The URL can be used to link to this page

Home My WebLink About14-141913- 014530 LAW OFFICE OF SNYDER & DORER Thomas S. Brumbaugh, Esquire 214 Senate Avenue, Suite 600 Camp Hill, PA 17011 Telephone Number: (717) 731 -0988 Brumbtl(nationwide.com THE PR0 HONO11AP rah MAR 10 !:;111: 56 CUMBERLAND COUNTY PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS COURT DIVISION NO. i L 1 ( 1 IN RE: SAMUEL TAYLOR MILLER, A MINOR, BY AND THROUGH HIS PARENTS AND NATURAL GUARDIANS, ROBBY LYNN MILLER AND DONNA LYNN MILLER PETITION FOR APPROVAL OF MINOR'S SETTLEMENT AND COMPROMISE Pursuant to Pa.R.C.P. 2039, Nationwide Mutual Insurance Company, by and through its attorneys, Snyder and Dorer, and Thomas S. Brumbaugh, Esquire, and Petitioners, Robby Lynn Miller and Donna Lynn Miller do hereby petition this Court to enter an Order approving the settlement and compromise of this action, and in support thereof aver the following: 1. Petitioners, Robby Lynn Miller and Donna Lynn Miller are adult individuals who at all times relative hereto resided, and continue to reside, at 197 Lawrence Lane, Carlisle, Cumberland County, Pennsylvania 17015. 2. Petitioners, Robby Lynn Miller and Donna Lynn Miller are the parents and natural guardians of the minor, Samuel Taylor Miller, who was born on October 25, 1996 and was 15 years old at the time of the incident that is the subject of this petition and who is currently 17 years old. 3. At all times relevant hereto, the minor Samuel Taylor Miller resided, and ate_ s I b$' 7 Sp ?4L continues to reside, with his parents at 197 Lawrence Lane, Carlisle, Cumberland County, Pennsylvania 17015. 4. At all times relevant hereto, Nationwide Mutual Insurance Company ( "Nationwide ") provided automobile insurance, including coverage for bodily injury, to Kim S Weaver and Robert Weaver pursuant to policy number 58 37 C 103276. A copy of the Declarations Pages for the policy is attached hereto as Exhibit "A." 5. On or about August 28, 2012, the minor Samuel Taylor Miller was a passenger in a 1996 Honda Civic, operated by Brady Weaver and owned by Kim S Weaver and Robert Weaver, when Brady Weaver lost control of the vehicle and struck a tree. 6. Following the accident, the minor Samuel Taylor Miller was initially transported to the Carlisle Regional Medical Center and then transferred to the Penn State Milton S. Hershey Medical Center, where he was admitted from the date of the accident until August 30, 2012, for treatment of a right pneumothorax, minor concussion and right knee pain. Copies of the medical records for the treatment rendered to the minor Samuel Taylor Miller are attached hereto as Exhibit "B ". 7. After his discharge, the minor Samuel Taylor Miller had a follow up visit for removal of stitches. 8. The minor Samuel Taylor Miller has made a full recovery from his injuries, and no further treatment is necessary. 9. All of the medical bills associated with the accident have been paid, except for the following, which are attached hereto as Exhibit C: a. Carlisle Regional Medical Center: $1,251.23 2 b. Hershey Medical Center: $2,365.75 10. Medical bills in the amount of $8,849.26 were paid by Petitioners' health insurance coverage and a lien against the settlement is being asserted by the Rawlings Company LLC. Documentation of the lien is attached hereto as Exhibit "D." 11. Through discussions with Nationwide, Petitioners, Robby Lynn Miller and Donna Lynn Miller have negotiated a settlement of their son's claim in the amount of $15,000.00, plus payment of the Rawlings lien and the unpaid medical expenses. 12. Petitioners, Robby Lynn Miller and Donna Lynn Miller seek approval from this Honorable Court of the settlement agreement. 13. The $15,000 lump sum cash payment shall be deposited into a separate, restricted, interest bearing savings account or savings certificate in a federally insured institution having an office in Cumberland County, IN THE NAME OF THE MINOR ONLY. The separate savings account shall be titled and restricted as follows: Samuel T. Miller, a minor, not to be withdrawn before the minor attains majority or upon prior Order of Court. Alternatively, the savings certificate shall be titled and restricted as follows: Samuel T. Miller, a minor, not to be redeemed except for renewal in its entirety, nor to be withdrawn, assigned, negotiated, or otherwise alienated before the minor attains majority, except upon prior Order of Court. 14. Within 60 days of the Court Order approving the aforesaid settlement, Petitioners, Robby Lynn Miller and Donna Lynn Miller, with the assistance of counsel for Nationwide, will file certification of compliance and proof of deposit. 3 15. The aforesaid settlement and the Parent/Guardian Release and Indemnity Agreement (attached hereto as Exhibit "E" and incorporated herein by reference) will take effect and become binding on all parties upon the signing of the Court's Order approving the terms of the settlement. 16. Nationwide, by its counsel, Thomas S. Brumbaugh, Esquire, has filed this friendly Petition for court approval of the agreed settlement. No attorney - client relationship exists between Petitioners and /or Nationwide and /or Thomas S. Brumbaugh, Esquire, and counsel was not involved in any way in the settlement negotiations between Petitioners and Nationwide. 17. Petitioners, Robby Lynn Miller and Donna Lynn Miller, as parents and natural guardians of the minor, join the Petition and approve the proposed settlement because, under the circumstances, they consider it to be fair and reasonable compensation for their minor son. (See Exhibit "F "). WHEREFORE, Petitioners and Nationwide jointly request this Honorable Court to enter an Order approving the settlement and compromise as set forth herein and ordering distribution as set forth in the attached Order. Date: March 7, 2014 4 Respectfully submitted, LAW OFFICE OF SNYDER & DORER Thomas S. Brumbaugh, sy%' ire Attorney for Plaintiff Court I.D. No. 8903 02454001225010 t�► Nationwide® Shoemaker Ins Agency Inc On Your Side Po Box 148 Newville, PA 17241 Sign up for convenient, automatic bill payment with Nationwide Easy Pay. To learn more, ask your agent or log in to nationwide.com/easypay. How to Contact Us Your Nationwide Agent Customer Service Internet 24 -Hour Claims Reporting Hearing Impaired (TTY) Prepared on July 24, 2012 Page 1 of 2 Your Revised Policy Your bill is sent separately. Nationwide Auto Policy Policy Period: Jul 20, 2012 - Sep 24, 2012 Policy Number: 5837C 103276 Kim S and Robert Weaver 199 Lawrence Lane Carlisle, PA 17013 -9439 ✓ Declarations - These pages show your coverages under this policy. Carefully review these details and call Shoemaker Ins Agency Inc at 717.776.7229 if you have questions or want to make changes. • General Information • Coverage Details • Your Total Policy Premium ✓ Insurance Documents - Please keep these documents for future reference. Shoemaker Ins Agency Inc 717.776.7229 1.877.669.6877 Nationwide.com 1.800.421.3535 1.800.622.2421 Nationwide On Your Side NOTES: Prepared on July 24, 2012 Page 2 of 2 Ways You Can Save With Nationwide An additional premium of $ 222.40 is for recent policy change(s). The enclosed Declarations confirms changes made to your insurance coverage. Please verify change(s). Sign up for convenient, automatic bill payment with Nationwide Easy Pay, To learn more, ask your agent or log in to nationwide.com/easypay. Manage your account, make a payment, check the status of a claim and receive your bill by email with online Account Access. Visit nationwide.com/manage - see how easy it can be. Nationwide thanks you for your business. Our first priority is to serve you, our Customer. Whether you have a claim, a question, a concern, or just need a convenient service, our On Your Side promise means we'll be there to serve your needs. Thank you for choosing Nationwide. We value your business. 02454001225029 • • Nationwide® On Your Side Policyholder (Named Insured): Kim S and Robert Weaver 199 Lawrence Lane Carlisle, PA 17013 -9439 Prepared on July 24, 2012 Page 1 of 6 Your Policy Declarations Nationwide Auto Policy Policy Period: Jul 20, 2012 - Sep 24, 2012 Policy Number: 5837C 103276 Keep these Declarations for your records. General Policy Information Issued: July 24, 2012 These Declarations are a part of the policy named above and identified by the policy number above. They supersede any Declarations issued earlier. Your policy provides the coverages and limits shown in the schedule of coverages. They apply to each insured vehicle as indicated. Your policy complies with the motorists' financial responsibility laws of your state only for vehicles for which Property Damage and Bodily Injury Liability coverages are provided. Policy Period: July 20, 2012 - September 24, 2012 but only if the required premium for this period has been paid and only for six month renewal periods if renewal premiums have been paid as required. This policy is initially effective at (1) the time the application for insurance is completed, or (2) 12:01 a.m. on the first day of the policy period, whichever is later. Each renewal period begins and ends at 12:01 a.m. standard time at the address of the named insured stated herein. This policy expires at 12:01 a.m. at the address of the named insured stated herein. Your carrier is Nationwide Mutual Insurance Company, NAIC #23787. IMPORTANT MESSAGES: IF THIS DECLARATIONS PAGE SHOWS THAT COLLISION COVERAGE APPLIES TO YOUR AUTO, THERE IS ALSO COLLISION COVERAGE FOR DAMAGE TO A RENTED AUTO. COVERAGE IS SUBJECT TO CONDITIONS AND LIMITATIONS LISTED IN THE POLICY OR ATTACHED ENDORSEMENTS. Changes Made to Your Policy • Effective Jul 20, 2012 • Added Driver Premium Summary and Other Charges 2003 Chrysler Town And 1995 Honda Accord E 2003 Honda Accord E 1996 Honda Civic Dx Total For Policy Coverages Total Policy Premium $ 575.30 $ 543.10 $ 684.20 $ 579.40 $ 20.00 $ 2,402.00 How You Saved on this Policy with Nationwide • Passive Restraint • Good Student • Home & Car • Safe Driver • Anti Theft Device • Affinity Thank you for being a long -term customer. V - 105 • Accident Free • Multi Car Continued on the next page Nationwide® On Your Side For coverage definitions and descriptions, visit Nationwide.com Prepared on July 24, 2012 Page 2 of 6 Your Policy Declarations Nationwide Auto Policy Policy Period: Jul 20, 2012 - Sep 24, 2012 Policy Number: 5837C 103276 Listed Driver(s) Name Kimberly S Weaver Robert Weaver Holly Weaver Brady Weaver Date of Birth 02/09/64 12/13/67 11/29/91 12/22/95 Marital Status Married Married Single Single Insured Vehicle(s) and Schedule of Coverages 2003 Chrysler Town And VIN 2C4GP44L53R237857 Coverages Comprehensive and $ 1,500 IN Customization Including Car Key Replacement Coverage Collision and $1,500 IN Customization Including Pet Injury Collision Coverage Property Damage Liability Bodily Injury Liability Uninsured Motorists - Bodily Injury Underinsured Motorists - Bodily Injury First Party Benefits Option 1- Medical Benefit Option 2- Income Loss Benefit Option 4- Funeral Benefit Full Tort Vehicle Endorsements 3455A 3475 Limits of Liability Actual Cash Value Actual Cash Value Less $ 200 $ 25,000 Each Occurrence $ 50,000 Each Person $ 100,000 Each Occurrence (Non- Stacked) $ 50,000 Each Person $ 100,000 Each Occurrence (Non- Stacked) $ 50,000 Each Person $ 100,000 Each Occurrence $ 10,000 $ 10,000 Total $ 1,000 Monthly $ 2,500 Premium $ 69.00 $ 210.20 $ 95.60 $ 105.60 $ 6.30 $ 26.90 $ 51.70 $ 9.60 $ .40 Total for this Vehicle $ 575.30 Continued on the next page 02454001225038 ti Prepared on July 24, 2012 Page 3 of 6 Nationwide® Your Policy Declarations On Your Side Nationwide Auto Policy Policy Period: Jul 20, 2012 - Sep 24, 2012 Policy Number: 5837C 103276 Insured Vehicle(s) and Schedule of Coverages (continued) 1995 Honda Accord E VIN 1HGCD5550SA071720 Coverages Comprehensive and $ 1,500 IN Customization Including Car Key Replacement Coverage Collision and $ 1,500 IN Customization Including Pet Injury Collision Coverage Property Damage Liability Bodily Injury Liability Uninsured Motorists - Bodily Injury Underinsured Motorists - Bodily Injury First Party Benefits Option 1- Medical Benefit Option 2- Income Loss Benefit Option 4- Funeral Benefit FuII Tort Vehicle Endorsements 3455A 3475 Limits of Liability Actual Cash Value Actual Cash Value Less $ 200 $ 25,000 Each Occurrence $ 50,000 Each Person $ 100,000 Each Occurrence (Non- Stacked) $ 50,000 Each Person $ 100,000 Each Occurrence (Non- Stacked) $ 50,000 Each Person $ 100,000 Each Occurrence $ 10,000 $ 10,000 Total $ 1,000 Monthly $ 2,500 Premium $ 77.60 $ 156.60 $ 99.70 $ 113.30 $ 6.30 $ 26.90 $ 51.20 $ 11.00 $ .50 Total for this Vehicle $ 543.10 2003 Honda Accord E VIN 1HGCM566X3A066632 Coverages Comprehensive and $ 1,500 IN Customization Including Car Key Replacement Coverage Collision and $ 1,500 IN Customization Including Pet Injury Collision Coverage Property Damage Liability Bodily Injury Liability Uninsured Motorists - Bodily Injury Limits of Liability Actual Cash Value Actual Cash Value Less $ 200 $ 25,000 Each Occurrence $ 50,000 Each Person $ 100,000 Each Occurrence (Non- Stacked) $ 50,000 Each Person $ 100,000 Each Occurrence Premium $ 69.00 $ 276.10 $ 107.40 $ 123.40 $ 6.30 Continued on the next page Prepared on July 24, 2012 Page 4 of 6 Nationwide® Your Policy Declarations On Your Side Nationwide Auto Policy Policy Period: Jul 20, 2012 - Sep 24, 2012 Policy Number: 5837C 103276 Insured Vehicle(s) and Schedule of Coverages (continued) 2003 Honda Accord E VIN 1HGCM566X3A066632 Coverages Underinsured Motorists-Bodily Injury First Party Benefits Option 1-Medical Benefit Option 2-Income Loss Benefit Option 4-Funeral Benefit Full Tort Vehicle Endorsements 3455A 3475 Limits of Liability (Non-Stacked) $ 50,000 Each Person $ 100,000 Each Occurrence $ 10,000 $ 10,000 Total $ 1,000 Monthly $ 2,500 Total for this Vehicle Premium 26.90 62.90 11.60 .60 684.20 1996 Honda Civic Dx VIN 2HGEJ644XTH109750 Coverages Comprehensive and $ 1,500 IN Customization Including Car Key Replacement Coverage Collision and $ 1,500 IN Customization Including Pet Injury Collision Coverage Property Damage Liability Bodily Injury Liability Uninsured Motorists-Bodily Injury Underinsured Motorists-Bodily Injury First Party Benefits Option 1-Medical Benefit Option 2-Income Loss Benefit Option 4-Funeral Benefit Full Tort Vehicle Endorsements 3455A 3475 Limits of Liability Actual Cash Value Actual Cash Value Less $ 200 $ 25,000 Each Occurrence $ 50,000 Each Person $ 100,000 Each Occurrence (Non-Stacked) $ 50,000 Each Person $ 100,000 Each Occurrence (Non-Stacked) $ 50,000 Each Person $ 100,000 Each Occurrence $ 10,000 $ 10,000 Total $ 1,000 Monthly $ 2,500 Premium 69.30 185.60 $ 105.40 $ 118.20 6.30 26.90 55.00 12.10 .60 Total for this Vehicle 579.40 Continued on the next page 02454001225047 U. Prepared on July 24, 2012 Page 5 of 6 Nationwide @ Your Policy Declarations On Your Side Nationwide Auto Policy Policy Period: Jul 20, 2012 - Sep 24, 2012 Policy Number: 5837C 103276 Policy Level Schedule of Coverages Coverages Limits of Liability Roadside Assistance Plus - Covers Disablement Up To 100 Miles/$100 Lockout/ $ 500 Trip Interruption Endorsement 3436 Accident Forgiveness Feature - Currently Eligible To Use Premium 20.00 Incl Total for Policy Coverages 20.00 Policy Form V-037B V-3329 V-3393 V-3457 V-3453 V-3535 V-3436 V-3455A V-3475 and Endorsements Nationwide Auto Policy Amendatory Endorsement Guaranteed Automobile Insurance Coverage (Pennsylvania) Amendatory Endorsement (Pennsylvania) Amendatory Endorsement Amendatory Endorsement Roadside Assistance Coverage Car Key Replacement Coverage Pet Injury Collision Coverage For Office Use Only: 06/13/12 $ 222.40 Issued By: Nationwide Mutual Insurance Company Countersigned At: Harrisburg, PA. By: Andrew L Shoemaker Lut How to Contact Us Your Nationwide Agent Customer Service Internet 24-Hour Claims Reporting Hearing Impaired (TTY) Shoemaker Ins Agency Inc 717.776.7229 1.877.669.6877 Natlonwide.com 1,800.421.3535 1.800.622.2421 Nationwide® On Your Side Prepared on July 24, 2012 Page 6 of 6 This page intentionally blank 1 Y � � ' ro' � l _ _ i. \ _ _ ' � t � . it 1 I C 1 I �' 1 I' I I _1 r i I I i r i t. Report PAR120 Consultation Coid 85t) 10/031201210 19 44 CARLISLE REGIONAL MEDICAL CTR Page IZ Requested By SCHRIST 361 ALEXANDER SPRING RD CARLISLE PA 17015 Report Status Signed I� Pat Nbr 9533991 MILLER SAMUEL T Admit 08/28/2012 08 24 DOB 10!25/1996 Gender MALE Req By CHANDLER CHARLES II Discharge 08/28/2012 12 01 I Med Rec 0000791125 Pat Type E1 Location Type MED Diet 09/1412012 13 52 53587319 Transcribed 09/2612012 11 11 Physician BRAZE ADAM JAMES CARLISLE REGIONAL MEDICAL CTR Coid 858 Consultation Report Status Transcribed Patient Nbr 9533191 MILLER SAMUEL T Admit 08/28/2012 08 24 DOB 10/25/1996 Req By CHANDLER CHARLES II Discharge 06/28/2012 12 12 Med Rec 0000791125 Pat Type El Location 0000 - Type MED Dict 09/14/2012 13 52 53587319 Transcr 09 /14/2012 22 44 Dictating Physician 6165 BRAZE ADAM JAMES ------------------------------------------------------------------------------ DATE OF CONSULTATION 08/28/2012 REFERRING PHYSICIAN 1 CONSULTING PHYSICIAN Adam James Braze, DO REASON FOR CONSULTATION Traumatic pneumothorax HISTORY OF PRESENT ILLNESS This is a 15- year -old male who was front passenger in a car The driver lost control of the car and collided with a pole or tree There was significant intrusion into the vehicle The patient did hit his head and states he had some loss of consciousness He does have chest discomfort over the right chest He denies any difficulty breathing He is sore over the shoulder and denies any other injuries He denies any obvious lacerations PAST MEDICAL HISTORY None PAST SURGICAL HISTORY None MEDICATIONS None REVIEW OF SYSTEMS As per HPI Otherwise reviewed and were negative I Report PA5120 Consultation Coid BE 1010312012.10 19 44 CARLISLE REGIONAL MEDICAL CTR Page Re4uested iay SCHRIST 361 ALEXANDER SPRING RO CARLISLE PA 17015 I *r Report Status Signed t+� ' Pat Nbr 9533191 MILLER SAMUEL T Admit 0812812012 08 24 DOB 10/25/1996 Gender MALE Req By CHANDLER CHARLES 11 Discharge 08/2812012 12 01 1 Mod Roe 0000791125 Pat Type E1 Location - type MED Diet. 09/14/2012 1352 53587319 Transcribed 09/20012 11 11 ' Physician BRAZE ADAM JAMES (�+ PHYSICAL EXAMINATION HEENT Head, there are small abrasions on his head There were no obvious lacerations NECK Supple No 3ugular venous distention No masses No hematomas Trachea is midline CHEST Symmetrical respiratory movement LUNGS Clear to auscultation bilaterally HEART Regular rate No murmurs or rubs ABDOMEN Soft EXTREMITIES No clubbing cyanosis or edema No obvious derangement of the extremities There was a seatbelt sign over the right shoulder LABORATORY STUDIES Chest x -ray showed at least a 30% pneumo with mild mediastinal shift to the left There were no obvious rib fractures CT of the chest showed the same and did not show any rib fractures IMPRESSION 1 Status post motor vehicle collision 2 Traumatic right pneumothorax PLAN I will perform a closed tube thoracostomy on the right for the patients pneumothorax The patient needs higher level of care as the patient has loss of amnesia of the incident Therefore he does have in3ury At age 15 we do not have the appropriate intensive care for a 15- year -old Therefore, he should be transferred to a trauma center after chest tube placement Adam James Braze, DO DD Fri Sep 14 13 52 13 2012 DT Fri Sep 14 22 44 28 2012 53587319 /86168 CC h-+ Report PAS120 Operative Report Coid 851b 10/031201210 19 44 CARLISLE REGIONAL MEDICAL CTR Page I:) Requested by SCHRIST 361 ALEXANDER SPRING RD � CARLISLE PA 17015 IV Report Status Signed Pat Nbr 9533191 MILLER SAMUEL T Admit 08/281201 2 08 24 DOB 10/25/1996 Gender MALE Req By CHANDLER CHARLES II Discharge 08/28/2012 12 01 Mad Rec 0000791125 Pat Type E1 Location Type MED Diet 09/14/20121355 53587471 Transcribed 09/26/2012 11 11 V1 'Physician BRACE ADAM JAMES f- CARLISLE REGIONAL MEDICAL CTR Cold 858 Operative Report Report Status Transcribed Patient Nbr 9533191 MILLER SAMUEL T Admit 08/28/2012 08 24 DOB 10/25/1996 Req By CHANDLER CHARLES II Discharge 08/28/2012 12 12 Med Rec 0000791125 Pat Type E1 Location 0000 - Type MED Diet 09/14/2012 13 SS .53587471 Transcr 09/14/2012 21 49 Dictating Physician 6165 BRAZE ADAM JAMES ---- - - - - -- ------------------------------------------------------------------ DATE OF PROCEDURE 08/28/2012 PREOPERATIVE DIAGNOSIS A 25% right -sided pneumothorax after MVC POSTOPERATIVE DIAGNOSIS A 25% right -sided pneumothorax after MVC with mild tension pneumothorax PROCEDURE Insertion of 28- French closed tube thoracostomy in the right side and .intercostal nerve block performed SURGEON Adam James Braze D O ANESTHESIA 2 mg of Versed and 30 mL of 1W lidocaine ESTIMATED BLOOD LOSS Less than 5 mL COMPLICATIONS None INDICATIONS FOR PROCEDURE This is a 15- year -old male who was a passenger in a motor vehicle crash with significant intrusion The patient did have a seatbelt sign and he came to the ER for further evaluation and was found have a 25$ pneumothorax with subtle findings consistent with a tension pneumothorax The patient was offered closed 'tube thoracostomy Risks F-+ Reepport PAS120 Operative Report Cold 8% 1N/Q3/2012 10 19 44 CARLISLE REGIONAL MEDICAL CTR Page :b Requested By SCHRIST 361 ALEXANDER SPRING RD . CARLISLE PA 17015 Report Status Signed Pat Nbr 9533191 MILLER SAMUEL T Admit 08128/2012 08 24 M DOB 10/25/1996 Gender MALE Req By CHANDLER CHARLES 11 Discharge 081281201212 01 Mod Rec 0000791125 Pat Type E1 Location Type MEO Dict 09114/2012 13 55 53587471 Transcribed 09/261201211 11 Physician BRAZE ADAM JAMES benefits and alternatives were explained Informed consent was obtained DESCRIPTION OF PROCEDURE The patient was placed in a left decubitus position with_the right side up The right chest was prepped and draped in a sterile fashion After the patients chest was prepped and draped in a sterile fashion in the anterior axial line just below the nipple line, the interspace was decided to enter and was circumferentially anesthetized Then at the rib space and below in the posterior axillary line, the intercostal nerve was anesthetized with an additional 5 mL in each space Next an incision with a 10 blade was made in the anterior axillary line Blunt dissection was used to enter the chest and a 28- French chest tube was advanced towards the apex of the lung and clamped There was a rush of air released from the chest on entry to the pleura. The chest tube again was sutured to the patients skin and the suture was closed A dressing was applied and then the chest tube was unclamped and placed to a Pleur -evac The patient tolerated the procedure well No complications Postoperative chest x -ray will be obtained Adam James Braze, DO DD Fri Sep 14 13 55 4S 2012 DT Fri Sep 14 21 49 54 2012 53587471 186168 CC THIS DOCUMENT IS NOT A LEGAL COPY UNLESS SIGNED Authenticated by Adam J Braze DO On 09/26/2012 11 11 13 AM ------------------------------------------- DICTATED /TRANSCRIBED Report PAS-128 Radiology Results Cold 85P 10/03/201210 19 44 CARLISLE REGIONAL MEDICAL CTR Page '.-� Requested By SCHRIST 361 ALEXANDER SPRING RD (0 CARLISLE PA 17015 RADIOLOGY TEST INFORMATION N Tyypelsource RAD CHEST PA & LATERAL Medical Recor4 Number 0000791125 Account 9533191 Patient Name MILLER SAMUEL T Status Final DOB 10/25/1996 Gender MALE ., Result DatelTme 08/30/2012 16 22 Order Date 08/28/2012 Order # 9629386 Order Time 0840 Admit Date 08/28/2012 a PHYSICIANS Dictating MARTIN DOUGLAS J Signature MARTIN DOUGLAS J RESULT TEXT MVC Reason,Chest pain Bed Name 19 Procedure Acknowledge Date 08/28/2012 09 59 00 CHEST TWO VIEWS HISTORY Status post MVA, chest pain RESULT There is a moderate sized tension pneumothorax on the right No consolidation or pleural effusion Cardiac silhouette and pulmonary vasculature are unremarkable IMPRESSION 1 Moderate sized tension pneumothorax on the right 2 No acute cardiopulmonary abnormality MARTIN, MD DOUGLAS J Dictated By MARTIN MD DOUGLAS J Reviewed & Signed ------------------------------------------- Report PAR120 Radiology Results Cold 85M 101031201210 19 44 CARLISLE REGIONAL MEDICAL CTR Page '� Requested By $CHRIST 361 ALEXANDER SPRING RD t0 CARLISLE PA 17015 N 0 RADIOLOGY TEST INFORMATION by Type /source RAO CT CHEST WICONTRAST Medical Record Number 0000791125 Account 9533191 Patient Name MILLER SAMUEL T Status Final DOB 10/25/1996 Gender MALE M.. Result Datalrme 08/30/2012 16 21 Order Date 08/28/2012 Order # 9629041 Ul Order Time 0939 Admit Date 08/28/2012 PHYSICIANS Dictating MARTIN DOUGLAS J Signature MARTIN DOUGLAS J ltd RESULT TEXT MVC Reason Chest pain With IV contrast ONLY Bed Name 19 Procedure Acknowledge Date 08/2$/2012 09 56 00 CT CHEST WITH CONTRAST HISTORY Status post MVA, right sided pneumothorax RESULT Computed tomography axial scans were performed from the base of the neck through the upper abdomen with coronal and sagittal reconstructions after IV contrast administration of 50 cc of Isovue 3?0 Lungs There is a moderate sized right pneumothorax with mild tension to the left No focal consolidation or pleural effusion Airways Patent Bones Unremarkable Heart Unremarkable Pulmonary vasculature Unremarkable Skeleton Unremarkable There is no evidence of rib fracture Mediastinum Unremarkable Note is made of residual thymic tissue in the superior mediastinum Limited cuts through the upper abdomen Unremarkable IMPRESSION 1 Moderate sized right pneumothorax with mild tension to the left Re ort PAS120 Radiology Results Coed 85 h 10103/201210 19 44 CARLISLE REGIONAL MEDICAL CTR Page 2,-j Requested By SCHRIST 361 ALEXANDER SPRING RD CARLISLE PA 17015 RADIOLOGY TEST INFORMATION ' fy Type/source RAD CT CHEST W /CONTRAST Medical Record Number 0000791125 Account 9533191 Patient Name MILLER SAMUEL T Status Final DOB 10125/1996 Gender MALE k-+ Result Date/Time 08/30/2012 16 21 Order Date 08128/2012 Order # 9629041 in Order Time 0939 Admit Date 08/28/2012 PHYSICIANS Dictating MARTIN DOUGLAS J Signature MARTIN DOUGLAS J RESULT TEXT 2 Otherwise, unremarkable enhanced CT chest MARTIN, MD DOUGLAS J Dictated By MARTIN MD DOUGLAS J Reviewed & Signed ---- - - - - -- ------------------------ - - - - -- Re ort PAB120 Radiology Results Cord e 104031201210 19 44 CARLISLE REGIONAL MEDICAL CTR Page Requested By SCHRIST 361 ALEXANDER SPRING RD CARLISLE PA 17015 RADIOLOGY TEST INFORMATION Typelsource RAO CT HEADIBRAIN W/O CONTRAST Medical Record Number 0000791125 Account 9533191 Patient Name MILLER SAMUEL T Status Final DOB 10/25/1996 Gender MALE Result DatelTme 08/30/2012 16 19 Order Date 08/28/2012 Order # 9629384 Order Time 0840 Admit Date 08/28/2012 PHYSICIANS Dictating MARTIN DOUGLAS J Signature MARTIN DOUGLAS J RESULT TEXT MVC Reason,Trauma, Bed Name 19 Procedure Acknowledge Date 08/28/2012 08 55 00 CT BRAIN UNENHANCED HISTORY MVA, trauma Left eye contusion COMPARISON None The ventricles and extra - axial spaces are normal in size No hemorrhage mass or mass effect No parenchymal abnormality The .included paranasal sinuses and mastoid air cells are clear There is congenital non - union of posterior elements of C1 which is incidental No fracture IMPRESSION Normal exam No fracture No i.ntracranial bleed MARTIN MD DOUGLAS J Dictated By MARTIN, MD DOUGLAS J Reviewed & Signed t N Re ort PAS120 Radiology Results Cold 850 1003!2012 10 19 44 CARLISLE REGIONAL MEDICAL CTR Page 1;� Requested By SCHRIST 361 ALEXANDER SPRING RD CARLISLE PA 17015 RADIOLOGY TEST INFORMATION h-! N T yypelsource RAD CHEST PORTABLE Medical Record Number 0000791125 Account 9533191 Patient Name MILLER SAMUEL T Status Final DOB 10/25/1996 Gender MALE �.• Result DatelTme 08/28/2012 15 20 Order Date 08/28/2012 Order # 9628734 Order Time 1056 Adrrut Date 08/28/2012 PHYSICIANS Dictating GOODMAN JAY DAVID Signature GOODMAN JAY DAVID !M �xa RESULT TEXT MVC Reason,Chest pai.n,Post chest tube Bed Name 19 Procedure Acknowledge Date 08/28/2012 11 05 00 CHEST ONE VIEW 1 HISTORY 15 year -old male with right pneumothorax following right chest tube placement 1 RESULT Single AP erect radiograph of.the chest was performed at 11 04 AM with comparison made to a prior study obtained approximately two hours ago During the inte placed a right sided chest tube has been laced extending medially and projecting over the right suprahilar region A right sided pneumothorax is smaller estimated 10t remaining in the right apical region There as no effusion No left sided pneumothorax is seen There as no mediastinal widening the cardiac silhouette and mediastinal contours are stable Contrast is still seen within the collecting system of both kidneys No acute osseous abnormalities are seen IMPRESSION Smaller right sided pneumothorax following right chest tube placement estimated 10 -15t GOODMAN JAY DAVID Dictated By GOODMAN JAY DAVID Reviewed & Sagned I Report PA0120 Lab Results Coid 8 10 9312012 10 19 44 CARLISLE REGIONAL MEDICAL CTR Page Requested By SCHRIST 361 ALEXANDER SPRING RD CARLISLE PA 17015 N h+ LAB RESULTS PATIENT MILLER SAMUEL T MRN 0000791125 LOC QUO BILL# 9533191 DOB 10/25/1996 SEX M ORDERED BY CHANDLER MD ORDERED 08/28/2012 09 39 COLLECTED 06/28/2012 09 50 ORDER E0280222 RECEIVED 08/28/2012 09 53 tiµ ------------------------------------------------------------------------------ TEST NAME RESULT UNITS RANGES ABN FL ST WBC 12 4 x10 3 3 8 -11 0 H F RBC 5 23 x10 6 4 10 -5 70 F HGB 15 1 g /dl 12 5 -15 0 H F HCT 44 1 % 37 0 -48 0 F MCV 84 3 fl 80 0 -96 0 F MCH 28 9 pg 26 0 -34 0 F MCHC 34 2 9/dl 31 0 -36 0 F RDW 13 2 % 11 0 -16 0 F PLT 239 x10 3 140 -400 F Neut% 81 5 % 19 0 -79 0 H F Lymph% 11 3 % 15 0 -55 0 L F Mono% 6 8 % 1 0-8 0 F Eos% 0 3 % 0 0 -6 0 F Baso% 0 1 % 0 0-2 0 F Neut# 10 11 x10 3 3 00 -7 20 H F Lymph# 1 40 x10 3 1 00 -4 20 F Mono# 0 84 x10 3 0 00 -0 60 H F EoS# 0 04 x10 3 0 00 -0 40 F Baso# 0 02 x10 3 0 00 -0 20 F ----------------------------------------------------------------------- - - - - -- Report PAS120 Lab Resufts Coid 85 10103/201210 19 44 CARLISLE REGIONAL MEDICAL CTR Page Requested.By SCHRIST 361 ALEXANDER SPRING RD CARLISLE PA 17015 0 M LAB RESULTS PATIENT MILLER SAMUEL T MRN 0000791125 LOC QUO BILL# 9533191 DOB 10/2S/1996 SEX M ORDERED BY CHANDLER MD ORDERED 08/28/2012 09 39 kn COLLECTED 08/28/2012 09 50 ORDER E0280222 RECEIVED 08/28/2012 09 53 W ----- - - - - -- ------------------------------------------------------------------ TEST NAME RESULT UNITS RANGES ABN FL ST BUN 17 mg /dl 7 -18 F Sodium 141 mmol /1 136 -145 F Potassium 4 1 mmol /L 3 5 -5 1 F Chloride 102 mmol /l 98 -107 F Carbon Dioxide 30 9 mmol /L 21 0 -32 0 F FBS 96 mg /dl 70 -100 F Fasting Glucose Interpretation Normal fasting glucose 70 -100 Impaired fasting glucose 101 -125 /J (Patient may benefit from a 2hr Glucose Tolerance Test) Diagnostic for diabetes > =126 Calcium 9 9 mg /dl 8 5 -10 1 F Creatinine 1 1 mg /dl 0 8 -1 3 F I Protein Total 8 8 9/dl 6 4 -8 2 H F Alkaline Phosphatase 180 U/L 50 -136 H F AST 27 U/L 15 -37 F Albumin 4 6 g /dl 3 4 -5 0 F ALT 38 U/L 30 -65 F Bilirubin Cotal 0 6 mg /dl 0 0 -1 0- F ----- - - - - -- ----------------------------------------------------------------- I Re0ort PAB120 Physician Chart Coid 8� 101031201210 20 19 CARLISLE REGIONAL MEDICAL CTR Page Requested By SCHRIST 361 ALEXANDER SPRING RD CARLISLE PA 17015 1 0 tV Report Status Final Pat Nbr 9533191 MILLER SAMUEL T Admit 08/28/2012 08 24 DOB 10125/1996 Gender MALE Req By CHANDLER CHARLES II Discharge 08/28/2012 12 01 Med Rec 0000791125 Pat Type E1 Location F.+ Type MED Dict 08/28/20120823 EOPN9533191 Transcribed 08/2812012 12 01 tx{ Physician CHANDLER CHARLES II t I,rd Physician Documentation Carlisle Regional Medical Center Name Samuel Miller Age 15 years Sex Male DOB 10/25/1996 MRN 0000791125 Arrival Date 08/28/2012 Time 08 23 Accountk 9533191 Bed19 Private MD CRIM, RYAN ED PhysicianChandler, Charles Disposition 08/28 Electronically authenticated by charles chandler cc 11 28 Disposition Summary 08/28 Transfer ordered to Hershey Medical Center Diagnosis are Pneumothorax, Head Injury 11 34 cc - Reason for transfer Pediatrics - Higher level of care - Accepting physician as Daflitch - Condition is Stable - Problem is new - Symptoms are unchanged HPI 08 40 This 15 years old Caucasian Male presents to ER via Walk -in with cc complaints of Motor Vehicle Collision (MVC) Historical Allergies No known drug Allergies I Report PAB120 Physician Chart Coid 85 10!93/2012 10 20 19 CARLISLE REGIONAL MEDICAL CTR Page Requested By SCHRIST 361 ALEXANDER SPRING RD CARLISLE PA 17016 �? Report Status Final M Pat Nbr 9533191 MILLER SAMUEL T Admit 08/28/2012 08 24 N DOB 10/25/1996 Gender MALE Raq By CHANDLER CHARLES II Discharge 08/28/2012 12 01 Mod Rec 0000791125 Pat Type E1 Location w Type MED Dict. 08/28/2012 0823 EOPN9533191 Transcribed 0812812012 12 01 tai Physivan CHANDLER CHARLES II - Home Meds 1 None - PMHx None - Immunization history Last tetanus immunization up to date, Childhood immunizations are up to date Pneumococcal vaccine is not up to date, Patient has never been vaccinated Flu vaccine is up to date ROS 08 41 All other systems are reviewed and negative Neck Positive for cc injury or acute deformity Cardiovascular Positive for chest pain, Negative for Respiratory Negative for shortness of breath MS /extremity Positive for abrasion Negative for laceration paresthesias Exam 08 41 Constitutional This is a well developed well nourished patient cc who is awake alert, and in no acute distress Chest /axilla Normal chest wall appearance and motion Nontender with no deformity No lesions are appreciated Cardiovascular Regular rate and rhythm with a normal S1 and S2 No gallops murmurs, or rubs Normal PMI, no JVD No pulse deficits Respiratory Lungs have equal breath sounds bilaterally clear to auscultation and percussion No rales, rhonchi or wheezes noted No increased work of breathing no retractions or nasal flaring MS/ Extremity Pulses equal, no cyanosis Neurovascular .intact Full, normal range of motion Neuro Awake and alert GCS 15 oriented to person, place time and s.Li uation Cranial nerves II -XII grossly intact Motor strength 5/5 in all extremities Sensory grossly intact Cerebellar exam normaL Normal gait Vital Signs 08 32 BP 120 / 61 Pulse 84 Resp 14 Temp 98 3 Pulse Ox 98% dj 09 41 BP 119 / 066 Pulse 70 Resp 18 Pulse Ox 97% on R/A as i Report PAB120 Physician Chart Coid 8 101031201210 20 19 CARLISLE REGIONAL MEDICAL CTR Page Requested By SCHRIST 361 ALEXANDER SPRING RD CARLISLE PA 17015 0 N Report Status Final b Pat Nbr 9533191 MILLER SAMUEL T Adnut 08/28/2012.08 24 N DOB 10/25/1996 Gender MALE Req By CHANDLER CHARLES 11 Discharge 08/2812012 12 01 Mod Rec 0000791125 Pat Type E1 Location Type MED Diet 08128/2012 08 23 EDPN9533191 Transcribed 08/281201212 01 Physician CHANDLER CHARLES 11 ti I,rl 11 37 BP 122 / 061, Pulse 72, Resp 18, Pulse Ox 100% on 4 1pm NC as MDM 08 40 Patient medically screened cc 11 27 Data reviewed vital signs, nurses notes cc 09 39 Order name Cbc Complete Automated cc 09 39 Order name CMP cc 08 40 Order name Chest Pa T Lateral cc 08 40 Order name CT Head /Brain wo Contrast cc 09 39 Order name CT Chest with IV contrast cc 10 56 Order name Chest Portable dgl Dispensed Medications 08 42 Drug Motrin 400 mg Route PO as Signatures Dispatcher MedHost EDMS Albright Amy, RN RN as Johnstone Donna, RN RN d) Chandler, Charles MD MD cc ------------------------------------- - - - - -- Report PAB120 Disposition Summary Coid 85 103/2012 10 20 19 CARLISLE REGIONAL MEDICAL CTR Page Requested By SCHRIST 361 ALEXANDER SPRING RD CARLISLE PA 17015 N Report Status Final b Pat Nbr 9533191 MILLER SAMUEL T Admit 08/28/2012 08 24 to DOB 1012511996 Gender MALE Req By CHANDLER CHARLES II Discharge 08/28/2012 12 01 Mod Roc 0000791125 Pet Type E1 Location Type ME:D DicL 08/28120120823 EDDS9533191 Transcribed 08/2812012 12 01 V1 Physician CHANDLER CHARLES 11 ti.. t,a Discharge Summary Carlisle Regional Medical Center Name Samuel Miller Emergency Department Age 15 years Sex Male I DOB 10/25/1996 MRN 0000791125 Arrival 08/28/2012 08 23 Account #.9533191 Departure Date08 /28 /2012 Departure Time12 01 Private MD CRIM, RYAN Outcome Tiarsfer Location Hershey Medical Center Condition Stable Chief Complaint Motor Vehicle Collision (MVC) Diagnosis Pneumothorax Head Injury Prescriptions Follow up Custom Notes Attending Physician Chandler Mid Level Provider Accepting Physician Daflitch Orders Cbc Complete Automated, CMP, Chest Pa T Lateral CT Head /Brain. wo Contrast CT Chest with IV contrast Chest Portable Motrin Discharge Instruction Medication Reconciliation Form I I PENNSTA HERSHEY a Milton S Hershey Me( cal Center N Patent Name MILLER SAMUEL T MRN 2110219 Discharge Summary 01 RESULT STATUS Final 4 DOCUMENT SUBJECT ELECTRONICALLY SIGNED BY Simmons Lynn G (91412012 06 45 EDT) Santos Mary C (8/31/201211 59 EDT) DISCHARGE SUMMARY Name MILLER SAMUEL T HMC Number 2110219 DOB 10/25/1996 Date of Admission 08/28/2012 Date of Discharge 08/30!2012 Physician Santos Mary C Service Ped Surgery Discharge Diagnosis Right pneumothorax Other Dtagno%es Minor concussion Surgical Procedures None Vaccinations Received This Hospital Stay No vaccinations were given this hospital stay Discharge Medications 1 Acetaminophen hydrocodone (acetaminophen hydrocodone 325 mg 5 mg oral tablet) 1 tab by mouth every 4 hours as needed for Pain Moderate 2 Ibuprofen (ibuprofen 400 mg oral tablet) 1 tab by mouth every 6 hours as needed for Pain Mild Brief History of Present Illness Sam is a 15 yeas old male presenting as a transfer from Carlisle after an MVA early on 8/28112 He reports that he was in the passenger saal of the car riding at about 40 mph when the car struck a tree He was wearing a seatbelt and the airbag was deployed He reports that he did strike his head but is unsure of whether it struck the airbag or the windshield HE denies loss of conciousness or amnesia He did have some right sided chest pain which was exacerbated by breathing He was taken to Carlisle where a right sided pneumothorax was found and a chest tube was placed and put to suction Head neck chest and abdominal CT scans were performed and were reportedly negative other than the pneumothorax He did have He was transferred to HMC for further care of his chest tube Hospital Course Upon arrival to HMC a CXR was performed that showed some interval increase in size of right pneumothorax His chest tube was placed to 20 suction and an air leak was noted at this time Pain control was given with morphine and he was given a clear liquid diet without difficulty A repeat CXR several hours later showed decrease in size of pneumothorax Daterrime Printed 1012120121152 EDT Page 4 of 22 Pnnted By Toro. Vanessa D i PENN STATE HERSHEY � PDXTAI Milton S Hershey a IV Medical Center N Patent Name MILLER SAMUEL T MRN 2110219 Discharge Summary Qy and his chest tube was maintained on 20 suction overnight His diet was advanced to full that evening and was well Jh tolerated without nausea or vomding The following moming the air leak had resolved and his chest tube remained oto 20 overnight again He did well durng his second day and was transitioned to Lortab with morphine for breakthrough He had approximately 12 mL serosanguinous drainage from his chest tube that evening but no difficulty breathing His chest tube was placed to water seal during the following night A repeat CXR was performed the following morning and showed only a very my pneumothorax Chest tube was removed Repeat xray showed no additional pneumothorax Discharged to home with follow up with pediatnc surgery in approx 3 weeks Exam on Discharge General NAD HEENT NCAT MMM Heart RRR Chest CTA Abdomen soft NT /ND +BS Extremity Warm well perfused Neuro Motor and sensory intact Discharge# Care Instructions 1 nght chest dressing leave on for 5 days then you can remove 2 pain medications can cause constipation Take an over the counter laxative (like senekot or mire lax) as needed Concussion A concussion usually does not need treatment Most concussions get better with trne but it can take time Some peoples symptoms go away within minutes to hours Other people have symptoms for weeks to months When symptoms last a long time doctors call it post - concussive syndrome 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 acitvites that need a tot of concentration or a lot of attention such as excessive television or computer /video games Your child may take a pain relieving medication for headache such as acetaminophen (Tylenol) or ibuprofen (Motnn 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 activates. For more information see the head injury packet given to you at Hershey Medical Center Diet Guidelines regular diet drink plenty of liquids Date/Time Pnnted 10!2/201211 52 EDT Page 5 of 22 Pnnted By Toro Vanessa D w PENN SiATE HERSHEY Milton S Hershey Medical Center to Patent Name MILLER SAMUEL T MRN 2110219 Discharge Summary m Activity Guidelines avoid activities that may lead to impact/contact return to school see note provided Call your doctor If 1 Your child develops a fever of 1014 or higher 2 Your child experiences sudden onset of shortness of breath or severe pain or pain that cannot be controlled by medication 3 Your child has persistent nausea or vomiting 4 There is any increases redness firmness or drainage from the incisions 5 Any other questions or concerns For routine questions Monday through Friday 8am to 5pm call the Pediatric Surgery office at (717) 531 8342 For urgent questions or questions after hours call (717) 531 -8521 and ask for the pediatric surgery resident on call For emergencies go to the emergency department or call 911 Other Instructions Penn State Hershey Children's Hospital Injury Prevention Tips Teen Driver Safety 1 ALWAYS travel with your lap and shoulder seat belt snugly fastened 2 Never nde or drive under the influence of alcohol or drugs 3 Obey posted speed limits 4 Avoid distracted driving using cell phone or texting eating adjusting the climate or music controls 5 Urnrt the number of passengers riding with teen drivers Follow up appointment with pediatric surgery is listed on this discharge summary Some patents rind 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 Follow -Up Appointments Scheduled Penn State - Hershey Appointments Within the Next 90 Days 1 Follow Up with Suite 400 Peds Surgery at Univ Phys Ctr Suite 400 on 09/26/2012 at 12 45 pm Date/Time Printed 10/2/2012 1152 EDT Page 6 of 22 Printed By Toro Vanessa D a-► PENN STATE HERSHEY Milton S Hershey Medical Center N Patent Name MILLER SAMUEL T MRN 2110219 Discharge Summary C� Etectromc Signature on Pile �A CC Ryan C Cnm MD 366 Alexander Spring Roar! Carlisle PA 17015 Electronically Reviewed/Signed by Lynn G Simmons. MSN CRNP Author Signature DYTM 0910412012 06.45 AM Podatric Surgery Drs. Robert Crlley Biter Dillon Brett Engbrecht Kerry Pagelman Dorothy Rocourt Mary Santos Coleen Greecher MS RD CNSD Janet Shuefds MSN CRNP PNP BC Lynn Simmons MSN CRNP Electronicaly Reviewed/Signed by Mary C Santos. MDCosigner Signature Dt1Tm. 08 31/2012 11 59 AM Pediatric Surgery Drs. Robert Gilley Peter Dillon Brett Engbrecht Kerry Fagelman Dorothy Rocourt Mary Santos Coleen GreecherMS RD CNSD. Janet Shields MSN CRNP PNP $C. Lynn Simmons MSN CRNP LGS /JGM DD 08131/12 DT M31/121049 a I i 1 Dateffime Pnnted 10/212012 1152 EDT Page 7 of 22 Pnnted By Toro. Vanessa D h-+ PENN STATE HERSHEY � 03 Milton S Hershey ) Medical Center N Patent Name MILLER SAMUEL T MRN 2110219 ED Summary RESULT STATUS Final 1 DOCUMENT SUBJECT Transfer MVC with ptx ELECTRONICAI LY SIGNED BY DeFlitch Christopher (8/2812012 1314 EDT) Transfer MVC with ptx Patent MILLER, SAMUEL MRN 2110219 Age 15 years Sex Male DOB 10/2511996 Associated Diagnoses None Author DeFlitch, Christopher J Basic information Time seen Immediately upon arrival History source Patient, father EMS Arrival mode Ambulance ALS History limitation None History of Present Illness The patient presents with major trauma The onset was just pnor to amval The course of symptoms is constant Tape of injury motor vehicle collision (restrained passenger) The location where the incident occurred was at school Location chest The character of symptoms is pain The degree of bleeding is minimal The degree of pain is severe Exacerbating factois consist of movement breathing Associated symptoms headache denies loss of consciousness denies suspected cervical spine injury and denies paralysis Patient initially seen at cadisle reportedly negative head neck chest abd CT except p1x they had placed a chest tube already and requested transfer Review of Systems Additional review of systems information Unable to obtain due to Clinical condition Health Status Allergies Unknown Past Medical/ F-imilyl Social History Medical history Reviewed es documented in chart Surgical hirtary Reviewed as documented in chart. Family history Reviewed as documented in chart Social history Reviewed as documented in chart Physical Examination General Alert Vital Signs Skin Warm pink Head Normocephalic Not atraumatic On exam Mild left, frontal tenderness abrasion no ecchymosis no iacerabon no deformity no step off Date/Time Pnnted 10/2/2012 1152 EDT Page 8 of 22 Pnnted By Toro Vanessa D t� PENN STATE HERSHEY o Milton S Hershey o Medical Center Patent Name MILLER SAMUEL T MRN 2110219 w, ED Summary Neck Supple trachea midline no tenderness no step offs full range of motion Rs Eye Normal conjunctiva +151 Ears nose mouth and throat Oral mucose moist Cardiovascular Regular rate and rhythm Respiratory Breath sounds Right antenor diminished Chest wall No tenderness Bade Nontender Muscuioskeletal Normal ROM normal strength no tenderness Gastrointestinal Soft Nontender Non distended Normal bowel sounds Neurological Alert and oriented to ,person place time and situation No focal neurological deficit observed Psychiatric Cooperative Medical Decision Making Trauma team Trauma criteria met trauma team assembled trauma surgeon present Results review outside labs unremarkable including normal LIT Head Computed Tomography No acute disease process Chest X -Ray inital with ptx repeat with chest tube repeat in trauma bay with increase in ptx (Dr Santos aware) Radiology results Computed tomography outside chest PTX ' Impression and Plan. Diagnosis Head injury 959 01 (ICD9 959 01) Chest wall injury 9591 (ICD9 959 1) Traumatc pneumothorax 860 0 (ICD9 860 0) Calls- Consults • Trauma level 2 Plan Condition Stable Disposition Admit to inpatent Unit Addendum Signatures Wectronicai(y Reviewed /Signed (211--AUG 2012 13.14.001 by, Christopher J DeFiitch MD FACEP Director & Vice -Chair Associate Professor Department of Emergency Medicine 1 i i DaterTime Printed 10!212012 11 52 EDT Page 9 of 22 Printed By Toro Vanessa 0 6-+ O PENNST HERSHEY ° %0 Milton S Hershey a Medical Center N Patent Name MILLER SAMUEL T MRN 2110219 Chest 0) RESULT STATUS Final jh DOCUMENT SUBJECT PORTABLE X RAY CHEST PA OR AP VIEW PEDS 01 ELECTRONICALLY SIGNED BY SERVICE DATE/TIME 8/30/2012 16 35 EDT PORTABLE X -RAY CHEST PA OR AP VIEW- PEDS ' PATIENT NAME MILLER, SAMUEL T PATIENT MRN 02110219 PATIENT DOB 10/25/1996 EXAM DAT>~ OF SERVICE 08/30/2012 EXAM NUMBER 7734794 ORDERING PHYSICIAN SANTOS MARY C EXAMINATION PORTABLE X -RAY CHEST PA OR AP VIEW PEDS/PEDSFLOOR CLINICAL HISTORY SS IS -year old male with history of pneumothorax. status post chest tube removal 'COMPARISON Multiple priors most recent from 0942 hrs, August 30, 2012 FINDINGS There has been interval removal of the right chest tube The right apical pneumothorax is unchanged since the prior study from 0942 hrs, 08/30/2012 Lungs are clear Cardiomediastinal silhouette is normal Bones are unchanged. The small focus of air is noted within the right lateral subcutaneous soft tissues likely in the former tube tract IMPRESSION Interval remora] of right chest tube with stable size of right apical pneumothorax Dr Ruth Magee a is the dictating resident Attending rachologist signature incbcates review of both the images and the report and that the attending radiologist agrees with the interpretation Preliminary reports may not have been reviewed as yet by the attending radiologist DICTATED ME CHRATTA, SOSAMMA T REVIEWED AND SIGNED METHRATTA, SOSAMMA T Daterrime Printed 10/2/2012 1152 EDT Page 10 of 22 Printed By Toro Vanessa D 0 � OENN STATE HERSHEY Milton S Hershey Medical Center N Patient Name MILLER SAMUEL T MRN 2110219 Chest c DATE DRAFTED 08/30/2012 04 53 PM DATE OF FINAL SIGNATURE 08/30/2012 05 34 PM 1 � 1 Date/Time Pnnted 10/2/2012 1152 EDT Page 11 of 22 Printed By Toro.Vanessa 0 N FENNST HERSHEY o qr Milton S Hershey Medical Center iV Patent Name MILLER SAMUEL T MRN 2110219 Chest RESULT STATUS Final DOCUMENT SUBJECT PORTABLE X RAY CHEST PA OR AP VIEW PEDS 0 ELECTRONICALLY SIGNED BY SERVICE DATEITIME 8/29 /2012 06 41.EDT PORTABLE X -RAY CHEST PA OR AP VYFW- PEDS PATIENT NAME MILLER, SAMUEL T PATIENT MF N 02110219 PATIENT DOE 10/25/1996 EXAM DATE OF SERVICE 08/29/2012 EXAM NUMBER 7730984 ORDERING PHYSICIAN SANTOS MARY C EXAMINATION PORTABLE X-RAY CHEST PA OR AP VIEW PEDS/PEDSFLOOR CLINICAL HISTORY SS Pneumothorax 770 2, COMPARISON 08/28/2012 FINDINGS The tip of the right chest drain is stable in position Small right apical pneumothorax is identified which is similar to the prior study The heart and mediastlnum are stable Right basilar atelectasis is identified Lungs are otherwise cle it There is no pleural effusion IMPRESSION Stable small right apical pneumothorax Right basilar atelectasis DICTATED CHOUDHARY, ARADINDA K REVIEWED AND SIGNED CHOUDHARY, ARABINDA Y, DATE DRAFT ED 08/29/2012 08 25 AM DATE OF F1NAI SIGNATURE 08/29/2012 08 25 AM Date/Time Printed 10/2/2012 11 52 EDT Page 12 of 22 Pnnted By Toro Vanessa D 6-+ PENN STATE HERSHEY Q lo Milton S Hershey a Medical Center Patient Name MILLER SAMUEL T MRN 2110219 Chest'` RESULT STATUS Final p DOCUMENT SUBJECT PORTABLE X RAY CHEST PA OR AP VIEW PEDS ELECTRONICALLY SIGNED BY SERVICE DATE/TIME 812812012 15 25 EDT PORTABLE X -RAY CHEST PA OR AP VYEW- PEDS PATIENT NAME MILLER, SAMUEL T PATIENT MRN 02110219 PATIENT DOB 10/25/1996 EXAM DATE OF SERVICE 08/28/2012 EXAM NUMBER 7730374 ORDERING PHYSICIAN DEFLITCH, CHRISTOPHER EXAMINATION Portable erect chest at 1512 hours CLINICAL HISTORY SS Pneumothorax 770 2 COMPARISON Most recent chest at 1259 hours FINDINGS Tip of the right thoracotomy tube is unchanged, tap overlying the nght hilum There is partial re expansion of the rnght.lung and decreased size of the right pneumothorax Residual pneumothorax remains evident (annotated on the film) There is no mass effect Heart and medhastinucn are normal Both lungs are free of airspace disease Bony and soft tissue structures are normal as is the visualized upper abdomen IMPRESSION Improved expansion of the right lung and decreased size of the nght pneumothorax DICTATED BOAL, DANIELLE REVIEWED AND SIGNED BOAL, DANIELLE DATE DRAFTED 08/2 8/2012 03 37 PM DATE OF FINAL SIGNATURE 0828/2012 03 37 PM Date/Time Printed 10/2/2012 1152 EDT Page 13 of 22 Printed By Tom Vanessa D W OENNSTA HERSHEY - Milton S Hershey 0 Mechca.l. Center N Patent Name MILLER SAMUEL T MRN 2110219 Chest eT RESULT STATUS Final, DOCUMENT SUBJECT X RAY CHEST PA OR AP VIEW PEDS ELECTRONICAI LY SIGNED BY SERVICE OAT! /TIME 8/28/2012 13 08 EDT X -RAY CHEST PA OR AP 'VIEW- PEDS PATIENT NAME MILLER, SAMUEL PATIENT MR 02110219 PATIENT DOB 10/25/1996 EXAM DATE OF SERVICE 08/28/2012 EXAM NYJM13ER 7730260 ORDERING PHYSICIAN BREA, ISABEL J EXAMINATION X -RAY CHEST PA OR AP VIEW- PEDS /EMT CLINICAL HISTORY Multiple trauma COMPARISON Chest X -ray from outside hospital dated August 28, 2012 FINDINGS There is a moderate size right pneumothorax, increased in size since the prior outside study taken at 1 107 hrs, 08/28/2010 however there does not appear to be significant increased pressure rather greater collapse of the right lung There is a right chest tube in place with the tip oriented towards the right hilum The airway remains in the midlme, however the mediastsnum is slightly shifted to the left The left lung is clear without pneumothorax, effusion or focal consolidation The heart and mediastinum is normal There are no fractures identified IMPRESSION Moderate sizc right pneumothorax, increased in size since prior study with mild leftward shift of the mediastinum and greater collapse of the right lung Tip of right chest tube oriented towards right hilum Dr Magera dis( ussed the findings with Dr DeFlitch on 08/28/2012 Date/Time Printed 10/2/2012 1152 EDT Page 14 of 22 Printed By Toro. Vanessa D PENNSTATE HERSHEY a 40 Milton S Hershey a Medical Center N Patent Name MILLER SAMUEL T MRN 2110219 Chest` . m Dr Ruth Magera is the dictating resident Attending radiologist signature indicates review of both the image and the report and that the attending radiologist agrees with the interpretation Preliminary reports may not have been reviewed as yet by the attending radiologist DICTATED GOAL DANIELLE REVIEWED AND SIGNED BOAL, DANIELLE DATE DRAFTED 08/28/2012 0121 PM DATE OF FINAL SIGNATURE 08/28/2012 01 24 PM Date/Time Printed 1112/2012 1152 EDT Page 15 of 22 Printed By Toro.Vanessa D 4 � PENN HERSHEY 0 K" Milton S Hershey, 1Vlechcal. Center Patient Name MILLER SAMUEL T MRN 2110219 N Chest J `" 0 RESULT STATUS Final A DOCUMENT SUBJECT X RAY CHEST PA OR AP AND LATERAL VIEWS PEDa) ELECTRONICALLY SIGNED BY SERVICE DATEMME .8/30/201210 35 EDT X -RAY CHEST PA OR AP AND LATERAL VIEWS • PEDS PATIENT .NAME MILLER, SAMUEL T PATIENT hr11? N 02110219 PATIENT DOB 10/25/1996 EXAM DATE OF SERVICE 08/30/2012 EXAM NUMBER 7733499 ORDERING PHYSICIAN SANTOS, MARY C EXAMINATION X -RAY CHEST PA OR AP AND LATERAL VIEWS PEDS/PEDSFLOOR CLINICAL HISTORY 15 year 10 month male with pneumothorax COMPARISON August 29, 2012 FINDINGS Supine chest demonstrates right chest tube tip directed medially in the mid hemithorax Right apical pneumothorax is identified, smaller in size when compared to yesterday's examination Lungs are well expanded There is no focal consolidation or atelectasis Visualized upper abdomen is normal IMPRESSION Decrease in sizL. of right apical pneumothorax DICTATED METHRATTA SOSAMMA T REVIEWED AND SIGNED METHRATTA SOSAMMA T DATE DRAF) Ell 08/30/2012 11 18 AM DATE OF F114AL SIGNATURE 08/30/2012 11 18 AM Date/Time Pnntcd 10/2/2012 1152 EDT Page 16 of 22 Printed By Toro Vanessa D PENN STATE HERSHEY ° Q IV Milton S Hershey Medical Center Patent Name MILLER SAMUEL T MRN 2110219 Musculoskeletal RESULT STATUS final � DOCUMENT SUBJECT X RAY TIBIA & FIBULA RIGHT PEDS ELECTRONICALLY SIGNED BY SERVICE DATE/TIME 8/28/201213 34 EDT X -RAY TIBIA & FIBULA RIGHT - PEDS PATIENT NAME MILLER SAMUEL T PATIENT MRN 02110219 PATIENT DOB 10/25/1996 EXAM DATE OF SERVICE 08/28/2012 EXAM NUMBER 7730362 ORDERING PHYSICIAN DEFLITCH CHRISTOPHER EXAMINATION X RAY KNEE 1 -2 VIEWS RIGHT - PEDS/ER X ray tibia and fibula right CLINICAL HISTORY SS Limb Pain 729 5 15 year old male with leg pain status post motor vehicle accident COMPARISON None FINDINGS Right knee There is normal alignment of the spine of the nght knee There are no fractures or dislocations There is no soft tissue swelling or joint effusion Right tibia and fibula There is normal alignment of the knee and ankle There are no fractures or dislocations There is no soft tissue swelling or joint effusion IMPRESSION No acute osseous injury of the right knee, tibia or fibula Dr Lori Mankowski Gettle 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 Datef ime .Printed 10/2/2012 1152 EDT Page 17 of 22 Printed By Toro. Vanessa D b-+ PENN HERSHEY co co Milton S Hershey Medical Center N Patent Name MILLER SAMUEL T MRN 2110218 Musculoskeletal cr, 4$ DICTATED 130AL DANIELLE REVIEWED AND SIGNED BOAL, DANIELLE DATE DRAFTED 08/28/2012 0146 PM DATE OF FINAl SIGNATURE 08/28/2012 0147 PM Dateffime Pnnted 10/2/2012 1152 EDT Page 18 of 22 Pnnted By Toro.Vanessa D i Q PENN STATE HERSHEY co ig Milton S Hershey o Medical Center Patent Name MILLER SAMUEL T MRN 2110219 Musculoskeletal RESULT STATUS Final !s DOCUMENT SUBJECT X RAY KNEE 12 VIEWS RIGHT PEDS ELECTRONICALLY SIGNED BY SERVICE DATEITIME 8128/201213 34 EDT X -RAY KNEE 1-2 VIEWS RIGHT - PEDS PATIENT NAME MILLER SAMUEL T PATIENT MRN 0211 0219 PATIENT DOB 10/25/1996 EXAM DATE OF SERVICE 08/28/2012 EXAM NUMBER 7730361 ORDERING PHYSICIAN DEFLITCH CHRISTOPHER EXAMINATION X -RAY KNEE 1 -2 VIEWS RIGHT PEDS/ER X -ray tibia and fibula right CLINICAL HISTORY SS Limb Pain 729 5, 15- year -old male with leg pain status post motor velucle accident i COMPARISON None FINDINGS Right knee There is normal alignment of the spine of the right knee There are no fractures or dislocations There is no soft tissue swelling or joint effusion Right tibia and fibula There is normal alignment of the knee and ankle There are no fractures or dislocations There is no soft tissue swelling or joint effusion IMPRESSION No acute osseous injury of the right knee tibia or fibula Dr Lori Mankowski Gettle 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 Date/Tune Pnnted 1012/2012 1152 EDT Page 19 of 22 Pnnted By Toro . Vanessa D PENNST HERSHEY Milton S Hershey Medical Center` N Patent Name MILLER SAMUEL T MRN 2110219 Musculoskeletal DICTATED BOAL, DANIELLE REVIEWED AND SIGNED BOAL. DANIELLE DATE DRAFTED 08/28/2012 0146 PM DATE OF HNIAL' SIGNATURE 08/28/2012 0147 PM Datefrime Pnnted 1012/2012 11 52 EDT Page 20 of 22 Pnnted By Toro Vanessa D P+ PENN STATE HERSHEY rwi Milton S Hershey a Medical Center w Patent Name MILLER SAMUEL T MRN 2110219 Immunology f� Procedure MRSA Surveiga=6 ion Admtston Units Retrence Range [MSNDJ Collected DatelTime 8/2812012 16 30 EDT MRSA NOT detected O Order Comments 01 MRSA Surveillance (NP) on Admission MRSA Surveillance (NP) on Admission i I Date/Time Pnnted 10/212012 1152 EDT Page 21 of 22 Printed By Toro. Vanessa D r-+ PENN TE HERSHEY � Milton S Hershey IV ► Medical Center N Patent Name MILLER SAMUEL T MRN 2110219 t� Toxicology Procedure Amphetamine8 juj B9tfxturatea(u) Units Reference Range Gdlected Oateftime 812812012 20 25 EDT NONE DETECTEDO NONE DETECTED 01 Procedure Senzodi axmpines(u) Coca inem Units: Retereme Range: Collected Wr !'Time 8/28/2012 20' 5 EDT PRESUMPTIVE POSITIVE DRUG RESULT#i NONE DETECTED 01 Result Comments R1 Benzodiazepines(u) Uncorrtimf d intended liar Medical treatment purposes only Procedure Marquana.(u) (Jptates(u} Units RefereizGe Range Collected Dnt(Atme 8128/2012 20 25 EDT NONE DETECTEDOI PRESUMPTIVE POSITIVE DRUG RESULT R1 01 Result Comments R1 Opiateb(u) Unconirned intended for Medical treatment purposes only Order Comment. 01 Drugs of Abuse w NO confirm Urine (Urine Drug Screen NO confirm in house) [[Urine random]] Datefrime Printed 10/212012 1152 EDT Page 22 of 22 Printed By Toro Vanessa D alt MO 0,1 p,n 7 u,. ♦ 7 1t] 4 y t �j t 7 f3 r! //� �r S�$ Re £tL' (ti ^17 "1L 06 11 23 f 0,101 WAS i t xc k. $ L %A v44 ^4. c e s. ire 1,ni- k i, IM 1 &-. ', Oil 361 ALwXANDER SPRINGS ROAD CARLISLE PA 170A t 11 960 -1681 RADIOLOGICAL INTERPRETATION FAT.IEV N AME MILLER SAMUtL r PEED Rrc 791125 X RAY# 7 91125 ACCOUNT 9533 EXAV DAIS 8128/2012 0 0.8 1012b /1995 ORWRING Cl -AR-£S CHANDLER II MD 960-1695 ROOM FR ATTENGA NG Iv OINSW i I NG ROAN C is tI N, M D. 241-1322 H ISTORY MVC Reason T'rau"na° Bed Name 19 CT BRAIN UNENHANCED. HISTORY MVA trowne Left eye contusion. COMPAU SON None The ventrirles, ann extra- a.x°'aj spaces are rlarma in %IZe. No , temorrndge mass or iness ef'fec-. No parench, ma, abnormality The included pu- atjasal sCnuses and € astuid aiv ceps are clear There Is Congenital non -ulii on of posterior el a tc lit s of CI w h'i Ch Is ircidentaY. No friacture. IMPRESS ON Nurroa! exam No fraGtu No lntracrania bleed R_qBEb CCD A ND SIGjED 50 9GLA J MARTIN MCI INTERPRLi N6 PHYSICIAN OATc DICTATLO 8128 2012 DATE. 1 RANSL i I BLD 81 ?817012 1x 37 i RANSCRTPTI'ONISCIT" jX5 96?938I LONSULTING FAX PAGE 1 OP 1 Oil Foi n €grllsle Rag Nec Ctr (117) .? lZ 081311 P DAY�. %or% "t x `Lt f $1 to Vtie%% CIL LA 411;_ Lt It f L 1A 361 ALEXANOLR SPRINGS R13AD CARLIS, L PA 1701b NJ (731) 966 16133 RADIOLOGICAL I! tERPRETA1IQN PA1 twxr mm-,. M L.LER SA I #��U RE(, X RAYS 791.125 ACC Otlti�l # 3'a3.33.�3. FXAP BATE 8/2819012 D O R O1 ORDERING CHARLES CHANBLER II MO 960-.1695 0 0M ER CONSUL — ING RYAN C GRIM. M,). 240 -1322 HISTORY. Mn Re asoa,Chest pain, Red Name. 19 CHEST 740 VIEWS. H151CRY Status post MVA. 0est pair RESULT There is a ff"Od erdte 5; ped tensi pneumothorax pC the right NO eonsol i datl on or pleural of rust on Cardiac s1 th"et to and pulmonary Vaic lature are unre'nar kaa ld IMPRESS ON I Moderate s17ee tanslon pneumothoirax on thf► right 2 NO atu;.e Cardiopulmonary. abnormal ty REVINEC1 ANO S1GNr ff____ DOUGLAS u MARE IN, MD 117L PRLT1N(, PI- YSICIAh DATE D CTA 81 2812012 HATE ilcANSCRI B0 832812CIi2 12.29 TRANSCRIPTIONIST ,XS O62g.38h CONSULTING PAX PAGE I OF 1 From i£" 15 le Re' ped Cyr. � ct� 4 tlii� 44 °12,2 1r 13�i1i `sl�74 F 0 4st+.l.L.iLR ,lF &Alt.7s1�C,. 6 1 ux ^I V it:'h.l 367 ALEXAND' - �. SPRINGS II D CARLISLE PA 17015 till (717) 960 -1683 alt RADIOLOGICAL !NFFRPRFTA; IC# l" lid PATIENT NAME- MILLER. SAMU l T l��U ItEG �}1 ;?'�i�� X RAYS 7 7125 A CO UNT # 7 953319 p EXAM D A I E 8/2812017 ORDFRING CHARLES CHANDLER 11 MD goo 1696 ATTEN R(7131�� El ?5f]gg t TNT CONSOL 1' ING RYAN C. CRIM, M D ?40 -:1322 HISTORY mvC ffeaSOaatChe t fe.in; iN IV COratraSt ONLY Bed Name 19 CT CH-S[ Wa ] h CONI RAST. HISTORY Status post MV4. right .41 deQ Rneus othorax RE.S.TLt Cemput" tomagr'auh� axial sCbns were RerformeC from �hr hAse tat the neck throu. , hP upper abdOrrar�n wi th corana and sagitt.al reccn , ruct'lors after Iii contrast iq nlriv�tratjon of 5p cc of Isovie 3701 Lungs There Is a mad,rate s 3r .ag ht W -lumot horax with nil d ten%ion to the left No focal CMOTtdation or pleural effusion Airways. Patera Bores. Urr'ettarkaule , #part Uri: vvr kaLle i"u "wonary vasc€rlature- Unremarkabie Skeleton. Unremarkable There is no evidequ of rib frac -ure Mediast'niri Unremarkable hate is mace of resicaual tbymlc tissue in the SupPr#Or rnedaastinum Lv nitf -d cuts ' t.hrough the upper andoj4en Unreotnarkaole IMIRESSION 1'OW INJED ON PACE 2 ,t17 i X11 6.1 �I 1 a � ail P 8? w+ M ARLISIE REGIONAL ME01LAL LENT ER NJ 361 At HANorh SPRINGS ROAD CARLJSLE M 1701 ( T 17) 96€I 1683 RADIOLOG CAI. I N l E€IPRtTAT I ON F47UNT WE. HILL; 7 R SAMUFI i NED AEL # 191125 EXAM DATf 812 81 ?012 .B ,A#t ORD RING C►..B C4ANDL-R 17 Mb 960 -16 / ?5/l�}96 ROOM: ROOM: 1p 10 Al fEWN& C0HSU1 T1hG RYAN C CRIM M 24L-1 7 HIStoRt MVL R asoai:i�e�L W 4h IV contrast ONLY aed Name Ig 4 t oci�rat aizea r-ght pneumothorax with M11d tpnsi t,. the Otherwise. unrerraark4bje epha.rced CT chest i i DOUG —KS J MART l N Mg I NTERPRE 3 Nu PHYSIC AN BATE DI'M a to 67W012 UAT TRANSCRIBED 8/28/2012 1^-PS TRANSCRP '10NIST .,XS 962904: CPM'cU, Y I NG FAX PAC I U 2 t h, J u�a CARLISLE t~ P` FFG* GAL MEDICAL CENTER elf 361 ALLXANDER SPRINGS ROAD CARLISLA 1eM P,Y (727) 96C -1681 P,9 RAOM- 0GxCAt INTERPRETATION PAT'IFNI NAME: MIELtR SAMUwt T X -W# 7911 ?5 Mr.D RUC 791125 UAM DATE 81280012 ACCOUNT � 9633191 ORDERING AIIAN JAMES BRAZE, i3 O 733 -IIO(I 0 B3 10125/1996 AT I E #03 tG CHARL E'S ( HAM ER 11 MD 960 1695 ItOOi" ER ro"S 1L' Iha RYAN C »RIM M D 240 1322 HISTORY NVC Raa3on.Che�t paln;Pnst che,+t tube. ded Nalne 19 CHE S1 ONE V j rW. HISTORY 15 year mate with rlyh+ plellmo thcrax following r' ght cj tune alacei`ent, RESULT: S te AP erect radfograah of tr.e chest w a s obtai at 1 � biained AN with coirparlson �•r1 de to 8 r iJ # o apDroxtmat 0 ely two Eo��r� agp R study During the IntprVal. a r ight sicfad ches t� extendfng metila3l and tu be hds bPPn Placed Pegl0n- A r h� Dr'ojer. �ting Over the right sup�rahj l ar g sf0ed preumathoraxs esiimated '"enfi f"I rg in the right apical regi on Tmar e 1 st m4te :�r� left sideC reU att�oi^aa 1 s seen There Is no medi astina 3 No W1 c:eni ng� he oa "di ae si 1 #touette and merit ast 1 no f con Stable Contrast "5 St I i seen wit ttie tours are both k%neys No ar. at e GS,5eens , �bnor��ral f ti of e`ct 3 ng se stem of IMi�RFSSIQty Smaller right s 1 oed DneLarott orax f0310WI ng ri gh" Cnest t,,.be pl aceriert ftr Y I A i j G� E L JAY DAVID G€ ODMA& INTE RPRE71NC PHYSIG:At i DATE DICTATED 8I2812Cl2 DATt. TRAh$CRI8ER_ 8/2812/12 TRANSCRIPTIONIS3 ,1 X5 9 628134 CONS 1L71;'G rAv PA& . ilia tll 9i� I Cadisle Family Care 411 1533 Commence Avenue 1111 Suite 1 113 hIi Carlisle PA 17015 Phone 717 240 1322 Fax 717 240 0382 MILLER SAMUEL (00g IWMI99B.ID 9313) CC Sep 11 2012 Tue.08 59 AM k' removal of strtches crmclhershey med W HPI Suture removal sip MVA 9128/12 chest tube place sutures on right side p,1 Flu with surgeon 9126!12 CXR planned Rt Lung was expanded on 314 of way on discharge hid Mom concemed last evening while changing bandage Became lighted nausea SOB No pain medicines for 1 week no ibuprofen for 4 days Retumed to school headaches poor concentration ROS GEN PULM no complaintsno complaints NEURO as above PSCYh denies depression PMH wrsdome teeth extracted Pneumonia as a child several times never hospitalized Healthy Current on his immunizations SH 8th grader at Big Spring Middle &Ijoul Skis plays basketball Tobacco neg ETOH neg Denies recreational drugs lives with parents sister FH Father HTN MI Hypedipidemia Mother healthy MGM deceased polycystic kidney disease complications Allergies No Known Allergies (Updated by RYAN an 05!17!2011 09 48 AM) Mods None Reported Vitals T 98 2F Wt 146 5 lb BP 120164 P 74 RR 12 PE GEN WD WN NAD PULM CTAB SKIN still maceration at tube NEURO no focal findings AfP # POSTCONCUSSION SYNDROME (310 2) #TRAUMATIC PNEUMOTHORAX WITHOUT OPEN WOUND INTO THORAX (860 0) right # MOTOR VEHICLE TRAFFIC ACCIDENT OF UNSPECIFIED NATURE INJURING PASSENGER IN MOTOR VEHICLE OTHER THAN MOTORCYCLE (E8191) 1 recurrence of concussion symptoms off school until headaches resolve and then begin gradual reintroduction to school and homework return to school Is purely symptom driven d questions, please call me Recommend IEP meeting upon return to school Sam cannot be expected to make up all tests and all homework immediately This will be a graduated return 2 slr without difficulty Ordered /Advised Custom Order (recurrence of concussion symptoms off school until headaches resolve and then begin gradual reintroduction to school and homework return to school is purely symptom driven 0 questions please call me Recommend IEP meeting upon return to school Sam cannot be expected to make up all tests and all homew This will be a graduated return) IC09 Codes (E8191 310 2 860 0) ork Immediately Amaz1n9Charis. com The intonnatlon on this page is confideritlal PW Any release of this Information requires the written authorization of the pabent listed above ' 61a pt9 Nib MILLER SAMtjEL (DOS 1 01=1"OlD 33 73) ' Coded 99214 Sip 11 P1 TO 48 59 AM QII Ryan Cnm Mo $ Electronic Signsture Dt i }b }t� l I AmazingCharts com The information on this page is confidential wee 2 at 2 Any release of this information requires the wdtten auftmation of the patient listed above -, ,_ . � - r ��. ;� �. i _ _. n . �. r �� s —, t . l THE MILTON S HERSHEY MEDICAL CENTER P.O. BOX 853 HERSHEY, PA 17033 OUTPATIENT HOSPITAL STATEMENT FEDERAL ID: 251854772 PAGE: 1 PATIENT NAME: MILLER SAMUEL T VISIT DATE: 08/28/12 PATIENT ACCT#: 18098122 CLERK: CKF PHYSICIAN NAME: SANTOS MARY C DIAGNOSIS CODES: 8600 8509 E8161 ---UNIT - SERVICE CODE DESCRIPTION AMOUNT ------ -------------- --------------------------------------- ------------- 1 10277 7 PEDS PRIVATE RM 2471.00 1 16604 PEDS LVL II TRAUMA W/ 9724.00 1 46472 EMERGENCY VISIT, LEVE 1 46620 VENIPUNCTURE 1063.00 1 46699 THERA/DIAG INJECTION 25.00 196.00 1 46717 NONINVAS PULSE OX, MU 147.00 1 46937 THER IV PUSH,EA ADDL 85.00 1 100031 MRSA BY PCR 283.00 1 104711 DRUG SCREEN, URINE 165.00 1 246705 MORPHINE SULFATE 4 MG 3.20 3 246706 MORPHINE SULFATE 2 MG 18.90 2 307101 CHEST 1 VIEW 408.00 1 309106 KNEE 1-2 VIEWS 238.00 1 309110 TIBIA & FIBULA AP&LAT 234.00 1 600520 SPIRO INCENTIVE ADULT 18.00 1 10277 7 PEDS PRIVATE RM 2471.00 2 246706 MORPHINE SULFATE 2 MG 12.60 1 247811 IBUPROFEN 400 MG 3.00 4 273788 HYDROCODONE & APAP 5/ 12.00 1 307101 CHEST 1 VIEW 204.00 2 600520 SPIRO INCENTIVE ADULT 36.00 1 661516 SYSTEM,CHEST DRAIN AD 132.00 1 246706 MORPHINE SULFATE 2 MG 6.30 2 247811. IBUPROFEN 400 MG 6.00 1 273788 HYDROCODONE & APAP S/ 3.00 2 275658 APAP-HYDROCODON 325MG 6.00 1 307101 CHEST I VIEW 204.00 1 307102 CHEST 2 VIEW A/P LAT .246.00 -1 902040 AUTO/WORK COMP PAYMEN 7181.00- -1 902040 AUTO/WORK COMP PAYMEN 1917.54- -1 930119 BLUE SHIELD CONT ADJ 2194.26 - -1 910050 BLUE SHIELD PAYMENT H 4966.01- - 1 980090 HOSPITAL BAD DEBT W/O 2162.19- ----------------------------------------------- - Continue - THE MILTON S HERSHEY MEDICAL CENTER E P.O. BOX 853 HERSHEY, PA 17033 OUTPATIENT HOSPITAL STATEMENT i FEDERAL ID: 251854772 PAGE: 2 PATIENT NAME: MILLER SAMUEL T i PATIENT ACCT #: 18098122 VISIT DATE: 08/28/12 CLERK: CKF PHYSICIAN NAME: SANTOS MARY C DIAGNOSIS CODES: 8600 8509 E8161 - -- UNIT - -- SERVICE CODE DESCRIPTION AMOUNT - -- --------- - - - - -- - - - -- _ ----------- ------------ 1 980091 HOSPITAL BAD DEBT PLA - 2162.19 TOTAL CHARGES: 20583.19 PAYMENT RECEIVED: 18421.00 - BALANCE DUE: 21 62.19 The charge description and amount listed on this statement may not reflect all the services that were provided today, Additional charges may be assessed and will be reflected on your future billing statement. If you have any questions about the balance that you owe please contact patient financial services at 1 - 800 -254 -2619 OR 717- 531 -5069 i PENN STATE HFjjSI e N11 - MRN Name 00002110219 MILLER,SAMUELT PHYSICIAIN P. TK ,RGES Case Detail DOS DOE Doctor FC FOS DX MODF TMID Description Billed Amt Trans Amt Debl Ind Trans Code Trans Code Description Batch # Pl n Priority Plan Resp Party Batched Date Posted Date User 18098122 1 8/2812012 8/30/2012 26005 H 1 959.8 2600222 TR TEAM DIAL E $4,524.00 $4,380.11 925200 ! ACT 6 AUTO ALLOWANCE 82409 1 CAR CAR 10/5/2012 j 10/8/2012 HDR1 $4,524.00 $143.89 905010 'WKC OR AUTO PAYMEN 82409 1 CAR CAR 10/5/2012 10/8/2012 ; HDR1 2 8/28/2012 8/31/2012 77080 H 1 959.7 R 7773560 KNEE LIMITED FE $83.00 $10.36 905010 WKC OR AUTO PAYMEN 1 86048 1 1 CAR CAR 10/10/2012 10/12/2012 I HDR1 $83.00 $72.64 925200 ! ACT 6 AUTO ALLOWANCE r 86048 1 CAR I CAR 1 10!10/2012 110/12/2012 1 HDR1 3 8/28/2012 8/31/2012 77080 H 1 860.0 7771010 CHEST 1 VIEW $86.00 $9.55 905010 1 WKC OR AUTO PAYMEN 1 86048 1 CAR CAR 1 10/10/2012 110/12/2012 ! HDR1 $86.00 ! $76.45 1 925200 ACT 6 AUTO ALLOWANCE 86048 1 CAR CAR 10/10/2012 i 10/12/2012 1 HDR1 4 8/28/2012 8/31/2012 77080 H 1 860.0 76 7771010 CHEST 1 VIEW $86.00 $86.00 925200 ACT 6 AUTO ALLOWANCE 80119 1 CAR CAR 1/14/2013 1/15/2013 ADR7 5 8/28/2012 8/31/2012 77080 H 1 959.7 R 7773590 TIBIA & FIBULA $83.00 1 $9.17 905010 j WKC OR AUTO PAYMEN 86048 1 CAR f CAR 10t10/2012 t 10/12!2012 HDR1 $83.00 $73.83 925200 1 ACT 6 AUTO ALLOWANCE 86048 1 1 CAR j CAR F 10110/2012 i 10/1 212012 i HDR1 6 8/29/2012 9/1/2012 77645 H 1 860.0 7771010 CHEST 1 VIEW $86.00 $76.45 ( 925200 ; ACT 6 AUTO ALLOWANCE ? 82409 1 CAR CAR 10!512012 ! 10/8!2012 HDRt Wednesday, October 30, 2013 Page I of 5 i PENN STATE HERSHEY 10 ED ICAl- CENTEH �T Case Detail DOS DOE Doctor FC POS DX MODF TMl"D ✓ Description y B[[[ed Amc Trans Amt Debt Ind Trans Code Trans Code Description Batd: # Plan Prior[ry Plan Resp Parry Batched Date Posted Date User $86.00 $9.55 1 905010 i WKC OR AUTO PAYMEN 82409 1 j CAR 1 CAR j 10/5/2012 10/8/2012 7HDR1 7 8/28/2012 9120/2012 46325 H 3 959.01 4699285 EMERGENCY VLSI $539.00 1 $539.00 ( 422 3 BALANCE TRANSFER" r 99510 2 BSO I CAR i 10/29/2012 j 10/29/2012 $539.00 $539.00 422 BALANCE TRANSFER- 99510 I $539.00 I 1 CAR CAR 10/29/2012 1 10/29/2012 1 $0.00 L 2009 'MAXIMUM BENEFITS PAID 12063 1 I CAR I CAR 1 10/2912012 ( 10/29/2012 ADR7 $539.00 $61.50 1 1 946014 BALANCE TRANSFER` 94451 8 ` $539.00 $143.50 ! 916004 BLUE SHI ELD PAYMENT* 1 I GUA I BSO 11/28/2012 111/29/2012 = 94451 i 2 ISO ` BSO 11/2812012 11/29/2012 i $539.00 $334.00 E 916014 B SHIELD CONTRACTUAL ADJ* 94451 2 BSO BSO i 1/28/2012 11/29/2012 $539.00 $61.50 946014 i BALANCE TRANSFER* 94451 2 z ^� 1 � BSO BSO � 11/28[2012 : 11/29/2012 I $539.00 �$6i.50> 1 521 j CHARGE XFER TO AGENCY* 99910 8 i GUA 1 GUA 1 4/18/2013 4/18/2013 1 8 8/28/2012 10/8/2012 12716 H 3 959.01 9709241 OBS OFFICE/ER $92.00 $92.00 ! 422 BALANCE TRANSFER* i f 99510 2 ? BSO C2 1 11/12/2012 $92.00 $92.00 422 : BALANCE TRANSFER* j 99510 ± 1 CAR 2 ; 11/121201 2 i $92.00 1 $0.00 j 2009 i MAXIMUM BENEFITS PAID 24576 1 CAR CAR 1 11/12!2012 111/12/2012 AOR7 $92.00 $64.40 1 i 916004' BLUE SHIELD PAYMENT 96071 Z i BSO BSO 12/12/2012 l 12/1212012 $92.00 $27.60 1 ! 946014 ' BALANCE TRANSFER* $92.OQ i j 96071 2 BSO BSO ( 12[12/2012 (12[12!2012 1 $27.60 + 946014 'BALANCE TRANSFER 96071 ! 8 GUA BSO 12/12/2012 12/12!2012 $92.00 } ( $27.60 i 511 1 CHARGE TRANSFER TO AGENCY 79278 1 8 GUA GUA { 4/19/2013 j 4/19/2013 1 �r 9 8/30/2012 9/4/2012 77066 H 1 512.89 7771020 CHEST 2 VIEWS $103.00 $11.40 905010 WKC OR AUTO PAYMENT 86048 1 CAR CAR 10/10/2012 10/12!2012 HDRi $103.00 i $91.60 i 925200 ACT 6 AUTO ALLOWANCE s 86048 1 CAR CAR t 10[10/2012, 10/12/2012 HDR1 $103.00 $11.40 I 905010 ? WKC OR AUTO PAYMENT 86048 1 i CAR CAR 10/10/2012 .10/12/2012 1 HDR1 $103.00 $91.60 925200 1 ACT 6 AUTO ALLOWANCE 86048 1 CAR CAR 10/10/2012 10112/2012 (NDR1 Wednesday, October 30, 2013 Page 2 of 3 PENN STATE HERSHEY mEOICALCefrEK PHYSTC! A NT "'T TA, RGES Case Detail DOS DOE Doctor FC POS DX MODF TMID Description Billed Amt Trans Amt Debt ind Trans Code Trans Code Description Batch # Plan Priority Plan Resp Party Batched Date Posted Date User 10 8/30/2012 9/4/2012 77066 H 1 512.89 59 7771010 CHEST 1 VIEW $86.00 1 $9.55 905010 IWKCORAUTOPAYMEN 86048 1 i CAR CAR j 10/10/2012 110/12/2012 HDR1 $86.00 ! $76.45 925200 ACT 6 AUTO ALLOWANCE 86048 1 1 CAR ( CAR 10/10/2012 ' 10/12/2012 1 HDR1 18114848 1 9/26/2012 9128/2012 26005 UP 9 512.89 9699212 OUTPATIENT VISI $67.00 $8.22 946014 1 BALANCE TRANSFER` 96418 8 1 GUA I BSO 10/1012012 1 10110/2012 $67.00 1 $19.19 916004 BLUE SHIELD PAYMENT' 96418 j 1 BSO i BSO 10110/2012 1 10110/2012 $67.00 $39.59 916014 ! B SHIELD CONTRACTUAL ADJ` 96418 1 BSO BSO 10110/2012 10/10/2012 $67.00 $8.22 ( 946014 BALANCE TRANSFER' 96418 1 BSO ' BSO 10/10/2012 j 10/10/2012 $67.00 $8.22 ' 935003 SMALL BALANCE ADJUSTMENT 89104 8 GUA ; GUA 10/15/2012 10/15/2012 SBH1 18162377 1 9/12/2012 9/14/2012 26005 UP 9 850.0 9699214 OUTPATIENT VISE $205.00 $53.61 1 905010 WKC OR AUTO PAYMEN 1 95 1 1 CAR CAR 10115/2012 1 10117/2012 HDR1 $205.00 $151.39 1 1 925200 ACT 6 AUTO ALLOWANCE 95 1 CAR I CAR 10115/2012 110117/2012 HDR1 18166828 1 9/12/2012 9/15/2012 77080 H 0 786.05 7771020 CHEST 2 VIEWS $103.00 j $6.00 j 946014 BALANCE TRANSFER' 94802 1 8 GUA BSO ( 9/26/2012 ? 9/26/2012 $103.00 $6.00 1 1 946014 BALANCE TRANSFER" 94802 1 BSO BSO ( 9/26/2012 9126/2012 I $103.00 $14.00 916004 1 BLUE SHIELD PAYMENT' 94802 I 1 BSO 1 BSO 1 9/26/2012 i 9/26/2012 $103.00 $83.00 1 916014 B SHIELD CONTRACTUAL ADJ` i 94802 1 BSO I BSO 9/26/2012 1 9126/2012 1 $103.00 $6.00 { 946014 BALANCE TRANSFER' j 94802 1 BSO 1 BSO j 9/26/2012 9/26/2012 I $103.00 $6.00 946014 i BALANCE TRANSFER' 94802 8 1 GUA BSO j 9/26/2012 9/26/2012 Wednesday, October 30, 2013 Page 3 of 5 PENN STATE HERSHEY MWICP.LGE TER PHYSICIAN SICAt9,.N CHARGES Case Detail DOS DOE Doctor FC POS DX MODF TMID Description BilledAmt Trans Amt Debt Ind Trans Code Trans Code Description Batch # Plan Priorlty Plan Resp Party Batched Date Posted Date User . $103.00 ! $14.00 916004 BLUE SHIELD PAYMENT* 94802 I 1 i BSO + BSO j 9/2612012 i 9/26/2012 j $103.00 $ 916014 B SHIELD CONTRACTUAL ADJ* 94802 1 ! BSO ! BSO 9/26/2012 ' 9/26/2012 , $103.00 $6.00 935003 SMALL BALANCE ADJUSTMENT 75870 8 GUA GUA f 10/1/2012 1 10/1/2012 j SBH1 $10300 1 $6.00 f j 935003 ;SMALL BALANCE ADJUSTMENT 75870 8 GUA GUA 10/1/2012 10/1/2012 SBH1 18169044 1 9/21/2012 9/27/2012 61190 E2 9 339.20 9699244 OFFICE OR ER C $428.00 $0.00 2009 MAXIMUM BENEFITS PAID 24576 ! 1 I I CAR CAR 11/12/2012 11111212012 f ADR7 $428.00 $428.00 422 ; BALANCE TRANSFER* 99510 2 1 BSO CAR 11/12/2012 111112/2012 $428.00 $428.00 422 BALANCE TRANSFER* 99510 1 CAR CAR 1 11/12/2012 111112/2012 $428.00 I $51.00 1 j 946014 BALANCE TRANSFER* 1 95973 2 ` BSO 1 BSO 12/1212012 ! 12/12/2012 I $428.00 $258.00 j 916014 B SHIELD CONTRACTUAL ADJ* ! 95973 2 BSO j BSO 12112/2012 12112!2012 $428.00 i $119.00 916004 BLUE SHIELD PAYMENT* 95973 i 2 BSO j BSO i 12!1212012 ' 12/12/2012 $428.00 $51._0 946014 BALANCE TRANSFER* 95973 ! 8 GUA BSO 12/12/2012 € 12/12/2012 j $428.00 1 $51.0 % ! 511 CHARGE TRANSFER TO AGENCY 79278 I 8 GUA GUA 1 4/1912013 4/1912013 18217526 1 10/26/2012 10/31/2012 61190 E2 9 850.0 9699213 OUTPATIENT VISI $133.00 $0.00 2009 t MAXIMUM BENEFITS PAID 1 56235 4 CAR CAR 3/26/2013 1 3/26/2013 1 ADR7 $133.00 $133.00 1 422 ;BALANCE TRANSFER* j 99510 1 CAR CAR j 3/2612013 I 3/26/2013 $133.00 ! $133.00 422 I BALANCE TRANSFER* 99510 i 2 BSO CAR ' 3/26/2043 3/26/2013 $133.00 $16.84 946014 BALANCE TRANSFER* 95696 8 ! GUA BSO 4/17/2013 ! 4/1 712 01 3 $133.00 $76.85 1 j 916014 1 B SHIELD CONTRACTUAL ADJ* i 95696 2 ! BSO BSO i 4/17!2013 j 4/17/2013 $133.00 $46.84 j 1 946014 ;BALANCE TRANSFER* 95696 2 ! BSO BSO j 4/17/2013 4/17/2013 i 39 . ! 916004 $133.00 $ 1 BLUE SHIELD PAYMENT* 95696 1 2 BSO j BSO 4/17/2043 ! 4/17/2013 $133.00 ! I $16.84 \ 521 CHARGE XFER TO AGENCY* 99910 g I i i GUA 1 GUA 9/5/2013 9/5/2013 Wednesday, October 30, 2013 Page 4 of S PHYSICIAN CHARGE PENN STATE HERSHEY MWCAL CEN`61 Case Detail DOS DOE Doctor FC POS DX MODF TMID Description Billed Amt Trans Amt Debt &d Trans Code Trans Code Description Batch # Plan Priori & P Plan Res P 3' Batched Dare Posted Date User 18228098 1 9/26/2012 9/29/2012 77195 H 0 V58.8 7771020 CHEST 2 VIEWS $103.00 $103.00 1 422 ;BALANCE TRANSFER' 99510 $103. 1 CAR i CAR 11114!2012 11114 00 $10300 !2012 I . 422 BALANCE TRANSFER* r $103.00 99510 1 CAR ; CAR 11/14/2012 :11/14/2012 $0.00 2009 MAXIMUM BENEFITS PAID 26830 1 CAR 11/14/2012 11/14/2012 ADR7 $103:00 $103.00 422 BALANCE TRANSFER" $103.00 $0.00 1 ! 2009 99510 i 2 BSO I CAR 1 11/14/2012 111/14/2012 1 1 F MAXIMUM BENEFITS PAID 26830 I 1 CAR CAR i $103.00 $103.00 ( 11/14/2012 11/14!2012 !ADR7 42 2 BALANCE TRANSFER' ` 1 99510 2 i BSO 1 CAR ; 11/1412012 1 11/14/2012 I $103.00 $14.00 916004 BLUE SHIELD PAYMENT 1 • 96001 2 BSO BSO 12/12/2012 1 12/12/2012 $103.00 $6.00 946014 1 BALANCE TRANSFER' 96001 8 i GUA BSO 12/12/2012 (12/12/2012 r $103.00 1 946014 i BALANCE TRANSFER' ` I 96001 " 2 BSO BSO 12/12/2012 12/12/2012 1 $103.00 1 $6.00 ' 946014 i BALANCE TRANSFER* 96001 2 BSO $103.00 $6.00 1 BSO 12112/2012 112/12/2012 946014 BALANCE TRANSFER' 96001 ( 8 GUA I BSO 12/12/2012 ? 12/1212012 $103.00 $14.00 916004 1 BLUE SHIELD PAYMENT' 96001 2 I BSO 1 BSO 12/12/2012 112/12/2012" { $103.00 $83.00 916014 B SHIELD CONTRACTUAL ADJ' i 96001 2 BSO j BSO I 12/12/2012 12/12/2012 $103.00 $83.OQ I ! 916014 B SHIELD CONTRACTUAL ADJ' 96001 2 BSO BSO 12/12/2012 12/12/2012 $103:00 $6.00 I 935003 1 SMALL BALANCE ADJUSTMENT 56245 8 GUA GUA UA 12/17/2012 + 12/17/2012 SCJ1 $103.00 $6.00 1 1 935003 1 SMALL BALANCE ADJUSTMENT ' 56245 8 I GUA GUA 12/17/2012 112117/2012 t SCJ1 Wednesday, October 30, 2013 Page 5 of S 10/30/13 PAGE 001 HEALTH MANAGEMENT ASSOCIATES DA17 COID: 858 CARLISLE REGIONAL MEDICAL CTR AS OF 10/29/13 PATIENT: MILLER, SAMUEL T F /C: B P /T: E1 DSC CODE: 02 A /C: 9533191 ADMISSION: 08/28/12 DISCHARGE: 08/28/12 ------------------------------------------------------------------------ CHG DATE DPT REV BAT# HCPC M1M2M3M4 CHGCD DESCRIPTION QTY AMOUNT ^---------^----------------------•----------------------------^------ 08/28/12 412 250 5201 f�p 18160 IBUPROFEN 400MG 1 5.80 08/28/12 412 636 5201 J2250 ° 24440 MIDAZOLAM 1MG /ML 1 38,89 08/28/12 416 636 7600 J7030 02820 SODIUM CHLORIDE 1 153.33 08/28/12 418 255 5 Q9967 39345 LOCM 350- 399MG /M 50 225.50 08/28/12 428 324 8 71010 59 11180 CHEST 1V 1 278.31 08/28/12 428 324 8 71020 59 71020 CHEST PA & LATER 1 482.00 08/28/12 429 350 8 71260 70347 CT CHEST W /CONTR 1 1,878.82 08/28/12 429 351 8 70450 70450 CT HEAD /BRAIN W/ 1 1,657.52 08/28/12 436 301 30 80053 10607 COMPREHENSIVE ME 1 185.50 08/28/12 436 300 30 36415 36111 VENIPUNCTURE ROU 1 15.83 08/28/12 436 305 30 85025 85028 CBC COMPLETE AUT 1 101.56 08/28/12 480 450 5400 99285 00520 ER DEPT MAJOR VI 1 1,728.14 08/28/12 418 270 6009 06300 CANNULA NASAL 1 5.71 08/28/12 418 270 6009 12524 OXYGEN PER HOUR 1 14.57 CONTINUED.. SELECT: REV= * DEPT= * CH * DATE /MDCY= * TO /MDCY= * . CMD:I =DAR,2 = PAT,4= SUTNMAARY,5= TOP, 6= END, 7= RETURN,8 =BACKWARD,I2= UPD,ENTER= FORWARD i 10/30/13 PAGE 002 HEALTH MANAGEMENT ASSOCIATES DA17 COID: 858 CARLISLE REGIONAL MEDICAL CTR AS OF 10/29/13 PATIENT: MILLER, SAMUEL T F /C: B P /T: E1 DSC CODE: 02 A /C: 9533191 ADMISSION: 08/28/12 DISCHARGE: 08/28/12 -------------------------------------- CHG DATE DPT REV BAT# HCPC M1M2M3M4 CHGCD DESCRIPTION QTY AMOUNT -------------------------------- 08/28/12 418 272 6009 -- 22306 KIT PNEUMOTHORAX -- 735.71 - 08/28/12 480 450 6009 32551 RT �� 9$344 CHEST TUBE INSER 1 1,670.58 08/2$/12 418 270 5 10057 SOLUTION BETADIN 1 10.73 08/28/12 418 270 5 6 26770 TRAY CHEST TUBE 1. 299.75 08/28/12 418 270 5 62591 CATH TROCAR ALL 1 283.47 P � ----------------- - - - - - ----------- ----------------------------------------- INVALID KEY PRESSED TOTAL CHARGES 9,771.72 SELECT: REV= * DEPT= * CHGCD= * DATE /MDCY= * TO /MDCY= * CMD:I =DAR,2= PAT,4 =SUMMARY,5= TOP, 6 = END, 7 = RETURN,8 =BACKWARD,12 =UPD,ENTER= FORWARD 10/30/13 PAGE 001 HEALTH MANAGEMENT ASSOCIATES CARLISLE REGIONAL MEDICAL CTR DA17 COLD: 858 - - -- 361 ALEXANDER SPRING RD CARLISLE OF 10/29/13 PA 17015 PHHOO NE (717) 960 -1680 PATIENT: MILLER, SAMUEL T ----- - - - - -- TO: MILLER, ROB L jSS B P /T: E1 9533191 DSC CODE: 02 197 LAWRENCE LANE ION: 08/28/12 DISCHARGE: 08/28/12 CARLISLE PA 17015 INS CD: 950 /ATO LIBERTY MUTUAL, GROUP INS CD: 200 /BSI PBSHM 378 PPO a° POL ID: 238829730 D E P A R T M E N T GROUP 0099704 POL ID: CIDW15563 r � 412 PHARMACY 04 A M O U N T 416 IV THERAPY q 44.69 418 SUPPLIES - MEDICAL 153.33 428 RADIOLOGY - DIAGNOSTIC a 1.575.44 429 RADIOLOGY - CT SCAN 760.31 436 LAB � 3,536.34 480 EMERGENCY ROOM 302.89 PAYMENTS 3,398.72 ADJUSTMENTS 2,672.96 - 1,098.76- - * TOTAL 0.00 SELECT: REV= DEPT- * CHGCD= * DATE /MDCY. CMD :I= DAR,2apAT 4= DETAIL TO /MDCY= * 7- RETURN,B =BACKWARD, ENTER= FORWARD � A y 4 � y 10/30/13 HEALTH MANAGEMENT ASSOCIATES ACCOUNT #: 9533191 PAYMENT HISTORY TOT PAY + ADJ • DA09 Coll): 858 PAT NAME : MILLER, SAMUEL T 9,771.72 - PAY PLAN PAYMENT PAYMENT PROCESS PAY PLAN PAYMENT PAYMENT PROCESS CD CD DATE AMOUNT DATE CD CD DATE OT DATE T 9 78 06/29/13 1,251.13- 06/29/13 200 BS1 09/19/12 2,672 09/19/12 951�"�f 09/19/12 5,847.63- 09/19/12 Ck us � t I' CMD:1 =DAR,2= PAT,3= GAR,4= INS, 5= UB ,7= RTN,S =CMTI,9 =CMTU,10= BAL,II =LOG �� y From: GFi FaxMaker To: Thomas Brumbaugh Page: 2/5 Date: 2/11/2014 6:26:32 PM Rawlings Company LLC Post Office Box 2000 Submgafim Division LaGrange, Kentucky 40031 -2000 One Eden Parkway LaGrange, Kentucky 40031 -8100 Telephone (502) 587 -1279 February 11, 2014 Mr. Thomas Brumbaugh Snyder & Dorer 214 Senate Ave, Suite 600 Camp Hill, PA 1.7011 Re: Our Client: Blue Cross and Blue Shield of North Carolina Member /Patient: ROBBY MILLER/SAMUEL MILLER Date of Loss: 8/28/2012 Our Reference No.: 56593752 Your Client: Nationwide Dear Mr. Brumbaugh: Enclosed, please find a summary of the medical expenses paid by our client on behalf of SAMUEL MILLER. Please notify me if any of the charges are unrelated to the accident. If you have information that indicates our client has paid claims that are not listed on the attached summary, please advise so we may investigate. Otherwise, this summary is good for settlement purposes for 30 days from the date of this letter. Sincerely, Tames Smith Recovery Analyst (502) 8142520 FAX: (502) 753 -7029 jsh(arawlingscompany. corn Healthcare information is personal and sensitive information, and you, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Disclosure of this information without additional patient consent or as permitted by law is prohibited. This fax was sent with GF! FaxMaker fax server. For more information, visit: http: / /www.gfi.com Blue Cross and Blue Shield of North Carolina The Rawlings Company Tuesday, February 19, 2014 06:25 pm Patient's Name; S7NIM L LLER The Rawlings Company LLC Make Checks Payable To: Paid Amount Subject to Change. Member's Name: ROLLER Please call (502) 814 -2520 amount. Attn: James Smith .for the final paid File Number: 12NCN1000157 The Rawlings Company, Subrogation Division P.O. Box 2000, LaGrange, Representative: James Smith 0_ 9 , KY 40031 -2040 cV m Trent, Date In Trent. Date Out Claim No. Provider or Drug Name ICD9 N 0 ICD9 Deso, CPT CPT Desc. Bill Amount ifl 08/28/2012 08/28/2012 9009141218530 QUANTUM IMAGING AND Paid Amount 512.89 OTHER 71010 CHEST X -RAY, p THERAPEUTI PNEUMOTHORAX $36.00 $11.20 N SINGLE VIEW, r 08/28/2012 08/28/2012 9 009111202553 CARLISLE REGIONAL 860.0 PNEUMOTHORAX, 636 DRUGS EU ETAIL a MEDICAL CENT TRAUM W/O O $38.89 $11.25 m CODE a 08/28/2012 0$/28/2012 90 09141218$49 QUANTUM RGING AND 921.9 CONTUSION, EYE ?1020 CHEST X -RAY, t 0 N THERAPEUTI NOS $45.00 $14.00 • - TWO VIEWS Ln 08/28/2012 08/28/2012 90 09111202553 CARLISLE REGIONAL 860.0 PNEUMOTHORAX 305 O MEDICAL CENT LAB /HEktATOLOG} 6 UM W/O 0 $101.56 $25.62 m ci TRA C1 08/28/2012 08/28/2012 9009111202553 CARLISLE REGIONAL 860.0 PNEUMOTHORAX, 3 01 /C CENT TRAUM W/o O /CHEMISTRY $185.50 $47.88 v 08/28/2022 08/28/2012 9 009111202553 CARLISLE REGIONAL 860.0 PNEUMOTHORAX, o MEDICAL CENT TRAUM W/0 0 324 X $278.31 _ = RAY /CHEST LL L 08/2$/2012 08/28/2012 9009111202553 CARLISLE REGIONAL 860.0 PNEUMOTHORAX, 324 DX d MEDICAL CENT $482.00 $68.18 TRAUM W/0 O X- RAY /CHEST �- 08/28/2012 2012 28 08 9009241222624 Y / / QUANTUM IMAGING AND 860.0 PNEUMOTHORAX, 99221 INITIAL m f2 THERAPEUTI TRAUM W/O 0 HOSPITAL $157.00 $73.50 CARE, LOW U- 08/28/2012 08/28/2012 9 009111202553 CARLISLE REGIONAL 860.0 PNEUMOTHORAX, 270 COMPLEX �_ Y I MEDICAL CENT $614.23 c4 TRAUM W/O O SUPPLIES $177.60 3 @ 08/28/2012 08/28/2012 9009111202553 CARLISLE REGIONAL 860.0 PNEUMOTHORAX, 351 CT SCAN /HEAD $1,657.52 u_ d MEDICAL CENT TRAUM W/o 0 $439.25 0 08/28/2012 08/28/2012 9009111202553 CARLISLE REGIONAL 860.0 PNEUMOTHORAX, 450 o MEDICAL CENT TRAUM W/O O EMERG ROOM $1,728.14 $499.66 08/28/2012 08/28/2012 90 09111202553 CARLISLE REGIONAL 860.0 PNEUMOTHORAX, 350 CT SCAN r MEDICAL CENT TRAUM W/O O $1,878.82 $643.52 08/28/2012 08/28/2012 90 09111202553 CARLISLE REGIONAL $60,0 PNEUMOTHORAX, 450 EMERG ROOM ICAL CENT TRAUM W/O O $1,670.58 $483.02 Please write this number on your check: 12NCN1000157 1 Tax Id Number: 31- 1563156 Blue Cross and Blue Shield of North Carolina The Rawlings Company Tuesday, February 11, 2014 06:25 pm Patient's Name: SAMUEL MILLER Make Checks Payable To: Paid Amount Subject to Change. Member's Name: ROBBY MILLER The Rawlings Company LLC Please call (502) $14 -2520 Attn: James Smith amount. for the final paid File Number: 12NCN1000157 The Rawlings Company, Subrogation Division Representative: James Smith P.O. Box 2000, LaGrange, KY 40031 -2000 (V M Trmt. Date - E In Trmt. Date Out Claim No. Provider or Drug Name ICD9 ICD9 Desc. CPT CPT Deso. Bill Amount Paid Amount ( 08/28/2012 08/28/2012 9009111202553 CARLISLE REGIONAL 860.0 PNEUMOTHORAX, 272 STERILE $735.71 - $212.72 Cp MEDICAL CENT TRAUM W/O O SUPPLY N 08/28/2012 08/28/2012 9009241222130 CARLISLE HMA MULTI 512.89 OTHER 32551 INSERTION OF $469.00 $174.30 SPECIALTY PNEUMOTHORAX CHEST TUBE :? 08/28/2012 0$/28/2012 9009141218531 QUANTUM IMAGING AND 860.0 PNEUMOTHORAX, 71260 CONTRAST CT is $275.00 $65.80 j THERAPEUTI TRAUM W/o O SCAN OF CHEST c � 08/28/2012 0$j28/2012 90A9141218809 QUANTUM IMAGING AND 921.9 CONTUSION, EYE 7045A CT SCAN OF 2 $198.00 $51.80 THERAPEUTI NOS HEAD /BRAIN E °J o 08/28/2012 08/28/2012 9009111202553 CARLISLE REGIONAL 860.0 PNEtJMOTHORAX, 636 DRUGS /DETAIL $153.33 $44.34 a MEDICAL CENT TRAUM W/O O CODE 0 08/28/2012 08 / 28 /2 0 12 9009111202553 CARLISLE REGIONAL 860.0 PNEUMOTHORAX, 255 RUGS /INCIDENT $225.50 0 MEDICAL CENT TRAUM W/O O RAD 55.98 LL -0 E 08/28/2012 08/28/2012 9009111202553 CARLISLE REGIONAL 860.0 PNEUMOTHORAX, 300 LABORATORY MEDICAL CENT TRAUM W/O O 515.83' $0.03 0 x 08/28/2012 08/28/2012 9011131219870 ITS PAR PROFESSIONAL 959.01 INJURY NOS, HEAD 99241 OFFICE $92.00 $64.40 Y O CONSULTATION, cs ~ PROB FOC X 08/28/2012 08/3012012 9011121203232 ITS NOW PAR 860.0 PNEUMOTHORAX, 110 ROOM- BOARD /PVT 4 94 M t INSTITUTIONAL TRAUM W/O O 5 , 2.00 55,045.13 C9 _ 08/28/2012 08/28/2012 9010301219955 ITS PAR PROFESSIONAL 959.01 INJURY NOS, HEAD 99285 EMERGENCY Y $539.00 $143.50 DEPT VISIT 3 m , � 09/12/2012 09/12/2012 9009181203027 MILTON S HERS HIGH COMPLEX m HEY 786.05 SYMPTOM, 324 DX u MED ICAL SHORTNESS OF BRE X -RAY /CHEST $246.00 $108.80 y LL 3 x o 1 09/12/2012 09/12/2012 9009181220728 MSHMC RADIOLOGY 786.05 SYMPTOM, 71020 7TWO T X -RAY, $103.00 $14.00 y VIEWS 09/12/2012 900222131$610 ITS NON PAR 850.0 SHORTNESS OF BRE CONCU SSION, NO 510 CLINIC INSTITUTIONAL LOC $102.00 $22.94 09/21/2012 09/21/2012 �9011131219874 PAR PROFESSIONAL 339.20 POST - TRAUMATIC 199244 OICE $428.00 $119.00 HEADACHE, CONSULTATION, MOD COMPLEX } Please write this number on your check: 12NCN1000157 2 Tax Id Number: 31- 1563156 Blue Cross and Blue Shield of North Carolina The Rawlings Company Tuesday, February 11 2014 06:25 Yx �Y m p Patient's Name: SAMUEL MILLER Make Checks Payable To: Paid Amount Subject to Change. The Rawlings Company LLC Please call (502) 814 -2520 Member's Name: ROBBY MILLER Attn: James Smith for the final paid amount. The Rawlings Company, Subrogation Division Representative: James Smith File Number: 12NCK1000157 P.O. Box 2000, LaGrange, KY 40031 -2000 i L a N E U Trmt. Date In Trmt. Date Out Claim No. Provider or Drug Name ICD9 ICD9 Deso. CPT CPT Deco. Bill Amount Paid Amount N 09/21/2012 09/21/2012 9003291315421 ITS NON PAR 339.20 POST - TRAUMATIC 510 CLINIC $78.00 $14.36 io r INSTITUTIONAL HEADACHE, , 09/26/2012 09/26/2012 '9010011223132 MSHMC PEDIATRIC 512.89 OTHER 99212 OFFICE /OUTPT $6 7.00 $19.19 Q. a SURGERY PNEUMOTHORAX VISIT, EST, s PROB FOC u +� 09/26/2012 09/26/2012 9010021201428 MILTON S HERSHEY 512.89 OTHER 510 CLINIC $78.00 $14.36 j O MEDICAL PNEUMOTHORAX 0 09/2612012 09/26/2012 9011151218865 ITS PAR PROFESSIONAL V58.89 AFTERCARE NEC 71020 CHEST X -RAY, $103.00 $14.00 to TWO VIEWS o 09/26/2012 09/26/2012 9003291309419 ITS NON PAR V58.89 AFTERCARE NEC 324 X a $246.00 $108.80 m INSTITUTIONAL - RAY /CHEST 0 `o 0) 10/26/2012 10/26/2012 .9003281325251 ITS PAR PROFESSIONAL 850.0 CONCUSSION, NO 99213 OFFICE /OUTPT $133.00 $39.31 LL ca LOC VISIT, EST, Z XP PROB 2 10/26/2012 10/26/2012 9001281301612 ITS NON PAR 850.0 CONCUSSION, NO 510 CLINIC $78.00 $14.36 X INSTITUTIONAL LOC c- ca Y o TOTALS $18,180.92 $8,849.26 �— m LL F w t9 s Y Y .H Z X LL. x T LL F_ LL • Please write this number on your check: 12NCN1000157 3 Tax Id Number. 31.1563156 �� '\ i � 0 r I PARENT /GUARDIAN RELEASE AND INDEMNITY AGREEMENT 13- 014530 Cumberland County: No. Claim No. 58 37 C 103276 FOR AND IN CONSIDERATION of the payment of the sum of Twenty Seven Thousand Four Hundred Sixty Six and 24/100 Dollars ($27,466.24), the receipt of which is hereby acknowledged, We, the undersigned, parents and guardian of Samuel T. Miller, a minor of the age of seventeen, do hereby forever release, acquit and discharge Brady Weaver, Kim S. Weaver, Robert Weaver, Nationwide Mutual Insurance Company and their heirs, successors and assigns of and from any and all actions, causes of action, claims, demands, damages, costs, loss of services, expenses and compensation, on account of, or in any way growing out of, any and all known and unknown personal injuries and property damage which we may or hereafter have as the parents and guardians of said minor, and also all claims or rights of action for damages which the said minor has or may hereafter have, either before or after he has reached the age of majority, resulting or to result from a certain accident which occurred on or about the 28 day of August, 2012, at or near Green Hill Road, West Pennsboro Township, Cumberland County, Pennsylvania. AND IN FURTHER CONSIDERATION OF THE ABOVE PAYMENT WE DO HEREBY AGREE TO INDEMNIFY AND HOLD HARMLESS THE SAID Brady Weaver, Kim S. Weaver, Robert Weaver and Nationwide Mutual Insurance Company of and from all loss, damage and expense by reason of said accident should any claim, demand or suit therefore be brought by or on behalf of said minor child either before or after she has reached his majority. We further state that we have carefully read the foregoing release and indemnity agreement and know and understand the contents thereof, and we sign the same as our own free act. WITNESS p � ZMnd and seal this<a'O!� of kZfZ .cI t 2014. In present of /0 CAUTIO WBEFfD SIGNING (SEAL) Ro y L STATE OF COUNTY OF On this o � day of e " , 2014, before me ersonall y appeared Robby Lynn Miller to me known to be the person who executed the foregoing and acknowledged that he voluntarily executed the same as his free act and deed. trument, My Commission Expires 3LA P l i= �(, j1 Notary Pu ' Comm N NOTARIAL SEAL CAMELA J..MANGES, Notary Public Boro of Carlisle, Cumberland County tU1y Commiss Exp ires June 21, 2014 r , PARENT /GUARDIAN RELEASE AND INDEMNITY AGREEMENT 13- 014530 Cumberland County: No. Claim No. 58 37 C 103276 WITNESS `( �,� �l(( and and seal this of 2012. In presence f CA ION: RE SIGNI E'AL) Donna STATE OF k A1A-SV (Q4AL (-A COUNTY OF On this A�� day of �fu 4'1-y 2014, before me Donna Lynn Miller, to me known to be the erson who executed the fore oinally appeared and acknowledged that she voluntarily executed the same as her free act deed. e ument, My Commission Expires L 'Q /v Notary P c I ", .._ NOTARIAL SEAL r MELA J. MANGES, Not Public ro of Carlisle, Cumberlafid County ommission Expires June 21, 2014 �: ! i s 1 \\ � . � \ ` _i F 1 — — -- — 313 e 2014- Feb -2 12:44 PM Snyder and Darer 717 - 731 -09 13- 014930 LAW OFFICE OF SNYDER & DORER Thomas S. Brumbaugh, Esquire 214 Senate Avenue, Suite 600 Camp Hill, PA 17011 Telephone Number: (717) 731 -0988 Brumbt1 @nationwi de. IN 7HE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS COURT DIVISION IN RE: SAMUOHI�SR, A MINOR, BY A ND THROUGH NO. PARENTS AND NATURAL GUARDIANS, ROBBY LYNN MILLER AND DONNA LYNN MILLER JOINDER IN PETITION FOR APPROVAL OF MINOR'S SETTLEMENT AND COMPROMISE Petitioners, Robby Lynn Miller and Donna Lynn Miller, parents and natural guardians of the minor mue[ Taylor Miller do hereby join In the Petition for Court Approval of Minors' Settle ettt and o Ise. Rob Ly parent a d natural guardian of minor S muel Taylor Miller �ae. Donna Lynn Miller, pare nd natural guardl of minor Samuel Taylor iller Date: ILL 1 213 x .2014- Feb -2 12:44 PM Snyder and Dorer 717 - 731 - 13- 014530 LAW OFFICE OF SNYDER & DORER Thomas S. Brumbaugh, Esquire 214 Senate Avenue, Suite 600 Camp Hill, PA 17011 Telephone Number: (717)'131.09 6rumbt1(a�nativnwide.c IN THE COURT OF COMMON PLEAS OF OUR CUMI3 VISION COUNTY, PENNSYLVANIA ORPHANS C IN RE: SAMUEL THROU Y MI R, A MINOR, BY AND HIS NO. • PARENTS AND NATU R AND DONNA NS, ROBBY LYNN MILL LYNN MILLER ACCEPTANCE OF SERVICE OF MINOR'S SETTLEMENT AND COMPROMISE Petitioners, Robby Lynn Miller and Donna Lynn Miller, parents and natural guardians of the ' r, Sarnu I T ylor Miller do hereby accept service of the Petition for Court Appr al f in S lement and Compromise. R by nn Miller, parent and natural guardian of minor Samuel Taylor Miller e. Donna Lynn Miller, par and natural g a la of minor Samuel Tayly Miller Date: 1 13- 014530 LAW OFFICE OF SNYDER & DORER Thomas S. Brumbaugh, Esquire 214 Senate Avenue, Suite 600 Camp Hill, PA 17011 Telephone Number: (717) 731 -0988 Brumbt1(&-nationwide.com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS COURT DIVISION IN RE: SAMUEL TAYLOR MILLER, A MINOR, BY AND THROUGH HIS PARENTS AND NATURAL GUARDIANS, f NO. ROBBY LYNN MILLER AND DONNA LYNN MILLER CERTIFICATE OF SERVICE Thomas S. Brumbaugh, Esquire, attorney for Nationwide Mutual Insurance Company hereby certifies that he caused a true and correct copy of the attached Petition for Approval of Minor's Settlement and Compromise to be served by regular first class mail upon: Rob and Donna Miller 197 Lawrence Lane Carlisle, PA 17015 -9439 Petitioners Respectfully submitted, LAW OFFICE OF SNYDER & DORER Date: March 7, 2014 Thomas S. Brumbaugh, uire Attorney for Plaintiff Court I.D. No. 89037 f"--IED-OFFIC,!H br.THEPROTHONOTtaY 2814MAR 12 PM 2: 39 CUMBERLAND COUNTY PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS COURT DIVISION IN RE: SAMUEL TAYLOR MILLER, A MINOR, BY AND THROUGH HIS PARENTS AND NATURAL GUARDIANS, ROBBY LYNN MILLER AND DONNA LYNN MILLER NO. LJjLfl ORDER APPROVING MINOR'S SETTLEMENT AND COMPROMISE '97 AND NOW, this day of /706'r , 2014 upon consideration of the Petition for Approval of Minor's Settlement and Compromise, it is hereby ORDERED and DECREED that the settlement is APPROVED and Petitioners are authorized to enter into a settlement as set forth within the Petition. IT IS FURTHER ORDERED that the settlement proceeds are to be distributed as follows: a) $1,251.23 is to be paid to Carlisle Regional Medical Center; b) $2,365.75 is to be paid to the Penn State'Milton S. Hershey Medical Center; c) $8,849.26 is to be paid to Rawlings Company LLC; and d) $15,000.00 is to be deposited in an interest bearing savings account or savings certificate in a federally insured financial institution having an office in Cumberland County, IN THE NAME OF THE MINOR ONLY . The savings account or certificate will be marked as follows: Samuel T. Miller, a minor, not to be withdrawn before the minor4 attains majority or upon prior Order of Court. Alternatively, the savings certificate shall be titled and restricted as follows: Samuel T. Miller, a minor, not to be redeemed except for renewal in its entirety, nor to be withdrawn, assigned, negotiated, or otherwise alienated before the minor attains majority, except upon prior Order of Court. Within sixty (60) days from the date of the entry of the Order, Petitioners shall file a certification of compliance and proof of deposit of the settlement proceeds in accordance with this Order. Petitioners are hereby authorized to sign a full and final release of all claims on behalf of the minor and in favor of Respondent. The Prothonotary shall provide copies of this Order to Petitioners and to Thomas S. Brumbaugh, Esquire. BY THE COURT: 2 Distribution List: Law Office of Snyder & Dorer 214 Senate Avenue Suite 600 Camp Hill, PA 17011 ./efign: Thomas S. Brumbaugh, Esquire Rob and Donna Miller 197 Lawrence Lane Carlisle, PA 17015-9439 13-014530 LAW OFFICE OF SNYDER & DORER Thomas S. Brumbaugh, Esquire 214 Senate Avenue, Suite 600 Camp Hill, PA 17011 Telephone Number: (717) 731-0988 Brumbtl Anationwide.com Uri J THn, ..ii i :, tiY -5 1' 1:.39 CUi1BERL, O COUNTY PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS COURT DIVISION IN RE: SAMUEL TAYLOR MILLER, A MINOR, BY AND THROUGH HIS PARENTS AND NATURAL GUARDIANS, ROBBY LYNN MILLER AND DONNA LYNN MILLER NO. 14-1419 CERTIFICATE OF COMPLIANCE Thomas S. Brumbaugh, Esquire, attorney for Nationwide Mutual Insurance Company hereby certifies that the Settlement funds in the amount of $15,000.00 have been deposited in compliance with the Court's Order of March 12, 2014 with the account marked as set forth in said Order. A letter from the financial institution and the account information sheet showing that the funds in the account are not to be withdrawn until the minor's majority or upon prior order of court are attached hereto as Exhibit "A" and incorporated herein by reference. Date: May 1, 2014 Respectfully submitted, LAW OFFICE OF SNYDER & DORER Thomas S. Brumbaugh, vire Attorney for Plaintiff Court I.D. No. 89037 EXHIBIT A MEMBERS 1St FEDERAL CREDIT UNION 4/30/14 Snyder & Dorer 214 Senate Avenue, Suite 600 Camp Hill, PA 17011 Dear Sir or Madam: Re: Samuel Miller MAY 0 1 2014 / 3-0/L/530 Members 1st Federal Credit Union has established an account for Samuel Miller. The funds in the account have been placed in a savings account and frozen until 10/25/14, based on the court order. The enclosed document shows the account name and the restriction placed on those funds. Please contact us for any additional assistance. Any questions or further communications should be directed to Gregory P Schank, VP of Branch Operations at 1-800-283-2328, extension 6003. Respectfully, Stacey/2092 Account Specialist Members 1st FCU enclosure 5000 Louise Drive • P.O. Box 40 • Mechanicsburg, Pennsylvania 17055 • (800) 283-2328 • www.memberslst.org i asp I vi I t i Share/Loan List For Account: 0000552845 Account Type: O Ordered SAMUEL T MILLER Member Member 3 Type SSN Home Number SAMUEL T MILLER Primary ***-**- 8248 717-776-9989 197 LAWRENCE LANE CARLISLE, PA 17015 Share Description Rate Maturity Date Available Balance S 0000 REGULAR SAVINGS -$15,005.00 $ 15,000.00 DEPOSIT TOTAL $ 15,000.00 LOAN TOTAL $ 0.00 4/30/2014 13-014530 LAW OFFICE OF SNYDER & DORER Thomas S. Brumbaugh, Esquire 214 Senate Avenue, Suite 600 Camp Hill, PA 17011 Telephone Number: (717) 731-0988 Brumbtl Anationwide.com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS COURT DIVISION IN RE: SAMUEL TAYLOR MILLER, A MINOR, BY AND THROUGH HIS PARENTS AND NATURAL GUARDIANS, ROBBY LYNN MILLER AND DONNA LYNN MILLER NO. 14-1419 CERTIFICATE OF SERVICE Thomas S. Brumbaugh, Esquire, attorney for Nationwide Mutual Insurance Company hereby certifies that he caused a true and correct copy of the attached Certificate of Compliance to be served by regular first class mail upon: Date: May; , 2014 Rob and Donna Miller 197 Lawrence Lane Carlisle, PA 17015-9439 Petitioners Respectfully submitted, LAW OFFICE OF SNYDER & DORER Thomas S. Brumbaugh, Esquire Attorney for Plaintiff Court I.D. No. 89037