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13-4472
Nor" THE CHARTWELL LAW OFFICES, LLP A tiorneyfor Defendant BY: B. CRAIG BLACK, ESQ. Horace Mann Insurance Company Attorney I.D.: 36818 30 N. P Street, Suite 1050 Harrisburg, PA 17101 (717) 909-5170 IN RE: SYDNEY D. RICE COURT OF COMMON PLEAS CUMBERLAND COUNTY No. CIVIL ACTION - 7-') CD 5C PETITION FOR APPROVAL OF MINOR'S COMPROMISE And Now, this day of 2013 come Horace Mann Insurance Company and David Rice, par/ht artiVnatural guardian of Sydney D. Rice, by and through counsel, B. Craig Black, Esquire of The Chartwell Law Offices, LLP and hereby submit the instant Petition for Court Approval of Minor's Compromise proposed between Horace Mann Insurance Company, David Rice as parent and natural guardian of Sydney Rice and Colleen Rice, wherein the following is averred: 1. David Rice is an adult individual who currently resides at 40 Sycamore Drive, Mechanicsburg,PA 17050. 2. David Rice is the father of Sydney D. Rice, a minor(hereinafter"Sydney Rice"). Sydney Rice's date of birth is April 5, 2003. Her social security number is 207-80-2038. 3. Sydney Rice currently resides with her father, David Rice and mother Colleen Rice at 40 Sycamore Drive, Mechanicsburg, PA 17050. 0 to 1.-11 C1.7 y ff lof 4. On November 12, 2012, Sydney Rice was a passenger in her mother, Colleen Rice's vehicle. She was secured in a car seat in the rear driver's side seat of the vehicle. The vehicle was in the process of turning left onto Route 114 from Raspberry Drive, Silver Spring Township, Cumberland County when it was struck by another vehicle while attempting to enter onto the roadway. 5. As a result of the accident, Sydney Rice was airlifted to Milton S. Hershey Medical Center, ("MHMC"). She was evaluated and treated for facial lacerations and underwent diagnostic radiologic examinations to ensure the absence of any fractures and/or neurologic trauma. 6. Sydney Rice was admitted to MHMC overnight for observation and released the next day, November 13, 2012. During her admission she was evaluated by the pediatric trauma team and treated by the plastic surgery department who repaired her facial lacerations. True and correct copies of the care and treatment records for Sydney Rice at MHMC are attached hereto, labeled as "Exhibit A" and specifically incorporated herein by reference. 7. Sydney Rice recovered well from the surgical repair of her facial laceration and is thought to be in good health currently. Appended hereto, labeled as "Exhibit B" and incorporated herein is a letter from Sydney's attending plastic surgeon, John Potochny, M.D. describing Sydney's current status and his assessment and recommendations with respect to her future care and treatment. 8. Other than the initial care and treatment received by Sydney from Dr. Potochny and the pediatric trauma team at MHMC, Sydney has attended two (2) follow-up visits at Hershey Medical Center with the chief resident in the Division of Plastic Surgery. Sydney has not required any additional care or treatment by any other health care providers. As per the letter from Dr. Potochny (Exhibit "B"), it is anticipated that Sydney will not require future intervention in order to address any of the injuries which she sustained as a result of this motor vehicle accident. 9. At the time of the accident, the vehicle in which Sydney was a passenger was owned by Colleen Rice and was insured by Horace Mann Insurance Company. A copy of the Horace Mann Insurance Company Declaration Sheet for the pertinent policy is attached hereto, labeled as "Exhibit C"and specifically incorporated herein by reference. 10. The policy of insurance in place at the time of the accident provided for $100,000.00 in bodily injury limits. See "Exhibit C", supra. 11. Horace Mann Insurance Company has offered the entirety of its $100,000.00 bodily injury policy limit pursuant to a Proposed Structured Settlement to Sydney Rice. Sydney's father and natural guardian, David Rice believes that the acceptance of such a proposal is within the best interest of Sydney Rice. 12. Under the terms of the Proposed Structured Settlement, Sydney would receive the following periodic payments: a. The sum of$20,000.00 annually for four years guaranteed beginning on April 5, 2021 and ending on April 5, 2024; b. The sum of$50,805.60 as a guaranteed lump sum to be paid on April 5, 2025. 13. Total the sum to be paid to Sydney Rice on or before April 5, 2025 will accumulate 1 $130,805.60. 14. The structure contemplated by the proposed Release and Settlement Agreement would be placed with Pacific Life Insurance Company, an A.M. Best A+ rated company; Standard and Poor's A+rated company; and Fitch's A+rated company. 15. The terms of the proposed Release and Settlement Agreement are set forth in the proposed Release and Settlement Agreement, a copy of which is appended hereto, labeled as "Exhibit D" and specifically incorporated herein by reference. 16. The parties in this matter were able to reach an agreement for the proposed resolution of Sydney's claims without having to file litigation and there are no attorney's fees to be accounted for out of this Settlement proceeds. 17. There are no liens or claims raised on behalf of any medical provider, medical supplier, Medicare, Department of Public Welfare, ERISA eligible carrier or any other entity which need to be satisfied out of the proceeds of this Settlement. Sydney Rice did not receive medical assistance benefits, and all medical bills were paid through the Horace Mann policy first party benefits or by Capitol Blue Cross. Attached hereto, labeled as Exhibit "E" and incorporated by reference herein is a lien/interest clearance letter from Capitol Blue Cross waiving any interest it may have in any recovery. 18. David Rice hereby approves of the proposed Settlement as he believes it to be fair and reasonable in light of the insurance policy limits, and feels that it adequately compensates Sydney Rice for the extent and nature of injuries she sustained. See: Affidavit of David Rice attached hereto as "Exhibit F" and incorporated by reference herein. 19. Petitioners hereby seek This Honorable Court's approval of the proposed Minor's Compromise for the claims of Sydney Rice against Colleen Rice in the manor set forth in the Release and Settlement Agreement attached hereto as "Exhibit D", with proof of a deposit to be filed with the Court within sixty (60) days of the Court's approval pursuant to the Pennsylvania Rules of Civil Procedure. WHEREFORE, Petitioners respectfully request that This Honorable Court enter the attached Order approving the Compromise and Settlement as set forth herein above. THE CHARTWELL LAW OFFICES,LLP Date' By: c - A B Cray rai r lack,—Es—qu—i—re------, i A I Y I.D. NO: 36818 T 30 . 3rd Street, Suite 1050 Harrisburg, PA 17101 (717) 909-5170 (717) 909-5173 (fax) eblack@chartwelllaw.com Attorney for.Horace Mann Insurance Company EXHIBIT 66A99 r PENNSTATE ± i (p' Debra Rhoads 500 University Drive (717)531-6964 �=r Patient Financial Services Hershey,Pa 17033 Fax:(717)531-0494 C) E-mail:drhoads@PSU.EDU O CD December 5, 2012 N Horace Mann insurance j j PO Box 962 w �o Morrisville, NC 27560 .I, �° Patient Name: Sydney D. Rice Claim#: 16875C !S—,> CD w i To Whom It May Concern: i i Penn State University Hospital, The Milton S. Hershey Medical Center, Hershey, PA i 17033, is an Accredited Level 1 Trauma Center. In Compliance with Pennsylvania Law (ACT 6), physicians charges and facility charges associated with the treatment of a patient in an Accredited Trauma Center will be paid at 100% of the billed amount. The charges are exempt from the Medicare Reimbursement rate of the Medicare Fee Schedule times 110%. PLEASE REMIT PAYMENT OF 100% OF OUR CHARGE WITHIN 30 DAYS. If you have any questions, please feel free to contact me at my direct phone number, (717) 531-6964. Sincerely, 6 or De&a Maas Patient Account Associate Hershey Medical Center .Eastern AUtO DEC 2 7 7012--`- 0 PENNSTATE HERSHEY (D IN 11111111111111111111111111111 (C) PXT. Muto ,S. Hershey NAME: RICE. SYDNEY 7512438 OOs*: 10512938 DER D ITCH CHRISTO MD9: 46225 Medical Center. DOL 04/05/2003 VISIT 1)4ti: 11112/2012 0 1 1 nr- rhp;? SEX: F 0 :3 TRAUMA TEAM SIGN-IN SHEET LL SELF PAY (D 0 Date TRAUMA NUMBER f to TRAUMA LEVEL 1 2 3 Trauma Standby paged at hrs Trauma Response paged at hrs LO N. -0,00-0 ening j�� 0 ED Attd —C) 0 Trauma Attending Trauma Team Leader(PGY4/5) Ph Senior Trauma Resident(PGY 4/5) 0 00 Junior Trauma Resident(PGY 2/3) 0) Junior Trauma Resident(PGY 2/3) Junior Trauma Resident(PGY 1) Junior Trauma Resident(PGY 1) Emergency Med. Resident(PGY 213) Emergent y Med. Resident(PGY 2/3) Emergency Med. Resident(PGY 1) Trauma Physician Extender Trauma Physician Extender Anesthesiology Attending Anesthesiology Resident Certified Registered Nurse Anesthetist Respiratory Therapy Radiology Attending Radiology Resident Radiographer#1 (Diagnostic) A r t Y_ Radiographer#2 (Diagnostic) 6AOo�,'A 1 ;/63 3,5- Radiographer(CT) hc Emergency Medicine EMT Chaplain Pw%-I OR Technician/Nurse Pediatric Critical Care Attending Pediatric Critical Care Resident Child Life Specialist affyvk/,l 1Y Trauma Coordinator/Case Manager KIM WMC, OMIN " LN 9 0,WOTA Orthopaedics Pager 2002) Neurosurdery (Pager IO01) Plastic Surgery ENT PGY=Post Graduate Year Original Copy-Medical Records MR 414 Rev.1/08 Page 1 of 1 Eastern AutO Pink Copy-Emergency Dept TRAUMA TEAM SIGN-IN Sfff 7 ZOU Yellow Copy-Trauma I Services ,i w•5. l law v M. .ice. 7... 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I���\ t�{ ua 0 PENNSTATE HERSHEY NAME: RICE. SYDNEY '110M. Milton S.Hershey MP: 7512938 DOS;": 10512938 MD. DEFLITCH CHRISTO jjD#: 46325 Medical C6nter DOB: 04/05/2003 VISIT DATE: 11/120012 LOC,. EMER SEX: F tNSIIIS SELF PAY ED TRAUMA/RESUSCITATION FLOW SHEET jDate I I Time Stat Page 71me Pt r ed4,441 Response level 2 CJ Ambulance Helicopter: Interhospital Y N Age Sex Weight o Chart ci Labs 0 XR 0 CT PRE-HOSPITAL REPORT Q lk-r GS BP Clcl Loss of CoinsclousggsiRL Yes No Unknown #minutes HR Monitor Rhythm Immobilization: j�o CI _o6g Boa Splint RR Assistive Device Entrapped: Yes IJNO'j Unknown #minutes Spontaneous Rate/Pattern Self Extricated- Yes No S 0 P M H: V—) GCS Meds: Patent IV iite Ga L_Me sol'n Amt V_ No *1 0 0 Alle rgies: #2 0 0 #3 o o ITetanus: M -PRIM. SURVEY• . Airway Intervention Bracelet Location: a Patent Maintained Yes No 0 Mechanically maintained by 400 Oxygen mask I/min or_.L_% ID. Breathing 00 Airway&bag 0 Sponteneous rate/pattern Clo Err- slzeJrnr Blood Band, 0 Not breathing a%Mve device Ixatfm Sa02 Intubated by R*;— R7460055 Yas NO 00 Surgical airway-done by 111;w 0 0 Breath sounds R L Documenting Nurse: 0 0 Tachypnea Vent Settings 0 0 Intercostal retractions nine Support Nurse 0 0 Chest wall bruising Rate U* rcul ion R02 Physician signature: HR r{In(on arrival) Rhythm Tidal vol. mmHg(on arrival) PEEP Pulses R L Y- N. 1 0 Radial 00 Chest tube 0 Femoral sizes IV& Initial temp. qx1_W 54 0 0 up left -t A 0 0 Fir 00 Other intervention state J4 Patient covered 0 0 Hemorrhage? V_ Na 6�4 Warm blankets Y" N. 00 TV une, y"No 7 0 0 &terrial site i—size—g Patent? 0 0 Overhead warmer 0 0 rntwmf site 2_sbe_g Patera? C) 0 0 Chest site 3 . size_g Patent? 0 0 IV fluids warmed to 104°F 0 Abdomen 0 0 Arterial ime sue 0 PelvWretroperitoneal lft6-Repeat, mp,at 30_mlns. 0 Umbs MTP rime In/Wited* blan Pink Warm Pate Hot Cyanotic Cad Mottled COW Dry moist W47,711-40111-1711111Z MIMI GLASGOW J R '4,= Eye W49" — *1 UP If me•Opening T.voke COMA 9.12 Service called Arrived Response To in SCALE(GCS) 6-0 2 Trauma Attending L f ortho eest O"Onw ED Aftndmg Verbal confism 4 1 4 4 Neurosurg I Anesin, P=P.= W WOWS almd — AnestheSla Attending 2 1 �Ie 50-75m.Ha 272 Plasucr. seakir'. Uwe 1-49MM H9 I I senior Trauma Resident Beg A, 6j- 1) Other IkA. =T �d Na O Ptilse Pr Wt" 1; ReMPIMUMy Rate - 9 mm. 3 Other. an In min. 2 a No marar rmTwnsa 1 1 N_ MR IS: Eastern Auto ED TRAUMA/RESUSCITATION FLOW SHE ETEC 2 7 2012: F— SECONDARY SURVEY 0 Read ---ies No DesafPff-W X-ray 0 Scalp 6) 0 Laceration z,4\CK" V," G 0 0 vault Fracture Time Time cr Face 0 0 Basal Fracture Suspected CD �2'4y I C-spine Led$ CD 0 Laceration 0 0 Fracture - X.ray In 0 0 0 Jaw Instability I 1A e-• —Chest Eyes 0 0 Injury 'Other Abdomen/Pelvis 0 0 Decreased Vision Other Spines C) Ears 0 0 Hernotympanum Side: -Oth& Other 1 N O 0 CSF leak Side'. Other Nose 0 0 Bleeding Mouth 0 0 Tooih# eurovasculla=ent Neck Yes NO DesnYpbom Areas of Concern: 0 0 C-spine tenderness 0 0 0 Stepaft I crepltus � 0 0 Laceration 01 0 0 C-collar off time Pulse 0 0 0 Rehab collar time Ime Tamm Color _Capillary Refill Sensation Movement Pulse, I chest yes No 0 Chest wall injury Side: 0 0#ribs 0 0 Playsegmant CD 0 0 open pneumotharaK 00 0 0 Pneurnathom RIL CF) 0 0 Hemodurax R/L Abdomen Yes No vesaypon: 0 0 Skin contuslonlabrasion 0 (O.DIstension 0 0 Tenderneis &,A�J)9 injury Diagram 0 0 Guarding Fast t - Injury Diagram Key: Completed by Rectal heme: + - I= Open Fracture E = 15iochymosi5 Done by time 2= Amputation A = Abrasion NIG(oralln—S) 3= GSW C = Contusion Size_ Fr '4= Deformity I. iL- Laceration Inserted by time 5. Stab Wound S - Swelling Pedtoneat lavagoDft. 6. Bum T = Tenderness Done by time 7= Pain PW= Puncture Wound Return; 0 Clear 8= Rash I = Impaled Object 0 Pink 0 Gross blood Amount inhL5--d_cc Amount returned_cc fluid to fair 0 Yes cffN 0 NO Genitourinary Fffr Foley: 0 Yes 9 No 0 fieme+ Size Fr Inserted by time Itectal Tone: JD.Good 0 Decreased ���f�U U 0 Absent Prostate: 0 Normal Ov 0 Abnormal Blood c;bsftvLd at: Yes NO Vagina . 0 0 PJ!Ltum 0 6 Urethral meatus 0 0 Extremities 5 Ps Paralysis Parasthesia Pulses Pain Pallor Pain PU'7 Yes 0 yes 0 Yes 0 yes 4F 0 yes 0 RA No (W No r4o so No 0 NO—a Yes 0 yes 0 Yes ljo� Yes 0 yes 0 LA No No (7) No Pulses o 16 No a Yes es Yes yes 0 Yes(Q Yes 0 Yes 0 0 10 RL No No ek No 0 No 90 No 9) 0 0 es, as T,—S0 as 0 yes CP O. yes 0 No 0 00 0 No 41� No (D ILL No No Eastern Auto DEC 2 7 2012 ED TRAUMA/RESUSCITATION FLOW SHEET MR 157-- Trauma Resuscitation Flow Sheet Iap®���0© +����' Rime® Nursing Interventions • n mmoullmoom W V on 01113 "WI U 1191 MEN an W101 0 us ON EN 2-.? =V= VA np I LY,a 1.4 in 1MMMW r11 INN mmm MENNEN mmo MEN mmmmmommmons ONE mmmm mmmossommm ME mmmm annoommm ME WE 101 onsomomm��N ME ME mossomms ME wommomms 101 001 IN nommom ME IM1M1MM No sommom ME mm mom nommom 100 ==OMEN WON= 0 IN nomono - 110 0 monsomom 1MMM1M 111 0 IN MOONS Normal Ranges for Vital Signs Pupil Size(MM) MR-normals -Respirmin-ri BP-normals Infants 74150-100/70 Fetal Heart Tones 120-160 11-61 Infants 1 160 Infants 20- Toddlers 20-40 80/50:112/80 Toddlers 90-140 Preschool 23-3,4 =1 82/50 110/78 Preschool 80-110 School-Age 18-30 =a 84/54-120/80 0 School-Age 75-100 Adolescent 12-16 mi! 1" 0-90 88 Adolescent 6 1 2 3 4 5 • 7 8 9 .-J Crystalloid jOutput [Disposition at Discharge �� ������ Time arriv OTIme; RAW. M ff,M V!SW llllllllllllllllllllll[Valuablesi In HMC safe Given to family Name., Given to police Name-,- Other: DiSpeSitlon 0 OR 0 SIOU 0 Floor 0 Expired 0 Other mjeL._._ brqan/Tissue Donation • TOTAL OUTPUT: • Intake/Blood Components Medications PENNSTATE HERSHEY ��ti�11� C1 �111 �1tN1� Milton S.Hershey NA7: RICE. SYDNEY 045T: 10512938 MethCal e2lter Mp DEFLITCH C14RISTO ttD : A6325 1 1W 44/45/2443 VISIT DATE: 3111212412 SEX: F I-= EEIF P Y SELF PAY TRAUMA HISTORY AND PHYSICAL EXAMINATION, i��������ct��c�t�� Date: if Time: K"tip Hx of Present 111ness(HPI) MVC Betted? Yes ❑No ❑Airbag TiminglDurats`on. �'yvttvrs Eyes El Pedestrian r-1 Mcc' ❑Assault Signs/Symptoms: Amnesia?❑YeSZVLO ENT ❑Fail ❑sum ❑Electrical Loss of Consciousness?.❑Yes No Cardiovascular ❑Gsw ❑Stab ❑other Respiratory I r 4 aC GU J GI '°,f° Musculoskeltal r V-t Integumentary. . :.: �..:; 3,�,' Ptweighh Neurologic l 1V1o,�iifyit�g�ac�brs:... .:. • � ,,<,.,�:� ;...,;�:: -. i Broselowweight r: Other ❑Entrapment' .❑Ejection•. .Q Crush ❑Blast •� •�'•'. � All others negative/noncontributory. ;• , .; Helmet Yes No Envonmental Exposure B ypoihermia ❑miement, -.. , '.•: ` 5 ilF�is�i`� ,T r�>• ❑Chemical , ❑Biological ❑Radiation ❑Other. Allergies: , 1 Fall:Ht of fail: Fall from object: FFS:❑Yes ❑No Medications:Coumadin ❑Piavix ❑other. Other. Past Surgical Hr. "-C. `�}�121.t3''....,F,, ;��.. . ..,,� •,;_: s•._ .r;x t:a:'t.;S,<7:-, .r2a.; .• ,.:. S '`,•,u„? ': :.:t,:4,;,,;; Fami lY Hx Bleeding a ding Disorder❑Yes ❑No Airway.,or Patent ❑Obstructed Intubated: ❑OT ❑ NT +❑ Trach ❑other. gGnrontributatory/unobtamable Breathing: &[,ga lj Breath Sounds: Social Hr. Family Status: Circulation: P: BP: C l RR: ` -Z' Sat ❑Othe orylUobtorua ma6la' •'. Disability: GCS: M V E _ ❑Etoh ❑ Smoki Hx ❑lllega Drug FAST Exam: 545,q Exposure: Completed Last Meal: .. Last Tetanttr 5 nifary unJEy 2nd Vitals:Temp62 P. BP. R: `?t.0i Sat: 6 Wr HEENT: Head: (AX- 3 G— Eyes: 1-t 7 �°. Ears: TM's: (,t SUE r Battle's: d 2Gw, Face: Maxilla: Mandible: Nose: �-” .. «l::;,.i.... :r::. _,•_;�,.;�,.:�:,... Dentitia: vvof yvi Mouth: Dentures: Neck: Tenderness: All trepitus: Trachea MU rll Chest Wall:Ten demess: � Crepitus: Lungs: Back: . Tenderness: Cre u pit s: c Heart: lnit Abdomen: Distention: Kt) BS: Tenderness: Rectal: Tone Heme: Prostate:` fk Pelvis:Stable: Tgridemess: Vascular Exam; RadlaV Femoral 'Z-4 DP Z_. PT Right/Left ��� �I� LEGEND: L-laceration C&-closed fracture Resident 7761? Title pat Time a.mdpm. OFX-open fracture Ab-abraslon f J��y2, t`' ' q-,0 0 C-contusion COPYRIGHT,3998 PSG Orig-Chart...:: , MR till Rev.5/it TRAUMA HISTORY AN HY ICAL EXAMINATION Copy-TraumaServtces f�llllll llllllllll(Ilillllil�lilllllttl pastern AUte. DEC 2 7 2012 r 'TRAUM'A HISTORY AND PHYSICAL EXAMINATION CD .. I ;Citetiro[ gt' .taxi: _ ya.,+: Gla`sg'ow Coma Scale Trauma Score /y� n.: x ..4. .�?/ �Y�� }S.:^. �'"ff.+•S.'�'.::'f,�i�.''. �,?'t:+':R3 .:+Y`.•E'6'.. .'��•C J7,>`'.:4'`''.. l l C t 7 fire Opening Resp.Rate " SBP Q Cranial Nerves -- r Spinal Cord In t-No#re 2-Open to Pain 0-0 ,1070' N Motor: a'� t Open to Commandivoice 1-1-9 1-0-49 Spontaneous 2->36 ' x-50-69.: Ln. Verbal Response SensO :Pin rick vt.o v"i� t-None 3 25-35' ,...3-7„„0 90.., •, O ry. p Ti-tz 2-Incomprehensibleftans to Pain 10.24 >90. 3'-Inap ropdate/Cries to Pain �:.:.,•. PrOprlOCeptii)n yet t-t G =r Co used/Consolabte GCS lO t S AtertiOriented/interacts 0-3-4 Motor Response 1-5-7 j C3i L t-5 2-Deecnerebrate 2-8-10 r r 3-Decorticate 3- 1-13 W 11 1 4-Withdraws Wald avrs q .4-15 5 caGxes Pain j 1� "f bet's Tatar C:) 17.4"W3000 I> h' _�?� .s_:<.v�.y .:r : PT: Troponiti: UTA: ,:.,,. PTT: Myoglabin: rBili: � I(b CPK: Drug Screen:; 1" j (� ° r '� ALT: Amylase: 0) ABG: ALP: -IEas ['q , ETON: ECG: TEE: 7CRrays CSR: Pelvis: GT:.` catis` Hea t t CSpine: Lat. 'Extremities: Abdomen 1 AP Others: Odontoid T&L Spines: t�y�, ''((!� {. �] >�.. ,�.: ..r• ..'s? t'tx'rc .'fir•• :.k!`�,.r:3'.'�:i:"'..;:;,n;•:, :-rr,t:-_,-.°?_'. -J.t.RG,r t..��... r-. 7IeY..{.,�.L�p.{.'F s�'."'...'".f'�tra�T.l:r A',.5.#' Fi.M1'^Y: n'?i'4'-�i->S ^.d�3z.':'....r•-'r.x;''-aE,,...•:_•,:;x, ,.}a.'.,�.':,+.::.. :t»::.r 1:;;,;. .._...Y''i4 '.'_.$r• :F 4.i 4'' '�S:~:•i;�i.:�' '1.# �..:.'.:.•:•.'.n•.. .. Of saw and evaluated the patient and agree with the resident's findings and plans as written above. 0 See dictated note ❑I have reviewed the transport/EMS notes Admit: ❑PICLI El PIMC 4EVeds.Floor ❑SICU ❑NSICLI ❑IMC p NSIMC [1 Floor ' Neuro:GCS: ❑Consult NSGY p OR Crani p Repeat CT Consult Facial Trauma HEENT• Neck: 0 Consults ine 0 Miamil-Collar Q C-S ine Clear ©MR] Res CV: Gl:. ❑OR Exploratory ` GU: O Consult TIRO MS: ❑Consult Ortho/S ine ❑OR for Fracture I Psych:©Consutl Psych 0 Consult D+A . . „ i Proced6res:0 NG-Tube' ❑Udnary Catheter ❑A-line: 0 CvP s3: Chess tube: ©right El lest Q nPL- ' t asler�i Auto ni4f !s Attending Signature Datte"t"�7"�” ' Ti e MR 611 Rev.5/17 Orig- Chart TRAUMA HISTORY AND,PHYSICAL EXAMINATION copy-'.zraumaser�icPS Ped Surgery In pt Progresstote RICE, SYDNEY D - 7512938 CD (Q - Final Report* 0 I < Final Report CD 53 Document Contains Addenda 0 NJ PEDIATRIC SURGERY INPATIENT PROGRESS NOTE 0 Name: RICE, SYDNEY D 0 Patient Number: 7512938 0 DOB: 04/0512003 a Date of Service: 11/13/.12 0 co Hospital Day: 0 0 Surgical Hospital Day/Procedure: No procedures found No diagnoses found 24 HOUR EVENTS:Admitted overnight as a Trauma, s/p MVC SUBJECTIVE:Pt seen and examined by the Pediatric Surgery team. Currently, resting in bed without distress. Active Inpt Meds: amoxicillin 250 mg PO fid Active PRN Meds: morphine 1.5 mg IV q2h One Time Meds: (Completed) ceFAZolin 1,000 mg w/IV ONCE(Ordered) influenza virus vaccine 0.5 mL w/IM ONCE Active IV Meds: Dextrose 5%with 0.9% NaCl 1,000 mL+potassium chloride 20 mEq(D5-0.9% NaCl 1,000 mL+potassium chloride 20 mEq) 1,000 mL 70 mUHR OBJECTIVE: Vitals Temp Pulse BP RR Sp02 F102 11 Date Wt(kg) Wt(lb) 11/13 04:5436.6 96 87/48 24 97 --- 11 11/13 31.7 70 11/13 02:15 36.8 84 82/41 20 97 11113 31.7 70 11/12 22:52 -- 108 20 98 11/12 31.7 70 11/12 21:24 -- --- ----- 18 --- --- - 11 11/12 31.7 70 11/12 20:51 37 97 125/87 20 98 --- 24 Hr Tmax: 37.at11II220:51 Initial Wt: 11/12 kg 70 lb Printed by, Calloway, Earthenia D Page I of 4 Printed on: 12/5/2012 07:45 (Continued) Eastern Auto DEC 2 7 2012 C7 r I� Ped Surgery Inpt ProgressIfOte ` sv RICE, SYDNEY D 7512938 (5 *Final Report I 0 0 < CD IN'S&OUTS W 5' Input and Output-Last 24 hours(Last 8 hours) to Total In 220(220) Total Out: 0(0) Total Balance: 220(220) D5-0.9% NaCI 1,000 ML+potassium chloride 20 mEq: 910"21m IW Med Intake: 10 tim C Urine Count 1(1) 0 Input Z PO/NGT/GT Feeds I o TPN :_ — 00 output tput Urine Output(ml/kg/hr) :x 1 NGT/GT Output:_ Drain Output:— BM : Physical Exam: General :NAD HEENT:stitches on left frontal, dry blood j Heart:RRR Chest:CTAB Abdomen :soft, NT, ND Extremity:sensation intact Skin : Most Recent Lab Results over the last 24 Hours: No Latest CBC or BMP Found. ALT =41 on 11/12/201218:55 Amylase =97 on 11/12/201218:55 Lipase =281 on 11/121201218:55 PT =15.6 on 11/12/201218:55 PTT =32 on 11/12/201218:55 INR =1.25 on 11/12/201218:55 No Blood Gas Information Found. Printed by: Calloway, Earthenia D Page 2 of 4 Printed on: 12/5/2012 07:45 (Continued) Eastern Auto DEC 2 7 20I2 Ped Surgery In pt Progresslote RICE, SYDNEY D - 7512938 CD. (5 Final Report 0 CD Studies:Pending or Completed in the Last 24 Hours Chest XR Completed 0 C-Spine XR Completed Abdomen/Pelvis CT(Diaphragm to Symphysis Pubis).Completed 0 Brain CT.Completed 4. rQ Facial Bones CT Completed W ASSESSMENT:9 y/o female, s/p MVC with facial lacerations C) PLAN: 4-1. b1 )Day 2/7 of amoxicillin 2)Local wound care 4h. 00 3)Possible D/C 0 0) Disposition:Floor Signature Line Electronic Signature on File Electronically Reviewed/Signed by: Dorothy V Rocourt, MD Author Signature Dt/Tm:1 1/13/2012 08:11 AM Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Brett Engbrecht, Kerry Fagelman, Dorothy Rocourt, Mary Santos Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP, PNP-BC, Lynn Simmons MSN CRNP Electronically Reviewed/Signed by: Thu NPharn, MDCosigner Signature DtfTm: 1 1/1 312012 06:53 AM DVR DD: 11/13112 Addendum by Rocourt,Dorothy V on November 13,2012 08.25(Verified) Pediatric Surgery Staff Addendum: Patient seen and examined with the surgical team. I have reviewed the residents note and agree with the physical exam and plan of care with the following additions: doing well this morning. Concussive symptoms improved, no repetitive speach. Lacerations repaired by plastics, will continue on antibiotics as an outpatient. Advance diet as tolerated. Discharge home today. The questions and concerns of the father were addressed and he was updated with the plan of care. Subsequent Care Coding Selection Low Moderate High Printed by: Calloway, Earthenia D Eastern AutO Page 3 of 4 Printed on: 12/5/2012 07:45 DEC 2 7 2012 (Continued) x Ped Surgery In pt Pro gresslote RICE, SYDNEY D - 7512938 CD. Final Report 0 0 99231 99232 1 99233 Diagnosis CD x I 3 (n 0 Critical Care Coding Selection Critical Care Diagnosis Total time of Critical Care: cn 0 Discharge Coding Selection Cn 30 Minutes or Less More than 30 Minutes 0 0 99238 99239 Diagnosis 00 0) 1 No Charge-Pre/Post-Op Signature Line Electronic Signature on File Electronically Reviewed/Signed by: Dorothy V Rocourt, MD Author Signature Dt/Tm:11/13/2012 08:25 AM Pediatric Surgery. Drs. Robert Cilley, Peter Dillon, Brett Engbrecht, Kerry Fagelman, Dorothy Rocourt, Mary Santos Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP, PNP-BC, Lynn Simmons MSN CRNP Electronically Reviewed/Signed by: Tyler J Wallen, DOCosigner Signature Dt/Tm: 11/15/2012 03:44 PM DVR DD: 11/13112 Result Type: Ped Surgery lnpt Progress Note Date of Service: November 13,2012 05:28 Authorization Status: Modified • Author or Import Date: Wallen, Tyler J on November 13, 2012 05:31 Verified By: Pham,Thu N on November 13,2012 06:53 Encounter info: 10512938, HMC, Inpatient, 11/12/2012-11/13/2012 Printed by: Calloway, Earthenia D Page 4 of 4 Printed on: 12/5/2012 07:45 (End of Report) Eastern Auto DEC 2.7 2012 0 r_ . CAR Z HORAC& MTANW INSURA# PO BOX 962 MORRISVILLE NC 27560 HEALTH 9NSURANCE CLARM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 10 J:IJPICA CASE ID: 00010512938 PICA 0 1, MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER la.INSUREDS I.D.NUMBER (For Program In Item 1) :3 :](Mirdicer.#) CHAMPUS HEALTH PLAN BLKLUNG E](Medicaid#)[:](Sponsces SSN) F-1(MWnh-,1D#)F�(SSN-,1b) [:](W) Mom 16875C < 1, (D 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) S.PATIENTS BIRTH DATE SEX 4.INSUREDS NAME(Last Name,First Name,Middle Initial) -1 - 611 (n. RICE, SYDNEY D 1 A 3MO F® FREDERICKSON OUTPATIENT CENTER 0 'S.PATIENTS ADDRESS(No.,Street) S.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 1 40 SYCAMORE DR Self[:]Spouse[]ChildM Other 0 CITY jSTATE 8,PATIENT STATUS CITY STATE. MECHANICSBURG IPA Single M Married Q' OthrF] 0 Ul P _x ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(include Area.Coda) Full Time Part-Tim TI 1 17050 (717) 608-1747 Employed El sird-ant Student 0 9.OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER J uiRICE, COLLEEN J AD111212 C) LLI a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(Current or Previous) a.INSUREDS DATE OF BIRTH SEX -0 MM DD YY :z YWP80117575903 00505817 YES NO ME] FE] W b.OTHER INSURED'S DATE OF BIRTH 1:1 Pq MM DO YY SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME C G !12i1970 FM YES NO L PA 0 ME] Pq n c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME 0) S NO HORACE MANN INSURANCE FREDERICKSON OUTPATIENT C YES- M d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? CAPITAL BLUE CROSS CAI IN YES [:]NO ti yes,return to and complete Item s a-d. I� READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSUREDS OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNEDj%I_GH&MJRE ON FILE DATE 11 14 2012 SIGNED SIGNATURE ON FILE 14. )ATE OF CURRENT: ILLNESS(First symptom)OR IS.IF PATIENT HAS HAD SAME OR SIMILWILLNESS. 16.DATES PATIENT UNABLE WORK IN CURRENT OCCUPATION INJURY(Accident)OR GIVE FIRST DATE MM I Do I M MM DD YY 1MM1 1 1D2D 12 Oyyl 2 4 PREGNANCY(wp) 1 i FROM I t TO t ;"'E 17.NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18.- ------------------------ HOSPITALIMM ZATION DATES YY RELATED TO CURRENT SERVICES 17b. NPI I Do I MM FROM 111 12 i 2012 To 111 flil 26Y12 - 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAS? $CHARGES 1.'- 1:1 YES In NO I I 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY(Relate items 1,2,3 or 4 to Item 24E by Line) 22.MEDICAID RESUBMISSION CODE ORIGINAL REF.NO. I. 1959. 01 3, 1 1 23.PRIOR AUTHORIZATION NUMBER 24.A. DATE(S)OF SERVICE IPLA'61 rC. I D.PROCEDURES,SERVICES,OR SUPPLIES E F. G. H. I. J. 2: From TO (Explain Unusual Circumstances) DIAGNOSIS DAYS EPSW ID RENDERING 0 OR Fg� MM •Do YY MM DD YY MG CPT/HCPC$ I MODIFIER UNn DIAL PROVIDER to. 11�22 12 1 1 1211 199222 1 l 1 1 112 1 45241001 11 _NPI 12553716$8 0 W NPI- -- ----------------W 3 _ --------- -- �CqRDS NPI 4 I Va Roals NPI ------- W cc 0 a e M as ern IAU LU NPI 5 ----- -------- I- - A.- DEL 3 e 014 /pp ---- -----I--------- 6 t t t i i i i NPI 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENTS ACCOUNT NO. 27.#OCEPT�,SSIGNM 28.TOTAL CHARGE 29.AMOUNT AID 30.BALANCE DUE [E orgovt.clams son W?' NT 251857035 [:IFXI 23190167lF6BO YES ONO $ 4521001 $ doos 452400 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.SERVICE FACILITY LOCATION INFORMATION 33.BILLING PROVIDER INFO&PH 717) 531-700" a INCLUDING DEGREES OR OFIEDEN71ALS (I certify that the statements on the reverse HERSHEY MEDICAL CENTER DIV PEDIATRIC SURGERY kiJ MMT aAff7dMAbTTkY 500 UNIVERSITY DRIVE P 0 BOX 858 MC A410 V HERSHEY PA • 7033 HERSHEY PA 17033-0858 SIGNED 11 14 201 a. 12554,8208 I 2AT - Fb,E I I . I- NUCC Instruction Manual available at:www.nuce.org APPROVED OMB-0938-0999 FORM CMS-1500(08-Q5) 17—BECAUSE THIS FORM IS USED BY VARIOURAMNERNMENT A, ,D PRIVATE HEALTH PROGRALdft'tEE SEPARATE INSTRUCTIONS ISSUED BY 9:APPLICABLE PROGRAMS. IF— .,$, W NOTICE.Any person who knowingly files a statement of claim containing any misrepresentation or any false,Incomplete or misleading Information may be guilty of a criminal act punishable under law and may be subject to civil penalties. REFERS TO GOVERNMENT PROGRAMS ONLY MEDICARE AND CHAMPUS PAYMENTS:A patient's signature requests that payment be made and authorizes release of any information necessary to process C)the claim and certifies that the information provided in Blocks 1 through 12 is true,accurate and complete.In the case of a Medicare claim,the patients signature 0 authorizes any entity to release to Medicare medical and nonmedical Information,including employment status,and whetherthe person has employer group health Z) insurance,liability.no-fault,workers compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made.See 42 < CFR 411..24(a).If item 9 is completed,the patient's signature authorizes release of the information to the health plan or agency shown.In Medicare assigned or CD CHAMPUS participation cases,the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary as the full charge, 5; and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge 0.determination of the Medicare carrier or CHAMPUS fiscal intermediary if this Is less than the charge submitted.CHAMPUS is not a health insurance program but :3 makes payment for health benefits provided through certain affiliations with the Uniformed Services.Information on the patient's sponsor should be provided in those items captioned in"Insured":i.e.,items la,4,6,7,9,and 11. 0 BLACK LUNG AND FECA CLAIMS NThe provider agrees to accept the amount paid by the Government as payment in full.See Black Lung and FECA instructions regarding required procedure and Cp diagnosis coding systems. SIGNATURE OF PHYSICIAN OR SUPPLIER(MEDICARE,CHAMPUS,FECA AND BLACK LUNG) I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me or were furnished C)incident to my professional service by myemployee under my immediate personal supervision.except as otherwise expressly permitted by Medicare or CHAMPUS .D.regulations. (31 CDFor services to be considered as"incident"to a physician's professional service,1)they must be rendered under the physician's immediate personal supervision by his/her employee,2)they must be an integral,although incidental part of acovered physician's service,3)they must be of kinds commonly furnished in physician's offices,and 4)the services of nonphysicians must be included an the physician's bills. ForCHAMPUS claims,I further certify that I(orany employee)who rendered services am notan active duty memberof the Uniformed Services oracivillan employee 4y of the United States Government or a contract employee of the United States Government,either civilian or military(refer to 5 USC 5536).For Black-Lung claims, 00 0 1 further certify that the services performed were for a Black Lung-related disorder. 0)No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations(42 CFR 424.32). NOTICE:Any one who misrepresents orfalsifies essential information to receive payment from Federal funds requested by this form may upon conviction be subject to fine and Imprisonment under applicable Federal laws. NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE,CHAMPUS,FECA,AND BLACK LUNG INFORMATION (PRIVACY ACT STATEMENT) We are authorized by CMS,CHAMPUS and OWCP to ask you for information needed in the administration of the Medicare,CHAMPUS,FECA,and Black Lung programs.Authority to collect information is in section 205(a),1862,1872 and 1874 of the Social Security Act as amended,42 CFR 411.24(a)and 424.5(a)(6),and 44 USC 3101;41 CFR 101 et seq and 10 USC 1079 and 1086;5 USC 8101 et seq;and 30 USC 901 et seq;38 USC 613;E.O.9397. The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility.It Is also used to decide tithe services and supplies you received are covered by these programs and to insure that proper payment is made. The information may also be given to other providers of services.carriers,intermediaries,medical review boards,health plans,and other organizations or Federal agencies,forthe effective administration of Federal provisions that require otherthird parties payers to pay primary to Federal program,and as otherwise necessary to administerthese programs.For example,it may be necessary to disclose information aboutthe benefits you have used to a hospital or doctor.Additional disclosures are made through routine uses for information contained in systems of records. FOR MEDICARE CLAIMS:See the notice modifying system No.09-70-0501,titled.'Carder Medicare Claims Record,'published In the Federal Register,Vol.55 No.177,page 37549,Wed.Sept 12,1990,or as updated and republished. FOR OWCP CLAIMS: Department of Labor,Privacy Act of 1974,"Republication of Notice of Systems of Records,'Federal Register Vol.65 No.40,Wed Feb.28, 1990,See ESA-5,ESA-6,ESA-12,ESA-13,ESA-30,or as updated and republished, FOR CHAMPUS CLAIMS:PRINCIPLE PURPOSE(S):To evaluate eligibility for medical care providedby civilian sources and to issue payment upon establishment of eligibility and determination that the services/supplies received are authorized by law. ROUTINE USE(5•Information from claims and related documents may be given to the Dept.of Veterans Affairs,the Dept,of Health and Human Services and/or the Dept.of Transportation consistent with their statutory administrative responsibilities under CHAMPUS/CHAMPVA;to the Dept,of Justice for representation of the Secretary of Defense in civil actions;tothe Internal Revenue Service,private collection agencies,and consumer reporting agencies in connection with recoupment claims;and to Congressional Offices in response to inquiries made at the request of the person to whom a record pertains,Appropriate disclosures may be made to other federal,state,local,foreign government agencies,private business entities,and individual providers of care,on matters relating to entitlement,claims adjudication,fraud,program abuse,utilization review,quality assurance,peer review,program integrity,third-party liability,coordination of benefits.and civil and criminal litigation related to the operation of CHAMPUS. DISCLOSURES:Voluntary:however,failure to provide information will result in delay in payment or may result in denial of claim.With the one exception discussed below,there are no penalties under these programs forrefusing to supply information.However,failure to furnish information regarding the medical services rendered or the amount charged would prevent payment of claims und6rthese programs.Failure to furnish any other information,such as name orclalm number,would delay payment of the claim.Failure to provide medical information under FECA could be deemed an obstruction. It is mandatory that you tell us if you know that another party is responsible for paying for your treatment.Section 1128B of the Social Security Act and 31 USC 3801- 3812 provide penalties for withholding this information. You should be aware that P.L 100-503,the"Computer Matching and Privacy Protection Act of 1988,permits the government to verify information byway of computer matches, MEDICAID PAYMENTS(PROVIDER CERTIFICATION) I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the State's Title XIX plan and to furnish Information regarding any payments claimed for providing such services as the State Agency or Dept.of Health and Human Services may request. I further agree to accept,as payment in full.the amount paid by the Medicaid program forthose claims submitted for payment under that program,with the exception of authorized deductible,coinsurance,co-payment or similar cost-sharing charge. SIGNATURE OF PHYSICIAN(OR SUPPLIER);I certify thatthe services listed above were medically indicated and necessary to the health of this patient and were personally furnished by me or my employee under my personal direction. NOTICE:This is to certify that the foregoing information is true,accurate and complete.I understand that payment and satisfaction of this claim will be from Federal and State funds,and that any false claims,statements.or documents,or concealment of a material fact,may be prosecuted under applicable Federal or State laws. According to the Paperwork Reduction Act of 1995,no persons are required to respond to a collection of information unless it displays a valid OMB control number.The valid OMB control number for this information collection is 0938-0999 The time required to complete this information collection is estimated to average 10 minutes per response,including the time to review instructions,search existing data resources,gather the data needed,and,complete and review the information collection.It you have any comments concerning the accuracy of the time estimate(s)or suggestions for improving this form,please write to;CMS,Attn:PRA Reports Clearance Officer,7500 Security Boulevard,Baltimore,Maryland 21244-1850 This addross is forcomments andlorsuggestions only.DO NOT MAIL COMPLETED CLAIM FORMSTO THISADDRESS. I� PENNSTATE CD own Debra Rhoads 71 5 ! gyp" 500 University Drive ( � 31-6964 ':' Patient Financial servl�es Hershey,Pa 17033 Fax:(717)831-0494 E-mail:drhoads@PSU.EDU O CD December 13, 2012 o' C ' Horace Mann Insurance N j PO Box 962 Io Morrisville, NC 27560 cn U Patient Name". Sydney b. Rice IZ Claim#: 16875C C) 0 rn I To Whom It May Concern: Penn State University Hospital, The Milton S. Hershey Medical Center, Hershey, PA 17033, is an Accredited Level I Trauma Center. In Compliance with Pennsylvania Law (ACT 6), physicians charges and facility charges associated with the treatment of a patient in an Accredited Trauma Center will be paid at 100% of the billed amount. The charges are exempt from the Medicare Reimbursement rate of the Medicare Fee Schedule times 110%. PLEASE REMIT PAYMENT OF 100°!o OF OUR CHARGE WITHIN 30 DAYS. If you have any questions, please feel free to contact me at my direct phone number, (717).531-6964. Sincerely, TRAUMA PAYMENT 12 Patient Account Associate Hershey Medical Center Eastern Auto DEC 2 6 2012 I .? ..•; CAR Z HORACE `MANN" INSURAO }� PO BOX 962 ! MORRISVILLE NC 27560 a HEALtH INWRANCE CLAIM FORM gPP�ROVo�BY NATI . ; ONAL UNIFORM CLAIM COMMITTEE 08(05 (� .P>,CA CASE ID: 00010512938 PICA O 1. .MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a.INSURED'S I.D.NUMBER (For Program In item 1) G '(Medicare#) (Msdicald# GRAMPUS n HEALTH PLAN BLKLUNG )❑(Sponsor's SSN) t_..i(Member1D#)❑(SSN or ID) (SSN) ®(ID) 16 8 7 5 C (D 2:PATIENTS NAME(Last Name,First Name,Middle Initial) 3,PATIENTS BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) %n RICER SYDNEY D 61 1 cog 1 2603M F[]X FREDERICKSON OUTPATIENT CENTE O 5.PATIENTS ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 4 0 SYCAMORE DR Self[]Spouse[]Child[E Other❑ CITY STATE 8,PATIENT STATUS CITY STATE.. ., 1\) MECHANICSBURG IPA SingteMXX M..WM Other O ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(tnckide Area Code) t'} 17.0 5 Q (717) 6 0 8-17 4 7 Employed❑ Futl-Time❑ Part-Time❑ Student Student 90. IN$URED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENTS CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER Cn RICE,;'. COLLEEN J AD111212 0 O a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(Current or Previous) a.INSURED'S DATE OF BIRTH SEX.. M ` . .P,$Q117575903 00505817 YES NO MM ; DD i YY M❑ F[] 0 b.OIHEFt)QQURED'YY ATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME 0 :06 1 12 1 1970 M11 FM YES F�NO VJ c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME 0) FREDERICKSON OUTPATIENT C YES X NO HORACE MANN INSURANCE feel d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? ) � CAS T TAL BLUE CROSS CAI C IN YES E]NO M yes,return to and complete item 9 a-d.; READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13,INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize #2.•?Aj'tENT'$OR AUTHORIZED PERSON'S SIGNATURE t authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician brsu' het f P Y 9 P YS PP,•_4 tp.probess_this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. ' below. -�i kNtl)-MGNATURE ON FILE DATE 12 04 2 012 SIGNED SIGNATURE ON FILE I 14.pATE OF CURRENT: ILLNESS(First symptom)OR 15,IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION ti � MM..I DD I YY INJURY(Accident)OR GIVE FIRST DATE MM t DD t YY MM I DO t YY MM i DQ i YY • .: 2 0124 PREGNANCY(LMP) i I FROM i i TO i ?"•'„it�T'•�?E 17.NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES ____..,______ MM DD YY MM DD RUCOVRT MD, DOROTHY V 17b. NPI 12 5 5 3 716 8 8 FROM M111' 121 2012 TO 11 i 131 26Y12 i 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES YES MX NO { 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY(Relate Items 1,2,3 or 4 to Item 24E by Line) 22,MEDICAID RESUBMISSION CODE ORIGINAL PER NO. 873 42 3. IE815 1 23.PRIOR AUTHORIZATION NUMBER 4. 24.A. DATE(S)OF SERVICE B. C, D.PROCEDURES,SERVICES,OR SUPPLIES E. F. G. H. From Ta PtACE (Explain Unusual Circumstances) DIAGNOSIS °OR Pte, to. RENDERING.. CJ I D)' YY MM OD W SERVICE EMG CPT/HCPCS MODIFIER POINTER $CHARGES UNITS Pan gUnL. PROVIDER ID. N t= { lj-JV22 121 j ` f-9 199252 1 1 1 1123 1 3801001 11 NPI 1841241700_ O 2 t, i i r I 711A Mph I NPI 3 ----- ! NPI An Team i i NPI 0 5 ' .:� '... ' 1 1 1I Ea t rP -Ave-q------- .6 1 1 1 1 1 1 E -241 ------ -•- NPI p FN 28. EQERAL TAX I.D.NUMBER SSN E!N 26,PATIENT 78 ACCOUNT NO. 27•(For govP daCms see bac; � 28•TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE D A-' ---;-5 7.035 ❑[X 23390070OF6B0 FXYES ONO $ 38400 $ d00 $ ` 8000 O 31.'SIGNAT RE OF PHYSICIAN OR SUPPLIER $2.SERVICE FACILITY LOCATION INFORMATION 33.BILLING PROVIDER INFO&PH# {71 3 - () ,n INCLUDING DEGREES OR CREDENTIALS (I64�,�tifny that the�statements on the�reverse�} HERSHEY MEDICAL CENTER DIV PLASTIC RECONST SURG : os PVJ VI�Y s•1vadeeffti V f-b 500 UNIVERSITY DRIVE P 0 BOX 858 MC A410 HERSHEY PA 17033 IHERSHEY PA 17033-0858 a. b. a. 1255482081b. I n B(s;NED X 12 04 201 WATE iUFJG Ip�i uctioh Manual available at:www.nuce.org APPROVED OMB-0938-0999 FORM CMS-1500(08id6) r—BECAUSE THIS FORM IS USED 13Y VARIOUEWERNMENT AND PRIVATE HEALTH PROGRAPOPEE SEPARATE INSTRUCTIONS ISSUED BY KWLICABLE PROGRAMS. 0)XNOTICE:Any person who knowingly files a statement of claim containing any misrepresentation or any false,incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties. G' REFERS TO GOVERNMENT PROGRAMS ONLY ='MEDICARE AND CHAMPUS PAYMENTS:A patient's signature requests that payment be made and authorizes release of any information necessary to process reauthorizes any entity to release to Medicare medical and nonmedical 12 is true,accurate and complete.In the case of a Medicare claim,the patient's signature rmation,including employment status,and whether the person has employer group health tnsurance,liability,no fault,worker's compensatran or other insurance which is responsible to pay for the services for which the Medicare claim is made.See 42 authorizes CFR 411.24(a).I€item 9 is completed,the patients signature release of the information to the health plan or agency shown.In Medicare assigned or charge(p CHAMPUS participation cases,the physiaran agrees to accept the determination of the Medicare carrier or CHAMPUS fiscal Intermediary as the full charge, and the patient is responsible only far the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge — fiscal intermediary if this is less than the charge submitted.CHAMPUS is not a health insurance program but :3 s 3make payment for health benefits provided through certain affiliations with the Uniformed Services.Information on the patient's sponsor should be provided in those items captioned in"Insured";i.e.,items 1a,4,6,7,9,and 11. 0 BLACK LUNG AND FECA CLAIMS *"The*"The provider agrees to accept the amount paid by the Government as payment in full.See Black Lung and FECA instructions regarding required procedure and coding systems .X SIGNATURE OF PHYSICIAN OR SUPPLIER(MEDICARE,CHAMPUS,FECA AND BLACK LUNG) (i'31 cerfifythatthe services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me orwerefumished incident to my professional service by my employee under my immediate personal supervision,except as otherwise expressly permitted by Medicare or CHAMPUS regulations. (,11For services to be considered as`Incident"to a physician's professional service,1)they must be rendered under the physician's immediate personal supervision Eby his/her employee,2)they must be an integral,although incidental part of acovered physician's service,3)they must be of kinds commonly furnished In physician's offices,and 4)the services of nonphysicians must be included on the physician's bills. Z For CHAMPUS claims,I further certify that I(or any employee)who rendered services am not an active duty member of the Uniformed Services ora civilian employee 4pof the United States Government or a contract employee of the United States Government,either civilian or military(refer to 5 USC 5536).For Black-Lung claims, 01 further certify that the services performed were for a Black Lung-related disorder. 00' 65No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations(42 CFR 424,32). NOTICE:Any one who misrepresents orfalsifies essential information to receive payment from Federal funds requested by this form may upon conviction be subject to fine and imprisonment under applicable Federal laws. NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE,CHAMPUS,FECA,AND BLACK LUNG INFORMATION (PRIVACY ACT STATEMENT) We are authorized by CMS,CHAMPUS and OWCP to ask you for information needed in the administration of the Medicare,CHAMPUS,FECA,and Black Lung programs.Authority to collect Information is in section 205(a),1862,1872 and 1874 of the Social Security Act as amended,42 CFR 411.24(a)and 424.5(a)(6),and 44 USC 3101;41 CFR 101 et seq and 10 USC 1079 and 1086;5 USC 8101 et seq;and 30 USC 901 et seq;38 USC 613;E.O.9397. The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility.It is also used to decide if the services and supplies you received are covered by these programs and to insure that proper payment is made. The information may also be given to other providers of services,carriers,intermediaries,medical review boards,health plans,and other organizations or Federal agencies,for the effective administration of Federal provisions that require other third parties payers to pay primary to Federal program,and as otherwise necessary to administerthese programs.For example,it may be necessaryto disclose information aboutthe benefftsyou have usedto a hospital ordoctor.Additional disclosures are made through routine uses for information contained in systems of records, FOR MEDICARE CLAIMS:See the notice modifying system No.09-70-0501,titled,'Carrier Medicare Claims Record,'published in the Federal Register,Vol.55 No.177,page 37549,Wed.Sept.12,1990,or as updated and republished. FOR OWCP CLAIMS: Department of Labor,Privacy Act of 1974,"Republication of Notice of Systems of Records,"Federal Register Vol.55 No.40,Wed Feb.28, 1990,See ESA-5,ESA-6,ESA-12,ESA-13,ESA-30,or as updated and republished. FOR CHAMPUS CLAIMS:PRINCIPLE PURPOSE(S):To evaluate eliciibilityfor medical care provided by civilian sources and to issue payment upon establishment of eligibility and determination that the services/supplies received are authorized by law. ROUTINE USEft Information from claims and related documents may be given to the Dept.of Veterans Affairs,the Dept.of Health and Human Services and/or the Dept.of Transportation consistent with their statutory administrative responsibilities under CHAMPUS/CHAMPVA;to the Dept,of Justice for representation of the Secretary of Defense in civil actions;to the Internal Revenue Service,private collection agencies,and consumer reporting agencies in connection with recoupment claims,and to Congressional Offices in response to inquiries made at the request of the person to whom a record pertains.Appropriate disclosures may be made to other federal,state,local,foreign government agencies,private business entities,and individual providers of care,on matters relating to entitlement,claims adjudication,fraud,program abuse,utilization review,quality assurance,peer review,program integrity,third-party liability,coordination of benefits,and civil and criminal litigation related to the operation of CHAMPUS. DISCLOSURES:Voluntary;however,failure to provide information wilt result in delay in payment ormay result in denial of claim.With the one exception discussed below,there are no penalties underthese programs for refusing to supply Information.However,failure lot urnish information regardingthe medical services rendered orthe amount charged would prevent payment of claims under these programs.Failure to furnish any other information,such as name or claim number,would delay payment of the claim.Failure to provide medical information under FECA could be deemed an obstruction. It is mandatory that you tell us if you know that another party is responsible for paying for your treatment.Section 1128E of the Social SecurityAct and 31 USC 3801- 3812 provide penalties for withholding this information. You should be aware that P.L.100-503,the Computer Matching and Privacy Protection Act of 1989',permits the govemment to venfy information byway of computer matches. I , %� I )_., , •• — MEDICAID PAYMENTS(PROVIDER CERTIFICATION) I hereby agred tb k6ep such records as are necessary to disclose fully the extent of services provided to individuals under the State's Title XIX plan and to furnish information regarding any payments claimed for providing such services as the State Agency or Dept.of Health and Human Services may request. .'; .. I further agree to accept,as p&yment In full,the amount paid by the Medicaid program for those claims submitted for payment underthat program,with the exception of authorized deductible,coinsurance,co-payffi&616r similar host-sharing charge. SIGNATURE OF PHYSICIAN(OR SUPPLIER):I certify that the services listed above were medically indicated and necessary to the health of this patient and were personally furnished by me or my employee under my personal direction. NOTICE.This is to certify that the foregoing information is true,accurate and complete.I understand that payment and satisfaction of this claim will be from Federal and State funds,and that any false claims,statements,or documents,or concealment of a material fact,may be prosecuted under applicable Federal or State laws. According to the Paperwork Reduction Act of 1995,no persons are required to respond to a collection of information unless It displays a valid OMB control number The valid OMB control number for this information collection is 0938-0999.The time required to complete this information collection is estimated to average 10 minutes per response,including the time to review instructions,search existing data resources,gather the data needed,and complete and review the information collection.If you have any comments concerning the accuracy of the time estimate(s)or suggestions for improving this form,please write to:CMS,Attn:PRA Reports Clearance officer,7500 Security Boulevard,Baltimore,Maryland 21244-1850. This address isforcomments andforsuggestions only DO NOT MAIL COMPLETED CLAIM FORMS TO THIS ADDRESS. r7 PENNSTATE HERSH EY WMI Wton S Hershey NAME: RICE. SYDNEY MUI: 51.29 OOS#: 10512938 iWMe MD. DIFLITCH CHRISTO HD#: 46325: Medical Center D04t 04/0512003 T DATE 11/12.12012 VJV rf4r-R SEX F 0 TRAUMA TEAM SIGN-IN SHEET SELF PAY CD 0 Date TRAUMA NUMBER :3 TRAUMA LEVEL 1 2 3 N Trauma Standby paged at hrs Trauma Response paged at hrs T V F R Ln ED Attending Trauma Attending Z Trauma Team Leader(PGY4/5) Senior Trauma Resident(PGY 415) 00 Junior Trauma Resident(PGY 2/3) Junior Trauma Resident(PGY 2/3) Junior Trauma Resident(PGY 1) Junior Trauma Resident(PGY 1) Emergency Med. Resident(PGY 2/3) Emergent Med. Resident(PGY 2/3) Emergenc y Med. Resident(PGY 1) Trauma Physician Extender Trauma Physician Extend_er Anesthesiology Attending Anesthesiology Resident Certified Registered Nurse Anesthetist Respiratory Therapy Radiology Attending Radiology Resident Radiographer#1 (Diagnostic) A r I -e"'I Radiographer#2 (Diagnostic) I �18 33— aiv.f. j Radiographer(CT) CIV IC Emergency Medicine EMT I Chaplain I V4NZ',A IYA-Z�Jl 3-1 OR Technician/Nurse k,;23 7T__ Pediatric Critical Care Attending Pediatric Critical Care Resident Child Life Specialist 1. 4 Trauma Coordinator/Case Manager uX JrMMei WN§A 140 0ffiN"'_S67,L @W ff. M I.PA P� IMM. _ f ivai Orthopaedics Pager 2002) Neurosurgery (Pager 1001) Plastic Surgery C d ti L t--j fit Auto ENT DEG 2 6 204 PGY=Post Graduate Year Original Copy-Medical Records MR 414 Rev.1108 Page I of 1 Pink Copy-Emergency Dept TRAUMA TEAM SIGN-IN SHEET Yellow Copy-Trauma Services PENNSTATE HERSHEY Illllll�lllllillilllll[Illlillllllllllllllll FM. Milton S.Hershey NAME: RICE. SYDNEY Y MR#: 7512938 00Sr: 10512938 Medical Center MD: DEFLITCH CHRISTO MD#: 46325 DOB: 04/05/2003 VISIT DATE: 11/12/2012 LOC: EMER SEX: F ' S: SE F P SELF PAY j ED TRAUMA/RESUSCITATION FLOW SHEET � III�IIII�IIIiI��(I ,� Date ` I Time Stat Page Time Pt d Response level f11 2 Ambulance+ Helicopter: 1- kl� j Interhospital Y N Aged1&f� Sex X::: Weight w O Chart o.Labs o XR O CT PRE-HOSPITAL • • • r ' BP G� 46 Loss of COnsci0O5n • Yes No Unknown #minutes HR Monitor Rh m Immobilization: -Co CI orig Boa Splint RR Assistive Device Entrapped: Yes o Unknown #minutes Spontaneous Rate/Pattem Self Extricated: Yes No S 02 PMH: GCS • Meds: Patent IV Site Gagge Sol'n Amt Ye: rib #1 0 o Allergies: #2 0 0 #3 0 0 Tetanus: PRIMARY SURVEY :: *-' (13y,17�. r` 3_ d.."L.a'. 3•. •°5 3F s•r 'y Airway Intervention Bracelet Location: 0 Patient Mainmined ves No O Mechanically maintained by ®O Oxygen mask 115 1 1min or % ID: Breathing 00 Airway&bag 4D-Spontaneous rate/pattern 00 ETT- 5&4/wn Blood Band: — — --- ' O Not breathing assistive device locaffon R�4605 Sa02 /ntubated by R#: • Yes No 00 Surgical airway-done by O O Breath sounds R L Documenting Nurse: O 0 Tachypnea Vent Settings O O Intercostal retractions Time Support Nurse: o O Chest wall bruising mate U. Glrcul Ion F102 Physician Signature: HR I{In(on arrival) Rhythm Tidal vol. Sap o mmHg(an arrival) PEEP Pulses R L Yen No Yes No Hypothermia .• O Radial 00 Chest tube o Femoral size: right ,' Initial temp. 0 o PT left c 1� Patient covered O o Pr 00 other intervention state O O Hemorrhage? na Ne Warm blankets Yes No 00 IV line yes No o o Ertcvna/ sue 1 size_g Patent? o o Overhead warmer O O In&.Mal site 2 size_g Patent? O O o Chest sites size_g Patent? o o ]V Fluids warmed to 104°F O Abdomen o o Arterial line site R O PeIviSJretroperitoneai epeat,temp.at 30 mins. O limbs MTP Time Initiated.• Slan / / Pink V Warm V Pale Hot Cyanotic cool Mottled Cold Dry Moist Eye • Sp"neous • GLASGOW 4 Member i e ime Ime opening Tovriee -3 3 COMA 9-12 I Service called Arrived 1 Response To N 2 SCALE(GCS) 6-8 2 2 Trauma Attending None I (Total Points 4-5 1 Ortho . Best oriented from atnve) 3 o ED Attending verbal n 9 Lc >89mm H 4 4 Neurosurg Response naPProP to svo elood 7689mm H Anesthesia Attending ��jj InmmP le sounds' 2- 2 Pressure 50.75mm 2 2 Plastics �LG� Nane t 1 1.49mm 1 1 Senior Trauma Resident Best 0 command No Puke D Other motor L001@es pa 5 Respiratory 1 29 min. 4 - , Response i 2xs 7 m Ra > mm. 3 Other exion pain min: 2 2 Etension(pain) 1• n. 1 1 , No motor response 1 1 None 0 O Ea 4tra MR 15: —> Illl�ll�llil�llli���ll��llll�l���lllll�����1� ED TRAUMA/RESUSCITATION FLOW SHEET DEC 2 6 2glZ 0 IZ 7 1 SECONDARY 0 Head Yes No X-ray O scalp � O Laceration C0 O Vault Fracture J� �6,r w\ckm Vy*`\r�V Fate O O Basal Fracture Suspected -� Time Time C� 0 O Laceration ^ �� ine g. ead of spin e O O Fracture .. X ray Q O Olawinstability !Dap A� " '' Peies Chest =3 Eyes O O Injury, Other Abdomen/Pelvis O O Decreased Vision � �,/Jy? Other Spines 0 Ears O O Hemotympanum Side:, i Other Other N O O CSF teak Site: Other (71 Nose O O Bleeding -..% Mouth O O Tooth# eurovasc:5 ar meet Neck Yes No OesarpNon: Areas of Concern: O 0 C-spine tenderness g O (u Stepoffs'/crepihis �� 4�h 0 O Laceration O O C-collar off time Pulse Assessed: Q C) O O Rehab color time Time Temp. Color Cipillary Capillary Refill Sensation Movement Puts Chest Yes No DeA0 pbom' O A§Chest wan Injury Side: - { O O#ribs t/ O O O Rats segment `.� 0 O O Open pneumothorax 00 O O Pneumothorax R/L O O Hemothorax R/L Abdomen yes No Desarptlon: O O Skin wntuslon/abrasion O %.Distension 4vVY W" O O Tenderness Injury Diagram rr- O O Guarding Fast + - Injury Diagram Key: 4A& _ Come by . Rectal heme: + 1 Open Fracture E F-cchymosis Done by time 2- Amputation A = Abrasion N/G(arai/nasal) 3= 6SW C = Contusion Size Fr 4- Deformity L = Laceration Inserted by time 5- Stab Wound S Swelling Oeritoneal lavage/DPA: 6= Bum T = Tenderness Done by time 7 Pain PW= Puncture Wound Return: O Clear 8= Rash I = Impaled Object O Pink O Gross blood Amount#mused cc Amount returned cc y Fluid to lab: O Yes 2 cry-A O No - +✓ Genitourinary Qesvrpban: Foley: O Yes p.No O Heme+ a o Size Fr ' Inserted by time Rectal Tone: 0 Decreased O eveased O Absent Prostate: O Normal OV , O Abnormal Blood observed at: Yos No Vagina O O Rectum 00 Urethral meatus O O Extremities 5 Ps Ivarawis Parasthesia Pulses Pain Pallor J JYes O Yes O Yes Yes O Yes O f/) RA No (0. No BO No No 0 No 0 es O Yes O Yes 1& Yes O Yes O LA lNo 0 No 0 No O No C• No 0 h as O Yes O Yes q Yes O Yes O RL No A No f) No O No 91) No 0 Yes O Yes O Yes$ Yes O. Yes O LL No No (b No O No No 0 Eastern Auto DEC 2`6 2012 ED TRAUMA/RESUSCITATION FLOW SHEET MR 157".. I a ? • ; ass • z I • • Trauma Resuscitation Flow Sheet Nursing Interventions 000■o • ff"We LAMM ONE IM r . , MUNIM■r■■I■�■Irr■ENO U&I � , .? IMEMMM crrR 000.9 MP"r ■ ■■■Mr■■ rrr�■ONE ■�■■■■■■■■■■■r■■■■ ■ ■■■■■■■■■rrr■■■■ ■ ■■■■■■■■■rrr■■■■ ■�■■■■■■■■■M■■■�r�rr■■■■ ■�■■■■■■■■■errNONE • ■ ■■MMI■■■■■■Irr■■N■ ■■■■■■■■■■■■■■i■■r�i■rrr■■■■ ■r■i■■■■■■■■■i■■111■■■■ ■�■■�■■■rr■■■■■■110■■■■ ■M■■■■■■■■■■■■irrr■■■■ r■r■r■■■IME■■■■r■■■■�rrr■■■■ MIN ■�M■r■■■■■■■■r■■■■�rrr■■■■ ■�i�■�irii■�i■�ir�i■■■iii■■■i Normal Ranges for Vital Signs [Pupil Size(MM) retal Heart Tones • .• • .••• • .• a •• Toddlers 90-140 :• • :• • Preschooll :• • :• •• Adolescent iAdolescen •• • i • Crystalloid joutput Disposition at Discharge notified 96T1 �Urine catheter Unable to reAcb_O Time: • In HMC safe Given to family Name: Given to police Name: 0 Floor 0 Expired 0.Other Time. ■■■■■■_■— —Or an/Tissue Donation Intake/Blood Components Medications ■m■■� ■■m� ��■�� immm lJ PENNSTATE HERSHEY s~3 111111111[I111111111��1111111[I�1111111111 CD FM Milton S.Hershey NAt1E: RICE, SYDNEY 005 : 10512936 McCllcal Center Np `DEfLITCN CNRI5TO ti0#: 46325 i 006: EFLITC2003 VISIT DATE. 21!12/2012 LOC: ENER SELF PAY TRAUMA HISTORY AND PHYSICAL EXAMINATION 111i�i1���1�11Pi11� < N ate: Time: , p' Tr ixta '°'" ': `r N. Hx of Present Illness HPI ROS :.. MVC Belted? Yes ❑No -❑Airbag Timing/Duration 2,0.' Eyes 0 Pedestrian ❑MCC f ❑'Assault Signs/Symptoms:. Amnesia?❑YesZfN ENT C& ,, ❑Fall ❑Bunt ❑Electrical - Loss of,ConsdousnesS?'^❑'Yes No Cardiovascular ❑GSw ❑Stab ❑other Respiratory ! 1 W GU GI a 01 61nQ Musculoskeltal. -0 � Integumentary 7��x '- �+�' yc�• r:;; T,.:_tr,� �:;at..�,.r. Pt weight Neurologic Broselow weight- Other 00 ❑Entrapment* ❑Ejection`.ry❑Crush ' [] NirAllothorsne rs negativelnon coninbutory co Helmet❑Yes❑No ❑Environmental Exposure ❑Hypothermia ❑impalemertt"P .€Meilica{<r�EIC lC �'' tl'tlf+3t .€tC iii' ISO °' '" ❑Chemical ❑Biological ❑Radiation ❑Other. Allergies: Fall:Hto##all: Fall from object FFS:❑Yes❑No Madicaiions:Coumadin ❑Pla& ❑Other Other. Past SurgicalHic UvLeJ 'Fir S' ;:? ' ,' e`n' :r':=fir. ' 7 F. f 'Family Hte Bleeding Disorder❑Yes []No Airway: Patent ❑obstructed Intubated: ❑OT ❑ NT ❑'TraEh ❑other PNoncuntdbutatory/Unobtainable' Breathing: CI"ZCe,}f Breath Soands: Soda!flt4 Family Status: Circulation: P: BP: RR: 7' Sat: , ❑other. I Nonwntributatory?Unobtai6abte Disability. GCS: M V E _ �� ❑Etah, ❑ Smoki Hx ❑tllega Orug FAST Exam: c? Exposure: Completed Last Meal: last Tetanus: Secgriclaty�Ji iy 2nd Vitals:Temp _P BP R w O2 Sat Q wT HEENT: Head: tam 3 Gwr Eyes: 1-t V 2 t P6 FTC Ears: TM's: 0 t ca r Battle's: C.tnn Face: Maxilla: Mandible; °--��-`�:• y, '�., Nose: N`r" pent ia: tAja Mouth: 1-,CT-4 Dentures: Neck: Tenderness: NT Crepitus: trachea hi�L: Chest Wall:Tenderness: Crepitus: Lungs: ( :;,='1.:J." ` " r;•.:.: Back: Tenderness: CrepituS: C.: Heart: tn/1 Abdomen: Distention: A(t) BS:. Tenderness: Rectal: Tone Heme: Prostate: Pelvis:Stable: Tenderness: Vascular Exam: Radial,'' Femoral 24 DP PT tfofNO: Right/Left !?1.1, �`` Waceration Cfic-closed fracture Resident Si #u Title Dal Time a.mJp m. 4FX-open fracture Ab abrasion ( � �� � ' r 0 0 C—contusion COPYRIGHT,ev 5/11 TRAUMA HISTORY AND PHYSICIE WINA"0 Copy-Tr a services l�llll11111111111111111111I111(1111f11i • .. • DEC 2 61012 TRAUMA HISTORY AND PHYSICAL EXAMINATION cD � i'_h•�T,q.,,o:.-•,_ `';:>:-e=':S.•":":.,..•y-:;; ':,`,�:"'�. si.' :''.'�;;�}I:.r'�?:,�3:5` :°�•;::as�i''rj°?; I egrulo`gtrdfaxdt<it;: ,yr :,:;°: yf;. Glasgow Coma Scale Trauma Score n Eye Opening c to Res .Rate :SBP• . 0 Cranial Nerves: = .(, S inal Cord In jury: 1-None P V ,pr" 2-Open.to Pain 0-0 0-0 Motor: ' L vv q- Open to CommandlVoice 1-1_9 a Spontaneous 2->36 . .. Z: 50-69 � Verbal Response Sensory: rick n o✓t-� 1-None 3-25-35. . ..:3-70-90 0 ry p T 1-12 2-Incomprehensible/Moansto Pain 010-24 .0>90 3-InapppropriatelCties to Pain Proprioception �,p.• 111_ cC„� conlused/eonsoiabie yes I �� S AledlOriented/Interacts 0-3-4 0 Motor Response 1-5-7 N I t-S t-None 2 8-10 2-Decerebrate Cil� r ' 3-Decorticate 3- 1-13" ' 4,-Withdraws 4-1 S' W 5 ralizes Pain IO (� be ++ Total`. �G Ln otal: G . ias'CC'1siides:Evtiiad Y' ; ;';; V i� J r�r PT: } Troponin: VIA: 1 I PTT: ,� Myoglobin: : '• ,i (� ( T:Bili: CPK: Drug Screen: • �� 0 31° 3 Q °� r�� ALT: Amylase: 00 ABG: ALP: JC-8 (A Q; ETOH:• CF) ECG: TEE: BHCG: X=Ray's: CSR: WM Pelvis: O'-�Saiis::'''; Hea ?,.ee JJbr Si l�u 'Fteaifid'T; 1 Opine: Lai: :'. : Extremities: Abdomen' :,. 'AP Others: Odontbid T&L Spines: UISat'"nab r'3 "t T �::',:='>- r ::_4` .`Y::.• '.-�qs6..;, 01 saw and evaluated the patient and agree with the resident's findings and plans as written above. ' ❑See dictated note ❑I have reviewed the transporVEMS notes ; Admit: ❑PICU ❑PIMC 4EfNds.Floor ❑SICU ❑NSICU ❑IMC ❑NSIMC ❑Floor Neuro:GCS: ❑Consult NSGY ❑OR Crani ❑ Repeat CT Consult Facial Trauma HEENT: Neck: ❑Consult Spine ❑Miami 1-Collar ❑C-S ine Clear ❑MRI Res p: CV: GI: ❑OR Exploratory GU- ❑Consult URO MS: ❑Consult OrtholS ine ❑OR for Fracture Psych:❑Consutl Psych ❑Consult D+.A Procedures:❑NG-Tube ❑Urinary Catheter ❑A-line: Cl CVP(s): Chest tube: ❑ri ht El left 11 DPL rP / VGA cJ'. 1. 7 AUtO DEC 2 6 2012 r Attending Signature Date Time orig -Chart ' MR 611 Rev.5/11 Copy•.Traunna•Services .TRAUMA HISTORY AND PHYSICAL EXAMINATION x Consult RICE, SYDNEY D - 7512938 cn *Final Report' n * Final Report CD CONSULT o -D, Name: RICE, SYDNEY D HMC Number: 7512938 DOB: 04/05/2003- 1 Date of Service: 11/12/2012 0 Q REASON FOR CONSULTATION: Facial lacerations. Z HISTORY OF PRESENT ILLNESS: Sydney is a 9-year-old girl who was a restrained backseat passenger involved I in a motor vehicle accident. She was seen as level trauma activation where she was found to have repetitive CD speech,questionable change in mental status both in the field and on trauma evaluation;therefore, she underwent 00 CT scan of the head and facial bones. She has extensive soft tissue injury involving the left side of her forehead and rn in both the hair-bearing and forehead skin as well as left cheek up to the commissure of her mouth. For this reason, plastic surgery was consulted. The patient is in distress and has repetitive questioning. Her father is at her side and consoling her. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. MEDICATIONS: None. ALLERGIES: No known drug allergies. REVIEW OF SYSTEMS: As per HPI, otherwise negative. PHYSICAL EXAMINATION: Afebrile, vital signs stable. General: Repetitive questioning; alert and following commands. GCS 14. HEENT: Significant facial lacerations both partial-thickness and full-thickness involving the hair-bearing scalp on the left side, the frontal region as well as the forehead skin. There'is a crush component as well. Additionally,there are areas of partial-thickness skin loss. She is able to animate on that side suggesting the frontal branch is intact. She also has a significant full-thickness skin and muscle laceration from the left cheek to the left-sided commissure but not through and through the mucosa. There are no intraoral lacerations, no loose teeth and the occlusion is appropriate. Otherwise, on examination, her cranial nerves were grossly intact. Pupils were equal, round and reactive. There was no septa!hematoma. Extraocular movements intact. Her C-collar was in place immobilizing her C-spine. PERTINENT LAB AND X-RAY: Craniofacial CT scan did not demonstrate any bony abnormality. ASSESSMENT AND PLAN: This is a 9-year-old girl involved in a motor vehicle accident with significant facial lacerations. V Printed by: Calloway, Earthenia D Eastern Auto Page 1 of2 Printed on: 12/13/2012 06:59 (Continued) DEC 2 6 2012 i C7 x Consult RICE, SYDNEY D - 7512938 Final Report " 3 I n � Under local anesthesia at the bedside, I repaired the facial lacerations with absorbable sutures;first using 5-0 CD Monocr l suture in deep dermal interrupted fashion followed by 6-0 chromic and 5-0 plain gut suture to I reapproximate the skin edges. The patient tolerated the procedure well. The operative sites were cleaned and dried Z5* and Bacitracin was applied. We will follow up the patient in approximately 1 week to ensure appropriate healing and :3 absence of infection. She should-be placed on antibiotics for approximately 1 week and we have suggested Io amoxicillin to the trauma team. Dad was present during the procedure and was educated with respect to the areas P, N of partial-thickness skin loss,that they may result in hyper-or hypopigmentation with respect to the adjacent skin. cn w Dr. Potochny is in agreement with the assessment and plan. I0 .p CO Consultation Coding Selection Min Brief Intermediate Extensive Comprehensive Diagnosis 99251 99252 99253 99254 99255 I� X 0 CO rn #461082 1 personally evaluated this patient.on rounds with the Plastic Surgery House Staff. I evaluated her wounds and discussed recommendations for care and follow-up with her father. I agree with the above transcribed note by Dr. Michellotti. John Potochny, M.D., teaching attending, Plastic Surgery Signature Line Electronic Signature on File Electronically Reviewed/Signed by: Brett F Michelotti, MD Author Signature Dt/Tm:11/14/2012 06:03 AM Electronically Reviewed/Signed by: John D Potochny, MDCosigner Signature Dt/Tm: 11/14/2012 04:40 PM BFM/SAT DD: 11/12/12 DT: 11/1211222:-57 Result Type: Consult Date of Service: November 12, 2012 00:00 Authorization Status: Final Subject: Consult Author or Import Date: Michelotti, Brett F on November 12, 2012 22:26 Verified By: Potochny, John D on November 14, 2012 16:40 Encounter info: 10512938, HMC, Inpatient, 11/12/2012- 11/13/2012 Contributor system: ESCRIPTION01 Printed by: Calloway, Earthenia D Page 2 of 2 Printed on: 12/13/2012 06:59 Eastern Aut®(End of Report) DEC 262012 0 PENNSTATE v O Debra Rhoads 500 University Drive (717)531-6964 cc Patient Financial Services Hershey,Pa 17033 Fax:(717)531-0494 E-mail:drhoads @PSU.EDU C7 O December 13, 2012 o' I 0 N Horace Mann Insurance PO Box 962 10 Morrisville, NC 27560 .p CPatient Name: Sydney D. Rice Claim#: 16875C 0 0 rn i To Whom It May Concern: Penn State University Hospital, The Milton S. Hershey Medical Center, Hershey, PA 17033, is an Accredited Level 1 Trauma Center. In Compliance with Pennsylvania Law (ACT 6), physicians charges and facility charges associated with the treatment of a patient in an Accredited Trauma Center will be paid at 100% of the billed amount. The charges are exempt from the Medicare Reimbursement rate of the Medicare Fee Schedule times 110%. PLEASE REMIT PAYMENT OF 100% OF OUR CHARGE WITHIN 30 DAYS. If you have any questions, please feel free to contact me at my direct phone number, (717) 531-6964. Sincerely, Eastern AUtO T� DEC 2 6 2012 J9e a Jqhaad6 Of Patient Account Associate oti% PAYMEN1 Hershey Medical Center ��3 i 0 CAR - - HORACEv MANN INSURA I� X500 PO BOX 962 MORRISVILLE NC 27560 w �.HEALTH INSURANCE CLAIM FORM � 3 APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 U I0 PICA CASE ID: 00010512938 PICA 0 1. MEDICARE MEDICAID TRICARE CHAMPVA. GROUP FECA OTHER Ia.INSURED'S I.D.NUMBER (For Program in Item 1) (Medicare CHAMPUS HEALTH PLAN BLK LUNG ❑(Medicaid#)❑(Sponsor s SSN) ❑(MemberID#)❑(SSN or ID) ❑(SSN) ®(l D) 16 8 7 5 C CD 2.PATIENTS NAME(Last Name,First Name,Middle Initial) 3.PATIENTS BIRTH DATE SEX 4.INSUREDS NAME(Last Name,First Name,Middle Initial) � RICE, SYDNEY D 811 6S 1 2603M F® FREDERICKSON OUTPATIENT CENTS O S.PATIENTS ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) I 40 SYCAMORE DR self❑Spouse[]Child® Other[:] � CITY STATE 8.PATIENT STATUS CITY STATE MECHANICSBURG IPA Single Married❑ other❑ --k ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(Include Area Code) `$ Full- Time Part•Time 17050 (717) 608-1747 Employed❑Student ❑ Student ❑ ( p 9:OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER LL UIRICE, COLLEEN J AD111212 a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(Current or Previous) a.INSURED'S DATE OF BIRTH SEX YWP80117575903 00505817 ❑YES NO MM i DD i W M❑ F❑ CO) j b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? MM DD W PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME p I p 06 1 12 i 1970 ME] F❑X ®YES ❑NO I P 21 2E c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME FREDERICKSON OUTPATIENT C OYES ❑X NO HOP-ACE MANN INSURANCE d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? CAPITAL BLUE CROSS CAI C ®YES ❑NO H yes,return to and complete Item'9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.l also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. • I SIGNED SIGNATURE ON FILE DATE 11 30 2012 SIGNED SIGNATURE ON FILE j 14.DATE OF CURRENT: ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM I DD I W INJURY(Accident)OR GIVE FIRST DATE MM I DD I W MM I DD I YY MM I DD I W 11 121 2 0124 PREGNANCY(LMP) I I FROM I I TO 17.NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18.HOSPITALIZATION DATES RELATED TO C MM ENT SERVICES -- -- ------------------- yY 17b. NPI FROM 11i 121 2 012 To 11 31 2 U 12 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES ❑YES ❑X NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY(Relate Items 1,2,3 or 4 to Item 24E by Line) 22.MEDICAID RESUBMISSION CODE ORIGINAL REF.NO. 1. 1959. 01 3. I 23.PRIOR AUTHORIZATION NUMBER 2: 4. L. 24.A. DATE(S)OF SERVICE B. C.' D.PROCEDURES,SERVICES,OR SUPPLIES E. F: G. H. I. J. � From To PUKE (Explain Unusual Circumstances) DIAGNOSIS ORS ID. RENDERING O MM- DD W MM DD W SERVICE EMG CPT/HCPCS I MODIFIER POINTER $CHARGES I UNIIS Flan QUAL. PROVIDER ID.# f= 11 3-21bl2l ' 1 1 211 199238 1 i 1 1 1 12 1 218100 1 NPI 1255371688 I I I NPI 3 I I I I C(MI)SAWAC I NPI 4- PI ut o f S 5 I f �1�0 I DES ------------ 117)53 1-6914 NPI I-------------- g 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENTS ACCOU NO. 27.#CCEPT ASSIGNMUT? 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE - i or govt.claims see ba 251857035 ❑❑X 233501429FGB0 ❑AYES In NO $ 21 00 $ 600$ 21800 O 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.SERVICE FACILITY LOCATION INFORMATION 33.BILLING PROVIDER INFO&-PH# 717) 531 -7097 o INCLUDING DEGREES OR CREDENTIALS ob (I certify that the statements on the reverse HERSHEY MEDICAL CENTER DIV PEDIATRIC SURGERY Rty p�l{an mad'J5ftt 3T Y 500 UNIVERSITY DRIVE P 0 BOX 858 MC A410 g V IHERSHEY PA 17033 IHERSHEY PA 17033-0858 � SIGNED 11 30 2 01rTE a b a. 12 5 5 4 8 2 0 8 b• • NUCC Instruction Manual available at:www.nueo.org APPROVED OMB-0938-0999 FORM CMS-1500(08-05) r—BECAUSE THIS FORM IS USED BY VARIOUWERNMENT AND PRIVATE HEALTH PROGRAWEE SEPARATE INSTRUCTIONS ISSUED BY KAPPLICA13LE PROGRAMS. A 5 1 XNOTICE:Any person who knowingly files a statement of claim containing any misrepresentation or any false,incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties. G. REFERS TO GOVERNMENT PROGRAMS ONLY 1:TMEDICARE AND CHAMPUS PAYMENTS:A patient's signature requests that payment be made and authorizes release of any information necessary to process 1 12 Is true,accurate and complete.In the case of a Medicare claim,the patients signature reauthorizes any entity to release tQ Medicare medical and nonmedical information,including employment status,and whether the person has employer group health insurance,liability,no fault,worker's compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made.See 42 CFR 411.24(x).If item 9 is completed,the pollen#5 signature es release of the information to the health plan or agency shown.In Medicare assigned or charge(p CHAMPUS participation cases,the physicsan agrees to acceptthe determination of the Medicare carrier or CHAMPUS fiscal intermediary as the full charge, and the patient is responsible only#or the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge N•determmation of the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submitted.CHAMPUS is not a health insurance program but makes payment for health benefits provided through certain affiliations with the Uniformed Services.Information on the patient's sponsor should be provided in those items captioned I "Insured";i.e.,items la,4,6,7,9,and 11. 0 BLACK LUNG AND FECA CLAIMS The provider agrees to accept the amount paid by the Government as payment in full.See Black Lung and FECA instructions regarding required procedure and N) c.diagnosis coding systems -.11 SIGNATURE OF PHYSICIAN OR SUPPLIER(MEDICARE,CHAMPUS,FECA AND BLACK LUNG) CA)l certify that the services shown onthisformwere medically indicated and necessary for the health of the patient and were personally furnished by me orwere furnished 10* cident to my professional service by my employee under my immediate personal supervision,except as otherwise expressly permitted by Medicare or CHAMPUS .f,.:gulations C11 For services to be considered as"incident"to a physician's professional service,1)they must be rendered under the physician's immediate personal supervision C:)by his/her employee,2)they must be an integral,although incidental part of a covered physician's service,3)they must be of kinds commonly furnished in physician's offices,and 4)the services of nonphysicians must be Included on the physician's bills. For CHAMPUS claims,I further certify that I(or any employee)who rendered services am not an active duty member'of the Uniformed Services or a civilian employee of the United States Government or a contract employee of the United States Government,either civilian or military(refer to 5 USC 5536).For Black-Lung claims, 01 further certify that the services performed were for a Black Lung-related disorder. 00 0-)No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations(42 CFR 424.32). NOTICE:Any one who misrepresents or falsifies essential information to receive paymentfrom Federal funds requested by this form may upon conviction be subject to tine and imprisonment under applicable Federal laws. NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE,CHAMPUS,FECA,AND BLACK LUNG INFORMATION (PRIVACY ACT STATEMENT) We are authorized by CMS,CHAMPUS and OWCP to ask you for Information needed in the administration of the Medicare,CHAMPUS,FECA,and Black Lung programs.Authority to collect information is in section 205(a),1862,1872 and 1874 of the Social Secunty Act as amended,42 CFR 41124(a)and 424.5(a)(6),and 44 USC 3101;41 CFR 101 et seq and 10 USC 1079 and 1086;5 USC 8101 el seq;and 30 USC 901 et seq;38 USC 613;E.C.9397. The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility.It is also used to decide if the services and supplies you received are covered by these programs and to insure that proper payment is made. The information may also be given to other providers of services,carriers,intermediaries,medical review boards,health plans,and other organizations or Federal agencies,for the effective administration of Federal provisions that require otherthird parties payersto pay primaryto Federal program,and as otherwise necessary to administerthese programs.Far example,it maybe necessary to disclose information aboutthe benefits you have used to a hospital or doctor.Additional disclosures are made through routine uses for information contained in systems of records. FOR MEDICARE CLAIMS:See the notice modifying system No.09-70-0501,titled,'Carrier Medicare Claims Record,'published in the Federal Register,Vol.55 No.177,page 37549,Wed.Sept.12,1990,or as updated and republished. FOR OWCP CLAIMS: Department of Labor,Privacy Act of 1974,"Republication of Notice of Systems of Records,"Federal Register Vol.55 No.40,Wed Feb.28, 1990,See ESA-5,ESA-6,ESA-112,ESA-13,ESA-30,or as updated and republished. FOR CHAMPUS CLAIMS:PRINCIPLE PURPOSE(5):To evaluate eligibility for medical care provided by civilian sources and to issue payment upon establishment of eligibility and determination that the services/supplies-receivedareauthorized-by4aw. ROUTINE USE(S):Information from claims and related documents may be given to the Dept,of Veterans Affairs,the Dept.of Health and Human Services and/or the Dept.of Transportation consistent with their statutory administrative responsibilities under CHAMPUSICHAMPVA;to the Dept.of Justice for representation of the Secretary of Defense in civil actions;to the Internal Revenue Service,private collection agencies,and consumer reporting agencies in connection with recoupment claims;and to Congressional Offices in response to inquiries made at the request of the person to whom a record pertains.Appropriate disclosures may be made to other federal,state,local,foreign government agencies,private business entities,and individual providers of care,on matters relating to entitlement,claims adjudication,fraud,program abuse,utilization review,quality assurance,pear review,program integrity,third-party liability,coordination of benefits,and civil and criminal litigation related to the operation of CHAMPUS. DISCLOSURES:Voluntary;however,failure to provide information will result in delay in payment or may result in denial of claim.With the one exception discussed below,there are no penalties under these programs for refusing to supply information.However,failure tofurnish information regarding the medical services rendered or the amount charged would prevent payment of claims under these programs.Failure to furnish any other information,such as name or claim number,would delay payment of the claim.Failure to provide medical Information under FECA could be deemed an obstruction. It is mandatory that you tell us if you know that another party is responsible for paying for your treatment.Section 1128E of the Social Security Act and 31 USC 3801- 3812 provide penqlttes fq>withholding this information. You should be aware that P,L' 100-503,the"ComputerMatching and Privacy Protection Act of 19887,pennitsthe governmeritto verify information byway of computer matches. MEDICAID PAYMENTS(PROVIDER CERTIFICATION) I hereby agree to keep stfoh rec&rds•as are necessary to disclose fully the extent of services provided to individuals under the State's Title XIX plan and to furnish information regarding any payments claimed for providing such services as the State Agency or Dept.of Health and Human Services may request. I further agree to accept,as payment in full,the amount paid by the Medicaid program forthose claims submitted for payment under that program,with the exception of authorized deductible,coinsurance,-c-o'-paym-enit-or's-iniilar cost-sharing charge. SIGNATURE OF PHYSICIAN(OR SUPPLIER),I certify that the services listed above were medically indicated and necessaryto the health of this patient and were personally furnished by me or my employee under my personal direction. NOTICE:This is to certify that the foregoing information is true,accurate and complete.I understand that payment and satisfaction of this claim will be from Federal and State funds,and that any false claims,statements,or documents,or concealment of a material fact,may be prosecuted under applicable Federal or State laws. According to the Paperwork Reduction Act of 1995,no persons are required to respond to a collection of information unless It displays a valid OMB control number.The valid OMB control number for this information collection is 0938-0999.The time required to complete this information collection is estimated to average 10 minutes per response,including the time to review instructions,search existing data resources,gather the data needed,and complete and review the information collection If you have any comments concerning the accuracy of the time estimate(s)or suggestions for improving this form,please write to:CMS,Attn•PRA Reports Clearance Off tcer,7500 Security Boulevard,Baltimore,Maryland 21244-1850. This address is forcomments and(orsuggestons only.DO NOT MAIL COMPLErED CLAIM FORMSTOTHISADDRESS, I� PENNSTATE HERSHEY j Illllf C' sX1 Milton S. Hershey NAME: RICE, SYDNEY IfIIff101111{Illllllllflfllllllffllffl iW Medical Center 'K'": 7512938 MDS 10512938 MD: OEFLITCH CHR15T0 MD»: 46325 I� DOB: 04/05/2003 VISIT DATE: 11/12!1012 LOC: EMER SEX: F ° TRAUMA TEAM SIGN-IN SHEET �IIIIIIII1111�111111, SELF PAY m o' Date TRAUMA NUMBER I . TRAUMA LEVEL 1 2 3 N w Trauma Standby paged at hrs Trauma Response paged at hrs I .. _ .\• - •. .'!'7:1• Y .I".�Y•aS.a J'.`: .f.' •. ••'1 ,1:� ��... •..4'a:: O t ...-.. .�.,.-...• :�• is qtr.: Y 'J• Y J.rl.�:: . S .•. J,RESPO.NS�TEAM MEMBER FL;'•i N ME ;� :,_ r >•%- rr;. :Time'bf'A. �.. C) ED Attending t Noe -0 Trauma Attending s-t7 IZ Trauma Team Leader PGY4/5 o o Senior Trauma Resident PGY 4/5 00 Junior Trauma Resident PGY 2/3 rn Junior Trauma Resident PGY 2/3 Junior Trauma Resident PGY 1 Junior Trauma Resident PGY 1 Emergency Med. Resident PGY 2/3 Emergency Med. Resident PGY 2/3 Emergency Emergen2y Med. Resident PGY 1 Trauma Physician Extender Trauma Physician Extender , Anesthesiology Attending o Anesthesiology Resident Certified Registered Nurse Anesthetist Respiratory Therapy Radiology Attending Radiology Resident Radiographer#1 Diagnostic Y ( 5' Radiographer#2 (Diagnostic) F g 3 Radiographer CT Emergency Medicine EMT Chaplain All 3't OR Technician/Nurse Pediatric Critical Care Attending Pediatric Critical Care Resident Child Life S eciaiist Nei Trauma Coordinator/Case Manager - i��J CO'NSULTA'NT MEMBERS` SAME. �M.r r s_s.,. ... Ewa..� ._ 5�° ��x :itneof Arrlvai Orthopaedics Pager 2002) Neurosurgery (Pager 1001) L Plastic Surgery ENT PGY=Post Graduate Year Original Copy-Medical Records MR 414 Rev.1108 Page 1 of 1 Pink Copy-Emergency Dept. IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII TRAUMA TEAM SIGN-IN SHEET Yellow Copy-Trauma Services 0 PENNSTATE HERSHEY NA CC '12'118 Milton S.Hershey MR7.-7R5 129,81YIINIY Do ! 10'5 MD: DEFLITCH CHRISTO 140- 4632 DOB.' 04/05/2003 *SiT DATE: 11/1212012 Medical Center SEX: F LOC-. EMER NS F P SELF PAY ED TRAUMA/RESUSCITATION FLOW SHEET Date Time Stat Page Time d Response level 2 LjtL�j M Interhospital Y N :K Weight Ambulance H_tkopte Age Sex O Chart 0 Labs 0 XFt PRE-HOSPITAL REPORT B;Pct, ;(0 6- of Consclousgossl Yes No Un nown #minutes HR Loss Monitor Rhythm Immobilization: -Co CI Kng Boa M Splint RR Assistive Device Entrapped: Yes o Unknown Spontaneous Rate/Pattern Self Extricated: Yes No S 0 PMH: (Z) GCS Meds- Patent IV Site Gau a Sol'n Amt Yes No #1 LYN,t 0 0 Alle rgies- #2 0 0 #3' o o Tetanus: PRIMARY SURVEY,(5y.,XJf.'2N0 mm Airway Intervention Bracelet Location: Patient Maintained Yos Na el_ Mechanically maintained by opo oxygen mask _11min or_% ID*. Breathing 00 Airway&bag o spontaneous ratE/pattern 00 ETT- sww�_ Blood Band, 0 Not breathing assistive device lwavon Sa02 Incubated R7460 Yes No L O Surgical airway-done by Documenting Nurse, _.S I 0 0 Breath sounds R dq 0 0 Tachypnea Vent Settings 0 0 intercostal retractions Time Support Nu.kpi�) 0 0 Chest wall bniising Rate Circul ion F102 Physician Signature: 41�1 HR r(im(on a rd v-a 1) Rhythm— ___JMMHg(on arrival) PEEP IPulses R L 90R.- 1, ...... Y_ No Yes No 2 0 RadW 00 Chest tube 0 r-emoral size: 9 t Initial temp. 0 0 up left 0 0 PT 00 Other Intervention(state) Patient covered 0 0 Hemorrhage? Yes N. Warm blankets Yes At. 00 TV Une Yes NO 0 0 Zd&7V/ site i—size—g Patent? 0 0 overhead warmer 0 0 157tMat site 2 stze_g Patent? fl C site3—size—s; Patent? 0 C` hest 0 0 IV fluid,warmed to 104°F 0 Abdomen 00 Arterial line site JqJA 0 Peivisiretropedtoneal RepeatTemp.at 30 0 Limbs MTP rime 1171ttaW.• Slon Pink Warm Pate Hot Cyanouc coot Mottled cold Dry Moist =22",A% I QNSM,AVE" Eye 4 COMA 9-12 semoe Called Arrived I R.�porse To 1. SLUE{GCS) t-8 Trauma Attending • 7ED A:ding t - Vajbal N_ (Total Pbft 1-5 Sj ftm ) Neurosurg 0 ED Attending stood 7f,89MM H9 4 P�Poro* Anesthesla Attending I.Wropre"n.m M.S Plastics Z 2 Premm so-75orn go =P11 —�_ or T,.U., wit iAqm i I Senior Trauma Resident P Bad a CNlor Motor coca es PSin P-Ontary other Pesiwtisa a raves PH Raft 29/ In. on(P-1n; UU (;.M) Eastern Auto MR 15: EC 26 2012 ED TRAUMA/RESUSCITATION FLOW SHEET' ' n w (D I SECONDARY SURVEY i n Head Yos No Qsalptlan: X-ray O Scalp 0 o Laceration :3 1 Yv 6w\ ;\r. O O Vault Fracture �A � Time Time�=- C Face O o Basal Fracture Suspected ) blY. 0 O laceration 0f �Q Lateral C-spine d O O Fracture ` (� est X-ray spine 1 Q O O law Instability ( 1,(^ C�CSt�O✓� Pelvis Chest ::3 Eyes O O Injury Other Abdom r/Pdvis O O Decreased vsion Ote Spines CD an O O Hemotympanum Side: ' ` p Other Other N QO O CSF leak Slde: Other N 0 Nose O O Bleeding Mouth O O Tooth Neurovascula r ent (� Neck Yes No Desafpobn. Areas of Concern: O Q pine tenderness I O O ®ste Stepoffs/ceplbrs U - .06 O O Laceration 01 O O C-do11ar off time Pulse Assessed: C O O Rehab collar time Time Tem . Color Capillary Refill Sensation Movement Puts Chest Yes No OesafpCon: O 10 Chest wag injury Side: y, " Jr O O an'bs � ��G L O O Flail segment C 00 O O open pneum x othora t0 O O Pneumothorax R/L s. O O Itemothorax R/L Abdomen Yes•No Opsclpdon: O O Skin contuslon/abrasion r , O q.Dlstenslon O O Tenaemess Injury Diagram O O Guarding �� e� Fast + - Injury Diagram Key: Completed by Renal heme: + - 1= Open Fracture E = Ecchymosis Done by time 2= Amputation A = Abrasion N/G(oral/nasal) 3= GSW C = Contusion i Size Fr 4= Deformity L = Laceration Inserted by time 5- Stab Wound 5 = Swelling• Peritoneal lavage/DPA: 6= Bum T - Tendemess Done by time 7= Pain PW= Puncture Wound Return: O Clear 8= Rash I = Impaled Qbject O Pink O Gross blood Amount infused cc y V Amount returned Cc ..n Fluid to lab: O Yes 3 to' O No Genitourinary Desrdatibrr: Foley: O Yes 9 No O Herne+ o size Fr ' Inserted by time Rectal Tone: JO.Good O Deceased i O Absent Ov Prostate: O Normal O Abnormal i Blood observed at: Yes No I Vagina O O Rectum O 6 Urethral meatus O O Extremities 5 Ps Paratysis Parasthesla Pulses Pain Pallor ' Yes O Yes O Yes 6 Yes O Yes O PA No Bb. No 40 No No 0 No 9) Yes O Yes O Yes® Yes O Yes O ` LA No No B No O No eb No 0 1 Yes O Yes O Yes @ Yes O Yes O gti RL No A No Q No O No 0 No 0 Yes O Yes O Yes 0 Yes O, Yes O LL No No 0 No O No-0 No 0 Eastern Auto DEC 2 6 2012 ED TRAUMA/RESUSCITATION FLOW SHEET MR isr" r . r Y ,� : ass �� • � ' , • Trauma Resuscitation Flow Sheet ®UENA °©©©!�•fell Nursing Interventions MMIMM UPS M ONE Flail ME ONO mmmmr0 101001 MEN wmmw 0ENE mmwm ■o IMININUMM ==r==ME INNER ENO w�=====ENEONME 110 ==w==NNEINNEM 011 =====ME 01111000■ 011 110110 0111111 me MENEM 011 011 MMINM ME SOMME 011 IMMINE mm M SOMME IME mmmmm ■E �NIEMEN EMS iiiiiiNE EMS Normal Ranges for Vital Signs I pupil Size(MM) .0 Infants 30-60 Infants 74150-1"" Infants 120-160 Toddlers 20-40 Toddlers ao/50-1�2/.11 Toddlers 90-1-10 Preschool 23-34 Preschool 82150-110/78 preschool :: : :� �� • Adolescent .� • Crystalloid Output Disposition at Discharge _ _Family notified la Time:___ In HMC safe Given to family Name:-i Given to police Name; SICU Floor 0 Expired 0 Other Time: ■w----_-� -O n/Tissue Donation • TOTAL• • intake/Blood Components Medications FORM -�mm r • • 1 , if- PENNSTAT�E�.�HERSHEY IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIiIiIIIfIIII N F MUton S.Hershey NAI1E: RICE SYDNEY 005 10512938 Medical Center ho"'DEFLITCH CHRISTO flD— 46325 D08: 04/05(2003 VISIT DATE: 11112!2012 SEX: F n INS' EtiLF ER PAY SELF PAY o TRAUMA HISTORY AND PHYSICAL EXAMINATION IIIIIIIIE�IIIIIIIiIIII < / Date: Z,7, Time: nee O 7 ;o Hz of Present Illness(HPI) ROS �.. MVC Belted? 'Y.Yes .Q,No "Q Airbag Timing/Duration , tivcq Eyes O ❑Pedestrian ❑MCC ❑Assault Signs/Symptoms:.'Amnesia?.❑Yes2rN ENT , HIV El Fail El Burn ❑Electrical Loss of Consciousness? ❑.Yes No Cardiovascular ❑GSw ❑Stab ❑Other: -� Respiratory 9 GU (a mvq �ac . GI 01 Musculoskeltal ; CD �t C Integumentary Neurologic , adtfyi'g ,.;3, Ptweighr. Broselow weight: Other ❑Entrapment' ❑Ejection ❑Crush ❑Blast All others negativelnon contributory' Helmet El Yes ❑No ❑Environmental Exposure ❑Hypothermia ❑Impalement P,aSt tVlettlt; t,$grgiCat;< 3ti1lt�t,Soe�at'Hi5;4C�+ 3a tq ❑Chemical. ❑Biological ❑Radiation ❑Other. Allergies: Fall:Ht of fall: Fall from object FFS:❑Yes ❑No Medications: Coumadin ❑Plavix ❑other. Other. Past'Siirgical Hic --p— iiT1�1�!<S Q :,,:k;' x Vii, hG.;,`; ' `. Family H)c Bleeding Disorder El Yes El no Airway Patent ❑Obstructed Intubated: ❑OT ❑ NT ❑ Tradi Q Other"' Noncontdbutatory/Unobtainabie• Breathing: G f ea tr Breath Sounds: Soda!Hz Family Status: ` Circulation: P: V BP: LI RR: 22— Sat: Cf3 ❑Other: YG Noncontributatorylunobtainable Disability: GCS: M V—Aq E _ ❑Etoh ❑Smoki Hx ❑Blega Drug FAST Exam: cr, Exposure: Completed . Last Meal: Last Tetanus: ¢Sec6itdary5uriiej+?2nd Vitals:Temp cf BP. R: .'200 Satl0 WT HEENT: Head: t.a.- '�61'" Eyes: I-L72- 101( (� � Ears: TM's: G t(uc f Battle's: . . Face: Maxilla: Ul.f� Mandible: Nose` C♦/` Dentitia: VV oi vAcj Mouth; JtS4 Dentures: i > Neck: Tenderness: 1 Crepitus: Trachea ML: ( Chest Wall:Tenderness: Vli T Crepitus: 14 t Lungs: l " ( c ! Back: Tenderness: d Crepitus: Heart: V* cw N4 l~ In/i Abdomen: Distention: 1rV.t) BS: Tenderness: Rectal: Tone Heme: Prostate: Pelvis:Stable: Tenderness: Vascular Exam: RadiauA Femoral 2-4 DP -z,4 PT 11 LEGEND: Right/Left �l� ���, L-laceration .• Cfx{losedfiracture Resident St atu Title Dat Time a.mlp.m. OD(-open fracture Ab-abrasion ���� .100 C-contusion C./ COPYRIGHT,1998 PSGH§ Orig -Chart MR 611 Rev.5/11 TRAUMA HISTORY AND PHYSICAL EXAMINA { to rri�p/�1U IC DEC . I IIIIIIII IIIII li 111111 IIIII Illll 1111 ill! DEC2 � 2012 TRAUMA HISTORY AND PHYSICAL EXAMINATION (D I (�euro�ogtca!Exam : Glasgow Coma Scale Trauma Score pCranial Nerves. t 1 `t�C t Spinal Cord In jury: c t'� iY None°`ng Resp.Rate .SBP :D �"� 2-Open to Pain 0-0 0-0 G Motor: v�c/ c �� Open to CommandlVoice 1-1-9 . 1-0-49 Spontaneous 2->36 2.-'50-69 I Verbal Response Sensory:Pinprick +t.o J t T 1-12 1-None 3 25 735 .,.,3-70.90 0` ry p 2-IncomprehensibliAloansto Pain 10-24 .0'>90. . :3 :�__-�� 1 3-Inap ropriate/Cries to Pain Proprioception vL0 � ) co used/consolame GCS O �� S Alert/Odented/Interaar 0-3-4 .p Motor Response 1-5-7 1-Rorie N �t-s 2-8-10 01 2•Decerebrate y�— 3-Decorticate 1-13 4-Withdraws. " 4- 4-1'S. W (I �,caiize,. Pai G d n Total•O h. ;iab staff s Evaftiater"r ;: *yv:;'. rn_r <ii :s'^.:.,; PT: Tro onin:. UTA: PTT: Myoglobin: lu T:Bili: CPK: Drug Screen:.. 0 1° 3. r U! ALT. Amylase:. 00 ABG: ALP: 4E-a: ETOH-. ECG: TEE: BHCG: Ra CSR: (�Q Pelvis: 7Cl Scans:- Head/f?, ,�e JJvr' feacwx: [ Opine: Lat Extremities: Abdomen AP Others:. Odontoid T&L Spines: x.> AtteTtdl457 73plan 7, ,7 7-7 7 ^ "t Yoh" 1'�.,3•._F�t�.�ye � �. � _ .� r � �'r} tii`S�,��4, Y- t' ( I saw and evaluated the patient and agree with the resident's findings and plans as written above, n ❑See dictated note ❑I have reviewed the transport/EMS notes Admit: ❑ PICU ❑PIMC eEf?eds.Floor ❑SICU ❑ NSICU ❑ IMC ❑ NSIMC ❑Floor Neuro:GCS: 1,4 ❑.Consult NSGY ❑OR Crani ❑ Repeat CT Consult Facial Trauma HEENT: Neck: ❑ Consult Spine' ❑Miami 1-Collar ❑C-S ine Clear ❑MRI Res CV: Gl: ❑OR Exploratory GU: ❑Consult URO MS: ❑Consult Ortho/S ine ❑OR for Fracture Psych:❑Consutl Psych ❑Consult D+A Procedures:❑NG-Tube ❑Urina• Catheter ❑A-line: ❑CVP(s): Chest tube: ❑fight ❑left ❑OPL: /1 .r r� Attending Signature Date Time Orig =;Chart MR 611 Rev.5/11 C rn Au Trauma Services TRAUMA HISTORY AND PHYSICAL EXAMIi 'I1t? DEC:2"6 2012 - n Ix .D/C Summary RICE, SYDNEY D'- 7512938 * Final Report l I 0 * Final Report * m DISCHARGE SUMMARY to � Name: RICE, SYDNEY D � HMC Number: 7512938 DOB: 04/05/2003 w Date of Admission: 11/12/2012 lC Date of Discharge: 11/13/2012 cD Physician: Rocourt, Dorothy V I� Service: Ped Surgery rnDischarge Diagnosis: Soft tissue lacerations of the face Other Diagnoses: Concussion Surgical Procedures: Repair of facial soft tissue lacerations per Plastic Surgery 11/12112 Vaccinations Received This Hospital Stay: 11/13/2012 influenza virus vaccine Discharge Medications: 1. Amoxicillin (amoxicillin 250 mg/5 mL oral liquid) 7 mL by mouth 3 times daily. 2. Acetaminophen (Tylenol)400 mg by mouth every 4 hours, as needed for Fever/Mild Pain. Brief History of Present Illness: Sydney is a 9-year-old girl who was a restrained back seat passenger involved in a motor vehicle accident. She was seen as level 2 trauma activation where she was found to have repetitive speech, questionable change in mental status both in the field and on trauma evaluation; she was upgraded to a level one in the field. Arrival GCS 14, therefore, she underwent CT scan of the head and facial bones. She has extensive soft tissue injury involving the left side of her forehead and in both the hair-bearing and forehead skin as well as left cheek up to the commissure of her mouth. For this reason, plastic surgery was consulted. Hospital Course: Patient was admitted to Pediatric Surgery Service on 11/12/12. Plastic surgery was consulted for repair of facial laceration. Her C-collar was cleared as CT of spine was negative for any bony injuries. She was placed on amoxicillin for infection prophylaxis. She is to take this antibiotic for a total course of 7 days. Her diet was advanced and tolerated it well. Her pain was controlled. She was stable and discharged on 11/13/2012 with a follow up clinic appointment with Plastic Surgery in 1-2 weeks. - Exam on Discharge: Physical Exam: _ Facial laceration to hair bearing scalp (left), frontal and forehead skin-with sutures in place i Printed by: Calloway, Earthenia D Page 1 of 4 Printed on: 12/13/2012 07:01 `Continued) Eastern AUTO DEC 262012 r I� D/C Summary RICE, SYDNEY D - 7512938 (E * Final Report I C) o Frontal motor branch distribution intact Sensation in tact in V1, V2 V3 distribution CD (n Heart:RRR 5' Chest:CTAB l:3 Abdomen :soft, NT, ND 0 Extremity :sensation intact, moving all extremities N Dictation#463710 Cn w Care Instructions: l0 1. see the head injury care instructions. Most concussions get better with time, but it can take time. Some people's can symptoms go away within minutes to hours. Other people have symptoms for weeks to months. 0 To help your brain heal after a concussion: ;;z --Rest the body: Make sure your child gets plenty of sleep. When awake, he should avoid heavy exercise or too I � much physical activity. 0 rn --Rest the brain: Your child should avoid doing activities that need a lot of concentration or a lot of attention, such as excessive television or computer/video games, or texting. Return to school only after completely symptom-free. --Your child may take a pain-relieving medication for headache, such as acetaminophen(Tylenol)or ibuprofen (Motrin,Advil)as directed on the bottle. --Your child MUST be cleared in clinic before you can do strenuous physical activities, play sports, or do you usual activities. Some patients and families experience increased emotional symptoms after injury, particularly after a head injury. It is common and completely normal to have a gradual return to normal sleeping/eating/coping routines. Visit aftertheinjury.org for interactive tools and information. 2. laceration care-wash with soap/water, dry and apply a thin layer of bacitracin twice/day until healed. Avoid weather/sun exposure. Clean away any remaining crusts with peroxide. Sit upright as much as possible to decrease facial swelling. 3. oral care after meals and before bedtime. If toothbrush is too painful, use rinses with children's mouthwash (without alcohol,which can burn). Please continue your Amoxicillin for 7 days for treatment of your facial lacerations. Diet Guidelines: regular diet. drink plenty of liquids. Activity Guidelines: avoid activities that may lead to falls or impact for the next AND cleared at follow-up. NO: jumping, climbing, sports/PE/training or recess/playground play, riding things with wheels. return to school-see note provided. Upon return to school, parents, school staff and patient should monitor for increased/returned symptoms (headaches, fatigue, difficulty concentrating or processing information, any confusion). If this occurs, it may signal that it is too soon to return, or a modified schedule may be needed. Please call to let us know if this occurs. Printed by: Calloway, Earthenia D Page 2 of 4 Printed on: 12/13/2012 07:01 (Continued) Eastern Auto DEC 262012 r i'I I; D/C Summary RICE, SYDNEY D.- 7512938 0 *Final Report I n 0 Z) CD Call your doctor if: in Call 717-531-8521 (operator-ask for the pediatric surgery resident on-call): fever greater than 101 F, increased . o severe pain, persistent vomiting, any confusion, agitation or excessive sleepiness, increased redness/drainage from I D wounds. O N for routine questions during the weekdays, please call the pediatric surgery office at 717-531-8342. Cil W Other Instructions: lC You will have a follow up appointment with Plastic Surgery in 1-2 weeks. You should receive a phone call to schedule a cn this within 1-2 days. If you do not hear from the office, please call 717-531-8953 to schedule this appointment. 0 0 Follow-Up Appointments: 7 I-1i. Scheduled Penn State-Hershey Appointments Within the Next 90 Days. 0 rn 1. Follow-Up with PRS, UPC Resident at Plastic Surgery- Univ Phys Ctr Suite 3200 on 11/20/2012 at 02:30 pm 2. Follow-Up with Suite 400 Peds Surgery at Univ Phys Ctr Suite 400 on 12/12/2012 at 03:15 pm i Signature Line Electronic Signature on File Electronically Reviewed/Signed by: Thu N Pham, MD Author Signature Dt/Tm:1 1/14/2012 07:53 AM Electronically Reviewed/Signed by: Dorothy V Rocourt, MDCosigner Signature Dt/Tm: 11/14/2012 09:45 AM Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Brett Engbrecht, Kerry Fagelman,Dorothy Rocourt,Mary Santos Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP, PNP-BC, Lynn Simmons MSN CRNP TNP /LEM DD: 11/13/12 DT: 11/13/1222:34 Result Type: D/C Summary Date of Service: November 13, 2012 18:12 Authorization Status: Final Printed by: Calloway, Earthenia D Page 3 of 4 Continued Printed on: 12/13/2012 07:01 Eastern Aut® ( ) DEC 2 6 2012 C� r I� D/C Summary RICE, SYDNEY D - 7512938 Final Report " I C7 Subject: D/C Summary � Author or Import Date: Pham, Thu N on November 13, 2012 22:34 Verified By: Rocourt, Dorothy V on November 14, 2012 09:45 o' Encounter info: 10512938, HMC, Inpatient, 11/1212012- 11/13/2012 I 0 N Cn W I i 0 Cn 0 I 0 rn i i I Printed by: Calloway, Earthenia D Page 4 of 4 Printed on: 12/13/2012 07:01 Eastern Aut® (End of Report) DEC 2 6 2012 n PENNSTATE v Debra Rhoads 500 University Drive (717)531-6964 Patient Financial Services Hershey,Pa 17033 Fax: (717)531-0494 E-mail:drhoadsePSU•EDU C� O December 13, 2012 0 I� 0 N Horace Mann Insurance PO Box 962 I NC 27560 o C) Patient Name: Sydney D. Rice l� Claim#: 16875C 0 0 0 'I To Whom It May Concern: Penn State University Hospital, The Milton S. Hershey Medical Center, Hershey, PA 17033, is an Accredited Level 1 Trauma Center. In Compliance with Pennsylvania Law (ACT 6), physicians charges and facility charges associated with the treatment of a patient in an Accredited Trauma Center will be paid at 100% of the billed amount. The charges are exempt from the Medicare Reimbursement rate of the Medicare Fee Schedule times 110%. PLEASE REMIT PAYMENT OF 100% OF OUR CHARGE WITHIN 30 DAYS. If you have any questions, please feel free to contact me at my direct phone number, (717) 531-6964. Sincerely, Q,g,t,.d� �v F,r X , Patient Account Associate ,,,Q.°,° AUtO Hershey Medical Center ��S r CAR � � HORACE MANN INS&* PO BOX 962 � MORRISVILLE NC 27560 w HEALTH INSURANCE CLAIM FORM a C= APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 J0 PICA CASE ID: 00010512938 PICA FTT 0 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1 a.INSURED's I.D.NUMBER (For Program In Item 1) 1 (Medicare# (Medicaid# CHAMPUS HEALTH PLAN BLK LUNG )❑ )❑(Sponsor's SSN) ❑(memb-IDN❑(SSN or ID) ❑(SSN) M 00 16 8 7 5 C (p 2.PATIENTS NAME(Last Name,First Name,Middle Initial) 3.PATIIENT's BIRTH DATE SEX 4.INSURED's NAME(Last Name,First Name,Middle Initial) MM DID . RICE SYDNEY D 0410512003M FX❑ FREDERICKSON OUTPATIENT CENTER O 5.PATIENTS ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED's ADDRESS(No.,Street) l� 40 SYCAMORE DR Self[-]Spousa❑ChildE] other❑ CITY STATE 8.PATIENT STATUS CITY STATE Z � MECHANICSBURG PA Singled Mauled other❑ a � ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(Include Area Code) � Full-Time Part-Time W 17050 (717 6 0 8-17 4 7 Employed❑ student ❑ student ❑ o U 9.OTHER INSURED's NAME(Last Name,First Name,Middle Initial) 10.IS PATIENTS CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER CnRICE COLLEEN J AD111212 w a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(Current or Previous) a.INSURED's DATE OF BIRTH SEX EZ YWP80117575903 00505817 ❑YES �NO MM i DD i YY M❑ F❑ Z b MM ER NSSURED's ATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME O o 06 1 M[] FQ QYES ❑NO p 12 1 1970 Wc.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME ~ FREDERICKSON OUTPATIENT C ❑YES 1"1 HORACE MANN INSURANCE w d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? d CAPITAL BLUE CROSS CAI C L YES ❑NO //yes,return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED_�I�-N-AT�F,E OZT Fjj,E DATE SIGNED E 14.DATE OF CURRENT: ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM I DO I YY INJURY(Accident)OR GIVE FIRST DATE MM I DD I YY MM I DO I YY MM I DD I YY 11112 12 012 PREGNANCY(LMP) 1 1 FROM I I TO I I 17.NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a; " 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES --- -- =--=------=-==-=--=---- = MM 1 DD I YY MM I DO 1 YY 17b. NPI FROM 111 12 1 2012 TO 11 1 13 1 2012 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES ❑YES E]NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY(Relate Items 1,2,3 or 4 to Item 24E by Line) 22.MEDICAID RESUBMISSION CODE ORIGINAL REF.NO. 1. 1959. 01 3. 1 PRIOR AUTHORIZATION NUMBER 4. �. 24.A. DATE(S)OF SERVICE B. C. D.PROCEDURES,SERVICES,OR SUPPLIES E. F. G. H. L J. From To PIACEO (Explain Unusual Circumstances) DIAGNOSIS DQAYRS FPS ID. RENDERING O MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $CHARGES UNRS Plan QUAL PROVIDER to.# 53 _.. ..,: N 156 0793 O 23_ 99285 1 12 ! 9 100 1 PI 841 _ I --\ �I? -- ------------- ¢ l h NPI W _ .. f 3 _ _ ___---w--- Y a I I I I -,� � :. + I NPI A IL I: i. . i.:... '....... ._ h`' 1�E NPI O .yam St r. u .® . cc DEC 5 I I I I 1 ��1 �°•6�$ 1 t NPI --------------• U � NPI a N 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENTS ACCOUNT NO. 27.#CCEPT ASSIGNbv1FkNT? 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE a orgovr.claims see ac 1 O 251857035 0® 233202598F6B0 ❑YES ❑NO $ 53900 $ Q001$ 53 00 O 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.SERVICE FACILITY LOCATION INFORMATION 33.BILLING PROVIDER INFO&PH# 717 5 31-7 0 9 7 o INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse HERSHEY MEDICAL CENTER DIV OF EMERG ROOM Cb N OLaI,�ke�t1TX1 agAIT ma'96t;hs[@Df,) P 500 UNIVERSITY DRIVE P O BOX 858 MC A410 g HERSHEY PA 17033 1HERSHE Y PA 17033-0858 0r) SIGNED 11 2 7 2 O 10ATE a• b.. a• 12550: '2 0 8 b': NUCC Instruction Manual available at:www.nucc.org APPROVED OMB-0938-0999 FORM CMS-1500(08-05) r BECAUSE THIS FORM IS USED BY VARIOUWERNMEN°( AND PRIVATE HEALTH PROGRAPSEE SEPARATE INSTRUCTIONS ISSUED BY I�APPLICABLE PROGRAMS. �7 NOTICE:Any person who knowingly files a statement of claim containing any misrepresentation or any false,incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties. (D (Q' REFERS TO GOVERNMENT PROGRAMS ONLY 3 MEDICARE AND CHAMPUS PAYMENTS:A patient's signature requests that payment be made and authorizes release of any information necessary to process the claim and certifies that the information provided in Blocks 1 through 12 is true,accurate and complete.In the case of a Medicare claim,the patient's signature 0 authorizes any entity to release to Medicare medical and nonmedical information,including employment status,and whether the person has employer group health O insurance,liability,no-fault,workers compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made.See 42 CFR 411.24(a).if item 9 is completed,the patient's signature authorizes release of the information to the health plan or agency shown.in Medicare assigned or NCHAMPUS participation cases,the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary as the full charge, and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge N. determination of the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submitted.CHAMPUS is not a health insurance program but O makes payment for health benefits provided through certain affiliations with the Uniformed Services.Information on the patient's sponsor should be provided in those :3 items captioned in"Insured";i.e.,items 1 a,4,6,7,9,and 11. IO BLACK LUNG AND FECA CLAIMS -p The provider agrees to accept the amount paid by the Government as payment in full.See Black Lung and FECA instructions regarding required procedure and N) diagnosis coding systems. -.% SIGNATURE OF PHYSICIAN OR SUPPLIER(MEDICARE,CHAMPUS,FECA AND BLACK LUNG) IW I cerfify thatthe services shown on thisformwere medically indicated and necessaryforthehealth of the patient and were personally furnished by me or were furnished incident to my professional service by my employee under my immediate personal supervision,except as otherwise expressly permitted by Medicare or CHAMPUS � regulations. U1 For services to be considered as"incident"to a physician's professional service,1)they must be rendered under the physician's immediate personal supervision O by his/her employee.2)they must be an integral,although incidental part of a covered physician's service,3)they must be of kinds commonly furnished in physician's offices,and 4)the services of nonphysicians must be included on the physician's bills. For CHAMPUS claims.I further certifythat I(or any employee)who rendered services am not an active duty member of the Uniformed Services or a civilian employee ,p of the United States Government or a contract employee of the United States Government,either civilian or military(refer to 5 USC 5536).For Black-Lung claims, O 1 further certify that the services performed were for a Black Lung-related disorder. CONo Part B Medicare benefits may be paid unless this for m is received as required by existing law and regulations(42 CFR 424.32). NOTICE:Any one who misrepresents or falsifies essential information to receive payment from Federal funds requested by this form may upon conviction be subject to fine and imprisonment under applicable Federal laws. NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE,CHAMPUS,FECA,AND BLACK LUNG INFORMATION (PRIVACY ACT STATEMENT) We are authorized by CMS,CHAMPUS and OWCP to ask you for information needed in the administration of the Medicare,CHAMPUS,FECA,and Black Lung programs.Authority to collect information Is in section 205(a).1862,1872 and 1874 of the Social Security Act as amended,42 CFR 411.24(a)and 424.5(a)(6),and 44 USC 3101;41 CFR 101 et seq and 10 USC 1079 and 1086:5 USC 8101 et seq;and 30 USC 901 et seq;38 USC 613;E.O.9397. The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility.It is also used to decide if the services and supplies you received are covered by these programs and to insure that proper payment is made. The information may also be given to other providers of services,carriers,intermediaries,medical review boards,health plans,and other organizations or Federal agencies,forthe effective administration of Federal provisions that require other third parties payers to pay primary to Federal program,and as otherwise necessary to administerthese programs.Forexampie,itmaybe necessaryto disclose information aboutthe benefits you have used to a hospital ordoctor.Additional disclosures are made through routine uses for information contained in systems of records. FOR MEDICARE CLAIMS:See the notice modifying system No.09-70-0501,titled,'Carrier Medicare Claims Record.'published in the Federal Register,Vol.55 iNo.177,page 37549.Wed.Sept.12,1990,or as updated and republished. FOR OWCP CLAIMS: Department of Labor,Privacy Act of 1974,'Republication of Notice of Systems of Records,"Federal Register Vol.55 No.40,Wed Feb.28, 1990,See ESA-5,ESA-6,ESA-12,ESA-13,ESA-30,or as updated and republished. FOR CHAMPUS CLAIMS:PRINCIPLE PURPOSE(S):To evaluate eligibility for medical care provided by civilian sources and to issue payment upon establishment of eligibility and determination that the services/supplies received are authorized by law. ROUTINE USE(S):Information from claims and related documents may be given to the Dept.of Veterans Affairs,the Dept of Health and Human Services and/or the Dept.of Transportation consistent with their statutory administrative responsibilities under CHAMPUS/CHAMPVA;to the Dept.of Justice for representation of the Secretary of Defense in civil actions:to the Internal Revenue Service.private collection agencies,and consumer reporting agencies in connection with rocoupment claims.and to Congressional Offices in response to inquiries made at the request of the person to whom a record pertains.Appropriate disclosures may be made to other federal,state,local,foreign government agencies,private business entities,and individual providers of care,on matters relating to entitlement,claims adjudication,fraud.program abuse,utilization review,quality assurance,peer review,program integrity,third-party liability,coordination of benefits,and civil and criminal litigation related to the operation of CHAMPUS. DISCLOSURES:Voluntary;however,failure to provide information will result in delay in payment or may result in denial of claim.With the one exception discussed below,there are no penalties underthese programs for refusing to supply information.However,failure to furnish information regarding the medical services rendered orthe amount charged would prevent payment of claims under these programs.Failure to furnish any other information,such as name orclaim number,would delay payment of the claim.Failure to provide medical information under FECA could be deemed an obstruction. It is mandatory that you te))us if you know that another party is responsible for paying for your treatment.Section 11286 of the Social Security Act and 31 USC 3801- 3812 provide penaitiesf66r withholding this.information. You should be aware that P.L.100-503,the'Computer Matching and Privacy Protection Act of 1988",permits the government to verify information byway of computer matches. MEDICAID PAYMENTS(PROVIDER CERTIFICATION) I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the State's Title XIX plan and to furnish information regarding any payments claimed for providing such services as the State Agency or Dept.of Health and Human Services may request. I further agree to accept,as payment in full the amount paid by the Medicaid program for those claims submitted for payment under that program,with the exception of authorized deductible,coinsurance,co-payment or similar cost-sharing charge. SIGNATURE OF PHYSICIAN(OR SUPPLIER):I certify that the services listed above wore medically indicated and necessary to the health of this patient and were personally furnished by me or my employee under my personal direction. NOTICE,This is to certify that the foregoing information is true.accurate and complete.I understand that payment and satisfaction of this claim will be from Federal and State funds,and that any false claims,statements,or documents,or concealment of a material fact,may be prosecuted under applicable Federal or State laws. According to the Paperwork Rediiction Act of 1995,no persons are required to respond to a collection of information unless it displays a valid OMB control number.The valid OMB control numberfor this information collection is 0938-0999 The tift6required to complete this information collection is estimated to average 10 minutes per response,including the lime to review instructions,search exis:ing data resources,gather the dais needed,and complete and review the information collection,it you have any comments concerning the accuracy of the time estimate(s)or suggestions for improving this torm.please write to;CMS.Attn:PRA Reports Clearance Officer,7500 Security Boulevard,Baltimore,Maryland j 21244.1850. This address isforcommemsandlor suggestions only 00 NOT MAIL COMPLETED CLAIM FORMS TO THIS ADDRESS C� I� PENNSTATE HERSHEY CD Milton S. Hershey NAME: RICE. SYDNEY II'IIII�"'I�IIII�I'l1II�IlI'Illlll�l�hll��l h1R 4: 7512938 005=: 10512938 MD: DEFLITCH CHRISTO MD4: 46325 ® Medical Center DOB: 04/05/2003 VISIT DATE: 11112!2012 IOC{: EMER SEX: F TRAUMA TEAM SIGN-IN SHEET �. �III�IIlI11IlIIIIfIIII SELF PAY I cD o Date TRAUMA NUMBER ' I CD TRAUMA LEVEL 1 2 3 IN j Trauma Standby paged at hrs Trauma Response paged at hrs IW o RES;PON, SE TEAM MEMBER` Tim'e''of' l Atriva' cn ED Attending CD _0 Trauma Attend in �fl Z7 Trauma Team Leader PGY4/5 GHQ I� Senior Trauma Resident PGY 4/5 CO CD Junior Trauma Resident PGY 2/3 W Junior Trauma Resident PGY 2/3 Junior Trauma Resident PGY 1 Junior Trauma Resident PGY 1 Emergency Med. Resident PGY 213 Emergency Med. Resident PGY 2/3) Emergency Med. Resident PGY 1 Trauma Physician Extender Trauma Physician Extender Anesthesiology AttendingD Anesthesiology Resident Certified Registered Nurse Anesthetist Respiratory Therapy% Radiology Attending Radiology Resident Radiographer#1 (Diagnostic) A { f S Radiographer#2 (Diagnostic) Radiographer CT ; e q CD Emergency Medicine EMT Chaplain 3'i OR Technician/-Nurse Pediatric Criticai Care Attending Pediatric Critical Care Resident Child Life Specialist Trauma Coordinator/Case Manager :'.YTK z*• •A'_*s, ,�q'v=+. w^ v ' ': ,� rwr e;�"-.s ux, r s�.'. `.�?; f•.ISz+ ka� l _ IT NAM S Orthopaedics Pager 2002) Neurosurgery (Pagel- 1001) Plastic Surgery ENT PGY=Post Graduate Year Original Copy-Medical Records MR 414 Rev.1/08 Page I Illlllllllllll ll11111111111111111111I ll of 1 TRAUMA TEAM SIGN-IN SHEt stern AU t Ye{ Emergency low C py-T auma Se Dices DEC 2 6 2012 n PENNSTATE HERSHEY 11111111111Illllllllilllllililllllllll!111111 �7 NAME: RICE. SYDNEY Ma!lton S.Hershey MR#: 7512938 005#: 103512938 MD: DEFLITCN CHRISTO MD#: 46325 Medical Center DOB: 04)05/2003 VISIT DATE: 11/12i2012 LOC: EME I SEX: F S: SELF P Y SELF PAY i ED TRAUMA/RESUSCITATION FLOW SHEET Date I 1 1 (Q I Time Stat Page Time Pt ed � Response level �.J 2 Ambulance Helicopter: L �C l��(� Interhospital Y N Age ��� Sex Weight v O Chart O Labs O XR O CT REPORT ; .• Cyr Cns 1r 183P qC( (C Loss of Consciousn Yes No 2 Unknown #minutes HR Monitor Rhythm Immobilization: -Co Cl Ong Boa Splint RR lAssistive Device Entrapped: YesQ26JUnknown #minutes S ontaneous Rate/Pattem Self Extricated: Yes No S 02 PMH: GCS Meds: Patent IV Site Gauge Sol•n Amt Yes No #1 0 0 Allergies: #2 • O #3 0 O Tetanus: PRIMAf2Y SURVEY B• ;Dr: `";r, ?'k: ± t z•,,, st. ra� y Airway Intervention Bracelet Location: 0 Patient Maintained Yes No O Mechanically maintained by OP oxygen mask 1/min or % ID: Breathing 00 Airway&bag Spontaneous late/pattem 00 ETT- size/an Blood Band: O Not breathing assisHve device /orab'on R�4605 Sa02 Incubated by R#: Yea No 00 Surgical airway-done by O O Breath sounds R L Documenting Nurse: O O Tachypnea Vent Settings try O O Intercostal retractions Time Support Nurse: 1 ` O O Chest wall bruising Rate Circul ion Floe Physician Signature: HR riin(on aniva)) Rhythm Tidal Vol. '. SBP_ 0 mmHg(on arrival) PEEP Pulses R L Yes No Yes No • •1- O Radial 00 Chest tube /,� - , O Femoral size: right �( Initial temp. O O DP Lett /JJ''.. O O FT 00 Other intervention state = IE Jf Patient covered O O Nemohmge? res No Warm blankets Yes No O O IV Une yes No 0 0 Erternai site 1 size_g Patent? 0 0 Overhead warmer O O Intemal site 2 size_g Patent? O O o Chest sloes size_g Parent? o O IV fluids warmed to 104°F O Abdomen O O Arterial fine site O Pelvis/retropedtnneal Re eattem .at 30 mins. O Umbs MTP Time InIbPa ed.• Ski —n 1/ Warm Pale Hot Cyanotic Cool Molded Cold Dry Moist �92=411111& • • • • • • Eye s neous GUI,GOW , 7Senior Pin• t e time lime coming To volts '3 3 COMA 9-12 I Service called Arrived Response To In 2 SCALE(GCS) 6-8 Trauma Attending None 1 (Total Paints 4-5 Onho ILest o from above) 3 ED Attending �- verbal 4 ,s9mm H Neurosurg Response napProp to wo 3 Blood 76a9tnm H ArleStitesla Attending prehensbie sounds 2 2 Pressure s0-7smmH /..rJ Plast1C5 �••W 6• 1.49mm Trauma Resident --/C"(`yG'+�► �' aw Obeys mmmand No Pulse 0 Other _ Motor Loa ins pa s Resplrafnry 10-29 min. 9 Response taws pan) Rate 9 mm. of heT, 1 n pain 9 mn. 2 2 Extension t� 1- No motor response 1 1 None D MR 15: –1 Ea rn IIIIIII{11�{11{11{�IIIIIIII111{IIIIIII{�{1111 ED TRAUMA/RESUSCITATION FLOW SHEET DEC 2'6 2011 I v m 3 I SECONDARY n Head Yes No a�prfan: X-ray • scalp 0 O Laceration r O o vault Fracture � ` W Time Time c� CDFace O O Basal Fracture Suspected �-' �® O Laceration C� V� terai C-spine W O O Fracture _�((�� � � est X-ray Q O O law instability I 1.l '(ti. cka,&—k Pelvis (.nest :3 Eyes O O Injury - Other Abdomen/Pelvis I C 0 O Decreased Vision 1" ft�) Other Spines Ears O O Hemotympanum Side: Other Other N O O CSF leak Side: Other Nose O O Bleeding Mouth O O Tooth# Neurovascu ar ssment W NeCk Yes No DesoYpNon: Areas of Concern: O Q C-spine tenderness O O ®Stepoffs/aepihms -P� O O laceration mil. OO O C-cagar off time pulse Assessed: C O O Rehab collar time Time Tem . Color Capillary Refill Sensation Movement Pulse, Chest Yes No G�saiption: O A Chest wag Injury Side: p ' Jr I O o arms OO O Flail segment , O O Open pneumothorax O O Pneumothorax R/L O O Hemothorax R/L -. Abdomen Yes No D—OYPr(on: O O Skin contusion/abrasion n' '�/t`v_�,,,,•.i An O .Distension 0'0 Tendemess Injury Diagram O O Guarding Fast + - Injury Diagram Key: . Completed by Rectal heme: + - 1= Open Fracture E = Ecchymosls Done by time 2= Amputation A = Abrasion N/G(oral/nasal) 3= GSW C = Contusion Size Fr 4= Deformity L = Laceration Inserted by time 5- Stab Wound S = Swelling Peritoneal lavage/DPA: 6- Bum T = Tenderness Done by time 7= Pain PW= Puncture Wound Return: O Clear 8= Rash I = Impaled Object O Pink O Gross blood Amount infused cc Amount retumed or Fluid to lab: O Yes t� O No Genitourinary Des ptlon: Foley. O Yes P No O Herne+ Size Fr ° Inserted by time Rectal Tone: g?,Good O Decreased O Absent Prostate: O Normal / - O Abnormal Blood observed at: Yes No Vagina 00 Rectum 00 Urethral meatus O O Extremities 5 Ps Paralysis Parasthesia Pulses Pain Pallor Yes O Yes O Yes� Yes O Yes O J RA No Q. No 4V No No mfg No Psi (1 Yes O Yes O Yes® Yes O Yes O IA No a No Q No O No Q) No Yes O Yes O Yes Q� Yes O Yes O RL No A No Q No O No OD No 0 Yes O Yes O Yes 11 Yes O, Yes O LL No No lb No O No 10i No Eastern AL AO DEC262012 ED TRAUMA/RESUSCITATION FLOW SHEET MR 1541- ` t 8 5 5 , , • • • Trauma Resuscitation Flow Sheet Nursing Interventions 10t0�10 tact ,: �cn:: .�,• ; 11 son 0111M ■ .- rte; - : �r�c� mil■■m.all■... rya _ ■■ . O0ty,0� © � 0111 MENEM No ■rte■rrr■■■■N..■■■■ • 1111 r■�MONSOON... ■��rr■r■.■.E..■.r■ 11111 r■■■mills■■■ MINIM 00 ■�M11rrr�■..MINIM■■■ 0111 0 so 11 0 0 INS OEM 0 11 Normal Ranges for Vital Signs Pupil Size(MM) norFetaltjeartTones 20 ., ., Infants 741j50-100"" Infants 120-160 Toddlers Toddlers 80 0_Toddlers •, Preschool 23-34 Preschool 82/50-110 Preschool 80-110 120/80 Adolescent School-Age 75-100 , : Adolescent •• • : • Crystalloid joutput IDispositionat Discharge ��®®®®®l♦ s i Urine--voided— -rime arrived: In HMC safe Given to• ■rrr� ��� . .. • . .. - ■ri■■r�■■�■■■�.l_ . SICU 4b Floor 0 Expired ■rr--■_r— Or an/Tissue Donation Intake/Blood Components Medications C7 i PENNSTATE HERSHEY OM*�r'7 ton r S.Hershey ��ttillittt�tiitil�tluii�tltunilaliiititi N ey NA(IE: RICE, SYDNEY 005»: 10512938 Medical Center NR�: 7512938 46325 MD; DEFLITCH CHRISTO �ZSIT GATE: 11/12f2012 D06: 04/05/2003 SEX: F LOL: ENER SELF PAY TRAUMA HISTORY AND PHYSICAL EXAMINATION ilill(�II� i Date: ,1 7"/`Z Time: Hx of Present!))Hess(HPIj ROS j • MVC Belted? Yes D No` ❑Airbag TimmgJDuraUon yvtivu: Eyes ❑Pedestrian ❑Mcc 'p Assauh Signs/Symptoms: Amnesia- ❑Yes d'� ENT L�Gt,w ❑Fall '❑Burn ❑Electrical Loss of Cbnsci6dsness? ❑Yes No Cardiovascular ❑GSW ❑stab ❑Omer Respiratory ,^ GU � Uar GI rt. LA &Qut.S� Musculoskeltal Integumentary M.od�:� :•F or G' e,;;l .,, .: ,,,� ;,7 Pt weight: Neurologic I Broselowweight: Other ❑ Entrapment' ❑Ejection p crush ❑Blast 61 others negative/non contributory ZD • '. S• a,.YYc. r f=.rS1.:.w.. n . S �Gi �,,.t. aHelmeC❑Yes ❑No ❑Environmental Exposure ❑ YP othermia []impalement kry =•r ❑Chemical ❑Biological p Radiation ❑other: Allergies: Fall:Ht of fall: Fall from object: FFS:p Yes ❑No Medications: Coumadin ❑Plavix ❑Other, t Other. `Past Surgical Hic to e Family Hr. Bleeding Disorder p Yes ❑No Airway: Patent ❑Obstructed Intubated: ❑OT ❑ NT ❑ Track pother: mm�tributatory(Unobtainable Breathing: GI ea tr Breath Sounds: Social Hx: Family Status: Circulation: P: BP: 4 -RR: 2"2— Sat: ,6 ❑Other:;, a'd"NoncontributatoryNnobtainable Disability GCS: M V AYE _ V ! ❑'Eton ' ❑Smoki Hx p Mega D ug FAST Exam: Q Exposure: Completed Last Meal: Last Tetanus: SecaraySSLtvy 2nd v rcals:Tem � P. R.• 40t- ?WT pt 2 nnri HEENT: Head: a v G Eyes: 72— , Ears: TM's: G t cct 1- Battle's: 2-CV—- <'. Face: Maxilla: � Mandible: Nose: IV t �JofvA r �.: •`il.'.,.1,.s:.M x2 Zvi ff :1��A4 v Mouth: L +� J t 0 Dentures: r:>1'S;• ', ... A Neck: Tendemess: Crepitus: Trachea NIL: r Chest Wall:Tenderness: f Crepitus: '"' :r a'•-->: ,., �:- Lungs: Back: Tendemess: Crepitus: rr ; Heart: ob- e-tq q i Abdomen; Distention. At b BS:, Tenderness: -� Rectal: Tone Heme: Prostate:. £: Pelvis:Stable: Tenderness: 1 Vascular Exam: Radial,,. Femoral `2.'4 DP Z,4 PT LEGEND: Right/Left j,�i �, �' L-laceration C&-closed fracture Resident Si atu Title Dat Time a.mlp.m. OFX-open fracture Ab-abrasion tql) Q('Y )\�\-7, 1 q,r o 0' C-confusion COPYRIGHT,1996 PSGH Orig -Chart MR 611 Rev.5/11 TRAUMA HISTORY AND PHYSICAL EXII�I AUtw-Trauma services. DEC 2 6 2012 rn- it TRAUMA HISTORY AND PHYSICAL EXAMINATION (o cam• I Trauma Score Glas ow Coma Scale 0 Cranial Nerves: .� at , t r2� Spinal Cord In•u : c 1 �Y.opening Resp.Rate sep ,[1„�, 2-Open to Pain 0-0 0-0 Motor: tq { Open to Command/Voice 1-1-9 1-0-49 Spontaneous 2->36 2:-50-69. "_ Verbal Response Sensory: rick ru�r t'i 1-None 3-25735. 3-70-90 p ry p 71-12 2-InomprehensibielMoanstoPain �41D 24' >90 3-Inapppropriate/Cries to Pain Proprioception ;,��,wLc( co nfu3edrebnsolabie GCS I O � S klerVOrientedlinteracts 0-3-4 4�h Motor Response 1-5-7 t-None 01 t-s 2-Decerebrate 2-8-10 3-Decorticate 3- 1-13 4-Withdraws �� W 5 21izes Pain V 4-15 YS O 1` .a r ( / 5 Total:-P 'total: 1 aEiS/5fsrdies;Etraliia'2d h* ' r o ," PT: T o : _ ,> _jo r ponin: UTA: _0 ._.. p y l" �� r PTT: a Myogiobin: T:Bili: CPK: j Drug'Screeii: I� (G • O rl ALT. Amylase: 00 ABG: ALP: -K:3 ('k. 7 ETOH-- ECG: TEE: BHCG:.. X=Rays,;; CSR: Pelvis: G7 Sraisr Head 4% por Read> CSpine: Lat Extremities: Abdomen t�J AP Others: Odontoid AYigio .; T&L Spines: JI$: •r ;t4 �r.r$,; .,u.r, „a;yPx:x;r:2::i•sii%i', FaC,: �AtE�tld1�9 Nofe Flan a � r .,, ., ...,�-.;.:r,•:,�. -��'. .. �, .., .� 01 saw and evaluated the patient:and agree with the resident's findings and plans as written above. ❑See dictated note ❑I have reviewed the tramportlEMS notes Admit: ❑PICU ❑PIMC cETPeds.Floor ❑SICU ❑NSICU ❑IM,C ❑NSIMC ❑Floor Neuro:GCS: ❑Consult NSGY ❑OR Crani ❑Repeat CT Consult.Facial Trauma HEENT: Neck: ❑Consult S ine ❑Miami'1-Collar ❑ C-S ine Clear ❑MRI Res CV: GI: ❑OR Exploratory GU: 1 Consult URO MS: ❑Consult Ortho/S ine ❑OR for Fracture Psych:❑Consutl Psych ❑Consult D+A Procedures:❑NG-Tube ❑Urinary Catheter ❑A-line: ❑NP(s): Chest tube: ❑ri ht ❑left ❑DPL r Attending Signature Date Tirrie MR 611 Rev.5/11 O.ong - Chart TRAUMA HISTORY AND PHYSICAL E [(3VU ® py`7raGmaServices DEC262012 C7 Ix ED Summary RICE, SYDNEY D - 7512938 cCD. * Final Report I n 0 * Final Report CD I S2 Trauma-major 0 1 I Patient: RICE, SYDNEY D MRN: 7512938 �p Age: 9 years Sex: Female DOB: 4/5/2003 Associated Diagnoses: None Cn Author: Olympia, Robert P w lo) History of Present Illness cn The patient presents with major trauma and restrained back seat passenger behind driver involved in MVC with CD impact on driver's side-noted to be somnolent en route with GCS of 8-lacerations to face-. I� Review of Systems 41� Constitutional symptoms: Negative except as documented in HPI. rnSkin symptoms: Negative except as documented in HPI. Eye symptoms: Negative except as documented in HPI. ENMT symptoms: Negative except as documented in HPI. Respiratory symptoms: Negative except as documented in HPI. Cardiovascular symptoms: Negative except as documented in HPI. Gastrointestinal symptoms: Negative except as documented in HPI. Genitourinary symptoms: Negative except as documented in HPI. Musculoskeletal symptoms: Negative except as documented in HPI. Neurologic symptoms: Negative except as documented in HPI. Endocrine symptoms: Negative except as documented in HPI. Hematologic/Lymphatic symptoms: Negative except as documented in HPI. Allergy/immunologic symptoms: Negative except as documented in HPI. Additional review of systems information:All other systems reviewed and otherwise negative. Health Status Allergies: . No allergies have been recorded. Past Medical/Family/Social History Medical history Negative. Surgical history: Negative. Family history: Not significant. Social history: Reviewed as documented in chart, Family/social situation: Intact family. Physical Examination General: Alert, no acute distress, presented with cervical collar and hard board restraints-cleared clinically off hard board . Printed by: Calloway, Earthenia D Page 1 of 3 Printed on: 12/13/2012 06:55 (Continued) Eastern Aut® DEC 2 4 2012 I; ED Summary RICE, SYDNEY D - 7512938 Final Report l . n Vital Signs Skin: Warm, dry, pink, intact, no rash, no petechiae or purpura. Head: Normocephalic, atraumatic, 3 cm laceration to left forehead and left cheek. o Neck: Supple, No lymphadenopathy. I :3 Eye: Pupils are equal,round and reactive to light, extraocular movements are intact, normal conjunctiva. C Ears, nose, mouth and throat: Tympanic membranes clear, oral mucosa moist, no pharyngeal erythema N or exudate. Cn Cardiovascular: Regular rate and rhythm, No murmur, Normal peripheral perfusion, No edema. Iw Respiratory: Lungs are clear to auscultation, No wheezes, rales, or rhonchi. O Chest wall: No tenderness. Back: Nontender. CD Musculoskeletal: Normal ROM, no tenderness, no swelling. a Gastrointestinal: Soft, Nontender, Non distended, No organomegaly. :Z Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit I-P. observed, CN II-XII intact, normal sensory observed, normal motor observed. 00 Lymphatics: No lymphadenopathy. rn Psychiatric: Cooperative. Medical Decision Making Trauma team: Trauma criteria met. Differential Diagnosis: Contusion, fracture, laceration, head injury, neck injury, spinal cord injury. Rationale: Trauma Level labs sent-airway patent and breathing unlabored and spontaneous-circulation intact-sent for Cspine and Chest X-ray and CT head and face, abdomen and pelvis. Impression and Plan Diagnosis Head injury 959.01 (ICD9 959.01) Facial laceration 873.40 (ICD9 873.40) head contusion 920 (ICD9 920) Contusion of the face 920 (ICD9 920) Plan Condition: Stable. Disposition: Admit: Rocourt, Dorothy V. Addendum Signatures: Electronically Reviewed/Signed(12-NOV-2012 19:35:00)by: Robert P. Olympia, MD Result Type: ED Summary Date of Service: November 12, 2012 18:58 Authorization Status: Final Subject: Trauma-major Printed by: Calloway, Earthenia D Page 2 of 3 Printed on: 12/13/2012 06:55 (Continued) Eastern Auto DEC 2 6 202 C� �x ED Summary RICE, SYDNEY D - 7512938 Final Report s I n � Author or Import Date: Olympia, Robert Pon November 12, 2012 19:01 m Verified By: Olympia, Robert P on November 12, 2012 19:35 (n Encounter info: 10512938, HMC, Inpatient, 11/12/2012- 11/13/2012 o' I - O -P N CP W O Cn O dP O 00 07 I I Printed by: Calloway, Earthenia D Page 3 of 3 Printed on: 12/13/2012 06:55 (End of Report) Eastern Auto DEC 2 6 2012 C_ PENNSTATE (D � Debra Rhoads 500 University Drive (717)531-6964 I� Patient Financial Services Hershey,Pa 17033 Fax; (717)531-0494 E-mail;drhoads @PSU.EDU O0 (DI December 3, 2012 C' I 0 -P N Horace Mann Insurance Cn PO Box 962 to Morrisville, NC 27560 CDPatient Name: Sydney D. Rice I� Claim#: 16875C rD �( .� .p 0 00 o� To Whom It May Concern: Penn State University Hospital, The Milton S. Hershey Medical Center, Hershey, PA 17033, is an Accredited Level 1 Trauma Center. In Compliance with Pennsylvania Law (ACT 6), physicians charges and facility charges associated with the treatment of a patient in an Accredited Trauma Center will be paid at 100% of the billed amount. The charges are exempt from the Medicare Reimbursement rate of the Medicare Fee Schedule times 110%. PLEASE REMIT PAYMENT OF 100% OF OUR CHARGE WITHIN 30 DAYS. If you have any questions, please feel free to contact me at my direct phone number, (717) 531-6964. Sincerely, 'TRAUMA , Deha Jr?hoa& ' 110% PAY#WEh#j Patient Account Associate Hershey Medical Center ' Q Eastern . .LAO DEC 17 2012 r CAR *� s HORACE MANN INSUROE PO BOX 962 MORRISVILLE NC 27560 �F HEALTH MSURANCE CLAN FORM �APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 U PICA CASE ID: 00010512938 PICA FTT O1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a.INSURED'S I.D.NUMBER (For Program in Item 1) C (Medicare#)❑(Medicaid#)❑(Sponsors SSN) ❑(Member[D#)❑(SSN or HEALTH ❑BILK LUNG X(ID) 16 8 7 5 C 0 CD 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.PMT IIENrs BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) (n RICE SYDNEY D 04' 05' 2003`x❑ F© FREDERICKSON OUTPATIENT CENTER Q 5.PATIENTS ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 40 SYCAMORE DR self❑Spouse[:]Child other❑ 0 CITY STATE B.PATIENT STATUS CITY STATE N MECHA,NICSBURG pA Single Marred❑ other❑ O Ul ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(Include Area Code) W 17050 (717) 608-1747 Emplo ed❑ Stu Time❑ Student ) I, y Student Student 'r•0 C) 9.OTHER INSURED's NAME(Last Name,First Name,Middle Initial) 10.IS PATIENTS CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER UI RICE, COLLEEN J AD111212 CD a.OTHER INSURED's POLICY OR GROUP NUMBER a.EMPLOYMENT?(Current or Previous) a.INSURED'S DATE OF BIRTH SEX W YWP80117575903 00505817 El YES Im NO MM i DD i W M❑ F❑ CD b.OTHER IDo SDURED'S TE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME 06 i 12 1970 M❑ Fa YES ❑NO I P� OO c.EMPLOYER'S NAME OR SCHOOL NAME C.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME I- FREDERICKSON OUTPATIENT C YES NO ❑ ❑X HORACE MANN INSURANCE d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? IL CAPITAL BLUE CROSS CAI C YES ❑NO If yes,return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED's OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for' to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED,SIGNATURE ON FTT.P. DATE SIGNED 14.DATE OF CURRENT: ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM 1 DD I YY 4 INJURY(Accident)OR GIVE FIRST DATE MM I DD I W MM I DD I W MM I DD I W 11112 12 012 PREGNANCY(LMP) I I FROM I TO I I 17.NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM I DD I W MM I DD I W. DEFLITCH MD, CHRISTOPHER 17b. NPI 1134187354 FROM 111 12 12012 TO 111 13' 2012 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES ❑YES ©NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY(Relate Items 1,2.3 or 4 to Item 24E by Line) 22.MEDICAID RESUBMISSION CODE ORIGINAL REF.NO. 1. 1959 .19 3. 1 959 8 �r 23.PRIOR AUTHORIZATION NUMBER 2Fj819 1 a. 24.A. DATE(S)OF SERVICE B. C. D.PROCEDURES,SERVICES,OR SUPPLIES E. F. G. H. 1. J. From To PLACE OF (Explain Unusual Circumstances) DIAGNOSIS DAYS ID. RENDERING MM DD W MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $CHARGES UNRS tRa.."' OUAL. PROVIDER to.# 7- 11f221$121 1 21 71010 26 1 1 1 12 86 100 1 --PI 158862177 0 E 11122 � 12 1 21 172020 26 1 32 1 73 100 1 NPI 1588621775 w 3 - AMINI -- -------------- -I I 0. v � I I I I N Aa�telrn ®ut I __ OL r\ PI O Y ®EGIA 7 42 NPI-- --------- ----- NPi 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENTS ACCOUNT NO. 27.00CEPT ASSIGNM%NT? 28. TAL C ARGE 9.AMOUNT PAID 30.BALANCE DUEL:: or govt.Calms see bac 5185.7035 ❑® 232006018F6B0 YES ❑NO $ 159 0 $ Ob0 $ 15900 O 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.SERVICE FACILITY LOCATION INFORMATION 33.BILLING PROVIDER 17) 5-11 -7097' INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse HERSHEY MEDICAL CENTER DIV OF DIAG RADIOLOGY N 1/alandaa� vl�LLhLof�m CAP to ; 500 UNIVERSITY DRIVE P O BOX 858 MC A410 g � HERSHEY PA 17033 HERSHEY PA 1 033-0858 n SIGNED 11 15 201&TE a. b. x•1255482089 b. ' NUCC Instruction Manual available at:www.nucc.org APPROVED OMB-0938-0999 FORM CMS-1500(08-05) rBECAUSE THIS FORM iS USED BY VARiOUS.tERNMENT"AND PRIVATE HEALTH PROGRAM,-EE SEPARATE INSTRUCTIONS ISSUED BY IKAPPLICABLE PROGRAMS, �IJ NOTICE:Any person who knowinglyfiles a statement of claim containing any misrepresentation or any false,incomplete or misleading information may Nbe guilty of a criminal act punishable under law and may be subject to civil penalties. CQ REFERS TO GOVERNMENT PROGRAMS ONLY =MEDICARE AND CHAMPUS PAYMENTS:A patient's signature requests that payment be made and authorizes release of any information necessary to process the claim and certifies that the information provided in Blocks 1 through 12 is true;accurate and complete.In the case of a Medicare claim,the patient's signature reauthorizes any entity to release to Medicare medical and nonmedical information,including employment status,and whether the person has employer group health O insurance,liability,no-fault,worker's compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made.See 42 CCFR 411.24(a).If item 9 is completed,the patient's signature authorizes release of the information to the health plan or agency shown.in Medicare assigned or :;D CHAMPUS participation cases,the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary as the full charge, and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge -• determination of the Medicare carver or CHAMPUS fiscal intermediary if this is less than the charge submitted.CHAMPUS is not a health insurance program but O makes payment for health benefits provided through certain affiliations with the Uniformed Services.Information on the patient's sponsor should be provided in those �:3 items captioned in"Insured";i.e.,items ia,4,6,7,9,and 11 O BLACK LUNG AND FECA CLAIMS NThe provider agrees to accept the amount paid by the Government as payment in full.See Black Lung and FECA instructions regarding required procedure and Cn diagnosis coding systems. SIGNATURE OF PHYSICIAN OR SUPPLIER(MEDICARE,CHAMPUS,FECA AND BLACK LUNG) (-')I certify that the services shown on this form were medically indicated and necessary forthe health of the patient and were personally furnished by me or were furnished O incident to my professional service by my employee under my immediate personal supervision,except as otherwise expressly permitted by Medicare or CHAMPUS .p,regulations. U1 For services to be considered as"incident"to a physician's professional service,1)they must be rendered under the physician's immediate personal supervision off ces,and 4)ithe employee,2) of no physic ansr must be included eluded on(the physician's bills. clan's service,3)they must be of kinds commonly furnished in physician's For CHAMPUS claims,I further certify that I(or any employee)who rendered services am not an active duty member of the Uniformed Services or a civilian employee .p of the United States Government or a contract employee of the United States Government,either civilian or military(refer to 5 USC 5536).For Black-Lung claims, O1 further certify that the services performed were for a Black Lung-related disorder. �No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations(42 CFR 424.32). NOTICE:Any one who misrepresents orfalsifies essential information to receive paymentfrom Federal funds requested by this farm may upon conviction be subject' to fine and imprisonment under applicable Federal laws. NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE,CHAMPUS,FECA,AND BLACK LUNG INFORMATION (PRIVACY ACT STATEMENT) We are authorized by CMS,CHAMPUS and OWCP to ask you for information needed in the administration of the Medicare,CHAMPUS.FECA,and Black Lung programs.Authority to collect Information is in section 205(a),1862,1872 and 1874 of the Social Security Act as amended,42 CFR 411.24(a)and 424.5(a)(6),and 44 USC 3101;41 CFR 101 et seq and 10 USG 1079 and 1086;5 USC 8101 et seq;and 30 USC 901 et seq:38 USC 613;E.O.9397. The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility.It is also used to decide if the services and supplies you received are covered by these programs and to insure that proper payment is made. The information may also be given to other providers of services,carriers,intermediaries,medical review boards,health plans,and other organizations or Federal agencies,forthe effective administration of Federal provisions that require otherthird parties payers to pay primary to Federal program,and as otherwise necessary to administerthese programs.Forexample,it may be necessary to disclose information aboutthe benefits you have used to a hospital or doctor.Additional disclosures are made through routine uses for information contained in systems of records. FOR MEDICARE CLAIMS:See the notice modifying system No.09-70-0501.titled,'Carrier Medicare Claims Record,'published in the Federal Register,Vol.55 No.177,page 37549,Wed.Sept.12,1990,or as updated and republished. FOR OWCP CLAIMS: Department of Labor,Privacy Act of 1974,'Republication of Notice of Systems of Records,"Federal Register Vol.55 No.40,Wed Feb.28, 1990,See ESA-5,ESA-6,ESA-12,ESA-13,ESA-30,or as updated and republished. FOR CHAMPUS CLAIMS:PRINCIPLE PURPOSE(S):To evaluate eligibility for medical care provided by civilian sources and to issue payment upon establishment of eligibility and determination that the services/supplies received are authorized by law. ROUTINE USE(S):Information from claims and related documents may be given to the Dept.of Veterans Affairs,the Dept.of Health and Human Services and/or the Dept.of Transportation consistent with their statutory administrative responsibilities under CHAMPUS/CHAMPVA;to the Dept.of Justice for representation of the Secretary of Defense in civil actions;to the Internal Revenue Service,private collection agencies.and consumer reporting agencies in connection with recoupment claims;and to Congressional Offices In response to inquiries made at the request of the person to whom a record pertains.Appropriate disclosures may be made to other federal,state,local,foreign government agencies,private business entities,and individual providers of care,on matters relating to entitlement,claims adjudication,fraud,program abuse,utilization review,quality assurance,peer review,program integrity,third-party liability,coordination of benefits,and civil and criminal litigation related to the operation of CHAMPUS. DISCLOSURES:Voluntary:however,failure to provide information will result in delay in payment or may result in denial of claim.With the one exception discussed below,there are no penalties underthese programs forrefusing to supply information.However,failure to furnish information regarding the medical services rendered orthe amount charged would prevent payment of claims underthese programs.Failure to furnish any other information,such as name orclaim number,would delay payment of the claim.Failure to provide medical information under FECA could be deemed an obstruction. It is mandatory that you tell us if you know that another party is responsible for paying for yodrtreatment.Section 1128E of the Social Security Act and 31 USC 3801- 3812 provide penalties for withholding this information. You should be aware that P,L'100-503,the"Computer Matching and Privacy Protection Act of 1988",per mitsthe governmentto verify information byway of computer matches. MEDICAID PAYMENTS(PROVIDER CERTIFICATION) I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the State's Title XIX plan and to furnish information regarding any payments claimed for providing such services as the State Agency or Dept.of Health and Human Services may request. further agree to accept,as payment in full,the amount paid by the Medicaid program forthose claims submitted for payment under that program,with the exception of authorized deductible,coinsurance,co-payment or similar cost-sharing charge. SIGNATURE OF PHYSICIAN(OR SUPPLIER):I certify that the services listed above were medically indicated and necessary to the health of this patient and were personally furnished by me or my employee under my personal direction. NOTICE:This is to certify that the foregoing information is true,accurate and complete.I understand that payment and satisfaction of this claim will be from Federal and State funds,and that any false claims,statements,or documents,or concealment of a material fact,may be prosecuted under applicable Federal or State laws. According to the Paperwork Reduction Act of 1995,no persons are required to respond to a collection of information unless it displays a valid OMB control number.The valid OMB control number for this information collection is 0938-0999,The time required to complete this Information collection is estimated to average 10 minutes per response,including the time to review instructions,search existing data resources,gather the data needed,and complete and review the information collection.It you have any comments concerning the accuracy of the time estimate(s)or suggestions for improving this form,please write to:CMS,AIM:PRA Reports Clearance Officer,7500 Security Boulevard,Baltimore,Maryland 21244-1850. This address is for comments and/or suggestions only.DO NOT MAIL COMPLETED CLAIM FORMS TO THIS ADDRESS. 17- CAR. HORACE MANN INSURE ;a PO BOX 962 MORRISVILLE NC 27560 �+ HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 V PICA CASE ID: 00010512938 PICA FFF o 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a.INSURED'S 1.D.NUMBER (For Program in Item 1) YYY CHAMPUS HEALTH PLAN 13LKWNG (Medicare#)❑(Medicaid#)❑(Sponsor's SSN) (MemberlD#) (SSN or ID) (SSN) ®(I D) 16 8 7 5 C (D 2.PATIENTS NAME(Last Name,First Name,Middle Initial) 3.PATIENTS BIRTH"' SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) ((n RICE, SYDNEY D 811 6% 126(031E] F® FREDERICKSON OUTPATIENT CENTER O S.PATIENTS ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 40 SYCAMORE DR Self❑Spouse❑Child® Olher[ CITY STATE 8.PATIENT STATUS CITY STATE o N MECHANICSBURG PA Single® Married Other[ 0 ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(Include Area Code) c9 GJ ED 17050 (717 6 0 8-17 4 7 Employed Full-Time❑ Student 80 o P Student Student O 9.OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER Ic 2 c3lRICE, COLLEEN J AD111212 °w O a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(Current or Previous) a.INSURED'S DATE OF BIRTH SEX YWP80117575903 00505817 YES El MM i DD ; W M� F[] ll b.OMTMHER INSURED'S Y ATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME p 0 0611211970 M� F® YES NO L A j 00 c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME �FREDERICKSON OUTPATIENT C [IYes NO HOP-ACE MANN INSURANCE W d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? CAPITAL BLUE CROSS CAI C [X YES []NO It yes,return to and complete Rem 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE 1 authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below, below. sIGNEDSIGNATURE ON FILE DATE 11 15 2012 SIGNED SIGNATURE ON FILE 14.DATE OF CURRENT., ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 1"'�' ;1°� 2X12 INJURY(Accident)OR GIVE FIRST DATE MM 1 DD 1 W MM I DD 1 W MM I DO I YY ' PREGNANCY(LMP) FROM I I TO 17.NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18.HOSPITALLIIZATIODNN DATESYRELATED TO CURRENT DSERVICE� EFLITCH MD, CHRISTOPHER nu. NPI 334 87354--------- FROM111 12 12012 TO 11113 2012 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES YES 91 NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY(Relate Items 1,2,3 or 4 to Item 24E by Line) 22,MEDICAID RESUBMISSION 959 19 CODE ORIGINAL REF.NO. 3. I�. 23.PRIOR AUTHORIZATION NUMBER A819 1 4. L . _ 24.A. DATE(S)OF SERVICE B. C. D.PROCEDURES,SERVICES,OR SUPPLIES E. F. G. H. I. J. :7 From To PLACE (Explain Unusual Circumstances) DIAGNOSIS OA ID. RENDERING. 0 MM DD W MM DD W SERVICE EMG CPT/FiCPCS MODIFIER POINTER $CHARGES UNITS Plan DUAL. PROVIDER ID.# 1 t, 6-- .q d 1122g12 I 1 1 1:21 1 174177 P6 ' 1 1 1 112 543 100 1 NP-1 1588621775 0 � . -- -------------- F= 1 i I I r NPI 6cc 3 7"�tl /q N ED----------- 6S I I I I I I 9. P" g� _ rn __ ______________ CC 1 zebra" 5 � Ito W Tea -- -------------- - us p^� 17)531-' l� ' NPI -=------------ � a. 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENTS ACCOUNT NO. 27.(For g vPL cleans see FFNT? 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE'" 51857035 QP-C-1 232006018F6B0 ©YES [NO $ 543b0 1 $ 0 0 $ 543 0 O 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.SERVICE FACILITY LOCATION INFORMATION 33.BILLING PROVIDER INFO&PH# (717)531-7097 , o (NCLUDINGDEGREESOR nthere erne HERSHEY MEDICAL CENTER DIV OF DIAG RADIOLOGY (I certify that the statements on the reverse OAQ, toM9I1lang3%NTEM1EreotE 500 UNIVERSITY DRIVE P O BOX 858 MC A410 4 HERSHEY PA 17033 HERSHEY PA 17033-0858 n SIGNED 11 15 2 01;ATE a. b' a.125548208 9 b• NUCC Instruction Manual available at:www.nuce.org APPROVED OMB-0938-0999 FORM CMS-1500(08-05) r BECAUSE THIS FORM iS USED BY VARIOUS&ERNMENT AND PRIVATE HEALTH PROGRAM .EE SEPARATE INSTRUCTIONS ISSUED BY I�APPLICABLE PROGRAMS. NOTICE:Any person who knowingly files a statement of claim containing any misrepresentation or any false,incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties. REFERS TO GOVERNMENT PROGRAMS ONLY MEDICARE AND CHAMPUS PAYMENTS:A patient's signature requests that payment be made and authorizes release of any information necessary to process the claim and certifies that the information provided in Blocks 1 through 12 is.true,accurate and complete.In the case of a Medicare claim,the patient's signature 0 authorizes any entity to release to Medicare medical and nonmedical information,Including employment status,and whether the person has employer group health D insurance,liability,no-fault,worker's compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made.See 42 C CFR 411.24(a).If item 9 is completed,the patient's signature authorizes release of the information to the health plan or agency shown.in Medicare assigned or (D CHAMPUS participation cases,the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary as the full charge. and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submitted.CHAMPUS is not a health insurance program but makes payment for health benefits provided through certain affiliations with the Uniformed Services.Information on the patient's sponsor should be provided in those items captioned in"Insured";i.e.,items 1a,4,6,7,9,and 11, 0 BLACK LUNG AND FECA CLAIMS NThe provider agrees to accept the amount paid by the Government as payment in full.See Black Lung and FECA instructions regarding required procedure and Ut diagnosis coding systems. —' SIGNATURE OF PHYSICIAN OR SUPPLIER(MEDICARE,CHAMPUS,FECA AND BLACK LUNG) W I certify that the services shown on this form were medically indicated and necessary forthe health of the patient and were personallyfurnished by me or were furnished C)incident to my professional service by my employee under my immediate personal supervision,except as otherwise expressly permitted by Medicare or CHAMPUS p regulations. C,For services to be considered as"incident"to a physician's professional service,1)they must be rendered under the physician's immediate personal supervision -D by his/her employee,2)they must be an integral,although Incidental partof a covered physician's service,3)they must be of kinds commonly furnished in physician's offices,and 4)the services of nonphysicians must be included on the physician's bills. For CHAMPUS claims,I further certify that I(orany employee)who rendered services am not an active duty memberof the Uniformed Services or a civilian employee _P,of the United States Government or a contract employee of the United States Government,either civilian or military(refer to 5 USC 5536).For Black-Lung claims, CDI further certify that the services performed were for a Black Lung-related disorder. O-)No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations(42 CFR 424.32). NOTICE:Any one who misrepresents or falsifies essential Information to receive payment from Federal funds requested bythis form may upon conviction be subject to fine and imprisonment under applicable Federal laws. NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE,CHAMPUS,FECA,AND BLACK LUNG INFORMATION (PRIVACY ACT STATEMENT) We are authorized by CMS CHAMPUS and OWCP to ask you for information needed in the administration of the Medicare,CHAMPUS,FECA,and Black Lung programs.Authority to collect information is in section 205(a),1862,1872 and 1874 of the Social Security Act as amended,42 CFR 411.24(a)and 424.5(a)(6),and 44 USC 3101;41 CFR 101 et seq and 10 USC 1079 and 1086:5 USC 8101 at seq;and 30 USC 901 et seq;38 USC 613;E.O.9397. The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility.it is also used to decide if the services and supplies you received are covered by these programs and to insure that proper payment is made. The information may also be given to other providers of services,carriers,intermediaries,medical review boards,health plans,and other organizations or Federal agencies,forthe effective administration of Federal provisionsthat require other third parties payers to pay primary to Federal program,and as otherwise necessary to administerthese programs.For example,it may be necessary to disclose information about the benefits you have used to a hospital or doctor.Additional disclosures are made through routine uses for information contained in systems of records. FOR MEDICARE CLAIMS:See the notice modifying system No.09-70-0501,titled,'Carrier Medicare Claims Record,'published in the Federal Register,Vol.55 No.177,page 37549,Wed.Sept.12,1990,or as updated and republished. FOR OWCP CLAIMS: Department of Labor,Privacy Act of 1 974,"Republication of Notice of Systems of Records,"Federal Register Vol.55 No.40,Wed Feb.28, 1990,See ESA-5,ESA-6,ESA-12,ESA-13,ESA-30,or as updated and republished. FOR CHAMPUS CLAIMS:PRINCIPLE PURPOSE(S):To evaluate eligibility for medical care provided by civilian sources and to issue payment upon establishment of eligibility and determination that the services/supplies received are authorized by law. ROUTINE USE(S):Information from claims and related documents may be given to the Dept.of Veterans Affairs,the Dept.of Health and Human Services and/or the Dept.of Transportation consistent with their statutory administrative responsibilities under CHAMPUS/CHAMPVA;to the Dept.of Justice for representation of the Secretary of Defense in civil actions;tothe internal Revenue Service,private collection agencies,and consumer reporting agencies in connection with recoupment claims;and to Congressional Offices in response to inquiries made at the request of the person to wham a record pertains.Appropriate disclosures may be made to other federal,state,local,foreign government agencies,private business entities,and individual providers of care,on matters relating to entitlement,claims adjudication,fraud,program abuse,utilization review,quality assurance,peer review,program integrity,third-party liability,coordination of benefits,and civil and criminal litigation related to the operation of CHAMPUS. DISCLOSURES-Voluntary;however,failure to provide information will result in delay in payment or may result in denial of claim.With the one exception discussed below,there are no penalties under these programs for refusing to supply information.However,failure to furnish information regarding the medical services rendered or the amount charged would prevent payment of claims under these programs.Failure to furnish any other information,such as name orciaim number,would delay payment of the claim.Failure to provide medical information under FECA could be deemed an obstruction. It is mandatory that you tell us if you knowthat another party is responsible for paying for your treatment.Section 1128B of the Social Security Act and 31 USC 3801- 3812 provide penalties for withholding this information. You should be Awarethat P.L.100-503,the"Computer Matching and Privacy Protection Act of 1988",permits the government to verify information byway of computer matches, MEDICAID PAYMENTS(PROVIDER CERTIFICATION) I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the State's Title XIX plan and to furnish information regarding any payments claimed for providing such services as the State Agency or Dept.of Health and Human Services may request. I further agree to accept,as payment in full,the amount paid by the Medicaid program for those claims submitted for payment under that program,with the exception of authorized deductible,coinsurance,co-payment or similar cost-sharing charge. SIGNATURE OF PHYSICIAN(OR SUPPLIER):I certify that the services listed above were medically indicated and necessary to the health of this patient and were personally furnished by me or my employee under my personal direction. NOTICE:This is to certify that the foregoing information is true,accurate and complete,I understand that payment and satisfaction of this claim will be from Federal and State funds,and that any false claims,statements,or documents,or concealment of a material fact,may be prosecuted under applicable Federal or State laws. According to the Paperwork Reduction Act of 1995,no persons are required to respond to a collection of information unless it displays a valid OMB control number.The valid OMB control number for this information collection Is 0938-0999,The time required to complete this information collection is estimated to average 10 minutes per response,including the time to review instructions,search existing data resources,gather the data needed,and complete and review the information collection,if you have any comments concerning the accuracy of the lime estimate(s)or suggestions for improving this form,please write to,CMS,Attn:PRA Reports Clearance Officer,7500 Security Boulevard.Baltimore,Maryland 21244-1850 This address isfarcomments and/or suggestions only.DO NOT MAIL COMPLETED CLAIM FORMS TO THIS ADDRESS. PENNSTATE HERSHEY l f I PxM Milton S. Hershey NAME: RICE. SYDNEY 4I{{III{{{I{II{fII111��{I���I{{II�{II{III{{I (Q MR#: 7512938 OOS9: 10512938 MD: DEFLITCH CHRIS TO VISIT 46325 Medical Center DOB: 04/05/2003 VISIT DATE: 11x12!2012 l LS L : SELF PAY O SELF F PAY 0 TRAUMA TEAM SIGN-IN SHEET m N Date TRAUMA NUMBER o' I° � TRAUMA LEVEL 1 2 3 N U' Trauma Standby paged at hrs Trauma Response paged at hrs w _ o >RES -O.N.$'E''TEAM`IVtEMBER' - �' i •-.' Tirrie'of'A"ciival - r. `N IVIIE. J cn ED Attending ° Trauma Attending S0 I� Trauma Team Leader PGY4/5 p Senior Trauma Resident PGY 4/5 ° 00 Junior Trauma Resident PGY 2/3 rn Junior Trauma Resident PGY 2/3 Junior Trauma Resident PGY 1 Junior Trauma Resident(PG Y 1 Emergency Med. Resident PGY 2/3 Emergency Med. Resident PGY 2/3 Emergency Med. Resident PGY 1 Trauma Physician Extender Trauma Physician Extender Anesthesiology Attending O Anesthesiology Resident Certified Registered Nurse Anesthetist Respiratory Therapy Radiology Attending Radiology Resident (e A n W Radiographer#1 Diagnostic r 1 5-Radiographer#2 (Diagnostic) Radiographer CT l " Emergency Medicine EMT Chaplain 3'l OR Technician/Nurse Pediatric Critical Care Attending Pediatric Critical Care Resident Child Life Specialist Trauma Coordinator/Case Manager CO.SUTio►NT` MEMBERS � -NAME - =�.. ,, ?la3 �`• TimmeofAirival Orthopaedics (Pager 2002) Neurosurdery (Pager 1001) Plastic Surgery ENT PGY=Post Graduate Year ® ® (Original Copy-Medical Records MR 414 Rev.1108 Page 1 of 1 Eastern A ut6d�•Pi w Copy-Trauma rge SeDcpt. TRAUMA TEAM SIGN-IN SHEET DEC 17 2012 n t PENNSTATE HERSHEYIIIIIIIIIIIl1111111lIIIIlIIIIIIIIIIIIIIIIIII( NAME: RICE. SYDNEY OOsm: 10512938 M Milton S. Hershey MRV: 7512938 7 MD: DEFLITCH CHRISTO MD#: 46325 Medical Center DOB: 04/05/2003 VISIT DATE: 11/1Zi2012 LOC: EMER SEX: F 5:1 SELF PyY SELF PAY i i ED TRAUMA/RESUSCITATION FLOW SHEET �111IIIII�IIIII�III�� Date Time Stat Page TiWPt ed Response level 2 Ambulance Helicopter: 4� � j M Interhospital Y N Age Sex Weight O Chart o Labs O XR PRE-HOSPITAL • I .. ka GS r U Cp�P BP GC( Loss of Consciousn Yes No Unknown #minutes HR Monitor Rhythm Immobilization: -Co CI ong Boap Splint RR lAssistive Device Entrapped: Yes o Unknown #minutes Spontaneous Rate/Pattem Self Extricated: Yes No S 02 PMH: I acs . - Meds: Patent IV Site Gauge Soi'n Amt YS No #1 0 o Allergies: #2 • o #3 o o Tetanus: PRIMARY SURVEY•(By;Dr:': .. 41'. 4 Airway Intervention Bracelet Location: 0 Patient Maintained Ye No O Mechanically maintained by ®O Oxygen mask i/min or % ID: Breathing 00 Airway&bag O Spontaneous rate/pattern 00 ETT- size/an Blood Band: O Not breathing assistive device /oration R74605 SaO2 intvbated by R#: Yos No 00 Surgical airway-done by ._ O O Breath sounds R L Documenting Nurse: Ed O O Tachypnea Vent Settings ry O O Intercostal retractions Time Support Nurse: lt� O O Chest wall bruising Rate Circul ion 1`102 Physician Signature: HR r/in(on arrival) Rhythm Tidal vol. SSP �Q mmHg(on arrival) PEEP Pulses R L _ Hypothermia Management Yes No Ys No O Radial O O Chest tube �` v o Femoral size: right 7( Initial temp. O O DP belt ,l/. O O Pr 00 Other intervention state - (!` Patient covered ' O O Hemorrhage? —OF Y s No Warm blankets yes No O O IV Line Yes No O O EKema1 site size_g Patent? o o Overhead warmer O O lntemar slte2 size_g Patent? O O O Chest site 3 size_g Patent? o o IV fluids warmed to 104OF O Abdomen O O Arterial fine slte o Pelvis/retroperimneal Re eattemp.at 30 mins. O Limbs MTP Ttme Initiated.' In Pink � warm I/ Pale Hot Cyanotic Crx�l Eastern Auto Mottled Cold Dry Moist _ 17 qnv) • • • • Eye • • , 6 nexus GLASGOW • , 4 �• • t e r"'a 'Me Opmin9 To volx -3 3 COMA 9-12 ( Serwloe called Arrived Response To M 2 SCALE(GCS) 6.8 2 2 Trauma Attending None 1 rrotal PaMts 1-5 1 3 Ortho Bast ones from above) 3 ED Attendln9 '�'. •_. verbal Con 9 t�Ic >B9mm H 4 Neurosurg Response napProp to 3 3 Blood 76B9mm 11 Ar1e51tie51a Attending Inmmp+ehens@te sounds 2 2 Pressure a7-m H 2 2 ^�rJ Plastics None 1 1 Si9mm 1 3 Senior Trauma Resident Best 0 command No Pulse 0 Other _ Motor Lom ins paln 5 Rsplratory Rew.nsc maws pa ) Rate >29/min. Other oxlon pain 3 9 min. z 2 Lxtens�on(pain) 1- m n. 1 1 No motor response 1 Nang 0 0 MR 15: —� East errs Auto I�I�II�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII ED TRAUMA/RESUSCITATION FLOW�PF T, 2012 C� r m SECONDARY n Head Yes No Desrnpdon: X-ray O Scalp Q O Laceration Z3 O 0 Vault Fracture /"' I '� U�r W Tlme Time Cam' C Fare O O Basal Facture Suspected CD ® O Laceration �� �^� Lateral C-spine O O Fracture , � est X-ray ed n e O O Jaw instability t e,— .n 1A` Pelvis (hest Eyes O O Injury 'Y�4Tp Other Abdomen/Pelvis O O Decreased Vision AM Other Spines Ears O O Hernotym panum Side: e Other NO O CSF leak Side: 7 ""' Other Nose O O Bleeding Ln Mouth O O Tooth# Neurovascu ar ment W Neck Yes No Desa/pHon: Areas of Concern: O @ C-spine tenderness C O ®Stepoffs/crepitus -P:1 O O Laceration 01 O O C-collar off time Pulse Assessed: C) O O Rehab mbar time Time ITemp. Color Capillary Refill Sensation Movement Puls Chest Yes No Desoicuen: O A Chest watt injury Side: — Jr � O O Flail segment 0 O O open pneumothorax 00 O7 O O Pneumothorax R/L O O Hemothorax RA Abdomen Yes No Desaipuon: O O Skin contusion/abrasion O (4.Distension O O Tendemess Injury Diagram O O Guarding Fast + - � Injury Diagram Key: Completed by Rectal heme: + - 1= Open Fracture E = Ecchymosls Done by time 2= Amputation A ='Abrasion N/G(oral/nasal) 3= GSW C = Contusion Size Fr 4= Deformity L = Laceration Inserted by time 5= Stab Wound S = Swelling Peritoneal lavage/DPA: 6= Burn T = Tenderness Done by time 7- Pain PW= Puncture Wound Return: O Clear 8= Rash I = Impaled Object O Pink O Gross blood Amount infused cc Amount returned m Ruld to lab: O Yes L 3 O No Genitourinary D—ptlon: Foley: O Yes P No O Heme+ 0 Size Fr Inserted by time Rectal Tone: (D.Good O Decreased O Absent Prostate: O Normal Pv O Abnormal Blood observed at: Yes No Vagina O O Rectum 00 Urethral meatus O O Extremities 5 P5 Paral sts Parasthesia Pulses C.4 Pain Pallor Yes O Yes O Yes 4 Yes O Yes O RA - No 6P. No 4n No,@R No 0 No Yes O Yes O Yes Yes O Yes O , LA No 0 No 8' No O No 0) No ® n Yes O Yes O Yes Yes O Yes O RL No A No 123 No O No tD No W Yes O Yes O Yes 0 Yes O, Yes O LL No No 6 No O No<0 No ® �q Auto [,gL, Eastern Au o DEC. . MR 75: ED TRAUMA/RESUSCITATION FLOW SHEET A y - 1 • 1. r , , • Trauma Resuscitation Flow Sheet �O© ON Nursing Interventions • 1�►tiF �71lJrilr � ■ ! ■1111■■■■■■■■■ MEN 00i ,: W, w■■■■■■■011 • ►,L •• 1�; " : E■Ca ■1111■■■■■■■■■ MEN ■ ■ ■EM Now INE N ■ INS■■■■■■■■■OEM 11110 ��■■■■■■■■■■■■■■■■ MEN ■�■■■■■1111111 son 1111■■ ■�■■■■■0011■■■■■■■■ ■�■■■■■1111■■■■■■NNE • ■�100■■■■■■1111■■■■■■■ MEESE ■ INN■■■■1111■■■■■■■0■ ■�■■�■■011■■■■■011■■ 1 ■■1111■0010■■■■■NNE ■�■■■■■■�■■■■■■■■■■■ ■O■■■■■■■■■■■■■NNE ■ ■■■■■■■■■■■■■■■■ ��■�i■1i■�i■�i■■�i■■■■■■■■i■■ Normal Ranges for Vital Signs f Pupil Size(MM) Fetal Heart Tones 61 0-60 Infants 74150-100170 Infants 120-160 ! Toddlers 20-40 Toddlers Elo/50-112/80 Toddlers .0 82/50-110/78 Preschool :0 :, 120/80 ;School-Ago 75-100 Adolescent 1Z-16 Adolescent 94/62-140/88 Adolescent • 60-90 • Crystalloid joutput IDiSposition at Discharge lllllllllllllllllllll'Urine catheter In HMC safe Given to family Name: Given to police Name: Disposition 0 OR 0 S10.1 0 Floor 0 Expired 0 Other Time. Or an/Tissue Donation Intake/Blood Components Medications C) PENNSTATE HERSHEY a IIItUtlllllllllilllllllill Illtllllltlilll(II M>7ton S.Hershey NAVE: RICE. SYDNEY 10512938 — Medical Center oosR: MA 1• 7512938 u: 41325 VISIT DATE: 11112/2012 ND: OEFLIT/ CHRIS70 SE DOB: 04105(2003 Ste; F LOC INS EHER P { SELF PAY o TRAUMA HISTORY AND PHYSICAL EXAMINATION �IUIIIt�11II11i(�I�III. (D Date; f }Z�Z, Time: o" Hx of Presetifi lllness`(HPI) ROS --I Mvc Belted? XYes ❑No ❑Airbag Timing/Duration. -2XP 1,44 '-< Eyes 00 ❑Pedestrian ❑MCC ❑Assault Signs/Symptoms: .Amnesia?❑YesFff—N ENT N ❑Fall ❑Bum ❑Electrical Loss of Consciousness? ❑Yes No Cardiovascular ❑Gsw ❑stab ❑other. Respiratory W GU O } ac ' CI pv� y1nQt,t3� Musculoskeltal O Integumentary :M`gdVi tii5 Ptweight: Neurologic ;:. ,.: eroselowweight: ' Other /O ❑Entrapment' ❑Ejection ❑Crush ❑Blast ' All others negative/non contributory T .ro..., r...rt, , •.b ...�_;anz.,:x:n.. ..i�'..•S'i r t'< .y Helmet❑Yes ❑No ❑Environmental Exposure ❑Hypothermia ❑Impalement Past7Ult=dli1;�tlXjtCdly Fat{It�}►,S�CIHC H1StcFry'; '+• ,. ❑Chemical ❑Biological ❑Radiation ❑Other; Allergies: (��' l Fail:Ht of fall: Fall from object; FFS:❑Yes ❑No Medications: Coumadin ❑Plavix ❑other: Other. Past Surglcal mtc vt� pFRr1air e}L,, z' = <` Family Me Bleeding Disorder E]Yes ❑No Airway:` Patent ❑Obstructed Intubated: ❑OT ❑ NT ❑VTrach ❑Ottier. UNoneontributatoryAlnobtainable Breathing: O'ga tr Breath Sounds: Social Hx: Family Status: ����y Circulation: P: V BP: b� RR: �T Sat 16 ❑,Other: 1R.ncontributatory/Unobtainable Disability: GCS: M V E _ ❑,Etoh ❑Smoki Hx ❑Illegal Drug FAST Exam: 5,5,c{ Exposure: Completed. last Meal: Last Tetanus: :5etDgdlry:Stttvey72ndVitals:TempP: BP. R: 20.OZSat:I WT aN✓? HEENT: Head: C RA-1 -'2(-I'll Eyes: 1''1,72. .,. ( PC • "ri" • Ears: TM's: C,t vGt f- Battle's: Q t 7 Cw, Face: Maxilla: Off Mandible: Nose: N ' Denthia: nl v t W ! Mouth: Dentures: ;'; Neck: Tenderness: ( Crepitus: Trachea ML' :-�. Chest Wall:Tenderness: ✓ Crepitus: Lungs: Back: Tenderness: Crepitus: Q IT Heart: afi Gr++(!HC i' tnit Abdomen: Distention: fVb BS:. Tenderness: ' `. Rectal: Tone Heme: Piostate: ::f, Pelvis:Stable: Tenderness: ".� Vascular Exam: Radial..' Femoral `2-4 DP -Z,4 PT Ri ht/Left L-48ce ' . 9 � .� 9)N L—Laceration Cix—dosed.fracture . Resident Xp'atu Title Dat Time a.mlp.m. OFX—open fracture Ab—abrasion'j` ) q',0 () C—contusion COPYRIGHT,1 Odg -Chart MR 611 Rev.5111 TRAUMA HISTORY AND PHYSICAL EXAMINATION Copy-Trauma services fillllilillllllllllllltlllllllllllllll ll Eastern Auto DEG 17 2012 C ) r I� v TRAUMA HISTORY AND PHYSICAL EXAMINATION ( ca _ I Nearal Glasgow Coma Scale 9 aa Trauma Sc are p Cranial Nerves: — lT { Spinal Cord In'u : c,a Eye Opening Resp,Rate SBP .one 2-Open to Pain 0-0 0-0 < Motor: C Open-to Command/Voke 1-19 1°-0-49 Spontaneous 2->36 2.:50-.691-. Verbal Response 3-25-35; 3-70-90 Sensory:Pinprick vt of t•'t T,-12 2-IncoomprehensibleAloarstoPain I J 1 1 0-24 >90 0 3-Inapppropriate/Cries to Pain Pro p rioce p tion tr CesedlCnsolable GCS&Ao rUOrntedilnterat 0-3-4 0 0 r Motor Response 1-5-7 N i 1-5 1-None 2-8-10 2-Decerebrate 01 r{— 3-Withdraws ws 3- 4-13 4-Withdraws �/./'iT' , (,J 5 ,aUps Pain 4- 4-55` 6eys Total: O tabsJS#udies.Evtiated ,,a • c, Y ,;': r� , PT:' _j� Troponin: U/A: >... -�t-� �•`:.." `� . PTT: Myoglobin: ITU T:Bili: CPK: Drug Screen: 3 rub ALT: 3o Amylase: 00 ABG: ALP: -Kft (k ' ? ETOH'% ECG: TEE: BHCG: X=Ra}(s< CSR: (��(} Pelvis: Ci'Sratis Head i%c� JJ�r CSpine: Lai A Extremities: Abdomen• AP Others: ,Y 4 .Rid Odontoid Ariga.:�1. 3 T&L Spines:. 0% Atending NO6G:fIG[l� . [ I saw and evaluated the patient and agree with the resident's findings and plans as written.above. El See dictated note ❑ 1 have reviewed the transport/EMS notes Admit: ❑PICU ❑ PIMC 4ffPeds.Floor ❑SICU ❑NSICU ❑IMC ❑ NSIMC ❑Floor Neuro:GCS: ❑Consult NSGY El OR Crani ❑ Repeat CT Consult Facial Trauma HEENT: Neck: ❑Consult.S ine ❑ Miami J Collar ❑C-S ine Clear ❑ MRI Res CV: Gl: ❑ OR Exploratory GU: ❑ Consult URO MS: ❑Consult Ortho/S ine ❑OR for Fracture Psych:❑Consutl Psych ❑Consult D+A Procedures:❑NG-Tube ❑Urinary Catheter ❑A-line: ❑CVP(s). Chest tube: ❑ri ht ❑left ❑QPL• 14 aii., -Q. /Itz 4 _./-0 � ern AG to DEC. 1 7 2012 Attending Signature Date Ti e Orig '-'Chad MR 611 Rev.S/tt TRAUMA HISTORY AND PHYSICAL EXAMINATION ..' copy-Trauma Services C7 v Abd CT RICE, SYDNEY D - 7512938 cQ Final Report Z I n * Final Report (D o CT ABDOMEN AND PELVIS WITH CONTRAST- PED : PATIENT NAME: RICE, SYDNEY D Io PATIENT MRN:07512938 N PATIENT DOB: 04/05/2003 EXAM DATE OF SERVICE: 11/12/2012 IW EXAM NUMBER: 7859483 cn ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER 0 I� EXAMINATION: o CT Abdomen and Pelvis rn CLINICAL HISTORY: 9-year-old female status post motor vehicle collision with head injury. COMPARISON: None. TECHNIQUE: Contrast-enhanced CT of the abdomen and pelvis after 100 mL Omnipaque 300. FINDINGS: Abdomen Liver, Gallbladder& bile ducts: Liver is normal. Intrahepatic bile ducts are nondilated. Gallbladder and extrahepatic bile ducts are normal. Pancreas:Normal Spleen: Round 4 mm hypodensity in the spleen is too small to characterize.No traumatic injuries to the spleen. . Adrenals: Normal Kidneys, collecting system and ureters:Normal. Retroperitoneum, lymph nodes, and vessels:Normal Bowel& Mesentery: Bowel is nonobstructed. Moderate stool load is noted. The appendix is normal, visualized on axial image 92/130. Printed by: Calloway, Earthenia D Page 1 of 2 (Continued) �A Printed on: 12/3/2012 14:33 pastern ) DEC 17 2012 n . r i� Abd CT RICE, SYDNEY D - 7512938 v c�. "Final Report I C7 0 < Pelvis m Bladder: Normal for degree of distention. Uterus: The uterus is not well visualized.No adnexal mass. 0 ID Ovaries & adnexa: No adnexal mass C) Extraperitoneal, lymph nodes,vessels:No extra peritoneal lymphadenopathy.No free fluid N Cn Osseous and body wall:There are no fractures. Io Lower chest: Trace dependent atelectasis. Small amount of subsegmental atelectasis in the visualized portion of the right middle lobe. No free air or pleural fluid 0 i� IMPRESSION: o No acute abnormality in the abdomen or pelvis. 00 rn Dr. Bradford discussed the findings with Dr. Rocourt at the time.of imaging. Dr. Ray Bradford is the dictating resident. Finalized report status indicates the signing attending has reviewed the images and report, and agrees with the interpretation. Preliminary report status should be regarded as NOT interpreted by the attending radiologist. DICTATED: BOAL, DANIELLE REVIEWED AND SIGNED: BOAL,DANIELLE DATE DRAFTED: 11/12/2012 07:31 PM DATE OF FINAL SIGNATURE: 11/12/2012 09:09 PM Result Type: Abd CT Date of Service: November 12, 2012 19:18 Authorization Status: Final Subject: CT ABDOMEN AND PELVIS WITH CONTRAST-PED Author or Import Date: Boal, Danielle K on November 12, 2012 19:31 Encounter info: 10512938, HMC, Inpatient, 11/12/2012- 11/13/2012 Contributor system: IDX01 Printed by: Calloway, Earthenia D Page 2 of 2 Printed on: 12/3/2012 14:33 Eastern Auto (End of Report) DEC- 17 2012 C7 x C-spine XR RICE, SYDNEY D - 7512938 cn. *Final Report I n * Final Report cD S o• X-RAY SPINE 1 VIEW- CERIVICAL PEDS I� PATIENT NAME: RICE, SYDNEY D o PATIENT MRN:07512938 N PATIENT DOB: 04/05/2003 U' EXAM DATE OF SERVICE: 11/12/2012 EXAM NUMBER: 7859478 ° ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER cn 0 I EXAMINATION: o . X-RAY CHEST PA OR AP VIEW- PEDS/EMT rn CLINICAL HISTORY: Trauma. COMPARISON: None FINDINGS: CHEST: Cardiomediastinal silhouette and pulmonary vasculature are normal.No focal consolidation, pleural effusion, or pneumothorax. Bones and soft tissues are normal. SPINE: The cervical spine is visualized from the craniocervical junction to Tl-T2. Vertebral body heights and disc spaces are maintained. Alignment is normal with loss of normal cervical lordosis. Prevertebral soft tissues are normal. Visualized calvaria and mandible are normal. IMPRESSION: Normal examinations of the chest and cervical spine. Dr. Dejan Samardzic is the dictating resident. Finalized report status indicates the signing attending has . reviewed the images and report, and agrees with the interpretation. Preliminary report status should be regarded as NOT interpreted by the attending radiologist. DICTATED: BOAL,DANIELLE . REVIEWED AND SIGNED: BOAL,DANIELLE Printed by: Calloway, Earthenia D Page 1 of 2 Printed on: 12/3!2012 14:33 (Continued) i Eastern Auto DEC 17 2012 C� r I�q C-spine XR RICE, SYDNEY D - 7512938 cn. Final Report I n Z) DATE DRAFTED: 11/12/2012 08:54 PM DATE OF FINAL SIGNATURE: 11/12/2012 08:56 PM I: . Result Type: C-spine XR Date of Service: November 12, 2012 18:58 CD Authorization Status: Final Subject: X-RAY SPINE 1 VIEW-CERIVICAL PEDS Cn c Author or Import Date: Boal, Danielle K on November 12, 2012 20:54 Encounter info: 10512938, HMC, Inpatient, 11/12/2012- 11/13/2012 C Contributor system: IDX01 cn 0 -o I 0 0 rn Printed by: Calloway, Earthenia D Page 2 of 2. Printed on: 12/3/2012 14:33 Eastern Auto (End of Report) DEC 17 202 C7 I�o Chest XR RICE, SYDNEY D - 7512938 W * Final Report I n 0 * Final Report * CD o X-RAY CHEST PA OR AP VIEW-PEDS :3 PATIENT NAME: RICE, SYDNEY D tC PATIENT MRN:07512938 N PATIENT DOB: 04/05/2003 EXAM DATE OF SERVICE: 11/12/2012 Iw EXAM NUMBER: 7859477 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER cn 0 I� EXAMINATION: � X-RAY CHEST PA OR AP VIEW-PEDS/EMT rn CLINICAL HISTORY: Trauma. COMPARISON: None FINDINGS: CHEST: Cardiomediastinal silhouette and pulmonary vasculature are normal.No focal consolidation, pleural effusion, or pneumothorax. Bones and soft tissues are normal. SPINE: The cervical spine is visualized from the craniocervical junction to T1 J2. Vertebral body heights and disc spaces are maintained. Alignment is normal with loss of normal cervical lordosis.Prevertebral soft tissues are normal. Visualized calvaria and mandible are normal. IMPRESSION: Normal examinations of the chest and cervical spine. Dr. Dejan Samardzic is the dictating resident. Finalized report status indicates the signing attending has reviewed the images and report, and agrees with the interpretation. Preliminary report status should be regarded as NOT interpreted by the attending radiologist. DICTATED: BOAL,DANIELLE REVIEWED AND SIGNED: BOAL,DANIELLE Printed by: Calloway, Earthenia D Page 1 of 2 Printed on: 12/3/2012 14:33 (Continued) Eastern Auto DEC. 17 2012 C� I� �u Chest XR RICE,,SYDNEY D - 7512.938. cn " Final Report C7 DATE DRAFTED: 11/12/2012 08:54 PM DATE OF FINAL SIGNATURE: 11/12/2012 08:56 PM' I� Result Type: Chest XR o Date of Service: November 12, 2012 18:58 Authorization Status: Final Subject: X-RAY CHEST PA OR AP VIEW- PEDS W Author or Import Date: Boal, Danielle K on November 12, 2012 20:54 I Encounter info: 10512938, HMC, Inpatient, 11/12/2012- 11/13/2012 C) Contributor system: IDX01 cn 0 co i 0 rn Printed by: Calloway, Earthenia D ���® Page 2 of 2 Printed on: 12/3/2012 14:33 Eastern (End of Report) DEG 2012 n PENNSTATE � . 0 v (D Debra Rhoads 500 University Drive (717)531-6964 Patient Financial Services Hershey,Pa 17033 Fax: (717)531-0494 E-mail:drhood5@P5U,EDU n O G December 3, 2012 0 I 0 N Horace Mann Insurance CTI PO Box 962 Io Morrisville, NC 27560 41. o Patient Name: Sydney D. Rice Claim#: 16875C I 0 00 rn To Whom It May Concern: Penn State University Hospital, The Milton 5. Hershey Medical Center, Hershey, PA 17033, is an Accredited Level 1 Trauma Center. In Compliance with Pennsylvania Law (ACT 6), physicians charges and facility charges associated with the treatment of a patient in an Accredited Trauma Center will be paid at 100% of the billed amount. The charges are exempt from the Medicare Reimbursement rate of the Medicare Fee Schedule times 110%. PLEASE REMIT PAYMENT OF 100% OF OUR CHARGE WITHIN 30 DAYS. If you have any questions, please feel free to contact me at my direct phone number, (717) 531-6964. Sincerely, Deka Patient Account Associate 1-0- 0. Hershey Medical Center Eastern ALA6 DEC 17 202 CAR HORACE MANN INSURE 1a I; PO BOX' 962 MORRISVILLE NC 27560 w (D.HEALTH OMSURAMICE CLAM FORM 13 APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 IV TO PICA CASE ID: 00010512938 PICA Q 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a.INSURED'S I.D.NUMBER (For Program in Item 1) 1 (Medicare#) (Medicaid# CHAMPUS HEALTH PLAN BLKLUNG )❑(Sponsors SSN) El(MemberlD#)❑(SSN OUP (SSN) (ID) 16 8 7 5 C 2.PATIENTS NAME(Last Name,First Name,Middle Initial) 3.PATIENTS BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) tn. RICE, SYDNEY D A 1 2603,E j F® FREDERICKSON OUTPATIENT -CENTE 0 5.PATIENT'S ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) Io 40 SYCAMORE DR Self❑Spouse❑Child® Other[] .p CITY STATE B.PATIENT STATUS CITY STATE N MECHANICSBURG PA Single® Married Other 0 ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(Include Area Code) CA 170-50 (717) 608-1747 . Employed Full-Time❑ Part Time p Student Student 41. 9.OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: ti.INSURED'S POLICY GROUP OR FECA NUMBER iJ o ctiRICE, COLLEEN J AD111212 a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(Current or Previous) a.INSURED'S DADTDE OF BIRTH SEX YWP80117575903 00505817 E]YES ®NO M� F❑ b.OTHER INSURED'$DATE OF BIRTH SEX b.AUTO ACCIDENT? b.EMPLOYER'S NAME OR SCHOOL NAME � MM DO YY PLACE(stale) 0 0611211970 M� F® YES �NO L_� 0 C.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME FREDERICKSON OUTPATIENT C 11 YES �NO HOP-ACE MANN INSURANCE d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? CAPITAL BLUE CROSS CAI C QX YES 0 NO If y-1 return to and complete item 9 a-d. IL READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician cr supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED SIGNATURE ON FILE DATE 11 15 2012 SIGNED SIGNATURE ON FILE 14..,MDATE OF CURRENT, ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 11 i 1DL i 2 n 2 41 INJURY EGNANCY(LMP)R GIVE FIRST DATE MM 1 DD 1 YY FROM MM 1 DD 1 YY TO MM 1 DD 1 YY 17.NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a, 18.HOSPITALIZATION DATES RELATED TO CURRENT ENTDSEERVICES DEFLITCH MD, CHRISTOPHER 17b. NPI 1134187354----------- FROM 111 12 i 2012 To lli 131 2012 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES YES ❑NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY(Relate Items 1,2,3 or4 to Item 24E by Line) 22.MEDICAID RESUBMISSION 1. 19:59 . 0 1 3 I E 819 1 CODE ORIGINAL REF.NO. 23.PRIOR AUTHORIZATION NUMBER 0 Z. 1873 . 0 4, 1 959 09 24.A. DATE(S)OF SERVICE C. D.PROCEDURES,SERVICES,OR SUPPLIES E. F. G. H. I. J. From To JPIAGB�OFJ (Explain Unusual Circumstances) DIAGNOSIS OoRS Io. RENDERING 0 .MM. DD YY MM DD YY SFAVIC£ EMG CPTMCPCS MODIFIER POINTER $CHARGES UNITS' Plan DUAL. PROVIDER ID.it 1- 111220121 I i 1211 170450 26 1 1 i 123 404100 1 NPI 1740428978 - 0 Is M 11 220121 1 i 21 1 170486 126 1 1 i 43 539 1001 1 NPI 1740428978 cc w 3 I 1 ➢I AL K® ---------- 1 I I I I I t 1 D l ra h 1 ad -N P-1 -------------- 0 4 1 1 1 7 531-696 6 1 1 1 - 25.FEDERAL TAX I.D.NUMBER SSN ON 26.PATIENT'S ACCOUNT NO, 27.ACCEPT ASSIGNMF I f7 28.TOTAL CHARGE 29.AMOUNT PAID* 30.BALANCE DUE or govt claims,see bac X251857035 �� 232005630FGB0 YES �NO $ 943100 1 $ 01001$ 943100 O 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.SERVICE FACILITY LOCATION INFORMATION 33.BILLING PROVIDER INFO&PH# 717) 531-7097 q INCLUDING DEGREES ORCREDENTIALS HERSHEY MEDICAL CENTER DIV OF DIAG RADIOLOGY cb (I certify that the statements on the reverse 0Opt �rSbim15 are rlTdAiUartthereof.) 500 UNIVERSITY DRIVE P 0 BOX 858 MC A410 o HERSHEY PA 17033 1HERSHEY PA 17033-0858 j 11 15 2 01 a• b. r SIGNED 2OATE 1--12554820891L NUCC Instruction Manual available at:www.ni)cc.org APPROVED OMB-0938-0999 FORM CMS-1500(08-05) I ............ r BECAUSE THIS FORM IS USED BY VARIOUEWERNMENT AND PRIVATE HEALTH PROGRA EE SEPARATE INSTRUCTIONS ISSUED BY APPLICABLE PROGRAMS. Vo NOTICE:Any person who knowingly files a statement of claim containing any misrepresentation or any false,incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties. iF (a REFERS TO GOVERNMENT PROGRAMS ONLY :T MEDICARE AND CHAMPUS PAYMENTS:A patent's signature requests that payment be made and authorizes release of any information necessary to process c)the claim and certifies that the information provided in Blocks I through 12 is.true,accurate and complete.In the case of a Medicare claim,the patients signature authorizes any entity to release to Medicare medical and nonmedical information,including employment status,and whetherthe person has employer group health 7 insurance,liability,no-fault,worker's compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made.See 42 < CFR 411.24(a).If item 9 is completed,the patients signature authorizes release of the information to the health plan or agency shown.In Medicare assigned or CD CHAMPUS participation cases,the physician agrees to accept the charge determination of the Medicare carrier orCHAMPUS fiscal intermediary as the full charge, and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submitted.CHAMPUS Is not a health insurance program but 0 makes payment for health benefits provided through certain affiliations with the Uniformed Services.Information on the patient's sponsor should be provided in those items captioned in"Insured";1,e.,Items la,4,6,7,9,and 11. 0 BLACK LUNG AND FECA CLAIMS The provider agrees to accept the amount paid by the Government as payment in full.See Black Lung and FECA Instructions regarding required procedure and diagnosis coding systems. SIGNATURE OF PHYSICIAN OR SUPPLIER(MEDICARE,CHAMPUS,FECA AND BLACK LUNG) I certify that the services shown on this form were medically indicated and necessary forthe health of the patient and were personally furnished by me orwere furnished C)incident to my professional service by my employee under my immediate personal supervision,except as otherwise expressly permitted by Medicare or CHAMPUS Ji.regulations. 0,For services to be considered as"incident!'to a physician's professional service,1)they must be rendered under the physician's immediate personal supervision -0 by his/her employee,2)they must be an integral,although Incidental part of a covered physician's service,3)they must be of kinds commonly furnished In physician's z Offices,and 4)the services of nonphys(cians must be included on the physician's bills. For CHAMPUS claims,I further certifythat I(orany employee)who rendered services am notan active duty member of the Uniformed Services ora civilian employee .p of the United States Government or a contract employee of the United States Government,either civilian or military(refer to 5 USC 5536),For Black-Lung claims, 0 1 further certify that the services performed were for a Black Lung-related disorder. 00 0)No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations(42 CFR 424.32). NOTICE:Any one who misrepresents orfalsifies essential information to receive payment from Federal funds requested bythis form may upon conviction be subject to fine and Imprisonment under applicable Federal laws. NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE,CHAMPUS,FECA,AND BLACK LUNG INFORMATION (PRIVACY ACT STATEMENT) We are authorized by CMS,CHAMPUS and OWCP to ask you for information needed in the administration of the Medicare,CHAMPUS.FECA,and Black Lung programs.Authority to collect information Is in section 205(a),1862,1872 and 1874 of the Social Security Act as amended,42 CFR 411.24(a)and 424.5(a)(6),and 44 USC 3101,41 CFR 101 et seq and 10 USC 1079 and 1086:5 USC 8101 et seq;and 30 USC 901 et seq;38 USC 613;E.O.9397. The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility.It is also used to decide if the services and supplies you received are covered by these programs and to insure that proper payment is made. The information may also be given to other providers of services,carriers,intermediaries,medical review boards,health plans,and other organizations or Federal agencies.for the effective administration of Federal provisions that require other third parties payers to pay primary to Federal program.and as otherwise necessary to administerthese programs.For example,it maybe necessary to disclose Information about the benefits you have used to a hospital or doctor.Additional disclosures are made through routine uses for Information contained In systems of records. FOR MEDICARE CLAIMS:See the notice modifying system No.09-70-0501,titled,'Carrier Medicare Claims Record.'published in the Federal Realster,Vol.55 No.177,page 37549,Wed,Sept.12,1990,or as updated and republished. FOR OWCP CLAIMS: Department of Labor,Privacy Act of 1974,'Republication of Notice of Systems of Records,'Federal Register Vol.55 No.40,Wed Feb.28, 1990,See ESA-5,ESA-6,ESA-12,ESA-13,ESA-30,or as updated and republished. FOR CHAMPUS CLAIMS:PRINCIPLE PURPOSE(S):To evaluate eligibility for medical care provided byciVilian sources and to issue payment upon establishment of eligibility and determination that the services/supplies received are authorized-bylaw.- - - -- ROUTINE USE(5X.Information from claims and related documents may be given to the Dept,of Veterans Affairs,the Dept.of Health and Human Services and/or the Dept.of Transportation consistent with their statutory administrative responsibilities under CHAMPUSICHAMPVA;to the Dept,of Justice for representation of the Secretary of Defense in civil actions;to the Internal Revenue Service,private collection agencies,and consumer reporting agencies In connection with recoupment claims;and to Congressional Offices in response to inquiries made at the request of the person to whom a record pertains.Appropriate disclosures may be made to other federal,state,local,foreign government agencies,private business entities,and individual providers of care,on matters relating to entitlement,claims adjudication,fraud.program abuse,utilization review,quality assurance,peer review,program Integrity,third-party liability,coordination of benefits,and civil and criminal litigation related to the operation of CHAMPUS. DISCLOSURES:Voluntary:however,failure to provide information will result in delay in payment or may result in denial of claim.With the one exception discussed below,there are no penalties underthese programs for refusing to supply information.However,failure to furnish Information regarding the medical services rendered orthe amount charged would prevent payment of claims under these programs.Failure to furnish any other information,such as name or claim number,would delay payment of the claim.Failure to provide medical information under FECA could be deemed an obstruction. It is mandatory thaf you tell us If you know that another party is responsible for paying for your treatment.Section 1128E of the Social Security Act and 31 USC 3801- 3812 provide penalties for withholding this information. You should be aware that P.L.100-503,the"Computer Matching and Privacy Protection Act of 19887,permits the government to verify information byway of computer matches. MEDICAID PAYMENTS(PROVIDE4 CERTIFICATION) I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the State's Title XIX plan and to furnish Information regarding any payments claimed for providing such services as the State Agency or Dept.of Health and Human Services may request. I further agree to accept,as payment in full,the amount paid by the Medicaid program forthose claims submitted for payment underthat program,with the exception of authorized deductible,coinsurance,co-payment or similar cost-sharing charge. SIGNATURE OF PHYSICIAN(OR SUPPLIER).I certify tbatthe services listed above were medically Indicated and necessary to the health of this patient and were personally furnished by rap, or,my,wpIqyee.finder,mypersonal direction. NOTICE:This is to certify that the foregoing information is true.accurate and complete.I understand that payment and satisfaction of this claim will be from Federal and State funds,and that any false claims,statements,or documents.or concealment of a material fact,may be prosecuted under applicable Federal or State laws. According to the Paperwork Reduction Act of 1995,no persons are required to respond to a collection of information unless it displays a valid OMB control number.The valid OMB control number for this information collection is 0938-0999.The time required to complete this information collection Is estimated to average 10 minutes per response,including the time to rmnew instructions,search existing data resources,gather the data needed,and complete and review the Information collection.It you have any comments concerning the accuracy of the time estimate(s)or suggestions for improving this form.please write to:CMS,Alin;PRA Reports Clearance Officer,7500 Security Boulevard,Baltimore,Maryland 21244-1850 This address is for comments andlor suggestonsonly.DO NOT MAIL COMPLETED CLAIM FORMS TO THIS ADDRESS. 0 177 Z PENNSTATE HERS?Ey I All loll 11111111111 11111111111E IN ORM Milton*S. Hershey NAME: RICE ,SYDNEY 5129 Oos#: 105129313 M U. : 7 Medical Center MD:-DEFLITCH CHRISTO MD9: 46325: Doat 04105/2003 VISIT DATE 11/1212012 LOC: EMER SEX: F N 5 ,1 SELF PAY 0 111,1 §1r, I TRAUMA TEAM SIGN-IN SHEET < tD 0 Date TRAUMA NUMBER la :3 TRAUMA LEVEL 1 2 , 3 • Trauma Standby paged at hrs Trauma Response paged at hrs TT AM' .EM13-EW 'ME: ED Attending er" (9, Trauma Attending Trauma Team Leader(PGY4/5) rho .� Senior Trauma Resident(PGY 4/5) 0 00 Junior Trauma Resident(PGY 2/3) Junior Trauma Resident(PGY 2/3) Junior Trauma Resident(PGY 1) Junior Trauma Resident(PGY 1) Emergency Med. Resident(PGY 2/3) Emergency Med. Resident(PGY 2/3) Emer gency Med. Resident(PGY 1) Trauma Physician Extender Trauma Physician Extender Anesthesiology Attending A, Anesthesiology Resident Certified Registered Nurse Anesthetist A- Respiratory Therapy Radiology Attending Radiology Resident Radiographer#1 (Diagnostic) Radiogra her#2 (Diagnostic Radio rapher(CT) (le— Emergency Medicine EMT Chaplain OR Technician/Nurse Pediatric Critical Care Attending IBM Pediatric Critical Care Resident Child Life Specialist Trauma Coordinator Case Manager --:YA4WW= r� .61�72 &M Sun W11 T ffi.=4 Orthopaedics Pager 2002 Neurosurgery (Pager 1001) Plastic Surgery ENT Eastern PGY=Post Graduate Year DEC.-I 7 206 nal Copy-Medical Records MR 4114 Rev.1108 Page 1 of I Pink Copy-Emergency Dept. 111111111111111111111 Fill 11 Ill HE TRAUMA TEAM SIGN-!N SHEET Yellow Copy-Trauma Services 0 PENNSTATE HERSHEY N FM Milton S,Hershey NOV"7'5'1'29i8....ly O ": 5 CD MD-- I STO M4#:7 416032"29" ,�.DEF ITCHC11R Medical Center 0 � 04!05/2003 L VISIT DATE: 11/1212012 LOC: EMER SEX: F ED TRAUMA/RESUSCITATION FLOW SHEET SELF ii PAY SELF SELF PAY Date T57 Y 71me Stat Page Time Pt �ed Response level 2 Helicopter. - Weight Ambulance He _jj Interhospital Y N Age Sex 0 Chart o Labs o XA 0 CT PRE-HOSPITAL REPORT I CAS MIM P 9`3 14(6 Loss of Conscious aosx;_ Yes No Unknown #rninutes HR Monitor Rhythm Immobilization; -Co tqW CA Ong Boa 0d Splint RR JAssistive Device Entrapped: Yes tjN6jUnknown #rninutes Spontaneous Rate/Pattern Self Extricated: Yen No SpO2 PMH: GCS • Meds: Patent IV Site Ga e Sol'n Amt_ Y_ Na #1 0 0 Allergies: #2 • 0 #3 .0 Q ITetanus: PRIM. RY SURVEY Airway Intervention Bracelet Location: 0 Patient Maintained Ys No 0 Mechanically maintained by V Oxygen mask 1jmmor_% ID: I Breathing 00 Airway&bag 0 Spontaneous rate/pattern 00 E17- sfzWaj Blood Band: 0 Not breathing assistive device Sa02 fnattated by R74605 Yes Ab 00 Surgical airway-done by 0 0 Breath sounds R L Documenting Nurse, FVtnM---A' 0 0 Tachypnea Vent Settings 0 0 rime Support Nurseftd�� 0 0 Chest wall bruising Rate Physician Signature: Giroul ton F102 ci HR ro(on arrival) Rhythm ndal Val. I mmHg(on arrival) PEEP Z: Pulses R L Yes no Yo.No N.—I 0 Radial 00 Chest tube 0% :�i� 0 Femoral size: light Iniffial temp. I 0 0 op left 0 0 Pr 00 Other intervention(state) P t., q Patient Covered War 0 0 Hemorrhage? 7 7a Y�No Warm blankets Ye. No 00 TV Une Wks Na 0 0 Eytemal sitel_sbe_g Patent? 0 0 Overhead warmer 0 0 zwernal site 2_size_g Patent? 0 0 0 Chest sites_slze_g� Patent? 0 0 N fluids warmed to 104OF 0 Abdomen 00 Arterial line site 0 PelAs/rebropedomeal Repeat'temp.at 30 mans. 0 Limbs MTP 77-me 1171t0ted., Pink Warm Pate Hot Cyanotic cool Mottled Cold Dry moist GLASGOW 1 me Ime 'P Eye .=e "M oponing To"ice -3 3 COMA 9-12 37 _T I Service called Arrived I Response SCALE(GCS) 6.0 Trauma Attending one —1 x [total Points i-S artho 3 —ok ED Attending Vest criesaed fMMb—) Vzm, ConfUsed bysaxic > Response l4applopriate MM j Blood 7&Vgrvn Mg j -3.Anesthesia Attending fncompremnsue sounds 2 2 Presstne 50-75..Hq 2 2 k__ Plastics N-Y None` 1•49roni Hn I :11sertior Trauma Resident 0 aw 2��Wnd Other �01 Motor P", Mimi Response EN; Rate >'I�P/Mm. j Other Flexion(pain) &Svmln. 2 2 Elleftoon(pain) z 00 mo` ponso —0 tom t Aut - MR 15: L-Castei U I JOIN 11111111111111111111131111111111 ED TRAUMA/RESUSCITATION FLOW SHEWC-1 7 2012 0 iy (D SECONDARY SURVEY 0 Head -ye-s--No- 0 scalp 0 OlLaceration re 0 0 vault rractu 11me Time Face 0 0 Basal Fracture Suspected va�y (D +) 0 0 Laceration Lateral C-spMe 0 0 Fracture est X-ray 0 0 0 Jaw Instability ckexA Pelvis Chest :3 Eyes 0 0 Injury Other —Abdomen/Pelvis 0 0 Decreased Vision AM Other —Spines 0 Ears 0 0 Hemotympanum Side: —Other Other IV 0 0 CSF leak Side. —other V1 Nose 0 0 Bleeding Mouth 0 0 Tooth# . Neurovascu ar ment Neckyw No Dkesofpffon: Areas of Comm: 0 0 C-spine tenderness 0 0 0 Stepoffs/crepitus 0 0 Laceration Ul 0 0 C-colla, Pulse Assessed: (D 0 0 Rehabmllarltme rime Tamp. Color Ca HIa -Refill Sensation Movement Pulse, Chest Yes NO 0 a Chest wall Injury Side: 0 0 ribs 0 0 F780sagment 0 0 0 Open pneumothom 00 00 0 0 Pneumothorax RX 0 0 Hemothorax R/L Abdomen I-, VO4 No Desoypt(W.. 0 O Skin contusion/abraslon 0 (.Distension 0 0 Tendemess Injury Diagram 0 0 Guarding A. Fast + - Injury Diagram Key. Completed by Rectal heme: + 1= Open Fracture E = EochymoSLS Done by time 2= Amputation A = Abrasion N/G(oral/nasal) 3= GSW C = Contusion Size_ Fr 4= Deformity L = Laceration Inserted by time 5= Stab Wound S = Swelling kritomeal lavage/DPA* 6= Burn T - Tendemess Done by time 7= Pain PW= Puncture Wound Return: 0 Clear 8- Rash I = impaled Object 0 Pink 0 Gross blood Amount Infused_cc Amount rebimed_cc_ Fluid to lab: 0 Yes cyy-x 0 Na Genitourinary Foley: 0 Yes P No 0 Heme+ size r, Inserted by time Rectal Tone: O.Good 0 Decreased 0 Absent [A Prostate: 0 Normal OV, 0 Abnormal Blood observed at: Yes No Vagina 00 Rectum 00 Urethral meatus 0 0 Extremities 5 Ps Para bLaLs Parasthesta Pulses Pain Pallor Yes 0 yes 0 Yes 4F Yes 0 Yes 0 IRA No (99, No 4V No R& No 0 No ID Yes 0 Yes 0 Yes 1j) Yes 0 Yes 0 LA No 1@ No 13 No 0 No tb No 0 Yes 0 Yes 0 Yes 4 Yes 0 Yes 0 RL No 0 No lb NO 0 NO 01 NO 9) Yes C, Yes 0 yes 0 Yes 0 Yes 0 LL No N. .6 0 No No 0 Eastern Auto DEC. . 7 202 - " ED TRAUMAlRESUSCITATION FLOW SHEET MR 154 M � � f • � 1 1. t� t /t 1 ) t ,)• f r 1 f DIM e • Trauma Resuscitation Flow Sheet SOME Nursing Interventions sono ■!r!■lir�wlrilw�rr/l�����!!!! ONES ONE ��i■�i�iiiiiiiMEMO !!rl/r !!!! I NI!!!! iiiiNINE 0 MMMMEMM 11101100 No MEN 0 Normal Ranges for Vital Signs I Pupil Size(MM) 120-1650 30-60 00 tl t fr4orm Infants 120-160 20 t / 80/50-112/80 Toddlers 9D-140 / 110/78 000 80-110 1 1 :1 If _ i Adolescent 60-90 • • Crystalloid loutput _Disposition at Discharge NEE=MM mmm ; � �m=nHMCsafe Mwen to police Name� 0 Floor - ■�-�l���� Or an/Tissue Donation Intake/Blood Components Medications l PENNSTATE HERSHEY .. IIIt111111t11 11111111111111111 N11t 0111111ti FM Milton S.Hershey dos 10512938 Medical Center tie, SYDNEY �T: ty0; DEFL1TCH CHRISTd VIS; DATE- 11!1212012 D08: 0410512003 SEX: F 1 LOC: Et1Eft SELF PAY TRAUMA HISTORY AND PHYSICAL EXAMINATION, �11�11J1111F11111�Y111 j Date: t ,Jam, Time: t ry Gg t a Iraliria y:.n:' Hx of Present illness(HPi) ROS 1 MVC Belted? ;Yes.. ©No ❑Anhag Tltning/Duration:. 2,C1 0464 s Eyes Q Pedestrian Q MCC ©Assault Signs/Symptoms: Amnesia?❑Yesa-N ENT ❑Fall ❑Burn ❑Electrical Loss of Consciousness? ❑Yes No Cardiovascular ❑GSW ❑stab ❑other Respiratory l l GU c; " GI erg rfnQ Musculoskeltal Integumentary .; .:.,., ,. :,.,.,t, n. •,, Pt weight Neurologic 1 ;Nadi i :11:;h fY rt ;FactfirtS. ,<3:•. .,:.v, ",ij,::,:3r:: ; Broselowweightt _ Other Q Entrapment ❑Ejection ❑Crush Q Blast. Ail others negative/non contributory I u,.r .,,..•.,.r^.-t E Helmet:❑Yes Q No Q Environmental Exposure ❑Hypothermia Q Impalement ICi VF21411 $04* Q Chemical ❑Biological Q Radiation Q Other. Allergies: ' i Fall:Ht of fall: Fall from object FFS:Q Yes Q No Medttatitins:coumadin ❑Piavue ❑other. 1 I Other. Past Surgical Hx Cif PCIl17Ey• 8 ,� ! Fatuity Hiii Bleeding Disorder Q Yes Q No Airway.-O Patent ❑Obstructed Intubated: ❑OT ❑ NT ❑ trach ❑Other NonoomAutatoryNnobtainable Breathing: G[,ea tr 4 f Breath Sounds: sodaf Hx: Family Status: p�y Circulation: P: V BP: G Ll RR: 2-Z Sat Mother J Noncontdbutatory?Unobtainable' 94 VA Disability: GCS: M V E _ LJ [I Et.hn Q Smoki Hx Q Iliega omg FAST Exam: 55,cf Exposure: Compleied ' Last Meal: '' last Tetanus: Iecaindary'Sitrvey 2nd Vitals:Temp•_P: BP. R:20025at z illy HEENT: Head: t Wc, �i G Eyes: t'i,:7 2.. ...t, Ears: TM's: C tot,r• Battle's: • Face: Maxilla: f C Mandible: — = x'• . Nose: 0r Dentitia: j of urir :;';: t R,• , .;.t . Mouth: LPIX. +-i 1 d,,0 Dentures: ,. .4.;i.' . s �: ,r... Neck: Tenderness: NT Cre rtus: Trachea Mi Chest Wall:Tenderness: rr1E T Crepitus: Lungs: CIA YV( Back: Tenderness: 0 Crepitus: x Heart: �G Gctrurq W1. Abdomen: Distention: IV Bs. Tenderness: -`. 4, f �• ,� Rectal: Tone Herne: Prostate:,' r j Pelvis:Stable: Tendemess: Vascular Exam: RadiaQA Femoral '2-4 DP VA 1 PT Right/Left �• '� � J" i 1 t--lace ' • 1--laceration Cfx-Closed fracture• Resident Si atu Title Dat 4 Time aanjp.m. OFX-open fracture Ab-abrasion 6 ' )NWZAz' ) q*,Q () C-contusion COPYRIGHT,1998 P5GH - 4r'tg -Chart MR 611 Rev.slt 1 TRAUMA HISTORY AND&���E�N�ATION copy-Trauma services'' ' ' 1111111111 Jill 111111111111111111111111111 DEC' 17 2012 u TRAUMA HISTORY AND PHYSICAL EXAMINATION m i :Neurotogicai Ei-a�►?.,y''y,:��_ ' 'A°''' `;`' 7 Glasgow Coma SWe Trauma Score C 1-� Eye Opening rteSp.Rate S8P p Cranial Nerves: ~ -= Spina[Card In'u 1-None 2-Open to Pain 0-0 '0-0 Motor: � L Open to CommandlVoice C 1-1-9 1' 049 CD 4 Spontaneous 2->36 .2 50.69.. Verbal Response 3-25-3L!'' -3 70-90 Sensory:Pinprick n.,pAr'� . T 1-12 t-Inane p' ,2-Incomprehensible/Moans to Pain 10-24' >90' 0 3-Inapppropriate/Cdes to Pain 1 Proprioception vwitL� Contus6WConsolabie GCS t VT `�5 Alertiodentedtinteracts 0-3-4 Motor Response 1-5-7 • ) 1-None L t-s 2-8-16 2-Qecetebrate cil r �J r 3.Oecae 3-t,1-3 4-Wthdraws �4- 4-15 . " W 5• caliaes Pain ' IO (6' beys Total: 'Ca sTS4dies: talaateii:.; '` ,. .r,; °;r`r` � := <:,1• ^, PT: Tro onin: .0/A• CD 1 y PTT: Myoglobin: l� 1f( `I 10 �. T:Bili: CPK: Drug Screen... o � `j.Q rGrt� AIT: I jj Amylase: 00 AB G: ALP: -Ka ' ETON: C� ECG: TEE: BHCG: 7C oys`, CSR: (n4- Pelvis: :S ais° Head ate' JJ¢�r lL Sc �;uL =Read"l, CSpine: Lat. A Extremities:° ' .:. Abdomen AP Others:. Odontoid' Aigo; `:s T&L Spines: ;:�•..: .•C.. .`F'�:q`Yr'.a;' ,`�.."`_•i.#.q':tic:�o�:+'�iv�v1:«'�S�t-`,i:if:^•'=;Fht: "�'x- fit :L:. :� �L'.'•':. ?�.'. A•tteli€iirl'"-blot°=>5iatit, ns.. .-,:�-. i-,. 49I saw and evaluated the patient and agree with the resident's findings and plans as written above. 0 See dictated note El I have reviewed the transport/EMS notes , Admit: 0 PICU ❑PIMC• 5ETPeds.Floor 0 SICU O NSICU ❑IMC ❑NSIMC p Floor Neuro:GCS: O Consult NSGY p OR Crani 0 Repeat CT Consult Facial Trauma HEENT- Neck: 0 Consult Spine [!-Miami!,Collar 0 C-S ine Clear 0 Mill Res Cv: Gl: ❑OR Exploratory GU: D Consult URO MS:. ❑Consult 0rth6/S ine ❑OR for-Fracture Psych:❑Consull Psych ❑Consult D+A Procedures:0 NG-Tube ❑Udnary Catheter ❑A-line: ❑Np(s): Chest tube: ❑light 0 left ❑tipt A, )C . - �2tlz.Q r" ' Eastei DEC. 17 2012 i �I• j Attending Signature Date Tcrtfe"�— Orig Chart MR 611 Rev.5131 Copy-7tauma services TRAUMA HISTORY AND PHYSICAL EXAMINATION;--:' Ix Face CT RICE, SYDNEY D - 7512938 * Final Report CD * Final Report 9. CT FACIAL BONES WITHOUT CONTRAST-PED 0 PATIENT NAME:RICE, SYDNEY D o PATIENT MRN:0751293 8 rev PATIENT DOB: 04/05/2003 EXAM DATE OF SERVICE: 11/12/2012 EXAM NUMBER: 7859486 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER 0 T I� EXAMINATION: b CT HEAD AND FACIAL BONES WITHOUT CONTRAST PED/CTRAUMA rn CLINICAL HISTORY: trauma-' COMPARISON: None TECHNIQUE: Routine tomographic images of the brain are obtained from the skull base to the vertex without intravenous contrast. FINDINGS: Head: There is no acute hemorrhage or mass effect. The gray-white differentiation is maintained.Brain volume is normal for age. There are no extra-axial collections. The ventricles are normal in size. Cerebral tonsils are in normal position. Soft tissue defect and edema are seen along the left frontal bone with some small hyperdensities in the skin.No calvarial fracture is noted. There is mucosal thickening in the ethmoid and maxillary sinuses. Face: There is a dense opacity in the superficial soft tissues of the left cheek with overlying defects in the soft tissue.There is no acute facial bone fracture. I I Easterly Auto Printed by: Calloway, Earthenia D Page 1 of 2 Printed on: 12/3/2012 14:29 DEC. 17 2012 (Continued) n v Face CT RICE, SYDNEY D - 7512938 I (D. " Final Report 3 ° I n O ' mThe right maxillary sinus is fluid-filled,there is layering fluid in the left maxillary sinus. Small amount of o• fluid in several of the ethmoid sinuses. Frontal sinuses are clear. . i 0 rrQ IMPRESSION: Iw 1. No acute intracranial injury. ° 2. No acute facial fractures. 0 -0 3. Left frontal scalp laceration/herriatoma with a few small hyperdensities likely foreign body/debris: I� 4. Radiodense foreign body in the soft tissues of the left cheek,please correlate with physical exam. rn Dr. Ray Bradford is the dictating resident. Finalized report status indicates the signing attending has reviewed the images and report, and agrees with the interpretation. Preliminary report status should be regarded as NOT interpreted by the attending radiologist. DICTATED: OUYANG,TAO - REVIEWED AND SIGNED: OUYANG,TAO, DATE DRAFTED: 11/12/2012 08:23 PM ' DATE OF FINAL SIGNATURE: 11/12/201208:23 PM Result Type: Face CT . Date of Service: November 12,2012 19:20 Authorization Status: Final Subject: CT FACIAL BONES WITHOUT CONTRAST-PED Author or Import Date: Ouyang, Tao on November 12, 2012 20:23 Encounter info: 10512938, HMC, Inpatient, 11/12/2012- 11/13/2012 Contributor system: IDX01 I Printed by: Calloway, Earthenia D Page 2 of 2 Printed on: 12/3/2012 14:29 Eastern AUt® (End of Report) DEC 17 2012 C7 • Head CT RICE, SYDNEY D - 7512938 CD 3 In CT HEAD WITHOUT CONTRAST PED 0 PATIENT NAME: RICE, SYDNEY D m PATIENT MRN:07512938 v, PATIENT DOB: 04/05/2003 :0 EXAM DATE OF SERVICE: 11/12/2012 to EXAM NUMBER: 7859485 N ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER w w C EXAMINATION: o CT HEAD AND FACIAL BONES.WITHOUT CONTRAST PED/CTRAUMA o CLINICAL HISTORY: rn trauma COMPARISON: None TECHNIQUE: Routine tomographic images of the brain are obtained from the skull base to the vertex without intravenous contrast. FINDINGS: Head: There is no acute hemorrhage or mass effect. The gray-white differentiation is maintained. Brain volume is normal for age. There are no extra-axial collections. The ventricles are normal in size. Cerebral tonsils are in normal position. Soft tissue defect and edema are seen along the left frontal bone with some small hyperdensities in the skin.No calvarial fracture is noted. There is mucosal thickening in the ethmoid and maxillary sinuses. Face: There is a dense opacity in the superficial soft tissues of the left cheek with overlying.defects in the soft tissue. There is no acute facial bone fracture. The right maxillary sinus is fluid-filled,there is layering fluid in the left maxillary sinus. Small amount of fluid in several of the ethmoid sinuses. Frontal sinuses are clear. Printed by: Calloway, Earthenia D Page 1 of 2 Printed on: 12/3/2012 14:30 (Continued) Eastern Auto DEG-I 7 202 Ix Head CT RICE, SYDNEY D - 7512938 cD cn' .0 IMPRESSION: 0 1. No acute intracranial injury. Q 2. No acute facial fractures. o' Io 3. Left frontal scalp laceration/hematoma with a few small hyperdensities likely foreign body/debris. Cn 4. --Radiodense foreign body in the soft tissues of the left cheek,please correlate with physical exam. Dr. Ray Bradford is the dictating resident. Finalized report status indicates the signing attending has C° reviewed the images and report, and agrees with the interpretation. Preliminary report status should be regarded as NOT interpreted by the attending radiologist. 0 I� DICTATED: OUYANG,TAO o REVIEWED AND SIGNED: OUYANG, TAO rn DATE DRAFTED: 11/12/2012 08:23 PM DATE OF FINAL SIGNATURE: 11/12/2012 08:23 PM Result Type: Head CT Date of Service: November 12, 2012 19:20 Authorization Status: Final Subject: CT HEAD WITHOUT CONTRAST PED Author or Import Date: Ouyang, Tao on November 12, 2012 20:23 Encounter info: 10512938, HMC, Inpatient, 11/12/2012-11/13/2012 Contributor system: IDX01 Printed by: Calloway, Earthenia D Page 2 of 2 Printed on: 12/3/2012 14:30 Eastern Auto (End of Report) DEC 17 2Oi2 i - 'MS HERSHEY MEDICAL CENTER2 2 3a 110491.7 b.MED. " I 500 UNIVERSITY RIVE W.O.BOX 856 REC.:k '7 _ 38,' "'' " 0131 HERSHEY PA 170330856 HERSHEY PA 17033 6FEDTAXNO. 6 FROM MENT.COVETHR'THROUGH 7 sv (p 7175315218 7175314010 25-1854772 111212 1 111212 (Q 8 PATIENT NAME•:':::;.::•. a 9 PATIENT ADDRES$:;: .,a 40 SYCAMORE DR b IRICE,SYDNEY D. b IMECHANICSBURG PA a 17050 a tO BIRTHDATE 11 SEX " :[ '''''A4MISSION <'' 16 DHR 176TAT ' "• CONDITION CODE$• 29 ACDT 30' 12 DATE': 13 HR 14 TYPE 75 SRC 18• 19: 20 21'" 22. "23 '.24`' ?25:`.' =23' -.27 -28' STATE ''•f ' � 04052003 1 1 1 A., 1 1 01 PA C 31".OCCURRENCE • 33- OCCURRENCE' -35'1 OCCURRENCE'SPAN• 36 •OCCURRENCE'SPAN •' 37 . :CODE ,:.DATE.:. •• •• CODE•. .BATE •� .• CODE, FROM THROUGH CODE "FROM ' `.THROUGH °02 111212 11 111212 . 0 .... .r.:....: .. .. .. .. :3 38 39" VALUE CODES' •• 41 VALUE CODES AUTO INSURANCE CODE• •°.AMOUNT::: - • • :CODE AMOUNT . I O a AO 17055,00 NHORACE MANN INSURANCE r° " PO BOX 962 ,....: . .:_... ...: .:.... W MORRISVILLE,NC 27560 O 42 REV.CD, 43 DESCRIPTION 44 HCPCS I RATE/HIPPS CODE 45 SERV.DALE 46 SERV.UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 0540 - AMBULANCE A0431 IHQN 111212 . 1 14065 1)0 ' 0540' 'AMBUUINC'E _ A0436 IHQN".' t.: :111212.:.:.,..:.. : 19 33251)0,. 7 a 10 :. :::::, •.::.....• .. 10 DI4 ,.RE C�3R D s A . .ACRD ,.: .. .• -. 12 Debra�hoods 14 .RA -6 13 • 17 ,5 16 ... ... i..•.... ... _ G N(.•j l 17 El 17 - , p��j7l1 17 1B i. .... 21 .. .. .. .. - - 21 210001 PAGE 001 OF 001 CREATION DATE 112812 • 17390:00 1 5210:1 ..53A9f2 . 1568435477 50•PAYER NAME - S1 HEALTH PLAN ID 54 PRIOR PAYMENTS 55.EST.AMOUNT DUE 56 NPI. INFO "'9Et{: .: AAUTOINSURANCE Y• ° Y 57 6 CAPITAL BLUE'CROSS' •Y• Y OTHER::. ':... .. . .. 3 PAV ID c 581NSURED'S NAME 59P.REL 601NSURED'S UNIQUE 10 67 GROUP NAME "' 621NSURANCEGROUP NO.: ' RICE,SYDNEY D. 18 16875C AD111212 A B RICE'SYDNEY D. ':... :.:':'' :;. ';.:.' - 18.YWP.80117575903,:. <.;.,..;':::;:;•.,: 0050581.7..::,. c c 63 TAEATMENT:AUTHORIZATION bODE3 "' '` ::<'.: 64 DOCUMENT CONTROL NUMBER. t. 65 EMPLOYER NAME •'•> A . . :. . .: step . c . 02012 .. . •• C 6 8'1349 ;. 780.97 69 69 ADMIT. 70 PATIENT•• ir, { nom'` E8121` .-DX REASON DX' i•.: :'CODE' ECI r: 74 ''•COPDEINCIPAL PROCEODA E::.;: ••• .... • b., ,, .OTHER PROCEDURE 76 ATTENDING::.:,NP11407876162 9UA! OB M D419098 CODE .` "DATE LAsTLUBIN FIRSTJEFFREY • ••• • 'd.' 'OTHER PROCEDURE':': .CODE" DATE •i ••• B •• 77 OPERATING: NPI IX1AL LAST FIRST SOREMARKS AUTO INSURANCE 61 a B3 341600000X 7s.(HER NPI ouu HORACE MANN INSURANCE p :.. . ::.: :...., LAST FIRST PO BOX 962 c 79OTHER NPI QUA MORRISVILLE NC 27560 d LAST FIRST UB-04 CMS•1450 APPROVED OMB NO. �SC�,:'u rmn LIC9213257 THE CERTIFICATIONS ON THE REVERSE APPLY i0 THIS BILL AND ARE MADE A PART HEREOF. �Bli en'•c,m•e.. n . I MS HERSHEY MEDICAL CENTER PAGE: 1 CD 500 UNIVERSITY DRIVE co' I� HERSHEY, PA 17033 C7 Statement on: 11/29/12 at 08 :43 AM 0 Guarantor: RICE COLLEEN J N 40 SYCAMORE DR MECHANICSBURG, PA 17050-0000 Patient: RICE SYDNEY D �0 Visit # : 18451491 w -----------'---------- -------------- ------- ------ ------------'------------ Date Svc Code Descri ption Units Debits Credits I -------------------------------------------------------------------------------- o 111 /12/12 * 1 7111.0 8 I AIR AMBULANCE. MI EAGE 1 19 • 1 �:3 3 2 5 . 0 0' I. ---------------------------------------------------------- --------------------- * - Not posted Balance: 17390 . 00 . -------------------------- 0 00 rn Eastern Auto DEC- 10 2012 C7 m . ''- ;3r.;':.;••,c. r.:'y?-n,°+.'.,c"tC�i ±:2?%`(yi''�'Y•:r:"'?7• r n ... , _ _ :�ifeLioir �Dv'isi'cjn•••; ,,;_{ ,..:� . 500<U:ri`iversiijir,Dcive;°Hers,hey _PA::1�7033 . .-. < = '(71.7 =531-7777 FAX.(71:7)'531=0861 CD :Transport'Request:,Division'CGT Air='Carlisle O N Medical Record Number: 7512938 Run information w Request#: 1211-0572-A Svc Date: 1111212012 Name: Rice,Sydney Io Type: Helicopter Air-On-scene(Traum Addr: 40 Sycamore Drive Priority: Emergent Cnn Dispo: Patient Transported Mechanicsburg,PA 17050 O Ph: 717- - ReferNng'Agencyl Location ' DOB: 0410512003' Name: Cumberland County Comm Age: 9 yrs. Sex: F o Carlisle,PA 17013 - SS: - - Race: 00 @ Scene: Next of Kin: Location: Pleasant View Pk-Silver Sprig( `' Loc County: Cumberland PA Loc CSZ: MECHANICSBURG,PA 17055 .Ev'ent.Tltnes •_' •.' ;�. ::: :; ••, Call Rcvd: 18:04:25 on 11/12/2012 Receiving Agency Name: Penn State Hershey`Med Center Notify Pit: 18:05:19 on 11/12/2012 Hershey,PA 17033 Wx Confirm: 18:05:29 Unit: Emergency Department Respond: 18:07:00 Ar Bedside: 18:19:48 Rec MD: Learning,James Liftoff. 18:11:32 Dp Bedside: 18:32:33 Arrive 1: 18:16:48 Personnel Depart 1: *18:34:33 Crew 1: Maljevac,Dale DEM Arrive 2: . *18:42:47 Ele edTlmes(min) Crew 2: Matter Jr.,Paul PRM Depart 2: 18:44:39 Dispatch: 1 CreW 3: Arrive 3: 18:46:07 Wx Check: 0 CreW 4: Depart 3: 19:22:22 Liftoff: 4 Arrive 4: 19:34:21 Response: 6 Pilot 1: Jones,Rick Fly to Pt: 5 Dispatcher. Ross,Gary Fly with Pt: 8 Med ctrl: Harkey,Kent Other Fit: 14 Tot Leg Time: 27 On Scene: 18 Aircraft Bedside: 13 Ident: N611 LL (Dauphin 365-N2) Total Crew: 87 Mileages/Block Times. Loaded Miles: 19.0 sm(PtoP);Actual: 19.3 sm in Service: 19:34:55 Total Miles: 54.0 smMax,Alt: 0 Completed: 19:34:55 on 1'1112/2012 PatldntWeight category andOlagnows Category: Pediatric-Trauma Pt Weight: 35 kg Diagnosis: Multiple Trauma Mechanism: Accident-Motor Vehicle Allergies: NKDA :1 Y1xi9+i,+�iKR1o?•iv5 OrNUbY:_ .A N14.�Ca.c.'� 11iL:�'i�SC:LT4NR[.LOrsY.TJ+-i'>WtiY.sli^i:f:.'S•.aY+.'a".0".se'p.Om"-+i:+:�w.'d=Jtsgf.�µ�'W.G?•l141Y��Y:W'AL:sgY^:Fi�,a Eastern A, if-n 7.5T2938R.icedney p "Page- 1`of,:4'`.', •.,tip `r s:.. ... -. ...-:- ., ...:..w-,u.... ... ._... .w.,.a...•-..-w yr•o.,..� .. .. r..csoc.ans,: r ...f..•izna�.N•..�.:a.�es.v,>....�... .r... . r a CD FI,IghtFie'cjuest;Printtint-,Request:#;.-12.1.--5�2r-'A: - O D Chief Complaint: (n Motor Vehicle Crash p` Date&Time of Injury/Onset: 1111212012 17:50 low History.of Present Illness: Life Lion three was dispatched to Cumberland County,Silver Springs Township,per in flight report,this is a cri pediatric patient who was involved in a motor vehicle crash, no other information was available.Silver Springs W ambulance and West Shore paramedics were on the scene at the LZ upon aircraft arrival,.initial patient IC contact occurred in the rear of the ambulance,patient in supine position with blood pressure,pulse oximetry, p cardiac monitoring ongoing,long board,CID in place,one IV with NSS infusing at a KVO rate,verbal face to 0 face report received from EMT-P from West Shore ALS who provided the following report:this patient was -p the restrained rear drivers side occupant of a vehicle that was involved in a motor vehicle collision,car was I� "T"boned by another car with impact on the drivers side where the patient was sitting. Driver of the car was also injured and is being transported the HMC via ground. Unknown speed, unknown LOC,"altered"mental o status,there is approximately 12-18 inch intrusion on the drivers side. Currently patient in the rear of the rn ambulance be treated by the EMS crew,patient currently non-verbal,combative,attempting to pull out IV in the left arm, high flow oxygen via NRB at 15 liters. A rapid trauma assessment was completed,see exam area of this chart for additional information obtained during head to toe assessment. Obtained transport consent by implied consent. Mother(driver)of patient is aware that daughter is being transported via Life Lion. Patient is being transferred to Hershey Medical Center due to the designation as a level one trauma center with pediatric speciality available. Assessment by RN Maijevac who spoke to patient in calm manner and explained what happened,patient is still agitated,moving all extremities and attempting to remove IV and monitoring equipment. For patinet and crew safety,wrists were secured to the long board with cravats: Circulation was check prior to leaving the LZ and upon arrival at HMC.While the patient was placed on the pro-pak monitor for continuous monitoring of non-invasive blood pressure, heart rate and oxygen saturation, RN Maijevac inserted a 18 gauge hepwell in the right a/c.After insertion of the iV, patient became somnolent and remained that way for duration of the transport,vital signs within normal limits,patient did not verbalize to Crew during our encounter with her. Litter was removed from the ambulance, patient was placed on the Life Lion litter,covered for thermoregulation purposes,secured to the litter with four sets of straps including a • shoulder harness, hot loaded and secured in the aircraft into the primary position with the assistance of four firefighters Aid Prior to Arrival:EKG-3-4 Lead Obtained, Immobilize-C-collar Applied,Restraint-Physical, Non- Rebreather Mask,Access-Peripheral,Oxygen Prior Aid performed by:Other Healthcare Provider Physical-Exam: Assessment @ 18:21:00: **Other:SKIN:Multiple abrasions and lacerations to face.HEENT:Abrasions and contusions to the facial area,there is dried blood noted on the forehead,cheeks and chin,there is a ABD pad held in place with tape to the forehead.There is a laceration noted in the left forehead by the hairline,slight oozing of blood when ABD pad was removed,ABD pad resecured with two inch tape.Appears to be no drainage from eyes, nose or ears,facial bones are stable to palpation,no loose teeth,a laceration to the left lip and cheek area. Maintains airway with a NRB mask at 15 liters,mask is taped in place to long board. NECK:"Trachea is midline without tugging,cervical collar in place,fully immobilized on a long backboard,unable to palpate the neck due to cervical collar in place. CHEST&LUNG:Breathing is unlabored®ular,breath sounds are clear to auscultation,equal bilaterally with good aeration with symmetrical rise and fall of the chest.HEART ASSESSMENT:.Heart is regular rate&rhythm.ABDOMEN:Soft, no tenderness on palpation,no rigidity,no visible signs of trauma. BACK: Patient was immobilized prior to our arrival by paramedics and remains,fully immobilized on a long spine board, Medic reports no significant findings on pt cervical spine,back or buttocks prior to immobilization.EXTREMITIES:Patient IV in.the left arm placed by West Shore ALS,right arm hepwell by RN Maijevac, spontaneously moving all extremities, EYE'S:4mm, equal, round&reactive to 7592938 :.st.e rn '2 of 4 DEC 10 2012 C7 CV Flight Request Prini6u,t-Request#: 1211=0572=A. ! 1 '.J-A'1M:F.'.CV:i:F iw ..i Jn'L:u AN frsi "w.. =•aM 1W.'6. 1.L9WL1CAl:aW :f—ut'•••`-•• ••••1i9T.'aitY•avS.' -WVI::: �' Physical Exam:.....continued �p light MENTAL: Presently with eyes closed, making incomprehensible sounds,does not-follow commands, j restless and agitated. Neuro: No.verbal response when asked questions,does not open eyes•when asked, p' swallow's without difficulty,airway is patent. to Past Medical-History: N Healthy U1 . w Treatment: tC Upon arrival in the aircraft, patient was hot loaded& placed head first in the primary position,oxygen was p changed to the LOX system&continued at its previously described rate,glucose of 106 was obtained, during transport patient was continually reassessed with no changes in her physical exam,she remains CD a non-verbal.Vital signs remain within acceptable limits, no further treatment was indicated for or initiated by IZ this crew. Medical command was contacted with detailed patient report at approx 1836, no further orders' .p were received from Dr. Learning. Life lion arrived at Hershey Medical Center without incident. Pt was hot off 0 loaded, oxygen was switched to a portable cylinder and transferred with assist of Emergency Department 0) Technicians to the trauma bay,patient report was provided to the trauma team. Both oxygen and IV fluids were continuing at their previously described rates, IV remains patent, care was assumed by the trauma team.After initial evaulation of the trauma team, patient was moving all extremities and talking to the team•in full sentences. Electronically signed: Dale Maljevac, RN. November,13,2012 @ 0930 Report given to Trauma Team by Maljevac, Dale. lab Values: Vital Sign's . Tune NIBP P• R 'Effort:- 02. :.Pain.;.Sddation ; . '.Notes•: 18:25 123/80 91 132 20 Normal 99% 5 1 ' 18135 99/46 59 112 18 Normal 99% 18t41 102/68 75 96 18 Normal 99$ 5 4 Vital Assessaiiiht Time EKG Temp'GCS Score AVPU PTS Glu Notes 18:25 Sinus Rhythm 2 2 5 9 0 . 18:35 Sinus Rhythm 2 2 5 9 0 106 EVMGCS 'Airway'Management Time Method Rate Cbnc.ETT Tries S!U Who - Notes PTA Non-Rebreather Mask i 15 0$ I S IV Fluids and Drip Medications Time Access Method Site, Rate' ' Dose Notes Who Fluid/Medication Infused Ga. Concentration Eastern Ee '751-293 VRice;Sydney Page 3 of 4;' `. C7 I • t N �4 Flight l2equest:Printout'�Request'#:•1211=0572�A :..:.as:+...�ua.o-. .r:x•�..,...e a..aw,*�+.xi,.• .v cx a..:¢�.•.Mn>o.r. :crvrawe. �, w. •t.. - s.• cwru- O IV Fluids acid DHp Medications- (D Time Access Method Site Rate . Dose Notes —1 Who Fluid/Medication. Infused Ga. . Coni;entration- _ O PTA Access- Infusion Contin. Antecubits' XVO mi/hr i Complications: None; Authorization: Normal Saline 50.0- 18.0 Protocol (Standing Order) C18:22 Access- Peripheral Antecubita Complications: None; Authorization: N DEM Other (specify in Meds) 0.0 18.0 Protocol (Standing Order); Notes: Saline lock W io Total Intake (Pre-Transport) 0 (During Transport) 50 .p Total Output(Pre-Transport) 0 (During Transport) 0 O I-P . O '• Co Cm Place EKG Strip Here SIGNATURES Dale Maljevac Paul R. Matter RN EMT-P Eastern Auto DEG 10 2012 7512938 Rice, Sydney- Page 4'of 4 i i I 0 PENNSTATE HERSHEY 3 PRM MIltOII S. Hershey NAME: RICE, SYDNEY II'lull"II'II��II�I�II�I�III�����'II�III�'I , I� MR.';: DEFLITCH CHRISTO 11D�,: 46325:x38 Medical Center DOB: 04/05/2003 VISIT DATE: 11/12!2012 LOC: EHER SEX: F il�lll�l5 `�lll �il SELF PAY � TRAUMA TEAM SIGN-IN SHEET -• ,, If I II 1111 . CD ..S Date TRAUMA NUMBER I 0 N TRAUMA LEVEL 1 2 3 CP Iw Trauma Standby paged at hrs Trauma Response paged at hrs REN.SE:TEAM'MEMB.E ?:= �:,.: ?yV" ,:•,,_; :: .•,.i., R; ' -Fry•.L:i`1":N' �AIIE: ;s<:• ter...r:';TiSne o ED Attending t 'a Trauma Attendin Egg'0 l� Trauma Team Leader PGY4/5 a Senior Trauma Resident PGY 4/5 0 00 Junior Trauma Resident PGY 2/3 Junior Trauma Resident PGY 2/3 Junior Trauma Resident PGY 1 Junior Trauma Resident PGY 1 Emergenc .Med. Resident PGY 2/3 Emergency Med. Resident PGY 2/3 Emergency Med. Resident PGY 1 Trauma Physician Extender Trauma Physician Extender , Anesthesiology Attendingt� Anesthesiology Resident Certified Registered Nurse Anesthetist Respiratory Therapy Radiology Attending Radiology Resident (a !� Radiographer#1 Diagnostic it f S -Radiographer#2 Diagnostic) 18 3 3-' Radiographer CT 'e I Emergency Medicine EMT Chaplain sm OR Technician/Nurse I Pediatric Critical Care Attending Pediatric Critical Care Resident c;pn1 $YS Child Life Specialist Trauma Coordinator/Case Manager � CONSUTAT MEIBERS` NAME : r'=��'r �..... _. Y �: - � °t� ':.• S rimeof,A rival Orthopaedics Pager 2002) Neurosurgery -(Pager 1001) Plastic Surgery ENT PGY=Post Graduate Year Auto Copy-Medical Records MR 414 Rev.1108 Page 1 of 1 Eastern A u$® Pink Copy-Emergency Dept. TRAUMA TEAM SIGN-IN SHE E�EC. 10 2082 Yellow Copy-Trauma services J Z 'MS HERSHEY MEDICAL CENTER 2 3'n" 1w, 38-1 500 UNIVERSITY DRIVE P!!f'BOX 8x56 f' REG:##' 7512-175B., :_- ; 111 5 FED.TAX NO. 6':•:STATEMENT COVERS PERIOD ]7 p� HERSHEY PA 170330856 HERSHEY PA 17033 FROM.. THROUGH (p 7175315218 7175314010 25-1854772 111212 1 111312 (Q 8'PATIENT-NAME -'.; a 0ATIENTADDRESS:, ,} a,4O SYCAMORE DR b RICE SYDNEY D. p. MECHANICSBURG PA d 17050 ADMISSION, ,.., CONDITION CODES, - .' ,:. 29 ACDT 30 , 10 BIRTH 11 SEX 12 DATE'_" 13 HR:•74NPE'15SflC 16 DHR 17STAT ':'1S :'"79. :•:'20' ''.21'::::22 '23: 24• 25 26.:• 27:••:•:28::;.STATE ,•:: D 04052003 F 111212 19 5 11 18 01 A6_ C5 PA G 31 OCCURRENCE'.,' 33 pCCURRENCE. ' • 35. OCCURRENCE SPAN 36 '',OCCURRENCE SPAN 37 O) CODE DATE •• • .• .CODE 'DATE •• •. • CODE: FROM•;"•'::`.•' THROUGH CODE' FROM:',.'.-:- ''.THROUGH x•02 111212 11- 111212 38 89. .:.VALUE CODES •. 41 VALUE CODES' AUTO INSURANCE �( CbDE ;:':::AMOUNT .c-:'::'.. CODE'. AMOUNT.•.. O , � , a N HORACE MANN INSURANCE f' �3 ':', -4 ,i b C11 PO BOX 962 .. .. .. , :.: . C IW MORRISVILLE,NC 27560 d :... O 42 REV.CD. 43 DESCRIPTION 44 HCPCS I RATE!HIPPS CODE 45 SERV DATE 46 SERV.UNITS 47 TOTAL CHARGES 48 NONCOVERED CHARGES. 49 0120 ROOM-BOARD/SEMI 1 2471 b0 ' C9 0250 PHARMACY' : = ::23 37;95 : . RAIA WA -00255 DRUGS/INCIDENT RAP 1 103:00 3 :.: . /®:` 0258 IV SOLUTIONS ::... . � -- . . :'2 . ' :�::,�•;:-.•.'5:05`.; ..'.;>::>;�:-': '?•,•.'� :':�.:s 4 0270,.•MED-SUR SUPPLIES.„.. ® 1 , -. 18;00 . 5 p [6 .. 6 00 0300 LABORATORY OR L`AB i��� FId! 1.1 :':'695 00 :..., O 0320 DX X-RAY 1 234:00 0324...DX X-RAY/CHEST ... : ;, ; .,.. •:.:,.. ;.,..,204.00..•.> •', , ..:.,. :: ..:,: :.:'::' 035.•, CT•SCAN••..,•,,, 1. 3920:00,. . 9 X. ,.0351 .. CT.SCAN/HEAD, -...-:' ,' DIC-. REC-OR S ATT CBED.:;;'.: :,: :...::.:• :., .. ;:. :::.::,9 2 2918::00. ” 0450 EMERG.ROOM „... Debra I�®ads .: . . . . :.. ? .. 108800 „ 0460 PULMONARY.:FUNC. .. . 11$O/'WKC Teaffi 2 ;:.':.147:00 ".0636,,.DRUGS/DETAIL•,CQDE•..:•; ..,,. ,.., ::, 20 , . .. . 8$:30 � t3 14 0682.. TRAUMA LEVEL.11...... .:...... :. (.. •. -- 1 -972.4;00. .. i4 15 ,6 V 19 Q/ (x .'., .. . 7. 17 17 is 16 •/J�J� 19 21 C/ :ZO "0001 PAGE 001 OF 001 CREATION DATE 112212 • 21650 30 23 ': 'S2REL '.� ... ... 50 PAYER NAME .' 51 H£ALTN PLAN ID woo sd PRIOR PAYMENTS''' S5 EST.AMOUNT DUE' S6 NPI 1568435477 AUTOINSURANCE Y Y s7 A a CAPITAL:BLUE CROSS :. :. Y 1( OTHER a PRV ID c 5 ...RED'S NAME; •, 59 P.REL 601NSURED'S UNIQUE ID ,, 61 GROUP NAME ' .S2INSURANCEGROUP NO. RICE,SYDNEY D. 18 16875C AD111212 A a RICEAYDNEY:D.,. -..:' : ... :..:. ..:.......,18.YWP801'17575903,.. ... ...' :. 00505817 683REATMENT AUTHORVATION CODES `':, 84 DOCUMENT CONTROL NUMBER' :85 EMPLOYER NAME',' A A � C 0 87342 Y 85Q0 Y 8730 V V6481 87344 Y c 6a 9 r �' ;•; ;:'i:• 6B ADMIT 7342 70PAOIN o:.. t�,, 71 0282 ecI, E8191 ';,ti; �:•79 :. 74, , .PRINCIPAL'PROCEDURE' .' - •••• . - b.' OTHER PROCEDURE:• •75' �6 ATTENDING, ,NP11255371688 ��- CODE''•. •.: .DATE •. .• .-,.. ,CODE .. DATE. 8659 111212 9955 111312 LAsTROCOURT FIRsTDOROTHY • - d. OTHER PROCEDURE ' - 77,OPERATING NP11 841241700 QuAL •o .• .:'CODE .DATE•: •. LAsTPOTOCHNY FIRSTJOHN BOREMARKS AUTO INSURANCE a"a 63282N00000X is OTHER,', NR1255371688 9u HORACE MANN INSURANCE b . IASTROCOURT FIRSTDOROTHY :...: PO BOX 962 7B oTHEa NPI au ::. . MORRISVILLE NC 27560 •d.�. •.•::.<:.'...•. .. � . ' •. .. .. ....': LAST FIRST U13C4CMS-1450 APPROVED OMB NO. LIC9213267 THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. C7 + r MS HERSHEY MEDICAL CENTER PAGE: 1 500 UNIVERSITY DRIVE HERSHEY, PA 17033 C7 Statement on: 11/26/12 at 06 :58 AM 0 Guarantor: RICE COLLEEN J 40 SYCAMORE DR �. MECHANICSBURG., PA 17050-0000 Patient: RICE SYDNEY D �o Visit #: 10512938 IQ -------------------------------------------------------- ------------------------ w Date I Svc Code I Description I Units Debits I Credits -------------------------------------------------------------------------------- 0 11/12/12 16604 PEDS LVL II TRAUMA W/ 1 9724 .00 Cn 0 11/12/12 42354 9 PEDS SEMI PRIV MED/ 1 2471.00 -p 11/12/12 46472 ' EMERGENCY VISIT, LEVE 1 1063 .00 11/12/12 46620 VENIPUNCTURE 1 25 . 00 11/12/12 46717 NONINVAS PULSE OX, MU 1 147 . 00 0 11/12/12 101003 ABO BLOOD GROUP 2 118 .00 rn 11/12/12 101004 ANTIBODY SCREEN 1 118 . 00 11/12/12 101005 RH TYPE 1 59.00 11/12/12 104009 AMYLASE, BLOOD 1 75 . 00 11/12/12 104097 LIPASE , 1 77 . 00 11/12/12 104156 SGPT (ALT) 1 26 .00' 11/12/12 104433 BASIC METABOLIC PANEL 1 73 . 00 11/12/12 105052 PARTIAL THROMBOPLAS T 1 65 . 00 11/12/12 105059 PROTHROMBIN TIME 1 34 . 00 11/12/12 105656 CBC W/PLT AUTO 1 50 . 00 11/12/12 245206 LIDOCAINE 10MG/ML 2 3 .25 11/12/12 245553 LIDOCAINE-EPINEPHRINE 2 3 . 90 11/12/12 245710 BUPIVICAINE 10 ML 1 6 .40 11/12/12 246705 MORPHINE SULFATE 4 MG 1 5 . 00 11/12/12 246836 FENTANYL CITRATE 2 ML 1 5 .25 11/12/12 246841 SODIUM BICARBONATE 50 1 10 .60 11/12/12 274218 CEFAZOLIN SODIUM BAG 2 14 .30 11/12/12 307101 CHEST 1• VIEW 1 204 . 00 11/12/12 307201 SPINE 1 VIEW ANY LEVE 1 234 . 00 11/12/12 310501 CT HEAD UNENHANCED 1 1282 . 00 11/12/12 310528 CT 'SINUS MAXILLOFAC U 1 1636 . 00 11/12/12 310702 OMNIPAQUE 300MG/ML 75 1 103 . 00 11/12/12 310848 CT ABD/PELVIS ENHANCE 1 3920 . 00 11/12/12 621386 IV KCL 20MEQ+D5 NACL 1 7 . 00 11/12/12 627070 IV .EXT SET 90 W/FLASH 1 18 . 00 11/13/12 245574 POTASSIUM CHLORIDE 10 10 11.20 11/13/12 246002 AMOXICILLIN 250 MG 1 3 . 00 11/13/12, 246226 FLU VACC (FLUARIX) 0 . 1 35 .40 11/13/12 241882 D5W 0 . 9% NACL- 1000ML 2 5 . 05 11/13/12 250256 ACETAMINOPHEN 80MG 5 3 . 00 11/13/12 274189 HYDROCOD BITARTRATE A 1 8 . 95 11/13/12 274289 AMOXICILLIN 250MG ORA 14 6 . 00 -------------------------------------------------------------------------------- * - Not posted I Balance: 1 21650 .30 Eastern Auto------------- DEC- 10 2012 C7 . *+ I� ED Summary r RICE, SYDNEY D - 7512938 m . cn' *Final Report' I C7 0 m o * Final Report I o Trauma-major N Patient: RICE,SYDNEY D MRN: 7512938 IW Age: 9 years Sex: Female DOB: 4/512003 0 Associated Diagnoses: None Author: Olympia, Robert P 0 History of Present Illness I� The patient presents with major trauma and restrained back seat passenger behind driver involved in MVC with C) impact on driver's side-noted to be somnolent en route with GCS of 8-lacerations to face-. 00 0) Review of Systems Constitutional symptoms: Negative except as documented in HPI. Skin symptoms: Negative except as documented in HPI. Eye symptoms: Negative except as documented in HPI. ENMT symptoms: Negative except as documented in HPI. Respiratory symptoms: Negative except as documented in HPI. Cardiovascular symptoms: Negative except as documented in HPI. Gastrointestinal symptoms: Negative except as documented in HPI. Genitourinary symptoms: Negative except as documented in HPI. Musculoskeletal symptoms: Negative except as documented in HPI. Neurologic symptoms: Negative except as documented in HPI. Endocrine symptoms: Negative except as documented in HPI. Hematologic/Lymphatic symptoms: Negative except as documented in HPI. Allergy/immunologic symptoms: Negative except as documented in HPI. Additional review of systems information:All other systems reviewed and otherwise negative. Health Status . Allergies: .- No allergies have been recorded. Past Medical/Family/Social History Medical history Negative. Surgical history:-Negative. Family history: Not significant. Eastern Aut® Printed by: Hitz, Brenda K ® Zd1Z Page 1 of 3 Printed on;• 11'/26/2012 06:58• .DEC (Continued) " h r i Y ED Summary RICE, SYDNEY D - 7512938 1 CD. "Final Report* C7 0 D CD C p' Social history: Reviewed as documented in chart, Family/social situation: Intact family. loo Physical Examination N General: Alert, no acute distress, presented with cervical collar and hard board restraints'-cleared cr! clinically off hard board . IQ Vital Signs Cn Skin: Warm, dry, pink, intact, no rash, no petechiae or purpura. Head: Normocephalic, atraumatic, 3 cm laceration to left forehead and left cheek. Neck: Supple, No lymphadenopathy. Eye: Pupils are equal, round and reactive to light, extraocular movements are intact, normal conjunctiva. I� Ears, nose,mouth and throat: Tympanic membranes clear,oral mucosa moist, no pharyngeal o erythema or exudate. � Cardiovascular: Regular rate and rhythm, No murmur, Normal peripheral perfusion, No edema. Respiratory: Lungs are clear to auscultation, No wheezes, rales, or rhonchi. Chest'wall: No tenderness. Back: Nontender. Musculoskeletal: Normal ROM, no tenderness, no swelling. Gastrointestinal: Soft, Nontender, Non distended, No organomegaly. Neurological: Alert and oriented to person, place,time, and situation, No focal neurological deficit observed, CN II-XII intact, normal sensory observed, normal.motor observed. Lymphatics: No lymphadenopathy. Psychiatric: Cooperative. Medical Decision Making Trauma team: Trauma criteria met. Differential Diagnosis: Contusion,fracture, laceration, head injury, neck injury, spinal cord injury. Rationale: Trauma Level 2 labs sent-airway patent and breathing unlabored and spontaneous-circulation intact-sent for Cspine and Chest X-ray and CT head and face, abdomen and pelvis. Impression and Plan ' . Diagnosis Head injury 959.01 (ICD9 959.01)` Facial laceration 873.40(ICD9 873.4.0) head-contusion.:920 (ICD9 920) Contusion of the face'•920(ICD9 920) Plan . Conditiom.Stable. Disposition:-Admit: Rocourt, Dorothy V. Printed by: . Hitz, Brenda K Page 2 of 3 Printed on:"' ` '11/26/201206:58 (Continued) Eastern , utO DE O:Z012 1 ED Summary RICE, SYDNEY D - 7512938 cn to *FinalAeport O M m W. 0 =3 Addendum 100 Signatures: N Electronically Reviewed/Sic ned(12-NOV-2012 19:35.00)by: Cn Robert P. Olympia,MID W I • 0 cn 0 Result Type: ED Summary' Date of Service: November 1.2, 2012 18:58 I� Authorization Status: Final Subject: Trauma-major 000 Author or Import Date: Olympia, Robert P on November 12, 2012 19:01 rn Verified By: Olympia, Robert P on November 12, 2012 19:35 Encounter.info: 10512938, HMC, Inpatient,.11/12/2012- 11/13/2012 i Printed by: Hitz, Brenda K Page 3 of 3 Printed on: 11/26/2012 06:58 (End of Report) Eastern Auto DEC-10 2012 C7 . r Ask v PENNSTATE HERSHEY IIIIIIIIIIIIlIlI11111I1I11NI1lIll�llllllill Sm Milton S.Hershey Medical Center gip'DE FLITCH CHRTSTO yiSiT DATE?911/12/2012 DOB: 04/05/2003 SEX: F LOC-. ENER SELF PAY jjIIjIjj O E�II F III11�l P •• a 0 TRAUMA HISTORY AND PHYSICAL EXAMINATIONII. < W. ate: 7j Time: o .� • Hx of Present Illness(HPI ROS I o jFMVC, Belted?` Yes O No ❑Airbag Timing/Duration 2,0 yHfvu Eyes 4N. F-1 Pedestrian []MCC ❑assault Signs/Symptoms: Amnesia?❑Y es VNP ENT 5C,, N ❑Fall ❑Burn ❑Electrical Loss of Consciousness? ❑Yes No Cardiovascular. W ❑Gsw ❑Stab ❑other, Respiratory to GU 41. bay GI Cn �y,Q Musculoskeltal j Integumentary Pt weight- Neurologic ' I� �llut�l}rliP Broselowweight: Other 111j CDEl Entrapment' ❑Ejection ❑Crush ❑Blast NAll others negative/non'contributory Helmet:[I Yes❑No ❑Environmental Exposure ❑Hypothermia ❑Impalement ttl ❑Chemical ,❑'Biological ❑.Radiation ❑Other. Allergies- :`I r Fall:Ht of fall: • Fall from obiect FFS:❑Yes ❑No Medications: Coumadin O Plavix ❑Other. I Other. past SurgiealNx . Family We Bleeding Disorder❑Yes [I No Airway Patent ❑Obstructed intubated: ❑OT ❑ NT ❑ Trach El Other. 7N—,mmntributatory/66obtainable .; AgMtk Breathing:. c(eair `;' Breath Sounds: Sodal Fix: family Sfatris:' Circulation: 'P: BP: �0'i RR: �?' Sat: o ❑Other 1 Noncontributatory/Unobtainable 44�04 Disability: GCS: M V A'IE _ `LI ❑Etoh' ❑SZ Hx ❑Illega Drug FAST Exam: Cr -Exposure:. Completed -Last Meal:• Last Tetanus: _ e 2nd Vitals:Temp BP, R: 20 62 Sate VJf ✓ Lq —P: HEENT: Head: t a- 3 CvP1 Eyes: 1-t 7 2.. 01 F 90 P Ears: :TM's: .C,I.fp f Battle's: Q 2c can . Face: Maxilla: Mandible: Dentitia: odtVA Nose: N`r call .. .. Mouth: COX-c r n {,0 Dentures: 1 .. PJedc: Tenderness: /V f Creptus; Trachea MU. �`?• / , Chest Wall:Tenderness: Aff Crepittu: "� ... .. *� Lungs: Back: Tenderness: © Crepitus: O• `- Heart: f Wt ;v r Abdomen:.Distention: N b BS: Tendemesi. Rectal:"Tone• theme: .Prostate: }. Pelvis:Stable; Tenderness: rn L® Vascular Exam: Radially1 Femoral 2'� DP V4 PT I , DEC 10 2 U ° LEGEND:Right/Left L-l - . aceration Cho-dosed fracture-" Resident Si to Title Dat r Time a.m:lp.rrL OFX-open fracture Ab-abrasion' 1�p . PAY q_.0 0: 'C—contusion . ;C07YRIGHT,1998 PSGH ' odg,= Chart ''•• MR 611 Rev.5/11 TRAUMA HISTORY AND PHYSICAL EXAMINATION Copy=Tradnraservi6es IIIIIIIIIIIIIIIIII lIIlillllillllllllllll , � ��� TRAUMA HISTORY AND PHYSICAL EXAMINATION ; 3 Giasgbw Coma Scale Trauma.Score oCranial Nerves: — L S final Cord in jury.; 3.7 TNO.9 nmg' Resp.We 'SBP =1 2-Open to Pain 0-0 0-U < Motor: 4 �`Open to CommandNoice; 1-1-9 1:0-49 (p V Spontaneous . 2->36 2-50.69 verbal Response 3-25-35' 3-70-90 . 1-None O Sensory:Pin rick n m ZA Y,-tz 2-Incom prehensibleftahs to Pain ,� 10.24 0>90 :3 3-In y ap ropriateVes to Pain- Pro rioCeption p tl`t-L6{-/� Co Consolabie . .:• GCS ® Atertl0rientedlintera,t, 0-3 -4 i �► Motor Response 1-5-7 [1-5 2- None 2-8-10 . rr- 3- mte 113 4•Wrthdraw 4'- 4-15'• 5 1¢es Pain M I C7 Total- .p .' oral• 01 PT: -Troponin.,'• U/A: t '— PTT: �2 Myoglobin: TV I i� U T:Bili: CPK: Drug Screen: C) 1`� J-� - r � ALT.." Amylase: 00 ABG: ALP: 4Gw, CA ETON: ECG: TEE: BHCG: CSR: Vo Pelvis: Hea Jlla�� L COO CSpine: Lat Extremities: Abdomen' AP Others: Odonto'Id .. T&L Spines: i91 saw and evaluated the patient and agree with the.resident's findings and;plans as written above. ❑See dicfated note ❑1 have reviewed the transport/EMS notes Admit: ❑PICU- ❑PIMC 4TPeds.Floor ❑SICU ❑NSiCU ❑IMC ❑NSiMC ❑Floor Neuro:GCS: ❑Consult NSGY ❑OR Crani ❑Re eat CT Consult Facial Trauma HEENT: Neck: ❑Consult Spine ❑Miami J-Collar ❑C-S ine Clear' ❑•MRI ' Res CV. GI: ❑OR Exploratory GU: '❑Consult URO Eastern Auto . MS: ❑Consult Ortho/S ine ❑OR for Fracture Psych:❑Consud Psych ❑Consult D+A Elkl . Procedures:❑NG-Tube ❑urinary Catheter ❑A-line: ❑GVPis hest tube-' ©jjqjh O eft 11M. [)G • Y I Attending 9 Si nature Date Ti'�rie't" Orig -Chart MR 611 Rev.5111 C6py-Trauma services• ; TRAUMA HISTORY AND.PHYSICAL EXAMINATION ,. y • .. i CD CD cn- u ' O TRANSFUSION 1 111111 ldldl dlld111111IIIII lilll Ilidl IIII IIII 00 PENN STATE NU . . ._ " /� im • HERSHEY MEDICAL CENTER t `��}�®� NAME: TRAUMA, 7512938 BLOOD BANK- MR#: 7512938 005x: 10512938 HERSHEY PA 17033 — I MD: DEFLITCH CHRISTO htD.., 46325 DIRECTOR PA 1CLINICAL 03 LABORATORiES ❑CROSSMATCH (XM) DOB: 01/01/1900 VISIT DATE: 03!0612013 (ABO/RH,ANTIBODY SCREEN,UNITS) LOC: EMER SEX: U "- M.CREER,M.D. fli EL F'PAY SELF PAY lldlIIIIIIIIIII SPECIAL REt�UESTS-CALL 8232' COMPONENT #UNITS _ _- F' PACKED CELLS _ SPECIMEN COLLECTED AND BLOO B APPLIED BY: EXCHANGE TRANSFUSION VOL GRANULOCYTES((MGR) SIGNATURES TIME: l z.a. a Q- ❑INTRAUTERINE TRANSFUSION VOL �`HP,AC�STEMCELLS(XBAMS) RECIPIENTS tD FICATION VER D, DATE: p El FRESH(LESS THAN 8 DAYS) IVFOfMATION RECUIRED V" ' TYPE AND SGREEN(TSC) O #UNITS TAT (ABO/RH,ANTIBODY SCREEN,0 UNITS) O'Q' DIAGNOSIS J .� ❑LESS THAN 5 DAYS ❑•OB TYPE AND SCREEN(OBIS) ❑ROUTINE m yI (PEDIATRIC HEART SURGERY) #UNITS (ABO/RH,ANTIBODY SCREEN,0 UNITS) ORDERING.PHYSICIAN N,. COLLECT ON: .Q':• ❑LIMITED DONOR PROTOCOL ❑NEONATAL TRANSFUSION(NEOX) FOR SURGERY W. ❑OTHER - (ABO/RH,ANTIBODY SCREEN) DATE SPECIFY HOLD SPECIMEN(HOLD FOR TRANSFUSION i : • ❑ ) DATE ' CUNICALPATHOLOGISTEVALUATION (NO TESTING PENDING ORDERS) KEEP UNITS AVAILABLEATALLTIMES REQUIRED t ADULT PINK PER 4 UNITS (NEW SPECIMEN REQUIRED EVERY 72 HOURS) " ❑IRRADIATED ! EACH TR LA13ELTHAVE PREVIOUS TRANSFUSIONS � J ❑YES - ❑NO DATE ❑WASHED pil CHART COPY �aster.r� .Aut® ' DEC. 10'2012 �. C7 PENNSTATE HERSHEY CD. IIIIIIIIl iI lIIIIlllilillllil�llillllfllllll (a Milton S. Hershey NAME: RICE. SYDNEY MR7: 7512938 OOS4: 10512938 �� A� { MD: OEFLITC2 CHRI5T0 VISIT 46325. ' O MtiIIICCIt Center LNC: EMLF5P2003 VISIT DATE: 11112!2012 SEX: F F € SELF PAY TRAUMA TEAM SIGN-IN SHEET IIIIIIII�IIIIIIII��II CD Date TRAUMA NUMBER I N TRAUMA LEVEL 1 2 3 Cn Ico Trauma Standby paged at hrs Trauma Response paged at hrs ':r.. .;.., 'r'.�;:,*.ii':'• ..t: r+�sYi� s..�'S,;', j .p TRES;PO.N.S:E'"TEA10'."MEMBER^ " �" k•t:s. Ill' 'IUIE': is r;•j Ti(rie'"of'1rriiral':. C ED Attending4 ( 6 Trauma Attending I� Trauma Team Leader PGY4/5 ra rF� o Senior Trauma Resident PGY 4/5 rn Junior Trauma Resident PGY 2/3 Junior Trauma Resident PGY 2/3 Junior Trauma Resident PGY 1 Junior Trauma Resident PGY.1. Emergenc 'tiled'. Resident PGY 2/3). Emergency Med. Resident PGY 2/3 Emergency'Med. Resident PGY 1) . Trauma Physician Extender Trauma Physician.Extender Anesthesiology Attendinga Anesthesiology Resident Certified Registered Nurse Anesthetist Respiratory Therapy Radiology Attending Radiology Resident (a A �f Radiographer#1 (Diagnostic). - A Y I S Radiographer#2 Dia nostio, F - Radiogra her CT Emergency Medicine EMT v Cha plain ' 3't OR.Tech iician/Nurse. 1 Pediatric.Critical Care Attending Pediatric Critical Care Resident Child Life Specialist Trauma Coordinator/Case Manager ci CUN `NM O SiLTATMEMER . Timeiof'Arrivat' Orthopaedics Pager 2002) Neurosurgery (Pager 1001) Plastic..Surgery s ENT. . UE6 20'7 PGY=Post Graduate Year Original Copy-Medical Records MR-41.4. Rev.1108 Page 1 of 1 Pink Copy-Emergency Dept. IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII!!I TRAUMA TEAM SIGN-IN SHEET Yellow Copy-Trauma Services C7 • PENNSTAT7E HERSHEY 11I�111111�I�11�N�1111�14�1�9IIlll4�ill�ll r1} . Eton S.Hershey NAME: RICE. SYDNEY (I) Y MR»: 7512938 � 005;€: 10512938 MD: DEFLITCH CHRISTO MD#: 46325 -Medical Center D08: 0410512003 VISIT DATE: i1I12f2012 3' LOt: EMER SEX: F F PAY i Io ED'TRA►UMAIRESUSCITATION FLOW SHEET 3 - CD Date' time Stat Page Time Pt r erg' . _ Response•level",(I 2 CD Ambulance (. ,Helicopter: Interhospitai Y N Age, "' Sex Weight Q o Chart o Labs o XR - o CT : p p 10 �. el 4 N f T1 C.7 11� E 13P �{c( (rs Coss of Consciousn L Yes . No t nknown #minutes 01 HR Monitor Rhythm Immobilization: •Co CI ong Boa Splint CD RR Assistive Device Entrapped: Yes o Unknown #minutes Spontaneous Rate/Pattem Self Extricated: Yes No +� S 02 PMH: GCS CD . Meds: oo Patent CFI . IV. S'te Ga a SoPn Amt ray No #1 O O Allergies: #2 • 0 #3 O O Tetanus: :._.. PRIMARY SURVEY �B'y,.,<Dc:' �: �s�',§�c'&V.z �.t 1 � :�•'.. rs�z ���a•, .s' Airway Intervention Bracelet Location: �j Patient Maintained• o Mechanically maintained by 610 -Oxygen mask lhnln or 56 ID: Breathing` •• 00 Airway&bag - 05pontaneous ratejpattern 00 Err- sizefon - 81ood sand: O Not breathing assistive device Gao3don SaO2 . • intvbater/by - R#: R74605 ras Na 00 Surgical airway done by -0'•0.�.preath**sggnds•,R:;`•t••::.-;.. :;•., •i a':+'_'- Documenting Nurse: O,yO TdchyPneat' :: ,, 7.i;.• Vent Settings e� O O.;IriterCO5ta1 retractions Time Support Nurse: 1 ' o O Chest wall bruising Rate Circul ion F132 - Physician Signature: HR in.(on arrival) Rhythm Tidal Vol. SBP•' _/mmHg(on arrival) PEEP �,•.�n'-'. Pulses R t all WIN Yes No - - • 'I"No 2Q� O Radial 00 Chest tube •' / tri o Femoral size: right ( Initial temp. O 0 DP left . 0 0 Pr O 0 other intervention(State)- '•- tom.r7t/r Patient covered � O O Hemarrhagei ras Na Warm blankets YeJ•NO 00 IV une - Yes Np 0 0 Ertemaf scat sze_g Patent'? O o Overhead warmer q.'C?:;7ntetnal.•.:^::: sRe 2—size' .._g Patent? O O . f)Ctttst site she_ _g Patent? o .o IV Fluids warmed to 104°F O Abdomen 00 Arterial line site o Peivs)retmperlmrteai Repezittiernp.at 30 mans. O Umbs MTP rime Inidated.• 5kin . Pink .mil Warm Pale •Hot Cyanotic. Cool ' Mottled .Cold _ •• ,, . . . - ., Dry Moist . . • 0 M • • • Eye ntanawz • l L4gGOw S 4 • e .. Ime rme O{xdtng To roo§x '3 3 COMA 9-12 i service failed Arrived _ Respcnw T.gin 2 SCALE(GM) 6-8 2 2 Trauma Attending - N-e 1 ITatal Pom[s 9•s 1 1 Ortho - W Orton Ram above) ED Attending ' verbal 1 Ic >89mm H 9 4 Neuresurg� - RasDa�se nappmpnate 3 stood Jrs89mm Anesthesia Attending / f�`J' Inmmprehen9Cte soumis 2 2 Preswre 50-ismmH 2 2 �� Plastics None 1 1 •1•A9mm 1 1 Senior Trauma Resident Best D mmmand No Puke B Other Molar. ices Pam S Baler 101 mm. 4 - Response m pa ) Rate > s m. Other- n path 6-9 mtn. 2 Pam 1• min. No moter rasr+atsa 1 None 0 0 MR 15: =� 7n Au II�1�I�III¢II1IIdI�IlIIII9III�liIlIIIIIII[!I ED TRAUMA/RESUSCITATION FLOW SHEe'r F-DEC-1 0 2012 CD Odead Yes No rxszrpaorr' X-ray n Scalp .0 O Laceration O O Vault Fracture t y�^' ("_ t Tlme Time CT (D Face O O Basal Future Suspected :. :,2_••O•Q F�tacture ... ,•: est 9 r O O Jaw Instobility ( l�•� P��- Pelvis Chest Eyes' '0 O Injtuy _ Other Abdomen/pelvis ' O O Deaeased Vision f0 .(JYt,4.i1 h/n Other �n � Fars O Ci Hemotympanum Side: ` t Other Other N O O CSF leak Side: Other Now O O Bleeding �. Mouth O O Tooth# . - eue+oVascu of meet W IV Yes No De-YAdon: eC Areas of Concern: O 10 C-spine tenderness O 0 Stepof.I crepltus O O laceration" ����J�u'•• 'u C O O C-collar off time Pulse Assessed: -� O O Rehab collar time Time Temp. Color Capillary Refill Sensation Movement Pull Chest: .Yes No 0IN&Ptlmr: O AD Chest wall Injury Side: N 0 O O s ribs 0 O O F7att segma»t 00 O O Open pneumothorax t) O O Pneumothorax R/L O O Hemothorax R/L �. Abdomen Yes Ne Desntpdon: LJ� ' O O Sidnconbaton/abrasion J `�-- O t�.Dlstenslon j�� O O Tenderness Injury Diagram : O O Guarding Fast: 4!Injury Clia 3 n K 4jY { 'by., . YSV i N•- Rectal hame: + 1- Open Fracture E = Ecchymosis Done by time 2. Amputation A = Abrasion NtG(oral/nasal) 3= GSW C 'a Contusion Size Fr' 4- Deformity L = Laceration Inserted by time —5. Stab Wound S = Swelling Peritoneallavage/DPA: ..6= Sum• T '= Tenderness Done by 'time 7= Pain PW= Puncture Wound Return: O Clear S a Rash I = impaled Object O Pink' O Gross blood M1� Amount infused cc, Vj ` Amounrietumed cc Fluid to lab: O Yo s+ O No GenitOUrinaly 0.scriP#on: Foley: O Yes P No O Heme+Size Fr ° ° . Inserted by time Rectal Tone: O.Good t O Deceased O Absent Prostate: O Normal r� O Abnormal Blood observed at: Yes No Vagina O O Reaurn O 0 Urethral meatus O O Extremities 5 Ps paralysis Parasthema Pulses Pain Pallor . Yes O. Yes O Yes f$• Yes O Yes O RA No (0, No BD No le No 10 No & Yes O Yes O Yes 0 yes O Yes O LA No 9 No a No O No 4b No Q Yes O Yes O Yes(Q Yes O Yes O S.,_ IRL' - No A No No O No 9D No 1) Yet"O Yes O Yes O Yes 0, Yes O LL No Na O No 4 No da No Eastern Auto DEC-1 0 2012 ED TFRAUMA/RESUSCITATION!FLOW SHEET MR isr- i1 • i a / I i Trauma.,Resuscitation.Fldvi►Sheet • N � urs ro in Interventns IVLJ?j NA INN WA 110010111101101 MOM = I.MW R, 111011115011130 ONE ON WOM Una I—AMMOM 101 [M.. ON MM1rVV MINE Muslim INS! mmmm X111 10 INN 0 • 1110 1110100110110 MEN OMENS =====MEMO Now No MMMMMEEMM Is mmm®m MM11M1I§MMM1 011 M11100 mm mooloommmo - 0111110111101 ONE 1011 mm mmmomossisomm INN mm ��■■ 1011 moiammom i�MM 11100011111 0 iINN 0 N.orkriaGR'a I+�s'forVital.'Signs: Piupil;5ize als no `�i .i •t,.i I t I 100f70 120-160 Toddlers 20-40 Toddlers 80/50 :• - 1 1 1 S0_110 • 0 1 . 1 {{ - - I * : r i Cry$taNbiii p_;P `: :,...... , .. „ „�.: .. : . .�..; :. •: •.._�•� Is ositio at Dis' MERITTIMA In HMC safe Given to family Name: Given to police Name- 0 Floor 0 Expired 0 Other Time: ■�----�-� Or an Tissue Doriatiob • J TOTAL t • s rAw ram MOO L U1 ,ffm n PENNSTATE HERSHEY IIIIIIIII{Illlfllllllllllllllll{IfIIIIIIINIf NAME: RICE SYDNEY CQ MRii: 75129 8 OOS#:'10512936` I? PM ton S. Hershey MD: DEFLITCH CHRISTO MD",: 46325 - A }� DOB: 04/05/2003 VISIT DATE: 11/12/2012 (� Centerr IOC: EMER SEX: F ;, . i Q '. � .�. ;. •. ••. ..: `- ''.,'c:� .'. .'.:,•• .:,';;•,. ". . .�•::� INS•IHII11111111it �•'�'SEL'•F' !'". ..,; SELFP,fi.Yz;'"... , ... . .r y L. PATIENT BELONGINGSIVALUABLES RECORD m can Penn State Hershey Medical Center is not responsible for personal items brought to the hospital. O A safe is available for valuables such as cash, important documents, credit cards and jewelry that I� cannot be sent home.All personal items retained at the bedside are the sole responsibility of the C patient, including but not limited to such things as money,dentures eye glasses and hearing aides. LnP ' N ' Name: Date: W I Unit: " Disposition o 'Home Or.'.Othe • •C_ut,..: ; Cn belongings Descript'on'i ;�; � � ` ':N/A .-w/Famil With P 'tient Throw awa ; c. .CasFiier 0 Clothing I� Glasses/Contacts O Hearin Aid Right / Left (circle) W Dentures Upper, Lower, P rtial (circle) Keys 'Yes or(C ircle) Other r > '•yvi� a{xq{�s.�Kt }gk"'a•5 J�HOmeor' ; Oilier:t�i.Ut�'li°..'4.:.•l.i :.. Valuables Desciiption;:'": :;N! , wiFamil Mith Patierit Tl*,o,.*:awa',Etc: 'CasFiidr Rings Earrin s Watch V. Necklace Bracelet' Money Wallet/Purse Other-(credit card, etc.) Completed by:',-,, Patient/Witness: Received by: Relationship to Patient: 'Released to: Receiving area in Hospital: viii# Released by: Agency: TO.BE FILLED OUT WHEN VALUABLES ARE BEING SENT TO CASHIER This facility cannot assume responsibility for items retained in your possession.Patient understands that by signing below,he/she is aware of this policy and verifies that the items listed above as inventory sent to the cashier are correct and that the envelope has been sealed in his/her presence. signature of patient/witness date DEPOSITS WITHDRAWALS Date. . Received by _,Hospital Repfe'sentabye Ba stern Person Transporting Valuables to Cashier Rdceived by PatienWamily/Other DEC' 0 2012 _ {;... Received by Cashier Date Drivers License Number `%•::•.:r '• - MF%884 Rev.6108 PATIENT BELONGINGS/VALUABLES RECORD pnkCop Bs ngirigs,Bajg Gold:File IAlilll 1888 II 811181 18{81(till Ill!!III - • i + r _� PENIVSTATE HERSHEY + 1111 111111111III III lllltlli!!I(ililllfllll NAME: RICE, SYDNEY RR, 7512938 00S-; 10512938 Milton S.Hershey', MD: DEFLITCH CHRISTO MDA: 46325 �3 Medical Center DOB: 04/05/2003 VISIT•DATE:•11/12/2012 O L7OC;:.EMER. SEX:.F III 1 LF PA "SELF PAY 0 tRAUMAANESTHESIA CONSULT (IIII�III1111111, CD Date _"A[ei ht" I(d N Time - Weight L 1,V Consulted by Emergency Department Dr. ❑ Age Sez. 10 History Physical Exam Assessment&Plan .. 41. C General Appearance Assessment: . N U1 �C Belted / Unbelted Vital Si n : ASA PS E L O Fall BP Pulse -�2� Injuries �'`� S OZ Temp I� O •I1tICC� Glasgow oma Scale= D' Other g BPI:. Neu o: . Airway: :. . : " O Tibie of Incident: : :.❑ i. ct. ..,• Adequate •:;` ;• ::;:,InjiYiSes" i'• ;iK-Cervical Collar in place ❑ Marginal Level of Pain(i-10) ❑ ❑ Difficult Mechanism of injury:_ p O Lbcation: l.w Ventilation: 0 HEENT: Adequate spontaneous 0 Function impairment: ❑ Needs Mechanical Vent Loss of consc_iousness due to: Teeth Circulation:., PM Hx: Airway:Malampati Score 4.-t,�'11.� ' � -4 Minimal`Blood L;os§ a 'History;obtained from EMS Pupils: ' p C ❑ Shock Grade 1 2 3 4 ❑ Allergie& Size R L _l 1 <750mL,15%volume React R -�G •L�,�� 2 = 750-1500mL,15-300/a volume ❑ `Drugs. 3 = 1500-2000mL,3040%volume g Che 4 ="2000-2500mL;40-50%volume Clear to auscultation Trachea midline ❑' Labored breathing A�i�/ne hetic Plan: :❑ :Medical. ❑ Discussed care with trauma team ❑ leader . . Rea : ❑ Reviewed'x-rays p Surgical1/1 �/ egular rate&rhythm ❑ Reviewed laboratory results • ❑: Murmur,... . •ROS-.� . ❑.' Pulses r_ ❑ :Meets criteria for immediate fidl Y/ Diabetes ❑ Induction-&•Intubation Y:/. Chest Pain/Chest Pressure Q 13 . Accompany to CT Scan. Y/N 'Short of b iratory Distress domen: ❑ 'Accompany to'OR •Y N :Dizziness:... .. O Benign ❑ Analgesia/Sedation Y- N Nausea/Vomiting Tender ❑ Monitoring . Y•/N I)ysuria ❑ Bowel sounds Y./ :.Deformity. d;• ❑ •Other Other ❑ ❑All•other'systems reviewed-negative E emities: No further intervention SHa� No apparent fx , Y/N Tobacco. p Y/N .EtOH YIN. Drugs C/ "GU: Family His ory: '/! ❑ ,Foley ❑ No ontiibuting ❑ CU 3 .,99241*,99242.951243:x9924Y!?,. SaW and evafUated.the patient and agree Attending Signature: s -t'ti�'�-�✓� #_ ww with the resident s.plan,as.written. Date: Time: 0 I.paersonally performed the evaluation. Resident/CRNA Signature:: # Date' Tune' MR 1153'Rev:9/09 Page'i of 1 " 712r?►UMAANESTHESIAC SU T 1111111111111111 Il11tl III 1111111111111111 EN Tern rn A U t® Green Copy-Medical ' DEC"10 2012' I� Consult RICE', SYDNEY D - 7512938 Final Report" O : . . . : . o' *Final Report 0 N CONSUL'T'' Name: RGCE; SYDNEY D*: 0 HMC Niiirlber: 751.29.38;, Cn DOB: 04/05/2003 C) Date of Service: 11/12/2012 -0 I� REASON FOR CONSULTATION: Facial lacerations. rn HISTORY OF PRESENT ILLNESS: Sydney is a 9-year-old girl who was a restrained backseat passenger involved in a motor vehicle accident. She was seen as level 2 trauma activation where she was found to have repetitive speech, questionable change in mental status both in the field and on trauma evaluation; therefore, she::. underwent CT scan of the head and facial bones. She has extensive soft tissue injury involving the left side of her forehead and in both the hair-bearing and forehead skin as well as left cheek up to the commissure of her mouth. For this reason, plastic surgery was consulted. The patient is in distress and has repetitive questioning. Her father is at her side and consoling her. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. MEDICATIONS: None. ALLERGIES: No known drug allergies. REVIEW.OF SYSTEMS:- As per HPI, otherwise negative. PHYSICAL EXAMINATION: Afebrile,vital signs stable. General: Repetitive questioning; alert and following commands: GCS 14. HEENT: Significant facial lacerations both.partial-thickness and full-thickness involving the hair-bearing scalp on the Jeft side, the frontal region as well as the forehead skin. There is a crush component as well. Additionally, there are areas of partial-thickness skin loss. She is able to animate on that side suggesting the frontal branch is.intact. She also has a significant full-thickness skin_ and muscle laceration from the left cheek to the left-sided commissure but riot through and thr6dgh the mucosa. There are no intraorbi'lacerations,,no loose teeth and'6e occlusion is_appropriate. Otherwise, on'examination, her cranial'nerves were grossly.intact..Pupils were equal, round and reactive. There was no septal herpatoma. Extraocular movements intact. Her C=collar Printed by: Hitz, Brenda K Page 1 of 3 Printed on:. 11/26/2012 06:59 (Continued) Eastern Auto DEC- 10 2012 C7 I� Consult RICE, SYDNEY D -_7512938 m (a ",Final Repot n 0 (D p' was in place immobilizing her C-spine. Io PERTINENT LAB AND X-RAY: Craniofacial CT scan did not demonstrate any bony abnormality. .p Cn ASSESSMENT AND PLAN: This is a 97year-old girl involved in a motor vehicle accident with significant facial W lacerations. Io ,p Under local anesthesia at the bedside, I repaired the facial lacerations with absorbable sutures;first using 5-0 o Monocryl suture in deep dermal interrupted fashion followed by 6-0 chromic and 5-0 plain gut suture to 0 reapproximate the skin edges. The patient tolerated the procedure well. The'operative sites were cleaned and :z dried and Bacitracin was applied. We will follow up the patient in approximately 1 week to ensure appropriate I� healing and absence of infection. She should be placed on antibiotics for approximately 1 week and we have p suggested amoxicillin to-the trauma team. Dad was present during the procedure and was educated with respect 00 to the areas of partial-thickness skin loss, that they may result in hyper-or hypopigmentation with respect to the rn adjacent skin. Dr. Potochny is in agreement with the assessment-and plan. Consultation C ding Selection in Brief Intermediate Extensive Comprehensive Diagnosis 99251 199252 99253 99254 99255 X #461082 I personally evaluated this patient on rounds with the Plastic Surgery House Staff. I evaluated her wounds and discussed recommendations for care and follow-up with her father. I agree with the above transcribed note by Dr. Michellotti.' John•Potochny, M.D.,teaching attending, Plastic Surgery Signature Line Electronic Signature on File Electronically Reviewed/Signed by: Brett F Michelotti; MD "Author-Signature Dt/Tm:11/14/2012 06:03 AM 'Electronically Reviewed/S�igned by: John D Potochny, MDCosigner Signature DtITm: 11/1412012 04:40 PM Printed by: Hitz, Brenda K Page 2 of 3 Printed on: 11/26/2012 06:59 (Continued) Eastern Auto DEC-10 2012 I C7 . ' RICE; SYDNEY` D - 7512938 Final Report Zr 0 m 0' BFM/SAT DD: 11/12/12 DT: 11/12/1222:57 Ip Result Type: ..Consult N' Date of Service: November 12, 2012 00:00 N Authorization Status: Final Subject: Consult Author or Import Date: Michelotti, Brett F on November 12,2012 22:26 Verified-By: Potochny; John D on November 14, 2012 16:40 o Encounter info: 10512938, HMC, Inpatient, 11/12/2012- 11/13/2012 -0 Contributor system: ESCRIPTION01 I� 0 Co rn Printed by: Hitz, Brenda K Page 3 of 3 Printed on: 11/26/2012 06:59 (End of Report) Eastern Auto DEC- 10'202 l� Chest XR RICE, SYDNEY D - 7512938 CD cCD *Final Report s ; I 0 3 CD o' * Final Report .F, X-RAY CHEST PA OR AP VIEW-PEDS cn PATIENT NAME: RICE, SYDNEY D W PATIENT MRN:07512938 PATIENT DOB: 04/05/2003 EXAM DATE OF SERVICE: 11/12/2012 o EXAM NUMBER: 7859477 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER i� a oa 6} EXAMINATION: X-RAY CHEST PA OR AP VIEW-PEDS/EMT =. ` CLINICAL,HISTORY: Trauma. COMPARISON: None FINDINGS: CHEST:-Cardiomediastinal silhouette and pulmonary vasculature are normal.No focal consolidation, pleural effusion,or pneumbthorax. Bones and soft tissues are normal. SPINE: The cervical`spine is visualized from the craniocervical junction to TI J2.Vertebral body heights and disc spaces are maintained:Alignment is normal with loss of normal cervical lordosis. Prevertebral'soft tissues are normal. Visualized calvaria and mandible are normal. IMPRESSION: Norrrial•-examiriations of the chest and cervical spine. Printed,by:.: :Hiitz,'Brenda K Page 1 of 2 Printed on: 11/2612012 06:59 (Continued) Eastern Auto : .' : DEC' 10 2012 C7 . I� Chest XR RICE, SYDNEY D - 7512938 Final Report* I0 O N 5• Dr:-Dejan Samardzic is the dictating resident. Finalized report status indicates the signing attending-has'! reviewed the images and report, and agrees with the interpretation.Preliminary report status should be °A regarded as NOT interpreted by the attending radiologist. N I Imo, DICTATED: BOAL,DANIELLE I 0 REVIEWED AND SIGNED: BOAL, DANIELLE U, DATE DRAFTED: 11/12/2012 08:54 PM °� DATE OF FINAL SIGNATURE: 11/12/2012 08:56 PM I� Result Type: Chest XR C) Date of Service: November 12, 2012 18:58 rn Authorization Status: Final Subject: X-RAY CHEST PA OR AP VIEW-PEDS Author or Import Date: Boal, Danielle K on November 12, 2012 20:54 Encounter info: 10512938, HMC, Inpatient, 11/12/.2012- 11/13/2012 Contributor system: IDX01 Printed by: Hitz, Brenda K Page 2 of 2 Printed on: 11/26/2012 06:59 (End of Report) Eastern AUt®. DEC- 10 2012 C7 . C-spine XR RICE, SYDNEY D - 7512938 i cD *Final Report 3 n 0 m v, - s' * Fine! Report* X-RAY SPINE 1 VIEW- CERIVICAL PEDS 0, PATIENT NAME: RICE, SYDNEY D (+ w PATIENT MRN:07512938 io PATIENT DOB: 04/05/2003 gyp, EXAM DATE OF SERVICE: 11/12/2012 EXAM NUMBER: 7859478 ORDERING PHYSICIAN: DEFLITCH,CHRISTOPHER a Co 0? EXAMINATION: X-RAY CHEST PA OR AP VIEW-PEDS/EMT CLINICAL HISTORY: Trauma. COMPARISON: None FINDINGS: CHEST:-Ca diomediastinal silhouette and puliiionary vasculature are normal.No focal consolidation, pleural'effusion, or pneumothorax. Bones and soft tissues are normal. SPINE: The cervical spine is visualized from the craniocervical junction to T1-T2. Vertebral body heights and•disc'spaces are maintained.Alignment is normal with loss of normal cervical lordosis. Prevertebral soft tissues are normal. Visualized calvaria and mandible are normal. IMPRESSION: Norwal'examinations of the chest and cervical spine. Printed by'-: ....Hitz, Brenda K Page 1 of 2 Printed on: 11•!26/2012 06:59 (Continued) Eastern Auto DEC- 10 2012 C7 I l � C-spine�XR RICE, SYDNEY D - 7512938 im T) *Final Report.* � I 0 0 CD cn o' Dr. Dejan Samardzic is the dictating resident. Finalized report status indicates the signing attending has t Io reviewed the iniagesand report, and agrees with the interpretation. Preliminary report status should:be N regarded as NOT interpreted by the attending radiologist. cn DICTATED: BOAL, DANIELLE Imo, REVIEWED AND SIGNED: BOAL,DANIELLE DATE DRAFTED: 11/12/2012 08:54 PM CD DATE OF FINAL SIGNATURE: 11/12/2012 08:56 PM Result Type: C-spine XR O Date of Service: November 12, 201218:58 Co rn Authorization Status: Final Subject: X-RAY SPINE 1 VIEW CERIVICAL PEDS Author or Import Date: Boal, Danielle K on November 12, 2012 20:54 Encounter info: 10512938, HMC, Inpatient, 11/12/2012- 11/13/2012 Contributor system: IDX01 Printed by: Hitz, Brenda K a Page 2 of 2 Printed on: 11/26/2012 06:59 �St�,�'CS Auto (End of Report) � , 9EG� ® 201 i t i ` Abd CT RICE, SYDNEY D - 7512938 CD Final Report I 0 0 3 CD o' * Finaf Report CT ABDOMEN AND PELVIS WITH CONTRAST-PED PATIENT NAME: RICE, SYDNEY D PATIENT MRN:0751293 8 is PATIENT DOB: 04/05/2003 Ul EXAM DATE OF SERVICE: 11/12/2012 ° EXAM NUMBER: 7859483 � ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER i� a ao Q' EXAMINATION: CT Abdomen and Pelvis CLINICAL.HISTORY: 9-year-old female status'post motor vehicle collision with head injury. COMPARISON: None. TECHN1'QUE: ,. c ,Contrdst-enhanced CT of the abdomen and pelvis after 100 mL Omnipaque 300. FINDINGS: Abdonien Liver,O'allbladder &'bile ducts: Liver is normal. Intrahepatic bile ducts are nondilated. Gallbladder and-exfralh6patic bile ducts are normal. Pancreas:Normal Spleen: Round 4 mm hypodensity in the spleen is too small to characterize.No traumatic injuries to the spleen Adrentals: Normal. Printed by: Hitz, Brenda K Pagel of 3 Printed op: 11/26/2012 06:59 (Continued) Eastern AUtO ..:DEG-10 2012 C7 IW Abd CT RICE, SYDNEY,D - 7512938 cam, *Final Repo.rt. n 0 c CD o Kidneys, collecting system and ureters 'Normal. io Retroperitoneum,lymph nodes, and vessels:Normal Bowel& Mesentery: Bowel is nonobstructed. Moderate stool load is noted. The appendix is normal, I Cn visualized on axial image 92/130. W Io Pelvis Bladder: Normal for degree of distention. 00 Uterus: The uterus is not well visualized.No adnexal mass. Z Ovaries & adnexa: No adnexal mass 4-1. Extraperitoneal, lymph nodes,vessels:No ertra-peritoneal lymphadenopathy. No free fluid . °') Osseous and body wall:There are no fractures. Lodver crest: Trace dependent atelectasis.Small amount of subsegmentai atelectasis=in the visualized portion of the right middle lobe.No free air or pleural fluid .IMPRESSION: No acute abnormality in the abdomen or pelvis. Dr.Bradford discussed ihe'findings with Dr. Rocourt at the time of imaging. Dr. Ray Bradford'is the dictating resident. Finalized report status indicates the signing attending has reviewed the images and report, and agrees with-the interpretation. Preliminary report 9tatusshould be regarded as NOT interpreted by the attending radiologist. DICTATED::.BOAL,DANIELLE - REVIEWED AND SIGNED:'BOAL;DANIELLE DATE-DRAFTED:'11/12/2012 07:31 PM DATE OF-FINAL;SIGN.A TURE:-1.1/f 2/2012'09:09 PM ' =' Result•Typ'e: .� :Abd CT Date of Service: -Novernber, 12, 2012.19.:18 .; Authorization Status:. Final Printed by: Hitz, Brenda K Page 2 of 3 i Printed-on: 11/26'/2012'b6:69` (Continued) Eastern Auto" : . DEC' 10 2012 Abd 'C RICE, SYDNEY D - 7512938 c(D. "".Final Report 0 (D Subject: CT ABDOMEN AND PELVIS WITH CONTRAST-PED I� Author or Import Date: Boal, Danielle K.on November 12, 201219:31 0 Encounter info:• 10512938, HMC, Inpatient, 11/12/2012- 11/13/2012 N Contributor system: IDX01 w I 0 cn . 0 I� 0 00 rn Printed by: Hitz, Brenda K Page 3-of 3 Printed on: 11/26/2012 06:59 (End of Report) Eastern Auto DEG 10 2012 r I� Head CT RICE, SYDNEY D - 7512938 3 I n CD CT HEAD WITHOUT CONTRAST PED I o• PATIENT NAME: RICE, SYDNEY D I-1 PATIENT MRN:07512938 0 PATIENT DOB: 04/05/2003 _P-1 EXAM DATE OF SERVICE: 11/12/2012 EXAM NUMBER: 7859485 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER 0 0 EXAMINATION: I� CT HEAD AND FACIAL BONES WITHOUT CONTRAST PED/CTRAUMA 0 co rn CLINICAL HISTORY: trauma COMPARISON: None TECHNIQUE: Routine tomographic images of the brain are obtained from the skull base to the vertex without intravenous contiast. FINDINGS: Head: There is no acute hemorrhage or mass effect. The gray-white differentiation is maintained.Brain volume is normal for age. There are no extra-axial collections. The ventricles are normal in size. Cerebral'tonsils are in normal position. Soft tissue defect and edema are seen along the left frontal bone with some small hyperdensities in the skin.No calvarial fracture is noted. There is mucosal thickening in the ethmoid and maxillary sinuses. Face: There is a dense opacity in the superficial soft tissues of the left cheek with overlying defects in Printed by -Ritz, Brenda K Page 1 of 2 Printed on: 11/26/2012 06:59 (Continued) Eastern Auto DEC- 10 2012 Head CT RICE, SYDNEY D - 7512938 CD 3 ' O • c the soft tissue. There is no acute facial bone fracture. m 0 The right maxill smus.is fluid-filled there is layering fluid in the left maxillary.sinus. Small amount I:3 of fluid.in several•of the ethmoid sinuses. Frontal sinuses are clear. 0 tv IMPRESSION: lC)) I.No acute intracranial injury. a 2.No acute facial fractures. I� 3.Left frontal sea 1p laceration/hematoma with a few small hyperdensities likely foreign o body/debris. 00 a' 4.Radiodens e foreign body in the soft tissues of the left cheek,please correlate with physical-exam. Dr.Ray Bradford is the dictating resident.Finalized report status indicates the signing attending-has reviewed the images and report, and agrees with the interpretation.Preliminary report status should be regarded as NOT interpreted by the attending radiologist. DICTATED: OUYANG, TAO.- . REVIEWED AND SIGNED: OUYANG,TAO DATE DRAFTED: 11/12/2012 08:23 PM.. DATE OF.FTNAL SIGNATURE: 11/12/201.2 08:23 PM Result Type: Head CT Date-of Service; November 12, 201219:20 Authorization Status: Final Subject: CT HEAD WITHOUT CONTRAST PED Author or Import Date: Ouyang, Tao on November 12, 2012 20:23 Encounter.info:• 10512938, HIVIC, Inpatient, 11/12/2012-11/13/2012 Contributor system: 10X01 Printed'by.- Hitz, Brenda K Page 2 of 2 Printed on:' 11/26/2,012 06:59 (End of Report) pastern Auto . . . • DEC �. � 2012 • 0 iZ X Face CT RICE, SYDNEY D - 7512938 m ' " Final Report ' I 0 m o' * Final Report 10 CT FACIAL BONES WITHOUT CONTRAST-PED PATIENT NAME: RICE, SYDNEY D PATIENT MRN:07512938 10 PATIENT DOB: 04/05/2403 4�1 EXAM DATE OF SERVICE: 11/12/2012 EXAM NUMBER: 7859486 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER l� o , co EXAMINATION: CT HEAD AND FACIAL BONES WITHOUT CONTRAST PED/CTRAUMAt CLINICAL HISTORY: trauma COMPARISON: None TECHNIQUE: Routine tomographic images of the brain are obtained from the skull base to the vertex without intravenous contrast. FINDINGS: Head: There is no acute hemorrhage or mass effect. The gray-white differentiation is maintained.Brain volume is normal for age.There are no extra-axial collections.The ventricles are normal in size. Cerebral tonsils are in normal position. Printed by: Hitz, Brenda K Page 1 of 3 Printed on: 11/26/2012 06:59 (Continued) Eastern AlUtC DEC` n I� Face CT RICE; SYDNEY D - 7512938 (B, *Final Report' C7 O cn o' Soft.tissue defect and.edema are seen along the left frontal bone with some small hyperdensities in the l� skin.-No calvarial fracture is noted. There is mucosal thickening in the ethmoid and maxillary sinuses. 0 Face: There is a dense opacity in the superficial soft tissues of the left cheek with overlying defects in w the soft tissue.There is no acute facial bone fracture. Io The right maxillary sinus is fluid-filled,there is layering fluid in the left maxillary sinus.,Small amount CD of fluid in several of the ethmoid sinuses. Frontal sinuses are clear. Z l4:11 00 IMPRESSION: rn 1.No acute intracranial injury. 2.No acute facial fractures. 3.Left frontal sea 1p laceration/hematoma with a few small hyperdensities likely foreign body/debris. 4.Radiodens e foreign body in the soft tissues of the left cheek,please correlate with physical exam. Dr. Ray Bradford is the dictating resident. Finalized report status indicates the signing attending has ,reviewed-the images and,report,.and agrees-with the interpretation. Preliminary report status should he regarded as NOT interpreted by the attending radiologist. •DICTATED: OUYANG,TAO REVIEWED AND SIGNED: OUYANG, TAO DATE DRAFTED:,11/12/2012 08:23 PM DATE OF FINAL SIGNATURE: 11/12/2012 08:23 PM Result Type: Face CT Date of Service: November 12, 2012 19:20 Authorization Status: Final . Subject: CT FACIAL BONES WITHOUT CONTRAST-PED Author or Import Date: Ouyang, Tao on November 12, 2012 20:23 Encounter info: 1.0512938, HMC, Inpatient,11/12/2012- 11/1312012 Printed by: Hitz, Brenda K Page 2 of 3 Printed on' - .11/26/2012 06:59 (Continued) nte Eastern A . .• . . . � . • DEC' 102012 Face,CT RICE., SYDNEY D -7512938 �p *Final Report CD cn p Contributor system: IDX01 N W 0 cn 0 0 00 rn Printed by: Hitz, Brenda K Page 3 of 3 Printed on: 11/26/2012 06:59 (End of Report) Eastern Auto DEC. 10 2012 Ped Surgery Inpt Progress Note RICE, SYDNEY D - 7512938 m • Final Report 3 n 0 CD 0' ; ,. * Final Report to Document Contains Addenda • N U1 ' W ' 10 PEDIATRIC SURGERY INPATIENT PROGRESS NOTE 0 Name: RICE, SYDNEY D l� Patient Number: 7512938 DOB: 04/05/2003 - 0oo Date of Service: 11/13/12 rn Hospital Day: 0 Surgical Hospital Day/Procedure: No procedures found No diagnoses found' 24 HOUR EVENTS:Admitted overnight as a Trauma, s/p MVC SUBJECTIVE:Pt seen and examined by the Pediatric Surgery team. Currently, resting in bed without distress. Active Inpt Meds: amoxicillin 250 mg PO tid Active PRN Meds: morphine 1.5 mg IV q2h One Time Meds: (Completed) ceFAZolin 1,000 mg w/IV ONCE(Ordered) influenza virus•vaccine 0.5 mL w%IM ONCE :°�: . •. ` Active IV Meds: Dextrose 5%with 0.9% NaCl 1,000 mL+ potassium chloride 20 mEq (D5-0.9% NaCl 1,000 mL+potassium chloride 20 mEq) 1,000 mL 70 mL/HR OBJECTIVE:_... Vitals Temp Pulse BP 'RR Sp02 F102 Date Wt(kg) Wt(lb) 11413 04:54.36.6 96 87/48 24 97 11/13 31.7 70 Printed by: Hitz, Brenda K Page 1 of 5 Printed on:- 11/26/2012'06:59 (Continued) Eastern AutO r DEC 0 2D12 Ped Surgery Inpt Progress Note RICE, SYDNEY D - 7512938 CD *-Final Report C7 O CD to ' O' 11/13 02:15 36.8.:.. 84, 82/41 20 97 --- II 11/13 31.7 70 l:3 1:1/12 22:52 ---- 108 ---- 20 98 --- (I 11/12 31.7 70 O 11/12 21:24 --- --- ---- 18 --- --- 11 11/12 31.7 70 N 11/12 20:51 37 97 125/87 20 98 --- Cn 24 Hr Tmax: 37 at 11/12 20:51 W Initial Wt: 11/12 kg 70 lb o O IN'S&OUT'S Z Input and Output-Last 24 hours(Last 8 hours) 0 ' Total In: 220(220) Total Out: 0(0) Total Balance: 220(220) rn D5-0.9% NaCl 1,000 mL+ potassium. chloride 20 mEq: 210 (210) Med Intake: 10 10 Urine Count 1(1) Input PO/NGT/GT Feeds TPN : — Output Vrine-0utput(ml/kg/hr) :x 1 NGT/G7 Output:— Drain:Output:_ BM : I Physical'Exam: " General :NAD HEENT:stitches on left frontal, dry blood Heart:RRR Chest:'STAB " Abdomen.:soft, NT, ND Extremity':sensation intact Skin : Most Recent Lab Results over the last 24 Hours: i Printed by: Hitz, Brenda K Page 2 of 5 Printed"on: 11/26/2012 06:59 (Continued) pastern AUt® . �. C7 Ped-:'Surgery Inpt Progress Note RICE, SYDNEY.D - 7512938 CD Final Report 113 ki O 7 (D O I� No Latest CBC or BMP Found. ALT =41 on 11/12/201218:55 IW Amylase =97 on 11/12/201218:55 o Lipase =281 on 11/12/2012 18:55 4h. 'PT = 15.6 on 11/12/201218:55 Cn 0 PTT =32 on 11112/201218:55 'D INR =1.25 on 11/12/2012 18:55 l p No Blood Gas Information Found. o ' I rn Studies: Pending or Completed in the Last 24 Hours Chest XR Completed' C=Spine XR Completed Abdomen/Pelvis CT(Diaphragm to Symphysis.Pubis). Completed 'Brain CT. Completed Facial Bones CT Completed ASSESSMENT:9 y/o female, s/p MVC with facial lacerations PLAN: 1 )Day 2/7 of amoxicillin 2)Local wound care 3 )Possible D/C Disposition:Floor Signature Line Electronic Signature on File Electronically Reviewed/Signed by: Dorothy V Rocourt, MD Author Signature Dt/Tm:11/13/2012 08:11 AM Pediatric-Surgery: Drs,. Robert Cilley, Peter Dillon,.Brett Engbrecht, Kerry.Fagelman, Dorothy Rocourt, Mary Santos Printed by: Hitz, Brenda K Page 3 of 5 Printed'on`..:: 11/26/20.12.06:59 (Continued) I j Eastern Aut® j DEG- 10 2012 C7 Ped Surgery Inpt Progress Note RICE, SYDNEY D - 7512938 * Final Report n o m W. Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP, PNP-BC, I� Lynn'Simmons MSN CRNP` o . N Electronically Reviewed/Signed by: Thu N Pham, MDCosigner Signature Dt/Tm: 11/1312012 06:53 AM tr IW DVR DD: 11/13/12 0 CD Addendum by Rocourt,Dorothy V on November 13, 2012 08:25(Verified) -0 Pediatric Surgery Staff Addendum: ;z Patient seen and examined with the surgical team. I have reviewed the resident's note and agree with the I physical exam and plan of care with the following additions:doing well this morning. Concussive symptoms 0 improved, no repetitive speach. Lacerations repaired by plastics,will continue on antibiotics as an outpatient. oD Advance diet as tolerated. Discharge home today. The questions and concerns of the father were addressed and rn he was updated with the plan of care. Subsequent Care Coding Selection Low Moderate High 99231 99232 99233 Diagnosis i X Critical Car e.Coding Selection' j Critical Care Diagnosis Total time of Critical Care: I i Dischar a Codin Selection 30 Minutes or Less More than 30 Minutes 99238 '99239 Diagnosis No Charge t Qp , • .. . • Signature Line Printed by: Hitz, Brenda K Page 4 of 5 Printed on: 11/26/2012 06:59 (Continued) Ped.'Su.rgery..• 1•n-pt Progress Note RICE, SYDNEY.D - 7512938 CD' 'Final Report n I 0 i < i CD oElectronic Signature on File O • N Electronically Reviewed/Signed by: Dorothy V Rocourt, MD Author Signature Dt/Tm:11/13/2012 08:25 AM Cn Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Brett Engbrecht, w Kerry Fagelman, Dorothy Rocourt, Mary Santos Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP, PNP-BC, Lynn Simmons MSN CRNP Ut Electronically Reviewed/Signed by: Tyler J Wallen, DOCosigner Signature Dt/Tm: 11/15/2012 03:44 PM l� O DVR DD: 11/13/12 O rn Result Type: Ped Surgery Inpt Progress Note Date'of Service:. November 13, 2012 05:28 Authorization Status: Modified Author or Import Date: Wallen, Tyler J on November 13, 2012 05:31 Verified By: Pham, Thu N on November 13, 2012 06:53 Encounter. info: 10512938, HMC, Inpatient, 11/12/2012 -11/13/2012 Printed by: Hitz, Brenda K Page 5 of 5 Printed on: 11/26/2012 06:59 (End of Report) DE� C7 . PRS Inpt Progress Note RICE, SYDNEY D - 7512938 Co Final Report 3 ' I n O CD I 0' * FMAI Report N tr Iw PLASTIC RECONSTRUCTIVE SURGERY .. 4�1 INPATIENT PROGRESS NOTE C•n C) Name: RICE, SYDNEY D I Patient Number: 7512938 p DOB: 04/05/2003 rn Date of Service: 11/13/12 Hospital Day: 1 SUBJECTIVE:_Improved perseverations, questions since lastnight _ No issues over night _x Pain well controlled _ Pain NOT well controlled Nausea/vomiting s Other: OBJECTIVE: Vitals: Tmax: 37.0 T: 36.6 HR: 96 RR: 24 BP: 87/48 Sp02: 97( No Vent.DetaiI Found. Input and Output-Last 24 hours(Last 8 hours) Total In: 290 (280) Total Out: 0 (0) 1 Total Balance: 290(280) •D5 0.:9%,NaCI-1,000 mL+potassium Printed by.: :• *:,-Ritz., Brenda K Page 1 of 3 Printed on, ;11126/201206;59 (Continued) Eastern AutO DEC 10 202 PRS I.npt,Progress.Note RICE, SYDNEY D - 7512938 cu Final Report C7 , O CD chloride 20 mE 280.X80 ID Med Intake: 10(0)'... 0 N Urine Count 1(1) W I0 Active Inpt Meds: con amoxicillin 250 mg PO tid 0 Active PRN Meds: a morphine 1.5 mg IV q2h One Time Meds: (Completed) I.p, ceFAZolin 1,000 mg w/IV ONCE(Ordered) 0 influenza virus vaccine 0.5 mL w/IM ONCE 0 Active IV Meds: Dextrose 5%with 0.9%.NaCl 1,000 mL+ potassium chloride 20 mEq (D5-0.9% NaCl 1,000 mL+potassium chloride 20'mEq) 1,000 mL 70 mL/HR Most Recent Lab Results over the last 24 Hours: No Latest CBC or BMP Found. No Albumin, Pre-Albumin,or Transferrin labs found. Physical Exam: Facial laceration to hair bearing scalp(left), frontal and forehead skin-with sutures in place Frontal motor branch distribution intact Sensation in tact in V1,V2 V3 distribution ; C Collar in plcae ASSESSMENT: 9 year old Female s/p motor vehicle accident with significant facial lacerations. PLAN 1 )_Continue 7 day total course of augmentin 2)_Ok to d/c to home as per PRS Printed-by: `' Hitz, Brenda I<- ' Page 2 of 3 Printed on: 11/26/2012 06:59 (Continued) Eastern Aut® DEC.10 2012 C7 l� PRS Inpt Progress Note RICE, SYDNEY D - 7512938 (D. "Final Report*. 3 • O O (D p' 3)Will follow up in PRS clinic in 1-2 weeks 4:1 Signature Line N Electronic Signature on File cn Io Electronically Reviewed/Signed by: Brittany J.Behar, MD Author Signature DtlTm:11/13/2012 07:30 AM can Electronically Reviewed/Signed by: John D Potochny, MDCosigner Signature Dt/Tm: 11/14/2012 04:37 PM p I BJB DD: 11/13/12 o 00 Result Type: PRS Inpt Progress Note Date of Service: No 13, 2012 07:28 Authorization.Status: • Final Author or Import Date: Behar, Brittany J on November 13, 2012 07:30 Verified By: • _ Behar, Brittany J on November 13,2012 07:30 Encounter info: 10512938, HMC, Inpatient, 11/12/2012-11/13/2012 Printed by: Hitz, Brenda K 'Page 3 of 3 Printed on: 11/2612012 06:59 (End,of Report) • �St�C� �V,t® � ED •�� 2012 D 0 ♦ 4 ' • , l� D/C Summary RICE, SYDNEY D - 7512938 CD. *Final Report 0 0 o' * Final Report I O DISCHARGE SUMMARY N C37 W Name: RICE, SYDNEY D Ip HMC Number: 7512938 DOB: 04/05/2003 o Date of Admission: 11 112/2012 U Date of Discharge: 11/13/2012 to Physician: Rocourt, Dorothy V Co rn Service: Ped Surgery Discharge Diagnosis: Soft tissue lacerations of the face Other Diagnoses: Concussion Surgical Procedures: Repair of facial soft tissue lacerations per Plastic Surgery 11/12/12 Vaccinations Received This Hospital Stay: 11/13/2012 influenza virus vaccine Discharge Medications: 1.Amoxicillin (amoxicillin 250'mg/5 mL oral liquid)7 mL by-mouth'-3 times daily. 2.Acetaminophen (Tylenol)400 mg by mouth every 4 hours, as needed for Fever/Mild Pain. Brief History of Present Illness: Sydney is.0.9-year-old girl who was a restrained back seat passenger involved in a motor vehicle accident. She was-seen as level 2 trauma activation where she was found to have repetitive speech, questionable change in mental'status both in the field and on trauma evaluation; she was upgraded to a Level one in the field.Arrival GCS 14. therefore, she.underwent CT scan of the head and facial bones. She has extensive soft tissue injury involving the left side of her forehead and in both the hair-bearing and forehead skin as well as left cheek up to the commissure of her mouth. -For this reason, plastic surgery was consulted. Hospital Courser Patient was admitted to Pediatric Surgery Service on 11/12/12. Plastic surgery was consulted for repair of facial laceration,. Her C-collar was cleared as CT of spine was negative for any bony injuries. She was placed on Printed by: Hitz, Brenda K Page 1 of 4 Printed on' -11/26/2012 06:59 - (Continued) Eastern Aut® DEC-10 2012 C7 D/C Summary RICE, SYDNEY D.- 7512938 CID Final Report* . n 0 tD 0 amoxicillin for infection prophylaxis. She is to take this antibiotic for a total course of 7 days. Her diet was I� advanced and tolerated it well. Her pain was controlled. She was stable and discharged on 11/1 3/2012 with a C follow up clinic appointment with Plastic Surgery in 1-2 weeks. Cn Exam on Discharge: W Physical Exam: _ 1 Facial laceration to hair bearing scalp (left), frontal and forehead skin -with sutures in place p Frontal motor branch distribution intact C) Sensation in tact in V1, V2 V3 distribution Heart:RRR Chest:CTAB I� Abdomen:soft, NT, ND o Extremity :sensation intact, moving all extremities � Dietation.#463710 Care Instructions: 1. see the head injury care instructions. Most concussions get better with time, but it can take time. Some people's symptoms go away within minutes to hours. Other people have symptoms for weeks to months. To help your brain heal after a concussion: --Rest the body: Make sure your child gets plenty of sleep.When awake, he should avoid heavy exercise or too much physical activity. --Rest the brain: Your child should avoid doing activities that need a lot of concentration or a lot of attention, such as excessive television or computer/video games, or texting. Return to school only after completely symptom-free. . --Your child may take a pain-relieving medication for headache, such as acetaminophen (Tylenol)or ibuprofen (Motrin,Advil) as directed on the bottle. --Your child MUST be cleared in clinic before you can do strenuous physical activities, play sports, or do you usual activities. 'Some"patients and families experience increased emotional symptoms after injury, particularly after a head injury. It is common and completely normal to have a gradual return to normal sleeping/eating/coping routines. Visit aftertheinjury'.org for interactive tools and information. 2. laceration care-wash with soap/water, dry and apply a thin layer of bacitracin twice/day until healed. Avoid weather/sun exposure. Clean away any remaining crusts with peroxide. Sit upright as much as possible to decrease facial swelling. 3. oral care after meals and before bedtime. If toothbrush is too painful, use rinses with children's mouthwash Printed by: Hitz, Brenda K Page 2 of 4 Printed on: 11/26/2012.06:59 (Continued) Eastern Aut® C7 I� D/C Summary RICE, SYDNEY D - 7512938 cD Final Report*, n 0 CD o (without alcohol,which can burn). I° -Please continue your Amoxicillifi for 7 days for-treatment of your facial lacerations. .p Cn Diet Guidelines: W regular diet. drink plenty of liquids. I °p Activity Guidelines: cn avoid activities that may lead to falls or impact for the next AND cleared at follow-up. NO: jumping, climbing, ° sports/PE/training or recess/playground play, riding things with wheels. I� return to school-see note provided. Upon return to school,.parents, school staff and patient should monitor for ° increased/returned symptoms (headaches, fatigue, difficulty concentrating or processing information, any rn confusion). If this occurs, it may signal that it is too soon to return, or a modified schedule may be needed. Please call to let us know if this occurs. Call your doctor if: Call 71-7-531-8521 (operator-ask for the pediatric surgery resident on-call): fever greater than 101 F, increased severe pain, persistent vomiting, any confusion, agitation or excessive sleepiness, increased redness/drainage from wounds. for routine questions during the weekdays, please call the pediatric surgery office at 717-531-8342. Other Instructions: You will have a follow up appointment with Plastic Surgery in 1-2 weeks.You should receive a phone call to schedule this within 1-2 days. If you do not hear from the office, please call 717-531-8953 to schedule this appointment. Follow-Up.Appointments: . Scheduled Penn State-Hershey Appointments Within the Next 90 Days. 1.. Follow-Up with PRS, UPC Resident at Plastic Surgery-Univ Phys Ctr Suite 3200 on 11/20/2012 at 02:30 pm 2. Follow-Up with Suite 400 Peds Surgery at Univ Phys Ctr Suite 400 on 12/12/2012 at 03:15 pm Signature Line Printed by: Hitz, Brenda K Page 3 of 4 Printed on: 11/26/2012 06:59 (Continued) .Eastern. AU t0' D/C Summary RICE, SYDNEY D - 7512938 (a Final Report 0 Electronic Signdture on File Electronically Reviewed/Signed by: ThuNPham, MD Author Signature Dt/Tm:11/14/2012 07:53 AM Cn Electronically Reviewed/Signedby: Dorothy V Rocourt, MDCosigner Signature Dt/Tm: 11/14/2012 09:45 AM :Z Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Brett Engbrecht, Result Type: D/C Summary Date of Service: November 13, 2012 18:12 Authorization Status: Final Subject: D/C Summary Auth&or"Import Date: *Pham, Thu N on November 13-2012 22:34 Verified By: Rocourt, Dorothy Von NoVem�er 14, 2012 09:45 Encounter info: 10512938, HMC, Inpatient, 1.1112/2012- 11113/2012 Printed oh., 11/26/201� 06:59. (Erid.of Report) Eastern AUtO DEC- 10 2012 _ C7 r It CD cam' I0 Flowsheet Print Request p Patient: RICE, SYDNEY D Printed by: Hitz, Brenda K MRN: 7512938 New Results Printed on: 11/26/2012 06:59 cD Results o .Ch°erriis iy; '' 'Na ' 'k -.0 �."H.0O3 'Anion I ii/i2/2012 58:55 140 3.0 L 104 24 12 Cfiemistry:r.`: - ` f'"Glu _'Ca N 11/12/2012 18:55 110 H 8.7 L cn CBC.',: 77 WBC EHgb 'f, Hck is RBC•. E,.MCV I� 11/12/2012 18:55 11.91 11.9 34.9 L 4.07 85.7 Coagulation:;;*;°: .;.. : znPT G?INR :.'PTT C) '11/12/2012 18:55. 15.6 H 1.25* H 32 Liver/GI ; � _ -�' vyk E%:ALT. ?Lipase. €"Amy{ase I� 11/12/201218:55 : . 41 281 97 Blood'Banks: -::, ' ' ABO/Rh ABO Recheck Antibody Scr Expires.at 0600AM ..: R Number . O') 11/12/2012 18:55 . A POSITIVE A POSITIVE NEGATIVE 11/15/2012 R74605 Coht�inkr'�H—,-' i ;Lab;''' Green..(Lithium hiepa.... 11/12/201218:55 [Multiple] Fastern Auto Page 1 pEC. Q 2012 Z ` M1 I v (D. Flowsheet Print Request o Patient: RICE, SYDNEY D Printed by: Hitz, Brenda K MRN: 7512938 New Results Printed on: 11/26/2012 06:59 CD Results ` i •Cret Estimated GFR , Black R... Estimated GFR,.non-Black..." BUN 11/12/201218:55 15 0.61 Pending Pending I� Chemistry' N 11/12/2012 18:55 w CBC•`.: MCHC 11 M C H T RDW Er,Pits I0 11/12/201218:55 34.1 29.2 12.2 243 .P Cgagulation:', cn 00 11/12/2012 18:55 L°iVer/GI; I41, 11/12/201218:55 00 Bldod Bank: :;r. : }-:�.Component Type If U... 0) 11/12/2012 18:55 RED CELLS 0 Confaifiers Held16A.a. 11/12/2012 18:55 Eastern Auto DEC 10 202 Page 2 I ' N CD 3 Flowsheet Print Request p Patient: RICE, SYDNEY D Printed by: Hitz, Brenda K MkN: 7512938 New Results Printed on: 11/26/2012 06:59 CD Results o Cleiistry° :;'`: ., ;n: ::-:Estimated GFR,.Comm... I:3 11/12/201218:55 Pending 1.1/12/201218:55 10 11/12/.201218:55 10.4 0 11/12/2012 18:55' � Liver%GI�:f `:.``.•'.._ • I� 11/12/2012 18:55 Blood Barak. 0 11/12/2012 18:55' �C�ritaii=i�t'���;H��lci;�in�'Lab:�•: • 11/12/2012:1$:55 Eastern AUt® • • DEC:10 2012 . Page 3 R CAR Z 1141 rL HORACE MANN INSUR*E 1 IX 1; 1- PO BOX 962 W MORRISVILLE NC 27560 F HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08105 PICA CASE ID: 00018447683 PICA FTT 0 1. MEDICARE.MEDICAID CHAMPVA GROUP FECA OTHER Ia.(NSUREDS I.D.NU BER (For Program In Item 1) 0 TRICARE Fj ❑r A (SSN PLAN 8IXLUNG[7X (Sponsorls SSN) (Mernber)Do S LrIOI (SSN) (ID) 16875C Z3 :j(Mbdice.#) (Medicaid#) CHAMPUS N < 1:1 (D 2.PATIENTS NAME(Last Name,First Name,Middle Initial) &PATIENTS BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) I DO i f'A. RICE, SYDNEY D 04 051 20YY 03m[-] FMX FREDERICKSON OUTPATIENT CENTER 0 5,PATIENTS ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No,,Street) 1 40 SYCAMORE DR Self❑Spouse❑Chl1d[N Other❑ C) CITY -ISTATE 8.PATIENT STATUS CITY STATE MECHANICSBURG PA Single RX Mwded❑ Other[] ZIP CODE TELEPHONE(include Area Code) Full-Tim if ZIP CODE TELEPHONE(include Area Code) 17050 (717) 608-1747 Employed 1:1 Student'F-1 s2al.770 I C) -9.OTHER INSUREDS NAME(Last Name,First Name,Middle Initao 10.IS PATIENTS CONDITION RELATED TO: 11.INSUREDS POLICY GROUP OR FECA NUMBE R uIRICE, COLLEEN J AD111212 C) a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(Current or Previous) a-INSURED'S DATE OF BIRTH SEX SC 0 MM DO YY YWP80117575903 00505817 NO F❑ Z F�YES rX b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? MM DO YY PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME o 06 1 12 1 1970 M❑- F[E M YES F No L P < c.EMPLOYER'S NAME OR SCHOOL NAME C.OTHER ACCIDENT? c,INSURANCE PLAN NAME OR PROGRAM NAME 0) Z !g I FREDERICKSON OUTPATIENT C [:]YES NO HORACE MANN INSURANCE d.INSURANCE PLAN NAME OR PROGRAM NAME Od=RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? CAPITAL BLUE CROSS CAI YES [:]NO ffy.,return to and..plate Rain 9 -d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other Information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED.qTC,NAT17R'F- ON RTT.F. DATE NED SIG --qIGN TTTRP ON FILIF 14.DATE OF CURRENT: ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, IS.DATES PATIENT UNABLE TO WORK IN CURRENT PATION C�l, YY MtfNT 0 YY MM i DO i YY INJURY(Accident)OR GIVE FIRST DATE -MM I DO I YY MM 601�Y 11 12 1.2 012 4 PREGNANCY(LMP) i 1 FROM I I TO 17.NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES -------------°---------- FROM NIM i DO YY . MM DO YY 17b. NPI TO 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAS? $CHARGES ❑YES �NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY(Relate Items 1,2,3 or 4 to Item 24E by Line) 22.MEDICAID RESUBMISSION ODE OD ORIGINAL REF.NO. 1. 1873 . 8 23.PRIOR AUTHORIZATION NUMBER 248_1_9 , 9 4. 24.A. DATE(S)OF SERVICE C. D.PROCEDURES,SERVICES,OR SUPPLIES I B G. I H. 1. J. From TO PLACE (Explain Unusual Circumstances) DIAG7�OSISJ DAYS EP801 ID. RENDERING' 0 OR MM DO YY MM DO YY ;�E MODIFIER I POINTER $CHARGES UNrrS PC DUAL PROVIDER ID.If 11�02 1 121 1 1 1221 199212 1 1- 112 t 67 1001 1-1- L-N-PI-.1-841241700 LL 2 -- NPI ---------------Z MMINNI ID-Obn DO Ar"' Ac�yrl]Di cc I W 3 i i i i i i -L------------- IL NPIL 7 I -Nuttiffili i r r1hm I I F 0 lu I -C ---- ----------------Cy NPI (71 ADAM 1 NPI---I-------------- I ---- 25,FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENTS ACCOUNT NO. j27.,CC,,EPT.,SSIGNWE T? 28.TOTAL CHARGE 29.AMOUNT PAID 130.BALANCE DUE or 04S see 251857035 IM 233101106FGB 0 FYES ONO $ 0100 $ 67100 O 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.SERVICE FACILITY LOCATION INFORMATION 33.BILLING PROVIDER INFO&PH# INCLUDING DEGREES OR CREDENTIALS (717) 531 -7097 (I certify that the statements on the reverse HERSHEY MEDICAL CENTER DIV PLASTIC RECONST SURG p 01pbtfttpn,%tTa10 VdAl TrIb 500 UNIVERSITY DRIVE P 0 BOX 858 MC A410 1HERSHEY PA 17033 HERSHEY PA 17033-0858 SIGNED 11 26 201.ATE Tb. a.I 125548208_91b. NUCC Instruction Manual available at:www.nucc.org APPROVED OMB-0938-0999 FORM CMS-1500(08-65) BECAUSE THiS FORM iS USED BY VARIOUS./ERNMENT AND PRIVATE HEALTH PROGRAMWE SEPARATE INSTRUCTIONS ISSUED BY ISAPPLICABLE PROGRAMS. e ;+NOTICE:Any person who knowingly files a statement of claim containing any misrepresentation or any false,incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties.. CD G* REFERS TO GOVERNMENT PROGRAMS ONLY IZTMEDICARE AND CHAMPUS PAYMENTS:A patient's signature requests that payment be made and authorizes release of any information necessary to process the claim and certifies that the information provided in Blocks 1 through 12 is true,accurate and complete.In the case of a Medicare claim,the patient's signature reauthorizes any entity to release to Medicare medical and nonmedical information,including employment status,and whether the person has employer group health 0 insurance,liability,no-fault,worker's compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made.See 42 <CFR 411.24(a).If item 9 is completed,the patient's signature authorizes release of the information to the health plan or agency shown.In Medicare assigned or CD CHAMPUS participation cases,the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary as the full charge, 1 and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier or CHAMPUS fiscal Intermediary if this is less than the charge submitted.CHAMPUS is not a health insurance program but makes payment for health benefits provided through certain affiliations with the Uniformed Services.Information on the patient's sponsor should be provided in those items captioned m'Insured";i.e.,items 1 a,4,6,7,9,and 11. O BLACK LUNG AND FECA CLAIMS The provider agrees to accept the amount paid by the Government as payment In full.See Black Lung and FECA instructions regarding required procedure and diagnosis coding systems. Ul __& SIGNATURE OF PHYSICIAN OR SUPPLIER(MEDICARE,CHAMPUS,FECA AND BLACK LUNG) WI certify thatthe services shown on thisform were medically indicated and necessaryforthe health of the patientand were personally furnished by me orwerefumished Incident to my professional service by my employee under my immediate personal supervision,except as otherwise expressly permitted by Medicare or CHAMPUS regulations. LrlFor services to be considered as"incident"to a physician's professional service,1)they must be rendered under the physician's immediate personal supervision Moll ces and his/her 4)Itthe s services ches of no physiciansr integral,although Included onithe physician's billllsyslclan'sservlce,3)they mustbe of kinds commonly furnished in physician's For CHAMPUS claims,I furthercertify that I(or any employee)who rendered services am not an active duty member of the Uniformed Services ora civilian employee Hof the United States Government or a contract employee of the United States Government,either civilian or military(refer to 5 USC 5536).For Black-Lung claims, Of further certify that the services performed were for a Black Lung-related disorder. �No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations(42 CFR 424.32). NOTICE.,Any one who misrepresents orfaisifies essential information to receive paymentfrom Federal funds requested bythis form may upon conviction be subject to fine and imprisonment under applicable Federal laws. NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE,CHAMPUS,FECA,AND BLACK LUNG INFORMATION (PRIVACY ACT STATEMENT) We are authorized by CMS,CHAMPUS and OWCP to ask you for information needed in the administration of the Medicare,CHAMPUS,FECA,and Black Lung programs.Authority to collect information is in section 205(a),1862,1872 and 1874 of the Social Security Act as amended,42 CFR 411.24(a)and 424 5(a)(6),and 44 USC 3101;41 CFR 101 et seq and 10 USC 1079 and 1086;5 USC 8101 et seq;and 30 USC 901'et seq;38 USC 613;E.O.9397. The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility.It is also used to decide if the services and supplies you received are covered,by these programs and to insure that proper payment is made. The information may also be given to other providers of services,carriers,intermediaries,medical review boards,health plans,and other organizations or Federal agencies,for the effective administration of Federal provisions that require other third parties payers to pay primary to Federal program,and as otherwise necessary to administerthese programs.Forexample,it may be necessaryto disclose information about the benefits you have used to a hospital ordoctor.Additional disclosures are made through routine uses for information contained in systems of records. FOR MEDICARE CLAIMS:See the notice modifying system No.09-70-0501,titled,'Carrier Medicare Claims Record,'published in the Federal Re q ster,Vol.55 No.177,page 37549,Wed.Sept.12,1990,or as updated and republished. j FOR OWCP CLAIMS: Department of Labor,Privacy Act of 1974,"Republication of Notice of Systems of Records,"Federal Register Vol.55 No.40,Wed Feb.28, 1990,See ESA-5,ESA-6,ESA-12,ESA-13,ESA-30,or as updated and republished. FOR CHAMPUS CLAIMS:PRINCIPLE PURPOSE(S):To evaluate eligibility for medical care provided by civilian sources and to issue payment upon-establishment of eligibility and determination that the services/supplies received are authorized-by law. ROUTINE USE(SI,Information from claims and related documents may be given to the Dept.of Veterans Affairs,the Dept.of Health and Human Services and/or the Dept.of Transportation consistent with their statutory administrative responsibilitiesander CHAMPUS/CHAMPVA;to the Dept.of Justice for representation of the Secretary of Defense in civil actions fto the internal Revenue Service,private collection agencies,and consumer reporting agencies in connection with recoupment claims;and to Congressional Offices in response to inquiries made at the request of the person to whom a record pertains.Appropriate disclosures may be made I to other federal,state,local,foreign government agencies,private business entities,and individual providers of care,on matters relating to'entitlement,claims adjudication,fraud,program abuse,utilization review,quality assurance,peer review,program integrity,third-party liability,coordination of benefits,and civil and criminal litigation related to the operation of CHAMPUS. ' i DISCLOSURES:Voluntary;however,failure to provide information will result in delay in payment or may result in denial of claim.With the one exception discussed below,there are no penalties underthese programs for refusing to supply information.However,failure to furnish information regarding the medical services rendered or the amount charged would prevent payment of claims under these programs.Failure to fumish any other information,such as name or claim number,would delay payment of the claim.Failure to provide medical information under FECA could be deemed an obstruction. It is mandatory that you tell us if you know that another party is responsible for paying for your treatment.Section 1128B of the Social Security Act and 31 USC 3801- 3812 provide penalties for withholding this information. i You should be aware that P.L.100-503,the"Computer Matching and Privacy Protection Act of 1988",permdsthe government to verrfy information byway of computer matches. MEDICAID PAYMENTS(PROVIDER CERTIFICATION) I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the State's Title XIX plan and to furnish information regarding any payments claimed for providing such services as the State Agency or Dept.of Health and Human Services may request. I further agree to accept,as payment in full,the amount paid by the Medicaid program for those claims submttted-for payment under that program,With the exception of authorized deductible,coinsurance,co-payment or similar cost-sharing charge. SIGNATURE OF PHYSICIAN(OR SUPPLIER):I certify that the services listed above were medically indicated and necessary to the health of this patient and were personally furnished by me or my employee under my personal direction. NOTICE:This is to certify that the foregoing information is true,accurate and complete.I understand that payment and satisfaction of this claim will be from Federal and State funds,and that any false claims,statements,or documents,or concealment of a material fact,may be prosecuted under applicable Federal or State laws. According to the Paperwork Reduction Act of 1995,no persons are required to respond to a collection of information unless it displays a valid OMB control number.The valid OMB control number for this information collection is 0938-0999.The time required to complete this information collection is estimated to average 10 minutes per response,including the time to review instructions,search existing data resources,gather the data needed,and complete and review the information collection.If you have any comments concerning the accuracy of the-time estimate(s)or suggestions for improving this form,please write to:GMS,Attn:PRA Reports Clearance Officer,7500 Security Boulevard,Baltimore,Maryland 21244-1850. This address isforcommentsand/orsuggestionsonly DO NOT MNLCOMPLETED CLAIM FORMSTO THIS ADDRESS. I; .Outpt Note RICE; SYDNEY D - 7512938 *Final Report* I 3 ' � Electronically Reviewed/Signed by: John D Potochny, MDCosigner Signature Dt/Tm: 11/26/2012 02:54 PM cu p' MDF/CO DD: 11/20/12 DT: 11/21/12 19:10 lc) Result Type: Outpt Note N. Date of Service: November 20, 2012 00:00 cn Authorization Status: Final W Author or Import Date: Flurry, Mitchell D on November 20, 2012 15:45 I Verified By: Potochny, John D on November 26, 20'12'14:54 Encounter info: 18447683, Hospital Based Offices, Clinic, 11/20/2012-11/21/2012 CD Contributor system: CBAY01 Z 0 rn i iPrinted by: Calloway, Earthenia D Page 2 of 2 Printed on: 11/29/2012 12:35 (End of Report) LESS-tarn Allkwto DEC 0 4 2M I r 'MS HERSHEY MEDICAL CENTER }' 3 m 1 68 .1 N MED. I 500 UNIVERSITY DRIVE 0 UNIVERSITY DR REC.# .? 93$ HERSHEY PA 170330856 HERSHEY PA 17033 6FED,TAXNO. 16::,•• ATEMENT:COVERSP IOD. T .FROM THROUGH � 7175315218 7175314010 25-1854772 112012 112012 (Q^•&,PATIENT NO a S PATIENT'ADDRESS" a 40 SYCAMORE DR b;RICE SYDNEY D. n MECHANICSBURG PA :d 1705p 10 BIRTHDATE 11 SEX 'ADMISSION '''' :• 16 DHR/7 STAT : '.:::.::". CONDITION CODES-, ,- 2S ACDT 30'- 12 DATE 13 HR 14 TYPE 46 SRC 18 .19. :.20 •' 21 22 23' 24: 25'. 26`' 2T•• 28'=•1TATE :•'` O 04052003 F ' 3 J. 1 01 PA 31 . OCCURRENCE.. + •• 33 OCCURRENCE'. . •• 96': 'OCCURRENCE SPAN 36 ,OCCURRENCE SPAN 3T CODE'. DATE,•• •r CODE`' -DATE •r r• :CODE. •:• :..FROM,.... THROUGH. CODE FROM 02 111212 a 06 .. .. - .. .. .. ,. ... .., b 3COt1E•: '.VALUE CODES .. ...a .. 4��..•.. , . F.:,.VN,AUMEOUNT.: , I AUTOINSURANCE , ap HORACE MANN INSURANCE W J,TER) l .l;b PO BOX 962 O MORRISVILLE,NC 27560 :..;: �� 42 REV.CD, 43 DESCRFrION 44 HCPCS 7 RATEt HIPPS CODE 46SENDATE 46 SEW UNITS 4770TAL CHARGES 49 NON-COVEREDCHARGI:S 49 0510 CLINIC 99212.. .,, .. .,. ,_ ..., .. .,. .11.2012, W :1' 90 p0_.- .. ...•: ':.- ., .: 2 :..•: d (V0) 1 so n n ,9 ... .. . .. �{ ...111"',,, .. ...:, .: ,B t . Is -6964 9 • : .. {iii-. .t-t. ,'/,f ... ..... Is 20 21 21 , .-. 22 0001 PAGE 001 OF 001 CREATION DATE 112612 • 9000 SOPAYER'NAME,,:•.<•} :-.:. . . . . .,,..... . .... •, , FEL' seASO .. -. .. .. 51 HEALTH PLAN 10, .. 54 PR10'R PAYMENTS• : ' 66 EST,AMOUNT DUE":"' 56 NPt 1 : $EB. ....: ,.: 568435477 A AUTO INSURANCE_ Y Y 57 A CAPITAL BLUE.CROSS ::' ' ::.`'.:;... .. . Y, Y' v.,;.;; :;;:;:'.,;.`: ..:` :.::' '•` OTHER c PRV ID e fa„3,INSUAED'S NAME ';; '•'"'}' S9 P.REL:60•MSURF�'S UNI I •• 61 GROUP NAME 62 INSURANCE GROUP N0. .. ....... ..... , .... ....... .. .... :. .:..:. - A RIGE,SYDNEY D. 18 16875C AD111212 : A 9 RICE,SYDNEY'D: :..: 18 YUVP841175759Q3.: .., ;• ;: :. . .. : 005058!7:,:.,. •:.: ;,',;,, B ^c 69$REATM£NT AUTHORIZATION CODS :•:. ,: . .. .,I. ,.,.•. •, 64 DOCUMENT•CONYROL NUMBER •.• '': 46 EMPLOYER NAME':•:i,{::.::::•,.:: ;. .. A 69 ADMIT 70PATIENT t'- rPPS. 72' E8199- i '� DX: REASON OX ..CODE . EOE; S• Td:. •,PRINCIPAL PROCEDURE ,'.+ . •�:: h OTHER PRO DUKE,...:•--75 7¢AITENOiNf3, NP11 841 241 700 •„ OD.. OB MD056224L - CODE 'DATE .r' t' CODE :DATE' LASrPOTOCHNY FIRSTJOHN •••a r tL OTHER PROCEDURE , .. ODDE.. DATE ' 7r:rsP£RATINa• r• O 8412417p0 " OB MDO56224L LASTPOTOCHNY FRSTJOHN SO REMARKS AUTO INSURANCE 81Oa B 282N00000X UOTHER.;; NPI qu HORACE MANN INSURANCE b :'= ;:•.., . ' ., ...:..•.':�.�: :.: •...� LAST FIRST ' PO BOX 962 ,aTHEA'`' NPI OU MORRISVILLE NC 27560 .if usr FIRST US-04 CMS-1450 APPROVED OMB NO. c„ THE CEKTIFICA IONS ON THE REVERSE APPLY TO THIS BILL A DARE MA A ART EO. B�'Bnro�-o-+.LICS213257 MS HERSHEY MEDICAL CENTER., PAGE : 1 cD 500 UNIVERSITY DRIVE 3 HERSHEY, PA' 17033 , �0 Statement on: 11/29/12 at 09 :09 AM S. arantor: RICE COLLEEN J < 40 SYCAMORE DR CD MECHANICSBURG, PA 17050-0000 0 Patient : RICE SYDNEY D Visit #: 18447683 o Nr----------------=--------------------------- Date . .J. Svc Code Description Units Debits Credits c — ---------- --=---- ---------=----—------------------------- ------------------'— CI 11/20/12 -787103 + OP' VISIT, EST PT, 'LEV 1 ( 90A.0 ------------- ------------------------------ --------------------I-- ----------I 0o * - Not posted Balance: 90 . 00 Ia ---------------------- ---- 00 _ .- 0 R Eastern Apgtc DEC 0 4 2012 ;0 1 .0utpt Note RICE, SYDNEY D - 7512938 Final Report 0 0 Final Report CDs _c n. OUTPATIENT NOTE 0 I Name: RICE, SYDNEY D HIVIC Number: 7512938 DOB: 04/05/2003 LF! Date of Service: 11120/2012 Location is ChiefResident Clinic. Cn 'C0 Reason is followup after IVIVC and facial laceration. I Z This is a 9-year-old female, who on 11/1212012 was restrained back seat passenger in a-motor vehicle accident, she -14- has level 2 trauma. round to have change in mental status,was brought into Hershey Medical Center for evaluation. 0 00 She had extensive soft tissue'injury of the left side of the face for which Plastic Surgery was consulted. This was 0) washed out, repaired in the emergency room. The patent is here for her initial followup visit. Since her accident,the patient and the family has not had any major complaints and no signs of infection. No significant drainage or purulence from the incisions. No fevers or chills or.nausea or vomiting. Overall the parents and the patient are pretty happy with ith the outcome so far. They have been taking good care of the lacerations. They have been having her shower daily and wash these lacerated areas and apply bacitracin liberally. On physical exam, she has multiple abrasions-and lacerations on the left forehead all of Which appear to be healing well. There are no signs of any erythefna or infection. She has one large laceration starting at the left oral commissure as well as a small laceration on the left cheek. All these lacerations are well-approximatpd and healing appropriately. ASSESSMENT AND'PLAN: This is a 9-year-old female involved in a motor vehicle accident on 11/12/2012 that was repaired in the emergency room. These wounds are healing appropriately., Parents are helping her to take good care of these lacerations,as welt as staples of her operation injuries. I told the parents to Continue the bacitracin until the abrasions have healed over fully. At that point,they can start using skin tape. Asked that they see us back in approximately 1 month for further discussions about the scar management as they are very concerned about making sure they do everything they can do to have'these scars be as small as possible. The parents were reasonable and appreciative of my advice today and agireed to be seen again in I month. I asked that if they have any questions,they can feel free to call our clinic or set up an earlier followup. 479073 Signature Line Electronic Signature on File Electronically Reviewed/Signed by: Mitchell D Flurry, MD Author Signature DttTm:11/2712012 08:34 AM Printed by: Calloway, Earthenia D Page I of 2 Printed on: 11129/201210:02 (Continued) DEC 0.4 2012 I� • .Outpt Note RICE, SYDNEY D - 7512938 (D• *Final Report 3 I n Electronically Reviewed/Signed by: John D Potochny,. MDCosigner Signature Dt/Tm: 11/26/2012 02:54 PM (D p' MDF/CO DD: 11/20/12 DT: 11/21/12 19:10 tCD Result Type: Outpt Note p Date of Service: November 20,.2012 00:00 Cnn Authorization Status: Final w Author or Import Date: Flurry, Mitchell D on November 20, 2012 15:45 I Verified By: Potochny, John D on November 26, 2012 14:54 C) C) Encounter info: 18447683, Hospital Based Offices, Clinic, 11/20/2012-11/21/2012 C) Contributor.system: CBAY01 I44- C 00 rn Printed by: Calloway, Earthenia D Page 2 of 2 Printed on: 11/29/2012 10:02 (End of Report) I " DEC 0 4 201z ,t \ HORACE MANN 0 �X I5�0 P.O.BOX 962 w HEALTH INSURANCE CLAIM FORM ���� MORRISVILLE,NC 27560 � APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08105 U IIy 3 PICA I? t PICA rTT ! I� 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER Ia.INSURED'S I.D.NUMBER (For Program in Item 1) 1 (Medicare#) (Medicaid CHAMPUS HEALTH PLAN BLKLUNG ffj J❑(Sponsor's SSN) (MemberlON)❑(SSN or ID) (SSN) (ID) 16$75C ' 2.PATIENTS NAME(Last Name,First Name,Middle Initial) 3.PATIENTS BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) N RICE,SYDNEY 04 MIA b3OD 120M M[:] Fr� AME N• 5.PATIENTS ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 40 SYCAMORE DRIVE Selt>©Spouse[_ Chlldo Other IQ CITY STATE 8.PATIENT STATUS CITY STATE -06 MECHANICSBURG N PA Single _ Married❑ Other U1 ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(Include Area Code) 17050 Employed Full-Time Part-Time 717 )000-0000 o W Student Student 0 Q 9.OTHER INSUREDS NAME(Last Name,First Name,Middle Initial) 10.IS PATIENTS CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER Z LL Uj •p o Ln a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(Current or Previous) a.INSURED'S DATE OF BIRTH. SEX YES ®NO MM i.DD i W M F El b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? b.EMPLOYER'S NAME OR SCHOOL NAME MM I DO I YY PLACE(State) p A 1 I MO F0 ®YES ONO L-J B c.EMPLOYER'S NAME OR SCHOOL NAME• c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME f- Q YES ®NO w d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? d YES NO ff yes,return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM, 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process[his claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 11112/2012 SIGNATURE ON FILE SIGNED DATE SIGNED 14.DATE OF CURRENT: ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 11MM h 2 DO 012 INJURY(Accident)OR GIVE FIRST DATE MM I DD I W MM I DD I W MM I DO I W PREGNANCY(LMP) I I FROM I 1 TO 17.NAME OF REFERRING PROVIDER OR OTHER SOURCE 17, 1 G SLF000 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES __ MM I DO I YY MM I DO I YY SELF,REFERRAL 170. NPI FROM I TO I 1 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES ' C COLLAR.PT COMBATIVE,FLIGHT CREW REQUESTED RESTRAINTS. YES [NO , 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY(Relate Items 1,2,3 or 4 to Item 24E by Line) 22.MEDICAID RESUBMISSION CODE ORIGINAL REF.NO. 1• Sp 9.01. HEAD INJURY 3. 23.PRIOR AUTHORIZATION NUMBER 780.09 ALTERED LEVEL OF 2.L_• CONSCIOUSNESS 4. t 17055 - 24.A. DATE(S)OF SERVICE B. C. D.PROCEDURES,SERVICES,OR SUPPLIES E. F. G. H. 1.• J. Z From To PLACEO (Explain Unusual Circumstances DIAGNOSIS Dnvs ePSDT ( P ) OR � ID. RENDERING O MM DD YY MM DD YY SERVICE EMG CPTlHCPCS MODIFIER POINTER $CHARGES UMrS Plan gUAL PROVIDER ID.# t- l I I I I 1111 EMERGENCY TRANSPORT I I 2_ 25-1 Z6B2rLEi___--- 11 112 12012 11 112 12012 41 YES A0429 11 SI 1 1 I 1,2 650.00 1 1 1 NPI /275693814 0 O U. I 1I 1 2_ 25-x768266-_-----.Z 11 112 12012 11 112 X2012 41 ES A0425 Sl I I 1 1,2 13.00 1 NPI 1275693814 CC w 3 I i I NPI d 4. fD i f I I I hs. ' '-'-? 0./v O Z 5 I - G�Z------- . I I I I I I 1 1 NPI n' 25.FEDERAL TAX I.D.NUMBER SSN EIN . 26.PATIENTS ACCOUNT NO. 27.�CCEPT OSSIGNM%W? 26.TOTAL'CHARGE 29.AMOUNT PAID 30.BALANCE DUE ' or govt.clams,see bac 25-1768266 ❑ X❑ 12-221179 X�YES NO $ 663.00 $ 0.60 $ 663.00 31.SIGNATURE OF PHYSICIAN OR SUPPLIER• 32.SERVICE FACILITY LOCATION INFORMATION 33.BILLING PROVIDER INFO&PH# (717 )214-6018 INCLUDING DEGREES OR CREDENTIALS <MOTOR VEHICLE ACCIDENT YELLOW BREECHES EMS INC. (I certify that the statements on the reverse -rOM: MECHANICSBURG,PA 17055 ply to this bill an re made a part thereof.) <LANDING ZONE> PO Box 726 TO: MECHANICSBURG,PA 17,055 . ..!tP���, .��7�,.,, •i'/2 -• .... ., :...•• New.Cumberland,PA.17070-0726::.:...:.._--. (�, 1 8/201.2 onni&"Stone :.. . ,.i, ;r::::.;:b', .. a b.G225�17682'66F;: •' SIGIVE[7•"� `r•DATE' :- `a"' 1275693$14 NUCC Instruction Manual available at:www.nucc.org PLEASE PRIJVT OR TYPE APPROVED OMB-0938-0999 FORM CMS-1500(08-05) 0 BECAUSE THIS FORM IS USED BY VARiOUQ QOVERNMENT AND PRIVATE HEALTH PROGRA?-` SEE SEPARATE INSTRUCTIONS ISSUED BY APPLICABLE PROGRAMS. 0 A NOTICE:Any person who knowinglyfiles a statement of claim containing any misrepresentation or any false,incomplete ormisigading information may 0) be guilty of a criminal act punishable under few and may be subject to civil penalties. REFERS TO GOVERNMENT PROGRAMS ONLY =r MEDICARE AND CHAMPUS PAYMENTS-A patients signature requests that payment be made and authorizes release of any information necessary to process the claim and certifies that the information provided in Blocks I through 12 is true,accurate and complete.In the case of a Medicare claim,the patient's signature 0 authorizes any entity to release to Medicare medical and nonmedical information,including employment status,and whether the person has employer group health 0 insurance,liability,no-fault,workers compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made.See 42 Z) CFR 411.24(a).If item 9 is completed,the patients signature authorizes release of the information to the health plan or agency shown.In Medicare assigned or < CHAMPUS participation cases,the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary as the full charge, (D , and the patent is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge (n determination of the Medicare carver or CHAMPUS fiscal intermediary it this is less than the charge submitted.CHAMPUS is not a health insurance program but 5* makes payment for health benefits provided through certain affiliations with the Uniformed Services.Information on the patients sponsor should be provided in those :3 items captioned in"Insured',i.e.,items la,4,6,7,9,and 11. 0 BLACK LUNG AND FECA CLAIMS .r-,. The provider agrees to accept the amount paid by the Government as payment in full.See Black Lung and FECA Instructions regarding required procedure and N) diagnosis coding systems. Cn I SIGNATURE OF PHYSICIAN OR SUPPLIER(MEDICARE,CHAMPUS,FECA AND BLACK LUNG) W I certifythat theservices shown on this form were medically indicated and necessaryforthe health of the patientand were personally furnished by me orwere furnished incident to my professional service by my employee under my immediate personal supervision,except as otherwise expressly permitted by Medicare or CHAMPUS 0 regulations. Cyl For services to be considered as"incident'to a physician's professional service,1)they must be rendered under the physician's immediate personal supervision C) by his/her employee,2)they must be an integral,although incidental part of a covered physician's service,3)they must be of kinds commonly furnished in physician's offices,and 4)the services of nonphysicians must be included on the physician's bills. ForCHAMPUS claims,I further certify that I(or any employee)who rendered services am not an active duty member of the Uniformed Services oracivilian employee of the United States Government or a contract employee of the United States Government,either civilian or military(refer to 5 USC 5536).For Black-Lung claims, 0 I further certify that the services performed were for a Black Lung-related disorder. 00 No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations(42 CFR 424 32). NOTICE,Any one who misrepresents or falsifies essential information to receive paymentfrom Federal funds requested by this form may upon conviction be subject to fine and imprisonment under applicable Federal laws, NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE,CHAMPUS,FECA,AND BLACK LUNG INFORMATION (PRIVACY ACT STATEMENT) We are authorized by CMS,CHAMPUS and OWCP to ask you for information needed in the administration of the Medicare,CHAMPUS,FECA,and Black Lung programs.Authority to collect information is in section 205(a),1862,1872 and 1874 of the Social Security Act as amended,42 CFR 411.24(a)and 424.5(a)(6),and 44 USC 3101;41 CFR 101 et seq and 10 USC 1079 and 1086;5 USC 8101 et seq,and 30 USC 901 et seq;38 USC 613;E.O.9397. The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility.It is also used to decide if the services and supplies you received are covered by these programs and to insure that proper payment is made. The information may also be given to other providers of services,comers,intermediaries,medical review boards,health plans,and other organizations or Federal agencies,forthe effective administration of Federal provisions that require other third parties payers to pay primary to Federal program,and as otherwise necessary to administerthess programs.Forexample,it maybe necessary to disclose information aboutthe benefitsyou have usedto a hospital ordoctor.Additional disclosures are made through routine uses for information contained in systems of records FOR MEDICARE CLAIMS:See the notice modifying system No.09-70-0501,titled,'Carrier Medicare Claims Record,'published in the Federal Register,Vol.55 No 177,page 37549,Wed.Sept.12,1990,or as updated and republished FOR OWCP CLAIMS: Department of Labor,Privacy Act of 1974,"Republication of Notice of Systems of Records,"Federal Register Vol.55 No.40,Wed Feb.28, 1990,See ESA-5,ESA-6,ESA-12,ESA-13,ESA-30,or as updated and republished. FOR CHAMPUS CLAIMS:PRINCIPLE PURPOSE(S).To evaluate eligibility for medical care provided by civilian sources and to issue payment upon establishment of eligibility and determination that the services/supplies received are authorized by law. ROUTINE USE(M:Information from claims and related documents may be given to the Dept.of Veterans Affairs,the Dept,of Health and Human Services and/or the Dept.of Transportation consistent with their statutory administrative responsibilities under CHAMPUS/CHAMPVA;to the Dept.of Justice for representation of the Secretary of Defense in civil actions;to the Internal Revenue Service,private collection agencies,and consumer reporting agencies in connection with recoupment claims;and to Congressional Offices in response to inquiries made at the request of the person to whom a record pertains Appropriate disclosures may be made to other federal,state,local,foreign government agencies,private business entities,and individual providers of care,on matters relating to entitlement,claims adjudication,fraud,program abuse,utilization review,quality assurance,peer review,program integrity,third-party liability,coordination of benefits,and civil and criminal litigation related to the operation of CHAMPUS. DISCLOSURES:Voluntary;however,failure to provide information will result in delay in payment or may result in denial of claim.With the one exception discussed below,there are no penalties underthese programs for refusing to supply information.However,failure to furnish information regardingthe medical services rendered orthe amount charged would prevent payment of claims underthese programs.Failure to furnish any other information,such as name orcialm number,would delay payment of the claim.Failure to provide medical information under FECA could be deemed an obstruction. It is mandatory that you tell us d you know that another party is responsible for paying for your treatment.Section 1128E of the Social Security Act and 31 USC 3801- 3812 provide penalties for withholding this information. You should be aware that P.L.100-503,the"Computer Matching and Privacy Protection Act of 1988",permits the government to verify information by way of computer matches. MEDICAID PAYMENTS(PROVIDER CERTIFICATION) I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the State's Title XIX plan and to furnish Information regarding any payments claimed for providing such services as the State Agency or Dept.of Health and Human Services may request. I further agree to accept,as payment in full,the amount paid by the Medicaid program forthose claims submitted for payment under that program,with the exception of authorized deductible,coinsurance,co-payment or similar cost-sharing charge. SIGNATURE OF PHYSICIAN(OR SUPPLIER):I certify that the services listed above were medically indicated and necessary to the health of this patient and were personally fumished by me or my employee under my personal direction. NOTICE:This is to certify that the foregoing information is true,accurate and complete I understand that payment and satisfaction of this claim will be from Federal and State funds,and that any false claims,statements,or documents,or concealment of a material fact,may be prosecuted under applicable Federal or State laws. According to the Paperwork Reduction Act of 1995,no persons are required to respond to a collection of information unless it displays a valid OMB control number The valid OMB control number for this information collection Is 0938-0999 The time required to complete this information collection is estimated to average 10 minutes per response,including the time to review instructions,search existing data resources,gather the data needed,and complete and review the information collection It you have any comments concerning the accuracy of the time estimate(s)or suggestions for improving this form,please write to•CMS,Attn.PRA Reports Clearance Officer,7500 Security Boulevard,Baltimore,Maryland 21244-1850. This address tsforcomments a d1or n suggestionsonly.DO NOTMAILCOMPLETED CLAM FORMS TOTHISADDRESS I � L i i Pennsylvania 9MS Report ScrviceName Station unit Name,No.&Type KANo. bate Yaliow Brt2chts>rMS.Inc. Yellow Breechcs EMS 01/3101101/BLS 1300950 } i 1/11/2012 Inciacnt.Location • County.Munigpalitv&Incident Zip PSAPIneid.No. (�D Raspberry Drive and Rr 114,Mechonia$bur,,PA 170d5 CURSERLAND,Silver Spring Towpship,17055 Succt or Highway O Reeefviu;Agency 4 Universilyu0spital-Hershey I Patient Now Crew Sydney Rice CI:Baer;Cam $MT 094976 N ep Street Address , C2r 40 Sycamore Drive G) C3: » City ` CJ� I ty State ' Zip O Mechanicsburg PA 17090 C4' C.? QSex :age DOB Phone No. Primary Caregiver: C1 Driver. 0o y, Female 9 Yews 04/03I?003 1(717) - �0 ;Patient Number Social Sec.To. Pt,Nve)oht Mitt age out On-Scene Dest. , Iu I� PrivatcPhysician Driver's License 34.9 36.9 5811 71.5 00 Times 00 Transporting Assist Units Assist OS W08t Short ALS,Inc. Response Time:, 0 911: Resp6nse Outcome Nature of Incident ER Time:• 6 Dispatch: 17:55 Transported ALS , OS Time:i 9 Bnroute: 17:55 Respopse Mode Transport Mode IrRH Time: 3 Arrive Scene: 18:01 C�1 Emergency 'Emergency CO Destination Time: 44 Contact: 1$:0 3 Patient Condition on Scene Patient Condition at Facility Total Time: 62 Depart Scent: 18:10 V'1 Life-Threatening Not Applicable Time Out of 0 Arrive: 18:13 W Quarters: Available: 18:57 N' In Quarters: V1 Chief Com Qlaint: None Voiced.Auto accident victim with a bead injury. Curren t Medsr None known Allergies(mods): None Known PIUHx; T lJrown Narrative Dispatched and responded to Silver Springs Township,,raspberry Drive and Rt. 114,Mechanicsburg, 17055 class 1 with Silver Springs BLSU,Medic 88 and fire department for an auto accident with an unconscious patient. Advised enroute that there was possibly 1 patient,in and out of con$60USnesS. No other information available. Fire command requested Life Lion t0 the scene- Ambulance 72 and medic 88 arrived on the scene pzior to ambulance 191. Printed On: 1I/12/2012 20:03 Provider EMStat Peporting(c)1998-201?.Med Media,Inc. All Rights Reserved. Q-W'3R,to;Q 4�F UtC IDEC 0 3 2M 4 t - • f 1 Ifs• , • Pennsy�vania EMS Report ' I(!� SenieeName Vnitilo PCR No. bate Yellow Breeches EMS.Inc. 0 0112101101113LS 1200950 < Patient Name < Aate oC$irth r Social SeCLrify irumaGe PSAP , Sydney Rice 0143/2003 , p + �o Arrived on the scene and was directed to tuna our ambulance around. We were told that we were going N to transport the patient that was being frown by Life Lion. We turned the BLSU around and approached cn the patient, The patient was at that time being taken out of the back seat of the vehicle on the passenger A side. She was being placed on-a LSD. There was already a cervical collar in place_ The was being done by ambulance 72's crew and the fire department. The patient was in and out of consciousness and was Ln combative at times. She was placed on the litter and secured with available straps. She was then taken C° to the rear of ambulance 191 and planed inside by ambulance 72's crew and medic 88 Quirk, C1 was :F- originally going to drive to the landiztg zone but was then requested to provide care in the back of the �-, BLSU. Cl took over primary patient care as the BLS provider with assistance from an EMT from 0 ambulance 72, rn PE: patient is a 9 year old female who is in and out of consciousness. She has periods of quietness and then will open her eyes and become combative. HEENT: patient had a large laceratioulavulsion on her forehead. patient had blood I her mouth,but her teeth appeared to be intact.She also had a laceration + on the left side of her face near her mouth and one at the comer of her mouth.-pupils: round and reactive to fight. Neck: no noted injury or deformity. Skin: pink,warm and dry. Chest: symmetrical upon•inspiration. Abdomm-, soft to palpation: Upper extremities: Patient had blood on her hands,but could not find any injury to either hand..Lower extremities: no noted injury or deformities•nbted:,. Movement in all extremities when the patient became agitated. Vital signs as_charted. Continued treatment: Patient's clothing was removed by ttze EMT from ambulance 72. )Blankets were used to pad the voided areas on the long spine board. The ALS provider placed the patient on 15 LPTM via NRB mask, prior to being placed into the BLSU a bandage was placed on the patient's forehead, C 1 did not visualize the injury. The patient continued to be combative at times and would pull at her cervical collar,bandages and IV sites. She would move her legs out from the long board straps. At the direction of the ALS provider the EMT from company 72 tied the patient's legs to the Iong spine board. This attempt was unsuccessful. Her legs were then secured properly to the long,spine board individually with cravats. Enroute to the Landing Zone the patient's vital signs were obtained. Continued to assess the patient and assisf A•LS as requested. Alter arriving at 6e landing zone,the Might medics boarded the BLSU: They then requested that the patient's arm be secured to the Iong spine board using cravats, This was done by the flight crew. Patient was taken out of the BLSU and placed on the Life Lion Litter_ She was secured using available straps, She was then placed back onto the BLS litter and secured. The patient was then wheeled to Life Lion at the direction of the flight medic. She was transferred to Life Lion, All times are approximate and from ursynchronized sources: Printed On: 11/12/201220:03 �s� Previd g EMStat Rcpordng(c)1998-2012,Med Media,Inc. All Rights Reserved. aatdr¢ x�AU I' DEC 0 Zu iZ 0 Pennsylvania EMS Report Str�iceName Unit No PCR Na. Datt Yellow Breeches EMS,Inc, 0112101101/BLS 1200950 1111312012 Patient?iame , Dhtc of Birth Social Security[Number PSAP CD $ydnty Mice 04/031x003 - O ` I7 , O N Note: Keegan from Wes[Shore was the driver to the landing zone. W END/cab ► 0 094976 cn O Time Events provider Comments '0 18:01 Immob:Cervical Collar Other O 00 18:01 Immob;Board-Lon; other 18:03 Immob:C-Spine Imm.Dev. Other 18.04 Misc:Bah*e;SUCCeSS:Ul;Pt.Respoase;Vnchsnged Other 18:04 Immob:Full Spinal Immobilization Other 18:06 OxVaen:Oeyoatt 10-15 1pm:Liters:15;Pt.Response:Unchanged Other ALS provider 18:10• Viuds;Pulsc:84,Resp:14:CT.titnetry:91%w B.P.:108152'(1vWusl Cuff);GCS: Baer,Cam 18:13 Immob:Patient Restrained;Pc Response;Unchanged Other Lower cWemitics 18:15 Vitals:Poise:100;Resp:l3:B,P,:150/90(Manual Cuff):GCS:2/38 Other EMT from 72 I 1.8:18 Immob:PatieniRestrained Other Flight medio,uppttewmities Printed On: 11/l.,7/201....22 0:03 � Provnder EMStat Reporting(c)1998-2012,Med Media,Inc. All Ri2bts Rcsomd. FOS Sitkof frA Auto DEC 0 v 20'2 CD o' i0 In i� Q i U7 i d , o PENNSTATE HERSHEY_ m XM Milton S.Hershey IV iVledical Center M.C.A410 m P.O.Box 854•Hershey,Pennsylvania 17033-0854 m HORACE MANN rt r' [D PO BOX 962 MORRISVILLE NC 27560 , i c i i Ir • f E -»d'r FFt'-4th i i I EXHMIT ..B.. PENNSTATE Milton S.Hershey Medical Center College of Medicine Penn State Milton S.Hershey Medical Center Tel: (717)531-8521 Penn State College of Medicine Health Information Services,HU24 500 University Drive P.O.Box 850 Hershey,PA 17033-0850 M(10--i M RE: RICE,SYDNEY D I JUN 0 3 2013 BY---------------------- May 22, 2013 Name: RICE, SYDNEY D HIVIC Number: 7512938 DOB: 04/05/2003 Date of Service: 05/22/2013 Ms-Collen Rice 40 Sycamore Drive Mechanicsburg PA 17050 Dear Ms. Rice: This letter is a followup to your request for a summary letter regarding the care received by your daughter, Sydney D. Rice,following a recent automobile accident with facial injuries. Sydney D Rice was seen at the Hershey Medical Center in the Emergency Department on 11/12/2012,for facial lacerations following a motor vehicle collision where she was a restrained backseat passenger. She was seen as a level 2 trauma activation and found to have repetitive speech and change in mental status at the time of her evaluation, and therefore, underwent a CT scan of the head and facial bones. She did have significant soft tissue injuries on the left side of her forehead in both the hair-bearing and skin of the forehead as well as the left cheek up to the commissure of her mouth. For this reason, Plastic Surgery was consulted and I am the attending plastic surgeon. Sydney was found to have no facial fractures, but underwent repairs of her lacerations of the face, forehead, and cheek region on 11/12/2012. Sydney has since been evaluated by our chief residents in followup on 11/20/2012, and again on 12/27/2012. During those followups, she was noted to have wounds that were healing appropriately and instructions for further care of those wounds were given to you, Sydney, and your husband. At the time of last followup on 12/27/2012, Sydney was noted to have healing scars,which were at that time immature, slightly reddened and raised and so she was instructed on massaging these scars two to three times a day and you were instructed that changes in the scars as they mature can occur over the next one year or so. If after one year, her scars are unfavorable an opportunity for reassessment and possible cosmetic scar revision would be a possibility if you desire to pursue that. To my knowledge, Sydney is currently not receiving any other care for the treatment of her injuries that were sustained in this accident. A This document has been electronically signed. Patient Name: RICE,SYDNEY D Patient Number: 7512938 Page I of 2 For information about our physicians and services,contact the MD Network. 1-800-233-4082 www.pennstatehershey.com 0 complete detailed medical record is available to you and can be obtained by contacting the Medical Records Department of the Hershey Medical Center. This completes the summary of the care that was received by Sydney D. Rice through the Plastic Surgery Division to treat her lacerations as a result of this accident. If I could be of further assistance, please do not hesitate to contact me. 856781 Electronic Signature on File CC: B. Craig Black, Esquire Chartwell Offices, LLT 30 North 3rd Street Suite 1050 Harrisburg PA 17101 CC: Colleen J. Rice 40 Sycamore Drive Mechanicsburg PA 17050 CC: Forward 1 to: CC: Forward 2 to: Sincerely, John D Potochny, MD Author Signature Dt/Tm: 05/24/2013 02:00 PM JDP/MJ DD: 05/22/13 DT: 05/23/13 11:27 This document has been electronically signed. Patient Name: RICE,SYDNEY D Patient Number: 7512938 Page 2 of 2 For information about our physicians and services,contact the MD Network. 1-800-233-4082 www.pennstatehershey.com EXHIBIT 66C99 1r'�I Horace-Mann Retirement Annuities and Life,Auto, Educated Financial Solutions Homeowners and Group Insurance NOTARIZED STATEMENT I HEREBY CERTIFY THE ATTACHED TO BE AN EXACT COPY OF THE POLICY AND DECLARATIONS SHEET AS INDICATED a SIGNED Michael Brown,BI State Team Leader Connie Yancey-Davis,BI State Team Leader Eastern Auto Claim Service District Office Horace Mann Insurance Company 1 SUBSCRIBED AND SWORN BEFORE ME THIS �� DAY s � " OF W , O t SIGNED 60iary Pohl!" VW21c�'Cour�ly 1`fori{�CarOil)1"'� 1712015 V. com 1 i The Horace Mann Companies 3005 Carrington Mill Blvd Ste 200 (919)380-4121 Morrisville,NC 27560 EiiItY Shearin H o race .l!/Ianrn Founded by Educators for Educators Renewal Premium Notice ® Policy information Page -,I of 4 Transaction date 09/04/2012 Auto policy number 37-59683360 3.9 Named Insured Insured by RICE, DAVID E Horace Mann Property&Casualty 40 SYCAMORE DR Insurance Company MECHANICSBURG PA 17050-7925 P.O. Box 19463 Springfield, IL 62794-9463 Vehicle Policy Year 2001 Type Readable car policy Make VLVO Number 37-59683360 Model S40 Term (months) 06 VIN YV1VS29561.F734208 Continuous renewal policy Effective 10/22/2012 12:01 AM standard time Expiration 04/22/2013 12:01 AM standard time 0 Your coverage Coverage and premium changes are provided as follows subject to the terms of the policy. Coverage Description Limit of liability Deductible Premium A Bodily Injury Liability Each Person $100,000 $46.40 ._ Each Occurrence $300,000 B Property Damage Liability Each Occurrence $50,000 $45.00 C Medical Expenses Each Person $5,000 $16.00 C2 Income Loss Each Month up to $1,000 Included in C Maximum Benefit $5,000 C5 Funeral Services Each Person $1,500 Included in C D Comprehensive Actual Cash Value $100.00 $28.10 E Collision Actual Cash Value $500.00 $69.00 JS Uninsured Motor Vehicle-Stacked Each Person $50,000 $12.10 Bodily Injury Each Accident $100,000 R Rental Reimbursement Each Day $30 $6.40 Aggregate $600 SS Underinsured Motor Vehicle-Stacked Each Person $50,000 $28.80 Bodily Injury Each Accident $100,000 Renewal premium $251.80 Renewal amount due $251.80 EFT fee $4.50 013490 315 ® Policy information Page 2 o 4 Transaction date 09/04/2012 Auto policy number 37-59683360 3-9 ®Your rating information Rate information Additional rating information Use Work or School Educational Employee Household Classification MBAA Member Discount Inexperience 0 Multi-line Discount Accident/violation points 00/00 EFT Discount Insurance score M Territory 82 Age of the policy Symbol HO Age of the vehicle Y/V/D N 1312 Resident drivers we insure Number of vehicles we insure Anti-Theft Discount Airbag Discount Principals Association If any of the information above is not correct, please contact your agent. • Listed drivers for your vehicle RICE, DAVID E CLASSED DRIVER RICE, COLLEEN J • Your representative FRONK, DONALD B FRONK INS &FIN SERV 5236 E TRINDLE RD MECHANICSBURG, PA 17050 717-697-9723 ® Policy information Page 3 of 4 Transaction date 09/04/2012 Auto policy number 37-59683360 3-9 ® About your policy& endorsements Applicable policy and endorsement forms If you wish to change the tort option that currently applies to CC-NOOPA I(08-06) Readable Car Policy our policy, you must notify our agent, broker or company CC-NO I PA 1(09-06) Readable Car Policy Amendatory y P �' y f9 y e p 3 and request and complete the appropriate form. Endorsement-Pennsylvania CC-N 11003(1 1-1 1) Preferred Provider Endorsement The following discounts are available to all drivers who meet CC-N04PA I(10-06) Uninsured/Underinsured Motor eligibility requirements: Vehicle Amendatory Endorsement- Pennsylvania Driver Improvement Course Credit CC-V09PA2(07-1 1) Pennsylvania Surcharge Disclosure Passive.Anti-Thief Discount Statement Passive Restraint Discount CC-N06076(02-09) Educator Advantage Endorsement For further information on these discounts or eligibility CA-N50PA1 Notice- Insurance Consultation requirements, please contact your agent. Services Exemption Act The laws of the Commonwealth of Pennsylvania, as enacted PA0002 Full Tort Option applies to this policy by the General Assembly, only require that you purchase Notice(s),policy and endorsement forms included in liability and first-party medical benefit coverages. Any this package additional coverages or coverages in excess of the limits required CC-V09PA2(07-1 f) Pennsylvania Surcharge Disclosure by law are provided only at your request as enhancements to _ Statement basic coverages. The information below contains the premium necessary for your policy with the minimum coverages required Please read the following important by law. _ information about your policy. Bodily Injury Liability Limit Premium The laws of the Commonwealth of Pennsylvania give you the Each Person $15,000 right to choose either of the following two Tort Options: Each Occurrence $30,000 A. "Limited Tort" Option—This form of insurance limits $33.60 —_ your right and the rights of members of your household Property Damage Liability to seek financial compensation for injuries caused by Each Occurrence $5,000 other drivers. Under this form of insurance, you and $41.40 other household members covered under this policy Medical Expenses may seek recovery for all medical and other Each Person $5,000 out-of-pocket expenses, but not for pain and suffering $19.00 or other nonmonetary damages unless the injuries Total Premium $94.00 suffered fall within the definition of"serious injury," as set forth in the policy, or unless one of several other exceptions noted in the policy applies. Any person who knowingly and with intent to defraud any B. "Full Tort" Option—This form of insurance allows you insurance company or other person files an application for to maintain an unrestricted right to seek financial insurance or statement of claim containing any materially Use compensation for injuries caused by other drivers. information or conceals for the purpose of misleading, Under this form of insurance, you and other household information concerning any fact material thereto commits a members covered under this policy may seek recovery fraudulent insurance act, which is a crime and subjects such for all medical and other out-of-pocket expenses and person to criminal and civil penalties. may also seek financial compensation for pain and suffering or other nonmonetary damages as a result of injuries caused by other drivers. 0134904/5 ® Policy information Page 4 of 4 Transaction date 09/04/2012 Auto policy number 37-59683360 3-9 ® About your policy& endorsements (continued) Please read this additional information The Horace Mann Companies include: Horace Mann Insurance Company; Horace Mann Property about your policy &Casualty Insurance Company; Horace Mann Life Insurance Horace Mann's Privacy Pledge Company; Horace Mann Investors, Inc.; Horace Mann Lloyds; You entrust our company with your future when you Horace Mann Service Corporation; Teachers Insurance become a Horace Mann client. And you expect us to value that Company; Allegiance Life Insurance Company; and Educators trust, respect your privacy and protect your personal Life Insurance Company of America. information. To show we have earned that trust, we want to explain how we gather and use your personal information. NOTICE-INSURANCE CONSULTATION SERVICES We collect non-public personal information about you. EJCEMPTION ACT This includes: We may provide consultation service such as inspections or -Information we receive from you,such as your name, surveys of your property in accordance with the provisions of address, and beneficiaries; the policy. These services may reduce the likelihood of injury, -Information about your transactions with us,our death or loss. affiliates or others,such as your policy coverage and This notice is required to be provided to you by the payment history; and "Insurance Consultation Services Exemption Act'of -Information we receive from consumer reporting Pennsylvania. This act provides that we,our agents, employees, agencies, such as your credit standing, or service contractors are not liable for damages from injury, We use this information to issue and service your policy and death or loss occurring as a result of an act or omission by a to offer you other insurance or financial products. We may use person in the course of such services. any of the information we collect within The Horace Mann The Act does not apply: Companies as allowed by law. We may also provide any of this 1.if the injury, death or loss occurred during the actual information as otherwise required or permitted by law, performance of the consultation services and was caused including sharing it with companies that perform marketing or by our negligence or the negligence of our agents, other services on our behalf or companies with whom we have employees or service contractors; joint marketing arrangements. We require these other 2. to consultation services performed under a written service companies to keep your personal information confidential and contract not related to the policy; or to use that information only for the purpose of the marketing or 3.if an act or omission by us,our agents, employees or service arrangement. service contractors is determined by law to constitute a In addition, we restrict access to your personal information crime, actual malice or gross negligence. to those employees or companies who need access to that information to provide products or services to you or to us. We also have physical, electronic and procedural safeguards in place to guard your personal information. We understand the importance of privacy and therefore, we use these privacy practices and policies to protect the personal information of prospective and former customers as well as our current customers. Thank you for choosing Horace Mann. We appreciate the trust you have placed in us. Questions? Please call our Customer Care Center toll free at 800-999-1030 or e-mail us at:www.horacemann.com CL-VJA401 Readable car policy Pennsylvania This policy,is a legal contract between you and us. READ YOUR POLICY CAREFULLY Horace Mann Property &Casualty Insurance Company Teachers Insurance Company Horace Mann Insurance Company A Stock Company I Horace Mann Plaza Springfield,Illinois CC-NOOPAI (8106 Table of Contents Section IV—physical damage coverages Defined words......................... I Comprehensive—coverage D....................... I 1 ........................ Insuring agreements................. •- ................................2 Collision—coverage E............... When coverage applies............... . .....•.......... 12 ..........................2 Clothes and luggage . sere coverage applies........................................2 Rental car—repayment of deductible....................12 Two or more insureds..........................................2 Limits ofliabilit Policy changes. 12 .....................................................2 Settlement of loss............ Renewal...............................................................2 Emergency .....er..geI..........•..........l2 g my road service—coverage I.....................12 Cancellation.................... .......••.••.........................3 Rental reimbursement—coverage R.....................12 Action against us.................................................. Sound system coverage—coverage DI..................13 Agreement with stare law.....................................3 Trailer coverage........_.. Reporting a claim—your duties..............................3 .....,.13 Coverage for the use of other cars...........................13 Notice to us of an accident or loss............................3 .... Definitions.....•..................... ......13 Notice to us of claim or suit.....................................3 When coverages D,DI,E and I Other duties under physical damage Do not apply Coverage................................... If there is other coverage................................ Other duties under first party benefits.............. .•. ........3 No benefit to bailee................... Other duties under uninsured and •••........--••••......--••-•14 Action against us....................................................14 Underinsured motor vehicle coverage.......................4 Our right to recover our payments.,.......................14 Insured's duty to cooperate with us..........................4 Appraisal.............. 14 Section I—liability coverages Two or more vehicles................. ...................•, 15 Bodily injury liability coverage A """-'..-" Section V—notice endorsement............. 5 Property damage liability coverage B.................... """ ''.1 In addition to the Iimits of liability...........................4 Trailercoverage............ .......................... .5 Coverage for the use of other cars..................... Whois an insured?..........•....................... Non-owned cars........................ 5 .............. What is not covered.................. Limits of liability.............. Ifthere is other coverage...........................................6 ...................... Financial responsibility law.......................................6 Action against us.......................................... .6 ........... Our right to recover our payments...........................6 Section II—first parry benefits medical Expenses—coverage C•......................... ...7 Income loss—coverage C2.............. 7 Accidental death—coverage C4..........•...................7 Funeral services—coverage C5............., .....7 ............ Definitions............................. What is not covered............................. 8 Policy period;territory.............................................8 Limitsof liability......................................................8 Priorities of policies................................•..............• 9 Action against us.-,.............__............... 9 Customary charges for treatment............... Non-duplication of benefits............................................................ Section III-uninsured/underinsured motor Vehicle coverage...................... ........9 Uninsured/underinsured motor vehicle Coverage—coverage J........................................9 What is not covered.............................................. Limit of li ability.............. .................. ..........I I Other insurance.....•.......................... Arbitration.............................................. 1 I O Readable car policy Page I Aivate Passenger Car means a car of the private Refined words passenger,station wagon or utility vehicle type designed to We define some words used in the policy.This makes it carrypersons and their luggage. easier to read and understand.Defined wards are printed Relative means a person related to you by blood,marriage in bold face italics. or adoption who lives with you,It includes your unmarried As used in the policy: and dependent child who is away at school. You and Your mean the named insured shown on the Spouse means your husband or wife while living with you. declarations page and the named insured's spouse if a Ternporary Substitute Car means a car or trailer not resident of the same household. owned by you or a resident of your household,if the Wye, Us and Our mean the Company providing the ternpotvrry substitute car replaces your car for a short insurance. time.Its use must be with the consent of the owner. Your car must be out of use as a result of its breakdown,repair, Here are other defined words and phrases used in the servicing,damage or loss.A temporary substitute car is policy. not a non-owned car.. Bodily Injury tneans bodily injury to a person and all Trailer means a trailer or semi-trailer designed for use with resulting sickness,disease or death. a private passenger car or a utility vehicle. Car means a four wheel land motor vehicle designed for Utility Yehicle means a pick-up or van with a load use mainly on public roads,It does not include any vehicle capacity of not more than 2,000 pounds and not used for While located for use as a dwelling or other premises. commercial purposes.This definition also includes a Car Business means a business or job the purpose of which detachable living quarters unit designed for use with a is to sell,lease,repair,service,transport,store or park land privatepassenger car or utility vehicle. motor vehicles or trailers. Your cap-means the car that you own which is described fissured means the person,persons or organization defined on the declarations page. as insured in the specific coverage. Loss is defined in Section N. Newly.ticquired Car means a car newly owned by you if it: 1. replaces your ea9,or 2. is an added car and we insure all other cans owned by you on the date of its delivery to you; but only ifyou: 1. tell us about it within 30 days after its delivery to you;and 2. if you have more than one of our car policies,tell us which one is to apply;and 3. pay us any added premium due. Non-oumed Car means a private passenger car or utility vehicle not. 1. owned by; 2. registered in the name of;or 3. furnished or available for the reguiar or frequent use of You or your relatives.The use must be within the scope of consent of the owner or person in lawful possession of it. Occupying means in,on,entering or alighting from.. Person means any human being. b_Readable car policy _ Page 2 Insuring agreement Policy changes Policy Terms policy based: 'Weagree to insure yore according to the terms of this The terms of this policy may be changed or waived only by 1. on your payment of premium for the coverages you chose;and 1. an endorsement;or 2. in reliance on your statements in your application 2. the revision of this policy form to give broader and the declarations page, coverage without an extra charge.If any coverage you carry is changed to give broader coverage,we will give You agree,by acceptance of this policy,that this policy you the broader coverage without the issuance of a contains all of the agreements between you and us or any new policy as of the date we make the change of our agents. effective. Unless otherwise stated on the declara-tions page,you are Change of Interest the sole owner of your car. No change of interest in this policy is effective unless we Unless otherwise stated on your car application for this consent in writing.However,if you die,we will protect as insurance: named insured: L neither you not any member ofyour household has, I.your surviving spouse; within the past 3 years,had a license to drive or 2. any person with proper custody of your car,a newly vehicle registration suspended,revoked or refused. acquired ear or a temporary substittete car until a 2.your car is used forpleasure• legal representative is qualified;and then When coverage applies 3. the legal representative while acting within the scope Your coverages are shown on the declarations page and of his or her duties. apply to accidents and losses that take place during the Policy notice requirements are met by mailing the notice to policy period.The policy period is shown on the the deceased named insured's last known address. declarations page and is for successive periods of six Joint and Individual Interests—When there are two months if the required renewal premium is paid,Payments must be made on or before the end of the current policy more named insureds,each acts for all to cancel or c period.The policy period begins and ends at 12:01 A.M. change the policy. Standard Time at the address shown on the declarations Renewal page. Unless we mail or deliver a notice of cancellation to you Where coverage applies within 60 days of the policy effective date,we agree- Your coverages apply: 1. to continue in force until the annual anniversary date; 1. in the United States of America,its territories and and possessions,and Canada;or 2. to renew the policy for the next policy period at the 2.while the insured vehicle is being hi ed between rates then in effect unless we snail to you written g' pp notice of our intention not to renew.The notice will their ports. be mailed to your last known address at least 30 days The following coverages apply in Mexico within 50 miles before the end of the current policy period.The of the nearest United States border: mailing of it shall be sufficient proof of notice. Section I.—Liability These agreements to continue and renew are void if we Section II.--First Party Benefits send cancellation notice to you if Section IV.—Physical Damage ].you failed to pay the premium when due;or A physical damage coverage loss in Mexico is determined 2. the driver's license of on the basis of cost at the nearest United States point. a. you; Two or more insureds b.your relative;or Our liability under this policy is not increased if more than c. any other person who drives your car was under one person is shown as the insured on the declarations suspension or revocation in the 12 months prior to page. the renewal date;or Readable car policy Pte. 3 3,you misrepresented a material fact to us. Agreement with state law Cancellation Terms of this policy which do not agree with the laws of How You May Cancel the stare where this policy is issued are amended to agree You may cancel your policy by written notice.mailed or wide those laws. delivered to us.The notice must give us the date to cancel, which must be later than the dateyou mail or deliver it to Reporting a claim —your duties VS. Notice to us of an accident or loss How and When We May Cancel You must give us or one of our agents written notice of the We may cancel your policy by written notice mailed to accident or loss as soon as reasonably possible. The notice your last known address.The notice shall give the date must give us: cancellation is effective.It will be mailed to you at least: 1.your name;and 1. 15 days before the cancellation effective date if the 2. the names and addresses of all persons involved;and cancellation is because: 3. the hour,date,place and facts of the accident or lass; a. you did not pay the premium;or and b. the driver's license of 4. the names and addresses of witnesses. (1) you;or Notice to us of claim or suit (2) your relative;or If a claim is made or suit is brought against an insured, (3) any other person who usually drives your ear that insured must at once send is every summons or legal was under suspension or revocation its the 180 process received. days prior to the renewal date. Other duties under the physical damage 2. 30 days before the cancellation effective date if the coverages cancellation is for any other reason. when there is a loss,you or the owner of the property also We cannot cancel this insurance unless: shall: 1.you fail to pay the premium when due;or 1, make a prompt report to the police when the loss is 2. the driver's license of: the result of theft or larceny. 2. protect the vehicle from further damage. Vewili a. you;or pay any reasonable,expense incurred to do it. b.yanr relative;or 3. file with us,within 91 days after the loss,sworn proof c. any other person who usually drives your car of loss in a form required by us. was under suspension or revocation in the ISO days 4. permit us to inspect and appraise the damaged prior to the renewal date;or property before its repair or disposal. 3..you misrepresent a material fact to us;or 5. provide all records,receipts and invoices,or certified 4.you defraud us. copies of them. We may snake copies. The mailing of it shall be sufficient proof of notice. Other duties under first party benefits Return of Unearned Premium The person making claim also shall: Ifyou cancel,premium may be earned on a short rate basis. 1. if an accident occurs,give us-written notice If we cancel,premium will be earned on a pro rata basis. adequately identifying the insured and reasonably Any unearned premium may be returned at the time:ve accessible facts concerning the time,place and cancel or within a reasonable time thereafter. Delay in the circumstance of the accident shall be given as soon as return of unearned premium does not affect the practicable by or on behalf of each insured to us or cancellation. any of our authorized agents. Action against us 2. as soon as practicable give us written proof of claim, There is no right of action against in until all the terms of under oath if required,fully describing the nature and extent of Godi6 itz'u. treatment and this policy have been met. y ry' rehabilitation received and contemplated and Readable car policy page� other information to assist us in determining the 1. make any payment or assume any obligation to amount due and payable. others;or 3. give us proof of claim upon forms furnished by us 2.incur any expense,other than for first aid to others, unless we fail to supply such forms within 15 days after receiving notice of claim. Section I —Liability coverages 4.submit to mental and physical examinations by physicians selected by us when and as often as we Bodily Injury Liability--Coverage A may reasonably require. We will pay the casts of Property Damage Liability—Coverage B such examinations. You have these coverages if Coverages A and B are shown 5. if we request,sign papers to enable its to obtain on the declarations page. medical reports and copies of records. A copy of Wewill: such medical report will be forwarded to such 1, pay damages which an insured becomes legally liable insured upon his written request. to pay because of 6. if benefits for income loss are claimed,authorize its to a. bodily it jury to others;and obtain details-of all earnings paid to him by an employer or earned by him since the time of injury or b. damage to or destruction ofpropetty including during the year immediately preceding the date of the loss of its use, accident. caused by or resulting from the ownership, Other duties under uninsured and maintenance or use ofyour car,and underinsured motor vehicle coverage 2. defend any suit against an insuredfor such darnages The person making claim also shall: with attorneys hired and paid by us. We will not 1, give us all the details about the death,injury, defend any suit after we have paid the applicable limit of our liability. treatment and other information we need to determine the amount payable. In addition to the limits of liability 2. be examined by physicians chosen and paid by us as We will pay on behalf of an insured any costs listed often as we reasonably may require.A copy will be below-resulting from an insured accident: sent to the person upon written request. If the person 1. court costs of any suit for damages, is dead or unable to act,his or her legal representative 2, interest on all damages owed by an insuredas the shall authorize us to obtain all medical reports and result of a judgment until we pay,offer or deposit in records. court the amount due under this coverage. 3. report a hit-and-run accident to the police promptly 3, premiums or costs of bonds: and to us within 30 daps. a. to secure the release of an insureds property 4, let ussee the insured car the person occupied in the attached under a court order.The amount of the accident. bond we pay for shall not be more than our limit 5. give us proof of claim on forms we furnish. of liability; 6. send us at once a copy of all suit papers if you,your b, required to appeal a decision in a suit for damages; relative or other person sues the party liable for the and accident for damages, c. up to$250 for each bail bond needed because of Insured's duty to cooperate with us an accident or traffic violation involving the use of The insured shall cooperate-with us,and when asked, your car. assist us in: We have no duty to furnish or apply for any bonds. 1. making settlements; 4. expenses incurred by an insured: 2.securing and giving evidence; a. for loss of wages or salary up to$35 per day if we 3. attending,and getting witnesses to attend,hearings ask the insured to attend the trial of a civil suit; and trials. b. for first aid to others at the time of the accident;or The insured shall not,except at his or her own cost, c. at our request. voluntarily: ® Readable car policy. Pages We have the right to investigate,negotiate and settle any What is not covered claim or suit. In addition to the limitations of coverage in "WHO IS AN Trailer coverage INSURED"and"TRAILER COVERAGE", Bodily Injury and Property Damage Liability coverages There is No coverage: apply to trailers only when the trailer is attached to your 1.WHU E ANY CAR OR TRAILER INSURED car except as follows. UNDER THIS SECTION IS: There is No coverage for wailers: a. RENTED TO OTHERS OR USED TO CARRY 1. if designed or used to carry persons; PERSONS FORA CHARGE.This does not 2. while used for business purposes; apply to the use of your car on a share expense 3. while used as premises; bans. 4. if it is not designed for use with a private passenger b. USED BY ANYP.ERSONEMPLOYED OR ENGAGED IN ANYWAY IN A CAR car or utility vehicle;or .BUSINESS.This does not apply to: 5. when used with a motor vehicle we do not insure. (1) you;or Coverage for the use of other cars (2) any relative,agent,employee or partner of Bodily Injury and Property Damage Liability coverages yours or your spouse.The coverage is excess extend to the use,by an insured,of newly acquired car,. for these persons. a temporary substitute car or a non-owned car while c. USED IN PREPARATION FOR ANY being used with the permission of the owner. IMPROMPTU,PREARRANGED OR Who is an insured? ORGANIZED RACING,SPEED, When we refer to your car,a newly acquired car or a DEMOLITION OR STUNTING CONTEST temporary substitute car,insured means: ORACTMTY,OR USED IN THE EVENT ITSELF. 1.you; 2. FOR ANY BODILYINJURY: 2.your relatives, a. TO A FELLOW EMPLOYEE WHILE ON THE 3. any other person while using your car if its use is within the scope of your consent;and JOB AND ARISING FROM THE MAINTENANCE OR USE OF A VEHICLE BY 4.any other person or organization liable for the use of ANOTHER EMPLOYEE IN THE your car by one of the above insureds. EM.PLOYER'S BUSINESS.You are covered fit When we refer to a non-awned car,insured means such injury to a fellow employee. 1.you b. TO ANY EMPLOYEE OF AN INSURED 2.your relatives,and ARISING OUT OF HIS OR HER EMPLOYMENT.This-does not apply to a 3. anyperson or organization which does not own or household employee who is not covered or hire the car but is liable for its use by one of the required to be covered under any worker's above persons compensation insurance. Non-owned cars c. CAUSED INTENTIONALLY BY THE There is no coverage for non-owned cars: INSURED. 1.WHILE BEING REPAIRED,SERVICED OR 3. FOR ANY DAMAGES: USED BY ANY PERSON WHILE THAT a. TO PROPERTY OWNED BY,RENTED TO, PERSONIS WORIONG IN ANY CAR IN CHARGE OF OR TRANSPORTED BY AN BUSINESS;OR INSURED.But coverage applies to a rented 2.WHILE USED IN ANY OTHER BUSINESS OR residence or private garage damaged by a car we OCCUPATION.This does not apply to aprivate insure. passenger car driven or occupied by you. b. CAUSED INTENTIONALLY BY THE INSURED. 4. FOR ANY OBLIGATION OF AN INSURED,OR HIS OR HER INSURER,UNDER ANY TYPE OF 0 Readable carpolicy Noo 6 WORKER'S COMPENSATION OR DISABILITY proportionate share with other collectible liability OR SIMILAR LAW. insurance. 5. FOR LIABILITYASSUMED BYTHE LIVSUA-PD Financial responsibility law UNDER ANY CONTRACT ORAGREEMIENT Out-of-State Coverage 6. EXCEPT AS TO YOU,WHILE YOUR CAR IS If an insured under the liability,coverage is in another state SUBJECT TO ANY CONDITIONAL SALE OR or Canada and,as a non-resident becomes subject to its PURCHASE AGREF'h4ENT NOT DECLARED motor vehicle compulsory insurance,financial IN THE POLICY. responsibility or similar law: 7. FOR BODILYVVJURYOR PROPERTY L the policy will be interpreted to give the coverage DAIMAGE FROM ANY NUCLEAR REACTION, required by the law;and RADIATION OR RADIOACTIVE the coverage so given replaces any coverage in this CONTAMINATION,ALL WHETHER policy to the extent required by the law for the CONTROLLED OR UNCONTROLLED OR insured`s operation,maintenance or use of a car HOWEVER CAUSED,OR ANY insured under this policy. CONSEQUENCE OF ANY OF THESE. Any coverage so extended shall be reduced to the extent Limits of liability other coverage applies to the accident.In no event shall a A car and an attached trailer are considered one car. persons collect more than once. Therefore,the limits are nor increased. Financial Responsibility Law—When certified under The limits of liability are not increased because more than any law as proof of future financial responsibility,and one person or organization may be an insured while required during the policy period,this policy shall When two or more motor vehicles are insured under this comply with such law to the extent required.The insured section the limits apply separately to each. agrees to repay its for any payment we would not have had Single limit liability coverage to make under the terms of this policy except for this The amount of Bodily Injury Liability,Coverage A,and agreement. Property Damage Liability,Coverage B,arc shown on the Action against us declarations page as a single limit. We will pay up to this There is no fight of action against as until the amount of amount for all damages resulting from any one occurrence damages all insured is legally liable to pay has been finally for which an insured is legally liable- determined by: We will apply the limit of liability to provide any separate 1. judgment after actual trial,and appeal,if any;or limits required by law for Bodily injury or Property 2. agreement between the insured,the claimant and us. Damage Liability,However,this provision will not change Any person or organization who has secured a judgment our total limit of liability. that has been sustained,if appealed,or a written agreement Split limit liability coverage of settlement,may be paid up to the amount of insurance The amount of Bodily injury Liability,Coverage A,is afforded by this policy. shown on the declatatioms page.The amount indicated by TWs policy does not: "Each Person"is the amount of coverage for all damages 1. give any person or organization the right to include due to bodily injury to one person.The amount indicated -as as a party to any suit againstyou to determine by"Each Occurrence"is the total amount of coverage for your liability, 0 injury damages due to bodily inju to two or more persons in the same occurrence.The amount of Property Damage 2. give you or your legal representative the fight to Liability,Coverage B,is shown on the declarations page. bring as into any suit brought against you to We will pay damages for which an insured is[legally liable determine your liability. up to these amounts. Bankruptcy or insolvency of the insured or his or her If there is other coverage estate shall not relieve us of our obligations. If an insured is using a temporary substitute car or Our right to recover our payments Von-owned car,out,liability insurance will be excess over The right of recovery of any party,we pay passes to us. other collectible insurance.If more than one policy applies Such party shall: to an accident involving your car,we will bear our 1. not hurt our rights to recover;and ® Readable car policy Page 7 2. help us get our money back. Income loss means eighty(84%)percent of gross income actually lost by an eligible person.Income Ioss.includes Section 11 -- first party benefits reasonable expenses actually incurred for hiring: i. a substitute to perform the work a self—employed Medical Expenses—Coverage C eligibleperson would Have performed except for In accordance with the Pennsylvania Motor Vehicle bodily injury,or Financial Responsibility Law,we will pay first party 2. special help,thereby enabling a person to work, benefits for medical expenses arising from bodily injury to thereby reducing loss of gross income. an eligible person resulting from the maintenance or use of a motor vehicle as a vehicle. Income loss does not include: Medical expenses means reasonable and necessary charges 1. loss of expected income for any period following the for: death of an eligible person,or 1. medical treatment,including but not limited to: 2. expenses incurred for services performed following a. medical,hospital,surgical,nursing and dental the death of an eligible person,or services; 3. any loss of income during the first five(5)working b. medications,medical supplies and prosthetic days the eligible person did not work after the devices;and accident because of the bodily in/my. c, ambulance; Accidental Death--Coverage C4 2. medical and rehabilitative services,including but not In accordance with the Pennsylvania Motor Vehicle limited to: Financial Responsibility Law,we will pay first party benefits for accidental death arising from bodily hilwy to a. medical care; the named insured or relative resulting from the b. licensed physical therapy,vocational rehabilitation maintenance or use of a motor vehicle as a vehicle. and occupational therapy; Accidental death means the death of the named insured or c. osteopathic,chiropractic,psychiatric and relative if death occurs within 24 months from the date of psychological services;and the accident.The death benefit shall be paid to the d. optometric services,speech pathology and executor or administrator of the estate of the named audiology; insured or relative. 3. nonmedical remedial care and treatment rendered in Funeral Services—Coverage CS accordance with a recogn Zed religious method of In accordance with the Pennsylvania Motor Vehicle healing. Financial Responsibility Law,we will pay first parry All medical treatment and medical and rehabilitative benefits for funeral services arising from bodily injury to services must be provided by or prescribed by a person or an eligible person resulting from the maintenance or use of facility approved by the Department of Bealth,the a motor vehicle as a vehicle, equivalent governmental agency responsible for health Funeral Services means reasonable expenses directly related programs or the accrediting designee of a department or to the funeral,burial,cremation or other form of agency of the state in which those services are provided. disposition of the remains of the deceased digibleperson. Payment of medical expenses incurred after 18 months The expenses must be incurred as a result of the death of from the date of the accident causing bodily injury shall be the eligibleperson and within 24 months from the date of made only if within 18 months from the date of the the accident, accident causing injury it is ascertainable with reasonable Definitions medical probability that further expenses may be incurred Bodily injury means accidental bodily harm to a person as a result of the injury. and that person's resulting illness,disease or death. Income Loss—Coverage C2 CatastropbicLoss Trust-Fund means the Fund established In accordance with the Pennsylvania Motor Vehicle under the Pennsylvania Motor Vehicle Financial Financial Responsibility Law,we will pay first party Responsibility Law(75 Pa.C.S.Ch. 17 F.). benefits for income loss arising from bodily injury to an Eligible person means: eligiblepersou resulting from the maintenance or use of a 1. the named insured or any relative, motor vehicle as a vehicle. ID Readable car policy page s 2. any other person who sustains bodily injury A.INTENTIONALLY INJURING OR a. while occupying the insured motor vehicle,or ATTEMPTING TO INTENTIONALLY 6. while anon-occupant of a motor velricle if injured INJURE HIMSELF OR ANOTHER, as a result of an accident in Pennsylvania involving B.COMMITTING A FELONY,OR the insured motor vebide.An unoccupied parked C.SEEKING TO ELUDE LAWFUL irtaured motor vehicle is not a motor vehicle APPREHENSION OR ARREST BY A LAW involved in an accident unless it was parked in a ENFORCEMENT OFFICIAL; manner as to create an unreasonable risk of injury. 5. ANY PERSONENGAGED IN THE BUSINESS Insured sootor vehicle means a motor vehicle: OF REPAIRING,SERVICING,OR OTHERWISE 1. to which the bodily injury liability insurance of the MAINTAINING MOTOR VEHICLES IF THE policy applies(and for which a specific premium is BODILYINJURYARISES OUT OF THAT charged),and BUSINESS UNLESS THE CONDUCT OCCURS 2. for which the named insured maintains First Party OFF THE BUSINESS PREMISES; Benefits as required under the Pennsylvania Motor 6. ANY PERSONNOT OCCUPYING AMOTOR Vehicle Financial Responsibility Law. VEHICLE OTHER THAN THE NAMED Motor vehicle means any vehicle which is self-propelled INSURED OR ANY AMTIVE,IF THE except one which is propelled: ACCIDENT OCCURS OUTSIDE THE OF PENNSYLVANIA; 1.solely by human power. 7.ANY PERSON SUSTAINING BODILYINJURY 2. by electric power obtained from overhead trolley AS A DIRECT RESULT OF LOADING OR wires,or UNLOADING ANY MOTOR VEHICLE; 3. upon rails. 8. ANY PERSONWHILE MAINTAINING OR What is not covered USING AMOTOR VEHICLEWHILE These coverages do not apply to bodily injury to: LOCATED FOR USE AS A.RESIDENCE OR PM VISES; I.ANY PERSONWHO IS THE OWNER OF A 9. ANY PERSONDUE TO WAR,WHETHER OR CURRENTLY REGISTERED MOTOR VEHICLE NOT DECLARED,CIVIL WAR, FOR WHICH FINANCIAL RESPONSIBILITY IS INSURRECTION,REVOLUTION OR NOT PROVIDED,EVEN IF THAT PERSONIS REBELLION OR ANY ACCOMPANYING ACTS OCCUPYING OR STRUCK BY AMOTOR OR CONDITIONS:AND VEHICLE FOR WHICH FINANCIAL, RESPONSIBILITYIS PROVIDED; 10. ANYPERSONCAUSED BY NUCLEAR 2.ANY PERSON WHILE OCCUPYING A RADIOACTIVITY OR EXPLOSION. MOTORCYCLE,MOTOR-DRIVEN CYCLE, Policy Period;Territory MOTORIZED PEDALCYCLE OR LIKE TYPE These coverages apply only to accidents which occur VEHICLE REQUIRED TO BE REGISTERED during the policy period and within the United States of UNDERTITLE 75 ORA RECREATIONAL America,its territories and possessions or Canada. VEHICLE NOT INTENDED FOR HIGHWAY USE; Limits of liability 3. ANY PERSONOTHER THAN THE NAMED 1. Our liability for benefits with respect to bodily INSURED ORANY RELATIVE,WHO injury to any one eligible person in any one motor KNOWINGLY CONVERTS AMOTOR vehicle accident is limited to the amount shown on VEHICLE IF THE BODILYINJURYARISES the declarations page for each coverage shown;or OUT OF THE MAINTENANCE OR USE OF 2.If the declarations page shows that Combination THE CONVERTED VEHICLE; Benefits apply,we will pay: 4. ANY PERSONWHEN THE CONDUCT OF THAT PERSONCONTRIBUTED TO THE BODILYINJURYSUSTAINED BYTHAT PERSON,WHILE O Readable car policy__ _ Page 9 Benefit Limit Fourth-The insurer providing benefits on any motor Coverage C— Subject to Aggregate Limit vehicle involved in the accident if the eligible person is Medical Expenses not(I)occupying a motor vehicle,and(2)provided Coverage C2— Subject to Aggregate Limit coverage under any other policy. Income Loss The"First"category listed above is the highest level of priority,and the"Fourth"category listed above is the Coverage C4— Subject to amount shown in lowest level of priority. Accidental Death the Declarations If two or more policies bave equal priority: Coverage C5— Subject to amount shown in Funeral Services the Declarations 1. the insurer against which the claim is first made shall The Aggregate Limit is shown on the declarations page. process and pay the claim as if wholly responsible. The Aggregate Limit is the total amount payable for all 2, the maximum recovery under all policies will not benefits(as defined and limited in this section)with respect exceed the amount payable under the polity with the to bodily injury to any one eligible person in any one highest dollar limits of benefits. motor vehicle accident for expenses and loss incurred For the purposes of determining priorities,an unoccupied within three years from the date of the accident. parked motor vehicle is not a motor vehicle involved in an Benefits shall not be increased for any eligible person by accident unless it was parked in a manner as to create an adding together the limits of liability! unreasonable risk of injury. 1. under this policy because there are multiple motor Action against us vehicles covered under this policy,or No action shall lie against us on the part of any eligible 2. under multiple motor vehicle policies coveting an person unless such person has filly complied with all the eligible person for the same loss. terms of these coverages. Any amount payable by us under the terms of these Customary charges for treatment coverages: The amount rue will pay to a person or institution 1. for medical expenses greater than$100,000 shall be providing treatment,accommodations,products or services excess over any amount paid or payable under the to an eligible person for an injury covered by medical Catastrophic Loss Trust Fund,and expense benefits shall not exceed the amount the person or 2. for First fart Benefits shall be excess over all benefits institution customarily charges for like treatment, Party accommodations,products and services in cases involving that an eligible person receives or is entitled to no insurance. receive under any workers'compensation law or similar law. Non-duplication of benefits Priorities of policies No eligible person shall recover duplicate benefits for the same elements of loss under this or any other similar We will pay First Parry Benefits in accordance with the automobile insurance including self-insurance. following order of priority. We will not pay if there is another insurer at a higher level of priority.The priority order is: Section III — UninsuredlUnderinsured First-The insurer providing benefits to the eligible motor vehicle person as a named insured. Uninsured/Underinsured Motor Vehicle—� Second-The insurer providing benefits to the eligible Coverage J person as a relative who is not a named insured under In accordance with the Pennsylvania Motor Vehicle another policy providing coverage under the Financial Responsibility Law,we will pay damages which Pennsylvania Motor Vehicle Financial Responsibility an inured is legally entitled to recover from the owner or Law. operator of either an uninsured motor vehicle or Third-The insurer of the motor vehicle which the underinsured motor vehicle,but not both,because of eligible person is occupying at the time of the accident, bodily injury: 1. sustained by an insured,and 2. caused by an accident. Readable car policy Aage 10 The owner's or operator's liability for these damages must 3. to whitch a boddy injusy liability bond or policy arise out of the ownership,maintenance or use of the applies at the time of the accident but the bonding or unimuredniotor vehicle or undetituaredutotor vehicle. insuring company. Wewlli pay damages under this coverage arising out ofan a. denies coverage;or accident with an underinsured viotor vehide only after the limits of liability under any applicable bodily injury b. is or becomes.- liability bonds or policies have been exhausted by payment (1) solvent;or of judgments or settlements. (2) involved in insolvency proceedings. The amount of damages we will pay is subject to The Uninsuredniotor vehicle does not include: pro-visions of our Limit of Liability. No judgment for damages arising out of a suit brought 1. an anderinsm-ed urotor vehkL-,or against the owner or operator of an uninsured viotor 2. any vehicle or equipment owned or operated by a vehicle or underiam-ed motor vehicle is binding on its self-insurer under any applicable inotor vehicle law, unless we. In addition,neither uninsured inotor vehicle nor 1. received reasonable notice of the pendency of the suit underiluaredmotor vehick includes anyvehicle or resulting in the judgment;and equipment: 2. had a reasonable opportunity to protect our interests 1. owned by or furnished or available for thexegular use in the suit. of you or your relative. Insured as used in this section ineans; 2.owned by any governmental unit or agency, I-you or your rektive. 3.operated on tails or crawler treads. 4. designed mainly for use off public roads while not on 2.any other person occupArgyour car. public roads. 3. anypin-son for damages thatperson'is entitled to recover because of bodibi injury to which this 5.while located for use as a residence or premises. coverage applies sustained by aperson described in 1. What is not covered Underiusuredinotor vehicle means a land motor vehicle UADERMUPED MOTOR VEHIMLE COVERAGE or trailer of any type to which a bodily injimy liability FOR BODLEYIWURYSUSTAINED BY ANY bond or policy appliev at the time of the accident but its PERSON. limits for bodily injury liability is not enough to pay the I- IF THAT PERSONOR THE LEGAL full amount the insured is legally entitled to recover as REPRESENTATI'VE SETTLES THE BODILY IA7URYCLATM WITHOUT OUR CONSENT. Underinsuredinotor vehicle does not include an 2.WHILE OCCUPYING YOUR CAR WHEN IT IS uninsured motor vehicle, BEING USED TO CARRY PERSONS OR Uninsured7notor vehicle means a land motor vehicle or PROPERTYPOR A FEE.THIS EXCLUSION trailer of any type. DOESNOTAPPLYTOA I- to which no boeftly h6ury liability bond or policy SHARE-THR-EXPENSE CAR POOL. applies at the time of the accident, 3. USING AVEHICLE WITHOUT A REASONABLE BELIEF THAT THAT PARSON 2.which is a hit and run vehicle whose operator or IS ENTITLED TO DO SO. owner cannot be identified and which CabSeS an accident resulting in bodily injuryWithout hitting; THIS COVERAGE S14ALL NOT APPLY DIRECTLY OR INDIRECTLY TO BENEFIT a. you or your relative, ANY INSURER OR SELF-INSURER UNDER h. a vehicle which you or your relative are ANY OF THE FOLLOWING OR SIMILAR LAW- occupying,or I.WORKER!S COMPENSATION LAW,OR c� your car. 2. DISABILITY BENEFITS LAW. If there is no physical contact with the hit and Tun vehicle the facts of the accident must be prova — ® Readable car policy page I I Limit of liability Second-The policy affording Except as provided in the following paragraph,the limits of UuitsuredlUnderinsuredMotor Vehicle Coverage liability shown on the declarations page for to the insured as a named insured or relative. UninsuredlUuderinsuredMotor Vehicle Coverage is our 2.we will pay tinily our share of the loss. Our share is maximum limit of liability for all damages resulting from the proportion that our limit of liability bears to the any one accident.Tbis is the most we will pay regardless of total of all limits applicable on the sane level of the number of: priority. 1. insureds; Arbitration 2. claims made; If we and an itzsured do not agree: 3. vehicles or premiums shown on the declarations page; I.whether tbatperson is legally entitled to recover or damages from the owner or operator of an ruzitunred 4. vehicles involved in the accident. motor vehicle or underbutired motor vehicle; If bodily injury is sustained in an accident by you or your 2. as to die amount of damages; relative,our maximum limit of liability for all damages in either party may make a written demand for arbitration. any such accident is the sum of the limits of Liability for Arbitration shall be conducted in accordance with the UttirtstitedlUndetiruuredMotor Vehicle coverage shown provisions of the Pennsylvania Uniform Arbitration Act. on the declarations page applicable to each vehicle.Subject Each party will select an arbitrator.The two arbitrators will to this maximum limit of liability for all damages,the most select a third.If they cannot agree within 30 days,either we will pay for bodily injury sustained by an insured other may request that selection be made by a judge of a court than you or your relative is the limit shown on the having jurisdiction.Each party will: declarations page applicable to the vehicle the insured was 1, pay the expenses it incurs;and occupying at the time of the accident.This is the most we will pay regardless of the,number of 2, bear the expenses of the third arbitrator equally. 1. insureds; Unless both parties agree otherwise,arbitration will take place in the county in which the insured lives.Local rules 2. claims made;or of law as to procedure and evidence will apply.A decision 3. vehicles involved in the accident- agreed to by two of the arbitrators will be binding. However,no insured-will be entitled to receive duplicate payments for the same elements of loss. Section IV— Physical damage Any amounts otherwise payable for damages which the coverages insuredis legally entitled to recover from the owner or Comprehensive Coverage D operator of an uninsured motor vehicle or rnzderimured motor vehicle because of bodily injury caused by an You have this coverage if Coverage D is shown on the accident,shall be reduced by all sums paid because of the declarations page.If a deductible applies,the amount is bodily injury by or on behalf of persons or organizations shown on the declarations page. who may be legally responsible.This includes all sums paid We will pay for loss to your car EXCEPT LOSS BY under Section 1. COLLISIONbut only for the amount of each such loss in Any payment under these coverages will reduce any excess of the deductible amount,if any. amount that person is entitled to recover for the same Breakage of glass,or loss caused by missiles,falling objects, damages under Section 1. fire,theft,larceny,explosion,earthquake,windstorm,hail, water,flood,malicious mischief or vandalism,riot or civil Other insurance commotion is payable under this coverage.Loss due to If there is other applicable similar insurance available under hitting or being hit by a bird or an animal is payable under more than one policy or provision of coverage: this coverage. 1. the following priorities of recovery apply: Supplementary payments First-The Unitmured(UnderinsuredMotor Vehicle Wewifl: Coverage applicable to the vehicle the insured was oeeupyingat the time of the accident. L repayyou for transportation costs ifyour entire car is stolen. We will pay up to$10 per day,but not more than a total of$300,for the period that begins 48 ID Readable car policy page 12 hours after yore tell us and the police of the theft,The Any deductible amount that applies is then subtracted. period ends when the car is returned to use or we If your car is a van,pick-up or recreational vehicle,the offer to pay for loss, inost we will pay for loss to your insured vehicle is the 2. pay general average and salvage charges for which you lower of: become legally liable because of your car being 1. the actual cash value;or transported. 2. the stated awwwtsbown on the declarations page; Collision—Coverage E or You have this coverage if Coverage E is shown on the 3, the cost of repair or replacement. declarations page.The deductible amount is shown on the declarations page. Any deductible amount that applies is then subtracted.If at Collision means your car hit or was hit by another object the time of loss the actual cash value is greater than the stated amount shown on the declarations page,you will or vehicle,and includes upset. pay part of the loss.Our portion of the payment is that We will pay for loss to your car caused by collision but percentage that the actual cash value bears to the stated only for the amount of loss that exceeds your deductible antouutat the time of the loss. amount.If the collision is with another motor vehicle --Settlement of LASS Comprehensive and insured with its,you do not pay your deductible if it is p $100 or less.This waiver of deductible does not apply if Collision Coverage the vehicles involved are owned by you or a resident of We have the right to settle a loss with you or the owner of your household. the property in one of the following ways; Clothes and Luggage---Comprehensive and 1. Pay up to the actual rush value, Collision Coverages 2. repair or replace the property or part with like kind We will pay for loss to clothes and luggage owned by you .and quality less any depreciation; or your relatives.These items must be in or on your cat. 3. return the stolen property and pay for any damage Your car must be covered under this policy for. due to the theft;or 1. Comprehensive,and the loss must be caused by fire, 4. take the property at an agreed value,but it cannot be lightning,flood,falling objects,explosion,earthquake abandoned to us, or theft.If the loss is due to theft,YOUR ENTIRE Wlren there is loss to your car,clothes and luggage in the CAR MUST HAVE BEEN STOLEN;or same occurrence,any deductible will be applied.first to the 2. Collision,and the loss must be caused by eollfsimi. loss to your car. You pay only one deductible. We will pay up to$200 for loss to clothes and luggage in Emergency Road Service—Coverage l excess of any deductible amount shown for comprehensive You have this coverage if Coverage I is shown on the or collision.Two hundred dollars($200)is the most we declarations page. Vewill pay the fair cost incurred for will pay in any one occurrence even though more than one your car up to the limits shown on the declarations page person has a loss.This coverage is excess over other for. collectible insurance. Rental car—repayment of deductible 1. mechanical labor at the place of its breakdown; 2_ towing to the nearest glace where the necessary We will repay you the difference between yattr repairs can be made during regular business hours if Comprehensive or Collision deductible amount and airy it will not run; greater deductible amount you are required to pay under a car rental agency's Comprehensive or Collision coverage in 3. towing it out if it is stuck on or immediately next to a effect on a rental car. public highway; Limits of Liability—Comprehensive and 4• delivery of gas,oil,loaned battery,or change of tire. WE DO NOT PAY FORTHE COST OP THESE Collision Coverages ITEMS. The limit of our liability for loss to property or any pan of it is the lower oft Rental Reimbursement Coverage R 1. the actual cash value,or You have this coverage if Coverage R is shown on the declarations page. the will repay you up to the amount 2, the cost of repair or replacement. shown on the declarations page when you rent a car from a ID Readable car policy �agt 13 car rental agency or garage because of a Comprehensive or Collrsiotr type loss to your car beginning: 3. furnished or available for the regular or frequent use of 1.when it is inoperable due to the loss;or you or your relatives. 2, if it can run,when you leave it at the shop for agreed repairs; Coverage for the use of other Lairs and ending: The coverages in this section you have on your car extend to a loss to a newly acquired car,a temporary substitute 1.when it has been repaired or replaced;or car or a non-owned car.These coverages extend to a 2. when we offer a fair cash settlement for the loss. non-owned car while it is driven by or in the custody of This coverage does not apply in the event your entire car is you or your relatives.Its use has to be within the scope of stolen. the consent of the owner or person in lawful possession. Sound System Coverage--.Coverage Dl Definitions You have this coverage if Coverage DI is shown on the Actual cash value is determined by market value,age and declarations page. condition at the time the loss occurred. We will pay for loss by theft of any: Loss means each direct and accidental loss of or damage to: 1. citizens or commercial band radio; 1.your cat, 2. transceiver; 2, its equipment which is common to the use of your ca 3. a vehicle; 3. radio telephone;or 3, clothes and luggage insured;and 4. radio transmitter 4. a detachable living quarters attached to or removed permanently installed in your car and from your car for storage.Detachable living quarters 5. any specialized antenna for use with any of the above. includes its body and items securely fixed in place as a This coverage does not include loss by theft of any permanent part of the body. You must have told us about the l electronic transmission device wholly or partially designed ]Wing quartets before the loss and paid any extra premium needed. to prevent radar detection or any other law enforcement detection measures. StatedAmount is the dollar value shown by the model The most we will pay for any single loss is the amount type on the declarations page. shown on the declarations page. When Coverages D, D I, E, I and R do not Trailer coverage apply. Owned Trailer There is No coverage under Coverages D,DI,E, Your Trailer is covered: I and R for: L-when it is described on the declarations page with an 1. A NON-OWNED CAR: applicable premium amount shown;and a. WHILE BEING REPAIRED,SERVICED OR 2. for coverages shown as applying to it. USED BY ANY PERSON WHILE THAT Non-Owned Trailer or Detachable Living PERSONIS WORKING IN ANY CAR Quarters BUSINESS;OR Any Comprehensive or Collision coverage in force on your b.WHILE USED IN ANY OTHER BUSINESS car applies up to$500 for loss to anon-owned: OR OCCUPATION.This does not apply to a private passenger car driven or occupied by you 1. trailer,or of your relatives. 2. detachable living quarters unit used by you or your 2.LOSS TO ANY VEHICLE: relatives. a. WHILE RENTED TO OTHERS OR USED A non-owned trailer or detachable living quarters unit is TO CARRY PERSONS FOR A CHARGE. one that is not: This does not apply to the use of ; PP y yea•car on a share I. owned by; expense basis. 2. registered in the name of;or b. DUE TO TAKING BY GOVERNMENTAL AUTHORITY. Q Readable car policy Page 14 c. DUE TO WAR OF ANY KIND. d. DUE TO NUCLEAR REACTION, If there is other coverage If there is other insurance covering the loss at the time of RADIATION OR RADIOACTIVE the accident,we will pay only our share of any damages, CONTAMINATION,ALL WHETHER Our share is determined by adding the limits of this CONTROLLED OR UNCONTROLLED OR HOWEVER CAUSED,ORANY insurance to the limits of all other insurance that applies on CONSEQUENCE OF ANY OF THESE. the same basis and finding rile percentage of the total that our limits represent. e. USED IN PREPARATION FOR ANY When this insurance covers a tannporary srtLstitute car or IMPROMPTU,PREARRANGED,OR ORGANIZED RACING,SPEED noa:-awned car,we will pay only after all other collectible insurance has been exhausted. DEMOLITION OR S'T'UNTING CONTEST exhausted. ORACTIVITY,OR USED IN THE EVENT When this insurance covers a newly acquired cur,this ITSELF. policy won't apply ifyou have other collectible insurance. 3. THE COST OF TOWING,TRANSPORTATION When more than one coverage is applicable to the loss,you OR SALVAGE OPERATIONS OF YOUR CAR may recover under the broadest coverage but not both. WHILE WITHIN THE REPUBLIC OF LMXICO. No benefit bailee There is No coverage tinder Coverages D, E and These coverages shall not benefit any carrier or other bailee R for: for hire liable for the lass. 1.LOSSTO ANY VEHICLE DUE TO: Action against us a. WEAR AND TEAR,FREEZING, There is no action against us until 30 clays after we get the AIECH.ANICAL OR ELECTRICAL insureds notice of accident or loss BREAKDOWN OR FAILURE.This does not apply when the loss is the result of a theft covered Our right to recover our payments by this policy.Not does it a 1 to emer en The right of recovery of any party we pay passes to us. PP y g cY road service. Such party shall: b. CONVERSION,EMBEZZLEMENT OR I- not hurt our rights to recover,and SECRETION BY ANY PERSONWHO HAS 2. help us get our money back. THE VEHICLE DUE TO ANY LIEN, Appraisal RENTAL OR SALES AGREEMENT. If an agreement cannot be reached regarding the amount of 2. LOSS TO TIRES unless: loss,then either you or we may demand that the amount a. stolen,or damaged by fire or vandalism;or be determined by appraisal.The written demand must be b. other loss covered by this section happens at the made within 60 days after we receive proof of loss, same time. If either makes a written demand for appraisal,each will 3.LOSS TO TAPES FOR RECORDING OR select a competent,independent appraiser and notify the REPRODUCING SOUND. other of the appraiser's identity within 20 days of receipt of the written demand.The two appraisers will then select a 4.LOSS$Y THEFT OF ANY ELECTRONIC competent,impartial umpire.If the two appraisers are RECEIVING,RECORDING OR PLAYBACK unable to agree upon an umpire within 15 days,you or we DEVICE.This does not apply to a radio,tape can ask a judge of a court of record in the state where the recorder or player or any combination thereof if it is appraisal is pending to select an umpire. permanently installed.Slide mounts or like devices The appraisers will then det are not considered to be a permanent installation. ermine the amount of the damage stating separately,in detail,the actual cash value 5. LOSS BY THEFT OF ANY CITIZENS BAND at the time of loss and amount of loss.If the appraisers RADIO,HANI RADIO,RADIO TELEPHONES submit a written report of any agreement to:a,the OR ANY OTHER ELECTRONIC amount agreed upon will be the amount of the damage or TRANSMISSION DEVICE. value'.If the appraisers fail to agree within a reasonable 6.LOSS TO ANY SPEAKERS IF THEY ARE NOT time,they will submit only their differences to the umpire. PERMANENTLY INSTALLED. Written agreement so itemized and signed by any two of these three sets the amount of loss Each appraiser will be ®Readable car policy Page rs paid by the party selecting that appraiser.Other expenses of the appraisal and the compensation of the umpire will be paid equally by you and its. Two or.more vehicles If two or more of your cars are insured for the same coverage,the coverage applies separately to each. In witness whereof,we have caused this policy to be signed by our Secretary and our President at Springfield,Illinois, and,if required by state law:this policy shall not be binding unless countersigned by an authorized agent of ours. Ann M.CaparrGs Peter H.Heclonan Corporate Secretary President Section V—Notice/Endorsement ® Indorsements Pennsylvania amendatory and such concealment,allegation or misrepresentation was endorsement material to the acceptance of the risk by us. CC-NO I PA 1 (9/06) This provision amends your"Readable car policy_" Section If -- First party benefits Defined Words WHAT I5 NOT COVERED The definition of private passenger car is amended to read Item 1 is amended to read as follows: as follows: 1. ANY PERSONWHO,AT THE TIME OF THE Private passenger car means a four wheel motor vehicle, ACCIDENT: except recreational vehicles not intended for highway use, a. IS THE OWNER OF ONE OR MORE which is insured by a natural person and: REGISTERED MOTOR VEHICLES AND 1, is a passenger car neither used as a public or livery NONE OF THOSE MOTOR VEHICLES conveyance nor rented to others;or HAVE IN EFFECT."THE FINANCIAL 2. has a gross weight not exceeding 9,000 pounds and is RESPONSIBILITY REQUIRED BY THE not principally used for commercial purposes other PENNSYLVANIA MOTOR VEHICLE than farming. FINANCIAL RESPONSIBILITY LAW;OR The term does not include any motor vehicle insured b. IS OCCUPYING AMOTOR VEMCLE exclusively under a policy covering garage,automobile sales OWNED BY THAT PERSON FOR WHICH agency repair shop,service station or public parking place THE FINANCIAL RESPONSIBILITY operation hazards. REQUIRED BY THE PENNSYLVANIA MOTOR VEHICLE FINANCIAL Insuring Agreements RESPONSIBILITY LAW IS NOT IN EFFECT. Cancellation How and When We Nay Cancel This provision is amended to read as follows: We may cancel your policy by written notice mailed to your last known address. The notice shall give the date cancellation is effective. It will be mailed to you at least: 1. 15 days before the cancellation effective date if the effective date of the cancellation is because: a. you did not pay the premium;or b. the drivels license of the named insured was under suspension or revocation in the 180 days prior to the renewal date. 2. 60 days before the cancellation effective date if the cancellation is for any other reason. We cannot cancel this insurance unless: I.you fail to pay the premium when due;or 2. the driver's license of the named insured was under suspension or revocation in the 180 days prior to the renewal date;or 3.you: a. conceal a material fact from ur,or b. make a material allegation contrary to fact;or G make a misrepresentation of a material fact Preferred Provider Endorsement CC-N 11003 (11/11) This endorsement amends your"Readable car policy". Rental Reimbursement-Coverage R Under"Rental Reimbursement-Coverage R",the following is added: The aggregate limit of liability as shown on your declarations page for this coverage does not apply if your covered loss is repaired by a Horace Mann A+Repair facility. Definitions The following definition is added: "Horace Mann A+Repair facility"means a member of our current designated network of car repair facilities that have agreed to provide car related repair services to our clients. 0 Endorsements Uninsured/Underinsured Motor b. is or becomes: Vehicle amendatory endorsement CC-N04PA I{10106) (1) insolvent within G years of the date of the accident;or Amend Section 111- Uninsured/Underinsured Motor Vehicle and any applicable endorsements ofyour �2) involved in insolvency proceedings. "Readable Car Policy" as follows: Uninsured motor vehicle does not include: Uninsured/Underinsured Motor Vehicle— 1. an"nderinsured motor vehicle,or Coverage J 2. any vehicle or equipment owned or operated by a The definition of insured is replaced by the following self-insurer under any applicable motor vehicle "Insured"as used in this section means: law. In addition,neither uninsured motor vehicle nor 1,you' underinsured motor vehicle includes any vehicle or 2.your re& ives; equipment: 3. any other person who,at the time of the accident,is 1. owned by or furnished or available for the regular occupying. use ofyou or your relative, a. your car,a ternporarysubstitute car,or a newly 2. operated on rails or crawler treads. acquired car,provided the operation and the 3. designed mainly for use off public roads while not actual use of such car is with your permission and on public roads. is within the scope of such permission; 4. while located for use as a residence or premises. b. a car not owned by you or any rebuive,but driven by you within the scope of the owner's Other insurance consent, unless the other person owns or holds The Arbitration section has been deleted. title to a car. Such other person occupying a car used to carry persons for a charge is not an insured 4. any person entitled to recover damages because of bodily injury to of death of an insured under 1. through 3.above. The following is amended: Uninsured motor vehicle means a land motor vehicle or trailer of any type: 1. to which no bodily injury liability bond or policy applies at the time of the accident. 2. which is a hit and run vehicle whose operator or owner cannot be identified and which causes an accident resulting in bodily injury without hitting; a. you or your relative, b. a vehicle which you or your relative are occupying,or c. your car. If there is no physical contact with the hit and run vehicle the facts of the accident must be proved. 3. to which a bodily injury liability bond or policy applies at the time of the accident but the bonding or insuring company: a. denies coverage;or Horace Mann Property & Casualty convicted of a moving traffic violation;or Insurance Company (e) hit by a hit-and-run driver if the accident is reported to CC-VO9PA2 (07/11) the proper authorities within 24 hours;or Surcharge disclosure statement (f) involved in an accident resulting in damage by contact In compliance with Pennsylvania law,we are providing you with animals or fowl;or with this surcharge disclosure statement to explain our (g) involved in an accident resulting in physical damage, method of surcharging for chargeable accidents and limited to and caused by flying gravel,missiles or violations. Higher premiums are charged for drivers based falling objects;or upon the number of chargeable accidents and or chargeable (h) involved in an accident in a no-fault state and it can be violations accumulated during the experience period. The reasonably determined that the insured was not at experience period is the preceding 35 months. In no fault. event,will we surcharge for more than 36 months. (i) operator was involved in an accident when using a A. Chargeable losses vehicle while on duty as a paid or voluntary member of A chargeable loss means an accident for which payments a police or fire department or first aid squad or any law totaling$1,450 in excess of any self-insured retention or enforcement agency. This does not include an deductible applicable to the named insured under either a accident occurring after the emergency situation ceases Property Damage Liability coverage or a Collision coverage or after the vehicle ceases to be used in response to or a combination of both have been made. Such a such emergency. chargeable accident must involve the owner,applicant,or (j) in an accident resulting in an amount being paid on any usual operator of the vehicle. We surcharge based on behalf of an insured under Basic First Party Benefits the number of at-fault accidents. The first accident results coverage only. in a surcharge of approximately 45%. Additional at-fault B. Violations accidents in the experience period result in larger surcharges. 1. A chargeable violation is any violation as defined below If the insured has been insured with us for five consecutive involving the owner,applicant or any usual operator of Years,and all members of the household have been free of a the automobile which results in conviction therefore. chargeable loss during that five-year time period,we will We surcharge based on the number of chargeable waive the surcharge premium for the first chargeable loss. violations. The first violation results in a surcharge of However,if the insured or any member of the household approximately 200%. Additional violations in the has a second chargeable loss during the same experience experience period result in larger surcharges. period,the first chargeable loss shall be used in computing a. Drag racing or competitive driving on public the total surcharge, streets or highways; Exceptions: b. Operating a motor vehicle without owner's Accidents occurring under the following circumstances will consent; not be counted,if it can be demonstrated that the owner, c. Driving while intoxicated or under the influence applicant or each operator(s)residing in the same of drugs; household was: d. Hit-and-run or leaving the scene of an accident (a) lawfully parked (an automobile rolling from a parked resulting in bodily injury; Position shall not be considered as lawfully parked,but e. Driving while license suspended of revoked; shall be considered as the operation of the last operator);or f. Failure to comply with compulsory insurance or (b) reimbursed over 50%by,or on behalf of,a person financial responsibility laws; responsible for the accident or has judgment against g. Refusing to take an alcohol detection test; such person;or h. A driver's license record shows an entry of implied (c) struck in the rear by another vehicle,and has not been consent. convicted of a moving traffic violation in connection 2. Conviction of a violation which occurred in any state with the accident-,or which does not identify such violation in the precise (d) not convicted of a moving traffic violation in terminology used herein shall be assigned points or the connection with the accident but the operator of the violation described herein which most closely parallels other automobile involved in such accident was the actual conviction. Conviction is defined as any violation of a law or ordinance where there has been a lea of it by the operator involved in the chargeable loss or Plea guilty,a violation. forfeiture of bail,or a judgment by a coup. 4. Any surcharge involving an operator of the lapsed or Two or more automobiles cancelled vehicle who is no longer a resident of the The surcharges as determined above shall apply to each household will not be transferred to any other policy. vehicle in accordance with the following: The surcharge is calculated as a percentage of premium, I. When two or more automobiles are insured and are and therefore the actual dollar amounts of surcharge will driven by members of the same household,surcharges Vary from policy to policy. The Factors that affect the shall be applied as follows: premium include amount of coverage,location, use of car, a. For new business,surcharges will apply to the type of car,and the age,sex,and marital status of the policy under which the driver responsible for the classified operator. You can determine the points assigned chargeable accident or violation is principal to you by looking at your declarations page. If you would operator or rated operator. If the driver is neither like additional information concerning these surcharges, principal nor rated driver, but is a licensed please contact your Agent. operator in the household or a usual non-resident operator,surcharges will apply to the policy insuring the vehicle most often operated by the driver. b. Surcharges will not apply to chargeable accidents or violations by drivers that are neither operators in the household nor usual operators of vehicles we insure. Surcharges for drivers permanently leaving the household will be deleted effective the date we are notified the driver has left the household. c. Surcharges applying to household operators or usual operators that are insured with another company will be deleted effective the date we are provided proof of other insurance. Proof is evidence the driver is insured and rated with another company. d. Surcharges resulting from claims paid by Horace Mann will follow the rules shown above. Chargeable accidents when the driver is a household resident or usual operator,will be surcharged on the policy under which the claim is paid. At the insured's request,surcharge adjustments will be made consistent with a, b and c above. 2. If an additional vehicle is insured,the new policy will be rated as new business in accordance with#I above, except that any surcharges that are charged against the existing policy or policies may be transferred to the additional vehicle,but will not be charged on more than one policy. 3. When one of two policies is cancelled or lapsed,any surcharge from that policy will be transferred to the remaining policy at renewal. If there is more than one vehicle remaining insured with us,the surcharge being transferred will be transferred to the first renewing vehicle or,if identifiable,the vehicle driven most often Educator advantage endorsement quality;ry;or CC-N06026 (2109) 2. Cost of a new car which is of similar make,model, If CC-N06026 prints on your declarations,this body type and year. endorsement amends your"Readable car policy." We reserve the right to select the method we use to settle a claim by either repairing the damaged car,replacing the Defined words damaged car,or by paying for the loss in money. The following definition is added: We will not replace a car which: "New car"means a car purchased by you which has had I.. is more than 1 year old. The age of the car shall be determined by comparing the date you purchased the no previous owner other than the manufacturer or a car and the date of loss, dealership and which at the time you took possession had an odometer reading of less than 500. 2. has an odometer reading of over 40,000 miles at the time of the loss, Section I — Liability coverages 3. is not a new car, 4.you own or acquire during the policy period not The following provision is added: shown on the declaration page unless it is a newly Transportation of students coverage acquired car,or We provide coverage for you up to the limits of liability set 5.you do not own. forth in the policy declarations page while you are Emergency Road Service— Coverage I transporting students to and from school activities in a vehicle insured under Section I-Liability coverages. The introductory paragraph is replaced with the following. We do not provide coverage if this transportation is You have this coverage if Coverage I is shown on the provided for a fee other than reasonable mileage or expense declarations page. We will pay the fair cost incurred for reimbursement,nor do we provide coverage if this your car up to the increased limit shown on the transportation is done in the course and scope of your declarations page for: employment on a regular basis,such as driving a regularly established bus route. Section V— Physical damage coverages Comprehensive—Coverage D Under"Comprehensive—Coverage D,"the following paragraph is added: If this coverage has a deductible, the deductible is waived entirely for a covered loss which results from malicious mischief or vandalism that occurs on or within 500 feet of school property,or while away attending a school-sponsored event,and which is reported to the police. The following coverage is added: Replacement or repair for damage to your auto coverage Under"Limits of liability_Comprehensive and Collision Coverages,"the first paragraph is replaced by the following: The most we will pay for the loss to your car will be the lesser of the: 1. Reasonable cost of repair with parts of like kind and Horace Mann Property & Casualty convicted of a moving traffic violation;or Insurance Company (e) hit by a hit-and-run driver if the accident is reported to CC-V09PA2 (07/11) the proper authorities within 24 hours;or Surcharge disclosure statement (0 involved in an accident resulting in damage by contact In compliance with Pennsylvania law,we are providing you with animals or fowl;or with this surcharge disclosure statement to explain our (g) involved in an accident resulting in physical damage, method of surcharging for chargeable accidents and limited to and caused by flying gravel,missiles or violations. Higher premiums are charged for drivers based falling objects;or upon the number of chargeable accidents and or chargeable (h) involved in an accident in a no-fault state and it can be violations accumulated during the experience period. The reasonably determined that the insured was not at experience period is the preceding 35.months. In no fault. event,will we surcharge for more than 36 months. (i) operator was involved in an accident when using a A. Chargeable losses vehicle while on duty as a paid or voluntary member of A chargeable loss means an accident for which payments a police or fire department or first aid squad or any law totaling$1,450 in excess of any self-insured retention or enforcement agency. This does not include an deductible applicable to the named insured under either a accident occurring after the emergency situation ceases Property Damage Liability coverage or a Collision coverage or after the vehicle ceases to be used in response to or a combination of both have been made. Such such emergency. chargeable accident must involve the owner,applicant,or (j) in an accident resulting in an amount being paid on any usual operator of the vehicle. We surcharge based on behalf of an insured under Basic First Party Benefits the number of at-fault accidents. The first accident results coverage only. in a surcharge of approximately 45%. Additional at-fault B. Violations accidents in the experience period result in larger surcharges. I A chargeable violation is any violation as defined below If the insured has been insured with us for five consecutive involving the owner,applicant or any usual operator of years,and all members of the household have been free of a the automobile which results in conviction therefore. chargeable loss during that five-year time period,we will We surcharge based on the number of chargeable waive the surcharge premium for the first chargeable loss. violations. The first violation results in a surcharge of However,if the insured or any member of the household approximately 200%. Additional violations in the has a second chargeable loss during the same experience experience period result in larger surcharges, period, the first chargeable loss shall be used in computing a. Drag racing or competitive driving on public the total surcharge. streets or highways; Exceptions.- b. Operating a motor vehicle without owner's Accidents occurring under the following circumstances will consent; not be counted,if it can be demonstrated that the owner, c. Driving while intoxicated or under the influence applicant or each operator(s)residing in the same of drugs; household was: d. Hit-and-run or leaving the scene of an accident (a) lawfully parked(an automobile rolling from a parked resulting in bodily injury; position shall not be considered as lawfully parked,but shall be considered as the operation of the last e. Driving while license suspended or revoked; operator);or f. Failure to comply with compulsory insurance or financial responsibility laws; (b) reimbursed over 50%by,or on behalf of,a person responsible for the accident or has judgment against g. Refusing to take an alcohol detection test; such person;or h. A driver's license record shows an entry of implied (c) struck in the rear by another vehicle,and has not been consent. convicted of a moving traffic violation in connection 2. Conviction of a violation which occurred in any state with the accident;or which does not identify such violation in the precise (d) not convicted of a moving traffic violation in terminology used herein shall be assigned points or the connection with the accident but the operator of the violation described herein which most closely parallels other automobile involved in such accident was the actual conviction. Conviction is defined as any violation of a law or by the operator involved in the chargeable loss or ordinance where there has been a plea of guilty,a violation. forfeiture of bail,or a judgment by a court. 4. Any surcharge involving an operator of the lapsed or Two or more automobiles cancelled vehicle who is no longer a resident of the The surcharges as determined above shall apply to each household will not be transferred to any other policy. vehicle in accordance with the following: The surcharge is calculated as a percentage of premium, 1. When two or more automobiles are insured and are and therefore the actual dollar amounts of surcharge will driven by members of the same household,surcharges vary from policy to policy. The factors that affect the shall be applied as follows: premium include amount of coverage,location,use of car, a. For new business,surcharges will apply to the type of car,and the age,sex,and marital status of the policy under which the driver responsible for the classified operator. You can determine the points assigned chargeable accident or violation is principal to you by looking at your declarations page. If you would operator or rated operator. If the driver is neither like additional information concerning these surcharges, principal nor rated driver, but is a licensed please contact your Agent. operator in the household or a usual non-resident operator,surcharges.will apply to the policy insuring the vehicle most often operated by the driver. b. Surcharges will not apply to chargeable accidents or violations by drivers that are neither operators in the household nor usual operators of vehicles we insure. Surcharges for drivers permanently leaving the household will be deleted effective the date we are notified the driver has left the household. c. Surcharges applying to household operators or usual operators that are insured with another company will be deleted effective the date we are provided proof of other insurance.Proof is evidence the driver is insured and rated with another company. d. Surcharges resulting from claims paid by Horace Mann will follow the rules shown above. Chargeable accidents when the driver is a household resident or usual operator,will be surcharged on the policy under which the claim is paid. At the insured's request,surcharge adjustments will be made consistent with a,b and c above. 2. If an additional vehicle is insured,the new policy will be rated as new business in accordance with#1 above, except that any surcharges that are charged against the existing policy or policies may be transferred to the additional vehicle, but will not be charged on more than one policy. 3. When one of two policies is cancelled or lapsed,any surcharge from that policy will be transferred to the remaining policy at renewal. If there is more than one vehicle remaining insured with us, the surcharge being transferred will be transferred to the first renewing vehicle or,if identifiable,the vehicle driven most often EXH[dBIT "D°° SETTLEMENT AGREEMENT AND RELEASE This Settlement Agreement and Release (the"Settlement Agreement") is made and entered into this day of , 2012, by "Claimant" Sydney Dianne Rice, a Minor, by and through her Parent and Natural Guardian, David E. Rice "Defendant" Colleen Rice "Insurer" Horace Mann Property Casualty Insurance Company Recitals A. On or about November 12, 2012 Claimant Sydney Dianne Rice (DOB 04/05/2003), a minor, was injured in an accident occurring at or near Hogstwon and Rasberry Road, Mechanicsville, Bucks County, Pennsylvania. Claimant alleges that the accident and resulting physical and personal injuries arose out of certain alleged negligent acts or omissions of Defendant, and has made a claim seeking monetary damages on account of those injuries. B. Insurer is the liability insurer of the Defendant, and as such, would be obligated to pay any claim made orjudgment obtained against Defendant which is covered by its policy with Defendant. C. The parties desire to enter into this Settlement Agreement in order to provide for certain payments in full settlement and discharge of all claims which are, or might have been, the subject matter of the Complaint, upon the terms and conditions set forth below. Agreement The parties agree as follows: 1 .0 Release and Discharge 1 .1 In consideration of the payments set forth in Section 2, Claimant hereby completely releases and forever discharges Defendant and Insurer from 1 any and all past, present or future claims, demands, obligations, actions, causes of action, wrongful death claims, rights, damages, costs, losses of services, expenses and compensation of any nature whatsoever,whether based on a fort,contract or other theory of recovery, which the Claimant now has, or which may hereafter accrue or otherwise be acquired, on account of, or may in any way grow out of the incident described in Recital A above, including,without limitation, any and all known or unknown claims for bodily and personal injuries to Claimant, or any future wrongful death claim of Claimant's representatives or heirs, which have resulted or may result from the alleged acts or omissions of the Defendant. 1.2 This release and discharge shall also apply to Defendant's and Insurer's past, present and future officers, directors,stockholders, attorneys, agents, servants, representatives, employees, subsidiaries, affiliates, partners, predecessors and successors in interest, and assigns and all other persons, firms or corporations with whom any of the former have been, are now, or may hereafter be affiliated. 1.3 This release, on the part of the Claimant, shall be a fully binding and complete settlement among the Claimant, the Defendant and the Insurer, and their heirs, assigns and successors. 1.4 The Claimant acknowledges and agrees that the release and discharge set forth above is a general release. Claimant expressly waives and assumes the risk of any and all claims for damages which exist as of this date, but of which the Claimant does not know or suspect to exist,whether through ignorance, oversight, error, negligence, or otherwise, and which, if known, would materially affect Claimant's decision to enter into this Settlement Agreement. The Claimant further agrees that Claimant has accepted payment of the sums specified herein as a complete compromise of matters involving disputed issues of law and fact. Claimant assumes the risk that the facts or law may be other than Claimant believes. It is understood and agreed to by the parties that this settlement is a compromise of a doubtful and disputed claim, and the payments are not to be construed as an admission of liability on the part of the Defendant, by whom liability is expressly denied. 1 .5 The Claimant warrants and represents that all outstanding liens for medical services relating to the matters encompassed by the Settlement Agreement have been or will be satisfied upon execution and the distribution of the monies provided for in this Settlement Agreement. The Claimant agrees to indemnify and hold harmless Defendant and Insurer, their successors, agents and assigns, from any lien, claim or entitlement to any portion of the monies paid or to be paid under the terms and conditions of this Settlement Agreement. 2 2.0 Payments In consideration of the release set forth above, the Insurer on behalf of the Defendant agrees to pay to the individual(s) named below (the"Payee(s)") the sums outlined in this Section 2 below: 2.1 Periodic payments made according to the schedule as follows (the "Periodic Payments"): $20,000.00 annually for 4 years guaranteed, beginning 04/05/2021 and ending on 04/05/2024. $50,805.60 guaranteed lump sum paid on 04/05/2025, Payee: Sydney Dianne Rice All sums set forth herein constitute damages on account of personal injuries or sickness, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended. 3.0 Claimant's Rights to Payments Claimant acknowledges that the Periodic Payments cannot be accelerated, deferred, increased or decreased by the Claimant or any Payee; nor shall the Claimant or any Payee have the power to sell, mortgage, encumber, or anticipate the Periodic Payments, or any part thereof, by assignment or otherwise. 4.0 Payee's Beneficiary Any payments to be made after the death of the Payee pursuant to the terms of this Settlement Agreement shall be made to the Estate of Sydney Dianne Rice, or to such person or entity as shall be designated in writing by Sydney Dianne Rice, upon reaching age 18, to the Insurer or the Insurer's Assignee. If no person or entity is so designated, or if the person designated is not living at the time of the Payee's death, such payments shall be made to the estate of the Payee. No such designation, nor any revocation thereof, shall be effective unless it is in writing and delivered to the Insurer or the Insurer's Assignee. The designation must be in a 3 form acceptable to the Insurer or the Insurer's Assignee before such payments are made. 5.0 Consent to Qualified Assignment 5.1 Claimant acknowledges and agrees that the Defendant and/or the Insurer may make a "qualified assignment",within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as amended, of the Defendant's and/or the Insurer's liability to make the Periodic Payments set forth in Section 2.1 to Pacific Life & Annuity Services, Inc. (the "Assignee"). The Assignee's obligation for payment of the Periodic Payments shall be no greater than that of the Defendant and/or the Insurer (whether by judgment or agreement) immediately preceding the assignment of the Periodic Payments obligation. 5.2 Any such assignment, if made, shall be accepted by the Claimant without right of rejection and shall completely release and discharge the Defendant and the Insurer from the Periodic Payments obligation assigned to the Assignee. The Claimant recognizes that, in the event of such an assignment, the Assignee shall be the sole obligor with respect to the Periodic Payments obligation, and that all other releases with respect to the Periodic Payments obligation that pertain to the liability of the Defendant and the Insurer shall thereupon become final, irrevocable and absolute. 6.0 Right to Purchase an Annuity The Defendant and/or the Insurer, itself or through its Assignee reserve the right to fund the liability to make the Periodic Payments through the purchase of an annuity policy from Pacific Life Insurance Company (the "Annuity Issuer"). The Defendant, the Insurer or the Assignee shall be the sole owner of the annuity policy and shall have all rights of ownership. The Defendant, the Insurer or the Assignee may have Pacific Life Insurance Company mail payments directly to the Payee(s). The Claimant shall be responsible for maintaining a current mailing address for Payee(s) with Pacific Life Insurance Company. 7.0 Discharge of Obligation The obligation of the Defendant, the Insurer and/or Assignee to make each Periodic Payment shall be discharged upon the mailing of a valid check in the amount of such payment to the designated address of the Payee(s) named in Section 2 of this Settlement Agreement. 4 8.0 Warranty of Capacity to Execute Agreement Claimant represents and warrants that no other person or entity has, or has had, any interest in the claims, demands, obligations, or causes of action referred to in this Settlement Agreement, except as otherwise set forth herein; that Claimant has the sole right and exclusive authority to execute this Settlement Agreement and receive the sums specified in it; and that Claimant has not sold, assigned, transferred, conveyed or otherwise disposed of any of the claims, demands, obligations or causes of action referred to in this Settlement Agreement. 9.0 Governing Law This Settlement Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. 10.0 Additional Documents All parties agree to cooperate fully and execute any and all supplementary documents and to take all additional actions which may be necessary or appropriate to give full force and effect to the basic terms and intent of this Settlement Agreement. 11 .0 Entire Agreement and Successors in Interest This Settlement Agreement contains the entire agreement between the Claimant, the Defendant, and the Insurer with regard to the matters set forth in it and shall be binding upon and inure to the benefit of the executors, administrators, personal representatives, heirs, successors and assigns of each. 12.0 Effectiveness This Settlement Agreement shall become effective immediately following execution by each of the parties. 5 Claimant: Sydney Dianne Rice, a Minor, by and through her Parent and Natural Guardian, David E. Rice By: Date: Insurer: Horace Mann Property Casualty Insurance Company By: Date: 6 E jH131T 6699 ; ' Fax Server 3/13/2013 9: 04 : 47 AM PACE 1/001 Fax Server �C °Mit �f Jim � Capital BlueCross FAX TRANSMISSION SHEET To-Be Delivered Upon Receipt This transmission, including the cover sheet, is 01 page(s). Please Deliver The Following� Pages To: Name: Adam Barrett Fax Number: 1-919-380-5994 Message: Please accept this fax as acknowledgement of receipt of your fax dated.3.8.13, re your client Sydney Rice's auto accident on 11 .12.12. Capital BlueCross does not express a subrogation lien or interest in your clients case. If you need to respond, please fax the response to fax # 800-929-0557, attn OPL-. Thank You Fasten/ AUtO MAR 13 2013 From: Seth (CBC) Date. Faxed: Wednesday, March 13, 2013 9:04:32 AM Telephone Number: A return message, if required, should be faxed to . Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance CompanyO, Capital -Advantage Assurance CbmpanyV and Keystone Health Plan6 Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. IMPORTANT: THIS MESSAGE IS INTENDED FOR THE USE OF THE INDIVIDUAL OR ENTITY TO WHICH IT IS ADDRESSED AND MAY CONTAIN INFORMATION THAT IS PRIVILEGED, CONFIDENTIAL, AND/OR EXEMPT FROM DISCLOSURE UNDER APPLICABLE LAW. IF THE READER OF THIS MESSAGE IS NOT THE INTENDED RECIPIENT OR THE AGENT RESPONSIBLE FOR DELIVERING THE MESSAGE TO THE INTENDED RECIPIENT,YOU ARE HEREBY NOTIFIED THAT ANY, DISSEMINATION, DISTRIBUTION, OR COPYING OF THIS COMMUNICATION IS STRICTLY PROHIBITED. IF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR,PLEASE NOTIFY THE SENDER IMMEDIATELY BY TELEPHONE(COLLECT)TO ARRANGE FOR THE RETURN OR DESTRUCTION OF THE INFORMATION, TFANKYOU FOR YOUR COOPERATION. EXH]GBIT "]F" THE CHARTWELL LAW OFFICES, LLP Attorney for BY: B. CRAIG BLACK, ESQ. Horace Mann Insurance Company Attorney I.D.: 36818 30 N. 3d Street, Suite 1050 Harrisburg, PA 17101 (717) 909-5170 IN RE: SYDNEY D. RICE COURT OF COMMON PLEAS P- -01 TY No. CIVIL ACTION - AFFIDAVIT OF DAVID RICE 1, David Rice, being duly sworn according to law, and subject to the penalties of 18 Pa.C.S.A. Section 4904 relating to unsworn falsification to authorities, depose and state the following: 1. 1 am the parent and natural guardian of Sydney D. Rice. 2. On November 12, 2012, my daughter was involved in a motor vehicle accident in which my wife, Colleen Rice was attempting to turn left onto Route 1 ]4 from Raspberry Drive in Silver Spring Township, Cumberland County, Pennsylvania. 3. My daughter received surgical repair of facial lacerations and an extensive diagnostic work up to rule out internal injuries and a potential concussion following the accident. 4. My daughter has recovered well from the surgery and is currently in good health, with no side affects or other complications from the accident or surgery. 5. At the time of the accident, my wife had motor vehicle insurance with Horace Mann Insurance, which provided for$100,000 in bodily injury limits. 6. Should this Honorable Court approve the proposed settlement between my daughter, my wife and Horace Mann Insurance Company, I will execute a Release with Horace Mann Insurance on behalf of my daughter for the entire $100,000 policy limits and the proceeds will be used to purchase an annuity with Pacific Life Insurance Company (an A.M. Best A+ rated company), which will pay periodic payments in four (4) equal installments of Twenty Thousand ($20,000) dollars commencing with her eighteenth -pril 5, 2011 and yeai-l-, therea-#er until April 5'. 2024- iahteentb (I 8'h),birthday on A Y together with a final lump sum payment of Fifty Thousand Eight Hundred Five Dollars and sixty cents($50,805.60)to be paid on April 5, 2025. 7. 1 have read, approved and signed the Petition for Approval of Minor's Compromise that will be filed with the Court, and understand that this Affidavit will be used as supporting evidence. 8. 1 have read and fully understood the contents of this Affidavit and the Petition for Approval of Minor's Compromise. SWORN TO AND SV_USCRIBED before me this day of . 2013 DAVID RICE Notary ��COMMONWEALTH OF PENNSYLVANIA t NOTARIAL SEAL ASHLEY M,VHOBIAS.Notary Public &MW0tDr%7WP4 CW"IW Count' My Conftsl6ri E*k"Janwjy 27,2M7 2� �3 SEP -6 PH 3= CUMBtRLA ID COUNTY PENNSYLVANIA IN RE: SYDNEY D. RICE COUPZ T OF COMMON PLEAS CUMBERLAND COUNTY o. 2 / fq 702 �U�l JURY TRIAL DEMANDED CIVIL ACTION - ORDER AND NOW, this day of 2013, upon consideration of the Petition of David Rice, as parent and natural guardian of Sydney Rice, and Horace Mann Insurance Company for approval of Settlement of minor Sydney Rice is hereby Ordered and Decreed'that the Petition is GRANTED and the Proposed Settlement is hereby approved. It is further ordered that the full proceeds of the Settlement ($100,000.00) shall be utilized to purchase an annuity with Pacific Life Insurance Company under the terms and conditions specified in the Release and Settlement Agreement attached to Petitioners' Petition as "Exhibit D". Petitioner shall file proof of deposit of the Settlement amount with the Prothonotary within sixty (60) days of the entry of this Order. The Court hereby authorizes David Rice, as parent and natural guardian of Sydney Rice to execute the proposed Release and Settlement Agreement as appended to the Petition on behalf of said minor. 00 N CDP BY THE COURT, v M t Uj (1: J. 4/4/►,3 THE CHARTWELL LAW OFFICES, L'LP t S i� s i'ON O iiiitorney for Defendant BY: B. CRAIG BLACK, ESQ. t`.[":' O , _ eft fclxace Mann Insurance Company Attorney I.D.: 36818 30 N. 3rd Street, Suite 1050 CU� BERLANO COUNTY Harrisburg, PA 17101 PENNSYLVANIA (717) 909-5170 IN RE: SYDNEY D. RICE • COURT OF COMMON PLEAS • CUMBERLAND COUNTY No. 13-4472-Civil • • CIVIL ACTION MINOR'S COMPROMISE PROOF OF DEPOSIT And Now, this 3/S! day of , 2013 come Horace Mann Insurance Company and David Rice, parent and natural guardian of Sydney D. Rice, by and through counsel, B. Craig Black, Esquire of The Chartwell Law Offices, LLP and hereby FILES THIS Proof of Deposit of Settlement Funds pursuant to this Honorable Court's Order dated September 6, 2013. Petitioner hereby affirms and attests that the settlement funds were utilized to purchase an annuity with Pacific Life Insurance Company pursuant to the terms and conditions set forth in the Petition for Approval of Minor's Compromise, as approved by this Honorable Court. Attached hereto, labeled as Exhibit "A", and incorporated herein is a receipt issued by Pacific Life Insurance Company for the purchase of said annuity. THE CHARTWELL LAW OFFICES, LLP Date: iv/3//20i3 By: �e B. Cr.'g Black, Esquire A •RNEY I.D. NO: 36818 I 3rd Street, Suite 1050 arrisburg, PA 17101 (717) 909-5170 cblack@chartwelllaw.com chartwelllaw.com Attorney for Horace Mann Insurance Company FxF1,1 ,Brii "A" A PACIFIC LIFE STRUCTURED SETTLEMENTS 700 Newport Center Drive Newport Beach, CA 92660 Acknowledgment of Receipt of Premium Premium has been received for the following: Ciaimant(s): Sydney Rice Premium: $100,000:00 Date Received: 412612013 Reference(Vo.: 13000552 Thank you for placing your business with us, If you have any questions about the above, please contact us at 877-784-0622 option 2. Structured Settlements New Business Fax to: (7041544-6556 Kevin Capte Pacific Life refers to Pacific Life insurance Company and its affiliates,including Pacific Life&Annuity Company.Insurance products are issued by Pacific Life Insurance Company In all states except New York and in New York by Pacific Life&Annuity Company.Product availability and features may vary by state.Each company Is solely responsible for the financial obligations accruing underthe products it issues.Insurance product and rider guarantees are backed by the financial strength and claims paying ability of the issuing company. , . HORACE MANN PROPERTY&CASU-'TY INSURANCE COMPANY(HPC) h--1 Horace Mann' . .2:P.g.:-..g. i414*,n.:R.,l .g2 :: 10 .0400.R.RggagAiiii6iieg' „VI-Founda try Educators for Educarers 04/18/2013 10:50:01 4001829909 $99,000.00 Claim Number Sub Loss Date LOB ST Policy# Region 16875C 7 11(12/2012 A 37 59683360 75 Insured: RICE,DAVID E Check Issued By: Adam Barrett , . Reason: Full release any/all claims re Bodily injury of:Sydney Rice DETACH BEFORE DEPOSITING THE FACE OF THIS CHECK IS PRINTED BLUE-THE BACK CONTAINS A SIMULATED WATERMARK ,;..,,v.:.,, HOR),NOtgOANN PROPER4.rektASUALTY94URANCE OgiAPANNebIPC).,:.., ..ji . , 1-.3.;.......:!. " ''''C'e) Horace Mann , .. ::: ,.- •..k, lq. . .. . '. ,,..d:;'''''', :"''':.-;:.:`1'., '..:.. „',,..,:' -".A .";!....g;4004 829909:,. 3,,...t;:'iriwrrded 1 1 i Eduosrors fOrigturga Al:S....'„.,:'- '; ii.. ::', ''' ,,,•Ar,.... • ..'';''?... eavii4A1: •:!::: ,:• . .j':: .,..1,..tiate,a0.:.Mann Ptaza 13pcirlititield,IL. v5:-Wit.5-00(11 's.:.'---: •ii: 14•;:„(217)747-543 . ..„.:,...j..:.:.ti!, DA.3" , . ,. -,:...,T,e ,0• j':. '',''.7.0-g620.,,,, 4:::1-.1;p0:4999-1 MCI:,...,,, '''k'::: ,,,;..k.•1u',...k.::ii.,:' .:;'04/18/20IP1t):50:131 ,j> 4,..'".:,-'' 711 ciamtNwrbm • LosSpat#i - ST ,,..:,ir....;PolICO :I.P,41P'.V...'' . .,; (4:Irit*1"- •..""1.4.5.02012 . 3/,:; 1-;;t9583360 •.' t..5 ;., .... -..,. !...,1:Ariii*ninet.h07k*iii1 and 00/00balars ..," ., ''...':::.i.--?.•;:i.:-.~•:: 'r 4tli01111t.F.ig:':::',:.-.',*'-:-,%:,:'., :,,,.:;,'-:-.:.:::,;,.:•'" ..::',.- PIMTOfi-IE ORDVFOF: .':::;-:;,::1 ‘'''.'*: " ,,..,::.:teli,l'.: ....!:..:,. :?,, - ::.:.:1.5 -,:...,:.. .. ' $99,000.00 P6offic Life atiii.Annbity SeiVides, Inc <-;..1::., ), 4. ,..:::;:, ..'..,'::::. ..,•:::-...:;.i.:::',. 'R• ....,.,, VOID AFTER 90 DAYS J PACIFIC LIFE AND ANNUITY SERVICES, INC 1420 s fy . , .,-- ,.. . ...-, •- . - ,...- 700 NEWPORT CENTER.DRIVE SOWPORTBEACH,CA 92660 t,:,:: :Second sigRztturerdcliAred il amotArtM ii400:00 or greater.: ::: -''''. .,,. ...... -. r .•••...-;:'''';::',-, •.,..- •,.. .- .r...ic_!..J..1 — ,,. •-,-, -Z',z '. ,- .... i•' 00 La 2990 Tim 1:0 7 L L 2620 LI: 00?it'll 72118 , HORACE•MANN PROPERTY&GAS'"1_TY INSURANCE COMPANY(HPC) aHorace Mann- Founded by Educators for Educators 04/18/2013 10:50:01 4001829908 $1,000.00 Claim Number ' Sub Loss Date LOB ST Policy# Region 16875C 4 11112/2012 A 37 59683360 75 Insured: RICE,DAVID E Check Issued By: Adam Barrett Reason: Full release any/all claims re Bodily Injury of:Sydney Rice DETACH BEFORE DEPOSITING THE FACE OF THIS CHECK IS PRINTED BLUE-THE BACK CONTAINS A SIMULATED WATERMARK .. ,... ...,. . ..„ :...„,.. ,„.....!,.. ...,,,._..„ „. ..,... .. ...... —,1 •,:...: :•••• • ,.p,. •.-• HOFIACe.MANN PROPEO,(teCASUALTY9NSURANCE CcI44P4NY'(FIPC),,, "••„:„,:., .,.. :;:. : .. ••• Horace Montt '::: ,' t::,,,' - .--. ,,,,,.%::,4,,,, ..,,-.;;.= ... .',..:4001 829908-... PayabreA: ' .,.... iiiitioncdEceak '''' '.:, , - , .., " " .,.• .:,' ..' -.- '''.. I ,.:•':. .(217)747-$gAl '-,•4, .-..1-zkidt:44Mann Reza EIR) piritrigtleid,IL 21.oe715-0001 .., :„'S i ;:-..F:. p■etirEi. . ,,,7::,:.-16620 146oass-loso,....„. -,3:.:::> *., ,:s>;1,.-.1 ,,<7. •Ar:.'''.:;''. .':', '''' ,•.,:', " 1'04/18i201310 5001 711•";.:::':•::, - - ciab-r1.107,b01,: Lq..„,i-Raio::- - ST 1...,.-; ;.,Polid54 I .1*.!;q!'Ir' :0:•., ',:, .:, '!'' 667C.:• , i4,00642 37 k 1.59683560 'F, ,.i. "' "'' .''.':" ,.'.:::-:','''!':.1P.Y' ::::::::,,•;!': ;:!'''. :.: ,,,. --.1 , ':'):-:::■;;\'''',,:'•'"• ....•:,:., OkOthousand,a0CIO/100 DcifOrkqe .,'..:ik.i.i.,:,,,.•.i.a:'.;:;i::,::i.'W.g...;,;;;,:•?:.':f..*:,:::•;*;::.;;:,:•,:::,:,.•::::;:.f:::: • ::'' •'..,(. 'i,.',4 ::::i::::.:::;:::Me.:::i:::::*iirpittptleTt:::::;::::::vi:::,,....:::::, PAYItitHE ORDER OF ,„........, ..„. ,..-, . ';,>„....,. ,.....•. ,.:... ***********$1,000.00 •'•;:-0.4tific Life ati&Mribity SeigiiiC6s, Inc ,...,..ri:`,. '1;;:. e .,..,4 ''....:: ,,-,. ':,:*:;:::::,' --:.:,..;;'''':.:: : • VOID AFTER 90 DAYS • -'.." -.::•:';''.KOIL TO: ., „. ... •':.f.., -, . .„-::.,.,.:.-. .. • . .. • •-•,',:.,;:;.:, PACIFIC LIFE AND ANNUITY SERVICES, INC :,..,..4.. • . •:-'•:,...- .,, .-- 700 NEWPORT CENTER DRIVE NEWPORT BEACH,.CA 92660 ..:.: ...4 ,„.... ,. . 121 .,. ''.'.'•.•.• . ..•.• :... -:::' •..:,•:'' _ '';:41.44' Ill 1,00 18 2 9908111 10 71 i 26 20 11: 00 71m0 7 2111 i