HomeMy WebLinkAbout12-1500V
.
rncO ,-M ms- F7:3
. ? 7:3
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PErI,V6NIA°
C:1._ ?.,
IN RE: JOIELL STONER, NO. la - I L2D Cl.ur /?rH i
a Minor
PETITION FOR COURT
APPROVAL OF MINOR'S
SETTLEMENT
PETITION FOR COURT APPROVAL OF MINOR'S SETTLEMENT
COMES NOW, Petitioner, Kim Wells, as parent and natural guardian of Jozell Stoner, by
and through Griffith, Strickler, Lerman, Solymos & Calkins, and Michael B. Scheib, Esquire,
and files a Petition for Court Approval of Minor's Settlement, and in support thereof avers as
follows:
Jozell Stoner ("Jozell") is a minor who has a date of birth of May 12, 1995, and is
currently 16 years of age.
2. Jozell resides with her mother, Kim Wells, at 21 Country View Estates, Newville,
PA 17241.
3. This matter arises out of a motor vehicle accident that occurred on April 3, 2011,
2011 at which time Jozell was 15 years old.
4. On the aforesaid date, Jozell was an unrestrained back seat passenger in a motor
vehicle driven by Brandon L. Barrick and owned by Stanley and Mary Barrick.
103-175 PO A`rV
e 8x101
F
The accident occurred on Mohawk Road, Lower Mifflin Township, Cumberland
County and resulted in Brandon Barrick losing control of the vehicle, striking a safety fence and
rolling over, resulting in Jozell being ejected from the vehicle.
6. As a result of the aforementioned accident, Jozell was taken by Newville EMS to
Carlisle Regional Medical Center
At Carlisle Regional Medical Center Jozell was evaluated with concussion
without loss of consciousness, acute contusion, acute dislocation, acute fracture, pneumothorax,
traumatic liver laceration, traumatic splenic laceration. Due to the Jozell's condition it was
recommended by Dr. Adam Braze that Jozell be transported to Hershey Medical Center. A true
and correct copy of the report of Carlisle Regional Medical Center is attached hereto as Exhibit
"A"
8. Jozell was admitted to Hershey Medical Center on April 3, 2011 where she was
diagnosed with head injury as well as fracture of the processes of lumbar and cervical vertebrae,
a right scapula fracture, fracture of an upper right molar (tooth #3), and a chipped maxillary
incisor (tooth #8). A true and correct copy of the Consult report is attached hereto as Exhibit
«B„
9. On April 3, 2011 Jozell underwent surgery for the removal of a obliquely
fractured lingual cusp of tooth #3. A true and correct copy of the Operative Report is attached
hereto as Exhibit "C".
10. On April 5, 2011 Jozell was discharged from Hershey Medical Center with a
discharge diagnosis of left C7 transverse process fracture, right L1 transverse process fracture,
r
right comminuted scapular fracture and right pulmonary contusion. A true and correct copy of
the Discharge Summary and ED Summary are attached hereto as Exhibit "D".
11. There was a follow-up visit on April 27, 2011 with Dr. Mark S. Dias, MD of
Hershey Medical Center in which Dr. Dias discharged Jozell from his care and advised to
follow-up on an as-needed basis. A true and correct copy of pages 1 and 2 of the Outpatient
Letter is attached hereto as Exhibit "E"
12. Jozell does not currently have any doctor appointment scheduled due to the
accident and has not received any additional medical treatment as a result of the accident.
11. At the time of the accident, Stanley and Mary Barrick were insured by Encompass
Insurance Company Insurance with bodily injury limits in the amount of $100,000.00 per person
and $300,000.00 per accident. A true and correct copy of Stanley and Mary Barrick's
declarations page is attached hereto as Exhibit "F" .
12. There is currently an outstanding lien in the amount of $12,542.69 with The
Rawlings Company for unpaid medical bills incurred because of the accident. A copy of the
letter of Connie Sattizahn of Encompass Insurance acknowledging the lien is attached hereto as
Exhibit "G".
14. Kim Wells, as the parent and natural guardian of Jozell Stoner, has presented a
claim to Encompass Insurance Company.
16. Kim Wells, as the parent and natural guardian of Jozell Stoner, and Encompass
Insurance Company, have agreed to a settlement of the claim in the amount of $55,296.82, which
shall be made payable in the following payments:
a. A payment in the amount of $40,750.00 shall be paid by Encompass
Insurance Company to Kim Wells as parent and natural guardian of Jozell Stoner
to be deposited in a savings account in the name of Jozell Stoner, a minor.
b. A payment in the amount of $12,542.69 shall be paid by Encompass
Insurance Company to The Rawlings Company to satisfy the outstanding lien for
unpaid medical bills for the treatment of Jozell Stoner.
18. On January 19, 2012 Encompass Insurance Company paid West Shore
Emergency Medical Service the amount of $1,172.12 and to Commercial Acceptance Company
the amount of $832 for payment to satisfy outstanding bills regarding the treatment of Jozell
Stoner.
19. The aforesaid payments were funded from the settlement payment of the claim in
the amount of $55,296.81. A copy of the payment information is attached as Exhibit "H".
20. Pursuant to Pa.R.C.P. 2039(2) the amount $40,750.00 is to be deposited in a
savings account in the name of Jozell Stoner, a minor, with proof of deposit to be filed within
fourteen (14) days from the date of the approved settlement.
21. Kim Wells, as parent and natural guardian of Jozell Stoner, understands that
Attorney Michael B. Scheib was retained by Encompass Insurance Company to obtain court
approval of the minor's settlement. Attorney Scheib were not involved in the decision to settle
this claim. Attorney Scheib will not be paid from the settlement funds.
22. Kim Wells, as parent and natural guardian of Jozell Stoner, believes that this
settlement is fair and reasonable compensation for the injuries suffered by her daughter Jozell
Stoner.
23. Kim Wells, as parent and natural guardian of Jozell Stoner, understands that if the
Court approves the settlement, Jozell Stoner will be barred from filing any other type of claim or
lawsuit as a result of the April 3, 2011 accident.
24. Kim Wells, as parent and natural guardian of Jozell Stoner, understands that if the
Court approves the settlement, she will be required to execute a document which releases Stanley
and Mary Barrick and Encompass Insurance Company as a result of the April 3, 2011 accident.
25. Kim Wells, as parent and natural guardian of Jozell Stoner, believes that the
approval of this settlement is within the best interest of her daughter, Jozell Stoner.
WHEREFORE, Petitioner, Kim Wells, as parent and natural guardian of Jozell Stoner,
respectfully requests this Honorable Court approve the minor's settlement of this matter.
GRIFFITH, STRICKLER, LERMAN,
S(
By:
York, PA 17402-3737
Telephone: (717) 757-7602
Supreme Court I.D. No. 63868
110 South Northern Way
VERIFICATION
I, Kim Wells, as parent and natural guardian of Jozell Stoner, a minor, verify that the
statements made in the foregoing Petition For Court Approval of a Minor's Settlement are true and
correct, upon my personal knowledge or information and belief. This verification is made subject to
the penalties of 18 Pa.C.S. §4904, relating to unworn falsification to authorities.
c,
Date: f:a- ?21, 26 J/ , 20yI'lo1 l
im W s nt and natural guardian of
Jozell ne
w n
a
J
.Q
REPRINT CariisleRegional Medical Center REPRINT
- 361 Alexander Spring Drive, Carlisle, PA 17013
(717)960-1695
Patient: STONER, JOZELL A DOS: 5112M995 Patient #: 9492244 MRN: 0000775387 Date In: 41312011
CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: PF3 04/03/201105:05
STOVER, JOZELL A is a 1.5 year old F that presented to the Emergency Department at 04:50 by ALS-
W Shore. The patient was triaged at 04:50 with the.following vital signs: T: 97.7 TA, P: 68 Regular, R:
24 Unlahored, BP: 120/068, SP02: 97 Amt-RA, Pain: 10 Upper Arm. The patient's primary care
physician is ROSARIO, ELISEO.
Chief Complaint -1tv1VA - A>VfBULATORY AT SCENE
Exam Time: 0.5:05.
History obtained from: patient.
Onset of symptoms was immediately prior to arrival in the Emergency Department- Symptoms came on.
suddenly.
Symptoms are present now.
Accident was Patient's car rolled over at least one time. At time of impact, patient was seated in rear
seat on driver's side. Patient was unrestrained. Damage to vehicle was severe.
Symptoms located in the right arm, neck.
On 0 to 10 pain scale, patient rates pain as 10/10 at this time. Symptoms are severe.
15 year old female unrestrained back seat passenger brought in from rollover mva.
REVIEW OF SYSTEMS: PF3 04/03/201108:12
All (other) systems have been reviewed and are negative.
Neurological: negative headache.
Musculoskeletal: positive back pain, positive extremity pain, positive neck pain.
Constitutional: positive chills.
PAST MEDICAL AND SURGICAL HISTORY: PF3 04/03/201106:49
Past Medical History: positive none.
Reproductive History: LIViP: 1 WK AGO.
Tetanus Status: unknown.
Immunizations: up to date.
FAIMILY AND SOCIAL HISTORIES, ALLERGIES AND MEDS: PF3 04/03/201 1 06:49
Allergies: nkda
Medications: none
Social History: Child's primary caregiver is mother.
Physician Documentation (Pro-MED Clinical Systems, L.L.C.)
Printed on, 04/0312011 09:03
Page 1 of 4
REPRINT
REPRINT
PAGE 215" RCVD AT 511012011 1:36:39 PM [Central Dayligpt Time]* SVR:A0185-XFX0006-S115 * DNIS:51381 " CSID:7179603524' DURATION (mm-ss):02-18
REPRINT Carlisle Regional Medical Center REPRINT
361 Alexander Spring Drive, Carlisle, PA 170-13
(717)960-1695
Patient: STONER, JOZELL A DOS: 511211995 Patient #: 9492240 MRN: 0000775387 Date in: 413120i1
PHYSICAL EXAMINATION: PF3 04/03/201108:13
General: Vital sums noted- Pulse Oximetry results noted. Patient arrived in ED on backboard, with (-
collar in place.-
REENT: loose tooth
Neck: C-collar in place. abrasion under c collar with localized discomfort
Respiratory: Lung Sounds: clear bilaterally.
Cardiovascular: Heart rate is normal.
Abdomen: No evidence of guarding, mass, rebound tenderness.
Musculoskeletal/Extremity: Right Upper Extremity: Shoulder -- Pain in right arm, holds in flexion,
avoids movement
Skin:
Location: bolls arms.
Neurologic: !Mental Status: awake and alert.
Psychiatric: anxious
DIAGNOSTIC TEST RESULTS: PF3 04/03/201106:49
...._......_
Pulse Oximetry .... ............. ..... . ----- --.__ - T _. _
Fi02: room air 02 Saturation: .97%
Interpretation: { Interpretation: Normal
Radiology:
Computerized Tomography Scan: Brain -- No acute disease- Cervical Spine -- No acute fracture.
Chest -- contusion of right lung, no pneumothorax, fractures of the right scapula, fracture of the right
transverse process of L 1 Abdomen/Pelvis -- No acute disease.
LABORATORY:
Orders/Procedures
PF3 Ur Bact = LARGE reviewed as Abnormal
PF3 Ur LE = 500/ul reviewed as Abnormal
PF3 Ur WBC == 2540 reviewed as Abnormal
ED COURSE AND TREATMENT: PF3 04/03/201108:12
Treatment & Reevaluation: Patient has received: intravenous fluids, 20 n-L/kg normal saline
intravenous bolus.
Note: Reviewed films with patient and her family.
Treatment & Reevaluation: Patient has been medicated with: Rocephin 1000 mgs intravenously.
Physician Documentation (Pro-MED Clinical Systems, LLC.)
Printed on: 04/031201109:03
Page 2 of 4
REPRINT
REPRINT
PAGE 315 * RCVD AT 5110/2011 1:36:39 PM [Central Daylight Time] * SVR:A0185-XFX0006-S115 * DNIS:51381 * CSID:7179603524 * DURATION (mm-ss):02-18
REPRINT Carlisle Regional Medical Center REPRINT
361 Alexander Spring Dtive, Carlisle, PA 17013
(717)960-1695
Patient: STONER, JOZELL A DOS: 511211995 Patient #: 9492240 MRN: 0000775387 Date 1n: 413/2011
CONSULTATION & CRITICAL THINKING: PF3 04/03/201 1 08:20
The following diagnoses were considered based on the patient's clinical presentation: Concussion
Without Lass of Consciousness, Acute Contusion, Acute Dislocation, Acute Fracture, Pneumothorax,
Traumatic Liver Laceration, Traumatic Splenic Laceration.
Case discussed with Dr. BRAZE, ADAM J. Time of consult: 08:40. S/He agrees that patient's condition
merits admission to hospital.
S/He recommends transfer of patient.
Case discussed with Dr. **NONSTAFF, PHYSICIAN. Time of consult: 08:47. S/He recommends
transfer of patient. Dr. Kass
CLINICAL EN PRESSION: PF3 04/03/201 1 06:48
1. Motor Vehicle Accident
2. Fractures of the right scapula
3. Fracture of the right transverse process of L l
4. Minima.( contusion of the right middle lobe and right upper lobe
5. Urinary Tract Infection
DISPOSITION: PF3 04/03/201 1 08:39
Disposition: Patient will be transferred to: Hershey Medical Center. Transfer forms completed.
Disposition date/time: 04/03/201108:44.
Discussed care; with patient and family. Explained findings, diagnosis, and need for follow-up care.
Critical Care Services Rendered: 30-74 minutes.Note:Total critical care time documented does not
include time spent on separate procedures.
PHYSICIAN ORDERS
(1) CT Scan Head w/o Contrast [PF3} sent at 4/3/2011 5:19
(1) CT Scan C-spine w/o contrast [PF3] sent at 4/3/2011 5:19
(1) CT Scan Chest w./ contrast [PF3] sent at 4/3/2011 5:19
(1) Shoulder, Trauma, 3v [PF3] sent at 4/3/20115:19
(1) Elbow 3 view [PF3] sent at 4/3/2011 5:19
(1) Urine Dip [PF3] sent at 4/ 3/2011 5.30
(1) Urine Preg :Dip [PF3] sent at 4/3/2011 5:30
(1) Urinalysis (Send to Lab) [PF3] sent at 4/3/2011 5:53
(1) Urine Culture [PF3] sent at 4/3/2011 5:53
(1) CT Scan Abd/Pelvis w/o contrast [PF3] sent at 4/3/20117:57 [by: MAL, Verbal]
(1) **IV Insertion [PF3] ordered at 4/3/20115:17
(1) Pulse Ox-Continuous [PF3] ordered at 4/3/2011 5:17
(1) Blood Pressure Monitor Only [PF3] ordered at 4/3/20115:17
(1) :Normal Saline Bolus one liter iv [PF3] ordered at 4/3/2011 5:17
(1) Urine Dip [PF3] ordered at 4/3/2011 5:45 [by: DMR, Verbal order read back]
Physician Documentation (Pro-MEt3 Clinical Systems, L.L.C.)
Printed on: 04/03/201109:03
Page 3 of 4
REPRINT
REPRINT
PAGE 415 * RCVD AT 511 0120 11 1:36:39 PM (Central Daylight Time] * SVR:A0185-XFX0006-S115 * DNIS:51381 * CSID:7179603524 * DURATION (mm•ss):02-18
REPRINT Carlisle Regional (Medical Center I? I4PMN- T
361 Alexander Spring Drive, Carlisle, PA 17013
(717)960-1695
Patient: STONER, JOZELL A D06: 5112!1995 Patient#: 94922411 MRN: 0000775387 Date In: 41312011
(i) Urine Preg [PF3] ordered at 4/3/2011 5:45 [by: I74R, Verbal order read back]
(1) Cath Collection [.PF3] ordered at 4/3/20116:16 [by: I)MR, Verbal order read back]
(1) Baciwcin/dsg [PF3] ordered at 4/3%2011 7:30 [by: GAO, Verbal order read back]
(1) IS/ Rocepimn 1000 mg [PF3] ordered at 4/3/2011 3:39
PArRICIA L *FRIERSON_MD MD All text in this document clearly marked by PF3 has been
authored and legally signed by use of electronic device. 04%03/2011 09:03
4
Physician Documentation (Pro-MED Clinical Systems, L.L.C.)
Printed on. 0410312011 09:03
Page 4 of 4
REPRINT
REPRINT
PAGE 515 * RCVD AT 511012011 1:36:39 PM [Central Daylight Time] * SVR:A0185-XFX0006-$115 ' ONIS:51381 ' CSID:7179603524 * DURATION (mm-ss):02-18
®4
N
6
J
4
PENNSTATE HERSHEY
Milton S. Hershey
IV Medical Center
Patient Name: STONER, JOZELL A
MRN: 7509408
Date of Birth: 5/12/1995
Patient Gender: Female
Penn State Hershey Tel: (717) 531-8055
Milton S. Hershey Medical Center
Health Information Services, HU24
500 University Drive
P.O. Box 850
Hershey, PA 17033-0850
Visit Number: 10509408
Visit Type: Inpatient
Patient Location: 7MBE; 7224; 01
:.................. Consult ...._.........._......................_....................__.._:__`.
RESULT STATUS:
DOCUMENT SUBJECT:
ELECTRONICALLY SIGNED BY:
Final
Clou ghe rty, Marianna (4/5/2011 14:30 EDT)
CONSULT
Name: STONER, JOZELL A
HMC Number: 7509408
DOB: 05/12/1995
Date of Service: 04/03/2011
HPI: The patient is a 15-year-old Caucasian female who was reportedly an unrestrained rear seat passenger in a rollover
MVA from which she was ejected. She was seen at Carlisle Hospital and evaluated, then transferred to Hershey Medical
Center. She reportedly has head injury as well as fracture of the processes of lumbar and cervical vertebrae, a right
scapula fracture, fracture of an upper right molar (tooth #3), and a chipped maxillary incisor (tooth #8). She remains in a
cervical collar and is currently reportedly refusing MRI due to claustrophobia.
PAST MEDICAL HISTORY: noncontributory. She is not diabetic to my knowledge, has no history of heart murmur or
valvular heart disease, and is not on any anticoagulants.
ALLERGIES: NKDA.
EXAM: Head and neck exam is within normal limits except for an Ellis Class II fracture of tooth #8, her maxillary right
central incisor, and an Ellis Class III fracture of tooth #3, her maxillary right first molar which has a large pulp exposure.
There is no evidence of mandibular or alveolar fractures. Her occlusion is within normal limits without any stepoffs. She
has no trismus and her TMJs are normal on palpation with no crepitus noted, with a normal range of movement, and
without deviation of the mandible. She has no facial or intraoral edema or suppuration. She has no lacerations of her lips
either intraorally or extraorally. There is no palpable lymphadenopathy.
DIAGNOSTIC IMAGING: Periapical radiographs were taken of teeth # 3 and #8. The periapical radiograph of tooth #8
reveals a fracture that extends into the dentin and is small, approximately 1 mm X 2 mm. Periapical radiograph of tooth 43
reveals an Ellis Class III fracture with a lingual cusp that is obliquely separated from the tooth and only attached to gingiva.
There is a large pulp exposure here.
ASSESSMENT AND PLAN: Because the fractured lingual cusp on tooth #3 poses an aspiration risk and because this
fractured portion of tooth is non-salvageable, removal of the fractured portion of tooth #3 is recommended with local
anesthesia. The patient and her mother (via phone) were advised that the patient should follow up with her regular dentist
on discharge. Both patient and mother were advised that endodontic (root canal) treatment and a crown or extraction of
Date/Time Printed: 5/19/2011 18:42 EDT Pagel of 27
Printed By: Collin's,Nikki L
-PENN STATE HERSHEY
Milton S. Hershey
Medical Center
Patient Name: STONE=R, JOZELL A MRN 7509408
Consult
tooth #3 will be necessary due to the large area of nerve exposure. Consent was obtained from the patient's mother over
the phone with Nurse, Rachel, present. After discussing the options, risks, benefits, cost, and alternatives of all treatment
options, mother gave consent for administration of local anesthesia and removal of the obliquely fractured lingual cusp or
tooth #3. Mother's questions were answered. The patient has no known indication for SBE prophylaxis. No post-op
antibiotics are recommended at this time for the patient upon discharge from a dental standpoint since she has no
intraoral or extraoral facial lacerations.
160284
Electronic Signature on File
Electronically Reviewed/Signed by: Marianna Clougherty, DDS Author Signature Dt/Tm:05.04.2011 02:30 PM
MC /DKW DD: 04104111 DT: 04/05/11 06.43
Date/Time Printed: 5/19/2011 18:42 EDT Page 2 of 27
Printed By: Callins,Nikki L
J
Q
W
J
W
H
N
C
J
J
Q
PENNSTATE HERSHEY
M 1ton S. Hershey
IV Medical Center
Patient Name: STONER, JOZELL A
MRN 7509408
Operative Report
RESULT STATUS:
DOCUMENT SUBJECT:
ELECTRONICALLY SIGNED BY:
Final
Clougherty, Marianna (4/5/2011 14:38 EDT)
OPERATIVE REPORT
Name: STONER, JOZELL A
HMC Number: 7509408
DOB: 05/12/1995
Date of Service: 4/3/2011
SURGEON: Marianna Clougherty, DDS
ASSISTANT(s): Peds Nurse, Rachel
PREOPERATIVE DIAGNOSIS: The patient is a 15-year-old Caucasian female who was the unrestrained rear seat
passenger in a rollover MVA. She has multiple injuries including a reported head injury, lumbar and cervical vertebrae
process fractures, right scapular fracture, fracture of upper right molar #3 and chipped tooth #8, her maxillary right central
incisor.
POSTOPERATIVE DIAGNOSIS: Same
OPERATION PERFORMED: Removal of obliquely fractured lingual cusp of tooth #3.
ANESTHESIA: Local using 1 carpule of 2% lidocaine with 1:100,000 epinephrine (1.7 ml)
FINDINGS: The patient is a 15-year-old female who requires removal of the obliquely fractured portion of tooth #3
because it is an aspiration risk and is only slightly attached to the palatal gingiva. No premedication or postoperative
antibiotics are required as the patient has no intraoral or extraoral lacerations and no indication for SBE prophylaxis.
OPERATION: The patient remained in her bed on the 7th floor and in her cervical collar for the duration. The anesthesia
used was 1 carpule of 2% lidocaine with 1:100,000 epinephrine. A 2 x 2 gauze was unfolded and placed in the distal
portion of the patient's oral cavity to act as a throat pack. The lingual cusp of tooth #3 which was obliquely fractured was
removed without complication. The throat pack was removed. Bleeding was minimal with negligible blood loss.
Consent was obtained from the patient's mother prior to the procedure over the phone with nurse, Rachel, present. Spoke
with patient's mother, Kim Wells, and discussed options, risks; benefits, cost and alternatives of all treatment options, and
mother had consented to this procedure prior to commencement of the procedure.
160287
Date/Time Printed: 5/19/2011 18:42 EDT
Page 3 of 27
Printed By: Collins,Nikki L
-PENNSIA-FE HERSHEY
1 1 Milton S. Hershey
Medical Center
Patient Name: STONER, JOZELL A
MRN 7509408
.,_._..._........_..___.._._.?__._...._._..?_.._......_._.........._.?......._?..?.__...?
« ................................?._...__._?_.._.___._..__.........?.?...............?.....Operative Report
Electronic Signature on r7e
Electronically Reviewed/Signed by: Marianna Clougherty, DDS Author Signature Dt/Tm:05.04.2011 02:38 PM
MC /AMO DD: 04104111 DT.' 0410511107.09
Date/Time Printed: 5/19/2011 18:42 EDT Page 4 of 27
Printed By: Collins,Nikki L
4
J
4 D
J
4
r
PENNSTATE HERSHEY
Milton S. Hershey
Medical Center
Patient Name: STONER, JOZELL A
MRN 7509408
............. _.................._..........._,......._., ...
Discharge Summary
RESULT STATUS:
DOCUMENT SUBJECT:
ELECTRONICALLY SIGNED BY:
Final
.D/C Summary
Santos, Mary C (4/6/2011
(4/5/2011 17:07 EDT)
14:42 EDT); Albright,William B
DISCHARGE SUMMARY
Name: STONER, JOZEL L A
HMC Number: 7509403
DOB: 05/12/1995
Dale of Admission: 04/03/2011
Date of Discharge: 04105/2011
Reason for Discharge: Stable for Discharge
Physician: Santos, Mary C
Service: Peds Surgery
Discharge Diagnoses:
Left C7 transverse process fracture
Right L 1 transverse process fracture
Right comminuted scapular fracture
Right pulmonary contusion
Other Diagnoses:
UTI on arrival
Concussion with amnesia to event
Chipped right maxillary molar
Surgical Procedures: Right maxillary molar extraction
Vaccinations Received This Hospital Stay:
No vaccinations were given this hospital stay.
Discharge Medications:
Acetaminophen-oxycodone (acetaminophen-oxycodone 325 mg-5 mg tablet) TAKE 1-2 TABLETS BY MOUTH EVERY SIX
HOURS AS NEEDED FOR PAIN_
Brief History of Present Illness:
This is a 15-year-old female who was transferred from Carlisle hospital for definitive pediatric trauma care. She arrived at their
hospital at approximately 0430 in the AM following a rollover MVA. She was not wearing a seat belt. It was reported that she was
ejected and found some distance away. It was also reported that the car did catch fire after the incident- The outside hospital did a
urinalysis which reportedly showed a UTI. She was treated with IV Rocephin.
Hospital Course:
Date/Time Printed: 5/19/2011 18:42 EDT
Page 5 of 27
Printed By: Collins,Nikki L
- - - PENNSZATE HERSHEY
Milton S. Hershey
WV Medical Center
Patient Name: STONER, JOZELL A
MRN 7509408
Discharge Summary« ...................
She was a level 2 trauma transfer. Studies revealed a right clavicle fracture, left transverse process of C7, right transverse process
fracture of L1, concussion with amnesia (unknown loss of consciousness), pulmonary contusion, chipped right maxillary molar which
was extracted, She was admitted to the 7th floor after studies were completed. Miami J collar remained on. T/L spines were cleared.
An MRI was ordered of the cervical spine, however she was not able to remain still and it was reordered for 4/4 in the later am.
Anesthesia was consulted for assistance with the MRI. She had started clears but was subsequently was made NPO. Sling was on for
comfort due to the right clavicle fracture. PT/OT therapies were ordered and she was passed for home. OT did note some loss of
memory regarding the accident and some confusion. This began to clear as the day went on. MRI of the C spine showed edema
around C7 tp without evidence of cord injury, and incidental finding of Chiari I malformation. The Cervical spine was cleared by
Neurosurgery. The patient's diet was advanced and tolerated well. Pain was controlled with oral pain meds. Rocephin treatment was
completed for the UTI diagnosed at the outside hospital. At the time of discharge the patient had normal bowel and bladder function.
The patient was deemed stable for discharge with appropriate follow up appointments and medications.
Exam on Discharge:
NAD/AAOx3
Neck: Supple, non tender, lull RONI, collar removed
C TAB
RRR, no murmurs
R arm in sling (for comfort), neurovascularly intact, normal 5/5 motor
Abd: Soft, NT/ND, normal bowel sounds
Care Instructions:
1. R arm - sling to comfort. Use as tolerated.
2. See the head injury care instructions. The key to getting better after a head injury is to rest when tired, avoid overstimulation and
overtiredness. If ANY activity increases symptoms, stop and rest in a quiet area.
3. Pain medications can cause constipation. Take an over-the-counter laxative (like Senokot or MiraLax) as needed. Please do not
operate motor vehicles while taking pain medications.
Diet Guidelines:
Regular diet. Encourage plenty of liquids.
Activity Guidelines:
Avoid activities that may lead to falls/impact for the next 6-8 weeks. No jumping, climbing, sports, PE, riding things with wheels, etc.
Return to school - at parents' discretion once paia/mobility are improved, and return of normal energy level - likely up to a week.
Upon return, parents, pt and school staff should monitor for return/increased symptoms (headaches, fatigue, difficulty concentrating or
processing information). If this occurs, it may signal that it is too soon to return, or a modified school attendance schedule may be
needed. Please call to let us know if this occurs.
Call your doctor if.
Please call 717-531-8521 (operator - ask for the pediatric surgery resident on-call): fever greater than 101F, increased severe pain,
persistent vomiting, increased swelling/pain or color changes to RUE (blue/grey/white); and mental status changes.
For routine questions during the weekdays, please call the pediatric surgery office at 717-531-8342.
Please call the number above and ask for the neurosurgery resident on call if you develop confusion or headaches/vomiting.
Date/Time Printed: 5/19/2011 18:42 EDT Page 6 of 27
Printed By: CoHins,Nikki L
-PENNSTATE HERSHEY
Milton S. Hershey
Medical Center
Patient Name: STONER, JOZELL A
MRN 7509408
_._......._ .,
........... _................_.. .... ............ ` ....._.__......._......,.................._._......_ __ ...........
Discharge Summary
Other Instructions:
Penn State Hershey Children's Hospital Injury Prevention Tips: Teen Driver Safety
1. ALWAYS travel with your lap and shoulder seat belt, snugly fastened.
2. Never ride or drive under the influence of alcohol or drugs.
3. Obey posted speed limits.
4. Avoid distracted driving - using cell phone or texting, eating, adjusting the climate or music controls.
5. Limit (he number of passengers riding with teen drivers.
You will need to notify your dentist of the right molar extraction. You will need to be evaluated for any follow up treatment for this
molar injury.
Follow-Up Appointments:
Scheduled Penn State - Hershey Appointments Within the Next 90 Days.
Follow-Up with Dias, Mark at Pediatric Bone & Joint and Neuroscience East Campus on 04/27/2011 at 01:15 pm
160999
Electronic Signature on File
CC: Eliseo Rosario, Jr, MD
804 Belvedere Straot
Carlisle PA 17013
Electronically Reviewed/Signed by: William B Albright, MD Author Signature Dt/Tm:05.04.2011 05.07 PM
Electronically Reviewed/Signed by: Mary C Santos, MDCosigner Signature Dt/Tm: 06.04.2011 02:42 PM
Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Brett Engbrecht,
Kerry Fagelman, Dorothy Rocourt, Mary Santos
Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP, PNP-BC,
Lynn Simmons MSN CRNP
WBA /JJR DD: 04105111 DT: 04105111 15.37
Date/Time Printed: 5/19/2011 18:42 EDT Page 7 of 27
Printed By: Collins,Nikki L
-PENN SIATE: HERSHEY
IR?1 Milton S. Hershey
Medical Center
Patient Name: STONER, JOZELL A MRN 7509408
.............. ........ --............... . ................. ........... .... .,..............................?
ED Summary
RESULT STATUS:
DOCUMENT SUBJECT:
ELECTRONICALLY SIGNED BY:
Final
Motor vehicle crash - major
Kass,Lawrence E (4/3/2011 11:27 EDT)
Motor vehicle crash - major
Patient: TRAUMA, 7509408 MRN: 7509408 OOS: FIN: 10509408
Age: 111 years Sex: Unknown DOB: 1/1/1900
Associated Diagnoses: None
Author: Kass, Lawrence E
Basic Information
Time seen: Immediately upon arrival.
History source: Patient.
Arrival mode: Ambulance.
History limitation: None.
History of Present Illness
The patient presents following motor vehicle collision. The onset was before 5 AM. The Collision was unknown. The
patient was the passenger and in the rear seat. There were safety mechanisms including no seat belt. multiple
abrasions. Fracture of scapula and spinous processes.. The degree of pain is minimal. The degree of bleeding is
minimal. Risk factors consist of alcohol abuse. Therapy today: none. Associated symptoms: none. Additional history:
unrestrained RS pass in rollover. Seen at Carlisle hospital and evaluated. Transferred here for further mgt. Given Toradol
just prior to transfer. Transfer uncomplicated and without intervention..
Review of Systems
Constitutional symptoms: Negative except as documented in HPI.
Additional review of systems information: All other systems reviewed and otherwise negative.
Health Status
Allergies: .
No allergies have been recorded.
Past Medical/ Family/ Social History
Medical history
Negative.
Surgical history: Negative.
Physical Examination
Vital Signs
Per nurse's notes.
General: Alert, no acute distress.
Skin: multiple abrasions to elbows and back.
Head: Atraumatic.
Date/Time Printed: 5/19/2011 18:42 EDT
Printed By: Collins,Nikki L
Page 8 of 27
•-PENNSTATE HERSHEY
1 Milton S. Hershey
Medical Center
Patient Name: STONER, JOZELL A
MRN 7509408
.......................?
:. ------ ................................................ ................ .................................... ...................... .................................................. ................ .........
ED Summary
Neck: Trachea midline, no tenderness.
Eye: Pupils are equal, round and reactive to light, normal conjunctiva.
Ears, nose, mouth and throat: Tympanic membranes clear.
Cardiovascular: Regular rate and rhythm, No murmur, Normal peripheral perfusion.
Respiratory: Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal,
Symmetrical chest wall expansion.
Chest wall: On exam: Right, tenderness, no crepitus, no subcutaneous emphysema.
Musculoskeletal: Normal ROM, normal strength, no tenderness.
Gastrointestinal: Soft, Nontender, Non distended, Normal bowel sounds.
Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit observed.
Psychiatric: Cooperative.
Medical Decision Making
Trauma team: Trauma criteria met, trauma team assembled, trauma surgeon present.
Differential Diagnosis: Motor vehicle collision, head injury, trunk injury, internal hemorrhage, spinal injury.
Impression and Plan
Plan
Condition: Stable.
Disposition: Patient care transitioned to: Time: 04/03/2011 11:27:00, Santos, Mary C.
Addendum
Signatures:
Lawrence E. Kass, MD, FACEP, FAAEM
Associate Professor, Department of Emergency Medicine
ViceChair for Education, Residency Director
Hershey Medical Center
PO Box 850, MC H043, Hershey, PA 17033
(717)531-1443 Fax:(717)531-4441
Date/Time Printed: 5/19/2011 18:42 EDT Page 9 of 27
Printed By: Collins,Nikki L
P-0
0a
c7
w
a E
J
Q
( ENNSIATF HERSHEY
1 1i lton S. Hershey
Medical Center
Patient Name:
MRN:
Date of Birth:
Patient Gender:
..........................
STONER, JOZELL A
7509408
5/12:! 1995
Female
RESULT STATUS:
DOCUMENT SUBJECT:
ELECTRONICALLY SIGNED BY:
April 27, 2011
Name: STONER, JOZI=LL A
HMC Number: 7509408
DOB: 05/12/1995
Date of Service: 04/27/2011
Eliseo Rosario, Jr, MD
804 Belvedere Street
Carlisle, PA 170'13
Dear Dr. Rosario:
Dias, Mark S (4/29/2011 17:21 EDT)
Jozell returns to Pediatric Neurosurgery on 4/27/1 1 in follow-up of her motor vehicle crash. She was a rear seat
passenger, unrestrained, and was ejected from the vehicle. The vehicle burst into flame. She came in with a modest
head injury with a fracture of the transverse processes of C7 and L1. She recovered quickly from her minor head injury,
and did well while in the hospital. She had some other injuries to her dentition and scapula, but was able to be discharged
to home without further incident. Morn tells me that she is pretty much back to her usual state of mind. She has
underlying ADHD and some mood swings, which predated the accident. She is back to her usual, somewhat
dysfunctional self. She has no intellectual decline, and has not had any headaches, nausea, vomiting, seizures, change in
behavior or intellect, or other signs or symptoms of elevated intracranial pressure. The patient's interim past medical
history and review of systems are.otherwise noncontributory.
On examination, the patient is awake, alert, and engaging. Funduscopic examination shows no papilledema. Extraocular
movements are full without limitation of up gaze, extraocular palsies, or nystagmus. Facial movements are symmetrical.
Facial sensation is intact and symmetrical in all three divisions of the trigeminal nerve. Hearing is intact to finger rub
bilaterally. Tongue and uvula are midline. Sternocleidornastoid and irapezius strength is 5/5 and symmetrical. Muscle
strength is 5/5 in all groups tested without pronation or drift. Tone and bulk are normal. Rapid alternating movements are
performed well. Gait and station are normal for heel and toe walk. Balance and coordination are age appropriate.
Penn State Hershey Tel: (717) 531-8055
Milton S. Hershey Medical Center
Health Information Services, HU24
500 University Drive
P.O. Box 850
Hershey, PA 17033-0850
Visit Number: 15853691
Visit Type: Clinic
Patient Location: HD10
...........................................................................
Outpatient Letter
Final
Date/Time Printed: 6/30/2011 00:04 EDT' Page 1 of 15
Printed By: Collins,Nikki L
. PEA NSTATE HERSHEY
Milton S. Hershey
Mediud `enter
Patient Name STONER, JOZELL A MRN 7509408
--------------
....._....._...__...Outpatient Letter
.
I reviewed her MRI scan performed while in the hospital. Of note, she has a Chiari malformation with about 9 mm of
tonsillar descent below the rim of the foramen magnum, but without any other issues, and no syringomyelia. Mom and I
discussed the issue of her Chiari, which I think is a complete incidental finding. She has no symptoms referable to this.
She and her mother and I briefly discussed some of the symptoms of Chiari malformation. She is actually the one child in
the family who does not have chronic headaches, than God. She has no scoliosis by history or examination. There are
no sensory motor symptoms. She has no swallowing dysfunction or dysphonia. At this point I think this is an incidental
finding, and unless she were to develop symptoms, I would not recommend any further follow-up imaging or treatment. I
will discharge her irom my care to follow-up on an as-needed basis. Thanks again for allowing me the opportunity to care
for her.
#207347
Electronic Signature on mile
CC: Eliseo Rosario, Jr. MD
804 Belvedere Street
Carlisle PA 17013
Sincerely,
Mark S Dias, MD, FAAP Author Signature DtlTn7: 29- 04,2011 05:21 PM
Professor and Vice Chair of Clinical Neumsurrgery
Chief of Pediatric Neurosurgery
Penn State Millon S. Hershey Medical Center
PO Box 850
Hershey, PA 17033
MSD fCJK DD: 04127111 DT- 04I28111 10:16
Date/Time Printed: 6!30/2011 00:04 EDT Page 2 of 15
Printed By: Collins,Nikki L
Y
J
Q
W
W
w F
a
F-
J
J
Q
ti
Policyholder:
STANLEY BARRICK
MARY BARRICK
12 WEIST RD
NEWVILLE PA 17241-8739
Policy Number: Policy Period:
240450543 03127/2011 to 03127/2012
Insurance Provided By:
Encompass Home & Auto Ins. Co.
2775 Sanders Rd.; Northbrook, IL 60062-6127
Description:
VIN:
Rated Driver:
Use:
Class Code:
BODILY INJURY
(per person/per accident)
PROPERTY DAMAGE
(per accident)
LIMITED TORT OPTION
FIRST PARTY BENEFITS (FPB)
COVERAGE:
240450543
Vehicle 1
2005 FORD FOCUS
1FAFP34N25W288630
MARY BARRICK
Pleasure
2321
Agent:
JEFFREY L BOUDER INS AGENCY
19 SOUTH HIGH ST
NEWVILLE PA 17241
PHONE: 717-776-4051 470-114308-0000
Policyholder Since:
12:01 AM Standard Time 0312008
24 HOUR CLAIM REPORTING 800-588-7400
$100,000/300,000 $98.00
$50,000 $72.00
Applies
President Secretary
Vehicle 2
1999 FORD TRUCK F250
1 FTNX21 F6XEE09343
STANLEY BARRICK
Work 3.1-9.9
2363
P
$100,000/300,000 $83.00
$50,000 $59.00
Applies
Continued on Next Page Page 01 of 05
MOTOR VEHICLE PROTECTION (Coverage applies only if a premium or limit is shown)
Vehicle 1
Vehicle 2
COVF(2AGES PREMIGS LIWJT?
BASIC FPB COVERAGE $10.00
Medical Expense Benefit $5,000 $5,000
Work Loss Benefit Excluded Excluded
(per month/maximum)
Funeral Expense Benefit Excluded Excluded
Accidental Death Benefit Excluded Excluded
COMPREHENSIVE (Comp) $100 Deductible $39.00 $100 Deductible
COLLISION (Coll) $500 Deductible $185.00 $500 Deductible
DEDUCTIBLE WAIVER
Deductible will be waived if your windshield is repaired, not replaced.
Premium Per Vehicle
PRA. li _
$4.00
$60.00
$128.00
$334.00
11 cle 2
DISCOUNTS AND CHARGES $ Vehicle i Veh
Loss Free Discount Applied Applied
Anti-Lock Brake Discount Applied
Passive Restraint Discount Applied
Passive Restraint Discount (Driver and Applied
Passenger side)
Anti-Theft Discount (Passive Device) Applied
Homeownership Discount Applied Applied
Future Effective Date Discount Applied Applied
Preferred Protection Discount Applied Applied
TOTAL-VEHICLE(S)
Your Total Premium For All Vehicles $738.00
IMPORTANT INFORMATION ABOUT YOUR MOTOR VEHICLE COVERAGE
Below are annual premiums for the minimum required coverages and limits for Limited Tort. Please note that the
Limited Tort option may not be available on certain vehicles.
Bodily Injury $15,000/Person $30,000/Accident
Property Damage $5,000/Accident
First Party Benefits Medical Expense $5,000
$404.00
Vehicle 1
$84.00
$64.00
$10.00
Vehicle 2 Vehicle
$71.00
$52.00
$4.00
DRIVER INFORMATION
Name Date Licensed Date of Birth
01 STANLEY BARRICK 04/18/1964 04118/1948
02 MARY BARRICK 05/24/1961 05/24/1945
240450543
Continued on Next Page
Page 02 of 05
MOTOR VEHICLE PROTECTION (Coverage applies only if a premium or limit is shown)
LIENHOLDER/OTHER INTERESTED PARTIES INFORMATION
Vehicle 2 Loan Number Type of Interest
SUSQUEHANNA VALL EY FEDERAL CR Lienholder
UNION(RETAIL)
P O BOX 25242
FORT WORTH TX 76124-2242
GENERAL POLICY INFORMATION
The coverages and limits shown here are subject to the restrictions, conditions, and exclusion of the policy and its
endorsements.
YOUR POLICY IS SUBJECT TO THE FOLLOWING FORMS AND ENDORSEMENTS
G1-72228-A (01-07) TRANSITION ENDORSEMENT - SPECIAL
MOTOR VEHICLE SEGMENT
G1-72244-A (01-07) DELETION OF TOWING COVERAGE
G1-72245-A (01-07) DELETION OF TRANSPORTATION
COVERAGE - SPECIAL
G1-72254-A (01-07) INTRODUCTION
G1-72262-A (01-07) GENERAL PROVISIONS
G1-72267-A (01-07) SPECIAL MOTOR VEHICLE
G1-72416-A (02-07) AMENDMENT OF MOTOR VEHICLE PROVISIONS
- PENNSYLVANIA
G1-72417-A (02-07) FIRST PARTY BENEFITS COVERAGE -
PENNSYLVANIA
G1-72437-A (02-07) WHAT LAW WILL APPLY AND WHERE LAWSUITS
MAY BE BROUGHT
PLEASE READ THIS IMPORTANT INFORMATION CONCERNING YOUR POLICY
G1-40173-C (02-09) ENCOMPASS INSURANCE PRIVACY POLICY FOR
CUSTOMERS
G-15383-A (03-90) IMPORTANT INFORMATION FOR PENNSYLVANIA
UNIVERSAL SECURITY POLICYHOLDERS
G-15395-B (06-95) IMPORTANT INFORMATION ABOUT TORT OPTIONS
FOR YOUR MOTOR VEHICLES
G-15397-A (03-90) IMPORTANT INFORMATION ABOUT UNINSURED
MOTORISTS COVERAGE WAIVER OF COVERAGE
G-15398-A (03-90) IMPORTANT INFORMATION ABOUT UNDERINSURED
MOTORISTS COVERAGE WAIVER OF COVERAGE
G-15399-A (03-90) YOUR WAIVER OF UNINSURED/UNDERINSURED
MOTORISTS COVERAGE
G-15400-D (01-02) IMPORTANT INFORMATION REGARDING
PREMIUM DISCOUNTS
G-15401-B (06-95) NOTICE OF MINIMUM REQUIRED AUTOMOBILE
240450543
Continued on Next Page Page 03 of 05
GENERAL POLICY INFORMATION
PLEASE READ THIS IMPORTANT INFORMATION CONCERNING YOUR POLICY
COVERAGES
'G-15402-A (03-90) IMPORTANT INFORMATION REGARDING YOUR
MOTOR VEHICLE IDENTIFICATION CARDS
G1-71197-A (10-04) IMPORTANT CLAIM REPORTING INFORMATION
G1-72431-B (01-08) PENNSYLVANIA SURCHARGE DISCLOSURE
STATEMENT
G1-74503-A (08-09) IMPORTANT NOTICE ABOUT RENEWAL DOWN
PAYMENTS
G1-74515-B (01-10) IMPORTANT NOTICE ABOUT THE ENCOMPASS
PREFERRED PROTECTION DISCOUNT
'G-39558-H (05-07) PENNSYLVANIA FINANCIAL RESPONSIBILILTY
INSURANCE IDENTIFICATION CARD
I-LO910-A (01-81) PENNSYLVANIA NOTICE
9-23210-E (04-00) RENTAL AUTOMOBILE COVERAGE NOTICE
The forms marked with "*" reflect revised or new forms included with this coverage summary.
SUMMARY OF YOUR POLICY'S PREMIUMS
P r W
Co?era
Motor Vehicle $738.00
Total For All Exposures $738.00
For any insurance need, or questions on your policy, contact your independent agent, whose name and number are
shown on the first page of this Coverage Summary.
240450543
Page 04 of 05
AGENT'S USE ONLY
Policy Level
Renewal Number 3
Auto Tier Level Tier 122
Multi-Car Rating 38
Vehicle Level Veh 1 Veh 2
Territory 433 433
Symbol - Comprehensive N G
Symbol - Collision N G
Auto Merit Discount Level 000 000
Sex F M
Marital Status M M
SRM 4 4
Coverage Level Veh 1 Veh 2
Liability Rating Modifier Liability 1.130 1.000
Liability Rating Modifier 1.220 1.000
Personal Injury Protection
Physical Damage Rating 1.320 1.000
Modifier Comprehensive
Physical Damage Rating 1.570 1.000
Modifier Collision
240450543
Page 05 of 05
J
Q
LL!
w G
a
J
Q
ncompass-
Creating protection around you
P.O. Box 16203, ,Reading, PA 19612
1/30/2012
KIM WELLS FOR JOZELL STONER
21 COUNTRY VIEW ESTATES
NEWVILLE PA 17241
encompassinsur-ance_com
Connie Sattizahn AIC AIS SCLA
Staff Clm Serv Adl
Telephone (610) 401-2324
(800) 936-4203 x12324
Facsimile (866) 257-2201
Internet connie.sattizahn@encompassins.com
Claim Number: Z01763631C
Date of Loss: 04/03/2011
Claimant: Jozell Stoner
Injured Party: Jozell Stoner
Our Insured. Stanley and Mary Barrick
Insuring Company. Encompass Home and Auto Insurance Company
Dear Ms. Wells:
This letter will confirm our offer of $55,296.81 that has been extended to settle Jozell Stoner's
claim.
Upon approval from the court, Encompass Home and Auto Insurance Company will issue a
separate check in the amount of $40,750 for Jozell as directed by the court. A separate check will
then be issued to The Rawlings Company in the amount of $12,542.69 to satisfy their outstanding
lien.
Encompass Home and Auto Insurance Company did issue payments of $1,172.12 to West Shore
Emergency Medical Service and $832 to Commercial Acceptance Company to satisfy outstanding
bills at these facilities, out of the above settlement proceeds.
I have enclosed copies of our payment history screens showing the payments that were issued to
satisfy the outstanding medical bills. Please do not hesitate to contact me if you have any further
questions or concerns.
Sincerely,
Connie Sattizahn AIC AIS SCIA
CC: Michael B. Scheib
Enc: Copies of payment history screens
Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false,
incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and the
payment of a fine of up to $15,000.
®a
? ?
w
c
_._-----
J
4
c
r
PI - PAYMENT INFORMATION
ALC ZO 'LAIM# 20176363 DESK# ZM INS/DBA BARRICK, STANLEY AND MARY
LN ISSDAT PAYEE AMOUNT CK/DRAFT# USER/ID PS
04 011812 COMMERCIAL ACCEPTANCE COM 832.00 102233836 OZOCSAT I
PAYEE COMMERCIAL ACCEPTANCE COMPANY AUTH/ID C470756
REV AMT
ADDRESS PO BOX 3268 VENDOR#
CITY SHIRESMANTOWN ST PA ZIP 17011 TIN
EXPENSE
SEND/TO
ADDRESS
CITY ST ZIP
R/C RSN AGCY#712347-KIMBERLY WELLS FOR JOZELL STONE TYPE C ACCT 028 AT A
SFX CVCD DT FROM THRU C TE PC TR PMT/AMOUNT M/A GROSS/BILL NTP
031 BODI 21 832.00 FHA 0.00
SELECT CLMT
ID OZOCSAT
PI - PAYMENT INFORMATION
ALC ZO CLAIM## 20176363 DESK# ZM INS/DBA BARRICK, STANLEY AND MARY
LN ISSDAT PAYEE AMOUNT CK/DRAFT# USER/ID PS
03 011812 WEST SHORE EMERGENCY MED 1172.12 102233835 OZOCSAT I
PAYEE WEST SHORE EMERGENCY MED SVC AUTH/ID C470756
REV AMT
ADDRESS 205 GRANDVIEW AVE STE 211 VENDOR#
CITY CAMP HILL ST PA ZIP 17011 TIN
EXPENSE
SEND/TO
ADDRESS
CITY ST ZIP
R/C RSN ACCT #1106436Y & 1106421-JOZELL STONER TYPE C ACCT 028 AT A
SFX CVCD DT FROM THRU C TE PC TR PMT/AMOUNT M/A GROSS/BILL NTP
031 BODI 21 1172.12 FHA 0.00
SELECT CLMT ID OZOCSAT
s
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
IN RE: JOZELL STONER,
a Minor
NO. /,2 /5oo Civi l T rn
PETITION FOR COURT
APPROVAL OF MINOR'S
SETTLEMENT
ORDER
AND NOW, this I LOttlay of 2012, it is hereby ORDERED that:
1. The Court APPROVES the Petition for Approval of Minor's Settlement.
2. A payment in the amount of $40,750.00 shall be paid by Encompass Insurance
Company to Kim Wells as parent and natural guardian of Jozell Stoner to be
deposited in a savings account in the name of Jozell Stoner, a minor.
3. A payment in the amount of $12,542.69 shall be paid by Encompass Insurance
Company to The Rawlings Company to satisfy the outstanding lien for medical
bills for the treatment of Jozell Stoner.
3. There shall be no counsel fees or costs deducted from the settlement.
4. Counsel shall file an affidavit within fourteen (14) days of the date of this
ORDER certifying that said payment was deposited into a savings account in the
name of Jozell Stoner, a minor.
BY THE COURT,
Distribution List
V/ Michael B. Scheib, Esq.
110 S. Northern Way
York, PA 17402
V Kim Wells
21 Country View Estates
Newville, PA 17241
p; es
JUD
:r -tj
fir"
-[' C: >
-4 G
F C")
c-
G
to
..
c3
rv `.
ECG