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CUt
PENNS ERLAN
C COUNTY
YLVANIA
Johnson, Duffle, Stewart & Weidner
By: John A. Lucy, Esquire
I.D. No. 203948
301 Market Street
P. O. Box 109
Lemoyne, Pennsylvania 17043-0109
(717) 761-4540
jal@jdsw.com
IN RE:
Attorneys for Petitioner
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHEYENNE COMITTINO, a Minor,
?l g civ,?
NO.:
PETITION FOR LEAVE TO COMPROMISE MINOR'S CLAIM
AND NOW, comes the Petitioner, Chastity Comittino, as parent and natural guardian of
Cheyenne Comittino, a minor, and Petitions this Honorable Court to approve settlement of the
personal injury claims of Cheyenne Comittino as against Eugene M. Siegfried and Jeannie
Siegfried, and their minor son, Andrew Siegfried, and Erie Insurance ("Erie") and in support
thereof aver as follows:
No suit has been filed in this personal injury action. The terms of the settlement
have been reached without the need for litigation.
2. Cheyenne Comittino is the natural daughter of the Plaintiff, Chastity Comittino.
The Comittinos reside at 384 Cortland Circle, Shippensburg, Pennsylvania. l
e LIJ
504742 J2 f?•a 3 y 0 0(
3. This arises out of an accident which occurred on or about November 21, 2011,
involving the Minor, Cheyenne Comittino.
4. As the Plaintiff was a Minor and is currently unrepresented, this Petition has been
drafted by counsel for the Siegfrieds and Erie.
5. As more fully outlined below, this compromise arises out of a rock throwing
incident that occurred on November 21, 2011, at the Siegfrieds' residence located at 74
Cortland Circle, Shippensburg, Pennsylvania 17257.
6. As a result of this rock throwing incident, the minor Plaintiff sustained an injury to
her mouth which broke one of her front upper teeth.
7. As noted above, Cheyenne Comittino's date of birth is March 2, 1997, and she
was a minor at the time of this accident.
8. At the time of this incident, the Siegfrieds were insured by Erie under a home
protector policy with $500,000 per person bodily injury limits. The police was in effect at the
time of this incident.
9. Dental work was done to the minor Plaintiff's Tooth No. 9 (one of the front upper
teeth) and a temporary denture was placed at that time.
10. According to the minor Plaintiff's physicians, an implant will be needed to replace
Tooth No. 9 in the future.
11. As a result of this accident, the minor Plaintiff treated with Currie and Hect Oral &
Maxillofacial. See records of minor Plaintiff attached hereto as Exhibit "A".
12. As of the date of this Petition, Erie has tendered Two Thousand Dollars
($2,000.00) to cover medical payments toward the work already done by the Plaintiff's treating
physicians. There is a balance for Currie and Hect of Eight Hundred and Twenty-Seven Dollars
($827.00).
13. The Plaintiff's treating physicians opine that the minor Plaintiff will require future
work and have provided the following estimates: (1) Currie and Hect - Three Thousand, Eight
2
Hundred and Fifty Dollars ($3,850.00); to Michael Denning, D.D.S. - One Thousand Six
Hundred and Fifteen Dollars ($1,615.00). See Plan Cost Estimate attached hereto as Exhibit
"B"
14. Therefore, the minor Plaintiff will have future necessary dental work for a total of
Six Thousand, Two Hundred and Ninety-Two Dollars ($6,292.00).
15. The parties have reached an agreement for settlement for bodily injury at Six
Thousand Dollars ($6,000.00) in addition to the cost of future work for a total of Twelve
Thousand, Two Hundred and Ninety-Two Dollars ($12,292.00). See Release executed by the
parties attached hereto as Exhibit "C".
16. Petitioners propose that Six Thousand Dollars ($6,000.00) be paid in a lump sum
and deposited into a restricted minor's account at the Patriot Federal Credit Union for the benefit
of Cheyenne Comittino.
17. The remaining balance of Six Thousand, Two Hundred and Ninety-Two Dollars
($6,292.00) shall be made directly to the minor Plaintiff's mother for the payment of future
medical treatment.
18. Chastity Comittino, as parent and natural guardian of Cheyenne Comittino, join
and agree that the proposed total settlement of Twelve Thousand, Two Hundred and Ninety-
Two Dollars ($12,292.00) is in the best interest of their daughter, Cheyenne Comittino.
19. The undersigned counsel shall cause to be filed with the court a document of the
court's choosing as proof that a total of Six Thousand Dollars ($6,000.00) has been deposited in
a restricted account for the benefit of Cheyenne Comittino, and that a separate draft in the
amount of Six Thousand, Two Hundred Ninety-Two Dollars ($6,292.00) has been provided to
the parent, Chastity Comittino, for the purpose of future medical treatment of the minor Plaintiff's
injuries, if necessary.
3
WHEREFORE, Petitioner, Chastity Comittino, as parent and natural guardian of
Cheyenne Comittino, a minor, respectfully request this Honorable Court to authorize the parties
to enter into this agreement and sign the Order disbursing funds as outlined hereto.
Respectfully
S) cr.
Date: NovwA ber 6 , 2012
Date: November a , 2012
JOHNSON, DUFFIE,
BY:
ART & WEIDNER
Sohn A. cy, Esquire
Attor I.D. No. 203948
301 arket Street
P . Box 109
Lemoyne, PA 17043-0109
(717) 761-4540
jal@jdsw.com
Counsel for Petitioner
asti m ino, as Parent and Natural
Gua i of Cheyenne Comittino, a Minor
4
??
DEC-28-2OJ11 WED 04;03 PM CURRIE-AND HECHT WS FAX No. 7175305184
Oral and Maxillofacial
Surgeons, P.C.
P. 001
William R, Currie, D,D,S,
Fredrick L. Hecht, D,M:D,
25 Eastgate Drive • Carlisle, PA 17015 • 717,249,7007 - 800.889.4437 • (fa4 717.2499060
127 Walnut Bottom Road - Shippensbutg, PA 17257 - 717530.1120 • (fax) 71 Z530,5184
Currie-hechtoms,com
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Fax ' Me
Date:
To: ri e A?tn' Narru
Fax # _ I_&X- S45 - nyn
From:
# of Pages:
C he y nnc Com it? i no
Clc:1m ,wO101q)9)09930
•DEC-28-2'011 WED 04:04 PM CURRIE AND HECHT OMS PAX No. 7173300184 P.002
PLEASE =0 Erie Insurance Group
DO NOT PO Box 2013
STAPLE Mechanicsburg PA 17055
IN THIS (?
AREA Attn: )garrq Pe_+erscA
rT-I-IPIOA HEALTH INSURANCE CLAIM FORM _A I-M
1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER In. INSURED'S 1.0. NUMBER (FOR PROGRAM IN ITEM 1)
HEALTH PLAN BLK LUNG
? (A) ? (nMl*W'h? ? (Spa-" $SAf ] (VA FAb MJ ? ISSN orlD) ? (SSN ® (10)
010171209930
2 PATIENT'S HAMS (Last Name, Feat Name. VJdde Initial) 9. PA nENTSIBIRTIi DATE g 4. INSUREO'S NAME (Lest Name, FM Name, Middle Inltlel)
Cornittino Che anne 0 `'u; $x 1 157 M F 21 Comittlno Chastity
S PATIENTS ADDRESS (No„ Stroet) a PATIENT RELA710 SHIP 701NSt)R 7. INSUREO'S ADDRESS (No., Street)
394 Cortland Circle W[] BP0-[] Child R] Other[1
384 Cortland Circle
CITY STATE B, PATIENT STATUS CITY STATE
Shi ensbu PA alnflleQ MarrieclEl OtherE] Shi ensbur PA
ZIF CODE TELEPHONE (Induce Area Code) ZIP CODE TELEPHONE (INOLUDE AREA CODE)
17257 (717) 530-5220 Er"p"V F 5 = P St;, 0 17257 (717} 414-8723
9, OTHER INSURER'S NAME (Last Name, Flrel Name, Meidle Inmw) 10. PATIENTS CONDITION 18 RELATED TO: 11. INSURER'S POLICY GROUP OR FECA NUMBER
Comittl o C sti
a. OTHER INSURER'S POLICY OR GROUP NUMPFR e. EMPLOYMENT? (CURRENT OR PREVIOUS) a INSURED06 DATE OF BIRTH SEX
MMI DD , YYYY
859948398 ? YES ® NO 08 ; 26 11971 ME] F R]
b. OTHER INSURED'3 DATE
MM DD YYYY OF BIRTH SEX
b. AUTO ACCIDENT) PLACE(State)
b. EMPLOYER'S NAME OR SCHOOL NAME
?-•?
08 126 i 1971 M L J F Ibl
? YES ® No' II
Q EMPLOYER'S NAME OR SCHOOL NAME c OTHER ACCIDENT? L......J c. INSURANCE PLAN NAME OR PROGRAM NAME
® YES ? NO
d. INSURANCE PLAN NAME OR PROGRAM NAME 1 Od RESERVED FOR LOCAL USE d, 13 THERE ANOTHER HEALTH BENEFIT PLAN?
YES W NO 11 M yea, ratum to and complete Item 9 R4
READ BACK OF FORM BEFORE COMPLETING l SIGNING THIS FoRm or
2
PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I auftgri:e die roleasa of any Irtedicmj oal or dher informgfion n 1S. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
Payment of mad,* benaflts le N1e underalgrted phyakian a aupplier for
to Pmmms this dens. t aLte requasl payment of eovamment benefBe 6II)ier t0 m11'ealf t1r to If16 party t+ho aCeept8 a,gfpnrneM
below, sarvicas desalbad below,
SIGNED Signature on File
12' 28,'2011 Signature on File
DATE SIGNED
14. DATE OF CURRENT: ILLNESS (Flret symptom) OR 16._F5 PATIENT HAS HAD SAME OR SIMILAR ILLNESS
MM DD YYYY 115, PATES PATIEFfT UNABLE TO VYORK IN CURRENT OCOUPATION
INJURY (Aecidard) OR GIVE FIRST DATE MM • DO YYYY MM 100 IYYYY MM 00 ' YYYY
PREGNANCY Up) , FROM I I TO I
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 178. I.D. NUMBER OF REFERRING PHYSICIAN 1 B. HOSPITALIZATION 507T65 RELATED TO CURRENT SERVICES
Michael R Denning DDS 0TH000 MM I00 YYYY MM OD I YYYY
I 1
I
FROM I TO
,
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
13 YES ® NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (RELATE ITEMS 1,2,3 OR 4 TO ITEM 246 BY LINE) 22. MEDICAID RESUBMISSION
1. ! 87363 Broken fractured tooth/t 3.1 CODE ORIGINAL REP. NO.
23. PRIOR AUTHORIZATION NUMBER
2 917 _ Struck/person abject 4. I__
4, A C E F 0 H J K
DATE(S) OF SERVICE
From
To Niece
of Type
of PROCEDURES, SE
fE>4la4n
Unusu RVICES, OR SUPPUE
al Clrr DIAGNOSIS
S CHARGES DAYS
On EP&OT
Fa ily
EMS
COB RESERVED FOR
DO
M
YYYY MM DD
yyy s
Ba
CMC
PCS SIER ER
I MODIFIER CODE
UNITE
plan LOCAL USE
12 14 2011 12 14 12011 11 1 99203 av - taw Rt, Exam 30
12
76,00
1
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I 1
I
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, I
I I I
I
1
I` I
I 1
i
,
25. FEDERAL TAX LQ.NUMBER SSN EIN 28. PATIENTS ACCOUNT NO. 27, ACCEPT ASSIGNMENT? TO. TOTALCHARGE 29, AMOUNT PAID 30; 6ALANCEDUe
(I"a40+2 Clglms, Ties 4pck)
.25.1715 ,49 ? ® 96321 ! 69837 YES No s 7000 i 70,00
31. SIGNATURE OFJ7HYSICIAN OR SUPPLIER 32. NAME AND ADDRESS OF FACILITY WHERE 5ERVICE5 WERE M. PHYSICIANS
SUPPLIER'S BILLING NAME
ADDRESS
ZIP CODE
tNCLUOINC DEGREES OR PREDENTIALS
(I
ceRliy that the statements on the mverx RENDERED (If otmer than home or ofnee) ,
,
,
8 PHONE e
,
aPP1r to this >iu -and are made Pen tharecG) OTS. Currie $ Fit?Cht
Oral
'a Maxillofacial
PC
David. ran D :S ?D? ,
hest. ate Drive
Carlisle A 17015-9124 717-249-7007
SIGNED DA PIN# GRP#
r+.cn?=rrsrrrr vrv r rr-a
SS/ex - 8.0.1.27
-DEC-2°-2011 WED 04:04 PM CURRIE AND HECHT OMS FAX No. 7175305184 P•003
PLEASE I SYl # Erie Insurance Group
00 NOT MEN 0 PO Box 2013
STAPLE i I 1 I °*0g4`0 Mechanicsburg PA 17055
IN THIS
AREA Attn: )garrq Pcf,rson
FICA
HEALTH INSURANCE CLAIM FORM a". rm
1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER is. INSURE0'S LD, NUMBER (FOR PROGRAM IN ITEM 1)
(""pro "`1 (Madk& x1 HEALTH PLAN 9LK LUNG ? f9pdrreorsSSN,? (yAFAS.V? (SSIVar112) ? tssny N] (rot 010171209930
2. PATIENTS NAME (Last Name, First Name, Middle In18al) 3.
P
8
ATIENNT
TT" DATE 8EX
DIIR 4, INBUAMYS NAME (Lost Name, Rra! Nerve, Middle Inldat)
Comittino Che anne ?
ut
p
Y
O:i M, U1 11yd7 ME]
;
F
C omittln0 hastl
S. PATIENTS AOp ESS (No„ Street) 8, PATIENT RELATIONSHIP TO INSURFO 7, INSURED'S ADDRESS (NO., Street)
384 Cortland Circle Self[] Spouae Child Other 384 Cortland Circle
CITY TATE e. PATIENT STATUS CITY 8YAYE
Shi ensbur PA
r ainuis? Marrted? other[:] Shi ensbur PA
.
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE)
17257 q1 7) 530-5220 Empldy"O F $FTI?? ? P s _>y= 17257 (71 ? 414-8723
s, OTHER INSURER'S NAME (Last Name, First Name, Middle Inltfal) 10. PA'rlg NVS CONDITION 18 REATED TO; 11, INSURER'S POLICY OROUP OR FECA NUMBER
Gornittino Chest!
a. OTHER INSUREDS POLICY OR GROUP NUMBER a EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH SEX
raMt DD , YYYY
859948398 ? YE8 ® NO 08 ;26 ;1971 M 0 F
b. OTHER INSURER'S DATE OF BIRTH sex
MM + DO ' YYYY b. AUTO ACCIDENT? PLACE(Slals) b. EMPLOYER'S NAME OR BCHOOL NAME
r?
08 ' 211:1971 M ? F 131
? YES NO
a EMPLOYER'S NAME OR SCHOOL NAME
?
L
c. OTHER ACCIDENT?
r- INSURANCE PLAN NAME OR PROGRAM NAME
® YES NO
d. INSURANCE PLAN NAME OR PROGRAM NAM 1Od, RESERVED FOR LOCAL USE d. 15 T HERE ANOTHER HEALTH BENEFIT PLAN?
YES 21 NO ? Ryes, mtum to and oomplaia italn a;-d,
READ BACK OF FORM BEFORE COMPLETING 6 SIGNING THIS FORM
2. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize itte release of any madleal or oiler Irdormallon necaesary 13. INBURED•8 OR AUTHORIZED PERSOMe SKW4ATURE I "art"
payment of medical benenle to the undenilgried pttyelclan or supplier for
to process this claim, I also naquaat Payment d govamment benefits either to my"ff or to Mho party who accepts aeeglnmerd
ba1a1Y, sevia m det lbad bftW.
SIGNED Signature on T=ile DATE 12' 28 :2011 Signature on File
14. DATE OF CURRENT: ILLNESS (Flret symptom) OR
MM
DD YYYY I& IF PATtaw HAS HAD SAME OR SIMILAR ILLNESS 1B. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
i
INJURY (Auddant) OR GIVE; FIRST DATE MM DD i YYYV MM ID13 'YYYY MM DD 1 YYYY
PREGNANCY(LMP) , FROM ' TO
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
Michael R Denning DDS OT-1000 MM +DD YYYY MM DD, YYYY
' t
FROM ; TO
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAO? S Gw+RGES
Q YEa [Z NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (RELATE ITEM$ 1,2,3 OR 4 TO ITEM 24& BY LINE) 22. MEDICAID RESUBMISSION
1. i 873 63 Broken/fractured tooth/t 3.1
-.? CODE ORIGINAL REF. NO.
23. PRIOR AUTHORIZATfoN NUMBER
z EI 917,_ Struck/person object 4, L-.-
24. A
DATE(S) OF SERVICE
From To 8
['lace
or C
Type
of D
PROCEDURES, SERVICES, OR SUPPLIE
[Expieln Unueuei ClrcumetarLOee) E
D
O0 t8 F
$ CHARGFA G
DAYS
OR H
EpSDi
FWAY I
EMG J
COB K
RESERVED FOR
M DO YYYY MM DD Sanita GPTIMCPG5 MODIFIER C UNIYs PIN LOCAL USE
, I
12 21 ;2011
12 :21 :2011
11
2 Bone rapt
20900 cemdnt graft, #a~9
1
12
606.00
1
12 21 2011
12 21 '2011
111
7 Gen
09220 I Apes/ 30 Min
P1 ? OX
12
49x.00
1
12 21 2011 12 :21 2011 11 2 07210 Surolcal ext, #9 12 175.00 1
12 21 2011
12 ? 21 201
11
7 Genera(
D9221 neslQddt 75 Min
P1 ' Qx
12
70,00
1
25. PrDgRAL TAK I.D. NUMBER $SN SIN 2a, PAnFNrs ACCOUNT N0. 27. ACCRPT ASSIGNMENT7
' (Far govt rJafrris, tax back) 28. TOTAL CHARGE 2B. AMOUNT PAID 30. BALANCE DUE
2 1715449' ? ® 9632 /.6.9637 ? YES NO s 1335'.00 s $ 1335.00
31. SIGNATURE OF PHYSICIAN OR SUPPLIER V. NAME,ANDADDRESS OF FA0ILr1Y WHERE SERVICES WERE
INCLUDING DEGREES OR CREDENTIALS RENDERED (11 other than home or olflos) 33. PHYSICIANS, SUPPLIER'S BILLING NAME, ADORE88, ZIP CODE
a PHONE t"
R aati[y that the slalemards on the mvarae
apply to Ihin bill and ara made a part thereof.) Drs, Currie 8& Hecht
David 0 Tran D.D.S. M.D. Oral $ Mexillofacial, PC
25 Eastgate Drive
12 2? 11 Carlisle PA 17015-9124 717-249-7007
SIGN P INS GRP9
PLEASE PRINT OR TYPE
551ex - e.a.12r
SEC-28.-2011 WED 04.04 PM
Patient Summary
CURRIE AND HECHT OMS FAX No. 7115305184
Name: Cheyenne Comittino
Phone:7175305220
DOB: 1997-03-02
Created On., 12/07/201110:04 AM
Posted To: Oral Surgery Currie-Hecht
Address: 25 Ea4ate Drive, Carlisle, 17015, PA, USA
Phone:7172497007
Posted By: Michael Denning
Phone: 7175325811
Treatment: Implant consult #9
Appointment: Patient WIII Call for Appointment
Teeth to be extractse
Consultation: Implants
P. ON
L-.. y., J tT l A
Case notes:
Extract and Implant consult for #S.Patlent was hit in mouth with a rock, Root canal was done and prepping for the crown
was started when a fracture was found on the lingual.
View orioinal referral at 12121I-15 Collaborator
Attached Case Photos
www,pbhscu#oborator.com - pagr 1/7
.DEC-28•-2011 WED 04:04 PM CURRIE AND HECHT OMS FAX No. 7115305184 P•005
9
DIAGNOSIS SHEET Name
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,DEC-28-2011 WED 04:04 PM
CURRIE AND HECHT OMS
FAX No,
ooc
Gh er nn
DATE ANESTH. DIAGNOSIS
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Michael R. Denning, DDS v' l
9435 Molly Pitcher Highway
Shippensburg PA 17257
(71.7) 532-5811 05/15/2012
TRE,A.'?mmm FLAN E mmE
Cheyenne Comittino
384 Courdand Circle
Shippensburg PA 1.7257
Patient ID# 3737-2
Thoth
Surf
Code Description Tool
Pea Allowed
Amount Insurance
Estimate Write
Off Paitiont
Portion
Phase 1
9 D2740 crown - porcelain/c- 980.00 980.00 980.00
9 D6057 Custom Abutment 635.00 635.00 635.00
Totals 1615.00 1615.00 980.00 635.00
insurance: Erie Insurance
BlueCr. oss.81 ueShi eld
United. Concordia
The amounts shown in the insurance column are ESTIMATES only.
Actual insurance benefits will be deterrrlined by the insurance carrier.
The patient is responsible for payment of the FULL amount of all procedures performed.
VAY•-22-2012 TUE 0214 P? CURRIE AND HHCHT OW FAX No. )1]3305184 H.001
for , r) s U-rar)ca S Ue rr) en t ?Iiil
CURRIE A HECHT IMPY,A41- FE15 I:STIMATIff
Patient Name:Vhe lann C'AItt fV)O Area of implant:_ ?.,..
Dpg; 99 Referring Dentist:
patlent 1D#; ?A (7 &5 r'I Doctor_, n2An
Date: 5- +a 2J Q _
Phgse 1 Teeatml t Plan:
Implant Consultation (D931O) $ -
Radiographs: A. Panorex(70355-00330) $
S. 3-D Image- 20 Sec. ( D0322 or 40 Sec. 00353) $
> hR= If Treatme plan:
extraction per tooth (D734"7210)
Grafting Material (07953)
Membrane (D4266) $
Slnus Uft: A.11hru the osteotoM/aflni sinus lift $
[3 Standard Lift (21210)
PRP $.rt-?_ i?
)mplant plagnpAlc Workup: A. Ra,diOAMphlC Sterrt (D5892) $
0. Surgical Guide (DS290) $
Implant Surgery (per Implant): Ma>dlla / Mandible (D6010) $-LLAW
integration TmIms $ ? .
Abutment/1(espers per unit $
Temporary Grown/Flipper (D5920/DZ97D) $, ?/ . On --
General Anesthesia (09Z20) $ D0
Phi III Treatment Plan: Implant Uncovering: Fee included in the lmplantfee
Pease r?pr:1 t+o exact lee W al will depend won ppwft n Mow provided and map be come car lase 00" ex"maW. `rW:r erJMOte 19 vabd
fivr * h gnbl9 ftern OAS date and may imcr9Aatornervleas provided akerthst tMtrta. I wWar- t nd'>rttrttaK fOn4 "0 ft tluo'ft days} WAce.
OrWrIal 472py itl wvn m Pmlent Ot W" at Pppo + h dit-k Serra Mat=
-roia1,: 1$X3800 M 58CO
GENERAL RELEASE OF ALL CLAIMS
KNOW ALL PERSONS BY THESE PRESENTS, that I, CHASTITY COMITTINO, Parent
and Natural Guardian of CHEYENNE COMITTINO, a Minor, intending to be legally bound
hereby, and in consideration of the payment of TWELVE THOUSAND TWO HUNDRED AND
NINETY-TWO ($12,292.00) DOLLARS, receipt whereof is hereby acknowledged, have
remised, released and forever discharged, and by these presents do for myself, my successors,
agents, assigns, heirs and insurers hereby remise, release and forever discharge EUGENE M.
SIEGFRIED and JEANNIE SIEGFRIED and ERIE INSURANCE, their administrators, personal
representatives, successors, agents, assigns, officers, directors, workmen, employees
(hereinafter "Releasees"), and all other persons, firms, corporations, associations or
partnerships, of and from all actions, causes of action, wrongful death and survival claims, suits,
underinsured motorist claims, controversies, trespasses, damages, judgments, and demands in
any form whatsoever, at law or in equdy, arising, from or by reason of any and al known, or
unknown, foreseen or unforeseen bodily or personal injuries, damages and death sustained by
Cheyenne Comittino relating to personal injury arising out of a rock throwing incident which
occurred on November 21, 2011, at or near the Siegfried residence, located at 74 Cortland
Circle, Shippensburg, Cumberland County, Pennsylvania 17257
In further consideration of the above payments, the undersigned will indemnify and hold
harmless Releasees from any and all liability arising from liens or subrogation claims, including
any workers' compensation or medical liens or payments due or claimed to be due under any
state or federal law, regulation or contract.
It is understood and agreed that this is the compromise cf a doubtful and disputed claim,
and that this Release and payment is not to be construed as an admission of liability on the part
of the parties released, and that the Releasees deny liability therefor and intend merely to avoid
further litigation and buy their peace.
It is further understood that the terms of this settlement and Release are to be kept
strictly confidential and are not to be disclosed to anyone.
The undersigned declares and represents that no promise, inducement or agreement
not stated herein has been made to the undersigned and that this Release contains the entire
agreement between the parties hereto, and that the terms of this Release are contractual and
not a mere recital.
THE UNDERSIGNED HAS READ THE FOREGOING RELEASE, HAS HAD AN
OPPORTUNITY TO DISCUSS IT WITH AN ATTORNEY, AND FULLY UNDERSTANDs IT.
IN WITNESS WHEREOF, and intending to be legally bound, we have hereunto set our
hand and seal this \,?)_ day of (?eCa(Y)Lr)?71- 2012.
TNESS:
COMMONJA&TH OF VAM-
NOTARIAL SEAL
PAMELA A. SWITALSKI, Notary Public
Born of Shippensburg, Cumberland County
NSYL-
My Commission Expires V arch 24, 2010
A C M TTINO,
Paren atural Guardian of
CHEYENNE COMITTINO, a Minor
2
GENERAL RELEASE OF ALL CLAIMS
KNOW ALL PERSONS BY THESE PRESENTS, that I, CHASTITY COMITTINO, Parent
and Natural Guardian of CHEYENNE COMITTINO, a Minor, intending to be legally bound
hereby, and in consideration of the payment of TWELVE THOUSAND TWO HUNDRED AND
NINETY-TWO ($12,292.00) DOLLARS, receipt whereof is hereby acknowledged, have
remised, released and forever discharged, and by these presents do for myself, my successors,
agents, assigns, heirs and insurers hereby remise, release and forever discharge EUGENE M.
SIEGFRIED and ;JEANNIE SIEGFRIED and ERIE INSURANCE, their administrators, personal
representatives, successors, agents, assigns, officers, directors, workmen, employees
(hereinafter "Releasees"), and all other persons, firms, corporations, associations or
partnerships, of and from all actions, causes of action, wrongful death and survival claims, suits,
underinsured motorist claims, controversies, trespasses, damages, judgments, and demands in
any form whatsoever, at law or in equity; arising from or by reason of any and all known or
unknown, foreseen or unforeseen bodily or personal injuries, damages and death sustained by
Cheyenne Comittino relating to personal injury arising out of a rock throwing incident which
occurred on November 21, 2011, at or near the Siegfried residence, located at 74 Cortland
Circle, Shippensburg, Cumberland County, Pennsylvania 17257
In further consideration of the above payments, the undersigned will indemnify and hold
harmless Releasees from any and all liability arising from liens or subrogation claims, including
any workers' compensation or medical liens or payments due or claimed to be due under any
state or federal law, regulation or contract.
It is understood and agreed that this is the compromise of a doubtful and disputed claim,
and that this Release and payment is not to be construed as an admission of liability on the part
of the parties released, and that the Releasees deny liability therefor and intend merely to avoid
further litigation and buy their peace.
It is further understood that the terms of this settlement and Release are to be kept
strictly confidential and are not to be disclosed to anyone.
The undersigned declares and represents that no promise, inducement or agreement
not stated herein has been made to the undersigned and that this Release contains the entire
agreement between the parties hereto, and that the terms of this Release are contractual and
not a mere recital.
THE UNDERSIGNED HAS READ THE FOREGOING RELEASE, HAS HAD AN
OPPORTUNITY TO DISCUSS IT WITH AN ATTORNEY, AND FULLY UNDERSTANDs IT.
IN WITNESS WHEREOF, and intending) to be legally bound, we have hereunto set our
hand and seal this _ day of 5? Q Vv? ITV' 2012.
ITN SS:
AS M INO,
Parent-an d Natural Guardian of
OMMONWrEAUhOFPtNWYLIIVANIA CHEYENNE COMITTINO, a Minor
NOTARIAL SEAL
PAMELA A. SwiTALSKI, No{„Pry Public
Bw of Shippensburg, Cumberland County
My Commission Expires War&, ?4, 207/
2
13
Ai R -3 F fl! i
M�'D COUNT';'
rl'Nil'SY" VANIk
Johnson, Duffle, Stewart&Weidner
By: John A. Lucy, Esquire
I.D. No. 203948 Attorneys for Petitioner
301 Market Street
P. O. Box 109
Lemoyne, Pennsylvania 17043-0109
(717) 761-4540
jal@jdsw.com
IN RE: IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHEYENNE COMITTINO, a Minor,
NO.: 12-7418
AMENDED PETITION FOR LEAVE TO COMPROMISE MINOR'S CLAIM
AND NOW, comes the Petitioner, Chastity Comittino, as parent and natural guardian of
Cheyenne Comittino, a minor, and Petitions this Honorable Court to approve settlement of the
personal injury claims of Cheyenne Comittino as against Eugene M. Siegfried and Jeannie
Siegfried, and their minor son, Andrew Siegfried, and Erie Insurance ("Erie") and in support
thereof aver as follows:
1. No suit has been filed in this personal injury action. The terms of the settlement
have been reached without the need for litigation.
2. Cheyenne Comittino is the natural daughter of the Plaintiff, Chastity Comittino.
The Comittinos reside at 384 Cortland Circle, Shippensburg, Pennsylvania.
3. This arises out of an accident which occurred on or about November 21, 2011,
involving the Minor, Cheyenne Comittino.
546682
4. As the Plaintiff was a Minor and is currently unrepresented, this Petition has been
drafted by counsel for the Siegfrieds and Erie.
5. As more fully outlined below, this compromise arises out of a rock throwing
incident that occurred on November 21, 2011, at the Siegfrieds' residence located at 74
Cortland Circle, Shippensburg, Pennsylvania 17257.
6. As a result of this rock throwing incident, the minor Plaintiff sustained an injury to
her mouth which broke one of her front upper teeth.
7. As noted above, Cheyenne Comittino's date of birth is March 2, 1997, and she
was a minor at the time of this accident.
8. At the time of this incident, the Siegfrieds were insured by Erie under a home
protector policy with $500,000 per person bodily injury limits. The policy was in effect at the
time of this incident.
9. Dental work was done to the minor Plaintiff's Tooth No. 9 (one of the front upper
teeth) and a temporary denture was placed at that time.
10. According to the minor Plaintiff's physicians, an implant will be needed to replace
Tooth No. 9 in the future.
11. As a result of this accident, the minor Plaintiff treated with Currie and Hect Oral &
Maxillofacial. See records of minor Plaintiff attached hereto as Exhibit"A".
12. As of the date of this Petition, Erie has tendered Two Thousand Dollars
($2,000.00) to cover medical payments toward the work already done by the Plaintiff's treating
physicians.
13- The Plaintiff's treating physicians opine that the minor Plaintiff will require future
work and have provided the following estimates: (1) Currie and Hect —Three Thousand, Eight
Hundred and Fifty Dollars ($3,850.00); to Michael Denning, D.D.S. — One Thousand Six
Hundred and Fifteen Dollars ($1,615.00). See Plan Cost Estimate attached hereto as Exhibit
2
14, Therefore, the minor Plaintiff will have future necessary dental work for a total of
Six Thousand, Two Hundred and Ninety-Two Dollars ($6,292.00),
15. The parties have reached an agreement for settlement for bodily injury at Six
Thousand Dollars ($6,000.00) in addition to the cost of future work for a total of Twelve
Thousand, Two Hundred and Ninety-Two Dollars ($12,292.00). See Release executed by the
parties attached hereto as Exhibit"C".
16. Petitioners propose that Six Thousand Dollars ($6,000.00) be paid in a lump sum
and deposited into a restricted minor's account at the Patriot Federal Credit Union for the benefit
of Cheyenne Comittino.
17. Chastity Comittino, as parent and natural guardian of Cheyenne Comittino, join
and agree that the proposed total settlement of Twelve Thousand, Two Hundred and Ninety-
Two Dollars ($12,292.00) is in the best interest of their daughter, Cheyenne Comittino.
18. The undersigned counsel shall cause to be filed with the court a document of the
court's choosing as proof that a total of Six Thousand Dollars ($12,292.00) having been
deposited in a restricted account for the benefit of Cheyenne Comittino.
WHEREFORE, Petitioner, Chastity Comittino, as parent and natural guardian of
Cheyenne Comittino, a minor, respectfully request this Honorable Court to authorize the parties
to enter into this agreement and sign the Order disbursing funds as outlined hereto.
Respectful subm ed,
JOH ON, DUFFI STEWART &WEIDNER
n&Luy, Esquire
Att I.D. No. 203948
30�,'- arkt treet
P� Box 109
Lemoyne, PA 17043-0109
(717) 761-4540
jal@jdsw.com
Date: April 2, 2013 Counsel for Petitioner
3
t
Chastit Co
ttino as Parent and Natural
Guardi f Cheyenne Comittino, a Minor
Date: �j �I , 2013
4
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Oral and Maxillofacial
SUrgeons, P.C. Wi{liam R,Currie, D.D.S,
Fredrick L,Hecht,D.M:p,
25 Eastgate Drive Carfisle,PA 17DiS • 717,244.7007 800.889-4437 • (fa4 717.2499060
127 Walnut Bottom Road • Shippensburg,PA 17257 717-530.1120 (fax)717.5345184
Currie-h2chtoms,com
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DO NOT 1/4?()?9&0 PO Box 2013
STAPLE M Mechanicsburg PA 17055
IN THIS
AREA PiLn: )qar1'q PefC,' I`50n
FICA HEALTH INSURANCE CLAIM FORM PICA FM
'L MEZItARE MEDICAID CKAMPIIJS CHAMPVA GROUP FECA 'OTHER I a, INSURED'S La NUMBER (FOR PROGRAM IN ITEM I
HEALTH PLAN ]ILK UUNG
iLl rmactom ❑rm-&-w 19 ❑ (sponw-ssNE-1 (VA 7;&a)❑ (ssN-C) 0 rssA9 [Z r1o;
PATIENT'S NAME 11-sai Nome,MW Name,NVOCIS M1091) 3, PATIENTS BIRTH DATE SEX 4 INSURED'S NAME-(Last Name,-VV,Name,MIMIs lnitlW)
comittino che 02r; ff; 1567 MM F 2 Comiffino Ch2stltv
E, PATIENTS ADDRESS(Na„Sirval) a PATENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS(Nc,,Sire%Q
354 Cortland Circle suit-[] "PotmO[3 ch"d KI Oulef'❑ 384 Cortland Circle
Cr;Y $TAT?, k PATIENT STATUS CITY STATE
Shippensbur -J PA singl-❑ mams4❑ othero Shipp nsburg PA
CODE TELEPHONE(Indudb Ate$Coda) Zip CODE TELEPHONE(INCLUDE AREA CODE]
V17) 530-5220 F;mploys'o pu,`,-�ZO P8,7ZeF-1 17257 k7 17} 414-8723
2, OTHER INSURER'S NAME Pat Name,Firx Name,MIddIs InlVal) ILL PATIENrS CON12MON 18 RELATED TO. II. INSUIREV`Z POLICY GROUP OR FEVA NLW15EK
Gornitting Qhs's%
O HER INSURED'S POLICY OR GROUP NUMQER a.EMPLOYMENT?(CURRENT OR PREVIOUS) " INSUREM DATE OF BIRTH SEx
M* DO i YYYY
YES NO 08 ,`26 :1071 u
IL OTHER INSURER'S DATE OF BIRTH SEX h AUTO ACCIDEN7 pLADE(Stio) b�EMPLOYER'S NAME OR SCHOOL NAME
MM � Do �YYYY
08 28 r 1971 IM ❑ F ❑YES NOL___j
z,EMPLOYERS NAME OR SCHOOt.NAME OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME
Z YES NO
d-INSURANCE PLAN NAME OR PROGRAM NAME; 104 RESERVED FOR LOCAL USE d,IS THERE ANOTHER HEALT H SENE',-74 PLAN?
Yt$0 NO❑ jfyre,,Tatum to and complete Item 0 9-1
READ BACK OF FORM BEFORE COMPLETING 3 SIGNING THIS FORM 12. INSURED'S OR AUTHORIZED PERSON'S SIGNAT URE I ft*orI:t6
Z PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the ratease of wV medical or other informmfion necessary p0matt of medlecil bermfiki it the Lmddmignmd phytlOtn or suppffeir fov
tDpramams this rime, t also reclumst ppymqrt of governmont banaft Other to myself or to the patty who avicapu.assiunrrani o-;rvlc=dRsw1ba4 Wow,
below,
SIGNER-Signature on File DATE 12� 28;2011 WINED Signature on File
f14. DATE OF CURRENT., ILLNESS(Firm symptom)r OR 1 8. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS 16, DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM :DD �YYyy INJURY(Apmiderd)OR GIVE FIRST DATE MM DID yyyy MM IDD IYn`Y MM DO YYYY
PREGNANCY(LMP) - FROM 70
17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17e. (.0.NUM2ER OF REFER;UNG PHYSICIAN 18. HOSPITALIZATION D.'kTFG RELATED TO CURRENT SERVICES
YY-
Michael R Denning DDS OTHOOO FROM MM IOD rffy MM OD YY
1s. RESER VEI)FOR LOCAL US E
20. OUTSIDE LAV $CHARGES
YES 21 No
j2t+DIAGNOSIS 09 NATURE OF ILLNESS OR INJURY(RELATE 7-,MG J,2,2 OR 470 nUM245 SY 9-Z MEDICAID RESU8MISSION IEIEIE CODE ORIGINAL REF.NO.
87363 Brokeriftmoturedtooth/t I;.I I
2a, PRIOR AUTHOR17ATION NUMBER
z—,E217— Struck/person Object
A 1 0 ( C D E F G H, I i K
DATE(S)OF SERVtOE yva DAYS III` FOR
g DIAGNOSIS .8
In tri RESERVED r
From To of at 3 CHARGES 08 Cos
j,e81PROCEDUR5a,SERVICES,OR SUPPUE!
MM I CODE UNI7,6 Plan LOCALUSE
LM 00 Y.ry
ew Ft'Ex
112 114 X201 12 14 i261 1111 1 99203 OV l 12 7df,00
4-
12E. F75DERAL TAX LM.NOMBER SSN EIN 128.PAnw7s ACCOUNT No, 27,ACCSFTASSIGNMEN7? 28, TOTALCHARGE 12S, AMOUNT PAID 3C, BALANCE DUE
25"7164,49 195321 169837 El YES 5D .NO 7C'()O $ 1;
70,00
34. vek TURF QFPWYSICLAN OR SUPPLIER 37 NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33, PHYSICIAN'S,SUPPLIER'S BILLING NAME ADDRESS,ZIP CODE
INCLUCINC DEGREES OAPREDENTIALS RENDERED(if other vian home or office) &PHONE*
tt meelfiY that the statements w the reverse Drs.Currie&Hecht
',5tap(y to this .and are made z.p;-m thwpof,) Oral&Ma0lofaciat,PC
vidi.Kraft D S- .D. 2S 5astosts Drive
AA",1 rsrlisfe PA I T015-9124 717-249�-7007
17
7*0 OWMA? PIN*
PLEASE PRINT OR TYPE
nljpq I I Aye v
LEASE Erie insurance Grout)
DO NOT WMIMMIN PC) Box 2013
S7 APL-- Mechanicsburg PA
IN-
Hli'
AREA Peterson
=FICA HEALTH INSURANCE CLAIM FORM PicA FT7
M MEDICARE MEDICAID CHAMPU3 CHA FECA OTHER is. INSURE-D'S LD.NUMBER (FOR PROGRAM IN ITEM 1)
H;Ar_TJ4 PLAN 9LKLUNG
❑(Ma"Is *-os-Id (spa,,soes ssiv)E] rVmApFvbA o)❑ �(Esowj-p q ❑ (nlv; 010171209930
7- PATIENTS NAME(Last Name,First Name,Middle Iriltlal) 5, -AT p4r 8 BIRTH DATE 4, INSURED'S NAME fLnt Nams,First Nutria,Miedia Initial,'
Comittino Cheyenne O�'; '1'97 ME] F M Cornitino Chastity
a, PATIENTS ADDRESS(Np,,Strpot) S, PATIENT RELATIONSHIP TO INSURED 7. WSURFO*S ADDRESS(No.,Street)
384 Cortland Circle Sall a.spouse[7 ChIldKI 0118"El .354 Cortland Circle
crry STATE & PATIENTSTATUS CITY STATE
Shjppensbura PA alrlg ❑ marriadD dther❑ Shippensbimg PA
ZIP CODE TELEPHONE(Include Area Coda) 71F CODE TELEPHONE(INCLUDE AREA CODE)
17257 17) 53M220 Employs 17257 {71 7) 414-8723
I k7 10 -*Stunnf.--J StUdeng-J I
S, OTHER INWRED1 NAME(Last Name,Pirat,Name,ivildoile tnlfist) io.PATIENT'S CONDITION IS REIATrD TO; 11, INSURED'S POLICY GROUP OR FICA NUMBER
Gombno Chastity
z.OTHER INSUREDS POLICY OR GROUP NUMBER INSURED'S DATE Q BIRTH SEX
a.EMPLOYMENT?(OURRENT OR PREVIOUS) MM t DO 11;YYYY
I ❑Yes 1Z No 08 125- :1971 F
h.OTHER INSURED'S DATE OF BIRTH SEX 6.AU70 ACCIDENT? pLACE(Sjqje� b.EMPLOYERS NAME OR 8GHO0_' NAME
Mm ; DO Yyyy
08 t26 1971 YES NO,
EMPLOYERS NAME OR SCHOOL NAME c OTHER AOOIDENT7 c.INSURANCE PLAN NAME OR PROGRAM NAME
YES 13 NO
d.IIZURANr E PLAN NAME OR PROGRAM NAME I Od, RESERVED FOR LOCAL USE d.15 THERE ANOTHER HEALTH BENEFIT PLAN?
I YES 21 NO❑ .1f,,oc,return I-and dornpialt Rom 9 a4
READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM 13. INSURED'S OR AUTHORIZED PER80NS SIGNATURE I authorize
Z.PATIENTS OR AUTHORIZED PERSON'S SIGNATURE: I autharhm the release of my medical at other information nou-nusty payment of medical benefits to the undereloned phyalolan or supplier for
tc praaass this claim, (elm rnquasiPpympnt of govatnmant hanalrrts Elliot to mssaif ar4a tha Par`•P whe sz opts assjgnmant earvi--t e1nolbad below.
belay,
SIGN ED Signature on File DATE 12: 28 :2011 Signature on File
SIGNED
114. DATE OF CURREWn ILLNESS(First symptom)OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS 18.DATES PATIENT UNABLE 70 WORK IN CURRENT OCCUPATION
I MM On YYYY INJURY fAcciidant)OR GW_FIRST DATE MM r DO rry-Y MM 'Do 1YYyy MM 1>0 I YYYY
1 PREGNANCY(LMP) FROM 70
117. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 178. LD.NUMBER OFF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
M 100 YYYY Doi YYYY
R Denning DDS OTHOOO I To W
FROM I I
ig. RESERVED FOR LOCAL USE M OUTSIDE LABS 11CHARGES
1
❑YES � NO I I I
121. DIAGNOSIS OR NATUPF OF ILLNESS OR INJURY(RGLAT-.ITEMS 1,2,3 OR 4 TO ITEM 249 BY LINE) 4. MEDICAID RIESUBM13SION
i.', 873 L3 Brokenifractured tooth/t CODE ORIGINAL PEP,NO.
23. PRIOR AUTHORMATION NUMBER
z Struck/person ob.laot 4,1
414, A 1 9 1 0 1 1 D - - E F I G H I j j I K
OATE(S)OF SERVICE I PIM Type I'RocEDURES,SERVICES,OR SUPPLIE$ DIAGNO618 EPSOT p -0 FOR
'n of nuaitall Circumstances) $CHARG98 OR Fpndly _Me 008 RESERVE
-I,-. Yyyl MM 00 Yn4aervlcal BR WP CRAH(ISPIACUS I MODIFIER CODE UNITS Man LOCAL USE
1 5one rvpl rl
j;*m� t graft,0 1
12 21 .1 2011 1 12 1 21 2011 2 20900 12 1
Gan*ml Ahes/30 Win
ZJ 12 G 21 !20111 12 1 21 120111 11 1 7 D9220 jP1 ; QX 12 490',00 I
2.1 12 5�1 2011 12 :2 1 '2011 11 12 Q7210 1 Su 12 175.00 1 1
G11111 MI,
I Dg221 fna&1*Ldd1 1 70.04
,1 2 1201, 1.2,. 2 1. 2011111 7 P1 OX 12
2E FEDZRAL TAX LQ.NUMBER SSN SIN 28,PATIENTS ACCOUNT NQ. 27. ACCEPT ASSIGNMENT? 21 TOTAL CHARGE 29• AMOUNT FIAID 3D, BALANCE DUE
(-,a,Pon ciainis,San beck)
51,71,649" 95395322/.&9537 YES [T No s 1335'OQ Y 1335.00
-- .
311. SIGNATURE OF PHYSICIAN OR SUPPLIER FkZ..NAME AND ADDRESS OF FAoLrrywHERE SERVICES WERE 33. PHYS_1ciAW'S,SUPFLIEFV5 51,L ING NAME,ADORERS,7JI,CODE
INCLUDING DEGREES OR CREDENTIALS RENOEREO(It other then home crofflas) &PHONE V
0 certify that[He 4.iumorriz an the revatme Drs,Currie&Hecht
oppiy to this WI and are mad,a"M thispROQ Oral&Maxillofadal,PC
David 0 Tran D.D.S. M.D. 25 Eastgate Drive
12 z 11 Carlisle PA 17015-9124 1 717-R49-7007
t SIGN PINS GRP9
PLEASE PRINT OR TYPE
U -LO".CU! I tiry'r;� !Ifl;
j _ G58 D
PatiOnt Summary
Nama:Cheyenne COmlttino
Phone:7175305Z20
DOR:1997-03-02
Created On., 12/072011 10:04 AM
Posted To:Oral Surgery Currie-Hecht
Address:25 Eastgate Drive,Carlisle,17015,PA,USA
Phone:71724@7007
Posted By;Michael Denning
Phone: 717-s325811
Treatment:implant consult#S
Appointment:patient Will Gall for Appointment _
Teeth to be exb-acte ;#B !
Consultafion:Implants ..
Case notes;
Extract and Implant consult for MPatlent was hit in mouth with a rook,Root canal was done and prepping far the crown
was started when a fracture Was faund on the lingual.
View origins[referral ai PBHS Collaborator
Attached Case photos
X737- JP.
www,pbhscoltaborator--corn-Pop!1!2
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LIIIy
DIAGNOSIS SHEET Name
2 3 4 5 8 7 8 to it 12 13 ,a T5 is
A 9 CD E F
T S R O F Q N M L K
UlLi
9 d
I
32 3' 3C 29 28 27 2H 25 24 22 22 21 20 t9 7fl P
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(Oct 3�
DATE ANES M, DIAGNOSIS as k •r, Deni TR`F-NT
ti
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( d 1152 G
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r
C7g�h'f &d"�1ee? 2aT8�ar tiff / /
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MYa.
�fY-7i-?f)f9 TII- (12 12 ok,r( u L
t!���, 4Li uhff
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E. o For t f)8 t.v ark o &etaI e m e n,� �10/,,l V4 --7
CURRIE a ffECFT i IMPLANT rEi 8STIMATE
i'at}ent Name- 1] y( fY"tf L�f P o AFu of Implant_ Q
DC*. Referring Dentist: (}
F2taent 1J#: [°9 FA 7
Rate: 5-sir 0?.)c�
PM,sa!-Treatment Plan:
lmplarit Ccnsultatlon(D9?10)
RadiogMphs:A.Panorex(70355-DD33o) $
5.3-D Image-?,a Sac.(DO322 or 40 See.D0353)
Phase If Tr82tm8rit P;an-
Extraction Psrtooth(D7144-072-10)
Grafbng Material 077453)
Membrane(D4266)
Sinus Lit", ,a.11tf'ts the QsteotOM/rnini si»as flit $
EL Standard 1t$(2 1210) 5
PV $-Loam—
�r;lplant ptagruastic Warkup. A.R�Ci'ra$raphlc Stent{p5892) $ '
R.Surgical Guide{Da"z9Qj $
IMPlant Surgery(per im*tft); W4122/Mandible(D6010) $ ( Cy0
blTegratiattTasting $ 50, x
bvtment/X.aepers per unit $-
Tempo;ary Crcx Klppmr(05920/p2-5TJ)
General Arresthesla(L?s20)
Phase IE1 Treatment Plarr implant Un=vering:Fes included in the hnplanttea
F°iease natau Yho exact tea total w51t depend upon AP*$SR DCh+lacs ProvIdad One map tr=_mare or ies: in 'MmOtAo.The c5L4i t tC!s vast
z`+�r FEx W;Ot379 Pram ets date and m'ay invaar 9 ternerv7-c Provided mFmrthnt She,I under-ne xttxkafi fs!v!►Sill h?das.hn d�synt se�+j z.
t?rigirsal sxpy FJuAn t�pmSant[+t'ttn're n±appafrrtmr?ttt haY,arct 5#�netxre/dam:
Ct1 3$00SwC3
J
N�Ohael R.Denning,DDS
9435 Melly Pitcher Highway
Shippensburg Pty 17257
(717}532-3811
os4sMl2
TItEA'I'1VTFNT PLAN ESTIMATE
Cheyenne Camittino
3&4 Courdand Circle
Shippensbnra PA 1.7257
Pwtient ID#3737-2
Tooth surf code Description Total Allowed Insurance Write Pationt
Phase 1 Pea Amount Estimate Off Portion
i
D2740 ='uw-n _ norcelain/c— 980.00 980.00 980.00
9 D6057 Custom A utmez)t 635.00 635.O0
635.00
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1
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Totals 1515.00 1615.06 980.b0 635.00
lr,SUranee: Erie Irt5ur&ace
$lucG�asg.BlveShield -
United Concordia
The amounts shown in the insurance column are ESTIMATES or).l.y.
Actu€tl insurance benefits will be determined by th.e insurance, carrier.
The Patient is responsible for payment of the FULL amount of all procedures performed.
y
GENERAL RELEASE OF ALL CLAIMS
KNOW ALL PERSONS BY THESE PRESENTS, that I, CHASTITY COMITTINO, Parent
and Natural Guardian of CHEYENNE COMITTINO, a 'Minor, intending to be legally bound
hereby, and in consideration of the payment of TWELVE THOUSAND TWO HUNDRED AND
NINETY-TWO ($12,292.00) DOLLARS, 'receipt whereof is hereby acknowledged, have
remised, released and forever discharged, and by these presents do for myself, my successors,
agents, assigns, heirs and insurers hereby remise, release and forever discharge EUGENE M.
SIEGFRIED and JEANNIE SIEGFRIED and ERIE INSURANCE, their administrators, personal
representatives, successors, agents, assigns, officers, directors, workmen, employees
(hereinafter "Releasees"), and all other persons, firms, corporations, associations or
partnerships, of and from all actions, causes of action, wrongful death and survival claims, suits,
underinsured motorist claims, controversies, trespasses, damages, judgments, and demands in
any form whatsoever, at law or in eguiiv, arising from or by reason of any and al known or
unknown, foreseen or unforeseen bodily or personal injuries, damages and death sustained by
Cheyenne Comittino relating to personal injury arising out of a rock throwing incident which
occurred on November 21, 2011, at or near the Siegfried residence, located at 74 Cortland
Circle, Shippensburg, Cumberland County, Pennsylvania 17257
In further consideration of the above payments, the undersigned will indemnify and hold
harmless Releasees from any and all liability arising from liens or subrogation claims, including,
any workers' compensation or medical liens or payments due or claimed to be due under any
state or federal law, regulation or contract.
It is understood and agreed that this is the compromise cf a doubtful and disputed claim,
and that this Release and payment is not to be construed as an admission of liability on the part
of the parties released, and that the Releasees deny liability therefor and intend merely to avoid
further litigation and buy their peace.
It is further understood that the terms of this settlement and Release are to be kept
strictly confidential and are not to be disclosed to anyone.
The undersigned declares and represents that no promise, inducement or agreement
not stated herein has been made to the undersigned and that this Release contains the entire
agreement between the parties hereto, and that the terms of this Release are contractual and
not a mere recital.
THE UNDERSIGNED HAS READ THE FOREGOING RELEASE, HAS HAD AN
OPPORTUNITY TO DISCUSS IT WITH AN ATTORNEY, AND FULLY UNDERSTANDS IT.
IN WITNESS WHEREOF, and intending to be legally bound, we have hereunto set our
hand and seal this day of
Lei rn�._' 2012.
TNESS:
Wg) C atMITTINO,
Parer u
atural Guardian of
CHEYENNE COMITTINO, a Minor
—COWAONWEALTH OF PE NNSYLVANIA-
' NOTARREWAL
PAMELA A.swrrALSKI,Notary Public
Boro of Shippensburg,Cumberland County
*Commission Expires March 24,201a
2
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the foregoing Amended Petition for Leave
to Compromise Minor's Claim has been duly served upon all counsel of record by depositing the
same in the United States First Class Mail, postage prepaid, in Lemoyne, Pennsylvania, on April
2, 2013, as follows:
Chastity Comittino
384 Cortland Circle
Shippensburg, PA 17257
JOHNS DUFFIE STEWART& WEIDNER
ucy, Esquire
546682
ti
Johnson, Duffle, Stewart&Weidner
By: John A. Lucy, Esquire
I.D. No. 203948 Attorneys for Petitioner
301 Market Street
P. O. Box 109
Lemoyne, Pennsylvania 17043-0109
(717)761-4540
jal@jdsw.com
IN RE: : IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHEYENNE COMITTINO, a Minor,
NO.: /0? qI
ORDER APPROVING COMPROMISE, SETT�LEMENT AND DISTRIBUTION
AND NOW, this Jr 44\ of a�,= , 2013, upon consideration of the
Amended Petition for Leave to Compromise an action involving the Minor, it is hereby
ORDERED that Petitioner is authorized to enter into a settlement with the Defendants in the
gross amount of Twelve Thousand, Two Hundred Ninety-Two Dollars ($12,292.00) on behalf of
the Minor. Chastity Comittino as mother and natural guardian, is authorized to sign a Release
and to make the matter settled, discontinued and ended with prejudice as to Eugene M.
Siegfried and Jenny Siegfried and their minor son, Andrew Siegfried, and their insured, Erie
Insurance.
The settlement amount shall be distributed as follows:
TO: Chastity Comittino as parent and natural guardian of Cheyenne Comittino, a
minor - $12,292.00 to be deposited into a restricted, federally insured savings account marked
no withdrawals prior to age of 18 without court approval".
546682
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tf:
Counsel shall provide to the court within 30 days from the date of this Order proof of
such deposit.
It is further ORDERED that upon application to this court, Chastity Comittino may
withdraw funds from the restricted account for the sole purpose of any future procedures, as a
result of the subject accident prior to the minor reaching majority. The dollar amount of the
withdrawal, if any, for any updated procedures shall be approved by the court prior to the
withdrawal.
BY THE CO
J.
Distribution:
John A. Lucy, Esquire, Johnson Duffie Stewart&Weidner, 301 Market Street, P.O. Box 109, Lemoyne,
P 17043-0109 (717) 761-4540
ittin 384 Cortland Circle Shi ensbur PA 17257
LLChastity Com o, k PP 9.
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Johnson, Duffie, Stewart &Weidner
By: John A. Lucy, Esquire
I.D. No. 203948 Attorneys for Petitioner
301 Market Street
P. O. Box 109
Lemoyne, Pennsylvania 17043-0109
(717) 761-4540
jal @jdsw.com
IN RE: IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHEYENNE COMITTINO, a Minor,
NO.: 12-7418
PRAECIPE TO ENTER PROOF OF DEPOSIT
TO THE PROTHONOTARY:
Kindly file and docket the within Proof of Deposit pursuant to the Order of April 5, 2013.
Respe tfd y )ub itted,
HNSON, IE, STEWART-,&-WEIDNER
BY
J n° l
oh �4`- ucy, esquire
`Attorney I.D"No. 203948
301-Market Street
P.O. Box 109
Lemoyne, PA 17043-0109
(717) 761-4540
jal @jdsw.com
Date: May 1, 2013 Counsel for Petitioner
553681
04/26/2013
Account Summary for Account 5000094220 COMITTINO,CHEYEN
Account 5000094220 General Membership
Name Prime (0) (Locator: 1): CHEYENNE D COMITTINO
Comment (0) (Locator: 16): **NO WITHDRAWS UNLESS BY COURT ORDER
Comment(1) (Locator: 17): UNTIL MEMBER ATTAINS THE AGE OF 18
Comment(2) (Locator: 18): 3/2/2015 AT WHICH TIME MEMBER MAY WD FDS
Tracking 38 (0) (Locator:4): Account Information
Tracking 55 (1) (Locator:9): Credit History
Note: 4 Notes
Share ID 00: PRIME SHARE ACCOUNT 12,292.00
Hold (0) (Locator: 20): Check Hold expired 04/26/13 200.00
Hold (1) (Locator:21): Check Hold expires 04/30/13 4,800.00
Hold (2) (Locator:22): Check Hold expires 05/06/13 7,292.00
Name Resp (0) (Locator: 19):CHASTITY D COMITTINO
App ID 00: Z MEMBERSHIP APPLICATION Membership
Person (0) (Locator: 3): CHEYENNE D COMITTINO
Person (1) (Locator: 5): CHASTITY D COMITTINO
Note: 4 Notes
Cred Rep (0) (Locator:7): 000104/26/13 CHEYENNE D COMITTINO
Cred Rep (1) (Locator: 8): 0002 04/26/13 CHASTITY D COMITTINO
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