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HomeMy WebLinkAbout14-2933UTHONG 201411'5,Y P11 2: 50 CUMBERLAND CCUN ' IN THE COURT OF COMMON PLEAS PENNS YLyp NIA OF THE 9TH JUDICIAL DISTRICT PENNSYLVANIA - CUMBERLAND COUNTY BRANCH IN RE: Avery Hostetler, A Minor, by Christie and Brian Hostetler, : NO. )(,(_ 9g33 C� Parents and Natural Guardians 1 JOINT PETITION PURSUANT TO PA. R.C.P. 2039 TO COMPROMISE AND SETTLE MINOR'S CLAIM, ALLOW COUNSEL FEES AND EXPENSES, AND DIRECT DISTRIBUTION To the Honorable, the Judges of said Court: The Petition of Christie and Brian Hostetler, parents and natural guardians of Avery Hostetler, a minor, respectfully represents: 1. Petitioner, Christie Hostetler, is an adult individual living and residing at 58 Independence Drive, Shippensburg, Cumberland County, Pennsylvania, 17257. 2. Petitioner, Brian Hostetler, is an adult individual living and residing at 58 Independence Drive, Shippensburg, Cumberland County, Pennsylvania, 17257. 3. Petitioners are the natural parents and guardians of Avery Hostetler, a minor, born January 4, 2013. LAW OFFICES DILORETO, COsENrM0 $ BOLINGER PC 330 LINCOLN WAY EAST P.O. BOX 866 CHAMBERSBURG, PA 17201 /41 LAW OFFICES DOREro, COSENrwO & BoLINGER PC 330 LINCOLN WAY EAST P.O. BOX 866 CHAMBERSBURG, PA 17201 4. On August 23, 2013, Avery Hostetler, a minor, was brought by Petitioner, Christie Hostetler, to Kids Kount Child Care Center, located at 211 East Garfield Street, Shippensburg, Cumberland County, Pennsylvania, for the purpose of child care for Avery Hostetler, a minor. 5. On said date, after Petitioner, Christie Hostetler, left Kids Kount Day Care Center to go to work, Avery Hostetler, a minor, sustained a non-displaced fracture of the left proximal ulna when Michelle Hoover, an employee at Kids Kount, pushed Avery Hostetler's stroller down a hallway when Avery Hostetler's left elbow became caught between the stroller and the metal leg of a cot. 6. On August 23, 2013, Avery Hostetler, a minor, was taken by Petitioner Christie Hostetler from the Kids Kount Day Care Center to Shippensburg Family Walk In Clinic where the doctor reduced Avery's left elbow and diagnosed the Claimant with a suspected partial subluxation of the radial head.. A copy of the Shippensburg Family Walk In Clinic record is attached as Exhibit A. 7. On August 24, 2013, Petitioner, Christie Hostetler took Avery Hostetler, a minor, to Med Express as Avery Hostetler continued to be unable to extend her left arm. Med Express recommended that Avery go to the Chambersburg Hospital ER for treatment. A copy of the Med Express records is attached as Exhibit B. LAW OFFICES DILOREro, COSENTINO & BOLINGER Pc 330 LINCOLN WAY EAST P.O. BOX 866 CHAMBERSBURG, PA 17201 8. The minor, Avery Hostetler was seen at the Chambersburg Hospital ER on August 24, 2013, and was diagnosed with an acute non-displaced olecranon fracture on x-ray film and was referred to Robert Lyons, M.D., an orthopedic specialist, for further follow up and treatment. A copy of the Chambersburg Hospital Records is attached as Exhibit C. 9. On August 26, 2013, Avery Hostetler, a minor, saw Dr. Robert Lyons who diagnosed` Avery Hostetler with a closed fractured ulna olecranon process and applied a long-arm splint with loose fitting Ace wraps. A copy of Dr. Robert Lyons Records is attached as Exhibit D. 10. On September 3, 2013 and September 30, 2013, Dr. Lyons again saw Avery Hostetler, applied a new long-arm posterior splint with ace wraps, and took follow up x-rays that showed a small ossicle at the level of the fracture medially. 11. Because of concern with regard to the ossicle, Christie Hostetler took Avery Hostetler, a minor, see Roger Robertson, M.D., at Summit Orthopedic for a second opinion. Dr. Roberson reviewed the x-rays, performed a physical examination and concluded. that the left proximal non-displaced ulnar fracture was healed and that there should be no permanent long-term sequelae of the injury. A copy of the Summit Orthopedic records is attached as Exhibit E. UAW OFFICES DILORETO, COSENTIN0 & BOLINGER PC 330 UNCOLN WAY EAST P.O. BOX 866 CHAMBERSBURG, PA 17201 12. Due to injuries sustained by Avery Hostetler, a minor, on August 23, 2013, Capital Advantage Insurance Company, the private health insurance carrier acquired by Petitioners Christie and Brian Hostetler, made conditional medical payments on behalf of Avery Hostetler, a minor. 13. Socrates Inc., on behalf of Capital Advantage, is asserting a subrogation lien in the amount of $1,279.27 for conditional payments made on behalf of Avery Hostetler, a minor. A copy of correspondence sent to undersigned counsel by Socrates Inc., dated April 11, 2014, confirming the asserted lien amount is attached as Exhibit F. 14. The Markel Corp., has agreed to pay the subrogation lien, in full. 15. At the time of the incident set forth above, Kids Kount Day Care Center was insured under a policy of insurance through Markel Corp. Insurance. 16. Following the occurrence above set forth, Christie Hostetler and Brian Hostetler, in their capacities as parents and natural guardians of Avery Hostetler, a minor, entered into a contingent fee agreement with the law firm of DiLoreto, Cosentino & Bolinger, PC, to advise, represent and assist them in prosecuting a claim for damages against any responsible parties arising out of the August 23, 2013 LAW OFFICES DILoRETo, COSENTINO & BOLINGER PC 330 UNCOLN WAY EAST P.O. BOX 866 CNAMBERSBURG,PA 17201 incident. A copy of the contingent fee agreement is attached and marked as Exhibit G. 17. As a result of the efforts of the law firm of DiLoreto, Cosentino & Bolinger, PC, and through their negotiations with Markel Corp. as the carrier for Kids Kount Day Care Center an agreement has been reached whereby Markel Corp. as the carrier for Kids Kount Day Care Center, will pay $10,000.00 to settle the liability claim of the minor, Avery Hostetler. A copy of the email from Markel Corp. Confirming said resolution is attached as Exhibit H. 18. Petitioners believe that the settlement as set forth above is in the best interest of the minor. 19. Petitioners have been advised by counsel and understand that should this settlement be approved, there will be no future or further payments from Kids Kount Day Care Center or Markel Corp. as its liability carrier for liability claims against Kids Kount Day Care Center or Markel Corp. arising out of the August 23, 2013 incident. 20. Petitioners, with advice by counsel, executed a General Release, totally and fully discharging Kids Kount Day Care Center and Markel Crop from any obligation to pay additional sums for liability claims with respect to the injuries sustained by the minor. See executed Release Agreement attached as Exhibit I. LAW OFFICES DILoRETo, CosENTP10 & BOLINGER PC 330 LINCOLN WAY EAST P.O. BOX 866 CHAMBERSBURG, PA 17201 • • 21. The fee agreement between Petitioners and counsel provides for a. 25% attorney fee and payment of litigation costs. Counsel agrees that the attorney fee is inclusive of litigation costs. As such, the counsel fee totals $2,500.00. 22. It is proposed that the net proceeds of this settlement payable to the minor, Avery Hostetler, will be deposited in a federally insured savings account or savings certificate as required by Pa. R.C.P. 2039(b)(2). 23. The parties to this settlement do not believe an evidentiary hearing before the Court his necessary, but the parties and undersigned counsel stand ready to participate in a hearing should the Court order one. 24. WHEREFORE, Petitioners request this Honorable Court to enter an Order providing the following: a. Approve the settlement of the minor's claim against Markel Corp. as the liability carrier for Kids Kount Day Care Center for the total sum of $10,000.00; b. Approve the agreement for payment of counsel fees, inclusive of costs, in the amount of $2,500.00 to DiLoreto, Cosentino & Bolinger, PC; c. Direct payment of the net recovery of $7,500.00, to the minor Plaintiff, with the net settlement proceeds to be deposited in a federally insured savings account or savings certificate as required by Pa. R.C.P. 2039(b)(2); and d. Grant leave to Petitioners to execute all necessary documents to effectuate the settlement as set forth in this Petition. Date: April 073 , 2014 LAW OFFICES DILOREEO, COSENTINO & BOLINGER PC 330 LINCOLN WAY EAST P.O. BOX 866 CHAMBERSBURG,PA 17201, Respectfully submitted, DILORETO, COSENTINO & BOLINGER, PC By Victoria P. Edwards, Esquire Attorney for. Petitioners Supreme Court ID No.: 200372 330 Lincoln Way East P.O. Box 866 Chambersburg, PA 17201 (717) 264-2096 Marshall Dennehey Warner Coleman & Goggin By Allison M. Domday, Esqu' Attorney for Defendants Supreme Court ID No.:307547 100 Corporate Center Drive Suite 201 Camp Hill, PA 17011 (717) 651-3538 We verify that the statements made in this Petition are true and correct. We understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. DATE: April a4, 2014 LAW OFFICES DiLoaEro, COSENTNO & BOLINGER PC 330 LINCOLN WAY EAST P.O. SOX 866 CHAMBERSOURG,PA 17201 QC nstie Hostetler �1L LAW Brian ostetler • • IN THE COURT OF COMMON PLEAS OF THE 39TH JUDICIAL DISTRICT PENNSYLVANIA - FRANKLIN COUNTY BRANCH IN RE: Avery Hostetler, : ORPHANS' COURT DIVISION A Minor, by Christie and Brian Hostetler, : NO. Parents and Natural Guardians CERTIFICATE OF SERVICE I hereby certify that a copy of the foregoing Petition was served this date by United States First Class Mail, postage prepaid, addressed as follows: Date: May LI, 2014 LAW OFFICES DLLORETO, CosENfNO & BOLINGER PC 330 UNCOLN WAY EAST P.O. BOX 866 CHAMBERSBURO,PA 17201 Christie and Brian Hostetler 58 Independence Drive Shippensburg, PA 17257 Markel Claims Service Center P.O. Box 2009 Glen Allen, VA 23058 Kid's Kount Day Care Center 211 E Garfield St. Shippensburg, PA 17257 DILORETO, COSENTINO & BOLINGER, PC By Victoria P. Edwards, Esquire Attorney for Petitioners 330 Lincoln Way East P.O. Box 866 Chambersburg, PA 17201 (717) 264-2096 EXHIBIT A Fax* (/1/)-b3Z-35ti1 Page q t i f/b1134 Mae; 0043113 SUM T FAMILY eivoy E *Oa* .00e O142O13Sn,K F SPShlurse Nola Family Current.Merai Prior to:Viett Predritolone Sodkun Phosphate 1 Adanalett NKDA Wt 22Ib 12oz Wt Prier; Iller 2oz as 005/23/13 WI Of +4Ib 104 Wt kg: 10,319 Wt of 05123/13 Wt kg DM +2097 Puler 112 Amp: 20 T: 98,2 AX1L4ARY Wrig; 47th Trine:4ton: Or. Garin Sandoval is my suparvisirephracien ,/ month clidt orriesievith avrobiem with his left eta". The the let aththearel nst using o* froth end difficult to know accident or anytling Ike diet. Itiorn bckigs him in now. because .tenter said he heti been tawoeing irmoived any sort of to favor hie Itiff etc*. #2;.,yery pleasant yowl(' boy 22 pow ds Na acute tigress ' data, Neck it impala Ear, ;*W it** ameat s hellion,. I dod extern" rotate and extend the left forearm al the Oboe end felt a stroll pop, Al Auspatt rney wek ftearS boons pedIel sublto.abon of the "goy os.*radu P t have asked the mom SO last *emir ey* on the ornith he isnot fevonnell over the nett 24 ha**. 2. She is to fOttcre UP hate if there is any Worries or torments. head °alba left vrtiith I was sure he is.: his *1»e. Asment at 719:43 Painjain1 Foroarm Cali ?km Fax* (717)-532-3561 Page 5 of 7 #76634 OZ. ;John A 4r#iOMC Dabst Dietbied: 08/2502013 Tbinbcpted 0$‘27/2013 011flt2O13 2O pin O�fQ 013 chXam • (1I/) -53Z-3561 Page 6 of / 1/66311 SUIMMTPNTINCEAN SERVIOES-FAAULYALAMCE NORSE NOTE DOW 04041, NORKOY1.0,E:HOStetkir (71P1Tt W IT006:-0110412013 Sew F Aar mac 2 wks Ace* 157238 Phone: Nino Nolia. LEFT ELBOW IN.AIAy AT DAYCARE IMAAAA, iffill4016# MICHAEL LEMASTER 08/21,201. • amw.T1 vAIM ! "; P/q. 1." S!, wpits lamOmmiti -011 AT*ioriis. 0:51114 113S0044s. ti:otI0,to Boa scpAT wuno3ay !IpAaLsw. s -.141471, 4911T1,4 Mor4WWVAVI4SAIWIIP0(OV Aidia 'lig 090 242; oT14IPIP02d: PoTTTPAI matmun70 4114,4 4.024 trAitioW EXHIBIT B • Patient Health Record Patient Name: AVERY HOSTETLER Demographic Information: AVERY HOSTETLER 58 INDEPENDENCE DR SHIPPENSBURG PA 17257 Home Phone: (717)477-2345 Date of Birth: 01/04/13 Insurance Company: BMPA: CAPITAL BLUE CROSS Group: CTK361 Member Number: CTK80108242205 Visit Date: 8/24/2013 Rendering Physician: Christopher Snyder Patient Name: AVERY HOSTETLE. Seen At MedExpress Chambersburg 1048 Lincoln Way East, Suite 101 Chambersburg, PA 17201-2820 Phone: 717-287-2273 Fax: 717-281-4882 Chief Complaint Patient comes in today for a Injury to upper extremity. pt injured left arm yesterday, was seen at urgent care last night and dr popped it back in, still not extending it (SOURCE: Family Member) HPI Patient Reports Injury to upper extremity [Mod. Fact.: Worse Movement Location: Reports Left, elbow; Assoc. Sx: Reports Contusion, . Swelling; Free text: Was in Daycare yesterday and left arm got caught - wasn't moving it- went to urgent care last night dr popped It back In, still not extending it Timing: Reports Intermittent; Context Reports Twisted) PMH Past Medical History is unremarkable city water electric heat pets indoor no smokers immunizations utd Surgery Hx No Surgical History ROS Musc/Skel Patient Reports Swelling Pain Skin/Breast Patient Denies Abrasion; Laceration Cur Rx Patient is not currently on any medications Allergies Active: Reviewed Allergies; No known allergies; No known drug allergies Social Hx Reviewed Social Hx Fam Hx 'GENERAL has a Hx of Hypertension Vitals PULSE: 138 bpm, RESP: 20 breaths/min, TEMP: 98.3 , WEIGHT: 23 lb, O2SAT: 100% (12:03 PM) Exam General NORMAL: Vitals signs were noted by provider, No acute distress, Patient appears well-developed Cardiac NORMAL: Radial pulse is normal Musculoskeletal ABNORMAL: Swelling is present at upper arm, Tenderness noted Lateral aspect of left upper arm, child was not moving left elbow- there was an area of ecchymosis noted laterally- withdrew from palpation Neurological NORMAL: Appropriate tactile sensation 'rocedures OFFICE VT -NEW LV 2 [99202] QTY (1) SERVICES PROVIDED IN AN URGENT CARE CENTER [S9088) QTY (1) Printed by samantha.newell on 9/18/2013 Page 2 of 3 NP Patient Name: AVERY HOSTETL Pain, elbow (719.42) We recommend you go immediately to the nearest Emergency Department for further evaluation. We recommend that you go directly there from here and that you do not eat or drink anything until after you have been evaluated by the ER and cleared by them to eat and drink Dictation I sent the patient to the ER- we could xray it here but if there was any problem I wouldn't be able to manage a 7 month appropriately with a fracture or dislocation appropriately. Child was not extending arm at elbow and withdrew from touch. This record was electronically signed by Christopher Snyder, DO on 03/24/13 at 12:53 PM Printed by samantha.newelt on 9/18/2013 Page 3 of 3 EXHIBIT C • CHAMBERSBURG HOSPITAL EMERGENCY DEPARTMENT 411 S CHAMBERSBURG, PA 17201 Chart Copy Afbantbew r Fi1g- '.... Other Doctor information: 1111111111111111111111111111' 111111p1111111 NIY IOCATICNCODE CER ARRIVAL WHIN 4 CLERK%INITIAL$ T ACCOUNT n0. AWENGEA H00049629818 TYPE ER MEDICAL MON N•. H678383 may." '•,';.�I�`y;;, -WI NAME AND ADDRESS TELEPNORE NC. HOSTETLER.AVERY ELIZABETH (717)477-2846 SB INDEPENDENCE DR SHIPPENSBURG.PA 17257-822 456-69.5239 PATIENT ERPLOYER NAME AND ADDRESS - PRMARY TELEPN0NE NO. CHILD UNDER IBYRS • PIN MASS SC - OATS QF FERYICS 08124/13 TIME. 1334 RACE CA ADE 07M 20 DATE OF SIRTH 01104/2013 SET F MARITAL STATUSNENTOF S KIR - HOSTETLER.CHRISTIE M MD (717)477-2349 ^ PR ADD/ CRnMnh1T! ' OCC CDD! 05 •• - TIME OF OCC DATE @F OCC I PBfnal to HMV• 08123/13 HOSTETLER,CHRISTIE M4717}477-2345 "�:•,. N:m:£ AND AD0&$ RFLAFION TO wren HOSTETLIA,CHRI TIE AA 58 INDEPENDENCE DR TO. NO. SHiPPEiVSBUR(3,Pa 17257822 - 6644 • 207-66-0108 0AURANTOR IM?WYER NE 301 LORTZ CHAMBERSSURG,PA (7171207.3275 INFORMATION • • AVE 17201 • • ;u> � INEURAN E COMPANY CAPITAL BL CROSS POLICYHOLDER . HOS TETLER.CRIAN J FIELATIONEHIPlP0LECY CERTIFICATE/GROUP • DA CTK90108242201 00519393 • a:.• CAPITAL 51. CROSS- PO BOX 779508 HARRISBURO.PA 17177-9503 (/!00)307 3SB5 ;" 3• iF REASON FOR Vf8RIDIAONOSISATTENDING ARM DOCTOR Marx M.D.,David f? "..w -.z.. ' FAMILY COCIOR Hannegan M.O.. Erin A (7171203-0550 • PRIMARY CARE DOCTOR Hannagen M.D.. Etin A (7171253-0550 Other Doctor information: 1111111111111111111111111111' 111111p1111111 NIY Patient's Chief Complaint Rm PriR Fority T EN: T 1 7 EMERECORD ill fiJi 111 1 11H MR.EDT. 111111 `Iil�i ECU Doctor4 lime Seen ..17iT rebdated ©Addendum O Attending Note/Teaching Physician present for keypprlprooend EvelManagement . 0 CC Time = min, excludes billable procedures C] Conscious sedation min • • • • • • • 0 LABS / Results To Go 0 Old records from: - 0 Cal] • • • 0 Hospltalist © Consu tant 0 Crisis 0 Social Service • • Time: 0 MPO 7 ED Meal Cardiac 0 ED Meal Clear Liquids 0 ED Meal. Diabetic 0 ED Meal Reed CI PULSE OX Order C] NI fl HYPDXIC Monastic Impression A 4. le 4.41e41714444 Gf 1,444-0v7. F • ' )q Discharge 3 No. T`..„r to a. -i,.a - I' Isii1 Condition on Discharge !/ Emergent 0 Nen-Emergentff Referred To; Tme Deteporeatnt s) , lifitl t' Icin tyrsiaa” n ^ armature Referral Physician% Signature Dischaga Time ' Name: HOSTETLER,AVERY ELIZABETH Pt Phone: Emer Notify: Acct No: HO0049829819 MR NO: 1-167$383 DOR/AGE: 01 /04/?013 07M ant Sex: F `ueney Department (Attending Doctor Time Notified Achambersbuairg. r ' ems.:"•" Chante. , PA nmu4ms *' a°n m .3mc EMERGENCY DEPARTMENT RECORD PODBIm (811/11) Date 08/24/13 Primary Cara Physician Hannagan M.D., Erin A Time 1325 HSM0521326 Chambersburg Hospital Emergency Department Patient Instructions Signature Page -Patient Name: HOSTETLER,AVERY ELIZABETH ' Account Dumber: H00049629019 Service Date: 08/24/13 Medical Record #: H67$383 I• I hereby acknowledge receipt and understanding of discharge instructions given to me during my emergency department visit. , Patient, Parent, or Responsible Party Date Care ,a,4Q1_,t .] g is- 1.0 Date Time Attention: Worker's Compensation Cases • If your visit to the Emergency Department is work related, and you are expecting your . employer to be responsible for payment, then all follow up must be completed.by your employer's workman's compensation provider. All references within this departure packet to "Family Physician", "Your Physician", etc. should,be ignored, and follow up should occur with the workman's compensation provider. ° • 11111 II111181111 J hambersfurrg. Hos fta! ..sar.r I Sr.* NM iuK.thi1.1as .1.tme.,.et,y.PA In, Patient Name: Account #: Med Rec #: Admit Date: HOSTETLERAVERY EUZABET H00049629819 14678383 08124/13 CONSENT FOR EXAMINATION, TREATMENT AND PROCEDURE I agree and give my consent to any examination, treatment, or procedure and all services provided by the hospital's nurses and other employees that the attending physician or his/her assistants may deem necessary or advisable during my stay or visit in this Hospital. It is understood that this consent does not include operation or surgical procedures which may require informed consent. If such operations or surgical procedures are required during my hospitalizationivisit, I understand that I will be asked to give specific consent for these operations or procedures. i hereby authorize payment directly to Chambersburg Hospital for the hospital benefits otherwise payable to me by Medicare&Medicaid, or by any other third party payer. I understand that the services I am being registerec for today may require physician(s) services that will be billed in conjunction with and independently of the hospital charges. This form also authorizes those physicians to bill and accept assignment I understand that I am financially responsible to the Hospital and the physician(s) for charges and balances not covered by this assignment I understand Chambersburg Hospital is permitted to release information necessary for the completion of insurance claims, Including MedicarelMedicaid claims, relative to this hospitalization/visit. I understand that if I do not present accurate, current and complete billing information at the lime of services, I agree to be responsible for any amounts not covered by insurance. If covered by Medicare, I certify that the information given by MB in applying for payment under the Social Security Act s correct. I request payment of authorized Medicare benefits for me or on my behalf for any services furnished to me, by or in the Hospital (including physician services) be made to Chambersburg Hospital. E assign the benefits payable for physician services to the physician or organization to submit a claim to Medicare for payment of my benefits. I understand that I am financially responsible to the Hospital for charges not covered by this assignment If covered by Medical Assistance, I certify that the.infomiation I have provided is true, correct, and accurate. I understand that payment and satisfaction of this claim will be from Federal end State funds, end that any false ciaEms. statements, documents or concealment of material facts may be prosecuted under applicable Federal and State laws. Witness (2(]( E Patient Signature Date Name Dept. OR Authorized Person"" IVUIA 110Z --Date ; Relationship to Patient c..4/1)01I "' When a patient is a minor, incompetent, or unable to sign, the signature of the person authorized to give consent is required. Provider: The Chambersburg Hospital I was offered a Patient's Dill of Rights Brochure registration at The Chambersburg Hospital. Patients Indole For patients with Medicare: I was given a Beneficiary Right to Know card during registration. Patient's Initials Do you have an Advance Directive? © Yes-1:1715— Would estJNO "Would you like information on anAca Directive? O Ye Information provided? Q Yes -"Lao (NIA if Lab or Diag. Radiology Department) 111111! 101 1 Of III 11111 11111 1 liii MR.CON POO!2lsaretiites (O:OND.R:10liO) 1PE CHAMBERSBURG HOSPI"AL 112 North Seventh Street Chambersburg, PA 17201 • PATIENT NAME: HOSTETLER,AVERY ELIZAI31i 267-3000 MEDICAL RECORD #: H678383 ACCOUNT #: H00049629819 ADMISSION DATE: PATIENT TYPE: DEP ER H: DISCHARGE DATE: 08/24/13 ROOM/BED: REPORT #: 0825-0016 SERVICE DATE: 08/24/13 DOB: 01/04/2013 ATTENDING PHYSICIAN: PHYSICIAN: David G Marx M.D. EMERGENCY ROOM REPORT REPORT STATUS: Signed CHIEF COMPLAINT; Arm injury. HISTORY OF PRESENT ILLNESS: This is a 7 -month-old, who apparently had some sort of arm injury while she was at daycare yesterday. She was being pushed in a stroller and her arm was somehow caught. Parents are unaware of the exact mechanism. Subsequently, she has not been moving her arm nearly as much as she uses her right arm and clearly less than usual. No obvious deformity or ecchymosis. The patient was seen at walk-in clinic, thought to have radial head subluxation. A pop was felt with supination and pronation movement. The child is still not moving well and was brought to the hospital for further evaluation. PAST MEDICAL HISTORY: Negative. PHYSICAL EXAMINATION: vital signs remain stable. Child is clearly not moving her left upper extremity nearly like her right, but she does have some spontaneous movement. No obvious deformity. No palpable tenderness over the clavicle, humerus, or forearm. X-ray of humerus and forearm demonstrates what appears to be a nondisplaced olecranon fracture. IMPRESSION: Acute nondisplaced olecranon fracture. PLAN: Discharged home in an OCL splint. Follow up with orthopedics on Monday. 824873/577131647/ <Electronically signed by David G Marx M.D.> 08/28/13 1627 Transcriptionist: A Dictated: 08/24/13 1503 Transcribed; 08/25/13 0152 CC: Additional copy: Other Medical Record #'s: Page . of DEPARTMENT: CHAMBERSBURG H=M 411 411 THE CHAMBERSBURG HOSPITAL SUMMIT HEALTH CENTER 112 North Seventh Street Rhonda Brake Shreiner Women's Center Chamberoburg, PA 17201 Summit Diagnostics Services Departments of Chambersburg Hospital (717) 267-7149 PATIENT NAME: HOSTETLER,AVERY ELIZABETH MEDICAL RECORD #: H678383 ACCOUNT #: H00049629819 PATIENT LOC: CER DOB: 01/04/2013 PATIENT TYPE: DEP ER H: ORDER #: 0824-0076 ROOM/BED: REPORT #: 0825-0022 PHONE #: (717)477-2345 ADMITTING DIAGNOSIS: ARM RADIOLOGIST: Michael E Shivers M.D. ORDERING PHYSICIAN: Marx, David G M.D. DIAGNOSTIC IMAGING REPORT STATUS: Signed DATE OF SERVICE: 08/24/2013. HISTORY: Left arm pain. LEFT RADIUS AND ULNA: Two views of the left radius and ulna are obtained. Lucency in the olecranon is noted with possible nondisplaced fracture seen in this location. No other definite fractures or dislocations Identified. IMPRESSION: 1. Possible nondisplaced fracture of the olecranon. ICD9 Code: <Electronically signed by Michael E Shivers M.D.> 08/25/13 1206 Transcriptionist: TMA Dictated: 08/24/13 1408 Transcribed: 08/25/13 0744 CC: Erin A Hannagan M.D.; David G Marx M.D. Additional copy: Other Medical Record #'s: Page _ of I DEPARTMENT: DIAGNOSTIC IMAGING 73090 • • THE CHAMBERSBURG HOSPITAL SUMMIT HEALTH CENTER 112 North Seventh Street Rhonda Brake Shreiner Women's Center Chambersburg, PA 17201 Summit Diagnostics Services Departments of Chambersburg Hospital (717) 267-7149 PATIENT NAME: HOSTETLER,AVERY ELIZABETH MEDICAL RECORD #: H678383 ACCOUNT #: H00049629819 PATIENT LOC: CER DOB: 01/04/2013 PATIENT TYPE: DEP ER H: ORDER #: 0824-0077 ROOM/BED: REPORT #: 0825-0026 PHONE #: (717)477-2345 ADMITTING DIAGNOSIS: ARM RADIOLOGIST: Michael E Shivers M.D. ORDERING PHYSICIAN: Marx, David G M.D. DIAGNOSTIC IMAGING REPORT STATUS: Signed DATE OF SERVICE: 08/24/2013. HISTORY: Left arm pain. LEFT HUMERUS, 2 VIEWS: Two views of the left humerus are obtained. No definite fracture or dislocation is seen in the left humerus. Lucency seen in the olecranon on the anterior projection could represent a nondlsplaced fracture. IMPRESSION: 1. No fractures or dislocation seen in the humerus. 2. Possible nondisplaced fracture of the olecranon. ICD9 Code: <Electronically signed by Michael E Shivers M.D.> 05/25/13.1206 Transcriptionist: 'TMA Dictated: 08/24/13 1410 Transcribed: 08/25/13 0745 CC: Erin A Hannagan M.D.; David G Marx M.D. Additional copy: Other Medical Record #'s: Page _ of DEPARTMENT: DIAGNOSTIC IMAGING 73060 DATE: 09/18/13 @ 0934 410ummit Health ABS **LIVE** USER: PJAMISON ATTESTATION STATEMENT III PAGE 1 STETT.T.R,WFRY 7. TMT CP .ft WOC4q6,,q141 . • ADM DATE: 08/24/13 ATTEND PHYS: Marx M.D.,David G DIS DATE: 08/24/13 DISC!! DISP: HOME LOS: 1 PT CLASS: CMCRER mur #: H678383 SEX: F AGE: 07M 20D DOB: 01/C4/2013 FIN CLASS: BC ABS STATUS: FINAL DIAGNOSES: ADMIT: 813.01 FX OLECRAN PROC ULNA -CL PRINC: 813.01 FX OLECRAN PROC ULNA -CL SECOND: E928.9 ACCIDENT NOS POA? OPERATIONS: DRG: STATUS $ REIMS MIN -LOS MAX -LOS STD -LOS GRP VERB GRP FC 30 BC I certify that the narrative descriptions of the principal and secondary diagnoses and the major procedures performed are accurate and complete to the best of mg knowledge. DATE: DATE: 09/18/13 9 0936 nese: R.TARTRON Summit Health PHA "LIVE' Wadi catian nier:harge enmmary Rapnrt. PAGE 1 O9/TRJ13 mEnrcATTnl DTsrmARRF. RTIMARY MA.. R(1RTF.TT.RR,AVRAY Ri.T7.ARRTR Admit llai..e arae ONM fall Unit NumEE793133 Discharge Date Sex F Account Num H00019629019 - Status DEP ER Allergies No Known. Allergies (NKA) xxx Continued on Page 2 xxx This document is part of the legal medical record. DATE: 09/10/13 @ 0936 n8£R: R.TANT"nON Summit Health PHA **LIVE** Nadiration niarharia RoNnary Rapo t PAGE 2 09/1R/1A Gam. Rftg9ReTam, AORRV l:T.T2APOPH Medi ration liArhnrge Summery Arnnnnh Annn&RA4411114 w0Y.3vify:txldes e r: •1ia7�&f �B Yl4 DR6r: ilat!e 'P:sine Oq®ac;.;li�ne 20130104 1H.3 RRATARR RRTDTNRRR OLD: NRfii: No grown A11eraie4 rodded. NKA 20130104 1057 BOILAN COOK OLO: NSW: 20130E24 1320 HEATHER BON:LLAS OLD: Date: am: Ai l ar5y Liar. f onfi rnad: Tata: RP.rl�aefl:•:t.- IPR :•: Administered By Pharmacy Allergy History Hatapasg Type hAlOrg# 1TRT.R£R1 AOl) No Known :Mar -glee PHA.HBA FILED HRI.HHN EDIT nR/24/17 - Tuna: 1320 sal Printed By PJA0IsCW 09/18/13 0936 This document i.e mart of the legal medical record. R 1 R4R •: �.fRlPR:: DATE: 09;18/13 @ 0937 Summit Health OE **LIVE*• PAGE 1 USER: PJAMISON PATIENT DISC9ARGE SUMMARY - CUSTCM PATIENT NAME: HOSTETLER,AVERY ELIZABETH AGE/9: 07M 20D/E amis./me: 08;24/13 ACCOUNT MUM.; 1500049629819 VEITq: H670383 LACE : CER - EMERGENCY ROOM PT STATUS: DE? ER ATTEND/ER DR: Marx M.D.,David G ROCE : CER BED: CER NEE #: HSM0521326 :..CATEGDe7::•:PLOCEDERS:•.:;:;::::.::':::.:.:::::.:::..:::.:::::::::.::::•::•:::>:;.:GRE:.t7StEtTIik.:BSC:.>:::: ::.::: :.9RV:{SATE/TIME:P12: !OR!:: :: ATEO::;:::::.::ORDEN INE:.::.:ESUS:-:_ RAD RAD FOREARM 2 V UNI (FARM) 08/24/13 1343 MARX 08/24/13 1342 S 1 RES (C) 0824-0076 POM ORDER OR: Marx M.D.,David G (MARK) SITE: CHBG DEVICE: ECL-PHYS4 9ecE: PROVIDER (D) OENET:Z.EDNINTR - TRAUMA - MINOR (S; Left or Right: LEFT Signs & Symptoms: TRAUMA Evaluate For: Additional _nfo: COMPLETED: Status updated by ITS ITS ORDER #: 0024-0076 Eg DATE TIES USER DEVICE EVENT POE PROVIDER SRC 1 08/24/13 1343 MARX ECU -PR/S4 order entered in Order Management 2 08/24/13 1343 MARX ECU-PHYSI order source is PROVIDER - signature is necessary for entry 3 08/22/13 1343 MARX ECU-PHY54 order entry signed for MARX 4 08/21/13 1393 OE System HSM-BG6 order transmitted 5 08/23/13 1344 OE System HSM-BG6 order's status changed from TRANS to LOGGED 6 08/24/13 1344 OE System HSM-BG6 quantity edited via ITS: old value - 7 08/24/13 1415 PACS HSM-BGE order's status changed from LOGGED to TAKEN 8 08/25/13 0745 TARNOLO HSM-BG6 order's status changed from'TAKEN to COMP 9 08/25/13 120' SHIVER HSM -EGG order's status changed from COMP to RESULT a.#h'EGD'BY.'41OE6DIIRS:. •:'•:':;':•:;r'.'. . dike%DATE T3miLais'.':'.'.':'.fiiRY'DATE/TIP '.PR.''T`..::.:N I1T66`>:•:':•:::'.'.OADER...R.IJr':•::..FROI[.:' RAD RAD HUMERUS UNI (SUMER) 08/24/13 1343 MARX OB/24/13 1342 S 1 RES (C) 0824-0077 POM ORDER DR: Marx M.D.,David G (MARK) SITE: CHBG DEVICE: ECL-PHYS4 SRCE: PROVIDER (D) DENET:Z.EDMINTR - TRAUMA - MINOR (5: Left or Right: LEFT Signs & Symptoms: TRAUMA Evaluate For: Additional :nfo: COMPLETED: Status updated by ITS ITS ORDER #: 0824-0077 iii. DATE TIME USER DEVICE EVEIIT POE PROVIDER SRC 1 08/24/13 1391 MARX ECU-PHYS4 order entered in Order Management 2 08/24/13 1343 MARX ECU-PHYS4 order source is PROVIDER - signature is necessary for entry 3 08/24/13 1343 MARX ECU-PHYS4 order entry signed for MARX 4 08/21/13 1343 OE System HSM-BG6 order transmitted 5 08/21/13 1344 OE System HSM-EGO order's status changed from TRANS to LOGGED 6 08/21/13 1394 OE System ESM -EGO quantity edited via ITS: old value - 7 08/24/13 1415 PACS HSM-BG6 order's statue changed from LOGGED to TAKEN 8 08/25/13 075] TARNOLD HSM-BG6 order's status changed from TAKER to COMP 9 08/25/13 1207 SHIVER HSM-BG6 urder's SLaLus chauyed Rum COMP Lu RESULT .AT ogy .p. Ng ......................................................................... CAT$806Y. ' . 8R9CEDVRS:; :::::; :::.:•:;::•:;•::::'::'::'::'::':;':.:':.:' .:';.::; :; :•::•:;.�'QitC .DA7Ts/TIME. NS:. ' : :' . ' .> :' .SRV :pAATElTII� .PR .4iT`.�'�.�' STATUS•:':.:':.•`:.:':;': ORDER . 4Ua' �. ' :>IIRUH :; TX SPLINT OCE LONG ARM (SPLINTOCLA) 08/24/13 1505 MARX 08/24/13 1`505 S TRW (N) 0824-0249 POM ORDER DR: Marx M.D.,David G (MARX) SITE: CHBG DEVICE! ECL-PHYS4- ERCE: PROVIDER (D) Comments: Esi DATE TIME USER DEVICE EVENT POE PRDVIDER SRC 1 08/24/13 1505 MARX . ECU-PHYS4 order entered in Order Management 2 08/24/13 1505 MARX ECU-PHYS4 order source is PROVIDER - signature is necessary for entry 3 08/24/13 1505 MARX - ECU-PHYS4 order entry signed for MARX 4 08/24/13 1505 OE System HSM-BG6 order transmitted DATE: 09/18/13 @ 0938 Summit Health EOM **LIVE" RaRR: OaAMTRON Patient Audit Trail PAGE 1 ........../. - ... :Vett*Oe• Ropi3Oiikri:oi1tyitA.K..01* We 601104qRPQ1419We 30:•04t'l.l., ......:=;...:::i7i,;#::.,•••o;..4:4: . . . . . . . 'Ii.*.P1 ... •i•:);.4.,a-s4.,;4i Tiii.linii-Ii....r. 4itil:Iiirili..i.iilv-...4i .1::hi4i,:i4's . . Lee.. , ... Occurred Date/TimmfUser Recorded Date/Time/User 08/24/13 1326 HEATHER BONHAM(' enna-->ON/24/13 132S RN Event Arrival Date/Time Edited OR:24113 1326 PPRTITMR RONT1MAR, None -->Level 4 Fast Track (CH Only) RN Priority Edited 08/24/13 1326 HEATHER BONILLAE, None-->CHAMBERSE1RG ER RN Location Changed 06/24/13 1126 HEATHER RONTT.TAS, None -->ARM RN Raaann fnr Viait Editmd 08/24/13 1326 HEATHER BONILLAS, Nnne--?TeaURRD 'LIMA -UPPER PODV - AC RN Chief Complaint Edited 06/24/13 1325 HEATHER RONTI.MAS, AN 06/24/13 132g PRATHER RONTLTAR, None -->SIGN IN RN Status Rriant Rditmd 08/24/13 1327 HEATHER BONILLAS, RN 08124/13 1327 HEATHER BONILLAS, Arrival mmda nal -rigid Accompanied By Parent Presentation Al,rt Preferred Language English Symptoms Status Constant History of Preset Illness L3FT ARM INJURX, NOT USING LEFT ARM WHEN CRAWLING Emotional Issues No safety Issues (aouse/neglect) No Religions TOCIIAC Wel Age Appropriateness Related To Growth a Development Yes Barriers To Iearaing None Learning Prefereaces No Preference RN ED Triage Documented 08/24/13 1327 HEATHER BONILLAS, RN 08/24/13 1327 HEATHER EONILLAS, Have you ever had the infectious bacteria MR9A2 N Comment: NB Have you ever ha3 the infectious bacteria' VRE3 N Comment: NB RN ED MORO Documented 08/24/13 1327 HEATHER BONILLAS, RN 08/24/13 1328 HEATHER BONILLAS, Pest madicel wienory Review and ReviRinn EMR Rrivimamd No Changes Smoking Status REQUIRED Never smoker MESA N comment: NB PRE N Comment: NB RN ED Past Medical History Documented 08/24/13 1327 HEATHER BONILLAS, RN 08;24/13 1328 HEATHER BONILLAS. Weight (Kilograms) 10.9 Melnnleted Weight in rgs 111.41) Weight (gms) 10430.00 Weight Measurement method Actual Height (Inches) 27 Height (Calculated Centimeters) 88_6 EMI 22 RN ED Triage Height and weight Documented DATE: 09/10/13 @ 0938 VaRR: Paamrgow Summit Health BDM "LIVE.* Patient Audit Trail PAGE 2 ......... :VA**0.1 • •. -..•.......:...•..•...•..•..•.....•. . • .. • .. •..•....•. liMMYMFA.4.AV13.9Y.A.R.L.PrY ..:4M4.:Ne:.:.; . . • ,• .. •..•,.• .•..• .406.:...4t*AF4.41Maf*.!6,04 "-JNOO,:: .eloi.i.c-rs....*d• TN,TNAR,f.AIMANOIN111-AARW.... r H4119-4.9API: - .•...-..... •..•.F..• M. 20. 1 ' .. .. .. . • .. . .. •..•.... Mal..e: cW7.818 4... .• .• • . . :.: Occurred Dete/Timefaser 08/24/13 1327 HEATHER BONILLAS, RN Pain RammripTinn (OmeNrranma 31) Pain Location None oftin ennln Used FmAcc Recorded Date/Time/User 08/24/13 1328 HEATHER BONILLAS, RN Event ED Pain Initial Assessment Documented 0R/24/11 1529 NNATHFIR RONTMLAR, RN Medication Reconciliation Type Full Med ReC ED Med Rea Source Other Family 013;24/13 1379 NRATWNR RONTT,LAR, RN CO MRelinAMinn RernnmiliAMion ronNTRnr.Rd 0A/24/11 1329 Rwomns. IRRP3fC Temperature (F) 00_4 mamparaturo troirtulamed calcine) 36.891114 Source Rectal nulen Rate 152 Respiratory Rate 34 PN1R. nv 9R 02 Delivery Method Room Air OA/24/11 1129 amour's. (IASC:mn rn ViTal signc(1mTh-lyr)TnfanR nnetounanRad Nnna-->MMRNMA MTT.T.RR, MAN OBi24/13 1329 HEATHER BONILLAS, RN Nurse Assigned uone-->25 OR124/13 1329 HPRTHRR RONTLTAS. RN Room Changed SIGN IN -->IN ER ROOM 08/24/13 1329 HEATHER BONILLAS, RN status Event Edited None -->Mare M . D . , David 8, AP OR/24/13 1 330 MX.VT11 C MARX, /4 n, SR 12117=1e:ion ancigned IN ER ROOM -->READY FOR DI STUDY 08/24/13 1344 GLENDA MIIMER, LPN Statue Event Edited 00124/13 1358 GIENDA MILLER, IPN Primary Physical Assessment Completed Ey Physician Low Riek Fall Interventions Applied Y Patient Identifization Confirmed (Patient Unable to 08/24/13 Provide) 1358 GLENDA MILLER, LPN Name Stated by Family flare Of Rirth by Falsity ED Basic Care Documentation Documented READY FOR DI STUDY -->MD RE-EVALUATION OB:24/13 1410 SHAVER MORRIS Status Event Edited 08/24/13 1499 GLENDA MILLER, IPN Call Bell Within Reach T Bed Position Semi Fowler's Patient Activity glenping Activity Comment parent holding 08/24/13 1450 GLENDA MIIIER, LON ED safety/Comfort/Nutrition Documented 06/24/13 1504 DAVID G MARX. M D. P.O Additional Instructions Edited There appears to be a non-displaced olecranon fracture_ Splint has beet placed. DATE: 09/18/13 0 0938 Summit Health EMI "LIPS.* nsve, OTAMIRON Patient Audit Trail PAGE 3 ............. .. ... . .. . . ,. ... .... .., . .., . .. . . ., . .. :44:04tA*Nt .. 0.1i*M"iiA.i9i0i0"6.A.K06 .:*.41.04r:: 010.§01: ...........•... 410..iitat.'ed.clerris• • :.:14' :4.1141:vid. . .'..'•• ' -:- Pi'.2'011/ ' ............ , . . .... ,.......,. ... . . .........„ . ., . . . . . . • 04,4 a.v..ro.r:. ...-4. . Awilylia ii.N..1". 1411,-1.11,0011..ww .1; 4,....k. . . . . . . . ....... . . .4646i.e': 447R1d1 • •...... .•.... '•' LeO . ... .• ... • ".".' .,. .•..-. Occurred Date/Time/Raer Recorded Data/Time/User Please keep splint dry. Mmy ramnvo to hatha Avery and Event than replace with ACE bandage. 08/34/13 1504 Orthopedic Appointment navin Pi MANX, 14 n, AP nepartsrn Forms AdiTnd 08/24/13 1504 Mone-->ENGIISH OLV/D s MARX, 74 Dr AP Patient Language Edited 08124/11 1504 ntvrn a MANX. X n, Patient Instructions - Page 1 me Patient nischarge rnstructione Edited 08124/13 1504 Usennsan M.D.. Erin A TOM M.D.,Albart DAVID G MARX, M D, AP , Referrals Edited 0824/13 1504 None7-700/24/13 1504 DAVID G MARX, M D. ml. Departure Packet Printed 08/24/11 1812 amEmnm XTTTAN. TON OR/E4/11 1514 Pain Reassessment (Occurrence al) PsinT.nestion Pinna Pain intensity 0 Pain Reassessment Comment Smiling and playing atsunn MTTTNR, TON En Pain Reasmansmant nocumanted 08/24/13 1513 GLENDA MILLER, LPN 08/24/13 1514 Patient Education Given Yes Patient Verbalises understanding of sdecation civan Y Patient Identification Confirmed (Patient Unable to Provide) Name Date splint (Occurrence al) Splint Location arm Musculoskeletal Location Modifier Left Splint Type Used Plaster Pulses Present X Skin Color Normal Skin Temperature Normal rani 1 1 ;fry 114fi l 1 Temp than I Pe rtned4 Reason For Splint Pain Management Optimal Positioning Post splint Sensation WNI Patient Tolerated Procedure Well Y GLENDA MILLER, LPN Stated by Family of Birth by Family ED Splint/Sling (CCI Long Arm) Documented . 08/24/13 1513 GLENDA MILLER, IPN 08/24/13 1516 GLENDA FULLER, Leff Patient Identification Confirmed (Patient Unable to Provide) Name Stated by Family nava of Birth by Pnnily Outcome Of Patient Stay Discharged Patient Condition on Discharge Good Node of Exit Carried Discharge Status Die charged Discharged To Home Departure Medication List Reviewed and Given TO 'Family Member ED Admit, Discharge, Transfer Documented • • pe1Tp3 X1 HUH4U:JUL'LU UOJK'1du1LNUN OJ.LIJII<--euuN uoTaeeada[i Ai6MT3d 8T9T £T/62180 pal3edaa 1uan3 9T9T £T/1,2/90 3WOH<--000N pay}pH uu}y}duda}U H191 E1/6G/HU P -'LYNLA ##YJ1C#J,<--NULJ,OLL'1KJL:d-#U UW• ;Tp3 ;uan3 sn;a;6 Hd2 '113T2I13 YQN979 9TST ET/62/9O auoNC--S2 PeLIue4L, Luuc/# Nd'1 '11a'L1.114 KUNN'1J H LS L G L/4G /NU - pe4vauin0oa yea48 L YJU Ouu'1 - IUAy •...d T.PPV /m C Tenet eoiAaeg 3O TeAe2 04 eAwa Le,guJ. 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PA 1.720.1-6003 Page 1 of 2 Date: 08/24/13 Account Num: H00049629819 Med Rec Num: H678383 Patient: HOSTETLER,AVERY ELIZABETH Location: CER Physician: Marx M.D.,David G Patient Visit Information Staff Your caregivers today were: Physician Marx M.D.,David G Nurse GM Patient Instructions Reviewed *Patient Instructions - Page 1 received 08/24/13 - 1504 Activity Restrictions or Additional Instructions There appears to be a non-displaced olecranon fracture. Splint has been placed. Please keep splint dry. May remove to bathe Avery and then replace with ACE bandage. Follow-up Please contact the following to make an appointment for follow-up care. Note: HMO patients require a PCP referral prior to making an appointment. Hannagan M.D., Erin A , Keystone Pediatrics 830 Fifth Ave, Ste 103 Chambersburg, PA 17201 Ph: (717)263-0550 Tom M.D.,Albert Summit Orthopaedics 120 North 7th Street Chambersburg, PA 17201 Ph: (717)263-1220 Orthopedic Appointment The orthopedic office will call you the next weekday morning to schedule a follow-up appointment. • • Cantrstg Hospital app aifjtkete- LW Summit FAsittat 312 t* ot•ti: Seventh Street • 99. Box 6005 Chatmbe . irg. PA 1:72(11.-600S Page 2 of 2 Date: 08/24/13 Account Num: H00049629819 Med Rec Num: H678383 Patient: HOSTETLER,AVERY ELIZABETH Location: CER Physician: Marx M.D.,David G *Patient Instructions - Page 1 The following pages include discharge instructions related to your treatment in the Emergency Department. Please Note: If the letters "CER" display beneath your name - in the upper right hand corner of this page, then you were treated in the Chambersburg Emergency Department. If you have any questions about your care, please call (717) 267-7146. If the letters "WER" display beneath your name - in the upper right hand corner of this page, then you were treated in the Waynesboro Emergency Department. If you have any questions about your care, please call (717) 765-3400. Attention: Worker's Compensation Cases If your visit to the Emergency Department is work related, and you are expecting your employer to be responsible for payment, then all follow up must be completed by your employers workman's compensation provider. All references within this departure packet to "Family Physician", "Your Physician", etc. should be ignored, and follow up should occur with the workman's compensation provider. THERE WERE NO CHANGES MADE TO HOME MEDICATIONS UNLESS INDICATED IN THE *MEDICATIONS* and/or *ADDITIONAL INSTRUCTIONS* SECTION(s). Attention Return to the Emergency Department or call your family doctor immediately if you develop new symptoms, if your symptoms have not improved, or if any aspect of your condition should suddenly worsen. • A&Chambersb urg... Hospital an affiliate of Summit /iealth 112 North Seventh Street • P.O. Box 6005 Chambersburg, PA 17201-6(05 • Page 1 of 2 Date: 08/24/13 Account Num: H00049629819 Med Rec Num: 11678383 Patient: HOSTETLER,AVERY ELIZABETH Location: CER Physician: Marx M.D.,David G Patient Visit Information Staff Your caregivers today were: Physician Marx M.D.,David G Nurse GM Patient Instructions Reviewed *Patient Instructions - Page 1 received 08/24/13 - 1504 Activity Restrictions or Additional Instructions There appears to be a non-displaced olecranon fracture. Splint has been placed. Please keep splint dry. May remove to bathe Avery and then replace with ACE bandage. Follow-up Please contact the following to make an appointment for follow-up care. Note: HMO patients require a PCP referral prior to making an appointment. • Hannagan M.D., Erin A Keystone Pediatrics 830 Fifth Ave, Ste 103 Chambersburg, PA 17201 Ph: (717)263-0550 Tom M.D.,Albert Summit Orthopaedics 120 North 7th Street Chambersburg, PA 17201 Ph: (717)263-1220 • edic A • .01 • The orthopedic office will call you the next weekday morning to schedule a follow-up appointment. ostetler, Avery SM05241326 1/4/2013 MONTH Elizabeth :•59 5874.00• EXHIBIT D 09//0/13 03:08 PM Richer Orthopaedic CM Fax* (717).-83 Page 2 of 8 x9473 Date: 08/26/13 RICHARDS ORTHOPAEDIC CNTR & SPORTS MED Name: Avery E Hostetler DOB: 01/04/2013 Sex: F Age: 7 mos. 3 wks Acct#: 42625 Subjective CC: HPI: A 7 -month-old female presents with her parents. Date of Injury August 24, 2013. At that time she was at a Kids Count, a daycare and Shippensburg. According to her parents. They were told by the employees of the daycare that there brings child back in side, and she suddenly reached her arm out and somehow impacted her left elbow. The parents were told that she was okay and a glass did not pick her up until the end of the day. But then she was not using her arm she was taken to the emergency room. X-rays of the left humerus and left elbow done at Summit Hospital ER showed a nandispiaced olecranon fracture. She was placed In a long-arm splint with Ace wraps and presents here for followup. The parents report no other injury to the child and they seemed to be appropriately concerned. Child is otherwise healthy and reaching her milestones including sitting up. Current Meds Prior to Visit: No Active Medications Allergies: NKDA PMH: Problem List 719.42 - Paln Joint Upper Arm Medical Problems: None Surgical Hx: No Past History of Procedure Reviewed and updated. FH: , Noncontributory, Unknown. Reviewed and updated. SH: Personal Habits: Smoking: Patient has never smoked.. (Exercise Type/Frequency) Reviewed and updated. Objective Exam: She appears In no acute distress and babbling comfortably. Left elbow: Shows mild ecchymosis. I'm able to passively range her elbow from 10-115" with only minimal apparent discomfort. No deformity shoulder, wrists otherwise nontender Dx Studies: [ 1 09/16713 03:08 PM Richa Orthopaedic EM Fax* (717)4-83 Page 3 of t3 #9473 [I Assessment: 1. 719.42 Pain Joint Upper Arm 2. 813.01 FX Ulna Olecranon Process Closed Care Plan: Correspond's : Clinical Visit Summary Assessment Nondlsplaced left olecranon fracture and a 7 -month-old Plan: This Is highly suspicious for abuse but could also be accidental but somewhat Tess plausible. We called social services, and they stated that In less we thought this was an intentional act that would not be Investigated. We discussed that we would contact social services with the parents. Social services stated that there would be no Investigation and, thus, we thought this was repetitive or intentional which we cannot verify.. A long-arm splint was reapplied with loose tatting Ace wraps. Followup In one week for repeat x-rays of the left elbow. Earlier if any problems. We discussed with the parents that the splint is simply for symptomatic relief and could be removed that the child is having a problem with it thanks sincerely On August 28, 2013 9am, after speaking with Cumberland County Social service yesterday and Franklin County Social service yesterday, I was instructed to call CHILDLINE of the department of public welfare. They are basd in Harrisburg at phone number 1-800-932-0313. I spoke to Jennifer Miller at that office. And gave her the details. The child could not develop the necessary force to cause a fracture like thls on her own. It is plausible that it could have been an accident or abuse or simply not being careful enough at the daycare. I discussed also that the parents seemed completely appropriate and concerned. Child line stated that they would then callCumberland County Social services. The note was completed utilizing Dragon speech recognition soivrate. Grammatical errors, random word insertions, pronoun errors, and Incomplete sentences we occasional consequences of chis system due to software limitation. My questions or concerns about the contend, text or information contained within the body of Ns dictation should be directly addressed to the physician for tdariflootton. if you have any questions or concerns, please do not hesitate to call us et 717-414-7798. Robert Lyons, M.D. Seen by. 08(28/2013 09/16/13 03:08 PM Richer Orthopaedic CN Fax* (717)- 4=83 Paye 4 of 8 19473 ®z Date: 08/26/13 l ItSTORY SUMMARY - RICHARDS ORTHOPAEDIC CNTR a SPORTS MED Name: Avery E Hostetler Acct#: 42625 Sex: F DOB: 01/04/2013 Age: 7 mordhs PMH: Problem List 719.42 - Pain Joint Upper Arm Medical Problems: None Surgical MC No Past History of Procedure FH: , Noncontributory, Unknown. SH: Personal Habits: Smoking: Patient has never smoked.. (Exercise Type/Frequency) ROS: Const Dentes constitutional symptoms. Eyes: Denies eye symptoms. ENMT: Denies ear symptoms. Denies nasal symptoms. Denies mouth or throat syrnptoms. CV: Denies cardiovascular symptoms. Reap: Denies respiratory symptoms. GI: Denies gastrointestinal symptoms. Musculo: Dentes musculoskeletal symptoms. Skin: Denies skin, hair and nail syrnptoms. Neuro: Denies neurologic symptoms. Psych: Dentes psychiatric symptoms. Endocrine: Denies endocrine symptoms. Hems/Lymph: Denies hematologic symptoms. • • RICHARDS ORTHOPAEDIC CNTR & SPORTS MED 144 8TH STREET CHAMBERSBURG, PA 17201-2752 (717)-414-7798 Summary of Todays Visit Avery E Hostetler 08/26/13 Visit with LYONS, ROBERT P , MD Problem List Pain Joint Upper Arm (719.42) Allergies No Known Drug Allergy Medications New LYONS, ROBERT P , MD No Active Medications Future Appointments 09/03/13 Tue 9:OOa Loc: 1 LYONS, ROBERT P , MD Loc: 1 Main Office RICHARDS ORTHOPAEDIC CENTER & SPORTS MED 144 8TH STREET CHAMBERSBURG, PA 17201-2752 Phone: (717)-414-7798 Fax: (717)-504-8342 09/16/13 03:08 PM Ricfa Urthopaedic CM Fax* (717) ►�-83 Pogo 5 of 8 *94/3 rJ: COUNTY CHILDREN AND YOUTH SERVICES August 29, 2013 alarm - lreserrbeg Penalin - Preffetkie We&keg Them Services Bmldir ,16 West TEgb Street, Suite 200, Carlisle, PA 17013-2961 Telephones: 1488-697-0371, Extension 6120 Fu: (717) 240-6433 t3�9L LCCYfglccpa res •k 3.3,13 Richard's Orthopecfics 144 S 8' Street Chambersburg PA 17201 RB: - Avery Hostefiv, DOB: 1/4t2013 To Whom It May 1 am writing to inform you that I am the Hostetler family caseworker. 1 would appreciate receiving a copy or summary of your contacts from providing medical care to child(ren). It would also be beneficial if you would send a copy or summary of the immunization records. If child(ren) is receiving treatment at this time for a specific illness or condition, please nota this and explain the rec m mended brcatmenl. It is felt that these reports would assist the Agency in developing are appropriate casework service plan for the family and we would be better able to coordinate our efforts to insure that the medical needs of the child(ren) are being addressed. Enclosed is a release of information form signed by the parent If you have any questions or additional concerns, please contact me. Thank you for your assistance with this request. Sincerely (NALA0bivArcitt' Corinne Bennett Intake Caseworker (717) 240-6582 Ili09/15/13 03:09 PM Richar Orthopaedic CN Fax, (717)_101q-93 Page 6 of 8 1911/3 0: Cumberland Comity Cldldrest & You Services Human Services NM* 16 West Hieb St., Suite 2$ Carlisle, 11A. 11•13-1961 (717)2404120 VAX:717)Z4S-6433 Client/Cluld: Consent to Release %Atoll Information Awy Harte -frier I hereby authorize Cumbetiand County Children & Youth Services to receive to/from: Name: Practice/Hospital: Aehaid5 OrHiqedieg.5 the following information for the purpose of eafe.' "ti.12/7/ Information to be received may include: yMedical History and also any Medical Records Regarding: rt Mental Health Records, Psychistric/Peychological Evaluations Dug and/or Alcohol Treatment Records; Results of H.I.V. testing andior Treatment of Related Diagnosis I• on Records, Lab Tests and Results Obsavations, Diagnosis, Medications Recommendations, Compliance to Rmmidaiion Verbal and Written Consultation I have read this &MI carefully and understand the above statanents. I understand that I may revoke this consent at anytime with a request in writing to Cumberland County Children & Youth Services. This release will automatically expire one year beyond the date signed. ******e.•••••••*****•*************,•••*••*••••.******•••*************•«Silili***** Date Signature of Parent/Client Date To Receiving Agenoy/Instianticec This infatuation hes been disclosed fionirecords whose confidentiality is protected by Stale Law and Departmental Reguletions. It is unlawful to make diackeys of any mall &this infeconticea vatted prior mime content of the perm to whom it pcitsfaa and the agencyfiratituble who developed the notarial, CCIC&YS 6/00 09/16/13 03:08 PM Richa Orthopaedic CN Fax* (717)4-83 Page 7 of 8 *9473 F7= Date: 09/03/13 RICHARDS ORTHOPAEDIC CNTR & SPORTS MED Name: Avery E Hostetler DOB: 01/04/2013 Sex: F Age: 7 mos, 4 wks Acct#: 42625 Subjective CC: HPI: She presents with her parents. Her mom quit her job and she is no longer at the daycare. Parents state she appears more comfortable but she still not bearing weight on her left arm. She's been wearing the Tong arm splint is much Is possible Current Meds Prior to Visit: No Active Medications Allergies: NKDA PMH: Problem List: 719.42 - Pain Joint Upper Arm Medical Problems: None Surgical Hx: No Past History of Procedure Reviewed, no changes. FH: , Noncontributory, Unknown. Reviewed, no changes. SH: Personal Habits: Smoking: Patient has never smoked.. (Exercise Type/Frequency) Reviewed, no changes. Objective Ht: 27" 2'3" Wt: 21 Ib BMI: 20.3 Ht%: 52nd Wt%: 92nd Exam: In general, she Is In no acute distress. She appears happy and comfortable. Left elbow: Trace ecchymosis but Is resolving. I can take her elbow through a passive range of motion of 10-120, and full pro -no supination without her showing any discomfort. No deformity Ox Studies: 2 views obtained here reviewed by me. Left elbow x-rays: Fracture line is not visible A new Tong -arm posterior splint was applied left arm using a 3 inch OCL and to 2 inch Ace wraps. She tolerated this well Assessment: 1. 813.01 FX Ulna Olecranon Process Closed Care Plan: 09/16/13 03:08 PM Rich* Orthopaedic CN Fax* (717)4-83 Page 8 of 9 19473 E_ Med Current : No Active Medications Correspond's : Clinical Visit Summary, Release Of Med Records Assessment Doing well. Plan: Wear the splint for another week near continuously and then wean the splint off over the next week. Followup In 4 weeks for final x-rays of bilateral elbows for completeness, earlier if any problems. Parents are happy with this plan. Thank you sincerely This note was competed utilizing Dragon speech recognition software. Grammatical errors, random word inserions, pronoun errors, and incomplete sentences are occasional consequences of this system due to software limitation. Any questions or concerns about the content, text or information contained within the body of this dictation should be directly addressed to the physician for clarification. If you have any questions or ooncems, please do not hesitate to call us at 717-414-7798. Robert Lyons, M.D. Seen by. 09/03/2013 10/11/13 09:00 AR Rich Orthopaedic CH Fax* (717)0R-0 Page if ot IF 110180 El CUMBERLAND COUNTY CHILDREN AND YOUTH SERVICES ?meeting Children — freserrins Families — Proneedne Weil -being Human Services Building, 16 West High Street, Smite 200. Carlisle, PA 17013-2961 'Mechem 14111-697-0371, beleadoe 6120 Fax: (717)240-6433 Enna: CCCY@acpattet kok 000kkv10 I IN N111. September 30, 2013 Dr. Robert Lyons Richards Orthopaedic Center 144 South Sth Street Chainbersburg, PA 17201 RE: Avery Hostetler Dear Dr. Lyons: Cumberland County Children and Youth Services has completed the investigation regarding physical abuse that you reported to the Agency on August 28, 2013 and has concluded the case to be unfounded. Cumberland County Children and Youth Services will not provide ongoing services to the family. If you have any questions, please feel free to call. Sincerely, IbtUAKISL lArtit4 Corinne Bennett CPS Caseworicer CB/bdr 10/11/13 09:00 AM Rich. Orthopaedic CH Fax', (717)14-8 Page 2 of 4 110185 DI' Date: 09/30/13 RICHARDS ORTHOPAEDIC CNTR & SPORTS MED Name: Avery E Hostetler DOB: 01/04/2013 Sex: F Age: 8 mos, 3 wks Acct#: 42625 Subjective CC: HPI: Baby Sustained a nondisplaced left olecranon fracture and an injury at daycare August 24, 2013. She presents with her parents. They think she Is using her elbow appropriately now out of the cast Current Meds Prior to Visit: No Active Medications Allergies: NKDA PMH: Problem List: 719.42 - Pain Joint Upper Arm Medical Problems: None Surgical Hx: No Past History of Procedure Reviewed, no changes. FH: , Noncontributory, Unknown. Reviewed, no changes. SH: Personal Habits: Smoking: Patient has never smoked.. (Exercise Type/Frequency) Reviewed, no changes. Objective Ht: 27" 2'3" Wt: 221b Wt Prior: 21Ib as of 09/03/13 Wt Dif: +1Ib BM1: 21.2 Ht%: 35th Wt%: 93rd Exam: Left elbow: No ecchymosis. No deformity she is using it well she's leaning on it to crawl no limitation of motion. She's reaching with it Normal exam Dx Studies: X-rays left elbow. 2 views obtained here reviewed by me: Within normal limits. There Is a small ossicle at the level of the fracture medially which I expect to remodel with time tl Assessment: 1. 813.01 FX Ulna Olecranon Process Closed Care Plan: Med Current No Active Medications Correspond's : Clinical Visit Summary 10/11/13 09:00 AR RiCha orthopaedic CH Fax* (/1/) 4-8 Page 3 of 4 8101Ub ®- Assessment: Doing well. Plan: Activity as tolerated followup In 6 weeks for final x-rays of left elbow. Thank you sincerely This note was completed utilizing Dragon speech recogrilon software. Grammatical errors, random word insertions, pronoun errors, and incomplete sentences are occasional consequences of this system due to software limitation. My questions or concerns about the content, text or information contained within the body of this dictation should be directly addressed to the physician for clarification. If you have any questions or concerns, please do not hesitate to call us at 717-414-7798. Robert Lyons, M.D. Seen by: 09(30/2013 EXHIBIT E Date: 02/07/14 Narne: Avery E Hostetler • • Summit Orthopedics DOB: 01/04/2013 Sex: F Age: 13 mos, 3 days Acct#: 157236 OFFICE NOTE/HOSPITAL HISTORY AND PHYSICAL Current Meds: No Active Medications Allergies: NKDA PMH: Surgical Hx: No Past History of Procedure FH: Father: thyroid issues. Mother: stomach issues/kidney stones. SH: Personal Habits: . (Smoking)Seat Belt Car: Always uses seat belt - (5/23/2013). Wt Prior: 221b 12oz as of 08/23/13 Wt kg Prior: 10.319 as of 08/23/13 Transcription: Avery Hostetler CHIEF COMPLAINT: Status post fracture of left proximal ulna. HISTORY OF PRESENT ILLNESS: This is a 13 month, 3 day-old female who presents with her mother for evaluation of her left elbow. On 08/24/2013 she sustained an injury to the left elbow with a nondisplaced proximal ulnar fracture. She was in a stroller going by cots and a bed when her arm was caught. She had pain. Presented emergently to Chambersburg Hospital. X-rays were obtained. She was followed by Dr. Lyons through the Richards Orthopedic Center. Subsequent to that, because of the concern of any long • term sequelae, she presents for alternate orthopedic opinion and assessment. There is also an evaluation by Cumberland County Children in Youth Services which revealed that there is no evidence of child abuse. She did have a prior fracture of her clavicle at birth, but otherwise is healthy and is the 4th child of the mother. She states that the elbow was in a splint for approximately 2-3 weeks and subsequently child is using arm freely. PHYSICAL EXAMINATION: • Reveals that she has essentially symmetrical range of motion of the left elbow without tenderness. There is no evidence of limitation with flexion, extension; supination, pronation, arch range of motion. No significant bony tendemess. X-rays from Chambersburg Hospital 08/24/2013 were reviewed which reveals a nondisplaced fracture of the left proximal ulna. IMPRESSION: Healed nondisplaced fracture of the left proximal ulnar. RECOMMENDATION: Reviewed pathology with the mother. Advised that there should be no permanent Avery E Hostetler DOB 01/04/2013 Page #2 long term sequelae of this injury as she gets older. The injury did not involve he growth plate and was nondisplaced, so did not affect the articular cartilage contour. Reassurance was given All questions were answered. Assessment #1: 719.43 Pain Joint Forearm Care Plan: Follow Up : As needed, itcP9Li kis711€444,), Electronicaly signed by: Roger J Robertson,MD Seen by: Date Dictated: 02/07/2014 Date Transcribed: 02/15/2014 cc: Bradley Bollinger 330 Lincoln Way East P.O. Box 866 Chambersburg, PA 17201 02/23/2014 9:01 am Avery E Hostetler Acctit 157236 DD 02/07/2014 SUMMIT PHYSICIAN SERVICES Page #2 EXHIBIT F • Victoria P. Edwards, Esquire Dtl.oreto, Cosentino & Bolinger 330 Lincoln Way East P.O. Box 866 Chambersburg, PA 17201 SOCRATES, INC. 111 Ryan Court, Suite 300 Pittsburgh, Pennsylvania 15205-1310 www.socratesinc.com E-mail: subrogation@socratesinc.com Telephone: (800) 680-4806 (412) 278-5811 Facsimile: (412) 278-5861 April 11, 2014 Re: Capital advantage Insurance Company *Patient: Hostetler, Avery Contract No.: 801082422 Date of injury: August 23, 2013. Dear Atty. Edwards: As you are aware, this: firm has been retained to provide outsourcing subrogation services to Capital Advantage Insurance Company*, a subsidiary of Capital BlueCross (collectively "Capital") with regard to the above -referenced subrogation case. Enclosed please find a copy of an additional clairn(s) paid by Capital; therefore, the preliminary subrogation claim amount is $1,279.27, paid as of April 11, 2014. We reserve the right to provide you with and shall expect you to request an updated Capital Record of Claim Payments prior to the .final settlement and/or resolution of this subrogation case with this fine, As you are aware, the Self -Funded Plan's contractual subrogation interests administered by Capital Advantage Insurance Company are separate and distinct from that of Medicare and/or any other Blue Cross Plan(s). When appropriate, please ensure that the draft is made payable to **SOCRATES, INC., ESCROW ACCOUNT. If you should have any questions regarding this matter, please feel free to call me. Very truly yours, SOCRATES, INC. Kelly Ralston Claims Recovery Specialist. Enclosure " Health care benefit programs issued or administered by Capital BtueCross and/or its subsidiaries. Capital Advantage Insurance Companf, Capital Advantage Assurance Company° and Keystone Health Plan® Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of program and provider relations for all companies. SOCRATES. INC., provides outsourcing subrogation smices. ra,be2014i114 CS Explanation of Benefits Patient: Avcry E H001d r ID#: t0tot2422 Group*: 00519393 Provider: MO11P" tets' IJr1 x Care - %a4: College Gizmo, 1323805(/5 300 Received: 08126/2013 Completed: 00131120 U Check#: 401i312259 Paid To: RIFIDF.XPRESS URGET CARE • STATE RESPONSIBILITY COPAYMENT 14000 123.00 1500 20.00 0 ptcyte1.E IXIINSURAME 0.00 14t00 L2$40 lSO* 20,1 0.0* 0.00 000 0.00 Page I MESSAGE COOP 105.00 K05 Oe0 1E48 Os - CO Explanation of Message Codes K0S This Paticipati08 Provider has avecdnot to bill you (=the diffareooe bemoan the Total Cbarga eod the Alba/able Ammar. Policy or Internal Rules: 11 a message above truncates payment was denied based on Internal policy, guidelines or rules, copies of those are available, free of charge. upon request to Customer Service. A copy of the specific rule, guiderne, or protocol relied upon in the adverse benefit determ:natlan will be provided tree o' charge upon If 61141n✓:otr request by you or your authorized representative N 7 500944* Explanat on of Benefits rnotittp `i 08/24(24)13 DIAoicia; Ile MAMMA AJT• 0812412013 04,C) Patient: E Hosicila• tot 801082427 Group. 00519393 PrOvider Ch"therthu'll HosPital 41: 00/242013 it13,417TE0(X); • • 00120101.3.4' • P.M0.130. 'SYPS9T..15,..;•Z- •-ir clakno: tzanentoe • Received: °813°12°13 COMOietert 09/97/21313 Check#: 400584550 paid To: CHAMBERSIUMLICKPITAL 0 1, , ;,,,,,,7rif.'"tz„''''f';,-„Ttii,ftiFt, tit 0.00 000 0,00 0,90 0,00 ';000„,!! .;(.40; iY;;,• 7600 10000 0,00 0,00 000 Page 1 t.r 0.00 000 0.00 000 1 • 10240. •80.5 L4.3.04 TOTALS -1.,:;1'7 i;:?. '• -• • •••• , • .03.' •••,' '.; :;": ';-"' ;•-• alt - • ;•.., • • ; ; "„ •••-; "•• i; :";!" ;;*. ; • •.• r • ; ;•,,,•'1‘; - , .• „, g21;co--. ••, ;• "mr•sea rm./26121 : if a message above Indicates, payment was denied based on Irdernal policy; guidelifleS or rules. copies of those are avallabfe, free of charge, upon request to Customer Service. A copy of the specific rule: guidellne,-or protocol felled upon in the adverse benefit determination will be provided free of charge upon request by you or your authorized representative. N 7 . 390151 • Explanation of Benefits 2 FROM TO. 0144.0013 Mi24+20 11 01,024/V313 narurttiti TALS mai DEICRIPTICOMFURVICE MACHOS -11C RAII(01.4"XiT, OP (R INV P.ROV) DVA;NOSTiC ft.A.DIOLOUY. OP (RIM/ PROV) Patient Arcs 1 Restrain 140104:2422 Group* e°519)93 Provider: shircri-Mi°1"1 L. CKAIOGE 11 00 9,46 31.00 9.17 61.01 17.61 2334 claim#: 1174710319M Received: 0941'2013 completeci: 09i07/20 13 Check: 1°2"7768 Paid To: CHANALIIERSRURC MAO NG ASSN 'TATE Pogo 1 atm; AMOUNT MESSAGE COMMENT E =NM ithaliiRANCE .PA COOES • 0.00 0.110 000 0.00 0.00 11.46 1C95 0.00 9.00 . 9.17 , KOS 0.00 0.00 Lei) 0.00 0.09 11,03 0.00 0.00 (a.3 Explanation of Message Codes Nos This Participating Provider his aimed not to bill you for the eilfama heritecothc Tocsi (laitc and die ALluv.A18: Amount. Polley or Internal Rules: If a message above Inatcates payment was denied based on internal pol,cy. guidelines or rules, copies of those are available. Tree of charge, upon request lo Customer Service. A copy of the specific rule, guideline, or protocol relied upon in the adverse benefit determination wfl be provided free of charge upon (1t,040 request by you or your authorized representative, N 7 02420100 Explanation of Benefits Patient: 4":2). •c.. Fj of: 801082422 Groop#: 0019393 Provider: LY°"' FIcte'l • ciairnft: 1324j 1497160 Received: c4112P12013 •complete:I: 0811/20 check #: °261'4194 paid To: IOC/LARDS OR? OPA Page f Explan ion of Message if a message above Inc:163Na payment was an fa d based on innficy guidefines or Nies, copies of those are eValiable free of charge, upon request to Customer Service. copy of the specic rfile, guideline ters; po or protocol re,' pod in the adverse benefit cfeterrnination will be provided free of charge upon request by you or yOui- eufharked eseifntative. E' 7 S0110906 Explanation of Benefits panern: Averj, flO$ rod k0108422 gyp: 00'51919, provider: Ly,;,,T. Rabat O. CraJm# 132491411300 Receive: a"6/1313 COtr►pfeted; 1614"12°14 Ch$Ck/t 1026673(,2 RIcfuRbSOR r. YorInter !RU If message "zr to Cuatoo request by you e ndlcafes�; A oopY 0I the w85 ciente Aur a(u1ro sent AWB, d based on infernal rop entative, 9uldeline; ar p policy, gUldelf tocol relied uppn r��e those are available, free of nation will be , upon provided charge, . free of es! 50110906 Aon Explanation of Benefits Patient: A vaY E. Hustt der to#: S01032422 Group#: 47519393 provider, Lyan4, Robert P, Ctaim4: /32781338400 neceNed: 10rost2013 Completed: 10/092013 Check#: 10e6898" Pad TO: RICHARDS ORTHOPAEDIC CENTER AN Page I LINE SERV" DAM a °a DESCRA711011Or SERVER I RIONI TO MMES. 0900/2013 I nooivos'ne RADIOLOGY, OP 09/3012013 2 01/30/2013i DIAGNOSTIC RADIOLOGY, OP 09/3012013 CLAM TOTALS TOTAL ALLOWABLE p.�o IABABER RESPONSIBAJTY ' OTHER CHARGE ' AMOUNT RESPONSIBILITY CORA DEDUCLIBLE COINSURANCE OTHER NSURANCE „ •• . 79.00 1004 48.96 009 0.00 0.00 0.00 0.00 30.04 79.00 30.04 7' 4$96 - 0.00 0.00 0 00 ' 0.00 0.00 30.04 K03 158.00 IWO 9191 0.00000 1.00 0.00 0.00 Explanation of Message Codes Kas The Participating Provide/ bas weed not to bill you for the difference between ago Total Charge and the Allowable Amnum t.. Policy or Internal Rules: It a iiessage ribove Indicates payment was denied based on internal pollz;y, Qtrcrelines or rules. copies of those are aveable, tree ol charge, upon request to Customer Service. A copy of the specific rule. gudeline, cr protocol relied upon in the adverse benefit deter*nalion AilI be proviced free al charge upon request by you or your authcnzed represerrtatIve, N 7 50110906 Explanation of Benefits TOTALS Patient! A vtlY E Husunier 10#: 301002422 Groupq: 00519393 PrOY4er: 14(111‘. Ruben P. Ciairml: 13119)395900 Received: 11/15/2013 Completeo: 1116/21113 Check4: 102701207 paid To: ItICITARI3S ORTHOPAEDIC C139TER AN AllOVIAILE PROVIDER - CHARGE , *TOW AE$POM3LIJTY coArl.seir ceauctieLe caueucwace 79.00 30.04 4&96 0.00 0.00 0.00 0.00 PT.00 1 • Page 1 AMOWIT TACITSATIE • FAR . :CODES 30.04 1(03 sp.1:611 Explanation of Message Codes Kos This Panieiperibg Provide has agreed Dot to bill you Tee the daretenit bet*eea theloal Charge and the Allowable Amount :7: Policy or Internal Rules: If a message above :ndicates payment Was dented based on Internal poky. guidelines or rules. copies uf hose are available, free of charge. upon request to Customer Service. A copy of the specific rule, guideline, or protocol relied upon in the adverse benefit deterTninattell be provided free of charge upon hi request by you or your authorzeo representative. N 7 30110906 Explanation of Benefits Patient. AvLiy floaterIcr 1J CS DATE " DEsawrnotooF6ERMS gRom, TO SERVICES 0.1.417(2014 OFFICk vim( ramo 14 • CLAIM TOTALS 11)#: GroupP: Provider: 8010E124u 01419393 Robertson, Rug= 1. ciaiinfi,, 140571711500 Received: 02/26.'2014 c cirpciterj: 0310112014 TOTAL CHAIM nom 124.110 paid rc.: St1MMIT (MT PAEDICS Pc 1 •ALLOVIABLB PROVIDER MEMBER RESPONSIBILITY .0T/11/4 AMOUNT MPW.OF AMOUNT RBSPONSIBIUTY COPAYMENT DEDUCTIBLE COINSURANCE OTHER INSURANCE ' PAID CODES 05.20 .15,4n 20.0C 000 Oji 0,00 040 69,20 1Le5 *20 35.81 10.00 SOO 0.00 0.00 DM 0410 Explanation of Message Codes Kos rranicipa Wig Provider bar agreed not to bill you fur the difference Wen= rhe Tout charge and the AUtrurable Amount. • • to 73:A0 Policy or Iritornul Roo: 11 •4 abtx,e1nOic.rite.4 pUrrrionl aeitiOd bIl.S•41 on ntiunnl 1hoa a ilt, IrE; Or.a•go. rk.zruceti.1 10 Clp.:1,11-rer !:7ervicc. A 0Ory of 11).!. tip:N:111c rL.guido1fre. or puol(;col the. .c•10.eirningozril picy1nio:1 tree ctaIrge tgre;r: 0217.130n • ;: rogue.: !iCti ot vow' ••;:i .r!hOr ot: NV1i.isentative • N 7 EXHIBIT G LAW OFFICES Dtomo, Comore & Boman PC MO LINCOLN WAY EAST P.O. SOX 068 CHAMBERSOUREL PA 17201 CONTINGENT FEE AGREEMENT Made and entered into this 3rd day of October , 2013, Between Christie Hostetler on behalf of Avery Hostetler, of Shippensburg, Pennsylvania, hereinafter called "Client" AND DiLoreto, Cosentino & Bolinger, PC, a professional corporation of the Borough of Chambersburg, Franklin County, Pennsylvania, hereinafter called "Attorneys", WITNESSETH: WHEREAS, Avery Hostetler was injured on or about August 23, 2013, when she was injured by the negligence of an employee of Kids Kount in Cumberland County, Pennsylvania; and WHEREAS, Avery Hostetler sustained personal injury; and WHEREAS, Client desires to prosecute a claim against the said Kids Kount for the damages above indicated; and WHEREAS, Client has engaged the services of Attorneys, and desires to provide for compensation to said Attorneys for their services in this connection. NOW, THEREFORE, KNOW YE that the parties hereto, intending to be legally bound hereby, agree as follows: 1. Client has engaged. Attorneys to advise, assist and represent her in prosecuting the claim above set forth and to take all such steps as in Attorneys' judgment are .necessary and desirable to that end. 2. Client will cooperate in all respects in furnishing and seeking such evidence and information as can by reasonably diligent search be obtained for preparation and presentation of the cause, and in arranging for compromise or for trial, and will in all respects in the premises heed and follow the advice of Attorneys. 3. Attorneys shall be paid 1/3 of the gross recovery realized by them if suit be brought, and 1/4 of the gross recovery realized by them if no suit be brought, whether the same be realized by way of compromise or settlement or by way of verdict and judgment or otherwise payable, unless Attorneys are required to • • prosecute such aspect of the claim, in which case Attorneys shall charge on a time and expense basis in connection with the claim for first party benefits. In the event that the claim is resolved by a structured settlement, Attorneys' fees shall be paid in full from the initial lump sum payment. 4. In the event Attorneys are successful in obtaining a recovery, Kids Kount shall reimburse Attorneys for all costs incident to bringing or carrying on suit, incident to service of process, and costs and charges of taking depositions and discovery, and charges for expert witnesses. Attorneys shall advance such costs. Client shall have no obligation to reimburse Attorneys for those expenses if Attorneys are not successful in obtaining a recovery. 5. Attorneys shall do all the necessary and required paperwork, presentation of motions, petitions, and rules for the prosecution of the claim, and they shall, if they consider it desirable, institute suit in such court as they in their judgment consider appropriate for prosecution of the claim, and they shall take such steps as in their judgment are necessary and desirable to discover and learn the identity and whereabouts of witnesses, and they shall take such steps as they consider necessary and desirable to bring the case to trial at a reasonably early date and they shall as well, conduct, should the opportunity present itself, negotiations for settlement of the cause. IN WITNESS WHEREOF, the parties have hereunto set their hands and seals the day and year first above written. Christie M. Hostetler on Behalf of Avery E. Hostetler DILORETO, COSENTINO & BOLINGER PC By Victoria P. Edwards LAW OFRcES DtLOFFTO. CosENTnO & Bance PC 330 LINCOLN WAY EAST P.O. BOX BBB CNAMBERBBURO,PA 17201 (SEAL) (SEAL) I EXHIBIT H • From: Victoria Edwards <vedwards@dcblaw.com> Subject: Fwd: Avery Hostetler, Claim #C030535 Date: April 23, 2014 9:41:05 AM EDT To: Alison Hile <Ahile@dcblaw.com> Victoria P. Edwards, Esquire DiLoreto, Cosentino & Bolinger, P.C. 330 Lincoln Way East P.O. Box 866 Chambersburg, PA 17201 Phone (717) 264-2096 Fax (717) 264-2508 vedwards@dcblaw.com Begin forwarded message: From: "Doyle, Stephanie" <sdovle@MarkelCoro.com> Subject: Avery Hostetler, Claim #C030535 Date: April 17, 2014 3:05:23 PM EDT To: "Victoria Edwards (vedwards@dcblaw.com)" <vedwards@dcblaw.com> Ms. Edwards, Please let this confirm that we have agreed to settle your client's claim for a lump sum of $10,000 plus we will pay the outstanding lien of $1279.27 and the $20 co -pay from the 2/7/14 appointment under the med pay coverage. I have asked Tim McMahon with Marshall, Dennehey to assist us with the court approval if he is conflict free. Once I hear back from him indicating there are no conflicts I will have him contact you directly. Thanks and feel free to contact me with any questions. Stephanie Doyle, CCLA Sr. Claims Examiner Markel -Claims Glen Allen, Virginia Toll Free: (800) 362-7535 x118812 Direct: (804) 217-8812 www.markelcom.com Please report all new losses to newclaimsesnarkelcorp.com and send all other claims correspondence to markelclaimsCcr�.markelcorp.com. • o EXHIBIT I GENERAL RELEASE AND SETTLEMENT AGREEMENT FOR AND IN CONSIDERATION OF the payment to Brian Hostetler and Christie M. Hostetler, individually and as the parents and guardians of Avery E. Hostetler, a minor, on behalf of minor Avery E. Hostetler, the sum of Ten Thousand Dollars ($10,000.00), and other good and valuable consideration, Brian Hostetler and Christie M. Hostetler, individually and as the parents and guardians of Avery E. Hostetler , a minor, being of lawful age, have released and discharged, and by these presents do for themselves, their heirs, executors, administrators, and assigns, release, acquit and forever discharge Kids Kount Day Care Center, Michelle Fisher, Emily Goshorn, Deborah Mackinick, Michelle Hoover, Markel Corporation, Essex Insurance Company ("Releasees") and any and all other persons, firms, insurers, and corporations, whether herein named or referred to or not, of and from any and all past, present and future actions, causes of action, claims, demands, damages, costs, loss of services, expenses, compensation, third party actions, suits at law or in equity, including claims or suits for contribution and/or indemnity, of whatever nature, and all consequential damage on account of, or in any way growing out of any and all known and unknown personal injuries, death and/or property damage resulting or to result from an incident that occurred on or about August 23, 2013, at or near 211 East Garfield Street, Shippensburg, Cumberland County, Pennsylvania. We hereby declare and represent that the injuries sustained by the minor may be permanent and progressive and that recovery therefrom is uncertain and indefinite, and in making this release and agreement it is understood and agreed that we rely wholly upon our own judgment, belief and knowledge of the nature, extent and duration of said injuries, and that we have not been influenced to any extent whatever in making this release by any representations or statements regarding said injuries, or regarding any other matters, made by the persons, firms or corporations who are hereby released, or by any person or persons representing him or them, or by any physician or surgeon by him or them employed. Page 1 of 3 • In entering into this General Release and Settlement Agreement, we represent that we have had to the opportunity to consult an attorney for legal advice, specifically, Victoria P. Edwards, Esquire, of the Law Offices of DiLoreto, Cosentino, & Bolinger, P.C., and that we have read this General Release and Settlement Agreement. We understand that the terms and implications of entering into this General Release and Settlement Agreement and they are voluntarily accepted by us. It is understood and agreed that we will indemnify and hold harmless the Releasees and will satisfy any claim regarding any and all liability arising from any outstanding health insurance lien, Medicare lien, or Medicaid lien with regard to any medical, disability, or compensation payments paid or payable in connection with the incident. Payment hereunder shall not constitute an admission of liability by the parties released, who expressly deny any liability to the undersigned. This General Release and Settlement Agreement contains the ENTIRE AGREEMENT between the parties hereto, and the terms of this release are contractual and not a mere recital. This General Release and Settlement Agreement is to be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. We state that We have carefully read the foregoing two (2) page General Release and know the contents thereof, and sign the same as my own free act. My signature appear on page two (2) of the General Release. CAUTION: READ BEFORE SIGNING Page 2 of 3 WITNESS my hand and seal this 9.141 day of IN THE PRESENCE OF Name (kk - Address 3301.31\0AI\ �9 aant rsbwrg. P� \13c 05/1213925.v1 y , 2014. (SEAL) Brian ostetler, individually, and as parent and guardian of Avery E. Hostetler, a minor, on behalf of Avery E. Hostetler, a minor (SEAL) istie Hostetler, individually, and as parent and guardian of Avery E. Hostetler, a minor, on behalf of Avery E. Hostetler, a minor Page 3 of 3 LAW OFFICES DIL.ORETO, COSENTI NO & BOLINGER PC 330 LINCOLN WAY EAST P.O. BOX 866 CHAMBERSBURG, PA 17201 IN THE COURT OF COMMON PLEAS OF THE 9TH JUDICIAL DISTRICT PENNSYLVANIA - CUMBERLAND COUNTY IN RE: Avery Hostetler, A Minor, by Christie and Brian Hostetler, : NO. ll./.,,aq33 Parents and Natural Guardians ORDER APPROVING SETTLEMENT OF MINOR'S CLAIM, APPROVING AGREEMENT FOR PAYMENT OF ATTORNEY FEES AND DIRECTING DISTRIBUTION OF SETTLEMENT PROCEEDS On P/120, 2014, a Petition to settle the claim of Avery Hostetler, a minor, to approve the agreement for the payment of attorney fees, and to direct distribution of settlement proceeds, having been presented to the Court, IT IS ORDERED AND DECREED that the proposal to settle the minor's liability claim as to Markel Corporation as the liability carrier for Kids Kount Day Care Center for $10,000.00 as set forth in the attached Petition is approved. The fee agreement between Christie Hostetler and Brian Hostetler, parents and natural guardians of the minor, Avery Hostetler, and DiLoreto, Cosentino & Bolinger, PC, for the payment of fees in the amount of $2,500.00, inclusive of litigation costs, is approved. In addition to the settlement proceeds, the lien held by Capital Advantage Insurance Company, in the amount of $1,211.07, was paid by Markel Corp. in full and final satisfaction of the lien asserted by Socrates, Inc., on behalf of Capital Advantage Insurance Company for conditional payments made to Avery Hostetler's medical providers for treatment rendered to Avery Hostetler as a result of injuries sustained in the subject incident. The net settlement proceeds of $7,500.00 payable to the minor shall be deposited in a federally insured savings account or savings certificate as required by Pa. R.C.P. 2039(b)(2). The funds shall not be withdrawn during the minority of Avery Hostetler without Order of Court except to the extent necessary to pay any income tax on the income derived from the account or certificate. Taxes may be paid from the interest income without further Order of this Court. When the minor attains her majority, the funds in the account or certificate shall be paid to her. Satisfactory proof of establishment of the account in accordance with the terms of this Order shall be filed of record by the Hostetler's counsel. C.C3-' C.V fr6. t-C_L 1444y t.ati,d slaopq LAW OFFICES DILORETO, COSENTINO & BOLINGER PC 330 LINCOLN WAY EAST P.O. 80X 866 CHAMBERSBURG, PA 17201 BY THE COURT FILED"vrF10E OF THE PROTHONOTARY ':; 20IJUL 28 P1112: t CUMBERLAND COUNTY PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF THE 9TH JUDICIAL DISTRICT PENNSYLVANIA — CUMBERLAND COUNTY IN RE: Avery Hostetler, A Minor, by Christie and Brian Hostetler, Parents and Natural Guardians NO. 14-2933 CIVIL PROOF OF DEPOSIT OF MINOR'S FUNDS Now come Christie and Brian Hostetler, parents and natural guardians of the minor, Avery Hostetler, through their attorney, Victoria P. Edwards, and provide the following Proof of Establishment of Minor's Account: 1. A Certificate of Deposit has been established for the minor beneficiary, Avery Hostetler, pursuant to the May 20, 2014 Order of Court in the above captioned matter, as confirmed by correspondence from Santander Bank dated July 2, 2014, a copy of which is attached as Exhibit A. Date: July 24, 2014 LAW OFFICES DILORETO, COSENTINO & BOLINGER PC 330 LINCOLN WAY EAST P.O. BOX 866 CHAMBERSBURG, PA 17201 Respectfully submitted, DILORETO, COSENTINO & BOLINGER, PC By Victoria P. Edwards, Esquire Attorney for Claimant Supreme Court ID No.: 200372 330 Lincoln Way East P.O. Box 866 Chambersburg, PA 17201 (717) 264-2096 VERIFICATION I, Victoria P. Edwards, as Attorney for the Petitioners, Christie and Brian Hostetler, as Guardians of Avery Hostetler, a minor, hereby affirm that the facts set fourth in the foregoing Proof of Deposit are true and correct. I hereby acknowledge that the facts set forth in the aforesaid Proof of Deposit are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. Date: July 24, 2014 LAW OFFICES DILORErO, COSENTINO & BOLINGER PC 330 LINCOLN WAY EAST P.O. BOX 866 CHAMBERSBURG, PA 17201 By Victoria P. Edwards, Esquire Attorney for Claimant Supreme Court ID No.: 200372 330 Lincoln Way East P.O. Box 866 Chambersburg, PA 17201 (717) 264-2096 Exhibit A 6 Santander* Certificate of Deposit Receipt This receipt is issued by Santander Bank, N.A. to: AVERY HOSTETLER 58 INDEPENDENCE DR SHIPPENSBURG PA 17257 The account evidenced by this receipt is subject to and further explained in the terms and conditions as contained in the deposit account agreement and the certificate of deposit disclosure. Account Number: IRA Account: Yes Date Opened: 07/02/2014 Amount: $7,500.00 Term: 1095 DAY(S) Maturity Date: 07/01/2017 Interest Rate: 1.2400 No X APY: 1.2500 Interest Disbursement: Accrued to Account Interest Payment Frequency: Monthly from Issue Date Effective 10/17/2013 This account is not negotiable and not transferable. Personal Signature Card 7681568832 Branch: 0353 Team Member Name: Merritt,Anthony Darnone Date: 07/02/2014 Participant 1 Name: AVERY HOSTETLER Date of Birth: 01/04/2013 SSN/ITIN MEMO Street Address: 58 INDEPENDENCE DR Home Phone: 17174772345 Cell Phone: City/State/Zip: SHtPPENSBURG, PA 17257 work Phone: Oceupaiort NEVER EMPLOYED Mailing Address(if Different) Primary ID: OTH - IDB: 14-2933 Issu St: PA Issu Ot: 05/20/2014 Exp Dt: 05/20/2032 US City/State/Zip: Secondary ID: BC - Issu St PA Issu DI 01/04/2013 US Employer's Name: Country of Citizenship: UNITED STATES Email Address: CIP Certified: NO Verification: Approved 07/02/2014 Approval: 7/2/2014 12:36 1 of 2 is Equal Housing Lender. Santander Bank, N.A. is a Member FDIC and a wholly ownedsubsidiary of Banco Santander,S.A. 2013 Santander Bank, N.A. ( Santander and its logo are registered trademarks of Banco Santander, SA or its affiliates or subsidiaries in the United States and other countries. Personal Signature Card Branch: 0353 Team Member Name: Merritt,Anthony Damone Date: 07/02/2014 Nnber/rype Ti ��Tom, Ti orL ax epotinng Accounts Opened 1Re1atlonship T pe unt°Ads rest 11101116.... Subject to Backup Withholding illh AVERY HOSTETLER OWNER (INDIVIDUAL) 58 INDEPENDENCE. DR SHIPPfASBURG, PA 17257 om er a e Customers Nafn,y Customer Services - Debit Card elephone Bankirn O n me Banking' AVERY HOSTETLER 'To activate Telephone Banking, please call 1-877-768-2265 Taxpayer Identification Number (TIN) Certification and Agreements and Disclosures TIN Certification: if my taxper Identification Number (TIN) is shown above as the TIN being used for tax reporting, I certify under penalties of perjury that: 1. The TIN shown on this form is my correct TIN, and 2. Unless the box labeled "Subject to Backup Withholding" is checked above, I am not subject to backup withholding because. (a) I am exempt from backup. withholding, or (b) 1 have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest 'ordividends, or (c) the IRS has nettled me that I am no longer subject to backup withholding, and' 3. I am a U.S. person (including a U.S. resident alien). Certification Instructions: The taxpayer whose TIN is being used for tax reporting must check the box labeled 'Subject to Backup Withholding' if the taxpayer has been notified by the IRS that the taxpayer is: currently subject to backup withholding because the taxpayer has failed to report all interest and dividends on the taxpayers tax return. Important Reminder: if nota "U.S. Person," certify foreign status separately, using appropriate Form W-8, if applicable. Important Account Opening Information: Federal law requires us to obtain sufficient information to verify your identity. You may be asked several questions and to provide one or more forms of identification to fulfill this requirement In some instances we may use outside sources to confirm the information. Agreements: The undersigned authorzes Santander Bank, NA. to obtain consumer reports from consumer reporting agencies. The undersigned person agrees to the terms of and acknowledges receipt of the following: CI Deposit Agreement © Fee Schedule 0 Overdraft Opt -in Notice 0 Rate Information 0 Privacy Policy 0 CD Disclosure The Internal Revenue. Service does not require your consent to any provision of this document other than thecertification required to avoid backup withholding. X AVERY HOSTETLER 056-59-5239 Date Approved 07/02/2014 7/2/2014 12:36 2of2 in Equal Housing Lender. Santander Bank, N.A. is a Member FDIC and a wholly owned subsidiary of Banco Santander,S.A. 2013 Santander Bank, N.A. 1 Santander and its logo are registered trademarks of Banco Santander, S.A. or its affiliates or subsidiaries in the United States and other countries. Santander IMPORTANT INFORMATION ABOUT YOUR CERTIFICATE OF DEPOSIT Your New Account. The interest rate on the certificate of deposit account (*CD") you opened or about which you inquired today is %, which corresponds to an annual percentage yield oV-1-Y%. The term of your CD is425Your CD will mature on The interest rate will not change during the term of your CD, unless you have opened a Rising Rate CD (RRCD). .) If you have a RRCD you may Visit your local branch to request that we increase your interest rate one time during the terrn of your CD to the current RRCD rate in.effect the day the request is made. Current interest rates can be obtained by calling 1-877-768-2265, visiting your local branch, or by going to www.santanderbank.com and clicking on www.santanderbank.com/risingrate. Minimum Balance. A minimum balance of $500 is required to open a personal certificate of deposit account ("Retail COI a minimum balance of $500 is required to open a Business CD, and a minimum balance of $100.000 is required to open a Retail Jumbo, Wholesale Jumbo, or Business Jumbo CD. Maximum Balance. A maximum opening balance of $99,999.99 is permitted for Retail and Business CDs. There is no maximum opening balance for a Retail Jumbo, Wholesale Jumbo, or Business Jumbo CD. Term. Variable Term CDs: Some of our CDs, such as our 3-5 month CD, permit you to select the actual number of days for your CD Term within the range of days allowed in that CD. When your CD matures, we will use this same number of days to establish your new CD term unless you instruct us otherwise. Sol you selected 97 days as the term of your original CD, the term for your next CD after automatic renewal into the same product will also be 97 days. Fixed Term CDs: All other CDs, such as our 1 Year CD, have a pre -determined number of days in the term, which will approximate but not always equal the exact number of days corresponding to the period indicated in the name of the CD. For example, a 9 Month CD always has 273 days in the term no matter when in the calendar year it is opened. Please call or visit a branch for further details on the exact number of days for each CD term we offer. The term of a 1, 2, 3, 4, 5 or 10 Year CD is always based on a 365 day year, even in leap years. The maturity date for your CD is noted on the front of this notice. If you wish to select a different maturity date, please call or visit your local branch during the CD grace period. Otherwise, the maturity date for your CD will be the date shown on the front of this notice. Credlting and Compounding of Interest. Interest on your Retail, Business, and Retail Jumbo CD is compounded daily. Interest on your Retail or Business CD is credited to your account every month. Interest on your Retail Jumbo CD or Business Jumbo CD is credited to your account at maturity, unless you have a Retail Jumbo CD or Business Jumbo CD with a term greater than one year, in which case the interest is credited monthly. Interest on Wholesale Jumbo CDs, which are owned by govemment, municipal, and business customers, is credited to your account at maturity. Computing Your Interest. Interest on your CD is calculated using the daily balance method. We apply the daily periodic rate that corresponds to the interest rate on your account to the principal in your account each day. We use a 365 -day year for Retail CDs and a 360 -day year for all Jumbo CDs when calculating the daily periodic rate that is applied each day. Interest will begin to accrue on the business day you make a deposit to your account. The annual percentage yield that applies to your CD assumes that no withdrawals of principal or interest are made before the maturity date. Any withdrawal of interest or principal will reduce the amount of interest you eam on your CD. Mid -Atlantic and New England Effective: 10/17/2013 • • Transaction Limitations, Penalties, and Fees. After your CD is opened, you may not make any additional deposits into the account. You may make withdrawals of principal from your account before the maturity date of your CD only' if we agree to permit you to make the withdrawal. If we permit you to make the withdrawal to your CD, we will impose the applicable early withdrawal penalty described below: o Early Withdrawal Penalties for Retail CDs o Three months' interest on the amount withdrawn if the term of your Retail CD is one year or less. o Six months' interest on the amount withdrawn if the term of your Retail CD is more than one year or Tess than five years. o One year's interest on the amount withdrawn for Retail CDs with a term of 5 Years or longer. o Early Withdrawal Penalties for Business Business Jumbo, Retail Jumbo. and Wholesale CDs o Three months' interest on the amount withdrawn for Business, Business Jumbo, and Retail Jumbo CDs with terms under 5 Years o One year's interest ontheamount withdrawn for Business, Business Jumbo, and Retail Jumbo CDs _with •terms of 5 Years or longer. o Three months' interest on the amount withdrawn for all Wholesale Jumbo CDs. We may at our discretion waive the early withdrawal penalty if any owner of your CD is adjudicated incompetent or dies, or if the CD is part of an Individual Retirement Account and you are at least 59'/ years of age and have requested periodic distributions that will occur at least annually. We may ask for documentation showing us that you are eligible for a waiver of the early withdrawal penalty. If we permit you to close your. CD before the maturity date, you may lose any interest that has accrued but not been credited to your account. Interest may be withdrawn at any time without penalty after it is credited to your account. If we permit you to: make a withdrawal from your CD on or before the maturity date we will also charge a $35 CD Early Withdrawal fee. Renewal Policy. All CDs, with the exception of Wholesale Jumbo CDs, will automatically renew at maturity. You have a grace period of seven days beginning the day after the maturity date to withdraw some or all of the funds in your account without being charged an early withdrawal penalty. Interest is not paid on amounts withdrawn. Mid -Atlantic and New England • Effective: 10!17f2013