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Home My WebLink About11-7509 NT' GLORIA JACKSON, ET AL ? ?So vA Plaintiff SM- MYN J. BISCHOF IV Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 20 : Civil Term NOTICE TO DEFEND YOU HAVE BEEN SUED IN COURT. IF YOU WISH TO DEFEND AGAINST THE CLAIMS SET FORTH IN THE FOLLOWING PAGES, YOU MUST TAKE ACTION WITHIN TWENTY (20) DAYS AFTER THIS COMPLAINT AND NOTICE ARE SERVED, BY ENTERING A WRITTEN APPEARANCE PERSONALLY OR BY AN ATTORNEY AND FILLING IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. YOU ARE WARNED THAT IF YOU FAIL TO DO SO THE CASE MAY PROCEED WITHOUT YOU AND A JUDGEMENT MAY BE ENTERED AGAINST YOU BY THE COURT WITHOUT FURTHER NOTICE FOR ANY MONEY CLAIMED IN THE COMPLAINT OR FOR ANY OTHER CLAIM OR RELIEF REQUESTED BY THE PLAINTIFF. YOU MAY LOSE MONEY OR PEOPERTY OR OTHER RIGHTS IMPORTANT TO YOU. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO THE TELEPHONE OR THE OFFICE SET FORTH BELOW TO FIND WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 1-800-990-9108 717-249-3166 0 d ouv4 s64a00 F d a-&91 ?( 9- 4 C24s3g-? CIVIL ACTION - COMPLAINT COUNTI 1. Plaintiffs Gloria Jackson and Jonathan Jackson, are adult individuals, husband and wife residing at 906 North 16th Street, Harrisburg, PA 17103. 2. Plaintiffs Gloria S. Jackson and Jonathan C. Jackson are the Parents and Natural Guardians of Jonea Jackson and Romello Jackson, minors, who also reside at 906 North 16th Street, Harrisburg, PA 17103. 3. Plaintiff Talford Smith is an adult individual residing at 517 Rittenhouse Square, Mechanicsburg, PA 17050. 4. Defendant Stephen Bischof is an adult individual residing at 937 Woodbridge Drive, Enola, PA 17025. At all times material hereto, Plaintiff Gloria S. Jackson was operating a 2001 Dodge Caravan, and Plaintiffs Jonathan C. Jackson, Jonea Jackson and Romello Jackson, both minors as well as Plaintiff Talford Smith were passengers in the motor vehicle being operated by Plaintiff Gloria S. Jackson. 6. At all times material hereto, Defendant Stephen Bischof owned, operated, possessed and controlled a 2008 Honda motor vehicle. T On or about March 6, 2010, Plaintiff Gloria S. Jackson was operating her vehicle Northbound on Route 15 in Camp Hill Borough, Cumberland County Pennsylvania, in the left thru lane approaching the intersection of North 21St Street, as the vehicle in question was facing a steady green traffic signal. 8. At all times material hereto, Defendant Stephen Bischof was traveling Southbound on Route 15 in Camp Hill Borough, Cumberland County Pennsylvania, in the left thru lane approaching the intersection of North 21" Street, who attempted to make a left turn where there is a "No Left Turn" Sign posted at the intersection in question. 9. At all times material hereto, Defendant Stephen Bischof made a left turn at the aforementioned intersection and violently struck Plaintiffs' vehicle causing the collision in question. 10. As a result of the aforesaid motor vehicle accident, Plaintiffs Gloria S. Jackson, Jonathan C. Jackson, Jonea Jackson and Romello Jackson, both minors, as well as Plaintiff Talford Smith, suffered serious personal injuries more fully described hereinafter. 11. The aforesaid motor vehicle accident was caused solely by the carelessness and negligence of the Defendant and was in no manner due to any act or omission on the part of the Plaintiffs. 12. As a result of the negligence of Defendant, Plaintiff Gloria S. Jackson suffered severe and disabling injuries to the bones, muscles, skin, nerves, tendons, ligaments, tissues and blood vessels of her body, including without limitation of the foregoing, multiple contusions, lumbar strain and sprain, cervicobrachial syndrome, thoracic strain and sprain, cervical strain and sprain, minor right paracentral disc protrusion at C2/3, small hermangioma at T1, minor prominence of central canal of cord posterior to C5/6 vertebral body suggestive of a small syrinx, and other secondary problems and complications, the full extent of which are not yet known and some or all of which are permanent in nature. 13. As a result of the negligence of Defendant, Plaintiff Jonathan C. Jackson suffered severe and disabling injuries to the bones, muscles, skin, nerves, tendons, ligaments, tissues and blood vessels of his body, including without limitation of the foregoing, thoracic strain and sprain with subluxation, lumbar strain and sprain with subluxation, cervical strain and sprain with subluxation, bilateral hip contusion, right upper abdominal contusion, left ankle strain, left knee contusion and strain, headaches, pelvic strain and sprain with subluxation, mild bilateral facet joint hypertrophy L4/5 and US 1, mild bilateral neural foraminal narrowing at L5/S1, lumbar facet joint injection at L4/5 and bilateral L5/S1, lumbar epidural steroid injection right L5/S1, mild right carpal tunnel syndrome as well as compression neuropathy at wrist and elbow, bulging of annulus at C3/4 and C4/5, moderate to severe bilateral foraminal stenosis at C6/7, and other secondary problems and complications, the full extent of which are not yet known and some or all of which are permanent in nature. 14. As a result of the negligence of Defendant, Plaintiff Jonea Jackson, a minor suffered severe and disabling injuries to the bones, muscles, skin, nerves, tendons, ligaments, tissues and blood vessels of her body, including without limitation of the foregoing, multiple contusions and left jaw pain, cervicalgia, cervical strain and sprain, thoracic strain and sprain, lumbar strain and sprain, headaches, upper extremity strain and sprain, and other secondary problems and complications, the full extent of which are not yet known and some or all of which are permanent in nature. 15. As a result of the negligence of Defendant, Plaintiff Romello Jackson, a minor suffered severe and disabling injuries to the bones, muscles, skin, nerves, tendons, ligaments, tissues and blood vessels of his body, including without limitation of the foregoing, facial contusion, cervical strain and sprain, thoracic strain and sprain, lumbar strain and sprain, cervical joint dysfunction, and other secondary problems and complications, the full extent of which are not yet known and some or all of which are permanent in nature. 16. As a result of the negligence of Defendant, Plaintiff Talford Smith suffered severe and disabling injuries to the bones, muscles, skin, nerves, tendons, ligaments, tissues and blood vessels of his body, including without limitation of the foregoing, multiple contusions, cervical strain and sprain, thoracic strain and sprain, lumbar strain and sprain, cervicobrachial syndrome, left ankle strain, C4/5 minimal bulging, C5/6 mild broad bulging, C6/7 broad bulging of disc, C7/T1 broad circumferential bulging of disc with minimal flattening ventral thecal sac, some annular bulging at L5/S1, left shoulder strain and sprain, and other secondary problems and complications, the full extent of which are not yet known and some or all of which are permanent in nature. 17. As a result of the negligence of Defendant, Plaintiffs have in the past been prevented and in the future will be prevented and precluded from attending to their normal duties, occupations and avocations; in addition, they have suffered and will in the future continue to suffer pain, mental anguish, humiliation, the inability to engage in their normal activities and inability to pursue the normal and ordinary pleasures of life. 18. As a result of the negligence of Defendant, Plaintiffs have in the past required and will in the future continue to require medical care and/or rehabilitative care and other treatment, and Plaintiffs have in the past required and will in the future continue to incur expenses for medical care and/or rehabilitative care to attend to, treat, alleviate, minimize and/or cure their conditions. WHEREFORE, Plaintiffs Gloria S. Jackson, Jonathan Jackson, Jonea Jackson, a minor, Romella Jackson, a minor and Talford Smith each demand judgment in their favor and against Defendant, Stephen J. Bischoff, for a sum not in excess of Fifty Thousand ($50,000.00) Dollars, together with lawful interest and costs. COUNT II PLAINTIFFS v. DEFENDANT 19. Plaintiffs incorporate paragraphs one through eighteen (1-18) as though set forth at length herein. 20. The accident and resulting injuries and damages described above were caused by the carelessness and negligence of Defendant Stephen Bischof, both generally and in the following respects: a) Operating the above stated vehicle at a high and excessive rate of speed under the circumstances; b) Failure to have the above stated vehicle under proper and adequate control at the time; C) Operating the above vehicle without due regard to the rights, safety and position of Plaintiffs; d) Failure to keep a proper and adequate lookout ahead; e) Failure to keep a proper and adequate lookout for other traffic; f) Disregarding traffic signals in direct violation of the Motor Vehicle Code; g) Failure to keep a proper and adequate lookout for other traffic signs and/or signals posted; h) Making illegal and improper turns; i) Turning directly into the path of an oncoming vehicle; j) Being otherwise negligent under the circumstances; and 5 k) Violation of applicable ordinances and provisions of the Motor Vehicle Code of the Commonwealth of Pennsylvania. WHEREFORE, Plaintiffs Gloria S. Jackson, Jonathan Jackson, Jonea Jackson, a minor, Romella Jackson, a minor and Talford Smith each demand judgment in their favor and against Defendant, Stephen J. Bischoff, for a sum not in excess of Fifty Thousand ($50,000.00) Dollars, together with lawful interest and costs. 1 BILY ND M. BILY, for Plaintiffs Date: September 30, 2011 VERIFICATION I, RAYMOND M. BILY, ESQUIRE, state that I am the Attorney for Plaintiffs in the attached matter and that the facts set forth in the foregoing Civil Action-Compliant are true and correct to the best of my information, knowledge and belief. Further, I understand that all statements made herein are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. ND M. BILY, for Plaintiffs SHERIFF'S OFFICE OF CUMBERLAND COUNTY Ronny R Anderson -7 7 fI Sheriff ; , F pt4lytr 01 ?IUgPl Jody S Smith '`? L? Chief Deputy Richard W Stewart Solicitor s F i? n I I S Y LV l i I ", .. Gloria Jackson Case Number vs. Stephen J. Bischof, IV 2011-7509 SHERIFF'S RETURN OF SERVICE 10/13/2011 08:08 PM - Michelle Gutshall, Deputy Sheriff, who being duly sworn according to law, states that on October 13, 2011 at 2008 hours, she served a true copy of the within Complaint and Notice, upon the within named defendant, to wit: Stephen J. Bischof IV, by making known unto himself personally, at 937 Woodridge Drive, Enola, Cumberland County, Pennsylvania 17025 its contents and at the same time handing to him personally the said true and correct copy of the same. SHERIFF COST: $43.44 October 18, 2011 MICHELLE GUTSHALL, DEPUTY SO ANSWERS, RON R ANDERSON, SHERIFF !q GauntySuite Sheriff Teleosc t, inc. REIFF AND BILY T"ONOTARY ICE C-FFICE IF THELP O THONOTARY By: Raymond M. Bily, Esquire ' I.D. #44677 101! NOV -7 PM 3: 25 2011 NOV -7 P? =? 1125 Walnut Street CUMBERLAND COUNTY Philadelphia, PA 19107CUMB TRI.AND PENNSYLVANIA 215-246-9000 pERYEV. 215-246-9012 GLORIA JACKSON, ET AL. COURT OF COMMON PLEAS CUMBERLAND COUNTY V. NO. 2011-75-09 STEPHEN J. BISCHOF, IV. PRAECIPE TO SUBSTITUTE VERIFICATION TO THE PROTHONOTARY: Please substitute the Verification of Plaintiff, Talford Smith for that of Plaintiffs counsel on the Civil Action-Complaint. VERIFICATION I, Talford Smith, state that I am the Plaintiff in the attached matter and that the facts set forth in the foregoing Civil Action - Complaint, are true and correct to the best of our information, knowledge and belief. Further, I understand that all statements made herein are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unworn falsification to authorities. Date: lOkq Im i ALF S ITH REIFF AND BILY By: Raymond M. Bily, Esquire I.D. #44677 1125 Walnut Street Philadelphia, PA 19107 215-246-9000 215-246-9012 op rkF OTHO OTAR,? 1011 NOV -fir PH 3:CUMBERLA?'a ?4 PENlVS YL VA14 A T Y GLORIA JACKSON, et al. COURT OF COMMON PLEAS CUMBERLAND COUNTY V. NO. 2011 STEPHEN BISCHOF, IV PLAINTIFFS' RESPONSE TO DEFENDANT'S NEW MATTER 21. Denied. The allegation contained in this paragraph contains a conclusion of law to which no answer is required under the Pennsylvania Rules of Civil Procedure. In addition, after reasonable investigation the plaintiff is without sufficient information to form an opinion as to the truth or admissibility of evidence pertinent to the allegations, therefore strict proof is demanded at the time of trial. 22. Denied. The allegation contained in this paragraph contains a conclusion of law to which no answer is required under the Pennsylvania Rules of Civil Procedure. In addition, after reasonable investigation the plaintiff is without sufficient information to form an opinion as to the truth or admissibility of evidence pertinent to the allegations, therefore strict proof is demanded at the time of trial. 23. Denied. The allegation contained in this paragraph contains a conclusion of law to which no answer is required under the Pennsylvania Rules of Civil Procedure. In addition, after reasonable investigation the plaintiff is without sufficient information to form an opinion as to the truth or admissibility of evidence pertinent to the allegations, therefore strict proof is demanded at the time of trial. 24. Denied. The allegation contained in this paragraph contains a conclusion of law to which no answer is required under the Pennsylvania Rules of Civil Procedure. In addition, after reasonable investigation the plaintiff is without sufficient information to form an opinion as to the truth or admissibility of evidence pertinent to the allegations, therefore strict proof is demanded at the time of trial. 2.5. Denied. The allegation contained in this paragraph contains a conclusion of law to which no answer is required under the Pennsylvania Rules of Civil Proce( lure. In addition, after reasonable investigation the plaintiff is without sufficient information to form an opinion as to the truth or admissibility of evidence pertinent to the allegations, therefore strict proof is demanded at the time of trial. 26. Denied. The allegation contained in this paragraph contains a conclusion of law to which no answer is required under the Pennsylvania Rules of Civil Procedure. In addition, after reasonable investigation the plaintiff is without sufficient information to form an opinion as to the truth or admissibility of evidence pertinent to the allegations, therefore strict proof is demanded at the time of trial. 27. Denied. The allegation contained in this paragraph contains a conclusion of law to which no answer is required under the Pennsylvania Rules of Civil Procec are. In addition, after reasonable investigation the plaintiff is without sufficient information to form an opinion as to the truth or admissibility of evidence pertinent to the allegations, therefore strict proof is demanded at the time of trial. 28. Denied. The allegation contained in this paragraph contains a conclusion of law to which no answer is required under the Pennsylvania Rules of Civil Procedure. In addition, after reasonable investigation the plaintiff is without sufficient information to form an opinion as to the truth or admissibility of evidence pertinent to the allegations, therefore strict proof is demanded at the time of trial. 29. Denied. The allegation contained in this paragraph contains a conclusion of law to which no answer is required under the Pennsylvania Rules of Civil Procedure. In addition, after reasonable investigation the plaintiff is without sufficient information to form an opinion as to the truth or admissibility of evidence pertinent to the allegations, therefore strict proof is demanded at the time of trial. 30. Denied. The allegation contained in this paragraph contains a conclusion of law to which no answer is required under the Pennsylvania Rules of Civil Procedure. In addition, after reasonable investigation the plaintiff is without sufficient information to form an opinion as to the truth or admissibility of evidence pertinent to the allegations, therefore strict proof is demanded at the time of trial. WHEREFORE, Plaintiffs respectfully request that judgment be entered consistent with Plaintiff's Complaint and that the Defendant's New Matter be stricken. REIFF AND BILY iND M. BILY, E?QUIRE for Plaintiffs Dated: �� /��Sl."�•' In The Court of Common Pleas of Cumberland PIaintiff County, Pennsylvania No. Defendant Civil Action—Law. Oath We do solemnly swear (or affirm)that we will support, obey and defend the Constitution of the United States nd the Constitui-on of this Commonwealth and that we will discharge the duties of our office with delity. Siena ure Signature Signature Name (Chairman) ame Name Law Firm Law Finn Law Firm l O S 3or 111 h S�, Address // Address Address Ll L�rr�s l� l 7d�� ?aY9 cam!is 70 13 Citv, Zip City — Zip City, Zip Award We, the undersigned arbitrators, having been duly appointed and sworn (or affirmed), make the following award: (Note: If damages for delay are awepied, the shall be se Par ely state) ,� , / cam v�5 m /USA' Svdt �OOC?Ul, Aoarlb lJ`uov7'" Qit smfc� Ica �%' a ?orzl, Sr.�Y4 � .y( _...- itrator dissents.,... n e i iiCAble: _. . MCC Date of Hearing: o) � Date of Award: S�l - ;> Notice of Entry of Award Now, the AX day of , 20/.3 , at AP,:53 , K. the above award was entered upon the docket and notice the of given by mail to the parties or their attorneys. Arbitrators' compensation to be paid upon appeal: S y/1,p -S - By. Prothonotary Depury pay AV#to( rn. /3;ly,czfr 513113 lZil-e- BY: Joseph R. D'Annunzio Law Office of Joseph R. D'Annunzio Identification No. 23384 4309 Linglestown Road, Suite 211 Harrisburg, PA 17112 (717) 901-5002 Fax: (717) 901-5012 OF 1- ILED-OFF7('):. PROTHONOT • ZVI SEP -4 A,11!: CUtiCERLA NDVA COUNTY PENNS YLNIA Attorney for Defendant, Stephen Bischof IV IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA GLORIA JACKSON, ET. AL, V. STEPHEN BISCHOF IV, Plaintiffs, Defendant NO. 2011-75-09 CIVIL ACTION — LAW JURY TRIAL DEMANDED PETITION TO MARK ARBITRATION AWARD AS SATISFIED To the Honorable the Judges of the said Court, the Defendant, Stephen Bischof IV, respectfully represents: 1. On October 3, 2011, the Plaintiffs, Gloria S. Jackson, Jonathan C. Jackson, individually and as the parents and guardians of Jonea Jackson and Romello Jackson, and Plaintiff, Talford Smith, together filed a Complaint in this Honorable Court seeking to recover money damages for injuries sustained as a result of a motor vehicle accident that occurred on March 6, 2010. 2. On October 17, 2011, the Defendant, Stephen Bischoff IV filed an Answer and New Matter to this Complaint. 3. On May 2, 2013, the matter was heard in arbitration before a panel of arbitrators. 4. On May 2, 2013, the arbitrators found in favor of all Plaintiffs and against the Defendant. They awarded Plaintiff Jonea Jackson, three thousand dollars ($3000.00), Plaintiff Romello Jackson, five thousand dollars ($5000.00), Plaintiff Gloria Jackson, fifteen thousand dollars ($15,000.00), Plaintiff Jonathan Jackson, twenty thousand dollars ($20,000.00) and Plaintiff Talford Smith, ten thousand dollars ($10,000.00) for a total award of fifty three thousand dollars ($53,000.00). A true and correct copy of the arbitration award is marked as Defendant's Exhibit "1", attached hereto, and incorporated by reference. 5. The Defendant, Stephen Bischoff IV, did not appeal this arbitration award and thus it became final. 6. On June 3, 2013, the insurance carrier for Stephen Bishoff IV sent to Raymond M. Bily, Esquire, the attorney for the Plaintiffs, settlement checks pursuant to the arbitration award. These checks were sent by certified mail and were received by Attorney Bily on June 6, 2013. A true and correct copy of the transmittal letter as well as the return receipt card are marked as Defendant's Exhibit "2", attached hereto and incorporated by reference. 7. Although, the attorney for the Defendant requested that Attorney Bily provide a praecipe marking the arbitration award as being satisfied, no such praecipe has been submitted to date. 8. On November 19, 2013, counsel for Defendant sent to counsel for the Plaintiffs a letter requesting that Attorney Bily file either a petition seeking approval of the minor's compromise settlement or the praecipe marking the case as satisfied. A true and correct copy of the letter is marked as Defendant's Exhibit "3", attached hereto and incorporated by reference. 9. On June 3, 2014, counsel for the Defendant wrote to counsel for the Plaintiffs enclosing a praecipe to mark the case as satisfied and requested that counsel for the Plaintiffs sign the praecipe and return it. A true and correct copy of the letter is marked as Defendant's Exhibit "4", attached hereth and incorporated by reference. 10. Counsel for the Plaintiffs has failed to provide and continues to fail to provide a praecipe marking the arbitration award as satisfied. 11. The failure to provide a praecipe marking the arbitration award as being satisfied has prejudiced the Defendant, as it appears as a judgment of record that has not been satisfied. 12. Counsel for the Defendant requests that this Honorable Court enter an order directing the Prothonotary of this Honorable Court to mark the arbitration award as satisfied on the Court's dockets. Further, counsel for the Defendant requests that this Honorable Court impose sanctions on the Plaintiffs for their failure to promptly provide a praecipe marking the arbitration award as being satisfied although their counsel has been requested to do so on multiple occasions. WHEREFORE, Defendant Stephen Bischof IV requests that this Honorable Court enter an order directing the Prothonotary of Cumberland County to mark the arbitration entered on May 2, 2013 as being satisfied. Further, the Defendant requests that this Honorable Court impose sanctions on the Plaintiffs for their failure to promptly provide a praecipe marking the arbitration award as satisfied after numerous requests to do so. Date: 2.0/* Respectfully submitted, Joseph R. D'Annunzio, Esquire Counsel for the Defendant 07410/ e '7/ / Plaintiff In The Court of Common Pleas of Cumberland County, Pennsylvania No. .// - .73-0fi Civil Action — Law. Oath We do solemnly swear (or affirm) that we will support, obey and defend the Constitution of the United States d the Constitution of this Commonwealth and that we will discharge the duties of our office with Ydelity. Name (Chairman) 71-e.h-d /7G2? -6, it/5 041 Law Firm 5_0? 54 - Address „tiArg Name ) 10.4142, Law Firm 301 H„re4 Address 47461C2— Signature laurf.1) 1-4)Kaip Name Nce, (,›40exs Law Firm 2 west fqJj9 Address 2,(f AryrA.-L-- M 71/10 (PCI13te Pti- /70/3 City, Zip City, I Zip City, Zip Award We, the undersigned arbitratorshaving been duly appointed and sworn (or affirmed), make the following award: (Note: If damages for delay are awed, they- shall be slea_72tely state)4) L1)•2 47// lark ,145 extrZfr-r .A70e-tv a _01 1)0", if/2 , 5A -rat 30/LI 4:5-‘70a, , ,5-‘7,0g)- , • a747/41n0 -2, oav 54j• elga.4e9 .itr - - - - ator; dissents - 7:71 041-AriA„. 021- ...0s Date of Hearing: Date of Award: ne( Now, the day of Notice of Entry of Award , 20/3 , at Jg , P.M., the above award was entered upon the docket and notice the 'of given by mail to the parties or their attorneys. Arbitrators' compensation to be paid upon appeal: -CO Prothonotary 111. 6; y Ilhniolzia, eopi-eS ilAaa /r1 5 /3 /13 fzi Deputy EXHIBIT 2 LAW OFFICE OF JOSEPH R. D'ANNUNZIO ATTORNEYS AND SUPPORT ASSOCIATES ARE EMPLOYEES OF GOVERNMENT EMPLOYEES INSURANCE COMPANY 4309 Linglestown Road, Suite 211 Harrisburg, PA 17112 Telephone: 717-901-5002 Facsimile: 717-901-5012 June 3, 2013 Raymond M. Bily, Esquire REIFF & BILY 1125 Walnut Street Beasley Building Philadelphia, PA 19107 RE: Jackson et all v. Bischof IV Dear Ray: Please be advised that the Defendant did not appeal the award by the arbitration panel that was entered on May 2, 2013. Pursuant to the award of the arbitrators, the following checks have been issued and are enclosed: 1) a check in the sum of three thousand dollars ($3000.00) made payable to Gloria Jackson and Jonathan Jackson as parents and Guardians of Jonea Jackson, a Minor and Reif and Bily, Their Attorneys; 2) a check in the sum of five thousand dollars ($5,000.00) made payable to Gloria Jackson and Jonathan Jackson as parents and Guardians of Romelo Jackson, a Minor and Reif and Bily, Their Attorneys; 3) a check in the sum of fifteen thousand dollars ($15,000.00) made payable to Gloria Jackson, Jonathan Jackson, and Reif and Bily, Their Attorneys for the award entered in favor of Gloria Jackson; 4) a check in the sum of twenty thousand dollars ($20,000.00) made payable to Jonathan Jackson, Gloria Jackson, and Reif and Bily, Their Attorneys for the award entered in favor of Jonathan Jackson; 5) and a check in the sum of ten thousand dollars ($10,000.00) made payable to Talford Smith and his Reif and Bily, His Attorneys. Together with these checks you will also find five separate releases for each of the parties to sign, with the parents signing for each of the minor children. Please do not endorse the checks until the releases have been signed and notarized and you have mailed them back to me. Also, when you send the executed releases, please include a praecipe to mark the arbitration award as satisfied. I trust that you will find these documents to be in order but please feel free to call me if you have any questions. Very truly yours, Joseph R. D'Annunzio JRD/ks cc: Stacy Webster - Claim #0329618850101042 Stephen Bischof a— ra m Iv ru rR Q a C] O LI J CD, m ru r' - Posta GE'Tf IED (Domestic MA L C .IP Mall On ; o Insurance Coverage Pro ded) Postage Certified Fee Return Receipt Fee (Endorsement Required) Restricted Delivery Fee (Endorsement Required) Total Postage & Fees Postmark Here Sent To Street, Apt. No.; or PO Box No. City, State, ZIP+4 ? UiGtl✓Vli t `' UA \al � sL 11 PS orm 800. August 2006 ER: COMPLETE THIS SECTION • Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery Is desired. • Print your name and address on the reverse so that we can return the card to you. • Attach this card to the back of the mailpiece, or on the front If space permits. 1. Article Addressed to: 11;k, �wyf1 6gu,5✓ f ir,4 4 1 je/\ 6 ;COMPLETE THIS SECTION'CN DELIVERY A. Signature X ❑ Agent Addressee C. Date of Delivery D. Is delivery - + s differen�rom If YES, en t r� (livery addess b ❑ Yes ❑ No 3. Service Type edified Mail ❑ Registered 0 Insured Mall 0 Express Mail Return Receipt for Merchandise 0 C.O.D. 4. Restricted Delivery? (Extra Fee) 0 Yes 2. Article Number (Transfer from service label) 7012 3050 0000 1622 6319 PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 EXHIBIT 3 LAW OFFICE OF JOSEPH R. D'ANNUNZIO ATTORNEYS AND SUPPORT ASSOCIATES ARE EMPLOYEES OF GOVERNMENT EMPLOYEES INSURANCE COMPANY 4309 Linglestown Road, Suite 211 Harrisburg, PA 17112 Telephone: 717-901-5002 Facsimile: 717-901-5012 November 19, 2013 Raymond M. Bily, Esquire REIFF & BILY 1125 Walnut Street Beasley Building Philadelphia, PA 19107 RE: Jackson et all v. Bischof IV Dear Ray: On September 24, 2013, I wrote to you a letter asking for your cooperation in bringing this matter to a conclusion. You will recall that we reached a settlement in this case and that you needed to obtain Court approval for the minors' settlements. In my letter to you on September 24, 2013, I asked that you please file a petition seeking approval of the minors' settlements. I have not heard from you since that time. I am sure that you are as eager as I am to get this matter concluded before the end of this year. Therefore, I ask that you please file a petition seeking Court approval so that we can bring this matter to a conclusion. I thank you for your time and attention to this matter. Very truly yours, Joseph R. D'Annunzio JRD/ks cc: Stacy Webster - Claim #0329618850101042 Stephen Bischof LAW OFFICE OF JOSEPH R. D'ANNUNZIO ATTORNEYS AND SUPPORT ASSOCIATES ARE EMPLOYEES OF GOVERNMENT EMPLOYEES INSURANCE COMPANY 4309 Linglestown Road, Suite 211 Harrisburg, PA 17112 Telephone: 717-901-5002 Facsimile: 717-901-5012 June 3, 2014 Raymond M. Bily, Esquire REIFF & BILY 1125 Walnut Street Beasley Building Philadelphia, PA 19107 RE: Jackson et al v. Bischof IV Dear Mr. Bily: Enclosed for your signature, please find a Praecipe to mark this case satisfied. Please sign and return the Praecipe to me as soon as possible, so that I may file it with the Court. If you have any questions, please feel free to contact me. Very truly yours, . Joseph R. D'Annunzio JRD/ks cc: Stacy Webster - Claim #0329618850101042 Stephen Bischof, IV CERTIFICATE OF SERVICE I hereby certify that I am this day serving a copy of the foregoing document upon the person(s) and in the manner indicated below, which service satisfies the requirements of the Pennsylvania Rules of Civil Procedure, by depositing a copy of same in the United States Mail, first-class postage prepaid, addressed as follows: Raymond M. Bily, Esquire 1125 Walnut Street Beasley Building Philadelphia, PA 19107 Counsel for Plaintiff(s) Date: IIJi J Kimberly 8Iielper GLORIA JACKSON, et al., : IN THE COURT OF COMMON PLEAS OF Plaintiffs, : CUMBERLAND COUNTY, PENNSYLVANIA v. : CIVIL ACTION — LAW : No. 2011-7509 STEPHEN BISCHOF IV, Defendant. IN RE: PETITION TO MARK ARBITRATION AWARD AS SATISFIED ORDER AND NOW, this /0 day of September, 2014, upon consideration of the within petition, it is hereby ordered that: 1. A rule is issued upon the respondent to show cause why the moving party is not entitled to the relief requested; 2. The respondent shall file an answer to the motion within 20 days of this date. 3. The motion shall be decided under Pa.R.C.P. 206.7. 4. Argument shall be scheduled if requested in the answer. .staymond M. Bily, Esquire 1125 Walnut Street Beasley Building Philadelphia, PA 19107 .Joseph R. D'Annunzio 4309 Linglestown Road Suite 211 Harrisburg, PA 17112 :rlm copeP/N1 BY THE COURT: REIFF AND BILY By: Raymond M. Bily, Esquire LD. #44677 1125 Walnut Street Philadelphia, PA 19107 215-246-9000 215-246-9012 GLORIA JACKSON, et al. V. STEPHEN BISCHOF, IV t:ILE11-0FPICLI THE PROTHONO rrk 4 2014 SEP 22 PM CWIBERLi1NO CO r Y PENNSYLVANIA COURT OF COMMON PLEAS CUMBERLAND COUNTY NO. 2011-75-09 PLAINTIFFS' RESPONSE TO DEFENDANT'S PETITION TO MARK ARBITRATION AWARD AS SATISFIED1 Plaintiffs, by and through their attorney, Raymond M. Bily, Esquire hereby move this Honorable Court to enter an Order denying Defendant's Petition to Mark Arbitration Award as Satisfied, as follows: 1. Admitted. 2. Admitted. 3. Admitted. 4. Admitted. Admitted. 6. Admitted. 7. Admitted. By way of further answer, despite numerous attempts by Plaintiffs" counsel, the parents of the minor Plaintiffs have refused to sign the necessary Verifications to be attached to the Minor's Compromise Petitions. As a result, Plaintiffs' 1 Oral argument is requested. 8. Admitted. By way of further answer, despite numerous attempts by Plaintiffs" counsel, the parents of the minor Plaintiffs have refused to sign the necessary Verifications to be attached to the Minor's Compromise Petitions. As a result, Plaintiffs' counsel is unable to file the Minor's Compromise Petitions with the Court. See letters to Gloria and Jonathan Jackson attached hereto as Exhibit 1. 9. Admitted. 10. Admitted. By way of further answer, despite numerous attempts by Plaintiffs' counsel, the parents of the minor Plaintiffs have refused to sign the necessary Verifications to be attached to the Minor's Compromise Petitions. As a result, Plaintiffs' counsel is unable to file the Minor's Compromise Petitions with the Court. See letters to Gloria and Jonathan Jackson attached hereto as Exhibit 1. 11. Denied. The allegation contained in this Paragraph contains a conclusion of law to which no answer is required under the Pennsylvania Rules of Civil Procedure. In addition, after reasonable investigation, the Plaintiffs are without sufficient information to form an opinion as to the truth or admissibility of evidence pertinent to the allegations. Therefore, strict proof is demanded at the time of trial. 12. Neither admitted nor denied. By way of further answer, despite numerous attempts by Plaintiffs' counsel, the parents of the minor Plaintiffs have refused to sign the necessary Verifications to be attached to the Minor's Compromise Petitions. As a result, Plaintiffs' counsel is unable to file the Minor's Compromise Petitions with the Court. See letters to Gloria and Jonathan Jackson attached hereto as Exhibit 1. VERIFICATION I, RAYMOND M. BILY, ESQUIRE, state that I am the Attorney for the Plaintiffs in the attached matter and that the facts set forth in the foregoing PLAINTIFFS' RESPONSE TO DEFENDANT'S PETITION TO MARK ARBITRATION AWARD AS SATISFIED are true and correct to the best of my information, knowledge and belief. Further, I understand that all statements made herein are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Y ND M. BILY, ES IRE A to ey for Plaintiffs' REIFF AND BILY By: Raymond M. Bily, Esquire LD. #44677 1125 Walnut Street Philadelphia, PA 19107 215-246-9000 215-246-9012 GLORIA JACKSON, et al. V. STEPHEN BISCHOF, IV COURT OF COMMON PLEAS CUMBERLAND COUNTY NO. 2011-75-09 CERTIFICATE OF SERVICE I, Raymond B. Bily, Esquire, attorney of record in the above -captioned matter, represent and warrant a true and correct copy of PLAINTIFFS' RESPONSE TO DEFENDANT'S PETITION TO MARK ARBITRATION AWARD AS SATISFIED was served upon the following via United States First Class Mail, postage pre -paid: Date: nc Joseph R. D'Annunzio, Esquire Law Office of Joseph R. D'Annunzio 4309 Linglestown Road, Suite 211 Harrisburg, PA 17112 By: ay Att ond M. Bily, Esq ney for Plaintiffs GLORIA JACKSON, et al., • IN THE COURT OF COMMON PLEAS OF Plaintiff • CUMBERLAND COUNTY, PENNSYLVANIA • vs. • CIVIL ACTION—LAW NO. 11-7509 STEPHEN BISCHOF, IV, Defendant : IN RE: DEFENDANT'S PETITION TO MARK ARBITRATION AWARD SATISFIED ORDER AND NOW, this 2 a day of October, 2014, argument on the Defendant's Petition to Mark Arbitration Award Satisfied is set for Wednesday, October 15, 2014, at 1:30 p.m. in Courtroom Number 4, Cumberland County Courthouse, Carlisle, PA. BY THE COURT, - AL Kevin ' . Hess, P.J. '� Ra mond M. Bil Esquire Y Y� q The Beasley Building 1125 Walnut Street Philadelphia, PA 19107 ✓ Joseph R. D'Annunzio, Esquire 4309 Linglestown Road, Suite 211 Harrisburg, PA 17112 :rim ,R c , r--) REIFF AND BILY By: Raymond M. Bily, Esquire I.D. #44677 1125 Walnut Street Philadelphia, PA 19107 215-246-9000 215-246-9012 GLORIA JACKSON, et al. v. STEPHEN BISCHOF, IV FILED OFFICE ,4, KiI4 OCT -3 3:2 CU;:tt r COURT OF COMMON PLEAS CUMBERLAND COUNTY NO. 2011-75-09 PETITION FOR LEAVE TO SETTLE OR COMPROMISE MINOR'S ACTION To the Honorable, the Judges of the Said Court: The Petition of ROMELLO JACKSON, a minor, by and through GLORIA JACKSON AND JONATHAN JACKSON, parents and natural guardians of ROMELLO JACKSON, respectfully represent: 1. Minor Plaintiff, ROMELLO JACKSON, resides with his parents, GLORIA JACKSON and JONATHAN JACKSON at 6635 Evelyn Street, #7, Harrisburg, Pennsylvania 17111. 2. Minor Plaintiff ROMELLO JACKSON was born on July 18, 2006 and his Social Security Number is 159-84-2877. 3. On or about March 6, 2010, Minor Plaintiff was a passenger in his parents' automobile when they were involved in an automobile accident on Route 15 at or near the intersection of North 21st Street in Camp Hill Borough, Cumberland County, Pennsylvania. 4. As a result of the accident, Minor Plaintiff was taken by rescue to Harrisburg Hospital for examination. The records reflect the Minor Plaintiff complained of knee abrasion, knee pain, left linear abrasion on cheek and a forehead hematoma with minimal ecchymosis. He was examined, a CT Scan of his head and neck were performed which were negative and he was discharged. A true and correct copy of Minor Plaintiff's emergency room records are attached hereto, made part hereof and marked as Exhibit "1". 5. Minor Plaintiff sought follow up care from David W. Gerhart, D.C.. Dr. Grehart treated Minor Plaintiff for the injuries he sustained. On August 23, 2010, Dr. Gerhart concluded Minor Plaintiff had reached maximum medical improvement and discharged Minor Plaintiff. A true and correct copy of Dr. Gerhart's final medical report is attached hereto, made a part hereof and marked as Exhibit "2". 6. Attached hereto, made part hereof and marked Exhibit "3" is a statement signed by Petitioners, GLORIA JACKSON AND JONATHAN JACKSON, acknowledging Minor Plaintiff has achieved a full and complete recovery from the accident on March 6, 2010, and their approval of the settlement and distribution. 7. The Contingent Fee Agreement signed by Petitioners GLORIA JACKSON and JONATHAN JACKSON entitles Plaintiff's counsel to retain 331/3 % of the gross recovery together with reimbursement of costs. A true and correct copy of the Agreement is attached hereto, made part hereof and marked Exhibit "4". 8. Attached hereto, made part hereof and marked Exhibit "5" is a letter from the Department of Public Welfare confirming it has a lien in the sum of $100.92. 9. All of Minor Plaintiff's medical bills have been paid to date. 10. There are no other fees or deductions which will be made from the above distribution. WHEREFORE, Petitioners request they be entitled to enter into the settlement recited above and that the Court enter an Order of Distribution as follows: 1. Department of Public Welfare $100.92 2. Reiff and Bily, reimbursement of costs $202.73 3. Reiff and Bily, legal fee [33 1/3 % of $4,696.35] $1,565.29 4. Balance to ROMELLO JACKSON, minor, to be placed in a restricted account subject to the restrictions indicated in the attached Order $3.131.06 TOTAL RECOVERY $5,000.00 Respectfully submitted, REIFF D BILY By: Date: 021,' /14 R ymond M. Bily, E re VERIFICATION I, Raymond M. Bily, Esquire, hereby duly sworn according to law, deposes and saws that he is the attorney for the Petitioner and as such is duly authorized to take this Affidavit; and, further, based upon the underlying facts, medical treatment and minor Plaintiff's recovery, he believes the proposed settlement is fair and reasonable and should be accepted. Date: 3- (Vay Ray and M. Bily, Esq VERIFICATION The undersigned, GLORIA JACKSON and JONATHAN JACKSON, are the Petitioners in this action and verify that the statements made in the foregoing Petition to Settle or Compromise Minor's Action are true and correct to the best of their knowledge, information and belief. We understand that false statements made herein are subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsification to authorities. THAN JAC Date:9- REIFF AND BILY By: Raymond M. Bily, Esquire I.D. #44677 1125 Walnut Street Philadelphia, PA 19107 215-246-9000 215-246-9012 GLORIA JACKSON, et al. v. STEPHEN BISCHOF, IV COURT OF COMMON PLEAS CUMBERLAND COUNTY NO. 2011-75-09 CERTIFICATE OF SERVICE I, Raymond B. Bily, Esquire, attorney of record in the above -captioned matter, represent and warrant a true and correct copy of Plaintiff's Petition for Leave to Settle or Compromise Minor's Action was served upon the following via United States First Class Mail, postage pre -paid: Joseph R. D'Annunzio, Esquire Law Office of Joseph R. D'Annunzio 4309 Linglestown Road, Suite 211 Harrisburg, PA 17112 Date :3O$e 'ad!`( By: mond M. Bily, Es A orney for Plaint 's ire Ar , Patient Name: Nus Sta: Hosp Svc: Pt Status: *****Pinnacleg,Aalth Outpatient Facesheet*" rm JACKSON ,ROMELLO Room/Bed: HER ET Pt Type: Patient Info: SSN: 910-03-0193 Address: 715 CUMBERLAND POINT Marital Sts: Fin Class: A Patient Employer Info: Empr Name: CHILD Address: State: Guarantor Name: Address: State: Sex: Zip Cd: Info: JACKSON ,JONATHAN 715 CUMBERLAND POINT, PA Zip Cd: 17055 Guarantor Employer Info: Empr Name: STUDENT Address: State: Zip Cd: Emergency Contact Info: Name: JACKSON ,GLORIA Address: 715 CUMBERLAND COURT State: PA Zip Cd: 17055 Home Phone: 717-458-5126 Insurance Information: Ins Code: 590 Priority: 2 Subscriber: JACKSON ,ROMELLO Group #: Employer: GATEWAY HEALTH PL Ins Code: Subscriber: Group #: Employer: Ins Code: Subscriber: Group #: Employer: Ins Code: Subscriber: Group #: Employer: Adm Date: Adm Dr No: Complaint: X99 Priority: 1 JACKSON ,JOHNATHAN SAFE ATUTO Priority: Priority: 03/06/10 00193 MVA Time: 16:48 Patient No: Med Rec No: Admit Date: Areas: Birthdate: City: State: Phone No: Religion: Occupation: City: Phone: .100237774 910030193 03/06/10 07/18/2006 Age: 3 HARRISBURG PA Zip Cd: 17055 717-458-5126 NPS Race: A Patient Rel: P City: HARRISBURG Phone: 717-458-5126 Occupation: City: Phone: Patient Rel: M City: MECHANICSBURG Work Phone: Description: GATEWAY HEALTH PLAN Policy #: 22653870 Precert #: Description: SAFE AUTO Policy #: 197544395 Precert #: • Description: Policy #: Precert #: Description: Policy #: Precert #: Adm M : INFO FRM PTS FATHER Dr Name: EMERGENCY ROOM ASSOC Source: MAGUIL Resp Party: I hereby ceiAlfy that I have revieweclithc FROM @O2N,ZPPRADF1 information in my file and that I has, medical tre Tient each and every time inictcd: in the ods • • CONSENT FOR TREATMENT — I consent to the rendering of medical care, which may include diagnostic procedures and such medical treatment as my attending or consulting physician considers to be necessary. I also understand that, absent emergency circumstances, no Invasive or experimental procedure will be performed upon me unless or until I have had an opportunity to discuss the procedure with my physician and give informed consent to the procedure. I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may involve risk of injury or even death. I acknowledge that no guarantee has been made to me regarding any examination or treatment in this hospital. PRE -CERTIFICATION REQUIREMENTS —if my insurance company or third party requires pre -certification, then I understand that it is my responsibility to contact them to obtain such certification. EXCEPTION: Medicare. ASSIGNMENT OF INSURANCE BENEFITS — I hereby authorize my Medicare and/or medical insurance benefits payable to me under the terms of my insurance policies to be paid directly to Pinnacle Health Hospitals. If my attending physician and/or other physician associated with him or whom he may designate accepts insurance assignment, then I hereby authorize my Medicare and/or medical insurance benefits to be paid directly to those physicians. I assign any and all legal rights that I have to collect benefits to Pinnacle Health Hospitals: I understand that I am financially responsible for non -covered services, as well as any deductibles, coinsurance or amounts in excess of insurance benefits. I permit a copy of this consent to be used in place of the original. GRIEVANCE APPEAL CONSENT — I hereby authorize Pinnacle Health Hospitals to act on my behalf in requesting a reconsideration of a medical determination made by my managed care plan or utilization review entity regarding my medical care. ADVANCE DIRECTIVES -INPATIENTS ONLY — I understand that Pinnacle Health Hospitals will provide me with written Information regarding my right to make health care treatment decisions in compliance with the Patient Self -Determination Act of 1990. This information will be provided in the Patient Handbook. MEDICARE INPATIENTS ONLY — I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. I acknowledge that I have received a copy of 'An Important Message from Medicare'. My signature acknowledges my receipt of this message from Pinnacle Health and does not waive any of my rights to request a review or make me liable for any payment. I realize that lifetime reserve days are a once lifetime maximum of 60 days. If I should use all of my full days and co-insurance days, I agree to use my lifetime reserve days for any remaining days. PRIVACY NOTICE - I acknowledge that I have received a copy of Pinnacle Health System's Privacy Notice. PERSONAL VALUABLES — Pinnacle Health Hospitals is not responsible for personal items brought to the hospital. A safe is available for valuables such as cash, important documents, credit cards and jewelry that can not be sent home. All 4.-d personal items retained at the bedside are the sole responsibility of the patient TELEPHONE AND TELEVISION - I understand that there is a minimal daily charge per day charge for the availability of 1 telephone (local calls only) and television service as these services are not covered by insurance. This amount will be charged to my home telephone bill of which I am authorized to accept charges and allow the release of only information to the telephone company that is necessary to bill for those services. PATIENT ANONYMITY (Facility Director Opt Out for Patients in the Emergency Department and Those Assigned to an In -House Bed) - I request Pinnacle Health Hospitals to control the knowledge of my identity and presence during this course of care only. I acknowledge that the Pinnacle Health Hospitals Patient Anon ity Policy has been explained to me and that I have been provided with the guidelines. Signature of Patient or L T - epresentative Date Signed SENT MUST BE SI,- D BY THE PATIENT'S LEGAL REPRESENTATIVE IN THE OF A MINOR OR WH' HE PAT . T IS PHYSICALLY OR MENTALLY INCAPACITATED. : u� PIPDate Signed of P: ent or Legal R Printed Name of Legal Representative and Relationship to Patient Patient is unable to sign because: Hospital Representative --Yrt d, PINNACLEHEALTH Hosp tals fl; .) elf SENT FOR TREATMENT Hospital Representative • iii Hi 11111 lUll 11111111 AD1005 Form INV 9790 (04/33) MR (MD) 1111111111111 111111111111111111111111111 MR: `* •030193 CASE: 100237774 JACKSON ,ROMELLO M DATE: 03/06/10 DOB: 07/18/2006 Phi!: AGE: 3 D it \ilF`t.�:�� l.��gy?-•'"`.: I hereby Iver tity that? r'i`ce. r e information- i ; my file treatment and every time initi�:.&:t+ medical �. eat;• each in the e 'orris . 'DIAGNOSED VERIFIED . 1 PROCESSED IF DEPARTMENT Age I Date of Birth 07/18/2006 SSN 910030193 }larrisburg Hospital 111 S. Front St. Harrisburg PA 17101 Sex Date 03/06/10 03/06/10 910030193 /00237774 JACKSON ,ROMELLO M M 07/18/2006 III IIIc 11 II III III III III MDRO NO MDRO Chief Complaint: MVA Police Notified: ❑Yes O No By: Chief Comp: HPI: Location: Quality/Severity Timing/Duration Context: Modifying Factors Assoc Symptoms: ROS: unable to obtain because Const: Psych: EYES: ENT: Resp: CV: GI: GU: MS: Integ: Neuro: Endo: Hem/Lymph: All/Immun: 0 "All other systems negative" 0 See nurse's note - reviewed Hx: Allergies: Primary Care Phys: Dr. Time In ❑ Medical Command Date/Time Accident: III MI Hx, cont: Social: Tobacco: Cb w k.- X"^ -\11:25k "^-\ Livi Com(%\...-LivingSituation "AD r 5QA GU: PE: SpOz Const: Mental Status/Psych: EYES: ENT: Head/Neck: Resp: CV: ETOH: C7 Meds: Medical: Family: cetv\e-- Integ: Neuro: MS: Lymph: ED Course: Test Interpretation: Procedures: T ❑ See nurse's note - reviewed ❑ Time out procedure completed: Patient Identification and procedure confirmed Identified correct side/site: correct position; special equipment and requirements Dx: e CC Minutes: Dictated Service Bed Type Follow -Up Rei rai \Consult 0 Condition on ischdrge 0Admission 023 hr obs 0 Transfer .- ischarge 0 Med/Surg ❑Telemetry ,p,Cripcal Care 0 Psych _ .. Name: Time: Stable !Improved Other 111 E.D. Physician ";.y� � �► Physician's Assistant/ Mid-level Practitioner FORM 531 Ih r111lll1lA11 167 ER Triage Private Physician Resident/Student u Certify that I have MEDICA in%rfation in my file and medical treatment 'rea h r n Ui 8 TRIAGE / PRIMARY NURSE PRIMARY NURSE 0 cc Date: Time: • 8itfabt111'Q '.: CICGOH AcUlty;: 01 . ©2 . 4 i 5 .� �CQ )1 D 1 u i. f, p'. ..I YVf ..... os J/O : a4it.SOi�.j x. • PatientName•il dAfle• $e (k9) ...: .... ... . Vital Signs t.evel.ot Consdousnass Ventilation Circulation Chief Complaint ."ear e+atcg. A4 114. 3 .. ("Acid vt�'lrc�v ua? 7rr .Par Star).' Temp 3ZU ert a�1• ❑Veibal • C7 Pain 0 Unresponsive ,C-1e1W ..I ❑Obstructed L7 Laboredesenf ❑ Non -Labored .. ., CI ❑Intubated UtSos (site) A /0 fzete�' ik10711/4P. egg,—Seco BP: Dr p O absent r ular ❑ i ular e9 � rung 0 weak • coal h .e C C�ic1! .. Pulse: I I0 c r.z'€077 () A f�c a0 Rasp: SPOT: it � tl SYozi : U t I�Ltl p 2, h . OMH:ctSii Ailealill 0 ,1.fYftA 1344reet0l $ 0/41,-1010LOG .. LMP: f,1147A Lactation J/A 0 ❑N Pain Scale: 0 -- 10 TriageNurse'a 1)700 �1cS�tor PRE -HOSPITAL CARE UNIT: LOCi77 4 Mode of Arrival: ' Patient Disposition:# ■ Waiting Room Arriv Suspected Abuse; Adu Chi 0 ALS 0 Wheelchair 0 Ambulatory ❑ Carried 0 Vital Signs BP;, .-- P:i 3a R.LS identified Needs 0 Speaks No English Language. 0 Unusual/suspicious marks 0 Sexual Abuse Loss of Consciousness 0 No ❑Yes Translation By: 0 Domestic Violence 0 Safe Referral Airway 0 Oral 0 Nasal 0 ET Tube Size• IMMUNIZATIONS Oxygen 0 NC Um 0 NRM I/m PSH / Social 0 Suicide Risk Plan TETANUS: Pulse ox RA c Oxygen Childhood 0 UTD 0 Not UTD H,-, , a v, `�`� Heart Rhythm CPR Started 0 No ❑ Yes Time Triage Protocols/ Interventions. Medications,' AED 0 No ❑ Yes Time ��w/vv�t�v e //, ,, n o z)/ A166Dextrostick C ati IV Therapy Gauge Site Solution Mg / dl Medications Administered Pre -hospital Signature of Provider: �f �� j (/ Triage / Primary Nurse: ,4 //y fx3 . Time/e2 C f%Od�` VENTILATION ASYMMETRICAL & UNLABORED oAREA CLEAR LABORED ❑WHEEZING ❑ L ❑ R ❑ RALES/RHONCHI ❑ L ❑ R ❑ DIMINISHED ❑ L ❑ R 0 RETRACTIONS ROCULATION (site') NEURO) (L.ERT pdklENTED 0 DISORIENTED 0 GLASCOW COMA SCALE ❑ HEADACHE 0 STIFF NECK 0 DIZZINESS EMOTIONALjGCOOPERATIVE ��jqA ❑ UNCOOPE TIVE 0 ANXIOUS 0 FLAT AFFECT - 0 AVOIDS EYE CONTACT _ pI JyV ❑BABY 4rr�' fBDOMEN TRAUMA �1f.000� •culjrEr I/tl`+ ❑ABRASION• `h St PAIN 0 DENIES ❑NA GU 0 DENIES ❑1 A 0 RETENTION 0 DYSURIA ❑ �L� GYN 0 DENIES NA 0 VAGINAL BLEEDING 0 NORMAL FLOW ❑ABNORMAL FLOW NURSING DIAGNOSIS ❑INEFFECTIVE AIRWAY CLEARANCE 0 INEFFECTIVE BREATHING PATTERN ❑ IMPAIRED GAS EXCHANGE 0 FLUID VOLUME DEFICIT 0 ALT. BODY TEMP ❑ALT. TISSUE PERIPHERAL / CARDIAC / CEREBRAL 0 IMPAIRED SKIN INTEGRITY 0 PAIN: ACUTE / CHRONIC 0 IMPAIRED MOBILITY ❑INEFFEC 'COPI� r -i_' _.! CO Qua (i Radiatl a(¢ SEVER! -10) Time GI ❑DENIES ca NA ❑ NAUSEA ❑ VOMITING 0 DIARRHEA 0 CONSTIPATION 0 DARK STOOLS 0 N I�SOFT ❑FIRM •❑DISTENDED ❑TENDER. 0 DISCHARGE. ,�P})LSES ,C.1jRESENT 0 ABSENT CJ STRONG 0 WEAK REGULAR 0 IRREGULAR EENT 0 DENIES 514‘ VISUAL ACUITY: ❑CORRECTED ❑ NOT CORRECTED OLP ❑wvo ❑ CAPILLARY REFILL: ❑ <2 SEC ❑ >2 SEC SK PINK ❑ PALE 2rDRY ❑ DIAPHORETIC ❑ CYANOTIC ❑ JAUNDICE OD• ❑LACERATIO U ❑ BOWEL SOUNDS: ❑ PRESENT ❑ ABSENT OS* ❑ ECCHYMOSIS: �,•,. I ❑ EPISTAXIS ❑ R ❑ L ❑ EARACHE ❑ R ❑ L ❑ SORE THROAT ❑ DEFORMITY: I ❑ BURNS. ❑ SEE BODY DIAGRAM (ON BACK) I PRIMARY NURSE SIGNATURE. ` (/ 4-6w/et TIME: PINNACLEHEALTH Hospitals EMERGENCY NURSING ASSESSMENT SHEET II III I1I 11111 110 II 1110 IIIIII Form INV 7482 (02/09) MR (InD) ED2505 IIIII11 III 11111I illVIII Innl MR: ***030193 CASE: 100237774 JACKSON,ROMELLO M DATE: 03/06/10 DOB: 07/18/2006 Ph #: I hereby clartify that�I have kevie`v6§Ethe medical information in my file and that I have received medical treatments the each and every time indicated ANTERIOR LEFT POSTERIOR BODY SITE INJURIES CODE 0 NA A - ABRASION AV - AVULSION B - BURN C - CONTUSION D - DEFORMITY L - LACERATION P - PUNCTURE SW - STAB WOUND S - SWELLING AMP - AMPUTATION s LEFT HAND ANTERIOR POSTERIOR RIGHT HAND ANTERIOR GLASCOW COMA SCALE EYE OPEN 4 - SPONTANEOUS 3 - TO SPEECH 2- TO PAIN 1•NONE PUPIL SIZE R - REACTIVE S - SLUGGISH N - NONREACTIVE POSTERIOR BEST MOTOR RESP. 6 - OBEYS COMMAND 5 - LOCALIZES PAIN 4 - WITHDRAWS 3 - ABN,FLEXION 2 - ABN EXTENSION • 1 - NONE 1 2 3 4 $ 8 BEST VERBAL RESP. 5 - ORIENTED 4 - CONFUSED 3 - INAPP WORDS 2- INCOMP SOUNDS 1,- NONE 7 8 8 .....•s • • I iti., herebV cer:{#<<-,• s,;; < ja .. information in my ilii -).and that rEl medical treatment each and tt me itPr, the records Patient Name* Patient S S #• Page • of Procedures Medications CI ECG0 Labs* 0 UA' DATWIME DR DOSE ROUTE SITE INIT rt X -Ray: CI 8Cx2 BC1: BC2: I it rri rin 11 S` 'RD kV 0 CT: C3 uis: 0 ABS* IVSolutions.. . OATE(I1ME SrrESIZE SOLUTION / VOLUME RATE INIT • at' .• :, .. . • . • .. . •.• • . • . • . , . Date/Time BP P R Sp02 02 1 —O Pain (0. 10) Narrative , n/- Vt€t 95 4r t-.941 + C011 Cg 5?. il--- ' - s. . ik ai4 in , , , , ,.. en atour_P ,36.i, "t' CA '0' 66 0 (.4.4y..601 0 ,--..5 /'-, .... , _ rear' Air -14 • df 41 Of ' 4 -.. - IA) • .• P -X hr.c.114,1 / . . . f c c—e--.S. 4 caL GL) C4-4/ OW 61-r t r7/04C• (rein 1,9 tticlijO • ( A Cu' .ct-cmi) /,4.3C....1) //livt.0/0 i A 1o., el /1c1c Mt—Judi / ac(ct • Pi e:4e/ 126...0 sn-ia_a abro.c3/em I) /ed -1.41... / (.0 e,/1.4 A_ Sky) (2L&. 0.1...t. c... cie, II IA -I-4" -...gwe I 0)CjL4j> a - _I I V, C kV) X .-? . (I) trio 44..0.441.A P -- Tbic '7) ad._ ,- e...tvx c.. in ./.. Cl— e,S. . 4 . I S3 . II, 0.4, ILdli. ' Fi— • • 40 t\OCY).refi- C ni \ ci-v— . ..iimpirir P J180 tz crvi-A. iA) t,•• /IP [4j/21/w/ 14VGi_0' - Admitted Disposition Assessment ,_ , Ini la's / S,gnature 0 Admit 0 23° hr OBS Time:_ B/P:._ P: R if aim' , -. ,-... Attending: Pain: (0 - 10) Sp02. Bed #: 0 Discharged 0 Transferred Report called by. (see Transfer form) To: Time. In the care of To Bed. Monitor 0 Yes 0 No 0 Pt/Pamily verbalized understanding of O/C Instructions Mode: 0 W/C 0 0 Written Instructions given by: Stretcher Advanced Directives Discussed 0 Mode: 0 Ambulatory 0 W/C 0 Helicopter Copy available 0 0 EMS 0 Carried 0 Crutches RN RN 4, Pi NNACLEHEALTH Hospitals 11 Form INV 7483 (02/09) MR (IMI) 11 111 EMERGENCY NURSING FLOW SHEET CONTINUATION 11111111111 ED2505 11111 111111111111311118 - MR: ** *030193 CASE: 100237774 JACKSON ,ROMELLO M - DATE: 03/06/10008: 07/78/2006 erebY CSO,i 1t reviewEmihcbrnedc;,:t Phil. thahave . i Tiorrnatioli;A,rghfite and that have recevved medical t eatn ent (rMinllritlitioretiyiftime tU in the re Urinalysis Reference Ranges: Protein Negative Glucose Negative Bilirubin Negative • Ketones Negative Blood Negative Nitrates Negative Leukocytes • • Negative Urobilinogen Normal pH 5.0-8.0 Specific Gravity 1.003-1.030 Blood Glucose Monitor Reference .Range:. 74-118 mg/di.: Troponin I Reference Range: <0.03 ng/mL - 0.49 ng/mL I hereby certify that I have reviewed the medical information in my file and that I have received i medical treati ,ant each and every time indicated in the recd !s • Page Procedures Medications CI ECG: 0 Labs: 0 UA: DATE/TIME DRUG DOSE ROUTE SITE INIT s 0 0 X -Ray: BCx2 BC): BC2: DCT 0(115: 0 AS& IV Solutions . • . DATE/TIME SITE SIZE SOLUTION/VOLUME RATE INIT war . .• • : -.. . . Date/Time BP P R Sp03 0, I 0 Pain (0- 10) Narrative .. / 75;- — /JAI $ /at A. ft.ow A4(y(j- A tMO 'kUh• .. • • ..... ' ..._:.4... , kno__.... arra: „..,,,..." ,,,, // „------- I- .--------1 1 ,------- .-------- ,------] ,------ ir Admitted ssment Initials • : • e 0 Admit 0 23° hr OBS ,4__Dispositio • Time:ffill. B/P: • .40'40. / /,,, P, t er e 7 1 Attending: Pain: (0 - 10) Sp02.ik (/‘ W,1!"/ ( 7,10' 9 Bed ar 'ged 0 Transferred Report called by. (see Transfer form) To: Time' In the re of M044 3 To Bed' Monitor t/ lized understanding of 0 Yes 0 No Mode: 0 W/C 0 Stretcher DM Instructions ajrucio ' • Advanced Directives Discussed 0 Copy available 0 RN Mode:,2-A-mbulatory 0 W/C 0 Helicopter 0 EMS 0 Carried 0 Crutches RN EMERGENCY NURSING 41> PINNACLEHEALTHFLOW SHEET 11(4Puals CONTINUATION Ill 0 Ill 11110111PM Form INV 7483 (02/09) MR E02505 onD) INIMINEN i Ii A MR: "030193 CASE: 100237774 JACKSON ,ROMELLO M M DATE: 03/06/10 DOB: t8/2OO Phil: DR:A‘f.Aa- -At hereb that t have reviewed tho information in my file and that Jwip media treatment each and ovafy e 00;4' Urinalysis Reference Ranges: Protein Negative Glucose Negative Bilirubin Negative Ketones Negative Blood Negative Nitrates • Negative Leukocytes Negative Urobillnogen Normal pH 5.0-8.0 Specific Gravity . 1.003-1.030 Blood Glucose Monitor Reference Range: 74-118 mg/dL Troponin I•Reference Range:. <0.03 ng/mL - 0.49 ng/mL • 1 hereby eby ce'i tify that 1 havereviewed the a information n !n my 'e and < that y, 4 j havehave medical t(oatme ' , every le incii.,i4d. e records • arrisburg ED 782-3297 Please note that the instructions circled or checked below pertain to you. �` You have been discharged with the diagnosis of t L) ((�f'y ( T I 1,,r, ` The examination and treatment you have received in the Emergency Department have been rendered on an emergency basis, and not intended to be a substitute for ongoing care provided by a primary care physician or specialist. Not all of your medical problems may be known, diagnosed and/or treated at this visit. It is important for you to follow up with your physician and to return to the Emergency Department if you become worse in any way. General Instructions Rest for Off work / school from to Return to work on Light duty for Regular duty urn to the Emergency Department immediately if expectedly worse or not improved. 2. Emergency Department on 3. Family Physician 4. See Dr. at 5. Call the following clinic within one business day for to be seen in _day(s): _Hamilton Health Center, 1821 Fulton Street Community Health Center: _Children & Teen Center, 2nd Fl _Women's Outpatient, 3rd Fl Kline Health Center, Landis Bldg. 2nd Floor: _Adult Outpatient Clinic _Orthopedic Clinic _Surgical Clinic Kline Family Practice Center on AM / PM. an appointment Supplemental Instruction��AA��ww ` Sheet O Medication(s) 00.1 U (4 Ot15 II ❑ Caution 232-9971 782-4650 782-4700 782-6421 782-2142 782-6421 782-2100 6. If you smoke you are advised to stop. Please call 717-221-6250 or access www.pinnaclehealth.org for more information on smoking cessation. X -Ray Instructions • Radiology Studies - Including plain X-rays, CT/MRI Scans and Ultrasounds. Your Radiology Studies have been reviewed by an Emergency Physician, Physician's Assistant or Radiologist. A final Radiologist's interpretation will be reported and you or your doctor will be notified of any abnormalities which require follow-up. • PINNACLEHEALTH Hospitals Emergency Department Patient Instruction Sheet i E02507 Form INV 29001 (12!08) MR (PMI 11111 neous - Medications may cause drowsiness. - No alcoholic beverages. - Do not drive, operate machines, or perform risk taking activities. I hereby acknowledge receipt of these Instructions, I will arrange for follow-up care as I have been instructed. I will take the medication lis to my physician. 'o atlent or Respons :le Person t4/6 ate Discharge atient From Emergency Department. R. . Signature rgna re PI NNACLEHEALTH Hospitals Emergency Dbpart P.O. Box 8700 Harrisburg, PA 17105- ment 00 OR/ Date Harrisburg - 782- QUAL/]'v • 2 • Substitution Permissible , M.D., D.O. IN ORDER FOR A BRAND NAME PR WRITE "BRAND NECESSARY" •- 11 CT TO BE 01$PENSED. BRAND MEDICALLY NECES E PRESCRIBER MUST Y" IN THIS SPACE ES MAY REFILL PAUca DEA No PRINT LABEL A Firat copy - Patient PHYSICI r,1:'t1':Ir 1110111111311111 MR: * **0301 93 CASE: 100237774 '\ M V JACKSON ,ROMELLO M y cer l f -ilq dRAtte re\/le.\P = WfrA, ,a L PRESCRIPTICINtOrrnatiOn in Amy the and that + E`1`a,AtL ;3'i..f each and every time in the re -,D RORD ti 3l' OR' 4-4*//1 Second copy • Medical R-� Third co — �/ Date Time LEVEL OF INTENSITY (LOI): (Please complete a Level of Intensity Order Form for any 101 Il -V) Allergies: • Procedures Supplies ❑cardiac Monitor ONasogastric tube OFoley Catheter OStraight Catheter ❑IV: 002 LPM ❑Pulse Oximetry ❑Non-invasive COHbg OPeak Flow ❑Neb Treatment: Lab Time: ❑ ABG ❑ Acetone ❑ Amylase ❑ ALT/AST ❑ Ammonia ❑ BMP ❑ Cardiac ❑ BNP ❑ CK - Total ❑ CK - MB ❑ CK - Index 0 Troponin I ❑ CBC w/auto diff ❑ COHbg ❑ Comp Met Panel ❑ CRP ❑ D -Dimer (DVT) ❑ Electrolytes ❑ ETON Initials: ❑ G1 0 Hepatic Panel O H&H ❑ Lactic Acid ❑ Lipase ❑ Magnesium ❑ Myoglobin ❑ PT/INR ❑ PTT ❑ Qual HCG ❑ Quant HCG p Rpt Cardiac ❑ CK - Total ❑CK - MB 0 CK - Index ❑ Troponin I ❑ TSH N.5 Sed rate rinalysis S Drug Levels ❑ Acetaminophen ❑ Aspirin ❑ Carbamazepine ❑ Digoxin ❑ Lithium ❑ Phenobarbital ❑ Phenytoin ❑ Theophylline ❑ Urine Tox. ❑ Valproic acid Blood Bank ❑ Type & Cross ❑ Type & Screen ❑ Rh Factor Cultures ❑ Blood x ❑ Chlamydia ❑ GC ❑ GC/Chlamydia (gene amp) ❑ erpes ❑ Sputum ❑ Stool ❑ Stool - C -diff ❑ Throat/strep ❑ Urine ❑ Wound: Bedside Testing ❑ BGM ❑ PT/INR ❑ CG4+ 0 Qual HCG (urine ❑ Chem 8+ 0 Troponin I } AMI Orders CHF Orders Acute Stroke Orders If ST Elevation MI 0 Thrombolysis (Order sheet) 0 STAT Cardiology Consult with (PreCath orders) ASA 325 mg po 0 STAT, D Given PreHospital, 0 Taken at Home Beta Blocker 0 Metoprolol mg IV q_ minutes X 3 (do not give if BP< and/or HR< ). 0 Metoprolol _mg po D Carvedilol mg po (if EF anticipated to be under 40%) Diuretic: D Furosemide mg IVP, 0 Bumetanide mg EVP If urine output <200mL within 30 minutes consider redosing IV Vasodilating Agent: 0 Nitroglycerin mcglmin IV ❑ Vital Signs q 15 minutes 0 IV: 0.9 NSS @ 50 mUhour 0 BGM ❑ Strict NPO until dysphagia evaluation ❑ Aspirin 300mg PR x 1 dose ❑ Notify physician if: SBP >180, DSP >105, change in neuro status. ❑ Stroke Alert Team called @ Time: Time dditional Orders: Radiolo y, Time Initials: Portab e -r -spine ❑CXR ❑Pelvis Spine:D C ❑ T ❑ US ❑ Ankle L R ❑ CXR ❑ Elbow L R ❑ Facial ❑ Femur L R ❑ Finger L R ❑ Foot L R ❑ Forearm L R ❑ Hand L R ❑ Hip L R ❑ Humerus L R ❑ Nasal ❑ Knee L R ❑ KUB O Ob Series ❑ Pelvis ❑ Ribs L R D Shoulder L R 0 Skull ❑ Tib/Fib L R ❑ Wrist L R Symptom: ❑ U : ❑ Venous Doppler: ❑ MRI: ❑ V -Q Scan ❑ Other: Physician's signature: • I • 4, PINNACLEHEALTH Hospitals EMERGENCY DEPARTMENT PHYSICIAN'S ORDERS Form INV 30747 (08108) MR MD) u� E02502 n 111111111111 Patient Identification 111111111111111111111111111111111111111111111111111 MR: * * *030193 CASE: 100237774 JACKSON , ROMELL O M M I herebM6/1 0O :07/18/2006 ,dic itif4 1 is have re�„ietru�d e rrt.. <1 inforrn it in my file and that" av received medical eatr -nt each and every time indicated he record ACCT#=00100237774 • PinnacleHealth System P.O. Box 8700 Harrisburg, PA 17105-8700 EMERGENCY DEPARTMENT TRAT,'.c.CRIBED DATE=03/09/2010 07:,'.?., UDN= 2834354 JACKSd. ROMELLO M RM#: MRN: 910-03-0193 CASE: 00100237774 DOB: 07/18/2006 ADM: 03/06/2010 CHIEF COMPLAINT: Motor vehicle crash. HISTORY OF PRESENT ILLNESS: Three-year-old male who was apparently restrained in his car seat, but the car seat was not restrained. The patient apparently was in the back seat, and when they were rear-ended on the driver's back side, the patient apparently flew from the back seat to the very, very back of the van. Dad states no loss of consciousness. The patient complains of facial pain only. REVIEW OF SYSTEMS: Other than integumentary for the facial swelling, as well as a small abrasion across the cheek, unless otherwise stated in this report or unable to obtain because of the patient's clinical or mental status as evidenced by the medical record, the patient's positive and negative responses for review of systems for the constitutional, eyes, ENT, cardiovascular, respiratory, gastrointestinal, neurological, genitourinary, and musculoskeletal systems and related systems to the presenting problems are either stated in the HPI or were not pertinent or were negative for the symptoms and/or complaints related to the presenting medical problem. 4 PAST HISTORY: The patient's primary care physician is at Hershey Medical Center, Dr. Mark Widome. THE PATIENT HAS NO KNOWN DRUG ALLERGIES. Medications include albuterol and Flovent. Past medical history is significant for asthma. SOCIAL HISTORY: The dad does smoke. The patient does not go to daycare PHYSICAL EXAMINATION: Vital signs: Temperature of 37; pulse of 116; respirations 30. 02 saturations are 100% on room air. Constitutional: Alert, very well -appearing toddler who is on a long spine board and C-collar; otherwise, in no apparent distress. Mental status/Psychiatric: He seems to be very alert and acting appropriately. HEENT: Pupils equal and reactive to light. Extraocular movements intact. The nose and throat are clear. TMs are clear bilaterally. The rest of the facial contusions will be described in the integumentary portion. Cardiovascular: No murmurs or gallops. Heart sounds normal. Respiratory: Clear to auscultation and percussion. Gastrointestinal: No masses or tenderness. No hepatosplenomegaly. Integumentary: He does have a small hematoma on the left forehead, as well as minimal ecchymosis. The patient also has a linear abrasion going across his left cheek with some swelling of the left cheek as well. However, the patient, again, for the HEENT, can open his mouth without any difficulty. Neurologic: He seems to move all extremities with no focal deficits. EMERGENCY DEPARTMENT PHYSICIAN TEST INTERPRETATION: We did do a CT of the,. head and face, which showed no intracranial bleed, as well as n e ,�s44tx re`s`, of the skull or of the facial bones.CE'4!{ YiC r t y voni rnyr file and G rolca ,ie Medica EMERGENCY DEPARTMENT COURSE: For his emergen�i';c �[i1�c',.ib`b'r�C; I did 1;l the clinically clear him off the,,v ong spine board and C-co114.,. We did give him ice to- the face, Motrin 175 ,7-' po, and we cleaned the f '' � with some bacitracin applied to the area. DISPOSITION: The patient, at this time, was walking around, did not seem to be in any pain at all, and was discharged to the care of his parents. They were given a supplemental sheet regarding the head, the facial contusion, and told to follow up with their primary care physician and return to the ED for any worsening of symptoms. They can use Motrin over the counter for any pain. DIAGNOSTIC IMPRESSION: 1. Facial contusion. 2. Status post motor vehicle crash. They are to use ice to the area .for the next 24-48 hours on the left side of the face. The rest of the family was discharged with the patient. Patient: JACKSON, ROMELLO c: Signed by DUNHAM MD, ELEANOR on 15 -Mar -2010 01:34:05 -0400 ELEANOR F. DUNHAM, MD DD: 03/06/2010 2834354 ER REPORT ER REPORT DT: 03/09/2010 /tm /jlmi D#: ER REPORT tbe ds .n F R v.....,. t"^J.'. r pylon-Fcc.,;"•••• ,•,' - w"nn w+le Tc. 'w,' • Abdominal Pain Contact your physician If any of the following occur: 1. Pain becomes severe or steady. 2. Vomiting persists. 3. Blood appears in vomitus, stool, or urine. 4. Shaking chills or high fever. 5. Abdomen swells. 6. Constipation or diarrhea. 7. Failure to improve as expected. ▪ -LT- r Supple ntai Instructions • Burns 1. Keep injured area elevated. 2. Change dressing only if instructed to do so. 3. Leave blisters alone. 4. Return to ED if signs of infection appear. (Signs are listed under #3 of "Lacerations, Abrasions, Punctures".) 5. Take any prescribed medications es prescribed. 6. Return for wound check as instructed. Culture Results You will be contacted only if test results indicate that you need additional or different treatment. You will not be called if the test is negative or your current treatment Is adequate. Your physician may obtain results by calling the hospital. Lab results will be given only to your physician. D0 NOT call the Lab for results. �Hcad Injury �,; our dans have found no evidence at this time of serious injury and .t rdo not feel that hospital admission is necessary. However, conditions may change within the next 12 to24 hours (or even longer). Please contact this hospital immediately if any of the following occur: 1. Mental confusion 2. Difficulty In arousing. (The patient should be awakened every 2 hours • during the first night.) 3.. Persistent, repeated vomiting (once or twice is not uncommon). 4. Severe. continued headache. 5. Stiffness of neck. fever. 6. Trouble with speech, balance, vision, weakness of either arm or leg. 7. Bloody or clear fluid dripping from the ear or nose. 8. Convulsions (fits or seizures). Tetanus 1. If you were given a tetanus toxoid Injection while you were to the Emergency Department, make a note of it. 2. It Is normal for the arm to be sore or a slight amount of redness to be present at the sight. 400. 4 i`�3. You may run a low grade fever for the next day. : if a more severe reaction occurs, see your physician or Emergency Department Lacers ons, Abrasions,..Punctures d areas 8i'tlre Iss" ng should be kept clean and dry for 48 hours. Keep sutured area elevated. _ If continuous seepage, pain, fever, swelling, or redness of wound occurs, physician attention will be necessary. _ Ice pack to affected areas – on 20 minutes, off 10 minutes for 24 to 48 hours. Continue as needed to reduce swelling. _ If blood or medication soaks through dressing, call physician. _ Have sutures removed by physician in days. l:.i. Eye, Ear, Nose, Mouth Instructions .1. — Warm/cool compressions over eye(s) most of the day. • Wear eye patch until _ Avoid bright lights, TV, reading for hours. - 00 NOT drive if eye Is patched and be careful when walking down steps and using sharp instruments. - If bleeding occurs through nasal pack, call your physician. Small ice pack to nose – on 20 minutes, off 10 minutes until most of the swelling has subsided. _ Rest. _ Liquid diet for days. _ Rinse with mouthwash or warm water after each meal and at bed time.. Medical Diet _ force fluids _ soft diet clear liquids _ as tolerated No milk or dairy products for hours. Liquid diet (soups, jello, clear liquids). Sweetened tea, gingerate, or diluted juice may be given as ounces every -- hours for the next hours. Begin weakened formula when stools have improved and diarrhea has subsided. _ When stools have become formed, a gradual return to full strength formula or diet may be attempted. _ If diarrhea is persistent or excessive, call your physician or Emergency Department. _ No fried or spiced or greasy foods. _ No alcoholic beverages. No coffee except decaffeinated. Fever Give tepid bath to help reduce fever. - If fever cannot be controlled after use of Tylenol and tepid bath, call your physician or Emergency Department. Splint Care _ Elevate affected part on pillow. - Apply ice bag x 24 hours. Follow medications and follow-up care Instructions. Sprains and Bruises Elevate affected part on pillow and rest. - Ice pack on affected part – 20 minutes on. 10 minutes off. Do for 24 to 48 hours. - Wear ace wrap for . Rewrap daily. - Use crutches for days. _ Begin to bear weight on day. _ If affected part becomes blue, cold. white, numb, or swollen or painful, return to the Emergency Department. _ Wear sling for days. Use splint for days. - Use warm packs for 30 minutes at a time every hours. POOR QUALITY ORIGINAL PINNACLEHELTH 111111110110111111011111111111111111 Emergency Department Supplemental Instructions Fan NV54424ID'U04)MR bmayav42-11(PM) First copy - Patient IIIIIIInIUII Patient Information IIIII IIII IIII iiIIl llll! IIJHll1 MR: ***030193 CASE: 100237774 JACKSON ,ROMELLO M M DATE: 03/06/10 DOB: 07/18/2006 1 harebyp * fy that I have revietAt qht-- inecRea1 intorrrtd-ion in my file and that, Secondfif44W i Ill r c c'i V in the re,- -ds 03/09/2'010 23:46 PinnacleHealth Hospitals James A. Piper, M.D., Medical Director Harrisburg, PA Phone: (717)782-5564 Fax: (717)782-5958 H# : 910030193 Name: JACKSON,ROMELLO M Acct: 100237774 Phys. 1: EMERGENCY ROOM ASSOCIATES Phys. 3: TEST: UNITS: LO -HI: Page 1 Loc : HER BD/Age: 07/18/2006 3Y Sex: M Admit: 03/06/2010 Discharge: 03/09/2010 ********************** Urinalysis - Macroscopic ************** Color Appearance Specific Glucose Bilirubin Acetone Gravity ******** Occult Blood 1.003- NEG NEG NEG NEG 1.030 03/06/10 R1726 YELLOW CLEAR 1.015 NEGATIVE NEGATIVE NEGATIVE NEGATIVE TEST: UNITS: LO -HI: Urinalysis - Macroscopic pH Albumin Urobilinogen Nitrates Leukocyte Esterase E.U. 5.0-8.0 NEG NORM NEG NEG 03/06/10 R1726 7.5 NEGATIVE NORMAL NEGATIVE NEGATIVE OP Medical Records Copy Final END OF REPORT hereby certify that I have reviewed the medical information in my file and that I have received. medic:as treatment n;.ch and Viae-t?ry time ?if.rfica tPc.i P1NNACLEHEALTH System Radiology Imaging Report MR#: 910030193 SSN: 910030193 ADM: 000100237774 DOB: 07/18/2006 AGE: 3Y BED: HER- PTCLASS: E HER NAME: JACKSON, ROMELLO 715 CUMBERLAND POINT CIR HARRISBURG, PA 170555493 ORD DR: DUNHAM, ELEANOR F ORD#: 90001 ATT DR: EMERGENCY ROOM, ASSOCIATES PCP: WIDOME, MARK REASON: Trauma COMMENTS: MVA R/O FX PROCEDURE: CTS - PROCEDURE DATE: ***Final Report*** HARRISBURG CT DEPARTMENT 0486 - CT MAXOFACIAL W/O CONTRAST 70486 Mar 6 2010 5:48PM ACCESSION#: 6428736 EXAM: CT brain without contrast. History: Trauma Comparison: None. Results: Multiple axial images were obtained from base to vertex without intravenous contrast. There is no evidence of hydrocephalus. There is no evidence of intracranial hemorrhage. There is no evidence of a mass lesion or major arterial distribution infarction. No focal abnormalities of density are identified within the brain. The skull is unremarkable. The visualized portions of the paranasal sinuses are unremarkable. Miscellaneous: None IMPRESSION: Unremarkable CT of the brain. Exam: CT facial bones, axial with sagittal and coronal reformations History: Trauma Comparison: None. Results: There is no evidence of fracture of the facial bones. The paranasal sinuses are well-aerated and unremarkable in appearance. There is an incidental small retention cyst in the right maxillary sinus There is no evidence of a soft tissue mass. The laryngeal structures are unremarkable. 1 hereby certify that 1 have revi,;,{,.d.::. information in my file and that medical treaten 1:,ach and �e.A Qin/ .0 the leQ Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at: 1-717-782-3240. Printed: March 6, 2010 6:18 PM PINNACLEHEALTH System Radiology Imaging Report MR#: 910030193 SSN: 910030193 ADM: 000100237774 DOB: 07/18/2006 AGE: 3Y BED: HER- PTCLASS: E HER NAME: JACKSON, ROMELLO 715 CUMBERLAND POINT CIR HARRISBURG, PA 170555493 ORD DR: DUNHAM, ELEANOR F ORD#: 90001 ATT DR: EMERGENCY ROOM, ASSOCIATES PCP: WIDOME, MARK REASON: Trauma COMMENTS: MVA R/O FX Miscellaneous: None Unremarkable CT examination of the facial bones. DICTATED: (03/06/2010 06:06PM) TRANS: (QITA) ON: 03/06/2010 18:07 INTERPRETED AND REVIEWED BY: CHARLES B AUSTIN, M.D. ELECTRONICALLY SIGNED: 03/06/2010 18:07 In the event of any questions regarding this report, a Quantum Radiologist can be reached by phone at 932-8030. t\ -e rr'�: a,,ie tev\e\, teck kk fre fed eert�fy ��,at�ile and trial. %,Erle ita;t x �1etf3�y infosnai;ea 1t1 nt eado and F ;1 P,C�t� 2� treaifilP,�``•`R be cecotd 1/ Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at: 1-717-782-3240. Printed: March 6, 2010 6:18 PM PINNACLEHEALTH System Radiology Imaging Report MR#: 910030193 SSN: 910030193 ADM: 000100237774 DOB: 07/18/2006 AGE: 3Y BED: HER- PTCLASS: E HER NAME: JACKSON, ROMELLO 715 CUMBERLAND POINT CIR HARRISBURG, PA 170555493 ORD DR: DUNHAM, ELEANOR F ORD#: 90002 ATT DR: EMERGENCY ROOM, ASSOCIATES PCP: WIDOME, MARK REASON: Trauma COMMENTS: er core 19 RIO FX _ ICB ***Final Report*** HARRISBURG CT DEPARTMENT PROCEDURE: CTS - 0450 - CT BRAIN W/O CONTRAST 70450 PROCEDURE DATE: Mar 6 2010 5:48PM ACCESSION#: 6428745 EXAM: CT brain without contrast. History: Trauma Comparison: None. Results: Multiple axial images were obtained from base to vertex without intravenous contrast. There is no evidence of hydrocephalus. There is no evidence of intracranial hemorrhage. There is no evidence of a mass lesion or major arterial distribution infarction. No focal abnormalities of density are identified within the brain. The skull is unremarkable. The visualized portions of the paranasal sinuses are unremarkable. Miscellaneous: None IMPRESSION: Unremarkable CT of the brain. .. ;i to Lc', Exam: CT facial bones, axial with sagittal and coronal reformations �,r, fc�vit' �p 5'v+E41� it (3 \ Vie, : t �, :. ned\cat medic it �o 'ill 111V and tia. , �}-tics c History: Trauma 2' Oe end ,rim t �teC Zo\ tre r lack l end is .. oto �\ tte�iC�' ` i g / Mir 1 Comparison: None. Results: There is no evidence of fracture of the facial bones. The paranasal sinuses are well-aerated and unremarkable in appearance. T ere is an incidental small retention cyst in the right maxillary sinus There is no evidence of a soft tissue mass. The laryngeal structures are unremarkable. Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at: 1-717-782-3240. Printed: March 6, 2010 6:18 PM PINNACLEHEALTH System MR#: SSN: ADM: DOB: 910030193 910030193 000100237774 07/18/2006 AGE: 3Y BED: HER- PTCLASS: E HER Radiology Imaging Report NAME: JACKSON, ROMELLO 715 CUMBERLAND POINT CIR HARRISBURG, PA 170555493 ORD DR: DUNHAM, ELEANOR F ORD#: 90002 ATT DR: EMERGENCY ROOM, ASSOCIATES PCP: WIDOME, MARK REASON: Trauma COMMENTS: er core 19 R/O FX ICB Miscellaneous: None Unremarkable CT examination of the facial bones. DICTATED: (03/06/2010 06:06PM) TRANS: (QITA) ON: 03/06/2010 18:07 INTERPRETED AND REVIEWED BY: CHARLES B AUSTIN, M.D. ELECTRONICALLY SIGNED: 03/06/2010 18:07 In the event of any questions regarding this report, a Quantum Radiologist can be reached by phone at 932-8030. Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at: 1-717-782-3240. Printed: March 6, 2010 6:18 PM 1- Patient's Name: Date Of Injury: Claim #: Treating Doctor: Date Of This Report: PERSONAL INJURY FINAL REPORT Gerhart Family Chiropractic 303 South 32nd Street Camp Hill PA 17011 (717)761-CARE(2273) Romello M. J. Jackson March 6, 2010 489401 Dr. David W. Gerhart August 23, 2010 Current Diagnosis: Initial hyperextension/hyper flexion sprain/strain injuries of cervocthoracic soft tissues, etc. Patient now suffers from residuals subsequent to the fibrosis of repair process of once damaged soft tissues. Present Condition: Patient's condition has reached a point of maximum medical improvement. He continues to have periodic flare-ups of the neck with stiffness at times of increased use and or stress. Future Treatment Plan: Continue to treat patient on an "as need" basis subsequent to flare-ups of his condition at times of increased use or stress. Prognosis: As the patient's condition has reached a point of maximum medical improvement, no additional subjective and objective improvement can be expected with continued regularly scheduled treatment. Therefore, the subjective and objective residuals noted must be considered to be permanent effects of the injuries sustained in this accident. These residuals create a need for future treatment for palliative purposes. We will use this boy's requirements for "as need" care as the basis for determining his future care. Signed:/(9,, 1 hereby certify that } bave ev; i information in my tileand ta 2t'nave ;ife3 t�<i<:U d m6CiCu1 tr:t each `every VERIFICATION The undersigned, Petitioners GLORIA JACKSON and JONATHAN JACKSON, hereby represent and warrant that they are the parents, natural guardians of Minor Plaintiff, ROMELLO JACKSON, who resides with them. The undersigned verify that Minor Plaintiff, ROMELLO JACKSON, has recovered from his injuries. Accordingly, Petitioners believe it is in their son's best interest to accept the settlement offer of Five Thousand ($5,000.00) Dollars. The undersigned also approve the distribution in the within Petition. Petitioners understand the statements made in this Petition are true and correct and are subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsifications to authorities. ATHAN JAC D.te:9/ N 4 Jeffrey M. Reiff & Associates P.C. The Beasley Building 1125 Walnut Street 3`d Floor Philadelphia Pa. 19107-4918 I (we) hereby constitute and appoint Jeffrey M Reiff & Associates P.0 .as my (our) attorneys in my/our claim for damages against or any other person, firm or corporation or entity liable for those damages, which damages resulted from any injury or breach of contract that occurred on 3 ' (�1 . l(we) do not wish to compensate my/our attorney on an hourly basis or on any type of retainer agreement, but, on the contrary wish that he and his entire law firm work on my behalf and advance legal costs and expenses on my behalf. As compensation for their services rendered and to be rendered I agree to pay my/our attorneys from the total gross proceeds of the recovery a percentage of any and all amounts recovered from the party or parties responsible for the injuries or damages sustained by the client. Such percentage to be received by the attorney shall be computed as follows: forty percent (40%) if the case is settled without suit: forty-five percent (45%) after commencement of any legal action: fifty percent (50%) after the commencement of a trial or on filing an appeal from a final judgment made and entered thereon. Attorney's fees shall be figured on the total gross recovery or settlement. It is further agreed that the client shall be responsible from their portion of the recovery for all court costs, costs for investigation, experts, subpoenas, photographs, depositions, court reporter fees, reports, postage, photocopying, supplies, long distance calls, travel, parking, witness statements, computerized research and any and all other expenses directly incurred in the investigation or litigation of this claim. Client agrees that attorney may borrow funds from a commercial bank to finance or pay such court costs and all other expenses and charge client reasonable interest to be added to all costs. In some instances the fee may be regulated by lawful statute. If so all parties agree to be bound thereby. If a structured settlement is reached, the firm's fee is due and payable at the time of the settlement and is computed on the basis of present value. It is further agreed that all medical bills will be charged to and against the clients share. I/we authorize my/our attorneys to pay all bills for medical and hospital treatments from the proceeds of any settlement or verdict for services made necessary by the injuries sustained in the above mentioned accident. In the event that no money is recovered in this case the client shall not be responsible for any legal fees incurred as a result. It is understood that my/our attorney may employ experts and investigators. It is agreed and understood that this employment is upon a contingent fee basis and if no recovery is made I/we will not be indebted to my/our attorney for any sum whatsoever as attorneys fees. For the purpose of this litigation only my attorneys are authorized to negotiate, endorse, deposit and distribute any checks received from the defendant insurance carrier on my behalf. In the event that my/our attorney has committed to the prosecution of my/our case and I then make a determination to discontinue the case or retain another attorney the client shall immediately pay all costs and expenses incurred by the attorneys and in addition shall pay the attorneys the reasonable value of their services performed to date billable at an hourly rate of $395.00 per hour or the appropriate percentage of the last settlement offer which ever is greater. The client hereby grants to the law firm an irrevocable first lien on any recovery in the amount of the legal fee calculated pursuant to the above referenced percentage formula. This agreement is only for services rendered on behalf of the client in this claim for damages. The attorney may charge the client additional fees for any and all other legal matters handled by the above firm which are not directly related to this case which will be billed separately. The client agrees that Uwe will not receive any advances or loans on the case and agree not to request same from the above office. Attorneys may, at their own expense use or associate with other attorneys in the representation of the aforementioned claims. Client agrees to the referral of client's case to other attorneys, if necessary and the payment of a referral fee to the firm. Client agrees to sign any additional documents to facilitate the association of the other firm in accepting client's case representation. Attorney and the other firm will share the attorneys fees specified herein and will agree among themselves as to the division of said attorneys fee which will not exceed the percentage stated herein. Client agrees to cooperate with attorneys at all times and to comply with all reasonable requests by attorneys. Client further agrees to keep attorneys advised of their whereabouts at all times, and to 'provide attorneys with any change of address, phone number, business affiliations or change of marital status.. It is understood and agreed that the attorneys cannot warrant or guarantee the outcome of the case and attorneys have not represented to the client that the client will recover all or any of the funds desired, Client realizes that attorneys will be investigating the law and facts applicable to the claim on a continuing basis and should attorneys learn something which in the opinion of the attorneys makes it impractical for them to proceed with the claim, then the attorneys may withdraw from further representation of client by sending written notice to clients last known address. If client makes any material misrepresentation to attorney then attorney shall have an immediate right to cease legal representation and hold client accountable for any and all costs advanced including but not limited to fees calculated at $395.00 per hour. This agreement constitutes the sole and only agreement to the parties hereto and supersedes any prior understandings or written or oral agreement between the parties respecting the within subject matter. This agreement shall be construed under and accordance with the laws of The Commonwealth of Pennsylvania and the rights, duties and obligations of the clients and attorneys regarding attorneys' representation of clients and regarding anything covered by this agreement shall be governed by the laws of The Commonwealth of Pennsylvania. Any and all disputes, controversies, claims, or demands arising out of or relating to this agreement or any provision hereof, the providing of services by attorneys to client, or in any way relating to the relationship between attorneys and client, whether in contract, tort or otherwise, at law or in equity, for damages or any other relief, shall be resolved by binding arbitration pursuant to the Federal Arbitration Act in accordance with the Commercial Arbitration Rules then in effect with the American Arbitration Association. Any such arbitration shall be conducted in the County of Philadelphia Pennsylvania pursuant to the substantive federal laws established by the Federal Arbitration Act. Any party to any award entered in such arbitration proceeding may seek a judgment upon the award and the judgment may be entered by any by any federal or state court in Philadelphia Pennsylvania U.S.A having jurisdiction. This Agreement shall be binding upon and inure to the benefit of the parties hereto and their respective heirs, executors, administrators, legal representatives, successors and assigns. Also if any one or more of the provisions contained in this agreement shall for any reason be held to be invalid, illegal, or unenforceable in any respect, such invalidity, illegality, or unenforceability shall not effect any other provisions thereof and this agreement shall be construed as if such invalid, illegal or unenforceable provision had never been contained herein. I certify and acknowledge that I am not now represented by any other attorneys for this claim and that I have had the opportunity to read this agreement. I further state that I have voluntarily entered into this agreement fully aware of its terms and conditions The undersigned client has before signing this contract received and read the same and understands each of the paragraphs set forth herein. The undersigned has signed the statements, received a signed copy to keep and refer to while being represented by the undersigned attorney. Signed and accepted this ( day ofLi14() J , 20/0 Client (r Firm Rep �� Q1Vt1�Q .Q VilACIAk i pennsylvania DEPARTMENT OF PUBLIC WELFARE 3anuary 9, 2014 REIFF & BILY DENISE CASH MAN LEGAL ASSISTANT THE BEASLEY BLDG 1125 WALNUT ST PHILADELPHIA PA 19107 Re: Rorn,atio Jackson (minor).. CIS #: 560183361 Incident Date: 03/06/2010 Dear Ms. Cashman: Pursuant to your request, please be advised that the Department's statement of claim dated 04/25/12 in the amount of $100.92 is current. Thank you for your cooperation in this matter. If you have any questions, please contact me. ,Z z Sincerely, ikbent_i Nathan L. Snyder TPL Program Investigator 717-772-6266 717-772-6553 FAX Bureau of Program Integrity I Division of Third Party Liability I Recovery Section PO Box 8486 ! Harrisburg, Pennsylvania 17105-8486 COMMONWEALTH OF PENNSYLVANIA BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY RECOVERY SECTION PO BOX 8486 HARRISBURG, PA 17105-8486 April 25, 2012 STATEMENT OF CLAIM SUMMARY JACKSON, ROMELLO 560 183 361 UPDATE TO PREVIOUS SOC DATED 01/05/2012 MEDII APPROVED ,„ Yana' , PREVIOUS SOC CURRENT SOC 1,941.00 .00 256.25 .00 PRIOR REIMB/ADJ (155.33) TOT, 1,941.00 100.92 PREVIOUS SOC CURRENT SOC .00 .00 .00 REIMBURSEMENTIR D 100.92 )MMONWEAL�TH OF PENNSYLVANIA 'ARTMENT 0 P BL C WELFARE Page 1 of 1 REIFF AND BILY By: Raymond M. Bily, Esquire I.D. #44677 1125 Walnut Street Philadelphia, PA 19107 215-246-9000 215-246-9012 GLORIA JACKSON, et al. v. STEPHEN BISCHOF, IV FILED-OFFICE:: CF THE PRO THONO TA 20111 OCT --3 p 3: 50 CUMBERLAND COUNTY PENNS YLVANIA COURT OF COMMON PLEAS CUMBERLAND COUNTY NO. 2011-75-09 PETITION FOR LEAVE TO SETTLE OR COMPROMISE MINOR'S ACTION To the Honorable, the Judges of the Said Court: The Petition of JONEA JACKSON, a minor, by and through GLORIA JACKSON AND JONATHAN JACKSON, parents and natural guardians of JONEA JACKSON, respectfully represent: 1. Minor Plaintiff, JONEA JACKSON, resides with her parents, GLORIA JACKSON and JONATHAN JACKSON at 6635 Evelyn Street, #7, Harrisburg, Pennsylvania 17111. 2. Minor Plaintiff JONEA JACKSON was born on November 27, 2003 and her Social Security Number is 045-06-6464. 3. On or about March 6, 2010, Minor Plaintiff was a passenger in her parents' automobile when they were involved in an automobile accident on Route 15 at or near the intersection of North 21st Street in Camp Hill Borough, Cumberland County, Pennsylvania. 4. As a result of the accident, Minor Plaintiff was taken by rescue to Harrisburg Hospital for examination. The records reflect the Minor Plaintiff complained of headache, neck, pain in abdomen and jaw pain. She was examined, X -Rayed and released. Attached hereto, made part hereof and marked as Exhibit "1" are copies of her emergency room records. 5. Minor Plaintiff followed up with her Pediatrician, where the doctor indicated the pain Minor Plaintiff was experiencing was musculoskeletal. Attached hereto, made part hereof and marked as Exhibit "2" is a copy of the office note. 6. Minor Plaintiff also received treatment from David W. Gerhart, D.C. who indicated that by September 13, 2010, Minor Plaintiff has reached maximum medical improvement and, therefore, was discharged from his care. Attached hereto, made part hereof and marked as Exhibit "3" is a copy of Dr. Gerhart's report. 6. Attached hereto, made part hereof and marked Exhibit "4" is a statement signed by Petitioners, GLORIA JACKSON AND JONATHAN JACKSON, acknowledging Minor Plaintiff has achieved a full and complete recovery from the accident on March 6, 2010, and their approval of the settlement and distribution. 9. The Contingent Fee Agreement signed by Petitioners GLORIA JACKSON and JONATHAN JACKSON entitles Plaintiff's counsel to retain 331/3 % of the gross recovery together with reimbursement of costs. A true and correct copy of the Agreement is attached hereto, made part hereof and marked Exhibit "5". 11. Attached hereto, made part hereof and marked Exhibit "6" is a letter from the Department of Public Welfare confirming it has no lien against the recovery in this action. 12. All of Minor Plaintiff's medical bills have been paid to date. 13. There are no other fees or deductions which will be made from the above distribution. WHEREFORE, Petitioners request they be entitled to enter into the settlement recited above and that the Court enter an Order of Distribution as follows: 1. Reiff and Bily, reimbursement of costs $236.89 2. Reiff and Bily, legal fee [33 1/3 % of $2,763.11] $920.44 Date: 305 3. Balance to JONEA JACKSON, minor, to be placed in a restricted account subject to the restrictions indicated in the attached Order $1,842.67 TOTAL RECOVERY $3,000.00 Respectfully submitted, REIFF AN ! BILY /Lf By: and M. Bily, E ire VERIFICATION I, Raymond M. Bily, Esquire, hereby duly sworn according to law, deposes and saws that he is the attorney for the Petitioner and as such is duly authorized to take this Affidavit; and, further, based upon the underlying facts, medical treatment and minor Plaintiff's recovery, he believes the proposed settlement is fair and reasonable and should be accepted. Date: 34, at LI &///,/r Ray and M. Bily, Esqui VERIFICATION The undersigned, GLORIA JACKSON and JONATHAN JACKSON, are the Petitioners in this action and verify that the statements made in the foregoing Petition to Settle or Compromise Minor's Action are true and correct to the best of their knowledge, information and belief. We understand that false statements made herein are subject to the penaities of 18 Pa. C.S. §4904 relating to unsworn falsification to authorities. ATHAN JAC Date: / REIFF AND BILY By: Raymond M. Bily, Esquire I.D. #44677 1125 Walnut Street Philadelphia, PA 19107 215-246-9000 215-246-9012 GLORIA JACKSON, et al. COURT OF COMMON PLEAS CUMBERLAND COUNTY V. NO. 2011-75-09 STEPHEN BISCHOF, IV CERTIFICATE OF SERVICE I, Raymond B. Bily, Esquire, attorney of record in the above -captioned matter, represent and warrant a true and correct copy of Plaintiff's Petition for Leave to Settle or Compromise Minor's Action was served upon the following via United States First Class Mail, postage pre -paid: Joseph R. D'Annunzio, Esquire Law Office ofJoseph R. D'Annunzio 4309 Linglestown Road, Suite 211 Harrisburg, PA 17112 Date: 50 S'efra0)`1 By: ond M. Bily, Esqu re Att.rney for Plaintiffs DIAGNOSED - VERIFIED _._...� PROCESSED EMERGENCY DEPARTMENT 1Age6 Date of Birth 11/27/2003 J SSN 910000752 Harrisburg Hospital 1.11 S. Front St. Harrisburg PA 17101 i Sex F Date 03/06/10 03/06110 910000752 100237775 JACKSON ,.JONEA A 11/2712003 iRm��,oeo�p� Chief Complaint: MVA/L HIP PAIN Police Notified: ❑Yes 0 N By: Chief Comp: HPI: Location: Duality/Severity Timing/Duration Context: Modifying Factors: Assoc Symptoms: ROS: unable to Const: Psych: EYES: ENT: Resp: CV: , / GI: .�(i (/ GU: J Y6 MS: L/A-vii6,0 tj.: 7( ( C) Primary Care Phys: Dr. Time In 71 0 Medical Command Date/Time Accident: -firv`c'Ai) Integ: Neuro: l� Endo: Hem/Lymph: Ail/Immun: ❑ "Alt other systems negative" 0 See nurse's note - reviewed Hx: Allergies: Meds: Medical: Family: Hx, cont: Social: Tobacco: Drugs' EtOH: Living Situation: PE: BP / POT R 1(-) T Sp02 Wt 0 See nurse's note - reviewed Const. -- Mental Status/Psych: EYES: "-- ENT: ---" , Head/Neck: ---"t Head/Neck: Resp: c` CV: GI: GU: Integ: ..- F Neuro: MS: Lymph: ED Course: Test Interpretation: Procedures: PcbtA o Time out procedure completed: Patient Identification and procedure confirmed identified correct side/site: correct position: special equipment and requirements q� PiNai CC Minutes: Dictated Service Bed Type Follow -Up Referral Consult ❑pdttrn Discharge_ ❑Admission 023 obs ❑ Transfer v9.Dischargcs 0 Med/Surg ❑Telemetry ❑ Criticat Care 0 Psych Name: Time: ❑ Staa1 ❑ Improved Other E.D. Physician Physician's Assistant/ Mid-level Practitioner FORM 531 111111111111111111 187 ER Triage 01 'l I ; f . Qriyats i?#tysipiaflc hereby tt :t ;� 3 �� i information :rt my file {:ts i • t �fiQ tfler;t/SPude.91d medical treatment 'au l-. a. r, he i eCo MORD-- 1111111111110111111111111111111111111111111111111 141 • JCV a TRIAGE / PRIMARY NURSE Vii= •••• • ;ate? ::, ':. .;v;',y.. ✓- +" _ -. i .. •, j ° �c Tim(3 �` - % y;=' -� b ;Han' sbUrtg ;,;[7 CGOH ,..• , Acuity,•'.O j : • O 2>, O a :- 4�, .Patlent:Name&- ` ' i.'- • r'>.r-;, ;i. "%A" ' '' .. 4' " �. ' a• '' • **t • ..,. 'c- hAge: z 'Sez: Wt. (kgp ,. .-:.. • %• `•�-..�i.• 4.-: Corisciousnesls pentllatk n'- ..,: if Circulatio•••.);;': %f" Chle%Complaint: M V 14(' ' .,•` - i - ,� �'x s < •>:'°,.�• -: �•• %' �,>'• ..:. � _ � �2 " of ti. Af .0 CIOr ?r ! 0 Pulses` : ' '' (' • i 6� 11 "% "';.' •� I {� . t .': - o' .GI A1eie;,64: .:''. 1 p/, v ! I ci.Vetba —,) i I. sne . - : ', ) /., rile]. (ri • .4P,w :BP :: '7;.-D : •� .`•❑Obstructed: id •.( 4 i••••• '• . C =L. d. S '�`., , _ ,'.i• .O Pain`y',�•,,r. s<40 • '' %17 O'presen� • i C' / :<v� Qf :P.u1se .:. > y% =Res : i.� � 0 A'-:eu �.% P c ; u.-•.' O a rn espiinsl a NC9444ored•. `Xnefc^ •I „. O.yM,. .. ii• Orr guler :Oirregutar' 0 •` p ;.o%.-.• ., �SPar.ie; .•{j: '-'*'! 96��'':i. y .3/�k-I •'••ti .cc.`,$.!, . ' :• •,; lntub91V.', .< O•stron g IOweak,1 • •• • A . , • -B �� . .4 Peg,.2,-,,,,,,.."• l ` b `£' , : Wok: "%r ;;:: 4. •� ? : s. . , .5�%+, `Pertinant'PMF{;' .« '�; .i. ,'% ' ` , :k' .•• :Y T•1fi /. •c' i• =:1,,,, `t.t '�.,'..,;%;-; ice•- 'Rr (1g1P:-.13. N%A' ::Lactation O WA 1] Y ❑% N : .., r - • ;c • 'Pa}n'Scate 0.10, := <:: rf _ E£. :.^ .;y. ' 'fie .. . ,... ,•. ' >lFiage Nurse• join ...A +�.{ PRE -HOSPITAL CARE UNIT: ��" Mode of Arrival: Patient Disposition: 0 Rm# 0 Waiting Room Arrived with: Suspected Abuse; Adult/Child 0 BLS GALS 0 Wheelchair D Ambulatory 0 Carried 0 Vital Signs BP: p.1� Rc ii 0 No Identified Needs 0 Speaks No English Language. 0 Unusual/suspicious marks 0 Sexual Abuse Loss of Consciousness ❑ No y ` Translation By: 0 Domestic Violence D Safe Referral Airway i* U I t� ' Nasal O ET Tube / Size• IMMUNIZATIONS r� Oxygen { 1 ❑ rii Um 0 NRM I/m PSH / Social 0 Suicide Risk Plan• TETANUS: Pulse ox RA 3 Oxygen Childhood D UTD • D Not UTD Heart Rhythm CPR Started 0 No 0 Yes Time Triage Protocols/ Interventions: Medications AEO 0 No 0 Yes Time IV Therapy Gauge Site Solution Oextrostick Mg / dl Medications Administered Pre -hospital Signature of Provider: Triage / Primary Nurse' Time. VENTILATION ❑ SYMMETRICAL & UNLABORED ❑CLEAR ❑LABORED ❑ WHEEZING 0 L 0 R ❑ RALES/RHONCHI ❑ L D R ❑ DIMINISHED CI L D R 0 RETRACTIONS CIRCULATION ❑ PULSES (site') NEURO ❑ALERT ❑ORIENTED 0 DISORIENTED ❑GLASGOW COMA SCALE — — — — ❑HEADACHE 0 STIFF NECK 0 DIZZINESS EMOTIONAL 0 COOPERATIVE 0 UNCOOPERATIVE ❑ANXIOUS 0 FLAT AFFECT 0 AVOIDS EYE CONTACT 0 BABY TRAUMA ABIOlt PAIN ❑GENIES 0 N AREA: OU CI DENIES ❑NA 0 RETENTION ❑ DYSURIA ❑ FOIEY OYN 0 DENIES 0 NA ❑VAGINAL BLEEDING ❑ NORMAL FLOW 0 ABNORMAL FLOW: HU RSAM__PMAND.6IS 0 INEFFECTIVE AIRWAY CLEARANCE 0 INEFFECTIVE BREATHING PATTERN 0 IMPAIRED GAS EXCHANGE 0 FLUID VOLUME DEFICIT 0 ALT. BODY TEMP ❑ ALT. TISSUE PERFUSION PERIPHERAL / CARDIAC / CEREBRAL ❑IMPAIRED SKIN INTEGRITY ❑PAIN; ACUTE /CHRONIC 0 IMPAIRED Mo91LRY 0 INEFFECTIVE COPING CI OTHER: Quality RaalatXm SEVERITY (0 - 10) TI "e GI 0 DENIES 0 NA 0 NAUSEA O VOMITING ❑DIARRHEA ❑CONSTIPATION 0 OARK STOOLS ❑ABDOMEN CI ❑$OFT ❑FIRM ❑DISTENDED ❑ TENDER: ❑DISCHARGE: CI PRESENT ❑ABSENT ❑ STRONG ❑ WEAK ❑ REGULAR 0 IRREGULAR ❑ EDEMA LENT 0 DENIES 0 NA VISUAL ACUITY. ❑CORRECTED ❑NOT CORRECTED ❑JVD ❑CAPILLARY REFILL: ❑ <2 SEC ❑ ›2 SEC SKIN ❑PINK ❑PALE DORY D DIAPHORETIC ❑CYANOTIC D JAUNDICE OD. ❑ LACEERRATTION• 0 BOWEL SOUNDS: D PRESENT ❑ ABSENT OS: ❑ECCHYMOSIS• ❑ EPISTAXIS D R ❑ L ❑EARACHE 0 0 0 SORE THROAT ❑ DEFORMITY* - - - ❑BURNS• ❑ SEE BODY DIAGRAM (ON BACK) PRIMARY NURSE SIGNATURE: 4, PINNACLEHEALTH Hospitals EMERGENCY NURSING. ASSESSMENT SHEET 1111111111111111111 MR: ***000752 CASE: 100237775 11111111111111111111 Ill 111111JACKSON ,JONEA A DATE: 03/06/10 DOB: 11/27/2003 i?by cert��y ti' at I t.; reviewed `". ;_. ".` _ : gAGEt 6 information 111 m, _; eo ;-r4 11._ . .. l. FortnINVT4B2(0?J09)MR ED2505 t ��ry time indicated ated medical treaLll',e� Ei GI c;r? r''� 1 the re ''s Page _ of.,__ Procedures Medications 0 ECG: 0 Labs* ❑ UN DATE/TIME DRUG DOSE ROUTE SITE IN1T ax �] w*ay. 116-5 ❑ BCx2 BC1: BC2• ❑ CT ❑ U/S: ❑ ABG• IV Solutions DATE/TIME SITE SIZE SOLUTION /VOLUME RATE INIT ii Date/Time 8P P R SpO: O: l O Pain (0 - 10) Narrative IW ''...- - - 7 41;4? 04 i V a0144 S. 2-/U1.7 17 12- - -11D .11 -era-- e . % 0,1,,,,,, -? * /„" / f / ► r. S'tr i to u w1-. ae-e-s-P dc* -c -y 6 LI • 4) ei(16123' T, ifs/!fc6�a ,, . • p 181-15" p AiurtAAA(1 1214 is s:?5 (,„ fr, ;d -C44 s DIA) -1-9,4/ b Ain -----r%z4' J I, 1 I Admitted Disposition Assessment Initials / Signature ❑ Admit ❑ 23° hr OBS Time:(90b B/P:____ P: R Attending. PPain/(0 - 10) Sp02. Bed #. aDischarged 0 Transferred Report called by see Transfer form) To: Time• In the care of To Bed- Monitor Egeamily ❑ Yes 0 No verbalized understanding of D/C Instructions Mode: 0 W/C 0 0 Written Instructions given by: Stretcher Advanced Directives Discussed 0 Mode: Ambulatory ❑ W/C 0 Helicopter Copy available 0 0 EMS 0 Carried 0 Crutches RN RN �/ EMERGENCY \6 PINNACLEHEALTH FLOW Hospitals CONTINUATION 11111111 SHEET NURSING III1Lreby cet 1111111111111110 II8III111IIIII1IU{I1III1) MR: * * *000752 JACKSON ,JONEA t%t i I DAT ^ 03'9 vie'/r CASE: 100237775 A F ch ' D G de 62003 I ave Form INV 7483 (02/69) MR (MD) intern -13410n in rn,/p, every titr ED2505 m, di i treatment Or t1 �� vcr t I in th 4 ords 4 dicate Urinalysis Reference, Ranges: Protein Glucose • Bilirubin • Ketones Blood• • Nitrates Leukocytes Urobilinogen ' . pH Specific Gravity • • • - Negative . Negative .Negative Negative Negative Negative Negative Normal 5.0-8.0 1.003-1:030 • Blood Glucose Monitor . • • Reference Range: • 74-11.8 mg/dL . • Troponin I Reference Range:. <0.03 ng/mL, - 0:49 ng/mL a :t;ereey certify h re,by y that I haver fan in my file d reviewed the vri el medical treatment � ," that i 'received. tnd e VES indic ill ecor ', ,�? L frj�ir(,Q.€uiialto • s Harrisburg ED 782-3297 Please note that the'instructions circled or checked below pertain to you. You have been discharged with the diagnosis of The examination and treatment you have received in the Emergency Department have been rendered on an emergency basis, and not intended to be a substitute for ongoing care provided by a primary care physician or specialist. Not all of your medical problems may be known, diagnosed and/or.treated at this visit, it is important for you to follow up with your physician and to return to the Emergency Department if you become worse in any way. General Instructions Supplelnental jnstruction Sheet Rest for 0 Off work / school from to Medications) Return to work on Light duty for Regular duty Follow-up Care; 1. Return to the Emergency Department immediately if unexpectedly worse or. not improved. 2. Emergency Department on 3. Family Physician 4. See Dr. on at AM / PM. 5. Call the following clinic within one business day for an appointment to be seen in _day(s): Hamilton Health Center, 1821 Fulton Street 232-9971 Community Health Center: _Children & Teen Center, 2nd Fl 782-4650 _Women's Outpatient, 3rd Fl 782-4700 Kline Health Center, Landis Bldg. 2nd Floor: _Adult Outpatient Clinic 782-6421 _Orthopedic Clinic 782-2142 _Surgical Clinic 782-6421 _ Kline Family Practice Center 782-2100 6. If you smoke you are advised to stop. Please call 717-221-6250 or access www.pinnaclehealth.ong for more information on smoking cessation. 0 Yes 71, f/ ( ❑ Miscellaneous . ❑ Caution C X -Ray Instructions • Radiology Studies - Including plain X-rays, CT/MRI Scans and Ultrasounds. Your Radiology Studies have been reviewed by an Emergency Physician, Physician's • Assistant or Radiologist. A final Radiologist's interpretation will be reported and you or your doctor will be notified of any abnormalities which require follow-up. • • • 4, PINNACLEHEALTH Hospitals Emergency Department Patient Instruction Sheet • 111111 till lHl 11111 ll lIl 002507 Form INV 29001 (12/081 MR (PMI First copy Patient:';. - Medications may cause drowsiness. - No alcoholic beverages. - Do not drive, operate machines, or perform risk taking activities. I hereby acknowledge receipt of these instructions, I will arrange for follow-up care as I have been instructed. I will take the medication list to myphysician. Signature of P tient or Responsible Persgn Date I Discharge Pktient From Emergency Department. R.N. Sign/ere Physician Signature 4> PINNACLEHEALTH �knn Emergency Department OR Q% /A / I'T P.O. Box 8700 O V/`j/� Harrisburg, PA 17105-8700 . RIeq J Date ? -1 -16 Harrisburg - 782-3297 Substitution Permissible , M.D., D.O. IN ORDER FOR A BRAND NAME PRODUCT TO BE DISPENSED, THE PRESCRIBER MUST WRITE "BRAND NECESSARY" OR "BRAND MEDICALLY NECESSARY" IN THIS SPACE MAY REFILL TIMES PA Lic # DEA No PRINT PHYSICIAN NAME LABEL ALLPfE.SR,Re1P3f£1A}Si';-,f.'$ l i Second copy - Medical icYlrs 1111111111 111111111 gill NIIL 1 1III MR: * * *000752 CASE: 100237775 JACKSON ,JONEA A DATE: 03/06/10 anc DOB: 11/27/2003 AGE: 6 rd c• ,II •0. Record F a a Date Time LEVEL OF INTENSITY (LOI): (Please complete a Level of Intensity Order Form for any L01114) Allergies: Procedures . Supplies ❑ Cardiac Monitor O ECG ❑ Nasogastric tube ❑ Foley Catheter ❑ Straight Catheter 0 IV: O O2 LPM— O Pulse Oximetry O Non-invasive COHbg ❑ Peak Flow ❑ Neb Treatment: Lab Time: Initials. Drug Levels Cultures ❑ ABG ❑ Acetone ❑ Amylase O ALT/AST O Ammonia ❑ BMP ❑ Cardiac ❑ BNP ❑ CK - Total OCK - MB ❑ CK - Index O Troponin I ❑ CBC w/auto diff ❑ COHbg ❑ Comp Met Panel ❑ CRP ❑ D -Dimer (DVT) ❑ Electrolytes ❑ ETOH ❑ Glucose ❑ Hepatic Panel ❑ H&H O Lactic Acid ❑ Lipase ❑ Magnesium O Myoglobin O PT/INR ❑ PTT ❑ Qual HCG ❑ Quant HCG ❑ Rpt Cardiac O CK - Total ❑CK-MB ❑ CK - Index ❑ Troponin I ❑ TSH ❑ Sed rate ❑ Urinalysis ❑ Acetaminophen ❑ Aspirin O Carbamazepine ❑ Digoxin O Lithium ❑ Phenobarbital ❑ Phenytoin ❑ Theophylline ❑ Urine Tox. ❑ Valproic acid Blood Bank ❑ Type & Cross ❑ Type & Screen ❑ Rh Factor ❑ Blood x O Chlamydia ❑ GC ❑ GC/Chlamydia (gene amp) ❑ Herpes ❑ Sputum ❑ Stool ❑ Stool - C -diff ❑ Throat/strep 0 Urine 0 Wound. Bedside Testing ❑ BGM ❑ Qua! HCG (urine) ❑ Troponin I AMI Orders If ST Elevation MI 0 Thrombolysis (Order sheet) ❑ STAT Cardiology Consult with (PreCath orders) ASA 325 mg po 0 STAT, ❑ Given PreHospital, 0 Taken at Home Acute Stroke Orders ❑ Vital Signs q 15 minutes 0 IV: 0.9 NSS @ 50 mUhour ❑ BGM ❑ Strict NPO until dysphagia evaluation ❑ Aspirin 300mg PR x 1 dose ❑ Notify physician if: SBP >180, DBP >105, change in neuro status. ❑ Stroke Alert Team called @ Time. ED Protocols Date ❑ ED Abdominal Pain Protocol initiated O ED Chest Pain Protocol initiated ❑ ED Pain Management Protocol initiated Time ❑ ED Asthma Protocol initiated 0 ED Fever Protocol initiated Additional O er / Radiol Time - Initial Portable: ■ C-spine ❑ CX - ■ Pelvis SpinT ❑us 0 A - L R ❑C ❑ Elbow L R ❑ Facial ❑ Femur L R O Finger L R ❑ Foot L R ❑ Forearm L R ❑ Hand L R ❑ Hip L R ❑ Humerus L R ❑ Nasal ❑ Knee L R O KUB ❑ Ob Series ❑ Pelvis ❑ Ribs L R ❑ Shoulder L R ❑ Skull ❑ Tib/Fib L R O Wrist L R Symptom: OCT: ❑ US. O Venous Doppler: 0 MRI ❑ V -Q Scan ❑ Other Physician Signature 4, PINNACLEHEALTH Hospitals EMERGENCY DEPARTMENT PHYSICIAN ORDERS 111111111111 Form INV 30747 108/09) MR tlnD) 1111111111111111111111 E132502 Printed Name (printed) i111llllll~f1 Patient Identification 1111111111 1111 MR: *"000752 CASE: 100237775 F JACKSON ,JONEA A DATE: 03/06/10 Ph#: _ AGE:.vqed ,r_: ', v -,E{ i7erE,}b' ei`tify that i have, ; received ;r�i\Jea at wary t lived information in m'� file and that medical treatment in ach a the r ,., d : s : ; tire.^,41I, DOB: 11/27/2003 ACCT#=002.00237775 PinnacleHealth System P.O. Box 8700 Harrisburg, PA 17105-8700 EMERGENCY DEPARTMENT TRAN;CCRIBED DATE=03/09/2010 06:x;?:, UDN= 2834355 JACKSOr ' JONEA A RM#: MRN: 910-00-0752 CASE: 00100237775 DOB: 11/27/2003 ADM: 03/06/2010 CHIEF COMPLAINT: This is a 6 -year-old female who presents to the emergency department with a chief complaint of jaw pain. HISTORY OF PRESENT ILLNESS: She was a restrained rear passenger in an MVA. Her mother was driving. REVIEW OF SYSTEMS: The patient has no fever. No vision problems or hearing problems. She has left jaw pain. She has no hearing problems. No asthma. No heart problems. No nausea. No vomiting. She has had renal tumor surgery in the past. She has no laceration. She is ambulatory. No seizures. No diabetes. No anemia. PAST HISTORY: SHE HAS NO ALLERGIES; is on no medicines. FAMILY HISTORY: Her parents are both alive and well. PHYSICAL EXAMINATION: Vital signs: Pulse is 84; respiratory rate is 20; temperature is 34. She has a normal body habitus. Awake, alert, and oriented. She has pain in the left side of her jaw. Pupils are equal. Ears are normal. Heart is regular. Lungs are clear. Abdomen is soft. Skin is warm and dry. She moves all extremities. Thyroid is not enlarged. No cervical lymphadenopathy. EMERGENCY DEPARTMENT PHYSICIAN TEST INTERPRETATION: X-ray was taken of her chest, her neck, and her jaw; these were negative. DISPOSITION: The patient may take Tylenol for the pain. DIAGNOSTIC IMPRESSION: Multiple contusions and left jaw pain. Patient: JACKSON, JONEA c: Signed by HILDREW MD, LANCE on 12 -Mar -2010 15:35:59 -0400 EDWARD L. HILDREW, DO DD: 03/06/2010 2834355 ER REPORT ER REPORT DT: 03/09/2010 /tm/kpci D#: ER .REPORT nereby certify that E have reviewed the medical W/�infformatio,�jn yiin my file{ and that II have received' A}:�pdicaI treatrne nt each and every �� it indicated in .th'�°cords PINNACLEHEALTH System Radiology Imaging Report MR#: SSN: ADM: DOB: 910000752 910000752 000100237775 11/27/2003 AGE: 6Y BED: HER- PTCLASS: E HER NAME: JACKSON, JONEA 715 CUMBERLAND POINT CIR MECHANICSBURG, PA 17055 ORD DR: HILDREW, EDWARD L ORD#: 90002 ATT DR: HILDREW, EDWARD L PCP: WIDOME, MARK REASON: Trauma COMMENTS: ***Final Report*** HARRISBURG DIAGNOSTIC DEPARTMENT PROCEDURE: DIA - 2050 - CERVICAL SPINE MIN 4 VIEWS 72050 PROCEDURE DATE: Mar 6 2010 7:07PM ACCESSION#: 6428738 EXAM: Cervical spine, 5 views HISTORY: Neck pain status post recent motor vehicle accident. RESULT: Routine projections of the cervical spine where obtained. No prior examinations are available for comparison. On the lateral projection, all 7 cervical vertebrae are well demonstrated. There is a normal cervical lordosis. There is normal cervical vertebral alignment. The intervertebral disc spaces are preserved. The vertebral bodies are of normal height. The posterior elements are intact. There is no evidence of neuroforaminal encroachment. The atlantoaxial relationship as well as the appearance of the dens is normal. The prevertebral soft tissues are unremarkable. There is no evidence of acute fracture. IMPRESSION: no acute osseous abnormality identified. If pain persists or there are localizing neurologic symptoms, consider CT or MRI for further evaluation. DICTATED: (03/07/2010 11:05AM) TRANS: (PSC/PS) ON: 03/07/2010 11:32 INTERPRETED AND REVIEWED BY: PATRICIA BARRY -LANE, MD ELECTRONICALLY SIGNED: 03/07/2010 11:32 In the event of any questions regarding this report, a Quantum Radiologist can be reached by phone at 932-8030. hg,rety cE:Ttify that I have review(,::!ci thr3, information in ail/ fit() r -1 that have , Ca. treatment eac* , every e indicated in cords Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at: 1-717-782-3240. Printed: March 7, 2010 11:28 AM PINNACLEHEALTH System MR#: 910000752 SSN: 910000752, ADM: 000100237775 DOB: 11/27/2003 AGE: 6Y BED: HER- PTCLASS: E HER Radiology Imaging Report NAME: JACKSON, JONEA 715 CUMBERLAND POINT CIR MECHANICSBURG, PA 17055 ORD DR: HILDREW, EDWARD L ORD#: 90003 ATT DR: HILDREW, EDWARD L PCP: WIDOME, MARK REASON: Trauma COMMENTS: er core 8 ***Final Report*** HARRISBURG DIAGNOSTIC DEPARTMENT PROCEDURE: DIA - 0110 - MANDIBLE COMP MIN 4V 70110 PROCEDURE DATE: Mar 6 2010 7:04PM ACCESSION#: 6428739 EXAM: Mandible, 5 views HISTORY: Pain status post motor vehicle accident. RESULT: Bone mineralization is normal. The mandibular condyles are intact. No mandible fracture is identified. No significant bone destruction is appreciated. There is no significant soft tissue abnormality. IMPRESSION: Negative radiographic examination of the mandible. DICTATED: (03/07/2010 11:04AM) TRANS: (PSC/PS) ON: 03/07/2010 11:32 INTERPRETED AND REVIEWED BY: PATRICIA BARRY -LANE, MD ELECTRONICALLY SIGNED: 03/07/2010 11:32 In the event of any questions regarding this report, a Quantum Radiologist can be reached by phone at 932-8030. I hereby certify that I have revi ,;vr, information in my ,fife medical t en and that f every nd , ir7 ,.,:,...; Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you haye received this communication in error, please notify us immediately at: 1-717-782-3240. Printed: March 7, 2010 11:33 AM PINNACLEHEALTH System Radiology Imaging Report MR#: 910000752 NAME: JACKSON, JONEA SSN: 910000752 715 CUMBERLAND POINT CIR ADM: 000100237775 MECHANICSBURG, PA 17055 DOB: 11/27/2003 AGE: 6Y ORD DR: HILDREW, EDWARD L BED: HER- ORD#: 90003 PTCLASS: E HER ATT DR: HILDREW, EDWARD L PCP: WIDOME, MARK REASON: Trauma COMMENTS: er core 8 ***Final Report*** HARRISBURG DIAGNOSTIC DEPARTMENT PROCEDURE: DIA - 4507 - CHEST PA LAT 71020 PROCEDURE DATE: Mar 6 2010 7:04PM ACCESSION#: 6428823 EXAM: Chest, 2 views; 1845 hours History: Six year-old female with chest pain status post motor vehicle accident. Result: Erect PA and lateral projections of the chest were obtained. No prior examinations are available for comparison. The cardiomediastinal silhouette is within normal limits. The pulmonary vasculature is not congested. The lungs and pleural spaces are clear without evidence of focal airspace consolidation, lung contusion, pleural effusion or pneumothorax. Motion on the lateral projection somewhat degrades evaluation of the retrosternal clear space. And repeat lateral projection would be beneficial for further evaluation if clinically indicated. The visualized osseous structures are unremarkable. IMPRESSION: No acute cardiopulmonary abnormality. DICTATED: (03/07/2010 11:03AM) TRANS: (PSC/PS) ON: 03/07/2010 11:32 INTERPRETED AND REVIEWED BY: PATRICIA BARRY -LANE, MD ELECTRONICALLY SIGNED: 03/07/2010 11:32 In the event of any questions regarding this report, a Quantum Radiologist can be reached by phone at 932-8030. I hereby certity that I in my the ank".:1 that I : • treatrnent a,nd eveiy in ecmds Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at: 1-717-782-3240. Printed: March 7, 2010 11:28 AM . � " ��# Harrisburg ED732-3 87 Please note that the instructions circled or checked below pertain to you. You have been discharged with the diagnosis of The examination and treatment you have received in the Emergency Department have been rendered on an emergency baaio, and not intended to be a substitute for ongoing care provided by a primary care physician or specialist. Not all of your medical problems may be known, diagnosed and/or treated at this visit. It is important for you to follow up with your physician and to return to the Emergency Departmenif you become worse in any way. General Instructions Supplemental Instruction Sheet Rest for 0 Medication(s) Off work / schofrom to Return to work on Light duty for Regular duty 'Follow-up Care: C 'mthe unexpectedly worse or not improved. 2. Emergency Department on 3. Family Physicia 4. See Dr. on at AM/PM. 5. Call the following clinic within one business day for an appointment to be seen in day(s): ...._...Hamilton Health Center, 1821 Fulton Stree23249971 Community Health Center: __Children & Teen Center, 2nd Fl 782-4850 ..........Women's Outpatient, 3rd Fl 782'4700 Kline Health Center, Landis Bldg. 2nd Floor: _......Adult Outpatient Clinic 782-6421 ..Orthopedic Clinic 782'2142 ......Surgical Clinic 782-6421 .._...Kline Family Practice Center 782'2100 G. If you smoke you are advised to stop. Please call 717-221-6250 or accesfor more information on smoking cessation. Yes ( Lo, /0? O Miscellaneous [] Caution - Medications may cause drowsiness. - No alcoholic beverage . - Do not drive, operate machines, or perform risk taking activities. I hereby acknowledge receipt of these instructions, I will arrange for follow-up care as I have been instructed. I will take the medication list to hysician. X -Ray Instructions Radiology Studies - Including plain X-mya, CT/MRI Scans and Ultrasounds. Your Radiology Studies have been reviewed by an Emergency Physician, Physician's Assistant or Radiologist. A final Radiologist's interpretation will be reported and you or your doctor will be notified of any abnormalities which require follow-up. PIMNAC0EHEA[TH Hospitals Emergency Department Patient Instruction Sheet I 11 1111 I DO ED2507 Form IW 29001 (12/08) MR Discharge P entmResponsible Pers .n Date tient From Emergency Department. R.N. Sig ure Physician41164 Signature PI NNAC0EUEAO-H � Hospitals Emergency Department P.O. Box 8700 Harrisburg, PA 17 5-8700 heF�hv�8�/\/ -'. .' - -.~ /n medical trg8' _ Date/� � u '�� Harrisburg 782-3297 -'' hat ihe va a ve Substitution Permissib IN ORDER FOR A BRAND NAMPRODUCT TO BE DISP WRITE "BRAND NECESSARY" OR "BRAND MEDICALL MAY REFILL PA Lic # DEA No TIMES PRINT PHYSICIAN NAME LABEL ALL PRESCRIPTIONS M.w,o.O. SED, THE PRESCRIBER MUST ECsSSARY^IN THIS SPACE 11111111111111111111111111111111111111111111111111111 MR: *°°000752 CASE: 100237775 JACKSON ,JONEA A r DATE: 03/06/10 Ph#:AGE: 6 DOB: 11/27/2003 `-� First coin; -P"v°" OENNSTATE HERSHEY I 5 5 Milton S. Hershey Medical Center CC: Friati kAS.1.1- HPI: We, "16 1)Lit 1-e-4,--,tAk:14Medications 73r2e..r2,5%4_ ef3t pevl- Li-//3-L.(A.Ateviewed SOLS. hLer- ftrieft SC>e /Ude CC e A r r04 -r - CY4) dr "- f "tr- FM -e z A-0 A. weeS 7-05 PMH: 64. pA-r7ccAir /4A4'e 434-e.. p3-7.4 4- 3/11 Op 5 Oc 4,144.41 4?-te.-4Z porritx,r,s --7)-zirce,a ?no co At, ref Ce-4-4:1-)27/At 121 -v7 -AA./ pr /W•-) 401 .1,41-kn- re, . vi+r24-IcA s4414 rrIvt.fic, vf3 p+rm.)A0T 11 -(A -re., LA' ( Y N YN YN YN ROS: 0 ugh 0 ore throat 3 0 ear pain 0Xcongestion o O-1.appetite 0 omiting 0diarrhea 0 0 abd pain LI Weyer 0 0 dysuria 1 Temp: 59. k ttif headache J activity myalgia 0 0 chest pain .0 joint pain 0 eye complaints 4 uw.p.t.4. /R) HR: RR: BP: Exam: Ca if Normal Appearance Eyes Ears/Nose/Thr Neck Lymph Chest/Lungs Heart Abdomen Genitalia EKt/Back Skin Neuro Student/Resident kt Atedz: M11) ; / lit40R4s. Wic-,rsete .43 T>IC 1.4rve-A g-000 p=i+ cits.tC34 . LA44344. . i -1-4•AS Col•Ary q iLkaccGrIeJZ, IA. %4•1 wi p if re -GLI 1124,A4gwirz' . AJ 1471 1.141,...... . , t cmen p,..444,G P'kreralaOrria0 id 0-11(3 i•-0 viltzli ko 1;)r..-“r‘i di, D v. e 41..rt 4w.A.2,11.4 :4-0(z n i Tic iv,: 17:: p:ve, D -341.4_, INtrA rt:, 1::)=--A2,0 ce,A,stfz. Tzr...repe4.44.4•5, PW=IIMA-L-Te.04.4 ...,;•-ct,,,r1.43.-po....a.us 11111411111111111111111111111111k1it NAME: JACKSON tIlati: 1462686 0034: 14180013 MD: DUDA LAURA M MDU: 61210 006: 11/27l2003 VISIT DATE: 03109/2010 LOC: P ED7SEX: F INS: GATEWAI HEALTH FLAN31 COPAN' 00 1111111111111111111111 Nursing Assessiirt Age: Informant: 43:----) ,', Paln Present? ID no>Elyes (see reverse) Concerns: i-7-- / Li. '71 %/ill Allergies: 111.K, A PCP: Signature: A--4-1-st-. Time: if ll ?e) 02 sat 1 HT: FtlAchaA) Lab Results: A.01447, (A 7,9-1G/ Alt , A407-72414/ 624-9-`tA-c. Chrf Assessment: b y/a. p-./ -,e Nv4 par -A4 (-.4SWA t'Srt..41r Plan: r- IAJC-42v4I-arria 4304 twv44. Preceotor o Ce:Pur; 11 -if 4P-ri.J.kr O cirOS/L 0 ttiz 1.1-z.esr•-• 0 soil-, Rro.,-• 0 Lu cm 1WT: I. 3 04 kg O -('C io,-ecr- 4.1r. ,;-; t)or )19.A2Tcluez;b0-; 0,41A, rct.0.3, ;-/6 • 90,4A cIA C)1 i•aft.4.44 4.41 - , PcLun nAtvi ztt&, J -L VA,W )r -r14), Nursing Orders: Au- bohle, exbi<N,, Of7 ovebtf, L.4a p+ -)'V osmert-peirr_ (/- C4 Frja, P.0;-/lAY, "Ft -404e) Vats,/ 7-)0V1,i P i-5'141ton /4•14-111C-to,f7 c-02-tr c--4. e7e7 , C. , '-11 ll.1-1 -' ',' • • - -1-• , ‘• ' Preceptor Note: ' c'' ' e; T , ,/ ' ' ' • , ri- --,- ' WI- r Ir?...um cr,;„,,v, e-sr4-1 f:ll'"It ni? al 117.-,? 1 it -0-1-4i 1i'e/-' it ria_vn ci,„4, 1-0, j'flo11 &- 1,7kzun i I , \ 1 Or"-Cuy iv,..111'4 Qt.. p. (cm 'um(' ,..;r016....r, i C Ali rl i ''srji . oriAttending Note: ‘-'7•7711-,. t'llii7,7-6,.' f-;.. ...,,/ 1.44,E4 ifi-L..0, ci<j•,...c.1 . Li ..iti,.,./.,i, .41 VA - eii_a 7. u (4‘..-...i. -i .4,0,; ,,i•r1cieg-if RTC: WCC j days/weeks/months forc.neciical t ". ":1 in m : --ne reatme ‘..• 4,1' 4 Med list to earentIpatient: 0 given Fri denied CRNP/ TIME Form 741-102 Rev 1/10 Page 1 of 2 A ON, • _u_244z___CRNP D/ 0 everse side /MD/DO trad 1 TIM ACUTE/FOLLOW UP VISIT FORM PENN STATE HERSHEY CHILDREN'S HOSPITAL UNIVERSITY PEDIATRIC ASSOCIATES Pain Assessment Form: Location:() CO-.") )-1.u-c1,..) Intensity: Wong/Baker Pediatric Face Scale ..._ - 0-10 Scale t -c-4,-- Onset/Duration: 3 , Preverbal/Nonverbal Pain Scale Alleviating/Aggravating Factors:: -tr Present Management: Patient Goal for Acceptable Relief: Aek Observation of Site: ASat o"Yi A Signature: ADDITIONAL INFORMATION: FOLLOW UP INFORMATION: 7.1I Follow up patient and lab information 1 hereby certify that 1 have reviewed the information in my We -nd that 1 have rec.:eveci medica1 treatment ea t _nd every time indicated in cor El Follow up assessment and plan Family notified of results Signature: Date: Patient's Name: Date Of Injury: Claim #: Treating Doctor: Date Of This Report: PERSONAL INJURY FINAL REPORT Gerhart Family Chiropractic 303 South 32nd Street Camp Hill PA 17011 (717)761-CARE(2273) Jonea A. Jackson March 6, 2010 489401 Dr. David W. Gerhart September 13, 2010 Current Diagnosis: Initial hyperextension/hyper flexion sprain/strain injuries of cervocthoracic and lumbar paraspinal soft tissues, etc. Patient now suffers from residuals subsequent to the fibrosis of repair process of once damaged soft tissues. Present Condition: Patient's condition has reached a point of maximum medical improvement. She continues to have periodic flare-ups of the neck and lower back with stiffness at times of increased use and or stress. Future Treatment Plan: Continue to treat patient on an "as need" basis subsequent to flare-ups of' her condition at times of increased use or stress. Prognosis: As the patient's condition has reached a point of maximum medical improvement, no additional subjective and objective improvement can be expected with continued regularly scheduled treatment. Therefore, the subjective and objective residuals noted must be considered to be permanent effects of the injuries sustained in this accident. These residuals create a need for future treatment for palliative purposes. We will use this girl's requirements for "as need" care as the basis for determining her future care. Signed: hereby certify information iri medical treatm : ;. n �, VERIFICATION The undersigned, Petitioners GLORIA JACKSON and JONATHAN JACKSON, hereby represent and warrant that they are the parents, natural guardians of Minor Plaintiff, JONEA JACKSON, who resides with them. The undersigned verify that Minor Plaintiff, JONEA JACKSON, has recovered from her injuries. Accordingly, Petitioners believe it is in their daughter's best interest to accept the settlement offer of Three Thousand ( 3,000.00) Dollars. The undersigned also approve the distribution in the within Petition. Petitioners understand the statements made in this Petition are true and correct and are subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsifications to authorities. Jeffrey M. Reiff & Associates P.C. The Beasley Building 1125 Walnut Street 3'd Floor Philadelphia Pa. 19107-4918 I (we) hereby constitute and appoint Jeffrey M Reiff & Associates P.0 .as my (our) attorneys in my/our claim for damages against or any other person, firm or corporation or entity liable for those da ages, which damages resulted from any injury or breach of contract that occurred on 3 -W-fO . l(we) do not wish to compensate my/our attorney on an hourly basis or on any type of retainer agreement, but, on the contrary wish that he and his entire law firm work on my behalf and advance legal costs and expenses on my behalf. As compensation for their services rendered and to be rendered I agree to pay my/our attorneys from the total gross proceeds of the recovery a percentage of any and all amounts recovered from the party or parties responsible for the injuries or damages sustained by the client. Such percentage to be received by the attorney shall be computed as follows: forty percent (40%) if the case is settled without suit: forty-five percent (45%) after commencement of any legal action: fifty percent (50%) after the commencement of a trial or on filing an appeal from a final judgment made and entered thereon. Attorney's fees shall be figured on the total gross recovery or settlement. It is further agreed that the client shall be responsible from their portion of the recovery for all court costs, costs for investigation, experts, subpoenas, photographs, depositions, court reporter fees, reports, postage, photocopying, supplies, long distance calls, travel, parking, witness statements, computerized research and any and all other expenses directly incurred in the investigation or litigation of this claim. Client agrees that attorney may borrow funds from a commercial bank to finance or pay such court costs and all other expenses and charge client reasonable interest to be added to all costs. In some instances the fee may be regulated by lawful statute. If so all parties agree to be bound thereby. If a structured settlement is reached, the firm's fee is due and payable at the time of the settlement and is computed on the basis of present value. It is further agreed that all medical bills will be charged to and against the clients share. I/we authorize my/our attorneys to pay all bills for medical and hospital treatments from the proceeds of any settlement or verdict for services made necessary by the injuries sustained in the above mentioned accident. In the event that no money is recovered in this case the client shall not be responsible for any legal fees incurred as a result. It is understood that my/our attorney may employ experts and investigators. It is agreed and understood that this employment is upon a contingent fee basis and if no recovery is made I/we will not be indebted to my/our attorney for any sum whatsoever as attorneys fees. For the purpose of this litigation only my attorneys are authorized to negotiate, endorse, deposit and distribute any checks received from the defendant insurance carrier on my behalf. In the event that my/our attorney has committed to the prosecution of my/our case and I then make a determination to discontinue the case or retain another attorney the client shall immediately pay all costs and expenses incurred by the attorneys and in addition shall pay the attorneys the reasonable value of their services performed to date billable at an hourly rate of $395.00 per hour or the appropriate percentage of the last settlement offer which ever is greater. The client hereby grants to the law firm an irrevocable first lien on any recovery in the amount of the legal fee calculated pursuant to the above referenced percentage formula. This agreement is only for services rendered on behalf of the client in this claim for damages. The attorney may charge the client additional fees for any and all other legal matters handled by the above firm which are not directly related to this case which will be billed separately. The client agrees that Uwe will not receive any advances or loans on the case and agree not to request same from the above office. Attorneys may, at their own expense use or associate with other attorneys in the representation of the aforementioned claims. Client agrees to the referral of client's case to other attorneys, if necessary and the payment of a referral fee to the firm. Client agrees to sign any additional documents to facilitate the association of the other firm in accepting client's case representation. Attorney and the other firm will share the attorneys fees specified herein and will agree among themselves as to the division of said attorneys fee which will not exceed the percentage stated herein. Client agrees to cooperate with attorneys at all times and to comply with all reasonable requests by attorneys. Client further agrees to keep attorneys advised of their whereabouts at all times, and to provide attorneys with any change of address, phone number, business affiliations or change of marital status.. It is understood and agreed that the attorneys cannot warrant or guarantee the outcome of the case and attorneys have not represented to the client that the client will recover all or any of the funds desired, Client realizes that attorneys will be investigating the law and facts applicable to the claim on a continuing basis and should attorneys learn something which in the opinion of the attorneys makes it impractical for them to proceed with the claim, then the attorneys may withdraw from further representation of client by sending written notice to clients last known address. If client makes any material misrepresentation to attorney then attorney shall have an immediate right to cease legal representation and hold client accountable for any and all costs advanced including but not limited to fees calculated at $395.00 per hour. This agreement constitutes the sole and only agreement to the parties hereto and supersedes any prior understandings or written or oral agreement between the parties respecting the within subject matter. This agreement shall be construed under and accordance with the laws of The Commonwealth of Pennsylvania and the rights, duties and obligations of the clients and attorneys regarding attorneys' representation of clients and regarding anything covered by this agreement shall be governed by the laws of The Commonwealth of Pennsylvania. Any and all disputes, controversies, claims, or demands arising out of or relating to this agreement or any provision hereof, the providing of services by attorneys to client, or in any way relating to the relationship between attorneys and client, whether in contract, tort or otherwise, at law or in equity, for damages or any other relief, shall be resolved by binding arbitration pursuant to the Federal Arbitration Act in accordance with the Commercial Arbitration Rules then in effect with the American Arbitration Association. Any such arbitration shall be conducted in the County of Philadelphia Pennsylvania pursuant to the substantive federal laws established by the Federal Arbitration Act. Any party to any award entered in such arbitration proceeding may seek a judgment upon the award and the judgment may be entered by any by any federal or state court in Philadelphia Pennsylvania U.S.A having jurisdiction. This Agreement shall be binding upon and inure to the benefit of the parties hereto and their respective heirs, executors, administrators, legal representatives, successors and assigns. Also if any one or more of the provisions contained in this agreement shall for any reason be held to be invalid, illegal, or unenforceable in any respect, such invalidity, illegality, or unenforceability shall not effect any other provisions thereof and this agreement shall be construed as if such invalid, illegal or unenforceable provision had never been contained herein. I certify and acknowledge that I am not now represented by any other attorneys for this claim and that I have had the opportunity to read this agreement. I further state that I have voluntarily entered into this agreement fully aware of its terms and conditions The undersigned client has before signing this contract received and read the same and understands each of the paragraphs set forth herein. The undersigned has signed the statements, received a signed copy to keep and refer to while being represented by the undersigned attorney. Signed and accepted this 6 day ofy'V10,vik../ , 2010 Client Finn Rep , Q fyt s. 1n A ^ n~~°^~^^~y~°~~"""=" DEPARTMENT OF PUBLIC WeLFARE December 16, 2013 REIFF & BILY GRACIE GRUNDY THE BEASLEY BUILDING 1125 WALNUT STREET PHILADELPHIA PA 19107 Re: Jonea Jackson (minor) CIS #: 900168013 Incident Date: 03/06/2010 Dear Ms. Grundy: Pursuant to your request for a statement of claim, the Departrnent of Pubtic Welfare, Third Party Liability, Casualty Unit, has reviewed the information you provided regarding the above -referenced incident. It has been determined that DPW has no medical and/or cash assistance claim for this incident. if you have any questions, please feel free to contact me. Nathan L. Snyder TFLProgian) Investigator - 717-772-6266 717-772-6553 FAX Bureau of Program Integr;ty Dvision of Third Party Liability | Recovery Section GLORIA JACKSON, et al. COURT OF COMMON PLEAS CUMBERLAND COUNTY v. • NO. 2011-75-09 STEPHEN BISCHOF, IV ORDER APPROVING SETTLEMENT AND ORDER FOR DISTRIBUTION tk AND NOW, this day of , 2014, upon consideration of the Petition for Leave to Compromise a Minor's Action, it is hereby ORDERED and DECREED that Petitioner is authorized to enter into a settlement with Defendant in the gross sum of Five Thousand ($5,000.00) Dollars. Defendant shall forward all settlement drafts or checks to Petitioners' counsel for proper distribution. IT IS FURTHER ORDERED and DECREED that the settlement proceeds be allocated as follows: To: ROMELLO JACKSON, a minor $3,131.06 DATE OF BIRTH: SOCIAL SECURITY NUMBER July 18, 2006 159-84-2877 IT IS FURTHER ORDERED and DECREED that the settlement proceeds be distributed as follows: To: Reiff and Bily - Costs: (a) Records from West Shore EMS $27.28 (b) Records from Harrisburg Hospital $47.00 (c) Records from Mechanicsburg Chiropractic Ctr. $67.20 (d) Records from David W. Gerhart, D.C. $61.25 (e) Department of Public Welfare $100.92 TOTAL COSTS: $303.65 To: Reiff and Bily - Legal Fee: Fee [33 1/3 of 4,696.35 (after costs have been taken out ...... 1,565.29 The balance, the sum of $3,131.06 And any interest thereon, payable to the minor, shall be distributed as follows: COUNSEL, and not the parent(s) or guardian(s) of the minor, is hereby authorized and specifically DIRECTED to execute all documentation necessary to deposit the funds belonging to the minor in an interest bearing savings account or savings certificate in a federally insured bank or savings institution having an office in Cumberland County, Pennsylvania, IN THE NAME OF THE MINOR ONLY. The savings account or certificate shall be marked as hereinafter directed. The savings account shall be titled and restricted as follows: ROMELLO JACKSON, a minor, not to be withdrawn before minor attains majority or upon prior Order of Court. The savings certificate shall be titled and restricted as follows: ROMELLO JACKSON, a minor, not to be redeemed except for renewal in its entirety, nor to be withdrawn, assigned, negotiated or otherwise alienated before the minor attains majority, except upon prior Order of Court. If no withdrawals are made from the investments authorized by this Order, the depository may pay over the balance on deposit when the minor attains majority, as defined with reference to 20 Pa. C.S.A. §102, without further Order of this Court. Counsel shall file with the Office of the Prothonotary within sixty (60) days from the date of this Order, proof of the establishment of the accounts as required herein, by Affidavit from counsel certifying compliance with this Order. Counsel shall attach to the Affidavit a copy of this Order as well as a copy of the Certificate of Deposit or bank account title page showing the amount deposited and containing the required restrictions. The Affidavit shall further contain a specific averment by counsel that counsel, and not the parent(s) and/or guardian(s) of the minor, established the account(s) and deposited the funds therein as directed above. 3 mai co =rn ='D (Pr- -Ow ery <a) -To es P2z p4 -a.. Di Ly 941-y J. 'IgAimu.u2..k) GLORIA JACKSON, et al. v. STEPHEN BISCHOF, IV COURT OF COMMON PLEAS CUMBERLAND COUNTY NO. 2011-75-09 ORDER APPROVING SETTLEMENT AND ORDER FOR DISTRIBUTION th AND NOW, this 0 day of a, 2014, upon consideration of the Petition for Leave to Compromise a Minor's Action, it is hereby ORDERED and DECREED that Petitioner is authorized to enter into a settlement with Defendant in the gross sum of Three Thousand ($3,000.00) Dollars. Defendant shall forward all settlement drafts or checks to Petitioners' counsel for proper distribution. IT IS FURTHER ORDERED and DECREED that the settlement proceeds be allocated as follows: To: JONEA JACKSON, a minor $1,842.67 DATE OF BIRTH: SOCIAL SECURITY NUMBER November 27, 2003 045-06-6464 IT IS FURTHER ORDERED and DECREED that the settlement proceeds be distributed as follows: To: Reiff and Bily - Costs: (a) Records from UPG Pediatrics on Hope Drive $29.51 (b) Records from David W. Gerhart, D.C. $81.25 (c) Records from Mechanicsburg Chiropractic Ctr. $60.17 (d) Records from West Shore EMS $27.28 (e) Records from Harrisburg Hospital $38.68 TOTAL COSTS: $236.89 To: Reiff and Bily - Legal Fee: Fee [33 1/3 of $2,763.11 (after costs have been taken out) $920.44 The balance, the sum of $1,842.67 And any interest thereon, payable to the minor, shall be distributed as follows: COUNSEL. and not the parent(s) or guardian(s) of the minor, is hereby authorized and specifically DIRECTED to execute all documentation necessary to deposit the funds belonging to the minor in an interest bearing savings account or savings certificate in a federally insured bank or savings institution having an office in Cumberland County, Pennsylvania, IN THE NAME OF THE MINOR ONLY. The savings account or certificate shall be marked as hereinafter directed. The savings account shall be titled and restricted as follows: JONEA JACKSON, a minor, not to be withdrawn before minor attains majority or upon prior Order of Court. The savings certificate shall be titled and restricted as follows: JONEA JACKSON, a minor, not to be redeemed except for renewal in its entirety, nor to be withdrawn, assigned, negotiated or otherwise alienated before the minor attains majority, except upon prior Order of Court. If no withdrawals are made from the investments authorized by this Order, the depository may pay over the balance on deposit when the minor attains majority, as defined with reference to 20 Pa. C.S.A. §102, without further Order of this Court. Counsel shall file with the Office of the Prothonotary within sixty (60) days from the date of this Order, proof of the establishment of the accounts as required herein, by Affidavit from counsel certifying compliance with this Order. Counsel shall attach to the Affidavit a copy of this Order as well as a copy of the Certificate of Deposit or bank account title page showing the amount deposited and containing the required restrictions. The Affidavit shall further contain a specific averment by counsel that counsel, and not the parent(s) and/or guardian(s) of the minor, established the account(s) and deposited the funds therein as directed above. CO1MS /121‘1-CaC 2t.ig R4-1.7 J igitaugAi2.16 I o cVl • REIFF AND BILY By: Raymond M. Bily, Esquire I.D. #44677 1125 Walnut Street Philadelphia, PA 19107 Phone: 215-246-9000 Fax: 215-246-9012 GLORIA JACKSON, et al. V. STEPHEN BISCHOF, IV E 0 - if -F7 cc jj itiNy Pp; COURT OF COMMON PLEAS CUMBERLAND COUNTY NO. 2011-75-09 ORDER TO SATISFY AWARD OF ARBITRATORS TO THE PROTHONOTARY: Kindly satisfy the Award of Arbitrators in the above matter. REIFF AND Date: October 14, 2014 By: 711. Ra mond M. Bily, Esq re A orney for Plaintiffs REIFF AND BILY By: Raymond M. Bily, Esquire I.D. #44677 1125 Walnut Street Philadelphia, PA 19107 Phone: 215-246-9000 Fax: 215-246-9012 GLORIA JACKSON, et al. v. STEPHEN BISCHOF. IV AFFIDAVIT IN RE: JONEA JACKSON, A MINOR Oi. �1 I- I C E OCT 27 FH L_4ri COUNTY y NN PE;LNAN`�1 COURT OF COMMON PLEAS CUMBERLAND COUNTY NO. 2011-75-09 I, RAYMOND M. BILY, hereby state and affirm that I have complied with the Order issued on October 8, 2014 by the Honorable M.L. Ebert, Jr. as follows: On October 20, 2014, a Certificate of Deposit in the amount of $1,842.67 was issued by Citizens Bank, 1417 Walnut Street, Philadelphia, PA 19102, titled and restricted as follows: "Jonea Jackson, a minor, not to be redeemed except for renewal in its entirety, nor to be withdrawn, assigned, negotiated or otherwise alienated before the minor attains majority, except upon prior Order of Court." A copy of the Certificate of Deposit is attached hereto as Exhibit 1. A copy of the October 8, 2014 Court Order is also attached hereto as Exhibit 2. I verify that counsel, and not the parents and/or guardians of the minor, established the account and deposited the funds as indicated above. I verify that the statements in this Affidavit are made subject to the penalties of 18 Pa. C.S. §4904, relating to unsworn falsification to authorities. DATE: a ndl? RA OND M. BILY, ESQUI Img Citizens Bank. 71K ACCOUNT TITLE: JONEA JACKSON COURT ORDER NO W/D BEFORE 11/27/2021 Certificate of Deposit Personalized Summary TERM: 10 Month CD ACCOUNT #: 6260783171 INTEREST RATE: 0.10% APY*: 0.10% AMOUNT: $1,842.67 ISSUE DATE: 10/20/2014 MATURITY DATE: 08/16/2015 INTEREST PMT OPTION: Reinvest Your certificate of deposit (CD) account is subject to the rules and regulations of Citizens Bank of Pennsylvania Mania Your CD account automatically renews at maturity under the terms outlined in the maturity notice you will receive prior to your maturity date. If you would like to make changes to your CD or choose not to renew at maturity, you have a grace period of ten (10) calendar days after the maturity date to make changes or withdraw the funds in your account and avoid being charged a bank penalty. This summary does not constitute a receipt from the Bank. Deposits are subject to verification by the Bank and all checks and other items are accepted in accordance with applicable federal and state laws. 'The Annual Percentage Yield (APY) assumes no withdrawals are made from your account before maturity. A withdrawal will reduce eamings. Except as disclosed and permitted under your deposit account agreement with the Bank, there is a penalty for early withdrawals. If you close your CD account before maturity, you will not receive any accrued, unposted interest. CUSTOMER COPY This document is part of your deposit account agreement with Citizens Bank of Pennsylvania Please keep this document for future reference. If any information in this document conflicts with your deposit account agreement, your deposit account agreement controls. Prepared By: Brandon Heaven State: PA Date: 10/20/2014 Branch #: 558 Member FDIC. GLORIA JACKSON, et al. v. STEPHEN BISCHOF, IV COURT OF COMMON PLEAS CUMBERLAND COUNTY NO. 2011-75-09 ORDER APPROVING SETTLEMENT AND ORDER FOR DISTRIBUTION AND NOW, this C� flay of nA, - , 2014, upon consideration of the Petition for Leave to Compromise a Minor's Action, it is hereby ORDERED and DECREED that Petitioner is authorized to enter into a settlement with Defendant in the. gross sum of Three Thousand ($3,000.00) Dollars. Defendant shall forward all settlement drafts or checks to Petitioners' counsel for proper distribution. IT IS FURTHER ORDERED and DECREED that the settlement proceeds be allocated as follows: To: JONEA JACKSON, a minor $1,842.67 DATE OF BIRTH: SOCIAL SECURITY NUMBER November 27, 2003 045-06-6464 IT IS FURTHER ORDERED and DECREED that the settlement proceeds be distributed as follows: To: Reiff and Bily - Costs: (a) Records from UPG Pediatrics on Hope Drive $29.51 (b) Records from David W. Gerhart, D.C. $81.25 (c) Records from Mechanicsburg Chiropractic Ctr. $60.17 (d) Records from West Shore EMS $27.28 (e) Records from Harrisburg Hospital $38.68 TOTAL COSTS: $236.89 To: Reiff and Bily - Legal Fee: Fee [33 1/3 of $2,763.11 (after costs have been taken out) $920.44 The balance, the sum of $1,842.67 And any interest thereon, payable to the minor, shall be distributed as follows: COUNSEL, and not the parent(s) or guardian(s) of the minor, is hereby authorized and specifically DIRECTED to execute all documentation necessary to deposit the funds belonging to the minor in an interest bearing savings account or savings certificate in a federally insured bank or savings institution having an office in Cumberland County, Pennsylvania, IN THE NAME OF THE MINOR ONLY. The savings account or certificate shall be marked as hereinafter directed. The savings account shall be titled and restricted as follows: JONEA JACKSON, a minor, not to be withdrawn before minor attains majority or upon prior Order of Court. The savings certificate shall be titled and restricted as follows: JONEA JACKSON, a minor, not to be redeemed except for renewal in its entirety, nor to be withdrawn, assigned, negotiated or otherwise alienated before the minor attains majority, except upon prior Order of Court. If no withdrawals are made from the investments authorized by this Order, the depository may pay over the balance on deposit when the minor attains majority, as defined with reference to 20 Pa. C.S.A. §102, without further Order of this Court. Counsel shall file with the Office of the Prothonotary within sixty (60) days from the date of this Order, proof of the establishment of the accounts as required herein, by Affidavit from counsel certifying compliance with this Order. Counsel shall attach to the Affidavit a copy of this Order as well as a copy of the Certificate of Deposit or bank account title page showing the amount deposited and containing the required restrictions. The Affidavit shall further contain a specific averment by counsel that counsel, and not the parent(s) and/or guardian(s) of the minor, established the account(s) and deposited the funds therein as directed above. ste TRUE COPY FROM'RECORD in Testirnony Whereof, 1 -here unto set my hand and the s - of said Court at Carlisle, ,Pa. This ay of .20...' PrOtho rY REIFF AND BILY By: Raymond M. Bily, Esquire I.D. #44677 1125 Walnut Street Philadelphia, PA 19107 Phone: 215-246-9000 Fax: 215-246-9012 OF GLORIA JACKSON, et al. v. STEPHEN BISCHOF. IV 1: 17 .n j0 CUN3Er cou; i y PEP S i LVi', NIA r AFFIDAVIT IN RE: ROMELLO JACKSON, A MINOR COURT OF COMMON PLEAS CUMBERLAND COUNTY NO. 2011-75-09 I, RAYMOND M. BILY, hereby state and affirm that I have complied with the Order issued on October 8, 2014 by the Honorable M.L. Ebert, Jr. as follows: On October 20, 2014, a Certificate of Deposit in the amount of $3,131.06 was issued by Citizens Bank, 1417 Walnut Street, Philadelphia, PA 19102, titled and restricted as follows: "Romello Jackson, a minor, not to be redeemed except for renewal in its entirety, nor to be withdrawn, assigned, negotiated or otherwise alienated before the minor attains majority, except upon prior Order of Court." A copy of the Certificate of Deposit is attached hereto as Exhibit 1. A copy of the October 8, 2014 Court Order is also attached hereto as Exhibit 2. I verify that counsel, and not the parents and/or guardians of the minor, established the account and deposited the funds as indicated above. I verify that the statements in this Affidavit are made subject to the penalties of 18 Pa. C.S. §4904, relating to unsworn falsification to authorities. DATE: a,64, RAY OND M. BILY, ESQ - IRE cREV 04117111) d cettOc teFpnl XX Citizens Bank - ACCOUNT TITLE: ROMELLO JACKSON COURT ORDER NO W/D BEFORE 07/18/2024 Certificate of Deposit Personalized Summary TERM: 10 Month CD ACCOUNT #: 6260783198 INTEREST RATE: 0.10% APY*: 0.10% AMOUNT: $3,131.06 ISSUE DATE: 10/20/2014 MATURITY DATE: 08/16/2015 INTEREST PMT OPTION: Reinvest Your certificate of deposit (CD) account is subject to the rules and regulations of Citizens Bank of Pennsylvania (Bank.). Your CD account automatically renews at maturity under the terms outlined in the maturity notice you will receive prior to your maturity date. If you would like to make changes to your CD or choose not to renew at maturity, you have a grace period of ten (10) calendar days after the maturity date to make changes or withdraw the funds in your account and avoid being charged a bank penalty. This summary does not constitute a receipt from the Bank. Deposits are subject to verification by the Bank and all checks and other items are accepted in accordance with applicable federal and state laws. *The Annual Percentage Yield (APY) assumes no withdrawals are made from your account before maturity. A withdrawal will reduce earnings. Except as disclosed and permitted under your deposit account agreement with the Bank, there is a penalty for early withdrawals. If you close your CD account before maturity, you will not receive any accrued, unposted interest. CUSTOMER COPY This document is part of your deposit account agreement with Citizens Bank of Pennsylvania Please keep this document for future reference. If any information in this document conflicts with your deposit account agreement, your deposit account agreement controls. Prepared By: Brandon Heaven State: PA Date: 10/20/2014 Branch #: 558 Member FDIC. GLORIA JACKSON, et al. v. STEPHEN BISCHOF, IV COURT OF COMMON PLEAS CUMBERLAND COUNTY NO. 2011-75-09 ORDER APPROVING SETTLEMENT AND ORDER FOR DISTRIBUTION AND NOW, this P day of al . , 2014, upon consideration of the Petition for Leave to Compromise a Minor's Action, it is hereby ORDERED and DECREED that Petitioner is authorized to enter into a settlement with Defendant in the gross sum of Five Thousand ($5,000.00) Dollars. Defendant shall forward all settlement drafts or checks to Petitioners' counsel for proper distribution. IT IS FURTHER ORDERED and DECREED that the settlement proceeds be allocated. as follows: To: ROMELLO JACKSON, a minor $3,131.06 DATE OF BIRTH: July 18, 2006 SOCIAL SECURITY NUMBER 159-84-2877 IT IS FURTHER ORDERED and DECREED that the settlement proceeds be distributed as follows: To: Reiff and Bily - Costs: (a) Records from West Shore EMS $27.28 (b) Records from Harrisburg Hospital $47.00 (c) Records from Mechanicsburg Chiropractic Ctr. $67.20 (d) Records from David W. Gerhart, D.C. $61.25 (e) Department of Public Welfare $100.92 TOTAL COSTS: $303.65 To: Reiff and Bily - Legal Fee: Fee [33 1/3 of $4,696.35 (after costs have been taken out) $1,565.29 The balance, the sum of $3,131.06 And any interest thereon, payable to the minor, shall be distributed as follows: COUNSEL, and not the parent(s) or guardian(s) of the minor, is hereby authorized and specifically DIRECTED to execute all documentation necessary to deposit the funds belonging to the minor in an interest bearing savings account or savings certificate in a federally insured bank or savings institution having an office in Cumberland County, Pennsylvania, IN THE NAME OF THE MINOR ONLY. The savings account or certificate shall be marked as hereinafter directed. The savings account shall be titled and restricted as follows: ROMELLO JACKSON, a minor, not to be withdrawn before minor attains majority or upon prior Order of Court. The savings certificate shall be titled and restricted as follows: ROMELLO JACKSON, a minor, not to be redeemed except for renewal in its entirety, nor to be withdrawn, assigned, negotiated or otherwise alienated before the minor attains majority, except upon prior Order of Court. If no withdrawals are made from the investments authorized by this Order, the depository may pay over the balance on deposit when the minor attains majority, as defined with reference to 20 Pa. C.S.A. §102, without further Order of this Court. Counsel shall file with the Office of the Prothonotary within sixty (60) days from the date of this Order, proof of the establishment of the accounts as required herein, by Affidavit from counsel certifying compliance with this Order. Counsel shall attach to the Affidavit a copy of this Order as well as a copy of the Certificate of Deposit or bank account title page showing the amount deposited and containing the required restrictions. The Affidavit shall further contain a specific averment by counsel that counsel, and not the parent(s) and/or guardian(s) of the minor, established the account(s) and deposited the funds therein as directed above. Ap C) .- —; CO 03 :11 r w --4 c) SAD -,c TRUE CORY FROM RECORD In TeStimorZ,y whereof; 1 "here_ unto set my hand andf!i' ' I ofsa d C.Qd ort arlisle, Pa. ,is ay of �: -=- 20 / Prothonot