HomeMy WebLinkAbout05-3221F\FILFS\ ATAFILE\ .ga13050\CU,c.t\356eII
C.a d'. 7/8/05 4.16PM
Revived'. 8/10/05 1 I:J2AM
3050.356
Thomas J. Williams, Esquire
David R. Galloway, Esquire
MARTSON DEARDORFF WILLIAMS & OTTO
I.D. 17512
I.D. 87326
10 East High Street
Carlisle, PA 17013
(717) 243-3341
Attorneys for Defendants
CONSTANCE L. FLECK,
Plaintiff
V.
DAVID ENGLAND and
HELEN ANN ENGLAND,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 05-3221
CIVIL ACTION - LAW
JURY TRIAL DEMANDED
DEFENDANTS' ANSWER TO PLAINTIFF'S COMPLAINT
AND NOW, come Defendants David England and Helen .Ann England by and through their
attorneys, MARTSON DEARDORFF WILLIAMS & OTTO, and hereby reply to Plaintiff's
Complaint as follows:
1. Denied. After reasonable investigation, Defendants are without knowledge or
information sufficient to form a belief as to the truth of the averments in this Paragraph. Said
averments therefore are denied and strict proof thereof is demanded at trial.
2. Admitted.
3. Admitted in part and denied in part. It is admitted that Helen Ann England is an adult
individual currently residing at 3400 Green Street, Harrisburg, Dauphin County, Pennsylvania,
17110. It is denied, however, that Defendant Helen Ann England, is a competent adult. To the
contrary, Defendant, Helen Ann England, is in a near comatose state and has been for nearly a year.
4. Admitted and denied in part. Defendants admit they were in management and/or
control of the premises located at and known as 1312 and 1316 Mallard Road, East Pennsboro
Township, Cumberland County, Pennsylvania (hereinafter the "Premises") and were responsible for
maintaining the property. It is denied, however, that Defendants owned or possessed the Premises.
To the contrary, Defendants are Trustees of a trust containing the Premises.
5. Admitted.
6-17. Denied. The averments of Paragraph 6-17 are denied in accordance with Pa.
R.Civ.P.1029(e).
WHEREFORE, Defendants David England and Helen Ann England respectfully request
that this Court dismiss Plaintiff's Complaint with prejudice and enter judgment in their favor and
against Plaintiff, together with an award of such costs, interest and other relief as the Court deems
just and reasonable.
MARTSON DEARDORFF WILLIAMS & OTTO
By r??
Thomas J. Williams, Esqui e
David R. Galloway, Esquir
MARTSON DEARDORFF WILLIAMS & OTTO
10 East High Street
Carlisle, PA 17013
(717) 243-3341
Date: August 10, 2005 Attorneys for Defendants
VERIFICATION
The foregoing Answer is based upon information which has been gathered by our counsel
in the preparation of the lawsuit. The language of the document is that of counsel and not our own.
We have read the Answer to the extent that the document is based upon information which we have
given to our counsel, it is true and correct to the best of our knowledge, information and belief. To
the extent that the content of the document is that of counsel, we have relied upon counsel in making
this verification.
This statement and verification are made subject to the penalties of Pa. C.S. Section 4904
relating to unsworn falsification to authorities, which provides that if we make knowingly false
averments, we may be subject to criminal penalties.
Date: July 11 , 2005
Date: July L, 2005
Helen Ann England
CERTIFICATE OF SERVICE
I, Tricia D. Eckenroad, an authorized agent of Martson Deardorff Williams & Otto, hereby
certify that a copy of the foregoing Answer was served this date by depositing same in the Post
Office at Carlisle, PA, first class mail, postage prepaid, addressed as follows:
W. Scott Henning
HANDLER, HENNING & ROSENBERG, LLP
1300 Linglestown Road
Harrisburg, PA 17110
MARTSON DEARDORFF WILLIAMS & OTTO
(tTn a D. Eckerroad
Ten East High litreet
Carlisle, PA 17013
(717) 243-3341
Date: August 10, 2005
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W. Scott Henning, Esquire
I.D.#32298
HANDLER, HENNING & ROSENBERG, LLP
1300 Linglestown Road
Harrisburg, PA 17110
Telephone: (717) 238-2000 Attorney for Plaintiff
Fax: (717) 233-3029
E-mail: Henning HHRLaw.com
CONSTANCE L. FLECK, : IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff,
No. OS-3aaI ub'L(
V.
DAVID ENGLAND and CIVIL ACTION - LAW
HELEN ANN ENGLAND,
Defendants : JURY TRIAL DEMANDED
NOTICE
YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following
pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a
written appearance personally or by attorney and filing in writing with the Court your defenses or objections to
the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and
a judgment may be entered against you by the Court without further notice for any money claimed in the
Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other
rights important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO
TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH
INFORMATION ABOUT HIRING A LAWYER.
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH
INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A
REDUCED FEE OR NO FEE.
Lawyer Referral Service
4th Floor, Cumberland County Courthouse
Carlisle, PA 17013
(717) 240-6200
AVISO
USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las demandas que se presentan
mas adelante an las siguientes paginas, debe tomar acci6n dentro de los pr6ximos veinte (20) dias despu6s
de Is notificaci6n de esta Demands y Aviso radicando personalmente o por medio de un abogado una
comparecencia escrita y radicando en la Corte por escrito sus defenses de, y objecciones a, las demandas
presentadas aqui an contra suya. Se le advierte de qua si usted falls de tomar acci6n como se describe
anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la
demanda o cualquier otra reclamaci6n o remedio solicitado por el demandante puede ser dictado an contra suya
por la Corte sin mas aviso adicional. Usted puede perderdinero o propiedad u olros derechos importantes para
usted.
USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE
UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE
INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO.
SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA
LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN
CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN.
Lawyer Referral Service
4th Floor, Cumberland County Courthouse
Carlisle, PA 17013
(717) 240-6200
W. Scott Henning, Esquire
I.D.#32298
HANDLER, HENNING & ROSENBERG, LLP
1300 Linglestown Road
Harrisburg, PA 17110
Telephone: (717) 238-2000 Attorney for Plaintiff
Fax : (717) 233-3029
E-mail: Henning@HHRLaw.com
CONSTANCE L. FLECK,
Plaintiff,
V.
DAVID ENGLAND and
HELEN ANN ENGLAND,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
No. OS - 32-Z1
CIVIL ACTION - LAW
Defendants
(21 (j,L
JURY TRIAL DEMANDED
COMPLAINT
AND NOW, comes the Plaintiff, Constance L. Fleck, by and through her attorneys,
HANDLER, HENNING & ROSENBERG. LLP, by W. Scott Henning, Esquire, and brings
forth this Complaint against Defendants, David England and Helen Ann England, and avers
as follows:
1. Plaintiff, Constance L. Fleck, is a competent adult individual currently residing at
1055 Mummasburg Road, Gettysburg, Adams County, Pennsylvania 17325-8514.
2. Defendant, David England, is a competent adult individual currently residing at 3400
Green Street, Harrisburg, Dauphin County, Pennsylvania 17110.
3. Defendant, Helen Ann England, is a competent adult individual currently residing
at 3400 Green Street, Harrisburg, Dauphin County, Pennsylvania 17110.
4. At all times material hereto, Defendants, David England and Helen Ann England,
were in ownership, possession, management and/or control of the Premises located
at and known as 1312 and 1316 Mallard Road, East Pennsboro Township,
Cumberland County, Pennsylvania, and were responsible for maintaining the safe
condition of the property.
5. At all times material hereto, Plaintiff, Constance L. Fleck, was lawfully upon said
Premises.
6. At all times material hereto, Defendants, David England and Helen Ann England,
who had exclusive control of said Premises, had permitted to be installed and exist,
a door would "stick" in the doorjamb and would not open properly.
7. At all times material hereto, there were no warning signs posted on the Premises
so as to provide visible warning of the unsafe condition of the door.
8. On or about April 19, 2004, Plaintiff, Constance L. Fleck, was exiting the laundry
facilities of said Premises at 1312/1316 Mallard Road, East Pennsboro Township,
Cumberland County, Pennsylvania when the aforementioned door failed to open
upon Plaintiff's pushing upon it whereby Plaintiffs arm passed through a window on
the door thereby causing severe personal injuries to Plaintiff.
9. The occurrence of the aforementioned incident and the resulting injuries to Plaintiff,
Constance L. Fleck, were caused directly and proximately by the negligence of
Defendants, David England and Helen Ann England and/or their agents, servants,
-2-
workmen or employees, acting in the scope of their authority and employment,
generally and more specifically as set forth below:
a. In causing or permitting a door of said Premises to remain in such a
condition that it was prone to sticking in its jamb, thereby posing an
unreasonable risk of injury to the Plaintiff and to other persons lawfully upon
the premises;
b. In causing or permitting a door of said Premises to be placed in the
basement of said Premises which was prone to sticking in it's jamb, thereby
posing an unreasonable risk of injury to the Plaintiff and to other persons
lawfully upon the premises;
C. In causing or permitting a door, of said Premises, which was found to be
defective in its initial location, to be removed from one location at said
Premises and reinstalled in another location at said Premises, thereby
posing an unreasonable risk of injury to the Plaintiff and to other persons
lawfully upon the premises;
d. In causing or permitting a door of said Premises to remain, which was prone
to sticking in its jamb, when Defendant knew or should have known the
likelihood that the door was, could be, or had become a hazard to individuals
lawfully utilizing the Premises;
e. In failing to make a reasonable inspection of said Premises which would
have revealed the existence of the dangerous condition posed by the door
of said Premises, and thereby allowing the same to be and remain a
dangerous condition when the Defendant knew or should have known of it;
-3-
f. In failing to ensure the door at said Premises was maintained in a safe
condition so as to prevent injury to the Plaintiff and other persons lawfully
upon the Premises;
g. In failing to post a warning sign or device in the area to notify of the
dangerous condition of the door of said Premises;
h. In failing to properly adjust the door on said Premises so as to avoid the
situation in which the door wold stick in a closed position thereby causing a
hazard and resulting injuries to the Plaintiff;
In failing to ensure that the glass pane in said door was of a reasonable
design and appropriate safety material and/or thickness so as to avoid the
situation in which Plaintiff's hand and arm could readily pass through the
glass pane thereby causing injury to the Plaintiff;
j. In failing to maintain the door in a reasonably safe condition that would
prevent Plaintiff, Constance L. Fleck, from being injured as her hand passed
through the glass as the door stuck in a closed position; and
k. In allowing to remain, a door not maintained in a proper state of repair and/or
not maintained free of hazardous conditions.
10. Defendants, David England and Helen Ann England had actual knowledge or
should have known through the exercise of ordinary care and diligence that the
aforementioned door on said Premises would stick in the door jamb in a closed
position, thereby causing Plaintiff, Constance L. Fleck's, hand to pass through the
door's glass pane as she was trying to open it.
-4-
11. As a direct and proximate result of the negligence of Defendants, David England
and Helen Ann England, Plaintiff, Constance L. Fleck, sustained serious injuries
including, but not limited to, severe lacerations of her forearm.
12. As a direct and proximate result of the negligence of Defendants, David England
and Helen Ann England, Plaintiff, Constance L. Fleck, has undergone great physical
pain, discomfort and mental anguish and she will continue to endure the same for
an indefinite period of time in the future, to her great detriment and loss, physically,
emotionally and financially.
13. As a direct and proximate result of the negligence of Defendants, David England
and Helen Anne England, Plaintiff, Constance L. Fleck, has been, and may in the
future be, hindered from attending to her daily duties to her great detriment, loss,
humiliation and embarrassment,
14. As a direct and proximate result of the negligence of Defendants, David England
and Helen Ann England, Plaintiff, Constance L. Fleck, has, and may in the future,
suffer a loss of life's pleasures.
15. As a result of the negligence of Defendants, David England and Helen Ann
England, Plaintiff, Constance L. Fleck, has suffered lost wages/income and may in
the future continue to suffer a loss of income and/or loss of earning capacity.
16. As a direct and proximate result of the negligence of Defendants, David England
and Helen Ann England, Plaintiff, Constance L. Fleck, has been compelled, in order
to effect a cure for the aforesaid injuries, to expend large sums of money for
medicine and medical attention, and may be required to expend large sums of
money for the same purposes in the future, to her great detriment and loss.
-5-
17. Plaintiff, Constance L. Fleck, believes and, therefore, avers that her injuries are
permanent in nature, including the permanent scarring, disfigurement and nerve
damage.
WHEREFORE, Plaintiff, Constance L. Fleck, seeks damages from Defendants,
David England and Helen Ann England, in an amount in excess of the compulsory
arbitration limits of Cumberland County.
Respectfully submitted,
HANDLER, HENNING & f3?OSENBERG, LLP
DATE: ?O?oa'JUJ? BY
W. Scott
Attorney for Plaintiff
-6-
VERIFICATION
The undersigned hereby verifies that the statements in the foregoing document
are based upon information which has been furnished to counsel by me and
information which has been gathered by counsel in the preparation of this lawsuit.
The language of the documeni is of counsel and not my own. I have read the
document and to the extent that it is based upon information which I have given to
counsel, it is true and correct to the best of my knowledge, information and belief. To
the extent that the contents of the document are that of counsel, I have relied upon
my counsel in making this Verification. The undersigned also understands that the
statements made therein are made subject to the penalties of 18 Pa. C.S. Section
4904, relating to unsworn falsification to authorities.
ance L. Fleck
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Grated: 9/20/OE 0-06PM
Revised 6130105 11-19AM
Thomas J. Williams, Esquire
David R. Galloway, Esquire
MARTSON DEARDORFF WILLIAMS & OTTO
I.D. 17512
I.D. 87326
10 East High Street
Carlisle, PA 17013
(717) 243-3341
Attorneys for Defendants
CONSTANCE L. FLECK, IN THE COURT OF COMMON PLEAS OF
Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA
V. NO. 05-3221
CIVIL ACTION - LAW
DAVID ENGLAND and
HELEN ANN ENGLAND,
Defendants JURY TRIAL DEMANDED
PRAECIPE
TO THE PROTHONOTARY OF CUMBERLAND COUNTY
Enter the appearance of MARTSON DEARDORFF WILLIAMS & OTTO on behalf of
Defendants David England and Helen Ann England in the above matter.
MARTSON
Thomas J. Will am'g;
David R. Galloway, I
Ten East High Street
Carlisle, PA 17013
(717) 243-3341
WILLIAMS & OTTO
Attorneys for Defendants
Dated: June 30, 2005
CERTIFICATE OF SERVICE
I, Tricia D. Eckenroad, an authorized agent for Martson Deardorff Williams & Otto, hereby
certify that a copy of the foregoing Praecipe was served this date by depositing same in the Post
Office at Carlisle, PA, first class mail, postage prepaid, addressed as follows:
W. Scott Henning, Esquire
HANDLER, HENNING & ROSENBERG
1300 Linglestown Road
Harrisburg, PA 17110
MARTSON DEARDORFF WILLIAMS & OTTO
Y
?cia D. Ecke road
D East High Street
Carlisle, PA 17013
(717) 243-3341
Dated: June 30, 2005
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SHERIFF'S RETURN - OUT OF COUNTY
CASE NO: 2005-03221 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
FLECK CONSTANCE L
VS
ENGLAND DAVID ET AL
R. Thomas Kline
, Sheriff or Deputy Sheriff who being
duly sworn according to law, says, that he made a diligent search and
and inquiry for the within named DEFENDANT , to wit:
ENGLAND DAVID
but was unable to locate Him
deputized the sheriff of DAUPHIN
serve the within COMPLAINT & NOTICE
County, Pennsylvania, to
On July 12th , 2005 , this office was in receipt of the
attached return from DAUPHIN
Sheriff's Costs:
Docketing
Out of County
Surcharge
Dep Dauphin Cc
Postage
So answ? -?
18.00 ?'
9.00 ?,r -
10.00 R. Thomas Kline
36.00 Sheriff of Cumberland County
.74
73.74
07/12/2005
HANDLER HENNING ROSENBERG
Sworn and subscribed to before me
this 19 ? day of
206 ? A.D.
in his bailiwick. He therefore
In The Court of Common Plus of Cumberland Countyq Pennsylvania
Constance L. Fleck
VS.
David England et al
SERVE: 05-3221 civil
David England No.
June 30, 2005
Now,
hereby deputize the Sheriff of
I, SHERIFF OF CUMBERLAND COUNTY, PA, do
Dauphin
County to execute this Writ, this
deputation being made at the request and risk of the Plaintiff.
Sheriff of Cumberland County, PA
Affidavit of Service
Now, 20`, at
within
upon
at
by handing to
a
and made known to
o'clock M. served the
copy of the original
So answers,
the contents thereof.
Sheriff of
Sworn and subscribed before
me this day of 20`
COSTS
SERVICE $
MILEAGE
AFFIDAVIT
County, PA
(,Offtrk -of .e "Ii?4,er ff
Mary Jane Snyder
Real Estate Deputy
William T. Tully
Solicitor
Dauphin County
Harrisburg, Pennsylvania 17101
ph: (717) 255-2660 fax: (717) 255-2889
Jack Lotwick
Sheriff
Commonwealth of Pennsylvania FLECK CONSTANCE L
vs
County of Dauphin ENGLAND DAVID
Sheriff's Return
No. 1173-T - - -2005
OTHER COUNTY NO. 05-3221
J. Daniel Basile
Chief Deputy
Michael W. Rinehart
Assistant Chief Deputy
AND NOW:July 5, 2005 at 2:42PM served the within
COMPLAINT upon
ENGLAND DAVID by personally handing
to DAVID ENGLAND DEFT 1 true attested copy(ies)
of the original COMPLAINT and making known
to him/her the contents thereof at 3400 GREEN STREET
HARRISBURG, PA 17110-0000
Sworn and subscribed to
before me this 6TH day of JULY, 2005
A?
NOTARIAL SEAL
MARY JANE SNYDER, Notary Public
Highspin, Dauphin County
My Commission Expires Sept. 1, 2006
So Answers,
e,;
Sh
eriff Dauphin y, a.
BY -
Deputy Sheriff
Sheriff's Costs:$36.00 PD 07/05/2005
RCPT NO 208422
BH
SHERIFF'S RETURN - OUT OF COUNTY
CASE NO: 2005-03221 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
FLECK CONSTANCE L
VS
ENGLAND DAVID ET AL
R. Thomas Kline
.00
16.00
07/12/2005
HANDLER HENNING ROSENBERG
duly sworn according to law, says, that he made a diligent search and
and inquiry for the within named DEFENDANT , to wit:
ENGLAND HELEN ANN
but was unable to locate Her
deputized the sheriff of DAUPHIN
, Sheriff or Deputy Sheriff who being
in his bailiwick. He therefore
serve the within COMPLAINT & NOTICE
County, Pennsylvania, to
On July 12th , 2005 , this office was in receipt of the
attached return from DAUPHIN
Sheriff's Costs:
Docketing
Out of County
Surcharge
Sworn and subscribed to before me
w
this _1,_ day of
JovS A.D.
Prot?otary
So answers
6.00 _
.00
10.00 R. Thomas Kline
.00 Sheriff of Cumberland County
In The Court of Common Pleas of Cumberland County, Pennsylvania
Constance L. Fleck
vs.
David England et al
SERVE: Helen Ann England
No. 05-3221 civil
June 30, 2005
Now, , I, SHERIFF OF CUMBERLAND COUNTY, PA, do
hereby deputize the Sheriff of
Dauphin
County to execute this Writ, this
deputation being made at the request and risk of the Plaintiff.
Sheriff of Cumberland County, PA
Affidavit of Service
Now,
within
upon
at
by handing to
a
and made known to
So answers,
the contents thereof.
Sheriff of
Sworn and subscribed before
me this day of 20
r
20_, at o'clock M. served the
copy of the original
COSTS
SERVICE
MILEAGE _
AFFIDAVIT
County, PA
S
Wf 1 )af e o$hrri f f
Mary Jane Snyder
Real Estate Deputy
William T. Tully
Solicitor
Dauphin County
Harrisburg, Pennsylvania 17101
ph: (717) 255-2660 fax: (717) 255-2889
Jack Lotwick
Sheriff
Commonwealth of Pennsylvania FLECK CONSTANCE L
vs
County of Dauphin ENGLAND DAVID
Sheriff's Return
No. 1173-T - - -2005
OTHER COUNTY NO. 05-3221
J. Daniel Basile
Chief Deputy
Michael W. Rinehart
Assistant Chief Deputy
AND NOW:July 6, 2005 at 10:19AM served the within
COMPLAINT upon
ENGLAND HELEN ANN by personally handing
to DAVID ENGLAND HUSBAND OF DEFT
1 true attested copy(ies)
of the original COMPLAINT and making known
to him/her the contents thereof at 3400 GREEN STREET
HARRISBURG, PA 17110-0000
Sworn and subscribed to
before me this 8TH day of JULY, 2005
NOTARIAL SEAL
MARY JANE SNYDER, Notary Publio
Highspire, Dauphin County
My Commission Expires Sept. 1, 2006
So Answers,
?J
/ 7VSheriff of Dauphin County, Pa.
Z?CSrnav A
B?'<
Deputy Sheriff
Sheriff's Costs:$36.00 PD 07/05/2005
RCPT NO 209422
BH
CONSTANCE L. FLECK,
plaintiff
V.
DAVID ENGLAND and
HELEN ANN ENGLAND,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 05-3221 CIVIL
RULE 1312-1. The petition for Appointment of Arbitrators shall be substantially in the following form:
PETITION FOR APPOINTMENT OF ARBITRATORS
TO THE HONORABLE, THE JUDGES OF SAID COURT:
George B. Faller, Jr., Esquire counsel for CheV
,,,aWdefendant in the above action (or actions),
respectfully represents that:
1. The above-captioned action (or actions) is (are) at issue.
2. The claim of the plaintiff in the action is $ not in excess of $35,000.
The counterclaim of the defendant in the action is
The following attorneys are interested in the case(s) as counsel or are otherwise disqualified to sit as arbitrators.
George B. Faller, Jr., Esquire, W. Scott Henning, Esquire
WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to whom the case shall be
submitted.
Re ct lly tt
ge B. Faller, r.
ORDER OF COURT
AND NOW, _, in consideration of the
foregoing petition, Esq.,
Esq., and Esq., ate appointed arbitrators in the above captioned action (or
actions) as prayed for.
By the Court,
P.J.
CONSTANCE L. FLECK,
Plaintiff
V.
DAVID ENGLAND and
HELEN ANN ENGLAND,
Defendants
IN THB COURT OF COMMON PLEAS OF
CUMBERLAND COUN'T'Y, PENNSYLVANIA
NO. 05-3221 CIVIL
RULE 1312-L The Petition for Appointment of Arbitrators shall be substantially in the following form:
PETITION FOR APPOINTMENT OF ARBITRATORS
TO THE HONORABLE, THE JUDGES OF SAID COURT:
George B. Faller, Jr., Esquire counsel for thek?Wdefendantintheaboveaction(oractions),
respectfully represents that:
1. The above-captioned action (or actions) is (are) at issue.
2, The claim of the plaintiff in the action is $ not in excess of $35,000.
The counterclaim of the defendant in the action is
The following attorneys are interested in the case(s) as counsel or are otherwise disqualified to sit as arbitrators:
George B. Faller, Jr., Esquire, W. Scott Henning, Esquire
WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to whom the case shall be
submitted.
ORDER OF COURT
AND NOW,
foregoing
Esq., and i
actions) as prayed for.
s?• ?,pb
0
Re ct lly tt
i
i
lBe. Faller, r.
UL in consideration of the
7 7
4- 1 Esq.,
Esq., are appointed arbitrators in a above captioned action (or
B ¢ Court,
P.J,
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W. Scott Henning, Esquire
I.D.#32298
HANDLER, HENNING & ROSENBERG, LLP
1300 Linglestown Road
Harrisburg, PA 17110
Telephone: (717) 238-2000 Attorney for Plaintiff
Fax: (717) 233-3029
E-mail: Henning@HHRLaw.com
CONSTANCE L. FLECK,
Plaintiff,
V.
DAVID ENGLAND and
HELEN ANN ENGLAND,
Defendants,
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
No. 05-3221
: CIVIL ACTION - LAW
JURY TRIAL DEMANDED
PLAINTIFF'S ARBITRATION EXHIBITS
In accordance with Pennsylvania Rule of Civil Procedure 1305(b), the following
documents are attached which the Plaintiff intends to introduce into evidence at the time
of the arbitration of this case
1. Medical Records from East Pennsboro Ambulance Service;
04/19/2004
2. Medical Records from Holy Spirit Hospital;
04/19/2004
3. Medical Records from Orthopedic Institute;
04/19/2004 through 08/02/2004
4. Medical Records from Drayer Physical Therapy;
05/12/2004 through 07/01/2004
5. Medical expense billing summary (with corresponding billing statements); and
6. Photos of scarring.
Respectfully Submitted,
HANDLER,
Date: August 7, 2006
By
W. Scott Henning,`Esc
I.D. #32298 //
1300 Linglestown R4
Harrisburg, PA 17110
(717) 238-2000
Attorney for Plaintiff
LLP
1
?rW D Pennsylvania EMS Report
Service Name
East Pennsboro Ambulance Service Unit No.
2101801 PCR No.
0400677 PSAP Incid. No.
040046865 Date
04/19/2004
Incident Location
1312 Mallard Rd: A t. C Tr# 346 CL 2 MCD
21909 Receiving Agency
Holy Sin it Hos ital
O Patient Name
Constance Fleck Phone No.
17 763.8876 Age
29 Years Date of Birth
02/27/1975 Social Sec. No.
200-54-4360 Sex
Female
? Street Address Crew Times
1••4 1312 Mallard Rd.-Apt. C A #1 Fink, Keith E 144536 911
.I.0 City State Zip
Camp Hill PA 17011 A #2
A #3 Trapnell, William E 162254 Dispatch
Enroute 15:20
15:22
? Patient Number
Mship
A #4
Arrive Scene
15:28
b
.+ I N7,7 Contact 15:29
Private Physician Out On-Scene Dest. In Depart Scene 15:42
a James 88311 88315 88316 86316 Arrive Facility 15:47
Transporting Assist Units OS Time Medical Command Physician
-Ch MCC Available 15:59
ief -Complaint, Lac ft
eration to Le forearm
Current Meds: None er afient
-Allergies made : NKDA
Narrative
PMH: None per patient
Dispatched (CCCC) for an immediate response to the above location for a laceration, class 2,
response. Additional information: 29 y/o female, conscious and breathing who accidently put
her arm through the window. She has a laceration noted to her forearm and it is possibly
down to her bone.
AOS: Pound a female patient laying supine on the hallway floor appearing awake and alert
while a neighbor (physicians assistant) was holding pressure w/ a towel to her left arm.
HPI: The patient stated that around 15:15 hours, she was walking up from the basement and
had went to open the door w/ her left arm when the glass she pushed on broke through
causing a laceration. She ran upstairs and yelled for her neighbor who got a towel and
applied pressure prior to calling ems for assistance.
PE: The patient is awake and alert denying no other pains or problems other than what is
listed above. She does state that she feels a little dizzy and sick to her stomach but denies
having any headaches or vision problem. HEENT in unremarkable w/ her PEARL and no jvd
present around the throat area. Her chest appears equal to rise and fall w/ her lungs
sounding clear upon exam. No abdominal complaints are present w/ the patient having full
mobility of all extremities w/ the exception of her left arm which she rates at a 10/10 on the
pain scale. She also states that she has some numbness and tingling present in the hand and
there is a + radial pulse present. No radiation is present and there are some minor cuts noted
to her hand that have stopped bleeding. The laceration was about 2 1/2 to 3 inches long and
deep down to the bone w/ moderate bleeding present.
0
00
W
J
W
O?
O
TX: The patient was assessed while a hpi was gathered. She then had the laceration checked
prior to placing about 5 4x4's on it and wrapping it w/ kling. Her pulse was re-checked and
was present. She had a set of vs taken prior to assisting her into a standing position and
walking w/ assistance down to the ambulance where she was seated and secured onto the
litter for transport. She was continuously monitored for any changes along the way and
Provider
Printed On: 04/19/2004 18:07
EMStat Reporting(c) 1998-2004, Med-Media, Inc. All Rights Reserved Page: I of 2
Rt? D .'ennsylvania EMS Report
Service Name Unit No. PCR No. Date
East Pennsbom Ambulance Service 2101801 0400677 - 04119/2004
Patient Name Date of Birth Social Security Number MCC Medical Command Physician
Constance neck 0287/1975 200-54.4360
offered none upon arrival where she was taken into the ED and brought to a bed located it
hallway A. She slid herself over to the bed transferring her care and report to staff on duty
Keith Fink
Emt #144536
15:35 Banda c Al A2
15:38 76 24 108/18 4/5/6 1 _I vs-assessment and h pi completed crew cao x 3-laceration to ieft forearm
0
,A
O
J
J
W
W
Provider
Printed On: 04/19/2004 18:07
EMStat Reporting(c) 1998-2004, Med-Media, Inc. All Rights Reserved Page: 2 of 2
SS 1212 MA LLARD in WA40 HILL /PA f 179 j 1 2i 761 00"
PRE
L
ITHDATEZ :
WWHO ET PATP IQ'S LAW Atli NONE
a1CfEN0
,.,. E _.. : , ,,,
S r j
DRES
: PH.
;ASE WFORMATIEN
NIT BRI i80018 ED GROUP RED SOURCE1 ED PATIENT TYPQ E'..
M77 rx" .I.Cit' pX
iMPLAINT: LT ARM W.?
_, t N BY! BLS
RiME.'• ,
ACCIDENT INFORhAT10-i
0.. .'.r i1±r,. P r.Cr. ..l.,t r'.I,..Y r... ..A.,'. D i .uv+a GLASS IN A A.. :r.
PRIVACY M071CE! 0-IT-WA 01 ER!
GUARANTOR WORMATYON.
)DRESS: 1112 MALLARD yy, /CAMP I....'... /PA/12011 H 17 762 -6276
!PLCYER: HEALT H AMERICA CONTAT T NAME;:
INSURANCE WFORMAT ION
PLAN ?, ad,. _::.ANi::.. co COB PILI CY GROUP 1.
'I 202 HEALTH :``"'r.1
AMERICA ' :
205403600'; '
'.. .
ir.. ..1.;!"'1 . ......f-+i_- i.:: F'f is_
.ft? : .:.r.....
.... ...EN . .:f . FMD ., .,!Q,
Ivv.LEN `n.''f.. v. 7LESV 10ONSTANCE
...
END W .. W .
15156 04/:v/54 TR?h 5yQ'jRQ%W:.
Trip Number:
Patient Number:
Address:
City/State/Zip:
Phone:
Member:
Transported From:
Transported To:
East _ ennsboro Ambulance SL rice
Patient Services Charge Form - PCR: 0400677
0400677 Patient Name: Constance Fleck Date: 04/19/2004
1312 Mallard Rd: Apt. C
Camp Hill, PA 17011
(717) 763-8876
No
1312 Mallard Rd: Apt. C Tr# 346 CL 2
Holy Spirit Hospital
Service/Type Charges
Call Type: Prehospital
Waiting Time: 0 Minutes
Medicare Checks
0 Moved by Stretcher - protocol
® Hemorrhaging
? Bed Confined Before
Chief Complaint: Laceration to L forearm
Reason for Transport: Traumatic Emergency
ICD-9 Code 1: Bleeding
Insurance Information
Date of Birth: 02/27/1975
Age: 29 Years
SSN: 200-54.4360
Sex: Female
Crew 1: Fink, Keith
Crew 2: Trapnell, William
Crew 3:
Crew 4:
Loaded Mileage: 1 Miles
Origin Zip Code: 17011
? Bed Confined After
? Unconscious/Shock Present
ICD-9 Code 2:
? Health America
1
1
100103004
200544360
01
Guarantor Information - Self
Stock Charges
Gloves er air) 1 01 2
4x4 36 036 5
Kling 39 039 1
Billing Notes:
Printed On: 04/19/2004 18:07
EMStat Reporting(c) 1998-2004, Med-Media, Inc. All Rights Reserved Page: I of I
Consent Form with 6.,jnature Authorization and Assly:tment of Benefits
YOUR PRIVACY RIGHTS
East Pennsboro Ambulance Service, Inc. is required by law to inform you of your rights as a patient and how we will
use or disclose your Protected Health Information (PHI).
In the course of treatment we obtain health information, document the health care services provided to you, and
obtain information for payment for our services. This information is considered confidential and will only be disclosed
as allowed by the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA permits disclosure of
PHI for treatment, payment, and operations.
We are providing you a copy of our Notice of Privacy Practices. A copy of our complete privacy policy is
available for your review prior to signing this consent form, or you may request a copy of the privacy policy by
calling (717)732-5552.
1 understand my privacy rights concerning Protected Health Information (PHI) and I agree to the use of this
information for treatment, payment, and operations as described above.
My signature acknowledges receipt of the Notice of Privacy Practices from East Pennsboro Ambulance Service, Inc
Patient Signature: X Date:
Patient Name:
.......................................................................... a...,
Billing Authorization for Payment and Assignment of Benefits
I request that payment of authorized Medicare, Medicaid, or other health insurance benefits be made on my behalf to
East Pennsboro Ambulance Service, Inc. or its billing agent, for any services furnished to me by that supplier. I
authorize any holder of medical information about me to release any information or documentation needed to
determine these benefits or the benefits payable for related services to the Centers for Medicare and Medicaid
Services, its agents and carriers, and East Pennsboro Ambulance Service, Inc. or its billing agent. I permit a copy of
this authorization to be used in place of the original. i understand that this authorization may be used by the supplier
for all services in the future unfit such time as I revoke this authorization in writing.
Patient Signature:X Date
..............................................................................f
If the patient is unable to sign, an authorized representative may sign on behalf of the patient. Signature by an
authorized representative of the patient acknowledges receipt of the Notice of Privacy Practices, authorization to
release medical information as needed for treatment, payment, and operations, and authorization to bill Medicare,
Medicaid, and/or any other insurance carrier on behalf of the patient.
Representative's Signature: XX Date
Relationship of representative to the patient: ? Spouse ?Son/Daughter ?Power of Attorney (POA)
?Guardian ?Other.
Representative's Phone Number.'
Address of Representative:
Patient is unable to sign because patient is:
? unconscious/unresponsive ? receiving immediate medical treatment unable to move extremity
? not competent ? a minor with no family present ? immobiliz d ,, ff IIt/'J?
l2jther: ?t(L,e ae.ylti EMT Signatures
00102C rev 4/1/2003
h1
a
Date: I Age: Z FMD: Log In: 1
Name t C81c? BI Q,SAT Triage:
/
Mode of Arrival: BLS ? ALS ? Other ? T P -
i EL R I Room:
Triage Chief Complaint
ced Directl
D
as
Nc ?
ed
No ?
`
e to measles, c xn pox, TB7
No?
T
J
Loca
[ PMH Checklist: None ? MI ? HTN ? CAD
Intencale
>F I OB' CHF? ASTHMA ? CANCER ? STROKE
Ad
lt
B
k
?
NIDDM ? IDDM ? u
ong
a
e
4
1 Surgeries? Char
- Ache Dull ? S
QT
Ai
?r
'
PresBurning
Other ?
Wii J, Throiati g ?
Z
Dura
Allergies
Frequency
What relieves Pai
n?
Latex Allergy Yes ? N]
' `•,, ' !? C3Ccswgl" ' Immunizations: UTD ? Not UTD ? Triage Notes:
Tetanus LMP
i ; HOH ? Speaks English: Yes No 0
Treatment 0 Triage
Medications: Info obtained by: EMT O Medic El List ? Bottles D Patient ?
Mods Dose Meds Dose Mods ose
Meds Unknown C1 Injury: Place Occurred Home? Work? Other? Skin C olor: WNL Mottled?Cy notic?
Skin
11 ?
mp Coal
Location On E?pdy: Dist
al
ul ses:
ul
?
0 Y
W
LJ
s
ED:]
Defor ity: Yes? NoD
fti `' i r
i
1
1
l Ecchy os+s: Yes D No D
1
„ ..
Ik,, Triage I to Radiology at
Holy Spirit Hospital i
". -I in ? ' -1 1 j w R
41 a 492 t
Camp Hill, PA 17011 rLCC`; Co413T114C L
1712 ttALL41110 RC, Ell
John R. Dietz ECU ' C a r o µ t L t p A 1 7011
Nursing Assessment 021;7/1175 7b? -1111876 =
290-54-454#0 E01 6R0U!
1'
Cost Cot
rLCCx , -
'
200S443600i
zoo-ECU ,mz,an Rrv. is CHART COPY 04110/04
n
initial Lab & X-Ray Orders:
Labs,
( ) Acalaminophen [ ] DOAS I I Thrombolpic Labs '
[ I Acetone (SAGE) ( I ESP [ I Tox Screen
[ ] Alcohol (ALCO) ] I Glucose [ I Urine Tox Screen
[ I Amylasan*aae I ] HOGS I I TSHR
I I APTT [ ] HIV I I Type&Croaa _ a of units
[ I BBH ( ] Uver (BOP)
[ I Blood Cultures Proille I I Type & Screen
I I BMP j i Lyles I) UA: I I DIP I I DIAG.
( ) CBCP [ I Phenobarb [ I Urine C & B
[ I CMP [ I PTP ( I Urine HCG
[ I CRPI [ J Selloylete I I WC Breath Ak:o Test
I ] Digoxin [ I Theo I I WC Drug Screen
[ J Dllantin I 1 Other.
Radlo/odv
I I Abd/Obstr. Series I I KUB
[ J Ankle R L i ) US Spine
[ I Clavlde R L ( I Mandible
f I Cerv. Spine Pl. / Let. [ I Nasal
[ ] Chest Rm. / Pon / TPA [ I Orbit R L
I) Elbow R L I I Pelvis
[ I Facial [ J Pyedgram IVP
( I Femur R L [ I Ribs R L
[)Finger R L [ I Shoulder R L
I] Foot R L 11 Skull
jMForres" Sternum
l I Ham! [ I T/Spme
[ 1 Hip R L [ I TIb / Fib R L
[ I Humerus R L ` ] Toe_ R
[ ]Knee R L R
I ] Oder. Ime R7/J)It.
Ultrasound: CT: (WasWlth cohtrast; WOdilllth'90F
( 1 Abdomen ( I Abdomen/Pelvis W WO I I VQ Slicers
[ ) Duplex Doppler ] I Brain/Head W WO [ )
Echo- Gallbladder I I Chest W WO cardiogram
( I Pelvic/ I I Spiral chest for PE
Transvaginal [ J Other:
Tlme/CRT/Int.
REASON:
Soeclmetywculturm
I ] Bete Strap AG Rapid ( I Stool C & S
I 1 GenhaaUGanital [ ] Stool 0 & P
( ] Chlemydla ( I Stool C, Dlftidle
I ] GC Culture I ] Tdchomonas
I I Monospot (rapid) ] j Wound C& S
( I Sputum C & S [ I Other:
Billing Classification:
PHYSICIAN CHARGE FACILITY CHARGE
[ I Level I [ ] Level I I I Accident
[ ] Level II [ ] Level II [ 1 Medical
[ I Level III I ] Level III [ ] Case 1
[ I Level IV [ I Level IV I ) Extended Hre.
I ] Level V [ J Level V
Holy Spirit Hospital
Camp Hill, PA
John R. Dietz Emergency Center
Physician Order Sheet
aoe,ECU REV. 10000 VVIW
CHART COPY
I^
Cardiac
[ I Monitor
I EKG
[ 102-IJMin.
I 102 Saturation
Respire
I ] ABG's
[ I Peak Flows Before/After Reap. Tx.
( ] Respiratory Tx.
Medications / IV's / Additional Orden
Detamme D eJtre.
V: S DSW/ LR/ DS/ASN DS.gNS
0/KV01Infuse at m
[ Obtain old records I?Vj Td
Protocol In[tlated f
1 ? It
Il
? /Or4 / O
S c,
r 2]
+GLJJ
Initials: J!S gnature:
Initials: Signature: _ RNIMIA
Dictated: Half( ] Completed [ J r? CRITICAL CARREL: - hippy.
Disgnclstlc Impress[ ?"? nr2D?^'+ wr^'r W?. ?j
-I"? r on r? ( s
Data:
F.r ).
I . I A4 419492 [
Lfr.t :o;+STR?CE L
11[1 +,4CLA30 RV,
c+ev Jrit P4 EX?
Fo i l
17 1`75 763-Son
54 4360 ED 4ROUf
rite cols 402 2:0054434001
C4/19ina
Appearance:
0_
•Qolo Spinach; Mental Status:
OCarMCbua OUnWOperatlve R plratory:
mMrlcyl Gastrointestinal OR/A
O snks pain leympbme Treum w
Location
41-
Jpr `3 gpmaI
,Pqm ?
y
J
NL
r pbatergle Ocambatlve nd III???MMMaborod ruses Odl.Mtea
.
s
]
Iroi 1
Is
le lma
Oobaee Ofluehed Opal OaNmed
adakd Elcyanatic Odry Otalkative
Oam
Olaundiced Odlaphorabc Ornumbltng
Goa.' Omotuad Orman Obaby
OWA Oncrmel Oabnormal Ooonfueed Oanxious
0 Med b: 4hysknnl
reon ReeP"re b9Umull
XfA" 0approprlete
Odelayed
.Mratnueeduslomlbw oheet Olaborad
OS?
Oo°ugh
O02 ucUve®
%So( Ov Ping Oconsipallon
OHemelemask
Lest ant
OAbtlonan fonder
Odialendod-aflrm Own ? nsbn
ftrelioai
O oel
Odelonnity
Oburns:
O?teeding. }
Oedema a me
Nauro o WA
Oheadwhe ERL R L
Oslllfnwk im
Oneck Pain Pinpoint O O
Ofaclal droop Dilelad O O
Onumbnecs: Fixed a O
Sluggish O O
non-reactive O 0
Oweakness GUI GYN owA
gk" we O flank pain L / R
puency ORadial
Ourgency Severity 10
00ysuna
OHemalune Oumthrel discharge
Orelendon Ovaglnal discharge
pother: Oveginal deeding
Ofoley present C vas ular:
OCheal paln rtes
area:
Seventy _710
Ooonstant Oshorp
Ointermitlent Odull
Obummg Oheavy
OSOe Opleudlic
anon-redkting Oradisdng:_
rtauses 1
O Monitored My?hm: See
nuroing Aaeees^Mant
spacer
Oedema:_
O calf lendemesµ R I L
Owil" urpdness
ompisary Will:
Orapo Odekyed
PATIENT OBSERV TIO S: EENT snks are OwA
Completed by: Time: Eyss Earn Noae Tftroal
Protocd IMaeted: SW N Labe dons X-ray done
I ball vAMin reach rolk upup x2 OCorrpanlon wlat patient
duro lamed Od"rad Amon L I R Acuity: L_/_ OPain LIR OoongeeUon Poore
Odauda vision L / R R / Otllacherye OdralrolM drooling
OPhotophobk L/ R OwiM IaMee O x L I R dyephapia
NURSING ASSESSMENT:
R)f Signature: Time:
IVTMnpygmglbnwms:o'^emamneuarvwmplwacn l•eemel•eMnane o•eocnymwla Medlastions
e• n S+hsraness ewnrmin rHeea
DOW
T Aml Sduson 9xa Site Palo Ahempls a. IMWI Dotal
TIRW Drug Route 814 Mot Re
v
°e s Notes o Notes
lias
(t
X I .11Y -
a
-n: Lk 0
.30
1 t^ '
4 ADMIT I DISCHARGE I NSFER'
X41schaigod /accompanied
??bulatory c pambul
??
top ome ursi A OR
.1 A Insbucllofla given t
* o:
t1antd Ofamlly Operan
to t O0
Oconsenl aigrn
n Odd records sent to floor Oclothing sheet done
1 nature: a
-
lscharga OAdmission 023hr Obs Rooms
called to R ILPN
CanplUge:,
allstactory OCnb Deco d to mgrgue
Olmp ad; all a Is 110
RN Signature:
Hol Spirit Ho I I 11
Camp Hill, PA 17011 TLFCK ,CO'.5 ANCE L
John R. Dietz ECU ;317 MALL 00 R1
Patient Observation 1 Assessment I Notes
aoarxa OMITw txw C! - fl If ItL Pit 1701t'
C; 211 2 7/ 1117 5 7 t+3-d6 716,
ZCO-5E-4360 to 6111t
r;,[T ,[oxs aoZ
CHART COPY 04/ 19/04
,I d
our
20as4436001
v
Holy Spirit Hospital
Department of Radiology and Diagnostic Imaging
Camp HIM, Pennsylvania 17011
(T17) 763-2600
PATIENT: FLECK, CONSTANCE L DICTATION DATE: Apr 19 2004 5:49P
MR#: 419492 TRANSCRIPTION DATE: Apr 19 2004 5:49P
SOC SEC: 200-54.4360
ORD DR: MARIPAT GATTER M.D.
PT TYPE: E ADM DATE: 04119/2004
DOB: 02/27/1975 ARRIVAL DATE: 04/19/2004
LOCATION: ER1- HOSP SERVICE: ER1
***Final Report***
EXAMINATION: LEFT FOREARM 73090 - 04119/2004
COMMENTS: Indication: Laceration
There Is laceration of the soft tissues of the proximal left forearm medially and laterally. No opaque foreign material Is
identified in the soft tissues.
The bones of the left forearm are unremarkable
CONCLUSION: As above
DICTATED BY: HOWARD BRONFMAN M.D. / PSC
DATE OF EXAM: 04119/2004
SIGNED BY: HOWARD BRONFMAN M.D.
DATEITIME: Apr 19 2004 5:49P
Imaging Services Consultation
Page 1
150 „0m) CORSWATM REPORT
T-"
' o n /JI`y7 !J
All
)'1 64
W oL
(z c 4t+AR e
V ^ ? crLn. /C C Cra.''r^ h aW'Q ?U (2? aK? r
G f7i?.? V,EAALq I .w_
lil
? CONSULT (WITH CARE)
? CONSULT ONLY
tEPORT
IEOUESTED
IEGARDING
10:
EIONAT
DATE
G
Fla--jQ
NOTIF[EO BY OATe
HOLY SPIRIT ROSPITAL TwE a
CAMP MkL, PLNNSYLVANM
,
OE,/13/1994 23:12 7326489 EAST PENNSAORO IM;. ?PAGI
?
Penusylvtwin EMS Report" tU
?_
service Nave UaR Ne. r'CR Ne. -- -
PSA lava. No. Date
E.t Pemulmo Atohalsoos satvloe ?_.._. 2101501 0400671:
6165 09/IViWa
larldeat Laeatlaa MCD Recri 4 my
1312 1 RdW C TV# 745 CL 2 21909 HAi "'t_ _ 'rv
t'iiNl , Now t hone No. Age Date of IRh social Sec. No.? Sea
1717116 9 76 29 Yeats
t 0212711 75 200-54.4360 Ism,'.
4
Ctrrw Times
_
t-4 1312 Ma0ard 8d. AN. C _ ?,,, A Sl Pink, Keith P 14453 911
4W CRY Seale 'Lip A 02 TraPMl4 Wilham it 16225 Dispatch 1 `
c4qit t? wo PA 17011
A
Enroute 15:
?
Meet Naarher Meatbenhlp A p4 Arrive Seen I }
r,r No Contact I S
prisule ?hyeltlar Out On,Seoae
134 a Depart Scene I > ..
i
F
1 ` •t'
ili
Jatem 65311 55715 5 rr
ac
ty
16 5 _716 Arr
Transpeetioll Aetht Ualtr OS Time Medial Constrained Phyrtdan MCC Avertable 1 ti `
In Qaartrn U `
ter k
_?._ _....
._.__ ....._.._ __.....?.__
_
Car s _.....?......
Aligritiess wi :
Narrative
PMH: None per patlatt
Dispatched (CCCC) for an immediate response to the above lo t! n for laceration, class w
response. Additional Information: 29 y/o female, conscious and br athin who accidently pu,
her arm through the window. She has a laceration noted to her fb arm and it is possibly
down to her tone.
AOS: Found a female patient laying supine on the hallway floor ap earing awake and alert
while a neighbor (physicians assistant) was holding pressure w/ a well her left arm.
I
HPI: The patient stated that around 15:15 hours, she was walking p fro the basement anO
had went to open the door w/ her left arm when the glass she pus don broke through
causing a laceration. She ran upstairs and yelled for her neighbor hog t a towel and
applied pressure prior to calling ems for assistance.
PE: The patient Is awake and alert denying no other pains or probl ms o!
listed above. She does state that she fools a little dizzy and sick 't her s
having any headaches or vision problem. HEENT in unremarkable wl he
present around the throat area. Her chest appears equal to rise a d fall
sounding dear upon exam. No abdominal complaints are preserit / the
mobility of all extremities w/ the exception of her left arm which sh rates
pain scale. She also states that she has some numbness and ting ing pr
there is a + radial pulse present. No radiation is present and there are s(
to her hand that have stopped bleeding. The laceration was about 2 112
deep down to the bone w/ moderate bleeding present.
or than what is
mach but denies
PEARL and no iv4i
1/ her lungs
latient having toll
It a 10/10 on the
sent in the hand a'
no minor cuts nolt"
3 3 inches long )r
Q
.41
g
J
00
W
J
Cis
W
Q?
A
O
TX: The patient was assessed while a hpi was gathered. She the had the laceration checks
prior to placing about 5 4x4's on It and wrapping it w/ kling. Her pu se was re-checked and
was present. She had a set of vs taken prior to assisting her into standing position and
walking w/ assistance down to the ambulance where she was seat d and secured onto the
litter for transport. 6he was continuously monitored for any ct'iaant) salon the way and
Pmt
Printed On: 04/19/200418:07
EMSUt Keporfi*c) 1995-2004, MW4A@dik Lo. All Riots RoservrA Page.
06/11/1994 ?3:12 7326484 LAST YE.NNS}fUhdU r N18
Pennsylvania EMS Report
ianda]fleoYl.. __....._..... ... 17111 Ion
r.tle.q Naar Date of 11mb social security Numbe. MCC M Inl cu
Conrnact Fleck 07!1711975 700.54.4360
offered none upon sriftl where she was taken Into the ED and br ught
hallway A. She slid herself over to the bed transferring her care a I reps
Keith Fink
Emt#144536
ell luu•nn,
O
A
O
O
a
J
W
I, 1
Q
Printed On: 04/19421*4 1&07
EMArt Atportly(c)199s-2004, Ms1.1.4ndla, 6c A01iOua Asevd
end Phydct.a
a bed located in
to staff on duty
Prk Irr
I
ORTH(jrLDIC INSTITUTE OF PENNSYLVj.- A
(717) 761-5530
),tient: Constance Fleck Chart #: 16790206
)B: 02/27/75 SSN: 200 54 4360 Page # 6
-----------------------------------7-----------------------------------------
B/02/2004 CURTIS A. GOLTZ, D.O. -CONTINUED-
OFFICE VISIT
has 5/5 muscle strength. She is neurovascularly intact with good grip
strength.
DIAGNOSIS: S/P repair complex laceration left arm.
PLAN: I carried out a long and thorough discussion with Constance. I'll
allow her to return to any activity she wishes and I'll see her back on a
p.r.n. basis.
CAG/ram
cc: Geoffrey James, M.D. via fax
ORTHU zMIC INSTITUTE OF PENNSYLVhy 41A
(717) 761-5530
stient: Constance Fleck Chart #: 16790206
DB: 02/27/75 SSN: 200 54 4360 Page # 5
------------7-----------------------------------------
-----------------------
5/05/2004 CURTIS A. GOLTZ, D.O. -CONTINUED-
OFFICE VISIT
5/13/2004 CURTIS A. GOLTZ, D.O.
REQUEST FOR RECORDS
Office notes copied, billed by Quadramed and mailed to HANDLER, HENNING &
ROSENBERG, LLP.
cah
6/15/2004 CURTIS A. GOLTZ, D.O.
OFFICE VISIT
Trindle Road Office
CHIEF COMPLAINT: Status post repair of complex laceration, left forearm.
HISTORY OF COMPLAINT: Constance returns with very little complaint of pain.
She states her stiffness is much improved and that her pain is almost
nonexistent.
REVIEW OF SYSTEMS: The patient's review of systems, past medical history,
family history, and social history have been re-evaluated and reviewed.
PHYSICAL EXAM: She is alert, oriented and pleasant. Her left forearm
incision, both volarly and dorsally, is clean, dry and well healed. She is
neurovascularly intact distally with full range of motion and near full
strength.
DIAGNOSIS: Status post repair of complex laceration, left forearm.
PLAN: I carried out a long, thorough discussion with Constance. I explained
to her we will check her back one more time in a period of six weeks, sooner
if she has problems. She may return to work full duty.
CAG/dnk
CC: Geoffrey James, M.D. via fax
8/02/2004 CURTIS A. GOLTZ, D.O.
OFFICE VISIT
Spine Center
CHIEF COMPLAINT: S/P repair complex laceration left forearm.
HISTORY OF COMPLAINT: Constance returns with no complaints of pain.
REVIEW OF SYSTEMS: The patient's review of systems, past medical history,
family history, and social history have been re-evaluated and reviewed.
PHYSICAL EXAM: She is alert, oriented, and pleasant. She has a normal
stance and gait and she is well developed. Her left arm demonstrates no
erythema, ecchymosis, or swelling. She has two well healed incisions one
along the lateral aspect of her forearm and one along the volar aspect. She
/c'?79oa
iWD Appointment ors 6115104 PHYSICAL THERAPY 0ty?
. D R AY E R PROGRESS NOTE
PhAiral Therapy institute Date: 6/7/04
i mdhg fhe Way w Cmd aeatra
Patient: Constance Fleck
Date of Birth:2/27/75 Total
Diagnosis: Laceration left forearm .Visits Attended: 8
Date of Evaluation: 5/12/04 • NS (not rescheduled): 1
Physician: Dr. Goltz • Cancel (not rescheduled): 0
- Pain with palpation and with left UE stretch overhead and into abduction.
- Sensitive to touch at scar on dorsal forearm.
Scar on dorsal forearm is minimally raised and adherent.
Emplavment/Activity Status: Working regular duty within own restriction.
Objective:
• AROM: WNL through left UE with some effort required to reach end range.
• MMT: Left Right
Shld Flex 4/5 5/5
Abd 4/5 5/5
Ext 4/5 5/5
Elbow Flex 4/5 515
Ext 4+/5 5/5
Wrist Flex 4+/5 5/5
Ext 4/5 5/5
Rotation 4/5 515
EDC 4-/5 5/5
• Strength; Right Left
Grip 1 45lbs 15lbs
U. 55lbs 18lbs
V 50lbs l5lbs
Pinch Lateral 19lbs 4lbs
Tip 16lbs 41abs
Palmer 18lbs 5lbs
Functional: Using left UE for all necessary activities with modifications as needed secondary to pain. Continues to be
limited with any reaching and lifting activities.
Assessment; Patient has demonstrated good progress with ROM returned to WNL. She is able to achieve normal range
with effort at the end range. She continues to have deficits with decrease in strength and soft tissue limitations and
tightness. She will benefit from ongoing therapy to return to normal use without modifications.
Rehabilitation Prognosis/Potential: Good
Mechanicaburg Center 5275 E. Trindla Rand ? Suite 110 m Mecheuiceburg, PA 171150 -PROM 717-790.9920 - Pn%: 717-7906992:.
Constance Fleck
Page 2 Progess Report
DRAYER
Pltysical Therapy Institute
L the Way m cad If-lk
Updated Short Term Goals: (To be achieved in 3 weeks)
1. Increase grip strength xl5lbs.
2, Increase MMT left UE x % grade.
3. Return to full ROM without soft tissue tightness.
4. Retum to full function with left UE use and leisure/work activities.
program.
with therapy for flexibility and strengthening, scar management,
Freunencv-, 3x/week Duration: 4 weeks
home
I have discussed the above findings, assessment, revised treatment plan and expected outcomes with this patient The patient
is aware of the diagnosis as well as prognosis and voluntarily agrees to continue participation in physical therapy services at
DRAYER PHYSICAL THERAPY INSTITUTE.
Thank you again for this referral!
I will continue to keep you informed of any changes in thepadent's status and the treatment plan.
Therapist's Signature:
Date:
OC
In accordance with accepted medical practice standards, 1 hereby certify that the above named patient is under my care and requires
physical therapy rehabilitative services for the problem(s) identified above. As such, 1 request that Drayer's physical therapy stiff
continually evaluate and assess the patient's used for such services and provide a detailed patient care plan for my approval recertification
to be reviewed every 30 days at least.
Physician's Comments:
Physician's Signature:
Please return this Progress Note to Drayer Physical Therapy.
Thank You.
Mechanicsburg Center n275 I . !iindle rlmd -Suite 110 - Dd&du.icvbure. PA 17050 - YHONC: 717.700.9990 -W; 717.700.90;'
DRAYER
Physical Therapy Institute ?? f5
Leading the Way to Good Health -
PATIENT NAME: Constance Fleck DATE: 5/12/04
REFERRING PHYSICIAN: Dr. Goltz DIAGNOSIS: Complex laceration left forearm
DATE OF ONSET: 4/19/04 DATE OF BIRTH: 2/27/75
DATE OF SURGERY: NA AGE: 29
INJURED SIDE: Left HAND DOMINANCE: Right
SUBJECTIVE HISTORY: Patient reports that she was at her apartment and she was pus ing a g ass
door open with her left arm and states that the door was stuck in the frame and when she applied
increased pressure the glass in the door broke and she sustained a complex laceration of the left forearm
on the lateral and medial aspect. She states she was taken to the ER immediately and had "internal and
external stitches" in the ER. She was sent home and referred to OIP where she saw Dr. Goltz. She states
that x-rays revealed no fractures or associated injuries. She was referred to hand therapy for evaluation
and treatment and she now presents to therapy with left UE in a guarded position, complaints of pain with
all motions and extreme hypersensitivity on the left forearm. She states that the lateral laceration is worse
in symptoms than the medial laceration and she has difficulty with performing with digital extension.
FUNCTIONAL ABILITIES AND RESTRICTIONS: Patient reports that she tends to avoid use of left
UE due to the pain and sensitivity. She is able to use it as a functional stabilizer for some activities. She
states that she requires assistance with her dressing and significant increase in time to complete activities.
She describes any activity requiring bilateral use such as typing, opening bags and containers and getting
dressed are most difficult.
WORK STATUS: Patient is employed by Health America. She does work from home, but herjob entails
typing.
PAIN RATING: Patient reports pain at severe level with any attempt of motion or any tactile sensation
in the forearm. She states that it decreases to minimal level at rest.
PAST MEDICAL HISTORY: Significant for migraines, history of neck injury.
MEDICATIONS: Advil every 4 hours, using Dermacream for scar management. She states that she does
have Vicodin which she takes pm, mainly at night time.
PATIENT GOALS: To regain full use of left UE.
OBJECTIVE FINDINGS:
• Inspection: patient presents with well healed incisions on the lateral and medial aspect of left
forearm. There is noted soft tissue adherence to underlying tissues. She presents with left UE in
an extreme guarded position.
• Swelling: Patient presents with minimal inflammation noted of forearm. No limitations in ROM
from the swelling.
• AROM left UE:
Shoulder Flexion 920
IR/ER WFL, however there is significant tightness at end range in
which she describes soft tissue limitations. v, 7 IS
Mechanicsburg Center 5275 E. Trindle Road -Suite 110 - Mechanicsburg, PA 17050 -PHONE: 717-790.9920 - F= 717-790-9923
Constance Fleck
Page 2
AROM left UE Cont'd:
Elbow Extension 330
Flexion
Forearm Supination
Pronation
Wrist Extension
Flexion
With elbow
DRAYER
Physical Therapy Institute
Leading the Way to Good Heakh
1500
620
820
550
620 with elbow flexed
in maximum extension:
Extension 350
Flexion 520
• Left hand Active ROM: Index
MP 0-700
PIP 0-650
DIP 200
Middle Ring Small
25-900 35-900 15-900
60-850 60-800 45-850
20-200 20-200 15-550
Patient's ROM is limited by complaints of pain.
• Strength not tested at time of evaluation.
• Sensation: Patient does report parathesias into the ulnar nerve distribution and she was found to
have diminished light touch in ulnar nerve distribution.
There were no other significant findings during the evaluation.
Sincerely
b
Jean Gress OTR/LCHT
License # OC 002173 L
Mechanicsburg Center 5276 E. Trindle Road ? Suite 110 ? Mechanicsburg, PA 17060 - MONE: 717-790.9920 - Fag: 717-790-9923
ORTHOPEDIC INSTITUTE OF PENNSYLVANIA
875 POPLAR CHURCH ROAD, CAMP HILL, PA 17011
PHONE: (717) 761-5530 • FAX: (717) 737-7197
yyHAND THERAPY PRESCRIPTION
NAME: DATES,
DIAGNOSIS:
EVACUATION & TREATM?
Moist Heat
Electrical StimulatiorvTens
Ultrasound
Phonophoresis
10% Cortisone Creme
D r. Wound Care
Whirlpool
ing Changes
(jAA ve
ScarMana eme
a 'Co
esensltvation
Nerve Gliding
ADL Education
Splinting
Static
Iontophoresis
Paraffin
Fluidotherapy
3 x Week x 30 days
Strengthening Dynamic
Arthritis Management Other
Joint Protection
rk Simplification
D.O.
YWATION
ORTHOPEDIC INSTITUTE OF PENNSYLVANIA
875 POPLAR CHURCH ROAD, CAMP HILL, PA 17011
3916 TRINDLE ROAD, CAMP BILL, PA 17011
890 POPLAR CHURCH ROAD, SUITE 108, CAMP HILL, PA 17011
450 POWERS AVE., HARRISBURG, PA 17109
32 NORTHEAST DRIVE, STE. 201, HERSHEY, PA 17033
TELEPHONE: 761-5530
G' ?V Awce /:7L/ &0A?
PATIENT'S NAME
The above patient was seen in our office on _/0
The ve patient is under my care and may return
to ork school on
Limitations:
The above patient is presently totally
The above patient is unable to take y
M.D.
D.O.
ORTHG-. DIC INSTITUTE OF PENNSYLV!?..LA
(717) 761-5530
itient: Constance Fleck Chart #: 16790206
)B: 02/27/75 SSN: 200 54 4360 Page # 4
----------------------------------------------------------------------------
4/20/2004 CURTIS A. GOLTZ, D.O. -CONTINUED-
OFFICE VISIT
She was given a prescription for Vicodin and a note for work in the office
today.
CAG/ram
LTR-DR GOLTZ CORRESPONDENCE
(Ref) JAMES, M.D., GEOFFREY M.
4/27/2004 CURTIS A. GOLTZ, D.O.
TEL/MESG-MESSAGE TO CHART T
Constance called complaining of pain, numbness, burning, fingers stiff in her
forearm. States she cannot sleep, using 2 vicodin at night and 2 advil 2
4hrs, no grip strength, incision sore to touch. Per Dr. Goltz this can be
expected for her serious laceration and can be expected for at least 4 wks.
Patient so informed. CAG/sam
5/04/2004 CURTIS A. GOLTZ, D.O.
DISABILITY FORM
Completed disability form for UNUM Provident. Copy made for chart. Patient
to pick at Poplar./kmw
5/05/2004 CURTIS A. GOLTZ, D.O.
OFFICE VISIT
Trindle Road Office
CHIEF COMPLAINT: Complex laceration status post.repair left forearm.
HISTORY OF COMPLAINT: Constance returns with some continued complaint of a
dull aching pain although much improved since I last saw her.
REVIEW OF SYSTEMS: The patient's review of systems, past medical history,
family history, and social history have been re-evaluated and reviewed.
PHYSICAL EXAM: She is alert, oriented, and pleasant. Her left forearm
incisions both volarly and dorsally are clean, dry, and healing well. She is
neurovascularly intact distally with some mild tenderness with range of
motion about the elbow, wrist, and fingers. She has good capillary refill.
DIAGNOSIS: S/P repair complex laceration left forearm.
PLAN: I carried out a long and thorough discussion with Constance. I
recommended some formal hand therapy for range of motion and strengthening.
I'll check her back in a period of six weeks sooner if she has problems.
CAG/ram
cc: Geoffrey James, M.D. via fax
---------------------------
ORTHO..,DIC INSTITUTE OF PENNSYLVt-_.iA
(717) 761-5530
atient: Constance Fleck Chart #: 16790206
JB: 02/27/75 SSN: 200 54 4360 Page # 3
-----------------------------------------------------------------------------
4/19/2004 WILLIAM J. POLACHECK, M.D. -CONTINUED-
HOLY SPIRIT HOSPITAL CONSULT
She was seen in consultation in the emergency room on Monday afternoon. A
full consult was dictated from the emergency room. She sustained lacerations
to her left forearm. They were concerned about the possibility of a deeper
injury. Her x-rays were normal. I saw no sign of a tendon injury. She
appears to have some weakness in her wrist and finger extension, but this may
be secondary to pain. The E.R. doctor will close her lacerations and splint
her. She will be rechecked in the office later in the week.
WJP/lam
4/20/2004 CURTIS A. GOLTZ, D.O.
OFFICE VISIT
Thank you for consulting me on CONSTANCE FLECK. I had the pleasure of seeing
her at the Trindle Road Office on April 20, 2004, regarding her arm.
CHIEF COMPLAINT: Laceration left arm.
HISTORY OF COMPLAINT: Constance is a 25-year-old claims specialist who
states on 04/19/04 while at home she was pushing a door and her left arm when
through the glass. She did sustain lacerations over the volar and dorsal
aspects of her proximal forearm. She was seen at Holy Spirit Hospital where
x-rays were obtained which revealed no foreign objects and no fractures. She
was told that there was no tendon involvement. The underlying fascia as well
as the skin was repaired and she was referred to orthopedics for definitive
diagnosis and management.
REVIEW OF SYSTEMS: Review of systems, past medical history, family history
and social history have been recorded and reviewed.
PHYSICAL EXAM: She is alert and pleasant. Her left arm demonstrates some
mild ecchymosis proximally. She has a straight laceration about the proximal
aspect of her volar forearm and dorsal forearm approximately 4 cm in length.
The skin is well approximated suture using a nylon suture. She is
neurovascularly intact distally and demonstrates full use of all of her
tendons.
DIAGNOSTIC TESTS: Review of outside x-rays demonstrate no fracture and no
foreign objects.
DIAGNOSIS: Complex laceration status post repair left forearm.
PLAN: I carried out a long and thorough discussion with Constance. I placed
her in a well padded soft wrap and demonstrated some active and passive range
of motion exercises that I would like her to do. I'll check her back in a
period of ten days for suture removal.
------------------------------------------------------------------------------
Datd `- -2_D -Dc)4 Tir I S Doctor .lr Gl:(fi s (TG Chart #
Patient Name i- ?C C- co,nSr,?w) ( e (_ .
Lost I-Irst
Address ?'J1 Z ti{ s { a(o1 2a - Q fjar WYLwl- CL,)
treet or KUM ute
C 0 ??,Il P71 17011 -IZZj
rty tate Lip Code
Phone 111"163- `?1c F :Saw ?J - --SSN---2_DO-j14-1436_o
_.-------- ome-----____. _ or
DOB 2 -Z1 -1 `l 1 J Age 25 Sex 1 eN1 ?? Marital Status M (-S) W D
Employer o V 2>\ ( { / Occupation c( 2' M S S D? Ci2 15
3"1Li icckrr 7r we Ha,-ci.s4xA_,rr Q I?I'I i
street lty tare Zip Code
Mother 0_6 r V(\ `(_t i .? i DOB 10 - 9 - 3 Work # ?)S b- 4 L D O
Employer S? 1`nS CLLJO
Father +J J A? DOB Work #
Spouse n[ I A, DOB
Work
Child (School) Responsible Parry if
Alternate/Other Contact /
Injury W DOI q-1°I" U"I Sports Auto Work Related.
Accident De ption & S} Wo,S y9wshl(lA UY) G duw at ?IyeytL b
L
Date Symptoms first appeared if not injury
INSURANCE
Primary He C? ?l r?yY?2X I CCU Hyy?
C ?`3
Address ?• 0. -7
A 4Y-v Ca nQev*? S Qoo mS
Group # joulo56 00`? Locz daAtKy
, 6-NZ
Policy# Zo6__?(-1-` YoO -0
Subscriber's Name C6 n Sta)f? a T `e J_
Address 1. ? 12 - Cl ?? 6.0 L? - 40t C?
C6Li'V'?`?r??<< A ?1a11
Family Dr. \
? ? ? J(iv`t "
Address
Secondary
Address
Group #
Policy #
Subscriber's Name
Address
Referring Dr.-wj!?-? SC1 XY? C_?
Send letter to: Fancily Dr. Referring Dr. Neither
C_
r
HEALTH HISTORY Update:
The following is very important to us m taking care of your health. Please take time to completely and accurately fill out q ")
all of this information. Please also make sure you update this information as changes occur. S?
Patient's Name &M/1i6LA U-? n Q
ChartNumber ! I U A?
Medications You Are Taking
(Also list herbal supplements and vitamins)
Medication Name Amount Freouencv
i?a?en as nee?ee?
ire you taking diet medication? No Yes
Allergies (Drugs and Other Allergies)
'enicillin No X 'Yes reaction
coal Anesthetic No Yes--reaction
.ylucaiay awucaine) -
ether Allergies
Hospitalizations
Ist serious illness and injuries or operations and approximate year.)
ear Serious illness, iniurv or sureerv Hospital
Past Medical History
Have you or members of your family ever been told that any of
you have:
Abnormal Bleeding
Blood clots / phlebitis
Cancer / tumor
Diabetes
Drug abuse
Eczema / psoriasis
Bpilepsy / seizes
Heart Condition
High or low blood pressure
Liver disease / hepatitis /
Your
You Family Describe
[ ] Ll
[ I f}fi M0.tClrta? grund(JaJ`?
[ ] ?U M?ct??u'``?
yellow jaundice [ 7 T l
Kidney / bladder problems I I 17
Lung disease [ ]
Prostate problems [ 7 ' [ I
Stroke [ ] [ ]
Thyroid disease [ ] [ ]
Tuberculosis [ ] [ ]-
Ulcer in stomach/
.
duodenum
Osteoporosis
Arthritis
Other bone /joint disease
Any nervous system disease
Height
Social History
Do you smoke? No X Yes Amount
Do you drink alcohol? No_ Yes-TAmoumWI /l( Z "3 z
Do you use street drugs? No5? Yes_ Amount
Continued on back of page..........
Patient's Name W&n ' kw OL-?
During the past year, have you had:
1 heartburn or indigestion? ...................................................................
2 bowel movements that were bloody or tarry? .....................................
3 any recent change in your bowel habits? ............................................
4 frequent urination during the day or night? ..........................................
5 any recent loss of control of your bladder? .........................................
6 burning with urination? ......................................................................
7 difficulty starting your urination? ........................................................
8 excessive urination? .........................................................................
4
Chart # t b 1-l "'
No Yes x
No= Yes
No
X Yes
_
_
No X Yes
No x Yes
No? _
Yes_
No Yes_
No Yes
9 excessive thirst? ............................................................................... No K Yes_
10 shortness of breath or wheezing?., ....................
"**'* .... *'** ...... * ....... "" No_L,_ Yes
11 :
chronic cough? ................................................................................. No X Yes
12 chest pain with activity? .................................................................... No= Yes
13 racing heart or palpitations-q.? ............................................................... No Yes
14 swollen feet or ankles? ..................................... .................................. No-?K Yes
15 frequent headaches? ....... :................................................................ No Yes
16 dif-cuityhearing? .............
...............................................................
Nom
Yes
17 dental or other mouth problems? ........................................................ No X,_ Yes .
18 frequent nose bleeds? ....................................................................... No X Yes
_l9- easy_bnusmg2_-...____..-.,__.......... ..____..__._.-_-.--_-°._.........._.. ---No-X-
__---------
Yes...
20 skin rashes? ..................................................................................... No__X_ Yes_
21 aching muscles or joints? ................................................................... No Yes
22 swollen joints? .................................................................................. No
X Yes
23
cold hands /feet?... ........................................... a ............................ o. c
--
No _
Yes X
24 gangrene?. ....................................................................... 0 ........... No= Yes
25 loss of consciousness? ...................................................................... No Yes
26 recent numbness in arms or legs? ...................................................... No Yes
27 chronic fatigue? ................................................................................ No Yes
28 uncontrolleTblwding? ...................... ....... ........................................... -. N- - - Yes_- -
29 weight loss? ............ :............................................ ............................. No X Yes
30 weight gain? ..................................................................................... No-7 Yes
3I heat / cold intolerance? ..................................................................... No? Yes
The above information is true and correct to the best of my belief.
Patientsignature( Date-ZOt)4
1(o7Rv;)
WILLIAFI J POLACHEC From:t ical Records 04/20/0 '0:35 Page 3 of 4
ADM. DATE: 04/19/2004
SS * 200-54-4360
HISTORY OF PRESENT ILLNESS: She had accidentally put her left arm through a piece of
glass. Dr. Getter was concerned about numbness in the hand and loss of function. Her
radiographs were reported as showing no fracture or retained glass.
PHYSICAL EXAMINATION: She has two lacerations, one on the dorsal ulnar aspect of the
proximal forearm and one on the palmar aspect of the proximal forearm. The palmar wound is
superficial. It is not through the subcutaneous fat and does not pose a risk to the deeper
tendons and nerve. The dorsal laceration is in the area of the radial nerve. By exam, however,
it does not appear to have violated the muscle itself. There is no sign of any muscle retraction
or division. She complains of numbness in the entire left hand. This is true on both the palmar
and dorsal surfaces which would be a nonanatomic finding. Initially she would not move the
fingers but with encouragement I could get her to demonstrate wrist and finger extension as well
as finger abduction. Her sensation pattern is hard to define. She has altered sensation in all
five digits on both the palmar and dorsal surfaces.
IMPRESSION: Laceration, left forearm.
PLAN: I do not believe she has a division of her radial nerve because the wound itself appears
to be too superficial. I recommended just closing the skin incisions and splinting the forearm.
She should be reexamined in a few days once she has less pain. I recommended that she see
Dr. Daily in our practice in case she does have any nerve injury. He would be the specialist in
the group who could better deal with a nerve injury were it tibia finding on repeat exam.
Pace 1 of 2
HOLY SPIRIT HOSPITAL
Camp Hill, PA NAME: Fleck, Constance L
17011 M R#: 419492
ROOM: ER1
CONSULTATION REPORT DR.: WILLIAM J POLACHECK, JR, MD
COPY TO: WILLIAM J POLACHECK, JR, MD
:WILL1,4M J POLACHEC From:l ical Records
r
NAME: Fleck, Constance L
MR#: 419492
04/20/0 0:36 Page 4 of 4
WILLIAM J POLACHECK, JR, MD
WP/bb
DOC #: 446761
D: 04/19/2004
T: 04/20/2004 1:10 P
000665105
cc: ER PHYSICIANS
WILLIAM J POLACHECK, JR, MD
Paae 2 of 2
HOLY SPIRIT HOSPITAL
Camp Hill, PA NAME: Fleck, Constance L
17011 M R#: 419492
ROOM: ER1
CONSULTATION REPORT DR.: WILLIAM J POLACHECK, JR, MD
COPY TO: WILLIAM J POLACHECK, JR, MD
ORTHOPEDIC INSTITUTE OF PENNSYLVANIA
875 POPLAR CHURCH ROAD, CAMP HILL, PA 17011
PHONE: (717) 761-5530 • FAX: (717) 737-7197
?`.1?jHAND THERAPY PRESCRIPTIO IN r
NAME: r& v C C. ?l"? ?c , DATR- 5 k (ft
DIAGNOSIS:
EVALUATION & TREATM Wound Care
Whirlpool a Co
Scar Mana eme
Moist Heat in Changes esensmzation
Electrical StimulatioraTens . Nerve Gliding
Ultrasound ve
(j ADL Education
Phonophoresis AA Splinti ng
10% Cortisone Creme static
Iontophoresis Strengthening Dynamic
Paraffin Arthritis Management Other
Fluidotherapy Joint Protection
rk Simplification
=x30 9-4?i D., .
VP ATION
ORTHOPEDIC INSTI.;TE OF PENNSYLVANIA
875 POPLAR CHURCH ROAD, CAMP HILL, PA 17011
3916 TRINDLE ROAD, CAMP HILL, PA 17011
890 POPLAR CHURCH ROAD, SUITE 108, CAMP HILL, PA 17011
-- 450 POWERS AVE., HARRISBURG, PA 17109
32 NORTHEAST DRIVE, STE. 201, HERSHEY, PA 17033
----- TELEPHONE: 761-5530
w
PATIENT'S NAME
The above patient was seen in our office on ^71 / 0 / O'.
The above patient is under my care and may return
to work / school on / / /
Limitations: /vC) L¢ae' - z,,./z-//-l /2?GJAC 1A C
5' :3 --O 4.
The above patient is presently totally disabled.
The above patient is unable to take gyryeJ _4P lop,
M.D.
D.O.
DRAYER
Physical Therapy Institute
Leading the Way to Good Health
PATIENT NAME: Constance Fleck DATE: 5/12/04
REFERRING PHYSICIAN: Dr. Goltz DIAGNOSIS: Complex laceration left forearm
DATE OF ONSET: 4/19/04 DATE OF BIRTH: 2/27/75
DATE OF SURGERY: NA AGE: 29
INJURED SIDE: Left HAND DOMINANCE: Right
SUBJECTIVE HISTORY: Patient reports that she was at her apartment and she was pushing a glass
door open with her left arm and states that the door was stuck in the frame and when she applied .
increased pressure the glass in the door broke and she sustained a complex laceration of the left forearm
on the lateral and medial aspect. She states she was taken to the ER immediately and had "internal and
external stitches" in the ER. She was sent home and referred to OIP where she saw Dr. Goltz. She states
that x-rays revealed no fractures or associated injuries. She was referred to hand therapy for evaluation
and treatment and she now presents to therapy with left UE in a guarded position, complaints of pain with
all motions and extreme hypersensitivity on the left forearm. She states that the lateral laceration is worse
in symptoms than the medial laceration and she has difficulty with performing with digital extension.
FUNCTIONAL ABILITIES AND RESTRICTIONS: Patient reports that she tends to avoid use of left
UE due to the pain and sensitivity. She is able to use it as a functional stabilizer for some activities. She
states that she requires assistance with her dressing and significant increase in time to complete activities.
She describes any activity requiring bilateral use such as typing, opening bags and containers and getting
dressed are most difficult.
WORK STATUS: Patient is employed by Health America. She does work from home, but her job entails
typing.
PAIN RATING: Patient reports pain at severe level with any attempt of motion or any tactile sensation
in the forearm. She states that it decreases to minimal level at rest.
PAST MEDICAL HISTORY: Significant for migraines, history of neck injury.
MEDICATIONS: Advil every 4 hours, using Dermacream for scar management. She states that she does
have Vicodin which she takes pm, mainly at night time.
PATIENT GOALS: To regain full use of left UE.
OBJECTIVE FINDINGS:
• Inspection: patient presents with well healed incisions on the lateral and medial aspect of left
- forearm. There is noted soft tissue adherence to underlying tissues. She presents with left UE in
an extreme guarded position.
• Swelling: Patient presents with minimal inflammation noted of forearm. No limitations in ROM
from the swelling.
• AROM left UE:
Shoulder Flexion 920
IR/ER WFL, however there is significant tightness at end range in
which she describes soft tissue limitations.
DRAYER
Constance Fleck Physical Therapy Institute
Page 2 Lording the WaY ro Gaad Health
AROM left UE Cont'd:
Elbow Extension 330
Flexion 1500
Forearm Supination 620
Pronation 820
Wrist Extension 550
Flexion 620 with elbow flexed
With elbow in maximum extension:
Extension 350
Flexion 520
• Left hand Active ROM: Index Middle Ring Small
MP 0-700 25-900 35-900 15-900
PIP 0-650 60-850 60-800 45-850
DIP 200 20-200 20-200 15-550
Patient's ROM is limited by complaints of pain.
• Strength not tested at time of evaluation.
• Sensation: Patient does report parathesias into the ulnar nerve distribution and she was found to
have diminished light touch in ulnar nerve distribution.
There were no other significant findings during the evaluation.
Sincerely
Jean Gress OTR/LCHT
License # OC 002173 L
., .... - - • _.:._v..__ 1? ?anon - nn...•e. a11 .9en.neOn - nnV 919_9gn.992A
DRAYER
Physical Therapy Institute
Leading the Way W Good Heahh
EVALUATION/ PLAN OF CARE
PATIENT NAME: Constance Fleck DATE: 5/12/04
REFERRING PHYSICIAN: Dr. Goltz DIAGNOSIS: Complex laceration left forearm
DATE OF ONSET: 4/19/04 DATE OF BIRTH: 2/27/75
DATE OF SURGERY: NA AGE: 29
INJURED SIDE: Left HAND DOMINANCE: Right
PROBLEMS:
1. Increased pain left UE.
2. Increased hypersensitivity left UE.
3. Decreased AROM and PROM due to soft tissue limitations.
4. Inability to perform work and leisure activities due to above limitations.
ASSESSMENT: Patient presents with significant loss of function of left UE following a complex
laceration.
REHABILITATION POTENTIAL: Good for goals as stated
SHORT TERM GOALS (to be achieved in 2 weeks):
1. Patient will demonstrate minimal to no hypersensitivity in the left forearm.
2. Patient will demonstrate increase in AROM elbow to be within 10° of full extension.
3. Patient will demonstrate increase in total active motion of digits by 30°.
4. Patient will demonstrate ability to use left UE as a functional assist without increase in pain.
LONG TERM GOALS (to be achieved in 8 weeks):
1. Patient will demonstrate full AROM throughout left UE.
2. Patient will demonstrate ability to use left UE for all leisure and work activities without increase
in pain.
3. Patient will demonstrate strength to be WFL throughout left UE.
4. Patient will report 0-1/10 pain with all activities and use of left UE.
TREATMENT PLAN: Patient will participate in hand therapy with treatment consisting of thermal
modalities, manual therapy techniques, scar modifications, ROM and stretching, progressing to
strengthening, patient education and instruction in HER
FREQUENCY: 3x per week
DURATION: 8 weeks
THANK YOU FOR T??S?FERRAL
Therapist's signature / ,/(V?? ?C? Date 2,?Jz
?- Gress OTR/LCHT License # OC X02173 L
In accordance with accepted medical practice standar ereby certify that the above named patient requires rehabilitation services for the
problem(s) identified above. As such, I req di h enter's professional staff evaluate and assess the patient's needs fod services and
provide a detailed patient plan of care for ap r to be revinved every thirty days.) \[} '104
Physician's Signature Date
Mechanicsburg Center 5276 E.'1lindle Road - suite 110 - Mechanicsburg, PA 17050 - PHONE: 717-790-9920 - nex: 717-790-9929
Constance Fleck
Page 2 Progress Report
PIK" rF..
DRAYER
Physical Therapy Institute
Lending the Way ro Gwd Health
Updated Short Term Goals: (To be achieved in 3 weeks)
1. Increase grip strength xl5lbs.
2. Increase MMT left UE x %z grade.
3. Return to full ROM without soft tissue tightness.
4. Return to full function with left UE use and leisure/work activities.
Treatment Plan: Continue with therapy for flexibility and strengthening, scar management,
program.
Frequency: 3x/week Duration: 4 weeks
home
I have discussed the above findings, assessment, revised treatment plan and expected outcomes with this patient. The patient
is aware of the diagnosis as well as prognosis and voluntarily agrees to continue participation in physical therapy services at
DRAYER PHYSICAL THERAPY INSTITUTE.
Thank you again for this referral!
I will continue to keep you informed of any changes in the patient's status and the treatment plan.
Therapist's Signature:
Date: (?,e (
License: OC
In accordance with accepted medical practice standards, I hereby certify that the above named patient is under my care and requires
physical therapy rehabilitative services for the problem(s) identified above. As such, I request that Drayer's physical therapy staff
continually evaluate and assess the patient's need for such services and provide a detailed patient care plan for my approval/recertification
to be reviewed every 30 days at"°-
Physician's Comments:
Physician's Signature:
Please return this Progress Note to Drayer Physical Therapy.
Thank You.
Oi.-AOPEDIC IN' UTE OF PENNSYLVANIA
875 POPLAR CHURCH ROAD, CAMP HILL, PA 17011
PHONE: (717) 761-5530 • FAX: (717) 737-7197
HAND THERAPY PRESCRIPTION
NAME: DAT(?,(.;- S ?? 1 ?11L
DIAGNOSIS l cwnc .? f,CC' ?/ Y ^iif(r1
EVALUATION&TREATM, . Wound Care Edema Cog4stl,
Whirlpool Scar M agemeO
Moist Heat -Omssing Changes Desensitization
Electrical StimulatiorVrens ROM Nerve Gliding
Ultrasound Active ADL Education
Phonophoresis AA Splinting
10% Cortisone Creme Static
lontophoresis Strengthening Dynamic
Paraffin Arthritis Management Other
Fluidotherapy Joint Protection
?rk Simplification
3 x Well, x 30 days 19
D.O.
AVFPPTIV4ZY(1A1 TT4VRAPV1N.QT1T1TTR
FED. I.D. # 75-305029 01
Evaluation Modalities-: Direct Contect-Required Other'Procedures /Supplles
ption CPT UNITS 59 Description CPT UNITS d Description CPT UNITS 5'.
:valuation-PT 97001 i Ultrasound (ea. 15 min) 97035 1. TENS Instruction 64550
iluation-PT 97002 lontophoresis (ea. 15 min) 97033 Casting
Orthotic 29799
:valuation-OT 1
iluation-OT j 97003
97004 ( 1 E-Slim Attended (ea. 15 min)
Biofeedback 97032
90901 Orlhotic Checkout (ea. 15 min)
Onhotic Fiflingfrraining (ea. 15 min) 97703
97504
1 Muscle Test 1 95831 _ Self Care/Home Management 97535 Prosthetic Training (ea. 15 min) 97520
ofMotion 95851 Modalities -;DirecUContactNo t'Required t Splint:- L
_
aI Performance TesUMeas 97750 Hot/Cold Pack 97010 Splint: L
Functional Drills-ea 15 min) Mechanical Traction 97012 Splint Repair L4205
.Procedures -Direct,CordacRe ed E-StimUnattended 97014 Supplies:
eutic Activities (ea. 15 min) 97530' r Vasopneumatic 97016
?utic Procedure (ea. 15 min) 97110 Paraffin Bath 97018
luscular Re-ed (ea. 15 min) 97112 Whirlpool/Ruido Therapy 97022
Therapy (ea. 15 min) 97140 Wound Cara Tracking Medicare Non-Medicare
aiming (ea. 15 min) 97116 Wound Care Selective 97601 Time In 3 Lt
)e (ea. 15 min) 97124 j Wound Care Non-Selective 97602 Time Out fC
Therapy (ea. 15 min) 97113 Total Time
Therapy
D 97150
IAGNOSIS
e • e Total it Units •f
Cx NS R/S Date
Reason:
it changes has patient seen since last visit:
ient's perceived progress toward functional long term goals:
ient's chief clo:
:tive:
ass refs{ to this patient's flow sheet for details specific to thepropedures/modalities and specific exercises utilized during today's treatment. Changes included:
?1 F ?c?' v ciftF n . ?ru f r cv d a?awL- l ??i rtc cue ?? ?/? N&-l1
rrentiv: ROM: Strength:
lction: Swelling:
ssment:
dent's progress has been: Excellent Go Fair Poor
)rapist's assessment of patient's progress toward functional Ion rm-goals: 0% / 10% / 25% / 50% / 75% / 100%
3's: Met / Partially Met / Not Met Reason:
lei: 4te ? Y-?
-Progress current treatment
-Achieve by next visit / week
-Modify current treatment
-Other
N Visits
to If in
Brief-Eval/Progress Note next visit
D/C patient
License # c: °???'-e 7 -,? ( 5/12/14
.wcn nravcarAT T14PIDAPV TNCTYTT1TP
FED. I.D.# 75-3050291 Ll '.Evaluation ?Modalities •Direct Contact -Required Other Prociedures/Suppilies
iption CPT UNITS i 59 Description CPT _ UNITS 5e Description CPT UNITS 5
'-valuation-PT ?I
aluation-PT .97001
97002 Ultrasound (ea. 15 min) 97035 I
lontophoresis fee, 15 min) 97033 TENS Instruction
Onhotic Casting 1 64550
29799
-valuation-OT 97003 E-Slim Attended (ea. 15 min) 97032 Odhotic Checkout (ea. 15 min) 97703 _
aluation-OT
1 97004 Biofeedback 90901 Onholic Fitting/Training (ea. 15 min) 97504
_
it Muscle Test 95831 Self Care/Home Management 97535 Prosthetic Training (ea. 15 min) 97520
_
of Motion -1 95851 ???fff Modalities -,Direct CorltactNoPRequired 1 Splint: L _
:al Performance Test/Meas 97750 Hot/Cold Pack 1 97010 Splint - i L _
Funciionsl Drills-ea. 15 min) Mechanical Traction 97012 Splint Repair - L4205 _
'Procedures -'Direct'Contact red E-Slim Unattended 97014 Supplies: _
ieutic Activities (ea. 15 min) 97530 - Vasopneumatic 97016
e
ulic Procedure (ea. 15 min) 97110 Paraffin Bath 97018
_
nuscular Re-ed (ea. 15 min) 97112 '- Whirlpool/Fluido Therapy 97022
11 Therapy (ea. 15 min) 97140 :Wound Care Tracking + Medicare Non-Medicare
raining (ea. 15 min) 97116 `-? Wound Care Selective 97601 Time In
Ige (ea. 15 min) 97124 Wound Care Non-Selective 97602 Time Out /D 0
c Therapy (ea. 15 min) 97113 Total Time 7.i
Therapy
D 97150
IAG
NOSIS
¦ LOD
E Total 4t Units S
Cx
Reason:
at changes has patient seen since last visit: (.f/i.r7't tf.
light's perceived progress toward functional long term goals:
tient's chief c/o:
ter:
-five:
this patient's flow sheet for details specific to the pr
Irrentiv: ROM:
action:
her:
?ssment: = -
rtient's progress has been: Excellent Good j
erapist's assessment of patient's progress toward functional long term goals:
G's: Met/ Partially Met / Not Met Reason:
her 74Z) ??GCi'.?2CG?4-v
and specific exercises utilized during today's treatment. Changes included:
e,eti?7a,-, .
Swelling:
Fair Poor
0% / 10% / 25% / 50% / 75% / 100%
-Progress current treatment plan
j 1
LiAchieve by next visit west /-y''0l CO 21jan.?
-Modify currant treatmen?i
nfher
Brief-Eval/Progress Note next visit
D/C patient
a Visits ela ve to S in POC/ uthorization
Therapist Signature ? .lam,?- , c'
1313 NAVAHO ROAD
NS R/S Date
License u Ue: G'L r / 7' ?..Z
CAMP HILL, PA 17011
r
AVER PHVRTCAT, TNFRAPV TNRTTTTTTF. cl?4)
FED. I.D. # 75-3050291
Evaluation Modalities -Direct,Contact: Required Other;Procedurea(Suppiles
Iption CPT UNITS 59 Description CPT UNITS 59 Description CPT UNITS
Evaluation-PT 97001 Ultrasound fee. 15 min) 97035 TENS Instruction 64550
alualion-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Casting 1 29799
Evaluation-OT 970031 _ E-Slim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97703
aluation-OT 97004 Biofeedback 90901 Odhotic Fiding/rraining (ea. 15 min) 97504
1 Muscle Test 95831 j Self Care/Home Management 97535 Prosthetic Training (ea. 15 min) 97520
of Motion
95851 ;Modalities - Direct Co ntact No t Required .. II Splint: L
___
,al Pedormance TestlMeas 97750 Hot/Cold Pack 97010 SplinC L
Functional Drills-ea. 15 min) !1 Mechanical Traction 97012 Splint Repair L4205
Procedures -,Direct !Contact Required E-Slim Unattended _ 97014 Supplies:
ieutic Activities (ea. 15 min) 97530 ';2-_ Vasopneumatic 97016 _
emit Procedure (ea. 15 min) 97110 Paraffin Bath 97018
nuscoiar Re-ed (ea 15 min) . 97112 j Whirlpool/Fluido Therapy 97022
it Therapy (ea. 15 min) 97140 1 Wound Care Trackin Medicare Non-Medicare
aming (ea. 15 min)
9711 fi Wound Care Selective 97601 Time In
_
_
age (ea. 15 min) 97124 Wound Care Non-Selective 97602 Time Out
c Therapy (ea. 15 min) 97113 Total Time
Therapy 97150
e •
• • • .9 'C Total # Units
PAIN IN JOINT, FOREARM
719,43
Cx NS R/S Date
Reason:
at changes has patient seen since last visit:
;ient's perceived progress toward functional long term goals:
:lent's chief c/o: _C .-c"=r ,t•?,> 1?
1ec
:five:
ease refer to this PAtient's flow sheet for details specific to the procedures/modalities nand specific exerci.
rrentiv: ROM: Strength:
fiction: Swelling:
ter:
ssment:
[tent's progress has been: Excellent Goof Fair Poor
3rapisl's assessment of patient's progress toward functional Ion 'lertni> goals: 0% / 10% / 25% / 50% / 75% / 100%
G's: Met / Partiall Met / Not Met Reason
y
ter:
Progress current treatment plan
?y
-Achieve by next visit / week J
-Modify current treatment
-Other
# Visits . -reli-ve to # in P /Authorization
Therapist Signature ?'yp-yI , ? /
FLECK, CONSTANCE 350401307 FLECK,
1313 MALLARD ROAD
DATE OF TEL
CAMP HILL, PA 17011 13IRTill
2/27/75 7)7 763 8876
utilized during today's treatment. Changes included:
r/J /Jc?G?
Brief-Eval/Progress Note next visit
D/C patient
License # j cDdZ/
CONSTANCE
HEALTH AMERICA
2
Ticket 8: 140008956
PTypet: 75
AY'F,R PHYSICAi, THERAPY INSTiTiJTF.
FED. I.D. # 75-3050291
Evaluation Modalities -:Direct Contact. Required Other Procedureg/Supplies
iption _ CPT ! UNITS 's9 Description CPT UNITS 59 Description CPT UNITS ?'
Evaluation-PT
aluation-PT 97001
97002 Ultrasound (ea. 15 min)
lontophoresis (ea. 15 min) 97035
97033 ) TENS Instruction
Orthotic Casting 64550
29799
Evaluation-OT 970031 E-Stim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97703
aluation-OT
11 Muscle Test 970041
95831 Biofeedback
Self Care/Home Management 90901
97535 Onhotic Fkling/rraining (ea. 15 min) 1
Prosthetic Training (ea. 15 min) 97504
97520
. of Motion _ __-yI
:al Performance TS Meas 95851
97750T ^: Modalities -: Direct Co
HoVCold Pack ntact'NotlRequired
97010 Splint:
Splint:
L -I
Functional Drills-ea. 15 min) Mechanical Traction 97012 Splint Repair . L4205
Procedures - Direct. Contact' Required - E-Slim Unattended 97014 Supplies:
ieutic Activities (ea 15 min) 975301 Z Vasopneumatic 97016
eulic Procedure lea 15 min) 97110 j ?- Paraffin Bath 97018 ?-
nuscular Reed (ea. 15 min) 97112 Whirlpool/Fluido Therapy 97022
dTherapy (ea. l5 min) 97140 Wound Care -`Tracking - Medicare Non-Medicare
airing (ea. 15 min) 197116 11 Wound Care Selective 97601 Time In ,gyp
ge (ea. 1l) 97124 Wound Care Non-Selective 97602 Time Out J QCJ
c Therapy (ea. 15 min) 97113 _ Total Time
Therapy 97150
• NO S IS
I r s • Total # Units
PAIN IN JOINT, FOREARM
at changes has patient seen since last visit:
:tent's perceived progress toward functional long term goals:
719.43
Cx NS R/S Date
Reason:
:ient's chief c/o:
ier:
:five:
ase refer to this patient's flo sh for details specific to the. pr modalities and specific exercises utilized during today's treatrr
9 9E9
,uy,vrr- ?CiLr) d ta?F, !Gfc??G?ztlf?-n XlTr? Sze
SC
nently_ ROM: -? Strength:
lction: Swelling:
ter.
ssment:
ient's progress has been: Excellent `... Good/ Fair Poor
).rapist's assessment of patient's progress toward functional long term goals: 0% / 10% / 25% / 50% / 75% / 100%
u s: Met / ,Partially Met / Not Met Reason:
Progress current treatment plan Brief-Eval/Progress Note next visit
-Achieve by next visit / week _ D/C patient
-Modify current treatment
-Other
N Visits - -r ative to # in PO /Authorization
Therapist Signature _J Z/77--f CC/v`- License# ?}C.C'021
GUARANTOR NAME ANDADDAESS OATIENT NO. PATIRNTtNAME - DOCTOR NO.• I. .SATE'.
FLECK, CONSTANCE
1313 MALLARD ROAD
CAMP HILL, PA 17011
3509&1307 1 FLECK CONSTANCE
2
ATP Mn I.
cxet is 14oae
PTypek: 75
.AVER PHYSICAL THERAPY INSTITITTE
FED. LD. # 75-30502
:Evaluation < -Modalities-:Direct Contact Required Other. Procedures/Supplies
ription CPT UNI7S 59 Description CPT UNITS 59 Description CPT UNITS
Evaluation-PT _ 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction j 64550
valuation-PT 97002 - j lontophoresis (ea. 15 min) 97033 Orthotic Casting 29799
Evaluation-OT 97003, E-Stim Attended tea. 15 min) 97032 Onhotic Checkout (ea. 15 min) 97703
valuation-OT 97004 Biofeedback 90901 Onhotic FittingRraming (ea. 15 min) 97504
it Muscle Test 95831 Self Care/Home Management - 97535. Prosthetic Training (ea. 15 min) 97520
e of Molion 95851 Modalities-Direct Contact No t Required Splint: L
cal Performance Test/Meas : 97750 Hot/Cold Pack 97010 SplinC LL
Functional Drills-ea. 15 min) Mechanical Traction 97012 Splint Repair L4205 j
:-.ProceduW$ ?ZirectContact Required ` E-Slim Unattended ! 97014 Supplies:
xutic Activities (ea. 15 min) 97530 ! Vasopneumatic 97016
ieuiic Procedure {ea 15 minm 97110 ?
muscular Re-ad (ea 15 min) 97112 Paraffin Bath 97018
WhirlpooVFluido Therapy 97022
--
-- --
al Therapy (ea.l5min)97140
-
+. 'Wound Care r:
Care
Tracking
Medicare
Non-Medicare
raining (ea. 15 min) '97116 Wound Care Selective 97601 Time In
age (ea. 15 min) i 97124 Wound Care Non-Selective 97602 _ Time Out
is Therapy (ea. 15 min) 97113 Total Time
Therapy 97150
DIAGNOSIS
• CODE Total # Units
PAIN IN JOINT, FOREARM
719.43
Cx
Reason:
NS R/S Date
at changes has patient seen since last visit: 6e) ,l1rC?_m? r?7/] 7fi A4 s::?Q ,Ir
bent's perceived progress toward functional long term goals:
bent's chief c/o: •;j1,Q,rir7 ?.r i/ >?/7 /7?( ",?i?n•J? O/I 1/
her.
ctive:
3ase refer to this patient's flow sheet for details specific to the procedures/modalities and specific exercises utilized during today's treatment. Changes included:
irrently: ROM: e-
nclion:<<i ??n/?ls l?i,>sY? t?irJf?l'll7 "
her: 5 ,0/i Lci7
Sentient:
Bent's progress has been: Excellent Good
erapist's assessment of patient's progress toward functional long term goals:
'G's: Met / Partially Met / Not Met Reason: !
her: ?O l?nn a-? ?/7O/? ?/J"•l 4::,e e Ct
/
-Progress current treatment plan
-Achieve by next visit / week
-Modify current treatment
Other
Brief-Eval/Progress Note next visit
D/C patient
# Visits relative to # in P C/Authori ation
Therapist Signature . (9License # 0c -e -.: o 7D 0a
FLECK, CONSTANCE 380401307 FLECK CONSTANCE
1313 MALLARD ROAD
'.D'AT.E OF TELEPHONEf
CAMP HILL, PA 17011 BIRTH NO:. ' 'h ODE : r S
CAMP
2/27/75 1 7 763 8876 16 HEALTH AMERICA
Strength:
Swelling:
Fair Poor
0% / 10% / 25% / 50% / 75% / 100%
2
Ticket 1: 146009341
PTypeN: 75
AYER PHYSICAL THERAPY INSTITUTE
l ICJ
!Evaluation Modalities -DirectContactRequired OtherProcedures/Suppiies
Iptlert CPT UNITS 1159 Description CPT NITS i 59 Description I CPT UNITS
?valuation-PT 97001 Ultrasound (ea. 15 min) 97035 l TENS Instruction 64550
aluation-PT j 97002 lontophoresis (ea. 15 min) 97033 tic astiny 29799
?valuation-OT 97003 E-Stim Attended (ea. 15 min) 97032 L
tic Checkout (ea. 15 min) 97703
aluation-OT 97004 Biofeedback lic Pitting/training (ea. 15 min) 97504
it Muscle Test 95831 Self Care/Home Management 97535 j Prosthetic Training (ea. 15 min) 97520
of Motion 95851 1 'Modalities-Direct Contact No t'Re fired Splint: L
al Performance TesVMeas 97750 Hot/Cold Pack 97010 Splint: L
Functional Drills-ea. 15 min) 1
Procedures-Direct Contact '
Required Mechanical Traction
E-Stim Unattended 97012
197014 Splint Repair
Supplies: _C4205
emit Activities lea. 75 min) 97530
:uric Procedure lea 15 min) 197110
nuscular Re-ed (ea. 15 min) 197112 Vasopneumatic
Paraffin Bath
WhirlpooffRuldo Therapy - 97016
97018
97022 -' - ?_
I Therapy (ea 15 min) 197140
aining (ea. 15 min) 97176 J _ Wound Care
Wound Care Selective 97601
:Tracking
Time In
Medicare
Non-Medicare
ge (ea. 15 min) 97124 Wound Care Non-Selective 97602 Time Out H00
Therapy (ea. 15 min) 97113 Total Time -'
Therapy 97150
:D IA G I
N •
• Total # Units
PAIN IN JOINT, FOREARM
it changes has patient seen since last visit: 1-7 V i%,A+
ient's perceived progress toward functional long tens goals:
ient's chief c/o:
er:
719.43
FED. I.D.# 75-3050291
C
Cx NS R/S Date
Reason:
:tive:
ase refer to this patient's flow sheet for details specific to the procedures/modalities and specific exercises utilized during today's treatment. Changes included:
/'l4W??' : TII. 11 /1Gi ntli i'.? ?Yli /Y n /?y it ., w s.- n /JA'r!."AO/J//i .. e
rre? ROM: If " V"' P"Y7 Strength: V
rction: L?-? Swelling:
ter: (1 ri uluI V " 1?lt /oL4) rf 51112
asment
U
ient's progress has been: Excellent Good Fair Poor
:rapist's assessment of patient's progress toward functional long term goals: 0% / 10% / 25% / 50% / 75% / 100%
3's: Met / Partially Met / Not Met Reason:
ter. _-S`Iw C_ G/,'1 /?C7t l2Ly? l.? Cyt:Y /l?l t 2 Sf?Cf /wtg
"Progress current treatment plan Y-0 7 .S'f7? dt. .51Zt t V
-Achieve by next visit / week
-Modify current treatment
Other
I Visits relative to
)/I # ?/Authorization
Therapist Signature /;;77 ?h-//.(yy1 -
FLECK, CONSTANCE
1313 MALLARD ROAD
CAMP HILL, PA 17011
Brief-Eval/Progress Note next visit
- D/C patient
300401307 1 FLECK
License # 0X---&Z/ 73C
CONSTANCE 1 2
c[et 4: 14000
PTypel: 75
tAYER PHYSICAL THERAPY INSTITUTE
719.43
Evaluation Vocialittes ?DirectContactRequired..'! Other: Procedureal5upplles
-
ription CPT UNITS 59 Description CPT tl,NITS 59 Description CPT _UNITS I;
Evaluation-PT 97001 Ultrasound (ea. 75 min) 97035 TENS Instruction 64550
raluation-PT 9700211 lontophoresis (ea. 15 min) 97033 Odhotic Casting 29799
Evaluation-OT 1 97003 j E-Slim Attended (ea. 15 min) 97032 Odhotic Checkout (ea. 15 min) 197703
valuation-OT _ 1 970041 Biofeedback 90901 Onhotic FittinglTraininy (ea. 15 min i 97504
at Muscle Test
e of Motion 95831
95851 _ _?
_ Self Care/Home Management 97535
rModalities -'Direct Contact NotRequired, - Prosthetic Training (ea 15 min)
Splint: 97520
L
j
cal Performance Test/Meas 97750 Hot/Cold Pack 7010 1- Splint: L 1
. Functional Dnlls-ea. 15 min) Mechanical Traction
1 7012 Splint Repair L4205
Procedures - Direct Contact'Re a ` d '.
peuhc Activities (ea 15 min) 975301 E-Stim Unattended
Vasopneumatic 97014
97016
-? Supplies: _ __ -~
uhc Procedure (ea. 15 min) 97110 - - Paraffin Bath
97018 I
-?
muscular Be-ed lea. 15 min 97112
m Whirlpool/Fluido Therapy 97022
at Therapy (ea. 15 min) 97140 I j
raining (ea. 15 min) 97116 j
age (ea. 15 min) 97124 (Wound Care
Wound Care Selective 97601
Wound Care Non-Selective 97602
7racking
Time In
Time Out
Medicare j
Non-Medicare
/Q
is Therapy (ea. 15 min) 97113 i Total Time
Therapy 97150
DIAG o
ICD-9 CODE Total # Units
PAIN IN JOINT, FOREANN
at changes has patient seen since last visit:
bent's perceived progress toward functional long term goals:
tient's chief c/c:
ter.
:tive:
:ase refer to this patient's flow sheet for details specific to the procedures/modalities and specific, ex r is is utilize durin today's treatment. Changes included:
rrently: ROM: Strength:
nction: Swelling:
ter.
ssment:
bent's progress has been: Excellent ood _ Fair Poor
arapist's assessment of patient's progress toward functional long term goals: 0% / 10% / 25% / 50% / 75% / 100%
G's: Met / Partially Met / Not Met Reason:
ter:
Progress current treatment plan TU -I h7i?U?17a
-Achieve by next visit / week
-Modify current treatment
-Other
9 Visits n etive to k in C/Authorization
Therapist Signature / ,JT7??%,,.v/
FLECK, CONSTANCE
1313 NALLARD ROAD
CANP HILL, PA 17011
FED. I.D. # 75-3050291 jf?
Cx NS R/S Date
Reason:
380401307 1 FLECK
2/27/7
Brief-Eval/Progress Note next visit
D/C patient
License#
CONSTANCE 1 2
HEALTH ANENICA Ticket is 14060
PType#: 75
J?
:AVER PHY.SiCAT, THERAPY iNSTiTiTTF,
FED. I.D. # 75-3050291
-Evaluation Modalities -:Direct Contact Required Other Procadures/Supplies
'Iption CPT UNITS 59 Description CPT UNITS 59 Description CPT UNITS
Evaluation-PT _ 97001
aluation-PT 97002 Ultrasound (ea. 15 min) 1197035 r
lontophoresis (ea. 15 min) 97033 ! TENS Instruction _
Orthotic Casting 64550 _?_
29799
Evaluation-OT 97003 E-.Slim Attended (ea. 15 min) 97032 Ortholic Checkout (ea. 15 min) 97703 _
aluation-OT 197004 d
Al Muscle Test 95831 Biofeedback
Self Care/Home Management 90901
97535 j Orthotic Fitting/lraining fee. IS min)
Prosthetic Training (ea. 15 min) 97504
97520
j
ofMotion^ 95851 Modalities-" Direct Contact NotRequired Splint: L ?
:al Performance TesUMeas 97750 j Hot/Cold Pack 97010 Splint L _
Functional OriNs-ea. 15 min) Mechanical Traction 97012 Splint Repair ? L4205
- Procedures •Direct 'ContectFie Required ` E-Stim Unattended _ 97014 Supplies
mutic Activities (ea 15 min) 97530 "
eulic Procedure (ea. 15 min) 97110
muscular Re-ed (ea. 15 min) 97112 i Vasopneumalic 97016
Paraffin Bath 197018
Whirlpooffiddo Therapy j 97022
_ -
?
Therapy(as 15mirt 97140,
al Wound`Care Tracking: ' Medicare Non-Medicare
_
97116
raining (ea. 15 min) Wound Care Selective 97601 Time In 1. O
_
age tea. 15 min) 97124 Wound Care Non-Selective 97602 Time Out
is Therapy (ea: 15 min) 97173 Total Time T'- u
Therapy 97150
DIAGNOSIS
a' • a Total # Units Ci
PAIN IN JOINT, FOREARM
at changes has patient seen since last visit:
bent's perceived progress toward functional long term goals.
Cx NS RIS Date
Reason:
719,43
bent's chief
ter: 1?P [, A,,P-el iz -
Ctive:
,ase refer to this patient's flow sheet for details specific to the procedures/modalities and specific exercises utilized during today's treatment, Changes include&
rre tl: ROM: / •? ' ° Strength:
'tction: Swelling:
ter: ?L? Z/ZPE
aliment:
:ient's progress has been: Excellent Good Fair Poor
:rapist's assessment of patients progress toward functional long term goals: 0% / 10% / 25% / 50% / 75% / 100%
3's: Met / Partially
M
e
/ Not Met Reason:
t
/
t
?
??UV
ter: 1JV64 1/ 'i,71Jl/J
Progress current treatment plan
-Achieve by next visit / week
-Modify current treatment
-Other
I Visits tive to # in PO Authorization
Therapist Signature
FLECK„ CONSTANCE
1313 MALLARD ROAD
Brief-Eval/Progress Note next visit
D/C patient
380401307 1 FLECK
License # 6e Oct 17,3&
CONSTANCE 1 2
CARP HILLS PA 17011 ?slRTrt , ' : e.Ma , ,001)1513ESCRIPTtON° - • ?CER-T.
2/27/75 7 I7 763 8876 1 HEALTH AMERICA Ticket 4:
PTypeB:
75
AYER PHYSICAL THERAPY INSTITUTE
719.43
''.Evaluation 'Modalities -:DlrectContect:Required 'Other" Procedures/Suppiles
iption CPT UNITS 59 Description CPT 41NITS 59 Description CPT UNITS 5
_
Evaluation-PT _ 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550
aluation-PT 97002 lontophoresis (ea. 15 min) 97033 li Orthotic Casting 29799
?valuation-0T 97003 E-Stim Attended (ea. 15 min). ! 97032 Orthotic Checkout (ea. 15 min) 97703
aluation-OT 97004 Biofeedback - 90901 Onhotic Filtingrtraining (ea. 15 min) 97504
it Muscle Test 95831 j Self Care/Home Management 97535 Prosthetic Training (ea. 15 min) 97520
of Motion 95851 : !!Modalities-:Direct Co ntact' No t Rg ired Splint: L
:al Performance Test/Meas ! 977501 Hot/Cold Pack 97010 a Splint: L
Funcibnal Drills -ea 15 min) Mechanical Traction 97012 Splint Repair L4205
Procedures-DlrecU ntactRegulred ! E-Stim Unattended 97014 Supplies:
outic Activities (ea. 15 min)
97530 g
Vasopneumatic
97016 _
eutic Procedure (ea. 15 min) 97110 Paraffin Bath 97018
nusculai Re-ed (ea 15 min) .
it Therapy (ea. 15 min) 97112
971401 1 Whirlpool/Fluldo Therapy 97022
'. :. Wound Care
Tracking - Medicare
Non-Medicare
_
ainmg (ea. 15 min) 97116 Wound Care Selective 97601 Time In p Q
ge (ea. 15 min) 97124 Wound Care Non-Selective 97602 Time Out zo
c Therapy (ea. 15 min) 97113 Total Time ^ i7
Therapy
• 971501
DS IS 1
I • CODE Total # Units
PAIN IN JOINT, FOREARN
)t changes has patient seen since last visit:
ient's perceived progress toward functional long term goals:
tent's chief c/o:
ier.
:tive:
FED. I.D. # 75-3050291
CX
Reason:
NS R/S Date
ase refer to thjs patient's flow sheet for details specific to the or cedures/modalittes and specific a ercises utilized during today's treatment , Changes included:
??? '
rrently: ROM: (rength:
fiction: Swelling:
ter:
ssment:
fen's progress has been: Excellent Good Fair Poor
)rapist's assessment of patient's progress toward functional long Perm goals: 0% / 10% / 25% / 50% / 75% / 100%
G's: Metj Partially Met / Not Met. Reason:
ter: C44,L 7 4 6?4,h( %I-"-,4 6,7e?O? j'. i'- &4-a?
Progress current treatment plan V'?"` a-61J6e
Brief-Eval/Progress Note next visit
.Achieve by next visit / week D/C patient
-Modify current treatment
-Other NDV & -71?
4 Visits relative to 9 in P /Authorization
Therapist Signature ?? 1 / License x &0001 7, 3
GUARANTOR NAME AN ADDRESS PATIENT NO.
PATIENT NAME . , _ `', DOCT.OR•NO. ATE-"
FLECK, CONSTANCE 380401301 FLECK CONSTANCE 2 9
1313 NALLARD ROAD
°DATE OF TELEPHONE _ -INSURANCE
CARP HILL, PA 17011 "BIRTH N0. '.'.CO OE ',DESCRIPTIQN CERTIFICATE NO.
-:.
PType#: 75
LAYER PHYSICAL THERAPY INSTITUTE
57
FED. I.D. # 75-3050291
Evaluation' "' ;Modalities-Direct Contact' Required OtheriProcedures/Supplies
rlptlen CPT j UNITS ! 59 Description CPT UNITS 59 Description CPT uNITS
Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 ! TENS Instruction 64550 t
von-PT 97002 lonlophoresis (ea. 15 min)) 97033
I
Unhotic Casting
29799
Evaluation-OT
Evaluation-OT
valuation-OT !. 97003 !
97004 E-Slim Attended (ea. 15 min)
Biofeedback 97032:
90901 Onhotic Checkout (ea. 15 min)
Udhotic FiltingRraining (ea. 15 min) ! 97703
97504
al Muscle Test 95831 Self Care/Home Management 97535 Prosthetic Training (ea. 15 min) 97520
= of Motion __
cal Performance Test/Meas 95851
1377,50 _ Modelltles - Direct Co
Hot/Cold Pack _ ntecfNot•Required -
97010 I, Splint:
Splint L
L
. Functional Drills-ea. 15 min) j Mechanical Traction 97012 Splint Repair L4205
Procedures -Direct : Contact Requited E-Stun Unattended _ 97014 _
Supplies:
ueutic Activities (ea. 15 min)
ieutic Procedure (ea. 15 min) min 97530 _
10 Vasopneumatic
Paraffin Bath 97016
97018 _
muscular Re-ed (ea 15 min)
al Therapy (ea. 15 min)_ 97112
971401 Whlrlpool/Ruido Therapy 97022 1
-Wound Care
Tracking Medicare T---?
Non-Medicare
raining (ea. 15 min) 97116 Wound Care Selective 97601 Time In j •Tj-(?
age (ea. 15 min) 97124: Wound Care Non-Selective 97602 Time Out '. ZO
is Therapy (ea. 15 min) 97113 ' - Total Time
Therapy
I r 97150
•
e • e Total # Units
PAIN IN JOINT, FOREARN
Cx NS R/S Date
Reason:
719.43
at changes has patient seen since last visit: F)'
lient's perceived progress toward functional long term
tient's chief c/o:
ter.
;five:
this patient's flow sheet for details specific to the procedures/modalities and specific exercises utilized during today's treatment. Changes included:
G f'fic CQert i. Z& (15 7,V r3'tdt C w -
rrently: ROM:
fiction:
ter:
ssment:
Jam's progress has been: Excellent Good
:rapist's assessment of patient's progress toward functional long term goals:
G's: Met // Partially Met / Not Met Reason:
ter:
Strength:
Swelling:
Fair Poor
0% / 10% / 25% / 50% / 75% / 100%
Progress current treatment plan
Achieve by next visit / week 1< ''J ,STtvs+yv-•'?/I[.1??.? Qtr' rrT)
-Modify current treatment
Other
Brief-Eval/Progress Note next visit
D/C patient
q Visits relative to # in POO thorization
Therapist Signature ?4r7 ,L -,)21al % License# A?'&Z/zy_
FLECK, CONSTANCE 380401307 FLECK CONSTANCE
1313 NALLAED ROAD
^! DATEbF, TELEPHONE ?
CAMP HILL, PA 17011 BIRTH i:No.. ''CODE, 1 1: s DESCRIPTI(iury
2/27/75 717 763 8816 6 HEALTH HERICA
2
Ticket 1: 140010497
PTypeM: 75
:AYFR PRYWAT. THERAPY TNST1TTITF
FED. I.D. # 75-3050291 31
Evaluation " Modal(ties - Direct Contact'. Required Other Procedures/Supplies
UNITS 99
'iption CPT 1,
Description
CPT UNITS
1
59
Description
CPT UNITS
97001
Evaluation-PT Ultrasound (ea. 15 min) 97035 r TENS Instruction 6
___
aluation-PT 7002 11 lontophoresis (ea. 15 min) 97033. Orthotic Casting 29799
0
Evaluation-OT 970031 E-Slim Attended (ea. 15 min) 97032 Cirrhotic Checkout (ea. 15 min) 977
aluation-OT 97004 1 Biofeedback 90901 Orthotic Fittingrrraining (ea. 15 min) 97504
it Muscle Test_ 95831 _
?- - Self Care/Home Management 97535 Prosthetic Training (ea. 15 min) 97520
-
:ofMotion
95851 'Modalities - : Direct Contact Not:Req fired Splint: ? L T
_
.it Performance TesUMeas, 97750 _ Hot/Cold Pack 97010 / Splint: L ?-
Functional Dnlls-ea 15 min) Mechanical Traction - 97012 Splint Repair L4205
Procedures-Direct: ContactReguiretl -:
reutic Activities (ea. 15 min)) 97530 ' E-Stim Unattended 97014
Vasopneumatic
97016 Supp_hes:_ j
_ ~
euttc Procedure (ea 15 min)) 97110 Paraffin Bath 97018
-
nuscular Re-etl (ea 15 min) 97112 Whvipool/Fluido Therapy 97022 ? I
it Therapy (ea. 15 mm_) ] 97140 - Wound Care 1 Tracking - Medicare Non-Medicare
?
raining (ea. 15 min) 97116 _ Wound Care Selective 97601 _ Time In .246
gge (ea. 15 min) _ 97124 Wound Care Non-Selective 97602 Time Out L /j-
c Therapy fee. 15 min) 97113 Total Time
Therapy 97150 Total # Units (p
• NOS IS • • •
PAIN IN JOINT, FOREARN
at changes has patient seen since last visit:
Bent's perceived progress toward functional long term
lient's chief c/o:
ier:
719.43
Cx NS R/S Date
Reason:
,five:
ease refer this patient's flow sheet for details specific to the procedures/modalities and specific exerci es utilized during today's treatment. Changes included:
?(.C,I?I l??i?CU"1'> /,??z'Z-0'2G/ f ,/?-??? /2,?%
vrently: ROM: Strength:
nction: Swelling:
ier:
ssment
tient's progress has been: Excellent Good Fair Poor
erapist's assessment of patient's progress toward functional long term goals: 0% / 10% / 25% / 50% / 75% / 100%
G's: Met / Partially Met / Not Met Reason:
ner tiX/(?AC ?? ?? ?
-Progress current treatment plan Brief-Eval/Progress Note next visit
-Achieve by next visit / week D/C patient
-Modify current treatment
Other l'IUv -v ?/?JC2/"7? y /-(??.Q" e+Y!9 .-
r c
# Visits -relative to # in PO /Authorization
Therapist Signature / /A1/ /l/l ! G'N? License # duJZl73L
FLECK, CONSTANCE 380401307 FLECK CONSTANCE
1313 RALLARD ROAD -DATE OF . TELEPHONE`, _
BIRTH ,NO.' CODE` :"DESC
CARP HILL, PA 11011
2/27/75 717 763 8876
HEALTH ARERICA
2
:CERTIFICATE NO
Ticket 0: 140010496
PTypet: 75
e4
AYER PHYSICAL THERAPY INSTITUTE
FED. LD. # 75-3050291 O?/
Evaluation Modalities-.Direct: Contact Required Other Procedures/Supplies
lption CPT I UNITS i 59
-valuation-PT 97001 Description CPT UNITS i 59
Ultrasound (ea. 15 mm) 97035 ! 1 Description
TENS Instruction CPT
j 64550 i UNITS 5
alualkil 97002, lontophoresis (ea 15 min) 97033 Orthotic
Castiny 29799
valuation-OT l 97003 !
3luation-OT 97004 E-Stim Attended lea. 15 mil 97032
Biofeedback ! 9090 _
Onhotic Checkout (ea. 15 min)
Orlhotic Fitting/Training (ea
15 min) 97703
97504
d M
l
T
9583 lf C
S
/H
M
97535 .
P
usc
e
est
1 e
are
ome
anagement rosthetic Training (ea. 15 min) 97520
oiMotion 95851
t P
rf
T
UM
9775 :Moralities-Direct Contact NotReq'ired
H
ld P
k 97010 '1
t/C Splint
__
S
l L__ _
a
e
ormance
es
eas
Functional Drills-ea 15 min) o
o
ac
-I_ i
Mechanical Traction 7012 i _
p
inl _
Splint Repair L
14205
Procedures - Direct Contact Required ? E btim Unattended 97014. _? Electrodes A4556
eutic Activities lea 15 min) 97530 :3
u
Procedure lea 15 min) 97110 Vasopneumatic 97016
Paraffin It
97018 Supplies:
?
s
nuscularReed(eal5min) 97112 --
T
Whirfpool/FluidoTherapy 197022 __ _
-
a ea. 15 min) 97140
) 977 ?
'TherPYI
Wound Care
Wound Care
Trackin.' Med
g
Trackina Med
icare
icare
Non-
Non-Medicar
Medica
r
e
e
_
aln_ing (ea. 15 min)
ge (ea. 15 min) 97116 I
+-
97124.1 Wound Care Selective 197601 _
Wound Care Non-Selective 197602 Time In
__ __
Time Out
f pp
-7/rj
_
1 _
?- _
c Therapy lea. 15 min) 13
97 Total Time
Therapy 97150, Total # Units
D IAGNOSIS • • e
PAIN IN JOINT, FOREARK
719.43
Cx NS R/S Date
Reason:
it changes has patient seen since last visit:
tent's perceived progress toward functional
k
term goals: _
,,, r,A
iant's chief c/o:
ier:
tire:
ase refer to this patient's flow sheet for details specific to the procedures/modalities and specific exercises utilized during today's treatment. Changes included:
S ;,lo
J f e a Yl-(:x _n w ,?« aa1 fi ,?! /t rl KL?
rrently: ROM: SLength:
fiction: Swelling:
ter:
asment:
ient's progress has been: Excellent Good Fair Poor
irapist's assessment of patient's progress toward functional long term goals: 0% / 10% / 25% / 50% / 75% / 100%
3's: Met / Partially Met / Not Met Reason:
ter: ?. ?7iU/iZf_[:° -.t'?f' ___
-Progress current treatment plan- 7u`f'iL Brief Re-eval/Progress Note Next Visit
--Achieve by next visit/ week D/C patient
-Modify current treatment
Other
I Visits lative to A in PO /Authorization
Therapist Signature License # ?-
GUARANTOR NAMEAND ADDRESS PATIENT Il l PATIENT NAME Y DOCTOR NO. -:DATE:
FLECK, CONSTANCE 380401307 FLECK CONSTANCE 2 11 0
1313 NALLARD ROAD
DATE OF TELEPHONE. INSURANCE
CAMP HILL, PA 17011 BIRTH ? NO. CODE DESCRIPTION CERTIF.ICATE'NO:-
2/27/75 71 7 763 8876 1
1
6 HEALTH AMERICA
Ticket l; 140011290
PTypel: 75
A'YER PHYSICAL THERAPY INSTITUTE
FED. I.D.# 75-3050291
Evaluation - Modalities - '. Direct :Contact PRequired Other Procedures/Supplies
1P1100 CPT UNITS 59
valuation-PT 11197001 Description
Ultrasound (ea
15 min) CPT-I UNITS 59
-- --
97035 DeeCl'IpflOn
-- -
TENS Instruction CPT
64550 UNITS 5
.
aluation-PT -97?002, lontophoresis lea 15 min) _ 97033 _
1
- Orthotic Casting 29799 If
valuation-OT _1 97003 1 ?- E Stlm Attended (ea. 15 min) 97032 i_
__ Odhmic Checkout (ea. 15 min) 97703
_
aluation OT 97004 Bloieedback
- --- ----- 90901
- _-- Orthotic Fittingr1raining (ea-1 975
5 min) 04
-
if Muscle Tesl 95831 u
_ _ Self Care/Home Management 97535 Prosthetic Training (ea.
- 15 min) 97520
T--
-
--
of Motion ! 95851
l
M
97750
-
P
d
T
U
-Modalities -Direct
H
/C
ld P
k
Contact Not Required
970
0 /
SpIIN
t:
li
---
-
+L -
eas
11
a
e
or
m
ance
es
-' -? ot
o
ac
_ 1 Sp
nt
_ L
1
Funct
ional
Drills-
ea 15
mm)
Procedures - Direct
`Contact [jd`qu. `d
; Mechanical Traction _
ed
E 97012
97014 Splint Repair
Ele
f rodes L4205
?A4556
(
duea 15 mm) 97530 r
euilc
i
e
h
P
d
15 mi
97110 ? -
_
pneu atic
Vasosa
Paratfin tn Bath is Bath
_1
T- _
97016
I
97018
P
--
Su lies
?
?-_ ? --
roc
e
ure
eu
roce
re l
a
?
c
n) 1 ?
-
nuscular Reed ea 15 min 97112 -
--
Whirlpool/Fluido Therapy 1 97022 - - - - I
II Therapy (ea. 15 min)
9 417 J Wou nd Cam . Tracking Medicare Non-Meadicare
?
arcing (ea i5 mm) 9711 1
ge (ea. 15 min) .. 97124 I -
Wound Care Selective
Wound Care Non-Selective 97601
97602 Time In
Time Out
c Therapy (ea. i5 min) 97113 TOtal Time
Therapy 971501 Total # Units
• • • P r, • e
PAIN IN JOINT, FOREARM
719.43
Cx NS R/S Date
Reason:
at changes has patient seen since last visit:
ient's perceived progress toward functional long term goals:
'.tent's chief c/o:
ter:
;five:
ase refe to this patient's flow sheet for details specific tothe proceduies/modali ti-esJai?d specific exercises u ilized during today's treatn
G t'
rrently: ROM:
f - Strength:
iction: Swelling:
ter:
ssment:
lient's progress has been: Excellent Good Fair Poor
:rapist's assessment of patient's progress toward functional long term. goals: 0 % / 10 % / 25% / 50 % / 75 % / 100 %
3's: Met /'?,?Partially Met/ Not Met Reason: -
ter: / ( (2' 1
-Progress current treatment plarK,"?d!L Brief Re-eval/Progress Note Next Visit
-Achieve by next visit / week D/C patient
-Modify current treatment
-Other
# Visits rel' five to # in POC thonzation
/A
I
) ?
w _ (j(G??ZI ?J L
Therapist Signature r . License #
GUARANTOR NAME AND DRESS - PATIENT NO. PATIENT.NAME :DOCTOR NO.6" 24 OVATE
FLECK, CONSTANCE 300401307 FLECK CONSTANCE 2 4 0p
1313 MALLARD ROAD
CAMP HILL
PA 11011 DATE OF TELEPHONE INSURANCE <
, BIRTH NO. - rnnG -neennronnu CE TIF T
Changes included:
1G FrI'IQ..
TfciFt PTypei: 75
,AYER PHYSICAL THERAPY IRrSTITUTE
FED. I.D. # 75-3050291
'Evaluation Modalities - Direct Contact Required Other ProcedureaMupplies
1ption CPT UNITS
Evaluation-PT :97001 159 Description CPT UNITS :59
Ultr
d
15
i
97
035 Description ' CPT UNITS 5
asoun
(ea.
n) _
m
_
- TENS Instruction 16455o
aluation-PT 97002, lontophoresis lea 15 min)
97033
1 Onhotic Casting 29799
Evaluation-OT_ 97003 _? -
E-Slim Attended (ea 15 min) 97032 - Orthotic Checkout (ea. 15 min) 97703
aluahon OT 97004 Biofeedback 0901- -- r
t Orthotic FitunglTraining (ea. 15 min) 97504
-
- -
a Test ?
?-
_
---_? - - --
--T---
Self Care/Home
Management
Prosthetic Training (ea 15 min) 97520
-- - --
95851 _ _
Motion
al Performance Test/Meas 97750 -Direct Contact
Modalities
ntactNot Required
HotiCold Pack 97010
Splint:-
L
Splint. L
'-
Functional Drills-ea 15 min) Mechanical Traction 97012 Splint Repair p5
Procedures - Direct Contact Re 1red EStim Unattended 197014 j Electrodes
A4556
xtulic Activities (ea 15 min) ' 97530 t?- - -- --
Vasopneumalic 97016 - -
- _
Supplies
r
e
c
Procedure lea 15
971107
min)
Paraffin Bath 9701
6 -
u-
-m
-
__
scu
Tlai Re ed ea 15 min 97112
Whlrlpool/Fluido Therapy 9702
2
eN
it Therapy (ea. 15 min) 9714 j _ Wound Cat cking ? Medicar -Medicare
rammg (ea. 15 min) : 97116
I
o (ea 15 min)) 97124
-1 Wound Care Selective 97601
NonSelective 97602_
Wound
Care in
g
_
is Therapy (ea. 15 min) 97113
-- _
_
J
--- __
L //, 1 Cc)
-7
Therapy 97750 its
Total# (y
• • • • •
PAIN IN JOINT, FOVEARN
at changes has patient seen since last visit: No je
Bent's perceived progress toward functional long term goals:
719,43
Cx NS - R/S Date
Reason:
rent's chief c/o: WI-0 T iU 1
1ec
,five:
ase 1efeI to this patient's. flow sheet for details specific to the procedures/modalities and specific exercises utilized during today's treatment.
r
rrr?_ ROM: r Strength:
lction: Swelling:
ter.
ssment:
Gent's progress has been: Excellent Good Fair Poor
)rapist's assessment of patient's progress toward functional long term goals: 0% / 10% / 25% / 50% / 75% / 100%
3's: Met / Pa ially Met / Not Met Reason: _ I--eI7
ier: i
-Progress current treatment plan Brief Re-eval/Progress Note Next Visit
-Achieve by next visit / week D/C patient
-Modify current treatment
_Other_
V Visits relative to N in POC/Authorization
Therapist Signature - '07TH
u-Fli
License M
6 ?6ad2/7 J?.
GUARANTOR NAME ANDADDRESS PATIENTNO PATIENT: NAME DOCTOR'NO. ATE
FLECK, CONSTANCE
1313 MALLARD ROAD 300401307 FLECK CONSTANCE 2 9
DATE OF TELEPHONE INSURANCE - '.
CAMP HILL PA 17611
i BIRTH NO. - CODE '. `DESCRIPTION CERTIFICATE Nn "-
included:
__-TFcTeTT7TW
PTypet: 75
AVER PHYSICAL THERAPY INSTITUTE
FED. I.D. # 75-3050291
'Evaluation '-Modalities- Direct Contact; Required Other; Procedures/Supplies
piled CPT UNITS 59 DBSCdptlOn IT OPT i_ UNITS '59 Description CPT UNITS 5i
valuation-PT - 97001 Ultrasound (ea. 15 min) 197035 TENS Instruction 64550
to rid PT
9700 T
lontophoresis (ea. 15 min)
97033 --
Gdhotic Casting
29799 _
:valuation-0T 97003 _ _
E-Slim Attended (ea. 15 min) 97032 _ Urfhotic Checkout (ea. 75 min) 97703
duation-OT _ 97004 _ ? Biofeedback 90901 Orthotic Fifting/Training (ea. 15 min) 97504
I Muscle Test !
of Motion 95831
95851 _ _
1 Self Care/Home Management 97535 '
'.. 'Modalities - Direct Contact Not Required- Prosthetic Training (ea. 15 min)
Splint 97520
al Performance TesUMeas] 97750 HotlColdPack 197010 Spllnl L T
unctional Drills-ea 15 min)
Mechanical Traction
9709 _ _
Spilnt Repair
__
L4205 -
Procedures - Directi Contact' Required ;
uric Activilies (ea 15 min) 97530 g E-Stim Unattended 1
Vasopneumatic 97014 1 -
97016 ~ Electrodes _
Supplies: A4556 _
_
-f
iuiic Procedure (ea 15 min) 0 Paraffut Bath 97018
wscular Re ed lea 15 min) 97112 Whirlpool/Fluido Therapy 97022
Therapy (ea. 15 min) 11971401 - '.Wound Care - Tracking Medicare on-Medicare
ammg fee. 15 min) '971161
ae (ea. 15 min) 971241 Wound Care Selective 197601 1
---,--'-
Wound Care Non-Selective 197602 Time In
Ti Me Out
Therapy (ea. 15 min) 97113 ! - Total Time ?-S
Therapy 971501 L-1 Total # Units
D • •
PAIN IN JOINT, FOREARM
Cx NS R/S Date
Reason:
719.43
d changes has patient seen since last visit
tent's perceived progress toward functional long term goals: 51'?-t<Co Jk-e 0. r ,' t/T
8414/ .7 f, j udi v.?.
ITIT cne ?J I^5
er:
tive:
ese. refer to this patient's flow sheet for details specific to the procedures/modalities and specific exercises utilized during today's treatment. Changes included:
rently: ROM: Strength:
fiction: Swelling:
er: aA (kta- (...cam. p? ?lorYS?-E.u
;sment:
tent's progress has been: Excellent Good Fair Poor
rapist's assessment of patient's progress toward functional long term goals: 0% / 10% / 25% / 50% / 75% / 100%
3's: Met / Partially Met / Not Met Reason: P) Ldu"-s aco? v ]2 t /v,?-l
er:
-Progress current treatment plan CUA Lt wt (0c-
.Achieve by next visit / week
.-Modify current treatment
-Other
I Visits ref 've to f! in POC/Authorization
Therapist Signature ta.t - !?r•7?'
rireIosurne uaue.eunr&rnneecc XIMAT.ICAIT xrnQ nwr
FLECK, CONSTANCE 380901301 FLECK
1313 NALLARD ROAD
DATE OF TELI
CAMP HILL, PA 17011 BIRTH
Brief Re-eval/Progress Note Next Visit
D/C patient
2/27/75 747 763 8876
License# (168'-173
NT+NAME DOCTOR NO. ?,
CONSTANCE 6 11
INSURANCE
`DESCRIPTION CERTIFICATZNC
16 HEALTH AMERICA Ticket 1: 110011539
?Type#: 75
Patient: Constance Fleck
PHYSICAL
DRAYER
Physical Therapy Institute Date: 7/1/04
Leading the Way to Grad Health
??
Date of Birth: 2/27/75 Total #:
Diagnosis: laceration *Visits Attended: 17
Date of Evaluation: 5/12/04 • NS (not rescheduled): 0
Physician: Dr. Goltz • Cancel (not rescheduled): 1
SUBJECTIVE STATUS/PROGRESS
Currently:
• 0/10 pain with all use of left UE.
Independent with all ADL and homemaking activities.
Employment/Activity Status: Working full time within own restrictions.
Obiective:
• AROM left UE WNL's throughtout.
• No symptoms of nerve compression in left UE.
• MMT:
Shoulder
Flexion 5/5
Abduction 4+/5
Extension 515
Grip right left
1. 60# 55#
II. 80# 75#
V. 75# 50#
Pinch
Lateral 22# 18#
Tip 16# 13#
Palmer 20# 17#
Functional: Using left UE for all activities WNL's. Continues to describe minimal decrease in endurance with all
activities.
Assessment: Nice progress noted and benefits from current treatment. Patient will be seen 1 more week to set up
review an extensive strengthening HEP for left UE.
Rehabilitation Prognosis/Potential: Good for continued progress with HEP.
Updated Short Term Goals: (To be achieved in weeks)
1. N/A secondary to pending discharge.
?lo1G?
Ig
THERAPY ??-
PROGRESS NOTE
Mechanicsburg Center 5275 )i. bindle Reed - Suite 110 - Mechanicsburg, PA 17050 - PnONZ: 717.790.9920 - rm: 717-790-9928
Constance Fleck
Page 2 Progess Report
Treatment Plan: Plan to discharge patient to
Frequency:
D RAYE R
Physical Therapy Institute
Leading the Way to Good Heatth
on
Duration:
I have discussed the above findings, assessment, revised treatment plan and expected outcomes with this patient. The patient
is aware of the diagnosis as well as prognosis and voluntarily agrees to continue participation in physical therapy services at
DRAYER PHYSICAL THERAPY INSTITUTE.
Thank you again for this referral!
1 will continue to k ep you informed of any changes in the patient's status and the treatment plan.
Therapist's Signature: , OTY- LGt fr Date: '71 / leg
Jean Gress OTR, LCHT License: OC 002173 L
In accordance with accepted medical practice standards, I hereby certify that the above named patient is under my care and requires
physical therapy rehabilitative services for the problem(s) identified above. As such, I request that Drayer's physical therapy staff
continually evaluate and assess the patient's need for such services and provide a detailed patient care plan for my approval/recertification
to be reviewed every 30 days at least. /I ,
Physician's Comments:
Physician's Signature:
Please return this Progress Note to Drayer Physical Therapy.
Thank You.
Date:
Mechanicsburg Center 5276 E. Trindle Road - Suite 110 - Mechanicsburg, PA 17050 - PHONE: 717-790-9920 - rix: 717-790-9923
AVER PHYSICAL THERAPY INSTITUTE FED. I.D. # 75-3050291
Evaluation Modalities • Direct Contact Required Other ProcedurealSupplies
Iptlon CPT UNITS j 59 Description CPT UNITS 59 Description CPT UNITS 5
cvalualion-PT 97001 Ultrasound (ea. 15 min)
97035 TENS Instruction 64550
tluation-PT _ _
970021 _
-- --
lontophoresis (ea. 15 min)97033
Cirrhotic Casting 29799
'valuation-OT 970031 E-Stim Attended (ea. 15 min) 97032 Odhotic Checkout (ea. 15 min) j 97703
iluation-OT 97004 {r -i
-
- Biofeedback 90901 Onhotic Fittingrrraining (ea. 15 min) .97504 1
I Muscle Test_ 95831 v
~ Self Care/Home Management 197535 Prosthetic Training (ea. 15 min) 97520
o1 Motion 95851 _ 'Modalities-Direct. Contact Not Required Splint
al Pedoimance TesNvieas 97750 Hot/Cold Pack 9701_0_ ( ) _ Splint: j L
Functional Drills-ea 15 mint Mechanical lracaon 9701J_
1! Splint Repair L4205
Procedures • Direct.Conteet Required .
E Stim Unattended 9I 7014 _ __
6 Electrodes A4556
eulic Activities (ea. 15 min) 97530 Vasopneumatic - 9701
j
? Supplies: j
uric Procedure (ea 15 min) 97110 Paraffin Bath _ _ 197018
----4 r
wscular Reed (ea 15 min) j 97112 7
Whtrlpool/Fluido Therapy 97022
1
ITherapy(ea 15 min) __ 97140
16 Wound Care Tracking" Medicare Non-Medicare
aining (ea. 15 mm) , 971 Wound Care Selective
97601 Time In -?'3U
ge (ea 15 min) _ 97124 _
Wound Care Non -Selective _7602 _
Time Out
;Therapy (ea. 15 min) 97113 Total Time _
Therapy 97150 Total # Units CG
D • • • •
Tent's chief c/o:
er. 0a t /- l.C-eV?t-LGLQ.' ,Z6
Live:
ase refer to this patient's flow sheet tot details specific to the procedures/modalities and specific exercises utilized during today's treatment. Changes included:
xentiv: ROM: Strength:
fiction: Swelling:
er:
isment: _
Tent's progress has been: Excellent Goo - Fair Poor
irapist's assessment of patient's progress toward functional long term goals: 0% / 10% / 25% / 50% / 75% / 100%
3's: Met /Partrti?allly Met / Not Met Reason:
/ h%' Phi ell a^
er: Ao*? --L
• , 1'OP
-Progress current treatment plan Brief Re-eval/Progress Note Next Visit
-Achieve by next visit /? ee Nf? A.A/ D/C patient
-Modify current treatment A46 60? 71
_Othet
I Visits relative to in POC/Authorization
Therapist Signature l o-(!? G LCNT License f7 WV 73 d-
GUARANTOR NAME AN ADDRESS PATIENT NO. PATIENT. NAME DOCTOR NO. 7K1/ kFbATE
-nTR-,mrnu6r-- 381401397 FLECK
1313 MALLARD ROAD
CARP HILL, PA 17011 'DATE OF TELEPHONE INSURANCE
CODE p
Prypet: 75
It changes has patient seen since last visit:
Tent's perceived progress toward functional long term goals:
DRAYER
Vhf icel rwnry LWhuW
raw??u rr.. u., • rw rwrux
Patient Name: Constance Fleck
Discharge Summary
Date: 7/14/04
DOB: 2/27/75 Physician: Dr. Goltz Total #: • Visits: 17
Dx: laceration left UE Last Treatment Day: 7/1/04 • # Cx: 0
Date of Evaluation: 5/12/04 • # NS: 1
Goals bfTreatment 'Met Partially Met Not Met, Unable to Assess
? j Pain Level to 0-1/10 with left UE activities. ? ? ? ?
? ? Functional Ability to use left UE for all activities ? ? ? ?
without increased pain.
? ] ROM of left UE to WNL. ? ? ? ?
? q Strength of left UE to WFL. ? ? ? ?
Treatment Goals NotMetI)ue To:
N/A
to normal, premorbid status at this time (patient concurs).
Disehfie eTlan 'Disehar P.ra'uosts?'?'
?Patient is to follow a specific home exercise program (see Comments below). ? Excellent ? Good ? Fair o Poor
? Equipment has been ordered for home use (see Comments below). Addl Comments:
o Letter sent to patient to alert him/her of D/C decision(MD authorized).
? Other:
• HEP/Equipment: Continue with scar management, strengthening, and ROM HEP.
• Equipment: T-band for strengthening.
• Final D/C Status: See final progress report dated 7/1/04
Signature of Therapist: License # OC 002173 L Date: 9/14/04
Jean Gress OTR, LCHT
I Heidel, Mrs. Constance L. Case Type: PML DOI: 04119/2004 LimDate:4/19/2006
Case #: 209345 ( ) Class: Assigned: WSH Date Opened: 04/29/2004
817/2006 11:11 AM
Value Summary Report
Page 1 of 1
Value Code Dates of Service Total Amount Total Paid Reduction Deduct From Client
Date Paid Payment Amount Paid By/To Lien
MED 4/19/2004 - 4/19/2004 432.00 0.00 0.00
613/2004 432.00 Health Insurance/ Provider
East Pennsboro Ambulanc Service
MED
4/19/2004 - 4/1912004
Holy Spirit Hospital
MED
2,057.29 0.00 25.00
10/28/2004 2,032.29 Health Insurance/ Provider
4/30/2004 0.00 Client / Provider
210.14 Health Insurance / Provider
370.00 210.14 148.45 50.00
Orthopedic Institute of Pennsylvania
MED
4/20/2004 - 8/2/2004
Dr. Goltz
5/12/2004 - 7/1/2004 3,075.00 0.00 0.00
10/28/2004 3,075.00 Health Insurance/ Provider
Drayer Physical Therapy Institute
--- - ----------- - - - - - - - - -
rotals $ 5,934.29 $ 5,749.43 $ 75.00
Liens $ 0.00
There are no unvalued Items on this report.
Subtotals: ED $ 5,934.29 Paid By: lient $ 0.0
Health Insuranc $ 5,749.4
96/02/2004 12:49 7172146020 CORNERSTONE ADMIN
East x ennsboro Ambulance Servxe Inc
50 S HUM.ER STREET
O Box 47
NOLA, PA 17025
117) 732-555.2 Ext.
!'A(it. t75/ b /
Rec,cipt 05/28/04
Patient Trip
r-FLECK, CONSTANCE Date of Service: 4/19/2004
312 MALLARD ROAD Rm/Apt: APT C Run Number: 16,604
AMP HILL, PA 17011 PU Locati.on: 1312 MALLARD ROAD
DO Location: Holy Spirit Hospital
'redit Description Trip Date Check # Post Date Amount
ayment - Check 2004-04-19 0073-A 5/26/2004 $432.00
Dcr4w@210: 'T'otal Charges $ 432.00
Total Credits $ 432.00
Current balance $ 0.06
mcueNetTM Printed on 528/2004 at 12:06:41PM Page 1
ewerl \RascueNet\6ysrpt\RECEIPT.RPT
2 ..,.:. Ha SPIRIT HOSPITAL ' PAGE NO.
$? 1
PE OF DATE OF BILL DATE Cad-. N 2:19T ST
31LL PREV. BILL
CAMP. HILL, PA 17011 {?
BIRTH 3JATE , HOSP. NO.
717,', 763-2141 BOJ 'BIRTH-DATE'
- ??.1. 02/2775 9000
17
t PATIENT NAME PATIENT NUMBER SEX AGE ADMISSION DATE DISCHARGE DATE DAYS
[ ? 4
C.O.si INSURANCE COMPANY NAME GROUP NUMBER POLICY NUMBER
RANTOR
CONSTANCE L FLECK. -1 HEALTH AMERICA ROOS4436001
TAME 1314 MALLARD RD
CND ,'`
CAMP HILL PA 17011
DRESS LATTER MARIPAT L
?v
„
PLE
ASE RET4iflN THIS PORTION WITH YOUR PAYMENTt,' AMOU
AYM NT
ENTF I
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Y
(
n!+lS K 1, Ym pt. vn"4 ki iY trc? Yy?, e-R54c ?", l{f, e [ }rv . alk S+i, t "
E DESCRIPTION OF SERVICE TOTAL EST. COVERAGE EST. COVERAGE EST. COVERAGE EST. COVERAGE PATIENT
ED HOSPITAL SERVICES CODE CHARGES INS. CO. NOA INS. CO. NO.2 INS. CO. NO.3 INS. CO. NOA AMOUNT
AI . OF CURRENT CHARGES, PAY MENTS AND ADJUSTM T'S
i9 UMP SET 3Y TYP011613931 53. 00 53. 00
:9 ORAZEPAM 2MG/MO14414022 25. 00 25. 00
19 ORPHINE 5MG VIO14428325 6. 00 6. 00
14 MORPHINE 5MG VIO144283257 6. 09 6. 00
19 IDO/EPI 1% 30MO14472014 7. 00 7. 00
L9 TETANUS/DIPT A 014499002 35. 00 35. 00
19 ICODIN TAB HP 0144999142 14. 00 14. 00
.9 BANDAGE ACE 3" 021410136 3. 54 3. S4
l9 ERMABOND 0114123517 87. 75 87. 75
19 ACL 0.9 1000 011613063 21. 00 21. 00
t9 IV CATH 011720704 14. 00 14. 00
19 TRANSPARENT DRE011720702 1. 00 1. 00
L9 AST OCL 4 0117209305 23. 00 23. 00
1.9 EFT FOREARM 013650130 123. 00 123. 00
',9 EVEL V FC 0117105768 667. 00 667. 00
19 'D LEVEL IV PC 011710583 259. 00 259. 00
.4 AY REP LAC-SP,0117304S0 ' 359. 00 359. 00
.9 ON-EVA EAR/PULO11730555 35. 00. 35. 00
.9 EP LAC SID, NK,T0117:30685 25,7. 00 257. 00
.9 PP OF SHORT AR011730465 58. 00 SS. 00
DX 959.3 DX 0.00
.A E FORWARD 0. 00
[MA RY OF CURRENT CHARGES
PHARMACY 250 149. 00 149. 00
M/S SUPPLIES 270 150. 29 150. 29
DX X.-RAY 320 1.23. 00 123. 00
EMERGENCY ROOM 4SO 1635. 00 1635. 00
-T OTAL OF CURR. CHARGES 2057. 29 2057. 29
FEDERAL (DENT. NO. 23w1512747
0 T AL S' 1 2057. 29 2057. 29
iTIENT NUMBER REFER ALL QUESTIONS TO THE
PLEASE SEND PAYMENT T0:
'
`LD30S271'S BUSINESS OFFICE
(717) 788-218e.
HOLY SPIRIT HOSPITAL
.PAY 'THIS AMOUNT
a0.9C
503 NORTH 21ST STREET CHARDS NOTTIPOSTED WHENATHIS BILLEWAS PREPARE
LY SPIRIT HOSPITAL CAMP HILL, PA. 17011-2288 TTHEI AMOUNTS CSHOWNIEUNDERR EESSTTIMTEDNWISURRANC
MP HILL, PA COVERAGE.
OSL DBA GIRTH ]INSTITUTE OF FAA 08-•09--011.
8715 POPLAR CHURCH ROAD
E.I;t'1MP HILL. PA 17011
717-761-5530
TAX ID 0: 231875547
=1TIEN1 9 167902 FLECK , CONJTANCE PA BAL..: -68.59
INS 8AL„: 50.02.1
CT'H BAL.: .00
3ERV C INS A LINE INVOICE RUNNING
)A'T'E: I
------- NV
--- RP S
----- DR 1'=ROCa DL- SC;
-------------------- COMMENT CO
----------- COA
--- PL-
---- AMOUNT
--------- BALANCE
----
- BALANCE
-
--
-
42004 4 7 2 IS CLATE E: HGE:I LATER 01 .00 -
--
. 00 --
--
-
.00
CURTIS A GC.ILTZ DU DIAG:
42004 5 7 2 IS CL...ATE CHGEE LATER 01 .00 .00 .00
CURTI{S A GCLTZ DO DIAG'.'
42004 6 7 2 IS 99242 OFFICE & U 896 2Y 01 95.00 95.00
CURTIS A GCL.TZ DC DIAG: 881.10 E849.0 E=:927
51804 6 7 2 HA H. AME:R CF(. 1163558/5 2 05 -6059 26.41
51804 6 7 2 HAD,J I-1. A. AD,J 2 05 .00 26.01
50204 6 7 2 CADJ COURTESY CE'1G ERROR 05 -°9`:;.00 -68. 59 -68.59
50504 7 7 2 18 CLATEE CHGE LATER 01 .00 .00 -68.591
CURTIS A BOLTZ DG DIAG: 861.10
10504 8 7 2 18 99213 OFFICE CUT 896 3Y 01 60.00 -8.59
CURT IS A BOLT Z DC DIAG: 881.10 E 549. 0 E927
51404 8 7 2 PC.; PIERSONAL.. 1016 3 05 -10.00 -18.59
10104 8 7 2 HA H. AME R CK. 1168914/1 1. 3 05 -31.48 -50.07
0104 8 7 2 HADJ H. A. ADJ 3 05 -18.52 .00 -68.5.9
11904 10 7 fc 19 99242 OFFICE & 0 696 5Y BE 95.00 26.41
WILL.IF-i M J PDLPt C'rHECK DIAG: 881.10 F_549.0 E920 .8
12104 10 7 2 HA H. AME'CR CK. 1177115/1 5 05 -78.59 -52.18
12104 10 7 2 E•ADJ H. A. ADJ 5 05 -16.41 .Cho _68.59
o1504 12 7 2 IS C;L.ATE CHGE LATER 01 .00 .00 -68.51D
CURTIS A BOLTZ 1.U DIAS: 881.10
61504 13 7 2 IS 99213 OFFICE OUT 896 7Y 01 60. 010 -B. 51..?
CURTIS A BOL..TZ. DO DIAS: 881.10 I:E849.0 E920 .8
'0204 13 7 2 PC"; PERSONAL 1030 7 05 --10.00 --18.59
'2004 13 7 2, HA H. AMER CK. 1189363 7 05 • 31..4.8
-50. 07
'::004 13 7 HADY N.A. ADJ 7 05 --18.52 .00 --68.59
40204 14 7 2 18 C:.A-I"EE CHGE LATER 23 W o .00
68. ;55
CURTIS A BOL.TZ DO DIAG: 881.14D
................._.... ...........- .............. ..... ..... -.._...-..._...._..... ... END OF PATIENT HISTORY ---- -.--_........ ....._.-.........................._ ._.....-......-.......... ....,........,......_._.
T07A L_S **, CHARGES: 310.00 PAYMEN'T'S: -- 230. 14 ADJU STE r -- 148.45
2004 `:' 7 d IS 99213 OFFICE CAST 696 GY 01 6111.04: 60.01D
WRT IS A BOL.TZ DG DIAG: L381. 10 £:849.0 E920.8
{. 9 7 ..
- .. ::: ?
(,...RE; VISA
-, i{.,r?A r?, c.
..r+ ..,
t:., T: r..-? _ --1.0.TI1r 50.00
i
??rsz tv?
------ --- ----- -------- END ?F= 1:NSL .IRANCE HISTO RY ---- --------- -------- -------
z TOTA
TOTA LS
LS ** , CHARGES: 60.00 PAYMENTS: -°10. 00 ADJU STS: .0Q.,
OCT-28-2004-THU 09:30 AM DRAY °T MBURG
DRAYE•R
Fbycical'fl?aay rnatltuta
LM&V *a VI" 0 COW MWM
DRAYER PHYSICAL THERAPY TNST•iTUTE
Mechauicslawg Clinic
'52-75 E. Trindle Road
suite 110
Mecbanicsburg, PA 17050
Phone:(717)790-9920
Fax: (717)790.9923 '-
To;*Udkr- AMnfT f J?gSart?Mj,
Fax:3-$07A v(
;Phone;
i
?a:
FAX No. 7177909'
From 1! ems"
Date: 10128104
T'.ages:f
cc: //
0 Urgent W or Review 0 Please Comment 0 Please 1reply 0 Pleg
. ? I
I
'!Important Notice:.
THIS FACSIMILE MAY CONTAIN MFORMATION THAT IS PRIVILEOED, CONFIDENTIAL, AND/OR On
'PROTECTED FROM DISCLOSUBRE TO ANYONE OTHER THAN ITS INTENDED RBOIPTMN{'S (S). ANY
DISSEMINATION ORUSE OF THIS FACSIMILE OR ITS CONTENTS BY PERSONS OTHER THAN THE IN'
RBCIPIBNT (S) IS STRICTLY PROH®ITED. IF YOU HAVE RECErVED THIS FACCIMILE IN $RROR, PLE
:IMMEDIATELY BY TELEPHONE OR BY A VASCIMILE SO THAT WE MAY CORRECT OUR INT9RNAL P
PLEASE THEN SHRED AND DISPOSE OF THE FACSIMILE. THANK YOU. .
l?
P. 001/004
Recycle
nced
us
OCT-28-2004-THU 09:30 AM DRA PT MBURG PAX No, 7(7790. J
R1P001oW Patient xranaaoti0ne by Patient
DRAYER PHTSTCAL THUM INSTITUTE
USSR - THERESA
ICI INS NAB 8D1lECRIERa
390901307 PIECE CONSTANCE 1313 MALLARD ROAD 0016-HEALTH An FLECK co
7 17 763 8876 075-01-00 20054436001 1001030004
CAMP HILL PA 17011
SEKi WAY DR# RDR PAT RSlATLQNB k8C VARS
380401307 FLECK COMBTANCE F 02/21/79 2 ,48 2 6
0 - 30 3% - 60 61 = .90 91 - 120 •
" 121-154 OVER 150 ' POSTED UMPOSTRD TOM !SAL PEN
0. 00
:0.00 0.00 0.00 0.00 ,0.00. 0.00 0.00 0100 0
.1 T e agog U COM6TANC8 FLECK Total: 216.00
05/12/04 MESS ; GOLTZ NECMNIC82URG ?
051204 91003 - S-OCCUPATIONAL TH 719.43 -PALM IN JOINT, - 01 125.00
' 051204 97930 - 2-THEEAP90TIC ACT 719.43 -FAIN IN JOINT, 01 40.00
051204 97035 - 2-DLTRREOOND, EAC 719.43 -PAIN IN JOINT, O1 30.00
051204 8703.0 - 2-NOT OR COLD Pu 719,43 -PAIN IN JOINT„ 01 20.00 '
0517044 '-HEALTH AMERICA -0008891-Y-N-P cleared
215.00 / 36.13•/ .00 / ,00 / 179,97
1 T 9 8912 0 CONSTANCE FLECK Total:' 1170.00 .
.05/3.3/04 GREBE GOLTZ MECHANICSBURG
061304 97630 - 2-TBERRPEOTLC ACT 719:43 02
-PAIN IN P 50.00
051304 97140 - 2-MANUAL TKIRAPY, 719.43 INT'.
-PAIN IN 'JOINT,.' OS 40.00
061304 97035 - 2-OLTRASUM, MC 719.43 -BALN•IN JOINT, Ol 30.00,
061,304 ' 97010 - 2-E0T OR COLD PAC 719.43 -PAIN IN JOINT, 01 20.00 1
051701- -ERALTM AMERICA -000
9121-'VS-P CLeared , ,
11(0.100 / 17.49 .00 / 92, a1
I T * 0956 D CONSTANCE FLECK Totaly 110.00
05/17/04 (RZSS GOLTZ NECHRELCRRURR
051704 97530 - 2-THENABBUTIC ACT 719.43 -PAIN IN JOINT, 02 80,00 1
051704 97140 - 2-1gNBAL lHORAPY, 719.43 -PATH IN JOINT, OS 40,00
051704 97056 - 2-ULTRABOUND, KAC 719.43 -PAIN IN dOriTt, 01 30.00
051744 97010 - 2-ROT OR COLD PAC 719.43 -PAIN IN JOINT, OS 20.00 i
091904= -HEALTH AMZ4ZCA -008 9561-Y-11-P cleared.
170.00 / 77.49 /• .00 / ,00 / 92:51
1 Tit 8958 O CCNBTANca PLECK Total: 170.00
05121/04 GREBE OOLTZ MECHANICSBURG '
• 052104 97530 - 2-T1RRAPEUTYC ACT 719.43 -PAIN IN JOINT, 02 00.00
032104 97140 - 2-MANUAL TEKRARY, 719.43 -TAIN IN JOINT, O1 40.00
052104 97035 - `2- nnuu DPND, Mac 719.43 -PAIN IN JOINT, • 01 ... 30.00-
052104 97010 - 2-HOT OA COLD Pu 719.43 -PAIN IN JOINT, al 20.00
05R404j -IMUMH ANCRICA 0052391-Y-N-P cleared
170.00 / 77.49 / ,00 / .00 / 92.51
1 T 9 9341 U CONSTANOR FLFAR Totals '170,00
05/24/04 GAMES 0=1 YECNA11IC8BORO
062104 97630 - -THERAPEUTIC ACT 719.43 -PAIN IN Join, 02 80.00
052404 97140 - -MANUAL THERAPY, 719.47 •-RAIN IN JO7.NT„ 01 40.00 '
062404 97035 ' - -ULTRASOUND, EAC .719.43 -PAIN IN JOINT, 01 30.00
052404 97010 - -HOT ON COLD PAC 719.43 -PAIN IN JOINT, B1 20.00 i
052704- .HEALTH AMERICA -0093411-Y-9-P cleared
170.00 / 71,42./ .00'7 '.00 / 92,31 i
I
' T 4- 9342 0 CONSTANCE FLECK Total: 1 0.00
05/2
6/04 GRESS + GOLTZ MECCHANICSBURG .
052604 CANCEL - -CANCELLED APR' 719.43 -PAIN IN JOINT, . 01 0.00
100 / .00 .00 / ,OQ / .00
1 ' T 9, 9343 0 coftTANCs OLE= Total: ? 0'.OD?,
06/27/04 mlEea ': ODLTZ ibCRANIC88UR0
032104 CANCEL - -CANCELLED APPT 719.43 .-PAIN IN,JOINT, O1 0.00
.00.1 .00 / .00 / .100
1 T 0 95'22 0 CONSTANCE FLOOR Total: 0.00
06/01/04 Guam UOLTZ iffiCHANSC96UA0 '
060104 CANCEL -, -CANCELLED APPT 719.43 -PAIN IN JOINT, 01 0-00••
' .00 / .00 / .00 / .00 / ..00
1 T 9' 9523 U CONSTANCE
PLECC !
Total: 170. DO '
06(03/09 MESS
' GOLTZ MSCBANLCBBURG
060309 9)830 - 2-THERAPEUTIC ACT 719.43
1 -PATH IN JOINT, 02 00.410
060304 97L40
- 2-MANUAL THERAPY, 719.43 -PAIN IN JOINT, 01 40.00
060304 97035 - 2-ULTRASOUND, INC 719.43 -RAIN IN JOINT, 01, 30.00
060304 97010 + 2-NOT OR COLD PAC. 719.43 -RUN 311 JOINT, O1 20.00
' 061004-, -9H1kLTW AMERICA 4095231-Y-N.P olaarad- '
' 170.00 / 77.49, / .00 / DO / 92.,5E
1 T S 95$9 0 GDNSTANCO FLECK Totals 210.00
06104/09 3 GOLT2 MECRANIC9BURG
060401
' 975 97530 0 - 2-THERAPEUTIC ACT 719.93 -kh" IN JOINT, 03 120
00
060404 91140 - 2-MANUAL THERAPY, 719.43 -PAIN IN JOINT, 01 ,
40.00
060004 97055 2-UL9'RA Q=, ERC 019.43 rRAIR IN JOINT, 01 30.00
060404 .97010 - 2-SOT OR COLD PAC 719.43 -SAID IN JOINT, 01 20.00
061004= -HEALTH AMERICA -0096241-Y-N-P cleared
210.00 / 100.53 / .00 / ..00 / 109.47
1 T 9 102'92 O COMTANCE FLECK Totals 1295.00
i
P. 002/004
DATE 10/28/2004
TINN 09,32
PAGE 1
an SCx BNPN
Y Y
AR9
PAT•BAL LAST AGING
0.00 ,10/27/04
OCT+28-20.04-THU 09:31 AM
1"001891 Patlend
700YRR PHYSICAL THERAPY INSTITOTN
UBaR - THERESA .
DRA`. PT MBURG FAX No. 717790S
Transactions by Patient
.06/01/04 GRESS GMTZ MECRANICURNKG
080704 97004 - 3-OCCUPATIOKOIL TO 719.!3 • -PAIN IN JOINT, 01
060704 97530 - 2-THERAPEUTIC ACT 719.43 -9AIN IN 001NT, , 03
060704 97035 - 2-ULTAA50000, 3210 119.43 -'VAIN 11 001NT, 01
060704 97010 - 2-ROT OR COLD PAC 719.43 -PATH IN JOINT, 01
061004- -HEA7SH AMERICA -0102421-Y-N-P cleared
245;00 / 81.21 ! .00 (. .00 / 163.79
1 T • 9525 U CONSTANCE FLECK Tata1K 17Q.00
06/08104 GAMES • OOLTR . MECHANICSBURG
060804 87530 - 2-THERAPEUTIC ACT, 719.43 -PAIN IN JOINT, 03
060804 9703b - 2-ULTRASOUND, RAC 719.43 -PAIN IN JOINT, O1
060804 97010 i - 2-HOT OR COLD PAC 719.43 -PAIN IN JOINT, OT
061004- -HEALTH AMERICA -0095251-Y-N-P cleared
170-00 / 51.21 / .00 / .00 / .88.79
1 T 6 104197 U CONSTANCE FLECK Totals `170.00
Od/10104 GRESS + GOLTZ MECNAMICSSURG
061004 97530 - 2-THERAPEUTIC ACT 719.49 +BAIR IN JOINT, 03
061004 97033 - 2-BLTRA5o0ND, EAC 719.43 -PAIN 10 JOINT, 01
061004 97010 -'2-HOT OR COLD PAC 719.43 -PAIN IN JOINT, •01
0611041 -HEALTH AMERICA -0104971-Y-N-9 cleared .
170.00 / 81.21 / •.00 / .00 / 98:79
1 T # 10496 0 CONSTANCE FLECK Total: 210.00
0015/04 GRESS i GOLTZ NBcHANICSBURO
061504 97530 - 2-THERa9E0TTc ACT 719.43 - -PAIN IN JOINT, 04
061504 47033 : - 2-ULTAASOUNO, SAC 719:43 PAIN IN JOINT, al
061304 97010 - 2-HOT OR COLD PAC 719,43 -PAIN IN JOINT, 01
061604- -HEALTH AMERICA -0104961-Y-N-P Cleared
21000 / 104.25 .00 ( 700 / 105,75
..1 T # '11290 V'CONSTRACE FLECK Total: 170.00
06/22/04 GRBSS GOLTZ 1RCHANICSNORO
062204 97530 - 2-THERAPEUTIC ACT 719.43 -RAIN IN JOINT, 03
062204 97035 - 2-ULTRA900N0, EAC 719.43 -PAIN IN JOINT, 01
062204 97010 - 2-HOT OR COLD PAC 719.43• -RAIN IN i7QZW, 01
062404', -HEALTH XUR.ICA -0112901-Y-N-P cleared
170.100 / 47.00 / .00 / .00 / 123.00
1 T # 11$91 D CONSTANCE riam Total: 220.00'
.06/24/09 GRESS GOLTZ NECHRKICIMOM
062404 97330 - 2-7EE31ASSU1'IC ACT 719:47 -PAIN IN JOINT,. 04
. 062404 97112 - 2-NEVRON08CULAR R 719.43 -RACE IN #QINT, a1
062404 97010 -2-NOT OR COLD RAC 719.43 -PAIN IN JOINT, 01
062504- -HEALTH ANSRICA -0112911-Y-M-P cleared
220.00 / 47.00 / .00 / .00 / 173.00.
1 T # 11992 0 CONSTANCE FLECK Total, 220.00
06/25/04 ORHSS SOLVE MECRANICBRORG
•062504 97530 - 2-THERAPEUTIC ACT 719.43 -PAIN IN JOINT, 04
062504 97140 - 2-WWOAL THERAPY, 719.43 -PAIN•IN JOINT, 01
062604 97010 - 2-10T OR COLV• PAC 719.43 -PAIN IN JOINT, 01
062804ti -HEALTH AMERICA •-0112921-Y-N-P cleared
220.00 / 47.00 / .00 / .00 / 113.00
1 T # 1169 U CONHYANCE PLECK Total: 140,00
06/28/04 GERMAN : ARGUE OOLT2 MECHANICSBURG
062604 97630 - -TWRRMMMC ACT 719.63 -PUN LW JOINT, 03
062804 97010 - -NOT OR 0= PAC 719.43 -PAIN IF JOINT,- , 01
063004- -HEALTH AMERICA -0115391-Y-N-P Cleared
140:00 1 47.00 / 0D / .00 / 93.00 '.
1 T 9 11640 U CONSTANCE TLECK Total: 0.00
06130/04 =955 G=z MECHANICSBURG
063004 CANCEL ' - -CANCELtsb APVT 719.43 -PAIN in JOINT, 01
X00 / Do./ .00 / .06 ./ ..00
1 T # 11046 0 CDMBTANCE FLECK Total* 265.00
01/01/04 GRESS GOLT1 MECHANICSBURG
070104 97004 3-00CURA1I00Z TH 719.43 -PAIN IN 14"AT, '01
070104 97530 - 2-THERAPEUTIC ACT 719.43 -PAIN IN,JOINT, 04
070104 97010 : - 2-HOT OR COLD PAC 719,43 -PAIN 331 JOINT, 01
070504-, -WEALTH AMINX06 -D118481-Y-N-R cleared
255.00 / 47.00 / .00 / 00'/ 206.00
06/04/04 0016-PMT WEALTH ANRRICA 061400066891 r9 21132V999
0002 i 35,13- 140008683
06/04/04 001"/0 WEALTH AMERICA C#1400050091 r# 211330999
0002 ' 179.87- 140008889
0610004 0016-TNT HEALTH AMERICA 0#1400089121 1# 211949999
0002 77.49- 140008912
06/04/09 0016-N/O HEALTH AMERICA C#1400089121 r# 211380999
0002 : 92,51- 140008912
06/04104 0016-PMT WEALTH AMERICA 061400009661 r9 211960999 .
0002 77,49- 140008956
06/04/04 0016-W/O HEALTH AMERICA 041400069561 r# 211370999
0002 92.61- 140008956
06106104 0016-PMT HEALTH AMERICA x#1400089691 r# 214020999
0002 77.49- 140008959
06/09/04 0016-M/,0 HEALTH AMERICA. 041400089681 r# 214030999
i •
1
l
l
L
1
1
1
1
i
7s. 00
'120.00
30.06
20.00
i
120.00
30'.00
20.00
f
I
120.00 '
30.00
20.00
160.00
30.00 ,
20.00
120.00
30.00
20.00
i.
160.00
40.00
2o.pD ,
I
i
160.00
40,00
20,d9'.
i
120.00
20.00
i
D.oO
75.00•
160.00
20.00
36.13-
179.87-
77.49-
.92.51-
77.49-
92.51-
71.4p-•
92,61-
i'
1
i
i
P• 003/004
OATS 10128/2004
TVA 09132
PAGE 2
OCT-•28-2004-THO 09:31 AM DRA'. PT MBURG FAX No,717790E
1693 Patent Transactions by patient' -
R PHYSICAL THERAPY INSTITOVS
USER - TRSREIIA '
0002 ;, 92,51-
06/09/04 0016-PN7 HEALTH AMEIIICA
0002 77.49-
0 6/09/Od 0016-W10 HEALTH AMERICA
0002 .: 02.61-,
06/29/04 0016-PET HEALTH AlEAICA
0012 }748-
. 06/23/04 0016-W?0 iiiiTH AMERICA
0002 •922..31-
51-
06/29/04 0016-714'1' HEALTH AMERICA
.0002 : 100.59-.
.06/29/04 0016-W/,0 HEALTH AMERICA
0002 . 109.47=
06/23/Oi 0016-PHT HEALTH AMERICA
0002 81,21-
06/23/04 0016-W/O HEALTR AMERICA
0002 88.79-
06/23/04 0016-PMT HEALTH AMERICA
0002 • 01.21-
06/23/04 0016-0/0 HEALTH AMERICA
0002 : 88,79-
06/30/04 0016-6W HEALTH AMERICA
.0002 81.21-
06/30/04 0016-W/,O HEALTH AMERICA
0002 : 163,79-
07/07/04 D016-10fT UALT41 AMERICA
0002 104,25-
07/07/04 '0016-W/0 RHALTH AWRICA
0002 i 105,75-
07/13/04 0016-PMT NEALTH AM CA
0002 47.00-
07/13/04 OQ16-W/O HEALTH AMERICA
0002 - 123.00-
07/15103 0016-714'1' HEALTH ANCRICA
.0002 - 47.00-
07115/04, 0016-W/O HEALTH AMERICA
'0002 ? 173.00-
07/15104 0016-Mg HEALTH AMERICA
0002 . 47.00-
07/15/04 0016-8/O HEALTH MORICA
0002 : 173.00-
07/15/04 0016-93PT H=TH AMERICA
0007 . 47.00-
01/15/04 0016-F/D HEALTH AMERICA
0007 93.00-
07/2#/04 0016-M mraLTH A03RICR
0002 • 47,00-
07/28/04 0016-W/O HEALTH AMERICA
.0002 208.00-
140008966
a#1400097411 sf 21b1.80989 1
140009741
c#14DOD93411 z# k151Qv099 1
1400DO34 009941
0#1400095231 xf '227110999 1
140009629
0#1400095291 rf. 22712V999 1'.
' 140009527 '
081400095241 r# k2713U999 1
140009524
01400096241 r8 ?27140999 1
1400D962d
081400095251 c# 227180900 1
140009525
c#1400095251 r8 927160999 1
140009526
c#1400101971'r# 227170999 1'140016401,
0#1400304011 rf. 22718V999 1
140010497 '
0#1400102421 r19: 23402U999 1
140010242
011400102421 r# 234030999 I
. 140010242
0#1400104061 r# 940870999 1
140010496
•0140010496) r# 240880099 1
140010496-
C114100112001 r# , 246S40999 1
'140011290
0#1400112901 rf 240SSU0.09 i
140011290
0#1400112911 r# 24867U999
140011291'
0#1400112911 r# 2411880999
140011291
0#1400112921 r# 248890999
140011292
001'400112921 c# 248800999
140011282
0#1400115391 x# 24899UODS
140011539
001400115391 r# 249000999
'140011539 '
C#1400118481 r# 265230999
140011846
0#1400410481 r# 265240999
140011848
i
77.49-
92.51-
77:99- ' •
9x.51-
100.93
.109.41-
i
81.81-
88.79-
81.21-
88.79-
el.a1- '.
189.79-
109.2b- •105.75-
47.00-
123.00-
47.00-
173.00-
47.00-
173.00-
47.09-
93.00-
47,00-
'2ae.V1- '
Print Order : Patient f
9at4,ent #I
Posting Dates
start
360401307
01/01/1979
atop
380401907
12/11/2078
I
I
i
P. 004/004
DATE 10/28/20
TIIR 09,
7110E
(,0
',"? ?,?r?,.
s?>.
?? _ ...
W. Scott Henning, Esquire
I.D.#32298
HANDLER, HENNING & ROSENBERG, LLP
1300 Linglestown Road
Harrisburg, PA 17110
Telephone: (717) 238-2000 Attorney for Plaintiff
Fax: (717) 233-3029
E-mail: Henning@HHRLaw.com
CONSTANCE L. FLECK,
Plaintiff,
V.
DAVID ENGLAND and
HELEN ANN ENGLAND,
Defendants,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
No. 05-3221
: CIVIL ACTION - LAW
JURY TRIAL DEMANDED
CERTIFICATE OF SERVICE
On August 7, 2006, 1 hereby certify that a true and correct copy of Plaintiffs
Arbitration Exhibits were served upon the following by depositing in U.S. Mail:
George B. Faller, Jr., Esquire
Martson Deardorff Williams & Otto
Ten East High Street
Carlisle, PA 17013
Respectfully Submitted,
ROSENBERG,LLP
Date: 8/7/06 By:
W.
X,C
N
Nye
W
Constance L. Fleck
Plaintiff
David and Helen England
Defendant
In The Court of Common Pleas of Cumberland
County, Pennsylvania No. 0 5 - 3 2 21
Civil Action - Law.
Oath
We do solemnly swear (or affirm) that we will support, obey and defend the Constitution o the United
States and the Constitution of this Commonwealth and that we will discharge the duties of ur office
with fidelity _
i?
Signature Signature
William P. Doug'Tas
Name (Chan man)
Douglas Law Office
Law Firm
43 W. South St.
Anthony DeLuca
Name
Law Film
113 Front St.
Craig A. Diehl
Name
Law Firm
3464 Trind e Rd.
Address
Carlisle 17013 Boiling Springs 17007 Camp Hill 7011
City, zip city, zip city, Zi
108019 Award 7 10783
We, the undersigned arbitrators, having been duly appointed and sworn (or affirmed), make the
following award: (Note: If damages or delay are awarded, they shall be ep tely .)
? C
Arbitrato dissents. ert name if pplical
Date of He T
wring: July 5, 2007
VAL
va?+a+aa+?u i
Date of Award: July 5, 2007
rNotice of Entry of Award
Now, the tti day of JUIv 20 Q , at R:,3a _L-M., the above a? ardwas
entered upon the docket and notice thereof given by mail to the parties or their attorneys.
Arbitrators' compensation to be paid upon appeal: $ WO , pp
II
By:
/ Prothonotary Deputy
n?
DVb
Prop,-
?Kh