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Home My WebLink About04-5831 Metzger. Wickersham, Knauss & Erb, P.C. By: Clark De Vere, Esquire Attorney LD. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, P A 17110-0300 (717) 238-8187 cdv@mwke.com TAKENYA WATSON, a minor, by JO WATSON, her cousin and guardian, and JO WATSON, in her own right, Plaintiffs v. LIBERTY FORGE GOLF COURSE, INC. individually and t/d/b/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC. individually and t/d/b/a LIBERTY FORGE GOLF COURSE, : and LIBERTY FORGE GOLF, LLC, individually and t/d/b/a LIBERTY FORGE GOLF COURSE, Defendants Attorneys for Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. ~ - S'd'dl Ctul,L '---rf:Ln\ JURY TRIAL DEMANDED NOTICE TO DEFEND TO: Liberty Forge Golf Course, Inc., t/d/b/a Liberty Forge Golf Course 3425 Simpson Ferry Road Camp Hill, PA 17011 TO: Liberty Forge Hospitality, Inc., t/dlb/a Liberty Forge Golf Course 3425 Simpson Ferry Road Camp Hill, PA 17011 314410-1 TO: Liberty Forge Golf, LLC, t/d/b/a Liberty Forge Golf Course 3425 Simpson Ferry Road Camp Hill, PA 17011 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 forth 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 Plaintiffs. 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, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (800) 990-9108 314410-1 NOTICIA LE BAN 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 que si usted no se defiende, la corte tomara medidas y puede entrar una orden contra usted sin previa aviso a notificacion y por cualquier queja 0 alivio que 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 TlENE ABOGADO 0 SI NO TlENE EL DINERO SUFIClENTE DE PAGAR TAL SERVICIO, VAYA EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUY A DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA A VERIGUAR DONDE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. Cumberland County Bar Association 32 South Bedford Street Carlisle, P A 17013 (800) 990-9108 314410-1 TAKENYA WATSON, a minor, by JO WATSON, her cousin and guardian, and JO WATSON, in her own right, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA v. CIVIL ACTION - LA W LIBERTY FORGE GOLF COURSE, INe. individually and t/d/b/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC. individually and t/d/b/a LIBERTY FORGE GOLF COURSE, : and LIBERTY FORGE GOLF, LLC, individually and t/d/b/a LIBERTY FORGE GOLF COURSE, NO. Otf- Si31 {1;; ~P- Defendants JURY TRIAL DEMANDED CIVIL COMPLAINT 1. Plaintiff, Jo Watson, is an adult individual and cousin and legal guardian of Takenya Watson, a minor child (hereinafter "Minor Plaintiff'), and resides at 230 North Second Street, Steelton, Dauphin County, Pennsylvania, 17113. 2. Minor Plaintiff is 12 years old, having been born on December 5, 1991, and has selected her cousin and guardian, Jo Watson, to represent her interests in this matter. 3. Defendant, Liberty Forge Golf Course, Inc. (hereinafter "Liberty Forge"), is a Pennsylvania corporation with a principal place of business located at 3425 Simpson Ferry Road, Camp Hill, Cumberland County, Pennsylvania, 17011, and trades and does business as Liberty Forge Golf Course. 4. Defendant, Liberty Forge Hospitality, Inc. (hereinafter "Liberty Forge"), is a Pennsylvania corporation with a principal place of business located at 3425 Simpson Ferry Road, Camp Hill, Cumberland County, Pennsylvania, 17011, and trades and does business as Liberty Forge Golf Course. 314410-1 5. Defendant, Liberty Forge Golf, LLC (hereinafter "Liberty Forge"), IS a Pennsylvania limited liability company with a principal place of business located at 3425 Simpson Ferry Road, Camp Hill, Cumberland County, Pennsylvania, 17011, and trades and does business as Liberty Forge Golf Course. 6. Liberty Forge operates a facility at 3804 Lisbum Road, Mechanicsburg, Cumberland County, Pennsylvania, 17055 that offers activities for corporate outings and encompasses an 18-hole golf course, guided canoe, raft, and kayak activities, miniature golf, fishing, golf lessons, garden tours, and cooking and horticulture seminars. 7. On July 20, 2003, Minor Plaintiff, Takenya Watson, along with her sisters, Tashawna Davenport and Takeita Foster, were attending a Williams Sonoma Company sponsored picnic which was held on Liberty Forge's premises. 8. The sisters were the guests of Mr. Jamar Foster who was an employee of Williams Sonoma. 9. The Williams Sonoma guests were allowed to participate in all of Liberty Forge's recreational activities and there were approximately 100 Williams Sonoma guests in attendance. 10. Many of the guests were driving around in golf carts and the company's picnic tent and gazebo were situated close to the golf cart rental area. 11. During the picnic, Minor Plaintiff and her sister, Tashawna, went over to the golf cart rental area to inquire about receiving a golf cart. 12. The girls got into a golf cart and discovered that there was no key in the ignition. 13. At that point, an employee of Liberty Forge drove up and Tashawna asked him for the golf cart ignition key which he took out of his pocket and handed to her without question, instructions, warning, or inquiries regarding Tashawna's age or driver's license. -2- 314410-1 14. Next, Tashawna and Takenya drove around the golf course for approximately 30 to 45 minutes when suddenly Tashawna, who was driving the golf cart, attempted to turn left and the cart tipped over onto its right side. When the cart tipped over on its right side, Minor Plaintiff s right leg became pinned under the right side ofthe cart, causing serious injury to her. COUNT I Minor Plaintiff v. Defendants 15. Paragraphs 1 through 14 hereof are incorporated herein by reference as if fully set forth. 16. Liberty Forge knew or should have known that it was not proper to entrust a golf cart to a 13-year-old minor child and an II-year old minor child without questioning them or asking for a driver's license or giving instructions on the proper use of the vehicle or giving any safety wanungs. 17. Defendants are vicariously liable for the actions and/or omissions of their agents, servants, and/or employees acting within the scope of their authority. 18. Further, at the time of the accident Minor Plaintiff and all of the Williams Sonoma guests were business invitees of Liberty Forge. 19. Liberty Forge had a duty as the owner ofthe premises to ensure that its property did not have hazardous conditions which could cause injuries to its guests and to Minor Plaintiff in particular. 20. Defendant, Liberty Forge, individually or by its agents, servants, workmen, and/or employees acting within the scope of their authority, breached their legal duty to the public and to the Plaintiffs in particular, and were negligent in the following particulars: - 3 - 314410-1 (a) Failing to take the necessary protective and precautionary measures to ensure that its guests, including Minor Plaintiff, were safe; (b) Failing to properly supervise or control its guests while they were operating its golf carts; (c) Failing to properly train its guests in the operation of its golf carts; (d) Failing to provide its guests with proper direction before allowing them to operate the golf carts; (e) Failing to warn its guests regarding hazards associated with operating its golf carts; (f) Allowing guests who may be unfit or incompetent to operate or drive its golf carts; (g) Failing to have in place proper procedures, rules, regulations, protocols, or safety measures to ensure that other guests are not endangered by operation of their golf carts by guests; (h) Failing to take the proper precautions to protect the Minor Plaintiff from the negligent, careless, and reckless conduct of other guests; (i) Allowing a 13-year-old minor to be entrusted with a golf cart without verification of a driver's license; and CD Allowing a minor, whom Defendant should know, because of her youth, inexperience, or otherwise, to be likely to use the golf cart in a manner involving unreasonable risk of physical harm to herself and others, drive the golf cart. 21. As a direct and proximate result of the aforesaid negligent, careless, and reckless conduct of Defendarlts, Minor Plaintiff sustained, and in the future may sustain, serious and - 4- 314410-1 debilitating injuries, some of which are or may be permanent, which include, but are not limited to, the following: (a) Injuries to her right leg including a fracture. 22. As a direct and proximate result of the aforesaid negligence, carelessness, and recklessness of Defendants, Minor Plaintiff has undergone, and in the future will undergo, great physical pain, mental pain, discomfort, inconvenience, distress, embarrassment, and humiliation, past and future loss of her ability to enjoy the pleasures oflife, and limitations in the pursuit of daily activities, all to her great loss and detriment. 23. As a direct and proximate result of the aforesaid negligence, carelessness, and recklessness of Defendants, Minor Plaintiff has been scarred and disfigured. 24. As a direct and proximate result of the aforesaid negligence, carelessness, and recklessness of Defendants, Minor Plaintiff may suffer a loss of earnings, loss of productivity, loss of household services and a loss of earning capacity. WHEREFORE, Plaintiffs demand judgment against the Defendants, either individually and/or jointly and severally, for the aforesaid damages in an amount which exceeds the limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest and/or damages for delay and costs of prosecution. 25. forth. COUNT II Plaintiff Jo Watson in Her Own Ri2ht v. Defendants Nee:lie:ence Paragraphs 1 through 24 hereof are incorporated herein by reference as if fully set - 5 - 314410-1 26. By reason of the aforesaid injuries sustained by the Minor Plaintiff, her legal guardian, Plaintiff Jo Watson, has been forced to incur liability for medical treatment, medicine and similar miscellaneous expenses in an effort to restore the Minor Plaintiff to health and makes a claim therefore. 27. Because of the nature of Minor Plaintiffs injuries, Plaintiff Jo Watson may be forced to incur similar medical expenses in the future and a claim is made therefore. 28. By reason of the aforesaid injuries sustained by the Minor Plaintiff, her legal guardian, Plaintiff Jo Watson, has suffered a loss of earnings and may incur similar losses in the future. WHEREFORE, Plaintiffs demand judgment against the Defendants, either individually andlor jointly and severally, for the aforesaid damages in an amount which exceeds the limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest andlor damages for delay and costs of prosecution. METZGER, WICKERSHAM, KNAUSS & ERB, P.C. By lli_,~.- ~ Clark De Vere Attorney J.D. No. 68768 Andrew C. Spears, Esquire Attorney J.D. No. 87737 P.O. Box 5300 3211 North Front Street Harrisburg, PAl 711 0-03 00 (717) 238-8187 ,/ Attorneys for Plaintiffs Dated: \\- \\-~~ - 6- 314410-1 VERIFICATION I, Jo Watson, as cousin and legal guardian of Minor Plaintiff, Takenya Watson, hereby certify that the following is correct: The facts set forth in the foregoing Complaint are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Complaint is that of counsel and not my own. I have read the Complaint, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Complaint is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Complaint are made subject to the penalties of 18 Pa. e.S.A. ~4904 relating to unsworn falsification to authorities. ( Dated: II 15! O~ ~) \jJ):ki)~ Jo ~son 314410-1 VERIFICATION I, Jo Watson, hereby certify that the following is correct: The facts set forth in the foregoing Complaint are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Complaint is that of counsel and not my own. I have read the Complaint, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief To the extent that the content of the Complaint is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Complaint are made subject to the penalties of 18 Pa. C.S.A. 94904 relating to unsworn falsification to authorities. J~so~&rj Dated: I [ I '5/ 0 ~ 314410-1 p "q. ~~0 ~ ~ ~~ ~ '-L.. ,;..'.;' t~ p ~:i ~~~ 0IIj/1;,~- G:) ::.1 '. ,; r' ') C"-, l'" ~_~~ I :.n ~1,.. '''1 ~;' - -j-I ll1 p-= rn '''-I " () ;, -Y: 8 Johnson. Duffie, Stewart & Weidner By: C. Roy Weidner, Jr. 1.0. No. 19530 301 Market Street P. O. Box 109 Lemoyne, Pennsylvania 17043-0109 (717) 761-4540 crw@jdsw.com Attomeys for Defendants Plaintiffs IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA NO. 04-5831 CIVIL ACTION - LAW TAKENYA WATSON, a minor, by JO WATSON, her cousin and guardian, and JO WATSON, in her own right, v. LIBERTY FORGE GOLF COURSE, INC., individually and tldlb/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC., individually and tld/b/a LIBERTY FORGE GOLF, LLC, individually and tldlb/a LIBERTY FORGE GOLF COURSE, JURY TRIAL DEMANDED Defendants APPEARANCE AND NOW, this 16th day of December, 2004, enter the appearance of C. ROY WEIDNER, JR., 1.0. 19530, on behalf of Defendants in the above captioned suit. NER :241294 5774-498 CERTIFICA TE OF SERVICE AND NOW, this 16th day of December, 2004, the undersigned does hereby certify that she did this date serve a copy of the foregoing appearance upon the! other parties of record by causing same to be deposited in the United States Mail, first class postage prepaid, at Lemoyne, Pennsylvania, addressed as follows: Clark DeVere, Esquire Metzger Wickersham 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 JOHNSON, DUFFIE, STEWART & WEIDNER By:~4c#~~ ) . helle H. pangler :241284 5774-498 . :... ......) ") . ' " :. , c. : "\ 1 J' " , 1-' , ,'] ( - ; , , , , r " --- I , po_ , i --, (,) .- -"'. --..~ .....1..:.. Johnson. Duffle, Stewart & Weidner By: C. Roy Weidner, Jr. I.D, No, 19530 301 Market Street p, O. Box 109 Lemoyne, Pennsylvania 17043-0109 (717) 761-4540 crw@jdsw.com Attorneys for Defendants Plaintiffs IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY. PENNSYLVANIA NO. 04-5831 CIVIL ACTION - LAW JURY TRIAL DEMANDED TAKENYA WATSON, a minor, by JO WATSON, her cousin and guardian, and JO WATSON, in her own right, v, LIBERTY FORGE GOLF COURSE, INC" individually and tJdlb/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC" individually and tJdlb/a LIBERTY FORGE GOLF, LLC, individually and tJdlb/a LIBERTY FORGE GOLF COURSE, Defendants DEFENDANTS' ANSWER TO COMPLAINT AND NOW; this 14th day January, 2005, come Defendants, through its undersigned attorneys, and answer Plaintiffs' complaint as follows: 1, - 2, Denied. After a reasonable investigation, Defendants are without knowledge or information sufficient to form a belief as to the truth thereof. 3, Denied. On the contrary, Liberty Forge Golf Course is a duly registered fictitious name of Liberty Forge Hospitality, Inc., which operate Liberty Forge at 3804 Lisburn Road, Mechanicsburg, Lower Allen Township, Cumberland County, Pennsylvania, 4. Denied. It is denied that Liberty Forge Hospitality, Inc.'s principal place of business is located at 3425 Simpson Ferry Road, Camp Hill, Cumberland County, Pennsylvania, On the contrary, that is its registered office and its principal plaice of business is located at 3804 Lisburn Road, Mechanicsburg, Lower Allen Township, Cumberland County, Pennsylvania. 5, Admitted in Part. Denied in Part. It is admitted that Liberty Forge Golf, LLC is a Pennsylvania limited liability company with its office located at 3425 Simpson Ferry Road, Camp Hill, Cumberland County, Pennsylvania, It is denied that it trades and does business as Liberty Forge Golf Course. On the contrary, Liberty Forge Golf Course is a duly registered fictitious name of Liberty Forge Hospitality, Inc. 6. Admitted in Part. Denied in Part. It is admiitted that Liberty Forge Hospitality, Inc. trading as Liberty Forge Golf Course, a duly registered fictitious name, operates a facility at 3804 Lisburn Road. Mechanicsburg, Cumberland County, Pennsylvania as averred. It is denied that any other named Defendant operates that facility. 7, Admitted. 8. Denied. After a reasonable investigation, Defendants are without knowledge or information sufficient to form a belief as to the truth of said al/erment. 9. Admitted in Part. Denied in Part. It is admitted that the Williams Sonoma guests were allowed to participate in all the then existing activities to the same extent that any other guest would be allowed, except for the restaurant and deck, That they were allowed to participate contrary to the policies and restrictions then applicable to all guests or use the restaurant and deck is denied, The number of guests actually in attendance is denied in that after a reasonable investigation, Defendants are without knowledge or information sufficient to form a belief as to the truth of said averment. 10. Admitted in Part. Denied in Part. It is admitted that guests were driving golf carts. The remainder of this averment is denied. 11. - 12. Denied. After a reasonable investigation, Defendants are without knowledge or information sufficient to form a belief as to thEl truth of said averments, 13. Denied. This averment is specifically denied. On the contrary, it is believed and therefore averred, that the girls, including the minor Plaintiff, acquired the golf cart from another guest or after it had been abandoned by another guest. 14. Admitted in Part. Denied In Part. It is admitted that one of the girls operating the cart tipped the cart over on its side and that the minor PIElintiff suffered an injury to her leg. The remainder of this averment is denied. COUNT I Minor Plaintiff v. Defendanl~s 15, Admitted In Part. Denied In Part. Paragraphs 1 - 14 hereof are incorporated by reference herein. 16, Denied. It is specifically denied that the golf cart was entrusted to the minors by Defendants or those acting on its behalf. By way of furthm denial, Defendants had in place procedures to prevent minors and other inexperienced operators from acquiring posseSSion and use of its golf carts from Defendants. 17. - 19. Denied. These averments are deemed denied as conclusions of law to which no responsive pleading is required. 20. Denied. This averment is deemed denied as a conclusion of law to which no responsive pleading is required. By way of further deni.al, any negligence on the part of Defendants and those acting on its behalf is specifically denifld, On the contrary, Defendants and its employees at all times acted reasonably under the circumstances. 21, - 24. Denied. Any negligence on the part of Defendants and its employees is denied and paragraph 20 hereof is incorporated by reference herein, By way of further denial, after a reasonable investigation, Defendants are without knowledge or information sufficient to form a belief as to the averments regarding Plaintiff's injuries, WHEREFORE, Defendants demand that Plaintiffs' complaint against them be dismissed. COUNT 11- NEGLIGENCE Plaintiff Jo Watson v. Defendants 25, Admitted in Part. Denied in Part. Paragraphs 1 - 24 hereof are incorporated by reference herein, 26, - 28. Denied. After a reasonable investi9ation, Defendants are without knowledge or information sufficient to form a belief as to the truth of these averments. WHEREFORE, Defendants demand that Plaintiffs' complaint against them be dismissed, JOHNSON, DUFFIE, STEWART & WEIDNER ~~- /, ~:=-. ! .' ~,O/ By: / ?' / : oy Wf3idner, Jr. :241897 5774-498 VERIF/CA TlON The undersigned says that the facts set forth in the fore!~oing are true and correct. This verification is made subject to the penalties of 18 Pa. C,S.A ~ 4904, relating to unsworn falsifications to authorities, KWE W'I~ urt , I lams Dated: ~1-1\-,6~ CERTlFICA TE OF SERVICE AND NO~ this 14th day of January, 2005, the undersiflned does hereby certify that she did this date serve a copy of the foregoing document upon the other parties of record by causing same to be deposited in the United States Mail, first class postage prepaid, at Lemoyne, Pennsylvania, addressed as follows: Clark DeVere, Esquire Metzger Wickersham 3211 North Front Street P.O, Box 5300 Harrisburg, PA 17110-0300 JOHNSON, DUFFIE, STEWART & WEIDNER BY:~~L~ o~1 -!U1-i/h/[j 'chelle H. pangler :241897 5774-498 <,.~"l \...:..:. (]) C-, . Johnson, Duffie, Stewart & Weidner By: C. Roy Weidner, Jr. I.D. No, 19530 301 Market Street p, 0, Box 109 Lemoyne, Pennsylvania 17043-0109 (717) 761-4540 crw@jdsw,com Attorneys for Defendants TAKENYA WATSON, a minor, by JO WATSON, her cousin and guardian, and JO WATSON, in her own right, Plaintiffs IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 04-5831 CIVIL ACTION - LAW v, JURY TRIAL DEMANDED LIBERTY FORGE GOLF COURSE, INC., individually and tld/b/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC., individually and tld/b/a LIBERTY FORGE GOLF, LLC, individually and tld/b/a LIBERTY FORGE GOLF COURSE, Defendants v, WILLIAMS-SONOMA, INC., Additional Defendant PRAECIPE FOR WRIT TO JOIN ADDITIONAL DEFENDANT TO THE PROTHONOTARY: AND NOW, this ~y of January, 2005, issue a Writ of Summons on behalf of Defendants joining Williams-Sonoma, Inc., 3025 Market Street, Camp Hill, Cumberland County, Pennsylvania as an Additional Defendant in the above captioned action and cause the Sheriff to serve the same forthwith at said Additional Defendant's principal place of business as set forth above. :243154 5774-498 ~~..l!f"RT & WEIDNER -- C. Roy Weidner, Jr, CERTIFICA TE OF SERVICE AND NOW, this 19th day of January, 2005, the undersigned does hereby certify that , she did this date serve a copy of the foregoing document upon the other parties of record by causing same to be deposited in the United States Mail, first class postage prepaid, at Lemoyne, Pennsylvania, addressed as follows: Clark DeVere, Esquire Metzger Wickersham 3211 North Front Street P,O. Box 5300 Harrisburg, PA 17110-0300 JOHNSON, DUFFIE, STEWART & WEIDNER By: ~.I~/~ ,2/ ~~ Chelle H. Spangler :243154 5774-498 ("', '"' ';'....:: ",\\ ~ "",i c;' ---- Cumberland County, ss: The Commonwealth of Pennsylvania to WILLTIIMS-SONrMA. TOC. (Name of Addiilional Defendant) You are notified that LIBERTY FORGE GOLF COURSE, INC., INDIVIDUALLY AND T/D/B/A (Name (s) of Defendant (,) ) LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC., INDIVIDUALLY AND T/D/B/A LIBERTY F'()R';F. (,'()T,F' T.Tr, TNTlT\TTDTTlITTV lIN[> T/D/Il/~ lIIlERTY FORGE OOLF COURSE has (have) joined you as an additional defendant in this action, which you are re- quired to defend. I>ate JANUARY 20, 2005 ClJR'T'TS R. TON(; IIrot!lronotary ~aD/>"p~f24~Y'~ D ty (SEAL) WILLIAMS-SONOMA, INC. 3025 MARKEl' STREET CAMP HILL, PA ~""wc..n :;: ~ d ~ t" I Eli I ~ ~ ~~. ;.- H H t" gJ ~ >-l gJ I~ ~~I~~ O~ t" ~ ~ 15~ ~ ~ 0 SZ~ .... . H . ~ [fJ I o-l.... I d [fJ to d ~ ~ (J1 ~~ 8~ 15""3 I~ ""...... I'" iR ::J;J> ~ >-l I~ [fJ"l ~ H >-l"l ~a t>l t>l E:: ~ n >oJ 1llH~ o t>l. S H to S H < .... t3 . t"'..... . ~ F! ~ ~ H W c.. t" ;; ;J> I [fJ~ H "l t" 0 I~ 00 ~ :;: H H n H 0 toj.... g . t" ~d 8 H a t w ~z ~fl ~ ~ iR ~ :0 ~ tojtoj H r ;;l ZO >-l t>l ~ ~ i>'H H H H .3 ~1ll 0;.- @ 'e eS c.. >z ~ Io~ Ht" 0 r ;..- H <"l c.. ~ ~ ~ ~ t>lH H 0 S [iJ ~~ ~~ ~ 3 >-l " :0 ~l I~ >-l ,~ ..., ~~ ~gj ~ H ~ . < [fJ~ ~~ H 8 >-l >-lgJ ~ ...... ~~ ~ 0 ...... to to ...... ...... ;J> ;J> MARSHALL, DENNEHEY, WARNER, COLEMAN & GOGGIN BY : DAVID F. WHITE, ESQ. IDENTIFICATION NO.: 55738 620 WEST GERMANTOWN PIKE SUITE 350 PLYMOUTH MEETING, P A 19462 (610) 941-7900 (610) 941-8133 (FAX) dfwhite@mdwcg.com Attorney for Additional Defendant, Williams-Sonoma TAKENY A WATSON, a minor by JO WATSON, her cousin and guardian, and JO WATSON, in her own right v, COURT OF COMMON PLEAS CUMBERLAND COUNTY LIBERTY FORGE GOLF COURSE, INC. Individually and t/d/b/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC" individually and t/d/b/a LIBERTY FORGE GOLF COURSE, and LIBERTY FORGE GOLF, LLC, individually And t/dlb/a LIBERTY FORGE GOLF COURSE NO. 04-5831 RULE TO FILE JOINDER COMPLAINT TO THE PROTHONOTARY: Kindly enter a Rule upon Defendant, LIBERTY FORGE GOLF COURSE, to file a Joinder Complaint in the above captioned matter within twenty (20) days or suffer Judgment of Non-Pros. ~k DA V ' F. WHITE, ESQUIRE ADAM F. SORCE, ESQUIRE Attorneys for Defendant Williams Sonoma ,~ . .. RULE TO FILE COMPLAINT AND NOW, this ~'1Jay of )F\b ,2005, a Rule is entered upon the Defendant to file a JOINDER Complaint in the above captioned matter within twenty (20) days from the date ofthis Order, 0A/7~;t ~ (prothonotary) . . TAKENY A WATSON, a minor by JO WATSON, her cousin and guardian, and JO WATSON, in her own right v, COURT OF COMMON PLEAS CUMBERLAND COUNTY LIBERTY FORGE GOLF COURSE, INC. Individually and t/d/b/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC" individually and t/d/b/a LIBERTY FORGE GOLF COURSE, and LIBERTY FORGE GOLF, LLC, individually And t/d/b/a LIBERTY FORGE GOLF COURSE NO. 04-5831 CERTIFICATE OF SERVICE I, Adam F, Sorce, Esquire, Attorney for Defendant, Williams-Sonoma, hereby certify that a true and correct copy of The Rule to File Joinder Complaint upon Defendant, LIBERTY FORGE GOLF COURSE was served upon all parties listed below, via First Class Mail, postage prepaid, on this date: Clark DeVere, Esquire METZGER, WICKERSHAM, KNAUSS & ERB, P.C. P.O. Box 5300 3211 North Front Street Harrisburg, P A 17110-0300 C, Roy Weidner, Jr., Esq, JOHNSON, DUFFIE, STEWART & WEIDNER 301 Market Street Lemoyne, P A 17043-0109 DATE: )'1)\ (to a~,~ ADAMF. SORCE, ESQUIRE ------ ~ ~ CF> ~ T-' -<> <:7 ::; :/> <f!. = 0' - SHERIFF'S RETURN - REGULAR CASE NO: 2004-05831 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND WATSON TAKENYA ET AL VS LIBERTY FORGE GOLF COURSE ETAL RONALD HOOVER , Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law, says, the within WRIT TO ADD'L DEFEN. was served upon WILLIAMS SONOMA INC the ADD'L DEFENDANT, at 0921:00 HOURS, on the 24th day of January , 2005 at 3025 MARKET STREET CAMP HILL, PA 17011 by handing to SHEMlKA DEVAN, HR GENERALIST, ADULT IN CHARGE a true and attested copy of WRIT TO ADD'L DEFEN. 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 10.36 .00 10.00 .00 38.36 ~f/'<C/ y~ ? ...?;::f;::'1':;":n::..~ -f'~--4? R. Thomas Kline 01/25/2005 JOHNSON DUFFIE STEWART WEIDNER Sworn and Subscribed to before By: 6~d~J Deputy Sheriff me this ..('~ day of d.a..l:"~.I7 JO-v{ A.D. ,/\ - ~,.~ ()~~ ' Prothonotary J ... t SHERIFFIS RETURN - REGULAR CASE NO: 2004-05831 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND WATSON TAKENYA ET AL VS LIBERTY FORGE GOLF COURSE ETAL RONALD HOOVER , Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon LIBERTY FORGE GOLF COURSE INC TDBA LIBERTY FORGE GOLF COURSE the DEFENDANT , at 0957:00 HOURS, on the 2nd day of December, 2004 at 3425 SIMPSON FERRY ROAD CAMP HILL, PA 17011 by handing to MARCIA DESFORGE, SECRETARY, ADULT IN CHARGE a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge 18.00 10.36 .00 10.00 .00 38.36 So Answers: -;;i>""'(~:~~:J::",:<;::.:.r.....c. ,~ .'{ //?.A" f~ < R. Thomas Kline 12/06/2004 METZGER WICKERSHAM Sworn and Subscribed to before By: , ~ ~~? -=:x:/ Deputy Sheriff me this day of A.D. " SHERIFF'S RETURN - REGULAR CASE NO: 2004-05831 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND WATSON TAKENYA ET AL VS LIBERTY FORGE GOLF COURSE ETAL RONALD HOOVER / Sheriff or Deputy Sheriff of Cumberland County/Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon LIBERTY FORGE GOLF LLC TDBA LIBERTY FORGE GOLD COURSE the DEFENDANT / at 0957:00 HOURS, on the 2nd day of December / 2004 at 3425 SIMPSON FERRY ROAD CAMP HILL, PA 17011 by handing to MARCIA DESFORGE, SECRETARY, ADULT IN CHARGE a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge So Answers: 6.00 .00 .00 10.00 .00 16.00 ,." ~ :;J/ .f , R. Thomas Kline 12/06/2004 METZGER WICKERSHAM Sworn and Subscribed to before By: (/ , / f ~c:;.ek"" ~- -:- ~/1' Deputy Sheriff me this ~ A.D. ~7J '"" SHERIFF'S RETURN - REGULAR CASE NO: 2004-05831 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND WATSON TAKENYA ET AL VS LIBERTY FORGE GOLF COURSE ETAL RONALD HOOVER , Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon LIBERTY FORGE HOSPITALITY INC TDBA LIBERTY FORGE GOLF COURSE the DEFENDANT , at 0957:00 HOURS, on the 2nd day of December, 2004 at 3425 SIMPSON FERRY ROAD CAMP HILL, PA 17011 by handing to MARCIA DESFORGE, SECRETARY, ADULT IN CHARGE a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge So Answers: 6.00 .00 .00 10.00 .00 16.00 Kline R. 12/06/2004 METZGER WICKERSHAM Sworn and Subscribed to before By: ~!?i:f me this j,;l day of oZ.Du-() A. D. .. Johnson, Duffie, Stewart & Weidner By: C. Roy Weidner, Jr. I,D, No. 19530 301 Market Street p, 0, Box 109 Lemoyne, Pennsylvania 17043-0109 (717) 761-4540 crw@jdsw,com Attorneys for Defendants " TAKENYA WATSON, a minor, by JO WATSON, her cousin and guardian, and JO WATSON, in her own right, IN THE COURT OF CO ON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA NO, 04-58 1 Plaintiffs CIVIL ACTION LAW JURY TRIAL DE AND ED v. LIBERTY FORGE GOLF COURSE, INC., individually and tJd/b/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC" individually and tJd/b/a LIBERTY FORGE GOLF, LLC, individually and tJd/b/a LIBERTY FORGE GOLF COURSE, Defendants v. WILLIAMS-SONOMA, INC., Additional Defendant NOTICE TO DEFEND YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claim set forth in the following pages, you must take action within twenty (20) days after this Complain and Notice are served, by entering a written appearance personally or by attorney and filing in wr ing with the Court your defenses or objections to the claims set forth against you, You are warn that if you fail to do so the case may proceed without you and a judgment may be entered again you by the Court without further notice for any money claimed in the Complaint or for any other c im or relief requested by the Plaintiff. You may lose money or property or other rights important t you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF Y DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW, T IS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER .. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OF ER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 Telephone: (717) 249-3166 A visa USTED HA SIDO DEMANDADO/A EN CORTE, Si usted desea defen rse de las demandas que se presentan mas adelante en las siguientes paginas, de be tomar ci6n dentro de los pr6ximos veinte (20) dias despues de la notificaci6n de esta Demanda y Avi 0 radicando personalmente 0 por medio de un abogado una comparecencia escrita y radicand en la Corte por escrito sus defensas de, y objecciones a, las demandas presentadas aqui en con a suya, Se Ie advierte de que si usted falla de tomar acci6n como se describe anteriormente, e caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demand 0 cualquier otra reclamaci6n 0 remedio solicitado por el demandante puede ser dictado en contr suya por la Corte sin mas aviso adicional. Usted puede perder dinero 0 propiedad u otr s derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIAT ENTE, SI USTED NO TIENE UN ABOGADO, LLAME 0 VAYA A LA SIGUIENTE OFICINA. ES A OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABO ADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGE OFREZCAN SERVICIOS LEGALES SIN CARGO 0 BAJO COSTO A PERS CUALlFICAN, POSIBLE IAS QUE NAS QUE Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 Telephone: (717) 249-3166 . Johnson, Duffie, Stewart & Weidner By: C. Roy Weidner, Jr. LD,No.19530 301 Market Street p, 0, Box 109 Lemoyne, Pennsylvania 17043-0109 (717) 761-4540 crw@jdsw.com Attorneys for Defendants ~ TAKENYA WATSON, a minor, by JO WATSON, her cousin and guardian, and JOWATSON, in her own right, IN THE COURT OF CO ON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA Plaintiffs v, CIVIL ACTION LAW JURY TRIAL DE ANDED LIBERTY FORGE GOLF COURSE, INC., individually and tJd/b/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC., individually and tJd/b/a LIBERTY FORGE GOLF, LlC, individually and tJd/b/a LIBERTY FORGE GOLF COURSE, Defendants v. WilLIAMS-SONOMA, INC., Additional Defendant DEFENDANTS' COMPLAINT AGAINST ADDITIONAL DEFENDANT t AND NOW, this ~ day of March, 2005, come Defendants, upon a ca against Additional Defendant whereof the following is a statement: e of action 1, On November 18, 2004, Plaintiff filed a complaint against Defendant , a copy of which is attached hereto, incorporated by reference herein and marked as Exhibit "A hereto, 2, Defendants filed an answer on January 19, 2005, a copy of which s attached hereto, incorporated by reference herein and marked as Exhibit "B" hereto. . , 3, Additional Defendant is Williams-Sonoma, Inc., a corporation w h regularly conducts business at 3025 Market Street, Camp Hill, Cumberland County, Pennsyl nia, 4. Plaintiff's complaint claims that the minor Plaintiff suffered personal injuries at a picnic sponsored by Additional Defendant on July 20, 2003 at Defendants' golf co se in Lower Allen Township, Cumberland County, Pennsylvania. 5, Additional Defendant's picnic described in Plaintiff's complaint wa conducted pursuant to a written contract, a copy of which is attached hereto, incorporated y reference herein and marked as Exhibit "C" hereto. 6, Under the Conduct of Events clause of the Food and Beverage Serv e Standard Terms and Conditions of the contract between Defendants and Additional Defenda , Additional Defendant undertook to variously: A,Conduct the event in an orderly manner, 8, Assume full responsibility for the conduct of all persons in att dance, D. Indemnify and hold Defendants harmless against any an all claims, including those caused or contributed to by the negligence f Additional Defendant or any guest or invitee. COUNT I BREACH OF CONTRACT 7, If minor Plaintiff was injured as claimed in paragraph 14 of Plaintiff' complaint, her injuries were a direct result of Additional Defendant's breach of the contractua obligations undertaken by Additional Defendant in the written contract comprising Exhibit "c" he to, 8. As a result of said breach, Additional Defendant is liable for any and II damages suffered by Defendants as a result thereof. . , WHEREFORE, Defendants request that Additional Defendant be found s ely liable to Plaintiffs or liable to Defendants by way of contribution and indemnity, COUNT 11 NEGLIGENCE 9, In addition to the contractual obligations set forth in the Conduct of vent clause referred to above, Additional Defendant undertook a duty to Defendants to conduc the event in a reasonable manner, 10. Additional Defendant was careless and negligent in the conduct of he event in the following respects: A. Failing to require parental or in loco parentis supervision of nor invitees of employees. B. Failing to take steps to prevent minor invitees of emp yees from accessing or attempting to access golf carts and operate the C. Failing to warn employees and their invitees that minors wer not to use golf carts. D, Failing to warn employees and minor invitees of emplo es of the dangers of improperly using golf carts. E. Failing to properly supervise and control minor invitees. 11, As a result of Additional Defendant's negligence, the minor Plaintiff uffered the damages and injuries complained of in their complaint WHEREFORE, Defendants demand that Additional Defendant be found so Iy liable to Plaintiffs. or liable to Defendants by way of contribution and indemnity, . ~ COUNT 11/ INDEMNIFICA TION 12, In addition to the indemnification requirements of the Conduct of Ev ts clause in the contract between Defendants and Additional Defendant comprising Exhibit "c hereto, the Exclusion of Liability and Assumption of Risk clause of the contract further obligat s Additional Defendant to indemnify and hold harmless Defendants from Plaintiffs' claims. WHEREFORE, Defendants demand judgment against Additional D endant for indemnity and to hold it harmless from Plaintiffs' claims, JOHNSON, DUFFIE, STEWART & WEI NER :244245 5774-498 . VERIFICA TION I, Kurt E. Williams, verify that the statements made in the foregoing comp int are true and correct to the best of my knowledge, information and belief. I understa that false statements made herein are subject to the penalties of 18 Pa.C.S.A. ~4904 relatin to unsworn falsification to authorities. By: K Dated:__N$)..{'..N'\ l Q ,1-0$( . . CERTIFICA TE OF SERVICE /} '2 rd- AND NOW, this ~ day of March, 2005, the undersigned does hereby c ify that she did this date serve a copy of the foregoing document upon the other parties of recor by causing same to be deposited in the United States Mail, first class postage prepaid, t Lemoyne, Pennsylvania, addressed as follows: Andrew C. Spears, Esquire Metzger Wickersham 3211 North Front Street P,O. Box 5300 Harrisburg, PA 17110-0300 David F. White, Esquire Adam F, Sorce, Esquire Marshall, Dennehey, Warner Coleman & Goggin 620 West Germantown Pike Plymouth Meeting, PA 19462-1056 JOHNSON, DUFFIE, STEWART & WEI NER By: ~ . helle H, Spangler :244245 5774-498 ~x~~~ ~ " Metzger, Wickersham, Knauss & Erb, p,c. By: Clark De V ere, Esquire Attorney l.D. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 (717) 238-8187 cdv mwke.com TAKENYA WATSON, a minor, by JO WATSON, her cousin and guardian, and JO WATSON, in her own right, Plaintiffs v, --~ LIBERTY FORGE GOLF COURSE, INC. individually and tJdIb/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC. individually and tJdIb/a LIBERTY FORGE GOLF COURSE, : and LIBERTY FORGE GOLF, LLC, individually and tJdIb/a LIBERTY FORGE GOLF COURSE, Defendants Attorneys for Plaintiffs IN THE COURT OF COMMON LEAS CUMBERLAND COUNTY,PE SYL V ANlA CNIL ACTION - LAW NO. JURY TRIAL DEMANDED NOTICE TO DEFEND TO: Liberty Forge Golf Course, Inc., tJdfb/a Liberty Forge Golf Course 3425 Simpson Ferry Road Camp Hill, P A 17011 TO: Liberty Forge Hospitality, Inc., tJdfb/a Liberty Forge Golf Course 3425 Simpson Ferry Road Camp Hill, P A 17011 314410-1 TO: Liberty Forge Golf, LLC, tJdIb/a Liberty Forge Golf ourse 3425 Simpson Ferry Road Camp Hill, P A 17011 " " YOU HA VB BEEN SUED IN COURT. If you wish to defend against the claims set orth in the following pages, you must take action within Twenty(20) days after this Complaint an Notice are served, by entering a written appearance personally or by attorney and filing in writ' g with the Court your defenses or objections to the claims set forth against you. You are wame that if you fail to do so the case may proceed without you and a judgment may be entered agains you by the Court without further notice for any money claimed in the Complaint or for any other cl 'm or relief requested by the Plaintiffs. You may lose money or property or other rights important t you. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY B PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFF SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORT THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A L Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (800) 990-9108 314410-1 " . NOTICIA LE RAN DEMANDADO A USTED EN LA CORTE. Si usted qui ere defend e de estas demandas expuestas en las paginas siguientes, usted tiene viente (20) dias de plazo a1 artir de la fecha de la demanda y la notificacion. Usted debe presentar una apariencia escrita 0 e persona 0 por abogado y archivar en la corte en forma escrita sus defensas 0 sus objeciones a las d entrar una orden contra usted sin previo aviso a notificacion y por cualquier qu~ a 0 contra de su persona. Sea avisado que si usted no se defiende, la corte tomara medi y puede pedido en la peticion de demanda. Usted puede perder dinero 0 sus propiedades 0 otr s derechos importantes para usted, LLEVE ESTA DEMANDA A UN ABODAGO IMMEDIATAMENTE, SI 0 TIENE ABOGADO 0 SI NO TIENE EL DINERO SUFICIENTE DE P AGAR TAL SERVI EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUY A DIRE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE C SEGUIR ASISTENCIA LEGAL. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (800) 990-9108 314410-1 TAKENYA WATSON, a minor, by 10 WATSON, her cousin and guardian, and JO WATSON, in her own right, Plaintiffs IN THE COURT OF COMMON LEAS CUMBERLAND COUNTY, PE SYLVANIA v. CNIL ACTION - LAW LIBERTY FORGE GOLF COURSE, INC. individually and tJdIb/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC. individually and tJdIb/a LIBERTY FORGE GOLF COURSE,: and LIBERTY FORGE GOLF, LLC, individually and tJdIb/a LIBERTY FORGE GOLF COURSE, NO. Defendants JURY TRIAL DEMANDED CIVIL COMPLAINT 1. Plaintiff, loW atson, is an adult individual and cousin and legal ardian of Takenya Watson, a minor child (hereinafter "Minor Plaintiff'), and resides at 230 No Second Street, Steelton, Dauphin County, Pennsylvania, 17113. 2. Minor Plaintiff is 12 years old, having been born on December 5, 19 , and has selected her cousin and guardian, 10 Watson, to represent her interests in this matter. 3. Defendant, Liberty Forge Golf Course, Inc. (hereinafter "Liberty F Pennsylvania corporation with a principal place of business located at 3425 Simpson Camp Hill, Cumberland County, Pennsylvania, 17011, and trades and does business Liberty Forge Golf Course, 4. Defendant, Liberty Forge Hospitality, Inc. (hereinafter "Liberty Fo e"), is a Pennsylvania corporation with a principal place of business located at 3425 Simpson rry Road, Camp Hill, Cumberland County, Pennsylvania, 17011, and trades and does business s Liberty Forge Golf Course. 314410-1 . . 5. Defendant, Liberty Forge Golf, LLC (hereinafter "Liberty For e"), IS a Pennsylvania limited liability company with a principal place of business locat at 3425 Simpson Ferry Road, Camp Hill, Cumberland County, Pennsylvania, 17011, and trad and does business as Liberty Forge Golf Course. 6. Liberty Forge operates a facility at 3804 Lisbum Road, Mec anicsburg, Cumberland County, Pennsylvania, 17055 that offers activities for corporate 0 tings and encompasses an 18-hole golf course, guided canoe, raft, and kayak activities, mi ture golf, fishing, golflessons, garden tours, and cooking and horticulture seminars, 7. On luly 20, 2003, Minor Plaintiff, Takenya Watson, along with er sisters, Tashawna Davenport and Takeita Foster, were attending a Williams Sonoma Company sponsored picnic which was held on Liberty Forge's premises. 8, The sisters were the guests of Mr, lamar Foster who was an e ployee of Williams Sonoma. 9. The Williams Sonoma guests were allowed to participate in all of Libe y Forge's recreational activities and there were approximately 100 Williams Sonoma guests in a endance. 10, Many of the guests were driving around in golf carts and the comp y's picnic tent and gazebo were situated close to the golf cart rental area. 11. During the picnic, Minor Plaintiff and her sister, Tashawna, went over 0 the golf cart rental area to inquire about receiving a golf cart. 12. The girls got into a golf cart and discovered that there was no key in th ignition. ]3, At that point, an employee of Liberty Forge drove up and Tashawna sked him for the golf cart ignition key which he took out of his pocket and handed to her witho question, instructions, warning, or inquiries regarding Tashawna's age or driver's license. -2- 314410-1 .' '. 14, Next, Tashawna and Takenya drove around the golf course for appro to 45 minutes when suddenly Tashawna, who was driving the golf cart, attempted to the cart tipped over onto its right side, When the cart tipped over on its right s Plaintiff s right leg became pinned under the right side of the cart, causing serious inj ately 30 left and COUNT I Minor Plaintiff v, Defendants 15. Paragraphs 1 through 14 hereof are incorporated herein by reference as . f fully set forth. 16. Liberty Forge knew or should have known that it was not proper to e st a golf cart to a 13-year-old minor child and an II-year old minor child without questioning th or asking for a driver's license or giving instructions on the proper use of the vehicle or giving any safety warmngs. 17. Defendants are vicariously liable for the actions and/or omissions of servants, and/or employees acting within the scope of their authority. 18. Further, at the time of the accident Minor Plaintiff and all of the Willi Sonoma guests were business invitees of Liberty Forge. 19. Liberty Forge had a duty as the owner of the premises to ensure that its operty did not have hazardous conditions which could cause injuries to its guests and to Minor laintiff in particular. 20. Defendant, Liberty Forge, individually or by its agents, servants, wor en, and/or employees acting within the scope of their authority, breached their legal duty to the p lie and to the Plaintiffs in particular, and were negligent in the following particulars: - 3 - 114410-1 . (a) Failing to take the necessary protective and precautionary measur s to ensure that its guests, including Minor Plaintiff, were safe; (b) Failing to properly supervise or control its guests while they we operating its golf carts; (c) Failing to properly train its guests in the operation of its golf carts (d) Failing to provide its guests with proper direction before allow. g them to operate the golf carts; (e) Failing to wam its guests regarding hazards associated with opera g its golf carts; (f) Allowing guests who may be unfit or incompetent to operate or ve its golf carts; (g) Failing to have in place proper procedures, rules, regulations, p tocols, or safety measures to ensure that other guests are not endangered by operation of their g lf carts by guests; (h) Failing to take the proper precautions to protect the Minor Plain from the negligent, careless, and reckless conduct of other guests; (i) Allowing a 13-year-old minor to be entrusted with a golf c without verification of a driver's license; and G) Allowing a minor, whom Defendant should know, because of er youth, inexperience, or otherwise, to be likely to use the golf cart in a manner involving unre nable risk of physical harm to herself and others, drive the golf cart. 21. As a direct and proximate result of the aforesaid negligent, careless, conduct of Defendarlts, Minor Plaintiff sustained, and in the future may sustain, riOllS and - 4- 314410-1 . debilitating injuries, some of which are or may be permanent, which include, but are no limited to, the following: (a) Injuries to her right leg including a fracture. 22. As a direct and proximate result of the aforesaid negligence, carele sness, and recklessness of Defendants, Minor Plaintiff has undergone, and in the future will un rgo, great physical pain, mental pain, discomfort, inconvenience, distress, embarrassment, and iliation, past and future loss of her ability to enjoy the pleasures of life, and limitations in the pur it of daily activities, all to her great loss and detriment. 23. As a direct and proximate result of the aforesaid negligence, carele sness, and recklessness of Defendants, Minor Plaintiff has been scarred and disfigured. 24. As a direct and proximate result of the aforesaid negligence, carele suess, and recklessness of Defendants, Minor Plaintiff may suffer a loss of earnings, loss of prod tivity, loss of household services and a loss of earning capacity. WHEREFORE, Plaintiffs demand judgment against the Defendants, either' dividually and/or jointly and severally, for the aforesaid damages in an amount which exceeds th limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest and/or d ages for delay and costs of prosecution. 25. forth. COUNT II Plaintiff Jo Watson in Her Own Ril!ht v. Defendants Nel!lil!ence Paragraphs I through 24 hereof are incorporated herein by reference as . f fully set - 5 - 114410_1 " 26. By reason of the aforesaid injuries sustained by the Minor Plaintif her legal guardian, Plaintiff 10 Watson, has been forced to incur liability for medical treatrnen medicine and similar miscellaneous expenses in an effort to restore the Minor Plaintiff to health d makes a claim therefore, 27. Because of the nature of Minor Plaintiffs injuries, Plaintiff 10 Wats n may be forced to incur similar medical expenses in the future and a claim is made therefore. 28. By reason of the aforesaid injuries sustained by the Minor Plaintif her legal guardian, Plaintiff loW atson, has suffered a loss of earnings and may incur similar I sses in the future. WHEREFORE, Plaintiffs demand judgment against the Defendants, either . dividually and/or jointly and severally, for the aforesaid damages in an amount which exceeds th limits of compulsory arbitration in Cumberland County, Pennsylvania, plus interest and/or delay and costs of prosecution. ages for METZGER, WICKERSHAM, KNAUSS & E , P.c. By Clark DeVere Attomey LD. No. 68768 Andrew C, Spears, Esquire Attomey LD. No. 87737 P.O. Box 5300 3211 North Front Street Harrisburg, P A 17110-0300 (717) 238-8187 Attorneys for Plaintiffs Dated: \\- n-IJ~ -6- 314410~1 . VERIFICATION I, 10 Watson, as cousin and legal guardian of Minor Plaintiff, Takenya Wa n, hereby certify that the following is correct: The facts set forth in the foregoing Complaint are based upon information w ch I have furnished to counsel, as well as upon information which has been gathered by counsel or others acting on my behalf in this matter, The language of the Complaint is that of counsel d not my own. I have read the Complaint, and to the extent that it is based upon information w . ch I have given to counsel, it is true and correct to the best of my knowledge, information, and be ef. To the extent that the content of the Complaint is that of counsel, I have relied upon such ounsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid omplaint are made subject to the penalties of 18 Pa. C.S.A. ~4904 relating to unsworn fals cation to authorities. Dated: uJI5 ( O~ 1.1Aill.Lt '. VERIFICATION I, Jo Watson, hereby certify that the following is correct: The facts set forth in the foregoing Complaint are based upon infonnation w ch I have furnished to counsel, as well as upon information which has been gathered by counsel an or others acting on my behalf in this matter. The language of the Complaint is that of counsel d not my own. I have read the Complaint, and to the extent that it is based upon information w ch I have given to counsel, it is true and correct to the best of my knowledge, information, and be f. To the extent that the content of the Complaint is that of cOlmsel, I have relied upon such ounsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid omplaint are made subject to the penalties of 18 Pa. C,S.A. S4904 relating to unswom fals' cation to authorities. Dated: J1//5/ O~ I '11AAHL1 -------- t )(\-,\\\ f\ ~ Johnson, Duffie, Stewart & Weidner By: C. Roy Weidner, Jr. I.D.No.19530 301 Market Street P. O. Box 109 Lemoyne, Pennsylvania 17043-0109 (717) 761-4540 crw@jdsw.oom Attomeys for Defendants [] Opy TAKENYA WATSON, a minor, by JO WATSON, her oousin and guardian, and JO WATSON, in her own right, Plaintiffs IN THE COURT OF COM ON PLEAS OF CUMBERLAND COUNTY, ENNSYLVANIA NO. 04-583 CIVIL ACTION LAW JURY TRIAL DE NDED v. LIBERTY FORGE GOLF COURSE, INC., individually and Vd/b/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC., individually and Vd/b/a LIBERTY FORGE GOLF, LLC, individually and tJd/b/a LIBERTY FORGE GOLF COURSE, , D -" ._; -'f- \.0 Defendants C.::-I DEFENDANTS' ANSWER TO COMPLAINT Ul C", AND NOW, this 14th day January, 2005, come Defendants, through its u dersigned attorneys, and answer Plaintiffs' complaint as follows: 1. - 2. Denied, After a reasonable investigation, Defendants are without kn wledge' or information sufficient to form a belief as to the truth thereof. 3. Denied, On the oontrary, Liberty Forge Golf Course is a duly register d fictitious name of Liberty Forge Hospitality, Inc., which operate Liberty Forge at 3804 Lis rn Road, Mechanicsburg, Lower Allen Township, Cumberland County, Pennsylvania. 4. Denied, It is denied that Liberty Forge Hospitality, Inc.'s princip place of business is located at 3425 Simpson Ferry Road, Camp Hill, Cumberland County, Pe nsylvania. On the contrary, that is its registered office and its principal place of business is 10 Lisburn Road, Mechanicsburg, Lower Allen Township, Cumberland County, Pennsy 5. Admitted in Part, Denied in Part, It is admitted that Liberty Forge a Pennsylvania limited liability company with its office located at 3425 Simpson Camp Hill, Cumberland County, Pennsylvania. It is denied that it trades and does Uberty Forge Golf Course. On the contrary, Uberty Forge Golf Course is a du fictitious name of Liberty Forge Hospitality, Inc. 6. Admitted in Part, Denied in Part, It is admitted that Liberty Forg Inc. trading as Liberty Forge Golf Course, a duly registered fictitious name, operate 3804 Lisburn Road, Mechanicsburg, Cumberland County, Pennsylvania as averred. that any other named Defendant operates that facility. 7. Admitted, usiness as registered Hospitality , a facility at It is denied 8, Denied, After a reasonable investigation, Defendants are without k owledge or information sufficient to form a belief as to the truth of said averment. 9. Admitted in Part. Denied in Part, It is admitted that the Willia s Sonoma guests were allowed to participate in all the then existing activities to the same e nt that any other guest would be allowed, except for the restaurant and deck. That they wer allowed to participate contrary to the policies and restrictions then applicable to all guests or use the restaurant and deck is denied. The number of guests actually in attendance is died in that after a reasonable investigation, Defendants are without knowledge or information ufficient to form a belief as to the truth of said averment. 10. Admitted in Part, Denied in Part, It is admitted that guests were driving golf carts. The remainder of this averment is denied. 11. - 12. Denied, After a reasonable investigation, Defendants re without knowledge or information sufficient to form a belief as to the truth of said averments. 13. Denied, This averment is specifically denied. On the contrary, it is therefore averred, that the girls, including the minor Plaintiff, acquired the golf cart f guest or after it had been abandoned by another guest. 14. Admitted in Part, Denied in Part, It is admitted that one of the gir the cart tipped the cart over on its side and that the minor Plaintiff suffered an inju The remainder of this averment is denied. COUNT I Minor Plaintiff v, Defendants lieved and m another operating to her leg. 15. Admitted in Part. Denied in Part, Paragraphs 1 - 14 hereof are i corporated by reference herein. 16. Denied, It is specifically denied that the golf cart was entrusted to th Defendants or those acting on its behalf. By way of further denial, Defendants h procedures to prevent minors and other inexperienced operators from acquiring pos use of its golf carts from Defendants. 17. -19. Denied. These averments are deemed denied as conclusio which no responsive pleading is required. 20. Denied. This averment is deemed denied as a conclusion of law t responsive pleading is required. By way of further denial, any negligence on Defendants and those acting on its behalf is specifically denied. On the contrary, Def its employees at all times acted reasonably under the circumstances. 21. - 24. Denied. Any negligence on the part of Defendants and its e denied and paragraph 20 hereof is incorporated by reference herein. By way of fu after a reasonable investigation, Defendants are without knowledge or information form a belief as to the averments regarding Plaintiff's injuries. minors by d in place ssion and of law to which no ployees is er denial. fficient to WHEREFORE, Defendants demand that Plaintiffs' complaint against them be d missed. COUNT 11- NEGLIGENCE Plaintiff Jo Watson v, Defendants 25. Admitted in Part. Denied in Part, Paragraphs 1 - 24 hereof are i rporated by reference herein. 26. - 28. Denied, After a reasonable investigation, Defendants knowledge or information sufficient to form a belief as to the truth of these averments WHEREFORE, Defendants demand that Plaintiffs' complaint against them be d missed. JOHNSON, DUFFIE, STEWART & WElD ER :241897 5774-498 . VERIFICA TION The undersigned says that the facts set forth in the foregoing are true and c rrect. This verification is made subject to the penalties of 18 Pa. C.S.A. 9 4904, relating unsworn falsifications to authorities. ....." Dated: ~I -1\- pt; . . CERTlFICA TE OF SERVICE AND NOW, this 14th day of January, 2005, the undersigned does hereby certi that she did this date serve a copy of the foregoing document upon the other parties of record y causing same to be deposited in the United States Mail, first class postage prepaid, at Lemoyne, Pennsylvania, addressed as follows: Clark DeVere, Esquire Metzger Wickersham 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 JOHNSON, DUFFIE, STEWART & WEI By: :241897 5774-498 ----------- fx\~t C ~----- . , - , '" t>' . \ LIbert - ~ , . .... "~ 'Q) \ .~. -::'. JI~ {JJ 3804 Lisbum Road, Mechanicsburg, PA 17055- Phone: 717-795-9880 Fax: 71 795-1002 June 18,2003 Williams-Sonoma Gary Clausi Dear Gary: Thank you for your interest in Liberty Forge for your upcoming event. The enclosed proposal s prepared especially for your event. Should you wish to make any changes or have any questions and concerns, please give me a call we can discuss them. 1 am looking forward to working with you on all aspects of this event. Please be advised that the prices quoted here are subject to change after twelve months from the te of this proposal On behalf of our staff, we look forward to the pleasure of serving you and your guests here at Li great event! Sincerely, Leeann Compton Director of Sales and Marketing Williams-Sonoma Business Phone: (717) 214-6303 Proposal Event Name: Company Picnic Booking 10# 188 Page I of2 Proposal . -- . - ;; ";;r- Libert ~\ ''''' . \" , , , 3804 Lisbum Road, Mechanicsburg, PA 17055- Phone: 717-795-9880 Fax: 711 79 5-1002 Home Phone: SalespersOn: Leeann Sherman Fax: (717) 214-6403 FuncdoD Details Date Start-End Time Function SetuD '~~ted RoO! Rental 07/20/2003 . \\~~~ - 05:00 pm Meeting Banquet 700 Liberty ig $0.00 (Rounds) Ton ~~ \;!PfYI-3PfY) Special Note.: Sunday, 07/20/2003 Meeting - n u es aD activities as well as food I Food 8< I I Service Time I Service Type I Item I C ". I Char"" I 12:00 pm Dinner Derault Amount ror Dinner (Food & Beverage) 7 $24,19 Food Service. NoteS: I Bst Services 1 I Semce Time I Service Tyt>e I Item rO .1 Char"" 1 Bar Service. Notes: I Audio Vwual" Mise. Setuu I I Service Time I Service Tyt>e I Item rOt I Chame 1 A. V & Setup Note.: I Rec:rc atioIUIl Activities 1 I Service Time I Service Type I Item I Q~ T Char"" I Recreational Activities Notes: All included in the $30.000 inclusive price for fly fishing. golf lessons, petting zoo. Ii. r trips, trolley service, parlcing(valet trolley), ax, gratuity, driving range, pond fishing. fishing guides, & picnic meal F..dftn....... Tota1~ Catesmrv Discount Srv am. Sub Tot Taxi Tax Total Room _ $0,00 $0,00 $0.00 SO.OO $0.00 $0.00 $0.00 Aud;o V-...J I< _ Setup $0.00 SO.OO SO.OO SO.OO SO.OO $0,00 $0.00 Bou Senioco $0,00 SO.OO SO,OO SO.OO $0.00 $0,00 $0.00 Food & Jlcvaoge m,933.00 SO.OO SlO47,94 $19,980.94 $1015.98 $0.00 $20,996.92 PuldDglT_ Control $0.00 SO,OO SO,OO SO.OO $0.00 $0.00 $0.00 R=ea_ $0,00 $0,00 $0.00 SO.OO $0.00 $0,00 $0.00 Grand. Totals $16,933.00 $0,00 SlO47.94 $19,980,94 $1015.98 $0.00 $20.996.92 Page 2 of2 Proposal JI~ .. . Liberty Forge Food and Beverage Service Standard Terms and Condition Definitions: As used herein, the following terms shall have the following meanings: ",Evenr - the golf outing, tournament, private function forming the subject of the Reservation Agreement ("Agre:emenr): "Liberty Forge" or ''IF'' - Liberty Forge Ho lnc; "Patron" - the person, corporation, entity, organization or association contracting with Liberty forge for the Event. Guaranteed Number. Patron shall, at least fourteen (14) days prior to the date of the Event. specify in writing to Uberty For in attendance. The number shall constitute a guaranteed minimum and Patron will be charged accordingly. ddlng, banquet or other itality, Inc. and/or LFGC. the exact number to be Cancellation by Patron: If Patron cancels the Event or otherwise terminates this Agreement at least six (6) months prior to e date of Event, or jf the Agreement is terminated by Liberty Forge for breach thereof by Patron, the deposit will be forfeited as liquidated damages. I the event of cancellation by Patron within six (6) months prior to the date of Event, the Patron will be accessed a cancellation fee of twenty~five (25) pe nt of the estimated charge of the Event, or the deposit, whichever is greater. Payment in Advance: Unless credit has been established in advance by Patron with Liberty Forge, payment In full of the en made in cash, approved check or credit card prior to the date of the Event. If such payment is not made, IF may terminate th or part of the Patron's deposit in accordance with the above provisions. Full payment will be due in accordance with the term the parties, but in no case later than the start of the Event. Taxes: In addition to the charges set forth elsewhere in this Agreement, Patron agrees to pay applicable federal, state, muni imposed or applicable to the Event or this Agreement Price Increases: Prices quoted herein for events scheduled more than twelve (12) months after the date hereof are subject t the Consumer Price Index (CPI), All Items, Philadelphia. Pennsylvania. LF agrees to be bound by the price quoted herein for the date of the signed agreement Excused Non-Perfonnance: If for any reason beyond its control including, but not limited to strikes, labor disputes, accidents restrictions or regulations an travel, commodities or supplies, acts of war, terrorist attacks or acts of God and LF is unable to under this Agreement, such non-performance is excused and LF may terminate this Agreement without further liability of any n Patron's deposit. In no event shall LF be liable for consequential damages of any nature. If for any reason the space reserved Event, LF may substitute other space at Liberty Forge, comparable in quality and Patron agrees to accept such substitutions. Provision of Beverages and/or Food: Neither Patron nor any of Patron's guests or invitees may bring any beverages and/or without express written permission from LF. Gratuity: Prices quoted do not include the standard eighteen (18) percent service gratuity. Conduct of Event: Patron undertakes to conduct the Event in an orderly manner, in full compliance with applicable federal,s regulations and Rules of Conduct of liberty Forge. Patron assumes full responsibility for the conduct of all persons in attendan done to premises or property of liberty Forge caused of attributable to Patron, or Patron's agents, invltees. employees, or inde employed by Patron. Patron agrees to indemnify and hold harmless LF, its agents, shareholders, officers, employees and each any and all claims, liabilities, or costs (including reasonable attorney's fees by reason of personal injury or death or property da otherwise) arising out of or connected with the Event or this Agreement, caused or contributed to by the negligence of Patron, 0 agent of Patron or any independent contractor hired by Patron. Upon the request of LF. Patron shall produce and maintain, at i insurance. in such amounts, upon such tanns. and with such responsible insurance companies as accepted by LF, including liability coverage (with specific endorsement acknowledging the insuring of the contractualliabillties assumed by Patron above.} compensation employer's liability and automotive liability coverages as may be required by LF. Certificates of the issuance of e defivered to LF at least thirty (30) days prior to the Event. Each such pollcy shall name Uberty Forge as additional insureds. Su considered primary notwithstanding any similar insurance carried by any of the above named parties. Displays and Decoration! Patron's Property: All displays, decorations, and equipment proposed by Patron shall be subject to LF and none may be attached or displayed without prior approval of LF. Any rersonal property of Patrooor Patron's guests or in Uberty Forge premises and left thereon, either prior to, during, or following the Event, shall be sole risk of Patron and LF shall no of or damage to any such property, for any reason. Security: If required, in the sole judgment. of LF, LF shall provide (at Patron's sole cost and expense) security personnel necess LF) to maintain adequate security and/or traffic control measures in light of the size and nature of the event Any security expens will be presented to Patron at least thirty (30) days prior to Event and be shall payable at that time by Patron. Alcoholic Beverages: Uberty Forge, as a licensee, is responsible for the administration of the sale and service of alcoholic beve with PA Uquor Control Board Regulations. It is LF policy, therefore, that all alcoholic beverages must be supplied by LF. If alcoh be served on LF premises (or elsewhere Uberty Forge's alcoholic beverage license) LF will require that beverages be dispensed bartenders. LF's alcoholic beverage license requires LF to (1) request proper identification (photo 10) of any person of questionab alcoholic beverage service if the person is either underage or proper identification cannot be produced and (2) refuse alcoholic be person who, in LF's judgment, appears intoxicated. Alcoholic Beverage Indemnification: Patron hereby indemnifies and holds harmless, LF, its agents, shareholders. officers, emp the foregoing against any and all claims, liabilities, or costs (including reasonable attomey's fees and whether by reason of person damage or otherwise) arising out of, or connected with this Agreement or service of alcohol at the Event, including but not limited t damages incurred by LF, intoxication by guests, invitees and agents of Patron, service of alcohol to minors, civil, criminal and/or re loss of license caused by or contributed to, by the negligence of Patron or any guest, invitee, agent of Patron or any (ndependent Patron. Exclusion of Uability and Assumption of the Risk: As a condition of use of Liberty Forge and all associated facilities, including golf course, practice range. volleyball court, miniature golf courses. Yellow Breeches Creek, Lower Allen Community Park, any dini contract price must be Agreement and retail all erein agreed to between al or other taxes rice increases equal to period one (1) year from overnment regulations, its obligations re and shall return the not available for the of any kind to LF and local laws and and for any damages ndent contractors f the foregoing against ge or loss or ny guest, invitee, or expense, policies of rehensive general such worker's policy shall be insurance shatl be rior written approval of lees brought onto the e liable for any loss {in sole opinion of payabie by Patron ges in accordance c beverages are to iy by LF servers and age and refuse rage service to any yees, and each of jury. death. property ny consequential latory liabilities in tractor hired by t not limited to the facility and pro sl'ftJp (the ~Facilities"). the Patron and/or any u~_. of the Facilities (the ~Patrons") assumes all risk of pe\~-,oal injury, death, or roperty loss resulting .. from any cause whatsoever, including but not limited to: the scooters, and other recreational equipment; collision with natural r manmade objects; dangers associated with lightning, maintenance and irrigation equipment, water hazards, ponds, streams, dunes, sand traps, recast and unforecast weather, practice putting greens, tees, fairways, greens, driving range, volleyball courts, motorized golf carts, miniature golf rses, driveways, roads, cart paths, bridges, parking lots, and the Yellow Breeches Creek; travel within or beyond the Facilities; or negligence of any e (including golf course and/or practice range design and layout), breach of contract or breach of statutory duty of care on the part of LFGC, Inc., Ube Forge Golf Course, Liberty Forge Hospitality Inc., Liberty Adventures, Inc., Liberty Forge Arboretum, the John G. Williams Scholarship Foundatio or any affiliate or subsidiary of LFGC, Inc. and/or the American Group Companies, their officers, stockholders, managers, advisors, employees, gents, representatives and sponsors of any tournament, party, outing, league, or other Event and their assigns (hereinafter collectively referred to as Uberty Forge~). Patrons agree that Uberty Forge shall not be liable any such personal injury, death or property loss or damage and releases Liberty F ge and waives all claims with respect thereto. Patron further agree to indemnify and hold Liberty Forge harmless from any property damage, personal jury, or death resulting from golf balls hit by Patrons, Patron's use of the Far;i1ities or Patron's use of Liberty Forge golf carts, scooters, bicycles, boa or any other equipment offered for use by Liberty Forge wherever the injury, death, or damage may occur. Patrons agrees that any litigation involving iberty Forge shall be brought solely within the Courts of Cumberland County, Commonwealth of Pennsylvania and shall be within the exclusive juri iction of said Courts. Patrons further agrees Ulat these conditions and any rights, duties and obligations as between Liberty Forge and Patrons shal be governed by and interpreted solely in accordance with the laws of the Commonwealth of Pennsylvania and no other jurisdiction. Arboretum and Golf Course: Patron, guests, and invitees of any event are not permitted on the golf course, in gardens, or a oretum without prior written permission of LF. Arrangements for photographs taken in the arboretum and gardens must be made in advance. Music:: and Entertainment: Disc jockeys, bands, and other entertainment are permitted in the Wedge, on the deck, in the Lib elsewhere at Liberty Forge with prior written approval from LF. However, as a PA l.Jquor Control Board licensee, LF must and approve, terminate, and/or control the volume of any entertainment at the event. Top Tent and eserves the right to Time: Any function that may run over the time stated in this agreement will be charged $500.00 per hour (or any portion there f) over and above any balance due for the event. No Smoking: Smoking is prohibited in certain venues at Liberty Forge. Patron, its invitees and guests are requested to obse such prohibitions for everyone's enjoyment. The above provisions, Terms and Conditions and detail specifications as outlined in e Proposal are approved and accepted. alron o rJ3 Oat (., . ~ r-',' c..~ ','.:, >,J \~"-) ... C,.l C) -n .... -r' .~ r~ "-1 :.-) \:;0., ,-I ') " .. \ , ., \.-:..i - MARSHALL, DENNEHEY, WARNER, COLEMAN & GOGGIN BY: DAVID F, WHITE, ESQ.!ADAM M, SORCE, ESQ, IDENTIFICATION NO,: 55738/88711 620 Freedom Business Center, Suite 300 Kiug of Prussia, P A 19406 (610) 354-8250 (610) 354-8299 (FAX) dfwhite(aJmdwee,eom asorce(aJmdwce,com Attorney for Additional Defeudaut, Williams-Sonoma, Ine, TAKENYA WATSON, a minor by JO WATSON, her cousin and guardian, and JO WATSON, in her own right COURT OF C MMON PLEAS CUMBERLA D COUNTY v, LIBERTY FORGE GOLF COURSE, INC. Individually and t/d/b/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC" individually and t/d/b/a LIBERTY FORGE GOLF COURSE, and: LIBERTY FORGE GOLF, LLC, individually And t/d/b/a LIBERTY FORGE GOLF COURSE: v, WILLIAMS-SONOMA, INC. NO, 04-5831 ENTRY OF APPEARANCE TO THE PROTHONOTARY: Kindly enter our appearance on behalf of Additional Defendant, Wi Iiams-Sonoma, Inc., in the above-captioned matter. Date: ~/ \~~ 126_AILIAB rSILLPG\729244ILTMI030261001] 1 MARSHA , DENNE HEY, WAR ER, e. ~~LE AN & OG,~IN BY: 7, DA VI F, WHITE, ESQUI E ADAM M, SORCE, ESQUI CERTIFICATE OF SERVICE I, Adam M. Sorce, Esquire, do hereby certify that a true and correct copy of Entry of Appearance was served upon all parties by first class mail on the below list d date at the following addressees: Clark DeVere, Esquire METZGER, WICKERSHAM, KNAUSS & ERB, P.c. P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 C. Roy Weidner, Jr., Esq. JOHNSON, DUFFIE, STEW ART & WEIDNER 301 Market Street Lemoyne, P A 17043-0 I 09 Respectfully subjpitted, L{,{/L'( Dated: -------- Q (." ~ ~ !O ?O \ C' ;j; \~' ~!~ .::. ';:\t~ ::"2. 9r. ::;I...,., - 1f': " '<1 -o'eJ .'J, ~l.. t),I...) -,',7. :<^\ ?)('") ?::rc, ,--->\ .v ':-.q .'. -.:; -:;&. - .' c..fl - - TO: ALL PARTIES YOU ARE HEREBY ~OTIFIED TO FILE A WRITTEN RESPO:'JSE TO THE E1\CLOSED ANSWER WITH ]\EW MATTER AND NEW MATTER COUNTERCI,AIM WITHIN TWENTY 20 YS FROM SERVICE HEREOF OR A JUDGM A BE E RED AGAINST YOlJ. BY: AD M. SORCE, ESQUIRE A TIORNEY FOR ADDITIONAL DEFENDANT MARSHALL, DENNEHEY, WARNER, COLEMAN & GOGGIN BY: DAVID F, WHITE, ESQ./ADAM M. SORCE, ESQ, IDENTIFICATION NO,: 55738/88711 620 Freedom Business Center, Snite 300 King of Prussia, P A 19406 (610) 354-8250 (610) 354-8299 (FAX) dfwhite(almdwcl!,com asorce(a)mdwc1!.com Attorney for Additional Defendant, Williams-Sonoma, Inc. TAKENYA WATSON, a minor by JO WATSON, her cousin and guardian, and JO WATSON, in her own right COURT OF COMMON PLEAS CUMBERLAND COUNTY v, LIBERTY FORGE GOLF COURSE, INC. Individually and t/d/b/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC., individually and t/d/b/a LIBERTY FORGE GOLF COURSE, and: LIBERTY FORGE GOLF, LLC, individually And t/d/b/a LIBERTY FORGE GOLF COURSE: NO, 04-5831 WILLIAMS-SONOMA, INC'S ANSWER TO JOINDER COMPLAINT OF LIBERTY FORGE GOLF COURSE, INC. WITH NEW MATTER AND NEW MATTER COUNTERCLAIM Now comes Additional Defendant, Williams-Sonoma, Inc., by and through undersigned counsel, and for its Answer to the 10inder Complaint of Liberty Forge Golf Course, Inc., states as follows: I. Admitted in part, denied in part. It is admitted that a copy of Plaintiffs' Complaint was attached to the Joinder Complaint. After reasonable investigation, Answering Defendant is without sufficient infonnation to form a belief as to the truth of the remaining averments in paragraph I of the 10inder Complaint or the allegations contained in Plaintiffs' Complaint. Therefore, they are denied. Any remaining allegations are denied pursuant to Pa. R.C.P. 1029 and as conclusions of law which require no response. 2. Admitted in part, denied in part. It is admitted that a copy of Defendant's Answer was attached to the Joinder Complaint. After reasonable investigation, Answering Defendant is without sufficient information to form a belief as to the truth of the remaining averments in paragraph 2 of the loinder Complaint or the allegations contained in Plaintiffs' Complaint. Therefore, they are denied. Any remaining allegations are denied pursuant to Pa. R.C.P. 1029 and as conclusions oflaw which require no response. 3. Admitted. 4. Admitted in part, denied in part. It is admitted that Plaintiffs' Complaint claims that the minor plaintiff suffered personal injuries. All remaining allegations are denied pursuant to Pa. R.c.P. 1029 and as conclusions oflaw which require no response. 5. Denied. After reasonable investigation, Answering Defendant is without sufficient information to form a belief as to the truth of the averments of paragraph 5 ofthe Joinder Complaint. Therefore, they are denied. 2 6. Denied. It is specifically denied that the conduct of events clause is limited as Defendant states in paragraph 6 ofthe 10inder Complaint. After reasonable investigation, Answering Defendant is without sufficient information to form a belief as to the truth of the remaining averments of paragraph 6 ofthe 10inder Complaint. Therefore, they arc denied. Any remaining allegations are denied pursuant to Pa. R.C.P. 1029 and as conclusions of law which req u!re no response. WHEREFORE, Answering Defendant demands judgment in its favor, together with interest, costs and attorney's fees. COUNT I BREACH OF CONTRACT 7. Denied. It is specifically denied that Answering Defendant breached any contractual obligations undertaken by it. After reasonable investigation, Answering Defendant is without sufficient information to form a belief as to the truth ofthe remaining averments of paragraph 7 of the Joinder Complaint. Therefore, they are denied. Any remaining allegations are denied pursuant to Pa. R.C.P. 1029 and as conclusions oflaw which require no response. 8. Denied. It is specifically denied that Answering Defendant breached any contractual obligations undertaken by it. Additionally, Answering Defendant specifically denies that it is liable for any and all damages suffered by Defendant as alleged. After reasonable investigation, Answering Defendant is without sufficient information to form a belief as to the truth of the remaining avemlents of paragraph 8 of the Joinder Complaint. Therefore, they are denied. Any remaining allegations are denied pursuant to Pa. R.C.P. 1029 and as conclusions oflaw which reqUIre no response. 3 WHEREFORE, Answering Defendant demands judgment in its favor, together with interest, costs and attorney's fees. COUNT II NEGLIGENCE 9. Denied. It is specifically denied that Answering Defendant undertook a duty to Defendant to conduct the event in a reasonable manner. After reasonable investigation, Answering Defendant is without sufficient information to fonn a belief as to the truth ofthe remaining averments of paragraph 9 ofthe 10inder Complaint. Therefore, they are denied. Any remaining allegations are denied pursuant to Pa. R.C.P. 1029 and as conclusions oflaw which require no response. 10. Denied. Answering Defendant specifically denies that it was careless and/or negligent. After reasonable investigation, Answering Defendant is without sufficient information to form a belief as to the truth of the remaining averments of paragraph 10 ofthe 10inder Complaint. Therefore, they are denied. Any remaining allegations are denied pursuant to Pa. R.C.P. 1029 and as conclusions oflaw which require no response. 4 II. Denied. It is specifically denied that Answering Defendant was negligent. It is further specifically denied that minor plaintiff suffered any damages or injuries as a result of Answering Defendant's negligence. After reasonable investigation, Answering Defendant is without sufficient information to form a belief as to the truth of the remaining averments of paragraph II of the 10inder Complaint. Therefore, they are denied. Any remaining allegations are denied pursuant to Pa. R.C.P. 1029 and as conclusions oflaw which require no response. WHEREFORE, Answering Defendant demands judgment in its favor, together with interest, costs and aUomey's fees. COUNT III INDEMNIFICATION 12. Denied. It is specifically denied that the contract is limited as stated in paragraph 12 of the 10inder Complaint. After reasonable investigation, Answering Defendant is without sufficient information to form a belief as to the truth of the remaining averments of paragraph 12 of the 10inder Complaint. Therefore, they are denied. Any remaining allegations are denied pursuant to Pa. R.C.P. 1029 and as conclusions oflaw which require no response. WHEREFORE, Answering Defendant demands judgment in its favor, together with interest, costs and aUomey's fees. NEW MATTER 13. Plaintiff was contributorily negligent or comparatively negligent. 14. Plaintiff was comparatively negligent to a degree greater than the causal negligence of the Answering Defendant, the existence of any negligence on the part of the Answering Defendant being expressly denied. 15. The Plaintiff assumed the risk of her activities. 5 16. Answering Defendant was not careless, reckless or negligent in any respect. 17. The injuries, damages, and losses allegedly sustained by the Plaintiffs were caused entirely or contributed to by the negligent acts or omissions of individuals and/or entities other than the Answering Defendant. 18. The injuries, losses or damages alleged sustained by the Plaintiffs were not proximately caused by the Answering Defendant. 19. Plaintiffs' claims may be barred in whole or in part by the applicable doctrines of res judicata and/or collateral estoppel 20. Plaintiff was not injured on Answering Defendant's property. 21. Defendant's Joinder Complaint fails to state a cause of action upon which relief may be granted. WHEREFORE, Answering Defendant demands judgment in its favor and against the Defendant, Liberty Forge Golf Course, Inc. 6 NEW MATTER COUNTERCLAIM PURSUANT TO PA, R.c.p, 2252(d) 22. Answering Defendant hereby incorporates his responses to the allegations contained within the Joinder Complaint and incorporates the same as though fully set forth at length herein. 23. Should there be a finding ofliability against Answering Defendant, Williams- Sonoma, Inc., which liability is specifically denied, then Additional Defendant, Williams- Sonoma, Inc., demands entry of judgment in its favor and against Defendant, Liberty Forge Golf Course, Inc., individually and t/d/b/a Liberty Forge Golf Course, Liberty Forge Hospitality, Inc., individually and t/d/b/a Liberty Forge Golf Course and Liberty Forge Golf, LLC, individually and t/d/b/a Liberty Forge Golf Course, the aforesaid Defendant being alone liable to the Plaintiffs or liable over to Defendant, Williams-Sonoma, Inc., or jointly and severally liable to Defendant, Williams-Sonoma, Inc., directly as the party primarily responsible for the alleged injuries of Plaintiffs by way of a contribution and/or indemnity. WHEREFORE, Answering Defendant demands judgment in its favor, together with interest, costs and attomey's fees. Respectfully submitted, MARSHALL, DENNE HEY, WARNER, COLEMAN AND OGGIN i BY: DAVID F. WHITE, ESQUIRE ADAM M. SORCE, ESQUIRE Attorneys for Additional Defendant, Williams-Sonoma, Inc. Date: / 5 \26~A\L1AB\ArS\[.[.PG\ 28601\LTM\03026\OOl 11 7 VERIFICATION David F. White, Esquire, being duly swom according to law deposes and says that he is authorized to take this verification on behalf of Defendant, Williams-Sonoma, Inc., and that the facts set forth in the foregoing Answer of Williams-Sonoma, Inc. to Liberty Forge Golf Course, Inc.'s Joinder Complaint with New Matter and New Matter Counterclaim are true and correct to the best of his knowledge, information, and belief. This verification is subject to 18 Pa.C.S. 94904 which provides for certain penalties for making false statements. ,'\ '"' \ : '.) LI Ill.. ~ DATE: - i \' ll~ CERTIFICATE OF SERVICE I, Adam M. Sorce, Esquire, do hereby certify that a true and correct copy of Answer of Defendant, Williams-Sonoma, Inc., to Liberty Forge Golf Course, Inc.'s 10inder Complaint with New Matter and New Matter Counterclaim was served upon all parties by first class mail on the below listed date at the following addressees: C. Roy Weidner, lr., Esq. JOHNSON, DUFFIE, STEWART & WEIDNER 301 Market Street Lemoyne, P A 17043-0109 Clark DeVere, Esquire METZGER, WICKERSHAM, KNAUSS & ERB, P.c. P.O. Box 5300 3211 North Front Street Harrisburg, P A 17110-0300 Dated: . /' 1-1//'-1 / Q) Respectfully su~mitted, sa~ ADAM M. SORCE, ESQUIRE ~~:' :::., -- cP --- (. If' c..,.; TAKENYA WATSON, a minor, by JO WATSON, her cousin and guardian, and JO WATSON, in her own right, Plaintiffs IN THE COURT OF COMMON PL AS CUMBERLAND COUNTY, PENNS LV ANIA v, CIVIL ACTION - LA W LIBERTY FORGE GOLF COURSE, INe. individually and t/d/b/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INe. individually and t/d/b/a LIBERTY FORGE GOLF COURSE,: and LIBERTY FORGE GOLF, LLC, individually and t/d/b/a LIBERTY FORGE GOLF COURSE, NO,04-5831 Defendants v, WILLIAMS-SONOMA, Additional Defendant : JURY TRIAL DEMANDED PLAINTIFFS' REPLY TO NEW MATTER AND COUNTERCLAIM OF ADD TIONAL DEFENDANT WILLIAMS-SONOMA, INC. AND NOW, come Plaintiffs, Takenya Watson, a minor, by Jo Watson, her cousin guardian, and Jo Watson, in her own right, by and through their counsel, Metzger, Wicker ham, Knauss & Erb, and hereby file this Reply to New Matter and Counterclaim of Additional Defendant Williams-Sonoma, Inc. as follows: 13, Conclusions oflaw, no reply required, If a reply is required, the averments are specifically denied and denied pursuant to Pa. R.C,P. No, 1029(e) and 1030 (note), By w yof further reply, Plaintiffs were not contributorily or comparatively negligent in any manner nd answering Defendants have failed to specify how Plaintiffs would have been contributoril or comparatively negligent. Moreover, Plaintiff Takenya Watson is a minor. 14, Conclusions oflaw, no reply required, If a reply is required, the averments are 325864-1 specifically denied and denied pursuant to Pa, R.c.p, No, 1029(e) and 1030 (note), By w of further reply, any negligence on the part of the Plaintiff, which is specifically denied for th purposes of this Reply, was not greater than the negligence of Defendants, either individu jointly, Moreover, Takenya Watson is a minor. 15. Conclusions oflaw, no reply required. Ifa reply is required, the averments are specifically denied and denied pursuant to Pa. R.C,P, No, 1029(e) and 1030 (note), By wa of further reply, Plaintiff did not knowingly and expressly assume the precise risk which cau injuries relating to the within incident. Moreover, Plaintiff Takenya Watson is a minor. 16. Conclusions oflaw, no reply required. If a reply is required, the averments re specifically denied and denied pursuant to Pa. R.c.p, No, 1029 (e) and 1030 (note), By w yof further reply, Plaintiffs were not negligent, careless or reckless in any manner. Answering Defendants were negligent and careless as set forth in the Joinder Complaint filed in this a tion, which is incorporated herein by reference, 17, Conclusions of law, no reply is required, If a reply is required, the avermen s are specifically denied and denied pursuant to Pa. R.C.P, No. 1029(e). By way of further repl , Plaintiffs cannot properly respond since Answering Defendant has failed to identify the ot individuals or entities they are referring to, Nonetheless, the Answering Defendant is negl' ent and the cause of Plaintiffs' injuries and damages, either individually and/or jointly and sev rally, as set forth in the Complaint and Joinder Complaint filed in this action, which are incorpor ted herein by reference, 18, Conclusions oflaw, no reply is required. If a reply is required, the avermen s are specifically denied and denied pursuant to Pa, R.C.P, No. 1029(e), By way of further repl Plaintiffs' injuries and damages were proximately caused by Answering Defendant, either 325864-1 individually and/or jointly and severally, as set forth in the Complaint and Joinder Compl int filed in this action, which are incorporated herein by reference, 19, Conclusions of law, no reply is required, If a reply is required, the averme ts are specifically denied and denied pursuant to Pa, R.c.p, No. 1029(e). By way of further repl , Answering Defendant has not pled sufficient facts to establish the elements necessary to establish the doctrines of res judicata and/or collateral estoppel. 20. Conclusions oflaw, no reply is required. If a reply is required, the averme specifically denied and denied pursuant to Pa. R.C.P, No. 1029(e). By way of further repl , Answering Defendant may have been in control of the property in question by written con between Answering Defendant and other Defendants as more specifically set forth in the J inder Complaint filed in this action, which is incorporated herein by reference, 21, Paragraph 21 is directed to parties other than the Plaintiffs and therefore no reply is required, If a reply is required, the averments are conclusions oflaw, again for wh ch no reply is required. By way of further reply, Defendants' Joinder Complaint states claims up n which relief can be granted and no Preliminary Objections have been filed to the Joinder Complaint. WHEREFORE, Plaintiffs Takenya Watson, a minor by Jo Watson, her cousin and guardian, and Jo Watson, in her own right demand that judgment be entered in their favor d against Defendants and/or Additional Defendants as set forth in the Complaint and Joinder Complaint filed in this action. 325864-1 REPL Y TO NEW MATTER COUNTERCLAIM 22, Paragraph 22 is an incorporation paragraph and therefore no reply is requir d. Moreover, the averments are directed to parties other than the Plaintiffs and no reply is re uired, 23, The crossclaim is directed to parties other than the Plaintiffs and therefore 0 reply is required. If a reply is required, the averments are conclusions of law, again for w ich no reply is required. By way of further reply, the Defendants are liable, either individually a or jointly and severally, as set forth in the Complaint and Joinder Complaint filed in this acti n, which are incorporated herein by reference, WHEREFORE, Plaintiffs Takenya Watson, a minor by Jo Watson, her cousin and guardian, and Jo Watson, in her own right demand that judgment be entered in their favor d against Defendants and/or Additional Defendants as set forth in the Complaint and Joinder Complaint filed in this action, METZGER, WICKERSHAM, KNAUSS & ERB, p, , By Dated: Lj-,:J~-05 Clark De V ere, Esquire Attorney J.D. No. 68768 P,O, Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 (717) 238-8187 Attorneys for Plaintiffs 325864-1 VERIFICATION I, Jo Watson, hereby certify that the following is correct: The facts set forth in the foregoing Plaintiffs' Reply to Additional Defendant's New atter and Counterclaim are based upon information which I have furnished to counsel, as well information which has been gathered by counsel and/or others acting on my behalf in this The language of the Plaintiffs' Reply to Additional Defendant's New Matter and Counterc aim is that of counsel and not my own, I have read the Plaintiffs' Reply to Additional Defendant' New Matter and Counterclaim, and to the extent that it is based upon information which I have g ven to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Plaintiffs' Reply to Additional Defendant's New Matter and Counterc aim is that of counsel, I have relied upon such counsel in making this Verification. I hereby ackno that the facts set forth in the aforesaid Plaintiffs' Reply to Additional Defendant's New Ma Counterclaim are made subject to the penalties of 18 Pa. C.S,A. S4904 relating to falsification to authorities, Dated: Y-23-0G ~l~~ Jo tson 325864-1 VERIFICATION I, Jo Watson, cousin and guardian of Takenya Watson, a minor, hereby certify t at the following is correct: The facts set forth in the foregoing Plaintiffs' Reply to Additional Defendant's New Matter and Counterclaim are based upon information which I have furnished to counsel, as well information which has been gathered by counsel and/or others acting on my behalf in this atter. The language of the Plaintiffs' Reply to Additional Defendant's New Matter and Counterc aim is that of counsel and not my own, I have read the Plaintiffs' Reply to Additional Defendant s New Matter and Counterclaim, and to the extent that it is based upon information which I have g ven to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Plaintiffs' Reply to Additional Defendant's New Matter and Counterc aim is that of counsel, I have relied upon such counsel in making this Verification. I hereby ackno ledge that the facts set forth in the aforesaid Plaintiffs' Reply to Additional Defendant's New Ma er and Counterclaim are made subject to the penalties of 18 Pa, c.S,A. 94904 relating to u sworn falsification to authorities, Dated: ~'l~/cfi' ~ ~lJcrl-d)C2Yj J 0 atson 325864-1 CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, PC" hereby certify that I served a true and exact copy of the Plaintiffs' Reply to New Marter and Crossclaim of Additional Defendant Williams-Sonoma, Inc, with reference to the foregoing ction by first class mail, postage prepaid, this )..~I- day of +1 j , 2005, on the followi Adam M. Sorce, Esquire David F, White, Esquire MARSHALL, DENNEHEY, WARNER, COLEMAN & GOGGIN 620 West Germantown Pike, Suite 350 Plymouth Meeting, P A 19462 C. Roy Weidner, Esquire Johnson, Duffie, Stewart & Weidner 301 Market Street p, O. Box 109 Lemoyne, P A 17043-0109 Clark De V ere, Esquire 325864-1 .. Johnson, Duffie, Stewart & Weidner By: C. Roy Weidner, Jr. '-D. No. 19530 301 Market Street P. O. Box 109 Lemoyne, Pennsylvania 17043-0109 (717) 761-4540 crw@jdsw.com Attorneys for Defendants TAKENYA WATSON, a minor, by JO WATSON, her cousin and guardian, and JO WATSON, in her own right, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 04-5831 Plaintiffs CIVIL ACTION - LAW v, JURY TRIAL DEMANDED LIBERTY FORGE GOLF COURSE, INC., individually and t/d/b/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC., individually and t/dlb/a LIBERTY FORGE GOLF, LLC, individually and t/d/b/a LIBERTY FORGE GOLF COURSE, Defendants v. WILLIAMS-SONOMA. INC., Additional Defendant DEFENDANTS' REPL Y TO NEW MA TTER OF ADDITIONAL DEFENDANT WILLIAMS-SONOMA, INC. -Ht AND NOW, this ~ day of Apri / , 2005, come Defendants, replies to the l1ew matter of Additional Defendant Williams-Sonoma, Inc. as follows: NEW MATTER 13. Admitted, 14. Denied. I " . 15. Admitted, 16. Denied, 17. Denied, 18. Denied, 19. Admitted, 20. Admitted, 21. Denied. WHEREFORE. Defendants demand judgment in their favor. NEW MA ITER COUNTERCLAIM PURSUANT TO PA. R.C,P. 2252(d) 22. - 23. Denied, The averments of the joinder complaint are incorporated herein, WHEREFORE. Defendants demand judgment in their favor. 1:249273 ~77 4-498 a:.F1E. STEWART & WEIDNER C. Roy Weidner, Jr. .-1' VERIFICA T/ON I, Kurt E. Williams, verify that the statements made in the foregoing reply to new matter are true and correct to the best of my knowledge, information and belief. I understand that false statements made herein are subject to the penalties of 18 Pa.C.SA 94904 relating to unsworn falsification to authorities. By: urt E. Williams, President Dated: 1 F~J o( .. CERTlFICA TE OF SERVICE AND NOW, this ~~ay of .Aprl I , 2005, the undersigned does hereby certify that she did this date serve a copy of the foregoing document upon the other parties of record by causing same to be deposited in the United States Mail, first class postage prepaid, at Lemoyne, Pennsylvania, addressed as follows: Andrew C. Spears, Esquire Metzger Wickersham 3211 North Front Street P.O. Box 5300 Harrisburg, P A 1711 0-0300 David F. White, Esquire Adam F. Sorce, Esquire Marshall, Dennehey, Warner Coleman & Goggin 620 Freedom Business Center, Suite 300 King of Prussia, PA 19406 JOHNSON, DUFFIE, STEWART & WEIDNER BY:~.i~/~ ~ ~L/U . helle H. Spangler - 1:249273 5774,498 -------- ....> ~~ ,'" -7:: 'i"~ --< I N ~ ~l :;:I" :n f'r':: -:)\' " ,19 ~.~~ (?~ ~">~<:A '~.?~' q '~-:~ (;J o - T AKENY A WATSON, a minor, by 10 WATSON, her cousin and guardian, and JO WATSON, in her own right, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA v. CNIL ACTION - LAW LIBERTY FORGE GOLF COURSE, INC. individually and tJd/b/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC. individually and tJd/b/a LIBERTY FORGE GOLF COURSE,: and LIBERTY FORGE GOLF, LLC, individually and tJd/b/a LIBERTY FORGE GOLF COURSE, NO.04-583I Defendants v. WILLIAMS-SONOMA, Additional Defendant: lURY TRl.<\L DEMANDED PETITION FOR APPROVAL OF MINOR SETTLEMENT AND NOW, comes the Petitioner, 10 Watson, as cousin and guardian of minor Takenya Watson, and petitions this Court for approval of a settlement of a minor's case in accordance with Pa. R.C.P. 2039, and in support ofthe Petition avers as follows: I. Petitioner, 10 Watson, is an adult individual residing at 230 North Second Street, Steelton, Dauphin County, Pennsylvania. 2. Petitioner, 10 Watson, is the cousin and guardian of minor Plaintiff, Takenya Watson, who resides with her, and who is 13 years old, having been bom on December 5, 1991. 3. Petitioner, 10 Watson, was awarded legal and prirnaryphysical custody of minor Plaintiff, Takenya Watson pursuant to an Order entered on April 9, 2004 to No. 1179 CV 2004 332099-1 by the Honorable Todd A. Hoover, ofthe Dauphin County Court of Common Pleas. See copy of Order attached hereto and incorporated herein by reference as Exhibit "A". 4. Minor Plaintiff, Takenya Watson, has selected Petitioner 10 Watson, as her cousin and guardian, to represent her interests in this petition, 5. On July 20, 2003, minor Plaintiff, Takenya Watson, along with her sisters, Tashawna Davenport and Takeita Foster, were attending a Williams Sonoma Company sponsored picnic which was held on Liberty Forge's premises. 6. During the picnic, Minor Plaintiff and her sister, Tashawna, who was 13 years old, secured a golf cart which they drove around the course. 7. After driving around for approximately 30 to 45 minutes, Tashawna, who was driving the golf cart around a curve, attempted to turn left and the cart tipped over onto its right side. When the cart tipped over on its right side, Minor Plaintiffs right leg became pinned under the right side of the cart, causing injury to her. 8. As a result ofthe accident, Takenya Watson sustained a fracture of her right leg. She was placed in a varus long leg cast in order to realign the fracture and given a knee immobilizer. Minor Plaintiff attended 12 sessions of physical therapy with the Orthopedic Institute of Pennsylvania. A true and correct copy ofthe medicall records are attached hereto as Exhibit "B" and incorporated herein by reference. 9. Takenya has had no further medical treatment related to this accident since October 2, 2003, when she was discharged by her orthopedic surgeon, and has no appointments scheduled. 10. The medical bills for Takenya's treatment as a result of the injuries sustained in 332099-1 this accident amounted to $4,492,00 and have been paid by the Department of Public Welfare. See Medical Bill Summary and medical bills attached hereto and incorporated herein by reference as Exhibit "C". 11. A lien has been asserted by DPW in the amount of$585.53 of any settlement reached in this matter and that amount will have to be paid out of any settlement proceeds. See Statement of Claim ofDPW attached hereto and incorporated herein by reference as Exhibit "D". 12. At the time ofthe aforesaid accident, minor Plaintiff was an 11 year old student and not employed. Therefore, there is no wage loss claim. 13. A settlement in the amount of$IS,OOO is proposed. The settlement offer represents the tender of $7 ,500 by the Liberty Forge Golf Course, Inc. Defendants and $7,500 by Additional Defendant Williams-Sonoma, Inc, A copy ofthe proposed General Release of All Claims is attached hereto as Exhibit "E" and incorporated herein by reference. 14. Petitioner, on behalf of minor Plaintiff, Takenya Watson, has retained the services of the law offices of Metzger, Wickersham, Knauss & Erb to represent them and has agreed to pay a twenty-five percent (25%) contingent fee to said attorneys. A copy of the Contingent Fee Agreement between Petitioner and her counsel is attached hereto and incorporated herein by reference as Exhibit "F". 15. It is Petitioner counsel's professional opinion that the settlement is in the best interest of the minor Plaintiff under the circumstances ofthis case, which opinion and settlement is acceptable to Petitioner. 16. The Petitioner proposes to place minor Plaintiffs settlement proceeds in a 332099-1 federally insured account at a bank, credit union or savings and loan association organized and existing under the laws ofthe Commonwealth of Pennsylvania in the name ofthe minor Plaintiff in accordance with Pa. R.C.P. No. 2039. 17. The Petitioner desires the funds to be made available to the minor Plaintiff when she attains her eighteenth birthday on December 5, 2009, except as authorized by prior Court Order. 18. The Petitioner has further agreed to payout of their share of the recovery any and all costs incurred or advanced on their behalf. The amouot of the costs that were incurred and advanced on Petitioner's behalf to date in this matter by Metzgl~r, Wickersham, Knauss & Erb total $476.07. An itemization of these costs is attached hereto, incorporated by reference herein and marked as Exhibit "G". 19. The entire settlement is for claims arising from personal physical injuries and is not subject to income tax pursuant to Internal Revenue Code gI04(a)(2), 20. Petitioner requests that the Court approve the settlement set forth above and order that the proceeds be distributed as follows: TOTAL AMOUNT OF SETTLEMENT $15,000.00 To be paid to Metzger, Wickersham, Knauss & Erb for counsel fees -(3,750.00) To be paid to Metzger, Wickersham, Knauss & Erb for expenses -(476.07) To be held in escrow for DPW lien -(585.53)* Takenya Watson and Jo Watson, her Cousin and Natural Guardian $10,188.40 *Petitioner's counsel will negotiate amouot with DPW and any amount left over after negotiation will also be placed into minor Plaintiff s account. 332099-1 21. Petitioner requests that the net amount due to minor Petitioner be distributed in accordance with your Court's Decree. 22. Petitioner requests that the remainder of the settlement proceeds representing attomey's fees, expenses and reimbursements be distributed immediately. WHEREFORE, Petitioner, 10 Watson, Cousin and Guardian of Takenya Watson, respectfully requests this Honorable Court approve the Settlement and Distribution of the Proceeds or, in the altemative, to set up a hearing on this Petition. METZGER, WICKERSHAM, KNAUSS & ERB, P.C. By ~~~ Clark De V ere, Esquire Attomey J.D. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, P A 1711 0-0300 (717) 238-8187 Attorneys for Plaintiffs Dated: ,-Z2--65" 332099-1 JO WATSON IN THE COURT OF COMMON PLEAS DAUPHIN COUNTY, PENNSYLVANIA PLAINTIFF vs. ....., = = .r.- """ -0 ::0 SHARON WATSON and KENNETH EARLY No. 1179 CV 2004 Pl::-.' ;~::: ..',- :':":C,; ;p,c c-: "" =.: '-P. o c.J1 -c. .. N DEFENDANTS ORDER ~ AND NOW THIS 9th day of April, 2004, the Plaintiff having appeared for a custody conference on April 5, 2004 before Judith A. Calkin, Esquire, and the Defendants being served by not appearing, it is hereby ORDERED AND DECREED as follows: 1. Jo Watson, the maternal second cousin of the minor child shall maintain legal and primary physical custody ofTakenya Watson (DOB '12/5/91). 2. Mother, Sharon Watson, and Father, Kenneth Early, shall have visitation or partial custody of the minor child at times and places mutually agreed upon by the Plaintiff and either parent. 3. During any period of custody or visitation, the parties to this order shall not possess or use controlled substances or consume alcoholic beverages to the point of intoxication. The parties shall likewise assure, to the extent possible, that other household members andlor houseguests comply with this prohibition. -0 'Xl C~} 0 ::u -"i'lM "'f1(") Jc:;J-r, r,,::;::: i'-..)P' 10 4. The parties shall refrain from making derogatory Gomments about the other party in the presence of the child and to the extent possible shall prevent third parties from making such comments in the presence of the child. BY THE COURT: q,~ l~ Todd A. Hoover, Judge DISTRIBUTION: Jo Watson, 230 North 2nd Street, Steelton, PA 17113 Sharon Watson, 1420 Vernon Street, Harrisburg, PA 17'103 Kenneth Early, Dauphin County Prison, 501 Mall Road, Harrisburg, PA APR 1 2 2004 Itlereby certify that the foregoing is a true and correct CO]P tile original fllad. ~~,~ Protllonotary AUS 13 200? CERTIFICATION The copies of records for which this certification is made are true and complete reproductions of the original or microfilmed medical records which are in the offices of Lower Allen Township. The original records were made in the regular course of business at or near the time of the matter recorded. The certification is given pursuant to 42 Pa,C.S. Ch. 61 Subch. E (relating to medical records) by the custodian of the records in lieu of his or her personal appearance, Patient: Takenya Watson SSN: 209-72-9709 DOB: 12/05/91 Medical Record No.: ()3 I 05'.2 I Number of Pages: tI Dated: gill /03 IdlmtAl'P1~ Aj~~(J./ of Lower Allen Township Subscribed and Swom to before me thisf,tday of ~ 2003. J9Jfuflt iZ- ~J , commission expires on: $ - (ct - Q3 285915,1 Pennsylvania EMS Report (C~\P~ Service Name llnitNo. peR No. I County Incid. No. 1 Date Lower Allen Township EMS 210090 ] 0:, ]052] 85965 117/2012003 Incident Location Me!) Rct:civing Facility 3804 L1SBURN RD 2]9]2 Harrisburg Hospital ~ Patient Name Phone No. Ag(~ I nate of Birth Social Sec. No. Sex T AKENY A WATSON EARL Y (717) 985,] 99] ]] ] 21051199] 209,72.9709 Female == Street Address Crew Times ..... 230 N 2ND ST A#1 Erickson, Brian EMT 097065 Dispatch ]63] ... Citv State Zir A#2 Regal, Marie EMT 066444 Enroute 16;33 == d) StEEL TON PA ]7 ]] A#3 Arrive Scene ]6:50 .... ,\L8 "nit I Membership A#4 Depart Scene ]7:02 ... ~ No Arrive Facility ]7: ]9 ~ Pri'olate Physician Out On.Scem' Dest. In Available ]7:46 32964 32970 32980 32984 In Ouarters ]8:00 Medical Command Physician MCC Cbiei"Cunmlaint: TRA\NAT]C LEG INJURY RESIn r OF GOLF CART ]NJURY I Current Metis: NONE Aller2ies (meds): NONE PMHx: In MI nCf-11< n COPD n "BP n Diab, r1C;ancernNQlle Knuwrl o w """' o Ul N """' Narrative PMH: NONE QO W .&;;. o QO QO N .&;;. C1N# 85965 D]SPATCHED CLASS] TO LIBERTY GOLF COURSE FOR A LEG INJURY, ON AIR INFO, 15 YIO FEMALE WITH A LEG ]NJURY AS RESULT OF THE GOLF CARE ROLLING OVER. ARR]VED ON SCENE TO F]ND AN]] YIO FEMALE L Y]NG ON THE GROUND ON HER R]GHT SIDE, PT STATES THAT HER 15 YIO SISTER WAS DR1V]NG THE CART. TOOK A TURN TOO FAST AND ROLLED THE G01.F CART OVER THE CART CAME TO REST ON HER RIGHT LEG HER FAM]LY ROLLED THE CART OFF AND CALLED9] ], MED]CAT]ON' NONE ALLERCiJES: NONE P,E,: ]] YIO BLACK FEMALE CAAOx3 BREATH]NG NORMALL Y WITH A PATENT A]RWA y, STRONG RAD]AL PULSES NOTED, HEENT ]NTACT, PUPILS EQUAL AND REACT]VE TO LIGHT, MUCOUS MEMBRANES INTACT C,SP]NE ]NTACT NO DEFORM1T]ES, NO JVD OR TRACHEA DEV]ATlON NOTED, CHEST SYMMETRICAL WITH EQUAL RISE AND FALL, LUNGS CLEAR AND EQUAL B] LATERALLY, ABDOMEN NON TENDER. NON DISTENDED PELVIS INTACT, LEFT LEG UNREMARKABLE. UN]NJURED, RIGHT LEG CLFAR TO KNEE, PT COMPL,\INS OF PAIN RATED AS AN 8 OUT OF ]O]N THE AREA BEH]ND HER KNEE. AREA ]S UNREMARKABLE STRONG POPLITEAL PULSE NOTED, LOWER LEG UNREMARKABLE, UPPER EXTREM]T1ES UNREMARKABLL AND UN]NJURED, TX UPON ARR1V]NG ON SCENE PT ASSESSED BY A L RIGHT LEG ]MMOB]LlZED W]TH PADDED BOARD SPLINT PT TRANSFERRED ON TO LllTER AND PLACED IN AMBULANCE, CREW ENROllTE HARRISBURG ECU, WIl1LE ENROllTE PT CONDITION MON]TORED BY A], A ] GAVE HBG EClI A BLS NOT]F]CAT10N PATCH, ARRIVED HBG WITHOUT CHANGE IN PT CONDIT]ON, PT PLACEIJ ]N FRACTURE ROOM AS DIRECTED BY STAFF, A] GAVE NURS]NG STAFF REPORT CARE TRANSFERRED,<<EN[)>> 8."P, 161 10610 I (~fO ]H12 ]00 \6\ \};{)i4 % ASSESSMENT PADDED BOARD SPLINT APPLIED TO R]GHT KNIT VITALS 097065 CREW ~)97065 ENROIJTE HBG Copyright. 2000 Med~Mcdiu. All Rights Reserved Page: lof2 Provide! Pennsylvania EMS Report t(QJf>~ Service Name Unit No. peR No. lnate Lower Allen Township EMS 2100901 0310521 07/20/2003 Patient Name 1 Date of Birth Social S~curity Number I MCC 1 Medical Command Physician T AKENY A WATSON EARL Y 12/0511991 209,72.9709 , Q W ~ Q Ul N ~ QO W ~ Q QO QO N ~ Copyright. 2000 Mcd-Medi<l. ;\11 Rights Rtscrved Page: 2 of2 Provider Lower Allen Township EMS Patient Services Charge Form t(Q)~V Trip Number: Patient Number~ Add ress: CitylStatelZip: Phone: Member: 0310521 Patieut Name: TAKENY A WATSON EARLY Date: 0712012003 230 N 2ND ST STEELTON, PA ]71]3 (7] 7) 985,1991 No Date of Birth: Agle: SSN: Sex: 121051199] ]] 209.72.9709 Female Insurance Information Copyright. 2000 Med-Media, All Rights Reserved Page: ) of 1 1 \,~ '> PINNACLEHEALTH !ll4 Hospitals JPHY51CIAN L~EL Of CA,"RE' 0\ 0 N MED. EMER. 0 y OIl Ov ON , 0111 0 ClitlCill Cat!:! 0 A .... MEDICAL RECORDS TIME OUT; o FIRST PLACE WATSON EARLY ,TAKENYA '(:IS..,-"r:,'--<::}'7I?\'::"l Non-ED Physician: DAher Hours. D Private Attending '~vY~ v~~ ~.I.I.ll VITAL SIGNS AT TRIAGE V11 AL SIGNS IN DEF'T BP ~HYSIC'AN'S REPORT (HPI. IMPRESSION... TXI DYES D DENIED 0 AUTHOFul./l.T10N<< I~~~ ROOM ASSnCI MEDICAL RECORDS REQUEBTED ,F ACCiDeNT. WHERE OCCUAREO j::, C. PER PT j$FGNIFIOANT OTHER FAMfL Y PHYS,ICIAN 'riME IN DEPT BAl. TZ R I CHAI,1I D \, pOllee NOTlf"lEO BY FAIR 0 PooA 0 CRITICAL 0 DOA --10 YES 0 NO p A T ALLERGIES: Ntl:OA. SEE NURSES N TETANUS: ,.5 YEARS, <5 YEAAS. OT ,- I U W fr H- " H- .J " Ii M J I CONSULT 0 NAME TIME ./ DK;T A fED ....n - . TIME , ROOM'" llAGNOSTlC IMPRESSION r..:- ( /'lC- ) I .~' ., r~RVICE I MQ B~ I [JSCH TIME I :Oll.OW-UP CONOITlON ON D1SCHAAM \ 0 ADMITS o TRANSFER REFERRAL S , I I OTHER f'HYSlClAN'S ASSISTANTIMEDICAl STUDENT E.O. f'>HYSlC~_ OTHER LAST 015. DATE , -k.., _ IESIDENT PRIVATE f'HY~C1AN Nl,JRSE LAST ER REG GUARANTOR NAME GUARANTOR EMPLOYER INFORMATION Wr:1TSnN .m NOT \:111'I..C'II. [c HOME"71 ",l'-'J85--19,,'jlwoRK ... ,. NOTIFICATION NAME wAT:~nN , SH(~RO~.-' PA,TlENT EMPLOYER INFDRMATlON !HOME71 7-'''2-3t:.-ill1 '33wORK 717., .. CHIL.D tiOSP SERV I AREAS TO VISIT DIAG. CODE RELIGION HEP I I NON i PATIENT # I DATE TIME I AGE DATE OF BIRTH I S M R SOC",l SECURITY. I prr Fie I MEDICAL RECORD# T'ooc r~'f<;'" 1 f, 7 ~~TIE~~~~~: ~N~~~DO~:S~ 0:41 \1 ~_i:: '05/'31 IF S A 2:Ql'37c~'37IZiSlr E: DI ,':0972:'3709 1001' INSURANCE CO, NAME GROUP NO.1 POLICY NUMBER SUBSCRIBER NAME ;WATSON E~RI_Y ,TAKENYA 5')1/1 / I3ATEWAY H I ;::::i::~2et 10 t 3 WATSON ERRI_ \ I ':~:'::\IZ1 l'-J ::~ND ST STFFlTON , I '_"1' "_?', j-':; , ImMF71 7"3fle,:';' 3'3 [ W~" .. .. LUJ41l (Rev, 2103) JSHnnl.. Date Time LEVEL OF INTENSITY (LOn: (Plea.e complete. Level of Intensity Order FOrnI for ally LOIII.V) ALLERGIES: Procedures I Lab X-Ray SUDDlies . . OCardiac Monitor Time I Initials: OHIV Tjmellnitials: '-'1f},1 rl~ OECG OABG o Lipase Portable: DC-spine 'OCXR OPelvis ONas~stric tube o Acetone o PTlINR Spine: DC OT DUS OFoley atheter o Amylase OPTT o Ankle OStratght Catheter o Basic Metabolic Profile L R o Knee L R DV: o Cardiac Panei o Qualitative HCG OCXR OKUB o CK - Total o Quantitative HCG o Elbow L R o Ob Series o CK ' MB o Repeat Cardiac Iso o Facial o Pelvis o CK - Relative Index o CK - Total o Femur L R o Ribs L R OCh_ LPM o Troponin I OCK.MB o Finger L R o Shoulder L R DPuise Oxime--sy- OCBC o CK - Relative Index o Foot L R~" ~ DPeak Flow o Complete Metabolic Panel :JTroponill\ D Forearm L R Tib/Fib []Aerosol Treatment: o Electrolytes o Rh Factor D Hand L R Wrist o ETOH DRPR DHip L R D Glucose D Type and Cross D Humerus L R o HEtjatic Panel o ape and Screen o Naaal DH H o nnal sls : DRUG L: SPECIAL STUDIES: o Blood CullUre x_ o Herpes o Acetaminophen o Phenytoin OCT: o Chlamydia o Sputum o Aspirin o Phenobarbilal OMRI: .0 GC culture o Throallstrep o Carbamazeplne o Theophylllnll o Ultrasound: [j GCIChiamydia DUrine o Digoxin DUrine DVenogram: (gene amplification) 0 Wound:_ D Lithium D Valprolc acid DVenous Doppler. DV-Q Scan OOlher: n.... Time Addition-I Orders: ~ Physiclan's signature: _ (, Patient tdentific:ation ~) PINNACLEHwTH 11.1.1111111 Hospiul~ EMERGENCY DEPARTMENT PHYSICIAN'S ORDERS M'R: 209729709 CASE: 240016720 W.A TSON EARL Y , TAKENY A F IUIIIIII.I O,o.TE: 07/20/03 OOB: 1210S/1991 PhI: 717985.1991 AGE, " DR: SSN: 209729709 1"..... I.... t'" Form ur42-20{08I02) MA jPMI Patient Name: WATSON EARLY ,TAKENYA Room/Bed / pt# 240016720 Home Address: 230 N 2ND ST City: STEELTON St: PA Zip: 17113 Sex: F' Age: 11 Med Rec#: 209729709 DOB: 12/05/1991 Home Phone: Work Phone: Soc Sec#: 209-72-9709 Contraindications Type Description .; NKA Reaction NONE Sev Date Found 07/20/03 Type: 1~Drug, 2~Food, 3~Misc Allergy, 4~No Known Allergies Severity: 1~Severe, 2~Moderate, 3~Mild Allergies previously entered in Patient Profile. Please update contraindications. NKA Date of Pneumonia Vaccine information from previous admission: Date of Flu Vaccine information from previous admission: ALLERGY IDENTIFICATION FORM PERMANENT CHART COPY 17:24 07/20/03 FROM P1B8,ALLERGF1 1<SPT1668 Pinnacle Health Emergency beparfmem Report 71201200317:43:51.49 Page: 1 Patient Name: Patient DOS: Date of Service: TAKENYA WATSON EARLY 121511991 71201200317:24 MRID: Visit 10: Sex: 209729709 240016720 F EMS REPORT: . 17:36 Unit: lower Allen Township EMS Condition: Alert. Vital Signs: BP:112160. P: 100. R: 16. Palpable pulses. Interventions: Splint applied to extremity. Cervical Spine Stabilization: Piaced On back board. TRIAGE. 1739 PRIMARY ASSESSMENT: Airway patent, spontaneous respirations not labored, pulses present '~nd strong. CHIEF COMPLAINT: 11 year old female patient arrived by ambulance. Injured her right knl!!e that began minutes ago. Patient reports: 315 -- severe pain VITAL SIGNS 7/201200317:41:00 BP:127/48 T:36.50C P:88 R:16 CURRENT MEDICATIONS: None. ALLERGIES: Nkda MEDICAL/SURGICAL HISTORY: None. Last tetanus vaccination was less than 10 years ago NURSING DIAGNOSIS: Acute Pain TRIAGE ACUITY: 3 Urgent TRIAGED TO: Main ED Patient was taken via litter to department. - Genia Greenland RN 17:43 Electronically reviewed and signed by: Genia Greenland n 712012003 Results WATSON EARLY ,TAKENYA F 11 i,tn Dr: EMERGENCY ROOM ASSOCI Adm Dt: 07/20/03 EA / PT ACCESS Isol: HER Pt#: 240016720 Mr#: 209729709 --------------------------------------------------.------------------------------ val/Obsv Code: Abnormal Ind: Critical Ind: Order No: Normal Desc: Comment: EMERGENCY RP Date/Time: 07/23/03 13:25 Body Sit.e: Body position: Problem No: Goal No: HARRISBURG HOSPITAL 111 Sout.h Front. Street. Harrisburg, PA 17101 EMERGENCY DEPARTMENT HISTORY: An 11-year-old with complaint of pain in the right knee, The patient and her sister were apparently riding in a golf cart today. The golf cart rolled and the patient was on the passenger side of the vehicle, she put her leg out to try and stop, She comes in complaining of pain and discomfort to the right leg, She apparently was not. able to get and ambulate following the incident because of leg pain, She denies any other injuries. The patient has no significant past medical or past surgical history, No current or chronic medications. On Review of Systems the patient denies any headache, denies any neck pain, denies any chest or abdominal discomfort. Denies any upper extremity discomfort. PHYSICAL EXAMINATION: The patient is awake, alert, She is pleasant and cooperative and appears to be relatively comfortable when lying still, She is quite uncomfortable, complaining of leg pain, when moving. The skull is normocephalic and atraumatic. There were no raccoon eyes or Battle signs, no rhinorrhea, no otorrhea. No facial bone tenderness, Pupils equal, round, reactive to light and accommodation. Extraocular muscles intact, The cervical spine is nontender with a full range of motion without restriction, The thorax and abdomen are atraumatic, Upper extremities have a full range of motion with no focal bony tenderness, Left lower extremity is unremarkable. Pelvis is stable, The patient is tender to palpation at the right tibial plateau. There is no obvious deformity. There is just a small joint effusion, TREATMENT: X-ray of the right knee, right tibia and fibula were obtained. There is a right tibial plateau fracture. DISCHARGE INSTRUCTIONS/FOLLOW UP: Consultation and transfer of care to orthopedics. DIAGNOSTIC IMPRESSION: Fracture of the right tibia. c: REVIEWED AND ELECTRONICALLY SIGNED BY: R. SCOTT RANKIN, DO 08/18/2003 08:22 R. SCOTT RANKIN, DO ~~==~~=~=====~~~~~~~~=~~Text Continued on Next Page~~~~~~~~~~~~~~~~~~~~~~~~ 16:22 10/31/03 FROM @01E,ZRPRTGF3 PMN43040 Results WATSON EARLY, TAKENYA F 11 .c,tn Dr: EMERGENCY ROOM ASSOCI Adm Dt: 07/20/03 EA / PT ACCESS Isol: HER Pt#: 240016720 Mr#: 209729709 --------------------------------------------------------------------------------- Val/Obsv Code: Abnormal Ind: Critical Ind: Order No: Normal Desc: Comment: EMERGENCY RP Date/Time: 07/23/03 13:25 Body Site: Body Position: Problem No: Goal No: Patient: Takenya Watson Early DD: 07/20/2003 DT: 07/23/2003 /lc D#: 1236741 ~~~~~~~~~~================~==~=End of Report~=,.,.~~~~~~~~~~~~~~~~~~~~~~~~~~~ 16:22 10/31/03 FROM @01E,ZRPRTGF3 PMN43040 Page of PrDCll<lures ona OEG O~: O~ iJ X-Rey 0 BC1:_BC2:_ (reference see back) :JeT. DUlS' OASG ::J BGM (70-110)_ 0 Hem~vtt(-): 0 GaSlTOCCUlt(-), QIl.1EITIl.IE, {)f\UG DOSE ~OUTE SITE INIT .- OATF!TIM' I T I IT lD....mme BP P R I n 2.-< /...,i.V~ 11<;\ 1-, ,l? "'('z, l~ QI\LU\ ITl;/J P ~ 1)1- - V A. J J.. A' _ _L A .JIJ.~ 11_ ~ _ --'<----- I~o 11..[ L (,V#/ /1/1./_.1. i /" '" .u.~ <..: PI- ~ '/ W. c.;, , I. "., ,+, ~ ,~~ J\,.-A-;" ,...f~...(T II" \.~..,,, ....u...., /" 'T / / / ~ / ~ I,,,", A \ I/"( 'V .........-..... \ 'JI' / 1/ ;-- / n "\ r- ..-7 1/.../ rl _I. 1,.1/,.." ,I 1/ "T' I / / 1/ /" 1/0 ~ / NARRATIVE I'...... ~o~" 1/ _' ..hY "q/ ~ ~-<I r-/,,- -, ~. c"'O:;P; ~,w~/ rod-u..-..." , -n-w-' >=>1 ~"'. . "205 ;/..... 1~6r;." ,_ -..7/ jf PtIF~milv ""rbaliled unders18ndina c~f discnarae instructions. <FT. ^ , / h"::"/.-,..I ~ H.-Yh A..<,."d.L-J 7JltJvn 1//Y.Jt- ", DI.~ InitielslSlgnature " Y/' ll....- rJ Admitted Physician: Admissions caKed: Becl#, Time: Report called by:_time:~'a:_ Md. To Bed: a e. Monilor:D Yes 0 No Mode: D WC D Stretcher 00 Discharged o Transferred (lee trlll'l9fershHr) - .oA i:.; .j~ E1):j'\- "Z) .J f:\.l... CY In Ine care of: 'rvc.-.,..,.'1 11\ ft.))! o Ambulatory 0 Ambulanco It we rJ Carried ~l Other: ~) PINNAClEHEALTH ~ Hospitals EMERGENCY NURSING FLOW SHEET CONTINUATION PATIIENT IDENTIFICATION 11.1...11111 1''' /11111111111111111 MR: 2011729709 CASE: 240016720 WATSQWEARLY,TAKENYA F DATE: 07/20/03 DOS, 12/05/1991 Ph#: 7'17' 985,1991 AGE: 11 Forml~V ?4tl3 losr.zcoalMR (PM) (FO<m.rly!;l401-56Bl DR, SSN,209729709 _....~'_..........~_._-- - "'.....-----._-~-........'.,.........~ .- '---'''I"!'"nrr Vlfll'\l ,~-,~-," ..----------'----'.'~-- o 2. 03. . . '-- '. ,J4. t~~t o "1 ) , 'I' ~~ o '-, ". ~ri!;bUrg ED 782-5257 t, '"' '. ... ". '.... k ...... Pleaa, note that the Instructions circled or chec ed below pertain to !fou. @7/tf;.. 6 ,'-, CGOH ED 657-7295 You have been discharged with the diagnosis 01 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 medical care, II you develop problems and complications, contact your physician or this Emergency Department. r----------------------------- I ~\.. Dot :;;/I"/cB I ~, P1NNACLE=H · . I I I I I I I I I I I I I I Emergency Dep.rtment P.O. Box 8700 Hamsburg, PA 17105,8700 /' 1 I - , ..---r 1/". # l' ... -//1-f'.PJ- - ,-. / / ?- hk ,;;(!)Jj)1r--- /' -iI,,}J ,~ \ ./ .~ ~'l .T'~C:':__~~/::':"/l./ ...... ; l~ ORO!:R FOR A BRAND NAME PRODUCT TO BE DISPENSED, THE PRESCRIBER MUST WRITE "BRAND NECESSARY. OR .BI~ANO MEDICAL L Y NECESSARY. IN THIS SfJACE General Inetructlone Resllor Off work / school from Retu m to work on Light duty for Follow-up Care 1 Return to the Emergency Depertment immediately if unexpectedly worse or not improved, Emergency Department on Family Physicien See Dr. to Diet force ftuidu_ soft diet_ clear liquids_ as tolerated Supplemllntallnalnlctlons Sheet CI Yes Medlcationlsl 7' .,0 ~," / 'f. / 11.fU c: . ~~u-",-, on ~M"c.llan~o,u::, , . ~ Ji ," _, .~~ -'< - /. ~;"'1.1;~.~ ." ~ t,/tJ , ' Regular duty I hereby i1cl<nowledge receipt of these Instruetions. that I have hod emergency treatment only, and that I mey be released before all my medical problems Bre known or treated. r will arrange for follow-up care as I have been instructed. x\ UJ"TL1'1 1Jzo/n') SI~~8'IUre~~.~1 or Reapon!llble ~~n 0.. V ,,< _ 7/~4J R.N, Signature Signllture Hln1obu'll ' 782.5257 CGOH,657,7295 "1>1 5. C~1l for an appointment w' in following Clinic: 7hl-5'l3L) _ Adult Outpatient. Community Hea~h Center, 4th FI (782-6421) _ Surgical Clinic. Community Hea~h Center; 4th FI (782-6421) _ Orthopedic Clinic, Commun~y Health Center. 4th FI (782.2142) _ Chiklren 1\ Teen Center, Community Healtl1 Center, 2nd FI (782-4650) Womens Outpatient Hearth Center, Community Heatth Center 3rd FI (782-'1700) _ Kline Family Practice Center. Landis Bldg. 2nd FI (782,2100) at AM/PM hours / days to the .M,D., 0,0 /1.1.111..,1 ~) PINNACLEHEALTH ~ H~itab "I MAY REFILL ~.,/ TIMES PA Lie' /;>YJ4'?/&2Q OCANa ,,4,v/)<VB 22. o 11111111.1 Laboratory Inatrucllo08 Call for results of pending lab tests. X-Ray Instructions Your x-rays have been read by the Emergency Physician. If any abnormalities are found that have not been called to your attention, you or your doctor will be called immediately. Sometimes, fractures or abnormalities may nol show up on x-rays for several days. If symptoms persist or get worse. call your Physician or return to the Emergency Department More x-rays may have to be taken. 8 Subst"ution Pennlssib.. Mfl: 209729709 CASE: 240016720 W...ITSON EARLY ,TAKENYA F DATE; 07/20/03 008: 12/05/1991 Ph#: 717 985.1991 AGE: 11 DR: SSN:2D9729709 F(rm IN\' 29CXl1 ('2102) MR (PM) First copy - PldLlint hcond eopy . MecHeal Record. Thll"d copy . E.D. Record Emergency Department Patient Inetructlon Sheet / .....~,.,~., ,,' _r,. .. "' . )' (.,'/" t " ".,,-../~;~-'f/J PRINT PHYSICIAN ~E LABEL ALL PRESCRIPTIONS Results WATSON EARLY ,TAKENYA F 11 Atn Dr: EMERGENCY ROOM ASSOCI Adm Dt: 07/20/03 EA / PT ACCESS Isol: HER Pt#: 240016720 Mr#: 209729709 --------------------------------------------------------------------------------- Val/Obsv Code: KNEE 2V RT Abnormal Ind: Critical Ind: Order No: 2001 Normal Desc: Comment: ***Final Report*** HARRISBURG DIAGNOSTIC DEPARTMENT EXAM: DATE: EXAM: DATE: 90001 Jul 20 90001 Jul 20 TIBIA FIBULA RIGHT - DIA - 1271 2003 5:49PM KNEE 1 OR 2 VIEWS RIGHT - DIA - 1264 2003 5:49PM Date/Time: 07/20/03 17:49 Body Site: Body Position: Problem No: Goal No: RIGHT KNEE AND RIGHT TIBIA AND FIBULA 1755 HOURS HISTORY: Pain after a fall from a golf cart, RESULT: The medial proximal right tibial epiphysis appears widened. There is no definite evidence, however, of knee joint effusion, There is no evidence of fracture, otherwise, CONCLUSION: There is questionable widening of the medial proximal right tibial epiphysis. Two confirm this finding, comparison radiograph of the left knee could be obtained, or alternatively, followup films could be obtained in several days, D: Jul 21 2003 7:38AM RPM/ams T: Jul 21 2003 1:49PM / AMS DICTATED BY : RICHARD P MOSER, MD ELECTRONICALLY REVIEWED: Jul 21 2003 3:51PM PMN45382 ===============================End of Report=============================== 10:28 11/12/03 FROM @001,ZRPRTGF3 Re.sul ts WATSON EARLY ,TAKENYA F 11 Acn Dr: EMERGENCY ROOM ASSOCI Adm Dt: 07/20/03 EA / PT ACCESS Isol: HER Pt#: 240016720 Mr#: 209729709 --------------------------------------------------.------------------------------ Val/Obsv Code: Abnormal Ind: Critical Ind: Order No: Normal Desc: Comment: CONCLUSION: There is questionable widening of the medial proximal right tibial epiphysis, Two confirm this finding, comparison radiograph of the left knee could be obtained, or alternatively, followup films could be obtained in several days. KNEE 2V RT Date/Time: Body Sit.e: Body POE:ition: Problem No: Goal No: 07/20/03 17:49 2001 D: Jul 21 2003 7:38AM RPM/ams T: Jul 21 2003 1:49PM / AMS DICTATED BY : RICHARD P MOSER, MD ELECTRONICALLY REVIEWED: Jul 21 2003 3:51PM PMN45383 ===============================End of Report=============================== 10:28 11/12/03 FROM @OOl,ZRPRTGF3 CONSENT FOR TREATMENT ~) Harrisburg Hospital 111 S. Front St. Harrisburg PA 17101 07/20/0~ 209729709240016720 WATSON EARLY ,TAKENYA F 1?/05/19~1 00193 Ili..IIIMII CONSENT FOR TREATMENT, I consent to the rendering of medicel care, which may include diagnostic procedures and such medical treatment as my attending or consulting physician considers to be necessary. I also understand that, absent emergency circumstances, no invasive or experimentel procedure will be performed upon me unless or until I have had an opportunity to discuss the procedure with my physician and give informed cc,nsent to the procedure. I understand that the practice of medicine end surgery is not an exact sciance and that diagnosis and treatment mey involve risk of injury or even death. I acknowledge thet no guarantee has been made to me ragarding any examinetion or treetment in this hospital. PRE.CERTIFICATION REQUIREMENTS- If my insurance company Of third'party requires pre,certificetion, then I understend that it is my responsibility to contact them to ootain such certificlltion. EXCEPTION: Medicare. ASSIGNMENT OF INSURANCE BENEFITS, I hereby authorize my Medicare andlor medical insurance benefits payable to me under the terms 01 my insurance policies to be paid directly to Pinnacle Health Hospitals, If my attending physician andlor other physician associated with him or whom he may designate accepts insurence assignment, then I hereby authorize my Medicare andlor medical insurance benefits to be paid directly t" those physicians. I assign any and all legal rights that I have to collect benefits to Pinnacle Health Hospitals. I understand that I am financially responsible for non-covered services, as well 88 any deductibles, coinsurance or 8mounts in ,excess of insurance benefits. ( permit a copy of this authorization to be used in place of the original. GRIEVANCE APPEAL CONSENT. I hereby authorize Pinnacle Health Hospitais to act on my behelf in requesting a reconsideration of a medical determination made by my managed care plan or utilization review entity regarding my medical care, ADVANCE DIRECTIVES-INPATIENTS ONLY. I understand that Pinnacle Health Hospitals will provide me with written Information regarding my rights to make health care treetment decisions in compliance with the Patient !,elf,Detarmlnation )S;ct of '-990. This information will be provided in the Patient Handbook. MEDICARE INPATIENTS ONLY. I cartify that the informetion \liven by me in alPplying for payment under Titia XVIII of the ilocial Security Act is correct. I aCknowledge that I have recelvad a copy of .,!I,n Important Message from Medicare". My Ilignature acknowledges my receipt of this messege from Pinnacle Health and does not waive any of my rights to request n review or make me liable for any payment. I reafize that lifetime resarva days are a once lifetime maximum of 60 days. If I should use all my full days and cO-Insurance days, I agree to use my lifetime reserve days for any remaining days. /1 v.r:L, PRIVACY NOTICE, i acknowladge that I have receivad a copy of Pinll8cle Haalth System's Privacy Notice V,41 PERSONAL VALUABlES. Pinnacle Haalth Hos!?ltals is not responsible for personal Items brought to the hospital. hnlt) A safe is available for veluables such as cash, 1m portent documents, medit cards end jeweiry that can not be sent home. All personal items retained et the badslda are the sole responsibility of the patient. , ,d::[ TELEPHONE AND TELEVISION, I understand thet there is a $3 per d"y chsrlle for the availability of telephona V' Ilni'l (local calls only) and talevision service as these servicas are not covered by ",surance. This amount will be charged to my home telephone bill of which I am authorized to accapt charges and allow the release of only thet information to the telephone company that is necessary to bill for those services. PATIENT ANONYMITY - (Facility Directory Opt Out for Patients in the Emergency Department and Those Assigned to an In,House Badl ' I have requested Pinnacle Health Hospitals to control the knowiedge of my identity and presence during this course of care only. I ecknowledge that the Pinnacle Health Hospital's P!ltient Anonymity PoliCY has been explained 10 me and that I have been provided with the guidelines. , l~ignBture of Peltient or Legel Representati....e Date Signed CONSE T MUST BE SIGNED BY THE PATIENT'S LEGAL REPRESENTATIVE IN THE SE A OR. OR THE PATIENT IS PHYSICALLY OR MENTALLY INCAPACITATED. 7 '4,() .~ ete S\gne Printed neme ot L6Qe\ reptesent8tlVe and Rel8tlOnshlp to Pattent F',atlent is unable to sign because: ~~)" n:s&o , Form INV 9790 (04/2003\ MR 1S3~ H08pltal Repre&entatlVe MEDICAL RECORD Form 502 ORTHOP"l.lIC INSTITUTE OF PENNSYLVAJ),~A (717) 761-5530 Patient: Takenya M, Watson Early DOB: 12/05/91 SSN: 209 72 9709 Chart #: 22015806 Page # 1 7/22/2003 JOHN R, FRANKENY II, M,D, OFFICE VISIT Powers !tvenu"-0liic~ CHIEF COMPLAINT: was at a company that upset. As you may know, she is a very cute ll-year-old girl who picnic with relatives when she was riding in a golf cart HISTORY OF COMPLAINT: She twisted her right knee. This injury occurred two days ago. She was seen in the emergency room and placed in a knee immobil,zer and presents for follow-up care. She was told she had a fracture. REVIEW OF SYSTEMS: Review of systems, past medical history, family history and social history have been recorded and reviewed. PHYSICAL EXAM: On examination, she has tenderness and swelling around the proximal tibia. There is no calf tenderness or swelling. She has soft compartments. Her skin is intact. DIAGNOSTIC TESTS: Outside x-rays reveal a minimally displaced fracture of the proximal tibial physis. There is slight valgus openIng. IMPRESSION: Proximal tibial physeal fracture. PLAN: She was placed in a varus cast in order to realign this fracture. It is a long leg cast and she will be in it for 5 weeks. They will bring the knee immobilizer at that time so she can begin weightbearing in the knee immobilizer at the next visit. JRF/krt LTR-DR, FRANKENY CORRESPOND (Ref) SZADA, M.D., MARYJO 8/26/2003 JOHN R, FRANKENY II, M,D, OFFICE VISIT Powers Avenue Office CHIEF COMPLAINT: Takenya was seen today for recheck of her right leg. PHYSICAL EXAM: Upon removal of her cast, her leg is in Slood alignment. She is neurovascularly intact. Her compartments are .soft. DIAGNOSTIC TESTS: Recheck x-rays reveal excellent alignment of the right tibial fracture. IMPRESSION: Status post tibial fracture right leg with casting PLAN: A knee immob,lizer for weightbearing as tolerated therapy and she will be rechecked in four to six weeks. ,f she is ready to return back to gym class. She is off to I will decide then ORTHOP8DIC INSTITUTE OF PENNSYLVAJ:.JIA (717) 761-5530 Patient: Takenya M, Watson Early DOB: 12/05/91 SSN: 209 72 9709 Chart #: 22015806 Page # 2 8/26/2003 OFFICE VISIT JOHN R, FRANKENY II MD -CONTINUED- _. - JRF/skb cc, Maryjo Szada, M.D. faxed RADIOLOGY RESULTS RIGHT LEG X-RAYS, Recheck x-rays reveal excellent alignment of the right tibial fracture. IMPRESSION, SEE ABOVE STUDY JRF/skb 9/02/2003 JOHN R, FRANKENY II MD TEL/MESG-MESSAGE TO CHART T Faxed a note at mom's request to Steel High attn, Carol Holoern stating she needs help to and from school transportation due to her knee being in a brace and trouble walking. /bam TEL/MESG-MESSAGE TO CHART T Note was faxed to Takenya's school for her to get help wIth transportatIon to and from school while she is wearing her knee brace. /bam 10/02/2003 JOHN R, FRANKENY II MD OFFICE VISIT Powers Avenue Office CHIEF COMPLAINT, Takenya returns following a right leg ::racture. PHYSICAL EXAM, She has full range of motion. There is no tenderness. She has normal strength and normal gait. IMPRESS.ION, Status post closed treatment tibia fracture right, doing well PLAN: I will see her back on an as needed basis. It has been a pleasure sharing in this very sweet young ladyls care. JRF/skb cc, Maryjo Szada, M.D. faxed ------------------------------------------------------------------------------- \, J,"l' ',~f'::. ! ' .- -' Da\~I'~ld-()2, T'me3:L\"'))r~~ ~~nc\\zorLl::l \1, ('l.:\ ~"',' r, -)\ -In \, n (J Patient Name "I '. :r ':'L~I \ - r'C" ( .,t! \ ,\ ,r,f' ("\ \ \ "- Address X(-) (l ~{\P 6 \iJ F J f'-'" \ ',\ S~orRlr.\lRou~ '-;-")T'::'L\Tcn "" Phone . O\~-=- \ q c\ \ HQrTlll - DOB \ d - :'J J~ \ Employer \:'\S Chart~ ~.::z-{J I,~ If \\1\ M' PF\ SO" n \\':) "p ;;JDQ-I,'3.-QlOO; S SS# Age "". ,\ Sex F Marital S\'3hJS Occupation Mother ",,\, <..~)O S'" 010 Sill.. .p .-- DOB Ch~<t; '} ~ W# - Employer Employer -~\\~\-... \J~-&~\\ OuB W# Spouse OOB W# Employer Child (School) _~I1.\\OI\. 'fJaMtI\.\Q;-..{ [ Responsible Party if Child Atternate/Other Contact Injury \,,\Q S ij Accident Description 6\ mv~ h\O Auto~ 0 Work Relaled NO . \\ ieI\c..~~ .... 1;-IAlla, \ 1\ l Date of Symptoms first appeared jf not injury INSURANCE Primary C-:>C0-fJAJO l.: .l U Secondary NrX\jE Address Address ~ ~ \'\jO\"I.- Q" \ c " ,\ II.{' <....) VlSv\ ) GJUUp #; Group # POlicy # J) 'd. (j \ (~ \S Subscriber's Name ~ .cJ~~ \ POlicy # Subscriber's Name Address Address Family Of. ~l-; l ;:rV\Df\ Referring Dr. ,~ ~ ,\0 Address Address Send letter 10: Family Dr.~_ Referring D~_ Neilher \"-~,su.d S PJ'i..~ /0 ~ .~ CP -- ---n [<-. 7- ?SJ ~ 6' 6- c! ~ :) q ~ HEALTH HISTORY 1/2 zj~Jd~ ?,~ 03 eI IO,.l. .cac...u The following is very important to us in taking care of your health. Please take time to completely and accurately fill out all of this information. Please also make sure you update this information as changes occur. Patient's N_a~.-\(). '<..s! ~ \:5'- \ ~ ~')~ - ewl ~ ~ Medications YOlI:Are_Taking (Also list herbal supplements and vitamins) Medication Name Amount Freauencv ;i":.,, Are you taking diet medication? No_ Yes_ Allergies (Drugs and Other Allergies) Penicillin Local Anesthetic N~'Yes _reactio~i~;" ~ Yes -reaction (xylocaine, novocaine) Other Allergies Hospitalizations (List serious illness and injuries or operations and approximate year.) ~ Serious i11ne~s injuTV or sur2:erv Hosnital Chart Number ~ ISS Past Medical History Have you or membe:rs of your family ever beed told that-any of you have: Your You Family Describe Anemia [ ] [ ] Asthma [ ] [ ] Abnormal Bleeding [ ] [ ] Blood clots / phlebitis [ ] [ ] ,Cancer / tumor [ ] [ ] "Diabetes [ ] ~] (''':',nnQ ",",c,+1Al'r- ,,", , Drug abuse [ ] [ ] Eczema I psoriasis [ ] [ ] 'Epilepsy / seizures [ ] [ 1 Heart Condition [ ] [ ] ; High or low blood !pressure [ ] [ ] , Liver disease / hepatitis / yellow jaundice [ ] [ ] Kidney / bladder problems [ ] [ ] Lung disease [ ] [ ] Prostate problems [ ] [ ] Stroke [ ] [ ] Thyroid disease [ ] [ ] Tuberculosis [ ] [ ] Ulcer in stomach / duodenum [ ] [ ] Osteoporosis [ ] [ ] Arthritis [ ] [ ] Other bone / joint disease [ ] [ ] Any nervous systern disease [ ] [ ] Height ~'y Weight \ \ 'J Social History Do you smoke? Do you drink alcohol? Do you use street drugs? N"O--> Y os No---. Yes= m--., Yes_ Amount Amount Amount Continued on back of page. . .. . . . . .. During the past year, have you had: I heartbumor indigestion'!................................................................... 2 bowel movements that were bloody or tarry'!..................................... 3 any recent change in your bowel habits'!............................................ 4 frequent urination during the day or night'!.......................................... 5 any receulless.oLeontrol of your bladder'!......................................... 6 h . . h . .''1 ul1Hng WIt urinatIon. ...................................................................... 7 difficulty starting your urination?....................................................... 8 excess; 'Ie urination?...... .... .... ................... ....................,......... ......... 9 excessive thirst?... ........... ............... ............. ............... ........ ............. 10 shortness ofbrealh or wheezin~?....................................................... 1 I chronic cough?................................................................................ 12 chest rain withaclivily?................................................................... 13 . hi' .' 'I racmg eart or pa pllatlons, ............................................................... 14 swollen feet or ankles?..................................................................... 15 (regucol headaches'! ....................................................................... ]. 6 <Ii fliculty hearing? ............................................................................ 17 dental or other mouth problems?.........................................,........,.... ],8 frelj'lent nose bleeds? ... ........ .....................,...................................... ],9 easy bruising? ....... ...... ...................................................................... 20 ski n rashes'!................................................,........... ..... ........... .'........ 21 aching muscles or joints? ................................................................... 22 swol I en joinls'! ....... ...................... ..... ................................... ............. 23 co Id hands.f feet'!:............ ............ ............................... ........,............ 24 go n grene?....................................................................................... 25 loss of consciousness? .................................. .................................... 26 recent numbness in arms or legs?...................................................... 27 chronic fatigue? ..... ... ............... ..... ............ ........................... ....... ...... 28 uncon trolled bleeding?. ........... ,..., .,..........,................. .............. ...... ... 29 weighlloss?. ..... .... ........... ... ....... ................ ....... ..................... ......... 30 weight gain? ...... ....... ........................ .................... ........................... 3 I heat f cold intoletnnce?..................................................................... The above information is truc and correct to the best of my belief, Patient signatllre~~-\ )J~ }1> Yes - ~ Yes - N~ Yes N~ Yes - ~ Yes - No Yes ~ Yes - No_ Yes - ~ Yes Yes ~ - Y~s__ ~- Yes - ~- Yes - ~- Yes_ ~. Yes - Yes - N~ Yes ~ - Yes Yes - Yes - ~ Yes ~==- Yes - ~ Yes Yes ~ Yes - Yes ~"- Yes ~ Yes ~ Yes ~ Yes Yes - Date '1. - ~d.- O.j ORTHO~JO:DIC INSTITUTE OF PENNSYLVMIA (717) 761-5530 Patient: Takenya M, Watson Early DOB: 12/05/91 SSN: 209 72 9709 Chart #: 22015806 Page # 1 --------------------------------------------------.---------------------------- 8/26/2003 JOHN R, FRANKENY II, M, RADIOLOGY RESULTS -, RIGHT LEG X-RAYS, "Recheck x-rays reveal excellent alignment of the right tibial fracture. IMPRESSION, SEE ABOVE STUDY JRF/skb -Jp'k...f\~k;~IMJ"D E55534 V --------------------------------------------------------------- - '-..--- \ . / / ... ---_. :D ~{;:d . - )> m jl ~~i~;~i~ '" :1 ~6 0 ~ r= .. )>:tl 0 ""' ~ r. Z", :D m ~~ "'m m Z c""';o m~ -1 , z'" (f) --l :l>"':tzj;I ~ ~;l -< P;:t.:: en <Ii ;r::",~. ~. !-~ ~- m ~oz.o' oCllg 0" (f) ~'" t s7'~~i~' ,,\3 0 ~> r-. ~~~ r!: "'''' ",'" g9-<r.-<i.1~b "" -<'" m ",0=- 3:" . . ~O ,> .~. 3:~b~9 ~" Z ~ OZ a op" 9 ]'l'1~ 0 ",'" . ~." ;; . " 0 .z "''' ",> ". ~i: 0 "';:: ." ". >m j:Il~ ,,~~ ~ z." t;:;i:;{ "'''' "',..." :t: ;::0 ero 0 me:> SO:::~3:~3:3: e;~~ ." "'CO '" - " :i~~g~g~g . " " "''''' "'-'" >.... >>an c=; "_.~.--; ~o s:~2j8~~~ ::::;::::r: co m CII a....."',.." __ ,c Z zm r-mmr-mmm :;;~" m", l ~:gQ ~ " - m<n ~~" ::l <n ." zOO / ",m ot:!2> '" >z ;j :D<n ~;;.tj -< m ,'" i'ii-H"m~'-:Jl:OG) ",,," 0 i/./ Z:"--1 ",,,," .., "'5~~Fl;oo;n "ci: ~--lX ." s:2zmm ~,," ." // , , .~ ~~ ~~~~~f-5~~ -l"", 'i 0",- I ( ~f-' ;Ilr-c.;E;n-< ~:;Q1= ~ I >'" '.-<.:E~"'D:4C~;1> <0. '" ,,0> J11>~ I m:D ~~~lJl~~:gzl :;:; (J) I ",05 {):::r.- . mlTl ~S':::i . ~\ mm ?>~P:Z:3:' g", tn~O >' . r:D ~o3:m' :::.SIl . -l- :z '" '-....,/ 0;:: o' b~l::l993: t=5~"'" ;;:: r .... ~ c: . '. . o. .- 0 m~ 0 ~ :'t\" P -l '" l' ,. "'~ .... '" " tn'" tn S ,.. ~ x , '" ~" m > m " "'i: " Z m." :t '" ~ :< :to 0 ~ ~r z '" !" ::; ~~3:3:~~3:0~ -' ~ g,)t m ~;;;i~g~~~~ 8~ "l ~ - &. ~ _..... <.n~.l>.~~~ " ~ . ~ .. ,@ .... "'" at.> - ~~m<./'l~a>""NO> W mmmmrm 0 VISITATION ORTHOPEDIC INSTITUTE OF PENNSYLVANIA /' 875 POPLAR CHURCH ROAD, CAMP HILL, PA 170t I 3916 TR1NDLE ROAD, CAMP HILL. PA 17011 890 POPLAR CHURCH ROAD. SUIT!; 108. CAMP HILL, PA 17011 450 POWERS AVE., HARRISBURO. PA 170109 --------32 NORTHEAST DRIVE, STE. 201, HERSHEY, PA 17033 - TELEPHONE: 761-5530 00 R M?JGL PS:~ \c The above patient was seen in our office on -:Y I 2u I.. 0..3. Y The abo~nt is under my care and may return towork~])>n 2? I 617 / 02 . Limitations: / ~ M.D. 0.0, \( ---.... .,. ( ! , \ , , ,_...... ~ ----"'/~ C):J. O/5'i 3S" jO-d 3:30 - ..r-- /:. ~ :lIp. ORTIiOPEDIC INSTITUTE OF PENNSYLVA]~IA PUYSICAL TUEKAPY TELEPHONE: (717) 920.4950 FAX: (717) 920.4955 Initial Evaluation P~NlIme:TAKENYA WATSON-EARLY Date of Eval: 09/02/03 Date of Birth: 12/05/91 Age: II Sex: F Diagnosis: Tibial Plateau Fracture Involved Side: 0 Left .r Right 0 Both Date oflnjury/OD!let: 07/20103 Referring Physician: Dr. Frankeny Surgical Procedurl~: N/A Date of Surgery: N/A I SUBJECTIVE mSTORY ;;:,:;."" " Patient is an II-year old female who presents to PT w/a diagnosis of a (R) tibial plateau fracture. Patient reports the injury occurred while driving a golf cart when it tipped onto her leg. She was taken to the ER where x-rays were performed and were (+) for the diagnosis. She was given crutches and an immobilizer and instructed to use at all times. Patient continued use of these items until last week. Patient has a follow-up appointment w/Dr. Frankeny on 10/02/03. Currently, patient's chief complaint is L ROM of the (R) knee w/constant stiffness. Patient denies pain at this time. Patient reports discomfort is T w/knee ROM. Pain Ratin!!: 0110 currently, 6/10 at worst, 0110 at best. Functional Abilities and Restrictions: Patient reports difficulty squatting, kneeling and walking hills. OccuDational Work Status: Patient is a student. Social Historv and Interests: Patient is active in cheerleading, basketball and skating; however, is unable to do these activities 20 to injury. Past Medical Historv: Unremarkable. General Health: Good Medical Precautions: None Medications: None Patient's Goals for PT: OBJECTIVE FINDINGS Observation and InsDection: Patient presents w/poor quad and VMO tone. Mild pocket of swelling noted superior patella. Palpation: No tenderness elicited. Sensation: WNLs to light touch LE dermatomes. c-~ 0R1110P!:DIC SlJROtoNS. LTD. UARRISBURG OJllllCB 450 POWERS AVE. REAR ENTRANCE "'-SEP 1 e 20DJ -- -.-.... Page 2 Takenya Watson-Early Initial Evaluation 09/02/03 Girth: 1. R 10 cm above: 4gem 44cm 5 cm above: 42.5 em 40.7 em mid patella: 39 em 39 em 5 cm below: 35cm 35 em 1 Oem below: 37.1 em 36.3 cm ROM: 1.-------- -~ R 0-1180 0:"" 800 Joint Mobilitv: Patellar is normal. Stren!rth: - SI.enlith Left Rieht Flexion 4/5 4/5 Extension 4+/5 4+/5 Knee flexion 4+/5 4/5 Knee extension 4+/5 4/5 Gait: Patient currently ambulating w/(R) knee immobilizer w/o an AD. The above information represents all significant subjective and objective findings. Please refer to the enc{osed Plan of Care/or my assessment, treatnrent goals, and treatment plan. Please sign and return the Plan of Care to Orthopedic Institute of PA Physical Thenrpy. IfYDu wish, make a copy for your records Thank you for this referral I will keep you informed of any changes in the patlent's natus Dr the treatment plan. Therapist's Signature: Jami ~ Date: 1ft! 10 C, License #PT015482 /~ --~ /" d),utS! -3~ /oj?!3 3:Yb / a(~;Ip. ORTl10PEDIC INSTITUTE OF PENNSYLVAIiIA PHYSICAL TUERAPY TELEPtlONE, (717) 920.4950 FAX, (717) 920-4955 ------------- '~ DISCHARGE SUMMARY Patient Name: TAKENYA WATSON-EARLY Date: 09/29/03 DOO, 12/05/91 Dx. (R) Tibial Plateau Fx. Date of Evaluation: 09102103 Physician: Dr. Frankeny Last Treatment Day: 09/26/03 Total#: -Visits: 13 ,# ex: 0 '#NS: 0 GIl.:~l1I!el1tIDMt o i functional ability o iROM ,{ ! pain level to 0 - 1/10 at worst .[ Patient will present w/normal single leg stance on (R) LE > 30 seconds .r Patient will present w/normal quad and VMO tone ,{ Patient will be independent in HEP .r Patient will return to activities including cheerleading and basketball ,{ i strength of (R) LE to 4+ to 5/5 tlo I 'ft"a~~~fl!Q' o Insufficient Treatment time o Severity of Dysfundion o Patient did not keep Appts Met o o ,{ Partially Met o o o Not Met o o o Unable to Assess o o o ,{ ,{ ,{ o o o o o o o o o o ,{ o o o o ,{ o o Surgical Intervention Required o Rx discontinued by Physician o Treatment Ineffective- o Patient Non-Compliance o Other: o Other: Disclllit~!lbt~i\hi.." i.i:i!iP~iit .r Patient has received maximum benefit from physical therapy/has returned to normal, premorbid status at this time (patient concurs). o Patient bas met all or at Jeast 90% of discharge criteria (patient concurs). o No subjective/objective/functional improvement in pt's status within a 4 week or longer period ofPT (discussed wfMD prior to DIe of pt). o Rx discontinued by physician. o Patient missed 3 consecutive therapy appts OR 5 total appts WiD canceling or contacting the clinic (MD notified prior to ole of patient). o Unable to successfully contact patient in 3 attempts after patient did not attend therap)' for a full week (discussed w/MD prior to Ole). o Further treatment indicated but has not been ordered by physician. o Patient choice. o Other: IDiscJiargd'bm .r Patient is to follow a specific home exercise program (see Comments below) o Equipment has been ordered for home use (See Comments below) o Letter sent to patient to alert him/her of Die decision (MD authorized) o Otber: ~iscli'an~e' Proanosis ,{ Excellent 0 Good ACId I Comments: o Fair 0 Poor CommeDt5; :;_:~:'~t>;;,;\?;- HEP/Equipment: Patient instructed in continuing REP of ROM and strengthening exerc.ises. . Equipment; . Final Die Status: Pain 0110 at all times, no TTP, normal quad and VMO tone, normal AROM (R) knee, strength grossly 4+ to 5/5 tJo. Patient ambulating independently w/normal gait pattern. Date: -3J1o I t5?J . Charles, MPT ATC, License #PT015482 veT = 2 2003 Signature ofTherapis ORTH01'!:OIC SlJRQ~Ol'lS, I.TD, HA.RRlSBURG OIT'lCE 450 POWERS AVE. REAR ENTRANCE: CERTIFICATION The copIes of records for which this certification is made are true and complete reproductions of the original or microfilmed medical records which are in the offices of Orthopedic Institute of Pennsylvania. The original records were made in the regular course of business at or near the time of the matter recorded. The certification is given pursuant to 42 Pa.C,S. Ch. 61 Subch. E (relating to medical records) by the cllstodian of the records in lieu of his or her personal appearance, Patient: Takenya Watson SSN: 209-72-9709 DOB: 12/05/91 Medical Record No.: S\ ~{)/~f> Number of Pages : Dated:EI Ii I 0 ~ C..0\AA.~(" ~t.hv\A.R'- of Orthopedic Institute of Pennsylvania Subscribed and Sworn to before me this I.i day of fI/ 0 V ,2003. Notary Public ~;t ~.:JJ My commission expires on: NOTARIAL SEAL CATHY L. GINGRICH, NOTARY PUBLIC EAST PENNSBORO TWr.. CUMBERlANO CO. MY MMISSION EXPIRES APRil 2 2007 285915.1 ""~,,,"'"."'~'~"";-~~;t' ",,~-'" ;",,,,,..-, /''''' ,fi,f ..... Tp' ~~, ~.L ORTllOPEDlC INSTIT1JTE OF PENNSYLVANIA PIIYSICAL TUERAPY TELI\PHONE: (717) 920-4950 PAX: (717) 920.4955 Initial Evaluation Patient Name: TAKENYA WATSON-EARLY Date of Eval: 09/02/03 Date of Birth: 12105191 Age: 11 Sex: F nate ollnjury/On."t: 07120103 Involved Side: 0 Left .r Right 0 Both Referring Physician: Dr. Frankeny Surgical Procedure: N/A Date of Surgery: N/A Diagnosis: Tibial Plateau Fracture Patient is an II-year old female who presents to PT w/a diagnosis of a (R) tibiaI plateau fracture. Patient reports the injury occurred while driving a golf cart when it tipped onto her leg. She was taken to the ER where x-rays were perfonned and were (+) for the diagnosis. She was given crutches and an immobilizer and instructed to use at all times. Patient continued use of these items until last week. Patient has a follow-up appointment w/Dr. Fnmkeny on 10/02/03. Currently, patient's chief complaint is 1 ROM ofthe (R) knee w/constaot stiffness. Patient denies pain at this time. Patient reports discomfort is i w/knee ROM. Pain Ratin!!: 0110 currently, 61! 0 at worst, 0/] 0 at best. Functional Abilities and Restrictions: Patient reports difficulty squatting, kneeling and walking hills. Occupational Work Status: Patient is a student. Social Historv and Interests: Patient is active in cheerleading, basketball and skating; however, is unable to do these activities 2' to injury. Past Medica] Historv: Unremarkable. General Health: Good Medical Precautions: None Medications: None Patient's Goals for PT: Observation and Inspection: Patient presents w/poor quad and VMO tone. Mild pocket of swelling noted superior patella. Palpation: No tenderness elicited. Sensation: WNLs to light touch LE dermatomes. Oll.TI10I'CDIC SllfIOWNS, I.TD. IIAKRlSBURQ olTl<Z- 450 poweRS AVE. Page 2 Takenya Watson-Early Ioitial Evaluation 09/02/03 Girth: 10 cm above: 5 cm above: mid patella: 5 cm below: 1 Ocm below: 1< 49cm 42.5 cm 39cm 35cm 37.1 cm R 44cm 40.7 cm 39 cm 35 em 36.3 cm ROM: 1. 0-1180 R 0- 800 Joint Mobilitv: Patellar is nonna!. Flexion Extension Knee flexion Knee extension Gait: Patient currently ambulating w/(R) knee immobilizer w/o an AD. The aboPe injomwnon represents all significant subjectillt! and objectivejindlngs. PletJSe refer to the enclosed Plan of Care for my tlS$t!SS1IU!nt, treotmen1. goals, and trl!Jltment plan. Please sign and return the Plim of Care to 011.hopedil: Institute of Pit. Physical TheNp!. /fJ'Oll wish, 1IIlIke 0 copy for your records Thank you for this riferral. I wUl keep you informed of any change.s in the patient's status 01' /he treflImen1 plan. Therapist's Signature: ~ ~ Date: 1{6f d?/ Jami, r/es, MPT, A~C, License #PT015482 .---"'-'-'.""''"' :>>0/5/6 .3S" -',....."...- .It' ~Ip. ORTIIOPEDIC INSTITUTE or PENNSYLVANIA PHYSICAL TUERAPY TELBl'HONE: (717) 920.4950 FAX: (717) 920-4955 Plan of Care Patient Name: TAKENYA WATSON-EARLY Date of Eva I: 09/02/03 Date of Birth: 12/05/91 Age: 11 Sex: F Diagnosis: Tibial Plateau Fracture Date of Injury/Onset: 07120103 Involved Sid.: 0 Left .r Right 0 Both Referring Physicia.n: Dr. Frankeny Surgical Procedure: NfA Date of Surgery: N/A * Please refer to the enclosed Initial Evaluation as needed for the Problem List: 1. 1 ROM. 2. 1 strength. Assessment SUmmary: Patient presents to PT and seems to be doing well following a (R) tibial plateau fracture. Patient would benefit from PT intervention at this time. PotentiallPro!!nosis for Rehab: Good for stated goals. 3. Impaired gait. 4. Poor muscle tone. Short Term Goals Ito be achieved in 3 weeks): 1, Patient will report pain at worst to be 3/10. 2. Patient will present w/nonnal AROM of (R) knee. Lon!! Term Goals Ito be achieved in 6 weeks): 1. Patient will report pain at worst to 0 - 1/1 O. 2. Patient will i strength of (R) LE to measure 4+ to 5/5 t/o. 3. Patient will present w/normal single leg stance on R) LE> 30 seconds. 3. Patient will present w/fair quad and VMO tone. 4. Patient will ambulate independently w/normal gait pattern. 4. Patient will present w/normal quad and VMO tone. 5. Patient will be independent in HEP. 6. Patient will retum to activities including cheerleading and basketball. I will be treating Takenya w/modalities as needed in conjunction w/an program strengthening progressed as tolerated, neuromuscular reeducation and functional activities. Modalities will include but are not limited to moist heat and electrical stimulation for reeducation of quadricep muscle. Freauencv: 3 x week Duration: 6 wl:eks I have fully discussedtfle above treatmentplan and expected outoolltes with Takenya Wmson-Ea,ly. She is aware of the diagn.osis ilndprognosis and has voluntarily agreed to participate in physical therapy services. Thank you for this referral! Therapist's Signature: rwAAAiAIV'L~~ J'P{l./ Date: q /t/ ~ /t;;tLtf5t~rles, MPT, Al1 ,License #PT015482 fCertiflcation/ In accordance with accepted medical practice standards, 1 hereby certify thaI the ahove nahU!d patient requires rehabi/itation services/or the problem(s) identified above. As such, J request that the center's prole a eva ua a sess the patient's nel~dfo" said services and provide a detailed patient care plan or my 'Provo/ (t be iewed every 30 days). Physician's Comments: Physician's Signature: Date: ORrno C UROOONS, LTD. flARRlSBURO omce 450 POWERS AVE. REAR ENTRANCE SEP 1 0 2003 DRAYER PHYSICAL THERAPY INSTITUTE FBD.,l.D. #75.3050291 Inilial EvaJua,on.PT 97001 , ,/ Description CPT UNITS 59 TENS Instruction 64550 Re-evaluation.PT 97002 . Ultrasound (ea. 15 mini 97035 Orthotic Casting 29799 Initial Evaluatlon-oT 97003 Iontophoresis (ea. 15 min) 97033 Orthotic Checkout (ea. 15 mini 97703 Re-evaiuation-OT 97004 E.Stim Attended (ea. 15 mini 97032 Orthotic FrtlinQITraining (ea. 15 minI 97504 Manual Muscle Test 95831 Biofeedback 90901 Prosthetic Training (ea. 15 mln) 97520 RanllEl 01 Motion 95851 Self Care/Home Management 97535 Physical Periormance TestlMeas 97750 ~ (F.C.E. Functional Drills..ea. 15 min) Electrodes A4556 Strapping. Hand or Finger 29200 ~ Mechanical Traction 97012 , Strapping. Elbow or Wrist 29260 l.E<Slim Unattended 97014 , Strapping . An~e 29540 Vasopneumalic 97016 Strapping' Knee 29530 Therapeutic ProcecIure (ea. 15 min) 97110 Paraffin Bath 97018 Strapping. Toes 29550 Neuromuscular Re-ed (ea. 15 min) 97112 WhirloooVFluido Therapy 97022 Splints. Finger (slailc) 29130 Manual Therapy (ea. 15 mini 97140 Splints, FinQer (dynamic) 29131 Gait Training (ea. 15 mini 97116 Strapping.forearm.Hand (static) 29125 Massage (ea. 15 mini 97124 Slrapping,Farearm,Hand (dynamic) 29126 Aquatic Therapy (ea. 15 min) 97113 Wound Care Seiective 97601 Group Therapy 97150 Wound Care Non,Seiec!ive 97602 SERViCE REQUEST NOTES WATSON, JO m NORm 2ND STREET STEELTON, PA 11113 2/05/91 111 985 1991 21 GATElIAY HEALTH PL DRAYER PHYSICAL THERAPY INSTITUTE !J FED., I.D. #75,305029] Deocrlptlon CPT UNITS 59 Direct Contact ReGulred ,/ Description CPT UNITS 5' Initial E",,'ualion,PT 97001 ,/ Description CPT UNITS 59 TENS Instruction 64550 Re-evaluation.PT 97002 Ultrasound (ea. 15 mini 97035 Orthotic Casting 29799 initial Evaluation.OT 97003 lontcohoresis (ea. 15 mini 97033 Orthotic Checkout(ea. 15 min) 97703 Re-evaluation,OT 97004 E'Stim Attended (ea. 15 mini 97032 Orthotic FittingiTraining (e.. 15 mini 97504 Manual Muscle Test 95831 Biofeedback 90901 Prosthetic Training (ea. 15 mini 97520 Range of Motion 95851 SeH Care/Home Manaoement 97535 PhvSicai Pertormanco TesUMeas 97750 ~ we.E. Functional DriI~..a. 15 mill) Electrodes A4556 Strapping. Hand or Finger 29280 ~ ~nicaJ Trection 97012 , Strapping' Elbow or Wrist 29260 ~Stim Unattended 97014 T Strappino ' Ankle 29540 Vasopneumatic 97016 Strapping' Knee 29530 Therapeutic Procedure (ea. 15 min) 97110 Paraffin Bath 97018 Strapping' Toas 29550 Neuromuscular Re-ed (ea. 15 min) 97112 Whirlpool/Fiuido Therapy 97022 Solints. Finger (static) 29130 Manuai Therapv (as. 15 min) 97140 Splints. Finoer (dynamic) 29131 GaHraining (ea. 15 mini 97116 Strapping-Forearm.Hand (static) 29125 Massaoe (ea. 15 mini 97124 Strapping-Forearm-Hand (dynamic) 29126 Aquatic Theronv (ea. 15 min) 97113 Wound Care Selective 97601 Group Therany 97150 WOUTld Care Non.Selective 97602 DIAGNOSIS I C D9 CODE . PAIN IN LIKB 729.5 SERVICE REQUEST NOTES fIN 1M !l1f/ei. 0 ~ fzv MiL: f( de et-- I1J ~ LE l'irkcl ft'<L+ . ~ -- _V'~~I - - STBBLroH, PA 17113 27'GATEWAY KEALTK PLAN DRAYER PHYSICAL THERAPY INSTITUU: FED., I.D. # 75.305029 I Description CPT UNITS 59 Direct ConteclR9<lulr9d ./ Description CPT UNITS , Inmal Evaluation.PT 97001 ./ Description CPT UNITS 59 TENS Instruction 64550 Re-evaluation-PT 97002 Ultrasound (ea. 15 mini 97035 Orthotic Castino 29799 Initial Evaluatlon,OT 97003 Iontophoresis (ea. 15 mini 97033 Orthotic Checkout (ea. 15 min) 9n03 Re.evaluation.OT 97004 E,Stim Attended (ea. 15 min) 97032 Orthotic FlttingfTraining (ea. 15 min) 97504 Manual Muscle Tesl 95631 Blole9dback 90901 Prosthetic Training (ea. 15 mini 97520 Range 01 Motion 95851 Sell CareJHome Management 97535 Physical Perionnance TesUMeas 9n50 ~ (F.G.E. Functional Drills-ea. 15 minI Electrodes A4556 Strappin. ' Hand or Finger 29280 ~ '1I1echanical Traction 97012 Strapping, Elbow or Wosl 29260 ~,Stim Unattended 97014 I Straooing , Ankle 29540 Vasopneumafic 97016 Strapping. Knee 29530 Therapeutic Procedure (ea. 15 min) 97110 Paraffin Bath 97018 Strapping' Toes 29550 Neuromuscular Re-ed (ea. 15 min) 97112 WhinpooVFluido Therapy 97022 Splints. Finger (staticl 29130 Manuai Therapy (ea. 15 mini 97140 Splints, Finger (dynamic) 29131 GaitTrainin. (ea. 15 mini 97116 Strapping.Foreann'Hand (static) 29125 Massage (ea. 15 mini 97124 Strapping.Foreann,Hand (dynamic) 29126 Aquatic Therapy (ea. 15 minI 97113 Wound Care Seiective 97601 Group Therapy 97150 Wound Care Non,Selec/ive 97602 DIAGNOSIS I C D 9 CODE . PAIN IN LIRB 129.5 SERVICE REQUEST NOTES P + 5!-n.J.,- s le~ --fb.1 s. t'f.. pr,j( 17m)) 4 rut! f)tv/A- Pf- e.{ n IlI\AJI't- It- ~ S t: co ()rJ d /1 a. () rJd- HStu'vl. I 1'- f.li. wi- rv K --fw( 1) I v'. [,J: JoJl Ii<. ( l1ow-c l/bV Sxs ';1110 [) (j f..{.' hi It..<.. I JD-y ( WATSOR, JO 230 RaiTH 2RD STiEET STEELTOR, PA 17113 2/05/91 717 985 1991 2'1 GATEWAY HEALTH PL DRAYER PHYSICAL THERAPY INSTITUTE FED., I.D. #75,3050291 DescrlDllon CPT UNITS 59 Direct Contact Required ,/ Description CPT UNITS I Inilial Evalualicn'PT 97001 ,/ Description CPT uNrrs 59 TENS Instruction 64550 Re-evaluation-PT 97002 Uttrasound (ea. 15 mini 97035 Orthotic Casting 29799 Inttial Evaluatlon.OT 97003 lonlophoresis (ea. 15 mini 97033 Orthotic Checkout lea. 15 min) 97703 Re-evaluation.OT 97004 E.Stim Attended (ea. 15 mini 97032 Orthotic FittingfTraining (ea. 15 mln) 97504 Manuai Muscle Test 95831 Biofeedback 9!J9()1 ProslhetlcTraining (ea. 15 mini 97520 Ranoe of Motion 95651 Self Care/Home Management 97535 Physical Performance Test'Maas 97750 - (F.C.E. Functional DriJjs-ea 15 min) Electrodes A4556 Strapping. Hand or Rnger 29290 ~ ./wIllchanleal Traction 97012 Strapping. Eibow or Wrist 29260 E,Stim Unattended 97014 Straoping . Ankle 29540 Vasopneumatic 97016 Strapping. Knee 29530 Therapeutic Procedure (ea. 15 min) 97110 Paraffin Bath 97018 Strapping. Toes 29550 Neuromuscular Re-ed (ea. 15 min) 97112 WhlripooilRuido Therapy 97022 Splints. Finger (static) 29130 Manual Therapy jea. 15 mln) 97140 Splints, Finger (dynamic) 29131 GattTralning (ea. 15 mini 97118 Strapping.Forearm.Hand (static) 29125 Massage (ea. 15 mini 97124 Strapping. Forearm-Hand (dynamic) 29128 Aquatic Therapy (ea. 15 mini 97113 Wound Care Seiective 97601 Group Therapy 97150 WOlJnd Care Non.Selective 97802 DIAGNOSIS I C D9 CODE . PAIB IH LII8 129,5 SERVICE REQUEST NOTES u ~- M +-to p~J cjtu(~tj ?n WATSOH, JO 231 HOiTH 2ND STiEET STEELTOR, PA 17113 2/15/91 717 985 1991 27 GATEWAY HEALTH P DRAYER PHYSICAL THERAPY INSTITUTE FED., LD. # 75.3050291 ~2 Description CPT UNITS 59 Direct ContBCI Required 0/ DescrlOtlon CPT UNITS ! Inilial Evalualion'PT 97001 0/ Description CPT UNITS 59 TENS Inslruction 64550 Re'Bvaiustion,PT 97002 U~r"ound (B.. 15 mini 97035 Orthotic Casting 29799 Initial Evaluauon-DT 97003 JonlophorBsis lB.. 15 min) 97033 Orthotic ChBckout (B.. 15 mini 97703 Re-svaiu.tion,OT 97004 E.Stim AtiendBd (Ba. 15 mini 97032 Orthotic FlttlngfTraining (ea. 15 min) 97504 Manuai Muscle Test 95831 Biofeedback 90901 Prosthetic Trainino (ea. 15 mini 97520 Range 01 Motion 95651 Self Care/Home Management 97535 Physical Pertormanes TesVMe.. 97750 - (F.C.E. Functional Dril1s-ea. 1S min) Electrodes A4556 Straooing , Hand or Finger 29280 ~ ,-\Q('echanicai Traction 97012 Strapping, Elbow or Wrist 29260 E.Stlm Unatiended 97014 Strapping' Ankle 29540 Vasopnsumalic 97016 Strapping, Knee 29530 Therapeutic ProcedlJfe (ea. 15 min) 97110 - Paraffin Bath 97018 Strapping. Toes 29550 Neuromuscular R&-ed (ea. 15 min) 97112 WhidpoollFluido Therapv 97022 Splints. Finoer (static! 29130 Manual ThBrapy (ea. 15 mini 97140 Splints. Finger (dynamic) 29131 GaitTraining (ea. 15 mini 97118 Strapping.Forearm,Hand (static) 29125 Massage (ea. 15 mini 97124 Strapping-Forearm-Hand (dynamic) 29126 Aquatic Therapy (ea. 15 mini 97113 Wound Care Selective 97601 Group Therapy 97150 Wound Care Non,SBIBctive 97602 . . . . . . PAIR IR Ll1Ill 729.5 SERVICE REQUEST NOTES <2<' 0<, OY~ ~ C' 6J u;. ;AU fWI c Pi- t v1u~ w ~(" 4(jj* 1Jtitz;rn ~~ ( G<rVcf -10 a.J1'lJ:]. C- (1(~ IJt-- WATSON, JO 238 RORTH 2ND STREET STEELTOH, PA 17113 DRAYER PHYSICAL THERAPY INSTITUTE FED ID #75.3050291 --ro .,. . Description CPT UNITS 59 Direct Contact Required " DeacrlDllon CPT UNITS I Initial Evaluation'PT 97001 " Deacrlpllon CPT UNITS 59 TENS Instruction 64550 Re-evaluation.PT 97002 Uttr..ound (ea. 15 mini 97035 Orthotic Castin9 29799 InOlal Eveluation-OT 97003 Iontophoresis (sa. 15 min) 97033 Orthotic Checkout (ea. 15 min) 97703 Re-evaiuation.QT 97004 E.Stim ADended (ea. 15 mini 97032 Orthotic FlttingITraining (ea. 15 min) 97504 Manual Muscle Test 95831 Biofeedback 90901 Prosthetic Tralnino lea. 15 min) 97520 RanDe of Motion 95851 Sett CareJHome Managemant 97535 Physical Performance TestiMe.. 97750 ~ (F.G.E. Functional DtlUs.... 15 min) Eiectrodes A4556 Strappino ' Hand or Finoer 29280 ~ Mechanical Traction 97012 Strapping. Eibow or Wrist 29260 E.Stim Unattended 97014 Strapping. Ankie 29540 Vasopneumetic 97016 Strapping. Knee 29530 Therapeutic Procedure (ea. 15 min) 97110 Paraffin Bath 97018 Strapping. Toes 29550 Neuromuscular Rs-ee1 (ea. 15 min) 97112 WhinpoollFluido Theraov 97022 Splints. Finger (static) 29130 Manual Therapy lea. 15 min) 97140 Splints. Finger (dynamic) 29131 GattTraining lea. 15 min) 97116 Strapping.Forearrn.Hand (sianc) 29125 Massage (ea. 15 mini 97124 Strapping-Forearm-Hand (dynamic) 29126 Aquatic Therapy (ea. 15 min) 97113 Wound Care Seiectlve 97601 Group Therapy 97150 Wound Care Non-5elective 97602 PAIN Ifi LIMB m,5 SERVICE REQUEST NOTES 8" f+- . 0 I'Ll) YLRMJ c/O. ~ndO. 0" pt; rfiMUwr, it ' P-f, ~ ~ fljttL 2u~ VU4'r ~. -I- ~ f1 w{~ ft, ~ fb ~ c ~ Iflltru.~ g~UlJ.c,I ~io -dZt~ fLJ ,4([L WATSON, JO 238 NOirR 2ND STREET srEELrON, FA 17113 Jj;" DRAYER PHYSICAL THERAPY INSTITUTE FED., I.D. #75-3050291 .:'\ 19 , ---.,\'::;-"'! , Description CPT UNITS 59 Direct Contact Required ./ Deacrlptlon CPT UNITS 5l InRial Evaluation-PT 97001 ./ Descrlpllon CPT UNITS 59 TENS Instruction 64550 Re-evaluation-PT 97002 Ultrasound (ea. 15 mini 97035 Orthotic Casting 29799 Inmal Evaluation-OT 97003 Iontophoresis (ea, 15 mini 97033 Orthotic Checkout (ea. 15 mini 97703 Re-evaluation-OT 97004 E.Stim Attended (ea, 15 mln) 97032 Orthotic FittingiTraining (ea. 15 min) 97504 Manual Muscle Test 95831 Biofeedback 90901 Prosthetic Tr.inino Ie.. 15 mini 97520 Range of Motion 95851 Self CarelHome Management 97535 Physical Pertormance TesllMeas 97750 ~ (F.C.E. Functional Orif/s-ea. 15 min) Electrodes A4556 Strapping - H.nd or Finger 29280 ~ M"&'anical Tr.ction 97012 Strapping - Elbow or Wrist 29260 E-Stim Unattended 97014 Strapping - Ankle 29540 Vasopneumatic 97016 Strapping - Knee 29530 TherapauticProcedure (ea. 15 min) 97110 Paraffin Bath 97018 Strapping - Toes 29550 Neuromuscular Re-ed (ea. 15 min) 97112 WhirlpooVFluldo Therapy 97022 Splints - Finger (static) 29130 Manual Therapy (ea. 15 mini 97140 Splints - Finger (dynamic) 29131 GattTralning (ea, 15 mini 97116 Strapping-Forearm-Hand (static) 29125 Massage (ea. 15 mini 97124 Strappjng~Foreann-Hand (dynamic) 29126 Aquatic Therapy (ea. 15 mln) 97113 Wound Care Selective 97601 Group Therapy 97150 Wound Care Non-Selective 97602 PAIK II LIKB 129.5 SERVICE REQUEST NOTES {07 f7 !h- b " / VATSOH, JO 230 HORTH 2KD STREET 5TEELTOH, PA 11113 2/05/91 717 985 1991 21 GATEWAY HEALTH PLAH DRAYER PHYSICAL THERAPY INSTlTUTI: FED.. 1 D. #75-3050291 t'? Description CPT UNITS 59 Direct Contact Required ./ Description CPT UNITS 9 Initial Evafuatlon-PT 97001 ./ Description CPT uNrrs 59 TENS Instruction 64550 Re-evaluation-PT 97002 Uttrasound (ea. 15 mini 97035 Orthotic Castino 29799 Inmal Evaluation-OT 97003 Iontophoresis lea. 15 mini 97033 Orthotic Checkout (ea, 15 mini 97703 Re-eveluation-0T 97004 E-Stim Attended (ea. 15 mini 97032 Orthotic FlttingiTraining (ea. 15 min) 97504 Manual Muscle Test 95831 Biofeedback 90901 Prosthetic Training (ea. 15 mln) 97520 Ranae of Motion 95851 Se~ Care/Home Management 97535 Physical Pertonnance TesVMeas 97750 - (F.C..E. Functional DriJJs-ea. 15 min) Electrodes A4556 Strappino - Hend or Finger 29280 ~ Mechanical Traction 97012 Strapping - ElboW or Wrist 29260 E-Stim Unattended 97014 Strappino - Ankle 29540 Vasopneumatic 97016 Strappino - Knee 29530 Therapeutic Procedure (ea. 15 min) 97110 Paraffin Bath 97018 Strapping - Toes 29550 NeuromuscUlar Re-ed (ea. 15 min) 97112 WhirlpooVFiuido Therapy 97022 Splints - Finger (static) 29130 Manual Therapy (ea. 15 mini 97140 Splints - Finger (dynamic) 29131 Ga. Training (ea, 15 min) 97116 Strapping-Foreerm-Hand (stalic) 29125 Massaoe (ea. 15 mln) 97124 Strapping-Forearm-Hand (dynamic) 29126 Aquatic Theraov (ea. 15 mini 97113 Wound Care Selective 97601 Group Therapy 97150 Wound Care Non-Selective 97602 PAIN IN LIKB 729. S SERVICE REQUEST NOTES .8~ 14. rep lIVt5 Yki ~ twr jrvVL 'fu )c!ifv / _D; . jJJ/l~. OleA rnH "fc /fr'f:(]YY 6~ WATSON, 30 230 NORTH 2ND STREET STEELTON, FA 17113 DRAYER PHYSICAL THERAPY INSTITUTE, FED 1 D # 75-3050291 ",. . Desci\ptlon CPT UNITS 59 Direct Contact Required ./ Description CPT UNITS 5 Initial Eva/uation-PT 97001 ./ Description CPT UNnrs 59 TENS Instruction 64550 Re-evaluation-PT 97002 Ultrasound (ea. 15 min) 97035 Orthotic Casting 29799 Initial Evaluation-OT 97003 Iontophoresis (ea. 15min) 97033 Orthotic Checkout (ea. 15 min) 97703 Re-evaluation-OT 97004 E-Stim Attended (ea. 15 mini 97032 Orthotic Filtinglfralnin9 (ee. 15 mln) 97504 Manual Muscle Test 95831 Biofeedback 90901 Prosthetic Training (ea. 15 min) 97520 Ranoe of Motion 95851 Self Cere/Home Menagement 97535 Physical Pertormance TestlMeas 97750 - I"C.E. FuncIiooaIDrllls-e.. 15 m~) Electrodes A4556 Strapping - Hand or Finaer 29280 ----- Mechanical Traction 97012 Strapping - Elbow or Wnst 29260 E-Stim Unattended 97014 Strapping - Ankle 29540 Therape~ Actlvilies (ea. 15 mln) 97530 Vasoprwumatic 97016 Strapping - Knee 29530 Therapeutic Procedure (ea. 15 min) 97110 Paraffin Bath 97018 Straoping - Toes 29550 Neuromuscular Re-ed (ea. 15 min) 97112 WhinpooVFluido Therapy 97022 S~infs-Fmger(Mati~ 29130 Manual Therapy (ea. 15 min) 97140 Splints - Flnaer (dynamic) 29131 GattTrainlna lea. 15 min) 97116 . 5trappmg-Forearm-Hand (static) 29125 Massage (ea. 15 min) 97124 Strepplng-Foreerm-Hand (dynamic) 29126 Aquatic Therapy (ea. 15 mini 97113 Wound Care Selective 97601 Grouo Therapy 97150 Wound Care Non-Selective 97602 PAIR IH LIKB 729.5 r-- \\1 ~~ / 'p.;r \~ \W\/:; L / \...J/ ~ ',- X___I 7\\\ " 0---.... \ / / \J " \j /1 "\... v--- WAT50H, JO 230 BORTH 2KD STREET 5TEgLTOK, PA 17113 2/05/91 111 985 1991 21 GATEWAY HEALTH PLAH DRAYER PHYSICAL THERAPY INSTITUTE FED ID #75-3050291 \'0 ",. . Description CPT UNITS 59 Direct Contact Required ./ Description CPT UNITS ! In~ial Evaluation-PT 97001 ./ Description CPT UNncs e9 TENS Instruction 64550 Re-evaluation-PT 97002 Ultrasound (ea, 15 min) 97035 Orthotic Castina 29799 InRial Evaluation-OT 97003 /ontoohorasis (ea, 15 min) 97033 Orthotic Checkout (ea. 15 mini 97703 Re-evaluation-OT 97004 E-Stim Attended (ee. 15 mln) 97032 Orthotic Fitting!Training (ea. 15 minI 97504 Manuel Muscle Test 95831 Biofeedback 90901 Prosthetic Trainino lea 15 mini 97520 Range of Motion 95851 Self Care/Home Management 97535 Physical Pertormance TasVMeas 9n50 - (F.G.E. FUflCIiooaI OIiIls-ea. 15 min) Electrodes A4555 Strapping - Hand or Finoer 29280 ~ Meclw>ical Traction 97012 Strapping - Elbow or Wr~t 29260 E-Stim Unattended 97014 Strapping - An~e 29540 Vasopneumatic 97016 Strapping - Knee 29530 Therapeutic Procedure (ea. 15 min) 97110 Paraffin Bath 97018 Strapping - Toes 29550 Neuromuscular REHKI (ea. 15 min) 97112 WhinpooVFluido Therapy 97022 Splints - Finaer {static) 29130 Manual Therapy (ea. 15 min) 97140 Splints - Finger (dynamic) 29131 GattTraining (ea. 15 mini 97116 Strapping-Foreann-Hend (stalic) 29125 Massaae (ea. 15 min) 97124 Strapping-Foreenn-Hand (dynamic) 29126 Aquatic Therapv (ea. 15 min) 97113 Wound Care Selective 97601 Group Therapy 97150 Wound Care Non-Salective 97602 . . . . . . PAIH II LIKB . . . . WAT50H, JO 230 HORTH 2HD STREET 5TEELTON, PA 17113 2/05/91 711 985 1991 27 GATEWAY HEALTH PLAB .~ DRAYER PHYSICAL THERAPY INSTITUTE: FED., I.D. # 75-3050291 ~ DesciiPilan CPT UNITS 59 Direct Contact Required ./ Deecripllon CPT UNITS S fnitial Eva/uation-PT 97001 ./ Description CPT UNITS 59 TENS Instruction 64550 Re-evaluation-PT 97002 Ultrasound (ea, 15 minI 97035 Orthotic Casting 29799 Inmal Evaluation-OT 97003 lonlDDhoresi8 (ea, 15 min) 97033 Orthotic Checkout lea. 15 mini 97703 Re-evaluation-OT 97004 E-Stim Attended (ea, 15 min) 97032 Orthotic F1llingITrainin9 (aa, 15 mini 97504 Manual Muscle Test 95831 Biofeedbeck 90901 Prosthetic Training lea, 15 min) 97520 Range at Motion 95851 Self CarelHome Menagement 97535 Physical Performance TesVMeas 97750 - (F.C.E. Functional DrIlls..., 15 minI Electrodes A4556 Strappino - Hand or Finoer 29280 ~ Mechanical Traction 97012 Strapping - Elbow or Wlist 29260 E.Stim Unattended 97014 Strapping - Ankle 29540 Vasopneumatlc 97016 Strappino - Knee 29530 Therapeutic Procedure (ea. 15 mln) 97110 Paraffin Bath 97018 Strapping - Toes 29550 Neuromusadar Re-ed (ea. 15 min) 97112 WhinpooVFIuido Therapv 97022 Splints - Flnoer (static) 29130 Ma/llJ81 Therapy lea. 15 minI 97140 Splints - Finger (dynamic) 29131 GaftTraining (ea, 15 mini 97116 Strapping-Foreann-Hand (static) 28125 Massaoe (ea. 15 minI 97124 StrappingwForeann-Hand (dynamic) 29126 Aquatic Therapy (ea, 15 mini 97113 Wound Care Selective 97601 Group Therapy 97150 Wound Care Non-8elective 97602 PAIH IH LIMB 729.5 SERVICE REQUEST NOTES MATSOH, JO 230 HORTH 2HD STREET STEELTON, PA 17113 2/85/91 111 985 1991 27 GmNAY HEALTH PLAB DRAYER PHYSICAL THERAPY INSTITUTE FED I.D. #75-3050291 63J .. Descripllon CPT UNITS 59 Direct Contact Requlrad ./ Deacripllon CPT UNITS ! Initial Evaluation-PT 97001 ./ Description CPT UNITS 59 TENS Instruction 64550 Re-evaluation-PT 97002 Ultrasound (ea. 15 mini 97035 Orthotic Cesting 29799 Inmal Evaluetion-OT 97003 lontoohoresis (ea. 15 mln) 97033 Orthotic Checkout (ea, 15 mini 9n03 Re-evaluation-OT 97004 E-Slim Attended (sa. 15 min) 97032 Orthotic Fltling/Training (ea. 15 minI 97504 Manual Muscle Test 95831 Biofeedback 90901 Prosthetic Trainino (ea. 15 min) 97520 RaI1l1ll of Motion 95851 Se~ CareIHome Management 97535 Pttysical Performance TesVMeas 97750 - (F.C.E, Functional Drills-e.. 15 mini Electrodes A4558 Strepping - Hand or Finoer 29260 ~ Mechanical Traction 97012 Strapping - Elbow or Wrist 29260 E-Slim Unattended 97014 StraoDino - An~e 29540 Vasopneumatic 97016 Strapping - Knee 29530 ThoIapeutic Procedure (ea, 15 mini 97110 Paraffin Bath 97018 Strapping - Toes 29550 Neurom~.rRe-ed(ea, 15min) 97112 WhirlDooVFluido Therapv 97022 Splints - Finoer (static) 29130 Manual Theraoy (ea. 15 mini 97140 SDUnts - Finger (dvnamic) 29131 GeitTrainlng (ea. 15 mini 97116 Slrapplng-Forearm-Hand (static) 29125 ! Massane lea. 15 min) 97124 Strapping-Forearm-Hend (dynamic) 29126 Aquatic Therapy (ea. 15 mln) 97113 Wound Care Selective 97601 Group Therapy 97150 Wound Care Non-Selective 97602 PAIN IK LIKB 129.5 SERVICE REQUEST NOTES ~-, , VlJti{ . V(~ () G -bD tI1iP ~~a~frL ---- WATS0H, JO 230 NORTH 2ND STREET STEELTON, PA 11113 2(05/91 717 985 1991 27 GATEWAY HEALTH PLAB PHYSICAL THERAPY INSTITUTE 11 FED., 1.0. # 75-3050291 lesc:ripllon CPT UNITS 59 Direct Contact ~red ./ Descripllon CPT UNITS 5 nitial Evaluaijon-PT 97001 ./ DescrlptiDn CPT UNITS' 59 TENS Instruction 64550 'le-evalualion-PT 97002 Uttrasound (ea. 15 mini 97035 Orthotic Castine 29799 nitial Evaluation-0T 97003 Iontophoresis (ea. 15 mln) 97033 Orthotic Chsckout (ea. 15 min) 97703 Ae-evaluation-OT 97004 E-Slim Attended (ea. 15 mini 97032 Orthotic F1ttingITrainino (ea. 15 mini 97504 Manual Muscle Test 95831 Biofeedback 90901 Prosthetic Training (ea. 15 mini 97520 Rance of Motion 95851 Self CareIHome Manaoement 97535 Physical Perlonnance TesllMeas 9n50 ~ (EG.E. FunctJon~ 0rIIIs..., 15 mini Electrodes A4556 Strapping - Hand or Fin!ler 29280 ~ Mechanical Traction 97012 Strapping - Elbow or Wnst 29280 E-Slim Unattended 97014 Strapolno - Ankle 29540 Vasopneumatlc 97016 Strapping - Knee 29530 TilerapeuIicP_lea.15min) 97110 1 Paraffin Bath 97018 Strapping - Toes 29550 Neuromusculer Re-ed (ea. 15 mini 97112 WhirtpoollFluido Theraoy 97022 SoIints - Flnoer Istatic) 29130 Manual Therapy (ea. 15 mini 97140 Splints - Finaer (dynamic) 29131 Gatt Training (ea. 15 mini 97116 Strappina-Forearm-Hend (static) 29125 M.....;e (ea. 15 mini 97124 Strapping-Foreann-Hand (dynamic) 29126 Aquatic Theranv (ea. 15 minI 97113 Wound Care Seiective 97601 . Group Therapy 97150 Wound Care Non-Selective 97602 PAIK IH LIHB 729.5 SERVICE REQUEST NOTES DRAYER \o;~ ~ f1J- C M !WI do - o l, (lM at F tNJj-, ~, Pr Cxffw~. fiv Dle- k .p', JJ {c if; f11ff DfO; I~- Ja~/r1 ~ WATSON, 10 230 HORTH 2HO STREET STEELTOH, PA 17113 2/05/91 117 985 1991 27 GATEIIAY HEALTH PLAN _.,....,..,-,,_"~'~...''''..'"'''''ry0,. .y'-' ~</~Ip. ORTHOPEDIC INSTITUTE OF PENNSYLVANIA PIfYSICAL TUERAPY TIlLEPHOl'll!: (7]7) 920-4950 FAX: (7]7) 920-4955 DISCHARGE SUMMARY Patient Name: TAKENYA WATSON-EARLY Date: 09/29/03 DOD: ]2/05191 DJ:. (R) Tibial Plateau Fl.. Date ofEvaluBtion: 09/02103 Physidan: Dr. Frankeny Last Treatment Day: 09/16103 Total #: 'Visits: ]3 .#C" 0 '#NS: 0 <~~~I_t,"'''" 0 t functiona'abiJity 0 0 0 0 0 iROM 0 0 0 0 .r 1 pain level to 0 - 1Il0 at worst .r 0 0 0 .r Patient will present w/normal single leg stance on (R) LE > 30 seconds .r 0 0 0 .r Patient will present w/normal quad and VMO tone .r 0 0 0 .r Patient will be independent in HEP .r 0 0 0 .r Patient will return to activities including cheerJeading and basketball 0 0 0 .r .r i strength of (R) LE to 4+ to 5/5 tJo .r 0 0 0 'I.',rea'tn"m't'IGti~Milt'\l!1~'lIIti;o~,;;!(,~~ , o Insufficient Treatment time o Severity of Pysf"nction o Patient did not keep Appts o Surgical Intervention Required o Rx discontinued by Physician o Treatment Ineffective o Patient Non-Compliance o Other: o Other: r Patient has received maximum benefit from physical therapyJhas returned to normal, premorbid status at this time (patient concurs). o Patient has met all or at least 90%, of discharge criteria (patient concurs). o No subjective/ohjectlve/functiona' improvement in pt's status within a 4 week or longer period ofPT (discussed wlMD prior toPIC of pt). o Rx discontinued by physician. o Patient missed 3 consecutive therapy appts OR 5 total appts w/o canceling or contacting the clinic (MD notified prior to DIe of patient). o UnabJe to succ.essfully contact patient in 3 attempts after patient did not attend tberap~' for a full week (discussed w/MD prior to Ole). o Further treatment indicated but has not been ordered by physician. o Patient choice. o Other: ..{ Patient is to follow 8 specific. home exercise program (see Comments below) o Equipment has been ordered for home use (See Comments below) o Letter sent to patient to alert himlher ofDIC decision (MD authorized) o Other: G!)iS\!hlim'~roiiiii.i..:C'., ,',; :-c':7:":'::-_."lcc,..,,~ '''.. ",....... ,:'1 ..r Excellent 0 Good 0 Fair 0 Poor Addl Comments: HEPlEquipment: Patient instructed in continuing HEP of ROM and strengthening . Equipment: . FinaJ DIe Status: Pain OlIO at all times, no TIP, normal quad and VMO tone, normal AROM (R) knee, strength grossly 4+ to 5/5 tio. Patient ambulating independently w/normal gait pattern. Signature ofTherapis CfIJD/63 ORTHonblC 5URQroNS, LTD. JlA.RlUSBURO OITlCE 450 POWERS AVE. MEDICAL BILLING SUMMARY FOR TAKENYA WATSON Medical ProviderCs) Lower Allen Township EMS DateCs) 07/20/2003 TOTAL PAYMENTS BY GATEWAY (DPW) PinnacleHealth @ Harrisburg Hospital 07/20/2003 TOTAL PAYMENTS BY GATEWAY (DPW) Orthopedic Institute of Pennsylvania (physician services) Orthopedic Institute of Pennsylvania (physical theTapy services) 07/22/2003 08/26/2003 10/02/2003 TOTAL PAYMENTS BY GATEWAY (DPW) 09/02/2003 09/04/2003 09/06/2003 09/08/2003 09/10/2003 09/12/2003 09/15/2003 09/17/2003 09/20/2003 09/22/2003 09/24/2003 09/26/2003 TOTAL PAYMENTS BY GATEWAY (DPW) TOTAL MEDICAL BILLS TOTAL PAYMENTS BY GATEWAY (DPW) AmountCs) $ 415.00 $ 415.00 $ 70.00 $ 566.00 $ 566.00 $ 248.38 $ 733.00 63.00 0.00 $ 796.00 $ 170.50 $ 255.00 170.00 170.00 180.00 220.00 180.00 180.00 120.00 120.00 400.00 560.00 160.00 $2,715.00 $ 96.65 $4,492.00 $ 585.53 *Takenya Watson reserves the right to supplement this Medical Billing Summary. 286990-1 pG3T~~~Y1~~~'rXH ALBANY l NY 12211 (C(Q)\?'\{ i a: UJ " a: <( (.l t PLEASE'. D<;! NOT 'STAf-LE IN THIS AREA [-1 iPICA HEALTH INS 'RANCE CLAIM FORM PICA 1Tl" I 1 MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHS~ 101. INSURED'S 1.0. NUMBER (FOR PROGRAM IN ITEM 1) r n n HEALTH PLAN n BlK LUNG 0 il (Medicare II) n/MediCaiC iI) 0 (Sponsor's SSN) (VA File #) (SBN or ID) (SSN) (10) 22201013 2 PATIENTS NAME (laSt Name. First Name. Middle Initial) 3. PATIENT'S BIRlH DAlE SEX 4 INSUREO'S NAME (Last Name, ~irsl Name. Middle Initial) WATSON M~~,"",,; YY nn EARL Y TAKENYA 1 05 991 M F WATSON EARLY TAKENYA I 5 PATIENT'S ADDRESS (ND., Stref!l) 6. PATIENT RELATIONSHIP TO INSURED 7, INSURED'S ADDRESS (No" Slrtef) 230 N 2ND ST s," [}:Spo'''D Chi.D 0.""0 230 N 2ND ST CITY I STA.TE 8. PATIENT STATUS CJTY ! STATE % PIOI Marri8dD Other 0 STEEL TON 0 STEEL TON Sing1eOO PA ;: <( ZIP CODE: I TELEPHONE (Include Area COde) ZIP CODE i TELEPHONE (INCLUDE AREA CODE) :;: ( 717 9851991 Employed 0 Full-Time D pan-TimeD ( 71 -7 985 1991 a: 17113 Student Student 17113 0 .. 9 OTHER INSUREO'S NAME (Last Name. First Name. Middle Initial) 10.IS PATIENT'S CONDITION RE,LATED TO: 11, INSURED'S POLICY Gf:!OUP OR FECA NUMBER ;! Q w a OTHER INSURED'S POLICY OR GAOUP NUMBeR a. EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'S DATE OF BIRTH SEX II: MM , DO I YY ::l DYES [Yo 12051991 MD '0: Ul ;! b OTHER INSURED'S DATE OF BIRTH SEX b, AUTO ACCIDENT? PLACE (State) tl. EMPLOYER'S NAME OR SCHOOL NAME Q MM 00 , yy I Mn 'n DYES [Yo % , L.--1 <( I c EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PR;OGRAM NAME ... % DYES [koo W , GATEWAY HEALTH ;: c! INSURANCE PLAN NAME OR PAOGRAM NAME , Od. RESERVED FOR LOCAL USE: (I. IS THERE: ANOTHER HEALTH BENEFIT PLAN? <( 0- DYES D<NO "yes. return to and complete item 9 a-d. I READ BACK OF FORM BEFORE COMPLEnNG & SIGNING THIS FORM. "13, INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12 PATIENT'S OF! AUTHORIZEO PERSON'S SIGNATURE 1 authorize lhe release of any medical or otller inlormation necessary payment 01 medical benetllS to the undersigned Physician or supplier for to process this claim, I also requeSI payment of government benefils either to myself or 10 the party who accepts assignment services described beIo...... ~ below SIGN[D ._ "'T ,..,., "'TO - DATE .~ SIGNEo "'., ...., r- TO r- 14 DATE OF CURAENT: ~ ILLNESS (First symptom) OR 1$. IF PATIENT HAS HAD SAME; OR SIMILAR ILLNESS. IS. OATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION r I M~7:: DO : YY INJURY (Accident) OR GIVE FIRST DATE MM , DO I YY MM,OD,YY MM,DO,Yy . -=, 7' PREGNANCY(lMP) , FROM , , TO , , 17. NAME OF REFERRING PHYSICIAN OA OTHER SOURCE 17a. 1.0. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM , DO , YY MM 00 , yy "ROM , , TO , I , , I 19 RESERVED FOR LOCAL USE '20. OUTSIDE LAB? $ CHARGES DYES 01<0 I 01 01 01 21. DIAGNOSIS OR NATURE OF ILLNESSOA INJURY. (RELATE ITEMS 1.2.3 OR 4 TO ITEM 24E BY LINE) t 22, MEDICAID AESUBMISSION CODE r ORIGINAL REF NO, " ' 959...? 3 L......._ 23. PRIOR AUTHORIZATION NUMaeR 2 L2l.9. ;'>6 4 L...... . I 24 A a C 0 E F G H I J K '% FrcPmATE(S) OF SERVICETo P~oe T,pe PROCEDURES. SERVICES. OR SUPPLIES DAYS EPSDl RESERVED FOR 0 . OlAGNOS1S 01 01 (Explain Un~&Ual Circumstances) CODE $ CHARGES OR Family EMG coe LOCAL USE ;: MM DO yy MM 00 YY S-., $eM CPT/HCPCS MODIFIER I UNITS Plan <( 1217'202003 1217"'''-::':'''''' ! ..."no, '" I c>... 1'" , :;: "- 'l "c:n..:n..n.. , ~I V II: I 0 , IL , , , 'W0011 I SH MED t: , ;! 2 07<202003 012021210::: 4 9 12 f..5:0l0l 1G N Y II: W , :::; I , , , , , 0- 3 , , , , 0- ::l , Ul , I , , a: I , , , , , 0 4 , , , , , Z , , I , , <( , , , , , , (; 5 , , U; , > , , I , , :r , , , , , 0- 6 , 25, FEDERAl TAX J.D, NUMBER SSN EIN 126. PATJENT'SACCOUNT NO 127. ACCEPT ASSIGNMENT? 28. TOTAl CHARGE 129_ AMOUNT PAID 30. BALANCE DUE I nn I Q~ govt. OS, see back) ':''>'''''''''''''''''7 017. "'''''=', 1 YES NO . '" 1 '" : ",,,,' f7I : "'''' $ Ai=" ]Oll'" 31 SIGNArURE OF PHYSICIAN OR SUPPLIER 32. NAME AND AOOR~SS OF FACILITY WHERE SERVICES WERE 33. PHVSrCIAN'S. SUPPUER'S BfLLrNG NAME, ADDRESS. lIP CODE I INCLUOING DEGREES OR CREDENTIALS RENDERED (I' other than home or office) & PHONE # (I certiry that the statements on the r9VElrse FROM: Lowe\" Allen Township EMS I] apply to Ihls bill a,nd are made a part Ihereof.) 3804 LISBURN RD ( 17055) 1993 HUMMEL AVENUE iTo: CAMP HILL, Pj 17frP slMi&lERL Y PUTRIC OATE 073 03 HARRISBURG HOSPITAL PIN# 15l21448B GRP, 7) 975-7575 (APPROVED 8Y AMA COUNCIL ON MEDICAL SERVICE 8188) PLEASE PRINT OR TYPE FORMHCFA.t50a (12.90) FOAM OWCP.1S00 f::QRM RRB-'SOQ 1. 1--03--03 oSL DBR ORTH INSTITUTE OF PR 875 POPLAR CHURCH RORD CRMP HILL PR 17011 717....7E..l.~"5530 TAX ID #: 231875547 PATIENT: 220158 WRTSON ERRLY ,TRKENYR M PRT BRL_: 11-1S BRI_: oTH Bt"L: .00 .00 .00 ------------------------------------------.--------.----------------------------- LINE INVOICE RUNNING RMOUNT BRLRNCE BRLRNCE SERV C DRTE INV RP S DR PROC DESC INS R COMMENT CO C#R PL ------------------------------------------------------------------------------- 072203 1 6 1 35 CLRTE CHGE LRTER JOHN R FRRNKENY II M DIRG: 072203 2 6 1 35 27530 FX TIB PRX 1139 7811 JOHN R FRRNKENY II M DIRG: 823.00 091603 2 6 1 GATE GRTEWRY PR 580105 091603 c 6 1 GRDJ GRTEWRY RD 072203 3 6 1 35 LLCS LL CAST SY 7811 JOHN R FRRNKENY II M DIAG: 823.00 091603 3 6 1 GRTE GRTEWAY PA 580105 091603 3 6 1 GADJ GATEWAY AD 082603 4 6 1 35 90000 DC JOHN R FRANKENY II M DIAG: 823.00 082603 5 6 1 45 73590 LEG 1139 7811 JOHN R FRRNKENY II M DIAG: 823.00 102103 5 6 1 GRTE GRTEWRY PA 593218 102103 5 6 1 GADJ GATEWAY AD 100203 6 6 1 35 90000 DC JOHN R FRRNKENY II M DIRG: 823.00 ------------------------ END OF PATIENT HISTORY *** TOTALS ***. CHRRGES: 796.00 PRYMENTS, .00 . 01~ 0'- 00 c:~ . lY 121'" 681. 0121 co 1 tZJ&::" -141. 7~ .-' ,,-, 1 05 -~539 .. EJ5 lY 0'''' 1::'-::. 00 IC~ ...)1.-." 1 05 . 00 1 0~ !:::,".-, 1210 -' --,JC.. IZi ;::~ . 121121 ,~y 0;;:~ f,3. 0121 ... lZIc' -2'3. 15 -' i:-~ 1il5 -...~,,;).. 85 121'-' 0C1 co ",81. 00 53i'::3. E5 .0k', .00 ~5c:.. 0121 5E~. 1ZI121 .00 . ell~ .00 .0121 53.00 33..85 .00 .00 .00 .00 =============================================================================~ -- 170.50 ADJUSTS: - 525.50 HH-LJ-LUU4-W~U lU~;;;;;')J. FAX No, 717 920 4955 p, 001 l\Jo'[OUl JUE BELOW INCLUD~ci INS aJ\LANCE. AMOUNT YOU. CURRENTLY OWE IS $ TAX ID#23-1875547 alP PHYSICAL THERAPY PT-0065 1 JO WATSON 230 NORTH 2ND STREET STEELTON PA 17113 02/25/04 0.00 WATSON-EARLY TAKENYA 9000237 TAKENYA M WATSON-EARLY 09/02/03 97001 PHYSICAL THERAPY EVALUATION 1;!5.00 125.00 09/02!D3 97530 THERAPEUTIC ACTIVITIES (ONE ON BO.OO 205.00 09/02/03 97010 HOT OR COLD PACKS'THERAPY 20.00 225.00 09/02/03 97014 ELECTRICAL STlMU~TION THERAPY :1O.00 255.00 09/04/03 GATEWAY HEALTH P~ # 25591 Filed TAKENYA M WATSON-~Y 09/04/03 97530 THERAPEUTIC ACTIVITIES (ONE ON 120.00 375.00 09/04/03 97010 HOT OR COLD PACKS THERAPY :W.OO 395.00 09/04/03 97014 ELECTRICAL STIMULATION THERAPY 30.00 425.00 09/05/03 GATEWAY HEALTH PLAN # 27891 Filed TAKENYA M WATSON-~Y 09/06/03 97530 THERAPEUTIC ACTIVITIES (ONE ON 120.00 545.00 09/06/03 97010 HOT OR COLD PACKS: THERAPY :20.00 565.00 09/06/03 97014 ELECTRICAL STIMULATION THERAPY 30.00 595.00 09/09/03 GATEWAY HEALTH PLAN * 29121 Filed TAKENYA M WATSON-EARLY 09/08/03 97530 THERAPEUTIC ACTIVITIES (ONE ON 1-50.00 755.00 09/08/03 97010 HOT OR COLD PACKS THERAPY :20 .00 77 5.00 09/10/03 GATEWAY HEALTH PLAN * 29701 Filed TAKENYA M WATSON-EARLY 09/10/03 97530 THERAPEUTIC ACTIVITIES (ONE ON 200.00 975.00 09/10/03 97010 HOT OR COLD PACKS'THERAPY 20.00 995.00 09/11/03 GATEWAY HEALTH PLAN * 30711 Filed TAKENYA M WATSON-EARLY 09/:1.2/03 97530 THERAPEUTIC ACTIVITIES (ONE ON 150.00 1155.00 CONTINUED ON NEXT PAGE FAX No, 717 920 4955 p, 002 FEB-25-2004-WED 10:00 AM OIP PHYSICAL THERAPY '<:ENYA CHART #: 9000237 BI'LL TO: WATSON-EARLY 09/12/03 09/15/03 09/15/03 09/15/03 09/17/03 09/17/03 09/18/03 09/25/03 09/25/03 09/26/03 10/01/03 10/23/03 10/23/03 10/23/03 10/23/03 10/23/03 10/23/03 10/23/03 10/23/03 10/23/03 10/23/03 10/23/03 10/23/03 10/23/03 10/23/03 97010 97530 97010 97530 97530 HOT OR COLD PACKS THERAPY GATEWAY H~TH PLAN # 32611 Filed TAKENYA M WATSON-EARLy THERAPEUTIC ACTIVITIES (ONE ON ROT OR COLD PACKS THERAPY GATEWAY HEALTH PLAN # 33851 filed TAKENYA M WATSON-EARLY THERAPEUTIC ACTIVITIeS (ONE ON GATEWAY HEALTH PLAN # 35171 filed PM'!' GATEWAY HEALTH PLAN c# 25591 1'1/0 GATEWAY HEALTH c# 25591 TAKENYA M WATSON-EARLY. THERAPEUTIC ACTIVITIES (ONE ON GATEWAY HEALTH PLAN # 41611 Filed DENIED EWAY HE~TH PLAN c# 27B91 1'1/0 GATEWAY HEALTH c# 27891 DENIED EWAY HE~TH PLAN a# 29121 '1'1/0 GATEWAY HEALTH c# 29121 DENIED EWAY HEALTH PLAN c# 29701 1'1/0 GATEWAY HE~TH a# 29701 DENIED EWAY HE~TH PLAN c# 30711 1'1/0 GATEWAY HE~T~ c# 30711 DENIED EWAY HEALTH PLAN c#' 32611 1'1/0 GATEWAY HEALTH a# 32611 DENIED EWAY HE~TH PLAN a# 33851 1'1/0 GATEWAY HEALTH c# 33851 DENIED EWAY HEALTH PLAN a# 35171 1'1/0 GATEWAY HEALTH a# 35171 ~w.oo 1175.00 11>0.00 1335.00 ;W.OO 1355.00 120.00 1475.00 96.65- 1378.35 158.35- 1220.00 160.00" 1380.00 0.00 1380.00 170.00- 1210.00 0.00 1210.00 170.00- 1040.00 0.00 1040.00 180.00- 860.00 0.00 860.00 220.00- 640.00 0.00 640.00 180.00- 460.00 0.00 460.00 180.00- 280.00 0.00 2BO.00 120.00- 160.00 CONTINUED ON NEXT PAGE ... ._---..*...........,.,...-- H~-LJ-LUU4-WhU lU:UU AM Ull-' PHY~lCAL THEl\APY FAX No. 7~ 7 92C 4955 BILL TO: WATSON-EARLY '<ENYA CHART #: 9000237 ?, OC3 TAKENYA M WATSON-EARLY 09/20/03 97530 THERAPEUTIC ACTIVITIES (ONE ON l:~O,OO* 280.00 02/20/04 GATEWAY HEALTH PLAN *1600066841 Filed TAKENYA M WATSON-EARLY 09/22/03 97530 THERAPEUTIC ACTIVITIES (ONE ON l:W _ 00* 400.00 02/20/04 GATEWAY HEALTH PLAN #1600066851 Filed TAKENYA M WATSON-EARLY 09/24/03 97530 THERAPEUTIC ACTIVITIES (ONE ON 160.00' 560.00 02/20/04 GATEWAY HEALTH PLAN #160006.6861 Filed CURRENT 400.00 30 DAYS 0,00 60 DAYS > 90 DAYS. 0.00 160.00 TOTAL INS PENDING 560.00 560.00 9000237 alP PT 875 POPLAR CHURCH RD . CAMP HILL. PA 17011 OIP PHYSICAL THE 717 920 4950 . TOTAL DUE 0,00 f9\"-V'~V' .'iL ~ l'~'" .\ PINNACLE HEALTH HOSPITAL PINNACLE HEALTH HOSPITAL PO BOX 2353 HARRISBURG PA 17105 717-230..3717 August 8, 2003 MElZGER WICKERSHAM ATTN: STEPHANIE GRATKOWSKIE 3211 N FRONT ST HARRISBURG PA 17110-0300 Dear Sir or Madam: I have received your request for medical bills for Takenya Watson. Unfortunately at this time, I can not forward the bills to you due to the patient having medical assistance (Gateway). I have forwarded the request to the Department of Public Welfare, Office of Administration, TPL - Casualty Unit, PO Box 8486, Harrisburg PA 17105-8486, Phone # 717-772-6622 or 717-772..6023. If you have any questions please feel free to give me a call Monday .- Friday 8am to 4pm at 717-230- 3717. Sincerely, ~~- Diana Mcintyre Customer SelVice Representative E 'd E6EL 'ON *' COfINONWEAI..'TH OF PE.NNSYLVANIA m:.PAR,'TMiNT OF PUBLle WEI.FARE BUREAU OF FINANCIAL OP&RA1'IOfll5 TPL. SECTION - CASUAL'1Y UNIT PO BOX ~ !1i1e6 HARRISaURG PA 17105.&4&6 Febnlary 5, 2004 STATEMENT OF CLAIM SUMMARY ~ :'!'IAME' "i WATSON, TAKENYA 11),:, ./ ,', 720115275 UPO,/l.TE TO PREVIOUS soe DATED 11/1712003 N1sblCAi: "I, , ,"', " , '\'I""J'II'I"':~"~ES" ; !'ow(!' A"'RR6VED ""t,'ll:!.:'" ,':.' ,:,,' .:.; , " PREVIOUS soe 472,45 472.45 CURRENT see 113,08 113.08 , . ',','. ,J l ~i,'.' :~", 585.53 585,53 .::r~;''':'''''I'~'\lh8i:: , .: I ''':~ ,t :,<;;;!.., I!., I~' ,00 _00 .00 - . :,;'. '. 'I" 'il:r',:In9~I.iiQ~\:.Tfi,9F',P.~~NS:-tW'ANJA ,:"',":' .:'I,;,,:'/',~itT'<M'~\Jli~I~,Vjs,~F~J;(E "~'I I~ 'll," ;;;!\"~'I'i\l'~\ ~::,,:, '!f~'!lN':"'2~15d~IJ-1.1~ ',:,!'} "': " .,. :',~<(I , /)./> , ' ,~, <71 'II.' I AII1I8VIl Al~Vd O~E MdO ~W:(, tOO(,'OI'~lj . ',t', j' ~~ ",': , . ,', ' " "':'",,~,(,, ': ", "!~'~I', lip h' 'I' , ' " . ~'~ ,r ' ' , ,. , , '0" ',: ~ " ~tNi(/r"=t!J_' :,7 ";~piiw.!t',:,: :: 'l'll;:' . : . '" I ,,: ",", '., ":l: ',';:"',1'":,,,\ February 5, 2004 STATEMeNT OF C~AIM N~lO' WATSON,TAKENYA ] ,ID . 720115276 RANKIN R SCOTT PO BOX 468 EAST PETERSBURG PA 17520 ""~'~.$e~CE ,~"Y/llE~T p~-W: ,:, ,'f'" ,: ~~,9.~,".: i:. ;.;" :-:~~'~;]:US!:lAl;;i:~~I<:s:l ~WAl>i>a,~~1 07120/03 . 07/2.0103 DIAGNOSIS 1; 92380 DIAGNOSIS 2 : PROCEDURE: 27530 11126/03 33150355801 FX_TIBIA_NOS.CL.OSED 113.08 113.08 CL.OS TRT TIBIAL FX,PROX (PLAT) :WO/MANIP , """''':''1> .,' " ' 'II\:~~"" " ' , , ,JQ1AL ci'l 'JW' .,I,,,..,.,IJr)' .,f I . " hJ ,I', ~ " , ,I, It ~ilq.~~ '-':;'/ ~111 ,'I",", . '. < ,)1'1:'161'1;":,:.../' I,' "Ij RANKIN R SCOTT 01 1215072 ] 113.08 I 113.08 t'd Wi 'ON ^1!lI8~!1 ^lH~d GHE MdG ~m:c; tooc; '01 '83j '* COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPl SECTION - CASUAL TV UNIT PO BOX . 8486 HARRISBURG PA 17105-84aS November 17, 2003 STATEMENT OF CLAIM SUMMARY WATSON, TAKENYA 720115276 ~ 472.45 November 17, 2003 STATEMENT OF CLAIM WATSON, TAKENYA 720115278 ] BOAL DANIELLE MS HERSHEY MED CTR-RDLGY PO BOX 854 HERSHEY PA 17033 09/02103 - 09/02103 DIAGNOSIS 1 : 7295 DIAGNOSIS 2 : PROCEDURE: 97530 09/18103 PAIN IN LIMB 325100503006 14.30 14.30 THERAPEUTIC ACTIVITIES DIRECT PT CONTACT(DYNAMIC ACT TO IMPROVE FUNC) ECH 15 MIN 09/02103 - 09/02103 09/18103 325100503005 14.30 14.30 DIAGNOSIS 1: 7295 PAIN IN LIMB DIAGNOSIS 2 : PROCEDURE: 97530 THERAPEUTIC ACTIVITIES DIRECT PT CONTACT(DYNAMIC ACT TO IMPROVE FUNC) ECH 15 MIN 09/02103 - 09/02103 09/18/03 325100503004 18.43 DIAGNOSIS 1: 7295 PAIN IN LIMB OIAGNOSIS 2 : PROCEDURE: 97014 APPLICAT MODAL ONE/MORE AREA5:ELECTRICALSTIMULAll0N (UNATTENDED) 18.43 09/02103 - 09/02103 DIAGNOSIS 1: 7295 DIAGNOSIS 2 : PROCEDURE: 97001 09/18103 PAIN IN LIMB 325100503001 49.62 49.62 PHYSICAL THERAPY EVALUATION,INITIAL BOAL DANIELLE 01 0661165 96.651 96.65 , November 17, 2003 STATEMENT OF CLAIM WATSON, TAKENYA 720115276 ] MOSER RICHARD P JR 2527 CRANBERRY HIGHWAY WAREHAM MA 02571 07120/03 - 07/20/03 09/04103 322600270101 11.00 11.00 DIAGNOSIS 1 : 9597 LOWER_LEG_INJURY _NOS DIAGNOSIS 2 : PROCEDURE: 73560 RADIOLOGIC EXAM,KNEE;ONEI1WO VIEWS 07/20/03 - 07/20/03 09/04103 322600270001 11.00 11.00 DIAGNOSIS 1 : 9597 LOWER_LEG_INJURY _NOS DIAGNOSIS 2 : PROCEDURE: 73590 RADIOLOGIC EXAM;TIBIA & FIBULA,AP & LAT VIEWS MOSER RICHARD P JR 22.00 I 22.00 I 01 1172233 November 17, 2003 STATEMENT OF CLAIM WATSON, TAKENYA 720115278 ] FRANKENY JOHN R II 10 W CHOCOLATE AVE STE 105 HERSHEY PA 17033 07/22/03 - 07/22/03 09/11/03 323300681001 141.35 141.35 DIAGNOSIS 1: 82300 FX_UPPER_END_ TIBIA-CLOSE DIAGNOSIS 2 : PROCEDURE: 27530 CLOS TRT TIBIAL FX,PROX (PLAT) ;WO/MANIP 08126/03 - 08126/03 10/16/03 327600320501 29.15 29.15 DIAGNOSIS 1: 82300 FX_UPPER_END_TlB~-CLOSE DIAGNOSIS 2 : PROCEDURE: 73590 RADIOLOGIC EXAM;TIBIA & FIBULA,AP & LAT VIEWS FRANKENY JOHN R II 170.50 I 170.50 I 01 1234470 November 17, 2003 STATEMENT OF CLAIM WATSON, TAKENYA 720115276 ] PINNACLE HEALTH HOSPITALS PINNACLE HEALTH HOSPITALS PO BOX 2353 HARRISBURG PA 17105 07120103 - 07120103 DIAGNOSIS 1: 82380 DIAGNOSIS 2: 9597 PROCEDURE: W9047 08/07103 32160372703 77.00 FX_ TlBIA_NOS-CLOSED LOWER_LEG_INJURY_NOS ER SUPP SERV,SPECIAL EMERGENCY SERV(E-A)(ENROLLME:NT APPROVAL REQUIRED) 77.00 07120103 - 07120103 DIAGNOSIS 1: 82380 DIAGNOSIS 2: 9597 PROCEDURE: 73560 08107/03 32160372702 FX_ TIBIA_NOS-CLOSED LOWER_LEG_INJURY_NOS RADIOLOGIC EXAM,KNEE;ONEflWO VIEWS 18.15 18.15 07120/03 - 07120103 DIAGNOSIS 1: 82380 DIAGNOSIS 2: 9597 PROCEDURE: 73590 08107103 321603T2701 FX_ TIBIA_NOS-CLOSED LOWER_LEG_INJURY_NOS RADIOLOGIC EXAM;TIBIA & FIBULA,AP & LAT VIEWS 18.15 18.15 PINNACLE HEALTH HOSPITALS 11 1553472 113.30 113.30 November 17, 2003 STATEMENT OF CLAIM WATSON, TAKENYA 720115276 ] GATEWAY HEALTH PLAN,INC lWO CHATHAM CENTER SUITE 500- PITTSBURGH PA 15219 07/20/03 - 07120/03 DIAGNOSIS 1: 959T DIAGNOSIS 2: 71946 PROCEDURE: W0011 08114/03 321600908502 10.00 LOWER_LEG_INJURY _NOS JOINT PAlN-L1LEG EACH LOADED OR UNLOADED MILE BEYOND THE THE FIRST 20 MILES OF A ROUND TRIP 10.00 OT/20/03 - 07/20/03 08/14/03 321600908501 60.00 80.00 DIAGNOSIS 1: 9597 LOWER_LEG_INJURY_NOS DIAGNOSIS 2: 71946 JOINT PAlN-LlLEG PROCEDURE: W0015 VAS CERTIFIED AMBULANCE EMERGENCY (PRE-HOSPITAL) TRANSPORTATION SERVICE GATEWAY HEALTH PLAN, INC 70.00 70.00 51 8888888 ". Johnson, Duffie, Stewart I' -"leidner By: C. Roy Weidner, Jr. I.D.No.19530 301 Market Street P. O. Box 109 Lemoyne, Pennsylvania 17043-0109 (717) 761-4540 crw@jdsw.com Attorneys for Defendants TAKENYA WATSON, a minor, by JO WATSON, her cousin and guardian, and JO WATSON, in her own right, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 04-5831 Plaintiffs v. CIVIL ACTION - LAW JURY TRIAL DEMANDED LIBERTY FORGE GOLF COURSE, INC., individually and tld/b/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC., individually and tld/b/a LIBERTY FORGE GOLF, LLC, individually and tld/b/a LIBERTY FORGE GOLF COURSE, Defendants v. WILLIAMS-SONOMA, INC., Additional Defendant GENERAL RELEASE OF ALL CLAIMS KNOW ALL MEN BY THESE PRESENTS, that TAKENYA WATSON, a minor, by JO WATSON, her cousin and guardian, and JO WATSON, in her own right (hereinafter for convenient reference "Releasors", or "we") for and in consideratiCln of the payment made by or on behalf of LIBERTY FORGE GOLF COURSE, INC., individually and tld/b/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC., individually and t1d/b/a LIBERTY FORGE GOLF, LLC, individually and tld/b/a LIBERTY FORGE GOLF COURSE (hereinafter for convenient reference collectively "Liberty Forge") and WILLIAMS-SONOMA, INC., any and all insurers, agents, representatives, employees, officers, directors, attorneys, predecessors, successors, divisions, subsidiaries and affiliates, and all and evelY person, firm or entity who is or may be liable on account of their actions, (hereinafter for convE3nient reference "Releasees") of FIFTEEN THOUSAND DOLLARS ($15,000.00), the receipt and sufficiency of which is hereby acknowledged, do for ourselves, our heirs, executors, administrators, successors, insurers, and assigns hereby remise, release, and forever discharge completely and absolutely Releasees from any and all actions, causes of action, suits, suit costs, claims, damages and demands of every kind, name or nature whatsoever, known or unknown, whether in law or in equity, which we or anyone claiming through us in any way may have or will claim or could claim to have against Releasees, including, but not limited to, any and all claims, damages, losses, costs or injuries whatsoever based upon or in any way arising out of, related to or resulting from or to result from a certain incident which is the subject of the above-captioned lawsuit, and any and all claims which we, our heirs, successors, and assigns have made or could havEl made, whether accrued or not, whether known or unknown, whether anticipated or unanticipated and whether or not asserted in a suit now pending. It is understood and agreed that the total consideration recited above is payable as follows: Liberty Forge Williams-Sonoma, Inc. TOTAL $7,500.00 $7,500.00 $15,000.00 It is further understood and agreed by Releasors that neither of the above named Releasees shall be responsible for more than their share specified above of the total consideration. We intend that this release shall be complete and shall not be subject to any claim of mistake of fact, or of law, and that it expresses a full and complete settlement of liability denied by Releasees, and, regardless of the adequacy or inadequacy of the amount paid, this release is intended to avoid these and future claims or lawsuits agslinst Releasees. The payment referred to herein is in compromise of a doubtful and disputed daim and such payment is not to be construed as an admission of liability on behalf of Releasee:> or anyone on their behalf. To the contrary, Releasees expressly deny any liability. By their signatures below the Releasors and their couns,el agree that they will satisfy any future, debts, liens, claims or indemnity obligations which apply, now or in the future, to all or any part of the settlement proceeds, or to the various claims which are herein released, and that they will jointly and severally indemnify, defend and hold the Releasees harmless for any claims, or alleged claims, with regard to same, including the payment of reasonable attorneys fees actually incurred in the defense and/or the resolution of such claims or alleged claim. Releasors further certify, state, declare and acknowledge that they have had their own legal representation throughout these proceedings in the person of Clark DeVere, Esquire and have been advised by him in all matters pertaining hereto and admit that no representations of fact or opinion have been made by Releasees or anyone acting on their behalf to induce this compromise or payment or release. In making this settlement, Releasors certify, state, declare and acknowledge that they have not relied on any statements or representations by Releasees of either the extent of financial responsibility or extent of legal responsibility of Releasees and that it is their intention that this release be complete and shall cover all losses, damages and injuries insofar as they relate to Releasees. As further consideration for the amount paid to Releasors, we further agree that any suit filed by us on our behalf shall be marked settled, discontinued and ended of record. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital. IN WITNESS WHEREOF AND INTENDING TO BE LEGALLY BOUND HEREBY, Releasors have hereunto set their hands and seals this day of 2005. WITNESS: Clark DeVere, EsqUire Takenya Watson, a minor, by Jo Watson, her cousin and guardian (SEAL) Jo Watson (SEAL) CAUTION: READ BEFORE SIGNING - YOU ARE SIGNING A GENERAL RELEASE OF ALL CLAIMS AGAINST THE RELEASEE, COMMONWEALTH OF PENNSYLVANIA COUNTY OF ss: ON THIS the day of , 2005, before me, the undersigned officer, personally appeared JO WATSON, as guardian of TAKENYA WATSON, known to me or satisfactorily proven to be the person whose name is subscribed to the foregoing instrument, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and offidal seal. Notary Public COMMONWEALTH OF PENNSYLVANIA COUNTY OF ss: ON THIS the day of , 2005, before me, the undersigned officer, personally appeared JO WATSON, known te> me or satisfactorily proven to be the person whose name is subscribed to the foregoing instrument, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. Notalry Public :25435D 5774-498 CONTINGENT FEE AGREEMENT ':I 'oIi!e, ;:]0 0",rs"", individually and as parent(s) and natural guardian(s) of fa k l'JI'(4.. ",Ja. f50^ , retain and authoriz<e the law firm of Metzger, Wickersham, Knauss & Erb, P.C" to do whatever they deem necessary or desirable in order to represent my d ocJ,fhr in all claims for compensation and reimbursement for personal injuries, wage loss, and economic and other damages resulting from an ~CJ{ t: Ccr i- Gee _ that occurred on cr 6/'0", r 7 /z.v /0 '? . I 1. Attorney's Fees: The fee of the attorneys shall be contingent as follows: (a) Twenty-five percent (25%) of gross reCOVf:ry; (b) SHOULD THERE BE NO RECOVERY BY SUIT OR SETTLEMENT, SAID ATTORNEYS DO NOT HAVE ANY CLAIM AGAINST US OF ANY KIND FOR LEGAL SERVICES RENDERED_ 2. Expenses of Litil!ation: Actual expenses incurred on the business of the client shall be borne by the client and my attorney shall be reimbursed out of the balance, after deduction of attorneys fees, of any recovery for all legal expenses incurred in the prosecution of this claim which have not already been paid by me. We do hereby agree to pay all expenses incurred by our attorney in the preparation and presentation of this case and do understand that these expenses include, but may not be limited to, costs of medical Teports and records, stenographic expenses connected with depositions, expert witness fees, photocopying charges, and mileage charges connected with the rendering of legal services, We understand that we are responsible for payment of these expenses regardless of the eventual outcome of the case and further understand that if our attorney deems it necessary, we may be asked to advance these costs prior to the incurring of any such expenses or the scheduling of any deposition. Document#: 234/30.1 3. We hereby further agree that our attorney may charge us reasonable additional compensation if it is necessary to try the case more than once, if the case is appealed, or if proceedings in other courts are necessary because of the change of circwnstance of a party or for other reasons, 4. We hereby further agree that our attorney is hemby authorized to bring suit or to settle and compromise the claim, to execute all docwnents pertaining thereto, and to do all lawful acts requisite for effecting the claim on our behalf 5 . We further authorize our attorney to payout of any proceeds of settlement or trial any unpaid medical bills for treatments or services made necessary by the injuries sustained in this accident and any workers' compensation liens. 6. We agree that our attorney accepts this employment on the condition that he will investigate this claim, and if it appears to be a recoverable claim, he will proceed to handle the claim; but if, after investigation, the claim does not appear to be mcoverable, said attomey shall then have the right to rescind this Agreement. 7. We hereby further agree that if we decide to tfnninate this authority before any settlement is offered or any award is obtained the firm shall be entitled to reasonable compensation for all work done on the case up to that point. We agree that reasonable compensation for Clark DeVere, Esquire, or any other attorney involved in the handling of this case, shall be Two Hundred Dollars ($200.00) per hour, or such higher rate as shall constitute his standard billing rate at the time that the work is performed or the agreed upon percentage fee of one-third of any ultimate recovery, whichever is greater. 8. We agree that our attorney may withdraw from this case at any time after reasonable notice to us, and we agree to keep him advised of our whereabouts at all times and to cooperate at all times in the preparation and trial of this case, to appear upon reasonable notice for depositions and Court appearances, and to comply with all reasonable requ(:sts made of us in connection with the preparation and presentation of this case. Document #: )82430. ] - 2 - 9 . We also understand that if the investigation reveals that a parent is contributorily negligent in causing the accident the attorney's representation will solely be limited to representing the injured minor and there will be no representation of the parent. I also waive any conflict of interest that may arise by my meeting with the attorney to discuss the case. 10. I understand and agree that in the event that my account is turned over for collection because of unpaid fees and/or costs/expenses, I will be responsiblf' for payment of the costs of suit as well as reasonable attorney fees incurred in the collection of the monies owed to Metzger, Wickersham, Knauss & Erb, p,c. IN WITNESS WHEREOF, I have signed below on this Z&~day of .r ",IT ,2003. 0, l5JGJvQ&4) 'CTIf'ENT: CLIENT: METZGER, WICKERSHAM, KNAUSS & ERB, P.C. ATTf~ ~ DeV(:re, Esquire Document #: /82430.1 - 3 - 07/19/2005 10:49 AM Page 1 of 4 200072 / Watson, Ms. Takenya Settlement Memorandurr! DEDUCT AND RETAIN TO PAY: Metzger Wickersham ChartONE, Inc.; Harrisburg Hospital medical records ChartONE, Inc.; OIP medical records & bills Commons, Mr. Tracy; Witness fee Cumberland County Prothonotary; Certification of subpoenas Cumberland County Prothonotary; Certification of subpoenas Cumberland County Prothonotary; Filing fee for Complaint Cumberland County Sheriff; Deposit for service of Complaint. Douglass, Mr. David L.; Witness fee Kelly, Mr. Andrew C.; Witness fee Lower Allen Township Police Dept; Medical and billing records for ambulance Lower Allen Township Police Dept; Police accident report Lyter, Mr. Charles M.; Witness fee Metzger Wickersham; Copies Metzger Wickersham; Fax Metzger Wickersham; Long distance phone Metzger Wickersham; Postage Refund - Cumberland Co. Prothonotary Refund - Cumberland County Sheriff Total due Metzger Wickersham $ 26.43 $ 32.!55 $10.00 $12.00 $ 8.00 $ 55.S0 $ 100.00 $10.00 $10.00 $10.00 $10.00 $10.00 $ 91.152 $ 37.00 $ 3.85 $ 82.76 $ -4.00 $ -29.54 $ 476.07 Total Deductions Total Amount Due To Client Less Previously Paid To Client Net Amount Due Client $ 476.07 $ -47607 $ 0.00 $ -476.07 I hereby approve the above settlement and distribution of proceeds. Date: Name: VERIFICATION I, Jo Watson, as cousin and guardian of Takenya Watson, hereby certifY that the following is correct: The facts set forth in the foregoing Petition fOT Approval of Minor Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Settlement is that of counsel and not my own. I have read the Petition fOT Approval of Minor Settlement, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief, To the extent that the content of the Petition for Approval of Minor Settlement is that of counsel, I have Telied upon such counsel in making this Verification. I hereby a,~knowledge that the facts set forth in the aforesaid Petition fOT Approval of Minor Settlement are made subject to the penalties of 18 Pa. C.S.A. 94904 relating to unsworn falsification to authorities. J !~d d' o tson, as cousm an guar Ian of Takenya Watson Dated: ~ 8~ \ QV) 332099-1 CERTIFICATE OF SERVICI!j;, I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P_C., heTeby certify that I served a true and exact copy of the a Petition to Approve Settlement and Distribution ofPToceeds with reference to the fOTegoing action by first class mail, postage prepaid, this~~ayof ,J..){'( ,2005, on the following: Adam M. Sorce, Esquire David F, White, Esquire MARSHALL, DENNEHEY, WARNER, COLEMAN & GOGGIN 620 West Germantown Pike, Suite 350 Plymouth Meeting, P A 19462 C. Roy Weidner, Esquire Johnson, Duffie, Stewart & Weidner 301 Market Street P. 0_ Box 109 Lemoyne,PA 17043-0109 c~~ Clark e ere, Esquire 332099-1 ,- ....."- .-.:'> () ("":^) ,,;-n <;..--' ,.1"' <.c- (;'-. . r~.) u~ (~. :: -- c' - T AKENY A WATSON, a minor, by JO WATSON, her cousin and guardian, and JO WATSON, in her own right, Plaintiffs '>' RECEIVED JUL 2 6 ZOO~ IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA v. CIVIL ACTION - LAW LIBERTY FORGE GOLF COURSE, INe. individually and tJd/b/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC. individually and tJd/b/a LIBERTY FORGE GOLF COURSE, : and LIBERTY FORGE GOLF, LLC, individually and tJd/b/a LIBERTY FORGE GOLF COURSE, NO.04-583 :i Defendants v!. WILLIAMS-SONOMA, Additional Defendant : JURY TRIAL DEMANDED ORDER AND NOW, this ~ day Of~, 2005, upon presentation and due consideration of the foregoing Petition for Approval of Minor Compromise Settlement and Distribution of Proceeds, it is heTeby ORDERED and DECREED in accordance with the provisions ofPa. R.C.P. 2039 that the Petition is GRANTED. Payment of attorney fees and expenses as listed in the Petition is approved and payment of $10,188.40 to minor Petitioner, Takenya Watson, is directed to be: made as follows: (a) The sum of$10,188.40 to be distributed on behalf of Takenya Watson to be deposited in one or more savings accounts in the name of Takenya Watson in banks, building and loan associations, savings and loan associations, or credit unions, deposits in which are insured by a Federal government agency, provided that the amount deposited in anyone such savings institution shall not exceed the amount to which accounts are thus insured, OT in one or more accounts in the name ofTakenya Watson 332099-1 ^ t ~~i '\ c:l\ ~~~ ~ 'f ~ i , < 'I 11,1 I.. ~n'l' SOOl L'1 < 'co 1 ,.~ :JH =',-) investing only in securities guaranteed by the United States Government or a Federal governmental agency managed by responsible financial institutions, (b) No withdrawal can be made from said chosen account until Takenya Watson attains majority, except as authorized by a prior court order of this Court. (c) Petitioner shall provide proof of deposit by filing proof thereof with the Prothonotary of Cumberland County. (d) Counsel shall be permitted to collect an attorney's fee equivalent to twenty-five percent (25%) of$15,000, or $3,750 and reimburseml~nts of costs in the amount of $476.07. (e) The sum of$585.53 repTesenting the DPW lien for m,~dical bills shall be held in escrow until negotiation between counsel and DPW. .My remaining funds after negotiation should be deposited in an account as indicated in subparagraph (a) above, 332099-1 - Johnson, Duffie, Stewart & Weidner By: C. Roy Weidner, Jr. I.D. No. 19530 301 Market Street P. O. Box 109 Lemoyne, Pennsylvania 17043-0109 (717) 761-4540 crw@jdsw.com Attorneys for Defendants TAKENYA WATSON, a minor, by JO WATSON, her cousin and guardian, and JO WATSON, in her own right, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 04-5831 Plaintiffs v. CIVIL ACTION - LAW LIBERTY FORGE GOLF COURSE, INC., etal., JURY TRIAL DEMANDED Defendants v. WILLIAMS-SONOMA, INC., Additional Defendant PRAECIPE TO SETTLE AND DISCONTINUE TO THE PROTHONOTARY: Please mark the above captioned action settled and discontinued, including all counterclaims, crossclairns and joinders of additional parties, METZGER WICKERSHAM BK/.. ?/;i~ Clark DeVere EIDNER MARSHA ,DENNEHEY, WARNER, COLE N G GIN By: DISCONTINUANCE CERTlFICA TE AND NOW, Q~ I (?- ':J (Y)..s as above directed. ....lEpI I AR CERTIFICA TE OF SERVICE AND NOW, this 1:.1-1;{ day of~~n'&'r, 2005, the undersigned does hereby certify that she did this date serve a copy of the foregoing document upon the other parties of record by causing same to be deposited in the United States Mail, first class postage prepaid, at Lemoyne, Pennsylvania, addressed as follows: Clark DeVere, Esquire Metzger Wickersham 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 Adam F. Sorce, Esquire Marshall, Dennehey, Warner Coleman & Goggin 620 Freedom Business Center, Suite 300 King of Prussia, PA 19406 JOHNSON, DUFFIE, STEWART & WEIDNER BY:/1'~;.t~.4~ 'chelle H. Spangler :249273 5774-498 C) .' ... , ~. ,..., :":i~ ":;]' c,..:; _.,~, , C,) (~ TAKENYA WATSON, a minor, by JO WATSON, heT cousin and guardian, and JO WATSON, in heT own right, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA v. CIVIL ACTION - LAW LIBERTY FORGE GOLF COURSE, INC. individually and t/dIb/a LIBERTY FORGE GOLF COURSE, LIBERTY FORGE HOSPITALITY, INC. individually and t/dIb/a LIBERTY FORGE GOLF COURSE,: and LIBERTY FORGE GOLF, LLC, individually and t/dIb/a LIBERTY FORGE GOLF COURSE, NO.04-583I Defendants v. WILLIAMS-SONOMA, Additional Defendant : JURY TRIAL DEMANDED PRAECIPE TO FILE PROOF OF DEPOSIT TO THE PROTHONOTARY: As directed by the Court Order entered in the above-captioned action on July 31, 2005 by the Honorable J. Wesley Oler, please file the Proof of Deposit from the PSECU which is attached hereto and incorporated heTein by reference as Exhibit "A". Also attached as Exhibit "A" is a letteT from PSECU dated September 9, 2005 indicating that the amount of$10,188.40 has been placed in a restricted account until minor Takenya Watson attains the age of 18. METZGER, WICKERSHAM, KNAUSS & ERB, P.C. By c;:~~u_ Clark De ere, Esquire Attorney J.D. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 (717) 238-8187 Attorneys for Plaintiffs Dated: q-I..J-o~ 332099-1 PSECIiI the finaneia/link", September 9,2005 METZGER WICKERSHAM KNAUSS ATTY CLARK DEVERE 3211 NORTH FRONT STREET POBOX 5300 HARRISBURG PA 17110-0300 & ERB PC RE: COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA TAKENYA WATSON 209-72-9709 No, 04-5831 To Whom It May Concern: As directed by the court order, we have placed the amount of $1 0, 188.40 in a court approved share. Enclosed you will fmd a copy of the transaction receipt. This share has been restricted until the minor reaches the age of 18. This account is federally insured by NCUA- National Credit Union Administration, a US Government Agency. If you have questions, call us at 234.8484 in Harrisburg or call our toll-free number 800.237.7328. At the menu prompt, enter Option 6, then extension 3570. A trained Member Service Representative will help you. Thank you for allowing us to be of service to you. Sincerely, Member Service Representative Certificate/IRA Department Cc: 10 Watson Pennsylvania State Employees Credit Union Main Address: 1 Credit Union Place, Harrisburg, PA 17110-2990 . (717) 234-8484 . (800) 237-7328 !..' . Mailing Ad:'ce~, pOBa< 6701}cl:'a"i,bu'g,.P~17J06:701.3: EU17n:21 OO!TDDL'.(800) 472,1.967 " Savings federally Insured up to $100,000 by the National Credit Union Admlnlstrotlon www.psecu.com PSECIt; 1;..,1iJlWhmmlUilr:I.IIII1I1I'1:I;j,'lT:lilflllnr.TiI PO. Box 67013 (717) 234-8484 (Harrisburg) Harrisburg, PA 17106-7013 (800) 237-7328 (Nationwide) website - http://www.psecu.com TRKENYA M WATSON .TO Lo.IATSDN 235 SWATRRn ST STEELTON PR 17113 Ef~F,l_,{ kcount IZi209XXXXXX WATSON EARLY, TAK EFFECT: 09/09/05 POST, 09/09/05 TLR: 0145 !\IEXT :D DUE DATE PRINCIPAL INTEREST FEES TRAN .AMOUNT PREV BAL NEW BALANCE '1 10,188.40 ll!lI::lOS it to REGULAR SHAflE 0.00 0.00 10,188..4121 18.05 10,206.45 SEQ: #IS 10'+88 ~.....;-;,,--.i.-,- __ ~,~_ __..::..........;.:_ ::...."....-.._. ~..... .;..~~~ .;.....::.....;......__..... __..- ....._ _.___'- _ .......;;_...;...;,..; ...;:;:..::..~___ _~__ _..;...;.. .;;......;.......;....;... ...;...;.....::....::....::...;;.;..;..;;.......___ ...:.._ ._.___ ;hecli Rece ;;vec:l' TOD (717) 777-2100 (800) 472-1967 CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & ETb, P.C., hereby certify that I served a true and exact copy of a Praecipe to File Proof of Deposit with TefeTence to the foregoing action by fiTst class mail, postage prepaid, this 13V'--aayof '5rk/Yl/Ju ,2005, on the following: Adam M. Sorce, Esquire David F. White, Esquire MARSHALL, DENNEHEY, WARNER, COLEMAN & GOGGIN 620 West Germantown Pike, Suite 350 Plymouth Meeting, PA 19462 C. Roy Weidner, Esquire Johnson, Duffie, Stewart & Weidner 301 Market Street P. O. Box 109 Lemoyne, PA 17043-0109 cC~~llire 332099-1 ,. ~{l '-:-3_ ;\' , ~ " , (;. ct"': (J;