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HomeMy WebLinkAbout13-0491s `ll t p ' HANDLER, HENNING & ROSENBERG, LLP Andrew C. Spears (PA 87737) 1300 Linglestown Road, Suite 2 11arrisburg, PA 17110 Ph.: 717.238.2000 l'as: 717.233.3029 l-:-mail spears a?hhrlaw.com Attorneys for Petitioners IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN THE MATTER OF JAHMIR MCNEIL, a minor by and through his natural parent and guardian, JASMINE CHESTER 1Vj No. L) L? I 1 MINOR'S COMPROMISE PETITION FOR LEAVE TO COMPROMISE MINOR'S ACTION Pursuant to Pa.R.C.P. 2039, Jasmine Chester ("Ms. Chester"), the natural parent and legal guardian of minor, Jahmir McNeil ("Jahmir"), by her attorneys, HANDLER, HENNING & ROSENBERG, LLP, by Andrew C. Spears, Esquire, petition this Honorable Court to enter an Order permitting settlement and compromise of this action, and in support thereof, aver: Jahmir was born on June 26, 2007, and is therefore five years old and minor.' He currently resides with his mother, Ms. Chester, at 2206 C Cedar Run Drive, Camp Hill, PA 1701 1, Cumberland County, Pennsylvania. Jahmir was two (2) years old at the time of the incident. QMt *1o3.7sva ?IcN ?t5s 2. Petitioner, Ms. Chester, is an adult individual and said minor's natural parent and legal guardian, and she currently resides with Jahmir at 2206 C Cedar Run Drive, Camp Hill, PA Cumberland County, Pennsylvania. ?. The tortfeasor, Carlos Gonzalez-Collazo, is an adult individual and citizen of the Commonwealth of Pennsylvania with a last known address of 2209 Cedar Run Drive, Camp Hill, PA. Cumberland County, Pennsylvania. 4. On or about May 2, 2010, Jahmir was crossing the parking lot in front of his home to go play at the community playground. 5. At approximately the same time and place, the tortfeasor, Carlos Gonzalez- Collazo, was the owner and operator of a 2000 Ford Explorer bearing Pennsylvania registration number GR.K8400 ("Tortfeaisor's vehicle"). 6. Suddenly, and without warning, Tortfeasor's vehicle violently collided with .Jahmir as he crossed the parking lot. 7. As a direct and proximate result of the negligence of tortfeasor, Carlos Gonzalez- Collazo. Jahmir suffered a fractured eye socket, right frontal hemorrhage, and left pulmonary contusion. 8. Jahmir was treated by Hershey Medical Center and Mechanicsburg Family Practice and is undergoing occupational and speech therapy for his injuries. A copy of his most recent medical records from Hershey Medical Center is attached hereto and marked as Exhibit A. 2 9. At the time of the incident, Jahmir was not insured under an automobile insurance policy and received first party medical benefits from the tortfeasor's automobile insurance, Mercury- Insurance Group. 10. At the time of the collision, tortfeasor, Carlos Gonzalez-Collazo, was insured under an automobile insurance policy issued by Mercury Insurance Group. 11. Mercury Insurance Group has offered to settle Jahmir's claim against Carlos (ronzalez-Collazo for policy limits of ,$15,000.00. A copy of the proposed Release is attached hereto and marked Exhibit 13." 12. At the time of the incident, Jahmir was insured under health insurance from the Department of Public Welfare and received medical benefits from the Department of Public Welfare in the most recent amount of $15,092.31. 13. The Department of Public Welfare has agreed to a 50150 split of proceeds to satisfy their lien, asking for $5,438.21. A copy of the Department of Public Welfare Lien is attached hereto and marked Exhibit "C." A copy of the Agreement to reduce the lien to a 50150 split is attached hereto and marked Exhibit "D." 14. Counsel is of the opinion that said settlement is reasonable and in the best interests of Jahmir. 15. Ms. Chester believes said settlement is in the best interests of Jahmir and proposes to accept the offer of $15,1300.00, thereby releasing Carlos Gonzalez-Collazo and Mercury Insurance Group from any and all claims, suits, and/or actions related to this matter in the future. 3 16. Andrew C. Spears, Esquire, of HANDLER, HENNING & ROSENBERG, LLP, has been the attorney for the minor in this action and requests reasonable counsel fees of $3,750.00 for services rendered plus costs and expenses of $373.59 pursuant to a Contingent Fee Agreement signed by Petitioner, Ms. Chester. The 25% fee represents a reduction from the 33- 1 /3°% fee agreement signed by the Petitioners on behalf of her minor son. Thus, the total amount requested for attorney's fees and costs is $4,123.59. Copies of the Contingent Fee Agreement and billing summary are attached hereto and marked Exhibit "E" and Exhibit "F," respectively. 16. Petitioners further request this Honorable Court to order the balance, $5,438.20, to be placed into a restricted, interest-bearing account in the name of the minor, Jahmir McNeil, marked not to be withdrawn until the age of 18, on June 26, 2025. 4 WHEREFORE, Petitioners request this Honorable Court: a. Approve the above-stated Compromise: b. Authorize the payment of fees above-stated from funds due the minor; and c. Direct payment of the net funds due, in accordance with the above-state Compromise. Respectfully submitted, HANDLER, HENNING & ROSENBERG, LLP Date: By: Andre ;Spears, Esquire I.D. # PA 87737 1300 Linglestown Road, Suite 2 Harrisburg. PA 171 10 717.238.2000 - Phone 717.233.3029 - Fax spears@hhrlaw.com Attorneys for Petitioner Jasmine Chester PENNSTATE UP Milton & Ikrshey Medical Center College of Mein Penn State Milton S. Hershey Medical Center Tel, (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Dive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: MCNEIL, JAHMIR J PSUHMC MRN: 1706977 Patient Sex: Male Date of Birth: 6/26/2007 Patient Location: lil)I 1, , Visit Number: 15844136 Visit Type: Clinic. O u t p a t i e n t L e t t e r D o c u m e n t Final Document Electronically Signed by: Bramley, Harry P April 15, 2011 Name: MCNEIL, JAHMIR J HMC Number: 1706977 DOB: 06/26/2007 Date of Service: 04/15/2011 Kiran Sharma, M.D. 910 Century Drive Suite 150 Mechanicsburg, PA 17050 Dear Dr. Sharma: 4/21/2011 9:12:57 PM I had the opportunity see Jahmir McNeil Vn foliowup in the Penn State Concussion Program on April 15th, 2011. He presents to the clinic with his mother. As you recall, Jahmir is a 3-year-old who is status post left elbow fracture brain injury when he struck by a car on May 2nd, 20'10. Mom indicates that he is receiving some speech therapy as well as occupational therapy in the home and also has been getting some behavioral therapy through the Philhaven. She indicates that he is very active, playful and his physical mobility seems to be quite good His behavior overall continues to be a major issue. Mom indicates that he is a handful and at times can get very angry. On exam, generally he looks well, no apparent distress, pleasant, interactive within the exam room. Mucous membranes are moist. Lungs have good air movement. He is well perfused. Neurologically, he remains grossly intact. He also appears to be very cooperative throughout the exam and does follow directions and is very pleasant. Date Printed: 1212811011 Time Printed: 11:04 AM 'ANEW PENNSTATE sm Milton S Hershey Medical C rater College of Medicine Patient Name: MCNEIL, JAHMIR J PSUHMC MRN: 1706977 O u t p a t i e n t L e t t e r D o c u m e n t Final Document Electronically Signed by: Bramley, Harry P 4/21/2011 9:12:57 PM ASSESSMENT: Jahmir is a 3-year-old, status post brain injury and orbital fracture close to a year ago, who continues to do very well. Behavior and speech delay tend to be a major issue. RECOMMENDATIONS: In regards to his behavior, continue with the behavioral therapy certainly makes sense. I have discussed certain medications such as Risperdal with mom in the past and again during the visit today, and I am not sure if this would be helpful or not. Mom also has opposed. In regards to speech delay, again indicated that speech therapy with major focus of treatment and will continue with this. Overall, Jahmir looks quite well and doing fairly well and mom agrees. I did schedule a followup appointment, see him back in about 4 to 5 months but told mom to contact me with questions, concerns that she may have prior to next visit. Thanks for allowing me to participate in the care of the patient. Please contact me if questions. 184592 Electronic Signature on File CC: Kiran Sharma, MD 910 Century Drive Suite 150 Mechanicsburg PA 17050 Sincerely, Harry P Bramley, DO Author Signature Dt/Tm: 21.04.2011 09:12 PM HPB /CO DD: 04/15111 DT: 04/16/11 18:59 Date Printed: 1212812011 Time Printed: 11.04 AM RELEASE KNOW ALL BY THESE PRESENTS THAT I, JASMINE CHESTER, PARENT AND LEGAL GUARDIAN OF MINOR JAHMIR MCNEIL, for and in consideration of the sum of FIFTEEN TIIOUSAND DOLLARS AND ZERO CENTS ($15,000.00), paid by Mercury Insurance Company, release and forever discharge every person or entity of any description, including without limitation, The Mercury Insurance Company, Carlos Gonzalez-Collazo, their heirs, predecessors, successors, assigns, executors and administrators, of and from all, and all manner of, actions and causes of action, suits, debts, dues, accounts, bonds, covenants, contracts, agreements, judgments, claims and demands whatsoever in law or equity, for all claimed and as of yet unclaimed consequential damages or extra-contractual damages, including bad faith, treble or punitive damages, arising out of a claim for bodily injury to JAHMIR MCNEIL incurred as a result of a May 2, 2010, motor vehicle accident. The undersigned promises to obtain a release and discharge such lien or reimbursement right, and to defend, indemnify and hold harmless the parties released and the persons, firms or corporations making the payment herein, from any costs, expenses, attorney fees, claims, actions, judgments, or settlements resulting from the assertion or enforcement of such lien or reimbursement right by any person or entity having such lien or right. This Release does not apply to any Underinsured Motorist (UIM) claims and/or litigation, and/or and extra-contractual damages that may arise out of said UIM claim(s), including bad faith, and treble or punitive damages. IN WITNESS WHEREOF, I have hereunto set my hand and sea] on the day of 2013. SIGNED, SEALED AND DELIVERED in the presence of: Witness JASMINE CHESTER, PARENT AND LEGAL GUARDIAN OF MINOR JAHMIR MCNEIL K COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY CASUALTY UNIT P.O.BOX 8486 HARRISBURG, PA 17105-8486 February 11, 2011 HANDLER HENNING & ROSENBERG LLP ANDREW C SPEARS ESQUIRE 1300 LINGLESTOWN RD HARRISBURG PA 17110 Re: Jahmir Mcneil (minor) CIS #: 410373516 Incident Date: 05/02/2010 Dear Attorney Spears: Pursuant to our previous'correspbndence'please be advised that our claim against your client's personal injury award is detailed on the attached statement of claim. Social Security Act §1902(a)(7) requires that this recipient information be safeguarded, used by you solely to recover funds that we provided. 'Disclosure for other purposes is subject'to.criminal and monetary penalties. Please contact this office well in advance of settlement so that we can provide you with an updated statement of claim. In the event that the Department continues to provide your client with medical and/or cash assistance, the amount of our claim will increase accordingly. This statement does not include any other claims which may exist. If copies.of bills.are needed, please:-contact the.providers directly.. Refer them to the Medical Assistance Bulletin, No. 99-09-03 (Effective Date 03/20/09). Checks should be made payable to the Department of Public Welfare and sent to my attention at the above address. We request that with all transmittal of funds,'you provide the Department with a copy of the final distribution sheet. Please advise us of your position.regarding payment of the Department's claim in this matter, as well as the present status of this case. If you have any further questions, please contact me. Thank you for your cooperation in this matter. Sincerely, Elizabeth M. Wilson TPL Program Investigator 717-214-1868 717-772-6553 FAX Enclosure I COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX-8486 HARRISBURG PA 17105-8486 February 10, 2011 STATEMENT OF CLAIM SUMMARY L NAME MCNEIL, JAHMIR ID 410 373 516 aMFDICAL: USUAL CHARGE ' asANITAPPROVED CLAIMS 48,396.60 19,227.01 CAS?Ii AE 91D VERED ff , UNT§ .- J CURRENT SOC 06M8110 - 02/01/11 696.00 SEM "DP.W l 19,923.01 rt J?j COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE,, EIN; '23 60??1-?.3< COMMONWEALTH-OF PENNSYLVANIA CEPARTMENT:OFjPUBLIC,WELFARE February 10, 2011 STATEMENT OF CLAIM NAME MCNEIL, JAHMIR ID", 410 373 616 BRENT GEOFFREY J 92 TUSCARORA ST ARRISBURG PA 17104 4'E'OS ICE P4 M ORIGINAL CKl`1 A?JUS •? (.' r, 's• :.max 09/02/10 - 09102/10 09102/10 0071886800000001 0071886800000001 DIAGNOSIS 1 : V720 EYE & VISION EXAMINATION DIAGNOSIS 2: 0000000 PROC CODE. V2020 FRAMES, PURCHASES 09102/10 - 09/02/10 09/02110 0071886800000002 0071886800000002 DIAGNOSIS 1 : V720 EYE & VISION EXAMINATION DIAGNOSIS 2: 0000000 PROC CODE: V2199 NOT OTHERWISE CLASSIFIED, SINGLE VISION liRrr USUAL C GE 3MOUNT APPROVED 15.00 15.00 100.58 100.58 p -; AL BRENT GEOFFREY J 115.58 115.58 s r 001639488 0001 NPI CQMMOWV ALTH OFPENNSYLVANIA DEPARTMEN70F;P,UBLIC?WELFARE February 10, 2011 STATEMENT OF CLAIM NAME" MCNEIL, JAHMIR ID; s 410 373 516 PENN STATE THE MILTON S HERSHEY MED 500 UNIVERSITY DR ERSHEY PA 17033 DATE OF'SERVICE PAYMENT DATE 'ORIGINAL CRN ADJUSTD RN USUAC'CHARGES'. AMOU T+APPROUED 05/02110 - 05/04/10 06/02110 014015020 32102013801400001 23,995.40 13,549.27 DIAGNOSIS 1 : 8026 FX ORBITAL FLOOR-CLOSED DIAGNOSIS 2: 85300 TRAUMATIC BRAIN HEM NEC PROC CODE : 000000 05102/10 - 05/02/10 06123110 01651256901 32102017682460001 DIAGNOSIS 1 : 9698 INJURY MLT SITEJSITE NEC DIAGNOSIS 2: 96901 HEAD INJURY, UNSPECIFIED PROC CODE : A0431 AMBULANCE SVC,CONV AIR SVC,ONE WAY(ROTAR 11,839.00 3,172.00 P DE., B`\ T s { PENN STATE THE MILTON S HERSHEY MED CTR 35,834.40 16,721.27 f ? 24 100765310 0034 NPI -COMMONWEALTHOF PENNSYLVANIA DEPARTMENTOF?PUBLIC W,EL'FARE' February 10, 2011 STATEMENT OF CLAIM NAME MCNEIL, JAHMIR ID 410 373 516 WEST SHORE ADV LIFE SUP SVC 503 N 21ST ST AMP HILL PA 17011 DATE C?F'SERVIGE .-PAYWrNT DATE- } GRIGIq'AL,CRN ADJUSTEL1°?RN ._ ' USUAL'CHARGES x: AMOUN 'PPRCVEDt 05/02110 - 05/02/10 09129/10 02631774101 32102912871350001 938.04 80.00 DIAGNOSIS 1 : 95909 INJURY O F FACE AND NECK PROC CODE: A0432 PARAMEDIC INTERCEPT,RURAL AREA,TRANSPORT E?O iDER SUB T` WEST SHORE ADV LIFE SUP SVC 938.04 80.00 26 001173277 0001 NPi: 1516960749 C COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF`PUBLIC -WELFARE February 10, 2011 STATEMENT OF CLAIM NAME MCNEIL, JAHMIR ID` 410373516 BOAL DANIELLE 500 UNIVERSITY DR HERSHEY PA 17033 j DATE OF SERVICE PAYMENT DATE"1 ORIGINAL CRN "ADJUSTED CRhJ US 4 J g ES RM19 APPROVE ' 05/02/10 - 05/02110 05131110 01330699301 32101652532860001 478.00 77.16 DIAGNOSIS 1 : 95919 OTHER INJURY OF OTHER SITES OF TRUNK PROC CODE : 72193 COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; 05/02110 - 05/02110 05131110 01330699302 32101652532860002 527.00 85.04 DIAGNOSIS 1 : 95919 OTHER INJURY OF OTHER SITES OF TRUNK PROC CODE : 74160 COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN; 05/02110 - 05102/10 05/31/10 01330699401 32101652533180001 75.00 10.80 DIAGNOSIS 1 : 95919 OTHER 'INJURY OF OTHER SITES OF TRUNK PROC CODE : 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VI 05/03/10 - 05/03/10 05/31 /10 01330699303 32101652532860003 75.00 10.80 DIAGNOSIS 1 : 95919 OTHER INJURY OF OTHER SITES OF TRUNK PROC CODE : 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VI 05103110 - 05103/10 05/31/10 01330699304 32101662532860004 73.00 11.58 DIAGNOSIS 1 : 95919 OTHER INJURY OF OTHER SITES OF TRUNK PROC CODE : 73610 RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, 05103/10 - 05/03110 05131/10 01330699305 32101652532860005 73.00 11.58 DIAGNOSIS 1 : 95919 OTHER INJURY OF OTHER SITES OF TRUNK PROC CODE: 73560 X-RAY EXAM OF KNEE 1 OR 2 `PROVIDER SUB TOTAL BOAL DANIELLE 1,301.00 206.96 31 000667165 0001 NPI: 1588621775 COMMONWEALTH OF PENNSYLVANIA.' DEPARTMENT OF'PUBLIC','WELFARE CILLEY ROBERT E 500 UNIVERSITY DR February 10, 2011 STATEMENT OF CLAIM j:NAME MCNEIL, JAHMIR ID - 410 373 516 IERSHEY PA 17033 DATE OF SLPVICE PAYMENT DATE: ` . ORIGINAUCPN. ADJUSTED-_CRN?SUAL'CHARGES 'A.MOUNTAPPRC)VE© 05/02/10 - 05102/10 05/31/10 01330702001 32101652743720001 4,268.00 275.62 DIAGNOSIS 1 : 9598 INJURY MLT SITEISITE NEC PROC CODE : 99245 OFFICE CONSULTATION FOR A NEW OR ESTABLI ` T CILLEY ROBERT E P RO D R SUB TO AL 4,268.00 275.62 f"''= £ 31 001273218 0002 NPI: 1396794012 COMMONWEALTHOF PENNSYLVANIA DEPARTMENT.OFPUBLIC_WELFARE. February 10, 2011 STATEMENT OF CLAIM NAME MCNEIL, JAHMIR ID 410 373 516 DETTORRE MICHAEL D 500 UNIVERSITY DR ERSHEY PA 17033 s -DATE'OFS -RVICE PAYMENTDATE° ORIGI 05/02110 - 05102110 05/31110 01330695101 DIAGNOSIS 1 - 8600 TRAUM PNEUMOTHORAX-CLOSE PROC CODE : 99291 CRITICAL CARE FIRST HOUR 05/03110 - 05103110 DIAGNOSIS 1 : 8600 PROC CODE : 99291 ' ADJUSTE. 'RN I USUAL-c4RGES" AM 32101661446640001 674.00 05131110 01330695102 32101661446640002 TRAUM PNEUMOTHORAX-CLOSE CRITICAL CARE FIRST HOUR 674.00 PPROVE[ 275.97 275.97 ,TA DETTORRE MICHAEL D 1,348.00 551.94 a 31 001412625 0001 NPI: 1336137439 GaMMONWEALTH OF, PENNSYLVANIA DEPARTMENT OF,,PUBLIC WELFAFE . February 10, 2011 STATEMENT OF CLAIM N,4ME MCNEIL, JAHMIR ID 410 373 516 BRAMLEY HARRY P 670 CHERRY DR HERSHEY PA 17033 DATE OF,SERV.ICE -:PAYMENT DATE,; , « RIGINAL'CRN J ADJUSTED GRN 1 L1S?iACtrCHARGES *MOUNP' APRROVED 06/04110 - 06104110 06/30/10 01680694801 32102011845680001 353.00 65.00 DIAGNOSIS 1 : 95901 HEAD INJURY, UNSPECIFIED PROC CODE : 99244 OFFICE CONSULTATION FORA NEW OR ESTABLI p$ g f Lp~ BRAMLEY HARRY P 353.00 65.00 31 001745060 0006 NPI: 1598715088 n C - COMMONWEnALTH;OF PENNSYLVANIA DEPARTMENT OF'PUBLIC WELF ARE February 10, 2011 STATEMENT OF CLAIM NAME, MCNEIL, JAHMIR ID, 410 373 516 MCGINN JOHNATHAN D 500 UNIVERSITY DR HERSHEY PA 17033 IT DY>T OF ERVI'611E-jr PAYMENT"DA?Th-" i 0RIGINi9L` CRN AD`JUSTE aRN k ;ts xM 05103110 - 05103/10 05131110 01330700901 32101661218900001 DIAGNOSIS 1 : 8028 FX FACIAL BONE NEC-CLOSE PROC CODE : 99253 INITIAL INPATIENT CONSULTATION FORA NEW T p B bs6AL'7C4RGESz: AMOUN- 331.00 54.60 OVIDEUBTOT4L' MCGINN JOHNATHAN D 331.00 54.60 4 - 31 001840514 0006 NPI: 1831156728 'COMMONWEALTH OF PENNSYL•VANIP, DEPARTMENT OF PUBLIC WELFARE -, ,. _ February 10, 2011 STATEMENT OF CLAIM NAME- MCNEIL, JAHMIR {ID ' 410 373 516 WILKINSON MICHAEL J 500 UNIVERSITY DR ERSHEY PA 17033 DATE OF SERVICE- sPAYMENTDATE. ORIGINAL<C? ADJUSTED C * 31L CHARS 91 4'1?T fkPPROVED„ 05103/10 - 05/03/10 05131110 01330689001 32101663038660001 331.00 54.60 DIAGNOSIS 1 : 8028 FX FACIAL BONE NEC-CLOSE PROC CODE : 99252 INITIAL INPATIENT CONSULTATION FOR A NEW 05/19/10 - 05119110 06/14/10 01480898601 32102011602180001 213.00 140.01 DIAGNOSIS 1 : 3682 DIPLOPIA PROC CODE : 99243 OFFICE CONSULTATION FOR A NEW OR ESTABLI 06117110 - 06117/10 07/19/10 01811544601 32102291942850001 162.00 63.70 DIAGNOSIS 1 : 8026 FX ORBITAL FLOOR-CLOSED PROC CODE : 99213 OFFICEIOUTPATIENT VISIT EST ROVIDER,'SUB TOTAL WILKINSON MICHAEL J 706.00 258.31 5` ` t" '-<! 31 100843318 0002 NPI : 1427097773 COMMONWEALTH OF PENNSYLUArNIA DEPART,MENT,OF,_PUBGC WELFARE February 10, 2011 STATEMENT OF CLAIM NAME; MCNEIL, JAHMIR ID 410 373 516 WEINSTEIN JOEL M 500 UNIVERSITY DR HERSHEY PA 17033 DATE':OF'SERVICE PAYIJIENT DATE g OR?INf SRN d S 17 `N USUAL FiAFZ DES j s©?f APPRn`?EC - 06/25/10 - 06/25110 07/26/10 01880576001 32102291334090001 26.00 8.19 DIAGNOSIS 1 : 3679 REFRACTION DISORDER NOS PROC CODE : 92015 DETERMINATION OF REFRACTIVE STATE 06/25/10 - 06126110 07/26/10 01880676002 32102291334090002 213.00 140.01 DIAGNOSIS 1 : 3679 REFRACTION DISORDER NOS PROC CODE : 99243 OFFICE CONSULTATION FOR A NEW OR ESTABLI ?iDE UBsT©TA WEINSTEIN JOEL M 239.00 148.20 w f i.r 31 101356064 0001 NPI: 1811951650 COMMONWEALTH' OF-PENNSYL, ANIA DEPARTMENT OF',,FUBLIC WELFARE February 10, 2011 STATEMENT OF CLAIM NAME` MCNEIL, JAHMIR ID` 410373516 IANTOSA MARK R 500 UNIVERSITY DR HERSHEY PA 17033 DATE OF'SERVICE ' PAYMENT DAB E ORIGItJ+A?i' CR , q #... f DJUSTED CRN g ''ti!$x SlJ L CHgRGES, °AMOUNT APPROVED 05103/10 - 05103/10 05131110 01330686101 32101652577140001 300.00 30.94 DIAGNOSIS 1 : 85200 TRAUM SUBARACHNOID HEM PROC CODE 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR 05/04/10 - 05104/10 05131110 01330686102 32101652577140002 113.00 30.94 DIAGNOSIS 1 : 85200 TRAUM SUBARACHNOID HEM PROC CODE: 99231 SUBSEQUENT HOSPITAL CARE, PER DAY FOR TH 05125/10 - 05125/10 08126/10 02230683601 32102501523100001 162.00 63.70 DIAGNOSIS 1 : 85200 TRAUM SUBARACHNOID HEM PROC CODE: 99213 OFFICEIOUTPATIENT VISIT EST P OVIDER SUB TOE IANTOSA MARK R 575.00 125.58 31 101710147 0001 NPI: 1386694925 COMMONINEALTd i'OF PENNSYLVANIA DEPARTMENTOF PUBGC`WELFARE C February 10, 2011 STATEMENT OF CLAIM NAME MCNEIL, JAHMIR 1 D-, : 410 373 516 SHARMA KIRAN 910 CENTURY DRIVE NECHANICSBURG PA 17055 ?ATE'OF SF_RV.ICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN .-, sUSUAL CHARG S Ttmg k1U[3 NTA€PPROVED 05107110 - 05/07110 05/26/10 01320551201 32101652924960001 118.00 54.42 DIAGNOSIS 1 : 71907 JOINT EFFUSION-ANKLE PROC CODE : 99214 OFFICE/OUTPATIENT VISIT EST 05126110 - 06/26110 06/09/10 01520401801 32102002906440001 79.00 35.00 DIAGNOSIS 1 : 71947 JOINT PAIN-ANKLE PROC CODE : 99213 OFFICEIOUTPATIENT VISIT EST OPROVIDE r SHARMA KIRAN 197.00 89.42 d°-a 31 101913462 0001 NPI: 1710978309 COMMONVVEAUTH,OF, PENNSYLVANIA DEPARTMENT?OFPUBLIC WELFARE February 10, 2011 STATEMENT OF CLAIM NAME MCNEIL, JAHMIR 11) 410 373 516 LEAMING JAMES M 500 UNIVERSITY DR IERSHEY PA 17033 BATE'®F VIC A MERYT ® ' DU F S ER DQ Y FGIN4L CRN > A ShE ?R 7 - S ., C fiOVED A 05102110 - 05/02/10 06107/10 01410479501 32102002698060001 470.00 72.00 DIAGNOSIS 1 : 9598 INJURY MLT SITE/SITE NEC PROC CODE : 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALU PROM *.E ,GDTAL'- LEAMING JAMES M 470.00 72.00 31 102098035 0001 NPI: 1134292733 COMMONWEALTH OF PENNSYLVANIA P bEPARTMENT,OF PUBLIC`WELFARE February 10, 2011 STATEMENT OF CLAIM NAME= MCNEIL, JAHMIR ,ID 410 373 516 OUYANG TAO 500 UNIVERSITY DR HERSHEY PA 17033 L DATL OF SERVI E IRL ! PAYMENT.CATE ORIGINAL' ADJUSTED CF4V i 05102/10 - 05/02/10 05131/10 01330697401 32101652624270001 DIAGNOSIS 1 : 8026 FX ORBITAL FLOOR-CLOSED PROC CODE 70450 COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR B 05/02/10 - 05/02/10 05131/10 01330697402 32101652624270002 DIAGNOSIS 1 : 8026 FX ORBITAL FLOOR-CLOSED i PROC CODE 72126 COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL I 05102/10 - 05102110 05131110 01330697403 32101652624270003 DIAGNOSIS 1 : 8026 FX ORBITAL FLOOR-CLOSED PROC CODE : 70486 COMPUTERIZED AXIAL TOMOGRAPHY, MAXILLOFA _ W:. 352.00 56.52 478.00 77.18 470.00 75.59 PROVIDER SUB T5 OUYANG TAO 1,300.00 209.29 31 102327684 0001 NPI: 1740428978 COMMOMNEALTH?OF PENNSYLVANIA- DEPARTMENT;0F'PUBLIC+WELFARE February 10, 2011 STATEMENT OF CLAIM NAME MCNEIL, JAHMIR ID 410 373 516 BARBIERI CAROLYN A 500 UNIVERSITY DR ERSHEY PA 17033 PATE',bF SERVICE I PAYMF ®ATE ORIGINAL' CRN . " % r? DUSTED CRN ?S iAL CHAf? S RI©1JNTrAPPROUE 05/02110 - 05/02/10 05131110 01340732001 32101652631650001 114.00 110.78 DIAGNOSIS 1 : 9598 INJURY MLT SITE/SITE NEC PROC CODE : 99243 OFFICE CONSULTATION FOR A NEW OR ESTABLI nf?ft® IDER SUB TOTA BARBIERI CAROLYN A 114.00 110 78 31 102336979 0001 NPI : 1023230596 . CQMMONWEALTH:OF>PENNSYLVANIA ?DEPA?tTMENT OF;P.UBLIC WELFARE February 10, 2011 STATEMENT OF CLAIM NAME' MCNEIL, JAHMIR ID 410 373 516 SANTOS MARY C 500 UNIVERSITY DRIVE HERSHEY PA 17033 OF SERVI"CEO PA 161E 1JT DATE'? O fOINA `A, D STED CRN ??", SUAL CHr1RGES ~AI?0014T APPPP( D} 05103/10 05103110 05131110 01330701601 32101652716200001 113.00 30.94 DIAGNOSIS 1 : 9598 INJURY MLT SITEISITE NEC PROC CODE: 99231 SUBSEQUENT HOSPITAL CARE, PER DAY FOR TH 06104/10 - 05!04/10 06131110 01330701602 32101662716200002 113.00 30.94 DIAGNOSIS 1 : 9598 INJURY MLT SITE/SITE NEC PROC CODE : 99231 SUBSEQUENT HOSPITAL CARE, PER DAY FOR TH DER SUB TDTAL:, SANTOS MARY C 226 00 61 88 - 31 102376301 0001 NPI: 1932136702 . . 00m"INEALTH OF PENNSYLVANIA DEPARTMENT OFPUBLICVVELFARE February 10, 2011 STATEMENT OF CLAIM NAME MCNEIL, JAHMIR ID 410 373516 BRENT GEOFFREY J 92 TUSCARORA ST HARRISBURG PA 17104 DATE OF SER 71E @PA ,t1ENT DATE r OiC INALE'CRN 3DJIJSTED CRN iUSULC C4I1NT APPROVE 08/27110 - 08127/10 09/02110 DAVGHP0071886801 32102841298990001 15.00 15.00 DIAGNOSIS 1 : V720 EYE & VISION EXAMINATION PROC CODE : V2020 FRAMES, PURCHASES 08/27/10 - 08/27/10 09/02/10 DAVGHP0071886802 32102841298990002 65.58 65.58 DIAGNOSIS 1 : V720 EYE & VISION EXAMINATION PROC CODE : V2199 NOT OTHERWISE CLASSIFIED, SINGLE VISION OVdDUB OTA? 1i BRENT GEOFFREY J 67 001639488 (1001 NPI : 1336141654 80.58 80.58 pennsytvania DEPA'R'TMENT-Or?P'UBLJC WELFARE June 12, 2012 HANDLER HENNING & ROSENBERG, LLP ANDREW C SPEARS ESQUIRE 1300 LINGL'ESTOWN RD STE 2 HARRISBURG PA 17110 Re: Jahmir Mcneil (minor) CIS #: 410373516 Indiaent Date: 0 10 i Dear Attorney Spears: The Department of Public Welfare maintains a claim in the amount of $15,092.31 for the above-referenced incident. After attorney fees and costs, the Department agrees to accept 50% of the client's net settlement. The net payment due is $5.482.96. Checks should be made payable to the Departme.nt of Public Welfare and sent to my attention at the address listed below. We Bequest that with all transmittal of funds, you provide the Department with a copy of the final distribution sheet. In the event you have already brought or will bring any action resulting in a further recovery, we reserve the right to seek recovery of any unpaid portion of our medical/cash claim. This settlement in no way affects our future rights. Thank you for your cooperation in this matter. If you have any further questions, I please contact me. Sincerely, r Elizabeth M. Wilson TPL Program Investigator 717.-214-1868 717-772-6553 FAX !'. i Bureau of Program Integrity Division of Third Party Liability I Recovery Section e PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486 _ z'. CONTINGENT FEE AGREEMENT I, Jasmine Chester, as Parent and/or Legal Guardian of Jahmir McNeil do hereby retain HANDLER, HENNING & ROSENBERG, LLP., of Harrisburg, Pennsylvania, as my attorneys in this matter to represent me and to process, negotiate, arbitrate a settlement or to institute in my name, any legal proceedings or actions that, in their judgment are necessary, against VjtLri611)/i cl/2/_`M or against anyone else as a result of injuries and damages I sustained in an incident that occurred on 00/Q0/ 000. C)5(DZ(1016 I agree not to settle, negotiate or adjust the above claim or any proceedings based thereon without the written consent of my said attorneys. In consideration of the services so to be rendered by Handler, Henning & Rosenberg, LLP, I hereby covenant, promise and agree to pay them for their professional services rendered, THIRTY-THREE AND ONE-THIRD PERCENT (33 Vs%) of whatever sum is recovered as a result of settlement without lawsuit; or FORTY PERCENT (40%) of whatever sum is recovered after lawsuit is filed or in the event of arbitration or mediation. I will reimburse Handler, Henning & Rosenberg, LLP. for any necessary expenses advanced on my behalf in pursuing my claim. Examples of typical expenses include Court filing fees, investigation, auto mileage, photocopies, court reporters, medical records, expert witness fees, etc. I further understand that my attorney(s) may have to resolve Medicare, Medicaid, and/or private health insurance reimbursement claims or liens for past and/or future medical care. My attorney(s) may associate separate experts/case workers who will assist with the reimbursement of claims or liens. The expense of any such service will be treated as a case expense. If no money is obtained, client will not owe a legal fee or expenses. I also agree to take possession of my medical files at the conclusion of this case. My failure to take possession of these files within 60 days after the conclusion of the case will authorize my lawyers to destroy said files. I agree that HANDLER, HENNING & ROSENBERG, LLP. may associate additional lawyers to assist with this case and I agree to the sharing of fees between lawyers. I understand the terms herein apply to other lawyers associated on this case. l understand that the association of other lawyers does not increase the amount of the attorney fees at the conclusion of the case. Counsel reserves the right to withdraw if they desire to do so, for any reason(s) they deem proper. I acknowledge that I have read, approved and understood the above Contingent Fee Agreement and I acknowledge having received a copy of the same. The terms set forth herein are accepted. ! IN WITNESS WHEREOF, I have hereunto set my hand and seal this ! ?Aday of Ma \/, 2010. l (SEAL) min Ater, as Parent and/or Legal uardia of Jahmir McNeil r3 r:Uk` i andlar, anning? C lient No: 215380 osanbarg,LLA Matter: 000000 Attorney: ACS ATTORNEYS AT LAW My 1300 Linglestown Road, Harrisburg, PA 17110 P re-Bill No: 44271 Bill Date: January 02, 2013 Jahmir McNeil 2206 Cedar Run Drive Apt C Camp Hill, PA 17011 INVOICE PAYMEN T DUE UPON RECEIPT EXPENSES 05/17/2010 LOWER ALLEN TWP POLICE 15.00 CASE 05/17/2010 $15.00 01/31/2012 CC- SDS - PENN STATE HERSHEY MEDICAL CENTER 237.16 CASE 01/31/2012 $237.16 01/31/2012 CD formating/copying/burning 3.00 CD 01/31/2012 $3.00 12/26/2012 STAR-MED LLC 88.16 CASE 12/26/2012 ,. $88.16 01/31/2013 Fax Charges 10.00 FAX 01/31/2013 $10.00 01/31/2013 Mileage 13.00 MILE 01/31/2013 $13.00 01/31/2013 Postage Costs 4.00 POS 01/31/2013 $4:00 01/31/2013 Postage Costs 1.10 POST 01/31/2013 $1.10 01/31/2013 Long Distance Telephone Charges 2.17 TELE 01/31/2013 $2.17 TOTAL EXPENSES $373.59 Total due this invoice $373.59 TOTAL BALANCE DUE $373.59 Handier Henning & Rosenberg LLP Attorneys at Law VERIFICATION I, JASMINE CHESTER, natural parent and legal guardian of JAHMIR MCNEIL, a minor, hereb verifies that the statements in the foregoing document are true and correct to the hest of my knowledge, information and belief. I understand that the statements made therein are made subject to the penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities. JAINE NESTER ZZEIR l par nt and guardian of NEIL, a minor Date: )-?--7 ' / =)- 1300 LINGLESTOWN ROAD, SUITE 2 1 HARRISBURG PA 17110 717 238 2000 f 717 233 3029 toll free 800 422 2224 1 www.hhrlaw.com ?44 Hancver 717 630 H2O(? ; 1"In castei 7 17 43l 40?)t?