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HomeMy WebLinkAbout03-0396IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA In re Anthony Brunner, a minor No. ORPHANS COURT DIVISION PETITION FOR SETTLEMENT OF A MINOR'S CLAIM AND DiSTRIBUTiON OF PROCEEDS Petitioners, Roger and Deb Brunner, as parents and natural guardians of minor Anthony Brunner, through their attorney Timothy L. Salvatore, of the law firm Katherman, Briggs & Greenberg, LLP, hereby respectfully petition the Court as follows: 1. Roger and Deb Brenner ("Petitioners"), husband and wife, are adult individuals who reside at 308 Walnut Lane, Carlisle, Pennsylvania. 2. Petitioners are the parents and natural guardians of Anthony Brunner, a minor (DoB 08/17/1985). 3. On June 13,2001, minor Anthony Brunner fell offof a climbing wall at Jungle Jim's Adventure World, in Rehoboth, Delaware when the safety cable snapped due to corosin (sic). 4. Petitioners maintain that the fall was caused by the negligence of Jungle Jim's Adventure World and its employees, servants or agents in failing to maintain and inspect the safety cable. 5. As a result of the fall, g_n_thony Brunner suffered !ow back strain_/sprain (See medical records attached hereto as Exhibit "A"). 6. Anthony Brunner has recovered from his acute symptoms and has been discharged from active care. 7. Anthony Bmnner's health care providers include Rehoboth Beach Volunteer Fire Department, Sussex Emergency Association, Beebe Medical Center, Alexander Springs Rehab, Carlisle Pediatric and Appalachian Orthopedic. 8. As a result of the accident, Petitions have incurred $3,031.00 in medical expenses related to Anthony Brunner's medical treatment (See medical bills attached hereto as Exhibit "B"). 9. Petitioner health care insurer, Highmark Blue Cross/Blue Shield ("Highmark"), has paid for all of Anthony Brunner's medical expenses. 10. Highmark has asserted a right of reimbursement or subrogation against Anthony Brunner's tort recovery for the medical expense it has paid on his behalf(See lien letter and payment log attached hereto as Exhibit "C"). 11. Scottsdale Insurance Company has offered $15,000.00 for settlement of Anthony Brunner's claims (See Release attached hereto as Exhibit "D"). 12. Petitioners believe that the offer is fair and reasonable and have agreed, contingent upon Court approval to accept this offer in settlement of Anthony Brunner's third-party claims. 13. Petitioners have executed a contingent fee agreement with the law firm of Katherman, Briggs & Greenberg, LLP, provided for a contingent fee of twenty-five percent with reimbursement of expenses advanced from Petitioners recovery. 14. Katherman, Briggs & Greenberg, LLP has advanced the following expenses: a. $21.00 - filing fees; and b. $66.16 - medical records (See firm cost card attached hereto as Exhibit "E"). 15. Petitioners propose distribution of the available proceeds, $15,000.00 as follows: ao $87.16 to Katherman, Briggs & Greenberg, LLP for reimbursement of costs advanced; $3,750.00 to Katherman, Briggs & Greenberg, LLP as attorney's fees; $1,845.08 to Highmark Blue Cross/Blue Shield in satisfaction of its subrogation claim; and $9,317.76 to be invested in Anthony Brmmer's name in a blocked account with a federally insured banking institution from which no withdrawal shall be made during Anthony Bmnner's minority without prior leave of the Court. Wherefore, Petitioners request that the Court enter an Order authorizing settlement of Anthony Bmnner's claims and distribution of the settlement proceeds as set forth in this Petition. Date: · ~uire 717-848-3838 Tele 717-854-9172 Fax Attorney for the Plaintiff Attorney ID No. PA 77398 VERIFICATION I verify that the foregoing facts are true, upon my personal knowledge or information and belief. This verification is made subject to the penalties of 18 Pa. C.S. § 4904, relating to unswom falsification to authorities. VERIFICATION I verify that the foregoing facts are true, upon my personal knowledge or information and belief. This verification is made subject to the penalties of 18 Pa. C.S. § 4904, relating to unswom falsification to authorities. Date Deb Brenner IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA In re Anthony Brunner, a minor No. ORPHANS COURT DIVISION CERTIFICATE OF SERVICE On this day, the attached Petition for Settlement of a Minor's Claim and Distribution of Proceeds was sent by first-class pre-paid mail, facsimile transmission, personal delivery, or commercial overnight delivery, as indicated below, to each of the following: Debbie Turner Scottsdale Insurance Company 8877 N. Gainey Center Drive P.O. Box 4120 Scottsdale, AZ 85258 [ ]~-class pre-paid mail [ '¢I facsimile to ] personal delivery [ ] commercial overnight delivery ] commercial two day delivery I certify that the foregoing is true and correct subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. Date: 7~t/~ #! Timothy Li Esquire KATHERMAi & GREENBERG 7 East Market Street York, PA 17401 71%848-3838 Tele 717-854-9172 Fax Attorney for the Plaintiff Attorney ID No. PA 77398 EXHIBIT A B~ebe Medical Center Emergency Department - 424 Savannah Rd. Lewes, DE 19958 (302)645-3554 Patient: Anthony Brunner 6/13/01 Care Provider: Kevin Bristowe,MD 4:12:02 PM Page: 1 LOW BACK PAIN: Three out of every four people will have an episode of disabling back pain during their lifetime. Most commonly the pain is due to straining of the muscles and ligaments in the low back. Usual treatment includes: 1) Rest on a firm surface. Avoid lying on your stomach. 2) Ice pack the painful area. After a few days, gentle heat may be used intermittently to relax the area, or ice packs can be continued. 3) Medication may be needed -- muscle relaxers and antiinflammatory medicines are commonly used. 4) As the back improves, exercises are prescribed to strengthen the back and abdominal muscles. Your doctor will advise you on the proper care for your back at each stage in your recovery. You may be better in a few days -- or healing may take several weeks. If new symptoms of a "herniated disc" (radiation of pain, numbness, or tingling down the back of the leg or weakness in the leg) occur, you should be re-examined. Further testing may be necessary. CONTUSION: Your injury has resulted in a contusion -- a crushing of the deep tissues. No injury to important structures was detected during the- physician's exam. Contusions vary in the amount of pain they cause, and in the length of time required for healing. Typically, the area will become bruised, and will remain painful to touch for two or three. week~. However, most patients are back to working and playing within a few days. After the initial period of rest and cold-packs, your symptoms (together with the doctor's recommendations) will determine how rapidly you can get back to full activity. Usually this means "do what feels okay, but don't do things that.hurt." If re-examination was recommended, it's important to follow up as instructed. Call the doctor or return any time if pain increases, if swelling becomes severe, if you develop numbness or weakness in an injured extremity, or if any other alarming symptoms occur. USE OF ACETAMINOPHEN: Acetaminophen may be taken for pain relief or fever control. It's much safer than aspirin, offering a wider range of "safe" dosages. It is safe during pregnancy. Some brand names are Tylenol, Panadol, Datril, Anacin 3, Tempra, and Liquiprin. Acetaminophen can be repeated every four hours. The following are maximum recommended dosages: Age Dose Drops Elixir 0-3 mo 40 mg .4 ml (1/2) 4-11 mo 80 mg .8 ml (full) 1/2 tsp 1 yr 120 mg 1-1/2 drprs 3/4 tsp 2-3 yr 160 mg 2 droppers 1 tsp 4-5 yr 240 mg 1-1/2 tsp 6-10 yr 320 mg 2 teasp 11-14 yr 480 mg 3-4 teasp adult 650 to 1000 mg Chewable (80 rog) 1 tab 1-1/2 tab 2 tabs 3 tab 4 tab 5-6 tab *Suppositories are available in 120 mg and 325 mg strength. IBUPROFEN: Ibuprofen is an excellent, safe drug for pain control. In Patient: Anthony Brunner 6/13/01 4:12:02 PM Page: 2 addition, it has potent antiinflammatory effects which are beneficial, especially in the treatment of injuries, arthritis, or tendonitis. It's best to take ibuprofen with food. Persons with ulcer disease or allergy to aspirin should notify their physician of this before taking ibuprofen. Take the medication exactly as prescribed. Don't take additional doses unless instructed to do so by your doctor. If you develop wheezing, shortness of breath, hives, faintness, stomach pain, vomiting, or dark black stools, return for re-evaluation at once. FOLLOW-UP CARE: You should call your private physician tomorrow for a follow-up appointment in 2-3 days. Let your doctor know that you were seen in our Emergency Care Center and how you are doing. If you are unable to get a timely appointment, or if you are worsening, call us, or return to the hospital. DRIVING ABILITY: The patient IS / IS NOT medically cleared to drive. GENERAL INSTRUCTIONS: Thank you for choosing us for your medical needs. We hope you're satisfied with the care you received. Please call if there is any problem. Any condition can change. Some diseases worsen despite proper treatment. Some problems begin with unusual or vague symptoms, and may require passage of time for symptoms and findings to develop before the correct diagnosis can be made. If your condition changes significantly, you should call or return for re-examination. All X-rays are interpreted by a radiologist. This is usually done within 24 hours. If there is any important difference between the radiologist's and your physician's reading of the X-rays, you'll be notified. I understand, and have received a copy of, these instructions. (Entiendo estas instrucciones y he recibido copia de ellas.) Patient [Or Representative] Nurse [Witness] 27 Brookwood Avenue ALEXANDER SPRING REIAn_B, INC. Carlisle, PA 17013 THIS INFORMATION IS FOR YOUR RECORDS. THANK YOU FOR YOUR REFERRAL (717) 245-2341 **INITIAL EVALUATION** PATIENT: Anthony Brunner BIRTH DATE: 08/17/85 PHYSICIAN: J. Lynn Hoffman, M.D. DIAGNOSIS: Lumbar pain secondary to blunt trauma DATE PT INITIATED: 09/12/01 PATIENT ID~: 8909 S: Anthony reports that he was on vacation doing rock climbing in Delaware. He was actually at the beach, but he was rock climbing, when he was rappelling and his line broke and he fell 20 feet, landing on his feet, but eventually injuring his lower back. At that time, they weren't sure of his injuries, so he was put on a spine board and stabilized and taken to the hospital for evaluation, but the x-rays were negative and he was released. The injury was on 06/13/01. He reports that the x-rays again were negative. He has not had any previous treatment, no previous zn]ury. He is in otherwise good health. His pain level is 2-4/10. He zs not taking any medications and he is currently a 10th grade student at Cumberland Valley High School with interests in track and field, biking, hiking, and basketball. O: This individual ambulates to physical therapy clinic. He is accompanied by his mother. On examination, he has good range of motion of the trunk. Forward bending is full. Extension is full. Side bending and rotation are also full but there is pain on forward flexion as well as rotation and side bending to both sides, but it is end range pain. He actually feels good when he extends. His worse position is sitting, his best position is walking. He likes prone on elbows as a way of decreasing his pain, which he does on his own. His pain level, again, is 2- 4/10. He reports that things that increase his pain at home currently are work-outs at home which are approximately 1 hour a day, and he also has difficulty sleeping because of restlessness and having to change positions. He does have temporary relief with hot packs to the lower back area. He does have a negative slump test bilaterally, negative straight leg raise test. However, straight leg raising, he does have hamstring tightness at 50 degrees bilaterally. Gentle manual distraction of the sacrum did decrease his pain. He also had tenderness to direct palpation of both sacroiliac joints as well as the entire lumbar spine. On the initial visit, he did tolerate ultrasound 1.2 watts/cm2 for 5 minutes at 100% power to the lumbar spine, and that was followed by moist heat to the lumbar spine done in a prone position. Assessment: Patient has sprain/strain of the lumbar spine and sacroiliac joints after a 20 foot fall while rock climbing. Interventions 2 times/week for 4-8 weeks A. Electrotherapeutic modalities to assist with healing and repair. B. Manual therapy techniques to improve circulation. C. Patient/caregiver education to develop HEP. D. Physical agents/mechanical modalities to assist with healing and repair. Prognosis/Rehab Potential: Good Short Term Goals: 1. Begin modalities to assist with healing and repair in order to improve ADL's. 2. Improve hamstring flexibility to improve forward bending. Long Term Goals: 1. Resume sports activities. Intervening Factors Which May Modify Frequency/Duration of Care: Therapist: JBB/md Date: 09/12/01 27 Brookwood Avenue Name: Anthony Brunner Date of Birth: 08/17/85 Physician: Diagnosis: Alexander Spring Rehab, Inc. Carlisle, PA 17013 Physical Therapy Plan of Treatment Initial">/ Interim ID~: 8909 Date Initiated: J. Lynn Hoffman, MD Period Covered: Lumbar pain due to blunt trauma 09/12/01 09/12-11/12/01 Impairments (none=O, mild=l, moderate=2, severe=3, absolute=4, N/T=not tested) A. NT aerobic capacity K. 2 pain B. 0 balance L. 0 posture C. 0 circulation M. 0 psychosocial D. 1 deformity N. 1 range of motion E. 0 endurance O. NT reflexes F. 0 gait/locomotion P. 0 respiration/ventilation G. 1 joint integrity & mobility Q. 0 sensation H. 0 motor control R. 0 skin integrity I. 1 muscle length S. 0 strength J. 0 neural mobility Functional Limitations (none=O, mild=l, moderate=2, severe=3, absolute=4) A. 0 Activities of Daily Living Especially: 2 Instrumental Activities of Daily Living Especially: Structured sports activities. Bo C. 0 Body Mechanics Especially: (717) 245-2341 Assessment: Interventions 2 A. B. C. Patient has sprain/strain of the lumbar spine and sacroiliac joints after a 20 foot fall while rock climbing. times/week for 4-8 weeks Aerobic conditioning to Airway clearance techniques to Aquatic therapy to Balance training to Body mechanics instruction/ergonomic training to Electrotherapeutic modalities to assist with healing and repair. Exercise to Functional training (ADL, IADL, assistive devices) to Gait training to Manual therapy techniques to improve circulation. Neuromuscular re-education to Orthotics/prosthetics prescription, fabrication and/or training to Patient/caregiver education to develop HEP. Physical agents/mechanical modalities to assist with healing and repair. Work conditioning/hardening to Wound management to Other: Q. Please see reverse RE: Anthony Brunner Plan of Treatment September 12, 2001 Page 2 Pro~nosis/Rehab Potential: Good Short Term Goals: 1o Begin modalities to assist with healing and repair in order to improved ADL's. 2. Improve hamstring flexibility to improve forward bending. Long Term Goals: 1. Resume sports activities. Intervening Factors Which May Modify Frequency/Duration of Care: Joseph/g. B~etza, P.T., AqUa. PT-001299-E Physician Comments: I certify that I have examined the patient and rehab services are necessary and will be provided while the patient is under~ny care. The plan of treatment will be reviewed every60 days or as the patient's conditio~lw%~ants. This patient does not require a social needs assessment. ~ ~ Physician: Date: PATIENT: ALEXANDER SPRING REHAB, INC. ~- ALEXANDER SPRING REHAB, INC. ~<O~-PAT IENT~: .~s~~y%~. ~~ ~ · ~ ' ~~~.~~- - ~_-- ._ ~~. . . ·J -" ~S ~ '/, z'~l~ f~,.. ~,~ ~ I~.~ ~<~ ~-.~ ~ ~,- ~ ~ ~~.~~.~_~,~ .- .-~ 5~,~-~ ~,~,, .-. . ~ · ~ -~r, ~. ~,,~ . .~ / , , _ -t~ '~,~ .~~. ~- ~ ~.O~ ~ 1~.= ~/[. I,IAME: EXERCISE TA=TACTILE ASSISTANCE, I1' '~ / ROM MMT VC=VERBAL CUES, S=SUPERVISION, I=INDEPENDENT ~0 PAT I ENT: lo-l-o( ALEXANDER SPRING REHAB, INC. 27 Brookwood Avenue Alexander Spring Rehab, Inc. Carlisle, PA 17013 Physical Therapy Discharge Summary This information is for your records. (717) 245~2341 Name: Anthony Brunner 'ID~: 8909 Date of Birth: 08/17/85 Date Initiated: 09/12/01 Physician: J. Lynn Hoffman, MD Date Discharged: 10/03/01 Diagnosis: Lumbar pain due to blunt trauma. Impairments (none=O, mild=l, moderate=2, severe=3, absolute=4, N/T=nottested) At Eval A. aerobic capacity NT B. balance 0 C. circulation 0 D. deformity 1 E. endurance 0 F. gait/locomotion 0 G. joint integrity & mobility 1 H. motor control 0 I. muscle length 1 J. neural mobility 0 K. pain 2 L. posture 0 M. psychosocial 0 N. range of motion 1 O. reflexes NT P. respiration/ventilation 0 Q. sensation 0 R. Skin integrity 0 S. strength 0 At 0 0 t 0 0 0 0 0-1 0 0 0 0 1 NT 0 0 0 0 Functional Limitations (none=0, mild=l, moderate=2, severe=3, absolute=4) A. Activities of Daily Living Especially: At Eval At D/C 0 0 B. Instrumental Activities of Daily Living Especially: 2 1 0 0 C. Body mechanics Especially: Interventions Patient was seen 8 visits in 3 weeks. Treatment included: A. aerobic conditioning B. airway clearance techniques C aquatic therapy D balance training E body mechanics instrUction/ergonomic training F X electrotherapeutic modalities G X exercise H functional training (ADL, IADL, assistive devices) I. gait training J. X manual therapy techniques K. neuromuscular re-education L. orthotics/prosthetics prescription/fabrication and/or training M. X patient/caregiver education N. X physical agents/mechanical modalities 0. work conditioning/hardening P. wound management Please see reverse RE: Anthony Brunner Discharge Summary October 3, 2001 Page 2 Discharge/home program: Knee to chest, pelvic tilts, squats. piriformis, trunk rotation, hamstring stretch, Reason(s) for discharge: A. Patient achieved desired goals and outcomes. B. X Patient achieved 2 of .2 goals but failed to progress With remaining goals. C. Patient failed to comply with the plan of care. D. Patient declined to continue therapy. E. Physician discontinued therapy. Therapist: Joseph. ~uletza, P.~.~, PT-001299-E Date: 10/19/01 JBB/alw minimal APP/~I_ACHIAN ORTHOPEDIC CENTER~ LTD. Thomas J. Green, M.D. D~niel P. ttely, John C. Rodgers, M.D. PATIENT BILLING INFO~~N FORM 1 D~mwoody Drive CaxLisle~ PA 17013 Telephone: (~17) 249-6112 }'ax: (717) 249-6235 Street HOMOPHONE: 7~ ~//~ ss : ?O- REFERRING PHYSICIAN: /~ EMPI'.OYt~: SEX: ~--M __F city WORK PHONE: ~-~ /'7(> / ._5 State Zip SPOUSE WORK#: MARITAL STATUS: ~'- S __ M D W EMPLOYER ADDRESS: P~__ ON I~ESPONSIBI~IE FOR BILL: ADDRESS: Streeu ~o~PHO~: '7~ WO~ PHO~: '7 POLICY #: I~SURED: __ PATIENT City: State: Zip: S~-COND~R¥ It~I~TH INSUR/t. NCE: ADDKESS: street: ci~ POLICY #: GROUP #: IN~: ~ PATIENT __ SPOUSE/OTHER ('Hame:) GROUP #¢. __ . State: Zip: IS VISIT I~k~I~r~TED TO: WOREIW. AN~ COMP: AUTO ACCIDENT: WORK COMP OR AUTO ENISURANCE CO: INSI/KED'S DOB: N © YES DATE OF IN]-gRY: O YES DATE OF IN]'URY: WORK COMP ORAUTO INSURANCE ADDRESS: POLICY #: PHONE #: GROUP #: ADJUSTER HANDLING CLAIM: "I authorize Appalachian Orthopedic Center, Ltd. to accept this signature on file as authorization to submit a claim to my insu.ra_nce company. My signatture authorizes paYment may be made directly to Appalachian O~opedic Centez, Ltd. IfWorkman's Compensation or Auto Accident, I authorize the release of my medical records. Regardless of irusuzance benefits, I underst~_nd that I remain financially responsible for all fees for services rendered." ~ Signature of Pa--fient~Au-thorized Representative ~ ' "I request that paYment of authorized Medicare Benefits be made either to me or on my behalf to Appalachian Orthopedic Cente~, ~.td. for any services fuxnished me by that physician or supplier. I authorize any holder of medical information about me, to release to the Health Care Financing Administration end its agents, any information needed to determine these benefits or the benefits payable for related services" OFFICE RECORDS PATIENT NAME DATE OF BIRTH PAGE # 01/29/02 OV PROBLEM: Back pain. HISTORY AND PRESENT ILLNESS: Anthony sustained an injury to his back when .he fell at a climbing gym last summer down in Delaware. He was taken to the hospital at that point(June 2001) and found to have no fracture. An assessment of soft tissue injury was made and Anthony was treated with medication, rest and limited activity. His back pain persisted but has recently started to improve. He has now started to develop knee pain on the right side. No specific trauma, but pain is associated with climbing stairs or walking or running or jumping. PAST MEDICAL HISTORY: His past medical history is noncontributory. His family history is positive for diabetes and hypertension. No previous surgeries. SOCIAL HISTORY: He is a nonsmoker, nondrinker, and denies illicit drug use. REVIEW OF SYSTEMS: Review of his cardiovascular, respiratory and endocrine systems is negative. PRESENT MEDICATIONS: Vicodin. PHYSICAL EXAM: Shows excellent flexion and extension of the spine. No lateralizing signs in the lower extremities. There is pain with patellofemoral compression and some weakness on straight leg raise against resistance. Rev'iew of the bone scan done in December shows no abnormality. IMPRESSION: Resolving Iow back pain and patellofemoral pain in the right knee. PLAN: Advise gentle motion exercises. Advil as needed for knee pain. Follow up if symptoms are not steadily improving. DPH/jmn cc: Peds (18) ~IILISLE PEDIATRIC ASSOCIA'f A PROFESSIONAL CORPORATION STEPHEN J. KREBS, M.D. J. LYNN HOFFMAN, M.D. DEBORAH RAUBENSTINE, M.D. DIANNA RUD~ PA-C HOLLY C. HOFFMAN, M.D. ELISEO ROSARIO, JR., M.D. ELENA MAN, M.D. 804 BELVEDERE STREET, CARLISLE, PA 17013 243-1943 December 29, 2001 Appalachian Orthopedics 1Dunwoody Drive Carlisle, PA 17013 RE: Anthony Brunner DOB: 8-17-85 Dear Friends: Anthony is a healthy 16 year old young man who fell while rock climbing this past June. He landed on his feet after a 20 foot fall, then fell down on his coccyx, subsequently complaining of low back pain. He was evaluated in the ER where x-rays demonstrated no fracture. He was treated symptomatically. At his check-up on 8-29-01 he still was complaining of episodic back pain. Nevertheless his physical examination was unremarkable. He subsequently completed a course of physical therapy at Alexander Spring Rehab, but this accomplished little in the way of sympt6matic relief. Because of his ongoing complaint I obtained a bone scan on 12-11-01. This was remarkable only for the suggestion of partial obstruction of the right kidney. No increased bony uptake was demonstrated. A subsequent renal ultrasound demonstrates bilateral hydronephrosis L > R, and an IVP is scheduled. In discussing the hydronephrosis with Ed Dagen, he feels it is unlikely that this would be responsible for any back pain. In light of the post-traumatic nature of his symptoms, I therefore recommended your evaluation and recommendations. Sincerely, J~ynn Hoffman, M.D. JLH/bsr 4C G~41T. N~URO. 17.' Date: Ht. ~.~ Wt. i~t B.P.. iO2/(~O Allergies Psychosocial PE./Normal ,/' Abnormal [] Home Interval History Illness/injury/surgery ~/e ,v.~ ~ ..~Y~,,~.o~, ti, lo Meds histo~ Future Plans Concerns Ed ucatio, n/employment Activities Drugs/alcohol/cigarettes Sexuality Suicide/depression Gen. App. IZi Teeth J G.U. Head I~' Neck J~ Tanner stage..~ Eyes IZl' Chest I~ U/A V.A. CI Tanner stage._.__ Ext. Ears ~ Lungs I~ Neuro. Nose' ~ Head ~ . Skin Throat I~l'Abdomen I~ Back Comments ]' Counseling I Impression J ,,4.~,;. ~, ~.~, Treatment ~ ~t o.~. ~p'- Follow-up ~y~ t ~ 17yrs. Date: Interval History J I Illness/injury/surgery Meds Future plans Concerns Ht. Wt. B.P.. Allergies Psychosocial PE./Normal ,/' Abnormal [] Home Education/employment Drugs/alcohol/cigarettes Sexuality Suicide/depression Gen. App. Q Teeth Q G.U. Q Head . Q Neck Q Tanner stage___ Eyes Q Chest Q U/A Q V.A. Q Tanner stage.___ Ext. Q Ears Q Lungs -' CI Neuro. 13 Nose Q Head Q Skin Q Throat QAbdomen Q BackQ Counseling J Impression J Treatment J Follow-up ALEXANDER SPRING REHAB, INC. 27 Brookwood Avenue Carlisle, PA 17013 THIS INFORMATION IS FOR YOUR RECORDS. THANK, YOU FOR YOUR REFERRAL **INITIAL EVALUATION** (717} 245-2341 PATIENT: Anthony Brunner BIRTH DATE: 08/17/85 PHYSICIAN: J. Lynn Hoffman, M.D. DIAGNOSIS: Lumbar pain secondary to blunt trauma DATE PT INITIATED: 09/12/01 ~ PATIENT ID#: 8909 S: .Anthony reports that he was on vacation doing rock climbing in Delaware. He was actually at the beach, but he was rock climbing, when he was rappel!ing and his line broke and he fell 20 feet, landing on his feet, but eventually injuring his lower back. At that time, they weren't sure of his injuries, so he was put on a spine board and stabilized and taken to the hospital for evaluation, but the x-rays were negative and he was released. The injury was on 06/13/01. He reports that the x-rays again were negative. He has not had any previous treatment, no previous injury. He is in otherwise good health. His pain level is 2-4/10. He is not taking any medications and he is currently a 10th grade student at Cumberland Valley High School with interests in track and field, biking, hiking, and basketball. O: This individual ambulates to physical theramy clinic. He is accompanied by his moth examination, he ~as good rang~ of motion of the trunk. F?rwar~ bending is full. ExtenSion ~ full Side bending and rotation are also full but there is pa~n on forward flexion as well as rotation and side bending to both sides, but it is end range pain. He actually f~els good when he extends. His worst position is sitting, his best position is walking. He likes prone on elbows as a way of decreasing his pain, which he does o '. . . - 4/10. He reports that thin~s .~ ...... ~_ __. _ n his own. H~s pain level, again, i 2- are approximately 1 hour a~ that 1 ...... ~= ~ pa~n at home currently are work-outs at home w~ and he also has difficulty sleeping because of restlessness and ichday, having to change positions. He does have temporary relief with hot packs to the lower back area. He does have a negative slump test bilaterally, negative straight leg raise test. However, straight leg raising, he does have hamstring tightness at 50 degrees bilaterally. Gentle manual distraction of the sacrum did decrease his pain. He also had tenderness to direct palpation of both sacroiliac joints as well as the entire lumbar spine. On the initial visit, he did tolerate ultrasound 1.2 watts/cm2 for 5 minutes at 100% power to the lumbar spine, and that was followed by moist heat to the lumbar spine done in a prone position. Assessment: Patient has sprain/strain of the lumbar spine and sacroiliac joints after a 20 foot fall while rock climbing. - Interventions 2 times/week for 4-8 weeks A. Electr°therap~Utic modalities to assist with healing and repair. B. Manual therapy techniques to improve circulation. C. Patient/caregiver education to develop HEP. D. Physical agents/mechanical modalities to assist with healing and repair. Prognosis/Rehab Potential: Good Short Term Goals: 1. Begin modalities to assist with healing and repair in order to improve ADL's. 2. Improve hamstring flexibility to improve forward bending. Long Term Goals: 1. Resume sports activities. Intervening Factors Which May Modify Frequency/Duration of Care: ~herapist: fBB/md Joseph~B. B~Ietza, P.T. ATC~'"'PT-001299-E Date: _ 09/12/01 27 Brookwood Avenue Alexander Spring Rehab, Inc. Carlisle, PA 17013 Physical Therapy Discharge Summary This information is for your records. Name: Anthony Brunner ID#: 8909 Date of Birth: 08/17/85 Date Initiated: 09/12/01 Physician: J. Lynn Hoffman, MD Date Discharged: 10/03/01 Diagnosis: Lumbar pain due to blunt trauma (717) 245-2341 Impairments (none=0, mild=l, moderate=2, severe=3, absolute=4, N/T=not tested) A. aerobic capacity B balance C circulation D deformity E endurance F gait/locomotion G joint integrity & mobility H motor control I. muscle length J. neural mobility K. pain L. posture M. psychosocial N. range of motion O. reflexes P. respiration/ventilation Q. sensation R. skin integrity S. strength At Eval At D/C NT NT 0 0 0 0 1 1 0 0 0 0 1 0 · '0 0 1 0-1 0 0 2 0 0 0 0 ..0 1 1 NT NT 0 0 0 0 0 0 0 0 Functional Limitations (none=0, mild=l, moderate=2, severe=3, absolute=4) A. Activities of Daily Living Especially: At Eval At D/C 0 0 B. Instrumental Activities of Daily Living Especially: C. Body mechanics 0 Especially: Interventions Patient was seen A. B. C. D. E. F. X G. X H. I. L. M. N. 0. P. 8 visits in 3 weeks. Treatment included: aerobic conditioning airway clearance techniqUes aquatic therapy balance training body mechanics instruction/ergonomic training electrotherapeutic modalities exercise functional training (ADL, IADL, assistive devices) __ gait training X manual therapy techniques __ neuromuscular re-education __ orthotics/prosthetics prescription/fabrication and/or training X patient/caregiver education ' X physical agents/mechanical modalities __ work conditioning/hardening __ wound management Please see reverse .ARL]SLE REGIONAL MEDICAL CE,,,ER RADIOLOGZCAL INTERPRETATION PATIENT NAME; X-RAY~: EXAM DATE: ORDERING: ATTENDING: CONSdLTING HISTORY: BRUNNER ANTHDNY L 816197 12/11/2001 a LYNN HOFFNAN,MD PED LOW BACK PAIN BONE SCAN LOW BACK PAIN MED REC ACCOUNT D.O.B.: ROOM: 816197 7104474 08/17/1985 OP SPECT BONE SCAN OF THE LUMBAR SPINE HISTORY: Low back pain, trauma. Pre~do~Js films not available. RADIONUCLI.)E: 99mTc HDP DOSE: 0.70 cc : 22.0 mci No abnormal uptake is seen in the lumbar spine. The study includes most of the pelvis and thoracic spine, as well. There is prominence of the right renal collecting system on the Dosterlor Dlanar views. This is also seen on the coronal and sagittal views, This degree of prominence is unusual, and I would suggest further evaluation of the right kidney for possible partial obstruction (This does not appear to involve the entire renal area.). IMPRESSION: Negative bone scan of the lumbar spine. increased Jptake in the mid arid upper portions of the right kidney, unJsual. Suggest further evaluation such as an IVP. REVIEWED AND SIGNED DAVID ROYAL,MD INTERPRETING P~YSICI&N DATE DICTATED: DATE TRANSCRIBED: TRANSCRIPTIONIST; 8630298 12/11/2~1 12/11/2001 EAH ORDERING FAX. PAGE i OF 1 DAVID R. ROYAL, M.D. KEITH S. PUMROY, M.D. M. DANE WALLISCH, M.D. DEB DURISEK, M.D. JOFFRE LEWIS, M.D. WALNUT BOTTOM RADIOLOGY Belvedere Medical Center 850 Walnut Bottom Road Carlisle, PA 17013 Phone # 717 245-0071 Fax # 717 245-0180 DIAGNOSTIC RADIOLOGY MAMMOGRAPHY ULTRASOUND DOPPLER SONOGRAPHY Brunner, Anthony L. (8-17-85) 308 Walnut Lane Carlisle, PA RENAL ULTRASOUND L2315 12-19-01 Dr. J. Lynn Hoffman INDICATION: Abnormal kidney on bone scan The right kidney measures 12.7 cm pole to pole and there is grade one hydronephrosis. Statistically, grade one hydronephrosis is unlikely to be obstructive. The left kidney measures 13 cm pole to pole and there is grade two hydronephrosis. Although grade two hydronephrosis may be obstructive in origin, it may also be normal, due to back pressure from bladder distension for instance from prostatism or even reflux. Consequently, it is nonspecific. At the time of the examination, the bladder was moderately full. SUMMARY: Grade one hydronephrosis on the right which is unlikely to be clinically significant. Grade two hydronephrosis on the left which is nonspecific and probably due to back pressure from b~dder distension which considering the patient's young age is probably~io~ogical rather than related to prostatism. Joffr/Lewi~, M.D. ~ JL/slI~12-2<~Q~"~ MANIMOGRAPHY ACCREDITED BY THE FDA AND AMERICAN COLLEGE OF RADIOLOGY ULTRASOUND and VASCULAR DOPPLER SONOGRAPHY ACCREDITED BY THE ACR ~ .,~,LISLE REGIONAL MEDICAL CENI~., RADIOLOGTCAL INTERPRETATION P~. ~ ENT NAME: X - RAY~; EXAM DATE: ORDERING; ATTENDING: CONSULTING HISTORY: BRUNNER ANTHONY L 816197 1/21/2002 J LYNN HOFFMAN,MD PED BILATERAL HYDRONAPHROSIS IVP SAME MED REC ACCOUNT D.O.B.: ROOM; 816197 7118568 08/17/1985 OP IVP WiTH TOMOGRAMS INDICATION: Hydronephrosis on ultrasound. The scout film is unremarkable. Both kidneys concentrate and excrete contrast. There is no evidence of mass or hydronephrosis. The ureters are gracile as seen segmentally. The urinary bladder is normal and there is no significant post void residual. SUMMARY: Negative exam. REVIEWED AND. SIGNED JOFFRE P LEWIS MED INTERPRETING PHYSICIAN DATE DICTATED; DATE TRANSCRIBED: TRANSCRIPTIONIST: 8547473 1/21/2002 1/21/2002 JNA ORDERING FAX PAGE i OF i REGIONAL MEDICAL CENT' RADIOLOG!CAL INTERPRETATION PATIENT NAME: X-RAY~: EXAM DATE: ORDERING: ATTENDING: CONSULTING HISTORY: BRUNNER ANTHONY L 816197 12/11/2001 J LYNN HOFFMAN,MD PED LOW BACK PAIN BONE SCAN LOW BACK PAIN MED REC ACCOUNT D.O.B.: ROOM: 8Z6197 7104474 08/17/1985 OP SPECT BONE SCAN OF THE LUMBAR SPINE HISTORY: Low back pain, trauma. RADIONUCLIDE: 99mTc HDP Previous films not available. DOSE: 0.70 cc = 22.0 mCi No abnormal uptake is seen in the lumbar spine. The study includes most of the pelvis and thoracic spine, as well. There is prominence of the right renal collecting system on the posterior planar views. This is also seen on the coronal and sagittal views. This degree of prominence is unusual, and I would suggest further evaluation of the right kidney for possible partial obstruction (This does not appear to involve the entire renal area.). IMPRESSION: Negative bone scan of the lumbar spine. increased uptake in the mia and upper portions of the right kidney, unusual. Suggest further evaluation such as an IVP, REVIEWED AND SIGNED DAVID ROYAL,MD INTERPRETING PHYSICIAN DATE DICTATED: DATE TRANSCRIBED: TRANSCRIPTIONIST: 8630298 12/11/20@1 12/11/2001 EAH ORDERING FAX PAGE 1 OF 1 CARLISLE REGIONAL MEDICAL CENTER RADIOLOGICAL INTERPRETATION PATIENT NAME: X-RAY#: EXAM DATE: ORDERING: ATTENDING: CONSULTING: HISTORY: BRUNNER ANTHONY L 816197 12/11/2001 J LYNN HOFFMAN,MD PED LOW BACK PAIN BONE SCAN LOW BACK PAIN MED REC #: ACCOUNT #: D.O.B.: ROOM: 816197 7104474 08/17/198s OP SPECT BONE SCAN OF THE LUMBAR SPINE HISTORY: Low back pain, trauma. Previous films not available. RADIONUCLIDE: 99mTc HDP DOSE: 0.70 cc = 22.0 mCi No abnormal uptake is seen in the lumbar spine. The study includes most of the pelvis and thoracic spine, as well. There is prominence of the right renal collecting system on the posterior planar views. This is also seen on the coronal and sagittal views. This degree of prominence is unusual, and I would suggest further evaluation of the right kidney for possible partial obstruction (This does not appear to involve the entire renal area.). IMPRESSION: Negative bone scan of the lumbar spine. Increased uptake in the mid and upper portions of the right kidney, unusual. Suggest further evaluation such as an IVP. REVIEWED AND SIGNED DAVID ROYAL,MD INTERPRETING PHYSICIAN DATE DICTATED: 12/11/2001 DATE TRANSCRIBED: 12/11/2001 DATE SIGNED: 12/13/2001 TP-ANSCRIPTIONIST: EA_H 8630298 REPRINT NM BONE SCAN SPECT NM TC 99 OXIDRONATE PER MC/ PAGE 1 OF 1 EXHIBIT B A TYPE OF BILL CYCLE OUTP. DATE OF BILL 06118/0]. DATE OF PREV. BILL BEEBE MEDICAL CENTER P BOX 828790 PN,~A, PA 302 645-3546 FEI ~ 5100&7938 19 :RTH-DATE 08/17/85 C E PATIENT NAME BRUNNER ,ANTHONY GUARANTOR NAME AND ADDRESS RO~ER ~RUNNER 308 WALNUT LANE CARLISE PA 17013 PATIENT NUMBER SEX AGE ADMISSION DATE DISCHARGE DATE I6~2c2726 M 15 06/13/01 O,E INSURANCE COMPANY NAME IDAYS I COMMERCIAL BRISTOWE MD, KEVI~ GROUP NUMBER POUOY NUMBER ~90018011 DATE OF DESCRIPTION OF I SERVICE TOTAL EST. COVERAGE EST. COVERAGE : EST. COVERAGE EST. COVERAGE PATIENT SERVICE HOSPITAL SERVICES CODE CHARGES INS. CO. NO. 1 INS. CO. NO. 2 INS. CO. NO. 3 INS. CO. NO. 4 AMOUNT ~ALAN3E FORWARD O. O0 ~UMMA~Y OF CURRENT CHARGES PHARMACY . 98 . c28 RADIOLOGY 602. 50 602. 50 EMERGENCY SERVICES 179. O0 179. O0 ~UB-T]TAL OF CURR. CHARGES 782. 48 782. 48 AS A COURTESY, WE HAVE BILLED T~E INSURANCE COM- PANY LISTED ABOVE, BAS:'D ON INF]RMATION =ROVIDED ~Y YOU. PLEASE VERIFY THIS INFORMATION A~D CONTA( F US AT (302)~45-354~ WITH ANY CORRECTIONS SELF P~ f INDICATES YOU ARE RESP]NSIBLE FOR PAYMENF. PLEASE PAY AMOUNT SHOWN IN TN E PATIENT AMOUNT C~]LUMN. : ~8~ ~8 ?~8'~ ~8:~ PLEASE' REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY ON ALL NQU R ES FOR ANY CHARGES NOT POSTED WHEN THIS BILL~ : ~. ~ CORRESPONOENCE. WAS P~EPARE~. OR IF INSU~A~CE CARRI~S DO ~ PAY ANY PART OF THE AMOUNTS SHOWN' ~'~z ~'.,l~: ~¢~ ~ ~ BEEBE MEDICAL CENTER PHILA, PA UNDER ESTIMATED INSURANCE COVERAGE. SUSSEX EMERGENCY ASSOCIA' PO BOX 3012 WILMINGTON, DE 19804 For all billing questions, call: (800) 456-4629 Ext: Tax ID: 51-0381623 Patient Name: ANTHONY BRURNER BB080968 ROGER BRUNNER 308 WALNUT LANE CARLISLE, PA 17013 192 IF PAYlN~ BY VISA OR MASTERCARD RLL OUT BELOW 10/01/01 / $289.00 BB080968 CHARGES AND CREDITS MADE AFTER STATEMENTI SHOW AMOUNT DATE WILLAPPEAR ON NEXT STATEMENT. [ PAID HERE SUSSEX EMERGENCY ASSOCIATES PO BOX 3012 WILMINGTON, DE 19804 [] Please check box if above address is incorrect or insurance information has changed, and indicate change(s} on reverse side. PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT iN ENCLOSED ENVELOPE Date Procedure Code Description Diagnos is Charge Credit 06/13/01 99284 EMERGENCY DEPT VISIT 847 2 $243 O0 06/13101 73080 ELBOW~ iNTERP:ONLY i 847.2 $23.00 06/13/01 72100 LUMBAR INTERp ONLY '~:* . · 847.2 $23.00 ' ' ~: . : ' ' ' Amount Due: J $289 O0 This -p SUSSEX EMERGENCY ASSOCIATES ,DE1 234 questions, call: (800)456'4629 Ext: 192 SEE .LING INFO REHOBOTH BEACH VOL. FIRE DE~ PO BOX 327 REHOBOTH BEACH, DE 19971 For all billing questions, call: (302) 422-404'7 Tax ID: 23-7004483 Patient Name: ANTHOZmJ~ G8004037 MR 308 WALNUT LANE CARLISLE, PA 17013 Ext: IF PAYING.ElY VISA OR MASTERCARD, FILL OUT BELOW 07/10/01 $275.00 G8004037 CHARGES AND CREDITS MADE AFTER STATEMENT SHOW AMOUNT DATE WILL APPEAR ON NEXT STATEMENT. PAID HERE $ REHOBOTH BEACH VOL. FIRE DEPT PO BOX 327 REHOBOTH BEACH, DE 19971 '-] Please check box if above address is incorrect or insurance information has changed, and indicate change(s) on reverse side. PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT IN ENCLOSED ENVELOPE Date Procedure Code DeScriPtion Diagnosis Charge Credit 06/13/01 A0429 AMBuLANcE SERvlCEi BBS 724.5 $275.00 THEREcORDS WE HA'VE'REbEIVED, DO: NOT HAVE INSURANCE INDICATED:: HOWEVER;''iF~YO~ DO: HAVE' INSURANCE PLUSE CALL OuR O~icE'0~i'~OMPLETE THE REVERSE sIDEOFTHtS BIE~ANDRE~U'RN IT~ .. · ' CALE',~ YdU HAVE BS/BcoRiNSURANCE Amount Due: $275.00 I This bill is for REHOBOTH BEACHVOL FIRE Questions and information can be submitted at www.proassoc.com/p~.htm 24 REHOBOTH BEACH VOL. FIRE DEPT PO BOX 327 REHOBOTH BEACH, DE 19971 Patient Name: ANTHONY BRUNNER Account No.: G8004037 Tax ID: 23-7004483 For all billing questions, call: (302)422-4047 Ext: ARLISLE PEOIATRIC ASSOCIATES BELVEDERE ST ARLISLE, PA 17013 17/243-1943 edera! ID : 23-2423789 ItemLzed Statement Printed: 03/13/2602 Page: 1 (c) Medic 7:37 AN atient 8RUNNER, TONY PatiO: 6133 308 WALNUT LANE Dob: 68/17/1985 CARLISLE, PA 17013 Age: 16 717/766-1124 Guarantor 0006133-0061 BS SS AcctlO: 6133 8RUNNER, ROGER SSN : 174-58-4308 308 WALNUT LANE CARLISLE, PA 17613 717/766-1124 Employer: RELIZON CORP Address/Telephone#: Insurance Company Policy ) Oroup ( Other Info Holder Effective Oate(s) 1:BLUE SHIELD PA HIM288425977 4379780 BRUNNER, DEBORAH P.O. BOX 890062 C'AMP HILL, PA 17089-0062 ervice Date(s) Patient Name Code Description Qty/Src Charged Open Provider Place Case# 6/20/61 BRUNNER, TONY 99213 EXPANDED OFFICE VISIT E 1.88 43.00 0.00 RAUBENSTIN CPA OTHER INS COVERAGE - PAY DUE DiagP: 724.5 BACK PAIN 06/20/01 PCA PATIENT PAYMENT-CASH Prsn! -10.06 09/12/01 PCK PATIENT PAYMENT-CHECK Prsnl -33.08 16/85/01 BSPY BLUE SHIELD PAYMENT Insur -33.00 11/09/81 RP REFUND GUARANTOR Prsnl 33.00 8/29/01 BRUNNER, TONY 99394 CHECK UP 1217 E 1.00 56.08 6.80 OiagP: V20.2 WELL CHILD 08/29/61 PCA PATIENT PAYMENT-CASH Prsnl -16.00 18/17/81 BSPY BLUE SHIELD PAYMENT Insur -27.00 10/17/81 8SWO BLUE SHIELO WRITE OFF Insur -19.60 11/09/01 8RUNNER, TONY REFUND PER REQUEST OF GUARANTOR HOFFMAN CPA urrent Balances Totals From 66/81/2061 Thru 83/12/2002 ccount Balance : 0.00 Charges : 99.80 pen Balance : 0.00 Personal Payments : -53.00 ersonal Balance : 0.80 Insurance Payments: -68.00 nsurance Balance : 0.00 Total Payments : -113.00 udget Balance : 0.00 Adjustments : 14.00 olIection Balance: 0.00 Co11. Payments : 0.00 Coll. Adjustments : 0.00 PLEASE DO N(~ STAPLE IN .THIS AREA 2. PATIENT WALNI L'A:NE PA BLUE SHIELD ~-~ 'po BOXY. 890062 17089 *0062 ZIP CODE Area Code) : ~1.3. 1124 . 9. OTHER INS Single ~ Married [~ t Name, First Name, Middle )RAH :3 ~ 8 r W ~ LNUT EANE F~ ~c~RLZSLE Other ;6 PA 1124 EMPLOYER'S d. NAME 12. PATIEN'P:S;OR EMPLOYMENT? [CURRENT OR* PREV OU~) NO. 43797 00 -PA,B UE:~ services described I 19. RESERVED FOR LOCAL USE -.' !~: '?: 21. DIAGNOSIS OR NATUR~oF U-NESS OR N JURY (RI~LATE ITEMS 1,2,S OR'4. TO ITEM 24E B~ uN-E'~'-:* ~ M~ ;: DD SSN EIN 23'~ the reverse IOSEPH BULETZA CHARGES -REHAB 17013 -- ;~27'~'BROOKWOOD-,.AVE EX. ANBER' .:~':P'R ~NG :R~H'AB'. 27 'BROOK~OOD AVENUE tRL[SLE PA' Z70~3 :- 245 2341 e/.) ....... ~P/.EASEP~INT OR TYPE ' '" , APPROVED oOMM~ FORMHCEA..15oo [12-9o), FORM RRB-iS00, ' , ,. APPROVED ~-1~15-0055 FORM OWCP-1500, APpROVED, OMB-0720-OO01 [CHAMPUS) PbEASE DO NOT STAPLE IN- THIS AREA I PA BLUE SHIELD ,- P 0 --~ B 0 X; ~'~89'0062' ....... ? -" ;I.-7e89 :.ee62~: ?- ~- 1.-.~MEDCA, RE ~--~'MEDICAJD .,,. !=- CHAMPUS :,. * CHAMPVA.~.. -= ~GROUP - ' FECA ...... .OTHER la. INSURED'S I.D. N~JMBER : -. := ~: ' (FOR PROGRAM JN ITEM 1). ~; '~;'.' r'"~'- ' '., · ,~. - ~. ;~ ~ ~ ' . ~ '~EALTHPLA~[~'-~LKLUNGr';'~ :~ "~l~d~re ~) ~ (M~d~id*h~r (~r~r'~ ~N)~ ~A ~ ~ (SSN ~ ID) ' ¢~N) "- (lO) 2 PAT EN~ S NAME (~$~ Name~ Erst Name~ M dd~ n t a) · -. - 3, PATIeNtS BIRTH DATE "" ' SEX . - 4. INSURED'S ~ME (~t Name, ~rst N~e, Midd~ Initial) ' ........... '~ ~ ..... ~J,;;.MM~ ..,.. D~ ', ~ M~. F ' · 5. ~TIEN~'S ~O~E~ (N~;' ~r~t) ... '. ,. ,q2 ;J/,..,'. ' ; --~ 'z: 6. ?~E~ RE~TIONSHIp ~0 INSURED~.. , · 7. IN~U~ED~SAD. DRESS.(No? 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W9728C~-. m: , .,, . ~1- e--': -: , .. ~,.8 ,88 '2. 25. FEDE~L T~ I.D. NUMBER 88N 81N 26. PATIENT'8 ACDUNT NO. 27. ACCEPTASSlBNMENT? r 28. TOTAL CrinGE,, -. , ~ A~OUNT PA D ~. BA~NOE DUE 23:~: 2e-~;':~.'':' .... :-8~.e~-,- ,~, :~- -, ..~--I~,~,--~,? .:... -,.~. -. 27 ~-e ~ 0 00 ~ 271 31. SIG~TURE OF PHYSIC~N' OR. SUPPLIER ' ' ~. ~ME AND ADDRESS OF FAClL~ WHERE SERVICES WERE ' ' ~. PHYSICI~'S SUPPUER'S BILLING N~E ADDRESS, ~P CODE INCLUDING DEGREES OR CREDENTIALS RENDERED (If mher th~ h~e or offi~) & PHONE ~ - · ~,, ' . . - . , _ (I ~ th~.the s~temen~ ~ the re~ . 30SEPH BULET~A PT?"':": "'~27z"~;~O'bK'b:OODVgg'E :~'"~'""' ' 2'7 8ROOKN'OOD'AVENUE ' ' -' .::'.':', '~'."'"~ :~';~ :: t; .,~92'8:el-'' ~;A'~'.~'~S'L:~?~_ PA ~ ~-'~ ''~ ~7'ei3 '. CAR'L~LE'' PA Z'Tei3'. 245 2341 s,g~E~'": ;.:'/- '':~::~' '::'o~::t:...-'.~:::/:,.;"..,;:~;.~:-':~": :: .,..-.'.' .:: ._.' .'..'"" ,,..5e~.259 .- ~ ..' - ~,.~. ..... ' (APPROVED BY AMA COUNCIL~3N M~DICAL sERvIcE 8/88~)' -PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM HCFA-'I'500 (12-90), FORM' BRB-1500,' APPROVED OMB-1215-0055 FORM OW(P;1500, APPROVED OMB-0720-0001 (CHAMPUS) PA BLUE SHIELD PLEASE" DO NOT STAPLE .... IN'THIS'- AREA · "' .... ~S,i- c:~q~,~ , ; :~JH,~PU~5 , ;~ ¢ ~, CHAMPVA.- -., GROUP - FECA OTHER ~a NSURED S D NUMBER ' (FOR PRoG~ 2, PATIE~'SNAME(~s~NBme,Fimt.N~me Midde ntal) , .: - 3 ~EN~'S~RTHDATE ' ~' S~ 4 NSUREDs~E(~Name RrstName Mddelniti~ 5, PATIENt'S AD~BE~ (No, Street~ . ~ , 6~ PATIENT. RE~ONSHIP TO INSURED . 7. INSURED'S ~DRESS (No. ~reet) 3'e8 "3e'8 wALNUT LANE' ZIP CODE TELEPHONE (Include Area Code) C A R L ~ S L E ' ziP ~DE ~LEPHONE (INCLUDE 9. OTHER INSURED'S ~ME (Last Name, First Name, M]ddl~ Initial). 10. IS PATIENt'S ~NDITION RE~D TO: 11. INSUBED'S 43797 ee a. OTHER INSURED~S POLICY OR GROUP NUMBER' -':.- ' · . :~ EMPLOYMENTS (CURRE~ OR PR~ OUS)' a NSURED S DA~ OF B b OTHER NSURED'S DATE 9F BI ~ , ~ . ' I .- · 'MM. 6D ; YY . · . R~.~ sSEX..r;~, ,. - b..AUTOA~IDE~?; · ~;..*':~(~) b. EMPLOYER'S NAME OR ~H~L N~E c. EMPLOYER'S NAME OR SCHOOL NAME ' ' ' c. O~ER ACC DE~? . d. INSURANCE P~N NAME OR PROGRAM NAME 1~, RESEHVED FOR LOCAL USE , *. d. 18 THERE ANO~ER H~TH BENEF~ P~N? :, . .- . R~CK OF FORM B~QRE ~MPL~NG & SIGN NG ~ $ FORM; .... ~, . 13 NSURED'S OR AU~ORIZED PER~N'S S GNA~RE ~n~ .... , TO 17. N~E' OF R~P~HHING PHYSIC~ OR O~EB ~URCE . :' 17~ I.D~ NUMBER'~F ;;~; LHRING.P~ySIC~ _ . . - ,I - 18. HOSPIT~I~T ON DA~S.RE~D TO CURRE~ SERV 21, DIAGNOSSOR~TUREOF LLNE~OR ~URY RE~MS123 R ' ...... ~ ~R~EDURE~SE~VCES, ORSUPPLES -; :D~GNOSlS.-'. ; ~..:$CHARG~ .. - DAYS EPSDT ~.T~$ , '. .., ..... ,-.- 1 INCLUDING DEGREES OR CREDE~S '~p~E~O~FACIL~W~ERESERVICESWERE ~ PHYSICIAN'S SUPP/I~-'q EDICAL SERVICE 8/88) 'PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM HCFA-1500 (12-90), FORM RRB-1500, APPROVED OMB-1215-0055 FORM 0WCI~.I~0. APPROVED 0M~072~001 ICHAMPH~) 0141445-000I Ci BP Ac. ctiD: 178707192 BRUHNER, P.[OER L SSN : 170--70-7192 I :REYNOLDS & i;SYHOLDS ATTN: INSURAHCE P.O. BOX F;rouo .~ OtheT ...... Holde', i745~308 ....... ,xUo~ L a~ ......... - BOX ~688 8A"'DN, OttiO 45401 ,'z,~o~,~:,,, 04311305 BRUNNCI;:~ ROGER L De, viue Date (sD F~ua'rb Hame Code ,,p~,, P'~ovideT ~"--~ £4('j "OO ."Or' · ~., c~,, ~-, BRUHHER, ANTHC'~4Y L 03/21/00 05/09/0~ 85185/00 !0/26/97 ~ C, I'=H 05/09/00 il/i2~ ~ ANTHO,YY ' ~t~UNNER, ~ BRUNNER, AHi'HOHY L u, nnr_r.~ ~NT,~UJ'.i~. L BRUNNER, ANTHONY L S3242 DiagP: ~' DC',': BTA CRA 25605 DiagP:. ,~,~,~ 0, >.~o C!P ~SI:' 99024 73108 BiagP; 81342 CIP BSP 990~4 CONgJLTATION LOW-MOD/OFF OR ER 1.08 115.00 0.00 GREEN FRACTURE,RADIUS, DiSTAL Q4D BLUE SHIELD ADJUSTMENT Insu'~ BLUE SHIELD PAY~NT Insu'r DEBIT TO ACCOUNT P'rs~l 1i5.80 CREDIT TO ACCOUNT Prsnl .-45.00 TREAT ..... r -, ram~TURE RADIUS/ULNA FR~CTuR~,,~HDIUS,~Io A~ END COMMERCIAL iNSURANCE PAYMENT BLUE SNIELD PAYMENT POST-OP VISIT, IN~UIED GLOBAL k ~H~R%~DIUo, Dio IH: END WRIST 2V X-RAY FRACTURE,RADIUS, DISTAL END C~MERCIAL INSURlkNCE PAYNEHT BLUE SHIELD PAY~NT FOal--dr VISIT, I~LUDED GLOBAL FRACTURE~RADIUS DISTAL END me [I. 1 .... 758.80 8G i ig'SLCP -----a ' am OFF OFF i.00 8.00 8.08 GREEN OFF Ii~sLt'¢ =r n. Insur -"13.80 1.00 0.00 ~.00 GREEN OFF ~u¢, e,w Balances Account Balance Open Balance Pe~sonat Bilance Insurasce Balance Budget Balance D.00 0.0E~ 0.00 Totals From 08/0i/'1999 Thru 12/11/2~002 --'~"~!: : 934.00 Insm'ar~-e F'ay~nts: -889.00 ~ ut~ Payments : -4~89.00 Adjust,~ents : -45.00 APPALACHIAN ORTHOPE,~iC CTR LTD Federal ID: c~-~o~/~: Pa~e: i Medic Patient BRUNNER, ANTHONY L Pat:D: 170707192 308 WALNUT LANE Dob: 88/17/1985 CARLISLE, PA 17013 Age: 16 .'-.I ~L,.¢ahCe t:o~,ioany Policy ~ Group ~ i:PR BLUE SHIELD HIM808485977 4379788 P.O. BOX 8~086~ CAMP' HILL, PA 17089-0062 0881445-0081 BS BRUNN~;, Af~THONY SSN Other info Holder Effective Date 81/29/08 BRUN~ER, ANTHONY L 99814 OV ESTAB PT MODERATE-HiGH 1.00 o,,. 00 t ~, ,, -- DiagP: 8460 LUMBAR ....... 'r~ ,~,, ~,ELL. FEmORaL DISEASE ui, cJ/~c CASii CASH [~YMc~ - H~N,, YOU P'rsnl -10.80 88/13/88 BSa' BLUE SHIEL~ PAYMENT Ins(~'~~ -43.88 8~, t~, o~ BSA [~LIE J,,~8 A2JUSTMENT '-- - ~.su,' '38.88 ~ ........ : Charges Ope~ Balance : 8.00 [ .............. e~ =u,~ Payments Pe'rsonai Balance : 0.00 ....... ,'- ..... ~-. ~,,=u ,a.ce Balance: ~.~,~, Total P'ayr, tents E:udg,st Balance : 8.08 Adjustments ~.uz !ec,.ior, L~alance: 0.00 EXHIBIT C A?R. 2~. 2003 IO'lSAM PAUL J. GITNIK & ASSOCIATES, LLC ATTORNEYS AT LAW Paul d. Gitaik Centre 1201 Broughton Road Pittsburgh, Pennsylvania 15236-3451 Telephone: (412) 653-8702 E-mai/: associates~gitnik, com Facsimile: (412) 655-8721 NO. 6985 ?, 2/.~ April 23, 2003 T/mothy L Salvatore, Esquire Katherman, Briggs & Greenburg 31 South Queen Street i York, PA 17403 Re: Highlnark *Patient: Brunner, Anthony Agre~ement No.: 2084259770 Date.ofln.~nry: Jun 13, 2001 D~ar Mr. Salvatore: As you are aware, this law firm has been retained as legal counsel in conjunction with **SOCRATES, INC., to provide outsourciag slubrogation services to Highrnark with regard to the above-referenced subrogation case. Enclosed please find a copy of the tel' ' indicates that I-lioh~--¢ ..... L .... P trmnary Record of Claim Payments nr ..... ~, ,-,. u: ....... provmeyou with and sl~alI e"-ec ........ t .. ~,~,u-,o.uo, paid a~ of Mar 06, 2002 We re ......... ' -- settlement and/or resolution of this subro¢,ation c .... ,p.[a. tfi.d ?ghmark R, ecord of Clmm Payments prior to the fln~ As you are aware, Highmark's subrogation llen is separate and distinct from that of Medlcare, Pennsylvania Blue Shield and/or any olh~ Blue Cross and/or Blue Shield Plan(s). ~ When appropr/ate, please ensure that the draft is made payable to SOCRATES, INC.~ ESCROW ACCOUNT. If th/, i~ a workers' compensation case, please nme that the cost containment provisions of the Workers' Compensatior~ Act, 77 P.S. § 53 I, do not apply to a subrogated insurance carrier and our client expects reimbursement of the ~11 amount of the subrogation lien. Fumlval v. W.C.A.B. (S/ye), 757 A.2d 433 (Pa. Cmwlth. 2000). i -- -~ Ify~u should have any questions regarding this mallet, please feel free to call me. Very truly yours, PAUL J. GITNIK & ASSOCIATES, LLC PJG/em Enclosure Paul J. Gimik This inf'Onnadon has been disclosed lo you from tecord~ whose confidcnriallty may bc prmectod by state and federal law. Any further di~closut.e 0fthi$ ' , ' mfotmauon without ~h= prior wrinen consent Or authorizagon of thc person to whom it 0ermins may be prohlbitcd. SOCRA"[E$, INC., provides out~our~-ing ~ubrogatJon services. H;Gl*k'l~t( BLUE CR*OS~ BLUE SHIELD JOSEPH AG R~TS P~RAH= E~E~O~;CHPD772d) PATZENT ~E~ B~ER ~T~ AGREEMENT: 208~97~D ~: 0~379700 ATT~, C~E: GP~I LZEN A.HO~JNT: PROJ~CT~ 96~76 PAGE FAZD PAZD AJ~? DATE 1¢3.00 eZ/OZ/2D~2 6~720 33.00 09/27/~001 Zlo.ao 10/23/200~ 6e69D 90.00 12/07/200~ a2,oo L2/22/2~a2 ~&9,06 ~2/2&/200~ 72q20 q&.O0 02/~9/201~ SY$ ADJ Cl~ N CI~ H ID~P ~ ClIP H EXHIBIT D PARENTS-GUARDIAN RELEASE AND INDEMNITY AGREEMENT (Claim No.:746315-39) FOR AND IN CONSIDERATION of the payment to me/us of FIFTEEN THOUSAND AND NO/100THS Dollars ($15,000.00), inclusive of all liens, the receipt of which is hereby acknowledged, I/we the undersigned, parent(s) and/or guardian(s) of ANTHONY BRUNNER a minor, do forever release, acquit, discharge and covenant to hold harmless the JUNGLE JIMS, INC. T/A JUNGLE JIMS ADVENTURE WORLD and SCOTTSDALE INDEMNITY COMPANY, their heirs, successors and assigns of and from any and all actions, causes of action, claims, demands, damages, costs, loss of services, expenses and compensation, on account of, or in any way growing out of, any and all known and unknown personal injuries and property damage which we may now or hereafter have as the parent(s) and/or guardian(s) of said minor, and also all claims or rights of action for damages which the said minor has or may hereafter have, either before or after he/she has reached his/her majority, resulting or to result from a certain accident which occurred on or about the 13TH day of JUNE 2001, at or near/18 COUNTRY CLUB ROAD, REHOBETH BEACH, DE. I/we further promise to bind myself/ourselves jointly and severally, my/our heirs, administrators and executors to repay to the said JUNGLE JIMS, INC. T/A JUNGLE JIMS ADVENTURE WORLD and SCOTTSDALE INDEMNITY COMPANY their heirs, successors and assigns any sum of money, except the sum above mentioned that he/she/they may hereafter be compelled to pay on behalf of said minor because of the said accident. It is further understood and agreed that this settlement is the compromise of a doubtful and disputed claim, and that this payment is not to be construed as an admission of liability on the part of the JUNGLE JIMS, INC. T/A JUNGLE JIMS ADVENTURE WORLD by whom liability is expressly denied. I/we further state that I/we have carefully read the foregoing release and know the contents thereof, and I/we sign the same as my/own free act. Signed this day of ,20 ROGER BRUNNER, Father DEB BRUNNER, Mother STATE OF ) ) ss COUNTY OF ) On this ~ day of 20 , before me appeared ROGER BRUNNER, father and DEB BRUNNER, mother and who acknowledged the execution of the foregoing instrument. My Commission Expires: Notary Public EXHIBIT E IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA In re Anthony Brunner, a minor ORPHANS COURT DIVISION ':.~ ~'~ AND NOW, this day °:~n~ e~t eme" 20 , after ~ue3;5 :~': const-Oeratio~...co ':;:' ..... a.:.,this Court, being satisfied with the propriety of the t and distributi6n sought~y Petitioners, hereby enters the following order: 1. The proposed settlement is fair, reasonable, and in the best interest of minor Anthony 2. The proposed distribution is approved as follows: a. $87.16 to Katherman, Briggs & Greenberg, LLP as reimbursement of costs advanced; b. $ 3,750.00 to Katherman, Briggs & Greenberg, LLP as attorney's fees; and c. $1,845.08 to Highmark Blue Cross/Blue Shield in satisfaction of its subrogation claim; and d. $9,317.76 to be invested in Anthony Bmnner's name in a blocked account with a federally insured banking institution from which no withdrawal shall be made during Anthony Brunner's minority without prior leave of the Court. 3. The funds to be invested in Anthony Brunner's name shall be deposited in an account with a federally insured banking institution from which no withdrawal of funds shall be made during Anthony Brunner's minority without prior leave of the Court. A proof of deposit shall be filed of record with this Court within fifteen (15) business days. The account must be restrictively endorsed in accordance with the withdrawal restrictions set forth in this Order. A copy of this Order shall be provided to the depository bank. Counsel shall assist in the deposit if necessary. Upon minor, Anthony Brunner's (DoB 08/17/1985) attaining the age of eighteen (18), the balance of the account shall be turned over to Anthony Brunner, without further Order of Court. 4. Petitioner may execute all releases necessary to effectuate this settlement and discontinue the action against Defendant. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA In re Anthony Brunner, a minor No. 2003-00396 ORPHANS COURT DIVISION PRAECIPE TO FILE CERTIFICATE OF DEPOSIT To the Orphan's Court of Cumberland County: Please file the attached Certificate of Deposit pursuant to the Court's Order of May 14, 2003. Date: Respectfully Submitted, KATHERMAN, BRIGGS & GREENBERG T~7 East Marl[et Street ~ York, PA 17401 717-848-3838 Tele 717-854-9172 Fax Attorney for the Plaintiff Attorney ID No. PA 77398 ® TIME DEPOSIT AUTOMATICALLY RENEWABLE PERSONAL CD 32 THROUGH 90 DAYS Opening Date Account Number Taxpayer ID Number JUNE 09r 2003 247412021926565 170707192 This Receipt Acknowledges That The Depositor Named Below Has Deposited With This Bank The Sum Of S ************************ Depositor Name And Address ANTHONY BRUNNER 308 WALNUT LANE Term CARLISLE PA 17013 Maturity Date Interest Rate Per Annum Annual Percentage Yield 00.75% 69 DAYS AUGUST' 17, 2003 00.75% ~nterest Payment Disposition Account to Credit CAPITALIZE NOT TRANSFERABLE Interest Payment Frequency/Period 69 DAYS PROD-TYPE: 202 PROMO CD: Issued by FIRST UNION NATIONAL BANK YORK / YORK SQUARE /~ W o 0