM: X-ray right knee, two views CLINICAL HISTORY: 8-year-old with trauma COMPARISON: Correlated with X-ray left knee 11/2/2010 FINDINGS: No acute fracture or dislocation. Joint alignment is well maintained. No joint effusion. Soft tissues are normal. IMPRESSION: Normal right knee. Dr. Kenneth Montini is the dictating resident. Finalized report status indicates the signing attending has reviewed the images and rep(it,'aad agrees mith the interpretation. Preliminary report status should be regarded as NOT interpreted by the attending radiologist. ; Date/Time Printed: 2/28/2011 04:32 EST Page 22 of 33 Printed By: Tice,Cindy L F I PENNSTATE HERSHEY F1 Milton S. Hershey 1W Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 Musculoskeletal DICTATED: METHRATTA, SOSAMMA T REVIEWED AND SIGNED: METHRATTA, SOSAMMA T DATE DRAFTED: 11/03/2010 10:44 AM DATE OF FINAL SIGNATURE: 11/03/2010 10:44 AM Date/Time Printed: 2/28/2011 04:32 EST Printed By: Tice,Cindy L Page 23 of 33 E 4 t ,'?. PENNSTATE HERSHEY FXT- Milton S. Hershey WF Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 ..................................................................................................................................Chest ............................................................................................................................... : . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : RESULT STATUS: Final . DOCUMENT SUBJECT: X-RAY CHEST PA OR AP VIEW- PEDS ELECTRONICALLY SIGNED BY: SERVICE DATE/TIME: 11/2/2010 09:32 EDT X-RAY CHEST PA OR AP VIEW- PEDS PATIENT NAME: SHIRK, NEIL PATIENT MRN:07508612 PATIENT DOB: 04/09/2002 EXAM DATE OF SERVICE: 11/02/2010 EXAM NUMBER: 6601003 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER EXAM: AP portable supine chest. CLINICAL HISTORY: 8-year-old male status post trauma. COMPARISON: None. FINDINGS: The patient remains on the trauma board which obscures bone detail. The cardiothymic silhouette is normal. The lungs are well inflated. There is no focal consolidation, effusion, or pneumothorax. No fractures are noted. IMPRESSION: No trauma to the chest. Dr. Rebecca Roller is the dictating resident. Finalized report status indicates the signing attending has reviewed the images and report, and agf ee$ with the interpretation. Preliminary report status should be regarded as NOT interpreted by the attending radiologist. Date/Time Printed: 2/28/2011 0A:32 EST Printed By: Tice,Cindy L Page 12 of 33 PENNSTATE HERSHEY FM Milton S. Hershey iV Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 Chest DICTATED: BOAL, DANIELLE REVIEWED AND SIGNED: BOAL, DANIELLE DATE DRAFTED: 11/02/2010 09:47 AM DATE OF FINAL SIGNATURE: 11/02/2010 10:04 AM Date/Time Printed: 2;28/2011 04:32 EST Printed By: Tice,Cindy L ?-go 13 of 33 PENNSTATE HERSHEY FX7 Milton S. Hershey 1W Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 ........................................................................................................................ ....................................................................................................................ED`Summary :......................................................................................................................................................................................................................................................... 2 RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: Trauma - major Patient: SHIRK, NEIL F MRN: 7508612 Age: 8 years Sex: Male DOB: 4/9/2002 Associated Diagnoses: None Author: Geeting, Glenn K Basic Information Time seen: Immediately upon arrival. History source: EMS. Arrival mode: Air ambulance. History limitation: Language barrier. Final Trauma - major Geeting,Glenn K (11/2/2010 13:18 EDT) OOS: FIN: 10508612 History of Present Illness The patient presents with major trauma, bicycle accident and minivan hit the patient riding a bike unhelmeted. The onset was just prior to arrival. The course of symptoms is fluctuating in intensity. Type of injury: auto v bicycle. The location where the incident occurred was in the street. Location: Head face. The character of symptoms is pain and bleeding. The degree of bleeding is moderate. The degree of pain is moderate. Exacerbating factors consist of none. The relieving factor is none. Risk factors consist of age. Therapy today: emergency medical services. Associated symptoms: altered level of consciousness. Additional history: not wearing helmet. Review of Systems Additional review of systems information: All other systems reviewed and otherwise negative. Health Status Allergies:. No allergies have been recorded. Past Medical/ Family/ Social History Medical history Negative. Surgical history: Negative. Family history: Not significant. Social history: Not significant. < < ; Physical Examination ; Vital Signs Oxygen saturation. General: Alert. Skin: Warm, dry. Date/Time Printed: 2,128/2011 04:32 EST Page 7 of 33 Printed By: Tice,Cindy L i r- PENNSTATE HERSHEY Milton S. Hershey VP Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 ED Summary .................................................... ........................................................._......_...,........_..........._.........._.............................................._....._................... ........... ... Head: Normocephalic, On exam: Frontal, forehead, facial, swelling, abrasion, laceration, bleeding. Neck: Supple, trachea midline, no tenderness. Eye: Pupils are equal, round and reactive to light, extraocular movements are intact, normal conjunctiva. Ears, nose, mouth and throat: Oral mucosa moist, no pharyngeal erythema or exudate. Cardiovascular: Regular rate and rhythm, No murmur. Respiratory: Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal. Chest wall: No tenderness, No deformity. Back: Nontender, no step-offs. Musculoskeletal: Normal ROM, normal strength. Gastrointestinal: Soft, Nontender, Non distended, Normal bowel sounds. Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit observed. Lymphatics: No lymph adenopathy. Psychiatric: Cooperative, appropriate mood & affect. Medical Decision Making Trauma team: Trauma criteria met, trauma team assembled, trauma surgeon present. Differential Diagnosis: Contusion, fracture, sprain, laceration, abrasions, head injury, neck injury, spinal cord injury. Orders Launch Order Profile (Selected). Inpatient Orders Ordered Adult Skin Assessment on Arrival: Chest XR: ED Assessment: ED Nursing Charge: IV insertion: Neuro Check: Non-rebreather Mask: Oxygen Saturation Checks: Pelvis XR: Pulse Oximetry Continuous: Safety/Quality Verification: Vital Signs: Vital Signs: Ordered (Collected) ALT Level: Amylase Level: BMP: CBC w Platelets and Diff: Lipase Level: PT/INR: PTT: Type and Screen (for possible tx): Ordered (Exam Started) OXCHEST: OXCSP: Date/Time Printed: 2/28/2011 04:32 EST Printed By: Tice,Cindy L r r C r Page 8 of 33 /7 PENNSTATE HERSHEY F Milton S. Hershey qF Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 ED Summary OXPELVIS: Ordered (Pending Collection) Urinalysis, Complete (Basic& Micro): Ordered (Scheduled) Head CT.: OCABDOMEN: OCCHEST: OCCSP: OCLSP: OCPELVIS: OCTSP: Completed Consult, Physician: ED Visit: Cardiac monitor: Within normal limits, Rate 98. Results review: Lab results : Laboratory . 11/2/2010 10:45 Color (u) Appear (u) Glu (u) Bili (u) Ketones SG Hgb (u) pH (u) Prot (u) Urobili Nitrite (u) Leuk Est WBC (u) RBC (u) Bact (u) Casts 11/2/2010 09:30 Na K C1- HC03 Anion Gap Glu WBC (Modified) WBC Hgb Hgb (Modified) Hct (Modified) Hct Date/Time Printed: 2/28/2011 04:32 EST Printed By: Tice,Cindy L STRAW CLEAR NEGATIVE mg/dL NEGATIVE NEGATIVE mg/dL 1.010 MODERATE 6.0 unit 30 mg/dL Abnormal 0.2 EUML NEGATIVE NEGATIVE 5-9 /HPF 1-4 /HPF? FEW Casts 140 mmo/L 3.5 mmol/L 106 mmo]_/L 25 mmol/L' 9 mmol/L 180 mg/dL, Hh- EXPANDED PROFILE ORDERED K/uL C l C l ? ? V L. 32.2 K/uL !:ritical' High 11.7 g/dL' EXPANDED PROFILE O'ta!1PED g/dL EXPANDED PROFILE ORDERED % 34.9 % LOW Page 9 of 33 IO PENNSTATE HERSHEY 1X7- Milton S. Hershey IV Meclical Center Patient Name: SHIRK, NEIL F MRN 7508612 ....................................................................E p.Summary......................................................................................... ........ .............. ............................... . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ........ ......... ..... ................... . . . . . . . . . . . . . . . . . . . . . . RBC EXPANDED PROFILE ORDERED M/uL (Modified) RBC 4.55 M/uL MCV 76.7 fL LOW MCV EXPANDED PROFILE ORDERED fL (Modified) MCHC EXPANDED PROFILE ORDERED g/dL (Modified) MCHC 33.5 g/dL MCH EXPANDED PROFILE ORDERED pg (Modified) MCH 25.7 pg RDW EXPANDED PROFILE ORDERED % (Modified) RDW 14.6 % Plts EXPANDED PROFILE ORDERED K/uL (Modified) Plts 286 K/uL MPV 9.8 fL MPV EXPANDED PROFILE ORDERED fL (Modified) Type of Diff: MANUAL Immature Gran% 0 % Neut % 38 0 Lymph% 59 % HI Mono% 3 0 Baso % 0 % Eos% 0 0 Immat Gran, Abs 0.0 K/uL Neut, Abs 12.2 K/uL HI Lymph, Abs 19.0 K/uL HI Mono, Abs 1.0 K/uL Baso, Abs 0.0 K/uL Eos, Abs 0.0 K/uL Hem Comment PLATELET MORPHOLOGY NORMA L RBC Morphology NORMAL ALT 73 unit/L HI Lipase 208 unit/L'', Amylase 140 unit/L' 'HI Request of Physician CBC diff?rh-ittial cc , Action Taken Test ADDEp„ Green (Lithium Heparin) Specimen`,avdilable,from 0 to 3 days based on s pecimen stability. Please use addon order ff,y(iu wish to order testing. Lavender Specimen availabl-a :from 0 to t 3 days based on specimen stability. Please use addon order if you wish to order testing. Date/Time Printed: 2/28/2011 04:32 EST Page 10 of 33 Printed By: Tice,Cindy L /R PENNSTATE HERSHEY FXM- Milton S. Hershey qP Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 ...........................,...............,.....,....,.,....,.,..,..,.,,.,...,,,,,..,,,.....,,.,,,,......,,..,.,..,,..., ,,,.,.,...,,,,..,,,..,,..,..,,,.,,....,,.,....,,.,,.....,..,.... ED`Summary ........................... ..,...,..,,..,....,,..,,,,...... .....,,,.,.......,......,..,.,,.,..,..,...,,,..,.........,. ..........:................................................... ...........................,....? Blue Specimen available from 0 to 3 days based on specimen stability. Please use addon order if you wish to order testing. 11/2/2010 09:12 ABO/Rh ABO/Rh ABO Recheck ABO Recheck Antibody Scr NEGATIVE; Expires at 0600AM on 11/05/2010 R Number R08327 Component RED CELLS # units 0 Head Computed Tomography: No acute disease process. Chest X-Ray: No acute disease process. Radiology results: Computed tomography, reviewed radiologist's report. Impression and Plan Diagnosis Head injury 959.01 (ICD9 959.01) Facial laceration 873.40 (ICD9 873.40) Abrasion of the face 910.0 (ICD9 910.0) head contusion 920 (ICD9 920) Contusion of the face 920 (ICD9 920) Plan Condition: Guarded. Disposition: Admit: to Inpatient Unit. Follow up with: Jay Townsend within Call physician within next business day. Notes: care of this patient occupied 30 minutes of critical care time. Addendum Signatures: Electronically Reviewed/Signed (02-NOV-201013:17:00) by; Glenn K. Geeting, MD 1 ? 1 1 l 1 4 Date/Time Printed: 2/28/2011 04:32 EST Printed By: Tice,Cindy L Page 11 of 33 '1o PENNSTATE HERSHEY Milton S. Hershey qP Medical Center Patient Name: SHIRK, NEIL F MRN: 7508612 Date of Birth: 4/19/2002 Patient Gender: Male Penn State Hershey Tel: (717) 531-8055 Milton S. Hershey Medical Center Health Information Services, HU24. 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Visit Number: 10508612 Visit Type: Inpatient Patient Location: 7MBE; 7224; 01 ....................._._........_........_._.._......__...._._.........._........_....................................Added `Tests ...................................................................._._.._......................................_........., Procedure Request of Physician Action Taken Units Reference Range Collected Date/Time .111212010 09:30 EDT CBC differential 01 Test ADDED 01 ............................................. .............. Order Comments 01: Added on Lab order [[This request should be used to add test(s) to samples that are already in the lab. If an appropriate sample is available, the test(s) will be performed. Refer to the RESULTS tab in POWERCHART to check the status of your request.]] Date/Time Printed: 2/28/2011 04:31 EST Printed By: Tice,Cindy L Page 1 of 9 al PENNSTATE HERSHEY PM. Milton S. Hershey IV Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 .........................................................................................................................Blood Bank........................................................................................................................ Procedure ABO/Rh A B 0 Recheck Antibody Scr Expires at 0600AM on Units' Reference Range Collected Date/Time 11/2/2010 09:12 EDT A POSITIVE 01 A POSITIVE 01 NEGATIVE01 11/05/2010u' Procedure R Number Component # Units Units Reference Range' Collected Date/Time .11/2/2010 09:12 EDT R083270' RED CELLS of 0 of Order Comments 01: Blood Type/Antibody Screen (Type and Screen (for possible tx)) [[Pink tube; Deliver to Blood Bank. Additional Blood Bank arm band and requisition are required (R number identification).]] i t f f t t t t Date/Time Printed: 2/28/2011 04:31 EST Printed By: Tice,Cindy L Page 2 of 9 l.2 PENNSTATE HERSHEY FM Milton S Hershey qF Med:ical Center Patient Name: SHIRK, NEIL F MRN 7508612 CBC :..............................................................,...,...,......,,....,...,...............,..........,.,.,.,...,,,.,.,....,,,,,.,,,,,,.,,....,..,,,,,,..,.,..,,..........,................. .....,..,,.,........................ ............,.... Procedure WBC WBC H b Units K/uL g/dL Reference Range, [4.5-13,5] [4.5-13.5] [11.5-15.5] Collected Date/Time 11/3/2010 0717 EDT 12.001 - 10.3L01 1 1/2/201 0 0930 EDT 32.2'R' EXPANDED PROFILE ORDERED R2 11.7 Result Comments R1: WBC CHECKED RESULTS PHONED READ BACK KRONMULLER 11/02/10 10:00 R2: WBC REQUEST CREDITED Corrected on 11/02 AT 1030: Previously reported as 32.2 ADJUSTED FOR NUCLEATED RBC'S CHECKED RESULTS PHONED READ BACK MR KRONMULLER 11/02/10 10:00 Procedure Hgb Hct Hct Units °'o Reference Range [11.51-15.5) [35-45] [35-45] Collected Date/Time :11/3/2010 07:17 EDT - 31.6 poi 1 1/21201 0 09:30 EDT EXPANDED PROFILE ORDEREDR3 .. 34.9 ......... .........: EXPANDED PROFILE ORDERED R4 Result Comments R3: Hgb REQUEST CREDITED Corrected on 11102 AT 1030: Previously reported as 11.7 R4: Hct REQUEST CREDITED Corrected on 11/02 AT 1030: Previously reported as 34.9 Procedure' RBC RBC MCV Units M/uL fl Reference Range [4.00-5,20] [4.00-5.20] [77-95] Collected Date/Time ? 11/3/201007:17 EDT 4.1301 76.5L 0 1 1/2/201 0 09:30 EDT 4.55 EXPANDED PROFILE ORDERED RS. .. _ ............ ........ ................... ......._.............. ...............:.................... ...................................... ....... ........................ ....,....... .............. ....: Result Comments R5: RBC REQUEST CREDITED Corrected on 11/02 AT 1030: Previously reported as 4.55 Date/Time Printed: 2/28/2011 04:31 EST Page 3 of 9 Printed By: Tice,Cindy L _) 2 PENNSTATE HERSHEY FM Milton S. Hershey ® Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 CBC .............................................,...................................,,................................................... ......... ... --...............................,...............:.........................:......................... Procedure MCV MCHC MCHC Units- g/dL Reference Range, [77-95] [31-37] [31-37] Collected DaleTime :11/3/2010 0717 EDT 32.601 : ............... ...... ......... _.... .... '11/2/2010 09:30 EDT EXPANDED PROFILE ORDEREDR6.. ... ........_ ..... ............ ............ ........ 33.5 EXPANDED PROFILE ORDERED R' Result Comments R6: MCV REQUEST CREDITED Corrected on 11/02 AT 1030: Previously reported as 76.7 R7: MCHC REQUEST CREDITED Corrected on 11/02 AT 1030: Previously reported as 33.5 Procedure MCH MCH' RDW Units' pg' o0 Reference Range [25-33] [25-33] [12.0-16,4] Collected Date/Time 11 13/2010 07:17 EDT 24.9 01 : 14.9 O1 _.. ..._ ........ .. .. _ .. _....... ........ 1 1/2/201 0 09:30 EDT 25.7 EXPANDED PROFILE ORDERED RB 14.6. Result Comments R8: MCH REQUEST CREDITED Corrected on 11102 AT 1030: Previously reported as 25.7 Result Comments R9: RDW REQUEST CREDITED Corrected on 11/02 AT 1030: Previously reported as 14.6 R10: Plts REQUEST CREDITED Corrected on 11/02 AT 1030: Previously reported as 286 Procedure MPV MPV Units fl Reference Range [8.7-12.5] ! [8.7-12.5] Collected Date/Time .11/3/2010 0717 EDT 10 2 O1 - 1 M M 1 ' 1 1 Type of Diff lmrriature Gren°l 0% AUTO 01 p of ................ -.__.. . .. ........ ........ . _...... ......... ......... ....... ..:.._...... ............... Date/Time Printed: 2;28/2011 04:31 EST Page 4 of 9 Printed By: Tice,Cindy L (! PENNSTATE HERSHEY Milton S. Hershey Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 ............... CBC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................. ....... . . . . . . . . . . . . . . . . . . .......... . . . ........................ . . . . ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . ................. .. . ..... Procedure MPV MPV Type of Diff: Immature Gran% Units fl- Reference Range; [8.7-12.5] [8.7-12.5] [0] Collected-Date/Time 11/2/2010 09.30 EDT 9.8 EXPANDED PROFILE ORDERED"" MANUAL 0 _........ _._.. _....:_. ........... ........... .............. ................ ........ _ .... __. _ . _ .: Result Comments R11: MPV REQUEST CREDITED Corrected on 11/02 AT 1030: Previously reported as 9.8 Procedure Neut% Lymph% Mono% Baso°o Eos% Immat Gran,AbS Neut,Abs Units o „ % °o % % K'uL K,uL Reference Range [35-71] [25-45] [0-10] [0-2] [0-61 [0.0] [1.8-8.0] Collected DateJime 11/3/201007:17 EDT 6301 23 0' 14HO1 001 00, 0.00i 7.6°i 1 1 /2/201 0 09.30 EDT 38 59 3 " 0 0 0.0 12.211 Procedure Lymph,Abs Mono,Abs Baso,Abs Eos,Abs He m Comment Units K'uL K`uL K/uL K/uL Reference Range [1.2-6.8] [0-12] [0-0.2] [0-0,7] Collected Date/Time 11/3/2010 07:17 EDT 2.801 1.7 H01 0.001 0.001 11/2/2010 09.30 EDT 19.0" 1.0 0.0 0.0 PLATELET MORPHOLOGY NORMAL': : Procedure' RBC Morphology Units Reference Range Collected Date/Time :11/2/2010 09:30 EDT NORMAL Order Comments 01: Complete Blood Count w Differential (CBC w Platelets and Diff) [[Lavender tube; Panel includes WBC count, RBC count, Hgb, Hct, Platelet count and Differential]] Date/Time Printed: 2/28/2011 04:31 EST Printed By: Tice,Cindy L , rrrrr „ r r ??tt Page 5 of 9 PENNSTATE HERSHEY Milton S. Hershey VP Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 .__. ....... --- - - - -------- - -- Chemistry .:..--- ......... - .. ............................... .................................................................................... Procedure Na k CI- HC03 Anion Gap GIu Units mmol/L mmol/L mmol/L mmol/L mmDVL mg,/dL Reference Range (137-145] [3.5-,5.1] [96-107] [22-30] [5-14] [74-106] Collected Date/Time 11/2/2010 09:30 EDT 140 3.5 106 25 _ 9 180 Date/Time Printed: 2,128/2011 04:31 EST Printed By: Tice,Cindy L Page 6 of 9 4 ?(C PENNSTATE HERSHEY Milton S. Hershey ® Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 .. . . . . . . . . . . . . .. . . ............ .....................................................11-1.............................: I m m u n o%g y....................................................1-1111-11....,...................................................... Procedure M R S A Surveii I ance,on Admission Units Reference Range [MSND] Collected Date/-Time 11/2/2010 13:34 EDT MRSA NOT detected 01 ................... Order Comments 01: MRSA Surveillance (NP), on Admission MRSA Surveillance (NP), on Admission Date/Time Printed: 2/28/2011 04:31 EST Printed By: Tice,Cindy L rrrr, , r , E rrttr FC r?r r E ' ? r r r E r i r r ! t r??r Page 7 of 9 ,3-7 PENNSTATE HERSHEY Milton S. Hershey iW Medical Center Patient Name: SHIRK, NEIL F Liver/GI Procedure ALT, Lipase Amylase Units unit'L unit/L uniUL Reference Range [13-691 [23-3001 [30-1101 Coliected Date/Time .11/2/2010 09:30 EDT 73" 208 140H Date/Time Printed: 2/28/2011 04:31 EST Printed By: Tice,Cindy L MRN 7508612 4 ( c l f l ( 1 ( 1 l 1 i l4lL V L li f I l f 1 1 f ( . 1 f t 5 f'f 1 1 1 ? 1. l 1 Page 8 of 9 QS PENNSTATE HERSHEY FM-1 Milton S. Hershey Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 Urine J :........: ................,...,..,..,...,,..,,..,......._.......................,............,...,...,.,,.....,.,,.,.....,.,...,....,.....,...,.,..., .,,,.,.,.,..,,......,,.,,....,.......,..........,,.....,.,,.,,.,..,..,..,.,.,..,......,........,,....... Procedure` Color (u) Appear (u) Gtu (u) Bili (u) Ketones Units Reference Range [NEG] [NEG] [NEG] Collected Date/Time :11/2/2010 10:45 EDT ......... ......_.. STRAW01 .... CLEAR01 ...... ....... NEGATIVE01 NEGATIVE 01 _.... .... ....__ ...................... ._. NEGATIVE 01 _......_. _..... _._ ._ .: Procedure SG Hgt (u) pH (u) Prot (u) Urobili Nitrite (u) Units unit mg/dL EU/dL Reference Range [NEG] [4.5-8.0] [NEG] [01-1 01 [NEG] Collected Date/Time 11/2/201010:45 EDT 1.01001 MODERATE@ o' 6.0c" 30 01 } 0.201 NEGATIVE01 Procedure Leuk Est WBC (u) RBC (u) Bact (u) Casts Units, Reference Range [NEG] [0-4] [0-4] [NONE] Collected DatefTime 11/2/2010 10:45 EDT NEGATIVE01 5-901 ........ ..............._._ 1-40' FEW@01 1-4 GRANULAR"' i _ .................... ....... ............. Order Comments 01: Complete Urinalysis (Basic&Micro) (Urinalysis, Complete (Basic&Micro)) [[Urine, sterile container]] E Date/Time Printed: 2/28/2011 04:31 EST Printed By: Tice,Cindy L Page 9 of 9 ,?C/ Patient Discharge Instructions * Final Report * SHIRK, NEIL F - 7508612 * Final Report * PENN STATE MILTON S. HERSHEY MEDICAL CENTER 1-717-531-8521 PATIENT DISCHARGE INSTRUCTIONS If you have any questions, please contact your physician. Date of Admission: 11/02/2010 Date of Discharge: 11/03/2010 Reason for Discharge: Stable for Discharge Physician: Service: Destination: Discharge Diagnosis: Facial Abrasions Discharge Diagnosis: :Facial Abrasions Other Diagnoses: Left knee tibial fracture Santos, Mary C Peds Surgery 2033 RITNER HIGHWAY, SHIPPENSBURG, PA 17257 ln?? l •4 30` Printed by: Wamba, Rachel M Printed on: 11/3/2010 16:15 ?/?It SS# !93 8'4 8378' r 73 0, /'5 ?12 Page 1 of 8 / f ? 5 ,? 7 7 (Continued) < VLl. ?n Patient Discharge Instructions SHIRK, NEIL F - 7508612 * Final Report * Other Diagnoses: Left knee tibial fracture Surgical Procedures: None Diagnostic Imaging: CT chest, abdomen, and pelvis 1. No evidence of acute traumatic injury. 2. Tiny trace fluid within the pelvis. 3. Calcification within the left lobe of the liver, which maybe secondary to granulomatous disease versus prior trauma. Vaccinations Received This Hospital Stay: No vaccinations were given this hospital stay. Printed by: Wamba, Rachel M Printed on: 11/3/2010 16:15 Page 2 of 8 (Continued) PSAient Discharge Instructions * Final Report * Discharge Medications: Medication Dose SHIRK, NEIL F - 7508612 Special Instructions bacitracin topical 1 appl topically 2 times daily Apply to abrasions on face till healed. ndansetron (Zofran) 4 mg by mouth every 6 hours, as needed for Nausea and Vomiting Care Instructions: 1. See the head injury care instructions. The key to getting better after a head injury is to rest when tired. Avoid overstimulation and overtiredness, as may increase symptoms. If ANY activity increases symtpoms, stop and rest in a quiet area. 2. Facial abrasions/lacerations - wash with soap/water, dry and apply a thin layer of bacitracin twice/day until healed. Avoid sun/wind exposure, as will burn very easily. Avoid potential contact in dirty areas (Mulch, dirt/soil, animal areas). 3. Nonweight bearing on left lower extremity until cleared by orthopedic team at follow-up. Keep Knee immobilizer on when ever upright. Take off at least 1-2 times at day while lying down to check skin. No crearris/lotions/powders on skin under brace. 4. Please follow up with your PCP in the next several weeks regarding this admission. We did note a mild anemia on Neil's lab work. He may want to do some additional testing. We suggest taking a multi vitamin with iron daily, 5. Keep long leg cast clean and dry See cast care instructions 6. Follow all instructions given to you by physical therapy Care Instructions: 1. See the head injury care instructions. The key to getting better after a head injury is to rest when tired. Avoid overstimulation and overtiredness, as may increase symptoms. If ANY activity increases symtpoms, stop and rest in a quiet area. 2. Facial abrasions/lacerations - wash with soap/water, dry and apply a thin layer of bacitracin twice/day until healed. Avoid sun/wind exposure, as will burn very easily. Avoid potential contact in dirty areas (Mulch, dirt/soil, animal areas). 3. Nonweight bearing on left lower extremity until cleared by orthopedic team at follow-up. Keep Knee immobilizer on when ever upright. Take off at least 1-2 times at day while lying down to check skin. No creams/lotions/powders on skin under brace. 4. Please follow up with your PCP in the next several weeks regarding this admission. We did note a mild anemia on Neil's lab work. He may want to do some additional testing. We suggest taking a multi vitamin with iron daily. 5. Keep long leg cast clean and dry See cast care instructions 6. Follow all instructions given to you by physical therapy 7. For constipation take an over the counter stool softener like Senna or Colace, increase fiber in diet., increase liquid intake Printed by: Wamba, Rachel M Printed on: 11/3/2010 16:15 Page 3 of 8 (Continued) 3a ien' Discharge histructions "a' L * Final Report * Diet Guidelines: regular diet. encourage plenty of liquids. SHIRK, NEIL I'= - 7508612 Diet Guidelines: regular diet. encourage plenty of liquids. Neil must drink at least one liter of fluids every day. Appetite will improve with time. Activity Guidelines: avoid activities that may lead to falls/impact for the next 2 weeks: No jumping/climbing, sports, riding things witl' wheels, contact with large animals. no weight bearing on left lower extremity (no standing or walking) ; wheelchair as needed, walker progressing to crutches with outpatient physical therapy Return to school - at parents discretion once no longer symtpomatic at home. (No headaches, tiredness, dizziness, etc). Activity Guidelines: avoid activities that may lead to falls/impact for the next 2 weeks: No jumping/climbing, sports., riding things with wheels, contact with large animals. no weight bearing on left lower extremity (no standing or walking) ; wheelchair as needed, walker progressing to crutches with outpatient physical therapy Return to school - at parents discretion once no longer symtpomatic at home. (No headaches, tiredness, dizziness, etc). Call your doctor if: Please call 717-531-8521 (operator- ask for the pediatric surgery resident on-call): fever greater than 101 F, increased severe pain, persistent vomiting, increased redness/drainage/foul odor from any wounds. Also call for toes that are no longer nice and pink and warm, call if they are discolored and cool and he can no longer wiggle them. for routine questions during the weekdays, please call the pediatric surgery office at 717-531-8342. Call your doctor with questions regarding Orthopaedic Surgery = Call with any questions concerning fevers > 101 °F, chills, redness, swelling, drainage, pus or any questions you feel necessary - Monday - Friday Sam-4:30pm Call (717) 531-8532 - Ask to speak to Cindy Reighard CRNP , Pediatric Orthopedics - Evenings or Weekends call the hospital operator (717) 531-8521 and ask for the Orthopaedic resident on call to be paged 1-'rinted by: Wamba, Rachel M Printed on: 11/3/2010 16:15 Page 4 of 8 (Continued) ?3 Patient Discharge Instructions Final Report'' SHIRK, NEIL F - 7508612 Call your doctor if: Please call 717-531-8521 (operator- ask for the pediatric surgery resident on-call): fever greater than 101 F, increased severe pain, persistent vomiting, increased redness/drainage/foul odor from any wounds. Also call for toes that are no longer nice and pink and warm, call if they are discolored and cool and he can no longer wiggle them. for routine questions during the weekdays, please call the pediatric surgery office at 717-531-8342.. Call your doctor with questions regarding Orthopaedic Surgery - Call with any questions concerning fevers > 101 °F, chills, redness, swelling, drainage, pus or any questions you feel necessary - Monday - Friday 8am-4:30pm Call (717) 531-8532 - Ask to speak to Cindy Reighard CRNP , Pediatric Orthopedics - Evenings or Weekends call the hospital operator (717) 531-8521 and ask for the Orthopaedic resident on call to be paged Other Instructions: Penn State Children's Hospital - Injury Prevention Tips - Biking/B/ading/Skating/Scooter Safety • Always use protective gear - helmets, wrist guards, knee and elbow pads. • Practice controlling speed and stopping. • Avoid areas with puddles, bumps, oil, sand, gravel and steps. • Children under age 10 should not ride bicycle on streets without an adult. Learn traffic rules and practice on quiet streets with an adult first. • Bicyclists on streets must follow the same laws as car drivers. Ride on the right, use hand signals before turning or stopping, obey traffic rules, and beware of motor vehicles. • Stop and look both ways for cars at driveways. Other Instructions: r. '_d by: Wamba, Rachel M Printed on: 11/3/2010 16:15 Page 5of8 (Continued) ?V • Make sure that drivers can see you. During daylight hours, a brightly-colored helmet/shirt is easiest to see. If your child is not home by dusk, he/she should call you to be picked up. ieni Discharge Instructi©ns Final Report " SHIRK, NEIL F - 7508612 Penn State Children's Hospital - Injury Prevention Tips - Biking/B/ading/Skating/Scooter Safety • Always use protective gear - helmets, wrist guards, knee and elbow pads. • Practice controlling speed and stopping. • Avoid areas with puddles, bumps, oil, sand, gravel and steps. • Children under age 10 should not ride bicycle on streets without an adult. Learn traffic rules and practice on quiet streets with an adult first. • Bicyclists on streets must follow the same laws as car drivers. Ride on the right, use hand signals before turning or stopping, obey traffic rules, and beware of motor vehicles. • Stop and look both ways for cars at driveways. • Make sure that drivers can see you. During daylight hours, a brightly-colored helmet/shirt is easiest to see. If your child is not home by dusk, he/she should call you to be picked up. Neil is to follow up with Dr. Hennrikus of Pediatric Orthopedics on November 11, 2010. Please call 531-7006 for appointment time and directions to 30 Hope Drive, East Campus Follow-Up Appointments: No Follow-Up Appointments have been scheduled. Discharging Provider: Simmons, Lynn G =; iniZd by: Wamba, Rachel M Printed on: 1113/2010 16:15 Page 6 of 8 (Continued) W-11 3 -anent Discharge Instructions "Final Report ' SMOKING is a major health issue. SHIRK, NEIL F - 7508612 - Smoking greatly increases the risk of heart disease, cancer and stroke. - If you and your family don't smoke, continue this healthy choice! - Remember to avoid secondhand smoke. - If you or anyone in your household does use tobacco products, please follow any smoking cessation advice/counseling you received while in the hospital. - If you would like more information about how to live tobacco free, please call the numbers or access the websites below: PSHMC Care Line 1-800-243-1455 Pennsylvania Free QUITLINE 1-800-QuitNow (1-800-784-8669) http://1800quitnow.cancer.gov http://www.determinedtoquit.com F i ".:A by: Wamba, Rachel M Printed on: 11/3/2010 16:15 Page 7 of 8 (Continued) 2(0 Patient Discharge !ns.tructions SHIRK, NEIL F - 7508612 * Final Report * Result Type: Patient Discharge Instructions Date of Service: November 03, 2010 16:15 Authorization Status: Final Author or Import Date: Wamba, Rachel M on November 03, 2010 16:15 Verified By: Wamba, Rachel M on November 03, 2010 16:15 Encounter info: 10508612, HMC, Inpatient, 11/2/2010 - i'i!ied by: Wamba, Rachel M Page 8 of 8 Printed on: 11/3/2010 16:15 (End of Report) 37 KODI -;Personalize & Print PENNS ATE HERSHEY Children's Hospital Discharge Instructions: Caring for Your Child's Plaster Cast Pagel of 2 96546 Your child will be going home from the hospital with a plaster cast in place. A cast helps your child's body heal. A damaged cast can keep the injury from healing well. Take good care of your child's cast. If the cast becomes damaged, it may need to be replaced. Your child has broken his/her bone. This bone is located in his/her Keep the Cast Dry A wet cast can crumble and fall apart. Take these steps to keep the cast dry: • Have your child avoid all activities in which the cast could get wet. • Take special care to keep the cast dry when your child bathes or showers. Wrap the cast in plastic bags. Use heavy tape to secure the plastic so that water won't leak in. • Don't soak the cast in water, even if it's wrapped in plastic. • If your child must go out in rain or snow, cover the cast with waterproof clothing or plastic. • Use a hair dryer turned to the "cool" setting to dry a cast that has become wet. Call your child's doctor if the cast has not dried within 24 hours. Other Cast Care • Don't allow your child to stick things in the cast, even to scratch the skin. Objects put in the cast may get stuck. Your child's skin may be cut and become infected. If your child's skin itches, try blowing air into the cast with a hair dryer turned to the "cool" setting. • Don't let your child pick at the padding of the cast. Padding protects your child's skin and must be kept intact. • Don't cut or tear the cast. • Cover any rough edges of the cast with cloth tape or moleskin. (You can buy this at a pharmacy.) • Never try to remove the cast yourself. Activity . Help your child to exercise all the adjacent joints not immobilized by the cast. If your child has a long leg cast, exercise the hip joint and the toes. If your child has an arm cast or splint, exercise the shoulder, elbow, thumb, and fingers. • Elevate the part of your child's body that is in the cast above the level of the heart. This helps reduce swelling. Follow-Up Make a follow-up appointment as directed by our staff. When to Call Your Child's Doctor Call the doctor right away if your child has any of the following: https:'/www.luamesondemand.coi-i/P;-i.i.tController.as;j: 2 k 11/3/2010 KODI -Personalize & Print Page 2 of 2 . Tingling or numbness in the injured body part . Severe pain that cannot be relieved . Cast that feels too tight or too loose . Swelling, coldness, or blue-gray color in the fingers or toes Cast that is damaged, cracked, or has rough edges that hurt Cast that gets wet and doesn't dry within 24 hours ......... © 2000-2010 The 5tayWell Company, 780 Township Line Road, Yardley, PA 19067. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions. https://www.kramesondemand.coiii/PrintControlIer.aspx 11/3/2010 k E C PENNSTATE HERSHEY F 1 Milton S. Hershey ` E Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 ...__..........._._............._................,.............._._.............._..........,..._,.........,? ............................................................................._.........._....__...._..._.....Discharge `Summary RESULT STATUS: Final ` DOCUMENT SUBJECT: D/C Summary ELECTRONICALLY SIGNED BY: Simmons,Lynn G (11/9/2010 06:37 EST); Santos,Mary C (11/4/2010 1 535 EDT) DISCHARGE SUMMARY Name: SHIRK, NEIL P HMC Number: 7508612 DOB: 04119/2002 Date of Admission: 11/02/2010 Date of Discharge: 11/03/2010 Reason for Discharge: Stable for Discharge Physician: Santos, Mary C Service: Peds Surgery Destination: 2033 RITNER HIGHWAY, SHIPPENSBURG, PA 17257 Discharge Diagnosis: Facial Abrasions Other Diagnoses: Left knee tibial fracture Surgical Procedures: None Diagnostic Imaging: CT chest, abdomen, and pelvis 1. No evidence of acute traumatic injury. 2. Tiny trace fluid within the pelvis. 3. Calcification within the left lobe of the liver, which may be secondary to granulomatous discasc verses p~io- trauma. , Vaccinations Received This Hospital Stay: No vaccinations were given this hospital stay. " Discharge Medications: 1. Bacitracin topical 1 appl topically 2 times daily. Apply to abrasions on face till healed. 2.Ondansetron (Zofran) 4 mg by mouth every 6 hours, as needed for Nausea and Vomiting. Brief History of Present Illness: Date/Time Printed: 2/28/2011 04:32 EST Page 3 of 33 Printed By: Ti!;e,Cindy I_ q0 PENNSTATE HERSHEY Milton S. Hershey Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 Discharge Summary ............................................................................... 8 yo male who was an unhelmeted bicyclist presents as a Level 2 trauma after being struck by a motor vehicle at 45 mph. He sustained abrasions and contusion to his face. Hospital Course: Patient arrived as a level 2 trauma activitation. CT scan of head, c-spine, face, and chest demonstrated no acute injuries. X-ray of left knee demonstrated moderate joint effusion and suspect fracture through the tibial spine at the midportion of the proximal tibial epiphysis. Patient was admitted for observation on the Pediatric Surgery service. Throughout his hospital course, he remained afebrile with stable vital signs. Orthopaedics was consulted and did not recommend surgical intervention. Instead, they placed his left knee in an immobilizer. Once seen by the Orthopedic attending his immobilizer was removed and a left long leg cast was applied. His WBC count at admission was elevated (WBC 32.2) but decreased to WBC 12 by the second day of admission. Microcytic Anemia was also noted (10.3/31.6 with MCV 76.5 and MCH 24.9). and it was suggested they follow up with his PCP. Physical therapy was consulted. He was unable to safely use crutches on his initial evaluation. Following a second session with PT, it was felt he was not safe to use crutches at this time. A wheelchair and walker were ordered with follow up PT sessions closer to home to teach Neil how to transition to crutches. Family preferred to use their family resources to obtain the equipment. Equipment was then not ordered from this end but they do have the SW contact info if needed. The patient was hemodynamically stable at the time of discharge. He will be followed by Pediatric Orthopedics, Dr. Hennrikus. Exam on Discharge: HEENT: echymoses of right eye lid, multiple abrasions on nose, cheeks, and forehead CVS: regular rate Pulm: CTAB Abd: soft, NT, ND Ext: Left leg in long leg cast toes warm, able to wiggle Care Instructions: 1. See the head injury care instructions. The key to getting better after a head injury is to rest when tired. Avoid overstimulation and overtiredness, as may increase symptoms. If ANY activity increases symtpoms, stop and rest in a quiet area. 2. Facial abrasions/lacerations - wash with soap/water, dry and apply a thin layer of bacitracin twice/day until healed. Avoid sun/wind exposure, as will burn very easily. Avoid potential contact in dirty areas (Mulch, dirt/soil, animal areas). 3. Nonweight bearing on left lower extremity until cleared by orthopedic team at follow-up. Keep Knee immobilizer on when ever upright. Take off at least 1-2 times at day while lying down to check skin. No creams/lotions/powders on skin under brace. 4. Please follow up with your PCP in the next several weeks regarding this admission. We did note a mild anemia on Neil's lab work. He may want to do some additional testing. We suggest taking a multi vitamin with iron daily. 5. Keep long leg cast clean and dry See cast care instructions 6. Follow all instructions given to you by physical therapy 7. For constipation take an over the counter stool softener like Senna or Colace, increase fiber in diet., increase liquid intake ?e..rr cr . Diet Guidelines: regular diet. encourage plenty of liquids. Neil must drink at least one liter of fluids every day. `App6tite will improve with time. Activity Guidelines: Date/Time. Printed: 2/28/2011 04:32 EST Printed By: Tice,Cindy L Page 4 of 33 "f PENNSTATE HERSHEY 0M. Milton S. Hershey Rp Medical Center Patient Name: SHIRK, NEIL F ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Discharge Summary MRN 7508612 avoid activities that may lead to falls/impact for the next 2 weeks: No jumping/climbing, sports, riding things with wheels, contact with large animals. no weight bearing on left lower extremity (no standing or walking) ; wheelchair as needed, walker progressing to crutches with outpatient physical therapy Return to school - at parents discretion once no longer symtpomatic at home. (No headaches, tiredness, dizziness, etc). Call your doctor if: Please call 717-531-8521 (operator- ask for the pediatric surgery resident on-call): fever greater than 101 F, increased severe pain, persistent vomiting, increased redness/drainage/foul odor from any wounds. Also call for toes that are no longer nice and pink and warm, call if they are discolored and cool and he can no longer wiggle them. for routine questions during the weekdays, please call the pediatric surgery office at 717-531-8342. Call your doctor with questions regarding Orthopaedic Surgery - Call with any questions concerning fevers > 101 OF, chills, redness, swelling, drainage, pus or any questions you feel necessary - Monday - Friday 8am-4:30pm Call (717) 531-8532 - Ask to speak to Cindy Reighard CRNP , Pediatric Orthopedics - Evenings or Weekends call the hospital operator (717) 531-8521 and ask for the Orthopaedic resident on call to be paged Other Instructions: Penn State Children's Hospital - Injury Prevention Tips - Biking/Blading/Skating/Scooter Safety Always use protective gear - helmets, wrist guards, knee and elbow pads. Practice controlling speed and stopping. Avoid areas with puddles, bumps, oil, sand, gravel and steps. Children under age 10 should not ride bicycle on streets without an adult. Learn traffic rules and practice on quiet streets with an adult first. Bicyclists on streets must follow the same laws as car drivers. Ride on the right, use hand signals before turning or stopping, obey traffic rules, and beware of motor vehicles. Stop and look both ways for cars at driveways. Make sure that drivers can see you. During daylight hours, a brightly-colored helmet/shirt is easiest to`sec., If your child is not home by dusk, he/she should call you to be picked up. Neil is to follow up with Dr. Hennrikus of Pediatric Orthopedics on November 11, 2010. Please'call 531-7006 for appointment time and directions to 30 Hope Drive, East Campus M Y Follow-Up Appointments: < No Follow-Up Appointments have been scheduled. 365682 Date/Time Printed: 2/28/2011 04:32 EST Page 5 of 33 Printed By: Tice,Cindy L .Y -% PENNSTATE HERSHEY MOM Milton S. Hershey 40 Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 Discharge Summary ................................................................................. Electronic Signature on File CC: JayA Townsend, MD 100 South High Street Newville PA 17241 Electronically Reviewed/Signed by. Lynn G Simmons, MSN, CRNP Author Signature Dt/Tm:09.11.2010 06.37 AM Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Brett Engbrecht, Kerry Fagelman, Dorothy Rocourt, Mary Santos Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP, PNP-BC Lynn Simmons MSN CRNP Electronically Reviewed/Signed by. Mary C Santos, MDCosigner Signature DUTm: 04. 03:35 PM Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Brett Engbrecht, Kerry Fagelman, Dorothy Rocourt, Mary Santos Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP, PNP-BC, Lynn Simmons MSN CRNP LGS /CR DD: 11103110 DT.' 11103110 19:11 Date/Time Printed: 2/28/2011 04:32 EST Printed By: Tice,Cindy L r r , t ?L?4b4 Page 6 of 33 L/. 3 PENNSTATE HERSHEY /?1 Milton S. Hershey qP Medical Center Patient Name: SHIRK, NEIL F MRN: 7508612 Date of Birth: 4/19/2002 Patient Gender: Male Penn State Hershey Tel: (717) 531-8055 Milton S. Hershey Medical Center Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Visit Number: 10508612 Visit Type: Inpatient Patient Location: 7MBE; 7224; 01 ...................................._..........................................................................................., .............Consult RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: CONSULT Name: SHIRK, NEIL F HMC Number: 7508612 DOB: 04/19/2002 Date of Service: 11/03/2010 Final Hennrikus,William L (11/8/2010 16:18 EST) Reason for consult is called by the trauma doctors to evaluate young child who is on his bike hit by a car transported for trauma care. Patient was not wearing a helmet. He has had a nice workup by the trauma team with complete evaluation The patient's orthopedic injury noted to date is a left tibial spine fracture, nondisplaced. The injury also has associated swollen knee. I have examined the patient, interviewed the mom and the dad. The patient has no allergies. Lives at home with his family. No prior surgery. No major medical illnesses. No history of smoking or drinking and no other major complaints other than the swollen knee at,,fts.?oint orthopedically. He also has some abrasions over his face and cared for by the trauma team. EXAM: Vital Signs: Stable. He is swollen +1 effusion left knee. Capillary refill, light touch, compartments-are $oft. Opposite leg is nontender. Skin: Intact. Capillary Refill: Normal. Upper extremities are nontender. Spine` `Nontender. Pelvis: Nontender. Radiographs of the left knee showed the tibial spine fracture nondisplaced. Date/Time Printed: 2/28/2011 04:32 EST Printed By: Tice,Cindy L plc/ Page 1 of 33 PENNSTATE HERSHEY F Milton S. Hershey IV Medical Center Patient Name: SHIRK, NEIL F MRN 7508612 ASSESSMENT: Tibial spine fracture, left knee. PLAN: Long leg cast in extension for 6 weeks. Weight bear as tolerated. Serial exams for other injuries. Anti-inflammatories, oral pain medicines as needed. We will see the patient back in approximately 10 days in a clinic for recheck, height, weight, physical exam, and no sports for about 3 months. 366084 Electronic Signature on File Electronically Reviewed/Signed by: William L Hennrikus, MD Author Signature Dt/Tm:08.11.2010 04:18 PM WLH/SMG DD: 11103110 DT: 11/05/1015:33 i l Date/Time Printed: 2/28/2011 04:32 EST Printed By: Tice,Cindy L Page 2 of 33 CA--- ,z7 ?( PENNSTATE HERSHEY Milton S. Hershey W Medical Center Penn State Hershey Tel: (717) 531-8055 Milton S. Hershey Medical Center Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: SHIRK, NEIL F Visit Number: 15453424 MRN: 7508612 Date of Birth: 4/19/2002 Visit Type: Clinic Patient Location: HD10 Patient Gender: Male Outpatient Note RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: Final Hennrikus,William L (2/11/2011 19:33 EST) OUTPATIENT NOTE Name: SHIRK, NEIL F HMC Number: 7508612 DOB: 04/19/2002 Date of Service: 02/07/2011 Age, 8. Follow up 8-year-old, tibial spine injury left knee here for recheck. Patient was injured 11/3. No complaints. He is back to normal activities, working on the farm and doing normal work around the house. He is here with his dad. The patient has an allergy to penicillin and sulfa, gets a rash. He is a third grader, private school in Amish Country. He has had prior chickenpox. No heart disease, fever, diabetes, weight loss. Dad is 55, healthy. Mom is 65, healthy. EXAM: Vital signs stable, 54-3/4 inches, 67 pounds. Knee motion 0 to 135. Cruciate stable. Collateral ligaments stable. No effusion. Meniscal signs negative. He can toe walk, heel walk, hop, and jump without difficulty. Leg lengths are equal. Spine is straight. Abdomen is soft. Upper extremities supple. Carrying angle 8 degrees. Grasp, release, light touch, pulse normal Fluoro imaging of the left knee shows a well-healed underlying tibial eminence fracture. ASSESSMENT: Healed tibial eminence fracture left knee. PLAN: Activities as tolerated. We have braced his quadriceps circumference today. It is approkfn`.afely 1.5!Crfl,s.maller. Continued farm work, biking, sports activity. Follow up p.r.n. or as-needed p.r.n. basis. 44223 ` Electronic Signature on File Electronically Reviewed/Signed by: William L Hennrikus, MD Author Signature Dt Tm:11.02.20 i 1 07:33 PM WLH /CO DD: 02107111 DT 0210811103:53 Date/Time Printed: 2/28/2011 04:31 EST Page 1 of 1 Printed By: Tice,Cindy L / f " / { - 1 st Statement PENNSTATE Pa e 1 of 2 Milton S. Hershey Medical Center PO Box 643291 Thank you for allowing Penn State Milton S. Hershey Pittsburgh, PA 15264-3291 Medical Center to provide you with services. Please note we have no insurance information recorded to bill for these services. If this is incorrect, please contact our office with the information; otherwise we look forward to receiving your payment in full. IVAN SHIRK 1v01941 RITNER HWY 2033 SHIPPENSBURG PA 17257-9554 liiilllirilirlililrlrliiillrlirrlrlrililiilrilritliiillililiil , Patient Name SHIRK NEIL F Statement Date 02/17/11 Service Date(s) 02/07/11 Type of Service OUTPATIENT Account Number 15453424 New Charges/Adj $ 0.00 New Payments/Adj $ 0.00 Account Balance $ 72.00 Amount Pending Insurance $ 0.00 Amount You Owe $ 72.00 This new statement has been specially designed with you in mind. Let us know what other improvements we should make. Please e-mail your ideas to: Statementideas 5nhmc psu edu or write to us at: Penn State Milton S. Hershey Medical Center Statement Ideas, PO Box 854, MC A410 Hershey, PA 17033 C=ffaw DATE DESCRIPTION AMOUNT 02/07/11 REH OLITPT VISIT EST 72.00 TOTAL 72.00 r •-r // Y / P i V &12 3,1T drAMi For billing questions or insurance changes- Para preguntas acerca de su factura o cambios de seguro contamos con representantes disponibles para asistir a la comunidad hispana. Phone: (717) 531-5069 or (800) 254-2619 Available Hours: Monday, Tuesday & Wednesday 8:00 am to 5:30 pm Thursday & Friday 8:00 am to 4:30 pm Written Correspondence: Penn State Milton S. Hershey Medical Center Patient Financial Services Department PO Box 854, MC A410 Hershey, PA 17033-0854 Please Note: Your physicians will bill separately for their professional services. HERSHEYST-01 ........................................................... 4(A' 'FNNSTATE Ifie College Nfedicirie?c? tenter IVAN Z SHIRK 2033 RITNER HWY SHIPPENSBURG PA 17257-9554 ACCOUNT # 7508612 IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES DATE F}R+pCE6VRE 1)tAG QTY DESCRNPTION COR>: £4Df PATIENTv NEIL F SHIRK 7508612 STATEMENT DATE: 02118111 LAST STATEMENT DATE: 12/11110 FED TAX ID # 25185703E INS CHARGE PAYMt4tI GUARAKTOI ADJUS7AAENT BALAk - » 15453424 PERFORMED BY: WILLIAM L HENNRIKUS MD ORTHOPAEDICS DIVISION PLACE OF SVC; OP PHYSICIAN 123.D0 123.00 IE 02/D7/11 99213 V54.16 OUTPATIENT VISIT EST BALANCE: NEIL F SNTAK $123.00 I * INDICATES NEW FINANCIAL ACTIVITY SINCE LAST BILL. PAYMENTS OF 5839.52 APPLIED TO YOUR CHARGES NOT INCLUDED ON THIS BILL. IF YOU HAVE ANY QUESTIONS ABOUT THE AIO.NT YOUR INSURANCE COMPANY PAID, CONTACT THEM DIRECTLY. FOR ANY OTHER QUESTIONS REGARDING YOUR BALANCE, PLEASE CONTACT OUR OFFICE. IF PAYMENT HAS BEEN MADE, THANK YOU AND DISREGARD THIS BILL. PLEASE NOTE: TO KEEP YOUR ACCOUNT CURRENT, OUR POLICY IS TO APPLY YOUR PAYMENT TO THE OLDEST OUTSTANDING BALANCE. ` THANK YOU FOR USING MSHMC PHYSICIANS GROUP FOR YOUR THIS PHYSICI E1 SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING CONTACT US AT 717-531-5069 OR 80D-Z%-2619, BETWEEN BOOM AND 5:3DPM MONDAY THROUGH WEDNESDAY OR BETWEEN 8:DRAM AND 4:3DPM THURSDAY AND FRIDAY. <- ' / B TOTAL CY ? "BALANCE SUMMARY RESPONSIBLE PARTY POLI $ 123.00 to jeep GUARANTOR RESPONSIBILITY IMPORTANT: PLEASE DETACH AND RETURN BOTTOM PORT(ON Of STATEMENT WlTN YntlR PavMFNT C/1 ° N Cl) T N O C\l ° LO N T ?' rn N m p T T Z W a? a? O :..) Z O7 W 111 W 0 W O Ir- d. O U W Z r O ?W CO WZ Lil 0 O °O ZZ J ]?Ul 3: E (.0 w?=°° z I(f)r m A? W ca n. LO N U- f-- O T Z = na- mm 2) YQWn cc: LL Z -0 EE Lu Cf) M J~? Qom. uJ o :c ZUcvcn O O O O U) In O N N O T O r ? p 0 LO N O N O ? 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DESCRIPTION OF CHARGE QUANTITY UNIT PRICE` AMOUNT ALS EMERGENCY LEVEL 1 A0999 1.0 967.62 967.62 20GTT TUBING A0394 1.0 14.72 14.72 ANGIOCATH (14-24) A0394 1.0 6.72 6.72 EXTENSION SET 8" NEEDLELESS A0394 1.0 12.52 12.52 INF CONTROL GLOVES (PR) A0382 1.0 1.00 1.00 NSS 0.9% 1000cc Bag A0394 1.0 3.48 3.48 OP SITE A0394 1.0 1.92 1.92 SALINE PREFILLED SYRINGE A0394 1.0 2.56 2.56 Total C arges 1010.5 Ji DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMO Total Credits 0.00 PLEASE PAY THIS AMOUNT- INVOICE DUE UPON RECEIPT -4- $1010 54 RETURNED CHECK FEE - $31.00 . PATIENT NAME:: - SHIRK, NEIL F CALL NUMBER: 102012$ AMOUNT PAID: 11I11%204G IMPORTANT MESSAGES: THIS INVOICE IS YOUR RESPONSIBILITY. Please forward this itemized statement to your Ins Carrier and MAKE PAYMENT D g+ r DIRECTLY TO US. Please include Invoice Numbers on your check. /oUT WEST SHORE EMS - CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011 ?'- I ?i D cl? W h7 Cn z ?y d r? O >0N) W 0 cn cmn cn c D m ? vo D mfg v co C) N C N m 1 -A m 0 PRESORTED FIRST CLASS I`r c = L F L _ i F ?. C ilasler E. o ?Q 1 N 00 C a, -4 v p CJJ o CO cc V m STATEMENT OF PHYSICIAN SERVICES 'I o (VAN Z SHIRK VNSTATE 2033 RITNER HWY 'fhe Milton S. Hershey Medical Center SHIPPENSBURG PA 77257-9554 = 11111110 ' ® The College of Medicine EMENT > f 141 ACCOUNT # 7508612' = 11!06110 FINANCIAL SERVICES [ IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT 1 I; TAx ID 4 251857035 11tV NINT1 GUAP-ANTG( : pROC- EWRE ., ,t tAG Qr•{ iZESCR1pfIdN INS CHARGE: AP , .STMENT BALANCE )ATE COUEF= CODE > PATIENT: NEIL f SHIRK 7508 612 10508612 11102110 TO 11/03/10 PERFORMED BY: MARY C SANTOS MD DIV PEDIATRIC SURcIRr PLACE OF SVC: EMERGENCY ROOM 4524 DO 11102/10 44221 954.8 . E ? T ?E 0.[I0 4524.00 PAID BENEFITS I MAX 12/01/10 PERFORMED BY: KRISHNAMOOR THAMBURAJ MO DIV OF DIZ RADIOLV PLACE OF SVC: INPATIENT 507 00 11/02/10 7212826 459.8 . SPINE IC CT THORAC 0.00 PAYMENT AIJTO 11/30/1D 11/02110 7048626 954.09 CT MAXILLOFACIAL UNENH 4'.8.00 1911,00- 0.00 WC OR AUTO PAYMENT 11130/1D 11/02/10 7212526 959.8 SPINE UNENHAN 5[17.00 CERVICAL !;Ot•0o- 0.00 ,O PAYMENT 11/30/10 11/02/10 7045026 959.01 3':73.00! LNENHANCED CEO Cw :575.00- 0.00 R AUTO PAYMENT C 11/30/10 11/02/10 7213126 959.8 CTL.U' R SPINE NENHANCE 507. 011 1.31.00- 376.00 PAYMENT 11130/1D PERFORMED BY: DANIELLE K GOAL MD DIV OF DIAG 110IOLOGY 11!02/10 n26026 959.19 00 H 543 • CT ?? 0'00 12/01/10 BENEFITS PAID M !i? 3.00- 0.00 HKC OR AUTO PAYMEN 12/02/10 11/00110 7356026.117 793.7 77.0 ? U 77.00- 0.00 A T'0 PAYMENT W 11/30/10 11/02/10 7101026 954.19 8D„0[? CHEST N E 1 O.DD ¢ 12/01/10 EFITS PAID E IMl k1 B 30.D- 0.00 12/02/10 NCC OR AUTO PAYMEN 11/02/ID 7416026 959.19 C T ABDOMEN ENHANCED 559.011 0.00 * 12/01/10 MAXIMUM BENEFITS PAID 559.00- 0.00 12/02!10 WC OR AUTO PAYMEN PERFORMED. BY: SOSAMMA T METHRATTA MD DIV OF DIAL RADIOLO'Y 11/02/10 7356026.RT 459.7 KNEE LIMITED 77. 0.00 77.00 MAXIMUM BENEFITS PAID * 12/01/10 PERFORMED BY: DANIELLE K BOAL MD DIV OF DIAL RADTDL.OG' 11/DZ/10 7219326 954.19 CT PELVIS ENHANCED 0.00 12/01110 MAXIMLRI BENEFITS PAID !;07.00- O.DO 12102/10 NCC OR AUTO PAYMEN ? CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON?BA,`X gNSTATE The Milton S. Hershey Medical Center vo The College of Medicine 'VAN Z SHIRK 2033 RITNER HWY - -- _.; rI hi ENT SHIPPENSBURG PA 97257-9554 v,vE: {;Z111I10 LA';r S1ATEM9ENT ACCOUNT # 7508692 DVE. 1106110 2 r.:: ?_ FED TAX ID # 259 857035 IF ANY QUESTIONS, PtFnsE CONTACT: MSHMC PATIENT FINANCIAL SERVICES PAYMENT1 GUARANTOR PROCEDURE ; :DIAL QTY DESC:RIPTION INS C-IARGE, ADJUSTNIENT BALANCE ATE_ CODE -CODE PERFORMED BY: GLENN K GEETING MO DIV OF EMERG ROOM PLACE OF SVC: EMERGENCY ROOM 714.00 1/02/10 99291 959.8 CRITICAL CARE FIRST HR 0.00 2/01/10 MAXIMUM BENEFITS PAID 714,00_ 0.00 2/02/10 WC OR AUTO PAYMEN 1/02/10 1/2/01/10 12/02/10 PERFORMED BY: HIROKO SHIKE MD DIV CLINICAL PATHOLO(Y PLACE OF SVC: INPATIENT 130.00 85060.GC 288.60 PERIPH BLOOD SMEAR 0.00 MAXIMUM BENEFITS PAID 130.00- 0.00 WC OR AUTO PAYMEN 11/02/10 99242 11/30/10 12/01/10 PERFORMED BY: PADMANI X DHAR MD DIV OF ANESTHESIA PLACE OF SVC: EMERGENCY ROOM 172;.QD gS9.8 OFFICE/ER CONSULT-PROF CO 137.60- WKC OR AUTO PAYMEN 0.00 34.40 MAXIMUM BENEFITS PAID PERFORMED BY, MARY C SANTOS MD DIV PEDIATRIC SURGERY 11/03/10 99238 959.8 11/30/10 11/03/10 27530.LT 823.00 12/01/10 11/10/10 99024 V54.16 PLACE OF SVC: INPATIENT 202.00 HOSP DISC DAY LESS 30 MIN 202.00 O AD WKC OR AUTO PAYMENT PERFORMED BY: WILLIAM L HENNRIKUS MO ORTHOPAEDICS DIVISION FX TIBIA POOL SMP WO RE 2211.00 MAXIMUM BENEFITS PAID 0.00 2211.00 15199085 PERFORMED BY: WILLIAM L HENNRIKUS MD ORTHOPAEDICS DIVISION PLACE OF SVC: OP PHYSICIAN O.DO 0.00 POST-OP FOL-UP VISIT 15217673 PERFORMED BY: MICHAEL M MOORE MD DIV OF DIAG RADIOLOGY PLACE OF SK : OP HOSPITAL 77.00 77.00 11/10/10 7356026 719.06 KNEE LIMITED 47249.40 BALANCE: NEIL F SHIRK E INDICATES NEW FINANCIAL ACTIVITY SINCE LAST BILL. *D1* WE HAVE NOT RECEIVED YOUR PAYMENT IN FULL. YOUR ACCOUNT IS PAST DUE. PLEASE SEND PAYMENT IMMEDIATELY. IF PAYMENT HAS BEEN MADE, THANK YOU AND DISREGARD THIS BILL. PLEASE NOTE: TO KEEP YOUR ACCOUNT CURRENT, OUR POLICY IS TO APPLY YOUR PAYMENT TO THE OLDEST OUTSTANDING BALANCE. CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK r L. STATEMENT OF PHYSICIAN SERVICES IVAN Z SHIRK NNSWE 2033 RITNER HWY The Milton S. Hershey Medical Center SHIPPENSBURG PA 17257-9554 ® The College of Medicine 7 x rrnl 1UT ff 7508612 =E cn ?^ i9 STATEMENT ' WiT E: 1211110 LAST STATEMENT D J E: 11(06110 FED TAX ID # 251857035 L SERVICES CHARGE PAYMENT] GUARANTOR IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL ADJUSTMENT BAl.,4t?CE )ATE Ptiocti?URE_ RiAG QTY DESCRIOTION I CODE CODE THANK YOU FOR USING MSHMC PHYSMS REGARDING THIS PH5ILLY YSICPLEASE SERVICES. IF YOU HAVE ANY QUESTIONS CONTACT US AT 717-531-5069 OR 800-254-2619, BETWEEN 8:00AM AND 5:30PM MONDAY THROUGH WEDNESDAY OR BETWEEN 8:ODAM AND 4:30PM THURSDAY AND FRIDAY. PIAKT eu..JF-MW .-- -*** GUARANTOR RESPONSIBILITY $ 7299.40 0 Vo p? ? 83952 5 - -- -_ IMPpRTItNTc PLEASE OETACH_AND RETURN BOTTOM PORTION OF STA7Ek?ENT WITH YOUR To: ADDRESS SERVICE REQUESTED g l ? ) 0 5 o4? •J?.?ljwt'f ? fG?i 1i,,ltlntt,ittil?,i?,tttttill?ttl?t,ltjtlt?i,t>>ii?1r1111ti1t?. ?-g- 1 st Statement PENNSTATE Pa e 1 of 3 Milton S. Hershey to Medical Center PO Box If you have any questions regarding this bill please 643291 Pittsburgh, PA 15264-3291 contact our office. If not, we look forward to receiving your payment in full. IVAN SHIRK 2V00001 2033 RITNER HWY SHIPPENSBURG PA 17257-9554 SHIRK NEIL F Patient Name 12/16/10 Statement Date Service Date(s) 11/02/10 - 11103/10 Type of Service INPATIENT Account Number 10508612 New Charges/Adj $ 0.00 New Payments/Adj $ 0.00 Account Balance $ 25,235.25 Amount Pending Insurance $ 0.00 Amount You Owe - $ 25,235.25 This new statement has been specially designed with you in mind. Let us know what other improvements we should make. Please e-mail your ideas to: or write to us at. Penn State Milton S. Hershey ica C, Statement Ideas, PO Box 854, MC A410 Hershey, PA 17033 AMOUNT DATE DESCRIPTION 11102/10 7 PEDS PRIVATE 20880.00 11/02110 ABO BLOOD GROUP 0.00 11/02/10 ANTIBODY SCREEN 99,00 11/02110 AMYLASE, BLOOD 63.00 11102/10 GLUCOSE, BLOOD 20,00 65.00 11/02/10 LIPASE 22.00 11/02/10 SGPT (ALT) 42.00 11/02/10 ELECTROLYTES Continued on next page... r:billing:questions;or insurance:changes: Para preguntas acerca de su factura o cambios de seguro contamos con representantes disponibles para asistir a la comunidad hispana. Phone: (717) 531-5069 or (800) 254-2619 Available Hours: MondaayY & Friday 00 amstoa4 30 pm to 5:30 pm Written Correspondence: Penn State Milton S. Hershey Medical Center Patient Financial Services Department PO Box 854, MC A410 Hershey, PA 17033-0854 HERSHEYST-01 Please Note: Your physicians will bill separately for their professional services. C-9 Page 2 of 3 4mm 11M "a- Amount Date Description CBC W/PLT/DIFF AUTO 68.00 11102/10 RINALYSIS-BASIC & MICROS 55.00 11102/10 U DANSETRON 2MG/ML 2ML 3.00 11/02/10 ON 171.00 11/02/10 CHEST 1 VIEW 200.00 11/02/10 KNEE 1-2 VIEWS LEFT 1079.00 11/02/10 CT HEAD UNENHANCED 2239.00 11/02/10 CT THORAX ENHANCED 1544.00 11/02110 CT ABDOMEN ENHANCED SINUS MAXILLOFAC UNENH 1377.00 11/02/10 CT CT C-SPINE UNENHANCED 1197.00 11/02/10 CT T-SPINE UNENHANCED 1115:00 11/02/10 CT L-SPINE UNENHANCED 1126.00 11/02/10 CT PELVIS ENHANCED 1756.00 11/02110 ULSE OXIMETER SNSR NEO 48.00 11/02/10 P AMBUBAG PED W/MASK 90.00 11/02/10 11102i10 IV 5`/.DEX 0.9%NACL 500ML 4.00 67.00 11/02/10 IMMOBILIZER, KNEE FOAM 134.00 11102110 COLLAR ASPEN CERV CHLD 50.00 11/02/10 RH TYPE ROUTINE VENIPUNCTURE 23.00 11/02110 THERA/DIAG INJECTION 150.00 11/02/10 ONINVAS PULSE OX, MULTI 136.00 11/02/10 N EMERGENCY VISIT, LEVEL 846.00 11/02110 KNEE 1-2 VIEWS RIGHT 20 0.00 0.0 11/02/10 MNIPAQUE 300MG/ML 1000C 7 0 11/02/10 O NKAUER SUCT W10 VENT 1.00 11/02110 YA ANKAUER SUCT TB W/O VENG 1.00 11102/10 Y 238.00 11/02/10 MRSA BY PCR EDS LEVEL II TRAUMA CARE 8185.00 11/02/10 P CBC W/PLT/DIFF AUTO 68.00 11/03/10 11.25 11/03/10 BACITRACIN 15 IV 5%DEX 0.9%NACL 1000ML 3.00 11/03/10 GAIT TRAINING 15 MIN 76.00 11/03/10 THERAPEUTIC ACTIV 15 MIN 76.00 11/03/10 NITIAL EVALUATION-PT 228.00 11103/10 P I . As a courtesy to our patients, Penn State Milton S. Hershey Medical Center submits billable charges to insurance companies. Generally, payment is expected in full upon receipt o your statement. If you are experiencing difficulty in understanding the bills or making payments, we are pleased to offer individual services from our Financial Counselors. Our team is Building, 2nd floor, with you personally in the Academic Support Suite 2106 (on campus just east of the Tumain esday hospital and University Physicians Center) M fndsda & Friday 8:00 am- Wednesday, 8:00 am 5:30 pm, Y 4:30 prn. . Our Financial Counselors na budg t plan or'financial you qualify for a special program, consideration. Continued on next page . . Department of Public Welfare 1-800-692-7462 . Children's Health Insurance Program (CHIP) 1- 800-543-7101 (uninsured children and adolescents under age 19) . AdultBasic Program 1-800-462-2742 (Uninsured adults between. the ages of 19 and 64} M ` By Mail: Please remit payment by check, money order or credit card in the envelope provide is can be made over the By Telephone: Credit card pay telephone by contacting our office at (717) 531-5069 or (600) 254-2619. the Academ c Support credit card at our office nd money orrder or Person: Building. ?O Patient Name: SHIRK NEIL F Account Number: 10508612 Page 3 of 3 Activity Continued Amount Date Description Amount Date Description 12/01/10 AUTOMORK COMP PAYMENT 0.00 TOTAL 25235.25 HERSHEYST04 Q w g ¢ co a a U U w a a. _ N y G. cr U d i_ \ V I!1 N !L (A ?E W G1)- St Statement Paelof2 INSTATE !ton S. HeTSheS' eliM dical Cter pp BoX 64 PA 15261-3291 p?ttsbur9h, 1 S Hershey 41 State tigilton please note s. e allowing Pet'n servic ill ou for vide you with ed to b for Thank y record our otfice Medical Center to Pro information lease contact .e n o insurance incorrect, p and to wee haV If this is we lock forty , otherwise services ation these full. with the inform ent In receiving your Palm 1V01038 2033 REN BURG PA 17257-9554 SHIPP Ilili?tlilrililr?liil?ill1rrlliltlril SHIRK NEIL F 11!15110 patient Name 11110110 Statement Date ouTPATIENT Service Date(s) 15217673 Type of Service $ 0.00 ber p.00 Accoun $ t Nue IAdI New Char9 $ 200p0 New I aymentslAdl p.00 Account Balance 200,00 ending insurance Amount P You owe Al-nount esigned s been specially (new ha at other This new in d• Let us know wh with you in m m Improvements we should aye. our ideas to: Please e"mall y a me su.edu tementideas ° h dical Center 1 AMOUNT pesCRIPTtON 200.00 ` DATE 200 00 ZKNEE 1-2V1r-- LEF F 11110110 TOTAL ?60'00 2 0 1/0 7r ?l c11at1`?es' os con r2nGe de $egur0 es contain ti LlS;or tov" bios a 11in tl?1 factura o cam urudad hispan ' acerca de su ara asistir a la coin rn Para preguntas onibles p 254.2619 am to 5:30 p 8:00 tantes disp 800) & Wednesday represen 111) 531-5069 or ( Wednesday Pm phone: ( lvionday,Tuesday 8:00 am to A,Vailable Hours: $z Friday Thursday Medical Center Corresp0°den lton S • 1lershey Written pennState M ices Department patient Financlal Se410 Pp gox 854, MCN-0954 Hershey> FA 1033 Sta or w A410 i viceS r+eRSr+EY rite to us at: Hershey MeC Penn State Milton S• gox 854,M feSSiolla? se " Statement Ideas, Po or tlteiY pro epartitely .. 17033 Hershey, PA bill S ur l?ysiccails will .. please Note. . ....... . Y0 F 1A Tr1 -,E Q Q \Q? v Q 1 'Tt n r D N i? its c -o ? m C7 n n O5 O v o n A N c) o m n ?n ?f 1 St Statement PENNSTATE Milton S. Hershey Pa e 1 of 2 10 Medical Center Thank you for allowing Penn State Milton S. Hershey PO Box 643291 Pittsburgh, PA 15264-3291 Medical Center to provide you with services. Please note we have no insurance information recorded to bill for these services. If this is incorrect, please contact our office with the information; otherwise we look forward to receiving your payment in full. IVAN SHIRK 1VOO25s 2033 RITNER HWY SHIPPENSBURG PA 17257-9554 I???III???I??I?I?i?l?l???ll?l???l?I??I?I??I??I??II???II?I?I??I Patient Name SHIRK NEIL F DATE DESCRIPTION AMOUNT Statement Date 12/18/10 12/13/10 REH OUTPT VISIT EST 72.00 12/13/10 Service Date(s) TOTAL 72.00 Type of Service OUTPATIENT Account Number 1521.9445 /J ? ? n l/ New Charges/Adj $ 0.00 00 0 /' J ,? f ? c 1 . New Payments/Adj $ Account Balance $ 72.00 Amount Pending Insurance $ 0.00 / O 5 7?' U Amount You Owe $ 72.00 I This new statement has been specially designed For billing questions or insurance changes: with you in mind. Let us know what other Para preguntas acerca de su factura o cambios de seguro contamos con representantes disponibles para asistir a la comunidad hispana. improvements we should make. Phone: (717) 531-5069 or (800) 254-2619 Please e-mail your ideas to: Available Hours: Monday, Tuesday & Wednesday 8:00 am to 5:30 pm Statementideas(a)hmc. sp u.edu Thursday & Friday 8:00 am to 4:30 pm or write to us at: Written Correspondence: Penn State Milton S. Hershey Medical Center Penn State Milton S. Hershey Medical Center Patient Financial Services Department Statement Ideas, PO Box 854, MC A410 PO Box 854, MC A410 Hershey, PA 17033 Hershey, PA 17033-0854 Please Note: Your physicians will bill separately for their professional services. HERSHEYST-01 ........................................................................................................................................................................... ?? .T c?a+o.,,a.,+ nata . ?J4.Rl? f1 _ PalIont`t, ame" . count NuMn ei ?. h; C?? ??' . (I? i J _ Q w 4? 2 ? O U J in cZ S U w n. rc U) to LL S LL C/) N O o H LL S Q C?1 1 k r Ul M r LL N .:r W G( Statement of'Hospifal Services p>?NIVSTaTE 1 st Statement XM Milton S. Hershey Pa e 1 of 2 Medical Center PO Box 643291 Thank you for allowing Penn State Milton S. Hershey Pittsburgh, PA 15264-3291 Medical Center to provide you with services. Please note we have no insurance information recorded to bill for these services. If this is incorrect, please contact our office with the information; otherwise we look forward to receiving your payment in full. IVAN SHIRK 1VO1037 2033 RITNER HWY SHIPPENSBURG PA 17257-9554 ?Illll?llllll?illlllllllllllllillllll?llllllilllllllllllllllll Patient Name SHIRK NEIL F DATE DESCRIPTION AMOUNT Statement Date 11/15/10 1 1/10%10 11/10110 REH OUTPT VISIT EST 72.00 Service Date(s) TOTAL 72.00 Type of Service OUTPATIENT Account Number 15199085 C_ /l New Charges/Adj $ 0.00 /? r New Payments/Adj $ 0.00 Account Balance $ 72.00 _ Amount Pending Insurance $ 0.00 D f f (? Amount You Owe $72.00 f V This new statement has been specially designed 'Font illiTtc,,,,gttestions or instrrance..ctim ges: with you in mind. Let us know what other Para preguntas acerca de su factura o cambios de seguro contamos con improvements we should make. representantes disponibles para asistir a la comunidad hispana. Phone: (717) 531-5069 or (800) 254-2619 Please e-mail your ideas to: Available Hours: Monday, Tuesday & Wednesday 8:00 am to 5:30 pm State mentideas(g?hmc.psu.edu Thursday & Friday 8:00 am to 4:30 pm or write to us at: Written Correspondence: Penn State Milton S. Hershey Medical Center Penn State Milton S. Hershey Medical Center Statement Ideas, PO Box 854, MC A410 Patient Financial Services Department Hershey, PA 17033 PO Box 854, MC A410 Hershey, PA 17033-0854 Please Note: Your physicians will bill separately for their professional services. HERSHEYST-01 ............................................................................................ 67 J Q O W g ? p a O C, Q U_ U w o- d r ¢ C/) d LL V? a A J U ? F= O ? x 1 r•- -r+ i^ w a7 FK F PENNSTATE PM Milton S. Hershey Medical Center Po Box 643291 Pittsburgh, PA 15264-3291 1 st Statement Pane 1 of 2 IVAN SHIRK 1V01326 2033 RITNER HWY SHIPPENSBURG PA 17257-9554 IIIIII1111111111111111111I1I ZEN= Patient Name SHIRK NEIL F 12/23/10 Statement Date 11/02/10 Service Date(s) OUTPATIENT Type of Service 15221054 Account iJurnber $ 0.00 New Charges/Adj _$0 00 New Payments/Adj $ 17,119_00 Account Balance $ 0.00 Amount Pending Insurance 17 719.00 Amount You Owe This new statement has been specially designed with you in mind. Let us know what other improvements we should make. Please e-mail your ideas to: Statementideas(a)hmc_as u_.edu or write to us at: Penn State Milton S. Hershey Medical Center Statement Ideas, PO Box 854, MC A410 Hershey, PA 17033 We have billed your insurance company for these services. Your insurance company has notified us of their refusal to pay this claim and may have communicated with you directly about the reason why. Under the circumstances we have no alternative but to request payment from you. Please send your payment for the full amount. Any questions concerning the insurance company's rejection of this claim should be submitted to them directly. AMOUNT DATE DESCRIPTION AIR AMBULANCE TRANSPORT 11839.00 11/02/10 AIR AMBULANCE MILEAGE 5880.00 11/02/10 AUTO/WORK COMP PAYMENT 0.00 12/01110 17719 00 TOTAL Fortirlling;questions orinsuraiice-changes: Para preguntas acerca de su factura o cambios de seguro contamos con representantes disponibles para asistir a la comunidad hispana. Phone- (717) 531-5069 or (800) 254-2619 Available Hours: Monday, Tuesday Wednam to esday 4:30 0 am to 5:30 pm Thursday Written Correspondence: Penn State Milton S. Hershey Medical Center Patient Financial Services Department PO Box 854, MC A410 Hershey, PA 17033-0854 HERSHEYST-01 sicians will bill separately for their professional services. Please Note: Your phy 6 Q CCC??? O W cn cc a U U w a d H 6 N N ? Q tL ?/w. Y I ^ Cl) F= ?C Ln r L. ?n u. STATEMENT OF PHYSICIAN SERVICES ENNSTATE IVAN Z SHIRK 2033 RITNER HWY The Milton S. Hershey Medical Center SHIPPENSBURG PA 17257-8554 The College of Medicine 2/15110 S1 kTEMENT ACCOUNT ## 7508612 X111 d IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES :E TAX ID ## 251857035 PRQq3 i. i DATE CODE DIAG QTY DESCRIPTION CODE ,-,- INS' CHARGE r', YNIENT[ ,D 115'T11AE NT GUARANTON BALANCE >>> PATIENT: NEIL F SHIRK 7508612 10508612 PERFORMED BY: MARY C SANTOS MD DIV PEDIATRIC SURGERY PLACE OF SVC: EMERGENCY ROOM 11102/10 99221 959.8 TRAUMA TEAM DIAL EVAL INT 4524. 'CI 12101110 MAXIMUM BENEFITS PAID 0,[10 4524.07 PERFORMED BY: KRISHNAMDOR THAMBURAJ MO DIV OF DIAL RADIA.I PLACE OF SVC: INPATIENT 11102/10 7212826 959.8 CT THORACIC SPINE UNENHAN 507.1113 11/30/10 WC OR AUTO PAYMENT 5037,00- 0.03 11/02/10 7048626 959.09 CT MAXILLOFACIAL UNENH 498.01 11/30/10 WC OR AUTO PAYMENT 018.00- 0.00 11/02/10 7212526 959.8 CT CERVICAL SPINE UNENHAN 507.E11 11/30/10 WC OR AUTO PAYMENT 501.00- 0.00 11102/10 7045026 959.01 CT HEAD UNENHANCED 373.01 11130/10 WC OR AUTO PAYMENT 373.00- 0.00 11102/10 7213126 959.8 CT LUMBAR SPINE UNENHANCE 507,fu0 11/30/10 WC OR AUTO PAYMENT 131.110- 376.00 PERFORMED BY: DANIELLE K. BOAL MO DIV OF DI AL RADIOLOGY 11102/10 7126026 959.19 CT THORAX W/CONTRAST ENH 543.DiO 12/01/10 MAXIMUM BENEFITS PAID 0.110 12/02/10 WC OR AUTO PAYMEN 543.00- 0.00 11/02/10 7356026.LT 793.7 KNEE LIMITED 77.40 11/30/10 WC OR AUTO PAYMENT 71'.00- 0.00 11/02/10 7101026 959,19 CHEST I VIEW 80.W 12/01/10 MAXIMUM BENEFITS PAID [).Do 12/02/10 WC OR AUTO PAYMEN SO. Do- 0.00 11/02/10 7416026 959.19 C T ABDOMEN ENHANCED 559.40 12101110 MAXIMUM BENEFITS PAID 11.00 12/02/10 WC OR AUTO PAYMEN 559. Do- 0.00 PERFORMED BY: SOSAMMA T METHRATTA MD DIV OF DIAG RADIOLOGf 11/02/10 7356026.RT 959.7 KNEE LIMITED 77A 12/01/10 MAXIMUM BENEFITS PAID 0. OD 77.00 PERFORMED BY: DANIELLE K GOAL MO DIV OF DI AL RADIOLOGY 11/OZ/10 7219326 959.19 CT PELVIS ENHANCED 507.130 12/01/10 MAXIMUM BENEFITS PAID 0.00 12102110 WC OR AUTO PAYMEN 5071.00- D.DD Wises. CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON Fk:.H: "7 / ENNSTATE 2AT'Z-7,4ENT OF PHYSICIAN SERVICES The Milton S. Hershey Medical Center The College of Medicine 4VAN Z SHIRK 2033 RITNER HWY SHIPPENSBURG PA 17257-9554 IF ANY QUESTIONS, POSE CONTACT: MSHMC PATIENT FINANCIAL SERVICES UAT?;. PROCEDURE DIAL QTY E-SCRIPTIQN INS CttEk?i,E. ODD COE F PERFORMED BY: GLENN K GEETING MD DIV OF EMERG ROOM PLACE, OF SVC: EMERGENCY ROOM 11/02/10 99291 959.8 CRITICAL CARE FIRST HR l?•D0 12/01/10 MAXIMUM BENEFITS PAID 12/02/10 WC OR AUTO PAYMEN l - ii'J - NT J15110 lfTEMENT '2J11110 E::) 1 AX ID 4 251857035 4'vMENTI GUARANTOR! ?,001A.TIMENT BALANCE C. ID 714.00- 0.00 PERFORMED BY: HIROKO SHIKE MO DIV CLINICAL PATHOLOGY PLACE OF SVC: INPATIENT 11/02/10 8506D.GC 288.60 PERIPH BLOOD SMEAR 00 12/01110 MAXIMUM BENEFITS PAID (1.00 12/02/10 WKC OR AUTO PAYMEN 130.00- 0.00 PERFORMED BY: PADMANI X DHAR MD DIV OF ANESTHESIA PLACE OF SVC: EMERGENCY ROOM 11/02/1D 99242 959.8 OFFICE/ER CONSULT-PROF CO x7:.00 11/30/10 WC OR AUTO PAYMEN 117.50- 12/00/10 MAXIMUM BENEFITS PAID (11. 0D 34.40 PERFORMED BY: MARY C SANTOS MD DIV PEDIATRIC SURGERY PLACE OF SVC: INPATIENT 11/03/10 99238 959.8 HOSP DISC DAY LESS 30 MIN 20!AX 11/30/10 WC OR AUTO PAYMENT 20:.00- 0.00 PERFORMED BY: WILLIAM L HENNRIKUS MD ORTHOPAEDICS DIVISTtIN 2211JX 11/03/10 27530.LT 823.00 FX TIBIA PROXML SMP NO RE 12/01/10 MAXIFIM BENEFITS PAID 0.00 2211.00 15199085 PERFORMED BY: WILLIAM L HENNRIKUS MD ORTHOPAEDICS DIVI![CN PLACE OF SVC: OP PHYSICIAN 11/10/10 99D24 V54.16 POST-OP FOL-UP VISIT D.DtI 0.DO 15217673 PERFORMED BY: MICHAEL M MOORE MD DIV OF DIAG RADIOLOGY PLACE OF SVC: OP HOSPITAL 11/10/10 7356026 719.06 KNEE LIMITED 77,00 77.00 BALANCE: NEIL F SHIRK $7299.40 IF YOU HAVE ANY QUESTIONS ABOUT THE AMOUNT YOUR INSURANCE COMPANY PAID, CONTACT THEM DIRECTLY. FOR ANY OTHER QUESTIONS REGARDING YOUR BALANCE, PLEASE CONTACT OUR OFFICE. IF PAYMENT HAS BEEN MADE, THANK YOU AND DISREGARD THIS BILL. PLS GIVE TO RMF1 THANK YOU FOR USING MSHMC PHYSICIANS GROUP FOR YOUR PHYSICIAN SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL, PLEASE CONTACT US AT 717-531-5069 OR 800-254-2619, BETWEEN 8:0OAM AND 5:3OPM MONDAY THROUGH WEDNESDAY OR BETWEEN 8:00AM AND 4:30PM THURSDAY AND FRIDAY. CHECK BOX AND ENTER AIiYAIDDRZOS O IE`5?@!Jt`??i;E CY;u RRIaC I,0[, `' °s ON --? raeiwwws n 1 STATEMENT OF PHYSICIAN SERVICES :NNSTATE 0333 RITNER HWY 10 The Milton S. Hershey Medical Center SHIPPENSBURG PA 17257-9554 The College of Medicine ACCOUNT # 7508612 `PAC E °9 pfp r I?r .: ?d1 12/15/10 1 `.1 i fl1TEMENI 1;iJ 1111 Q 3 IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES F1 1) fAX ID # 251857035 PROCEDURE DIAG INS ; IiAR? A- I M!MENTL GUARAMR QTY 1)!~SCl?I?'TION?- k:JUaTPAENT BALANCE DATE CODE' CODE BALANCE SUMMARY RESPONSIBLE PARTY POLICY i *** GUARANTDR RESPONSIBILITY -1'249.40 __________`?__?______IMPORT?NT_P?EASEpET?CH AND (tETURN B07TOM PORTION Of STA7EMENT W!'t•H '!;!)I1FC ?;, 8,'''14A h T_ ,__,_,_____________,_________ STATEMENT DATE GUAPJ INTOR Nk 5F:1IISI13ILITY: MINIMUM PAYMENT: BF6 12115110 '11; IT'99.110 $ 7299.40 MSHMC PHYSICIANS GROUP . BILLING SERVICES P O BOX 854 HERSHEY PA 17033-0854 00007508612 UP 01:1001311011011729940121510 111111111111111111111111111111111111a1111111111111110111111111 "air MSHMC PHYSICIANS GROUP IVAN Z SHIRK TO: 2033 RITNER' HWY PO BOX 643313 SHIPPENSBUhi'G PA, 17257-9554 PITTSBURGH PA 15264-3313 FOR CREDIT CARD PAYMENT, PLEASE FILL IN INFORMATION BELOW fF/CE USE ONLY CHECK ONE 1505612 _M/C ({ ( I I I I III I I I (1 1 1 _==?Jfflgllf. __== == CARD NUMBER EXP DATE $ 7299.40 01/05/11 _ -VISA -_-.?- DISC At4==- CARDHOLDER NAME (PRINT) 1:liI?1:?fS1--- IC: 176130 "YP c DMND CREDIT CARD SIGNATURE MSHN1C Pk IYSICEAIrS r CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK o MW Lo I a C7 co ? c? ? Q cv CJ ? CD OJ E .J d co o? v d r r ?a a3lac?s;?aa a Ln N r--1 Q ? CY. x W x?z m Z a, > o .r., to a i t N Cr , tYJ .. LLJ xU ? ° = j cnv?? ?o ? r C [1. G G Z Z w CL tt r' r e F i<: IVAN Z SHIRK ENNSTATE 2033 HITNEr HW r E:NT The Milton S. Hershey Medical Center SHIPPENSBURG PA 17257-9554 ® The College of Medicine 11061i E 5=7711061 V"i ACCOUNT # 7508612 - IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES L' SAX ID # ?-L 5A j PROrEUUFtE 1?jAG INS CHARGE PAYMENTt GUA,RAM" BATE:' QTY QESCRiPTHCIN ADJUSTMENT ULANCE GOI}E° ; CODE »> PATIENT: NEIL F SHIRK 75DB612 10508612 11/02/10 TO 11/03/10 PERFORMED BY: MARY C SANTOS MD DIV PEDIATRIC SURGERY PLACE OF SVC: EMERGENCY ROOM 11/02/10 99221 959.8 TRAUMA TEAM DIAG EVAL INT 4514,001 4524.00 E 11/02/10 7212826 E 11/02/10 7048626 e 11/02/10 7212526 e 11/02/10 7045026 e 11/02/10 7213126 I E 11/02/10 7126026 I e 11/02/10 7356026.LT I * 11/02/10 7101026 11/02/10 7416026 i 11/02/10 7%6026.RT 111/02110 7219326 PERFORMED BY: KRISHNAMOOR THAMBURAJ MD DIV OF DIAL RWIOLD PLACE OF SVC: INPATIENT 959.8 CT THORACIC SPINE UNENHAN 5117. DO .507.00 959.09 CT MAXILLOFACIAL UNENH 4118 498,00 959.8 CT CERVICAL SPINE UNENHAN 507,00 507.00 959.01 CT HEAD UNENHANCED 13. 00 373.00 959.8 CT LUMBAR SPINE UNENHANCE 507.00 507.00 PERFORMED BY: DANIELLE K BOAL MD DIV OF DIAL RADIOLOGY 959.19 CT THORAX W/CONTRAST ENH 543.00 543.00 793.7 KNEE LIMITED 77.00 77.00 959.19 CHEST 1 VIEW 80.00 80.00 959.19 C T ABDOMEN ENHANCED 559.00 559.00 PERFORMED BY: SOSAMMA T METHRATTA MO DIV OF DIAL RADIOLOGY 959.7 KNEE LIMITED 77.00 77.00 PERFORMED BY: DANIELLE K GOAL MD DIV OF DIAG RADIOLOGY 959.19 CT PELVIS ENHANCED 507.00 507.00 PERFORMED BY: MARY C SAM MO DIV PEDIATRIC SURGERY If 11/03/10 99238 959.8 HOSP DISC DAY LESS 30 MIN 202.00 202.00 BALANCE: NEIL F SHIRK $8961.00 * INDICATES NEW FINANCIAL ACTIVITY SINCE LAST BILL. IF YOU HAVE ANY QUESTIONS ABOUT THE AMOUNT YOUR INSURANCE COMPANY PAID, CONTACT THEM DIRECTLY. FOR ANY OTHER QUESTIONS REGARDING YOUR BALANCE, PLEASE CONTACT OUR OFFICE. IF PAYMENT HAS BEEN MADE, THANK YOU AND DISREGARD THIS BILL. PLEASE NOTE: TO KEEP YOUR ACCOW CURRENT, OUR POLICY IS TO APPLY YOUR PAYMENT TO THE OLDEST OUTSTANDING BALANCE. CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS C 4W E Fay: 7 ? --------- --- -- - -- ---- F?C?. C" 'EN??Tf?? IV,AN Z SHIRK ? C 2.333 RITNER 'H', d f _ -- The Milton S. Hershey Medical Center SHIPPENSBUIRG PA 17257-9554 ?' ''r?.s'ENr The College Of Medicine r' hrl= 11106110 LAS1" STATEMENT " FINANCIAL SERVICES FED TAX ID # 25? 85i0a5 t? ?,tsv ????srlc° ?e??r, rLl?;:?E ?:?r,?c???: I FIFr?IC PATIENT PROCEDURE DIAL QTY DESCR1PTIfyN INS, CHARGE DATE PAYNIENTI GUARANTK9F CODE CODE ADJUS"IMENT BALANCE THANK YOU FOR USING MSHMC"PHYSICIANS GROUP FOR YOUR PHYSICIAN SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL, PLEASE CONTACT US AT 717-531-5D69 OR 800-254-2619, BETWEEN 8:00AM AND 5:30PM MONDAY THROUGH WEDNESDAY OR BETWEEN 8:OOAM AND 4:30PH THURSDAY AND FRIDAY. BALANCE SUMMARY RESPONSIBLE PARTY POLICY 9 TOTAL *** GUARANTOR RESPONSIBILITY S 8961.D0 DETACH ANA RETURN BOTTOM PORTION OF STATEMENT WITS( YOUR Phi Y'MEN7 ___________? STATEMENT DATE: GUARANTOR RESPONSIBILITY; MINIMUM PAYMENT BF6 11106110 $ 8961.00 $ 8961.00 MSHMC PHYSICIANS GROUP BILLING SERVICES HERSHEXY PA 17033-0854 00007508612 UP 0000000000896100110610 11 1111111111111111111 11111p 1 111111 111 00000124 Mall MSHMC PHYSICIANS GROUP IVAN Z SHIRK Td- 2033 RITNER HWY PO BOX 643313 SHIPPENSBURG PA PITTSBURGH PA 15264-3313 PFFICE USE ONLY FOR CREDIT CARD PAYMENT, PLEASE FILL IN INFORMATION BELOW CHECK ONE M/SCA CARD NUMBER EXP DATE $ 8961 -DISC CARDHOLDER NAME (PRINT) F660 -' ------------------- - - 02 17257-9554 7508612 11/27/10 CREDIT CARD SIGNATURE I MSHMC PHYSICIANS GROUP CHECK- BOX ;Itlt? ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK __7'H To: ADDRESS SERVICE REQUESTED r -7-7 rClvly,) IHI r- Milton S. Hershey Medical Center The Milton S. Hershey College of Medicine Medical Center AUTHORIZATION FOR RELEASE OF HOSPITAL RECORDS Health Information Services, P.O. Box 850, Hershey, Pennsylvania 17033 Name of Patient / s`1 !P Social Security ??j p 7J O Phone # (7/7) 7747 7Qg F Date*of birth ? / // l2Or7 Medical Record Number THIS AUTHORIZATION WILL NOT BE ACCEPTED UNLESS ALL ITEMS ARE COMPLETED. THE INFORMATION BEING DISCLOSED MAY INCLUDE HIV/AIDS, DRUG/ALCOHOL ABUSE & MENTAL HEALTH DATA. I HE THORIZE HERSHEY MEDICAL CENTEPUUNIVERSITY HOSPITAL TO RELEASE TO OR B. RECEIVE FROM (Circle One) PROGRESSIVE CASUALTY INSURANCE COMPANY (Name of aut bPJ$yAstitution, or other) SUITE 150 CAMP HILI, PA 17011 (Street) (City) (State) (Zip Code) - Reason for Request: rr',' G 1 Y`^ 10-35145-a--171 Type of information to be released consists of: DISCHARGE DATE(S) ?- - (? OUTPATIENT VISIT DATE(S? ?( ?1-tt7•-ltD- i?-?3-tu Discharge Summary (ies) History+ Physical Operative Report Diagnostic Test(s) Indicate Type of Test & Date Other (please specify) - This consent is subject to revocation at any time except to the extent that the person who is to make the disclosure has already taken action in reliance on it. If you wish to revoke this authorization, you must do so in writing to the address at the top of this form, to the attention of the HMC Privacy Officer. If not previously revoked, this consent will terminate ninety (90) days from the date of signature.. Failure to sign this form will not impact your right to receive care at Hershey Medical Center, Neither our treatment nor your payment is conditioned upon your signaturc on this form. I hereby release the provider of said records from any legal responsibility or liability in connection with the release c the rec ds indicated and herein. {? 7, j/ Signature of Patten Representative Date 7f?th?R (Relationship if signed by other than Patient) 7 i - 70 F3 wi4,d - MUST BE SIGNED PHONE Note to recipient of information: This information has been disclosed to you from the records protected by Pennsylvania Law. Pennsylvania Law prohibits you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains. MR 543 Rev. 3/03 AUTHORIZATION FOR RELEASE OF HOSPITAL RECORDS 7 x X ?,?,? ? ? 79 III/KIMMEL INS & FIN 165 E WASHINGTON ST CHAMBERSBURG, PA 17201 ROBERT G KOSER 130 SPRINGFIELD RD SHIPPENSSURG,PA 1725-/ Auto Insurance Coverage Summary This is your Declarations Page Your policy information has changed PROGREWYE® DR/YE'/nsurance Policy number: 50283298-2 Underwritten by. Progressive Preferred Insurance Co October 2, 2010 Policy Period: Jun 24, 2010 - Dec 24, 2010 Page 1 of 3 717-263-6360 III/KIMMEL INS & FIN Contact you- agent for personalized service, progressive agent.com Online Service Make payments, check billing activity, update policy information or check status of a claim. 800-274-4499 To report a claim. Your coverage began on June 24, 2010 at 12:01 a.m. This policy expires on December 24, 2010 at 12:01 a.m. This coverage summary replaces your prior one. Your insurance policy and any policy endorsements contain a full explanation of your coverage. The policy limits shown for a vehicle may not be combined with the limits for the same coverage on another vehicle unless the policy contract or endorsements indicate otherwise. The policy contract is form 9610A PA (05/06). The contract is modified by forms 4884 PA (08107), Z445 PA (03/07) and Z538 (10/08). COLLISION COVERAGE FOR RENTAL VEHICLES IF THIS POLICY PROVIDES COLLISION COVERAGE, IT WILL APPLY TO VEHICLES YOU RENT, BUT NOT TO VEHICLES RENTED FOR 6 MONTHS OR MORE. Policy changes effective October 1, 2010 Changes requested on: Requested by: ........................................... Premium change: Changes:............................... _ ........................................................................ Oct 1, 2010 02:14 p.m. ........................................................................ LARRY ROSENBERRY FROM IIVKIMMEL INS & FIN ............ -$6.00 ........................................................................... . The vehicle information for the 1997 Pontiac Trans Sportes has changed. M & T BANK has been removed as a lienholder on the 2005 Chevrolet Express G3500. SOVEREIGN BANK has been removed as a lienholder on the 2003 Chrysler PT Cruiser Tour ED, Underwriting Company Progressive Preferred Insurance Co P.O. Box 6807 Cleveland, OH 44101 800-876-5581 Drivers and household residents Additional information ...................................................................................................... ROBERT G KOSER First Named insured ...................................................................................................... PATSY L KOSER Four, 64'3-1 Pi, (04/07) N Continued 1# D Outline of coverage 2005 Chevrolet Express G3500 VIN 1GAHG39UI51155267 ....................... limits ............................. Liability To Others ............................ Bodily Injury Liability $100,000 each person/$300,000 each accident Property Damage Liability .. .. .. .. .... .. ... . ............. . $100,000 each accident . .............................. F ir st y Part B e nefits ...................................................... Medical Expenses $5,000 each person Uninsured Motorist - Nonstacked ................................................... $15,000 each person/$30,000 each accident ............ Un e rinsured Motorist Nonstacked .......................................... ..... ......... . . . ... ............................. . . . . . . . . . ch . . . each . . . person . . /$30 . ,000 . . accident .. $15,000 ea . ................ Comprehensive ........................................................................ Actual Cash Value Collision Actual Cash Value .............. ...... Total premium for 2005 Chevrolet . ..... .... ...._........................... .................. . 2003 Dodge Ram 2500 Quad St/Slt VIN 3D7K.U28D03G765506 .................... Limits ........................................... Liability To Others ............................................................................. Bodily Injury Liability $100,000 each person/$300,000 each accident Property Damage Liability $100,000 each accident First Party Benefits Medical Expenses $5,000 each person Uninsured Motorist - Nonstacked ............... ......... $15,000 each person/$30,000 each accident Underinsured Motorist -Nonstacked _ ....................................... , person !$30 , 000 ea c h ................... $ 1 5 000 ea ch accident ................................... Policy number: 50283298-2 ROBERT G KOSER Page 2 of 3 Deductible Premium $208 27 3 .................7 . $100 ................... 53 $500 158 ................................. $456 Deductible Premium $230 28 Comprehensive Actual Cash Value $100 Collision ......... Actual Cash Value $500 Total premium for 2003 Dodge . . . . . . . . . . . . . . . . . . 2003 Chrysler PT Cruiser Tour ED VIN 3C4F`f58B93T655268 ........... ... ........... ............ ........... ..._...... Limits .......... . Deductible Liability To Others ..... .....................,......... ........ Bodily Injury Liability $100,000 each person/$300,000 each accident Property Damage Liability $100,000 each accident First Party Benefits Medical Expenses .... ....__ .......................... . . $5,000 each person . . ................ Uninsured Motorist - Nonstacked ................ .P................... ........... . $15,000 each erson/$30,000 each acci dent Underinsured Motorist Nonstacked $15,000 each person. $30,000eaIch accident Comprehensive Actual Cash Value $100 Collision ......................................................... Actual Cash Value $500 3 7 52 178 $498 Total premium for 2003 Chrysler 1997 Pontiac Trans Sportes VIN 1GMDX0360VD241802 ..................................... ................. Limits Deductible ....... . educt Liability To Others ... ........................................... ........................... . . . . . ... . Bodily Injury Liability $100,000 each person/$300,000 each accident Property Damage Liability ............. $100,000 each accident .............................................. First Party Benefits ............ Medical Expenses $5,000 each person Uninsured Motorist Nonstacked $15,000 each personl$30,000 each accident Underinsured Motorist Nonstacked .......... ._ .... ......... .................... $15,000 each person/$30,000 each accident ... Total premium for 1997 Pontiac _............ ..._...................... .......__ .. . ........................... Total 6 month policy premium ................................... . Premium $101 20 2 4 29 131 $287 Premium $77 14 2 4 .......... $97 $1,338 Form 6489 PA (04/07) 19 continued 9'( Policy number: 50283298-2 ROBERT G KOSER Page 3 of 3 Premium discounts Policy 50283298-2 ................................................................................................. continuous insurancei platinum, multi-car, advance quote, association membership and home owner Vehicle .................. 2005 Chevrolet Express G3500 2003 Dodge Ram 2500 Quad St/Slt 2003 Chrysler PT Cruiser Tour ED 1997 Pontiac Trans Sportes Lienholder information ............................................................................................ anti-theft device and airbag anti-theft device and airbag anti-theft device and airbag airbag ....................................................................................................................................................... Lienholder. SOVEREIGN BANK PO BOX 16255 READING, PA 19612 2003 Dodge Ram 2500 Quad St/Slt (3D7KU28DC3G765505) Tort Option This policy provides limited tort insurance. Information Regarding Your Premium A surcharge of $298.00 due to violations or accidents is included in the total policy premium. Company officers President Secretary Form 5489 PA (04/07) 9 a 9,3 PARENTS' RELEASE AND INDEMNITY AGREEMENT Page 1 of 2 KNOW ALL BY THESE PRESENTS: That the undersigned, individually and as legal parent(s) and guardian(s) of NEIL F. SHIRK, a minor (hereinafter "Releasors"), for the sole consideration of FORTY TWO THOUSAND TWO HUNDRED FORTY SIX DOLLARS AND 10/100 CENTS ($42,246.10), receipt of which is hereby acknowledged, have remised, released, and forever discharged and covenant to hold harmless ROBERT G. KOSER, their heirs, administrators, executors, successors, agents, employees, subsidiaries, affiliates and assigns (hereinafter collectively referred to as "Releasees"), from any and all claims, demands, damages, costs, expenses, loss of services, actions and causes of action, belonging to the said Releasors arising out of any act or occurrence up to the present time, and particularly on account of personal injury, disability, property damage, loss or damages of any kind sustained or that may hereafter be sustained by the said Releasors in consequence of an accident that occurred on or about the NOVEMBER 2, 2010, at or near Stoughstown Road near its intersection with McCullough Road, in Shippensburg, Pennsylvania. To procure the payment of the stated consideration, the Releasors hereby declare: that no representations about the nature and extent of the said injuries, disabilities or damages made by any physician, attorney or agent of Releasee, nor any representations regarding the nature and extent of legal liability or financial responsibility of any of the parties released, have induced the Releasors to make this Release & Indemnity Agreement; that this Release is entered into in consideration of all known and unknown injuries, disabilities and damages, and also the possibility that the injuries sustained may be permanent and progressive and recovery therefrom uncertain and indefinite, so that consequences not now anticipated may result from the said accident. Yy PARENTS' RELEASE AND INDEMNITY AGREEMENT Page 2 of 2 The payment made to the undersigned is upon Releasors warrant that no consideration has been received heretofore from any person, firm or corporation, nor has Releasors released heretofore any person, firm or corporation from any claim or liability for the said accident. Releasors agree to indemnify and hold harmless said Releasee from any additional sum of money that Releasee may hereafter be compelled to pay on account of the injuries to said minor because of said accident. The Releasors understand that the Releasees admit no liability of any sort by reason of said accident and that said payment in compromise is made to terminate further expense and controversy respecting all claims for damages that Releasors have heretofore asserted or might personally or through personal representatives hereafter assert because of said accident. I have read this release and understand it. Signed: Witness Date Witness Date STATE OF COUNTY OF IVAN SHIRK, as parent and natural guardian of NEIL F. SHIRK, a minor LYDIA SHIRK, as parent and natural guardian of NEIL F. SHIRK, a minor On this day of ,2 , before me personally appeared , to me known to be the person (s) who executed the foregoing instrument, and acknowledged this as a tree act and deed. My commission expires Notary Public Claim No.: 103545277 Ir IN THECOURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION IVAN SHIRK and LYDIA SHIRK, As Parents and Natural Guardian of NEIL F. SHIRK No. Petitioners V. : ROBERT G. KOSER, Respondent CERTIFICATE OF SERVICE On this 15`t' day of April , 2011, I, Barrie B. Gehrlein, Esquire do hereby certify that I served a true and correct copy of the Petition For Court Approval Of Minor's Settlement Pursuant To Pa. R.C.P. 2039 by First Class Mail, postage prepaid, upon the following: Ivan Shirk Lydia Shirk 2033 Rittner Hwy Shippensburg, PA 17257 Bv: AGAP?*-nd D)$ERNARDO, LLP rie B. Gehrlein, Es ire Attorney I.D. No. 6283 1 ?0 East Chestnut Street Llaiaster, PA 17602 (717)"397-9444 Phon (717) 397-`239 leak Attorney for Robert G. Koser IVAN SHIRK and LYDIA SHIRK, IN THE COURT OF COMMON PLEAS OF As Parents and Natural Guardians of : CUMBERLAND COUNTY, PENNSYLVANIA NEIL F. SHIRK, Petitioners V. ROBERT G. KOSER, NO. 2011 - 3774 CIVIL TERM -Arm Respondent NJ Y c-? aG ? ORDER OF COURT' AND NOW, this 26TH day of APRIL, 2011, a hearing on the Petition for Court Approval of Minor's Settlement is scheduled for THURSDAY, MAY 26, 2011, at 1:30 p•m• in Courtroom # 3. By ourt, Edward E. Guido, J. ?Barrie B. Gehrlein, Esquire Ivan Shirk Lydia Shirk CD F am c: --+? s,-I Q -?; ?? to :sld IN THECOURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION IVAN SHIRK and LYDIA SHIRK, As Parents and Natural Guardian of NEIL F. SHIRK No. dolt - 377 Petitioners V. ROBERT G. KOSER, Respondent CERTIFICATE OF SERVICE 0 On this 15" day of April , 2011, I, Barrie B. Gehrlein, Esquire do hereby certify that I served a true and correct copy of the Petition For Court Approval Of Minor's Settlement Pursuant To Pa. R.C.P. 2039 by First Class Mail, postage prepaid, upon the following: Ivan Shirk Lydia Shirk 2033 Rittner Hwy Shippensburg, PA 17257 FL NAGAP ' nd D?fBERNARDO, LLP . ......... By: re eh e B. 2No.6283 I1 ?0 East CLaster, (717)7- (717) 397Attorney for Robert G. Koser 01 11 li.N 13 A 10:F"? i UMBEKLAx"L+ ?C v°1i" T' IN THECOIJRT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION IVAN SHIRK and LYDIA SHIRK, As Parents and Natural Guardian of : NEIL F. SHIRK Petitioners v. ROBERT G. KOSER, Respondent AND NOW this /3? No. 11-3774 Civil ASSIGNED TO: JUDGE EDWARD E. Gt)IDO ORDER day of 2011, upon consideration of the instant original and Amended Petitions for Court Approval of Minor's Settlement it is hereby ORDERED that the Amended Petition is GRANTED. The Court hereby approves the Minor's Settlement and further orders that the settlement proceeds be distributed as follows: 1. The sum of $42,246.10 be paid directly to IVAN SHIRK and LYDIA SHIRK, for reimbursement of medical expenses that they have previously paid as Parents and Natural Guardian of the minor NEIL F. SHIRK. 2. The sum of $7,500.00 for the pain and suffering sustained by Minor Petitioner, Neil F. Shirk will be placed in a federally insured, interest bearing account in the name of the minor Neil F. Shirk that shall not be made available to the minor until he should attain the age of eighteen (18) years, without further order from this court. Proof of said deposit shall be made with the court no later than thirty (30) days from the date of this order. Petitioners shall execute the appropriate Release necessary to conclude this matter in the form attached to the Amended Petition as well as the required Praecipe to Discontinue the action. Cap 9.s rn.".t tYd, u 6., ft3?l/ uA THE C J. EDWARD E. GUIDO FILED-OFFICE AIR OF THE PROTHONOT z X31 { J!1. 22 p,N 11: 12 CUMOFR YLVANUA °, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION IVAN SHIRK and LYDIA SHIRK, As Parents and Natural Guardian of NEIL F. SHIRK Petitioners IV. No. 11-3774 Civil ASSIGNED TO: JUDGE EDWARD E. GUIDO ROBERT G. KOSER, Respondent PRAECIPE TO FILE PROOF OF DEPOSIT TO THE PROTHONOTARY: ,I m Pursuant to the Court's prior approval of the Minors' Settlement in the above-case kindly file of record, the proof of deposit attached hereto By: Date: June 21, 2011 _, GL FLANAGAN and B. Ovhrlein, Esqu ev I.D.''No. 62839 150 East Chestnat free Lancaster, PA 17602 (717) 397-9444 Phone (717) 397-2397 Fax Attorney for Defendant Robert G. Koser ARDO, LLP No. 11-3774 Civil EXHIBIT 44 A 99 JUN-16-2011 THU 0513 PM ACNB 717+776+4361 P. 02 Certificate of Deposit Receipt Account Number: 900043204011 This rcccipt is issued to: IRA Number: NEIL F SHIRK Amount $ 7,500.00 IVAN Z SHIRK AND Date Opened 06/16/2011 LYDIA S SHIRK PARENTS AND NATURAL GUARDIANS Term 25 Month special CD 2033 RITNER HWY Maturity Date 07/16/2013 SHIPPENSBURG PA 17257 Interest Rate 1.490 % Annual Percentage Yield 1.50% ACNB BANK 16 LINCOLN SQUARE PO BOX 3129 GETTYSBURG, PA 17325 The account evidenced by this receipt is subject to and further explained in the terms and conditions contained in the account agreement and account disclosures. The account is Not Negotiable and Not Transferable. Only the items checked apply. (ill Fixed Interest Rate ? Variable Interest Rate R Additions Permitted ® Automatically Renewable ? Single Maturity (not automatically renewable) ? Callable M Notice Account Interest will be: ? mailed to the owner(s). added to principal (compounded). ? paid to account No, N Interest will be compounded monthly. Interest will be credited every 012 Months and added back the account Certificate of DepOAlf N00aipi 8ankere 8ystonl.TM Woltere Kluwer fmencial SBrV1401 C 1994, 2008 conic-eK-LAZ 3/11/2008 Pepe 1 01 1 '73o- iga7 Tyedd;e- [UJ14AVV,s 5 IN THECOURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION IVAN SHIRK and LYDIA SHIRK, As Parents and Natural Guardian of NEIL F. SHIRK Petitioners V. ROBERT G. KOSER, Respondent t No. 11-3774 Civil ASSIGNED TO: JUDGE EDWARD E. GUIDO ??// ORDER AND NOW this 13 r^ _ day of RDE 2011, upon consideration of the instant original and Amended Petitions for Court Approval of Minor's Settlement it is hereby ORDERED that the Amended Petition is GRANTED. The Court hereby approves the Minor's Settlement acid further orders that the settlement proceeds be distributed as follows: 1. The sum of $42,246.10 be paid directly to IVAN SHIRK and LYDIA SHIRK, for reimbursement of medical expenses that they have previously paid as Parents and Natural Guardian of the minor NEIL F. SHIRK. 2. The sum of $7,500.00 for the pain and suffering sustained by Minor Petitioner, Neil F. Shirk will be placed in a federally insured, interest bearing account in the name of the minor Neil F. Shirk that shall not be made available to the minor until he should attain the age of eighteen (18) years, without further order from this court. Proof of said deposit shall be made with the court no later than thirty {30} days from the date of this order. Petitioners shall execute the appropriate Release necessary to conclude this matter in the form attached to the Amended Petition as well as the required Praecipe to Discontinue the action. TRUE COPY FROM RECORD In Testimony whereof, i here wft set"hand and ttaf of saW?? , Pa. This ??y CW 20 THE C J. EDWARD E. GUIDO No. 11-3774 Civil IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION IVAN SHIRK and LYDIA SHIRK, As Parents and Natural Guardian of NEIL F. SHIRK No. I1-3774 Civil Petitioners V. ASSIGNED TO: JUDGE EDWARD E. GUIDO ROBERT G. KOSER, Respondent CERTIFICATE OF SERVICE On this 21S' day of June , 2011, I, Barrie B. Gehrlein, Esquire do hereby certify that I served a true and correct copy of the Praecipe To File Proof Of Deposit by First Class Mail, postage prepaid, upon the following: Ivan Shirk Lydia Shirk 2033 Rittner Hwy Shippensburg,13A 17257 ?LANAGAN am" RNA , LLP By: $ame B. Gehr 'n, Esquire `Attorney I.D. No.9 150 East Chestnut Street Lancaster, PA 17602 (717) 397-9444 Phone (717) 397-2397 Fax Attorney for Robert G. Koser s ci2MBERLAND COUNT.,. 31'Ei4NSYL1/AH1A IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION IVAN SHIRK and LYDIA SHIRK, As Parents and Natural Guardian of NEIL F. SHIRK Petitioners V. : ROBERT G. KOSER, Respondent No. 11-3774 Civil ASSIGNED TO: JUDGE EDWARD E. GUIDO PRAECIPE TO SATISFY, DISCONTINUE AND END TO THE PROTHONOTARY: ORIGINA Please mark the docket in the above matter settled, satisfied and discontinue with prejudice. and DiBERNARDO, LLP By: Date: September 13, 2011 B 'e . GJN'oi. quire orne I.39 East et Lan caster, (717) 397-9444 Phone (717) 397-2397 Fax David D. Buell, Prothonotary 20 No. 11-3774 Civil IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION IVAN SHIRK and LYDIA SHIRK, As Parents and Natural Guardian of NEIL F. SHIRK No. 11-3774 Civil Petitioners V. ASSIGNED TO: JUDGE EDWARD E. GUIDO ROBERT G. KOSER, Respondent CERTIFICATE OF SERVICE On this 13th day of September , 2011, I, Barrie B. Gehrlein, Esquire do hereby certify that I served a true and correct copy of the Praecipe To Satisfy, Discontinue And End by First Class Mail, postage prepaid, upon the following: Ivan Shirk Lydia Shirk 2033 Rittner Hwy Shippensburg, PA 17257 GAN-*,pd DiBERNARDO, LLP By: B **e B. Gehrlein, qu ey I.D. No. 6 39 50 t Chestnut treet Lancas r, PA 1 02 (717) 39 - Phone (717) 397-2397 Fax