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Home My WebLink About04-5728 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No. ()ll_ S7). f 20 Civil Action - (X ) Law ( ) Equity RALPH E. PROBST, and PHYLLIS W. PROBST, his wife, 2425 GARRISON AVE HARRISBURG, PA 17110 EDITH M. CADY 107 BEECHWOOD DR. MECHANICSBURG, P A 17055 vs. JURY TRIAL DEMANDED Plaintiff(s) & Addresses Defendant(s) & Addresses PRAECIPE FOR WRIT OF SUMMONS TO THE PROTHONOTARY OF SAID COURT: Please issue writ of summons in the above-captioned action. Writ of Summons shall be issued and fOlwarded to ( )Attomey (X)Sheriff JOSEPH 1. DIXON, ESQUIRE 126 STATE STREET HARRISBURG PA 17101 (717)236-8515 Names/Addressffelephone No. Of Attorney ,o"" .....---- I _//-~ 8igruitafe of Attorney Supreme Court ID No. 28290 Date November 12, 2004 WRIT OF SUMMONS TO THE ABOVE-NAMED DEFENDANT(S): EDITH M. CADY YOU ARE NOTIFIED THAT THE ABOVE-NAMED PLAINTIFF(S) HASIHA VB COMMENCED AN ACTION AGAINST YOU. ~~ /2 ufo . _. Protho~tary D1f r- Date: I~ /~, ':2fJlJ'I by "-/" 'l~i ~ 0 ~..LJ Deputy ( ) Check here if reverse is issued for additional information. ,...,,) 0 C? = -n ~ c".,:,) c.. ..1..- --I r ~ ~ -"-,," -C-r, c,:) ri'p:;;.;. $ , . ~:;: -r'l~ tv -, ,t] 9 C). .., 2;f '" . !; 0-' :~;1 ~~ - ~.' .....:. CI\. 0) "- ~:;'a "' V\ _.,,~.. "" _"i~ . ) - 0-, (, , ~!? ~i 'd ( ~ ,;; :::1 ............... <...,,) IN THE COURT OF COMMON PLEAS, CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION RALPH E. PROBST and PHYLLIS W. PROBST, his wife, Plaintiffs . . v. File No. 04-5728 Civil EDITH M. CADY, Defendant PRAECIPE AND RULE TO FILE X A COMPLAINT A BILL OF PARTICULARS TO THE PROTHONOTARY/CLERK OF SAID COURT: Issue rule on Plaintiffs to file a Complaint in the above case within twenty days after service of the rule or suffer a judgement of non pros. DATE: ld-/ i 1/0'1 signature: ~~ k 4' Pr int Name: Richard H. Wix, Esq. Attorney for: Defendant Address: 4705 Duke Street Harrisburg. PA 17109 Telephone No: (717) 652-8455 Supreme Court ID No.: 07274 NOW, D~c ~I , ~Lf, JfLE I~~SUED AS ABO~ LuvaZG T< dfo Prothonotary B~aIb]..O. P. 77tJ1&.1J.C Deputy (NOTE: File in duplicate) PROTHON.-12 " ... i f (-) -: I' t.....;> ~...:') c:~) ..J-- (:::1 ,- \.~") 1".' ("""'I " 1 ;1 C,) RALPH E. PROBST and PHYLLIS W. PROBST, his wife, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA NO. 04-5728 Plaintiffs v. CIVIL ACTION - LAW EDITH M. CADY COMPULSORY ARBITRATION Defendants NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set for against you. You are warned that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP CUMBERLAND COUNTY LAWYER REFERRAL SERVICE Court Administrator Cumberland County Courthouse Carlisle, P A 17013 (717) 240-6200 NOTICA LE HAN DEMANDADO A USTED EN LA CORTE. Si usted quiere defenderse de estas demandas expuestas en las paginas siguientes, usted tiene viente (20) dias de plazo al partir de la fecha de la demanda y la notificacion. Usted debe presentar una apariencia escrita 0 en persona 0 por abogado y archivar en la corte en forma escrita sus defensas 0 sus objeciones alas demandas en contra de su persona. Sea avisado gue si usted no se defiende, la corte tomara medidas y puede entrar una orden contra usted sin previo aviso 0 notificacion y por cualguier gueja 0 alivio gue es pedido en la peticion de demanda. Usted puede perder dinero 0 sus propiedades 0 otros derechos importantes para usted. LLEVE ESTA DEMANDA A UN ABODAGO IMMEDIATAMENTE. SI NO TIENE ABOGADO 0 SI NO TIENE EL DINERO SUFFICIENTE DE P AGAR TAL SERVICIO, VA Y A EN PERSONA 0 LLAME FOR TELEFONO A LA OFICINA COY A DIRECCION SE ENCUENTRA ESCRIT A ABAJO PARA A VERIGUAR DONDE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. CUMBERLAND COUNTY LAWYER REFERRAL SERVICE Court Administrator Cumberland County Courthouse Carlisle, PA 17013 (717) 240-6200 By: /1 /7 // (..---// ! "' J~eph J. Dixon, Esquire Attorney ID No. 28290 126 State Street Harrisburg, PAl 71 0 1 (717) 236-8:515 Attorney for the Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA RALPH E. PROBST and PHYLLIS W. PROBST, his wife CIVIL ACTION-LAW Plaintiffs NO. 04..5728 v. EDITH M. CADY, COMPULSORY ARBITRATION Defendant COMPLAINT AND NOW, this I( , day of If/A. ,2005 comes the Plaintiff Ralph E. Probst by and thorough his attorney Joseph J. Dixon, Esquire who respectfully avers as follows: 1. The Plaintiffs are Ralph E. Probst and Phyllis W. Probst, adult individuals who reside at 2425 Garrison Avenue, Harrisburg, Dauphin County, Pennsylvania 17110. 2. The Defendant is Edith M, Cady an adult individual who resides at 107 Beachwood Drive, Mechanicsburg, Cumberland County, Pennsylvania 17055. 3. The facts and occurrences herein took place on November 21, 2002 at approximately 12:27 on Sporting Hill Road at Hampden Center in Hampden Township, Mechanicsburg, Cumberland County, Pennsylvania. 4. At aforesaid time and place, the Plaintiff Ralph E. Probst was traveling southbound on South Sporting Hill Road in Hampden Township, Cumberland County, Pennsylvania. 1 5. At aforesaid time and place, the Defendant Edith M. Cady was exiting Hampden Center crossing two (2) lanes of northbound traffic on Sporting Hill Road and attempting to enter the southbound lanes of Sporting Hill Road. 6. At aforesaid time and place, the Defendant Edith M. Cady drove her motor vehicle into the left side of a 1991 Chevrolet S I 0 truck owned and operated by Ralph E. Probst. 7. At said time and place, the Defendant Edith M. Cady was driving a 1987 Buick Electra four door sedan. 8. Said collision was due to the negligence and carelessness of the Defendant which consist ofthe following: a. Failure to properly turn in to an intersc:cting street; b. Failure to keep alert and maintain a proper watch for the presence of other motor vehicles on the highway; c. Failure to keep proper watch for traffic on the highway; d. Failure to yield to traffic while entering a cross road; e. Failure to drive her motor vehicle with due regard for highway and traffic conditions which were existing and of which she was or should have been aware of; f. Failure to properly and adequately control her motor vehicle; g. Failure to apply her breaks in sufficient time to avoid striking the Plaintiff's motor vehicle. 9. Said collision was in no way caused by the actions or conduct ofthe Plaintiff. 10. As a sole and proximate result of the accident, the Plaintiff Ralph E. Probst has suffered from severe and permanent injuries. These injuries include but are not limited to cervical strain sprain, thoracic strain sprain, lumbosacral strain sprain, aggravation of degenerative arthritis, Impingement Syndrome of the right shoulder, left knee injury, left knee 2 aggravation of degenerative joint disease, lef1c hand pain, right hand pain, acute traumatic Lumbar Facet Syndrome, traumatic thoracic spinal joint dysfunction, traumatic spinal joint dysfunction, traumatic cervical spine joint dysfunction, cervical acceleration-decel'~ration disorder, traumatic activation of arthritic symptoms in the lumbar spine. II. As a result of the injuries sustained, the Plaintiff has undergone in the past and will undergo in the future great pain and suffering. 12. As a result of the injuries sustained, the Plaimiffhas been advised and therefore avers that he will have continuing problems and limitations in his activities. 13. As a result of his injuries, the Plaintiff has been obliged to undergo and receive medical care, spend various sums of money, incur expenses for the injuries he sustained. The total amounts of th'~se losses are unascertained at this time. 14. As a result of the injuries, the Plaintiff may have in the future the necessity to incur addition financial expenses and losses, the total amount of which are unascertained at this time. 15. As a result of aforesaid injuries, the Plaintiff has suffered a substantial inconvenience in his life and a decrease in the quality of his life. WHEREFORE, the Plaintiff prays this Honorable Court enter a judgment against the Defendant in the amount of Twenty Five Thousand Dollars ($25,000.00) an amount requiring Compulsory Arbitration. COUNT II PHYLLIS W. PROBST V. EDITH M. CADY 16. Paragraphs I though 15 are incorporated herein by reference and made a part hereof. 17. As a result of the injuries sustained by her husband, Phyllis W. Probst has been and will be deprived of assistance, companionship, consortium and 3 society of her husband, all which has been and will be to her great loss and detriment. 18. As a result of the incident described in this Complaint, the Plaintiff Phyllis W. Probst has suffered a permanent diminution in her ability to enjoy life and life's pleasures. WHEREFORE, the Plaintiff prays this Honorable Court enter a judgement against the Defendant in the amount of Twenty Five Thousand Dollars ($25,000.00) an amount requiring Compulsory Arbitration. Respectfully submitted, By: /,,/"--/ - r ~ Joseph J. Dixon, Esquire Attorney ID No. 28290 ] 26 State Street Harrisburg, P A 17101 (717) 236-8515 Attorney for the Plaintiff Dated: / Ij //r;. / / ./ J l 4 VERIFICATION I verify that the statements made in this teAl 12#/ ~ 7 , are true and correct. I understand that false statements herein are made SUbjl~ct to the penalty of 18 Pa. C.S. ~4904, relating to unsworn falsification to authorities. Dated: / /~/ err ~E~. RALPH E. PROBST and PHYLLIS W. PROBST, his wife IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA Plaintiffs CIVIL ACTION - LAW v. NO. 04-5728 EDITH M. CADY COMPULSORY ARBITRATION Defendant CERTIFICATE OF SERVICE AND NOW, this 11 th day of January, 2005, I, Joseph J. Dixon, Esquire, hereby certify that I have served a true and correct copy of the foregoing Complaint this day by depositing the same in the United States Mail, first class, postage prepaid, in the Post Office at Harrisburg, Pennsylvania, addressed to: WIX, WENGER & WEIDNER RICHARD H. WIX, ESQUIRE 4705 DUKE STREET HARRISBURG, PA 17109-3099 By: z. -;7 .toseph J. Dixon Attorney ID No. 28290 126 State Street Harrisburg, P A 17101 (717) 236-8515 Date: I I / ; / / ")' //////7 / ..' /' I l- '(/'1 t' Attorney for Plaintiff ", .....,.\ ("1 .~, (~- "-'. .' .- -- -'" ", ;::- t,..) ~ RALPH E. PROBST and PHYLLIS W. PROBST, his wife, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 04-5728 Civil v. CIVIL ACTION - LAW EDITH M, CADY, Defendant COMPULSORY ARBITRATION NOTICE TO PLEAD To: Ralph E. Probst and Phyllis W. Probst; and Joseph J. Dixon, Esquire, Attorney for Plaintiff You are hereby notified to plead to the enclosed New Matter within twenty (20) days from service hereof or a default judgment may be entered against you, Respectfully submitted, WIX, WENGER & WEIDNER By f~ Ack.J,J-.L \.Jx Richard H. Wix, Esq" ID# 07274 Attorneys for DefEmdant 4705 Duke Street Harrisburg, PA 17109-3099 (717) 652-8455 Dated: 02/01/05 RALPH E. PROBST and PHYLLIS W, PROBST, his wife, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 04-5728 Civil v, CIVIL ACTION - LAW EDITH M, CADY, Defendant COMPULSORY ARBITRATION DEFENDANT'S ANSWER WITH NEW TO PLAINTIFFS' COMPLAINT AND NOW comes the Defendant, by her attorneys, Wix, Wenger & Weidner and sets forth the following Answer with New Matter to Plaintiffs' Complaint 1, Admitted. 2. Admitted. 3, Admitted, 4. Admitted. 5. Admitted. 6, Denied as stated. Admitted that there was contact between the two vehicles, 7. Admitted, 8. Admitted that the accident was due to the negligence of the Defendant. 9. Denied. 10, Denied. 11. Denied. 12, Denied. 13. Denied. 14, Denied, 15, Denied. 16. Defendant incorporates herein by reference her answers to paragraphs 1 through 15 of Plaintiffs' Complaint 17. Denied, 18, Denied. NEW MATTER 19, Plaintiffs' claims are barred in whole or in part by the provisions of the Pennsylvania Motor Vehicle Financial Responsibility Law. WHEREFORE, Defendant demands judgment against the Plaintiffs. Respectfully submitted, WIX, WENGER & WEIDNER By ~~ ~ 4 Richard H, Wix, Esq., ID# 07274 Attorneys for Defendant 4705 Duke Street Harrisburg, PA 17109-3099 (717) 652-8455 Dated: 02/01/05 2 VERIFICATION I, Edith M. Cady, have read the foregoing Defendant's Answers to Plaintiffs' Interrogatories which have been drafted by my counsel. The factual statements and/or denials contained therein are true and correct to the best of my knowledge, information and belief. I am authorized to make this verification, This verification is made only as to the factual averments contained therein and not to legal conclusions and averments authorized by counsel in his capacity as attorney for the party or parties hereto. This verification is made subject to the penalties of 18 PA. C,S. Section 4904, relating to unsworn falsification to authorities which provides that, if I knowingly made false averments, I may be subject to criminal penalties. Date: :;2) I) D') g ~ ~ '" /I - I n,)n, ar- Edith M, Cady , CERTIFICATE OF SERVICE~ AND NOW, this 1st day of February, 2005, I, Gaye Crist, an employee of the firm of Wix, Wenger & Weidner, attorneys for Defendant, hereby certify that I served the within Defendant's Answer with New Matter to Plaintiffs' Complaint this date by depositing a copy of same in the United States mail, postage prepaid, in Harrisburg, Pennsylvania, addressed as follows: Joseph J. Dixon, Esquire 126 State Street Harrisburg, PA 17101 WIX, WENGER & WEIDNER -A~ -01Nf Gaye Crfst j"\ ,-') :, ,'J .--n -~-,? :. ",'\ \, 1 f"'\ \;,}-' \ C,.) _n -'. '-;': f'''' (/' SHERIFF'S RETURN - REGULAR CASE NO: 2004-05728 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND PROBST RALPH E ET AL VS CADY EDITH M CPL. MICHAEL BARRICK r Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to lawr says, the within WRIT OF SUMMONS was served upon CADY EDITH M the DEFENDANT r at 1410:00 HOURSr on the 6th day of December r 2004 at 107 BEECHWOOD DRIVE MECHANICSBURGr PA 17055 by handing to EDITH M CADY a true and attested copy of WRIT OF SUMMONS together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge So Answers: 18.00 8.14 .00 10.00 .00 36.14 ,.,''OJ . ,,:/ ~#~ o~}~?';n':..,&tC. .,,('.~~~ A^ R. Thomas Kline Sworn and Subscribed to before 12/07/2004 JOSEP:y~IXON~~ ~ h'f ~ ~puty S erl me this {.... E::- day of ~ . / Lf.J,AA~ :.26V 5 A. D . n. J Q ~~ "t~ ~honotary I -r I RALPH E. PROBST and PHYLLIS W. PROBST, his wife, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 04-5728 Civil v. CIVIL ACTION- LAW EDITH M. CADY, Defendant COMPULSORY ARBITRATION MOTION OF DEFENDANT EDITH M. CADY TO COMPEL DISCOVERY BY THE PLAINTIFFS AND NOW comes Defendant Edith M. Cady, by her attomeys, Wix, Wenger & Weidner and sets forth the following Motion to Compel Discovery: 1. This litigation arises out of a motor vehicle accident that occurred on or about November 21 , 2002. 2. On or about December 22, 2004, Defendant Cady served upon Plaintiff Ralph E. Probst two sets of Interrogatories and a Request for Production of Documents, True and correct copies of Defendant Cady's Interrogatories directed to Plaintiff Ralph E. Probst, Sets I and II and the Request For Production are attached hereto as Exhibits "A,", "B," and "C," respectively and incorporated herein by reference. 3. As of this date, the Plaintiff has failed to provide Answers to Interrogatories or a Response to the Request for Production of Documents" and likewise Plaintiff has failed to object to any of Defendant Cady's discovery requests. 4. The Plaintiff's answers to Interrogatories and Response to Request for Production of Documents are long overdue. . WHEREFORE, Defendant Cady respectfully requests Your Honorable Court to enter an Order compelling the Plaintiff to provide complete answers to Interrogatories, Sets I and II and a response to the Request for Production of Documents by a date certain, or suffer sanctions pursuant to Pa.R.C.P. 4019. Respectfully submitted, WIX, WENGER & WEIDNER Dated: 71 &/c")' By ~ (~&Jt L-.h; Richard H. Wix, Esq., ID# 07274 Attorneys for Delfendant Cady 4705 Duke StreE~t Harrisburg. PA 17109-3099 (717) 652-8455 ~ CERTIFICATE OF SERVICE AND NOW, this ~ day of July, 2005, I, Gaye Crist, an employee of the firm of Wix, Wenger & Weidner, attorneys for Defendant, hereby certify that I served the within Defendant's Motion to Compel Discovery by the Plaintiffs this date by depositing a copy of same in the United States mail, postage prepaid, in Harrisburg, Pennsylvania, addressed as follows: Joseph J. Dixon, Esquire 126 State Street Harrisburg, PA 17101 WIX, WENGER g, WEIDNER ~~1vJ Gaye Cn . RALPH E. PROBST and PHYLLIS W. PROBST, his wife, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAt\ID COUNTY, PENNSYLVANIA NO. 04-5728 Civil v. CIVIL ACTION - LAW EDITH M. CADY, Defendant JURY TRIAL DEMANDED DEFENDANT'S INTERROGATORIES DIRECTED TO PLAINTIFF RALPH E. PROBST, SET - I TO: Ralph E. Probst; and Joseph J, Dixon, Esquire, Attorney for Plaintiffs PLEASE TAKE NOTICE that you are hereby required pursuant to Pennsylvania Rules of Civil Procedure, Rules 4005 and 4006, as amended, to file the original and serve upon the undersigned a copy of your Answers and Objections, if any, in writing and under oath to the following Interrogatories within thirty (30) days after service of the Interrogatories. The Answers shall be inserted in the space provided, If there is insufficient space to answer an Interrogatory, the remainder of the Answer shall follow on a supplemental sheet These shall be deemed to be continuing Interrogatories, If, between the time of your Answers and the time of trial of this case, you, or anyone acting in your behalf, learn of any further information not contained in your Answers, you shall promptly furnish said information to the undersigned by Supplemental Answers, WIX, WENGEFl & WEIDNER By 'K, (),,'h,'- f-.I lJ,r Richard H. Wix, Esq., ID# 07274 4705 Duke Stl~eet Harrisburg, PA 17109-3099 (717) 652-845,5 Attorneys for Defendant Dated: p-l J. d-./ O'l Exhibit "A" ~ INTERROGATORIES - SET I 1. State your full name, address, Social Security Number and date of birth. ANSWER: 2. If you have at any time during your lifetime been admitted as a patient in a hospital for any illness, accident, ailment or condition, state names and addre!sses of hospitals in which you were confined or treated, the conditions for which you were treated, and the dates of your hospitalization. ANSWER: 3. State the name and address of any doctors or other health care personnel who have examined or treated you for injuries received in the accident referred to in your Complaint. ANSWER: 4. If you were involved in an accident previous or subsequent to the accident complained of in this action, state where and when the accident took place; the nature and extent of your injuries and conditions resulting from such accident, including whether or not the injuries or conditions were temporary or permanent, and the names and addresses of the doctors who attended you. ANSWER: 5. If you have ever filed an action against any person for damages for personal injuries, other than this action, state the caption of the case, including the name of the person you sued, the name of the Court, and term and n'umber of the action. ANSWER: 6. State the names and addresses of each employer or business for whom you have worked during th,e five year period preceding this accident, including the nature of your duties and the dates when you were engaged in such employment. ANSWER: 2 . 7. What were your gross and net earnings for the five year period preceding this accident, and the years subsequent to this accident, on a weekly or monthly basis? ANSWER: 8. Set forth in detail any and all expenses, and losses which you claim resulted from the accident, which form the basis of this suit, stating the nature of the same and the names and addresses of the parties to whom the bills were incurred. ANSWER: 9. State the name and last known address of all persons from whom you or anyone acting on your behalf has obtained any report, statement, memorandum or testimony concerning the accident or damages resulting therefrom which is involved in this cause of action. ANSWER: 3 10. state the names, addresses and relation of any persons who are financially dependent upon you, in whole or in part for their support, giving the ages of all such persons and relationship to you. ANSWER: 11. State the names, ages, present: addresses and occupations of all of your children and your spouse. ANSWER: 12. State specifically each and every area of your body that was physically injured in the accident: referred to in your Complaint, including a complete description of each such injury and your present condition as to each such injury. ANSWER: 4 13. If you still suffer pain from any of your injuries and conditions resulting from the accident referred to .in your Complaint, state specifically the frequency and nature of the pain and the injuries from which it emanates. ANSWER: 14. Set forth the manner in which any of your disabilities resulting from the accident referred to in your Complaint have or will affect your earning capacity in the future. ANSWER: 15. What is the name and last known address and present whereabouts, if known, of each person whom you or anyone acting in your behalf knows or believes to have witnessed said accident. ANSWER: 5 16. What is the name, last known address and present whereabouts, if known, of each person whom you or anyone acting in your behalf knows or believes to have any relevant knowledge of the conditions at the scene of the accident existing prior to, at or immediately after the same? ANSWER: 17. Give the names and addresses of.any witnesses known to you or your counsel whose names were not, given in answer to Interrogatories Nos. 15 and 16, including but not limited to your medical witnesses, whether or not you intend to call any of said persons as witnesses at trial. ANSWER: 18. Set forth each residence address you have lived at in the past ten years, stating the specific dates applicable to each such address. ANSWER: 6 19. If you have any permanent scar:s or disfigurements resulting from any injury sustained in the accident referred to in your Complaint, please state a description of the scar or disfigurement and whether any plastic or reconstructive surgery has been performed or is contemplated. ANSWER: 20. If you have sustained, as a result of the accident, any medically determinable physical or mental impairment which has prevented or will prevent you from performing all or substantially all of your customary daily activities, state the nature of the impairment which prevents you from performing such activities and what activities you are no longer able to perform. ANSWER: 21. State whether you have been unable to perform satisfactorily all duties required of you in your employment since the date of the accident, indicating with particularity 7 those duties which you were unable to perform and the names and addresses of all persons having knowledge of such facts, including your supervisors and employers at the time of such incapacities. ANSWER: 22. State the name and address of the company or other persons to whom any claim has been presented by you or anyone acting on your behalf for no-fault benefits or medical and surgical benefits or loss of income alleged to have resulted from the accident referred to in your complaint. ANSWER: 23. State the identity, address and qualifications of any expert witnesses you expect to call at trial. ANSWER: 8 .. RALPH E, PROBST and PHYLLIS W. PROBST, his wife, Plaintiffs IN THE COUR:T OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 04-5728 Civil v, CIVIL ACTION - LAW EDITH M. CADY, Defendant JURY TRIAL DEMANDED DEFENDANT'S INTERROGATORIES DIRECTED TO PLAINTIFF RALPH E. PROBST, SET -II TO: Ralph E. Probst; and Joseph J. Dixon, Esquire, Attorney for Plaintiffs PLEASE TAKE NOTICE that you are hereby required pursuant to Pennsylvania Rules of Civil Procedure, Rules 4005 and 4006, as amended, to file the original and serve upon the undersigned a copy of your Answers and Objections, if any, in writing and under oath to the following Interrogatories within thirty (2,0) days after service of the Interrogatories, The Answers shall be inserted in the space provided, If there is insufficient space to answer an Interrogatory, the remainder of the Answer shall follow on a supplemental sheet These shall be deemed to be continuing Interrogatories, If, between the time of your Answers and the time of trial of this case, you, or anyone acting in your behalf, learn of any further information not contained in your Answers, you shall promptly furnish said information to the undersigned by Supplemental Answers. WIX, WENGER: & WEIDNER Dated: I'd--l.),,)./ctf By '~\C~'-vi,- Ii l~ Richard H. Wix, Esq., ID# 07274 4705 Duke Street Harrisburg, PA 17109-3099 (717) 652-8455 Attorneys for Defendant Exhibit "B" . INTERROGATORIES - SET II (MOTOR VEHICLE ACCIDENTSl 1. If you are a named insured und'~r any policy of motor vehicle insurance, state the name and addrl~ss of the insurer, the. policy number, your tort selection, the amount of your liability coverage, and the amount of your underinsurance coverage. ANSWER: 2. If the vehicle in which you were an occupant was insured under a policy of motor vehicle insurance, state the namE' and address of the insurer, the policy number, the tort selection, the amount of liability coverage, and the amount of underinsurance coverage. ANSWER: ~ 3. At the time of the accident referred to in your Complaint, state whether you or vour SPOUSE! were the titled owner of any motor vehicle. ANSWER: 4. If you answered "yes" to Interro<gatory No.3, for each vehicle state: a) The titled owner of the vehicle; b) The year, make and model of the vehicle; c) The V. I. N. number of each vE!hicle; d) The motor vehicle insUranCE! policy applicable to each vehicle; e) Whether any of the vehicles 1Nere not insured at the time of the accident referred to in your Complaint. ANSWER: - 2 - 5. If you are, or were, eligible to receive benefits for medical expenses or income loss under any policy or motor vehicle insurance, Workers' Compensation, social Security Disability, Medicare, Medicaid, or any program, group contract or other arrangement for payment of benefits for any pecuniary loss for which you are making a claim, state the following: a) The name and address of the insurer and the policy number, plan number or group contract numbe,ri b) The amount of any benefits paid to you or on your behalf for medical expenses and/or income loss. ANSWER: - 3 - 6. Have you at any time, or are you currently preparing or maintaining any records, notes, logs, ledgers or diaries that in any way describe your injuries, treatments or activities since the accident referred to in the Plaintiff's Complaint? a) If you answered "yes" to the, above question, where are said documents located? b) If you will do so without a Motion to Compel, please attach a copy of said documents to the answers to the Interrogatories. DATE: IJ)~O<{ BY: WIX, WENGER 61 WEIDNER ~r~ j.J. f+; Attorneys for the Defendant 47 ()S--!5ilke-' st:reet Harrisburg, PA 17109 (717) 652-84~;5 - 4 - RALPH E, PROBST and PHYLLIS W. PROBST, his wife, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 04-5728 Civil v, CIVIL ACTION - LAW EDITH M. CADY, Defendant JURY TRIAL DEMANDED FIRST REQUEST FOR PRODUCTION OF DOCUMENTS TO: Ralph E, Probst; and Joseph J. Dixon, Esquire, Attorney for Plaintiffs AND NOW, this -},'} ~ .\... day of 'l) <'.( 1.',..):. ...- ,2004, pursuant to Pennsylvania Rules of Civil Procedure 4009, as amended, come(s) Defendant Edith M, Cady, by her counsel, WIX, WENGER & WEIDNER, and request(s) said parties to produce for inspection, examination and copying, at the law office of counsel for the requesting party, not later than thirty (30) days after service of this Request, the following documents: 1, All statements, signed statements, transcripts of recorcted statements, interviews or affidavits of any person or witness relating to, referring to, or describing any of the events surrounding the alleged accident in question as referred to in Plaintiffs' Complaint. including those relating to the happening of the accident or to Plaintiffs' injuries or losses, 2, All expert opinions, expert reports, expert summaries or other writings of experts in your custody or control or in the custody or control of your attorney, insurer, or anyone else acting on your behalf, which relate to any aspect of the subject matter of this litigation, 3, All reports, opinions, records, correspondence of all physicians, osteopaths, chiropractors, or other practitioners of the healing arts who have treated, examined or consulted with you at any time, 4. All hospital records relating to you, both before and after the date of the accident, up to the present time. Exhibit "e" ... r, ,. - . 5. All bills, invoices or statements of charges from all physicians, osteopaths, chiropractors, hospitals, medical associates, or other medical practitioners, relating to treatment, examination or consultation of you, associated with injuries or conditions allegedly sustained in the accident in question which is the subject matter of this litigation. 6. All written records or writings of whatsoever kind in your care, custody or control or in the care, custody or care of your (Plaintiffs) employer, evidencing or dealing with lost wages, lost income or reduced earning capacity allegedly sustained by you as a result of the accident in question which is the subject matter of this litigation, 7. All photographs, plans, drawings, sketches or diagrams in your possession, custody or control, or in the possession, custody or control of your attorney, your insurer, or anyone else acting on your behalf, dealing with any aspect of this litigation, including but not limited to the vehicles, instrumentalities, or accident site, involved in the accident in question which is the subject of this litigation, including injuries sustained by you, Such documents shall include any documents made or prepared up through the present time, with the exclusion of the mental impressions of you attorney or his conclusions, opinions, memoranda, notes or summaries, legal research or iegal theories, and those documents prepared in anticipation of litigation by your representative which would disclose the representative's mental impressions, conclusions or opinions respecting the value or merit of a claim or defense, 8, All documents prepared by you, or by any ilnsurer, representative, agent or anyone else acting on your behalf, except your attorney, during or as part of an investigation of the accident in question which is the subject matter of this litigation, including injuries sustained by you. Such documents shall include any documents made or prepared up through the present time, with the exclusion of the mental impressions of your attorney or his conclusions, opinions, memoranda, notes or summaries, legal research or legal theories, and those documents prepared in anticipation of litigation by '-- '" : , . mpressions, mental I resentative's the rep . uld disclose . or delense, your representative WhIC:p::ing the value or merit of ~0~1:: five l5) years preceding the inions re Returns conclusions or op Federal Income 120)( 9 Copies of your resent time, , ted typed, , cident and up to the p " includes written'd~~:d, i~cluding date of your aC , "documents 1uced or repro d ta processing ed to herein, however pro( nications, a analyses, OlE:, As referI' raphic matter, I' written commutes. memoranda, drawings, . ltb--- recorded, or g telegramS, 0 agreements, nO hS diagrams, \I of the ondence, ntracts, rotOgrap, ies of an, I' corresp nits tapes, cO dars, filmS" p' (including cop ion custodY 0 storage u diaries, calen other wntlnq in the possess I '01 yoU, your proie~t,~n~l meetings, 0/ :;~th6r yoU ares~~: custodY or cO~~~urers, or any mlnu e gardleSs 0 . the posses s officers, foregoingf' t~e original) now ~n agents, employee , control 0 I' present counser'behalf). etc shall mean mer 0 n yOU injuries, for acting 0 , to PI~'lntlffS losses, Other person 0 herein II references death case, a eS injuries, etc ER & WEIDNER . I~ a"" decedent's losS . WI)!", WENG Plalntl\l s /j t\ ~,-:x . I', " ",C'"c,'-- " 07274 \ ,-",'L 10::; By _ \-I \Ni)(. EsQ" . p,ichard ' Defendant AttorneyS lor eet 4705 DuKe str H~09-309g \-IarrisbUrg, P~5 l7H) 652-84 . .. . . w . . ; . '::,> {s,:--. .-.::r; ~ l-~'..: -- -- rr; "::-{ .,,<:, "'~ " ,~ '"~',-' r~} f.:,J() ....""1., ~ f" _ ,'S!> ,,':,-':Jt,:{i (_::rf).J .:;}/ 0,"" ~~,j r-... " . RALPH E. PROBST and PHYLLIS W. PROBST, his wife, Plaintiffs IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA v. CIVIL ACTION - LAW EDITII M. CADY, Defendant NO. 04-5728 CIVIL TERM ORDER OF COURT AND NOW, this 14th day of July, 2005, upon consideration of the Motion of Defendant Edith M. Cady To Compel Discovery by the Plaintiffs, a Rule is hereby issued upon Plaintiffs to show cause why the relief requested should not be granted. RULE RETURNABLE within 20 days of service. BY THE COURT, J Joseph J. Dixon, Esq. 126 State Street Harrisburg, PA 17101 Attorney for Plaintiffs Richard H. Wix, Esq. 4705 Duke Street Harrisburg, P A 17l 09-3099 Attorney for Defendant . ~ 1. /S'-(l~ ~ Q---, :rc \ \ ~.: r"\'" ,", ,A..l.n;\..' 'l \ :\1 \;!d 11 \ '\\\n~~1. )..O{'.O:{0tUDdd 3'r\1. :,0 3:)\:\~(y-C\j\\:) , . " . .x,;,;:: :T,,;t/. . . . RALPH E. PROBST and PHYLLIS W. PROBST, his wife, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 04-5728 Civil v. CIVIL ACTION - LAW EDITH M. CADY, Defendant JURY TRIAL DEMANDED To: Orthopedic Institute of PA You are required to complete the following Certificate of Compliance when producing documents or things pursuant to the Subpoena. CERTIFICATE OF COMPLIANCE WITH SUBPOENA TO PRODUCE DOCUMENTS OR THINGS PURSUANT TO RULE 4009.22 I, ~:J. L. 4'~ r , ~ ' certify to the best of my knowledge, information and belief th; all docum or things required to be produced pursuant to the subpoena issued on December 22,2004 have been produced. ~, ~.~~ Represen~tive, OrthOpedic I titute ofPA Date: -0z / h:)' , . . COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND RALPH E. PROBST and PHYLLIS W. PROBST, his wife, Plaintiffs v. EDITH M. CADY, Defendant File No, 04-5728 Civil SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANTTO RULE 4009.22 TO: Orthopedic Institute of PA, 875 Poplar Church Road, Camp Hill, PA 17011 (Nocne of Person or Entity) Within twenty (20) days aNer service of this subpoena, you are ordered by the court to produce the following documents or things: All medical records, notes, correspondence and other documents relatinq to Ralph E. Probst. at wix, Wenqer & Weidner, 4705 Duke Street, Harrisburg, PA 17109-3099 (Address) You may deliver or mail legible copies of the documents or produce things requesled by this subpoena, together with the certificate of compliance, to the party making this request at the address listed above, You have the right to seek in advance the reasonable cost of preparing the copies or producing the things sought. If you fail to produce the documents or Ihings required by this subpoena within twenty (20) days arter its service, the party serving this subpoena may seek a court order compelling you to comply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: Name Richard H. Wix, ES~. W~x, Wenger & We~ ner 4705 Duke Street Address: Harrisburq, PA 17109-3099 Telephone: (717) 652-8455 Supreme Court ID ;; 072 7 4 Altorney For: Defendant Date: ~l .-:2.J. ,.J 1')(') t; I Seal of I e Courl Prothonotary/Clerk, Civ' "ion '_ ~(J/he. !?7f/Z4/'iff,~ eputy (EH.7/97) , , ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patient: Ralph E. Probst DOB: 06/19/27 SSN: 195 16 3609 Chart #: 19092201 Page # 7 ------~----------------------------------------------------------------------- 1/31/2003 OFFICE VISIT RONALD W. LIPPE MD -CONTINUED- His left knee has a varus alignment with pseudovalgus laxity. He is tender along his medial joint line. DIAGNOSTIC TESTS: I reviewed the outside x-rays of his knees, that you kindly obtained and sent along, and those show some thinning of the medial joint space of his left knee and some osteophyte formation there. DIAGNOSIS: 1. 2. Impingement syndrome right shoulder, improving Left knee DJD PLAN: I explained to Mr. Probst that I am pleased that he responded well to the injection of his shoulder and as his knee is only minimally symptomatic at this point, we are going to continue to treat this expectantly. I told him that if his symptoms change or worsen, we could consider other invention. I told him that reconstructive surgery for this knee may be an option down the line but as he states that he has problems with his heart and he is possibly a transplant candidate, I do not think surgery would be our first option. If he has any other problems, he is to bring it to my attention. As always, it is a pleasure sharing in the care of this very nice gentleman. RWL/skb cc: Joseph Kandra, M.D, faxed RWL LETTERS (Refl FREDERICK DC, RANDY 10/29/2003 RONALD W. LIPPE MD REQUEST FOR RECORDS Office notes copied, billed by Quadramed and mailed to JOESPH J. DIXON, ATTORNEY AT LAW. els ------------------------------------------------------------------------------ ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patient: Ralph E. Probst DOB: 06/19/27 SSN: 195 16 3609 Chart #: 19092201 Page # 6 12/19/2002 OFFICE VISIT with Triam diacetate under several weeks to improve. recheck, . RONALD W. LIPPE, M.D. -CONTINUED- sterile conditions and told him to give this I will see him again in p,r,n, for clinical Thanks again for allowing me to participate in the care of this very nice gentleman, RWL/rah cc, Randy Frederick, D,C, RADIOLOGY RESULTS RIGHT HUMERUS XRAYS, AP and lateral xray of his right arm that I obtained today shows normal bony architecture in his humerus and well-maintained subacromial space. IMPRESSION, See above study, RWL/rah RWL LETTERS (Ref) KANDRA, M,D" JOSEPH 1/09/2003 RONALD W. LIPPE, M.D. REQUEST FOR RECORDS Office notes copied, billed by Quadramed and mailed to JOSEPH J DIXON, ATTORNEY AT LAW, dIm 1/31/2003 OFFICE VISIT I had the pleasure of seeing Avenue Office on January 31, RONALD W. LIPPE, M.D. our mutual patient Ralph Probst in the Powers 2003 in follow-up, CHIEF COMPLAINT, He has been having difficulty with his right shoulder since his motor vehicle accident. HISTORY OF COMPLAINT, He has also had pain in the medial aspect of his left knee and this is worse with activity. It was severe in nature a few weeks ago but is now improved and he only has minor discomfort in the knee. His right shoulder responded beautifully to his subacromial injection, REVIEW OF SYSTEMS, The patient's review of systems, past medical history, family history, and social history have been re-evaluated and reviewed. PHYSICAL EXAM: Range of motion of his shoulder is full. His impingement sign is now negative. He has good active abduction in his shoulder. He is neurovascularly intact in his right upper extremity. ------------------------------------------------------------------------------ ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patient, Ralph E. Probst DOB, 06/19/27 SSN, 195 16 3609 Chart #: 19092201 Page # 5 1/31/2002 ALEXANDER KALENAK, M.D. OFFICE VISIT forward flexion above 90 degrees and forward flexion with internal rotation above 90 ?egrees. Hawkin's test is not provocative. Speed's and O'Brien's tests are negative, No tenderness to palpation about the joint. No tenderness in the greater tuberosity, No tenderness in the AC joint, -CONTINUED- DIAGNOSIS, Cuff tendinopathy, impingement syndrome - left shoulder PLAN, Discussed his diagnosis and treatment options, exercise program. Activity modification as necessary. indicated at the present time, Return pm. Continue with home No surgery is AK/skb cc, Joseph Kandra, M,D, faxed 12/19/2002 RONALD W. LIPPE, M.D. OFFICE VISIT I had the pleasure of seeing our mutual patient Ralph Probst in the Powers Avenue Office on December 19, 2002, in follow-up, CHIEF COMPLAINT, Right shoulder. HISTORY OF COMPLAINT, As you know he is a very nice 75 year old gentleman who was involved in a motor vehicle accident on 11/21/02, Apparently he was hit on the driver's side, He was unrestrained and injured his right shoulder, Since that time he has had pain in the shoulder in the anterior aspect with radiation down the lateral aspect of the arm. It is worse with any type of activity. He has received excellent conservative care so far but unfortunately his pain continues. REVIEW OF SYSTEMS, The patient's review of systems, past medical history, family history, and social history have been re-evaluated and reviewed, PHYSICAL EXAM, On exam today he is a healthy-appearing gentleman in no acute distress. He is tender over his anterior acromion and he has a positive impingement sign at 90 degrees forward elevation worse with internal rotation. He has good active function in his shoulder. He is neurovascularly intact in his right upper extremity. He is bright, alert, cooperative and appears otherwise healthy, DIAGNOSTIC TESTS, AP and lateral xray of his right arm that I obtained today shows normal bony architecture in his humerus and well-maintained subacromial space. DIAGNOSIS, It appears to me Mr, Probst has posttraumatic subacromial impingement syndrome in his right shoulder. PLAN, We discussed treatment options for this, I injected his right shoulder --------------------------------------------------------------------- ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patient: Ralph E. Probst DOB: 06/19/27 SSN: 195 16 3609 Chart #: 19092201 Page # 4 ~2/11/2001 ALEXANDER KALENAK, M.D. OFFICE VISIT isometrics, and straight lifting exercises and ultrasound. Continue anti-inflammatory medication. Return should symptoms not progressively and completely resolve, -CONTINUED- AK/ mj h cc, Joseph Kandra, M,D" via autofax RADIOLOGY RESULTS RIGHT THUMB X-RAYS, the MP joint and IP X-rays of.the right thumb show mild arthritic changes at joints. IMPRESSION, See above study, AK/mjh LEFT SHOULDER X-RAYS, X-rays of his left shoulder show minimal arthritic changes and no other significant bone or joint abnormalities! whatsoever. IMPRESSION, See above study, AK/mjh 12/21/2001 TEL/MESG-MESSAGE Faxed script for ALEXANDER KALENAK, M.D. TO CHART T a North coast comfort hand splint to Teufel's Camp Hill AK/ckb 1/31/2002 ALEXANDER KALENAK, M.D. OFFICE VISIT Powers Avenue Office CHIEF COMPLAINT, Left shoulder pain, HISTORY OF COMPLAINT, Ralph has been having trouble with his left shoulder, He underwent physical therapy but that seemed to be provocative, His pain level was 4 when he went in and then came out with pain level -10. The pain is localized out to the deltoid area, Definitely aggravated by the falls he has been Subject to, He feels a lot better today, His doctor changed his blood thinner medication, He does biking for non-impact aerobic activity, He feels that he can do his own home exercise program. REVIEW OF SYSTEMS, The patient's reVlew of systems, past medical history, family history, and social history have been re-evaluated and reviewed. PHYSICAL EXAM: Shows a full range of motion with some provocation of pain on ------------------------------------------------------------------------------ ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patient: Ralph E. Probst DOB: 06/19/27 SSN: 195 16 3609 Chart #: 19092201 Page # 3 11/13/2001 LEVEL TWO RICHARD J. BOAL, K.D. -CONTI NUED- RJB/jjr cc: Joseph Kandra, M.D. via fax 12/11/2001 ALEXANDER KALENAK, K.D. OFFICE VISIT Poplar Church Road Office CHIEF COMPLAINT: Right thumb, HISTORY OF COMPLAINT: Ralph is a 75 year-old gentleman who's been having trouble with his left shoulder and right thumb since delivering a bowling ball and the ball got caught on his thumb, He flipped and landed on his left shoulder, Years ago, he had trouble with his right shoulder too, but that seemed to be resolved, Things are getting better, His thumb is feeling better also, REVIEW OF SYSTEMS: The patient's review of systems, past medical history, family history and social history have been re-evaluated and reviewed, PHYSICAL EXAM: Physical examination of his right thumb shows minimal tenderness to palpation and percussion over the MP joint and over the thenar eminence, He has excellent grip strength, Position of the thumb to the index and little finger are minimally provocative, No obvious atrophy, Neurovascularly intact distally, Physical examination of the left shoulder shows some contraction in range of motion especially on internal rotation, Difficulty touching the sacroiliac area, Otherwise, can touch the occiput and opposite shoulder without too much difficulty. There is, however, a positive Neer test. Negative Speed, O'Brien, and Hawkin's tests. Some crepitus on range of motion. Minimal tenderness to palpation and percussion over the greater tuberosity. DIAGNOSTIC TESTS: X-rays of the right thumb show mild arthritic changes at the MP joint and IP joints, X-rays of his left shoulder show minimal arthritic changes and no other significant bone or joint abnormalities, whatsoever. DIAGNOSIS: 1, Strain and sprain, MP joint, right thumb, 2, Rotator cuff tendinopathy and impingement syndrome, secondary to an impaction type injury, left shoulder, PLAN: Discussed diagnosis and treatment options. Continue to work on strengthening exercises and resume bowling when symptoms completely resolve. Discussed diagnosis and treatment options. Start a program of ice, ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patient: Ralph E. Probst DOB: 06/19/27 SSN: 195 16 3609 Chart #: 19092201 Page # 2 ------------------------------------------------------------------------------ 11/13/2001 RICHARD J. BOAL, M.D. LEVEL TWO Trindle Road Office CHIEF COMPLAINT: Ralph Probst returned and had some concern about his left leg, HISTORY OF COMPLAINT: He did rupture his quadriceps last year and now he has a mass in the left leg, He does not have pain with it, but he states there is a lump present, REVIEW OF SYSTEMS: The patient's review of systems, past medical history, family history and social history have been re-evaluated and reviewed, PHYSICAL EXAM: Ralph is a well-developed, well-nourished male in no acute distress, He is alert and oriented x 3. Examination of the hip reveals no swelling, ecchymosis or visible masses. There is no abnormal tenderness about the anterior capsule or over the greater trochanter and no palpable masses. Muscle tone is normal with no . increased pain with compression of the iliac crest. Range of motion reveals normal flexion, extension as well as internal and external rotation. Abduction and adduction are normal and there is no hip flexion contracture in extension and 90 degree flexion, There is excellent strength of the hip flexors, extensors, abductors and adductors. Sensory examination reveals normal sensation over the anterior and lateral thigh, Femoral pulses are normal. Provocative tests show a normal gait with no evidence of a limp, equal leg lengths, and a negative Trendeleriburg test, There is no swelling, effusion, ecchymosis, deformity, or tenderness about the knee, There is no increased temperature about the knee, There is full range of motion and painfree motion without crepitation. Patellar grind test and patellar apprehension are negative. The patient has a negative Lachman maneuver, a negative Losee maneuver, and a negative pivot shift test. There is also a negative reverse Lachman maneuver. There is no evidence of medial or lateral instability or anterior/posterior instability. There is a negative McMurray Sign, Deep tendon reflexes, motor strength, and sensation are all within normal limits, The patient has good peripheral pulses, Examination of the hip and ankle are also grossly within normal limits. He has a mass over the anterior aspect of the leg, especially when he contracts his muscle, and I think this does represent ruptured quadriceps, which has retracted proximally. He has no pain and there does not appear to be any fluid present, DIAGNOSIS: Mass, which is contracted muscle of the left quadriceps. PLAN: He is going to continue to use the leg as tolerated. I do not think there is any treatment necessary for this. He will return to see me only as needed, ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patient: Ralph E. Probst DOB: 06/19/27 SSN: 195 16 3609 Chart #: 19092201 Page # 1 -----------------------------------------------------------~------------------ 9/14/2001 RICHARD J. BaAL, M.D. LEVEL THREE poplar Church Road Office CHIEF COMPLAINT: RALPH PROBST is being seen in consultation at the request of Joseph Kandra, M,D, for evaluation of his left leg injury. HISTORY OF COMPLAINT: Ralph is a friend of Dick Patterson's, He, about six weeks ago, was bowling and injured his left leg, He states that he felt something pull while he was bowling and developed pain in the left quadriceps area, He then noticed discoloration on the medial aspect of the left thigh, He is here for evaluation, He states he is getting better, In fact, he recently did bowl again without difficulty, REVIEW OF SYSTEMS: Review of systems, past medical history, family history and social history have been recorded and reviewed, PHYSICAL EXAM: Ralph is a well-developed, well-nourished male in no acute distress. He is alert and oriented x 3. - I have examined him today and there is no swelling, effusion, ecchymosis, deformity, or tenderness about the knee. There is no increased temperature about the knee, There is full range of motion and painfree motion without crepitation. patellar grind test and patellar apprehension are negative. The patient has a negative Lachman maneuver, a negative Losee maneuver, and a negative pivot shift test. There is also a negative reverse Lachman maneuver. There is no evidence of medial or lateral instability or anterior/posterior instability, There is a negative McMurray Sign. Deep tendon reflexes, motor strength, and sensation are all within normal limits. The patient has good peripheral pulses, Examination of the hip and ankle are also grossly within normal limits, However, he does possibly have a slight amount of decreased range of motion of the left hip, He is intact neurovascularly. I have bone graft, On palpation of his quadriceps, he has some very minimal tenderness over the central portion of quadriceps. I think Ralph does have a partial ruptured quadriceps, which is resolving, DIAGNOSIS: Partial rupture, left quadriceps, PLAN: I showed him stretching exercises for his quadriceps, I am going to see him back as needed. RJS/j j r LTR-DR BOAL CONSULT (Ref) KANDRA, M,D" JOSEPH ---------------------~----------------------------------~-----~--------------- .IuD. U, 1992 Joaepb J. Kaa4ra. K.D. 1100 Colonial load Harrisburg. PA 17112 Dear Dr. Kandra: 'Ibis 1. 10 ret.nBC. to youI' patten: Ialpb I. hobot tal IUS ~ Av.nua, Harr1sburs, r_ylvan1a vbo 11l1.ft "- folJ.avUa d=e ApI'U :lO, 1992. for a pa:lAt\&1 rt&bt bee. .. IIIl we:'" ad tlIe 1IItsrpratation by the I'8diololt.e ViU' Cllat tMft _ .. u.onal,1"- pra..nt. 1Iowavar, blpb d14 contuue to ha". .tl"i'tcaAt pda of 'Ua kn.. aacI vhen I r."uvoc! tlIe ltII tbo ..co... tm.. 1 tbr-vt 1 eolI1' ... . . horizontal teu 111 tho ponniol' haft of tbo ...tal _t'"<lu. IeeaUM. of perabtent s)'lIIllto... I talt that .. U~acotI7 __ Wkat". On June 9. 1992 under ae"aral ....atboe1.a &t. tho ~a1l4v"" Slu:atc:a1 c:.atu, I explorsd his r1aht knee. I did fW a boriaoGtal tear of tbo po.torior born of tho ...dial ...abc.... A. p~be c:o\&1cl be 1'Qt 'lato thia tMr aacI 1 vaa then able to draa vtth uao tbo pouuior bona of the Mdial _iac:u8 iDto the lIl8X:lmua waillhtbearu& 81''' of * M<l1'" joiDt wpae.. 1 felt that this vas almou earta1aly tIIta IC&UM of Ua pam. lbe pouarlor bom of the ...d1a1 _niac... .... r8lllQ..-d. tba hal..,,:o of tbo b.e __ Donul vich the axcaption of aOM Orad. I c:ll-.o---'K1a of all articular aut'tace.. Ho v1th.tood the prcceduro vall &DeS I v1ll c~tiaue to follow h:lm to the completion of tb:l.s probl... S1Dc:erely yours, 1U.chard .1. Patterson, H.D. '#J/))..t BEST POSSNib~L OOCUMENT OUE TO QRIGI ;:<1,- PRO@ .~ r ~JP.!!<j.; . . .. '^'/~~~;'T~tf,;-:!fi.1.;:~0~';,ti?~ ,.?~l'~~';i May II. ,,,;: ,,,.,/; ."""""'L':,:~'", # ~~,/f '-~; -';~":!':>-''''''-.~;~.:?~~ . ~'" _:~ ".~;._~,;,i;:--.;~.c, .~ ::t.~~~,'~'; He Is still having pain In his knee and he I. "blnder'aIcing" the..d~1 joint line but the MRI did not reveal any tears. I believe uu. is perhaps an ' Irritation with an infla_lion of the -.dial side of the. knee periMlps of his menl5Cus. . don't thln""..,ything should bedane at this ~.,. I did give him .. prescription for no _e Vlcodln HId "'iIppoin~t to relum to see me In two IDOnths,lf he Is sUIl Mving difficulty. RJP JUN U 4 1m He called recently and told _ that he had . Iotot ~In. I brought hi. in to see me. He has a $ignlflcant amount of ~In In.hls kMe.ln;fact. tw MY' IQMtlMl he will be driving along and will have 50 lIuc:h ~In he will bave to pull over to the lIlde of the rCl.old. The pain Is in the IIec1lal jOint line and on ....-lnatlon. he is locally tender there, Cirade III "",..", . " I went over his MRI and there Is a strong wgg_do" "-tthere I. . tear of the posterior horn of the nwdlal 1IIlIIl1SC:l,lI.. I WCcIhI. \tat I "IIOU1d explonhll knee ..nd If I found. tear I would ,.lDOve It. 'I'to&d hi. "-tt Mlght,not" find Iny tear. . 1'50 pointed Ol,It to hi. t.Nat the... ... riIka. . .nuIIbef: of . which I _-numerated, as' weU as twneflta.' He .... ~ to N"" '.dMtSurgery . . and It hall bun scheduled. .. . RJP June U, 1992 ootE FOR CHART ' , Mr. Probat called concerned about the lllIIOUIIt of pdn _ sveU1n& tbat be had post-oJ>. He had called lllllt ownin8 and apoke to Ill'. bl who xeeJ l'lded 1co applicationa. Dr. Patterson felt thllt thb wu tlOl'IIDl in hi. poIt-operative courae IlIld that ho IIl4Y continue on ice for . day or !IO II)C\l and -return IIlI planned. R.JP/clv " BEST POSSIBLE QUALITY DUE TO ORIGINAL DOCUMENT '., ~'3i..."". JUN 1 6 \992 v~ '/1:S:j He has been hiving pain In his rIght knee but today It doesn't seem to be too bad. He Wilks with an elCalll~t gait. On _Inatlon. the ROM of his knee II from 0 to 1300, He has ec:chymosls on the medial side of the knee. I think he Is doing well. I a. having the stitches removed today and I told him to sit In a warm tub of water twice a day for 20 .inutes or so to put. heat on his knee and he Is then to exet'c:lse It~, I gave hi. a prescription for nq Talwln to be taken I q II hout's pm for pain because the Vlcodln didn't seem to help. He Is to return In 2 weeks ,a~. not to work In the Interim. ' RJP RJP, JUt 1 3 1992 ~"'. -"; ~;>. \'j$:r #ttk~ K<<r Mr.',' O? 1994 " ..BESTPO$SIBLE QUALITY DU,ErO ORIGINAl DOCUMENT " .......:.~:~, ,."h . ,.;" DO YOU HAVE OR HAVE YOU HAD: 110 V---'. L.---- L-- 01_" Epilapsy Hepatitis A or B -~ Abno!'ma' 8100" Proassure Abnormal Bleeding or Clolling (Hemophilia, PI1leblUs' ,,~ ~ ~ ~ .~ !;I Anemia Hearl Con<litlon Caneer If YES. EXPLAIN: Sl(/~ v-- Asthma ".. --' ~ A / ..---. ~I ~ L---" --' Frequent Injections '7 ~ A.rthritls Other BonelJolnt Olaea... Blood Tranafueion Ulce,. or Sfomach probl.m. Olh.r medlnal dls.asea or pro'>lem. ' P~IMI Llal: .liibff ~rl_! c' <' I) pfEC;Svt<,; ~ P,IOI SIlIQlltV (please Ilsll - l' ~'r '.vir. t ---- ~:'_P ..,~_, r L' -'-_.~_...._- '.j' 'liA iiPPtN{)tC1?/'t'Y YMt II _noWll , Q 't )..-- ? '-1._ ... 1..1...1 t --... . ..1 :s c.<!" c),,'lfA' 1'1_ '17 SmoOd? v.._ No_ , BEST POSSIBI.E QUALITY DUE TO ORIGINAL DOCUMENT liST ANY MEDICATIONS YOU ARE TAKING: Prescr\ptl;On and 0.... the Count.' "ecUcalioftl; E',(Sn\ptes.: "'d~ll. A.$plrln, 81M ContfOl piUs ME YOU ALLERGIC TO: NZ--- z;:..---- YES "'-' -. ~ ...__ tNoo-.... Xyloealne, 0dW _........ or Drug.: jjRVIL. L.Clf.... TI'-~ ~6 (1 ~ -fI f..' ~ ref- . UST:T/tL!tV I Y ~l ,'age, 'fvo":;,:~f'::i;" : - '~ "'Ka 10" 1994~'~~1: ", :;~,-,r "~~" ',"-'~::~'r;~'?~'~,~:..:. '~i:.. MRI: Physician's IJllagina Center 'O',:Apdl 22. 1994 '''''.-,',4 Left Shoulder: -Diffuse supraspinatus tendonitis vith poor definition of the superior aargin of the tendon at several locations ~ndicating a partial thickness rotator cuff tear.- "JoelD~Svart3:, H. D. IHP.9ESSIOR: ;';'" Traumatic tendonit1s 'of the left rotator cuff. ;f , .iJ , Initially, I injected the left rotator;eqft v1tb, 10, cc. of Xylocaine 1% and 100 JIIg. of Hydrocortisone Acetate. 1 'PUt bill on range of motion exercises to bedoue twice: a day. I also aave him a prescription for ~~2 Vicodin in cas. be gets a Cortisone flan. I think the prog:1osis 1.' go04. &e.,1. to return in 10 days and is not to york in the interta. ;~ 1,; J: " Best personal regards. <,-,.,.; , . ~ ,s.t.nc,~,~: fGun., , t 'J; " , lu'chard:J. Patteraon, H. O. RJP/ckb ec: Stuart A. Hart~an. ~. O. . ':hBEST POSSIBLE QUALITY DUE TO ORIGINAL DOCUMENT f' f: N NSYlV'^ j.;'i ^ qtltIQfW~r.~ Hay 10. 1994 '1{ .f.,,' 1 ,. Joseph J. Kandra. H. D. 1199 Colonial Road Harrisburg, PA 17112 Dear Doctor Kandra: ,t . This is in reference to Ralph E. Probatat 2425 Harrisburg, Pennsylvania who I llIaw in .1' office and obtained the following tofora.tion: CC: ?aln in the leftabQulder. UJSTORY: This is a 66-year-Old white ..1. ~~....an {or Hargo-Flexible Packaging Co.pany who at4t.. t~at un "-rc~ 23, 1~94 (about six weeKa /lgo) he dipped and'fllll vlljlo lIolna to IIh mll.Ubox landing on hilll left upp." extltellltty. " "'" ""c, Carrtson Avenue, on May 9, 1991, He had quite a bit of pain in ht..houlder and had it x-rayed. No abnormali ti es we re foulld bllt ho h.s continued p*ln. lit! hall had phyaical therapy bllt dc!>pito tht.the pl'in JlQl'lIIhtlll. fll! hus not been working. He states that ho hila \IIw"r had p*ln oftlttll tyl'<! in hill ahoulder. Jlels III good ll,t'l\et:lIl health oth.,rvhe. r took caro of him for fl menlscal problQ~ sQveral,ears a&o and he has gotten an excellent result. PHYSICAL EXAHIHATION: This is IIveU-devdoped. vel1-noucished white male in no acute dIstress. . Left Shoulder: Tende.rnessoyer the' anterior aspect of the rotator cuff, Grade II to III. R8n8e of motion is forward flexion. 135 ; abduction, 90 . ". ;1'. J\ ROENTGENOGRAMS: Polyclinic Medical Center HArch 23, 1994 Left Shoulder & Humerus: No abnormalities noted. .~~ ;.1.,\:;" ,"~~'..'. , 'f' ~ . '1';"..t1IlY J;. ':~.' .~ ". ,~ '" ~ i-r/.'-!, ' ,. ';',.~."";'. . ...ii, 0" '".>"c-i':., 'r ':~'",.. c.... ......,. ..,..~' ~~,'. "~~:<,~~"~ - -)'-- ;;:,.- ',,\,,:':"~~;~ j ,'.,5.~ ~.." :.~.,. " .. j" He baa bad over 5Q~"I.p~o;,~' .., '. _..'. kq. ,... . .<,r .~. "'~,~.:: ' ha. beea doing hia-:.xexci... nll~~T~~~' '''I~''!'~." Qa'.""'bera is no tenderness of the'le!t' rotato~C1Iff'-aDd be' caa ~forva!:d flex to about 175.. I think he ia doing excellently. I .. coing to allow hi. to return to work on Hay 23. 1994 full dQty. If be has trouble, ho iB to call ae.othervise, be i. discharged. lLJP ';~ !'v:1 l1 1994 .~; He COllie" in because be has continual pain in hi. left .hCl'llc1er. Tt occurs prilllarily wben aotion of his sboulder occurs and it is a catching painful event that both~r. hi. ai&ftiflcantly. U. is ~~rk1ng, hovever. ' ~ 1f . ..~~ "v "-,;: .'~~ " J rn exalllination today, while he vaa aovin& hi. left .houlder about, h~ had several episodes oC sharp pain io hi. left shoulder that ~.lu"ed him to bend over. The ROK of "ia sboQlder 1. abduction, 17().; forward Clexion, 170.. Ke 1s tender o~er tbe .nte~lor ~.pect or the ,-ntator cuff. ,., ':'t"., T re-injecled his ahaulder with 18 ceo of Xyloc.lnolJ .Qd lOOaa. of HydrocortiBone Acetate. t gave h1ft a pr..c~ptlQftfQr ')0 Vicodin [ 0 be taken tabs 1 q 4 hOllrs pro for I"'tn. . I bave ..lted bJa to return co 8ee lIIe in three wee~. with bb Mll ..cI th. pl.1ft ftll'l. ot h18 .houlder. rr he i8 not relieved, J told hi. 1 v.. 101nl to treat ~ta .. " ._outder impingement syndrome and do 8ur,\lery vnere t 1lfOulfl do " NOllr procedure Rnel illl'pection of the rotator ('\Itt vitb ,o..thl. r.pair. UP ~... '/: ;1 \~ , .!'. <I' JS.' His sholllder ill bottiH'. lh! only ba. 501 ot the pain he had or1ginally. He etill has dtaeoatort when he abducts it and gets to about 80.. Ke bas tenderne.. ot tbe rotator cuff. T believe that he could Cet over this probl.. very nicely with continued exercise. and tha us. of ..proayn 500 ag. b.i.d. which I prescribed. r aave ht. an appointaent to return in tvo months for re-evaluation. ,; F I , UP , BEST POSSIBLE QUALITY DUETO ORIGINAL DOCUMENT ,- ~'~i.F~~i~: .....' April 30, .99:1 ~ '. .. ,\~,'" Joseph J, Kandra, M. D. 1100 Colonial Road Harrisburg, PI. 17112 , .l Dear Doctor Kandra: This Is In ,.eferenee to Ralph E. P"obst of :IUS Garrl_ Avenue, Harrllburv, Pennsylvania who I saw In my offlce on AprU 30. 11ft ..-d ob...ned tIw following Information: CC: Right knee pain. HISTORY: This Is a "'-year-old white .Ie p,....... tor .Har9nahclalglng :. Company who state. that he devloped ~t IcMe paln MMNt .,....~. .... fo,. /10 app...ent !'eason. He lIbsolutely recalls no,tnUM. He... algnlflCllnt pain on the Inside of his knee. It bathe..s I\Ua ., "'Pt In ~ and_t_. it bothe,.s him so mueh he says he could cry. He do.s not d.se,.lbe any locking, clldl.lng. Of' giving a.ay. 'truted him fo,. a similar problem In his l.ft IcMe In .,.. ..-d .. .vent\llllly- got over It. . . ',"': ,','., ..;i '-~li 1, He Is In good general health othe...I.. although .. does hilve hypertensIon aOld had a detached retina. PHYSICAL EXAMINATION: This Is . .aU-o."aIorp.d. _II-nourIshed whIte male In no acut. dl.tr.... H. .alk. with a no..-I gait. Right Kn.e: T.nderness oyer the a"ten..dlal jolnt line, Crade III. No McMurray's sIgn. No llga_tw. laxIty. ROENTGENOGRAMS: On. Patterson, Utto", Lonergan, Yucha, Boal & Bands Office April 30, 1992 Right Knee With Standing AP of Both Knns: No abnormalities noted. IMPRESSION: Right knee pain-possible torn ~Ial meniscus. i; " ',~ Initially, I am sending him for an MRI of his right knee to ascertain whether 0" oot he has a to,.o meniscus. I told him if one was found h. may need an BEST POSSIBLE QUALITY DUE TO ORIGINAL DOCUMENT Best perlOml' regards. ~ J. httenan. ... 0., " .,' ,...;;,,:':.,~., '~;,:.>. .:~' 'ill ~~~I " it Ai !.i-I )" " tj ;1' 1; ... ....>.11.... ~;~~~ ",\: Slncenly yours. '. RJP/ckb .,'; "::".~' ~ f':'fli:~ Hq ;" ",:;'_,:5>~~'1> -~,~. ;'<it;:;~S,'~ :.. ___<~;~';',;::1'~~:~.':-'3~'~:,:." ."-,, ~-.:; ;;~l.;..;'"gi;~ ,~.~~ '..~"1 ':,' ~:.'~:' '::-<'''',-, -~ . ""," "t"}''l, ~'j :~i". i" ".~......'i ".,' "1 j.i' '.,'". : .:.~ ~'-" ,.' .........- :~-7~(~.~.~:~:..;;~~.r~~:..'.~~".;;~;{.~. "~', ,!.'~~- ;,:1';1;'., ',~\toli~~,"'~'(~':" {;~;:r~'::7:'-;~~::~i '-'; '.,,...~~';'.'.i ;;;5r(~>-, ._~. _~"''''~f .....~' ~c"",{""..t,~" (\..tt-'A:''''-f~,1~': J_C-;,_";:i": - --. _ .. .~. -j. e'....';.,-..,.;- ..:t-'-, 'Ii :~ (~rf . .;;:~ '~.;.J.' .~ '.'.- '''' '-'0 ',:,-:.. .-(0<('-'(- - ,0:', .~, ~~ " -' (, "~ <, -<;, ~ '::S:::-.'-;,' , BEST POSSIEtE ~8~NT QUE TO ORIGIN^L ":r.,f"' (ri" !' t. ./:.' " .,'~ ' ,.; :, ;.i (~;~-";."')' -~ ;>~: ;~ :. .1~ /;' ,;":-", ;'-; ::;j" ,-~ .;~ "k ~ :1 < ~; . :~~ ~:~...~ ,~: 4.'-,-~" '~~~' """'''.u:>>cI ;""I.M.Q.. lHQIMS.J. ~M. Q. ~J.~M.D. Sept.-ber I. 190 '!, Joseph J. Kandra. M. D. 1199 Colonial Road Harrisburg. PA Dear Doctor: This Is In reference to Ralph E. Probst. of 2US ~rrison Av_. Harrisburg. Pennsylvania who I saw In ..y office on Sept_raw- I. '''I and obtained the (aI/owing In(onnatlon: CC: Pain In the left knee. HISTORY: This Is a 61-year-Old white _I. pres.-n for tQIni5bufg Packaging Company who states that his 141ft In," ~ to bother ,,_ two months ago at work. He was sitting at hil desJc and aU of a suc:Ican turned his left leg outward "nd had the plln. H. Met been working on his pre.. previous to this tl_ wher. he does iI slgnJfk:ilnt --..nt of climbing up and down step. and getting Into vuloul poaltlonl. Since then he has had difflculty except for the lut two Weekl It hiI. not been bothering him too lIIuch. The plln I. Mdlilllly llnd Is c.hiIl'Kterllecl by sharp. sudden pains with quick turning of the knee. H. clenlu ilny locking. cl/cklng or giving away. PHYSICAL EXAMINATION: This II a weU-d4Ivelopecl. well~nourllhecl whit. male In no acute dlltress. Lltft I<nee: Ringe of motion Is nol'llllll. TenderrlU' over tho Intltromedlal Joint line. Crade I. No McMurray', sign. No ligamentous laxity. No drlwer sign. ROENTCENOCf:AMS: Drll. Patterson, Utton, Lonergan, Yucha, , Boal's OffiCe September I, 1988 Le(t Knee: Negative. IMPRESSION: Probable torn medial meniscus, left knee. I think this gentleman should have an arthroscopy to ascertain whether or not he has a torn meniscus and If one Is found the offending portlon removed. . . BEST POSSIBLE QUALITY DUE TO ORIGINAL DOCUMENT He would like to watch It for awhile and I. therefore. gllYe eu.. .... ~n~\t to return to see .. In three weeks for r_vakation. H. Is to QlI.__ If neeenary . TItanic you for the referral of this p41tient. !:tncawly yours. RIchard J. httllnon. II. D. RJP/ckb ...., ".'-'; , . .,,;~ ~ . ". -~ , '-'. .,'..-$ -" . ~...>. , BEST PCSSIBLE QUALITY " DUE TO ORIGlNALDOCUMENl .'-o'd;" :1:':; '_6~':'';;' , . ".. ".'" ~"'.. .'. ,"!"'iJ~:~' His knee Is better, H. no longer has any'sJgnI~t''''IdelI_.'-'1~lly. and this could very well be . sprain. I _ going to have hi-. ~ back in six weeks for re-evaluatlon If he Is still hilvlng trouble. O~ise. discharged. RJP INOV I 0 1988 I'~'UIV{/ , BEST POSSfBlEQUALITY DUE TO ORIGINAL DOCUMENT _' ..1_" ~ \ , r-e .Iv' <:? PH"'-"~ ,.,., ."..':'-, --;,.t,:://1::: '1f~... ' i: 00<'" ~ jijoIeP s '- \~ t-- ~ 4-~>\1.. (" - Iv- $-~O +->O~"Z- J€--\ \ U30 No 5~ /(-'1,) ~ ~:ilI Ir11rl/;L . ' ~f)0 ~ P.... cP siC[ c;' ..,l- :z 0 J. (, .J:l-'1 i :frc E- ~ .,..,.,l./-''''' 5" o-i.{.,N ~;JffI 0 1-~1 i ~6)IC"tlO'" - ,j -- ~~_,-:,,\_ .'" __ \ ~ G i.,' f' 0 qU- ):;_,.01'--':' U --- ~-"'--'- / I 7' (: if :f1:';Li/~ ~ _ l "- <1 'l'" f,:,....>'~~ , \ _' 'A '_ ,. . /.11.. T("~~.;)I' - _ ~ ___:- l. ~ I J. ;r:;:--' I .it_ /.. , -; C> [", ~ ?(;" 7.> !.~' i:f e,e.';- t-l :5f:j... ,.N- ",>,. ?' ,LL"f :~ -- --' \ ------ ------ -----~ --,-- ~~---~- .}~ ,------- -----.--- --- 00 YOU HAVE CMl HAVE YOU twk ~," ~'~.jr'.~pr:i' ".,.~;,210:,.",,, .\~;.:/;s," '~' ~~'" ",J~,.Jii5'::! >. . - . DI_tea Hepalllls A Of B ~ / .-----:. ~ ______.',s. ~, -'~~ Epilepsy Abnormal BlOOd Pressure Abnormal BllI8dlng or Clotting (Hemophilia. Phlebftls' ~.. ~ ....--' C- ~...--'- Anemia Heart Condlllon Cancer If YES. EXPLAIN: Asthma Frequeollolecllons Arthrlll. ? - Olhe, Bone/Joint 01_... BlOod Trao.'u.loo Ulc.r. or Stomach problema OIMr medlcsl dl..a... or problem. . PLI!AaI LIaT: Prior SOlgert (plea.e 11111 , '/ 1-K. J{ /t; E '#,'1--/<:1, A~.~- ~'~' , ~ '.. /1 ff'cr,.J 'l)'( arJ 17'1<.' I', ,1 I , f' (r:... fV I Po- y.., IllulClwtl H_ Y~kad? Y.. _ No_ , BEST POSSIBLE QUALITY OUE TO ORIGINAL DOCUMENt. LIST ANY MEDICATIONS YOU ARE TAKING: .-fz:~ __--.2 ~~--- [ ...J, <2-,. .D {/ . ARE YOU ALLERGIC TO: _aln l.ocaI _lclI \NOVec:eIne. XylOCalMl 0tt\Ief ~'f"''OM or 0ruQa: YES NO V V?" Prescription and aver the Counter Uedicatkma EJl:amples: Adyll, ....~Irln. Birth Control pUll ::Ll ~.IJ I P-i ,J t ;"~;', CERTIFICA'r'E'(]F 11E~DICAt_ !~ECESSJ:TY el:;:E~.:)CFIPT TO!'.! I)(j'TE': .....j;):.i}...!~Q!..~..... ~- /10yn- pp" mp,,'Pm I ' 31 ~/-1{ m .....~.. ...................P......".p...p.._..-....................................-.-...............-..........-....-......-....."................."... F~ATIENT~ .8al.ph F~('otlS'~ 2425 G2!~1'.isl~r\ Ave H ;:\ 1" t-.. :i. ~::. b u l~' <:.:.. :' '''.J', 1"\.., .,'-c.;.!,-'. '.' .t.!....... FI:;~DC~r.!Ci~3:r:3 ;. D T (~(31'.lC).~~ I ~:::': g \ G HT 4t-tu IY\ B -A l2- 1-\'"\('; t-J s, 1)UF~A.TION OF NEED (CIF~C!.pE ONE) .... (nc'nth~~ l~, mol"! t.h'f.:. ." './ (':'~~':"'l~' I... :i. HI' ':::! 'to :i. ~Tii::: C)t.h,:::'f" !~~~~~l~~: ....,'....-. f<d]t:;~ DESCRIpYJC)!~ OF' REQ..JIRED Oj~.T\..~().I.IC DEVICE~;: ~D<2..-n-\Q.M3T R1Gt\'\huME:, SpUr+ WRlS-' I-\f\~u O~S\S I C:>.:':' I'" ,1_]. 'Y=yt h~:\'.t t.hc,: ~:;~ IJC'../f.::' (h::~'V'L (:f.:.:' l;.! n:1. i::]"1 j' j"!~';""v'j:::. n [.n {.:.:.~::.c !.- '1, hi,:.?!,:; ~1 D.n d .aJ.l SUP1:l,11es an(j services inc\G21,t~1 ~112l;'e.to 2~P n\edi(:~'l',( the 2j:~r)0e...nalne~j p~'tl.Gr)t" ......,....;.(fir c.;;:;;:;....;; f ., .E:i.qn,::J, tUI"JC;: 1/"Lv' ,..........:6 '.:~: ':t: ~:~~ "-i~~; '.i~ ;~j ;::~. ~~:;;j' l"JF'TJ',; ~j;:: A].p/a!'ldF ,<~.i.en6: rr! ...." ~3'.?:~; !"C,rp.l..;';\j"" Chi.." '. .C':;"<..mp Hi 11:; Pi:";! h. h'c,;:'i,Ci;, 11 ( '7:L '.')') '"/ ,~~ 1. . =5 ::::':.:~O I~J.0aS2 ('etll!~n to: H{;);'..iC3EF,.' F' (-C)';;~ the t :i. >.::':;: ,::~; Oi";.: II.;.' '. 'L c:::. \ n;' db.::', T C U F:' E l... C) \,. t. \"j r'::, '1:.:L -::: ,\.; "..' ,. :::l ';:;. .t :..~ F- '1;.:\ ," ,H ::. ~:; .:j <: J..... t, (.~ ':::. ..,.'. ::::::~::;:,:' E: .}.:::,j:3 ... ... "/'!:.h ':~: '!:.I"C"E"'t i. ~;l~:i ~'II:L n CJ'f'f:i_ ~::'::.;. :::,:: ~.:.\ :l ,.;t T 1" :L n d :\. (:,:" r::C}.,:'\d i"l~';',.:''')''--' ::.;::':..;.["'q F (:\ :L"?:Lll ('7:;. .. :.::,{./.:. "i;'i.~.;i2:i. '?:L ~.~ i".1 H,::,nc)'../;;:~',,-' !.;.l,,::'! (~arnD Hill F'A J.70:;,], :J:i.?: :"i',r!(.;;<.!:,.i.;.i:.o~'..ln Pt, ( ')' l-.?) '.?~'::,:\. ....:::;: 1 f::5:L '. ~? 'j ....:, (1 ')' '.' .L :;':'~ '/ -:' u-y BEST POSSIBLE QocUAu~kNT DUE TO OR\G\N~L 0 v J t.i ~ \\ ?,,~1 3~'" -:0 Time.,9 '21-) Doctor~i' A~ h, L Address r0L\o5 fur\\'~:'f1~) t\~ )~, . _~"U'O "'" PA -H~L\O \-- ..... phone tj ',)- \ 0 008\..0--' \q - TYcvi Cha~ fd Date Patient Name ..., Sex -CO 1'I1l0 ss~J95-lCO -?].Cog Marital Slatu. en i Age Employer Occupation s~ "'" ..... IIp Mother 008 W# Employer Father 008 W# - Employe.: Spouse DOB W# Employer Child (School) Responsible Party If Child ---- ~ [.. Alternate/Other Contact Injury 'p Accident Description c , ~ .- '( /' Date of Symptoms first appeare<1 if not injury ciJ ('(\(J,1::'rf\ ~ INSURAN~ary t\\ \s-\6J:O \ (\'>-,\UuflU) Co,seCOndary 1\\ Q('\ '\ Address ~ o?>W,5 K,C\ f\ K-& . ~U '\ \: C \11-'1?ss \--\~~~Q \~\\\~ --- -- ,- C -:;, STOUp. #- Ci~~:. \>'= -I \ ~ nQ..(, GuL\ 'Puli~, # ,n~l.-'lC'i D (), ;L) ,jl'\ subscriber's Name rGJ....\l\'\ ) Address Family Dr. ( b-).Q~ KOJ\c:LrO--- \f\l)Referring Dr, Ro. $'~ \.~ r ('{> Ct> r i ( J\ Address Address Fam"YOL~ p.eiemngD4 Send letter to: Neither bate la.' 1\- 01 Time Patient Name ~ rubs-\- L J 0 () Doctor ~le-..---c. 1(, ClIart# \ 0.. c/l-:)..d-. ~lp'h , (~ ... Address :;)lrdS Gc. r n S; ,-rn ~ _.....QfR\:nll~ \~b~ ~ - Phone 5'-tC- 4"ils ...... .- OOB [' l C1.- ;)/ Age '/'-( Sex rh ..2- \')110 "" 88# \C;)'-u-3<.Do1' MerIlal Slatus rn Employe< O<:cupatiOn ..... co, - "" Molher OOB WI Employer Father OOB W# Employel; Spouse DOS WI Employe< Child (School) Responsll>Ie Party If Child AnematelOtl1er Conlact Injury '() 001 11'1 <t-C/ Sports Auto Work Related Accident Description p\- c..=_< ("--,0 u. )1; n :) ,')Clr"->~~ \Z. '"'1h Vr" t> \r-. ~n+- +~ , cD sP.. /(-4--- "-$ . Date of Symptoms first appeared If no( Injury INSURANCE Primery ('l"\jl <:\, : Secondary ~5 Address Address Group # GroUp # 0 Co):: ~ 000 0 \) POlicy # ~ 65 I (is I u 3&of \ Subscriber's Name ~-p J-, . Policy# \ q:J IV 3L~Q4. JC::, Addr.... Family or.~os.e.ph ;,f.,Ar-. ~ ""'0 Referring Or, \ \ " Address Address Send letter to: Family 0"+ Referring Or, '-. No<<l1ot ~ DateQ11Q =TmeJ,LD ~ ~ Patient Name "'~ Propst ~ , -Jl=f= .;2 c.j, ~s G Ql..~L.\!9:- /'Ivv- . rIB G- ~ Phone 6~ ~ '-/9 IS- DOB & =- cr- Ra-7 Age f<. ~A& Chart # J909d~ pC ~ ... Address wo;,~ SS# If II (J /qs:-i& -3&07 (Yl sex~ Marital Slatus Employer Occupation ..... Clly - .. Mother DOB W# Employer Father DOB W# Employer Spouse "7\--. ~ \\ { s ~t G ~ d.- DOB W# \;. ~ -......... ~ Employer Child (SchOol) Responsible Party if Child ARematelOlher Contact Injury rVn DOl Sports Auto Work Related Accident Description Oate of Symptoms first appeared if not injury INSURA~~ary fY\. ~ A (.0 -\!~ /(c:. - 7, - <.f , ~ e'~_A"A () (0<::: ~I ~("A.t!.1-- Secondary Address Address Policy # G o (p ~ () 0 0 (')(")'0 B S I '7 S I L .3 0 09 RalfL, Group # Group # SUbscriber's Name Address Family Or. '- S. A:::s V . . - Address -;] O.5e.fJh Referring Dr, ,/os.., PI, K~~ tI49 Address k t~ r'C~ ;J1p , Send letler to: Family Dr, ~ Referring D~ Neither -CP~ HEALTH mSTORY \'lo9'(l.~ lJJulal< <1-/~-of /1- /3 -tJl (2vll-6'f t 31'rP (/) The following is very important to us in taking care of your health. Please take time to completely and accurately fill out all oftbis informatien. Please also. make sure yeu update this information as changes occur. Patient's Name ~\fh" ~'YQb.s-+ , Medications You Are Taking (Also list herbal supplements and vitamins) Medication Name A.mount Freouency Areyo,-!taking dietmedicatien? No_ Yes_ Allergies (Drugs and Other Allergies) Penicillin No JL"Yes_-reaction Local Anesthetic Nohes_.reaction (xylocaine, noyocaine) Other Allergies Hospitalizations (List serious illness and injuries or openltions and approximate year.) Hospital ~ o .----- Chart Number Past Medical History I. 3/' 0 (3 ~ Have you or members of your family ever been told that any of you have: Social History Ne~s_Amount No0es Amount NoL Yes_Amount Anemia Asthma Abnormal Bleeding Blood clots / pWebitis Cancer / tumor Diabetes Drug abuse Eczema / psoriasis Epilepsy I. seizures Heart Conditien High or low blood pressure Liver disease / hepatitis / II ' di "i>" ye ow Jaun ce J;:~'\,-;~,~. ..C-'..,\-..~.",:""'f~--"--- Kidney I bladder problems Lung disease Prostate,problems Stroke Thyroid disease Tuberculosis Ulcer in stomach / duodenum Osteoperosis Arthritis Other bene / joint disease Any nerveus system disease Height ~ / /5." De you smoke? De you drink alcohol? De you use street drugs? Your Describe You Family U [] [][ ] [e[] LJ (] [] n [] [if' ~-Z-~..-,-- Ll [] Lr:, [ I ..r [] &x'~~ ~/ ~~ '. [J_~"u/ ~a-oa.d.M [ ] [ ] [ ] LJ (] 1l'1~~ [] M~ [] [] (] [] [ ] [ ] [ ] [ ] '( ] ~ /?ahv~ [ ]p [V(~ [ ] ~] d O't) fl--. Weight Continued on back of page",,,,,,.. During the past year, have you had: 1 hcartburn or indigestion'?.,..,.........",..............".....",..............."..,.,." 2 bowel movcments that were bloody or tarry'?.........,.......,..............,.... 3 any rccent change in your bowel habits'?...............,..........,......,.......... 4 frcquent urination during the day or night?.......,...........,..................... 5 any reccnt loss of control of your bladder'?.........,...........................,... 6 burning with urination'?",.".,.,.........,...........,...........................,..,...,.. 7 difficulty starting your urination'?..................................,.................,.. 8 excessi ve uri na tion '?,......,....".,.,.........".,. ......',...'.......,,'..., .....',........ 9 excessive thirst? "." .......',...,.....".""........................,' "......"..,.."" ,... 10 shortness of breath or wheezin~'I...........................................,...,....... II chronic cough'!"".",.....""".,......."",...,.........,..........,........',........."" 12 chcst pain with activity'?...........,..........,..............,.............................. 13 'I t I't t'" 'I ' raclOg lear or pa pI a tons. ......................,....,....,.............................. 14 swollen feet or ankles'l.......,....................................................,...,..... 15 Jreqtlcnt headaches'!. ......'..,..............'............'.......... "..."......,...."... 16 di fliculty hcaring'?"'......,..,..."...................................'''..,................. 17 dental or other mouth problems?....................,.........,.."".....,..........., 18 frcquent nose bleeds'? .................,....,......................................."....... 19 easy bruising? ",..,.,........,.....,.........,.,...........,....................'......,.'.,'... 20 skin rashes?.."..,.,...... .....,.... .....',..,.............................,....... ..... ,........ 21 aching muscles or joints'l..............,..........,...................,.....,............... 22 swoll en join ts'?",...,...........,.............................,......,.....,....",.,..,..".... 23 cold hands.1 feet'?;.""....,..........,........................,........"'................... 24 gangrcne'? ".."........." .................. ........,...,.....,'............. ,......... ,......... 25 loss of consciousness'?,.".......",..........."...................,.......,....,'......." 26 recent numbncss in arms or legs?,..................,.................................. 27 c hronie fatigue'?",...,....."., .:,......"".. ..... ....... ...........""...."..,....,..'..... 2 8 uncon tm lied bl eed ing'?",....".""......".........".............................,......., 29 weight loss'? ," "" ",,'..,.,......,....,,'....,.............'..",.,....,.. ,.....'.,.......,,'.. 30 weight ga in?,...,.".".,.."..,...........,....,...,.............."......",.....",.... ......, 31 heat I cold intolerance'/.."'..............."'."'......"'................................. The above infonnation is truc and correct to the best of my belief. Patient signature, tf-a# ( - .t1~ .No_ Yes ~ No ~ Yes_ NO----7 Yes_ No~ Yes_ No /' No :> No No /' Yes_ Yes Yes Yes No /' Yes No- Yes ~ No----;7' Yes- , No_ Y~s ~ No_ Yes /~-; No 1/ Yes NOZ Yes= . No~ Yes_ NoV NoV No(/"" No~ No_ No--L' No V Nor/' No'~ No -;7' NoV No...tL NoV No V No_ Yes Yes_ Yes Yes~ Yes/ /~~r Yes~ Yes_ Yes_ Yes Yes Yes_ Yes Yes Yes Yes Date 7'- (t{ .- Cl ( ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patient: Ralph E. Probst DOB: 06/19/27 SSN: 195 16 3609 Chart #: 19092201 Page # 2 ------------------------------------------------------------------------------ 12/19/2002 RONALD W. LIPPE, M.D. RADIOLOGY RESULTS RIGHT HUMERUS XRAYS, AP and lateral xray of his right arm that I obtained today shows normal bony architecture in his humerus and well-maintained subacromial space. IMPRESSION, See above study, RWL/rah r?M ~ ~ IrJ:>. ------------------------------------------------------------ ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patient: Ralph E. Probst DOB: 06/19/27 SSN: 195 16 3609 Chart #: 19092201 Page # 1 ------------------------------------------------------------------------------ 12/11/2001 RADIOLOGY RESULTS RIGHT THUMB X-RAYS: the MP joint and IP ALEXANDER KALENAK, M.D. X-rays of the right thumb show mild arthritic changes at joints, IMPRESSION: See above study, ~~ AK/mjh LEFT SHOULDER X-RAYS: X-rays of his left shoulder show minimal arthritic changes and no other significant bone or joint abnormalities, whatsoever. IMPRESSION: See above study, ~~/.-~ ~~ AK/mjh ------------------------------------------- ----------------------------------- ~ v ~~ ., 110 1'V 450 Powers Avenue HEALTHSOUTH. INITIAL PLAN OF CARE RETURNTO: Harrisburg, PA 17109 r!lf (j OTHER (717) 558-8511 ,... PT (J OT (J SLP (717) 558-9317 fax Patient name: &~I SSI: i"lr'-I".]' OnsetDate:-t'ro'iro"',,~SOCDate: /Z./I~/cl Therapist r.:>., r PrIorhosphOnHon(foraurentepisode):From To ,t:J N1A Primary Diagnosis: IL, c.. ~. Treatment DIagnosis: ~- ~ Rehab potential: IJ EJ<cellenl~GOOd IJ Fair Physician: 'P..... 1..",~_.J~r 1L...'&~~_k Celtlftcatlonperiod:From 1Z.I,z/'"To 1/ 1/102- =ent Plan: Treabnenl may indude the following: . alities "''or'f I I'h.~", ,..., Iv c v'_ 0 FmelT.Auldt...dt.iIy 0 Functional Basetlne/FCE (3':(ROMIPROM ,. <...c.- Q.I'llsIuI8 and/or Body Mechanics 0 Onsite Jllb Assessment 9'Slretcl1ing (passive) ~ COOICilloo.... 0 Wert Hanlening/Conditioning 81lanuaI TherapylMobillzation 0 VIsual pen:llIIIIIaIlIlinlng 0 Wert Tr.lIISilion Onsile 8slrengthening Exercises 0 SpIntingIllltho 0 Home Evaluation IiJ-t1Cme Exercise programIPT Education 0 ColP1iIive I8IIalr*Ig 0 Other o Massage/MyoIascial Release 0 Camunicallon 0 Other o BalanceIGait ActivitiesITransfers 0 Swallowing o ~L's 0 IscIdnetic Tes1lng 01'atienticaregiver participated In development of trealmelIt plan. TREATMENT FREQUENCY::z. TIllES/WEEK DURATION: ~ WEEKS IJ1 VISIT Patient Proble,rns: (Re~ tor referral) G}lsain in ('() S tdd 0 ! ,,,,,,,,.dl.y capa:iIy o ! bedlmat mobility status 0 SIdn bnlalrdolo~waund o ! ambulation status/gail abnonnality/dysf. un ~ lIE stnlngIb o ! w/c mobility 0 ! RIUB LE stnlngIb o ! lransfer status 0 ! ned<I/nIlk slnlngIh [J Abnormal tone b! L encUance o ! sensation/proprioception 131 ~ lIE ROM o ! visual perception 0 ! RIUB LE ROM o ! oognition 0 Jcinl 1It........aII, d I o ! communication skills !2r'Jolnt h).....liII) d t'"..> "" LQ o Swallowing difficulties 0 Softlissue~ Short Term Goals: Target Date: a.1 Zu,(<>'l. I.Patienlwill: l' @ .$~Ij Ell- k/">'1 0 -70 2. Patient will: l' ~ s'=f.:i e= .,. 1, d 0 - IrS" 3. Patienlwill: -V ~.: J t ,/ ,I)",:", 3/1 <> Lo~erm Goals: Target Date:' 1/ " I.o.Z t Decrease pain to level O. z I ,~ at WIllSt to a/Iow Q1Nfer funcllonaI mcbiIily 2. 0 Increase bedlmat mobility andlor transfer status to 3. 0 Increase functional walking loIerance to 4. 0 Improve gail mechanics 5. 0 Increase wlc mobility to (distance) with 6. 0 Increase sensation/proprioceptionlvisual perception to improw! funcIianaI AOI:s such as 7. 0 Improve oognitlvelcomrnunication skills to COIMIunicate wams. needs & Ideas across multiple environments 8. 0 Patient will tolerate most advanced diet wIout signs & SymplIlmS d difliaIity 9. 0 Inaease functional standing tolerance to minutes 10, g !lJIPIDve skin integrityIS~'ngladhesjOlJS 11. ~J)l:tl!ase strength o( ~ .J 1../ P from &--' rl..,j, to '-'^' L to improve functional molliBty/AOL's. 12. B1ncreaseROM of C SkId from G~,~,~~ 10 <--"It.. toimprovefunclianalmobility/AOL's. 13, 0 Improve abiiily to lift with safe body mechanics to decrease pain; ability to... posture for AOL's to decrease pain. 14, 0 Improve balance/coordination for functional skills such as 15. 0 RTW at modified/nannel duties; ability to pertonn normal household AOL's. 16. 0 Improve fine motor skills for functional AOL's such as 17. 0 Decrease edema , 18. ~m to activities of~port 19. BPatientl Family Education 1%) k~1' 20, 0 Other Therapist Signature/Date (establishing POC) '/'7 i:> /..4~..-<= /7' ,I 2 ;' 12/'" I M thera 1st has reviewed m Plan of Care with me. Patient/C;/re wer Sf, nalllrelDate I cettify the need for these setVices /umished under this plan oIlteatmenllJlldwhilo_my..... .PHYSICIAN SIGNATURE lOA TE : o PoslInI dysfuncIIoo o ~.lIX\lIl8l' body mechanics o ! blIIanceIcooIdn o ! I1n:IfonaI sIaIusIADL'sAvork skills o ! tine ..dOl/dexterity o EdemaISweIIing o ~AlIIesions ~ (j/ /Z.T<:- o Ht..li,-.... o AmputaIion OOlher 4. Patient will 5. PatIent wiI: 6. PatIent will: (cistance) in miootes with . devicelassistance. assistance. - Page 1 at 1 Revised 03101 ClHRC2001 306- Plan at COre . . , . . # HEAL THSOUTH UE ADDENDUM ~Initial o Re.eval ODIC cD /LTC fa / ft.. Patient Name: J&. {.PI, . ~~6,J1- Diagnosis KEY: ROM is passive unless indicated otherwise with an "A". Use standard muscle test grades for strength. WFL = Within Functlonal Umit NIT = Not Tested · Denotes Pain LEFT ."" 'ROMISTRENGTH ".. .' RIGHT INITIALS . ROM STRENGTH ACTION ROM STRENGTH lL(o. -.;1 ,. SHOULDER Fl..EXION 180" <..N PL- $" r -f'"H SHOULDER EXTENSION 60" (hO. i/$/ ,. SHOULDER EX. ROTAnON goo I 1.... ~ ~/~ SHOULDER IN. ROTATION goo i40' 4-!-/<(, HORIZONTAL AOBOUCTIOH HORIZONTAL ADDUCTION APlEY INT ROT , APLEY EXT ROT FOREARM PRONAnON 80" WRIST FlEXION /EXTENSION rnCY' " WRIST ROOD . ,- I. ./ . .' ..... .CooRDINATION UPPER EXTREMITY LEFT RIGHT Comments GROSS OWFl .WFL ~v QIImpaired CJlmoaired FINE 'Cl:WFl WFl CJlm....ired GRIP STRENGTH left RighI I HANODOMlNANCE RI L . FLEXI81UTY LEFT R1GJ{T Comments Upper Trap I levator Scapula / Anterior Scalenes / Pee Major 'J; / Pee Minor J,/ / Foreann Aexors I Forearm Extensors I Otller: I SENSATION N = Nanna! NIT = Not Tested I = Imnaired A = Absent Shoulder Uooer Ann Forearm Hand L R L R L R L R Ll Touch .J Sham-Dull ^' Ir localization AI :r Shoulder Elbow Wrist Anoen Proorioceotion I .,1 I I T I 1--.1 I / Stereoanosis I r 'fl I I I I I \v SIGNATUR PI INITIALS ~ SIGNA TURE/TITLE INITIALS Page 1 at 2 Revised 03101 ClHRC :D01 316- ue Addendum "/tEAL THSOUTH UE ADDENDUM Re- Ipl, /a. 6.s i- L Patient Name: , " Diagnosis ({J l?- re S.f-/f,?'. , . KEY: += Positive Test . = Neaative Test NT = Not Tested NA= Not ADDllcable LEFT SPECIAL TESTS RIGHT LEFT' :t ,:<,j~iSPECIALLTESTS' "'., I', RIGHT . . INITIALS r , - Neer Impingement N I'IfnfuI NIC 120" , .,........., Hawkins Kennedy Imp lJIollldc - 0ulIet -t Supraspinatus Test ULTT IINIUHIRN - Drop Ann Test E1bowVl/guI/Vuua Tilt - Apprehension AnllPost SbowTlaell - Clunk Test I.IIIIIId ~odyIIIJa Tilt AnUPostllNF Instability Elbow FlBIan Tilt . / Yergasons + S,IIeL -'oS kJl- Hyper HP't) End-Feel Joint MobllitylPlay Segment Hyper HvDo End-Feel Pron. Teres "(Ii) SVndrome Test G-H Ant T c--~J~I..". PIncb Grip Tilt ./' G-H Post . .... I 0llIer. ,/ G-H Inf. ... .1.1 Other: ./' A.c V s.c ../ Scaoula 8bow OBSERVATIONS: Tone, Movement Patterns. Reflexes, Deformity, SIdn Integrity: 'r rL) VT <~....ki.-h" ~., z ~ 1,-. (...., ~t:: rL..l Co,r~ ;",", ",-bd- . ..' ..........k,;~l:H~~~~~~~~~,'~,~.~j.,:;:..~cJr~~i!i:i~:~"~... .'.ri....';,),')... Occiput Shoulders L:~,J lW ~ Scapula Clavicles Cervical Lordosis Thoracic Kyphosis 1- ;;:, ------k .J lumbar Lon:fosis Posture/Obvious mechanical stress points .&L.1d '" .,.. CERVICAL I~I~; ... . . c.. -"'i, . . ,,;",,:>" .. .. >' .....;C'.;:':' .. . . , '0."... . '. '. , ,'j~~~-~ ~:;;('~~:;-~/'~ ..(:,: ..-.. 'Y"".' ....., ..',.'c'., .n, Rom CompIes.Mi Distraction Strength Comments Palpation: (' -~ TTP LV , /-~J~~r lub .s.....L. .-:..c:..-....- ;_1 6wn.... ) ~ .. Comments: DATE I SIGNA TUREITITlE I INITIALS I DATE I SIGNA TUREITITlE I INmALS ,<.1'2.1 ,I '7'""_ i? (/ .//''-/ L ,0,../ 7H I I I . Page2012 Revised 03101 CHRC2001 316- UE Addendum or HEAL THSOUTHDfSCHARGE ASSESSMENT ~ Physical Therapy o Speech Therapy /2o<jd-d, Occupational Therapy o OL~er Y-3 PATIENT NAME: f2u./ PL f/'G'!"sl- :7- )'l1' af7)71:. addressograph SS#: IQ,-IC:, ~ :;:<.,<>2- Discharge Date: If <(/0"- Evaluation/Addendum: I Diagnosis: &R'L- OChronic Pain/FMS OFoot/Ankle Admission Date: I"Z I,"Z I 0 I OCommunication o VlSUallPerceplual Referring Physician: i7"" /l/<',...~./,,/, '~t,.~,~_t OCognitive DUE Addendum Primary Physician: ODysphagia OLE Addendum o Cervical o Hand - o Lumbar o OIher . DURABLE MEDICAl EQUIPMENT 1 Assistive Devices: o Standard Walker ~~Olling Walker a Hemi Walker OQuad Cane. Large / Small Base i 0 Straight Cane None o Ofher I i Bathroom Accessories 1& None OShower Chair OBench o Grab Rails o BSC ! Other Equipment ClHospital Bed CI Wheelchair CI Cushion J:1 OIher /lwle- , I PAIN ASSESSMENT .. . .. PAIN REI!IEF STATUS I Pain es CINe "if MedicationIProcedure fie/....il C-I. /" 6.-. '" , IL) 5/..,IJ '[JRe/axation Techniques . I If Yes, location: I Pain Scale (0 -10) Now Best_ Worst~ o Modality/Activity that decreases pain: , ! Pain Symptoms: ,mDull o Sharp ClBuming o Referred i ClNumbness ORadicular 0 Throbbing OOther IIa Modality/Activity that increases pain: 1 ~-k..., i , (Use comment section for detailed desaiotionl ~oJ.r~".5 S,.,)al. f,.r:k P<"",=LI.,,~ c~.,.' I Frequency CI No Pain Oless Than Daily ..! Daily aDaily -Increases throughout day I JiIIConstant o Nioht oain CI DistUrbed SIMn a 0Iher: '~ rZI Comments: ?/ r...."'~f-f .H...f It.! fl,ld "-IIr .-b"",," ~ .1<::-...,'" c~r t...--""'.., oS . -rt......--e f< ~ c..,.., sh-...I- i:>"L", I.. ('t. \ d./..{ REASON FOR D/C: ClGoals Met ClMedicaJ Condition CI Reached Maximal Potential o Benefits Utilized I CI Objective findings inconsistent with patienfs complaints and/or diagnosis. aNon Compliance )lIOIher 5" Ie 1" ;.. ,'~ ",,~,,~J ij(EatieatlCaregiver Training Desaiption of Training Provided: vi: Sol--<-<, /~., "''':) I ~ Pr- I flYct..-t. .',_ ;..--~ ' T reatmenl Receivetl: M 1--1 /1/?-<Jr? /7/&,r-/ .<t:;,-C'-h1::-:~,. .fA "--~"'~h.......,.., it:..e io..-?,hJ ~- dl!~~C"/h~~J' tt.."....,e. J '. J n h.J' ;?of . Summary of Progress: ? r rC"c/ ;: Tr _I ri..', ~~,:.,j. rr. t<%.",>,> ~,~~~~ r I."" ,j.,eJ ; ~ /4'0. j'b.} 'f<-~' lie/?, ~~- ~ 3",.-\ 1'1< s/--.. ;, r/r ~""""n/", .~ . (l-;' 5(.,,1). /'~ ~p~.-h I-<,~t @ 5'4/<1 ,.4.." -/~ t...~-.$e. , ft.".". ,? u_ _~ "':0 t .I~' '" I RECOMMENDATION: OContinue with HEP as issued '" I-t. . . I- e::.../I ClEquipment needs 1 ClResume Therapy c..-.o--..+ liar allow up with physician ~'" .sh o/' 1"'1 L--,,-,_~ ClOther - COMMENTS: Pt vie. h-<-VV1 ?T :r ^ /,.,1 /h..t.',. ..a -.z;.~~,,'?!"...J:J C ,/-r <,?- d I I:"',!..~.:;..hd h ~':><"1.4:-G ,t /'" r-:> t'F .5,..5 .cc->...... A~..., ..::f, , / "'''rt:// '--o:J..-:, e... 0.- , /?- SIGNA TURErrITLE INITIALS TLE Page 1 at 1 . . Revised 03101 HealthSouth Sports Medlclne & Rehab 450 Powers Avenue Center HARRISBURG, Pa 17109 il (1& eHRC 2001 360- Oi5dmge Assessment \--" c:,? , ',',' (f~ ~-l~ .-' ?\-p. ~~,~:\::~) r',,") I'" ......'--. "\~ c:? ('-J "" .,;~ RALPH E. PROBST and PHYLLIS W. PROBST, his wife, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 04-5728 Civil v, CIVIL ACTION - LAW EDITH M, CADY, Defendant JURY TRIAL DEMANDED To: Randy S. Frederick, D.C./ChiroPlus of Locust Lane You are required to complete the following Certificate of Compliance when producing documents or things pursuant to the Subpoena. CERTIFICATE OF COMPLIANCE WITH SUBPOENA TO PRODUCE DOCUMENTS OR THINGS PURSUANT TO RULE 4009.22 I, tl~ ~Il ~(I}.YlvU\.. ,certify to the best of my knowledge. information and belief that all documents or things required to be produced pursuant to the subpoena issued on December 22, 2004 have been produced. aQ R~ __DC R~ndY S. Fred~D.c. Date: )- 111-6::( WIX, WENGER 8 WEIDNER RICHARD H. WIX THOMAS L. WENGER DEAN A WEIDNER STEVEN C. WILDS THERESA L. SHADE WIX. D^ VID R. GETZ STEPHEN J. DZURANIN STEVEN M. WILLIAMS JEFFREY C. CLARK PETER C. HOWLAND STEPHEN P. SMITH KATHRYN L. WI)( A PROFESSIONAL CORPORATION ATTORNEYS AT LAW 4705 DUKE STREET HARRISBURG. PENNSYLVANIA 17109-3099 January 10, 2005 (717) 652-8455 FAX (717) 652-6290 WWN.wwwpalaw.com "ALSO M[MBER MASSACHUSETTS SA" Randy S. Frederick, D.C. ChiroPlus of Locust Lane 4607 Locust Lane Harrisburg, Pi:'. 17109 Re: Probst v. Cady Ralph Probst D.O.B.: 06/19/1927 S.S.#: 195-16-3609 To Whom It May Concern: Enclosed for service upon you is a Subpoena to Produce Documents or Things for Discovery Pursuant to Rule 4009.22, Please note that you are required to complete the enclosed Certificate of Compliance and that all copies must be photocopied on one side onlv. Your cooperation in this matter is appreciated. Should you have any questions or desire further information, please telephone the undersigned at (717) 652-8455. Very truly yours, .~ ~:-vl N l~'6"" Richard H. Wix RHW /gc Enclosures cc: Joseph J, Dixon, Esq. (w/enc) Downtown Harrisburg Location, P.O. Box 845, 508 North Second Street, Harrisburg, PA 17108-0845 (717) 234.4182; Fax (717) 234-4224 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND RALPH E. PROBST and PHYLLIS W. PROBST, his wife, Plaintiffs v. EDITH M. CADY, Defendant File No, 04-5728 Civil SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANTTO RULE 4009.22 TO: Randy S. Frederick, D.C., ChiroPlus of Locust Lane. 4607 Locust Lane, (Name 01 Person or Entity) Harrisburg, PA 17109 Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following documents or things: All medical records, notes, correspondence and other documents realtinq to Ralph E. Probst. at Wix, Wenqer & Weidner. 4705 Duke Street. Harrisburg. PA 17109-3099 (Address) Vou may deliver or mail legible copies of the documents or produce things requested by this subpoena, together with the certificate of compliance, to the party making this request at the address listed above. Vou have the right to seek in advance the reasonable cost of preparing the copies or producing the things sought. If you fail to produce the documents or things required by this subpoena within twenty (20) days after ils service, the party serving this subpoena may seek a court order compelling you to comply with it. THIS SUBPOENA WAS ISSUED AT THE REOUEST OF THE FOLLOWING PERSON: Name Richard H. Wix, ES~. W~x, Wenger & We~ ner 4705 Duke Street Address: Telephone: Harrisburq. FA 17109-3099 (717) 652-8455 Supreme Court 10 # 07274 Attorney For: Defendant Date: frc d~ ..::lnn~ Seal of the ourt Prothonotary/Clerk, Ci ivision ~O~ 97f/l,uoLr--. Deputy ,,-u ,'07\ TO THE NEW PATIENT OUTliNE OF PROCEDURE FOR NEW PATIENTS 1. STEP ONE: ALL NEW PATIENTS ARE REQUESTED TO FILL OUT A PERSONAL HEALTH mSTORY QUESTIONNAIRE. 2. STEP TWO: YOUR FIRST CONSULTATION WITH THE DOCTOR TO DISCUSS YOUR HEALTH PROBLEMS. 3, STEP THREE: CHIROPRACTIC EXAMINATION AND ORTHOPEDIC AND NEUROLOGICAL EXAMINATION AS RELATED TO CHIROPRACTIC CARE FOR yOU. 4. STEP FOUR: THE DOCTOR WILL ADVISE YOU AS TO THE NEED OF ADDITIONAL PROCEDURES SUCH AS X-RAYS TESTS, IF NECESSARY. 5. STEP FIVE: YOU WILL BE GIVEN A "REPORT OF FINDINGS" ON YOUR SECOND SCEDULED VISIT. THE DOCTOR WILL INFORM YOU AS TO YOUR EXAMINATION RESULTS. YOU WILL ALSO BE ADVISED CONCERNING FINANCIAL ARRANGEMENTS AND INSURANCE COVERAGE AS APPROPRlA TE. 6. STEP SIX: AFTER YOU RECEIVE YOUR REPORT OF FINDINGS, YOUR RECOMMENDED COURSE OF CARE WILL BE EXPLAINED TO YOU. 7. STEP SEVEN: TREATMENT WILL BEGIN AND CONTINUE AS SCHEDULED UNTIL MAXIMUM CORRECTION FOR YOU HAS BEEN OBTAINED. 8. STEP EIGHT: AFTER MAXIMUM CORRECTJl:lN, A SCHEDULE OF CARE WILL BE RECOMMENDED, I UNDERSTAND AND AGREE THAT MY HEALTH AND OR ACCIDENT (WORKERS' COMPENSATION OR AUTO) INSURANCE POLICIES ARE AN ARRANGEMNT BETWEEN MY INSURANCE CARRIER AND MYSELF, I ALSO UNDERSTAND OUR OFFICE WILL PREPARE ALL HEALTH INSURANCE CLAIM FORMS AND OR REPORTS IN ORDER TO MAKE COLLECTION FROM MY INSURANCE CARRIER, ANY AMOUNT AUTIlORlZED TO BE PAID TO DR FREDERICK WILL BE CREDITED TO MY ACCOUNT HOWEVER, I CLEARLY UNDERSTAND THAT ALL SERVICES RENDERED ME ARE CHARGE DIRECTLY TO MY ACCOUNT AND IN THE EVENT OF MISINTERPRETATION OF MY INSURANCE CONTRACT, I WOULD THEN BE HEW PERSONALLY RESPONsmLE FOR THE BALANCE OF MY ACCOUNT, IN THE EVENT THAT COLLECTION ACTIVITY WOULD NEED TO TAKE PLACE, I WOULD BE HEW RESPONSmLE FOR, BUT NOT LIMITED TO ATTORNEY FEES THA T MAY BE INCURRED. X-RAYS ARE THE PROPERTY OF CHlROPLUS OF LOCST LAND AND COPIES CAN BE PURCHASED. PATIENTSlGNATURE 11# (c fJ~ DATE: Iv f2-C L.-- Referred by: Date: PATIENT INFORMATION Patient's name: Patient's address: City, State, Zip: ~~~~42;f:ljJ nil 6 Home phone #: 'S /.. cf S'" Work phone #: ~ SocialSec.#:' -/& -3t,IY/ Date of Birth: tJG/ 19 /1'1d5 Patient's sex: al emale No. of children: ;;, Marital Status: arrie SinglelDivorced/Separated Student? F or PT? Height: (;, I / I' Weight: It> Person Responsible for paying the bills: Subscribers address: Patient's Employer: Address: Type of work: (PLEASE CIRCLE ONE) ctkaltJ> Tnsl.\t~Self-pay Insurance Company: Insured's Name: ~) IF AUTO ACCIDENT (Please Complete) Circle One I was the:~ Passenger Vehicle Owner-Auto Insurance Company: Insurance Co. Address: ..... /7/) 'l- Telephone # of Insurance Co.: --5' +"0 "". 7 5?' Date of Accident: t:>;Z Policy #: (J tJ)f .%3/01) ~~~ Adjuster Name: ' ve. ct , Claim#: /.5--,s-.t/.)7J tf;r'30 31<\11 Attorney's Name: /J o!{(h ~ /dh , Phone #: "?1.?^ ~ ~ Attorney's Address: / __ S'______ bP;a?;I'./ ~, j4 _2Q1 IF WORKERS' COMPENSATION (Please Complete) Employer: ~ it Address: Phone # / ~" Supervisor: Date of Injury: / Workers' Compo Insurance Co. Address: Telephone #: Ji Attorney's Name: Attorney'sTelephone #: Ye. U No )fye. [] No U Yeo )(NO :]1( Yes {] No : () Yes ji!;No ;~Ye' U No ;;X l'es U No Have you had previous chiropractic care? Dr. 11 yes, how l~"h.s it been 11'5' you'.... been t ..ted~ Were you hO'Ptialfzed?t:{~... _itted ILJ.2Jjj2..':>- Date discharged !L-1),l1_f2:2.. Were you treated in anoth.r t.cil'ty tor this conditlQ01 Where Have x.rays been tlllken or w.. llo work. proposed and/or c leted1 When f/-...<)--o2- Have you had any operations? Exp in List any drugs you ar. taking: ~ Co you heve morning stiffne.. which tast. more an 30 m{nutea?~ j Are you interestfd in improvfne your &enor.l well befng e. ~oll a' ijispensing w1th the symptoms that brouQht you to our otf~c.. ~"" - ' Below is a list of conditions which may seem unretated to the purpose of your .ppoint~nt. However, take tlme to answer these questions carefully as these problems con .ffect your overall diagno~i$, treatment pl~n, and whether of not you are accepted for cue. :)("Y'. : () Yes : )fl" [] Yes (] YeS [J Yes () Yes (] Yes n Ves [] Yes [J No K'NO C1 No ~o ~No XNo )l:'No J("NO xtrNO )YNO Have ~ou .ver had cancer? I~ Ar. you losinu wei~ht with~t tryinQ1 Do.. your poin woke you LIp at night? Haye yo~ had. chanae tn bladder or bowel nobitl? Hive you had a sore thlt doesn't h..l? Kave you recently had any unu8~l 'btoedinQ or ~!fchlrge? 00 you ho.e 0 thickenlng/l~ In the breast anyw~er.l Are you ha.ing indige.tlon or difficulty swall~ing? Do you have. nlsging cough or hoaraeness? Hive you had an obvious change in I wart or mote? Circle any of the following conditions YOU currently ha~e or that tend to be . re,urrent problem. Check (~ those you hive had in the past but are no longer a Droblem. ~ /JIeadacheS) Allergies Hayfever Hive,S t'IiltiWe) l.Iei ght lO.55 CARDIOVASCULAR RESPIRATORY Chest Difficult br 1 PersisUnt cough (jlood pres~re probleffi!! A.th~.~r bronchitis (Rapid or irreg. he.rtbe~ Swollen ankles Varicose veins Hardenfn~ of ~rteries legs hurt after walking ~ndiCitj;;:) Scarlet fever VenereaL diseau Whooping cough AIDS CASTRO-INTESTINAL POQr .ppet i te Excessive hung,r Difflcul t swallowrng Difficutt chewing Excessive thirst Froqy.nt nausea vomiting CENITO-URINARY bdomin.l pain Pain/burning on urinatipn' Di.rr ea Difficulty starting urin. Constipation Jnability to control u~ine Sl5ck/bloody stool Frequent urination ~emorrhoids Oiscolored urine <:LndiQes~;oor, Sladder trouble G.. of bloating Kidney infection or .too.. Liver trouble Sex""l dy>function liell blodder probl_ Prostate trouble(Males) Colon trouble EENT 1f~robl- E r robl_> Hanl/sinus " Throat trouble loss of taste loss of' smell fEMALE Menstrual pain II irreSlut.rity vaginal pain II infection If discharg. Il bleeding Breast pain/lumps Hot f I ashes Are you pregnant1 (] Y.. (] No Date of last period1 _1_1- NERV()JS SYSTEM ~ Paralysis ~ f.int\oll (fonfuSlon ) cforgetfu~nes~ DepresslOA Convulsions Musel I Irk.s Wer~ousnes~/ ur.alslia nsoani. Malaria Tubtrculosi$ <Ia""er ~") Epi iepay Circle anY of the Chicken pox~ D hbete. J.nemilli Pnel.a1lOi. foUowinQ diseases A.t,oholism Arthritrs--. ~Iase ') Meas~.s YOU have had. Typhoid fever, Mental dilorder Rheunatic fever Diptherfa Goiter LI..IIbaSlO Eczema Hl..IrpS; Polio J nfl uenza Small pox Pleurisy Signature: CQfJIJlenU : ~~.. f-Il~ Dote ('J..-- / (1--1 01..-- 80~C PAIN SCALE: DATE: ON A SCAL.E OF 1 - 10 PL.ACE AN X IN YOUR CURRENT PAIN L.EVEL " .. NORMAL. LOW PAIN MODERATE PAIN (10 (11 ()' (12 ()S 'INTENSE PAIN ( ) 7 ~ ( ) 3 I I 9 ( ) 6 RANSFORD PAIN DRAWINC: EMERCENCY I I 10 (dull ill;he ..u)(pin$/needles ooo)(burning xxx)(numbness. :::) {st;lbbing 1111 ", \- X-.\ ,.~' " PATIENT'S SICNATURE, q~ E- (I~ .' GENERAL I. -N DISABlllTYINDEX QUES.DNNAIRE Tho ntinB S<:al... bolow arc doaijlled to me""lIle tho c1c1lRO 10 whkh ...nral..pc~ of your life are presently disrupte<l by Chronic poin. In other wOI<ls, We would like 10 know bow muoll your paiIl It p,l;CVCIlIin& YOIl fro", doing wbat you would nonnally do, or from doing H u weU .. you normally would. Rcspol,ld 10 each CAtoBOl}' by iIldicaWli tho ""crl1/1lmpact of pain in your Iif., nOI JUSt wh.o <he p.in i$ "' lt$ worst. . For ..011 of the s~ ~~t~~1~ of daily IIvlns listed. PLEASE CIRCLE THE NUMBER WHICH BEST DESCRIBES YOUR TYPICAL LEVEL OF A . A score of 0 "'.ans no disability al all. and a score at 10 .isci!i.s that all of the activitie. in whleh you wollld IlOrmally bo il1volvcd hovo bccJllotally disxuptcd "" pteVel1lOd by YOut pain. Re...ised M:uch 15, 1993 1, F4RlUyIHom. RfSpOMlbllilios. This c:ateSory refeNIO ",,"vitie. rclalOd 10tll4 home or family. It indud.. chore, and duties perlonned llJ1)und the house (e.II_, yard work) and e"&IIdo or favoN for otherfamily memben (0,8" driving lhe children 10 5011001). o 1 Complelely abie to function 2 3 4 s 6 (I) 8 9 10 Totally unable 10 funclion ~. RfCN/l.tiQn. Thill caleiory ilIc1ud.. bobbies, spam, snd other similar leitllR lime activitie., o 1 . ComplelOly .hle to function z 3 4 (1) 6 7 8 9 10 Totally unable to function 3. SoeuuAd/viq. Thi. category ref... to activities which Involve panicipatlon wilh friend. and .cquain..n.., other Ih." tamUy mc-mbert, 11 includea parties. theater. concerts, dinina Ol,,l.tl and other lOCial functions. o 1 Completely able to function 2 f3j - 4 s 6 7 8 9 10 Totally unable 10 funclion 4. Occupation. This Cilellory RfenlO activities lbat are . part of or directiy related to oo.'s job. This includes nonpaying jobs u well, .uoll U Ihal of. bomemaker OJ volunt..r work... o 1 Completely able to function 2: ,r1J 4 5 6 7 8 9 10 TOlilly un.bi. 10 funclion 5. Self Carl, This ~lesOry includes activities which involve pcoooal mainlell.allce and independent daily livin~ (og, twng a N\ower, drlvinio selima 4",..0<1, .te.). o 1 Completely able to function 2 3 Q s (; 7 8 9 10 T01.lJy unable to function 6. LI/...suppot1,4tIMI1. This Clltcllory ref 011 10 buic life.supportina bohaviol1 such as earing, sleeping, and breathini, o 1 (j) Complelely , , able to function , . ..<, . -40~ _ roTAlSCORE:4/~D" SlON^TURB: qo~ r- atf~ 'or re-ordarln,g information. conlact: H::nVATOR METHODS,INC., P.O. ~ 80317, Phoenix, AZ 85Q60.Q317 Telepbone: (602) 224-<J220; Facsimile: (602) 224-0230 3 4 s 6 7 8 10 Totally unable to funclion 9 DATE: tv'" {).-Cl V f . "/ PATIENT NAME: i~4,;y h ~ HolE T TODAY'S DATE IS: /..:l- /~ - o'-L- /f/~ , I UNDERSTAND THAT IF I AM PREGNANT AND HAVE X-RAYS TA~EXl'OSE MY LOWER TORSO TO RADIATION,IT IS POSSIBLE TO INJURE THE FETUS. I HAVE BEEN ADVISED THAT THE 10 DAYS FOLLOWING ONSET OF A MENSTUAAL PERIOD ~ENERALL Y CONSEDERED TO BE SAFE FOR X-RAY EXAMS. .~ WITH THOSE'FACTORS IN MIND. I AM ADVISING MY DOCTOR THAT: I AM PREGNANT YES NO I COULD BE PREGNANT YES NO '. I AM LA TE WITH MY 'MENSTRUAL PERIOD \ , . I AM TAKING ORAL (JO~RACEPTIVES \ I RAVE AN IUD \ \\ \ lRAVERADA TUBALLIGATI0N I RAVE HAD A HYSTERECTOMY IRA VE IRREGULAR MENSTRUAL PERIODS MY LAST MENSTRUAL PERIOD BEGAN ON: COMMENTS: DON'T KNOW DON'T KNOW' YES NO -YES NO YES NO YES NO YES NO YES NO WlTH FULL UNDERSTANDING OF THE ABOVE, AND BELIEVING THAT I AM NOT CURRENTLY AT RISK, I WISH TO HAVEAN X- RAYEXAMINATION PERFORMED NOW. SIGNATV, "...~~'~~ - (l~ WITNESS: '7'f~, < (. ') '"'" <: CONSENT TO TREAT & RELEASE OF INFORMATION I herehy authorize Dr. Frederick, and whomever he may designate as assistants to administer chiropractic care including examination, consultation, x-rays and or treatment necessary to: Name of patient:~ L f II" f - f!<. C f} S r 1 2- J-- OJ CJ '2-- Day Year Dated this: ou. Month I hereby authorize ChiroPlus of Locust Lane to obtain and or release any medical information that may be pertinent to my treatment should that be necessary, f~ tJ?~ r Patient Signature: Witness Signature: " .,' -.j' " ',T NAME RALPH r 1ST. .3 Me AY YR TREATMENT VAS APPOINTMENTS & MISC. ~ .0, . . ' , ... .{~ f, If (0' ~J 1'T /ll1t11f-. ~ /O.,j NkJ a(ff cJJtlV~ {eA, (~,. 1 1~1. ..r.') . L (}'V)J Ie, , J. 7/ I~~ ~11 ')( 162 JiP)); rr:~"::Jl <'1.7\ /FOr, Itl (J 1'~ ra #Jt . r, "/l1\<./lIIV --'. 1.....-,:~lJ,~~tt\. ~ 'I1l~' / ~ IJ.J 1t1'171: 161/9 YJ1IlVJ/fJ Iv.;) rl2>/AJ C" TU,. (Q/J (J.. III 0 J. /h.;;? II.//I( Lr11A'l1'p <J~o CJU~ ^/J ~ J.A _ I.",\," I~(I~' \j'i:.- c / _ "<1j m J I' Jc, 1l5L __ W'f!.ltf!f!.!~ " ~~...) (J b?f; n dl") ~~ :}..4... ))' J ~ ~ )~p, )p(21 'J);;;S d. ,\ (\ ( ." (\ Irf)~ J ,<r~..:~ _ !- IQ. /i i.6 Ifb J I... ,>I /t~~Y'Vl....' UP tD ~ r.-,.l4 l-"/~';-- 6~ ~~[ ?~ /1 }? flL Jh.v1) ;'~~ '0<.. - I I' II C .~ 1\)/4 .: lr~~ (/t: ~( ([.;\ t!1.'fi,P1;o iZw,....!5~ ..--- (u-J..,o~ ~ . OJ. I G~ If (h. v 0 ~ 9;) aJ,,", flrt lVi\ (hWf _ yt fJJ< 02. l(ellF"I-~I/fj:~ tthfo 1,() 1A Jf1t- G. -t ~",l;)bt.m ?9 )/1 hi Z7J z'< L_ 'If? ~'(/ f(r)...f.1A/1 (,Ith duo - .n ... - L ~ .....~ ^ "'" , ll.: -r -..-+- : q,f'- .~ ..\2- b (J J.- I f'~ ,:/ ,(& ('f'ArJlP q.l) ~ jJA (' Iii fIJ./? (~ ?~_ /2, c I tV I (J If. II f 10 JIM,.I 7 JlJ ./-1,-0 - rCt:5{J.,. (' IJ If.-L, ,u 4 .2 ~ () Y HmP iil/$jI3, 'i' . " 7.0 Lf2. (6) ~<.. ~rrVlti-. ". 'fd_ . (.{:... p,,(~"),1 th)j.,~.(j (1::qq . Ill;;/) (~c4 .fV fiG) '-I .~ I"~ b t.{ {-Imp if, 5//31 fY1 H 'n -\ (J n((a(c;) ~(.o ~( 'fiit::'" 1~\~ fI /10 ()L{ I1mp/i/L;)2jX, ITIro,';'~) ~1/) Ct2. ~ <,f)?'f r.., ~ , , 'Vr~ II ~. ry ft . ~~' ') II )'c; ~( ~ tll '2- ~~~I) L. W , / // I' ! terN ~ ~'-""'1 - Ye.rN -, .2002 Charge per vlsft ustName: Dr.,FRRnF.R TC'K ,First: Initial HomeN: 545-4915 '"1J4.~ (.O('l... t )~'i I. WorkN: Diagnosis: 1. 2. INITIAL NOTES: 3. "111,1- 4. '1:;13.'1 (t. \ (SJe u CHG. MO. DAY YR. TREATMENT -. I- COMMENTS AD] TRMT. 1/ t., ()) CI.. ( (_ I..! 't1 !'GfJ') (Ud .f Ot'Jr. 1ft: li';""~ ,..... , . r.1-HlO?r..1 ChiroPlus of Locust Lane 4607 Locust Ln Harrisburg, P A 17109-4449 Phone: (717) 545-60<,!3 May 2, 2004 MEDICARE OF PA CLAIMS PROCESSING P,O, BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST Accident Date: Claim Number: Policy: Dear, DOS 4/30/04 S: STAlED illS NECK AND BACK ARE DOING BETfER. VAS PAIN GRADE 2.0, 0: LFT ROTATION TO CERVICAL REGION 40 DEGREES GRADE 2 PAIN STIFFNESS POSTURAL ANALYSIS UNREMARKABLE Bll.A1ERAL CERVICAL RT LUMBAR MYOSPASM CERVICAL LATERAL DROP PIECE Bll.AlERALL Y C4C5 ACUTE SUBLUXATION L4L5 ACUTE SUBLUXATION SI JOINT RT SIDE ACUTE SUBLUXATION AND SACRAL REGION DECREASED MYOSP ASM AND TRIGGER POINTS TO CERVICAL LUMBAR REGIONS LFf SHOULDER EXTREMITY MANIP A: IMPROVING P: IF/HMP TO CERVICAL SHOULDER REGIONI23 AND 23 MA'S/MANIP/WILL SEE PRN Sincerely, RANDY FREDERICK, D,C, " ChiroPlus of Locust Lane 4607 Locust Ln Harrisburg, PA 17109-4449 Phone: (717) 545-{)()63 May 2, 2004 MEDICAREOFPA CLAIMS PROCESSING P,O. BOX 898200 CAMP lllLL P A 17089-2000 Regarding: RALPH PROBST Accident Date: Claim Number: Policy: Dear, DOS 4/26/04 S: STAlED HE FEELS BEITER HE NOTICES AN IMPROVEMENT IN IDS NECK, BACK, AND SHOULDER AREAS, VAS PAIN GRADE 4,0, 0: RT ROTATION TO CERVICAL REGION 45 DEGREES GRADE 2 PAIN STIFFNESS POSTURAL ANALYSIS UNREMARKABLE DECREASED MYOSPASM TO CERVICAL LUMBAR REGIONS ACUTE SUBLUXATION C5C6 CERVICAL LATERAL DROP PIECE TO TIIAT REGION LUMBAR FIXATION ACUTE SUBLUXATION UL5 SI SACRAL REGION RT SIDE POSTURE MANIP LFr SHOULDER EXTREMITY MANIP TRIGGER POINTS CERVICAL LUMBAR REGIONS SLIGHT DECREASE A: IMPROVING P: IF/HMP TO SHOULDER AND LUMBAR REGIONI31 AND 31 MA'S/MANIPIWlLL SEE PRN Sincerely, RANDY FREDERICK, D,C, tt//tf! 0 V PURPOSE: To determine if any health problems you may be having are due to stress. Name 1. 4Uf.I fr\(J135T Age 7" Address City <- Occupation Spouse Occupation ~ Phone (Home) (Work) State/Prov. _ ZiplPostal # Hours per week currently working # Hours per week currently working Jl T Check off any of the following symptoms you have experienced in the past 6 months: ~ HeadacheslMigraines ~ Fatigue 8. Paintrension/Numbness ~Neck 1& Legs .~ Shoulders l8i Anus t& Low Back ~ands 1<1 Insomnia/Sleep Problems ~ Digestive Trouble ~ Constipation ~ Diarrhea J'<f Gas l( Bloating %J. Irritability &1 Sinus Problems/Allergies ~ Asthma o Menstrual Problems ~ Bladder Trouble ~)( & Ringing in Ears gr Nervousness IX! Dizziness i}lf Weight Trouble o Other LliL- or:: '7(1{'''-'1 Which of the above bothers you the most? a .... (=--.1 How long have you been bothered by the condition? '7 <0 y;,;,,~ AS Describe how it feels or affects you when it is at its worst. L {I<f - H r; L L- .1[] Does this cause you to be: 00 Does this affect your work: ~ ~oody p;:( Decision Making ~.lrritable ~ Poor Attitude ~ Interrupt Sleep ~ Decreased Productivity ~Restricted on Daily Activities ,gJ Exhausted at End of Day R Unable to Work Long Hours Does this affect your life: jQ Lose Patience with Spouse or Children . tl-Restricted Household Duties o Hinders Ability to Exercise or Participate in Sports ,gL, Interferes with Ability to Participate in Hobbies or Other Desired Activities FOR OFFICE USE ONLY There are several alternatives available to you. Please check the item most appropriate for you. D I would like to come to the Doctor's office for a complete evaluation. This will allow me to find out if! can be helped by Chiropractic without any financial barriers. D I would like the Doctor to call me to discuss my health problems before making an appointment. If possible. I would like to see the doctor on: D Monday D Tuesday D Wednesday D Thursday D Friday D Saturday The following times mayor may not be available, Please select two options. Our office will call to confirm your appointment. o 9 a.m. D 10 a.m. D 11 a,m. D 12 noon D 2 pm. D 3 p.m. D 4 p,m. D 5 p.m. D 6 p,m. @ EXPAND PRODUCTS ITEM,. 316 ChiroPlus of Locust Lane 4607 Locust Ln Harrisburg, PA 17109-4449 Phone: (717) 545-&>63 April 25, 2004 MEDICARE OF PA CLAIMS PROCESSING P,O, BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST Accident Date: Claim Nnmber: Policy: Dear, DOS 4/23/04 S: STAlED HE HAS A FLARE UP TO IDS RT SHOULDER AND BACK AREAS, VAS PAIN GRADE 7,0, 0: LIT ROTATION TO CERVICAL REGION 45 DEGREES GRADE 2 PAIN STIFFNESS RT LOW HAND LIT LAlERAL ILIUM MANIP BILAlERAL CERVICAL MYOSPASM CERVICAL FIXATION C5C6 CERVICAL LAlERAL DROP PIECE ACUTE SUBLUXATION C5C61HORACIC FIXATION L4L5 RT AND LIT SI JOINT FIXATION MANIP MANIP TO SACRAL REGION TRIGGER POINTS CERVICAL LUMBAR REGIONS A: FLARE UP, PHASE I FOR MEDICARE, PATIENT FIlLED OUT A QV AS PAIN CHART, PRESENT 62, AVERAGE 64, BEST 48, WORST 50, PLEASE N01E TIIAT TIllS IS NOT RELAlED TO PATIENTS AUTOMOBILE ACCIDENT; TIllS IS A DIFFERENT INJURY AND DIFFERENT TYPE OF CONDmON, P: IF/HMP TO CERVICAL LUMBAR REGIONS/I8 AND 13 MA'SIMANlPIWILL SEE ON MONDAY Sincerely, RANDY FREDERICK, D,C, Patient Name(Print) - ({1fL/H (:. _ (f!,o/f5T Oate_Lf- .z-" - eLf Patient 10 # Please draw the location of your pain or discomfort on the images below. Use the symbols shown to represent the type(s) of pain: Cbiro Plus of Locust Lane Dr. Ra'ndyF~ck <M07 Locust Lane tIluri.....p,J\ 17109 111-545-6063 CL L.- ~ ~ u....vil...J . PJ r r ') ( --<. f) " " < ? ' ? , - . ( , , , t\ ~ ( ~ \) ~ \1 D=Oull, B = Burning N = Nump I J \.. ( \ I S = Stabbing/Cutting T = Tingling (Pins & Needles) C = Cramping ^ ) On the scales below, please draw a vertical line representing your pain or discomfort: Rate the pain you have right now: Rate your pain at its best in t!1e past week: No Pain Unbearable Pain No Pain 0J-1 Unbearable Pail 1/ , ~ Rate your average pain in the past week: Rate your worst pain in the past week: No Pain Unbearable Pain No Pain Unbearable Pail C \1 II t 5'0 PULLEY STRENGTH WEAKEST TO STRONGEST: opurple,pink,lavendar,orange,(~1 REHAB WORKSHEET 'yellow and green.(S~Dongest) ACCOUNT NUMBER PATIENT NAME ICALPlJ- (J rt/0;::'T AREA OF COMPLAINT Lr3 J- S hY)l jJ./ DATE STARTED J - .3 ) - 03 DATE i-f, _ C If- ((- c , '-/~ _('po i ~-).,)- (."'5 EX# WEIGHT rG (- "- {~ ~ (r(, , SET/REPS ( -I'C; (- Ie /r Ie 1- Iv 1- Ie f- It: /- IC :~fI:; ;'"i1j 1/1/L 5 rol~ 2 .~6b~1I ~t(O - 3. 'NJS Pi LL, '!21; , 4.~Oh/ !xu'lZ.. EVw'h K/)' 5.~Jltll/ A~ /:>j)U 6. hl>)~' f1~( COMMENTS '7 ?j 7J 7J 1fT ~?/ - 7:) REHAB SIGN IN SHEET "'t.' PATlENTNAME:MLffl - E - PRe !35T --.".... lATE: TIME IN: TIME OUT: PATIENT INITIALS tf-II-(i) ~-SJ ?- 2-S-JI1 C?~ /Hh-C'7) ?;- fir 3'-}?~ crt#' lf~L 3 -() . ~A-d~/i/Vl 9-(J~ V ~ , , . REHAB SIGN IN SHEET PATIENTNAME:-,-R-J1L Pl..{ pn..uaSr ATE: TIME IN: TIME OUT: <[, PATIENT INITIALS '~ ~~ R~ @ rg.GJ a< ct/} p) rf~ I -''J( -0') ~-3f 2....?1 01 So' J-:) b 2 .f -q'3 ' 6". 1..'1- .a a\ ... '9 b' ,37 .Ih ). 'fo-c} ~,i7 AM 1,' 12.0) f.2.'L' AfII\ 0. ,14-03 S J~J A'1 )... .~ .c3 f3 ,-/0 If ~ 2-1S,c) S.L) A 1'1 'j ), 0) &-.4) A-'" 5-5-(/) ~'" c A' '}-7-v) ~_'i-) AM . .to.{/) B-'1? Atl1 - f)..,- d) S' '70 IY Il1 ? ...{ y.. () g- .'fj ),. f41 3t?v) ?,.4S- ('ff11 .3 U -ci) g....cS(t ~ j.Ji{,O) t~ If> AM '}'1- 0 ' is -) tJ ~. /l1 )-31-C} '('.:L,) 1\ f!1 . L) -2j-03fY4.JA~ 4 -1 -05 6'- /J-;f/7 . M 9.o/AJ1 --- .,0 j ,.t 841 Af11 . 9sv N1 - (YO 1\ fI) _/1. Af1 8.$ /11\ - 15';f; ,- trf1 q.S'5 r-(~ M 1-1) /j11 <? -( 5't'f P'j S- "?5 ftf1 &- -/JII fI1. . cC- AM $- - J5Afr\ C(- IJAI? f? '- 'fJA~ tZ C(~ &j CiI ( V/ V\01 Cc./ fJ~ f1Cf/J ifv?' w q f(eP '1Q~ " ChiroPlus of Locust Lane 4607 Locust Ln Harrisburg, PA 17109-4449 Phone: (717) 545-6063 July 7, 2003 MEDICAREOFPA CLAIMS PROCESSING P,O, BOX 898200 CAMP Hll.L P A 17089-2000 Regarding: RALPH PROBST AccidentDate: 11-21-2002 Claim Number: Policy: Dear, DOS 7/2/03 S: STATED VAS PAIN GRADE 1.5. 0: POSTURAL ANALYSIS UNREMARKABLE RT AND LIT CERVICAL MYOSPASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL DROP PIECE LUMBAR FIXATION L4L5 RT SIDE POSTURE MANIP RT SI JOINT FIXATION A: IMPROVING P: HVG/HMP TO LFT SHOULDER AND lHORACIC REGION/lNTERSEGMENf AL TRACTION TO lHORACIC LUMBAR REGION/MANIP/CONTINUOUS ULTRA SOUND TO CERVICAL lHORACIC REGION/WILL SEE ON FRIDAY AND DO REEVALUATION Sincerely, RANDY FREDERICK, D,C, ChiroPlus of Locust Lane 4607 Locust Ln Harrisburg,PA 17109-4449 Phone: (717) 545-6063 July 1, 2003 MEDICARE OF P A CLAIMS PROCESSING P,O, BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: Policy: Dear, DOS 6/30/03 S: STAlED CONTINUES TO NOTICE AN IMPROVEMENT WITII TREA1MENT, PATIENT IS OOING MORE ACTIVITIES OF DAILY LIVING AND HE DOES NOTICE A LITTLE BIT OF A FLARE UP, VAS PAIN GRADE 0: RT CERVICAL MYOSPASM CERVICAL FIXATION CSC6 RT LAlERAL CERVICAL MANIP LUMBAR FIXATION L4L5 RT SIDE POSTURE CERVICAL LATERAL DROP PIECE SI JOINT FIXATION MANIP A: IMPROVING P: IF/HMP TO CERVICAL THORACIC REGIONSIlNTERSEGMENTAL TRACTION TO THORACIC LUMBAR REGION/CONTINUOUS ULTRA SOUND TO CERVICAL THORACIC REGION/MANIPIWILL SEE ON WEDNESDAY Sincerely, RANDY FREDERICK, D,C ChiroPlus of Locust Lane 4607 Locust Ln Harrisburg, PA 17109-4449 Phone: (717) 545-6063 June 29, 2003 MEDICAREOFPA CLAIMS PROCESSING P,O. BOX 898200 CAMP HILL PA 17089-2000 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: Policy: Dear, DOS 6/25/03 S: STA1ED VAS PAIN GRADE 4,0, 0: POSTURAL ANALYSIS UNREMARKABLE A: IMPROVING P: IF/HMP TO THORACIC REGIONIMANIP/CONTINUODS DL1RA SOUND TO THORACIC REGIONIINTERSEGMENT AL TRACllON TO THORACIC REGION/WILL SEE 2X FOR I WEEKlWILL SEE ON MONDAY AND FRIDAY Sincerely, RANDY FREDERICK, D,C, ChiroPlus of Locust Lane 4607 Locust Ln Harrisburg, PA 17109-4449 Phone: (717) 545-6063 June 29, 2003 MEDICARE OF PA CLAIMS PROCESSING P,O, BOX 898200 CAMP HILL PA 17089-2000 Regarding: RALPH PROBST AccidentDate: 11-21-2002 Claim Number: Policy: Dear, DOS 6/23/03 S: STATED VAS PAIN GRADE 2,0 TO MID BACK AREA. TODAY HE NOTICES AN IMPROVEMENT, HE SAID TIIAT WHEN HE SLEEPS TIllS TENDS TO AGGRAVATE HIS SYMPTOMS. HE HAS DIFFICULTY GETI1NG TO SLEEP, FINDING A POsmON TIIAT IS COMFORTABLE, SINCE HE HAS UNDERGONE TREATMENT, HE IS ABLE TO SLEEP EASIER. 0: POSTURAL ANALYSIS UNREMARKABLE LFr CERVICAL BlLA TERAL THORACIC LFf LUMBAR MYOSPASM DECREASED CERVICAL MYOSPASM NOTED DECREASED TRIGGER POINTS TO TRAPEZIUS REGION LUMBAR MYOSP ASM CERVICAL FIXATION C2C4 LATERAL CERVICAL DROP PIECE UL5 LFf SIDE POSTIJRE LFf SI JOINT FIXATION A: IMPROVING GRADUALLY P: HVG/HMP TO CERVICAL THORACIC REGlON/MANIP/CONTINUOUS ULTRA SOUND TO THORACIC REGlONIINTERSEGMENT AL TRACTION TO THORACIC REGlON/WlLL SEE 2X FOR 1 WEEK/WILL SEE ON FRIDA Y/BLOOD PRESSURE 130/84 PRIOR TO MANIP; 124/82 AFTER MANIP Sincerely, RANDY FREDERICK, D, C. ChiroPlus of Locust Lane 4607 Locust Ln Harrisburg, PA 17109-4449 Phone: (717) 545-6063 June 17, 2003 MEDICARE OF PA CLAIMS PROCESSING P.O, BOX 898200 CAMP HILL PA 17089-2000 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Nnmber: Policy: Dear, DOS 6/16/03 S: STATED HE HAD A BAD WEEKEND, HE HAD A LOT OF PAIN IN HIS MID BACK AREA AND DOWN INTOTIffi LFT ARM. VAS PAIN GRADE 6,0. 0: POSTIJRAL ANALYSIS UNREMARKABLE LIT CERVICAL LIT LUMBAR BILATERAL THORACIC MYOSPASM CERVICAL LATERAL DROP PIECE C5C6 LFT LATERAL DROP PIECE THORACIC FIXATION T5T6 PRONE MANIP LUMBAR FIXATION L4L5 LIT SIDE POSTURE MANIP A: IMPROVING SLOWLY, BUT FLARE UP OVER WEEKEND P: IF/HMP TO THORACIC REGlON/INTERSEGMENTAL TRACTION TO THORACIC LUMBAR REGION/CONTINUOUS ULTRA SOUND TO THORACIC REGlON/MANJPIWILL SEE 2X WEEK FOR 2 WEEKSIWILL SEE ON FRIDAY Sincerely, RANDY FREDERICK, D,C, . ChiroPlus of Locust Lane 4607 Locust Ln Harrisburg, PA 17109-4449 Phone: (717) 545-{i063" June 22, 2003 MEDICAREOFPA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: Policy: Dear, DOS 6/20/03 S: STATED VAS PAIN GRADE 4.0. 0: POSTURAL ANALYSIS UNREMARKABLE LFf CERVICAL LFf LUMBAR MYOSPASM BILATERAL rnORACIC MYOSPASM CERVICAL FIXATION CERVICAL LATERAL DROP PIECE C5C6 LFf SIDE rnORACIC FIXATION T5T6 PRONE MANIP LUMBAR FIXATION UL5 LFf SIDE POSTIJRE MANIP A: IMPROVING P: IFIHMP TO rnORACIC REGIONIMANIPICONTINlJOUS ULTRA SOUND TO rnORACIC REGION/INTERSEGMENT AL TRACTION TO rnORACIC REGIONIWILL SEE 2X FOR I WEEKIWILL SEE ON MONDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. ChiroPlus of Locust Lane 4607 Locust Ln Harrisburg, PA 17109-4449 Phone: (717) 545-6063 June 15, 2003 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST AccidentDate: 11-21-2002 Claim Number: Policy: Dear, DOS 6/13/03 S: STATED STILL HAS A LOT OF PAIN IN IDS MID BACK AND A LITTI..E BIT IN IDS NECK AREA. LFf KNEE IS ACTING UP A LITTI..E BIT. 0: POSTURAL ANALYSIS UNREMARKABLE LFf KNEE EXTREMITY FIXATION MANIP LFf CERVICAL LFf LUMBAR BILATERAL rnORACIC MYOSPASM DECREASED RT CERVICAL MYOSPASM CERVICAL FIXATION C5C6 LATERAL CERVICAL DROP PIECE TO LFf SIDE rnORACIC FIXATION T5T6 PRONE MANIP LUMBAR FIXATION UL5 LFf SIDE POSTIJRE MANIP A: IMPROVING SLOWLY P: IFIHMP TO rnORACIC REGION/CONTINlJOUS ULTRA SOUND TO rnORACIC REGION/INTERSEGMENT AL TRACTION TO rnORACIC LUMBAR REGIONIMANIPIWILL SEE 2X WEEK FOR 2 WEEKSIWILL SEE ON MONDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. ChiroPlus of Locust Lane 4607 Locust Ln Harrisburg, PA 17109-4449 Phone: (717) 545-{i063 June 10, 2003 MEDICAREOFPA CLAIMS PROCESSING P.O. BOX 898200 CAMPHILLPA 17089-2000 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: Policy: Dear, DOS 619103 S: ST ATED VAS PAIN GRADE 6.0. HAS PAIN ACROSS THE SHOULDER AREA AND DOWN INTO THE NECK AND ARM. 0: POSTURAL ANALYSIS UNREMARKABLE LFf CERVICAL BILATERAL rnORACIC LFf LUMBAR MYOSPASM CERVICAL FIXATION C5C6 LFf LATERAL CERVICAL MANIP rnORACIC FIXATION T5T6 PRONE MANIP LUMBAR FIXATION UL5 LFf SIDE POSTURE LFf SI JOINT FIXATION MANIP TO SACRAL REGION CERVICAL LATERAL DROP PIECE C5C6 A: NO CHANGE P: IFIHMP TO CERVICAL rnORACIC REGION/INTERSEGMENT AL TRACTION TO THORACIC LUMBAR REGION/CONTINlJOUS ULTRA SOUND TO THORACIC LUMBAR REGIONIMANIPIWILL SEE 2X WEEK FOR 3 WEEKSIWILL SEE ON FRIDAY Sincerely, RANDY FREDERICK, D.C. , ChiroPlus of Locust Lane 4607 Locust Ln Harrisburg, PA 17109-4449 Phone: (717) 545-{i063 June 8, 2003 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST AccidentDate: 11-21-2002 Claim Number: Policy: Dear , DOS 6/6/03 S: STATED VAS PAIN GRADE 6.0. STILL HAVING PAIN IN IDS MID BACK, NECK AND LFT ARM AREA. 0: BILATERAL CERVICAL THORACIC RT LUMBAR MYOSPASM CERVICAL FIXATION C2C4 LATERAL CERVICAL DROP PIECE C5C6 BILATERALLY THORACIC FIXATION T5T6 PRONE MANIP LlL2 RT SIDE POSTIJRE MANIP A: NO CHANGE P: IFIHMP TO CERVICAL THORACIC REGIONS/20 AND 17 MA'SIMANIP/INTERSEGMENTAL TRACTION TO rnORACIC LUMBAR REGION/CONTINlJOUS ULTRA SOUND TO THORACIC REGIONIWILL SEE 2X WEEK FOR 3 WEEKSIWILL SEE ON MONDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. ChiroPlus of Locust Lane 4607 Locust Ln Harrisburg, PA 17109-4449 Phone: (717) 545-{i063 June 8, 2003 MEDICAREOFPA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL PA 17089-2000 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: Policy: Dear , DOS 6/4/03 S: STATED WAS UNABLE TO CONTINUE WITH TREATMENT DUE TO MAJOR HEART SURGERY; HE HAD BYPASS SURGERY. MEDICAL PHYSICIAN GAVE mM THE OKAY TO COME IN FOR CARE FOR THE AUTOMOBILE ACCIDENT RELATED INJURY. HE IS HAVING PROBLEMS WITH HIS NECK AND BACK AND IN THE SHOULDER BLADE ON THE LIT SIDE. V AS PAIN GRADE 6.0. DUE TO HEART CONDmON WILL NOT DO REHAB. 0: POSTURAL ANALYSIS RT LOW HAND LFf LATERAL ILIUM MANIP RT CERVICAL RT LUMBAR MYOSPASM BILATERAL THORACIC MYOSPASM CERVICAL FIXATION C5C6 RT LA 'fERAL CERVICAL MANIP LUMBAR FIXATION UL5 RT SIDE POSTIJRE RT SI JOINT FIXATION rnORACIC FIXATION T5T6 PRONE MANIP A: FLARE UP. SET PATIENT UP ON A NEW TREATMENT PLAN, 2X WEEK FOR 4 WEEKS. P: IFIHMP TO THORACIC REGIONIl4 AND 20 MA'S/CONTINlJOUS ULTRASOUND TO THORACIC REGIONIINTERSEGMENT AL TRACTION TO rnORACIC LUMBAR REGIONIMANIPIWILL SEE 2X WEEK FOR 4 WEEKSIWILL SEE ON FRIDAY Sincerely, RANDY FREDERICK, D.C. ChiroPlus of Locust Lane 4607 Locust Ln Harrisburg, PA 17109-4449 Phone: (717) 545-{i063 April. 19, 2003 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: Policy: Dear, DOS 4/16/03 S: STATED HIS KNEE WAS ACTING UP A LITTI..E BIT. HIS NECK BACK ARE VAS PAIN GRADE 2.5. 0: LFf KNEE EXTREMITY FIXATION MANIP RT LUMBAR LFT CERVICAL MYOSPASM CERVICAL FIXATION C5C6 LFT LATERAL CERVICAL DROP PIECE LUMBAR FIXATION L4L5 RT SIDE POSTIJRE MANIP A: IMPROVING GRADUALLY P: IFIHMP TO SHOULDER BACK AND KNEE AREN34 AND 34 MA'SIINTERSEGMENTAL TRACTION TO rnORACIC LUMBAR REGIONIMANIP Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG P A 17109-4449 Phone: (717) 545-6063 April 13, 2003 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: Policy: Dear, DOS 4/11/03 S: STATED OVERALL NECK AND BACK ARE IMPROVING WITH TREA TMENT. VAS PAIN GRADE 2.0. 0: LFT KNEE FIXATION EXTREMITY MANIP MILD RT LOW HAND LFT LATERAL ILIUM MANIP RT CERVICAL RT LUMBAR MYOSPASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL MANIP LUMBAR FIXATION UL5 RT SIDE POSTIJRE RT SI JOINT FIXATION MANIP TO SACRAL REGION A: IMPROVING SLOWLY P: IFIHMP TO CERVICAL SHOULDER LUMBAR REGIONS/21 AND 23 MA'S/INTERSEGMENTAL TRACTION TO THORACIC LUMBAR REGIONIMANIP Sincerely, RANDY FREDERICK, D.C. ChiroPlus of Locust Lane 4607 Locust Ln Harrisburg, PA 17109-4449 Phone: (717) 545-{i063 Apri127,2oo3 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST AccidentDate: 11-21-2002 Claim Number: Policy: Dear, DOS 4123/03 S: STATED HE IS GETTING A LOT OF PAIN IN THE LFT SIDE OF HIS LOWER BACK ESPECIALLY WITH THE WEATHER CHANGE. THE WEATHER HAS AGGRAVATED HIS SYMPTOMS. VAS PAIN GRADE 4.0. 0: POSTURAL ANALYSIS UNREMARKABLE LIT CERVICAL LFT LUMBAR MYOSPASM CERVICAL FIXATION C5C6 LFT LATERAL CERVICAL MANIP LUMBAR FIXATION UL5 LIT SIDE POSTIJRE LIT SI JOINT FIXATION A: FLARE UP P: IFIHMP TO SHOULDER AND LUMBAR REGIONSIINTERSEGMENT AL TRACTION TO rnORACIC LUMBAR REGIONIREHABIMANIPIWILL SEE IX WEEK FOR A FEW WEEKSIWILL SEE ON WEDNESDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURGPA 17109-4449 Phone: (717) 545-6063 April 8, 2003 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: Policy: Dear, DOS 417103 S: STATED NOTICES SOME PAIN IN THE LFT BUTTOCK AND INTO THE BACK OF HIS LEG. VAS PAIN GRADE 3.0. A LITTLE FLARE UP OF THE LFT KNEE TODAY. 0: LFT KNEE FIXATION EXTREMITY MANIP LFT CERVICAL LFT LUMBAR MYOSP ASM CERVICAL FIXATION C5C6 LFT LATERAL CERVICAL DROP PIECE LUMBAR FIXATION UL5 LFT SIDE POSTIJRE LFT SI JOINT FIXATION MANIP TO SACRAL REGION A: FLARE UP P: REHAB/IFIHMP TO LUMBAR KNEE SHOULDER REGIONS/INTERSEGMENTAL TRACTION TO rnORACIC LUMBAR REGIONIMANIPIWILL SEE 2X WEEK FOR 1 WEEKlWILL SEE ON FRIDAY Sincerely, RANDY FREDERICK, D.C. ~., ~$ 0t/x:orv ATTORNEY AT LAW 126 STATE SmEET . HARRISBURG, PA 17101 PHONE: (717) 233-8757 . FAX: (717) 233-5860 EMAIL: dixonlaW@paonline.com wvvw.dixonlaw.baweb.com March 11, 2003 CHIROPLUS OF LOCUST LANE ATTENTION: DR. RANDY FREDERICK 4607 LOCUST LANE HARRISBURG, P A 17109 Dear Dr. Frederick: I spoke with Ralph Probst today and he told me that you needed an additional supply of my business cards. I am enclosing them herewith. Thank you for your consideration. V~)P!VilY yo '. I , ~ \ Joseph J. Dixon JJD/jw Enclosure CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 April I, 2003 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: Policy: Dear, DOS 3131/03 S: STATED VAS PAIN GRADE TO NECK AND BACK AREAS IS 1.5. PATIENT IS CONTINUING TO IMPROVE WITH TREATMENT. PATIENT IS DOING ACTIVE PHASE OF REHAB. 0: RT LUMBAR MYOSP ASM LUMBAR FlXA TION UL5 RT SIDE POSTURE RT SI JOINT FIXATION MANIP TO SACRAL REGION A: IMPROVING P: REHABIIFIHMP TO THORACIC LUMBAR SPINE REGIONSIINTERSEGMENT AL TRACTION TO THORACIC LUMBAR REGIONIMANIPIWILL SEE 2X WEEK FOR 2 WEEKSIWILL SEE ON FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 April 6, 2003 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: Policy: Dear, DOS 4/4/03 S: STATED NECK AND BACK CONTINUE TO IMPROVE WITH CURRENT TREATMENT. VAS PAIN GRADE 1.5. 0: POSTURAL ANALYSIS UNREMARKABLE IMPROVED CERVICAL MOBILITY AND DECREASED MYOSPASM LIT CERVICAL MYOSPASM FIXATION CERVICAL FIXATION C5C6 LFT LATERAL DROP PIECE LUMBAR FIXATION L4L5 RT SIDE POSTURE RT SI JOINT FIXATION A: IMPROVING P: REHABIIFIHMP TO CERVICAL LUMBAR SHOULDER REGIONSIINTERSEGMENT AL TRACTION TO THORACIC LUMBAR REGIONIMANIPIWILL SEE 2X WEEK FOR 1 WEEKlWILL SEE ON MONDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. L~'{\ . . ~(\J~ '\ // . Kec.DV'o o( V^'f~t- {\o(Y\ (!\\ \S~k ~-\u t+&S (1.o~\ Y1\'Strfut6 rS Pr~ V\: Ll~'-1 \V\. 1;:0 f!::P 'f.. BC\ 0 tr\ 3 CJ)... r'f\Q 'r\" \ \ ) ~\:\ n OB=\ ' ~. " ~o~ ;- CD~o.~\~ ---- CHlROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 March 30, 2003 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL PA 17089-2000 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: Policy: Dear, DOS 3/28/03 S: STATED CONTINUES TO IMPROVE. VAS PAIN GRADE 1.5. 0: POSTURAL ANALYSIS UNREMARKABLE IMPROVED CERVICAL MOBILITY DECREASED CERVICAL MYOSPASM LUMBAR FIXATION UL5 RT SIDE POSTIJRE MANIP RT SI JOINT FIXATION MANIP TO SACRAL REGION A: IMPROVING P: REHABIIFIHMP TO RT SHOULDER LUMBAR SPINE REGIONS/16 AND 13 MA'SIINTERSEGMENTAL TRACTION TO THORACIC LUMBAR REGIONIMANIPIWILL SEE 2X WEEK FOR 2 WEEKS Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 March 30, 2003 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: Policy: Dear , DOS 3/24/03 S: STATED NECK AND BACK CONTINUE TO IMPROVE. VAS PAIN GRADE 1.5. 0: POSTURAL ANALYSIS UNREMARKABLE DECREASED CERVICAL MYOSPASM RT LUMBAR MYOSPASM LUMBAR FIXATION L4L5 RT SIDE POSTURE MANIP RT SI JOINT FIXATION MANIP TO SACRAL REGION LFT KNEE EXTREMITY FIXATION MANIP A: IMPROVING P: REHABlIFIHMP TO RT SHOULDER LUMBAR SPINE AND LFT KNEE REGIONSI13 AND 16 MA'SIINTERSEGMENTAL TRACTION TO THORACIC LUMBAR REGIONIMANIPIWILL SEE 2X WEEK FOR 3 WEEKSIWILL SEE ON FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 December 10,2002 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL PA 17089-2000 Regarding: RALPH PROBST Accident Date: Claim Number: Policy: Dear, DOS 12/9/02 S: STATED STILL NO CHANGE IN THE SHOULDER. AGAIN, NOT SURE IF ACCIDENT MAY HAVE AGGRAVATED THE SYMPTOMS IN HIS SHOULDER AREAS. VAS PAIN GRADE 8.0. PATIENT ALSO STATED HE IS HAVING SOME P AlN IN THE LOWER BACK FROM THE AUTOMOBILE ACCIDENT. ADVlSEDPATIENT THAT IF THE SYMPTOMS PERSIST, THAT WE WOULD DO A FULL EXAM AND MOST LIKELY HIS SYMPTOMS WILL BE RELATED TO THE AUTOMOBILE ACCIDENT AND NOT HIS PRIOR PROBLEM. 0: RT SHOULDER FIXATION EXTREMITY MANIP CERVICAL LATERAL DROP PIECE TIB L1L2 PRONE MANIP ACUTE SUBLUXATION CERVICAL THORACIC LUMBAR REGIONS A: NO CHANGE P: IF/CP TO RT SHOULDER AND CERVICAL REGION/34 AND 21 MA'SIPULSED ULTRASOUND TO RT SHOULDER/1.5 WCM21MANIP Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 December 7, 2002 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL PA 17089-2000 Regarding: RALPH PROBST Accident Date: Claim Number: Policy: Dear, DOS 12/6/02 S: STATED RT SHOULDER NO CHANGE STILL UNCOMFORTABLE AND P AINFUL. VAS PAIN GRADE 8.0. O:RT CERVICAL MYOSPASM rnORACIC AND LUMBAR MYOSPASM CERVICAL FIXATION C5C6 LATERAL CERVICAL DROP PIECE RT SIDE RT SHOULDER RANGE OF MOTION rnORACIC FIXATION TlT3 L1L2 ACUTE SUBLUXATION C5C6 TlT3 L1L2 A: NO CHANGE P: IF/CP TO RT SHOULDER AND CERVICAL REGION/17 AND 20 MA'SIPULSED ULTRASOUND TO RT SHOULDER/1.5 WCM2IMANIPIWILL SEE ON MONDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 December 7, 2002 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL PA 17089-2000 Regarding: RALPH PROBST Accident Date: Claim Number: Policy: Dear , DOS 12/4102 S: STATED FELT BETTER, BUT HE WENT BOWLING AND THIS MAY HAVE AGGRAVATED HIS SYMPTOMS, BUT ALSO IT COULD BE DUE TO THE ACCIDENT HE WAS IN THAT IS AGGRAVATING HIS SYMPTOMS. VAS PAIN GRADE 8.0. 0: RT CERVICAL BILATERAL THORACIC RT LUMBAR MYOSPASM RT SHOULDER EXTREMITY RANGE OF MOTION CERVICAL FIXATION C5C6 CERVICAL LATERAL DROP PIECE rnORACIC FIXATION TlT3 LlL2 PRONE MANIP ACUTE SUBLUXATION C5C6 UL5 A: IMPROVING P: IF/CP TO RT SHOULDER AND CERVICAL REGION/CONTINUOUS ULTRASOUND TO RT SHOULDER/1.5 WCM2IMANIPIWILL SEE ON FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 December 3, 2002 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST Accident Date: Claim Number: Policy: Dear, DOS 12/02/02 S: STATED HE SAW HIS MEDICAL PHYSICIAN WHO PRESCRIBED MEDICINE FOR THE PAIN AND MEDICATION TO HELP HIM SLEEP. PATIENT HAD A CONSUL TA TION WIrn DR LIPPI. ADVISED PATIENT THIS IS A GOOD IDEA. PATIENT WILL FINISH UP HIS TREATMENT PLAN. DOES NOTICE SOME IMPROVEMENT WITH CARE, NOT SURE BUT HE MAY BE GETTING SOME AFFECTS FROM THE ACCIDENT HE WAS IN. VAS PAIN GRADE 3.0, BUT THE PAIN DOES VARY. 0: CERVICAL FIXATION C5C6 RT LATERAL CERVICAL MANIP CERVICAL DROP PIECE RT SHOULDER FIXATION EXTREMITY MANIP rnORACIC FIXATION TlT3 PRONE MANIP LUMBAR FIXATION L1L2 A: IMPROVING SLOWLY P: IF/CP TO RT SHOULDER AND CERVICAL REGION/21 AND 24 MA'S/CONTINUOUS ULTRA SOUND TO RT SHOULDER/1.5 WCM2IMANIP Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 November 26, 2002 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST Accident Date: Claim Number: Policy: Dear, DOS 11/25102 S: STATED WAS A BAD WEEKEND. ADVISED PATIENT IT MIGHT BE RELATED TO THE AUTOMOBILE ACCIDENT. WILL NOT SEE PATIENT THIS WEEK DUE TO VACATION AND HOLIDAYS. ADVISED PATIENT THAT IF SYMPTOMS GET WORSE, MAY CONSIDER REPORTING IT UNDER THE AUTO. VAS PAIN GRADE 9.0. 0: RT CERVICAL BILATERAL rnORACIC RT SHOULDER FIXATION RANGE OF MOTION EXTREMITY MANIP THORACIC FIXATION TI T3 L1L2 PRONE MANIP CERVICAL FIXATION C5C6 WIrn CERVICAL DROP PIECE ACUTE SUBLUXATION C5C6 TlT3 L1L2 A: FLARE UP P: IFIHMP TO RT SHOULDER AND CERVICAL REGIONIPULSED ULTRASOUND TO RT SHOULDERlMANIP/WILL SEE ON MONDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 November 24, 2002 MEDICARE OF P A CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST Accident Date: Claim Number: Policy: Dear , DOS 11/22/02 S: PATIENT RECALLED HE WON A BOWLING TOURNAMENT A FEW MONTHS AGO BUT IT MAY HAVE AGGRAVATED HIS RT SHOULDER STATED HE WAS IN AN AUTOMOBILE ACCIDENT YESTERDAY, 11/21/02 AT 12:15 PM. HE WAS TAKEN BY AMBULANCE TO THE HOSPITAL BECAUSE HE WAS DIZZY. AN EXAM WAS PERFORMED, HIS BLOOD PRESSURE WAS HIGH, BUT NO FRACTURES WERE NOTED. CURRENTLY NOT HAVING A LOT OF PAIN FROM THE ACCIDENT. ADVISED PATIENT THAT IF THE SYMPTOMS SHOULD CHANGE WIlHIN THE NEXT FEWS DAYS TO LET ME KNOW AND IF SYMPTOMS DUE FLARE UP FROM THE ACCIDENT A REEVALUATION WILL BE PERFORMED. VAS PAIN GRADE 8.0. 0: RT CERVICAL MANIP CERVICAL FIXATION C5C6 LATERAL CERVICAL DROP PIECE THORACIC FIXATION T1 T3 L1L2 PRONE MANIP RT SHOULDER RANGE OF MOTION AGAINST RESISTANCE A: IMPROVING SLOWLY P: IFIHMP TO RT SHOULDER AND CERVICAL REGION/42 AND 9 MA'S/CONTINUOUS ULTRA SOUND TO RT SHOULDERlMANIPIWILL SEE 3X WEEK FOR 1 WEEKlWILL SEE ON MONDAYIBLooD PRESSURE 150/80 Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 November 23, 2002 MEDICARE OF P A CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST Accident Date: Claim Number: Policy: Dear, DOS 11/20/02 S: STATED STILL GETTING A LOT OF PAIN DOWN THE RT ARM. HE IS UNCOMFORTABLE AT NIGHT WHEN HE IS TRYING TO SLEEP. VAS PAIN GRADE 10.0. PATIENT CONCERNED BECAUSE HE IS NOT MAKING ANY IMPROVEMENT. DISCUSSED WIrn PATIENT THAT HE WANTS TO DO THE FULL TREATMENT PLAN AND SEE IF HE NOTICES A DIFFERENCE AT THAT TIME. 0: RT CERVICAL BILATERAL THORACIC RT LUMBAR MYOSP ASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL DROP PIECE RT SIDE RT SHOULDER RANGE OF MOTION AGAINST RESISTANCE THORACIC FIXATION TlT3 LUMBAR FIXATION L1L2 ACUTE SUBLUXATION C5C6 L1L2 TlT3 A: NO CHANGE P: IFIHMP TO RT SHOULDER/20 AND 20 MA'S/CONTINlJOUS ULTRA SOUND TO RT SHOULDERlMANIPIWILL SEE 3X WEEK FOR 2 WEEKSIWILL SEE ON FRIDAY Sincerely, RANDY FREDERICK, D.C. TO THE NEW PATIENT OUTLINE OF PROCEDURE FOR NEW PATIENTS 1. STEP ONE: ALL NEW PATIENTS ARE REQUESTED TO FILL OUT A PERSONAL HEALTH HISTORY QUESTIONNAIRE. 2. STEP TWO: YOUR FIRST CONSULTATION WITH THE DOCTOR TO DISCUSS YOUR HEALTH PROBLEMS. 3, STEP THREE: CHIROPRACTIC EXAMINATION AND ORTHOPEDIC AND NEUROLOGICAL EXAMINATION AS RELATED TO CHIROPRACTIC CARE FOR YOU. 4. STEP FOUR: THE DOCTOR WILL ADVISE YOU AS TO THE NEED OF ADDITIONAL PROCEDURES SUCH AS X-RAYS TESTS, IF NECESSARY. 5. STEP FIVE: YOU WILL BE GIVEN A "REPORT OF FINDINGS" ON YOUR SECOND SCEDULED VISIT. THE DOCTOR WILL INFORM YOU AS TO YOUR EXAMINATION RESULTS. YOU WILL ALSO BE ADVISED CONCERNING FINANCIAL ARRANGEMENTS AND INSURANCE COVERAGE AS APPROPRIATE. 6. STEP SIX: AFTER YOU RECEIVE YOUR REPORT OF FINDINGS, YOUR RECOMMENDED COURSE OF CARE WILL BE EXPLAINED TO YOU. 7. STEP SEVEN: TRE:ATMENTWILL BEGIN AND CONTINUE AS SCHEDULED UNTIL MAXIMUM CORRECTION FOR YOU HAS BEEN OBTAINED. 8. STEP EIGHT: AFTER MAXIMUM CORRECTION, A SCHEDULE OF CARE WILL BE RECOMMENDED. I UNDERSTAND AND AGREE THAT MY HEALTH AND OR ACCIDENT (WORKERS' COMPENSATION OR AUTO) INSURANCE POLICIES ARE AN ARRANGEMNT BETWEEN MY INSURANCE CARRIER AND MYSELF. I ALSO UNDERSTAND OUR OFFICE WILL PREP ARE ALL HEALTH INSURANCE CLAIM FORMS AND OR REPORTS IN ORDER TO MAKE COLLECTION FROM MY INSURANCE CARRIER. ANY AMOUNT AUTHORIZED TO BE PAID TO DR. FREDERICK WILL BE CREDITED TO MY ACCOUNT HOWEVER, I CLEARLY UNDERSTAND THAT ALL SERVICES RENDERED ME ARE CHARGE DlRECTL Y TO MY ACCOUNT AND IN THE EVENT OF MISINTERPRETATION OF MY INSURANCE CONTRACT, I WOULD THEN BE HELD PERSONALLY RESPONSffiLE FOR THE BALANCE OF MY ACCOUNT. IN THE EVENT THAT COLLECTION ACTIVITY WOULD NEED TO TAKE PLACE. I WOULD BE HELD RESPONSffiLE FOR, BUT NOT LIMlTED TO ATTORNEY FEES THAT MAYBE INCm.RED. X-RAYS ARE 1HE PROPERTY OF CHIROPLUS OF LOCST LAND AND COPIES CAN BE PURCHASED. . PATIENT SIGNA TURE,d' f?~ f -tf?~d- DATE: /1- t-{)J- [] Yes No Have you had prevIous chiropractic cere? Dr. If yesf how long hiS it been since you've been treated: Were you hosptiellzed? Oete admitted ___,___,___ Oete dlscherged ~___,___ Were you treated in another facility for this condition? Wher. Have x-rays been taken or wa. tab work proposed.and! r cc:lq)teted1 Wh J. Hive you had any operations? Ex lain ~ i List any drugs you are tlking: ? e. Do you have morning stfffnesa whle tasts /ROr. Are you fnterested in f~rovlng your 8S that brought you to our office. ';II No J( No ;t45 No II No II Yes II Yes [] Yes ~Yes ~ ;~s? ~ -~Yes [] No [] No Below is a list of conditions whichmey seem unrelated to the purpo~e of your appointment. Howeverf take ti~ to answer these questions carefully as these problems can effect your overall diagnoSis, treatment plan, and whether or not you are accepted for care. : )(Yes : (] Yes : :If Ye. II Yes II Yes II Yes II Yes : .YOs [] Yes II Yes Have you ever had cancer? !fK/ h le.~-c 11...3 Ar. you losing weight wIthout trying? Doe. your ~in ..ake you up at night? Have you h.d . chafl8e in bledder or bowel habits? Have you had a sor. that doesn't heal? Have you recently had any I..nUsual bleeding or discharge? Do you have e thlckeninQ'I"", in the breest anywhere? / J' ,J_J' . Are you having iQdi.est~ or difficulty swellowi",,~"'1' /V~ 00 you have a nagging cough or hoarseness? ,~ Have you hid an obvious chlnge in 8 wart or mole? [J No ".. No II No ~No )(No ~NO 'Jl No []~ 1I(No "NO ~ any of the following conditions you currently have or that tend to be e recurrent problem. Check ,\Ii those you have had in the past but are no longer a problem. ID!! eafara, t ",!i,:" GASTRO- INTESTINAL em ~~-<: . Poor appetite e r fS'(Y~ It:j Sl-S: . Excessive hunger Nose\/sinu5 tl Difficult swallowing Throat trouble Difficult chewing loss of taste Excessive thirst Loss of ~mell Frequent nausea Vomiting . Abdominal pain Diarrhea Constipation Block,bloody stool ~f!nnl"rhoi ds o rod1 ges t ~ O!!> Ga. of bloating stones Liver trouble Gell blsdder problems Colon trouble IDiru1 Headaches Allergies Hayfever Hives . ~Fr J;,...."'r~:+'5 ~ei!ilht loss ill!ill Menstrual pain II irrelfularity Valfinat pain II infection II di scharie II bleeding Breast pain/lumps Hot fleshes Are you pregnant? II Yes II No Date of last period? -'-'- NERV(XJS SYSTEM NUttIness Paralysis Dizzinesi hinting Confusion For-getfulnes'l Depression Convulsions Muscle Jerks Nervousness Neuralgia Insoonia GEN lTD. UR I NARY Pain/burning on urination Difficulty starting urine Jnability to control urine frequent urination Discolored urine Bladder trouble tOc*1ey infection or Sexusl dysflMlCtion Prostate traubleCMales) Circle anv of the Ch f cken pox ;-) Diabetes Anemia pneunoia followinCl diseases Alcohol ism ~f~ ( . art dis~ /Meas~es YOU hllve had. Typhoid fever Kental disorder RheuMt\C fever Oiptheria ~.. A ndicitis · Seer e ever Venereal disease Whooping cOUUh AIDS Signotur'x "v~~ Conmenu : Miliaria Tuberculosis ~nC.r--="Sk(;' Epilepsy Polio Influenza Smel l pox Pleurisy Goiter LUIt>sgo EC2em11 M....,. ~: i/!.~ Date ;L..J ~, f22,.. BORG PAIN SCALE: OATE: //-~.l;:-o 2..._ ," ON A SCALE OF 1 - 10 PLACE AN X IN YOUR CURRENT PAIN LEVEL '. .1 NORMAL LOW PAIN MODERATE PAININTEt'~E1PAIN EMERCENCY ( ) 0 ( ) 1 ( ) . W ( )10 ( ) 2 ( ) 1 ( ) 5 ( ) 6 ( ) B ( ) 9 RANSFORD PAIN DRAWINC: (dull i1Che .+i')(pin$/needles ooo)(burning xxx)(numbncss._ ==~)(stabbing IIIl !\. PATIENT'S SlCNATURE~~ (' - f!~- , . GENERAL 1. .N DISAB1LlTYINDEX QUES.DNNAIRE 'the ralin& $Cales below ItC deujlled 10 meuure the dcp:e 10 wbldJ _ral upecta of your life are prcoeolly disNpled by CIlIO,uC pain. In other words, we WOIl!d like 10 knOW how much YOllr paiII b JlICVCllIiD& you twin doing what you would nonnally do, or from doing 11 II weU as YOl1 normally would. Rcapo,gcl1O each caregory by Indicatinglho l1>'t',alllmpact of pain in your Ufe, not ju>! when the pain i. al itS worsr, . For each of lb. o~ ~~~~1:o;: of wly living liatcd. PLEASE CIR~ THE NUMBER WlDeH BEST DESCRIBES YOUR TYPICAL LEVEL OF A , A acere of 0 means no di511bility atlli1, IUld lacere of 10 signifies Ibat all of tbe activities in whicb you would normelly be Involwd have beclllOtally diaru.ptcd '" P='Ien~ by your pa.in. . !l..ViKd March I~. J 993 t. F_Il1/Homl RUpOIUlbiIJJiu. TIlls eal"lllfY refera 10 &livilie, I'Clatcd 10 ~ home or family. Itlnchldc. chore. and dUll" performed uound lite house (e.I-, yard work) and .rrllllde or faVOII for other family membeT$ (e.g., drivina the children to school). o 1 Comp1.lely able 10 function 2 3 " @ 6 7 8 9 10 Totally unable to function ~. RI"",Admt. Thia clIlCgory lnolud... hobble.. oports, IIld other .imilar le~ time activities. o 1 . Completely able 10 function 2 3 4 ('S) 6 7 8 9 10 Totally unable, \0 function 3. StXkUAdlviq. This category ret6rs 10 activities whiclllnvolv. participation with friOJl.ds and acquaintances other lhan famUy m....~I$. tt incll.1dca partiea. theater, eonUrts, dlniDa out, lIDd other "",ial functions. o 1 Complelel)' able to functiOJ> (v 3 .. 5 6 7 8 9 10 Totally unable to function 4, OccupDJio... TIlls calegory refen 10 activltie. thaI a... s part of or directly related 10 aile', job, This includes nonpaying jobs u well, such .. lh.t of. hotllemaker Q1 volunteer worker. o 1 Completely .bl, to function z, 3 4 s 6 7 8 9 10 Totally unable to function 5. S,lf CfIl". This eategory ineludc. activities which involve pcnollal mainlell&Dcc and indcpcndclll daily living (eg, loking a oltower, driving, IIcuin& dressed, alC.). CoG:;]>, 1 2 3 4 S 6 7 8 9 TO~~Y oblc to function unable to funClion 6. Lq..sUPporfAellvu,. Thll Cllosory refers 10 haJic Iife.supporting behaviors such as eating, sleeping, and breathing. o 1 Completely , abl!,!!> fund,:;- ~ roTALSCOllB: /<1 Gu ' SlONA1VRBXtf,.~ <Z 'or te-ardarlna iIIformMion. contact: ~CTIVATORMETIIODS, INC., P.O. Box 80317. Phoenix, AZ 8S060-0317 2 (2) 4 s 6 7 8 10 TOlaUy .. unable 10 funcllon 9 Itl~. DATE: //-- t -{) 2--- Telephone: (602) 224-0220; l'ac:olmile: (602) 224.(2)( Referred by: ,ae. 4/ .' !J Date: / /- ,s-- cJ:L Patient's name: Patient's address: City, State, Zip: PATIENT INFORMATION ft!r!:;,:!,: ~fr3:J~Y~f' 0 / Home phone #: S~,-:. ~915 Work phone #: ~J1- Social Sec. #: - l t, - 2,(" ('J cr Date of Birth: 0 /.1 <; / /9,,;( 7 Patient's sex: a male No. of children: _ Marital Status: arrie ingleIDivorced/Separated Student? F or PT? Height: I,' I Weight:......2<74 Person Responsible for paying the bills: A1L. l' j ~. m 1,. <:;/- Subscribers address: ..<7a-.4___ Patient's Employer: Address: Type of work: ~-e7i;' "p E CIRCLE ONE) ealt ranc Self-pay (please complete), ". ) nsurance Company: ~-e",~..':"g~ Afr../~~ ( t5k~ <<;.?/~ lei Insured's Name: lPr. / /, - .... b <i IF AUTO ACCIDENT (Please Complete) Circle One I was the: Driver Passenger Vehicle Owner-Auto Insurance Company: Insurance Co. Address: Telephone # ofInsurance Co.: Date of Accident: Adjuster Name: Attorney's Name: Attorney's Address: ~ Policy #: Claim#: Phone #: IF WORKERS' COMPENSATION (Please Complete) Employer: Address: Phone # Supervisor: ~ Date of Injury: i / / Workers' Compo Insurance Co. /)1 Ill. Address: Telephone #: j Attorney's Name: Attorney's Telephone #: CONSENT TO TREAT & RELEASE OF INFORMATION I hereby authorize Dr. Frederick, and whomever he may designate as assistants to administer chiropractic care including examination, consultation, x-rays and or treatment necessary to: ~/f h Ill, t/&h1 h.e f- Month Name of patient: Dated this: E. , (!..oksf- j, Day 2'/~o J.- Year I hereby authorize ChiroPlus of Locust Lane to obtain and or release any medical infonnation that may be pertinent to my treatment should that be necessary. /: /, ......, Patient Signature: U:' \ Witness Signature: J" FIELD CLAIM OFFICE 6345 FLANK DR, SUITE 1000 HARRISBURG PA 17112 PHONE NUMBER: 717-54(1.7500 OFFICE HOURS: MONDAY-FRIDAY 8:0(1..5:30 ~ Allstate. You're in good hands. March 14, 2003 ~. . .~~ r'J'l,~..!'fl.L.~...J~&O~s:r:;::l".":, 2425 GARRISON AVE HARRISBURG PA 17110-9402 Allstate Insurance Company Claim Number: 1554506830 3K4 Our Insured: RALPH E PROBST Date of Loss: November 21, 2002 Dear Ralph: With regard to payment of benefits under the above captioned claim, please be advised that this automobile contract provides medical payments coverage up to a maximum amount of $5,000.00 and previous payments have exhausted this coverage. All future bills should be submitted to the group health carrier. Thank you. Sincerely, DAVE MOODY Allstate Insurance Company SM06jOjOljl G52-2 FIELD CLAIM OFFICE 6345 FLANK OR, SUITE 1000 HARRISBURG PA 17112 ~AlIstate. You're in good hands. PHONE NUMBER: 717-540-7500 OFFICE HOURS: MONDAY-FRIDAY 8:00-5:30 March 14, 2003 /RAiPJi:~ ;;~i~ '-'242"5" ARKISON AVE HARRISBURG PA 17110-9402 Allstate Insurance Company Claim Number: 1554506830 3K4 Our Insured: RALPH E PROBST Date of Loss: November 21, 2002 Dear Ralph: With regard to payment of benefits under the above captioned claim, please be advised that this automobile contract provides medical payments coverage up to a maximum amount of $5,000.00 and previous payments have exhausted this coverage. All future bills should be submitted to the group health carrier. Thank you. Sincerely, DAVE MOODY Allstate Insurance Company SM06/0/01/l G52-2 CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 November 23, 2002 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL PA 17089-2000 Regarding: RALPH PROBST Accident Date: Claim Number: Policy: Dear, DOS 11/18/02 S: STATED VAS PAIN GRADE 8.0 TO THE RT SHOULDER AREA. 0: RT CERVICAL MYOSPASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL MANIP TlT3 PRONE MANIP CERVICAL MANIP WITH LATERAL DROP PIECE TO THE RT SIDE L1L2 PRONE MANIP RT SHOULDER RANGE OF MOTION EXTREMITY FIXATION MANIP ACUfE SUBLUXATION C5C6 TlT3 L1L2 A: NO CHANGE, SLIGHT IMPROVEMENT COMPARED TO INITIAL PRESENTATION BUT STILL HAVING A LOT OF PAIN. P: IFIHMP TO RT SHOULDER AND CERVICAL REGION/32 AND 21 MA'S/CONTINUOUS ULTRA SOUND TO RT SHOULDERlMANIPIWILL SEE 3X WEEK FOR 2 WEEKSIWILL SEE WEDNESDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 November 17, 2002 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST Accident Date: Claim Number: Policy: Dear , DOS 11/15102 S: STATED STILL HAVING A LOT OF PROBLEMS WITH HIS SHOULDER, ESPECIALLY IF HE MOVES HIS ARM BACK INTO EXTENSION IT HURTS. HE HAS TO TAKE MEDICA TION AT NIGHT TO SLEEP DUE TO THE PAIN. VAS PAIN GRADE 8.0 UPON CERTAIN MOVEMENTS. 0: RT CERVICAL MYOSP ASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL DROP PIECE THORACIC FIXATION TlT3 LlLL. PRONE MANIP ACUTE SUBLUXATION C5C6 TlT3 UL5 L1L2 RT SHOULDER RANGE OF MOTION AND EXTREMITY MANIP A: CHANGED THERAPY FROM CP TO HMP AND TO INCLUDE CONTINUOUS ULTRASOUND. IMPROVING SLOWLY P: IFIHMP TO RT SHOULDER AND CERVICAL REGION/CONTINlJOUS ULTRA SOUND TO RT SHOULDERlMANIPIWILL SEE 3X WEEK FOR 3 WEEKSIWILL SEE MONDAY WEDNESDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. .' ,'~':. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 November 16, 2002 MEDICARE OF P A CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL PA 17089-2000 Regarding: RALPH PROBST Accident Date: Claim Nwnber: Policy: Dear, DOS 11/13/02 S: STATED OVER THE WEEKEND HE HAD A LOT OF PAIN OVER THE WEEKEND. HE HAD A FLARE UP. VAS PAIN GRADE 4.0. 0: POSTURAL ANALYSIS MILD RT LOW HAND LFT LATERAL ILIUM MANIP BILATERAL CERVICAL THORACIC MYOSPASM CERVICAL FIXATION C5C6 CERVICAL LATERAL DROP PIECE BILATERALLY RT SHOULDER FIXATION EXTREMITY MANIP SOFT TISSUE MANIP THORACIC FIXATION TlT3 PRONE MANIP SOFT TISSUE MANIP CERVICAL THORACIC REGION RT SHOULDER RANGE OF MOTION AGAINST RESISTANCE A: FLARE UP P: IF/CP TO CERVICAL RT SHOULDER REGIONI15 AND 19 MA'SIMANIPIWILL SEE 3X WEEK FOR 4 WEEKSIWILL SEE THlJRSDA Y AND FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 November 16,2002 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST Accident Date: Claim Number: Policy: Dear , DOS 11114/02 S: STATED NOT MUCH CHANGE IN HIS NECK AND BACK AND SHOULDER TODA Y. VAS PAIN GRADE 8.0. 0: BILATERAL CERVICAL MANIP WITH CERVICAL LATERAL DROP PIECE BILATERALLY rnORACIC FIXATION TlT3 L1L2 PRONE MANIP ACUTE SUBLUXATION CERVICAL rnORACIC LUMBAR REGION C5C6 LlL2 TI T3 RT SHOULDER RANGE OF MOTION A: NO CHANGE P: IF/CP TO CERVICAL RT SHOULDER REGIONI14 AND 11 MA'SIMANIPIWILL SEE 3X WEEK FOR 4 WEEKSIWILL SEE ON FRIDAY Sincerely, RANDY FREDERICK, D.C. CHlROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 November 10, 2002 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL PA 17089-2000 Regarding: RALPH PROBST Accident Date: Claim Nmnber: Policy: Dear , DOS 11/8/02 S: STATED MAYBE A SLIGHT IMPROVEMENT WITH PAIN TO THE ARM AND SHOULDER AREA. VAS PAIN GRADE 7.0. 0: POSTURAL ANALYSIS UNREMARKABLE RT CERVICAL BILATERAL THORACIC RT LUMBAR MYOSPASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL MANIP WITH CERVICAL LATERAL DROP PIECE C5C6THORACIC FIXATION T5T6 PRONE MANIP L1L2 PRONE MANIP SOFT TISSUE MANIP TO RT SHOULDER RT SHOULDER EXTREMITY FIXATION MANIP TRIGGER POINTS RT TRAPEZIUS REGION A: PATIENT BEGINNING TREATMENT PLAN TODAY. DISCUSSED RISKS AND BENEFITS OF TREATMENT AND X-RAY FINDINGS. P: IFICP TO CERVICAL rnORACIC REGIONIMANIPIWILL SEE 3X WEEK FOR 4 WEEKSIWILL SEE WEDNESDAY lHURSDA Y AND FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 November 10,2002 MEDICARE OF P A CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL PA 17089-2000 Regarding: RALPH PROBST Accident Date: Claim Number: Policy: Dear , DOS 11/6/02 X-RAYS TAKEN ON 11/6/02. CERVICAL THORACIC AP AND LATERAL AND SHOULDER THORACIC VIEW. CERVICAL AP VIEW: C4C5 RT LATERAL LIST C5C6 MILD DECREASE IN DISC SPACE. CERVICAL LATERAL VIEW: CERVICAL LORDOSIS C2C7 48 DEGREES SLIGHTLY BELOW NORMAL RANGE OF 30 TO 43 DEGREES. SUSPECTED SLIGHlr DEGENERATIVE JOINT DISEASE C5C6. rnORACIC AP VIEW: SPINOUS PROCESS DEVIATION TO RT SIDE NOTED. RT SHOULDER REGION: UNREMARKABLE. rnORACIC LATERAL VIEW: MODERATE DEGENERATIVE JOINT DISEASE ANTERIOR VERTEBRAL BODY MARGINS SUGGESTIVE OF DEGENERATIVE JOINT DISEASE. Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 November 10, 2002 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL P A 17089-2000 Regarding: RALPH PROBST Accident Date: Claim Number: Policy: Dear, DOS 1\16/02 S: PATIENT PRESENTED WITH PAIN DOWN THE RT ARM AND INTO THE SHOULDER AND NECK AREA. VAS PAIN GRADE 10.0. 0: RT CERVICAL MYOSPASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL DROP PIECE THORACIC FIXATION T5T6 PRONE MANIP SOFT TISSUE MANIP RT SHOULDER REGION A: EXAMINATION TODAY FINDINGS WRITTEN INTO CHART NOT DICTATED ON TAPE. X- RAYS TAKEN CERVICAL rnORACIC AP AND LAT AND SHOlLDER THORACIC VIEW L7 REVIEWED PRIOR MANIP. P: IF/CP TO CERVICAL AND RT SHOULDER REGION/17 AND 18 MA'SIMANIPIWILL SEE ON FRIDAY Sincerely, RANDY FREDERICK, D.C. '_,,';~'; . _ CONSULTATION J sc~. ()i)><,j) Lrlr NAME RALPH PROBST REFERRAL- PRE/CON - D/A- MAJOR COMPLAINT - @ DATE 11-06-02 ~,t5{~ () ~y 0 (' >-t- tvA-- g~ If\. rrlL ! -f (\0-'<;;, So~L V--0< S l? -4 (2 '- (,<:> C(~, rl)f'-PCt~ e (I.. (Y\,((h\~~~ i W4-~' I-,J~ U-~ p+9-.. pGS . , 0lA-t Jv D' ~b~-~{~'^~~ I c:Y VA-b I ib (L',( S', ($Jb~~ ~ v 1"' D~ ~-iU ~ rlL Grl tt~.~(.f-~, Prior Surgery I . I' Iltfuj ~I qi 'I. ~ C{'i1lv--- (Y."U f~ (2) qef(,\'~ - GJ 0-(~~ nv-l ~\g l ~ \0Q~~ ~k' ~ D<.i(\Jl~ . ~ (Jc.-~ ~ ~ p v:- \0 \vvJ&v ~D l' NOTES Prescription medications currently taken V l\ ~4A . C\ru~ A &'t1l<\J L..-''::~ W "'- J~ ~ - ~ ~\ \'-7~ 6 ~ )~ ~O' lC(~<-.n, Cf.p I /?c. 0/1 ~)rok01 . ) ~or-t'J ~0ID (" J.5~~l'VI[;;?f'l /J.L';'~,,<jc'r /6C''J)i.:?,,j';,,'J /)JI( ...; .<'"1 . /J 7" " - . /1 f 1)/Vi'1 rr // t_J.:l n J ~>J- J2t-~'"' /0-i:: ~- O. v" '~I "".' (I. ) dI' -j \i rc. '.'> ,-"~,,,..'...; / u...... .<:-V'l..,........;'-{ / ,)' - , -"pJ<- /V"-Y/LU,.., .I("-"",'} 1_,-11'1 1f,/~/f:fi'ii;'f"~'j."""j'1r1 _ {t'jj'f,"as,-)1...- .+J i-', / - f/JD. .., f'-'~ ,ltE 4,)0')"J 3[0 )~ If ./' /Cl- ~,;{~: Y>~.J' ) c. "J'{:'-~) f - CENrE1IS "" MEDICAIIE. MEDICAID SE1lV1CES MEDICARE - Coordination of Benefits 1-800-999-1118 or (TTY/TDD): 1-800-318-8782 ****FIRST CLASS MAIL- R:144 T: P: F:90435 JOSEPH DICKSON 126 STATE ST HARRISBURG PA 17101-1026 1,.,111",1",111""".11",1111"".1.1,1"".1.1,11",,11,1 January 30, 2004 DEAR JOSEPH DICKSON: RE: Beneficiary Name: RALPH E PROBST HICH: 195163609A Date of Illness or Injury: 11/21/2002 CD '" CD Medicare has been advised that you have been retained to represent the above beneficiary for matters which occurred as a result of the above referenced illness/injury date. Medicare acknowledges that you may file a claim and/or a civil action against a third party on your client's behalf, seeking damages for injuries he/she received and medical expenses he/she incurred as a result of the above illness/injury. IS> Ol The purpose of this letter is to advise you of the applicability of the Medicare Secondary Payer Laws. Per 42 D.S.C. 1395y (b) (2) and 1862 (b)(2)(A)(ii) of the Act, Medicare is precluded from paying for a beneficiary's medical expenses when payment "has been made or can reasonably be expected to be made. . . under a Workers' Compensation plan, an automobile or liability insurance policy or plan (including a self-insured plan) or under no-fault insurance." However, Medicare may pay fi)f a beneficiary's covered medical expen:ses conditioned on relrribuiserncat tc ~<w{~dic,lr~ from prcceed& received pursuant to a third party liability settlement, award, judgment or recovery. OJ . In these instances, Medicare's reimbursement is reduced by a pro rata share of procurement costs. It is in your and your client's best inter,est to keep Medicare's payment and the obligation to satisfy Medicare's claim in mind when negotiating and accepting a final dollar amount in settlement of1he claim with the third party. Medicare's claim must be paid up front out of settlement proceeds before any distribution occurs. Moreover, Medicare must be paid within 60 days of receipt of proceeds from the third party. Interest may be assessed, if Medicare is not repaid in a timely manner. Repayment of Medicare's condi1ional payments must be made to 1he local Medicare contractor or the lead contractor handling this case. Continued.. . - CENTEl/S "" MEDIC4/IE. MEDICAID SERVICES MEDICARE - Coordination of Benefits 1-800..999-1118 or (TTYrTDD): 1-800-318-8782 CONSENT TO RELEASE FORM Kindly furnish JOSEPH DICKSON Medicare records relating to the illness/injury that occurred on: 195163609A Beneficiary IllC#: o o I I Beneficiary Name: RALPH E PROBST '" 0> o CD '" CD Beneficiary's Signature "' 0> 0> IX) Signature of Beneficiary's Legal Representative (if applicable) Signature of Representing Attorney Signature of Third Party (Insurer) with a copy of my 11/21/2002 Date Signed Date Signed Date Signed Date Signed ,)'v , . ~ DATE: IJ ~ (' / .~ Q ~ -~-"'~EC~ ~ISAB~;;;";~~;;~=~'-5il~'~Jr~"'-'''''1 Please Read: This questionnaire is designed to enable us to u,nderstand how mu(:h your neek palo :~ has affeC'ted your abUIl)' to manage your everyday activities. Please answer each Section by circling ~ the ONE CHOlCR Ihal most applies to you. We realize that y.c>u may feel that more than one slate- ~ ment may relate 10 you, but PLEASE, JUST CIRCLE THE ONE CHOICE WHICH MOST f CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW. i . M.~..l... '-~~~'Ri'f;tl)"'"'t_llolf"e'll-"",.;:m5til'W_'..-s_;<t:I.';.;II"II4\.;.~:~'I\"":"'~~m."!:"".~iWJ+':;>1f;~<#,,''''':rH''_~''''~'.~C:~\'' ScdlOlll - hla l1>ten,lty S<<t10D 6 _ CODCeDtralloD ") 4' 1 bave ~o ,pain at tbe moment. ....,. ^ I c.tU) c;on,,~n(ralc. (wi)' whe;n 1 want to-~th o~culty. B The pun IS very miJd al (he moment. ~ 1 can c::oncentra(e fully when J want to \lr'1tb slight TIle pain is ",oderato altlle moment. difficulty. o The paio is fairly severe at the momeot. C 1 have a faiT degree of difficuJry in conctmrating when E The pa.ia is \fer)' severe at the motnenL I want to.. F The: . is tb(. worS{ ima . ..btc at lbt; moment. 0 1 h-ave a tQt or dirTlt-ulry io. COQcentrating wb~n I want to. E I hayc a !~reat deal of diffu;uity in COnCl:nlratLng Whl:D 1 want to. F I cannQ{ conceDtrate at all. . SoetIIlII 2 - Pe......., Care (Wa.blng, Dnssl"'llo .~.) , \A I c:a.D look aftor m""'lf norma11vwithout causing extra . '-. ... ~ pam. J- , I tall look aner m,.,elf normally, bul it Cll~' oxtra pain. \ It i. pAinful to look aftenD)'SclI ud I am slow and CoIleful. o I Deed some help, but minasc mo'l of my penonaJ c.ue, 1:: 11leed bolp """ry day in mOS( "J><<U oC .elI CAte. F I <10 nOl 01 dre&Sed, I w..b with dillieu! and Sl. ill bed. SooctIOlIl 3 - UllI"lI A. I tall lift boa.,. 'Weights withOllt extra paUl. e I UJllif\ be..,. 'Weigbu.but it gi~ cxu. paiD. C PaiD preveDts me from liftiDg hea.,. w.:igbts off tbe noor, but I c.u. manage if they are coovewently po>itioned, for (lWIlple, 00 a table. o Paia jlm'ea.ls m~ from lilting heavy we~t.. but I C4ll m.... \igbt to medium weighls if IbrJl are cODvenietly positioDed. I .... 11ft very lighl weights. I ClUlIIOC 11ft or CIlT)' aJl.)tbi at all. ).. E F ',' SctIotl 4 - IUoIdI... :L .. I tall read as mucb jlS [ Wl1lltO with no pain in my Deck. 8 I call reAd as much as I waIlt to with slight pain in my ned:. C I tall read as much.. I WllII witb moderate pain in ...y DOClr.. o I C&D1Iot rcad as much as I want be.eause or moderale po.ia in "'Y .oek. E 1 CUUlQt read at all. Sc<:tlOD 7 - W otll. ^ I (a,g, do as much work. as J want to. Il I can only do lOy usual work, but no more, 1 <:an do most of my usual work, but no ",Qr.. I cannot do lOy usual work. E I can bArdly do "'y WOlI at all, F I can.not (10 an Work at all. SedlOD 8 - l>rivtag 2- ^ J can dr'ive my ClIl' without IDY Deck pain. I can drive my CAt as 10llg as I wa.ol with s~t pain in my Dcck, C I can drive illY car u.lollg ~ I want with moderate pain in my neck. o I ca.nnoi. drive my ear ..long as I want becallSe of rno<I.ra"e pain In my neck. E I can bardly drive at all because of '""'10 pain 1.0 my neck. I' I "'nnQI: drive my car al an. ..., . ;;, SectJoa 9 - SleeplPll ^ I haV(O no trouble ~eeping. B My $1e<:p i. .lJghtly dUtur<<d (te.. tban 1 boW' .lccpJ=). C My sleep is IIlildly dlsturbecl (1-2 hollO sleeple.u). My sleel) is modeTltely QistUtbc<l (2.3 bo\ll'S sl""'pl....). My sleel' u gmat1r. disturbed (3-" bOlll'$ slecpleso). M sloe) is com ctel distlJ1'bcd (5-7 hours &luplco.<). SectIon 10 - RtcnalloQ Se<tI... 5 - H.....Io.. ^ I .... ablo to .~ In all of my rccr...tiooal activil~ ^ I have DO beadacbco al all. J- witb DO Deck pain at aU. I have.lisht bc.adacbes which. c.omc infrequently. I am able to enpge.in all of DIY rccc.tlion.o1.ctMtie&, I """'" moderate be.adacbe4 which come irUrequo.tly. with soo,. pain in mr neck. D I ktll: modenle bc.tdacbc> nw. <:0_ &.equcntly. C 1 un abl. to e~ Ul ",,,,t, bat aot all of my wlUal E I hnc -.rc b...dachoa wbIcb. COI11e freq\lCntly. r~"i""..\ activilles because of pain in my ned. F I ha..e lIe"".~"", almost all the liIDoo_ 0 I un abl,. 10 e"8"iC In a few of my usual rccr:cati01Ul1 .,' activitios \>cQuoc of pain In my DCd<. . After V"""", <t _. 1991 e I (laD hatdly do any rocrc&tioaal acrlvit:ico t>eea..... of pain ~ /ry ~~ o/th.J""",tIJ %, MII1I/J1I'IIUM (ltId, in "'Y n,ock, " !'It ol 171 cs F I c:&IUIO" do re<:ro.tiODaI .crlvitica at all. _11l(t-..l /) J CommenlS:</~ c:.. t::::&'Y" ~~ ,~.d. O/./soJ:J Lt-)..I" SIGNATURE:_ #~?-.,fU' ,,' ., 7-r(-" ~ " ...., 0"'" I ;0 CDO _0 0 ~O 'DO <1\ ~ $i' :J U> 01- 0- '0 CD 1I Z ~-Z ...."- CD z ~3~3 ~ ) u 0 0(5' I 1 9- - 3~ c ....,CY Cf o' ;;;: CD rog .f CO <0 :J 0 ~ ~ - "'0 -. 1->-+- 0' CDO ~ .~""p :J ~ 'DZ "l.~ 'V =<' ~ , """Oc <' '<l>'~3 CD ~3:0" , ~<<l> <l>~ C> C> 1'3 C> 1'3 U. ~ ~ ~ ~ -0 U. - 8 ... C> 8:.8 g; g: 0- C> .... C> .... u. ~ u. u. <i. 'if ...... < --' . . .... '.c.0. ....... :.... ... .. .... i . I ..D "- ....> >;i . . .n .... < " .. . " .. h;' .. . . ..> . , .. .... . ~ '(,. .. I> . .' ~ (j) .. .... ~ 0 ~ ............. . )- ... - '.. ..... <. .. . . r- i . - ........ . ... .' .. '" . '. .' " .. .' '.' - . 8 ... .' . )- .. .... - .. . .. . . ...... . . r-- 8 ..' . )- . .... I . '-- . .... . - (j) . . . 0 )- r- . '. - '. . . - . (j) . 0 )- . .- - . - 8 .. . )- . . '. .- . - .. .. . . - (j) ~ . .- . - . . . . - . '. (j) 0 . )- ". . .- . . - . . \. . , . ~5' 3: 0' o' o - -+..>. m CDv>< ..)0 3 *~- o o 1'3 -+ CD o 8. c.> CD o 8. .... CD o o U. -+ CD o 8. 0- CD o o .... -+ CD o 8. ... <D "Tl!rn-r-m;:o zO-....(')m,.,,.,on m(')Z)>Zm....Z-)>s:: '1J o -+ (5' :::> "t en z o 3 CD .... o 5' ur ~ (' -U ~ ;:> o ;p <J' ~ ." Q - -. CD ::J - ." ... o CO ... CD en en G) ... Q "0 =r COMPLETE REVERSE SIDE AND RETURN TO: MUTUAL OF OMAHA INSURANCE CO. PO BOX 1602 OMAHA NE 68101 '- ' The Medicare contractor that wilrhandle the specifics ofthis case to recov\;l)' is: MUTUAL OF OMAHA INSURANCE CO. PO BOX 1602 OMAHA NE 68101 Phone: (866)734-1521 This contractor will coordinate with other Medicare offices to obtain a summary of conditional payments made to date. If a settlement has already been reached, please provide the following information to the Medicare contractor listed in the preceding paragraph: I. Authorization from your client to release Medicare specific paid claims data. If you do not have a release on file, the enclosed release form must be signed by both you lmd your client and returned to the above Medicare contractor. (A release must be returned, even if a settlement has not yet been reached.) 2. A copy of the settlement agreement indicating the settlement date and total amount of the award. 3. An itemized statement of attorney fees and procurement costs. 4. The name, address and telephone number of the automobile or liability insurer involved, and if available, the policy number, claim number and adjuster's name. 5. Ifmonies were available through personal injury/med-pay, or another form of coverage, indicate the total coverage amount and an itemization of benefits paid. If you have any questions regarding Medicare's right of recovery as outlined, please con1act the Medicare contrac10r listed above. Enclosure: Consent to Release form CC: RALPH E PROBST NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE INFORMATION (PRIVACY ACT STATEMENT) The Social Security Act mandates the collection of this information, The purpose of collecting this information is to properly pay medical insurance benefits to you or on your behalf, Information collected may be given to health insurance providers and suppliers of services (and their authorized billing agents) directly or through fiscal . intermediaries or carriers, for administration of title XVIII; and to an individual or organization for a research evaluation, or epidemiological project related to the prevention of disease or disability, or the restoration or maintenance of health. The identification number we are using is your Medicare Health Insurance Number. While furnishing the information on this form is voluntary, the Medicare program may not be able to make accurate claims payment when the requested information is not available in its records. Public Law 100-503, the Computer Matching and Privacy Protection Act of 1988 permits the government to verify information by way of computer matches. Anyone who knowingly and willfully makes or causes to be made a false statement or representation of a material fact for use in determinin9 a right to payment under the Social Security Act commits a crime punishable under Federal law by fine, imprisonment, or both. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0214. The time required to completE! this information collection is estimated to average 5 minutes per responder, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information coUection, If you have any'suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland 21244-1850. =#=- (&f6tof;) It- - u . Complrt.rlf CIIor". per vlslt . Lo# ~me: Homelf: . First: Inltlol Yurlf _200~ Dr'F.IU!'I)EIUCK 24~5 GARRISON AVENUE H1'.RRISBURG, PA. 17110 Dlognosls: 1., A{'< )6-19-27 2. ~ CAD INITIAL NOTES: I)/ttt 0(' A(ll' (7)F:II, Wo"'lf: . 131). '1".) ~'""fu i. ,,1, "'\ I. . II-if-Od..... ./ 11. ~ . k 1lI(j,.? CHG. MO. DAY YR. TREATMENT COMMENTS AD) TRMT. IJ- il lJ.) ~ ( L J \.. 'r'\ t:> A ( 1- l.1-n ..l1'l~,. j.. (/~ I Nt.,;;') 'l\0;.oLc. ('ry;.,)p irk i)~ - CH002CJ RALPH r 13S'I'. PAY'tENTNAME , (1f~ fA I,J () j II/I1Pj/~ flfhn:::rr: uJ 'I..tlli l\ ,p 1;) . 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IJ<"'~ fo,.P. q~ ~), ; 1Jl7\7b~r 'y; ) r t'<~ 11^.OlJ{ r111~i. ~p l1,'{) ~,.,.'.,Jivp"""~: Clct/JtJ, ~,' ~ ') ~ rr'"\ )...l"; "f' 1 J: IT. I.. \.p lh l.i]) ! r"J5.}} (tt~ _ q) tt;." WJ f1.f 11 r y~ I J A ~ j ..hy{Ji~j!t '~i!t """ ~I<z: tB'(t<, c. I f' J' ( tA",~~ l)~ I )~ ^:),. tk.n '1k0(;-,....,~ UIl -:i!/\.- '1-jy'. C''tdA,A;)..ll '1~ } J c., ~ rhFiP)')J- '1"( 'Ah?/~rlw:? J/:r.1L; ,. /1 X"" ~ 'Cl_,- :\N'vl: , I". .) I [~ ~3) If r'\ $JJU<. I }I 1/1\ )J'rvvphl~xf ,k.PP In --: ""1.iJ ~L-)" L " I 2..0 3 UIM9 J tlt, ~YZ-.)I ifit4-"Lfj~, 1 '"1\ (8/V\. '-' 1-= 91f71~" I ?7~ d?> /rh...J; . ~I?l~~ G _~ CJ/~tYtfiJd\' ("'f I ':'l '-l <Y3 It.f.t; / If: ;.. i?J ~p. ....(. () (['J:!IA.: 1A kc--'V'4 ('/~ ; 1 '7 0'7, J+/'rp {~'? .:;: ,k {iCG4( frt:. ~..,.) O.lU.,bt fJ.N' ~'V . L~tf1 { - ~\ L 1 J I.. ". i&/l4 wJ.{ (-1/1' N(~ fO,j;. Mtmf'<l'''''- \.. ~ ~.Ih,.,-r -~/~,~: <-::4. (....Pn- %(~--<;iJ, '1'0 I j() f)"1!E, t~ 'itf>1/)!t~~.'tl111~Jlif '2..~ 1--)1,....~J ":1r,14(~ fP.>:. / ~ I o.~ 'Ii: Hm//;~ ~ J fliolEw1 LI~ ~D7~_ 'b.~ r;jJ. \-(.;;t:..J(. ~ L '5 c)";} [r,11.1rf.1IfO/1!!:.,'J)~3.u rf<':IiJu c'AklIJ.t 6~JI1 1 6 (}") -b- IJrrrv-o ~ I J;~'Jih..~ 1~O {~ ~ f, / /-';;1\!Rtl pl 7 I ~ } T m'ti II . J... L1 ;..r;.::Jn ~ r~(~/~)//Jyfl\'IIIf ~L Irs ()~ ) -r )Ol'lf~q:,~~lP-JD ~!f~(l(J I'1v ':-" CHG TMT ~(/' ~~ ~- I~a. ~//.'/J ~/ ~(f("J 1Jf~_ '~n "r tW- ('.,/- (~ MO. DAY YR, TREATMENT VAS APPOINTMENTS & MISC. PATIE:NT NAME RALPH I JBST. ",. , -' CTMTHG MO. DAY YR, TR~JMENT ,IJ.,..... . (f "/./, '7- J z.. ('fJ). N"f.}J~ ~ 1"_ f2rmb H--ID (Ll~ L 1.S. ftJ s G- 'Pl;- U'W~J L nJ ()l.. J.h-vw? IJ.7l ?/> r/2 J/l . ~k /Ar kL.'X:" /. ~.i1.11'~ 1~/~ L .L ~.. )~, d.. Z&I1- OA '1<0Q, 111;;( )/R) 'g.'II?l-!_ l.t7 ?.- 2 ~ )~'w ~-l~ ~~ (" r.I/'/f(jj r~L_.'J:. '# "~~_ ..~.. '<, tf\ )Jr,.;,1 ~ 14 '1lN;I . '.D "',,1 Ibh-r9 C<9.. ~ .h. I/pw '~-::> f\~ ~IJ-- 7'1... !f~l~I()(('ilitt'n~c1f),...1If11i . ~ ~ I O-~ IJ-,/ti .f. i :LI1 /YtwI; ).(j /hi..? -r /"'Uf'1/~ {~d. ?? 10 01), HIi1t-",piC1!ti/2dllf1014'1f/)j <' 4w IJ'-I~ ~i"\~(fv1.v rA_ ~')1-- ~ ,I. '>)); j';- OlfL L 1 1'\-- J~n "'~ ~I /1- Q. i;1:i~. ' , '.I t;J ":\ J lj rn }~h; 11' Z1 ~.P ~lD (i){JwJ,/ l' ,jJd.tt:/5j;.. .. I) W... ~ I~ 03 l~f1"P hf II. (b;,'dli,ffr...JrJ Jl.{) ~)t (L~Of, J.o!i'<j~ 1''-;(1., .~ 7/ 1M J;-}MJJ J)I-. Ii" ~_D /V :) .M)J:I1f!>c 1!J4tctiJ~, ~ ;,,1 ~ w k'\ lrtJ'l'l; hf'~r ~~ ^^ I~ 7'71 ~)Lvr .-j-==- .14,(\':~&' ~, 3 zt 7P> Jh...o ~ '~; roi ",fl I~'.C: 2b~~'~ (Jq1, 3 ,) fR ~ II - 7.t' hh 10 ~{lrp_ iJ.vj Ll U r\<. ))y"j~(jq/,r-....l~ (6" I C G-j~~l. ~/7 -;;. ~' -J ~~ i ~ I/f,-{ fYn~lf)iT tZ'4I.4fl, '>,0 fL\~.. ''L,' J..th u.'i~ /f'f1 7] I) o.li? \ I ~-.L v rr .II)J- ,21j,?~ J-u 'r'-k f.:~ P:u..t ~ w. \ 10 C~ t\;"" \ (~f. rf (-~\ rT -Y /CI t, _ 'Il. (' i/JA: 1 ~ 1, '( \ 0:\ IJ,'..p)Vt1J k"~ IY./O '-'" I-(~~.J h(~, fU)~ _ ill I-L () ~ HmfJ/)Jf4iJ tr.-f;j 'mJlYJffJ IL f) /~ W I') \ ,{/\f4, MoI\.~ "'~- lJl t', O~ ~\iC'~hth~rl tl. ,n I 8< e P I/.K (~irt-7J,.lll"~ I" f~.J '//,'/1 lP q D'J. 1f/)1/JIJJ3/R- 11$ ,Vlf4'1?;iJ ~~'.:;-; C J,m (~/_ 1A.17~~ ~' 'H;;J. U)~ r\ )~)n JT' rJj ~1t:A\ rJi,v (:fJlJ{f,.I1IL~ J ( . ~ ~ l)/.I rt-..JJ.,[.; 'i",,_ I, tK~ ,':t '~ ~~\~!,~'r~~~ I:;::::>;f/_?<P:fhr :rfl. 7, 11 f\7- .v/^ lti" J T~ WI lth.:iJr ),;) fI'-/~(gy '~ till, v'f'/i.V/1Il I~ t '51'; .~~ I~ t{ J( (J) ('rrp,f r}<;) f'J.,l4k-'. (,,j (j~- ,..l ') 7 f -. ) ~/trJ, u f, ~I/.~ Nil ~1'f Ill' ( ,lfK"'- ,;: -=y J) I I'~ PI' I U~~>fl -l.'D " *- f-k.O ^'&. 'R-I t- ,] ft -:J,., {LE f)lr.>c --U~ )..)U,~-; 'n'i.o . t /I..V',i;~1.-in / VAS APPOINTMENTS & MISC. NAME CHIROPLUS OF LOCUST LA! RALPB P'ROBST ~ . Dr. Randy Frederick CASE # AGE ..... 10- (,-19-27 15.0.B. Occupation c; 10 DATE DATE DATE Prone Examination DATE { ( /{):;q 7-Il-bJ - (% J).. \ \ \7\ U' ABDOMINAL L R & oj ~ ~ l' ( 1-63 - e--~~ttlYl- j;v( fUr 6-r ri()( fL.t ~r (4/) t4'D ~.... p~ tlvC~ (gJ;c.A1 ~1 POSTURAL L o~w hand r L or R lateral pelvic translation L or R forward hand _! forward head carriage ---l L or R cervical lean '; Other _-I- Total Posture Points 1___/ r:y/l,;t'>...::;' }<{ "1~(~i}3 -::: (lu) ~ = ..f ~ 1 /(",;, -; tv..! b~ +- t.{ MURPHYS L R Exam 1 Date II-b'O l. Exam 2 Datj".lI.o'6 - ~ Exam 3 Date ')).. w.J'L eJo (.- Total Points 19 )~ CHIRO~)PLUS .'1:.--" :Randy Frederick, D.C. 4607 Locust Lane : t, Harrisburg, Pa. 17109 Of Locust Lane Pain Relief Center (717) 545-6063 fax:(717) 545-8510 -----~ -,---~--- ---- August 28, 2003 : Joseph Dixon Anomey At Law 126 State Sneer Harrisburg, P A 171 0 1 RE: Ralph Probst Claim # 15545068303K4 Date of Accident: November 21, 2002 Dear Attorney Dixon, Enclosed you will find my final report for my patient Ralph Probst for injuries sustained in an automobile accident on November 21, 2002. Along with the Final Report you will find the balance due Chiroplus of Locust Lane. Medicare did pay on his claims but maxed out - you will also find enclosed the itemized ba1ance sheet of unpaid claims and a reduced payment from Medicare with the correct amount which is $3150.54. If you have. any additional questions please don't hesitate to contact l)I() personally. Sincercly, iJUvDll ~redericli, D.C. Enclosures . / CHIRO~Pr.US Randy Frederick, D.C. 4607 Locust Lane . . . Harrisburg, Pa. 17109 Of Locust Lane Pain Relief Center (717) 545-6063 fsx:(717) 545-8510 Final Report August 19, 2003 Allstate llIsurance Company Claim 0ffice Attn: Dave Moody 6345 Flank Drive, Suite 1000 Harrisburg, P ^ 17111 RE:Ra1phProbst Date of Accident: November 21, 2002 Claim No.: 1554506S303K~ Dear Mr. Moody: On December 11, 2002, Mr. Ralph Probst, a 75-year-old Caucasian male, presented to our office for injuries sustained in an automobile accident on November 21, 2002. Enclosed is a final report Q!lsed on examination findings of July 11, 2003. Chief Complaints The patient's chief complaint were that of lower back pain, mid back and neck regions, left knee, right ann and sboulder, and right band pain. The patient graded.liis painusing a Visual Analog pain grade scale ('1 AS). The patient had a substantial reduction in pain grade. Upon date of the his final treaunent andeX8Juination on July 11, 2003, his VAS pain grade was 1.0: luitially, the patient presented with a VAS pain grade of 10.0 out 10.0. Although the patient's pain grade of his symptoms IS down to 1.0 at present, the patient does continue to have periodic exacerbations of his symptoms and may have days where his VAS pain grade can be much higher than 1.0. These symptoms are a direct result following the patient's automobi\(: accident on November 21, 2002. He stated he has made substantial improvement with treatment. The pati,ent does not have the constant severe pain. " Examination Findings The following findings are based on an examination, which was performed on July II, 2003. Patient's ~eight 6'1 Yo"; weight 190 100; blood pressure was 120/90; and pulse was 72. Cervical range of motion with pain or stiffness left rotation 60 degrees.stiffness; right rotation 60 degrees stiffness; left lateral flexion 30 degrees stitfuess; and right lateral flexion 30 degrees pain. Lumbar range of motion with pain and or stiffness, flexion 50 degrees with pain; ex1lension 30 degrees pain; and left lateral flexion 20 degrees with pain. Positive cervical orthopedic tests, apley scratch test was positive bilaterally,lumbar orthopedic test, nuero10gic stress test was positive 011 the right side, Palpation revealed right cervical myospasm on the right side, suboccipital cervical regions, cervical fixation CI C4 C5C7 noted on the right. Right =vical myospasm noted, left lumbar myospasm noted L3 through LS region ;::: with lumbar spinal joint fixations L3 U L5 and left SI region along \'lith trigger points to the right trapezius region. Diagnostic Impression 1. 724.8, Acute Traumatic Lumbar Facet Syndrome, residual 2. 847.0, Cervical Acceleration I Deceleration Disorder, slight residual 3.739.2, Traumatic Thoracic Spinal Joint Dysfunction, resolved 4. 739.3, Traumatic Lumbar Spinal Joint Dysfunction, residual 5.739.1, Traumatic Cervical Spinal Joint Dysfunction, residual 6. 739.6, Trauniatic Left Knee Fixation, residual 7. Suspected Traumatic. Activation of an Arthritic Symptom Complex to the Lumbar Region, residual . . Prognosis and Treatment Plan 10 my professional opinion, based on this patient's history, examination findings, x-ray findings, and symptoms, his injuries are a direct resn1t of the automobile accident on November 21, 2002. This patienr has made substantial improvement from his original presentation to our office on December 6, 2002:Hease note that this patient's last date oftreatmenr for the il1juries sustained in the automobile accidenr ofNovemher 21,2003, was July 11, 2003. It is my professional opinion that this patient has sustained a permanmt soft tissue injury to the capsular joints of the lumbar cervical spine along with a permanent activation of an arthritic symptom complex, which was aggravated by the trauma of the automobile accident The :patient also has sustained a permanent soft tissue injury to the right sJloulder. This patient filled out a revised oswestry low back pain disability n"1d<:x questionnaire. The patient's score was 28/60~47 percent disability. The patient also filled out a neck pain disability index questionnaire; his score was 23/60=38 percent disability. Copies of the questionnaires are enclosed for your review. Initially, the patient's examination score was 39 positive findings out of a possible 100 points. The patient had made a 17 percent improvement with residual of 32 positive findings. These questionnaires along with residual cervical lumbar spinal joint dysfunction and pain on range of motion, my.ospasm, and trigger points are indicative of a permanent soft tissue injury. It is my professional opinion that this patient will continue to suffer from a permanent exacerbations of his symptoms. Although, on date of reeva1uation, his symptoms were substantially reduced, it is most likely he will suffer from continned periodic exacerbations of pain to the cervical and lumbar regions along with right shoulder pain. This opinion is evidenced by the patient's permanent pain on range of motion, permanent cervical and lU1llb:,u' spinal joint fixations along with the trauma to an arthritic region in his lumbar spine. It is my professional opinion that the automobile accident will advance the arthritic changes in his lumbar spine, which will result in permanent symptoms to the lumbar spine. lfyou have any questions pertaining to this case, please contact this office at (717) 545-{i063. Sincerely, ~tr1LlC, . ~pJrederick, D.C. Enclosures cc: Joseph Dixon, Esq. . . Claim History Otl-Z!l-z003 . .._ ..... ... ~ ~.1,. , ........ .L J..L "'.LJ..I..l.1U,U.U. J.J.w.L.I,w.L ....1......... '" I J l' 11.1.......______..__ RALPH PROBST Ca6e: MR' Account 187l1.....date: 08-28-2003 Pt Portion:.OO Balance: 315~~ 2425 GARRISC~, AVE Last Visit 07-11-2003 HARRISBURG PA 17110 Home: 545-4915 Work: Payor Primary: MEDICARE OF PA Secondary: Altyl3rd: JOSEPH F. DIXON Contact Phone 763-5700 233-8757 Date Printed Amount Service From Service To Payor 12-13-2002 705.00 12-12-2002 12-13-2002 ALLSTATE INS p 396.49 Type Amount PaklDale Paid TracerDate 12-16-2002 150.00 12-16-2002 12-16-2002 ALLSTATE INS P 105.87 12-18-2002 150.00 12-16-2002 12-18-2002 ALLSTATE INS P 105.87 12-20-2002 150.00 12-20-2002 12-20-2002 ALLSTATE INS P 105.87 12-23-2002 150.00 12-23-2002 12-23-2002 ALLSTATE INS P 77.87 12-27-2002 300.00 12-27-2002 12-27-2002 ALLSTATE INS P 105.87 12-27-2002 150.00 12-27-2002 12-27-2002 ALLSTATE INS P 105.87 12-30-2002 150.00 12-30-2002 12-30-2002 ALLSTATE INS P 105.87 01-03-2003 115.00 01-03-2003 01-06-2003 160.00 01-06-2003 01-03-2003 ALLSTATE INS P 01-06-2003 ALLSTATE INS P -~-".-, 12-27.2002 01-06-2003 01-06-2003 01-06-2003 01-15-2003 01-27-2'003 01-27-2003 01-27-2003 119.45 01-27-~~003 01-06-2003 150.00 01-08-2003 01-08-2003 ALLSTATE INS P 105.87 01-10-2003 150.00 01-10-2003 01.10-2003 ALLSTATE INS P 105.87 01-10.2003 150.00 01-10-2003 01-10-2003 ALLSTATE INS P 01-13-2003 150.00 01-13-2003 01-13-2003 ALLSTATE INS P 105.87 01-15-2003 240.00 01-15-2003 01-15-2003 ALLSTATE INS P 144.51 01-17-2003 150.00 01-17-2003 01-17-2003 ALLSTATE INS P 105.87 01-20-2003 150.00 01-20-2003 01-20-2003 ALLSTATE INS P 105.87 01-22-2003 150.00 01-22-2003 01-22-2003 ALLSTATE INS P 105.87 01-24-2003 150.00 01-24-2003 01-24-2003 ALLSTATE INS P 105.87 01-27-2003 385.00 01-27-2003 01-27-2003 ALLSTATE INS P 168.92 01-29-2003 150.00 01-29-2003 01-29.2003 ALLSTATE INS P 168.92 01-27-:1003 01-27-:2003 01-27.2003 02-03.2003 02-10.2003 02-10.2003 02-14.2003 02-14-2003 02-1 fl-2003 02-111-2003 } /5', 1)0 } 50 _0 '0 V\ ~ CI "0 :) u- o - o' :J ;0 o :J CO CD '" ;;:: o - ,5" :J z 0(0' 3~ CD 'U o -+ <D- ::J , '" ~ ~o s.~ SG-o -00 en.[- 0- &~~~ c ....0" CD 0- " CD CD CD ~~ U ~. ,- <l) 0"""'" (/) ii~\f ~ I . z o 3 CD I)J ~~ .--L ' . "1JZ cvtOC u>~3 (;ri<'Q" CD"( o o 0> en . ~ ~ ..0 . "'- ~ (j) ""- ~ uJ 0 ,.... > ~ ~ r- - . - (j) 0 > r- - ~ (j) I 0 > r- '- - (j) 0 > r- - - (j) 0 > r- - r- ~ > r- - r- (j) 0 > '- r- - (j) 0 > - r- , - . <.n l:: ~ J>, <.n <.n <:> <.n <.n ~ 0- <.n ..... <.n 0> <:> ~ 8 - r:---:- :\> r -V <:> <.n <:> "" <:> ~ l:;: ..... <:> g:.C3 -0 o S' c;r ~2. 0" a: o - en 0 ~ .,J~ O~ o - enS. '"'"""" ~ o ;;p -r -, o 9- "" CD o o (,,> en '"tJ a :::!: CD ::J - o 9- <.n CD '"tJ ... o <C ... CD en en (i) ... a "C ':T o 9- J>, CD o Q 0- iD o 9- ..... CD "T'l:rn-r-rn:::Q zO-....()m""""O() m()Z>Zm....Z->:s:: KEVI~O O$WESTKV LOW lI4CKPAl~. .D,liABILlTY QUfSTIONNAIRf "'1J(~D -;. ~ PLEASE RE.J.o. This questionnaire is de$igned to enable us to understand how much your low hack p';;;;-\;'~s dl({'(Il.'d I .1biJily 10 man.age your everyday aClivities. Please answet.each"se.::llon by circling lhe ONE CHOICr Ih.lI mO!i1 applies YOU. We realize Ihal you may (cellhal more Ihan one stalement may rei ale 10 you, bul PUIISE lUST CIRCLE THf ON CHOlet WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM I~IGHT NOW. SECTION I-J'ilUt Inlemil)' SI.'CTION 6-SlMWiinl . . A, The pain comes and soes and is very mild. A. I can sland as long as I wanl ~llhoUI pain. B. The pain is mild and does nOl vary much. <. 1-- ~~ I have some p~in while Sl"nriln~. bUI II rloes nol The pain come$ and gOft and is moderate..J ' n\ increase wllh lime. . The pain is moderale and does nO( Vilry much. \l..S-' I c~nnol sland ror lonF;er Ihan 1 hour wilnoul incrp~ f. The pain comes and goes and is severe. palQ,~ '. . . f. The pain is severe and does not vilry much. 0, I cann~ sland (or longer Ihan 1/2 hour w"hout IncreaSing pain. SlCTIONZ-I'ffSlJllYl c~~ E. I cannol st.and (or longer Inoln 10 minutes wilhoul A. I would not have 10 change my way o( washing or increasing' pain. . . dreuing in order 10 avoid piin. "2.... F. f avoid sl;mdinR. because il increase~ Ihl' PM" slralg B; "I do not: normally cha,nRe my way of w~s.hinR ex V away. dressing even though II c.u.... some palO. Washing and dreuing increa.... .he pain, bul . manage not to change my way of doing il. 0 O. Washing and dressing Increa_ the pain and I Hnd il nKe$sary 10 change my way o( doing il. . f. Becau>e o( Ihe pain, I am unable 10 do some washlOg and d'e~inG without help. f. Becau>e o( Ihe p.in, I am unable 10 do any w..hinS 1)r dr....ing wilhout help, SECTION J-Lihill8 A. I can lift heavy weighls wilhout exlra pain. :>:-- I can 11ft heavy weighlS, but it cause$ extra pain. C. Pain plevents me (,0m lilting heavy weights off the Ooor. O. Pain prevenl. me (rom lifting heilVY weights 0(( Ihe Ooor, bull can manage il Ihey are conveniently positioned, e,g., on a lable. E. Pain prevents..me (rom lifting heavy weishts, bul I can manage lighl 10 medium weighlS illhey ilre convenienlly posilioned. O. f. I can only lilt very lighl weigh!>, al the most.. SECTION 4-Wollking ').... A. Pilin does not pr~venl me (rom walking any distance. Pain prevenls me (rom walking more Ihan 1 mile: I C. Pain prevenls me from Wilking more Ihan 1 /2 m~le. D. Pain prevenls me (rom walklnll more Ih.n 1/4 mile. E. I can only walk while using a cane or on crulches. f. I am In bed mn~ o( Ih€' lime" ilM h.1Vf' 10 rrilwllo the loilel. SKTION5~m~ ~ .1\.' I can sil in any chilir ilS long ilS I like Without pain;,) B. I can only .il in my lavorlle chilir as long as I like, Pain prevents me Irom sining more lban 1 hour. Pain prevenls me Irom sining more Ihan I 12 hour. f. r .Iin prevenls me from sining more than 10 minutes. f. Pain prevenls me from sinin~ al all. / SECTION 7-S1~nl A. I get no pain in bed. B. t get pain in bed, bul il does nol pr~venl me Irom"Z sleeping well, .,' V ~I 8ec~u5e of pain, my normal OI~ht S !iIPPp IS reduced leu than one"quaner. O. Because of pain. my normal ni~hl'~ ~h'('p is reduced Ie.. Ihan one.half. E. Because o( pain, my normal nighl" ,loop i, reduc"", Ie.. Ihan Ihrce-quane... F. Pain prevenl. me from sleepin~ al all. Si:cTION s-Sociiil L if. A. My social life is normal "nd give, me no p,lin, ~) M~ sociallile is normal, bUI increases Ihe desree of pa~ . . C. Pain has no siHnWcanl effecl on my 'oClal life apan limiling my more energl'lic inll'rr:'ib, l',R., rl.lnrinJ;. t: Pain has re.uicled my social life ano I rio nol go ou very often, f. Pain ha. reslriCled my .ocial li(e 10 my home. F. I have hardly any so<iallife ""c.luse of the pain. 51KT/ON '-Trneling A. I set no pain while traveling. B. I gel some pain while Iravelin~, bul none o( my u'u forms of Ir.lyel make il any worse. /(:')1 ~el exlra pain while IravelinA, hUI il rioe. nol coml \....:: me 10 seek olhernative (orms of Ir .wel. D. I sel exua pain while Irawlin~ whirh rumpel, me II seek ahernalive (orms o( "avel. , e, Polin reslricts all lorms 01 Iravel. ~ F. Pain prevenlS alllorms of ""vel eXCer' Ih.ll rione Iyi . down. S,KTION IO-Clwnlinl D~gfff of Pilin d--- ^. My pain is rapidly gelling beller. ((11';> My pain "ueluates, bUI overall i. ddinill'ly gelling [ --C. My pain seem. 10 be gelling beller, bUI improvemeo i2 ad . /l tJV .Iow al ",,_nl. SIGNATURE: ..~ ( ".~. O. My pain Is neither 8elling bener nor wor'e. f, My pain i. gradually worsenlnll, ? .- t' / /' C/ ;> f. My Wlin i. rapidly wor>ening. . . ~ DATE: r; - ( I .~ () ~ '--=-=~~-""~E~~ ~ISAB~~:~~'~N-;;;~=r.M."fJ~7~'~""Ji;C;;:/"'-'""l Plean Read: This questionnaire is designed to enable us to undemand how much your neck pain :\ has affecte.d your abUiry to manage your eve.ryday aClivities. PI"a.e answer each Seelion by circling i the. ONE CHOICE thaI most applies to you. Wc realize Ihat you may feel thaI more lhan one Slate. ~ ment may relale 10 you. but PLEASE, JUST CIRCLE THE ONE CHOICE WHICH MOST } ~~~~:: ~~~~~~~!~~~~O~~~~~~~l!~~:~~~~~,~~.~~~~~~~~,.'~r_~'.',~_~~~~i ScclIoa 1 - hla laleasl!)' ~ 1 baw DO pala 1.( tbe mOm~nl. B The pain it yery mild ill Lhe momenL. ne p.a.1.n i5. moderale .II {Ii( moment. o The pain is fairly severe al the COOm.eol. E The pa.iA is very $(:vere i1t the m01'l'1enl. F The ';. tbl: warS( ima . able al lbe moment. PATIENT DATE: J: .SoodI....:t - ............1 Can (Wasbl"&, Dn:ssl"80 etc.) , IA [Call look .trel m~lf Donnallv wllhoul Cllll5ing enra . ,~. " ~J>I'll. J- , I can \001 altcr my>tlf normally, but it ClIl$<:S cXlra pain. . \ It i. po.infuI to look altcnD~clf ...d 1 am slow IUld cucful. o I aeed ..,mc help, bUI monge most of my p"noDal ca.n;. E 1 lIeed help C'lCry day ;" mOl( lLSpecu of .elf CAte. F I do nOl el drc&5cd, I wash wilh difficul and ",y ia ~d. Seal"" 3 - UftI.... A I Call lift bca", weighlS without eXlra pain. ).. I <:.ulil\ beavy weigh~,buI II givc. e:<tra pain. e Pain prevcnl$ mc Irom lifti.ng heavy M:ighLs off the 11001, but I c.&Ilmaaagc if Ihey are conveniently posilioned., lor tllIJIlple, onJIolable. o PaiD pmelll.llll~ fro", J.iJ\ilIg heavy weight), but I Call m~ light to medium _ights if (h~ are coavellietly !">"itlOae<l. E I ..... 11ft very ligh' weights. F I ClUlIlOlIift or carry atI~bi al all. " SectMA 4 - Rtalll~ ::L . .. I ~ IUd as much as I Watlt to with no pm in my neck. II I Call IUd a.s much as I WOIlt 10 with slighl pain in my aed. C I Call rcad as mueD as I ~t with moderale p&in in lilY ""lI. D I ~ot read &3 muc:h as 1 ~t bc.ca.usc of moderale po.ia iD my neu. E l~r""datall. SectIOD 6 - CODCeDlratloD .., A I can (;onc,~ntralc fuJ.l)" wh~n 1 WOlnt to vw;(h o<1'a!mculty: I C~" €;onc.entrace full)' when I want 10 witb s.lig..bt difficult)'. C I have a Ia:ir degree of dlfficuJry in conccDtfJuing when I want to. D 1 have: a.1Q'i or diCTiculry in COQC'c.nlrarlng wben I wa.n( to. E I h..ve.8. great deal of difflCU.lty io conce.olrarlng when 1 wa.ot to. F I cannQ{ c'~occa{ratc at all, ~\Oll 7 - w.."' ^ 1 (;IW do lH. much work.'as 1 want la, B I Carl only do my usual work, but DO more. I can do OIOsl of my usual worll, but DO Illore. I cannot do my u.ual work. E I can barcUy do any wOlk at ..u. l' I ca.nnot (10 any Work .\ ill. ~oa S - D1~vl"l 2- A ] ea.n drive lilY ClU' without acy Deck pm. I can drive my ClU' l.'i long as I WaDI with slight pain in lilY Deck. e ] can drive my cu ./..lollg l.'i I w.nt wilh moder~te pain in my Deck, D I cannot <ir;.,e my car u long as I wan' bcc.ouse or ltKXIe"l< pm In my neck. E I CAll h.,.dly drive at all ~cau.>o of ~ro PJ.in i.o ary neek, F ] Cinnot drive my car at all. ...., . > SectJOIl 9 - Sleeplpg A 1 bave DO trouble sleeping.. B My $!<<op i. &lightly di5turbed (Ie... tbon I hour .lcepJ=). e My .lccp is mildly d.lsturbed (1-2 boun sleepl=). My .Jeep b moderately d.isturbe4 (2.3 hours .Jeepl....). My ,leep if V""tlr. dl.tW't>ed (3-j hours sleep]"",,), M slee ;. com etel di.stU'bcd (5-7 hours lIe<:ples.s). S<<UolllO - JLe<raUoll s...u"" 5 - K......elo... A I ..... able to eng.asc IA all Qf my reacatioDaI ac.tivitie.l., A I ~ DO hcadaeb.. at all. J- with ao D"ek pain II ill. I b.aw'li6ln h...<IIchcs which c.o<ne infreque.ntly. I am Ible to eftP8".in ill of my r"",cat.io.n.aJ IctMtiea, I....... modera.e beada<:bca which come iDlrequently. wilh som.. paI.n in my.ned:. D I ba.~ moderate beada~ whIeIl come lr,eq~glly. C 1 un .blo 10 C"PCC lJl "''''1, blJt _ all of my U6u.a1 e 1 b...". severe headachc6 wllkh come hcq\lellUY. rc=.\iQI~I.<:tiviI\e$ ~ClI""" Qf pai.II iD IlI'f lleCk. F I ~ be.....~"<, aim"". alllhe~, . . D I..... able 10 e"Pl'< I.n. a f... of my usual reacatlOJUU .,' o,etiYiti.. l)eQuo.e of' pm I.n. my oed. R . fqJ.... Af1C1 V"""'" ol Ml<<, 19'91 E I (:Il.ll wdly do any reere&tioDalaeliviti.co bec:a~ of pAin ..."....,.. 'J~f1"oJrh.Jocun"'Ol.MiRljJ1l'Jllltv>tlDld inmyDC<;k.. '" 170 cs F I ea.DDOl.iIo reacatlonal .otivitics .r oil ~ 10(1...,1 /j _/ a:)Quncnts:,/~ c;. red" ~ p~ .~d O--'/"'../.../ '(')..('01 SIGNATURE'_Ll4"'.'-'j'~-. '. '7--r(- Cl_~ '. ~~ ~ .~. ,4~ " tl", :-'?5ir ~r~~" ~~)~1.\.:P _ ~"-::;~:d,",J-'" November 9, 2004 Joseph Dixon Attorney At Law 126 State Street Harrisburg, Pa 17101 ~iro ~us of st:ocustst:anfJ 4607 st:ocust st:ane. %rrisburg, ~~a 17109 (717) 545-6063 fax: 545-8510 %ndy 3. 'Zlrederick, ~.qt. RE: Ralph Probst Claim#15545068303K4 Date of Accident: November 21, 2002 Dear Attorney Dixon, Enclosed you will find the outstanding claims and n,;}tes for Ralph Probst. The remaining balance due on his account is $2805.00. Should you have any questions pertaining to this case, please contact me at (717)545-6063. Sincerely, CfL LuJJLl~/1?fvU Chrissie Pezzuti Office Manager . . . CAlS/ aNTBtSb'MB/ICAIIE,l/I1JtCADstIYKB I Q MUTUiJWOmiJHiI MUTUAL of OMAHA (NSORANCE COMPANY Medicare Area P.O. Box 1602' Omaha, NE 68101 I 866 734 1521 (For Provider Use Only) www.mutualmedicare.com A CMS Contract~d Intermediary March 2:5, 2004 LS JOSEPH DICKSON ATTORNEY AT LAW 126 STATE STREET HARRISBURG,PA 17111 Re: RALPH E. PROBST HIe No.: 195-16-3609A Date of Accident: 11/21/02 Dear MR. DICKSON: Enclosed is a copy of the Claim Reimbursement Summary which includes the total amounts paid by Medicare for each intermediary and carrier. These amounts are subject to change as more claims may process. When imal settlement has been reached, please provide written documentation on vour letterhead that includes the date of settlement, the total amount of settlement, the attorney fees (exact dollar amount) and percentage, and an itemization of other costs directly related to securing the settlement or judgment. Once we receive th,~ statement, we will contact the other Medicare contractors involved for a final amount and then we will calculate the total Medicare payment to be repaid. If a liability insurer sends you a check intended to repay Medicare benefits and it is made payable to you, Medicare and other parties, Medicare cannot endorse th,~ check and send it back to you. Federal regulations require that all other parties involved endorse the check first. Medicare will then deposit the check to satisfy the conditional payment and the remainder ofthe proceeds will be returned to you. Medicare will not provide updated amounts until we have received settlement information. However, Medicare beneficiaries do receive Medicare Summary Notices which may help you determine which claims have been paid by Medicare. Please ke:ep in mind providers have up to two years from the date of service to submit claims to Medicare for processing. 85084473.913 '" z.<; 0'" _E ~~ ::01ii W::l 1-'5 -::0 0 CO CO CO 0 '<t '<t '<t 0 ai ai ai * ..- ..- .... l() It) It) EI7 * * Iii D:: <( U , i5 w I- :!! z en fa W Ql ~ u I- '2: l- ll) Z lI) Z en D:: Ql UJ D:: UJ Z - 0 C/) ~ 0 :!! t;: I- ~ I- , Ql ~ en c: U os a- U - Ql ~ u I- ~ a- t;: CD 'C :J Ql oJ c: Ql I- Ql 0 I- Ql :<i Z :2 , z <( lD "" 0 t; Vl 0 Z Ql Vl U - U 0 :c ::l t;: i= ell <( ~ Q) lD "" .c C,) c: i5 en x Ii: Ql I- ::l UJ D:: C/) CD D:: Z os C: <( UJ Cl <( <( 0 .c :2 x 0 a. J: - a. C,) UJ Z oJ 0 rn 0 oJ oJ <( <( <( CD CD CD lD <( ~ t: t: l- t: t: CO t: I- OS '" 0 '" OS 0 '" 0 0 a- 0.. I- a. a. Q. 0.. l- I- o CO N N :t? ~ o t3 '" ~ 'E o () <( 0 CD ...J f2 :J 0 UJ J: oJ C/) CD c: Cl ~ 0 ~ Z UJ ~ ~ c: UJ OS ~ 0:: Q. X C/) W z :2 '\: I- 0 0 Z I- ..c: 0 0.. lI) :2 ..., ~ Z Z 0:: ct UJ J: b en u Q) .. -g en 0 0 U c: Cl u OS .. is en 0 - ~ Q) ..- 0 -g '<t co -g Ol '<t .!!! 0 ..- '" c: 0 U .... .... UJ N '0 N Cl> Cl '" a. ..,. o o N in ~ o ~$ 0iaxm' ATTORNEY AT LAW 126 STATE SmEET. HARRISBURG. PA 17101 PHONE: (717) 233.8757 . FAX: (717) 233.5860 EMA1L:.d\xonlaw@paonline.com lNWW.dixonlaw.baweb.com April 5, 2004 RALPH PROBST 2425 GARRISON AVENUE HARRISBURG, PA 17110 Dear Ralph: I received the enclosed letter from the agency representing Medicare on your case. Please call if there are any questions. Very truly yours, ~~ JJD/jlw Enclosures 2 If you have any questions, please contact me at the number listed below. Sincerely, ~rrf~ Kaila McGehee Recovery Analyst Medicare Secondary Payer (402) 351-4339 Fax (402) 351-3521 Business Hours 7:00 a.m. - 4:30 p.m. Monday-Friday Central Tiime Ene. cc: RALPH PROBST 2425 GARRISON A VB HARRISBURG, PA 17110 ALLSTATE INSURANCE 4502 DERRY STREET HARRISBURG, PA l71lI FILE COpy . . 1fV~~~ OS~ESTIY LOW IACUAIN 'DllAIIUrr QUESTIONNAIRE '"'l!Xf{,o .; l{iio PLEASE READ: Th,s quesl,onnaore IS. ~'gned to enable us 10 undenland how much your low hack pain'~~s .1(('(It'd your ability 10 manage your everyday aCllvltles. Please answer each'sec'ion by circling ,he ONE CHOler ,h.ll mo.' .pplies '0 YOU. We realize Iha. you may (eel that more Ihan one Slalement may relale 10 you. bUI PLfIlSE JUST CIRCLE THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOURPROBUM RIGHT NOH/, SECTION 1-/1';" IntMSity SECTION 6-J:lMwiin8 A. The pain comes and gars and Is very mild. A. I can sland as long as I wanl wilhoul pain. 8. The pain is mild and dars not vary much. <. 'f-- (!) I have som.! pain while stanrlinH, hUI il doe. nol ~ The pain comes and goes and is moderale..J . A) Increase wilh lime. . . The pain i, moderate .nd does no( vary much. . \l.SI' I ca,1OoI .I.nd lor lonHer 'h.n I hour wi'hnu' incr. ,ing f. The pain comes and goes and i, severe. paiQ.~_ F. The pain is severe and does f10l vary much. D. I canna( st.nd(or longer lhan 1/2 hour wi,houl Increasing pain. SECTIONd2~h I cahre I h' E. I cannot sland lor longer Ih.n 10 minu'e. wilhoul A. I w~1 not ave 10 c .nge my way 0 was Ing or Increasing' pain, dreum8 in order 10 ~void piln. . f. I ..void standinR. because il increase~ lhla polin srraighl 8.. do no( normally change my way of wash,ng or '2.... .way dreosing even lhough il causes oome pain. V . C. Washing and dressing increases the pain, bul I manage SECTION T-SJI.n, /\OlIO change my way of dolng iI. ^ A. I gel no pal/l In bed. O. Wa>hlng and dressing Increases the pain and I find il 8. I get pain in bed. but it does nol pr~ven' me Irorrr'Z. necessary to change my way 01 doing iI. sleeping weill. v f. 8ecause oIlhe pain, I .m unable 10 do some wuhing ~ Bec.use 01 I,ain, my norm.1 night's .It'.p is reduced by and. drcHing without help. less than on,e..quar1er, ' F. Because 01 the pain, I am unable 10 do .ny wa.hing 1)r D. Because 01 pain, my normal nigh". ,I...,p i. reduced by dfftSing wilhoul help, less Ihan one-hall. E. Because o( pain, my normal nighl" .Ieep i. reduced by SECTION J-LihityJ less Ihan three-quarters.. ^. I, can Ililtlt heh avyweighhls Wbuilhoul exlra pain. J.:- F. Pain prevenls me from sleepinH al all. can I eavy welg Is, I il causes exlra pain. , . Pain prevents me (rom lilting heavy weighls off the Roor. SECTION 8-5<JCiclI Life ...A-- O. Pain prevents me Irom lining heavy weighls 0(1 the Ooor, ^. My sociallil'e is normal and give. me no p,lin, bull can manase illhey are convenienlly posilioned, (!) M~ sociallllie is normal, !Jul increases the deSree o( my e.g., on a lable. pa,n. E. Pain prevenls me lrom lihing heavy weighls, bull can C. Pain has no significant effeel on my .nei.lllire apart Irom manage lighllO medium weighls i( they are conveniently Ilmiling my mO'e energl'lic inl.'re".. l'.g., rl,lOcinH. elC. positioned. D. Pain h.s reslricled my social lire .nrll rlo not go out F. I can only lilt very lighl weights, al the most. very ohen, J-- E. Pain has reslricled my weial lire 10 my home. SECTION 4-W.lIkin& F, I have hardl-r any sociallif. bee.luse of Ihe pain, ^. Pain does noc prevenl me Irom walking any dislance. Pain prevenls me Irom walking more Ihan 1 mile. SECTION J-Tw'eling _ ~ C. Pain prevents me (rom walking more Ihan 1/2 mile. 11.. I gel no pain while Iraveling. "' D. Pain prevents me Irom walking more Ihan 1/4 mile. B. I get some p'ain while traveling. bul none or my usual E. I can only walk while using a cane or on crull'hes. forms ollra"el make II any worse. F. I .1m in bed mO'1 01 ,he Ii"", ,lnrl h.we In rrawl,o Ihe ~I He! exlr. p"in while traveling, bUI I' does no/ compel toilet. ~ me '0 seek "hernalive lorms o( Ir.wel. D. I gel exlra pain while trawling which rnmpel. me 10 seek ahernative lorms o( Iravel. E, Pain reSlrlcls all (orms o( 'ravel. F, Pain prevenl,' all (arms of Ir.wel eleep' 111,11 done lyinS dawn. SECTION S-s;nin8 '2.... ^., I can sil in any chair as long as I like wi/houl painJ B, I can only sil In my (avorile chair as long as I like. Pain prevents me Irom sining more t~n 1 hour. Pain prevenls me Irom sining more than 1/2 hour. E. ,.. .Iin prevents me lrom sining more .hin 10 minules. f. Polin prevents. me lrom s.ittinG 011 all. ..2.--- PATIENT SECTION ID-(:lwnging Degfer Df Pain d-. ^. My pain is r;.pidly gening bener. . ~ My pain nuc'uales, bUI overall is ddinill'ly gelling bener. ~ /J "-C: My pain seems 10 be gening bener, bu' improvement is . SIGNATURE-' ~ ~ #- slow at pres<,nl. . . .. '" :",r D. My pain Is neither 8ening bener nor worse. -;2 ;> E. My pain is gradually worsening, . .- / / ..... C/ . F. My pain is rilpidly worsening. DATE: ChiroPlus of Locust Lane 4607 Locust Ln Harrisburg, P A 17109-4449 Phone: (717) 545-{i063 July 13, 2003 MEDICARE OF PA CLAIMS PROCESSING P.O. BOX 898200 CAMP HILL FA 17089-2000 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: Policy: Dear, DOS 7/ll/03 S: STATED IS DOING BETTER IN HIS NECK AND BACK AREAS. TREATMENT HAS HELPED HIS SYMPTOMS FROM THE AUTOMOBILE ACCIDENT ON NOVEMBER 21, 2002. HOWEVER, PATIENT DOES NOTICE THAT HE DOES HAVE SOME PERIODIC PAIN AND SOME RESIDUAL THINGS WHEN HE BOWLS TOO MUCH OR DOES CERTAIN ACTIVITIES. VAS PAIN GRADE 1.0. 0: POSTURAL ANALYSIS UNREMARKABLE RT CERVICAL LFT LUMBAR MYOSPASM CERVICAL FIXATION C5C6 LFf CERVICAL LATERAL DROP PIECE LUMBAR FIXATION UL5 RT SIDE POSTURE RT SI JOINT FIXATION MANIP MANIP TO SACRAL REGION A: PATIENT REEVALUATION TODAY FINDINGS WRITIEN INro CHART NOT DICTATED ON TAPE. IN MY PROFESSIONAL OPINION, THE PATIENT HAS REACHED MAXIMUM CHIROPRACTIC IMPROVEMENT FOR INJURIES SUSTAINED n.. AN AUTOMOBILE ACCIDENT OF NOVEMBER 21, 2002. PATIENT WILL BE RELEASED FROM CARE FOR TREATMENT lHOSE INJURIES FOLLOWING TODAY'S TREATMENT. IT IS MY PROFESSIONAL OPINION, THAT THIS PATIENT HAS SUSTAINED SOME PERMANENT DAMAGE TO THE CERVICAL LUMBAR REGIONS TO THE JOINT AND MUSCLE AREAS TO THE FACET CAPSULE AND NERVE AREAS IN THE CERVICAL LUMBAR REGION DUE TO THE AUTOMOBILE ACCIDENT. IT IS ALSO MY PROFESSIONAL OPINION THAT THIS PATIENT WILL CONTINUE TO SUFFER FROM PERIODIC EXACERBATIONS OF SYMPTOMS DUE TO THESE INJURIES AND WILL MOST LlKEL Y HAVE AN ACCELERATION OF ARlHRITIC CHANGES TO THE CERVrCAL AND LUMBAR REGIONS DUE TO THE TRAUMATIC INJURIES SUSTAINED ON NOVEMBER 21, 2002. .. P: IFIHMP TO CERVICAL LUMBAR REGIONS/CONTINUOUS ULTRA SOUND TO CERVICAL LUMBAR REGION/INTERSEGMENTAL TRACTION TO THORACIC LUMBAR REGIONIMANIP Sincerely. RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST vINE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 March 22, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 3/21/03 S: STATED HE CAN FEEL IT IN HIS LOWER BACK. PATIENT LIKES TO BOWL, ONE OF HIS ACTMTIES OF DAILY LIVING-HIS HOBBY, INTEREST. HE NOTICED AFTER BOWLING, HIS LOWER BACK FLARED UP. VAS PAIN GRADE 2.0. SOME DISCOMFORT THE OTHER DAY IN HIS LFT KNEE. 0: LFT KNEE FIXATION EXTREMITY MANIP POSTURAL ANALYSIS RT LOW HAND LFT LATERAL ILIUM MANIP RT CERVICAL RT LUMBAR MYOSPASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL MANIP LUMBAR FIXATION L4L5 RT SIDE POSTURE MANIP CERVICAL LATERAL DROP PIECE FOR CERVICAL MANIP UL5 RT SIDE POSTURE RT SI JOINT FIXATION MANIP ,. A: SLIGHT FLARE UP P: REHABIIFIHMP TO SHOULDER LUMBAR SPINE AND LFT KNEE REGIONSI15 AND II MA'SlINTERSEGMENT AL TRACTION TO THORACIC LUMBAR REGIONIMANIPIWILL SEE 2X WEEK FOR 3 WEEKSIWILL SEE ON MONDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. v..-""''''-:,, _-"-"-,,..,,,_".,.-.,.," CLIENT'S PERMISSION TO RELEASiINFORMATION TO :.( )\,y ~$ \ ,V) \)-( It..CA--'i \ e~~. ..' A-'v--<.\..-') Y-Y:'( <>\.i.n (~ . \ '..-.L'M.. DATE: '3-- 1\ /.7) This is to advise you that I have retained Joseph attorney to represent me in all matters concerning ~Y\6 hi .r ~ Q.,;IM.J...- ('-(A..x.. ,\...t."J"-' J.. Dixon' as my . mj I hereby authorize and request that you release to my attorney any and all .information ,which he requests in oI:der that my interests can bestbe'.!?erved. ~~ a&t CHIROPLUS OF LOCUST L4NE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 March 18, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SIDTE 1000 HARRISBURGPA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 3117/03 S: STATED VAS PAIN GRADE 2.0. A LITTLE BIT OF A FLARE UP IN THE LFT KNEE TODAY. 0: RT CERVICAL RT LUMBAR MYOSP ASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL DROP PIECE WITH CERVICAL MANIP LUMBAR FI)(ATION UL5 RT SIDE POSTURE RT SI JOINT FIXATION MANIP TO SACRAL REGION LFT KNEE FIXATION EXTREMITY MANIP LUMBAR FIXATION UL5 RT SIDE RT SI JOINT FIXATION MANIP A: IMPROVING GRADUALLY P: REHABlIFIHMP TO CERVICAL LUMBAR LFT KNEE REGION/lNTERSEGMENTAL TRACTION TO rnORACIC LUMBAR REGION/MANIPIWILL SEE 2X WEEK FOR 4 WEEKSIWILL SEE ON FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST L4NE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-60113 March 16, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURGPA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 15545068303K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 3/14/03 S: STATED TODAY HE HAS A FLARE UP. CAN FEEL SOME PAn" IN THE BACK AND NECK AREAS AND IN THE LFT KNEE. VAS PAIN GRADE 2.0. 0: LFT KNEE FIXATION EXTREMITY MAN1P POSTURAL ANALYSIS UNREMARKABLE RT CERVICAL RT LUMBAR MYOSP ASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL MANIP WITH CERVICAL DROP PIECE RT SIDE LUMBAR FIXA nON UL5 RT SIDE POSTURE MANIP RT SI JOINT FIXATION MANIP A: SLIGHT FLARE UP P: REHABIIFIHMP TO LUMBAR LFT LO.WER EXTREMITY KNEE REGIONIINTERSEGMENT AL TRACTION TO THORACIC LUMBAR REGIONIMANIPIWILL SEE 2X WEEK FOR 4 WEEKSIWILL SEE ON MONDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. . CHIROPLUS OF LOCUST L4NE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 March 16,2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 3/12/03 S: STATED CONTINUES TO IMPROVE WITH CARE. HE STILL CONTINUES TO HAVE PAIN IN THE NECK AND BACK AREAS, BUT HE IS NOTICING AN IMPROVEMENT WITH TREATMENT. HE STILL IS HAVING DIFFICULTY DOING HIS HOBBIES HE LIKES SUCH AS BOWLING, BUT THE OTHER DAY HE WAS ABLE TO BOWL A LITTLE BIT BETTER VAS PAIN GRADE 2.0. 0: POSTURAL ANALYSIS RT LOW HAND LFT LATERAL ILIUM MANIP LFT CERVICAL LFT LUMBAR MYOSP ASM CERVICAL FIXATION C5C6 LFT LATERAL CERVICAL MANIP LUMBAR FIXATION UL5 LFT SIDE POSTURE MANIP LFT SI JOINT FIXATION MANIP TO SACRAL REGION A: IMPROVING P: REHAB/IFIHMP TO LUMBAR SHOULDER REGIONSIINTERSEGMENTAL TRACTION TO THORACIC LUMBAR REGIONIMANIP/WILL SEE 3X WEEK FOR 1 WEEK/WILL SEE ON FRIDAY AND THEN ANTIClP A TED DECREASE IN TREATMENT FREQUENCY Sincerely, RANDY FREDERICK, D.C. . CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 March 11, 2003 AlLSTATE INSURANCE COMPANY FlEW CLAIM OFFICE 6345 FLANK DRNE,SUITE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 3/10/03 S: STATED FEELS WEAK OR OUT OF IT. ASKED PATIENT IF WE COULD CHECK illS BLOOD PRESSURE, 124/60. NECK AND BACK CONI1NUES TO IMPROVE WITH CARE. VAS PAIN GRADE 1.5. 0: POSTURAL ANALYSIS UNREMARKABLE RT LUMBAR MYOSP ASM LUMBAR FIXATION LAL5 RT SIDE POSTURE MANIP RT SI JOINT FIXATION MANIP TO SACRAL REGION DECREASED RT CERVICAL MYOSPASM A: IMPROVING P: REHABIIFIHMP TO LUMBAR SHOUlDER REGlON/25 AND 22 MA'SIlNTERSEGMENIAL TRACTION TO THORACIC LUMBAR REGIONIMANIPIWILL SEE 3X WEEK FOR I WEEKIWlLL SEE WEDNESDAY AND FRIDAY Sin=ely, RANDY FREDERICK, D.C. cmROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 , March 11, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 317103 S: STATED CONTINUING WITH ACTIVE PHASE OF REHAB WHICH SEEMS TO BE HELPING. THE PATIENT NOTICES AN IMPROVEMENT. VAS PAIN GRADE .0. LFT KNEE CONTINUES TO DO WELL AND IMPROVE. 0: POSTURAL ANALYSIS UNREMARKABLE IMPROVED CERVICAL MOBILITY NOTED DECREASED CERVICAL MYOSPASM NOTED LUMBAR FIXATION IAL5 RT SIDE POSTURE MANIP RT SI JOINT FIXATION MANIP MANIP TO SACRAL REGION A: IMPROVING P: REHABlIFIHMP TO LUMBAR SHOULDER REGIONIINTERSEGMENTAL TRACTION TO THORACIC LUMBAR REGIONIMANIPIWILL SEE 3X WEEK FOR 1 WEEKlWILL SEE MONDAY WEDNESDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG P A 17109-4449 Phone: (717)545-6063 March 11, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURG PA \7112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 3/5103 S: STATED OVERALL CONTINUES TO IMPROVE WITH CARE. NOTICES AN IMPROVEMENT. PATIENT IS CONTINUING WITH ACTIVE PHASE OF REHAB WHICH SEEMS TO BE HELPING PATIENT. VAS PAIN GRADE 2.0. LFT KNEE CONTINUES TO IMPROVE. 0: RT CERVICAL RT LUMBAR MYOSPASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL DROP PIECE LUMBAR FlXA TION L4L5 RT SIDE POSTURE MANIP RT SI JOINT FIXATION MANIP DECREASED RT CERVICAL MYOSPASM AND LUMBAR MYOSPASM A: IMPROVING P: IFIHMP TO CERVICAL LUMBAR REGIONS AND SHOULDERSlREHAB/20 AND 19 MA'SIINTERSEGMENTAL TRACTION TO THORACIC LUMBAJR. REGIONIMANIPIWILL SEE 3X WEEK FOR 2 WEEKSIWILL SEE ON FRIDAY Sincerely, RANDY FREDERICK, D.C. ~$ q}ix:u/v ATTORNEY AT LAW 128 STATE STREET. HARRISBURG, PA 111 01 PHONE: (717) 233.8757 . FAX: (717) 233.:5860 EMAIL: dixonlaw@paonline.com VJ'IAIIN.dixonlaw. baweb.com March 11, 2003 CHIROPLUS OF LOCUST LANE ATIENTI0N: DR. RANDY FREDERICK 4607 LOCUST LANE HARRISBURG, PA 17109 Re: Our Client Ralph E. Probst Dear Dr. Frederick: As you know I represent Ralph Probst in all matters regarding the above referenced motor vehicle accident. In the past you have belm so kind as to provide me with a copy of your initial report and evaluation dated December 17, 2002. I would like to thank you for your kind cooperation on this matter. By this letter I would request copies of any additional follow up evaluations subsequent to December 17,2002. I have enclosed a release executed by my client to obtain this information and any charge for these copies will be promptly remitted. Very truly yours, //// ~---. /. ~- . Joseph J. Dixon JJD/jw Enclosure (I) c. Ralph Probst CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 March 4, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 3/3/03 S: STATED CONTINUES TO IMPROVE WITH CARE. PATIENT IS CONTINUING WITH ACTIVE PHASE OF REHAB. VAS PAIN GRADE 3.0. 0: RT CERVICAL RT LUMBAR MYOSPASM CERVICAL FIXATION C5C6 CERVICAL LATERAL DROP PIECE RT SIDE POSTURE MANIP LUMBAR FIXATION IAL5 RT SIDE POSTURE RT SI JOINT FIXATION MANIP TO SACRAL REGION A: IMPROVING GRADUALLY P: IFIHMP TO LUMBAR SPINElINTERSEGMENTAL TRACTION TO LUMBAR SPINEIMANIPIREHABlWILL SEE 3X WEEK FOR 2 WEEKSIWILL SEE WEDNESDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. ~< ~ .... m CD&>< y~ o~ 9. U- CD~ & o o .... CD o o .... CD o o .... CD o o .... CD o o CD o o .... CD o o .... CD " Q - -. CD ::J - " a (Q ... CD en en (i) ... Q "0 . ::r ~..... 0-1 " . '" , "'8 _0 0 0 ~ -Co ~r 'l ::J "'+~O- c(\ 'U (Q II Z ~z ~ 0 '" z < . -.c <:;) -0 0 oiD' Q. c c:::.-<il 3 d ~t- ~ 0 - 3'" c3 0' J~ =t ;;:: ",- '" 2'\ \ iD'", 0 r ::J 0 U "'~ 1/ - "'0_01' 0' ~-, ::J ai 'U C7' ...Q a~V' ~ 'Uz ~ \ ~ ..c. ~Q .",oc ~ lJ' ffi~3 '" vr<.~ "'~ o (11 o (11 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 8 ~ g I' :, I .' '" , [~~I,;~JTI .:' I' t,. ;-" I. 1.>/ 17 ~'.' ;,1 . I~ ,I: i ~:" :}:' .......r---.. L ~ rl" :.t ; '," ,,::1 .' -:-:- I . " " ''','' :... >, t. I . ''',: 1 ..., I -'-- (j) r ." . ': I 01 ',I > , I -....., " I, , '" -18' .... I, (0) j!?; ,>' I - .. I . . ,I. , _I " I ~ r- -, ' 1 . '. I I 1 I . N , I I ,.. 1 I I I I I , (11 C-(j) o > L-..... 0. '. . , . I ' ,I -I .' I". ~ I "j' I', , -,......, '".., '... -, I" ," 1 8 I > I -..... , 'I..'~ I: . mnz)>Zm....z-)>;;:: -'"- ~ ..... - .... I I I I " . , - 0> -nm-r-m;:;o zo-....nm"''''on 'U o .... (ii' ::J .... "," z o 3 CD ...., f' 0 :;;:, :r c;t r- --c: ,.c' ;:> c- ~ <J" \ CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 March 2, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 008363150 Dear DAVE MOODY, DOS 2/28/03 S: STATED NOTICES AN IMPROVEMENT SINCE HIS LAST TRElA TMENT. STILL HAVING LOTS OF PAIN IN HIS LOWER BACK, LEGS, LFT KNEE, AND RT SHOULDER AREA. VAS PAIN GRADE 3.5. 0: RT CERVICAL RT LUMBAR MYOSPASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL MANIP WIrn CERVICAL LATERAL DROP PIECE LUMBAR FIXATION UL5 RT SIDE POSTURE MANIP RT SI JOINT FIXATION MANIP LFT KNEE EXTREMITY MANIP A: IMPROVING GRADUALLY P: IFIHMP TO SHOULDER, BACK, AND KNEE REGIONSIMANIP/REHABIWILL SEE 3X WEEK FOR 2 WEEKSIWILL SEE MONDAY WEDNESDAY AND FRIDAY Sincerely, RANDY FREDERlCK, D.C. CHIROPLUS OF LOCUST 1.ANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 March 1, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUlTE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 2/26/03 S: STATED COULD FEEL A FLARE UP IN HIS BACK ON HIS TRIP TO A TLANT A. VAS PAIN GRADE 3.0. 0: POSTURAL ANALYSIS UNREMARKABLE RT CERVICAL RT LUMBAR MYOSPASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL MANIP WITH CERVICAL DROP PIECE RT SIDE LUMBAR FIXATION UL5 RT SIDE POSTURE MANIP RT SI JOINT FIXATION MANIP LFT KNEE EXTREMITY FIXATION MANIP A: FLARE UP P: REHABIMANIP Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 February 23, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 2/21/03 LETTER DATED 2/12/03 FROM DR LIPPIE SECOND OPINION ON SHOULDER AND KNEE LOGGED INTO CHART. Sincerely, RANDY FREDERICK, D.C. !lAI.I1rr IW.OO. M.D. RICJWIDJ. BOAt., M.D. ROOOKr R. DAlIMUS, M.D. STIlPIlEN W, DAlLllY, M.D. WILLIAM W. DeMUI1i, M.D., f' ALS. JOHN R. PRANKeNY II. M.D., f ALS. CUKTlS A. OOLTZ,O.o. RIa-wID N. HALLOCK M.D. , ORroORY A. NANJI,S. M.D. ROBeRT R lW'mDA. D.O" r .A.C,Q,,s. RONALD W. UPI'E, M.D" F A.C.5. JASON J. LIT1'ON, M.D. WlLLIAM J. POLACJ1I!CI\ JR., M.D, ~RNEST R. RUB&>, M.D. STEVY1 ~ WOLf, M.D. 1l10MM J. YUCJ1A.. M.D. ~Ip. ORTHOPEDIC IN'STITUTE OF PENNSYLVANIA TeLePHONe: (717) 761.5530 (800) 834.4020 FAX: (717) 737.7197 www.orthoinstituteofpa.com February 12, 2003 Randy Frederick, D.C. 4607 Locust Lane Harrisburg, PA 17109 RE: PROBST, RALPH E. 195 16 3609 Dear Dr. Frederick: I had the pleasure of seeing our mutual patient Ralph Probst in the Powers Avenue Office on January 31, 2003 in follow-up. CHIEF COMPLAINT: He has been having difficulty with his right shoulder since his motor vehicle accident. HISTORY OF COMPLAINT: He has also had pain in the medial aspect of his left knee and this is worse with activity. It was SE~Vere in nature a few weeks ago but is now improved and he only has minor discomfort in the knee. His right shoulder responded beautifully to his subacromial injection. REVIEW OF SYSTEMS: The patient's review of systems, past'.medical history,. family history, and social history have been re--evaluated and reviewed. PHYSICAL EXAM: Range of motion of his shoulder is full. His impingement sign is now negative. He has good active abduction in his shoulder. He is neurovascularly intact in his right upper extremity. His left knee has a varus alignment with pseudovalgus laxity. He is tender along his medial joint line. DIAGNOSTIC TESTS: I re....ric..ved th2: outBidex~:::,.:.ys of 1:i8 knees! tha,t you 1{i~dly obtained and sent along, and those show some thinning of the medial joint space of his left knee and some osteophyte formstion there. DIAGNOSIS: 1. 2. Impingement syndrome right shoulder, improving Left knee DJD PLAN: I explained to Mr. Probst that I am pleased that he responded well to the injection of his shoulder and as his knee is only minimally symptomatic at this point, weare going to continue to treat this . ",xpectantly. I. told him that if his symptoms change or worsen, we, could consider ot~er invention. I told him that reconstructive surgery for this knee may be an option down 0RTl101'W1C SURQeONS. l.TD, CAMP HILL OFFICE .39161"RJNDLE RD. ADDReSS ALL CORRESPONDENCE TO: 875 POPLAR CHURCH ROAD, CAMP HILL, PA 17011 tIARRISBURG OFFICE CAMP "ILL OFFICE I1ERSUEY OFFICE 450 POWERS Ave. 890 POPLAR CHURCH RO., STE. 108 32 NORTIfEAST DR., STE. 201 CAMP HILL OFFICE 875 POPlAR CHURCH RD. RE: PROBST, RALPH E. PAGE 2 February 12, 2003 the line possibly option. but as he states that he has problems with his heart and he is a transplant candidate, I do not think surgery would be our first If he has any other problems, he is to bring it to my attention. As always, it is a pleasure sharing in the care of this very nice gentleman. Sin~cr " i ( (. A_- Ron W. Lippe, M.D. RWL/ skb CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 February 1, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURGPA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 1127/03 GENERAL PAIN DISABILITY INDEX QUESTIONNAiRE, 35160=58 PERCENT. REVISED OSWESTRY LOW BACK QUESTIONNAiRE, 33/60=55 PERCENT. Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 January 25, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE, SUITE 1000 HARRISBURGPA 17112 Regarding: RALPH PROBST Accident Date: ll- 21- 2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 1/24/03 S: STATED OVERALL DOES NOTICE SOME IMPROVEMENT W1TH CARE. VAS PAIN GRADE 1.0 TO SHOULDER, 3.0 TO LOWER BACK. LFT KNEE IS ALSO IMPROVING 0: POSTURAL ANALYSIS UNREMARKABLE RT CERVICAL RT LUMBAR MYOSPASM CERVICAL FIXATION C5C6 CERVICAL LATERAL DROP PIECE RT SIDE LUMBAR FIXATION UL5 RT SIDE POSTURE MANIP SI JOINT FIXATION RT SIDE MANIP LFT KNEE EXTREMITY FIXATION MANIP A: IMPROVING P: IFIHMP TO LFT KNEE RT SHOULDER LUMBAR SPINEIPULSED ULTRASOUND TO LFT KNEE RT SHOULDER LUMBAR REGIONS/1.5 WCM2IINTERSEGMENT AL TRACTION TO THORACIC LUMBAR REGION/MANIP/WILL SEE MONDAY AND DO REEVALUATION AND DETERMINE IF PATIENT WILL MOVE TO A MORE ACTIVE PHASE OF REHABILITATIVE CARE Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG P A 17109-4449 Phone: (717) 545-6063 January 25, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURGPA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 008363150 Dear DAVE MOODY, DOS 1/22/03 S: STATED OVERALL NECK BACK AND SHOULDER IS IMPROVING. VAS PAIN GRADE 3.0, 0: POSTURAL ANALYSIS UNREMARKABLE RT CERVICAL Mi"OSPASM NO LFT CERVICAL MYOSPASM TO LFT IMPROVING RT LUMBAR MYOSPASM DECREASED LFT MYOSPASM TO LUMBAR REGION IMPROVING RT CERVICAL RT LUMBAR MYOSPASM CERVICAL FIXATION C5C6 LATERAL CERVICAL DRIP PIECE TO THE RT SIDE RT KNEE EXTREMITY FIXATION AND LUMBAR FIXATION UL5 RT SIDE POSTURE MANIP RT SI JOINT FIXATION MANIP A: IMPROVING P: IFIHMP TO LFT KNEE RT SHOULDER LUMBAR SPINEl23 AND 24 MA'SIPULSED ULTRA SOUND TO LFT KNEE RT SHOULDER LUMBAR REGIONS/1.5 WCM2IINTERSEGMENT AL TRACTION TO rnORACIC LUMBAR REGIONIMANIPIWILL SEE FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 February 15, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRlSBURGPA 17112 Regarding: RALPH PROBST Accident Date: \1-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 2/14/03 S: STATED VAS PAIN GRADE 3.0. 0: POSTURAL ANALYSIS RT LOW HAND LFT LATERAL ILIUM MANIP LFT KNEE FIXATION EXTREMITY MANIP RT LUMBAR MYOSPASM LUMBAR FIXATION UL5 RT SIDE POSTURE MANIP MANIP TO SACRAL REGION AND SI JOINT GOOD CERVICAL MOBILITY TODAY A: IMPROVING SLOWLY P: REHABIIFIHMP TO LFT KNEE RT SHOULDER LUMBAR SPINE REGlONS/17 AND 25 MA'SIINTERSEGMENTAL TRACTION TO THORACIC LUMBAR REGIONSIMANIPIWILL SEE 3X WEEK FOR 2 WEEKSIP A TIENT GOING OUT OF TOWN ON A TRIP AND WILL SEE IN A COUPLE OF WEEKS Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST Lt4NE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 February 15, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 2/12/03 S: STATED OVERALL VAS PAIN GRADE 3.0. PATIENT IS CONTINUING WITH ACTIVE PHASE OF REHAB. HE IS CONTINUING TO IMPROVE SLOWLY WIrn CURRENT CARE TO NECK BACK AND KNEE REGIONS. 0: LFT KNEE FIXATION EXTREMITY MANIP RT LUMBARMYOSPASM LUMBAR FIXATION L4L5 RT SIDE POSTURE MANIP RT SI JOINT FIXATION MANIF MANIP TO SACRAL REGION LFT KNEE FIXATION EXTREMITY MANIP A: IMPROVING P: REHABlIFIHMP TO LFT KNEE RT SHOULDER LUMBAR SPINE REGIONSIINTERSEGMENTAL TRACTION TO rnORACIC LUMBAR REGIONSIMANIPIWILL SEE 3X WEEK FOR 3 WEEKSIWILL SEE ON FRIDAY Sincerely, RANDY FREDERICK, D.C, CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURGPA 17109-4449 Phone: (717) 545-6063 February 11, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURGPA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 2/10/03 S: STATED IS GETTING SOME PAIN DOWN THE BACK OF THE LFT LEG. VAS PAIN GRADE 3.0. PATIENT IS CONTINUING WITH REHAB. 0: POSTURAL ANALYSIS UNREMARKABLE LFT KNEE FIXA nON EXTREMITY MANIP LFT LUMBAR RT CERVICAL MYOSP ASM LUMBAR FIXATION UL5 LFT SIDE POSTIJRE MANIP LFT SI JOINT FIXA nON MANIP TO SACRAL REGION CERVICAL FIXA nON C5C6 LFT LATERAL CERVICAL DROP PIECE A: SLIGHT FLARE UP P: REHABIIFIHMP TO LFT KNEE RT SHOULDER LUMBAR SPINE REGIONS/41 AND 23 MA'SIINTERSEGMENT AL TRACTION TO THORACIC LUMBAR REGIONSIMANIPIWILL SEE 3X WEEK FOR 3 WEEKSIWILL SEE ON WEDNESDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 .;;t February 9,2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURGPA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 008363150 Dear DAVE MOODY, DOS 2/7/03 S: STA TED PAIN IN THE LOWER BACK AREA. IMPROVING OVERALL. VAS PAIN GRADE 0: POSTURAL ANALYSIS RT LOW HAND LFT LATERAL ILIUM MANlP RT CERVICAL RT LUMBAR MYOSP ASM LUMBAR FIXATION UL5 RT SIDE POSTURE MANIP RT SI JOINT FIXATION MANlP MANIP TO SACRAL REGION RT CERVICAL FIXATION C5C6 RT LATERAL CERVICAL MANlP SI JOINT FIXATION MANIP TO RT SIDE LFT KNEE EXTREMITY MANlP A: IMPROVING P: REHAB/IFIHMP TO LFT KNEE RT SHOULDER LUMBAR SPINEREGIONSIINTERSEGMENTAL TRACTION TO LUMBAR REGIONSlMANlP/WILL SEE 3X WEEK FOR 3 WEEKSIWILL SEE ON MONDAY WEDNESDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST L4NE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 February 9, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURG PA 17\12 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 2/5103 S: STATED OVERALL DOING BETTER IN HIS NECK AND BACK. HE DID HAVE SOME SHOOTING PAIN IN THE BUTTOCK AREA. VAS PAIN GRADE 3.0. 0: RT LUMBARMYOSPASM LUMBAR FIXATION UL5 RT SIDE IPOSTIJRE MANIP SI JOINT FIXATION MANIP MANIP TO SACRAL REGION LFT KNEE EXTREMITY FIXATION MANIP A: IMPROVING GRADUALLY P: REHABlIFIHMP TO LFT KNEE RT SHOULDER LUMBAR SPINE REGlONS124 AND 21 MA'SIINTERSEGMENTAL TRACTION TO LUMBAR REGIONS/MANIP/WILL SEE 3X WEEK FOR 4 WEEKSIWILL SEE ON FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 February 4, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURGPA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 2/3103 S: STATED OVER THE WEEKEND, AFTER BEGINNING REHAB ON FRIDAY, HE WAS VERY SORE AND PAINFUL. HE FELT A LOT OF FLARE UP. VAS PAIN GRADE 3.0. PAIN IN THE LFT SI JOINT. 0: POSTURAL ANALYSIS RT LOW HAND LFT LATERAL ILIUM MANIP LFT LUMBAR RT CERVICAL MYOSPASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL DROP PIECE LFT KNEE FIXATION EXTREMITY MANIP LUMBAR FIXATION 1AL5 LFT SIDE POSTIJRE . MANIP LFT SI JOINT FIXATION MANIP A: FLARE UP P: REHABlIFIHMP TO LFT KNEE RT SHOULDER LUMBAR SPINE REGIONS/20 AND 22 MA'SIINTERSEGMENT AL TRACTION TO rnORACIC LUMBAR REGIONSIMANIPIWILL SEE 3X WEEK FOR 4 WEEKSIWILL SEE ON WEDNESDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURGPA 17109-4449 Phone: (717) 545-6063 February I, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 1/31/03 S: STATED OVERALL VAS PAIN GRADE 4.0 TO KNEE BACK AND SHOULDER. 0: RT LUMBAR MYOSPASM LUMBAR FIXATION UL5 RT SIDE POSTURE MANIP RT SI JOINT FIXATION MANIP MANIP TO SACRAL REGION LFT KNEE EXTREMITY FIXATION MANIP A: INSTRUCTED ON ACTIVE PHASE OF REHAB CARE. DELETION OF ULTRASOUND THERAPY. P: REHAB/IFIHMP TO LFT KNEE RT SHOULDER LUMBAR SPINE REGIONSI18 AND 20 MA'S/INTERSEGMENTAL TRACTION TO THORACIC LUMBAR REGIONSIMANIPIWILL SEE 3X WEEK FOR 4 WEEKSIWILL SEE ON MONDAY WEDNESDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST L4NE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 February 1, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUlTE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 008363150 Dear DAVE MOODY, DOS 1/29/03 S: STATED OVERALL CONTINUES TO MAKE SOME IMPROVEMENT IN IDS NECK, BACK, SHOULDER AND KNEE. VAS PAIN GRADE 3.0. 0: POSTURAL ANALYSIS UNREMARKABLE LFT CERVICAL LFT LUMBAR MYOSPASM LFT KNEE EXTREMITY FIXATION MANIP CERVICAL FIXATION C5C6 LATERAL DROP PIECE LUMBAR FIXA nON UL5 SI JOINT LFT SIDE POSTURE MANIP A: IMPROVING P: IFIHMP TO LFT KNEE RT SHOULDER LUMBAR SPINE REGIONS/20 AND 24 MA'S/CONTINUOUS ULTRASOUND TO SHOULDER BACK AND leFT KNEE AREAS/1.3 WCM2IINTERSEGMENTAL TRACTION TO rnORACIC LUMBAR REGIONSIMANIPIWILL SEE ON FRIDAY AND ON FRIDAY START REHAB CARE Sin=e1y, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG P A 17109-4449 Phone: (717) 545-6063 February 1, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE, SUITE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 1/27/03 X-RAYS TAKEN ON 1/27/03. LUMBAR SERIES. LUMBAR AP VIEW: U MILD RT LATERAL LIST L5 LFT LATERAL LIST RT HIGH ILIAC CREST 5 MIL METER DIFFERENCE. NO CHANGE FROM EARLIER X-RA YS TAKEN. LUMBAR LFT LATERAL BENDING VIEW: LACK OF VERTEBRAL BODY DEVIATION UL5 TO SIDE OF CONCAVITY SUGGESTIVE OF LACK OF NORMAL LUMBAR COUPLING MOTION UL5. IMPROVEMENT IN SPINOUS PROCESS DEVIATION TOWARD SIDE OF CONCAVITY. LUMBAR RT LATERAL BENDING VIEW: LACK OF SPINOUS PROCESS DEVIATION L3 TO L5 TO SIDE OF CONCAVITY. NO CHANGE FROM EARLIER X-RAYS. SUGGESTIVE OF LACK OF NORMAL LUMBAR COUPLING MOTION. LUMBAR LATERAL VIEW: L5S1 MODERATE DECREASE IN DISC SPACE UL5 FACET IMBRICATION SUSPECTED GRADE I SPONDYLOLISTHESIS NOTED AT L4L5. SLIGHT IMPROVEMENT IN UL5 IVS SPACE INCREASE. L5S1 SPOT VIEW: RT LATERAL LIST AT L5 WITH MODERATE DEGENERATIVE JOINT DISEASE L5SI. NO CHANGE FROM EARLIER X-RAYS TAKEN. Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 February 1,2003. ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE, SUITE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 1/27/03 GENERAL PAIN DISABILITY INDEX QUESTIONNAIRE, 35160=58 PERCENT. REVISED OSWESTRY LOW BACK QUESTIONNAIRE, 33/60=55 PERCENT. Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 February 1, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 1/27/03 S: STATED STILL HAVING A FAIR AMOUNT OF PAIN IN HIS LOWER BACK AREA AND SOME SHOULDER, NECK, BACK, AND LFT KNEE AREAS. VAS PAIN GRADE 3.0 TO HIS LOWER BACK REGION A SUBST ANTlAL IMPROVEMENT FROM INITIAL PRESENTATION. NOTICED THE RINGING HE HAD BEEN HEARING HAS DIMINISHED WITH CARE. 0: POSTURAL ANALYSIS UNREMARKABLE RT CERVICAL RT LUMBAR MYOSPASM LUMBAR FIXATION UL5 L3L5 RT SIDE LIL2 SI JOINT FIXATION MANIF' RT SIDE POSTURE MANIP CERVICAL FIXATION C5C6 RT LATERAL CERVICAL MANIP LUMBAR FIXATION L4L5 RT SIDE POSTIJRE MANIP CERVICAL FIXATION C5C6 WITH LA TI,RAL DROP PIECE TO RT SIDE LFT KNEE EXTREMITY FIXATION MANIP A: PATIENT REEVALUATION TODAY. FINDINGS WRITTEN INfO CHART NOT DICTATED ON TAPE. X-RAYS TAKEN, LUMBAR SERIES. P: IFIHMP TO LFT KNEE RT SHOULDER LUMBAR SPINE REGIONS/CONTINUOUS ULTRA SOUND TO LFT KNEEII.5 WCM2IINTERSEGMENT AL TRACTION TO rnORACIC LUMBAR REGlONIMANIPIWILL SEE ON WEDNESDAY AND FRIDAY AND ON FRIDAY START REHAB CARE Sincerely, RANDY FREDERICK, D.C. ORTHOPEUIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patient: Ralph E. Probst DOB: 06/19/27 SSN: 195 16 3609 Chart #: 19092201 Page # 1 ------------------------------------------------------------------------------- 12/19/2002 RONALD W. LIPPE, M.D. OFFICE VISIT I had the pleasure of seeing our mutual patient Ralph Probst in the Powers Avenue Office on December 19, 2002, in follow-up. CHIEF COMPLAINT: Right shoulder. HISTORY OF COMPLAINT: As you know he is a very nice 75 ,rear old gentleman who was involved in a motor vehicle accident on 11/21/02. )<pparently he was hit on the driver's side. He was unrestrained and injured his right shoulder. Since that time he has had pain in the shoulder in the anterior aspect with radiation down the lateral aspect of the arm. It is worse with any t'YPe of activity. He has l.-.eceived excellent conservative care BO far but unfortunately his pain continues. REVIEW OF SYSTEMS: The patient's review of systems, past: medical history, family history, and social history have been re-evaluatEed and rEeviewed. PHYSICAL EXAM: On exam today hEe is a healthy-appearing gentleman in no acutEe distress. He is tender over his anterior acromion and he has a positive impingement sign at 90 degrees forward elevation worse vlith internal rotation. He has good active function in his shoulder. He is neurovascularly intact in his right upper extremity. He is bright, alert, cooperative and appears otherwise healthy. DIAGNOSTIC TESTS, AP and lateral xray of his right arm t:hat I obtained today shows normal bony architecture in his humerus and well-maintained subacromial space. DIAGNOSIS: It appears to me Mr. Probst has posttraumatic subacromial impingement syndrome in his right shoulder. PLAN: We discussed treatment options for this. I inject.ed his right shoulder with Triam diacEetate under stEerilEe conditions and told him to give this several '.'leeks to impro....re. ! will see him egajn in p.T.n. for clinical recheck. Thanks again for allowing me to participate in the care of this very nice gentleman. RWL/rah cc: Randy Frederick, D.C. '1l.pOr llixj These Records arc not 10 be le.released wilhou\ 'minen il\Jlhorilation. federal and/or1.tale conlidenlialily lilWS may apply ---------------------------------- ----------------------------- , GENERALl_..N DISABllJTYINDEX QUES.DNNAIRE The ~liDi SQlts below arc deaiped to mca.suro the dell'" 10 w~ lICYomlllSpe~ of your Ufe arc pr,,"n~y disruptcl! by Cnrottie pUn. In othcrwordl. we would Uke to kDow bow lIluch YOllr paiII it pcevCJIliDa YOII;frwn doing wbal you wowd normally do, or from doing !t as weU /IS YOll DOrmaIIy wollkl. Rcspolld to each Cltoiory 'oy iDlllc&Eini tho ~,~l'llrnpacl of pain in your Utc, nOI JUSl wben Ille pain i. a, It$wont. . For nch of tho .~~;r~~~ of Odly llvinllll.tcd. PLEASE ClRcu. THE NUMBli:R WHICH BEST DESCRIBES YOUR TYPICAL LEVEL OF A . A _re ot 0 mcan. no diSAbiliry at all, and a lCOte ot 10 signiiies thai all of lhe aClivitie. in whicb you woiWl AOtmally be Jnvolvod bave \>oeD lOralIy diawptcd ll( p<GVCl1l4d. by YOut ~l&In. Revised Mar'h IS. 1993 1, F_/lJIlHom, RIISPOlll/b/JJ.tU., Thls CllOiOry refera 10 acdviliealdatcd 10 lb4 home 0' flUUUy. It incll.Kl.. chores and dUlies performed uo\Ull1 thc Itouac (c.$-, yard work) IlId cnand. or tavora for other flP1ily memt>.r. (c.g., drivinB thc chUdren to school). o 1 Complctcly able to function 2 ~ .10 TOlally unable 10 funclion o 4 9 6 7 8 :I. R.U'HIioIl. TlUa catelOlY irlciudea hoblli.., .porro, and otbcr simiW' IciJurc time llClivitie.. o 1 . Complt\ely able to function z 3 rv 6 7 8 9 10 Totall y unable to tunclion 4 1. S.,.;/4IIAail'iq, This ca'elol)' reta.. to >.etivities which Involve panicipatlon with friCJ1ds and acquaIQ..nc.. other lh.n famUy 1D0000bclll, Itlnclud.. patti... .bealer. CQno.e>:\S, dininll oot, JUld otbcl'lOClaJ function.. o 1 Completely able 10 function 2 3 (i) 9 10 Totally unable 10 funClion 8 5 6 4 4, OccuptJIIOIl. This ca,,&OI)' Rfen to activitielthat an: a part of or direCtly relaled 10 one'. job. This include. nonpaying jobs ... weill. ,,,,em &6 tba.t of.. hom~mwt ex vol"'n~cr welker. o 1 Complc.cly able to funClion 2 (0 s 6 7 8 9 10 Totally unable 10 function 3 5. S.UC/IIf, ThIs calejol)' includc'lc:tivities which involve pcl'lOllal mainl.cIll4CC and in~pelldeQI dlUy livin& (eg, laking a Iltowcr, drIvin"llcttin. dressed. ate.). o 1 Completely able to functio" 2 G> 9 10 Totally unable to nmclioo 5 7 8 3 4 6. LU...s"'pporcA,c1M1'l. Thil calolory refeI110 bliic lifc,sllpponina 'oehavlol$ slIen ~5 eating, sleeping, wd brealhin~. o 1 Completely . ~ ,:~[~.1O fun:~/b 1v. () roTAL SCORE: ~ ~rJ '" SIGNA1URB:~! {;I ~ f'_ 'or ~ InformatiOll, conlacl: ,cnvATOa METHODS, INC., P,O, Box 80317. Phoenix, AZ 85060-0317 2 3 o 9 5 7 4 10 TotaUy lUlable to tullcdDn 6 t!~ DATI!: J' 2-7 r 0,3 Telepllone: (602) :l:l4.():l20; F~i1o: (602) 224-023 REVIS~D OSWESTRY LOW BACK rAIN DISAillUT'r QUESTIONNAIRE 33 /0 =S3~ PLE~E REIIO, This questionnaire is. cJ.esigned 10 enable us to undersland how mueh your low h.ck p.in ho, Jllened your ability 10 ma?"g~ your ~v~ryd.1y aellvllles. PI~a... .nswer e.ch'seellon by circling Ih~ ONE (1,01([ Ih.lI mnll .ppli., 10 you. We reahze Ihat you'may lcellhal more Ihan one s,.,e_nf may relate 10 you. hul PLEASE lUST CIRCLE THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUI/PROBLEM RICHT NOH-: SECTION '-/lain Jnlcnsity A. The pain comes and goes and is very mild. B. The pain Is mild and does nOl vary much. 3 . The pain COI1le$ and goes and Is moderate. . The "..in is moder.le .nd does nol v.ry much. E~ The pain comes .nd goes and Is severe. F. The pain II severe and does noI v.ry much. SECTION 2--."'r.-..J Can A. I would nol holve 10 change my w.y 01 washing or dres$lng in order 10 i1vo,d pain. 11;1 do not'normally eh.nll~ my w.y 01 washinll or drn.ing ~n though II cauoe. """" "..In. C. W.shing .nd dressing incr~a_ .he "..In, bul I m.~e noI 10 change my way 01 doing h. . .; @ W.shlng .nd d~ssing incre..... the pain and IlInd I .... nece$$;uy 10 ch.nge my W.Y 01 doing II. . E. Becauoe ollhe pain. I am un.ble '0 do some w.shing and dressing wi.houI help. F. lIecauoe o( Ihe pain. I am unable '0 do any w.,hlng or dr_ing w"houI help. . SECTION 3-L;ft;ng A. I nn \ill heavy weighls withoul extra pain. B. I can lift heavy weighls, bu. il caU5e$ extra pain. C. Pain prevents me from lihing heavy weights off Ihe noor. D. Pain preyenls me Irom lining heayy welgh's olllhe noor, bUll can manage if Ihey are conveniendy positioned, e.g., on a lable. ,-' E. Pain prevents me Irom lihing heavy weighls. bul I eaii1 m.n.ge light 10 medium weights illhey .re convenienlly positioned. F. I c.n only lin very lighl weighlS. .tthe most. SECTION 4-W"lk;ng A. PAin does nOl pr~venl me Irom w.lking any dislance. {.. B. Pain preyents me Irom w.lking more lhan I mile. .;J ~ P.in prevenls me Irom walking more lhan 112 mile.' 1>. Pain ",events me (rom w.,klnll more lhan 1/~ mile. E. I c.n only w.lk while u,lng . c.ne or on crul<"hes. F. I ,1m in bed mO'1 o( Ihe IlffIl' and h,w.. 10 cmw'lo Ihe loilet. ':SECTION 5-Silting A. I can sil in any chair as long as 'like wi!hout pain.3 8. t can only sil in my lavorile chair as long as I like. Pain preyenlS me Irom sining more lhan I hour. D. PAin prevenls me Irom sining more than 1/2 hour. E. P.,in prevents me Irom sining more'I'an 10 minules. f. p..in pl\~v~n\~}rom SiuiQG~.,all. :'" . PATIENT SI~NATURE1~ c .W' DATE: 1- 2..7 ~ 03 . - SECTION 6-SlMtd;ng A. I c.n stand as long as I wanl wilhoul polin. B. I'have some' p.in while slanding, hul il C/"", nOl Increase with lime. C. I c.nnOl st.nd (or lonller Ihan I hour wilhoul inc,ea,ing /'rt- "..In, o I cannOl ".nd lor 10ngN Ihan 1/2 hour wilho,,' y . Incre.slng p;.ln, . "E. I cannot 51arld (or longer rh.ln 10 minures WilhoUf increasinR p..;n. F. I avoid sl..ndinR,. because it inClease!" Ihl' pain srraighl Away. SlCTION T-sJ.~ng A. I gel no p.ln In bed, B. I gef p.ln in bed. bUI il doe, nol prevonl me /rom ~ sleeping wel\, . @ Because of p..in, my normal niUhl's ~It.f"p is reduced y lfi5 than one..quaner. . D. Bec.uoe 01 p;.ln, my normal ni~hl" "<"'p i, ,educed hy less IhAn one"hall. E. Bec.uoe 01 p"in, my norm.1 ni~hl" sl,>op i, ,educed by less lhan Ihre.e-quaners.. F. Pain prevents me Irom sleeping ., all. SECTION B-So<ul Lif, A. My social Ufe is normal and Rives m~ no pain. ? B. My social life Is normal. bUI iner~.lSCS Iho degree o>l my pain. (9 Poin has no signilicanl eUeCl on my <nei.lll1le ilpillll,om \imiHnc my more enerS<<'lic inh',,,sts, (',g" n.lncing, elc. D. r.in ha5 re5lri,cled my social iile .,nd I do nol go oul very ohen. '-. E. P.in h.s reslrk'ed my ,oci.1 We 10 my home. f. I have hardly any sociallile hee.'u,e of the pain. SECTION 9-1,.,,,,lin& . A. I gel no p.1in while "av..ling. B. I gel some p.>ill while ".veling. bul none of my usual (orm, al".1Ie1 m.,kc II any worse. (9 I ReI exlrll pain whil. ".v.linR. hut il dc"" nol cnm".J me 10 _k aherna'ive (orms ol,r.lVel. D. I gel exlr. pain while trawling whith rllmp"l< me 10 _k .hern.live lorm5 ollr.vel. f. Pain reslriels all forms olllavel. F. Pain prevents al!1 (orms of tr.wel excop' Ih.l' done lying down. SECTION 1~loan8;ng Degree of Pain ;;;)..- ^. My pain i, rapidly gelling beller. . (i} My Pij" OUCluates. but overall is ddinih.'ly ~t:"'uinB ben~r. "t. My p.ln seems 10 be gening beller, bul improvemenl il . .Iow ,11 plesenl. D. My ",,'n Is neilher gening bener nor worse. E. My pain Is gr.d,u.Uy worsening. F. My pain Is rapidly worsening. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURGPA 17109-4449 Phone: (717) 545-6063 January 21, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 1/20/03 S: STATED OVERALL NECK BACK AND SHOULDER ARE IMPROVING, BUT STILL HAVING PAIN IN IDS KNEE. NOTICES AN IMPROVEMENT WITH TREATMENT IN IDS SHOULDER VAS PAIN GRADE 3.5. 0: LFT KNEE EXTREMITY FIXATION AND MANlP BILATERAL CERVICAL LUMBAR MYOSPASM CERVICAL FlXA TION C5C6 LATERAL CERVICAL MANIP BILA TERALL Y WITH CERVICAL DROP PIECE LUMBAR FlXA TION LAL5 RT AND LFT SI JOINT FIXATION MANlP MANlP TO SACRAL REGION A: IMPROVING P: IFIHMP TO LFT KNEE RT SHOULDER LUMBAR SPINEI20 AND 22 MA'S/PULSED ULTRA SOUND TO LFT KNEE RT SHOULDER LUMBAR REGIONS/1.4 WCM2IINTERSEGMENTAL TRACTION TO THORACIC LUMBAR REGIONlMANIPfWlLL SEE WEDNESDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 January 19,2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUlTE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 1/17/03 S: STATED KNEE HAS A SLIGHT IMPROVEMENT. A LITTLE BIT OF AN IMPROVEMENT IN TIffi SHOULDER AREA AND LOWER BACK. VAS PAIN GRADE 4.0. LFT KNEE IS DOING A LOT BETTER WIlli CURRENT TREATMENT. 0: LFT KNEE EXTREMITY FIXATION MANIP POSTURAL ANALYSIS UNREMARKABLE RT CERVICAL RT LUMBAR MYOSPASM DECREASED MYOSPASM TO CERVICAL REGION LUMBAR FIXATION L4L5 RT SIDE POSTIJRE MANIP RT SI JOINT FIXATION MANIP MANIP TO SACRAL REGION CERVICAL FIXATION C5C6 LATERAL CERVICAL MANIP WITH CERVICAL DROP PIECE LUMBAR FIXATION L4L5 RT SIDE POSTIJRE MANIP RT SI JOINT FIXATION MANIP MANIP TO SACRAL REGION A: IMPROVING GRADUALLY P: IF/HMP TO KNEE SHOULDER BACK AREASIl8 AND 12 MA'SIINTERSEGMENT AL TRACTION TO lliORACIC LUMBARREGION/PULSED ULTRA SOUND TO SHOULDER KNEE AND BACK AREAS/MANIP Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG P A 17109-4449 Phone: (717) 545-6063 January 18, 2003 ALLSTATE lNSURANCE COMPANY FJELD CLAIM OFFlCE 6345 FLANK DRIVE,SUlTE 1000 HARRlSBURGPA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 15545068303K4 Policy: 008363150 Dear DAVE MOODY, DOS 1/15/03 X-RAYS TAKEN ON 1/15/03. BiLATERAL LIT KNEE VIEW. LFT KNEE AP VIEW: SUGGEST1VE OF DEGENERATIVE CHANGES IN TIlE lNTERCONDULAR SPACE IN THE KNEE. LFT KNEE LATERAL VIEW: MiLD DEGENERATIVE CHANGES n'l TIlE PATELLA REGION. Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 January 18, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURGPA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 008363150 Dear DAVE MOODY, DOS 1115/03 S: STATED HAD A SEVERE FLARE UP OF illS KNEE PAIN. VAS PAIN GRADE WAS 10.0. CALLED illS ORlHOPEDlC SURGEON AND SET UP AN APPOINTMENT FOR THE END OF THE MONTII. ADVISED PATIENT WILL CHANGE THERAPY AND TOOK X-RAYS OF THE LFT KNEE AP AND LATERAL. ADVISED WILL DO MORE THERAPY TO THE KNEE AND IF IT DOES NOT RESOLVE WILL CONTINUE WIlH IDS APPOINTMENT AT THE END OF THE MONTH. VAS PAIN GRADE 4.0 TO THE NECK AND SHOULDER AREAS. 0: POSTURAL ANALYSIS UNREMARKABLE RT CERVICAL RT LUMBAR MYOSPASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL MANlP WITH CERVICAL LATERAL DROP PIECE LUMBAR FIXATION L4L5 RT SIDE POSTURE MANII' RT SI JOINT FIXATION MANlP MANlP TO SACRAL REGION LIT KNEE FIXATION EXTREMITY MANlP A: IMPROVING GRADUALLY. X-RAYS OF LFT KNEE DUE TO LIT KNEE FLARE UP. P: IF/HMP TO LFT KNEE RT SHOULDER AND BACK REGIONSII8 AND 23 MA'S/INTERSEGMENT AL TRACTION TO CERVICAL THORACIC REGION/PULSED ULTRA SOUND TO RT SHOULDER/1.5 WCM2IMANIP/WILL SEE ON 3X WEEK FOR I WEEK/WILL SEE ON FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG P A 17109-4449 Phone: (717) 545-6063 December 31, 2002 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE, SUITE 1000 HARRISBURGPA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 12/30/02 S: STATED OVER THE WEEKEND HE WAS DOING BETTER IN HIS NECK AND BACK. DISCUSSED WITH PATIENT HIS HOBBY OF BOWLING AND PATIENT REITERATED THAT PRIOR TO THE ACCIDENT HE WAS BOWLING ABOUT lOX A WEEK AND NOW HE ONLY GOES A COUPLE OF TIMES A WEEK. VAS PAIN GRADE 4.0. NOTICES AN IMPROVEMENT. PAIN IS STILL IN THE NECK, BACK, KNEE, SHOULDERS, BUT NOT AS SEVERE. 0: IMPROVED CERVICAL MOBILITY NOTED LFT KNEE EXTREMITY FIXATION AND MANIP PRONE POSITION KNEE INFLEXION LUMBAR FIXATION lAL5 RT SIDE POSTURE MANIP RT SI JOINT FIXATION MANIP MANIP TO SACRAL REGION A: IMPROVING P: IF/HMP TO THORACIC LUMBAR REGION/13 AND 13 MA'SIINTERSEGMENT AL TRACTION TO THORACIC LUMBAR REGION/PULSE ULTRA SOUND TO THORACIC LUMBAR REGION/1.5 WCM2/MANIP/W1LL SEE ON FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURGPA 17109-4449 Phone: (717) 545-6063 January 14. 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE, SUITE 1000 HARRISBURG P A 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 1/13/03 S: STATED HE CAN FEEL PAIN IN IDS LOWER BACK, PAIN IN THE SHOULDER, AND LIT KNEE. VAS PAIN GRADE 4.0 TO THE LOWER BACK AND KNEE. 3.0 TO THE OTHER AREAS. 0: LFT KNEE FIXATION EXTREMITY MANIP LFT CERVICAL LFT LUMBAR MYOSP ASM CERVICAL FIXATION C5C6 LFT LATERAL CERVICAL MANIP LUMBAR FIXATION lAL5 LFT SIDE POSTURE MANIP MANIP TO SACRAL REGION LIT KNEE EXTREMITY FIXATION MANIP A: IMPROVING GRADUALLY P: IF/HMP TO LUMBAR AND RT SHOULDER AND NECK REGIONS/13 AND 13 MA'SIINTERSEGMENT AL TRACTION TO CERVICAL TIfORACIC REGIONIPULSED ULTRA SOUND TO RT SHOULDERlI.5 WCM2IMANIPIWILL SEE ON 3X WEEK FOR I WEEKlWILL SEE ON WEDNESDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 December 29, 2002 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRlSBURGPA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Nmnber: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 1V27/02 S: STATED NOTICES EVERYTHING IS BEITER TODAY. STILL HAVING SOME PAIN. VAS PAIN GRADE 6.0. 0: IMPROVEMENT IN CERVICAL MOBILITY TODAY DECREASED CERVICAL MYOSPASM NOTED LUMBAR FIXATION L4L5 RT AND LFf SI JOINT FIXATION MANlP MANlP TO SACRAL REGION L4L5 MANlP TO LUMBAR REGIONS LFf KNEE EXlREMITY FIXATION MANlP WITH LUMBAR DROP PIECE WITH KNEE INFLEXION A: IMPROVING SLOWLY P: IFIHMP TO RT SHOULDER LUMBAR REGlONIINTERSEGMENTAL TRACTION TO THORACIC LUMBAR REGlONIPULSE ULTRASOUND TO RT SHOULDER/MANIP/WILL SEE ON MONDAY Sincerely, RANDY FREDERlCK, D.C. a~ea 8 wex3 L> --5b a~ea G wex3 -...... Cv~l{'l --C (' "( I 'l J a~ea ~ wex3 ~ , SAHd~nw ~~k 'J~ .' .:..-;; + (j J j ")+ ~Q V jz..::"",t7~ SlU!Od IlllO.L 'yY}~ 1-+ <W~OJ ~() o.-~7 ~--. ---~D"".'.'-----r~! J f .<;;l-n-.d Ot ~(/r:f,\) '-- ----- 01, ---------- ~~l..t . ~J // H. ~GV~a ( ,.. .-') ~ t,j ')(jj j 1 '"f) pue4 pJeMJO~ t:l JO 1 ~ ~ //. r uo!~elsueJ~ O!^lad leJa~el t:l JO 1 J+ ~T'<>J - \l J I pue4 M~O 1 b "v~n.lSOd 't:::.....0 S~U!Od aJn~sod le~o.L I Ja4~O uealleO!MaO t:l JO 1 aBepJeo pea4 pJeMJo~ r ~ \0 0-~ ~ , '''NIWOOB'' <t, (} lr 1 tl/1l\--C I 31\10 'i.,Q.L(-) ~Cl-lJ 31\10 NAME CHIROPLUS OF LOCUST U~. RALPH nOBST 'E . Dr. Randy Frederick CASE # AGE 75 6-19-27 D.O.B. Occupation DATE i J', )6).- I-1l~ ,., DATE DATE ~_(J"J.0 I.) DATE ( 1- DATE CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 January II, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SillTE 1000 HARRISBURG P A 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY. DOS 1/ I 0/03 S: STATED OVERALL STILL HAVING SOME PAIN IN THE BACK SHOULDER AND A LITILE BIT IN THE KNEE. VAS PAIN GRADE 3.5. 0: RT CERVICAL RT LUMBAR MYOSPASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL DROP PIECE LUMBAR FIXATION UL5 RT SIDE POSTURE MANIP RT SI JOINT FIXATION MANIP TO SACRAL REGION LFf KNEE FIXATION EXTREMITY MANIP LFf LUMBAR FIXATION UL5 LFf SIDE POSTURE MANIP A: IMPROVING GRADUALLY P: IF/HMP TO LUMBAR AND RT SHOULDER REGION/13 AND 13 MA'SIINTERSEGMENTAL TRACTION TO LUMBAR REGIONIPULSED ULTRA SOUND TO RT SHOULDERIMANIP/WILL SEE ON 3X WEEK FOR I WEEKlWILL SEE ON MONDAY WEDNESDAY AND FRIDAY Sin=ely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 January II. 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE, SUITE 1000 HARRISBURGPA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY. DOS 1/8103 S: STATED VAS PAIN GRADE 4.0. IMPROVING SLOWLY. KNEE IS SO-SO. 0: LFT KNEE FIXATION EXTREMITY MANIP POSTURAL ANALYSIS UNREMARKABLE RT CERVICAL RT LUMBAR MYOSPASM DECREASED MYOSPASM NOTED SLIGHT IMPROVEMENT CERVICAL FIXATION C5C6 RT LATERAL CERVICAL DROP PIECE NOTED LUMBAR FIXATION LAL5 RT SIDE POSTIJRE MANIP RT SI JOINT FIXATION MANIP LFT KNEE EXTREMITY MANIP AND FIXATION A: IMPROVING GRADUALLY P: IFIHMP TO LUMBAR AND RT SHOULDER REGIONIINTERSEGMENT AL TRACTION TO TIfORACIC LUMBAR REGION/PULSED ULTRA SOUND TO RT SHOULDERlMANIPIWILL SEE ON 3X WEEK FOR 2 WEEKS/WILL SEE FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 January 7, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE. SUITE 1000 HARRISBURGPA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 116/03 S: STATED SOME SORENESS IN 1HE RT LOWER BACK AND SHOULDER BUT OVERALL MAKING SLOW STEADY PROGRESS. STILL HAVING A LOT OF RINGING SENSATION IN 1HE EARS. VAS PAIN GRADE 4.0. 0: POSTURAL ANALYSIS UNREMARKABLE EXTREMITY FIXATION LFT KNEE FIXATION MANIP RT CERVICAL RT LUMBAR MYOSPASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL MANIP Willi CERVICAL DROP PIECE LUMBAR FIXATION L4L5 RT SI JOINT FIXATION MANIP A: IMPROVING SLOWLY P: IFfHMP TO LUMBAR AND RT SHOULDER REGION/INTERSEGMENTAL 1RACTION TO lliORACIC LUMBAR REGIONfPULSED UL 1RA SOUND TO RT SHOULDERlMANIPfWILL SEE ON 3X WEEK FOR 2 WEEKSfWILL SEE WEDNESDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 January 4, 2003 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUlTE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Nmnber: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, OOS 1/3/03 S: STATED OVERALL IMPROVING. OOING BETTER NOTICES SOME IMPROVEMENT. VAS PAIN GRADE 4.0. PATIENT IS CONTINUING TO HEAR A HIGH-PITCH NOISE IN HIS HEAD. 0: POSTURAL ANALYSIS UNREMARKABLE RT CERVICAL RT LUMBAR BILATERAL THORACIC MYOSPASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL MANIP THORACIC FIXATION T5T6 PRONE MANIP CERVICAL FIXATION WITH CERVICAL LATERAL DROP PIECE C5C6 THORACIC FIXATION T5T6 PRONE MANIP 14L5 RT SIDE POSTURE MANIP LFT KNEE FIXATION EXTREMITY MANIP A: IMPROVING GRADUALLY P: IF/HMP TO LUMBAR AND RT SHOULDER REGIONI13 AND 13 MA'S/INTERSEGMENTAL TRACTION TO THORACIC LUMBAR REGION/PULSED ULTRA SOUND TO RT SHOULDERlI.5 WCM2/MANIP/WILL SEE ON 3X WEEK FOR 2 WEEKS/WILL SEE MONDA Y WEDNESDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 December 28, 2002 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE, SUITE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 15545068303K4 Policy: 008 363150 Dear DA VB MOODY, DOS 12123/02 . S: STATED THE SHOT HELPED IDS SHOULDER FROM DR LIPPIE. HE IS STILL HAVING A LOT OF PAIN IN THE NECK, SHOULDER, AND BACK AREAS AND PAIN INTO THE LFT KNEE. VAS PAIN GRADE 9.0. 0: RT CERVICAL BILATERAL THORACIC RT LUMBARMYOSPASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL MANIP WITH CERVICAL LATERAL DROP PIECE THORACIC FIXATION T5T6 PRONE MANIP LUMBAR FIXATION lAL5 RT SIDE POSTURE MANIP LIT KNEE EXTREMITY FIXATION WITH KNEE INFLEXION WITH LUMBAR DROP PIECE A: FLARE UP P: IF/HMP TO RT SHOULDER LIT ARMIINTERSEGMENT AL TRACTION TO THORACIC LUMBAR REGIONIPULSE ULTRASOUND TO SHOULDER LIT ARM REGION/MANIP/WILL SEE ON FRIDAY FOR NEXT 2 WEEKS DUE TO HOLIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRlSBURGPA 17109-4449 Phone: (717) 545-6063 December 21, 2002 AlLSTATE INSURANCE COMPANY FIELD CLAIM OFFlCE 6345 FLANK DRNE,SUITE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 12/20/02 S: STATED GOT A SECOND OPINION FOR 1HE RT SHOULDER AS ADVISED PATIENT TO DO. WENT TO DR. LIPPIE. HAS BURSmS IN 1HE SHOULDER AND TRAUMA FROM 1HE AUTOMOBILE ACCIDENT BROUGHT ON PAIN. INJECTED HIM WITH CORTISONE. STILL HAVING IN 1HE BACK, NECK, AND IFf KNEE AREAS AND INTO 1HE ARM. VAS PAIN GRADE 7.5. 0: POSTURAL ANALYSIS UNREMARKABLE RT CERVICAL BlLATERAL LUMBARMYOSPASM CERVICAL FIXATION C5C6 RT LATERAL CERVICAL MANlP LUMBAR FIXATION IAL5 RT AND IFf SI JOINT FIXATION MANlP MANlP TO SACRAL REGION CERVICAL FIXATION C5C6 WITH CERVICAL LATERAL DROP PIECE TO 1HE RT SIDE IFf KNEE FIXATION EXTREMITY MANIP A: FLARE UP, BUT IMPROVING SLOWLY P: IFIHMP TO RT SHOULDER AND LUMBAR REGlONIINTERSEGMENT AL TRACTION TO rnORACIC LUMBAR REGION/CONTINUOUS ULTRA SOUND TO LUMBAR REGlONIMANlPIWILL SEE ON MONDAY AND FRIDAY FOR NEXT 2 WEEKS DUE TO HOLIDAY Sincerely, RANDY FREDERICK. D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 DeCember 21, 2002 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUlTE 1000 HARRISBURGPA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 12/lg/02 S: STATED HAD A GOOD DAY THE OTHER DAY, BUT TODAY HE CAN FEEL IT IN LOWER BACK, ARM. VAS PAIN GRADE 8.0. 0: LFT CERVICAL BILATERAL THORACIC AND RT LUMBAR MYOSP ASM LUMBAR FIXATION L4L5 RT SIDE POSTURE MANIP RT SI JOINT FIXATION MANIP CERVICAL LATERAL DROP PIECE TO LIT SIDE C5C6 LFT KNEE EXTREMITY FIXATION AND MANIP A: IMPROVING SLOWLY P: IFIHMP TO RT SHOULDER AND LUMBAR REGION/INTERSEGMENTAL TRACTION TO THORACIC LUMBAR REGION/CONTINUOUS ULTRA SOUND TO LUMBAR REGIONIMANIP/WILL SEE 3X WEEK FOR 4 WEEKS/WILL SEE ON FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURGPA 17109-4449 Phone: (717) 545-6063 December 21, 2002 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE, SUITE 1000 HARRISBURGPA 17112 Regarding: RALPH PROBST Accident Date; 11-21-2002 Claim Number; 1554506830 3K4 Policy: 008363150 Dear DA VB MOODY, DOS 12/16/02 S; STATED SATURDAYffiS BACK STARTED TO HURT; SUNDAY WAS OKAY; TODAY HE IS IN A LOT OF PAIN. VAS PAIN GRADE 9.0. 0: POSTURAL ANALYSIS RT LOW HAND RT LATERAL ILIUM MANIP RT LUMBAR MYOSPASM LUMBAR FIXATION LAL5 RT SIDE POSTURE MANIP RT SI JOINT FIXATION MANIP MANIP TO SACRAL REGION THORACIC FIXATION T5T6 PRONE MANIP LFT KNEE EXTREMITY FIXATION AND MANIP A; FLARE UP P: IFIHMP TO THORACIC RT SHOULDER AND LUMBAR REGION/INTERSEGMENT AL TRACTION TO THORACIC LUMBAR REGION/CONTINUOUS ULTRA SOUND TO RT SHOULDER AND LUMBAR REGIONIMANIP/WILL SEE 3X WEEK FOR 4 WEEKS/WILL SEE ON WEDNESDAY AND FRIDAY Sincerely, RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 December 14, 2002 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUlTE 1000 HARRISBURGPA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 12/13/02 S: STATED SYMPTOMS HAVE FLARED UP IN THE BACK, KNEE, ARM, AND NECK AREAS. VAS PAIN GRADE 9.0. 0: LUMBAR FIXATION L4L5 RT SIDE POSTURE MANIP RT SI JOINT FIXATION MANIP TO SACRAL REGION THORACIC FIXATION T4T5 PRONE MANIP IMPROVEMENT TO CERVICAL REGION LFT KNEE FIXATION EXTREMITY MANIP RANGE OF MOTION TO RT SHOULDER REGION A: FLARE UP. DISCUSSED X-RAY FINDINGS WITH PATIENT. P: IFIHMP TO LUMBAR SPINE AND CERVICAL REGION/INTERSEGMENTAL TRACTION TO THORACIC LUMBAR REGION/CONTINUOUS ULTRA SOUNDIMANIPIWILL SEE 3X WEEK FOR 4 WEEKSIWILL SEE ON MONDAY WEDNESDAY AND FRIDAY Sincerely, RANDY FREDERICK. D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 December 14,2002 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE. SUITE 1000 HARRISBURGPA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Nmnber: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY, DOS 12/12/02 X.RA YS TAKEN ON 12/12/02. CERVICAL AP AND LATERAL VIEWS, TIl0RACIC AP AND LATERAL VIEWS, LUMBAR SERIES. CERVICAL AP VIEW: C5C6 SPINOUS PROCESS DEVIATION TO RT SIDE. CERVICAL LATERAL VIEW: CERVICAL LORDOSIS C2C7 26 DEGREES BELOW NORMAL RANGE OF 30 TO 43 DEGREES. TIl0RACIC AP VIEW: T2T3 MILD RT LATERAL LIST NOTED. TIl0RACIC LATERAL VIEW: MODERATE DECREASE IN DISC SPACE ANTERIOR MARGIN SUGGESTIVE OF DEGENERATIVE JOINT DISEASE. LUMBAR LFT LATERAL BENDING VIEW: LI THROUGH L5 LACK OF SPINOUS PROCESS DEVIATION TO SIDE OF CONCAVITY SUGGESTIVE OF LACK OF NORMAL LUMBAR COUPLING MOTION. LUMBAR RT LATERAL BENDING VIEW: L5 LACK OF VERTEBRAL BODY DEVIATION TO SIDE OF CONCAVITY SUGGESTIVE OF LACK OF NORMAL LUMBAR COUPLING MOTION. LUMBAR LATERAL VIEW: L4L5 FACET IMBRICATION L5 MODERATE DECREASE IN DISC SPACE SUGGESTIVE OF DEGENERATIVE JOINT DISEASE. L5S1 SPOT VIEW: MODERATE DEGENERATIVE JOINT DISEASE DECREASE DISC SPACE WIlli OSTEOPHYTIC SPURRING SUGGESTIVE OF TRAUMATIC INSULT TO ARTIJRITIC COMPLEX. Sincerely. RANDY FREDERICK, D.C. CHIROPLUS OF LOCUST LANE 4607 LOCUST LN HARRISBURG PA 17109-4449 Phone: (717) 545-6063 December 14,2002 ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE 6345 FLANK DRIVE,SUITE 1000 HARRISBURG PA 17112 Regarding: RALPH PROBST Accident Date: 11-21-2002 Claim Number: 1554506830 3K4 Policy: 0 08 363150 Dear DAVE MOODY. DOS 12112/02 S: PATIENT PRESENTED WIlH SYMPTOMS FROM AN AUTOMOBILE ACCIDENT ON NOVEMBER 21. 2002. PATIENT PRESENTED WITH NECK, LOWER BACK, MID BACK, RT ARM, RT SHOULDER, LFT KNEE P AlN, AND SOME WEAKNESS IN TIiE LFT ARM AND HAND AREA. PATIENT WAS TAKEN TO TIiE EMERGENCY ROOM FOLLOWING TIiE ACCIDENT AND SYMPTOMS HAVE PROGRESSIVELY GOTTEN WORSE. PATIENT PRESENTED FOR EV ALUA nON AND TREATMENT OF TIiESE SYMPTOMS. 0: BILATERAL CERVICAL THORACIC LUMBAR MYOSPASM CERVICAL FIXATION C5C6 LATERAL CERVICAL DROP PIECE BILA TERALL Y LUMBAR FIXATION lAL5 BILATERAL SIDE POSTURE MANIP THORACIC FIXATION T5T6 PRONE MANIP LFT KNEE EXTREMITY FIXATION AND MANIP PRONE POSITION WITH KNEE INFLEXION A: PATIENT EXAMINATION TODAY; FINDINGS WRITIEN INTO CHART NOT DICTATED ON TAPE. X-RAYS TAKEN LUMBAR SERIES THORACIC CERVICAL AP AND LATERAL VIEWS REVIEWED PRIOR TO MANIP. PATIENT FILLED OUT A REVISED OSWESTRY FORM, 36/6lF60%.; GENERAL P AlN DISABILITY FORM, 24/60=40%. P: lFlHMP TO CERVICAL LUMBAR REGIONS/14 AND 20 MA'S/INTERSEGMENTAL TRACTION TO THORACIC LUMBAR REGION/CONTINUOUS ULTRASOUND TO LUMBAR REGIONIMANIP IN MY PROFESSIONAL OPINION BASED ON THE PATIENT'S IDSTORY, EXAMINATION FINDINGS, AND X-RAY FINDINGS, IDS INJURIES ARE A DIRECT RESULT OF IDS NOVEMBER 21,2002 AUTOMOBILE ACCIDENT AND NOT RELATED TO ANY PRIOR SYMPTOMS. Sincerely, RANDY FREDERICK, D.C. CHIROiiliY PLus Of Locust Lane Randy Frederick, D.C. 4607 Locust Lane Harrisburg, Pa. 17109 Pain Relief Center (717) 545-6063 fax:(717) 545-8510 --~-~--~~- ---~-~--- Initial Report December 17, 2002 All State Insuran,ce Company Claim Office Attn: Dave Moody 6345 Flank Drive, Ste 1000 Harrisburg, PAl 7112 .;'.. ., RE: Ralph Probst Date of Accident: November 21, 2002 Claim No.: 15545068303K4 Provider: Randy Frederick, D.C. Provider No.: 478570 Dear Mr. Moody: On December 11, 2002, Mr. Ralph Probst, a 75-year-old Caucasian male, presented to our office for uyuries sustained in an automohile accident on November 21,2002. Chief Complaints Patient presented with chief complaints of lower back pain along with neck, mid back, left knee, right arm, shoulder, and right hand pain. The patient stated that the onset of these symptoms were shortly after an automobile accident on November 21, 2002. The patient was hoping that the symptoms would reside; however, the symptoms have persisted and over the period of time have gotten worse. Therefore, the patient presented to our office on December II, 2002 for treatment of these injuries sustained in the automobile accident of November 21, 2002. The patient used a Visual Analog (VAS) pain grade scale to grade his pain. Upon presentation, his VAS pain grade was 8.0. History of Complaint Patient stated on NOVember 21,2002, approximately 12:20 p.m he was driving his truck. He was making a left tui:n.,ff of-the Carlisle Pike in Camp Hill on to another road. He stated that another vehicle drove out of a shopping center and drove through two lanes of traffic and hit his car on the drivers' side. At the time of the impact, the patient was not wearing his seatbe1t. He stated that some damage done to his vehicle, a 1991 S-IO Chevrolet Truck and the other vehicle also had some damage. The patient stated he was taken by ambulance to the Harrisburg Hospital's emergency room. Once at the emergency room, x-rays were taken of his head due to the fact that his blood pressure shot up very high. Patient stated that he had pain in the neck, mid back, lower back, left hand, right band, right ann, and pain in his right shoulder. Since the automobile accident of November 21, 2002, the patient stated he is having difficulties sleeping at night due to the pain. Since the automobile accident, he has not been able to pursue his hobby of bowling due to the pain. The patient stated his pain is daily in the regions mentioned above. He stated that the symptoms are worse when he is sleeping, sitting or standing in a prolonged position, and especially in the morning when he bends and lifts. He stated that he cannot find any particular position that alleviate his symptoms. He describes the pain in his neck as aclly, the pain in the lower back can be sharp and achy, and the pain in the mid back pain is achy. The pain into the right arm, hand, and shoulder are achy and sharp. Left knee pain is achy and sometimes sharp. He also has some weakness in the left arm. He stated that the pain in his neck is primarily on the left side, but can also be on the right side; lower back pain is more on the right side; and the mid back pain is bilaterally. He describes the pain as day and night. He also stated that since the accident he hears cracking-type noises in his neck. Past Medical History The patient recalls that as a child he had his appendicitis removed. Approximately 15 years ago he had surgery for a detached retina. About ten years ago, he had right knee arthritscopic surgery. The patient did recall being in an automobile accident about one year ago, but he had no injuries Or complaints following that automobile accident. Currently, the patient is taking multiple medications. The patient is taking 25 milgrams of coreg, lorazepan, trazodone, diovane, nexium, and lipitor. Most of this medication is for cholesterol, blood pressure and heart. He is also taking Centrum multivitamins. . . . The patient did initially present to our clinic for treatment of right shoulder and a neck problem. The patient continued with treatment at our clinic for that problem for a few days following the automobile accident. The patient stated he thought the symptoms from the automobile accident would subside, but the symptoms have persisted and have gotten worse. On December 12, 2002, the patient presented to our clinic for evaluation of those symptoms. In my professional opinion, the patient's prior symptoms were of a non-traumatic origin and not related to his current injuries and symptoms. Although the patient did have right shoulder pain prior to the automobile accident, he stated the pain in the right shoulder has gotten worse. ;.' J Physical Findings The following findings are based on an examination of December 12, 2002. Height: 6' 1"; weight: 210 lbs; blood pressure was 124/82; and pulse was 78. Cervical range of motion with pain, left lateral flexion 20 degrees, stiffuess noted on extension 20 degrees, left rotation 40 degrees stiffuess, right lateral flexion 20 degrees stiffuess. Lumbar range of motion with pain, flexion 40 degrees, extension 20 degrees, left lateral flexion 10 degrees. Positive cervical thoracic orthopedic test, apley's scratch test positive bilaterally, positive lumbar orthopedic test; sitting kemps bilaterally, leg drop bilaterally, milgrums bilaterally, and yoeman's test on the right side positive. nuerologic stress test on the left side and gillets test positive bilaterally. Palpation revealed bilateral cervical thoracic and lumbar myospasm. Trigger points were noted in the cervical thoracic lumbar trapezius and suboccipital regions bilaterally. Cervical spinal joint fixations were noted CIC4 C5C7 bilaterally, thoracic region T5T8, and lumbar region Ll through L5, along with bilateral sacroiliac joint fixations. Percussion with a reflex hammer revealed tellderness to the lumbar region on the right side. Deep pressure palpation revealed tenderness to the L4 L5 right SI joint region and palpation to the left knee tenderness. Upon examination, the patient had difficulty going from supine to prone and prone to sitting. Postural analysis revealed right low hand indicative of lumbar para spinal weakneSs. o. ':,t " X-Ray Findings The following fmdings are based on x-rays taken on December 12, 2002. A cervical ap and lateral views, thoracic ap and lateral views and a lumbar series were taken. Cervical ap view: C5C6 spinous process deviation to right side. Cervical lateral view: cervical lordosis C2C7 26 degrees below normal range of 30 to 43 degrees. Thoracic ap view: T2T3 mild right lateral list noted. Thoracic lateral view: moderate decrease in disc space anterior margin suggestive of degenerative joint disease. Lumbar left lateral bending view: Ll through L5 lack of spinous process deviation to side of concavity suggestive of lack of normal lumbar c~upling motion. Lumbar right lateral bending view: L5 lack of vertebral body deviation to side of concavity suggestive of lack of normal lumbar coupling motion. Lumbar lateral view: L4L5 facet imbrication, L5 moderate decrease in disc space suggestive of degc:.nerative joint disease. L5S1 spot view: moderate degenerative joint disease decrease disc space with osteophytic spurring suggestive of traumatic insult which may have created an arthritic symptom complex. Diagnostic Impression 1. 724.8, Acute Tra~c ,Lumbar Facet Syndrome 2.847.0. Cervical Acce1\OrationlDeceleration Disorder .- . - J'- ..1' . 3. 739.2, Traumatic Thoracic Spinal Joint Dysfunction 4. 739.3, Traumatic Lumbar Spinal Joint Dysfunction 5.739.1, Traumatic Cervical Spinal Joint Dysfunction 6.739.6, Traumatic Left Knee Fixation 7. Suspected Traumatic Activation of an Arthritic Symptom Complex to the Lumbar Region Prognosis and Treatment Plan In my professional opirtion, based on this patient's history, examination, and x-ray findings, his injuries are a direct result of the automobile accident on November 21, 2002. Please note that the patient was treated at our clinic prior to the automobile accident and that treatment was for a non related, non traumatic origin injury. This treatment was specifically to the right shoulder and slight stiffhess to the neck region. The patient's current presentation is that of injuries sustained in an automobile accident and of a traumatic origin along with a difference in pain prior type-sharp and constant versus some stiffhess and slight achiness. Please note that although the patient was treated for his right shoulder prior to the automobile accident, following the automobile accident he has noticed an increase in severity and duration of pain to the right shoulder and the trauma of the automobile accident has greatly aggrivated his right shoulder symptoms. .;:~ The patient is seeing an orthopedic surgeon Dr. Lippe for the evaluation of the injuries to the right shoulder region. The patient's current treatment plan will be that of three times a week for four weeks at which time the patient wiIl be reevaluated. Patient's treatment will consist of interferential stimulation, hot packs, continuos ultra sound, intersegmental traction to thoracic lumbar region, and spinal manipulation. Short- and Long-Term Goals Patient's short-term goals will be to reduce pain, decrease inflammation, and reduction of cervical thoracic lumbar spinal joint fixations and myospasm to those regions. Also, reduction and restoration of norrnalleft knee function due to fixation in that region and pain. Long-term goals for this patient will be restoration of normal lumbar spinal bio mechanics along with restoration of normal lumbar para spinal ml!sculature function. Also improvement in the patient's ability to perform activities of daily living. Following the irtitial period of care, the patient will be moved to a more active phase of care depending upon his response. The patient f1lled out a General Pain Disability Index and scored 24/60=40 percent. Also, the patient filled out a Revised Oswestry Low Back Pain Disability Index Questionnaire and scored 36/60=60 percent. Also, the patient's findings are graded on a point-by-point system with a possible 100 points maximum. The patient's positive points on his examination findings were 95 out of 100 possible points. ," Should you have any questions pertaining to this case, please contact this office at (717) 545-6063. Sincerely, ~~, cc: Joseph Dixion, Esq. Enclosure ;\ J REVISED OSWESTIY LOW BACIC rAIN DISABILITY QUESTIONNAIRE J0 ~o-4B PL~~E READ: This quesllonnaire Is. cJ.eslgned 10 enable us to undersfand how much your low hack p"in has ~lll'Cled your abll,'Y 10 manage your everyday actlvltles. Plea... answer each'sectlon by circling lhe ONE CHOlcr ,holl mosl applies 10 you. We realize Ihat you may leel that more Ihan one Slafe_nt may relate fo you, hul PLEASE JUST CIRCLE THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW. SECTION 'O-C""nging Degree of Pain , A. My pain is r"pidly gelling beller. l..f B. My pain nUCluales. bUI over~1I is ddinill'ly geuing ben~r. /1 ",'1 t. C. My pain seems 10 be gening beller, bu' improvemen. i, (L~Jf!:.f' ( I';. .tow al present. . ifl 0 ( , L/lu,tv (j)), My pain is neither gening ben..r nor worse. I . "i:' My pain Is gradually worseninR. f. My pain Is rapidly worsening. . , SECTION '-/lain InlrMity A. The pain comes and goes and is very mild. 8. The pain Is mild and does not vary much. C The "..In comes and goes and Is moderate. , tffj The pain I. modera.e and does not vary much. U 1:"" The pain comes and goes and Is severe. -I F. The pain Is severe and does noI yary much. SECTION 2-f't:.-..1 Can A. 'would noI have to change my way of washing or dres$ing in order '0 avoid pain. II; . do noI normally ch.nlle my way 01 washinR or ~ing even lhough II causes """" pain. C. Washing and dressing Increases lhe pain, but I manage noI to change my way 01 doing II. f!) Washing and dressing inc~ases the pain and I find ~.. necessary to change my way of doing il. E. Becauoe oIlhe pain, I am unable 10 do some washin and dr...ing wi.houl help. F. Becauoe 01 the pain. I am unable '0 do any wa,hing or dressing wl1houl help. . SECTION J-.Lifting A. I can Iill heavy weighls wilhout extra pain. B. I can lift heavy weights, but il cau5eS exlra pain. ..[ C. Pain prevenls me from Iihing heavy Wl'ighls off the n".,... Pain prevenls me from lining heavy weigh.. off .he ODOr, bull can manage illhey are convenienlly posilioned, e.g., on a lable. E. Pain prevents me from Iihing heavy weighls, bul I can manage lighl '0 medium weights if 'hey are convenienlly posilloned. F. I can only lift very Iighl weighls, al the most. SECTION 4-Walking 3 A. Pain does nOl prevenl me from walking any distance. . 8, Pain prevents _ Irom walking more Ihan 1 mile. . Pain prevents me from walking more Ihan 1/2 mile. . Pain prevents me Irom walklnll more .han 1/4 mile. E. I can only walk while using a cane or on crulches. F. I ,1m in bed mO<l of lhe ,'mr MId h,wC' In rI"wl 10 lhe loilel. SECTION S-Sifting A. I can sil in any chair as long as , like wi,houl pain. 1.(' 8. I can only sil in my lavorlte chair as long as I like. C. Pain prevenls me from sining more Ihan 1 hour. @ Pain prevents me Irom sininS morelban 1/2 hour. E~ I' ..in prevents me Irom slning more than 10 minutes. f. Pain prevenlHllO Irom sililllg .. all.'.. . PATIENT SIGNATURE: DATE: (2-12 JOOl-- SECTION 6-Standing A. I can stand as long as I want wilhoul p~in. 8. I have some pain while standing, hUI ;1 does nol Increase wilh lime. C. I cannot stand for lonller Ihan I hour wilhoul increasing @pain. . o I cannot sland lor longC'r than 112 hour wilhoul U . Increasing pain. -, E. I cannOC $land (or longer fhan 10 minules wilhour IncreaslnR pain. F. I avoid $landing. because it increase,; lhl,.' pain srraighl aw~y. . SECTION T-Skeping A. I gel no pain In bed. II. IlIeI pain In bed. bUI it does nor pr~vcn' me from sleeping well. C. Because 01 pain. my normal ni~h!'s ,Ipep is reduced by less than one-quaner. LI . n'5l Because Of pain. my normal ni~hl" '''-'-p i. reducW hy 1..7 less than one. half. E. Becauoe of pain. my norm.1 nigh!'s ,J,'rp is reduced by less .han Ihree'Cluarters., F. Pain prevents _ lrom sleeping al all. SECTION lI-SocUI tiff! A. My social life is normal "nd give, me no p.lin. C9 My sociallile is normal. but increoses thr degree'ol my pain. ;:L C. Pain has no signilicanl elfecl on my <ociallil.. apart from limiting my more energl'lic inh'rrsls, t.',~.. ri.mfing. elC. D. Pain has reslriCled my social lifc .nd I do nol go oul very often. E. Pain has restricted my soci.1 Iile 10 my home. F. I have hardly any social Iile hec.lu,e of the pain. SECTION J-Traveling . A. I get no pain while trav..\ing. ' B. Ige. some pain while traveling. bul none of my usual lorms of .ravel m,lke it any worse. (91 gel extra pain while traveling. hul il dO<'s nol com~ _ 10 seek allernalive (orms of lI.lVcl: :> D. I get extra pain while lravding whi,h Cflmpcl< me 10 seek ahernative lorms 01 travel. E. Pain restricts all lorms ollravel. F. Pain prevents all forms 01 trowel except Ih.l1 done lying down. _ _ -. CONS\)\..,./lo.,.\ON ~ _/-~ 12_11-02 pJl,.1S ~ l'.At.1?1\ 1?RO?>ST p.JI,.L e . L.. <3. oJ\;.J( ~("lor.uL ~ . . ;~;~q..o db k... I I'm 1ft)' I ,R co""""'" . '-7 ~ CJ tv- '''' '"" . _// S\ l"~\' \. 'u,,\'b l~' \) c..J ll. ;}l.o)- ,- n \ ~,. .' \,\_'L"'~ lY\i.)v' l)'}u ot~ "NY \~.,,'\\:,' .-u :.S'''''' <-{? 'f.Jo ~ J. \ ," S . . 'f "'- . ~ t "'.. cl rc~ ~,,6 t r'JJ\., LV"-.) )0-... C\M- ~ 'Vo \, C'~o u (J.. iV- " aH "l (0. ,\.", rkt fu ~..0v fIJ ;;ro '\..'0 \-'~ (o~J, , .' LJo ~t:<< ~ . A ,Jo... t1"WA tv-c"J/ n _. (g:Cu<,- ~ pv 0.%.\ 'O,~. ole 0"- oe~'o Lv'<-' \L,f. \c, \Y I.. ..' \:"-,,,:> l~ ./ "". \WL' \. i}Mb ,.,.... ~ . V" W"\. h,' L~~ tJ......\lNVv-- prior SUrge\"1' S'.. (\ w"," e ~ (}-i:;J '" y' \, 0 0:J J.1,e . ~; ,,,, I Lf::~~I:,}\ J" ,~ N\ ,-",';'" ".,Itb "\ '. '9>;, ~ ~.. lv--~ W ""~ "'-u v.-Io J_IC t' ~ . ,..;. \~OtO."'" . 1\<><"'''''0 14<>! . ~\"O ko"'b c."".\.,h,M'Io &,\, nh )c.1" ,,\cvJ, , ,c.LJd. _ ~q..\....f / . . \~ (\,9 .,...> >.{l ~ ,+^ ' :9 Q ",\~ OJ,..-<>-' \) ~l o~ ,\i.b 6;,\> .. . 'Vlol~ ~J ~ <5"J . ~ t" ~\\J~l ~o.... p{esC{iption medicatiOns CU{{entl'Y ta$en ~ ,y~ iQo+" c_ \'" I.- .(:0\ ~O\$-< (be v--' v., (\ W-l, (\- J\~"'\ L .'0 vJ-- (9l ~ (!!!}J @) ~r0- (0J"'-:- ,~ (J)Vs<\r-- e (l> t,rtJ'cvr~ ~(}-M $. ..\. r.,-- C~~~ r,k;\- f~ L~ cl"~~ 61hV_" ~ tu C? AA-, ;) t '" l. D CL 0J UvL/~ tCeJLJ- ~ t I... d (D d, fLc-",- ~ ClL'1tz tD l-(/ u v~, I q q ( b - ( () C ~ &> '1 tCLuJ2 Lv vjL dVOc. 6 (1"" u'u{Je OJ y() kvt c{ lVv-~c- ' A.o Jir Ct ~ c: l('- Cc b () W ~ l ~ Ct. vh,.-JJu Ce (;~tx ~.J\ C\D I f'\~(.l."'S \.."- 0-J (~ ( r ruf\ -rrtJ(\ ,<.J'c J ~ ~ f"" @J~ ~ <tJLt4 C'\~. 0J; ('at ~f trO-v'-k '2r~,/" +-- ", G()~ <Gl&&. tb o..u"o~ ~ ' '~G-~J~ boUJJJv s~ ~fv>- ~~ ;5Y ~~(/l-Cv~ lUtJ,/~ (JJ:t1., Jt'uJJ (l-uJl rr~ W iff IJ- L (:) 'f' (fro...-.l ~ n~uJt ('\;' 1;-()tJ, C (~J)~ .- r .,' '. ,14 ~) . \rJ 0 J'b ~~ ~-~ k(" ul~ ~LL\ ~J \>J'--~j ~ G~l ~ ~~ Qvti 1:0 l~, \I)OJJ\0 ~\\\ <((UJ~ I FIELD CLAIM OFFICE 6345 FLANK DR, SUITE 1000 HARRISBURG PA I7II2 PHONE NUMBER: 717-5040.7500 OFFICE HOURS: MONDAY.FRIDAY 8:00.5:30 November 22, 2002 RALPH E PROBST 2425 GARRISON AVE HARRISBURG PA 17110-9402 Allstate Insurance Company Claim Number: 1554506830 3K4 Our Insured: RALPH E PROBST Date of Loss: November 21, 2002 Dear Ralph, This letter is to advise you that I am the adjuster who will handle the medical part of your claim. Should you receive any medical bills, please put your claim number on them and send them to the address shown above. Also, please give your medical providers and any pharmacy the claim number and address so they may submit your bills directly to us. All prescriptions will be paid at 80%. Your medical benefit is $5,000.00. You do not carry any income loss benefits. As such, we will be unable to reimburse you for any time you may miss from work. Should you have any questions regarding the medical part of your claim, please feel free to call me at 800-546- 7574 ext 7565. Office hours are 8:00 AM until 4:30 PM. Sincerely, Q, t{\' DAVE MOODY Allstate Insurance Company ~~ SM06jOjOljl -..-_--..,~ 'Ct://{'E 6 _ 2S-"vlC, ~ ih/L Y Lop-,t1 ZJ. flJl1. (flTI vA^-) 1#1 G-, I I I~ A2.d"!)c7Ivc -(pr.s ;-;rEeL) 50"1 G : P loVIft\/- /fLf_ 'roo7i~'S'M C- : IV;; ^ (1/ "1 - 1.fO,41 G - t D/)I L..{/ I LIP 1/iT/{ ~ Zt;,v;? f OA fL(V" .; . (.?!v7A,vrv, , /Vi VL T(vlrltl>1l!t/ NJVIL - 2 - 0/)1 L.,y j" [2 C+c p (-f (r-,J f:>) (;/" Supplemental Instructions Abdominal Pain Contact your physician If any of the following occur. 1. Pain becomes severe or steady. 2. Vomiting perslsts. 3. Blood appears in vomitus. stool, or urine. 4. Shaking chills or high fsver. 5. Abdomen swells. 6. Constipation or diarrhea. 7. Failure to improve as expected. Burns 1. Keep Injured area elevated. 2. Change dressing only if Insfructed to do so. 3. Leave blisters alone. '4. Return to ED If slgns of infection appear. (Signs are listed under #3 01 "Lacerations, Abrasions. Punctures".j 5. Take any prescribed medications as prescribed. 6. Return for wound check as instructed. Culture Results You will be contacted only ff test results Indicate that you need addltional or different treatment You will not be called if the test Is negative or your current treatment is adequate. Your physician may obtain results by calling tha hospital. Lab results will r physician. DO NOT call the Lab tor results. " Head Injury ians have found no evidence at this time of serious injury and do not feel that hospital admission is necessary. However, conditions may change within the next 12 to 24 hours (or even longer). Please contact this hospital immediately if any of the following occur. 1. Mental confusion r2. SlfftStJ~ In areli8lAfiI. (1=1;6 l5&t1afrt sFiel::.iIS~.!. c1~t~t.ct'l6d ...vtlIY' flOUrs dd.:""tt....I;,;:I<l"lyllL.1 3. Persistent, repeated vomiting (once or twice is not uncommon). 4. Severe, continued headache. 5. Stiffness of neel<. fever. 6. Trouble with speech, balance, vision, weakness of either arm or leg. 7. Bloody or clear fluid dripping from the ear or nose. 8. Convulsions (frts or seizures). Tetanus 1. If you were given a tetanus toxoid Injection while you were in the Emergency Oepartment. make a note 01 it . 2. It Is normal for the arm to. be sore or a slight amount of redness to be present at the sight. 3. You may run a low grade fever for the next day. 4. If a more severe reaction occurs, see your physician or Emergency Department. lacerations, Abrasions, Punctures _ Sutured areas or dressing should be kept clean and dry for 48 hours. --..,- Keep sutured area elevated. ~ If continuous seepage, pain, fever, swelling, or redness of wound occurs, physician attention will be necessary. lee pack to affected areas - on 20 minutes, off 10 minutes for 24 to 48 hours. Continue as needed to reduce sweNing. If blood or medication soeks through dressing, call physiCian. _ Have sutures removed by physician in days. ~) PIN~ACLEHEA~TH ~ Hospitals Emergency Department Supplemental Instructions Form0742.1t {Oll2OOO)MA (F>M\ Eye, Eer. Nose, MOuth Instructions _ Wannlcool compressions over eye(s) most of tha day. _ Weareyepalchuntil- _ Avoid bright lights, TV. reeding for hours. _ DO NOT drllla If eye is patched and be careful when walklng down steps and using sharp instruments. - _ If bleeding occurs through nasal pack, call your physician. _ Small ice pack to nose .- an 20 minutes, off 10 minutes until most of the swelling has subslded. _ Rest. _ liquid dlellor days. _ Rinse with mouthwash or warm water after each meal and at bed time. Medical _ Rest. _ Drink plenty offluids. _ Take . orTylenolevery_hoursforflilverorpaln. _ Use Uqulprln or Tylenol infant drops for fever. _ No milk or dairy products for _ hours. _ Liquid dief (soups, jello, clear liquids). _ Sweetened tea, gingerale, or diluted juice may be given as_ ounces every _ hours lor1he next _ hours. _ aegin weakened formula when S\ools heve improved and diarrhea has subsided. When stools have become formed, a gradual ralum to full strength formula or diet may be attempled. If diarrhea is persistent or excessive, call your physician or Emergency Department. No fried or spiced or greasy foods. No alcoholic beverages. _ No coffee except decaffeinated. Give tepid bath to help reduce fever. _ If fever cannol be controlled after use of Tylenol and tapld bath, call your physiclan or Emergency Department Splint Care _ Elevate affected part on pillow. _ Apply Ice bag x 24 hours. _ Follow medications and rollow.up carelnsfruc\ion.. Sprelns and Bruises _ Eievele affected pan on pillow and rest _ Ice pack on affected part-20 mlnufeson. 10 minute. off. Dofor24to 48 hours. _ Wear ace wrap for _ Use crutches for days. _ Begin to bear weight on dsy. _ If affected pan becomes blue. cold, white, numb. or swollen or painful, retum to the Emargency Department. _ Wear sling for days. Use splint for _ days. _ Use wann packs for 30 minutes at a time every hours. . Rewrap dalty. ~1[:~ ,f~!111111I1111111 MR: 195163609 PROBST ,RALPH M DATE: 11/21/02 00B:06/19/1927 PhI: 717545-4915 DR: CASE: 223428541 AGE: 76 SSN: 195163609 Third CODY . E.O. Record Firc:t l"':nnv _ PP".".~t SAl"':ond conv - Medic~1 Records _ CGOH ED 657-729' ;;2 11i;.;risburg ED 782-5257 Polyclinic First Place _ First Place 657-7218 _ First Place 782-5908 782-2690 Please note that the instructions circled or ~ecked below PJrta1n to you. You have been discharged with the diagnosis of L.o. /" ""'--~ b" ~ .-.0 ~ --/': {/l~ The examination and treatment you have received in the Emergency Department have been rendered on an emergency basis only and are not intended to be a substitute for or an effort to provide complete medical care. If you develop problems and complications, contact your phYSician or this Emergency Department. General Instructions Rest for Off work / school from Return to work on Light duty for to Regular duty ~1I0W-UP Care LYReturn to the Emergency Department immediately if unexpectedly worse or not improved. 2. Emergency Department on 3. Family P~YSi.ci~ian . , Vsee Dr. L<,,---- --il / rJ-?-~ ~ ,1/ at 5. Call for an appointment within to the following Clinic: _ Medical Ciinic, Education Bldg, 2nd Floor (782-2421) _ Surgical Clinic, Education Bldg, 2nd Floor (782-2421) _ Orthopedic Clinic, Landis Bldg, 2nd Floor (782-2142) _ Pediatric Clinic. Kline Bldg, 4th Floor (782-4650) _ WomanCare Clinic, Professionai Bldg, 3rd Street, 3rd Floor (782-6500) on ""1'-----" ~'> PINNAClEHEALTH <4 Hospitals Emergency Departmenl CGOH.657-7295 Harrisburg-782-5257 Polyclinic-First Place P.O. Box 8 00' iTst Place'657-7218 First Place.782.5908 782-2690 Harrisburg.. A 17105-8700 Laboratory Instructions Call for results In x- Instructions YJ ur x-rays have been re he Emergency Physician. I any abnormalities are found t have not been called to your attention, you or your doctor will be called immediately. Sometime , fractures or abnormalities may 1'1 I show up on x-rays for several da s. i If symptoms persist or get worse I call your Physician or return to t e Emergency Department. More x-rays may have to be ) PINNAClEHEALTH Hospitals Emergency Department Patient Instruction Sheet Form 29001 (amOOD) MR (PM) "AM/PM. hou rs I days ~ Rx Diet force fluids_ clear liquids __ soft diet_ as tolerated_ SUPPlementallnstructlont~ (~ ~:;". ..-L. Medlca~~ '~ .J~~-Jz ~ "" fA ( l' 0._ CL-:J -- p ~~ A. . I hereby acknowledg... reCeipt of tl)e.sei~stl\lctjons,that I have hao emergency-treatment only, and that I may be r"'leas...d before all ~Y: medical problems are' known'or treatl?d. I will arrange ,for follow-up Care as I have. been " tt .. X p~, Date 1) Substituti ermissible IN ORDER FOR A BRAND NAME PROOUeI IV" DE 8IElP(tldo, THE PRE MUST WRITE "BRAND NECESSARY. OR "BRAND MEDICALLY HIS SPACE MAY REFILL TIMES PATIENT INFORMATION PHYSICIAN LABEL PROBST .RALPH MR:195163609 195163609 06/19/1927 75 M HER 2425 GARRISON A HARRISBURG PA 17110 717 545-4915 CASE, 223428541 i ,I r I i I PA lie # DEA No. PRINT PHYSiCIAN NAME LABEL ALL PRESCRIPTIONS First copy. 'Patient Second copy - Medical Records Third copy - E,D. Record 11/21/02 r IT'. .,:(~ ~(, ("1TJ t;ffn '~~(f \j NOTIFICA1.ONOF ACCIDENT INVESTIGATION HAMPDEN TOWNSHIP POLICE DEPARTMENT 230 SOUTH SPORTING HILL ROAD. MECIIANICSBURG. PA 17055-3097 . (717)761-2609 Notice is hereby given that the accident identified below is being investigated by the Hampden Township Police and that the Commonwealth or Pennsylvania Police Accident Report will be submitted as prescribed by Section 3746 (c) or the Vehicle Code. , POLICE INCIDENT NUMBER - TIME AND D~r: Of ACX:ENT :) .:~.(j ~ 11320 Jt.2i.v::?. ,- .',', 1~.:.<'7'1 LOCATION Of ACCIDENT II 'il'!' oJ.." , OFFICER'S NAME ,:~fi,,:'..jT;I; ;:; .ill II -.,' r ~"'''TlI! !Yi i fi f! "J l'r"-<i '-J UNIT ##1 UNIT #2 36. LEGALLY Y N 37. REG. be x 7,'-Jn .1 '8~WE 36. LEGAllY Y N 37. REG. YGZ<;(oIS" 138 ~1 PARKED'? 0 B; PUlE PARKED? 0 !&. PLATE 39. PA Tlfl:rtlfl I (,,/C'W 'S 11"1111"1 .11'i'!"1 39.PA~' li,CCT 1'~z.'lm):.OfJ.f'l ettfoo6F-SWEVIN ~EVIN 40. OWNER E ,,11 11; m, c"j... 40. OWNER /(l, I" L f,- 1J , (oJ, ,. r-. 41. OWNER l(ecrlnv)uJ /1)f 41. OWNER I ADDRESS I';f ADDRESS .2 if...~ S' (--;";' In ,!'"j YJ /ivo 42. CITY,STATE rrf(.~:I( ,,/i1{ C) ~\Jf(jJ1! f70SS' 42. CITY, STATE ).,;"",.\;, '01 IlU n/lO /I, ZIP CODE /I, ZIP CODE 43. YEAR I'P 44, MAK} , , v \J , r,J \ 43, YEAR I .' '../ 44. MAKE JC~~vrdcr '-I!. ? ; I. {( c/./ 45. MODEL (NOT (:1 ~, 46, INyS~ 45, MODel (NOT ('--J n -"'.i....1t r- 1'(J 46, "'i\r BODY TYPE) .' eel (';'f NO UNK 0 BODY TYPE) .' '. Y " NO UNK 0 ~~ODY j .i :~fPECIAl ~~EHlClE I~~ODY 1"1 U ~ SPECIAL' ~~EHlClE TYPE "j ri f USAGE OWNERSHIP TYPE , USAGE OWNERSHIP ~:NtTlAll~ct. 1(:9 ~EHIClE @JRAVEl I~ :NITIAl,~PAC~. . ~ ~~EHICLE <..:9JRAVEl POINT . !-. ,::.:J,i fi t I STATUS SPEED POINT, {i'!v\ L '.jG t STATUS SPEED ~~EHIClE '(:9 ~RIVER D C::) ~IVffi 1~~EHIClE "L",., @DRIVER D ~ PRIVER GRADIENT PRESENCE CONDITION GRADIENT '..1'.'..'..... PRESENCE CONDITION 56. DRIVER /(2 G ti 2. "~~ j & 157, r~TE 56, DRIVER fi("ii(,? l>Ct 1,6filTATE NUMBER NUMBER 58. DRIVER , 58. DRIVER NAME td/lh Ii ita J' C,ck NAME r...,,;!., h t. fir~iJ;r 59 DRIVER 1iJ7 Be.,,!, [".!ud ir. 59. DRIVER ."'U '.. " ADDRESS " ADDRESS \"--.')rnf" 60: CITY,STATE /}1 ,,.,,,' {j ~Hlit~J D,.ra 60. CITY. STATE /I, ZIP COOf & ZIP CODE 81, SEX F 62, DATE OF ?-I':;-3c 'J 63. PHONE 81S~ 62. DATE OF ,.' I'i-Z? I 8' PHONE BIRTH BIRTH tJl"" 64. CDMM. VEH. 65. DRIVER .~ I 66. DRIVER 64, COMM, Y~ 1(. 65. DRIVER 166. DRIVER 'C1 NIll CLASS '- SS, YON - CLASS C' (VI S5I 67 CARRIER 67. CARRIER 68. CARRIER 68. CARRIER ADDRESS ADDRESS , " 69. CITY. STATE 69. CITY, STATE & ZIP CODE /I, ZIP CODE 70, USDOT 1# ICCI P\JC. 70. USDDl # ICC# PUC, " ~:EH. I~ CARGO 74 GVWR ~~EH. ~ CARGO 74. GVWR .. CONFtG. BODY TYPE CONFIG. BODY TYPf 75. NO. OF I ~ ~AZAROOUS 77. RELEASE Of HAl MAT 75. NO. OF @ ~AZARDOUS 77 RELEASE OF HAl MAT AXLES MATERIALS Y !~I NG UNK [i AXLES MATERIALS Y Cl N [I UNK 0 IlISURANCl COM PAN:( I F"ff>1 fll,.TIJa I IN8UIIA/lCE COMPANI1II. _ t/fJ I/f:ii'- r:c U:JWi IIIfIlllMATJOII S/q e INFORMATION .\hle '171iv -UNIT 1'- POLICY NO. SGf7710c~JJ{).j -UHlT2- POllCV NO. oor?(,] ISA 07 Ix: , 85, DESCRIPTION OF DAMAGED PROPERTY 7/.fo ,. ~t /Ci.J!- ,- ~ ), - 0 S ' ~,:;" V OWNER I ADDAESS PHONE AOOITIONAlINfORMATtoN: 'J" .. y'"J ( j' f" , ,oj. . l'-"'Jr'" ") '. n.) ..> I;\. ft ct (Yl )j,v:J IIcJJp, ( "'f'f HIli f/h-;/;, 478570 PLEASE DO NOT STAPLE IN THIS AREA ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE/DAVE MOODY 6345 FLANK DRIVE SUITE 1000 HARRISBURG PA 17112 HEALTH INSURANCE CLAIM FORM 3 '" PICA ""T".1 ~~A ~n"Q"n "VA PICA ITI ' 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHEf1 1a. INSURED'S 1.0. NUMBER (FOR PROGRAM IN ITEM 1) I D D D DHEALTHPLANDBLKLUNGIxl (Medicare #) (Medicaid #} (Sponsor's SSN) (VA file #! (SSN or ID) (SSN) (10) 2. PATIENT'S NAME (last Name. Firs\ Name, Middle \fli\ial) 3. PATIENTS BIRTH DATE M[X] SEX FD 4. INSURED'S NAME (Last Name, First Name, Middle Initial) MM DO yy PROBST RIIT.PH !" :'1' D1\TDW !' Ofil <11927 5 PATIENTS ADDRESS ( No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street) ?A?<; ""~nnTC:()~l liVE se'f~spouseDchi'dD OtherD 2425 GARRISON AVE CITY !ST~: 8 PATIENT STATUS CITY I STATE W~OOTc:p.nR(.; SingleD Married IX] OtherD HARRISBURG PA ZIP CODE I Tt~E~H;N)E ~1;1~~Area Code) ZIP CODE TELEPHONE (INCLUDING AREA CODE) DFuU-Tirne Dpact-TimeD ( 545) 17110 Employed Student Student 17110 4915 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10, IS PATIENT'S CONDITION RELATED TO 11, INSURED'S POLICY GROUP OR FECA NUMBER 0 08363150 a, OTHER INSURED'S POLICY OR GROUP NUMBER a, EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH SEX DYES IX] NO MM DD yy MIX] FD 06:191:927 b. OTHER INSURED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (Sta\€) b. EMPLOYER'S NAME OR SCHOOL NAME MM DO YY I MD FD !XJ YES DNa I :m, c, EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c, INSURANCE PLAN NAME OR PROGRAM NAME DYES IX] NO d INSURANCE PLAN NAME 01"\ PROGRAM NAME lQd. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? DYES [X] NO If yes, return to and complete item 9 a-d READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12, PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authoriz€ the release of any medical or other information necessary to payment of medical benefits 10 the undersigned physician or sup plierfor process this claim, I also request payment of government benefits either to myself or to the party who accepts assignment below. saNiees describeti be-\cw SIGNATURE ON FILE 11092004 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OF CURRENT: ~ ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DO YY GIVE FIRST DATE MM DD yy MM , DO yy MM , DD yy 11h2002 INJURY (ACCIdent) OR PREGNANCY (LMP) FROM TO 17, NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. 1.0. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DO , yy MM DD yy FROM : TO : 19, RESERVED FOR LOCAL USE :~O, OUTSIDE LAB? $. CHARGES DYES IiJNO L I 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) ~ 22. MEDICAID RESUBMISS10N CODE I ORIGINAL REF, NO 1,1724 ~ LUMBAR FACET SYNDROM 31739-.2 THORACIC PI ~'3. PRIOR AUTHOFlIZATION NUMBER 21847 0 CERVICAL ACCELERATI041739 3 LUMBAR SPINA 24 A B C D E F G H I J K DATE(Sl OF SERVICE Place Type PROCEDURES, SERVICES, OR SUPPLIES DIAGNOSIS DAYS EPSDT RESERVED FOR From To " 0' CPTi~~Xt2'~fi Ufi~sual Clrcu;:;~~7~~~ CODE SCHAFlGES OR Family CMG COB LOCAL USE MM 'D " MM DO " Service ServlCS UNITS Plan 97012 I . : 070:22003 070:220:03 11 1 : 1 2 3 4" 25 ': 00 1 p-7UZ2lJl)j O/OLLOOj III J. <:H:l~41 1 2 3 4, ' 40:00 1 071:120:03 071:120:03 11 1 99213215 : 1 2 3 4, 75ioo 1 101112003 07112003 111 J. ' GUL!:U 1 2 3 4" 25:00 1 b71tL20Q3 071:12003 11 1 97035 I 1 2 3 4'" 25:00 1 lJ711<.uUJ Il/I1LUUj 1J.1 J. ~/U12 [1 2 3 4" 25:00 1 P71'120Q3 071'120:03 11 1 98941 I : 1 2 3 4 40100 1 I I : : : : 25 FEDERAL TAX I,D. NUMBER SSN EIN 26, PATIENTS ACCOUNT NO 1~7. ACCEPT ASSIGNMENT? 28, TOTAL CHARGE I ~9. AMOUNT PAID 30, BALANCE DUE 25 1769919 DO 1878 PI d'or govl. claims see back) S 255:00 $ : 1980 :00 YES []NO S 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32, NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE ~o ~'rne[!$mQffi:NAM'D'Di2!'ESS, ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDERED (If other than I10me or office) (I certily that the statements on the reverse LOCUST LN ~~I5IQ1'b~1S.~5~f1'!l'<Ih"'1J C HARRISBURG PA 17109-4449 11092004 (717) 545 6063 SIGNED DATE PI~J # IGRP -# ( > . . . C u ~ e u ~ ii ~ C 2 ~ I- 2 II. j:: .. 0. a: W a: a: <( u 1 i I I 2 z o ;:: <( ::;; a: o u. ~ a: w :J 0. 0. :J !/) a: o z <( 13 iii > J: 0. 4 5 6 1 '^DDW--'\I,,)"v b"^ ,'''''''''''Ir "^' "~nW'" ""I'l'"""" ~,,,,,\ PI F",.C;F PRINT nR TYPE APPROVED OMB-0938-00Q8 FORM CMS-1500 (12.90). FORM RRB.1500 APPROVFn OMR.t:J1') FORM Owr:p-1<;no, APPROVED OMB-0720.001 (CHAMPUS) BECAUSE THIS FOflM IS USED BY VAmQUCi ";O;i~RNMENT AND PRIVATE HEAtTH PROGRAMS, SEE SEPARATE INSTRUCTiONS ISSUED BY APPLICABLE PROGRAMS. NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties. REFERS TO GOVERNMENT PROGRAMS ONLY MEDICARE AND CHAMPUS PAYMENTS: A patient's signature requests that payment be made and authorizes release at any IniormatlOn necessary to process the claim and certifies that the information provided in Blocks 1 through 12 is true, accurate and complete. In the case of a Medicare claim, the patient's signature authorizes any entity to release to Medicare medical and nonmedical information, including employment status, and whether the person has employer group health insurance, liability, no-fault, worker's compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made. See 42 CFR 411.24(a). If item 9 is completed, the patient's signature authorizes release of the information to the health plan or agency shown. In Medicare assigned or CHAMPUS parti~ipation ca~es, the physician agrees. to acce:pt the charge determination of th~ Medicare carrier or CHAMPUS fiscal Intermediary as the full charge, and the patient JS responSible only for the deductible, cOInsurance and noncovered services. Comsurance and the deductible are based upon the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submittea, CHAMPUS is not a health insurance program but makes payment for health benefits provided through certain affiliations with the Uniformed Services, Information on the patient's sponsor should be provided in those items captioned in "Insured"; i.e., items 1a, 4, 6, 7, 9, and 11. BLACK LUNG AND FECA CLAIMS The provider agrees to accept the amount paid by the Government as payment in full. See Black Lung and FECA instructions regarding required procedure and diagnosis coding systems. SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE. CHAMPUS, FECA AND BLACK LUNG) I certify that the services shown on this form were medically indicated and necessaryforthe health of the patient and were personaffyfurnished by me orwere furnished incident to my professional service by my employee under my immediate personal supervision, except as otherwise expressly permitted by Medicare or CHAMPUS regulations. For services to be considered as "incident" to a physician's professional service, 1) they must be rendered under the physician-s Immediate personal supervision by hislher employee, 2) they must be an integral, although incidental part ota covered physician's service, 3) they must be of kinds commonly furnished in physician's offices, and 4) the services of non physicians must be included on the physician's bills. For CHAMPUS claims, I further certify that I (or any employee) who rendered services am not an active duty member of the Uniformed Services or acivilian employee of the United States Government or a contract employee of the United States Government, either civiliall or military (refer to 5 USC 5536). For BlaCk-Lung claims, I further certify that the services performed were for a Black Lung-related disorder. No Part B Medicare benefits may be paid unless this form is received as required by existing law and reguiations (42 CFR 424.32) NOTICE: Anyone who misrepresents or falsifies essential information to receive payment from Federal funds requested by this form may upon conviction be subject to fine and imprisonment under applicable Federal laws NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE, CHAMPUS. FECA, AND BLACK LUNG INFORMATION (PRIVACY ACT STATEMENT) We are authorized by eMS, CHAMP US and OWCP to ask you for information needed in the administration of the Medicare, CHAMPUS, FECA, and Black Lung programs. Authority to collect information is in section 205(a), 1862, 1872 and 1874 of the Social Security Act as amended, 42CFR 411.24(a) and 424.5(a) (6), and 44 USC 3101 ;41 CFR 101 et seq and 10 USC 1079 and 1086; 5 USC 8101 et seq; and 30 USC 901 et seq; 38 USC 613; E,Q, 9397 The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility. It is also used to decide jf the services and supplies you received are covered by these programs and to insure that proper payment is made The information may also be given to other providers of selvices, carriers, intermediaries, medical review boards, health plans, ana other organizations or Federal agencies, for the effective administration of Federal provisions that require other third parties payers to pay primary to Federal program, and as otherwise necessary to administer these programs. For example, it may be necessary to disclose information about the benefits you have used to a hospital or doctor. Additional disclosures are made through routine uses for information contained in systems of records. FOR MEDICARE CLAIMS: See the notice modifying system No. 09-70-0501, titled, 'Carrier Medicare Claims Record, published in the federal Register, Vol. 55 No. 177, page 37549, Wed. Sept. 12, 1990, or as updated and republished. FOR OWCP CLAIMS: Department of Labor, Privacy Act of 1974, "Republication of Notice of Systems of Records," F,j3deral Regist~.I Vol 55 No 40, Wed Feb. 28, 1990. See ESA-S. ESA-6. ESA'12, ESA-13, ESA.30, or as updated and republished, FOR CHAMPUS CLAIMS: PAINCIPLEfURPQS.B.Sl. To evaluate eligibility for medical care provided by civilian sources and to issue payment upon establishment of eligibility and determination that the services/supplies received are authorized by law ROUTINE USEiSt Information from claims and related documents may be given to the Dept. of Veterans Affairs, the Dept. of Health and Human Services and/or the Dept. of Transportation consistent with their statutory administrative responSibilities under CHAMPUS/CHAMPVA; to the Dept. of Justice for representation of the Secretary of Defense in civil actions; to the Internal Revenue Service, private collection agencies, and consumer reporting agencies in connection with recoupment claims; and to Congressional Offices in response to inquiries made at the request of the person to whom a record pertains. Appropriate disclosures may be made to other federal, state, local, foreign government agencies, private business entities, and individual providers of care, on matters relating to en~itlement, claims adjudication, fraud, program abuse, utilization review, quality assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil and criminal litigation related to the operation of CHAMPUS DISCLOSURES. Voluntary; however, failure to provide information will result in delay in payment or may result in denial of claim. WIth the one exception discussed below, there are no penalties underttlese programs for refusing to supply information. However, failure to furnish information regarding the medical services rendered or the amount charged would prevent payment of claims under these programs. Failure to furnish any other information, such as name or claim number, would delay payment of tile claim. Failure to provide medical information under FECA could be deemed an obstruction. It is mandatory that you tell us if you know that another party is responsible for paying ~or your treatment Section 11288 of the Social Security Act and 31 USC 3801- 3812 provide penalties fl"'T 'Nithholding thi~ information You should be aware that P.L. 100-503, the "Computer Matching and Privacy Protection Act of 1988", permits the government to verify Information by way of computer matches. MEDICAID PAYMENTS (PROVIDER CERTIFICATION) I hereby agree to keep such records as are nf)ccssary to disclose fully the extent of services provided to individuals under tile State's Title XIX plan and to furnish information regarding any payments claimed for providing such services as the State Agency or Dept. of Health and Humans Services may request. I further agree to accept, as payment in full, the a.mount paid by the Medicaid program for those claims submitted for payment under that program, with the exception of authorized deductible, coinsurance, co-payment or similar cost-sharing charge. SIGNATURE OF PHYSICIAN (OR SUPPLIER): I certify that the services listed above were medically indicated and nHcessary to the health of this patient and were personally furnished by me or my employee under my personal direction NOTICE: This is to certify that the foregoing information is true, accuraln dnd comp!ete_ I understand Uml paymen\ and satistaction 01 this ciaim will be trom Federal and State -- funds, and that any false claims. statements, or documents, or concealment of a material fac" Illay bo prosecutod under applicable Federal or State laws. According to the Papef\IVork Reduction .A.d of 109~) n') persof1(-:i are required to respond to a collection (If information unless it displays a valid OMB conlrol number. The valid OMS contra! number fOI tf-j,s ; (1jo. :-n,lt!u, coller;tion IS 0938-0008_ The time reqUired to complete thiS Iflformatron collection is estimated to average 10 minutes per response, inCluding t_he titne to r-evitwi ;nstrucl,ons, search existing data msources, g,ather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estJmate(s) or suggestions for irnproving this form, please write to: eMS, N2-14-26, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. 478570 PLEASE DO NOT STAPLE IN THIS AREA ALLSTATE INSURANCE COMPANY FIELD CLAIM OFFICE/DAVE MOODY 6345 FLANK DRIVE SUITE 1000 HARRISBURG PA 17112 HATH INSURANCE CLAIM FORM 2 III PICA (', M. 1 ""Ll "neo 'H\ .,vA E L PICA nT 1 1 MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHEr! 1<1_ INSURED"S I.D. NUMBER (FOR PROGRAM IN lTEM 1) , I (Medicare #)0 IMedicaidil'.iD fSpOIJso(s SSN) D (VA File II) o HEALTH PLAN DBlK l\.JNGf;l; (SSN or 10) ISSN) I y (10) 2. PATIENT'S NAME (Last Name. First Name Middle Initial) 3 PATIENT'S BIRTH DATE Mr;lSEXFD 4. INSURED'S NAME (last Name, First Name, Middle Initial) MM DD YY :'1' O"',OI-! 1;' () h:' Q1 :Q?7 00"''''''' ""TOI-! 1;' 5. PATIENT'S ADDRESS (No., Street) 6. PA:1Ir~f~ELATIONSH1PTO INSURED 7. INSURED'S ADDRESS (No., Street) . C ? Ll?" ('1\ DO T ""l'L. Z\\lJ': Sell I V spouseDCh,ldD OtherO ?Ll?~ ('''OOT<::n1\] Z\V"' j: < CITY I':: 8. PATIE:NT STATUS CITY lSTATE . . Single 0 Married [X] OtherD 1-!,,00-rC;R1JRr:; a pI>. C u. ZIP CODE I'(~:~N)E ;;~';'" Cod'l ZIP CODE TELEPHONE (INCL..UDING AREA CODE) ~ 1711 () DFulI.Time Dpart.TimeD ( 549 c: Employed Student Student 17110 4915 u. g, OTHER INSURED'S NAME (Last Name, Firsl Name, Middle Initiai) 10, IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER a; ::l o ()816<150 '" ;!: a, OTHER INSURED'S POLICY OR GROUP NUMBER a, EMPLOYMENT? (CURRENT OR PREVIOUS) a, INSURED'S DATE OF BIRTH MIxl SEX 0 DYES [X] NO MM DD,YY FD z 0~191:9?7 ..: b. OTHER INSURED'S DATE OF BIRTH b. AUTO ACCIDENT? PLACE (State) b, EMPLOYER'S NAME OR SCHOOL NAME .... Z MM : 00 : YY I MD SEXFD [X] YES DNO UJ U?A__I ;:: ..: c EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? :;, INSURANCE PLAN NAME OR PROGRAM NAME a. DYES [X] NO a: UJ d INSURANCE PLAN NAME OR PROGRAM NAME 100, RESERVED FOR lOCAL USE d IS THERE ANOTHER HEALTH BENEFIT PLAN? a: DYES [X] NO a: Jfyes, return to and complete item 9 a.d ..: c.> READ BACK Of FORM BEFORE COMPLETING & SIGNING THIS FORM. - 3. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I au\t1orlze 1 12, PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE i authorize the release of any medical or other inlcrmal\on necessary 10 payment of medical benefits to the undersigned physician or supplier for process trus Claim I also request payment 01 government benefits either to myself or to the party who accepts aS$ignment below services deSCribed below SIGNATURE ON FILE 03312003 SIGNATURE ON FILE SIGNED DATE SIGNED 14. DATE OF CURRENT: ~ ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 1 MM,DD,YY GiVE FiRST DATE MM DD yy MM DD yy MM DD , yy INJURY (Accident) OR : 11212002 PREGNANCY \lMP) : FROM : TO 17. NAME OF AEFERRING PHYSICIAN OR OTHER SOURCE 17a. 1.0, NUMBER OF REFERRING PHYSICIAN 19. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD yy MM DD yy FROM : TO : 19, RESERVED FOR LOCAL USE 20 OUTSIDE lAB? $ CHARGES DYES [XINO I I 21, DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, (RELATE ITEMS 1.2,3 OR 4 TO ITEM 24E BY UNE) ~ 2?, MEDICAID RESUBMISSiON CODE I ORIGINAL REF. NO 1,1724 ~ LUMBAR FACET SYNDROM3L1..:i9-.? THORACIC PI 2~; PRIOR AUTHOAIZA TION NUMBER 21847 0 CERVICAL ACCELERATI04L1..:i9 3 LUMBAR SPINA z: 0 24 A B C D E F G H I J K ~ DATE(SI QFSERVICE Place Type PROCEDURES, SERVICE-S, OR SUPPLIES DIAGNOSIS DAYS EPSDT ,,~ To 0' 0< ' CPTI~~"t'~~n Url~sual CirCU~~$(~~ $.CI-IARGES OR Fam'ily 'MG COB RESERVED FOR :; MM " " MM " " Service Service CODE UNITS Plan LOCAL USE a: I- : 0 ! G0283 I u. 01032003 01032003 11 1 : 1 2 3 4, 25: 00 1 ;!: 01032003 101032003 11 1 97035 I 1 2 3 4"'0 25: 00 1 a; UJ 01032003 01032003 11 1 97012 : 1 2 3 4\ 25: 00 1 :; a. U1U.JLUU.J IU1 1111 98~41 1 2 3 4' 40: 00 1 a. :> 03072003 03072003 11 1 G0283 I 1 2 3 4: 25i 00 '" 1 a: UjUILU03 10jOl 11 II 97012 1 2 3 4\ 25: 00 1 0 z 03072003 03072003 11 1 97110 I 1 2 3 4,;.. 50: 00 2 ..: U.JUILUU.J U.JUI,uUJ 11 .L ~T 1 2 3 4\ 40: 00 1 c.> in 031;02003 031;02003 11 1 G0283 I : 1 2 3 4i.\, 25 00 1 .. :I: 0::nUL003 03102003 11 97012 1 L 3 4,' 25: 00 1 a. J, 031;02003 031;02003 11 1 I 971101 1 2 3 4\ 50: 00 2 25. FEDERAL TAX I.D NUMBER SSN EIN 26, PATIENT'S ACCOUNT NO 1;7. ACCEPT ASSiGNMENT? 28 TOTAL CHARGE 1:9. AMOUNT PAID 30. BALANCE DUE 25 1769919 Du 1878 PI ~orgOvtcla'lmS$eebaCk) $ 355: 00 $ : $ 825: 00 YES CJ NO 31. SIGNATURE OF PHYSICIAN OR SUPPliER 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE ~E'~l!lR~I'(NAMEOD'l'JESSo ZIP CODE iNCLUDING DEGREES OR CREDENTIALS RENDERED (It other than home or office) (I certify that the statements on the reverse 41'; LOCUST LN ~W!:l'ji' biWl't'b~~t~1<"""b C HARRISBURG pA 17109-4449 03312003 (717) 545 6063 SIGNED DATE PIN j! IORP' 6 3 4 5 {~"ppn\ll=n RV ~."" "nl'""" n" "l=r"r~1 "1=0\111;1= A."~~\ PI FA~F PRINT OR TYPE APPROVED OMB-0938-0008 fORM CMS-1500 (12-90), FORM RRB-1500, APPROVFn OMR-1'1.r; F(lRM nwr:p-1"iOQ, APPROVED OM8.072.0-QQ\ ,CHAMP\JSj BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BY APPLICABLE PROGRAMS. NOTICE: Any pl!rson who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or mislea.ding information may be guilty of a criminal act punishable under law and may be subject to civil penalties. REFERS TO GOVERNMENT PROGRAMS ONl Y MEDICARE AND CHAMPUS PAYMENTS: A patient's signature requests that payment be made ana aL'lhori.ze~, release 01 dny ~Ilfo;iilii~ion necessary to process the claim and certifies that the information provided in Blocks 1 through 12 is true, accurate and complete. In the case of a Medicare claim, the patient's signature authorizes any entity to release to Medicare medical and nonmedical information, including employment status. and whcthnr +he 'Jcrson has employer group health insurance, liability, no~fault, worker's comp€nsation or other insurance which is responsible to pay for tho services tor wtlich the Medic"ye claim is made. See 42 CFR 411.24(a). If item 9 is completed, the patient's signature authorizes release of the information to the health plan or agency shown !n Medicare assigned or CHAMPUS participation cases, the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fi~cal intermediary as the full charge, and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the df,du(;l;ble ,He based upon the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submitted. CHAMPUS is not a health insurance program but makes oaymentfor health benefits provided through certain affiliations with the Uniformed Services Information on the patient.s spor",::;w:"hould be provided in tho..c;e items captioned in "Insured"; i.e., items 1 a, 4, 6, 7, 9, and 11 BLACK LUNG AND FECA CLAIMS The provider agrees to accept the amount paid by the Government as payment in full. See Black Lung and FECA Instructions regariJlng required procedure and diagnosis coding systems. SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE, CHAMPUS, FECA AND BLACK LUNG) I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally fu rnished by me or were furnished incident to my professional service by my employee under my immediate personal supervision, except as otherwise expressly permitted by Medicare or CHAMPUS regulations. For services to be considered as "incident" to a physician's profeSSional service, 1) they must be rendered under the physician.s Immediate personal supervision by his/her employee, 2) they must be an integral, although incidental part of a covered physician's service, 3) they must be of kinds commonly furnished in physician's offices, and 4) the services of nonphysicians must be included on the physician's bills, For CHAMPUS claims, I further certify that I (or any employee) who rendered services am not an active duty member of the Uniformed Services or a civilian employee of the United States Government or a contract employee of the United States Government, either civilian or military (refer to 5 use 5536). For Black-lung claims, ( further certify that the services performed were for a Black lung~related disorder. No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations (42 CFR 424.32) NOTICE: Anyone who misrepresents or falsifies essential information to receive payment from Federal funds requested by this form may upon conviction be subject to fine and imprisonment under applicable Federal laws. NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE, CHAMP US. FECA, AND BLACK LUIlG INFORMATION (PRIVACY ACT STATEMENT) We are authorized by eMS, CHAMPUS and QWCP to ask you for information needed in the administration of the Medicare, CHAMPUS, FECA, and Black Lung programs. Authority to collect information is in section 205(a), 1862, 1872 and 1874 of the Social Security Act as amended, 42 CFR 411 .24{a) and 424.5(a) (6), and 44 use 3101;41 eFR 101 et seq and 10 use 1079 and 1066; 5 use 8101 et seq; and 30 use 901 01 seq; 36 use 613; E,Q 9397 The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility. It is also used to decide if the services and supplies you received are covered by these programs and to insure that proper payment is made. The information may also be given to other providers of services, carriers, intermediaries, medica! review boards, health plans, and other organizations or Federal agencies, for the effective administration of Federal provisions that require other third parties payers to pay primary to Federal program, and as otherwise necessary to administer these programs. Forexample, it may be necessary to disclose information about the benefits you have used to a hospital or doctor. Additional disclosures are made through routine uses for information contained in systems of records FOR MEDICARE CLAIMS: See the notice modifying system No. 09-70-0501, titled, 'Carrier Medicare Claims Record, published in the Federal Register, Vol. 55 No. 177, page 37549, Wed, Sept. 12, 1990, or as updated and republished. FOR OWCP CLAIMS: Department of Labor, Privacy Act of 1974, "Republication of Notice of Systems of Records," Federal ReQister Vol, 55 No. 40, Wed Feb. 28. 1990. See ESA-5. ESA.6. ESA-12, ESA-13, ESA-30, or as updated and republished, FOR CHAMPUS CLAIMS: PRINCIPLE PURPOSE(SI: To evaluate eligibility for medical care provided by civilian sources and to issue payment upon establishment of eligibility and determination that the services/supplies received are authorized by law ROUTINE USElSi' Information from claims and related documents may be given to the Dept. of Veterans Affairs, the Dept. of Health and Human Services and/or the Dept. of Transportation consistent with their statutory administrative responsibilities under CHAMPUS/CHAMPVA; to the Dept. of .Justice for representation of the Secretary of Defense in civil actions; to the Internal Revenue Service, private collection agencies, and consumer reporting agencies in connection with recoupment claims; and to Congressional Offices in response to inquiries made at the request of the person to whom a record pertains. Appropriate disclosures may be made to other federal, state, local, foreign government agencies, private business entities, and individual providers of care, on matters relating to entitlement, claims adjudication, fraud, program abuse, utilization review, quality assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil and criminal litigation related to the operation of CHAMP US. DISCLOSURES: Voluntary; howevfH, failure to provide information will result in delay in payment or may result in denial of claim. With the one exception discussed below, there are no penalties under these programs for refusing to supply information. However, failure tofurnish information regarding the medical services rendered or the amount charged would prevent payment of claims under these programs. Failure to furnish any other information, such as name or claim number, would delay payment of the claim. Failure to provide medical information under FECA could be deemed an obstruction. It is mandatory that you tell us if you know that another party is responsible for paying for your treatment. Section 11288 of the Socia! Security Act and 31 use 3801- 3812 provide penalties for withholding this information You should be aware that P.L. 100-503, the "Computer Matching and Privacy Protection Act of 1 988", permitstf1e government to venfy information byway of computer matches. MEDICAtD PAYMENTS (PROVIDER CERTIFICATION) I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the State's Title XIX plan and to furnish information regarding any payments claimed for providing such services as the State Agency or Dept. of Health and Humans Services may request. I further agree to accept, as payment in full, the amount paid by the Medicaid program for those claims submitted for payment under that program, with the exception of authorized deductible, coinsurance, co-payment or similar cost-sharing charge. SIGNATURE OF PHYSICIAN (OR SUPPLIER): I certify that the services listed above were medically indicated and necessary to me heaith of this patient and were personally furnished by me or my employee under my personal directio~ NOTICE: This is 10 certify that the foregoing information is true, accurate and complete. I understand that payment and satisfaction of thi~i claim will be from Federal and State '---funds, and that any false claims, statements, or documents. or concealment of a materiallacj, may bo prGsecuted under applicable Federal or State laws. According to the Paperwork Reductio:, ~ct of 19~5, no per~ons are required to respond to a collection (;.) inforrT!8tion unless it displays a.valid .OMS control number The valid OMS control number for thiS Information collectIon IS 0938~DOD8.The tIme reqUired to complete thiS Information collection IS estImated to average 1C minutes per response, including the tIme to review instructions, search existing data resources, gather the data needed, and complete and review the mformatior collection. If you have any comments concerning the accuracy of the time estirnate(s) or suggestions for improving this form, please write to: eMS, N2-14-26. 750( Security Boulevard, Baltimore, Maryland 2\244-1850 , prKt y CI't-XU5LC - 7 ,- C I U ;Ci- ~~ P - - '" \ ~~p I fJ "l..(.AT . p..~4tfr ..;, c , 0 \)- I 1] t:J I I 1> tl I (; I l 0 LJ I I I ( ~ I [S. I I ! \ jJ. ~ ~ r::! ~ () ~'f~; l ~ n~- pl l0' ~ ~~ - - ~-=-- t:::. 5b::=. ~\J - ~. fr1 r - r:-RVCrK. II fI ~ ~ U D ::t:: j;... n L.i - --......,., I 1;U \' D i r --- C2 '" (:::'_'l (;:::'-:l C_rl () ..il :~;j -- hi(~;; ( , '~ ., ( "', N -" c.J '" W "2 ,.. :::2 .., RALPH E. PROBST and PHYLLIS W. PROBST, his wife, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA NO. 04-5728 Civil v. CIVIL ACTION - LAW EDITH M. CADY, Defendant JURY TRIAL DEMANDED PLAINTIFF'S ANSWERS TO DEFENDANT'S INTERROGATORIES (SET 1) And now this&\S+ day of (Sl.l.JL.i .2005, comes the Plaintiff Ralph E. Probst by and through his attorney, Joseph J. Dixon, Esqcir\, who respectfully answers interrogatories as follows; 1. Ralph E. Probst, 2425 Garrison Ave., Harrisburg, P AII'll 0 195-16-3609 2. As a child - appendectomy - Polyclinic Hospital 1979 - detached retinas, both eyes - Wills Eye Hospital, Philadelphia - doctor unknown right knee arthroscopic surgery - Grandview Surgery Center, Camp Hill - Dr. Patterson April 29, 2003 - open heart surgery - three bypasses and heart valve transplant- Harrisburg Hospital- Dr. Mark Osevala May 19, 2004 - stent placed in heart artery - Harrisburg Hospital - Dr. Dave 3. Dr. Ronald W. Lippe, M.D. Dr. Randy Frederick Dr. Joseph Kandra, M.D. 4. Had minor injuries but no injuries of any consequence. 5. None 6. Retired in 1995 7. N/A 8. See averments in complaint by way of further additional answer. The unpaid bill of Dr. Randy Frederick is two thousand eight hundred and five dollars ($2805).. The Medicare lien is four hundred ninety six dollars and ten cents ($496.10). 9. N/A 10. Phyllis W. Probst, 73, wife 2435 Garrison Ave., Harrisburg, PA 17110 Retired 11. Carl Probst, Camp Hill, P A, 3/5/52, Corrections Officer Kenneth Probst, Dauphin, P A, 3/24/53, Truck Driver David Probst, b. 11/27/56, d. 5/22/04 Dennis Probst, Marion, Ohio, 3/22/59, Army Corp of Engineers Diane Probst, Alexandria, VA, 6/14/64, Statistician, Department of Commerce JoAnn Probst, York, PA, 2/20/68, 911 Supervisor 12. Whole body was jarred, especially left shoulder, arm, neck and left knee Still in pain. 13. Constant pain on left side. 14. Retired - not working 15. No witnesses recorded. None came forth. 16. The Hampton Township Police office who responded to the accident. 17. None 18. 2425 Garrison Ave., Harrisburg, PA 17110 19. Just pain 20. Pain Loss of cognitive function Easily upset by stresses, such as paperwork Unable to concentrate Panic disorder 21. N/A 22. None 23. None 24. None Respectfully submitted, JO~~uire 126 State Street Harrisburg, PA 17101 (717) 236-8515 VERIFICATION I verify that the statements made in this f\~,,,, -\-'G:In%r~qf(5Cjf.)are true and correct. I understand that false statements herein are made subjel:t to the penalty of I 8 Pa. C.S. ~4904, relating to unsworn falsification to authorities. Dated;:::S-u.l~ ';) (I ~Q)C'fS, ~ f~ r1~ CERTIFICATE OF SERVICI~ AND NOW, this 6lt6i-day of3'UC{ ,2006, I, Joseph J. Dixon, Esquire, hereby certify that I have served a true and correct copy~f the foregoing document this day by depositing the same in the United States Mail, first class, postagl~ prepaid, in the Post Office at Hanisburg, Pennsylvania, addressed to: WIX, WENGER & WEIDNER RICHARD H. WIX, ESQUIRE 4705 DUKE STREET HARRISBURG, PA 17109-3099 By: /7 /\ ...--/ ~ixon, ESqii1Ie Attorney II) No. 28290 126 State Street Hanisburg, P A 17101 (717) 236-8515 Attorney for Plaintiff ...-, ~~J; , t"'>~) t''-' .c') .> !" W - RALPH E. PROBST, and PHYLLIS W. PROBST, his wife, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 04-5728 Civil v. CIVIL ACTION - LAW EDITH M. CADY, Defendant JURY TRIAL DEMANDED PLAINTIFF'S ANSWERS TO DEFENDANT'S REOUEST FOR PRODUCTION OF DOCUMENTS AND NOW, thisd\6> t- day o~ ,2005, comes the Plaintiff Ralph E. Probst, by and through his attorney, Joseph J. Dixon, Esquire, who respectfully avers as follows: l. None available 2. None available 3. See attached medical records 4. None available 5. See attached medical bills 6. None available 7. None available 8. None available Respectfully submitted, //1 /'1 / L-- / Joseph J. Dixon, Esquire 126 State Street Harrisburg, PA 17101 (717) 236-8515 Attorney For Plaintiff Date: VERIFICATION I verify that the statements made in this f1 ~*' -t D \(~fC'5f' ~c:.,<.., > , are true and correct. I understand that false statements herein are made subjel:;1 to the penalty of 18 Pa. C.S. ~4904, relating to unsworn falsification to authorities. Dated;:SuJ~ 61 \ 1 ~~s ~ E /Lu-.. CERTIFICATE OF SERVICE AND NOW, this~'6.+ day of~i<.l~ ,2006, I, JosephJ. Dixon, Esquire, hereby certify that I have served a true and correct copy 0 the foregomg document this day by depositing the same in the United States Mail, first class, postag,e prepaid, in the Post Office at Harrisburg, Pennsylvania, addressed to: WIX, WENGER & WEIDNER RICHARD H. WIX, ESQUIRE 4705 DUKE STREET HARRISBURG, PA 17109-3099 By: , \', ~ 'Joseph J. Dixo~ire Attorney ID No. 28290 126 State Street Harrisburg, P A 17101 (717) 236-8515 Attorney for Plaintiff --, ',,:::' c_ ,-:> (.:;'.:;1 z.5~ {'"'J I") -;-1 (:': I'J t...:l o .\ -I :L.-rJ rnf'::' ,-,1 Cj - RALPH E. PROBST and PHYLLIS W. PROBST, his wife, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 04-5728 Civil! v. CIVIL ACTION -- LAW EDITH M. CADY, Defendant JURY TRIAL DE:MANDED ANSWER TO MOTION TO COMPEL And now this~~ day of~ 2005 comes the Plaintiff Ralph E. Probst by and through his attorney, Joseph J. Dixon, Esqm7e, who respectfully avers as follows: 1. Admitted. 2. Admitted. 3. Admitted in part and denied in part. It is admitted that as oftae date of preparation of the motion, answers to interrogatories and request for production of documents were not filed. By way of further additional answer however, Plaintiff's counsel communicated to Defendant's counsel prior to the motion that the Plaintiff has accepted the last offer of the Defendant's to settle the case. This offer was for Thirty Five Hundred Dollars ($3500). By way of further addition answer contemporaneously with the filing of this answer, answers to interrogatories and answers to request for production of documents have been filed. 4. Admitted in part and denied in part. It is admitted that the answers to interrogatories and request for production of documents were not responsed to in a timely matter. By way of further additional answer, however, the Plaintiff has suffered severe health problems with heart surgery and has also suffered from the tragic loss oflife of his adult son. Wherefore, the Plaintiff requests this Honorable Court dismiss tht: motion filed against him. Respectfully submitted, ~ ///L--- Jo~ 1. DiXOn, Esquire 126 State Street Harrisburg, PA 17101 (717) 236-8515 Date: :::s (JJ~ ~ 1 I 'd\::~() S VERIFICATION I verify that the statements made in this f\ ~ -1"' G M\:'5t1' ITY\ . are true and correct. I understand that false statements herein are made subject to the penalty of 18 Pa. C.S. o ~4904, relating to unsworn falsification to authorities. Dated;:S~j, ~1 \ ~S f- /W- CERTIFICATE OF SERVICJE AND NOW, this ~ \-~+ day of..::s.u ~ ,2005, I, Joseph J. Dixon, Esquire, hereby certify that I have served a true and correct copy the foregoing document this day by depositing the same in the United States Mail, first class, postag.e prepaid, in the Post Office at Harrisburg, Pennsylvania, addressed to: WIX, WENGER & WEIDNER ATTN: RICHARD H. WIX, ESQUIRE 4705 DUKE STREET HARRISBURG, P A 17109-3099 L/l By: Joseph J. Dixon, Esquire Attorney ID No. 28290 126 State Street Harrisburg, P A 17101 (717) 236-8515 Attorney for Plaintiff >" (..) ~~ () c_:~ -t-1 c.n I ", N ~0 0,; RALPH E. PROBST and PHYLLIS W. PROBST, his wife, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 04.5728 Civil v. CIVIL ACTION - LAW EDITH M. CADY, Defendant JURY TRIAL DEMANDED PRAECIPE TO SETTLE. DISCONTINUE AND END Please mark the above-captioned case settled, discontinued and ended. Respectfully submitted, By: /l/l~ .foseph J. Dixon, Esquire Attorney No. 28290 126 State Street Harrisburg, P A 17101 (717) 236-8515 Attorney for Plaintiff Date: August 1, 2005 RELEASE KNOW ALL MEN BY THESE PRESENTS, that Ralph E. Probst and Phyllis W. Probst, his wife, of Harrisburg, Dauphin County, Pennsylvania, do hereby acknowledge that they have this day had and received of and from Edith M. Cady the sum of THREE THOUSAND FIVE HUNDRED and 00/100 ($3,500.00) DOLLARS in full satisfaction and payment of all sum or sums of money oWing, payable and belonging to them by any means whatsoever, for or on account of an accident which occurred on or about November 21, 2002 on Sporting Hill Road at Hampden Center, Hampden Township, Mechanicsburg, Cumberland County, Pennsylvania the subject of a lawsuit brought in the Court of Common Pleas of Cumberland County, Docket No. 04-5728 AND THEREFORE, the said Ralph E. Probst and Phyllis W. Probst, his wife, do by these presents remise, release, quit-claim and forever discharge the said Edith M. Cady, her heirs, executors and administrators, of and from the above claim, and of and from all actions, suits, payments, accounts, reckonings, claims and demands whatsoever, for or by reason thereof, or of any other act, matter, cause or thing whatsoever, from the beginning of the world to the day of the date of these presents. IN WITNESS WHEREOF, we have hereunto set my hand and seal the 2 q day of J uLt ~DO lj in the year of our Lord Two Thousand Five (2005). WITNESS: ~4-- rZtl~au GjI~ (j.>~k'r Ph~ W. Probst (SEAL) -h14- (SEAL) COMMONWEALTH OF PENNSYLVANIA COUNTY OF rn(}.LLph~ SS On the ~q day of J tL1.-r ,A.D. 2005, before me, the subscriber, ~~. H i~, Notary Public in and for said County, personally came the above named Ralph E. Probst and Phyliil; IN. Probst who in due fo,m uf iav'.' acknowledged the foregoing Release to be their act and deed, to the end that the same might be recorded as such. IN TESTIMONY WHEREOF, I have hereunto set my hand and official seal. ~.,;4tiIt$f;~, i/ ......M.......".~'" ,.' f" ., ,.... . ''''II, -4~ " 1; \; II,.. ". : " - .-.~....... .~) f:' . :tlo."-,'..(;.\ l , " '...' -< - 'I U Of s\ . , . 1. ... .!l: i ~ \ ~:. \ . J"''II~ ...<' j · . ,... - ''''if -., ~~ ' .' , "..," ~Y..~.~~/';- ",rf4..~,,,,!'>;,,.,,t#it" ~ /.- dLiJtt- Notary Public MY COMMISSION EXPIRES: NWE:rHO S"N. NtIIIIIIl8MI Sandra L ~. NcIlaIy PullIlc ~::.,~o-r:.~ Member. Ponnoytv_ AaIooIatlon 0' -.. , "" " -'...1'" '-. ~ :F:;. ~O<;'.) "fI';'<" t'.) /:iJ., . C) ;-- .. .~ , ", ,-::) \."_'J <-''';'"l o '--j-1 I (.",] -"->..