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HomeMy WebLinkAbout14-3685t?0 THONG 2014 JUN p; : F'EPNrrsYL COUNTY SCHMIDT KRAMER PC BY: MICHAEL E KOSIK, ESQUIRE I.D. # 36513 209 State Street Harrisburg, PA 17101 P (717) 232-6300 F (717) 232-6467 Attorneys for Plaintiffs mko sik(a,schmidtkramer. com CURT and AMANDA ALLEMAN, • Individually and as Parents and : IN THE COURT OF COMMON PLEAS Natural Guardians of : CUMBERLAND COUNTY, REBECCA ALLEMAN, : PENNSYLVANIA Petitioners • • No. • (o SS Cut i : Orphans Court Division Petition for Court Approval of Minor's Settlement Pursuant to Pa.R.C.P 2039 AND NOW, comes Petitioners Curt and Amanda Alleman as Parents and Natural Guardians of the minor Rebecca Alleman seeking Court approval of a settlement on behalf of the minor, Rebecca Alleman, respectfully representing the following: 1. Petitioner Amanda Alleman is the mother and natural guardian of 6 the minor Rebecca Alleman, who resides at 5 Adams Street, Apt. 1, Enola, /61 rs,,c r Pennsylvania, 17205. a' nl, ff 36/gS 2. Petitioner Curt Alleman is the father and natural guardian of the minor Rebecca Alleman, who resides at, 324 East Bird Street, Shippensburg, Pennsylvania 17257. 3. The minor, Rebecca Alleman, were born on October 31, 2007 and was approximately 3 months shy of her 5th birthday at the time of the accident and will be 7 years old this October. 4. Petitioners Amanda and Curt Alleman are separated but have joint custody of the minor, Rebecca Alleman. 5. The minor Rebecca Alleman was injured on August 10, 2012 while she was at the home of her babysitter Jennifer Zelner located at 140 East Columbia Road, Enola, Cumberland County, Pennsylvania 17025. 6. Ms. Zelner rented an apartment from Milo Smith who was the owner of the property located 140 East Columbia Road, Enola, Cumberland County, Pennsylvania 17025. 7. On August 10, 2012 Ms. Zelner, or someone under her direction, placed Rebecca on the elevated back porch or landing without direct supervision. 8. While on the porch or landing Rebecca Alleman, who was only four years old, sat or leaned against a railing which broke causing her to fall onto a paved driveway below sustaining extensive injuries as a result of the fall. See East Pennsboro EMS trip sheet attached as Exhibit A. 9. The minor Plaintiff Rebecca Alleman was immediately transported to Hershey Medical Center where she underwent extensive evaluation and treatment with her initial diagnosis including a concussion, left orbital fracture, and left femur fracture which required her to be hospitalized from August 10 through August 14, 2012. See Hershey Medical Center Discharge Summary attached as Exhibit B. 10. Rebecca Alleman made slow progress from the orthopedic injuries but eventually transferred out of a cast into a walker by September 20, 2012 and she improved as far as her nightmares or psychological injury. 11. By October 8, 2012, approximately two months following the accident she was released to begin resuming her normal activities from an orthopedic standpoint, however, Rebecca continued to have problems with headaches and a concern was raised regarding a possible closed head injury as a result of the facial fractures and the blow to her head. 12. Rebecca Alleman continued to have problems with headaches and reoccurring infections of her sinuses until it was eventually recommended by the ENT Department of Hershey to undergo an extensive frontal craniotomy on May 29, 2013. See Discharge Summery from Hershey Medical Center attached as Exhibit C. 13. This procedure appears to have improved the headaches and reoccurring infections that the minor Rebecca Alleman had been suffering and the only continuing concern appears to be with the long-term consequences of the closed head injury. 14. At this time the minor Plaintiff Rebecca Alleman is not actively treating and continues to be monitored by her parents. 15. At the time of the accident minor Plaintiff Rebecca Alleman was covered by her mother's health insurance plan based upon Petitioner Amanda Alleman's employment with ICF Consulting Group Inc. 16. As result of injuries sustained by Rebecca Alleman, Petitioners incurred medical charges, some of which were paid by private health insurance, some of which were paid by medical assistance, some which were paid by her parents or remain unpaid. 17. The medical insurance to which Petitioner Amanda Alleman had through her employer was through was an ERISA qualified plan which is asserting a right of subrogation in the amount of $43,741.20. See Statement of Claim attached hereto as Exhibit D. 18. Because it appeared that some payments may have been made by the Pennsylvania Department of Welfare, Petitioner's counsel contacted the Department of Welfare to see if there was any claim being made for reimbursement of medical expenses. A letter was received from the Recovery Section Manager dated April 14, 2014 advising that DPW has no claim against this individual. See letter attached hereto as Exhibit E. 19. Durable medical equipment in the form of a wheel chair and commode were provided by PRO2 Respiratory Services for which the bill was partially paid. The most recent statement of services shows an outstanding balance of $1,563.55. PRO2 Respiratory Services has agreed to accept $1,172.62 in satisfaction of the outstanding balance and will be paid out of the settlement. See statement and letter confirming a compromise attached as Exhibit F. 20. Hershey Medical Center, where the minor Plaintiff has received most of her care, still has an outstanding balance of $3,504.25 for the hospital care and $616.40 for the physician's care. Hershey has agreed to accept 50% of the outstanding balance in satisfaction of the bills. See letter from Hershey Medical Center attached as Exhibit G. 21. As a result of the Minor's injury occurring at the daycare run by Jennifer Zelner, Petitioners initially retained Attorney Michael E. Kosik of the law firm of Angino and Rovner who subsequently changed law firms to Schmidt Kramer, to represent them in this matter. 22. Petitioner asserted a claim against Jennifer Zelner since she was responsible for running the daycare and supervision of the daycare where the minor Plaintiff was injured. 23. Petitioners have been advised that Jennifer Zelner had no liability insurance to cover her for this incident. Inspite, of repeated requests for written confirmation of insurance, no additional information has been forthcoming. 24. Petitioners through their attorney also asserted a claim against Milo Smith, the owner of the property, on the basis that the property was not properly maintained, particularly for the activities that were being carried on at the property, i.e. daycare with small children. 25. Milo Smith was insured by Westfield Insurance Company, who although denying liability, has agreed to tender its policy limits of $300,000 in exchange for a General Release of all claims against Mr. Smith, Jennifer Zelner, and Westfield Insurance Company arising out of this accident. 26. Petitioners have agreed to place $100,000.00 of the settlement proceeds in a structured settlement that will provide an education fund for the minor when she turns 18 years old as well as providing for a monthly income which she would be attend a four year school. See Structured Settlement Agreement attached as Exhibit H. At this time of the accident Petitioner Amanda Alleman was a new employee with ICF Consulting Group and had been employed less than 90 days. 27. Petitioner Manda Alleman was permitted to remain off work for 30 days based upon the Family and Medical Leave Act (FMLA). 28. Due to the minor Rebecca Alleman's injuries Petitioner Amanda Alleman was not able to return to work within 30 days and lost her job. 29. Petioner Amanda Alleman did find a new job however, her new employment did not provide for medical coverage. 30. Petitioner Amanda Alleman was required to purchase private health insurance at a cost of $234.47 a month. 31. Petitioner Amanda Alleman would request that the Court would permit her to recover the cost of the private health insurance for the one year period from May 2013 through May 2014. See statement from Coventry Health Care showing the monthly cost of health care coverage paid by Petitioner Amanda Alleman totaling $2,831.64 attached as Exhibit I. 32. Petitioner believes the structure is a good measure providing for the minors needs given the fact that there would still be in excess of $60,000 available to place in a restricted account should an unexpected and unanticipated expense arise before Rebecca's 18th birthday. 33. Petitioner's counsel has had the structured settlement proposal reviewed by an independent structured settlement consultant, Keith Isleib, who has prepared an evaluation which confirms the structure proposal is acceptable. See evaluation of Keith Isleib attached hereto as Exhibit J. 34. As previously stated Petitioners engaged Michael Kosik from the law firm of Angino and Rovner, subsequently Schmidt Kramer, to prosecute this action for recovery against any potential defendants and entered into a contingency fee agreement with said attorney providing for professional services and percentage of the amount recovered plus expenses. 35. Your Petitioners agree, subject to approval of your Honorable Court, to pay Schmidt Kramer the sum of $90,000 for the work they have performed a petitioner's claim which amounts to a fee of thirty percent based upon the contingency fee agreement. 36. Schmidt Kramer has incurred expense of $1,115.88 in obtaining medical records in investigation, consultant fees, and filing fees to pursue the claim. 37. Petitioners have been represented by Attorney Michael E. Kosik since the inception of the claim. 38. A suit has not been filed against Jennifer Zelner or Milo Smith and the claim has been handled directly with Bonnie Piefer of the Westfield Insurance Company who concurs with the Petition for Court Approval. WHEREFORE, the Petitioner requests that this Court enter an Order approving the foregoing compromise settlement and allocations set forth in the attached Order. DATE: a, _ l 9 i ZO s 9F Respectfully submitted, SCHMIDT KRAMER PC Michael E. Kosik I.D.# 36512 209 State Street Harrisburg, PA 17101 P (717) 232-6300 F (717) 232-6467 Attorney for Plaintiffs CERTIFICATE OF SERVICE I, Michael E. Kosik, an employee of the law firm of Schmidt Kramer, P.C., do hereby certify that I am this day serving a true and correct copy of this Petition for Court Approval of Minor's Settlement Pursuant to Pa.R.C.P 2039 upon Bonnie Peifer, Adjuster, Westfield Insurance Group, 201 East Oregon Road, PO Box 3010, Lancaster, PA 17604 via United States first class mail. Michael E. Kosik Date: ?-0( �( Exhibit A Pennsylvania EMS Report Service Name West Shore EMS Station A Station Unit Name, No. & Type 32 / 2102232) SQUAD PCR No. 1214168 Date 08/10/2012 Incident Location 141 East Columbia Road, Enola, PA 17025 Home/Residence County, Municipality & Incident Zip CUMBERLAND, East Pennsboro Twsp. / Enola, 12.7eigiving Agency LIFE LION - Hershey Med. Ctr. PSAP Incid. No. C111477 NNIET:l.r.i''t, Patient Name 110i1:,in.:e Rebecca Alleman Street Address 208 North Enola Drive City Enola Sex Female Age 4 Years Patient Number Private Physician DOB 10/31/2007 State PA Phone No. (717) - Social Sec. No. Driver's License Zip 17025 Pt. Weight 23 kg. C1: Flickinger, Devin C2: C3: C4: Primary Caregiver: C1 EMT -P 118099 Driver: Transporting Assist Units East Pennsboro Twp EMS Assist OS 14:40 Out On -Scene Dest. In in es Response Outcome Care transferred (aeromedical, other XieMode Lights and Sirens Nature of Incident ALS Transport Mode Patient Condition on Scene Life -Threatening Patient Condition at Facility Response Time: 2 ER Time: OS Time: ER11 Time: Destination Time: Total Time: Time Out of 0 Quarters: 7 16 2 30 57 911: Dispatch: Enroute: Arrive Scene: Contact: Depart Scene: Transfer: Available: In Quarters: 14:35 14:37 14:44 14:45 15:00 15:02 15:32 Chief Complaint: Altered Sensorium Current Meds: None Allergies (meds): NKDA PMHx: None rorakt. „ Dispatch: Medic 85 dispatched with BLS by CCEOC to East Pennsboro Twp. -141 East Columbia Road for a fall victim. Immediately responded class 1 (emergency response). Aeromedical services were placed on standby. Once BLS arrived o/s A75 requested aeromedical services to fly and Co. 20 dispatched for LZ operations. Weather conditions: Hazy, Hot, Dry, Daylight. 0/S: Arrived o/s to find BLS & East Pennsboro PD o/s rendering patient care to a 4 y/o female who is supine on the paved driveway with cervical collar in place with cervical spine stabilization being applied. Note that patient is lethargic and is semi -responsive to verbal stimuli. Patient is immediately transferred onto a long spine board (LSB), secured with straps, vitals signs assessed by BLS, and ALS reassessed. Noted Printed On: 08/11/2012 16:39 Provider EMStat Reporting(c) 1998.2012, Med Media, Inc. All Rights Reserved. Page: 1 of 3 Pennsylvania EMS Report Service Name West Shore EMS Unit No 32 / 2102232 / SQUAD PCR No. 1214168 Date 08/10/2012 Patient Name Rebecca Alleman Date of Birth 10/31/2007 Social Security Number PSAP C111477 an obvious altered mental status and in conjunction with the mechanism of injury, ALS agreed that aeromedical services were required. 02 was applied @ 15 1pm via non-rebreather mask. HPI: Note that patients parents were notified of the incident. This 4 y/o female was reported to be at her babysitters and was outside sitting along the bottom rail of the railing. The babysitters husband o/s states that the spindles gave way and patient fell to the paved driveway. The babysitters husband also states that he did not witness the fall however was alerted by other witnesses. Prior to the incident, patient was without complaint. The babysitters husband states that patient was unresponsive when he approached the patient on the paved driveway. Denies witnessing any seizure like activity. PE: LOC: This 4 y/o —23 kg female presents awake, semi -alert, and not oriented to time or the event. Airway: Open, Naturally patent. Breathing: Normal rate, non -labored. Circulation: Strong (=) carotid, femoral & peripheral pulses, (+) Hemorrhaging from nose and mouth, and abrasions to the bilateral knees, Skin: Flesh tone pale, warm & dry. HEENT: (+) Swollen, ecchymotic hemotoma to the left forehead, (+) Swollen left orbit, (-) Circumoral cyanosis, Conjunctiva: Pink & Moist, Oral mucosa: Moist with blood event in the patient's mouth, (-) Avulsed teeth, Good skin turgor, Pupils are equal & reactive to light. Neck: (-) JVD, Trachea is midline. Chest: (-) Tenderness noted upon palpation & deep inhalation, (=) Chest rise & fall. Lungs: BBS/CTA. Abdomen: Soft without tenderness or masses, (-) Distention. PELVIS: (+) Tenderness to the left pelvic region, Stable. EXT: Limited ROM of the left leg due to extreme pain upon any type of movement, (+) Deformity of the left upper leg, (+) pulses & sensation throughout, (+) Abrasions to the bilateral knees. Sp02: 100% on 02. EKG: Sinus Tachycardiac without ectopy. Tx/Rx: See flowchart for Rx modalities. Patient was immediately transferred onto the stretcher after successfully transferred onto the long spine board. Patient was then transferred to Amb. 75 without difficulty via stretcher. While enroute to the landing zone on Amb. 75 patient remained in a supine position, fully immobilized with supplemental 02 applied @ 15 1pm via non-rebreather mask. Throughout Tx patient's vital signs and condition were monitored. Prior to arrival noted that patient was becoming more lethargic however still responding to crew especially post venipuncture. Note that due to patient discomfort regarding her left upper leg, any voided area was padded and the leg was kept in the position of comfort especially since patient had sensation, minimal movement, and pedal pulses present. Arrival: Arrived @ the landing zone at East Pennboro School District & transferred patient care and information to Life Lion Staff Paramedic Amanda Rosito. 02 continued. IV: Patent, Infusing well @ a wide open rate with NSS without infiltration nor irritation. TFI: —200 ml NSS. Medic 285 then returned/available without further incident. Note: Patient was a minor with significant injuries there for a copy of our Notice of Privacy Practices was not provided. Note: Picture #1 depicts the area from where the patient fell from and height of which she fell. Picture #2 depicts the missing spindles on the weathered railing. Printed On: 08/11/2012 16:39 EMStat Reporting(c) 1998-2012, Med Media, Inc. All Rights Reserved. Page: 2 of 3 Provider Pennsylvania EMS Report Service Name West Shore EMS Unit No 32 / 2102232 / SQUAD PCR No. 1214168 Date 08/10/2012 Patient Name Rebecca Alleman Date of Birth 10/31/2007 Social Security Number - - PSAP C111477 Devin L. Flickinger, EMT -P West Shore EMS .................. ime rovi 14:43 Other REQUESTED AIRMEDICAL SERVICES TO FLY 14:45 Misc: Assessment -Adult; Success: 0/0 Flickinger, Devin 14:47 Immob: Spinal Immobilization Other 14:49 Vitals: Pule: 140; Resp: 24; B.P.: 150/100 (Manual Cuft); GCS: 3/4/4 (None) Other 14:54 EKG/Defib: Cardiac Monitor; Rhythm: Sinus Tachycardia; Rhythm at Hospital: Sinus Tachycardia Flickinger, Devin 14:55 IV/I0: Venous Access -Extremity; Success: 1/0; Location: Antecubital -Left; Size: 20 G Flickinger, Devin 14:56 Med: Oxygen; Dose: 15 L/Min; Qty: 1; Route: Non Rebreather mask; Pt. Response: Unchanged Other 14:56 Med: Oxygen; Dose: 15 L/Min; Qty: 1; Route: Non Rebreather mask; Pt. Response: Unchanged Flickinger, Devin 14:58 IV/10: Venous Access -Extremity; Success: 1/1; Location: Antecubital -Right; Fluid: Normal Saline; Size: 20 G; Rate: Wide Flickinger, Devin 15:03 Misc: Transfer of Care; Success: 0/0 Flickinger, Devin Printed On: 08/11/2012 16:39 EMStat Reporting(c) 1998-2012, Med Media, Inc. All Rights Reserved. Provider Page: 3 of 3 Exhibit B PENN STATE HERSHEY MI Milton S. Hershey 11.1 Medical Center Patient Name: MRN: Date of Birth: Patient Gender: ALLEMAN, REBECCA K 1695323 10/31/2007 Female Discharge Summary 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: 19009299 Visit Type: Inpatient Patient Location: 3CWN; P3219; 01 RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: Name: ALLEMAN, REBECCA K HMC Number: 1695323 DOB: 10/31/2007 Date of Admission: 05/10/2013 Date of Discharge: 05/13/2013 Modified .D/C Summary Olson,Melanie R (5/14/2013 07:56 EDT); lantosca,Mark R (5/14/2013 06:43 EDT) DISCHARGE SUMMARY Physician: Iantosca, Mark R Service: Neurosurgery Discharge Diagnosis: Mucocele, Encephalocele, CSF leak, fracture of frontal sinus Other Diagnoses: Hx. Closed fracture of left distal femur Skull fracture Head trauma GERD (gastroesophageal reflux disease) Major Procedures and Tests: 5/10/13: Bifrontal craniotomy for exoneration of sinus, repair of encephalocele and CSF leak. Vaccinations Received This Hospital Stay: No vaccinations were given this hospital stay. Discharge Medications: 1. Albuterol (albuterol CFC free 90 mcg/inh MDI) 4 puff Inhalation every 2 hours, as needed for Wheezing. 2. Bacitracin topical (bacitracin topical 500 units/g ointment) 1 appl topically 2 times daily, as needed for See Order Comments. 3. Sodium chloride nasal (Ocean 0.65% nasal solution) in each nostril 6 times daily. 4. Polyethylene glycol 3350 (MiraLax) 17 g by mouth once daily, as needed for Constipation. 5. Acetaminophen (Tylenol) 480 mg by mouth every 4 hours, as needed for Fever/Mild Pain. Date/Time Printed: 6/14/2013 13:59 EDT Printed By: Tice,Cindy L Page 1 of 79 PENNSTATE HERSH-Y PIM Milton S. Hershey 1410 Medical Center Patient Name: ALLEMAN, REBECCA K MRN 1695323 ....................................................................................,.,......,..........,...,Discharge Summary....,.................,.,...............,.............,...........,......,..................................., Brief History of Present Illness: This patient presented with chronic episodes of sinusitis and mucosal retention cyst in the left frontal sinus in the setting of posttraumatic fracture. There appears to be extension of the dura if not brain tissue into the fracture site, constituting at least a meningocele if not an encephalocele. It was felt that operation from below carries a high-risk of CSF leakage. We therefore discussed with the family, our recommendations for repair of this. Given the high-risk of recurrent infections and potential extension into the intracranial compartment it was agreed with our ENT colleagues that the frontal sinus needed to be excluded. The safest way to perform this would be from above where any meningocele or encephalocele could be primarily repaired at the same time. We recommended a bifrontal craniotomy through by a bicoronal incision with bilateral frontal bone removal exenteration of the posterior wall of the sinus and mucosa with blockage of the frontal sinus intraoperatively to include a pericranial graft. This carried the best chances of long-term avoidance of infection or CSF leakage. The risks and benefits of the procedure were reviewed extensively with the mother who asked many excellent questions and the surgery was booked electively for the coming weeks pending our coordination of surgical schedules with our ENT colleagues. Hospital Course: Pt presented for the above procedure and tolerated this well without any complications. Pt did well immediately post op and admitted to PICU. No acute events following surgery. 5/11: Pt did well overnight without any acute events. Remained afebrile. Wound remained clean, dry, intact. No CSF leak. Downgraded to IMC and foley and A-line were removed. Starting to tolerate regular diet. 5/12: Pt downgraded to floor status. Playful, but had increased facial swelling and unable to open eyes. Remained afebrile. No CSF leak and wound remained clean, dry, intact. Tolerating regular diet well. 5/13: Pt did well again overnight without any acute events. Remained afebrile. No CSF leak. Wound remained clean, dry, intact. Tolerating regular diet well. Ambulating well. Decreased swelling and now able to open eyes. Asking to go home. Will be discharged to home in good condition. Exam on Discharge: Orientation: Awake, alert, and oriented to person, place, and time Cranial Nerves: Pupils equal, round, and reactive to light Extraocular movements intact Face symmetric Motor Function: 5/5 BUE and BLE without pronator drift Sensory Function: SILT x 4 Date/Time Printed: 6/14/2013 13:59 EDT Printed By: Tice,Cindy L Page 2 of 79 PENN STATE HERSHEY Milton S. Hershey RIP Medical Center Patient Name: ALLEMAN, REBECCA K MRN 1695323 Discharge Summary Cerebellar Function: Proprioception intact BUE Surgical Site: Incision c/d/i Care Instructions: May shower and wash over incision site and hair, but don't soak or scrub incision site. Sutures will dissolve on their own over the next several weeks. No need to be removed. Apply bacitracin ointment along incision site twice daily. No nose blowing per ENT. Diet Guidelines: Regular Activity Guidelines: Must keep both feet on the ground at all times an no wheels except for riding in a car x 12 weeks. May return to school when ready, but no recess or gym class. No swimming underwater. Call your doctor if: Watch for fever 101.5 or higher, redness, swelling or drainage from incision site. Watch for severe headaches, nausea, vomiting or changes in mental status. Watch for salty taste in throat or clear drainage from nose. Call 717-531-3828 for questions. Other Instructions: Will follow up with ENT in 1 week. They will contact you with date/time of appointment. Follow -Up Appointments: Scheduled Penn State - Hershey Appointments Within the Next 90 Days. 1. Follow -Up with Sohrabi, Sohrab at Univ Phys Ctr Suite 400 on 05/16/2013 at 09:00 am 2. Follow -Up with lantosca, Mark at Pediatric Bone & Joint and Neuroscience East Campus on 06/04/2013 at 11:00 am 3. Follow -Up with Baker, Mark at Nyes Road Suite A - Harrisburg on 07/26/2013 at 08:50 am Date/Time Printed: 6/14/2013 13:59 EDT Page 3 of 79 Printed By: Tice,Cindy L PENNSTATE HERSHIY FM Milton S. Hershey Medical Center Patient Name: ALLEMAN, REBECCA K Discharge Summary MRN 1695323 Electronic Signature on File CC: Mark S Baker, MD PSHMG - Nyes Road I 121 Nyes Road Suite A Harrisburg PA 17112 CC: Mark R lantosca, MD Pediatric Neurosurgery 30 Hope Drive Suite 2200 Hershey PA 17033 Electronically Reviewed/Signed by: Melanie R Olson, PA -C Author Signature Dt/Tm:05/14/2013 07:56 AM Physician Assistant Pediatric Neurosurgery Electronically Reviewed/Signed by: Mark R lantosca, MDCosigner Signature Dt/Tm: 05/14/2013 06:43 AM Associate Professor of Neurosurgery Penn State Milton S. Hershey Medical Center 500 University Drive, PO Box 850, MC H110 Hershey, PA 17033 Tel:(717) 531-8807 Fax: (717) 531-3858 MRO /JGM DD: 05/13/13 DT: 05/14/13 06:22 Date/Time Printed: 6/14/2013 13:59 EDT Page 4 of 79 Printed By: Tice,Cindy L PENN STATE HERSHEY Milton S. Hershey 411, Medical Center Patient Name: ALLEMAN, REBECCA K ............................... . . . ............. . . . . . . . . Operative Report .................. MRN 1695323 RESULT STATUS: Final DOCUMENT SUBJECT: Operative Report ELECTRONICALLY SIGNED BY: Iantosca,Mark R (5/16/2013 12:52 EDT) OPERATIVE REPORT Name: ALLEMAN, REBECCA K HMC Number: 1695323 DOB: 10/31/2007 Date of Service: 05/10/2013 PREOPERATIVE DIAGNOSES: 1. Posterior wall of frontal sinus fracture. 2. Chronic sinusitis/mucocele. 3. Post Traumatic Fronto -nasal Encephalocele POSTOPERATIVE DIAGNOSES: 1. Posterior wall of frontal sinus fracture. 2. Chronic sinusitis/mucocele 3. Post Traumatic Fronto -nasal Encephalocele OPERATION PERFORMED: 1. Bifrontal craniotomy for exenteration of frontal sinus. 2. Repair of Post -Traumatic Fronto -Nasal Encephalocele. 3. Repair of CSF leak. SURGEON: Mark Iantosca, MD ASSISTANT: John Kelleher, MD ANESTHESIA: General endotracheal anesthetic. ESTIMATED BLOOD LOSS: Less than 50 mL. DRAINS: None. FLUIDS: 800 mL. URINE OUTPUT: 200. CONDITION: Stable. COMPLICATIONS: None. SPECIMENS: None. FINDINGS: Posterior wall of left frontal sinus fracture with atretic encephalocele. Date/Time Printed: 6/14/2013 13:59 EDT Printed By: Tice,Cindy L Page 7 of 79 PENN STATE HERSHEY WM Milton S. Hershey INF Medical Center Patient Name: ALLEMAN, REBECCA K MRN 1695323 Operative Report INDICATIONS: Rebecca Alleman is a 5 -year-old female who suffered a previous trauma where she had a skull fracture as well as an orbital fracture and a posterior wall of her left frontal sinus fracture. This was treated conservatively. The patient then started developing chronic sinusitis infections for what she was placed on antibiotics; however, these continued to recur. She had a CT scan as well as MRI showing the posterior wall of the frontal sinus had not healed and actually there was some herniation of the frontal lobe either a mucocele or encephalocele appreciated in that area. The decision was made to repair this surgically because of her constant infections. OPERATION: The patient was taken to the operating room. She was identified by the operating staff. General endotracheal anesthetics were then used. She was placed in supine position with the horseshoe. First, ENT did endoscopic exploration of the maxillary sinus, which this part will be under the ENT part. Then, a bicoronal incision was then marked, prepped and draped in the usual sterile fashion. Using the 15 blade, the skin incision was then made, saving the pericranium and the skin was flapped without difficulties, all the way down to the top of the orbital rim. Then, a flap of vascularized pericranium was then taken and using the electrocautery demarcated, as well as a periosteal elevator. Then, with the drill, 2 bur holes were made on either side of the frontal sinus posteriorly and a burr hole was made over the keyhole on each side. Then the craniotome was used to do a bifrontal craniotomy without difficulties. We were slightly high off the frontal sinus. However, we were able to appreciate the encephalocele herniating inside of the posterior wall of the frontal sinus. The 4-0 diamond bur hole was then brought onto the field and the posterior wall of the frontal sinus was then taken away without difficulty and the encephalocele was retracted back from the open fracture of the posterior wall. This was coagulated and resected, the dural was repaired and overlayed with gelfoam. Then, the rest of the mucosa in the frontal sinus was then exenterated. ENT then, with a diamond bur when inside the frontal sinus and took down the rest of the mucosa. Then, a piece of bone from the craniotomy of about 1 x 1 cm was then placed on top of the frontal os, then a piece of temporalis muscle and fascia was placed on top, and Gelfoam was also placed on top of such. The vascularized pericranium was then flapped inside on top of the exenterated frontal sinus and below the frontal lobe dura. Tisseel was then used. There were no signs of CSF leak and/or any bleeding around it. The bone was then placed back and this was secured with plates and screws. The incision was then closed using 3-0 Vicryl and a running 4-0 locked Monocryl. Bacitracin and Telfa was used as a dressing. The patient was then extubated and taken to the PACU in stable condition.Dr Iantosca was present and scrubbed in for the entire procedure. #837695 Electronic Signature on File Electronically Reviewed/Signed by: John Kelleher, MD Electronically Reviewed/Signed by: Mark R Iantosca, MDCosigner Signature Dt/Tm: 05/16/2013 12:52 PM Associate Professor of Neurosurgery Penn State Milton S. Hershey Medical Center 500 University Drive, PO Box 850, MC H110 Hershey, PA 17033 Tel:(717)531-8807 Fax:(717)531-3858 JK /VSC DD: 05/13/13 DT: 05/13/13 16:24 Date/Time Printed: 6/14/2013 13:59 EDT Page 8 of 79 Printed By: Tice,Cindy L PENNSTATE HERSHEY WM Milton S. Hershey INIO Medical CenterT 4 Patient Name: ALLEMAN, REBECCA K . MRN 1695323 .............................................�.........�...........................:..:. Operative Report- :....:.....................�..................�........._ .........................� r RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY:' ' ' Name: ALLEMAN, REBECCA HMC Number: 1695323 ' DOB: .10/31/2007 ' Date of Service: 05/10/2013' .. _ . ` - Final � - Operative Repot!'' t •r• • v- Sohrabi,Soh'rab (5/21/2013 12:35 EbT) OPERATIVE'REPORT` ' K: :,r ... • PREOPERATIVE DIAGNOSIS: Chronic sinusitis, anterior and posterior frontal sinus fracture with resultant frontal sinus encephalocele. POSTOPERATIVE DIAGNOSIS: Chronic sinusitis, anterior and posterior frontal sinus fracture with resultant frontal sinus encephalocele. OPERATION PERFORMED: Nasal endoscopy with a left-sided maxillary antrostomy and partial anterior ethmoidectomy. SURGEON: Sohrab Sohrabi, M.D.- ASSISTANT: Antonio Portela, MD ANESTHESIA: General endotracheal. COMPLICATIONS: None. INDICATIONS: This is a 5 -year-old female who previously suffered a trauma and had an anterior and posterior frontal sinus fracture. This fracture was originally nondisplaced and both us and the neurosurgery team opted to watch it. A repeat scan was performed to make sure that the frontal sinus could clear itself. After a CT scan and a followup MRI, it found thickening in the frontal as well as the ethmoid and maxillary regions on the affected side as well as possible herniation of intracranial contents into the frontal sinus. At this point, a decision was made to fix this fracture via exoneration of the frontal sinus. This was done by Dr. lantosca. Before the surgery started we wanted to be sure there was no active infection which might compromise the formal sinus repair. Informed consent was obtained from the patient's mother. OPERATION: The patient was brought to the operating room, properly identified and laid supine on table. She was turned over to the anesthesiologist for intubation, induction and maintenance of anesthetic. Once this was achieved, the bed was turned 180 degrees. The neurosurgery team helped position the patient as they wanted it on the horseshoe for their portion of the case. A surgical time-out was called. Afrin pledgets were placed in the nose. They were then removed and nose was examined bilaterally. On the right side, the medial mucosa appeared healthy with no mucopurulent drainage from the middle meatus. On the left side, the affected side, however, we visualized thick mucoid drainage lateral to the middle turbinate. Therefore, the decision was made to inspect the maxillary sinus, and the anterior ethmoids. This was done, by taking down the uncinate using Tru -cutting forceps. The maxillary os was identified with a cell seeker and widened using Tru -cutting forceps. Inspection of the mucosa showed no purulence of the maxillary sinus Date/Time Printed: 6/14/2013 13:59 EDT Page 9 of f 79 Printed By: Tice,Cindy L� ' PENNSTATE HERSHEY WTI Milton S. Hershey 111, Medical Center Patient Name: ALLEMAN, REBECCA K MRN 1695323 Operative Report and very little inflammatory changes. Next the ethmoid bulla was entered and the surrounding bone removed. The lamina was not violated, neither was the skull base. There was no purulence seen at this point. No attempt was made to widen the frontal sinus ostia. At this point, the decision was made to go ahead with the second part of surgery. This was done by Dr. lantosca and will be dictated separately. I, myself, was present for the drilling of the frontal sinus both to completely take down the posterior wall and to remove the mucosa. This was done with a diamond bur. The ostium was free of mucosa before the repair was closed. The defect in the skull base was closed with first packed Surgicel then 2 pieces of cortical bone taken off of the craniotomy bone plate. Next, temporalis fascia and muscle were placed. Next, Gelfoam as well as Tisseel and healthy pedaled pericranial flap. This rest will be dictated by Dr. Iantosca's team. I was present for the entirety of my part of the procedure. There were no complications. #840749 Electronic Signature on File Electronically Reviewed/Signed by: Sohrab Sohrabi, MD Author Signature Dt/Tm:05/21/2013 12:35 PM SS /AMO DD: 05/14/13 DT: 05/14/13 16:29 Date/Time Printed: 6/14/2013 13:59 EDT Page 10 of 79 Printed By: Tice,Cindy L Exhibit C PENNSTATE HERSHEY PPM Milton S. Hershey IN Medical Center Patient Name: MRN: Date of Birth: Patient Gender: ALLEMAN, REBECCA K 1695323 10/31/2007 Female 1 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: 18243114 Visit Type: Emergency Patient Location: EMER ED Summary RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: Fever *ED Patient: ALLEMAN, REBECCA K MRN: 1695323 Age: 4 years Sex: Female DOB: 10/31/2007 Associated Diagnoses: None Author: Olympia, Robert P Final Fever *ED Olympia,Robert P (10/3/2012 17:44 EDT) Basic Information Additional information: Chief Complaint from Nursing Triage Note : Visit Reason. 9/30/2012 20:49 Visit reason Fever History of Present Illness The patient presents with fever. The onset was 1 days ago. The course/duration of symptoms is resolved. Associated symptoms: Decreased appetite, decreased activity. Reports that she is having some urinary accidents as well. . Temperature is 101.5 Fahrenheit. Risk factors consist of none. Prior episodes: occasional. Therapy today: Acetaminophen. 4 year old otherwise healthy girl presenting with 1x episode of fever earlier today, mother reports as 101.5, relieved with tylenol. Also reports associated decreased activity, and appetite. Still drinking, urinating and stooling as per usual. Denies any history of cough, rhinorrhea, SOB. Denies any history of abdominal pain, pain with urination/defecation. Denies any constipation/diarrhea.. Review of Systems Constitutional symptoms: Fever, decreased activity. Skin symptoms: Negative except as documented in HPI. Eye symptoms: Negative except as documented in HPI. ENMT symptoms: Negative except as documented in HPI. Respiratory symptoms: Negative except as documented in HPI. Cardiovascular symptoms: Negative except as documented in HPI. Gastrointestinal symptoms: Negative except as documented in HPI, Decreased appetite.. Genitourinary symptoms: Urinary accident.. Allergy/immunologic symptoms: Negative except as documented in HPI. Additional review of systems information: All other systems reviewed and otherwise negative. Health Status Allergies:. Allergic Reactions (All) NKA Date/Time Printed: 10/8/2012 10:13 EDT Page 1 of 6 Printed By: Bender,Sylvia R PENNSTATE HERSHEY Milton S. Hershey ;8 - 5 Medical Center Patient Name: ALLEMAN, REBECCA K MRN 1695323 ED Summary Medications: Launch Medications List (Selected). Inpatient Medications Ordered Zofran: 4 mg, buccal, q6h, PRN: Nausea and Vomiting Documented Medications Documented MiraLax: 17 g, PO, Daily Tylenol: 320 mg, PO, q4h, PRN: Fever/Mild Pain albuterol CFC free 90 mcglinh MDI: 4 puff, inhaled, q2h, PRN: Wheezing Past Medical/ Family/ Social History Medical history Negative. Surgical history: Negative. Family history: Not significant. Social history: Family/social situation: Intact family, lives with parent(s). Physical Examination Vital Signs Vital Signs. 9/30/2012 20:49 Temperature 38.0 DegC Temperature Route Oral Heart Rate 140 bpm Respiratory Rate 24 br/min Systolic Blood Pressure 121 mmHg Diastolic Blood Pressure 74 mmHg Sp02 98 % Measurements. 9/30/2012 20:49 Height 110.5 cm Height Method Actual Patient Weight 28.5 kg Weight 28.5 kg Weight Method Standing Scale Body Mass Index 23.34 kg/m2 General: Alert, no acute distress. Skin: Warm, intact, moist, no pallor, Perioral pallor.. Head: Normocephalic, atraumatic. Neck: Supple, no tendemess. Eye: Pupils are equal, round and reactive to light, extraocular movements are intact, normal conjunctiva. Ears, nose, mouth and throat: Tympanic membranes clear, oral mucosa moist, Mild orophyrangeal erythema, no discharge. No cervical lymphadenopathy.. Cardiovascular: Regular rate and rhythm, No murmur, Normal peripheral perfusion. Respiratory: Lungs are clear to auscultation, respirations are non -labored, breath sounds are equal, Symmetrical chest wall expansion. Date/Time Printed: 10/8/2012 10:13 EDT Page 2 of 6 Printed By: Bender,Sylvia R PENNSTATE HERSHEY .'1� Milton S. Hershey Medical Center Patient Name: ALLEMAN, REBECCA K MRN 1695323 ED Summary Chest wall: No tenderness. Gastrointestinal: Soft, Nontender, Non distended, Normal bowel sounds, No organomegaly. Neurological: No focal neurological deficit observed. Lymphatics: No lymphadenopathy. Psychiatric: Cooperative, appropriate mood & affect. Medical Decision Making Differential Diagnosis: Viral syndrome, upper respiratory infection, urinary tract infection, pharyngitis. Rationale: 4 year old female presenting with fever, decreased activity/appetite likely secondary to viral URl/phyrangitis. No evidence of UTI urine dip. Rapid strep negative, culture sent to lab to confirm. Not clinically dehydrated at this tiem. Tolerating adequate PO at this time. Advised mother to follow up if she continues to have fever over 4-5 days. . Results review: Lab results : Laboratory. 9/30/2012 22:02 Throat Screen THSC^CULTURE, GRP A STREP 9/30/2012 21:28 Rapid Strep Screen, POC Negative Rapid Strep Screen Ref Range [negative] Culture sent to lab for confirmation Yes 9/30/2012 21:16 Urine color urine dipstick Yellow U Appear Clear U Gluc Negative Glucose Urine Dipstick Ref Range [negative] U Bili Negative Bilirubin Urine Dipstick Ref Range [negative] U Ketones Negative Ketones Urine Dipstick Ref Range [negative] U Spec Gray 1.010 Specific Gravity Urine Ref Range [No Normal Defined] U Blood Negative Blood Urine Dipstick Ref Range [negative] U pH 7.5 pH Urine Dipstick Ref Range [4.5 - 8.0] Impression and Plan Diagnosis Date/Time Printed: Printed By: U Protein Negative Protein Urine Dipstick Ref Range [negative] U Urobilinogen 0.2 mg/dl Urobilinogen Urine Dipstick Ref Range [0.2 - 1.0 rng/dL] U Nitrite Negative Nitrites Urine Dipstick Ref Range [negative] U Leuk Est Negative Leukocytes Urine Dipstick Ref Range [negative] 10/8/2012 10:13 EDT Page 3 of 6 Bender,Sylvia R PENNSTATE HERSHEY 11 Milton S. Hershey Medical Center Patient Name: ALLEMAN, REBECCA K • MRN 1695323 ED Summary Upper respiratory infection 465.9 (ICD9 465.9) Plan Condition: Improved, Stable. Disposition: Discharged: Time 09/30/2012 22:47:00, to home. Patient was given the following educational materials: Upper Respiratory Infection (URI), Child, Upper Respiratory Infection (URI), Child. Follow up with: Mark Baker Within Call physician within next business day; Follow up with primary care provider Within Call physician within next business day. Counseled: Patient, Family, Regarding diagnosis, Regarding diagnostic results. Addendum Teaching -Supervisory Addendum -Brief Notes: Patient was seen and examined with EM resident - I agree with assessment and plan as noted above . Signatures: Electronically Reviewed/Signed (03 -OCT -2012 12:03:00) by: Waleed Abbasi, MD Electronically Reviewed/Signed (03 -OCT -2012 17:44:00) by: Robert P. Olympia, MD Date/Time Printed: 10/8/2012 10:13 EDT Page 4 of 6 Printed By: Bender,Sylvia R PENNSTATE HERSHEY WM Milton S. Hershey RP Medical Center Patient Name: MRN: Date of Birth: Patient Gender: ALLEMAN, REBECCA K 1695323 10/31/2007 Female Outpatient Letter V 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: 19254230 Visit Type: Clinic Patient Location: HD10 RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: June 4, 2013 Name: ALLEMAN, REBECCA K HMC Number: 1695323 DOB: 10/31/2007 Date of Service: 06/04/2013 Mark Baker MD PSHMG - Nyes Road 1 121 Nyes Road, Suite A Harrisburg, PA 17112 Dear Doctors: Final Outpatient Letter lantosca,Mark R (6/4/2013 14:32 EDT); Rohatgi,Pratik (6/4/2013 13:47 EDT) We had the pleasure of seeing Rebecca Alleman today in neurosurgery clinic, June 4, 2013, for followup. Rebecca suffered a fall in August of 2012, resulting in multiple facial bone fractures which eventually led to a frontal sinus exenteration on May 10, with bifrontal craniotomy. She was recently admitted to the hospital on May 29-30 for concern of CSF teak as family noticed some discharge from the left naris. She again had this discharge when she was admitted in the hospital witnessed by nursing; however, Rebecca was able to snort this nasal discharge, leading us to believe it was more mucus rather than CSF. During her hospital stay, she was afebrile and quite active. A head CT scan showed a foci of extradural pneumocephalus in the region where her Gelfoam was packed for her operation, but no intradural air. She was discharged home with activity restrictions and the family was instructed to take her temperature several times daily. She has had no fevers since she has been at home and has been quite active and playful; however, has been following her restrictions of no strenuous play activities, no play involving wheels and no swimming of any kind. On Sunday, Rebecca's mother noticed wetness under the naris that was quickly wiped away and 1 day ago, Rebecca's babysitter thought she saw nasal drainage again but Rebecca states quite adamantly that this was not and she was able to inhale it. She does not have significant headache, but had complaint of some mild head pain, lasting for about 25 minutes, responding well to Tylenol. She does not have positional headaches and has not had a stigmata of malaise or positional headaches suggestive of CSF leak. Rebecca's past medications, surgical, allergies, family, social history are unchanged since she was discharged from the hospital on May 30. Date/Time Printed: 6/14/2013 13:59 EDT Page 1 of 3 Printed By: Tice,Cindy L PENNSTATE HERSHEY Milton S. Hershey gir Medical Center Patient Name: ALLEMAN, REBECCA K MRN 1695323 Outpatient Letter On physical examination, Rebecca presents with a weight of 32.5 kilograms. She is alert and oriented to name, date, place and location. Pupils are equal, round and reactive to light. Her extraocular movements are fully intact. Facial musculature appears symmetric. Tongue protrudes midline. Hearing is intact bilaterally, no rhinorrhea or otorrhea were noted on otoscopic rhinoscopy exam. She did not have any indication of CSF leakage. With the head in a fully flexed position. She was able to produce full range of cervical motion without any pain or tenderness. She has full strength, sensation and normal tone in all 4 extremities and no pathological reflexes. Her surgical incision is well -healing. Assessment and Plan: Rebecca is doing quite well from her frontal sinus exenteration May 10 and though she has had 2 more questionable episodes of CSF leak, episodes themselves do not sound convincing for CSF leak and Rebecca's overall health and activity levels appear so well and non -concerning for a CSF leak. We will continue to restrict her physical activity and have not cleared her for swimming or water activities other than that of regular showering. We will see her in our office in 1 month's time. Thank you for allowing us to be involved with Rebecca's care and if we can provide any further assistance, please do not hesitate to contact our office. We look forward to seeing Rebecca and her mother in our office in 1 month's time. #880666 Electronic Signature on File CC: Sohrab Sohrabi, MD Penn State Milton S. Hershey Medical Center 500 University Drive PO Box 850 Hershey PA 17033 CC: Mark S Baker, MD PSHMG - Nyes Road I 121 Nyes Road Suite A Harrisburg PA 17112 Sincerely, Mark R lantosca, MD Associate Professor of Neurosurgery Penn State Milton S. Hershey Medical Center 500 University Drive, PO Box 850, MC H110 Hershey, PA 17033 Tel: (717) 531-8807 Fax: (717)531-3858 Author Signature Dt/Tm: 06/04/2013 02:32 PM Electronically Reviewed/Signed by: Pratik Rohatgi, MDCosigner Signature Dt/Tm: 06/04/2013 01:47 PM MR! /CB DD: 06/04/13 DT: 06/04/13 13:32 Date/Time Printed: 6/14/2013 13:59 EDT Printed By: Tice,Cindy L Page 2 of 3 Exhibit D 11000 Optum Circle 1 Eden Prairie, MN 55344 I www.optum.com RE: ALLEMAN, REBECCA K OPTUM File #: 19741370 DATE OF INJURY: 08/10/2012 Attached per your request is a copy of the medical payment summary showing benefits paid by UnitedHealthcare on behalf of the above patient for treatment of injuries sustained on the above date. The amount of benefits paid may change. Please contact us prior to settlement to obtain the total amount of benefits paid. Joni Stone Senior Analyst, Payment Integrity Optum Phone 952.205.0718 Fax 877.701.8884 __.�.n.:�.�.'.Ln.^.F;w,4_.,._..'\n✓;��M';vMiu �._v...n..'4t..\'h5\,•:'.:�.._\.•.�.'..:•.AJ_'vn_v..✓✓'v\.._wY�w�r�''..4��'\N\fin.n.•,��Y�✓�.n.r.�.J_'�M'vv\.'.vM�.+W�..._'.i_v_l..•_�.1._v\+_..•\+_�.. The information contained in this facsimile message may be privileged and confidential information intended only for the use of the individual or entity named above, If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. 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We will be happy to reimburse you for the postage. :dical Payment Summary �imant: ALLEMAN, REBECCA K to of Incident: 08/10/2012 3t Update: 02/04/2014 Number: 19741370 alyst: Joan ("Joni") Stone Please send all payments to: Optum 75 Remittance Drive Suite 6019 Chicago , IL 60675-6019 Tax ID # 41-1858498 Total Billed: $7E Total Paid: $41 Remaining Balance: $‹ Created On: 05/ ;t Date of Claim Number vice Provider Amount Billed Amount Paid Paid Capitated* Diagnosis Codes Date 0/2012 307941230701 0/2012 382212437701 0/2012 382366929001 0/2012 382476837601 0/2012 382476837801 0/2012 382476837901 0/2012 382629443301 0/2012 383138941501 0/2012 383220169601 0/2012 383800708401 0/2012 384436646801 0/2012 384657069801 0/2012 385803157901 0/2012 387672802401 1/2012 382476837701 1/2012 384628614201 3/2012 384628614101 3/2012 384921104201 3/2012 387752200001 4/2012 384628614001 0/2012 383337197601 0/2012 383549410001 DIV OF DIAG RADIOLOGY LEONARDUS M POTT MS HERSHEY MEDICAL CENTER MICHAEL M MOORE PAUL KALAPOS DIV OF DIAG RADIOLOGY KERRY M FAGELMAN MS HERSHEY MEDICAL CENTER WESTSHORE ADVANCED LIFE SUPPO PEDIATRIC CRITICAL INTENSIVE DEPT OF EMERGENCY MEDICINE MS HERSHEY MEDICAL CENTER KRISTINE E FORTUNA EAST PENNSBORO AMBULANCE SVC MICHAEL M MOORE KERRY M FAGELMAN ROBERT E CILLEY PRO2 RESPIRATORY SERVICES PRO2 RESPIRATORY SERVICES LLC DOROTHY ROCOURT SOHRAB SOHRABI MS HERSHEY MEDICAL CENTER $83.00 $15.02 08T20/2012 No 959.7 , E884.9 $428.00 $16,602.50 $272.00 $943.00 $408.00 $4,524.00 $27,452.60 $1,003.46 -> $2,275.00 $539.00 $12,217.32 $1,242.00 $859.00 $86.00 $260.00 $130.00 $603.60 $333.34 $9,016.94 $49.98 $175.95 $84.46 $212.82 $18,340.32 $830.81 $1,333.83 $371.89 $8,295.66 $948.75 $859.00 $15.63 $161.00 $80.50 $99.93 08/20/2012 08/16/2012 08/16/2012 08/16/2012 12/21/2012 08/17/2012 09/04/2012 08/29/2012 08/29/2012 09/11/2012 10/06/2012 09/19/2012 10/26/2012 08/16/2012 09/07/2012 09/07/2012 09/10/2012 No 959.8 , E888.8 No 959.8 No 959.19 , E884.9 , 821.20 , E887 No 959.01 , E884.9 , 800.00 No 959.19 , E884.9 , 959.8 , 82120 No 959.8 , E882 No 821.29 , 800.49 , 802.8 , 348.89 No 821.00 , 780.97 , 959.01 No 959.01 , 829.0 , E882 No 959.01 , 821.20 , E864.9 No 821.29 , 800.49 , 802.8 , 348.89 No 821.29 , E888.9 No 780.09 , 729.5 , 921.9 , 379.92 No V58.89 No 959.8 , E882 No 959.8 , E882 No 820.00 , 829.0 $2.21 $2.21 10/04/2012 No 820.00 , 829.0 $218.00 $133.00 $143.29 $46.87 09/07/2012 No 959.8 , E882 08/30/2012 No 829.0 , E882 $78.00 $55.30 08/31/2012 No 829.0 Diagnosis Desc. INJURY OTH&UNSPEC KNEE LE ANK&FOOT INJURY OTH&UNS OTH SPEC S INJURY OTH&UNS OTH SPEC S OTHER INJURY OTHER SITES T HEAD INJURY, UNSPECIFIED OTHER INJURY OTHER SITES T INJURY OTH&UNS OTH SPEC S OTH CLOSED FRACTURE LOWE FEMUR FRACTURE OF UNSPECIFIED P, FEMUR, CLOSED HEAD INJURY, UNSPECIFIED HEAD INJURY, UNSPECIFIED OTH CLOSED FRACTURE LOWE FEMUR OTH CLOSED FRACTURE LOWE FEMUR OTHER ALTERATION OF CONSCIOUSNESS ENCOUNTER OTHER SPECIFIEI AFTERCARE INJURY OTH&UNS OTH SPEC S INJURY OTH&UNS OTH SPEC S FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF I FEM FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF I FEM INJURY OTH&UNS OTH SPEC S FRACTURE OF UNSPECIFIED B' CLOSED FRACTURE OF UNSPECIFIED B1 CLOSED 3dical Payment Summary �imant: ALLEMAN, REBECCA K le of Incident: 08/10/2012 st Update: 02/04/2014 Number: 19741370 alyst: Joan ("Joni") Stone Please send all payments to: Optum 75 Remittance Drive Suite 6019 Chicago , IL 60675-6019 Tax ID # 41-1858498 Total Billed: $7E Total Paid: $4:.: Remaining Balance: $4r: Created On: 05/ .t Date of Claim Number vice Provider Amount Billed Amount Paid Paid Date Capitated* Diagnosis Codes 5/2012 384076504801 9/2012 384302548101 9/2012 384353499701 !9/2012 0/2012 0/2012 1/2012 1/2012 3/2012 3/2012 3/2012 3/2012 1/2012 1/2012 1/2012 1/2012 3/2012 385849111301 385400438701 385781637401 385781637601 385803154301 385683982901 385803153801 385952652701 387752199901 387964828501 387964832601 3881 741 021 01 388174102201 389030496101 3/2012 392383902801 3/2012 394084519301 3/2012 395982138501 SHYAMSUNDER B SABAT DIV OF DIAG RADIOLOGY MS HERSHEY MEDICAL CENTER LAWALLAT HERSHEY MICHAEL J WILKINSON MS HERSHEY MEDICAL CENTER MS HERSHEY MEDICAL CENTER MARK ROBERT IANTOSCA PRO2 RESPIRATORY SERVICES SOHRAB SOHRABI MS HERSHEY MEDICAL CENTER PRO2 RESPIRATORY SERVICES LLC DIV OF DIAG RADIOLOGY SOHRAB SOHRABI MS HERSHEY MEDICAL CENTER MS HERSHEY MEDICAL CENTER PRO2 RESPIRATORY SERVICES LLC PRO2 RESPIRATORY SERVICES LLC PRO2 RESPIRATORY SERVICES LLC PRO2 RESPIRATORY SERVICES LLC $94&00 $219.94 09/06/2012 $83.00 $18.77 $238.00 $168.74 $37.88 $37.03 $200.00 $97.80 $90.00 $63.81 $78.00 $55.30 $67.00 $0.03 $416.14 $38.61 $133.00 $46.87 $78.00 $55.30 $2.21 $2.21 $539.00 $125.58 $67.00 $0.03 $78.00 $55.30 $1,636.00 $1,159.92 $418.35 $40.82 $416.14 $38.61 $2.21 $2.21 $418.35 $40.82 09/07/2012 09/05/2012 09/19/2012 09/14/2012 09/18/2012 09/18/2012 09/19/2012 09/17/2012 09/19/2012 09/19/2012 10/04/2012 10/11/2012 10/06/2012 10/09/2012 10/09/2012 10/16/2012 11/15/2012 11/30/2012 12/17/2012 No 800.00 , 349.81 , 801.00 , E887 No V54.15 No V54.15 No 733.14 No 802.9 No 802.9 No 800.23 No 80023 No 820.00 , 829.0 No 829.0 , E882 No 829.0 No 820.00 , 829.0 No V54.19 , 801.00 , E884.9 No 829.0 , E882 No 829.0 No V54.19 , 801.00 No 820.00 , 829.0 No 820.00 , 829.0 No 820.00 , 829.0 No 820.00 , 829.0 Diagnosis Desc. CLOSED FRACTURE OF VAULT WITHOUT MENTION OF INTRAC AFTERCARE HEALING TRAUMA LEG AFTERCARE HEALING TRAUMA LEG PATHOLOGIC FRACTURE NECk OTHER FACIAL BONES, OPEN F OTHER FACIAL BONES, OPEN F CLOS FX VLT SKUL-DURL HEM CLOS FX VLT SKUL-DURL HEM FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF 1 FEM FRACTURE OF UNSPECIFIED B CLOSED FRACTURE OF UNSPECIFIED Bi CLOSED FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF I FEM AFTERCARE HEALING TRAUMA BN FRACTURE OF UNSPECIFIED 131 CLOSED FRACTURE OF UNSPECIFIED B' CLOSED AFTERCARE HEALING TRAUMA BN FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF 1 FEM FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF I FEM FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF 1 FEM FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF I FEM )dical Payment Summary timant: ALLEMAN to of Incident: 08/1 p/ 012CCA I( at Update: 02/04/2014 Number: 19741370 alyst: Joan ("Joni') Stone t Date of Claim Number Provider ,ice Please send all payments to: Optum 75 Remittance Drive Suite 6019 Chicago , IL 60675.6019 Tax ID # 41-.1858498 Amount Billed Amount Paid Paid ota sr$76.300.97 $43,741.20 tedDiagnosis Codes Total Billed: $7E Total Paid: $4 Remaining Balance: � Created $4` On: Diagnosis Desc. 051 OPTUM FAX c23,g «V 7P www.optum.com To: KOSIK, MIKE From: JONI STONE Fax: (717) 232-6467 Fax: (877) 701-8884 Phone: Phone: +1(952) 205-0718 Pages (Including Cover): 05 Wednesday, May 07, 2014 2:13:52 PM CST Comment: This facsimile transmission contains confidential information intended for the parties identified above. If you have received this transmission in error, please immediately notify me by telephone or return the original message at the address listed above. Distribution, reproduction or any other use of this transmission by any party other than the recipient is strictly prohibited. Exhibit E pennsylvania DEPARTMENT OF PUBLIC WELFARE April 14, 2014 RANGINO ROVNER MICHAEL E KOSIK ESQUIRE 4503 N FRONT ST HARRISBURG PA 17110-1799 Re: Rebecca Alleman SSN: ###-##-7080 Dear Attorney Kosik: 7-/Dc7 -Y7 Pursuant to your letter dated February 19, 2014, the Department of Public Welfare (DPW), Third Party Liability (TPL) - Casualty Unit, has reviewed the information you provided regarding the above -referenced individual. It has been determined that DPW has no claim against this individual. If you have any questions, please feel free to contact me. Sincerely, 0. pave.% Vince A. Porter Recovery Section Manager (717)772-6604 Bureau of Program Integrity I Division of Third Party Liability 1 Recovery Section PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486 Ex ibit F PR Monday, June 16, 2014 Curtis Alleman 208 N. Enola Drive Enola, PA 17026 RESP�"RA mi Y SEJ4 VIDES Re: Payment Arrangement for Rebecca Alleman Account Dear Mr. Curtis Alleman, To facilitate payment and resolution'of your outstanding balance, we are offering a 25% discount off your outstanding balance if payment is made by July 17th, 2014. Per our conversation with your attorney Michael Kosik on June 16, 2014, he has agreed to make a payment of $1172.66. Please remit payment via mail to: PRO2 Respiratory Services 741 3rd Avenue King of Prussia, PA 19406 Or call 610-768-0150 to pay via credit card. We appreciate your prompt payment of all outstanding amounts. Sincerely, Cheryl Brown Patient Account Representative 610-768-0150 PRO2 Respiratory Services Summary Statement 741 Third Ave King of Prussia, PA 19406-1409 DATE: Monday, November 11, 2013 Angino-Robner, Attn: Michael Kosik RE: ALLEMAN, REBECCA K 4503 N. Front Street Harrisburgh, PA 17110-1799 Make Payment To: PRO2 Respiratory Services Gemino HC fbo Pro2, P.O. Box 347456 Pittsburgh, PA 15251-4456 (610) 768-0150 Date of Service Invoice Number Qty Item Description Charges Credits Item Balance Customer Balance 8/13/2012 740193 1 COMMODE DROP ARM $109.67 $0.00 $109.67 $109.67 8/13/2012 740193 1 SEATBELT FOR WHEELCHAIR $27.77 $0.00 $27.77 $27.77 9/13/2012 746626 1 SEATBELT FOR WHEELCHAIR $27.77 $0.00 $27.77 $27.77 10/13/2012 772037 1 SEATBELT FOR WHEELCHAIR $27.77 $0.00 $27.77 $27.77 11/13/2012 797960 1 SEATBELT FOR WHEELCHAIR $27.77 $0.00 $27.77 $27.77 12/13/2012 823201 1 SEATBELT FOR WHEELCHAIR $27.77 $0.00 $27.77 $27.77 1/13/2013 846510 1 WHEELCHAIR, 14X14 $373.37 $345.51 $27.86 $27.86 1/13/2013 846510 1 SEATBELT FOR WHEELCHAIR $27.77 $0.00 $27.77 $27.77 1/13/2013 846510 1 ELEVATING LEGREST $15.00 $4.25 $10.75 $10.75 1/13/2013 846510 1 ANTI -TIPPERS FOR WHEELCHAIR $2.21 $0.00 $2.21 $2.21 2/13/2013 888609 1 WHEELCHAIR, 14X14 $373.37 $0.00 $373.37 $373.37 2/13/2013 888609 1 SEATBELT FOR WHEELCHAIR $27.77 $0.00 $27.77 $27.77 2/13/2013 888609 1 ELEVATING LEGREST $15.00 $0.00 $15.00 $15.00 BT-SUMST-25708 2/13/2013 888609 1 3/13/2013 908040 1 3/13/2013 908040 1 3/13/2013 908040 1 3/13/2013 908040 1 4/13/2013 1098276 1 4/13/2013 1098276 1 4/13/2013 1098276 1 4/13/2013 1098276 1 ANTI -TIPPERS FOR WHEELCHAIR WHEELCHAIR, 14X14 SEATBELT FOR WHEELCHAIR ELEVATING LEGREST ANTI -TIPPERS FOR WHEELCHAIR WHEELCHAIR, 14X14 SEATBELT FOR WHEELCHAIR ELEVATING LEGREST ANTI -TIPPERS FOR WHEELCHAIR Payments on Account $2.21 $0.00 $2.21 $2.21 $373.37 $0.00 $373.37 $373.37 $27.77 $0.00 $27.77 $27.77 $15.00 $4.25 $10.75 $10.75 $2.21 $0.00 $2.21 $2.21 $373.37 $0.00 $373.37 $373.37 $27.77 $0.00 $27.77 $27.77 $15.00 $4.25 $10.75 $10.75 $2.21 $0.00 $2.21. $2.21 $0.00 $0.00 $0.00 $0.00 Customer Balance $1,563.66 Comments: Patient Responsibility may reflect prior balances as well as current charges. Your account is up to date for payments received through the last day of the previous month. If paying by credit card, fill out form below: Card Type: Visa MC AMEX Card Number Exp Date Amount Card Holder Name Signature BT-SUMST-25708 Exhibit G PENNSTATE The Milton S. Hershey Medical Center Patient Financial Services P.O. Box 853 Hershey, PA 17033 (717) 531-0310 Schmidt Kramer 209 State Street Harrisburg, Pa 17101 ATTN: Michael Kosik RE: Rebecca Alleman MRN: 1695323 Dear Michael, Per our telephone conversation, the Hershey Medical Center and MS HMC Physician's Group is willing to settle this account for the above patient. The settlement offer for the physician's bill would be $224.23. Please make a check payable to MS HMC Physician's Group. The settlement offer for the hospital bills would be $1752.12. Please make that check payable to MS Hershey Medical Center. Both of these checks may be mailed together in the enclosed pre -paid envelope. I will do the adjustments on the account and once the payment arrives, it will be posted to the account, deeming the account paid in full for all 2012 balances. There is one balance for 2013 that I have referred back to our billing team to review. The patient did have health insurance at this time and we feel the health insurance should process and pay this claim. If you have any questions, please feel free to contact me. PHYSICIAN CHARGES MAN 00001695323 Case - 18030543 Name ALLEMAN,REBECCA K .Detail DOS DOE Doetor FC POS DX MODF MOD Descripticm Billed Ana ThzizsAm Debt Trans Code Trans Code Description Batch # Nan Priority Plan. Resp Pony Batched Doe Ported Dale User 8/20/2012 8123(2012 25015 UP 9 829.0 9699213 OUTPATIENT VISIT EST /111111111111, $133.00 - $5Q.00 412 BALANCE AFTER INS' 99510 8 GUA UHC 9117)2012 W18t2012 9133.00 $50.00 412 BALANCE AFTER INS 99510 1 UHC UHC 911712012 9/16/2012 $133.0D 546.87 915007 INSURANCE PAYMENT 83481 1 U1{C UHC 9/1712012 9/18/2012 HTH1 5133.00 3 925000 YOUR [NS URANCE ALLOWANCE 63481 1 UHC UI -IC 9117/2012 911812012 Frnii 5133.00 $50.00") 511 CHARGE TRANSFER TO AGENCY 19434 8 GUA GUA 2115/2013 2/15/2013 Wednesday, June 14 2014 Page 1 of 1 1 .L LUARG ;15 MRN 0000t695323 Case 18036986 Name ALLEMANABBECCA K Detail DOS DOE Doctor FC POS DX MODF TMID �SCrlpti©n Billed Arra Trans itin Debt hid Trans Code Trana Code Descrip tionIt etch it Plan Priority Plan Reap Pony Batched Dale Posted Date User 1 9.110/2012 9/12/2012 85125 11 9 802.9 0. 0 0.00 5007 2.20 $50.00 925000 9699203 OUTPATIENT VISIT NEW MMIIIIIMm.11110 IN URANCE 4328 1 UHC UHC 9/28/2012 9/28/2012 HTH1 YOUR INSURANCE ALLOWAN $200. $200.00 000 $50.00 412 BALANCE AFTER IN * 74328 412 Ffihinesday, June 11, 2014 511 BALANCE AFTER INS* CHARGE TRANSFER TO AG 1 UHC UHC 012 9510 a GUA UHC 9/28,1'2012 9510 1 UHC UHC 9128/2012 GUA UA 5/201 2 2 2 15/20 Page 1 tif PHYSICIAN CHARGES MRN 00041695323 Case 18038489 Name ALLEMAN,R BECCA K Detail DOS DOR Dor for FC PDS DX MODF TMID Description Bit(ed Ana Trans Am Ilett l(nd trans Code Trans Cade Description Batch Plan Priority Plate Resp Peaty Batched Del Posted Date User 1 9111/.2012 9/1512012 89150 E2 9 800.23 9699212 OUTPATIENT VISIT EST 567,00 55000 412 BALANCE AFTER INS` 99510 8 GUA UHC 10/5(2012 1015/2012 567.00 $50,00 • 412 BALANCE AFTER INS' 99510 1 UHC UHC 1015(2012 101512012 $67.00 516.97 925000 YOUR INSURANCE ALLOWANCE 81287 1 UHC UHC 1015/2012 10152012 H391 567.00 50.03 915007 INSURANCE PAYMENT 81287 1 UHC UHC 101512012 1015t2012 HBB1 $67.00k $50.00 511 CHARGE TRANSFER TO AGEKCY 19434 6 GUA GUA 211512013 211512013 Wednesday, /rare Il, 2014 Page 1 of I PHYSICIAN CHARGES MRN Case 00001695323 18089745 Name ALLEMAN,REBECCA K Detail DOS DOE Doctor FC FOS DX MODF TMID Description Billed Arm' Trans Ala DebtYnd Trans Code Tkans Code Descripiion Batch # Plan Marto, Plan Resp Party Batched Date Posted Date User 1 9/13/2012 9/15/2012 25015 UP 9 829.0 9599213 OUTPATIENT VISIT EST $133.00 $50.00 412 BALANCE AFTER INS 99510 8 GUA UM 10/5/2012 10/5/2012 $133.00 550.00 412 BALANCE AFTER INS 99510 1 UHC UHC 10/5/2012 10/5/2012 5133.00 346.87 915007 INSURANCE PAYMENT 81086 1 UHC UHC 1015/2012 1015!2012 H381 $133.00 13 925000 YOUR INSURANCEALLOWANCE 81086 1 UHC UHC 1015/2012 1015/2012 HBS1 $13300 $50.0 511 CHARGE TRANSFER TO AGENCY 19434 8 GUA GUA 2115/2013 2/15/2013 Wednesday, Jane Ii, 2014 Pagel of] MRN 00001695323 Case 18098334 Name ALLEIVIAN,REBECCA K Deiall DOS DOE Dojtor FC POS DX MODF IMID Descripiion Billed Ana Tran./1m Deband Trans Cede Trans Cad e Desert:Nan Halith# Plan Priority Plan Rasp Party Batched Dale Posted Dale User 1 8128/2012 8130/2012 32233 LP 9 382.00 9699213 OUTPATIENT VISIT EST $133.00 $71.87 915007 E PAYMENT UHC UHC 9(17,2012 9/19/2012 HBB1 $133.00 $36.13 925000 YOUR INSURANCE ALLOWANCE 64598 1 LII -IC UHC 9117/2012 9119/2012 HBB1 $133.00 $25.00 412 BA LANCE AFTER INS* 99510 8 GUA UHC 9/17/2012 9/1912012 $133.00 $25.00 412 . BALANCE AFTER INS 99510 - 1 UHC UHC 9/17/2012 9/1912012 133.00 ("1..\) 1 511 CHARGTRANSFERTOAGENCY 19434 8 GUA GUA 2115/2013 2(15/2013 Wednesday, June 11, 2014 Page 1 of 1 PHYSICIAN CHARGES MRN. 00001695323 Case 18103520 Name ALLEMAN,REBECCA K Detail DOS DOE DOCVOR FC POS DX MODF TMII) Description Bided Amt Tram s Ans Debt Tod Pram Code Trims Code Denripdon Batch # Plan Priority Plan Resp Palt, Batched Date Posted Dote User 1 10(1/2012 10/4/2012 25015 IJP 9 829.0 9699212 OUTPATIENT VISIT EST $57.00 $50.00 412 BALANCE AFTER INS 99510 5 GUA UHC - 10/19/2012 10/22/2012 567.00 550.00 412 LANCE AFTER )AS" 99510 1 UHC UIIC 10119/2012 10/22/2012 567.00 516.97 925000 YOUR INSURANCE ALLOWANCE 5948 1 UHC UHC 10/19)2012 10/22)2012 HTH1 $67.00 50.03 915007 INSURANCE PAYMENT 5948 1 UHC UHC 1W12012 10/22/2012 HTH1 557.00 $50.00 ) 511 CHARGE TRANSFER TO AGENCY 19434 8 GUA 1 GUA 2/15/2013 2/15/2013 Weibeestlay, Jane II, 2914 Forge 1 of MRN 00001695323 Case Name 19555330 ALLEMAN,REBECcA K .Detail DOS DOE .+ of for FC P05 DX MODF TMID Destrriplion Billed And Trans Am DebfWnd Trans Code Trans Code Description Batch # Plan Prim* Plan Resp Pasty Bafcked Date Posted Date Ter 1 7123/2013 7/2512013 32129 LN 9 1720.2 969939/3 PREV MED VISIT EST 5-11 YEARS $168.0175168.00 412 BALANCE AFTER INS` 99510 8 GUA AEK 8/23/2013 8/23/2013 $166.00 $168,00 412 BALANCE AFTER INS' 99510 1 AEK AEK 8123/2013 8/2312013 3168.000 2D32 CANNOT ID PATIENT 11362 1 AEK AEK 8/2312013 8;23/2013 ZTG2 3168.00 $158.00 ' 521 CHARGE XFER TO AG ENCr 99910 a GUA GUA 1110/2014 1(10/2014 Wednesday, Jane 11, 2014 Page 1of1 PHYSICIAN CHARGES MR.1V Case 00007512436 10512436 Name A I •LBMAN,RBBECCA K Detail DOS DOE Doctor FC POS DX MODE TMID .Description Billed Ami Tram Am Debt /fad Trans Code Trans Code Description Butch # Plan Priorily. Plan Resp Party Batched Date Posiad Dare User 1 811012012 8/13/2012 10254 H 3 959.8 9799244 OFFICE OR ER CONSULTATION $428.00 $333.34 915007 INSURANCE PAYMENT 46809 1 UHC UHC 8/312012 8131/2012 H681� $428.00 $94.66 $19.36 925000 YOUR INSURANCEALLCWAN 48809 1 UHC UHC 8/31/2012 8131/2012 HBB1 2 8110/2012 8/15/2012 77018 I 959.19 77 7771010 CHEST 1 VIEW $86.00 $3.91 412 BALANCE AFTER INS' 99510 1 UHC UHC 8/31/2012 8/3112012 HTH1 $86.00 $3.91 $19.36 412 BALANCE AFTER INS' 99510 8 GUA UHC 8131/2012 8/31/2012 8/3102012 $86.00 $15.83 $103.00 915007 INSURANCE PAYMENT 48688 1 UHC UHC 8131/2012 6/3112012 HTH1 $86.00 566.4E 925000 YOUR INSURANCE ALLOWANCE 48688 1 UHC UHC 8131/2012 8/31/2012 HTH1 $86.00 $3-99 - 813112012 511 CHARGE TRANSFER TO AGENCY 19434 S GUA GUA 2/15/2013 2/1512013 3 S/11/2 15/2012 77018 11 1 821.20 LT 7773550 FEMUR (THIGH) INCLUDING 0 $83.00 $6426 923000 YOUR INSURANCEALLOWANCE 48688 1 UHC UHC 8/31/2012 8131/2012 HTH1 $83.00 53.75 $19.36 412 BALANCE AFTER INS' 99510 -1 UHC UHC 8/31/2012 8131/2012 8/3102012 $83.00 53.75 $103.00 412 BALANCE AFTER INS" 99510 8 GUA UHC 8/3112012 8/31/2012 UHC $83.00 $14.99� 916007 INSURANCE PAYMENT 48688 1 UHC UHC 8/31/2012 8/3112012 HTH1 583.00 $3.75 - 813112012 511 CHARGE TRANSFER TO AGENCY 19434 8 GUA GUA 2/15/2013 2/15/2013 4 811012012 8/1512012 77018 H 1 821.29 LT 7773564 RAD EXAM KNEE COMPLETE INTE $103.00 578.80 925000 YOUR INSURANCE ALLOWANCE 48688 1 UHC UHC 8/31/2012 8/31/2012 HTH1 $103.00 $19.36 915007 INSURANCE PAYMENT 48688 1 UHC UHC 8/3102012 8/3112012 HTH1 $103.00 $4.84 412 BALANCE AFTER INS' 99510 1 UHC UHC 813112012 8/31/2012 $103.00 $4.64 412 BALANCE AFTER INS' 99510 8 ' GUA UHC 8/31/1012 - 813112012 $103.00 54.84 5 511 y CHARGE TRANSFER TO AGENCY 19434 8 GUA GUA 2116/2013 2115/2013 Wednesday, Jane H, 2014 Page 1 of 6 PHYSICIAN CAGES Detail DOS DOE Doctor FC POS DX MODF 77111D Description Billed Ana Trans Ant Debt Ind Trans Code Trans Code Description Balch # Pian Priority Plan Resp Party RQtched Date Posted Dale riser .5 811112012 8/15/2012 77018 H 1 V58.8 7771010 CHEST 1 VIEW $86.00 $3.91 412 BALANCE AFTER INS` 99510 1 UHC UHC 8131/IOfi2 8/31/2012 HKH1 $86.00 $3.91 412 BALANCE AFTER INS" 99510 r a GUA UHC 8131/2012 813112012 HDR1 $86.00 $15.63 915007 INSURANCE PAYMENT 486$8 1 UHC UHC 8131/2012 813112012 HTH1 $858.00 $68.46 �$3.9� 925000 YOUR INSURANCE ALLOWANCE. 48688 1 : UHC UHC 8131/2012 813112012 HTH1 $66.00 r 1$1$.87 511 CHARGE TRANSFER TO AGENCY 19434 8 GUA . GUA 2115/2013 2/15/2013 6 811012012 8/15/2012 77040 1=I 1. 959001 7770450 CT HEAD UNENHANCED $404.00 $18.87 412 BALANCE AFTER INS" 99510 8 GUA UHC 8/31/2012 8/31/2012 HKH1 $404.00 $309.64 925000 YOUR INSURANCE ALLOWAN 48674 1 UHC UHC $/3112012 $/31/2012 HDR1 $404.00 518.87 412 BALANCEAFiER INS` 99510 1 UHC UHC 8/31/2012 8/31/2012 HDR1 $404.00 $75.49 915007 INSURANCE PAYMENT 48674 1 UHG UHC 8131/2012 8131/2012 HDR1 $404.00 r 1$1$.87 $11 CHARGE TRANSFER TO AGENCY 19434 8 GUA GUA ' 2/1512013 2/15/2013 7 SfIono 13' 115/2012 77040 H 1 800.00 7770486 CT MAXJLLOFACIAL UNENHANC - $539.00 $25.12 412 BALANCE AFTER INS' 99510 1 UHC UHC 8/3112012 8/31/2012 HKH1 $539.00 $25.12 412 BALANCE AFTER INS' 99510 8 GUA UHC 8/3112012 813112012 HBB1 $539.00 5100.46 915007 INSURANCE PAYMENT 48674 1 UHG UFIC 8/31/2012 813112012 HDR1 $53900 $413.42 925000 YOUR INSURANCE ALLOWAN 48674 1 UHG UHC 8431/2012 8131/2012 HDR1 $53900 525.12 511 CHARGE TRANSFER TO AGENCY 19434 8 GUA GUA 2/15/2013 211512013 $ 8110/2012 8/15/2012 77195 11 I 959.19 7771010 CHEST I VIEW $86.00 $0.00 2019 DUPLICATE PREVIOUS 50281 1 UHC UHC 8/31/2012 914/2012 HKH1 $86.00 $15.63 915007 INSURANCE PAYMENT 74698 1 UHC UHC 11812013 119/2013 HBB1 $86.00 566.48 925000 YOUR INSURANCE ALLOWAN 74698 1 UMC - UHC 1/8/2013 1/9/2013 1-113B1 $86.00 $3.91 412 BALANCE AFTER INS' 99510 8 GUA UHC 11812013 11912013 $86.00 63.91 412 BALANCE AFTER INS" 99510 1 UHG UHC 1/8/2013 11912013 $86.00 $3.9P7/ 611 CHARGE TRANSFER TO AGENCY 19434 a GUA GUA , 2115/5013 2/15/2013 Wednr,day, lime 11, 2014 Page 2 of 6 PHYSICIAN CHARGES Data DOS DOE Doctor FC POS DX MODF T ID Description Billed Ann Trans Ant Debt Vnd Trans Code Tarns Code Deserr on Batch 1) Plan Priority Plan Rasp Party Batched Date Posited Dale User 9 8/10/2012 8/15/2012 77195 H I 959.8 7772020 SPINE ENTIRE VIEW $73.00 $3.43 412 BALANCE AFTER INS' 99510 1 UHC UHe 8/31/2012 9/4/2012 HKH1 $73,00 53.43 412 BALANCE AFTER INS' 99$10 1 UHC UHC 81312012 9/4/2012 HKH1 $73.00 $3.43 412 BALANCE AFTER INS* 99510 8 GUA UHC 8/312012 9/412012 HKH1 373.00 $3.43 412 BALANCE AFTER INS* 99510 6 GUA UHC $13112012 9/412012 $73.00 $13.73 ($3.75) 915007 INSURANCE PAYMENT 50281 1 - UHC UHC 8/31/2012 9/4/2012 HKH1 $73.00 $13.73 915007 INSURANCE PAYMENT 50281 1 UHC UHC 8131/2012 9/42012 HKH1 $73.00 $55.84 925000 YOUR INSURANCE ALLOWANCE 50281 1 UHC UHC 8!31/2012 9/4/2012 HKH1 $73.00 555.84 925000 YOUR INSURANCE ALLOWANCE 50281 1 UHC UHC 8/3112012 9/412012 HKH1 $7/00 $` .43 $11 CHARGE TRANSFER TO AGENCY 19434 8 GUA GUA 2/15/2013 2!15/2013 $73.00 $3.43) 511 CHARGE TRANSFER TO AGENCY 19434 8 GUA GUA 2/15/2013 2115/2013 10 8/10/2012 8/15/2012 77195 H 1 959.19 7772170 PELVIS ANTERPOSTER $83.00 53.75 412 BALANCE AFTER INS' 99510 8 GUA UHC 813112012 9/4/2012 HKH1 $83.00 $15.02 9155007 INSURANCE PAYMENT 50281 1 UHC UHC 8/3112012 0/4/2012 HKH1 $83.00 $64.23 9225000 YOUR INSURANCE ALLOWANCE 50281 1 UMC UHC 8/31;2012 9/412012 HKH1 $83.00 $3.75 412 BALANCE AFTER INS' 99510 1 UHC UHC 8131/2012 9/4/2012 $83.00 $83.00 ($3.75) 915007 511 CHARGE TRANSFER TO AGENCY 19434 8 GUA GUA 2/15/2013 2/15/2013 $8300 11. 8/10/20178115/2012 77195 H 1 821.20 59 7773560 KNEE LIMITED FEWER THAN 3 VI $83.00 $15.02 915007 INSURANCE PAYMENT 50281 1 UHC UHC 6/31/2012 9/4/2012 HKH1 $83.00 $64.23 925000 YOUR INSURANCE ALLOWANCE $0281 1 UHC ' UI -IC 8/31/2012 9(412012 HKH1 $83.00 $3,75 412 BALANCE AFTER INS" 99510 6 GUA UHC 6/31/2012 914/2012 $83.00 $3,75 412 BALANCE AFTER INS* 99510 1 UHC UHC 8131/2012 9(4/2012 $83.00 $0.18 915007 INSURANCE PAYMENT 74698 1 UHC UHC 118/2013 119/2013 HEB1 $8300 $0.16 419 INSURANCE UPDATED &BILLED 75455 $ GUA GUA 1110/2013 111012013 $83.00 50.18 419 INSURANCE UPDATED &BILLED 76455 1 UHC GUA 1/10/2013 1/10/2013 $83.00 ($3.59 i 511 CHARGE TRANSFER TO AGENCY 19434 8 GUA GUA 211512013 2/15/2013 Wednesday, Jane 11, 2014 Page 3 of 6 PHYSICIAN CES Detail DOS DOE Dour FC POS DX MODF TMID Description Billed And Trans Ain Deband Tran Code Trans Code Dexripaon Batch it Plan Priority Plan Resp Party Batched Dade Posted Daae User 1z 8/10/2012 8/15/2012 77195 11 1 821.20 7773550 FEMUR (THIGH) INCLUDING O $83.00 $3.75 412 BALANCE AFTER INS' 99510 1 UHC UHC 8131/2012 914/2012 HKH1 383.00 $3.75 INSURANCE PAYMENT 64089 412 BALANCE AFTER INS' 99510 8 QUA UHC 8/31/2012 914/2012 HKH1' 383.00 $14.99 915007 INSURANCE PAYMENT 50281 1 UHC UHC 8/31/2012 914/2012 HKH1 $83.00 $64.26 925000 YOUR INSURANCE ALLOWANCE 50281 1 UHC UHC 8/3112012 914/2012 HKH1 $83.00 $9.91 915007 INSURANCE PAYMENT 74698 1 UNC UHC 1/812013 1/9/2013 HBB1 $83.00 358.10 925000 YOUR INSURANCE ALLOWAN 74698 1 UHC UHC 1/812013 119/2013 HBB1 $83.00 $64.26 Y 925000 YOUR INSURANCE ALLOWAN 74698 1 UHC UHC 8/3112012 1/9/2013 11861 $83.00 $3.75 419 ` INSURANCE UPDATED &BILLED 75458 8 GUA GUA 1110(2013 1/10/2013 $83.00 $375 419 INSURANCE UPDATED &BILLED 75455 1 UHC GUA 1110/2013 1110/2013 13 8/10/2012 8/15/2012 77195 11 1 959.7 RT 7773560 KNEE LIMITED FEWER THAN 3 VI $63.00 $15.02 915007 INSURANCE PAYMENT 50281 1 UHC UHC 8131/2012 9/4/2012 j HKH1 $83.00 $64.23 INSURANCE PAYMENT 64089 925000 YOUR INSURANCEALLOWAN 50281 1 UHC UHC 813112012 9/4/2012 HKH1' $83.00 - $3.75 412 BA1.ANCEAFTER INS' 99510 8 GUA UHC 8/31/2012 9/4/2012 HBB1 $83.00 33.75 412 BALANCE AFTER INS' 99510 1 UHC UHC 8/3112012 914/2012 HBB1 $83.00 $37.75) 511 CHARGE TRANSFER TO AGENCY 19434 8 GUA GUA 2/15/2013 2/15/2013 14 8/18/2013"8/16/2012 26090 1 959.8 2600222 TR TEAM 01AG EVAL INF MOD $4,524.00 $53.20 412 BALANCE AFTER INS' 99510 1 UNC UHC 8/3112012 8131/2012 i $1,166.11 $4,624.00 $53.20 INSURANCE PAYMENT 64089 412 BALANCE AFTER INS' 99510 8 GUA UHC 8/3112012 8131/2012 $4,524.00 $212.82 915007 INSURANCE PAYMENT 48809 1 UHC UHC 8/31/2012 8T31/2012 HBB1 $4,524.00 $4,257.98 . 925000 YOUR INSURANCE ALLOWAN 48809 1 UHC UHC 8/31/2012 8/31/2012 HBB1 $4,524.00$53.20 511 CHARGE TRANSFER TO AGENCY 19434 8 GUA QUA 2/15/2013 2/15/2013 15 8/10/2012 8/28/2012 71050 B 1 959.01 9799475 INITINPT PED CRITICAL CR $1,931.00 3762.89 925000 YOUR INSURANCE ALLOWAN 64089 1 UHC UHC 9/1712012 911912012 HDR1 $1,931,00 $1,166.11 915007 INSURANCE PAYMENT 64089 1 UHC UHC 9/17/2012 91192012 HDR1 Wednesday, Jane 11, 2614 Page 4 of 6 PHYSICIAN CAWS Detail DOS DOE Doctor FC PAS DX MODF Description Billed Ann Trims tura DebitV'nd Trans Code Trams Code Description Batch g Plan Priority Plan Resp Party Batched Posted Date User 16 8/11/2012 8/28/2012 71050 H 1 959.01 9799233 DAILY HOSPITAL CARE $344.00 $136.85 915007 925000 YOUR INSURANCE ALLOWAN 64069 1 UHC UHC 9/1712012 911912012 HDR1 $344.00 $165.72 915007 INSURANCE PAYMENT 64089 1 UHC UHC 9/17/2012 9119/2012 HDR1 $344.00 $41.43 412 BALANCE AFTER INS` 99510 8 GUA UHC 9/17/2012 9119/2012 $344.00 $41.43 412 BALANCE AFTER INS" 99510 1 UHC UHC 9/1712012 9/19/2012 $344.00 ($$41,43) 511 CHARGE TRANSFER TO AGENCY 19434 8 GUA GUA 2/1512013 2115/2013 17 8/10120'L 914/2012 46360 H 3 959.01 4699285 EMERGENCY VISIT $539.00 $539.00 $167.11 925000 YOUR INSURANCE ALLCMAN 72674 1 UHC UHC 9/2812012 0/27/2012 HBB1 $371.89 915007 INSURANCE PAYMENT 72574 i UHC UHC 0/2612012 9/27/2012 HBB1 18 811112012 9(512012 26090 H 1 959.8 9799231 DAILY HOSPITAL CARE $130,00 $49.50 915007 925000 YOUR INSURANCE. ALLOWANCE 68505 1 UHC UHC 9/211'2012 9124/2012 HTH1 $130.00 $60.50 915007 INSURANCE PAYMENT 68695 1 UHC UHC 9/21/2012 2/2412012 HTH1 19 8/1.212012 9!51.2012 26090 $ 1 959.8 9799231 DAILY HOSPITAL CARE $130.00 $49.50 915007 925000 YOUR INSURANCE ALLOWANCE 68595 1 UHC UHC 9/2112012 9124/2012 H711 $130.00 $80.550 915007 INSURANCE PAYMENT 68595 1 UHC UHC 912112012 9124/2012 tiTH1 20 811312012 91512012 26075 H 1 959.8 9799231 DAILY HOSPITAL CARE $130.00 $49.550 915007 925000 YOUR INSURANCE ALLOWAN 68848 1- UHC UHC 9/21(2012 912412012 HDR1' $130.00 $80.50 915007 INSURANCE PAYMENT 68848 1 UHC UHG 9121/2012 9/24/2012 HDR1 21 8114/2012 9/5/2012 26010 H I 959.8 9799238 HOSP DISC DAY LESS 30 MIN $218.00 574.71 915007 925003 MEDICAID CONTRACTUAL ADJ 69160 1 UHC UHC 9124/2012 9/24/2012 HTH1 $218.00 $143.29 915003 MEDICAID PAYMENT 69160 1 UHC UI -IC 912412012 9124/2012 - IiTH1 22 8/10/2012 911412012 24011 H 1 821.29 LT 2427508 FX FEMUR DISTAL END SMP WO R $1,242.00 5948.75 915007 INSURANCE PAYMENT 84748 1 UHC UHC 10/5/2012 10/10/2012 HBB1 Wednesday, June 14 2014 Page 5of6 pHySIC N , S Detail DOS DOE Doc it FC POS DX MODF um) Description Baled Amt Transl[rn Deland Tans Cade Pans Code Description Batch # Plan Priority Plan Resp Party Batched Date Posted Date User $1,742.00 $293.25 925000 YOUR INSURANCE ALLAWAN 84748 1 UHC UIiC 10/ 012 10/10/2012 HBB1 Wednesday, June 11 2014 Page 6 of 6 Jun. 11. 2014 10:27AM No. 2915 P. 15 THE MILTON S HERSHEY MEDICAL CENTER P.O. BOX 853 HERSHEY, PA 17033 OUTPATIENT HOSPITAL STATEMENT FEDERAL ID: 251854772 PAGE; 1 PATIENT NAME: ALLEMAN REBECCA K PATIENT ACCT#: 18026523 PHYSICIAN NAME: LUBIN JEFFREY S VISIT DATE: 08/10/12 CLERK: CKF DIAGNOSIS CODES: 9598 E882 UNIT SERVICE CODE DESCRIPTION AMOUNT 1 711107 AIR AMBULANCE TRANSPO 14065.00 14.5 711108 AIR AMBULANCE MILEAGE 2537.50 -1 902005 COMMERCIAL PAY 1TOSP 9016.94- -1 920107 HMO DISCOUNT 4831.32- --1 980090 HOSPITAL BAD DEBT W/O 2754.24- 1 980091 HOSPITAL BAD DEBT PLA 2754.24 TOTAL CHARGES: PAYMENT RECEIVED: BALANCE DUE: 19356,74 16602.50- 2754.24 The charge description and amount listed on this statement may not reflect all the services that were provided today. Additional charges may be assessed and will be reflected on your future billing statement. If you have any questions about the balance that you owe please contact patient financial services at 1-800-254-2619 OR 717-531-5069 Jun. 11. 2014 10:27AM No. 2915 P. 16 THE MILTON S HERSHEY MEDICAL CENTER P.O. BOX 853 HERSHEY, PA 17033 FEDERAL ID: PATIENT NAME; PATIENT ACCT#: PHYSICIAN NAME: OUTPATIENT HOSPITAL STATEMENT 251854772 ALLEMAN REBECCA K 10512436 FAGELMAN KERRY M UNIT SERVICE CODE DESCRIPTION PAGE; 1 VISIT DATE: 08/10/12 CLERK; CRF DIAGNOSIS CODES; 82129 80049 8028 AMOUNT 1 1 4 4 4 4 4 1 1 1 1 1 2 1 1 2 2 1 1 1 1 1 2 2 2 1 1 10 1 10 10 100 6 10295 16600 39104 39105 39106 39107 39108 46473 46620 46699 46717 100031 101003 101004 101005 104009 104097 104156 104433 104435 105029 105037 105052 105059 105656 111001 246049 246144 246182 246264 246487 246633 246836 5 PEDS INTENS CARE UN PEDS LEVEL I TRAUMA W I STAT GASES I STAT NA (PICU) I STAT K (PICU) I STAT ION CA (PICU) I STAT HCT (PICU) ER,CRITICL CARE,30-75 VENIPUNCTURE THERA/DIAG IlQI7ECTION NONINVAS PULSE OX, MU MRSA BY PCR ABO BLOOD GROUP ANTIBODY SCREEN RH TYPE AMYLASE, BLOOD LIPASE SGPT (ALT) BASIC METABOLIC PANEL COMP METABOLIC PANEL FIBRINOGEN HEMOGLOBIN PARTIAL TtOMBOPLAS T PROTHROMBIN TIME CBC w/PLT AUTO GLUCOSE BEDSIDE MONTT CALCIUM CHLORIDE 100 EPXNEPHRINE HCL 1 MG/ GLYCOPYRROLATE 0.2 MG LIDOCAINE 100 MG/5 ML SUCCINYL CHOLINE 200 ATROPINE SULFATE 1 MG FENTANYL CITRATE 2 ML 5689.00 9724.00 568.00 116.00 116,00 188.00 120.00 2125.00 25.00 196.00 147.00 283.00 118.00 118.00 59.00 150.00 154.00 26.00 73.00 102.00 57.00 27.00 130.00 68.00 100.00 42.00 5.05 7.30 5.55 6.80 5.30 11.85 25.50 - Continue - Jun. 11. 2014 10:27AM No.2915 P. 17 THE MILTON S HERSHEY MEDICAL CENTER F.O. BOX 853 HERSHEY, PA 17033 FEDERAL ID: PATIENT NAME PATIENT ACCTSf: PHYS ICIAN NAME OUTPATIENT HOSPITAL STATEMENT 251854772 ALLEMAN REBECCA K 10512436 FAGELMAN KERRY M UNIT SERVICE CODE DESCRIPTION PAGE; 2 VISIT DATE: 08/10/12 CLERK: CKF DIAGNOSIS CODES: 82129 80049 8028 AMOUNT 1 1 15 1 2 4 1 2 1 1 2 2 1 1 1 2 1 1 1 1 2 2 2 1 1 1 1 1 1 1 2 2 1 246841 247089 251846 272129 272199 272425 273935 274385 275033 275175 275612 307101 307201 307220 309105 309106 309208 310501 310528 511202 511354 600510 600514 600516 600522 621105 621106 621273 626079 626081 627069 627070 627085 SODIUM BICARBONATE 50 VECURONIUM BROMIDE VERSED 5MG/5ML ROCURONIUM BROMIDE 5M ONDANSETRON 2MG/ML 2M MIDAZOLAM 1MG/ML 2ML PANTOPR.AZOLE 40 MG VI HEPARIN/NS FLUSH lU/1 PROAIR 90MCG PICU/NIC ETOMIDATE 2 OMG/ 10ML I FENTANYL 10MCG/ML 1ML CHEST 1 VIEW SPINE 1 VIEW ANY LEVE PELVIS 1-2 VIEWS FEMUR AP & LAT VIEWS KNEE 1-2 VIEWS KNEE 4 OR MORE VIEWS CT HEAD UNENHANCED CT SINUS MAXILLOFAC U VENTILATOR DAY INITIA MDI TREATMENT INITAL. PULSE OXIMETER SNSR A PULSE OXIMETER SNSR I PULSE OXIMETER SNSR N AMBUBAG PED W/MASK YANKAUER SUCT W/O V YANKAUER SUCT TB W/O IV 5%DEX 0.9%NACL 500 IV DILUENT DEx 5% 100 IV DILUENT NML SALINE ST EXT MICRO 60 IML B IV EXT SET 90 W/FLASH SET ADMIN-BIFITSE MEDE 10,60 12.25 7.60 12.90 3.00 6.00 13.85 37.10 57.15 17,75 39.00 408.00 234.00 268.00 283.00 476.00 386.00 1282.00 1636.00 1202.00 158.00 88.00 114.00 57.00 107.00 1.00 1.00 2.00 3.00 3.00 6.00 36.00 7.00 - Continue - Jun. 11, 2014 10:27AM No. 2915 P. 18 THE MILTON S HERSHEY MEDICAL CENTER P.O. BOX 853 HERSHEY, PA 17033 OUTPATIENT HOSPITAL STATEMENT FEDERAL ID: 251854772 PAGE! 3 PATIENT NAME: ALLEMAN REBECCA TC VISIT DATE: 08/10/12 PATIENT ACCT#: 10512436 CLERK: CKF PHYSICIAN NAME! FAGELMAN KERRY M DIAGNOSIS CODES! 82129 80049 8028 UNIT SERVICE CODE DESCRIPTION AMOUNT 3 630827 FOLEY CATH 14 FR N/ME 1 636505 STOPCOCK MANIFOLD FOU 1 636903 CATHETER FOLEY SILIC 1 670710 KIT MONITOR ADD-ON W/ 1 670851 CRASH CART DRAWER 4 3 670857 COLLAR ASPEN CERVICAL 1 670964 ASPIRATION DEVICE 1 11679 4 PEDS IMC 1 104106 MAGNESIUM 1 104129 PHOSPHORUS, BLOOD 1 104435 COMP METABOLIC PANEL 1 105029 FIBRINOGEN 1 105037 HEMOGLOBIN 1 105052 PARTIAL THROMBOPLAS T 1 105059 PROTHROMBIN TIME 1 105657 CBC W/PLT/DIFF AUTO 1 111001 GLUCOSE BEDSIDE MONIT 10 246425 PHYTONADIONE 10 MG/ML 9 246706 MORPHINE SULFATE 2 MG 5 251846 VERSED 5M0/5ML 2 272199 ONDANSETRON 2MG/ML 2M 1 273935 PANTOPRAZOLE 40 MG VI 1 274244 POLYETHYLENE GLYCOL -E 1 275612 FENTANYL 10MCG/ML 1ML 1 307101 CHEST 1 VIEW 1 309105 FEMUR AP & LAT VIEWS 1 600520 SPIRO INCENTIVE ADULT 3 621273 IV 55tDEX 0.9%NACL 500 1 667765 SCD SLEEVES, KNEE LEN 1 10277 7 PEDS PRIVATE RM 1 16681 INITIAL EVALUATION -PT 1 16700 THERAPEUTIC ACTIV 15 1 104435 COMP METABOLIC PANEL 189.00 11.00 15.00 24.00 152.00 480.00 9.00 3367.00 28.00 25.00 102.00 57.00 27.00 65.00 34.00 80.00 42.00 49.20 28.35 3,00 3.00 13.85 3.65 78.00 204.00 283.00 18.00 6.00 92.00 2471.00 261.00 90.00 102.00 - Continue Jun. 11. 2014 10:27AM No. 2915 P. 19 THE MILTON S HERSHEY MEDICAL CENTER P.O. BOX 853 HERSHEY, PA 17033 OUTPATIENT HOSPITAL STATEMENT FEDERAL ID: 251854772 PAGE: 4 PATIENT NAME: ALLEMAN REBECCA K PATIENT ACCT#: 10512436 VISIT DATE: 08/10/12 CLERK: CKF PHYSICIAN NAME: FAGELMAN KERRY M DIAGNOSIS CODES: 82129 80049 8028 UNIT SERVICE CODE DESCRIPTION AMOUNT 1 105657 CHC Wf/PLT/DIFF AUTO 80.00 1 246400 PROMETHAZINE 25 MG/ML 3.15 4 246706 MORPHINE SULFATE 2 MG 12.60 12 250256 ACETAMINOPHEN 80MG 9.00 1 250701 ACETAMINOPHEN 320MG/1 3.00 4 272199 ONDANSETRON 2MG/ML 2M 6.00 1 273935 PANTOPRAZOLE 40 MG VI 13.85 1 274244 POLYETHYLENE GLYCOL -E 3.65 10 274897 PANTOPRAZOLE 2MG/ML 7.90 1 10277 7 PEDS PRIVATE RM 2471.00 1 16694 GAIT TRAINING 15 MIN 90.00 3 16700 THERAPEUTIC ACTIV 15 270.00 1 56609 INITIAL EVALUATION -OT 271.00 1 56631 INSTR ADAPT EQUIP 15 79.00 4 250256 ACETAMINOPHEN 80MG 3.00 4 251174 ACETAMINOPHEN/CODEINE 6,00 2 272425 MIDAZOLAM 1MG/ML 2ML 3.00 2 274244 POLYETHYLENE GLYCOL -E 7.30 10 274897 PANTOPRAZOLE 2MG/ML 7.90 1 621385 IV KCL 20MEQ+D5 NA.CL 4.00 2 16700 THERAPEUTIC ACTIV 15 180.00 2 56631 INSTR ADAPT EQUIP 15 158.00 1 274244 POLYETHYLENE GLYCOL -E 3.65 - 1 902005 COMMERCIAL PAY HOSP 18340.32- -1 920107 HMO DISCOUNT 8812.28- - 1 902005 COMMERCIAL PAY HOSP 8295.66- -1 920107 HMO DISCOUNT 3921.34- -1 980090 HOSPITAL BAD DEBT W/O 300.00- 1 980091 HOSPITAL BAD DEBT PLA 300.00 - Continue - Jun. 11. 2014 10:28AM No. 2915 P. 20 THE MILTON S HERSHEY MEDICAL CENTER P.O. BOX 853 HERSHEY, PA 17033 FEDERAL ID; PATIENT NAME: PATIENT ACCT## : OUTPATIENT HOSPITAL STATEMENT 251854772 ALLEMAN REBECCA K 10512436 PHYSICIAN NAME; FAGELMAN KERRY M UJNIT SERVICE CODE PAGE: 5 VISIT DATE: 08/10/12 CLERK: CKF DIAGNOSIS CODES; 82129 80049 8028 DESCRIPTION AMOUNT TOTAL CHARGES: PAYMENT RECEIVED; BALANCE DUE: 39969.60 39669.60- 300.00 The charge description and amount listed on this statement may not reflect all the services that were provided today. Additional charges may be assessed and will be reflected on your future billing statement. If you have any questions about the balance that you owe please contact patient financial services at 1-800-254-2619 OR 717-531-5069 Jun. 11. 2014 10:28AM No. 2915 P. 21 THU MILTON $ HERSHEY MEDICAL CENTER P.O. BOX 853 HERSHEY, PA 17033 FEDERAL ID: PATIENT NAME; PATIENT ACCT# ; PHYSICIAN NAME; OUTPATIENT HOSPITAL STATEMENT 251854772 ALLEMAN REBECCA K 18042668 SCHOLFIELD KIMBERLY R UNIT SERVICE CODE DESCRIPTION PAGE; 1 VISIT DATE; 08/15/12 CLERK; CKF DIAGNOSIS CODES; 78060 AMOUNT 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 • 46471 46620 46716 621055 102105 104433 105657 600510 621044 621055 627070 902005 920107 902005 980090 980091 EMERGENCY VISIT, LEVE VENIPUNCTURE NONINVAS PULSE OX, SI KIT ER IV START CULTURE, BLOOD BASIC METABOLIC PANEL CBC W/PLT/DIFF AUTO PULSE OXIMETER SNSR A I V SODIUM CHLORIDE 0 KIT ER IV START IV EXT SET 90 W/FLASH COMMERCIAL PAY HOSP HMO DISCOUNT COMMERCIAL PAY HOSP HOSPITAL BAD DEBT W/O HOSPITAL BAD DEBT PLA TOTAL CHARGES; PAYMENT RECEIVED; BALANCE DUE: 668.00 25,00 97.00 25.00 147.00 73.00 80.00 44.00 2.00 25,00 18.00 553.65- 350.35- 150.00- 150.00- 150.00 53.65- 350.35 -150.00-150.00150.00 1354 .00 1204 .00- 150.00 The charge description and amount listed on this statement may not reflect all the services that were provided today. Additional charges may be assessed and will be reflected on your future billing statement. If you have any questions about the balance that you owe please contact patient financial services at 1-800-254-2619 OR 717-531-5069 Jun. 11, 2014 10:28AM No, 2915 P. 22 TUE MILTON S HERSHEY MEDICAL CENTER P.O. BOX 853 HERSHEY, PA 17033 OUTPATIENT HOSPITAL STATEMENT FEDERAL ID: 251854772 PAGE; 1 PATIENT NAME: ALLEMAN REBECCA K PATIENT ACCT#: 16086666 PHYSICIAN NAME: LUBIN JEFFREY S VISIT DATE: 08/25/12 CLERK: CKF DIAGNOSIS CODES: 07999 UNIT SERVICE CODE DESCRIPTION AMOUNT 1 46471 EMERGENCY VISIT, LEVE 668,00 1. 46620 VENIPUNCTURE 25.00 1 310501 CT HEAD UNENHANCED 1282.00 1 310528 CT SINUS MAXILLOFAC U 1636.00 - 1 902005 COMMERCIAL PAY HOSP 2410.20- - 1 920107 HMO DISCOUNT 1050,80- - 1 980090 HOSPITAL BAD DEBT W/O 150.00- 1 980091 HOSPITAL BAD DEBT PLA 150.00 TOTAL CHARGES: PAYMENT RECEIVED: BALANCE DUE 3761,00 3611.00- 150.00 The charge description and amount listed on this statement may not reflect all the services that were provided today. Additional charges may be assessed and will be reflected on your future billing statement, If you have any questions about the balance that you owe please contact patient financial services at 1-800-254-2619 OR 717-531-5069 Jun. 11. 2014 10:28AM No. 2915 P. 23 THE MILTON S HERSHEY MEDICAL CENTER P.O. BOX 853 HERSHEY, PA 17033 OUTPATIENT HOSPITAL STATEMENT FEDERAL ID; 251854772 PAGE: 1 PATIENT NAME: ALLEMAN REBECCA K PATIENT ACCT#: 18243114 PHYSICIAN NAME; OLYMPIA ROBERT P VISIT DATE: 09/30/12 CLERK; CKF DIAGNOSIS CODES: 4659 78060 UNIT SERVICE CODE DESCRIPTION AMOUNT 1 46121 URINALYSIS DIP PROCED 28,00 1 46469 EMERGENCY VISIT, LEVE 7.63.00 1 46976 STREP TEST GROUP A PO 38.00 1 102111 CULTURE, PATHOGEN SCR 73.00 4 273537 ONDANSETRON 4MG ODT T 3.00 - 1 902005 COMMERCIAL PAY HOSP 66.25- -1 920107 HMO DISCOUNT 88.75- - 1 980090 HOSPITAL BAD DEBT W/O 150.00- 1 980091 HOSPITAL BAD DEBT PTA 150.00 TOTAL CHARGES: PAYMENT RECEIVED: BALANCE DUE; 455.00 305.00- 150.00 The charge description and amount listed on this statement may not reflect all the services that were provided today. Additional charges may be assessed and will be reflected on your future billing statement, If you have any questions about the balance that you owe please contact patient financial services at 1-800-254-2619 OR 717-531-5069 SETTLEMENT AGREEMENT AND RELEASE This Settlement Agreement and Release ("Agreement") is made and entered into by and between Amanda Alleman and Curt Alleman, individually, and as parents and natural guardians of Rebecca Alleman, a minor, Milo Smith, Jennifer Zelner and Westfield Insurance Company (hereinafter collectively referred to as "the Parties"). "Claimant" shall collectively mean Amanda Alleman and Curt Alleman, individually, and as parents and natural guardians of Rebecca Alleman, a minor, and the respective heirs, executors, administrators, personal representatives, successors and assigns of same. "Insured" shall collectively mean Milo Smith, Jennifer Zelner and the heirs, executors, administrators, personal representatives, successors and assigns of same. "Insurer" shall collectively mean Westfield Insurance Company and the successors and assigns of same. I. RECITALS A. On or about August 10, 2012, at or near Enola, PA, Claimant claims to have sustained personal and physical injuries as a result of the alleged conduct of Insured (the "Incident"). In connection with the Incident, Claimant has made a claim seeking monetary damages on account of those injuries. B. Insured is insured by Insurer against liability arising from the Incident, subject to the limits set forth in the liability contract between Insured and Insurer. C. The Parties desire to enter into this Agreement to provide, among other things, for considerations in full settlement and discharge of all claims and actions of Claimant for damages that allegedly arose out of or due to the Incident, on the terms and conditions set forth in this Agreement. NOW THEREFORE, it is agreed as follows: II. RELEASE AND DISCHARGE A. Release and Discharge. In consideration of the cash payment(s) referred to in Paragraph III.A. and the promise to make the periodic payments referred to in Paragraph III.B. ("Periodic Payments"), Claimant hereby completely releases and forever discharges Insured and Insurer from any and all past, present or future claims, demands, actions, damages, costs, expenses, loss of services and causes of action of any kind or character, whether based on tort, contract or other theory of recovery, whether known or unknown, including any and all claims for loss of familial services and consortium, which have arisen in the past or which may arise in the future, whether directly or indirectly, caused by, connected with or resulting from the Incident. This release and discharge shall be a fully binding and complete settlement among all Parties to this Agreement and their heirs, assigns and successors. B. General Release. Claimant acknowledges and agrees that this release and discharge is a general release. Claimant expressly waives and assumes the risk of any and all claims for damages and expenses which exist as of this date but of which Claimant does not know or suspect to exist, whether through ignorance, oversight, error, negligence or otherwise, and which, if known, would materially affect Claimant's decision to enter into this Agreement. Claimant further agrees that Claimant has accepted the considerations set forth in Paragraph III as a complete compromise of matters involving disputed issues of law and fact. Claimant assumes the risk that the facts or law may be other than Claimant believes. It is understood and agreed to by the Parties that this settlement is a compromise of a disputed claim and that the payments are not to be construed as an admission of liability on the part of Insured, by whom liability is expressly denied. It is specifically understood and agreed that Claimant hereby waives any claim of interest, pre -settlement, post -settlement or otherwise, against Insured. C. Injuries Known and Unknown. Claimant fully understands that Claimant may have suffered personal injuries that are unknown to Claimant at present and that unknown complications of present known injuries may arise, develop or be discovered in the future, including, but not limited to, subsequent death or disability. Claimant acknowledges that the consideration received under this Agreement is intended to and does release and discharge Insured and Insurer from any claims for, or consequences arising from, the injuries which allegedly arose from the Incident; and Claimant hereby waives any rights to assert in the future any claims not now known or suspected even though, if such claims were known, such knowledge would materially affect the terms of this Agreement. D. Parties Released. This release and discharge shall also apply to Insured's and Insurer's past, present and future officers, directors, stockholders, attorneys, agents, servants, representatives, heirs, executors, personal representatives, employees, subsidiaries, affiliates, reinsurers, partners, predecessors, successors in interest, assigns and all other persons, firms or corporations with whom any of the former have been, are now or may hereafter be affiliated. III. PAYMENTS A. Payment at Settlement. In consideration of the release set forth in Paragraph II above, Insurer, on behalf of Insured, shall pay a total settlement in the amount of Three Hundred Thousand Dollars ($300,000.00). From this amount the sum of Two Hundred Thousand Dollars ($200,000.00) shall be payable in up -front cash per court order. In addition, Insurer has paid the amount of One Hundred Thousand Dollars ($100,000.00) to BHG Structured Settlements, Inc. to fund the Periodic Payments set forth below in Paragraph III.B. B. Periodic Payments. In consideration of the release set forth in Paragraph II above, Insurer, on behalf of Insured, agrees to pay or cause to be paid the following periodic payments (the "Periodic Payments"): (1) To Rebecca Alleman ("Payee"), the sum of Twenty Thousand Dollars ($20,000.00), payable annually, guaranteed for 4 payments, beginning on 08/01/2026 and ending on 08/01/2029. 2 (2) To Rebecca Alleman ("Payee"), the sum of One Thousand Dollars ($1,000.00), payable monthly, guaranteed for 48 payments, beginning on 08/01/2026 and ending on 07/01/2030. (3) To Rebecca Alleman ("Payee"), the sum of Forty Thousand Dollars ($40,000.00), guaranteed, paid on 10/31/2032. Should Rebecca Alleman die before 10/31/2032, then any remaining guaranteed Periodic Payments set forth in Subparagraphs III.B. (1), (2) and (3) shall instead be paid as due to the Estate of Rebecca Alleman ("Beneficiary"), upon proof of death being furnished to Assignee, or to such other beneficiary or beneficiaries as Rebecca Alleman shall designate, in writing, after reaching the age of majority and prior to her death, to Assignee. No such beneficiary designation or revocation thereof shall be effective unless it is in writing and delivered to Assignee. C. Nature of Payments. The Parties to this Agreement contemplate and intend that all payments set forth in Section III constitute damages received on account of personal and physical injuries or sickness, arising from the Incident, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended. D. No Changes in Periodic Payments. Claimant acknowledges and agrees that all, some or any part of the Periodic Payments cannot be accelerated, commuted, transferred, deferred, increased or decreased by Claimant or by any Payee or Beneficiary and that Claimant or any Payee or Beneficiary shall not have the power to sell, mortgage, encumber or otherwise anticipate all, some or any part of the Periodic Payments by assignment or otherwise. IV. ASSIGNMENT AND FUNDING OF PERIODIC PAYMENT OBLIGATION A. Assignment of Obligation. The Parties understand and agree that Insurer will assign its duties and obligations to make such future Periodic Payments to BHG Structured Settlements, Inc. ("Assignee") pursuant to a "Qualified Assignment," within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as amended. When such assignment has been made, Columbia Insurance Company will guarantee the performance of Assignee pursuant to a guarantee. Such assignment is accepted by Claimant without right of rejection and in full discharge and release of the duties and obligations of Insurer and all Parties released by this Agreement with respect to such Periodic Payments. Upon such assignment, it is understood and agreed by and between the Parties that Assignee shall make said Periodic Payments directly to the respective Payee and/or Beneficiary designated in Paragraph III, and that the Payee shall submit any request to change the Beneficiary directly to Assignee. B. Acknowledgment of Obligation Transfer. The Parties expressly understand and agree that, with Insurer's assignment of the duties and obligations to make such Periodic Payments to Assignee pursuant to this Agreement, all of the duties and responsibilities otherwise imposed upon Insurer by this Agreement with respect to such Periodic Payments shall cease, and instead such obligation shall be binding solely upon Assignee. The Parties further understand and agree that when the assignment is made, Insurer shall be released from all obligations to make such Periodic Payments and Assignee shall at all times be directly and solely responsible for, and 3 shall receive credit for, the Periodic Payments, and that when the assignment is made, Assignee assumes the duties and responsibilities of Insurer with respect to such Periodic Payments. C. Annuity Funding. The Parties understand and agree that Assignee will fund its obligation to make Periodic Payments by purchasing an annuity contract (the "Annuity Contract") from Berkshire Hathaway Life Insurance Company of Nebraska (the "Annuity Issuer"). When such Annuity Contract is purchased, Assignee shall be the owner of the Annuity Contract and shall have and retain all rights of ownership in the Annuity Contract. For its own convenience, Assignee may direct the Annuity Issuer to make all Periodic Payments directly to the respective Payees and/or Beneficiaries designated in Paragraph III. Each Payee and Beneficiary designated in Paragraph III shall be responsible for maintaining his/her current mailing address with the Annuity Issuer. D. Discharge of Obligation. The obligation assumed by Assignee to make each Periodic Payment shall be fully discharged upon the mailing of a valid check or electronic funds transfer in the amount of such payment on or before the due date to the last address for the Payee or Beneficiary on record with the Annuity Issuer. If the Payee or Beneficiary notifies Assignee that any check or electronic funds transfer was not received, Assignee shall direct the Annuity Issuer to initiate a stop payment action and, upon confirmation that such check was not previously negotiated or electronic funds transfer deposited, shall have the Annuity Issuer process a replacement payment. E. Status of Claimant, Payees, and Beneficiaries. Claimant, each Payee and each Beneficiary, as applicable, shall at all times remain a general creditor of Assignee and shall have no rights in the Annuity Contract or in any other assets of Assignee. Assignee shall not be required to set aside sufficient assets or secure its obligation to Claimant, each Payee or each Beneficiary in any manner whatsoever. F. Date of Birth. Claimant warrants and represents that Rebecca Alleman was born on October 31, 2007. Notwithstanding anything to the contrary in this Agreement, if the actual date of birth is not as stated above, and if Insurer or Assignee relies or has relied on the accuracy of the above -stated date of birth in determining the amount, timing and/or duration of the Periodic Payments or the cost of providing them, then Insurer or Assignee may adjust the amount, timing and/or duration of the remaining Periodic Payments so that Insurer or Assignee incurs no additional cost beyond that necessary to purchase the Annuity Contract on the date of assignment to provide Periodic Payments based on the above -stated date of birth. V. ENTIRE AGREEMENT The Parties acknowledge that this Agreement contains the entire agreement between Claimant, Insured and Insurer with regard to the matters set forth in it, that there are no other understandings or agreements between the Parties, verbal or otherwise, in relation to the Agreement except as expressly set forth in this Agreement and that the terms of this Agreement are contractual and not mere recitals. 4 VI. READING OF AGREEMENT In entering into this Agreement,- Claimant represents that Claimant :has completely read all of its terms, that such terms are fully understood and voluntarily accepted by Claimant, that Claimant has .been represented by counsel of Claimant's choice and that Claimant has been advised by Claimant's counsel as to the propriety and legal effect of executing it. VII. INDEMNIFICATION l: C • 'ft In further consideration of the payments and the promise to make the future Periodic Payments set forth herein, Claimant hereby discharges and agrees to indemnify and to save and hold harmless Insured, Insurer and all parties released from and against any and all medical or other liens or claims, or subrogation claims or liens, that are, have been in the past or may be in the future asserted against anyone as a result of the Incident. VIII. FUTURE COOPERATION All Parties agree to cooperate fully, to execute any and all supplementary documents and to take all additional actions that may be necessary or appropriate to give full force and effect to the terms and intent of this Agreement which are not inconsistent with its terms. IX. RELIANCE BY CLAIMANT This Agreement has been negotiated by the respective Parties. Claimant warrants, represents and agrees that neither this Agreement nor the compromise and settlement recited in it were induced by fraud, coercion, compulsion or mistake, nor is this Agreement made in reliance upon any statement or representation of any of the Parties released by this Agreement or their representatives, agents or attorneys. Claimant warrants, represents and agrees that Claimant is not relying on the advice •of Insured, Insurer or anyone associated with them, including their attorneys and the insurance broker, placing the Annuity Contract, as to the legal and income tax or other consequences of any kind arising_out of_this Agreement. Accordingly, Claimant hereby releases and holds harmless Insured, Insurer and any and all counsel or consultants for Insured and Insurer from any claim, cause of action or other rights of any kind which Claimant may assert because the legal, income tax or other consequences of this Agreement are other than those anticipated by Claimant. �' •.+. X. WARRANTY OF CAPACITY TO EXECUTE AGREEMENT •„ Claimant represents and.warrants,that, with the: exception of contingency fee contracts and any agreements whichmay exist. between Claimant and Claimant's counsel relative to the reimbursement of litigation expense, no -other person or entity has, or has had, any interest in the claims, demands,. obligations or causes of action referred' to in this Agreement, that Claimant has the sole right and exclusive authority to execute this Agreement and to receive the sums specified in it and that Claimant has not sold, assigned, transferred, conveyed or otherwise disposed of any of the claims, demands, obligations or causes of action referred to in this Agreement. 5 XI. COURT APPROVAL The Parties agree that Claimant will file petitions for all necessary court approvals, that all such petitions and orders shall be in a form satisfactory to all Parties and that this Agreement will not be effective until such approvals have been obtained. XII. CONTROLLING LAW This Agreement shall be construed and interpreted in accordance with the laws of the State of Pennsylvania. Dated: Dated: Amanda Alleman, individually, and as parent and natural guardian of Rebecca Alleman, a minor- Claimant Curt Alleman, individually, and as parent and natural guardian of Rebecca Alleman, a minor- Claimant Dated: Westfield Insurance Company By: Bonnie L. Peifer Approved as to Form and Content: Dated: By: Michael E. Kosik, Esq., Counsel for Claimant PENNSYLVANIA LAW REQUIRES INSURER TO NOTIFY CLAIMANT OF THE FOLLOWING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. 6 Qualified Assignment, Release and Pledge Agreement In Accordance With Internal Revenue Code Section 130 "Claimant -Secured Party(ies)": Rebecca Alleman "Assignor": Westfield Insurance Company "Settlement Agreement": Settlement Agreement and, 80ease [Exact title of. Settlement Agreement or Order] "Governing Law": State of Pennsylvania "Assignee -Debtor": BHG STRUCTURED SETTLEMENTS, INC. "Annuity issuer'": BERKSHIRE HATHAWAY LIFE INSURANCE COMPANY OF NEBRASKA "Effective Date": "Payee(s)": As shown in Addendum No. 1, Description of Periodic Payments Annuity Contract No.: This Qualified Assignment, Release and Pledge Agreement ("Agreement") is made and entered into as of the Effective Date by and among the undersigned parties with reference to the following facts: A. Claimant -Secured Party(ies) and Assignor are parties to or are otherwise subject to the above -referenced Settlement Agreement under which Assignor has liability to make certain periodic payments to the designated Payee(s) as specified in Addendum No. 1 of this Agreement (the Periodic Payments"). Where no Payee(s) other than Claimant - Secured Party(ies) are shown in Addendum No. 1, it is understood that any references herein to Payee(s) shall apply to Claimant - Secured Party(ies). B. Assignor and Assignee -Debtor wish to effect a "qualified assignment" within the meaning and subject to the conditions of Section 130(c) of the Internal Revenue Code of 1986, as amended (the 'Code"). C. Assignee -Debtor desires to grant to Claimant -Secured Party(ies) a secured interest to secure the liability being assumed by Assignee -Debtor to make the Periodic Payments. D. This Agreement will be effective contingent upon Assignee -Debtor's receipt of the full premium to fund the Periodic Payments contained herein. SS -2000 (12/2013)[S] Page 1 of 6 Now, therefore, in consideration of the foregoing and for other good and valuable consideration, the parties agree as follows: 1. Assignment and Assumption; Release of Assignor. Assignor hereby assigns to Assignee -Debtor, and Assignee -Debtor hereby accepts and assumes, all of Assignor's liability to make the Periodic Payments. Each Claimant -Secured Party hereby accepts and consents to such assignment by Assignor and assumption by Assignee -Debtor. Effective on the Effective Date, each Claimant -Secured Party hereby releases and discharges Assignor from all liability to make the Periodic Payments, including the failure of Assignee -Debtor to make any of the Periodic Payments and/or. Annuity Issuer to fund any of the Periodic Payments for any reason whatsoever. 2. Nature of Periodic Payments. The Periodic Payments constitute: i. damages (other than punitive daniages), whether by suit or agreement,.61- ii. compensation under a workers' compensation at on account of personarinjury or sickness in a case involving physical injuryOr- 'physical sickness, within the meanirig'J:if Sections 130(c) and 104(a) of the Code. 3. Extent of Assignee -Debtor's Liability. Assignee -Debtor's liability to make the Periodic Payments shall be no greater than the liability of Assignor as of the Effective Date. Assignee -Debtor assumes no liability other than the liability to make the Periodic Payments. Assignee-Debtoes liability to make the Periodic Payments shall be unaffected by any bankruptcy, insolvency, liquidation or rehabilitation of Assignor. 4. Qualified Funding Asset. Assignee -Debtor will fund the Periodic Payments by purchasing from Annuity Issuer a "qualified funding asset," as defined in Section 130(d) of the Code, in the form of an annuity contract (the "Annuity") issued by Annuity Issuer and providing for payments corresponding to the Periodic Payments. Assignee -Debtor shall be designated as the owner of the Annuity. All rights of legal ownership and control of the Annuity shall (subject to paragraph 9 of this Agreement) be and remain vested exclusively in Assignee -Debtor, including the right to receive and retain all benefits under the Annuity which are not inconsistent with the security interest granted under paragraph 11; provided, however, that the Annuity shall SS -2000 (12/2013) LSI Page 2 of 6 be used by Assignee -Debtor to fund the Periodic Payments and shall at all times be designated by Assignee -Debtor on its records as being taken into account, under Section 130 of the Code, with respect to this Agreement. Notwithstanding anything to the contrary contained in this Agreement, neither any Claimant -Secured Party, any Payee, nor any Successor Payee (as defined in paragraph 8 of this Agreement) shall hove any rights with respect to the AnnuitYyor the payments thereunder that woukt,ciuse anylarrrount attributable to the Annuity to be,:11rrently includable in the recipient siriCOnie or would otherwise affect -the det§rMiriation of when any recipient is treated as having received any payment for incerrit-tax purposes, or would otherwise ,preverit this Agreement from satisfying ail of "';theconthtiOfls for a "qualified assignment" :Within the meaning of Section 130(c) of the Code. 5. Delivery of Payments. Assignee -Debtor may instruct Annuity Issuer to send payments directly to Payee or Successor Payee, or to deliver payments by electronic funds transfer ("EF1m) to an FDIC -insured depository institution in the United States for credit (directly or indirectly) to an insured account in the name of such Payee or Successor Payee. Such direction of payments under the Annuity shall not be deemed to afford Claimant -Secured Party, Payee or any Successor Payee any rights of ownership or control of the Annuity. Each Claimant -Secured Party, Payee and any Successor Payee shall at all times keep Annuity Issuer apprised of such Claimant - Secured Party's, Payee's or Successor Payee's current mailing address and telephone number and, if Payee or Successor Payee receives payments by EFT, the name, address, ABA routing number and telephone number of the applicable U.S. financial institution and the account name and account number to which the payrnents are to be credited. Such notices shall be in a form provided by Annuity Issuer and must be received at least thirty (30) days prior to the date payment is due. 6. Discharge of Liability. Assignee -Debtor's liability to make each Periodic Payment to any Payee or Successor Payee designated to receive such payment shall be fully discharged upon: i. the mailing of a valid check on or before the due date for such payrnent to the address of record specified by Payee or Successor Payee; or ii. the initiation of an EFT payment on or before the due date for such payrnent to the United Sates financial institution account designated by Payee or Successor Payee If Payee or Successor Payee does not receive a scheduled payment by check, Payee or Successor Payee shall notify Assignee -Debtor. Upon receipt of such notification, Assignee -Debtor shall initiate a stop payment action for such check and upon confirmation that such check was not previously negotiated shall promptly mail a replacement check; or If Payee or Successor Payee does Ret:, receive a scheduled EFT payment, Payee Successor Payee shall notify Assighee- Debtor. Upon receipt of such notifipaltion, Assignee -Debtor shall initiate a-3race for such payment and upon confirmation that,..e1.2:7 such payment was not credited to 0,16,1 account shall promptly issOe‘e replacement EFT payment. 7. Acceleration, Transfer of , Payment Rights. None of the Periodic payments and no rights to or interest in any -of the Periodic Payments (all of the foregoing being hereinafter collectively referred to as "Payment Rights") can be 1. Accelerated, deferred, increased or decreased by any recipient of any of the Periodic Payments; or ii. Sold, assigned, pledged, hypothecated or otherwise transferred or encumbered, either directly or indirectly, unless such sale, assignment, pledge, hypothecation or other transfer or encumbrance (any such transaction being hereinafter referred to as a "Transfer) has been approved in advance in a "Qualified Order" as defined in Section 5891(b)(2) of the Code (a "Qualified Order") and otherwise complies with applicable state law, including without limitation any applicable state structured settlement protection statute. No Claimant -Secured Party, Payee or Successor Payee shall have the power to effect any Transfer of Payment Rights except as provided in sub -paragraph (11) above, and any other purported Transfer of Payment Rights shall be wholly void, invalid and unenforceable. If Payment Rights under this Agreement become the subject of a Transfer approved in accordance with sub- paragraph (ii) above the rights of any direct or indirect transferee of such Transfer shall be subject to the terms of this Agreement and any defense or claim in recoupment arising hereunder. 8. Contingent Beneficiaries. Any Periodic Payments to be made after the death of any Claimant -Secured Party, Payee or Successor Payee shall be made to such party as shall have been designated in, or in accordance with,cthe-Settlement Agreement or, if the Settlement Agreement does not provide for ,such" designation, then to the party desioat6d in conformity with this paragraph. 8. Any party so designated is referred to in this Agreement as a "Cpritingent Beneficiary." If no Contingent .,Beneficiary is living at the time of the death a Claimant -Secured Party, Payee or 'Successor Payee, payment shall be made to the decedent's estate unless otherwise provided in the Settlement Agreement. As used in this Agreement the term "Successor Payee" refers to a Contingent Beneficiary or an estate that has become entitled to receive Periodic Payments following the death of a Claimant -Secured Party, Payee or a Successor Payee. Except where a designation has been made in the Settlement Agreement, no designation or change of designation of a Contingent Beneficiary shall be effective unless such designation or change (i) is requested in a written request submitted to Assignee - Debtor in accordance with Assignee - Debtor's customary procedures for processing such requests; and (ii) is confirmed by Assignee -Debtor. However, Assignee -Debtor will not be liable for any payrnent made prior to receipt of the request or so soon thereafter that payment could not reasonably be stopped. Except for a designation that is expressly identified in the Settlement Agreement as irrevocable, any designation of a Contingent Beneficiary shall be deemed to be revocable; and no party that is designated as a Contingent Beneficiary (other than a party irrevocably designated as a Contingent Beneficiary in the Settlement Agreement) shall, solely by virtue of its designation as a Contingent Beneficiary, be deemed to have any cognizable interest in any Periodic Payments. 9. Termination of Settlement Agreement 1 Failure to Satisfy Section 130(c). If at any time prior to completion of the Periodic Payments, the Settlement Agreement is SS -2000 (12/2013) [S] Page 3 of 6 declared terminated in a final, non - appealable order of a court of competent jurisdiction (or in the case of a workers' compensation settlement, a final order of the applicable workers' compensation authority) or if it is determined in any final order or ruling that the requirements of Section 130(c) of the Code have not been satisfied in connection with this Agreement: (I) the assignment by Assignor to Assignee -Debtor of the liability to make the Periodic Payments and Assignee -Debtor's acceptance of such assignment shall be of no force or effect; (ii) Assignee -Debtor shall be conclusively deemed to be acting as the agent of Assignor; (iii) the Annuity shall be owned by Assignor; (iv) in the event the Settlement Agreement is not terminated;':,~, Assignor shall retain the liability to make the; Periodic Payments; (v) Assignee -Debtor shall have no liability to ,rake any Periodic Payments; and (vi) the parties hereto; agree to cooperate in taking such actions' as may be necessary or appropriate to;implemenV:: the foregoing. 10. Governing Law; , Binding Effect; Insolvency of AssigneeDebtor. -. i. This Agreement shall be ,goerned by and interpreted in accordance with the internal laws of the state -identified as Governing Law above; provided, however, that any Transfer of Payment Rights under this Agreement may be subject to the laws of other states in addition to the state designated above. ii. This Agreement shall be binding upon the parties hereto and their respective successors, heirs, executors, administrators and permitted assigns, including without limitation any party asserting an interest in Payment Rights. iii. If, due to insolvency or bankruptcy Assignee -Debtor has failed to make any of the Periodic Payments, and such failure is continuing, Claimant -Secured Party(ies), or in the event of the death of applicable Claimant -Secured Party(ies), Successor Payee shall have all of the rights and remedies of a secured party under the law then in effect in the State of Nebraska. 11. Claimant -Secured Party Status Assignee - Debtor hereby pledges and grants to Claimant -Secured Party(ies) a lien on and security interest in all of Assignee -Debtor's right, title, and interest in the Annuity and all payments therefrom in order to secure the obligation of Assignee -Debtor to make the Periodic Payments. Assignee -Debtor and Claimant -Secured Party(ies) shall notify Annuity Issuer of the lien created under this Agreement, and Assignee -Debtor shall deliver a copy of the Annuity to Claimant - Secured Party(ies) upon execution of this Agreement and receipt by Assignee -Debtor of the Annuity from Annuity Issuer. 12. Advice, Comprehension of Agreement. In entering into this Agreement, each Claimant- Secured- Party warrants, represents and agrees"that Claimant -Secured Party is solely relying on the;attomeys and advisors of -such Clairnant-Secured Party's own choosing;; and not upon Assignor, Assignee- Debtor;ortheir advisors, for advice regarding the` legal, government benefits and tax advice regarding the consequences of this •Agreement. Each Claimant -Secured Party • further warrants, represents and agrees that the terms of this Agreement have been completely read by and explained to such Claimant -Secured Party and are fully understood and voluntarily accepted by such Claimant -Secured Party. Furthermore, each Claimant -Secured Party hereby releases and discharges Assignor, Assignee -Debtor, Annuity Issuer, their affiliates and their respective employees and advisors e'Releasees") from any and all claims, rights, damages, costs or expenses of any nature whatsoever that such Claimant - Secured Party now has or may have in the future against such Releasees (i) with respect to the present and future taxation of this Agreement or the Periodic Payments; or (ii) the impact that this Agreement or the Periodic Payments may have on Claimant - Secured Party's eligibility for, and the quantum of, any governmental benefit payments. 13. Future Cooperation. All parties agree to cooperate fully and to execute any and all supplementary documents and take all additional actions, which are not inconsistent with its terms, which may be necessary or appropriate to give full force and effect to the terms and intent of this Qualified Assignment, Release and Pledge Agreement. Pursuant to its obligations under this paragraph 13, and without limitation, Assignor shall promptly provide Assignee -Debtor with copies of any required court approval with respect to the underlying settlement and executed copies of all required settlement documents. SS -2000 (1212013) [S] Page 4 of 6 14. Description of Periodic Payments. The Periodic Payments are as set forth in attached Addendum No. 1, which is hereby incorporated in and made a part of this Agreement. In the event of any conflict between this Agreement and the Settlement Agreement with respect to the Periodic Payments or the assignment made herein, the terms and conditions of this Agreement shall prevail. This Qualified Assignment and Release Agreement may be signed in one or more counterparts. Assignor: Westfield Insurance Company By: Assignee: BHG Structured Settlements, Inc. By: Authorized Representative Claimant(s) or Payee(s): By. Amanda Alleman, parent and natural guardian of Rebecca Alleman, a minor By: Curt Alleman, parent and natural guardian of Rebecca Alleman, a minor Attorney for Claimant(s): Approved as to Form and Content By Michael E. Kosik SS -2000 (12/2013) [SJ Page 5 of 6 Addendum No. 1 Description of Periodic Payments Payee: Rebecca Alleman (1) To Rebecca Alleman ("Payee"), the sum of Twenty Thousand Dollars ($20,000.00), payable annually, guaranteed for 4 payments, beginning on 08/01/2026 and ending on 08/01/2029. (2) To Rebecca Alleman ("Payee'), the sum of One Thousand Dollars ($1,000.00), payable monthly, guaranteed for 48 payments, beginning on 08/01/2026 and ending on 07/01/2030. (3) To Rebecca Alleman ("Payee"), the sum of Forty Thousand Dollars ($40,000.00), guaranteed, paid on 10/31/2032. INITIALS Assignor: Assignee•Debtor. Claimant -Secured Party or Payee: Attorney for Claimant SS -2000 (12/2013) [S] Page 6 of 6 Exhibit I Amanda A Alleman 5 Adams St Apt 1 Enola, PA 17025-2814 COVENTRY ltanitlJ tore Case Number 666V52 Original Inception 513/2013 For billing questions please call 81-877-849-9690 PREMIUM BILLING Billing Period Health Premium Pymt Amt. Paper invoice Fee NSF Fee Total Due May -13 •$ 234.47 $ 234.47 4/25/13 ' $ 234.47 Jun -13 $ 234.47 $ 234.47 6/5/13 $ - $ 234.47 Jul -13 $ 234.47 , 7/5/13 , - $ 234.47 Aug -13 $ 234.47 $ 234.47 8/5/13 $ - $ 234.47 Sep -13 $ 234.47 $ 234.47 9/6/13 $ - $ 234.47 Oct -13 $ 234,47 $ 234.47 10/5/13 $ - $ 234.47 Nov -13 $ 234.47 $ 234,47 1115113 - $ 234.47 Dec -13 $ 234.47 $ 234.47 12/5/13 • t 234.47 Jan -14 $ 234.47 $ 234.47 1/6/14 $ - $ .234.47 Feb -14 $ 234.47 $ 234.47 2/4/14 $ - $ 234.47 Mar -14 $ 234.47 $ 234.47 3/5/14 $ - $ 234.47 Apr -14 $ 234.47 $ 234.47 4/7/12 ( 5 234.47 Total billed = $ 1,406,82 $ - $ - � $ - , 1I PAYMENT HISTORY AND APPLICATION Billing Period Total Due Pymt Amt. Pymt Date Fees j Past Due May -13 $ 234.47 $ 234.47 4/25/13 $ - $ - Jun -13 $ 234.47 $ 234.47 6/5/13 $ - $ - Jui-13 $ 234.47 $ 234.47 7/5/13 , $ - , $ - Aug -13 $ 234.47 $ 234.47 8/5/13 $ - $ - Sep -13 $ 234.47 $ 234.47 9/6/13 $ - $ - Oct -13 $ 234.47 $ 234.47 10/5/13 $ - $ - Nov -13 - - - - $ 234.47 $ 234,47 1115113 $ - $ - Dec -13 $ 234,47 $ 234.47 12/5/13 $ - $ - Jan -14 $ 234.47 $ 234.47 1/6/14 $ - $ - Feb -14 $ 234:47 $ 234.47 2/4/14 $ - $ - Mar -14 $ 234.47 $ 234.47 3/5/14 $ - . $ - Apr -14 $ 234.47 $ 234.47 4/7/12 $ _ - $ - Total $ 1,406.82 1 I Exhibit J Kir2 [X "-SLIM ECONOMIC & STRUCTURED SETTLEMENT CONSULTANT LIFE CARE PLAN ANALYSIS SETTLEMENT ANALYSIS June 16, 2014 Michael Kosik, Esquire SCHMIDT KRAMER 209 State Street Harrisburg, PA 17101 RE: REBECCA ALLEMAN - Date of Birth: 10-31-2007 Email: mkosik@schmidtkramer.com Dear Attorney Kosik: This mater has settled with a portion being in the form of a Structured Settlement. The terms are: - Begin 08-01-2026 $20,000 per year for 4 years Certain - Begin 08-01-2026 $1,000 per month for 4 years Certain - On 10-31-2032 (25) - $40,000 We feel the Design, in providing for four years of College, along with a monthly stipend to allow for concentration on her studies, and concluded with a useful payment at age 25, is quite appropriate for the child. 514 Crest Lane, Pottstown, PA 19465 • Tel: 484-624-8560 • Fax: 484-624-8561 • Cell Phone 610-662-2668 • E -Mail: keithisleib@msn.com The Value is found in different ways. Certainly, the $168,000 in payments is significant. However, from the other side, the defense is paying $100,000 in order to provide these future payments. This represents an average annual rate of return of 3.57%, income tax free. Currently, the 20 year US Treasury rate is 3.14% and taxable. So, in today's market, a very good rate with no income tax. Addressing Security, there are several entities to viewed. 1. The defense, which promised to make the future payments, will assign its obligation to BHG Structured Settlements Inc. (BHGSSI), a "shell" company established for just such purpose. 2. In order to internally fund its accepted obligations, BHGSSI will purchase and own an annuity from Berkshire Hathaway Life Insurance Company (BHLIC), a highly rated entity (see Rating Summary sheet). We include a brief Financial Analysis and call attention to the high percentage of Total Surplus and AVR (asset valuation reserve) of 22.5%. It is 2' highest of any company in the Structured Settlement industry. 3. Additionally, the obligation of BHGSSI to Rebecca will be guaranteed by Columbia Insurance Company, another company highly rated. This makes the certainty of the future payments extremely high. SUMMARY The Structured Settlement portion of this settlement provides for timely and useful payments in the future which represent a good value in today's market and high security and certainty that those payments will be made. We hope this report provides the information necessary for the court to evaluate and feel comfortable with Rebecca's future. Should there be any unanswered questions, do not hesitate to contact me. Very truly yours 7S Date: ,/t �/' 1- Rating Summary of ei/`44.4;t e A. M. Best SUPERIOR A EXCELLENT A- B ++ VERY GOOD B + GOOD B FAIR B- Watcbiet LAO W w- Standard & Poor's AAA EXTREMELY STRONG AA - VERY STRONG Moody's Aaa EXCEPTIONAL. Aal Aa2 EXCELLENT Aa3 xrae,rsc ECONOMIC & STRUCTURED S7Tfs4ENT COJ%WZT4NT LOB Call PLAN 'Damn n S1TTLEIO r •ANALYSIS Fitch Weiss MA EXCEPTIONALLY STRONG AA + AA VERY STRONG AA- A+ A STRONG A - BBB + GOOD Wa List QU TA TING: "Pi" Thy rating a • • only on an analysis . • ubiehed banded, and other I , In the public domain NR NOT RATED Al A2 GOOD A3 Baal ADEQUATE Watch List W + UPGRADE W UNKNOWN W - DOWN GRADE NOT RATED A+ A STRONG A - BBB + GOOD W+ W W - Watch List UPGRADE UNKNOWN DOWN GRADE NOT RATED A+ A EXCELLENT A- B+ B GOOD 9 - FAIR NE NOT RATED C1Ueers KATHYIDocumentsWfe Company Rating Summary Sheet812014 8/1/2014 Company Berkshire Hathaway Life of NE A.M. Best Company (Best's Rating, 15 ratings) Standard & Poors (Financial Strength, 20 ratings) Moody's (Financial Strength, 21 ratings) Fitch Ratings (Financial Strength, 21 ratings) Weiss (Safety Rating, 16 ratings) Comdex Ranking (Percentile in Rated Companies) A++ (1) AA+ (2) C+ (7) 100 13,768,311 11,066,873 0 3,091,694 22.5% 10,793,207 36.3% 22.9% 0.0% 0.0% 0.0% 36.8% 4.0% 100.0% 5.00% 5.07% 6.19% 7.37% 6.79% 6.08% 7.89% 7.32% 4.96% 8.34% 6.71% 7.04% Total Admitted Assets Total Liabilities Separate Accounts ,11:>, Total Surplus & AVR As % of General Account Assets Invested Assets Bonds(%) Stocks(%) Mortgages(%) Real Estate(%) Policy Loans(%) Cash & Short Term(%) Other Invested Assets(%) Net Yield on Mean Invested Assets 2013 (Industry Average 4.03%) 2012 (Industry Average 4.46%) 2011 (Industry Average 4.45%) 2010 (Industry Average 4.56%) 2009 (Industry Average 4.63%) 5 Year Average (Industry Average 4.42%) Total Investment Retum 2013 (Industry Average 4.37%) 2012 (Industry Average 4.79%) 2011 (Industry Average 4.53%) 2010 (Industry Average 4.74%) 2009 (Industry Average 4.72%) 5 Year Average (Industry Average 4.63%) Asset Growth 2013 Total Admitted Assets 13,768,311 1 -Year Growth 25.9% 3 -Year Compound Growth 17.8% 2013 Total Surplus & AVR 3.091,694 1 -Year Growth 16.8% 3 -Year Compound Growth 19.1% A Bears Finandal Strength Rating opinion addresses the relative ability of an insurer to meet its agoing insurance obligations. it is not a warranty of a and y'sebs oculi tr �J and ability emy 10 meet its obligagons to vim. View our Notbe: Bests Credit Ratings for a di�rner notice Data for Year -Ed 2013 from the fife insurance companies' statutory annual statements. M dollar amounts are in thousands. Al ratings shown are current as of June 02, 2014. Presented by: Keith R hklb, 514 Crest Lane, Pottstown, PA 19465 Pham: 484-6244560 Ease: l®ktdslettQnwn.00m Pepe 1 of 4 Powered by VitaiSales Suite, a product of EbacExcharge. Company Berkshire Hathaway Life of NE NoMnvestment Grade Bonds (Class 3 - 6) Non -Investment Grade Bonds/Total Bonds Non -Investment Grade Bonds/Surplus & AVR Non -Performing Bonds (Class 6) Non -Performing Bonds/Total Bonds Non -Performing Bonds/Surplus & AVR Non -Performing Mortgages & Real Estate Non -Performing Mort & RE/ Total Mod & R.E. Non -Performing Mort & R.EJSurplus & AVR Non -Performing Assets/Surplus & AVR Bonds In or Near Default Problem Mortgages Real Estate Acquired by Foreclosure Total Non -Performing Assets/Surplus & AVR As a Percent of Invested Assets 5.0% 9.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Total Bonds Book Value Total Bonds Market Value Bonds Market Value/BookValue Quality Class 1: Highest Quality Class 2: Higher Quality Class 3: Medium Quality Gass 4: Low Quality Class 5: Lower Quality Class 6: In or Near Default 3,921,025 4,348,556 110.9% 84.2% 10.8% 4.2% 0.8% 0.0% 0.0% Weighted Bond Class 1.2 Maturity 1 Year or Less 32.7% 1 to 5 Years 5.5% 5 to 10 Years 19.6% 10 to 20 Years 18.6% Over 20 Years 23.6% Weighted Bond Maturity (Years) 10.5 A Best's Rnancial Strength Rating opinion addresses the relative ability of an insurer to meet Ss ongoing insurance ablgatlons. 8 is not a warranty of a company's financial strength and ability to meet its obligations to policyholders. View our Important Notice: Best's Credit Ratings for a disclaimer notice and complete details at hlpYrwww.ambssl.camfratingsfnotioe. Dela for Year -End 2013 from the We insurance companies' statutory annual statements. AB dour amounts are in thousands. Al ratings shown are current as of June 02.2014. Poisoned by: Keith R Ielelb. 514 Crest Lane. Pottstown, PA 10485 Phone: 484-8248580 Snail: keithialedlogynoLcom Page 2 of 4 Powered by Vie1Salee Su>te, a product of ElliaExdrange. Company Berkshire Hathaway Life of NE Total Income Total General Expenses Total General Expenses/Total Income Eamings Before Poky Dividends & Taxes Policy Dividends Policy Dividends/Eamings Pretax Earnings from Operations Federal Income Taxes Income Taxes/Pretax Eamings Net Earnings from Operations Net Realized Capital Gains Net Income As % of Admitted Assets Unrealized Capital Gains 4,688,448 24,361 0.5% 1,526,462 0 0.0% 1,526,462 486,108 31.8% 1,040,354 487,004 1,527,358 11.1% -209,298 2013 Total Premium Income 1 -Year Growth 3 -Year Compound Growth 2013 Ordinary life Premium 1 -Year Growth 3 -Year Compound Growth 4,073,228 18.0% 18.7% 374,726 -80.5% -43.2% Retum on Assets Retum on Equity 2013 Lapse Ratio 3 -Year Average Lapse Ratio Net Investment Income Required Interest Interest Margin Ordinary Life Expenses/Premiums General Expenses/Total Income Commissions & General Expenses/Total Income 9.5% 46.5% 4.3% 6.6% 510,594 318,217 60.596 2.3% 0.5% 1.1% A Best% Financial Strength Rating opinion addresses the relative ability of an insurer to meet Its ongoing Insurance obligations. it is not a warranty of a company's financial strength and ability to meet its obligations to poighoWars. View our Important Notice: Best's Credit Ratings for a disdaimer notice and =Vete details at httpJMnvw.amaeatC0mfaV gsm0uce. Data for Year -End 2013 from the Tire insurance companies' statutory arcual statements. All dollar amounts are in thousands. Ai ratings shown are current as of June 02.2014. Presented by. Keith R Isleib. 514 Creat Lane. Pottstown, PA 19465 Phone: 484-6244560 Email: losithisleibitmen.com Page 3 of 4 Powered by VgatSaies Suite. a product of El xchha ge. Company Berkshire Hathaway Life of NE Total Insurance In Force Ordinary Life Group Life Other Total Reinsurance Ceded % of In Force Ceded Ordinary Life Group Life Other Ordinary Life Policies In Force Average Policy Size ('in dollars) Ordinary Life Policies Issued in 2013 Average Policy Size (in dollars) 320,595,349 95.5% 4.5% 0.0% 411,223 0.1% 0.0% 0.0% 7,900,349 38,769 0 0 Net Premiums Written Individual Life Annuities Health Group Life Annuities Hearth Credit Life & Health Other Lines 4,073,228 9.2% 60.6% 0.0% 0.8% 29.4% 0.0% 0.0% 0.0% Net Earnings from Operations 1,040,354 Individual Life 48.5% Annuities 56.6% Health 0.0% Group Life 1.7% Annuities -7.0% Health 0.0% Credit Life & Health 0.0% Other Livres 0.3% A Best's Finandal Strength Rating opinion addresses the relative abrdy of an insurer to meet its agoing insurance obigatians. It is not a warranty of a company: financial strength and ability to meet Its obigdions to policyholders. View orr hrportsnt Nonce: Bears Credit Retinas for a dsdatnennotice and canpleta details at tarp•1/www.ambeal.caNratlrgelnclbe. Dap for Year -End 2013 from the ate insurance companies' statutory alma statements. Al dolor amazes are to thousands- Al ratings shown we anent as of June 02, 2014. Presented by: Kehr R tdeb, 514 Gest lane, Paestum, PA 19:85 Phare: 484824.8560 6rroi: ireitisleibelensacom Page 4 of 4 Powered by Vita ides Suite, a product of Ebbexcha ge. SCHMIDT KRAMER PC BY: MICHAEL E KOSIK, ESQUIRE I.D. # 36513 209 State Street Harrisburg, PA 17101 P (717) 232-6300 F (717) 232-6467 Attorneys for Plaintiffs mkosil< schmidtkramer.com CURT and AMANDA ALLEMAN, : Individually and as Parents and : IN THE COURT OF COMMON PLEAS Natural Guardians of : CUMBERLAND COUNTY, REBECCA ALLEMAN, : PENNSYLVANIA • Petitioners • 9 s etoi.LLWArvi. No. /2/ 31 i% AND NOW THIS 8 day of 1017 , 2014, upon consideration of the Petition for Approval of Minor's Settlement, it is hereby ordered that Petitioner is authorized to enter into a settlement in the gross sum of $300,000. Petitioner is authorized to sign a Settlement Agreement and Release and to mark the matter settled, discontinued, and ended. The settlement amount shall be distributed as follows: To: Schmidt Kramer PC, $75,000 for counsel fees; To: Schmidt Kramer PC, $1,115.88 for reimbursement of costs; ORDER To: Optum, $43,741.20 for reimbursement of ERISA qualified plan subrogation lien; To: PRO2 Respiratory Services, $1,172.62 for reimbursement of medical bills; To: MS HMC Physician's Group, $224.23 for reimbursement of medical bills; To: MS Hershey Medical Center, medical bills; 1,752.12 for reimbursement of To: Amanda Alleman $2,813.64 for reimbursement of private medical coverage; To: Amanda and Curt Alleman, as Parents and Natural Guardian of Rebecca Alleman, a Minor, $74,180.31 to be deposited into a restricted, federally insured account marked: "This money shall be held in trust not to be redeemed, withdrawn, negotiated, or in any way alienated, except for renewal in its entirety, before October 31, 2025, except by Order of this Court." Westfield Insurance Company is authorized to fund the structure settlement proposal identified in the Petition which provided for: 1. To Rebecca Alleman ("Payee"), the sum of Twenty Thousand Dollars ($20,000.00), payable annually, guaranteed for 4 payments, beginning on 08/01/2026 and ending on 08/01/2029. 2. To Rebecca Alleman ("Payee"), the sum of One Thousand Dollars ($1,000.00), payable monthly, guaranteed for 48 payments, beginning on 08/0112026 and ending on 07/01/2030. 3. To Rebecca Alleman ("Payee"), the sum of Forty Thousand Dollars ($40,000.00), guaranteed, paid on 10/31/2032. Should Rebecca Alleman die before 10/31/2032, then any remaining guaranteed Periodic Payments set forth in Subparagraphs 111.13. (1), (2) and (3) shall instead be paid as due to the Estate of Rebecca Alleman ("Beneficiary"), upon proof of death being furnished to Assignee, or to such other beneficiary or beneficiaries as Rebecca Alleman shall designate, in writing, after reaching the age of majority and prior to her death, to Assignee. No such beneficiary designation or revocation thereof shall be effective unless it is in writing and delivered to Assignee. TOTAL AMOUNT OF DISTRIBUTION: $300,000. Counsel shall provide to the Court, within fourteen (14) days from the date of this order, proof of such deposit. tYll tut_ 112 Kb ix/ 9PY ,7. ry) 1.14, BY THE COURT: SCHMIDT KRAMER PC BY: Michael E. Kosik Attorney at Law Attorney ID No.: 36513 209 State Street Harrisburg, PA 17101 (717) 232-6300 Fax (717) 232-6467 mkosik@schmidtkramer.com Attorney for Plaintiffs 2011, OCT 20 j: CUI-VERL AND COUNTY PENS YL ANI CURT and AMANDA ALLEMAN, Individually and as Parents and Natural Guardians of REBECCA ALLEMAN, Petitioners : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, : PENNSYLVANIA • • : No. 14-3685 Civil Term PROOF OF COMPLIANCE WITH COURT ORDER AND NOW, this (6 7‘-- day of aLL. , 2014, attached for filing is the Certificate Disclosure verifying that a restricted account has been opened for Rebecca Alleman, a minor, in accordance with the Order signed by M.L. Ebert, Jr., Judge on July, 28, 2014. Respectfully submitted, SCHMIDT K " PC (441 ichael E. Kosik Attorney at Law Attorney I.D. No. 36513 209 State Street Harrisburg, PA 17101 (717) 232-6300 SCHMIDT KR.AMER PC BY: MICHAEL E KOSIK, ESQUIRE I.D. # 36513 209 State Street Harrisburg, PA 17101 P (717) 232-6300 F (717) 232-6467 Attorneys for Plaintiffs mkosik@schmidtkramer.com CURT and AMANDA ALLEMAN, • . .._ Individually and as Parents and : IN THE COURT OF COMMON PLEAS Natural Guardians of : CUMBERLAND COUNTY, REBECCA ALLEMAN, : PENNSYLVANIA Petitioners • • • : No. : Orphans Court Division PROOF OF DEPOSIT I, Danielle Carbone, an employee for Orrstown Bank, hereby deposes and states: 1. On Ocblau- tO p 201 , an account was opened at the Orrstown Bank, Camp Hill branch and a check from Schmidt Kramer law office in the amount of S74,786.31 was deposited into the account. 2. The account was established as a minor's restricted account in the name of Amanda and Curt Alleman as parents and natural guardians of Rebecca Alleman, a minor with the restriction that no withdrawal is permitted until the minor turns 18, except as permitted by Court Order. 3. A copy of the Court Order of July 29, 2014 was provided to the Bank as well as a copy of Pa.R.C.P 2039 and the account complies with the requirements of those documents. Date: 10(10[201g Danielle Carbone SCHMIDT KRAMER PC IlAWI.MAPOCRECMC011614,00H9911 Amanda and Curt Alleman, as p/n/g of Rebecca Alleman a minor 8/15/14 Settlement Disbursed Mid Penn. - ESCROW Settlement 6677 74,180.31 74,180.31 ,:x,141. DATE CUSTOMER NAMCODE TAX YEAR E � � ..TIME DEPOSIT_] MA (CREDIT ) ACCOUNT NUMBER ' 'DESCRIPTION CUSTOMER .SIGNATURE =PREPARED BY I:500 hail ?0 20B: L 2 2 3 LOuo CODES 01 CURRENT YEAR DEPOSIT I I -PRIOR YEAR DEPOSIT 40, ROLLOVER 1N 43 INTERNAL TRANSFER 1N 46 DIRECT TRANSFER IN . DEPOSIT AMOUNT OlusTowr4 BANK A Tradition ofExcellence Camp Hill Member F.D. I.C. 10/10/2014 1:50:40 PM Effective Date: 10/10/2014 0190 * 4000 *0045 CD/IRA Deposit $74,180.31 Cash Amount: $0.00 Cash Back: $0.00 ALL ITEMS ARE SUBJECT TO VERIFICATION & COLLECTION wwworrstown.com Thank you! Orrstown Bank