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14-3556
ANAPOL SCHWARTZ BY: Christopher J. Marzzacco, Esquire Attorney ID #78262 4807 Jonestown Road Suite 148 Harrisburg, PA 17109 (717) 901-3500 cmarzzacco@anapolschwartz.com Attorneys for Plaintiff IC Pt:WT/ilotiOrilei, 2014 j JI -112 P11 1: 2 PENNSYLV'ANiAF,'T y IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GAGE HEISS, a minor, by and through his mother, JESSICA McCOY v. SHARON K. KING NO. SSS CIVIL ACTION - LAW PETITION FOR LEAVE TO SETTLE OR COMPROMISE MINOR'S ACTION TO THE HONORABLE JUDGE OF SAID COURT: The Petition of Gage Heiss, a minor, by his parent and natural guardian, Jessica McCoy, through their attorney, Christopher J. Marzzacco, Esquire, of Anapol Schwartz, respectfully requests approval to settle, and offers in support thereof the following: 1. Petitioner is Jessica McCoy, parent/natural guardian of Gage Heiss, minor. 2. The minor, Gage Heiss, was born on October 9, 2003. 3. The minor resides with his mother, Jessica McCoy, at 201 East Portland Street, Mechanicsburg, Pennsylvania, 17055. 4. A guardian was not appointed for the minor under the circumstances of this claim. 5. On April 26, 2014, the minor was visiting his grandparents and was playing outside of their residence. att446)t),��a CIL# �a�a 3 6. A German Shepherd, belonging to Sharon K. King, a neighbor, was running loose. The animal came onto the property and attacked the minor, biting him on his back, left shoulder blade area and upper right arm. (See Exhibit "A"). 7. Liability clearly rests on said dog owner. 8. As a result of the attack, the minor suffered bites and abrasions to his upper right back and right arm. 9. Medical treatment was received at Penn State Hershey Medical Center and Aspire Family Care. (See Exhibit "B"). 10. The minor has made a full recovery from his injuries as of the date of this petition. 11. Additional medical bills were paid through the Department of Public Welfare ("DPW"), for which a lien has been asserted in the amount of $782.26. (See Exhibit "C"). 12. No further medical treatment or billing is anticipated. 13. The third -party insurance carrier, Erie Insurance, has offered the sum of $11,000.00 in full and final settlement of minor's claim. (See Exhibit "D"). 14. Undersigned counsel, as attorney for the minor, believes that said settlement is fair, reasonable and in the best interests of the child under the circumstances of this claim for the following reasons: a. Incurring the expense and uncertainty of formal litigation would not serve the interests of the minor -Plaintiff; b. The minor's injuries have completely resolved; c. All medical bills are paid and no further expenses will be incurred; d. Petitioner, parent of the minor, agrees that the settlement is in the child's best interest. 15. Counsel has incurred $724.34 in expenses, such as court filing fees, medical record copy charges, postage, etc., for which reimbursement is sought. (See Exhibit "E") 16. Counsel requests legal fees in the amount of $2,750.00 (which equates to 25% of the settlement) for his work in this matter. (See Exhibit "F"). 17. Counsel has not, and will not, receive collateral payments from any third parties. 18. The net settlement payable to the minor after deduction of all costs is $ 6,743.40. WHEREFORE, Petitioners request that the Court allow them to accept the settlement described herein on behalf of the minor Plaintiff, Gage Heiss, sign a release and distribute the proceeds of the same as follows: TOTAL SETTLEMENT: $ 11,000.00 TO: Anapol Schwartz – For legal fees $ 2,750.00 TO: Anapol Schwartz - For reimbursement of costs $ 724.34 TO: DPW—For medical bills paid $ 782.26 TO: GAGE HEISS, a minor, the sum to be deposited in the $ 6,743.40 name of the minor only in federally insured savings accounts, certificates of deposit or credit union accounts or accounts investing only in securities guaranteed by the United States government or a Federal governmental agency managed by responsible financial institutions. The account(s) shall be marked "not to be withdrawn until the minor reaches the age of eighteen (18) years, except for the payment of local, state and federal income taxes on earnings of the certificate or account or upon further Order of the Court." BY: Respectfully submitted, ANAPOL SCHWARTZ Christopher J. Marzzacco, Esquire Attorney ID #78262 VERIFICATION I, the undersigned, Jessica McCoy, verify that the statements made in this document are true and correct to the best of my knowledge, information, and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. §4904, relating to unsworn falsification to authorities. Dated: Respectfully submitted, EXHIBIT A Lower Allen Township PD LA -12-03551 • Administrative ■ Gang Related • Paperless Officer: BRIANA GAUMER -1820 4/26/2012 • Investigation ■ Accident ■ Arrests Made Incident Report Form III e Suspects ■ Ready for DA / Prosecutor p Log Number LA -12-03551 Incident Number File Number Case Number UCR 26 ALL OTHERS EXCEPT SUMMARY TRAF Incident Type ORDVIO ORDINANCE VIOLATION Dispatcher Source DISP District 1203 Status NONACT Date Received 4/26/2012 Rcvd 1840 Disp 1840 Arry 1845 Clyd 1913 Disposition sum CLEARED BY SUMMONS INCIDENT OCCURRED AT OR BETWEEN Earliest Date and Time 4/26/2012 1815 (Thursday) Latest Date and Time 4/26/2012 1840 (Thursday) Location 1188 KINGSLEY RD CAMP HILL PA 17011 Cross Street Intersection • -- • • : • • rson ►a ue Premise Code RESID RESIDENCE/HOME Business Name Modus Operandi Coding VICTIM: ENTRY: PROPERTY. EXIT: AREA: METHOD: TIME OF DAY: WEAPON USED: Caller / Complainant Type Normal ■ Anonymous • Hangup ■ Refused ■ INVOLVED PERSONS if ,.( it[ts _yt i1 i E fP �. '} ii�:'P t S �.' .'. l Z �. 'T, - t i1 �, .} t y . { �, 4 1 1 ftsj.. .si:.k!',� �{,�i it f...J,.t:.5x. d..,iL✓. it .. � '~�. i..i.:i�f.�R1 ta, w -..a xa_Y,.,.w .._ t � .u:... :zl�.± .a ....,�1 ... ,x r �.._ t.,. ....i. i...� t... .:f.'. -.T �,.. .�: i.F i..Yl-f 1 �i�..� 1ii Name Last, First, Middle • Address Juvenile KING, SHARON K • Age Race Sex Ethnic Soc a ecu ty umber 48 W F N 210-58-8119 1176 KINGSLEY RD CAMP HILL PA 17011 Weight Height 503 Hair Eyes HAZ Phone Number (717 730-6783 Driver License Number 19971306 State PA Later Name edit IN Link Comments(( ���roro.F 1 ik tt �dt !.,te_.,..Cl:, d:S A55+ �_, ..'`..5.3_'.J. .,mi°... �,�saS u':1.. i- _,.!_.,-.:.. ...tsafl...r, ,� of r ..... a ._cs yE•...._,."r,. Name (Last, F rst, Middle) - Address Juven a MARSHALL, JUDITH ■ 1188 KINGSLEY RD CAMP HILL PA 17011 1 Y r:. ,gi. r n.._...._ Date o B rt 3/25/1942 .,,U. 7 ...:..• Age 70 f f ._, ue<.,. - ace W x OC ., � Sex F }' fi Gf C .��..:....• 1- �:..:.: Soda ecurity Number Weight Height Hair Eyes Phone Number (717) 731-9447 Driver License Number State Later Name edit III Link Comments . yy 7� ° �d � 6 ;,,�E �� r; F:'se ,s'F trty,, r r s u`�X t t, rP .5r,.:,„fi..,:?t om?, ;. ,,..-!ri.� :,.�,,,.a.,F::_;,ws.•]�•. ti.,,.....rai�f�..,, '�Ps:� ,5:. r k c zr ;I �„ �'' ' rS�s Date of Birth 11/19/1981 , tr �.�+st. nttFJ Race I W E4 Sex F ?� Et nic N :V iii u._ A. d Ft . i I ...r, Social Security Number `ame ast, ret, • iddie - Ad, ress uven le MCCOY, JESSICA ■ 5011 MCDONALD DR MECHANICSBURG PA 17050 Weight Height Hair Eyes Phone Number (717) 319-5065 Driver License Number State Later Name edit • Link Comments CITATIONS / SUMMONSES / WARNINGS LA -12-03551 4/26/2012 © APPROVED BY: FRANK WILLIAMSON PAGE 1 IRF 1.5 APPROVED ON: 5/14/2012 Lower Allen Township PD ❑ Administrative 0 Gang Related 0 Paperless Officer: BRIANA GAUMER -1820 ❑ Investigation ❑ Accident 0 Arrests Made ❑ Suspects 0 Ready for DA I Prosecutor LA -12-03551 4/26/2012 Incident Report Form CITATIONS / SUMMONSES / WARNINGS 171 Person Charged SHARON KING Violation TOWNSHIP ORDINANCE Plate 770 ;1" Business Charged Violation Location 1188 KINGSLEY RD CAMP HILL PA 17011 Officer ID 1820 Ticket Date 04/26/2012 Ticket Time 1840 Speed Related Speed Measured By State Year Make Model Cross Street Speed RP Posted Speed Limit Color District 1203 Approximate Speed Court Date Parking 0 Charges 2. 3. 4. 5. Primary Charge TO 65-3 Primary Charge Description RUNNING AT LARGE Arresting Officer 1 1820 BRIANA GAUMER Charge Count(s) 1 UCR Code 26 Arresting Officer 2 LFi�+i�Y Arrest Disposition CITE Blood / Alcohol Bail Arrest 0 Summons ❑k •escnp ion RESPONDING / INVOLVED UNITS, OFFICERS, TIMES Vehicle Officer 1 Officer 2 Officer 3 Officer 4 Unit 1 LA1 1820 Unit 2 LA16 1824 1817 Unit 3 Unit 4 Agency Numbers Units & Times Division Supervisor LA -12-03551 IRF 1.5 4/26/2012 APPROVED BY: FRANK WILLIAMSON APPROVED ON: 5/14/2012 PAGE 2 Lower Allen Township PD Narrative/Comment Sheet for: LA -12-03551 4/26/2012 TITLE: ROLL CALL SYNOPSIS By: laurien Judith Marshall called in reference to Sharon King's dog running loose and biting her grandson, King cited on this date for "Dog Running at Large". Page# 1 EXHIBIT B HEISS V. KING Records From: Milton S. Hershey Medical Center- Medical Records Records Of: Gage Heiss DELIVER TO: Jennipher Zougmore Anapol Schwartz 252 Boas St. Harrisburg, PA 17102 ORDERED BY: Anapol Schwartz Jennipher Zougmore Jennipher Zougmore 252 Boas St. Harrisburg, PA 17102 Claim #: Firm File #: 240639 Page Count: 43 11111111011111, 11.1 114 S. Chester Pike G1enolden PA 19036 • (610) 891-8247 • (610) 891-8248 • www.rrsnet.com Serving PA • NJ • DE • MD • OH • NY • CT 28039-1 PENNSWE HERSHEY WT. Milton S. Hershey WO Medical Center Health Information Services P.O. Box 8M); Mail Code H1.1 24 Hershey, PA 17033-0850 Q1 c: RE: Ga11) 3e— (Patient Name) (Patienti0CR/063 MRN) (Patient DOS mcniddiYYYY) Tel: (717)531-3793 Fax: (717) 531-5008 Pifarso@hrne.psu.edu Total Pages: (13 A. Certification of Medical Records ( Milton S. Hershey Medical Center (MSHMC) e MSHMC medical records for which this certification is made were created in the regular course at the Hershey Campus hospital, its contiguous dinics, or MSHMC facilities relying on either or both electronic medical record at or near the time of the matter recorded. Custodian of the Records, or designee Milton S. Hershey Medical Center Sworn to and subscribed before me This day of , 20 ( ) MSHMC Outpatient Services Community Practice Sites The MSHMC Outpatient Services Community Practice Site paper medical records for which this certification is made were created in the regular course of business at the MSHMC community practice site at at or near the time of the matter recorded. Practice Site Manager or designee MSHMC Outpatient Services B. Certification of Photocopies of Medical Records The copies of the enclosed records are true and complete reproductions of all the original paper, electronic or microfilmed medical records (Choose one): k Presented by the Milton S. Hershey Medical Center to HealthPort, Inc. for photocopying, OR ( ) Photocopied by Milton S. Hershey Medical Center Health Information Services • HealthPort, I c. authorized representative Custodian of the Records, or designee Milton S. Hershey Medical Center Sworn to and subscribed before me Sworn to and subscribed before me This \ 3 day of 34--k , 20 I-2- This day of , 20 This certification is given pursuant to 42 Pa. C, S, Ch. 61/Subch E (relating to medical records) by the custodian of the records, in lieu of his appearance. PENNSTATE HERSHEY P Milton. S. Hershey lir Medical Center Patient Name: MRN: Date of Birth: Patient Gender: HEISS, GAGE R 1631105 10/9/2003 Male Penn State Hershey Tel: (717) 531-8055 Milton S. Hershey Medical Center Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Visit Number: 17554221 Visit Type: Emergency Patient Location: EMER • i Consent I Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L Page 1 of 43 Patient Name: HEISS, GAGE R Date of Birth: 10/9/2003 * Final * PENNSTATE HERSHEY Milton S. Hershey Medical Center CONSENT FOR MEDICAL TREATMENT NAME: NEISS GAGE R MU: 1631105 00SA: 17554221 AO: KASS LAWRENCE E WOtl: 46154 009: 10/09/2003 VISIT MATE: 04/26/2012 OC: FUER SEX: M INS: GATEWAY HEALTH PLANDI COPAV 00 1111111NUIIIM1111 1111 111 111 MRN: 1631105 FIN: 17554221 MEDICAL AND SURGICAL CONSENT FOR TREATMENT: The undersigned is under the care of his/her attending physician(s) and hereby consents to and authorizes the Milton S. Hershey Medical Center (MSHMC) to provide the necessary medical treatments (including Emergency Department services), surgical procedures, anesthesia, x-ray examinations or treatments, laboratory procedures, drugs and supplies to the patient as ordered or requested by the Professional Clinical Staff of the MSHMC. I acknowledge that no guarantee or assurance has been made as to the results of medical treatments, surgeries, or examinations. For the purpose of advanced medical knowledge, I consent to the presence of medical students and other health care trainees. I understand they may participate in my care under the direct supervision of my attending physician(s). CONSENT TO ACCESS, REVIEW AND RETAIN PREVIOUS PRESCRIPTION MEDICATION INFORMATION: consent to and authorize MSHMC healthcare providers to access and review any of my electronic prescription medication history information which may be available through Surescripts Database, including but not limited to, prescriptions ordered and/or filled for me at any pharmacy which participates in the Surescripts Database. I understand that this historical prescription information will then become a permanent part of my electronic medical record at the Milton S. Hershey Medical Center. PATIENTS RIGHTS AND RESPONSIBILITIES: I acknowledge that MSHMC has provided me with written information on my rights and responsibilities as a patient. I am aware that a Patient Representative is available to me if I have additional questions or otherwise wish to speak with one. HOSPITAL MEDICAL RECORD RELEASE AUTHORIZATION: I acknowledge that the MSHMC Privacy Notice has been made available to me. I understand that MSHMC may disclose information about me and the treatment I am receiving, for purposes of continuous treatment, payment and health care operations. ASSIGNMENT OF BENEFITS: I assign and authorize payment,directly to MSHMC. I authorize any holder of medical or other information about me to release to my insurance carrier and its agents any information needed to determine these benefits or benefits for related services. I, the undersigned, certify that I have read, understand, and agree to the provisions contained within the consent form. The issues addressed on this form have been fully explained to me. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction. Patient's S'• •cure (or signature of person consenting on behalt of the patient) Relationship to the p • ' •1, If op cable Wit to Patients Signature ' MR 1181 Pagel of I Rev 7/11 Date Time AM .60 Date Time IUWdiIUIIIIUIIIIIIN11UUIWIU CONSENT FOR MEDICAL TREATMENT Facility: HMC White Copy - Medical Records Yellow Copy • Patient Page 2 of 43 PENNSTATE HERSHEY 1 .1 Milton S. Hershey 111, Medical Center Patient Name: REISS, GAGE R MRN 1631105 _._..w........................_...........,.,.....,.......�.�w.-. .�._.... ED DischargeInstructions..........w.......................................w...... .k..._.... �.... RESULT STATUS: Final DOCUMENT SUBJECT: ED Pat Edu ELECTRONICALLY SIGNED BY: Gaus,Autumn J (4/26/2012 22:59 EDT) ED Pat Edu Penn State Milton S. Hershey Medical Center Emergency Department Discharge Instructions Name: GAGE HEISS DOB: 10/9/2003 Chief Complaint: Animal Bite MRN: 1631105 Visit Date: 04/26/2012 20:02:00 FIN: 17554221 Current Date: 04/26/2012 22:59:24 Address: APT 6 MECHANICSBURG PA 170500000 Phone: (717)319-5065 Primary Care Provider: Name: Rayner, Richard M Phone: 717 901-3440 Emergency Department Care Providers: Primary Physician: Secondary Physician: IMPORTANT: We examined and treated you today on an emergency basis only. This was not a substitute for, or an effort to provide, complete medical care. In most cases, you must let your doctor check you again. Tell your doctor about any new or lasting problems. We cannot recognize and treat all injuries or illnesses in one Emergency Department visit. If you had special tests, such as EKG's or X-rays, we will review them again within 24 hours. We will call you if there are any new suggestions. After you leave, you should follow the instructions below. Follow -Up Instructions GAGE HESS has been given these follow-up instructions: Follow Up With: Where: Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L When: Page 3 of 43 PENNSTATE HERSHEY Par Milton S. Hershey quip Medical Center Patient Name: HEISS, GAGE R ED Discharge Instructions Richard Rayner 49 Prince Street Harrisburg, PA 17109 717 901-3440 Business (1) MRN 1631105 Within Call physician within next business day Comments: Follow up with PCP in 2-3 days for wound check. Keep areas clean and dry. Apply ice for swelling. Tylenol or motrin as directed for pain. Return to ED for any worsening symptoms. Let your PCP know you were given DT (tetanus) immunization in ED so you get the rest of the series. SMOKING is a major health issue. -Smoking greatly increases the risk of heart disease, cancer, and stroke. - If you and your family don't smoke, contine this healthy choice! - Remember to avoid secondhand smoke. -If you or anyone in your household does use tobacco products, please follow any smoking cessation advice/counseling you received while in the hospital. - If you would like more information about how to live tobacco -free, please call one of the numbers below. PSHMC Smoke Cessation Program 1-800-243-1455 Pennsylvania QUITLINE 1-877-724-1090 Are you or someone you love at the risk of suicide? Seek help as soon as possible by contacting a mental health professional or by calling: NATIONAL SUICIDE PREVENTION LIFELINE AT 1-800-273-8255 (TALK)/1-800-273-8255 Patient Education Materials GAGE HEISS has been given the following patient education materials: Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L Page 4 of 43 PENN STATE HERSHEY Milton S. Hershey 411, Medical Center Patient Name: HEISS, GAGE R ED Discharge Instructions Allergies: Shellfish Please Take the Following Medications MRN 1631105 Medication Dose Special Instructions amoxicillin -clavulanate (Augmentin 250 mg/5 mL oral liquid) new 10 mL - by mouth - every 12 hours Patient Visit Summary HEISS, GAGE R has been given the following list of patient education materials and follow-up instructions: Patient Education Materials Bite - Dog, Easy -to -Read; Tetanus and Diphtheria Vaccine Follow -Up Instructions With: Address: When: Richard Rayner 49 Prince Street. Harrisburg, PA 17109 Within Call physician 717 901-3440 Business (1) within next business day Comments: Follow up with PCP in 2-3 days for wound check. Keep areas clean and dry. Apply ice for swelling. Tylenol or motrin as directed for pain. Return to ED for any worsening symptoms. Let your PCP know you were given Di (tetanus) immunization in ED so you get the rest of the series. I, HEISS, GAGE R, have received the above patient education materials/instructions and have verbalized understanding: Patient Signature Date Provider Signature Date Date/Time Printed: 7/13/2012 14:32 EDT Page 17 of 43 Printed By: Tice,Cindy L Patient Name: HEISS, GAGE R Date of Birth: 10/9/2003 • Final Patient Visit_Summary 11111111111111110111111111111 NAME: 4EISS GAGE R WWI: 1631105 COSI: 17554221 IC: NASS LAWRENCE E 400: 46354 LOC: XS: 1100/0012003 VVIISIT TATE: 04/2612012 u it nitti4:_iiiIIIp TM PLA/431 COPAY 00 HEISS, GAGE R has been given the following list of patient education materials and follow-up instructions: Patient Education Materials Bite - Dog, Easy -to -Read; Tetanus and Diphtheria Vaccine Follow -Up Instructions With: Address: Richard Rayner 49 Prince Street Harrisburg, PA 17109 717 901-3440 Business (1) Comments: When: Within Call physician within next business day Follow up with PCP in 2-3 days for wound check. Keep areas clean and dry. Apply ice for swelling. Tylenol or motrin as directed for pain. Return to ED for any worsening symptoms.Let your PCP know you were given DT (tetanus) immunization in ED so you get the rest of the series. 1, HEISS, GAGE R, have received the above patient education materials/instructions and have verbalized understanding: Name: HEISS, GAGE It Facility: HMC Date Signature Date MRN. 1631105 OOS: 17554221 MRN:1631105 FIN: 17554221 Page 18 of 43 PENNSTATE HERSHEY P Milton S. Hershey Medical Center Patient Name: HEISS, GAGE R MRN 1631105 RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: ED Depart Summary Final Depart Summary Gaus,Autumn J (4/26/2012 22:59 EDT) Depart Summary Penn State Milton S. Hershey Medical Center Emergency Department Depart Summary PERSON INFORMATION Name HEISS, GAGE R Sex Male Marital Status Single MRN 1631105 Visit Reason Dog bite; Animal Bite Enc Type Emergency Track Group EMER Trk Gp Tracking Id 23045619 Checkin 4/26/2012 8:02 PM Arrival 4/26/2012 8:02 PM Address: APT 6 MECHANICSBURG PA 170500000 Age 8 Years Language English Phone (717)319-5065 Visit Id Specialty Med Service Emergency Medicine Discharge 4/26/2012 10:57 PM Checkout 4/26/2012 10:57 PM Acuity 4 Reg Status Start DIAGNOSIS Animal bite E906.5; Abrasion 919.0 POWERFORMS SCHEDULING PHYS DOC NOTES DEPART REASON INCOMPLETE INFORMATION PROVIDER INFORMATION Provider Ashton, Stephanie L Grendzinski, Steven R Gaus, Autumn J Role R.E.S. Clerical RN Assigned 4/26/2012 8:29 PM 4/26/2012 8:29 PM 4/26/2012 9:55 PM DOB 10/09/2003 12:00 AM PCP Rayner, Richard M Acct# 17554221 Referred by Dispo Type Discharge to Home LOS 000 02:55 Unassigned 4/26/2012 8:51 PM Date/Time Printed: 7/13/2012 14:32 EDT Page 19 of 43 Printed By: Tice,Cindy L 1 PENN STATE HERSHEY ! Milton S. Hershey Medical Center Patient Name: HESS, GAGE R ...... _ ED Depart Summary EVENTS INFORMATION Event Name Event Status Arrive Triage Arrive Registration Registration Arrive MD Bill MD Bill Arrive Dictate Dictate Arrive PT Belongings Complete Complete Complete Complete Complete Complete Complete Request Complete Bed Assign PT Belong Complete Arrive Bud Assign Complete Bed Assign Complete Arrive Med History Complete Med History Complete Arrive Update Attend Complete Update ED Attending Complete Arrive ED Secondary Complete ED Secondary Assess Complete PT Care Request Patient. Belongings Request MD Assess Request Resident Assess Complete Xray Complete Rx Complete Rx Complete Discharge/Transfer Complete LOCATION INFORMATION Arrival 4/26/2012 8:02 PM 4/26/2012 8:16 PM 4/26/2012 10:57 PM Nurse Unit EMER EMER EMER ORDERS INFORMATION Request Date/Time 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:02 P M 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:13 PM 4/26/2012 8:16 PM 4/26/2012 8:16 PM 4/26/2012 8:16 PM 4/26/2012 8:43 PM 4/26/2012 10:16 PM 4/26/2012 10:23 PM 4/26/2012 10:26 PM Start Time Order Type Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L Start Date/Time 4/26/2012 8:02 PM 4/26/2012 8:13 PM 4/26/2012 8:02 PM 4/26/2012 8:51 PM 4/26/2012 8:02 PM 4/26/2012 10:25 PM 4/26/2012 8:02 PM MRN 1631105 Complete Date/Time 4/26/2012 8:02 PM 4/26/2012 8:13 PM 4/26/2012 8:02 PM 4/26/2012 8:51 PM 4/26/2012 8:02 PM 4/26/2012 10:25 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:16 PM 4/26/2012 8:16 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 8:16 PM 4/26/2012 8:16 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 10:38 PM 4/26/2012 10:38 PM 4/26/2012 8:02 PM 4/26/2012 8:02 PM 4/26/2012 9:24 PM 4/26/2012 9:24 PM 4/26/2012 8:02 PM 4/26/2012 8;02 PM 4/26/2012 10:20 PM 4/26/2012 10:20 PM 4/26/2012 8:29 PM 4/26/2012 9:06 PM Room Triage 49 Check Out Status Stop Time Bed 4/26/2012 8:29 PM 4/26/2012 9:16 PM 4/26/2012 10:37 PM 4/26/2012 10:57 PM 4/26/2012 10:58 PM Provider Page 20 of 43 PENNSTATE HERSHEY Milton S. Hershey 411, Medical Center Patient Name: HEISS, GAGE R 4/26/2012 11:00 PM 4/26/2012 10:26 PM 4/26/2012 10:26 PM 4/26/2012 10:26 PM 4/26/2012 8:04 PM 4/26/2012 8:04 PM 4/26/2012 8:04 PM 4/26/2012 8:43 PM 4/26/2012 8:04 PM 4/26/2012 8:04 PM 4/26/2012 11:00 PM 4/26/2012 8:13 PM 4/27/2012 12:01 AM 4/26/2012 9:00 PM 4/27/2012 3:00 AM 4/27/2012 9:00 AM amoxicillin - clavulanate Discharge (ED) Discharge from ED. Document Infusion Stop Date/Time on EMAR Pharmacy Order Sets Patient Care Patient Care Ell Assessment Patient Care Patient Care Patient Care Humerus XR Radiology Patient Care Patient Care Pharmacy Patient Care Patient Care Patient Care Patient Care Patient Care Ped Skin Assessment on Arrival Safety/Quality Verification ED Nursing Charge ED Visit diphtheria -tetanus toxoids, DT (Pediatric) Vital Signs Level 4 and 5 (ED) Safety/Quality Verification Vital Signs Level 4 and 5 (ED) Vital Signs Level 4 and 5 (ED) Vital Signs Level 4 and 5 (ED) MEDICAL INFORMATION Allergy Info: Shellfish Prescriptions Given Prescription Display Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L ED Depart Summary Completed 4/26/2012 10:57 PM Completed 4/26/2012 10:58 PM Completed 4/26/2012 10:58 PM Completed Ordered Ordered Ordered Completed Completed Completed MRN 1631105 Ashton, Stephanie L Ashton, Stephanie L Ashton, Stephanie L 4/26/2012 10:58 PM SYSTEM 4/26/2012 8:04 PM SYSTEM 4/26/2012 8:04 PM SYSTEM SYSTEM 4/26/2012 9:16 PM Ashton, Stephanie L 4/26/2012 10:58 PM SYSTEM 4/26/2012 8:04 PM SYSTEM Completed 4/26/2012 10:37 PM Ashton, Stephanie L Ordered Ordered Ordered Ordered Ordered SYSTEM 4/27/2012 12:01 AM SYSTEM 4/26/2012 9:00 PM SYSTEM 4/27/2012 3:00 AM SYSTEM 4/27/2012 9:00 AM SYSTEM. Page 21 of 43 PENNSTATE HERSHEY 11117 Milton S. Hershey Medical Center Patient Name: HEISS, GAGE R ED Depart Summary MRN 1631105 amoxicillin -clavulanate (Augmentin Start: 04/26/12 22:26:00, 10 mL, PO, ql2h, Dispf# 100 mL, X 5 day, Stop: 250 mg/5 mL oral liquid) 05/01/12 22:26:00 DISCHARGE INFORMATION Discharge Disposition: Discharge to Home Discharge Location: PATIENT EDUCATION INFORMATION Instructions: Bite - Dog, Easy -to -Read; Tetanus and Diphtheria Vaccine Follow up: Follow -Up with: When: Comments: Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L Page 22 of 43 PENNSTATE HERSHEY IIRTI Milton S. Hershey Medical Center Patient Name: HEISS, GAGE R RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: Dog bite Patient: HEISS, GAGE R MRN: 1631105 Age: 8 years Sex: Male DOB: 10/912003 Associated Diagnoses: None Author: Kass, Lawrence E MRN 1631105 ED Summary Final Dog bite Kass,Lawrence E (5/4/2012 15:52 EDT) Basic Information Additional information; Chief Complaint from Nursing Triage Note : Visit Reason. 4/26/2012 20:11 Visit reason Animal Bite History of Present Illness The patient presents with a dog bite. The onset was just prior to arrival. The course/duration of symptoms is constant. The location where the incident occurred was at home. Location: Right upper extremity back. The character of symptoms is pain and bleeding. The degree of pain is moderate. The degree of bleeding is minimal. Risk factors consist of none. Rabies risk observation animal can be observed for 10days. Incident situation: a provoked attack: entered animal's domain. The dominant hand is the right hand. Prior episodes: none. Therapy today: over the counter medications including tylenol. Associated symptoms: none. patient presents to ED with dog bite to right upper arm and left side upper back. He was riding his scooter when the dog came out and bit the patient. Unsure of rabies vaccine however dog is of a known person and can be quarantined. Patient is not up to date on vaccines and mother unsure when she stopped vaccines therefore unsure of tetanus. Patient has pain to right upper arm however good ROM. Has abrasions to back and punctures and abrasion to arm. Denies any fever. . Review of Systems Additional review of systems information: All systems reviewed as documented in chart. Health Status Allergies: . Allergic Reactions (All) Severity Not Documented Shellfish- No reactions were documented. Canceled/Inactive Reactions 1A11) NKA Past Medical/ Family/ Social History Medical history Negative. Surgical history: oral surgery. Family history: Not significant. Social history: Family/social situation: Lives with parent(s). Problem list: Per nurse's notes. Date/Time Printed: 7/13/2012 14:32 EDT Page 23 of 43 Printed By: Tice,Cindy L PENNSTATE HERSHEY WM Milton S. Hershey Medical Center Patient Name: HEISS, GAGE R Physical Examination MRN 1631105 ED Summary Vital Signs Vital Signs. 4/26/2012 20:11 Temperature 36.9 DegC Temperature Route Oral Heart Rate 92 bpm Respiratory Rate 16 br/min Systolic Blood Pressure 115 mmHg Diastolic Blood Pressure 64 mmHg Sp02 98 % General: Alert, no acute distress. Skin: left upper thoracic back abrasions in the form of a dog mouth (from bite), right lateral humerus punctures and abrasions. Head: Normocephalic, atraumatic. Eye: Normal conjunctiva. Ears, nose, mouth and throat: Oral mucosa moist. Cardiovascular: Regular rate and rhythm. Respiratory: Lungs are clear to auscultation, respirations are non -labored. Gastrointestinal: Soft, Nontender, Non distended. Musculoskeletal: Normal ROM, normal strength, no swelling, no deformity. Neurological: Alert and oriented to person, place, time, and situation, normal sensory observed, normal motor observed. Psychiatric: Cooperative, appropriate mood & affect. Medical Decision Making Differential Diagnosis: Open animal bite, puncture wound, abrasion, animal scratch. Documents reviewed: Emergency department nurses' notes. Radiology results: X-ray, reviewed radiologist's report, No osseous abnormality identified. Notes: patient was afebrile and nontoxic appearing in no acute distress. He was neurovascularly and neurologically intact. Appears to have abrasions and punctures from a dog bite. After being in ED, police contacted mother and dog is up to date on rabies vaccine. He was given the start of the tetanus immunizations since he is not currently being immunized. He was started on augmentin. He will follow up with PCP.. Impression and Plan Diagnosis Animal bite E906.5 (ICD9 E906.5) Abrasion 919.0 (ICD9 919.0) puncture Plan Condition: Improved, Stable. Disposition: Discharged: Time 04/26/2012 22:23:00, to home. Patient was given the following educational materials: Bite - Dog, Easy -to -Read, Tetanus and Diphtheria Vaccine. Date/Time Printed: 7/13/2012 14:32 EDT Page 24 of 43 Printed By: Tice,Cindy L PENNSTATE HERSHEY IINM Milton S. Hershey Medical Center Patient Name: HEISS, GAGE R MRN 1631105 ED Summary Follow up with: Richard Rayner Within Call physician within next business day Follow up with PCP in 2-3 days for wound check. Keep areas clean and dry. Apply ice for swelling. Tylenol or motrin as directed for pain. Return to ED for any worsening symptoms. Let your PCP know you were given DT (tetanus) immunization in ED so you get the rest of the series. . Counseled: Patient, Family, Regarding diagnosis, Regarding diagnostic results, Regarding treatment plan, Regarding prescription, Patient indicated understanding of instructions. Addendum Signatures: jjectronically Reviewed/Signed (26 -APR -2012 20:48:00) by; Stephanie L. Ashton, PA Electronically Reviewed/Signed 104 -MAY -2,012 15:52:001 by: Lawrence E. Kass, MD, FACEP, FAAEM Associate Professor, Department of Emergency Medicine Vice -Chair for Academic Affairs Hershey Medical Center PO Box 850, MC H043, Hershey, PA 17033 (717)531-8955 x5, Fax:(717)531-4587 Date/Time Printed: 7/13/2012 14:32 EDT Page 25 of 43 Printed By: Tice,Cindy L PENNSTATE HERSHEY WM Milton S. Hershey Medical Center Patient Name: HEISS, GAGE R Musculoskeletal RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: SERVICE DATE/TIME: X-RAY HUMERUS RICHT - PEDS PATIENT NAME: HEISS, GAGE R PATIENT MRN:01631105 PATIENT DOB: 10/09/2003 EXAM DATE OF SERVICE: 04/26/2012 EXAM NUMBER: 7522730 ORDERING PHYSICIAN: KASS, LAWRENCE EXAMINATION: X-RAY HUMERUS RIGHT - PEDS/ER MRN 1631105 Final X-RAY HUMERUS RIGHT - PEDS 4/26/2012 21:15 EDT CLINICAL HISTORY: Pain in the right middle of anterior-posterior humerus, pain, and swelling. Dog bite. COMPARISON: None. FINDINGS: There is no osseous defect identified, specifically there is no fracture fluid or dislocation. The visualized portions of the elbow and shoulder are unremarkable. No gross soft tissue defect identified on radiograph. IMPRESSION: No osseous abnormality identified. DICTATED: MOORE, MICHAEL REVIEWED AND SIGNED: MOORE, MICHAEL DATE DRAFTED: 04/26/2012 09:45 PM DATE OF FINAL SIGNATURE: 04/26/2012 09:46 PM Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L Page 26 of 43 PENNSTATE HERSHEY IIRTI Milton S. Hershey Medical Center Patient Name: HEISS, GAGE R MRN 1631105 �. �.....� �......w.�....._..... ED Secondary Assessment Form...........................................................................w... DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATEIf]ME: ED Secondary Assessment Form 04/26/12 10:19 pm Performed by Gaus, Autumn J Entered on 04/26/12 10:20 pm ED Secondary Assessment - HMC Allergy 1. Shellfish Clinical HeightNVeight Height Height Method Body Mass Index Patient Weight Weight Method Weight Health Habits Reaction 120 cm Standing 18.06 kg/m2 26 kg Standing Scale 26 kg ED Secondary Assessment Form Final Gaus,Autumn J (4/26/2012 22:19 EDT) 4/26/2012 22:19 EDT Cigarette smoker Patient under 13 years of age Tobacco Product Use Patient under 13 years of age Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L Page 27 of 43 PENNSTATE HERSHEY P Milton S. Hershey 11, Medical Center Patient Name: HEISS, GAGE R MRN 1631105 ?.�........ ........ .. ._.., ,..,,.,..,....,,,�.��........ ED Triage Form....,.....,......_......,......�.�.� DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: ED Triage Form 04/26/12 08:11 pm Performed by Walsh, Karen E Entered on 04/26/12 08:13 pm ED Triage Complaint Chief Complaint Heart Rate Systolic Blood Pressure Diastolic Blood Pressure Respiratory Rate Sp02 Temperature Temperature Route Pain Intensity Pain scale used primary. During last month felt down ED Triage Tracking ------------ DCP Generic Code Triage Time Tracking Group Tracking Reg. Status Visit reason Tracking Acuity ED Triage Form Final Walsh,Karen E (4/26/2012 20:11 EDT) 4/26/2012 20:11 EDT attacked by German Shepard while riding his scooter, about 1830, pt has bite wound on left upper arm and skin tear on right upper arm, also abrasions to left upper back, unsure of vaccines for dog, police are working on it 92 bpm 115 mmHg 64 mmHg 16 br/min 98 % 36.9 DegC Oral 3 Wong Baker Pain Scale or depressed N/A Child under 13 without a behavioral disorder 04/26/12 20:13 EMER Trk Gp Start Animal Bite 4 Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L Page 28 of 43 PENNSTATE HERSHEY Milton S. Hershey 1111, Medical Center Patient Name: F EISS, GAGE R Interdisciplinary Narrative Form DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Interdisciplinary Narrative Form 04/26/12 08:30 pm Performed by Gaus, Autumn J Entered on 04/26/12 09:53 pm Interdisciplinary Narrative MRN 1631105 Interdisciplinary Narrative Form Final Gaus,Autumn J (4/26/2012 20:30 EDT) 4/26/2012 20:30 EDT Interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text pt to pdq per triage note, pt awake and alert in NAD, awaiting PA assessment for POC, family at bedside. DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Interdisciplinary Narrative Form 04/26/12 10:57 pm Performed by Gaus, Autumn J Entered on 04/26/12 10:58 pm Interdisciplinary Narrative Interdisciplinary Narrative Form Final Gaus,Autumn J (4/26/2012 22:57 EDT) 4/26/2012 22:57 EDT Interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text pts mother provided dc instructions, understanding verbalized, pt ambulated to checkout. Date/Time Printed: 7/13/2012 14:32 EDT Page 29 of 43 Printed By: Tice,Cindy L PENNSTATE HERSHEY Milton S. Hershey RV Medical Center Patient Name: HEISS, GAGE R Medication History Form DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Medication History Form 04/26/12 10:38 pm Performed by Gaus, Autumn J Entered on 04/26/12 10:38 pm Medication List Historical/Home Medications on Arrival Medication List Completed MRN 1631105 Medication History Form Final Gaus,Autumn J (4/26/2012 22:38 EDT) 4/26/2012 22:38 EDT Order Compliance: Obtained Performed by: Ashton, Stephanie L;Performed Date: 04/26/12 10:26 pm Date/Time Printed: 7'/13/2012 14:32 EDT Page 30 of 43 Printed By: Tice,Cindy L PENNSTATE HERSHEY 11417 Milton S. Hershey 40; Medical Center Patient Name: HEISS, GAGE R Substance NKA Recorded Date/Time Recorded By 7/10/2011 17:57 EDT Tice,Eileen M 1/23/2007 08:59 EST Lesh,Dana M MRN 1631105 Allergy History Reaction Status Canceled; Allergy Type Allergy; Reviewed By Ashton, Stephanie L; Reviewed Date/Time 4/26/2012 20:43 EDT; Recorded On Behalf Of Lesh,Dana M Reaction Status Active; Allergy Type Allergy; Reviewed By Grumbrecht,Rebekah L; Reviewed Date/Time 12/22/2009 13:42 EST; Recorded On Behalf Of Lesh,Dana M Substance Shellfish Recorded Date/Time Recorded By ............................................... 7/10/2011 17:57 EDT Tice,Eileen M Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L Reaction Status Active; Allergy Type Allergy; Reviewed By Ashton, Stephanie L; Reviewed Date/Time 4/26/2012 20:43 EDT; Recorded On Behalf Of Tice,Eileen M Page 31 of 43 PENNSTATE HERSHEY Milton. S. Hershey INIP Medical Center Patient Name: HEISS, GAGE R Recorded Date Recorded Time Recorded By Measurements 4/26/2012 22:19 EDT Gaus,Autumn J Procedure. Units Height cm 120 Height Method Patient Weight Weight ........................... . Weight Method kg kg Standing 26 Body Mass Index kg/m2 26 Standing Scale :......................... 18.06 Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L MRN 1631105 Page 32 of 43 PENN STATE HERSHEY Milton S. Hershey Medical Center Patient Name: HEISS, GAGE R Vital Signs Recorded Date 4/26/2012 Recorded Time 20:11 EDT Recorded By Walsh,Karen E Procedure Units Temperature DegC 36.9 Temperature Route ..................................... Heart Rate .................................... Respiratory Rate Oral bpm br/miri Systolic Blood Pressure ...................... Diastolic Blood Pressure .......... ............ .. . . SpO2 mmHg mmHg 92 16 115 64 98 Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L MRN 1631105 Page 33 of 43 PENNSTATE HERSHEY PIM Milton S. Hershey IWO Medical Center Patient Name: HEISS, GAGE R Procedure Pain scale used primary Pain Intensity MRN 1631105 PainAssessments_._.__._._..._�.__._._._�..._.,.�...._,......r.........�..�...�..............................., Recorded Date Recorded Time Recorded By Units Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L 4/26/2012 20:11 EDT Walsh,Karen E Wong Baker Pain Scale 3 Page 34 of 43 PENNSTATE HERSHEY P Milton S. Hershey IP Medical Center Patient Name: HEISS, GAGE R Intake & Output INTAKE - (mL) All time in EDT amoxicillin -clavulanate 8 Hour Total ............. 24 Hour Total 4/26/2012 - 4/27/2012 7a.m. 3p.m. 3p.m. 11p.m. 6.25 ::.:::.......... 6.25 Total 6.25 6.25 :OUTPUT - (mL) ...................... All time in EDT 8 Hour Total 24 Hour Total 4/26/2012 - 4/27/2012 7a.m. 3p.m. 3p.m. - 11p.m. 11p.m. -: Total 7a.m. No documented output results for date range Clinical Range Total from 4/26/2012 to 4/27/2012 ................................................................. ....... Total Intake Total Output 6.25 0 MRN 1631105 Fluid Balance 6.25 Date/Time Printed: 7/13/2012 14:32 EDT Page 35 of 43 Printed By: Tice,Cindy L PENNSTATE HERSHEY P Milton S. Hershey Medical Center Patient Name: HEISS, GAGE R MRN 1631105 �... ��.. �_.�......._......�.._`_Routine Care Documentation...... �.k..w ... �.... .... .... ... .... Procedure Recorded Date 4/2612012 Recorded Time 22:19 EDT Recorded By Gaus,Autumn J Cigarette smoker Tobacco Product Use Patient under 13 years of age Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L Patient under 13 years of age Page 36 of 43 PENN STATE HERSHEY P4 Milton S. Hershey 111, Medical Center Patient Name: HEISS, GAGE R Orders MRN 1631105 Order Date/Time: 4/26/2012 23:00 EDT Order: diphtheria -tetanus toxoids,DT (Pediatric) Completed .: :........ ...:....::.:.:.:.. _......:::.. ,..... .......... Order Status:, ... Completed Catalog Type: Pharmacy Ordering Physician: Ashton,Stephanie L Entered By: Gaus,Autumn J on 4/26/2012 22:37 EDT Order Details: 0.5 mL, injection, IM, ONCE, Routine, 04/26/12 23:00:00, 04/26/12 23:00:00 Order Comment: Order Date/Time: 4/26/2012 23:00 EDT Order: amoxicillin -clavulanate (Augmentin 400 mg/5 mL oral liquid) Order Status: Completed Catalog Type: Pharmacy Ordering Physician: Ashton,Stephanie L Entered By: Gaus,Autumn J on 4/26/2012 22:57 EDT Order Details: 500 mg, oral susp, PO, ONCE, Routine, 04/26/12 23:00:00, 04/26/12 23:00:00, Amoxicillin 400 mg -Clavulanate 57 mg/5 ml Order Comment: Order Date/Time: 4/26/2012 22:26 EDT Order: Document Infusion Stop Date/Time on EMAR Order Status: Completed Catalog Type: Patient Care Ordering Physician: SYSTEM Entered By: Gaus,Autumn J on 4/26/2012 22:58 EDT Order Details: 04/26/12 22:26:33, ONCE, Stopping On 04/26/12 22:26:33 ................. Order Comment: Document Infusion Stop Date/Time on EMAR Order Date/Time: 4/26/2012 22:26 EDT Order: Discharge from ED. Order Status: Completed Ordering Physician: Ashton,Stephanie L Entered By: Gaus,Autumn J on 4/26/2012 22:58 EDT Catalog Type: Patient Care Order Details: Routine, Requested Discharge Dt: 04/26/12 22:26:00, Discharge to Home Order Comment: Order Date/Time: 4/26/2012 20:43 EDT Order: Humerus XR Order Status: Completed Ordering Physician: Ashton,Stephanie L atalog Type: Radiology Entered By: Contributor_system,IDXOE01 on 4/26/2012 21:16 EDT Order Details: STAT, Requested Dt: 04/26/12 20:43:00, Right., Views: bite Order Comment: Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L *Standard Views, 1CD9: Trauma 959.8 History: dog Page 37 of 43 PENNSTATE HERSHEY M1 Milton S. Hershey Medical Center Patient Name: HEISS, GAGE R Orders MRN 1631105 Order Date/Time: 4/26/2012 20:13 EDT Order: Vital Signs Level 4 and 5 (ED) Order Status: DISCONTINUED Catalog Type: Patient Care Ordering Physician: SYSTEM Entered By: SYSTEM on 4/27/2012 02:01 EDT Order Details: 04/26/12 20:13:47, q6h Order Comment: Vital Signs Level 4 and 5 (ED) Order Date/Time: 4/26/2012 20:04 EDT Order: Safety/Quality Verification Order Status: DISCONTINUED Catalog Type: Patient Care Ordering Physician: SYSTEM Entered By: SYSTEM on 4/27/2012 02:01 EDT Order Details: 04/26/12 20:04:07, Midnight Order Comment: Safety/Quality Verification Order Date/Time: 4/26/2012 20:04 EDT Order: Ped Skin Assessment on Arrival Order Status: DISCONTINUED :Catalog Type: Patient Care Ordering Physician: SYSTEM Entered.By: . By: SYSTEM on 4/27/2012 02:01 EDT ................................................................................. Order Details: 04/26/12 20:04:07 Order Comment: Ped Skin Assessment on Arrival Order Date/Time: 4/26/2012 20:04 EDT Order: ED Assessment Order Status: DISCONTINUED Ordering Physician: SYSTEM Entered By: SYSTEM on 4/27/2012 02:01 EDT . Order Details: 04/26/12 20:04:07, ONCE, Stopping On 04/26/12 20:04:07 atalog Type: Patient Care Order Comment: ED Assessment Order Date/Time: 4/26/2012 20:04 EDT Order: ED Visit Order Status: Completed Ordering Physician: SYSTEM Entered By: SYSTEM on 4/26/2012 20:04 EDT Catalog Type: Patient Care Order Details: Request Dt: 04/26/12 20:04:06 Order Comment: ED Visit Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L Page 38 of 43 PENN STATE HERSHEY PPM Milton S. Hershey 11.0 Medical Center Patient Name: HEISS, GAGE R Orders MRN 1631105 Order Date/Time: 4/26/2012 20:04 EDT Order: ED Nursing Charge Order Status: Completed Ordering Physician: SYSTEM Catalog Type: Patient Care Entered By: Gaus,Autumn J on 4/26/2012 22:58 EDT Order Details: Request Dt: 04/26/12 20:04:06 Order Comment: ed nursing charge Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L Page 39 of 43 PENNSTATE HERSHEY PPM Milton S. Hershey Medical Center Patient Name: HEISS, GAGE R Medication Orders MRN 1631105 Order Date/Time: 412612012 23:00 EDT Order: diphtheria -tetanus toxoids,DT (Pediatric) Order Status: Completed Ordering Physician: Ashton,Stephanie L Entered By: Gaus,Autumn J on 4/26/2012 22:37 EDT Order Details: 0.5 mL, injection, IM, ONCE, Routine, 04/26/12 23:00:00, 04/26/12 23:00:00 Order Comment: Order Date/Time: 4/26/2012 23:00 EDT Order: amoxicillin -clavulanate (Augmentin 400 mg/5 mL oral liquid) Order Status: Completed Ordering Physician: Ashton,Stephanie L Entered By: Gaus,Autumn J on 4/26/2012 22:57 EDT Order Details: 500 mg, oral susp, PO, ONCE, Routine, 04/26/12 23:00:00, 04/26/12 23:00:00, Amoxicillin 400 mg -Clavulanate 57 mg/5 ml Order Comment: Order Date/Time: 4/26/2012 22:26 EDT Order: amoxicillin -clavulanate (Augmentin 250 mg/5 mL oral liquid) Order Status: Completed Ordering «:. ring Physician: Ashton,Stephanie L Entered By: SYSTEM on 5/1/2012 22.30 EDT Order Details: Start: 04/26/12 22:26:00, 10 mL, PO, g12h, Disp# 100 mL, X 5 clay, Stop: 05/01/12 22:26:00 Order Comment: Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L Page 40 of 43 PENNSTAI E HERSHEY MI Milton S. Hershey Medical Center Patient Name: HEISS, GAGE R MRN 1631105 Medication Administration Record Medications Admin Date/Time: 4/26/2012 22:57 EDT Charted Date/Time: 4/26/2012 22:57 EDT;; Medication Name: amoxicillin -clavulanate Augmentin 400 mg/5 mL oral liquid) Ingredients: AUG400S 500 mg 6.25 rnL Admin Details: (Auth) PO Action Details: Order: Ashton,Stephanie L 4/26/2012 22:23 EDT; Perform: Gaus,Autumn J 4/26/2012 22:57 EDT; VERIFY: Gaus,Autumn J 4/26/2012 22:57 EDT Admin Date/Time: 4/26/2012 22:36 EDT Charted Date/Time: 4/26/201222:37 EDT Medication Name: diphtheria -tetanus toxoids, DT (Pediatric) Ingredients: diphtheria -tetanus toxoids, DT (Pediatric) 0.5 mL Admin Details: (Auth) IM, Deltoid Left Action Details: Order: Ashton,Stephanie L 4/26/2012 22:16 EDT; Perform: Gaus,Autumn J 4/26/2012 22:37 EDT; VERIFY: Gaus,Autumn J 4/26/2012 22:37 EDT Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L Page 41 of 43 PENNSTATE HERSHEY Milton S. Hershey Medical Center Patient Name: HEISS, GAGE R Vaccine: diphtheria -tetanus toxoids,DT (Ped) Recorded By: Gaus,Autumn J Manufacturer: sanofi pasteur PowerChart MRN 1631105 Immunization Record ......................_._._... _,.,., �...,k Date Given: Age: 4/26/2012 22:36 EDT 8 years Site: Deltoid Left Lot Number: U3867BA Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L Route: Amount: IM a.5mL Expiration Date: Data Source: 4/18/2013 00:00 EDT PowerChart Page 42 of 43 PENNSTATE HERSHEY F1 Milton S. Hershey Medical Center Patient Name: HEISS, GAGE R Recorded Date Recorded Time Recorded By Procedure Units Height cm MRN 1631105 Height /Weight Measurements Height 4/26/2012 22:19 EDT Gaus,Autumn J 120 Procedure Recorded Date Recorded Time Recorded By Units 4/26/2012 22:19 EDT Gaus,Autumn J Patient Weight kg Date/Time Printed: 7/13/2012 14:32 EDT Printed By: Tice,Cindy L 26 Weight............................................................ ........ .._� .�� .�,�.,. , ,w� .�..., t Page 43 of 43 07/02/2013 02:37:00 PM Remote ID -> Page 13 / 33 History & Physical Report #10 Gage R Reiss 5/4/201211:25 AM Location: Aspire Family Medicine Patient #: 24040 DOB: 10/9/2003 Undefined / Language: English / Race: White Male History of Present Illness (Richard Rayner, MD; 5/4/2012 11:44 AM) Patient words: est. pt is here w/c of follow up on a dog bite on the right upper arm and the left side of the back Pt was given steristrips to close the wound on the upper arm. Doing well Some soreness still. NO drainage. The patient is a 8 year, 6 month old male who presents with a corn plaint of follow up to ER visit. Problem List/Past Medical (Richard Rayner, MD; 5/4/2012 11:46 AM) No past medical problems Allergies (Jeanine Pfaff, M.A.; 5/4/2012 11:31 AM) No Known Drug Allergies Family History (Jeanine Pfaff, M.A; 5/4/2012 11:31 AM) Heart disease. Family Members In General. Diabetes Mellitus Social History (Jeanine Pfaff, M.A.; 5/4/201211:31 AM) Living Situation. mom, sis• sees dad every other weekend Non Smoker/ No Tobacco Use Non Drinker/ No Alcohol Use Medication History (Jeanine Pfaff, M.A.; 5/4/2012 11:31 AM) Polytrim (10000-0.1UNIT/ML-% Solution 2 (two) drops to each eye Ophthalmic three tines daily, Taken starting 01/27/2012) Active. Past Surgical History (Jeanine Pfaff, M.A.; 5/4/2012 11:31 AM) None Other Problems (Richard Rayner, MD; 5/4/2012 11:46 AM) ORCHITIS/EPIDIDYMITIS NOS (604.90). LEFT OTITIS MEDIA NOS (382.9) CON) UNCTIVITIS NOS (37 .30) INFECTION, UP RESPIRAT, MLT SITES, ACUTE NOS (465.9) ENTERITIS, VIRAL NOS (008.8) DISEASE ACUTE BRONCHOSPASM (519.11) DYSFUNCTION, EUSTACHIAN TUBE (381.81) 6 YEAR WELL CHILD VISIT (V20.2) Review of Systems (Richard Rayner, MD; 5/4/2012 11:43 AM) General: Present- Feeling well. Not Present- Fatigue and Fever. Skin: Not Present- New Lesions and Rash. HEENT: Not Present- Headache, Visual Disturbances and Frequent Colds. Neck: Not Present- Neck Pain. Respiratory: Not Present- Cough and Difficulty Breathing. Cardiovascular: Not Present- Chest Pain and Difficulty Breathing Lying Down. Gastrointestinal: Not Present- Abdominal Pain Change in Bowel Habits, Chronic diarrhea and Constipation. Musculoskeletal: Not Present- Joint Pain and Swelling of Extremities. Neurological: Not Present- Numbness and Paresthesias. Endocrine: Not Present- Excessive Urination and Hair Changes. Hematology: Not Present- Easy Bruising and Nose Bleed. Vitals (Jeanine Pfaff, M.A.; 5/4/2012 11:29 AM) 5/4/2012 11:25 AM Weight: 57.25 lb Height 47 in Body Surface Area: 0.93 mz Body Mass Index: 18.22 kg/m2 Pulse: 64 (Regular) BP: 98/70 (Sitting, Left Arm, Standard) Physical Exam (Richard Rayne-, MD; 5/4/2012 11:46 AM) The physical exam findings are as follows: 07/02/2013 08:12 am Qage R. lieiss 1810/09/2003 Page 12/32 07/02/2013 02:37:00 PM Remote ID -> Page 14 / 33 General Mental Status -Alert. General Appearance - Well groomed. Not in acute distress. Orientation -Oriented X3. Posture - Normal posture. Gait -Normal. Hydration -Well hydrated. Integumentary Problem #1: Description: Appearance - Note: 5 mm linear lesion med mid prox RUE, scabbed; some brusing Assessment & Plan (Richard Rayner, MD; 5/4/2012 11:47 AM) INJURY DUE TO DOG BITE (E906.0) Impression: resolve a nicely; complete tetanus shot (never had series) Current Plans I Follow up as needed Note: NV for imm un in 2 mos /el:7> Signed electronically by Richard Rayner, MD (5/4/2012 12:56 PM) 07/02/2013 OB:42 am C3cje R. Feiss DOB 10/09/2003 Page 13/32 EXHIBIT C ` ennsylvani DEPARTMENT OF PUBLIC WELFAf February 4, 2014 ANAPOL SCHWARTZ ATTORNEYS AT LAW CHRISTOPHER J MARZZACCO ESQUIRE 252 BOAS ST HARRISBURG PA 17102 Re: Gage Heiss (minor) CIS #: 850164176 Incident Date: 04/26/2012 Dear Attorney Marzzacco: Pursuant to our previous correspondence, please be advised that our claim against your client's personal injury award is detailed on the attached statement of claim. Social Security Act §1902(a)(7) requires that this recipient information be safeguarded, used by you solely to recover funds that we provided. Disclosure for other purposes Is subject to criminal and monetary penalties. Please contact this office well in advance of settlement so that we can provide you with an updated statement of claim. In the event that the Department continues to provide your client with medical and/or cash assistance, the amount of our claim will increase accordingly. This statement does not include any other claims which may exist. If copies of bills are needed, please contact the providers directly. Refer them to the Medical Assistance Bulletin, No. 99-09-03 (Effective Date 03/20/09). Checks should be made payable to the Department of Public Welfare and sent to my attention at the above address. We request that with all transmittal of funds, you provide the Department with a copy of the final distribution sheet. Please advise us of your position regarding payment of the Department's claim in this matter, as well as the present status of this case. Bureau of Program Integrity 1 Division of Third Party Liability I Recovery Section PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486 pennsyLvani 6EPARTMt NT bf i U61.1c. If you have any further questions, please contact me. Thank you for your cooperation in this matter. Sincerely, Elizabeth D. James TPL Program Investigator 717-772-6397 717-772-6553 FAX Enclosure Bureau of Program Integrity 1 Division of Third Party Liability 1 Recovery Section PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486 COMMONWEALTH OF PENNSYLVANIA . BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY RECOVERY SECTION PO BOX 8986 HARRISBURG, PA 17105-8486 February 1, 2014 STATEMENT OF CLAIM SUMMARY HEISS, GAGE 850 164 176 QICA'ir � : i � '.". fin° USUAL•'CHARGES ?�" + r,1n`? * 4 � nr,AM7AP ROVED ter. a CLAIMS 4,149.88 782.26 �1A�, r �'Y�`i��� ryry :/`' . r�} 'Yt z }XI EFtI IYCOVE D M'«'G?a1iPyx'. *'.Y 4ZS >. x`.'b> SOOIaLA 4kMO �NT�'�, '4 -0;.- SMM` . CURRENT SOC — .00 REIMBURSE 782.26 OMMONWEAITHi OF IN tea: TOP `LEA QEPARTMENi C?F PUBLIC WELEARE Ay • ass�EIN�3t.23 60031013,k,,,„ Page 1 of 10 EXHIBIT D GENERAL U���8���� ,,~~�~~~~~ For the consideration of ELEVEN THOUSAND DOLLARS AND NO/1 ---- ' ----- dollars [$ 11,000.00 receipt of which is hereby acknowledged, l/we release and discharge, and for myself/ourselves my/our heirs, representatives, executors, administrators, successors and assigns, do hereby remise, release and forever discharge SHARON K STEVENS 01017129834—NJ hereinafter referred to as the releasee(s), his/her/their/its heirs, executors, administrators, insurers, successors and assigns, and any and all other persons, firms, corporations, associations, of and from any and all causes of action, suits, judgments, claims and demands of whatsoever kind, in law or in equity, known and unknown, which I/we now have or may hereafter have, and/or which the minor GAGE HEISS now has or may hereafter have, especially the claimed legal liability expressly deny(ies), arising from or by reason of any and all bodily or personal injury and or property damage known and unknown, foreseen and unforeseen which heretofore has/have been or which hereafter may be sustained by me/us or the minor aforementionearisingu�������monmu����pR��� �� ��� a�nrnoar��pH/�L '�mw��un�o/CU�8ER��� in the State of PENNSYLVANIA , in which the minor aforementioned sustained personal injuries and/or property damage. IIVVe agree that the consideration set forth is to and paid to me/us with respect to any and all damage to any m ty, either real or personal, of mine/ours or the minor afommmn{ioned, and with respect tany and all personal or bodily injury of mine/ours or the minor oforemendunod, whether presently known or unknown, foreseen or unforeseen or which may subsequently develop and the consequences thereof, all as arising from the aforementioned accident. I/\Ne further agree that the consideration set forth above is specifically to any right of contribution that I/we or the minor aforementioned may have ainst the releasee(s), his/her/their/its hoi,s, executors, ndministra\*m, innuras, successors and assigns relative to claims of others that may be brought against me/us or the minor aforementioned by reason of said accident. I/We further agree that the consideration set forth above is specifically a plicabie to that I/we or the minor aforementioned will not join nor attempt to join the nuensue<$^ his/her/their/its Ue|,s, executors, administrators, |nomnrs, successors and assigns in any capacity, in any action that may be brought against me/us or the minor aforementioned arising out of said accident. In consideration of the aforesaid payment, I/we for mysotflvvmemrs and my/our heirs, representatives, executors, administrators, successors, and assigns do hereby: (1) agree to indemnify and hold forever harmless the releasee(s) and his/hen1,s/the|r/=»m"entotives. administrators, or assigns, against loss from any and allhunhe la| demands actions that may hereafter be made atony time or brought against the releasee(s) by ma/us or the minor aformennunod, or by anyone in our behalf for the purpose of enfrciogahurthoru|oim.*orwhichUhisna|aaseisgiven; (2) warrant that I/we have received no money or other valuable consideration from any other person or persons by reason of any causes of action, ouitn, vovenmno, agreements, judgments, claims and demands of whatsoever kind, which I/we now have or may hereafter have, for injuries to person or property arising out of the enunemondonod accident or for the other matters for which this release is Intending Wstviltellegally bound thereby, WITNESS my/our hand(s) and seal(s) this day of c+°w WITNESSES: X' (Seal) C -111M (R) 04105 EXHIBIT E Page: 1 Gage Heiss June 02, 2014 5011 McDonald Drive Account No: 240639-0C Apt 6 Statement No: 931C Mechanicsburg PA 17050 Attn: 4-25-2014 HEISS, GAGE Draft Bill 08/07/2012 MEDICAL RECORDS - (13303) RECORD REPRODUCTION SOLUTIONS - MILTON S HERSHEY MEDICAL CENTER -MEDICAL & BILLING 130.09 04/10/2013 POLICE /ACCIDENT/FIRE REPORTS - (15159) LOWER ALLEN TOWNSHIP POLICE DEPARTMENT - POLICE REPORT 15.0C 04/22/2013 POLICE /ACCIDENT/FIRE REPORTS - (15159) LOWER ALLEN TOWNSHIP POLICE DEPARTMENT - INCIDENT COMPLAINT 10.0C 05/29/2013 RESEARCH- (13842) MEA SERVICES, INC. - 5/18/13 ID INSURER, POLICY # 450.0C 08/08/2013 MEDICAL RECORDS - (13303) RECORD REPRODUCTION SOLUTIONS - ASPIRE URGENT CARE 30.5C 05/30/2014 PROTHONOTARY (10603) PROTHONOTARY OF CUMBERLAND COUNTY - FILING FEE PETITION TO APPROVE MINOR'S SETTLEMENT 103.75 Total Advances 739.34 06/07/2013 VOID CHECK # 501481 4/10/13 LOWER ALLEN TOWNSHIP POLICE DEPARTMENT -15.0C Total Credits for Advances -15.0C Total Current Work 724.34 Balance Due $724.34 RXHIBIT F ANAPOL SCHWARTZ 1710 SPRUCE STREET PHILADELPHIA, PENNSYLVANIA 19103 CONTINGENT FEE AGREEMENT/POWER OF ATTORNEY THIS IS A BINDING LEGAL DOCUMENT. READ IT CAREFULLY BEFORE YOU SIGN IT. KEEP A COPY FOR YOUR RECORDS. Date: May 10, 2012 I, Jessica McCoy, as parent or legal guardian of Gage Hess; hereby constitute and appoint Christopher Marzzacco, Esq. of the law firm Anapol Schwartz, to prosecute a claim against The claimant is Gage Hess and the cause of action arose on Anapol Schwartz has agreed, at our request, to represent me/us for the above specific claim without payment of any retainer or an hourly fee for the investigations and legal work they will perform. Counsel may not receive any compensation, whatsoever, and may be required to wait a considerable period of time to receive any payment. I/We hereby agree in any claim brought on Client's behalf, to pay to Anapol Schwartz, for its services an amount equal to twenty-five percent (25%) of all funds or property accruing to Client as a result of Anapol Schwartz's services in securing a settlement without litigation; and an amount equal to thirty-three and one third percent (33 1/3%) of all funds or property accruing to Client as a result of Anapol Schwartz's services in securing a settlement after the filing of a lawsuit. From the net balance remaining, I/we agree to pay the expenses of suit, including filing fees, costs to obtain records, deposition costs, investigation fees, costs of witnesses, including expert witnesses, consultants to ensure Medicare/Medicaid compliance, and costs for trial. UWe are aware that Brian Perry, Esq. , will receive a referral fee out of the total attorneys' fee from Anapol Schwartz for acting as cooperating counsel. I/We understand that the payment of the cooperating counsel fee does not increase or affect the total contingent fee paid by me/us. I/We do not object to this division of fees. UWe acknowledge that my/our attorneys have advised me/us that the relationship of attorney and client is based upon mutual trust and confidence and that they will endeavor to keep me/us advised of important developments in their representation of me/us. They have further advised me/us that Uwe are free to communicate with them and ask them questions from time to time as appropriate. Pursuant to this agreement, said attorneys shall represent me/us and may institute suit on my/our behalf when, and if, they believe suit should be instituted. It is further understood and agreed that, upon notification to me/us (certified, registered or regular U.S. mail), said attorneys may withdraw as counsel in the event of me/our failure to cooperate of if they conclude, in their sole judgment, that the claim cannot be successfully prosecuted by them. In the event the attorneys withdraw as my/our counsel, they agree that I/we will not be obligated to pay them for any professional services they have rendered. I/We further agree that the notification to me/us shall be considered to take place upon mailing of said notification to the last address for me/us known to the attorneys in a pre -paid envelope deposited with the U.S. mail. v�b a It is further understood and agreed that, upon the completion of my/our claim and/or the closure of my/our file, Anapol Schwartz will only retain my/our file for a period of six (6) months. Thereafter, portions of my/our file (as selected by Anapol Schwartz) may be electronically retained and the physical file will be destroyed. Thus, it is my/our responsibility to inform Anapol Schwartz immediately upon the completion of my/our claim, if I desire the return of any portion of the file. I/We hereby authorize said attorneys to pay medical bills on my/our behalf directly to the physician(s) or hospital(s) concerned. I/We further agree that should I/we discharge said attorneys, my attorneys shall be entitled to immediate reimbursement of costs and disbursements and that I/we shall be liable to pay attorneys either a payment of a fee according to the above -agreed percentage of any settlement offers obtained prior to discharge or a payment based upon time actually expended or reasonably estimated at the attorney's prevailing rates for work performed prior to discharge. The obligation to reimburse Anapol Schwartz for attorneys' fees and costs shall be payable immediately after discharge. I/We hereby acknowledge that a copy of this document has been given to me/us and that I/we have been advised to retain it in my/our possession and that I/we have read and understood the contents of this document before I/we signed it. SHOULD NO MONEY BE RECOVERED BY SUIT OR SETTLEMENT, SAID ATTORNEYS ARE TO HAVE NO CLAIM OF ANY KIND AGAINST ME/US FOR ANY PROFESSIONAL SERVICES RENDERED. Jessica McCoy (Claimant) (Address) (Additional Claimant : me, if applicable) (Address (Signature of Ad• onal Claimant "1 nr JUN �� 2;:: n, C;UPiBER ANO %GUJt�i ANAPOL SCHWARTZ BY: Christopher J.Marzzacco,Esquire EPP�$Y�� kYi, Attorney ID 478262 4807 Jonestown Road Suite 148 Harrisburg,PA 17109 (717)901-3500 c marzzaccon ang o 1 schwartz.com Attorneys for Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GAGE HEISS, a minor, by and through his mother, r JESSICA McCOY NO. — L V. CIVIL ACTION - LAW SHARON K. KING ORDER AND NOW, this day of �L� 2014, upon the consideration of the unopposed Petition for Leave to Settle or Compromise Minor's Action, it is hereby ORDERED and DECREED that the proposed settlement of the above-captioned minor's personal injury claim for the total amount of$11,000.00 is approved and the Minor's mother and natural parent is permitted to sign releases to effectuate the same. IT IS FURTHER ORDERED, that the settlement proceeds be distributed as follows: TOTAL SETTLEMENT: $ 11,000.00 TO: Anapol Schwartz—For legal fees $ 2,750.00 TO: Anapol Schwartz - For reimbursement of costs $ 724.34 TO: The DPW—For medical bills paid $ 782.26 TO: GAGE HEISS, a minor, the sum to be deposited in the $ 6,743.40 name of the minor only in federally insured savings accounts, certificates of deposit or credit union accounts or accounts investing only in securities guaranteed by the United States government or a Federal governmental agency managed by responsible financial institutions. The account(s) shall be marked"not to be withdrawn until the minor reaches the age of eighteen (18) years, except for the payment of local, state and federal income taxes on earnings of the certificate or account or upon further Order of the Court." BY THE COURT: J. Goo *LCCL � Y �/atl//y ANAPOL SCHWARTZ BY: Christopher J. Marzzacco, Esquire Attorney ID #78262 4807 Jonestown Road Suite 148 Harrisburg, PA 17109 (717) 901-3500 cmarzzacco(@,anapolschwartz.com Attorneys for Plaintiff F.ILED-OFFIC or THE PRO THON0 TAR 2014 SEP -8 Ail IT: 4 CUMBERLAND COUNTY PENNSYLVANIA IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA GAGE HEISS, a minor, by and through his mother, JESSICA McCOY V. SHARON K. KING NO. 14-3556 Civil Term CIVIL ACTION - LAW AFFIDAVIT OF DEPOSIT The undersigned, counsel for Jessica McCoy, parent and natural guardian of Gage Heiss, a minor, hereby certifies that the net settlement amount of $6,743.40 as set forth in this Court's order dated June 24, 2014 was deposited into a restricted, federally insured account. Proof of Deposit is attached hereto as Exhibit A. BY: Respectfully submitted, ANAPOL SCHWARTZ Christopher J. Marzzacco, Esquire Attorney ID No. 78262 EXHIBIT A Payment Confirmation Page 1 of 1 ratairs /WOW sr Payment Confirmation The CCD Payment request below has been transmitted successfully. Template Information Template name: Request type: CCD Payment Company name/ID: Anapol Schwartz / 3232031638 Template description: client Debit account: - *7524 - 2 Trust Account Effective date: 09/03/2014 Transmit Status: Transmitted Confirmation number: 4291784398 Credit/Destination Accounts Approval History Information Approval status: 1 of 1 received Action ABA/TRC Account Account Type Name Detail ID Amount ANAPOL 231382555 *8271 Savings Gage Heiss client/240639 $6,743.40 Additional information: Gage Heiss - Restricted per Court Order - settlement 240639/client Total: $6,743.40 Approval History Information Approval status: 1 of 1 received Action User ID Date Enter Request ANAPOL 09/02/2014 03:49:14 PM (ED Approve/Transmit Request ANAPOL 09/02/2014 03:49:14 PM (ET) https://totalcashmanager.ebanking-services.com/nubi/Ach/Views/Ach/Ach_Request_Confir... 9/2/2014