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HomeMy WebLinkAbout02-0243COMMONWEALTH OF PENNSYLVANIA COUNTY OF: CO'I~ERI.~,._ND Mag. Dist. NO.: 09-3-01 DJ Name: Hon. HAROLD E. BENDER Address: 81 W3r.NUT BOTTOM ROAD P.O. BOX 361 SHIPPENSBUKG, PA Telephone: (717) 532 -7676 VICTOR JUMPER 237 STONEHOUSE ELD CARLISLE, PA 17013 17257'0361 NOTICE OF JUDGMENT/TRANSCRIPT CIVIL CASE PLAINTIFF: NAME and ADDRESS UJUMPER, VICTOR 237 STONEHOUSE RD CARLISLE, PA 17013 VS. DEFENDANT: NAME and ADDRESS FLUCHANSKY, MELIS~A 208 LUKGANAVE C/O ASHERWEINE~ ~HIPP~ISBU'RG, PA 17257 LDocket No.: CV-0000261-01 Date Filed: 11/26/01 THIS IS TO NOTIFY YOU THAT: Judgment: [-~ Judgment was entered for: (Name) ['~ Judgment was entered against: (Name) in the amount of $ 2: 0"/4 _ 9..1 DRFAUL? J~ID~-MI~NT PLTF on: Defendants are jointly and severally liable. Damages will be assessed on: This case dismissed without prejudice. Amount of Judgment Subject to Attachment/Act 5 of 1996 $ Levy is stayed for days or [--1 generally stayed. Objection to levy has been filed and hearing will be held: (Date of Judgment) 1 2/1 rt./n1 (Date & Time) Amount of Judgment $ 2,000.00 Judgment Costs $ 74.21 Interest on Judgment $ · 0(] Attorney Fees $ . Total $ 2,074.21 Post Judgment Credits $ Post Judgment Costs $ Certified Judgment Total Date: Time: Place: ANY PARTY HAS THE RIGHT TO APPEAL WITHIN 30 DAYS AFTER THE ENTRY OF JUDGMENT BY FILING A NOTICE OF APPEAL WITH THE PROTHONOTARY/CLERK OF THE COURT OF COMMON PLEAS, CIV{L DIVISION. YOU MUST INCLUDE A COPY OF THIS NOTICE OF JUDGMENT/'FRANSCRIPT FORM WITH YOUR NOTICE OF APPEAL. /~/~ / Date ~/~c~/~ ~W~ ,District Justice certify that this is a true and correct copy of the record of the proceedings containing the judgment. /-~/,,_~--'Date ~,/~~~:~~,,,~_. , District Justice My commission expires first Monday of January, AOPC 315-99 2006 SEAL In the Court of Common Pleas of Cumberland County, Pennsylvania To Prothonotary C~~ :ttomey for Plaintiff' FI EL'~DF:FICE No. OF *.:Hr: ?r;;: ;;tqOTAfiY 02HF~R-7 ?f~ 1:b8 OU~BEiq~AN~ COUNTY PENNSYLVAN~ Filed Term, 19 PRAECIPE 19 , Atty. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Charles W. Mitchell, Sr. Plaintiff VS. CIVIL ACTION LAW No. 02-343 Robert L. Myers Defendant JURY 'TRIAL DEMANDED PLAINTIFF'S ANSWERS TO DEFENDANTS INTERROGATORIES a.) Name at Birth: Charles William Mitchell; b) No; c.) Date and place of birth: Green County, Pennsylvania January 30, 1922; d.) SSAN: 186-12-1986; e.) Post secondary education at Philadelphia College of the Bible, Reformed Episcopal Seminary, missionary and locksmith training received a certificate; f.) Marital status: Widower; g.) Have you ever been divorced? No. h.) N/A; i.) No. 2. Dr. Ronald W. Lippe Orthopedic Institute of PA 875 Poplar Church Road Camp Hill, PA 17011 Holy Spirit Hospital 503 North 21~t St. Camp Hill, PA17011 Mr. Frank J. Diprima, MS 920 Century Drive Mechanicsburg, PA 17055 3. Dr. Ronald W. Lippe 4. See, 3. 5. a.) The truck did not strike the automobile, the automobile struck the Plaintiff's minivan on the passenger side when the Plaintiff was turning into his driveway and the Defendant was illegally proceeding down the berm passing a line of traffic. b.) When the Defendant's vehicle struck the Plaintiff's minivan, it pushed it sideways several feet in the direction the Defendant's vehicle was taking. c.) The Plaintiff estimates that the Defendant was traveling approximately 25 mph and the Plaintiff was slowly moving towards his driveway. 6. See, repair estimates from the Defendant's insurer. 7. See, 5(b). After the vehicles stopped they moved off of the berm and the southerly portion of Trindle Road. 8. Edema of left shoulder, cervical sprain/strain, torn rotator cuff approximately 5". 9. See, 8. 10. See medical records and the Claimant's doctor was: Dr. Ronald W. Lippe Orthopedic Institute of PA 875 Poplar Church Road Camp Hill, PA 17011 11. Holy Spirit Hospital. 12. The Plaintiff objects to this question because the Plaintiff has no duty to provide the names of any experts they consult unless they utilize them at time of trial. 13. The Plaintiff has had continuing residual problems that, inter alia, required an attempt at closed reduction of the shoulder. 14. See, 10. 15. See, 10. 16. No. 17. The Plaintiff was self employed. 18. The Plaintiff earned between $12,000 and $15,000 dollars per year except for the time period when he was giving almost lull time care to his wife who had cancer until her death. 19. N/A 20. The Plaintiff did not keep records of all persons who utilized his services as a locksmith during the five year time period the interrogatory requests. 21. See, 20. 22. See. 20. 23. See, 20. 24. Yes. 25. Locksmithing requires the use of two hand,,; and arms, the shoulder injury to the Plaintiff disabled him from doing most work as a locksmith because of his inability to utilize his injured arm and shoulder. 26. No. 27. $12,000 - $15,000. 28. Since the accident the Plaintiff has been unable to perform the essential functions of his profession and therefore has been unable to accept work. He estimates that his loss of income per year since the accident has been between $12,000 and $15,000 dollars a year. 29. No. 30. No. 31. Yes. The Plaintiff is currently disabled because of the complications of diabetes. 32. Since the accident at various times for medical treatment post surgery and recuperation and again for closed reduction of his shoulder. 33. Since the date of the accident. 34. No. 35. N/A 36. No. 37. The Plaintiff has had a long standing diabetic condition. 38. a.) police report; V E.R'I FI CAT IO N Subject Io the penelties of 18 Pa. C.S.A. 4904 re!atin, g to unsv;orn f.~Isificstion to -" "~-- m¢~ ,r,= ~c,s In the forecoing p~e~dina ~re true ~nd ~u,hor~,,=~, v,,e hereby ce~ify" -'" - '- ' ~ ~ correct to the best cf our ir, formationc,,o-- "Duh:,.- '-' B*-te: ' G -,D~'"'- IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Charles W. Mitchell, Sr. Plaintiff VS. CIVIL ACTION LAW No. 02-343 Robert L. Myers Defendant JURY 'TRIAL DEMANDED CERTIFICATE OF SERVICE I, David W. Knauer, hereby certify that I did this 28th day of June, 2004, serve a true and correct copy of the Answers to Interrogatories by United States mail, first class, prepaid addressed as follows: P. Brennan hart, Esquire Pietmgallo, Bosick & Gordon 38th Floor, One Oxford Centre Pittsburgh, PA 15219 / D~'id W~. l~nau-e~' ~ Attorney for Plaintiff Attorney I.D. No. 21582 411 -A East IVlain Street Mechanicsburg, PA 17055 (717) 795-7790 NOTIFICATION, OF ACCIDENT INVESTIGATION HAMPDEN TOWNSHIP POLICE DEPARTMENT 230 SOUTH SPORTING HILL ROAD, MECHANICSBURG, PA 17055-3097 ,,' (717) 761-2609 POLICE INCtDENT NUMBER TIME AND DATE OF ACCIDENT UNIT 41. OWNER 41, OWN~ 42. Cl~, STATE 45. MODEL (NOT 46. INS. ~7. BODY 48, SPECIAL OWNERSHIP ~TYPE USAGE ~ OWNERSHIP ~ GRAOIENT PRESENCE ~ CONDITIO~ ~ GRADIENT PRESENCE ~ CONDITIO~ 59. DRIVER 59 DRIVER 69. 61~, STATE 69. CI~, STATE & ZIP CODE & ZIP CODE 72. VEH 73. CARGO 74. GVWR ~VEH ~BODY TYPE 74 G~R 0WNER I AODRESS j PHONE ORTHOPEDIC INSTITUTE OF PENNSYLVA~£A (717) 761-5530 Patient: Charles W. Mitchell Chart ~: 09878301 DOB: 01/30/22 SSN: 186 12 1986 Page ~ 6 5/15/2002 RONALD W. LIPPE, M.D. -CONTIMUED- OFFICE VISIT 6/17/2002 RONALD W. LIPPE, M.D. PHYSICAL THERApy Script to continue PT faxed to 691-5564. tlc 7/02/2002 RONALD W. LIPPE, M.D. TEL/MESG-NURS TEL CALL Script for home TENS unit faxed to 691-5564. 7/10/2002 RONALD W. LIPPE, M.D. OFFICE VISIT Trindle Road Office tlc CHIEF COMPLAINT: Charles is now eight months status post acromioplasty and rotator cuff repair of his left shoulder. HISTORY OF COMPLAINT: He had been seeing some progress in therapy but he stopped it as he was having some pain. He has been working on exercises on his REVIEW OF SYSTEMS: The patient's review of systems, past medical history, family history, and social history have been re-evaluated and reviewed. PHYSICAL EXAM: His wound has healed nicely. Range of motion of his shoulder is limited with respect to full and forward elevation but he has good abduction and satisfactory rotation. He does have a positive impingement sign. DIAGNOSIS: It appears to me that Mr. Mitchell has some continued inflammation in his left shoulder and we discussed the treatment options for this. PLAN: I offered him an injection but he states that he would just prefer to just work on this on his own. He has been discharged from physical therapy. He states that~ considering his age. he thinks that he is doing relatively well. I told him that he could use his shoulder as tolerated and I will see him again in four months for clinical recheck. RWL/skb ORTHOPEDIC INSTITUTE OF PENNSYLV~qIA (717) 761-5530 Patient: Charles W. Mitchell Chart ~: 09878301 DOB: 01/30/22 SSN: 186 12 1986 Page # 5 1/16/2002 RONALD W. LIPPE, M.D. -CONTI~qUED- OFFICE VISIT CHIEF COMPLAINT: He is now 6 weeks status-post rotator cuff repair. He has some discomfort in the shoulder when he moves it. PHYSICAL EXAM: On examination today, his wound is healed nicely, but his range of motion of his shoulder is limited. He is neurovascularly intact in his left upper extremity. PLAN: I explained to Mr. Mitchell that I think he would ]benefit from a course of physical therapy at this point. We therefore made arrangements for that and I will see him in 6 weeks for clinical recheck. RWL/krt 2/18/2002 RONALD W. LIPPE, M.D. PHYSICAL THERAPY Script faxed to Health South 691-5564. script is expired, tlc Today is his first day of PT and his 2/27/2002 RONALD W. LIPPE, M.D. MISSED APPT LETTER (Msc) MISSED APPT LETTER, PATI 4/10/2002 RONALD W. LIPPE, M.D. MISSED APPT LETTER (Msc) MISSED APPT LETTER, PATI 5/15/2002 RONALD W. LIPPE, M.D. OFFICE VISIT Trindle Road Office CHIEF COMPLAINT: He is about six months status post left rotator cuff repair. HISTORY OF COMPLAINT: He stopped his therapy as his brother got sick having a stroke and he had to take care of him. He now comes in for follow up. REVIEW OF SYSTEMS: The patient's review of systems, past medical history, family history, and social history have been re-evaluated and reviewed. PHYSICAL EXAM: He is slightly tender to palpation over his anterior acromion and has a positive impingement sign at around 90 degrees that is worse with internal rotation. He has satisfactory motor function in his shoulder but discomfort at the extremes of motion. His skin is normal. His wound is well healed. PLAN: I explained to Mr. Mitchell that I believe he would benefit from resuming his physical therapy and he realizes that. I wrote a prescription for that and I told him to give that six to eight weeks to improve. I will see him at the end of that time to re-evaluate him. RWL/skb ORTHOFEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patient: Charles W. Mitchell Chart #: 09878301 DOB: 01/30/22 SSN: 186 12 1986 Page # 4 11/05/2001 RONALD W. LIPPE, M.D. -CONTINUED- LEVEL THREE PLAN: He would very much like to have this dealt with surgically and I certainly understand. I explained acromioplasty and rotator cuff repair to him along with all the risks and what is involved. He understands those quite well and we will go ahead and schedule this for him at his convenience. RWL/krt 11/28/2001 RONALD W. LIPPE, M.D. HARRISBURG HOSPITAL OUTPATIENT November 28, 2001 PINNACLE HF~LTH-HARRISBURG OUTPATIENT DIAGNOSIS: 2 cm longitudinal rotator cuff tear; left shoulder PROCEDURE: Left shoulder acromioplasty and repair of his left rotator cuff tear RWL/jln 12/04/2001 RONALD W. LIPPE, M.D. TEL/MESG-N~3RS TEL CALL Mr. Mitchell's son called stating that his dad is having alot of pain and is vomiting from the Vicodin. A prescription for Talacen was called in for the patient. jln 12/12/2001 RONALD W. LIPPE, M.D. OFFICE VISIT Trindle Road Office CHIEF COMPLAINT: He is two weeks st'atus post his left rotator cuff repair and he is doing quite well at this point. He has the expected soreness in his shoulder. PHYSICAL EXAM: His passive range of motion is satisfactory and he has relatively good active motion. He is neurovascularly intact in his left upper extremity. PLAN: I am currently pleased with Mr. Mitchell's progress and I told him that he could participate in activities within reason at this point. I will see him again in four to six weeks for clinical recheck. RWL/skb 1/16/2002 RONALD W. OFFICE VISIT Trindle Road Office LIPPE, M.D. ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patient: Charles W. Mitchell Chart ~: 09878328 DOB: 01/30/22 SSN: 186 12 1986 Page # 3 9/19/2001 RONALD W. LIPPE, M.D. -CONTINUED- LEVEL THREE family history and social history have been re-evaluated and reviewed. PHYSICAL EXAM: On exam today, he is a healthy-appearing gentleman in no acute distress. Range of motion of the shoulder is satisfactoi~ but he has a markedly positive impingement sign at 90 degrees forward elevation worse with internal rotation. The skin overlying his shoulder is normal. He has surprisingly good active range of motion of the shoulder. DIAGNOSTIC TESTS: I reviewed his MRI, which is consistent with arthritis and what appears to be a rotator cuff tear. DIAGNOSIS: I explained to Mr. Mitchell that he appears to have a rotator cuff tear. PLAN: He states he doesn't want surgery if at all possible. In an effort to decrease his symptoms, I injected his left shoulder subacromial space under sterile conditions and told him to give this 6-8 weeks to improve. I'll see him at the end of that time to reevaluate him. RWL/rah ADDENDUM/CORRECTION Original transcription that was done for the office visit dated October 19, 2001, mistakingly notes this as a problem with his right shoulder. The injury is to his left shoulder and he is being treated for sudh. jln 11/05/2001 RONALD W. LEVEL THREE Trindle Road Office LIPPE, M.D. CHIEF COMPLAINT: He continues to have difficulty with his left shoulder. HISTORY OF COMPLAINT: He saw some improvement with the injection, but it is not satisfactory for him. He came in today to essentially schedule surgery. REVIEW OF SYSTEMS: The patient's review of systems, past medical history, family history and social history have been re-evaluated and reviewed. PHYSICAL EXAM: On examination today, he is tender over his anterior acromion. He has a positive impingement sign at 90 degrees of forward elevation, worse with internal rotation. Range of motion of his shoulder is satisfactory. He has good motor function in his shoulder. DIAGNOSIS: It appears to me that Mr. Mitchell continues to have symptoms conszstent with a rotator cuff tear. ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patient: Charles W. Mitchell Chart #: 09878328 DOB: 01/30/22 SSN: 186 12 1986 Page # 2 10/06/1999 RONALD W. LIPPE, M.D. -CONTIbIUED- RADIOLOGY RESULTS and normal bony architecture. IMPRESSION: SEE ABOVE STUDY. RWL/krt 10/20/1999 RONALD W. LIPPE, M.D. LEVEL THREE Trindle Road Office CHIEF COMPLAINT: Charles returns for discussion of his lumbar MRI. Fortunately since I last saw him, his pain has resolved. He states he has no pain in his back or lower extremity. REVIEW OF SYSTEMS: The patient's review of systems, past medical history, family history and social history have been re-evaluated and reviewed. PHYSICAL EXAM: On examination today he still walks with a somewhat kyphotic lumbar spine, but he is neurologically intact in his lower extremities. His straight leg raise test is negative. He is bright, alert: and cooperative, and appears healthy. DIAGNOSTIC TESTS: I went over his MRI which does show significant spinal stenosis at L4-5, although it was read as only mild to moderate. DIAGNOSIS: I explained to Mr. Mitchell that he does have spinal stenosis in his lumbar spine, but currently it is asymptomatic and there is no need to intervene; he was happy to hear this. PLAN: We discussed the fact that if his symptoms recur or they worsen, he should bring it to my attention. Should that be the case, we would discuss further options. RWL/j ep 9/19/2001 RONALD W. LIPPE, M.D. LEVEL THREE Trindle Road office CHIEF COMPLAINT: Charles was involved in a motor vehicle accident on 0A/19/01, HISTORY OF COMPLAINT: Apparently he was in his driveway when another car hit him from behind. Since that time, he has had difficulty with pain in his shoulder. Pain is in his right shoulder. It is worse with activities, especially moving the shoulder. It awakens him at night. He has tried anti- inflammatory meds with little improvement. REVIEW OF SYSTEMS: ~he patient's review of systems, past medical history, DB APS#: 9423 07)2512'~01 RE: MITCHELL, CHARLES W 5016 E Trindle Road . Mechanicsburg PA 17055 DOB: 01/30/1922 SS#: 186 12 1986 STUDY: MRI of left shoulder REFERRING PHYSICIAN: Michael Warner DC CLINICAL HISTORY: Pain following MVA PULSE SEQUENCES: 1) Sagittal PD T2 2) Axial GRE 3) Coronal T1 T2 w/FS COMMENTS: There is degeneration of the glenohumeral adiculation. The anterior labrum appears to be avulsed and fragmenl:ed. There is hypedrop~ic degeneration of the AC joint which results in moderate impingement of the (,)tarot cuff. Increased signal in this area indicates a complete tear. This appears to traverse the entire thickness of the supraspinatus tendon[ Them is fit]id in the subdeltoid space and intermixed linear areas of ini:reased signal indicate degenerative tendinopathy. There are erosive changes related to the greater tuberosity and there is increased signal seen in the area of the greater~ tuberosity on inversion recovery images suggesting bone edema and an acute injury to this area, There are cystic deglenerative changes seen at the point of insedion of the rotator cuff t~ndons into the greater tuberosity. CONCLU§ION: Degenerative changes of the glenohumeraljoint with fragmentation and disruption of the anterior labrum. Degenerative changes in the AC joint results in moderate impingement of the rotator cuff tendons. The supraspinatus tendon demonstrates a complete tear with fluid in the subdel[oid space. Thickening and tendinopathy seen in the rotator cuff tendons. Area of bone edema in the greater tuberosity of the proximal humerus suggesting an acute injury to this region. There are CONTINUED ON PAGE 2 PAGE 2 RE; MITCHELL, CHARLES subchondral degenerative cystic changes seen in the greater tuberosity at point of insertion of the. rdt~tor cuff tendons. Thank you for referring this patient to us. Sincerely, Donald R. Buxton, Jr., M.D. DRB/ea EVALUATION REPORT Patient Name: CHARLES MITCHELL Evaluation Date: 7-13-01 1. Neck Strength/Endurance: The patient was able to complete most all the tests with moderate difficulty, he gave a good effort during the evaluation. He has muscle weakness in all directions tested. 2. Neck Flexibility/ROM: Tho patient performed the neck flexibility tests with a good effort. He has average flexibility and ROM in Iris neck. He had moderate stiffness and soreness. 3. Back Flexibility: He gave a good effort mad was able to perform and complete most of the flexibility tests with moderate difficulty. Tho patient had mild soreness in h/s back. His flexibility is below average in his upper and lower bank. 4. Back StrengtlffEadurance: The patient gave a good effort in performing the strength tests. He was able to enmplete all of the tests with moderate diffienlty. His back strangth is weak and needs improvement 5. Shoulder Strength/Endurance: He was able to perform all of the exercises with exnxeme difficulty. His shoulder strength is vuny weak in all directions tested. 6. Shoulder Flexibility: Tho patient was able to complete all flexibility tests with extreme difficulty. His flexibility is below average in his left shoulder and vea'y limited. 7. Prognosis: The patient's neck, back ,and shoulder streng~ are weak and neet[ improvement. The patient's .flexibility is below average in all areas tested. ~is left shoulder needs the most help. He will start rahab on 7-16-01. He will then be reevaluated in about six weeks;. Date RECEIVED ^ c .q 2001 _l l edicaJ Dept. Signature ~OH~ :~I~VN~ J~I~LLVd CHARLES lVflTCHELL Back Extension~? 2 sets 15 reps Abdominal Curl 2 sets 15 reps Front Raise Right 1 set 15 reps Side Raise Right I set 15 reps Rear Raise Right 1 set 15 reps Neck Flexion 1 set Neck Extension 1 set Neck Lateral Flexion Right1 set Neck Lateral Flexion Left 1 set 15 reps 15 reps 15 reps 15 reps Cardio: Treadmill 10 minutes DaM: Time Time Out: Total Throe: Date: T~e~: Ti~ Out: Tot~ T~e: Date: Time Out: Date: Time ~: Time Out: Date: '7- ~'3-o t Time In: Tmaa Ou~: to Total Time: ~. g' r~'.~-£ Time In: Io:OO Time Out: Total Time: Date: ~-~ Time la: Time Out: Total Time: Date: '7 Time la: tO Time Out: Total Time: Date: Time In: Time Out: Total Time: Date: - Time In: Time Out: Total Time: Date: Time In: Time Out: Total Time: Date: Tmae In: Tmae Out: Total Time: Date: Time In: Time Out: Total Time: Date: Time Ia: Time Out: Total Time: Date: Time In: Time Out: Total Time: RECEIVED ~b~. ~v;~ ..... [] Delalled ri Comprehensive [] Minimal 'l~ Minor ~] Low to Moderato SMENT: [] prob-Focused ~ Expanded pmb. Focused [] Moderate Io High ~]~ High I-I Detailed [] ~mpmhensN'e pLAN: [] Stralght-fo~ard ITl LoW Complexity I-I Moderate Complexity ~ High Complexity DATE H-105 . ':" ":.:*TOTAl= IECTIVES: I~":", IIiIdtatlonI. lavalily & fr~qu.flc~ oBJECTIVES: [] prob-Focused . ; prob-F~cused sEVER/TY; [] Minimal ;sMENT: [] pmb-Fix:used [] Minor [] Low (o Moderate [] Expanded prob. Focused [] Detailed [] Moderate to High [] High [] Detailed [] Comprehensive pLAN: [] Siralght-fo~vard [] LoW Complm~ity [] Moderate C'~mplexl'qt [] High .... ' ...... ~ Cop~lgh 0 1992 by H J Ross ~',/~ ~ ~ File g: Date of O.set: ~ ~Q'O, lent: O~EC~ES: ~ ~ P~F~u~ ~ ~ Pm~F~us~ ~ De~ll~ ~ C~pre~nshe SE~R~: ~ Minimal ~ MIn~ ~ Low to M~emte ~ M~te tD High ~ High ASSESSME~: ~ Pro~F~u~ ~ ~nd~ Pm~F~us~ ~ De~ll~ ~ Com~ehens~e ~ ~F~ (~ * p~: ~ Slmlght-fo~ ~ L~ Compl~ ~ M~emte Compie~ ~ High ~pl~ OBJECTIVES: CI Prob-Focused :SEVERITY:'. ' r-~ pmb-Focused [] Comprehens~vq [] Straight-forward Low Compleflty [] MederaLe Complexity [].High Complexity ATEOFVlSlT:' [.0I'TOTALTIMESPENT: )1~'~ DR'SINITL~LS:' : SEVERITY: [] Minimal ASSESSMENT: [] Prob. Focused [] Comprehensive I [] Minor ~ Low to Moderate [] Moderate to High [] High ~] Expanded Pro~F~us~ D De~fl~ ~ Comprehens~e PLAN: [] SKalght-l*orward Low Complexity [] Mederate C6mplexlty [] High Complexity ~5 c~l~t~hl · 1992 by H.J. RossCu,,,~y. lnc. All dghts rased*ed. NO pm1 mw be reprbclu~ed In rely way wflh~, vw~tt en pennisslofl. Patient: (']J~ ~?/c~.~? 7~,q~/4.~ Jg.~ File #: Date of Onset: DATEOIK~VI$1T.~i~'~'~:~ iTOTAUTIME'SPENT: .' ~"7~i~: e~':DR'8 INITIALS:= "'l~:~,,X~.':' VIB~CODE('t.I(~/"~'?~I,/r' ~ O~EC~ES. ~ Pm~F~u~ g ~ ~d~ Pro~F~ '~ ~ De~ll~ ~ Compr~ens~e ~ ~ ~ ASSESSME~. ~ Pr~F~u~ ~pa~ Pm~F~us~ ~ ~elall~l ~ C~pm~eqshle . ,~ ~ p ~ P~: ~ Straight-lo.rd ~ ~ ~mple~ ~ M~emte ~mpl~l~ ~.HIgh Compl~ ( DATE OF VlSlT:~;.~)'' ToTAI~ TIME SPENT: IbT~iW-: DR'S INITIALS:.. r~,,g,~. ~ O~EC~ES: ~ Pm~Fmu~ ~ ~panded ~F~u~ . SEVER~: .- ~ Minimal ~ Minor · Low to Mode~te ~ Mode~te ~o High ~ High  ASSESSMENT: ~ Pro~F~ · ~nded Pro~F~us~ ~ De~il~ ~ Com~eh~Ne  P~: ~ 8~Ighl-¢m~ ~ L~ Compl~ly D M~erale C&mpl~ly ~ High Compl~ H-'lO5 /~.~ ~ File ~:~~ Date of onset:~ Patient: Cepwlghl ~ 1~92 ~ H.J.R~C~mp=ny. lnc. H-105 ~1 ~s roso~d. No pad may ~ ropr~u~ In ~W ~y ~fho~ ~,en ~l~n. Patient: ~~ ~ File ~: Date of Onset:~-~ *~l O~ECTIVES: ~ Pm~F~u~ ~ ~ ~a~ Pro~F~used ~ De{;lll~ D ComprehensNe I' SEVER~: ~ MlnlmM ~ Minor ~ Low to Mode~te ~ Modemfe to High ~ High  ASSESSME~: ~ Pm~F~us~ ~ ~nd~ Pro~F~us~ ~ De.lied D Compfehe~Ne p P~N: ~ Straight-lo.rd · L~ Comple~ ~ M~erate Comp~ex[~ ~ High Compl~ O~u I'IVES: ~ Pm~us~ ~ ~kd~ P~bF~us~ ~ Detall~ ~ ~ CmprehensNe ASSESSMENT: ~ Pro~F~used ~ ~panded Pro~F~used ~ Delall~l ~ ComprehensNe P~N: ~ Slmlghbfo~rd · L~ Complexly ~ M~erate Complexlly ~. High Com~W leot:~ File #:~~ Date of Onset: ~TE!OF )BJECTIVES: =rob-Focused SEVERITY: [] Minimal ,SESSMENT: [] Prob-Focused pLANt F'l Straight-forward ~R'S"I] pi-ob-Focused [] Delalled [] Coi.p,c|,ci~].a [~] Minor [] Low to Moderato [] Moderate to High ~ High [] ExpaP. ded Prob-Focused r'l Detailed [] Comprehensive [] Low Complexity [] Moderate Complexity [] High CompleyJty ~.TE;OF-VISlT:~?~:' I~~TOTAL TIME SPENT::.~::' IOrYl'l ~=~:~D R'S IN!TIAE$::~q SUBJECTIVE5: [L~C~fl=n, IlmltaUonl, --varRY & frequanff) t( SEVERITY: .ri pr=b-Focused ~ to Moderate Expanded prob-Focused I'1 Delalied [] Comprehensive [] Comprehensive pLAN: [] Stralghl-folwarci ~ Low Complexity [] Moderate Complexity I-1.HIgh CamplexRy 1ATE' OF VlS[T: "7' l ~' (~t"TOTAE TIME SPENT:' "~; DR'S INITIALS: ':""~ r-I Prob-Focused ~ Expanded Prob-Focused [] Detailed [] CorrF SEVER~: " ~ Minimal ~ Minor ~ Law m Modest. ~ Modemt; to High ~ High ASSESSMENT: ~ Pro~F~us~., ~ ~nded Pro~F~us~ ~ Delail~ D C~mpicii~r~e [] Stralght-for,vard Low Complexity [] Moderate C;~mplexitY I 105 Cup.lob 0 1~92 irt ~J lghls r .erred...No__~mnY ~ r_e~odu~ ~ la~.vm~,Mtn°ut v*~*dlon permis~°n* File #: Date of Onset: ,~°'~b' 01 / R P H-lO5 PptJent: O~EC~S. ~ Pro~F~ ~ ~nd~ Pro~F~used ' ~ DelaYed ~ ComprehensNe SE~R~: ~ Minimal ~ Minor ~ Low go M~e~te ~ Mode~ie to High ~ High ASSESSMENT: ~ Pro~F~u~ ~ ~and~ Pro~F~us~ ~ Detag~ ~ Comprehe~Ne PLAN: E] $1raJghl4orward Low Compl~rty I-1 Moderate Comprexity File #: Date of Onset:.. [] High ComplexJty DATE::OENISlT:'; ' E 8PENTt;,'/~,~ :~ DR'$ INITIALS: ' KY7 J~LO SUBJI=C¥iVES: (L~c.U.., I;m;ba[;u,,% ~eve~ & r~.=,,~H O~EC~VES; ~ ~pai~d=d Pm~F~us~ ~ Detailed ~ Minimal ~ Minor Low to ASSESSME~: ~ Pm~F~us~ ~ ~panded Pm~F~used ~ Detall~ r'lComprehensive to High [] Comprehensive PLAN: [] Siraight-I'orward Low Complexily [] Moderate Comprexity ii. High Complexity }ATE OF:VISIT:':' : 'TOTAL'TIME SPENT:' IC~,,"YI~/~ :DR'S INITIALS: YY))C'~.I VIE SUBJECTIVES: (Location, ;;i,i;;,~;;o. i, ~evorfly & frequent} I I O~i-~'---'~iv'ES: [] Prob-.Focused [] Expanded Prob-Focused ~] Detailed [] Comprehensive SEVERITY: [] Minimal [] Minor F~ Low to Moderate [] Moderate to High [] High ASSESSMENT: r'l Ptob-Focused ,, [] Expanded Prob-Focused [] Detailed [] Comprehensive PLAN: [] Slfakjhi-rorward Fkq Low Complexity [] Moderate C&mplexlty [] High Complexity - COpyllghl ~ 1992 by N.J. Ros/Compafly Inc~ Patient: ('~ ~ ~, L~ 0 ~/~-~ ~-~-~ · File #~: Date of Onset: . , -~., . ~ ~ ~ · ~ SEVER~: ' ~ Minimal ~'MIn~ ~ Low to M~emte ~ M~e~te to High ~ High ASSESSMENT: ~ Pro~F~u~ _ ~nd~ Pro~us~ ~ Detag~ ~ Comprehensbe P~N.' ~ Slmlght-f~ ~ L~ C~H~ _ ~ M~emte Comple~W . ~ High Comple~ DATE OF VISIT::: ' :'~ ~: ::,TOTAL TIME SPENT: ;~:DR~S INITIA~.,"~:::": '~ :~: ' VISIT CODE ~ O~ECTIVES: ~ Pm~F~u~ ~ ~pand~ Pro~F~used [] Detsil~ ~ 'SEVER~: ' ~ MIn~al ~ Minor ~ Low ;o M~e=te · ~ Modemte m High'r: '= :~:,~'Hlgh ASSESSME~: ~ Pro~F~us~ ~ ~nd~ Pro~F~u~ ~ Delail~ ~ Comprehensive P~: D Slmight-io~rd D L~ Complexi~ D ~.=t. Co~,,~ RE~E~D'~ ........ ' Nhn ~A~H;~I ~nnf DATE OF VISIT: .TOTAL TIME SPENT: DR'S INITIAL,'~: ' VISIT CODE:. ' ::':~:: SUBJECTIVES: (Loc~Uon, IImI~iU~i, r-.vlrlty & I~.qulncY) OBJECTIVES: [] Pmb-Focused ~] Expande*d P~e~;%Cus~ I-1 Detailed [] Comprehensive SEVERITY: [] Minimal [] Minor [] Low to Mode~te D Moderate to High [] High ASSESSMENT: [] prob-Focused [] Expanded Pmb. Focused [] Detailed [] Comprehensive pLAN: [] Stralght4onr~rd [] Low Complexity [] Moderate C~mplexily [] High Complmdty H-105 CopyflgN {) 1992 by AJI r~ghls tr~sor~d. No part may be re.educed In any way wlthoul wltlen Patient', (~ O, J ~.,1 -/~' ~-c~, ] ) _ File #: Date of Onset; DATE :OF!V]81T ~,~:i,~;,~.I~[~TO:i,Aj~,,~TiM E .~ p EN?: h ~'~ ~'~[~%~!~ DR S;INITIAES.~r~vIsn;,'-CO DE.,~!~'~ SEV~: ~ Minimal ~ MIn~ ~ Low to M~e~te ~ M~e~te to High ~ High ASSESSME~: ~ Pro~F~u~ ~ ~nd~ pm~F~us~ ~ Detail~[ ~ Comprehensive P~N: ~ Slmlghl-fo~rd ~ L~ Compl~ ~ M~emte Compl~y ~ High Compl~ DATE OF VISIT:' ~'~ oq~,,: O)e~TOTAL' TIME SPENT: J (~ ~ ~ r,' DR'S INmALS: ~/~:~' :"-:- VISIT CODE::: O~C~ES: ~Pro~F~u~' ~ ~ ~anded Pro~F~us~ ~ Detall~ ~ C~pmh~sNe SEVER~:.. ~ Minimal ~ Minor ~ Low ~o Modem~e ~ M~e~te ~o Hl9h ~ High ASSESSME~: ~ Pm~F~ ~ ~ Pro~F~us~ ~ Delall~ D Com~ehens~e P~: ~ S~ht~rd · L~ Compl~ ~ M~emle C~mpl~ ~ High Compl~ Cop~plllhl e 1992 b,/ H, J. Ros.~ Compa.ay.,_~?. H-105 ~1 rights rosor~ed. No pad may be i'eprodum~d In an'/~e}~ wtlhoul wlillen pafmi~am,. Cop~h O 1992 b? H.J. Ross Company, lre. i..,; ~,M. ~-. ,~.~ · ...... .a~[ rlghta reserved. No pad may be reproduced in any vmy without wrltlen permlsslorL :ient: ~lc.~' i~c~'t File#:~_...~__ Date of Onset: ~-OL0 -01 )ATE -105 INITIALS::" *rob-Focused f-I Dula;;e~ o'M0derare CI Prob-Focused [] Expanded prob-Focused PLAN: [] Straight-foreard [] Low Complexity [] Moderate Complexity [] Detailed [] Comp, · TOTAL TIME SPENT? JC)r',qrrx DR'$ INmALS: SUBJECTIVES: (Location. IlmltaUons, sevet~y & frequency} I/ [] Prob-Focused [] Expmlded Prob-Focused [] Detailed [] Cer,:~,uheflsive SEVERITY: [] Minimal "[] Minor RI Low to Moderate [] Pmb-Focused I~1 Expanded Prob-Focused RI Moderate fo High [] High [] Detailed [] Cu,,,p~ehenslve PLAN: [] Stmlght4orward [] LoW Complexib/ [] Moderato C~mpiexity [] Hlgh Complexly Copyflgh! O 1992 by H.'J.R~ss Compa.ny.!nc. Patient: ('.Hcx~-I~¢ ~fl~,~-c.~l File#: Date of Onse]: q-~(.~.;O] I DATE OF VIS T, ~r~. ~I~TOT~L~TIME~DENT.: 161~31~. ,DR~ INITIAI:.8. '~/~Yl~ ,.Visit CODE, ~! O~C~E~: ~ Pr~F~ ~ ~ Pro~F~u~ ~ De~ll~ ~ Compreh~slve S~R~: ~ Minimal ~ Minor ~ Low to M~e~te ~ MoE~te to High ~ High  ASSESSMENT: ~ Pm~Fm~ ~ ~nd~ ProbF~u~ ~ Detail~J ~ Comprehe~Ne P~: ~ Stmlght-f~rd ~ L~ Compl~ ~ M~emte Comp~E~ ~ High Compl~ DATE OF. VISIT: 5-I"') :bl;~.TOTACTiME SPENT:./A J~3,~ DR'$ INITIALS: · ~ (/_J,J~ =~:..,.'VIsIT Q~EC~E~ ~ Pm~F~u~ ~ ~nded Pm~F~u~ ~ Det~k~ ~ C~pmhe~e SEVER~: -.. ~ Minimal ~ M~or ~ Low to Mode~to ~ Mode~te to High ~ High  ASSESSMENT: ~ Pro~F~ ~ ~pand~ Pro~F~ ~ De~ ~ C~prehe~be p P~: ~ S~lghl-fo~rd ~ L~ Compl~ ~ ~emte C~mpl~l~ ~ High Com~ H-105 Copyrlohl ~ 1692 by H. J. Ro~.scompany, ln~. Patient: CB Ar~ ~,[~ ~/ File ~: Date of Onset: ! Cop~tgh 0 ~g92 b~ File #: Date of Onset: D Dela]led [] Cu.~,reh~.,s;.~ [] Minimal ASSESSMENT: [] prob-Fecused PLAN: [] Straight- lo.yard [g-Low to Moderate [] Minor [] Expanded Prob-Focused [] Delalled Moderate to High [] High [] Low'Complexity [] Moderate Complexliy [] High Complexity ATE OF VlSlTi [] Lm'v Complexity Patient: ~--~CX--]~¢ /~,Jcc/a~l File #: Date of Onset: OBJECTIVES; [] Prob..For. used I~I Expandod Pmb-Focus~:l [] Delal~od i'1 Comprehensive SEVERITY: [] MlnlmaJ [] Minor ~ Low to Moderate ~ Mmlerate to High [] High A A"~-EssMENT: r'l Pmb'Fecusod m ExPandod Pmb'F°cused (s~.'~ ca'~ a' ~-t ca'~iuoal _~C[ i,y~, ~--~.~ rl Detailecl r'l Comprehanslve PLAN: [] Straight-forward ~-Low Complexity [] Moderate Comply:fry [] High Complexity DATE'O~,~qSlT:,.'C;'~":6~-G:I~i~TOTAI~TIME SPENT: 'lOm'rr~ DR'S INITIALS: * ~ ~:'~,':"' VISI~,,'CODE:'t/F;q~g, v O~ECTNES: ~ Pro~F~u~ ~ ~ Pro~F~ ~ Deta~ ~C~preh~ · .: ~'~'.~ ;:~:', ~:~ ~MIn~al · -. ,:' ~ Minor · Law ~o M~e~te ': '. ~ M~'~m to Hlgh;'~'~gh ~;~':  A~SSMENT: ~ Pm~F~ ~ ~ Pm~F~us~ ~ DelaD~ ~ C~p~n~e DATE OE~Srlti:,'.~:..~:(~"~OTAC:TIME SPENT: IO r~ ~ n DR'S INITIALS:. ~'h~.J'? ,.-VISIT ~EC~ES: ~ P~ ' ~ ~nd~ ProbF~' D Deified ~ Comp~ ~; _. ~ MI~ ~ Minor ~ Low 1o M~e~ ~ M~e~l~ ~o High ~SSM~: D Pro~F~u~ ~ ~d~ Pm~F~u~ D DotaJl~ D P~: ~ S~l~-f~d . ~ L~ C~ D ~te C~mpl~ ~ High c~g. ,at/ent..-~T~/~ ,~ ,}~/f~ A 4J __ File #: ~'~ - J~ ~db~ ~l~~ -~ , . ~ .~ .~.,~-~= ,,,~ -' ~ n~ ~ ~&~i~. ~~ ~.~f...~.. ', ,,, ~ ~,._~-~'~ O~EC~S. ~ ~F~ ~ ~ Pm~F~ ~ Del~l~ ~R~: ~ ~,,,,.m; ~ MIn~ ~ Low to M~omto ~ M~em,ro to High ASSESSMENT: ~ Pm~F~ ~ ~nd~ Pro~F~us~ , ~ De~ll~ ~ Com~eh~ ENT:'?i ' "~DR'8 INITIALS:'..'(I')~i ' .' OBJECilVES: [] Pmb-Focused ~.ocat~n. tests & lindTn Os) ASSESSMENT: [] Pmb-Fm;used PLAN: [] Slralght-forward : ' Law to Moderate [] Expanded Prob-Focused ,.~','~t [] Comprehensive [] Comprehensive [] Low Complexity []'~S--oderate Complexity ri. High Complmdty ;~;;~I.e_II;'~_--5(}'UI'~I~TAI:TIMESPENT: I.~m:J/'l DR'SlNITIALs: ~q~LL) VISlTCOOE~~ · _OBJECTIVES, [] Pmb-r~ [] Expanded Prob-I~used'--- [] Detailed [] Com-rehens~- J ASSESSME~: ~ P~F~u~ Il ~ Pro~F~us~ D Oelall~ P~N: ~ Stmlght/f~ ~ L~ Comp~ 0 ~le Csmpl~ INITIAL REPORT TO: Nationwide Insurance Company PATIENT: Charles Mitchell EMPLOYER: ~alf DATE OF INJURY/ONSET: 04-20-2001 Incident of Injury: "I ' ' was dnv~ng West on Trindle Road and was stopped to turn left into my driveway. A vehicle came up the berm of the road at a high rate of speed and hit me in right rear of my van as I turned in. Impact was ~reat pushing me 10 to 12 feet." Patients' Complaints: Neck, upper back, left shoulder and arm pain down to elbow, pain level 7. Tin,lin§ in left hand and in 1~; 3 fingers of right hand. Getting Hght headaches. Have some low back pa~a, mostly left side, dull ache with some numbness in toes offand on. Loss of balance at times with dizziness and chest pains occasionally. '. Objective Findings: Positive orthopedic tests, reduced ranges of motion, sp/nal muscle spasms and multiple vertebral subluxations all support the above mentioned complaints from the auto accident. X-Ray Analysis Summary: Cervical, thoracic and lumbo-sacral v/ews were taken - see report. Diagnosis - ICDA: E812.0 MVA with another velhicle (driver) 723.3 Acute moderate cer~4cal brachial syndrome +723.4 Acute moderate brachial neuralEia +723.1 Acute mild moderate cerv/cal~/a +840.9 Acute moderate shoulder p/fin 847.1 Acute m/Id moderate thorac/c sprain/strain 846.0 Acute mild moderate: lumbo-sacral sprain/strain +724.1 Acute m/Id lt~mbalgia Alternate Summary (Comments): Treatment consists of cervical, thoracic, lumbo-sacral and left-shoulder C.M.T., low volt galvanism and interseEmental traction. ~ 8= Michael R. Warner, D.C. Disability Dat~: Patient should refrain from any lifting more than 3 lbs., excessive.use of arms, bending, twisting or long periods of sitting. Examination Forms Attached: [ ] Yes IX ] No Additional Evaluations Attached: [ ] Yes IX ] No Accident Report Attached: [ ] Yes IX ] No Dat:e.;/a]~y 7, 2001~ RECEIVED I AY 9 2001 Hbg. Medical Dept. ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 atient: Charles W. Mitchell Chart %: 09878301 OB: 01/30/22 SSN: 186 12 1986 Page ~ 1 11/28/2001 RONALD W. LIPPE, M.D. HARRISBURG HOSPITAL OUT~ATIEN~-- ~_ November 28, 2001 PINNACLE HEALTH-HARRISBURG OUTPATIENT DIAGNOSIS: 2 cm longitudinal rotator cuff tear; left shoulder PROCEDURE: Left shoulder acromioplasty and repair of his left rotator cuff tear RWL/j In ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 ~tient: Charles W. Mitchell Chart #: 09878301 )B: 01/30/22 SSN: 186 12 1986 Page ~ 1 9/19/2001 RONi%.LD W. LIPPE, M.D. LEVEL THREE ~ Trindle Road office -- ~ CHIEF COMPLAINT: Charles was involved in a motor vehicle accident on 04/19/01. HISTORY OF COMPLAINT: Apparently he was in his driveway when another car hit him from behind. Since that time, he has had difficulty with pain in his shoulder. Pain is in his right shoulder. It is worse with activities, especially moving the shoulder. It awakens him at night. He has tried anti- inflammatory meds with little'improvement. REVIEW OF SYSTEMS: The patient's review of systems, past medical history, famil~ history and social history have been re-evaluated and reviewed. pHYSICAL EXAM: On exam today, he.is a healthy%appearing gentleman in no acute distress. Range of motion of the shoulder. is satisfacto~6 but he has a markedly positive impingement sign at 90 degrees forward elevation worse with internal rotation. The skin overlying his shoulder is normal. He has surprisingly good active range of motion of the shoulder. DIAGNOSTIC TESTS: I reviewed his MRI, which is consistent with arthritis and what appears to be a rotator cuff tear. DIAGNOSIS: I explained to Mr. Mitchell that he appears to have a rotator cuff tear. PLAN: Ha states he doesn't want surgery if at all possible, in an effDrt to decrease his slnnptoms, I injected his left shoulder subacromial space unier sterile conditions and told him to give this 6-8 weeks to improve. I'll see him at the end of that time to reevaluate him. RWL/rah APPLICATION FOR BENEFITS T NATIONWIDE MUTUAL INSURANCE COMPANY TO ENABLE US TO DETERMINE IF YOU ARE ENTITLED TO BENEFITS PLEASE COMPLETE THIS AND RETURN IT PROMPTLY. DATE: April 24, 2001 OUR POLICYHOLDER: Charles W Mitchell CLAIM NUMBER: 58 37 C 169820 04202001 01 DATE OF ACCIDENT: 04-20-2001 INJURED PARTY (if other than addressee): IMPORTANT: 1. To be eligible for benefits you must complete and sign this application. 3. Return proraptiy with copies of any b 2. You must also sign the enclosed records authorization. - Phone Nos. Home Business Date of Birth Social Security No. Your Residence At The Ti me of The Accident: Name/Address of Owner of Vehicle You Occupied/Operated: Insurance Co. of Vehicle Owner: Place of Accident(Street, City or Town and State A/;,4 7- / OA¢ I,¢ I l)~- Brief Description of Accident: Describe Automobiles Owned By You and By Any Member of Your Family Residing In the Same Household Automobile . Veh. ID Number Owner Insurer P. olicy No. License No. Veh. 2. Veh. 3. As a Result of This Accident Were You Injured? (~.~fYes ( ) No If Your Answer Is Yes, Complete The Rest of This Form. If No, Sign Here and Return ~his Form To U.s. __ .. SIGNATURE: ~ .~, ~ DATE: ~r_ ~. ~-~ -89/' Have you ever had the sadle on~imilar injur~? ()~t~es ~}'No If yes, explain Name of family physician WereyouTreatedByaDoetororOtherPersonFurnishingHealthServices? Yes~' No() Name and Address of Such a Person: If You Were Treated In a Hospital, Were You: An In-patient () An Out-patient () Treatment Dates: Hospital's Name and Address: Will you have more Health Expe~tses? Yes f/~,"N o () At the Time of Your Accident Did you Lose Time From Work? Yes ~ No () Were You In The Course of Your Employment (O'Yes () No If yes, How Much? If Yes, Date Disability From Work Began ~k~L~ Date You Returned To Work: What Are zour Average Gross Weeldy Earnings? $ ~ ~q4~,'o.,~ I/=t,:-,~ ~.,v pt, ecesved or Are You Ehgible For Any Mednca or D sub ~ty Benefits Under: Worker's Compensation Yes() No~~- FederalSocialSecurity yes() No(t.3,,.-'~ State Required Non-Occupational Disability Benefits Yes ( ) No ~ Any Other GovernmentaIBenefits Progi:am Yes ( ) No ~,) Describe Any Group, Health, or Accident Ins. Program Yes ( ) No (/..~ Company_ List Names and Addresses of Your m oyers For One Year Prior to Accident. Give Occupation and Dates of Employmetit. .... Employer and Address ~ Occupation Employer and Address Occupation From To ' '. ~' ' Al ~ Result o.f.Your Injury Have Ynn Had A?y Other Expen%es? Yes f/~ No ( ) If Ye~, Attach En01anation and Amouuts of Such Expenses. ,,'vt~/ Vz% A/ k4./ft $ Tb rbL6 0~'/~./44~ Applicant Authorizes ,helnsurer to SubmR Any a.d The Protect Its ~ghts of R~ove~ Provided For Under This Act. We R~ommend You AI~ Contuct Your Group Or HeaBh Insurance Carrier In the Event Your Expenses Exceed the First Pa~ Benefits Coverage. SIGNATU~ ~~ ~~ DATE Any person who knowingly and with intent to defraud any insurance company or other person file:s an application for insurance or statement of claim containing any materially false information or conceats for the puq~ose of misleading, nformation concerning ~qy fact material thereto commits a fraudulent insurance act. which is a crime and subjects such a person o cdm na and civil penalties P.O. Box 2655 * * Harrisburg, PA 17105-9971 Charles W Mitchell 5016 E Trindle Rd Mechanicsburg, PA 17055-3621 April 24, 2001 OUR INSURED: Charles W Mitchell INJURED PARTY: Charles W Mitchell OUR CLAIM NUMBER: 58 37 C 169820 04202001 01 DA]TE OF ACCIDENT: 04-20-2001 I authorize you to furnish to Nationwide Mutual Insurance Company or its representative, all my records concerning: 1. Hospital or medical/dental treatment, including diagnosis, prognosis., disability and service charges. 2. Earnings information, including rate of pay, job classification and loss of time from work. 3. School information, including loss of time, grades and reduced activities, if any. I also authorize Nationwide to furnish any of the above mentioned records to my group, health or accident insurance company. A c_opy of this authorization may be accepted with the same authority as the original. PATIENT'S NAME: ~N//~L Please Print PATIENT'S DATE OF BIRTH: PATENT'S SOC~ SEC~TY PAT~'S SIGNAl: Ct~ ATr: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of n'dsleading, information concerning any fact mater'ial thereto commits a fxaudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties. IF A MINOR, SIGNATURE OF PARENT OR GUARDIAN tny person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or tatement of claim containing any materially false information or conceals for the propose o1~ misleading, information concerning ny fact material thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil ,enalties. A brief description of the accident It was April the 19th at approx.4:45 in the afternoon,I was in my lane of traffic with my turn signal on indicating a left hand turn into my drive way when the light turned and the traffic began to move the moterist even with my driveway was kind enough to wait for me to enter my driveway,~at which time the moterist motioned for me to enter my drive way,which I proceeded to do. A moterist approximately sixteen or eighteen (:ars up the lane of traffic pulled out of th~ line of traffic and came roaring down the burm,and plowed into my van. The imp~dt was so great that it sli~ my van fifteen feet on the dry pavement.which destroyed & damaged all of my stock and broke a key machine. .V '.001 JANUARY FEBRUARY MARCH APRIL IVlAY JUNE MT W T ES SMTW T F S SMTW m F S SMT W T F S SII..TL.[.T.,F,[SMT W T F S 1 2 3 4 5 6 123 12 3 1 2 3 4 5 6 7 ,.,/..t)!~,~3.J4...(~. 12 S 9 10 11 12 13 4 5 6 7 8 9 1014 5 6 7 6 9 10 S 9 10 11 12 131a 6~,J~j~12 3 4 5 6 7 8 9 ~15 16 17 18 19 20 1112 13 14 15 16 17 1112 13 14 15 16 17 1516 17 18 220_21 131,J.~ ~10 1011 12 13 14 15 16 29 30 31 25 31 27 28 2526 27 28 29 30 31:Z~(~_~ 2728 ~;~) 31_ !425 26 27 28 29 ~ RECEIVED- AUG 0 ? AIG SPECIALTY AUTC* PIT'FSBURGH PA JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER SMT WT : S SMTW T F S SMT W T F S SMTW T F S SMTW T F S SMT W T F'S! 1~3 4 5(~7 1 2 3 4 1 1 2 3 4 5 6 12 3 1 8~j[~10(~12..~45 6 7 8~10.1.1,23 4 5 6 7 8,78 91011121345 6 7 8 910 23 4 5 6 7 8 ~[ !.0 11 12 13 14 15 9 10 11 12 13 14 15 15~'171~-19~21121i~)14't'5'~17~ 1~ ]/1819 20 2122141516171819 201112131415161716171819 20 2122 22 [3..,)24/~26 t !~ 25 19J~ 21 '2~.~1~ 24 232425262728292122232425262718192821222324123242526272829 ~)31 -- ' 26~7.)28 2913(,31 30 2829 30 31 2526 27 28 29 30 3031 Direct inquiries regarding this review to: Red Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 - Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA A bill audit, fee schedule and claims processing service GOOD HOPE FAMILY PHYSICIA/~S 1830 GOOD HOPE RD. ENOLA, PA 17025 MITCHELL, CHARLES 5016 EAST TRINDLE Re MECF~NICSBURG, PA 17055 POLICY HOLDER: RECEIVED PROVIDER: ID/PRGVIDER NO: 1-XAuG 0 ? 2002 PATIE MO: AIG SPECIALTY AU~TC' ] ACCIDENT DATE: MEDLOGIX ID: CALCULATION DATE: CLAIM NO: 5837C 16982004202001PA458Prt(14 COVERED INDIVIDUAL: MITCHELL, C}L~RLHS MITCHELL, CF~kRLES GOOD HOPE FAMILY PHYSICIA/~ 23-2933075 MITCCH312903 NATIONWIDE HARRISBURG, PA o4/2o/ol 130421A -009~ 12/18/01 EXPLANATION OF BENEFITS DIAGNOSES= 1) 840.4 ROTATOR CUFF (CAPSULE) SPRAIN 2} V72.83 OTH SPCF PREOP EXAM -THE MHD BOX. Provider's A~nount Billed .... : Allowed Amount .............. : TOTAL AMOUNT DUE.. .......... 62.00 36.89 36.89 Carrier's Responsibility .... : 36.89 DATE OF BBRVICB: 11/19/01 PA Automobile Si ITEMIZED CHARGES DATE SERVICE DIAGS UNITS CHARGE PAYMENT TYPE REDUCTION AMT DUE STATUF 11/19/01 93000 12 1.00 55.00 ' State Fee ~ 1i0% ( _ 25.11) 29.89 Electrocardiogram. routine ECG with at least 12 leads; wi=hin~erpretat:ion and report 11/19/01 36415 12 1.00 7.00 Prov Cnrg u 100% ( 0.00) 7.00 Routine venipunc~ure or finger/heel/ear stick for collection ofspecimen(s! Totals: 62.00 ( 25.11) 36.89 IF PAYMENT IS DUE, CHECK WILL BE MAILED UNDER SEPARATE COVER.. / THE A~OVE SERVICES ~AVE BEEN COMPUTED TO CONFOR/4 TO PSNNA HOUSE BILL 121 AUTO INSURANCE REFORM LAW, "ACT 6", AS AMENDED NOVEMBER 30. 1991. ALL CALCUI~TIONE REPRESENT 110% OF THE APPLICABLE MEDIC~RE FEE SCHEDULE. REC,O~94ENDED FEB, DRG AROUNT, 80% OF U&C; OB PROVIDE~ C~RGES, AS IN ACCORDANCE WITH SECTION 69.43. MedLogix Managed Care System V2.5 Rev 07/01 (c) 1997 Consolidated Services Group, Inc. PLEASE Nationwide Insurance Co. O0 NOT ST.APLE Medical Department INTHIS P 0 BOX F.,'9600 AREA Ha~m"isb,.n"g P'A 17106-9600 MEDICAID CHAMPUS CHAMPVA GROUP HEALTH PLAN HEALTH INSURANCE CLAIM FORM FECA OTHER la. INSURED'S ID NUMBER BLK LURG PICA [ (FOR PROGRAM [N ITEM ~016 East Tr.itnd].e Road STATE ' PA Z:PCOCE 1 T~LEPHONE ~rc~ceAreaCodel :17055 717) 766-4208 01-30 t9;-".;-2 Fj~, PATIENT STATUS Studen~ ~ Studenl [] 10. IS PATIENT'S CONOITION RELATED TO: Ca~/c 1.6=8co Mi t~hel l' Charl es 5016 East ]'r~ndle Road CITY Mechanicsburq STATE .l '7055 11. INSURED'S POLICY GROUP OR FECA NUMBER [ d ~NSURANCE PLAN NAME OR PROGRAM NAME 1Od. RESERVED FOR LOCAL USE d IS THERE ANOTHER HEALTH BENEFIT PLAN? i * ~' ~' ~ 'X- ~' r~YES [] NO Ilyes, retumtoandcOmpleleltemga-d. READ BACX OF FORM BEFORE COMPLETING & SIGNING THIS FORM. i!2. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I aulho~ize the ielease of any medical Ct olher mlorma~ion necessary [o process Ih~ claim. I also request paymenl of '~¢verrtment benefits either ID myse}l or to the pafly who accepts assignmen[ Signature On File 113001 04 1 ,~1 [~ t PREGNANCY!LMP ~ [8~0.4 Sprain, Rotator Cuf~fl 13. INSUREO'S OR AUTHORIZED PERSON'S SIGNATURE I authorize payment ol medical benefits to the undecs~gned physician or supplier for Signature On File z ~.~ Pat (Preo)et-at ive E:-~I .__ A 0 I P'ace PROCEDURES. SERVICES. OR SUPPLIES ! '-.]' 93000 l 9 01 i .3 19 01 -13; 3;6415 i 25 FEDERAL TAX I.D. NUMBER SEN EFN ' F'?,-;z"~ ~ .~, gl '7~ ]t SIGNATURBOF PHYSICIAN OR SUPPLIER ~l INCLUDING DEGREES OR CREDENTIALS iD Harr M.O. 23-2933075 OATE113001 BATES PATIENT UN;~L~ ;1~ WORK IN Cd RRbNT OCCUPATION- -'-- ,k 26 PATIENT'S ACCOUNT RO. PLEASE PRINT OR TYPE Good Hope Family Physicians 1830 Good Hope Road Enola PA 17025 27. ACCEPT ASS GNMENT? 28. TOTAL CHARGE 29. AbIOUNT PAID 30 BALANCE DUE mitL~mh.~lR90~ ~ YES [] NO $ $ )0 32, NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33. PHYSICIAN'S, EUPPLiER'S BILLING NAMF~t ~D~_.~,,t~7 7 ~ ~ 2 '7 00 1 · -c-_' 55 E F K RESERVED FOR CODE $ CHARGES LOCAL USE 20. OUTSIDE LAB? $ CHARGES D~rect inquiries regarding this review to: Med Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 . Fax (215) 661-0871 OSL DBA ORTHO INSTITUTE OF PA 875 POPLAR CHD-RCH RD CA~ HILL, PA 17011 MITCHELL, CHARLES 5016 EAST TRINDLE MECH~ICSBD-RG, PA 17055 5837C 16982004202001PA458 LIGHTNER, BRENDA A bill audit, fee schedule and claims processing service CLAIM NO: 5837C 16982004202001PA458Prt(14 COVERED INDIVIDUAL: MITCHELL, CHILRLES POLICY HOLDER: MITCHELL, CF~ARLES PROVIDER: RECEiV:S~/PHOViDEH HO: PATIENT NO: JA~I 0 3 2~¢2 PAYOR, Hbg. Me0icai De~sCiDEm' DATE, MEDLOGIX ID: CALCULATION DATE: OSL DBA ORTHO INSTITUTE OF 23-1875547 098783 0008 P NATIONWIDE 'F~%RRISBURO, PA 04/20/01 130421A -010A 12/29/01 EXPLA/~ATION OF BE1FEFITS DIAGNOSES: 1) 840.4 ROTATOR CUFF (CAPSULE) SPRAIN DATE OF SERVICE: 11/28/01 VENICLB TRAFFIC ACCIDENT INVOLVING COLLISION WITE MOTOR VEHICLE SERVICESVICES~ 2) E812.00~BR MOTOR THE M~D BOX ,. Provid.r's ~ount E:ll.d .... , ~,~,.00 II / L~ II --~"OWed ~ount .... : 1,028.70 il/ ~%~ / TOT~ ~O~ DUE ............ : 1,028. ' -'-" - :i Carrier s Respons~bzlzty 12 Autom e ITEMIZED C~GES DATE SERVICE DIAGS UNITS CHARGE PAYMENT TYPE REDUCTION AMT DUE STAT~J: 11/28/01 23410 12 1.00 2,249.00 state Fee ® 110% x 100% { 1,220.30) Repair of ruptured musculotendinous cuff {eg, rotator cuff); acute Totals: 2,249.00 ( 1,220.30) 1,028.70 1,028.70 IF PAYMENT IS DUE, CHECK ~WILL BE THE ABOVE SERVICES HAV~ BEEN COMPUTED TO CONFORM TO pENNA HOUSE BILL 121 AUTO INSHR~CE REFORM LAW. "ACT 6", AS AMENDED NO%~MBER 30 MedLogix Managed Care System V2.5 Rev 07/01 (c)1997 Consolidated Services Group, Inc PLEASE. 9786 NATIONWIOE DONOT PO BOX 69600 STAPLE HARRISBURG IN THIS AREA PA 17108-9600 lTL;HELL, CHAR_E.~ 1.4 ~ 5 PATIENT S ADDRESS (NO . StreeB 5016 EAST I-RINDLE ROAD CHAMPVA GROUP FECA OTHER HEALTH PLAN ELK LUNG 3 PATIENT'S BIRTH DA~ 01 30 192~ ~ F~ cI~MECHANICSBURG STATE PA PA zip CODE 17055 TELEPHONE tncude Area Codei (717~766-A379 a OTHER iNSURED S POLICY OR GROUP NUMBER b OTHER INSUREr'S DATE OF BIRTH SEX MM DD Y¥ c EMPLOYER'S NAME OR SCHOOL NAME HEALTH INSURANCE CLAIM FORM ta. INSUREDS I O NUMBER 5837C169820 E, PAT'ENT RELAT,ONSH,P TO,NEBREO Selt [] Spouse~ cn,10~ Omer~ 8 PAT,ENT ETATUE SingleMarriedOther tO. IS PATIENT'S CONDITION RELATED TO: MITCHELE-, CHARLES, W 5016 EAST TRIHDLE ROAD 'mTYMECHANICSBURG STATE PA PA ZIP CODE TELEPHONE IINCLUOE AREA CQDE~ 17055 (717~766-4379 I I INSURED'S POLICY GROUP OR FECA NUMBER 186121986 INSURED'S DATE OF EIRTH SEX btM OD YY 01 30 1922 M,~ F~, : EMPLOYER S NAME OR SCHOOL NAME : .2 INSURANCE PLAN NAME OR PROGRAM NAME NATIONWIDE INS CO INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH SENEF(T PLAN? E~YES [] NO If ye$. retum to and complete ilem P a.d READ BACK OF FORM BEFORE COMPLETING & SIGNING THiS FORM. PATIENT'S OR AUTHORIZE DPE RSON'S SIGNATURE I aulhorize lhe ~elease ol any medical or olh~r inlormation necessary ID process I6is claim. I also requesl paymenl of government benetils eilher to myself or to Ihe party wh~ accepts assignmen~ below SIGNATURE 0N FILE 12-13-01 E~GNED DATE 15 IE PATIENT HAS HAD SAME OR SIMILAR ILLNESS. O,VEE,RSTDATE A LTPPEZ' NAME OF REFERRINGM0 RONALoPHYSICIAN DRip,OTHER SOURCE IC34,5857a ID. NUMBER OF REFERRING PHYSICIAN 14. DATE OF CURRENT; ILLNESS (First syrnplcm) OR INJURY (Accideoll OR 4 PREONANOY(LMP, 19 RESERVEO FOR LOCAL USE 21. DIAGNOSIS OR NATURE OF tLLNES~OR INJURY. (RELATE iTEMS 1.2,3 OR 4 TO ITEM 24E BY LINE) ~18404 2.1E8120 4L__ 24 .~roDmATE(S} OF SERVlCETo llll 28 01 02 t DtAGNOSrS CODE i 2 C O ¢pe PROCEDURES. SERVICES. OR SUPPLIES 3f (Explain Unusual Circumstances) 26. PATIENT'S ACCOUNT NO 27. ACCEPT ASSIGNMENT? (For govt. claims, see backl 098783 0008 p ~ YES [] NO 25 FEOERAL TAX ID NUMBER SSN EIN 23-2875547 O~ 31 SIGNATURE OF PHYSICIAN OR SUPPLIER iNCLUDING DEGREES OR CREDENTIALS SlpNEO -- DATE ;APPROVEO BY AMA COUNCIL ON MEDICAL SERVICE 8 88) 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE HBG HOSP HA390098 SOUTH FRONT STREET HARRZSBURG PA 17101 0000390067 PLEASE PRINT OR TYPE 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I auihedze payment of medical benefits to the undersigned physician or supplier for sen4ces descnbed below SIGNATURE ON FILE SIGNED 1B DATES PATIENT i q*.a.~, E TO WORK IN CURRENT OCCUPATION MM DO YY M*.I DO YY FROM TO 18 HOSPITAUZATION ')ETE~, RELATED TO CURRENT SEB~I~ES -- MM DO YY ',~M DO YY FROMll 28 Gi TO 31 28 01 20. OUTSIDE LAB? $ ~.HARGES 2249.00 LI480429 28 TOTAL CHARGE 29 AMOUNT PAID $ 2249.00 $ .00 30 BALANCE DUE s2249.00 33. PHYSICIAN S. SUPPLIER'S BILLING NAME. ADDRESS ZIP CODE & PHONE # OSL 0GA 0RTH INSTITUTE OF PA 875 POPLAR CHURCH ROAD CAMP HILL PA 17011 761-5530 I GRP# ~ 6 0 2 9 9 PIN# FORM HCPA-'500 { 1E-90) FORM OWCP-i 500 FORM RRB-15CC )i~ ~ct inquiries regarding this review to: 4ed Path _240 South Broad Street ~uite 200 ~ansdale, PA 19446 rhone (215) 661-0500 - Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA A bill audit, fee schedule and claims processing service OSL DBA ORTHO INSTITITfE OF PA 875 POPLAR CHI/RCH RD C~4P HILL, PA 17011 MITCHELL, CHARLES 5016 EAST TRINDLE ROAD' MECHANICSBURG, PA 17055 CLAIM NO: 5837C 16982004202001PA458Prt(14 ~OVERED INDIVIDUAL: MITCHELL, CHARLES POLICY HOLDER: MITCHELL, CHARLES ~ROVIDER: ~ ID~PROVIDER NO: PATIENT NO: PAYOR = ACCIDENT DZ%TE: : MEDLOGIX .ID: CALCULATION DATE: OSL DBA ORTHO INSTIT~E OF 23-1875547 098783 0007 P .NATIONWIDE F~%RRISBURG, PA 04/20/01 130421A -008D 12/20/01 DIAGNOSES: 1) EXCEPTIONS REPORT EXPLANATION OF BENEFITS 840.4 ROTATOR CUFF (C~PSULE} SPP~IN DATES OF SERVICE: E812.0 OTHER MOTOR VEHICLE TRAFFIC ACCIDENT INVOLVING COLLISION WITR I~TOR VEHICLE THE M~D BOX- ~ Provider's Amount Billed .... : 203.71 Allowed Amount .............. : 201.05 TOTAL AMOUNT DUE ............ : 201.05 Carrier's Responsibility .... : 201.05 09/19/01 - 11/09/01 PA Automobile ST Dear Sir/Madam: On 12/20/01 the above named case was referred to the Review Department to evaluate coding, treatment, or billing as it relates to Section 69.24 of Act 6 amended November 30, 1991. Your bill for treatment on 09/19/01 has been reviewed. The following listing more appropriately describes the services rendered. ITEMIZED CHARGES DATE SERVICE DIAGS UNITS CH/LRGE PAYMENT TYPE REDUCTION AMT DUE STATUS 09/19/01 99213-25 12 1.00 50~00 prov Chrg · 100% ( 0.00) 50.00 office or other outpatient visit for the evaluation and management of anestablished 9atien=, which requires at 1 IF PAi~ENT IS DUE, CHECK WILL BE MAILED %tN-DER SEPA/~ATE CO%tEE. THE ABOVE SERVICES HAVE BEEN COMPUTED TO CONFOR/~ TO SENNA HOUSE BILL 121 AUTO INSURANCE REFORM LAW, "ACT 6". AS AMENDED N0~E~BER 30, 1991. ALL CALCULATIONS REPRESENT 110%. OF TEE APPLICABLE MEDICARE FEE SCHEDULE, RECOMMENDED FEE, DRG AMOUNT, 80% OF U&C; OR PROVIDER CF~RGSS, AS IN ACCOEDAMCE WITH SECTION 69.43. ~ PERSON WMO KNOWINGLY A~ WITH INTENT TO DEFRAUD AN~ INSU~CE COMPANY OR OTHER ~SRSON FILES AN APPLICATION FOE INSURANCE OR STATEME~f OF CLAIM CONTAINING A~ MATERIALLY FALSE INFORF~%TION OR CONCEALS FOR THE PURPOSE OF MISL~J~DING, INF0~RATION CUNCERNING A~ FACT MATERIAL TEERETO COMMITS A FRAUDULENT INSm~ANCE ACT, WHICH IS A CRIME A~ SUBJECTS SUCH A PERSON TO CRIMINAL A~ CIVIL MedLogix Managed Care System V2.5 Rev 07/01 (c}1997 Consolidat DiKect inquiries regardin9 this review to: Med Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 Fax CLAIM NO: 5837C COVERED INDIVIDUAL: MITCHt PAYOR: NATION HARRIS DATE SERVICE DIA 09/19/01 20610 12 Ar throcentesis ~ aspirat~ C~ RESOLUTION: CODE APPI 20610 12 Arthrocentesis ~ aspirat~ 09/19/01 J1030 12 INJECTION, METHYLPREDNI ! 11/05/01 99213 12 office or other outpati~ Status Codes: C2 ~ Denied pending Status Codes: RC - CR resolution: PLEASE NOTE: DISAGREEMEN~ A COPY OF BOTH THIS EXPLD~ Your Review has been'compl Nancy M Busfield, RN Medical Review Specialist (215) 661-0871 [6982004202001PA458 LL, CH3%RLES ~IDE BURG, PA 5837C 16982004202001PA458 LIGHTNER, BRENDA ITEMIZED CHA~RGES PAGE: 2 ~S UNITS CHA~RGE PAYMENT TYPE REDUCTION AMT DUE STATUS 1.00 100.00 (0.00) 0.00 C2 on and/or injection; major joint or bursa (eg,shoulder, hip, knee joint, subacromial bur OPRIATS, PROPER FEE ASSIGNED. 1.00 Prov Chrg ® 100% x 100% ( 0.00) 100.00 RC on and/or injection; major joint'or bursa (eg,should -=~ 1.00 3.71 SCare Fee ~ 110% ( 2.66) 1.05 OLONE ACETATE, 40 MG 1.00 50.00 Prov Chrg ~ 100% ( 0.00) 50.00 nt visit for the evaluation and management of anes~ablished patient, which requires at 1 Dtals: 203.71 ( 2.66) 201.05 ;iew. Review necessary for appropriate application of code. Pz)per code assigned OR Code appropriate, proper fee assigned. S OR COMPLAINTS MUST BE t%DDRESSED IN WRITING. PLEASE ENCLOSE ATION AND THE ORIGINAL BILL WITH ALL CORRESPONDENCE. eted by IF PAYMENT IS DUE, CHECK ~I,i~LL BE MAILED UNDER SEPARATE COVER. ! THE ~OVE SERVICES ~AVE BEEN COMPUT~ CHARGES, AB IN ACCORDANCE WITH SECTXON 69.43. A~ PERSON WHO KNOWINGLY A~ WITH INTENT TO DEFRAUD A~ INSU~CECOMPAN~OR OTHER PERSON PILES AN APPLICATION FOR INSUP-%NCE OH STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFOPJ4ATION CONCEP~NING ~u~rf FACT MATERIAL THERETO C~ITS A FRAUDULENT INSL~CE ACT, WHICH IS A CRIME A~4D SUBJECTS SUCH A PERSON TO CRIMINAL~24DCIVIL PENALTIES. MedLo~ix Managed Care System V2.5 Rev 07/01 (c)1997 Consolidated Services Group, Inc. PLEASE,. 9786 I',IATIONWTOE DO NOT P 0 B C '~ STAPLE HARRISo ,~ IN THIS AREA PA 17105-9, .' INS CO PICA HEALTHPLAH BLKLUNG IDIlTCHELL, CHARLES 5. PATIENTS ADDRESS [No . Sir eell 5016 EAST TRINOLE ClTYMECHANZCS8URG PA ROAD HEALTH INSURANCE CLAIM FORM FECA OTNEE la INSUREDSID NUMBER 5837C169820 01 30 1929 Employed~L~ Fu~l.Time~ Pa4-Time~ ZIP CODE TELEPHONE dncluOe Area Code} 170s5 ~ 0 IS PATIENTS CONDITION RELATED TO: a. EMPLOYMENT? ~CURRENT OR PREVIOUS} ~jYES bOTHER INSURED'S DATE OF BIRTH SEX MM DD YY M'-- E F~ C EMPLOYER'S NAME OR SCHOOL NAME INSURANCE PLAN NAME OR PROGRAM NAME bAUTO ACCIDENT? cOTHER ACCIDENT? F~NO 10d. RESERVEG FOR LOCAL USE READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM, PATIENT'S OR AUTHORIZED PERSONS SIGNATURE t authorize Ihe release ol any medical o~ other rnlormalion necessaly ID process Ibis claim. I also ~equest payment of gover nrnenl Oenelits el[her ID myself or to the p~uly who accepts assigr)~en{ pa~ow SIGNATURE ON FILE 12-03-~1 SIGNED ............... DATE ................... DATE OF CURRENT: ~ ILLNESS I Firsl symptom~ OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ~LLNESS 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE LIPPE M0 RONALD W 19. RESERVED FOR LOCAL USE 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (RELATE ITEMS 1,2.3 OR 4 TO ITEM 24E BY LINE~ } L8404 4.1 IB I ¢1 D Place Type PROCEDURES, SERVICES. ORSUPPLIES DD YY S~;lS~c, 99213CPT'HCPCS Ii MODIFIER DIAGNO~S ~ ~E8120 24 A FroDmATE{S) OF SERVICETo MM DD YY MM CODE 25. FEDERAL TAX I0 NUMBER SSN EIN 23-1875547 ~ ~ 1 2 26 PATIENT S ACCOUNT NO 27. ACCEPT ASSION/vlENT? tFor govt. claims, see uack 098783 O007 P [] YES [] NO 31 SIGNATURE OF PHYSICIAN OR SUPPL:ER INCLUDING DEGREES OR CREDENTIALS (I certily thai [he s[alemenls on Ihe reverse 2- (APPROVED 0Y AMA COUNCIL ON MEDICAL SERVICE 8;88) PICA (FOR PROGRAM IN ITEM t) MITCHELt~, CHARLES, W !5016 EAST TRINDLE ROAD STAT/A S,TYMECHANICSBURG PA ZIP CODE i7055 11 INSURED S POLICY GROUP OR FECA NUMBER 186121986 0i 30 1922 M~. ~r'~ NATIONWIOE INS CO d. IS THERE ANOTHER HEALTH BENEFIT PLAN? ~YES [] NO If yes. relum to and complete item 9 a-d 13 INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authonze SIGNATURE 0N FZLE ' 8. HOSPITALIZATION OAT':d RELATED TO CURRENT SERVfCES 20 OUTSIOE LAB"~ S CHARGES TA HAR ' -- 2 I - 30 BAL CE DUE PLEASE PRINT OR TYPE 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE :)3 PHYSICIAN S. SUPPUER'S EILLINO NAME. ADDRESS, ZIP CODE O~PLUONE~BA ORTH INSTITUTE OF PA 875 POPLAR CHURCH ROAO CAMP HILL PA 17011 761-5530 I ORR, 6 e 2 9 9 m ~ORU HCFA-,S00 i,~-~o) FORM OWCP-1500 FORM RRE-,SCC PLEASE 9786 NATI0iE!glIDE INS CO DONOT R0 BOX 69600 S ~,APLE HARRISBURG IN THIS AREA PA 17105-9600 APPBOVED OM8-0938 0008 '- 7-P,CA HEALTH INSURANCE CLAIM FORM P,CA ' HEALTH PLAN BLK LUNG ~ ,/o, 5837C169820 5016 EAST TRINBLE ROAD C~T¥i'4 E C HAil I 6 S B UR G IsT^rE PA ZIP CODE 17055 OTHER INSUREO'S NAME ILa$l Name, First Name. Middle Inillal OTHER INSURED S POLICY OR GROUP NUNIBER b OTHER INSURED S DATE OF BIRTH SEX MM OD ~.Y EMPLOYERSNAMEORSCHOOLNAME PATIENT S BIRTH DATE MM OD YY SEX 0l 30 1923~ ~ E~' PATIENT RELATIONSHIP TO INSURED I 7 INSURED S ADDRESS lNG Streel) S,o.s. o'"e'Z I 6016 EAST TRINDLE ROAD Emptoyed r~ Full-Time Pan-Time ~ Student D Student [] 10. tS PATIENTS CONDITION RELATED TO: Cn~pA M EC H A N I CSBUR G STATpEA ZIP CODE 17055 TELEPHONE (INCLUDE AREA CODE~ j (717)-766-4379 t I INSURED'S POLICY GROUP OR FECA NUMBER 186121986 a INSUREDS DATE OF BtRTH SEX MM DO YY 01 30 ~922 M~ ~,~ C. iNSURANCE PLAN NAME OR PROGRAM NAME NATION~4IDE INS CO INSURANCE PLAN NAME OR PROGRAM NAME 10d RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? DYES [] NO If yes, return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM, PATIENTS OR AUTHORtZED PERSON'S SIGNATURE I aulhodze the release ol any medical Gl other in(erma~ion necessa¢/ to process ihis claim I also r aquas[ payment Gl government benefils eilhe~ to myseR or to the pariy who accepts assignment b~o,~. SIGNATURE ON FILE 12-~3-01 S~GNED DATE IPPE M0 RONALD ~J C34585 t9 RESERVEO FOR LOCAL USE Et DIAGNOSIS OR NATURE OF tLLNESS OR tN JURY. (RELATE ITEMS t,2,3 OR 4 TO ITEM 24E BY LINE) L8404 - D(AGNOSI~ CODE 2. IE8120 24 A FroDmATB(S) OF SERVICETo MM DO YY MM OD YY 09 · 19 01 09 19 01 09 19 01 4¸1 99213 125 20610 J LT 23-1875547 8 I C D 03 6 03 ~ ' 03 9 BLOB0 J 098783 0006 I 2 1 2 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUOING DEGREES OR CREDENTIALS it cemly thai Ihe slalements On the reverse SIGNED DATE [APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8,881 i 2 27ACCEPTASSIGNMENT? ~FO~ govl ctm~s, see backl p [] YES [] NO 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED Ill olher lhan home or officel PLEASE PRINT OR TYPE 13 INSUREO'S OR AUTHORIZED PERSONS SIGNATURE I authorize SIGNATURE ON FILE SIGNED 15 DATES PATIENT UNABLE TO WORKIN CURRENT OCCUPATION MM DO YY MM DD YY FROM TO FROM TO___ ..... ~ DYES DNO ., 23 PRIOR AUTHORIZATION NUMBER F $ CHARGES 50.00 100.00 3.71 1 20 TOTAL CHARGE 29 AMOUNT PAID 30 BALANCE DUE -' 153.71 $ .00 $ 153.71 O~L 6BA 0RTH INSTITUTE OF PA 875 POPLAR CHURCH ROAD CAMP HILL PA 17011 761-5630 J GRP,, 160299 PIN# RESERVED FOd LOCAL USE ,_I480429 1.1480429 LI480429 Direct 'inquiries regarding this review to: Med Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 · Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA A bill audit, fee schedule and claims processing service WARNER CHIROPRACTIC CARE CTR. 5315 E. TRINDLE RD. MECHANICSBURG, PA 17055 MITCHELL, CHARLES 5016 EAST TRINDLE ROAD MECHANICSBURG, PA 17055 CLAIM NO: 5837C 16982004202001PA458Prt(14 COV]~RED I~)IVIDUAL: MITCHELL, CHkRLES POLICY HOLDER: MITCHELL, CF~ARLES RECEIVED PROVIUER: ~E UEIROP~CTiC C~E C AU6 2 1 20¢~ ID/PROVIDER NO, 25-1777526 PATIENT NO: 1730 PI ,~ug,~,edcalDep~. PAYOR: .NATIO~IDE ~RISB~G, PA ACCIDE~ DATE: 04/20/0~ ~DLOGIX ID: ~3~421A -003A C~C~TION DATE: 08/~4/0~ ~.~ EXPLANATION OF BENEFITS THE MED BOX Provider's Amount Billed .... : A11owedAmount .............. : TOTltLAMOUNT DUE ............ : Specialty: Chiropratic 1,153.00 1,000.66 1,000.66 Carrier's Responsibility .... : 1,000.66 PA'Automobile ST ITEMIZED CHARGES DATE SERVICE DIAGS UNITS CHARGE PAYMENT TYPE REDUCTION AMT DUE STATUE )7/02/01 98943-51 1-4 1.00 25.00 prov Chrg ~ 80% ( 5.00) 20.00 Chiropractic manipulative treatment (CMT); extraspinal, one or moreregions 37/02/01 98941 1-4 1.00 43 .00 State Fee $ 110% ( 3 .22) 39.78 Chiropractic manipulative trea=ment (CMT); spinal, three to four regions )7/02/01 97014 1-4 1.00 20.00 S~a~e Fee @ 110% ( 2.82) 17.18 Applica=ion of a ~odality to one or more areas;.electricaI stimulation(unattended) )7/02/01 97012 1-4 1.00 20.00 Prov Chrg U 100% ( 0.00) 20.00 Applicati_o~ of a modality to one or more areas; ~raction, mechanical £F PA]fMENT IS DUE, CHECK WILL BE MAILED UNDER SEPARATE COVER. ~ENALTiETsE~IAL THERETO COMMITS A FRAUDULENT INSUP~CE ACT, WHICH IS A CRIME A~ SUBJECTS SUCH A PERSON A~ CIVIL 4edLog±x Managed Care System V2.5 Rev 07/01 (c)1997 Consolid~ S~vi~es~Gr~up, Inc. ' Direct inquiries regarding this review to: · Med Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 · Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA PAGE: 2 CLAIM NO: 5837~!6982004202001PA458 COVERED INDIVIDUAL: MITCHELL, CHARLES PAYOR: NATIONWIDE HARRISBURG, PA ITEMIZED CHARGES DATE SERVICE DIAGS UNITS CHARGE PAYMENT TYPE REDUCTION AMT DUE STATUS 07/06/01 07/06/01 07/06/01 07/06/01 97012 1-4 1.00 Application of a m~dality to one or 07/09/01 98941 1-4 1.00 Chiropractic manipulative treatment 07/09/01 98943-51 1-4 1.00 Chiropractic manipulative treatment 07/09/01 97014 1-4 1.00 Application Of a modality to one or 07/09/01 97012 1-4 1.00 Application Of a modality to one or 07/11/01 98941 1-4 1.00 07/11/01 98943-51 1~4 1.00 07/11/01 97014 1-4 1.00 07/11/01 97012 1-4 1.00 07/13/01 98941 1-4 1.00 07/13/01 98943-51 1-4 1.00 07/13/01 97014 1-4 1.00 98943 -51 1-4 1.00 25 . 00 Prov Chrg · 80% Chiropractic manipulative treatment (CMT); ex=raspinal, One or morerec, ions 98941_~ 1-4 1.00 43.00 State Fee % 110% Chiropractic manipulative treatment (C~T); spinal, three to four regions 97014 1-4 1.00 20.00 State Fee · 110% Application of a modality to one or more areas; electrical stimulation(unattended) 20.00 Prov Chrg ~ 100% ~ore areas; traction, mechanical 43.00 State Fee · 110% (CMT); spinal, three to four regions 25. 00 Prov Chrg % 80% (CMT); extraspinal, one Or morere~ions 20.00 State Fee · 110%: more areas; electrical stimulation(unattended) 20. 00 Prov Chrg ~ 100% more areas; traction, mechanical 43 . 00 State Fee · 110% (CMT); spinal, three to four regions 25. 00 Prov Chrg · 80% (CMT); extraspinal, one or moreregions 20.00 State Fee ~ 110% more areas; electrical stimulation(unattended) 20.00 Prov Chrg @ 100% more areas; traction, mechanical 43.00 State Fee ~ 110% (CMT); spinal, three to four regions 25.00 Prov Chrg % 80% (CMT); extraspinal, one or moreregions 20. 00 State Fee · 110% more areas; electrical stimulation(unattended) IF PAYMENT IS DUE, CHECK WILL BE MAILED UNDER SEPAR3%TE COVER. s.00) 3.22) 2.82) 0.00) 3.22 5.00 2.82 0.00 3.22 5.00 2.82 0.00 3.22 5.00 2.82 20.00 39.78 17.18 20.00 39.78 20.00 17.18 20.00 39.78 20.00 17.18 20.00 39.78 20,00 17.18 MedLogix Managed Care System V2.5 Rev 07/01 (c)1997 Consolidated Services Group, Inc. Direct inquiries regarding this review to: Med Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 · Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA PAGE: 2 CLAIM NO: 5837C--16982004202001PA458 COVERED INDIVIDUAL: MITCHELL, CHARLES PAYOR: NATIONWIDE HARRISBURG, PA ITEMIZED CHARGES DATE SERVICE DIAGS LTN~TS CHARGE PAYMENT TYPE REDUCTION AMT DUE STATUS 07/13/01 07/16/01 07/16/01 07/16/01 o7/16/Ol 07/18/01 07/18/01 07/18/01 07/20/01 07/20/01 07/20/01 07/23/01 07/23/01 07/23/01 07/25/01 97012 1-4 1.00 20.00 Frov Chrg ~ 100% Application of a modality to one or more areas; traction, mechanical 98941 1-4 1.00 43.00 State Fee · i10% Chiropractic manipulative treatment (CMT); spinal, three to four regions 98943-51 1-4' 1.00 25.00 Frov Chrg Chiropractic manipulative treatment (CMT); extraspinal, one or moreregions 97014 1-4 1.00 20.00 State Fee · 110% Applicatio~ of a modality to one or more areas; electrical stimulation(unattended) 97012 1-4 1.00 20.00 Prov Chrg · 100% Application of a modality to one or more areas; traction, mechanical 98943-51 1-4 1.00 25.00 Prov Chrg S 80% Chiropractic manipulative treatment (C~T); extraspinal, one or moreregions 98941 1-4 1.00 43 .00 State Fee · 110% Chiropractic manipulative treatment (CMT); spinal, three to four regions 97012 1-4 1.00 20 .00 Frov Chrg ~ 100% Application of a modality to one or more areas; traction, mechanical 98941 1-4 1.00 43.00 State Fee · 110% Chiropractic manipulative treatment (C~4T); spinal, three to four regions 98943-51 1-4 1.00 - 25.00 prov Chrg · 80% Chiropractic manipulative treatment (CMT); extraspinal, one or moreregions 97012 1-4 1.00 20.00 Prov Chrg a 100% Application of a modality to one or more areas; traction, mechanical 98941 1-4 1.00 43.00 State Fee · 110% Chiropractic manipulative treatment (CMT}; spinal, three to four regions 98943 -51 1-4 1 . 00 28 . 00 Prov Chrg · 80% Chiropractic manipulative treatment (CMT); extraspinal, one or morereglons 97012 1-4 ' 1. 00 20. 00 Prov Chrg · 100% Application of a modality to one or more areas; traction, mechanical 97012 1-4 1.00 20.00 Frov Chrg Application of a modality to one or more areaL; traction, mechanical IF PAYMENT IS DUE, CHECK WILL BE MAILED UNDER SEPAP. ATE COVER. 0.00) 20.00 3.22) 39.78 5.00) 20.00 2.82) 17.18 0,00) 20.00 5.00) 20.00 3.22) 39.78 0.00) 20.OO 3.22) 39.78 5.O0) 2O.00 0.00) 2O.0O 3.22) 39.78 5.OO) 2O.O0 0.00) 20.00 0.00) 20.00 MedLogix Managed Care System V2.5 Rev 07/01 (c)1997 Consolidated Services Group, Inc. Direct inquiries regarding this review to: Med Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 · Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA PAGE: 4 CLAIM NO: 5837C~6982004202001PA458 COVERED INDIVIDUAL: MITCHELL, CHARLES PAYOR: NATIONWIDE HARRISBURG, PA DATE SERVICE DIAGS UNITS ITEMIZED CHARGES CHARGE PAYMENT TYPE REDUCTION AMT DUE STATUS 07/27/01 97012 1-4 1.00 Application of a modalit¥ to one 'or 07/27/01 9.894~ 1-4 1.00 Chiropractic manipulative treatment 07/27/01 98943-51 1-4 1.00 Chiropractic manipula=ive treatment 07/30/01 98941 1-4 1.00 Chiropractic manipulative.treatment 07/30/01 98943-51 1-4 1.00 Chiropractic ~nipula=ive treatment 07/30/01 99212-25 1-4 1.00 07/30/01 20.00 Prov Chrg · 100% more areas; traction, mechanical 43.00 State Fee · 110% (CMT); spinal, three to four regions 25.00 . P~ov Chrg ~ 80% (CMT); extraspinal, one or moreregions 43.00 State Fee · 110% (CMT); spinal, three to four regions 25.00 Prov Chrg · 80% {CMT); extraspinal, one or moreregions 45.00 Office or other Outpatient visit for the evaluation and management of anestablished 97012 1-4 1.00 20.00 Prov Chrg · 100% Application of a modality to one or more areas; traction, mechanical 0.00) 20.00 3.22 39.78 5.00 20.00 3.22 39.78 5.00 20.00 45.00 0.00 patient, which requires at 1 0.00 20.00 Totals: 1,153.00 Status Codes: DO - Denied. Office visit with manipulation. 152.34) 1,000.66 DO IF PAYMENT IS DUE, CHECK WILL BE MAILED UNDER SEPARATE COVER. MedLogix Managed Care System V2.5 Rev 07/01 (c)1997 Consolidated Services Group, Inc. PLEASE,. DO NOT STAPLE IN THIS AREA NATIONWIDE INSURANCE coMpANY/BRENDA LIGHTNE P O BOX 69600 HARRISBURG PA 17106 9600 CLM: 5837C169820042001 r~r~PICA MEDICARE CHAMPUS CHAMPVA HEALTH INSURANCE CLAIM FORM ~ECHANI CSBLTRG PATIENT'S BIRTH DATE SEX ~1:30~1:9~2 u~ . F[~ PATIENT RELATIONSHIP TO Ir',SUR ED PATIENT STATUS Studen, [] Studen, [] 0. IS PATIENT'S CONDITION RELATED TO: b AUTO ACC~.~NT?yES [] NoPLA~'~IaIell I c. OTHER ACCIDENT? PiCA (FOR PROGRAM IN ITEM M]~HEL~ CHARLES W STA~A 5016 E TRINDLE ROAD ~CHANICS~uRG TELEPHONE CNCLUDE AREA CODE) (717) 766 4379 ~)'1,3 ~L922~ ~ SEX SELF READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. SIGNED DATE 13. INSUREO'S OR AUTHORIZED PERSON'S SIGNATURE ~ authodze paymenl of medical benefits to the undersigned physician or supplier 'er~icesde'cg~ATf. TRE ON FILE SIGNED ' 6 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM ~ DD I yy MM I DD I yy FROM ~ I TO I I · 8 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM I DO I YY MM I DD I YY go OUTSIDE LAB? $ CHARGES ;!3. PRIOR AUTHORIZATION NUMBER 19 RESERVED FOR LOCAL USE CHARGES K RESERVED FOR LOCAL USE EIVED 30. BALANCE DUE ,00 15. IF PATIENT HAS HAD SAME OR S gvl~LA R ILLNESS. GIVEFIRSTDATE MM [ DD i~Y¥ 17a. I0 NUMBER OF REFERRING PHYSICIAN 723 1 +840 9 846 0 +724 1 El 4.1 A O E OIAGNOS~S To (Explain Unusual Circumstances} CODE DO MODIFIER 1234 98941 97014I 25 1777526 1730 PI 31 SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUO~NG DEGREES OR CREDENTIALS 0.8-02-2001 RENDERED (It other than home or office) 123 (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8188) PLEASE PRINT OR TYPE FORM HCFA-1500 (12-90) FORM OWCP-1500 FORM RRB*I§CO PLEASE .. DO NOT STAPLE IN THIS AREA CLM: 5837C169820042001 CITY MECHANI CSBURG b OTHERINSUREDSDATEOFStRTH SEX NAME OF REFERRING PHYSICIAN OR OTHER SOURCE NATIONWIDE INS'URJkNCE COMPANY/BRENDA LIGHTNET P 0 BOX 69600 ~ HARRISBURG PA 17106 9600 ~ HEALTHINSURANCE CLAIM FORM P'c^~-I-, li ~R~ ~1 D'~E~ (FOR PROGRAM IN ITEM lJ ~ Single [] Mamed ~ Omer [] Employed Student [] Studen~ [] RESERVED FOR LOCAL USE ~CHANICSBURG 0 L-'MRL YER'S NAME OR SCHOOL NAME SE.~'~ I~pr~¢e$sjh~c~-~i~``~%m~11~-~yr~]~4~3Ig1~bene~it~i~hert~myse~f~r~the~1~v~-~e~ts~n~ .... i¢.sdeSC~l~Arl~.]~ Ol~ ~I~ 14~.~ ~ ~,~T: IILLNESs {Firs' symptom) OR,NJURY (Accident) OR ,5. ,F PATIENT HAS HAD SAME OR SIMI~R ILLNESS G V~ F RST DATE Mb1/I DO,IYY 17a ID. NUMBER OF REFERRING pHysICiAN I PREGNANCY {LMPI I I 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 22 MEDICAID RESUSMiSSION CODE I ORIGINAL REF. NO $ CHARGES K RESERVED FOR 723 1 +840 9 846 0 +724 1 ~1 5 FEDERALTAX ID NUMBER 25 1777526 OE%"ZEZOR OREDTN 'AL 02- 1 98943~1, 1 2 3 4 PLEASE PRINT OR TYPE MECHANICSBURG PA (717) 766 5406 WA501675 IDRp~ 17055-3525 FORM HCFA-1500 (~2-90) FORM OWCP-1500 FORM RRB-1500 PLEASE . DO NOT' STAPLE IN THIS AREA NATIONWIDE INSURANCE COMPANY/BRENDA LIGHTNE! P O BOX 69600 : HARRISBURG PA 17106 9600 CLM:5837C169820042001 ~P,CA HEALTH INSURANCE CLAIM FORM p~cA~r~- GROUP FECA OTHER 1 INS RE ID. NUMBER ,, ,ED)CARE , D,OA,O CH MPUS OHAMPVA HEALTHP N__BLKLUNG 19 6 ,EORP"OCRA ,,NITE.,) C~ECHANI CSBURG STt , E'P£F 50 9 OTHER INSURED'S NAME (Last Name Firsl Name, Middle Initial) OTHER ]NSURED'S POLICY OR GROUP NUMBER b OTHER INSURED'S DATE OF BIRTH SEX 8 PATIENT STATUS Single [] Married E~ Other [] 10 iS PATIENTS CONDITION RELATED TO: b AUTO ACCI KNT? PLA~S. tale) ~Y~S C]No r I !gfCHANICSBURG STATE iNSURED S DATE OF SIRTH ~O"Z3~1,9¢22 L~ SEX ,SELF c EMPLOYER'S NAME OR SCHOOL NAME c OTHER ACCIOENT~ c INSURANCE PLAN NAME OR PROGRAM NAME E;YES READ BACX OF FORM SEFORE COMPLETING & SIGNING THIS FORM. 13.)NSURED'S OR AUTHORIZED PERSON'S SIGNATURE I aulhorize ~p~¢es$t~i~m~?~`~..].1~.~.ayf~)gFT~nJ~j~b~neIItsei~her'°myse~rI~t~ep~`~;x~pts~j~nt sec"ic~'s'~es¢~q'ATLI-RE ON FILE 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM ~ DD I YY INJURY (Accident) OR , I I PREGNANCY ~LMP) 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 19 RESERVED FOR LOCAL USE 2,. OI~)N~SIS~)R NA~/F~ILL~j~SS OR tN JURY (RELATE ITEMS 1.2.3 (~Rz~ ~O IT~.M 24E BY LINE) .~ il__ 3 L 723 1 +840 9 846 0 +724 1 4 L__ A O E PROCEDURES. SERWCES. OR SUPPLIES DIAGNOSIS (Explain Unusual Circumstances( CODE ' CPT/HCPCS MODIFIER DATES PATIENT URABLE TO WORK IN CURRENT OCCUPATION MM I DD r yy MM I DD I yy FROblI I TO HOSPITALIZATION DATES RELATED TO CURRENT SERVICES hiM J DD I YY MM t DO I YY FROM [ i TO I I 23. OUTSIDE LAB? $ CHARGES 23. PRIOR AUTHORIZATION NUMBER F K RESERVEDFOR SCHARGES LOCALUSE 97012 25 FEDERAL TAX ID NUMBER SSN EiN 26 PATIENT'S ACCOUNT NO 25 1777526 []~ 1730 PI [] NO 31 SIGNATURE OF PHYSICIAN OR SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE INCLUDING DEGREES OR CREDENTIALS RENDERED (If other than home or offlcel PLEASE PRINT OR TYPE BA ANCE GU ~04,~0 MECHANICSBURG PA (717) 766 5406 WA501675 iGnp* 17055-3525 FORM HCFA-~500 (12-90) FORM OWCP-1500 FORM FLEASE, DO NOT ~TAPLE IN THIS AREA CLM: 5837C169820042001 NATIONWIDE IN,SUPJLNCE COMPANY/BRENDA LIGHTNE[ P O BOX 69600 ~ HARRISBURG PA 17106 9600 · HEALTHINSURANCE CLAIM FORM P,CA~ MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER HEALTH PLAN eLK LUNG ~ MECHANI CSBURG PA ~a INSUREDSI0 NUMBER 6 PATtENT RELAT~ONSHtP TO INSURED I se,, Spouse C,,d[] o,he, a OTHER INSURED S POLICY OR GROUP NUMBER SingJe [] Married ~ Other Employed Full-Time ~l Student [] ParlJime Student 10 IS PATIENTS CONDITION RELATED TO: a EMPLOYMENT? (CURRENT OR PREVIOUS~ 186 12 1986 (FOR PROGRAbl IN ITEM MITCHELL CHARLES W 5016 E TRINDLE ROAD MECHANI CSBURG ZIP CODE 17050 OTHER INSURED'S DATE OF BIRTH SEX E~YBS []NO ,PAl TELEPHONE ;INCLUDE AREA CODE) (717i 766 4379 d iNSURANCE PLAN NAME OR PROGRAM ~IA,ME 10d. RESERVED FOR LOCAL USE READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12 PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize I~le ~elease Gl any medical or other mlormalion necessary to process thi i y I benefits either Io myself or SIGNED DATE INJURY (Acciae[~[/OR 15 tF PATIENT HAS HAD SAME OR SIbIILAR ILLNESS, GIVEFIRSTDATE MM i DD iYY 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 19. RESERVED FOR LOCAL USE 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (RELATE ITEMS 1,2.3 OR 4 TO ITEM 24E BY UNE~ 723 3 +723 4 847 1 % I 1. INSURED'S POLICY GROUP OR FECA NUMBER 5837C169820 a INSURED'S DATE OF 81RTH = EMPLOYERS NAME OR SCHOOL NAME ;SELF 13 INSURED'S OR AUTHORIZED PERSON'S SIGNATURE ( autborlze payment of med~cat benefits to the unde¢slgned physician or supplle~ se~e'sd'~ATURE ON FILE SIGNED 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPAT(ON MM I DO I YY MM I DO I yy 3 l__ 723 1 +840 9 846 0 +724 1 A I B D E DATE(S) DP SERVICE PROCEDURES. SERVICSS. OR SUPPLIES DIAGNOSIS From To (Explain UnusuaICircumstances} CODE ' MM DD YY MM DD CPTJHCPCS I MODIFIER 97012 1 2 3 07~520101 37252001 07~720:01 07~72901!11 07~02q01 07~02901]11 07~02001 07302001ill 125 FEOERAL TAX iD NUMBER 25 1777526 SSN EIN (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) 23 PRIOR AUTHORIZATION NUkIBER F S CHARGES RESERVED FOR LO~AL USE 98941 98941I 99212; 5 1234 1234 1234 431 00 43', 00 45', 00 26, PATIENT'S ACCOUNT NO 1730 PI ACCEPT ASSIGNMENT? 28 TOTAL CHARGE 29 AMOUNT PA'O 30 SALANDE DUE ~ ~o~o~ ¢,ai~,.,e~¢~l 241', 00 241', 00 2 NAME AND AGDRESS OF FAC~MTY WHERE SERVtCES WERE RENDERED (Il other Ihan home or olfice} 5~t~E~ TRINDLE RD MECHANICSBURG PA (717) 766 5406 E,N,WA501675 IORp, PLEASE PRINT OR TYPE 17055-3525 FORM HCFA-1500 (12-gO) FORM OWCP-1500 FORM RRB-1500 D~rect inquiries regarding this review to: Mud Path 12~0 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 - Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA A bill audit, fee schedule and claims processing service WAP/~ER CHIROPRACTIC CARE CT~ 5315 E. TRINDLE RD. ~ MECHANICSBURG, PA 17055 MITCHELL, CHARLES 5016 EAST TRINDLE ROAD- HECHANICSBURG, ~A 17055 CLAIM NO: 5837 6 82 04202001PA458Prt(14 COVERED I~DIVIDUAL: MITCHELL, CHARLES POLICY HOLDER: MITCHELL, CHARLES ]PROVIDER: TAX ID/PROVIDER NO: PATIENT NO: WARNER CHIROPP, ACTIC CARE C 25-1777526 1730 PI PAYOR: ACCIDENT DATE MEDLOGIX ID: CALCULATION DATE NATIONWIDE HARRISBURG, PA 04120/01 130421A -002B 08/18/01 DIAGNOSES: 1) ~) 3) 6) EXCEPTIONS REPORT EXPLANATION OF BENEFITS 723.3 CERViCOBRACHIAL SYNDROME {DIFFUSE) 723. I CERVICALGIA 847.1 R140RACIC SPRAIN 846.0 LUMBOSACRAL (JOINT) (LIGAMENT) SPRAIN 723.4 BRACRIAL NEURITIS OR RADICULITIS NOS 840.9 SPRAIN OF UNSPECIFIED SITE OF SHOULDER AND UPPER ARM DATES OF SERVICE: o~/~o'~/oz - 0s/30/0i THE MED BOX Provider's Amount Billed .... ~ Allowed Amount .............. : TOTAL AMOUNT DUE ............ ~ 1,429.00 1,281.02 1,281.02 Carrier's Responsibility .... : 1,281.02 PA Automobil( Dear Sir/Madam: On 06/18/01 the above named case was referred to the Review Department to evaluate coding, treatment, or billing as it reiates to Section 69.24 of Act 6 amended November 30, 1991. Your bill for treatment on 05/07/01 has been reviewed. describes the services rendered. ITEMIZED CHARGES DATE SERVICE DINGS UNITS CHARGE PAYMENT TYPE IF PAYMENT IS DUE, CHECK WILL BE MAILED UNDER SEPARATE COVER. The following listing more appropriatel] REDUCTION AMT DU~ MedLogix Managed Care System V2.5 Rev 06/01 (c)1997 Consolidated Serv , Inc. Direct inquiries regarding this review to: Med Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 - Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA PAGE: 2 CLAIM NO: 5837C--16982004202001PA458 COVERED INDIVIDUAL: MITCHELL, CHARLES PAYOR: NATIONWIDE HARRISBURG, PA ITEMIZED CHARGES DATE SERVICE DIAGS UNITS CHARGE PAYMENT TYPE REDUCTION AMT DUE STATUS 08/07/01 98941 1-4 1.00 Chiropractic manipulative treatment 05/07/01 98943-51 1-4 1.00 Chiropractic manipulative treatment 05/07/01 97014 1-4 1.00 Application of a modality to one or 05/07/01 97012 1-4 1.00 Application of a modality to one or 05/09/01 98943-51 1-4 1.00 Chiropractic manipulative treatment 05/09/01 98941 1-4 1.00 Chiropractic manipulative treatment 05/09/01 97014 1-4 1.00 Application of a modality to one or 05/09/01 97012 1-4 1.00 Application of a modality to one Or 05/11/01 98943-51 1-4 1.00 Chiropractic manipulative treatment 05/11/01 98941 1-4 1.00 Chiropractic manipulative treatment 08/11/01 97014 1-4 1.00 Application of a modality to one or 05/11/01 97012 1-4 1.00 Application of a modality to one or 05/15/01 98941 1-4 1'.00 Chiropractic manipulative treatment 05/15/01 97014 1-4 1.00 Application of a modality to one or 05/15/01 97012 1-4 1.00 Application of a modality to one or 43 .00 State Fee ~ 110% (C~T); spinal, three to four regions 25 .00 Prov Chrg ~ 80% (CMT); extraspinal, one Or moreregions 20 .00 State Fee · 110% more areas; electrical stimulation(unattended) 20.00 Prov Chrg · 100% more areas; traction, mechanical 25.00 Prov Chrg · 80% (C~T); extraspinal, one Or moreregioms 43. 00 State Fee · 110% (CMT); spinal, three to four regions 20. 00 State Fee ~ 110% more areas; electrical stimulation(unattended) 20.00 PrOV Chrg ~ 100% more areas; traction, mechanical 25.00 Prov Chrg ~ 80% (CMT); extraspinal, one or moreregions 43.00 State. Fee @ 110% (CMT); spinal, three to four regions 20. 00 State Fee @ 110% more areas; electrical stimulation(unattended) 20.00 Prov Chrg more areas; traction, mechanical 43 .00 State Fee · 110% (CMT); spinal, three to four regions 20.00 State Fee ~ 110% more areas; electrical stimulation(unattended) 20.00 Prov Chrg · 100% more areas; traction, mechanical IF PAY~4ENT IS DUE, CHECK WILL BE I~AILED ~NDER SEPARATE COVER. 3.22 5.00 2.82 0.00 5.00 3.22 2.82 0.00 5.00 3.22 2.82 0.00) 3.22) 2.82) 0.00) 39.78 20.00 17.18 20.00 20.00 39.78 17.18 20.00 20.00 39.78 17.18 20.00 39.78 17.18 20.00 MedLogix Managed Care System V2.5 Rev 06/01 (c) 1997 Consolidated Services Group, Inc. ~irect inquiries regarding this review to: Med Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 · Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA PAGE: 2 CLAIM NO: 5837C-16982004202001PA458 COVERED INDIVIDUAL: MITCHELL, CHARLES PAYOR: NATIONWIDE KARRISBURG, PA ITEMIZED CHARGES DATE SERVICE DIAGS UNITS CHARGE PAYMENT TYPE REDUCTION AMT DUE STATUS 05/15/01 98943 -51 1-4 1.00 Chiropractic manipulative treatment 0.5/16/01 98941 1-4 ~ 1.00 Chiropractic manipulative treatment 05/16/01 97014 1-4 1.00 Application of a modality to one or 05/16/01 97012 1-4 1.00 Application qf a modalit¥ to one or 05/16/01 98943-51 1-4 1.00 05/17/01 98941 1-4 1.00 05/17/01 97012 1-4 1.00 05/17/01 98943-51 1-4 1.00 05/18/01 98941 1-4 1.00 05/18/01 97014 1-4 1.00 05/18/01 97012 1-4 1.00 Application of a modality to one or 05/18/01 98943-51 1-4 1.00 05/21/01 98941 1-4 1.00 05/21/01 97014 1-4 1.00 05/21/01 97012 1-4 1.00 25.00 prov Chrg · 80% (CMT); extraspinal, one or moreregions 43.00 state Fee % 110% (CMT); spinal, three to four regions 20.00 State Fee · 110% more areas; electrical stimulation{unattended) 20.00 Prov Chrg · 100% more areas; traction, mechanical 25.00 Prov Chrg @ 80% (CMT); extraspinal, one or moreregions 43.00 State Fee · 110% (CMT); spinal, three to four regions 20.00 Prov Chrg · 100% more areas; traction, mechanical 25.00 Prov Chrg ® 80% (CMT); extraspinal, one or morereg~ons 43 .00 State Fee % 110% (CMT); spinal, three to four regions 20.00 State Fee ~ 110% more areas; electrical stimulation(unattended) 20.00 Prov Chrg · 100% more areas; traction, mechanical 25.00 Prov Chrg ~. 80% (C~T): extraspinal, one or morereg:ons 43 .00 State Fee % 110% (C~T); spinal, three to four regions 20.00 State Fee · 110% more areas; electrical stimulation(unattended) 20.00 Prov Chrg · 100% more areas; traction, mechanical IF PAYMENT IS DUE, CHECK WILL BE MAILED UNDER SEPARATE COVER. 5.00 3.22 2.82 0.00 5.00 3.22 0.00 5.00 3.22 2.82 0.00 5.00 3.22 2.82 0.00 20.00 39.78 17.18 20.00 20.00 39.78 20.00 20.00 39.78 17.18 20.00 20.00 39.78 17.18 20.00 MedLogix Managed Care System V2.5 Rev 06/01 (c)1997 Consolidated Services Group, Inc. Direct inquiries regardin9 this review to: Mad Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 · Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA PAGE: CLAIM NO: 5837C-16982004202001PA458 COVERED INDIVIDUAL: MITCHELL, CHARLES PAYOR: NATIONWIDE HARRISBURG, PA ITEMIZED CHARGES DATE SERVICE DIAGS UNITS CHARGE PAYMENT TYPE REDUCTION AMT DUE STATUS 05/21/01 05/22/01 05/22/01 05/22/01 05/22/01 05/23/01 05/23/01 05/23/01 05/23/01 05/25/01 05/25/01 05/25/01 05/25/01 05/29/01 05/29/01 98943-51 1-4 1.00 25.00 Prov Chrg · 80% Chiropractic manipulative treatment (CMT); extraspinal, one or moreregic,ns 98941 1-4 1.00 43.00 State F~e ® 110% Chiropractic manipulative treatment (CMT); spinal, three to four regions 97014 1-4 1.00 20.00 9rate Fee · 110% Application of a modality to one or more areas; electrical stimulation(~attended) 97012 1-4 1.00 20.00 Prov Chrg ~ 100% Application of a modality to ~ne or more areas; traction, mechanical 98943-51 1-4 1.00 Chiropractic manipulative treatment 98941 1-4 1.00 Chiropractic manipulative treatment 98943 -51 1-4 1 · 00 Chiropractic manipulative treatment 97014 1-4 1.00 Application of a modality to one or 97012 1-4 1.00 Application of a modality to one or 98941 1-4 1.00 Chiropractic manipulative treatment 98943-51 1-4 1.00 Chiropractic manipulative treatment 97014 1-4 1.00 Application of a modality to one or 97012 1-4 1.00 Application of a modalit, y to one or 98941 1-4 1.00 Chiropractic manipulative treatment 98943-51 1-4 1,00 Chiropractic manipulative treatment IF PAYMENT IS DUE, 25.00 Prov Chrg @ 80% (CMT); extraspinal, one or moreregions 43.00 State Fee ~ 110% (CMT); spinal, three to four regione~ 25.00 Prov Chrg @ B0% (CMT); extraspinal, one or moreregions 20.00 state Fee ~ 110% more areas; electrical stimulation(~attended) 20.00 Prov Chrg % 100% more areas; traction, mechanical 43.00 State Fee · 110% (CMT); spinal, three to four region~ 25.00 Prov Chrg · 80% (CMT); extraspinal, on~ or moreregions 20.00 State Fee · 110% more areas; electrical stimulation(%~attended) 20.00 Prov Chrg @ 100% more areas; traction, mechanical 43. 00 State Fee ~ 110% (CMT); spinal, three to four regions 25.00 Prov Chrg % 80% (CMT); extraspinal, one or moreregions CHECK WILL BE MAILED UNDER SEPAP. ATE COVER.. 5.00 3.22 2.82 0.00 5.00 3.22 5.00) 2.82) 0.00) 3.22) 5.00) 2.82) 0.00) 3.22) 5.00) 20.00 39.78 17,18 20.00 20.00 39.78 20.00 17.18 20.00 39.78 20.00 17.18 20.00 39.78 20.00 MedLogix Managed Care System V2,5 Rev 06/01 (c)1997 Consolidated Services Group, Inc. I1irect inquiries regarding this review to: Med Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 · Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA PAGE: 5 CLAIM NO: 5837C~16982004202001PA458 COVERED INDIVIDUAL: MITCHELL, CHARLES PAYOR: NATIONWIDE HA/{RISBURG, PA ITEMIZED CHARGES DATE SERVICE DIAGS UNITS CHARGE PAYMENT TYPE REDUCTION AMT DUE STATUS 05/29/01 05/29/01 05/30/01 05/30/01 05/30/01 05/30/01 05/30/01 97014 1-4 1.00 20.00 State Fee a 110% 2.82) 17.18 Application of a modality to one- or more areas; electrical stimulation(unattended) 97012 1-4 _.. 1.00 20.00 Prov Chrg a 100% 0.00) 20.00 Application of a modality to one or more areas; traction, mechanical 98941 1-4 ' 1.00 43.00 ~tate Fee · 110% 3 .22) 39.78 Chiropractic manipulative treatment (CMT); spinal, three to four regions 98943-51 1-4 1.00 25.00 Prov Chrg a 80% 5.00) 20.00 Chiropractic manipulative treatment (CMT); extraspinal, one or moreregions 97014 1-4 1.00 20.00 State Fee S 110% 2.82) 17.18 Application of a sodality to one or more areas; electrical stimulation(%unattended) 97012 1-4 1.00 20.00 Prov Chrg · 100% 0.00) 20.00 Application of a modality to one or more areas; traction, mechanical 99212-25 1-4 1.00 45.00 0.00) 0.00 Office or other outpatient visit for the evaluation and management of anestablished patient, which requires at CR RESOLUTION: CODE APPROPRIATE, PROPER FEE ASSIGNED. 99212--25 1-4 1.00 State Fee · 110% ( 7.28) 37.72 Office or other outpatient visit for the evaluation and management of anesta C7 RC Totals: 1,429.00 147.98) 1,281.02 Status Codes: C7 - Denied pending review. Modifier requires review. Status Codes: RC - CR resolution: Proper code assigned OR Code appropriate, proper fee assigned. PLEASE NOTE: DISAGREEMENTS OR COMPLAINTS MUST BE ADDRESSED IN WRITING. PLEASE ENCLOSE A COPY OF BOTH THIS EXPLAI~ATIO~ AND THE ORIGINAL BILL WITH ALL CORRESPONDENCE. Your Review has been completed by Lisa Battis, Medical Review Specialist IF PAYMENT IS DUE, CHECK WILL BE MAILED UNDER SEPARATE COVER. MedLogix Managed Care System V2.5 Rev 06/01 (c)1997 Consolidated Services Group, Inc. PLEASE DO," 7' ' STAPLE IN THIS AREA APPROVED OMB-0938-0008 NATIONWIDE INSLTR. ANCE cOMpANY'/BRENDA LIGHTNE P O BOX 69600 HARRISBURG PA 17106 9600 ~qRtCA CLM: 5837C169820042001 HEALTH INSURANCE CLAIM FORM P,CA ~---- (~,e~ ...... I ~ ~,~d ~ ~Sp ...... SSNJ ~ ~'/A~#~ ~ ~ (SSNo~,~) ~ ~SS~ ~ 186 12 1986 MITCHE~ C~LES W MITCHELL CHARLES W-~ 5016 E TRINDLE ROAD MECHANI CSBURG 3 PATIENTS gIRTH DATE SEX STATE ZIP CODE TELEPHONE InCude Area Codel 17050 (717)766 4379 9 OTHER INSURED S NAME (Las[ Name. Filst Name, Middle F[] b, OTHER INSURED S DATE OF 81RTH SEX C. EMPLOYER'S NAME OR SCHOOL NAME d INSURANCE PLAN NAME OR PROGRAbl NAME 8 PATIENT STATUS Single [~ Mamed [~ Other [] Employed [~ Full-Time Part-Time S,udent [] Studem [] 10 IS PATIENT'S CONDITION RELATED TO: [~YES []~O ~PA, I e. OT. RAC ; ; 5016 E TRINDLE ROAD MECHANI CSBURG L~IP CODE 17050 11 TNSUREO'S POLICY GROUP OR FECA NUMgER 5837C169820 '~11:3~1:9¥9. 2 SELF d IS THERE ANOTHER HEALTH BENEFIT PLAN? ~] YES [~ NO if yes, retuEn to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12 PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of a~y medical or othe~ inf~imation necessan/ ID Rrocess This claim. I also re(3uest aymem of government benefits either to myself o[ to the pauly wh~ accepts assignment ~e~ow SIGNATUR~ ON FILE 05 31 2001 SIGNED DATE ILLNESS (First symgtom) OR INJURY (Accident) OR ~ PREGNANCY ILMP) 14 DATE OF CURRENT: IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM ~ OD ~ YY 17a I O. NUMBER OF REFERRING PHYSICIAN 17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 19 RESERVED FOR LOCAL USE DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1.2,3 OR 4 TO ITEM 24E BY UNE) 723 3 +723 4 847 1 11 21723 1 +840 9 . L 846 0 +724 1 A B 0 E DATE(S) OF SERVtCE Place PROCEDURES, SERVICES. OR SUPPLIES DIAGNOSIS From To [ ol (Explain Unusual Circulnstances) CODE MM DD YY MM DO CPT/HCPCS I MODIFIER 3.1NSU R ED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize paymenl of medical benefits to the unders~gaed physician or supplier for services desc~bed below, SIGNATURE ON FILE SIGNED DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION ~2 MEDICAID RESUSMISSION CODE ~ ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER CHARGES 05072G01 05072001!11 -98941 05072G01 05072001 11 97014 050920101 05092001111 9894351 50920101 ~92001 97014 05~120101 05112~01;11 9894351 051120101 05112001ill 97014t 25 1777526 ~ 1730 PI SIGNATURE OF PHYSICIAN OR SUPPLIER 1234 234 1234 1234 1234 1234 27 ACCEPT ASSIGNMENT? [~or govt claims, see back) YES [] NO 43i 00 1 20', 00 251 00 1 20: OD 25[ 00 1 20:00 1 28. TOTAL CHARGE s 304:00 INCLUDING DEGREES OR CREDENTIALS (I C ertlly 1hat the stalements on the reverse ~ ~3~ ~ mW~f )DC 05-31-2001 (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8~88) K RESERVED FOR LOCAL USE WED 2~ AUOUNT PA~O 30. BAU, NOC DUS $ ', S 304 [ 0O PLEASE PRINT OR TYPE TRINDLE RD MECHANI CSBURG PA (717) 766 5406 WA501675 GRP# 17055-3525 PORM HCFA~15OO (12-90) FORM OWCP-1500 FORM RRB-t 5c PLEASE STAPLE iN THiS AREA ;~-i p,CA CLM: 5837C169820042001 NATIONWIDE INSUPJkNCE COMPANY/BRENDA LIGHTNE~ P O BOX 69600 ~ HARRISBURG PA 1.7106 9600 ~ HEALTHINSURANOE CLAIM FORM P,C^J-j-j~, 5016 E TRINDLE ROAD e,~.spous~ c,,o[~] O,h.,[] 17050 17171766 4379 E~;,o~ FuiI-Tme~ Pa.-Time~ C. EblPLOYER'S NAME OR SCHOOL NAME d. INSURANCE PLAN NAME OR PROGRAM NAME b. AUTO ACCIDENT? PLACE (State) ~¥E~ E~NO iPAi c. OTHER ACCIDENT9 1Od. RESERVED FOR LOCAL USE READ BLACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT'S OR AUTHORIZED PERSON'S SlONATU RE I authorize lee ~elease of any medical or olher inlormation necessary ~e,o'- SIGNATURE ON FILE 05 31 2001 15. IF PATIENT HAS HAD SAME OR SIMILAR iLLNESS GYEFRSTDATE MM ~ DO I YY 17a I O NUMBER OF REFBR~INGI PI~YSICIAN[ 14. DATE OF CURRENT: ~ iLLNESS {Eilsl symptom) OR '~ 2 ~ 0'0'1~ ,N JURY (Acc~d~n,I OR PREGNANCY (LMPi 19. RES 'ERVED ~FOR LOCAL USE 17. NAME OF REFERRING PHYSICIAN OR OTHER SDGRCE El. DIAGNOSIS OR NATURE OF ILLNESS DR ~NJURY (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) ~1723 3 +723 4 - 3 I 847__1 846 0 +724 186 12 1986 (FOR PROGRAM IN ITEM 4. INSURED'S NAME (Last Name First Name, Middle Initial) MITCHELL CHARLES W 5016 E TRINDLE ROAD CITY MECHANI CSBURG ZIP (;ODE TELEPHONE (INCLUDE AREA CODE) 17050 (7t7) 766 4379 ~ ~ II'ISURED'S POLICY GROUP OR FECA NUMBER 5837C169820 S1ZLF SEX c. INSURANCE PLAN NAME OR PROGRAM NAME d. IS THERE ANOTHER HEALTH BENEFIT PLAN? [] YES ~ NO If yes, return to and comptete item 9 a-d. 13.1NSURED'S OR AUTHORIZED PERSON'S SIGNATURE I autho6ze SIGNATURE ON FILE SIGNED 16 DATSS PATIENT UNABLE TO WORK iN CURRENT OCCUPATION MM ' DO , yy MM ~ DD ' YY HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM ~ OD t yy MM i DO i YY FROM ' I TO I1 '~ OUTSIDE LAB? $ CHARGES 21723 1 +840 9 ~ A i BJ c OATEIS) OF SERVICE Place~t Type 05112~01 05112001 1 Ub.LD~UU.L UD/D/UU/ I-L1- 05152 01 05152001 111 · o5 52o'o o 1520oi I 051520',01 0515200-1 i1I uE~62u0i 051620',01 051620101 05172(~01 05-31-2001 05162001 0517200iiil i05T72~OilliI 26 PATIENT'S ACCOUNT NO 27. ACCEPT ASSIGNMENT? ~/____~or govt claims, see back) 1730 PI YES [] NO 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 23 PRIOR AUTHORIZATION NUMBER E F PROCEDURES, SERVICES. DIAGNOSIS (Explain Unusual Circumstances) COCE ' $ CHARGES CPT/HCPCS I MODIFIER -970121 i 2 3 4 20: 970141 i 1 2 3 4 20100 970~2 , 98943~1 i- 1 2 3 4 251 00 97014t : 1 2 3 4 20:00 ~70i2 ' 9894351 : 1 2 3 4 251 00 970121,' 1 2 3 4 201 00 s 2991 O0 RESERVEDFOR LOCAL USE 29 AMOUNT PAiD 30. BALANCE DUE $ J ~ 299[00 5~'-Z~IE 'E TRINDLE RD MECHANICSBURG PA {717) 766 5406 p,,,WA501675 IGR-- 17055-3525 (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 888) PLEASE PRINT OR TYPE FORM HCFA-i500 (12-90) FORM OWCP.1500 FORM RRB-~$O0 PLEASE DO 'TT' ~TAPLE IN THIS AREA r-FTq R~cA CLM: 5837C169820042001 MITCHELL CHARLES W--- ~1,3~1,9~2 M[] F[] se,, Bp°use[] O,h.r[] APPRdVEO OMB-0938-0008 NATIONWIDE INSUP3kNCE COMPANY/BRENDA LIGHTNE P O BOX 69600 HARRISBURG PA 17106 9600 HEALTHINSURANOE CLAIM FORM 5016 E TRINDLE ROAD MECHANICSBURG I PA ZIp CODE 17050 OTHER INSURED S NAME (Last Name Firsl Name. Middle Initial) 8 PATIENT STATUS Employed [~ Full-Time Par~-Time Student [] Student [] 10. IS PATIENT'S CONDITION RELATED TO: c OTHERACr %? []NO READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12 PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or othel information necessaq/ to plccess tl~s claim I aisc request payment of government benefits either ~o mysell or to the party who accepts assignmen{ below. SIGNATURE ON FILE 05 31 2001 SIGNED DATE 14. DATE OF CURRENT · ILLNESS (First symptom) OR ~ 2 ~ 0'0'1~ INJURY (Accident) OR PREGNANCY ~LMRt 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM ~ DO ~ YY 17a ID NUiVIBER OF REFERRING PHYSICIAN lg RESERVED FOR LOCAL USE 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (RELATE ITEMS 1,2,3 OR 4 TO iTEM 24E BY LINEI 723 3 +723 4 847 1 -~ L723 1 +840 9 ~ i 846 0 +724 1 2 A D E DATE(S) OF BERV{CE PROCEDURES, DIAGNOSIS From To { Explain Unusual Circumstances) CODE MM DD YY MM DO CPT/HC PCS I MODIFIER 05172~01 05172001 -98943!;1 05182~01 05182001 97014 05182~01 05182001 98943! 052120:01 05~12001 97014 052120101 05~12001 98943!~1 ,i052220101 05~22001 125FBOE~ALTAXIDNUM8E~ SSN EIN 1 a INSURED'S ID. NUMBER (FOR PROGRAM IN ITEM 1 I 186 12 1986 MITCHEL~L CI4_ARLES W 7 INSURED'S ADDRESS !NO. Stree[) :5016 E TRINDLE ROAD CITY STAT¢,~ MECHANICSBURG ZIP COOE i 11 INSURED'S POLICY GROUP OR FECA NUMBER 5837C169820 SELF ~ [~YES [~ NO ilye~, return to and complete item 9 a-d. SIGNATURE ON FILE DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM I OD I yy MM I DD I yy F K RESERVED FOR $ CHARGES LOCAL USE 1 2 3 4 25', 00 1 2 3 4 20', 1 2 3 4 25', 00, 1 2 3 4 20~, 00 1 2 3 4 251~ 00 97014 1 2 3 4 20I, 00 26 RAT!ENYS ACCOUNT NO 27 ACCEPT ASSIGNMENT? ~!8 TOTAL CHARGE 29. AMOUNT PAiD 0¢ gOVt c~a~ms, see back) 25 1777526 ~ 1730 [.~'r ~YES [] NO $ 304'I 00 I ,31 SIGNATURE OF PHYSICIAN OR SUPPLIER 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE INCLUDING DEGREES OR CREDENTIALS RENOERED (If other than home or o~Ece) ~ 05-31-2001 (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8~88) PLEASE PRINT OR TYPE 55a/~'E~ TRINDLE MECHANICSBURG (717) 766 5406 WA501675 30 BALANCE DUE B 304100 17055-3525 FORM HCFA-~500 (12-90) FORM OWCP-1500 FORM RRB-150f PLEASE DO ~ '; T · ' S. TAPLE IN THiS AREA ~TT-]P,CA CLM:5837C169820042001 APPROVEO OMB-C938 0008 NATIONWIDE INSURANCE COMPANY/BRENDA LIGHTNE~ P O BOX 69600 c HARRISBURG PA 17106 9600 · HEALTHINSURANCE CLAIM FORM p,cA~l-lm~ MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP HEALTH PLAN SLK LUNG MITCHELL CHARLES W ._ i 5016 E TRINDLE ROAD II MECHANI CSBURG ZiP CODE 17050 i9. OTHER ~NSURED'S NAME )Last Name. First Name. Middle Initial) OTHER INSURED'S POLICY OR GROUP NUMBER OTHER INSURED S DATE OF BIRTH SEX EMPLOYER'S NAME OR SCHOOL NAME 186 12 1986 (FOR PROGRAM IN ITEM MITCHELL CHARLES W 5016 E TRINDLE ROAD CITY STATE MECHANI CSBURG PA ZIP CODE TELEPHONE )INCLUOE AREA CODE) ~L7050 (717) 766 4379 11 INSURED'S POLICY GROUP OR PECA NUMBER 5837C169820 SEX a ;NSURED'S DATE OF BIRTH b EMPLOYER'S NAME OR SCHOOL NAME SELF PATIENTS BIRTH DATE SEX PATIENT RELATIONSHIP TO INSURED sln ,e Marr,ed Other E~Es ~NO ,PA F No C INSURANCE PLAN NAME OR PROGRAM NAME d INSURANCE PLAN NAME OR PROGRAM NAME 1Od. RESERVED FOR LOCAL USE d IS THERE ANOTHER HEALTH BENEFIT PLAN? [~] YES ~' NO if yes, relurn to and complete item g a-d. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. ~2.PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release Gl any medical or olher information necessary to process this claim I alSO reques{ ayment of government benelds either to myself or Io the pan'y who accepts assignment below. SIGNATURe. ON FILE 05 31 2001 SIGNED DATE 13.1NSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize payment Gl medical benefits to the undersigned physician e¢ sup¢ier lot services described below. SIGNATURE ON FILE SIGNED 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM i DO i YY MM I DB ~ YY FROM ~ ~ TO I ~ 22. MEDICAID RESUBMiSSION CODE i ORIGINAL REF. NO 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, GIVE FIRST DATE NlM ~ OD i YY 17a ID NUMBER OF REFER~INGI P~YSICIANI !9. RESERVED FOR LOCAL USE 21. OlAGNOS~B OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMB 1,2,3 OR 4 TO ITEbl 24E BY LINE) 723 3 -+723 4 847 1 ~ [ 14. DATE OF CURRENT: ~ ILLNESS (First symptom) OR i~j~ 2 (~ 0~1 INJURY (Accidenl)OR PREGNANCY iLMP} 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 1[__ 3 J__ E.[723 i +840 9 ~. i 846 0 +724 1 A D E DATE(S) OF SERVICE PROCEDURES, DIAGNOSIS From To (Explain Unusu~lCircumslancas) CODE - MM OD YY MM DD CPT/HCPCS I MODIFIER 05222G01 05~22001 97012 05232001 05232001' 98941 052320101 0523200~ 97014 052520:01 05~52001 98941 052520:01 05252001 97014 1234 1234 1234 1234 1234 23PRIOR AUTHORIZATION NUMBER F K RESERVEDFOR $CHARGES LOCALUSE 43l oo 20! 00 43', oo 20', 00 052920101 05292Q01 98941 25. FEDERAL TAX ID. NUMBER SSN BIN 28 PATIENTS ACCOUNT NO. 25 1777526 ~ 1730 PI 3~ SIGNATURE OF PHYSICIAN OR SUPPLIER tNCLUDING DEGREES OR CREDENTIALS M~C~I~d ~ mW~R~,.!DC ~ -'31-2 SIGNED DATE 1234 27 ACCEPT ASSIGNMENT? or govt. claims, see back) YEB [] NO 32 NAN1E AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED (Ii other than home or office) 43J00 2BTOTALCHAROE 29AMOUNTPA~D 30~LANCEDUE s 304:00 s J s 304100 TRINDLE RD MECHANICSBURG PA (717) 766 5406 PIN#WA501675 IGRP~ 17055-3525 (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE FORM HCFA-1 ~00 (12-~O) FORM OWCP- t 500 FORM RRB-1500 PLEASE DC ,:.CT. ' STAPLE I~,1 THIS AREA i~ p,c~ CLM: 5837C169820042001 II ~4ED~CARE MEDICAID CHAMPUS CHAMPVA GROUP HEALTH PLAN ELK LUNG MITCHELL CHARLES W --- 5016 E TRINDLE ROAD MECHANICSBURG PA 17050 (717)766 4379 OTHER INSURED'S POLICY OR GROUP NUMBER b OTHER INSUREG'S DATE OF BIRTH SEX c. EMPLOYER'S NAME OR SCHOOL NAME 3 PATIENT'S SIRTH OATE SEX ~11~ ~c1',972, , NI ,~ 6 PATIENT RELATIONSHIP TO INSURED 8 P~,TIENT STATUS Sl,d.nl [] Stu~,nl [] 10. IS PATIENT'S CONDITION RELATED TO: INSURANCE PLAN NAME OR PROGRAM NAME a. EMPLOYMENTg (CURRENT OR PREVIOUS) r ,ES E~Es [~NO ,PA, I-IvEs I N° NATIONWIDE INSUR. ANCE COMPANY/BRENDA LIGHTNE~ P O BOX 69600 FULRRISBURG PA 17106 9600 HEALTH INSURANCE CLAIM FORM P,C^ ~ :L86 12 1986 MITCHELL CHARLES W 5016 E TRINDLE ROAD MECH/~I CSBURG PA :L7050 (717) 766 4379 5837C169820 ~011i3~)l?Y~ 2 M E~ F [] SELF 10d RESERVED FOR LOCAL USE READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12 PATIENTS OR AUTHORIZED PERSON'S SlGNATURE I authorize the release ol any medical or other information necessary to prccess Ihis claim I also reques~ ayment ol ~overnment benefits either to myself o¢ to the parb/who accepts assi nment ~e,o,~ SIGNATUR~ ON FILE 05 31 20~1 SIGNED DATE 14. DATE OF CURRENT: · ILLNESS (First symploml OR '~ 2 0~ 0'0' 1~ iNJURY IAcclde~lt, OR PREGNANCY ILXIP} 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE [5, IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRSTDATE MM ~ DO ~YY 17a I.O NUMBER OF REFERRING PHYSICIAN Ig RESERVED FOR LOCAL USE 21 G~AGNOSIS OR NATURE OF ILLNESS OR iNJURY. (RELATE ITEMS 1.2.3 OR 4 TO ITEM 24E BY LINE} 723 3 +723 4 847 1 31__ 1723 1 +840 9 ~ 1 846__ 0 +724 1 2 05292G01 05292001 98943!;1 1234 1234 .1.,.2 3 4 1..~. 3 4 05292G01 05292001 97012 98943!;1 97012 ,b,l or govl claims, see back} YSS [] NO 26 PATIENT'S ACCOUNT NO 1730 32 NAME AND AOORESS OF FACILITY WHERE SERVICES WERE RENDERED ( o her hah home or office) 05302G01 05302001 ~02G01 05302001 PLEASE PRINT OR TYPE 25 1777526 [],~, ! ~ ~tHA~3~ ~ mWD~RN~RoUD C I 05-31-200,1 C INSURANCE PLAN NAME OR PROGRAM NAME d IS THERE ANOTHER HEALTH BENEFIT PLAN? [] YES E~ NO If yes, Feturn to arid complele item 9 a-d. 1.'klNSURED S OR AUTHORIZED PERSON'S SIGNATURE 1 authorize payrnenl ol medical benefits to the undersigned physician er supplier fo~ services described below SIGNATURE ON FILE SIGNED .' '~ 1E DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION ~ .~ MM i OD ~ YY MM ~ OD ~ YY 1 El HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM I DD g YY MM ~ OD ~ YY 20, OUTSIDE LAB? $ CHARGES []YEs E NOI CODE ~ ORIGINAL REF. NO. 23 PRIOR AUTHORIZATION NUMBER $ CHARGES 201~ 00 25! 00 20', 00 RESERVED FOR : ',~. IVED 6 2001 Dept. 28 TOTAL CHARGE 29 AMOUNT PAID 30 BALANCE DUE s 218', 00 s ', ~ 218 ', 00 5~E ~ TRINDLE RD MECHAI~I CSBURG PA 17055-3525 (717) 766 5406 WA501675 { GRP# FORM HCFAo15~0 (12-90) Di,rect i~quiries regarding this review to: Med Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 - Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA A bill audit, fee schedule and claims processing service WARI~ER CHIROPP. ACTIC CARE CTR. 5315 E. TRINDLE RD. MECHANICSBURG, PA 17055 MITCHELL, CF~%RLES 5016 EAST TRINDLE ROAD MECF~NiCSBURG, PA ~7055 CLAIM NO: 5837C 16982004202001PA458Prt(14 CO~-ERED INDIVIDUAL: MITCHELL, CHARLES POLICY HOLDER: MITCHELL, CKARLES PROVIDER: ~T~ ID/PROVIDER NO: 25-1777526 .~? ~\~ Q. PATIENT NO: 1730 PI Bgq h\e6\ca\ A OR,. ATIO WIDE · FJURRI SBURG, PA ACCIDENT DATE: 04/20/01 MEDLOGIX ID: 130421A -005B CALCULATION DATE: 09/17/01 WAR1FER CHIROPRACTIC CARE C EXPLANATION OF BENEFITS DIAGNOSES: 1} 723.3 CERVICOBRACHIAL SYNDROME (DIFFUSE) 2) 723.1 CERV~ CAL~IA 3) 723.4 BRACHIAL NEURITIS OR RADICULITIS NOS 4) 840.9 SPRAIN OF UNSPECIFIED SITE OF SHOULDER kND UPPER AP.M 5) 847.1 T~ORACI C S PP-~I N 6) 846.0 LUMBOSACRAL (JOINT) (LIGAMENT) SPRAIN DATES OF SERVICE~ ~HE NED BO~ Provider's Amount Billed .... : 460.00 Allowed Amount .............. : 418.90 TOTAL AMOUNT DUE ............ : 418.90 Carrier's Responsibility .... : 418.90 os/ol/oz - os/15/o~ Speciai~y: Chiropra~ic PA Automobile S~ ITEMIZED CHARGES DATE SERVICE DIAGS UNITS CHARGE PAYMENT T~PE REDUCTION AMT DUE STATUS 08/01/01 97012 1-4 1.00 20.00 Prov Chrg @ 100% ( 0.00) 20.00 Application of a modality to one or more areas; traction, mechanical 08/03/01 98941 1-4_ 1.00 43.00 S~a~e ~ee ~ 110% ( 3.22) 39.78 Chiropraczic manipulative ~reatment (CMT); spinal, three to four regions 08/03/01 98943-51 1-4 1.00 25.00 Frov Chr9 · S0% ( 5.00) 20.00 Chiropractic manipulative treatment (CMT); ext~aspinal, one or moreregion$ 08/03/01 97012 1-4 1.00 20.00 Frov Chrg ® 100% { 0.00) 20.00 Applica~j%Dn of a modality to one or more areas; traction, mechanical IF PAYMENT IS DUE, CHECK WILL BE MAILED IINDER SEPARATE COVER. Direct inquiries regarding this review to: Med Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 . Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA PAGE: CLAIM NO: 5837C--16982004202001PA458 COVERED INDIVIDUAL: MITCHELL, CF~ARLES PAYOR: NATIONWIDE HARRISBURG, PA DATE SERVICE DIAGS UNITS ITEMIZED CHARGES CHARGE PAYMENT TYPE REDUCTION AMT DUE STATU.C 08/06/01 98941 1-4 1.00 43.00 state Fee ~ 110% Chiropractic manipulative treatment (CMT); spinal, three to four regions 08/06/01 98943-51 1-4 1.00 25.00 Prov Chrg · $0% Chiropractic manipulative treatment (CMT); extraspinal, one or moreregions 08/06/01 97012 1-4 1.00 20.00 Prov Chrg ® 100% Application of a modality to one or ~ore areas; traction, mechanical 08/08/01 98941 1-4 1.00 43.00 State Fee ~ 110% Chiropractic manipulative treatment (CMT); spinal, three to four regions 08/08/01 98943-51 1-4 1.00 25.00 Prov Chrg ~ 80% Chiropractic manipulative treatment (CMT); extraspinal, one or moreregions 08/08/01 97012 1-4 1.00 20.00 Prov Chrg ~ 100% Application of a modality to one or more areas; traction, mechanical 08/13/01 98941 1-4 1.00 43.00 State Fee ~ 110% Chiropractic manipulative treatment (~T); spinal, three to four regions 08/13/01 98943-51 1-4 1.00 25.00 Prov Chrg · 80% Chiropractic manipulative trea~men~ (CMT); extraspinal, one or moreregions 08/13/01 97012 1-4 1.00 20.00 Prov Chrg ~ 100% Application of a modality to one or more areas; traction, mechanical 08/15/01 97012 1-4 1.00 20.00 Prov Chrg · 100%. Application of a modality to one or more areas; traction, mechanical 08/15/01 98941 1-4 1.00 43.00 State Fee ~ Chiropractic manipulative treatment (CMT); spinal, three to four region~ 08/15/01 98943-51 1-4 1.00 25.00 Prov Chrg ® 80% Chiropractic manipulative trea=ment (C~T); extraspinal, one or moreregion$ 3.22 5.00 0.00 3.22 5.00 0.00 3.22 5.00 0.00) 0.00) 3.22) 5.00) Totals: 460.00 39.78 20.00 20.00 39.78 20.00 20.00 39.78 20.00 20.00 20.00 39.78 20.00 41.10) 418.90 IF PAYMENT IS DUE, CHECK WILL BE MAILED UNDER SEPARATE COVER. MedLogix Managed Care System V2.5 Rev 07/01 (c)1997 Consolidated Services Group, Inc. PLEASE DO NOT- ~TAPLL IN THIS AREA CLM: 5837C169820042001 NATIONWIDE INSURANCE COMPANY/BRENDA LIGHTNEi P O BOX 69600 ~ HARRISBURG PA 17106 9600 ~F~PICA MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHEF 3~. INS RE ' ID NUMBER ~ECHANICSBURG b OTHER INSURED'S DATE OF BIRTH SEX c EblPLOYER'S NAME OR SCHOOL NAME HEALTH INSURANCE CLAIM FORM (FOR PROGRAM IN ITEM ~ S,uOen/Ful"Time ~ Pa.-/imesludenl U (7t5)~ 4~9 Employed  INSURED S DATE OF 8IRTN a EMPLOYMENT~(CURRENI R PREVIOUS) ~3~22 ~ ~ SEX SELF READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12 PATIENT'S OR AUTHORIZED PERSON'S SlGNATU RE [ au[horize the release of any medicai or other information necessary b.,ow. 5~{3~A~'~J'R~" ~1~ g~'%~ t~' O~ ~lt~f SIGNED DATE ~ 5. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE PIRSTDATE MM I DO Ii YY 17a i D NUMBER OF REFERRING PHYSICIAN 13.1NSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 16 DATES PATIENT UNAPLE Tn WORK IN CURPENT OCCUPATION MM I DD I yy MM m DD I yy I INJURY (Accident) OR I ~ PREGNANCY (LMP) 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 19 RESERVEO FOR LOCALUSE 723 1 +840 9 846 0 +724 1 DATE(S) OF SERVICE PROCEDURES, SERVICES. DIAGNOSIS From TO (Explain Unusual Circumstances) MM OD YY MM DO CPTi~CPCS MODIFfER CODE - 20 OUTSIDE LAB? $ CHARGFS F K RESERVED FOR $ CHARGES LOCAL USE 123 08032~01 08032001 08062G01 08062001 98943!;1 98941I 234 1234 080620,01 08062001 11 I 97012 o8o82qo1 1080820011%%) 98943 1 25 1777526 1730 PI 1234 1234 1234 27. ACCEPT ASSIGNMENT? 25'~ 00 431 00 201~ 25:O0 43[ 00 0~ MECHANICSBURG PA (717) 766 5406 WA501675 17055-3525 tAP PRO¥ ED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE FORM HCFA-1 $0~ (12-90) PLEASE DO NO~ ..STAPLE IN THIS AREA NATIONWIDE INSUR. ANCE COMPANY/BRENDA LIGHTNE P O BOX 69600 HARRISBURG PA 17106 9600 CLM: 5837C169820042001 ~RICA HEALTH INSURANCE CLAIM FORM .SALT. PLAN S ..NG,PORRROG.A.,N, ,, I 8 PATIENT RE~TIONSH[P TO INSURED ~ C'~ECHANI CSBURG a OTHER INSUREDS POLICY OR GROUP NUMBER b OTHER INSURED S DATE OF BIRTH SEX INSURANCE PLAN NAME OR PROGRAM NAME 8 PATIENT STATUS Single [] Married ~ OIher [] 10 IS PATIENT'S CONDITION RELATED TO: b AUTO ACCENT? PLACl~;~lale) []YEs ~NO 10d RESERVEDFORLOCALUSE READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIEN"FS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release Of any medical or other information n~cessary to process t h i~.[i~,~¢..]~l~,a y r ~ f 9~ e~.~l~ ~nefits either to mysei~ or to the SIGNED DATE INJURY (Accident) OR I I PREGNANCY tLMP) 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 19 RESERVEDFORLOCALUSE 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS GIVE FIRSTDATE MM I DD Ii YY 17a. iD NUMBER OF REFERRING PHYSICIAN !2, D~IS~R NA~I;~ILL~SS OR ,.JURY (.E~T~ mT~s 723 1 +840 9 846 0 +724 1 ~2L 4.1 24 A )Explain UnusuDam Circumstances) E DATE(Si OF SERVICE PROCEDURES. SERVICES, OR SUPPLIES From TO DIAGNOS~S MM DO YY MM DO CPT~CPCS MODIFIER CODE ' f4kc zcss e C INSURANCE PLAN NAME OR PROGRAM NAblE 1;3 INSURED'S OR AUTHORIZED PERSON'S SIGNATURE [ authorize pay.em of medical benefils to the u~dersigned physician or sup.plier for se~icesde~'ATURE ON FILE SIGNED FROM[ I i ' - TO II II CHARGES K RESERVED FOR LOCAL USE 08152~01 08152001 08t520,01 0815200~ 8 09-07-200[ (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE ~88) 97012 98943~1 1234 1234 2oi 25'~ 00 2 ~L ~ .~E~T'S~C O U NT NO 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE PLEASE PRINT OR TYPE N:EC~ICSB~G PA 17055-3525 (717) 766 5406 WA501675 P,~m~ ~ GRP¢ FORM HCFA-1500 (12-~) FORM OWCP+1500 FORM Direct ~nquiries regarding this review to: Med Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 . Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA A bill audit, fee schedule and claims processing service WltR/q~R CHIROPP~ACTIC CA.RE CTR. 5315 E. TRINDLE RD. MECHANICSBU~G, PA 17055 MITCHELL, CHARLES 5016 EAST TRINDLE ROAD MECHANICSBURG, PA 17055 CLAIM NO: COVERED INDIVIDUAL: ~-~ POLICY HOLDER: PROVIDER: T~, ID/PROVIDER NO: PATIE~ 5837C 16982004202001PA458Prt(14 MITCHELL, CHARLES MITCHELL, CHARLES WARNER CHIROPP. ACTIC CARE C 25-1777526 1730 PI PAYOR: NATIONWIDE 'HARRISBURG, PA ACCIDE]NT DATE: 04/20/01 M~DLOGIX ID: 130421A -001B CALCULATION DATE: 05/18/01 DIAGNOSES: 1) 2) 3) 5) 6) EXCEPTIONS REPORT EXPLANATION OF BENEFITS 723.8 CERVICOBRAm4IAL SYNDROME (DIFFUSE) 723.4 BRACHI~.L NEURITIS OR RADICULITIS NOS 723.1 CERVI CALGI A 840.8 SPRAIN OF UNSPECIFIED SITE OF SHOULDER AND UPPER ARM 847. t THORACIC SPRAIN 846.0 LDMBOSACRAL (JOINT) (LIGAMENT} SPRAIN -DATES OP SERVICE: 04/26/01 - 05/03/01 :THE M~D BO~ Provider's Amount Billed .... : 703.00 Allowed Amount .............. : 669.58 TOTAL AMOUNT DUE ............ : 669.58 Carrier's Respo~sibility .... : 669.58 PA Automobile Dear Sir/Madam: On 05/18/01 the above named case was referred to the Review Department to evaluate coding, treatment, or billing as it relates to Section 69.24 of Act 6 amended November 30, 1991. Your bi. ll for treatment on-0%/26/01 has been reviewed. The following listing more appropriately describes the services rendered. ITEMIZED CHARGES DATE SERVICE DIAGS UNITS CHARGE PAYMENT TYPE REDUCTION AMT DUE STATUS IF PAYMENT IS DUE, CHECK WXLL BE MAILED UNDER SEPARATE COVER. MedLogix Managed Care System V2.5 Rev 04/01 (c)1997 Consolidated ~ices Group, Inc. D~rect inquiries regarding this review to: Med Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 - Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA PAGE: CLAIM NO: 5837~'~6982004202001PA458 COVERED INDIVIDUAL: MITCHELL, CH/~RLES PAYOR: NATIONWIDE HARRISBURG, PA ITEMIZED CHARGES DATE SERVICE DIAGS I/NITS CHA~RGE PAYMENT TYPE REDUCTION AMT DUE STATU~ 04/26/01 04/26/01 04/26/01 04/26/01 97012 1-4 Application of a modality 98941 1-4 1.00 43.00 State Pee · 110% ( 3.22) 39.78 Chiroprac=ic manipulative treatment (CMT); spinal, three to four regions 98943-51 1-4 1.00 25.~0 Prov Chrg ~ 100% ( 0.00) 25.00 Chiropractic manipulative treatment (CMT); extr~spinal, one or moreregibns 99203-25 1-4 ' 1.00 75.00 ( 0.00) 0.00 Office or other outpatient visit for the evaluation and management of anew patient, which requ/ires these three k CR ~SOLDTION: CODE APPROPRIATE, PROPER FEE ASSIGN~ED. 99203-25 1-4 1 . 00 Prov Chrg ~ 100% Office or other outpatient visit for the evaluation and ~nagement of anew p 1.00 20.00 prov Chrg ® 100% to one or more areas; traction, mechanical 04/27/01 98941 1-4 Chiropractic ~nipulative 04/27/01 98943-51 1-4 Chiropractic manipulative 04/27/01 97014 1-4 Application of a ~dality 04/27/01 97012 1-4 Application of a ~dality 04/30/01 98941 1-4 Chiropractic manipulative 04/30/01 98943-51 1-4 Chiropractic ~nipulat ire 04/30/01 97014 1-4 1.00 1.00 1.00 1.00 1.00 1.00 1.00 43 . 00 State Fee ~ 110% (CMT); spinal, three to four regions 28. 00 Prov Chrg ~ 100% (m4T); extraspinal, one or moreregions 20. 00 State Fee · 110% more areas; electrical stimulation(%!natcended) 20 .00 Prov Chrg % 100% more areas;_traction, mechanical 43. 00 State Fee ~ 110% (CMT); spinal, three to four regionl~ 28.00 Prov Chrg @ 100% (CMT); extraspinal, one or moreregions 20. 00 State Fea® ~10% 0.00) 75.00 0.00) 20.00 3.22) 39.78 0.00 25.00 2.82 17.18 0.00 20.00 3.22 39.78 0.00 25.00 2,82 17.18 04/30/01 05/01/0i 05/01/01 Application of a modality to o~e or 97012 1-4 1. 00 98941 1-4 1.00 Chiroprac=ic man~pulative treatment 98943-51 1-4 1.00 Chiropractic manipulative treatmen= more areas; electrical stimulation(unattended) 20. 00 Prov Chrg ~ 100% more areas; traction, mechanical 43.00 State Fee ~ 110% (CMT); spinal, three to four regions 25~00 Prov Chrg · 100% (CMT); extraspinal, one or moreregions IF PAYMENT IS DUE, CHECK WILL BE MAILED UNDER SEPARATE COVER. 0.00) 20.00 3.22) 39.78 0.00) 25.00 c7_~ THE ~OVE SERVICES ~AVE BEEN COMPUTED TO CONFORM ~ pENNA HOUSE BILL 121 AUTO INSURANCE REFORM LAW, "ACT 6", AS AMENDED NOVEMBER 30, MedLogix Managed Care System V2.5 Rev 04/01 (c) 1997 Consolidated Services Group, Inc. Direct inquiries regarding this review to: Med Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 · Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA PAGE: 3 CLAIM NO: 5837~6982004202001PA458 COVERED INDIVIDUAL: MITCHELL, CHARLES PAYOR: NATION-WIDE HARRISBURG, PA ITEMIZED CHARGES DATE SERVICE DIAGS UNITS CHARGE PAYMENT TYPE REDUCTION AMT DUE STATUS 05/01/01 05/01/0z 05/02/01 05/02/01 97014 1-4 1.00 20.00 State Fee ® Application of a modality to oNe-or more areas; electrical stimulation(urlattended) 97012 1-4 1. 00 20.00 Prov Chrg ® 100% Application of a w~dali~y to one or more areas; traction, mechanical 98941 1-4 1.00 43.00 s~ate Fee · Chiropractic manipulative treatment (CMT); spinal, three to four regions 98943-51 1-4 1.00 25.00 Prov Chrg ~ 100% Chiropractic manipulative treatment (CMT); extraspinal, one or moreregions 05/02/01 97014 1-4 1.00 20.00 State Fee a 110% · Application of a modality to one or more areas; electrical stimulation(~%attended) 05/02/01 97012 1-4 1.00 20.00 Prov Chrg · 100% Application of a modality to one or more areas; traction, mechanical 05/03/01 98941 1-4 1.00 43 .00 State Fee ® 110% Chiropractic manipulative treatment (CMT); spinal, three to four regions 05/03/01 98943-51 1-4 1.00 25.00 Prov Chrg · 100% Chiropractic manipulative treatment (CMT); extraspinal, one Or moreregions 05/03/01 97014 1-4 1.00 20.00 State Fee ~ 110% Application of a modality to one or more areas; electrical stimulation(w%attended) 05/03/01 97012 1-4 1.00 20.00 Prov Chrg · 10o% Application of a modality to one or more areas; traction, mechanical Totals: 703.00 ( Status Codes: C7 - Denied pending review. Modifier requires review. Status Codes: RC - CS resolution: Proper code assigned OR Code appropriate, proper fee assigned. 2.82) 17.18 0.00) 20.00 3.22) 39.78 0.00) 25.00 2.82) 17.18 0.00) 2O.OO 3.22) 39.78 0.00) 25.00 2.82) 17.18 0.00) 20..00 33.42) 669.58 IF PAYMENT IS DUE, CHECK WILL BE MAILED UNDER SEPARATE COVER. MedLogix Managed Care System V2.5 Rev 04/01 (c)1997 Consolidated Services Group, Inc. ~irect inquiries regarding this review to: Med Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 · Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA PAGE: CLAIM NO: 583~16982004202001PA458 COVERED INDIVIDUAL: MITCHELL, CHARLES PAYOR: NATIONWIDE H3%RRISBURG, PA S~a~us Codes: C7 - Denied pending review. Modifier re(p/ires review. Status Codes: RC - CR resolution: Proper code assigned OR Code appropriate, proper fee assigned. PLEASE NOTE: DISAGREEMENTS OR COMPLAINTS MUST BE ADDRESSED IN WRITING. PLEASE ENCLOSE A COPY OF BOTH THIS EXPLANATION'A/TD THE ORIGINAL BILL WITH ALL CORRESPONDENCE. Your Review has been completed by Peg Lenhart, RN Medical Review Specialist IF PAYMENT IS DUE, CHECK WILL BE MAILED UNDER SEP~tRATE COVER. MedLogix Managed Care System V2.5 Rev 04/01 (c)1997 Consolidated Services Group, Inc. PLEASE OO HOT STAPLE IN THIS AREA NATIONWIDE INSUR3L~CE COMPANY/BRENDA LrGHTNE P O BOX 69600 HARRISBURG PA 17106 9600 ~RICA CLM:5837C169820042001 HEALTH INSURANCE CLAIM FORM P,CA fi , HEALTHPLAN BLKLUNG~ 186 12 1986 [] ,.~,~ ....... - .,tedic~,~ :,© is ....... SS,U, ~ ,w ~,,e ~, [] ,SS~o.D, ~ ,SS,V,~ MITCHELL C~LES W ~i~3~922 ~, ~ ~ MITCHELL C~LES W 5016 E TRINDLE ROAD MECHANI CSBURG PA' i (717)766 43'79 ZIP CODE 17050 10 tS PATIENTS COMDiTIO"J RELATED TO' READ BACK OF FORM BEFORE CGklPLETING & SIGNING THIS FORM. ' medica~ or other inlermatien necessar/ ~oprocessthi$cla~mlalsore uesloayme~l.~ vr'mmenlbenelitseiihertomyse[le~tothepa ~' ho c~pts s i ment ~.,o~ SIGNAT~E O~ ~ILE ~ ~7 ~1 S~GNED DATE ~t2(9~001~ :NJURYIAcCidenI!OR GIVEFIRSTDATE MM I DD 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (RE~TE ITEMS 1.2.3 OR 4 TO ITEM 24E BY LINE) 723 3 +723 4 847 1 1{__ 3.1 z[723 1 +840 9 ~ I 846 0 +724 24 A B ! C D DATE!Si OF SERVICE ; place TypePROCEDURES SERVICES. OR SUPPLIES I 04262001 04262001i 11! -98941 !04262001104262001 11~- 9920325 i, ~0-4-~ZbZUU.!. lU~-XbZUU.i: ii I 04272001 !042720011111 98941] 04272&01 iii 97014 04302001 04302001 ii! 98941I !04302~01 04302001'111 DIAGNOSIS CODE- 1234 1234 97014 26 RATIENT S ACCOUNT NO ' E7 ACCEPT ASSIGNMENT? 25 1777526 ~ 1730 PI I ~bA~'~' ~DC 1234 1234 1234 1234 !5016 E TRINDLE ROAD cir~ i ST~ MECFL~NI CSBURG , 17050 (717) 766 4379 5837C169820 ,011,,3q~1,,922 ~ ~ SEX SELF [] YES [~ NO if yes, return to and complete ~tem 9 a-d 13 ~NSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize oayment of medical benefits to the undemigned physician or supplie~ for 'e'¥'ce'd"~'~fATURE ON FILE DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 43 751~ O0 43! 00 201 O0 431 O0 20:, O0 359; O0 ', 5~l~E '~ TRINDLE RD MECHANI CSBURG PA (717) 766 5406 P,~ WA501675 J GRP$ K RESERVED FOR LOCAL USE 30. BALANCE DUE s 3591 O0 17055 -3525 PLEASE DO NO,~ ,STAPLE iN THIS AREA NATION-WIDE INS~CE COMPANY/BRENDA LiGHTN-E P O BOX 69600 HA_RRISBURG PA. 17106 9600 ~lqP,C^ CLM: 5837C169820042001 HEALTH INSURANCE CLAIM FORM P,C~, ~tlWeccare~l~!ttedica,ci~l~~ ISr ...... SSN~[~;'zJYi!e=,__~ ,SSNorlD~ [] (SSA~) ~ ~C 186 12 1986 MITCHELL CHARLES W__ 5016 E TRINDLE ROAD MECH3MNICSBLTRG j PA s,ogle ~ Married ~ Other ZIP CODE Student [] Studenl 10 IS PATIENT'S CONDITION RELATED TO a EMPLOYMENT? (CURRENT OR PREVIOL'E [] YES ~NO ~O ,PA, MITCHELL CHARLES W 5016 E TRINDLE ROAD MECHAI',IICSBURG I PA ZIP CODE I TELEPHONE (INCLUDE AREA CODEi 17050 I (717) 766 4379 5837C169820 ~)'13~19~9. 2 SELF READ SACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. ~ 2 PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I auti~orlze the re~ease of any medical or olher inlormation necessan/ ~e~o'.~ SIGNDiTUP. E ON FILE 05 07 2001 S~GNEO DATE ~0'42(9~0"01~"JURV(Ac~ia~""O" ! GIVE F}RST DATE MM I~ DO It yy 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. ID NUMBER OF REFERRING PHYSICIAN 21 DIAGNOSIS OR NATURE OF tLLNESS OR INJURY. (RELATE (TEblS 1 2.3 OR 4 TO ITEM 24E SY LINEI ~1723 3 +723 4 3 I 847 1 13 I NSUREO'S OR AUTHORIZED PERSON'S SIGNATURE I aNt ho.ize payment of medical benefits to the undersigned physician or supptier ~or sen/ices described below SIGNATURE ON FILE SIGNED 16. DATES PATIENT UNABLE TO WORK tN CURRENT OCCUPATION E L723 1 +840 9 ~ [ 846 0 +724 1 o4~o2~ol 04~02001111! -970121 [ I 2 3 4 o%o(]___12J01 05_12_01~; 11[ 98.941 , 11 22 33 44 050120~01 105012001111 ' . 9894351 05012001 ~05012001~ 11~ ~ 97012~ ~ 1 2 3 4 ~F~o220o~ ~o50226o~ ~' 105022001 05022001~11 989435t ', 1 2 3 UbU220Ui ubU2ZOUl~ll~ ~ 97014~ ~05022001~ 11 ~oso32qoziosp3200z~zz ~ 9e943~z ~ ~ 2 3 4 ~ 25 1777526 ~ 1730 PI " ~ ~' 'DC APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8,88t 23 PRIOR AUTHORfZATiON NUMBER F K I DAYS RESERVEG FOR S CHARGES LOCAL USE 2o! ooi 1 25:001 1 2oi ooi i ED 2s oo; 1 20', 00!: 1 25'. 00'1 28 TOTAL CHARGE 29 AMOUNT PAJD 30 BALANCE DUE E 304! 00 s I s 304', 00 l~3~.q~E ~ TRINDLE RD PLEASE PRINT OR TYPE MECI-13LNICSBURG PA (717) 766 5406 WA501675 IGRp# 17055-3525 FORM HCFA.i~00 (12-90) FORM OWCP-1500 FORM RRO- 15C0 DO NOT. STAPLE IN THIS AREA NATIONWIDE INSURANCE COMPANY/BRENDA LIGHTNE P 0 BOX 69600 HARRISBURG PA 17106 9600 ~%.R,C¢, CLM: 5837C169820042001 HEALTH INSURANCE CLAIM FORM P~O.. I! ~,,.,~:.-~,~..,~_ .,,.~,,,c.,,.,.,~j ,spt ..... s~.¥,~,,,~.,~-.,,_ [] ,ss,,,o,o, ~, ,~,¥, LU,,o, 186 12 1986 MITCHELL CHARLES W :MITCHELL CHARLES W 5016 E TRINDLE ROAD~ MECHANI CSBURG f PAl ,",,,,,,e~ i~ ~ 17050 (?171 ?66 43?9 E.,¢o~,.~X Full-Time Part-T;me 5016 E TRINDLE ROAD ]MECHANI CSBURG I PA ZIP CODE 17050 TELEPHONE IINCLUDE AREA CBOE, (717) 766 4379 11 iNSURED S POLICY GROUP OR FECA NUMBER !58370169820 a INSUREDS CATE OF BIRTH SEX SELF ~YES E~ NO Il ye¢. retum to and complete item g a-d. SIGNATURE ON E~ILE 05 07 20~1 SIGNATURE ON FILE I 1,z DATE OF CURRENT· ILLNESS {First s!~mptcm) OR ,'OA 2 8~2 0'0 1 ~ INJURY (A¢¢iden;, OR 19 RESSRVED FOR LOCALUSE 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (RELATE ITEMS 1 2.3 OR 4 TO ITEM 24E BY LINE) 723 3 +723 4 847 1 3[__ 21723 1 +840 9 · [ 846 0 +724 t 05032q01 !05032001 11 I 97014 : 1 2 3 IUbUJT~UUI UbUJZUui,ii 97012 i 2 3 : ~ ~ ,,". ~' '~ "' I , ,,,,~, ~" 25 177F,¢'2~ ~%~ I 1730 PI ,~,*~' ~s rNC~F~O~Ak~5 I: 'R~NDERED df other than home or Mt.~)~k' .DC ~ [APPROVED BY A'vlA COUNCIL ON MEDICAL SERVICE & 88) 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 20 00 28 TO~AL CHARGE 29 AMOUNT PAID 30. BALANCE DUE s 401 00 : s 40:00 5~l~E~ TRINDLE RD MECHANICSBURG PA (717) 766 5406 WA501675 GRP# 17055-3525 PLEASE PRINT OR TYPE FORM HCFA-1500 (12-g0) FORM OWCP- 1500 FORM RRB- 1500 Direct. inquiries regarding this review to: M'ed Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 · Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA A bill audit, fee schedule and claims processing service WAP~FER CHIROPRACTIC CARE CTR. 5315 E. TRINDLE RD. M~C}L%NICSBURG, PA 17055 MITCHELL, CHARLES 5016 EAST TRINDLE ROAD MECHANICSBUR~, PA 170~5 CLAIM NO: 5837C~16982004202001PA458Prt(14 COVERED INDIVIDUAL: MITCHELL, CHARLES POLICY HOLDER: MITCHELL, CHARLES PROVIDER: TAX ID/PROVIDER NOG PATIENT NO: WAR/FER CHIROPRACTIC CARE C 25-1777526 1767 RH PAYOR: ACCIDENT DATE: MEDr.OGIX ID: CALCulATION DATE: NATIONWIDE · F~tRRISBURG, PA o4/2O/Ol 130421A -004B 08/24/01 EXCEPTIONS REPORT EXPLANATION OF BENEFITS DATES OF SERVICE: 07/i3/0i - 07/~0/0~ THE MED BOX Provider,s Amount Billed .... : 1,050.00 Allowed Amount .............. ~ 431.90 TOTAL AMOI/RT DUE ............ ~ 431.90 Carrier's Responsibility .... '~ 431.90 Specialty: Chiroprat ic PA Automobile ST Dear Sir/Madam: On 08/24/01 the above named case was referred to the Review Department to evaluate coding, treatment, or billing as it relates to Section 69.24 of Act 6 amended November 30, 1991. Your bill for treatment on D7/13/01 has been reviewed. The following listing more appropriately describes the services rendered. ITEMIZED CHARGES DATE SERVICe" DIAGS UNITS CHARGE PAYMENT TYPE REDUCTION AMT DUE STATU~ IF PAYMENT IS DUE, CHECK WI~LL BE MAILED D'~U~R SEPARATE COVER. ~edLogix Managed Care System V2.5 Rev 07/01 (c)1997 Consolidated~roup, Inc. Direct. inquiries regarding this review to: M~d Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 - Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA PAGE: 2 CLAIM NO: 5837C 16982004202001PA458 COVERED INDIVIDUAL: MITCHELL, CHARLES PAYOR: NATIONWIDE HARRISBURG, PA ITEMIZED CHARGES DATE SERVICE DIAGS UNITS CHARGE PAYMENT TYPE REDUCTION AMT DUE STATUn 07/13/01 07/16/01 07/16/01 07/18/01 07/18/0~ 07/20/01 07/20/01 07/23/01 07/23/01 07/25/01 07/25/01 07/27/01 07/27/01 07/30/01 97750 1-4 2.00 170.00 ( 0.00) 0.00 Physical performance test or measurement (et, musculoskeletal,fu~ctional capacity), with written report, each 15 CR RESOLUTION: DENIED. PROVIDE D(~CL~4ENTATION FOR ADDITIONAL PAYMENT. 97750 1-4 2.00 ( 170.00) 0.00 Physical performance test or measurement (et, musculo'skeletal,functional cap 97116 1-4 ' 1.00 55.00 S~ate Fee ® 110% ( 27.58) 27.42 Therapeutic procedure, one or more areas, each 1S minutes; gait training(includes stair climbing) 97110 1-4 1.00 55.00 State Fee a 110% ( 28.34) 26.66 Therapeutic procedure, one or more areas, each 15 minutes; therapeuticexercises to develop strength and enduranc 97116 1-4 1.00 55.00 State Fee a 110% 27.58) 27.42 · Therapeutic procedure, one or more areas, each 15 minutes; gait training(includes stair climbing) 97110 1-4 1.00 55.00 State Fee % 110% 2B.34) 26.66 Therapeutic procedure, one or more areas, each 15 minutes; therapeuticexercises to develop strength and enduranc 97116 1-4 1.00 55.00 State Fee U 110% 27.58) 27.42 Therapeutic procedure, one or more areas, each 1S minutes; gait training(includes stair climbing) 97110 1-4 1.00 55.00 State Fee ~ 110% 28.34) 26.66 Therapeutic procedure, one Or more areas, each 15 minutes; therapeuticexercises to develop strength and enduranc 97116 1-4 1.00 55.00 State Fee ~ 110% 27.58) 27.42 Therapeutic procedure, one or more areas, each 15 minutes; gait training(includes stair c~imbing) 97110 1-4 1.00 55.00 State Fee e 110% 28.34) 26.66' Therapeutic procedure, one or more areas, each lB minutes; therapeuticex~,=rcises to develop strength and enduranc 97116 1-4 1 .00 55.00 State Fee ~ 110% 27.58) 27.42 Therapeutic procedure, one or more areas, each 1S minutes; gait training(includes stair climbing) 97110 1-4 2.00 110.00 State Fee ~ 110% 56.67) 53.33 Therapeutic procedure, one or more areas, each 1S minutes; therapeuticexercises to develop strength and enduran¢ 97116 1-4 1.-00 55.00 State Fee ~ 110% 27.58) 27.42 Therapeutic procedure, one Or more areas, each 15 minutes; gait training[includes stair climbing) 97110 1-4 2.00 110.00 State Fee ~ 110% 56.67) 53.33 Therapeutic procedure, one or more areas, each 15 minutes; therapeuticexercises to develop strength and enduranc 97116 1-4 1.00 55.00 state Fee ~ II0% 27.58) 27.42 Therapeutic procedure, one or more areas, each ~15 minutes; gait training~'.includes stair climbing) IF PAYMENT IS DUE, CHECK WILL BE MAILED UNDER SEPARATE COVER. C2 R2 MedLogix Managed Care System V2.5 Rev 07/01 (c)1997 Consolidated Services Group, Inc. DirecT inquiries regarding this review to: ~ed Path 1240 South Broad Street Suite 200 Lansdale, PA 19446 Phone (215) 661-0500 · Fax (215) 661-0871 5837C 16982004202001PA458 LIGHTNER, BRENDA PAGE: CLAIM NO: 5837C 16982004202001PA458 COVERED INDIVIDUAL: MITC~LL, CHARLES PAYOR: NATIONWIDE HARRISBURG, PA ITEMIZED CHARGES DATE SERVICE DIAGS UNITS CHARGE PAYMENT TYPE REDUCTION AMT DUE STATU. 07/30/01 97110 1-4 1..00 55.00 State Fee ® 210% ( 28.34) 26.66 Therapeutic procedure, one or more areas, each 15 minu~es; therapeuticexercises to develop strength and enduranc Totals: 1,050.06 ( 618.10) 431.90 Status Codes: C2 - Denied pending review. Review necessary for appropriate application of code. Status Codes: R2 - CR Resolution: Denied. Provide documentation for additional payment. PLEASE NOTE: DISAGREEMENTS OR COMPLAINTS MUST BE ADDRESSED IN WRITING.. PLEASE ENCLOSE A COPY OF BOTH THIS EXPLANATION AND THE ORIGINAL BILL WITH ALL CORRESPONDENCE. Your Review has been completed by Peg Lenhart, RN Medical Review Specialist IF PAYMENT IS D~IE, CHECK WILL BE MAILED UNDER SEPARATE COVER,. MedLogix Managed Care System V2.5 Rev 07/01 (c)1997 Consolidated Services Group, Inc. DO NOT AREA CLM: 5837C169820042001 NATIONWIDE INSURANCE COMPANY/BRENDA LIGHTNE P O BOX 69600 HARRISBURG PA, 17106 9600 HEALTHINSURANCE CLAIM FORM CHAMPVA GROUP FECA OTHER HEALTH PLaN eLK LUNG ¥ MECHANI CSBURG 17050 (717)766 4379 OTHER INSURED S POLICY OR GROUP ¢'IU ~, SER 8 PATIENT STATUS 10 IS PATIENT'S CONDITION RELATED TO 186 12 1986 MITCHELL CHARLES W 5016 E TRINDLE ROAD CITY ST A~)E~ :MECH/LN'I CSBURG 17050 (717) 766 4379 ,5837C169820 ~ INSURED S DATE OF SIRTH ~)rl,3 ~1:9.2 2 MFK~ SEX SELF OTHER IHSURED'S DATE OF BIRTH SEX 3 AUTO ACCIDENT? PLACE IS)ale) [~VES ~J ,',0 ,PA, c OTHER ACCIDENT? [] ES d INSURANCE PLAN NAME OR PROGRAM NAME READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM 12 PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize Ihe release Gl any medical o¢ ether inlormation necessary to pr~eSS 'hi~io~y ~, ~.~ benefits ei:h.r ,o myself or 'o the pWt~ho~pf~w~nt 19 RESERVED FOR LOCAL1JSE 21 OtAGN SIS OR NATURE OF ILLNESS OR iNJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM E4E BY LINE) 72~ 3 +723 4 847 1 10d RESERVED FOR LOCAL USE d. ,S[~EyRE? NO[~ RN ;E ALT~,;:.~ ~:;uTr: t?ai~d •Droplet e item S a .d. 13 INSURED'S OR AUTHORIZEO PERSON'S S~GNATURE I au f~orize S%GNATURE ON FILE ~.r 3. L 723 1 +840 9 846 0 +724 1 A 0 DATE/S) OF SERVICE PROCEDURES, SERVICES From To (Expimn Unusual Circumstances) MM DD YY MM OD CPT/HCPCS I MODIFIER 23 PRIOR AUTHORIZATION NUMBER E F K DIAGNOSIS RESERVED FOR CODE S CHARGES LOCAL USE 97750 1234 07~62q01 07162001 07%82q01 07~82901 07202001~ 07~02001i 07~32q01 07~32901 11I 107~520:01 07~52901 lll' 6 [ 25 FEDERAL TAX ID NUMBER SSN EIN 25 1777526 97110 97110 97110 97110 97110I 26 PATIENT'S ACCOUNT N 1767 RH 1 2 3 4 551 00 1 2 3 551 00 1 2 3 4 55[ 00 1 2 3 55', 00 2 3 4 110~, 00 ~er 9ovl claims, see back) 775~ 00 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED (if Giber than home or office) 08-02-2001 PLEASE PRINT OR TYPE 2001 30 BALANCE DUE s 775 ,, 00 5~=¢1~E~ TRINDLE RD MECHANICSBURG PA 17055-3525 (717) 766 5406 WA501675 PL:~' 00 NOT STAPL~ NATIONWIDE INSURANCE COMPANY/BRENDA LIGHTNE P O BOX 69600 HARRISBURG PA 17106 9600 ~P,C~ CLM: 5837C169820042001 HEALTH INSURANCE CLAIM FORM HEALTHPIAN ~ 186 12 1986 [] ""~'~"-~' ~, "~'~"~"'" '"E~ '~"~°~"~"" [] '"'~'~"~ "' [] ,s.~~,,,,o, [] ,ss,,,, ,,o,~ MECHANI CSBURG p~ 17050 (717)766 4379 S,ude.~ [] Stu~e.t ~] 10 IS PATIENT'S CONDITION RELATED TO E~]YEs r~NO READ EACK OF FORM BEFORE COMPLSTING & SIGNING THIS FORM. 12 PATIENT S OR AUTHORIZED PERSON'S SIGNATURE I authorize lhe release Gl any medical or olher information necessar to proces¢ t hi~iG ~o-~'l~a y r ~oI ~"~ ~-I~ benefits either to myself or tO the p~vno~pl~nt DATE 14 A T ~O Fi~Ui~,R E NT: 4 ILLNESS (Fbs, symptom) OR ~,t~z (~ J~l INJURY{ACCident) OR I ~ PREGNANCY iLMPI 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS GiVE FIRST DATE MM ~ DD II YY 17a. fD NUMSER OF REFERRING PHYSICIAN 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 19 RESERVED FOR LOCAL USE 21 CIA N SiS RNATUR~OFILLNESSORINJURY.(RELATEITEMS1 2.3 R4TOIT M24EBYLINE) 7~ f +723 4 . ' ~147 I 723 1 +840 9 846 0 +724 24A D L 97116 i 07~ 020~01 07302001~ ! 25 1777526 97116 7~"~~EDS6 E~DORESSTRINDLEN° s~e~, ROAD MECHANI CSBURG I PA 17050 i (717) 766 4379 ~0113 ~1 ~22 M~ SEX F~ PA SELF d. IS T~HERE ANO~a~ R HEALTH BENEFIT PLAN'~ , i YES L~ NO if yes, relurn to and comp)Gte item 9 a-d 13 INSURED S OR AUTHORIZED PERSON'S SIGNATURE I authorize :aymenl of reed ca oenefits [o the undersigned physician or supplier for ~ ...... ~'~g~LTATURE ON FILE SIGNED 16 OATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM 00 I yy MM I OD I yy 20 OUTSIOE LAB~ S CHARGES S CHARGES 1 2 3 4 551 08-02-2001 1 2 3 4 55:00 26 PATIENT'S ACCOUNT NO 27 ACCEPT ASSIGNMENT? 1767 RH YES ~ 1¢2 NAME AND AOORESS OF FACILITY WHERE SERVICES WERE K RESERVED FOR LOCAL USE Dept. 275, 00 : s 275,,00 -5 '~=t~ E E TRINDLE RD MECHANI CSBURG PA (717) 766 5406 WA501675 P,~,~ I GRP# 17055-3525 (APPROVED SV AMA COUNCtL ON MEDICAL SERVICE 8;88) PLEASE PRINT OR TYPE FORM HCFA-I~O0 {12-90) PLEASE REMIT TO: Concentra Managed Care, Inc. P.O. BOX 660776 DALLAS, TX 75266-0776 Tel. (781)290-5350 Invoice Number: Invoice Date: 34752675 Oct29,2001 To Account: Attention: Claimant: Claim#: D.O.I.: Insured: Referral #: NATIONW~E INSURANCE CO. PO BOX 2655 HARRISBURG, PA 17105 BRENDA LIGHTNER Mr. CHARLES MITCHELL 5837C 169820 Apr 20,2001 002800394-01 RECEIVED AUG 0 ? 2ooz ;AIG SPECIALTY AUTO PITTSBURGH PA Statement of Professional Services Service: Date(s) of Service: Cost Peer Review Service 09/05/2001 $495.00 ROGER CAINE CHIROPRACTOR Total: $495.00 Total Amount Due: $495.00 Comments: IRS #: 04-2658593 *Please note "Remit To" address change above qECEIVED OCT 3 1 2001 HOg. Medical Dept, CONCENTRA MEDICAL EXAMS A DIVISION OF CONCENTRA MANAGED CARE, INC. Date: October 29, 2001 NATIONWIDE INSURANCE CO. PO BOX 2655 HARRISBURG, PA 17105 Claimant: Mr. CHARLES MITCHELL Account File: 5837C 169820 CRA File: 002800394-01 Insured: Date of Injury: 04/20/2001 ACT 6 TRACKING 'SHEET Initial Reconsideration DATE OPENED AT PRO LTR SENT REQUESTING MEDICALS MEDICALS RECEIVED SENT FOR REVIEW REPORT RECV'D FROM REVIEWER SENT-TO CARRIER INITIAL OUTCOME RECONSIDERATION OUTCOME A TX APPROP/ c// A B TX PARTIALLY APPROP B C TXNOTAPPROP~ -"~F_~,.,F;~V~, C D OTHER__ OCT 3 1 2§0] D INITI/~L UPHELD INITI.AL MODIFIED INITIAL REVERSED OTHER 700 AMERICAN AVENUE * SUITE 300 · l~l~.O~~d~ 19406 o PHONE (610) 33%8913 * FAX (610) 337-1637 ROGER CAINE, iD.C. CERTIFIED CHIROPRACTIC REHABILITATION DOCYOR 3237 BRISTOL ROAD, SUITE 102 9' BI~NSALIiM, PA 19020 9'(215) 891 - 8300 9. FAX (215) 750 ~ 0635- October 24, 2001 Suzanne Sehl, I~:N. Concentra Medical Examinations 700 American Avenue, Suite 300 King of Prussia, PA 19406 Re: Charles Mitchell Acct File: 5837C 169820 Date of Injury: 04/20/01 Provider: Michel Warner, D.C. Concentra File: 002800394-01 Dear Ms. Sehl: In reference to your recent request, I have reviewed the following records having to do with treatment for injuries alleged to have been sustained irt the motor vehicle accident of 04/20/01. 1) Michael Warner, D.C. a. Initial Report 05/07/01. b. Consultation Form 04/26/01. c. Examination Form (undated) d. Personal Injury Questionnaire 04/26/01. e, Description Of Accident Note (undated). f. Radiology Report Form (date not copied). g. SOAP Notes 04/26/01 to 08115101. h. Note (re: phone contact) 08/29/01. i. Rehabilitation Evaluation Report 07113101. j. Rehabilitation Notes 07/13/01 to 08115/01. k. Invoices 04/26101 to 07/25/01. 2) Magneticlmaging C~nter: a. MRI Report (left shoulder) 07/25/01. Additionally, on 10/19/01 I had a telephone conference with Dr. Warner. Having reviewed the above records, the following is a report of my observations and conc{uslons regarding chiropractic care delivered to this claimant: - ,ECEIVED OCT 3 2001 Page 2 ROGER CAINI~, D.(~, C~RTIFIED C~[IROPRACTIC R~HABILITATION DOCTOR Re: Charles Mitchell Date: 10/24/01 History: According to the available records, the claimant was injured in a motor vehicle acciden[ (rear end collision) on 04/20/01. There are no records pedaining to E.R. or primary medical care. On 04/26/01 the claimant sought treatment from Dr. Warner, who noted clinical signs and/or findings consistent with his diagnosis of post traumatic cervicai, thoracic and lumbosacral sprain/strain with associated pain, cervicobrachial syndrome with brachial neuralgia, and left shoulder sprain/strain with associated pain. Treatment consisted of chiropractic manipulation, physiotherapeutic modalities and therapeutic exercises: There are records pertaining to 47 treatment visits from 04/26/01 to 08/15/01. The note for 08/29/01 merely indicated that a phone call to the claimant was made that day. MRI of the left shoulder on 07/25/01 revealed "Degenerative changes of the gleno- humeral joint with fragmentation and disruption of the anterior labrum. Degenerative changes in the AC joint results in moderate impingement of the rotator cuff tendons", and "Thickening and tendinopathy seen in the rotator cuff tendons. Area of bone edema in the greater tuberosity of the proximal humerus suggesting an acute injury to this region. There are subchondral degenerative cystic changes seen in the greater tuberosity at point cf insertion of the rotator cuff tendons". ' Telephone Conference: During the phone conference, Dr. Warner confirmed that the last visit had been on 08/15/01. He indicated that active therapeutic treatment was discontinued at that time. He also indicated that the claimant's status at that timewas that the neck and lower back injuries were vlrtually resolved, and at maximum improvement level, but not necessarily at pre-injury status due to mild residual symptoms and due to the effects of the shoulder injury..Dr. Warner indicated that the left shoulder injury was not resolved, and that after the MRI he had referred the claimant to an orlhopedtc surgeon. Dr. Warner indicated his assessment that a surgical procedure to repair the internal joint disruption in the shoulder was probably indicated, but that the claimant had resisted the idea of seeing an orthopedist. During the phone~conference, Dr. Warner also desired to dk~cuss various factors and/or complications in this case that supported the overall treatment duration and number of treatment visits, as well as the need for a rehabilitation program. ROGE~ C~INE, D.C. CERTIFIED CHIROPRACTIC REHABILITATION DOCTOR Page 3 Re: Charles Mitchell Date; 10/24/01 Among the cor~licating factors identified by Dr. Warner Were the claimant's age (80), the cervical acceleration/deceleration injury arising from a rear end collision, severe degenerative changes in the claimant's cervical spine and left shoulder, the acute joint disruption in the left shoulder, and the apparent need for surgery. Dr. Warner indicated that he was not sure if the claimant had the orthopedic consultation yet, but he still recommended it. Dr. Warner stated that he did not anticipate any additional chiropractic treatment to be necessary for either the spinal or shoulder injuries. Determination: There is sufficient criteria to support the delivery of chiropractic care by Dr. Warner from 04/26/01 until 08/15t01 for treatment Of various injuries reported to have been sustained in the 04/20/01 MVA. This would include the rehabilitation program, for which there are appropriate and adequate records. This is because, given the complicating factors noted above, the overall treatment duration and number of treatment visits provided to this claimant were consistent with usual and customary guidelines for chiropractic management of this injury. Additionally, it is observed that treatment led to a reason- able. end point, namely MMI and virtual resolution of the cervical, thoracic and lumbar injuries, and an appropriate referral to an orthopedist for the shoulder injury. However, there is insufficient criteria and documentation to support the delivery of any additional chiropractic treatment beyond 08/15t01. This Is because there is insufficient objective, diagnostic criteria to substantiate that during the 04/20/01 MVA, the claimant had sustained a significantly complicated spinal injury, or one for which a protracted, indefinite or recurring chiropractic treatment plan was reascmable. It is also concluded that there is insufficient cdteria to support that chiropractic care is an appropriate treat- ment approach for the left shoulder injury. Regarding treatment for the cervical, thoracic and/or lumbar injuries, Dr. Warner did not identify sufficient objective, clinical and/or diagnostic criteria to support the necessity or appropriateness for additional chiropractic care, and he did not identify an objective anatomical basis for additional treatment, which he did not anticipate, and which would have to be differentiated from maintenance or elective care, and from treatment for subjective complaints consistent with the claimant's age and degenerative changes. Please Note: The above report was completed using the following guidelines for duration and frequency of care: OCT 3 2001 H~,¢ Medical Dept. RO(;ER CAIN'E, D.C. CERTIFIED CHIROPRACTIC REIIABILITAT1ON DOCTOR Page 4 Re; Charles Mitchell Date: 10/24/01 1) ~ation Facts. 3 Edition Ch~ropract~¢~ ~ (Marketing Research, Ltd., 1991). 2) Treatment Paradiqm For Cervical Acceleration/Deceleration Iniuries CWhiolash) Arthur Croft, D.C. (ACA Journal, 1993). The following general guidelines and/or professional resources were also used: 1) ghimDractic Standards Of Practice And Quality Of (:are (Aspen Publishers, 1992). 2) A Doctor's Guide~Tq Record Keel3inm Utilization IVI_~~ Review (Progressive Seminars, 1997). 3) Fundamentals Of Chiropractic Diaqno. sis And Manaqemen~ (Williams & Wilkins, 1991). 4) Guidelines For Chiropractic Quality Assurance And Practice Parameters: Proceedings Of The Mercy Center Consensus Conference (Aspen Publishers, 1993). 5) Ps¥choloqical Ascects Of Rehabilitation; Mark Hendler, D;C., Ph.D. (The Chiropractic Rehabilitation Association & Cleveland Chiropractic College, Rehabilitation Course Notes, 1994). 6) Rehabilitation Guidelines For Chiropractic, First Edition (The Chiropractic Rehabilitation Association, 1992). 7) Rehabilitation Of The Spine (Williams & Wilkins, 1996). 8) Selected Ethics And Protocols In Chiropractin (Aspen Publishers, 1991). Roger C~ne, D.C. 'qECE!VEE- OCT 3 1 2001 · , iedical Dept, CONCENTRA MEDICAL EXAMINATIONS A DIVISION OF CONCENTRA I~L~NAGED ,CARE, I~C. ACT 6 PENNSYLVANIA AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT REQUEST FOR RECONSIDERATItJN OF AN ORIGINAL PEER REVIEW 69.52.h Peer Review Procedures. "An insurer, provider, or insured may request, in writing, reconsideration of the initial PRO determination within 30 days from the date the initial determination is effected. A PRO may set a reasonable charge for the reconsideration but in no case shall the charge for the reconsideration exceed the charge for the initial review. An insurer shall make full payment of the charge for reconsideration to the PRO, but the amount paid for the reconsideration shall be ultimately borne by the party against whom a reconsideration determination is made. RECEIVED 700 AMERICAN AVENUE · SUITE 300 · KING OF PRUSSIA, PA 19406 · PHONE (610) 337-8913 · FAX (610) 337-1637 OCT 3 ~ 2001 Hbq Medical Dept. CONCENTRA MEDICAL EXAMINATIONS A A DIVISION OF CONCENTRA MANAGED CARE, [NC l NATIONWIDE INSURANCE CO. PO BOX 2655 HARRISBURG, PA 17105 Date: September 5, 2001 Claimant: Mr. CHARLES MITCHELL Account File: 5837C 169820 CME File: 002800394-01 Insured: Date of Injury: 04/20/2001 Dear BRENDA LIGHTNER: This will acknowledge our receipt of your request for Service on the above-referenced claimant. Thank you for your referral. We will give this assignment our prompt attention. Sincerely, Suzanne Seb. l, RN MED. REVIEW COORDINATOR RECEIVED SEP ! O 2OOl Hbg. Medical Dept. 700 AMERICAN AVENUE * SUITE 300 ,, KING OF PRUSSIA, PA 19406 ~, PH[ONE (610) 337-8913 · FAX (610) 337-1637 CONCENTRA MEDIC:AL EXAMINATIONS A DIVISION OF CONCENTRA MANAGED CARE, INC. Date: September 5,2001 WARNER CHIROPRACTIC CARE 5315 E TR1NDLE ROAD Mechanicsburg, PA 17055 Dear Provider: Claimant: Mr. CHARLES MITCHELL Account File: 5837C 169820 CME File: 002800394-01 Insured: Date of Injury: 04/20/2001 Concentra Medical Examinations was approved April 25, 1990 by the Insurance Department ofth~ Commonwealth of Pennsylvania as a PEER Review Organization. _.- We have received a request for a PEER Review. of your records on .the above named claimant by NATIONWIDE INSURANCE CO.--~ , under the Automobile Insurance Reform Act, Act VI of 1990. Based on the Act, you are required to submit all of your records that you want considered for this review. You can either mail or fax these records(610-337-1637 ). Please provide this information within 30 days of date of this letter. Act VI affords the Provider the opportunity to discuss their case with the reviewer print to the final determination being made. If you would like the opportunity, please complete the next portion of this page by indicating the days and times during which you would be available. The reviewer will then know the best time(s) to attempt to contact you for your input. If Concentra Medical Examinations. does NOT receive this back, we will not have the reviewer attempt to contact you. Please send your medicals back to Coneentra Medical Examinations with this request. FI YES, I WOULD LIKE THE OPPORTUNITY TO DISCUSS 'I~IS WITH THE REVIEWER. Providers Signature / Date I AM AVAILABLE FOR DISCUSSION ON THE FOLLOWING DAYS AND TIMES (NOTE: Please be as accurate as possible t? assist the reviewer in his / her contact attempts). TELE: lfyou have any questions or concerns and wish to discuss this matter, please contact me at (610) 337-8913. Sincerely, ECE!VED Suzanne Sehl, KN SEP 1 O 2001 MED. REVIEW COORDINATOR I' b J. Med!cal Dept. 700 AMERICAN AVENUE · SUITE 300 · KING OF PRUSSIA, PA 19406 · PHONE (610) 337-8913 ', FAX (610) 337-1637 (800)221-2315 ASSIGNMENT FOR REHABILITATION SERVICE NATIONWIDE MUTUAL INSURANCE COMPANY POLICYI-IOLDER NAME: Charles W Mitchell CLAIM NUMBER: 58-~7 C 169820 04202001 01 ASSIGNMENT DATE: September 5, 2001 To: Address: DATE OF LOSS: 04-20-2001 COVERAGE: Injured Person: Charles W Mitchell Age: 99 Occupation: Address: 5016 E Trindle Rd Meehaincsburg, PA 17055-3621 Home Phone'. No. Social Security No.: 186121986 Employer's Name: Employer's Address: Phone Number: Diagnosis: Cervicobrachial syndrome, cervical, thoracic sprain, lumbar sprains, sprain of shoulder Hospital(s): (Name & Address) Doctur(s): (Name, Address & Phone No.) Warner Chiropractic Care 5315 E Trindle Rd Mechanicburg, Pa 17055 717-766- 5406 Attorney: (Name, Address & Phone No.) David Knauer 411 A East Main St Mechanicburg, Pa 17055 717-795-7790 INSTRUCTIONS FOR REHABILITATION SPECIALIST 24 HOUR CONTACT REQUIRED ( ) ( ) Initial Evaluation ( ) IME ( ) Medical Coordination ( ) Vocational Placement ( ) Limited Assignment ( ) Other ( ) Vocational Assessment ( X ) PRO (PA ACT 6) ( ) Records Review Remarl~: Charles was injured in an auto accident 4-20-01 in which lfis van was hit from behind by another vehicle. [n the initial contact made with Mr. Mitchell 4 days later he stated he was not seen in the emergency department, nor was he physically injured. He stated he was shaken up slightly and had lightheadedness. The patient started treatment with a Chiropractor 4-26-01 and has continued to receive treatment to the present on the average of 3-4 times weekly. Treatment has consisted of passive and manipulations with no sigrfificant improvement made. Please review all notes and bills as being reasonable, necessary, and appropriate for this patient. Has the passive therapy been in an excess? If any treatment has become not reasonable, not necessfiry, or inappropriate at what date has this occurred? If the passive treatment has become in excess at what has this occurred? Date Received: Settlement: Savings: Date Closed: REASON FOR CLOSURE: Telephone the Cla_im Representative involved after initial contact has been made (see phone # below) ( ) Send Rehabilitation Evaluation report to: Brenda Lighiner(PA-02-29) 1. DCM: (Name, Address & Phone No.) D 2. ADJ: (l~ame, Address & Phone No.) , ~. ]~'~'~ 3. Rehab. Mgr.: (Name, A0dress & Phone No.) ~ * REHABILITATION EVALUATION * Total Rehab. Cost: CONCENTRA MEDICAL EXAMINATIONS A DIVISION OF CONCENTRA MANAGED CARE, INC. ROGER CAINE D.C. 3237 BRISTOL RD STE 102 BENSALEM, PA 19020 Date: October 5, 2001 Claimant: Account File: CME File: Insured: Date of Injury: Mr. CHARLES MITCHELL 5837C 169820 002800394-01 04/20/2001 DEAR REVIEWER: Enclosed please find the medical records on the above name claimant for your review. After you have reviewed the enclosed medicais, please RENDER AN OPINION REGARDING THE FOLLOWING DESIGNATED QUESTIONS: - Appropriateness and necessity of treatment for the DOI? - Please call the.provider, as per their request. Note date, time and person in your report PLEASE REVIEW TREATM~ENT BY WARNER CHIROPRACTIC CARE FOR MVA OF 4/20/01. PLEASE CALL PROVIDER AT 717 766-5406 Remarks: Charles was injured ia an auto accident 4-20_01 in which his van was hit from be _hind by another vehicle, hthe initial contact made with Mr. Mitchell 4 days hter he stated he was not ~een in the erqergency department, nar w~ he physically injured. He stated he was shaken up slightly and had lightheadedness. Tho patient ~i,,aed treatment with a ChiropraCtor 4-26.01 and has continued to ieceive treatment to the present on the average of ]-4 times weekly. Treatment has consisted of passive and m,,mlpuhflons with un significant improvement made. Please review all notes and bills as being reasonable, necessary, and appropriate for this patient. Has the passive therapy be~n iin an cxcess? If any ffeatment has become not reasonable, not necessary, _or inappropriate at what date has this n¢curmd? If the passive l~eatment has become in excess at what has this occurred? Suzanne Sehl, RN MED. REVIEW COOKDINATOR BRENDA LIGHTNER NATIONWIDE INSLIRANCE CO. PO BOX 2655 HARRISBURG, PA 17105 qECE!VED 700 AMERICAN AVENUE · SUITE 300 · KING OF PRUSSIA, PA 19406 · PHONE (6[~ ~r31-1~OI~[FAX (610) 337-1637 (800) 221-2315 - bg, , edic, al D pl, Knauer & Associates, LSC Attorneys-at-Law 41 lA East Main Street, Mechanicsburg, PA 17055 Telephone (717)'795-7790 Fax: (717) 795-7793 Emaih knauerOearlv.com David W. Knauer Nathanael J. Byerly May 3, 2001 Ms. Brenda Lightner Nationwide Mutual Insurance Company P.O. Box 2655 Harrisburg, PA 17105 RE: Your Insured: Charles Mitchell Your Claim Number: 5837C169820042b01 Date- of Loss: 4/20/01 Dear Ms. Lightner: Please be advise that your above insured has retained, our services to represent him for injuries he sustained as a result of the above accident. As we discussed in our telephone conference of April 27, 2001, my client has scheduled an appointment with Dr. Michael Warner, a chiropractor, and may be contacting Mr. Frank DiPrima, a psychologist for neuropsychological evaluation. Also, you provided me with the billing address of P.O. Box 69600, Harrisburg, PA 17106. By copy of this letter I will provide Dr. Warner and Mr. DiPrima with that address. Please have all contacts to him be made through our office. If you have any questions, kindly contact me. Very truly yours, David W. Knauer DWK:bm Cc: Mr. Mitchell Dr. Micael Warner Mr. Frank DiPrima \company\ Mitchell\05 -03 -01 lightner.ltr 2001 og. Medical Dopt, DOB